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Paramedic Care: Principles & Practice
Fourth Edition
Volume 4: Medicine
CHAPTER
6
Gastroenterology
Multimedia Directory
Slide 35
Digestive System Exercise
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Standard
• Medicine (Abdominal and
Gastrointestinal Disorders)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Competency
• 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.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• 500,000 gastrointestinal emergencies
every year.
• 300,000 due to gastrointestinal
bleeding.
• Last few years, number of patients over
60 risen from 3% to more than 45%.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Gastrointestinal (GI) emergencies
usually result from underlying
pathological process.
• Risk factors known to physicians; most
self-induced by patients.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Risk factors:
– Excessive alcohol consumption
– Excessive smoking
– Increased stress
– Ingestion of caustic substances
– Poor bowel habits
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Pain hallmark of acute abdominal
emergency.
• Three classifications of abdominal pain:
– Visceral
– Somatic
– Referred
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Visceral pain: originates in walls of
hollow organs (gallbladder or
appendix), in capsules of solid organs
(kidney or liver), or in visceral
peritoneum.
– Mechanisms that produce pain:
inflammation, distention ischemia.
– Cause varying intensities,
characteristics, locations of pain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Inflammation, distention, ischemia all
transmit pain signal from visceral
afferent neural fibers to spinal column.
– Often described as vague or poorly
localized, dull, or crampy.
– Many hollow organs first cause visceral
pain when distended.
– Then cause specific type of pain when
they rupture or tear.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Somatic pain: sharp type of pain that
travels along definite neural routes to
spinal column.
– Pain localized to region or area.
– Bacterial and chemical irritations of
abdomen commonly cause somatic pain.
– Degree of pain initially proportional to
spread of irritant through abdominal
cavity.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Referred pain: originates in region
other than where it is felt.
• Not true pain-producing mechanism.
– For example: dissecting abdominal
aortic artery, produces referred pain felt
between shoulder blades.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Referred pain patterns: (a) anterior.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Referred pain patterns: (b) posterior.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Assessment similar to trauma
assessment with expanded history.
• Ensure scene free and clear of any
apparent dangers.
• Always take Standard Precautions.
• Survey scene for potential evidence of
patient's problem (medication bottles,
alcohol containers, ashtrays, buckets
with emesis or sputum)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Look for mechanism of injury (MOI);
determine whether call is medical or
trauma.
• If trauma, immobilize cervical spine.
• Check responsiveness; airway patency.
• Evaluate respiratory functions; quickly
palpate pulse and check skin color,
temperature, and circulation, including
signs of bleeding and capillary refill.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• If life-threatening condition, treat it and
rapidly continue assessment to identify
any other life threats.
• Conduct secondary assessment.
• Conduct SAMPLE history (symptoms,
allergies, medications, past medical
history, last oral intake, events) and
more thorough history.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• OPQRST-ASPN history
– Onset
Sudden onsets generally caused by
perforations of abdominal organs or
capsules.
Gradual onset of pain associated with
blockage of hollow organs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• OPQRST-ASPN history
– Provocation/palliation
If pain lessens when patient draws legs
up to chest or lies on side, usually
indicates peritoneal inflammation.
If walking relieves pain, cause may be in
GI or urinary system.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• OPQRST-ASPN history
– Quality
Localized, tearing pain associated with
rupture of organ.
Dull, steadily increasing pain may
indicate bowel obstruction.
Sharp pain, particularly in flank, may
indicate kidney stone.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• OPQRST-ASPN history
– Region/radiation
Radiated pain common; it involves same
neural routes as referred pain.
Pain referred to shoulder or neck
associated with irritation of diaphragm.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• OPQRST-ASPN history
– Severity
Usually worsens as pathology of organ
advances.
– Time
Estimation of pain's time of onset
important to determine possible causes.
Any abdominal pain lasting over 6 hours
considered surgical emergency.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• OPQRST-ASPN history
– Associated symptoms
Try to determine content, color, smell of
vomitus.
Ask if vomitus contained any bright red
blood, “coffee grounds,” or clots.
Determining if patient has active
gastrointestinal bleed is imperative.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• OPQRST-ASPN history
– Associated symptoms
Changes in bowel morphology, color, or
smell can be only indication of lower GI
hemorrhage, gastritis, bleeding
diverticula.
Patients who have acute abdomen
usually have associated loss of appetite.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• OPQRST-ASPN history
– Pertinent negatives
Absence of symptoms with GI function or
presence of symptoms with urinary
function may be problem in urinary
system.
Pain in lowest part of abdomen can be
due to problems in reproductive system.
Cardiovascular history with referred pain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Ask about patient's last oral intake.
• Gastrointestinal emergencies that
cause chest pain:
– Gastroesophageal reflux
– Gastric ulcers
– Duodenal ulcers
– Gallbladder disease
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Obtain past medical history.
• Complete physical examination.
– Patient's general appearance and
posture strongly suggest apparent state
of health and severity of complaint.
– Take complete set of vital signs.
– Visually inspect abdomen before
palpating it, auscultating it, moving
patient.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Complete physical examination.
– Distention of abdomen ominous sign.
– Caused by buildup of free air due to
obstruction of bowel or hemorrhage.
– Signs of fluid loss: periumbilical
ecchymosis (Cullen's sign) and
ecchymosis in flank (Grey Turner's
sign).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Complete the physical examination.
– Auscultating abdomen provides little
helpful information.
– Palpating abdomen can define area of
pain and identify associated organ.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Highest priority when treating patient
with abdominal pain: secure and
maintain airway, breathing, circulation.
• Be prepared to suction airway of
vomitus and blood.
• Supplemental oxygen and aggressive
airway management may be indicated,
depending on patient's status.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Monitor circulation by placing patient
on cardiac monitor; frequently assess
blood pressure.
• Measurement of hematocrit will give
indirect measure of blood loss.
• Establish large-bore IV line in patients
who complain of abdominal discomfort.
• Avoid masking abdominal pain; will
limit pharmacological interventions.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
General Pathophysiology,
Assessment, and Treatment
• Place patient in comfortable position.
• Provide emotional reassurance.
• Keep voice and actions quiet and
collected.
• Persistent abdominal pain lasting longer
than 6 hours classified as surgical
emergency; always requires transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Gastrointestinal (GI) tract one long
tube divided structurally and
functionally into different parts.
• Organs: liver, gallbladder, pancreas,
vermiform appendix.
• Converts food into nutrient molecules
that cells can use; excretes solid
wastes from body.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
The gastrointestinal tract is one long tube divided structurally and functionally into different parts.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Digestive System Exercise
Click here to complete an interactive exercise on the digestive system.
Back to Directory
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Upper GI tract
– Mouth, esophagus, stomach, duodenum
(first part of small intestine).
– Physical digestion of food and some
chemical digestion take place here.
– As food passes through lower GI tract
(remainder of small intestine and large
intestine), nutrients absorbed into blood
and solid wastes formed and excreted.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Upper Gastrointestinal Bleeding
– Bleeding within gastrointestinal tract
proximal to ligament of Treitz.
– 300,000 hospitalizations per year; 10%
mortality rate.
Patients treat symptoms with home
remedies/over-the-counter medication.
Age of population increasing.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Six major causes of upper GI
hemorrhage:
– Peptic ulcer disease
– Gastritis
– Variceal rupture
– Mallory-Weiss tear (esophageal
laceration)
– Esophagitis
– Duodenitis
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Upper Gastrointestinal Bleeding
– Patient may experience hematemesis
(bloody vomitus) or, if it passes through
lower GI tract, melena.
– Blood in emesis bright red or looks like
coffee grounds.
– May be light or brisk and life
threatening.
– May vomit copious amounts of blood.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Upper Gastrointestinal Bleeding
– Bleeding may cause shock or
compromise airway.
– Tilt test: indicates if patient has
orthostatic hypotension.
– Hypotension suggests decreased
circulating volume.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Upper Gastrointestinal Bleeding
– General complaints: malaise, weakness,
syncopal (fainting), near-syncopal
(lightheaded) spells, tachycardia,
indigestion.
– Patient's general appearance may be
best indicator of condition's severity.
– Perform thorough physical examination.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Upper Gastrointestinal Bleeding
– Prehospital treatment: maintain patent
airway, oxygenation, circulatory status.
– Place patient in left lateral recumbent or
high semi-Fowler's position.
– Administer high-concentration
oxygenation via nonrebreather mask.
– Establish two large-bore IVs in patient
you suspect of gastrointestinal bleed.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Esophageal Varices
– Swollen vein of esophagus.
– Often rupture and hemorrhage.
– When they do, mortality rate over 35%.
– Causes: increase in portal pressure
(portal hypertension), consumption of
alcohol, ingestion of caustic substances.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Esophageal Varices
– Alcoholic liver cirrhosis accounts for
two-thirds of cases.
– Patients present initially with painless
bleeding and signs of hemodynamic
instability.
– Care should focus on aggressive airway
management, intravenous fluid
resuscitation, rapid transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Esophageal Varices
– Airway management top priority.
– Suction emesis frequently and diligently
from airway; endotracheal intubation
may be needed.
– Administer high-concentration oxygen
via nonrebreather mask.
– Octreotide is drug of choice for acute
variceal bleeding.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Esophageal varices occur when the esophageal veins dilate and emerge from their sheaths.
(Photo: © Dr. Bryan E. Bledsoe)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Acute Gastroenteritis
– Inflammation of stomach and intestines
associated with sudden onset of
vomiting and/or diarrhea.
– Pathological inflammation causes
hemorrhage and erosion of mucosal and
submucosal layers of gastrointestinal
tract.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Acute Gastroenteritis
– Adequate volume replacement
prehospital prevention strategy;
minimize hypovolemia or hypovolemic
shock.
– Individuals who abuse alcohol and
tobacco at high risk.
– Use of nonsteroidal anti-inflammatory
drugs (aspirin) breaks down mucosal
surfaces of stomach and GI tract.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Acute Gastroenteritis
– Other causes: stress, chemotherapeutic
agents, ingestion of acidic or alkalotic
agent, infections.
– Onset rapid and usually severe.
– Diarrhea associated with this condition;
fluid loss leads to dehydration.
– Due to dehydration and hemorrhage,
patient hemodynamically unstable.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Acute Gastroenteritis
– Treatment: supportive and palliative.
– Be prepared to clear airway of vomit or
secretions.
– Maintaining adequate oxygenation high
priority.
– Avoid hyperoxia; rehydrate patient.
– Exercise extreme caution; use Standard
Precautions.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Chronic Gastroenteritis
– Inflammation of gastrointestinal mucosa
marked by long-term mucosal changes
or permanent mucosal damage.
– Due primarily to microbial infection.
– Far more common in underdeveloped
countries.
– Transmitted via fecal–oral route or
through infected food or water.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Chronic Gastroenteritis
– Symptoms: nausea and vomiting, fever,
diarrhea, abdominal pain, cramping,
anorexia, lethargy, shock.
– H. pylori symptoms: heartburn,
abdominal pain, gastric ulcers.
– Prehospital treatment: protecting
yourself and patient from
contamination, monitoring ABCs,
transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Peptic Ulcers
– Erosions caused by gastric acid; occur
anywhere in gastrointestinal tract.
– Duodenal ulcers occur in proximal
portion of duodenum.
– Occur in males more than females.
– Important to get family history and
estimate of patient's last oral intake.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Peptic ulcer. (Photo: © Dr. Bryan E. Bledsoe)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Peptic Ulcers
– Causes: nonsteroidal anti-inflammatory
medications (aspirin, ibuprofen,
naproxen), acid-stimulating products
(alcohol, nicotine), or Helicobacter pylori
bacteria.
– Treatment in prehospital setting:
antacid treatment and support of any
complications such as hemorrhage.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Peptic Ulcers
– Blocked pancreatic duct can contribute
to duodenal ulcers.
– Duodenal ulcers: Zollinger-Ellison
syndrome; acid-secreting tumor
provokes ulcerations.
– Chronic ulcers can cause slow bleed
with resulting anemia; acute, severe
pain due to rupture of ulcer.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Peptic Ulcers
– Nausea and vomiting common.
– Massive hemorrhage can occur.
– Patients will appear very ill; signs of
hemodynamic instability.
– Treatment depends on severity of
patient's pain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Lower Gastrointestinal Disease
– Lower GI tract: jejunum and ileum of
small intestine and entire large
intestine, rectum, anus.
– As digestive fluid moves through small
intestine, nutrients absorbed into blood.
– Water absorbed and solid wastes form
in large intestine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Lower GI Bleeding
– Occurs in GI tract distal to ligament of
Treitz in conjunction with chronic
disorders and anatomic changes
associated with advanced age.
– Causes: diverticulosis, colon lesions,
rectal lesions, anal fissures,
inflammatory bowel disorders
(ulcerative colitis and Crohn's disease).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Lower GI Bleeding
– Symptoms: cramping, nausea,
vomiting, changes in stool.
– Most patients with lower GI bleeds have
not lost significant amounts of blood;
hemodynamic stability.
– Management will depend on physiologic
status.
– Watch airway and oxygenation status.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Ulcerative Colitis
– Classified as idiopathic inflammatory
bowel disorder (IBD); unknown origin.
– 75% of ulcerative colitis involves rectum
or rectosigmoid portion of large
intestine.
– Pancolitis: if it spreads throughout
entire colon.
– Proctitis: if limited to rectum.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Ulcerative Colitis
– Contributing factors: psychological,
allergic, toxic, environmental,
immunologic, infectious.
– Recurrent disorder with bloody diarrhea
or stool-containing mucus.
– Abdominal pain (cramping), nausea and
vomiting, fever, weight loss.
– Significant hemorrhage common.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Ulcerative Colitis
– Management depends on physiologic
status.
– Transport patient who presents with
lower GI bleeding or colicky pain to
emergency department.
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Paramedic Care: Principles & Practice, 4th Ed.
Ulcerative colitis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Crohn's Disease
– Idiopathic inflammatory bowel disorder.
– Tends to run in families; white females;
frequent stress; in Jewish population.
– Can occur anywhere from mouth to
rectum.
– Severe cases may involve any portion of
GI tract.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Crohn's Disease
– Complete intestinal obstruction, a
surgical emergency, can occur.
– Significant lower GI bleeding rare.
– Signs and symptoms: GI bleeding,
recent weight loss, intermittent
abdominal cramping/pain, nausea and
vomiting, diarrhea, fever.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Crohn's Disease
– Onset of a flare-up usually rapid.
– If patient is hemodynamically stable,
prehospital treatment largely palliative.
– Management depends on patient's
physiologic status.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Diverticulitis
– Common complication of diverticulosis.
• Diverticulosis
– Presence in intestine of diverticula,
small outpouchings of mucosal and
submucosal tissue that push through
outermost layer of intestine, the muscle.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Diverticulitis
– Inflammation of diverticula secondary to
infection.
– Lower left-sided pain; fever; increased
white blood cell count; nausea and
vomiting; tenderness on palpation.
– Prehospital treatment supportive.
– Hospital treatment: antibiotic therapy,
endoscopy, radiologic tests.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Hemorrhoids
– Small masses of swollen veins that
occur in anus (external) or rectum
(internal).
– Develop during fourth decade of life.
– Idiopathic (unknown cause); can result
from pregnancy or portal hypertension.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Hemorrhoids are small masses of swollen veins.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Hemorrhoids
– Internal hemorrhoids bleed during
defecation due to straining and then
thrombose into closed state again.
– External hemorrhoids result from
thrombosis of vein, often following
lifting or straining, causing bright red
bleeding with bowel movement.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Hemorrhoids
– Rarely cause significant hemorrhage.
– Physical assessment usually reveals
hemodynamically stable patient with
relatively normal appearance.
– Significant hemorrhage or bleeding
hemorrhoids in alcoholic patient warrant
closer monitoring and transport for
immediate follow-up.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Rectal Foreign Body
– Foreign body inserted into rectum with
patient's knowledge for various reasons
(sexual gratification or psychosis).
– Most swallowed foreign bodies pass
readily, but others may not.
– Rectal pain or pressure; infection or
shock.
– Prehospital treatment: supportive.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Bowel Obstruction
– Blockages of hollow space (lumen)
within small and large intestines; partial
or complete.
– Hernias, intussusception, volvulus,
adhesions are the four most frequent.
– Common causes: foreign bodies,
gallstones, tumors, adhesions from
abdominal surgery, bowel infarction.
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Paramedic Care: Principles & Practice, 4th Ed.
Inguinal hernia.
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Paramedic Care: Principles & Practice, 4th Ed.
Intestinal volvulus.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Bowel Obstruction
– Most common location for obstructions
is small intestine.
– Obstruction may be chronic; decreased
appetite, fever, malaise, nausea and
vomiting, weight loss, or if rupture
occurs, peritonitis.
– Onset sudden and acute: ingestion of
foreign body.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Bowel Obstruction
– Frequently vomit, with vomitus often
containing significant amount of bile.
– Diffuse visceral pain, usually poorly
localized to any one specific location.
– May be hemodynamically unstable.
– Distention, peritonitis, or free air within
abdomen secondary to rupture of
strangulated segment of intestine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Bowel Obstruction
– Look for scars from previous surgery.
– Bowel sounds may be present as highpitched obstruction sound.
– Palpation will reveal tenderness.
– Treatment: airway management,
oxygenation via nonrebreather mask,
position of comfort or shock position,
fluid resuscitation to prevent shock.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Mesenteric Ischemia
– When one of mesenteric arteries
becomes narrowed or occluded.
Superior mesenteric artery (SMA)
Inferior mesenteric artery (IMA)
– When blood flow through either of these
vessels reduced or stopped, abdominal
pain occurs.
– Nausea, vomiting, diarrhea common.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Mesenteric Ischemia
– Bowel will become ischemic and die,
causing infection.
– Prehospital treatment: hydration, pain
control, antiemetics.
– Treatment usually surgical.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Appendicitis
– Inflammation of vermiform appendix,
located at junction of large and small
intestines.
– 10 to 20% of population; young adults.
– Acute appendicitis most common
surgical emergency in field.
– Appendix no known anatomic or
physiologic function.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Appendicitis
– Can become inflamed; if untreated can
rupture, spilling contents into peritoneal
cavity and setting up peritonitis.
– Obstruction of appendiceal lumen by fecal
material.
– Common site of pain: McBurney's point, 1
to 2 inches above anterior iliac crest
along direct line from anterior crest to
umbilicus.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
McBurney point is a common site of pain in appendicitis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Appendicitis
– Once appendix ruptures, pain becomes
diffuse due to development of
peritonitis.
– Do not repeatedly palpate for rebound
tenderness; pressure that this exerts
can cause inflamed appendix to rupture.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Appendicitis
– Prehospital care
Place patient in position of comfort
Give psychological support
Manage airway to prevent aspiration
Establish intravenous access
Transport
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Cholecystitis
– Inflammation of gallbladder.
– Cholelithiasis: formation of gallstones;
causes 90% of cholecystitis cases.
– Cholesterol-based stones: obese,
middle-aged women with more than one
biological child.
– Antibiotic therapy, laparoscopic surgery,
lithotripsy, surgery.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
The gallbladder is located below the liver.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Cholecystitis
– Caused by gallstones; chronic or acute.
– Acalculus cholecystitis results from
burns, sepsis, diabetes, multiple organ
failure.
– Inflamed gallbladder causes acute
attack of upper right quadrant
abdominal pain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Cholecystitis
– Often pain occurs after meal high in fat
content; nausea and vomiting common.
– Distention and ecchymosis rare.
– Palpation may reveal diffuse right-sided
tenderness or point tenderness under
right costal margin; positive Murphy's
sign.
– Prehospital treatment: mainly palliative.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Pancreatitis
– Inflammation of pancreas.
– Four categories based on cause:
Metabolic
Mechanical
Vascular
Infectious
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Pancreatitis
– Metabolic causes, specifically
alcoholism, account for 80% of cases.
– Mechanical obstructions caused by
gallstones or elevated serum lipids.
– Vascular injuries caused by
thromboembolisms or shock.
– Infectious caused by infectious diseases.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Pancreatitis
– Mortality high (30–40%) due to
accompanying sepsis and shock; can
lead to multisystem organ failure.
– Digestive enzymes inflame pancreas
and cause edema; reduced blood flow.
– Decreased blood flow causes ischemia
and acinar destruction; acute
pancreatitis based on rapidity of onset.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Anatomy of the pancreas and surrounding structures.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Pancreatitis
– Acinar tissue destruction causes second
form, chronic pancreatitis.
– Due to chronic alcohol intake, drug
toxicity, ischemia, infectious diseases.
– Lesion can erode and hemorrhage;
causes intense abdominal pain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Pancreatitis
– Nausea followed by uncontrolled
vomiting; can aggravate hemorrhage.
– Patient will appear acutely ill with
diaphoresis, tachycardia, possible
hypotension.
– Prehospital treatment: supportive,
maintaining ABCs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Hepatitis
– Any injury to hepatocytes (liver cells)
associated with inflammation or
infection.
– High mortality rate.
– Six viruses: hepatitis types A, B, C, D,
E, G; most common causes.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Hepatitis
– Risk factors
Crowded and unsanitary living conditions
Poor personal hygiene that invites oral–
fecal transmission
Exposure to bloodborne pathogens
Chronic alcohol intake
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Hepatitis
– Symptoms' severity can range from
mild to complete liver failure and death.
– Hepatitis A (HAV): best known;
infectious hepatitis.
– Hepatitis B (HBV): “serum hepatitis";
transmitted as bloodborne pathogen.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Hepatitis
– Hepatitis C (HCV): pathogen commonly
responsible for spreading hepatitis
through blood transfusions; chronic and
often debilitating damage to liver.
– Hepatitis D (HDV): less common;
pathogen dormant until activated by
HBV.
– Hepatitis E (HEV): waterborne infection.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Hepatitis
– Hepatitis G (HGV): developed hepatitis
after transfusion; people with hepatitis
A, B, C can be super-infected with HGV.
– Possibly with jaundiced appearance;
upper right quadrant abdominal
tenderness.
– Severe nausea and vomiting, malaise,
photophobia, pharyngitis, coughing.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Illnesses
• Hepatitis
– Palpation may reveal enlarged liver.
– Prehospital treatment: mainly palliative.
– Secure ABCs and establish intravenous
access for fluid resuscitation or
antiemetic administration.
– Vaccinations available for hepatitis A
and B.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Abdominal pain can originate from wide
variety of causes; abdominal organs or
areas outside abdominal cavity.
• Patient's description of pain (sharp,
dull, burning, tearing, cramping) may
help narrow differential diagnosis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Prehospital management priorities:
maintain airway, breathing, circulation.
• Diagnosis can include multitude of
causes that cannot be identified without
laboratory and radiographic analysis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Correction of most life-threatening
conditions generally requires surgical
intervention.
• Airway management paramount
importance; patients suffer from severe
bouts of nausea and vomiting.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Be prepared to turn patient onto side if
necessary to clear large amounts of
vomitus from airway.
• Oxygenation can be adequately
stabilized by placing patient on highconcentration oxygen via nonrebreather
mask.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Fluid loss, hemorrhage, sepsis may
compromise circulatory status.
• Initiate fluid resuscitation for
hemodynamically unstable patient in
field, but never delay transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Patients who have abdominal pain
lasting over 6 hours should always be
evaluated by physician.
• Key to successful treatment of
gastrointestinal ailments: prompt
recognition, treatment, rapid transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.