Emergency Care Institute

01A Abdominal pain

Published on 12 Nov 2021 Printed on 4 Feb 2023

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Any person who presents with abdominal pain or discomfort.

This EPIC protocol is to be used by a registered nurse who has been appropriately assessed trained. The shaded portions blue or pink indicate where a nurse requires additional training and education to provide this level of care. EPIC protocols are supported by the NSW Health Policy Directive XXXXX and EPIC Medication Monograph XXXX.

History prompts

Always consider current medications, past admissions, allergies and past medical history.

  • Onset of symptoms
  • History of cardiac disease
  • Description of pain (consider PQRST)
  • Identify cardiac risk factors: age > 55, familial, hypertension, hyperlipidaemia, diabetes, smoking, Aboriginal & Torres Strait Islander
  • Prehospital treatment effect (if any)

Associated signs and symptoms

  • Nausea/vomiting
  • Sweating
  • Shortness of breath
  • Palpitations
  • Lethargy/fatigue
  • Pain/discomfort/heaviness
  • Radiation of pain

Red flags

Clinical and historical red flags and escalation criteria.  Refer to Senior Medical Officer and continue treatment.

Consider escalation early if no medical officer available as per local protocols.

  • Sudden onset
  • Peritonism/distended abdomen
  • Pregnancy
  • Known AAA
  • Recent abdominal or gynaecological surgery
  • Constipation/diarrhoea
  • >60 years of age
  • Altered level of consciousness
  • Immunosuppressed/steroids
  • Unrelieved pain
  • Guarding
  • Hypotension and tachycardia
  • Recent trauma
  • On anticoagulants
  • Suspected ectopic pregnancy
  • Symptoms of gastrointestinal bleeding

Clinical assessment and specified intervention

Position

AssessmentIntervention

Observe for patient guarding

Position of comfort for patient

Airway

Commence appropriate airway, respiratory and circulatory support.

AssessmentIntervention

Establish patency of airway.

If concern for airway patency, commence airway management and BLS measures as required.

Breathing

AssessmentIntervention
Observe respiratory rate and effort.  
Measure SpO2. If SpO2 < 95%, apply O2.
Auscultation of chest as clinically indicated.  

Circulation

AssessmentIntervention

Measure BP and HR.


Capillary refill (central and peripheral).

Attach cardiac monitor if any red flags identified or BP/HR fall within yellow or red BTF.

If SBP <90 mmHg fluid bolus as per medication section.

Electrocardiography

Obtain 12 lead ECG for all patients with epigastric pain or as clinically indicated.

Assess need for IVC and pathology.

IV cannulation and collect relevant pathology.

If SYS <90mmHg consider fluid bolus per medication section.

Disability

AssessmentIntervention

GCS, pupillary response and limb strength.

Obtain baseline. Repeat assessment as clinically indicated.

Pain Assessment/ Score – PQRST. If pain present, refer to 26A - Pain management

Exposure

AssessmentIntervention
Temperature Aim for normothermia. If abnormal assess clinical causes and consider EPIC sepsis protocol.
Skin inspection (including posterior surfaces). Skin temperature should be noted as well as surgical scars, skin integrity, wounds, medical devices and presence of abnormalities.

Fluids

AssessmentIntervention
Commence fluid balance chart.  
Commence NBM status.

Explain to patient requirement of NBM and when this will be reviewed.

Commence IV Fluid maintenance if NBM duration expected to exceed 4 hours, seek Medical officer input for same

Glucose/gastrointestinal

AssessmentIntervention
BGL measurement.  

GIT history (last ate/drank/bowels opened/passed urine/vomited).

Palpation of abdomen.

If ostomy bag present observe functioning and activity levels.

Presence of blood loss  
Abdominal assessment See focused assessment below.

Altered bowel habits

Commence stool chart.
Nausea and/or vomiting.

If continued nausea and vomiting, consider antiemetic.

For further advice, refer to 44A - Vomiting

Haematemesis of melaena

If bleeding, refer to 16A - GIT bleeding

Focused assessment - abdominal

Go to detailed abdominal focused assessment

Inspection Position the patient in supine position with abdomen exposed from xyphoid process to symphysis pubis. Look at all four quadrants and observe for skin colour / discolouration, scars, masses, prominent veins, tension (rigid or soft?) distension (contour), bruising, devices, pulsations, patient, or foetal movement.
Auscultation Bowel sounds – hyperactive, reduced, or absent over 4 quadrants.
Palpation With warm hands lightly palpate each region (1-2 cm) for: tenderness, pain (if present is it referred?), guarding, rebound tenderness, masses, pulses, signs of peritonism. If no signs elicited repeat with deep palpation (4-5 cm) to each region.
Percussion A drum-like (tympanic) sound should be heard in air filled areas dullness sounds occur over solid organs/masses or beneath fluid filled areas.

Repeat and document assessment and observations in order to identify trends, clinical deterioration and/or responses to interventions as per Between the Flags and Local CERS Guidelines.

Interventions / diagnostics

Radiology
Bedside eFAST (if accredited). Medical officer may order abdominal ultrasound +/- CT.
Pathology

UA – send for MSU if positive for nitrites and/or leucocytes
Hypovolemia or sepsis (shocked patient): VBG (if available).
RUQ/epigastric pain: LFT, Lipase. (Troponin if cardiac considerations).
History of alcohol abuse: LFT, Lipase.
Warfarinised: INR, if clinically indicated
Woman of childbearing age: Urine βHCG. Attend Quantitative βHCG if urine positive or known pregnancy.
If temp <35 oC or ≥38.5 oC: collect x2 blood cultures from different sites, await MO direction.

Specific treatment

Commence sepsis pathway if patient meets criteria.

Commence AWS for patients with a history of alcohol use.

If patient has a history of possible alcohol dependence proceed to thiamine hydrochloride in the medication section.

Medications

Medications within this guideline must be administered within the context of the EPIC medication monograph

DrugDoseRouteFrequency

Oxygen

6-15 L/min

Inhalation

Continuous

0.9% sodium chloride

10 mL flush

IV/IO

As required

250 mL (maximum 1000 mL)

IV/IO Once only. Repeat every 10 minutes (up to 1000 mL) until SBP >90 mmHg
300 mg IV/IM/IO Once only.

Disposition

Precautions and notes

  • Risk factors for AAA include smoking, male, elderly, Caucasian, atherosclerosis, hypertension, family history of AAA, other peripheral artery aneurysm (iliac, femoral, popliteal).
  • Peritonism typical symptoms include nausea, vomiting, poor appetite, and dull abdominal pain that turns into severe abdominal pain worsened by movement. Risk factors include liver cirrhosis, peritoneal dialysis, ruptured or perforated abdominal organ/ulcer.
  • Acute cholecystitis risk factors include elderly, female, obesity, diabetes mellitus, profound weight loss, fasting or family history.
  • Acute pancreatitis consider abdominal pain-upper right generalised, typically severe, may radiate to back, nausea, vomiting and diaphoresis, abdominal tenderness, abdominal distension.
  • Absent or diminished bowel sounds may indicate constipation, a bowel obstruction or a perforated viscous.
  • Anorexia is a common symptom of an acute abdomen.
  • Atypical presentations or a pain free abdomen can occur in the elderly, immunocompromised, or pregnant patients.
  • Elderly patients presenting with abdominal/loin/flank pain have a 14% mortality rate. Symptoms may be vague with low tolerance for shock. For example, a SBP of 90mmHg may be critical if previously hypertensive.
  • Opioid analgesics can be safely administered before full assessment and diagnosis in acute abdominal pain without increasing the risk of errors in diagnosis or treatment.

Reassessment

Always reassess your patient, communicate your findings, document and escalate when needed.

References

  • Australian Medicines Handbook (2020). Online Available [Accessed 9/11/2020]
  • Emergency Care Institute (2020) Abdominal Emergencies. Online Available [Accessed 9/11/2020]
  • Emergency Care Institute (2020) Acute Cholecystitis Online Available [Accessed 9/11/2020]
  • Winter, W and West, M. (2020) BMJ Best Practice: Assessment of acute abdomen. BMJ Publishing Group. Online Available [Accessed 9/11/2020]
  • Kendall,J & Moreira, M (2017) UpToDate Evaluation of the adult with abdominal pain in the emergency department. Online Available [Accessed 9/11/2020]
  • MIMS Australia (2020) Online Available [Accessed 9/11/2020]
  • Penner, R. & Fishman, M (2020) Up to Date: Evaluation of the adult with abdominal pain. Online Available [Accessed 9/11/2020]
  • Stern, S., Cifu, A & Altkorn, D (2015) Symptom to Diagnosis: An Evidence-Based Guide, Abdominal pain chapter 3. 3edn. Lange McGraw-Hill Education. Online Available [Accessed 9/11/2020

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Evidence informed EPIC protocols are based on grey literature, clinical consensus and rapid evidence checks led by the ACI’s Emergency Care Institute.
Collaboration EPIC protocols have been developed in collaboration with the NSW emergency care clinicians, NSW Health pillars, relevant Ministry of Health branches and ACI networks.
Currency Due for review: Jan 2026. Based on a regular review cycle.
FeedbackEmail ACI-ECIs@health.nsw.gov.au

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/networks/eci/clinical/epic/adult/abdominal-pain

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