Abdominal Pain Management in Pre-Hospital Environment

Abdominal Pain Causes and Management

• Diagnosing the causes of abdominal pain in the pre-hospital environment is not usually indicated, but understanding the possible reasons can assist in patient management.
• Associated signs and symptoms, such as hypotension, nausea, vomiting, bleeding, and traumatic damage, determine the management of patients with abdominal pain.

Associated Signs and Symptoms

• Hypotension is associated with: • Vascular emergencies (e.g., ruptured abdominal aortic aneurysms) • Ruptured ectopic pregnancies • Bowel obstructions • Traumatic damage to solid organs (e.g., spleen, kidney, liver) • Gastrointestinal bleeding
• Nausea and/or vomiting are important signs to consider.
• Bleeding from the mouth or rectum is a significant symptom.

Evaluating Patients with Abdominal Pain

Upper Abdominal Pain

• In patients with upper abdominal pain (above the umbilicus): • Males 35 years or older require a 12-lead ECG. • Females 45 years or older require a 12-lead ECG.

Lower Abdominal Pain

• In patients with lower abdominal pain (below the umbilicus): • Females of childbearing years should be treated as a possible ectopic pregnancy until proven otherwise.

Patient History and Medication

• The patient's past medical/surgical history is frequently helpful in determining the cause of their abdominal pain.
• Determining current medication use can assist in understanding the reasons for the patient's abdominal pain.

Abdominal Pain Diagnosis

• Location of pain is the most helpful information for determining cause of pain

Renal Colic (Kidney Stones)

• Pain starts in posterior flank and radiates to lower abdomen on same side
• Pain never crosses midline

Right Upper Quadrant Pain

• Gallbladder pain starts in right upper quadrant and may move to upper abdomen and mid back

Right Lower Quadrant Pain

• Possible causes: kidney stones, ectopic pregnancy, classic appendicitis
• Classic appendicitis pain starts in mid-upper abdomen or around umbilicus and later moves to right lower quadrant

Left Upper Quadrant Pain

• Possible cause: pancreatitis
• Pancreatitis often associated with history of pancreatitis, alcohol abuse, or gallbladder stones

Left Lower Quadrant Pain

• Possible causes: diverticulitis, ectopic pregnancy, kidney stones

Abdominal Pain Complications

• May be associated with nausea and/or vomiting, diarrhea or constipation, urinary symptoms, difficulty breathing, cough, fever
• Patients with history of gastric bypass surgery at increased risk for complications
• Complications can occur shortly after surgery or many years later
• Patients with abdominal pain after gastric bypass surgery should be transported to hospital for further evaluation

Pain Assessment Questions

• Onset of pain can be either sudden or gradual
• Pain can be constant or intermittent since its onset
• Pain may or may not have changed location since it started
• It is essential to determine if the patient has experienced similar pain before
• Identifying factors that exacerbate or relieve the pain is crucial
• Associated symptoms and clinical findings to be explored include: • Nausea • Vomiting • Diarrhea • Urinary symptoms • Shortness of breath
• Pain severity should be assessed on a scale of 1-10, with 10 being the worst
• Patient's self-medication attempts and their effectiveness should be noted
• In relevant cases, the timing of the last menses should be recorded

Initial Patient Assessment and Care

• Universal initial adult patient assessment and care is the first step in treatment

Hypotension Management

• Administer 500 mL IV bolus of normal saline to treat hypotension
• Repeat the normal saline IV bolus once if needed
• Inform the receiving hospital of the patient's status

Nausea and Vomiting Management

• Administer ondansetron (Zofran) ODT, 8 mg PO, to treat nausea and vomiting
• Alternatively, administer ondansetron (Zofran), 4 mg IVP/IO/IM, if available
• Treating abdominal pain often relieves associated nausea

Pain Management

• Consider pain management as part of the treatment plan

Vomiting Blood or Bleeding Management

• Start a saline lock in cases of vomiting blood or bleeding per rectum
• Administer normal saline only if the patient is also hypotensive or tachycardic