Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Wilderness and Rescue Medicine

Constipation The usual cause is dehydration. The large intestine absorbs fluid from feces, producing a hard stool that is difficult to excrete. The patient reports full- ness, cramping, and intermittent pain in the lower abdomen and pelvis. Constipation becomes bothersome when the patient feels uncomfortable; it becomes a prob- lem when the rest of the body begins to suffer. Constipation becomes an emergency when asso- ciated with serious abdominal pain. The four most common causes of constipation are dehydration, lack of opportunity for bowel movement, a low- fiber diet, or a bowel obstruction. Treatment of Constipation Hydration is the best initial treatment and often relieves the problem. The next step is the use a stool softener and mild stimulant such as Senna (Senokot) or docusate sodium (Colace). Mineral oil taken orally as an intestinal lubricant can reduce friction and allow stool to move. These treatments are very mild and generally safe. Laxatives such as bisacodyl (Dulcolax) given orally or by suppository stimulate the bowel to contract. This is most effective and least painful after hydration and the administration of a stool softener. Laxatives can be dangerous if the patient has a bowel obstruction. Do not use these drugs in the presence of serious abdominal pain.

Diarrhea

General Principles

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Serious: • Associated with serious abdominal or chest pain • Fluid losses exceed intake

• Persistent fever • Bloody diarrhea • Signs of shock

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Treatment of Diarrhea Mild diarrhea can be treated effectively with bismuth subsalicylate (Pepto-Bismol) or simi- lar over-the-counter preparations. Opioid anti- spasmodic drugs, such as loperamide, inhibit intestinal motility, allowing more time for the absorption of fluid. Beware of using loperamide if the cause of the diarrhea is bacterial infection, evidenced by blood or pus in the stool or the pres- ence of fever. Obstructing drainage can increase the severity of the infection. Replace fluid losses with oral or intravenous (IV) electrolyte solutions. Time will usually correct the situation, but if the problem persists longer than a week, medical advice should be sought. If signs of volume shock are present, evacuation should be urgent if fluids cannot be replaced quickly in the field. During evacuation, oral fluids should be given as quickly as the patient can tolerate.

Constipation

General Principles

Diarrhea

General Principles

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Anticipate: • Obstruction to infection • Serious abdominal pain Treatment: • Hydration • Stool softeners; Colace, Senokot • Laxatives*; Dulcolax, Ex-lax • Enema*

Anticipate: • Volume shock from dehydration Treatment:

• Fluid and easily absorbed food • Preserve body core temperature • Loperamide (Imodium) if no red flags (4 mg x 1 dose, then 2 mg after each loose stool) • Bismuth subsalicylate (Pepto-Bismol) • Antibiotics for traveler’s diarrhea (azithromycin, ciprofloxacin)

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* Not in the presence of serious abdominal pain.

©2018WMA

©2018WMA

An enema is viewed by most people as the treat- ment of last resort. Warm water is instilled into the rectum by gravity feed. A small amount may