Rosen & Barkin's 5-Minute Emergency Medicine Consult (16 page)

• For a woman in reproductive age group a pregnancy test is essential
  
• Where applicable for majority of cases, ultrasonography should be done with CT used in cases of negative or inconclusive ultrasonography.
  

• CBC
  
• Serum electrolytes, creatinine, and glucose
  
• ESR
  
• LFTs
  
• Lactic acid
  
• Serum lipase:
  
  • More sensitive and specific than amylase
    
• Urinalysis
  
• Stool analysis and culture
  
• Pregnancy testing (age reproductive women)
  

• EKG:
  
  • Consider if risk factors for coronary artery disease are present
    
• Abdominal radiograph: Supine and upright
  
  • CT is superior for suspected visceral perforation and bowel obstruction.
    
• Upright CXR:
  
  • Pneumoperitoneum
    
  • Intrathoracic disease causing referred abdominal pain
    
• US:
  
  • Biliary abnormalities
    
  • Hydronephrosis
    
  • Intraperitoneal fluid
    
  • Aortic aneurysm
    
  • Intussusception
    
• US (Doppler ultrasonography)
  
  • Volvulus and malrotation
    
  • Testicular and ovarian torsion
    
  • Hepatitis, cirrhosis, and portal vein thrombosis
    
• Abdominal CT:
  
  • Spiral CT without contrast:
    
    • Renal Colic
      
    • Retroperitoneal hemorrhage
      
    • Appendicitis
      
  • CT with intravenous contrast only:
    
    • Vascular rupture suspected in a stable patient (e.g., acute abdominal aortic aneurtsn [AAA], aortic dissection)
      
    • Ischemic bowel
      
    • Pancreatitis
      
  • CT with IV and oral contrast:
    
    • Indicated when there is a suspicion of a surgical etiology involving bowel
      
    • History of inflammatory bowel disease
      
    • Thin patients (low BMI)
      
    • Diverticulitis
      
  • CT angiography:
    
    • Mesenteric ischemia
      
    • AAA
      
• IVP:
  
  • CT has replaced the use of intravenous urography in detection of ureteral stones
    
• Barium enema:
  
  • Intussusception
    
  • Treatment and confirmation of intussusception is with air contrast enema.
    
• MRI:
  
  • If concerns for radiation exposure or nephrotoxicity
    
  • Contraindicated in patients with metallic implants
    

Ultrasonography and MRI should be preferred to prevent exposure of ionizing radiation to the fetus.

• AAA
  
• Abdominal epilepsy or abdominal migraine
  
• Boerhaave syndrome
  
• Adrenal crisis
  
• Early appendicitis
  
• Bowel obstruction
  
• Cholecystitis
  
• Constipation +/– fecal impaction
  
• Diabetic ketoacidosis
  
• Diverticulitis
  
• Dysmenorrhea
  
• Ectopic pregnancy
  
• Esophagitis
  
• Endometriosis
  
• Fitz-Hugh–Curtis syndrome
  
• Gastroenteritis
  
• Hepatitis
  
• Incarcerated hernia
  
• Infectious gastroenteritis
  
• Inflammatory bowel disease
  
• Irritable bowel syndrome
  
• Ischemic bowel
  
• Meckel diverticulitis
  
• Neoplasm
  
• Ovarian torsion
  
• Ovarian cysts (hemorrhagic)
  
• Pancreatitis
  
• Pelvic inflammatory disease
  
• Peptic ulcer disease
  
• Renal/ureteral calculi
  
• Renal Infarction
  
• Sickle cell crisis
  
• Spider bite (Black widow)
  
• Splenic infarction
  
• Spontaneous abortion
  
• Testicular torsion
  
• Tubo-ovarian abscess
  
• UTI
  
• Volvulus
  
• Referred pain:
  
  • Myocardial infarction
    
  • Pneumonia
    
• Abdominal wall pain:
  
  • Abdominal wall hematoma or infection
    
  • Black widow spider bite
    
  • Herpes zoster
    

• Under 2 yr:
  
  • Hirschsprung disease
    
  • Incarcerated hernia
    
  • Intussusception
    
  • Volvulus
    
  • Foreign body ingestion
    
• 2–5 yr:
  
  • Appendicitis
    
  • Incarcerated hernia
    
  • Meckel diverticulitis
    
  • Sickle cell crisis
    
  • HSP
    
  • Constipation
    

TREATMENT

• Nasogastric tube decompression and bowel rest
  
• IV fluids and electrolyte repletion
  
• Antiemetics are important for comfort.
  
• Narcotics or analgesics should not be withheld.
  
• Send for blood type and cross-match for unstable patient
  
• Surgical consultation based on suspected etiology
  

• Fentanyl: 1–2 μg/kg IV qh
  
• Morphine sulfate: 0.1 mg/kg IV q4h PRN
  
• Ondansetron: 4 mg IV
  
• Prochlorperazine: 0.13 mg/kg IV/PO/IM q6h PRN nausea; 25 mg PR q6h in adults
  
• Promethazine: 25–50 mg/kg IM/PO/PR
  

FOLLOW-UP

• Surgical intervention
  
• Peritoneal signs
  
• Patient unable to keep down fluids
  
• Lack of pain control
  
• Medical cause necessitating in-house treatment (MI, DKA)
  
• IV antibiotics needed
  

No surgical or severe medical etiology found in patient who is able to keep fluid down, has good pain control, and is able to follow detailed discharge instructions

The patient should return with any warning signs:

• Vomiting
  
• Blood or dark/black material in vomit or stools
  
• Yellow skin or in the whites of the eyes
  
• No improvement or worsening of pain within 8–12 hr
  
• Shaking chills, or a fever >100.4°F (38°C)
  

• Elderly patients are more likely to present with atypical presentations and life threatening etiologies requiring admission.
  
• Do not consider constipation if stool is absent in the rectal vault.
  
• Etiology requiring surgical intervention is less likely when vomiting precedes the onset of pain.
  

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• McNamara R, Dean AJ. Approach to acute abdominal pain.
  Emerg Med Clin North Am.
  2011;29(2):159–173.
  
• Ross A, LeLeiko NS. Acute abdominal pain.
  Pediatr Rev.
  2010;31(4):135–144.
  
• Yeh EL, McNamara RM. Abdominal pain.
  Clin Geriatr Med
  . 2007;23(2):255–270.
  

CODES

• 789.00 Abdominal pain, unspecified site
  
• 789.06 Abdominal pain, epigastric
  
• 789.07 Abdominal pain, generalized
  

BASICS

• Injury results from a sudden increase of pressure to abdomen.
  
• Solid organ injury usually manifests as hemorrhage.
  
• Hollow viscus injuries result in bleeding and peritonitis from contamination with bowel contents.
  

• 60% result from motor vehicle collisions.
  
• Solid organs are injured more frequently than hollow viscus organs.
  
• The spleen is the most frequently injured organ (25%), followed by the liver (15%), intestines (15%), retroperitoneal structures (13%), and kidney (12%).
  
• Less frequently injured are the mesentery, pancreas, diaphragm, urinary bladder, urethra, and vascular structures.
  

• Children tend to tolerate trauma better because of the more elastic nature of their tissues.
  
• Owing to the smaller size of the intrathoracic abdomen, the spleen and liver are more exposed to injury because they lie partially outside the bony rib cage.
  

DIAGNOSIS