14: The Acute Abdomen

1. 14: The Acute Abdomen

2. Cognitive Objectives(1 of 2) • Define the term “acute abdomen.” • Identify the signs and symptoms of the acute abdomen and the necessity for immediate transport of patients with these symptoms. • Define the concept of “referred pain.”

3. Cognitive Objectives(2 of 2) 4. Describe areas of pain or referred pain seen with the common causes of the acute abdomen. 5. Explain that pain in the abdomen can arise from other body systems.

4. Psychomotor Objectives 6. Perform a rapid, gentle assessment of the abdomen. • There are no affective objectives for this chapter.

5. Abdominal Pain • Common complaint • Cause is often difficult to identify; not necessary to determine cause • Need to recognize life-threatening problems and act swiftly

6. Physiology of the Abdomen (1 of 2) • Peritonitis • Irritation of the peritoneum • Peritoneum • Thin membrane lining the entire abdomen • Acute abdomen • Sudden onset of abdominal pain • Can be fatal

7. Physiology of the Abdomen (2 of 2) • Pain usually interpreted as colic; a severe, intermittent cramping pain. • Referred pain • Perceived pain at a distant point of the body caused by irritation of the visceral peritoneum

8. Causes of Acute Abdomen (1 of 2) • Nearly every kind of abdominal problem can cause an acute abdomen. • Substances lying in or adjacent to the abdominal cavity

9. Causes of Acute Abdomen (2 of 2) • Perforation of an ulcer • Gallstones that lead to inflammation (cholecystitis) • Inflammation of the pancreas (pancreatitis) • Inflammation or infection of appendix • Inflammation of pouches in large intestine (diverticulitis)

10. Urinary System • Kidneys can be affected by stones that form from materials normally passed in the urine. • Kidney infections can cause severe pain. • Patients are often quite ill, with a high fever. • Bladder infection (cystitis) more common, especially in women. • Patients usually have lower abdominal pain.

11. Uterus and Ovaries • Always consider a gynecologic problem with women having abdominal pain. • Causes of pain • Menstrual cycle • Pelvic inflammatory disease • Ectopic pregnancy

12. Other Organ Systems • Aneurysm • Weakness in aorta • Pneumonia • May cause ileus and abdominal pain • Hernia • Protrusion through a hole in the body wall

13. Ileus Paralysis of muscular contractions in the intestine Causes abdominal distention Nothing can pass normally out of stomach or bowel. Stomach can only empty through vomiting. Almost always associated with nausea and vomiting Signs and Symptoms of Acute Abdomen(1 of 2)

14. Signs and Symptoms of Acute Abdomen (2 of 2) • Distention • Anorexia • Loss of body fluid into peritoneal cavity • Fever may or may not be present. • Tenseness of abdominal muscles over irritated area

15. You are the Provider • You and your EMT-I partner are assigned to a high-school football game.  • After a tackle, one player remains on the ground with his knees pulled to his chest.  • You await evaluation by the team’s trainers. After a few moments, the player gets up and walks to the bench with assistance. • A few minutes later, the trainer motions you to come over. 

16. You are the Provider continued • What sorts of injuries can occur to the abdomen during contact sports such as football?

17. Scene Size-up • Ensure that the scene is safe. • Acute abdomen can be result of violence. • Consider ALS back-up. • Observe the scene closely for clues.

18. You are the provider continued • The patient explains that the wind was knocked out of him during the tackle when another player’s helmet “hit him in the gut.” • He now feels pain in his stomach, nausea.  • Given his description of the events and trainer’s comments, you believe this is an isolated injury to the abdomen.

19. You are the provider continued • What could be causing his pain and what other signs and symptoms could you expect the patient to have?

20. Initial Assessment • Ascertain chief complaint. • Note patient’s LOC using AVPU scale. • Check for adequate airway and treat appropriately. • Administer oxygen. • Assess for major bleeding. • Pulse and skin condition may indicate shock. • If evidence of shock exists, elevate patient’s legs 6˝ to 12˝ or to position of comfort.

21. Transport Decision • Transport gently. • Do not delay transport if patient has: • Life threat • Suspected internal bleeding • Poor general impression • Do not delay transport of pediatric or geriatric patients.

22. You are the provider continued (1 of 2) • The patient has been involved in recent physical activity, so observing his skin is not useful. • Pulse is regular, full, 130 beats/min.  • You carefully assist him to the cot and suggest that he lay down in a position of comfort. • He tells you that his left shoulder is beginning to hurt.  • You begin transport immediately. 

23. You are the provider continued (2 of 2) • What other conditions might have made his injury more likely to occur?

24. Focused History and Physical Exam • Local or diffuse abdominal pain/tenderness • Patient position • Rapid and shallow breathing • Referred (distant) pain • Anorexia, nausea, vomiting • Tense, distended abdomen • Constipation, bloody diarrhea • Tachycardia • Hypotension • Fever • Rebound tenderness

25. SAMPLE History • Use OPQRST to ask the patient what makes the pain better or worse. • Do not give the patient anything by mouth.

26. Focused Physical Exam (1 of 2) • Explain what you are about to do. • If no trauma, place patient supine with legs drawn up and flexed at knees. • Determine if motion causes pain and if distention is present. • Palpate the four quadrants of the patient’s abdomen gently.

27. Focused Physical Exam (2 of 2) • Determine whether patient can relax abdomen on command. • Determine whether abdomen is tender when palpated. • Palpate gently—rough palpation could cause further damage.

28. Baseline Vital Signs • Monitor for adequate ventilation. • Beware that changes in vital signs may be as a result of septic or hypovolemic shock.

29. Interventions • Based on assessment findings. • Anticipate vomiting. • Nausea is frequently lessened by low-flow oxygen. • If the patient exhibits signs of shock, place in Trendelenburg position.

30. You are the Provider continued • You ask the patient whether he has recently had mononucleosis. He seems surprised and confirms a recent history of “mono.”  • He did not tell his coach because he was afraid he wouldn’t be allowed to play.     • You apply high-flow oxygen and obtain a blood pressure while your partner initiates two large-bore IVs.

31. Detailed Physical Exam • You will not be able to make a diagnosis. • This exam may help provide more information. • Do not delay transport to perform this.

32. You are the Provider continued • Vital signs: • BP 96/64 mm Hg • Respirations 36 breaths/min • Pulse oximetry 95% receiving 15 L/min via nonrebreathing mask.  • He complains of feeling dizzy. • You place him in the shock position and cover him with a blanket.  • He remains awake and alert during transport; complains of severe abdominal pain throughout the call.

33. Ongoing Assessment • Patient’s condition may rapidly change. • Reassess ABCs. • Anticipate development of shock; treat even if there are no obvious signs. • Communication and documentation • Relay information as soon as possible so that appropriate resources are made available. • Include pertinent physical findings.

34. Emergency Medical Care • Take steps to provide comfort and lessen effects of shock; reassure patient. • Position patients who are vomiting to maintain airway. • Be sure to use BSI. • Clean ambulance and equipment once patient is delivered.

35. Review • MOST patients with an acute abdomen present with: A. dyspnea. B. diarrhea. C. hypotension. D. tachycardia.

36. Review Answer: D Rationale: Tachycardia (heart rate >100 beats/min) is commonly seen in patient’s with an acute abdomen; it is usually the result of severe pain. Hypotension is not seen in all patients with an acute abdomen; if the patient is hypotensive, you should suspect internal bleeding or a severe infection (sepsis). Many patients with an acute abdomen have increased respirations (tachypnea); however, dyspnea (a feeling of shortness of breath) is not common.

37. Review • MOST patients with an acute abdomen present with: • dyspnea. Rationale: Some patients may have increased respirations, but typically do not have difficulty breathing. B. diarrhea. Rationale: Diarrheamay be a symptom of some abdominal problems, but not in most patients. C. hypotension. Rationale: Hypotension isnot seen in most patients and should be suspected when shock is present. D. tachycardia. Rationale: Correct answer

38. Review 2. The ___________ lies in the retroperitoneal space. A. liver B. pancreas C. stomach D. small intestine

39. Review Answer: B Rationale: The pancreas, kidneys, and ovaries lie in the retroperitoneal space, which is behind the peritoneum, and are often the cause of acute abdominal pain. The liver, stomach, and small intestine are all found within the true (anterior) abdomen.

40. Review 2. The ___________ lies in the retroperitoneal space. • Liver Rationale: The liver isfound in anterior abdomen. B. Pancreas Rationale: Correct answer C. Stomach Rationale: The stomach isfound in anterior abdomen. D. small intestine Rationale: The small intestine isfound in anterior abdomen.

41. Review 3. A 34-year-old woman with a recent history of pelvic inflammatory disease presents with acute severe abdominal pain. Her abdomen is distended and diffusely tender to palpation. Based on your findings thus far, you should suspect: A. peritonitis. B. pancreatitis. C. appendicitis. D. cholecystitis.

42. Review Answer: A Rationale: Peritonitis—an inflammation of the thin membrane that lines the abdominal cavity—typically presents with acute abdominal pain. Causes of peritonitis include infection and blunt or penetrating abdominal trauma. The pain caused by peritonitis is typically diffuse (widespread), whereas appendicitis, pancreatitis, and cholecystitis (inflammation of the gallbladder) typically present with pain that is localized to a particular area.

43. Review 3. A 34-year-old woman with a recent history of pelvic inflammatory disease presents with acute severe abdominal pain. Her abdomen is distended and diffusely tender to palpation. Based on your findings thus far, you should suspect: • peritonitis. Rationale: Correct answer B. pancreatitis. Rationale: Pancreatitis is usually a localized pain (in one specific area). C. appendicitis. Rationale: Appendicitis is usually a localized pain (in one specific area). D. cholecystitis. Rationale: Cholecystitis is usually a localized pain (in one specific area).

44. Review 4. In which position do most patients with acute abdominal pain prefer to be transported? A. Sitting with head elevated 45° B. Supine with their legs elevated 12” C. On their side with their knees flexed. D. Fowler’s position with their legs straight

45. Review Answer: C Rationale: Most patients with acute abdominal pain prefer to lie on their side with their knees flexed (and usually drawn up into their abdomen). This position takes pressure of the abdominal muscles and may afford them pain relief.

46. Review 4. In which position do most patients with acute abdominal pain prefer to be transported? • Sitting with head elevated 45° Rationale: This isalso know as the semi-Fowler’s position. B. Supine with their legs elevated 12” Rationale: This isusually done in patients with hypotension. C. On their side with their knees flexed. Rationale: Correct answer D. Fowler’s position with their legs straight Rationale: This is when the patient is sitting straight up.

47. Review 5. A condition in which a person experiences a loss of appetite is called: A. ileus. B. colic. C. emesis. D. anorexia.

48. Review Answer: D Rationale: Anorexia is defined as a loss of appetite. It is a non-specific symptom, but is often associated with gastrointestinal diseases and abdominal pain.

49. Review 5. A condition in which a person experiences a loss of appetite is called: • ileus. Rationale: This is the paralysis of the muscular contractions that normally propel material through the intestine. B. colic. Rationale: This is a severe, intermittent cramping pain. C. emesis. Rationale: This isalso know as vomiting. D. anorexia. Rationale: Correct answer

50. Review 6. If a hernia is incarcerated and the contents are so greatly compressed that circulation is compromised, the hernia is said to be: A. reduced. B. ruptured. C. strangulated. D. hypoxemic.