Abdominal Pain Flashcards
What should your initial actions be for a patient presenting with abdominal pain?
- primary survey
- order UTP for young women
- Order blood products if hemodynamically unstable
- Bedside imaging if concern for pneumo- or hemoperitoneum
- Abx in setting of sepsis, peritonitis or perf
- provide analgesia
- immediate surgical consultation if hemodynamic instability or rigid abdomen
What aspect of the primary survey is usually of concern in the patient with abdominal pain?
circulation
What are the four things you should think about in a patient with abdominal pain and hemodynamic instability?
hemorrhage
sepsis
perforated viscus
necrotic bowel
What should immediately be done in a patient with abdominal pain and hemodynamic instability?
fluid resuscitation with 2 large bore IVs
Women of childbearing age with abdominal pain are presumed to have what until proven otherwise?
ectopic
What are the two best options for bedside imaging in abdominal pain?
portable upright or decubitus xray to identify pneumoperitoneum
US for hemoperitoneum
What is an important extra-abdominal etiology of critical abdominal pain?
ACS
Approximately 1in ___ pregnancies results in ectopics.
1 in 8
What is the current fatality rate for ectopic pregnancies?
only 0.05%
What percentage of ectopics are still misdiagnosed on the first patient encoutner?
40-50%
Overall, ectopic account for what percentage of pregnancy-related maternal deaths?
9%
What are the risk factors for ectopic pregnancy?
PID previous ectopic tubal surgery previous pelvic/abdominal surgery tubal pathology in utero DES IUD smoking infertility/inf treatment
What is the classic triad for ectopic presentation?
abdominal pain
delayed menses
vaginal bleeding
but this is not sensitive or specific!
What is the most common physical exam finding in ectopic?
tenderness on pelvic exam
True or false: most patients with an ectopic pregnancy have abnormal vital signs upon presentation to the ED.
false - most will have normal vital signs until they have experienced significant blood loss
Note: Paradoxic bradycardia can occur in ectopic pregnancy
What is the next management for an ectopic with hemodyamic instability?
call OB/GYN to take to the OR
What are the nextmanagement options for stable patients with ectopic in the first trimester of bleeding?
transvaginal ultrasound to look for IUP.
If you see an IUP, then a concurrent ectopic pregnancy is highly unlikely unless…
they received fertility treatments
What is the earliest sign of an IUP by transvaginal US?
double decidual sac sign
What is the discriminatory zone for B-hCG?
1500-2000 mIU/mL
meaning that if the B-hCG is this high, you should be able to visualize an IUP if it’s there
What are some US signs of an ectopic?
empty uterus
extraovarian mass
tubal ring sign
pelvic free fluid
For stable patients, diagnosing an ectopic in the absence of IUP is accomplished by what?
serial B-hCG levels (if doubling rate is not apprpriate, likely an ectopic)
What is the failure rate for methotrexate in single doses?
36% - necessiatating a second dose
What are the contraindications for MTX?
hemodynamic instability inability to return for FU breastfeeding immunodeficiency renal/liver/pulm disease PUD blood dyscrasias