Abdominal Pain Protocol
Nontraumatic
Valley Hospital Medical Center
Emergency Department
Patient enters Care System
EMS v.s. AMBULATORY
EMERGENCY DEPARTMENT
1.
TRIAGE - Acute Abdominal Pain < 1 week
Not Children / Trauma / or Pregnancy 3rd Trimester or First Month Post Partum
Get Postural (Orthostatic) Vital Signs if significant Nausea / Vomiting or Diarrhea
TRIAGE LAB ORDER: CBC, Serum HCG, CMP, Ua Dip**, Lipase***
**Ua Dip only after discuss need for Pelvic UTZ / CT to R/O Ectopic Pregnancy – full bladder
*** Lipase if BACKPAIN
Elderly with Abdominal Pain: ECG & CXR
(consider atypical presentation MI and Pneumonia)
TRIAGE ORDER:
TRIAGE ORDER:
IV Heparin Lock
IV Fluids: NS Bolus per protocol (after postural vitals)
Assess Pain and Nausea
Administer Zofran 4mg IVP for nausea per protocol
Refer to Pain Protocol
Pelvic Exam Set Up at Bedside – correct gurney / room
Female with pain below Umbilicus – Undress for Exam
PHYSICIAN TO EXAMINE prior to ordering IMAGING STUDIES
IN MOST CASES
KEY Nursing OVERVIEW:
1. Identify Patient Group / Postural Vitals / Labs Drawn / Fluid & Analgesia Assessment
2. RAPID MOVEMENT TO EXAM ROOM for ABDOMINAL Exam
+/- PELVIC
+/- RECTAL
Acute Abdominal Pain Protocol
2.
Nontraumatic
Emergency Dept Provider Evaluation
History & Physical with Abdominal +/- Pelvic +/- Rectal Exams:
Classical Appendicitis - RLQ Pain onset within 24 hours steadily worsening
Call Surgeon on Call (May be in-house and see immediately)
v.s. CT Abd/Pelvis + IV Contrast
Check Basic Lab / Fluids / Analgesia / Antiemetic – at Triage
Left Sided Lower Abdominal Pain & Sick – consider CT Abdomen / Pelvis with IV Contrast
Consider Enema Contrast. (Oral Route = 2 to 3 hours average prior to doing the study)***
Renal Colic – Spiral (Stone) CT
Screen urine for stone / Tordal 30mg IV max *
Tordal - caution in elderly / renal failure / dehydration
Upper Abdominal Pain - DO NOT LIMIT DIFFERENTIAL
in very ill, or elderly patient, or pregnant
Generally RUQ Ultrasound for GB Disease / Liver Disease & best for GB stones
CT ABDOMEN / PELVIS considered superior study overall.
DO NOT limit the Diagnosis – may still be atypical Appendicitis / Perforation / other Life Threat
KEY: ATYPICAL APPENDICITIS in Elderly – NEGATIVE CT DOES NOT RULE OUT DX !
Rectal Exam - In general – Still listed in ACEP protocol
+ Hemacult
Little help in Appendicitis
Pelvic Exam - In general – In female with Lower Abdominal / Pelvic Pain.
Acute Abdominal Pain Protocol
Nontraumatic
3. Confirmatory Studies
LAB
Provider Order
- consider
ABG
PT / PTT
Type & Hold v.s. Type and Cross if bleeding - Hemodynamic Instability or Co-Morbidity with GI Bleed
Do not base order on the Hgb/HCT which may not have
equilibrated yet.
Lipase if Backpain
Check Anion Gap (If Elevated consider differential and potential poisoning as cause of Abd Pain)
Order Lactate if Elevated AG or possible Sepsis – if > 4 consider Sepsis & high risk patient.
Serum Ketones & Lactate if DKA + ECG and Cardiac Enzymes
(MI is Key cause of DKA, and DKA often presents as Acute Gastroenteritis)
Urine Micro and Culture if indicated
Blood Cultures for Fever / Hypotension / Shock / Hypothermia & Tachypnea in elderly
Additional Studies as Indicated
XRAY
Provider Order – Consider
as Indicated
CT Abd / Pelvis Without Contrast / IV Contrast / Enema Contrast / PO Contrast **
UTZ Abd / Pelvis Pregnant
UTZ RUQ Gallbladder / Liver
AAS Acute Abdominal Series: Free Air / Obstruction / stones
Appendicolith < 10% Acute Appendicitis but very suggestive
CXR pneumonia
Remember : #1 Diagnosis on “Missed Appy” = AGE
#1 Diagnosis on “Missed DKA” = AGE
#1 Life-Threat triggering DKA in Adult Type I DM = MI
ALWAYS look for atypical presentations in this group
ALWAYS consider Mesenteric Ischemia prior to Discharge.
Acute Abdominal Pain Protocol
4.
Nontraumatic
Discharge Planning
KEY: a. ALL Patients discharged with ongoing NON-Traumatic Abdominal
Pain are advised that a repeat exam in 12 hrs is required.
b. ALL Patients discharge with abdominal pain whether resolved or
not, are advised that they must:
“Return for 2 to 3 hours of steady, progressive, persistant
Abdominal Pain, Fever > 100, vomiting, or problems.”
c. ALL Patients discharged with NON-Traumatic Abdominal Pain
are placed at “Bowel Rest” for 24 hours = Clear Liquids with
emphasis on small amounts frequently (2 tsp or 2 sips q 10 min)
Inability to keep fluids down constitutes rationale for immediate
re-evaluation & return to E.D.
d. ALL Patients are advised that a Normal Abdominal CT Scan
DOES NOT GUARANTEE
the absence of Appendicitis !
e. ALL Patients must be monitored for the next 24 to 48 hours, and
return to E.D. for ongoing, progressive or new problems.
Generally they will be observed at home by family members.
Acute Abdominal Pain Protocol
Nontraumatic
5. Admitting the Patient
ADMIT TO:
Surgeon
Admit Surgical Floor
Admit to O. R.
Consult in E.Dept.
Hospitalist
Admit to Observation
Admit to Medical Floor
Admit to Surgical Floor
Admit to PCU
Admit to ICU
Gastroenterologist
GI Bleed / PUD / ERCP
Biliary Disease
Pancreatic Disease
Liver Disease
Consult in E. Dept.
INTERQUAL OBSERVATION CRITERIA
VITAL SIGNS
Temp > 101 for 3 weeks or > 103 or < 95
Pulse > 100/min or < 60/min
Respiratory Rate > 24/min or < 12/min
Systolic B/P < 100 mmHg
RESPIRATORY LABS
Arterial Blood Gas pH > 7.45 or < 7.30; p02 < 60; pCO2 > 45
O2 Sat < 91%; PEF 50 to 70%; CO 25 – 29%; supplemental 02 > 28%
LAB
HCT < 25; Blood Sugar > 400 or < 50; BUN > 35; Creat > 3.0
K > 5.5 or < 3.0; Sodium > 150 or < 120
INTERQUAL INPATIENT ADMISSION CRITERIA
VITAL SIGNS
Temp > 104 or < 91
Pulse > 120 or < 45
Respiratory Rate > 35 or < 8
Systolic BP < 90 mmHg
RESPIRATORY LABS
Arterial Blood Gas pH > 7.50 or < 7.25; p02 < 56 or pC02 > 50
O2 Sat < 89%; PEF < 50%; CO > 30%; supplemental 02 > 40%
LAB
HCT < 18 or < 25 if over 65 Y/O; Platelets > 1 Million or < 75,000; INR > 2
PT > 1.5; PTT > 1.5; Blood Sugar > 500 or < 40; BUN > 65; Creatinine > 5.0
Potassium > 6.0 or < 2.5; Sodium > 160 or < 110; Calcium > 15 or < 5
Blood > 4 Units/24hrs; IV Fluids > 4 Liters/24hrs
MEDICATIONS
Analgesics > 3x in 24hrs
Bronchodilators > 6x in 24hrs
Diuretics > 2x in 24 hrs
Antibiotics > 3x in 24 hrs