Abdominal Emergencies

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Abdominal Emergencies

• Paramedic Program
• Chemeketa Community College

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Abdominal Emergencies

• Abdominal pain is a frequent complaint.
• Most difficult to dx
• Relies greatly on History
• Physical Exam may be helpful, always necessary

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Abdominal Emergencies, cont.

• Pathophysiology of abdominal pain
• Bacterial/viral Infection
• Chemical Irritation
• Circulatory compromise
• Trauma
• Tumor
• Obstruction

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Types of Pain

• Somatic and Visceral
• Merge in nerve pathway to brainDifficult to
  differentiate but
• Visceral are more cramping and diffuse
• e.g. Gas pains
• Somatic is more constant and localized
• e.g. Peritonitis

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Anatomy 101

• Abdomen - largest body cavity
• Separated by diaphragm and artificial plane at
  pelvis
• Bordered by spine and abdominal wall
• Quadrants

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Anatomy

• LUQ
• Spleen
• Pancreas (retroperitoneal)
• Stomach
• Left kidney (retroperitoneal)
• Splenic flexure of colon

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Anatomy

• RUQ
• Liver
• Gall bladder
• Head of pancreas
• Duodenum
• Right kidney (retroperitoneal)
• Hepatic flexure of colon

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Anatomy

• RLQ
• Appendix (supposed to be here)
• Ascending colon,
• Small intestine
• Right ovary, Fallopian tube
• LLQ
• Small intestine
• Descending colon,
• Left ovary, Fallopian tube

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• Flank lateral abdomen
• Peritoneal membrane lining the abdomen
• Most organs within peritoneum
• Retroperitoneal kidneys, part of duodenum, part
  of pancreas.

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• Solid organs
• Liver
• Spleen
• Pancreas
• Kidneys
• Adrenals
• Ovaries

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• Hollow organs
• Stomach
• Intestines
• Gall bladder
• Urinary bladder
• Uterus

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GI System

• Mouth
• Esophagus
• Stomach
• Intestines
• Salivary glands

• Teeth
• Liver
• Gall bladder
• Pancreas
• Appendix

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Circulatory system (abdominal cavity)

• Descending aorta
• Superior mesenteric and inferior mesenteric
  arteries
• Aorta divides
• Iliac arteries
• Inferior vena cava
• Portal system

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Genitourinary System

• Kidneys
• Ureters
• Urinary bladder
• Urethra

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• Male reproductive system
• Testes
• Epididymis
• Prostate
• Vas deferens
• Urethra
• Penis

• Female reproductive system
• Ovaries
• Fallopian tubes
• Uterus
• Vagina
• Vulva

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Pain Referral

• Pain isnt always where it seems!
• Visceral nerve fibers are shared
• Pain shows up away from the source
• e.g. Shoulder pain from diaphragm

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Upper Gastrointestinal Bleeding

• Peptic ulcer disease
• Erosive gastritis
• Esophageal Varices
• Mallory-Weiss Tear
• Esophagitis
• Duodenitis
• Drug Ingestion

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Peptic Ulcer Disease

• Ulcers in lining of esophagus, stomach, or
  duodenum Loss of protective effects
• 5 x more common after age 50

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Ulcers

• If pain, usually ceases after onset of severe
  bleeding
• 70-90 caused by Helicobacter pylori
• Antibiotic therapy
• Pain usually located in epigastrium or LUQ.
• May improve after antacids
• Can cause an acute abdomen-rigid, board-like
• Mortality from 3 8

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Gastritis

• Inflammatory response - Gastric erosions
  secondary to increased gastric acid secretion
• Associated with alcohol ingestion, drugs, stress
• Pt. c/o epigastric pain, belching, indigestion,
  N/V

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Gastritis

• Caused by ASA, Steroids, Alcohol, NSAIDS, Burns,
  Sepsis, Trauma
• Pain improves after eating
• Gastric ulcer may develop
• Most common presentation
• Restless
• Pale, cool, moist skin
• Hypotension

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Varices

• Swollen veins in lower 1/3 of esophagus
• Secondary to portal hypertension
• Most common cause alcoholic cirrhosis
• Accounts for 10 of all hematemesis, melena
• Mortality 40-70
• Guess what drug they use to treat this acutely

Beta Blockers
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Esophagitis

• Common disorder, but uncommon cause of
  significant GIB
• Esophageal reflux common
• Melena more common presentation

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Mallory-Weiss Tear

• Distal esophagus or proximal stomach
• Laceration
• Most common causes
• Alcoholism and hiatal hernia
• Belching, vomiting, blunt trauma, seizures,
  coughing
• Multiple bouts of non-bloody emesis followed by
  sudden hematemesis
• Bleeding usually mild to moderate, stops
  spontaneously

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Duodenitis

• Mean age of presentation
• 49 years
• Melena or hematemesis
• common
• Hemorrhage often self-limited

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Drug ingestion

• Aspirin (even moderate use) increases risk
• Alcohol and Aspirin have a synergistic effect.
• NSAIDs can also cause gastric erosions

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Upper GI Bleeding

• Assessment findings
• Acute/chronic
• Vomiting/hematemesis
• Stool/melena
• Meal history
• Chest pain/gas pain
• Altered mentation
• Skin pale, cool, moist

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Upper GI (cont.)

• Most common presentation
• Acute
• Painless
• N/V/hematemesis
• Melena
• Hypotension, tachycardia, pale, cool, moist skin

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Causes of Acute Upper GI Bleeding

• Peptic ulcer disease (50)
• Varices (10)
• Hemorrhagic gastritis (25)
• Esophagitis
• Mallory-Weiss tear

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Upper GI Bleeding (cont.)

• Management
• Oxygen
• Positioning
• IV, consider fluid challenge
• Consider MAST
• Gastric lavage
• Transfusion
• Psychological support

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Lower Gastrointestinal Bleeding

• Diverticulitis
• Angiodysplasia
• Carcinoma
• Rectal Disease

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Diverticulitis

• Presents in 50 of patients gt 60 year old
• Inflammation in or around diverticula -
  Retention of food residue and bacteria
• Present like appendicitis
• Pt c/o abdominal pain,
• fever, vomiting, anorexia,
• tenderness

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Diverticulitis

• Tx antibiotics, diet changes, possibly surgery
• Bleeding Diverticulitis
• Presents as painless rectal bleeding, commonly
  left-sided abdominal pain
• Tx prevention of shock

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Angiodysplasia

• Acquired disorder of unknown cause
• Most commonly found in cecum and ascending colon
• AV malformations in 25
• of patients gt 65 years
• Melena
• Difficult to diagnose
• 10-15 Mortality

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Carcinoma

• Uncommon cause of major LGIB
• Presentation diverse
• Painless rectal bleeding
• Weight loss
• Abdominal pain
• Treatment is prevention of shock

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Rectal Disease

• Most common cause of rectal bleed
• Bright red bleeding
• Inflamed veins of anal canal

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Other Abdominal Emergencies

• Gastroenteritis
• Crohns Disease
• Appendicitis
• Perforated abdominal viscus
• Bowel Obstruction
• Pancreatitis
• Cholecystitis
• Hepatitis
• Aortic Aneurysm
• Renal Calculi

• UTI
• Pyleonephritis
• PID
• Renal Failure
• Ovarian cyst
• Ectopic pregnancy
• Mittelschmirz
• Testicular torsion
• Epididymitis

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Gastroenteritis

• Causative organisms
• Many viruses, parasites
• Contracted via fecal-oral transmission,
  contaminated food, water
• S/S
• N/V, fever, abdominal pain, cramping, anorexia,
  lassitude, shock

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Crohns Disease/ Ulcerative Colitis

• Idiopathic, chronic inflammatory disease of
  intestines
• Crohns - involves rectum small bowel
• Ulcerative Colitis rectum and small bowel spared

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Crohns Disease

• Inflammatory disorder, small and large bowel
• Increased t-cell activity
• Lesions, fistulas
• Risk factors - positive family history, stress
• Pt. presents with irritable bowel, diarrhea,
  weight loss

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Appendicitis

• Obstruction appendical lumen
• Ulceration appendiceal mucosa (viral/bacterial)
• Pt c/o RLQ abdominal pain onset acute, originates
  at umbilicus, migrates to RLQ
• Presentation with N/V, fever, anorexia, rebound
  tenderness
• Tx fluid replacement,
• prevention of shock, surgery

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Perforated Abdominal Viscus

• Causes include perforated ulcers or diverticulum
• Presentation
• sudden onset abdominal pain
• generalized tenderness
• rebound tenderness
• rigid abdomen
• shock
• Tx IV fluids, antibiotics, surgery

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Bowel Obstruction.

• Causes include tumors,
• ingestion of FB, prior
• abdominal surgery,
• fecal impaction
• Hx
• progressive anorexia,
• fever, chills, skin pale,
• cool, moist, peritonitis
• Acute/chronic, N/V/D/Unable
• Hypotension, tachycardia
• Tx fluid replacement, prevention of shock

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Pancreatitis

• Inflammation of pancreas due to digestion of
  gland by its own enzymes
• Associated with chronic alcohol abuse, elevated
  lipids

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Pancreatitis

• Patient complaints
• Abrupt onset abdominal pain, mid-abdomen
  radiating to back and shoulders
• N/V
• Hypotension, tachycardia
• Pale, cool, moist skin
• Tx IV fluids, pain meds, NG tube

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Cholecystitis

• Inflammation of the gallbladder
• Obstruction by a gallstone in gallbladder neck,
  cystic duct, or common bile duct

Six Fs
Female Fertile Fair Fat Forty Flatulent
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Cholecystitis

• S/S
• Pain in RUQ, worse after meals, esp. high-fat
• Flank pain common may radiate to genitals
• Antacids dont relieve pain
• Skin pale, cool, moist
• Fever
• Tx pain meds, surgery

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Hepatitis

• Caused by viral infections, alcohol, substance
  abuse
• S/S
• Dull RUQ tenderness
• Decreased appetite, N/V
• Fatigue, H/A, malaise, photophobia, pharyngitis,
  cough
• Clay-colored stool
• Skin Warm, rash, jaundice
• Tx symptomatically

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Aortic aneurysm

• Usually elder or Marfans, c/o diffuse abdominal
  pain and severe back pain tearing sensation
  pulsitile mass
• Tx oxygen, 2 large-bore IVs, PASG
• Rapid transport

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Renal calculi

• Urinary tract obstruction kidney stones most
  common
• Age range is 20-50 y/o, most common in spring and
  fall 3 x more common in males
• Causes UTI, immobilization, increased calcium,
  gout, tumors

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Kidney Stones

• Onset acute, intense in back or flank, testicles
• Presentation restless, dysuria, hematuria,
  nocturia, frequent urination, N/V
• Tx IV fluids, surgery, ultrasound shock waves
• Complications infection, total obstruction

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Urinary Tract Infection (UTI)

• Cystitis most common (bladder infection)
• More common in females
• Can cause pyelonephritis
• fever, chills, flank pain
• S/S dysuria, hesitancy, discolored urine, lower
  abdominal pain, mentation changes
• Tx antibiotics, fluids

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Pyelonephritis

• Ascension of bacteria from a lower UTI into renal
  parenchyma
• Women more prone until 5th decade
• Pt typically febrile, c/o flank or low back pain,
  chills, tenderness below 12th rib at vertebra
  (CVA tenderness)
• Tx IV antibiotics

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Renal failure

• Acute (overall mortality 50)
• Rapid, potentially reversible deterioration of
  kidney function-retention of nitrogenous waste
  products, electrolytes
• Causes reduced renal blood flow shock,
  dehydration, vasopressors, renal injury, enlarged
  prostate, tumor

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Acute Renal Failure

• S/S
• Onset within hours
• Normal kidney function rapidly deteriorates
• Urine output oliguria, anuria
• Generalized edema
• Acidosis
• Uremia
• High concentrations of uric acid, potassium
• Tx Dialysis

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Acute Renal Failure

• Pt presents
• Severe dyspnea, pulmonary edema,hypotension,
  tachycardia, EKG findings, pericarditis rub
• Edema, JVD, ascites, rales at bases, wasted
  appearance,skin pasty yellow, extremities thin
• Urea crystals on skin (late sign)
• Seizures, muscle twitching

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Acute Renal Failure

• Treatment
• Oxygen, fluids, supportive
• Dialysis

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Chronic Renal Failure

• A progressive, irreversible systemic disease
• Secondary to diabetes, hypertension, Rx,
  autoimmune disorders
• In later stages, requires dialysis or renal
  transplant

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Chronic Renal Failure

• GI
• Anorexia, N/V
• Cardiopulmonary
• HTN
• Pericarditis
• Pulmonary edema
• Peripheral, sacral, periorbital edema

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Chronic Renal Failure

• Nervous system
• Anxiety, delirium, progressive obtundation
• Hallucinations, muscle twitching, seizures
• Metabolic
• Glucose intolerence
• Electrolyte disturbances
• Anemia

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Chronic Renal Failure

• Personality changes
• Fatigue
• Mental illness
• Uremic signs
• Pasty, yellow skin discoloration
• Thin extremities from protein wasting
• Uremic frost

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Dialysis Emergencies

• Vascular access
• Bleeding at site of puncture
• Thrombosis
• Infection
• Hemorrhage
• Regular exposure to hemodialysis
• Decrease in platelet function

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Dialysis

• Hypotension
• May result from rapid reduction
• in intravascular volume
• Compensatory mechanisms impaired
• Manage cautiously with fluids
• (200-300ml fluid bolus)
• Chest pain
• PVCs

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Dialysis

• Severe hyperkalemia
• Life-threatening emergency
• S/S weakness
• Tall T-waves, conduction slows (prolonged PR
  interval), depressed ST segments, sometimes lost
  P-waves
• If renal patient in cardiac arrest, consider
  calcium and sodium bicarbonate infusions

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Dialysis

• Disequilibrium syndrome
• Results from a disproportionate decrease in
  osmolality of ECF
• Usually mild HA, restlessness, nausea, fatigue
• May be severe confusion, seizures, coma

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Dialysis

• Air embolism
• Results from negative pressure on the venous side
  of the dialysis tubing or malfunction in the
  machine
• Embolus may be carried to right ventricle
• S/S severe dyspnea, cyanosis, hypotension,
  respiratory distress.
• Tx with high concentration of oxygen

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Pelvic Inflammatory DiseasePID
fallopian tube

• An infection of the uterus,
• fallopian tubes, ovaries,
• adjacent structures
• Usually sexually transmitted
• Pt presents with fever,
• chills, lower abdominal pain, vaginal bleeding
  and/or discharge, pain on walking or intercourse
• Tx supportive

ovary
cervix
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Ruptured Ectopic

• Life threatening
• Any time during fertile years
• Mimics other sign and symptoms
• Ask the questions

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Ovarian cyst

• Generally asymptomatic until complicated by
  hemorrhage, torsion, rupture, or infection
• Fluid-filled sac on ovaries if ruptured, blood
  spills into abdominal cavity
• Pt presents with abdominal pain,either gradual or
  rapid
• Onset often with exercise, intercourse, trauma,
  or pelvic exam

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Mittelschmerz

• Caused by ovarian bleeding following ovulation
• Pain on ovulation
• severe pain rare

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Testicular Torsion

• Most patients have congenital abnormality of
  genitals generally bilateral
• Twisting of spermatic cord, cuts off blood supply
• Rotation occurs medially
• Vascular occlusion occurs and infarction after 6
  hrs

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Testicular Torsion

• Usually occurs in children and teenagers
• Previous occurrence predisposes pt.
• Pt presents with severe testicular pain, lower
  abdominal pain, swollen testicle, tender, higher
  in scrotum knot may be palpated above testicle
• Usually sudden onset
• Tx pain meds

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Epididymitis

• Cellular inflammation begins in vas deferens and
  descends to lower pole of epididymis
• Inflammation of epididymis, secondary to
  gonorrhea, syphilis, TB, mumps, prostatitis,
  urethritis, indwelling catheter.

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Epididymitis

• Pt presents with fever, chills, inguinal pain,
  swollen epididymis
• 2/3 will have atrophy
• 30 of post pubertal boys with mumps

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Assessment findings

• Scene size-up
• Safety
• PPE
• General Impression
• Trauma
• Medical

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Assessment

• Initial assessment
• Airway
• Breathing
• Circulation
• Disability
• Chief Complaint

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Assessment

• Focused history
• OPQRST
• Previous history of same event
• N/V
• Change in bowel habits/stool
• Constipation
• Diarrhea
• Melena

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Assessment

• Focused history
• Weight loss
• Last meal
• Chest pain
• Focused physical examination
• Appearance
• Posture
• Level of consciousness
• Apparent state of health

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Assessment

• Focused Physical Exam
• Skin color
• Vital signs
• Inspect abdomen
• Auscultate abdomen
• Percuss abdomen (if you dare)
• Palpate abdomen
• Female abdominal exam
• Male abdominal exam

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Management/Treatment Plan

• Airway and ventilatory support
• High flow oxygen
• Resp. status
• Circulatory support
• EKG/pulse
• Monitor B/P
• Pharmacological interventions
• IV
• Pain management, as appropriate (usually call for
  medical consult)

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Lets Talk About Pain!

• Old thinking - Dont Mask the Pain so the Doc
  can better diagnose!
• New we are the patients advocate! Help them to
  manage their pain
• Current diagnostic tools DONT need pain as a
  guide!
• So, why dont we help with the pain?

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Management, Treatment (cont.)

• NPO
• Monitor mentation
• Monitor vital signs
• Position of comfort
• Transport considerations
• Persistent pain for gt 6 hours requires transport
• Gentle but rapid transport
• Psychological support
• Calm, caring attitude

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Management

• Transport Considerations
• If it hurt bad enough to call you
• Remember that guy you saw last night and didnt
  transport? Do questions like this make you
  nervous?

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Abdominal Emergencies

• Abdominal pain is a frequent complaint
• Most difficult to diagnose
• Relies greatly on History
• Physical Exam may be helpful, always necessary

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