Outdoor Emergency Care, Fourth Edition

Outdoor Emergency Care, Fourth Edition

CHAPTER 13: COMMON MEDICAL EMERGENCIES

Lesson Guide

Kathleen A. Olsen, Pebble Creek Patrol, Inkom, ID

Note: This lesson guide is provided in an electronic format in the OEC Instructor’s Tool Kit so you can modify and customize it to fit your course.

INSTRUCTOR TOOLS

·  OEC Instructor’s Manual, 4th edition (lesson guides, activities, skill guides)

·  OEC Instructors’ Tool Kit CD (lesson guides, PowerPoint presentations, activities, image bank)

·  OEC Test Bank CD (questions, scenarios—generate quizzes, chapter tests, midterms, finals)

·  Mechanism of Injury is more fully described in Chapter 18

·  www.nsp.org, www.patrol.org/instructor, www.OECzone.com

·  Activities section of this manual

·  Skill Guides

o  Vital Signs Determination (chapter 5)

o  Use of Oxygen and Airway Adjuncts (chapter 6)

o  Patient Assessment (chapter 7)

o  Bleeding Control/Shock Management (chapters 8 and 9)

STUDENT TOOLS

·  Outdoor Emergency Care, 4th edition

·  Student Workbook, 4th edition

·  www.nsp.org, www.OECzone.com

·  Skill Drill 13-1—Administering Glucose

·  Skill Drill 13-2—Using an Auto-Injector

·  BSI devices; e.g. rubber (latex) gloves, mask, goggles

·  Emergency care supplies

CORE OBJECTIVES for initial patrol training

Note: The objectives listed below are specific for first-time patroller training. All other objectives identified in the textbook should be used when customizing your course for other audiences and for continuing education purposes.

Cognitive (Information)

·  Identify the signs and symptoms of the acute abdomen and the necessity for immediate transport of patients with these symptoms.

·  Identify the patient taking diabetic medications with altered mental status and the implications of a history of diabetes.

·  State the steps in the emergency care of the patient taking diabetic medicine with an altered mental status and a history of diabetes.

·  Recognize the patient experiencing an allergic reaction.

·  Describe the emergency care of the patient with an allergic reaction.

·  Describe the mechanisms of allergic response and the implications for airway management.

·  List signs and symptoms associated with poisoning.

·  Describe the steps in the emergency care for the patient with suspected poisoning.

Affective (Comprehension)

None

Psychomotor (Application)

·  Perform a rapid gentle assessment of the abdomen.

·  Demonstrate the steps in the emergency care for the patient taking diabetic medicine with an altered mental status and a history of diabetes.

·  Demonstrate the emergency care of the patient experiencing an allergic reaction.

·  Demonstrate the steps in the emergency care for the patient with suspected poisoning.

CHAPTER SET

You are the rescuer

Use this activity to encourage discussion regarding the types and complexity of abdominal pain and diabetic emergencies. It provides a starting point for the presentation of the critical and time-sensitive nature of treating allergic reactions and the significance and concerns associated with understanding and treating problems resulting from substance abuse. This activity will allow students an opportunity to explore the significance and concerns associated with assessing and treating rapidly a patient with any one of these emergency problems.

Scenario

A brief stop for coffee in the lodge cafeteria turns into work when a 25-year-old woman just in front of you in the line collapses. You help the woman to the floor. She is complaining of “terrible stomach pain.”

1.  Why would a patient with a serious abdominal problem complain of pain elsewhere, such as the shoulder?

·  Abdominal pain is often referred to other areas of the body.

2.  How is it possible to go into shock from an “acute abdomen?”

·  Loss of body fluid into the abdominal cavity due to peritonitis (hypovolemic shock).

·  Vomiting with loss of fluids and electrolytes

·  Dehydration from metabolic abnormalities.

WORKBOOK ACTIVITY - Chapter 13

These exercises will allow students an opportunity to refresh their knowledge of the acute abdomen, allergic reactions, diabetes, poisoning, drug abuse, and other common emergencies that occur in the outdoor environment as well as facilitate a review of this lesson’s major topics.

ESSENTIAL CONTENT – COMMON MEDICAL EMERGENCIES

I.  The Acute Abdomen

A.  Abdominal pain

1.  Common complaint

2.  Cause is often difficult to identify, so not necessary to determine the exact cause

3.  Need to be able to recognize life-threatening problems and act swiftly.

B.  Physiology of the acute abdomen

1.  Sudden onset of abdominal pain

2.  Indicates peritoneal irritation

3.  Caused by infection, penetrating wound, blunt injury, and many diseases

4.  Major symptom is severe pain.

5.  Clinical signs are abdominal tenderness and distention.

C.  Peritoneum is the thin membrane that lines the entire abdominal cavity.

1.  Consists of two membranes and two types of nerves supply these areas.

a.  Parietal peritoneum lines the walls of the abdominal cavity.

i.  Supplied by the same nerves that supply the skin

ii.  Can perceive pain, touch, pressure, heat, and cold

iii.  The nerves cannot localize a point of irritation.

b.  Visceral peritoneum covers the surface of each of the organs in the abdominal cavity.

i.  Supplied by the autonomic nervous system, so the patient is less able to localize sensation.

ii.  Stimulated only when distension or forceful contraction of the hollow abdominal organs activates stretch receptors

iii.  Sensation is usually interpreted as colic, a severe, intermittent
cramping pain.

D.  Referred pain

1.  Perceived pain at a distant point of the body caused by irritation of the visceral peritoneum

2.  Result of connections between the body’s two separate nervous systems

a.  Spinal cord supplies sensory nerves to skin and muscles.

b.  Autonomic nervous system controls abdominal organs and the blood vessels.

c.  Nerves connecting these two systems cause the stimulation of the autonomic nerves to be perceived as stimulation of the spinal sensory nerves. Example: Acute cholecystitis may cause pain in the right shoulder, because the autonomic nerves serving the gallbladder lie near the spinal cord at the same anatomic level as the spinal sensory nerves that supply the skin of the shoulder.

E.  Peritonitis

1.  Irritation of the peritoneum caused by illness or injury

2.  Typically causes ileus, or paralysis of the muscular contractions in the intestine, which causes abdominal distention.

3.  Nothing that is eaten can pass normally out of the stomach or through the bowel.

4.  The only means by which the stomach can empty itself is through vomiting.

5.  Almost always associated with nausea and vomiting

6.  These signs and symptoms can accompany almost every type of gastrointestinal disease or injury.

F.  Signs and symptoms of acute abdomen

1.  Nausea and vomiting (ileus)

2.  Vomit (emesis), Anorexia

a.  Loss of hunger or appetite

b.  An almost universal complaint in gastrointestinal and abdominal disease or injury

3.  Loss of body fluid into the abdominal cavity

a.  Usually results from abnormal shifts of fluid from the bloodstream into body tissues.

b.  Decreases the volume of circulating blood

c.  May eventually cause shock

4.  May have normal vital signs or tachycardia and hypotension

5.  Fever may or may not be present.

6.  Abdominal pain and tenderness

a.  May be localized or diffuse and will vary in severity

b.  Localized pain provides a clue to the problem.

c.  Tenderness may be minimal or great.

7.  Tenseness of the abdominal muscles over the irritated area

a.  Board-like muscle spasm called guarding, which accompanies major problems

b.  Patients comfortable only when lying in one particular position, which relaxes muscles and lessens the pain.

c.  Patients with distention caused by peritonitis usually have abdominal pain, even when lying quietly.

d.  Patients may take rapid, shallow breaths because of pain.

e.  Tenderness on palpation of the abdomen or when patient moves

f.  Degree of pain and tenderness is usually related to the severity of peritoneal inflammation.

8.  Common signs and symptoms of acute abdomen

a.  Local or diffuse pain and/or tenderness

b.  A quiet patient who is guarding the abdomen (in shock)

c.  Rapid and shallow breathing

d.  Referred (distant) pain

e.  Anorexia, nausea, vomiting

f.  Tense, often distended, abdomen

g.  Sudden constipation or bloody diarrhea

h.  Tachycardia

i.  Hypotension

j.  Fever

k.  Rebound tenderness (less pain when direct pressure is applied, but very painful when pressure is released)

9.  Examining the abdomen

a.  Explain to the patient what you are about to do.

b.  Position patient supine with the legs drawn up and flexed at the knees.

c.  Evaluate and inspect for restlessness or quietness; whether motion causes pain; any characteristic position; distention; or obvious abnormalities.

d.  Palpate the four quadrants of the abdomen gently to determine whether it is tense (guarded) or soft.

e.  Determine whether the patient can relax the abdominal wall on command.

f.  Determine whether the abdomen is tender when palpated.

G.  Causes of abdominal pain

1.  Gastrointestinal and urinary tract

a.  Nearly every kind of abdominal problem can cause an acute abdomen.

b.  Any condition that allows pus, blood, feces, urine, gastric juice, intestinal contents, bile, pancreatic juice, amniotic fluid, or other foreign material to lie within or adjacent to the abdominal cavity can cause an acute abdomen.

c.  Technically, organs such as kidneys, ovaries, and other genitourinary structures are retroperitoneal but because they lie next to the peritoneum, problems in these organs can lead to an acute abdomen.

d.  Common abdominal conditions

i.  Acute appendicitis

ii.  Perforated gastric ulcer

iii.  Cholecystitis

iv.  Diverticulitis

2.  Indigestion

a.  A sign that the upper gastrointestinal tract is not functioning normally.

b.  Symptoms include pain, nausea and vomiting (a sign).

c.  Frequently associated with excess acid production.

d.  Can be brought on by: stress, infection, alcohol, and spicy meals.

e.  Can be an early sign of ulcer or cancer

f.  Pain is described as burning, dull, cramping or pressure

g.  Felt in the epigastric area

h.  Heartburn is a burning in the epigastric, throat and substernal regions

i.  A sign or acid in the esophagus

ii.  Can mimic cardiac pain

i.  Nausea is a sense of an impending urge to vomit

j.  Vomiting is the process of ejecting the stomach contents through the mouth.

k.  Stomach will empty due to stimuli which include:

i.  Infection

ii.  Food poisoning

iii.  Drugs

iv.  Alcohol

v.  Trauma,

vi.  Tumors, Ulcers

vii.  High altitude

viii.  Headache,

ix.  Motion sickness

x.  Various types of stress

l.  Nausea and vomiting can be mild, severe, acute or chronic. It can lead to serious side effects such as:

i.  Loss of fluids and electrolytes

ii.  Aspiration of vomit leading to obstruction and infection

iii.  Tears and bleeding in the stomach and esophagus

m.  If vomiting doesn’t subside transport to medical care

n.  Vomiting blood is almost always serious

o.  Usually associated with disease or injury to the stomach or esophagus which include:

i.  Ulcers

ii.  Tears due to vomiting

iii.  Esophageal varices

p.  Vomited blood can be bright red or when digested like coffee grounds

q.  Evacuated these patients to a hospital

3.  Diarrhea

a.  Passage of soft or liquid stools frequently

b.  Prolonged bouts lead to dehydration, starvation, and shock

c.  Accompanied by nausea and vomiting at time.

d.  Usually caused by contaminated food and water. Varies geographically.

e.  Caused frequently by infection by:

i.  Campylobacter, Salmonella, Shigella bacteria

ii.  Staphlococcus, which grows readily in some food.

iii.  Giardia lamblia protozoa

iv.  Cryptosporidium protozoa

v.  Escherichea coli (E-coli) colon bacillus

f.  Traveler’s diarrhea can be prevented through scrupulous attention to personal cleanliness and food preparation.

g.  Hospitalization can be necessary when nausea and vomiting accompany diarrhea.

4.  Blood in the stools

a.  Bright red blood in the stools is bleeding form the rectum or lower colon

b.  Can be from higher in the track with rapid passage to the bowel

c.  Usually hemorrhoids or anal fissure

d.  Darker blood (tarry stools) indicates bleeding in the upper tract.

e.  Causes include:

i.  Stomach ulcers

ii.  Polyps

iii.  Cancer

f.  Pepto-Bismol and vitamins can turn the stool dark

g.  Beets can turn the stool and urine red

h.  Inflammatory bowel disease can cause blood in the stools

i.  Tarry stools signify a condition that needs medical attention

j.  Bright red blood and pain in the anal region is usually from a bleeding hemorrhoid, fissure or abrasion.

5.  Colic

a.  Intermittent, severe pain caused by obstruction to hollow organs such as:

i.  Gall bladder

ii.  Bowel

iii.  Ureter

b.  Muscle contraction causes pain as contents pass obstruction.

c.  Common causes include:

i.  Gall stones

ii.  Kidney stones

iii.  Intestinal obstructions

iv.  Tumors

d.  Gall stones can be felt in the RUQ and below the right scapula

e.  Urethral colic (kidney stones) pain can be felt in the corresponding flank

f.  Intestinal colic pain can be felt peri-umbilical

g.  Can be symptom of serious disease

6.  Constipation

a.  The passage of hard dry stools at less than normal intervals

b.  Caused by:

i.  Limited activity

ii.  Dehydration

iii.  Anxiety

iv.  Lack of bulk (fiber)

c.  Not simply infrequent stools.

d.  The elderly are susceptible.

e.  Persistent constipation can be a sign of bowel cancer

f.  Fecal impaction may have to be digitally cleared.

7.  Difficulty swallowing

a.  Disphagia can be caused by abnormal function or the esophageal muscles, tumor, scar tissue or a foreign body

b.  It can be acute, chronic, or intermittent

c.  Usually a temporary muscle spasm

d.  Cancer is the most serious and all patients should get medical care.

8.  Jaundice

a.  A yellowing of the skin, mucous and sclera caused by accumulation of bilirubin in the blood.

b.  Can be seen also as brown urine or pale stools.

c.  Bilirubin is a normal by product of the metabolism of old red blood cells.

d.  If it exceeds normal levels jaundice occurs

e.  Common causes include:

i.  Liver dysfunction (hepatitis)

ii.  Gall stones