# Ruling out appendicitis?



## berkeman

Worked on a young patient the other day who was complaining of severe abdominal pain with acute onset.  Pain initially was in lower back and abdomen, moving over several minutes to mainly the LLQ.  LRQ was relatively pain free for most of this, including rebound palpation.  All vital signs were fine, and they were perfusing fine, but they were in severe pain to the point of incapacitation.

I ruled out appendicitis as a likely cause, but ectopic pregnancy and other possible causes were enough to justify sending the patient off in an ambulance to the nearest hospital stat.

I found out later in discussions with other EMS folks that I shouldn't have ruled out appendicitis so quickly, and there was at least one other thing I could have done to be more sure.  It turns out to be a pretty obscure condition, present in less than 1/10,000 people, but I know at least one friend-of-a-friend now who had this misdiagnosed...

What was I missing, and what else should I have checked before ruling out appendicitis?

http://en.wikipedia.org/wiki/Situs_inversus

.


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## WuLabsWuTecH

I don't think that you can really "rule out" appy in any situation presenting with pain in that region unless forwhatever reason you are already sure it is something else.

An aside: you transport lights/sirens for abdominal pain when it hasn't been identified?  We normally only respond light/sirens to emergencies and transport lights/sirens for very few cases.


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## KEVD18

i guess my wuestion to you is, why are you ruling in or out anything you cant treat?

since there nothing besides the basics(o2 prn, position of comfort, smooth ride etc), aside from documenting your exam findings, where is the necessity of a d/dx? i realize you want to form a clinical impression of your patient, but it seems like from your post that you want to arrive at a definitive diagnosis which isnt within our scope.

there are many things that would cause an acute abdomen. none of which you can treat. most are surgical cases. 

your best bet is to stick within your job. throrough exam with clinical finding documented and a professional presentation to the md. 

appendicitis can present with pain in the rlq, ruq, midline area, and in a diffuse manner(meaning anywhere in the abdomen). so you could very well be looking at appendicitis presenting with luq pain. you cant rule it out in the field.


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## KEVD18

WuLabsWuTecH said:


> An aside: you transport lights/sirens for abdominal pain when it hasn't been identified?  We normally only respond light/sirens to emergencies and transport lights/sirens for very few cases.



you cant fault the emt for how they transport a patient without first being intimately familiar with their state, local and service protocols. some department/companies transport _everything_ on lights. while you may not agree with it, its bad form to criticize someone for following their depts rules.


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## Ridryder911

I disagree. Wrong is wrong. First issue to not to place the patient in danger. There is only three or four issues that presents with abdominal problems that are emergencies. Triple A is definitely one of them. 

The criticism is not personal rather to maybe motivate one to change things. If enough pressure and research is demonstrated that things are wrong, then possibly some new protocols and changes will occur.   

R/r911


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## berkeman

KEVD18 said:


> i guess my question to you is, why are you ruling in or out anything you cant treat?
> 
> since there nothing besides the basics(o2 prn, position of comfort, smooth ride etc), aside from documenting your exam findings, where is the necessity of a d/dx? i realize you want to form a clinical impression of your patient, but it seems like from your post that you want to arrive at a definitive diagnosis which isnt within our scope.
> 
> there are many things that would cause an acute abdomen. none of which you can treat. most are surgical cases.
> 
> your best bet is to stick within your job. throrough exam with clinical finding documented and a professional presentation to the md.
> 
> appendicitis can present with pain in the rlq, ruq, midline area, and in a diffuse manner(meaning anywhere in the abdomen). so you could very well be looking at appendicitis presenting with luq pain. you cant rule it out in the field.



I agree 100%.  I think I didn't word my post correctly.  My patient clearly needed transport immediately -- the parents agreed, the FFs that responded agreed, and the ambulance crew agreed when they got there.  The level of the patient's pain was a clear indication that she needed to get to the ED quickly.  

And yes, my report to the FFs and to the AMR crew was that the RLQ was not sensitive to palpation or rebound, and that's what they wrote down.  That could be useful at the ED for the docs to know that at least at the start of the incident, the RLQ was not sensitive.  Could be different by the time she got the the ED.

I was just surprised by learning about the condition situs inversus later, and started thinking about situations where it could affect what I do, even as an EMT-B.  For example, if I'm in a wilderness setting, and am presented with mild but increasing abdominal pain, then it may be important for me to be able to start ranking the liklihood of appendicitis versus the other possible causes.  It could affect how I initially try to transport the patient, for example, like letting them walk versus having to carry them or trying to arrange other transport.  

And it also made me ask myself how I could figure out if a patient might have this condition, in case I were in a situation where it made a difference.  Listening for stomach sounds seemed like a good place to start.


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## medicdan

I agree re: not DXing-- the treatment doesnt change.
I have heard of ER docs who "knock" the stretcher of patients who they suspect of having an acute appendix. If the patient howls in pain from the movement (indicating either a perfed appendix or a faker, depending on quality of howl).


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## mycrofft

*I did the appy thing about forty five years ago*

The pain is not an acute onset, it starts and worsens and moves around or otherwise settles in the proper area over hours. I hate rough palpating or repeatedly rebounding patients in the field because if it's friable (or it's actually a leaky gallbladder instead) then you can cause harm beyond the agony. 

I'm in KED's kamp, cut to the chase, get nice VS and bowel sounds, tap for tympany, but in the end you're going in and not doing much on scene other than comfort and helping prevent shock.

(PS: whenever you go get a belly case, ask about use of laxatives, enemas, "colonics", or other diddling about with the nether region).


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## Outbac1

If the " RLQ is relatively pain free and was not sensitive to palpation or rebound" and the acute onset started in the lower back and moved around to the LLQ. Appendicitis would not be my first guess. I'm thinking more along the lines of a kidney stone. Although as others have said none of the poss causes, Appendicitis, AAA, Ectopic pregnancy etc. can be totally ruled out with out tests. 


 Hopefully my new XRAY glasses will help out with these types of diagnosis.


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## LucidResq

emt-student said:


> I have heard of ER docs who "knock" the stretcher of patients who they suspect of having an acute appendix. If the patient howls in pain from the movement (indicating either a perfed appendix or a faker, depending on quality of howl).



This is the heel-jar or Markle's test... heel jar meaning that if you bump into the heel of their foot they experience intense abdominal pain. The traditional way to perform this test is by having the patient stand on tiptoes and then fall quickly back onto their heels... but the ER doc way is as you described.

A positive heel jar test is a good sign of peritonitis... and while it very well may indicate appendicitis, peritonitis may result from any number of other conditions. 

Either way, it doesn't really matter. As Rid mentioned, with abdominal pain you might be looking for s/s of a specific, immediately life-threatening concern such as a AAA or rapid internal hemorrhage, but there is really no need to distinguish amongst other acute abdomen causes because, for one, in the field it is impossible to make an accurate diagnosis anyways, and for two, your treatment will not vary. 

My personal opinion is that in most situations it is best to make your urgency decisions based on your impression of the patient's condition... not your "diagnosis" (more like best guess in EMS). Even starting out as an EMT, you should get a general sense from people whether they're sick or not without them speaking a word. That instinctual judgment increases with your level of experience.


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## Brooks416

No one mentions the patients temp. To me that would help in making a decision about transport mode. Just a thought.


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## berkeman

Brooks416 said:


> No one mentions the patients temp. To me that would help in making a decision about transport mode. Just a thought.



All vitals were WNL.  Skin temp was good (no fever), and perfusion was good.  Patient was just in severe pain.


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## daedalus

funny, I fail to remember the last time I pulled out that dusty ultrasound machine from under the bench seat.


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## mycrofft

*The travel sounds like a kidney stone, but bellies gotta go in.*

Lucid, I liked your wording about how we learn to read their mojo frmo the doorway.


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## BossyCow

LRQ belly pain can mean way to many things for a female. I went to my local ER with it some years ago. The R/Os included UTI, Kidney Stone/infection, Appendicitis, Ectopic Pregnancy, Endometriosis, Ovarian Cyst, Gastritis, Colitis. After three days it was determined to be a ruptured ovarian cyst. But that was many tests later.


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## rhan101277

Ridryder911 said:


> I disagree. Wrong is wrong. First issue to not to place the patient in danger. There is only three or four issues that presents with abdominal problems that are emergencies. Triple A is definitely one of them.
> 
> The criticism is not personal rather to maybe motivate one to change things. If enough pressure and research is demonstrated that things are wrong, then possibly some new protocols and changes will occur.
> 
> R/r911



Shouldn't blood in the abdominal area reduce bowel sounds?  Also for Triple A the abdomen should be distending and you might find a pulsating mass unless it has already ruptured.  You should see S/S of shock, poor inferior distal pulses.  I know this is off subject but is there anything else important I am missing.


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## WiFi_Cowgirl

Have them jump up and down, or bend their knee up and cough.


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## ffemt8978

WiFi_Cowgirl said:


> Have them jump up and down, or bend their knee up and cough.



Are you seriously advocating that a patient with acute abdominal pain jump up and down so that you can "rule out" something you can't even diagnose to begin with?:wacko:


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## reaper

WiFi_Cowgirl said:


> Have them jump up and down, or bend their knee up and cough.



I know that EMT education is lacking, but you should really find a good school to retake it at!


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## downunderwunda

How can you definitivley rule anything in or out.

Even though we have a good grounding of education, we make an educated Provisional diagnosis. Based on experience there is a high probability we wil be right. 

Having said that, our education allows us to make decisions based on presentation. The basic foundation of EMS is treatment of symptoms, not differential diagnosis. Be aware of the problems & dont make it worse. Eg, dont give an anti emetic to a pt who has ingested a toxin.........

Treat what you see, do over complicate things. EMS is easy, lets keep it that way.


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## Veneficus

WiFi_Cowgirl said:


> Have them jump up and down, or bend their knee up and cough.



I don't suppose whoever told you this told you why this works and that it cannot be distinguished from peritonitis which could have several different causes.


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## WiFi_Cowgirl

ffemt8978 said:


> Are you seriously advocating that a patient with acute abdominal pain jump up and down so that you can "rule out" something you can't even diagnose to begin with?:wacko:




No..


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## Veneficus

WiFi_Cowgirl said:


> No..



If you are going to perform a test like this, just have the pt flex their hip while sitting, all you have to do is take the pressure off of psoas major, forget jumping up and down or coughing. At the begining of the cough it will increase intra abd pressure and pain so will the landing of a jump, right before they fall to the ground. (do no harm)

But all the test tells you really is that there is pain from peritoneal stretch receptors. It may not work depending on the normal anatomical variances of the cecum and appendix so when it works it really just narrows down where the inflamation is. In females there is so much in the area it is practically worthless.


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## BossyCow

Veneficus said:


> In females there is so much in the area it is practically worthless.



That's because we're _SPECIAL_


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## emtjack02

OP..Other s/sx for appendisitis include..
Rovsing's sign is present when tenderness is referred to the right lower quadrant when the left lower quadrant is palpated. 
Psoas sign is the increase of pain when the psoas muscle is stretched as the patient is asked to extend the hip. 
Obturator sign is the elicitation of pain as the hip is flexed and externally rotated.
Rebound tenderness is a late sign and w/o a prior exam would be relatively useless in regards to assessing for an appy.
I dont believe it's in our scope as pre hospital providers to rule anything out.  
In response to other post... blood will not necessarly decrease bowel sounds, a leaking aneurysm may not present as urgently as some may believe.  While they need to be seen they will not look horrible.


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## NebraskanPrincess

Question:  Someone mentioned abd distension on AAA - are we talking post- or pre-rupture?  They thought my mom had it but her only symptom was pain and tenderness - no distension and you could feel pulsation but she's itty bitty.  Probably another reason I should re-consider dieting for the new year, so someone could better palpate my abdominal aortic artery   Tee hee hee...

Remember, you can still detect a pulse in those who are little and especially peds patients, so palpating one doesn't always mean a AAA.

Was the heel-drop test recommended to find rebound tenderness?  I thought that test was only positive for peritonitis - help!


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## emtjack02

Princess, You're right sometimes pulsations are normal for people.  The heel drop is intended to assess for peritonitis.  Rebound tenderness is assessed by slowly pushing in and holding it for 5 or 10sec and then quickly take your hands off. If pain is reported when you quickly let go it's rebound tenderness. In appy's this is a late sign and generally indicates that it could have ruptured or extremely inflamed.


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## JPINFV

BossyCow said:


> That's because we're _SPECIAL_



Short bus special maybe.
h34r:


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