For 'newer' medics and students... abdominal pain management

[SpecialK]

I am fresh out of medic school and we were taught it. Now I am not just gonna press as hard as I can or anything ridiculous, but I would at this point in my career do a light test for it.

From memory the rationale for not using it is because it doesn't have any specific diagnostic value that will change what we do to the patient.

As I said previously, my abdominal examinations are pretty rubbish but I do have a quick palpate of their tummy. If they have a peronitic, rigid hard abdomen it's going to be quite obvious when I have a feel no?

Abdo pain in general is a pain in the, well, abdomen, I guess. It can be really hard figuring out if these patients need immediate referral somewhere or are safe to remain in the community with delayed referral or self-care.

Unless they have an obviously non-significant and well-manageable problem such as uncomplicated gastroenteritis or something I will generally recommend they go to ED, or at the very least, see their GP in the morning AND make an appointment with them while at the house. Most GP's also don't seem to like abdominal pain and their default is "unless it's minor they go to ED". Which I think is honestly best for the pt.

 

[Handsome Robb]

Unless they have an obviously non-significant and well-manageable problem such as uncomplicated gastroenteritis or something I will generally recommend they go to ED, or at the very least, see their GP in the morning AND make an appointment with them while at the house. Most GP's also don't seem to like abdominal pain and their default is "unless it's minor they go to ED". Which I think is honestly best for the pt.

I don't disagree. An acute abdominal complaint with an unknown cause is a high risk scenario.


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[MackTheKnife]

I remember being taught to stop testing for "rebound tenderness" years ago no? .....

Still an assessment tool in nursing.

 

[StCEMT]

From memory the rationale for not using it is because it doesn't have any specific diagnostic value that will change what we do to the patient.

As I said previously, my abdominal examinations are pretty rubbish but I do have a quick palpate of their tummy. If they have a peronitic, rigid hard abdomen it's going to be quite obvious when I have a feel no?

Abdo pain in general is a pain in the, well, abdomen, I guess. It can be really hard figuring out if these patients need immediate referral somewhere or are safe to remain in the community with delayed referral or self-care.

Unless they have an obviously non-significant and well-manageable problem such as uncomplicated gastroenteritis or something I will generally recommend they go to ED, or at the very least, see their GP in the morning AND make an appointment with them while at the house. Most GP's also don't seem to like abdominal pain and their default is "unless it's minor they go to ED". Which I think is honestly best for the pt.

I haven't ever actually had a patient with appendicitis, so I don't know. But then again, if memory serves right it starts out periumbilical and moves to where McBurney's point is? So I guess there are times where that would be true.

Same here, abdominal pain leaves so many doors I don't really go too crazy with trying to play doctor and find an answer in the 7 minutes I have them in my truck.

 

[VentMonkey]

I haven't ever actually had a patient with appendicitis, so I don't know. But then again, if memory serves right it starts out periumbilical and moves to where McBurney's point is? So I guess there are times where that would be true.

Same here, abdominal pain leaves so many doors I don't really go too crazy with trying to play doctor and find an answer in the 7 minutes I have them in my truck.

You'll "just know".They're typically doubled over in pain with no reasonable suspicion that they are "med seeking", have had copious bile in their vomit, and/ or have been dry heeving.

I agree with what most of the seasoned medics have posted on here (I know the op wanted newer paramedics' input), acute abdominal pain with any reason for suspicion to me gets antiemetics and pain control/ fluids, no real ifs ands or buts. I could care less what the ED staff does or doesn't think of my differentials.

As far as palpating the abdomen, I usually start from the farthest quadrant from their pain, and if it hurts there, I stop. I wouldn't want someone poking at my stomach for some quasi-reliable test if I have an acute abdomen.

I would think much like any half way decent paramedics, most ED docs and nurses worth a dime don't need to have some "sign" be the defining factor in a clinically diagnosed abdominal complaint...and most don't.

 

[StCEMT]

You'll "just know".They're typically doubled over in pain with no reasonable suspicion that they are "med seeking", have had copious bile in their vomit, and/ or have been dry heeving.

I agree with what most of the seasoned medics have posted on here (I know the op wanted newer paramedics' input), acute abdominal pain with any reason for suspicion to me gets antiemetics and pain control/ fluids, no real ifs ands or buts. I could care less what the ED staff does or doesn't think of my differentials.

As far as palpating the abdomen, I usually start from the farthest quadrant from their pain, and if it hurts there, I stop. I wouldn't want someone poking at my stomach for some quasi-reliable test if I have an acute abdomen.

I would think much like any half way decent paramedics, most ED docs and nurses worth a dime don't need to have some "sign" be the defining factor in a clinically diagnosed abdominal complaint...and most don't.

I don't doubt I could put 2 and 2 together and reach 4, its just the various tests that I don't know how certain they are or really if even necessary. At least not with appendicitis, others might be a bit more useful.

 

[NysEms2117]

As far as palpating the abdomen, I usually start from the farthest quadrant from their pain, and if it hurts there, I stop. I wouldn't want someone poking at my stomach for some quasi-reliable test if I have an acute abdomen.

As an idiot asking this... Isn't appendicitis a rebound pain? which is oddly distinct? please don't maul me if this is a stupid question

 

[VentMonkey]

I don't doubt I could put 2 and 2 together and reach 4, its just the various tests that I don't know how certain they are or really if even necessary. At least not with appendicitis, others might be a bit more useful.

This was more generalized so that others may understand my rationale as well. I'm sure you know 2 and 2 doesn't equal 10, etc.

As an idiot asking this... Isn't appendicitis a rebound pain? which is oddly distinct? please don't maul me if this is a stupid question

As far as the signs for me, again, I personally don't get too caught up on their reliability in the prehospital setting. Most of them are "nice to know", but I have yet to think of a time I have relayed to an EM physician a specific "sign" to correlate with my treatment modalities
and it being a defining moment in their decision-making. I don't know how pertinent they truly find it, but would guess it varies from doc to doc.

 

[StCEMT]

This was more generalized so that others may understand my rationale as well. I'm sure you know 2 and 2 doesn't equal 10, etc.

As far as the signs for me, again, I personally don't get too caught up on their reliability in the prehospital setting. Most of them are "nice to know", but I have yet to think of a time I have relayed to an EM physician a specific "sign" to correlate with my treatment modalities
and it being a defining moment in their decision-making. I don't know how pertinent they truly find it, but would guess it varies from doc to doc.

Probably doesn't change much for them. Guess I feel better knowing I don't walk in like "yea his stomach hurts like a sumbitch, he didn't like moving much....so yea....don't do that". But who knows, most of my abdominal stuff has been nursing home GI bleeds that they already know the problem.

 

[rescue1]

As an idiot asking this... Isn't appendicitis a rebound pain? which is oddly distinct? please don't maul me if this is a stupid question

It can be, but rebound pain doesn't = appendicitis. The current guidelines for acute appys tate "no physical exam findings, together or alone, can confirm a diagnosis of appendicitis". All these patients are getting imaged, so don't stress over an in depth assessment of the abdomen. Don't ignore the assessment either, but keep in mind many of the physical exam signs for abdominal pain have pretty low sensitivity and/or specificity so while you'll still see them done, they can only nudge you in the right direction, not tell you definitively what's going on.

 

[NysEms2117]

It can be, but rebound pain doesn't = appendicitis. The current guidelines for acute appys tate "no physical exam findings, together or alone, can confirm a diagnosis of appendicitis". All these patients are getting imaged, so don't stress over an in depth assessment of the abdomen. Don't ignore the assessment either, but keep in mind many of the physical exam signs for abdominal pain have pretty low sensitivity and/or specificity so while you'll still see them done, they can only nudge you in the right direction, not tell you definitively what's going on.

I've been told rebound is the "go to" field test(physical) for it though. I understand as soon as they get into the ER most likely before they even see a doctor they are getting imaged. Are there any other "quick and easy" tests for appendicitis?

 

[StCEMT]

I've been told rebound is the "go to" field test(physical) for it though. I understand as soon as they get into the ER most likely before they even see a doctor they are getting imaged. Are there any other "quick and easy" tests for appendicitis?

That bump test that was mentioned earlier in the thread. Markle's sign I think it was called.

 

[VentMonkey]

As one can see, there's a slew of "signs" that can cue you to lower quadrant abdominal ailments, none of which are exactly accurate or definitive.

http://emedicine.medscape.com/article/773895-overview#a1

Just my take, and why if I palpate the farthest quadrant from their complaint I cannot rule in or out a specific diagnosis, only treat them accordingly with what I have.

I rely more on other findings such as obvious signs of pain, copious N/V/D leading to volume depletion, fevers, chills, etc.; to me this is usually enough to paint a clinical picture as to how I should treat their otherwise vague complaint until relinquishing care to the ED and passing on what I may have found pertinent.

 

[EpiEMS]

AHRQ has a comparative effectiveness review of diagnostic tools for RLQ pain. Page 25 has a nice little table with sensitivity and specificity figures for clinical signs. Their conclusion is pretty unequivocal: "Clinical symptoms and signs and laboratory tests have relatively limited test performance when used in isolation." [Bold text mine]

 

[EpiEMS]

Also, FWIW, you can calculate 7 of 10 of the Alvarado score points prehospitally (only 3 points come from lab metrics that I don't think I can get in a usual BLS service).

 

[Handsome Robb]

As one can see, there's a slew of "signs" that can cue you to lower quadrant abdominal ailments, none of which are exactly accurate or definitive.

http://emedicine.medscape.com/article/773895-overview#a1

Just my take, and why if I palpate the farthest quadrant from their complaint I cannot rule in or out a specific diagnosis, only treat them accordingly with what I have.

I rely more on other findings such as obvious signs of pain, copious N/V/D leading to volume depletion, fevers, chills, etc.; to me this is usually enough to paint a clinical picture as to how I should treat their otherwise vague complaint until relinquishing care to the ED and passing on what I may have found pertinent.

I just like the word "markle".


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[RoadRat]

I'm a 4-month-old medic.

In class and in the ambulance we were hounded to never give narcotics for abdominal pain.
Zofran, yes.
Morphine or fentanyl, no.

Our instructors and even field preceptors went on, and on about referred pain and how the abdomen is essentially a black hole which cannot be correctly assessed due to the peritoneum.

Which is correct as long as the patient is isolated to care within an ambulance. I've had some blind arguments against abdominal pain management, but have since learned better.


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[EpiEMS]

In class and in the ambulance we were hounded to never give narcotics for abdominal pain.

Our instructors and even field preceptors went on, and on about referred pain and how the abdomen is essentially a black hole which cannot be correctly assessed due to the peritoneum.

Wow, I didn't imagine that this kind of "knowledge" was still being passed down. Have you been personally properly treating pain despite the preceptors?

 

[RoadRat]

Wow, I didn't imagine that this kind of "knowledge" was still being passed down. Have you been personally properly treating pain despite the preceptors?

Now that I'm on my own, I do treat abdominal pain properly, but at the disgust of my coworker. I've had two separate EMTs report me to higher-ups for improper patient care due to administering painkillers for abdominal pain. The supervisors they report me to also disagree with pain management for abdominal pain.

But, I keep going against the grain without any consequence other than the doubt of my coworkers.

It's a sad world out here.


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[StCEMT]

Well they can go piss up a rope. Pretty sure you can easily use research to show that they're being idiotic. Hopefully your future partner(s) aren't quite that obnoxious.