CEN, GI emergencies

higher percentage of body water

immature kidney function = decreased ability to concentrate and dilute urine

kidneys are more mobile - not well protected by fat

more anterior and not as well protected by ribs as in adults

vague s/s when they have significant abd injury

25-40%

inferior to diaphragm with 80-85% L of midline

histamine, acetylcholine, gastrin

denatures protein and break intermolecular bonds

1. storage of bile, passageway for bile, bile release

secretion of pancreatic juice for digestion of carbs, proteins, and fats

- secreation of bicarb to neutralize chyme

 - secretion of insulin and glucagon

mucoprotein necessary for intestinal absorption of vit B12 in ileum

deficiency of B12 causes pernicious anemia

2-6 hours after ingestion

responsible for phagocytosis, line the sinusoids, destroy old or defective RBC and remove bacteria and foreign particles from the blood

• liver
• gallbladder

• bilirubin
• HgB

• alpha - glucagon
• beta - insulin
• delta - somatostatin

food in small intestine

vagus nerve and parasympathetic NS

hormonal:  secretin and cholecystokinin

hepatic artery and vein

portal

inferior vena cava

increases activity of GI tract - innervated via vagus nerve

feeding center of hypothalamus

sateity center also in hypothalamus

4

4

9

bacteria in lg intestine

alkaline

metabolic acidosis, hypokalemia, hyponatremia, hypovolemia

• 1. epigastric/L of midline pain
• 2. "indigestion"
• 3. NV
• 4. may have hematemesis

• 1. epigastric/RUQ burning/gnawing pain
• 2. hematemesis/melena

• 1. epigastric/LUQ
• 2. may radiate to back, flanks, or L shoulder
• 3. boring/worsened by laying down
• 4 NV
• 5. mild fever
• 6. Cullen sign - bluish discoloration at umbilicus indicatioing intraperitoneal bleeding
• 7. Grey turner sign- bluish discoloration at flanks indicating retroperitoneal bleeding

• 1. epigastric/RUQ
• 2. referred to below R scapula
• 3. Murphy sign:  pain with deep breath while nurse palpates under R costal margin
• 4. cramping
• 5. NV
• 6. tenderness RUQ

• 1. epigastric or periumbilical pain later lecalized to RLQ
• 2. McBurney sign:  pain with palpation at McBurney point
• 3. Rovsin sign:  pain in RLQ with palpation of LLQ indicates peritoneal irritation
• 4. dull to sharp
• 5. anorexia, NVD
• 6. fever
• 7. leukocytosis
• 8. rebound tenderness indicates peritoneal irritation

• 1. epigastric or umbilical
• 2. spastic to dull
• 3. change in bowel habits
• 4. melena or hematchezia
• 5. hyperactive to hypoactive bowel sounds

periotonitis

pancreatitis

seen with bilirubin >3.0

liver disease, biliary obstruction excessive hemolysis

due infiltration of abd wall with blood

cchymosis to flanks indicative of retroperitoneal bleeding

pancreas, duodenum, kidneys, vena cava, aorta

ecchymosis around umbilicus indicative of intraperitoneal bleeding:  liver spleen

caused by B12 deficiency, liver disease, and pregnancy

cirrhosis, intra-abd malignancy, or R ventricular failure

end-stage heart failure or renal failure

intestinal obstruction

pulsatile swelling in the epigastrium suggests abd aortic aneurysm or an apigastric solid tumor overlying aorta

early mechanical small intestine obstruction

early mechanical large intestinal obstruction

if bruit noted check circulation to extremites:  if decreased BF is noted, aneurysm should be suspected

scratchy sound heard over inflamed spleen or neoplastic liver

infectious, neoplastic, or inflammatory process in peritoneal cavity

acute perforation of viscus with spillage of GI contents into peritoneal cavity

REFRAIN FROM ADDITIONAL ABD PALPATION AS THIS MAY BE AN ABD AORTIC ANEURYSM

• 1. polycystic kidneys
• 2. after renal transplant
• 3. malignant tumor - may cause seeding
• 4. recent surgery

peritoneal irritation

when significantly enlarged:  injury, leukemia, mononucleosis, portal HTN

elevated in dehydration

decreased in vomiting, diarrhea, or intestinal obstruction

decreases

• normal 3-4.5
• elefated in intestinal obstruction
• decreased in malnutrition or malabsorption sysndromes

diarrhea

elevated

0.3-1.3

6-8

3.5 - 5

150-200

40-150

cirrhosis, RA, biliary obstruction, liver tumor, hyperparathyroidism

56-190

• any pancreatic issues
• perforated peptic ulcer
• mesenteric thrombosis
• ectopic pregnancy
• renal failure
• mumps

1.5

5-36

• any liver issues
• cholestasisinfectious mononucleosis

15-45

liver issues, acute pancreatitis, dkeletal muscle disease or trauma

90-200

liver issues, hemolytic anemia, pancreatitis, muscular dystrophy, pulmonary infarction, MI, pernidious anemia, renal disease

15-20

may be abnormal

• 0.3-2.1
• lower in females

• increased in hepatocellular disease
• decreased in complete biliary obstruction

Dx biliary stones, ductal stricture, ductal compression, neoplasms of the pancreas and biliary system

contraindicated if pt is uncooperative or if bilirubin is >3.5

• 1. bowel prep with gastric irrigation and cathartics required before lower Gi
• 2. NPO 4 to 8 hrs prior to study
• 3. keep NPO until gag reflex returns if sedation used
• 4. monitor for indications of perforation hemorrhage

extremely rare and mainly in preemies

• most common in males age 10-30
• 2. foreign bodies
• 3. tumor of cecumor appendix
• excessive lymphoid tissue growth
• 5. recent barium enema

hardened accumulated feces

fussy and feeding poorly

diarrhea and difficulty ambulating

appendicitis - palpate LLQ cuases pain in RLQ

2/3 way from umbilicus to anterior superior iliac spine

appendicitis - pain on extension of R thigh with patient on L side

flex knees with pilows to help relax abd muscles

perforation, sepsis, preterm labor in pregnanacy

acute longitudinal tear of the esophagus caused by forceful retchin

spontaneous tear or rupturing of esophagus associated with vomiting

• 1. gastritis or peptic ulcer - genentic, substance abuse, diet, drugs/therapies:  NSAIDs, corticosteroids, drugs that increase acid production:  coffee, nicotine, hormones:  estrogen
• 2. high physiologic stress situation:  COPD, recent Sx, MI
• 3. Ingestion of strong acids or alkalis:
• 4. esophageal varices
• 5. cirrhoisis
• 6. hepatitis
• 7. chronic R ventricular failure
• 8. Mallory-Weiss tear or Boerhaave syndrome:  forceful vomiting

fibrotic liver changes & resistance to normal venous drainage of liver to portabl vein -> portal htn -> pressure to collateral circulation -> dilation of submucosal veins of the distal esophagus & stomach -> predisposition to bleed

• 1. increased intra-a bd pressure/valsalva maneuver
• 2. mechanical trauma:  poorly chewed foods, insertion NG tube
• 3. chemical trauma:  reflux
• 4. coagulopathies

• gastic pain usually occurs 30 min to 1 hr after meals
• duodenal pain usually occurs at night and 2-3 h after meals

1. slows blood loss by contricting arteries and decreasing portabl venous pressure

• 1. bradycardia
• 2. htn
• 3. water retention:  hyponatremia
• 4. chest pain
• 5. dysrhythmias
• 6. abd cramping and pain
• 7. oliguria

htn can increase bleeding - monitor BP

• vasporessin
• octreotide acetate/sandostatin

reduces splanchnic BF, gastric acid secretion, GI mobility, and pacreatic exocrine function

• 1. sclerosing agent injected into varix and surrounding tissue - scar tissue
• 2. esophageal variceal ligation:  rubber bands placed on target vessels
• 3. stop bleeding through measures that lower venous pressure:  beta blockers, placement of tube for balloon tamponade

• allows visulization during endoscopy
• removes blood from GI tract to prevent digestion of protein causeing elevation of ammonia

• 2 wk therapy with 3 drugs
• 1. bismuth subsalicylate/pepto bismol or proton pump inhibitor AND
• 2. metronidazole/flagyl and tetracycline OR
• 3. clarithromycin/biaxin and amoxicillin

elevated ammonia -> toxic to the brain

reflux that occurs more than 2X per wk

neurogenic impairment of esophageal motility that affects lower 2/3 of the esophagus

flux of acidic contents into esophagus

• burning or discomfort up and down epigastric area
• 1. worse bending over
• 2 radiate to back, chest, neck
• 3. worse 30 min after eating
• 4. may feel like something stuck in upper chest area
• 5. may c/o dyspnea and salivation

• 1. upperGI/barium swallow:  eval motility and ID reflux
• 2. endoscopy:  condition of esophageal and gastric mucosa
• 3. esophageal manomotrey:  measure function of LES

• 1. F, especially multiparous
• 2. usually >40 years
• 3. oral contraceptives/estrogen hormone replacment
• 4. sedentary
• 5. obesity
• 6. familial tendency
• 7. tumor

• 1. infection:  most common E coli
• 2. cholesterol synthesis abnormalities
• 3. pregnancy
• 4. immobility

any mechanism that alters body's ability to keep cholesterol, bile salts, and Ca in solution

• typical s/s and
• 1. jaundice
• 2. Murphy sign:  inability to take deep breath while abd is palpated beneath R colstal arch below hepatic margin
• 3. clay-colored stools, steatorrhea, dark amber urine if bile flow is obstructed

HIDA scan

• 1. herpes simplex and herpes zoster
• 2. epstein-barr
• 3. adenovirus
• 4. cytomegaloviurs
• 5. hepatitis, hepatotoxic drugs/toxins
• 6. ischemia and MODS
• 7. trauma
• 8. Reye syndrome
• 9. acute fatty liver of pregnancy
• 10. acute hepatic vein occlusion

occurs in children recovering from a virus

associated with aspirin use

liver cells fail to regenerate causing necrosis

• Liver cannont:
• 1. produce products:  proteins, carbs, bile - fat metabolism is impaired
• 2. make plasma proteins and inactivate hormones:  aldosterone, estrogen

- increased levels of aldosterone cause Na and water retention and excretion of K -> hypocalcemia, hypocalemia, etc

- cumulative drug effects frequently occur

- increased susceptibility to infection and sepsis

• 1. inability to store viitamins and manufacture clotting factor
• 2. fat-soluable vitamin ADEK deficincies may occur
• 3. clotting abnormalities occdur

hepatic encephalopathy r/t neurotixics such as ammonia accumlating

may be done to r/o neurologic cause of altered LOC

shows increase in glutamine

N-acetylcysteine/mucomyst

must be admin within 24 h of acetaminophen ingestions

multiple diverticular that are not inflamed

infection of the diverticula

true congenital diverticulum present at birth

• 1. mild tachycardia & htn
• 2. NV
• 3. diaphoresis
• 4. pruritis
• 5. visual disturbances
• 6. time disoreientation
• 7. tremors
• 8. anxiety, agitation
• 9. sleep disturbances

• Late:
• 1. marked tachycardia and hypertension
• 2. hyperthermia
• 3. dehydration
• 4. delirium
• 5. delusion
• 6. hallucinations
• 7. tonic-clonic seizures

• 1. lowfiber/highfat diet
• 2. increases with age
• 3. chronic constipation
• 4. previous spisodes of diverticulitis
• 5. hereditary factors

• 1. acute pain, constant, aching/cramping
• 2. may be LLQ or generalized
• 3. change in bowel habits
• 4. anorexia
• 5. low-grade temp
• 6. abd tenderness LLQ
• 7. palpable mass may be present
• 8. bowel sounds:  decreased or nrmal
• 9. peritoneal irritation
• 10. older patients:  mayu be afebrile with normal WBC and no abd tenderness

barium enema and colonoscopy - rarely done emergently - may cause perforation if done during acute episode

inflammation of the mucosal lining of the stomach and intestine

side-lying

initially NPO, fluids when vomiting stops

clear liquids X24 h then bland foods after 24 h (BRAT) bananas rice applesauce toast/tea

avoid carbonated, caffecinated, and high-sugar drinks

part of an internal organ bulges through and weakened area of a muscle

surgical emergency - cutting off blood supply and will result in necrosis if not relieved

hypoactive

• NPO
• sedation if in ED
• possible Sx

mechanical bowel obstruction caused when a loop of bowel telescopes within itself

complete twisting of a loop of intestine around its mesenteric attachment site

classic red "currant jelly" stool

caused by venous engorgement and ischemia of intestinal mucosa bleeding -> mixed mucus and blood

• 1. cries inconsolably
• 2. crampy abd pain
• 3. intermittent episodes of pain may be only s/s in older children
• 4. lethargy
• 5. facial grimacing, legs drawn up to chest
• 6. vomiting
• 7. sausage-shaped abd mass
• 8. red currant jelly stools

• 1.crying incosolably
• 2. absence of stools
• 3. failure to thrive
• 4. severe pain and bloating
• 5. abd distention
• 5. perstaltic waves may be visible
• 5. emesis may be bile in color
• 6. clinical indications of shock
• 7. bloody diarrhea

• NPO
• for intusssception:
• 1. hydrostatic reduction:   enema using barium or water-soluble contratst
• 2. surgica correction

• volvulus:
• 1. Sx - emergent if symptomatic
• 2. sigmoid volvulus:  endoscopic derotation of sigmoid colon may be done

• Neonates:  Dx within for 12 wks of life - occurs 4 X as often in males
• 1 erythromycin use in first 2 wks of life
• 2. turner syndrome - F with one of X chromosomes is defective or absent in some or all cells
• 3. phenylketonuria - inability of body to utilize phenylalanine (amino acid)
• 4. trisomy 18 - extra 18th chromosome

Adults:  edema from PUD and scarring from PUD or carcinoma

stomach will become markedly dilated in response to near-complete obstruction

• 1. no vomiting at birth - gradual onset
• 2. fussy, hungry after feeding
• 3. infrquent, hard stools
• 4. weight loss
• 5. decreased urination

Adults:  abd bloating, vomiting

• All: 
• 1. tachycardia, hypotension
• 2. projectile vomiting
• 3. jaundice
• 5. may have visible peristalsis noticeable prior to emesis
• 6. palpable epigstric/RUQ mass hard and mobile:  olive shape
• 7. bowel sounds hypoactive
• 8. succussion splash:  splashing sound audible when pt is rocked from side to side
• 9.  clinical s/s of dehydration
• 10. restlessness/lethargy

• 1. electroltyes: hypokalemia, hypochloremia
• 2. bilirubin elevated
• 3. ABG metabolic alkalosis
• 4. flat plate of abd:  air in stomac
• 5. ultrasound:  dilated stomach and pyloric thickeingin
• 6. upper GI:  gastric retention at 3-4 h - one or 2 thin bariu tracts and nonprogression of peristaltic wave from stomach to duodenum

antispasmodics:  atropine may be used to shorten pyloric canal and decrease thickening over several weeks

NPO

NG to decompress dilated stomach

women more than men

rule out other problems

pelvic exam - r/t ovarian tumors and cysts or endometriosis - mimic ibs

chronic inflammation of GI tract

ulcerative colitis, crohn's

segmental areas of entire GI tract

mouth to anus - most common is ileius

colon and rectum

• Crohn's                        Ulcerative colitis
• anywhere in GI              only colon and rectum
• R side of colon               L side of colon
• bleeding rare               gross rectal bleeding
• abscess/fistulas            no fistulas
• perianal lesion maybe   no perianal lesion
• patchy ulcerations         inflammation
• separate from health     uniform/diffuse
• areas
• sarcoidlike granulomas    no sarcoid
•                                      granulomas

• abd pain
• UC - bloody diarrhea 15-20Xperday with or without pus
• Crohn's:  diarrhea 3-5 Xperday - no blood but may have steatorrhea (fat in stool)
• abd tenderness:  R side crohn's, L side UC
• dehydration
• infection/sepsis
• acute abd if perforation occurs

corticosteroids, ABX, antipyretics

• 1. anemia
• 2. perforation
• 3. toxic megacolon - dilation of colon >5cm
• 4. abscess
• 5. sepsis

fluid leak into peritoneal cavity

progressive and irreversible destruction of the pancreas - necrosis of pancreas erodes into tissues and blood vessels -> hemorrhage

• 1. obstruction of common bile duct
• 2. alcoholism
• 3. hypertriglyceridemia
• 4. meds:  thiazides, estrogen, steroids, abx, opiates
• 5. peptic ulcer with perforation
• 6. cancer, especially of pancreas or lung
• 7. injury to pancreas
• 8. pregnancy - 34d trimester, ectopic
• 9. ovarian cyst
• 10. infections

• activation of pancreatic enzymes & pancreatic cell injury -> auto digestion of pancreas ->
• edema, necrosis, hemorrhage

inflammation causes necrosis of fat in pancreas and exudates with high albumin content -> hypoalbuminemia & ascites

fat necrosis -> precipitation of calcium -> hypocalcemia

may have sepsis and/or SIRS r/t necrotic toxins

• 1. recent heavy meal or drinking binge
• 2.epigastric pain:  aggravated by food, alcohol, walking, supine position
• 3. anorexia
• 4. dyspepsia, flatulence
• 5. NV
• 6. dyspnea
• 7. weight loss
• 8. weakness
• 9. tachycardia, hypotension
• 10. fever - usually low grade
• 11. abd distention tenderness guarding
• 12. grey turner sign:  ecchymosis over flank area
• 13. Cullen sign- ecchymosis at umbilicas
• 14. Chvostek sign- unilateral spasm of facial muscles when cheek tapped
• 15. Trousseau sign:  carpal spasm occurs when upper arm compressed with tourniquet or BP cuff
• 15. ascites
• 16. rebound tenderness
• 17. epigasric mass may be palpable
• 18. steatorrhea

decreased potassium, calcium, and magnesium

increased if endocrine function of pancreas is compromised

bilateral or only L pleural effusion, elevated L hemidiaphragm, L atelectasis

functional obstruction caused by loss of peristalsis

decrease BF to vessels that supply bowel  -> prolonged ischemia increases permeability of bowel and edema of intestinal wall -> normal bowel flora may penetrate bowel wall -> peritonitis

necrosis and perforation may occur

gas and fluids proximal to obstructions unable to move -> shifting of fluids from bowel into peritoneal cavity -> dehydration, hypovolemia, shock

• 1. anorexia
• 2. abd pain/distention/tenderness with perforation & peritoneal irritation
• 3. weight loss
• 4. urgency for BM
• 5. tachycardia, tachypnea, hypotension
• 6. hypoactive or absent bowel sounds
• 7. vomiting - may be bloody
• 8. urgent diarrhea - may be bloody
• 9. dehydration s/s
• 10. elevated temp

clear gastric fluid:  obstruction at pyloris

gastric contents and bile:  proximal small intestine, paralytic ileus

brown fecal:  obstruction in distal small intestine

change in bowel habits - thin, ribbonlike preogressing to constipation

Na high/low/normal, decreased potassium and chloride

• 1. tachycardia, tachypnea
• 2. fever
• 3. vomiting
• 4. abd tenderness, rigid/boardlike abd, guarding, rebound tenderness
• 5. diminished/absent bowel sounds

may show point of obstruction

endoscopy

reglan/metoclopramide

vascular obstruction, complete bowel obstruction, and perforations

blast effect on surrounding tissues

liver most often affected by penetrating trauma

spleen most often affected by blunt trauma , pancreas frequently injured with spleen

Kehr sign - L shoulder pain indicative of splenic rupture caused by blood below diaphragm tht irritates phrenic nerve

Rovsing sign- RLQ pain with palpation of LLQ indicates peritoneal irritation

seatbelt sign - ecchymosis across lower abd caused by seatbelt

hematoma, entrance/exit wounds,

Grey Turner or Cullen sign

Coopernail sign - ecchymosis of scrotum or labia - indicates fractured pelvis

• rigid abd - may indicate abd bleeding
• - Balance sign - resonance over R flank with pt on L side - indicates ruptured spleen
• - hypoperfusion or shock s/s

crush injury tor muscle breakdown occurring

r/o concurrenty thoracic injury

ID free air under diaphragm

free air in peritoneum

fluid/blood in pericardium, abd, or pelvis


visualization of spleen and liver

• 1. seatbelt sign
• 2. hematoma or ecchymosis in RUQ
• 3. lower R rib Fx
• 4. blunt/penetrating trauma
• 5. accel/decal MVA
• 6. presence of other abd injuries
• 7. RUQ pain/guarding - worse during inhalation
• 8. referred pain to R shoulder
• 9. increased abd girth/rigidity
• 10. tachycardia, hypotension
• 11. increased WBC
• 12. elevated liver enzymes
• 13. decreased Hgb and Hct
• 14. abnormal clotting studies
• 15. CXR - may show elevated diaphragm on R side
• 16. injury evident on FAST

• 1. seatbelt sign
• 2. local sign of injury LUQ
• 3. L pneumothorax
• 4. blunt or penetrating trauma to abd
• 5. accel/decal MVA
• 6. presence of other abd injuries
• 7. LUQ pain, tenderness, and guarding - increased with inspiration
• 8. increased abd girth and rigidity
• 9. Keher sign
• 10. balance sign
• 1. tachycardia, hypotension
• 12. decreased Hgb and Hct
• 13. injury evident on FAST

• 1. seatbelt sign
• 2. other abd injuries
• 3. MVC
• 4. blunt or penetrating injury to abd
• 5. epigastric, back, or shoulder pain
• 6. abd tenderness and guarding
• 7. increased abd girth
• 8. decreased bowel sounds
• 9. electrolyte imbalances - hyperglycemia or hypoglycemia
• 10. elevated serum lipase
• 11. elevated WBC
• 12.

• 1. penetratring trauma to abd
• 2. presence of other abd injuries
• 3. epiastric or LUQ pain and tenderness
• 4. hematemesis or bloody aspirate from NG tube
• 5. rebound tenderness
• 6. tachycardia, hypotension
• 7. elevated WBC
• 8. abd flat plate - free air

• 1. seatbelt sign
• 2. presence of other abd injuries
• 3. blunt trauma with decal
• 4. penetrating injury
• 5. local sign of injury
• 6. NV
• 7. abd pain, may be referred or rebound
• 8. absent bowel sounds
• 9. elevated WBC
• 10. abd flat plate - free air
• 11. positive fecal occult blood test

• 1. other abd injuries
• 2. blunt or penetrating abd injury
• 3. sudden decal in MVC or fall
• 4. abd distention and guarding
• 5. increased abd girth and rigidity
• 6. diminished femoral pulses if aorta or iliac injury
• 7. mottled lower extremities
• 8. Cullen sign
• 9. decreased Hgb and Hct
• 10. tachycardia, hypotension, shock

knees flexed while in supine position

• 1. open epiphyses until after adolescence
• 2. dislocations are rare  - if they occur there is usually a Fx involved
• 3. limping in children is rare  - look for a possible hip disorder

calcium and phosphate

• osteoblasts:  build new bones
• osteocytes:  maintain bone tissue
• osteoclasts:  maintain bone reabsorption

increased parathyroid hormone -> calcium and phosphate absorbed and moved into blood stream

D

breakdown of cartilage

autoimmunie disorder that can affect joints and cause symptoms similar to those of arthritis

alteration of the normal bone growth process of breakdown and rebuilding breaks down more quickly and grows back softer - bones bend and break more easily

autoimmune disorder that causes chronic inflammation that can affect joints

low bone density

brittle and weak bones

smoking weakens bones

corticosteroids

• reddish blue to purple - 24-48 hours
• greenish - 5 to 7 days
• yellow - 7 to 10 days
• brownish - 10-14 days
• no injury evident - 2 to 4 wks

angle of part is away from midline of body to an abnormal degree

deformity in which angle of part toward midline of body to abnormal degree

• prolonged immobility/immobilization
• Paget disease
• metastatic bone cancer

skeletal muscle damage

muscle damage

skeletal muscle damage

• gout
• acute tissue distruction

• CRP
• antinuclear antibodies
• serum rheumatoid factor

need 2 views of injured extremities with view of joint above and below

spinal cord injury without radiographic abnormality common

soak puncture wounds for 10 to 15 minutes.  other wounds should not be soaked

pull across wound rather than away from wound

• 1. pain
• 2. paresthesia
• 3. pallor
• 4. polar - cold
• 5. pulselessness
• 6. paralysis

apply to injures <24to 48 hours

20 to 30 min at a time for up to 48 hours after initial injury

use for chronic injuries/pain after exercise

chronic injuries or injuires that have no inflammation or swelling

before exercising to increase elasticity of joint connective tissues and stimulate BF

15 to 30 minutes at a time 

do not place directly on skin

• face 3-5
• scalp 5-8
• neck 3-5
• chest 7-10
• abd 7-10
• back 10-12
• joint surfaces 10-12
• nonjoint surfaces 7-10
• palm/sole 7-12

1 to 1/2 inches b/t axilla and crutches

30 dgree flexion of elbow

12 inches forward and 6 inches to side

up stairs:  uninjured leg goes up on first step then followed by injured leg and crutches

down stairs:  crutches placed down one step and then followed with injured leg and then the uninjured leg

- cane should reach pt wrist - handgrip level with ulnar side of wrist

- hold cane with elbow slightly bent in hand opposite injured side

 - cane and injured leg should move together - cane 4 to 5 inches forward

- up stairs uninjured leg moved first and followed by cane and injured leg

-= down stairs - cane placed on the step first and followed by injured leg then uninjured leg

handgrips should be level with the wrist crease