Abdominal Pain Red Flags

Why this matters

Many people with abdominal pain want to stay home. A few are bleeding inside the belly. The source may be a rupturing aortic aneurysm or an ectopic pregnancy, a pregnancy outside the uterus. Screen for those problems and support the patient. Do not make a surgical diagnosis on scene. You will not diagnose appendicitis in the ambulance.

Clinical sequence

1. Ask about pregnancy in every person who can be pregnant. Do not accept “I cannot be pregnant” as a clearance.
2. If an older adult has tearing back or flank pain, compare pulses in both arms and both groins.
3. Look for vomiting blood, black tarry stool, or fainting. Treat that as bleeding. Do not call it gastritis.
4. Treat shock first. Choose a hospital that can operate. You will not get a CT scan on scene.

Teaching points

• Aortic aneurysm. Think of this in an older adult with tearing back or flank pain, shock that looks worse than the belly exam, or femoral pulses that do not match. Those are the groin pulses. If they are bleeding, give fluid the way your damage-control protocol says. Do not run a large uncontrolled bolus. Go to a hospital that can operate.
• Ectopic pregnancy. Pelvic or abdominal pain, fainting, shoulder pain, a known pregnancy, or a missed period can all fit. Shock can be the first sign. Bleeding from the vagina may be light. Do not wait for heavy vaginal bleeding to take it seriously.
• Perforation and peritonitis. A perforation is a hole in the gut. Peritonitis is an angry belly lining. The belly is board-hard, they may have a fever, and they lie still because movement hurts. That is a surgical belly. An antacid does not fix it.
• Pain medicine. If your protocol allows pain medicine, document the belly exam before and after. Do not skip that exam. The medicine does not hide a surgical belly when the exam is written down.

Common errors

• Calling it gastritis in a 72-year-old with back pain and a low blood pressure.
• Skipping the pregnancy question in someone who can be pregnant.
• Accepting a refusal after fainting plus abdominal pain.

Practice

Related: GI bleed, Syncope.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol still decides care
• ACEP 2016 early-pregnancy clinical policy — ectopic stays on the list until imaging says otherwise; field job is shock and destination, not a CT
• 2022 ACC/AHA Aortic Disease Guideline — sudden tearing back/abdominal pain plus pulse deficit is a dissection/AAA destination problem, not “gastritis”
• You will not get a CT scan in the ambulance. Find the red flags and choose a hospital that can operate.