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Abdominal Emergencies 2

Abdominal Emergencies 2






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    Abdominal Emergencies 2 Abdominal Emergencies 2 Presentation Transcript

    • “Get in my Belly”Abdominal Emergencies
      Fred W. Wurster III, AAS, NREMT-P
    • Abdominal Emergencies
      Anatomy Review
      Non-hemorrhagic abdominal pain
      Gastrointestinal hemorrhage
      Treatment modalities
    • Abdominal boundaries
    • Peritoneum
      Abdominal cavity
      Double-walled structure
      Visceral and Parietal
      Separates abdominal cavity into two areas
      Peritoneal cavity or space
      Retroperitoneal space
    • Peritoneum
    • Abdominal anatomy
    • Abdominal anatomy
    • GI Structures
      Mouth/Oral Cavity
      Esophagus (digestive tract between pharynx & stomach)
      Stomach (hollow digestive organ, receives food from esophagus)
      Small Intestine (between stomach & cecum, composed of duodenum, jejunum, & ileum)
      Large intestine (from ileocecal valve to anus, composed of cecum, colon, & rectum)
    • GI Structures
      Salivary glands (produce/secrete saliva)
      Liver (solid organ in RUQ; produces/secretes bile, essential proteins, clotting factors; detoxifies; stores glycogen)
      Gallbladder (sac located beneath liver, stores/concentrates bile)
      Pancreas (Endocrine – secretes insulin/Exocrine - secretes digestive enzymes & bicarbonate)
      Appendix (attached to large intestine, no physiologic function)
    • Major Blood Vessels
      Inferior Vena Cava
    • Organs
    • Organs
      Gallbladder and bile ducts
      Urinary bladder
      Fallopian tubes
    • Abdominal quadrants
    • Right Upper Quadrant
      Transverse colon (partial)
      Ascending colon (partial)
    • Left Upper Quadrant
      Liver (partial)
      Transverse colon (partial)
      Descending colon (partial)
    • Right Lower Quadrant
      Ascending colon
      Fallopian tube
    • Left Lower Quadrant
      Descending colon
      Sigmoid colon
      Fallopian tube
    • Abdominal Pain
      Diffuse in nature
      Stretching of peritoneum of organ capsules by distension or edema
      Poorly localized
      Can be perceived at remote locations related to the affected organ’s sensory innervation
    • Abdominal Pain
      Sharp in nature
      Well localized
      Inflammation of parietal peritoneum or diaphragm
      Perceived at a distance from the affected organ
    • Non-hemorrhagic Abdominal Pain
      Inflammation of distal esophagus usually from GERD or hiatal hernia
      Sub-sternal burning pain (usually epigastric)
      Pain worsens when laying supine
      Sometimes temporarily relieved by Nitroglycerine
      Usually non-hemorrhagic
    • Esophagitis
    • Non-hemorrhagic Abdominal Pain
      Acute Gastroenteritis
      Inflammation of stomach and intestine
      May cause bleeding and ulcers
      Caused by:
      Increased acid secretion and biliary reflux
      Chronic EtOH use/abuse and medication (ASA, NSAIDS)
      Signs and Symptoms
      Epigastric pain, usually a burning sensation, tenderness on exam, nausea, vomiting, diarrhea, possible bleeding
    • Peptic ulcer disease
      Causes craters in mucosa of stomach and/or duodenum (duodenal two-three times more frequent)
      Four times more likely in males than female
      Caused by:
      Infectious disease (Helicobacter pylori (80%))
      NSAID use
      Pancreatic duct blockage
      Zollinger-Ellison Syndrome
    • Peptic Ulcer Disease
      Duodenal Ulcer
      20 to 50 years old
      High stress occupations or situations
      Genetically predisposed
      Pain when the stomach is empty
      Pain at night
      Gastric Ulcer
      Greater than 50 years old
      Employed in positions that require physical activity
      Pain after eating or when stomach is full
      Usually no pain at night
    • Peptic ulcer Disease
      Hemorrhage, perforation, progression to peritonitis, scar tissue accumulation, and potentially an obstruction
      Signs and Symptoms
      Steady, well-localized pain that is described as burning, gnawing, or hot-rock sensation
      Relieved by bland, alkaline foods/antacids (BRAN)
      Increased pain and symptoms with smoking, coffee, stress, spicy foods
      Changes in stool and skin color
    • Peptic ulcer disease
      Inflammation of the pancreas in which enzymes auto-digest gland
      Caused by:
      EtOH (80% of cases)
      Gallstones obstructing ducts
      Elevated serum triglycerides
      Viral or bacterial infections
    • Pancreatitis
      May lead to
      Peritonitis, pseudocyst formation, hemorrhage, necrosis, secondary diabetes
      Signs and Symptoms
      Mid-epigastric pain radiating to back
      Worsened by food and EtOH consumption
      Grey-Turner sign (flank discoloration)
      Cullen’s sign (peri-umbilicial discoloration)
      Nausea, vomiting, fever
    • Cholecystitis
      Gall bladder inflammation, usually secondary to gallstones (90% of cases)
      Risk factors (Five F’s)
      Fat, fertile, febrile, fortyish, and female
      Heredity, diet, BCP use
      Acalculus cholecystitis
      Burns, sepsis, diabetes, multiple organ systems failure
      Chronic cholecystitis (bacterial infection)
    • Cholecystitis
      Signs and Symptoms
      Sudden pain, often severe and cramping, in RUQ that radiates to right shoulder
      Point tenderness under right costal margin (Murphy’s sign)
      Nausea and vomiting
      Associated with fatty food intake
      History of similar episodes
      Can be relieved by nitroglycerin
    • Cholecystitis
    • Appendicitis
      Inflammation of vermiform appendix
      Usually secondary to obstruction by fecalith
      May occur in older persons secondary to atherosclerosis of appendiceal artery and ischemic necrosis
      Signs and Symptoms
      Classic: Peri-umbilical pain  RLQ pain/cramping, guards upon palpation
      Nausea, vomiting, low-grade fever
      Patient found right lateral recumbant in fetal position
    • Appendicitis
      Signs and Symptoms:
      McBurney’s sign – pain on palpation of RLQ
      Aaron’s sign – Epigastric pain upon palpation of RLQ
      Rovsing’s sign – Pain LLQ upon palpation of RLQ
      Psoas sign – Pain when patient extends right leg while lying on left side and/or flexes legs while supine
      Ruptured appendix - true emergency, temporary relief from pain followed by peritonitis
    • appendicitis
    • Appendicitis
    • Bowel obstruction
      Blockage of intestine
      Caused by –
      Adhesions (secondary to surgery)
    • Bowel Obstruction
      Fluid, gas, and air collect near obstruction site causing the bowel to distend impeding blood flow/halting absorption. Water and electrolytes collect in bowel lumen leading to hypovolemia. Bacteria from the gas above the obstruction causes further distension and the distension extends proximally. Finally necrosis and/or perforation occur at the site of the obstruction
    • Bowel Obstruction
      Signs and Symptoms
      Severe, intermittent, “crampy” pain
      High pitched tinkling bowel sounds
      Abdominal distension
      Nausea and vomiting
      Decreased frequency of bowel movements
      Change in bowel (semi-liquid or pencil-thin stool)
      If severe enough can have feces in vomitus
    • Hernia
      Protrusion of abdominal contents into groin (inguinal) or through diaphragm (hiatal)
      Often secondary to increased intra-abdominal pressure (coughing, lifting, straining)
      Can progress to ischemic bowel (strangulated hernia)
      Signs and symptoms:
      Pain increased with abdominal pressure
      Inguinal hernia may be palpable in groin or scrotum
    • Crohn’s Disease
      Idiopathic inflammatory bowel disease
      Occurs anywhere from mouth to rectum
      35-45%: small intestine, 40%: colon
      High risk groups: caucasian females, Jews, persons under high stress
    • Crohn’s Disease
      Mucosa of GI tract becomes inflamed and granulomas form invading the submucosa. Muscular layer of the bowel become fibrotic and hypertrophied. All of this causes an increased risk for bowel obstruction, perforation, or hemorrhage.
    • Crohn’s disease
    • Diverticulitis
      Pouches in the colon wall
      Typically found in older people
      Usually asymptomatic
      Related to diets with inadequate fiber
      Diverticula traps feces and becomes inflamed
      Occasionally causes bright red rectal bleeding
      Rupture of diverticula can lead to peritonitis and sepsis
    • Diverticulitis
      Signs and Symptoms
      Usually left-sided pain
      May localize to LLQ – commonly referred to as “left-sided appendicitis”
      Alternating constipation and diarrhea
      Bright red blood in stool
    • Diverticulitis
    • Hemorrhoids
      Small masses of veins in anus/rectum
      Most frequently develop when patients are in 30’s to 50’s
      Most are idiopathic, can be associated with pregnancy, portal hypertension, lengthy driving, constipation
      Bright red bleeding with pain upon bowel movement
      May become infected and inflamed
    • Peritonitis
      Inflammation of abdominal cavity lining
      Signs and symptoms
      Generalized pain, tenderness
      Abdominal rigidity
      Nausea, vomiting
      Absent bowel sounds
      Patient is resistant to movement
    • Hemorrhagic Abdominal Problems
      Gastrointestinal Hemorrhage
      Intraabdominal Hemorrhage
    • Esophageal Varices
      Dilated veins in esophageal wall
      Occurs secondary to hepatic cirrhosis, common to alcohol abusers
      Obstruction of hepatic portal blood flow results in dilation, thinning of esophageal veins
    • Esophageal Varices
      Portal Hypertension
      Hepatic scarring slows blood flow
      Blood backs up in portal circulation
      Pressure rises
      Vessels in portal circulation become distended
      Signs and Symptoms
      Hematemesis (usually bright red)
      Nausea, vomiting
    • Esophageal varices
    • Mallory-WeissSyndrome
      Longitudinal tears at the gastroesophageal junction
      Occur as a result of prolonged, forceful vomiting or retching
      Common in alcoholics
      May be complicated by presence of esophageal varices
    • Mallory-WeissSyndrome
    • Mallory-weisssyndrome
    • Peptic Ulcer Disease
      Ulcer erodes through blood vessel
      Massive hematemesis
      Melena may be present
    • Aortic Aneurysm
      Localized dilation due to weakening of aortic wall
      Usually older patients with a past history of hypertension, atherosclerosis
      May occur in younger patients secondary to:
      Marfan’s syndrome
      Usually occurs just above aortic bifurcation and may extend to one or both iliac arteries
    • Aortic Aneurysm
      Signs and Symptoms
      Unilateral lower quadrant pain, low back pain or leg pain
      May be described as tearing or ripping pain/sensation
      Pulsatile palpable mass usually above umbilicus
      Diminished pulses in lower extremities
      Unexplained syncope, often after bowel movement
      Evidence of hypovolemic shock
    • Aortic aneurysm
    • Ectopic Pregnancy
      Any pregnancy that takes place outside of uterine cavity
      Most common location in fallopian tube
      Pregnancy outgrows tube, causing tube wall to rupture
      Hemorrhage into pelvic cavity occurs
      Suspect in females of child-bearing age with abdominal pain and/or unexplained shock
      When was the patients LMP?
    • Ectopic Pregnancy
      Ectopic pregnancy does NOT necessarily cause a missed period
    • Ectopic pregnancy
    • Ectopic pregnancy
    • Assessment of acute abdomen
    • History
      • Where do you hurt?
      Try to pinpoint or have patient pinpoint
      What does pain feel like?
      Steady pain = inflammatory process
      Cramping pain = obstructive process
      Onset of pain?
      Sudden = perforation or vascular occlusion
      Gradual = peritoneal irritation, distension of hollow organ
    • history
      Does the pain travel anywhere?
      Gallbladder = angle of right scapula
      Pancreas = straight through to back
      Kidney/ureter = around flank to groin
      Heart = epigastrium, neck/jaw, shoulders, upper arms
      Spleen = left scapula, shoulder
      Abdominal aortic aneurysm = low back pain, radiating to one or both legs
    • History
      How long have you been hurting?
      > 6 hours = increased probability of surgical significance
      Nausea and/or vomiting?
      How much and how long
      Consider hypovolemia
      Blood or coffee ground emesis
      Any blood in GI tract = emergency until proven otherwise
      Urine changes?
      Change in frequency, color, or odor; or increased urgency,
    • History
      Bowel movements?
      Change in bowel habits?
      Change in color?
      Change in odor?
      Bright red
      Melena (black, tarry, and foul-smelling)
      Dark (suspect bleeding)
    • History
      Last menstrual period?
      Abnormal bleeding?
      In females, lower abdominal pain = gynecological problem until proven otherwise
      In females of child-bearing age, lower abdominal pain = ectopic pregnancy until proven otherwise
    • Physical exam
      Position and general appearance
      Still refusing to move = inflammation or peritonitis
      Extremely restless = obstruction
      Gross appearance of abdomen
      Consider possible third spacing of fluid
    • Physical exam
      Vital Signs
      Tachycardia = more important sign of volume loss than a falling blood pressure
      Rapid shallow breathing = possible peritonitis
      Consider performing a “tilt” test
      Bowel sounds
      Auscultate before palpating
      Listen for 1 minute in each quadrant
      Absent sounds= possible peritonitis, shock
      High pitched tinkling sounds = possible bowel obstruction
    • Physical exam
      Palpate each quadrant
      Palpate area of pain last
      Do not check rebound tenderness in prehospital setting
      All abdominal tenderness is significant until proven otherwise
    • Management
      Oxygen by NRM
      IV of Lactated Ringers or Normal Saline Solution
      Keep patient warm
      Monitor vital signs
      Monitor EKG – Consider MI with pain referred to abdomen in patients under 30 years old
      Keep patients NPO
    • Management
      Treat pain per protocols (some believe that masking/treating pain is wrong)
      Give a thorough report to receiving facility
      For aortic aneurysm considering taking patient to hospital that is capable of CT surgery