MOD F TECH 50 Acute Abdominal Problems

Question 1

Abdominal pain

Answer 1

The most common complaint dealt with by accident and emergency departments.

When the term ‘acute abdomen’ is used it is generally referring to the more-serious type of abdomen pain and not just minor benign conditions

Ambulance personnel need to be aware of the organs of the abdomen in order to appreciate the many problems which have to be dealt with

Question 2

Gastro-Intestinal

Answer 2

Component organs

Stomach

Small bowel

Large bowel

Gall bladder

Liver

pancreas

Signs and symptoms

Pain

Nausea

Vomiting

Haematemesis

Diarrhoea

Constipation

Malaena

Question 3

Urinary

Answer 3

Component organs

Kidneys

Ureters

Bladder

Signs and symptoms

Back and side pain

Painful urination

Frequent urination

Haematuria

Question 4

Female reproductive

Answer 4

Component organs

Ovaries

Fallopian tubes

Uterus

Signs and symptoms

Pain

Mentrual irregularities

Vaginal discharge/bleeding

Pain during intercourse

Signs of pregnancy

Question 5

Male reproductive

Answer 5

Component organs

Prostate

Seminal ducts

Signs and symptoms

Changes in urinary stream

Question 6

Vascular

Answer 6

Component organs

Aorta and it’s branches

Inferior vena cava and it’s sources

Signs and symptoms

Pain of a leaking aortic aneurism

Abdominal angina

Question 7

Abdominal Boundaries

Answer 7

• Diaphragm above
• Pelvic inlet below
• Abdominal muscles to the anterior
• Lower ribs, muscle, iliac bones laterally
• Lumbar vertebrae and illium to the posterior

Question 8

Peritoneal Abdomen

Answer 8

Peritoneal Abdomen

• Spleen
• Liver
• Stomach
• Gall bladder

Bowel

Question 9

Retroperitoneal Abdomen

Organs posterior to the peritoneal lining

Answer 9

• Kidneys
• Ureters
• Bladder
• Reproductive organs
• Inferior vena cava
• Abdominal aorta
• Pancreas

Question 10

Pelvic Abdomen

Answer 10

• Rectum
• Ureters
• Femoral arteries
• Femoral veins
• Pelvic skeletal structures
• Reproductive organs

Question 11

Causes of abdominal pain

Answer 11

The causes of abdominal pain are endless. Ambulance personnel need to recognise and manage the more-serious conditions appropriately

These are identified on the following slides

Question 12

Internal bleeding

Answer 12

Clues in the history may include :

• Vomiting blood,
• Materials resembling coffee grounds (haematemesis )
• Melaena
• Profuse vaginal bleeding

Question 13

Diverticulitis

Answer 13

Caused by faecal material seeping through the thin walled diverticula, which causes inflammation and possible abscesses

Signs and symptoms

• Irregular bowel habits
• Alternating constipation / diarrhoea / fever
• Pain, mild, getting worse, becoming constant

Question 14

Abdominal aortic aneurysm

Answer 14

• Weakening and dilation in the artery wall
• May initially be leaking with no signs
• Often the skin over the abdomen appears mottled and the legs look paler than the rest of the body

AAA Signs and symptoms may include

• Localised lower back or abdominal pain radiating to buttocks, sudden onset
• If blood is leaking into the retro-peritoneum, the patient may want to defecate
• Pale legs and mottled skin below the aneurysm
• Episodes of syncope at onset
• Palpable pulsating mass

Question 15

Kidney stones

Answer 15

Pain occurs as the stones begin to move down the ureter stretching its wall, causing great distress to patient.

The pain can be known as renal colic

Pain is usually in the side radiating to groin and is often associated with nausea and vomiting

Question 16

Ectopic pregnancy

Answer 16

Acute abdo pain in a female of childbearing age, accompanied by signs and symptoms of shock.

An Ectopic pregnancy should be assumed until otherwise proven.

This is a medical emergency!

Occurs in the 5th – 6th week after the last cycle

Rupture may lead to massive bleeding

Signs and symptoms

• Localised pain, may be confused with appendicitis
• Intermittent, colicky, visceral pain
• Fallopian tube either ruptures or aborts the embryo, both cause severe pain
• Pain may become diffuse thro the abdomen

Question 17

Pelvic inflammatory disease (PID)

Answer 17

Common cause of abdominal pain in females but rarely presents as an acute collapse

The severe forms of pelvic infection with the formation of tuboavarian abscess are rare but can present with features of systemic sepsis and abdominal pain

A history of PID predisposes to ectopic pregnancy

Question 18

Appendicitis

Answer 18

Is frequently misdiagnosed and up to one third of women of child-bearing age with appendicitis are considered as having pelvic inflammatory disease or UTI

Question 19

Immunosuppressed patients

Answer 19

For example, human immunodeficiency virus (HIV) and alcoholics can present atypically

Question 20

History taking - OPQRSTA

Answer 20

• Onset – sudden? gradual?
• Provokes or palliates - does any thing make it better/ worse?
• Quality - sharp / stabbing / dull
• Radiates - where does it go?
• Severity 1 – 10
• Timing - when did it start?, constant? Intermittent?, how long between pain?
• Associated signs and symptoms

Question 21

Associated signs and symptoms

Answer 21

•Nausea / vomiting,

–frequency, type

•Bowel habits,

–constipation, diarrhoea

• Chest pain / dyspnoea
• Menstrual history
• Painful urination

Question 22

History taking - S.A.M.P.L.E.

Answer 22

• Signs and symptoms
• Allergies
• Medications
• Past medical history inc. surgery (especially abdominal)
• Last oral intake
• Events leading up to illness

Question 23

An alternative acronym used to assist in history taking is SOCRATES; the following slides give examples of signs and symptoms, which point to possible diagnoses for abdominal pain using SOCRATES

Answer 23

Question 24

SOCRATES

Answer 24

Question 25

SOCRATES character

Answer 25

•Sharp, worsened by movement (peritonitis) • •Tearing pain (dissecting aneurysm) • •Dull ache (appendicitis, diverticulitis, pyelonephritis) • •Similar to previous pain suggests recurrent problems such as ulcer disease, gallstone colic, diverticulitis, or mittelschmerz (ovulation pain)

Question 26

SOCRATES radiates

Answer 26

Question 27

SOCRATES associated symptoms

Answer 27

Question 28

SOCRATES timings

Answer 28

Question 29

SOCRATES exacerbating/relieving factors

Answer 29

Question 30

SOCRATES severity

Answer 30

Question 31

Physical assessment

Answer 31

* ABC’s, position, distress * Skin, sweating / pallor, restlessness * Vital signs, i.e. signs of shock * If time critical - load and go, pre alert. * Treat on route, including ECG If not time critical, perform a thorough assessment, including * Pain, using pain score to assess * Assess temperature * Gently palpate all four quadrants for gauging, tenderness, spasm, mass, distension * Manage pain agressively

Question 32

Abdominal Assessment

Answer 32

* Can be carried out in under 1 minute * Inspect for scars, discolouration, masses, pallor * Should be round and symmetrical * Symmetrical distension may be from obesity, entangled organs, fluid, gas * Asymmetrical distension may be from hernias, tumours, bowel obstruction Things to look for * A flat abdomen is common in athletic adults * Convex abdo’s are common in children and unfit adults * Umbilicus should be free from swelling, bulges and inflammation * Abdominal movement during respiration should be smooth and even * Visible pulsations may be normal in thin adults * Remember marked pulsating masses may indicate A.A.A.

Question 33

Palpating

Answer 33

* Is useful in detecting fluid, air or solid masses * Warm hands, avoid sharp movements, steady even pace * Systematic approach either side to side or clockwise, concentrate feeling with fingertips, or the two handed technique may be used * Note : rigidity, tenderness, skin temperature • * Observe patients face for signs of discomfort * Examine the painful quadrant last to prevent guarding

Question 34

Remember

Answer 34

•20-25% of patients with abdo pain will have serious condition. • •Both ends of age spectrum require more vigilance. • •Elderly patients with internal bleeding have a higher mortality rate • •Adopt a high level of suspicion, obtain ECG’s • •Suspect AAA’s in anyone over 50 with back pain