Gastrointestinal/Genitourinary Pathologies:
Appendicits:
In appendicitis, there is an obstruction of the appendiceal lumen, typically by impacted, hard, feces. The appendix itself contains a significant amount of bacteria, that is then unable to escape, and proliferates causing inflammation of the appendix. The resulting inflammation causes abdominal pain that gradually worsens. If this condition is not treated, the appendix can become necrotic and rupture. In the event of rupture, the contents of the appendix spill into the peritoneal cavity and can cause peritonitis, and eventually may cause sepsis. The pain associated with appendicitis usually begins in the peri-umbilical region, as a dull aching, wavelike, pain that gradually worsens in intensity. Eventually the pain will migrate to the right lower quadrant at McBurney's point (located about halfway between the umbilicus and the right iliac crest. Patients also typically present with fever, nausea, and anorexia. Abdominal assessment will reveal tenderness in the RLQ, and may present with rebound tenderness as well. This is a surgical emergency, and EMS care is largely directed at supportive care, and management of potential shock. Ensure a patent and protected airway, monitor oxygen saturation and address issues as the arise. Establish IV access if authorized, and manage any hypotension that develops. Provide analgesic to treat pain. Transport to the appropriate facility.
Cholecystitis:
Inflammation of the gallbladder occurs when bile stones form within, and block the bile duct outlet. This causes bile to buildup in the gallbladder itself, and increase the pressure iside it. Ischemia of the tissue occurs, and pain is the logical result. The pain is generally felt in the right upper quadrant, and may radiate to the epigastric region and the right shoulder tip. The pain is typically constant, aching, and is provoked following ingestion of a meal high in dietary fat. The patient may be febrile, nauseated, and usually presents with a positive Murphy's sign (the patient experiences increased pain with pressure is placed on the RUQ and the patient takes a deep breath). This is a surgical emergency, and EMS treatment follows the same general pathway as that for appendicitis. Maintain airway, provide oxygen if indicated, establish IV access and manage hypotension, treat for pain and nausea. A 12-lead ECG is indicated as acute coronary syndrome can present in a similar fashion.
Pancreatitis:
The pancrease serves a dual role in the body, both in the endocrine and digestive systems. It produces insulin and glucagon in its role regulating blood glucose levels, as well as producing digestive enzymes in the gastrointestinal system. The pancreatic duct joins the common bile duct in allowing enzymes to enter the GI tract during digestion. When a stone occludes this duct, the digestive enzymes in the pancrease become trapped and can begin to autodigest the pancrease itself. This condition often presents with boring epigastric pain that can be felt through to the upper back. It is often associated with vomiting, and is exacerbated by eating, or consumption of alcohol. Once again, the prehospital treatment for this condition is similar to the above conditions. Maintain airway, provide oxygen if indicated, establish IV access and address hypotension, treat for pain and nausea. 12-lead ECG is indicated as ACS/MI presents in a similar fashion.
Bowel Obstruction:
The bowel can become obstructed for a number of reasons. Severe constipation is a common problem in the elderly, or those using routine narcotics. Conditions such as Crohn's Disease, Colitis, and Diverticular disease can cause abnormal scarring and adhesions to form. Surgical procedures can also result in abnormal healing and strictures. Regardless of the cause, digested matter is unable to pass the affected region of the bowel, leading to inflammation, increased pressure against the bowel wall, pain, nausea, and vomiting. These patients usually experience pain described as dull, aching, and wavelike (associated with peristalsis) and may report inability to have a bowel movement or pass gas. They may also report only loose watery stools if the obstruction is not complete. Fecal-emesis is present in complete obstructions that have gone unaddressed for a period of time. Abdominal tenderness, rigidity, and distension may also be noted. It is important to rule out any hematemesis or rectal bleeding especially if considering any analgesia using NSAIDs such as Toradol. Maintain the patient's airway, provide oxygen if indicated, establish IV access, address pain and nausea. If bleeding is occuring or suspected, use conservative fluids to avoid clotting factor washout.
Peptic Ulcer Disease:
The intestinal lumen is coated with a layer of mucous that prevents damage to the tissue by gastric juices and acid. When this layer is compromised, errosion of the tissue occurs, and ulceration ensues. The most common cause of this errosion is the bacteria H.Pylori, with other causes including things like prolonged periods of high stress, tobacco use, and alcoholism. Pain associated with ulcers is often described as “gnawing”, and may be provoked or relieved by consumption of food. The pain may be located anywhere on the abdomen, but often occurs in the epigastric region, where the stomach is located. Proton pump inhibitors are often prescribed to these patients to reduce the production of acid, and OTC medications such as Tums are sometimes found among the patients' medications. The long term complications of peptic ulcer disease are gastrointestinal bleeding, perforation, and infection. The prehospital treatment for these patients should be aimed at identifying potential GI bleeding, ruling out other serious causes for the pain (Ie: ACS/MI), addressing pain with analgesic if able (NSAIDs contraindicated), and transport to the ED.
Acute Gastritis:
Gastritis is a condition where there is a widespread inflammatory response throughout the GI tract. Causes are usually bacterial, or viral, and patients present with fever, nausea, diarrhea, and vomiting. Abdominal pain is often also present, and is described as intermittent cramping associated with urge to vomit or pass stool. The inflammatory response in the GI tract affects the ability of fluid and nutrients to be absorbed, because the microvili that are key to this process are inflamed and unable to participate in thier intended role. Complications include dehydration, electrolyte imbalances, and malnutrition. Treatment of these patients is supportive. Maintain ABCs, provide anti-emetics, treat for fever, and support rehydration with IV fluids.
Gastrointestinal Bleeding:
GI bleeding can occur for a number of reasons, and is classified as either upper or lower GI bleeding based upon the location where the hemorrhage originates. The ligament of Treitz is considered the dividing line, and all bleeding proximal to this site is considered upper, whereas bleeding distal to the ligament is lower. Discernment between upper and lower GI bleeding is based upon the characteristics of the hemorrhage that the patient presents with. Aside from the obvious, bleeding from the oral cavity, upper GI bleeding is identified by some degree of interaction with digestive products found in the stomach and small intestine. Coffee ground emesis, Melena, and bright red oral bleeding are all signifiers or upper GI bleeding. Lower GI bleeding usually presents as rectal hemorrhage consisting of bright red blood or blood in the stool itself. Causes of GI bleeding vary based on pathologies including, esophageal varices, Mallory-Weisse tears, Peptic ulcer disease, Foreign body ingestion, cancers of the digestive tract, and complications of diseases such as Crohn's/Colitis, or diverticular disease. Iatrogenic causes exist as well, as is often the case of post-colonoscopy bleeding. Lower GI bleeding does have common causes including hemmorhoids and anal fissures, although these are typically painful conditions, and patients are generally aware of them. Regardless of location or cause, GI bleeding should be taken seriously as there is significant volume within the GI tract to house a large amount of blood. Patients should be evaluated for evidence of shock including elevated respirations despite adequate oxygen saturations, tachycardia, and hypotension. In patients with a history of hypertension, consider the posibility of “Relative Hypotension”, when the patient presents with a “normal” blood pressure. The pressure may be abnormal for the patient if it is usally quite a bit higher. Hypotension should be managed conservatively as this is an active bleed, and we need to be careful not to exacerbate things by diluting clotting factors. Care is largely supportive, managing ABCs, estimating blood loss, and ensuring we treat for shock. A thorough history will be useful upon arrival at the ED, as it will help the Physician direct initial testing.
Ectopic Pregnancy:
Ectopic pregnancy is a term for any situation in which a fertilized embryo embeds itself in an area other than the uterine wall. The most common site for this to occur is in one of the fallopian tubes. As the cells of the embryo divide rapidly, and it gains in size, pressure against the wall of the fallopian tube increases causing sudden, severe, sharp pain in the affected region. Pain is felt in the lower abdomen on the affected side, and increases in intensity over time. This can be difficult to tell apart from appendicitis, which is why a thorough gynecological history is important in all female patients of childbearing age who present with abdominal pain. Further symptoms that make appendicitis less likely are the absence of anorexia or fever. In the event that the fallopian tube ruptures, a sudden drop in blood pressure can cause syncope, that is followed by evidence of hypovolemic shock. Management of the ectopic pregnancy is targeted at identifying the condition early and initiating rapid transport. ABCs should be managed, and shock needs to be treated as with all potential internal hemorrhage.
Urinary Tract Infections:
The cause of urinary tract infections is introduction of bacteria into the urethra. Bacteria (usually E.Coli) multipy rapidly and cause an immune response. If untreated, the infection can ascend to the bladder, nephrons, and the kidneys themselves. Long term infection ultimately leads to urosepsis. Patients with UTI often complain of urinary urgency, frequency, nocturea, fever, weakness, or alterations in LOA (young children or the elderly). UTI is more common in females than in males, due to a shorter urethra with closer proximity to the rectum. Treatment in hospital involves antibiotic therapy. In EMS, supportive care is the usual treatment unless there is evidence of sepsis. For the septic patient, IV fluids and management of fever are common protocols.
Kidney Stones:
Kidney stones occur when urea crystalizes , and lodges in the ureter. This obstructs urinary flow into the bladder and causes severe pain. Patients typically report sharp, 10/10, pain in the flank on the affected side. The pain often radiates to the groin on the affected side and is made worse by attempts at voiding. Treatment in the prehospital setting is aimed at pain management. Ketorolac (Toradol) is an effective medication as it addresses pain and the inflammatory response at work in this condition. In hospital, treatment will depend upon the size of the stone and degree of obstruction. It may be medically or surgically managed.
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