1. “A Belly Ache” Acute Abdominal Pain
Presence Regional EMS
March 2015 CE

2. Introduction Abdominal pain is a common complaint.
Cause of abdominal pain is often difficult to determine.
As an EMS provider you do not need to determine exact cause.
You should be able to recognize a life-threatening problem and act.
Acute abdominal pain that causes a person to summon EMS could signal a very serious medical condition

3. Abdominal Structure and Function
Abdominal cavity
Located below the diaphragm, and extends to the pelvis
Lined by the visceral and parietal peritoneum
Contains many vital organs within the peritoneal sheath, or retroperitoneal
The abdomen, or abdominal cavity, is located below the diaphragm and extends to the top of the pelvis. The abdominal cavity is lined with the peritoneum. Like the thoracic pleura, the abdominal peritoneum has two layers: the visceral peritoneum and the parietal peritoneum. The visceral peritoneum is the innermost layer and is in contact with the abdominal organs, whereas the parietal peritoneum is the outer layer. The two layers are separated by a space that contains serous fluid that acts as a lubricant.
The abdominal cavity contains many vital organs. The majority of the abdominal organs—including the stomach, spleen, liver, gallbladder, pancreas, small intestine, and part of the large intestine—are enclosed by the visceral peritoneum. There are however, there are some organs or portions of organs that are located behind the peritoneal space. This area is referred to as the retroperitoneal space. The kidneys, ureters, and abdominal aorta are located in the retroperitoneal space. Pain in the mid-back may be caused by problems with the kidneys.
Whereas other vital organs of the body, such as the heart, lungs, and brain, are contained within body cavities protected by bones, only the upper portion of the abdominal cavity is protected by the lower ribcage. The remainder of the abdomen has no bony protection, rather is protected only by the muscular layer of the abdominal cavity. When looking at mechanisms of injury, it is easy to see why injuries to the abdomen can be very serious.
© 2008 by Pearson Education, Inc.
Upper Saddle River, New Jersey
Prehospital Emergency Care, 8th Ed.
Mistovich/Karren/Hafen

4. Abdominal Structure and Function
Abdominal quadrants
Upper right quadrant
Upper left quadrant
Lower right quadrant
Lower left quadrant
Because you can’t use bones as reference points when assessing the abdomen, it is helpful to reference the abdomen by dividing it into quarters, or quadrants, using the navel, or umbilicus, as the central reference point.
 The abdominal quadrants allow the ability to reference specific regions of the abdomen for description purposes.
 The umbilicus serves as the central reference point for the four quadrants.
 The naming scheme comes from the location of the quadrant relative to the normal anatomic position.
 Some organ structures may be found in all four quadrants.
© 2008 by Pearson Education, Inc.
Upper Saddle River, New Jersey
Prehospital Emergency Care, 8th Ed.
Mistovich/Karren/Hafen

5. Abdominal Structure and Function
Some organs, such as the large intestine and small intestine, are found in more than one quadrant. Remember, in naming the quadrants, that right and left are the patient’s right and left.
 Left upper quadrant (LUQ)—contains most of the stomach, the spleen, the pancreas, and part of the large intestine. The left kidney is behind the abdominal lining.
 Right upper quadrant (RUQ)—contains most of the liver, the gallbladder, and part of the large intestine. The right kidney is behind the abdominal lining.
 Right lower quadrant (RLQ)—contains the appendix (a worm-shaped structure extending at the beginning of the large intestine), part of the large intestine, and the female reproductive organs.
 Left lower quadrant (LLQ)—contains part of the large intestine and the female reproductive organs.
© 2008 by Pearson Education, Inc.
Upper Saddle River, New Jersey
Prehospital Emergency Care, 8th Ed.
Mistovich/Karren/Hafen

6. Abdominal Structure and Function
The abdomen contains three types of organs:
Hollow organs
Solid
Vascular
The abdominal cavity contains three types of structures: hollow organs, solid organs, and vascular structures.
Hollow organs contain some type of substance that may leak out into the abdominal cavity if the organ is perforated or injured. When a hollow organ is perforated or injured, any substance that leaks into the abdominal cavity may lead to chemical or bacterial peritonitis. Hollow organs typically do not have the same amount of blood supply as solid organs; therefore, they tend not to bleed as much as solid organs.
Solid organs are very vascular (contain a large amount of vessels and blood). Some are covered by a thick fibrous capsule (liver, spleen, and gallbladder). When a solid organ is ruptured or injured, it tends to bleed excessively leading to severe shock.
Vascular structures are the large blood vessels found in the abdominal cavity. Portions of the descending aorta and the inferior vena cava are located in the abdominal cavity. Rupture or injury to either vessel will result in major bleeding, rapid blood loss, and death.
The function of most of the organs contained in the abdomen has to do with digestion of food and excretion of wastes. As an EMT, remember that you should not focus on determining which organ or specific illness may be causing a patient’s abdominal pain. Your priority is to recognize potential life threats related to acute abdominal pain and provide appropriate emergency medical care.
© 2008 by Pearson Education, Inc.
Upper Saddle River, New Jersey
Prehospital Emergency Care, 8th Ed.
Mistovich/Karren/Hafen

7. Abdominal Structure and Function
Review solid and hollow organs of the abdominal cavity.
© 2008 by Pearson Education, Inc.
Upper Saddle River, New Jersey
Prehospital Emergency Care, 8th Ed.
Mistovich/Karren/Hafen

8. Pathophysiology (1 of 4) Abdominal cavity is lined by peritoneum.
Also covers abdominal organs
Parietal peritoneum lines abdominal cavity.
Visceral peritoneum covers organs.
Foreign material such as blood, pus, or bile can irritate peritoneum.
Causing peritonitis

9. Pathophysiology (2 of 4)
“Acute abdomen” refers to sudden onset of abdominal pain.
Often associated with severe, progressive problems
All together, there are some 100+ different diagnoses of abdominal pain

10. Pathophysiology (3 of 4) Peritonitis Ileus Irritation of peritoneum
Typically causes ileus
Ileus
Paralysis of muscular contractions
Retained gas and feces cause distention.
Stomach empties by emesis (vomiting).

11. Abdominal Pain Two types of nerves supply peritoneum.
Parietal peritoneum is supplied by same nerves that supply skin of abdomen.
Perceive pain, touch, pressure, heat, cold
Visceral peritoneum is supplied by autonomic nervous system.
Produces referred pain

12. Acute Abdominal Pain
Abdominal pain may be from any one of numerous body systems
Cardiac or pulmonary
Gastrointestinal or urinary
Genital or reproductive
As stated previously, acute abdominal pain may arise from the cardiac, pulmonary, gastrointestinal, genital, urinary, reproductive, or other body systems.
© 2008 by Pearson Education, Inc.
Upper Saddle River, New Jersey
Prehospital Emergency Care, 8th Ed.
Mistovich/Karren/Hafen

13. Patient Assessment Patient assessment steps Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

14. Scene Size-up Scene safety BSI Mechanism of injury/nature of illness
May be the result of violence
Tearing pain may lead to an AAA.
Patient may be pale or sweating.
Gastrointestinal bleeding odor

15. Primary Assessment (1 of 2)
Identify and treat life threats.
Form a general impression.
Knees drawn up eases abdominal pain.
Airway and breathing
Abdominal pain may cause shallow, inadequate respirations.

16. Primary Assessment (2 of 2)
Circulation
Ask about blood in vomit or black, tarry stools.
Shock may be detected through pulse assessment.
Pulse strengths should be consistent.
Transport decision
Immediate if signs of significant illness

17. History Taking
Investigate chief complaint.
OPQRST
SAMPLE history

18. History Taking Common signs and symptoms: Pain or tenderness
Anxiety and fear
Guarded positioning
Rapid and shallow breathing
Rapid pulse, or changes in blood pressure
Nausea, vomiting, or diarrhea
Rigid or distended abdomen
Other signs and symptoms associated with shock.
Signs of internal bleeding—vomiting blood (either bright red or like coffee grounds), blood in the stool (bright red or dark and tarry, also very distinct smell).

19. Secondary Assessment Physical examination
Normal abdomen is soft and not tender.
Pain/tenderness: signs of acute abdomen
Expose and assess abdomen.
Palpate gently.

20. Secondary Assessment Palpate furthest away from location of pain first
Discuss the process of abdominal examination using inspection, identification of pain location(s), and palpation.
Assess if the abdomen feels soft or rigid. If the abdomen is rigid determine if the patient can relax the abdominal muscles upon request. Note any involuntary guarding—an abdominal wall muscle contraction that the patient cannot control, resulting from inflammation of the peritoneum. Involuntary guarding is also referred to as rigidity. In contrast, voluntary guarding is when the patient contracts the abdominal muscles, usually in anticipation of pain or an unpleasant sensation.
© 2008 by Pearson Education, Inc.
Upper Saddle River, New Jersey
Prehospital Emergency Care, 8th Ed.
Mistovich/Karren/Hafen

21. Secondary Assessment Vital signs
Check respiratory rate and pulse rate.
Monitoring devices
Pulse oximetry
Noninvasive blood pressure devices

22. Reassessment Frequent reassessment is important.
Assess interventions, including treatment for shock and emotional support.
Transport in comfortable position.

23. Emergency Medical Care
FR / BLS Care:
Keep airway patent (be alert for vomiting)
Place patient in position of comfort
Administer oxygen to maintain saturation at 94-99%
Calm and reassure the patient
Treat for shock
Initiate rapid transport
NEVER GIVE ANYTHING BY MOUTH
Follow these emergency care steps:
1. Keep the airway patent. Always be alert for vomiting and the potential for aspiration. It may be necessary to place the patient in the left lateral recumbent position to protect the airway. Be prepared to suction.
2. Place the patient in the position of comfort. If signs or symptoms of shock (hypoperfusion) are present, then place in a supine position with the feet elevated.
3. Administer oxygen at 15 lpm via a non-rebreather mask, if not already started during your initial assessment.
4. NEVER GIVE ANYTHING BY MOUTH.
5. Calm and reassure the patient.
6. If signs and symptoms of hypoperfusion are present, treat for shock.
7. Initiate a quick and efficient transport.

24. Emergency Medical Care
ILS / ALS Care:
Continue FR / BLS care
Apply cardiac monitor if needed; perform 12 lead EKS if indicated
Obtain vascular access
If significant nausea / vomiting present, administer Zofran 4mg IV or IM

25. Causes of Acute Abdomen
Ulcers
Protective layer of mucus lining erodes, allowing acid to eat into organ.
Common to stomach and small intestines
Signs and symptoms
Sudden burning pain to epigastric and LUQ before meals or during stressful situations
Nausea and vomiting (possible hematemesis)
If bleeding severe, possible hypoperfusion findings
Indications of possible peritonitis
Some heal without intervention.

26. Causes of Acute Abdomen
Cholecystitis
Inflammation of the gallbladder
Gallstones may form and block outlet.
Signs and symptoms
Sudden onset of pain to epigastric and RUQ
Tenderness to palpation to RUQ
More common at night, and after eating fatty foods
Low grade fever, nausea and vomiting
Most common to females between years of age

27. Causes of Acute Abdomen
Pancreatitis
Inflammation of the pancreas
Caused by obstructing gallstone, alcohol abuse, or other diseases
Signs and symptoms
Severe pain in the middle of the upper quadrants, referred back pain, nausea, vomiting, abdominal distention
Sepsis or hemorrhage may occur.

28. Causes of Acute Abdomen
Appendicitis
Inflammation or infection in the appendix
Signs and symptoms
Abdominal pain around umbilicus, and eventually to the RLQ
Nausea, vomiting, fever, chills
Lack of appetite
Abdominal guarding, rebound tenderness

29. Causes of Acute Abdomen
Esophagitis
Lining of esophagus becomes inflamed by infection or acids from the stomach.
Signs and symptoms
Pain in swallowing, heartburn, nausea, vomiting, sores in mouth

30. Causes of Acute Abdomen
Esophageal varices
Bulging or weakness to veins of esophagus
Commonly from various liver diseases
Can result in profuse, painless bleeding
Signs and symptoms
Vomiting large amounts of blood
Absence of pain or tenderness in abdomen
Rapid pulse, possibly low blood pressure
Breathing difficulty may be present
Pale, cool, clammy skin
Jaundice of skin, or yellowish coloration to eyes (common to hepatic diseases)

31. Causes of Acute Abdomen
Hernia
Caused by a small hole forming in the peritoneum.
The “strangulated” tissue may then become necrotic
Signs and symptoms
Sudden onset of abdominal pain (usually after heavy lifting or straining)
Fever
Rapid pulse
Other findings similar to intestinal obstruction

32. Causes of Acute Abdomen
Abdominal Aortic Aneurysm
Weakening of descending aortic wall
AAA is difficult to detect; use extreme caution when assessing or detecting.
Signs and symptoms
Onset of lower lumbar and abdominal pain
Possible “tearing” sensation
Nausea and vomiting
Mottled or spotty abdominal skin
Decreased or absent femoral or pedal pulses
Abdomen may become rigid and tender if the aneurysm bursts

33. Causes of Acute Abdomen
Diverticulitis
Fecal matter becomes caught in colon walls, causing inflammation and infection.
Signs and symptoms
Fever, malaise, body aches, chills

34. Causes of Acute Abdomen (Urinary System)
Cystitis (bladder infection) is common.
Also called urinary tract infection (UTI)
Caused by bacterial infection
Becomes serious if infection spreads to kidneys
Reports of urgency and frequency of urination

35. Female Reproductive Organs
Gynecologic problems are a common cause of acute abdominal pain.
Lower quadrant pain may relate to ovaries, fallopian tubes, or uterus.

36. Causes of Acute Abdomen
Ectopic pregnancy
Occurs when the fertilized egg implants in an area other than the uterus
Signs and symptoms
Dull, ache type pain, poorly localized
Becomes sharp, or “knife-like” abdominal pain localized on one side of the lower quadrants possibly radiating to one or both shoulders
Vaginal bleeding, may be heavy or light
Tender, bloated abdomen
Weakness or dizziness when sitting or standing
Signs of shock (hypoperfusion)

38. Review Answer the following questions as a group.
If doing this CE individually, please your answers to:
Use “March 2015 CE” in subject box.
You will receive an confirmation. Print this confirmation for your records, and document the CE in your PREMSS CE record book.
IDPH site code: E1215

39. Review Which of the following is NOT a solid organ? Liver Kidney
Spleen
Gallbladder

40. Review
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.
pancreatitis.
appendicitis.
cholecystitis.

41. Review MOST patients with an acute abdomen present with: dyspnea.
diarrhea.
hypotension.
tachycardia.

42. Review
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
Soft, nondistended abdomen
Tachycardia and restlessness
Constipation or diarrhea

43. Review The medical term for inflammation of the urinary bladder is:
cystitis.
nephritis.
cholecystitis.
diverticulitis.

44. Review
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.
firm palpation of the abdomen.
placing him in a sitting position.
oxygen at 4 L/min via nasal cannula.

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

46. Review
An 11 year old girl is complaining of right lower quadrant pain. She is lying in a fetal position and says that she feels like she wants to throw up. You are palpating her abdomen. As you release your hand from her abdomen, she cries out in pain and says that releasing her abdomen hurt worse than palpating it. This response is called:
epigastric pain
rebound tenderness
peritonitis
guarding

47. Answers D A B C