1. Principles of Patient Assessment in EMS

2. Focused History and Physical Exam of the Patient with Abdominal Pain

3. Introduction Abdominal pain has many etiologies. Abdominal pain has many etiologies. Many causes are not life-threatening and require only supportive care. Many causes are not life-threatening and require only supportive care. Life-threatening causes include: Life-threatening causes include: AMI AMI Ectopic pregnancy Ectopic pregnancy Acute appendicitis Acute appendicitis

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

5. Types of Abdominal Pain Visceral – pain is caused by stretching of nerve fibers surrounding the organs. Visceral – pain is caused by stretching of nerve fibers surrounding the organs. Often poorly localized, diffuse and difficult to describe Often poorly localized, diffuse and difficult to describe Patient may complain of feeling crampy or gaseous Patient may complain of feeling crampy or gaseous Patient may be guarding Patient may be guarding

6. Somatic – pain is caused by irritation of nerve fibers in the parietal peritoneum. Somatic – pain is caused by irritation of nerve fibers in the parietal peritoneum. Pain is usually more localized Pain is usually more localized Described as sharp and constant Described as sharp and constant Types of Abdominal Pain (Continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

7. Types of Abdominal Pain (continued) Referred – pain that originates from one area of the body and is also sensed in another area. Referred – pain that originates from one area of the body and is also sensed in another area. There are several referral patterns associated with abdominal pain There are several referral patterns associated with abdominal pain Review Table 15-1 Review Table 15-1 © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

8. Focused History Be alert for clues to extra-abdominal causes of abdominal pain such as AMI and ectopic pregnancy. Be alert for clues to extra-abdominal causes of abdominal pain such as AMI and ectopic pregnancy. Use OPQRST to elaborate on the chief complaint of abdominal pain. Use OPQRST to elaborate on the chief complaint of abdominal pain. Obtain a SAMPLE History on the patient. Obtain a SAMPLE History on the patient. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

9. Physical Exam Assess MS-ABCs, skin CTC, and signs of poor perfusion. Assess MS-ABCs, skin CTC, and signs of poor perfusion. Assess patient’s level of distress as mild, moderate, or severe. Assess patient’s level of distress as mild, moderate, or severe. Abdominal distress usually produces autonomic nervous system reactions such as tachycardia and diaphoresis. Abdominal distress usually produces autonomic nervous system reactions such as tachycardia and diaphoresis. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

10. After the IA, focus the exam on the CC. After the IA, focus the exam on the CC. Assess each of the 4 quadrants. Assess each of the 4 quadrants. Examine in this order: observe, auscultate, palpate, percuss. Examine in this order: observe, auscultate, palpate, percuss. Physical Exam © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

11. Observation Note the following: Note the following: Symmetry Symmetry Skin tone Skin tone Masses Masses Bulges Bulges Surgical scars Surgical scars Rashes Rashes Lesions Lesions Transderm patches Transderm patches Colostomy attachments Colostomy attachments © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

12. Observation (continued) Cullen’s sign – periumbilical eccymosis. Cullen’s sign – periumbilical eccymosis. Presacral edema – associated with limited mobility and cardiac history. Presacral edema – associated with limited mobility and cardiac history. Pulsations from the abdominal aorta are normal in thin persons. Pulsations from the abdominal aorta are normal in thin persons. Pulsations from masses/bulges are abnormal. Pulsations from masses/bulges are abnormal. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

13. Ask the patient about bloating/distension as it is not always obvious. Ask the patient about bloating/distension as it is not always obvious. Scaphoid abdomen – sinking, concave shape associated with dehydration or malnutrition. Scaphoid abdomen – sinking, concave shape associated with dehydration or malnutrition. Observation (continued) © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

14. Auscultation Listen for the presence or absence of bowel sounds (normal 5 to 30 times a minute). Listen for the presence or absence of bowel sounds (normal 5 to 30 times a minute). The most significant finding is the absence of bowel sounds (obstruction, inflammation of peritonittis). The most significant finding is the absence of bowel sounds (obstruction, inflammation of peritonittis). Assess only when time permits (2-5 minutes). Assess only when time permits (2-5 minutes). Auscultate prior to palpation. Auscultate prior to palpation. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

15. Palpation Warm hands and position the patient on the back. Warm hands and position the patient on the back. A normal abdomen should be soft, non- tender, without masses/bulges. A normal abdomen should be soft, non- tender, without masses/bulges. Note tenderness, temperature, guarding, and presence of abnormal structures. Note tenderness, temperature, guarding, and presence of abnormal structures. Three types of palpation: Three types of palpation: Light Light Deep Deep Rebound Rebound © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

16. Palpation (continued) Light palpation – using one hand to palpate approx. 1 cm in depth. Light palpation – using one hand to palpate approx. 1 cm in depth. Deep palpation – using one or two hands, palpate 2-3 inches. (Do not perform deep palpation on masses). Deep palpation – using one or two hands, palpate 2-3 inches. (Do not perform deep palpation on masses). Rebound tenderness – palpate one quadrant, then quickly remove hand. If the patient has pain with the release of pressure this is call rebound tenderness (associated with peritoneal irritation). Rebound tenderness – palpate one quadrant, then quickly remove hand. If the patient has pain with the release of pressure this is call rebound tenderness (associated with peritoneal irritation). © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

17. Percussion Performed by touching and tapping the fingertips on various body parts. Performed by touching and tapping the fingertips on various body parts. Determines size, position, and consistency of underlying structures. Determines size, position, and consistency of underlying structures. Most frequently used over the chest and abdomen. Most frequently used over the chest and abdomen. Not routinely performed in the prehospital setting due to time constraints. Not routinely performed in the prehospital setting due to time constraints. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

18. Diagnostic Tools Consider obtaining the following on the patient with abdominal complaints: Consider obtaining the following on the patient with abdominal complaints: ECG ECG Pulse oximetry reading Pulse oximetry reading Temperature Temperature © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

19. Features of Abdominal Pain The location of pain is not always an accurate indication of the cause of the pain. The location of pain is not always an accurate indication of the cause of the pain. Suspect any pain above the umbilicus as cardiac until proven otherwise. Suspect any pain above the umbilicus as cardiac until proven otherwise. In females of child bearing age suspect ectopic pregnancy until proven otherwise. In females of child bearing age suspect ectopic pregnancy until proven otherwise. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

20. Consider the many possible referral patterns of pain. Consider the many possible referral patterns of pain. Patients with severe pain may be difficult to assess. Patients with severe pain may be difficult to assess. Consider skin signs (CTC) Consider skin signs (CTC) Level of distress Level of distress Position of comfort/ guarding Position of comfort/ guarding Features of Abdominal Pain © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

21. Common Causes of Abdominal Pain Specific diagnosis is difficult, even in the ED. Specific diagnosis is difficult, even in the ED. Numerous causes: Numerous causes: Intra-abdominal Intra-abdominal Extra-abdominal Extra-abdominal Metabolic Metabolic Neurologic Neurologic © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

22. Inflammation, obstruction, infection, hemorrhage or any combination. Inflammation, obstruction, infection, hemorrhage or any combination. Conditions that require surgical intervention include: Conditions that require surgical intervention include: Appendicitis, ectopic pregnancy, tumors Appendicitis, ectopic pregnancy, tumors Cholecystitis, perforated peptic ulcer or viscus Cholecystitis, perforated peptic ulcer or viscus Dissecting and rupture aneurysm or bowel infarction Dissecting and rupture aneurysm or bowel infarction Common Causes of Abdominal Pain © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

23. Conclusion The focused physical exam of the patient with abdominal pain should be performed quickly to identify any significant injury, potential hemorrhage or indications of a possible surgical abdomen. The focused physical exam of the patient with abdominal pain should be performed quickly to identify any significant injury, potential hemorrhage or indications of a possible surgical abdomen. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

24. Specific diagnosis is not the objective. Specific diagnosis is not the objective. Obtain a FH and PE, consider life- threatening conditions such as AMI and ectopic pregnancy early! Obtain a FH and PE, consider life- threatening conditions such as AMI and ectopic pregnancy early! Conclusion © 2003 Delmar Learning, a Division of Thomson Learning, Inc.