Chapter 19 - Gastrointestinal and Urologic Emergencies

Abdominal cavity

1. Contains solid and hollow organs that make up three systems:

→ Gastrointestinal system + Genital system + Urinary system

2. Injury to a solid organ can cause shock and bleeding.

3. If perforation of hollow organs occurs, the contents will leak and contaminate the abdominal cavity.

Gastrointestinal System

1. Responsible for digestion process

2. Digestion begins when food is put into the mouth and chewed.

3. The stomach is the main organ of the digestive system → gastric juices break down food

4. The liver assists in digestion.

→ Secretes bile + Filters toxic substances + Creates glucose stores + Produces substances for blood clotting and immune function

5. The gallbladder is a reservoir for bile.

6. Food then travels to the small intestine, which consists of three sections:

→ Duodenum + Jejunum + Ileum

7. Colon (large intestine)

a. Food not broken down and used moves into the colon as waste product.

b. Water is absorbed and stool is formed.

8. The spleen is located in the abdomen but has no digestive function

Genital System

The abdominal space also holds male and female reproductive organs.

Urinary System

1. Controls discharge of certain waste materials filtered from blood by the kidneys

2. The kidneys are solid organs, and the ureters, bladder, and urethra are hollow organs.

3. There are two kidneys, one on each side.

4. Ureters join each kidney to the bladder.

5. The urinary bladder is located immediately behind the pubic symphysis.

6. The bladder empties to the outside of the body through the urethra.

7. A normal adult forms 1.5 to 2 L of urine per day.

Peritoneum

A membrane that lines the abdominal cavity and covers the organs of the abdomen

Parietal peritoneum: lines the walls of the abdominal cavity

Visceral peritoneum: covers the organs

Acute Abdomen

Refers to the sudden onset of abdominal pain

Often associated with severe, progressive problems requiring medical attention

Peritonitis

Can cause ileus, which is paralysis of muscular contractions that normally propel material through the intestine

→ Retained gas and feces causes distention + Stomach empties by emesis.

Diverticulitis + Cholecystitis + Acute appendicitis

Parietal Peritoneum

Supplied by the same nerves that supply the skin of the abdomen

→ These nerves can easily identify and localize a point of irritation

Visceral peritoneum

Supplied by the autonomic nervous system

→ These nerves are less able to identify and localize pain.

Ulcers

Protective layer of the mucous lining erodes, allowing acid to eat into the organ

→ Common cause of acute abdomen

Common Causes → infection of the stomach (bacteria) + chronic use of NSAIDs

Signs and Symptoms → Gnawing pain in the stomach + Nausea, vomiting, belching, and heartburn

Complications → Hematemesis + Melena + Peritonitis

Gallstones

May form and block the outlet from the gallbladder → common cause of acute abdomen

If the blockage is not relieved, inflammation of the gallbladder (cholecystitis) can occur.

Signs and symptoms

→ Constant, severe pain in the right upper or midabdominal region that may refer to the right upper back, shoulder area, or flank

→ Nausea, vomiting, indigestion, bloating, gas, and belching

Pancreatitis

Inflammation of the pancreas → common cause of acute abdomen

Common Causes → An obstructing gallstone + Alcohol abuse

Signs and symptoms → Severe pain in ULQ and URQ that radiate to the back + Nausea, vomiting, abdominal distention, and tenderness

Complications → Sepsis or hemorrhage

Appendicitis

Inflammation or infection in the appendix → common cause of acute abdomen

Signs and symptoms:

i. Initial pain that is generalized, dull, and diffuse, which may center in the umbilical area

ii. Pain later localizes to the right lower quadrant.

iii. May have referred pain

iv. Nausea, vomiting, anorexia, fever, and chills

v. Rebound tenderness

Complications:

i. Abscess

ii. Peritonitis

iii. Shock

Gastrointestinal hemorrhage

Symptom of another disease, not a disease itself

→ common cause of acute abdomen

→ May be acute or chronic + Can occur in upper or lower gastrointestinal tract

Common causes:

i. Upper GI tract: esophagitis, esophageal varices, or Mallory-Weiss tear

ii. Lower GI tract: inflammation, diverticulosis, diverticulitis, cancer, and hemorrhoids

Signs and symptoms:

i. Upper GI tract: hematemesis and melena

ii. Lower Gi tract: bright red stools

Esophagitis

Occurs when the lining of the esophagus becomes inflamed by infection or acids from the stomach

→ Common cause of acute abdomen

→ Gastroesophageal reflux disease (GERD)

Signs and symptoms:

i. Pain with swallowing and feeling like there is something stuck in his or her throat

ii. Heartburn, nausea, vomiting, and sores in the mouth

Esophageal varices

Amount of pressure within blood vessels surrounding the esophagus increases, frequently as a result of liver failure → common cause of acute abdomen

Common causes → Alcohol in industrialized countries + Viral hepatitis in developing countries

With a gradual disease process, patients will initially shows signs of liver disease

Rupture of varices is far more sudden

i. Signs and symptoms: sudden onset discomfort in the epigastric region or sternum + difficulty swallowing, vomiting of bright red blood + hypotension, and signs of shock

ii. Complications: significant blood loss

Mallory-Weiss syndrome

Junction between the esophagus and the stomach tears → common cause of acute abdomen

Common causes → Violent coughing or vomiting

Signs and symptoms → Signs of shock, upper abdominal pain, hematemesis, and melena

Gastroenteritis

Infection combined with diarrhea, nausea, and vomiting → common cause of acute abdomen

Signs and symptoms → diarrhea, with blood and/or pus, abdominal cramping, nausea, vomiting, fever, and anorexia

Complications → dehydration and shock

Diverticulitis

Lack of fiber in the diet causes the consistency of stools became more solid, requiring more intestinal contractions and increasing pressure in the colon → common cause of acute abdomen

Bulges in the colonic walls result from increased intestinal contractions

→ Fecal matter becomes caught in the bulges, allowing bacteria to collect, and resulting in inflammation and infection

Signs and symptoms → Abdominal pain localized more in the LLQ

Complications → Perforation of the intestinal wall leading to severe infection and shock

Hemorrhoids

Created by swelling and inflammation of blood vessels surrounding rectum → common cause of acute abdomen

Common causes → Conditions that increase pressure on the rectum or irritation of the rectum

Signs and symptoms → Painless, bright red bleeding during defecation

Cystitis

Bladder inflammation also called urinary tract infection (UTI)

Common cause → bacterial infection

Signs and symptoms → Midline lower abdominal pain + Blood in the urine + an urgency and frequency in urination + pressure and pain around the bladder

Complications → Kidney infection

Kidneys

Play a major role in maintaining homeostasis

When the kidneys fail, uremia results.

Kidney stones can grow over time and cause blockage.

Acute kidney failure

Sudden decrease in function

Common causes → hemorrhage, dehydration, trauma, shock, sepsis, heart failure, medications, drug abuse, and kidney stones.

Reversible with prompt diagnosis and treatment

Chronic kidney failure

Progressive and irreversible damage

Common causes → Diabetes or hypertension

Signs and symptoms → Lethargy, nausea, headaches, cramps, edema in the extremities and face, seizures, and coma

Will eventually require treatment with dialysis

These patients have an increased risk of heart failure and cardiac arrest.

Female reproductive organs

Gynecologic problems are a common cause of acute abdominal pain.

Lower quadrant pain may relate to the ovaries, fallopian tubes, or uterus.

Abdominal Aortic Aneurysm (AAA)

The aorta lies immediately behind the peritoneum → Weak areas can result in this → Difficult to detect.

Back pain with a tearing sensation

Use extreme caution when trying to assess or detect this.

If an aneurysm tears or ruptures, massive hemorrhage may occur.

Hernia

Protrusion of an organ or tissue through a hole or opening into a body cavity where it does not belong

→ Common causes → congenital defects, a surgical wound that has failed to heal, a natural weakness in an area such as the groin

Hernias may not always produce a noticeable mass or lump

Serious hernia signs and symptoms:

i. A formerly reducible mass that is no longer reducible

ii. Pain at the hernia site

iii. Tenderness when the hernia is palpated

iv. Red or blue skin discoloration over the hernia

Reducible Hernia

A hernia that poses little risk and can be pushed back into the body cavity

Incarcerated Hernia

A hernia that cannot be pushed back in and are compressed by surround body tissue

Strangulation of this is a serious medical emergency → Blood supply is compromised by the compressed surrounding tissue

Scene size-up

1. Scene safety and standard precautions

2. Mechanism of injury/nature of illness

→ Acute abdomen can be the result of violence, such as blunt or penetrating trauma.

→ Use assessment results to develop an early index of suspicion for life threats.

Primary assessment

1. The first priority is to identify and treat life-threatening conditions.

2. Form a general impression.

3. Airway and breathing → May present with shallow or inadequate respirations due to pain

4. Circulation

a. Assess for major bleeding.

b. Ask the patient about blood in vomit or black, tarry stools.

c. Pulse rate, quality, and skin condition may indicate shock.

d. Check pulses in both feet → a difference in pulse strength may indicate an aortic dissection.

5. Transport decision → immediate transport is warranted if there are signs of significant illness.

History taking

SAMPLE history:

a. Nausea and vomiting

b. Changes in bowel habits

c. Urination

d. Weight loss

e. Belching or flatulence

f. Pain

g. Other signs or symptoms

h. Concurrent chest pain

Secondary assessment

1. Positioning of the patient may give clues to the nature of illness.

2. Physical examination

a. The normal abdomen is soft and not tender to the touch.

b. Pain and tenderness are the most common symptoms of an acute abdomen.

→ → i. Localized pain may give clues to the problem organ.

→ → ii. Muscles of the abdominal wall may become rigid involuntarily (guarding).

3. Vital signs

a. A high respiratory rate with a normal pulse rate and blood pressure may indicate improper ventilations.

b. A high respiratory rate and pulse rate with signs of shock may indicate septic or hypovolemic shock.

c. If a patient has a dialysis shunt in his or her arm, avoid taking a blood pressure in the same arm as the shunt to avoid damaging it.

Reassessment

1. Because it is often difficult to determine the cause of abdominal pain, frequent reassessment is important.

2. Assess the effects of interventions, including treatment for shock and emotional support.

a. Transport the patient in the most comfortable position for him or her.

b. Consider ALS support.

3. Communication and documentation

Emergency Medical Care

A. Treat the patient for shock even when obvious signs of shock are not apparent.

B. Position patients who are vomiting to maintain a patent airway → (use a biohazard bag for vomit)

C. Wear gloves, eye protection, a gown, and a mask.

D. When the patient has been released to hospital staff, clean the ambulance and equipment.

E. Wash your hands even though you were wearing gloves.

F. Providing low-flow oxygen may decrease nausea and anxiety.

Dialysis Treatment

1. Filters the blood, cleanses it of toxins, and returns it to the body

2. If a patient misses a treatment, weakness and pulmonary edema can be the first in a series of conditions that become progressively more serious

Dialysis Adverse Effects

a. Hypotension

b. Dysrhythmias

c. Chest pain

d. Muscle cramps

e. Nausea and vomiting

f. Hemorrhage from the access site

g. Infection at the access site

Dialysis Patient Management

a. Manage XABCs.

b. Provide high-flow oxygen if indicated.

c. Manage any bleeding form the access site.

d. Position the patient sitting up in case of pulmonary edema or supine if the patient is in shock.

e. Transport promptly.