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Abdominal Pain — Acute

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

Overview

Acute abdominal pain is a common EMS complaint with a broad differential diagnosis spanning surgical emergencies, medical conditions, and gynecologic causes. The EMT-B cannot diagnose the specific cause prehospital but must recognize signs of shock, ensure NPO status, transport rapidly, and support the patient. Many abdominal emergencies require surgical intervention — prehospital treatment is supportive.

Common causes: appendicitis, food poisoning, pancreatitis, abdominal aortic aneurysm (AAA — high risk of rupture), gastritis, cholecystitis, kidney stones, intestinal obstruction, ectopic pregnancy, ovarian cyst, ulcers, trauma.

Key Points

  • Abdominal aortic aneurysm (AAA): older male, severe tearing/ripping abdominal or back pain, pulsatile abdominal mass, shock signs = transport immediately — highest priority
  • Ectopic pregnancy: woman of childbearing age + abdominal pain + missed period + shock = life-threatening
  • Peritonitis: board-rigid abdomen, rebound tenderness, severe pain — surgical emergency
  • Keep patient NPO (nothing by mouth) — potential surgical candidate
  • Allow position of comfort — typically knees flexed to reduce abdominal tension
  • Pain medications for abdominal pain are NOT contraindicated in the prehospital setting — do NOT withhold analgesia

Assessment Relevance

History (history-taking): - OPQRST: Onset (sudden = AAA, kidney stone; gradual = appendicitis); Provocation (movement worsens peritonitis); Quality (crampy = colic; constant = peritoneal irritation; tearing/ripping = AAA); Radiation (RLQ = appendicitis; RUQ = gallbladder; flank to groin = kidney stone; epigastric = pancreas); Severity; Time course - SAMPLE: Prior episodes, prior abdominal surgeries, last meal (NPO status), gynecologic history (LMP for females of childbearing age — ectopic pregnancy), medications (blood thinners worsen GI bleeding), prior AAA diagnosis - Vomiting: before pain (usually other cause) vs. after pain onset (peritoneal irritation) - Changes with movement: peritonitis worsens with movement; kidney stone patients writhe

Physical exam (secondary-assessment): - Vital signs: BP and pulse — shock signs (tachycardia, hypotension) indicate serious pathology - Skin: pallor, diaphoresis = poor perfusion - Abdomen: distention, rigidity (peritonitis), pulsatile mass (AAA), tenderness location - Femoral pulses in suspected AAA (diminished/absent = rupture)

Procedures

  1. Scene size-up (scene-size-up): medical NOI; trauma mechanism consideration if relevant
  2. Primary assessment (primary-assessment): ABCs; shock signs determination
  3. Keep patient NPO
  4. Allow position of comfort (typically knees flexed)
  5. If shock signs present: treat per shock (O2, position, warmth, transport immediately)
  6. Transport to appropriate facility; do NOT delay for interventions
  7. En route: IV access and fluid resuscitation (ALS scope)
  8. Reassessment (reassessment): serial vital signs; watch for deterioration

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

EMT-B scope: - Primary assessment; manage as indicated - Maintain patient NPO (nothing by mouth) - Allow patient to assume position of comfort - Transport to appropriate facility - History, physical exam, vital signs - En route: IV/IO access (ALS scope — EMT-B establishes access if trained) - If no contraindications, consider administration of pain medications (ALS scope for IV analgesics): - KETOROLAC (Toradol): Adult 10–30 mg IV/IO or 30–60 mg IM; Pediatric >1yr 0.5 mg/kg IV/IO/IM (max 30 mg) — reserved for suspected kidney stones; do NOT use with bleeding, AAA, GI bleed, or known kidney dysfunction - MORPHINE: Adult 4–10 mg slow IV/IO (2–4 mg every 10 min; max 10 mg); Pediatric (2–12 yrs) 0.05–0.1 mg/kg slow IV/IO - FENTANYL: Adult 25–100 mcg slow IV/IO every 5 min (max single 100 mcg; max total 300 mcg); Pediatric (2–12 yrs) 0.5–1 mcg/kg IV/IO or IM (max 2.0 mcg/kg) - Anti-emetics for nausea/vomiting: - ONDANSETRON (Zofran): Adult 4 mg IV/IO/PO/IM; Pediatric 0.05–0.1 mg/kg (max 4 mg) - PROMETHAZINE (Phenergan): Adult 12.5–25 mg PO/IV/IO/IM

Ketorolac note: Best reserved for kidney stone history; NOT for suspected bleeding (trauma, AAA rupture, GI bleeding); NOT in patients with known/suspected kidney dysfunction.

NREMT Relevance

  • NPO for all abdominal pain patients — potential surgical candidate
  • Position of comfort — knees flexed
  • AAA: older male + severe tearing back/abdominal pain + pulsatile mass + shock = immediate transport
  • Ectopic pregnancy: woman of childbearing age + LMP missed + abdominal pain + shock = life threat
  • Do NOT withhold pain medication prehospital — current guidelines support analgesia for abdominal pain
  • Peritonitis: board-rigid abdomen, rebound tenderness = surgical emergency
  • shock — abdominal catastrophes (AAA rupture, ectopic) present with shock
  • history-taking — OPQRST detail and gynecologic history are critical
  • secondary-assessment — abdominal exam, vital signs, femoral pulses
  • reassessment — serial vital signs; abdominal emergencies can deteriorate rapidly

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Abdominal Pain/Acute protocol (p. 32)