Abdominal Pain

[Chief1C]

According to our PCR program, in 2012, the most common "dispatch complaint" is abdominal pain. With accompanied hypotension, the symptoms usually side with a bleed, an aneurysm, or cardiogenic shock in which the patient begins to have digestive upset.

[MikeEMT]

Acute, rapid onset pain and she's clutching the right location. The lowered HR and BP makes me think that it might've burst. Appendicitis requires emergency surgery and I'm not sure what an EMT-B can do for it. I'll find out what medications she's on/allergic to, pertinent history, full assessment if one hasn't been performed already, and other info for the ED.

I'm not 100% positive that this involves the appendix, but if it does, I want to limit time on scene and get her to the nearest surgery center that can handle it.

Correct me if I am wrong but the patient is experiencing pain in their RUQ that is radiating to midline. Appendicitis usually presents in the RLQ doesn't it? I don't see anything other than pain the indicates Appendicitis. Tenderness? Vomiting? Hx of Appendicitis?

Does she have history of Liver problems? She is 6 weeks post partum, when was her last BM? Have her BM's been consistent and regualr?

What is her temp?

[HarryM]

As above for questioning. Needs an in-depth history taken. Would want to rule out AAA, cardiac conditions and any possible vaginal bleed before getting in a provisional diagnosis of exactly what sort of abdominal condition she might have...and that is realistically only going to be properly done with diagnostic equipment in ED. In terms of treatment some pain relief (would start with some Fentanyl due to hypotension), and 500 - 1000ml NaCl enroute for the hypotension.

Any signs of septic shock? If so then would consider Ceftriaxone depending on distance from home to ED.

[Bieber]

No masses, patient will BARELY let you touch her, and she is very tender to palpation with no rebound tenderness. EKG shows a sinus bradycardia with no ectopy. With some probing patient also admits to having had a cholecystectomy about a year ago and also of depression. No food, objects or toxins, no blood in the stool, urine or vomitus. No nausea/vomiting. Poop is normal, last bowel movement was around eight hours ago. No odor to the house.

Doc, pain is sharp, stabbing, no radiation, nausea/vomiting, temp is 98.4, no complications with any of her pregnancies (all vaginal deliveries). Patient was sleeping when her pain started. Abdomen is soft, very tender and painful to the epigastrium and right upper quadrant, no rebound tenderness, no bruising or rigidity.

Normal S1 S2 heart sounds with no extra sounds, lung sounds are clear and equal bilaterally.

CSC, think back to your abdomen anatomy with relation to the location of the appendicitis, as well as the typical presentation of it (no fever or nausea/vomiting). Do you want to request ALS backup?

Patient takes "something for depression" and is allergic to Lortab.

HEENT: Mucous membranes moist. No perioral cyanosis. Eyes PERRL.

Neck: Supple, no JVD, retractions, tracheal deviation.

Chest: Equal chest rise, adequate depth of respiration.

Abdomen: Painful/tender to epigastrium and RUQ. No bruising, distention, rigidity.

Pelvis: Stable.

Posterior: Normal on inspection.

Extremities: Neurovascular function intact x4, no numbness/tingling.

Const: Afebrile, no recent weight loss.

CV: Radial pulse weak, regular and slow. S1, S2 present, no extra sounds.

Resp: Lung sounds clear and equal bilaterally.

Neuro: GCS 15, Alert and Oriented x3, Affect: severe distress.

GI/GU: No melena, diarrhea, constipation, nausea/vomiting, or dysuria. Regular and consistent bowel movements. No vaginal bleeding or discharge.

Integumentary: Skin pale, dry.

MS: Normal.

Mike, no history of liver problems, alcoholism. HIV negative per patient. Patient denies history of aortic aneurism, Marfan's syndrome or Ehlers-Danlos syndrome.

Harry, how much Fentanyl do you want to give? You get an IV and begin infusing NS. Distance to the nearest appropriate facility is 20 minutes, and as mentioned above patient is afebrile.

Edited September 9, 2012 by Bieber

[DFIB]

Is the patient present jaundice?

Did her husband punch her in the stomach?

I am not sure, she does not seem to be hypovolemic but very well could be if the onset is quick. Her mucous membranes are moist and although her BP is tanking her HR is not compensating with tachycardia. I am thinking about unreported domestic abuse, a portal bleed, hepatitis,

Is she still suffering depression? How severe is her depression? Might she have ingested something?

I think I would treat this patient like she were in shock with an acute abdomen of unknown etiology. Increase volume, pain management, priority transport.

EDIT: What do you ALS guys think. Maybe a little epinephrine or vasopressin for this lady. Her BP and HR are my primary concern.

Is she from a third world country or traveled out of the country recently?

Edited September 9, 2012 by DFIB

[Bieber]

No jaundice, no trauma. Still suffering depression, husband thinks it's post-partum depression. Patient adamantly denies ingesting any toxins or anything like that.

How do we want to manage her blood pressure? How about her pain? What are we thinking? Do we have evidence of an inadequate pump, volume, or vasculature? Why?

[ERDoc]

Husbands are idiots (once a a guy tell me his wife was faking it and had anxiety when she had agonal resps with a pH of 6.9). Have we gotten a 12-lead yet?

[J306]

I'd like to know what she was prescribed for her depression, when the prescrition was issued, dosage, how many pills are remaining, when did she last take it? I'd like to gain more information on her recent mental state from the husband.. Has there been a history of depression? Has it gotten progressively worse? Associated anxiety or suicidal ideation?

I'm leaning towards a possible tricyclic anti-depressant overdose. Having hypotension accompanied with bradycardia causes me to think that we need to know more about this medication. Tricyclic anti-depressant OD's have been known to cause an ileus of the small bowel which would explain the RUQ abdominal pain.

Last bowel movement was 8 hours ago, but prolonged use of tricyclics can still cause ischemia progressing to necrosis.

Are bowel sounds present? Any ECG abnormalities on the 12-lead indicating OD?

As for tx:

If QRS >.10 and evidence of cyclic OD 1mEq/kg of sodium bicarb while bolusing normal saline to pressure of 100 mmHg

[Bieber]

12-lead shows a regular sinus rhythm rate of 40, normal axis deviation with no st-elevation/depression, t-wave inversion or other conduction abnormalities.

Patient's husband runs and grabs the wife's bottle of Zoloft. It appears that the patient has been taking it as prescribed with no unusual amounts missing.

As far as the mental state goes husband states he thinks she suffers from post-partum depression but it otherwise normal and no history of suicidal tendencies.

[DFIB]

What and when was her last oral intake?