Abdominal Emergencies

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Emergency Care
THIRTEENTH EDITION
CHAPTER
22
Abdominal Emergencies
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
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Abdominal Anatomy
and Physiology
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
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Abdominal Anatomy
and Physiology
• Abdomen contains many organs, from
several different body systems.
• Can cause confusion when determining
the cause of abdominal emergencies
• Thorough patient assessment key.
• Specific diagnosis may not be
necessary; treatment is the same for
most conditions.
continued on next slide
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Abdominal Anatomy
and Physiology
• Abdomen
 Region between diaphragm and pelvis
 Contains many organs and organ
systems that provide the following
functions:
•
•
•
•
Digestive
Reproductive
Endocrine
Regulatory
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Organs of the Abdomen
The structures and organs of the abdomen.
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Hollow Organs vs. Shallow
• Injury to a solid organ can cause shock
and bleeding.
• Breach into hollow organs causes
contents to leak and contaminate
abdominal cavity.
 Leads to infection.
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Abdominal Anatomy
and Physiology
• Abdomen divided into "quadrants"
 RUQ, LUQ, RLQ, LLQ
 Epigastric region
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Abdominal Quadrants
The abdominal quadrants.
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Abdominal Quadrants
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Abdominal Anatomy
and Physiology
• Organs of the abdomen
 Peritoneum
• Thin membrane lining the abdominal
cavity and covering each organ
 Parietal peritoneum attached to the
abdominal wall
 Visceral peritoneum covers each organ.
continued on next slide
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Abdominal Anatomy
and Physiology
• Organs of the abdomen
 Most enclosed within parietal
peritoneum
 A few lie in extraperitoneal space
(outside the peritoneum).
• Kidneys, pancreas, part of aorta lie in
retroperitoneal space, behind
peritoneum.
• Bladder and part of rectum lie inferior to
peritoneum.
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Peritoneal and Extraperitoneal
Space
The peritoneum and extraperitoneal (including retroperitoneal) space.
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Body Systems Located in the
Abdominal Cavity
•
•
•
•
Gastrointestinal System
Lymphatic System
Genital System
Urinary System
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The Gastrointestinal System
• Responsible for digestion process
• Digestion begins when food is chewed.
 Saliva breaks down food.
 Food is swallowed.
 Food travels to stomach.
• Stomach is main digestive organ.
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The Gastrointestinal System
• Liver assists in digestion.
 Secretes bile
• Aids in digestion of fats
 Filters toxic substances
 Creates glucose stores
• Gallbladder is a reservoir for bile.
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The Gastrointestinal System
• Small Intestine
 Duodenum
• Digestive juices from
pancreas and liver mix.
• Pancreas secretes enzymes
breaking down starches, fats,
protein.
• Pancreas produces
bicarbonate, insulin.
 Jejunum
• Absorbs digestive products
• Does most of the work
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The Gastrointestinal System
• Small intestine (cont’d)
 Ileum
• Soluble molecules are absorbed into
blood.
• Proteins, fats, starches reduce to amino
acids, fatty acids, simple sugars.
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The Gastrointestinal System
• Colon (large intestine)
 Food that isn’t used comes here.
 A movement called peristalsis moves
waste through intestines.
 Water is absorbed.
 Stool is formed.
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The Gastrointestinal System
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The Gastrointestinal System
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The Lymphatic System
• Spleen
 Located in abdomen
 No digestive
function
 Part of lymphatic
system
• Assists in filtering
blood
• Develops red blood
cells
• Blood reservoir
• Produces antibodies
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The Genital System
• Male reproductive
system:






Testicles
Epididymis
Vasa deferentia
Seminal vesicles
Prostate gland
Penis
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The Genital System
• Female
reproductive
system:





Ovaries
Fallopian tubes
Uterus
Cervix
Vagina
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The Urinary System
• Controls discharge of waste
materials filtered from blood
by kidneys
• Body has two kidneys, one on
each side.
 Lie on posterior wall of
abdomen
 Regulate acidity and blood
pressure
 Rid body of toxic waste
 Blood flow is high in kidneys.
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The Urinary System
• Ureters join each kidney to
the bladder.
• Bladder is located behind
pubic symphysis.
• Bladder empties urine outside
body through urethra.
 1.5 to 2 L of urine per day
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Abdominal Pain or Discomfort
Emergency Care, 13e
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Abdominal Pain or Discomfort
• Visceral pain
 Originates from the organs within the
abdomen
 Fewer nerve endings allow for only
diffuse sensations of pain.
 Frequently described as "dull" or "achy"
continued on next slide
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Abdominal Pain or Discomfort
• Visceral pain
 Colic (intermittent pain) may result from
distention and/or contraction of hollow
organs.
 Persistent or constant pain often
originates from solid organs.
continued on next slide
Emergency Care, 13e
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Abdominal Pain or Discomfort
• Parietal pain
 Originates from the parietal peritoneum
 Many nerve endings allow for specific,
efficient sensations of pain.
 Frequently described as "sharp"
 Pain is often severe, constant, and
localized to a specific area.
continued on next slide
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Abdominal Pain or Discomfort
• Tearing pain
 Most common type of abdominal pain
 Originates in the aorta
 Separation of layers of this large blood
vessel caused by aneurysm
 Retroperitoneal location of aorta causes
pain to be referred to back.
continued on next slide
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Abdominal Pain or Discomfort
• Referred pain
 Perception of pain in skin or muscles at
distant locations
• Abdomen has many nerves from different
parts of the nervous system.
• Nerve pathways overlap as they return to
the spinal cord.
• Pain sensation is transmitted from one
system to another.
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Abdominal Pain or Discomfort
• Referred pain
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Abdominal Pain or Discomfort
Emergency Care, 13e
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Abdominal Pain or Discomfort
Emergency Care, 13e
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Assessment and Care of
Abdominal Pain or Discomfort
Emergency Care, 13e
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Assessment and Care of
Abdominal Pain or Discomfort
• Many potential causes of abdominal
pain
• Role of EMT is not to diagnose.
• Focus efforts
 Perform thorough secondary
assessment.
 Identify serious or life-threatening
conditions.
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Scene Size-Up
• Scene safety:
 Make sure the scene is safe
• BSI:
 Always wear gloves.
 Be aware of odors.
• Mechanism of injury/nature of illness:
 Determine if patient's condition is medical, trauma, or
both.
• Additional resources:
 None
• C-spine precautions:
 Typically none needed
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Primary Assessment
• Form a general impression.
 Note patient age, sex, general
appearance, position, and environment.
• Obtain chief complaint
• Assess mental status:
 Check for responsiveness
• Assess airway:
 Make sure airway is patent and
adequate.
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Primary Assessment
• Assess breathing:
 Abdominal pain may cause shallow,
inadequate respirations.
 Consider application of supplemental
oxygen to any hypoxic abdominal pain
patient or in any situation where an
oxygen saturation is deemed to be
inaccurate
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Primary Assessment
• Assess circulation:
 Ask about blood in vomit or black, tarry
stools.
 Shock may be detected through pulse
assessment.
 Pulse strengths should be consistent.
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Primary Assessment
• Transport decision and prioritization:
 Classify the patient using CUPS
 If condition is unstable and there is
possible life threat:
• Address the life threat.
• Proceed with rapid transport.
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Secondary Assessment
History of the Present Illness
• Investigate chief complaint.
 Often based on previous medical
problems
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Secondary Assessment
History of the Present Illness
• Onset
 "What were you doing when your pain
started?"
• Provocation/palliation
 "What makes it better or worse?
Movement? Position?"
• Quality
 Describe the sensation of your pain in
your abdomen."
continued on next slide
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Secondary Assessment
History of the Present Illness
• Region/Radiation
 "Point to its location. Does it radiate or
move?"
• Severity
 "How bad is the pain on a scale of 1–
10?"
• Time
 "Do you have pain all the time? Is it
intermittent? Has it changed? How long
have you had it?"
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Secondary Assessment
History of the Present Illness
• S: Signs & Symptoms
Do you feel weak?
Do you feel light-headed?
Do you feel tired?
Have you had any recent illness?
Do you feel short of breath?
Do you have any back, flank, or
shoulder pain?
 Do you feel nauseous?






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Secondary Assessment
History of the Present Illness
• S: Signs & Symptoms
 Have you vomited?
• How often?
• What was in it?
• Any blood?
• Bright red color?
• Coffee ground emesis?
 Have you had recent weight loss?
 Have you had pain like this before?
 Any chest pain?
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Secondary Assessment
History of the Present Illness
• S: Signs & Symptoms





Have you been urinating very frequently?
Any painful urination?
Any blood in your urine?
What color is your urine?
Is there a foul smell in your urine?
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Secondary Assessment
History of the Present Illness
• S: Signs & Symptoms
 How are your bowel movements?
• Are they solid or liquid?
• When was your last bowel movements?
• Any blood in your stool?
• Is it bright red?
• Is it dark and tarry?
• Is it foul smelling?
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Secondary Assessment
History Specific to Female Patients
• "Where are you in your menstrual
cycle?"
• "Is your period late?"
• ”Do you have bleeding from the vagina
that is not menstrual bleeding?"
• "If you are menstruating, is your flow
normal?"
continued on next slide
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Secondary Assessment
History Specific to Female Patients
• "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 using birth control?"
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Secondary Assessment
Past Medical History
• A: Allergies
 Do you have any allergies?
• M: Medications
 What medications do you take?
• P: Pertinent past history
 Do you have any medical problems?
 Have you had any abdominal surgeries?
 Past history of acid reflux, AAA,
pancreatitis, GI bleeding, Diverticulitis
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Secondary Assessment
Past Medical History
• L: Last oral intake
 When is the last time you have had
something to eat or drink?
 What was it? Spicy or greasy?
• E: Events leading to emergency
 What were you doing when this started?
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Geriatric Note
•
•
•
•
Decreased ability to perceive pain
More serious causes of abdominal pain
More likely to be life-threatening
May be complicated by medications
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Pediatric Note
• Vomiting causes dehydration.
• Appendicitis is common in children.
• May have abdominal pain from
constipation.
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Secondary Assessment
Physical Examination
• Inspection
 Distention
 Discoloration
 Protrusions
• Palpation
 Use fingertips.
 Painful area last
continued on next slide
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Secondary Assessment
Physical Examination
• Palpation
 Normal abdomen is
soft and not tender.
 Rigidity
 Pain
 Guarding
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Secondary Assessment
Physical Examination
• Auscultation
 Listen for normal bowel sounds.
• Percussion
 Tap and observe for a high-pitched
sound (air) or a low-pitched sound
(fluid).
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Vital Signs
• Baseline, then every 5/15 minutes






Pulse
Respirations
Blood pressure
Skin color, temperature, and condition
Pulse oximetry
Mental status
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Treatments
• Maintain airway.
 Be prepared to suction.
 Have emesis bags on hand.
• Administer oxygen to hypoxic patient.
 Maintain oxygen saturations of 94 percent.
• Place in position of comfort.
 LLR for airway protection
• Provide palliative care and emotional support.
• Never allow the patient to eat or drink.
• Transport to appropriate facility.
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Reassessment
• Reassess every 15 for stable patients and
5 minutes for potential unstable/unstable
patients.
 Repeat the primary assessment.
 Reassess interventions effectiveness.
 Repeat focused exam on abnormalities found
during initial exam.
 Repeat vital signs
• Communication and documentation
 Communicate all relevant information to staff
at receiving hospital.
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Abdominal Conditions
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Appendicitis
• Inflammation or infection of appendix
• Signs and symptoms
 Nausea and sometimes vomiting
 Fever or chills
 Pain often initially referred to umbilical
region, followed by persistent RLQ pain
 Rupture of appendix
• Sudden, severe increase in pain
• Contents releasing into abdomen causes
severe peritonitis.
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Peritonitis
• Irritation of peritoneum, usually caused
by foreign material in peritoneal space
• Parietal peritoneum is sensitive,
especially to acidic substances.
• Irritation causes involuntary contraction
of abdominal muscles.
• Signs and symptoms
 Abdominal pain and rigidity
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Ileus
• Paralysis of muscular contractions.
• Retained gas and feces cause
distention.
• Stomach empties by emesis (vomiting).
• Typically caused by peritonitis.
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Cholecystitis/Gallstones
• Inflammation of the gallbladder.
• Often caused by blockage of its outlet by gall
stones (cholecystolithiasis).
• Unknown what causes gallstones but possible
from the liver releasing too much cholesterol.
• Symptoms often worsened by ingestion of fatty
foods.
• Signs and symptoms
 Severe RUQ or epigastric pain
 Pain often referred to shoulder
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Pancreatitis
• Inflammation of the pancreas.
 Caused by obstructing gallstone, alcohol
abuse, or other diseases.
• Signs and symptoms




Epigastric pain.
Often referred to back and/or shoulder.
Nausea and/or vomiting.
Abdominal distention.
• Sepsis or hemorrhage may occur.
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Gastrointestinal (GI) Bleeding
• Hemorrhage within the lumen of the GI
tract.
• May be acute or chronic.
• May be minor to severe.
• Blood eventually exits (mouth or
rectum).
• Often painless.
continued on next slide
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Gastrointestinal (GI) Bleeding
• Signs and symptoms
 Dark-colored stool (maroon to black),
often "tarry“. Think lower GI bleed.
 Bright red blood from rectum
(hemorrhoid). Think bleeding around
the site.
 Vomiting "coffee-ground" appearing
blood. Think bleeding in the stomach.
 Vomiting of frank blood. Think bleeding
in esophagus.
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Gastrointestinal (GI) Bleeding
• Signs and symptoms







Pain can be absent to severe.
Weakness
Lethargy
Altered Mental Status
Hypotension
Tachycardia
Afebrile
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Ulcers
• Protective layer of mucus lining erodes
from highly acidic gastric juices,
allowing acid to eat into organ.
• May lead to gastric bleeding.
• Can cause severe pain and peritonitis.
• Some heal without intervention.
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Esophageal Varices
• Capillary network in esophagus leaks.
• Frequently caused by alcoholism or
ingesting extremely acidic or alkaline
substances.
• Signs and symptoms





Fatigue
Weight loss
Jaundice
Anorexia
Spitting up bright red blood.
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Esophagitis
• Lining of esophagus becomes inflamed
by infection or acids from the stomach.
• Signs and symptoms





Pain in swallowing
Heartburn
Nausea
Vomiting
Sores in mouth
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Abdominal Aortic Aneurysm
• Ballooning or
weakening of inner
wall of the aorta.
• Tears and separates
from outer layers
(dissection).
• Weakened vessel
bulges, may continue
to grow.
• May eventually
rupture.
continued on next slide
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Abdominal Aortic Aneurysm
• Signs and symptoms
 Progressive (often sharp or tearing)
abdominal pain
 Frequently radiates to back (lumbar)
 Palpable abdominal mass, possibly
pulsating
 Possible inequality in pedal pulses
continued on next slide
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Abdominal Aortic Aneurysm
• Signs and symptoms
 Sudden, severe increase in pain may
indicate rupture.
• High aortic pressure causes rapid internal
bleeding.
• Sudden progression of shock
• Likely exsanguination (fatal hemorrhage)
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Abdominal Aortic Aneurysm
Animation
Click on the screenshot to view an animation on the subject of abdominal aortic
aneurysm.
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Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Mallory-Weiss Syndrome
• Junction between esophagus and
stomach tears causing severe bleeding.
• Vomiting is principal symptom.
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Gastroenteritis
• Infection from bacterial or viral
organisms in contaminated food or
water
• Signs and symptoms
 Abdominal pain
 Diarrhea
 Flatulency
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Hernia
• Hole in the muscle layer of abdominal
wall, allowing tissue or parts of organs
(commonly intestines) to protrude up
against skin
• May be precipitated by heavy lifting
• May cause strangulation of tissue or
bowel obstruction
• May require surgical repair
continued on next slide
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Hernia
• Signs and symptoms
 Sudden onset of abdominal pain, often
following exertion.
 Palpable mass or lump on abdominal
wall or crease of groin (inguinal hernia).
 Tenderness when the hernia is palpated.
 Red or blue skin discoloration.
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Diverticulitis
• Inflammation of abnormal pockets at
weak areas in lining of colon
• Chronic condition with flare-ups.
• Fecal matter becomes caught in colon
walls, causing inflammation and
infection.
• Signs & symptoms
 Fever, malaise, body aches, chills,
abdominal pain
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Hemorrhoids
• Created by swelling and inflammation
of blood vessels surrounding rectum
• Signs and symptoms
 Bright red blood during defecation
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Renal Colic
• Severe flank pain caused by kidney
stones traveling down the ureter
• Signs and symptoms
 Severe, cramping, intermittent pain in
flank or back
 Frequently referred to groin
 Nausea, vomiting
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Cystitis (Bladder Infection)
• Also called urinary tract infection (UTI).
• Caused by bacterial infection.
• Becomes serious if infection spreads to
kidneys.
• Signs and symptoms
 Frequent urination (polyuria)
 Painful or difficult urination (dysuria)
 Foul smelling urine
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Cardiac Involvement
• Pain from myocardial infarction may be
felt as abdominal discomfort.
 Epigastric pain
 Indigestion or digestive discomfort
• Always consider the possibility of a
cardiac emergency as a cause of
abdominal symptoms.
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Female Reproductive Organs
• Gynecologic problems are a common
cause of acute abdominal pain.
• Lower quadrant pain may relate to
ovaries, fallopian tubes, or uterus.
• Will discuss further in OB/GYN lecture.
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
Credits
• Background slide image (ambulance): Galina
Barskaya/ShutterStock, Inc.
• Background slide images (non-ambulance): ©
Jones & Bartlett Learning. Courtesy of MIEMSS.
• 2016 Pearson Education, Inc. Emergency Care,
13e, Chapter 22: Abdominal Emergencies.
• 2011 Jones & Bartlett Learn, LLC. Chapter 16:
Gastrointestinal and Urologic Emergencies.
Emergency Care, 13e
Daniel Limmer | Michael F. O'Keefe
Copyright © 2016, 2012, 2009 by Pearson Education, Inc.
All Rights Reserved
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