Definitive care for acute abdomen

Mind you, this is an EMT book saying this, but I think it’s wrong. I hope you can shed light on this.
The book says "Definitive care for acute abdomen is hospitalization and surgery"
I don’t think that’s right

It depends on how you define acute abdomen. If you define “acute” as something a surgeon needs to work on, then there you have it.





Nonetheless, the classic of the field, Cope’s Early Diagnosis of the Acute Abdomen (by William Silen in its modern versions), says in its first chapter, in italics,





“The term ‘acute abdomen’ should never be equated with the invariable need for operation.”





That said, many people with “acute abdomens” do end up going to the operating room, and because abdominal pain can represent a true emergency and one that can be easily and quickly solved, I think that learning the abdominal exam as a surgeon or ED physician would learn it is an essential skill for all physicians. Along these lines I highly recommend the above book on the topic as an excellent learning resource and ongoing reference. As with its author more generally (who was my teacher for a series of small group sessions last year, and who I admire very much), its approach is both surgical and concerned about not only patient outcomes but patient comfort and well-being.





j

As far as this circumstance is concerned, “acute abdomen” would be sudden abdominal pain which I would not have the skills to diagnose. My protocol (currently I hope to expand that )would be to apply oxygen, get vitals and history and transport with a physical exam if time permits.
Basically, this book is saying that all acute abdomen cases will be hospitalized and sliced.
I understand there are some, if not many, cases that need surgical intervention or hospitalization. If these authors were running the show, Lord help you if you have the stomach flu

From a triage/EMS point of view, it makes sense to get everyone to a place where a surgeon can lay hands on them.
j

Quote:

Basically, this book is saying that all acute abdomen cases will be hospitalized and sliced.
I understand there are some, if not many, cases that need surgical intervention or hospitalization. If these authors were running the show, Lord help you if you have the stomach flu


“Acute abdomen” is one of those things that you develop a sense for recognizing, and every belly pain is NOT an acute abdomen. So I don’t think the authors are advocating surgery for gastroenteritis.
But when someone DOES have an acute abdomen, they need to be evaluated and surgery needs to be on board. With a small bowel obstruction, for example, you’ll hospitalize 'em and try conservative measures first, but you’ll want surgery to have that patient on their radar because they can go south in a hurry.
Wackie, I think you’re getting hung up on the term “acute abdomen” here - it’s not as broad as I think you’re presuming. I am in a post-call fog so will not be able to give a succinct description of an acute abdomen but after awhile, you do know one when you see one. Even a terrible gastro isn’t usually going to look like an acute abdomen.
Mary

Quote:


Wackie, I think you’re getting hung up on the term “acute abdomen” here - it’s not as broad as I think you’re presuming. I am in a post-call fog so will not be able to give a succinct description of an acute abdomen but after awhile, you do know one when you see one. Even a terrible gastro isn’t usually going to look like an acute abdomen.
Mary


Here’s the definition it gives:
"Acute abdomen-A condition of sudden onset of pain within the abdomen"
If you, or someone, can 'splain to me the difference, I’d be thrilled.

To expand the earlier quote:





“The very terms ‘acute abdomen’ and ‘abdominal emergency,’ which are constantly applied to such cases, signify the need for prompt diagnosis and early treatment, by no means always surgical. The term ‘acute abdomen’ should never be equated with the invariable need for operation. It is common knowledge, however, that when confronted with a patient suffering great abdominal pain, it is often difficult to be certain about the exact intraabdominal lesion that has given rise to the symptoms. In some instances, the urgent need for operation may be so obvious that the need of transference of the patient to the care of a surgeon is clear. In other cases the observer may, if in doubt, think it wise to discuss the problem with a fellow practitioner before deciding on any course of action. There are, however, occasions when, with somewhat indefinite symptoms, there is justification for the development of clearer indications, to see if the condition will not improve spontaneously, and to temporize, as long as the patient is carefully observed at frequent intervals. Though in some cases it is impossible to be certain of the diagnosis, it is a good habit to come to a decision in each case; and it will be found that after a short time, the percentage of correct diagnoses will rapidly increase.” (Cope/Silen)





The gestalt that Mary is talking about is, I think, recognizing the distinct look and feel of people in the kind of pain that emanates from a condition which requires surgery. This is not only about the degree of pain but also the type of pain, the story they tell about it, how they felt on the car ride coming in, and so on.





The beauty of examining the acute abdomen is in its relationship to anatomy and even embryology. Understanding what region is innervated by what nerves allows you to understand why some pain localizes poorly and other pain localizes exactly; why inflammation against the bottom of the diaphragm often causes shoulder pain; and so on. Gastroenteritis produces a cramping and poorly localized pain because its process takes place entirely within the lumen of the bowel. Appendicitis also first produces a poorly localized pain that people think is “indigestion” and locate at their belly button; but then as the inflammation moves to encompass the whole appendix, the more specifically localizing nerves of the peritoneum get irritated, and the pain localizes very specifically. (Often, but not always, at a particular spot in the right lower quadrant of the abdomen known as McBurney’s point.) With this peritoneal irritation, a whole other set of signs also begin to appear as it worsens.





I am not good at any of this, but I aspire to be. The abdomen is very lovely.





Given that the quote above is from a respectably-sized book, it’s obvious that abdominal pain can’t be reduced to something very simple. For EMS purposes, getting people in a lot of pain to the ED for surgical evaluation is probably a reasonable protocol.





But you can always get better and better at it. Learning how to do the abdominal exam, how to take a good history of abdominal pain, and understanding that “the acute abdomen” is really a wild zoo of different creatures, each with their own special signs, is one way I have started to feel like I might be a real doctor some day.





j

The other point to consider here is that while people do seem to have an inherent suspicion of surgeons - that they will just do surgery on anyone willy-nilly, the truth is that surgeons operate when they NEED to. Asking for a surgical consultation is not the same as signing someone up for surgery. If, for example, you’re the ER doc evaluating that acute abdomen, and you ask for a surgeon to check them out, the surgeon may or may not conclude that the patient needs to go to the OR.
Mary