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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.