Urgent considerations
See Differentials for more details
Assess the patient using a systematic approach, evaluating airway, breathing, circulation, disability, and exposure (ABCDE).[21] Monitor vital signs and obtain large bore intravenous access.
Hypovolemia should be corrected with fluids and/or blood products as clinically indicated. O-negative blood can be given until cross-matched blood is available.
Patients with ruptured abdominal aortic aneurysm (AAA) or aortic dissection require especially careful fluid management. Aggressive fluid resuscitation before surgery in patients with ruptured AAAs is associated with an increased risk of perioperative death, independent of systolic blood pressure.[22] Lowest systolic blood pressure <70 mmHg is associated with higher 30-day mortality, compared with lowest systolic blood pressure ≥70 mmHg, in patients undergoing open or endovascular ruptured AAA repair (51% vs. 34%, respectively).[23] Typically, systolic blood pressure is maintained between 80 and 90 mmHg.[24]
Women of childbearing age should have a pregnancy test to exclude the possibility of ectopic pregnancy.[25] If ectopic pregnancy is suspected, send blood for blood typing and cross-matching and obtain an urgent gynecologic consult. Urgent gynecology consult is important for ovarian torsion as the longer an ovary is torsed, the less likely that it can be salvaged.
Urgent urologic consult should be obtained if testicular torsion is suspected.
Complete blood count, serum electrolytes, creatinine, and blood urea nitrogen are recommended in all patients; additional tests should be guided by the history.
Obtain a surgical consult before further diagnostic testing, if possible. This can help avoid unnecessary workup and determine whether operative management is needed.
In patients exhibiting evidence of hypovolemic shock with a known or suspected hemoperitoneum, it is imperative to proceed to surgery with a limited preoperative evaluation.
Consider giving an antifibrinolytic, such as tranexamic acid, to patients with suspected ongoing hemorrhage.[26]
Prophylactic antibiotics are recommended for patients with a perforated viscus, diverticulitis, appendicitis, mesenteric ischemia, or ruptured AAA. These patients can rapidly develop sepsis. If possible, blood cultures and other microbiologic samples should be taken before starting antibiotics.
Consider myocardial infarction in patients with epigastric pain, particularly if accompanied by sweating.[27] Obtain an ECG and serum troponin measurement; consult a cardiologist immediately if either is abnormal.
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