Gastroenterology in paramedic practice: Flashcards
The Acute abdomen:
- Sick’ / ‘unwell’ abdominal pain
• Clinical syndrome (no specific aetiology)
• Potential surgical emergency
o Destination considerations - Severe pain
- Sudden onset
- Rigidity
- Guarding
- Perfusion compromise = intra -abdominal sepsis?
Gastro - Oesophageal Reflux Disease
AKA “GORD” / “reflux”
• Common –20% of US population • Burning chest discomfort “heartburn” o 12L ECG critical o Burning pain predicts ACS o Transport critical
• Relation seen to asthma
•Management: ‘pink lady’ liquid
o Antacid + local anaesthetic
o Pain resolution does not rule out ACS
Oesophageal Foreign Body:
• 1 -2YO, elderly, psych most common • >2,5cm(W) or >6cm(H) problematic in adults • Dysphagia, choking, vomiting, pain - Oesophageal v tracheal DDx ? o Hypoxia o Chest auscultation o WOB o Non - reassurable > RR • Hx: ? unrealiable, unwitnessed • Emergency: o Sharp / elongated objects o Button batteries o >24 hours •Transport all • Most pass 48-72 hours
Gastroenteritis
•AKA “gastro” • Beware “just gastro” syndrome • Easily spread (nursing home outbreaks) • Usually benign • At risk: immunosuppressed, elderly, infants • Diarrhoea AND vomiting +/ - stomach cramps and fever - Treat and refer if safe to do so • Thorough cleaning of equipment and PPE
Bowel obstruction:
• Small or large intestine • Symptoms o Severe pain (cramps) o Distension o Vomiting (?faecal) o Constipation • Surgical Issue • Causes mesenteric ischaemia • Dx by x -ray and CT
Diverticulitis:
Diverticulitis = inflamed diverticula • Common • Benign to life threatening (large spectrum) • Aggressive to passive management • LLQ pain + fever (Caucasian) • RLQ pain + fever (Asian) • Chronic or acute presentations • Difficult Dx (to image or not to image)
Appendicitis
Common o 300,000 appendectomies in USA / year o 700,000 in Europe / year o 12% of males, 25% for females o Most common abdo pain aetiology • Imaging may not be required before surgery
Cholelithiasis and Cholecystitis:
• Gallbladder disorders • Cholelithiasis AKA gallstones • Cholecystitis AKA gallbladder inflammation • RUQ pain >> left upper back • 2100 - 0400 common • N&V + fever associated • Not related to meals • Recurrent post cholecystectomy in 2% • Definitive fix = surgery
Oesophageal Varices
• Dilated veins in oesophagus
• Consequence of portal hypertension
• Bleed acutely (bright) and chronically (dark)
• Varices can also form in the stomach, duodenum
and rectum
• Acute haemorrhage can lead to cardiac arrest
• Traumatic v medical arrest?
Gastrointestinal Tract bleeding (UPPER)
- peptic ulcers
- Oesophagitis
- Gastric/oesophageal varices
- Oesophageal tear (Mallory-Weiss)
Gastrointestinal Tract bleeding (LOWER)
- Diverticulitis
- Malignancies
- Colitis
- Haemorrhoids
GI bleeding Assessment:
- orifice
- colour – gives clues to origin = opposite for haematemesis / PR bleeding
- Consistency ( liquid v clots)
Haematochezia:
Bright red coloured bleeding from the rectum
Melena:
Dark coloured stools
Coffee ground hematemesis:
digested blood
GI Bleeding assessment
Haematemesis
Dark = Upper or Lower GIT
Bright = Upper GIT
PR Bleeding
Dark = Upper GIT
Bright = Lower GIT
Gastroenterology Symptomology:
Symptoms o Abdominal pain o Nausea and vomiting o Diarrhoea o Constipation o Abdominal distension o GI bleeding
• Clinical Practice Guidelines
o Analgesia
o Nausea and vomiting
o Hypovolaemia
Abdominal Pain:
Thorough assessment for red flags
• Consider patient administered
medication
Mild pain o OTC medications o PO paracetamol o ? Avoid anti -inflammatories • Moderate pain o IN fentanyl o PO paracetamol +/ - PO opioid • Severe pain o IV opioids o Morphine preferred o Fentanyl if N&V or hypotension o Other options?
Nausea and Vomiting:
- Ondansetron medication of choice
- PO (consider vomiting) or IV
- Indicated for adults and children
• Other options
o Metoclopramide
o Prochlorperazine
Hypovolaemia in gastroenterological conditions:
Dehydration: • Diarrhoea >>> vomiting • Beware electrolyte derangement • Stop source if possible • Kills slowly • Normal saline fluid replacement • Perfusion targets? • Replace over time lost?
GI Bleeding: • Haematemesis >>> PR bleeding • Acute v chronic? • Likely surgical issue • Cautious fluid administration • Appropriate destination • Perfusion targets? • Permissive hypotension
GI bleeding fluid replacement:
Only administer normal saline if the SBP is <80mmHg
• Stop when SBP >80mmHg
• Non compressible bleeding
• Surgical fix likely
• Ideal fluid replacement whole blood
• Normal saline can cause more harm than good
• Relation to trauma studies?
If a GI bleed arrests, will you manage them as a ‘medical’ or ‘traumatic’ arrest?
