abdominal pain and pregnancy EM

what is the difference between visceral and somatic pain

visceral is less localized and general, somatic is now more localized and specific (often goes from visceral → somatic as the peritoneum becomes inflamed)

abdominal pain safety net

vital signs w pulse ox, O2 supplements, IV access (and rainbow blood draw), NPO status

maybe: iv fluids, EKG, NG tube

possible associated sx w abdominal pain to ask about

fever/chills, N/V/D, back/chest pain, genitourinary complaints, skin changes

last meal/drink/bowel movement, mictrution, prev abd surgeries, similar episodes, pain characteristics (pain on/off, constant etc), sexual history (to include LMP)

what do all abdominal pain pts in EM require

rectal exam w stool guaiac and GU exam to include pelvic/testicular exam (eps for lower abdominal pain unless you can really pinpoint to it being something else)

sudden, spontaneous, non traumatic, 10/10 abdominal pain with involuntary guarding and possible rigidity/hardness, severe diffuse or localized tenderness to palpation and peritoneal signs (rebound tenderness, heel tap, shaking movement)

acute abdomen (goes to surgery)

DDX for abdominal pain in RUQ

hepatitis, cholecystitis, cholangitis, hepatomegaly, PUD, pancreatitis, retrocecal appencidictis, cardiac pain, pneumonia, PE

DDX for abdominal pain in LUQ

gastritis, PUD, pancreatitis, cardiac pain, pneumonia, PE

DDX for abdominal pain in MEG

gastritis, PUD, pancreatitis, gastroparesis, cardiac pain, pneumonia, PE, abdominal aortic aneurysm

DDX for abdominal pain in RLQ or LLQ

appendicitis, IBD, PID, mittelschmerz, ovarian cyst/torsion, TOA, endometriosis, uterine fibroids, ectopic preg, orchitis, testicular torsion, ureterolithiasis, mesenteric adenitis, hernia

DDX for abdominal pain in suprapubic region

cystitis, hernia, PID, preg, prostatitis, ovarian cyst/torsion, testicular torsion

DDX for abdominal pain in back/flank pain

ureterolithiasis, pyelonephritis, pancreatitis, cholecystitis, abdominal aortic aneurysm, M/S pain

DDX for abdominal pain diffuse or any quadrant

abdominal aortic aneurysm, cardiac pain, pancreatitis, DKA, bowel obstruction, hollow organ perforation, intra-abdominal hemorrhage, IBS, hastroenteritis, sickle cell crisis, mesenteric ischemia, IBD, weed hyperemesis, cyclical vomiting syndrome

what diagnostics can we rub for abdominal pain pts

CBC, CMP, lipase, preg, UA

maybe: EKG, blood cultures, lactic acid, cardiac enzymes, coag studies, fingerstick glucose, ABG/VBG, STD testing, type and cross, ETOH, urine tox, urine culture and sensitivity, acute abdominal imaging series, bedside/formal U/S, CT scan (w contrast pref), MRI

bedside U/S exam to identify free fluid (bleeding) in the abdomen or pelvis. used for blunt adn penetrating cardiac/chest trauma, preg trauma, pediatric trauma, undifferentiated, hypotension, undifferentiated abdominal pain, and to identify bleeding and ruptured organ

FAST exam

what areas are viewed in a fast exam

heart, RUQ, LUQ, pelvis

eFAST or extended FAST adds chest and lung viscera

treatment for UGIB/LGIB

assess hemodynamics and stabilize (SBP under 100 or HR over 100 indicates at least a moderate amount of blood loss), systolic BP drop indicates 30-40% loss of blood vol, dont rely on CBC or changes in Hbg/hct bc takes up to 24-72) 2 large bore IVs w blood products or intravascular fluid

correct coagulopathies if applicable

ceftriaxone (prophylactic), PPI octreotide followed by continuous infusion for suspected esophageal varices

causes of solid organ rupture

trauma, results in massive bleeding (splenorupture can be associated w mono → splenomegaly + minor trauma)

hollow organ causes

can be from lots of things like excessive dilation, infxn, acid/base erosion, trauma. often the end result of an acutely evolcing situation (ulcer, appendicitis, cholecystitis, urinary retention, bowel obstruction, ectopic preg

how does hollow organ rupture progress

progressing abdominal pain → period of pain improvement (bc organ ruptures and is no longer stretching) → worsening abdominal pain w fever → sepsis

hollow organ rupture tx

IV fluids, IV abx, vasoactive meds to maintain BP in septic shock, pain meds, foley or suprapubic catheter, surgery

acute or chronic ischemia of intestines resulting in life threatening situation. can be caused by acute embolus, vascular disease, or dec cardiac output. pt will have pain out of proportion w exam and will require either surgical re-vascularization or necrotic debridement

ischemic bowel disease

how do we treat all women of child bearing years w abd pain and how do we provide the best fetal care

treat al women of child bearing yrs w abd pain as though theyre preg untill ruled out w preg test. the best maternal care will provide the best fetal care (be aware of meds safety in pregnancy)

use the semi-left lateral decubitus position if possible to minimize IVC compression

what do we need to know about giving blood to preg pts

inc the vol in acute resuscitation by 50% to account for physiologic inc in of blood and plasma vol

can preg pts still get imaging done

yes, dont withold imaging needed for appropriate maternal trauma management (use shielding when possible)

things to know about vaginal bleeding in preg pt 20wks or less

could be potential spontaneous abortion (nothing we can do about that), do FAST exam, vaginal U/S for fetal activity and HR, obtain quantitiative serum hCG level(quant hCG used for trending), CBC (to eval for insidious blood loss) blood type, Rh factor,a dn antibody screen and UA

Rh-neg women should be treated w Rh) (D) immunoglobulin (RhoGAM) to prevent sensitization

can be discharged safely w close OB follow up

things to know about vaginal bleeding in preg pt over 20wks

admit STAT and get OBGYN, do FAST exam, obtain quantitiative serum hCG level(quant hCG used for trending), CBC (to eval for insidious blood loss) blood type, Rh factor,a dn antibody screen and UA

vaginal ultrasound to r/o abruptio placentae, placenta previa, and vasa previa while documenting fetal viability (do NOT perform a digital or speculum pelvic exam until a transvaginal US determines the location of the placenta bc could damage it)

how do we handle trauma in preg pt

besdise FAST and vaginal US to monitor fetal activity and HR< sterile pelvic ecam after US to identify injury/bleeding/amniotic fluid leakage (can use nitrazine paper pH strips and if you see ferning its amniotic fluid)

give Rho(D) immunoglobulin (RhoGAM) to Rh-neg preg women w abdominal trauma

women over 20wks preg need observation or admission for fetal monitoring

hypertension (systolic 140+, diastolic 80+) over 20wks gestation + either new onset proteinuria OR sudden inc proteinuria OR development of HELLP syndrome

preeclampsia

what is HELLP syndrome

hemolysis, elevated liver enzymes, low platelet count

treatment for mild preeclampsia

discharge to outpatient possible w very close OB f/u and after consulting w OB (get them in there that day)

treatment for severe preeclampsia (Systolic BP over 160)

only definitive tx is delivery

antihypertensives: labetalol, hydralazine, nifedipine

IV magnesium

transfer to appropriate center than can handle high risk preg

new onset seizures, w preeclampsia, in a woman between 20wks gestation and 4wks postpartum

eclampsia

eclampsia tx

antihypertensives: labetalol, hydralazine, nifedipine

IV magnesium

emergency OB consult for emergent delivery of fetus

a woman presenting to the ER in active labor, we need to be prepared to tx mother and baby once delivered (so dont treat alone). if youre in a hospital, attempt to get pt to OB floor of hospital unless delivery is imminent

emergency delivery

how do we define imminent delivery

complete cervical effacement and the fetus is at the vaginal introitus aka the baby is coming out and can see it (must loot at vaginal canal to tell)

what do we do in an emergency delivery

call OB to ED and prep to deliver, initiate maternal and fetal monitoring if possible, get IV access adn begin IV hydration, attempt to prep the perineum by washing it w mild soap and water and swabbing w iodine, assist in delivery