ABDOMINAL PAIN Flashcards
MANAGEMENT
PRIMARY SURVEY
A - STRIDOR.
B - RESPIRATORY RATE. >/ 30, 02 sats 90% on Fi02 30%. Work of breathing. Tracheal Position. Chest wall crepitus / chest rise.
C - MOTTLED APPEARANCE. GCS. Pallor. Cap Refill. Distal Pulses. Palpate Abdomen.
D - CHECK GLUCOSE. GCS, PERRLA, lateralizing signs
E - EXPOSURE, TAKE DOWN DRESSINGS
POCUS: ACUTE (FAST)
Lungs
Pleural Effusion
RUQ
LUQ
Subxyphoid
Aorta
Pelvic
POCUS: RUSH EXAM
HI-MAP
H - Heart (four-chamber view and parasternal)
I - Inferior vena cava (check for volume status)
M - Morrison’s pouch/focused assessment with sonography in trauma exam (looking for free fluid)
A - Aorta (to identify AAA)
P - Pneumothorax (looking for tension pneumothorax)
INITIAL MANAGEMENT
CIRCULATION
Adults:
Isotonic Crystalloid IV Bolus 30 cc / kg
Pediatrics:
10-20 ml/kg crystalloid bolus (will be dehydrated)
Transfuse pRBC and FFP 2:1
Norepinephrine:
0.05 - 0.5 ug / kg / min ~ (0.1-0.3 most common), if BP in boots (SBP 70 start at 0.3)
titrate by 0.02 μg/kg/minute every 5 minutes
OR
5 - 20 ug / min
Vasopressin:
0.02-0.1 U/min
Or
6 cc / hr
DISABILITY
Acetaminophen 1000 mg PO/PR q 6 hr. Caution with weight < 50 kg, Hepatic dysfunction
Toradol 10 mg IM. Avoid in renal disease, PUD, history of gastrointestinal bleed.
Fentanyl 0.25-1 µg intravenous push (maximum 100 µg) (q 15 - 60 min if severe pain)
Morphine 1-5 mg IV up to 10 mg q 4 hrs (q 15 - 60 min if severe pain)
Hydromorphone 0.5 - 1 mg IV q 4 hrs (q 15 - 60 min if severe pain)
Ketamine 0.3 ug / kg slow IV push over 15 - 30 min
Ondansetron 4 - 8 mg IV
Metaclopramide 10 mg slow IV Can administer with diphenhydramine 25-50 mg intravenous as prophylaxis against dystonia.
Haloperidol or droperidol 1.25-5 mg IV / IM for intractable nausea/vomiting, acute on chronic abdominal pain, gastroparesis, and cannabis hyperemesis syndrome
ANTIBIOTICS
Meropenem 1 g IV q 8 hours
Note: Preferred in patients who have recently received other antibiotics
Piperacillin-tazobactam 4.5 g intravenous q 8 hours
Combination therapy:
Ceftriaxone 2 g IV q 8 hours
Metronidazole 500 mg IV q 8 hours
EXPOSURE: TARGETED HISTORY AND PHYSICAL (SECONDARY SURVEY)
INVESTIGATIONS
Fingerstick Glucose
CBC
lytes
BUN, Cr
LFTs
lipase
lactate
β-hCG
+/- CK/TnI
ECG
CXR
POCUS
U/S (biliary pathology, ectopic, AAA)
CT abdo/pelvis with IV contrast
Include CT angiogram if concern for mesenteric ischemia
DISPOSITION
Abdominal aortic aneurysm - Vascular/general surgery
Ectopic pregnancy - Obstetrics/gynecology
Mesenteric ischemia - General surgery
Perforated viscus - General surgery
Intestinal obstruction - General surgery
DDx: CRITICAL DIAGNOSIS
Ruptured AAA
Mesenteric Ischemia
Intestical Obstruction
Perforated Viscus
Ectopic Pregnancy
Extra-Abdominal Disease (MI, DKA, Necrotizing Skin Infections)
DDx: DIFFUSE PAIN
AAA*
Bowel Obstruction*
Mesenteric Ischemia*
Perforated Viscus*
Appendicitis (early)
Gastroenteritis
Metabolic (DKA, Porphyria, Uremia)
Pancreatitis
DDx: RUQ
Hepatitis
Cholangitis*
Cholecystitis
Biliary colic
Fitz-Hugh-Curtis Syndrome
Retrocecal Appendicitis
Appendicitis in Pregnancy
Pneumonia
Pleural effusion
PE
DDx: EPIGASTRUM
Peptic Ulcer Disease
Gastritis
Acute Cholecystitis
*Mesenteric Ischemia
*Perforated Viscus
*SBO
*Thoracic Aortic Dissection
*Acute Coronary Syndrome
*AAA
Pericarditis
DDx: LUQ
Pancreatitis*
Gastritis / PUD
Splenic Pathology
MI*
Pneumonia
Pleural effusion
PE*
DDx: RIGHT FLANK
Colitis
Perforation*
Obstruction*
Renal colic
Pyelonephritis
AAA*
DDx: UMBILICUS
Colitis
Perforation*
Obstruction*
Aortic dissection*
AAA*
Early appendicitis
DDx: LEFT FLANK
Colitis
Perforation*
Obstruction*
Renal colic
Pyelonephritis
AAA*
DDx: RLQ
Appendicitis
Diverticulitis (Cecal)
Inguinal Hernia
Ectopic pregnancy*
PID
TOA
Ovarian torsion*
Testicular torsion*
epididymitis
orchitis
Renal colic
DDx: HYPOGASTRIC
UTI (Cystitis)
Renal colic
Obstruction*
DDx: LLQ
Diverticulitis
Inguinal Hernia
Ectopic pregnancy*
PID
TOA
Ovarian torsion*
Testicular torsion*
epididymitis
orchitis
Renal coliciculitis*
Ectopic pregnancy*
PID, TOA
Testicular torsion,
epididymitis, orchitis
Ovarian torsion
Renal colic
