Abdominal pain in the ER Flashcards
What are the three types of abdominal pain and how to they present? what causes each of these?
- Visceral - poorly localized and 2/2 stretching of unmyelinated fibers
- Parietal (somatic) - localized and 2/2 irritation of myelinated fibers of the parietal pleura covering peritoneum
- Referred - pain felt at a location distant to underlying cause. MC on ipsilateral side.
which type of pain begins as tenderness and guarding and progresses to rigidity and rebound tenderness.
parietal (somatic)
remember 2/2 myelinated fibers of parietal pleura.
what are the MC extra-abdominal etiologies
- DKA
- Alcoholic ketoacidosis
- Pneumonia
- PE
- Herpes Zoster
is genitourinary considered extra-abdominal or intraabdominal?
extra-abdominal
who is more likely to have less severe or atypical presentations of abdominal pain?
elderly population.
How much is mortality increased for abdominal complaints in elderly
6-8 fold
what etiologies should you consider for elderly population who have abdominal pain
- ischemic heart disease
- vasculopathies
- coagulopathies
pain with maximal intensity at onset is a red flag for what diagnoses
- ischemia
- dissection
- perforation
a gradual onset of abdominal pain is more suggestive of what types of diagnoses
- inflammatory
- infectious
- obstructive
if pain is constant or worsening over 6 hours what type of etiology is it likely
surgical
What diagnosis relates to each of the following aggravating/alleviating factor?:
- pain improves after meals
- pain worse after meals
- pain improves when upright and worse when supine
- pain worse with sudden movements and improves with stillness
- PUD
- Biliary Colic
- pancreatitis
- peritonitis
Vomiting AFTER the onset of pain suggests what type of etiology
surgical
bilious vomiting suggests what etiology
obstruction distal to pylorus
note: Vomitus is considered bilious if it has a green or bright yellow color, indicating larger amounts of bile in the stomach
from google^ just cuz idk what bilious meant.
coffee-ground or hematemesis suggests what etiologies
- PUD
- Varices
- aortoenteric fistula in pts with aortic aneurysm repair.
What etiologies are associated with the following diarrheal types:
1. loose/watery
2. mucoid
3. bloody
4. small scant amounts
- loose/watery - infectious or diverticulitis
- mucoid - infectious or inflammatory
- bloody - mesenteric ischemia or infectious
- small scant amounts - bowel obstruction
what may suggest infectious etiology in elderly and neonatal populations
lower body temperature
what do the following auscultations suggest:
* absence
* periodic high-pitched
* hyperactive medium pitch
* bruit
- absence - peritonitis or bowel obstruction
- periodic high-pitched - bowel obstruction
- hyperactive medium pitch - blood or inflammation within the GI tract
- bruit - abdominal aortic aneurysm
What tests peritoneal pain and who are these tests not reliable in?
- rebound
- heel tap
- jumping
- not reliable in elderly or pregnant population
what do the following signs indicate?
- Carnett’s sign¹
- Murphy’s sign²
- Psoas sign³
- Obturators sign⁴
- Rovsing sign⁵
- CVA percussion
- Carnett’s sign¹ - indicates abdominal wall pathology
- Murphy’s sign² - indicative of cholecystitis
- Psoas sign³ - indicative of a retrocecal appendicitis
- Obturators sign⁴ - indicative of appendicitis
- Rovsing sign⁵ - indicative of appendicitis
- CVA percussion - indicative of pyelonephritis
who has physiologic leukocytosis?
pregnant people (elevated WBC = normal)
what can be visualized with an ultrasound
- GB
- pancreas
- kidneys
- ureters
- urinary bladder volume
- uterus/fallopian tubes
- aortic dimensions
What is the preferred study for undifferentiated abdominal pain
CT scan
what are indications for NON contrast CT’s
- nephrolithiasis
- trauma
- hemoperitoneum
- bowel obstruction
what are indications for oral vs IV contrast for CT abdomen
what are CI to IV contrast
- serum Cr >1.5
- GFR <60 (unless life threatening)
- Caution w metformin
when is angiography indicated for abdominal pain?
mesenteric ischemia and massive lower GI bleeds!
if there is any concern for bleeding in an abdominal pain complaint, what labs must you get?
- Type and screen
- crossmatch
If there is evidence of shock in abdominal complaints, what lab should you order
ABG
Slides 21-25 is literally a huge flow chart. maybe glance at that
okie dokie
what is initial management for patients with abdominal pain?
- NPO!
- Hypotensive = Rapid infusions of IV crystalloids (NS/LR) 1 L bolus over 10-20 min.
- Normotensive = IV cyrstalloids 75-125ml/hour
what are go to antiemetics?
- ondansetron
- Metoclopramide
what might be co-administered w metoclopamide
- diphenhydramine (benadryl) to avoid extrapyramidal SE
- avoid if hx of akathisia or dystonic rxns.
what are pain goals for patients with abdominal pain?
- improve pain to a tolerable level (not to eliminate it!)
- improve pt cooperation (no gaurding)
what agents might we use as pain management
- morphine
- fentanyl
- ketorolac (toradol) - great for renal colic, avoid in peritonitis
what are indications for NG tube placement
- intractable emesis
- confirm upper GI bleed
- add light suction to decompress GI tract in a bowel obstruction
- consider in peritonitis and severe ileus
what are indications for a foley catheter
- bladder obstruction
- closely monitor I&O’s
- assess renal perfusion
what are the empiric antibiotics for suspected sepsis and peritonitis
- option 1 - pip/taz IV
- option 2 - gentamicin + metronidazole IV
- vary based on individual and ddx
according to the “when to order Contrast” article, when is IV contrast indicated
- Infection
- inflammation
- masses/malignancies
- vascular abnormalities
if a pt is known to have mild allergy to contrast, what do you give them
solumedrol 125 mg IV 1 hour prior to procedure and Benadryl 50 mg IV 15 minutes before procedure in all allergies except clear anaphylaxis
