Chapter 17. The acute abdomen
Abdominal emergencies usually present with acute abdominal pain in association with other symptoms and signs. The causes range from life-threatening conditions that require immediate resuscitation and laparotomy to those that require more conservative management.
Diagnosis may be difficult, consequently the paramedic should concentrate instead on assessing the severity of the patient’s condition and on managing it appropriately. In particular, it is important to detect patients who require immediate resuscitation and urgent transfer.
Pain is the major symptom of abdominal emergencies. It also has characteristics that can provide a clue to the underlying problem.
Irritation of the diaphragm, e.g. by blood, may produce pain referred to the shoulder-tip on the same side (due to shared innervations). A ruptured ectopic pregnancy may produce referred shoulder-tip pain.
• History
• Pain
• Vomiting
• Bleeding (haematemesis or per rectum)
• Altered bowel habit
• Shock
• Abdominal distension.
• Where is the pain?
• What type of pain is it (i.e. inflammatory, colicky or ischaemic)?
• Does the pain move?
• What makes the pain better?
• What makes the pain worse?
• How long has the pain been present?
• How rapid was the onset of pain?
• Have you had this pain before? If so, what happened?
• Patient can localise the area of tenderness precisely (early)
• Coughing precipitates abdominal pain in the area of tenderness (early)
• There is rebound tenderness in the painful area (intermediate)
• Reluctance to move (aggravates the pain)
• No abdominal movement with expansion of the chest on inspiration (late)
• Generalised rigidity of the abdominal wall (very late)
• Pyrexia.
Vomiting and GI haemorrhage
• Vomiting may accompany severe pain or be directly caused by the abdominal disease. It is a common presentation in most acute abdominal conditions
• Intestinal obstruction is one of the causes of vomiting
• Vomiting blood indicates disease of the upper gastrointestinal tract Unaltered, bright red blood (haematemesis) suggests an oesophageal lesion, whereas altered blood, resembling ‘coffee grounds,’ due to partial digestion, indicates a gastric or duodenal site
• Upper gastrointestinal bleeding can also give rise to melaena, altered blood being lost as sticky, black, ‘tarry’ stools with a characteristic smell
• Bleeding from the lower gastrointestinal tract is seen as altered blood if the lesion is in the proximal part of the large bowel (e.g. caecal or small bowel carcinoma) or as bright red blood if it lies more distally (e.g. haemorrhoids or rectal carcinoma)
• Patients will need intravenous fluids to treat dehydration or replace blood loss.
• Acute gastrointestinal bleeding
• Ruptured abdominal aortic aneurysm
• Trauma leading to abdominal vessels or organs being torn or ruptured
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