Principles of Patient Principles of Patient Assessment in EMS Assessment in EMS

Focused History and Physical Focused History and Physical Exam of the Patient with Exam of the Patient with

Abdominal Pain Abdominal Pain

IntroductionIntroduction Abdominal pain has many etiologies.Abdominal pain has many etiologies. Many causes are not life-threatening Many causes are not life-threatening

and require only supportive care.and require only supportive care. Life-threatening causes include:Life-threatening causes include:

AMIAMI Ectopic pregnancyEctopic pregnancy Acute appendicitisAcute appendicitis

The EMS provider should know The EMS provider should know clinical signs and symptoms and clinical signs and symptoms and history taking unique to the patient history taking unique to the patient with acute abdominal pain. with acute abdominal pain.

IntroductionIntroduction

Types of Abdominal PainTypes of Abdominal Pain Visceral – pain is caused by Visceral – pain is caused by

stretching of nerve fibers stretching of nerve fibers surrounding the organs.surrounding the organs. Often poorly localized, diffuse and Often poorly localized, diffuse and

difficult to describedifficult to describe Patient may complain of feeling crampy Patient may complain of feeling crampy

or gaseousor gaseous Patient may be guardingPatient may be guarding

Somatic – pain is caused by irritation Somatic – pain is caused by irritation of nerve fibers in the parietal of nerve fibers in the parietal peritoneum.peritoneum. Pain is usually more localizedPain is usually more localized Described as sharp and constantDescribed as sharp and constant

Types of Abdominal PainTypes of Abdominal Pain (Continued)(Continued)

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Types of Abdominal Pain Types of Abdominal Pain (continued)(continued)

Referred – pain that originates from Referred – pain that originates from one area of the body and is also one area of the body and is also sensed in another area.sensed in another area. There are several referral patterns There are several referral patterns

associated with abdominal painassociated with abdominal pain Review Table 15-1Review Table 15-1

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Focused HistoryFocused History Be alert for clues to extra-abdominal Be alert for clues to extra-abdominal

causes of abdominal pain such as causes of abdominal pain such as AMI and ectopic pregnancy.AMI and ectopic pregnancy.

Use OPQRST to elaborate on the Use OPQRST to elaborate on the chief complaint of abdominal pain.chief complaint of abdominal pain.

Obtain a SAMPLE History on the Obtain a SAMPLE History on the patient.patient.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Physical ExamPhysical Exam Assess MS-ABCs, skin CTC, and signs Assess MS-ABCs, skin CTC, and signs

of poor perfusion.of poor perfusion. Assess patient’s level of distress as Assess patient’s level of distress as

mild, moderate, or severe.mild, moderate, or severe. Abdominal distress usually produces Abdominal distress usually produces

autonomic nervous system reactions autonomic nervous system reactions such as tachycardia and diaphoresis.such as tachycardia and diaphoresis.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

After the IA, focus the exam on the After the IA, focus the exam on the CC.CC.

Assess each of the 4 quadrants.Assess each of the 4 quadrants. Examine in this order: observe, Examine in this order: observe,

auscultate, palpate, percuss.auscultate, palpate, percuss.

Physical ExamPhysical Exam

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

ObservationObservation Note the following:Note the following:

SymmetrySymmetry Skin toneSkin tone MassesMasses BulgesBulges Surgical scarsSurgical scars RashesRashes LesionsLesions Transderm patchesTransderm patches Colostomy attachmentsColostomy attachments

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Observation Observation (continued)(continued) Cullen’s sign – periumbilical Cullen’s sign – periumbilical

eccymosis.eccymosis. Presacral edema – associated with Presacral edema – associated with

limited mobility and cardiac history.limited mobility and cardiac history. Pulsations from the abdominal aorta Pulsations from the abdominal aorta

are normal in thin persons.are normal in thin persons. Pulsations from masses/bulges are Pulsations from masses/bulges are

abnormal.abnormal.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Ask the patient about Ask the patient about bloating/distension as it is not always bloating/distension as it is not always obvious.obvious.

Scaphoid abdomen – sinking, Scaphoid abdomen – sinking, concave shape associated with concave shape associated with dehydration or malnutrition.dehydration or malnutrition.

Observation (continued)Observation (continued)

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

AuscultationAuscultation Listen for the presence or absence of Listen for the presence or absence of

bowel sounds (normal 5 to 30 times a bowel sounds (normal 5 to 30 times a minute).minute).

The most significant finding is the The most significant finding is the absence of bowel sounds (obstruction, absence of bowel sounds (obstruction, inflammation of peritonittis).inflammation of peritonittis).

Assess only when time permits (2-5 Assess only when time permits (2-5 minutes).minutes).

Auscultate prior to palpation.Auscultate prior to palpation.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

PalpationPalpation Warm hands and position the patient Warm hands and position the patient

on the back.on the back. A normal abdomen should be soft, A normal abdomen should be soft,

non-tender, without masses/bulges.non-tender, without masses/bulges. Note tenderness, temperature, Note tenderness, temperature,

guarding, and presence of abnormal guarding, and presence of abnormal structures.structures.

Three types of palpation:Three types of palpation: LightLight DeepDeep ReboundRebound

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Palpation Palpation (continued)(continued) Light palpation – using one hand to Light palpation – using one hand to

palpate approx. 1 cm in depth.palpate approx. 1 cm in depth. Deep palpation – using one or two Deep palpation – using one or two

hands, palpate 2-3 inches. (Do not hands, palpate 2-3 inches. (Do not perform deep palpation on masses).perform deep palpation on masses).

Rebound tenderness – palpate one Rebound tenderness – palpate one quadrant, then quickly remove hand. quadrant, then quickly remove hand. If the patient has pain with the If the patient has pain with the release of pressure this is call release of pressure this is call rebound tenderness (associated with rebound tenderness (associated with peritoneal irritation).peritoneal irritation).

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

PercussionPercussion Performed by touching and tapping Performed by touching and tapping

the fingertips on various body parts.the fingertips on various body parts. Determines size, position, and Determines size, position, and

consistency of underlying structures.consistency of underlying structures. Most frequently used over the chest Most frequently used over the chest

and abdomen.and abdomen. Not routinely performed in the Not routinely performed in the

prehospital setting due to time prehospital setting due to time constraints.constraints.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Diagnostic ToolsDiagnostic Tools Consider obtaining the following on Consider obtaining the following on

the patient with abdominal the patient with abdominal complaints:complaints: ECGECG Pulse oximetry readingPulse oximetry reading TemperatureTemperature

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Features of Abdominal PainFeatures of Abdominal Pain The location of pain is not always an The location of pain is not always an

accurate indication of the cause of accurate indication of the cause of the pain.the pain.

Suspect any pain above the Suspect any pain above the umbilicus as cardiac until proven umbilicus as cardiac until proven otherwise.otherwise.

In females of child bearing age In females of child bearing age suspect ectopic pregnancy until suspect ectopic pregnancy until proven otherwise.proven otherwise.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Consider the many possible referral Consider the many possible referral patterns of pain.patterns of pain.

Patients with severe pain may be Patients with severe pain may be difficult to assess.difficult to assess. Consider skin signs (CTC)Consider skin signs (CTC) Level of distressLevel of distress Position of comfort/ guardingPosition of comfort/ guarding

Features of Abdominal PainFeatures of Abdominal Pain

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Common Causes of Abdominal Common Causes of Abdominal PainPain

Specific diagnosis is difficult, even in Specific diagnosis is difficult, even in the ED.the ED.

Numerous causes:Numerous causes: Intra-abdominalIntra-abdominal Extra-abdominalExtra-abdominal MetabolicMetabolic NeurologicNeurologic

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Inflammation, obstruction, infection, Inflammation, obstruction, infection, hemorrhage or any combination.hemorrhage or any combination.

Conditions that require surgical Conditions that require surgical intervention include:intervention include: Appendicitis, ectopic pregnancy, tumorsAppendicitis, ectopic pregnancy, tumors Cholecystitis, perforated peptic ulcer or Cholecystitis, perforated peptic ulcer or

viscusviscus Dissecting and rupture aneurysm or bowel Dissecting and rupture aneurysm or bowel

infarctioninfarction

Common Causes of Common Causes of Abdominal PainAbdominal Pain

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

ConclusionConclusion

The focused physical exam of the The focused physical exam of the patient with abdominal pain should patient with abdominal pain should be performed quickly to identify any be performed quickly to identify any significant injury, potential significant injury, potential hemorrhage or indications of a hemorrhage or indications of a possible surgical abdomen.possible surgical abdomen.

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

Specific diagnosis is not the Specific diagnosis is not the objective.objective.

Obtain a FH and PE, consider life-Obtain a FH and PE, consider life-threatening conditions such as AMI threatening conditions such as AMI and ectopic pregnancy early! and ectopic pregnancy early!

ConclusionConclusion

© 2003 Delmar Learning, a Division of Thomson Learning, Inc. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.