chapter 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 lar organ,
Women: uterus, fallopian tubes, and ovaries

Question 5

visceral peritoneum

Answer 5

covers the organs

Question 6

parietal peritoneum

Answer 6

attached to the abdominal wall

Question 7

extraperitoneal space

Answer 7

the area outside the peritoneum & contains retroperitoneal space

Question 8

retroperitoneal space

Answer 8

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

Question 9

What are the two main blood vessels and where are they located?

Answer 9

Aorta (largest artery): travels down through the diaphragm and traverses the retroperitoneal space
Inferior vena cava: behind the peritoneum

Question 10

visceral pain

Answer 10

• 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 11

parietal pain

Answer 11

-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 12

tearing pain

Answer 12

-Not very common
-Aorta 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 13

referred pain

Answer 13

• 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 14

appendicitis

Answer 14

-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 15

peritonitis

Answer 15

-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 16

cholecystitis/ gallstones

Answer 16

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 17

pancreatitis

Answer 17

• 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 18

Gastrointestinal (GI) Bleeding

Answer 18

• 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
• 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 19

Abdominal Aortic Aneurysm (AAA)

Answer 19

• 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 20

Hernia

Answer 20

• 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 21

Renal Colic

Answer 21

§ 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 22

Cardiac Involvement

Answer 22

§ 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 23

Primary Assessment of Abdominal Pain

Answer 23

§ general impression you obtain as you approach the patient will be valuable in determining the seriousness of the patient’s condition and the urgency of your care
§ Level of consciousness
§ you will be able to notice the early signs of shock. An altered mental status; anxiety; pale, cool, or moist skin; and rapid pulse and respirations will alert you to shock long before you would take a blood-pressure or see trends in the blood pressure
§ Position is important
§ Consider supplemental oxygen

Question 24

History Specific to Female Patients with abdominal pain

Answer 24

□ ectopic pregnancy (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.
□ Important Questions
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 25

OPQRST

Answer 25

onset, provocation/palliation, quality, region/radiation, severity, time

Question 26

What are the two procedures of physical examination of the abdomen?

Answer 26

inspection ( Look for distention, bloating, discoloration, abnormal protrusions, or other signs that appear abnormal or unusual) and palpation (fingertips of several fingers and gently press into the abdomen in each quadrant. While palpating, feel for rigidity or hardening and ask or observe whether this causes pain for the patient )

Question 27

How often should vitals be taken for patients with abdominal pain?

Answer 27

5 min; Since patients with abdominal pain may have an increased pulse simply as a result of the pain, serial vitals taken over time will help identify potentially dangerous trends

Question 28

Signs of Shock

Answer 28

○ shock will appear initially with increased pulse and respirations; pale, moist skin; and anxiety; Falling blood pressure will be a late sign

Question 29

Patient Assessment of 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 transport/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