1
Scene Size-Up & BSI ▼
- Gloves (vomitus, blood, feces exposure risk)
- Note patient position: knees to chest (peritoneal irritation), writhing (ureteral/biliary colic)
- Look for: blood in toilet/vomit, medication bottles, alcohol, signs of trauma
- Body habitus, jaundice, distension visible on approach
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2
Initial Assessment — Hemodynamic Status
- General impression: Ill-appearing vs well-appearing, diaphoresis, pallor
- Airway: Manage if vomiting — positioning, suction
- Circulation: Tachycardia + hypotension = hemorrhagic or septic shock → Load & Go
- Abdomen on approach: Rigid vs soft, distension, guarding
- Fever? Jaundice? Pregnancy? — Key history clues
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3
SAMPLE History ▼
- Signs & Symptoms: Pain, N/V, fever, diarrhea, constipation, urinary symptoms
- Allergies
- Medications: NSAIDs/steroids (GI bleed risk), anticoagulants, antibiotics, immunosuppressants
- Pertinent hx: Prior abdominal surgery (adhesions, ostomy), IBD, PUD, hernias, AAA
- Last oral intake & last BM
- Events: Alcohol use, trauma, sexual history, LMP (females of reproductive age → ectopic!)
- ⚠ Females: Always consider ectopic pregnancy, ovarian torsion, PID
- ⚠ Elderly/diabetics: May have absent or atypical pain — MI, PE can present as abdominal pain
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4
OPQRST Pain Assessment ▼
- Onset — sudden (vascular, perforation, torsion) vs gradual (infection, obstruction)
- Provocation — worse with movement (peritonitis), eating (ulcer, cholecystitis), meals (mesenteric ischemia)
- Quality — colicky/crampy (bowel/ureter) vs constant/severe (vascular/ischemia) vs burning (ulcer)
- Radiation — right shoulder (gallbladder), flank/groin (kidney stone), back (AAA, pancreatitis)
- Severity — 1–10. "10/10" sudden onset = vascular emergency until proven otherwise
- Time — duration, progressive worsening, prior episodes
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📍 Step 5 — Quadrant Location
Select Pain Location
📊 Step 6 — Interactive Differential
🧭 Associated Findings
Select all applicable symptoms/findings:
Select quadrant location and symptoms to generate differential
⚠ Peritoneal Signs — Surgical Emergency
Peritoneal signs = likely surgical emergency. Immediate transport. ALS intercept. NPO. Do not delay for further assessment.
Rigidity
Board-like abdominal wall. Involuntary guarding. Indicates peritoneal irritation.
Rebound Tenderness
Pain worse when pressure released. Classic peritonitis sign.
Guarding
Voluntary or involuntary muscle tensing with palpation.
Distension
Tympanic or distended abdomen. Obstruction, perforation, or ileus.
⚖️ Surgical vs Medical Assessment
🩺 Step 7 — Management
General Abdominal Pain Management
BLS Position of comfort — supine with knees flexed often reduces pain. Never force a position.
BLS NPO — Nothing by mouth. Surgical possibility, aspiration risk if vomiting.
BLS O2 — Only if SpO2 < 94% or hemodynamic compromise. Not routinely required.
BLS Nausea management: Position (semi-recumbent), basin available. ALS ondansetron (Zofran) 4mg IV/IM/ODT if available per protocol.
ALS IV access en route. NS bolus for hypotension/shock. Titrated fluids for suspected obstruction.
BLS Vital signs every 5 min for critical/unstable patients. Note BP trends — orthostatic hypotension suggests significant hemorrhage.
BLS Documentation: Onset time, LMP (females), last BM, surgical hx, character of pain — all critical for ED team.
🚨 ALS Intercept Criteria
🔴 ALS Request — Any of the following:
- Hemodynamic instability (HR > 120, SBP < 90)
- Signs of shock — cool/clammy/diaphoretic
- Suspected AAA rupture (pulsatile mass + back pain + elderly)
- Ectopic pregnancy with rupture (reproductive age female + peritoneal signs)
- Suspected bowel perforation (sudden severe pain, rigid abdomen)
- Mesenteric ischemia (elderly, pain out of proportion to exam)
- Uncontrolled vomiting requiring antiemetics
- Pain management (morphine/fentanyl)