Sandbox/hypogastric

Peritoneal signs, shock or toxic appearing

No

No

Yes

Symptoms, signs, risk factors or ECG suggestive of acute coronary syndrome

Symptoms, signs or risk factors suggestive of abdominal aortic aneurysm

❑ Initiate resuscitation ❑ Obtain immediate surgical consultation ❑ Perform bedside ultrasound (evaluate aorta, hemoperitoneum, pericardium and inverior vena cava) ❑ Obtain indicated tests and studies (e.g. x-ray, ECG, lactate, lipase and LFTs)

No

Yes

Appropriate management

❑ Surgical consultation ❑ Bedside ultrasound ❑ Abdominal CT

History, examination and risk factors suggest mesentric ischemia (pain out of proportion to exam)

Yes

No

❑ Surgical consultation ❑ Abdominal CT

History and examination suggest bowel obstruction (diffuse tenderness with distention and persistent vomiting) or perforation (rigidity with absent bowel sounds

Yes

No

Abdominal x-ray series

Where is pain localized

Presence of free air

Presence of obstruction

Absent free air and absent obstruction

Epigastric or upper right quadrant tenderness

Right lower quadrant tenderness

Left lower quadrant tenderness

Surgical consult

Abdominal CT

Abdominal CT

Hypogastric pain/Suprapubic pain

Left upper quadrant tenderness

Male

Female

No urinary symptom

Presence of dysuria and voiding dysfunction

Dysuria and voiding dysfunction

No urinary symptoms

Consider bowel or vascular disease

Urine culture, suprapubic USS and catheterization

Urine culture, pelvic ultrasound and catheterization

Pain at the cervix or vaginal fornices

Vaginal examination

Refer to general surgery

Consider prostatitis, cystitis or urine retention

Consider cystitis or extrinsic bladder compression causing urine retention

Consider gynecological referral

If examination was unremarkable, refer to general surgery

Refer to urology

Refer to urology