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Abdominal Emergencies 2


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  • 1. “Get in my Belly”Abdominal Emergencies
    Fred W. Wurster III, AAS, NREMT-P
  • 2.
  • 3. Abdominal Emergencies
    Anatomy Review
    Non-hemorrhagic abdominal pain
    Gastrointestinal hemorrhage
    Treatment modalities
  • 4. Abdominal boundaries
  • 5. Peritoneum
    Abdominal cavity
    Double-walled structure
    Visceral and Parietal
    Separates abdominal cavity into two areas
    Peritoneal cavity or space
    Retroperitoneal space
  • 6. Peritoneum
  • 7. Abdominal anatomy
  • 8. Abdominal anatomy
  • 9. 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)
  • 10. 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)
  • 11. Major Blood Vessels
    Inferior Vena Cava
  • 12. Organs
  • 13. Organs
    Gallbladder and bile ducts
    Urinary bladder
    Fallopian tubes
  • 14. Abdominal quadrants
  • 15. Right Upper Quadrant
    Transverse colon (partial)
    Ascending colon (partial)
  • 16. Left Upper Quadrant
    Liver (partial)
    Transverse colon (partial)
    Descending colon (partial)
  • 17. Right Lower Quadrant
    Ascending colon
    Fallopian tube
  • 18. Left Lower Quadrant
    Descending colon
    Sigmoid colon
    Fallopian tube
  • 19. 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
  • 20. Abdominal Pain
    Sharp in nature
    Well localized
    Inflammation of parietal peritoneum or diaphragm
    Perceived at a distance from the affected organ
  • 21. 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
  • 22. Esophagitis
  • 23. 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
  • 24. 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
  • 25. 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
  • 26. 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
  • 27. 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
  • 29. 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
  • 30. 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)
  • 31. 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
  • 32. Cholecystitis
  • 33. 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
  • 34. 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
  • 35. appendicitis
  • 36. Appendicitis
  • 37. Bowel obstruction
    Blockage of intestine
    Caused by –
    Adhesions (secondary to surgery)
  • 38. 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
  • 39. 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
  • 40. 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
  • 41. 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
  • 42. 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.
  • 43. Crohn’s disease
  • 44. 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
  • 45. 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
  • 46. Diverticulitis
  • 47. 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
  • 48. Peritonitis
    Inflammation of abdominal cavity lining
    Signs and symptoms
    Generalized pain, tenderness
    Abdominal rigidity
    Nausea, vomiting
    Absent bowel sounds
    Patient is resistant to movement
  • 49. Hemorrhagic Abdominal Problems
    Gastrointestinal Hemorrhage
    Intraabdominal Hemorrhage
  • 50. 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
  • 51. 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
  • 52. Esophageal varices
  • 53. 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
  • 54. Mallory-WeissSyndrome
  • 55. Mallory-weisssyndrome
  • 56. Peptic Ulcer Disease
    Ulcer erodes through blood vessel
    Massive hematemesis
    Melena may be present
  • 57. 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
  • 58. 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
  • 59. Aortic aneurysm
  • 60. 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?
  • 61. Ectopic Pregnancy
    Ectopic pregnancy does NOT necessarily cause a missed period
  • 62. Ectopic pregnancy
  • 63. Ectopic pregnancy
  • 64. Assessment of acute abdomen
  • 65. 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
  • 66. 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
  • 67. 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,
  • 68. History
    Bowel movements?
    Change in bowel habits?
    Change in color?
    Change in odor?
    Bright red
    Melena (black, tarry, and foul-smelling)
    Dark (suspect bleeding)
  • 69. 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
  • 70. 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
  • 71. 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
  • 72. 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
  • 73. 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
  • 74. 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