This is the protocol for Abdominal Pain:Abdominal Pain
Let’s break it down!
This protocol encompasses a very broad spectrum of illnesses. It’s not something that’s used for cramps or tummy aches, but rather for the acute onsets of severe abdominal pain that otherwise don’t have an obvious explanation. These complaints comprise 5%-10% of all ED visits. Although it’s not necessarily important to understand everything that could cause abdominal pain, it’s important to understand the big culprits in a young, soldier population:
Appendicitis: The most common abdominal surgical emergency worldwide; characterized by acute inflammation of the appendix with the risk of perforation; the lifetime risk of appendicitis is 7%-9%, with the far majority of cases occurring in the teens and twenties. It can be caused by an appendix obstruction, but the etiology is mostly uncertain. Pain is typically found in the right lower quadrant.
Cholecystitis: An acute inflammation of the gallbladder that typically occurs when bile is needed to break down material in the stomach but cannot exit the gallbladder due to an obstruction (gallstone); classically occurs in “fat, female, forty-year-old” patients following a fatty or greasy meal. It has a mortality of less than 1% but still accounts for up to 3-11% of hospital admissions. Pain is typically found in the upper right quadrant/upper center
Pancreatitis: An acute inflammation of the pancreas; the most common cause of hospitalization among those with gastrointestinal complaints; The most common cause is gallstones (40%-50%) with alcohol being the second most common cause (20%). Mortality is approximately 1% but can rise to 15%-30% if it develops into pancreatic necrosis. Pain is typically found in the epigastric and upper right quadrant
Perforated Ulcer: A peptic ulcer is a break along the inner lining of the stomach, intestine, or esophagus. Most ulcers are asymptomatic, but if the ulcer perforates all the way through the lining, it can be life-threatening. Perforated peptic ulcers carry a mortality of up to 20%. Pain is typically found in the upper left quadrant.
Diverticulitis: An acute inflammation of the large intestine; occurs when diverticula or “pouches” in the colon form and become infected/inflamed by bacteria, feces, etc. It’s a fairly common condition that can affect up to 66% of patients above the age of 80. Not typically a prevalent concern in the soldier population, but it always remains a possibility in those with a prior history of diverticula. The in-hospital mortality for patients with diverticulitis is 0.5-7.0% but it can rise to 45% if perforation occurs. Pain is typically found in the lower left quadrant.
Constipation/Fecal Impaction: Constipation is defined as 3 or fewer bowel movements in a week. For the most part, constipation is more uncomfortable than it is life-threatening. However, it becomes a fecal impaction when feces bulks up and causes a complete bowel obstruction Although not typically life-threatening, it can lead to severe complications if not treated. Pain is typically found in the lower right quadrant and middle regions.
Bowel Perforation (Blast Injury): Also known as “Blast Belly“; caused by a primary blast wave that results in an over-pressure of air-filled organs, particularly the small bowel. This is included in a non-tactical protocol is because these injuries can be extremely subtle and not show symptoms for days at a time.
The signs and symptoms listed don’t necessarily manifest together in all etiologies of abdominal pain, but rather serve as individual red flags for when to suspect an abdominal emergency. This is what each sign/symptom could indicate:
Severe, persistent, or worsening abdominal pain: indicates a hemorrhage or infection that is getting worse in the absence of treatment. Non-specific, but indicates that this is not a self-resolving issue.
Rigid abdomen: involuntary response by the abdominal muscles in response to a peritoneal irritation; designed to protect the abdominal organs from further damage.
Rebound Tenderness: Also known as “Blumberg’s sign“; refers to tenderness elicited by the release of abdominal pressure, rather than the application of it. It’s a very common test for appendicitis.
Fever: Any fever is a common indication for some bodily infection. Paired w/ abdominal pain, this can be an ominous sign for sepsis.
Uncontrollable Vomiting: Can be an indication of constant irritation of the GI tract, potentially caused by a virus, bacteria, hemorrhage, etc.
Absent bowel sounds: A reasonably noisy abdomen is typically a good thing; it means that your digestive tract is working properly. However, the absence of noise may indicate that there is a bowel obstruction.
Bloody vomitus/stool: An obvious indicator of bleeding in the GI tract; can sometimes be difficult to differentiate between blood and something naturally ingested in the diet.
Black tarry stools: Indicates bleeding in the upper GI tract. When blood is processed through the GI tract, it comes out the other end as black and tarry stools known as “Melena”. Smells awful too.
Coffee-ground Vomitus: indicates blood sitting in the stomach, will be darker the longer it sits before vomiting.
1. Keep patient NPO, except for water and meds
To properly diagnose and treat abdominal illnesses, we have to take external forces out of the equation…and that includes food. The patient’s diet may have been what initially sparked the abdominal pain, so removing food for the short term is a solid first step. It’s also going to help prep them for a potential surgical work-up by reducing the chance of vomiting during airway management.
2. Start IV, administer 1L Normal Saline bolus followed by 150mL/hr if needed.
Abdominal conditions are almost always paired with episodes of nausea/vomiting. Naturally, these patients will be dehydrated and unable to hold down PO fluids. Rehydration with controlled administration of Normal Saline is crucial for their recovery.
Not every abdominal pain patient is suffering from an infection, but we won’t really have a way of telling who is and who isn’t in our particular environment. Conditions like pancreatitis, cholecystitis, appendicitis, and diverticulitis can benefit from empiric antibiotic treatment. The benefits far outweigh the risks.
Ertapenem and Ceftriaxone are both broad-spectrum antibiotics that can kill a wide variety of causative bacteria. Metronidazole is added to Ceftriaxone to cover for additional anaerobe organisms that ceftriaxone can’t reach.
4. Treat per Pain Management protocol. (DO NOT GIVE NSAIDS)
Many of these conditions can be extremely painful; potentially warranting the use of narcotic agents like Morphine or Fentanyl from the pain management protocol. NSAIDs are generally avoided because they exert an effect on platelet-aggregation/clot production, which can be extremely dangerous for patients suffering from any internal bleeding.
5. Treat per Nausea/Vomiting protocol
Nausea/Vomiting is almost always going to be an issue for these patients. From the nausea/vomiting protocol, your best agents will be Ondansetron and Promethazine. In general, Ondansetron is typically better for the “nausea” phase. For active vomiting, Promethazine should be your go-to.
Acute onsets of abdominal pain should never be underestimated. In our setting, we’ll be unable to confirm any particular diagnosis, which is problematic because some of them will require surgery and/or prolonged treatment. Don’t mess with it, give them an Urgent evac.
Good luck out there!