Abdominal exam question

[Kevin Michael]

You wanna be suspect of any abd pain...

Pt history..would help..guarding..a visual...etc...etc

The spinal injury can cause internal injury..But the preasure of palp of the area should NOT be hard.....though...

Common Sense.....

[MikeEMT]

So I received a reply the other day from the Doctor (sorry its my long week and I haven't had time to post).

His reply was that it was put in there as a cautionary statement. If we on scene feel that the need for palpating an abdomen exists then we should do so even if a spinal injury exists or is suspected.

[kohlerrf]

I agree! You should never palpate the abdomen in spinal trauma or ever for that matter. Information gleaned from abdominal palpation is highly subjective, example; what if the patient is ticklish and tenses up when they have their abdomen prodded? Remember we are not in a warm doctors office with a decades long patient/doctor relationship. More over, there is a possibility (although very remote) that your poking around may exacerbate an existing condition like a fractured L3. Your course of treatment should be based on information that is more objective. I teach my students the technique of abdominal palpation for testing purposes, but I discourage its practical use in the pre-hospital setting.

[ERDoc]

Dude, how hard are you pushing that you are exacerbating a spinal injury?

EDIT: And what does a long term relationship have to do with competing a proper exam?

Edited January 28, 2013 by ERDoc

[Kiwiology]

Oh my god, this shit makes me want to bleed from my eyes and gets me so enraged I have some sort of black out and when I wake up somebody is covered in blood and I've got no idea what the fuck happened.

A proper abdominal examination includes inspection, palpation, percussion and auscultation and there is no reason why you shouldn't be performing such a proper examination on somebody who is complaining of abdominal pain, spinal injury or not. The only thing you really shouldn't be doing is rebound tenderness which is no longer useful.

If you are going to examine your patient please do it properly, but hey I forget "Paramedics aren't Doctors!" and hell, why even teach the Doctors how to do an abdominal exam, they can just put everybody in the CT machine right?

Now if you excuse me, it's time for my bedtime valiumz and various other uppers, downers and smoother-outers; I think i'd better get my Doctor to start me on some HTN medicines too, this place is not good for my blood pressure ...

[systemet]

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.

I think a lot of people are making a lot assumptions about how that AAA patient is going to present, and the value of palpation as a diagnostic aid.

Firstly, I'm firmly in the camp that believes that palpation of the abdomen is part of a thorough physical exam. If light palpation causes intense guarding, pain, or movement, then obviously we probably shouldn't palpate any harder, or again. The fact that light palpation elicits guarding, tenderness, pain, writhing, etc., is a potentially significant finding.

Palpation as a tool for AAA is going to be poorly sensitive, and, honestly -- poorly specific. Only a small percentage of people with AAAs are going to have a palpable pulsatile mass, and we are going to be lucky to identify it based on inspection or palpation. Thus, it's a poorly sensitive finding. Many of these patients are going to identified on abdominal XR, CT, or U/S. The sensitivity must decrease as the patient's body mass increases.

It may be a little more specific, perhaps. That is, if we find a pulsatile mass, the likelihood of AAA is probably a bit higher. But I bet if we try to call the subtler cases, e.g. "I feel like there's something pulsating there, but I'm not quite sure", in order to increase the number of patients we detect, then our specificity is going to plummet, i.e. we're going to call more false-positives.

There's also a disconnect here between the concept of acute and chronic presentations of a pathology, in this case, AAA. There's plenty of people walking around with significant AAAs, even up into the 8cm range. These people may have pulsatile masses, but may be managed medically or waiting for nonurgent surgical correction. They may present with abdominal pain from any number of other causes, and the signs/symptoms related to the chronic AAA may distract from the acute pathology.

If we consider AAA, I think it's likely that changes in the quality of the femoral or pedal pulses, or the perfusion of the lower extremities might be more useful than abdominal palpation. I'm sure one of the docs has a more educated opinion on this.

[MikeEMT]

I think a lot of people are making a lot assumptions about how that AAA patient is going to present, and the value of palpation as a diagnostic aid.

Firstly, I'm firmly in the camp that believes that palpation of the abdomen is part of a thorough physical exam. If light palpation causes intense guarding, pain, or movement, then obviously we probably shouldn't palpate any harder, or again. The fact that light palpation elicits guarding, tenderness, pain, writhing, etc., is a potentially significant finding.

Palpation as a tool for AAA is going to be poorly sensitive, and, honestly -- poorly specific. Only a small percentage of people with AAAs are going to have a palpable pulsatile mass, and we are going to be lucky to identify it based on inspection or palpation. Thus, it's a poorly sensitive finding. Many of these patients are going to identified on abdominal XR, CT, or U/S. The sensitivity must decrease as the patient's body mass increases.

It may be a little more specific, perhaps. That is, if we find a pulsatile mass, the likelihood of AAA is probably a bit higher. But I bet if we try to call the subtler cases, e.g. "I feel like there's something pulsating there, but I'm not quite sure", in order to increase the number of patients we detect, then our specificity is going to plummet, i.e. we're going to call more false-positives.

There's also a disconnect here between the concept of acute and chronic presentations of a pathology, in this case, AAA. There's plenty of people walking around with significant AAAs, even up into the 8cm range. These people may have pulsatile masses, but may be managed medically or waiting for nonurgent surgical correction. They may present with abdominal pain from any number of other causes, and the signs/symptoms related to the chronic AAA may distract from the acute pathology.

If we consider AAA, I think it's likely that changes in the quality of the femoral or pedal pulses, or the perfusion of the lower extremities might be more useful than abdominal palpation. I'm sure one of the docs has a more educated opinion on this.

I agree with you on this. I perform "proper" abdominal exams and I have discovered quite a few abnormalities in the process. I am quite frankly shocked by how many people don't perform palpation of the abdomen.

[scubanurse]

my favorite was an EMT that brought a patient to the ER while I was on a rotation down there who said the patient had an enlarged liver and was very sick because of this...patient had gastroenteritis, EMT had no clue what he was doing when he tried to palpate the borders of the liver. I'm all for proper abdominal exams if you've been trained to perform one.

The other statement we love hearing is absent bowel sounds...inorder to classify a patient as having absent bowel sounds you have to listen in all four quadrants for at least 5-8 minutes or so in each quadrant.

The biggest thing that people should take from an abdominal exam is that 1) if it hurts, don't push any more, 2) use it in conjunction with the rest of your exam. I always have epigastric pain on palpation... doesn't mean a thing on me. 3) Use your critical thinking skills.

[MikeEMT]

my favorite was an EMT that brought a patient to the ER while I was on a rotation down there who said the patient had an enlarged liver and was very sick because of this...patient had gastroenteritis, EMT had no clue what he was doing when he tried to palpate the borders of the liver. I'm all for proper abdominal exams if you've been trained to perform one.

The other statement we love hearing is absent bowel sounds...inorder to classify a patient as having absent bowel sounds you have to listen in all four quadrants for at least 5-8 minutes or so in each quadrant.

The biggest thing that people should take from an abdominal exam is that 1) if it hurts, don't push any more, 2) use it in conjunction with the rest of your exam. I always have epigastric pain on palpation... doesn't mean a thing on me. 3) Use your critical thinking skills.

I palpate all 4 quadrants. I am looking for tenderness, masses, hot to touch, or pain upon touch. I don't try to palpate the liver or anything like that. If I find something pertinent then I will tell the ER. I am not here to diagnose a specific problem thats what the MD's are for.

I don't listen to Bowel sounds either. Its not in our protocol and I wouldn't know what to listen for. Lung sounds and BP is all I use my stethoscope for. Though I am starting to listen to heart sounds, mainly for my own curiosity as I am fascinated with the heart.

I get a kick out of EMT's and Medics that try to act more knowledgeable than they are.

[scubanurse]

sounds like you're doing a good job then If you like the heart definitely try to check out the CAP lab in December... I too love cardiology and it was really neat getting to examine the cadaver hearts and look at the EKGs to help understand why blockages in certain arteries cause problems etc.