Any person, 16 years and over, who is afebrile with loin and/or flank pain.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
There should be a high index of suspicion for abdominal aortic aneurysm (AAA) in patients over 50 years with a first episode of afebrile loin pain.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Onset of symptoms
- Pain assessment–PQRST
- Pre-hospital treatment
- Past admissions
- Medical or surgical history
- Current medications
- Known allergies
Signs and symptoms
- Pallor
- Clammy
- Nausea and vomiting
- Dysuria
- Dark or blood coloured urine
- Radiation of pain into the groin
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Abdominal, urological or gynaecological surgery
- Female of childbearing age
- Over 50 years
- Known aortic aneurysm
- Recent trauma
- Pregnancy
Clinical
- Dizziness or syncope
- Hypotension
- Abdominal distension or rigidity
- Urinary retention
- Fever
- Severe pain not responding to analgesia
Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Position
Assessment | Intervention |
---|---|
General appearance/first impressions | Position of comfort |
Airway
Assessment | Intervention |
---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
Assessment | Intervention |
---|---|
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2) | Assist ventilation as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92% |
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure (initial includes both arms) Cardiac rhythm | Assess circulation Attach a cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern |
IVC and/or pathology | Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Disability
Assessment | Intervention |
---|---|
ACVPU | If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength |
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment, as clinically indicated |
Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment |
Exposure
Assessment | Intervention |
---|---|
Temperature | If fever present, consider sepsis (suspected) protocol |
Skin inspection, including posterior surfaces | Check and document any abnormalities |
Fluids
Assessment | Intervention |
---|---|
Hydration status: last ate, drank, bowels opened, passed urine or vomited | Commence fluid balance chart as required |
NBM | Consider clear fluids or NBM based on red flags and clinical severity |
Nausea and/or vomiting | If present, see nausea and/or vomiting section |
Glucose
Assessment | Intervention |
---|---|
BGL | Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol |
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Complete an abdominal focused assessment
Precautions and notes
- Assessment of abdominal pain is complex. Be aware of cognitive bias and focus on identifying red flags. Consider early escalation.
- If patient meets sepsis criteria, switch to sepsis (suspected) protocol and commence NSW Health Adult Sepsis Pathway. Urgent escalation of care and treatment is required.
- Consider abdominal aortic aneurysm (AAA) in any patient aged over 50 years who presents with abdominal, flank or back pain:
- Complete initial blood pressure on both arms. More than 20 mmHg difference between arms is abnormal. This can be an indicator of aortic dissection.
- The symptoms of a ruptured AAA may mimic renal colic, diverticulitis or gastrointestinal haemorrhage.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) provide the most effective available pain relief in renal colic.
- Opioid analgesics can be safely given before full assessment and diagnosis in acute abdominal pain, without increasing the risk of diagnostic errors.
- Elderly patients presenting with abdominal, loin or flank pain have a 14% mortality rate. Symptoms may be vague with low tolerance for shock. For example, an SBP of 90 mmHg may be critical if previously hypertensive.
- Consider gynaecological causes:
- Ectopic pregnancy – a medical emergency that can present as abdominal pain in early pregnancy
- Pregnancy in all females of childbearing age
- Ovarian torsion.
Interventions and diagnostics
Specific treatment
Consider bedside bladder scan if concern for urinary retention.
If renal colic is suspected, give one of:
- ibuprofen 400 mg orally once only
- or ketorolac 10 mg IM once only
- or indometacin 100 mg rectally once only.
Analgesia
Select pain score:
Pain score 1–3 (mild)
Give paracetamol 1000 mg orally once only
Pain score 4–6 (moderate)
Give:
oxycodone (immediate release):
- 16–65 years: 5 mg orally and, if required, repeat once after 30 minutes, maximum dose 10 mg
- 65 years and over: 2.5 mg orally and, if required, repeat once after 30 minutes, maximum dose 5 mg
and/or paracetamol 1000 mg orally once only
Pain score 7–10 (severe)
Give one of:
Fentanyl intranasal
- 16–65 years: 50 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 100 microg. Dose to be divided between nostrils
- 65 years and over: 25 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 50 microg. Dose to be divided between nostrils
Note: ensure an extra 0.1 mL is drawn up for the first dose to account for the dead space in the mucosal atomiser device
Fentanyl IV
- 16–65 years: 50 microg IV and, if required, repeat once after 5 minutes, maximum dose 100 microg
- 65 years and over: 25 microg IV and, if required, repeat once after 5 minutes, maximum dose 50 microg
Morphine IV
- 16–65 years: 5 mg IV and, if required, repeat once after 5 minutes, maximum dose 10 mg
- 65 years and over: 2.5 mg IV and, if required, repeat once after 5 minutes, maximum dose 5 mg
Morphine IM
- 16–65 years: 5 mg IM and, if required, repeat once after 60 minutes, maximum dose 10 mg
- 65 years and over: 2.5 mg IM and, if required, repeat once after 60 minutes, maximum dose 5 mg
and/or paracetamol 1000 mg orally once only
If pain does not improve with medication, escalate as per local CERS protocol.
Nausea and/or vomiting
If nausea and/or vomiting is present, give:
- metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
- or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
- or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only
Choice of antiemetic should be determined by cause of symptoms.
Radiology
Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.
Pathology
- FBC, UEC
- Urinalysis: mid-stream (preferred), clean catch or catheter urine. If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed
- Warfarinised: INR
- Temp less than 35°C or 38.5°C and over: take two sets of blood cultures from two separate sites
- Female of childbearing age: urine βHCG. If positive and within the first trimester, send serum βHCG for quantitative analysis
Medications
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
Drug | Dose | Route | Frequency |
---|---|---|---|
Fentanyl H, R | 16–65 years: 65 years and over: | IV/intranasal | Pain score 7–10 Repeat once if required after 5 minutes to maximum dose |
Ibuprofen H, R | 400 mg | Oral | Renal colic Once only |
Indometacin H, R | 100 mg | Per rectal | Renal colic Once only |
Ketorolac H, R | 10 mg | IM | Renal colic Once only |
Over 20 years: | Oral/IV/IM | Once only | |
Morphine H, R | 16–65 years:
65 years and over: | Pain score 7–10 | |
IV | Repeat once if required after 5 minutes | ||
IM | Repeat once if required after 60 minutes | ||
4 mg Maximum dose 8 mg | Oral/IV/IM | Repeat once if required after 60 minutes | |
16–65 years:
65 years and over: | Oral | Pain score 4–6 Repeat once if required after 30 minutes to maximum dose | |
Oxygen | 2–15 L/min, device dependent | Inhalation | Continuous |
1000 mg | Oral | Pain score 1–10 Once only | |
5 mg | Oral | Once only | |
OR | |||
12.5 mg | IV/IM | Once only | |
250 mL Maximum dose 1000 mL | IV/intraosseous | Bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Antonelli J, Maalouf N. Nephrolithiasis. London, UK: BMJ Best Practice; 2018 [cited 27/01/2023]. Available from: https://bestpractice.bmj.com.acs.hcn.com.au/topics/en-gb/3000101
- Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
- Curhan G, Aronson M, Preminger G. Diagnosis and acute management of suspected nephrolithiasis in adults. USA: Wolters Kluwer; 2019 [cited 27 Jan 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/kidney-stones-in-adults-diagnosis-and-acute-management-of-suspected-nephrolithiasis
- Favus MJ, Feingold KR. Kidney Stone Emergencies South Dartmouth (MA): Endotext; 2018 [cited 27 Jan 2023]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK278956/
- Fontenelle LF, Sarti TD. Kidney Stones: Treatment and Prevention. Am Fam Physician. 2019 Apr 15;99(8):490-6.
- Kendall J, Moreira M. Evaluation of the adult with abdominal pain in the emergency department. USA: Wolters Kluwer; 2020 [cited 27 Jan 2023]. Available from: https://www.uptodate.com/contents/evaluation-of-the-adult-with-abdominal-pain-in-the-emergency-department
- Knott L. Loin Pain: Causes, Symptoms, and Treatment. Leeds, UK: Patient; 2022 [cited 27 Jan 2023]. Available from: https://patient.info/doctor/loin-pain
- Leath C, Lowery W. Assessment of acute abdomen. London, UK: BMJ BEst Practice 2018 [cited 27 Jan 2023]. Available from: https://bestpractice.bmj.com.acs.hcn.com.au/topics/en-gb/503?acc=36422
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 13 Apr 2022]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
Currency | Due for review: Jan 2026. Based on a regular review cycle. |
Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/afebrile-loin-pain