Transcript Paramedic Care: Principles & Practice Volume 3

Paramedic Care:
Principles & Practice
Volume 3
Medical Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 13
Gynecology
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Anatomy and Physiology of the Female
Reproductive Organs
The Menstrual Cycle
Assessment of the Gynecological Patient
Management of Gynecological Emergencies
Specific Gynecological Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction
Gynecology
– Branch of medicine that deals with the health
maintenance and the diseases of women.
Mainly reproductive organs
Most patients that you will encounter will be
experiencing either abdominal pain or
vaginal bleeding.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of the
Female Reproductive Organs
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of the
Female Reproductive Organs
External Genitalia
– Accessory functions
Protect body openings
Important role in sexual functioning
Internal Genitalia
– Most important organs of reproduction
– The ovaries, fallopian tubes, uterus, and vagina
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
External Genitalia
Perineum
– Muscular tissue
that separates the
vagina and the
anus
Mons Pubis
– Fatty layer of tissue
over the pubic
symphysis
Labia
– Structures that
protect the vagina
and the urethra
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
External Genitalia
Clitoris
– Vascular erectile
tissue that lies
anterior to the labia
minora
Urethra
– Drains the urinary
bladder
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Internal Genitalia
Vagina
– Female organ of
copulation
– Birth canal
– Outlet for
menstruation
Uterus
– Site of fetal
development
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Internal Genitalia
Fallopian Tubes
– Transports the egg
from the ovary to
the uterus
– Fertilization usually
occurs here
Ovaries
– Primary female
gonads
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Uterus
Provides a site for
fetal development
Two major parts:
– Body (or corpus)
– Cervix (or neck)
Tissue layers
– Endometrium
– Myometrium
– Perimetrium
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Female Reproductive Anatomy
Click here to view an animation on female reproductive anatomy.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Menstrual Cycle
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Menstrual Cycle
Monthly hormonal cycle, usually 28 days
– Estrogen and progesterone
Influenced by FSH and LH
Prepares the uterus to receive a fertilized
egg
The onset of menses, known as menarche
– Usually occurs between the ages of 10 and 14
Menopause
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Phases of the
Menstrual Cycle
The Proliferative Phase
The Secretory Phase
The Ischemic Phase
The Menstrual Phase
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Proliferative Phase
First two weeks of the menstrual cycle
– Dominated by estrogen
– Uterine lining will gradually thicken and become
engorged with blood
Day 14
– Surge in leutenizing hormone (LH)
– Ovulation occurs
– Follicle develops the corpus luteum
If fertilization occurs, egg implants in uterus
– If not, the endometrium sheds in normal menses
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Secretory Phase
Stage immediately surrounding ovulation
– If the egg is not fertilized, the woman’s estrogen
level drops sharply
– Progesterone dominant hormone during this
phase
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Ischemic Phase
Estrogen and progesterone levels fall
without fertilization
The endometrium breaks down
– Vascular changes cause the endometrium to
become pale and small blood vessels to rupture
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Menstrual Phase
Menstruation
– Ischemic endometrium is shed, along with a
discharge of blood, mucus, and cellular debris
– A “normal” menstrual cycle depends on the
regular pattern
Premenstrual syndrome (PMS)
– Symptoms include:
Breast tenderness or engorgement, transient weight
gain or bloating, excessive fatigue, and/or cravings for
specific foods, migraine headaches
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Menstrual Phase
Menopause
– Menstruation occurs until a woman is 45 to 55
– Menopause signals the cessation of ovarian
function and the cessation of estrogen secretion
Periods decline in frequency and length until they
ultimately stop
Surgical menopause
– Hormone replacement therapy
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the
Gynecological Patient
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of the
Gynecological Patient
The most common emergency complaints of
women in the childbearing years are
abdominal pain and vaginal bleeding.
– Often due to problems of the reproductive
organs.
Conduct an initial assessment, focused
history, and physical exam as normal.
Conduct yourself professionally.
If patient is reluctant to discuss, transport
while treating any life-threats.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
History
Initial Assessment—SAMPLE
Does the patient complain of pain?
Use OPQRST
– Dysmenorrhea/dyspareunia
Associated signs or symptoms
Has she ever been pregnant?
– Gravida/parity/abortion
Document last menstrual cycle
Medications—Contraceptives
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Contraceptive Methods
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Physical Exam
Respect patient’s privacy
Be professional and explain all procedures
Observe patient
Check vital signs
Assess bleeding or discharge:
– Do not perform an internal vaginal exam in the
field
Abdominal examination
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of
Gynecological Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of
Gynecological Emergencies
General management of gynecological
emergencies is focused on supportive care
– Administer oxygen or assist ventilation as
necessary
– Treat for shock if indicated
Intravenous therapy
Cardiac monitoring
PASG consideration
– Hemorrhage control
Do not pack dressings in the vagina
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Specific Gynecological
Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Specific Gynecological
Emergencies
Gynecological Abdominal Pain
–
–
–
–
–
–
Pelvic Inflammatory Disease
Ruptured Ovarian Cyst
Cystitis
Mittelschmerz
Endometriosis
Ectopic Pregnancy
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pelvic Inflammatory Disease
An infection of the
female reproductive
tract
– Bacterial, viral, fungal
– The most common
causes of PID are
gonorrhea (Neisseria
gonorrhoeae) or
chlamydia (Chlamydia
trachomatis)
© Phototake NYC
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pelvic Inflammatory Disease
Predisposing factors
– Multiple sexual partners, prior history of PID,
recent gynecological procedure, or an IUD
– Infertility results from scarring of the fallopian
tubes
Signs and symptoms
– Abdominal pain (may intensify either before or
after the menstrual period)
Worsens during intercourse
– Patients may walk with a shuffling gait
– A yellow, foul-smelling vaginal discharge
– Midcycle bleeding
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pelvic Inflammatory Disease
Physical Exam
– Appearance reveals ill or toxic patient
– Moderate to severe abdominal pain
Worse with palpation
Rebound tenderness may be present
– Fever may or may not be present
Treatment
– Definitive treatment is IV antibiotics
– Prehospital treatment is supportive
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ruptured Ovarian Cyst
Cyst is a fluid-filled
pocket
– Usually the result of
a ruptured follicle
Corpus luteum cyst,
is often left in its
place
Blood causes
irritation of
peritoneum
– Results in pain
© Phototake NYC
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ruptured Ovarian Cyst
Physical Exam
– Moderate to severe unilateral abdominal pain
May radiate to back
– Dyspareunia, irregular bleeding, or a delayed
menstrual period
Cyst may rupture during sexual activity or physical
activity
– Vaginal bleeding may be present
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Cystitis
Urinary bladder infection
– Usually result of bacteria
May progress to kidneys
Signs and Symptoms
– Abdominal pain
– Urinary frequency, pain or burning with urination
(dysuria)
– Low-grade fever
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Mittelschmerz
Mid-cycle abdominal pain
– Peritoneal irritation during follicular rupture
– Usually self-limited
Signs and Symptoms
– Unilateral lower quadrant pain
– Low-grade fever
Treatment is symptomatic
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Endometritis
An infection of the uterine lining
– Results from miscarriage, childbirth, or
gynecological procedures
Dilation and Curettage (D & C)
Signs and Symptoms
–
–
–
–
Mild to severe lower abdominal pain
Bloody, foul-smelling discharge
Fever (101°F to 104°F)
Onset of symptoms usually 24-48 hours postprocedure
Complications of endometritis may include
sterility, sepsis, or even death
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Endometriosis
Condition in which endometrial tissue is
found outside of the uterus
– Most commonly in abdominal cavity and pelvic
cavity
– Tissue responds to the hormonal changes
associated with the menstrual cycle
– Usually seen in women between the ages of 30
to 40
Signs and Symptoms
– Dull, cramping pelvic pain, dyspareunia,
abnormal uterine bleeding, painful bowel
movements
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Ectopic Pregnancy
Implantation of a fetus
outside of the uterus
– Most commonly the
fallopian tubes
Signs and symptoms
– Severe, unilateral pain
with referred shoulder
pain on the same side
– Shock
– A late or missed period
© Phototake NYC
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of Gynecological
Abdominal Pain
Administer oxygen and establish
intravenous access if indicated
Make the patient comfortable and transport
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Non-Traumatic
Vaginal Bleeding
Rarely seen in the field unless it is severe
– Obtain history
Menorrhagia
– Excessive menstrual flow
– Be alert for signs of shock
Spontaneous abortion (miscarriage)
– Most common cause of non-traumatic bleeding
– Often associated with cramping abdominal pain
and the passage of clots and tissue
Other causes
– Cancerous lesions, PID, or the onset of labor
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Non-Traumatic
Vaginal Bleeding
Management
– Will depend on the severity of the situation
Initiation of oxygen therapy and intravenous access
– Absorb blood flow
Never pack the vagina
– Transport any blood or tissue to hospital
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Traumatic Gynecological
Emergencies
Causes of Gynecological Trauma
–
–
–
–
–
Blunt Trauma
Sexual Assault
Blunt force to Lower Abdomen
Foreign Bodies Inserted in Vagina
Abortion Attempts
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of
Gynecological Trauma
Apply direct pressure over laceration
– Source of bleeding may not be readily apparent
– Apply cold pack to hematoma
Establish IV if patient is severe or signs of
shock present
Potential organ rupture may lead to
peritonitis
Transport
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Sexual Assault
The most rapidly growing violent crime in
America
– 60 percent of all sexual assaults are never
reported
– Male victims represent 5 percent of reported
sexual assaults
– No “typical victim” of sexual assault
Most victims know assailants
– Sexual assault is a crime of violence
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Sexual Assault
Assessment
– Patient needs
emergency medical
treatment and
psychological support
– Legal concerns
– Victims of sexual abuse
should not be
questioned about the
incident in the field
– Respect the patient’s
modesty
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management Considerations
Protect the scene
Handle clothing as little as possible
If removing clothing, bag each item
separately
Do not cut through any tears or holes in
clothing
Place bloody articles in brown paper bags
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management Considerations
Do not examine the perineal area
Do not allow patient to change clothes,
bathe, or douche
Do not allow patient to comb hair, brush
teeth, or clean fingernails
Do not clean wounds, if possible
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Documentation
State patient remarks accurately
Objectively state your observations of
patient’s physical condition, environment, or
torn clothing
Document evidence turned over to hospital
staff
Do not include your opinions as to whether
rape occurred
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Anatomy and Physiology of the Female
Reproductive Organs
The Menstrual Cycle
Assessment of the Gynecological Patient
Management of Gynecological Emergencies
Specific Gynecological Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ