Division 4

Medical Emergencies

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Chapter 32 Gastroenterology

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Topics
General Pathophysiology, Assessment, and Management Specific Illnesses

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Pathophysiology
General risk factors
Excessive alcohol consumption Excessive smoking Increased stress Ingestion of caustic substances Poor bowel habits

Emergencies
Acute emergencies usually arise from chronic underlying problems.
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Abdominal Pain
Types
Visceral Somatic Referred

Causes
Inflammation Distention Ischemia
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Assessment (1 of 2)
Scene size-up and initial assessment
Scene clues Identify and treat life-threatening conditions.

Focused history
Obtain SAMPLE history. Obtain OPQRST history.
Associated symptoms Pertinent negatives
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Assessment (2 of 2)
Physical exam
General assessment and vital signs Abdominal assessment
Inspection, auscultation, and palpation Cullens sign Grey-Turners sign

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

General Treatment
Maintain the airway. Support breathing.
High-flow, high-concentration oxygen or assisted ventilations

Maintain circulation. Monitor vital signs and cardiac rhythm. Establish IV access. Transport in position of comfort.
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Specific Illnesses
The Gastrointestinal System
Upper gastrointestinal tract Lower gastrointestinal tract Liver Gallbladder Pancreas Appendix

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Upper Gastrointestinal Bleeding (1 of 2)

Causes
Peptic ulcer disease Gastritis Varix rupture Mallory-Weiss tear Esophagitis Duodenitis

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Upper Gastrointestinal Bleeding (2 of 2)

Signs and symptoms
General abdominal discomfort Hematemesis and melena Classic signs and symptoms of shock Changes in orthostatic vital signs

Treatment
Follow general treatment guidelines.
Begin volume replacement using 2 large-bore IVs.

Differentiate life-threatening from chronic problem.

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Esophageal Varices (1 of 2)
Cause
Portal hypertension
Chronic alcohol abuse and liver cirrhosis Ingestion of caustic substances

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Esophageal Varices (2 of 2)
Signs and symptoms
Hematemesis, dysphagia Painless bleeding Hemodynamic instability Classic signs of shock

Treatment
Follow general treatment guidelines.
Aggressive airway management Aggressive fluid resuscitation
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Acute Gastroenteritis (1 of 2)
Cause
Damage to mucosal GI surfaces
Pathologic inflammation causes hemorrhage and erosion of the mucosal and submucosal layers of the GI tract.

Risk factors
Alcohol and tobacco use Chemical ingestion (NSAIDs, chemotherapeutics) Systemic infections
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Acute Gastroenteritis (2 of 2)
Signs and symptoms
Rapid onset of severe vomiting and diarrhea Hematemesis, hematochezia, melena Diffuse abdominal pain Classic signs of shock

Treatment
Follow general treatment guidelines. Fluid volume replacement. Consider administration of antiemetics.
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Gastroenteritis
Similar to acute gastroenteritis
Long-term mucosal changes or permanent damage
Primarily due to microbial infection More frequent in developing countries

Follow general treatment guidelines.

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Peptic Ulcers (1 of 2)
Pathophysiology
Erosions caused by gastric acid Terminology based on the portion of tract affected Causes:
NSAID use Alcohol/tobacco use H. pylori

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Peptic Ulcers (2 of 2)
Signs and symptoms
Abdominal pain Observe for signs of hemorrhagic rupture.
Acute pain, hematemesis, melena

Treatment
Follow general treatment guidelines. Consider administration of histamine blockers and antacids.
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Lower Gastrointestinal Bleeding (1 of 2)

Pathophysiology
Bleeding distal to the ligament of Treitz Causes
Diverticulosis Colon lesions Rectal lesions Inflammatory bowel disorder

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Lower Gastrointestinal Bleeding (2 of 2)

Signs and symptoms
Determine acute vs. chronic. Quantity/color of blood in stool Abdominal pain Signs of shock

Treatment
Follow general treatment guidelines.
Establish IV access with large-bore catheter(s).
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Ulcerative Colitis
Pathophysiology
Causes unknown

Signs and symptoms

Abdominal cramping Nausea, vomiting, diarrhea Fever or weight loss Treatment Follow general treatment guidelines.
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Crohns Disease (1 of 2)
Pathophysiology
Causes unknown Can affect the entire GI tract Pathologic inflammation:
Damages mucosa Hypertrophy and fibrosis of underlying muscle Fissures and fistulas

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Crohns Disease (2 of 2)
Signs and symptoms
Difficult to differentiate
Clinical presentations vary drastically.

GI bleeding, nausea, vomiting, diarrhea Abdominal pain/cramping, fever, weight loss

Treatment
Follow general treatment guidelines.
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Diverticulitis
Pathophysiology
Inflammation of small outpockets in the mucosal lining of the intestinal tract Common in the elderly Diverticulosis

Signs and symptoms

Abdominal pain/tenderness Fever, nausea, vomiting Signs of lower GI bleeding

Treatment
General treatment guidelines
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Hemorrhoids
Pathophysiology
Mass of swollen veins in anus or rectum Idiopathic

Signs and symptoms

Limited bright red bleeding and painful stools Consider lower GI bleeding

Treatment
General treatment guidelines
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Bowel Obstruction (1 of 5)
Pathophysiology
Blockage of the hollow space of the small or large intestines Hernias

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Bowel Obstruction (2 of 5)
Pathophysiology
Intussusception

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Bowel Obstruction (3 of 5)
Pathophysiology
Volvulus

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Bowel Obstruction (4 of 5)
Pathophysiology
Adhesions

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Bowel Obstruction (5 of 5)
Pathophysiology
Other causes
Foreign bodies, gallstones, tumors, bowel infarction

Signs and symptoms

Decreased appetite, fever, malaise Nausea and vomiting Diffuse visceral pain, abdominal distention Signs and symptoms of shock

Treatment
Follow general treatment guidelines.
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Accessory Organ Diseases

GI accessory organs
Liver Gallbladder Pancreas Vermiform appendix

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Appendicitis (1 of 2)
Pathophysiology
Inflammation of the vermiform appendix. Frequently affects older children and young adults. Lack of treatment can cause rupture and subsequent peritonitis.

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Appendicitis (2 of 2)
Signs and symptoms
Nausea, vomiting, and low-grade fever. Pain localizes to RLQ (McBurneys point).

Treatment
Follow general treatment guidelines.

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Cholecystitis (1 of 2)
Pathophysiology
Inflammation of the gallbladder Cholelithiasis Chronic cholecystitis
Bacterial infection

Acalculus cholecystitis
Burns, sepsis, diabetes Multiple organ failure

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Cholecystitis (2 of 2)
Signs and symptoms
URQ abdominal pain
Murphys sign

Nausea, vomiting History of cholecystitis

Treatment
Follow general treatment guidelines.

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pancreatitis (1 of 2)
Pathophysiology
Inflammation of the pancreas
Classified as metabolic, mechanical, vascular, or infectious based on cause. Common causes include alcohol abuse, gallstones, elevated serum lipids, or drugs.

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pancreatitis (2 of 2)
Signs and symptoms
Mild pancreatitis
Epigastric pain, abdominal distention, nausea/vomiting Elevated amylase and lipase levels

Severe pancreatitis
Refractory hypotensive shock and blood loss Respiratory failure

Treatment
Follow general treatment guidelines.
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hepatitis (1 of 2)
Pathophysiology
Injury to liver cells
Typically due to inflammation or infection

Types of hepatitis
Viral hepatitis (A, B, C, D, and E) Alcoholic hepatitis Trauma and other causes

Risk factors

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hepatitis (2 of 2)
Signs and symptoms
URQ abdominal tenderness Loss of appetite, weight loss, malaise Clay-colored stool, jaundice, scleral icterus Photophobia, nausea/vomiting

Treatment
Follow general treatment guidelines.
Use PPE and follow BSI precautions.
Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary
General Pathophysiology, Assessment, and Management Specific Illnesses

Bledsoe et al., Essentials of Paramedic Care: Division 1V 2006 by Pearson Education, Inc. Upper Saddle River, NJ