Abdominal exam question

[MikeEMT]

I was taking my CE online course through our required website and the topic was abdominal pain. They were talking about palpating the 4 quadrants of the abdomen to determine pain and feel for abnormalities. However, they said to not palpate the abdomen if spinal trauma is suspected.

My question is why not? I understand C-spine precautions but I have never palpated an abdomen hard enough to effect the spine. Couldn't a trauma patient have an abdominal problem too that can only be discovered through palpation i.e AAA?

Anyone have any idea why not to palpate an abdomen on a spinal injury patient?

[Kiwiology]

Because whoever wrote that CCE is a moron

[Arctickat]

I never deep palpate the abdomen if there is a complaint of pain. If they have abd pain, what would palpating it reveal? They'd guard against your palpation, so it'll be rigid and it'll just hurt them more. Why would I want to intentionally cause greater pain to my patient?

Light palpation might reveal a AAA, but so could visualisation.

Edited January 10, 2013 by Arctickat

[YoungEMT95]

Assessments may cause pain, but it gains information as to what organs may be affected.

[scubanurse]

Assessments may cause pain, but it gains information as to what organs may be affected.

And what would you do differently if they had RUQ pain versus LUQ pain? All you'll be doing in the field is increasing the pain/anxiety of the patient with an exam that will be conducted in the ER as soon as the doc walks into the patients room. If they're complaining of lower abdominal pain and female, we consider it an ectopic until proven otherwise...no palpation necessary in the field for that... if it's RLQ pain then we will consider appendix until proven otherwise also, again, no palpation necessary in the field.

The patient, if they are reliable can point to where it hurts and you'll have a good idea of where the pain is and what could be involved.

In the field, there shouldn't be a clinical need to deep palpate the abdomen...if you suspect an abdominal aortic aneurism then you definitely shouldn't be palpating the abdomen as the pressure could cause a big problem.

Abdominal pain is tough even for the doctors, you have visceral pain and somatic pain, just too many variables to allow for a reliable exam in the field.

As to the OP, the idea might be that in the process of assessing the abdomen you could rock the patients lower thoracic and lumbar regions causing problems. While I doubt on the average patient that palpation could directly cause trauma to the spine, the rocking and shifting that can happen during an exam could displace a fracture. Just a thought, no way of telling what the author was getting at in your CE.

[MikeEMT]

Because whoever wrote that CCE is a moron

Our medical director - a nationally known and well respected doctor wrote the CE. Our CE website allows us to ask the doctor through a blog so I did that. It can take 14 days though to get a response so I figured I would ask here. Maybe somebody knew something I didn't.

I never deep palpate the abdomen if there is a complaint of pain. If they have abd pain, what would palpating it reveal? They'd guard against your palpation, so it'll be rigid and it'll just hurt them more. Why would I want to intentionally cause greater pain to my patient?

Light palpation might reveal a AAA, but so could visualisation.

Palpating the abdomen is part of our protocol in our exam. Ask patient where it hurts and palpate that quadrant last. While the goal isn't to hurt the patient it is expected that you will cause some discomfort. It is important to palpate the abdomen to feel for abnormalities with the organs. Distention, hot, pulsating, masses, etc are all things you can feel.

I have never heard of visualizing a AAA. I would assume if a AAA is bad enough that you can visually see the pulsating then it is close to rupture, or the patient is extremely thin. I have yet to see a AAA in the field though so I don't know. I was always told to palpate for a pulsating mass in the epigastric region and patient complaining of tearing feeling in their abdomen.

And what would you do differently if they had RUQ pain versus LUQ pain? All you'll be doing in the field is increasing the pain/anxiety of the patient with an exam that will be conducted in the ER as soon as the doc walks into the patients room. If they're complaining of lower abdominal pain and female, we consider it an ectopic until proven otherwise...no palpation necessary in the field for that... if it's RLQ pain then we will consider appendix until proven otherwise also, again, no palpation necessary in the field.

The patient, if they are reliable can point to where it hurts and you'll have a good idea of where the pain is and what could be involved.

In the field, there shouldn't be a clinical need to deep palpate the abdomen...if you suspect an abdominal aortic aneurism then you definitely shouldn't be palpating the abdomen as the pressure could cause a big problem.

Abdominal pain is tough even for the doctors, you have visceral pain and somatic pain, just too many variables to allow for a reliable exam in the field.

As to the OP, the idea might be that in the process of assessing the abdomen you could rock the patients lower thoracic and lumbar regions causing problems. While I doubt on the average patient that palpation could directly cause trauma to the spine, the rocking and shifting that can happen during an exam could displace a fracture. Just a thought, no way of telling what the author was getting at in your CE.

Our hospitals want us to give them a general idea as to what is going on. We don't just drop off patients and if we told them we didn't palpate we would be scolded. Were not expected to diagnose but we are expected to know more than RLQ = Appendicitis. Hence the indepth CE we were required to take.

[scubanurse]

I guess more of what I was getting at was that do you know what to feel for when palpating a liver? I would expect you to know which quadrant the patient is having pain in and what you've done for that pain...It's unrealistic in my opinion to ask an EMT or Medic to know how to palpate the abdomen to a doctors standards. It will also have minimal impact on your treatment in the field.

With regards to the AAA, a light touch midline will reveal a pulsating mass or not, no need to do much more palpation that that. On the super skinny elderly, you should be able to palpate a pulse from the AAA and should correlate with their Apical pulse.

I apologize if I seemed harsh with my comments, I'm just against causing more pain unless it's necessary, and in most cases in the field it won't change your management or transport criteria... Maybe one of the more experienced medics around here can help. I am absolutely for a thorough exam and learning as much as possible.

What more is the hospital looking for other than LRQ pain, patient hx of general abd pain, n/v, possible appy... all of that can be done without causing further distress to the patient in the ambulance and increase their anxiety/pain level before the doc gets to see them.

Edit to fix my tired spelling/grammar...

Edited January 10, 2013 by Kate_826

[Arctickat]

Mike, when you go to bed tonight, take a few moments to lay flat on your back and look at your bare belly.

Let me know if you notice anything interesting.

Doing a thorough abd exam is certainly important, but palpating without knowing what you're palpating for is like driving through a dark tunnel with no headlights.

What will you do if you confirm Appendicitis? AAA? Cholecystitis? Hepatomegaly? UTI? Full Bladder? Chrons? GI Bleed? Bowel Obstruction? What does the doctor do in the ER once you're done all your poking and prodding? Take your word for it that it's a gall stone and schedule surgery? We can determine most of those abdominal pains without poking the belly by conducting a proper history.

Edited January 10, 2013 by Arctickat

[MikeEMT]

I guess more of what I was getting at was that do you know what to feel for when palpating a liver? I would expect you to know which quadrant the patient is having pain in and what you've done for that pain...It's unrealistic in my opinion to ask an EMT or Medic to know how to palpate the abdomen to a doctors standards. It will also have minimal impact on your treatment in the field.

With regards to the AAA, a light touch midline will reveal a pulsating mass or not, no need to do much more palpation that that. On the super skinny elderly, you should be able to palpate a pulse from the AAA and should correlate with their Apical pulse.

I apologize if I seemed harsh with my comments, I'm just against causing more pain unless it's necessary, and in most cases in the field it won't change your management or transport criteria... Maybe one of the more experienced medics around here can help. I am absolutely for a thorough exam and learning as much as possible.

What more is the hospital looking for other than LRQ pain, patient hx of general abd pain, n/v, possible appy... all of that can be done without causing further distress to the patient in the ambulance and increase their anxiety/pain level before the doc gets to see them.

Edit to fix my tired spelling/grammar...

No worries, didn't think your comments were harsh. Your right, palpating wont change our treatment especially at the Basic level. It will however change how we transport, where we transport and whether patient is seen by a Dr immediately or in 10 minutes. Here the hospitals put a lot of faith in us. I had a patient, male, with LUQ Abdominal pain that increased upon palpation. Pain was non-radiating but would radiate to RLQ upon palpation. No masses felt, no pulsating felt but skin was hot to touch. This was relayed during the HEAR. Upon arrival at ER, a MD and RN were waiting for me. Pt was transferred to a hospital bed right there in the hallway and taken away (I am assuming to a MRI or possibly even OR).

I don't remember much about that patient as it was one of my first and I didn't think to follow up on him. I do remember it showed me the importance of doing a proper exam on my patients. Palpation doesn't have to be hard or necessarily painful. I use common sense when I palpate.

Mike, when you go to bed tonight, take a few moments to lay flat on your back and look at your bare belly.

Let me know if you notice anything interesting.

Doing a thorough abd exam is certainly important, but palpating without knowing what you're palpating for is like driving through a dark tunnel with no headlights.

What will you do if you confirm Appendicitis? AAA? Cholecystitis? Hepatomegaly?

gotta go, more later

In my case I see a beer belly lol.

[Arctickat]

In my case I see a beer belly lol.

All the better, watch what your beer belly does.