A pain in the guts
Paramedic prehospital ambulance abdominal pain
Ask yourself, honestly, is attending to a callout for ‘adult patient complaining of abdominal pain’ anywhere near your top ten of ‘let’s go partner’?
Maybe not quite in the basement with vomiting or diarrhea, yet I still think very far from the top.
What about ‘adult female with acute ectopic pregnancy’? That one jumped a few places. Or ‘adult patient with suspected abdominal aortic aneurysm’? Yeah, that’s on my higher up list too. Good paramedic emergencies.
And yet these could easily have been what was called in, if someone hadn’t simply categorised the problem as abdominal pain, where we started this conversation. See where this is going?
Let’s have a look at abdominal pain and see if we can separate the clinical findings that should make us sit up, park our bias, and pay attention. Are there even some red flags we can rely on to pick our trouble patients.
Before we even go on, let’s keep a few underlying dot points in mind:
• Abdominal pain is easy to say, far more challenging to diagnose. Nobody diagnoses hastily since there are so many options, with many overlapping in presentation. All that less serious noise is undermining.
• This overlap means serious causes will be mixed in with much less serious. Tricky. Red flags would be good.
• Further investigation is commonly needed. Not only for the cases that are clearly urgent, but also for all the others. All pain deserves an answer and hopefully resolution. Even if you establish a presentation is not particularly urgent, as many will be, that does not mean it doesn’t require follow through.
Start with reviewing how we even find out our decision-making information. We are told some things by the patient or relatives. This includes their known history (what has happened today or recently) and past history (that’s every other day before this event). Then we add in what we find for ourselves. This includes what we see, palpate, percuss and even auscultate. We’re not going to expand on the nuts and bolts of the actual examination here, only the findings. With those findings, it isn’t that important whether we divide the abdomen into four quadrants or the nine regions approach. The latter is a bit more specific in locale, your choice.
Now we mentioned findings. Let’s tease out ‘abdominal pain’ a little more than just ‘pain’ in the ‘abdomen’. Pain can be somatic. The outer lining peritoneum and superficial tissues have greater and more specific innervation. More nerves feeding more information into more specific spinal cord segments. The result is the body has a better understanding of what is going on. Pain is better able to be localised, easier to describe as sharp or stabbing or knife like and often includes findings such as tenderness to go with it.
On the other hand, visceral pain comes from deeper within. The organs themselves don’t need a whole lot of sensory innervation. You might prick your thumb and need to know about it, but it isn’t going to happen to your liver all that often. So visceral pain is vague, diffuse, poorly localised, harder to describe. Sounds a bit like cardiac pain – an organ of course. Fewer nerves feeding into less specific spinal segments or even via ganglion first.
And pain can be acute or chronic. Even here texts differ. Pain starting today is acute. Pain in three weeks can still be acute. Pain in three months, starting to become chronic. Six months, yep chronic.
That’s the pain itself. There are also associated features along with it. Vomiting, bowel and urine activity along with any changes, guarding or rigidity of the abdominal wall and of course any visible abnormality such as distension, bruising or pulsations.
Finally, there is the patient overall presentation. Their perfusion, consciousness, respiration and fever/coldness from vital signs all tell us how badly the patient is being affected by the pain.
With these our findings, now what features are helpful in raising warning signs? What the patient is doing when you find them can help. The patient rolling around, writhing in pain is a clue. That could mean something such as the agony of renal or biliary colic boring into them. However, it is not absolute since a patient lying very still could be trying to minimise exacerbating their peritonitis agony. What the patient is doing on arrival is helpful, but not absolute.
Pain location then? Serious cause pain can be found in all quadrants. A little more helpful is that pain away from the umbilicus tends to have increased potential for seriousness. Again, useful but not absolute.
Vomiting is also useful. You’ll need to dig a little deeper though and we’ll come back to that. Suffice to say, vomiting that comes after abdominal pain has a likelihood of surgical cause including appendicitis (1,2). On the other hand, abdominal pain that relieves somewhat after vomiting is suggestive of bowel obstruction (3). More clues but not absolute.
So to actual red flags.
Some patients are simply at higher risk when abdominal pain strikes, whatever its cause. Older patients, those with multiple comorbidities, those immunocompromised and those who have a history of excessive alcohol consumption all face difficulties with identifying the new problem amongst other chronic symptoms/signs. They also have reduced ability to compensate and respond to any new additional problem. Red flags.
Along those lines, some clues are not to be ignored. Scars suggest previous surgery. Previous abdominal surgery might mean one problem has been fixed, yet it also predisposes to adhesions, increasing the likelihood of bowel obstruction and, if near to fallopian tubes, ectopic pregnancy (4). Red flags.
Past history plays a further role if the pain being assessed has already been diagnosed. Once a patient can tell you they know they have a serious cause, your job is already two-thirds done. At the other end, no previous episode of abdominal pain should prompt the need to find out what is causing this one. Red flags.
On a side note, the finding of heart valve disease or recent atrial fibrillation should prick your ears up straight away. These have a strong association with clot and emboli formation leading to stroke. Those same offending clots can travel anywhere and in the company of new abdominal pain, should prompt the exclusion of mesenteric ischemia sooner rather than later (5). Very red flags.
Think pain, think onset. One onset that is easily underrated is trauma. In the trauma world, head, chest, pelvis and limbs always rate highly. They either affect vital signs badly, or they cause severe pain or deformity. The poor old abdomen is often overlooked in this excitement. The abdomen is the third most injured body region in trauma causing as many as 10% of traumatic deaths (6). Any suggestion of penetrating trauma is serious. Blunt trauma can be more varied though never underestimate its potential. Bruising, abrasions, tenderness should all prompt investigation. Serious abdominal pain in trauma may easily be only mild, particularly in the presence of other more notable distractors. Red flags.
Obstetric cause abdominal pain includes the earlier daunting ectopic pregnancy and later placental abruption. In the case of the latter, consider history in the presentation. Of course, don’t forget the onset of labour itself! If there is known or possible pregnancy found in the assessment, and always ask appropriate patients, then consider this a red flag with abdominal pain.
Pain findings of concern include any pain onset that comes on suddenly, is severe, is within the first say six hours or so since onset or has awoken the patient from sleep. Changing pain including location (for instance, appendix pain begins viscerally across the abdomen before becoming somatic as the inflammation affects the surrounding peritoneum) or intensity (getting worse is rarely a good thing) should always be considered red flags.
So too should referred or radiation of pain. Underlying innervation can lead to such things as shoulder tip pains associated with gall or splenic disease. Just as pain down an arm, neck or jaw suggests cardiac likelihood with chest pain, referred pains with abdominal pain should also prompt concern.
The description of the pain site can contain red flags. Rigidity of the abdominal wall, guarding over the area, tenderness, ascites or palpable pulsatile mass should all be considered red flags if detected.
Finally, physical patient findings, though not specific to abdominal pain causes, when associated form red flag warnings. Patients who have perfusion compromise are always in trouble. This includes shocked vital signs, syncope or clinical findings of dehydration. The latter particularly accompany ongoing vomiting or diarrhea.
Fever or sepsis signs are always of concern with abdominal pain.
Patients who have generalised ascites, recent unexplained weight loss, become jaundiced or developed rashes or signs of anaemia always raise red flags for further evaluation.
Vomiting, which has been mentioned, should always be explored further. Is there visible blood in it? How much? What about bile presence? Or faecal matter? And, of course ongoing vomiting not only leads to fluid imbalance, it can also lead to metabolic alkalosis.
Lastly, look for bowel or urinary changes. Blood in either is always concerning. A literal red flag. Regularity changes can suggest obstruction, gastrointestinal disease or indicate urinary infection.
Jeff Kenneally www.prehemt.com
1. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589–1594.
2. Witt K, Mäkelä M, Olsen O. Likelihood ratios to determine ‘does this patient have appendicitis?’: comment and clarification. JAMA. 1997;278(10):819–820.
3. Böhner H, Yang Q, Franke C, Verreet PR, Ohmann C. Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain. Eur J Surg. 1998;164(10):777–784
4. Tabibian, N., Swehli, E., Boyd, A., Umbreen, A. and Tabibian, J.H., 2017. Abdominal adhesions: A practical review of an often overlooked entity. Annals of Medicine and Surgery, 15, pp.9-13.
5. Gnanapandithan, K. and Feuerstadt, P., 2020. Mesenteric Ischemia. Current gastroenterology reports, 22(4), pp.1-12.
6. Arumugam, S., Al-Hassani, A., El-Menyar, A., Abdelrahman, H., Parchani, A., Peralta, R., Zarour, A. and Al-Thani, H., 2015. Frequency, causes and pattern of abdominal trauma: a 4-year descriptive analysis. Journal of emergencies, trauma, and shock, 8(4), p.193.