Page 617 - ACCCN's Critical Care Nursing

594 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

Adult presentations with acute
abdominal pain

• Take a detailed history
• Perform a rapid physical assessment
• Obtain urine β-HCG from any woman of child-bearing age

Practice Tip
Always “suspect the worst”
and perform serial
evaluations when needed

Suspect ruptured
Suspect acute abdominal aortic Suspect ectopic
appendicitis 90 79,88,89 pregnancy 92
aneurysm

• Right lower quadrant pain • A clinical triad of: • In any woman of child bearing-age who
• A clinical triad of: - Abdominal pain. complains of abdominal pain.
- RLQ pain. - Pulsatile mass. • In the presence of abdominal pain,
- Abdominal rigidity. - Hypotension. amenorrhoea, and irregular vaginal
- Migration of the pain from the • In the presence of the following risk bleeding.
periumbilical area. factors: • When the pain is sharp, low
• History of: - Age > 50. and laterol.
- Nausea and vomiting appeared after - Smoking history. • In the presence of the
the pain has started. - History of hypertension. following risk factors:
- Psoas sign. - History of atherosclerosis. - Smoking.
- Rebound tenderness. - A positive family history of AAA. - Infectious disease.
• Symptoms are less than 2 days. - Maternal exposure to diethylstilboestrol.
• The condition should be suspected in - Tubal pathology, surgery or sterilisation.
pregnant women who exhibit new - A previous ectopic pregnancy.
abdominal pain. - More than one sexual partner.
- Infertility.
- Previous abdominal or pelvic surgery.

Practice Tip
• Be extremely cautious when assessing female and elderly patients because of high risk of misdiagnosis.
• The elderly are at particular risk of critical and severe conditions.
• Any patient with acute abdominal pain and abnormal vital signs should be triaged to be seen within 30 minutes or less.

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FIGURE 22.1 An algorithm for triaging commonly missed causes of acute abdominal pain.

appendicitis continues to be a difficult ED diagnosis Ectopic Pregnancy
because of varied presentations. Women of childbearing
age with appendicitis are commonly misdiagnosed due An ectopic pregnancy is implantation outside the uterus;
to anatomical changes due to their pregnancy. Treatment most commonly in the fallopian tubes. Ectopic preg-
includes management of pain related symptoms and pro- nancies occur at a rate of about 11 : 1000 diagnosed
92
90
vision of intravenous hydration. Definitive treatment is pregnancies. Management is guided by the patient’s
surgical removal of the appendix. 90 haemodynamic state: stable patients with no tubular
ectopic may be managed with observation and drugs such
Bowel Obstruction as methotrexate; haemodynamically-unstable patients
will require resuscitation and surgical intervention.
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A bowel obstruction commonly results from impaired
peristaltic movement, hernias, adhesions and neo-
91
plasms. Presentation includes poorly-localised colicky ACUTE STROKE
pain that increases in intensity and location, with subse-
91
quent abdominal swelling and vomiting of faecal fluid. Cerebrovascular disease is very prevalent in developed
93
Management includes both conservative options (man- countries; the third-largest cause of death in Australia
agement of symptoms, placement of a naso-gastric tube accounting for about 40,000 strokes (acute cerebrovascu-
and replacement of intravenous fluids) and surgical lar accident [CVA]), with 73% of these initial strokes. The
therapy for neoplasms or hernias. 91 two general stroke classifications are: