Abdominal Pain — Acute¶

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf; UCLA EMT Ultimate Study Guide (2026) Last updated: 2026-05-06

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¶

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

NREMT Differentiators¶

Abdominal Conditions Comparison Grid¶

Condition	Age/Sex	Location	Quality	Key Finding	Priority
Appendicitis	Any; young adults	RLQ (McBurney's point)	Crampy → constant; worsens with movement	Fever, nausea, anorexia; rebound tenderness	High
Cholecystitis	Female, fat, 40s ("4 Fs")	RUQ	Colicky; radiates to right shoulder/scapula	After fatty meal; Murphy's sign	Moderate–High
Pancreatitis	Alcohol use; gallstones	Epigastric	Constant, boring; radiates to back	Worsens lying flat; better leaning forward	High
Kidney Stone (Renal Colic)	Any adult	Flank → groin	Severe, crampy, colicky	Patient writhes with pain; cannot find comfortable position	Moderate (pain-driven)
AAA (Ruptured)	Older male >60	Back / epigastric	Tearing/ripping	Pulsatile abdominal mass + shock	HIGHEST
Ectopic Pregnancy	Childbearing age female	Lower abdominal (one side)	Sharp, crampy	Missed LMP + shock	HIGHEST

KEY DIFFERENTIATOR — AAA: Older male + tearing abdominal/back pain + pulsatile abdominal mass = ruptured AAA. Femoral pulses may be absent or unequal. Treat as highest priority: O2, IV access en route, immediate transport. Do NOT palpate the mass aggressively.

KEY DIFFERENTIATOR — Kidney Stone vs. Peritonitis: Kidney stone patient writhes and cannot get comfortable. Peritonitis patient lies still (movement worsens pain). Movement behavior distinguishes them on the NREMT.

GI Bleed Vocabulary¶

Term	Meaning	Location implied
Hematemesis	Vomiting blood (bright red)	Upper GI (esophagus, stomach)
Coffee-ground emesis	Vomiting digested blood (dark brown)	Upper GI, bleeding slowed
Melena	Black, tarry, foul-smelling stool	Upper GI (blood digested through intestine)
Hematochezia	Bright red blood per rectum	Lower GI (colon, rectum)
Hemoptysis	Coughing blood	Airway / lungs — NOT GI

NREMT TRAP — Hemoptysis vs. Hematemesis: Hemoptysis = coughed up (airway). Hematemesis = vomited (GI). Both can look like blood, but origin determines treatment and priority.

Abdominal Quadrant Map¶

Quadrant	Organs	Common Emergencies
RUQ	Liver, gallbladder, right kidney	Cholecystitis, hepatitis
LUQ	Stomach, spleen, left kidney, pancreas (tail)	Pancreatitis (epigastric/LUQ), spleen injury
RLQ	Appendix, cecum, right ovary/fallopian tube	Appendicitis, ectopic pregnancy (R)
LLQ	Sigmoid colon, left ovary/fallopian tube	Diverticulitis, ectopic pregnancy (L)
Epigastric	Stomach, pancreas, aorta	Pancreatitis, AAA, peptic ulcer
Periumbilical	Appendicitis (early — migrates to RLQ)	Early appendicitis, small bowel obstruction

Shock Signs in Abdominal Emergencies¶

Abdominal pain + any of these = immediate priority transport:

Tachycardia (HR >100)
Hypotension (SBP <100)
Diaphoresis + pallor
Absent/unequal femoral pulses (AAA)
Missed period + abdominal pain (ectopic)
Altered LOC
Rigid, board-like abdomen

NREMT RULE: You cannot diagnose the cause of abdominal pain prehospital. Your job is to recognize shock, keep the patient NPO, allow position of comfort, and transport. The hospital finds the cause.

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)