# Advice on abdominal pain.



## Melclin (May 1, 2011)

Got a job this evening as I was settling down in front of a bowl of sweedish meat balls :glare:.

Backing an Intensive care crew who wanted to handball and abdo pain. 

88F with 6 week hx of feeling generally unwell, 3 day hx of nausea and vomiting that "comes and goes" experienced sudden onset 10/10 sharp LUQ abdo pain while vomiting. 

Haemodynamically stable BP 115/70 after 5mg of morphine (Her presenting BP was per the Intensive care crew 160/90 which seems plausible pre pain relief, but I don't trust those NIBPs). Paced rhytm @ 80. Resp 20, GCS 15, Clear chest. 

Hx of CAG, valve replacement, Af, pacemaker, Peptic ulcer disease and a few other things that I can't remember. 

I'm not being very specific because I'm looking for some discussion, this isn't really a who dun it. Management wise, all I did was give her another 2.5mgs morphine. The most important thing in these jobs seems to be coming up with a good hx&phys and working diagnosis to set her on the right care pathway with the appropriate triage category. 

This is the first job I've been too where I couldn't really come up with a decent working diagnosis and risk stratification. The best I could do was that she may have torn or herniated something during the process of vomiting. 

Anyone care to share posibilities about pts like this and on the risks of life threatening pathologies like a disecting AAA. What are some of the causes and profiles of sudden onset pain experienced while vomiting and that continues after the vomiting has subsided.


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## Veneficus (May 1, 2011)

There has to be more findings than this.

What else did you see or find, be descriptive.


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## Melclin (May 1, 2011)

I'll let you know if anything comes to mind after I've slept (I'm 13.5 hours into a night shift right now). I didn't have her for much more than about 10 minutes and she was deaf so getting the information out of her that I did was a challenge in itself. 

Like I said, I'm not asking you to diagnose her. Just for some advice or thoughts on looking into abdo pain like this, or ideas about sudden onset pain that occurs during vomiting.


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## RatMed (May 1, 2011)

Character of the pain, radiation, body position and movement influencing it or not? Is this the first time she's in the pain like this?
Palpation of the abdomen (and lower ribs)? Peritonitis signs?
Auscultation for signs of intestine obstruction? 
How did the vomit look like (blood present)?
Examination for kidney stones perhaps?
ECG and examination for heart failure just to be sure.

For the very little I know, LUQ is a strange locaton for abdominal pain like this.


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## jwk (May 1, 2011)

Sick old lady with abdominal pain and vomiting.  Lots of potential causes, from gas to pancreatitis to cancer.  She's got stable vital signs, you've got an IV, and given her something for pain.  That's really all you need.  

BTW - NIBP is used on every case in the OR in the US.  We don't even have a manual cuff if we wanted one.  They are very reliable, and the better quality machines are very good at dealing with motion artifact.  Almost nobody auscultates blood pressures anymore.


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## 18G (May 1, 2011)

There is so much in the abd that could be wrong that it is very difficult to impossible to pinpoint the cause of the pain in the prehospital environment. Without diagnostic imaging and blood work its anyones guess really out in the field. Granted some causes we can be pretty confident of with say appendicitis. 

As JWK said, all you can do is ensure they are hemodynamically stable, obtain IV access, treat the pain, nausea, and provide supportive care. Prehospital care isn't gonna change much with a precise diagnosis.


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## Trevor (May 2, 2011)

First thing that POSSIBLY comes to mind for me (with the VERY LIMITED info) is *Mesenteric Ischemia*... Fairly common in order people, especially with Afib. And, (Im trying to think of the EMRAP podcast episode), but i think it has something like (*pulls number out of  descending colon*) 40...ish% mortality... Doesnt nessicarily have to be related to the nausea/vomiting. Or it could be due to DHD from the nausea/vomiting... Again, very little info...


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## sweetpete (May 2, 2011)

Hey, completely new here and enjoying it so far. Currently in paramedic school and was curious about giving the morphine for pain.  Our current understanding is that this drug is contraindicated in cases of undiagnosed abdominal pain.

That being said, does patient discomfort typically overrule a vague contraindication (like the above)? Just was curious how you personally would view that dilemma.

Nonetheless, dx'ing abdominal pain in the field seems like a shot in the dark at best sometimes.

Thanks, 
Pete


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## mycrofft (May 2, 2011)

Ditto Ratmed. Bowel sounds, abdominal palp and maybe percussion (tympany). LUQ is descending flexion of large bowel, first place acute pain appears from buildup of gas and/or stool in large bowel. Meds the pt has been taking, including OTC's, herbals.

Also pancreas, not so good there. If vomitus was really biley, I've seen that with pancreatitis (the hospital dx after we sent them out).

Gee, I know. Give her a laxative...:wacko:  A cohort did that once, in accordance with standardized procedures, and sent the pt to the hospital with a ruptured appendix the next evening.

Opiates in abdo pain can mask s/s by reducing gut motility, as well as other direct pharmaco concerns I'm ignorant of.


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## J. Burdett (May 2, 2011)

W/ a hx of peptic ulcer disease according to occam's razor it's more than likely associated w/ that. Maybe a perforated ulcer? Mallory–Weiss syndrome? The pain could just be that... It hurts when you vomit. I would be more concerned about underlying cause of the colicky x3 days of N/V. IBS? Diverticulitis? Chloecystitis? Pancreatitis? CVS? We have alot more questions than answers. Imaging, lab values, and a good physical assessment would shed more light.


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## Trevor (May 2, 2011)

sweetpete said:


> Hey, completely new here and enjoying it so far. Currently in paramedic school and was curious about giving the morphine for pain.  Our current understanding is that this drug is contraindicated in cases of undiagnosed abdominal pain.
> 
> That being said, does patient discomfort typically overrule a vague contraindication (like the above)? Just was curious how you personally would view that dilemma.
> 
> ...




Pete- this varies from system to system. My system has pretty liberal pain medication protocols. I can givefentanyl 1 mcg/kg up to a mex of 300mcg for pretty much any type of pain i think needs it (including abdominal pain), and up to 400mcg for burns. There are no real contraindications about use of morphine in patient's with abdominal pain. Perhaps cautioned if the have hypotension (potentially from hemorrhage or acute abdomen). What your talking about probably refers to is the antiquated belief that "masking" someones pain prior to MD eval is bad... THIS IS NOT TRUE! 90% of these people will be getting imaging (usually CT) so its okay to relieve (or at least decrease) their pain. Caveot= As ong as its okay with your protocols. The title of my protocol is simply "Pain Management" and whether thats a headache, or a radius stickign out of someones wrist, doesnt really matter. Not treating pain is barbaric! I still cant believe that some systems have cant administer analgesia! (*hands the patient a stick and tells him to bite down*)...


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## sweetpete (May 2, 2011)

Trevor: Excellent response. I see what you're saying. Thanks for taking the time to "enlighten" a student.

Since were on the subject, I tend to agree with you 100%, not treating a patient's "pain" seems to be ancient medicine. Documenting that the pain was a 10/10 prior to administration and then documenting that the pain subsided to, say a 4/10 shouldn't fool anyone into thinking that the underlying symptoms or causes have miraculously been fixed. 

Thanks again for the info.
Pete


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## Smash (May 2, 2011)

sweetpete said:


> Hey, completely new here and enjoying it so far. Currently in paramedic school and was curious about giving the morphine for pain.  Our current understanding is that this drug is contraindicated in cases of undiagnosed abdominal pain.
> Pete



We aren't in the 1920s any more, it's ok to give pain relief to abdominal pain, even if you don't know what is causing it.  Analgesia "masking" diagnosis a particularly pernicious myth that sadly will just not die, despite the large amount of good data (and common sense) that demonstrates it's absurdity.

Please, please, please give pain relief.  Pain relief is one of the most important tools of medical care, yet one of the most poorly utilized.


Amoli HA, Golozar A, Keshavarzi S, Tavakoli H, Yaghoobi A. Morphine analgesia in patients with acute appendicitis: A randomised double-blind clinical trial.. Emergency Medicine Journal 2008;25(9):586–589.

Attard AR, Corlett MJ, Kidner NJ, Leslie AP, Fraser IA. Safety of early pain relief for acute abdominal pain. BMJ 1992;305(6853): 554–556.

Gallagher EJ, Esses D, Lee C, Lahn M, Bijur PE. Randomized clinical trial of morphine in acute abdominal pain. Ann Emerg Med 2006;48(2):150–160.

LoVecchio F, Oster N, Sturmann K, Nelson LS, Flashner S, Finger R. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997;15(6) 775–779. 

MahadevanM, Graff L. Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain. Am J Emerg Med 2000;18(7):753–756.

Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996;3(12): 1086–1092.

Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN, Kumar AM, Stair TO. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial. J Am Coll Surg 2003;196(1):18–31. 

Vermeulen B, Morabia A, Unger PF, Goehring C, Grangier C,Skljarov I, Terrier F. Acute appendicitis: influence of early painrelief on the accuracy of clinical and US findings in the decision to operate--a randomized trial. Radiology 1999;210(3):639–643


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## NomadicMedic (May 2, 2011)

I just had another medic tell me this on Saturday. He just snorted when I showed him the pain management line in the abdominal pain protocols. 

Not providing analgesia is simply cruel.


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## mycrofft (May 3, 2011)

*Manage pain without screwing the diagnosis,*

Got anything that doesn't act like laudanum?


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## Veneficus (May 3, 2011)

Trevor said:


> I still cant believe that some systems have cant administer analgesia! (*hands the patient a stick and tells him to bite down*)...



Is that any worse than agencies that have only 1 pain med and allow it in what amounts to sub theraputic doses. 

ie: 2mg morphine every 5 minutes.


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## mycrofft (May 3, 2011)

*Homeopathic EMS*

Just stick on the electrodes and don't turn on the defib.

A sidetrack to OP, belly pain can sometimes be of spinal origin. Have the pt draw a circle around the pain with their finger and see if it follows a dermatome or crosses midline.

Another set of hoofprints...appendicitis or diverticulitis can initially present with pain away from the primary site, oddly enough.

PS:SMASH, thanks for references!!!


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## rhan101277 (May 5, 2011)

Veneficus said:


> Is that any worse than agencies that have only 1 pain med and allow it in what amounts to sub theraputic doses.
> 
> ie: 2mg morphine every 5 minutes.



Here it is 2-4mg q 5 minutes up to 10mg max.  Must call for orders to manage abdominal pain w/ morphine or ketorolac.  We have a new med control physician so he may be adding fentanyl.

I had another abdominal pain yesterday, 10/10.  Previous history of ventral hernia surgery and the hernia came back.  This guy is in severe pain, tachy in the 130's.  I can't get a line so I have to simply monitor him and try to use diversion techniques.  It even look like his surgical wound had not completely healed.  He had some strange systemic skin bruising/discoloration going on that I have never seen before.


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## Smash (May 5, 2011)

rhan101277 said:


> Here it is 2-4mg q 5 minutes up to 10mg max.  Must call for orders to manage abdominal pain w/ morphine or ketorolac.  We have a new med control physician so he may be adding fentanyl.
> 
> I had another abdominal pain yesterday, 10/10.  Previous history of ventral hernia surgery and the hernia came back.  This guy is in severe pain, tachy in the 130's.  I can't get a line so I have to simply monitor him and try to use diversion techniques.  It even look like his surgical wound had not completely healed.  He had some strange systemic skin bruising/discoloration going on that I have never seen before.



Why not some IM morphine?  Not necessarily ideal, but better than nothing.


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## rhan101277 (May 5, 2011)

Smash said:


> Why not some IM morphine?  Not necessarily ideal, but better than nothing.



Yeah it would have been better than nothing, but with onset time anywhere from 10-30 minutes, for IM, he would be at ER to get IV morphine within that time.


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## MrBrown (May 5, 2011)

Hmm lets see 

10ml of salty water or 2mg of morphine .... which to choose, which to choose? 

You know what, hey mate, this stuff we're going to give you might cause some really funky dreams, just go with it OK? 

*Brown looks around for the nearest set of hands, you there, Smash type person, get Brown a pack of dextrose .... and put that down that ambophone the MAS Metro Clinician doesn't want to hear about crazy Brown again today!


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## usalsfyre (May 5, 2011)

rhan101277 said:


> Yeah it would have been better than nothing, but with onset time anywhere from 10-30 minutes, for IM, he would be at ER to get IV morphine within that time.



Call and ask for permission to nebulize 10mgs of morphine.


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## Smash (May 5, 2011)

usalsfyre said:


> Call and ask for permission to nebulize 10mgs of morphine.



This.  AND give him the 10mg IM, he might not thank you now, but he will in 10 minutes time.


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## Melclin (May 7, 2011)

I was sitting on a recliner at like 6 am with a copy of tintinalis and it wasn't much help, so I thought, I'll ask those clever chaps and chapettes on the interwebs. Like I said, I wasn't looking for a high level convosation and diagnosis, just a few light thoughts. Something like, "Yeah not sure, umm, well look for this and that and you know what, problem x jumps out at me" OR "Oh sudden onset LUQ pain with vomiting? Classic problem Y". Cheers to mycrofft, ratmedic and burdett, gave me a few things to think about.

With the sudden onset with vomiting, I thought something along the lines of malory-weis but it didn't seem to fit in terms of how the pain was presenting and there was no haematemesis.

+1 on pain management in abdo pain. Aside from the fact that its obviously inhumane to withhold, even in my short time in the job I have seen how patients are so much easier to accurately assess with some pain relief on board. Especially the doubled over abdopain. I had a bloke with a ?fractured rib the other day who couldn't remember any medical hx or meds and could barely tell us what happened for the pain even with 30mg of self administered oxycodone on board. He was so poorly communicative that it would have been easy to think it was abdo pain...and if you couldn't morph abdo pain.....:wacko:

Anyway 200mcq IN fent and 12.5 morphine later, we had a perfectly comfortable and communicative pt almost free of pain and easy to assess. 



jwk said:


> BTW - NIBP is used on every case in the OR in the US.  We don't even have a manual cuff if we wanted one.  They are very reliable, and the better quality machines are very good at dealing with motion artifact.  Almost nobody auscultates blood pressures anymore.



Yeah its not NIBP in general I have a problem with. Its just some of the ones on our monitors. They seem to error with any movement and are frequently quite different to the manual pressure. 

I think maybe they aren't calibrated as often as they should or maybe they get knocked about a bit. In any case my experience with them has not been great. 

I take the view that the first pressure should be manual and then you can set the NIBP to q-whatever and as long as its consistent then its all good in the hood.


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## rhan101277 (May 7, 2011)

usalsfyre said:


> Call and ask for permission to nebulize 10mgs of morphine.



Yeah I would hear crickets on the other line once I asked something such as this.  Though it would be hilarious to do so.


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## mycrofft (May 7, 2011)

*Thanks Melclin!*

Sitting here in a cheap office chair and typing advice at people in the field can be SO unrewarding sometimes....B)

On reflection, go ahead and slow that gut motility. Not doing anything constructive and it can be restarted anytime at the hospital.

And remember, when you hear footfalls, think emus, not ostriches, mate.


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## usalsfyre (May 7, 2011)

mycrofft said:


> Sitting here in a cheap office chair and typing advice at people in the field can be SO unrewarding sometimes....B)
> 
> On reflection, go ahead and slow that gut motility. Not doing anything constructive and it can be restarted anytime at the hospital.
> 
> And remember, when you hear footfalls, think emus, not ostriches, mate.



I get the sarcasm, but are you advocating NO pain management for abdominal issues? Because even after fairly major abdominal surgery (involving the gut) my wife got opiates, so the motility argument holds very little water.


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## mycrofft (May 7, 2011)

*Nope, not sarcasm. Just retracting my earlier suggestion.*

Gut motility, which can be retarded with opioids, is a diagnostic factor, but I realized after subsequent replies I was wrong about needing to serially auscultate them. Auscultate BS's as part of initial exam, then do whatever it takes to achieve analgesia; in many cases, the peristalsis may actually be harmful if there is possibility of gut contents escaping somewhere, or it is just fruitlessly (pun unintended) ramming gut contents against a mass or other blockage, or an intussusception.

So, the short answer is, no, I am not suggesting we let people writhe for our diagnostic convenience. I was wrong.:blush:

(PS: my better half had Roux-en Y, and yes, they ordered APAP wi. codeine susp. Yummy...).


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## WelshMedic (May 9, 2011)

*Pain management*

Hello all,

First off, re: the blue rinse with tummy pain, did you do a HCG test? Ectopic pregnancies are easily missed, you know 

Sorry, I can't help myself. Now into serious mode:

I recently suffered a very bad bout of food poisoning with abdominal cramps. Due to the nature of the complaint I was taken to hospital by my own colleagues. My painscore was initially 10+ (come on, I'm a man) but after some alfentanyl from my colleague it went down to a 2. It made a world of difference to me, I went from climbing the walls to a chilled state in about 2 mins. It also made me think about the importance of pain management in my own practice. And yes, now that I have been on the other end of the sitck, if they say it's 5 or more they get decent analgesia from me.

To withhold analgesia is just plain cruel. And has an effect on mortality and morbidity.

Carl.


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