1. 6
Gastroenterology

2. Multimedia Directory
Slide 35 Digestive System Exercise

3. Standard
Medicine (Abdominal and Gastrointestinal Disorders)

4. Competency
Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint.

5. Introduction 500,000 gastrointestinal emergencies every year.
300,000 due to gastrointestinal bleeding.
Last few years, number of patients over 60 risen from 3% to more than 45%.

6. General Pathophysiology, Assessment, and Treatment
Gastrointestinal (GI) emergencies usually result from underlying pathological process.
Risk factors known to physicians; most self-induced by patients.

7. General Pathophysiology, Assessment, and Treatment
Risk factors:
Excessive alcohol consumption
Excessive smoking
Increased stress
Ingestion of caustic substances
Poor bowel habits

8. General Pathophysiology, Assessment, and Treatment
Pain hallmark of acute abdominal emergency.
Three classifications of abdominal pain:
Visceral
Somatic
Referred

9. General Pathophysiology, Assessment, and Treatment
Visceral pain: originates in walls of hollow organs (gallbladder or appendix), in capsules of solid organs (kidney or liver), or in visceral peritoneum.
Mechanisms that produce pain: inflammation, distention ischemia.
Cause varying intensities, characteristics, locations of pain.

10. General Pathophysiology, Assessment, and Treatment
Inflammation, distention, ischemia all transmit pain signal from visceral afferent neural fibers to spinal column.
Often described as vague or poorly localized, dull, or crampy.
Many hollow organs first cause visceral pain when distended.
Then cause specific type of pain when they rupture or tear.

11. General Pathophysiology, Assessment, and Treatment
Somatic pain: sharp type of pain that travels along definite neural routes to spinal column.
Pain localized to region or area.
Bacterial and chemical irritations of abdomen commonly cause somatic pain.
Degree of pain initially proportional to spread of irritant through abdominal cavity.

12. General Pathophysiology, Assessment, and Treatment
Referred pain: originates in region other than where it is felt.
Not true pain-producing mechanism.
For example: dissecting abdominal aortic artery, produces referred pain felt between shoulder blades.

13. Referred pain patterns: (a) anterior.

14. Referred pain patterns: (b) posterior.

15. General Pathophysiology, Assessment, and Treatment
Assessment similar to trauma assessment with expanded history.
Ensure scene free and clear of any apparent dangers.
Always take Standard Precautions.
Survey scene for potential evidence of patient's problem (medication bottles, alcohol containers, ashtrays, buckets with emesis or sputum)

16. General Pathophysiology, Assessment, and Treatment
Look for mechanism of injury (MOI); determine whether call is medical or trauma.
If trauma, immobilize cervical spine.
Check responsiveness; airway patency.
Evaluate respiratory functions; quickly palpate pulse and check skin color, temperature, and circulation, including signs of bleeding and capillary refill.

17. General Pathophysiology, Assessment, and Treatment
If life-threatening condition, treat it and rapidly continue assessment to identify any other life threats.
Conduct secondary assessment.
Conduct SAMPLE history (symptoms, allergies, medications, past medical history, last oral intake, events) and more thorough history.
Teaching Tips
General pathophysiology and treatment will cover most abdominal emergencies. It is important to remember that most of the illnesses presented cannot be diagnosed in the field. Stress the importance of a thorough exam and history and prompt transport of patients who are acutely ill.

18. General Pathophysiology, Assessment, and Treatment
OPQRST-ASPN history
Onset
Sudden onsets generally caused by perforations of abdominal organs or capsules.
Gradual onset of pain associated with blockage of hollow organs.

19. General Pathophysiology, Assessment, and Treatment
OPQRST-ASPN history
Provocation/palliation
If pain lessens when patient draws legs up to chest or lies on side, usually indicates peritoneal inflammation.
If walking relieves pain, cause may be in GI or urinary system.

20. General Pathophysiology, Assessment, and Treatment
OPQRST-ASPN history
Quality
Localized, tearing pain associated with rupture of organ.
Dull, steadily increasing pain may indicate bowel obstruction.
Sharp pain, particularly in flank, may indicate kidney stone.

21. General Pathophysiology, Assessment, and Treatment
OPQRST-ASPN history
Region/radiation
Radiated pain common; it involves same neural routes as referred pain.
Pain referred to shoulder or neck associated with irritation of diaphragm.

22. General Pathophysiology, Assessment, and Treatment
OPQRST-ASPN history
Severity
Usually worsens as pathology of organ advances.
Time
Estimation of pain's time of onset important to determine possible causes.
Any abdominal pain lasting over 6 hours considered surgical emergency.

23. General Pathophysiology, Assessment, and Treatment
OPQRST-ASPN history
Associated symptoms
Try to determine content, color, smell of vomitus.
Ask if vomitus contained any bright red blood, “coffee grounds,” or clots.
Determining if patient has active gastrointestinal bleed is imperative.

24. General Pathophysiology, Assessment, and Treatment
OPQRST-ASPN history
Associated symptoms
Changes in bowel morphology, color, or smell can be only indication of lower GI hemorrhage, gastritis, bleeding diverticula.
Patients who have acute abdomen usually have associated loss of appetite.

25. General Pathophysiology, Assessment, and Treatment
OPQRST-ASPN history
Pertinent negatives
Absence of symptoms with GI function or presence of symptoms with urinary function may be problem in urinary system.
Pain in lowest part of abdomen can be due to problems in reproductive system.
Cardiovascular history with referred pain.

26. General Pathophysiology, Assessment, and Treatment
Ask about patient's last oral intake.
Gastrointestinal emergencies that cause chest pain:
Gastroesophageal reflux
Gastric ulcers
Duodenal ulcers
Gallbladder disease

27. General Pathophysiology, Assessment, and Treatment
Obtain past medical history.
Complete physical examination.
Patient's general appearance and posture strongly suggest apparent state of health and severity of complaint.
Take complete set of vital signs.
Visually inspect abdomen before palpating it, auscultating it, moving patient.

28. General Pathophysiology, Assessment, and Treatment
Complete physical examination.
Distention of abdomen ominous sign.
Caused by buildup of free air due to obstruction of bowel or hemorrhage.
Signs of fluid loss: periumbilical ecchymosis (Cullen's sign) and ecchymosis in flank (Grey Turner's sign).

29. General Pathophysiology, Assessment, and Treatment
Complete the physical examination.
Auscultating abdomen provides little helpful information.
Palpating abdomen can define area of pain and identify associated organ.

30. General Pathophysiology, Assessment, and Treatment
Highest priority when treating patient with abdominal pain: secure and maintain airway, breathing, circulation.
Be prepared to suction airway of vomitus and blood.
Supplemental oxygen and aggressive airway management may be indicated, depending on patient's status.

31. General Pathophysiology, Assessment, and Treatment
Monitor circulation by placing patient on cardiac monitor; frequently assess blood pressure.
Measurement of hematocrit will give indirect measure of blood loss.
Establish large-bore IV line in patients who complain of abdominal discomfort.
Avoid masking abdominal pain; will limit pharmacological interventions.

32. General Pathophysiology, Assessment, and Treatment
Place patient in comfortable position.
Provide emotional reassurance.
Keep voice and actions quiet and collected.
Persistent abdominal pain lasting longer than 6 hours classified as surgical emergency; always requires transport.

33. Specific Illnesses
Gastrointestinal (GI) tract one long tube divided structurally and functionally into different parts.
Organs: liver, gallbladder, pancreas, vermiform appendix.
Converts food into nutrient molecules that cells can use; excretes solid wastes from body.

34. The gastrointestinal tract is one long tube divided structurally and functionally into different parts.

35. Digestive System Exercise
Questions:
1. What is the function of the digestive system?
2. List the organs of the digestive system that food travels through in order as it enters the mouth and until it leaves the rectum.
3. How many muscle layers make up the digestive tract?
4. What type of muscle makes up the digestive tract?
5. Name four common medical emergencies that involve the digestive tract.
Click here to complete an interactive exercise on the digestive system.
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36. Specific Illnesses Upper GI tract
Mouth, esophagus, stomach, duodenum (first part of small intestine).
Physical digestion of food and some chemical digestion take place here.
As food passes through lower GI tract (remainder of small intestine and large intestine), nutrients absorbed into blood and solid wastes formed and excreted.

37. Specific Illnesses Upper Gastrointestinal Bleeding
Bleeding within gastrointestinal tract proximal to ligament of Treitz.
300,000 hospitalizations per year; 10% mortality rate.
Patients treat symptoms with home remedies/over-the-counter medication.
Age of population increasing.

38. Specific Illnesses Six major causes of upper GI hemorrhage:
Peptic ulcer disease
Gastritis
Variceal rupture
Mallory-Weiss tear (esophageal laceration)
Esophagitis
Duodenitis
Class Activities
Once you have discussed signs and symptoms of the various illnesses, have students get into small groups. Have them perform focused history and assessments on one another. The student being assessed should use the signs and symptoms specific to one of the illnesses. See if students can figure out a diagnosis based on the complaints presented.

39. Specific Illnesses Upper Gastrointestinal Bleeding
Patient may experience hematemesis (bloody vomitus) or, if it passes through lower GI tract, melena.
Blood in emesis bright red or looks like coffee grounds.
May be light or brisk and life threatening.
May vomit copious amounts of blood.

40. Specific Illnesses Upper Gastrointestinal Bleeding
Bleeding may cause shock or compromise airway.
Tilt test: indicates if patient has orthostatic hypotension.
Hypotension suggests decreased circulating volume.

41. Specific Illnesses Upper Gastrointestinal Bleeding
General complaints: malaise, weakness, syncopal (fainting), near-syncopal (lightheaded) spells, tachycardia, indigestion.
Patient's general appearance may be best indicator of condition's severity.
Perform thorough physical examination.

42. Specific Illnesses Upper Gastrointestinal Bleeding
Prehospital treatment: maintain patent airway, oxygenation, circulatory status.
Place patient in left lateral recumbent or high semi-Fowler's position.
Administer high-concentration oxygenation via nonrebreather mask.
Establish two large-bore IVs in patient you suspect of gastrointestinal bleed.

43. Specific Illnesses Esophageal Varices Swollen vein of esophagus.
Often rupture and hemorrhage.
When they do, mortality rate over 35%.
Causes: increase in portal pressure (portal hypertension), consumption of alcohol, ingestion of caustic substances.

44. Specific Illnesses Esophageal Varices
Alcoholic liver cirrhosis accounts for two-thirds of cases.
Patients present initially with painless bleeding and signs of hemodynamic instability.
Care should focus on aggressive airway management, intravenous fluid resuscitation, rapid transport.

45. Specific Illnesses Esophageal Varices Airway management top priority.
Suction emesis frequently and diligently from airway; endotracheal intubation may be needed.
Administer high-concentration oxygen via nonrebreather mask.
Octreotide is drug of choice for acute variceal bleeding.

46. Esophageal varices occur when the esophageal veins dilate and emerge from their sheaths. (Photo: © Dr. Bryan E. Bledsoe)

47. Specific Illnesses Acute Gastroenteritis
Inflammation of stomach and intestines associated with sudden onset of vomiting and/or diarrhea.
Pathological inflammation causes hemorrhage and erosion of mucosal and submucosal layers of gastrointestinal tract.

48. Specific Illnesses Acute Gastroenteritis
Adequate volume replacement prehospital prevention strategy; minimize hypovolemia or hypovolemic shock.
Individuals who abuse alcohol and tobacco at high risk.
Use of nonsteroidal anti-inflammatory drugs (aspirin) breaks down mucosal surfaces of stomach and GI tract.

49. Specific Illnesses Acute Gastroenteritis
Other causes: stress, chemotherapeutic agents, ingestion of acidic or alkalotic agent, infections.
Onset rapid and usually severe.
Diarrhea associated with this condition; fluid loss leads to dehydration.
Due to dehydration and hemorrhage, patient hemodynamically unstable.

50. Specific Illnesses Acute Gastroenteritis
Treatment: supportive and palliative.
Be prepared to clear airway of vomit or secretions.
Maintaining adequate oxygenation high priority.
Avoid hyperoxia; rehydrate patient.
Exercise extreme caution; use Standard Precautions.

51. Specific Illnesses Chronic Gastroenteritis
Inflammation of gastrointestinal mucosa marked by long-term mucosal changes or permanent mucosal damage.
Due primarily to microbial infection.
Far more common in underdeveloped countries.
Transmitted via fecal–oral route or through infected food or water.

52. Specific Illnesses Chronic Gastroenteritis
Symptoms: nausea and vomiting, fever, diarrhea, abdominal pain, cramping, anorexia, lethargy, shock.
H. pylori symptoms: heartburn, abdominal pain, gastric ulcers.
Prehospital treatment: protecting yourself and patient from contamination, monitoring ABCs, transport.

53. Specific Illnesses Peptic Ulcers
Erosions caused by gastric acid; occur anywhere in gastrointestinal tract.
Duodenal ulcers occur in proximal portion of duodenum.  
Occur in males more than females.
Important to get family history and estimate of patient's last oral intake.

54. Peptic ulcer. (Photo: © Dr. Bryan E. Bledsoe)

55. Specific Illnesses Peptic Ulcers
Causes: nonsteroidal anti-inflammatory medications (aspirin, ibuprofen, naproxen), acid-stimulating products (alcohol, nicotine), or Helicobacter pylori bacteria.
Treatment in prehospital setting: antacid treatment and support of any complications such as hemorrhage.

56. Specific Illnesses Peptic Ulcers
Blocked pancreatic duct can contribute to duodenal ulcers.
Duodenal ulcers: Zollinger-Ellison syndrome; acid-secreting tumor provokes ulcerations.
Chronic ulcers can cause slow bleed with resulting anemia; acute, severe pain due to rupture of ulcer.

57. Specific Illnesses Peptic Ulcers Nausea and vomiting common.
Massive hemorrhage can occur.
Patients will appear very ill; signs of hemodynamic instability.
Treatment depends on severity of patient's pain.
Knowledge Application
Many abdominal issues involve internal hemorrhage. What are some ways to determine if the patient has a significant hemorrhage? How will that impact your fluid resuscitation options?

58. Specific Illnesses Lower Gastrointestinal Disease
Lower GI tract: jejunum and ileum of small intestine and entire large intestine, rectum, anus.
As digestive fluid moves through small intestine, nutrients absorbed into blood.
Water absorbed and solid wastes form in large intestine.

59. Specific Illnesses Lower GI Bleeding
Occurs in GI tract distal to ligament of Treitz in conjunction with chronic disorders and anatomic changes associated with advanced age.
Causes: diverticulosis, colon lesions, rectal lesions, anal fissures, inflammatory bowel disorders (ulcerative colitis and Crohn's disease).

60. Specific Illnesses Lower GI Bleeding
Symptoms: cramping, nausea, vomiting, changes in stool.
Most patients with lower GI bleeds have not lost significant amounts of blood; hemodynamic stability.
Management will depend on physiologic status.
Watch airway and oxygenation status.

61. Specific Illnesses Ulcerative Colitis
Classified as idiopathic inflammatory bowel disorder (IBD); unknown origin.
75% of ulcerative colitis involves rectum or rectosigmoid portion of large intestine.
Pancolitis: if it spreads throughout entire colon.
Proctitis: if limited to rectum.

62. Specific Illnesses Ulcerative Colitis
Contributing factors: psychological, allergic, toxic, environmental, immunologic, infectious.
Recurrent disorder with bloody diarrhea or stool-containing mucus.
Abdominal pain (cramping), nausea and vomiting, fever, weight loss.
Significant hemorrhage common.

63. Specific Illnesses Ulcerative Colitis
Management depends on physiologic status.
Transport patient who presents with lower GI bleeding or colicky pain to emergency department.

64. Ulcerative colitis.

65. Specific Illnesses Crohn's Disease
Idiopathic inflammatory bowel disorder.
Tends to run in families; white females; frequent stress; in Jewish population.
Can occur anywhere from mouth to rectum.
Severe cases may involve any portion of GI tract.

66. Specific Illnesses Crohn's Disease
Complete intestinal obstruction, a surgical emergency, can occur.
Significant lower GI bleeding rare.
Signs and symptoms: GI bleeding, recent weight loss, intermittent abdominal cramping/pain, nausea and vomiting, diarrhea, fever.
Discussion Topics
Many abdominal issues are resolved surgically. How does this affect your treatment priorities? How does this affect your destination decision?

67. Specific Illnesses Crohn's Disease Onset of a flare-up usually rapid.
If patient is hemodynamically stable, prehospital treatment largely palliative.
Management depends on patient's physiologic status.

68. Specific Illnesses Diverticulitis Diverticulosis
Common complication of diverticulosis.
Diverticulosis
Presence in intestine of diverticula, small outpouchings of mucosal and submucosal tissue that push through outermost layer of intestine, the muscle.

69. Specific Illnesses Diverticulitis
Inflammation of diverticula secondary to infection.
Lower left-sided pain; fever; increased white blood cell count; nausea and vomiting; tenderness on palpation.
Prehospital treatment supportive.
Hospital treatment: antibiotic therapy, endoscopy, radiologic tests.

70. Specific Illnesses Hemorrhoids
Small masses of swollen veins that occur in anus (external) or rectum (internal).
Develop during fourth decade of life.
Idiopathic (unknown cause); can result from pregnancy or portal hypertension.

71. Hemorrhoids are small masses of swollen veins.

72. Specific Illnesses Hemorrhoids
Internal hemorrhoids bleed during defecation due to straining and then thrombose into closed state again.
External hemorrhoids result from thrombosis of vein, often following lifting or straining, causing bright red bleeding with bowel movement.

73. Specific Illnesses Hemorrhoids Rarely cause significant hemorrhage.
Physical assessment usually reveals hemodynamically stable patient with relatively normal appearance.
Significant hemorrhage or bleeding hemorrhoids in alcoholic patient warrant closer monitoring and transport for immediate follow-up.

74. Specific Illnesses Rectal Foreign Body
Foreign body inserted into rectum with patient's knowledge for various reasons (sexual gratification or psychosis).
Most swallowed foreign bodies pass readily, but others may not.
Rectal pain or pressure; infection or shock.
Prehospital treatment: supportive.

75. Specific Illnesses Bowel Obstruction
Blockages of hollow space (lumen) within small and large intestines; partial or complete.
Hernias, intussusception, volvulus, adhesions are the four most frequent.
Common causes: foreign bodies, gallstones, tumors, adhesions from abdominal surgery, bowel infarction.

76. Inguinal hernia.

77. Intestinal volvulus.

78. Specific Illnesses Bowel Obstruction
Most common location for obstructions is small intestine.
Obstruction may be chronic; decreased appetite, fever, malaise, nausea and vomiting, weight loss, or if rupture occurs, peritonitis.
Onset sudden and acute: ingestion of foreign body.

79. Specific Illnesses Bowel Obstruction
Frequently vomit, with vomitus often containing significant amount of bile.
Diffuse visceral pain, usually poorly localized to any one specific location.
May be hemodynamically unstable.
Distention, peritonitis, or free air within abdomen secondary to rupture of strangulated segment of intestine.

80. Specific Illnesses Bowel Obstruction
Look for scars from previous surgery.
Bowel sounds may be present as high-pitched obstruction sound.
Palpation will reveal tenderness.
Treatment: airway management, oxygenation via nonrebreather mask, position of comfort or shock position, fluid resuscitation to prevent shock.

81. Specific Illnesses Mesenteric Ischemia
When one of mesenteric arteries becomes narrowed or occluded.
Superior mesenteric artery (SMA)
Inferior mesenteric artery (IMA)
When blood flow through either of these vessels reduced or stopped, abdominal pain occurs.
Nausea, vomiting, diarrhea common.

82. Specific Illnesses Mesenteric Ischemia
Bowel will become ischemic and die, causing infection.
Prehospital treatment: hydration, pain control, antiemetics.
Treatment usually surgical.

83. Specific Illnesses Appendicitis
Inflammation of vermiform appendix, located at junction of large and small intestines.
10 to 20% of population; young adults.
Acute appendicitis most common surgical emergency in field.
Appendix no known anatomic or physiologic function.

84. Specific Illnesses Appendicitis
Can become inflamed; if untreated can rupture, spilling contents into peritoneal cavity and setting up peritonitis.
Obstruction of appendiceal lumen by fecal material.
Common site of pain: McBurney's point, 1 to 2 inches above anterior iliac crest along direct line from anterior crest to umbilicus.

85. McBurney point is a common site of pain in appendicitis.

86. Specific Illnesses Appendicitis
Once appendix ruptures, pain becomes diffuse due to development of peritonitis.
Do not repeatedly palpate for rebound tenderness; pressure that this exerts can cause inflamed appendix to rupture.

87. Specific Illnesses Appendicitis Prehospital care
Place patient in position of comfort
Give psychological support
Manage airway to prevent aspiration
Establish intravenous access
Transport

88. Specific Illnesses Cholecystitis Inflammation of gallbladder.
Cholelithiasis: formation of gallstones; causes 90% of cholecystitis cases.
Cholesterol-based stones: obese, middle-aged women with more than one biological child.
Antibiotic therapy, laparoscopic surgery, lithotripsy, surgery.

89. The gallbladder is located below the liver.

90. Specific Illnesses Cholecystitis
Caused by gallstones; chronic or acute.
Acalculus cholecystitis results from burns, sepsis, diabetes, multiple organ failure.
Inflamed gallbladder causes acute attack of upper right quadrant abdominal pain.

91. Specific Illnesses Cholecystitis
Often pain occurs after meal high in fat content; nausea and vomiting common.
Distention and ecchymosis rare.
Palpation may reveal diffuse right-sided tenderness or point tenderness under right costal margin; positive Murphy's sign.
Prehospital treatment: mainly palliative.

92. Specific Illnesses Pancreatitis Inflammation of pancreas.
Four categories based on cause:
Metabolic
Mechanical
Vascular
Infectious

93. Specific Illnesses Pancreatitis
Metabolic causes, specifically alcoholism, account for 80% of cases.
Mechanical obstructions caused by gallstones or elevated serum lipids.
Vascular injuries caused by thromboembolisms or shock.
Infectious caused by infectious diseases.

94. Specific Illnesses Pancreatitis
Mortality high (30–40%) due to accompanying sepsis and shock; can lead to multisystem organ failure.
Digestive enzymes inflame pancreas and cause edema; reduced blood flow.
Decreased blood flow causes ischemia and acinar destruction; acute pancreatitis based on rapidity of onset.

95. Anatomy of the pancreas and surrounding structures.

96. Specific Illnesses Pancreatitis
Acinar tissue destruction causes second form, chronic pancreatitis.
Due to chronic alcohol intake, drug toxicity, ischemia, infectious diseases.
Lesion can erode and hemorrhage; causes intense abdominal pain.

97. Specific Illnesses Pancreatitis
Nausea followed by uncontrolled vomiting; can aggravate hemorrhage.
Patient will appear acutely ill with diaphoresis, tachycardia, possible hypotension.
Prehospital treatment: supportive, maintaining ABCs.

98. Specific Illnesses Hepatitis
Any injury to hepatocytes (liver cells) associated with inflammation or infection.
High mortality rate.
Six viruses: hepatitis types A, B, C, D, E, G; most common causes.

99. Specific Illnesses Hepatitis Risk factors
Crowded and unsanitary living conditions
Poor personal hygiene that invites oral–fecal transmission
Exposure to bloodborne pathogens
Chronic alcohol intake

100. Specific Illnesses Hepatitis
Symptoms' severity can range from mild to complete liver failure and death.
Hepatitis A (HAV): best known; infectious hepatitis.
Hepatitis B (HBV): “serum hepatitis"; transmitted as bloodborne pathogen.

101. Specific Illnesses Hepatitis
Hepatitis C (HCV): pathogen commonly responsible for spreading hepatitis through blood transfusions; chronic and often debilitating damage to liver.
Hepatitis D (HDV): less common; pathogen dormant until activated by HBV.
Hepatitis E (HEV): waterborne infection.

102. Specific Illnesses Hepatitis
Hepatitis G (HGV): developed hepatitis after transfusion; people with hepatitis A, B, C can be super-infected with HGV.
Possibly with jaundiced appearance; upper right quadrant abdominal tenderness.
Severe nausea and vomiting, malaise, photophobia, pharyngitis, coughing.

103. Specific Illnesses Hepatitis Palpation may reveal enlarged liver.
Prehospital treatment: mainly palliative.
Secure ABCs and establish intravenous access for fluid resuscitation or antiemetic administration.
Vaccinations available for hepatitis A and B.

104. Summary
Abdominal pain can originate from wide variety of causes; abdominal organs or areas outside abdominal cavity.
Patient's description of pain (sharp, dull, burning, tearing, cramping) may help narrow differential diagnosis.

105. Summary
Prehospital management priorities: maintain airway, breathing, circulation.
Diagnosis can include multitude of causes that cannot be identified without laboratory and radiographic analysis.

106. Summary
Correction of most life-threatening conditions generally requires surgical intervention.
Airway management paramount importance; patients suffer from severe bouts of nausea and vomiting.

107. Summary
Be prepared to turn patient onto side if necessary to clear large amounts of vomitus from airway.
Oxygenation can be adequately stabilized by placing patient on high-concentration oxygen via nonrebreather mask.

108. Summary
Fluid loss, hemorrhage, sepsis may compromise circulatory status.
Initiate fluid resuscitation for hemodynamically unstable patient in field, but never delay transport.

109. Summary
Patients who have abdominal pain lasting over 6 hours should always be evaluated by physician.
Key to successful treatment of gastrointestinal ailments: prompt recognition, treatment, rapid transport.