Rosen & Barkin's 5-Minute Emergency Medicine Consult by Jeffrey J. Schaider, Adam Z. Barkin, Roger M. Barkin, Philip Shayne, Richard E. Wolfe, Stephen R. Hayden, Peter Rosen Page A

TREATMENT/PROCEDURES
Nasogastric tube decompression and bowel rest
IV fluids and electrolyte repletion
Antiemetics are important for comfort.
Narcotics or analgesics should not be withheld.
Send for blood type and cross-match for unstable patient
Surgical consultation based on suspected etiology
MEDICATION
Fentanyl: 1–2 μg/kg IV qh
Morphine sulfate: 0.1 mg/kg IV q4h PRN
Ondansetron: 4 mg IV
Prochlorperazine: 0.13 mg/kg IV/PO/IM q6h PRN nausea; 25 mg PR q6h in adults
Promethazine: 25–50 mg/kg IM/PO/PR
FOLLOW-UP
DISPOSITION
Admission Criteria
Surgical intervention
Peritoneal signs
Patient unable to keep down fluids
Lack of pain control
Medical cause necessitating in-house treatment (MI, DKA)
IV antibiotics needed
Discharge Criteria
    No surgical or severe medical etiology found in patient who is able to keep fluid down, has good pain control, and is able to follow detailed discharge instructions
FOLLOW-UP RECOMMENDATIONS
    The patient should return with any warning signs:
Vomiting
Blood or dark/black material in vomit or stools
Yellow skin or in the whites of the eyes
No improvement or worsening of pain within 8–12 hr
Shaking chills, or a fever >100.4°F (38°C)
PEARLS AND PITFALLS
Elderly patients are more likely to present with atypical presentations and life threatening etiologies requiring admission.
Do not consider constipation if stool is absent in the rectal vault.
Etiology requiring surgical intervention is less likely when vomiting precedes the onset of pain.
ADDITIONAL READING
Flasar MH, Cross R, Goldberg E. Acute abdominal pain.
Prim Care.
2006;33(3):659–684.
McNamara R, Dean AJ. Approach to acute abdominal pain.
Emerg Med Clin North Am.
2011;29(2):159–173.
Ross A, LeLeiko NS. Acute abdominal pain.
Pediatr Rev.
2010;31(4):135–144.
Yeh EL, McNamara RM. Abdominal pain.
Clin Geriatr Med
. 2007;23(2):255–270.
CODES
ICD9
789.00 Abdominal pain, unspecified site
789.06 Abdominal pain, epigastric
789.07 Abdominal pain, generalized
    ICD10
R10.9 Unspecified abdominal pain
R10.13 Epigastric pain
R10.84 Generalized abdominal pain

ABDOMINAL TRAUMA, BLUNT
Stewart R. Coffman
BASICS
DESCRIPTION
Injury results from a sudden increase of pressure to abdomen.
Solid organ injury usually manifests as hemorrhage.
Hollow viscus injuries result in bleeding and peritonitis from contamination with bowel contents.
ETIOLOGY
60% result from motor vehicle collisions.
Solid organs are injured more frequently than hollow viscus organs.
The spleen is the most frequently injured organ (25%), followed by the liver (15%), intestines (15%), retroperitoneal structures (13%), and kidney (12%).
Less frequently injured are the mesentery, pancreas, diaphragm, urinary bladder, urethra, and vascular structures.
Pediatric Considerations
Children tend to tolerate trauma better because of the more elastic nature of their tissues.
Owing to the smaller size of the intrathoracic abdomen, the spleen and liver are more exposed to injury because they lie partially outside the bony rib cage.
DIAGNOSIS
SIGNS AND SYMPTOMS
Spectrum from abdominal pain, signs of peritoneal irritation to hypovolemic shock
Nausea or vomiting
Labored respiration from diaphragm irritation or upper abdominal injury
Left shoulder pain with inspiration (Kehr sign) from diaphragmatic irritation owing to bleeding
Delayed presentation possible with small-bowel injury
ESSENTIAL WORKUP
Evaluate and stabilize airway, breathing, and circulation (ABCs).
Primary objective is to determine need for operative intervention.
Examine abdomen to detect signs of intra-abdominal bleeding or peritoneal irritation.
Injury in the retroperitoneal space or intrathoracic abdomen is difficult to assess by palpation.
Remember that the limits of the abdomen include the diaphragm superiorly (nipples anteriorly, inferior scapular tip posteriorly) and the intragluteal fold inferiorly and encompass entire circumference.
Abrasions or ecchymoses may be indicators of intra-abdominal injury:
Roll the patient to assess