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- 2. Introduction Objectives • Understand the structures that perform digestion and their functions and locations. • Describe the general assessment process for a patient with acute abdominal pain using the AMLS assessment pathway. • Know the conditions that may predispose a patient to an abdominal disorder. • Use history and assessment skills to identify life threats and abdominal disorders.
- 3. Anatomy and Physiology of an Abdominal Disorder • Upper gastrointestinal tract (UGI) • Lower gastrointestinal tract (LGI) • Accessory organs
- 4. Anatomy
- 5. Pathology
- 6. Pathology
- 7. Case 1 • Dispatch A 40-year-old female with a complaint of abdominal pain
- 9. Initial Observations • Scene safety considerations Is the scene safe?
- 10. Initial Observations • A family member greets you and tells you the patient is in the bathroom vomiting. • House appears in order. • You are directed to the patient in the bathroom. ©ullsteinbild/Getty.
- 11. Initial Observations • Cardinal presentation Patient is a 40-year-old female. She appears to be in pain and vomits as you arrive. • Chief complaint She tells you her stomach hurts.
- 12. Initial Observations • Primary survey Level of consciousness (LOC)—Awake and looking at you. Airway—Open and patent. Breathing—Respiratory rate 24; lungs clear to auscultation bilaterally. Circulation/perfusion—Strong, regular and rapid radial pulse, rate 102.
- 13. First Impression • Do you identify any life threats? • Is the patient sick/not sick?
- 14. First Impression • What are your initial differential diagnoses? • Which do you think are most likely? More Likely Less Likely
- 16. Detailed Assessment • History taking Ask patient whether having pain is normal for her. O—Sudden. P—Nothing seems to make it better or worse. Q—Cramping pain but seems to be more constant now. R—Started in the epigastric area, now in the right upper quadrant and radiates to the right shoulder. S—Pain is rated as 8 on a scale of 1 to 10. T—1 hour ago.
- 17. Detailed Assessment • History taking, continued S—Abdominal pain with nausea and vomiting. A—Penicillin. M—None regularly. P—Last menstrual period 3 months ago, normal; physician confirmed today that she is pregnant. L—Dinner about 3 hours ago. E—Sitting and watching television. R—Pregnant.
- 18. Detailed Assessment 110 100% 32 mm Hg 24 134/82 ECG: Figure 8-4, Introduction to 12-Lead ECG: The Art of Interpretation, Second Edition • Secondary survey Vital signs 100.4°F (38.0°C) ECGfrom:Introductionto12-LeadECG:TheArtofInterpretation, SecondEdition,courtesyofTomasB.Garcia,MD.
- 19. Mucosa slightly dry Mildly tachycardic, no murmurs; lungs clear and equal bilaterally, no distress Guards right upper quadrant No cyanosis Normal Awake and alert; no neurologic deficits; skin cool and slightly clammy
- 20. Detailed Assessment— Diagnostics BLS ALS Critical Care Blood glucose level • 90 mg/dL (5 mmol/L) Cardiac monitoring • Sinus tachycardia at 110 • 12-lead ECG, normal Ultrasound
- 21. Refine the Differential Diagnosis Abdominal aortic aneurysm Upper GI bleeding Ruptured appendix Diabetic ketoacidosis Cholecystitis/ cholangitis Irritable bowel syndrome Ectopic pregnancy Hepatitis Gastroenteri tis
- 22. Acute Cholecystitis • Risk factors: Female History of multiple pregnancies; current pregnancy Age greater than 40 years Obesity © CAVALLINI JAMES/BSIP/Alamy.
- 23. Acute Cholecystitis • Positive Murphy’s sign ©Capifrutta/Shutterstock.
- 24. Treatment • Basic life support (BLS) Support airway. Oxygen as needed. Position of comfort. • Advanced life support (ALS) Cardiac monitoring. IV fluids as needed. Antiemetics. Analgesics. • Critical care Antibiotics.
- 25. Ongoing Management • Continue to reassess the patient. Further refine the diagnosis. Modify treatment as necessary. Transport decision.
- 26. Case Wrap-Up • Diagnosis: Acute cholecystitis Cholecystitis: inflammation of the gallbladder usually due to obstruction of the biliary duct by gallstones • Case closure: Patient hospitalized with surgical consult for possible cholecystectomy.
- 27. Further Discussion • Using the AMLS assessment pathway should enable you to quickly identify life threats that should be managed when found. • Obtaining a thorough history and conducting a physical exam will identify differential diagnoses that will drive your treatment based on your scope of practice. • Failure to recognize an acute abdominal infection may lead to sepsis.
- 28. Case 2 • Dispatch A 68-year-old female with a complaint of abdominal pain What are your concerns as you respond to this call?
- 30. Initial Observations • Scene safety considerations Is the scene safe?
- 31. Initial Observations • A family member greets you. • House appears in order. • You are directed to the patient lying on the floor. ©Imagesbybarbara/E+/Getty.
- 32. Initial Observations • Cardinal presentation Abdominal pain and dizziness. • Chief complaint She tells you her stomach hurts and she is dizzy.
- 33. Initial Observations • Primary survey LOC—Opens eyes when you are talking; slow to respond. Airway—Open and patent. Breathing—Respirations rapid, shallow, and regular; breath sounds equal and clear bilaterally. Circulation/perfusion—Radial pulse present and regular; skin is pale, cool, clammy.
- 34. First Impression • Do you identify and life threats? • Is the patient sick/not sick?
- 35. First Impression • What are your initial differential diagnoses? • Which do you think are most likely? More Likely Less Likely
- 36. Ruptured abdominal aortic aneurysm Acute coronary syndrome PE Dysrhythmia Perforated bowel Aortic dissection GI bleed Pancreatitis Ischemic bowel Dehydration Cholecystitis Kidney stone First Impression
- 37. • History taking Ask the patient whether having pain is normal for her. O—Sudden abdominal and low back pain, followed by dizziness while folding clothes. P—Constant; does not change with movement or position. Q—Sharp, stabbing pain. R—Radiates down the right leg. S—Pain is rated as 6 on a scale of 1 to 10. T—Started about 45 minutes ago. Detailed Assessment
- 38. Detailed Assessment • History taking, continued S—Abdominal and low back pain, dizziness. A—Morphine and contrast dye. M—Lisinopril, aspirin, metoprolol, simvastatin. P—Hypertension, lipid disorder, hiatal hernia. L—Dinner that evening approximately 3 hours ago – soup and salad. E—Folding laundry; no recent illness. R—Uncontrolled hypertension, BP usually around 160 systolic; 90–100 diastolic.
- 39. 80 96% 34 mm Hg 24 100/68 ECG: Figure 8-4, Introduction to 12-Lead ECG: The Art of Interpretation, Second Edition • Secondary survey Vital signs 97.9°F (37.0°C) ECGfrom:Introductionto12-LeadECG:TheArtofInterpretation, SecondEdition,courtesyofTomasB.Garcia,MD. Detailed Assessment
- 40. No cyanosis; weak distal pulses 2+ edema; pulses weaker than in upper extremities; legs mottled Normal Regular rate and rhythm; no murmurs Lungs clear bilaterally Tender midline pulsatile mass Lethargic, but oriented; no neurologic deficits
- 41. Detailed Assessment— Diagnostics BLS ALS Critical Care Blood glucose level • 86 mg/dL (4.7 mmol/L) Cardiac monitoring • Sinus rhythm at 88 • 12-lead ECG, left ventricular hypertrophy Ultrasound (FAST) of the abdomen Chest and abdominal computed tomography (CT) Chemistry panel, urinalysis
- 42. Detailed Assessment— 12-Lead ECG Introduction to 12-Lead ECG: The Art of Interpretation, Second Edition, courtesy of Tomas B. Garcia, MD.
- 45. Refine the Differential Diagnosis Ruptured abdominal aortic aneurysm Acute coronary syndrome PE Dysrhythmia Perforated bowel Aortic dissection GI bleed Pancreatitis Ischemic bowel Dehydration Cholecystitis Kidney stone
- 46. Treatment • BLS Position of comfort. Oxygen as needed. • ALS Two large-bore IVs; be judicious with fluids. Cardiac monitoring. • Critical care Administration of blood or blood products.
- 47. Ongoing Management • Reassess the patient Further refine the diagnosis. Modify treatment as necessary. Transport decision.
- 48. Case Wrap-Up • Diagnosis: Abdominal aortic aneurysm (AAA) Discuss difference between an abdominal aortic dissection and an AAA. • Case closure: Patient admitted to surgery for aneurysm repair.
- 49. Further Discussion • Using the AMLS assessment pathway should enable you to quickly identify life threats that should be managed when found. • Obtaining a thorough history and conducting a physical exam will identify differential diagnoses that will drive your treatment based on your scope of practice. • Failure to recognize an abdominal aortic aneurysm in this case would be fatal.
Editor's Notes
- Discuss each learning objective and the importance of thoroughly understanding each one.
- GI tract: Begins at the mouth and terminates at the rectum. Upper GI: Tongue, salivary glands, esophagus, stomach, and duodenum. Lower GI: Remainder of small bowel (jejunum and ileum), colon, and rectum. Accessory organs Liver: Bile production, metabolic and hematologic regulation. Liver performs over 200 functions in the body. Gallbladder: Modifies and stores bile. Gallstones may form in the gallbladder. Pancreas: Secretes digestive enzymes, bicarbonate, electrolytes, and water. Also secretes glucagon (raise glucose levels), insulin (promotes entry of glucose into cells), and somatostatin (regulates other endocrine function).
- Review the locations of organs by quadrant. Anatomy Review the location of organs in each quadrant. RUQ: Liver, gallbladder, head of the pancreas, right kidney, part of the colon LUQ: Spleen, tail of the pancreas, stomach, left kidney, part of the transverse and descending colon RLQ: Appendix, ascending colon, small intestine, right ureter, right ovary and fallopian tube LLQ: Small intestine, descending colon, left ureter, left ovary and fallopian tube.
- Anatomy can direct you to the problem.
- Location of the pain often correlates to the involved organ.
- Case 1 involves a woman with a complaint of abdominal pain. Instructor note: For students other than prehospital practitioners, dispatch information can be modified for settings other than prehospital care.
- Review the steps of the AMLS assessment pathway. Assessment is a dynamic process that occurs simultaneously. The key is to slow the provider down and move through each of these steps so as not to miss an important piece of information needed to develop a differential diagnosis.
- Initial impression begins when the dispatch information is received. When you arrive on scene, assess for safety threats and situational clues. You’ll be able to determine how well your initial impression agrees with your initial observations. Follow standard precautions. Use personal protective equipment (PPE) to shield yourself from exposure to body fluids. At the scene, providers must ask themselves the following: Are the scene and crew safe? How many patients are involved? Do you have enough resources? Do you have the right resources? Is there any need for special PPE? What is your general impression?
- The family member directs you to the bathroom to see the patient.
- Instructor note: Differentiating cardinal presentation from chief complaint is important. The cardinal presentation is the patient’s medical problem – abdominal pain with vomiting. The chief complaint is what the patient complains of – her stomach hurts. For some patients, the cardinal presentation and chief complaint might be the same.
- Note the color and amount (if possible) of the emesis. Odor? Blood or coffee ground appearance?
- The patient is sick but there do not appear to be any life threats at this time.
- Instructor note: Ask the students to generate a list of possible problems. Discuss from the list of differentials for abdominal pain how you would categorize the different causes from more likely to less likely. Students may have lists that do match and/or lists that are shorter. Here are diagnoses to consider. Ask students to provide a rationale for each diagnosis that is shared. With the limited information provided, this patient could have multiple problems. Further history and assessment is needed. Cholecystitis, biliary colic (due to cholelithiasis), cholangitis Gastric or duodenal ulcer, gastritis, gastroesophageal reflux disease (GERD) Appendicitis Diabetic ketoacidosis Gastroenteritis Hepatitis Irritable bowel syndrome, inflammatory bowel syndrome Abdominal aortic aneurysm
- Instructor note: Students may debate how the conditions are categorized. Categories are not absolute and depend on the severity of the patient, which is not presented here. Keep an open mind with a broad differential at this initial stage. Take this opportunity to list all of the potential causes of the chief complaint/cardinal presentation. Later in the case you can narrow it down to a smaller number of causes that should still be of concern either due to their seriousness or their likelihood. Possible diagnoses include: Abdominal aortic aneurysm Upper GI bleeding Ruptured appendix Diabetic ketoacidosis Cholecystitis/cholangitis Irritable bowel syndrome Ectopic pregnancy Hepatitis Gastroenteritis
- Review history taking using the OPQRST mnemonic.
- Review history taking using SAMPLER. Instructor note: Patient is pregnant. Consider ectopic pregnancy.
- Instructor note: Discuss what the vital signs tell about the patient. Fever: Consider an infectious process. Respirations—24 breaths/min and regular Pulse—radial pulse, 110 beats/min and regular Blood pressure—134/82 mm Hg Pulse oximetry—100% on room air CO2— 32 mm Hg Temperature—100.4°F (38.0°C)
- Instructor note: Rebound tenderness in the upper right quadrant is an indication of peritonitis; consider cholecystitis, cholangitis, or an abscess. The patient has cool, clammy skin; consider compensated shock. HEENT: Head: Unremarkable Eyes: Unremarkable Ears: Unremarkable Nose: Mucosa slightly dry Throat: Mucosa slightly dry Heart and Lungs: Heart regular and mildly tachycardic, no murmurs Lungs clear and equal bilaterally, no respiratory distress Neuro: Awake and alert; no neurologic deficits; skin cool and slightly clammy Abdomen and Pelvis: Soft, nondistended, rebound tenderness RUQ Upper and Lower Extremities: Normal with equal strong movement
- Instructor note: Discuss how these diagnostics support the differentials. Findings are not significant.
- Instructor note: Discuss where the students would place the patient now. Use the “pen” in PowerPoint to make comments or circle the potential differential. Discuss each differential and either rule it in or rule it out. Abdominal aortic aneurysm: possible because of abdominal pain; needs confirmation with imaging tests, such as ultrasound or CT scanning. Upper GI bleeding: possible, however no blood has been documented in the patient’s vomitus. Ruptured appendix: unlikely because pain presentation in appendicitis begins at the navel and becomes worse at the lower right abdomen. Diabetic ketoacidosis: unlikely due to patient diagnostic findings. Cholecystitis/cholangitis: Cholecystitis is likely due to pain presentation – upper right quadrant radiating to right shoulder. More common in females and in pregnancy. Cholangitis is an ascending infection of the biliary tract. Presents with similar symptoms as cholecystitis but often with jaundice and may progress quickly to sepsis. Irritable bowel syndrome: Consider with abdominal pain and nausea and vomiting with peritoneal irritation. Ectopic pregnancy: possible because she is pregnant. The pain is more consistent with gallbladder disease, however. Hepatitis: possible due to right upper quadrant pain and vomiting, but lack of jaundice makes it less likely. Gastroenteritis: possible due to initial epigastric pain.
- Cholecystitis has a higher frequency in women. Pregnant women are at risk of developing cholecystitis due to biliary stasis. Older patients are at greater risk.
- Pain usually begins in the epigastric area and migrates to the right upper quadrant. The pain may be crampy initially and then becomes constant. Pain may radiate to the right scapula. Peritoneum may become irritated causing peritoneal signs and symptoms. Positive Murphy’s sign: While palpating the right subcostal region, have the patient take a deep breath. If the patient stops inhaling or complains of pain during the breath, the test is positive.
- The patient should be treated for acute cholecystitis. Describe what needs to be done in the field at this point. Support the airway and have suctioning available because vomiting is common. Instructor note: Ask students to give examples of antiemetics and analgesics. In patients with abdominal pain, do not give anything orally. Definitive treatment will be covered at the end of the case.
- Instructor note: Discuss with students the treatment options based on scope of practice and local protocols. Treatment should be directed at improving oxygenation and administering IV fluids, antiemetics, and analgesics and initiating transport. Ask students whether any changes in treatment should be considered.
- Acute Cholecystitis Signs and symptoms of cholecystitis include persistent right upper quadrant pain, nausea, vomiting, and fever. The condition will be treated urgently with antibiotics and cholecystectomy (gallbladder removal).
- Review the points listed above.
- Case 2 involves a 58-year-old woman with a complaint of abdominal pain. Instructor note: For students other than prehospital practitioners, dispatch information can be modified for settings other than prehospital care.
- Review the steps of the AMLS assessment pathway. Assessment is a dynamic process that occurs simultaneously. The key is to slow the provider down and move through each of these steps so as not to miss an important piece of information needed to develop a differential diagnosis.
- Initial impression begins when the dispatch information is received. When you arrive on scene, assess for safety threats and situational clues. You’ll be able to determine how well your initial impression agrees with your initial observations. Follow standard precautions. Use personal protective equipment (PPE) to shield yourself from exposure to body fluids. At the scene, providers must ask themselves the following: Are the scene and crew safe? How many patients are involved? Do you have enough resources? Do you have the right resources? Is there any need for special PPE? What is your general impression?
- EMS handoff: You respond to a residence, where you are met by family members who tell you the patient became dizzy and is lying on the floor. Follow standard precautions. Use personal protective equipment to shield yourself from exposure to body fluids.
- Instructor note: Differentiating cardinal presentation from chief complaint is important. The cardinal presentation is the patient’s medical problem – abdominal pain. The chief complaint is what the patient complains of – her stomach hurts and she is dizzy. For some patients, the cardinal presentation and chief complaint might be the same.
- Review the primary survey findings listed above.
- There are no immediate life threats. The patient is sick. The patient’s lethargy and vital signs could indicate shock.
- Instructor note: Ask the students to generate a list of possible problems. Discuss from the list of differentials for abdominal pain how you would categorize the different causes from more likely to less likely. Students may have lists that do match and/or lists that are shorter. Here are diagnoses to consider. Ask students to provide a rationale for each diagnosis that is shared. Acute coronary syndrome Ruptured aortic aneurysm Aortic dissection Pulmonary embolism (PE) Dysrhythmia Ischemic bowel GI bleed Dehydration Kidney stone Cholecystitis Perforated bowel Pancreatitis
- Instructor note: Students may debate how the conditions are categorized. Categories are not absolute and depend on the severity of the patient, which is not presented here. Keep an open mind with a broad differential at this initial stage. Take this opportunity to list all of the potential causes of the chief complaint/cardinal presentation. Later in the case you can narrow it down to a smaller number of causes that should still be of concern either due to their seriousness or their likelihood. Possible diagnoses include: Ruptured aortic aneurysm Acute coronary syndrome Pulmonary embolism (PE) Dysrhythmia Perforated bowel Aortic dissection GI bleed Pancreatitis Ischemic bowel Dehydration Cholecystitis Kidney stone
- Review history taking using the OPQRST mnemonic.
- Review history taking using SAMPLER. Instructor note: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor (used for hypertension). Aspirin is a pain reliever. Metoprolol is a beta blocker used to treat high blood pressure and chronic heart failure. Simvastatin lowers cholesterol and triglyceride levels.
- Instructor note: Discuss what the vital signs tell about the patient. Patient’s blood pressure is much lower than what is normal for her. Why isn’t the heart rate higher? Discuss the effects of beta blockers on the patient’s blood pressure. The patient isn’t perfusing adequately as evidenced by her altered mental status and pale, cool, and clammy skin. Respirations—24 and shallow Pulse—Radial pulse 80 beats/min and regular CO2— 34 mm Hg Blood pressure—100/68 mm Hg Pulse oximetry—96% Temperature—97.9°F (37.0°C)
- HEENT: Head: Unremarkable Eyes: Unremarkable Ears: Unremarkable Nose: Unremarkable Throat: Unremarkable Heart and Lungs: Regular rate and rhythm; no murmurs Lungs clear bilaterally Abdomen and Pelvis: Tender midline pulsatile mass; abdomen distended Neuro: Lethargic, but oriented; no neurologic deficits Upper Extremities: No cyanosis, weak distal pulses Lower Extremities: 2+ edema; pulses weaker than in upper extremities Legs mottled on exam
- Instructor note: Discuss how these diagnostics support the differentials.
- Left ventricular hypertrophy (LVH) can be caused by hypertension. One of the complications of LVH is aortic root dilation.
- Scan showing an abdominal aortic aneurysm.
- FAST shows the presence of blood in the abdominal cavity.
- Instructor note: Discuss where the students would place the patient now. Use the “pen” in PowerPoint to make comments or circle the potential differential. Discuss each differential and either rule it in or rule it out. Ruptured abdominal aortic aneurysm (AAA): likely with description of discomfort and shock–like symptoms; however, the patient is still alive. Often with rupture the patient will bleed to death in a short period of time. Acute coronary syndrome: likely initially but ruled out with OPQRST and 12-lead ECG. Pulmonary embolism: not likely as the oxygen saturations were 96% on room air and ruled out with diagnostics Perforated bowel: not likely – the description of the pain did not indicate, the patient had no fever, and it was ruled out with advanced diagnostics. Aortic dissection: most likely because of the presenting symptoms, past medical history, and diagnostics confirmation. GI bleed: likely with initial complaint of abdominal pain, but ruled out with assessment, history, and no evidence of upper or lower GI bleeding. Pancreatitis: likely but ruled out with assessment and history, no evidence hemorrhage in the abdominal cavity as with Cullen’s sign. Ischemic bowel: likely with complaint of abdominal pain but ruled out with a good history and physical exam. Advanced diagnostics showed no evidence. Dehydration: likely if there was significant vomiting, or if a history of other volume loss. Cholecystitis: not likely because of description and location of the discomfort—not collicky or radiating pain, or following a heavy meal. Advanced diagnostics ruled this out. Kidney stone: not likely – description and location of the discomfort—not collicky or radiating pain. Advanced diagnostics ruled this out.
- This patient should be treated for an abdominal aortic aneurysm. Remember to titrate fluids to patient’s condition. Use caution infusing large amounts of crystalloids. Her BP is normally about 160 systolic and 90-100 diastolic. Her current BP would indicate hypotension, but is high enough to perfuse her vital organs. Administering large amounts of fluid would raise her blood pressure and risk rupturing the aneurysm.
- Instructor note: Discuss with students the treatment options based on scope of practice and local protocols. Treatment should be directed at monitoring vital signs, establishing an IV, and initiating transport.
- Abdominal Aortic Aneurysm An AAA is an enlargement of part of the aorta caused by a weakness in the vascular wall. If the patient is older than 50 and is complaining of abdominal or back pain, an abdominal aneurysm should be considered, even if hypotension or a pulsatile mass are not present. Instructor note: It is important to make sure the condition is not cardiac related. The patient’s dizziness makes it important to rule out all other potential diagnoses quickly. In an abdominal aortic dissection, the aneurysm dissects, extending in size, causing a relative hypovolemia, sharp tearing pain with radiation to the low back. If the aneurysm dissects toward one leg or the other, the patient will complain of pain or numbness and pulses will be weaker or absent compared to the upper extremities. In an abdominal aortic rupture, patients quickly develop shock from blood loss.
- Review the points above.