1. Introduction to Emergency Medical Care 1
Advance Preparation
Prepare anatomy models for demonstration.
Research related multimedia links for illustration purposes.
Invite assistant instructors and programmed patients.

2. OBJECTIVES
24.1 Define key terms introduced in this chapter. 13, 15, 18, 20– Describe the location, structure, and function of the organs in the abdominal cavity. Slides 11– Explain the origins and characteristics of visceral, parietal, and tearing pain. Slides 18, 21–22
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3. OBJECTIVES
24.4 Associate areas of referred pain with the likely origins of the pain. Slide Recognize the common signs and symptoms of abdominal conditions, including appendicitis, peritonitis, cholecystitis, pancreatitis, ulcers, abdominal aortic aneurysm, hernia, and renal colic. Slides 24–35
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4. OBJECTIVES
24.6 Discuss the type of abdominal pain that may indicate cardiac involvement. Slide Discuss appropriate assessment and management of patients complaining of abdominal pain. Slides 38–47
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5. OBJECTIVES
24.8 Elicit key information in the history of patients complaining of abdominal pain, including history specific to female patients. Slides 41–43

6. MULTIMEDIA Slide 50 Abdominal Aortic Aneurysm Video
This video appears later in the presentation; you may want to preview it prior to class to ensure it loads and plays properly. Click on the link above in slideshow view to go directly to the slide.

7. Understanding the nature of abdominal pain
Becoming familiar with abdominal conditions that may cause pain or discomfort
How to assess and care for patients with abdominal pain

8. Topics Abdominal Anatomy and Physiology Abdominal Pain or Discomfort
Abdominal Conditions
Assessment and Care of Abdominal Pain or Discomfort
Planning Your Time: Plan 90 minutes for this chapter.
Abdominal Anatomy and Physiology (15 minutes)
Abdominal Pain or Discomfort (15 minutes)
Abdominal Conditions (30 minutes)
Assessment and Care of Abdominal Pain or Discomfort (30 minutes)
Note: The total teaching time recommended is only a guideline.

9. Introduction
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

10. Abdominal Anatomy and Physiology
Teaching Time: 15 minutes
Teaching Tips: The function of abdominal organ systems is an important topic, but it easily can drain time away from other important lessons. Consider taking this lesson out of the classroom by assigning homework and research projects. Use an anatomical model to demonstrate the positioning of abdominal organs. Relate the four quadrants of the abdomen to external landmarks. Demonstrate positioning on an actual abdomen. Refer to mechanism of injury to demonstrate why abdominal anatomy is important.

11. Abdomen Region between diaphragm and pelvis
Contains many organs and organ systems
Digestive
Reproductive
Endocrine
Regulatory
Point to Emphasize: The abdomen contains a variety of organs that accomplish a range of functions for the body. Digestion, secretion of insulin, filtration of blood, and the removal of toxins from the body are functions performed by abdominal organs.
Knowledge Application: Using a disassembled abdominal anatomy manikin, correctly reassemble the abdominal cavity. Label the organs as they are replaced.

12. Organs of the Abdomen continued
Discussion Topics: List and describe the major organ systems of the abdomen. Discuss the function of each system. How are the abdominal organs of a man different from the abdominal organs of a woman? Describe these differences.
Class Activity: Assign homework. Have students, using a blank anatomy diagram of the abdomen, correctly label and position the major organ systems.
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13. Organs of the Abdomen
Peritoneum: thin membrane lining the abdominal cavity and covering each organ
Parietal peritoneum lines abdominal cavity
Visceral peritoneum covers each organ
Talking Points: The peritoneal space is the potential space between these two layers. A small amount of peritoneal fluid occupies this space and provides lubrication.
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14. Organs of the Abdomen Most enclosed within parietal peritoneum
A few lie in extra-peritoneal space (outside the peritoneum)
Kidneys, pancreas, part of aorta lie in retroperitoneal space, behind peritoneum
Bladder and part of rectum lie inferior to peritoneum
Points to Emphasize: Most organs are contained within the peritoneum, but some are located in the retroperitoneal space. Reproductive organs contained within the abdomen are different in women from what they are in men.
Discussion Topic: Explain what is meant by the term retroperitoneal. Discuss examples of retroperitoneal organs.
Knowledge Application: Have students work in small groups. Assign each group a specific abdominal organ. Have each group research and present the organ’s location within the abdomen and its major function.
Critical Thinking: Consider penetrating trauma. How might knowledge of abdominal anatomy assist your assessment of mechanism of injury?

15. Peritoneal and Extraperitoneal Space
Knowledge Application: Using a manikin or programmed patient, use external landmarks to determine location of abdominal organs. Point out where organs would be with regard to visible landmarks.

16. Abdominal Quadrants Abdomen divided into “quadrants”
RUQ, LUQ, RLQ, LLQ
Epigastric region
Point to Emphasize: Anatomically, the abdomen is divided into four quadrants, using the midline and umbilicus as dividing points.
Talking Points: To describe the location of abdominal organs, or the location of pain or injuries, it’s helpful to divide the abdomen into four quadrants. Remember, always use the patient’s perspective (the patient’s right, not yours). A few structures lie in the center: stomach (epigastric region), bladder (suprapubic region).
Discussion Topic: Describe how the anatomy of the abdomen is divided into quadrants. Discuss external landmarks and the contents of each quadrant.

17. Abdominal Pain or Discomfort
Teaching Time: 15 minutes
Teaching Tips: Discuss etiology when describing the different classifications of abdominal pain. Give specific examples of organs that cause the particular type of pain. Use first-person testimony to describe the various types of pain. Students in class often have experienced the different pain classifications. Relate the classifications of pain to previous lessons on assessment. How might the memory aid OPQRST assist in assessing abdominal pain?

18. Visceral Pain Originates from the visceral peritoneum
Fewer nerve endings allow for only diffuse sensations of pain
Frequently described as “dull” or “achy”
Points to Emphasize: Both peritoneal and retroperitoneal organs can cause pain in the abdomen. Visceral pain originates in the organs within the abdomen and is often described as dull, achy, or intermittent.
Talking Points: Medical emergencies of the abdomen commonly cause pain or discomfort. Visceral pain is general and nonspecific; the patient will not be able to localize it or point to a specific area. Colic is not a disease, but a crampy, intermittent type of pain.
Knowledge Application: Have students work in small groups. Assign each group an abdominal dysfunction. Ask the group to research and present on the type of pain that is likely to be associated with its particular dysfunction.
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19. Visceral Pain
Colic (intermittent pain) may result from distention and/or contraction of hollow organs
Persistent or constant pain often originates from solid organs

20. 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
Point to Emphasize: Parietal pain arises from the parietal peritoneum and often is described as sharp, constant, and localized to a particular area.
Talking Points: Parietal pain is very easily located. Patient may be able to point to its specific location with a single finger.
Discussion Topic: Compare and contrast visceral pain with parietal pain. How are they different? Give specific examples.
Knowledge Application: Using programmed patients, practice assessing abdominal pain. Practice using the mnemonic OPQRST to aid evaluation of pain.

21. 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
Point to Emphasize: Referred pain is felt in a place other than the place where the pain originates.
Talking Points: The pain of a diseased gallbladder is often felt in the shoulder or scapula because the gallbladder nerve crosses the shoulder nerve and transmits its pain sensation to it. This is often used interchangeably with “radiating” pain.
Discussion Topic: Define referred pain. Give an example of an organ system that is likely to cause referred pain.
Critical Thinking: Are there non-abdominal organs that can cause abdominal pain? List and describe them.

22. Tearing 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
Point to Emphasize: Tearing pain typically refers to a dissection of the abdominal aorta.
Discussion Topic: Describe the etiology of tearing pain. Discuss the most likely cause.
Class Activities: List a classification of pain on a whiteboard. Have students come up and write an adjective that might describe that type of pain. Repeat until the pain is best defined. Assign a research project. Give students (or groups of students) a classification of pain. Ask them to research and present different types of abdominal problems that might be associated with their classification.
Knowledge Application: Describe an abdominal pain. Have students classify the pain, based on your description, and then discuss the possible origin.

23. Abdominal Conditions Teaching Time: 30 minutes
Teaching Tips: Emphasize the need to recognize life-threatening emergencies first and diagnose specific disorders second. Link assessment findings and the characteristics of pain to specific disorders. Tie this lesson to the previous discussion of pain classifications. There are excellent multimedia graphics that you can use to illustrate the pathophysiology of specific abdominal disorders. Use first-person testimony to describe specific abdominal problems. Students in class often have experienced abdominal dysfunctions.

24. Appendicitis Infection of appendix Appendectomy is usually indicated
Signs and symptoms
Persistent RLQ pain
Pain often initially referred to umbilical region
Rupture of appendix
Sudden, severe increase in pain
Contents released into abdomen causes severe peritonitis
Points to Emphasize: Assessment and management always will take a higher priority than determining the exact cause of abdominal pain. Specific assessment findings can point to particular types of abdominal problems. EMTs should use a thorough secondary assessment to work through a differential diagnosis.

25. 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
Knowledge Application: Have students work in small groups. Assign one type of abdominal dysfunction; then have the group research the pathophysiology and present its findings.

26. Cholecystitis Inflammation of the gallbladder
Often caused by blockage of its outlet by gall stones (cholecystolithiasis)
Symptoms often worsened by ingestion of fatty foods
Signs and symptoms
Sharp RUQ or epigastric pain
Pain often referred to shoulder

27. Pancreatitis Inflammation of the pancreas
Common with chronic alcohol abuse
Signs and symptoms
Epigastric pain
Often referred to back or shoulder
Talking Points: Remember, the pancreas is retroperitoneal, and pain is often felt in the back.
Knowledge Application: Use programmed patients to present a variety of types of abdominal dysfunctions. Practice assessment scenarios.

28. Gastrointestinal (GI) Bleeding
Hemorrhage within the lumen of the GI tract
May be minor to severe
Blood eventually exits (mouth or rectum)
Often painless
Gastric ulcers (holes in GI system from highly acidic gastric juices) can cause severe pain and peritonitis
Point to Emphasize: Bleeding can occur anywhere within the GI system, from the esophagus to the rectum. GI bleeding may be gradual or sudden, and it can be a life-threatening cause of shock.
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29. Gastrointestinal (GI) Bleeding
Signs and symptoms
Dark-colored stool (maroon to black), often “tarry” (Melena)
Frank blood from rectum (hemorrhoid)
Vomiting “coffee ground” appearing blood
Vomiting frank blood
Pain: absent to severe
Talking Points: Blood in the GI tract will begin to be digested, turning it brown or black. The color can indicate its origin in proximity to the exit. Frank red blood originates near the exit, black originates deep in the GI tract. Partially digested blood in the stomach forms tiny brown particles resembling coffee grounds.
Critical Thinking: You recognize GI bleeding. What findings might you associate with a life-threatening GI bleed?

30. Abdominal Aortic Aneurysm (AAA)
Weakening of inner wall of the aorta
Tears and separates from outer layers (dissection)
Weakened vessel bulges, may continue to grow
May eventually rupture
Point to Emphasize: Retroperitoneal, tearing pain should be assumed to be caused by an abdominal aortic aneurism. This type of abdominal pain can point to an immediately life-threatening problem.
Knowledge Application: List specific abdominal disorders and have students formulate their own lists of associated assessment findings.
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31. Abdominal Aortic Aneurysm (AAA)
Signs and symptoms
Progressive (often “tearing”) abdominal pain
Frequently radiates to back (lumbar)
Palpable abdominal mass, possibly pulsating
Possible inequality in pedal pulses
Talking Points: Patients with dissecting AAA must be transported rapidly. Avoid rough handling and repeated abdominal exams. AAA low in the abdomen may impede the femoral artery, causing inequality in the peripheral pulses of the legs.
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32. Abdominal Aortic Aneurysm (AAA)
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)

33. Hernia
Hole in the abdominal wall, allowing tissue or parts of organs (commonly intestines) to protrude under skin
May be precipitated by heavy lifting
May cause strangulation of tissue or bowel obstruction
May require surgical repair
Talking Points: Strangulation is interruption of blood supply caused when the organ is pushed through a small hole. Strangulation and bowel obstruction can be life-threatening emergencies.
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34. 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)

35. Renal Colic
Severe 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
Talking Points: These patients are often “writhing” in pain, unable to find a position of comfort. Patients may experience hematuria.
Class Activity: Assign a student an abdominal dysfunction and have the student act out the symptoms in front of the class. Ask the class to diagnose the student’s disorder.

36. Cardiac Involvement Pain of myocardial infarction can produce
Nausea or vomiting
Epigastric pain
Indigestion
Always consider the possibility of a cardiac emergency as a cause of abdominal symptoms
Point to Emphasize: Myocardial infarction sometimes can present as abdominal discomfort and should be considered in the assessment and treatment of a patient with abdominal pain.
Talking Points: Remember, cardiac emergencies may have “atypical presentations,” especially in the elderly, women, and diabetics.
Discussion Topic: Describe the pathophysiology and likely assessment findings for the following abdominal dysfunctions: appendicitis, cholecystitis, pancreatitis, GI bleeding, abdominal aortic aneurysm, hernia, renal colic, myocardial infarction.
Class Activity: Assign a research project. Give students a topic concerning a particular abdominal dysfunction. Have them research and present their findings to the class.

37. Assessment and Care of Abdominal Pain or Discomfort
Teaching Time: 30 minutes
Teaching Tips: Use programmed patients to add a level of realism to practice. Always focus on life threats. Be sure to include critical patients in any practice session. Relate this lesson to patient assessment. Bring OPQRST and SAMPLE to realistic use now. Palpating an abdomen means actually touching. Do not allow verbalization. Practice proper palpation techniques.

38. 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 history and physical exam
Identify serious or life-threatening conditions
Point to Emphasize: The focus of the assessment of a patient with abdominal pain should be to perform an accurate history and physical examination and to identify potentially serious conditions.
Talking Points: Provide comfort and emotional support.

39. Scene Size-Up Protect self from blood-borne pathogens
Be aware of odors
Determine if patient’s condition is medical, trauma, or both
Talking Points: The patient may have an infection. Protect yourself with proper PPE, be alert for vomiting, and protect your face and clothes. Conditions such as GI bleeding and UTIs have a unique odor. A medical emergency may have caused an accident and traumatic injury.

40. All patients with abdominal pain should be given OXYGEN immediately.
Primary Assessment
General impression
ABC’s
Level of consciousness
All patients with abdominal pain should be given OXYGEN immediately.
Points to Emphasize: Primary assessment findings will rapidly identify signs of a critical patient. After treating immediate life threats, conduct a secondary assessment to help differentiate abdominal disorders.
Talking Points: What position is the patient in? Does the patient appear to be in pain? Does the patient have an open airway? Is the patient breathing normally? Does the patient have adequate circulation (radial pulse, skin color). Apply oxygen 15 LPM via NRB as soon as possible. Is patient awake and alert?
Discussion Topic: Describe findings in the primary assessment of a patient with abdominal pain that might indicate immediate life threats.
Knowledge Application: Describe assessment findings and ask students to identify the patient whose abdominal pain is critical.

41. History of the Present Illness
O: “When did it begin? What were you doing?”
P: “What makes it better or worse? Movement? Position?”
Q: “Describe your discomfort.”
R: “Point to its location. Does it radiate or move?”
S: “How bad is the pain on a scale of 1–10?”
T: “Do you have pain all the time? Is it intermittent? Has it changed?”
Talking Points: OPQRST can help you remember what to ask about pain. Use open-ended questions; you want the patient’s answers, in patient’s own words, not your suggestions.
Discussion Topic: Discuss how the history of the present illness can help in making a differential diagnosis of a patient with abdominal pain.
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42. History of the Present Illness
Female patients
“Where in your cycle are you?”
“Is your period late?”
“Are you experiencing vaginal bleeding?”
“Is your flow normal?”
“Have you experienced this pain before?”
“Is it possible you are pregnant?”
“Are you using birth control?”
Talking Points: Remember, women have different abdominal anatomy then men, and unique medical concerns (pregnancy, menstruation, ovarian cysts, PID) that require additional questions. All women of childbearing age should be considered pregnant until proven otherwise. Ensure the patient’s privacy when asking these questions.
Discussion Topic: Describe specific questions that you might ask a female patient who complains of abdominal pain.

43. Past Medical History S: Symptoms A: Allergies M: Medications
P: Pertinent past history
L: Last oral intake
E: Events leading to emergency
Talking Points: SAMPLE can help you remember what to ask about medical history.

44. Geriatric Note: Assessment
Decreased ability to perceive pain
More serious causes of abdominal pain
More likely to be life-threatening
May be complicated by medications
Talking Points: Geriatric patients are more likely to be taking medications, possibly several of them. These may affect their condition. (Aspirin may worsen bleeding.) Some medications may mask their symptoms (pain medications; blood pressure medications may also lower heart rate, preventing tachycardia during shock).
Critical Thinking: What role might advanced life support play when dealing with a patient with abdominal pain?

45. Physical Exam Inspection Palpation (use fingertips; painful area last)
Distention
Discoloration
Protrusions
Palpation (use fingertips; painful area last)
Rigidity
Pain
Guarding
Talking Points: Ask the patient or family if this is patient’s normal appearance. (Don’t say, “Is your stomach always this big?”) Remember, rigidity is involuntary. Guarding is physical protection of the abdomen (may be with arms, hands, body position, or voluntary tightening of abdominal muscles).
Discussion Topic: Describe the technique for palpating the abdomen. What findings might be important?
Class Activity: Have students practice palpating the abdomen of the student sitting next to them.
Knowledge Application: Have students work in small groups. Using a programmed patient, practice assessing and treating patients with abdominal pain.

46. Vital Signs Baseline, then every 5 minutes Pulse Blood pressure
Respirations
Skin condition, color, temperature
Mental status
Talking Points: Pain alone may cause tachycardia (or bradycardia) or shallow breathing.
Discussion Topic: Describe the pathophysiology and likely assessment findings for the following abdominal dysfunctions: appendicitis, cholecystitis, pancreatitis, GI bleeding, abdominal aortic aneurysm, hernia, renal colic, myocardial infarction.
Class Activity: Write out the details of an assessment of a patient with abdominal pain. Provide a set of complaints; then ask students to list the steps that they would take to assess this patient further.
Knowledge Application: Using programmed patients, set up mock calls. Include scene clues and bystander information. Ask students to identify critical patients and to make differential diagnoses of abdominal pain.

47. Patient Care Maintain airway Administer oxygen Position of comfort
Be prepared to suction
Administer oxygen
15 LPM via NRB
Position of comfort
LLR for airway protection
Transport to appropriate facility
Point to Emphasize: Care for the patient with abdominal pain is often similar, regardless of the origin. Treat immediate life threats, administer oxygen, place the patient in a position of comfort, and initiate appropriate transport.
Discussion Topic: Describe the general treatment steps for a patient who is experiencing abdominal pain.

48. Think About It
An 89-year-old female with a history of diabetes, hypertension, and gallstones is complaining of nausea and dizziness about 20 minutes after eating.
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49. Think About It What are the concerns with this patient?
Is this an abdominal emergency, a diabetic emergency, or a cardiac emergency?
How will you know?
What will your treatment be?
Talking Points: Could this be life-threatening? If it’s cardiac, yes, and this patient is at high risk. While focusing on cardiac, your detailed assessment (with vitals, glucose level, and abdominal exam) should reveal the true cause. Treatment would include initial assessment, history, vitals, detailed physical exam, oxygen, position, call ALS, transport to appropriate facility.

50. Abdominal Aortic Aneurysm Video
Video Clip
Abdominal Aortic Aneurysm
Where is the most common location of an abdominal aortic aneurysm?
What causes an AAA?
Discuss what would happen if the aneurysm were to rupture.
What signs and symptoms might a patient with an AAA have?
Click here to view a video on the subject of abdominal aortic aneurysm.
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51. Chapter Review

52. Chapter Review
Abdominal complaints must be treated as serious emergencies requiring transport.
Diagnosis is difficult; your responsibility is to assess the patient and report findings.
Assessment should include thorough history, physical exam, and vital signs.
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53. Chapter Review
Quickly identify life-threatening emergencies: aneurysms, internal bleeding, shock.
Care consists of airway management, oxygen, positioning, transport.
Use standard precautions, including disinfecting equipment.

54. Remember
Abdominal organs provide a variety of important functions to the body.
The abdomen can be divided into four quadrants, with reference to the midline and umbilicus.
Classifications of pain can help identify specific abdominal dysfunctions.
continued

55. Remember
Assessment and management always take a higher priority than determining the exact cause of abdominal pain.
Knowledge of the characteristics of specific abdominal disorders can aid differential diagnosis when assessing a patient with abdominal pain.
continued

56. Remember
Care for a patient with abdominal pain should include treatment of immediate life threats, administration of oxygen, placing patient in a position of comfort, and appropriate transport.

57. Questions to Consider
What are five signs and symptoms of abdominal distress?
Describe the difference between visceral and parietal pain. Describe a condition that may be responsible for each.
Talking Points: Signs and symptoms of abdominal distress include nausea, vomiting, diarrhea, pain, distention.
Visceral pain arises from organs in the visceral peritoneum is general and nonspecific; the patient will not be able to localize it or point to a specific area. Parietal pain arises from organs in the parietal peritoneum and often is described as sharp, constant, and localized to a particular area.
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58. Questions to Consider
What is the emergency care for a patient experiencing abdominal pain or distress?
Name the four abdominal quadrants. How are the quadrants determined?
Talking Points: Emergency care for patient with abdominal distress involves monitoring for airway problems if the patient is vomiting, placing the responsive patient in a position of comfort, placing the unresponsive patient or the patient who is having difficulty maintaining an airway in a left lateral recumbent position for drainage from the mouth.
The four abdominal quadrants are LUQ, RUQ, LLQ, and RLQ. These are determined by a midline on the umbilicus.

59. Critical Thinking
You are called to a patient with abdominal pain. He describes the pain as severe and says it has been “on and off” over the past several days, becoming severe within the last hour.
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60. Critical Thinking What additional questions would you ask the patient?
In what position would he likely be most comfortable?
Talking Points: Questions should focus on where the pain is, where it starts from, and so on. Questions asked will be determined by the history of the present illness and other steps in the assessment. Best position is likely to be the one where least pressure is put on the painful area.

61. Please visit Resource Central on www. bradybooks
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