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CE ARTICLE Epidemiology Abdominal pain is Table 1: Body an extremely common complaint in the emer- gency setting, accounting for up to 10% of all emer- gency department visits.1 Although abdominal pain frequently occurs, it can be a frustrating chief complaint, as it is a rather non- specific problem that may not even directly represent the disease process actually affecting the patient. Because of their more complex anatomy, females of reproductive age require special consid- eration when they present with abdom- inal discomfort. A survey of women of reproductive age reported that 39% of this group experience non-menstrual pelvic pain yearly, which may manifest as abdominal pain.2 Every year in the United States, 5.8% of every 1,000 women presenting to an ED receive a diagnosis of pelvic inflammatory disease, and 1.1% of 1,000 women are diagnosed with an ectopic pregnancy.3 Cavities Cranial cavity Thoracic cavity Abdominal cavity Pelvic cavity pain receptors lie within both the skin and internal tissues and are able to pick up sensations related to temperature, swelling and vibration. Somatic pain is usually more focal- ized and may present as sharp pain, where visceral pain, some- times called peritoneal pain, is more generalized, dull and achy. Referred pain, on the other hand, occurs away from the injured organ and is a result of the brain’s inability to determine where the pain in a particular area is coming from. While the absolute reason for referred pain is uncertain and debated, it is thought to be a function of how the nerves develop in the fetal period along with crossed connections as they synapse. There are several organs in the These are both serious conditions carrying signifi- cant morbidity. Ectopic pregnancies also have a significant mortality. Anatomy The abdominal cavity is the largest internal cavity FAST FACT In order to rule out appendicitis, determine: 1. There has been no migration of pain 2. There is bilateral abdominal tenderness 3. There is no nausea or vomiting in the body (Table 1). Its complexity lies not only within its many structures, but also with its interaction of the nerves that innervate them. There are three distinct pathways in the abdomen that transmit pain: visceral, somatic and referred. Nociceptors sense and transmit pain sensation, which is described as either visceral or somatic. Visceral is pain sensed from the actual internal organs and their autonomic innervation that may be the earliest manifestation of pain. This pain is often a response to stretching or inflammation and is responsible for referred pain due to many organ nerve plexi and pathways crossing. Somatic 60 JULY 2011 | EMSWORLD.com lower abdominal quadrants, including the cecum, appendix, sections of the ascending colon, ureter and kidney on the right, and the sigmoid colon, sections of the descending colon, ureter and kidney on the left. The bladder lies midline. In the female patient, the ovaries and fallopian tubes are found bilaterally in the lower quadrants. The uterus is midline just poste- rior to the bladder. While it can be easily argued that the pelvis and abdomen are two distinct body regions, in the emer- gency setting they can be thought of as one, as pain in these quadrants presents in a similar manner. EMTs are trained to ask questions to characterize the situation in which the illness or pain presented, as well as to see how it has evolved. These questions, which follow the OPQRST mnemonic, address onset, provocation, quality, if the pain radiates, severity of the pain, as well as describing the time of onset and dura- tion. Additionally, there are some specific questions that can be asked of a woman experiencing abdominal pain to help further guide management and to narrow the etiology of the pain. While it is not a first responder’s job to come up with the diagnosis, many times it is helpful to think of a list of common possibilities that could be causing this pain. This list is known as a “differential diagnosis.” The differential diagnosis of abdominal pain should prioritize the diagnoses that are most common, as well as those likely to have a high morbidity or mortality. The questions asked of the patient should be aimed at trying to narrow down the EMT’s differential list. One rule of thumb for any woman of childbearing age is to assume she is pregnant until proven otherwise. It doesn’t matter if she had her menstrual cycle yesterday or six months ago, assume she is pregnant as you perform an assessment. Keeping this in mind, one must take a systematic approach to developing diagnoses. To develop a differential diagnosis, it is essential to have both a history of present illness and an accurate physical exam. Obtaining a history includes an accurate description of pain using the OPQRST mnemonic, as well as deter- mining the patient’s history of any abdominal problems and any specific symptoms previously experienced. There are several ways to perform an abdominal assessment. One option is the quadrant method, where the abdomen is broken down into four quadrants (upper right, upper left, lower right, lower left); however, a system-based approach can be a better assessment. Since pain does not always present in a specific area, limiting an assessment to one abdominal quadrant can make a differential diagnosis difficult. However, if you can approach the patient’s assess- ment one organ system at a time, it is less likely that something will be missed. Work from the head down, going system by system, developing a wide differential. Start wide and narrow it down based on presentation. Table 2 identifies body systems based on a list of conditions that may cause abdominal pain. This broad list of differentials can be narrowed down based on the presenta- tion of each particular case. For example, the absence of fever can eliminate many causes, such as infections, while pres- ence of bruising may support others. Keeping in mind that the management of most abdominal pain in the field will be similar, the questions in Table 3 can help identify when there might be a more serious cause.