Gastrointestinal and Urologic Emergencies

National EMS Education Standard 3. Explain the concept of referred pain. (p 614) Competencies 4. Understand that abdominal pain can arise from other body systems. (p 614) 5. Discuss the various potential causes of acute abdomen, including diverticulitis, cholecystitis, appendicitis, perforated gastric ulcer, aortic Medicine aneurysm, hernia, cystitis, kidney infection, kidney stone, pancreatitis, Applies fundamental knowledge to provide basic and selected advanced urinary tract infections, and ectopic pregnancy and pelvic infl ammation in emergency care and transportation based on assessment fi ndings for an women. (p 615) acutely ill patient. 6. Defi ne peritonitis and list its potential signs and symptoms. (pp 614–615) 7. Describe the assessment process for patients with acute abdomen. Abdominal and Gastrointestinal (pp 620, 623) Disorders 8. Discuss general management of a patient with acute abdomen. (pp 624–625) Anatomy, presentations, and management of shock associated with abdominal 9. Describe the procedures to follow in managing the patient with shock emergencies associated with abdominal emergencies. (p 619) Gastrointestinal bleeding (p 616) 10. Understand the anatomy and physiology of the renal system. (p 618) Anatomy, physiology, pathophysiology, assessment, and management of 11. Discuss the various types of urologic pathophysiology, including urinary Acute and chronic gastrointestinal hemorrhage (p 616) tract infections (UTIs), renal calculi (kidney stones), acute renal failure, and Peritonitis (p 614) chronic renal failure. (p 617) Ulcerative diseases (p 615) 12. Explain the purpose of renal dialysis. (p 626) 13. Describe potential complications of dialysis or a missed dialysis treatment. Genitourinary/Renal (p 626) 14. Describe the assessment process for patients with urologic emergencies. Blood pressure assessment in hemodialysis patients (p 626) (p 617) Anatomy, physiology, pathophysiology, assessment, and management of 15. Discuss general management of a patient with a urologic emergency. Complications related to: (pp 624–625) Renal dialysis (p 626) 16. Discuss assessment and management of specifi c urologic emergencies, Urinary catheter management (not insertion) (p 626) including urinary tract infections (UTIs), renal calculi (kidney stones), acute Kidney stones (p 618) renal failure, and chronic renal failure. (pp 617–618)

Knowledge Objectives Skills Objective 1. Demonstrate the assessment of a patient’s abdomen. (pp 617–618) 1. Understand the anatomy and physiology of the gastrointestinal system. (p 611) 2. Deﬁ ne the term “acute abdomen.” (p 614)

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Chapter 17 Gastrointestinal and Urologic Emergencies 611

Introduction occur during ventilation. If a person needs positive-pressure  ventilation, bag-mask ventilation can push air into the lungs. Abdominal pain is a common complaint, but the cause is often If the pressure of inhalation during breathing is too high, the diffi cult to identify, even for a physician. As an AEMT, you do esophagus dilates; air then follows the path of least resistance. not need to determine the exact cause of acute abdominal pain. Given the choice between moving through a large tube into You simply need to be able to recognize a life-threatening prob- a large open space (the stomach) or moving down a series of lem and act swiftly in response. Remember, the patient is in pain progressively smaller tubes (the trachea into the right or left and is probably anxious, requiring all your skills of rapid assess- mainstem bronchus), air will fl ow into the stomach. ment and emotional support. Intertwined around the esophagus are veins that drain into This chapter begins by explaining the anatomy and physi- an even more complex series of veins, which ultimately join ology of the gastrointestinal (GI) and genitourinary systems. together to form the portal vein. The portal vein transports It then discusses the pathophysiology of an acute abdomen, venous blood from the GI tract directly to the liver for processing including signs and symptoms of the acute abdomen and how of the nutrients that have been absorbed. If blood fl ow through to examine the abdomen. Next, it discusses the different causes the liver slows for any reason, the blood may back up through- of an acute abdomen and appropriate emergency medical care. out the entire GI system because this series of veins lacks any valves. The veins surrounding the stomach and esophagus then become dilated. Even a low amount of pressure may cause leak- Anatomy and Physiology ing or rupture of these vessels.  The esophagus does not absorb nutrients but rather pushes The Gastrointestinal System the food along using rhythmic contractions called peristalsis . The food travels through the diaphragm and comes to a The GI system is also known as the digestive tract. It consists of doorway—namely, the sphincter located at the junction of the the mouth and many organs. shows the four quad- esophagus and the stomach. The cardiac sphincter (which earns rants of the abdomen. shows the solid and hollow its name because people who have regurgitation of acid out of organs of the abdomen. the stomach into the esophagus often feel they are having a heart The digestive process begins with saliva, which is secreted attack) is designed to prevent food from backing up into the into the mouth to help lubricate food. The combination of pul- esophagus. verizing and lubrication creates a substance that can be easily When empty, the stomach is rather small, but it is capable moved. Saliva also contains enzymes that begin the chemical of stretching many times beyond its normal size to accommo- breakdown of foods—in particular, starches. These complex date meals. As the food enters this muscular organ, the stomach carbohydrates can be disassembled into simple sugars that are begins to secrete hydrochloric acid, which helps to break down more easily absorbed. In addition, some initial breakdown of the food. To mix the acid with the food more evenly, the stomach triglycerides occurs. also contracts, churning the acid and food mixture together until Once food is swallowed, it moves through the esophagus. a relatively smooth consistency is achieved. The material that This muscular tube is typically collapsed (that is, closed in on exits the pyloric sphincter, the doorway at the inferior portion of itself), which allows for air to easily fl ow into the lungs but the stomach, is called chyme. not into the stomach. This collapsed tube idea also explains The stomach absorbs some materials, such as water and fat- how gastric dilation and impairment of lung expansion can soluble substances (for example, alcohol). Alcohol is absorbed

YOUYOU aarere tthehe PProviderrovider PART 1

You are dispatcheddispatched to a local dialysis clinic for a ppatientatient who “needs transtransportport to the emeremergencygency dedepartment.”partment.” On your arrival, you are ggreetedreeted by clinic staff, who state that the ppatientatient receives dialysis every Monday, Wednesday, and FridFridayay because of anuria, and today (Monday) when he came in he “wasn’t actingacting riright”ght” and seemed a little short of breath. The clinicclinic staff tell you that they are unable to pperformerform dialysis on this ppatientatient until his mental status imimproves.proves. 1. What are some ppotentialotential causes of altered mental status in a ppatientatient receivinreceivingg dialysis? 2. On the basis of the information pprovided,rovided, what tytypepe of dialysis does this ppatientatient receive? 3.3. WhatWhat iiss aanuria?nuria?

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Costal arch

Liver Right Left Spleen upper upper quadrant quadrant Umbilicus Pancreas Iliac crest Right Left Anterior lower lower superior Kidney quadrant quadrant iliac spine Kidney

Pubic Inguinal ligament symphysis Ovaries

Esophagus Bile duct Diaphragm

Liver Stomach

Gallbladder Gallbladder Stomach Spleen Small Ureter intestine Small Large intestine Large intestine intestine Appendix Rectum Fallopian tubes Urinary bladder Uterus

slowly within the stomach, but it is rapidly absorbed within the duodenum. The longer the alcohol remains within the stomach, the slower the rate of its absorption into the bloodstream. The stomach is designed to release only small amounts of the Drinking alcohol with a fatty meal will delay gastric emptying as food into the duodenum, thereby enabling the small intestine to the stomach works to digest the difﬁ cult fats. better manage digestion. The exocrine portion of the pancreas The real purpose of the digestive system is revealed in the secretes several enzymes into the duodenum that assist with next portion of the GI system, the duodenum. The main func- digestion of fats, proteins, and carbohydrates. In addition, pan- tion of the GI system is to absorb resources for use by other cells creatic juice helps to neutralize gastric acids. in the body. The liver creates bile, which is then stored in the gallbladder. The duodenum is the ﬁ rst part of the small intestine. It is Bile is an enzyme used by the body to help break down fats. Bile where the pancreas, liver, and gallbladder connect to the diges- is released into the duodenum, where it helps to emulsify (that is, tive system. It is where the active stage of absorption begins. dissolve into solution) the fats.

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Chapter 17 Gastrointestinal and Urologic Emergencies 613

The liver also affects the GI system indirectly, through movements per day and one movement every 3 days. Of course, carbohydrate metabolism. Brain cells can burn only one this number varies based on the types of food a person eats, the fuel source—glucose. If the blood glucose level falls, the amount of water consumed, exercise level, and stress level. liver can convert glycogen into glucose. Dramatic drops in sugar glucose will cause the liver to convert fats and proteins The Genital System into sugar. As blood fl ows through the liver, fat and protein metabolism continues. Without a functioning liver, a person The abdominal space also holds the male and female repro- would soon die because he or she would not be able to use ductive organs. The male reproductive system consists of the any of the proteins that were absorbed from the GI system. In testicles, epididymis, vasa deferentia, seminal vesicles, prostate addition, the liver detoxifi es drugs, completes the breakdown gland, and penis. The female reproductive system includes the of dead red and white blood cells, and stores vitamins and ovaries, fallopian tubes, uterus, cervix, and the vagina. minerals. The real workhorse of the digestive system is the small The Urinary System intestine; 90% of all absorption occurs there. This 22' -long structure is divided into three sections: the duodenum (the last The urinary system performs two main functions for the body. section of the upper GI system), the jejunum (the fi rst part of It acts as the body’s accounting fi rm, keeping track of the elec- the lower GI system), and the ileum. The small intestine pro- trolytes, water content, and acids of the blood; and it acts as duces enzymes that work with the pancreatic enzymes to turn the blood’s sewage treatment plant, removing metabolic wastes, chyme into substances that can be directly absorbed by the cap- drug metabolites, and excess fl uids. The kidneys perform these illaries of the small intestine and thereby move into the blood- functions continuously, fi ltering 200 L of blood each day. stream. The urinary system consists of the kidneys , which fi lter Blood fi lled with these nutrients exits the intestinal circu- the blood and produce urine ; the urinary bladder, which lation and heads to the liver, where additional metabolism of stores the urine until it is released from the body; the ureters , fats and proteins takes place. The blood then leaves the liver which transport the urine from the kidneys to the bladder; and and enters the subclavian vessels. Water-soluble vitamins are the urethra , which transports the urine from the bladder out absorbed into the bloodstream for use by cells. of the body. The bean-shaped kidneys are found in the retro- The large intestine, or colon, is the next destination. The peritoneal space (behind the peritoneum), which extends from substance that arrives in this 5' -long structure is no longer the 12th thoracic vertebra to the third lumbar vertebra. The called chyme, but rather feces. The valve between the ileum right kidney is slightly lower than the left owing to the position and the fi rst portion of the large intestine is called the cecum. of the liver. The medial side of the kidney is concave, form- Located directly posterior to the ileocecal valve is the appendix. ing a cleft called the hilus , where the ureters, renal blood ves- This blind pouch is able to hold small amounts of material. If sels, lymphatic vessels, and nerves enter and leave the kidney the feces contains too much bacteria, indigestible foreign bodies . are present, or the appendix becomes compressed or twisted, it A fi brous capsule covers the kidney and protects it against can become infl amed, resulting in appendicitis. infection. Surrounding this capsule is a fatty mass of adipose Rising up from the cecum is the ascending colon. It attaches tissue, which cushions the kidney and holds it in place in the to the transverse colon, which runs from right to left. After a abdomen. A layer of dense fi brous connective tissue called the 90° turn, the descending colon begins. The end of the colon is renal fascia anchors the kidney to the abdominal wall. therefore found near the left lower quadrant. The sigmoid colon Once the urine enters the collecting ducts, it passes through then takes an “S” turn, which aligns its most inferior portion in the minor calyx, into the major calyx, and then into the renal the center of the abdomen. Attached to the sigmoid colon is the pelvis. From there, the urine moves through the ureter (one rectum, the last portion of the colon. The colon terminates at ureter from each kidney) and is stored in the urinary bladder. a sphincter called the anus, where the feces are expelled from Most of the bladder sits in the anterior abdominal cavity, but the the body. dome of the bladder sits in the posterior abdominal cavity, or The primary role of the large intestine is to complete the retroperitoneum, where the ureters and kidneys reside. When reabsorption of water. Although the majority of water is reab- empty, the bladder collapses, and the muscular walls fold over sorbed in the small intestine, the osmotic function within the onto themselves. In contrast, as urine accumulates, the bladder colon helps to solidify the digested material into a formed stool. expands and becomes pear-shaped. Normally, the brain exerts Failure of this portion of the bowel can lead to a soft, watery control over the urge to void, keeping the external urinary stool, termed diarrhea. sphincter contracted until conditions are favorable for urina- The colon is also the site of bacterial digestion. Bacteria tion. At this point, the inhibition of the external urinary sphinc- normally found within the colon help to fi nish the breakdown ter is reduced and the urine passes from the urinary bladder of the chyme. This breakdown produces gas as a by-product. into the urethra. Flatulence may be considered impolite, but it is certainly The beginning of the urethra, through which urine is normal. expelled, sits at the inferior aspect of the bladder. In females, The entire digestion process takes 8 to 72 hours. At the urethra exits at the site of the external genitalia. The female this pace, bowel movements normally range between three urethra is shorter than the male urethra (4 cm versus 20 cm).

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major symptom is the same: Minor calyx severe pain. The major clini- Major calyx cal signs are abdominal ten- Kidneys derness and distention. Anatomically, the peritoneum is not one membrane, Renal medulla but two. The parietal perito- Ureters neum lines the walls of the Renal pelvis Renal cortex abdominal cavity; the visceral peritoneum covers the surface of each of the organs in the Uninary bladder abdominal cavity. Two different types of Urethra nerves supply these two areas of the peritoneum. The parietal peritoneum is supplied by the same nerves from the spinal cord that supply the skin overlying the abdomen; it can therefore perceive many of the same sensations: pain, touch, pressure, heat, and cold. These sensory nerves can easily identify and localize a point of irrita- Pathophysiology tion. In contrast, the visceral peritoneum is supplied by the  autonomic nervous system. These nerves are far less able to Acute abdomen is a medical term referring to the sudden onset localize sensation. The visceral peritoneum is stimulated when of abdominal pain that indicates an irritation of the peritoneum , distention or contraction of the hollow abdominal organs acti- the thin membrane that lines the entire abdominal cavity. This vates the stretch receptors. This sensation is usually inter- condition, called peritonitis, can be caused by an infection, a preted as colic , a severe, intermittent cramping pain. Other penetrating abdominal wound, a blunt injury severe enough to painful sensations that occur because of an irritated visceral damage abdominal organs, and many diseases. In all cases, the peritoneum may be perceived at a distant point on the surface

YOUYOU aarere tthehe PProviderrovider PART 2

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Chapter 17 Gastrointestinal and Urologic Emergencies 615

of the body, such as the back or shoulder. This phenomenon shock. This problem can be compounded by massive internal is called referred pain . or external bleeding, resulting in severe inadequate perfusion Referred pain is the result of connections between the (shock). The patient may have normal vital signs or, if the perito- body’s two separate nervous systems. The spinal cord supplies nitis has progressed further, signs of shock (such as restlessness, sensory nerves to the skin and muscles; these nerves are a part tachycardia, and hypotension). When peritonitis is accompanied of the somatic (voluntary) nervous system. The autonomic ner- by hemorrhage, the signs of shock are much more apparent. vous system controls the function of the abdominal organs and Fever may or may not be present, depending on the cause the caliber of the blood vessels. The nerves connecting these of the peritonitis. Patients with diverticulitis (an infl ammation two systems cause the stimulation of the autonomic nerves to of small pockets in the colon) or cholecystitis (infl ammation of be perceived as stimulation of the spinal sensory nerves. For the gallbladder) may have a substantial elevation in temperature, example, acute cholecystitis (infl ammation of the gallbladder) which may be due to the infl ammatory process itself or an under- may cause referred pain to the right shoulder because the auto- lying infection. However, patients with acute appendicitis may nomic nerves serving the gallbladder lie near the spinal cord at have a normal temperature until the appendix ruptures and an the same anatomic level as the spinal sensory nerves that supply abscess starts to form. the skin of the shoulder . The more common abdominal emergencies, with most Peritonitis typically causes ileus , or paralysis of the mus- common locations of direct and referred pain, are listed in cular contractions that normally propel material through the . intestine (peristalsis). The retained gas and feces, in turn, cause abdominal distention. In the presence of such paralysis, nothing Causes of Acute Abdomen that is eaten can pass normally out of the stomach or through the bowel. The only way the stomach can empty itself, then, is Many organs in the abdominal cavity are covered by visceral by emesis , or vomiting. For this reason, peritonitis is almost peritoneum; parietal peritoneum covers the inside aspect of always associated with nausea and vomiting. These complaints the abdominal wall that forms the abdominal cavity. The entire do not point to a particular cause because they can accompany abdominal cavity normally contains a very small amount of almost every type of GI disease or injury. peritoneal fl uid to bathe the organs. Any condition that allows Peritonitis is associated with a loss of body fl uid into the pus, blood, feces, urine, gastric juice, intestinal contents, bile, abdominal cavity and usually results from abnormal shifts of fl uid pancreatic juice, amniotic fl uid, or other foreign material to lie from the bloodstream into body tissues. This decreases the vol- within or adjacent to this cavity can cause peritonitis and, thus, ume of circulating blood and may eventually cause hypovolemic an acute abdomen. Technically, organs such as kidneys, ovaries,

Table 17-1 Common Abdominal Conditions Condition Localization of Pain Appendicitis Around navel (referred); right lower quadrant (direct) Cholecystitis Right shoulder (referred); right upper quadrant (direct) Duodenal ulcer Upper midabdomen or upper back Synapse points area Diverticulitis Left lower quadrant Aortic aneurysm Low back and right lower quadrant (ruptured or dissecting) Cystitis (infl ammation of Lower midabdomen (retropubic) the urinary bladder) Kidney infection Costovertebral angle Gallbladder (pyelonephritis) Kidney stone Right or left fl ank, radiating to genitalia (referred) Pelvic infl ammation (in Both lower quadrants women) Pancreatitis Upper abdomen (both quadrants); back

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616 Section 6 Medical

and other genitourinary structures are retroperitoneal (behind Pancreatitis can be caused by an obstructing gallstone, alcohol the peritoneum). However, because they lie next to the perito- abuse, and other diseases. Severe pain may present in the upper neum, problems in these organs can lead to an acute abdomen. left and right quadrants and may often radiate to the back. Therefore, nearly every kind of abdominal problem can Other signs and symptoms accompanying the pain are nausea cause an acute abdomen. and vomiting, abdominal distention, and tenderness. Complica- tions like sepsis or hemorrhage can occur, in which case assess- Ulcers ment may also reveal fever or tachycardia. The stomach and duodenum are subjected to high levels of acidity. To prevent damage to these organs, protective layers of Appendicitis mucus line both organs. In peptic ulcer disease, the protective The appendix is a small recess in the large intestine. Infl am- layer is eroded, allowing the acid to eat into the organ itself mation or infection in the appendix is called appendicitis and during a period of weeks, months, or even years. is a frequent cause of acute abdomen. This infl ammation can Most peptic ulcers are the result of infection of the stomach eventually cause the tissues to die and/or rupture, causing an with Helicobacter pylori. Another major cause is long-term use abscess, peritonitis, or shock. Initially, the pain caused by appen- of nonsteroidal anti-infl ammatory drugs. Alcohol and smoking dicitis is more generalized, dull, and diffuse and may center in can also affect the severity of peptic ulcer disease by increasing the umbilical area. The pain later localizes to the right lower gastric acidity. quadrant of the abdomen. Appendicitis can also cause referred Peptic ulcer disease affects men and women equally but pain. The patient may also report nausea and vomiting, anorexia tends to occur more often in the older population. As people (lack of appetite for food), fever, and chills. A classic symptom age, the immune system’s ability to fi ght infection decreases, of appendicitis is rebound tenderness. Rebound tenderness is making infection more likely. The geriatric population, in gen- a result of peritoneal irritation. This can be assessed by pressing eral, also uses nonsteroidal anti-infl ammatory drugs frequently down gently and fi rmly on the abdomen. The patient will feel for arthritis and other musculoskeletal conditions. pain when the pressure is released. Women who are pregnant Patients with peptic ulcers experience a classic sequence of may not exhibit this symptom. burning or gnawing pain in the stomach that subsides or diminishes immediately after eating and then reemerges 2 to 3 hours Gastrointestinal Hemorrhage later. The pain usually presents in the upper part of the abdo- Bleeding within the GI tract is a symptom of another disease, not men but sometimes may be found below the sternum. With a disease itself. Gastrointestinal hemorrhage can be acute, which some patients, the pain occurs immediately after eating. Nau- may be shorter term and more severe, or chronic, which may be sea, vomiting, belching, and heartburn are common symptoms. of longer duration and less severe. All complaints of bleeding If the erosion is severe, gastric bleeding can occur, resulting in should be considered serious. hematemesis and melena (black, tarry stools containing blood). A GI hemorrhage can occur in the upper or lower GI tract. Some ulcers will heal without medical intervention, but Bleeding in the upper GI tract occurs from the esophagus to the often complications can occur from bleeding or perforation upper part of the small intestine. In the esophagus, problems (a hole through the wall of the stomach). More serious ulcerative might include esophagitis, esophageal varices, or Mallory-Weiss conditions can cause severe peritonitis and an acute abdomen. syndrome. Lower GI bleeding occurs between the upper part of the Gallstones small intestine and the anus. Bowel infl ammation, diverticulitis, The gallbladder is a storage pouch for digestive juices and waste and hemorrhoids are common causes of bleeding in the lower from the liver. Gallstones can form and block the outlet from the GI tract. gallbladder, causing pain. Sometimes the blockage will pass, but if not, it can lead to severe infl ammation of the gallbladder, called Esophagitis cholecystitis. This is a condition in which the wall of the gall- Esophagitis occurs when the lining of the esophagus becomes bladder becomes infl amed. In severe cases, the gallbladder may infl amed by infection or from the acids in the stomach (gastro- rupture, causing infl ammation to spread and irritate surround- esophageal refl ux disease). The patient may report pain with ing structures such as the diaphragm and bowel. This condition swallowing and complain of feeling like an object is stuck in his presents as a constant, severe pain in the right upper or midab- or her throat. Additional symptoms include heartburn, nausea, dominal region and may refer to the right upper part of the back, vomiting, and sores in the mouth. In the worst cases, bleeding shoulder area, or fl ank. The pain may steadily increase for hours can occur from the small capillary vessels within the esophageal or may come and go. Cholecystitis commonly produces symp- lining or the main blood vessels. toms about 30 minutes after a particularly fatty meal and usually at night. Other symptoms include general GI distress such Esophageal Varices as nausea and vomiting, indigestion, bloating, gas, and belching. Esophageal varices occur when the amount of pressure within the blood vessels surrounding the esophagus increases. The Pancreatitis esophageal blood vessels eventually deposit their blood into the The pancreas forms digestive juices and is also the source of portal system. If the liver becomes damaged and blood cannot insulin. Infl ammation of the pancreas is called pancreatitis. fl ow through it easily, blood begins to back up into these portal

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Chapter 17 Gastrointestinal and Urologic Emergencies 617

vessels, dilating the vessels and causing the capillary network of or frequent small liquid stools. The diarrhea may contain blood the esophagus to begin leaking. If pressure continues to build, and/or pus, and it may have a foul odor or be odorless. Abdom- the vessel walls may fail, causing bleeding. inal cramping is frequently reported. Nausea, vomiting, fever, In industrialized countries, alcohol is the main cause of por- and anorexia are also present. If the diarrhea continues, dehy- tal hypertension. Long-term alcohol consumption damages the dration will result. As the volume of fl uid loss increases, the interior of the liver (cirrhosis), leading to slower blood fl ow. In likelihood of shock increases. developing countries, viral hepatitis is the main cause of liver damage. Diverticulitis Presentation of esophageal varices takes two forms. Initially, Diverticulitis was fi rst recognized around 1900, when the types the patient shows signs of liver disease—fatigue, weight loss, of foods people ate began to change dramatically. In particu- jaundice, anorexia, edema in the abdomen, abdominal pain, nau- lar, the amount of fi ber within the US diet plummeted as the sea, and vomiting. This very gradual disease process takes months amount of processed foods eaten increased. to years before the patient reaches a state of extreme discomfort. As the amount of fi ber consumed as part of the diet By contrast, the rupture of the varices is far more sudden. decreases, the consistency of the normal stool becomes The patient will complain of sudden-onset discomfort in more solid. This hard stool requires more intestinal contrac- the throat. He or she may have severe diffi culty swallow- tions, subsequently increasing pressure within the colon. In ing, vomiting of bright red blood, hypotension, and signs of this environment, small defects within the colonic wall that shock. If the bleeding is less dramatic, hematemesis (vomit- would otherwise never pose a problem now fail, resulting ing blood) and melena (black, tarry stools) are likely. Regard- in bulges in the wall. These small outcroppings eventually less of the speed of bleeding, damage to these vessels can be turn into pouches, called diverticula. As feces travel through life threatening. Spontaneous rupture is often life threatening, the colon, some may become trapped within these pouches. and signifi cant blood loss at the scene may be evident. Major When bacteria grow there, they cause localized infl ammation ruptures can lead to death in a matter of minutes. and infection. The main symptom of diverticulitis is abdominal pain, Mallory-Weiss Syndrome which tends to be localized to the left side of the lower abdo- Mallory-Weiss syndrome may lead to severe hemorrhage. In men. Classic signs of infection include fever, malaise, body this condition, the junction between the esophagus and the aches, chills, nausea, and vomiting. Bleeding is rare with this stomach tears, causing severe bleeding and, potentially, death. condition. Because of the local infections of these pouches, Primary risk factors include alcoholism and eating disorders. adhesions may develop, narrowing the diameter of the colon Mallory-Weiss syndrome affects men and women equally but is and resulting in constipation and bowel obstruction. more prevalent in older adults and older children. Vomiting is the principal symptom. In women, this syn- Hemorrhoids drome may be associated with severe vomiting related to preg- Hemorrhoids are created by swelling and infl ammation of the nancy. The extent of the bleeding can range from very minor blood vessels surrounding the rectum. They are a common bleeding, resulting in very little blood loss, to severe bleeding problem, with almost half the population having at least one and extreme fl uid loss. In extreme cases, patients may experi- hemorrhoid by age 50 years. Hemorrhoids may result from ence signs and symptoms of shock, upper abdominal pain, conditions that increase pressure on the rectum or irritation of hematemesis, and melena. the rectum. Pregnancy, straining at stool, and chronic constipation cause increased pressure. Diarrhea can cause irritation. Gastroenteritis Hemorrhoids often result in bright red blood noted dur- Acute infectious gastroenteritis comprises a family of condi- ing defecation. This bleeding tends to be minimal and is easily tions revolving around a central theme of infection combined controlled. In addition, patients may experience itching and a with diarrhea, nausea, and vomiting. Bacterial and viral organ- small mass on the rectum. Typically, this mass is a clot formed isms can cause this condition. These organisms typically enter in response to the mild bleeding. the body through contaminated food or water. Patients may begin to experience an upset stomach and diarrhea as soon as Urinary System several hours or several days after contact with the contaminated matter. The disease can then run its course in 2 to 3 days Diseases and problems of the renal and urologic system can or continue for several weeks. cause acute abdominal pain. These conditions range from mild There are other types of gastroenteritis that are not infec- (urinary tract infections) to true emergencies (acute renal fail- tious but have all of the hallmarks of acute infectious gastroen- ure). Although the prehospital care for many urologic diseases teritis. Patients with this condition experience nausea, vomiting, is supportive, your ability to recognize the signs and symptoms and diarrhea from a noninfectious cause, such as medications, of the true emergencies is critical to providing your patients toxins from shellfi sh, or chemotherapy. with the best chance of a positive outcome. Diarrhea is the principal symptom in both types of gastro- Urinary tract infections (UTIs) usually develop in the enteritis. Patients may experience large dumping-type diarrhea lower urinary tract (urethra and bladder) when normal fl ora

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bacteria, which exist naturally on the skin, or other bacteria It is accompanied by an increase of toxins in the blood. Patients enter the urethra and grow. These infections are more common with ARF have an overall mortality rate of 50%, but the disease in women owing to the relatively short urethra and the proxim- is reversible if diagnosed and treated early. ity of the urethra to the vagina and rectum. A UTI in the upper If the urine output drops to less than 500 mL/d, the condi- urinary tract (ureters and kidneys) occurs most often when a tion is called oliguria . If urine production stops completely, the lower UTI goes untreated. Upper UTIs can lead to pyelonephri- condition is called anuria . Whenever ARF occurs, the patient tis (infl ammation of the kidney and renal pelvis) and abscesses, may experience generalized edema, acid buildup, and high lev- which eventually reduce kidney function. In severe cases, els of waste products in the blood. If left untreated, ARF can untreated UTIs can lead to sepsis. lead to heart failure, hypertension, and metabolic acidosis. Common symptoms in patients with a lower UTI include Chronic renal failure (CRF) is progressive and irreversible painful urination, frequent urges to urinate, and diffi culty in inadequate kidney function. This disease develops over months or urination. The pain usually begins as a visceral discomfort but years. More than half of all cases are caused by systemic diseases, then converts to an extreme burning pain, especially during such as diabetes or hypertension. In addition, CRF can be caused urination. The pain, which remains localized in the pelvis, is often by congenital disorders or prolonged pyelonephritis or can be a perceived as bladder pain in women and as prostate pain in men. secondary effect of some infections, such as strep throat. Sometimes the pain may be referred to the shoulder or neck. In As the nephrons of the kidney become damaged and cease addition, the urine will have a foul odor and may appear cloudy. to function, scarring occurs. The tissue begins to shrink and waste away as the scarring progresses, leading to a loss of neph- Renal System rons and renal mass. As kidney function diminishes, waste products and fl uid build up in the blood. Systemic complications can Kidney stones originate in the renal pelvis and result when develop, such as hypertension, congestive heart failure, anemia, an excess of insoluble salts or uric acid crystallizes in the urine and electrolyte imbalances. . This excess of salts is typically due to water intake Patients with CRF exhibit several signs and symptoms, that is insuffi cient to dissolve the salts. The stones consist of dif- beginning with an altered level of consciousness. In the late ferent types of chemicals, depending on the precise imbalance stages, seizures and coma are possible. The patients may also in the urine. present with lethargy, nausea, headaches, cramps, and signs of The most common stones—calcium stones—occur more anemia. frequently in men than in women and may have a hereditary In a case of CRF, the patient’s skin will be pale, cool, and component. These stones also occur in patients with metabolic moist, and the patient may appear jaundiced because of the disorders such as gout or with hormonal disorders. buildup of wastes. A powdery accumulation of uric acid, called Patients who have kidney stones will almost always be in uremic frost , may also be present, especially on the face. The pain. (Many rate kidney stone pain as 11 on a scale of 1 to 10.) skin may appear bruised, and muscle twitching may be present. The pain usually starts as a vague discomfort in the fl ank but Patients with CRF exhibit edema in the extremities and face becomes very intense within 30 to 60 minutes. It may migrate for- because of fl uid imbalances; they will also be hypotensive and ward and toward the groin as the stone passes through the system. have tachycardia. Pericarditis and pulmonary edema are also Some patients will be agitated and restless as they walk and common and should be considered during auscultation of the move in an attempt to relieve the pain. Others will attempt to chest. remain motionless and guard the abdomen. Either behavior makes palpation of the abdomen diffi cult. Vital signs will vary, Female Reproductive Organs depending on the severity of pain. The greater the pain, the higher will be the blood pressure and pulse. Gynecologic problems are a common cause of acute abdominal If a stone has become lodged in the lower part of the ureter, pain. Always consider that a woman with lower abdominal pain signs and symptoms of a UTI (frequency and urgency of uri- and tenderness may have a problem related to her ovaries, fal- nation, painful urination, lopian tubes, or uterus. and/or hematuria ) may be Pain may also be related to the normal menstrual cycle. present, but the patient will A common lower abdominal pain, often confused with appen- not have a fever. If a kid- dicitis but fairly short-lived, is called mittelschmerz . It is ney stone is suspected, be associated with the release of an egg from the ovary, char- sure to obtain a patient his- acteristically occurring in the middle of the menstrual cycle tory and a family history; between menstrual periods. Mittelschmerz may also be asso- both can supply important ciated with lower abdominal tenderness. Some women expe- information. rience painful cramps at the time of their menstrual periods. Acute renal failure In some, the discomfort may be crippling and the menstrual (ARF) is a sudden (possi- fl ow severe. bly during a period of days) A common cause of an acute abdomen in women is pelvic decrease in kidney fi ltration. infl ammatory disease (PID), an infection of the fallopian

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Chapter 17 Gastrointestinal and Urologic Emergencies 619

tubes and the surrounding tissues of the pelvis. With PID, A hernia is a protrusion of an organ or tissue through a hole acute pain and tenderness in the lower part of the abdomen in the body wall covering its normal site. Virtually any organ or may be intense and accompanied by a high fever. tissue in the body can herniate through its covering membranes Between 1% and 2% of all pregnancies are ectopic. The term in certain circumstances. Hernias can occur as a result of the ectopic pregnancy means that a fertilized egg has come to lie following: in an area outside the uterus, usually in a fallopian tube. A fal- A congenital defect, as around the umbilicus lopian tube is simply not large enough to support the growth of A surgical wound that has failed to heal properly a fetus and placenta for more than about 6 to 8 weeks. When Some natural weakness in an area such as in the groin the tube ruptures, it produces massive internal hemorrhage and Hernias always produce a mass or lump that is usually acute abdominal pain, generally on one side. In this situation, easy to detect. Extreme obesity may interfere with the ability to the acute abdomen may be associated with the onset of hypo- detect the mass. At times, the mass will disappear back into the volemic shock. body cavity in which it belongs. In this case, the hernia is said to be reducible . If the mass cannot be pushed back within the body, it is said to be incarcerated . Other Organ Systems Reducible hernias pose little risk; some people live with The aorta lies immediately behind the peritoneum on the spinal them for years. When a hernia is incarcerated, however, its con- column. In older people, the wall of the aorta sometimes devel- tents may become seriously compressed by the surrounding tis- ops weak areas that swell to form an aneurysm (a swelling or sue, eventually compromising the blood supply. This situation, enlargement of a part of an artery, resulting from weakening called strangulation , is a serious medical emergency. Immedi- of the arterial wall). The development of an aneurysm, unless ate surgery is required to remove any dead tissue and repair the acutely dissecting, is rarely associated with symptoms because hernia. it occurs slowly, but if the aneurysm ruptures, massive hem- The following signs and symptoms indicate a serious hernia orrhage may occur and, with it, the signs of acute peritoneal problem: irritation. The patient may also experience severe back pain The existence of the hernia itself because the peritoneum can, at times, be rapidly stripped away A previously reducible mass that can no longer be pushed from the wall of the main abdominal cavity by the hemorrhage. back inside the body Pain can also be associated with the pressure of blood on the Pain at the hernia site back itself. In such cases, bleeding usually leads to profound Tenderness when the hernia is palpated shock. Red or blue discoloration of the skin over the hernia

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620 Section 6 Medical

Patient Assessment Painful or frequent urination  Discolored urine accompanied by a strong odor Tachycardia Scene Size-up Hypotension  Fever SSceene Safeetyy A patient with urologic or renal problems may exhibit Scene safety is the paramount concern for all types of calls. Fol- extremes of activity. Is the patient constantly changing posi- low standard precautions, and use a minimum of gloves and tions in an attempt to fi nd a comfortable position (“the kidney eye protection. Consider donning a gown and covering your stone dance”)? Or is the patient sitting very still with the knees shoes with disposable, protective covers because there may be drawn to the chest? Is the abdomen distended or rigid? If you feces and urine on the fl oor and some patients may have active fi nd any life-threatening conditions, take immediate steps to projectile vomiting. Examples of additional resources for a GI correct them. patient include extra gloves, mask, gowns, change of uniform, suction equipment, extra linens, blankets, wash cloths, towels, and adult and child diapers. SpecialSpecial PPopulationsopulations As you proceed to the patient, observe the scene for safety threats to yourself and your partner, and determine the number Use a hands-off assessment to estestabablishlish a generalgeneral impres-impres- of patients at the scene. If your call involves going to the patient’s sionsion when dealindealingg with ppediatricediatric ppatients.atients. home and he or she does not come to the door, the patient may have had a syncopal episode (fainted). Request police assistance to help you gain access to the patient. Consider the need for additional or specialized medical resources. Call for additional Remember, it is not critical for you to determine the cause resources earlier rather than later. of acute abdomen but to recognize potential causes and provide the correct supportive care. Mechanism of Injury/Nature of Illness In forming your general impression, closely examine the The mechanism of injury or nature of illness, as with most location where the patient is found because it can provide hints medical complaints, will contribute to your initial impression. about what happened. Was the patient walking to the bathroom Early in the call, the only information available may have come when he or she passed out? Has the patient been sick for several from the dispatch center. Use this information to help choose days and camped out on the couch? Was the patient at work the amount of equipment you will take into the scene. Acute when a sudden bout of pain doubled him or her over? abdomen can be the result of violence, such as blunt or pen- One aspect of the general impression that is different for etrating trauma, so always be vigilant. Chapter 29, Abdominal GI patients is odor. What is the smell of the room or location and Genitourinary Injuries , discusses traumatic injuries in detail. of the patient? There are few EMS calls that rise to the level of Note that most calls for GI problems will not involve multi- noxious odor as those that involve upper GI bleeding. The foul- ple patients. However, a call for assistance at an offi ce build- smelling stool that accompanies these calls can make even an ing where several people are complaining about GI symptoms experienced AEMT nauseous. When dealing with these strong should lead you to suspect release of an agent. Biologic or odors, the key is to hold your ground. The sense of smell is the chemical agents, for example, can cause people to have abdom- most acute for about 1 minute, but then more than 50% of the inal pain, nausea, vomiting, diarrhea, and other GI signs and intensity of an odor is lost due to the olfactory nerve becoming symptoms. tired of sending the same signal. If you are faced with a strong odor on a call, stay in the environment. After 2 to 5 minutes, the Primary Assessment smell may be barely noticeable.  Airway and Breathing Form a General Impression Airway patency becomes a pertinent concern with a GI patient. The following is a checklist of common signs and symptoms of A patient who is vomiting has a greater chance to aspirate. In irritation or infl ammation of the peritoneum that you can use to patients who are awake and responsive, positioning is key to determine whether a patient has an acute abdomen: maintaining a patent airway. In patients who have an altered Local or diffuse abdominal pain and/or tenderness mental status, open the airway using the appropriate maneu- A quiet patient who is guarding the abdomen vers, and closely inspect it for foreign bodies. Remove or suction Rapid and shallow breathing any obstructions that are found. While evaluating the airway, Referred (distant) pain notice any unusual odors emanating from the mouth. Patients Anorexia, nausea, and vomiting who have extremely advanced bowel obstructions can have fec- Hematemesis (bright red or “coffee-ground” emesis) ulent breath, smelling of stool. Tense, often distended, abdomen GI problems rarely affect breathing directly. If a breathing Sudden constipation or bloody diarrhea problem is encountered, it typically stems from a severe compli- Dark, tarry stool (melena) cation. Ensure that the airway is clear. In particular, if the patient

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Chapter 17 Gastrointestinal and Urologic Emergencies 621

has aspirated, it can affect his or her ability to oxygenate and puddle. Spill another volume of water on a hard surface such as ventilate. Also, as a result of the abdominal pain, the patient a tile fl oor; again note the size of the puddle. may show shallow or inadequate respirations because deep breaths often intensify the pain. Transport Decision When making your transport decision, integrate the information Circulation obtained in the primary assessment. If the patient has positive The assessment of the circulatory system is essential in under- orthostatic vital signs (that is, serial vital signs change with a standing how the GI issue is affecting the body. As with all change in position), thoughtfully consider how the patient will patients, assess skin color, temperature, and condition (that be moved. Can the patient sit up in a stair chair, or will he or is, moist or dry and turgor). Determine the heart rate. Evalu- she pass out? Is the patient in critical condition so that he or she ate the peripheral pulses, and compare them with the central needs to be moved urgently? pulses. Remember to assess for major bleeding. The patient’s Certain patients should be transported quickly. Patients pulse rate and quality, as well as skin condition, may indicate who have airway, breathing, or circulation problems, including shock. Check the pulses in both arms because a difference in problems with pulse and perfusion, and patients with suspected pulse strength may indicate an abdominal aortic aneurysm. internal bleeding require rapid transport. Included in the group Many GI diseases involve pain and/or hemorrhage. As to package quickly and transport rapidly are patients who have a blood volume begins to drop, the body tries to compensate poor general impression, especially pediatric and geriatric patients. for this change by releasing catecholamines in the form of epi- Pale, cool, diaphoretic skin; tachycardia; hypotension; and altered nephrine and norepinephrine. These agents attempt to stabilize level of consciousness are all signs of signifi cant illness. blood pressure through vasoconstriction, increased heart rate, Ensure that the ride during transport is as gentle as possible and increased force of left ventricular contraction. Pain stim- for the patient. Drive smoothly and steadily. Rapid driving can ulates similar body responses. Either problem can leave the result in increased vehicle movement, potentially aggravating patient with tachycardia, diminished peripheral pulses, diapho- and possibly worsening the patient’s abdominal pain. resis, and pale, cool, clammy skin. Shock may be caused by hypovolemia or may be the result of a severe infection (sepsis). If evidence of shock (inadequate WordsWords ooff WWisdomisdom perfusion) is present, interventions should include high-fl ow oxygen, keeping the patient warm, and placing the patient in the An acute abdomen is characterized by abdominal ppainain and position dictated by local protocol for shock patients. Ensure that tenderness.tenderness. you provide prompt treatment for life threats, and do not delay in providing transport. Check the patient’s blood pressure. To ensure the accuracy of this measurement, obtain a manual pressure before you use History Taking one of the automated blood pressure machines.  Orthostatic vital signs will help you determine the extent Investigate Chief Complaint of bleeding that has occurred. First, have the patient assume Pain is often a fi nding of importance in patients with GI prob- a position of comfort, usually seated or lying down. Take an lems because it can indicate trauma, hemorrhage, infection, accurate blood pressure and heart rate. Next, have the patient or obstruction. As with the primary assessment, use OPQRST change positions (that is, have the patient stand or sit up). Use ( O nset, P rovocation / palliation, Q uality, R egion / radiation, caution, because the patient may lose consciousness with a S everity, and T iming of pain) to elaborate on the chief com- positional change. Wait a minute or two, and then repeat the plaint. describes the types of pain that may be experi- blood pressure and heart rate measurements. Normally, there enced with an abdominal problem. should be little change in the blood pressure or heart rate with In patients with a urologic problem, the patient history such a positional change. When a patient has a signifi cant loss and physical examination will provide the information needed of fl uid within the vascular space, however, there may be a to successfully manage the patient. Determining that the pain 10-beat increase in the heart rate and/or a 10–mm Hg drop in actually started in the fl ank and not in its present location of blood pressure. A decrease in a patient’s blood pressure while the lower right quadrant could mean the difference between a sitting up from a lying position or when standing up from a correct fi eld diagnosis of a kidney stone and an incorrect fi eld sitting position is called orthostatic hypotension . diagnosis of appendicitis. Similarly, determining that the patient When you examine a patient with a GI problem for gross has a history of diabetes and hypertension along with signs of bleeding, it is not unusual to fi nd large amounts of blood. Take uremia can help confi rm your impression of CRF. note of the amount of blood lost, focusing on being accurate. The emotional effects of seeing large amounts of blood could SAMPLE History lead people to overestimate the volume lost. The amount of The SAMPLE history will help elicit the relevant current and past blood in a toilet is particularly diffi cult to estimate owing to medical history. When asking patients about their complaints, dilution. To practice volume estimation, measure the amount of you often need to discuss subjects that are not commonly water in a glass, and then spill it on a carpet; note the size of the described with everyday language. It is important that you and

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622 Section 6 Medical

Table 17-2 Types of Abdominal Pain Abdominal Pain Type Origin Description Cause Visceral discomfort Hollow organs Diffi cult to localize; described as burning, Organ contracts too forcefully or is cramping, gnawing, or aching; usually felt distended (stretched) superfi cially Parietal pain/rebound Peritoneum Steady, achy pain; easier to localize than Infl ammation of the peritoneum (due pain visceral; increases with movement to blood and/or infection) Somatic pain Peripheral nerve Well localized pain; usually felt deeply Irritation or injury to tissue causing tracts activation of peripheral nerve tracts Referred pain Peripheral nerve Pain originating in the abdomen and causing Similar paths for the peripheral tracts “pain” in distant locations; usually occurs nerves of the abdomen and the after initial visceral, parietal, or somatic pain distant location

your patient have a common frame of reference. For example, mouth. Food or fl uid may only aggravate many of the symptoms. one person’s “diarrhea” may be another person’s “soft stool.” Also, the presence of food in the stomach increases the risk of Ask the following questions specifi c to the signs and symp- aspiration, especially if the patient needs emergency surgery. toms of a GI or urologic emergency: Finally, determine the events that led up to the patient’s Nausea and vomiting. Do you feel nauseous? Have you present illness. It is important to determine whether this is a vomited? How many times? In what period of time? Was medical emergency or related to trauma. Therefore, you need to there red blood? Did it look like coffee grounds? ask the patient about any recent trauma. The SAMPLE history may not affect the interventions you Changes in bowel habits. Has there been any change in your bowel habits? Have you been constipated? Did the perform, but it will help provide needed information for the stool look dark and tarry? Have you had diarrhea? Was physician in the emergency department to aid in determining there any red blood in it? the cause of the acute abdomen. Urination. Have you been urinating more or less often than usual? Is there pain when you urinate? Is the color of the Secondary Assessment urine dark or unusual? Is there an unusual odor?  Weight loss. Have you lost weight recently? How many If the secondary assessment is not performed at the scene, pounds? it is performed in the back of the ambulance en route to the Belching or fl atulence. Have you experienced belching or hospital. However, there will be situations when you may not fl atulence? For how long? have time to perform a secondary assessment if you have to Pain. What does the pain feel like? How long have you had continually manage life threats that were identifi ed during the this pain? Is the pain constant or intermittent? primary assessment. If the patient is in stable condition and has Other. Ask about any other signs or symptoms related an isolated complaint, the secondary assessment may be done at to this complaint, such as “Are there any changes you the scene. have noted recently that may be contributing to your In some situations, patients are comfortable only when lying pain?” in one particular position, which tends to relax muscles adjacent Concurrent chest pain. If the patient reports chest pain, to the infl amed organ and thus lessen the pain. Therefore, the use OPQRST. position of the patient may provide you with an important clue. For example, a patient with appendicitis may draw up the right Continue with the SAMPLE history. Does the patient have knee. A patient with pancreatitis may lie curled up on one side. any allergies? What are the patient’s current medications? Determine the patient’s general state of health through the Physical Examinations pertinent past history. Has the patient experienced this kind A healthy or normal abdomen should be soft and should not be of abdominal pain before? If the patient is female and of tender. An acute abdomen is characterized by abdominal pain childbearing age, determine the date of her last menstrual and tenderness. The pain may be sharply localized or diffuse period. This will help determine if the patient could possibly be pregnant or raise the suspicion of an ectopic pregnancy. Has the patient had any surgery or recent hospitalizations? Ask the patient about his or her last oral intake. It is WordsWords ooff WWisdomisdom important to determine whether the patient has ingested any substance that could be causing the acute abdomen. If eating When you are ppalpatingalpating the abdomen, always bebegingin on the side oppositeopposite from the site of ppain.ain. causes pain, discomfort, vomiting, or diarrhea, the patient will eat less often or stop eating. Do not give the patient anything by

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Chapter 17 Gastrointestinal and Urologic Emergencies 623

WordsWords ooff WWisdomisdom

An acuteacute aabdomenbdomen may inindicatedicate pperitonitis,eritonitis, in wwhichhich ggen-en- eralized signssigns can make it challenchallengingging to determine exactly where the pproblemroblem lies, even for pphysicians.hysicians. KnowinKnowingg abdom- inalinal assessment stestepsps well and recordinrecordingg your ﬁ ndingsndings in detail are imimportantportant early comcomponentsponents of the pprocessrocess that lleadseads to diadiagnosis.gnosis.

(widespread) and will vary in severity. Localized pain gives a clue to the problem organ or area causing it. Tenderness may be minimal or so great that the patient will not allow you to touch the abdomen. In some cases, the muscles of the abdominal wall become rigid in an involuntary effort to protect the abdomen from further irritation. This boardlike muscle spasm, called guarding , can be seen with major problems such as a perforated peptic ulcer or pancreatitis. Remember, a patient with peritonitis usually has abdominal pain, even when lying quietly. The patient can be quiet but 8. Palpate and wait for the patient to respond, looking for a have diffi culty breathing and may take rapid, shallow breaths facial grimace or a verbal “ouch.” Do not ask the patient, because of the pain. Usually, you will fi nd tenderness on palpa- “Does it hurt here?” as you palpate. tion of the abdomen or when the patient moves. The degree of 9. Determine whether the patient exhibits rebound pain and tenderness is usually related directly to the severity of tenderness (may be tender when direct pressure is peritoneal infl ammation. applied, but very painful when pressure is released). Use the following steps to assess the abdomen: This is an indicator of peritonitis. When you are palpating for rebound tenderness, you should use 1. Explain to the patient what you are going to do in terms of extreme caution. assessing the abdomen. 10. Determine whether the patient can relax the abdominal 2. Place the patient in a supine position with the legs drawn wall on command. up and fl exed at the knees to relax the abdominal muscles, 11. Guarding and rigidity may be detected. Guarding is unless trauma is involved, in which case the patient tensing of the abdominal wall muscles. will remain supine and stabilized. Determine whether the patient is restless or quiet and whether motion Vital Signs causes pain. Findings of a high respiratory rate with a normal pulse rate and 3. Expose the abdomen and visually assess it. Does the blood pressure may indicate the patient is unable to ventilate abdomen appear distended (enlarged)? Do you see any properly because deep breathing causes pain. A high respira- pulsating masses (indicates an aortic aneurysm)? Is there tory rate and pulse rate with signs of shock, such as pallor and any bruising of the abdominal wall? diaphoresis (profuse sweating), may indicate septic or hypovo- 4. Ask the patient where the pain is most intense. You lemic shock. will need to palpate in a clockwise direction beginning with the quadrant after the one the patient indicates is Monitoring Devices tender or painful; end with the quadrant the patient Use pulse oximetry and noninvasive blood pressure devices indicates is tender or painful. If the most painful area when these monitoring devices are available. It is recommended is palpated fi rst, the patient may guard against further that you always assess the patient’s fi rst blood pressure manu- examination, making your assessment more diffi cult ally with a sphygmomanometer (blood pressure cuff ) and and less reliable. stethoscope. 5. Remember to be very gentle when palpating the abdomen. Occasionally, an organ within the abdomen will be enlarged and very fragile and rough palpation could cause Reassessment further damage. If you see a pulsating mass, do not touch  it; doing so could cause the aorta to rupture. Because it is often diffi cult to determine the cause of an acute 6. Palpate the four quadrants of the abdomen gently to abdominal emergency, it is extremely important to reassess determine whether each quadrant is tense (guarded) or your patient frequently to determine whether the patient’s soft when palpated . condition has changed. Remember, the condition of a patient 7. Note whether the pain is localized to a particular quad- with an acute abdomen can change rapidly from stable to rant or diffuse (widespread). unstable.

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Vital signs must be reassessed and compared with the patient’s baseline vital signs. If anything changes en route to the SpecialSpecial PPopulationsopulations hospital, manage the problem and document any changes or additional treatment. AbdominalAbdominal injuries are ththee seconsecondd lleadingeading cause of serious Reassess the patient and then ask and answer the following trauma in children (after head ininjuries).juries). In ppediatricediatric ppatients,atients, questions (as appropriate): the intra-abdominal organsorgans are relativelrelativelyy lalarge,rge, makinmakingg them vulnerable to blunt trauma. For example,example, the abdomen Has the patient’s level of consciousness changed? in an infant or toddler often seems pprotuberantrotuberant because Has the patient become more anxious? of the largelarge liver. The liver and sspleenpleen extend below the rib Have the skin signs begun to change? cagecage in yoyoungung children and, therefore, do not have as much bony pprotectionrotection as they do in an adult. These ororgansgans have Has the pain gotten better or worse? a rich blood susupply,pply, so ininjuriesjuries to them can result in larlargege Has bleeding become worse or better? blood lloosses.sses. The kidneys are also more vulnerable to injuryinjury Is current treatment improving the patient’s condition? in children because theythey are more mobile and less well ssup-up- Has an already identifi ed problem gotten better? portedported than in adults. Finally, the duodenum and ppancreasancreas Has an already identifi ed problem gotten worse? are likely to be damageddamaged in handlebar ininjuries.juries. What is the nature of any newly identifi ed problems? OwingOwing to a smaller fl uid volume, children dehydrate quicklyquickly from vomiting.vomiting. Abdominal ppainain in children often Interventions is the result of constipation;constipation; however, aappendicitisppendicitis is also another frequentfrequent cause of abdominal ppain.ain. Remember to The goal of reassessment is to monitor your patient for changes assess fforor GI bleedingbleeding as well. ManagementManagement of ppediatricediatric en route to the hospital. Routine monitoring should include patientspatients with abdominal cocomplaintsmplaints is the same as that for heart rate, blood pressure, respiratory rate, and pulse oximetry. adults. Use a hands-off approachapproach to ggetet a ggeneraleneral imimpres-pres- If the patient has GI bleeding, continue to assess for signs of sion of the ppatientatient before touchingtouching in order to adeadequatelyquately shock. Equally important, you should determine what effect assess any sisignsgns of distress. your treatment is having. Before giving additional fl uid boluses, listen to the patient’s lung sounds to determine whether acute pulmonary edema is developing. If the patient wants to lie on his or her side, try to make that possible. Be sure that you can rapid transport is needed, consider air medical transport if observe and maintain the patient’s airway because vomiting is available. common. Patients with urologic emergencies, especially patients with Remember to call for paramedic backup if the patient’s signs and symptoms of renal failure, need reassessment. The condition is unstable. If transport time is extended and electrolyte imbalances caused by the buildup of toxins can cause major, rapid changes in the functioning of the body’s organs. Serial vital signs should be obtained and documented on the prehospital care report, at least every 5 minutes in cases of pos- SpecialSpecial PPopulationsopulations sible renal failure. Note any trends in the vital signs and level of consciousness because they can be indicators of disease progres- An older ppatientatient is jjustust as suscesusceptibleptible as a younyoungerger adult sion. Patients with possible urologic disease should not be given to an acute abdomen. However, the signssigns and symsymptomsptoms anything by mouth because this may induce vomiting or com- mightmight be different. Because of altered ppainain sensation, a plicate surgical procedures. geriatricgeriatric patientpatient with an acute abdomen maymay not feel aanyny If the patient’s condition undergoes a sudden, dramatic discomfort or maymay describe the discomfort as mild, even in change, repeat the rapid and detailed assessments as if this were severe conditions. Chest ppainain may also be misintermisinterpretedpreted as abdominal ppain.ain. a new patient. This will give you the best chance of modifying Because an older papatienttient has decreased bobodydy temtempera-pera- your care to adequately manage this new development. ture reregulationgulation and resresponse,ponse, conditions such as an acute abdomen, includingincluding peritonitis,peritonitis, may not ppresentresent with fever. Communication and Documentation However, if fever is ppresent,resent, it can be minimal. Geriatric Communicate with the receiving hospital early to allow hospital patientspatients mmayay not exhibit rrigidityigidity or gguarding.uarding. staff to recruit the resources necessary to treat your patient on OwingOwing to the older ppatient’satient’s resresponseponse to an acute abdo- arrival. Carefully document your fi ndings in your patient care men, a delay in identifyingidentifying the condition and seekinseekingg medical attention may occur, pputtingutting the ppatientatient at risk for comcompli-pli- report, and relay all relevant information to the receiving phy- cations. You should ask about the papatient’stient’s medical historhistory,y, sician or nurse. This information should include updated vital especiallyespecially the history of recent illness, to identify a ppotentialotential signs, changes in the patient’s level of consciousness, and any illness. Ask about abdominal discomfort, when the ppatientatient new or worsening complaints. lastlast had a bowel movementmovement,, whether she or he was consti- patedpated or had diarrhea, when the papatienttient last ate, and whether he or she vomited. AskingAsking these qquestionsuestions can helhelpp to rule Emergency Medical Care out appendicitis,appendicitis, bowel obstruction, and rurupturedptured bowel, but  remember that history taking should not delay transport. remember that history taking should not delay transport. The signs and symptoms of an acute abdomen signal a serious medical or surgical emergency. Ensure that you provide prompt,

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Chapter 17 Gastrointestinal and Urologic Emergencies 625

gentle transport for the patient; do not delay transport. Carry 9. Make the patient as comfortable as possible for transport. out the following steps as quickly as possible before transport. Place in a position of comfort, usually with the legs bent. 1. Do not attempt to diagnose the cause of the acute abdomen. Patients are more comfortable with their legs pulled up 2. Clear and maintain the airway. toward the abdomen because this position takes the 3. Anticipate vomiting. Place the patient in the recovery pressure off the abdominal wall and diminishes pain. position or position of comfort. Most patients feel better Conserve body heat with blankets, as needed. Provide in a lateral recumbent position with the knees pulled in gentle but rapid transport and constant psychological toward the chest. support. 4. Administer 100% supplemental oxygen, and be prepared 10. Monitor vital signs; these may change quickly. to assist ventilation if the patient has a reduced tidal vol- 11. Consider calling for additional paramedic backup if the ume (shallow breathing). patient’s condition shows any signs of instability. 5. Do not give the patient anything by mouth. Food or Remember that with PID, acute pain and tenderness in the fl uid will only aggravate many of the symptoms because lower part of the abdomen may be intense and accompanied by intestinal paralysis will prevent it from passing out of the a high fever. If you suspect PID, promptly transport the patient stomach. In addition, the stomach will have to be emptied to the emergency department for treatment. before surgery if it is required. The combination of acute abdominal pain and hypovole- 6. Document all pertinent information. Use OPQRST. Note mic shock mandates immediate transport to the hospital. Con- the presence of abdominal tenderness, distention, or sider an ectopic pregnancy in any female of childbearing age guarding. who presents with acute abdominal distress, especially in the 7. Anticipate the development of hypovolemic shock. presence of hypotension. Monitor blood pressure. Treat the patient for shock Pneumonia, especially in the lower parts of the lung, may when it is evident. Place the patient in the position dic- cause both ileus and abdominal pain. In this case, the prob- tated by local protocol for shock patients. lem lies in an adjacent body cavity, but the intense infl amma- 8. Establish IV access, and give a 20-mL/kg bolus of an iso- tory response can affect the abdomen. Treat and transport this tonic crystalloid if the patient presents with signs of hypo- patient as you would any patient with abdominal pain. volemia. Otherwise, maintain fl uid at a keep-vein-open The association of acute abdominal signs and symptoms rate. If kidney function is present, administer a bolus with shock could also signify an aneurysm and requires prompt of fl uid to the patient with a UTI and to a patient with transportation. Because this is a fragile situation with a large, a kidney stone. The fl uid will rehydrate the patient, and leaking artery, avoid unnecessary and vigorous palpation of an increased volume of urine will help fl ush any infec- the abdomen. Remember to handle the patient gently during tion from the system. For a patient with renal calculi, transport. Avoid fl uid only if the patient is hypotensive and the increased urine formation will help move the stone symptomatic. Increasing blood pressure could cause rupture of through the system. an aneurysm.

YOUYOU aarere tthehe PProviderrovider PART 4

Venous access is diffi cult in this patient,patient, but you are fi nally able to placeplace a 22-gauge22-gauge IV needle in the ppatient’satient’s rirightght hand. You radioradio to medical control, advisiadvisingng of the papatient’stient’s condition and are informed to withhold aanyny IV fl uid in this papatient.tient. You advise medicalmedical control that yyouou have an aapproximatelypproximately 7-minute estimated time of arrivalarrival..

YYouou concontinuetinue monimonitoringtoring ththee papatienttient en rouroutete ttoo ththee hhospital.ospital. On arrivaarrival,l, you give your reporreportt ttoo ththee emergency ddepartmentepartment nursenurse anandd compcompletelete your papatienttient care reporreportt wwhilehile your parpartnertner reareadiesdies ththee amambulancebulance for your nexnextt cacall.ll. 9. WhyWhy ddidid ththee memedicaldical concontroltrol pphysicianhysician ororderder ththatat no IV ﬂ uiuidd bbee aadministereddministered ttoo ththisis papatient?tient?

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626 Section 6 Medical

Any signs and symptoms of a hernia are cause for prompt transport to the emergency department. Table 17-3 Complications and Adverse Effects Finally, ARF and CRF can lead to life-threatening emergencies. of Dialysis Support of the ABCs is imperative. Be alert for the possibility of hypotension or pulmonary edema. Because of possible toxic Hypotension buildup and electrolyte problems, medications to regulate acidosis Muscle cramps and electrolyte imbalance and fl uids for volume regulation may Nausea/vomiting be required. Emergency transport and supportive care are often preferred over aggressive management in these patients. Hemorrhage, especially from the access site Infection at the access site Renal Dialysis Altered mentation, loss of consciousness  Air embolism The only defi nitive treatment in cases of CRF is renal dialysis . Electrolyte imbalance This is a technique for “fi ltering” toxic wastes from the blood, removing excess fl uid, and restoring the normal balance of elec- Myocardial ischemia trolytes. Renal dialysis and problems associated with it may require prehospital interventions. There are two types of dialysis—peritoneal dialysis and hemodialysis. In peritoneal dialysis, large amounts of specially formulated dialysis fl uid are infused into (and back out of ) the WordsWords ooff WWisdomisdom abdominal cavity. This fl uid stays in the cavity for 1 to 2 hours, When assesssessinsingg the blood pressurepressure of a patientpatient receivinreceivingg allowing equilibrium to occur. Peritoneal dialysis is very effec- dialysis,dialysis, use the arm that does not have the shunt! tive but carries a high risk of peritonitis; consequently, aseptic technique is essential. With proper training, however, peritoneal dialysis can be performed in the home. In hemodialysis, the patient’s blood circulates through a possibility of cardiac arrhythmias and the need for advanced life dialysis machine that functions in much the same way (albeit not support backup. Shock secondary to bleeding is also possible as elegantly) as the normal kidneys. Most patients undergoing from any number of causes. Patients with CRF, for example, are long-term hemodialysis have some sort of shunt, that is, a sur- very prone to duodenal ulcers; bleeding from those ulcers is not gically created connection between a vein and an artery that is unusual. Bleeding may also occur from the dialysis cannula. usually located in the forearm or upper arm. The patient is con- Also, if a patient misses a dialysis treatment, he or she nected to the dialysis machine through this shunt, which allows may experience weakness, pulmonary edema, or excesses of blood to fl ow from the body into the dialysis machine and back electrolytes. If your call involves a patient receiving dialysis, to the body. start with the ABCs: assess and manage the airway, breathing, The only time you will most likely see a dialysis machine is and circulation. Provide high-fl ow oxygen, and manage any if your service transports patients to and from dialysis centers. If bleeding from the access site. Position the patient sitting up in there is a dialysis machine in a private residence, treatments will cases of pulmonary edema or supine if the patient is in shock most likely be performed by a trained dialysis technician or pos- and transport promptly. sibly by the patient or family members. When you fi nd a shunt leaking during the dialysis cycle, see Patients requiring long-term dialysis usually go “on the if you can tighten the connection. If it has become disconnected machine” every 2 or 3 days for a period of 3 to 5 hours. Many at the vein, clamp the cannula and disconnect the patient from receive dialysis in the hospital or in community dialysis facili- the machine. In a suicide attempt, the patient may open up the ties, but a signifi cant number have home dialysis units. Patients cannula and allow himself or herself to exsanguinate. Keep in undergoing dialysis at home usually have extensive training in mind that patients receiving dialysis have often endured numer- the procedures, and often someone else in the home has also ous medical interventions to simply survive. If you encounter been trained. If a problem with the machine occurs, the patient this situation, immediately clamp off the cannula and apply may know a lot more about it than you do, so always ask what direct pressure. the patient has done before your arrival! Many dialysis patients also have urinary catheters. The cath- There are many adverse effects and complications that can eter is placed in the bladder so the urine can run into a bag. These occur with dialysis. These are listed in . catheters can often be a source of infection. The patient may report A sudden drop in blood pressure is not uncommon during fever and general malaise (illness) in addition to any symptoms or immediately after dialysis, but it can lead to cardiac arrest if not specifi c to kidney failure. Leave the device in place. Treat any signs promptly detected and treated. The patient may feel lightheaded and symptoms and transport the patient for further evaluation. or become confused, and often he or she yawns more than During transport, unless there is a life-threatening event, usual. Because dialysis alters the blood’s chemistry, an electrolyte make all attempts to deliver the patient to a hospital with dialysis imbalance may develop. For this reason, you should consider the capability.

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Chapter 17 Gastrointestinal and Urologic Emergencies 627

YOUYOU aarere tthehe PProviderrovider SUMMARY

1. WWhathat are some potpotentialential causes of aalteredltered menmentaltal sstatustatus in a 55.. You nonotete a ““bump”bump” in hhisis llefteft forearm. WWhathat is ththisis bbumpump anandd ppatientatient receivinreceivingg ddialysis?ialysis? wwhyhy is iitt imimportantportant ttoo AEMTs? CCommonommon causes of aalteredltered menmentaltal sstatustatus in a papatienttient receiv- Some papatientstients receiving ddialysisialysis hhaveave a sshunt,hunt, wwhichhich is a surgi- ing ddialysisialysis are ththee same causes of aalteredltered menmentaltal sstatustatus in cacallylly creacreatedted access pportort usuausuallylly llocatedocated in ththee forearm or uupperpper papatientstients wwhoho ddoo nonott receive ddialysis.ialysis. However, one of ththee arm. IItt is imporimportanttant for AEMTs ttoo recognize ththee presence anandd common causes of aalteredltered menmentaltal sstatustatus in a ppatientatient receiv- llocationocation of ththisis sshunthunt bbecauseecause ththee arm wiwithoutthout ththee sshunthunt sshouldhould ing ddialysis,ialysis, especiaespeciallylly wwhenhen ththee papatienttient hhasas missemissedd a ddialysisialysis bbee useused,d, if aatt aallll possipossible,ble, for blbloodood pressure measuremenmeasurementsts anandd aappointmentppointment or hhasas ggoneone llongeronger ththanan normanormall in bbetweenetween IV linlines.es. ttreatments,reatments, is an eelectrolytelectrolyte imimbalancebalance ththatat is ththee resuresultlt of ththee bbuildupuildup of ttoxinsoxins in ththee blbloodstream.oodstream. 66.. Does ththisis ppatientatient neeneedd IV access? TThishis papatienttient coucouldld bbenefienefi t from IV access for mumultipleltiple reasons. 2. On ththee bbasisasis of ththee informainformationtion pprovided,rovided, wwhathat ttypeype of ddialysisialysis FirsFirst,t, ththee ppatientatient hhasas an aalteredltered menmentaltal sstatustatus anandd sshortnesshortness of ddoesoes ththisis papatienttient receivreceive?e? bbreath.reath. TThosehose ttwowo conconditionsditions aalonelone are reason enougenoughh ttoo inserinsertt TThehe ttwowo ttypesypes of ddialysisialysis are pperitonealeritoneal ddialysisialysis anandd hhemodialy-emodialy- an IV llineine in ththisis ppatient.atient. Because ththisis ppatientatient hhasas a cchronichronic sis. In periperitonealtoneal ddialysis,ialysis, llargearge amounamountsts of speciaspeciallylly formuformulatedlated memedicaldical concondition,dition, hhee may hhaveave poor venous access. If ththisis is ththee ddialysisialysis fl uiduid are infusedinfused intointo (and(and bbackack ououtt ofof)) tthehe aabdominalbdominal case, iitt wouwouldld bbee pprudentrudent ttoo esestablishtablish IV access in ththisis ppatientatient cavcavity.ity. WiWithth proper ttraining,raining, periperitonealtoneal ddialysisialysis is ofoftenten perper-- wwhilehile hhee is sstilltill in somewsomewhathat sstabletable concondition,dition, bbeforeefore hhee sstartstarts ttoo forformedmed in ththee hhome.ome. ddecompensate,ecompensate, wwhenhen iitt wiwillll bbee ddiffiiffi cucultlt ttoo esestablishtablish accessaccess.. In hhemodialysis,emodialysis, ththee papatient’stient’s blbloodood circucirculateslates ththroughrough a ddialysisialysis macmachinehine ththatat funcfunctionstions in mucmuchh ththee same wawayy as ththee normanormall kkid-id- 77.. WWhathat are your ttreatmentreatment ooptionsptions for ththisis ppatient?atient? neys. TThehe papatienttient is connecconnectedted ttoo ththee ddialysisialysis macmachinehine ththroughrough a TTherehere are mumultipleltiple ooptionsptions for ttreatmentreatment in ththisis ppatient,atient, anandd sshunt,hunt, wwhichhich aallowsllows blbloodood ttoo fl ow from thethe bbodyody inintoto ththee ddialysisialysis some are bbetteretter ththanan oothers.thers. TThishis papatienttient presenpresentsts wiwithth raralesles macmachinehine anandd bbackack ttoo ththee bbody.ody. Because of ththee llargearge macmachineshines bbilaterally.ilaterally. CaCallll for parameparamedicdic bbackupackup for aadministrationdministration of memedi-di- rerequiredquired for hhemodialysis,emodialysis, ththisis ttypeype of ddialysisialysis is aalmostlmost excexclu-lu- cacationstions or ttoo aadministerdminister concontinuoustinuous ppositiveositive airway ppressureressure ththatat sivesivelyly founfoundd in ddialysisialysis cencenters.ters. TThehe papatienttient or famifamilyly wiwillll bbee aableble may bbee bbenefienefi cialcial in clearingclearing up thethe ralesrales aalso.lso. RegarRegardlessdless of ththee ttoo ttellell yyouou wwhathat ttypeype of ddialysisialysis ththee ppatientatient receives. HemoHemodialy-dialy- ttreatmentreatment ppathath you ddecideecide ttoo ttake,ake, 100% oxyoxygengen is inindicated,dicated, bbutut sis is ththee ttypeype of ddialysisialysis ththisis papatienttient is receivireceiving.ng. carefucarefull aattentionttention musmustt bbee given ttoo ththee papatienttient in case of more eemesis.mesis. 3. WhaWhatt iiss aanuria?nuria? AAnurianuria is ththee comcompleteplete cessacessationtion of urine pproduction.roduction. If ththee 88.. WWhathat coucouldld bbee a cause of ththisis ppatient’satient’s sshortnesshortness of bbreath?reath? urine output drops to less than 500 mLmL/d,/d, the condition is called Because ththereere is a llongeronger ttimeime frame bbetweenetween ddialysisialysis ttreat-reat- ooliguria.liguria. menmentsts over ththee weeweekendkend (2 ddays)ays) as opposeopposedd ttoo ththee mmoreore frefrequentquent ttreatmentsreatments dduringuring ththee weeweek,k, ththisis ppatient’satient’s sshortnesshortness 4. ThThee ppatientatient seems toto bebe answeringanswering allall questionsquestions appropriately,appropriately, of bbreathreath is pprobablyrobably causecausedd bbyy an accumuaccumulationlation of fl uiuidd insideinside bbutut more slowlyslowly thanthan whatwhat is reportedreported toto bebe normal.normal. ShouldShould of ththee bbody,ody, exacerexacerbatedbated bbyy ththee possipossibilitybility of increaseincreasedd sasaltlt anandd you approachapproach thethe dialysisdialysis staffstaff andand requestrequest thatthat hehe undergoundergo sugar inintaketake dduringuring ththee bbirthdayirthday parparty.ty. ddialysisialysis in an aattemptttempt ttoo hhelpelp improve hhisis menmentaltal sstatus?tatus? TThishis wouwouldld bbee a possipossibility,bility, hhowever,owever, iitt wouwouldld proprobablybably nonott bbee 99.. WWhyhy ddidid ththee memedicaldical concontroltrol pphysicianhysician ororderder ththatat no IV fl uiuidd bbee recommenrecommended.ded. DiaDialysislysis neeneedsds ttoo bbee performeperformedd on a rouroutinetine aadministereddministered ttoo ththisis papatient?tient? bbasis,asis, anandd missmissinging or ddelayingelaying a ttreatmentreatment mamayy hhaveave a majmajoror Owing ttoo ththisis papatient’stient’s anuric sstate,tate, hhypertension,ypertension, anandd impact on the patient’s well-being. The patient’s slowness to impact on the patient’s well-being. The patient’s slowness to ununknownknown ttimeime ununtiltil hhisis nexnextt ddialysisialysis ttreatment,reatment, ththee memedicaldical respond to questions, coupled with the patient’s statement respond to questions, coupled with the patient’s statement concontroltrol pphysicianhysician mosmostt llikelyikely ththoughtought ththatat ththee papatienttient was that this is not normal for him, warrant a trip to the emergency that this is not normal for him, warrant a trip to the emergency aalreadylready fl uiuidd overloaded.overloaded. ddepartment.epartment.

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628 Section 6 Medical

YOUYOU areare tthehe PProviderrovider SUMMARY, continued

EMS Patient Care Report (PCR) Date: 9-3-13 Incident No.: 20090154657 Nature of Call: Unknown medical Location: 512 E Main St

Dispatched: 0800 En Route: 0801 At Scene: 0809 Transport: 0832 At Hospital: 0839 In Service: 0903 Patient Information Age: 52 Allergies: Penicillin Sex: M Medications: Insulin Weight (in kg [lb]): 82 kg (182.2 lb) Past Medical History: End-stage renal failure, diabetes mellitus Chief Complaint: Altered mental status, SOB Vital Signs

O Time: 0819 BP: 226/108 Pulse: 140 Respirations: 36, rales Sp 2: 94% on 15 L/min

O Time: 0824 BP: 210/102 Pulse: 142 Respirations: 36, rales Sp 2: 95% on 15 L/min

O Time: BP: Pulse: Respirations: Sp 2: EMS Treatment (circle all that apply) Oxygen @ 15 L/min via (circle one): Assisted Ventilation Airway Adjunct CPR NC NRM Bag-Mask Device Deﬁ brillation Bleeding Control Bandaging Splinting Other Narrative EMS called to above location for man who needed to go to the emergency department. On arrival, met by dialysis clinic staff who stated patient regularly receives dialysis on M, W, and F. Today patient came in for regularly scheduled treatment, but staff found him slow to answer questions and mildly short of breath. Patient is conscious, alert, and oriented × 3 but is slow to answer questions. Both patient and staff state this is abnormal for him. Patient has mild shortness of breath, with rales bilaterally. Assisted patient onto litter, secured × 3. As we were preparing patient for transport, patient vomited × 1. Gave patient oxygen, 15 L/min, via nonrebreathing mask. Transport nonemergency basis to Kittson Memorial Hospital. 22-gauge IV established to right hand on third attempt, normal saline infusing TKO. Patient remains moderately short of breath. Report called to emergency department with condition and ETA. On arrival, care and report given to nurse without incident. **End of report**

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breakdown ofchyme. the siteofdigestionbybacteria,whichhelpstofi the digestedmaterialintoaformedstool.Thecolonisalso plete thereabsorption ofwater. Thisprocess helpssolidify process. role Theprimary ofthelarge intestineistocom- Thelarge intestine,orcolon,isthenextstepindigestive can bemovedintothebloodstream. digestedfoodintosubstancesthat duces enzymesthatturn earlier), thejejunum,andileum.Thesmallintestinepro- Thesmallintestineisdividedintotheduodenum(mentioned blood cells,andstores vitaminsandminerals. fi and onlyfuelsource forbraincells.Theliveralsodetoxi- Theliveralsoconvertsglycogenintoglucose,theessential intestine. respectively, whichultimatelyassistdigestioninthesmall begins. Thepancreas andliversecrete enzymesandbile, Theduodenumiswhere theactivestageofabsorption part ofthesmallintestine. food. Thematerialthenmovesintotheduodenum,fi The stomachsecretes hydrochloric acidtohelp break down Thestomachcanstretch manytimesbeyonditsnormalsize. may backupthroughout theentire GIsystem. tract totheliver. Ifbloodflow through theliverslows,blood form theportalvein,whichtransportsbloodfrom theGI Veins intertwinearound theesophagusandjoin togetherto rhythmic contractionscalledperistalsis. Once foodisswallowed,itmovesthrough theesophagusvia Thedigestiveprocess beginswithsalivatolubricatefood. use byothercellsinthebody. ThemainfunctionoftheGIsystemistoabsorbresources for divided intofourquadrants. tive tract.Itconsistsofthemouthandmanyorgans andis Thegastrointestinal (GI)systemisalsoknownasthediges- and specific structures withinthekidneys. der, ureters, urethra, maleandfemalereproductive organs, blad- system includesthekidneys,urinary Thegenitourinary es drugs,completesthebreakdown ofdeadred andwhite

& Bartlett

Learning, nish the nish LLC. rst NOT FOR SALE nitis, dependingonthecause. more apparent. Fevermayornotbepresent withperito- is accompaniedbyhemorrhage, thesignsofshockare much Peritonitiscanleadtohypovolemicshock.Whenperitonitis associated withnauseaandvomiting. by emesis,orvomiting.Therefore, peritonitisisalmostalways the bowel.Theonlywaystomachcanemptyitself,then,is that iseatencanpassnormallyoutofthestomachorthrough ultimately abdominaldistention.Inthissituation,nothing Peritonitistypicallycausesileus—paralysisofperistalsis—and ectopic pregnancy andpelvicinfl stone, pancreatitis,tractinfection,and,inwomen, urinary cystitis,kidneyinfection, hernia, aortic aneurysm, ticulitis, cholecystitis,appendicitis,perforatedgastriculcer, AcuteabdomencanbecausedbyGIorrenal sources, diver- abdomen. kindofabdominalproblem Nearlyevery cancauseanacute peritonitis and,thus,anacuteabdomen. cent tothismembraneintheabdominalcavitycancause amniotic fluid, orotherforeign materialtoliewithinoradja- urine, gastricjuice,intestinalcontents,bile,pancreatic juice, the peritoneum.Anyconditionthatallowspus,blood,feces, Manyabdominalorgans are covered byamembranecalled ovaries, fallopiantubes,oruterus. mayhaveaproblemnal painandtenderness related toher nal pain.Alwaysconsiderthatawomanwithlowerabdomi- Gynecologicproblems are acommoncauseofacuteabdomi- function. failure isprogressive and irreversible inadequatekidney resulting inarelease oftoxinsintotheblood.Chronic renal Acuterenal failure isasuddendecrease inkidneyfi pulse rate. groin. Thepainmaycauseanincreased bloodpressure and severe paininthefl intheurine.Symptomsincludeor uricacidcrystallizes Kidneystonesresult whenanexcessofinsolublesalts have afoulodorandbecloudy. sibly referred paintotheshoulderorneck.Theurinemay tion, frequent urges tourinate,diffi tract infectionincludepainfulurina- Symptomsofurinary OR DISTRIBUTION ank thatmaymigrateforward tothe

ammation.

cultyurinating,andpos-

ltration, 629 9/1/10 6:00 PM

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Abdominal pain may stem from other organ systems. If an the problem organ or area causing it. The abdominal muscles abdominal aortic aneurysm ruptures, massive hemorrhage may have become rigid, called guarding. may occur and signs of acute peritoneal irritation will pres- Take vital signs, and gently palpate the abdomen. If the ent. A hernia (protrusion of an organ or tissue through a hole abdomen is tender, the patient needs to be transported in the body) may eventually compromise blood supply, caus- urgently. ing a serious emergency. Note the degree of abdominal distention; this can also Transport patients with an acute abdomen promptly but provide clues to the severity of the patient’s condition. gently. Patients with acute abdomen may be comfortable only when Remember that GI complaints often involve body substances. lying in one particular position, for example curled up on Take extra gloves, masks, gowns, and other protective equip- one side or with the right knee drawn up. Note the patient’s ment and supplies with you to the scene. position. In a patient with an acute abdomen, the fi rst priorities Do not give the patient with an acute abdomen anything by are to assess airway, breathing, and circulation and then mouth. apply oxygen. Assist ventilation if the patient is breathing inadequately. Establish IV access. Consult with medical control to administer pain medication. When taking the patient’s history, ask when the symptoms began, how they have changed, the exact location of the Renal dialysis is a procedure for removing toxic wastes and pain, and how it feels. Also ask if there has been vomiting or excess fl uids from the blood. Patients receiving dialysis diarrhea. usually have a shunt through which they are connected to the dialysis machine. They are vulnerable to problems Remember airway concerns with a patient who is vomiting. such as hypotension, potassium imbalance, disequilibrium Open the airway using the appropriate maneuvers, and syndrome, and air embolism. closely inspect it for foreign bodies. Remove or suction any obstructions that are found. Vital Vocabulary Abnormal abdominal assessment fi ndings include exces-  sive nausea/vomiting or hematemesis, changes in bowel acute abdomen A condition of sudden onset of pain within the habits/stool, painful or frequent urination that is discol- abdomen, usually indicating peritonitis; demands immediate ored or has a strong odor, weight loss, belching/fl atulence, medical or surgical treatment. concurrent chest pain, and abdominal pain, tenderness, acute renal failure (ARF) A sudden decrease in fi ltration through guarding, or distention. the glomeruli of the kidneys. Pain is commonly located directly over the infl amed area aneurysm A swelling or enlargement of a part of an artery, resulting of the peritoneum, or it may be referred to another part of from weakening of the arterial wall. the body. Referred pain occurs because of the connections between the two different nervous systems supplying the anuria A complete stop in the production of urine. parietal peritoneum and the visceral peritoneum. appendicitis Infl ammation of the appendix. A healthy or normal abdomen should be soft and not tender. cholecystitis Infl ammation of the gallbladder. The pain in an acute abdomen may be sharply localized or chronic renal failure (CRF) Progressive and irreversible inadequate diffuse and will vary in severity. Localized pain gives a clue to kidney function as a result of permanent loss of nephrons.

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colic Acute, intermittent, cramping abdominal pain. crystallizing in the urine; may become trapped anywhere diverticulitis Infl ammation of a diverticulum, usually in the colon, along the urinary tract. creating abdominal discomfort; a diverticulum is an abnormal Mallory-Weiss syndrome A condition in which the junction pouch or sac. between the esophagus and the stomach tears, causing severe ectopic pregnancy A pregnancy in which the ovum implants bleeding and, potentially, death. somewhere other than the uterine endometrium. mittelschmerz Lower abdominal pain that is related to the normal emesis Vomiting. menstrual cycle, associated with the release of an egg from the ovary, occurring in the middle of the menstrual cycle between esophageal varices A condition in which the amount of pressure menstrual periods. within the blood vessels surrounding the esophagus increases, causing blood to back up into the portal vessels and ultimately nephrons The structural and functional units of the kidney that causing the capillary network of the esophagus to leak. form urine; composed of the glomerulus, the glomerular (Bowman) capsule, the proximal convoluted tubule, loop of esophagitis Infl ammation of the lining of the esophagus. Henle, and the distal convoluted tubule. gastroenteritis A family of conditions resulting in diarrhea, nau- oliguria A decrease in urine output to the extent that total urine sea, and vomiting; some have infectious causes. output drops to less than 500 mL/d. guarding Involuntary muscle contractions (spasm) of the abdomi- orthostatic hypotension A drop in systolic blood pressure when nal wall; an effort to protect the infl amed abdomen. moving from a lying or sitting to a standing position. hematuria The presence of blood in the urine. orthostatic vital signs Assessing vital signs in two different patient hernia The protrusion of a loop of an organ or tissue through an positions to determine the degree of hypotension; also known abnormal body opening. as the tilt test. hilus When used in the context of the kidneys, a cleft where the pancreatitis Infl ammation of the pancreas. ureters, renal blood vessels, lymphatic vessels, and nerves pelvic infl ammatory disease (PID) An infection of the female enter and leave the kidney. upper organs of reproduction, specifi cally the uterus, ovaries, ileus Paralysis of the bowel, arising from any one of several causes; and fallopian tubes. stops contractions that move material through the intestine. peristalsis Waves of alternate circular contraction and relaxation kidneys Solid, bean-shaped organs located in the retroperitoneal of the intestines or other tubular structure to propel the con- space that fi lter blood and excrete body wastes in the form tents forward. of urine. peritoneum The membrane lining the abdominal cavity (parietal kidney stones Solid crystalline masses formed in the kidney, peritoneum) and covering the abdominal organs (visceral resulting from an excess of insoluble salts or uric acid peritoneum). m o c . e n o z s m e . t m e a . w w www.aemt.emszone.com w

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peritonitis Infl ammation of the peritoneum. uremic frost A powdery buildup of uric acid, especially on the face. pyelonephritis Infl ammation of the kidney and renal pelvis. ureters A pair of thick-walled, hollow tubes that transport urine rebound tenderness Parietal pain that occurs when pressure from the kidneys to the bladder. is removed rather than applied; suggestive of a serious and urethra A hollow, tubular structure that drains urine from the blad- potentially life-threatening condition. der, passing it outside of the body. referred pain The pain felt in an area of the body other than the urinary bladder A hollow, muscular sac in the midline of the area where the cause of pain is located. lower abdominal area that stores urine until it is released from renal dialysis A technique for “fi ltering” the blood of its toxic the body. wastes, removing excess fl uids, and restoring the normal bal- urinary tract infections (UTIs) Infections, usually of the lower ance of electrolytes. urinary tract (urethra and bladder), which occur when normal renal fascia Dense, fi brous connective tissue that anchors the kid- fl ora bacteria or other bacteria enter the urethra and grow. ney to the abdominal wall. urine Liquid waste products fi ltered out of the body by the urinary strangulation Complete obstruction of blood circulation in a given system. organ as a result of compression or entrapment, an emergency visceral discomfort Crampy, aching pain deep within the body, the situation causing death of tissue. source of which is usually diffi cult to pinpoint; common with ulcers Abrasions of the stomach or small intestine. urologic problems.

79306_CH17_Pass3.indd 403 9/1/10 6:00 PM 79306_CH17_Pass3.indd 404 The medicaltermforinﬂ 1. ammation ofthe gallbladder is: 2. Referred painfrom acutecholecystitisistypicallyfound 3. 4. Which ofthefollowingismedicaltermforkidney 5.

Whichofthefollowingtypespainisdescribedasdif- Patients with urinary tractinfections(UTIs)willtypically Patientswithurinary in the: aching andisusuallyfeltsuperfi fi D. stones? D. D. Referred lowing is present withatriadofsymptoms.Whichonethefol- D. Renal hilus D. C. acute pyelonephritis C. C. C. Renal fascia Decreased frequency ofurination C. A. A. A. A. A. B. B. groin B. B. Renal calculi B. cramping,gnawing,or cult tolocalizeandasburning, Visceral Parietal Somatic Increased frequency ofurination acutecholecystitis acute pertussis jaw acute bronchiolitis leftshoulder rightshoulder Renalcortex Painfulurination Diffi

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directs youtothebackbedroom where youﬁnd thepatientlyinginbed,fetalposition, moaning Thepatientstatesthatshehas10/10severe abdominalpain,whichstartedintherightupperquad- Y © Jones cially? complaining ofsevere abdominalpain.Onarrivalyouare metbythepatient’s husbandwho ou are dispatchedtoawell-kept,upscaleresidential homefora46-year-old womanwhois &

Bartlett

Learning, in Action LLC.

NOT FOR Which membrane lines the walls of the abdominal cavity? Which membranelinesthewallsofabdominalcavity? 7. Additional Questions 6. When palpatingthefourquadrantsofabdomen, 8. Where ispaincommonlyfeltbyapatientexperiencing SALE

patient complainsofpain. you shouldalwaysstartwiththequadrantinwhich a ruptured ordissectingabdominalaorticaneurysm? None oftheabove D. D. C. Left upperquadrant C. A. A. Visceral peritoneum A. B. B. B. True False Potential peritoneum Right lowerquadrant Left lowerquadrant Parietalperitoneum Rightupperquadrant OR DISTRIBUTION

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