14: The Acute Abdomen

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14 The Acute Abdomen
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Cognitive Objectives (1 of 2)

1. Define the term acute abdomen.
2. Identify the signs and symptoms of the acute
   abdomen and the necessity for immediate transport
   of patients with these symptoms.
3. Define the concept of referred pain.

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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.

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Psychomotor Objectives

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

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Abdominal Pain

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

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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

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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

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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

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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)

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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.

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Uterus and Ovaries

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

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Other Organ Systems

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

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Signs and Symptoms of Acute Abdomen (1 of 2)

• 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

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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

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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 teams
  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. 

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You are the Provider continued

• What sorts of injuries can occur to the abdomen
  during contact sports such as football?

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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.

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You are the provider continued

• The patient explains that the wind was knocked
  out of him during the tackle when another
  players helmet hit him in the gut.
• He now feels pain in his stomach, nausea. 
• Given his description of the events and trainers
  comments, you believe this is an isolated injury
  to the abdomen.

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You are the provider continued

• What could be causing his pain and what other
  signs and symptoms could you expect the patient
  to have?

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Initial Assessment

• Ascertain chief complaint.
• Note patients 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 patients
  legs 6? to 12? or to position of comfort.

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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.

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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. 

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You are the provider continued (2 of 2)

• What other conditions might have made his injury
  more likely to occur?

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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

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SAMPLE History

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

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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 patients
  abdomen gently.

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Focused Physical Exam (2 of 2)

• Determine whether patient can relax abdomen on
  command.
• Determine whether abdomen is tender when
  palpated.
• Palpate gentlyrough palpation could cause
  further damage.

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Baseline Vital Signs

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

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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.

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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 wouldnt be allowed to play.    
• You apply high-flow oxygen and obtain a blood
  pressure while your partner initiates two
  large-bore IVs.

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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.

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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.

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Ongoing Assessment

• Patients 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.

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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.

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Review

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

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Review

• Answer D
• Rationale Tachycardia (heart rate gt100
  beats/min) is commonly seen in patients 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.

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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 Diarrhea may be a symptom of some
  abdominal problems, but not in most patients.
• C. hypotension.
• Rationale Hypotension is not seen in most
  patients and should be suspected when shock is
  present.
• D. tachycardia.
• Rationale Correct answer

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Review

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

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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.

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Review

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

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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.

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Review

• Answer A
• Rationale Peritonitisan inflammation of the
  thin membrane that lines the abdominal
  cavitytypically 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.

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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).

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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. Fowlers position with their legs straight

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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.

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Review

• 4. In which position do most patients with acute
  abdominal pain prefer to be transported?
• Sitting with head elevated 45
• Rationale This is also know as the semi-Fowlers
  position.
• B. Supine with their legs elevated 12
• Rationale This is usually done in patients with
  hypotension.
• C. On their side with their knees flexed.
• Rationale Correct answer
• D. Fowlers position with their legs straight
• Rationale This is when the patient is sitting
  straight up.

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Review

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

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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.

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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 is also know as vomiting.
• D. anorexia.
• Rationale Correct answer

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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.

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Review

• Answer C
• Rationale A strangulated hernia occurs when a
  hernia is incarcerated and compressed by the
  surrounding tissues. It is a serious medical
  emergency and requires immediate surgery to
  repair the hernia, remove dead tissue, and return
  oxygen to the tissues.

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Review

• 6. If a hernia is incarcerated and the contents
  are so greatly compressed that circulation is
  compromised, the hernia is said to be
• reduced.
• Rationale This is a mass or lump that will
  disappear back into the body cavity in which it
  belongs.
• B. ruptured.
• Rationale This is a mass or lump that bursts
  from internal pressure.
• C. strangulated.
• Rationale Correct answer
• D. hypoxemic.
• Rationale This is a decrease in arterial oxygen
  levels.

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Review

• 7. Which of the following signs or symptoms would
  you be the LEAST likely to find in a patient with
  an acute abdomen?
• A. Rapid, shallow breathing
• B. Soft, nondistended abdomen
• C. Tachycardia and restlessness
• D. Constipation or diarrhea

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Review

• Answer B
• Rationale Signs and symptoms of an acute abdomen
  include, but are not limited to, rapid and
  shallow breathing, a tense and distended abdomen,
  tachycardia, restlessness, and constipation or
  diarrhea.

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Review

• 7. Which of the following signs or symptoms would
  you be the LEAST likely to find in a patient with
  an acute abdomen?
• Rapid, shallow breathing
• Rationale This is a common sign of an acute
  abdomen.
• B. Soft, nondistended abdomen
• Rationale Correct answer
• C. Tachycardia and restlessness
• Rationale These are common signs of an acute
  abdomen.
• D. Constipation or diarrhea
• Rationale These are common signs of an acute
  abdomen.

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Review

• 8. Which of the following is NOT a solid organ?
• A. Liver
• B. Kidney
• C. Spleen
• D. Gallbladder

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Review

• Answer D
• Rationale The gallbladder is a hollow organ that
  concentrates and stores bile, which is produced
  by the liver. Other hollow organs include the
  stomach and intestines. The liver, spleen, and
  kidney are all solid organs.

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Review

• 8. Which of the following is NOT a solid organ?
• Liver
• Rationale The liver is a solid organ.
• B. Kidney
• Rationale The kidney is a solid organ.
• C. Spleen
• Rationale The spleen is a solid organ.
• D. Gallbladder
• Rationale Correct answer

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Review

• 9. A 70-year-old man presents with an acute onset
  of severe, tearing abdominal pain that radiates
  to his back. His BP is 88/66 mm Hg, pulse rate is
  120 beats/min, and respirations are 26
  breaths/min. Treatment for this patient should
  include
• A. rapid transport to the hospital.
• B. firm palpation of the abdomen.
• C. placing him in a sitting position.
• D. oxygen at 4 L/min via nasal cannula.

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Review

• Answer A
• Rationale Severe, tearing abdominal pain that
  radiates to the back is typical of an abdominal
  aortic aneurysm (AAA) it commonly occurs in
  older patientsespecially those with
  hypertension. Treatment includes high-flow oxygen
  and rapid transport. If the patient has signs of
  shock, place him or her supine and elevate the
  legs 6 to 12. Do not vigorously palpate the
  patients abdomen doing so may cause the
  aneurysm to rupture.

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Review (1 of 2)

• 9. A 70-year-old man presents with an acute onset
  of severe, tearing abdominal pain that radiates
  to his back. His BP is 88/66 mm Hg, pulse rate is
  120 beats/min, and respirations are 26
  breaths/min. Treatment for this patient should
  include
• rapid transport to the hospital.
• Rationale Correct answer
• B. firm palpation of the abdomen.
• Rationale A firm or vigorous palpation is
  contraindicated in patients with severe and
  sudden onset abdominal pain.

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Review (2 of 2)

• 9. A 70-year-old man presents with an acute onset
  of severe, tearing abdominal pain that radiates
  to his back. His BP is 88/66 mm Hg, pulse rate is
  120 beats/min, and respirations are 26
  breaths/min. Treatment for this patient should
  include
• C. placing him in a sitting position.
• Rationale Hypotension is treated by elevating
  the patients legs into the shock position.
• D. oxygen at 4 L/min via nasal cannula.
• Rationale High flow oxygen is indicated in the
  treatment of shock.

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Review

• 10. The medical term for inflammation of the
  urinary bladder is
• A. cystitis.
• B. nephritis.
• C. cholecystitis.
• D. diverticulitis.

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Review

• Answer A
• Rationale Cystitis is the medical term for
  inflammation of the urinary bladder. Nephritis is
  inflammation of the kidney. Inflammation of the
  gallbladder is called cholecystitis.
  Diverticulitis is a condition in which small
  pouches in the colon (large intestine) become
  inflamed.

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Review

• 10. The medical term for inflammation of the
  urinary bladder is
• cystitis.
• Rationale Correct answer
• B. nephritis.
• Rationale Nephritis is the inflammation of the
  kidney.
• C. cholecystitis.
• Rationale Cholecystitis is the inflammation of
  the gallbladder.
• D. diverticulitis.
• Rationale Diverticulitis is the inflammation of
  part of the large intestine.