my name is matthew deluhery. i'm an emergencymedicine physician with wheaten franciscanhealthcare, an emergency medicine specialist, working inmilwaukee and waukesha county. today's lecture is goingto be about the gi tract, as well as the gu andreproductive tract. we're going to spendquite a bit of time on the pathology of thoseparticular tracts, that's going to be towards the end.
the first part of this is goingto be a review of the anatomy and physiology of both the macroand micro parts of the anatomy. we'll get right into it. the gi system, i think we'reall very familiar with. it's for the digestionof food and then you absorb your waterand your nutrients. it's also part of thedetoxifying system, we'll talk quite about that whenwe talk about the liver as well as the gi role with it.
any disturbance, certainlyin the gi system, not only affects thatparticular system but can affect the body'shomeostasis in its entirety with it. grossly, i think we're quitefamiliar with the gi system. it makes a lot of intuitivesense to paramedics. they've dealt withit quite a bit. all we have to envision iswhat happens when you eat and when you swallow, startingwith the oral cavity going down
into the pharynx, theesophagus, into the stomach, small intestine, largeintestine, and the rectum. the important takehome point, and it'll be emphasized several times,is that the gi system is not only the physical areas thatthe food touches, but also all the different organs thatcontribute to this homeostasis, like the liver, the gallbladder,the saliva producing glands and that's veryimportant to remember when you consider the gi systemas a whole and different areas
that can go wrong with itthat critical care paramedics need to be familiar with. in particular, some ofthese accessory organs, like the salivary glands,we don't necessarily think of when we thinkof the gi system, but certainlythey're immediately needed to produce differentsorts of enzymes and buffers in order to aid in the initialsecretion from your mouth on down.
moving now to more of the microcomponents of the gi system. when we look at thewalls of these tracts, they're actually dividedinto four different layers, the mucosa, submucosa,the muscularis externa, and the serosa. those four layersare moving from what the food touches allthe way to the outside. the books tend toemphasize these four layers and find them to be veryimportant that the paramedics
are familiar with thesefour different layers. as we start on the insidewith the mucosa layer, we have a lot ofthe plicae in here, the lamina propecia in there. this is where a lotof the smooth muscle lives within the gi tract. as we move out to the submucosaand the muscularis areas we see a little bit more ofthe glands being produced. the blood vessels are in there.
and this is where we get a lotof the parasympathetic nervous system in these outer layers. and so, as you can see, asyou move into these deeper layers of it, we start tosee more of the neuromuscular areas. then in the veryend, the part that's furthest away from thefood, or the first part that a surgeon would touchis this the serosa layer. and this is the coveringof the gi tract.
moving back out, as we kindof work our way down the gi system, we'll kind of touch eachof these particular areas one at a time. we start with the oralcavity, the pharynx. it's in the mouth. and i think thatthis particular part is very intuitive for people. it's the mechanical digestion. the actual chewing,using your teeth,
the breaking down of thecarbohydrates, in particular, with your teeth and your tongue. saliva is produced from alot of these salivary glands in the mouth. and then, as you swallow, thepharyngeal muscles contract and you push downinto the esophagus. and as you move downin the esophagus, you get this ideaof peristalsis. that's a word that'svery commonly used,
it's a very complexneuromuscular pattern. your book doesn'temphasize all that, so i'm not goingto get into that. it's essentially theway your body moves the food from the mouth allthe way down into the stomach. it has a very richvascular supply to it from carotid, thedifferent arteries. we often divide the esophagusinto three different parts, the superior, the mediastinal,and the inferior part.
the esophagus doesn't do muchfor breaking down the food. it is purely a pipe that movesmaterial down into the stomach. as the food getsinto the stomach, the stomach is dividedinto four different areas, the cardiac sphincter,the fundus, the cardia, there's the body,and then the pylorus is at the very end of it there. these are not areasthat are grossly seen. you can't look at astomach and say, ah yes,
there's clearly the fundus area. these are areas that areseen both histologically and are just vaguelydrawn anatomically. the stomach is more on theleft side of the abdomen. it's in the left upper quadrant. it is immediatelyunder the diaphragm. the exact size can varyquite a bit on individuals. it can vary dependingon your food intake and how you have been digestingover the last couple of days.
and then, obviously, the stomachends with the pyloric sphincter that empties intothe small intestine. the four areas do have slightlydifferent anatomical parts to it. the body being the largest part. the pylorus beingthe part that's richest in the blood supply,needed mostly to help get the food intothe small intestine. there are three mainarteries or the blood supply
that helps keep the stomachrich and full of nutrients. there is the left gastricartery, the splenic arteries, and then one called thecommon hepatic artery. and that is something thatthe book emphasizes and could be used for testing, which is,what are the different blood supplies to the stomach? the stomach clearly isa digestive process. it is very active. the food moves aroundin the stomach.
people can hear theirstomach growling. they can hear the foodbeing broken down. and as a food breaks down itbreaks into something that we call, chime, c-h-i-m-e,some people do pronounce it, c-h-y-m-e, it can bespelled either which way. and that is just thebreakdown product of the food as it digests. and then this chimeactually exists the stomach, through the pyloric sphincter,and into the small intestine.
the small intestine is somewherebetween 15 and 25 feet, if you were to take it andstretch it all the way out. however, in your body,it's somewhat balled up. it takes a veryloop-de-loop type of track. and so it is notclearly 25 feet long. it touches everyquadrant of your abdomen. is a very frequent insult anda stabbing, or a shooting, or any kind of penetratinginjury, only because it's this kind of a twistingand turning type of path.
it is divided intothree different parts, just to exhaust us more. you can't just call itthe small intestine. the first part is theduodenum, the do-a-di-num, some people call it. then comes the jejunum,and then the ileum. all three of theseparts do different types of digestion for the nutrients. and so we will talk about allthree of these separately.
the duodenum is the shortest. it is very c-shaped. one part of it ishooked up to the stomach through the pyloric sphincter. and the other part ishooked up to the jejunum. it is predominantly in theretroperitoneal cavity. we're going to talk alittle a bit about what that means in a little bit. and it certainlyaids quite a bit
in the digestion of nutrients. the jejunum is where the bulkof the digestion and absorption of all your nutrients is. people find thisquite interesting. it takes nearly halfwaythrough the gi tract until you're seeing thebulk of the digestion and absorption inthe jejunum part. you're not seeing the majorityof it in the large intestine, or the stomach, which is acommon mistake that people
think. but it's predominantlythe small intestine, in the middle of thesmall intestine, where a lot of your absorptionactually takes place. the ileum is theterminal, or the end part, of the small intestine. it is about eight feet long. it actually has avalve at the end of it. this is quite emphasized.
at the end of thesmall intestine and the beginning ofthe large intestine is the valve, the ileocecal valve,is what is particularly called. predominantly to halt or tocontrol the flow of nutrients into the large intestine. the large intestine is almosta square shaped process. it ends, as you can see, inthe right lower quadrant, the end of the small intestinewhere your ileocecal valve is dumping into the cecum.
the intestine, thelarge intestine, is one of the more oddstructures, in that you actually ascend thefirst part of it. and you actually move up intothe right upper quadrant. it's one of the fewplaces in your body that you actuallygo against gravity. the food, at thatpoint, then moves across the transverse colon,down the descending colon, and into the sigmoid beforeit moves into the rectum.
the one thing i will emphasizeon this slide, is the appendix. it's noted in the rightlower quadrant there, just next to the cecum. we hear quite frequentlyof appendicitis. it's a frequenttransport for paramedics. it's right lower quadrantpain, nausea, vomiting. we clinically think quite abit of appendicitis there. and so, i will note thatthe appendix is actually part of the large intestine.
it looks like a rat tail it'soften frequently described. we suspect that it playsparts in the lymphatic system. it is not actually a partwhere the food or the breakdown takes place. and as you can seegraphically from this, to take out that appendixdoes not significantly limit your large intestinein any way, shape, or form. the large intestine isabout five feet long. it's responsible, also, forending the re-absorption,
electrolytes, and vitamins. it is a very large intestine. it's much bigger in diameterthan the small intestine. it's very visuallyable to be seen. it has quite a bitof arteries that help keep it very muchrich in blood supply, as it is such a large objectin your abdominal wall. breaking it downagain, the cecum is the part that the smallintestine material dumps into.
it is quite small. it's often described as a pouch. as you can see, it isright next to the appendix. so, if you were to havea particularly bad bout of appendicitis,you could actually get some cecal irritation,or infection, with that. the ascending colonis in the right side. it moves from thelower abdominal wall up to the upper abdominal wall,going right near your liver,
in the right upper quadrant. the colon then turnsand heads sideways from the right side to the leftside in the transverse colon here. as it continues, the sigmoiddumps down into the rectum. the rectum is the very endof the large intestine. it is still considered partof the large intestine. it's about the lastfive to six inches of your large intestines.
and that area is certainlyfor your fecal material. all digestion has beendone at this point in time. stepping away fromthe actual gi tract, but looking at yourabdominal cavity as a whole. if you were a surgeon and youwere to cut into your abdomen, and you were to look inside,we divide the abdominal cavity into three spaces,the peritoneal cavity, the retroperitoneal cavity,and then the pelvic cavity. these are not veryeasy to understand.
this is something that'soften very new for paramedics to understand. it's very commonthat the surgeons were to speak ofthese three spaces. and you may hear a mention. particularly, we use it whensomebody's bleeding in there cavities. the surgeons willuse terms like, this is a retroperitonealbleed, or a peritoneal bleed,
or the bleedingis in the pelvis. different organs are consideredto be in these three spaces, in particular. and we do appreciate them,when we open somebody up. the peritonealspace contains most of the organs ofyour abdominal area. it would be more anterior, or inthe front closer to your belly button. the stomach, the duodenum,the liver, the gallbladder,
the spleen are all inthis particular area. so as you canimagine, a stabbing near your belly button,or to your abdomen, is very likely to causea peritoneal bleed. towards the back, wehave a couple organs in this retroperitonealspace, predominately the kidneys, the uretersthat come out of the kidneys. the end of the duodenum, somecolon, and then your pancreas is in the back.
so stabs to your back,stabs to the sides, are more likely to causea retroperitoneal injury. and that's a verycommon term that we would use in the emergency room. and a critical care paramedictransporting a trauma, it would be very wiseof them to understand where this bleedingis coming from, as we could understand whatorgans would be affected by a peritoneal orretroperitoneal injury.
the pelvis is in the inferiorpart, or the lowest part, of your abdomen. this contains yourbladder, rectum, and then the femaleovaries, fallopian tubes. and so, as you couldimagine, with gravity, if somebody were walkingaround with a bleed, most of the bleeding,using gravity, would fall towards the bottomof the abdominal compartment, or in the pelvic space.
any injury to the femalereproductive system would cause pelvic bleeding. and so that is whywe use these terms, and i think it'simportant that paramedics are familiar with these terms. although you won't be ableto clinically diagnose whether something's in theperitoneal or retroperitoneal, but if you get report of oneof these types of issues, it should help you understandwhere exactly they're
bleeding from. couple other termsi wanted to mention. they're not organsof the gi tract, they are in theabdominal cavity. and they are things that i don'tthink our commonly understood in the layman'sterms, are the ideas of an omentum and a mesentery. and i wanted to spend acouple of minutes on these because many of you may neverhave heard these terms before,
but they're quiteimportant to the surgeons. and any time a surgeonopens somebody up, they're stuck dealing withthe mesentery and omentum. the mesentery is essentially aconduit, or a vascular network. it almost looks likea sheet of paper that helps connect all theorgans so that they don't move. when you suddenly stopa car, your intestines don't unfold andrefold, your liver doesn't move from theright upper quadrant
to the left side. everything kind of stays stuckto where it's supposed to be. and the mesenteryis this connection of these tissues that keepseverything where it's supposed to be, whetheryou're running, or in an aggressiveathletic activity, things don't rearrangeinside of you. it's almost like the glue thatkeeps everything together. and within this area is all thenerves and the blood vessels
that run throughoutyour abdominal wall. and as you couldimagine, if you need to remove an, organ you haveto dissect, or a cut out, part of this mesentery inorder to get to the origin. you can't just reach in andnicely scoop out your liver. you have to kind of cut outthe mesentery, or the glue, that sticks this intoits particular area. similarly, is thisidea of the omentum. there's two of them.
we call it the greaterand the lesser omentum. and it literally lookslike a yellow sheet, like a shade that'son a window that you encounter in yourabdominal wall. and it is, in the same way,it's fat, it's adipose tissue. and it is to insulateand protect these organs. so as you couldimagine, same thing, when you do a surgery youcan't just easily remove it, you'll have to gothrough the omentum.
same point in time, anothertransport that critical care paramedics will do quitea bit is for a small bowel obstruction, and we're goingto talk a little bit about that when we reach thepatho-physiology part of this lecture. but as you can imagine, onceyou destroy the omentum, or the mesentery, it'snot very easy to repair. it's hard to repair glue. we don't transplant one person'somentum into another one.
and so, once you destroythis, and the surgeon has to remove an organ,or take it out of the body to repair it, andthen put it back in, the way that all theseorgans are placed back into your abdominal cavity aregoing to be slightly different. and all the twists and theturns of the small bowel, the large bowel, the exactlocation of these organs are forever changed and thatcan lead to some pathology. and part of the reason thatwe're having these problems
is because we don'thave any great way to reproduce anomentum and a mesentery after those have beenremoved or destroyed. we've now gone throughthe entire gi tract. we started with the mouth. we went down the esophagus. we talked about the stomach. we talked about the smallintestine, the large intestine, and the rectum.
we talked a little bitabout what all those organs do for your body,in that regard. i want to then talk aboutall these accessory muscles, or the organs thathelp aid all these gi organs in what they need to do. we'll talk quite a bit aboutthe liver, the gallbladder, and the pancreas, asthose are the three most important organsthat your body uses. the liver isabsolutely gigantic.
on a lot of skinnypeople, people whose ribs are veryeasy to palpate, you can actuallyfeel your liver. you can feel it often inbabies and in small children. it is in the rightupper quadrant. it's right underneath your ribs. and it is divided into twomain parts, the right lobe and the left lobe. it has a ligament that runsright down the middle dividing
the two. the falciform ligament that'sa very visible ligament. we see it quite a bit whenwe do operations on people. there's the ligamentusterres as well. and then hiding, as youcan see in this picture, directly under the liveris the gallbladder. in fact, they're often whatwe call adhered, or stuck together. they're very close in atomicposition to one another.
the blood supply to theliver is very important. the liver's main jobis detoxification. you only have one liver. you can't livewithout your liver. and so, most of the bloodthrough your body at some point goes through your liver. the artery supplier, theblood that runs to your liver, is the hepatic artery. if you were to haveone pump of your heart,
25 percent of thatblood is ultimately going to go right to the liver. that's how important theliver is to your body. and then after theliver does what it needs to do,the venous output, or where the blood comesout of, is the hepatic vein, going directlyinto the vena cava. the liver does quite a bit. i don't think that we trulyknow everything the liver does.
we find that the predominantthings that it does is number one, isthe regulation of different metabolic features. it helps circulate, breakdown, the carbohydrates, fats, and amino acids, thelife supply of your body. it also helps circulatenew red blood cells. it helps to eliminate thosetoxins from your body. and then it alsoproduces bile that helps break downfat, in particular.
after bile is made itdumps into the gallbladder, which is essentiallyjust a storage device. and then it is excretedinto the duodenum. and as you recall,most of them break down of all of your nutrientsis in your small intestine. and as you remember,the duodenum is the very first partof your small intestine. and so this makes a lot ofsense that the bile that helps break down fats,and all the nutrients
that your livercreates is broken down into the first part ofthe small intestine. it's not broken down intothe esophagus or the stomach, it's broken downinto small intestine. and that predominantlyis because that's where the liver does dumpin all of these nutrients. the gallbladder, as imentioned, is actually attached to the liver. and it will store, and itwill concentrate your bile.
at times, it will overlyconcentrate your bile and form gall stones,which is something i think we're allvery familiar with. and oftentimes, whenyour right upper quadrant hurts after food,the problem is not that something'swrong with you liver, but it's often the gallbladder,because it's directly behind the liver. the gallbladder stores thisbile for when it's used.
when is it needed, well when youhave a particularly fatty meal. bile only breaks down fats,not carbohydrates, only fats. and so when it isneeded, the cystic duct connects the gallbladder to the duodenum. this bile knows itneeds to come out when your body has a high levelof cck, that is to the, go, or the green flag, if youwill, that the bile is needed to be utilized. now the gallbladderreally is not
a critical organ in your body. millions of people live withouttheir gall bladder every day. it is purely a storagedevice for the bile. bile is not madein the gallbladder. and that is acommon test question in the critical care is,where's the bile made? the answer is,actually in the liver. the gallbladder is purelya storage device for it. many people get theirgallbladder removed.
do they still make bile? yes. does the bile stillgo into the duodenum? does it go into the gallbladder? no, the gallbladder isgone at this point in time. and so yes, you can livewithout your gallbladder. it is purely the storage device. moving now from theright upper quadrant to really the middle partof your upper abdomen,
is the pancreas. the pancreas is very deepin your abdominal cavity. it's near your back. it's closer to your spinethan it is to your front. therefore, it's in theretroperitoneal surface. so if your pancreaswere to rupture open, when it were to bebleeding, you would be having aretroperitoneal bleed. it is about six inches long.
most surgeons describe it moreas a gelatinous structure, like jello. you can't justgrab your pancreas and whip it out, becauseit actually somewhat melts. it has a lot ofblood supply to it predominantly through pancreaticand pancreaticonduodenal artery. and as you can see, it'sin very close contact with your stomach,your small intestine,
and your gallbladder. the pancreas creates anawful lot of enzymes. some of them are for digestion. we talked a littlebit about the bile that helps break down fats. the pancreas also has enzymesthat help break down fats. but it also has the enzymes thathelp break down carbohydrates, lipids, and all theseother particular foods that you're eating.
those are called the exocrinefunctions of the pancreas. there's endocrinefunctions of the pancreas. and the one that we're mostcommon with is insulin. if you're a diabetic, youdon't have enough insulin. it's often because your pancreaswas either created wrong, or is malfunctioning. i want to keep in mind thatthese endocrine functions, there are two otherones and we're not going to emphasize this, yourbook doesn't emphasize it,
it's never been critical. but, along with theinsulin is the glucagon, and the somatostatin. those help aid in these exactsame endocrine functions of controlling your glucose,controlling your energy. i want to emphasize, again, thatthese three accessory organs, the food nevergoes in the liver, never goes in the gallbladder,never goes in the pancreas, but they are criticalto aiding the gi tract.
and they're veryclose to one another. they have similarblood supplies. they're physically veryclose to one another. and they work veryclose in hand in getting all these hormones towork with one another. and if one of thesewere to go wrong, if the liver wereto malfunction, it's very common to haveissues with the gallbladder and the pancreas.
similar, when yourpancreas is to malfunction, it's very common to have yourliver start to malfunction as well. they work very hand-in-handin homeostasis with your body. we've talked aboutit couple of times. i'll just make sure that iemphasize it one more time. this is the last slideon the gi particular part of the physiology, whichis the salivary ducts. there's the parotid ducts,the submandibular glands,
and the sublingual glands. they are all thereto help break down the saliva that goesimmediately into your mouth. and there are multiple ofthese that help make saliva. that concludes the partof the gi anatomy review. i did not go throughevery slide in depth. i want the students to make surethat they're reading the book. they're understanding all thedetails of all of these organs. my goal here isreally just to provide
an overview of all these organs. and to provide what i find to bethe critical parts of knowledge for those. we're going to move nowto the urinary system and just touch onthis very briefly. some books de-emphasize thisurinary system, in particular. but i did just want totouch on it very briefly. the urinary system clearlybegins with the kidneys. you have two kidneys, theright and left kidney.
their predominate jobis to filter the blood. it deals a lot with makingsure that your body is not too acidic or basic,detoxifies your body, and then, ultimately,creates urine. the kidneys are small. they're bean shaped organs. out of the kidneycomes the ureter. the ureters dump downinto the bladder, and then the bladderultimately enters
into the urethra, wherethe urine comes out of. the kidneys are very commonin describing three zones. the outermost zone iscalled the renal cortex. the middle zoneis in the medulla. and the innermost iscalled the call pelvis. and they each dodifferent parts. if you had a microscope andyou were looking at the kidney, you would see whatare called nephrons. there's hundreds, ifnot thousands, of them
in the kidney. and these are the littleworking units of the kidney. there are many of them. they are always workinginside your body. and their mainjob is to regulate the acid base of your body. when you zoom in and you were tolook at one of these nephrons, you'll see thatthe blood in urine takes this very winding course.
with the blood supplyvery intimately attached to these twists and turns. and the ultimategoal is to make sure that any toxins are notmissed in the blood. and any nutrients thatmay have accidentally been sucked into the kidneys areactually returned to the blood. there's this very longcheck and balance. in medical school, whenwe study the nephron, we study every millimeterof this system,
and understanding wherein these little nephrons toxins leave the blood, anytoxins our fully absorbed, anything that's accidentallycreated into the urine actually has a chance to go backinto the bloodstream. it's not highly emphasized inthis critical care lectures, and it's actuallyquite complex, and so i'm not going to touch onthat in particular other than to mention just acouple of highlights. and, again, thesenephrons are microscopic.
you can't see them doing this. it's far too small tosee with the naked eye. but there is oneparticular part, you'll see in the lowerpart, where you'll see the descending and theascending limbs, or loops, as we call it, theloop of henley. and in this particular areais where most of the toxins are eliminated in the nephron. the first part of it wouldbe called the arterial,
coming from the glomerulus. and then in a very endthe, distal tubular is where a final checkand balance is done. the capillaries, orthe blood supply to it, is ultimately where the goodrich blood is eliminated. the urine is full of thetoxins at this point in time. after this moving of thenutrients in the toxins this is done, the uretersremove the urine down into the bladder.
i think we're all veryfamiliar with the bladder. when you get somewhere around350 to 400 cc's of urine in your bladder, youhave the urge to urinate. the urine comes out the urethra. and you are able tovoid out your urine. and we're able totest, very easily, when this urinary system fails,or we call it renal failure. and it can be due to anyfour parts of the system when it fails, whether itbe the kidneys, the ureter,
the bladder, or the urethra. on the slide here is anumber of different reasons that you can have acute renalfailure, arf, as we call it. and i won't touch onthese in great detail. they're emphasized in your book. the goal is just torealize that there are a number ofdifferent problems that can go wrong inthe urinary system to cause you to havefailure of the system.
we'll touch briefly hereon the reproductive system. it's not the emphasisof this lecture. however, it's notmentioned anywhere else. and so the instructorswanted me to make sure that i at least mentionthese very briefly, not the emphasis of this lecture. on male side, wehave the testes, which is in the scrotum. they have a numberof protections.
the sperm is ultimately createdin the seminiferous tubulers, or the seminal vesicles,as they're called. when draining into theepididymis, when stimulated, sperm can be placed through thepenis in the ductus deferens area. there are two ejaculatory ducts. they pass through the prostate,which ultimately serves as the exit through the urethra. a priapism is thefirst pathology
that we frequently see. it is extraordinarily painful. it's a prolongederection of the penis. there are two differenttypes, so-called high flow and low flow. neither of which youcan tell as a paramedic. it needs certainblood testing to be able to tell which one is which. it is very common withmedications as well as
sickle cell diseaseto have one of those. the female reproductivesystem is all internal. you can't see it by looking. it involves theovaries, there are two of them, the right and left,that produce eggs once a month. those eggs pass throughboth fallopian tubes, down into the uterus, throughthe cervix, out the vagina. the monthly cycleis not something that is emphasizedhere, it's just
the gross anatomy inthis particular part. the fetus, or the baby when it'smade, is stored in the uterus. when the cervix dilates up toapproximately 10 centimeters, the baby will pass through thecervix and out into the vagina, out into the vulvular area. the cervix is the,so-called, exit pathway between the uterusand the vagina. generally, it iscompletely closed. when a very complexhormone interaction begins,
that's when the cervixstates to dilate, when you're approximately40 weeks pregnant. but the exact mechanism ofthat is not emphasized, or even mentioned in your books. i am not going to emphasizethat, in particular. but i wanted to makesure that, at least, you had a visualof what these two different reproductivesystems look like. that concludes the firstpart of this lecture, which
is the anatomy andphysiology part. i know that's a lot to take in. some of which is veryeasy to understand. a lot of the macroscopicparts are very intuitive, you've seen before,you've learned before, in your paramedic class. a lot of these interactionsof the hormones, the microscopic partsof this is new to you. it is very overwhelming.
i would encourage you to readthis chapter several times over and over again. ask questions of whatyou don't understand. my goal is not to makeyou all anatomy experts with this point, butat least to make sure that you're aware of thesedifferent anatomical parts, particularly aswe talk about what can go wrong witheach of these parts. so that you can understandwhat you're transporting
and can help you anticipatewhat could go wrong when one of theseorgan systems fails. we're going to move on to thesecond half of this lecture, which is really the pathology,or what can go wrong, in these different tracts. we're going to talk quitea bit about gi problems. it's unfortunately,a particular system that can fail quite often. we're going to talkabout not only how
to assess if something's goingwrong with the gi system, but ultimately how to treat. the first thing we're goingto talk about is gi bleeding. i'm sure it's something,as paramedics, you have seen quite a bit. the first part that wetry to do as physicians is trying to figure outwhere are they bleeding from. we divide it into an upper gibleeding and lower gi bleeding. and we really tryto inquire, is it
bleeding from the upperpart, or the lower part? because it's going to make adifference in the medicines we give and howexactly we treat it. and so we ask patients, orif the patients can't talk, we're going to askthe paramedics, were they vomiting blood? making me think it's moreof an upper gi problem. was it black or tarry stools? which would mean thatthe bleeding is probably
in the upper partand by the time it gets all theway to the rectum, that it's alreadyblack and dark. so black stools ortarry stools are more of an upper gi problem. or is it actuallybright red blood that's coming from the rectum? and these are thingsthat are very important. so if a patientcalls you and says,
i just bled in the toilet. as disgusting as it sounds, it'svery helpful to take a look. is it bright red bloodthat's coming out? is it black bloodthat's coming out? is it somewhere in between,almost maroon, or purple blood? that will help us tellif the bleeding is coming from the stomach,the small intestine, or the large intestine. the other part of gibleeding that we like to know
is, is it briskly bleeding? are they activelybleeding right now? is there blood on yoursheets from the transport in? and how long has thisbleeding been going on for? we always talk about abcs. we want to make sure that ifthe patient's bleeding is very brisk, that we'remonitoring their airway, we're checkingtheir vital signs. are they very tachycardic?
is their bloodpressure very low? is it hard to feel pulses? are they very threaded pulses? these are allthings that we need to know when we'remanaging a gi bleed. i wouldn't feed anybody. there should be no water. nothing to eat or drink whenthey're having a gi bleed, because the ultimateproblem is that food may
obstruct our views to seewhere they're bleeding from. and so make sure that thepatient doesn't eat or drink anything when you getin contact with them. gi bleeding can be very fatal. we have a lot ofmedications that can thin your blood that canmake bleeding very worse. it feels like everybodynowadays is either on aspirin, plavix, coumadin. there's these newmedications out there
that can also thin your blood. and so we get veryaggressive with making sure there are twoivs in these patients. we want large-bore ivs. we want to get veryaggressive in making sure that we can stabilizethese patients. even if they're notbriskly bleeding right now, your entire gi tractcould be filled with blood and we just don't know yethow bad this bleeding is.
so i would urgeparamedics, particularly with long transports,for a gi bleed patient to be very aggressive ingetting that second iv in place. and not just settling fora 22-guage iv in the thumb. but really putting inaggressive antecubital ivs in these gibleeding patients. we fluid resuscthese patients, we don't want themto go into shock. we're very aggressive withstarting normal saline boluses
in these patients. when they get tothe emergency room, we're very aggressivein making sure that we're typing andcrossing their blood type. that we are ready to give themmore blood, if at all possible. we would encouragethe paramedics, if you are able to giveblood, that if blood is being hung for a gipatient, i want a critical care paramedic that is capable ofcontinuing that blood in route,
because that is ultimately whatthe patient is going to need. blood loss of anythingover about a liter, a liter and a half,is going to need to start to haveblood replacement. and it is very easy to lose aliter of blood in the gi tract, it's very long. if your stomach isbleeding, by the time it moves all the way throughthe pyloric sphincter through your small intestine,your large intestine,
that entire area canbe filled with blood. and if they have oneurge to defecate, and they lose allthat blood, it's very easy that you'realready needing blood supply. and so that's why weget very aggressive with these gi bleeding. and we want you to reallywatch the human dynamics. the first sign that thebleeding may be severe would be some mild tachycardia.
they may feel alittle weak and dizzy when you stand themto get onto your cot. those are all things we needto know as the physicians, because those are signsthat this gi bleeding could be very extreme. we like to watch them on ekgs. all this blood loss canlead to arrhythmias. the heart can suffer from this. it's not uncommon to actuallysuffer a small heart attack
while having a gi bleedbecause of the blood loss. so i want these patientson the cardiac monitor. i want to know constantlywhat their heart rate is. if you're in routeand the heart rate is going from 70, to 90,to 110, to 130 in a row. let's worry about a patientthat's decompensating. even if they're not activelybleeding onto your cot they may be bleedinginternally into their gi tract. we want to know thingslike, are they incontinent?
are they having a largeamount of diarrhea? are they constipated? have they been vomiting all day? those are very importantfactors that we need to know fromour paramedics. upper gi bleeds are about fourtimes more common than lower. we're seeing a lotof this problem. there probably isn'ta day that goes by that we're not seeingthem in one of our hospitals.
over 100,000 patientsare admitted every year just for an uppergi bleed management. it's very commonfor us to see these. it's very common for themto activate a critical care paramedic. some of them needvery specialized care and we're transferringfrom facility to facility. so this will be a verycommon call in your career that you see.
the death rate isabout 10% in these. that hasn't changed. they can be very lethal. we have seen manypatients code in route to our facilitiesbecause of a gi bleed. that's why i want the ivfluids started immediately, two ivs placed. put them on a cardiac monitorin this point and time. we are seeing all theseblood thinning medications.
the elderly patients,they're just not able to handle thesegi bleeds, and so we do need to watch these veryaggressively in your ambulance in the back. what causes them to bleed? well, a number ofthings can go wrong. the most commonare stomach ulcers. too much acid in thestomach, in the duodenum, even in the ulcer, canwear away to the point
that they startto bleed in them. they can erode. we're going to talk a little bitabout varices, dilated veins. a blood vessel rupturingopen into your esophagus can be rapidly fatal. we're going to talk a littlebit about mallory-weiss tears. as well, as they are quitecommon this day and age. lower gi bleedshappen predominately in the large intestine.
they can happen at the veryend of the small intestine, these are also fatal. somewhere around 10% of thetime, one in 10 will die. the most common isdiverticular disease. and we're going to talk quitea bit about diverticulitis and diverticulosis, because itis a very big problem this day and age. we also see what we callavns, angiodysplasias. we see cancers, and we seecolitis causing gi bleeds
in the lower tract. and we will beable to figure out what is causing these bleeds. however, despitethe cause of them, they are all treatedthe exact same way. two ivs, cardiacmonitor, iv fluids, rapid transport to a hospital. anticipate that these patientscan go south en route. they can go south very quickly.
we have to have a very highconcern for these patients. you will never be faulted forbeing overly aggressive in a gi patient. let's move to anotherpathology that is very common, particularly,in the urban population, in the milwaukee area,peptic ulcer disease. these ulcers are very common. the mucosa of the esophagus, thestomach, the small intestine, can wear away.
it tends to exposeareas of the gi tract. an ulcer is just whatyou could imagine, as the wearing awayof part of the lining. peptic ulcers are in thestomach in and of itself. we see that about 16% of allulcers are in the stomach. somewhere around 30% arein the small intestine. they're also in the esophagus. and so it's verydifficult for us to tell where they are justby talking to the patient.
but they can be very painful. they can causenausea and vomiting. antacid can eventuallytreat these. they are predominatelydiet produced in nature, bad diet can leadto these ulcers. the peptic ulcers can bleed. if you wear awayenough of the lining, that you can actuallyerode a blood vessel, that's very common.
it was much more common inthe past, before antacids, but peptic ulcers canwear away to the point that it wears all the waythrough the stomach, all the way through theintestines, and you actually have stomach, orintestinal, rupture, and that is an emergencycondition, because essentially your stomach acid,or your stool, is draining into yourabdominal cavity, or your peritoneal cavity.
and that is a trueemergency resulting in immediate emergency surgery. much more common beforethe invention of antacids, but it is possible thatyou could have a stomach ulcer, or a peptic ulcer thatgoes so bad that it actually wears all the waythrough your stomach, and that we need totake in and patch out. we don't see thatas much these days as it actually erodes to thepoint that it starts to bleed,
and a peptic ulceractually turns into a gi bleed from erosioninto a vein or an artery. these vessels thatthey wear into can be small, medium, or large. the bigger the vesselthat it erodes into, the bigger the gi bleeding. because these arepredominately upper gi bleeds, you may see thevomiting of the blood, or you may seeblack, tarry stools.
unfortunately,peptic ulcer disease is very common to reoccur. once you get ulcers youare more common to get even more of them. and so a patient with a historyof peptic ulcer disease, who is now having a gi bleed,even if it was remote, it's very common that they haverecurrent peptic ulcer disease. the most common reasonwe see them is people are taking ibuprofen, motrin,aleve, or other nsaids,
very common for wearingaway the stomach. alcohol abuse, stress, verycommon for causing these ulcers to reoccur. we also see this disease calledh. pylori, helicobacter pylori. we know that is nowthe most leading cause of getting these all ulcers. to treat them, we actuallyneed to give patients two, if not three, antibioticsto attempt to rid themselves of this helicobacter infection.
the problem is, that it'soften very difficult to treat. it often goes quite a whileto where this helicobacter can get all over, in theesophagus, in the stomach, in the intestines. it can be a verydifficult thing to treat. and patients will get recurrent,over and over again, infections with this. they'll get bad ulcers. they'll get bad pain.
it'll start to wear away, andthey'll start to bleed with it. and so peptic ulcer diseaseis a very recurrent problem. once you get it,it's very common to have it for a lifetime. stress-related erosivesyndrome is very common. these are stressulcers that we see, very similar topeptic ulcer disease. we know very common that theycan be due to trauma, to burns, to being in an intensive careunit, to being on a ventilator.
all these stressrelated syndromes can certainly leadto stomach ulcers. any patient who is admittedto an icu at most hospitals automatically arestarted on antacids to help preventthis from occurring. because if a patienthas a severe head injury, a severetrauma, and then they get these horribleulcers and they start to get a gibleed, as you can
imagine a body that'salready under duress from a big surgery, abig issue, and now is having stomach ulcersfrom all these problems, is a lot for a body to take on. and so, icu doctors,the trauma doctors, anybody who admits the icu isvery aggressive in starting antacid medicationsand monitoring for ulcers beforethey even begin, because this is often veryfatal in these icu patients.
long-term vent. many of you will go to theselong-term care facilities where patients are onlong-term ventilators. it's very common forthem to get gi bleeding, even if all of their problemsare predominately respiratory. and so have a very low thresholdfor being very aggressive in these long-termvented patients. if they have a gibleed, it's very common that it's an upper gibleed, it's an ulcer,
and these patients canbleed quite heavily. the problem is thatmost of these patients are immunocompromised,their immune system is off focusing ontheir predominant issue that landed them in the icu. and the idea that theirnormal homeostasis, and their normal immunesystem, has been broken down. and they are just more at risk. the problem is that to fixthem takes more energy, more
problems, because theirhomeostasis, and their ability to heal, has already beencompromised because they have another issue going on. this is a very common thingthat we see in the hospital, is these stress-related ulcers. next up, we're going totalk about gastritis. it goes hand-in-hand withpeptic ulcer disease. it is also leading to theerosion, inflammation, of the mucosa.
this is what can easilylead to the peptic ulcers. it is very diet related. it is very commonwith this h. phylori. we can see it when we put acamera down, this redness, this inflammation, that cancertainly occur with it. there are a number ofdifferent kinds of gastritis. we can get it from stress. we can get it fromautoimmune, in particular. we can get it fromthe h. pylori.
they're very common. they're treatedvery aggressively with anti-inflammatorymedications. we can get gastritis whensomebody swallows something that they're not supposed to,bleach very common with it. as you can seefrom the pictures, you can actuallysee the gastritis. it is on the skin level. it is very easy forus to visualize this.
and we want to get veryaggressive with the gastritis before it leads tothe peptic ulcers. we see this in our cancerpatients with their radiation. unfortunately,radiation wears away the first lining of thestomach quite a bit. and even smalldoses of radiation can lead to gastritis. any of our breast cancerpatients, or any other cancer patient who isundergoing radiation,
they're very aggressive withalways starting an antacid right off the batto help prevent this cycle from startingwith the gastritis. varices is this very serious. we see these a coupleof times a year. they're very commonin patients who are alcoholics,who are cirrhotic, who have liver failure. as you can see fromthese pictures,
they're very dilated meatyveins right in the esophagus. we can see patients havethese veins ruptured open, and they can bleed todeath within minutes. it is often a veryviolent bleeding. their bleeding is profound. when they have this,it is very rapid. these patients are usuallyvery sick at baseline. they're not very healthy. they can often be ahomeless population,
a chronic alcoholic,that you can find. if those types of peopleare having a gi bleed, that is a true emergency. it can happen from easy aseating something like a potato chip, or anythingthat's sharp or crunchy. if one of theseveins breaks loose, it can easily be a lifethreatening emergency. about 60% of all patientswith liver disease, and we're going to talka little bit about what
causes liver diseasein a little bit, will develop these varices. they will watch any patientwith liver disease, sometimes every six months,sometimes every year, by putting a cameradown, by looking to see if they have varices. and the doctors are verycautious to tell them, you have varices. if you have any bleedingat all, you call 911,
and you get shippedinto the emergency room, because the mortalityrate is well over 50% at timeswith these bleeds. these patients need to oftenbe intubated very quickly. these patientsneed to be started on blood almost immediately. these are the patientsthat i would make sure that you are takingvery serious, because they're bleeding canbe extraordinarily profound.
any long term liver patienthas increased resistance to their blood flow, and sothe bleeding that can occur, the amount of bloodthat is in those veins, can be quite massive. and the problem is thata lot of these veins have increasedpressure behind them and any breaking loose can makethem bleed quite significantly, and the rupture can bequite large to the point that their plateletscan't clog that up.
many of these patients alsohave a decreased immune system, decreased plateletcount, and can make it very challengingfor this bleeding to stop. they often need eitheremergent endoscopy, which we'll talk about,or emergency surgery as rapidly as possible. along those same lines,not nearly as severe, is what's called amallory-weiss tear, and these are very common.
these are little tears atthe end of the esophagus. they're often caused fromretching, from vomiting. we see this in peoplewho are hung over. they're at homethe next morning, they're vomiting quite a bit. the first couple of vomitsare just regular vomit, and now they'revomiting pure blood. this is somethingthat we often see kind of early in the morningin the emergency rooms.
i was up vomiting, it seemedjust like regular vomit. now doc, all i amis vomiting blood. and what happens is allthat intragastric pressure, from all this retching, endedup causing a tear, or a rip, in the lower partof the esophagus. that rip is called amallory-weiss tear, or mallory-weiss syndrome. these will oftenstop spontaneously. we often need to watchthem in the emergency room.
we give them medicines tostop the retching, antiemetics like zofran, reglan, compazine. we give them some iv fluids. and we end up, ultimately,monitoring them for several hours to makesure this doesn't get worse. but this is very common. we see this in college. we see this is in patientswho are out celebrating, maybe they don't drink as often.
they start retching. they don't feel well. and then they, ultimately, endup having an upper gi bleed. on that note, i wantedto just take a pause, as we end talking aboutthe upper gi bleeding. we're going to move tothe lower gi bleeding. on this idea of, a patienthas an acute abdomen. there's no frank definitionfor what an acute abdomen is, it is a medicalterm for meaning,
that their belly is very tender. i think somethingis very seriously wrong in their abdomen. the most common things thatcan cause a quote unquote acute abdomen are gunshotones, stabbings, a ruptured aorticaneurysms, which would cause severeintra-abdominal bleeding. but if you have a patientwho looks very ill, is sweating, doesn't seemto be talking to you,
seems a little bit altered. you push on their abdomen,and it seems very rigid. it seems like it'sswelling with blood. they just seemed reallymarkedly tender on your exam, you'll often hear a doc saythey have an acute abdomen. now that is not a particulardisease that's causing that. there are multipledifferent diseases that can cause an acute abdomen. but i want you to just befamiliar with that term.
it usually means that someone isvery concerned that something's very wrong in their abdomen. and anytime that there'sa suspicion for any of those problems, itshould be a rapid transport. they should be ona cardiac monitor. they should havetwo ivs in place. they should be large ivs. and they should begetting iv fluids. and they should be veryaggressively monitored in route
by a critical care paramedic. and so if you hear thatterm, acute abdomen, i want your warninglights to go on, and for you to be veryconcerned for that patient. let's move to thelower gi tract now. we've talked alittle bit about what happens when somebodybleeds into the stomach, in the small intestine. we're going to talk alittle bit about lower gi
bleeding at first. because that's a very common,i imagine, almost all of you are transported somebodywith a lower gi bleed. and let's do the bigplayer right up front, which is thediverticular disease. diverticula arevery odd looking. when you look at somebody,they look like little mushrooms that have popped out ofyour colon, in particular. and they're verycommon in america.
they're often dueto dietary issues. and they say up toabout 70% of people will have diverticulardisease at some point in time. when you look at themwith the endoscopy and you go through the gi tract,as you can see in this picture, they look like little holes havebeen punched out in your colon. they're very odd lookingas you pass through, and they're very common. however, having adiverticula, in and of itself,
isn't serious. there are two things cango very wrong with them. they can get inflamed,or they can wear away to the point they wearinto a blood vessel and they can bleed. when they bleed, youhave diverticulosis. and it's very common, you'llhear docs say, -osis bleeds. diverticular bleeds are whenthese holes in your gi tract actually perforate into a bloodvessel, and they can bleed.
sometimes this pain can causequite a bit of inflammation. and when these littlepouches get infected, or have inflammation, wecall it diverticulitis. and they can get a lot of pain. that pain is predominantlyon the left lower quadrant part of their abdomen. sometimes it can be inthe right lower quadrant of their abdomen. obviously, withright lower quadrant,
we also a worry that'swhere the appendix is. and so we often jokethat diverticulitis is left-sided appendicitis. -osis bleeds, -itis haspain, is a very common saying in medical school. diverticular bleedsare very common. they can be very deadlydeadly, particularly depending on how big of a bloodvessel they wear into. it's usually bright redblood, out of your rectum.
it is very uncommonto have vomiting blood from a diverticular bleed. when somebody has this,we get very aggressive in the hospital. we check their blood counts. we get them typed and screened. we get them blood ready,in case it's needed. and we call our gi doctors, asthey need to have an endoscopy. they need to know how manydiverticula there are,
how big is the bleeding,how big is the blood vessel? sometimes we can fix thesediverticular bleeds just with an endoscopy. sometimes, dependingon how many they have, how many timesthey're bleeding, sometimes they need surgery. the way we tell this is thatwe do what's called, endoscopy. we put a camera either downtheir mouth or up their rectum, and we are able tovisualize what is going on.
now this can be a littledifficult at times. if they're bleedingquite heavily, we need to do a lot ofsuction to really see where the bleedingis coming from. if they're bleedingtoo briskly, we won't be able to tell wherethe bleeding is coming from. secondarily, if they justate a big mac on the way in, all that food is going toget in the way of seeing if they have a lot ofstool in their rectum,
we're not going to beable to see the walls. and so, endoscopy is notalways the most ideal study. , however it is the most commonthing that we start with to try to figure it out. the other thing wecan do is we can do what we call a taggedred blood cell scan. and that is, we takesome red blood cells, because it is your blood. we put a nuclear tag on it.
we take out your blood. we put this tag on. and we actually put theblood back into your body. and we take picturesof your gi tract. and we try to figure outwhere those tagged blood cells are coming outand bleeding from. and that will at least give ourgi doctors, and our surgeons, a clue for what part of thegi tract is bleeding from. do those red bloodcells come out
from the stomach, the smallintestine, the large intestine? we also use this ifwe think that they're bleeding in the small intestine. if we do what's called an egd,or we do an endoscopy down the mouth, that scope canonly get to the duodenum. we cannot scope from the mouthand get all the way through the gi tract. similarly, when wedo a colonoscopy, we can only get to the ileum, orthe and of the small intestine.
and so, most of the duodenum,the ileum, and the jejunum, we can't get with endoscopy. and if we think you'rebleeding in that middle part, these tagged redblood cell scans are something that we canuse, because endoscopy won't help us. the other thing that's rarelydone nowadays that we can do is, we can actuallypoke somebody in a leg, or an artery, andwe can snake a little coil up,
and we can actually put it inall these different arteries, and see which onehas broken loose. now that's a lot of contrast,that's a very invasive study. you have to putsomebody to sleep. you have to snake theseangiography coils into all these different arteriesto see what is bleeding, but it is an option thatwe have to do angiography, although we don't see thatdone nowadays in particular. i'll say it once again,because it is so common,
and is so frequent, thatcritical care paramedics see these gi bleeds. i want you to be very aggressivewith abcs, normal saline, giving blood, puttingthem on a cardiac monitor, and taking these very serious. i'll mention a coupleof other things that we do in rare instances. we'll talk about someballoon tamponade. we'll talk about octreotide.
octreotide, balloontamponade, tips procedures, are all used for these varicealbleeds, these cirrhotics who can rupture open veinsanywhere in their gi tract. we'll show you a picture of aballoon, the blakemore tube, in a little bit. octreotide is a medicinethat is given as a drip. it won't help all gi bleeds. it really onlyhelps patients who are having a variceal bleed.
tips is an emergencysurgery where we try to decrease thepressure in these veins. you can't do itwhile somebody is having an active,variceal bleed, but it is a liversurgery that can be done to try todecrease the pressure. and so if you have a patientwho is having a gi bleed, and they tell, aw, i'vehad a tips procedure done, or i've a couple oftips procedures done,
you should be very concernedthat what they're actually having is a variceal bleed. and i'll mention ngtubes now, quite a bit. we're going to showyou very briefly how to put these in laterin this presentation. but if you put an ng tube downthe nose into the stomach, and what's coming upis bright red blood, you can be very concernedthat that bleeding is coming from theesophagus, or the stomach.
if they're vomiting blood,you put an ng tube down, and all that's comingup is stomach acid, yellowish-green stuff,but no blood, then you can assume that thebleeding is probably coming from lower inthe small intestine, or the large intestine, orthe bleeding has stopped. so putting downan ng tube allows us to analyze the contentsof what is coming up, and help us ascertain wherethis bleeding is coming from.
oftentimes, we will giveantacids in these gi bleeds because peptic ulcersare so common for causing these bleeds. and so, you'll very commonly seeus give iv antacid medications, in an attempt totry to help heal the ulcers that have worn away. and so, i put this slide inonly because you will frequently transport somebody whois on an antacid drip. the most common wesee is iv protonics.
and it would be verycommon for you to show up to transport a patienthaving, most likely, an upper gi bleedfrom peptic ulcers, and they'll be gettingiv fluid, possibly blood, and they may be on aprotonics drip as well. and that is becausewe are assuming that this is ultimatelya peptic ulcer bleed. endoscopy is very common. we can see the bleedingquite actively.
the nice thing aboutdoing these endoscopies is not only can we see theulcer, the diverticular bleed, the mallory-weiss, thevarices that are bleeding, but we're also able to fix them. these are done bygi specialists, we don't do them as anemergency physician. there are some surgeonsthat can do this so that they can analyze ifthe bleeding is brisk enough that they actually needto take them to surgery.
but you can often, they'llcome down to the emergency room and do this. and this is usually they goto that we will ultimately do to not only figure out whatthe bleeding is coming from, but they can alsoinject epinephrine. they can try tocoil the bleeding. and endoscopy, inmost situations, are actually able to fix thebleeding within endoscopy. and then, they'll go indays, to weeks, later
and they will watchthe bleeding to make sure it hasn't re-blood, to makesure the ulcers are healing up. and so endoscopyis really the way that we canidentify, ultimately, what this bleeding is. and we can oftenfix the bleeding by injecting medicines orcoils through an endoscopy to try and fix the bleeding. that's a lot about gi bleeding.
let's move to some ofthe other pathology that we can see the gi tract. another very common thingwe see is pancreatitis. somebody has upper abdominalpain, nausea, and vomiting, we think quite a bitabout pancreatitis. those enzymes in the pancreasare very toxic to the body. a lot of the breakdownof your food can occur. and when the pancreasgets inflamed, it really can activateall those enzymes,
and it really goesinto overdrive. an inflamed pancreas can bean extraordinarily painful phenomenon. you'll see patients yelling,screaming, writhing in pain all of that pain is due tothe release of these enzymes that the pancreas produces. and the blood flowto the pancreas, and the fact that the pancreasis in the retroperitoneum, and it's very deep,makes this pain
to be very profoundfor patients. they're often nauseous. they're often vomiting. and that is due to all thesereleases of all these enzymes that normally shouldn't bereleased so aggressively. the course ofpancreatitis can be from very minor tolife threatening. it is often something that willput patients in the icu for. they can get very septic.
they can die. there's a lot ofcomplications that can occur from pancreatitis. when we think of it, weoften think of alcoholics. alcoholics can burnout their pancreas. they can get pancreatitisover, and over, and over again. we see it at timeswhen people go out for bachelor orbachelorette party. they're celebratingtheir birthday.
they drink too much. next thing you know, they havethis horrid upper abdominal pain, nausea, and vomiting. as you can imagine,this can worsen things. now you have pancreatitis. your nauseous, yourvomiting, from pancreatitis, now you get amallory-weiss tear, and so these canreally steamroll into various,serious, gi pathology.
you can get pancreatitisif a duct gets clogged. the most commonreason a duct gets clogged, from a gallstone that gets stuck, not in the gallbladder, butout of the cystic duct can come a stone andit can get stuck. then, all these enzymes thatnormally flow very nicely into your duodenum get stuck. your body tells yourpancreas, hey, we're not seeing any of theenzymes in the gi tract,
so it produces more, andmore, and more enzymes. the next thing you know,they have pancreatitis because they have aclogged gall stone. we can get this quiteoften from medications. high blood pressuremedications are very well known for causing pancreatitis. high cholesterollevels can cause this. there are many different causesof this, not just alcohol. and one of things i docaution paramedics is
when these patientsget these pancreatitis, we're often quick to say, thismust be an alcohol induced pancreatitis, this is somethingthey did to themselves. when in reality, we haveto very cautious, as there are many other causesof pancreatitis, that isn't something thatthey did to induce it. the pain is oftendescribed as constant, boring, radiating to the back. it can start suddenly.
these patients are oftenvery profoundly in pain. they can have nauseous,they can vomit, they can have tachycardia,their belly can be very tender. some of the complications thatcan happen from pancreatitis is that the pancreas,with all these enzymes that are being excreted, canalso wear a way into a blood vessel, and they canhave some bleeding. we call that hemorrhagicpancreatitis. and the most commonsigns we see of that
is called gray turner'sor cullen's sign. which is when youget some bruising, or it looks like bleeding,around the belly button, or on the sides, and that issomething that is quite rare. we don't see, but it's somethingthat we should be looking for, which is any sign that thispancreatitis has converted to a hemorrhagic pancreatitis. the way we check forit in the hospitals, we can check tosee what the level
of these pancreatic enzymes are. now we can't check for everyenzyme in the blood work, and the most common we lookfor is amylase and lipase. we know that the lipase is farmore sensitive, and specific. and so many hospitalswill only check lipase. some hospitals will checkthe amylase and the lipase. but when those areelevated, we get concerns that the patient haspancreatitis because there's too many of theseenzymes in the blood.
we also look at a coupleof other data points, and i mentioned these only sothat you can understand where we're at, to kind of determinehow sick this pancreatitis is. is it a mild pancreatitis? or is it a major pancreatitis? we look to see ifthey're very anemic. are their blood counts low? we look to see if theircalcium is very low. that's very worried.
do they have a whiteblood cell count? do they have a high glucose? are their liver functionsstarting to be affected? i mentioned that the pancreas,the liver, and the gallbladder, often are very intertwined. the more of these other bloodtests that are out of whack, the worse thispancreatitis can be. we can do a cat scan, andwe can see the inflammation around the pancreas.
and that will give us a detail,how much inflammation is there? how much bleeding is going on? does the inflammationlook like it's wearing into alarge blood vessel? and so we will often do catscans on these pancreatitis as a way to alsohelp us understand how significant thepancreatitis is. we can do an mri. we can do an ultrasound.
sometimes those aren'tquite as good as a cat scan, but i just wantedto make you aware that we do image thesepatients to make sure that we know how badtheir pancreatitis is. the other thing that can happenwith pancreatitis that we need to be aware of is that theycan, what's called, form cysts, or pseudo-cysts, whichare just like an abscess, is an infection that occurssecondary to pancreatitis, like an intra-abdominalinfection.
and that's the otherreason we do cat scans, we want to make surethat there's not an infection formingaround pancreatitis, because, at times, it needsvery aggressive antibiotics. so what do you do if youhave a patient that you think has pancreatitis? you keep them, nothing by mouth. you don't want anystimulation that could increase moreof these enzymes.
you want theseenzymes to calm down. so we give them iv fluids. we give them pain medications. we give themanti-nausea medications. we'll put an ng tube down,because we don't even want stomach acid passinginto the duodenum. we want absolutely nothing goinginto their small intestines. we will admit thesepatients into the hospital. if things get very bad, wewill ultimately give them,
what's called iv nutrition,or we call it, tpn, total parenteral nutrition,so that, at least, they can get some nutrients,but that nutrients will go through the iv, itwon't go through the gi tract. it can take oftenseveral days, to weeks, to get pancreatitis better. and so, these will be patients,again, very aggressive, putting an iv in,giving them iv fluids, giving them painmedicines, giving them
anti-vomiting medications. and they will,ultimately, very often, be admitted to ahospital for management. let's move to theother accessory organ that we talk about quitea bit, which is the liver. when the liver fails,we call that hepatitis. and many different thingscan cause hepatitis. we can get it from differentkinds of infections. we can get it from differentkinds of medications.
in the liver, we have alldifferent kinds of cells. some of these deadcells get removed. however, when itgets very inflamed, the ability to detoxifyreally goes down, and a lot of these toxinscan build up quite a bit, and can make the liverworse, and worse. when you have what'scalled, chronic liver failure, or fulminantliver failure, unfortunately thisis an ongoing issue,
and your liver willnever get well. acute liver failure,is something that can often be fixed. the liver is able to fix itself,although there are many times that, unfortunately, itcan't chronically do it. and you will notice thatthere's a couple of precursors that we can tell, and that youcould be asking your patients. if they have rightupper quadrant pain? if they have nausea, vomiting?
if they don't feel like eating? this can be leadingtoward a liver problem. interestingly enough, wenotice it quite a bit, their urine can be very dark. their stools can be very white. they can haveyellowing of their skin or eyes, which we calljaundice, or scleral icterus. they can start toget altered, a lot of these toxins thatthe liver breaks down
can actually goup to your brain, and we see patientsbeing altered. they seem usual. they're not able toanswer your questions. they can actuallyeven be comatose. that can be a sign that aliver problem is ongoing. and we have a number ofdifferent blood tests that we can do to assessthe liver function. the most common thatwe do, are what's
called an alt, and an ast. these are signs thatyou have too much liver enzymes in your bloodstream. they shouldn't be in yourbloodstream to that degree. we can check a whole otherkinds, bilirubin, albumin, ammonia. the goal is not necessarythat the paramedics should know all thesedifferent lab values, but that when you're gettingreports, and the nurse,
or the physician, orwhoever you're transporting tells you that theirliver function is off, that their liverfunction is elevated, that you recognizethat this is ultimately leading to a liverfailure picture. there's not a lot we can do. there are some medicines thatwe don't give by paramedics that we can try tohelp clear the liver, but this is ultimatelysupportive care.
liver transplants can be done. they are rare. they are done at only ahandful of facilities, but that certainly is anoption to help heal the liver. i wanted to includehere just a couple of slides on what would benormal and abnormal lab values. i'm not going to gothrough them one at a time, but i wanted to have thesein here for your reference. again, the same kinds ofthings for pancreatitis.
i'm not going to throughan exhaustive list of all the differentthings that can cause liver failure, as there are multiple. we worry a lot aboutmedications that can do it, a lot of differentinfections, you're all familiar withhepatitis b, hepatitis c, alcohol can certainlyruin your liver. there are a lot ofcongenital problems that can ruin the liver.
the goal is not always toknow what is causing the liver problems, but to recognize thatupper abdominal pain, nausea, vomiting, anorexia,yellowing of the skin, abnormal liverfunction, will need to seek treatment,and ultimately need an aggressiveevaluation for why they are in liver failure. in that regard, i wantedto talk a little bit about some of the devicesthat we, as physicians, use
to help control thegi and gu system. i think we've all seendialysis catheters before. these are used when the kidneysfail, not the gi system, but the gu system. when the kidneysfail, if the patient can get a kidney transplantthat's phenomenal. if they can't get atransplant, what we do is ultimately putthese catheters in. most commonly inan arm or a leg.
it can be in an upperarm, or a lower arm. it is where we connectan artery and a vein together, where we ultimatelywill take the patient's blood out of their system, runit through a machine, and back through. when we put a catheterin, because we're connecting two bloodvessels to each other, it takes severalweeks, to months, before you're able to use that.
when you say that theshunt needs to mature. so before we can do that,we actually put special ivs, either in their neck, theirshoulders, or their chest wall, and there's a number ofdifferent kinds of these that you'll hear about it. we can do dialysis throughthese kinds of catheters, as a paramedic,we shouldn't have much to do with these catheters. if they're infected, theyshould be handled with care.
the bleeding from a catheter,or a shunt in the arm, can be very severe. direct pressure,and rapid transport, is certainly recommendedwith these types of devices. ng tubes is alsosomething that i think paramedics need tobe very familiar with. and many agencies, you canactually put in ng tubes. and they're used for anumber of different reasons. if the intestinesare obstructed,
you can help by decompressingthe air by putting an ng tube in, and then hookingthem up to suction. we can suck out any contents. if somebody overdosed, weneed to take out their pills. we want to suck out thestomach, an ng tube can do that. and then, it can also beused, like we talked about, for pancreatitisor any times you want to rest theintestinal tract. the biggest things for criticalcare that we want to make sure
is that we know howto check placement, that you canconfirm its working, how to put themin, and certainly make sure you don'tpull them out in route. there are otherkinds of ng tubes, most commonly we callthem dobhoff tubes. they are feeding tubes. these are muchsmaller in diameter. and they are not forsucking out blood.
they are not for anysort of diagnostic test. but for people who can't eat. someone who just hadesophagus, stomach surgery. somebody who may be anorexicand having problems eating, we can put these smalltubes in and deliver feeding through this tube, and have itdump right into the stomach. and those can be kept infor several weeks at a time. they're called feedingtubes, or dobhoff tubes. i want to mentionthis, very briefly,
how to put an ng tube in. some of you will dothis in your career. some of you will neverdo this in a career. it's best to have thepatient sitting up. it's very difficultto put them in when a patient is lying flat. you want to, ideally, numb upthe nose, if at all possible, it's not always used. you want to measure by goingfrom the tip of the nose,
you want to go around theear, and then measure it down to the xiphoid process. you want to mark that eitherwith your finger, or a piece of tape, so that you know howlong to stick the tube down. you then lubricate the ng tube,so it goes down very smoothly. and when you put itin the nose, you often want to put itstraight back, and we tell nurses, young doctors,medical students, paramedics, when they're learning howto put these tubes in,
you don't want to aimit up toward the eyes, you don't want to aimit down toward the nose, you want to put it absolutelyparallel to the floor, and go straight back. as it goes straightback, the tube will naturally start tocurl down to the esophagus. we often will have patientsdrink, or sip, water with a straw to helpopen up the esophagus. the sipping of the wateralso helps distract them,
and gives them something to do. so they're not focused at allon putting the ng tube back. you want to advance thetube slowly and firmly. some patients will slightlygag as it goes down. that gagging shouldresolve itself after it hits the stomach. and so i oftenwill tell patients before i put atube down that this will be a littlemiserable for 30 seconds,
or so, until we can getthe tube all the way down. you want to reallywatch their arms. some patients as you're puttingthis down, will reach up and try to grab the tube out. and you want tohave somebody there to potentially watch their arms,so that you don't get the tube down, the patient panics,and rips the tube out. there's a numberof different ways after the tube gets down intothe stomach and into your mark,
that you want to confirm thatthe placement is just so. you can squirt a little bitof air down the ng tube, with your stethoscope youcan listen over the stomach, as you're seeing in themiddle picture here. if you hear a lot of stomachgurgling, and air going in, when you squirtthat air in, you can confirm that it's in placement. you can then suckback a little bit, and if yellowish-greenmaterial comes out,
you can be confirmed that you'regetting stomach contents out. most importantly,in my opinion, is to make sure that thistube is very well secured to their face. the last thing you wantto do is put the patient through getting thisng tube in, only to have it slide out in route. and so tape it to either anendotracheal tube, or the face, or to use a commercialattachment device
is very strongly recommended. there are othertubes that we use longer term, gastrostomytubes, jejunostomy tubes, that can be put in by a gi doctor,a radiologist, or surgeon. these are for morelong term feeding. and they're verycommon in patients either in long term carefacilities, nursing home facilities, patientswith cancer, very frequenttransports with it.
and they are whenthe food will not go through theesophagus, or the mouth, but actually be dumpeddirectly into the stomach, or the small intestines. and they can bevery long, and they can be very short in length. they are the secured into thestomach with a little balloon, as you can see. and then they're often adheredto the skin with a bumper.
they're very frequentlyused in all ages of children,adolescents, and adults. and there something thatyou will see accidentally pulled out everyonce in a while. in the emergency room, we'reable to replace the g tubes as the amount that you haveto put them in are very small. it's a relatively easyprocedure to replace them. however, i do want to makenote some sum of these tubes actually go into the stomach,through the pyloric sphincter,
and actually intothe small intestine. they can be a duodenaltube, or a jejunal tube, these are much morecomplicated to put in, and you can put thesein, predominantly because as we mentioned, mostof the absorption of nutrients is done in the small intestine. these are much longer,these are a little more complicated to pushin, and so these are much morechallenging when they
get pulled out toput them back in. and us, in the emergencyroom, often need a specialist toassist with these. and so, when you get calledto a problem with one of these stomach tubes,the most important question is what kind of tube is this? is it a g tube, that goesinto the gastric part of the stomach? is it a j tube, thatgoes into the jejunum?
sometimes, there are what'scalled a d tube, or one that goes intothe duodenum, that will help us, at thehospital, determine what needs to be replaced. if you can even bringin the pulled out tube, or the malfunctioningtube, or the cut tube, that is equallyas helpful to us. i will make mention that thereare these gj tubes, where they have two ports, onefor the stomach,
and one for the intestine. and what are thoseare often used for is a pill that needsto digest in the stomach can be put in theg part of the tube. food can be put in throughthe j part of the tube, so that it digests, and thoseare becoming much more common. for you folks, ifthey just happen to have one of thesetubes, you want to make sure that they aresecured, that they're not
loose, that they're nicelytaped down and secured. you want to make sure thatthere's no bleeding, infection, or leakage around the tube. and you want to make sure thatthe tops, or the little stop cocks on them, aren't open, orcan become dislodged in route. less common, is whatis called a t tube. and i know this feels like it'salphabet soup, and i apologize. there's g tubes,j tubes, t tubes, it's absolutely exhaustingto keep all these straight.
a t tube is somethingthat we really only see after gallbladder,or liver, surgery, and they're relativelyrare nowadays. and they are namedbecause they're t-shaped. if the bile isspilling out, if there was a complicationduring a surgery to remove a gallbladder, wedon't want that bile spilling into the intra-abdominal cavity. and so, we will put oneof these devices in.
what will be in thattube is actually the bile of the patient. that's usually not permanent. that is just to allowthat area to heal. but it's very important if apatient has a bag coming out of them, that you want tounderstand where that bag is attached to, and whatis the specimen that's coming out of it. so if a patient says, ihave a t tube in place,
you can assume acouple of things. that they likely recently had agallbladder, or liver, surgery, and that what should bedraining out is bile. this can put about a liter intothis big, at one point in time. and they can stay in forwell over a month at a time. and again, you want to make surethat this tube is very secure. you don't want this pullingout, because then the bile will be spilling into theirintra-abdominal cavity. and with well over aliter produced each day,
even in the shorttransport in, you can make thatpatient quite sick. and so you want to make surethat these t bags are well secured, and you want to assesshow much drainage is in them. unfortunately, thereare some patients we can't use a gtube, a j tube, in. either their esophagus, ortheir stomach due to cancer, or a bad blockageneeds to be removed or is unable to be usedat some point in time.
and we need to feed themby alternative techniques. and the most commonis what we call tpn, or totalperipheral nutrition. this is a science that'sstill being perfected. it's really not ideal. doctors would prefernot to use tpn, it's often a last ditchresort of nutrition, and it's essentiallyiv nutrition. it needs a nutritionist,a pharmacist,
to very closely calculatewhat goes into these bags. but it really is a last resort. unfortunately, tpn canlead to pancreatitis. there can, unfortunately,be germs, bacteria, that can get into these bags. it doesn't always do agreat job of nutrition. they often need tobe given continuous, 24/7 to keep thepatient with nutrition. there's often a reasonsomebody's on tpn,
they're usually not thehealthiest people at baseline. and they're veryat risk for either getting thrombosis or embolismsdue to this frequent changing of these bags. and so we really need towatch for complications with our patientswho are on tpn. an air embolism is justwhat it sounds like. it's a little amount of airthat gets into the blood supply, and its most common whenyou're changing these ivs.
tpn is often notgiven in a regular iv. it's often given in what we calla pick line, or a central line, so that tpn can go intoa major blood vessel, not a peripheral one. and so these airembolisms, and thrombosis, or clogs, that can occur canbe very serious in patients. you'll see patientsare transported quite often becausethey're catheter, or the iv that the tpnaccidentally falls out,
may become infected,needs to be changed, and we want to get thosechanged as quickly as possible, because these patientsoften need this tpn, it needs to be given24 hours a day. and that they can;t go quiteoften, long periods of time, without receiving their tpn. and so you will gettransports for this. you want to make sure that thatarea is quite clean, that it's covered, that anybleeding from the area
is dealt with withdirect pressure. i promised you earlier, i wantedto show you these blakemore minnesota tubes, some peoplejust call them minnesota tubes, some people callthem blakemore tubes. as you recall, these aretubes that we put down the mouth when somebody'shaving a variceal bleed. often a patient who hasliver failure, cirrhosis, maybe a chronic alcoholic. we don't put thesedown very often.
i would argue thatthese are very rarely placed in the emergency room. our preference would beto intubate the patient, to have a specialist come inand do endoscopy, a surgeon to do surgery. but if the bleeding is massivewith a variceal, or an upper gi bleed, we can put oneof these tubes down. they can be put downthe nose, we often will just put themdown the mouth.
we inflate these largeballoons, in a goal to apply directpressure to the bleeds. you can't stick yourfinger down their mouth far enough to really pressurethese variceal bleeds, and so this is a way totry to tamponade, or apply direct pressure,to these bleeds. what we do, is we try toput them on a pulley system so that we inflatethem, and then we pull them out of the mouthso that it is nice and taut.
and one of the traditionalways of doing this, is by putting a footballhelmet on the patient, after intubating them, afterputting down an ng tube, after putting downa blakemore tube, and tying the end ofthe blakemore tube to the face guard ofa football helmet. and so, one of the running jokesin the storage rooms of the er is, why do they have a footballhelmet in the storage room? and the answer is,most often, in case
we have one of thesebad variceal bleeds. internally, theylook like this, where you have one of the balloonstry to tamponade right at the esophagealstomach border. one in the esophagus,one in the stomach, in an attempt to try toinflate it as much as possible to slow down the bleeding. these are veryuncomfortable for patients. they are a lastditch heroic effort.
the vast majorityof patients will need to be intubated,and sedated, and put to sleep before oneof these tubes are put in. and these are often patientswho are absolutely critically ill, have vomited alarge amount of blood, are getting ivfluids, and blood. and i wanted to make youaware of these tubes, although my suspicion is noneof you will ever see a blakemore or a minnesotavariceal tube placed.
but i wanted toat least make sure that you are made aware of them. obviously, if anng tube is down, you're going to wantto do lots of suction to get that blood out. i would strongly recommendintubating the patient before transporting, ifthey have one of these in. and then certainly,a big concern, would be that youinflate the balloon
so much that the esophagusgets so dilated, that you're actually pushing on the air way,and that they would actually have problems breathingwith these tubes in. if they have any problemsbreathing at all, you're going to want to tryto deflate the balloons. unfortunately, that may make thebleeding worse, in that regard. you're going towant to make sure that these balloons staytied, and that they don't wiggle loose, in any which way.
and these can be verychallenging transports with these majorbleeding patients. the next bag that i want totalk about, is an ostomy bag. i'm sure most of you arevery familiar with these. these are attached to thesurface of the abdomen after the intestinesget resected. the patient doesn'thave bowel movements. the stool, the fecal material,actually goes into the bag. and because of this, havingbowel movements, or defecation,
is not controlled,because you don't have your rectal sphincters,like you're used to. i talk to paramedics quitea bit about these ostomies, and i tell them it's importantto know where the ostomy is, again, in the gi system. is it a colostomy, where it'sthe large intestine that's connected? is it an ileostomy, wherethe small bowel is collected? and you want to know, becauseit will make a difference for us
what is wrong with the patient. you can empty thesebefore transport, many patients know how toempty these themselves. you want to look at the tube,what's coming out, is it stool? is it blood? has any of theintestines, instead of being at theabdominal wall, has it actually fallen into the bag? is the intestines that youcan see, are they pink?
or have they turnedblack or ischemic at all? is the bag nicely attached? the surgical creation of theostomy is called the stoma. and it can be thesmall intestine it is not painful to touch. it can wiggle, or haveperistalsis with it. like the picture on theleft here, some of it can actually be stickingout of the skin, that doesn't worry us.
sometimes several inchescan come out of the skin, and would need to be placedback in by a surgeon or an er doctor, but you want tolook at that intestine before you transport. does it look pink and normal? or does it lookvery red, beet red, like there's an infection there? does it look black, like theblood supply has been cut off? so you not only want tolook at what is coming out
of the ostomy, but youwant to get your penlight, and you want to try to examinewhat the intestine looks like in the stoma, or ostomy. emptying an ostomypouch is something that you may need to do, ifyou have a long transport. you don't really want tobe doing this in route. the fecal material is often verysmelly, it's very disgusting. the last thing you wantto do is get halfway on a long transport,and realize that you
need to emptythey're ostomy bag. it's much better doing at thehome, at the nursing home, before transport. patients, or staffat the facility, should be able toassist you in doing it. i do want to mention ithere, just in case this ever comes up, but at the veryend, away from the stoma, is often a clamp. you can undo the clampand just use gravity
to help drain out the bag. very often, the samebag can be used. you don't need toreplace the entire bag. all you need to do isre-clamp the ostomy, and then you throw thestool down the toilet. the biggest thing, beingmake sure that your clamp is on securely. that any rollingthat needs to be done has been completed, becausethe last thing you want
is for this to leak the entireway in on the transport. the other very commoncatheter that either you will place in your career,or that you'll see, is what we call a foleycatheter, or urinary catheter. there are two different kinds. there are what we call,straight catheters, which patients, or staffwill put in, drain the urine, and pull right back out. otherwise called a temporary,or in-and-out catheter.
or they're indwelling, orchronic, foley catheters, which i'm sure almost allyou have ever seen before. these can becomequite complicated. they are a frequenter visit for us. they can become clogged,either with an infection, or if they're bleeding, youcan have a little blood clot. you can get utisor an infection. they can leak aroundthe vulva, or the penis. or they can becomedislodged or pulled out.
we really want to make sure thatthe patients don't pull them out. there's a balloon that getsblown up into the bladder, and so pulling on theballoon can either rupture the bladder open,or in a worst case scenario, the patients can teartheir urethra by pulling these balloons out, quite apainful and bleeding event i'll mention, again,how to place these. again, i suspect thatthis is something
that you would rarelydo in your career. but it is something that i wantto make you aware of how to do. it is a sterileprocedure, you do not use regular gloves for these. you want to make sure that youinsert the catheter all the way in, until you seeurine flowing from it. you want to blow up the balloon,that goes into the bladder. and you want to lightlypull back on the catheter until you reach somesmall resistance.
you want to make sure that thecatheter is obviously hooked up to the bag and thatit is flowing nicely. same procedure with the male. in fact, many people argueputting a catheter in a male is much easier than a female. the complication with the maleis that the prostate can often add some resistance. it can make it challenging toget all the way to the bladder. there are specialcatheters that we use,
called a coude catheter,if there were ever any problems gettingpast the prostate. i'll mention these,these are rectal tubes. they are temporary. they are often usedfor patients who are having profound diarrhea,and are in a bed bound state. they are, as youimagine, they are a tube that goes up the rectum, withthe goal to ultimately collect all the diarrheathat is occurring.
and these are certainly justtemporary in nature, nothing that we would keep permanent. if the patient neededsomething permanent, we would move towardsmore of an ostomy bag. rectal tubes do comeout relatively easily. and so you want to makesure, as a critical care paramedic, that they are secure,that they are well in place, any balloons are well inflated. and you want to make surethat any sort of bleeding
is identified. there's a couple of differentsurgical drainage systems that i want to makeyou folks aware of. there's what we calla penrose drain. they look like littlepieces of plastic. they often look like they wouldbe part of a foley catheter that is cut. they can be flat. and they are often sewninto a surgical wound,
either to keep infectionlike pus, or blood, out of the wound. they are open on one side,and so the blood or the pus will often just drainright out from them. therefore, some four-by-fours,or some gauze around them, would be very good idea. they're often stitched in there. they don't come out. we often stitchthose into place.
but i want to makeyou aware of them, so that you know what apenrose drain looks like. a little bit more formalthan a penrose drain, is what we call a jp drain,or a jackson-pratt drain. they're often calledgrenade drains, as well. the interestingthing about these, is these are often tocollect blood, in a surgical. you can place them anyway. they're very commonafter breast surgeries,
neck surgeries,abdominal surgeries. there's often more than one. i've seen up to five or six ofthem placed in big surgeries. the thing about them isthat they are under suction. and so if the grenadeis fully blown up, or looks like a grenade,they need to be opened, and they need to be emptied. but for the suction toactually be activated, you have to squeeze them sothat there are flattened,
and then you close them forthe suction to actually work. that they will notwork, if they're just kept in the grenade fashion. the hemovac drain,looks similar. they're a little more rigid thanthen the jackson-pratt drain. they will be the same thing. they will be held intoplace by a stitch, and they will slowlydrain the blood. they are a littleharder than the usual,
but they are drainedby the same exact way. they must be flattened inorder for the suction to work. they work exactlysimilar to a jp drain, but they are circularinstead of grenade. peritoneal dialysisis very common. we see these patientsoften able to manage at home all by themselves. unlike patients who have afistule in their arm or leg, peritoneal dialysis isdone in the abdomen, often
the lower abdomen. peritoneal dialysisis often done at night while the patient sleeps. they are often able tomanage it all by themselves. unfortunately, because peopledo it all by themselves, these drains can getinfected, and their abdomen can get infected,so-called peritonitis. these patients areactually often smart enough that they can give themselvesiv antibiotics at home,
through the drain, whenthey start to get infected. unfortunately, thesecatheters can fall out, the infections canget quite severe, and they can be calledfor transport in. any newly placed catheteris at risk for bleeding. so please make surethey're properly secure, that the patient, oryourself, doesn't accidentally pull them out whilebeing transferred. and please note, thatthese catheters often
go very deep, even intothe retroperitoneal area, or the pelvic area,of the abdomen. and so you want to be verycautious with removing them, because there could beup to a foot, even more, of the catheter actuallyinto the patient. a general checklistfor all these tubes certainly needs to be consideredby a critical care paramedic. you want to know what's theirpurpose, what fluid is coming out of them, is it properlysecured, has it been emptied,
what are the potentialcomplications that can arise from these tubes. so that you sound knowledgeable,and that you're up to date on what these linesare for these patients when they are takeninto the hospital. that's my last slide for this. this has been a long lecture. there's a lot ofinformation in it. it's exhausting, not only tolecture about, but to hear.
there's a lot of anatomy. there's a lot ofphysiology to take in. i did not read everyslide verbatim. please make sure you're readingthe book referencing the slides to make sure that you areaware of all the information. this is not an exhaustiveanatomy and physiology lecture, nor is it apatho-physiology lecture. there's a lot that can gowrong in the gi and gu tracts. i've tried to cover the mostimportant pathologies that
can occur. i tried to cover what we use, asphysicians, to try to alleviate these pathologies, talking aboutendoscopies, the various tubes that we use, howwe deal with all these different pathologies. please ask questions,share experiences, discuss what you have doneduring these transport to make them aseasy as possible. it takes quite a lot oftime to wrap your head
around this chapter. there's a lot of information,and please make sure that you are revisitingit over, and over again, as one time throughthis material is not going to be sufficient. and please, make sure thatyou're looking at the diagrams, trying to get a visual of howall these different diseases, the anatomy, flows together. make sure that youunderstand when something
goes wrong with the patientthat you are understanding why it is going wrong, and whatare the potential complications that can occur in route. but i'll leave it at that. and make sure thatyou're asking questions, and understand the material. thank you for your time.
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