Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

Wilderness and Rescue Medicine 206

muscle spasm causes involuntary guarding as the body protects the abdominal contents frommove- ment. Palpation elicits tenderness that tends to be specific to the problem area. Jostling or walk- ing the patient produces pain in the same loca- tion. Peristalsis slows or stops, and bowel sounds diminish dramatically. These are called peritoneal signs and indicate a serious problem within the abdomen. If appendicitis is allowed to progress, the organ may burst, spilling digestive enzymes and pus into the abdominal cavity and peritoneal lining. Pain is severe, constant, and will spread throughout the abdomen. Shock and death are often the result. The key to early recognition of appendicitis, or any other serious hollow organ problem, is the change in the character of pain from the cramp like and generalized pain of hollow organ disten- tion to the constant and localized pain of perito- neal inflammation. Other, less specific signs and symptoms like fever, diarrhea, vomiting, and tachycardia all add to your concern. The same progression of signs and symptoms can develop with other serious hollow organ problems and may present anywhere in the abdomen. It is not necessary to know exactly what you’re dealing with to know that it needs a surgeon and an operating room. Peritoneal signs indicate a serious abdominal problem regardless of the location or cause.

medical practitioner should be alert to the devel- opment of peritoneal signs following significant blunt trauma to the abdomen. With constant pain and localized tenderness, volume shock from internal bleeding is the anticipated problem.

This elk viscera demonstrates the membranous peritoneum, intestines, and a fractured liver. A similar type of pain can be caused by muscle contusion or strain of the abdominal wall. This may not be associated with any internal organs and is not serious, but it can be difficult to dis- tinguish from peritoneal irritation. This type of pain is usually relieved by rest and made worse specifically by use of the injured muscles. Even if the abdominal pain itself is identified as not serious, an illness with vomiting and diarrhea may lead you to anticipate volume shock from dehydration. The presence of blood or pus in the stool or vomit, or a persistent fever, could indicate a serious bacterial or viral infection within the gut that, like any other local infection, can become a serious systemic infection. If rehydration and definitive treatment in the field are not possible, evacuation is indicated even if surgery is not. Treatment of Abdominal Pain If an evacuation will exceed two hours, give fluids and calories to make up for normal and abnormal losses. This should be restricted to water, rehydra- tion solutions, and easily absorbed simple sugars. Oral pain medication should be restricted to acet- aminophen because nonsteroidal anti-inflamma- tory drugs (NSAIDs), like ibuprofen and aspirin,

Abdominal Pain

General Principles

8

Serious: • Constant, localized pain and tenderness • Aggravated by movement and palpation • Persistent fever • Bloody vomit or diarrhea • Signs and Symptoms of shock • Lasts more than 24 hours

*

Not Serious

Serious

©2018WMA

Other Abdominal Problems Solid organ rupture and bleeding can also cause irritation of the peritoneal lining. The wilderness