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CHAPTER 19 Abdominal pain
JJeffrey D. Ferguson and Michael Ferras
Introduction
Patients with abdominal complaints who activate the EMS system can be among the most challenging. Their histories may be nonspecific and their exams and vital signs may be unreliable indicators of the etiology or severity of their illnesses. Vital signs are frequently abnormal in critically ill patients. However, normal vital signs do not preclude the presence of a life‐threatening condition. Certain populations with abdominal pain commonly encountered by EMS personnel may deserve special attention, including the elderly, females of childbearing age, children, postbariatric surgery patients, and immunocompromised patients. Additionally, many significant extra‐abdominal conditions can present with mostly abdominal complaints.
Abdominal pain is the most frequent chief complaint in the emergency department, accounting for almost 9% of the total visits [1]. It is also one of the most common reasons to call EMS. At least 1 in 20 EMS calls is for abdominal complaints [2]. It is especially concerning in those over 60 years old, as one study found that 58% were admitted to the hospital and 18% needed surgical intervention [3]. Thus, EMS clinicians encounter patients with abdominal pain on a regular basis, but options for patient assessment and management are limited.
Approach to the patient with abdominal pain
Assessment and management of abdominal pain patients in the prehospital setting are difficult for a variety of reasons. The following objectives apply:
The initial priority must be to recognize patients with abnormal vital signs and provide hemodynamic support;
Consider life‐threatening conditions that can present with abdominal complaints (Box 19.1);
Recognize high‐risk patient populations, including the elderly, children, females of childbearing age, and patients who are immunocompromised (e.g., human immunodeficiency virus [HIV] patients, cancer patients, transplant patients, others receiving immunosuppressive agents); andBox 19.1 Life‐threatening conditions causing abdominal painAbdominal aortic aneurysm (ruptured)Acute myocardial infarctionAortic dissectionBowel obstruction/perforationDiabetic ketoacidosisEctopic pregnancy (ruptured)Envenomation (e.g., black widow spider bite)Mesenteric ischemiaPancreatitisPeritonitisPoisoning/overdose (e.g., iron tablets)Tubo‐ovarian abscess
Be aware of extra‐abdominal and systemic illnesses that can present with abdominal pain, including acute myocardial infarction, pneumonia, and diabetic ketoacidosis (Box 19.2).
Anatomy and physiology considerations
The peritoneum provides a potential space for air, blood, or other fluids in pathologic conditions. Some structures, such as the kidneys, ureters, pancreas, aorta, and portions of the duodenum, lie in the retroperitoneum. This area contains less sensory innervation, accounting for decreased pain perception and often poor localization of pathologic conditions involving these structures. The lungs, pleural cavity, and base of the heart are all in close proximity to the abdominal cavity and can be involved in conditions that may be perceived as abdominal pain.
The abdomen is traditionally divided into four quadrants by a vertical and horizontal line through the umbilicus. Use of the quadrant description provides not only common terminology, but it is also an important determinant in the development of a differential diagnosis of abdominal complaints (Box 19.3).
Box 19.2 Systemic causes of abdominal pain
Acute myocardial infarction
Acute
