14: The Acute Abdomen
Cognitive Objectives
(1 of 2)
1. Define the term “acute abdomen.”
2. Identify the signs and symptoms of the acute
abdomen and the necessity for immediate
transport of patients with these symptoms.
3. Define the concept of “referred pain.”
Cognitive Objectives
(2 of 2)
4. Describe areas of pain or referred pain seen with
the common causes of the acute abdomen.
5. Explain that pain in the abdomen can arise from
other body systems.
Psychomotor Objectives
6. Perform a rapid, gentle assessment of the
abdomen.
•
There are no affective objectives for this chapter.
Abdominal Pain
• Common complaint
• Cause is often difficult to identify; not necessary to
determine cause
• Need to recognize life-threatening problems and
act swiftly
Physiology of the Abdomen (1 of 2)
• Peritonitis
– Irritation of the peritoneum
• Peritoneum
– Thin membrane lining the entire abdomen
• Acute abdomen
– Sudden onset of abdominal pain
– Can be fatal
Physiology of the Abdomen (2 of 2)
• Pain usually
interpreted as colic; a
severe, intermittent
cramping pain.
• Referred pain
– Perceived pain at a
distant point of the
body caused by
irritation of the
visceral peritoneum
Causes of Acute Abdomen (1 of 2)
• Nearly every kind of abdominal problem can
cause an acute abdomen.
• Substances lying in or adjacent to the
abdominal cavity
Causes of Acute Abdomen (2 of 2)
• Perforation of an ulcer
• Gallstones that lead to inflammation (cholecystitis)
• Inflammation of the pancreas (pancreatitis)
• Inflammation or infection of appendix
• Inflammation of pouches in large intestine
(diverticulitis)
Urinary System
• Kidneys can be affected by stones that form from
materials normally passed in the urine.
• Kidney infections can cause severe pain.
• Patients are often quite ill, with a high fever.
• Bladder infection (cystitis) more common,
especially in women.
• Patients usually have lower abdominal pain.
Uterus and Ovaries
• Always consider a gynecologic problem with
women having abdominal pain.
• Causes of pain
– Menstrual cycle
– Pelvic inflammatory disease
– Ectopic pregnancy
Other Organ Systems
• Aneurysm
– Weakness in aorta
• Pneumonia
– May cause ileus and abdominal pain
• Hernia
– Protrusion through a hole in the body wall
Signs and Symptoms of
Acute Abdomen (1 of 2)
• Ileus
– Paralysis of muscular contractions in the
intestine
– Causes abdominal distention
• Nothing can pass normally out of stomach or
bowel.
• Stomach can only empty through vomiting.
• Almost always associated with nausea and
vomiting
Signs and Symptoms of Acute
Abdomen (2 of 2)
•
•
•
•
•
Distention
Anorexia
Loss of body fluid into peritoneal cavity
Fever may or may not be present.
Tenseness of abdominal muscles over irritated
area
You are the Provider
• You and your EMT-I partner are assigned to a highschool football game.
• After a tackle, one player remains on the ground
with his knees pulled to his chest.
• You await evaluation by the team’s trainers. After a
few moments, the player gets up and walks to the
bench with assistance.
• A few minutes later, the trainer motions you to
come over.
• What sorts of injuries can occur to the abdomen
during contact sports such as football?
You are the Provider continued
Scene Size-up
•
•
•
•
Ensure that the scene is safe.
Acute abdomen can be result of violence.
Consider ALS back-up.
Observe the scene closely for clues.
You are the
provider continued
• The patient explains that the wind was knocked out
of him during the tackle when another player’s
helmet “hit him in the gut.”
• He now feels pain in his stomach, nausea.
• Given his description of the events and trainer’s
comments, you believe this is an isolated injury to
the abdomen.
You are the provider
continued
• What could be causing his pain and what other
signs and symptoms could you expect the patient
to have?
Initial Assessment
•
•
•
•
•
•
•
Ascertain chief complaint.
Note patient’s LOC using AVPU scale.
Check for adequate airway and treat appropriately.
Administer oxygen.
Assess for major bleeding.
Pulse and skin condition may indicate shock.
If evidence of shock exists, elevate patient’s legs 6˝
to 12˝ or to position of comfort.
Transport Decision
• Transport gently.
• Do not delay transport if patient has:
– Life threat
– Suspected internal bleeding
– Poor general impression
• Do not delay transport of pediatric or geriatric
patients.
• The patient has been involved in recent physical
activity, so observing his skin is not useful.
• Pulse is regular, full, 130 beats/min.
• You carefully assist him to the cot and suggest that he
lay down in a position of comfort.
• He tells you that his left shoulder is beginning to hurt.
• You begin transport immediately.
You are the provider continued (1
of 2)
• What other conditions might have made his injury
more likely to occur?
You are the provider continued (2 of 2)
Focused History and Physical Exam
• Local or diffuse
abdominal
pain/tenderness
• Patient position
• Rapid and shallow
breathing
• Referred (distant) pain
• Anorexia, nausea,
vomiting
• Tense, distended
abdomen
• Constipation, bloody
diarrhea
• Tachycardia
• Hypotension
• Fever
• Rebound tenderness
SAMPLE History
• Use OPQRST to ask the patient what makes the
pain better or worse.
• Do not give the patient anything by mouth.
Focused Physical Exam (1 of 2)
• Explain what you are about to do.
• If no trauma, place patient supine with legs drawn
up and flexed at knees.
• Determine if motion causes pain and if distention is
present.
• Palpate the four quadrants of the patient’s
abdomen gently.
Focused Physical Exam (2 of 2)
• Determine whether
patient can relax
abdomen on command.
• Determine whether
abdomen is tender
when palpated.
• Palpate gently—rough
palpation could cause
further damage.
Baseline Vital Signs
• Monitor for adequate ventilation.
• Beware that changes in vital signs may be as a
result of septic or hypovolemic shock.
Interventions
•
•
•
•
Based on assessment findings.
Anticipate vomiting.
Nausea is frequently lessened by low-flow oxygen.
If the patient exhibits signs of shock, place in
Trendelenburg position.
• You ask the patient whether he has recently had
mononucleosis. He seems surprised and confirms
a recent history of “mono.”
• He did not tell his coach because he was afraid he
wouldn’t be allowed to play.
• You apply high-flow oxygen and obtain a blood
pressure while your partner initiates two large-bore
IVs.
You are the Provider
continued
Detailed Physical Exam
• You will not be able to make a diagnosis.
• This exam may help provide more information.
• Do not delay transport to perform this.
• Vital signs:
– BP 96/64 mm Hg
– Respirations 36 breaths/min
– Pulse oximetry 95% receiving 15 L/min via
nonrebreathing mask.
• He complains of feeling dizzy.
• You place him in the shock position and cover him
with a blanket.
• He remains awake and alert during transport;
complains of severe abdominal pain throughout the
call.
You are the
Provider continued
• Patient’s condition may rapidly change.
• Reassess ABCs.
• Anticipate development of shock; treat even if there
are no obvious signs.
• Communication and documentation
– Relay information as soon as possible so that
appropriate resources are made available.
– Include pertinent physical findings.
Ongoing Assessment
Emergency Medical Care
• Take steps to provide comfort and lessen effects of
shock; reassure patient.
• Position patients who are vomiting to maintain
airway.
• Be sure to use BSI.
• Clean ambulance and equipment once patient is
delivered.
Review
1. MOST patients with an acute abdomen present
with:
A. dyspnea.
B. diarrhea.
C. hypotension.
D. tachycardia.
Review
Answer: D
Rationale: Tachycardia (heart rate >100 beats/min) is
commonly seen in patient’s with an acute
abdomen; it is usually the result of severe pain.
Hypotension is not seen in all patients with an
acute abdomen; if the patient is hypotensive, you
should suspect internal bleeding or a severe
infection (sepsis). Many patients with an acute
abdomen have increased respirations (tachypnea);
however, dyspnea (a feeling of shortness of breath)
is not common.
Review
1. MOST patients with an acute abdomen present with:
A. dyspnea.
Rationale: Some patients may have increased respirations, but
typically do not have difficulty breathing.
B. diarrhea.
Rationale: Diarrhea may be a symptom of some abdominal
problems, but not in most patients.
C. hypotension.
Rationale: Hypotension is not seen in most patients and should be
suspected when shock is present.
D. tachycardia.
Rationale: Correct answer
Review
2. The ___________ lies in the retroperitoneal space.
A. liver
B. pancreas
C. stomach
D. small intestine
Review
Answer: B
Rationale: The pancreas, kidneys, and ovaries lie in
the retroperitoneal space, which is behind the
peritoneum, and are often the cause of acute
abdominal pain. The liver, stomach, and small
intestine are all found within the true (anterior)
abdomen.
Review
2. The ___________ lies in the retroperitoneal space.
A. Liver
Rationale: The liver is found in anterior abdomen.
B. Pancreas
Rationale: Correct answer
C. Stomach
Rationale: The stomach is found in anterior abdomen.
D. small intestine
Rationale: The small intestine is found in anterior abdomen.
Review
3. A 34-year-old woman with a recent history of pelvic
inflammatory disease presents with acute severe
abdominal pain. Her abdomen is distended and
diffusely tender to palpation. Based on your
findings thus far, you should suspect:
A. peritonitis.
B. pancreatitis.
C. appendicitis.
D. cholecystitis.
Review
Answer: A
Rationale: Peritonitis—an inflammation of the thin
membrane that lines the abdominal cavity—
typically presents with acute abdominal pain.
Causes of peritonitis include infection and blunt or
penetrating abdominal trauma. The pain caused by
peritonitis is typically diffuse (widespread), whereas
appendicitis, pancreatitis, and cholecystitis
(inflammation of the gallbladder) typically present
with pain that is localized to a particular area.
Review
3. A 34-year-old woman with a recent history of pelvic inflammatory
disease presents with acute severe abdominal pain. Her
abdomen is distended and diffusely tender to palpation. Based
on your findings thus far, you should suspect:
A. peritonitis.
Rationale: Correct answer
B. pancreatitis.
Rationale: Pancreatitis is usually a localized pain (in one specific
area).
C. appendicitis.
Rationale: Appendicitis is usually a localized pain (in one specific
area).
D. cholecystitis.
Rationale: Cholecystitis is usually a localized pain (in one specific
area).
Review
4. In which position do most patients with acute
abdominal pain prefer to be transported?
A. Sitting with head elevated 45°
B. Supine with their legs elevated 12”
C. On their side with their knees flexed.
D. Fowler’s position with their legs straight
Review
Answer: C
Rationale: Most patients with acute abdominal pain
prefer to lie on their side with their knees flexed
(and usually drawn up into their abdomen). This
position takes pressure of the abdominal muscles
and may afford them pain relief.
Review
4. In which position do most patients with acute abdominal pain
prefer to be transported?
A. Sitting with head elevated 45°
Rationale: This is also know as the semi-Fowler’s position.
B. Supine with their legs elevated 12”
Rationale: This is usually done in patients with hypotension.
C. On their side with their knees flexed.
Rationale: Correct answer
D. Fowler’s position with their legs straight
Rationale: This is when the patient is sitting straight up.
Review
5. A condition in which a person experiences a loss of
appetite is called:
A. ileus.
B. colic.
C. emesis.
D. anorexia.
Review
Answer: D
Rationale: Anorexia is defined as a loss of appetite. It
is a non-specific symptom, but is often associated
with gastrointestinal diseases and abdominal pain.
Review
5. A condition in which a person experiences a loss of appetite
is called:
A. ileus.
Rationale: This is the paralysis of the muscular contractions that
normally propel material through the intestine.
B. colic.
Rationale: This is a severe, intermittent cramping pain.
C. emesis.
Rationale: This is also know as vomiting.
D. anorexia.
Rationale: Correct answer
Review
6. If a hernia is incarcerated and the contents are so
greatly compressed that circulation is
compromised, the hernia is said to be:
A. reduced.
B. ruptured.
C. strangulated.
D. hypoxemic.
Review
Answer: C
Rationale: A strangulated hernia occurs when a
hernia is incarcerated and compressed by the
surrounding tissues. It is a serious medical
emergency and requires immediate surgery to
repair the hernia, remove dead tissue, and return
oxygen to the tissues.
Review
6. If a hernia is incarcerated and the contents are so greatly
compressed that circulation is compromised, the hernia is
said to be:
A. reduced.
Rationale: This is a mass or lump that will disappear back into
the body cavity in which it belongs.
B. ruptured.
Rationale: This is a mass or lump that bursts from internal
pressure.
C. strangulated.
Rationale: Correct answer
D. hypoxemic.
Rationale: This is a decrease in arterial oxygen levels.
Review
7. Which of the following signs or symptoms would
you be the LEAST likely to find in a patient with an
acute abdomen?
A. Rapid, shallow breathing
B. Soft, nondistended abdomen
C. Tachycardia and restlessness
D. Constipation or diarrhea
Review
Answer: B
Rationale: Signs and symptoms of an acute abdomen
include, but are not limited to, rapid and shallow
breathing, a tense and distended abdomen,
tachycardia, restlessness, and constipation or
diarrhea.
Review
7. Which of the following signs or symptoms would you be
the LEAST likely to find in a patient with an acute
abdomen?
A. Rapid, shallow breathing
Rationale: This is a common sign of an acute abdomen.
B. Soft, nondistended abdomen
Rationale: Correct answer
C. Tachycardia and restlessness
Rationale: These are common signs of an acute abdomen.
D. Constipation or diarrhea
Rationale: These are common signs of an acute abdomen.
Review
8. Which of the following is NOT a solid organ?
A. Liver
B. Kidney
C. Spleen
D. Gallbladder
Review
Answer: D
Rationale: The gallbladder is a hollow organ that
concentrates and stores bile, which is produced by
the liver. Other hollow organs include the stomach
and intestines. The liver, spleen, and kidney are all
solid organs.
Review
8. Which of the following is NOT a solid organ?
A. Liver
Rationale: The liver is a solid organ.
B. Kidney
Rationale: The kidney is a solid organ.
C. Spleen
Rationale: The spleen is a solid organ.
D. Gallbladder
Rationale: Correct answer
Review
9. A 70-year-old man presents with an acute onset of
severe, tearing abdominal pain that radiates to his
back. His BP is 88/66 mm Hg, pulse rate is 120
beats/min, and respirations are 26 breaths/min.
Treatment for this patient should include:
A. rapid transport to the hospital.
B. firm palpation of the abdomen.
C. placing him in a sitting position.
D. oxygen at 4 L/min via nasal cannula.
Review
Answer: A
Rationale: Severe, tearing abdominal pain that
radiates to the back is typical of an abdominal
aortic aneurysm (AAA); it commonly occurs in older
patients—especially those with hypertension.
Treatment includes high-flow oxygen and rapid
transport. If the patient has signs of shock, place
him or her supine and elevate the legs 6” to 12”. Do
not vigorously palpate the patient’s abdomen; doing
so may cause the aneurysm to rupture.
Review (1 of 2)
9. A 70-year-old man presents with an acute onset of severe,
tearing abdominal pain that radiates to his back. His BP is
88/66 mm Hg, pulse rate is 120 beats/min, and respirations
are 26 breaths/min. Treatment for this patient should
include:
A. rapid transport to the hospital.
Rationale: Correct answer
B. firm palpation of the abdomen.
Rationale: A firm or vigorous palpation is contraindicated in
patients with severe and sudden onset abdominal pain.
Review (2 of 2)
9. A 70-year-old man presents with an acute onset of severe,
tearing abdominal pain that radiates to his back. His BP is
88/66 mm Hg, pulse rate is 120 beats/min, and respirations
are 26 breaths/min. Treatment for this patient should
include:
C. placing him in a sitting position.
Rationale: Hypotension is treated by elevating the patient’s legs
into the shock position.
D. oxygen at 4 L/min via nasal cannula.
Rationale: High flow oxygen is indicated in the treatment of
shock.
Review
10. The medical term for inflammation of the urinary
bladder is:
A. cystitis.
B. nephritis.
C. cholecystitis.
D. diverticulitis.
Review
Answer: A
Rationale: Cystitis is the medical term for
inflammation of the urinary bladder. Nephritis is
inflammation of the kidney. Inflammation of the
gallbladder is called cholecystitis. Diverticulitis is a
condition in which small pouches in the colon (large
intestine) become inflamed.
Review
10. The medical term for inflammation of the urinary bladder is:
A. cystitis.
Rationale: Correct answer
B. nephritis.
Rationale: Nephritis is the inflammation of the kidney.
C. cholecystitis.
Rationale: Cholecystitis is the inflammation of the gallbladder.
D. diverticulitis.
Rationale: Diverticulitis is the inflammation of part of the large
intestine.