Life-saving tips for acute abdominal pain in children

Have an 'extremely low threshold' for these patients

Abdominal tenderness and rigidity, temperature more than 100.5° F, pallor, diaphoresis, or hypo/hyperactive bowel sounds. Any of these signs and symptoms is a red flag that a child's abdominal pain is possibly life-threatening, says K.C. Willis, MSN, CRNP, CEN, CCRN, EMT-P, nurse practitioner for emergency services at Lehigh Valley Hospital in Allentown, PA.

"Children may present atypically due to differences in pain tolerance and communication gaps," notes Willis.

Triage of children with abdominal pain can be challenging to even the most seasoned ED nurse, says Deb Jeffries, RN, CEN, an educator at Fairview, NC-based Triage First, which provides triage consulting and education services. Any pediatric patient that presents as limp, flaccid, or difficult to arouse; in decompensate shock; or with signs of sepsis is in a life-threatening situation, says Jeffries. "The triage nurse should always remember that pediatric patients in compensated shock may deteriorate suddenly to decompensated shock," she warns.

Assess the child's abdomen for distention, bowel sounds, rigidity, guarding, localization, rebound, and mottling, says Jeffries. "Worst-case scenarios that may present with life-threatening symptoms include perforated viscous with peritonitis and sepsis, bowel obstruction, intra-abdominal ischemic events, ruptured or lacerated organ, intussusception, and toxic ingestions," says Jeffries.

To improve care of children with abdominal pain, do the following:

  • Look for associated symptoms.

Ask about nausea, vomiting, changes in bowel/bladder habits, and appetite, says Willis. "Peripubescent girls should be asked about menstrual cycles and the possibility of being pregnant, and should always be tested regardless of response," he says.

  • Always examine the abdomen.

"I have seen emergency nurses not physically examine the abdomen during triage," says Willis. "The abdominal exam is vital in identifying an acute abdomen and potentially life-threatening abdominal emergencies. It should not be assumed that the 'physician will do it anyway.'"

  • Don't overlook atypical symptoms.

Recently, Willis cared for an 8-year-old girl with mild periumbilical pain, no fever, and no other constitutional symptoms. Her complete blood count was normal, and her pain was intermittent and colicky, but her abdominal/pelvic CT scan showed an acute appendicitis with phlegmon, and she required immediate surgery to remove the appendix that was on the verge of rupture, says Willis. "A low threshold for surgical consultation and observation admissions, and a high index of suspicion are necessary to accurately detect potentially life-threatening abdominal conditions," says Willis.

  • Don't assume that no significant injury exists just because none is visible.

If the child has experienced blunt trauma to the abdomen, it is unsafe to assume that because there is an absence of visual external markings such as contusion, abrasion, or ecchymosis and the child is "stable," that no significant injury exists, says Jeffries. "Children are at high risk for significant injury to intra-abdominal contents due to blunt trauma," she says. "The triage nurse should have a high index of suspicion of the potential for significant injury, even in the absence of external evidence and apparent stability of the patient."

  • Don't ignore nonverbal signs.

Young children can't tell you specifically where the pain is located, and even older children may have difficulty verbalizing specific symptoms, says Jeffries. "Therefore, the triage nurse must often rely on physical examination and the history as provided by the parent, guardian, or caregiver," she notes.

The younger the infant, the more subtle the signs, says Maureen Curtis Cooper, RN, BSN, CEN, a staff nurse in the pediatric ED at Boston Medical Center. "Careful attention must be paid to vital signs, and knowing the normals for the age of the child," she says. "Observe the child for normal growth and development activities. The less age-appropriate behavior seen, the more ill the child."

  • Do frequent assessments.

Worsening abdominal pain in a child who has sustained trauma can indicate presence or progression of previously undiagnosed internal bleeding, says Willis. Conversely, a child with appendicitis can have sudden relief of pain, which may mean inflamed appendix has ruptured with the release of pressure caused by pus buildup, he adds.

"The relief in pain is temporary; as peritonitis develops, the pain returns, and the child becomes acutely ill," Willis says. "Repeat abdominal assessment in children should occur every 15-30 minutes, and whenever a change is noted in pain level or constitutional signs."

Reassessments determine if the child needs emergent, urgent, or nonurgent interventions, says Cooper. "I recently took care of a 4-year-old boy who was kicked in the abdomen by a horse. The child persistently complained, 'It hurts a little bit right here,' pointing to a spot in the right lower quadrant," she says.

The child's initial abdominal CT scan was negative, but during the one-hour trip to X-ray for cervical spine completion films, the child's initially soft abdominal exam became rigid, and repeat CT with contrast showed a perforated intestine, says Cooper.

  • Don't assume constipation is the cause.

Constipation is the most common cause of abdominal pain in children coming to an ED, but a surgical cause was present in 2% of cases, according to a recent study.1

"There is a common misconception that grunting in an infant is constipation, when in reality it often is respiratory distress, and grunting represents premature closing of the glottis to provide positive end expiratory pressure," says Cooper.

There is a danger at triage that the nurse may assume the child is "just constipated," says Jeffries. "It is our responsibility to consider the worst-case scenario. Remember that the most obvious symptom is not always the most critical one."

Reference

1. Loening-Baucke V, Swidsinski A. Constipation as cause of acute abdominal pain in children. J Pediatr. Article in press, doi:10.1016/j.jpeds.2007.05.006.

Sources

For more information on treatment of pediatric abdominal pain, contact:

  • Maureen Curtis Cooper, RN, BSN, CEN, FAEN, Staff Nurse, Pediatric Emergency Department, Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118. E-mail: pmmkcoop@comcast.net.
  • Deb Jeffries, RN, CEN, Educator, Triage First, P.O. Box 1924, Fairview, NC 28730. Phone: (828) 628-8029. Fax: (828) 628-8025. E-mail: debjeffriesrn@yahoo.com.
  • K.C. Willis, MSN, CRNP, CEN, CCRN, EMT-P, Nurse Practitioner, Emergency Services, Lehigh Valley Hospital, Cedar Crest & Interstate 78, Allentown, PA. E-mail: kcw0143@yahoo.com.