This article is the part of a series on patients presenting to EMS with abdominal pain. For additional review of abdominal complaints and assessments, check out the first, second and third patient cases.
Assessment of abdominal pain
Abdominal complaints are difficult to assess because there are many different causes of abdominal pain that range from simple to complex and benign to life threatening. Properly performing an abdominal assessment is vital to guiding both EMS and emergency department treatment of a patient.
Begin the abdominal assessment by visualizing the abdomen looking specifically for any obvious trauma or abnormalities. Then palpate each quadrant of the abdomen using both shallow and deep pressure. Pay particular attention to any painful response by the patient or any obvious masses.
When building a differential diagnosis around a complaint of abdominal pain, it is important to understand which anatomical structures are under the area where the patient is experiencing pain. Right upper quadrant pain, for instance, can be associated with the liver or gall bladder [1].
In Will’s case, a visual assessment reveals no obvious trauma or bruising. Palpation results in pain and tenderness to the left upper quadrant with no masses felt.
Assessment of syncope
Syncope (or passing out) is another complicated patient presentation for EMS. A syncopal episode can occur for many reasons and requires that a careful and thorough history and assessment be performed. A patient can experience a syncopal episode due to underlying cardiac, neurologic or hemodynamic issues. As such, patients should have a 12-Lead ECG performed by ALS providers, have a blood glucose taken, a stroke/neurologic assessment performed and a full set of vital signs. Providers may elect to perform orthostatic vital signs (described below).
When collecting a history on a syncope patient, pay particular attention to the events leading up to the episode. Did the patient recently suffer a blow to the head? If so, work to rule in or out neurologic causes. Did the patient experience chest pain, diaphoresis or nausea? These may indicate an underlying cardiac issue.
Orthostatic vitals
When a patient is lying down, the heart does not need to work as hard to pump blood around the body. When a healthy patient moves from laying to sitting or standing, the body compensates for the increased difficulty in maintaining homeostasis due to gravity. This compensation occurs by constricting blood vessels in the body (increased peripheral vascular resistance) and may also take the form of increasing the rate and force of contraction of the heart (known as contractility).
In patients with a compromised ability to maintain homeostasis, the body may not be able to maintain blood pressure through normal means or may need to drastically increase the heart rate to remain homeostatic.
Assessing orthostatic vital signs involves measuring pulse and blood pressure while the patient is lying down and then again after standing up (at intervals of one and three minutes). Some clinicians may elect to measure heart rate and blood pressure when the patient is seated, between the lying and standing measurements. If one or more of the following is true, the test is indicative of a loss of blood volume:
- Decrease of systolic blood pressure of 20 mm Hg or more
- Decrease of diastolic blood pressure of 10 mm Hg or more
- Increase in heart rate of 20 beats per minute or more
It is important to note that this test has not been shown to reliably predict hypotension in pediatric patients or in adult patients with less than a liter of fluid loss [2].
In the scenario, Will does show positive orthostatic changes as well as an increase in the severity of his dizziness when standing.
Splenic rupture
As mentioned previously, one of the important steps in creating a differential diagnosis for abdominal pain is to understand the anatomy of the area where the patient is experiencing pain. In Will’s case, the left, upper quadrant of the abdomen is home to the spleen, a kidney (in the retroperitoneal cavity) and the colon [1].
The spleen is one of the solid organs in the body and as such is prone to fracture or rupture when the patient experiences a blunt trauma. Since the organs are highly vascular a patient can lose a large amount of blood volume which can be collect in the abdominal cavity before obvious bruising appears. This bleeding from the spleen can vary in rate depending on the severity of the injury.
In Will’s case a careful history would reveal that he was hit very hard by a defensive player during their game two days ago.
Conclusion
Based on Will’s presentation of dizziness and syncope he receives a BLS and ALS assessment. After successfully ruling out cardiac and neurologic causes, you elect to perform orthostatic vitals. As you suspect when his dizziness returns with standing up, Will’s systolic blood pressure drops by 30 mm Hg when standing and his heart rate increases by 24 beats per minute. These findings are indicative of hemodynamic instability and the presence of abdominal pain with a history of blunt trauma leads to a differential diagnosis of a spleen injury. Will is transported to the local trauma center by the ALS unit where an ultrasound reveals fluid in his abdomen. In surgery Will is confirmed to have a ruptured spleen which is repaired with a good expected outcome.
- References
Stern, S. D., Cifu, A. S., & Altkorn, D. (2006). Abdominal pain. In Symptom to diagnosis: An evidence-based guide (pp. 9-31). New York: Lange Medical Books. - Emergency Nurses Association. (2014, June). Clinical Practice Guideline Synopsis - Orthostatic Vital Signs. Retrieved from https://www.ena.org/practice-research/research/CPG/Documents/OrthostaticVitalSignsSynopsis.pdf
