abdominal and gastrointestinal emergencies

Nancy Caroline’s Emergency Care in the Streets, Eighth Edition Chapter 20: Abdominal and Gastrointestinal

Emergencies

© 2018 Jones & Bartlett Learning, LLC, an Ascend Learning Company

Chapter 20

Abdominal and Gastrointestinal Emergencies

Unit Summary

This unit reviews the structures that perform digestion and their functions and locations. After a

brief review of the general assessment process for a patient with an acute abdomen or other

abdominal emergency, the pathophysiology, assessment, and management of several common GI

conditions are discussed.

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.

Abdominal and Gastrointestinal Disorders

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

• Gastrointestinal bleeding (pp 1183-1187)

Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations,

prognosis, and management of

• Acute and chronic gastrointestinal hemorrhage (pp 1183-1187)

• Liver disorders (pp 1197-1198)

• Peritonitis (pp 1189-1190)

• Ulcerative diseases (pp 1185-1186, 1194)

• Irritable bowel syndrome (p 1195)

• Inflammatory disorders (pp 1194-1195)

• Pancreatitis (pp 1193-1194)

• Bowel obstruction (pp 1198-1200)

• Hernias (pp 1186, 1200-1201)

• Infectious disorders (pp 1196-1197)

• Gall bladder and biliary tract disorders (pp 1190-1191)

• Rectal abscess (p 1197)

• Rectal foreign body obstruction (pp 1201-1202)

• Mesenteric ischemia (pp 1202-1203)


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Knowledge Objectives

1. Describe the incidence, morbidity, and mortality of gastrointestinal emergencies. (p

1171)

2. Identify the primary risk factors for gastrointestinal disease. (pp 1171-1172)

3. Discuss the anatomy and physiology of the organs and structures of the gastrointestinal

system. (pp 1172-1175)

4. Explain how to size up scene safety when responding to a patient with a gastrointestinal

emergency. (p 1175)

5. List the personal protective equipment that is likely to be necessary during a call in

response to a patient with a gastrointestinal emergency. (p 1175)

6. Explain how to integrate pathophysiologic principles and assessment fi ndings to

formulate a field impression and implement a treatment plan for the patient with a

gastrointestinal emergency. (pp 1175-1180)

7. Evaluate the mechanisms by which airway patency might be compromised in the patient

with a gastrointestinal emergency. (p 1175)

8. Summarize assessment of breathing and circulation in a patient with a gastrointestinal

emergency. (pp 1175-1176)

9. Indicate the considerations that go into making a transport decision for the patient with a

gastrointestinal emergency. (p 1176)

10. Explore ways of investigating the chief complaint and taking the history of a patient with

a gastrointestinal disorder. (p 1176)

11. Describe the technique for performing a comprehensive physical examination on a

patient with abdominal pain, including percussion and auscultation of bowel sounds and

palpation to evaluate for pain and masses. (pp 1176-1179)

12. Discuss how orthostatic vital signs can help assess the extent of abdominal bleeding. (p

1179)

13. Consider the proper extent of pain management for the patient with an abdominal

emergency. (pp 1180-1181)

14. Discuss the pathophysiologic mechanisms that can cause hypovolemia. (p 1182)

15. Compare the pathophysiology, assessment, and management of upper gastrointestinal

bleeding with that of lower gastrointestinal bleeding. (pp 1183-1187)

16. Discuss the pathophysiology, assessment, and management of esophagogastric varices.

(pp 1183-1184)

17. Discuss the pathophysiology, assessment, and management of Mallory-Weiss syndrome

and Boerhaave syndrome. (pp 1184-1185)

18. Discuss the pathophysiology, assessment, and management of peptic ulcer disease and

gastritis. (pp 1185-1186)

19. Discuss the pathophysiology, assessment, and management of gastroesophageal refl ux

disease and hiatal hernia. (p 1186)

20. Discuss the pathophysiology, assessment, and management of hemorrhoids. (pp 1186-

1187)


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21. Discuss the pathophysiology, assessment, and management of anal fissures. (p 1187)

22. Discuss the pathophysiology, assessment, and management of esophageal pathologies,

including esophagitis, tracheoesophageal fistula, and esophageal stricture (or stenosis).

(pp 1187-1189)

23. Explain how the immune system responds to acute and chronic infl ammation within the

gastrointestinal tract. (p 1189)

24. Discuss the pathophysiology, assessment, and management of peritonitis. (pp 1189-1190)

25. Discuss the pathophysiology, assessment, and management of cholecystitis. (pp 1190-

1191)

26. Discuss the pathophysiology, assessment, and management of appendicitis. (pp 1191-

1192)

27. Discuss the pathophysiology, assessment, and management of diverticulitis. (pp 1192-

1193)

28. Discuss the pathophysiology, assessment, and management of pancreatitis. (pp 1193-

1194)

29. Discuss the pathophysiology, assessment, and management of ulcerative colitis. (p 1194)

30. Discuss the pathophysiology, assessment, and management of Crohn disease. (pp 1194-

1195)

31. Discuss the pathophysiology, assessment, and management of irritable bowel syndrome.

(p 1195)

32. Explain why the gastrointestinal system is vulnerable to infection and how the immune

system reacts to infection within the gastrointestinal tract. (pp 1195-1196)

33. Discuss the pathophysiology, assessment, and management of acute gastroenteritis. (pp

1196-1197)

34. Discuss the pathophysiology, assessment, and management of rectal abscess. (p 1197)

35. Discuss the pathophysiology, assessment, and management of cirrhosis. (pp 1197-1198)

36. Discuss the pathophysiology, assessment, and management of hepatic encephalopathy. (p

1198)

37. Discuss the pathophysiology, assessment, and management of esophageal obstruction. (p

1199)

38. Discuss the pathophysiology, assessment, and management of small- and large-bowel

obstruction. (pp 1199-1200)

39. Discuss the pathophysiology, assessment, and management of gastrointestinal hernias.

(pp 1200-1201)

40. Compare the four types of abdominal hernias: reducible, incarcerated, strangulated, and

incisional. (p 1201)

41. Compare rectal foreign body obstructions caused by swallowed objects with obstructions

caused by inserted objects. (pp 1201-1202)

42. Discuss the pathophysiology, assessment, and management of rectal foreign body

obstructions. (pp 1201-1202)


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43. Discuss the pathophysiology, assessment, and management of ischemic and neoplastic

disorders, including mesenteric ischemia and tumors of the colon, pancreas, and liver. (pp

1202-1204)

44. Describe lifestyle changes that reduce the likelihood of developing gastrointestinal

disease. (p 1204)

Skills Objectives

1. Demonstrate how to auscultate the abdomen to assess for diminished, absent, or abnormal

bowel sounds. (pp 1177-1178)

2. Demonstrate how to palpate the abdomen to assess for pain, rebound tenderness, and

masses. (pp 1178-1179)

3. Demonstrate how to palpate the right upper quadrant to assess for Murphy sign,

indicating cholecystitis. (p 1190)

Readings and Preparation

• Review all instructional materials including Chapter 20 of Nancy Caroline’s Emergency

Care in the Streets, Eighth Edition, and all related presentation support materials.

Support Materials

• Lecture PowerPoint presentation

• Case Study PowerPoint presentation

• Available charts and/or diagrams to display the anatomy of the abdominal cavity

Enhancements

• Direct students to visit Navigate 2.

• Consider visting the web link to the National Library of Medicine.

Content connections: Abdominal pain is typically discussed in relation to chest pain in an effort

to rule out a potential cardiac event. Abdominal pain is also discussed within the gynecology

chapter as well as obstetrics.

Cultural considerations: Some disease processes are more prevalent in certain ethnic cultures.

These are noted throughout this chapter. There are also cultures that may use traditional

medicines and rituals for abdominal illness. If this is prevalent in your local population, discuss as

available.

Teaching Tips


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• Students need to be aware of the difficulty in determining a cause of abdominal pain.

Anatomy and physiology of the abdominal region is vital to a thorough paramedic-level

assessment.

Unit Activities

Writing activities: Assign an abdominal condition to each student. The student will be

responsible for preparing a written paper on causes, signs, symptoms, treatment, and any other

related information.

Student presentations: Have students present their group assignment from below. Alternatively

students may be assigned to present their written assignment to the class.

Group activities: Divide the students into groups. Assign one of the abdominal quadrants to each

group. Students will prepare a chart of the type of medical condition(s) associated with that

quadrant along with appropriate signs/symptoms.

Visual thinking: Have students draw the digestive system from the mouth to the rectum. Each

structure should be labeled with the name and primary function of the structure.

Pre-Lecture

You are the Paramedic

“You are the Paramedic” is a progressive case study that encourages critical-thinking skills.

Instructor Directions

1. Direct students to read the “You are the Paramedic” scenario found throughout Chapter

20.

2. You may wish to assign students to a partner or a group. Direct them to review the

discussion questions at the end of the scenario and prepare a response to each question.

Facilitate a class dialogue centered on the discussion questions and the Patient Care

Report.

3. You may also use this as an individual activity and ask students to turn in their comments

on a separate piece of paper.

Lecture

I. Introduction

A. Gastrointestinal (GI) conditions can become life threatening because systemic

consequences can result from untreated or undertreated GI disorders.

B. The number of disorders causing abdominal pain, diarrhea, and nausea is high.

1. GI disorders account for 246,000 deaths and 21.7 million hospitalizations per year.

2. With the exception of septicemia, most GI disorders are generally not deadly.


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3. 25 to 40% of the population of the United States has gastroesophageal reflux disease

(GERD).

4. According to the National Institutes of Health, 60 to 70 million people are affected by

digestive diseases.

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

1. Two common behavioral factors increase the release of gastric acid in the stomach:

a. Smoking (nicotine)

b. Excessive drinking (alcohol)

2. Other activities that place patients at increased risk include:

a. Ingestion of caustic agents

b. Low-fiber diet

c. Ingestion of certain medications

i. Acetylsalicylic acid

ii. Nonsteroidal anti-inflammatory drugs (NSAIDs)

iii. Anticoagulants

d. Stress

II. Anatomy and Physiology Review

A. The entire journey of food from mouth to anus takes 8 to 72 hours.

1. Involves the liver, pancreas, stomach, intestines, and other structures

2. Varies according to the types of food you eat, the amount of water you consume, the

amount of exercise you get, and how much stress your body is under

B. Digestion begins in the mouth.

1. The molars crush and grind the food, allowing it to be more easily swallowed.

a. Changing the consistency of food prevents aspiration.

b. Enzymes in the saliva begin the chemical breakdown of complex carbohydrates into

simple sugars for easier absorption by the body.

C. Swallowed food is moved to the esophagus.

1. Hollow tube

2. Unless it is filled with food, the esophagus generally lies in a collapsed position, which

discourages air from entering it during breathing.

3. During bag-mask ventilation, air can be pushed into the esophagus as well as the lungs,

causing gastric distention.

4. Using a wavelike muscular contraction called peristalsis, food is moved inferiorly toward

the stomach.

D. In the stomach:

1. Hydrochloric acid is secreted to break down the food even more.

2. The stomach contracts and mixes the food and acid together.

3. Substances that are of small molecular size are absorbed, such as water, alcohol, caffeine,

and some medications.


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4. Chyme (food mixture) exits the pyloric sphincter and enters the duodenum.

5. Here the pancreas, liver, and gallbladder connect to the digestive system.

E. The main function of the GI system is to absorb the digested food to add fuel to

the body’s cells.

1. 90% of absorption occurs in the small intestine.

a. The pancreas secretes enzymes into the duodenum to assist with digestion of fats,

proteins, and carbohydrates, and to neutralize gastric acid.

b. The liver:

i. Produces bile, which is stored in the gallbladder and used by the body to break

down fats

ii. Promotes carbohydrate metabolism

(a) If blood glucose level falls, the liver converts glycogen into glucose.

iii. Detoxifies drugs

iv. Completes the breakdown of dead blood cells

v. Stores vitamins and minerals

2. The portal vein transports venous blood from the GI tract to the liver.

a. For a variety of reasons, blood flow through the liver can be slow.

i. The veins surrounding the stomach and esophagus can become dilated if blood

backs up.

ii. A small amount of pressure can cause leaking or rupture of these vessels.

iii. This bleeding can be minor or severe.

F. The colon (large intestine) moves the remaining waste products (feces) to be

eliminated from the body.

1. The main role of the large intestine is to complete the reabsorption of water.

2. Helps to solidify stool

3. Failure of this bowel function results in soft stool or diarrhea.

4. The colon is the site of bacterial digestion.

a. Bacteria help the breakdown of chyme.

b. Gas (flatulence) is a by-product.

G. The appendix is a small, saclike outcropping of the colon.

1. Has no known function

2. May become infected with retained fecal material

III. Patient Assessment

A. Good assessment is the foundation of good patient care.

1. GI system emergencies often result from a medical condition rather than trauma.

2. History of present illness is one of the most important areas of assessment.

3. Ask the patient about:

a. Dietary habits

b. Discharge from the body


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c. Types of pain

B. Scene size-up

1. Take standard precautions to prevent contact with infectious agents.

a. Wear personal protective equipment (PPE) as necessary:

i. Gowns (especially helpful when dealing with incontinent patients)

ii. Masks

b. Cleaning the patient helps provide some degree of dignity to a person humiliated by

the circumstances of his or her disease.

C. Primary survey

1. Form a general impression.

a. Where was the patient found?

b. What is the patient’s body posture?

c. Is there an odor?

i. An upper GI bleed may produce foul-smelling stool.

(a) After about 2 to 5 minutes, your nose will tire of the sending signal, and the

smell will not be as noticeable.

2. Airway and breathing

a. If a patient has vomited, they have a greater chance of aspiration.

b. Inspect the airway for foreign bodies, and remove or suction obstructions within the

airway.

c. Check for unusual odors.

i. Patients who have extremely advanced bowel obstructions can have breath

smelling of stool.

d. If a patient is having trouble breathing, it typically stems from a severe complication.

e. Monitor the patient’s capnography to ensure an effective respiratory pattern.

f. Breathing management includes:

i. Administering high-concentration oxygen

ii. Preventing aspiration

iii. Auscultating lung sounds

3. Circulation

a. Assess skin color, temperature, and moisture.

b. Determine pulse rate.

i. Compare peripheral pulses with central pulses.

4. Transport decision

a. Integrate the information from the primary survey.

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

c. Be careful when transporting a patient in severe pain.

i. Syncope is possible.

d. Choose the mode of ambulance.

i. Transportation of the patient with GI disease rarely requires lights and sirens.

D. History taking


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1. SAMPLE (Signs and symptoms, Allergies, Medications, Pertinent past medical history,

Last oral intake, Events leading up to the illness or injury) helps you gather information.

2. Many patients with GI disorders have a history of long-standing medical issues.

a. Disorders can quickly increase in intensity.

b. Ask if the issue has occurred before.

3. A common frame of reference is important.

a. One person’s diarrhea is another person’s soft stool.

4. Ask about:

a. Changes in bowel patterns or the color or type of stool

b. Recent onset of diarrhea, constipation, or nausea and vomiting

c. Recent weight loss

d. Patient’s last meal

i. Ask how the patient tolerates food.

E. Secondary assessment

1. There should be no major changes within the examination of the head, neck, or chest that

directly relate to GI concerns.

2. The major effects from GI disease on the nervous, cardiovascular, or respiratory systems

result from pain, hypovolemia, and/or infection.

a. Throat pain is possible if a patient has an esophageal pathology.

3. Examining the abdomen should involve greater detail.

a. Be professional and calming.

b. Place a pillow under the patient’s knees.

c. Make sure your hands are warm before touching the abdomen.

4. Check the skin for irregularities.

a. Scars indicating trauma or past surgery

b. Stretch marks (striae)

5. Abdomen asymmetry may be caused by:

a. Tumors

b. Hernia

c. Enlarged or distended organs

d. Pregnancy

6. Check the shape of the abdomen.

a. Flat, round, protuberant, or scaphoid (concave)

7. Auscultate the abdomen as appropriate given the time and noise level in your

surroundings.

a. Gurgles or clicks should occur 5 to 30 times per minute.

b. Borborygmi (“stomach growling”) indicates strong intestinal contractions.

i. May be normal or present with diarrhea

c. Increased activity in the bowel (hyperperistalsis) may also be present in cases of early

bowel obstruction.

d. Decreased bowel sounds can indicate decreased peristalsis (hypoperistalsis).

i. Can lead to bowel obstruction


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e. Absent bowel sounds (no sounds heard for 2 minutes) can indicate the intestines are

not contracting.

8. Percuss the abdomen.

a. The abdomen should be tympanic (empty sounding).

b. The upper left and upper right quadrants will sound duller due to the spleen and

abdomen.

c. Intestinal contents can dramatically modify the sounds heard.

9. Palpate the abdomen.

a. The abdomen should be soft and nontender.

b. Assess for discomfort, rigidity, and any masses.

i. Rigidity can indicate hemorrhage or infection.

c. Abdominal pain can indicate:

i. Trauma

ii. Hemorrhage

iii. Infection

iv. Obstruction

v. Other serious conditions

d. Types of pain include:

i. Visceral pain

ii. Parietal pain

iii. Somatic pain

iv. Referred pain

e. Rebound tenderness (parietal pain) occurs when the peritoneum is irritated.

i. May suggest a life-threatening problem

f. On light palpation, the abdomen should be smooth.

i. Note the presence of any masses, which may indicate:

(a) Engorged liver

(b) Bowel distention

(c) Aortic aneurysm

(d) Cancerous tumor

10. Obtain the patient’s orthostatic vital signs to gauge the extent of any bleeding.

a. Have the patient assume a position of comfort.

b. Determine the blood pressure and pulse rate.

c. Have the patient change positions, and quickly retake the blood pressure and pulse

rate.

d. A 20–mm Hg drop in systolic blood pressure, a 10–mm Hg increase in diastolic

blood pressure (a narrowing pulse pressure), or a 20-beat increase in pulse rate may

indicate significant blood loss.

11. Ultrasonography testing may also be available.

a. Research does not support its use in the prehospital setting at this time.

F. Reassessment

1. Routine monitoring includes:


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a. Pulse rate

b. Electrocardiogram

c. Blood pressure

d. Respiratory rate

e. Pulse oximetry

2. Assess for signs of shock if your patient has GI bleeding.

a. Capnography can provide some insight into the patient’s degree of shock.

3. Determine the effects of your treatment on your patient.

4. Auscultate for lung sounds before giving additional fluid boluses.

a. Valuable information in determining if the patient is deteriorating into heart failure

5. Be objective in your documentation, and treat your patient with respect.

IV. Emergency Medical Care

A. If your patient’s condition suddenly changes dramatically, repeat the

assessments so you can modify your care to manage the changes.

1. Patients may experience:

a. Severe pain

b. Severe dehydration

c. Hypotension

d. Extreme nausea

2. Patients cannot have anything to eat or drink.

a. If surgery is needed, food or drink could delay treatment.

3. Your main goals are observation of standard precautions, maintenance of ABCs, and

management of pain and nausea.

B. Pain management

1. The goal of pain medication in the field is to make the patient more comfortable rather

than to abolish the pain altogether.

2. Medications given to manage abdominal pain (intravenously, intraosseously, or

intramuscularly) include:

a. Meperidine hydrochloride (Demerol)

i. A synthetic narcotic that is often given with hydroxyzine to decrease nausea

b. Morphine

i. Narcotic that can cause hypotension and respiratory depression

c. Ketorolac (Toradol)

i. This medication is a non-narcotic and therefore does not tend to cause

hypotension and respiratory depression. It should be given with caution in

patients with renal disease or patients who are bleeding.

d. Nalbuphine (Nubain)

i. A synthetic narcotic that can cause hypotension and respiratory depression

e. Fentanyl (Sublimaze)


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i. This is a commonly used opioid agonist. It is very potent, rapid acting, and has a

short half-life. This narcotic can cause hypotension and respiratory depression.

3. Administer the following to address nausea:

a. Ondansetron (Zofran)

i. May cause damage to a developing fetus

ii. Not recommended as first-line agent for nausea and vomiting in pregnant patients

b. Diphenhydramine (Benadryl)

i. Typically used for allergic reactions, but also has antiemetic properties

ii. Be cautious when using this medication because it can cause drowsiness and a

drop in blood pressure.

c. Hydroxyzine (Vistaril)

i. Be cautious when administering this medication to patients who have taken any

medication that has central nervous system (CNS) depressive effects.

ii. Increases the CNS depressive effects of other medications

d. Promethazine (Phenergan)

i. Be cautious when administering this medication to patients who have taken any

medication that has CNS depressive effects.

ii. Increases the CNS depressive effects of other medications

iii. Tends to cause a marked burning sensation during injection. Administer slowly.

C. Fluid resuscitation

1. In patients who are dehydrated, the overall goal of treatment is to refill the cellular space.

2. Degree of hemodynamic stability will indicate use of hypotonic or isotonic solution.

a. Patients in stable condition should receive hypotonic solution at an infusion rate of

125 mL/h.

i. This will move fluids from the vascular space into the interstitial and then the

intracellular space, refilling the cells.

3. For profound dehydration, isotonic fluid would be needed to re-expand the vascular space

first.

a. Cells are dehydrated, but decrease in blood volume is life threatening.

b. Refilling vascular space takes priority over rehydrating cells.

c. This step is essential to ensuring adequate perfusion to the body’s vital organs.

4. Care for the patient with hemorrhaging is directed at maintaining perfusion of vital

organs.

a. Volume replacement is critical to ensuring adequate circulation to the vital organs.

i. Be careful: Very aggressive volume replacement can result in dramatic

hemodilution (dilution of the blood).

ii. Titrate fluids to a blood pressure of 90 to 100 mm Hg; do not normalize the blood

pressure.

5. If the blood pressure cannot be maintained at adequate levels to maintain peripheral

perfusion, then you may need to consider the use of vasoactive medications.

a. Dopamine and epinephrine are commonly used in the prehospital setting for blood

pressure support through vasoconstriction.


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i. Perform fluid resuscitation before administration to ensure sufficient fluid

volume.

6. Once the patient arrives at the hospital, blood administration will be critical to

stabilization.

a. Be prepared to manage blood products; patients with GI bleeding often require blood

replacement.

V. Pathophysiology, Assessment, and Management of

Specific Abdominal and Gastrointestinal Emergencies

A. The paramedic must have an understanding of many conditions to care

effectively for the abdominal patient.

1. In some EMS systems, paramedics are asked to help online medical directors determine

where a patient should be directed (hospital, family physician, clinic, etc).

2. The more you understand about a patient’s condition, the more you can educate them to

make better lifestyle choices to stay healthy.

B. Cholecystitis (inflammation of the gall bladder)

1. Patients should closely monitor the types of food they eat.

2. If these patients eat very fatty meals, they are more likely to have an attack of pain and

discomfort.

a. Patients must learn which foods to avoid.

i. They may need to try small amounts of fatty foods.

C. Hypovolemia

1. Caused by either:

a. Dehydration from vomiting and/or diarrhea

i. The body shifts water from inside the cells to interstitial space and into the

vascular space to maintain adequate fluid volume in the blood vessels, until the

patient has reached the limits of effectively moving fluid.

ii. Electrolyte levels are affected during this process.

(a) Especially sodium and potassium

(b) Electrolytes can either increase or decrease.

b. Hemorrhage, typically from rupture or destruction of a structure

i. Mechanisms for bleeding include:

(a) Trauma

(b) Erosion of the protective mucosal layers

(c) Chemical destruction of tissue

(d) Dilation of blood vessels

ii. Bleeding can occur slowly, over several days or weeks, or it can be sudden, with

a large volume of blood loss.

iii. Signs of shock are typically present.

(a) Anxiety and restlessness

(b) Pale, cool, clammy skin


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(c) Tachycardia

(d) Narrowed pulse pressure

(e) Increased respiratory rate

iv. Drop in blood pressure indicates significant volume loss.

(a) Patient is critically ill.

VI. Pathophysiology, Assessment, and Management of

Gastrointestinal Bleeding

A. Bleeding in the GI tract is a symptom of another disease, not a disease itself.

1. In general:

a. Upper GI bleeding causes melena (dark, tarry stool).

b. Lower GI bleeding causes hematochezia (bright red blood in the stool).

2. Presentation is variable, and each condition has its own pattern of progression.

3. Gathering information regarding onset is critical.

4. Gathering past medical history is also important.

a. Find out the medications the patient is taking.

i. Several medications can irritate the GI tract.

5. Ask the patient how long the complaints have been occurring.

6. Ask the patient if he or she is taking medications that affect coagulation.

a. This will help estimate how easily the bleeding can be controlled.

7. Treatment includes:

a. Fluid resuscitation

b. Establish an IV line.

i. 1,000 mL of normal saline solution or lactated Ringer

B. Upper gastrointestinal bleeding: Esophagogastric varices

1. Esophagogastric varices are caused by pressure increases in the blood vessels

surrounding the esophagus and stomach.

a. Occur when blood cannot easily flow through a damaged liver

b. Blood backs up into the portal vessels (portal hypertension).

c. Hepatitis C is the primary cause.

2. Assessment

a. Patients initially present with signs of liver disease, including:

i. Fatigue

ii. Weight loss

iii. Jaundice

iv. Anorexia

v. Edematous abdomen

vi. Pruritus

vii. Abdominal pain

viii. Nausea


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ix. Vomiting

b. When the varices rupture, patients may have:

i. Abrupt discomfort in the throat

ii. Severe dysphagia

iii. Vomiting bright red blood

iv. Hypotension

v. Signs of shock

c. If bleeding is less dramatic, hematemesis and melena are possible.

d. Hemoglobin level and hematocrit value will drop.

e. Elevated levels of liver enzymes should be expected.

3. Management

a. Prehospital treatment includes use of the general management guidelines.

i. Accurately assess the degree of blood loss.

ii. Volume resuscitation and airway suctioning may be needed.

iii. If level of consciousness (LOC) decreases, the airway may need to be secured.

b. In-hospital treatment includes stopping the bleeding and aggressive fluid

resuscitation.

i. An endoscopy may need to be performed.

(a) Endoscope is advanced into the esophagus.

(b) Fiberoptic tube is advanced into the stomach.

(c) Internal structures can be seen and specimens can be taken.

(d) Physician will attempt to control the bleeding directly at the site of

hemorrhage.

C. Upper gastrointestinal bleeding: Mallory-Weiss syndrome and Boerhaave

syndrome

1. Mallory-Weiss syndrome

a. Condition in which the junction between the esophagus and the stomach tears

b. Causes severe bleeding and potentially death

c. Generally due to severe vomiting

d. The tear occurs within the mucosal lining and does not travel entirely through the

wall of the esophagus.

2. Boerhaave syndrome

a. Condition in which the esophagus tears longitudinally and the tear travels entirely

through the wall of the esophagus, creating a hole

b. Typically presents after a large meal that included alcohol consumption

c. If not treated within 2 days, mortality is 90%

3. Assessment

a. Both conditions have a presentation linked to vomiting.

b. In women, vomiting associated with pregnancy; in men, it is associated with alcohol

consumption.

c. Mallory-Weiss syndrome presents with bleeding.

d. In extreme cases, patients will have:


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i. Signs and symptoms of shock

ii. Epigastric abdominal pain

iii. Hematemesis

iv. Melena

e. Boerhaave syndrome presents with vomiting accompanied by upper chest pain.

f. Swallowing often exacerbates the pain.

g. Patients have little bleeding due to the hole in the esophagus, but certain conditions

can result:

i. Septicemia

ii. Pneumomediastinum (air in the mediastinum)

iii. Mediastinitis (inflammation)

iv. Empyema (a pocket of pus, in this case within the chest)

v. Subcutaneous emphysema

h. Signs and symptoms can include fever, difficulty breathing, and chest pain.

4. Management for Mallory-Weiss syndrome

a. Aimed at determining the extent of blood loss

i. The effects of blood loss may be exaggerated because of dehydration from

vomiting.

b. In-hospital management may include:

i. Volume resuscitation

ii. Endoscopy

iii. Attempt to repair the tear

5. Management for Boerhaave syndrome

a. Aimed at management related to the potential for sepsis.

i. Complicating this presentation is the symptom of chest pain.

ii. Patient should be managed as if he had a myocardial infarction (MI) until proven

otherwise.

b. Call medical control to help with these patients.

c. In-hospital management may include:

i. Endoscopy

ii. Antibiotics

D. Upper gastrointestinal bleeding: Peptic ulcer disease (PUD) and gastritis

1. Peptic ulcer disease

a. Erosion of the protective layer of mucous that lines the stomach and duodenum

b. Acid begins to eat the organ itself.

c. Typically occurs over weeks, months, or years

2. Gastritis

a. Caused by the same imbalance between stomach acid and the protective layers

b. A pre-ulcerative state where the stomach is inflamed, but erosions have not yet

occurred

3. Both have a variety of causes


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a. Infection of the stomach with the bacterium Helicobacter pylori

b. Erosive gastritis, which may be from:

i. Chronic use of NSAIDs

ii. Severe burns or trauma

iii. Alcohol and smoking

4. Assessment

a. In both conditions, patients experience burning or gnawing pain in the epigastrium

that disappears after eating, but returns two or three hours later.

b. Other common symptoms include:

i. Nausea

ii. Vomiting

iii. Belching

iv. Heartburn

v. Dyspepsia (belching, bloating, and fatty food intolerance)

vi. Fatigue

vii. Anemia

c. In PUD, the ulcer is said to have perforated if erosion has eaten through the wall of

the stomach or duodenum.

i. Causes a sudden increase in pain, and pain is more diffuse

ii. Infection can easily occur

(a) Peritonitis (inflammation of the peritoneum) is the result, with rebound

tenderness and potential hypotension due to sepsis

5. Management

a. Accurately assess blood loss and manage hypotension.

b. Monitor orthostatic vital signs to determine fluid needs and transportation issues.

c. Be aware that sudden vomiting can occur with a change in position; use a stair chair

rather than having him or her stand up.

d. IV fluids may be needed based on degree of blood loss.

e. Sepsis may be a concern if you suspect a perforated ulcer.

f. Management for gastritis is supportive.

g. Consider antiemetics in patients with PUD and gastritis.

h. In-hospital management includes:

i. Acid neutralization

ii. Reduction therapies

iii. Endoscopy if needed

E. Upper gastrointestinal bleeding: Gastroesophageal reflux disease (GERD) and

hiatal hernia

1. Gastroesophageal reflux disease (GERD)

a. Condition in which the lower esophageal sphincter (LES) between the esophagus and

stomach opens, allowing stomach acids to travel up the esophagus

b. Also known as acid reflux disease

c. Can cause a burning sensation within the chest (heartburn)


Emergencies


d. Risk factors include:

i. Smoking

ii. Obesity

iii. Pregnancy

iv. Fatty fried foods

v. Alcohol

vi. Citrus fruits

e. If the reflux continues over time, it can cause damage to the esophageal wall and

possible bleeding.

2. Hiatal hernia

a. A protrusion of a portion of the stomach through the diaphragm

b. If a portion of the stomach becomes trapped superiorly to the diaphragm, it creates a

small pocket

i. Superior “door” is the LES

ii. Inferior “door” is the diaphragm

c. GERD-like symptoms can result, but most hiatal hernias are asymptomatic

d. Caused by increased intra-abdominal pressure

3. Assessment

a. Symptoms for GERD include:

i. Heartburn, which may increase when changing position

ii. Coughing or difficulty swallowing

iii. Bleeding resulting in hematemesis and melena

b. Hiatal hernias are only symptomatic when food and acid cannot be flushed efficiently

from the pocket.

i. Retained acid can cause erosion of the stomach wall, bleeding, and pain.

4. Management

a. Prehospital management for both conditions will generally be supportive.

b. Medical treatment focuses on decreasing the acidity.

i. Antacids

ii. Proton pump inhibitors

iii. H2 blockers

c. Surgical repair may be needed.

d. Symptoms of an MI attack can be confused with GERD.

e. Large amounts of antacid can cause metabolic alkalosis.

F. Lower gastrointestinal bleeding: Hemorrhoids

1. Pathophysiology

a. Result of swelling and inflammation of the vascular cushions surrounding the rectum

that can result in lower GI bleeding

b. Can be caused by conditions that increase pressure on or cause irritation of the

rectum

i. Causes of increased pressure include:

(a) Pregnancy


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(b) Straining at stool

(c) Chronic constipation

ii. Causes of irritation include:

(a) Anal intercourse

(b) Diarrhea

c. Hemorrhoids are divided into two types:

i. Internal: Painless but can prolapse (protrude from the anal canal)

ii. External: Painful and tend to have an area of swelling and clot formation

2. Assessment

a. Signs and symptoms include:

i. Bright red blood during defecation (hematochezia)

(a) Usually minimal and easily controlled

ii. Itching in the rectal area

iii. Small mass on the rectum

3. Management

a. Prehospital management is supportive.

i. Assess if a patient has a bleeding disorder or is taking anticoagulants.

ii. Obtain orthostatic vital signs to make sure the patient is hemodynamically stable.

b. In-hospital management may include creams.

c. Prevention includes eating a high-fiber diet and exercise.

G. Lower gastrointestinal bleeding: Anal fissures

1. Pathophysiology

a. Linear tears in the mucosal lining near and in the anus

b. Thought to be precipitated by large, hard stools

c. Other causes include Crohn disease, human immunodeficiency virus infection,

trauma, and anorectal cancer.

2. Assessment

a. Patients present with painful defecation.

i. Pain lasts for several minutes to several hours after the bowel movement.

ii. Because of pain, patients delay bowel movement, causing the feces to become

larger and harder and more painful, causing a vicious cycle.

3. Management

a. Prehospital care is supportive.

i. A 5-inch x 9-inch dressing can be placed over the anus to pad the area.

ii. Do NOT pack dressings into the fissure or anus.

b. In-hospital treatment is conservative.

i. Encourage patients to modify their diet, use analgesics if needed, take stool

softeners, and apply warm water after bowel movements.

ii. Most anal fissures heal without surgical intervention.


Emergencies


VII. Pathophysiology, Assessment, and Management of

Esophageal Pathologies

A. Esophagitis

1. Pathophysiology

a. Inflammation of the esophagus

b. Caused by an infectious process or by reflux of gastric secretions into the esophagus

i. Some medications can be irritating, as can chemotherapy or radiation therapy.

c. Effects are irritation and swelling regardless of underlying cause.

d. Dyspepsia (heartburn or choking) is the primary complaint.

2. Assessment

a. Expect dyspepsia with upper abdominal and lower chest pain.

b. Pain increases when patient bends or lies supine.

c. Symptoms include:

i. Water brash (bitter taste of gastric acid in the mouth)

ii. Dysphagia

iii. Odynophagia (painful dysphagia)

iv. Food impaction

(a) These later symptoms are more common in eosinophilic, medication-related,

and infectious esophagitis.

v. There are few physical signs directly related to this condition.

3. Management

a. Care is supportive in nature.

b. A confusing component of this condition relates to the symptom of chest pain.

i. It can be difficult to determine the cause of chest pain.

ii. Treat chest pain as myocardial infarction until proven otherwise.

c. For patients with dyspepsia, see the GERD section for management options.

d. For patients with dysphagia, see the esophageal stricture section for management

options.

B. Tracheoesophageal fistula

1. Pathophysiology

a. A fistula is an opening between two portions of the body or between a body part and

the outside of the body.

b. A tracheoesophageal fistula (TEF) is a connection between the esophagus and the

trachea.

c. Congenital or acquired

d. Common methods of acquisition are:

i. Cancer

ii. Trauma

iii. Iatrogenic means (caused by a medical procedure such as endotracheal

intubation)


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iv. Tumor with esophagus or trachea

v. Penetrating wound

e. TEF allows food to move from the esophagus into the trachea and eventually into the

lungs.

f. Serious consequences include:

i. Pneumonia

ii. Sepsis

g. The patient can die if left uncorrected.

h. To prevent TEF, patients receive a tracheotomy, which limits, but does not eliminate,

the risk of TEF.

2. Assessment

a. If TEF is due to cancer, the patient will present with:

i. Cough

ii. Fever

iii. Aspiration

iv. Excessive gas

v. Increased oral secretions

b. Patients who are intubated or have undergone a tracheostomy are more complicated

and may present with:

i. Decreased LOC

ii. Fever

iii. Sepsis of unknown origin

iv. Cough

3. Management

a. The main focus of the acute care of TEF patients is ensuring adequate ventilation and

managing potential sepsis.

b. Intubate as needed and reconfirm tube placement.

c. Use waveform capnography to provide early evidence of a misplaced tube.

d. Elevate the patient’s head to manage secretions.

e. Administer IV fluids and vasopressors if the patient is septic.

f. This condition will eventually require surgical repair.

C. Esophageal stricture or stenosis

1. Pathophysiology

a. A stricture (or stenosis) is an abnormal narrowing of a structure.

b. The esophagus can become narrowed as a result of:

i. Inflammation

ii. Tumors

iii. Infection

iv. Acid reflux

c. As the diameter of the esophagus diminishes, it becomes more difficult for the person

to swallow.

2. Assessment


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a. Most patients have a history of multiple episodes of choking.

b. May present with:

i. Volumes of secretions

ii. Sensation of choking

iii. Dysphagia that can progress to odynophagia

iv. Difficulty in breathing

v. Inability to speak

vi. Difficulty in managing oral secretions

3. Management

a. The main concern with esophageal strictures is airway compromise.

b. The patient may aspirate or have an obstruction.

c. Ensure the patient has a stable airway.

i. If the airway is stable, aggressive attempts at removal of the obstruction are not

needed.

ii. If the patient is unable to move air effectively, then treat the situation as an

airway obstruction and manage it appropriately.

d. Consider glucagon for patients with esophageal obstruction.

i. Causes dilation of the esophagus and helps allow obstructions to pass

ii. Glucagon has a limited effect on strictures (contact medical control to use the

medication for this purpose).

e. Have the patient sit upright.

f. Be prepared to assist with oral secretions.

g. If the patient has cleared the obstruction by your arrival, encourage the patient to go

to the emergency department.

VIII. Pathophysiology, Assessment, and Management of

Acute Inflammatory Conditions

A. Inflammation is a natural response to injury.

1. The purpose of inflammation is to help white blood cells in destroying or sealing off an

invading agent.

2. A change in vascular permeability and vasodilation causes redness and swelling.

a. Enables white blood cells to more effectively get to the area of damage

3. Inflammation in the GI system can occur at many levels.

a. Localized inflammation will cause localized signs and symptoms.

b. Patients with hepatitis (inflammation of the liver) usually have abdominal pain in the

right upper quadrant.

c. Patients with peritonitis (inflammation of the peritoneum) experience generalized

abdominal pain.

4. If peritonitis is caused by infection, bacteria may move into the bloodstream (sepsis).

a. The body responds to sepsis with a generalized inflammatory response.

b. A severe consequence is the depletion of resources to manage the infection.


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i. If a balance cannot be restored, death will occur.

5. Many of the diseases of the GI system are caused by inflammation.

a. Autoimmune condition: The body attacks and kills its own cells for no defined

reason.

B. Peritonitis

1. Pathophysiology

a. If an infectious agent can gain access to the peritoneum, this lining can become

inflamed.

b. Two main ways that infections occur are through:

i. The rupture of an internal organ

(a) Examples: appendicitis, ruptured bowel

ii. The movement of bacteria out of the intestines

(a) Ascites, or abdominal edema, is associated with this condition

c. In either case, the bacteria are able to flourish, and it does not take long until sepsis

can occur.

2. Assessment

a. Peritoneal irritation is displayed through abdominal pain.

i. Pain tends to be diffuse, with a focal point over the area of greatest irritation.

(a) For bowel rupture, the pain may be focused over the left upper quadrant.

(b) In appendicitis, the pain may be focused over the right lower quadrant.

(c) For a ruptured diverticulum, the pain may be focused over the left lower

quadrant.

ii. Pain will often:

(a) Increase with coughing (Dunphy sign)

(b) Be rebound in nature

iii. Symptoms include:

(a) Abdomen will be board-hard.

(b) Patients are often febrile and want to lie in a fetal position.

(c) Tachycardia, anorexia, nausea, vomiting, and dehydration also occur.

(d) These patients are at risk for both hypovolemic shock and septic shock.

3. Management

a. Patients are critically ill.

b. Management is directed at supporting vital signs.

c. Treat the patient for shock.

d. Be prepared to administer several fluid boluses to maintain blood pressure.

e. Norepinephrine may be indicated if sepsis is present.

f. Measure the patient’s lactate level to determine the state of generalized body

perfusion.

g. Antiemetics are indicated.

i. In cases of sepsis, do not use analgesics.

h. In-hospital management involves surgery, treatment with antibiotics, and support of

vital signs.


Emergencies


C. Cholecystitis and biliary tract disorders

1. Pathophysiology

a. Biliary tract disorders involve inflammation of the gallbladder, and include:

i. Cholangitis (inflammation of the bile duct)

ii. Cholelithiasis (stones in the gallbladder)

iii. Choledocholithiasis (at least one gallstone within the common bile duct)

iv. Cholecystitis (inflammation of the gallbladder)

v. Acalculous cholecystitis (inflammation of the gallbladder without gallstones

present)

b. Gallstones are believed to be caused by increased production of bile or decreased

emptying of the gallbladder.

c. Gallbladder inflammation may arise from decreased flow of biliary materials from:

i. Major trauma

ii. Sepsis

iii. Sickle cell disease

iv. Prolonged fasting

d. Risk factors include:

i. Women (two to three times more than men)

ii. Caucasians (more likely than African Americans)

iii. Older people

iv. Overweight or obesity

v. Extreme weight loss

e. The “five Fs” of cholecystitis related to people who have this condition most often

are:

i. Fair (Caucasian)

ii. Fat

iii. Female

iv. Fertile

v. Forty to fifty

2. Assessment

a. Classic pattern includes:

i. Two to three hours after eating a fatty meal, severe upper right quadrant

abdominal pain develops.

b. The abdominal pain can be quite severe.

c. In addition to the pain, the patient may demonstrate a positive Murphy sign.

i. Ask the patient to breathe out.

ii. Then take the tips of your fingers and palpate deeply along the intercostal margin

of the right upper quadrant.

iii. Ask the patient to inhale deeply.

iv. As inspiration continues, the diaphragm will drop and eventually come into

contact with the gallbladder.


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v. If the patient has cholecystitis, he or she may suddenly stop inspiring because of

a sharp increase in pain—a positive Murphy sign.

d. Other symptoms include nausea, vomiting, fever, tachycardia, and Charcot triad

(fever, right upper quadrant pain, jaundice).

3. Management

a. Prehospital management should focus on making the patient comfortable.

i. Pain medications include opiates.

ii. Medication for nausea is often necessary.

iii. If the patient has been vomiting, IV fluids may be necessary.

b. In-hospital treatment includes:

i. Antibiotics

ii. Pain medication

iii. Ultrasound

iv. Potential removal of the gallbladder through surgery

D. Appendicitis

1. Pathophysiology

a. Occurs when fecal or other matter builds up in the appendix, causing pressure

increase

b. Unless treated, the build-up of pressure will eventually cause the organ to rupture,

resulting in:

i. Peritonitis

ii. Sepsis

iii. Death

2. Assessment

a. Appendicitis is difficult to diagnose.

b. Classic presentation is divided into three stages:

i. Early—periumbilical pain, nausea, vomiting, low-grade fever, loss of appetite

ii. Ripe—pain in lower right quadrant (McBurney point)

iii. Rupture—decrease in pain (decrease in pressure); generalized pain, rebound

tenderness

c. It takes about 48 hours to progress from the early stage to the ripe stage.

d. If the appendix ruptures

i. Infectious material has access to the entire abdominal cavity.

ii. Pain becomes generalized throughout the abdomen.

iii. Signs of peritonitis

(a) Dunphy sign: Severe abdominal pain in the right lower quadrant with

coughing

(b) Rovsing sign: Pain in the right lower abdominal quadrant upon palpation of

the left lower abdominal quadrant

e. Patients will have an elevated white blood cell count and C-reactive protein levels.

f. Ultrasonography and CT help in diagnosing.

3. Management


Emergencies


a. Prehospital management includes an assessment for septicemia.

b. Volume resuscitation may not be adequate.

i. Use norepinephrine if crystalloids are not effective.

ii. Administer pain and antinausea medications.

c. In-hospital treatment includes:

i. Antibiotics

ii. Surgical removal of the appendix

E. Diverticulitis

1. Pathophysiology

a. Diverticulum: Weak area in the colon that begins to have outcroppings that turn into

pockets (diverticula)

b. Diverticulosis: Condition of having diverticula

c. Diverticulitis: Inflammation of diverticuli

d. A diet low in fiber creates more solid stool.

i. This hard stool increases colon pressure, resulting in bulges in the colonic wall.

ii. As feces travels through the colon, some of it may be trapped in these diverticula,

causing inflammation and infection, which can cause:

(a) Scarring

(b) Adhesions

(c) Fistula: Abnormal connection between two cavities

2. Assessment


i. Abdominal pain, usually localized on the left lower abdomen

ii. Classic infection signs (fever, malaise, body aches, chills, nausea, vomiting)

iii. Constipation or diarrhea

b. Adhesions can develop, narrowing the diameter of the colon

i. Can result in constipation and bowel obstruction

3. Management

a. Focuses on making the patient comfortable

b. Ensure severe infection is not present.

c. Patients may need fluids and/or norepinephrine to maintain blood pressure.

d. In-hospital treatment includes:

i. Antibiotics

ii. Allowing GI tract to rest by giving a liquid diet

iii. Surgery to remove pouches and repair fistulas

F. Pancreatitis

1. Pathophysiology

a. Pancreatitis (inflammation of the pancreas) occurs when the tube carrying enzymes

produced by the pancreas becomes blocked, leading to autodigestion of the pancreas.

b. Can occur suddenly or over many months

c. May be single or episodic attacks with remissions


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d. Causes include:

i. Increased alcohol consumption

ii. Gallstones

iii. Medication reactions

iv. Trauma

v. Cancer

vi. High triglyceride levels

2. Assessment


i. Sharp and sometimes severe pain in the epigastric area

ii. Pain radiating to the back

iii. Nausea

iv. Vomiting

v. Fever

vi. Tachycardia

vii. Hypotenstion

viii. Muscle spasms caused by hypocalcemia

b. Internal hemorrhage is a concern, and may be indicated by:

i. Cullen sign (bruising around the umbilicus)

ii. Grey Turner sign (bruising in the flanks)

c. Higher levels of lipase and amylase indicate more severe damage.

3. Management

a. Directed by general management guidelines

b. Assess for signs of severe hemorrhage.

i. If present, begin fluid resuscitation.

c. Meperidine is the better choice for pain management, in case of gallstones.

d. In-hospital management includes:

i. GI rest

ii. Fluid resuscitation

iii. Antibiotics

iv. Surgery to control bleeding or manage gallstones

IX. Pathophysiology, Assessment, and Management of

Chronic Inflammatory Conditions

A. Patients who have chronic inflammation of all or part of the GI tract are said to

have inflammatory bowel disease (IBD).

1. This broad definition covers both ulcerative colitis and Crohn disease.

2. In both conditions, this inflammation causes damage to the wall of the GI tract and places

patients at greater risk for cancer.

a. A similar sounding condition, irritable bowel syndrome (IBS), is different.


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i. Does not cause structural changes to the walls of the GI tract

B. Ulcerative colitis

1. Pathophysiology

a. Caused by a generalized inflammation of the colon

i. Causes a thinning of the intestinal wall and a weakened, dilated rectum

ii. Leaves colon prone to infections by bacteria and bleeding

b. Often peaks between ages 15 and 25 years and between 55 and 65 years

c. More prevalent in women than men

d. One in six patients reports a family member also having the disease.

2. Assessment


i. Gradual onset of bloody diarrhea

ii. Discharge of mucus via the rectum

iii. Hematochezia

iv. Mild to severe abdominal pain

v. Tenesmus (feeling of rectal fullness)

vi. Joint pain

vii. Skin lesions

viii. Infection symptoms (fever, fatigue, and loss of appetite)

3. Management

a. Determine the degree of hemodynamic instability.

b. Look for signs of shock.

c. If diarrhea or bleeding has caused sufficient volume loss, administer fluids.

d. Follow the general management guidelines.

e. In-hospital care includes:

i. Anti-inflammatory medications

ii. Antibiotics

iii. Antidiarrheals

iv. Surgical removal of diseased sections of the colon

C. Crohn disease

1. Pathophysiology

a. Similar to ulcerative colitis, but it usually involves the entire GI tract, especially the

ileum.

b. The presence of signs and symptoms outside the GI system supports the theory of an

autoimmune component behind the disease.

c. Family history and genetics play a role in the disease.

d. A series of autoimmune attacks leaves a scarred, narrowed, stiff, and weakened

portion of the small intestine, which can cause bowel obstruction.

2. Assessment


i. Chronic abdominal pain, usually in the lower right quadrant


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ii. Rectal bleeding

iii. Weight loss

iv. Diarrhea

v. Arthritis

vi. Skin problems

vii. Fever

b. Episodes may be mild to severe.

c. Coincidence with arthritis and arthralgia—patients often report hip, knee, and ankle

pain.

3. Management

a. Prehospital care should focus on general management guidelines, including:

i. Volume resuscitation if necessary

ii. Control of nausea and pain

b. In-hospital care focuses on:

i. Stopping the inflammation

ii. Correcting fluid imbalances

iii. Managing infections

iv. Creating an environment where the GI tract can heal itself

D. Irritable bowel syndrome (IBS)

1. Pathophysiology

a. Patients present with abdominal pain and bowel habit changes at least three days a

month for at least three months.

b. Pathology is unclear, but normal bacteria found within the small bowel may

overgrow, causing pain, distension, and changes in bowel habits.

c. Patients often show the following three factors:

i. Hypersensitivity of bowel pain receptors

ii. Hyperresponsiveness of the bowel’s smooth muscle, which produces cramping

and diarrhea

iii. Psychiatric disorder connection with IBS

d. Hyperresponsiveness of the bowel can cause areas of spasm.

i. Can stop fecal movement, creating constipation and bloating

ii. Can cause feces to move too quickly, causing diarrhea

e. Typically begins during childhood

f. Can be triggered by stress and is often associated with eating

2. Assessment

a. Although IBS is a chronic condition, you will typically be called when the patient is

having a flare-up of symptoms.

b. Signs and symptoms tend to be individualized, but patients may present with:

i. Abdominal pain or discomfort (diffuse, nonradiating)

ii. Diarrhea

iii. Steatorrhea

iv. Constipation


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v. Bloated feeling

3. Management

a. Management is mainly supportive.

b. Assessment should include the patient’s mood.

i. If depression and/or suicide are noted, treat accordingly.

c. Analgesia may be needed.

X. Pathophysiology, Assessment, and Management of

Acute Infectious Conditions

A. GI infection generally occurs when contaminated food is ingested or when the GI

tract ruptures.

1. According to the Centers for Disease Control and Prevention, each year approximately 48

million people in the United States get a foodborne illness.

a. Approximately 3,000 die.

b. People who have a more difficult time combating infection include those who are:

i. Immunocompromised

ii. Very old

iii. Very young

c. Traveling to other countries can also place patients at greater risk for food

intolerances and infections.

2. Infection can also be caused by damage to the GI system allowing GI contents to be

released into surrounding tissues.

3. As the infection continues, peritonitis and sepsis can occur.

B. Acute gastroenteritis

1. Pathophysiology

a. Family of conditions involving infection with fever, abdominal pain, diarrhea,

nausea, and vomiting

b. Can be caused by various organisms that typically enter the body via the fecal-oral

route (contaminated food or water)

c. The norovirus is often the cause in adults, while the rotavirus is often the cause in

children.

i. The majority of patients who die from gastroenteritis are infected with either

Norovirus or Clostridium difficile.

2. Assessment

a. Patients may show symptoms anywhere from several hours to several days after

contact.

b. The disease can last two or three days, or several weeks.

c. Signs and symptoms include:

i. Diarrhea of various types

ii. Abdominal cramping

iii. Nausea and vomiting


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iv. Fever

v. Anorexia

d. Patients with diarrhea should be assessed for dehydration, hemodynamic instability,

and electrolyte imbalance.

i. Watch for changes in LOC and signs of shock.

ii. Severely dehydrated patients can demonstrate skin tenting, weight loss

tachycardia, orthostatic hypotension, and dry mucous membranes.

3. Management

a. Prehospital management is directed by the general management guideline.

i. Determine the degree of fluid deficit.

ii. Rehydrate the patient.

iii. Obtain orthostatic vital signs to check if fluid resuscitation with isotonic fluids is

necessary.

iv. Perform cardiac monitoring.

v. Analgesic and antiemetic medications may be necessary.

vi. Teach patients about safe food and water use.

b. Protect yourself from contamination by vomit or stool. Use:

i. Gloves

ii. Gowns

iii. Masks

c. In-hospital care includes:

i. Rehydration

ii. Control of vomiting and diarrhea

iii. Identification of the organism involved

iv. Antibiotic therapy

v. Stabilization of electrolyte imbalances

C. Rectal abscess

1. Pathophysiology

a. Caused when the ducts carrying mucus to the rectal area become blocked

i. Allows bacteria to grow and spread to the anus

2. Assessment

a. Symptoms may include:

i. Rectal pain that increases with defecation, then fades

ii. Fever

iii. Itching (pruritus)

iv. Rectal drainage

v. Constipation due to patients putting off defecation because of pain

3. Management

a. Prehospital management should focus on keeping the patient comfortable while

transporting.



Emergencies


i. Surgery

ii. Drainage

iii. Repair

iv. Antibiotics

D. Liver disease: Cirrhosis

1. Pathophysiology

a. Few portions of the body can operate normally without a functioning liver.

b. The liver may be damaged by:

i. Infection (hepatitis)

ii. Direct trauma

iii. Toxic ingestion

iv. Autoimmune disorders

c. Cirrhosis is early liver failure, which may be hallmarked by:

i. Portal hypertension

ii. Deficiencies with coagulation

iii. Diminished detoxification

2. Assessment

a. The first clinical stage includes the following signs and symptoms:

i. Joint aches

ii. Weakness

iii. Fatigue

iv. Nausea and vomiting

v. Anorexia

vi. Urticaria

vii. Pruritus (itching)

b. As the disease progresses to further damage to the liver, symptoms and signs of the

second clinical stage appear:

i. Acholic stools

ii. Darkening of the urine

iii. Jaundice

iv. Icteric conjunctiva (yellow eyes)

v. Ascites

vi. Right upper quadrant abdominal pain

vii. Enlarged liver

viii. Dilation of blood vessels on abdomen surface

c. Common blood tests to gauge liver function include:

i. Aminotransferases

ii. Alkaline phosphatase

iii. Albumin

iv. Bilirubin

d. Coagulation studies determine the effect of the liver on coagulation.


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3. Management

a. Prehospital care should be supportive, following general management guidelines.

i. Focus involves bleeding control and medication administration.

ii. Use lower ends of medication dose range because the drugs will remain active

longer when the liver’s detoxification abilities are impaired.

b. In-hospital treatment includes supporting liver function.

i. Liver transplantation may be needed.

E. Liver disease: Hepatic encephalopathy

1. Pathophysiology

a. Brain impairment due to diminished liver function

b. Underlying causes may include:

i. Increased levels of ammonia, which affect neurons

ii. Diminished cellular energy supplies

iii. Change in blood-brain barrier permeability

2. Assessment

a. Symptoms can range from mild memory loss to coma.

b. Patients may present with:

i. Attention deficits

ii. Inability to concentrate

iii. Impaired complex reasoning

iv. Disorientation

v. Impaired behavior

vi. Incomprehensible speech

vii. Bradykinesia

viii. Shuffling gait

ix. Tremor

c. Clinical findings are more important than laboratory results.

i. Ammonia levels are not a good indicator of the severity of impairment.

ii. CT and MRI results are inconclusive.

d. May be precipitated by:

i. Infection

ii. Renal failure

iii. GI bleeding

iv. Constipation

e. Opiates, benzodiazepines, and psychotropic medication can make symptoms worse.

3. Management

a. Treatment is mainly supportive.

b. Ensure that LOC status is not from some other cause.

i. Check blood glucose levels, and assess for trauma and overdose.

ii. Take a medical history, focusing on:

(a) Infections


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(b) Renal function

(c) Bleeding

(d) Constipation

c. In-hospital treatment is geared toward:

i. Decreasing ammonia levels

ii. Managing the altered LOC

d. There is no definitive treatment other than liver transplantation.

XI. Pathophysiology, Assessment, and Management of

Obstructive Conditions

A. Obstructions within the GI system can occur anywhere from the oropharynx to

the rectum.

1. Rectal obstructions tend to occur in young men and the obstruction is usually a foreign

body.

2. Esophageal obstructions also tend to be caused by foreign bodies, but the population

tends to be children.

B. Bowel obstruction is a condition in which the intestines are unable to move

material through the digestive tract.

1. Two main reasons:

a. Paralysis of the intestines from:

i. Infection

ii. Kidney disease

iii. Impaired blood flow

iv. Medications (ie, narcotics and anesthesia)

b. Intestinal lumen diameter compromise, which can be caused by:

i. Neoplasms

ii. Intestinal tumors

iii. Swallowed objects

iv. Strictures (narrowing due to damage in the intestinal wall)

v. Hernia (intestine trapped and compressed)

vi. Intussusception (telescoping of the intestines into themselves)

vii. Volvulus (twisting of the intestines)

C. Esophageal obstruction

1. Pathophysiology

a. Obstructions within the esophagus typically occur at either the upper esophageal

sphincter (UES) or the lower esophageal sphincter (LES).

b. When children accidentally swallow objects, they are typically age 18 to 48 months.

i. Location of entrapment is at the UES, and possible objects include:

(a) Coins

(b) Toy pieces


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(c) Buttons

(d) Marbles

c. Adults tend to have entrapment at the LES.

i. Object can be almost anything that can fit in the mouth.

ii. In 90% of cases, if the object reaches the stomach, it will pass through the

remainder of the GI tract.

2. Assessment

a. Dysphagia is the primary symptom in these patients.

b. Presentation will be markedly different depending on the age of the patient and how

the obstruction occurred.

c. The UES is located close to the cricoid cartilage.

i. The cricoid cartilage forms a 360° ring that prevents severe impingement from

the esophagus in the event of obstruction.

d. Signs and symptoms can include:

i. Difficulty in breathing

ii. Sense of choking

iii. Drooling

iv. Inability to swallow

v. Pain

vi. Vomiting

vii. Gagging

e. In approximately one-third of children, there are no symptoms until they try to eat.

3. Management

a. Airway patency is the primary concern for these patients.

b. Allow the patient to sit in a high Fowler position.

c. Be prepared to manage oral sections with suction and have an emesis basin ready.

d. Use eye protection, mask, and a gown if there is a risk of vomiting.

e. Look into the mouth to see if the object can be easily removed, but don’t fight the

patient to remove it.

f. Keep the patient calm and allow the emergency department to remove the object.

g. If the patient has obvious airway compromise (as evidenced by hypoxia, cyanosis,

and altered LOC), a more aggressive investigation may be indicated.

h. Consider administration of glucagon.

i. Contact online medical control to use the medication for this purpose.

i. In-hospital management includes removal of the object with:

i. Magill forceps

ii. Foley catheter

iii. Endoscopy

(a) Sedation and pain management are an integral part of these procedures

j. Encourage patients to seek medical care even if the object is cleared when you arrive.

D. Small-bowel obstruction

1. Pathophysiology


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a. Postoperative adhesions are the main cause of small-bowel obstruction.

i. Scarring (adhesions) can constrict the diameter of the intestine or decrease the

ability of the intestine to dilate.

b. Other causes include:

i. Cancer

ii. Crohn disease

iii. Hernias

iv. Foreign bodies

2. Assessment


i. Crampy and intermittent abdominal pain

ii. Initial diarrhea, nausea, and vomiting (may be feculent)

iii. Increased pressure, leading to increased peristalsis

iv. Constipation

v. Hyperactive bowel sounds (early stages of obstruction)

vi. Hypoactive bowel sounds (late stages of obstruction)

vii. Fever

viii. Tachycardia

ix. Changes in electrolytes

x. Sepsis

b. Ask if the patient has a history of abdominal surgery.

i. If patient is unresponsive or unreliable, look for a scar that could indicate

surgery.

ii. Can occur decades after surgery

c. Can cause several localized changes

i. Swelling

ii. Ischemia (in cases involving strangulated obstruction)

3. Management

a. Treatment is supportive, with a concern for sepsis.

i. Monitor blood pressure, and perform volume resuscitation.

ii. Administer dopamine as needed.

iii. Use a nasogastric tube to decompress the stomach of any material.

iv. Antiemetics are indicated.

v. IV fluids may be needed.


i. Antibiotic therapy

ii. Imaging studies

iii. Surgery if needed

E. Large-bowel obstruction

1. Pathophysiology

a. Caused by either mechanical obstruction or colon constricture


Emergencies


i. Common causes of mechanical obstruction include:

(a) Colon cancer

(b) Diverticulosis

(c) Volvulus (twisting of the bowel)

b. Imaging studies determine the location and extent of obstruction.

i. Once located, many can be easily treated.

c. Can lead to increased permeability of the intestinal wall, resulting in sepsis

d. If the condition is caused by cancer, an erosion of the bowel into adjacent cavities

can occur, resulting in:

i. Feculent discharge from the vagina

ii. Fecaluria (feces in the bladder being discharged with the urine)

2. Assessment


i. Abdominal pain

ii. Nausea and vomiting

iii. Distended abdomen

iv. Absent bowel sounds

v. Peritonitis signs (fever, tachycardia, and pain) if bowel has ruptured

vi. Recent unexplained weight loss (if related to cancer)

vii. Gradually increasing difficulty in having bowel movements

3. Management

a. Should be the same as for small-bowel obstruction

b. May be a greater need for fluid resuscitation

F. Abdominal wall hernia

1. Pathophysiology

a. Organ or structure protrusion into an adjacent cavity

b. To check for an inguinal (intestinal) hernia:

i. Place fingers on the wall of the patient’s lower abdomen.

ii. Instruct patient to cough.

iii. If there is a weakness in the abdominal wall, it can be felt as a bulge.

c. Over 1 million hernia repairs are done each year in the United States.

d. Can be caused by any condition that causes intra-abdominal pressure, such as:

i. Obesity

ii. Standing for long periods

iii. Heavy lifting

iv. Straining during bowel movements

v. Chronic obstructive pulmonary disease

2. Assessment

a. There are four types of hernias in the abdomen:

i. Reducible


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(a) Will return to normal location either spontaneously or by manual

manipulation

(b) Patient experiences little discomfort.

ii. Incarcerated

(a) Organ is trapped in its new location

(b) Common problem is bowel obstruction

iii. Strangulated

(a) Intestine is trapped and squeezed, causing a lack of blood supply to the area

(b) Patient experiences severe pain and sepsis

iv. Incisional

(a) Intestinal contents herniate through a surgical incision

(b) Similar to evisceration

3. Management

a. Prehospital treatment should focus on supportive measures, including pain

management.

i. Closely assess for sepsis.

b. In-hospital treatment is aimed at reducing the hernia.

G. Rectal foreign body obstruction

1. Pathophysiology

a. Interferes with defecation

b. Can be introduced from:

i. Upper GI tract

(a) Indigestible swallowed objects may have difficulty passing and become

lodged in the rectum.

ii. Anal insertion

2. Assessment

a. Upper GI tract origination presents with:

i. Sudden onset of rectal pain with defecation

ii. Possible peritonitis if the rectum has been perforated

b. Knowing what type of object was inserted and whether removal has been attempted

will help determine if the rectum has been perforated.

i. Ensure assault has not occurred.

c. Findings may be limited to patient’s report of pain.

3. Management

a. Do NOT attempt to remove the object.

b. Prehospital management should be limited to patient comfort.

i. Treat with analgesia if indicated.

ii. Closely monitor vital signs.

iii. Be compassionate and nonjudgmental.


Emergencies


XII. Pathophysiology, Assessment, and Management of

Ischemic and Neoplastic Disorders

A. Mesenteric ischemia

1. Pathophysiology

a. Interruption of the blood supply to the mesentery

b. Has four main causes:

i. Acute arterial embolism

(a) Tend to come from a cardiac thrombus

ii. Acute arterial thrombosis

(a) Patients have underlying thrombotic disease in the mesenteric arteries.

Plaque buildup narrows the lumen, which can suddenly close off.

iii. Profound vasospasm

(a) Can occur with the use of cocaine, ergot poisoning, norepinephrine, or in

severe shock

iv. Mesenteric venous thrombosis

(a) A thrombus forms in one of the mesenteric veins and prevents blood from

leaving the intestinal veins. Blood begins to pool and creates back pressure

that prevents fresh blood from entering the area. Tissues are starved of

oxygen.

2. Assessment

a. Gradual or sudden onset, depending on the cause

b. Symptoms include:

i. Severe abdominal pain with ill-defined location

ii. Nausea, vomiting, and diarrhea

iii. Possible blood in stool

c. A thorough history is necessary.

3. Management

a. Patients require rapid transportation.

b. Monitor closely, and check vital signs for sepsis.

c. Fluid resuscitation should be initiated in cases of shock.

d. If sepsis is the cause of hypotension, use vasopressors to stabilize blood pressure.

e. Analgesics may be needed.

f. In-hospital treatment includes imaging studies, possibly thrombolytics,

anticoagulants, and antibiotics.

B. Neoplasms

1. Medical term for growths or tumors within the body that serve no purpose and are caused

by errors that occur during cellular reproduction

a. The altered cell reproduces and copies the error to its own daughter cells.

2. Categorized as either benign or malignant and primary or metastatic


Emergencies


3. Any portion of the GI system can develop a neoplasm or cancer.

C. Tumors of the colon

1. Pathophysiology

a. Colon, or colorectal, cancer is the most common form of cancer within the GI

system.

b. Cause is multifactorial.

c. Risk factors:

i. Diets high in red meat and low in fiber

ii. Smoking

d. Strong correlation between heredity and colorectal cancer.

e. Inflammatory bowel diseases, ulcerative colitis, and Crohn disease are also

associated with increased risk for colorectal cancer.

2. Assessment

a. Most common signs:

i. Abdominal pain, rectal bleeding, and changes in bowel habits

b. Screening catches many cancers before symptoms begin.

c. If cancer is found on the right side of the colon, patients tend to have bleeding and

diarrhea.

d. Left-sided tumors tend to cause obstruction.

3. Management

a. Care is supportive.

b. Resection of the colon may be needed.

c. Colostomy may be required.

D. Pancreatic tumors

1. Pathophysiology

a. The pancreas is located centrally in the upper abdomen and comprises both exocrine

and endocrine cells.

i. The vast majority of malignancies in this organ occur in the exocrine cells.

b. Causes include:

i. No direct cause (40%)

ii. Smoking (30%)

iii. Diet (20%)

iv. Heredity (10%)

c. Patients with diabetes may have an increased risk of pancreatic cancer.

2. Assessment

a. Gradual, insidious presentation that is often mistaken for other benign conditions

b. Common symptoms include:

i. Malaise

ii. Fatigue

iii. Nausea

iv. Vomiting


Emergencies


v. Midepigastric pain

vi. Back pain

vii. Anorexia and weight loss

c. Cancer on the head of the pancreas can cause obstruction of bile flow from the

gallbladder.

i. This will result in:

(a) Darkening of the urine

(b) Pale-colored stool

(c) Steatorrhea

d. Depression is more common in pancreatic cancer than any other abdominal cancer.

e. If the cancer has metastasized, it can lead to hepatic cancer and resultant liver failure.

3. Management

a. Care is supportive in nature.

b. This cancer is particularly fatal.

c. Many of these patients will have a living will, do not resuscitate (DNR) order, or will

be on hospice, so learn the wishes of the patient and family.

E. Hepatic tumors

1. Pathophysiology

a. Cancer of the liver is rare, but is more common among men.

b. Primary liver cancers within the United States are associated with cirrhosis.

c. Risk factors:

i. Alcohol consumption

ii. Hepatitis B and C

2. Assessment

a. The patient will likely have already been diagnosed prior to EMS involvement.

b. Expect the following symptoms:

i. Pruritus

ii. Jaundice

iii. Splenomegaly

iv. Cachexia (profound malnutrition and weight loss)

v. Ascites

vi. Abdominal pain

c. Patients may also experience the signs and symptoms related to cirrhosis and hepatic

encephalopathy.

3. Management

a. Supporting vital signs is critical.

b. Perform ECG monitoring.

c. Check potassium levels if possible.

d. Airway protection may be needed.

e. Perform positive pressure ventilation if patient shows signs of respiratory distress.


Emergencies


f. If administering medications, choose the lower end of the accepted range or increase

the time between doses.

g. Resectioning the liver (removal of a portion of the liver) may be necessary.

h. Talk with the patient and his or her family to determine whether there is an advance

directive (living will/DNR/medical power of attorney).

i. In-hospital care:

i. Supporting the patient’s vital signs

ii. Liver transplantation

XIII. Prevention Strategies

A. Because EMS is growing from delivery of 9-1-1 services to augmenting

nonemergency health care, it is important to consider prevention of disease.

1. Many patient behaviors can prevent or limit the severity of GI diseases, including:

a. Eating a diet high in fiber and low in fat

b. Eliminating smoking and controlling alcohol consumption

c. Lowering stress by meditation, exercise, and relaxation techniques

Post-Lecture

This section contains various student-centered end-of-chapter activities designed as

enhancements to the instructor’s presentation. As time permits, these activities may be presented

in class. They are also designed to be used as homework activities.

Assessment in Action

This activity is designed to assist the student in gaining a further understanding of issues

surrounding the provision of prehospital care. The activity incorporates both critical thinking and

application of paramedic knowledge.

Instructor Directions

1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the

end of Chapter 20.

2. Direct students to read and individually answer the quiz questions at the end of the

scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class

review and dialogue of the answers, allowing students to correct responses as may be

needed. Use the quiz question answers noted below to assist in building this review.

Allow approximately 10 minutes for this part of the activity.

3. You may want to ask students to complete the activity on their own and turn in their

answers on a separate piece of paper.


Emergencies


Answers to Assessment in Action Questions

1. Answer: B. Transports blood to the liver

Rationale: The portal vein is a plexus of veins that start in the abdominal viscera and

transport blood to the liver.

2. Answer: B. Esophagogastric varices

Rationale: Esophagogastric varices occur when the liver is sufficiently damaged to

restrict blood flow through the portal vein. This causes a backup into the esophagus

where leaking in the capillary network occurs.

3. Answer: C. Hematochezia

Rationale: Hematochezia refers to stool and blood that are incorporated together into the

same substance yet are easily distinguished from each other. This indicates lower GI

bleeding because the blood has the more typical red color.

4. Answer: A. Suction

Rationale: The most important step in managing this patient’s airway is adequate

suctioning. Insertion of a dual-lumen airway is contraindicated by the presence of

esophagogastric varices. Endotracheal intubation is the airway of choice once you can see

the vocal cords for placement. Oxygen is always beneficial; however, this patient will

need a definitive method of airway control to be effective.

5. Answer: D. Murphy sign

Rationale: Applying pressure near the liver and gallbladder while the patient breathes in

allows the diaphragm to come into contact with the gallbladder, causing a sudden

increase in pain. This is called a positive Murphy sign and indicates the patient has

cholecystitis.

6. Answer: B. Pancreatitis

Rationale: The enzymes the pancreas creates are designed to break down food into

substances that can be absorbed by the intestines. What happens if the tube carrying these

enzymes becomes blocked? The enzymes activate, and they begin to do their job. They

break down the protein and fat of the pancreas itself. This is referred to as autodigestion

of the pancreas. Inflammation of the pancreas, or pancreatitis, occurs. This process can

occur suddenly or over many months. Patients can have singular attacks or episodes of

attacks and retreats for a long time.

7. Answer: A. Palms

Rationale: Paleness can be difficult to detect in patients based on race, skin conditions,

and sun exposure. The palms will show paleness regardless of those variables.

8. Answer: D. Impairs the ability to form clots

Rationale: The effects of alcohol on the body are many and varied. Alcohol impairs

coagulation, therefore making it difficult for this patient’s hemorrhage to clot. Alcohol

increases urine production, resulting in dehydration. It also causes tachycardia, not

bradycardia. Finally, alcohol can affect the spleen both through direct means (cell


Emergencies


damage) and indirect means (liver failure). However, there is no evidence that this

prevents the spleen from contracting during shock.

9. Rationale: As with any patient, your initial priorities of management include addressing

problems with airway, breathing, and circulation. Any acute condition related to the

abdomen, chest, or nervous system warrants high-flow oxygen—regardless of room air

oxygen saturation.

Your patient’s presenting complaint of right upper quadrant pain is suggestive of

cholecystitis—an inflamed gallbladder. However, it could also indicate other intra-

abdominal conditions. Further management should consist of vascular access, with

isotonic crystalloid fluids given as needed to maintain adequate perfusion (ie, radial

pulses, adequate mental status), and transport to the hospital. Allow the patient to assume

a position of comfort—usually with his or her knees drawn into the abdomen—as this

may provide some pain relief by taking pressure off of the abdominal musculature.

Pain management is an important part of prehospital care. Not only is pain

psychologically distressing, it also increases oxygen demand and consumption—a

potentially unhealthy situation. Analgesia not only addresses the negative psychological

effects of pain and anxiety, it also addresses the potentially negative hemodynamic

effects.

If a patient is in severe pain, and his or her vital signs are stable, it is reasonable to

administer a narcotic analgesic (ie, morphine, fentanyl), regardless of the anatomic

location of the pain. Remember, the care provided by the paramedic is not limited to the

physical condition; the associated psychological effects of pain and anxiety should be

addressed as well. Follow your local protocols or contact medical control as needed

regarding the prehospital use of narcotic analgesics.

10. Rationale: Many paramedics are male, so assessing a female can be uncomfortable.

Couple this with the age of the child and the perceived difficulty increases. Ways to

manage these include:

• Have a female provider assess the patient if possible.

• Ensure as much privacy as possible.

• Ask the patient if she would like her parent to stay while you assess her.

• Be matter-of-fact with the assessment.

• Save the abdominal assessment for last.

This patient will need to answer all of the SAMPLE and OPQRST questions, including

potentially embarrassing ones such as last menstrual period, sexual activity, and method

of birth control. When asking, “Could you be pregnant?” you will need to explore more

deeply if the patient states a simple “no.” Ask her why she could not be pregnant. You

may need to enlist the help of the mother (parent) or separate her from her parent.

Teenagers are at a crossroads between childhood and adulthood. Adolescents will often

transition between stages depending on the situation. If they are stressed, they may

regress and act more childlike; when they are comfortable, they will act more adultlike.

You need to be flexible. Read the child and be ready to adjust.


Emergencies


Assignments

A. Review all materials from this lesson, and be prepared for a lesson quiz to be

administered (date to be determined by instructor).

B. Read Chapter 21, Genitourinary and Renal Emergencies, for the next class

session.

abdominal and gastrointestinal emergencies

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