EMS Hepatic Emergencies - Adults v Pediatric Jaundice

When EMS Providers encounter jaundice in patients, understanding the differences between adult and pediatric cases is essential for accurate assessment and intervention.

1. Etiology of Jaundice:

Adults: Jaundice in adults is often associated with liver disease, such as hepatitis, cirrhosis, or obstruction due to gallstones or tumors. 

Hemolysis (excessive breakdown of red blood cells) or pancreatic issues can also contribute to jaundice.

Pediatrics: In newborns and infants, jaundice is commonly due to physiological immaturity of the liver, resulting in an inability to process bilirubin efficiently. 

This condition is often benign and termed physiologic jaundice. Pathological causes in children can include hemolytic disease, infections, or biliary atresia.

2. Prevalence and Presentation:

Adults: Jaundice in adults is usually less common and more indicative of a potentially severe underlying condition. 

It may present with other signs of systemic illness, such as fever, weight loss, or abdominal pain.

Pediatrics: Jaundice is quite common in neonates, particularly in the first week of life. It may be noticeable in the eyes (scleral icterus) or skin. 

In older children, it is less common and may point to a serious issue.

3. Assessment Differences:

Adults: EMS providers should look for signs of liver dysfunction, such as changes in mental status (e.g., confusion or altered consciousness), abdominal distention, and a history of alcohol use or liver disease. 

Asking about dark urine or pale stools can also help identify underlying liver or biliary issues.

Pediatrics: In infants, checking for jaundice involves examining the skin under natural light. Special attention should be given to whether the jaundice is spreading from the face downward, which indicates increasing bilirubin levels. 

Noting feeding difficulties, lethargy, or poor weight gain is crucial in assessing severity.

4. Immediate Concerns:

Adults: Jaundice in adults often requires further evaluation for signs of liver failure, coagulopathy (e.g., easy bruising or bleeding), or potential sepsis in cases where infection is suspected.

Pediatrics: For neonates, a high bilirubin level (severe hyperbilirubinemia) can be a medical emergency, as it can lead to kernicterus, a type of brain damage. 

Any signs of jaundice persisting beyond two weeks or coupled with symptoms like high-pitched crying or arching of the back should prompt urgent attention.

5. Management Focus:

Adults: Management is often supportive, with emphasis on addressing the underlying condition. Transporting the patient to a facility equipped to diagnose liver issues is key.

Pediatrics: For neonatal jaundice, EMS Providers should ensure the baby is kept warm and hydrated. 

Transport to a pediatric-capable facility is crucial if severe jaundice or any concerning symptoms are noted.

Understanding these distinctions helps EMS Providers make informed decisions and prioritize care when faced with a jaundiced patient, ensuring they tailor their approach according to the patient's age and likely causes.

Further Reading

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

EMS Hepatic Emergencies - Scleral Icterus v Jaundice

For EMS providers, understanding the nuances of scleral icterus and jaundice is essential for accurate assessment and early intervention.

1. Scleral Icterus

Definition: Yellowing of the sclera (whites of the eyes) without concurrent skin yellowing.

Clinical Significance: Often the first visible sign of elevated bilirubin levels and an early indicator of liver dysfunction or hemolysis.

Implications: Identifying scleral icterus can suggest underlying conditions such as hepatitis, cirrhosis, or hemolytic anemia. 

Early detection can prompt the EMS Provider to prioritize further evaluation and expedite transport to the appropriate care facility.

2. Jaundice

Definition: Yellowing of both the skin and the whites of the eyes due to high levels of bilirubin in the blood.

Progression: Jaundice usually follows scleral icterus if the underlying cause continues or worsens.

Causes:

Pre-Hepatic: Conditions causing excessive breakdown of red blood cells (e.g., hemolysis).

Hepatic: Liver conditions impairing bilirubin processing (e.g., hepatitis, cirrhosis).

Post-Hepatic: Obstructions in bile flow (e.g., gallstones, tumors).

Symptoms & Associated Signs: Patients may also have dark urine, pale stools, fatigue, abdominal pain, and pruritus (itching).

Key Points for EMS Providers:

Assessment: Use adequate lighting when checking for scleral icterus or jaundice. Assess the patient’s history for recent liver disease, alcohol use, or risk factors for hemolysis.

Documentation: Record any visible signs and associated symptoms such as abdominal pain, confusion, or changes in consciousness, which could indicate worsening liver function or biliary obstruction.

Critical Situations: Rapidly progressive jaundice with symptoms such as altered mental status or significant abdominal pain may indicate acute liver failure or biliary sepsis, requiring urgent care.

Communication: Inform receiving facilities of the findings, which can be crucial for directing lab tests (e.g., liver function tests) and determining appropriate interventions.

Understanding these conditions allows EMS Providers to recognize early signs of potentially serious illnesses and ensure timely and effective patient management. 

Further Reading

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell

EMS Medical Terminology - Mallory-Weiss Syndrome

Mallory-Weiss Syndrome is a condition characterized by a tear in the mucous membrane of the lower esophagus or upper stomach, typically caused by severe vomiting or retching. It is an example of an eponymous medical term.

Mallory-Weiss Syndrome was first described in 1929 by George Kenneth Mallory and Soma Weiss, two American physicians at Boston City Hospital. They documented the condition in patients who had experienced upper GI bleeding following severe vomiting. 

Their work highlighted the mucosal tears at the gastroesophageal junction and led to the eponymous naming of the syndrome.

Unlike Boerhaave Syndrome, where the esophagus ruptures completely, Mallory-Weiss Syndrome involves only a partial tear of the mucosal layer. 

This condition is associated with upper gastrointestinal (GI) bleeding and is often self-limiting but can occasionally lead to significant hemorrhage.

Causes and Pathophysiology

Triggered by Severe Vomiting: The syndrome often occurs after repeated vomiting or retching episodes, usually related to alcohol intoxication, eating disorders, or acute gastroenteritis.

Other Causes: Coughing, lifting heavy objects, trauma, convulsions, or anything that increases intra-abdominal pressure.

Pathophysiology: The increased pressure from vomiting causes a longitudinal tear at the gastroesophageal junction, leading to bleeding.

Signs and Symptoms

Patients with Mallory-Weiss syndrome may present with:

• Hematemesis: Vomiting of bright red blood or "coffee-ground" emesis. A hallmark symptom.
• Melena: Black, tarry stools due to digested blood.
• Epigastric or Retrosternal Pain: Pain located in the upper abdomen or chest, which may be mistaken for other conditions like myocardial infarction.
• Signs of Hypovolemia: If bleeding is severe, look for signs such as dizziness, hypotension, pallor, and tachycardia.
• History of Severe Vomiting: Often after binge drinking or an illness causing repeated retching.

EMS Recognition and Prehospital Treatment

Patient Assessment Priorities:

• History Taking: Ask about recent vomiting, alcohol use, or illnesses that might have led to repeated retching.

Inquire about the color and amount of vomitus. Bright red blood is more suggestive of active bleeding, while coffee-ground emesis suggests older blood.

Determine any history of GI bleeding or relevant medical conditions (e.g., peptic ulcer disease, cirrhosis).

• Physical Examination: Assess for signs of hypovolemic shock: tachycardia, hypotension, altered mental status, and pallor.

Perform an abdominal exam to check for tenderness, guarding, or distension.

Check for melena, if possible.

• Differential Diagnosis: Always differentiate MWS from other causes of hematemesis or epigastric pain:

• Peptic Ulcer Disease
• Esophageal Varices (often linked to liver disease)
• Gastric Ulcers or Malignancies
• Boerhaave Syndrome

Patient Management Priorities:

• Airway Management: Ensure the airway is clear. Patients actively vomiting blood are at risk of aspiration.

Position the patient to prevent aspiration (e.g., left lateral recumbent position).

• Circulatory Support: Establish IV access and administer IV fluids (normal saline or lactated Ringer’s) if the patient shows signs of shock.

Monitor for worsening hemodynamic instability.

• Minimize Further Trauma: Advise the patient to avoid any further vomiting, coughing, or retching as it can exacerbate the tear.

Keep the patient NPO (nothing by mouth) to prevent further irritation.

Treat Nausea and Vomiting: If protocols allow, consider administering antiemetics (e.g., ondansetron) via IV to prevent further vomiting, which could worsen the tear.

• Oxygen Therapy: Administer oxygen if the patient has signs of hypoxemia or shock.

• Monitor: Continuously monitor vital signs, including heart rate, blood pressure, and mental status.

• Rapid Transport: Rapid transport to a hospital with endoscopy capabilities is crucial, as definitive diagnosis and management (e.g., endoscopic hemostasis) often require specialist care.

Key Considerations for EMS

• Monitor for Signs of Shock: Patients can quickly decompensate, especially if bleeding is significant.

• Avoid Overly Aggressive Fluid Resuscitation: While fluids are necessary to stabilize blood pressure, overloading can increase bleeding.

• Rapid Transport to Definitive Care: Most Mallory-Weiss tears are diagnosed and treated via endoscopy.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

Rawla, P., Devasahayam, J. (2023) Mallory-Weiss Syndrome. StatPearls  Treasure Island, Florida: StatPearls. Accessed September 20, 2024

Turner, A. R., Collier, S. A., & Turner, S. D. (2023) Boerhaave Syndrome. Treasure Island, Florida: StatPearls. Accessed September 14, 2024

EMS Particular Patient Populations - Geriatric Emergencies

EMS providers play a crucial role in managing geriatric emergencies, as the elderly population often presents with unique medical challenges.

Here are some key considerations, common presentations, and possible treatment plans for geriatric emergencies in the prehospital setting:

Key Considerations:

Physiological Changes: Aging leads to physiological changes, such as decreased organ function, altered drug metabolism, and reduced reserve capacity. Be mindful of these changes when assessing and treating elderly patients.

Atypical Presentations: Geriatric patients may present with atypical symptoms, making diagnosis challenging. For example, myocardial infarction may manifest as confusion or weakness rather than classic chest pain.

Polypharmacy: Elderly individuals often take multiple medications, increasing the risk of drug interactions and adverse effects. Obtain an accurate medication history and be alert to potential complications.

Frailty and Fall Risk: Falls are a common geriatric emergency. Assess for frailty, perform fall risk assessments, and address environmental factors that may contribute to falls.

Cognitive Impairment: Cognitive conditions like dementia can complicate patient assessment and communication. Collaborate with family members or caregivers for additional information.

Common Presentations:

Falls: Assess for injuries, especially head injuries and fractures. Consider the possibility of syncope, medication-related issues, or environmental factors contributing to the fall.

Chest Pain and Cardiac Issues: Look beyond classic symptoms; consider fatigue, shortness of breath, or altered mental status. Monitor for signs of heart failure or arrhythmias.

Respiratory Distress: Evaluate for pneumonia, chronic obstructive pulmonary disease (COPD) exacerbation, or heart failure. Be aware of potential complications related to decreased respiratory reserve.

Altered Mental Status: Determine the cause, considering infectious, metabolic, or neurological etiologies. Hypoglycemia, infections, and medication side effects are common contributors.

Abdominal Pain: Assess for gastrointestinal issues, urinary tract infections, or other abdominal pathologies. Consider the possibility of atypical presentations.

Common Treatment Plans:

Airway Management: Be prepared for airway management challenges, especially if the patient has altered anatomy or decreased respiratory reserve.

Pain Management: Manage pain appropriately, considering the potential for undertreatment due to fears of side effects or drug interactions.

Medication Administration: Administer medications cautiously, considering altered pharmacokinetics and potential drug interactions. Be aware of medications that may cause or exacerbate falls.

Fluid Management: Monitor fluid status carefully, especially in patients with heart failure. Adjust fluid administration based on the patient's hemodynamic status.

Transport to Appropriate Facilities: Consider transporting geriatric patients to facilities with expertise in the care of the elderly, as they may have specialized resources and staff.

Collaboration with Family and Caregivers: Communicate effectively with family members or caregivers to gather crucial information and involve them in the decision-making process.

Prevention Strategies: Provide education on fall prevention, medication management, and strategies to maintain overall health and well-being.

Conclusion:

EMS providers should approach geriatric emergencies with a comprehensive understanding of the unique challenges associated with the elderly population.

By considering the physiological changes, atypical presentations, and specific needs of geriatric patients, EMS providers can deliver more effective and tailored prehospital care.

Ongoing education and training in geriatric emergency medicine are essential for improving outcomes in this vulnerable population.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell