abscess causes signs of peritonitis. Rupture of a TOA carries a mortality of approximately 10% [40].
Children
Pediatric patients present a challenge to EMS clinicians for a variety of reasons. As a rule, pediatric patients are not high‐volume users of the EMS system. In addition, infants and children may be unable to describe their symptoms, which is particularly problematic given the importance of historical data in establishing a cause. It is important to discuss the history of the patient’s symptoms and the reason why EMS was called with a parent or guardian familiar with the situation. Nonspecific findings such as irritability, inability to be consoled, and poor feeding may be the only signs of an abdominal problem in the very young. Vomiting, oral intake, urine output, last bowel movement, presence of fever, sick contacts, and vaccination status are useful points from the history. The birth history is important when treating a neonate. Questions that should be asked include whether the pregnancy was at term at the time of birth, did the mother receive prenatal care, were there any complications during the delivery, did the patient require an extended hospital stay after the birth, and have there been any subsequent hospitalizations since birth for any reason. Vital signs can be difficult to interpret in the pediatric population due to age‐related variations and the tremendous physiologic reserve that these patients possess. The examination can be compromised by the patient’s fear of pain and of the unfamiliar examiner. Finally, abdominal pain is a particularly common complaint in many extra‐abdominal conditions, as discussed above [41].
Age is a key factor in the evaluation of abdominal pain in the pediatric patient. For patients up to 1 year old, some of the considerations include infantile colic, Hirschsprung’s disease, necrotizing enterocolitis, intussusception, pyloric stenosis, volvulus, and incarcerated hernia. Bilious vomiting accompanying abdominal pain in an infant is particularly concerning, often indicating an acute surgical problem. Between 2 and 5 years old, consider testicular torsion, Henoch‐Schonlein purpura (HSP), intussusception, and appendicitis. Older children between 5 years and adolescence can have inflammatory bowel disease, testicular torsion, HSP, and pharyngitis. This is not an all‐encompassing list, but more of a differential diagnosis with which to start when obtaining the history.
On initial presentation, it may be difficult for EMS clinicians to distinguish a benign condition in children from a true surgical emergency. Up to one third of pediatric patients admitted to the ED fail to have diagnoses at the time of discharge, and a significant number of ED discharge diagnoses may be incorrect [41, 42]. Extrapolating such information to prehospital conditions makes it apparent that there should be a low threshold for transporting pediatric patients with abdominal pain.
Immunocompromised
Many patients are considered relatively immunocompromised due to their underlying medical conditions. Examples include the elderly, cancer patients undergoing treatment, malnourished patients, diabetics, patients with end‐stage renal disease, patients on certain medications (e.g., chronic steroids and many medications for diseases such as rheumatoid arthritis and irritable bowel disease), and those with HIV infection but adequate CD4 counts. As a result of their underlying conditions, these patients have depressed inflammatory responses and tend to present later in their illness courses.
Of greater concern are patients who are more profoundly immunocompromised, many times based on treatments they receive for their underlying conditions. Examples include AIDS patients with low CD4 counts, transplant patients on chronic immunosuppressive medications, leukopenic cancer patients on chemotherapy, and patients with other conditions requiring immune modulating medications such as inflammatory bowel disease or rheumatoid arthritis. These patients present with an expanded list of serious conditions that may manifest as abdominal complaints, including neutropenic enterocolitis, graft‐versus‐host disease, cytomegalovirus‐related perforation, and tuberculous peritonitis [43]. Important questions to ask include history of fevers, vomiting and/or diarrhea, recent changes in medication regimen (including noncompliance due to financial or other logistical barriers), and any prior similar episodes. Transplant patients should have the date and location of their surgery noted. EMS protocols or direct medical oversight should provide the option for such patients to be transported to specialty centers capable of managing their potentially complex conditions when feasible. Because immunocompromised patients present late in their courses, their mortality tends to be high.
Obesity and bariatric surgery patients
Statistics from 2018 estimate that 42.4% of U.S. adults are obese, a condition with known links to increased rates of diabetes and heart disease [44]. Obesity may also be linked to an increase in abdominal complaints including dyspepsia, irritable bowel syndrome, and constipation, as well as abdominal wall hernias that predispose patients to bowel obstructions [45]. The care of the obese patient may be hindered by an unreliable physical exam and equipment that is not suited for the patient’s size.
Not surprisingly, the rate of bariatric surgery has increased dramatically in recent years. Two thirds of these patients will seek medical care, with 29% getting hospitalized, representing a 4‐ to 5‐fold increased likelihood of admission in this population [46]. It is important to understand and recognize complications that include ulceration and bleeding, perforation, and mechanical obstruction. It is imperative that EMS clinicians be aware of the increased rate of these conditions in this patient population.
Summary
Patients with abdominal pain can present a significant challenge to EMS clinicians. An approach that emphasizes immediate consideration of life‐threatening abdominal and extra‐abdominal conditions is imperative. The patient’s history and the location of the pain are the primary determinants of the differential diagnosis. Stabilization of ABCs and restoring hemodynamic stability remain the primary focus of patient management. Controversies in the use of pain medication in patients with abdominal pain and appropriate fluid resuscitation in the face of acute hemorrhage exist. Specific attention to high‐risk populations, including the elderly, women of reproductive age, children, immunocompromised, and bariatric patients, must be exercised.
References
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