Sandbox/algo

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

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