Gastroenterology in paramedic practice:

Question 1

The Acute abdomen:

Answer 1

• 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?

Question 2

Gastro - Oesophageal Reflux Disease

Answer 2

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

Question 3

Oesophageal Foreign Body:

Answer 3

• 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

Question 4

Gastroenteritis

Answer 4

•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

Question 5

Bowel obstruction:

Answer 5

• 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

Question 6

Diverticulitis:

Answer 6

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)

Question 7

Appendicitis

Answer 7

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

Question 8

Cholelithiasis and Cholecystitis:

Answer 8

• 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

Question 9

Oesophageal Varices

Answer 9

• 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?

Question 10

Gastrointestinal Tract bleeding (UPPER)

Answer 10

• peptic ulcers
• Oesophagitis
• Gastric/oesophageal varices
• Oesophageal tear (Mallory-Weiss)

Question 11

Gastrointestinal Tract bleeding (LOWER)

Answer 11

• Diverticulitis
• Malignancies
• Colitis
• Haemorrhoids

Question 12

GI bleeding Assessment:

Answer 12

• orifice
• colour – gives clues to origin = opposite for haematemesis / PR bleeding
• Consistency ( liquid v clots)

Question 13

Haematochezia:

Answer 13

Bright red coloured bleeding from the rectum

Question 14

Melena:

Answer 14

Dark coloured stools

Question 15

Coffee ground hematemesis:

Answer 15

digested blood

Question 16

GI Bleeding assessment

Answer 16

Haematemesis
Dark = Upper or Lower GIT
Bright = Upper GIT

PR Bleeding
Dark = Upper GIT
Bright = Lower GIT

Question 17

Gastroenterology Symptomology:

Answer 17

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

Question 18

Abdominal Pain:

Answer 18

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?

Question 19

Nausea and Vomiting:

Answer 19

• Ondansetron medication of choice
• PO (consider vomiting) or IV
• Indicated for adults and children

• Other options
o Metoclopramide
o Prochlorperazine

Question 20

Hypovolaemia in gastroenterological conditions:

Answer 20

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

Question 21

GI bleeding fluid replacement:

Answer 21

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?