Acute Abdomen March 2018 | by EMauthor Abdominal pain represents one of the diagnostic problems in the emergency department. The following points should be kept in mind in the approach to patients with acute abdominal pain. The most important initial assessment depends on proper history and physical examination. In many cases a specific diagnosis can not be reached with examination or the basic investigation. The primary aims of emergency management of acute abdomen are; •Resuscitation of unwell patients •Adequate analgesia of patients in severe pain •Broadly identifying patients with surgical abdomen who needs surgical referral •Identifying patients who need admission for further assessment/ specific investigations Patients who needs opiate because of the severity of the pain should not be discharged but should always be referred to the surgical team. This policy has been agreed with the surgical directorate. Do not miss ectopic pregnancy as a cause of abdominal pain in all women of child bearing age, all these patients should have urine B HCG testing Initial assessment History, detailed about the pain and any associated symptoms and includes previous episodes, co-morbid conditions, drugs. Physical examination, general and abdominal examination, with particular attention for signs of peritonism, masses, aortic aneurysm, hernial orifices and should always include a digital rectal examination with patient’s consent. Investigations •Urine dipstick and sample for MSU, test for pregnancy for all women of child bearing age •Bloods for FBC, Glucose, U&Es, LFT, Amylase when relevant •ECG for patients with upper abdominal pain above 35 years of age •Radiology should include •Erect chest x-ray when you suspect visceral perforation •Supine abdomen for bowel obstruction or generalised peritonitis X-rays are not indicated for the following •Constipation •Acute appendicitis •GI bleeding •Gastroenteritis •Gall bladder disease Management •For the unwell or very sick patient manage Airway, Breathing and Circulation. •Obtain venous access with a large bore cannula and obtain blood for necessary investigations •Give adequate analgesia, the best for patients with severe abdominal pain are IV opiates •Consider the need for IVF for patients who may be dehydrated eg vomiting or obstruction •Make sure to exclude possible medical causes of abdominal pain •Refer all patients with possible surgical abdomen to the surgical team. Indications for referral •Abdominal pain with possible surgical cause in the differential diagnosis •Possible infective process like diverticulitis or appendicitis •Cholecystitis but not gall bladder colic •Intestinal obstruction •Suspicion of visceral perforation •All patients who required IV opiates for control of abdominal pain •Suspicion of mesenteric ischaemia Pitfalls in management of abdominal pain •Rigidity may be absent in the elderly even in presence of serious intra-peritoneal sepsis •Fever may be absent in people with intra-peritoneal sepsis especially the elderly •Normal WCC does not exclude serious intra-peritoneal sepsis |
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