CHAPTER 41: Gastrointestinal Emergencies

INTRODUCTION

Abdominal pain, vomiting, diarrhea, and constipation are exceedingly common symptoms. In 2007, 10.8 million cases presented to emergency departments with gastrointestinal complaints, representing 9.2% of ED visits.¹ Twenty-one to forty-one percent of these patients, despite a full complement of diagnostic testing, leave the ED without a clear diagnosis.² There is diagnostic complexity in differentiating benign self-limited disease versus serious life-threatening conditions when evaluating these common gastrointestinal complaints. Patients arriving via EMS transport are more likely to require hospital admission, suggesting that EMS providers will encounter a sicker subset of the overall ED population.³ Evaluation of these patients is often a challenge as is the provision of education and medical oversight to the EMS provider and system.

Differentiating the seriousness of gastrointestinal complaints begins at the time of dispatch. Dispatch protocols often attempt to address severity of illness and consideration of pathology originating from an alternate organ system when determining the response to the “sick” or “abdominal pain” call types. It has been suggested that dispatch protocols relying on age and gender classification alone result in significant overtriage.⁴ Potential overuse of advanced life support (ALS) must be weighed against the benefits of ALS response: early electrocardiogram (ECG) interpretation, intravenous fluids, and medication administration. The diagnostic complexity of gastrointestinal complaints requires providers to approach them with a high level of suspicion and thorough evaluation, especially in higher risk populations such as the elderly, immunocompromised, women of childbearing age, and individuals with chronic disease.

OBJECTIVES

• Discuss the assessment of gastrointestinal emergencies.

• Understand common causes of gastrointestinal symptoms.

• Identify life-threatening gastrointestinal conditions.

• Discuss appropriate out-of-hospital management.

• Identify life-threatening nongastrointestinal conditions that commonly present with gastrointestinal symptoms.

• Discuss the use of ultrasound and other point-of-care testing in the prehospital environment.

• Discuss the use of narcotics for abdominal pain in the prehospital environment.

• Discuss the use of antiemetics for nausea or vomiting in the prehospital environment.

EVALUATION

Patients often present with one or more complaints, typically abdominal pain with associated symptoms such as nausea, vomiting, anorexia, diarrhea, or constipation. Atypical presentations of gastrointestinal conditions such as alterations in mental status, syncope, or jaundice with or without abdominal pain are responsible for some of the diagnostic uncertainty. The key to the appropriate diagnosis comes with a history and physical examination that is as complete as possible. Consideration of past medical and surgical history can significantly impact the differential diagnosis. The provider should complete the history with full awareness of time of onset, duration of the pain, the quality of the pain, the region or radiation of the pain, factors that provoke or palliate, and the severity of the symptoms. Utilization of a rapid assessment mnemonic such as OPQRST is helpful and should be encouraged (Table 41-1).