Download Acute abdominal pain

Acute abdominal pain
Recommend
 Consider ectopic pregnancy in all women of child bearing age (12-52 years) who
present with abdominal pain and / or vaginal bleeding
Background
 It is not necessary for the Registered Nurse or Aboriginal and/or Torres Strait Islander
Health Worker to make a definitive diagnosis. It is more important to recognise cases
which are significant, and to be able to present the history and findings in an ordered
manner to the MO
Related topics:
DRABC Resuscitation / the collapsed patient, page 34
 Vaginal bleeding in early pregnancy, page 405
 Lower abdominal pain in female, possible PID, page 484
Upper Gastrointestinal bleeding, page 171
Rectal bleeding, page 173
Testicular / scrotal pain, pages 179, 474
Bowel obstruction, page 174
 Renal colic, page 176
 Acute retention of urine, page 178
1.
May present with:
 Abdominal pain
 Off food, nausea, vomiting
 Can’t pass wind, constipation
 Vomiting up blood (haematemesis) or passing blood or tar-like (melena) bowel motions, see Upper
gastrointestinal bleeding and also see Rectal bleeding
 Fever, sweats, rigors
 Jaundice
 Abdominal wall pain/lump
 Scrotal pain, see Testicular / scrotal pain
 Abdominal distension or mass
 Inability to pass urine
 Vaginal bleeding
 Increased heart rate
 Hypotension/shock
2.
Immediate management:
DRABC resuscitation / the collapsed patient
 Take BP/heart rate/respirations
 If hypotension/shock insert large bore IV cannula (14 g or 16 g, if possible). Insert the largest you
can in the circumstances
 It is normal to start with IV Normal Saline or Hartmann’s Solution. MO will advise quantities and rate
 Give patient nil to eat or drink
 Consult MO urgently who will advise further management and arrange evacuation/hospitalisation
3.
Clinical assessment:
 If severe acute abdominal pain, assessment may be easier after analgesia (IM narcotic or preferably
IV) is given. Consult MO
 Obtain complete patient history - a careful history and examination will provide enough evidence to
establish an appropriate course of management to contend with the likely diagnosis
 previous history of similar episodes
o
past medical and surgical history
o
current medications and family history
o
menstrual history in women - are periods regular? when was the last? was it normal? Is the
woman taking any contraception?
o
alcohol intake – current and past
 Perform standard clinical observations +

urinalysis

urine pregnancy test (HCG) if childbearing age (12-52 years) female. If positive see Vaginal
bleeding in early pregnancy and consider possibility of tubal / ectopic pregnancy


4.
Assessment of the pain

check pain scale (0-10), how severe is the pain?

where is the pain? does it radiate? if so, where to? shoulder-tip pain?

is the pain sharp or dull, cramping?

does the patient get some relief by moving about ie. colic such as renal, biliary or bowel colic;
or does relief come from lying very still ie. peritoneal irritation/peritonitis from any cause?

are there any associated symptoms
o
e.g. off food, nausea, vomiting?
o last bowel movement, any blood observed or black and tar-like stools (melena)?
o
diarrhoea, constipation?
o
fever, sweating, rigors?
o
any blood, cloudy or offensive urine, burning or pain on passing?

Perform physical examination

inspection (look / smell)
o
is the abdomen distended or not?
o
is the shape of abdomen equal?
o
what is the colour and pigmentation?
o
inspect the hernial areas
o
inspect the scrotum in a male
o
are there scars present?

auscultation (listen
with stethoscope)
o
bowel sounds are sometimes useful, but may be difficult to interpret. Absence or faint
tinkling suggests bowel obstruction (see Bowel obstruction)
o
listen to the chest for air entry and added sounds (wheezes and crackles); pneumonia
and heart attack can present with abdominal pain

percussion (tapping)
o all four quadrants (right lower quadrant, right upper quadrant, left upper quadrant and then
left lower quadrant)
o is there dullness over any areas (liver? / stomach? / intestines? / spleen? / bladder?
o ask the patient is sit up (if possible) and check kidney area

palpation
o gentle palpation of the abdomen commencing at a site far removed from the indicated site
of pain
o where is the maximal tenderness?
o is there any guarding?
o are there any masses?
o palpate the hernial areas (above and below inguinal ligaments)
o palpate the scrotum in a male
o loins: sit the patient up and palpate over the renal angles for tenderness
Rectal examination - it is not necessary for nurses / health workers to perform in cases of acute
abdominal pain but it is essential in cases of haematemesis or cases of unexplained
hypotension/shock to detect melena (digested blood from upper gastrointestinal tract bleeding) (see
Upper gastrointestinal bleeding)
Management:
 Consult MO in all cases of acute abdominal pain using diagrams as a guide
 If board-like rigidity of abdomen, or pulsatile abdominal mass, insert large bore IV Cannula and
Consult MO urgently. MO will advise further management and arrange evacuation/hospitalisation in
a facility with appropriate surgical capability
 Do 12 lead ECG in all cases of upper abdominal pain in case of ischaemic chest pain: angina/heart
attack. Consult MO if abnormal or unusual
 If available MO may order erect chest X-ray (looking for air under diaphragm) and erect and supine
abdominal X-ray (looking for dilated bowel loops and air-fluid levels). These are probably the only
two reasons to perform plain abdominal X-rays
 Give patient nil to eat or drink


MO may advise to pass nasogastric tube if easy. Allow free drainage and aspirate periodically
The MO may ask the patient be catheterised
5.
Follow up:
 If in consultation with MO, patient not evacuated/hospitalised and allowed home, review next day
 See next MO clinic
6.
Referral / Consultation:
 Consult MO in all cases of acute abdominal pain.