Situation
Abdominal pain is a common presentation to the ED roughly 7% of all ED attendances.[1] There remains to be a substantial proportion of these patients who remain undiagnosed. On the flip side of this the most common surgical emergency to present to the ED is appendicitis.
Abdominal pain can be a feature of both surgical (I’m including gynae in this term) and medical problems. Elderly patients can often present with abdominal pain as a symptom and can often be misleading, always be wary of this.[2] Younger patients with a first presentation of Diabetes (often in DKA) can complain of a non specific type pain.[3] Early assessment and recognition can be key to moving investigations forward….and providing good patient care.
Background
The obvious ones are also the quite rare ones….I can count on one hand the number of actual pulsating masses bounding out of the abdomen that I’ve seen…but I’ll be beyond using my toes to count the number of leaking abdominal aortic aneurysms.
Where do you start?
Well, for a brief overview here’s a video on the sections of abdomen and some of the conditions associated with them
Assessment
Assessment begins from whenever or wherever you meet the patient. Waiting room- how do they stand? How are they walking? Do they look uncomfortable? Is there any evidence of jaundice?
Are they in a room, is there vomit bowls nearby? What position is your patient lying in (the one curled up in the fetal position or lying very still is likely to be big sick)?
For assessment much like Liz’s chest pain post (link here) we’ll use a PQRST pneumonic.
Provoke/Palliate- Is there anything making it worse or better? What were you doing when the pain started? Is the pain associated with any movement in particular or perhaps eating?
Quality- How is the pain described? Sharp/Cramping/Burning. Does it come and go?
Radiation- Has the pain moved since it started? Does the pain go anywhere? Typical pain for appendicitis would be central abdominal pain before isolating to the right iliac fossa. Traditionally the ectopic pregnancy red flag was shoulder tip pain….and be wary of the central pain radiating to back (especially aged over 65) for the big AAA.
Severity-What is the pain score out of 10? PLEASE re-evaluate after giving analgesia and if needs be get some more.
Timing/Trajectory-When did it start? Is the pain still the same? Is it getting better or worse?
Investigations…aside from the standard observations and NEWS there’s a whole host of other things to do. Generally abdominal pain will require a urine dip and for women of child bearing age add a B-HCG (with consent)…make sure that is on the list.
Blood wise will depend locally on what you have available to you but as standard, Venous blood gas, Full blood count, Urea and electrolytes, Liver function tests (certainly for Right upper quadrant pain….but if your not sure ask) and a CRP can be quite common too.
If the patient looks unwell to you, escalate it up (Using the SBAR tool) get two cannulas in (if you can) and include group and saves onto your list of bloods.
Recommendations
Further reading can be found
(LITFL if you haven’t discovered it already….is an amazing resource)
[RCN Emergency Nurse Competencies: CCT 2.1.3 CCT 2.2.1 CD1 4.1.3 CD1 4.2.1]
References-
[1]. Macaluso C, McNamara R. Evaluation and management of acute abdominal pain in the emergency department.International Journal of General Medicine. 2012; 5, 789-797. http://doi.org/10.2147/IJGM.S25936
[2]. Spangler R, Van Pham T, Khoujah D, Martinez J. Abdominal emergencies in the geriatric patient. International Journal of Emergency Medicine. 2014;7(1). https://doi.org/10.1186/s12245-014-0043-2
[3]. Umpierrez G, Freire AX. Abdominal pain in patients with hyperglycemic crises. J Crit Care. United States; 2002 Mar;17(1):63–7. https://10.1053/jcrc.2002.33030