Sandbox/algo

ACS: Acute coronary syndrome; AAA: Abdominal aortic aneurysm; RUQ: Right upper quadrant; RLQ: Right lower quadrant; LUQ: Left upper quadrant; LLQ: Left lower quadrant

Signs of peritonitis or shock ❑ Fever ❑ Abdominal tenderness ❑ Abdominal gaurding ❑ Rebound tenderness (blumberg sign) ❑ Diffuse abdominal rigidity ❑ Confusion ❑ Weakness ❑ Low blood pressure ❑ Decreased urine output ❑ Tachycardia

No

Yes

Signs and symptoms suggestive of acute coronary syndrome ❑ Risk factors: >40 years, smoking, diabetes mellitus, hypertension, obesity and high cholesterol ❑ Chest tightness radiating to the left arm and the left angel of the jaw ❑ Diaphoresis ❑ Shortness of breath ❑ Sense of impending death ❑ Nausea and vomiting For more details about management of ACS, click here

Signs and symptoms suggestive of abdominal aortic aneurysm ❑ Risk factors: smoking, alcohol, hypertension, high familial prevelance (genetic influences) ❑ Pulsating sensation of the abdomen ❑ Palpable abdominal mass ❑ If ruptured: hypovolemic shock, hypotension, tachycardia, cyanosis, and altered mental status

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

No

Yes

❑ Surgical consultation ❑ Bedside ultrasound ❑ Abdominal CT For more details about management of AAA, click here

Signs and symptoms syggestive of mesenteric ischemia ❑ Abdominal pain out of proportion to examination ❑ Bloody stools ❑ Shock ❑ Metabolic acidosis with dehydration

Yes

No

❑ Surgical consultation ❑ Abdominal CT For more details about management of mesenteric ischemia, click here

Signs and symptoms suggestive of bowel obstruction or Intestinal perforation ❑ Diffuse tenderness with distention ❑ Persistent vomiting ❑ Rigidity with absent bowel sounds ❑ Fecal vomiting ❑ Dehydration and electrolyte abnormalities

Yes

No

Abdominal x-ray series ❑ Presence of free air: Consult surgery ❑ Presence of obstruction: Order abdominal CT ❑ Absent free air and absent obstruction: Order abdominal CT

Where is pain localized

RUQ pain

RLQ pain

LUQ pain

Epigastric pain

Hypogastric pain

Approach to a female of child-bearing age

Peritoneal signs or shock

No

Yes

Pregnant

❑ Stabilize airway, breathing and circulation ❑ Obtain emergent surgical consultation ❑ Obtain pregnancy test ❑ Perform bedside ultrasound

No

Yes

Unilateral adnexal tenderness

Yes

❑ Perform ultrasound examination (consider ectopic pregnancy, appendicitis) ❑ Perform sterile pelvic examination (not in third trimester vaginal bleeding) ❑ Obtain quantitative HCG and other needed lab tests ❑ Obtain OB/Gyn and surgery consultation as indicated

No

US to rule out ovarian torsion or ovarian cyst

Intrauterine pregnancy

Ectopic pregnancy

Clinical pelvic inflammatory disease

❑ Assess appendix with US ❑ Obtain OB/Gyn and surgery consultation as indicated

Obtain OB/Gyn consultation

No

Yes

Predominant right lower quadrant tenderness

Toxic appearing or persistent vomiting

No

Yes

Adminster antibiotics as an outpatient

Admit, start IV antibiotics and consult Gyn