Abdominal, Gynecologic, Genitourinary, And

Detailed Lesson Plan

Chapter 23

Abdominal, Gynecologic, Genitourinary, and

Renal Emergencies

120–150minutes

Chapter 23 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes / Content Outline / Master Teaching Notes
5 / I.Introduction
A.During this lesson, students will learn about assessment and emergency medical care for abdominal, gynecologic, genitourinary, and renal emergiences.
B.Case Study
1.Present The Dispatchand Upon Arrival information from the chapter.
2.Discuss with students how they would proceed. / Case Study Discussion

• What are some possible causes for Parker’s fever and abdominal pain?
• What questions will give you important information about Parker’s condition?

5 / II.Acute Abdomen—Abdominal Structures and Functions
A.Acute abdomen or acute abdominal stress is a common condition.
B.Abdominal cavity is located below the diaphragm and extends to the top of the pelvis.
C.The abdominal cavity is lined with the peritoneum
1.Visceral peritoneum is the innermost layer and is in contact with the abdominal organs.
2.Parietal peritoneum is the outer layer.
D.Organs enclosed by the visceral peritoneum (stomach, spleen, liver, gallbladder, pancreas, small intestine, and part of the large intestine) are termed intraperitoneal.
E.Organs located behind the peritoneal space (kidneys, ureters, pancreas, and abdominal aorta are located in the retroperitoneal space.
F.Abdominal quadrants and regions
1.Abdominal quadrants—Use the umbilicus to divide the abdomen into quarters.

1. Left upper quadrant (LUQ)
2. Right upper quadrant (RUQ)
3. Right lower quadrant (RLQ)
4. Left lower quadrant (LLQ)

2.Nine regions

1. Right hypochondriac
2. Epigastric
3. Left hypochondriac
4. Right lumbar
5. Umbilical
6. Left lumbar
7. Right iliac
8. Hypogastric
9. Left iliac

G.Types of abdominal structures
1.Hollow organs contain some type of substance that may leak out into the abdominal cavity if the organ is perforated or injured.
2.Solid organs are very vascular, and a rupture or injury to a solid organ could lead to bleeding or severe shock.
3.Vascular structures are the large blood vessels found in the abdominal cavity, and rupture could lead to major bleeding, rapid blood loss, and death. / Teaching Tip
Draw the nine abdominal regions on the white board. Have students come up and write the names of the organs in their respective regions.
Discussion Questions

• In what quadrant or region of the abdomen is the appendix located?
• What is the location of the kidneys?
• What are examples of solid organs in the abdominal cavity?

5 / III.Acute Abdomen—Abdominal Pain
A.Pathophysiology of abdominal pain—Results from mechanical forces (stretching), inflammation, or ischemia (organ and tissue hypoxia)
1.If organ is torn, pain results from blood irritating the peritoneum.
2.Rapid distention of an organ causes pain.
3.Stretching of the peritoneum causes pain.
4.Pain from stretching a solid organ is usually a steady pain.
5.Inflammation may cause a crampy type of pain.
6.Pain associated with ischemia worsens as the organ becomes more hypoxic.
B.Types of abdominal pain
1.Visceral pain occurs when the organ itself is involved; pain is usually less severe, poorly localized, dull or aching, and constant or intermittent.
2.Parietal pain (somatic pain) is associated with irritation of the peritoneal lining; pain is more severe, localized, and typically constant.
3.Referred pain is actually visceral pain that is felt elsewhere in the body; pain is usually poorly localized but is felt consistently in the part of the body to which it is referred. / Weblink
Go to
and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource on information about abdominal pain.
Discussion Question
How is visceral abdominal pain different from somatic pain?
Critical Thinking Discussion
How could a problem elsewhere in the body, such as pneumonia, cause abdominal pain?
25 / IV.Acute Abdomen—Conditions That May Cause Acute Abdominal Pain
A.Peritonitis
1.Irritation and inflammation of the peritoneum
2.Occurs when blood, pus, bacteria, or chemical substances leak into the peritoneal cavity
3.Common signs and symptoms

1. Abdominal pain or tenderness
2. Nausea, vomiting, or diarrhea
3. Fever and chills
4. Lack of appetite
5. Positive Markle test

4.Markle “Heel Drop” or “Heel Jar” test

1. Instruct patient to stand on his feet with his knees straight.
2. Upon request, the patient should raise himself onto his toes and drop suddenly down on his heels with enough force to produce an audible thump.
3. The EMT can modify the Markle test by lifting each of the ankles of the supine patient and knocking the heels together or by making a fist and striking the bottom of the heel (“heel jar” test).
4. Be sure to watch the patient’s face for a grimace or listen for sounds indicating pain.

B.Appendicitis
1.Inflammation of the appendix usually caused by a blockage in the intestines
2.Common signs and symptoms

1. Abdominal pain or cramping
2. Nausea and vomiting
3. Low-grade fever and chills
4. Lack of appetite
5. Abdominal guarding
6. Positive Markle (“heel drop” or “heel jar”) test

C.Pancreatitis
1.Inflammation of the pancreas that causes severe pain in the middle of the upper quadrants of the abdomen
2.May be caused by ingestion of alcohol, gallstones, or infection
3.Common signs and symptoms

1. Abdominal pain (can be severe and radiate from the umbilicus to the back and shoulders)
2. Nausea and vomiting
3. Abdominal tenderness and distention
4. Mild jaundice (depending on cause)
5. Fever, rapid pulse, signs of shock (extreme cases)

D.Cholecystitis
1.Inflammation of the gallbladder and commonly associated with gallstones
2.More common in women and frequently occurs between the ages of 30 and 50
3.Common signs and symptoms

1. Sudden onset of abdominal pain located from the middle of upper quadrants to RUQ areas
2. Tenderness upon palpation of the RUQ
3. Belching or heartburn
4. Nausea and vomiting (contents may be greenish)

E.Gastrointestinal bleeding
1.Bleeding that can occur anywhere within the gastrointestinal tract and can be attributed to numerous causes
2.Usually classified as upper or lower
3.Common signs and symptoms

1. Abdominal pain or tenderness
2. Hematemesis
3. Hematochezia
4. Melena
5. Altered, mental status, weakness, or syncope
6. Tachycardia
7. Signs of shock

F.Esophageal varices
1.Bulging, engorgement, or weakening of the blood vessel in the lining of the lower part of the esophagus
2.Common to heavy alcohol drinkers or patients with liver disease
3.Caused by increased pressure in the venous blood supply system of the liver, stomach, and esophagus
4.Common signs and symptoms

1. Large amounts of bright red hematemesis
2. Absence of pain or tenderness in abdomen
3. Rapid pulse
4. Breathing difficulty
5. Pale, cool, clammy skin
6. Other signs and symptoms of shock
7. Jaundice

G.Gastroenteritis
1.Inflammation of the stomach and small intestines and commonly associated with abdominopelvic pain
2.Condition can be chronic or acute
3.Common signs and symptoms

1. Abdominal pain or cramping
2. Nausea, vomiting, and diarrhea
3. Abdominal tenderness
4. Fever and dehydration
5. Signs and symptoms of shock and hemorrhage (severe cases)

H.Ulcers
1.Open wounds or sore within the digestive tract
2.Breakdown of the lining that normally protects the intestine from the digestive fluids contained in the tract.
3.Signs and symptoms

1. Sudden onset of abdominal pain normally in the LUQ and epigastric area
2. Nausea and vomiting
3. Hematemesis, hematochezia, or melena or coffee-ground emesis in some cases
4. Signs or symptoms of shock (in cases of massive bleeding)
5. Peritonitis

I.Intestinal obstruction
1.Blockage that interrupts the normal flow the of intestinal contents
2.Can occur in both the small and large intestines and be either partial or complete
3.Common signs and symptoms

1. Abdominal pain, moderate to severe, depending on location of obstruction (crampy or colicky)
2. Nausea and vomiting
3. Constipation
4. Abdominal distension and tenderness
5. Abnormally prominent, high-pitched bowel sounds with auscultation in early stages

J.Hernia
1.Protrusion or thrusting forward of a portion of the intestine through an opening or weakness in the abdominal wall
2.Associated with increased pressure in the abdominal cavity during heaving lifting or straining
3.Common signs and symptoms

1. Sudden onset of abdominal pain (usually after heavy lifting or straining
2. Fever
3. Rapid pulse
4. Tender mass at point of hernia
5. Others similar to intestinal obstruction

K.Abdominal aortic aneurysm
1.Weakened, ballooned, and enlarged area of the wall of the abdominal aorta
2.May eventually rupture and is one of the most lethal causes of abdominal pain
3.Common signs and symptoms

1. Gradual onset of lower lumbar, groin, and abdominal pain
2. Rupture associated with sudden onset of severe, constant abdominal pain
3. Testicular pain in the male patient
4. Possible nausea and vomiting
5. Mottled or spotty abdominal skin
6. Pale, cool, clammy, and possibly cyanotic skin in legs
7. Absent or decreased femoral or pedal pulses
8. Pulsating abdominal mass (felt if abdomen is soft) or rigid and tender abdomen (if aneurysm has burst)
9. Cyanotic, cold, or mottled skin below waistline (if aortic aneurysm is starting to rupture)

L.Vomiting/diarrhea/constipation
1.Symptoms of many of the conditions previously discussed
2.EMT should be concerned if condition has persisted for hours (vomiting) or days (diarrhea), and the patient has become dehydrated. / Discussion Question
What is a positive Markle sign?
Discussion Question
What are some typical complaints associated with pancreatitis?
Discussion Question
What are causes of gastrointestinal bleeding?
Critical Thinking Discussion
What are some reasons gastrointestinal bleeding may not be diagnosed and treated promptly?
Weblink
Go to
and click on the mykit link for Prehospital EmergencyCare, 9th edition to access a web resource on gastroenteritis and dehydration.
25 / V.Acute Abdomen—Assessment-Based Approach: Acute Abdomen
A.It is not important that you try to isolate the exact cause of abdominal pain or distress in the prehospital setting, but rather that you simply correctly assess and identify that the patient is suffering abdominal pain and provide suitable emergency care based on the symptom.
B.Scene size-up
1.Check for scene safety and take Standard Precautions.
2.Look for mechanism of injury
3.Use all of your senses to size-up the scene.
C.Primary assessment
1.Stabilize spine injury if suspected.
2.Person with an acute abdomen generally appears very ill and assumes a guarded position with his knees drawn up and his hands clenched over his abdomen.
3.Ensure the patient has a patent airway with adequate breathing.
4.Apply high-flow, high-concentration oxygen therapy and assist the patient’s ventilations if they are inadequate.
5.Assess circulation.
6.Look for signs of shock.
7.Consider the patient a priority for transport if he meets any of the following criteria.

1. Poor, general appearance
2. Unresponsive
3. Responsive, not following commands
4. Shock
5. Severe pain

D.Secondary assessment
1.If patient is responsive, conduct history before the physical exam; if patient is unresponsive, conduct history after physical exam and vitals, gathering information from family or bystanders.
2.Important questions to ask during the history

1. Ask the OPQRST questions to get the full description of the pain.
2. Does the patient have any known allergies to medications, food, or other substances?
3. Is the patient currently taking any medications?
4. Does the patient have any pertinent past medical history?
5. When was the last time the patient had anything to eat or drink?
6. Has the patient’s appetite changed?
7. Has the patient been nauseated?
8. Did the patient vomit, and if so, what was the color and appearance?
9. What was the color of the patient’s last stools?
10. Has the patient had difficulty urinating?
11. Was the patient doing anything prior to the onset that led to the abdominal pain or distress?

3.Focus on the abdomen during the physical exam but still asses the rest of the body for signs and symptoms.
4.General guidelines for the physical exam

1. Determine if the patient is restless or quiet and whether pain is increased upon movement.
2. Inspect the abdomen to determine if it if distended. Ask the patient whether that is normal or not.
3. Gently palpate the abdomen using the quadrants as landmarks. Remember to start with the least painful area first.
4. Assess if the abdomen feels soft or rigid (involuntary guarding/rigidity versus voluntary guarding).
5. Assess if the abdomen is tender or nontender when touched.
6. When palpating the abdomen, note any masses that may be present and if they are pulsating.
7. Ask the patient if he has any pain on other body areas.
8. Document the quadrant in which any pain is located.

5.Obtain and document the patient’s baseline vital signs.
6.Signs and symptoms

1. Pain or tenderness
2. Anxiety and fear
3. Guarded position or other comfortable position
4. Rapid and shallow breathing
5. Rapid pulse
6. Blood pressure changes
7. Nausea, vomiting, and/or diarrhea
8. Rigid abdomen or guarding
9. Distended abdomen
10. Fever or chills
11. Belching or flatulence
12. Changes in bowel habits or urination
13. Other signs and symptoms associated with shock
14. Signs of internal bleeding

7.Do not waste time with extensive exams or palpation prior to initiating transport. Excessive palpation can worsen the pain and aggravate the cause.
E.Emergency medical care
1.Keep the airway patent.
2.Place the patient in the position of comfort.
3.If breathing is adequate, administer oxygen based on the SpO2 reading and patient signs and symptoms.
4.Never give anything by mouth.
5.Calm and reassure the patient.
6.If signs and symptoms of hypoperfusion are present, treat for shock.
7.Initiate a quick and efficient transport.
F.Reassessment
1.Reassess during transport.
2.Document and record vital signs and communicate to receiving facility. / Discussion Question
What are the management priorities for patients with acute abdominal pain?
Class Activities

• Divide students into small groups. Provide individual students in each group with an index card listing a cause of abdominopelvic pain. Instruct students not to share the information on the cards with their classmates. Ideally, each student will have a card, but at least one student in each group must have a card. Students will spend time researching the presentation of their condition and will develop a complaint and history to be elicited by the other students in their group. The other students must obtain a history to determine their classmate’s condition. Students will then discuss how well the complaints and history matched the condition.
• Provide ample opportunity for students to practice skills.

Knowledge Application
Given a series of scenarios of patients complaining of abdominal pain, students should be able to develop an index of suspicion for the cause and provide appropriate management for the patient.
5 / VI.Gynecologic Emergencies—Female Reproductive Structures and Function
A.Gynecology is the branch of medicine that studies health of the female patient and her reproductive system.
B.External genitalia (vulva)
1.Consists of vascular tissues called the perineum, mons pubis, labia, and the clitoris
2.Provides accessory functions to the internal organs that are used primarily for reproduction
C.Internal organs
1.Includes the vagina, uterus, ovaries, and fallopian tubes
2.Vagina functions as the birth canal during childbirth, receives the penis during sexual intercourse, and serves as a passageway for menstrual flow.
3.Ovaries are the primary sex glands located on each side of the uterus.
4.Fallopian tubes extend from near each of the ovaries to the uterus.
5.Uterus is the pear-shaped muscular organ which provides an appropriate site for egg implantation and fetal development during pregnancy. The endometrium lines the uterus and is sloughed off during menses.
15 / VII.Gynecologic Emergencies—Gynecological Conditions
A.Sexual assault
1.Act of violence and a crime that is defined differently by each state (most include sexual intercourse or other sexual activities that are performed without consent)
2.Make sure you follow your local protocols when dealing with a sexual assault patient.
3.Physical effects of rape or sexual assault

1. Traumatic injuries from beatings, chokings, and penetrations
2. Swelling, bleeding, and pain around the genital or rectal area
3. Sexual transmitted diseases
4. Possible pregnancy

4.Psychological effects of rape or sexual assault

1. Severe anxiety, depression, or fear
2. Inappropriate feelings of guilt
3. Flashbacks or nightmares
4. Emotional withdrawal, numbness, or irritability

5.Guidelines for when sexual assault has occurred

1. Address both the physical and emotional needs of the patient.
2. Always maintain patient confidentiality.
3. Do not allow the patient to change clothes, bathe, comb, or clean any part of the body. If the clothing was changed, collect it, bag it separately, and take it with you.
4. Do not cut through any holes or tears in the patient’s clothing. Handle the clothing as little as possible.
5. Do not touch or change anything at the crime scene unless it impedes emergency medical care.
6. Do not clean wounds, if possible. Treat wounds as you would other soft-tissue injuries.
7. Do not examine the genital area unless there is a life-threatening hemorrhage. Minor bleeding can be absorbed by a pad. Make sure all bloody articles are collected and transported with the patient.
8. Document all findings objectively and accurately.

B.Vaginal bleeding (nontraumatic)
1.May be caused by cancerous lesions, pelvic inflammatory disease, hormonal imbalances, spontaneous abortion, or labor.
2.EMT should not assume bleeding is occurring from menses; however, for girls about the age of ten, menses could be the cause of bleeding.
3.Common signs and symptoms of a spontaneous abortion

1. Lower abdominal or pelvic pain
2. Abdominal tenderness
3. Vaginal bleeding
4. Rapid pulse
5. Signs and symptoms of shock

C.Menstrual pain