A 20-year-old male with abdominal pain, that's the call. You arrive on scene and find your patient, Larry, lying on a couch in his dorm. His roommate lets you in and tells you he called 9-1-1 because his friend seems really sick. The patient looks at you as you approach and says, "My belly hurts badly." His skin is pink, warm and diaphoretic as you reach for a pulse. His pulse is strong and regular at 110. His breathing is shallow at a rate of 20. You ask your partner to obtain a set of vital signs while you complete your assessment. Your patient tells you he's been tired and has had a sore throat for the past two days. This morning, he developed abdominal pain, which he describes as a constant ache in his left upper abdomen and an ache in his left shoulder.
Abdominal pain can be a difficult complaint to assess. Many causes of abdominal pain aren't life-threatening, but some are. It may be difficult for you as an EMS provider to identify the exact cause of the pain, but you should be able to identify potential life-threatening causes and transport appropriately.
Anatomy of the Abdomen
The abdomen has nine regions. Down the sides of the abdomen there are the right and left hypochondriac regions, the right and left lumbar region and the right and left iliac regions. Down the middle of the abdomen are the epigastric region, the umbilical region and the hypogastric region. The typical EMS assessment redefines the abdomen into four primary regions: left and right upper and lower quadrants. The diaphragm creates the upper margin of the abdomen with the pubis being the lower margin. The umbilicus is in the center. In the abdomen, there are solid organs and hollow organs, all of which can bleed or swell. As a medical provider, you must have a working knowledge of abdominal anatomy. Properly locating the pain can identify the organs involved.
Types of Abdominal Pain
There are three primary presentations of abdominal pain: visceral, parietal and referred. Visceral pain is caused when the nerves on an organ sense an acute stretching of that structure's wall. This pain isn't well localized and is commonly described as an ache or cramp. Hollow organs will present with an intermittent colicky type pain, which can range from a mild ache to a severe cramping sensation, while the pain created by the solid organs is more constant. When asked to localize the pain, patients will commonly identify a region that's uncomfortable.
Parietal pain, also known as somatic pain, is caused by irritation to the parietal peritoneal wall. This type of pain is commonly described as "sharp" and "pinpoint" pain. When asked to localize their pain, patients will point to a specific spot. For example, patients with an inflamed appendix may point to a spot in the middle of the right lower quadrant known as McBurney's point. These patients may feel better with their knees drawn up, which relaxes the peritoneum.
Referred pain occurs when the brain is unable to localize the area of irritation. The brain will incorrectly identify the area of discomfort, telling the patient they hurt in an area different from the actual point of irritation. For example, inflammation of such upper abdominal organs as the gall bladder and the spleen commonly present with pain in the left or right shoulder. This is known as Kehr's sign.
Evaluation & Assessment
When evaluating a patient with abdominal pain, look at the abdomen. Note signs of distension. A distended abdomen that develops over a long period of time typically isn't painful; however, acute distention hurts. Scars suggest previous surgeries and bruising around the navel (Cullen's sign) or at the flanks (Grey Turner's sign) suggest abdominal bleeding. Ask the patient about bowel and bladder function. You'll want to know about frequency, consistency, odor and changes in discomfort during or after voiding or having a bowel movement. Consider any variation as being associated with the cause of the patient’s pain.
Ask about nausea, vomiting and the presence of blood in their stools or emesis. Blood in the gastrointestinal system can be partially digested when it's excreted. If blood is vomited, it can have a dark, coffee ground appearance. If it's present in stool, it may have a dark tarry appearance known as melena. Ask about recent trauma. With female patients, ask about the possibility of pregnancy.
Palpate the abdomen starting at the furthest region from the area of discomfort. Press down slowly but firmly, watching the patient to see if the pain presentation changes. Normal abdomens should be soft and non-tender.
If the patient tightens their abdominal muscles when you palpate, they may be guarding. If the abdomen is rigid, it may suggest blood, digestive juices, or bowel material may be present in the peritoneal cavity. Note any masses that could suggest tumors, obstructed bowel or aneurysms. Monitor the patient's vital signs and watch for signs of shock.
Treatment should include oxygen administration as tolerated by the patient. Establish an IV if within your scope of practice. Consider two IVs if the patient presents with hemodynamic instability and transport rapidly. Evaluate for other diseases that can present with abdominal discomfort, such as diabetic ketoacidosis and myocardial infarction. Pain medications, including fentanyl, are allowed in some systems, as is the administration of an antiemetic (Zofran, for example) if the patient presents with nausea.
After dropping Larry off at the hospital, you follow up with the emergency room physician and learn he had an enlarged spleen (splenomegaly) caused by the Epstein-Barr virus, more commonly known as mononucleosis, or "mono." Mono infects the B-lymphocyte, resulting in an inflammation of the spleen. This explained Larry's left upper quadrant abdominal pain and neck discomfort. Larry was kept in the emergency department for observation and was later sent home with orders to rest until the virus ran its course.