Ch. 22: Abdominal Emergencies

Question 1

spleen

Answer 1

filtering blood and assisting with immune response

Question 2

liver

Answer 2

removing toxins from the body

Question 3

Peritoneum

Answer 3

the membrane that lines the abdominal cavity (the parietal peritoneum) and covers the organs within it (the visceral peritoneum)

Question 4

organs enclosed in the peritoneum

Answer 4

§ Encloses stomach, liver, spleen, appendix, small and large intestines,
Women: uterus, fallopian tubes, and ovaries

Question 5

Two layers of peritoneum

Answer 5

□ Visceral peritoneum: covers the organs
□ Parietal peritoneum: attached to abdominal wall
With a slice space between the two layers contains a lubricant fluid

Question 6

Extraperitoneal space

Answer 6

area outside the peritoneum

Contains retroperitoneal space

Question 7

Retroperitoneal space

Answer 7

area between the abdomen and the back
® Inside: organs kidney, pancreas, aorta
Inferior: bladder and most of the rectum

Question 8

Visceral pain

Answer 8

§ originates from the organs (the viscera) within the abdomen
§ Organs don’t contain many nerves therefore often described as dull, achy, or intermittent and may diffuse or difficult to locate
§ intermittent, crampy, or colicky often comes from hollow organs of the abdomen.
dull and persistent often originates from solid organs.

Question 9

Parietal pain

Answer 9

§ arises from the parietal peritoneum, the lining of the abdominal cavity—thus, it is often referred to as peritoneal tenderness
§ more widespread and efficient nerve endings, pain originating from the parietal peritoneum can be more easily located and described than pain from the visceral organs.
§ Such irritation may be caused by internal bleeding (as from blood leaking into the peritoneum from an injured spleen) or infection/inflammation (such as pain in the RLQ from an infected appendix)
§ may be sharp or constant and localized to a particular area
§ pain as worsening when he moves and getting better when he remains still or lies with the knees drawn up.

Question 10

Tearing pain

Answer 10

orta and stomach have the ability to detect tearing sensations
§ expanding abdominal aortic aneurysm (AAA), the inner layer of the aorta is damaged and blood leaks from the inner portions of the vessel to the outer layers. This causes a tearing of the vessel lining and pockets of blood resting in a weak area of the vessel
□ Often sensed as a ‘tearing’ pain in the back
§ Patients with this problem often report burning or tearing pain and frequently bleed heavily as a result.

Question 11

referred pain

Answer 11

§ pain felt in a place other than where the pain originates
§ Gallbladder is diseased felt in the right shoulder blade
Common complaint associated with ectopic pregnancies

Question 12

appendicitis

Answer 12

§ Infection of the appendix
§ Most common cause of a person needing surgery
§ Signs and symptoms: nausea and sometimes vomiting, pain in the area of the umbilicus (initially), followed by persistent pain in the right lower quadrant (RLQ)
§ If ruptured: the patient will typically experience a sudden severe increase in pain
§ result of the bowel contents being let loose into the peritoneal cavity, leading to peritonitis

Question 13

peritonitis

Answer 13

§ the lining of the abdomen (very sensitive to foreign substances i.e. gastric juices, bowel contents, and blood)
§ may be the result of a medical condition (such as the inflammation of a ruptured appendix) or the result of trauma (such as bleeding from a ruptured spleen)
§ abdomen typically becomes extremely painful and rigid
□ Not a voluntary response as guarding
§ can also be accompanied by fever and other signs of infection
§ Potentially life-threatening emergency
needs prompt evaluation by a physician to determine the appropriate treatment, which is often surgery

Question 14

Cholecystitis/ Gallstones

Answer 14

§ Cholecystitis: inflammation of the gallbladder, often caused by gallstones
§ experience severe and sometimes sudden right upper quadrant (RUQ) and/or epigastric (upper central abdomen just below the xiphoid process) pain, which may radiate to the shoulder.
§ Often confused for chest pain
may be caused or worsened by ingestion of foods high in fat and can sometimes abruptly end as a stone frees itself and is passed

Question 15

Pancreatitis

Answer 15

§ inflammation of the pancreas, is common in patients with chronic alcohol problems
§ Pain found in epigastric area
§ Pain may radiate to the back and/or shoulders
in advanced cases can present with signs of shock

Question 16

Gastrointestinal (GI) Bleeding

Answer 16

§ Can occur anywhere from the esophagus to the rectum
§ Can be gradual, sudden or massive
□ Passes through the rectum or the mouth
§ May report abnormal black stool, maroon in color, and tarry in appearance
§ Vomiting of frank blood or coffee grounds
§ can be associated with pain but often occurs without pain
§ Painful GI bleeding most commonly occurs in patients with perforated ulcers in the stomach (gastric ulcers). These lesions are the result of acidic gastric juices wearing a hole in the upper gastrointestinal system
§ Presents in different ways
§ chronic gastrointestinal hemorrhage
□ Bleed in small vessels
□ Slow blood loss
□ Pale and weak
□ Eventually the patient develops signs and symptoms and shock
§ bleeding from the rectum or vomiting of either bright red blood or material that resembles coffee grounds. This type of bleeding is associated with the sudden onset of signs and symptoms of hypoperfusion.
§ blood vessels of the esophagus can become vulnerable often due to chronic alcohol ingestion or from hypertension in the liver. If these blood vessels rupture, massive upper GI bleeding can occur. This bleeding, because of its proximity to the pharynx, can threaten the airway and pose a serious life threat.

Question 17

Abdominal Aortic Aneurysm (AAA)

Answer 17

§ ballooning or weakening in the wall of the aorta as it passes through the abdomen. The weakening results in tearing of the internal layer of the blood vessel, which allows blood to escape into the weaker, outer layers.
§ Area grows and ruptures
§ Ruptured aneurysms are associated with an extremely high rate of death if they are discovered after they rupture
§ gradually developing abdominal pain, which can be described as sharp pain or tearing pain and may radiate to the back
A sudden rupture of the aorta typically causes rapid onset of excruciating abdominal and back pain. Signs of shock are usually present. Depending on the location of the AAA, there may be inequality between the femoral or pedal pulses.

Question 18

Hernia

Answer 18

§ hole in the muscle layers of the abdominal wall, allowing tissue—usually intestine—to protrude up against the skin
§ Aggravated by heavy lifting or straining
§ cause a sudden onset of pain, usually after lifting
§ A hernia may be palpated as a mass or lump on the abdominal wall or in the creases of the groin
§ Only life-threatening if the hernia causes an obstruction or twisting of the intestine
all patients with a painful hernia should be transported for further evaluation at the hospital.

Question 19

Renal Colic

Answer 19

§ Kidney stones
§ descend down the ureter on the way to the bladder, it can cause severe flank pain that often radiates anteriorly to the groin area
§ Visceral pain is often severe
§ May be associated with nausea and vomiting
“writhing” because they move around, trying unsuccessfully to find a position of comfort

Question 20

Cardiac Involvement

Answer 20

§ Pain from a heart attack may be felt as abdominal discomfort
indigestion or digestive discomfort, is commonly felt in the epigastric region (the area below the xiphoid, in the upper center of the abdomen). All epigastric abdominal pain should be considered cardiac in nature until proven otherwise

Question 21

OPQRSTU

Answer 21

onset. When did the pain or discomfort begin?
Provocation/palliation. What makes the pain better or worse?
Quality. Describe the sensation in your abdomen to me.
Region/Radiation. Point to or show me where the pain or discomfort is.
Severity. How severe is the pain or discomfort?
Time. How long have you had the pain or discomfort?

Question 22

ectopic pregnancy

Answer 22

(a pregnancy developing outside of the uterus) can be life-threatening conditions and must be considered in the history. Other conditions, such as ruptured ovarian cysts, pelvic inflammatory disease, and menstrual irregularities, can also cause significant pain.

Question 23

important questions to ask for ectopic pregnancy

Answer 23

® Where are you in your menstrual cycle?
® Is your period late?
® Do you have bleeding from the vagina now that is not menstrual bleeding? If you are menstruating, is the flow normal?
® Have you had this pain before?
® If so, when did it happen and what was it like?
® Is it possible you are pregnant?
Are you sexually active?

Question 24

Past Medical History: SAMPLE

Answer 24

Signs and Symptoms 
Allergies
Medications 
Pertinent Past History
Last Oral Intake 
Events Leading to the Emergency

Question 25

Geriatric Note

Answer 25

Older people may have a decreased ability to perceive pain; likely to have a more serious cause of their abdominal pain

Question 26

physical examination of the abdomen

Answer 26

inspect and palpation
§ First, inspect the patient’s abdomen. Look for distention, bloating, discoloration, abnormal protrusions, or other signs that appear abnormal or unusual.
Always palpate the area that has pain or discomfort last.
Once you have found pain, discomfort, or abnormality, there is no need to palpate further in that area

Question 27

identifying abdominal aortic aneurysm

Answer 27

, you may palpate a pulsating mass (abnormal bulge or lump). This mass may be found in conjunction with tearing or sharp pain in the back. This indicates an advanced aneurysm. If you gently palpate this mass, do not palpate it again. Instead, report this mass to the receiving hospital

Question 28

General Abdominal Distress

Answer 28

• complaints that appear nonspecific but involve the digestive system. Nausea, vomiting, and diarrhea are examples
○ Digestive system disorders, cardiac issues, diabetic issues, food poisoning, or the flu.
• assessment techniques discussed previously in the chapter will apply in the same manner to these patients. Determining if there is pain, tenderness, discomfort, or any associated complaints; the time of onset (sudden versus over a period of time); fever and malaise; and abdominal inspection and palpation are all appropriate
Place the responsive patient in a position of comfort. Place the unresponsive patient or the patient who is having difficulty maintaining an airway in a left lateral recumbent position for drainage from the mouth.

Question 29

Patient Assessment: Abdominal Distress

Answer 29

1. Perform a scene size-up, looking for clues to a possible mechanism of injury while taking Standard Precautions as well as safety precautions.
   
   2. Perform a primary assessment including the general impression of the patient’s level of distress, mental status, airway, breathing, and circulation. Consider oxygen. Make a trans- port/priority decision. Vomiting may cause airway compromise, so be prepared to suction.
   3. Assist the patient to a position of comfort. Calm and reassure the patient. This will help the patient and, by relaxing him, also help complete your next assessment steps.
   4. Perform a history, physical examination, and vital signs.
   5. Perform a reassessment every 5 minutes en route.
      Decision Point: Is the patient developing shock?

Question 30

Patient Care: Abdominal Distress

Answer 30

• despite the differences in patient presentation, you should follow these steps when treating a patient with an abdominal emergency.
1. While performing the primary assessment, maintain the patient’s airway. If the patient has an altered level of responsiveness, this will compromise the airway. Keep in mind that patients with abdominal emergencies may vomit. Suction whenever necessary.
2. Consider the need for oxygen. Administer oxygen to any patient who is hypoxic (as evidenced by a saturation of less than 94 percent or signs of hypoxia). Consider oxygen for any complaint complicated by respiratory distress or when pulse oximetry is unobtainable or reliable (such as in shock conditions). Maintain oxygen saturations of 94 percent using an appropriate oxygen delivery device such as a nasal cannula or nonrebreather mask.
3. Place the patient in a position of comfort (Figure 22-8). However, if shock and/or airway problems are present, position the patient to treat these conditions. The left laterally recumbent position will help maintain the airway.
4. Transport the patient promptly to an appropriate facility.
Never give a patient with a complaint of abdominal pain or discomfort anything by mouth