Abdominal Pain in Elderly Persons Treatment & Management
- Author: E David Bryan, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Prehospital Care
Elderly patients with severe abdominal pain, abnormal vital signs, or altered mental status should undergo the following:
- Large-bore IV placed with either normal saline or lactated Ringer solution (gauge fluid resuscitation by vital signs)
- Cardiac monitor and pulse oximetry
- Oxygen by nasal cannula or 100% face mask, depending on vital signs and pulse oximetry
Emergency Department Care
Care in the emergency department is dictated by the severity of presentation. Assess ABCs and vital signs immediately. Place patients on a monitor and start an IV or heparin lock. Administer oxygen to patients who appear to be seriously ill.
If the diagnosis of AAA is suggested, perform a rapid bedside ultrasound, if available.
Administer IV boluses of normal saline or lactated Ringer solution to patients with suspected volume loss. Carefully hydrate patients with a history of renal disease or congestive heart failure to avoid volume overload.
A Foley catheter may be helpful as a guide for volume resuscitation in patients who are sicker. Incontinence is not an indication for a Foley catheter.
Keep all patients with abdominal pain as nothing by mouth (NPO) until surgical pathology is excluded.
Place a nasogastric tube in patients in whom bowel obstruction, ileus, or upper GI bleeding is suspected.
Maintain a low threshold for ordering additional tests such as CT scan or ultrasound.
If biliary disease is suggested, dicyclomine (Bentyl) or glycopyrrolate (Robinul) may be administered for pain. NSAIDs are very effective for biliary colic but should be administered with caution to elderly patients.
In patients with undifferentiated abdominal pain, administering small doses of opioids is reasonable. Several studies have demonstrated this to be safe and effective without decreasing diagnostic accuracy.
- Morphine administered IV in doses of 2-4 mg is inexpensive and effective. Morphine, like all opioid analgesics, has been demonstrated to cause spasm of the sphincter of Oddi. This side effect should be taken into account when treating patients in whom biliary disease is suspected.
- Fentanyl has distinct advantages for use in the emergency department. Its short half-life allows for frequent reevaluations between doses. It also causes almost no increase in histamine release and minimal drop in blood pressure.
- Meperidine (Demerol) has been the traditional opioid of choice in biliary tract disease because it causes less sphincter of Oddi spasm. However, the incidence of adverse central nervous system effects, including seizures, have led many to caution against its use under any circumstance.
- Depending on the practice environment, contacting the on-call surgeon prior to administering opioids may be reasonable.
Initiate appropriate antibiotic coverage for patients in whom sepsis, cholecystitis, appendicitis, diverticulitis, or perforated viscus is suspected. Please refer to the article on the specific diagnosis for choice of antibiotics for a specific disease process (see Differentials).
Consultations
In patients in whom ruptured AAA or mesenteric ischemia is suspected, consult a surgeon immediately.
Consult a gastroenterologist immediately for patients with significant GI bleeding.
When the diagnosis is uncertain, obtain surgical consultation. Discharge of an elderly patient with abdominal pain should be the exception rather than the rule.
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