Abdominal Pain in Adults — Paramedic Side

Host 2: Alright, welcome back. Today, abdominal pain in adults, paramedic side. And let's be honest, belly pain is one of the most common calls we run, and one of the easiest to get lazy on.

Host 1: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 2: This is education, not medical direction. Follow your local protocols.

Host 1: So here's the plan. We'll start with the stuff you do on every one of these calls, BLS first, then ALS. Then we'll run through the conditions the Registry likes to test. Gallbladder, pancreas, ectopic pregnancy, Crohn's, Cullen's and Grey Turner's signs, kidney stones, hepatitis, peptic ulcers, and diverticulitis.

Host 2: And the big rule today. BLS before ALS. Every time. As a paramedic, you start with basic life support. Scene safety, B S I, primary assessment, airway, breathing, circulation. Then you add the advanced stuff.

Host 1: And on abdominal calls, B S I is not a throwaway line. Vomit, diarrhea, blood. Gloves at minimum, and eye protection if anybody is vomiting.

Host 2: So walk in, general impression. How is the patient lying? That alone tells you a ton.

Host 1: Patient lying perfectly still, knees pulled up, afraid to move? Think peritonitis. Something is irritating the lining of the abdomen, and every movement hurts.

Host 2: Patient who can't sit still, writhing, pacing, can't get comfortable? Think colic. Kidney stone is the classic.

Host 1: Then the primary. Airway first, especially if they're vomiting. Have suction ready. Breathing, and if they're hypoxic, give oxygen per your protocol. Circulation, and that's where you're hunting for shock. Skin color, temperature, moisture, heart rate, cap refill, mental status.

Host 2: Position of comfort for most of these. If they're showing signs of shock, lay them flat. If they're vomiting with a decreased level of consciousness, get them on their side so they don't aspirate.

Host 1: Nothing by mouth. These patients may be going to surgery.

Host 2: Then the history. OPQRST for the pain. SAMPLE. And for every woman of childbearing age, ask about her last menstrual period and the chance of pregnancy. Every one. No exceptions.

Host 1: Gentle palpation of all four quadrants, and you palpate the painful area last. You're looking for tenderness, guarding, rigidity, distension, and a pulsating mass. If you feel a pulsating mass, stop pressing.

Host 2: Now ALS. IV access. Cardiac monitor. And get a twelve-lead on the older patient with epigastric pain, especially diabetics, women, and the elderly, because an inferior MI can show up as a bellyache.

Host 1: Check a blood glucose. Fluids if they're hypotensive or showing signs of shock, per protocol. For suspected internal bleeding, a lot of systems titrate fluids to perfusion, like a radial pulse and mentation, rather than chasing a normal blood pressure. Pain management and antiemetics per your protocol. And reassess.

Host 2: Okay. Now the conditions. Let's start with the gallbladder. Cholecystitis.

Host 1: Inflamed gallbladder, usually from a gallstone blocking the outflow. Classic presentation is right upper quadrant pain, sometimes epigastric, often after a fatty or greasy meal. Nausea and vomiting. Fever if it's infected.

Host 2: And the referred pain is the test question. Gallbladder pain classically refers to the right shoulder, the right scapula, or that spot between the shoulder blades.

Host 1: And then Murphy's sign. You press on the right upper quadrant, under the rib margin, and have the patient take a deep breath. As the gallbladder moves down and hits your fingers, they catch their breath and stop inhaling because it hurts. That's a positive Murphy's sign.

Host 2: You'll also hear the old mnemonic, female, forty, fertile, and fat. Know it for the test, but don't let it blind you. Men, thin people, and young people get gallstones too.

Host 1: Now, here's a judgment call worth getting right. A lot of people mix up Kehr's sign with gallbladder pain. Kehr's sign, K E H R, is pain in the left shoulder. It comes from blood or irritation under the left side of the diaphragm, and the classic cause is a ruptured spleen.

Host 2: It can also show up with a ruptured ectopic pregnancy, when blood in the abdomen irritates the diaphragm. So Kehr's sign is left shoulder, and it's a red flag for bleeding. Gallbladder is right shoulder and between the scapulae.

Host 1: Next. Pancreatitis. Inflamed pancreas.

Host 2: Severe epigastric pain that often bores straight through to the back. Nausea and vomiting, sometimes a lot. The patient might be leaning forward or curled up with their knees to their chest, because lying flat makes it worse.

Host 1: The two big causes you'll see on the exam are alcohol and gallstones. And severe pancreatitis can make the patient really sick. Fluid shifts, shock, and in the hemorrhagic form, bleeding into the retroperitoneum.

Host 2: Which takes us right into Cullen's sign and Grey Turner's sign.

Host 1: Cullen's sign is bruising around the umbilicus, the belly button. Grey Turner's sign is bruising on the flanks.

Host 2: Memory trick. Cullen, C for center. Grey Turner, you have to turn the patient to see the flanks.

Host 1: Both point to bleeding in the abdomen or retroperitoneum. Hemorrhagic pancreatitis, ruptured ectopic pregnancy, ruptured abdominal aortic aneurysm, trauma.

Host 2: And the catch is these are usually late signs. They can take hours to days to develop. So if you don't see them, it doesn't rule anything out. If you do see them, that patient needs your attention.

Host 1: Next. Ectopic pregnancy.

Host 2: A fertilized egg implants outside the uterus, most often in a fallopian tube. As it grows, the tube can rupture, and that can cause life-threatening internal bleeding.

Host 1: Classic picture. Woman of childbearing age, missed or late period, sudden one-sided lower abdominal pain, and maybe some vaginal bleeding, which can be light or absent. Signs of shock if it's ruptured. And that left shoulder pain, Kehr's sign, if blood is irritating the diaphragm.

Host 2: She might not know she's pregnant. That's why you always ask about the last period.

Host 1: Treatment is hemorrhagic shock care. BLS first. Lay her flat, keep her warm, oxygen if hypoxic per protocol. Then ALS, I V access, fluids titrated per protocol, and rapid transport to a facility that can take her to surgery.

Host 2: Next. Crohn's disease.

Host 1: Crohn's is a chronic inflammatory bowel disease. It can affect any part of the G I tract, from the mouth to the anus, but it classically hits the end of the small intestine, the terminal ileum.

Host 2: So you can get right lower quadrant pain that looks a lot like appendicitis. Plus cramping, chronic diarrhea, sometimes bloody, weight loss, fatigue, and fever during a flare.

Host 1: And the patient usually knows they have it. What you're worried about on scene is the complications. Dehydration from all that diarrhea, bowel obstruction, abscess, and fistulas.

Host 2: And the comparison the exam may throw at you is ulcerative colitis. U C is limited to the colon and is known for bloody diarrhea. Crohn's can be anywhere in the tract.

Host 1: Next. Kidney stones.

Host 2: Sudden, severe flank pain that comes in waves and radiates down toward the groin. Nausea and vomiting. Blood in the urine. And that restless patient who can't find a comfortable position.

Host 1: And here's the paramedic-level catch. Older patient, first-ever kidney stone, especially with a history of hypertension or vascular disease? Think about an abdominal aortic aneurysm. A leaking triple A can look exactly like a kidney stone. Check pulses, check pressures, and look for that pulsating mass.

Host 2: Next. Hepatitis.

Host 1: Inflammation of the liver. Viral causes are the big ones for the test, plus alcohol and medications like acetaminophen in overdose.

Host 2: Signs and symptoms. Right upper quadrant pain or tenderness. Jaundice, yellow skin and yellow sclera. Dark urine. Clay-colored or pale stools. Fatigue, nausea, loss of appetite, and sometimes fever.

Host 1: And the scene safety part. Hepatitis A spreads mainly by the fecal-oral route. Hepatitis B and C spread through blood and body fluids. So B S I, sharps safety, and make sure your hepatitis B vaccination is current.

Host 2: Next. Peptic ulcers.

Host 1: An erosion in the lining of the stomach or the first part of the small intestine, the duodenum. The two big causes are H. pylori bacteria and NSAIDs, like ibuprofen and aspirin.

Host 2: Classic complaint is a burning or gnawing epigastric pain. The textbook teaching is that duodenal ulcer pain often gets better with food and comes back a couple hours later, and gastric ulcer pain can get worse with eating.

Host 1: The complications are what get you. G I bleeding, so ask about vomiting blood, coffee-ground emesis, and black, tarry stools, which we call melena. And perforation. Sudden, severe pain, and a rigid, board-like abdomen. That's peritonitis, and that's a surgical emergency.

Host 2: Next. Diverticulitis.

Host 1: Diverticula are little pouches in the wall of the colon. When they get inflamed or infected, that's diverticulitis. It's more common in older adults.

Host 2: Classic presentation is left lower quadrant pain. Some people call it left-sided appendicitis. Fever, nausea, and a change in bowel habits, constipation or diarrhea.

Host 1: And the related thing to know is diverticular bleeding, which can cause a lot of painless, bright red blood from the rectum. If there's enough of it, you've got a shock patient.

Host 2: Okay, let's wrap it. On every abdominal call, BLS first. Scene safety and B S I. Airway, especially with vomiting. Breathing, with oxygen if hypoxic. Circulation, and look hard for shock. Position of comfort, nothing by mouth.

Host 1: Then ALS. I V, monitor, twelve-lead when the heart could be the cause, glucose, fluids for shock, and pain and nausea management per protocol.

Host 2: And for the exam. Right shoulder and between the scapulae, think gallbladder. Left shoulder, Kehr's sign, think blood under the diaphragm, like a spleen or a ruptured ectopic. Murphy's sign is the gallbladder breath-catch. Cullen's is the belly button, Grey Turner's is the flanks. Pancreatitis bores to the back. Kidney stones writhe. Peritonitis lies still.

Host 1: By EMT Tutor, sponsored by Forrest Munden and EMT Tutor. I train people for the National Registry exam.

Host 2: This is education, not medical direction. Follow your local protocols. Stay safe out there.