Chapter 23: Abdominal, Hematologic, Gynecologic...

Glossary
Introduction
A diverse group of disorders can affect the organs of the abdominopelvic cavity.
Some of the systems that can produce those disorders include the gastrointestinal,
hematologic, gynecologic, genitourinary, and renal systems. In this module, you will
learn about the assessment and management of patients with disorders of those
systems.
In this lesson, you will learn how to recognize and manage abdominal emergencies
and emergencies of the hematologic, gynecologic, genitourinary, and renal systems.
Provided you read and study Chapter 23, complete the exercises at the end of the
chapter, and go through each lesson of this online course, you should be able to:

Describe the anatomy and physiology of the abdominal cavity and abdominal
organs.

Describe mechanisms of abdominal pain.

Describe the pathophysiology of common causes of an acute abdomen.

Describe the assessment-based management of acute abdomen.

Describe the pathophysiology of hematologic disorders.

Describe the pathophysiology of common gynecologic emergencies.

Describe the assessment-based management of acute gynecologic

emergencies.

Describe the anatomy and physiology of the genitourinary/renal system.

Describe the pathophysiology of emergencies of the genitourinary/renal

system.

Describe the assessment-based management of genitourinary/renal

emergencies.

Acute abdomen is a general term that is used for abdominal pain with a serious
underlying cause that often requires surgery. There are many underlying causes of
abdominal pain. In addition to causes within the abdomen, pain can be referred to
the abdomen from problems with the cardiopulmonary and other systems. Begin
learning about the causes, assessment, and management of abdominal pain by
reading your text section, Acute Abdomen. Be sure to study the accompanying
figures and tables. When you have finished reading, begin Lesson 1, where you can

reinforce key learning points and check your understanding. Be prepared: There are
many new terms in this module. Here are some medical terminology reminders:
-itismeans inflammation, and hemat- pertains to blood.

Lesson 1: Acute Abdomen

The abdominal cavity extends from the diaphragm to the pelvis. For purposes of
assessment and description, the abdomen is divided into four quadrants by
perpendicular lines that intersect at the umbilicus. The latter portion of the cavity is
called the retroperitoneal space. A double-layered membrane called
theperitoneum lines the abdominal cavity. The outer layer covers the abdominal
wall and is called the parietal peritoneum. The inner layer surrounds the organs and
is called the visceral peritoneum. The true abdominal cavity is separated from a
posterior cavity by a sheet of peritoneum. The organs are held in place by tissue
called mesenteries, which also carry the blood supply to the organs. Anteriorly,
layers of fatty connective tissue called the omentum cover the organs. The
abdominal cavity contains the organs of the digestive system, including those of the
alimentary canal and the accessory organs of digestion. Most of those organs are
located in the true abdominal cavity. The spleen, which plays roles in the immune
and hematologic systems, is in the abdomen, as well. The organs of the
urinary/renal system and the abdominal aorta and a large portion of the inferior
vena cava are in the retroperitoneal space. The lower portion of the abdomen,
which is called the pelvic cavity, contains the internal reproductive organs, distal
portion of the large intestine, and the urinary bladder. There are two basic
structures to abdominal organs: solid and hollow. Solid organs are highly vascular
and inelastic and can bleed profusely when injured. Hollow organs contain
substances such as digestive contents, urine, and bile. When a hollow organ is
injured, those contents can leak into the abdominal cavity, causingperitonitis.
When assessing a complaint of abdominal pain, you will ask about the quality,
location, radiation, and severity of the pain, among other things. That information
can give important information about the nature of the problem. The organs
themselves have sparsely distributed pain-sensitive nerves, and the nerves relay
pain information that is difficult for the brain to associate with an exact location.
That type of pain is called visceral pain. It tends to be less severe and often
described as dull or aching. The pain may be constant or intermittent. The
peritoneum, on the other hand, is well supplied with pain-sensitive nerves. When
the peritoneum is irritated, the pain is well localized. That type of pain is
called parietal pain or somatic pain. It tends to be well localized, located on one
side, more intense, usually constant, and often described as sharp. There are three
mechanisms that usually are responsible for abdominal pain: stretching,

inflammation, and ischemia. Stretching of a hollow organ usually produces a

cramping type of pain. Referred pain is visceral pain that is felt, not at the location
where the problem is occurring, but at a different location. That phenomenon occurs
because of sensory nerve pathways that are shared between the affected organ and
the site of the referred pain. Some types of disorders have classic patterns of
referred pain that can provide clues to the underlying problem.
Abdominal pain should always be considered a serious complaint. In the scene sizeup, take note of any indications that the patient has been vomiting and of the
characteristic odor that accompanies lower gastrointestinal bleeding. Note the
appearance of the vomitus. You may notice immediately that the patient is in a
characteristic guarded position. During the primary assessment, note the level of
responsiveness and general appearance. Ensure that the patient has an adequate
airway, and be prepared for vomiting.
Position the patient accordingly, and have suction immediately available. Breathing
may be shallow in patients with peritonitis because movement of the abdominal
wall is painful. Ensure adequate ventilations and oxygenation. Many conditions that
result in abdominal pain are likely to cause shock. Note from the general
appearance, level of responsiveness, and circulation whether shock is present.
Obtain baseline vital signs and a medical history, ensuring that you obtain all
information represented by SAMPLE. Use OPQRST to explore the chief complaint.
Ask about anticipated associated signs and symptoms, such as nausea, vomiting,
blood in the stool, constipation, and loss of appetite. Follow these guidelines for
examining the abdomen:

First, inspect the abdomen. Look for distention and indications of previous
surgery. Discoloration around the umbilicus and in the flanks may occur.

Ask the patient to point to the location of the pain; palpate that area last to
avoid the patients immediately tensing the abdominal muscles.

A normal abdomen feels soft, and there is no tenderness to palpation. Check

for involuntary guarding/rigidity and voluntary guarding.

Note any masses palpated in the abdomen and, if a mass is present, whether
it pulsates with the patients heartbeat.

Care of the patient with abdominal pain is supportive and includes the following:

Maintain a patent airway.

Ensure adequate breathing and oxygenation.

Place the patient in a position of comfort, which usually is lying on the side
with the knees drawn up, if his mental status and respiratory status allow.

Do not give anything by mouth.

Reassess frequently.

Transport without delay, but as gently as possible, because every bump,

acceleration, and deceleration is likely to increase the patients pain.

If the patient has inadequate breathing, altered mental status, or indications

of shock, consider requesting ALS.

An inflamed peritoneum can cause fluid loss into the abdomen, resulting in
dehydration.

Causes of Abdominal Pain

Peritonitis is irritation and inflammation of the peritoneum arising from the presence
of bacteria, the contents of hollow organs, pus, or blood in contact with the
peritoneum. Some substances, such as fresh blood, are not immediately irritating to
the peritoneum, and pain may be minimal despite a serious underlying problem.
Peritonitis is associated with abdominal pain, nausea, vomiting, loss of appetite, and
sometimes fever and chills. Any motion or stretching of the irritated peritoneum
results in increased pain. For that reason, patients with peritonitis often lie very still,
curled on their sides with the knees drawn up to reduce tension on the peritoneum.
The patient also often experiences an increase in pain when the heel of the foot is
jarred, since the impact travels upward from the lower extremity to the pelvis. A
positive heel jar or Markle test is a sign of peritonitis. You also may notice that when
you palpate the abdomen of a patient with peritonitis, the pain is increased upon
releasing the pressure of palpation. That finding is known as rebound tenderness.
Appendicitis is an inflammation and infection of the appendix, most often caused by
a blockage of the appendix. The initial pain is often dull, poorly localized, and felt
around the umbilicus. Later, as the peritoneum becomes inflamed, pain localizes to
the right lower quadrant. Nausea, vomiting, low-grade fever, and chills may be
present. Pancreatitis causes severe upper abdominal pain in the midline, often
radiating through to the back. The most common cause of pancreatitis is alcohol
abuse. Gallstones and infection also are causes. Pancreatitis is associated with
serious complications that can lead to death. The pain, nausea, and vomiting are
usually severe, and the patient often has a poor general
appearance. Cholecystitis is an inflammation of the gallbladder, usually resulting
from obstruction of the bile duct by gallstones. Often called a gallbladder attack,
cholecystitis can affect liver function and can lead to pancreatitis. The pain is

usually felt in the right upper quadrant and may radiate or be referred to the right
shoulder/shoulder blade area. Pain is more frequent at night and may occur after a
fatty meal.
Gastrointestinal bleeding can occur at several points along the gastrointestinal tract
and is often associated with shock, anemia, hematemesis, hematochezia,melena,
and abdominal pain or tenderness. Gastrointestinal (GI) bleeding is classified as
upper GI bleeding or lower GI bleeding. Esophageal varices are engorged varicose
veins in the esophagus that can rupture and bleed profusely. They are often found in
patients with liver disease, such as chronic hepatitis or cirrhosis. The patient will
likely vomit large amounts of blood and may be in shock. Airway management can
be complicated. Position the patient accordingly and have suction immediately
available. Other causes of upper GI bleeding aregastroenteritis and ulcers. Ulcers
may be associated with dark, coffee groundsappearing blood because of the action
of digestive enzymes on the blood. Lower GI bleeding can arise from conditions
such as colon cancer and diverticulitis.

Intestinal obstruction, often called bowel obstruction, can occur in the small
intestine or large intestine and can be partial or complete. Causes include
adhesions, hernia, tumors, fecal impaction, and twisting of the intestines. The
condition is most common in the elderly and is life threatening. The obstructed
bowel can become distended. The distention can interfere with circulation to the
wall of the bowel, allowing bowel bacteria to enter the abdominal cavity or causing
the bowel to weaken and rupture. The location and severity of the pain varies but
often is initially described as crampy and poorly localized. The patient may
complain of constipation, nausea, vomiting, and abdominal distention.
Abdominal aortic aneurysm (AAA) and aortic dissection often present with a pain
that is described as tearing or cutting. The pain may be felt in the abdomen,
flanks, or back. With dissection, the vessels that branch from the aorta can be
obstructed, leading to poor perfusion in one or both lower extremities. In AAA, there
sometimes is a pulsating mass in the abdomen. If that is noted, do not perform
further palpation. Both conditions can lead to rupture of the aorta and massive
bleeding that quickly result in death. Both conditions are true emergencies requiring
immediate transport.

Lesson 2: Hematologic Emergencies

Hematologic emergencies involve the blood. Although there are many hematologic
diseases, some that you may encounter as an EMT are anemia, sickle cell disease,
and hemophilia. Read your text section, Hematologic Emergencies. When you
have finished, return to Lesson 2 to reinforce key learning points and check your
understanding.

Anemia is a condition in which the red blood cell (RBC) count is lower than normal. It
can be caused by producing too few RBCs, abnormal destruction of RBCs, or loss of
RBCs. The decrease in RBCs means there is less hemoglobin to carry oxygen to the
cells. Shortness of breath may occur, especially with exertion. On occasion, you may
encounter a patient who has been bleeding slowly over time, such as from an
undetected GI bleed, and as a result has anemia. The skin and mucous membranes
are usually pale. Cyanosis is unusual because the hemoglobin that is present is fully
saturated; there just is not enough of it.
Sickle cell disease, or sickle cell anemia, is most common in African-Americans,
black Africans, and people of Middle Eastern, Caribbean, South and Central
American, and Mediterranean descent. It is an inherited disease in which an
abnormal protein in hemoglobin changes shape in low-oxygen conditions, causing
RBCs to take on a curved sickle shape. As a result, the abnormal cells undergo
unusual wear and tear as they squeeze through capillaries, causing them to be
removed from the bloodstream and destroyed sooner than normal RBCs, and they

are prone to causing obstructions in the capillary beds. Sickle cell crisis occurs when
obstruction of the capillary beds leads to tissue ischemia and infarction. The result
is severe pain in the affected area, which may include the bones, joints, chest, and
abdomen. The spleen is damaged early in life, and patients often suffer stroke,
vision loss, and kidney damage. Sickle cell crisis may present with shortness of
breath and light-headedness. Treatment includes administering oxygen and, if
transport times are prolonged, requesting ALS for pain management.
Hemophilia is a group of disorders that involve one or more inadequate blood
clotting factors. Hemophilia is inherited, and most types affect males, but not
females. Minor injuries can lead to significant, difficult to control bleeding that can
be either internal or external. Some patients with hemophilia keep clotting factors at
home that they can self-administer on schedule and in the event of an emergency.
Lesson 3: Gynecologic Emergencies
Common gynecologic complaints are abdominal pain, abnormal vaginal bleeding,
and abnormal vaginal discharge. Some gynecologic emergencies can be life
threatening. In all cases, you must protect the privacy and dignity of the patient.
Some gynecologic emergencies, such as spontaneous abortion, can be emotionally
devastating for the patient. Your empathy is critical in those situations. Begin
learning about gynecologic emergencies by reading your text section, Gynecologic
Emergencies. Study the tables and figures in the reading. When you have finished,
return to Lesson 3 to reinforce key learning points and check your understanding.

Sexual assault is a crime, and it must be reported according to your state laws.
Sexual assault has both physical and psychological consequences. The patient may
suffer traumatic injuries, contract sexually transmitted infections, or become
pregnant. The psychological effects include anxiety, fear, depression, feelings of
guilt or shame, flashbacks, nightmares, and other psychological consequences. Key
guidelines for managing sexual assault victims include:

Care for the patients physical injuries and provide emotional support.

Do not touch the patient without consent.

Discourage the patient from washing, showering, or using the restroom.

If law enforcement is not called to the scene, collect any clothing that has
been removed, and bag each article individually to be transported with the
patient. Paper evidence bags are preferred.

If you must cut the clothing, do not cut through holes or tears in the clothing.

Follow crime scene protocols, and avoid disturbing evidence.

If possible, do not clean wounds so that they can be processed as part of the
sexual assault examination.

Do not examine the genitals unless there is heavy bleeding that must be
controlled.

Do not ask for specific details of the assault; confine questions to those
needed to care for the patients injuries.

Be nonjudgmental.

Keep all information confidential, sharing only with other health care
providers and law enforcement as required.

During childbearing years, nonpregnant women usually have a menstrual period

each month. The onset of menstruation, menarche, may occur as young as age 10
years. In some cases, pain accompanies the menstrual
cycle. Dysmenorrheaand mittleschmerz are examples. Ovarian cysts also may form.
Most are asymptomatic, but some can be large or can rupture, leading to abdominal
pain. Abnormal nontraumatic vaginal bleeding has many causes. Spontaneous
abortion (miscarriage) and hormonal imbalances are common causes. Other causes
include endometriosis, endometritis, cancer, pelvic inflammatory disease (PID), and
labor. Spontaneous abortion occurs prior to 20 weeks gestation and can present
with vaginal bleeding, lower abdominal pain, and abdominal tenderness. Bleeding
can be severe enough to cause shock. In women, many sexually transmitted
infections (STIs) are asymptomatic. However, if untreated, some of them can lead to
PID and other serious health problems. There are varieties of STIs caused by
bacteria, viruses, fungi, and protozoans. When signs and symptoms occur, they can
include abdominal pain or tenderness; increased, abnormal-appearing, or foulsmelling vaginal discharge; and lesions (blisters or sores).
Some gynecologic emergencies can be life threatening because of hemorrhage or
sepsis (PID is a type of peritonitis). Ensure an adequate airway, breathing, and
oxygenation. A traumatic vaginal bleeding comes from the uterus and cannot be
controlled by direct pressure or packing the vagina. Use a pad to absorb the blood
flow. Key considerations in the history are determining the date of the last
menstrual period; how long bleeding has been occurring; how many pads or
tampons are saturated with blood in one hours time; the presence and character of

any abnormal vaginal discharge; and the presence of associated symptoms, such as
abdominal pain, pain with sexual intercourse or bowel movements, and fever.
Obtain baseline vital signs, transport without unnecessary delay, and reassess the
patient during transport.

Lesson 4: Genitourinary/Renal Emergencies

The urinary/renal system refers to the set of organs that filter the blood of wastes
and excess water to produce urine and excrete it from the body. Renal specifically
refers to the kidneys, while the lower urinary system refers to the ureters, urinary
bladder, and urethra. In males, because of the combined structure of the external
reproductive system and urethra, the term genitourinary system is used. To learn
about these structures and the disorders associated with them, read your text
section, Genitourinary/Renal Emergencies. Study the associated figures and
tables. When you have finished reading, return to Lesson 4 to reinforce key learning
points and check your understanding.
The kidneys play a critical role in maintaining the volume, composition, and pH of
the blood and in eliminating waste products from blood. Blood from the renal
arteries circulates through the intricate internal anatomy of the kidneys, where the
blood is filtered and urine is formed in a complex physiological process. Once urine
is formed, it travels from each kidney, by way of the ureters, into the urinary
bladder for storage. When the bladder is full, it can be emptied voluntarily by way of
the urethra. In females, the urethra is a short tube that runs along the anterior wall
of the vagina, opening just in front of the vaginal opening. Despite their proximity,
vagina and urethra are separate structures. In males, the urethra is part of both the
reproductive tract and the urinary tract. It passes through the prostate gland and
ducts from the reproductive tract open into the urethra. The male urethra is longer
than that of the female and runs the length of the penis.

Urinary tract infections (UTIs) are fairly common. They are especially common in
women and girls and in patients with urinary catheters. Common signs of UTI
include lower abdominal or pelvic pain, flank pain, frequent urge to urinate with
little urine produced, burning or pain on urination, blood in the urine, and cloudy or
foul-smelling urine. Fever is uncommon with lower UTIs but may occur with kidney
infection. Nausea and vomiting may occur. Untreated UTIs can lead to sepsis in
certain individuals. Renal calculi, or kidney stones, are formed of various types of
crystals that form in the kidneys. When the stones are passed through the ureters,
they cause pain and spasm of the ureters, resulting in intense flank pain. Irritation
of the ureter can lead to hematuria.
Renal Failure, Dialysis, and Urinary Catheters
Kidney, or renal, failure can be acute or chronic. In some cases, acute renal failure
(ARF) is reversible, once the underlying cause, such as shock, is reversed. Chronic
renal failure (CRF) worsens over time and is irreversible. Two of the primary causes
of CRF are hypertension and diabetes. In renal failure, the substances normally
eliminated through filtration of the blood in the kidneys remain in the bloodstream.
The consequences are water retention, electrolyte imbalances, and accumulation of
waste products. There are numerous life-threatening consequences of renal failure.
Patients with CRF must undergodialysis to remove waste products and restore the
proper fluid and electrolyte balance to the blood. In hemodialysis, blood is removed
from the body through a surgically created access site, filtered through a machine
with an artificial membrane that separates the blood from a special fluid
called dialysate. The filtered blood is returned to the body through the same access
site. In peritoneal dialysis, fluid is infused into the abdominal cavity, where it is
retained for a period of time before being drained out. The peritoneum acts as the
membrane that separates the blood from the dialysate. Hemodialysis is performed
several times per week in a specialized dialysis center. Peritoneal dialysis can be
performed at home, by the patient, but is not as effective as hemodialysis.
There are many potential complications of hemodialysis and peritoneal dialysis,
including hypotension and electrolyte imbalanceswhich can lead to cardiac
arrhythmias, heart failure, peritonitis, and infection. The access site in hemodialysis
involves the connection of an artery and a vein, and it is repeatedly accessed with a
needle. Because of that, and because hemodialysis patients must take
anticoagulants, bleeding from the site is a potential complication that can be life
threatening. Treatment for renal failure and dialysis emergencies is mostly
supportive, aimed at maintaining the airway, breathing, and circulation. If there is
hemorrhage from the access site, apply firm direct pressure and realize that the
bleeding will be difficult to control and you will most likely have to maintain direct
pressure throughout transport. Do not use a tourniquet on an extremity with a
dialysis access site, and do not take a blood pressure in an extremity with a dialysis
access site. Allow the dialysis center staff to discontinue dialysis and disconnect the
patient from the machine.

Patients with indwelling catheters are prone to urinary tract infections and also may
need to be transported for a number of other, unrelated conditions. Guidelines for
dealing with patients with indwelling catheters include:

Note the amount and appearance of the urine in the collection bag, and
document it. If the bag is full, empty it before transport.

When you must put the collection bag at the patients level to move him,
always clamp the tubing to prevent backflow of urine from the bag into the
urinary system. At all other times, keep the tubing unclamped and the bag
below the patients level.

Take care to avoid catching or pulling on the tubing. Despite the balloon that
anchors it in place in the bladder, the catheter can be pulled out, causing
injury to the bladder and urethra.

Never take a blood pressure in an extremity with a dialysis access site.

Renal Failure, Dialysis, and Urinary Catheters
Kidney, or renal, failure can be acute or chronic. In some cases, acute renal failure
(ARF) is reversible, once the underlying cause, such as shock, is reversed. Chronic
renal failure (CRF) worsens over time and is irreversible. Two of the primary causes
of CRF are hypertension and diabetes. In renal failure, the substances normally
eliminated through filtration of the blood in the kidneys remain in the bloodstream.
The consequences are water retention, electrolyte imbalances, and accumulation of
waste products. There are numerous life-threatening consequences of renal failure.
Patients with CRF must undergodialysis to remove waste products and restore the
proper fluid and electrolyte balance to the blood. In hemodialysis, blood is removed
from the body through a surgically created access site, filtered through a machine
with an artificial membrane that separates the blood from a special fluid
called dialysate. The filtered blood is returned to the body through the same access
site. In peritoneal dialysis, fluid is infused into the abdominal cavity, where it is
retained for a period of time before being drained out. The peritoneum acts as the
membrane that separates the blood from the dialysate. Hemodialysis is performed
several times per week in a specialized dialysis center. Peritoneal dialysis can be
performed at home, by the patient, but is not as effective as hemodialysis.
There are many potential complications of hemodialysis and peritoneal dialysis,
including hypotension and electrolyte imbalanceswhich can lead to cardiac
arrhythmias, heart failure, peritonitis, and infection. The access site in hemodialysis
involves the connection of an artery and a vein, and it is repeatedly accessed with a
needle. Because of that, and because hemodialysis patients must take

anticoagulants, bleeding from the site is a potential complication that can be life
threatening. Treatment for renal failure and dialysis emergencies is mostly
supportive, aimed at maintaining the airway, breathing, and circulation. If there is
hemorrhage from the access site, apply firm direct pressure and realize that the
bleeding will be difficult to control and you will most likely have to maintain direct
pressure throughout transport. Do not use a tourniquet on an extremity with a
dialysis access site, and do not take a blood pressure in an extremity with a dialysis
access site. Allow the dialysis center staff to discontinue dialysis and disconnect the
patient from the machine.
Patients with indwelling catheters are prone to urinary tract infections and also may
need to be transported for a number of other, unrelated conditions. Guidelines for
dealing with patients with indwelling catheters include:

Note the amount and appearance of the urine in the collection bag, and
document it. If the bag is full, empty it before transport.

When you must put the collection bag at the patients level to move him,
always clamp the tubing to prevent backflow of urine from the bag into the
urinary system. At all other times, keep the tubing unclamped and the bag
below the patients level.

Take care to avoid catching or pulling on the tubing. Despite the balloon that
anchors it in place in the bladder, the catheter can be pulled out, causing
injury to the bladder and urethra.