EM Basic- Abdominal Pain (NOT female specific) PDF

EM Basic- Abdominal Pain (NOT female specific) Labs- not everyone needs them but if you think it’s surgical abdominal (This document doesn’t reflect the views or opinions of the Department of Defense, the US Army or the pain, get them (r...

EM Basic- Abdominal Pain (NOT female specific) Labs- not everyone needs them but if you think it’s surgical abdominal (This document doesn’t reflect the views or opinions of the Department of Defense, the US Army or the pain, get them (reasons for getting them in parentheses) SAUSHEC EM residency, © 2011 EM Basic, Steve Carroll DO. May freely distribute with proper attribution) History UA/HCG for females (no culture unless you admit or treat for UTI) Look at the triage note and vitals and address them CBC (consultants want them, up to 30% of appys have normal WBC) Before talking the patient- look at them as they sit on the stretcher Chem 10 (hypokalemia can cause an ileus, low bicarb= acidosis, Appendicitis- usually want to remain very still creatinine for a CT) Kidney stones- usually writhing, can’t get comfortable Coags (standard pre-op lab, liver disease elevates coags before LFTs) OPQRST questions about pain LFTs (cholecysitis workups, may not need them for an appy) Onset, Provocation, Quality, Radiation, Severity, and Time Lipase (pancreatitis, amylase is unnecessary- not sensitive or specific) Associated signs and symptoms VBG with lactate (for older patients, high lactate = bad disease) Nausea/vomiting/diarrhea, back pain, urinary symptoms Female patients Pain control- don’t withhold it! Morphine 0.1mg/kg IV, most start with Missed periods, vaginal bleeding, discharge 4-6mg IV though. Write PRNs if you can. Give Zofran 8mg IV to PO intake counteract nausea/vomiting. Benadryl 25mg IV PRN for itching Relation of pain to food intake, worse pain with movement? Medical history PEARL- Demerol is a poor choice of opiate to use. It has lots of side Special attention to surgical history, previous colonoscopy effects and causes lots of euphoria. It doesn’t cause clinically significant sphincter of oddi spasm- that is a myth, there’s really no reason to use it Exam all. Morphine, fentanyl and dilaudid are all excellent painkillers Don’t dive for the abdomen- do an HEENT exam, heart/lung exam Uncover the abdomen and ask patient to point where it hurts the most Give IV fluids- younger people 1-2 liters, older patients- 500cc at a time Check bowel sounds first Can press down with stethoscope to see if they are tender Differential Diagnosis Start pressing opposite of where they have pain Appendicitis Start lightly and presser harder Cholecystitis If they have trouble relaxing, bend knees to 45 degrees Pancreatitis Peritoneal signs- usually indicate appendicitis or other surgical Diverticulitis pathology Bowel obstruction Lightly shake stretcher- for kids- have them jump up and down Bowel perforation All of these signs are positive if increased pain in RLQ Mesenteric ischemia Psoas sign- roll onto left side, extend leg back Kidney stone Obturator sign- flex and externally rotate right leg Gastritis Rovsing’s sign- push in LLQ, pain in RLQ Gastroenteritis Reverse Rovsing’s- push in RLQ, pain in LLQ (diverticulitis) AAA Murphy’s sign- patient takes a deep breath, push in RUQ, positive if patient stops inhaling due to pain PEARL- Do a testicular exam in all males- don’t miss a torsion! How to image the abdomen effectively by quadrants (female specific Bowel perforation- usually from a perfed ulcer or recent colonoscopy- causes excluded!) (CT A/P= CT abdomen and pelvis) be concerned if they have a rigid abdomen. Upright Chest x-ray can be helpful if you see free air, need the OR emergently LUQ abdominal pain- rarely requires imaging unless you have a rigid abdomen or suspect a bowel obstruction AAA- back pain, abdominal pain, syncope, hematuria among other presentations, elderly patient with HTN, use ultrasound to diagnose at Epigastric- rarely requires imaging. May get it for pancreatitis to check bedside- over 5cm needs the OR immediately, 2-5cm needs followup for pseudocyst but probably doesn’t need it in the ED. If you find pancreatitis, check a RUQ US for gallstone pancreatitis PEARL- mortality for STEMI?- 8% mortality for elderly patient with abdominal pain? 10% RUQ pain- RUQ US is the best test for cholecystitis PEARL- if your CT or US is negative but the patient still has a concerning RLQ pain- CT A/P for appendicitis. Can be done without contrast with abdominal exam, get a surgical consult- nothing is 100% same results, some institutions require PO and/or IV contrast Discharge instructions for abdominal pain Suprapubic- in isolation- usually a UTI Document a repeat abdominal exam before discharge LLQ pain- CT A/P for diverticulitis, once again +/- IV and or PO contrast Sample discharge conversation with the patient: Flank pain- CT A/P without contrast for kidney stones, CVA tenderness I think you have a GI bug. These usually get better on their PEARL: 20-30% of patients with stones have NO hematuria on UA own but we can make you feel better with zofran so that you can keep fluids down. However, I have been fooled before and BIG PEARL: Don’t write gastritis or gastroenteritis on a chart, better to sometimes early appendicitis presents like a GI bug. So if you say “abdominal pain” or “vomiting/diarrhea” as a diagnosis instead. go home and have increased pain, if you are vomiting BIG PEARL: For gastroenteritis- you need vomiting AND diarrhea. It can’t be gastroenteritis unless you have both constantly despite the zofran, if you develop new pain or it moves to your right lower abdomen, or if anything else is Other serious diagnoses: concerning you, please come back into the ER. Also, if you don’t feel better in 12-24 hours, you should come back in as Mesenteric ischemia- clot thrown into mesentery or low flow state, well. Classically an older patient with a-fib with pain out of proportion (patient in lots of pain but not tender on exam). Low flow mesenteric ischemia is PEARL- don’t discharge your patients with an excessive number of anti- usually a hypotensive patient on pressors in the ICU. Diagnosed with CT emetics. If they are taking zofran or Phenergan every 6 hours and they angiogram A/P. Need emergent surgery and/or interventional radiology aren’t better they need to come back to the ED, 5 tablets or ODTs is usually sufficient Bowel obstruction- patient with multiple abdominal surgeries, diffuse abdominal pain and vomiting as their chief complaint. Diagnosed with CT A/P, PO contrast is helpful (Contact: [email protected])