Option 1: Abdominal emergency

When you approach the patient, she appears unwell. She opens her eyes and tries to speak but can only get out a few words at a time; intermittently gasping, she pleads for help with her abdominal pain. Repeat vital signs are: blood pressure 85/68 mm Hg, heart rate 115 beats/minute, respiratory rate 32 breaths/minute, and SpO₂ 95%.

The patient retches frequently during your focused examination. On examination, you note the following:

• Heart: auscultation limited by rapid, shallow breathing; irregular rhythm present with no appreciable murmurs
• Lungs: mild wheezing and loud, equal breath sounds bilaterally
• Abdomen: grossly distended, diffusely tender, rebound tenderness present, bowel sounds absent
• Skin: cold, mottled; no IV access

In addition, you just learned the following information from the nurse:

• The patient appears significantly worse than 30 minutes ago.
• Laboratory studies were last drawn this morning, > 16 hours ago.
• The IV accidentally got pulled out after dinner, and the nurse has been unable to find any other “good veins.”
• There is no known history of atrial fibrillation.

Question: What are you going to do next?

Make your choices, then click on the explanation bubbles to reveal the answers.

• Consult cardiology for new atrial fibrillation.
• Call the rapid response team for help with IV access and fluid resuscitation.
• Order an abdominal CT scan.
• Consult the surgical service immediately.

Acute abdominal emergencies may exacerbate chronic conditions like COPD or arise from new medical issues such as atrial fibrillation. Focus initial management on the most life-threatening condition.

Most causes of acute abdomen require surgery for definitive management.

The rapid response team has placed two large-bore peripheral IVs. The on-call surgical resident is currently in the operating room but is sending a colleague, who should arrive shortly.

Question: What should you do while awaiting the surgical consult?

Make your choices, then click on the explanation bubbles for more information.

• Keep the patient NPO.
• Begin IV fluid resuscitation.
• Consider nasogastric tube placement.
• Order updated laboratory studies.
• Provide analgesia and antiemetics.
• Place a urinary catheter.
• Obtain a bedside ECG.
• Start broad-spectrum antibiotics.

Requesting a consult does not end your responsibility! Continue resuscitation and supportive care until the surgical team evaluates the patient and formally assumes care.

Once life-saving and supportive care are underway, think about potential causes of the patient’s deterioration (especially life-threatening ones) and diagnostics that may help narrow the differential. Staying one step ahead is key to timely management.

Immediately life-threatening diagnoses in patients with an acute abdomen

• Ruptured abdominal aortic aneurysm
• Aortic dissection
• Myocardial infarction
• Bowel perforation
• Mechanical bowel obstruction, including obstructed and/or strangulated hernia
• Acute mesenteric ischemia
• Acute pancreatitis
• Acute cholangitis
• Ruptured ectopic pregnancy

Clinical features and diagnostic findings for life-threatening causes of acute abdomen

Imaging may be part of this patient's further workup, depending on her clinical stability following resuscitative efforts, the suspected diagnosis, and/or the plan of the surgical team. Want some practice before it’s time to make the call (or, at least, a call to radiology)?

Image interpretation

Test your eyes on the following images. Identify the pertinent findings, then apply the AMBOSS overlay to confirm your answers.

While waiting for a member of the surgical team to arrive and evaluate the patient, you may need to perform some of these procedures to facilitate this patient's care. Take a few minutes to review them now or find them easily later on the AMBOSS Knowledge App.

• Nasogastric tube placement
• Transurethral catheterization
• Peripheral venous access
• Central venous access

Want to explore the other scenario? Jump over to “Option 2: Abdominal pain with stable vital signs.” You can also return to the main module; see “Pain in the gut wrap-up.”