Abdominal Exam

[chbare]

While I appreciate the theory of your concern, I am not aware of substantial evidence that suggests palpation is unsafe practice in a patient with a suspected AAA. I have seen evidence suggesting that palpation is one of a few manuvers (perhaps the only) during a physical exam that is of any value for detecting the said condition. While it can help secure a field diagnosis, I should also point out that palpation cannot exclude or rule out a diagnosis.

So, no an assessment would not rule out a AAA; however, it can produce highly compelling evidence suggesting AAA. In addition, I do not see how doing abdominal palpation in the field would delay transport times? Therefore, I appreciate your concerns; however, I could not fault somebody who palpates a patient with an acute abdomen.

Take care,

chbare.

[Lisa O]

On scene the patient was outwardly stable. From the history, visualization of the abdomen and vital signs this pt was potentially unstable 2 large bore were started in route, and run kvo, on arrival I advised the ER staff I was treating a rule out AAA and they confirmed it by a sono. Patient was taken to the O.R. he burst on the table but was saved. I did not palpate , auscultate or percuss in the pre-hospital setting did I harm the patient? What was a the very real possibility here had I delayed transport and started "gently manipulate, palpate, percuss and auscultate" this abdomen while the patient was sitting in his office chair? More importantly would your full abdominal exam rule out a AAA in the field?

Could palpating and / or manipulation have caused (or cause ) the AAA to rupture faster enroute rather then in the O.R.? Then I would think that not even touching the abdomen, in that situation, is the better choice.

[chbare]

Could palpating and / or manipulation have caused (or cause ) the AAA to rupture faster enroute rather then in the O.R.? Then I would think that not even touching the abdomen, in that situation, is the better choice.

Is there evidence to suggest palpation causes rupture?

Take care,

chbare.

[Lisa O]

Is there evidence to suggest palpation causes rupture?

Take care,

chbare.

I guess thats exactly what I am asking. I do not know, at all....... So, you just asked my question a whole lot better then I did..lol

[VentMedic]

While I appreciate the theory of your concern, I am not aware of substantial evidence that suggests palpation is unsafe practice in a patient with a suspected AAA. I have seen evidence suggesting that palpation is one of a few manuvers (perhaps the only) during a physical exam that is of any value for detecting the said condition. While it can help secure a field diagnosis, I should also point out that palpation cannot exclude or rule out a diagnosis.

But how many EMT-Bs in the U.S. are taught all the things that can go wrong in the abdomen or the complications? How many are given step by step instruction on how to or how not to palpate an abdomen? How many have felt a AAA in some of the ways it can present? How many know the many differeentials? Other than, tender or not and rigid or soft, there is not much instruction and these can be dependent on the patient and one's cold hands or comfort. I have seen med students and residents get their hands smacked by attendings when they just started poking around in a situation that warrants caution. Of course, that rarely happens because they generally have the education base to know they should wait for proper instruction and training to approach various situations.

I have seen various aneurysms start leaking for a variety of reasons and there is nothing more frightening for a physician than to have a patient scream in pain or just die on the stretcher during a physical exam. Perforations, foreign bodies, aneurysms and a few others that are suspected may need caution and if a physician suspects something serious, he/she may send the patient to CT Scan or do an ultrasound rather than aggressive palpation.

Edited January 1, 2010 by VentMedic

[chbare]

http://www.ncbi.nlm.nih.gov/pubmed/9892455?dopt=Abstract

A little dated, but clearly data gained from palpation can strengthen your field diagnosis and it does not appear to be inherently unsafe. Of course, I believe the studies quoted involved physician assessments. Therefore, I would not necessarily fault somebody for deferring the exam and initiating rapid transport based on other signs and symptoms. However, the same is true of somebody who does palpate.

An anecdotal situation; however, when I was a new nurse I took care of an otherwise healthy patient complaining of nausea. Clearly, a BS situation. I asked a few questions, listened to lungs, and obtained vital signs thinking the patient was not all that remarkable. Clearly, this may have led to a delay in the physician seeing the patient. When he did, he noted a pulsatile mass and we quickly changed gears. The patient ended up having a 6.5 cm AAA. It was "stable" fortunately and the primary diagnosis was a viral gastritis; however, the patient had follow up and repair. So, a good assessment can in fact make us change gears and consider additional problems that may otherwise go unnoticed.

In the situation described here, a high index of suspicion already existed however. With that, it is always nice to have as much data as possible so you can paint an accurate picture and emphasize the potential gravity of the situation to the receiving facility.

Take care,

chbare.

[ccmedoc]

I guess thats exactly what I am asking. I do not know, at all....... So, you just asked my question a whole lot better then I did..lol

"The clinician need not be afraid of properly palpating the abdomen because no evidence exists that aortic rupture can be precipitated by this maneuver."

Article by Dr. Robert E. O'Connor MD

Proper assessment provides a differential for the provider to work with..I believe that the OP should have shown the student or basic the proper method to palpation.

Definitely using this tool to differentiate (potentially) between a hernia, bowel obstruction, or AAA could be valuable..although all are potential surgical emergencies.

Palpation, percussion, and auscultation are invaluable tools, if skills are honed appropriately..IMHO

[Lisa O]

"The clinician need not be afraid of properly palpating the abdomen because no evidence exists that aortic rupture can be precipitated by this maneuver."

Article by Dr. Robert E. O'Connor MD

Proper assessment provides a differential for the provider to work with..I believe that the OP should have shown the student or basic the proper method to palpation.

Definitely using this tool to differentiate (potentially) between a hernia, bowel obstruction, or AAA could be valuable..although all are potential surgical emergencies.

Palpation, percussion, and auscultation are invaluable tools, if skills are honed appropriately..IMHO

Perfect.. thank you so much

[kohlerrf]

While I appreciate the theory of your concern, I am not aware of substantial evidence that suggests palpation is unsafe practice in a patient with a suspected AAA. I have seen evidence suggesting that palpation is one of a few manuvers (perhaps the only) during a physical exam that is of any value for detecting the said condition. While it can help secure a field diagnosis, I should also point out that palpation cannot exclude or rule out a diagnosis.

So, no an assessment would not rule out a AAA; however, it can produce highly compelling evidence suggesting AAA. In addition, I do not see how doing abdominal palpation in the field would delay transport times? Therefore, I appreciate your concerns; however, I could not fault somebody who palpates a patient with an acute abdomen.

Take care,

chbare.

Very lucid thinking. I agree, I too have not seen compelling evidence either way regarding palpation. I think we both agree that palpation cannot rule out this or any critical abdominal issue. Furthermore while palpation can support other findings leading to the r/o diagnosis my point is that your conclusion cannot be based on it. After all I have examined perfectly healthy individual and looked at their abdomen only to visually see the normal pulsing of the abdominal aorta. Does this runner with a twisted ankle get treated for a AAA?

If we stand back and think of a AAA or hot appendix or perforated bowel, these situations have swollen distended tissue that if left unattended do in fact burst and then the patient dies in seconds. Although there is no study that I am aware of that proves pushing on a thin wall aneursym or a swollen appendix will cause it to burst it would seem a logical assumption, as I have been successful with balloons. In light of the fact that nothing we find during palpation would change our rule out diagnosis that we based on the history vital signs patient presentation etc... I see no need to take the risk because what are the chances of the patient living long enough to make it to surgery if we are wrong. By telling the ER that you suspect an acute abdomen based on history vitals etc...and not pushing and probing you may buy the pt the times he needs to see the pro's on this subject. Above all do no harm.....

[VentMedic]

"The clinician need not be afraid of properly palpating the abdomen because no evidence exists that aortic rupture can be precipitated by this maneuver."

Article by Dr. Robert E. O'Connor MD

Did you read the section pertaining to prehospital?

http://emedicine.medscape.com/article/756735-treatment

That article also states:

Use of military antishock trousers (MAST) to reverse shock due to ruptured AAA may seem beneficial, but it may actually be detrimental. While their application theoretically offers temporary stabilization by compressing the leaking AAA and expanding hematoma, an undesirable reduction in cardiac output also occurs. Expedient transport of patients who are unstable is a therapeutic imperative for those who are deteriorating.

The physician authoring the article still believes MAST is on the trucks. But then, maybe they are in some areas.

Proper assessment provides a differential for the provider to work with..I believe that the OP should have shown the student or basic the proper method to palpation.

Definitely using this tool to differentiate (potentially) between a hernia, bowel obstruction, or AAA could be valuable..although all are potential surgical emergencies.

Palpation, percussion, and auscultation are invaluable tools, if skills are honed appropriately..IMHO

How many EMT books give much information about the different hernias, bowel obstructions, necrotic bowel or AAA?

Here's another articles as the search engines are full of them and it depends on the audience they are directed at as to whether palpation is emphasized but precautions are mentioned.

however, the sensitivity of the technique is based on the experience of the examiner, the size of the aneurysm, and the size of the patient. In a recent study, 38% of AAA cases were detected based on physical examination findings, while 62% were detected incidentally based on radiologic studies obtained for other reasons.

Does that mean it is ruled out if it is not felt? Does that change your destination? Where does "experience of examiner" place the EMT-B? These articles are primarily directed at MDs and advanced practitioners. Does 120 hours really prepare an EMT-B to tell the difference between a AAA and a bowel obstruction or the many presentations of both?

http://emedicine.medscape.com/article/463354-overview

Edited January 1, 2010 by VentMedic