Triage and stabilization of abdominal pain

A mock pain management case featuring a 4-year-old female, spayed schnauzer named Shelia with severe abdominal pain was presented today at the dvm360® Directions in Veterinary Medicine (DIVM) symposium in Miami, Florida. Shelia didn't eat for 48 hours and yelped when her owner picked her up, according to presenters Adam Christman, DVM, MBA, dvm360 chief veterinary officer, and Fred Wininger, VMD.¹

Adam Christman, DVM, MBA, dvm360 chief veterinary officer and Fred Wininger, VMD, presenting the mock pain management case.

Dr Mariana Pardo delivering her lecture on triaging and stablizing the abdominally painful patient.

Mariana Pardo, BVSc, MV, DACVECC, offered a deep dive into this schnauzer's case, during her lecture on abdominal pain that immediately followed the presentation of Sheila's condition. Pardo's talk addressed triage, stabilization, and initial condition management.²

Triage

When it comes to triage of the abdominally painful patient, Pardo advised to take a brief history and ensure the client gives a clear, concise summary of what the patient is currently experiencing. “I understand many of us are really busy with our day. But that's where having that communication of trying to concise things down and telling the owner [that] I need to have the most salient information to know what's going on. [That] is going to be the most important thing,” she said. A standard triage form clients can fill out may help a clinician narrow down the questions needed to be answered about the patient’s condition.

Veterinary professionals would then take vitals including temperature, heart rate, respiratory rate, and blood pressure, examine if the patient is breathing appropriately and its gums are a good color, and perform a brief physical exam. Using all these approaches together can help determine if the patient needs immediate treatment or not.

Pardo noted that pets can have an acute abdomen and not be that painful. Additionally, animals are often good at coping with pain so it can be hard to identify. Some signs of pain to look for include the following:

• Arched posture
• Prayer position
• Restlessness
• Abdominal splinting
• Guarding of abdomen
• Aggressivity with abdominal palpation
• Reluctance to walk
• Stiff gait
• Lowered head position
• Partially closed eyes
• “Feigned” sleep
• Decreased grooming activity
• Hiding
• Vocalization

Pardo also shared that she uses Point of Care Ultrasound (POCUS) as part of initial triage on all patients as this can provide invaluable insight into what the pet is experiencing in a noninvasive, affordable way. “Ultrasound is incredibly valuable because especially in patients that are unstable, with a very simple tool, you can get tons of information without putting the patient on the side, or it's back to take X-rays, it is not terribly painful or uncomfortable. And within 2 to 3 minutes, get tons of information,” she explained.

Stabilization

After determining the patient is experiencing severe pain, the first step Pardo would take is to administer medications that can help ease the distress. “One of the important things would be give pain medications right away because our bloodwork is probably going to take 20 to 30 minutes depending on how fast our machine is running…Your X-rays are probably also going to require having a discussion with the owner…So, pain medications are the first thing that I'm going to do for this patient once I've assessed that it is actually in pain," Pardo said.

Early analgesia has various benefits including better patient management, helping to control pain-induced tachycardia and hypertension, preventing immunosuppression from chronic pain, and helping to manage pain-induced nausea. Pardo suggested using opioids, such as buprenorphine, fentanyl, hydromorphone, or methadone. Some notes to consider are that buprenorphine will reverse mu opioids if given together, fentanyl is short-acting and requires a continuous rate infusion (CRI) to maintain analgesia, and hydromorphone may cause vomiting and panting. Pardo typically goes with methadone as it has fewer adverse effects compared to the others. If opioids are not available in the hospital or if the pet experiences known adverse effects when taking these drugs, some other pain management options to consider include ketamine, dexmedetomidine, lidocaine, gabapentin, and tramadol.

Once the patient is administered pain medication, clinicians can implement fluid therapy, continuous monitoring, antiemetics, and point of care diagnostics. Pardo said to assess if the patient is hypovolemic and administer fluid therapy. She advised checking the blood pressure and doing pain scoring.

Pardo recommended using the Modified Glasgow composite measure pain scale in which a score of more than 6/24 or 5/20 suggests that rescue analgesia is recommended. “[It’s a] very simple scoring system for your team to do,” she said. “And that way we can track things and see where the patient is at."

Considerations

Pardo emphasized again that abdominal pain isn’t always present with an acute abdomen and that doesn’t rule out a problem. Cats in particular are tricky as they disguise pain well and can have confusing behavior. Very ill patients might not show signs of pain as their body is solely focused on surviving and doesn’t have the energy to display pain.

Last, Pardo said veterinary professionals should not have tunnel vision. Just because the pet is a specific breed, it doesn’t mean it is experiencing a certain condition associated with that breed. All abdominal organs can be culprits, she noted.

References

1. Christman A, Wininger F. Welcome, Opening Remarks and Today's Case. Presented at: Directions in Veterinary Medicine; Miami, Florida. May 19-20, 2023.
2. Pardo M. From the Generalist & Specialist's Perspective. Triage & Stabilization of Abdominal Pain. Presented at: Directions in Veterinary Medicine; Miami, Florida. May 19-20, 2023.