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Abdominal Pain ProtocolSpecial ConsiderationsCommon causes in young healthy adults include appendicitis, cholecystitis, pancreatitis, perforated ulcer, and diverticulitis.Appendicitis is the most common out of these and it typically presents with colicky periumbilical pain that migrates to the lower right quadrant pain. Rupture or perforation of the appendix increases significantly after 36 hours of onset and it can be deadly. Diagnosis should be made quick!Cholecystitis is caused by a buildup of bile in the gallbladder. Gallstones are a primary cause. Pain is typically found in the upper right quadrant and it is common for patients to experience this after ingesting fried, greasy, spicy, or fatty foods. Not very common in the younger, male population.Pancreatitis is becoming more common in recent years, but the vast majority (80%) of cases are still caused by gallbladder disease or alcohol abuse. Pain is typically found in the upper right quadrant and the mid-epigastric region. Treatment is typically supportive. Perforated ulcers occur when an ulcer or open sore goes all the way through the wall of the stomach/intestine. Pain will be sudden and sharp around the affected area with bleeding noted in vomitus or stools. Soldiers who smoke, abuse alcohol, and abuse NSAIDS are most at risk for this. Immediate surgery is typically required to control bleeding.Diverticulitis is caused by an inflammation of the pouches (diverticula) along the walls of the intestines (typically in the colon on the left side). Pain is typically found in the lower left quadrant and may result in fever, bloating, constipation, or rectal bleeding (rare). Not common in young population, but very common in the older population (50% chance in patients over age 60). May be treated with antibiotics.Consider constipation/fecal impaction as a potential cause of abdominal pain.Have a suspicion for constipation/fecal impaction if the patient has been sedentary, had a low-fiber diet recently, has not been able to defecate recently, or has been taking any new medications, especially opiate medications (they slow the digestive system). Pain is typically dull and familiar. Hydration and moderate use of laxatives will typically help. For fecal impaction, an enema may be required. Consider bowel perforation if abdominal pain begins within 72 hours of blast injuryMay present many days after the blast. Be suspicious! Signs and Symptoms Suggestive for Urgent EvacuationSevere, persistent, or worsening abdominal pain is the key sign. Mild GI issues will typically resolve themselves within a day. Otherwise, it’s likely something more serious.Rigid abdomenReferring to a stiffness of the abdominal muscles. May be a sign of any of the conditions listed above!Rebound abdominal tendernessSpecifically refers to appendicitis. Also known as “Blumberg’s sign”. When pressure is slowly placed on the appendix and suddenly released, the PT may feel a severe, sharp pain. Validity of this method has been questioned. FeverThis would indicate a prostaglandin response from an infection (cholecystitis, diverticulitis, etc.)Absence of bowel soundsNo bowel sounds may indicate a blockage (constipation/fecal impaction) or a response to slowed digestive processes (caused by opiates)Focal percussive tendernessSensitivity to mild percussion is unusual for mild abdominal complaints. Be weary!Uncontrollable vomitingVomiting is a very common symptom for a number of conditions, but more than a few episodes of vomiting should concern you.Presence of bloody vomitus or stoolsBright red vomitus indicates an upper GI bleed (ex. Stomach, esophagus, etc.). Bright red blood in stools indicates a lower GI bleed (rectum or end of colon). Presence of black tarry stoolsBlack tarry stools is the result of blood from an upper GI bleed mixing with digestive fluids and take on the appearance of tar. It also smells awful!Presence of coffee ground vomitusThe “coffee grinds” are clumps of coagulated blood from an upper GI bleed, typically from esophageal varices or gastric ulcers. ManagementStart IV with normal saline (NS), 1L bolus, followed by NS 150mL/hr. Keep NPO except for medications or PO hydration Patients with abdominal pain are likely to be dehydrated from vomiting or lack of fluid intake for fear of nausea. Normal saline is appropriate for this. Avoiding substances by mouth (“NPO”) is necessary in order to prevent further exacerbation of conditions that are often initiated by foods/liquids, like cholecystitis, pancreatitis, and diverticulitis. Ertapenem (Invanz) 1 g IV dailyErtapenem is a broad-spectrum, carbapenm antibiotic that is readily available to medical personnel and commonly used for complicated intra-abdominal infections. It is not necessarily going to be appropriate for every abdominal pain etiology, but will adequately treat things like cholecystitis, diverticulitis, appendicitis….if an infection is present. The Ertapenem should be given via IV over 30 minutes.OR ceftriaxone (Rocephin) 1 g IV daily, plus metronidazole (Flagyl) 500 mg PO q8hrCeftriaxone is a broad-spectrum 3rd generation cephalosporin that also used for intra-abdominal infections. Treat per Pain Management Protocol (DO NOT USE NSAIDS)Treat per Nausea and Vomiting ProtocoolDisposition-Urgent evacuation to a surgical facilitySigns and Symptoms Suggestive for Continued ObservationsEpigastric burning painPresent bowel soundsNausea and/or vomitingAbsence of rebound tendernessIf diarrhea is present, treat per Gastroenteritis ProtocolManagementAntacid of choiceRanitidine (Zantac) 150 mg PO bid or rabeprazole (Aciphex) 20 mg PO dailyPO hydrationDispositionObservation and re-evaluationPriority evacuation if symptoms not controlled by this management within 12 hours. TCCC Drugs:-Fentanyl-Morphine-Ketamine-Meloxicam-Tylenol-Midazolam-TXA-Saline/LR-Hextend-Moxifloxacin-Ertapenem-CefotetanGarrison Drugs:-Tylenol-Ibuprofen-Diphenhydramine-Ranitidine-Epi (1:1000)-Aspirin-Zofran-Phenergan-Pseudophedrine-Azithromycin-Bisacodyl-Fluconazole-Loperamide (immodium) ................
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