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CE ARTICLE anything about it because she is so afraid she might be pregnant, she just wants to put it out of her mind and hope it will go away. Her vital signs reveal that she is tachycardic and her blood pressure is 118/76. She is extremely uncomfortable and screams each time you attempt to move her. This information provides a high index of suspicion for ectopic preg- nancy. An ectopic pregnancy is when a fertilized egg does not properly implant in the uterus, but instead implants or grows somewhere outside of the uterus. The most common site of implantation outside the uterus is the fallopian tube, which can rupture if a fetus begins to grow inside the closed tube. Classically, the pain is severe, to the lateral aspects of the pelvis and unilateral. Unfortunately, the presentation is highly variable. When an ectopic pregnancy is suspected, perform a visual inspection This patient warrants rapid trans- port to an emergency department, IV access and frequent vital signs moni- toring. Two IVs are not necessary except in the case of profound hypotension that is not responsive to initial fluid therapy. Reassess the patient regularly, and consider the Trendelenburg posi- tion if she becomes hemodynamically unstable. The receiving ED should be informed early of the critical nature of this patient in order to activate necessary personnel. This is a surgical emergency. Case #3 Changing our patient’s presentation slightly, as Michael enters the dorm room, the patient complains of an intense gnawing pain between her umbilicus and her sternum that she says feels like it is burning through her back. She says she just got back from Mardi Gras in New Orleans this morning and has consumed a great deal of alcohol over the last “Most abdominal pain is vague and may not lead you directly to the pathology.” of the external aspect of the vagina to check for gross bleeding. An internal pelvic exam is not indicated, as it will not change the prehospital management of this patient. A patient is likely to have positive pregnancy test results because she is, in fact, pregnant, but unfortunately in the wrong location. Vaginal bleeding or spotting can often be confused with having a menstrual period, so a patient may not know she is pregnant. One might question why a normal low blood pres- sure in this patient is concerning. In a healthy 19-year-old, a blood pressure of 96/56 would be great; however, because this patient is in intense pain and prob- ably anxious, one would expect her blood pressure to be higher. The whole clinical picture is important when assessing a patient. While it’s important to not just treat numbers, her clinical picture suggests she is in compensatory shock, most likely secondary to intravascular blood loss secondary to a ruptured ectopic pregnancy. week or so. She says the pain, which is constant and unrelenting, started this morning and has gotten progressively worse. The most common causes of acute pancreatitis are gallstones and exces- sive alcohol consumption.11 Ecchymosis, or bruising, on the fl anks (Grey Turner’s sign) or around the umbilicus (Cullen’s sign) are signs of blood in the abdominal cavity, which suggests pancreatic necrosis and abdominal bleeding. Other diseases or injuries that cause internal bleeding may also mimic these signs, and it is impor- tant to note that they typically take 24–48 hours to manifest. Patients with pancreatitis often complain of pain originating inferior to the sternum and radiating posteriorly. The pain is usually constant and gnawing; however, if there is involvement of the gall- bladder with gallstones, pain may present in sharp bursts that come and go. Jaundice can be present when the biliary tract is obstructed. These patients’ hemodynamic status should be monitored closely, as a Treatment of Abdominal Pain in the Field and Beyond As shown in Table 2, there are many different pathologies contributing to abdominal pain. Remember, however, that common things are common, so management should be based on the common etiologies of abdominal pain. Don’t go looking for a zebra when the horse is right in front of you. Luckily, the emergency treatment of most abdom- inal pain is the same. While we have previously discussed the importance of considering the complex anatomy of females of childbearing age, anatomy doesn’t really change the management greatly on an EMS call. As always, the ABCs come first. Most abdominal pain EMSWORLD.com | JULY 2011 63 The Alvarado Scale The Alvarado Scale can be used to determine that a patient is likely suff ering from appendicitis. The mnemonic MANTRELS is used to remember the scale, which is detailed below. The presence of any item on the scale receives one point, with the exception of right lower quadrant tenderness and leukocytosis (increased white blood cell count), both of which receive two points. A score of 5–6 is compatible with acute appendicitis; 7–8 is probable appendicitis; 9–10 is very probable. M-migration of abdominal pain to the right iliac crest region A-anorexia/appetite loss N-nausea and vomiting T-tenderness/pain in the right lower quadrant R-rebound tenderness E-elevated temperature (fever above 37.3°C) L-leukocytosis S-shift of leukocytes to the left. signifi cant amount of fl uid can leave the intravascular space, the blood vessels, and go into the tissues or body cavi- ties. Management of this patient should consist of a thorough physical exam, close monitoring of vital signs, IV fl uid hydration, keeping her NPO, and emergent transport in a position of comfort to a notifi ed emer- gency department.