Sandbox/branch

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

Left upper quadrant tenderness

Patient history

Pulmonary symptoms

Urinary symptoms

Colic

Consider pulmonary embolus or pneumonia

Consider urinary tract infection or nephrolithiasis

Consider a hepatobiliary cause or nephrolithiasis

Physical examination

Tachypnea, hypoxia or pulmonary findings

Costovertebral or suprapubic tenderness

Perform ultrasonography of abdomen, if non diagnostic, consider nephrolithiasis

Chest x-ray, if nondiagnostic, helical CT and D dimer assay to evaluate for pulmonary embolism

Perform a urinalysis

Pyuria

Hematuria

Consider urinary tract infection or pyelonephritis

Consider nephrolithiasis