Page 616 - ACCCN's Critical Care Nursing

Emergency Presentations 593

blood pressure differences (>20 mmHg) between the Administration of a narcotic analgesia in acute abdomi-
arms may be evident. CXR will be abnormal in 80–90% nal pain does not hinder assessment or obscure abdomi-
of cases; a widened mediastinum is present in 50% of nal findings, nor cause increased morbidity or mortality,
87
cases. 69,79 Diagnosis is confirmed by contrast CT. Man- and may allow for a better abdominal examination.
agement is aimed at aggressive control of blood pressure Incremental doses of a narcotic minimise pain but not
and pulse with sodium nitroprusside and beta blockers, palpation tenderness. Analgesics enable relaxation of the
relief of pain with narcotic analgesia and referral and/ patient’s abdominal muscles and decrease anxiety, poten-
or transport to cardiothoracic services for definitive sur- tially improving information obtained from the physical
gical intervention. 79 examination. 87
Venous blood samples are collected for full blood count
ABDOMINAL SYMPTOM (FBC), urea, electrolytes, creatinine (UEC), and amylase
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PRESENTATIONS and lipase. A dipstick urinalysis can suggest specific
disease (e.g. leucocytes and/or blood with urinary tract
Acute abdominal pain is a common complaint, account- infection; haematuria with renal colic), within the context
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ing for 5–8% of all presentations to the ED. 80,81 A specific of other clinical findings and formal microscopy.
cause for the presenting abdominal pain will not be Women of child-bearing age with abdominal pain provide
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found in 30–40% of patients of all ages; for children a the challenge of a broader range of potential causative
diagnosis of non-specific abdominal pain accounts for up pathologies, although history and physical examination
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to 60% of cases. About 20% of adult patients presenting are unreliable in determining pregnancy. If pregnancy
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will require surgical intervention and/or hospital or a pregnancy-related disorder is possible, a urine
admission. 82,83 beta-human chorionic gonadotrophin (hCG) test is
performed. Test sensitivity is extremely high; a positive
Common causes in the elderly include biliary tract disease finding occurs within a few days of conception, and
(25%), diverticular disease (10%), bowel obstruction accuracy is com parable to blood sampling. An ectopic
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(10%) or malignancy (13%). Elderly patients are more pregnancy may be missed if pregnancy is not considered;
likely to have catastrophic illnesses rarely seen in younger an ectopic pregnancy is extremely unlikely if the hCG
patients, including mesenteric ischaemia, leaking or rup- result is negative. 85
tured abdominal aortic aneurysm and myocardial infarc-
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tion. 80,81,83 Up to a third require surgical intervention,
while 15% will not have a cause for their abdominal pain CANDIDATE DIAGNOSES AND MANAGEMENT
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found. Presentations by elderly patients are often com- Common abdominal diagnoses for acute abdominal
plicated by a delay in seeking medical attention, atypical pain are abdominal aortic aneurysm, appendicitis and
presentations, associated medical conditions, medica- bowel obstruction.
tions and cognitive function.
Abdominal Aortic Aneurysm
ASSESSMENT, MONITORING Abdominal aortic aneurysm (AAA) is a common cause of
AND DIAGNOSTICS death in all patients over the age of 65 years and is

Patients presenting with abdominal pain are assessed responsible for 0.8% of all deaths. 82,88,89 The traditional
quickly for any disturbance to airway, breathing or circu- presentation is acute pain in the back, flank, or abdomen,
lation requiring close monitoring, immediate medical with hypotension and a palpable abdominal mass in the
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assessment and/or resuscitative interventions. Abnormal older patient. Missed diagnoses primarily occur because
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vital signs are suggestive of clinically significant abdomi- physical examination is frequently unreliable. Many
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nal pain. A thorough history includes location and patients with dissecting AAA are misdiagnosed with renal
timing of onset, quantity, quality and radiation of pain, colic, because of haematuria present, no palpable pulsa-
88,89
associated symptoms, previous history and general state tile mass and flank pain. Other common misdiag-
of health. A complaint-specific history and physical noses include diverticulitis, gastrointestinal haemorrhage,
examination is performed for a differential diagno- acute myocardial infarction and musculoskeletal back
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sis. 80,81,83 Physical assessment includes visual inspection pain. Abdominal aortic aneurysms are surgically
of the abdomen with the patient in a supine position, repaired more than any other type of aneurysm. A rup-
followed by auscultation, then gentle palpation and per- tured AAA is fatal unless a patient receives immediate
88,89
cussion of all four quadrants of the abdomen, working resuscitation and surgical intervention.
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towards the area of reported pain (see Chapter 19 for
more details). While location of the pain is important, it Appendicitis
can be misleading, as various pathological processes can Appendicitis is the most common acute abdominal pain
localise to different areas of the abdomen (see Figure presentation that requires a surgical intervention. Diag-
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22.1). An ECG is considered to rule out myocardial nosis is based on clinical assessment as there is no specific
ischaemia or infarction, as some cardiac patients may test available to confirm diagnosis. Appendicitis can
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present with upper abdominal pain as the predominant mimic almost all acute abdominal pain presentations,
symptom (see previous section). Myocardial ischaemia and is frequently misdiagnosed as gastroenteritis during
may also be caused by the physiological stress of the the initial ED visit, or pelvic inflammatory disease or
intra-abdominal pathology. 80 urinary tract infection. Whilst a well-studied disease,
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