Prehospital education has classically fallen very short when it comes to
an abdominal assessment. Check all four quadrants for tenderness or
rigidity and that’s about it. We learn where the underlying organs are
and then there's something about rebound tenderness for appendicitis, but if
you ask any given prehospital provider about how to do a medical abdominal
assessment that is about all you will get.
What I would like to cover in this four part series is how to do a good
abdominal assessment that will help you recognize
the conditions requiring immediate surgical intervention, or lead to
a very poor outcome for the patient if left unattended. As I have
said before I believe paramedics are experts in what will kill someone in
the next 20 minutes. So let's expand upon that and talk about what serious
abdominal emergencies need surgical intervention or may lead to death in the
next 24 hours if not recognized and subsequently treated appropriately.
Keep in mind this assessment and discussion is outside of trauma or obstetrical
emergencies. Those two areas are completely different and I believe
prehospital education does a pretty good job in recognition of those types of
emergencies. It's the nebulous abdominal pain we are going to discuss. By the
way, abdominal pain where I work is considered a BLS emergency and may be first
assessed by an EMT with no ALS training. The conditions and assessment tools
I'm going to teach you in these articles are not rocket science and do not
require advanced knowledge of EKGs, IVs, or pharmacology. These are standard
assessment skills every prehospital provider should commit to memory.
I
plan on writing about each quadrant and also wrapping up with some general
guidelines. Let's start this in the
right upper quadrant. The medical emergencies I want to talk about in
this area are cholecystitis, ascending cholangitis, and perforated duodenal
ulcer. Cholecystitis is inflammation of the gall bladder. Ascending cholangitis
is an infection of the bile duct and both cholecystitis and cholangitis can be
caused by the presence of gall stones. A perforated duodenal ulcer can be life
threatening and is a hole, most often on the anterior surface of the duodenum, that
is formed which allows gastric contents to enter the abdomen. A duodenal
ulcer requires immediate surgical intervention and can lead to sepsis, profound,
shock, and death if left unattended. An inflamed gall bladder may need surgical
intervention and acute cholangitis can also lead to multiple organ failure,
sepsis, profound shock, and death. This makes these conditions true medical
emergencies and something every prehospital provider should be aware of.
The first assessment technique I want you
to add to your arsenal is checking for Murphy's sign. Murphy's
sign is a maneuver used to differentiate upper right abdominal pain. It is
performed by asking the patient to breathe out and then exerting pressure to
the upper right quadrant just below the costal margin which is just below the
bottom of the lower rib cage. Then ask the patient to take a deep breath in
while keeping pressure in this location. If the patient experiences an
increase in pain this is a positive Murphy's sign and is indicative of an
inflamed gall bladder.
Murphy's sign can be
just as helpful if it is negative. It is usually negative in ascending
cholangitis and perforated ulcers. It is a good assessment tool to give
you more information about the origin of the patient’s upper right abdominal
pain. If the test is positive you should then ask the patient if they have had
their gall bladder removed as this is a very common surgery. An inflamed and
infected gall bladder could be the source of their URQ abdominal pain. If the
test is negative you can further differentiate the origin of the pain if the
patient has a fever.
RUQ
pain with fever and negative Murphy's sign
1) Ascending Cholangitis
2) Perforated Duodenal Ulcer
Ascending Cholangitis
You should begin to
suspect ascending cholangitis when the patient is complaining of RUQ
abdominal pain and Murphy's sign is negative. Then
check for fever and jaundice. Jaundice is best seen in the eyes as it
may be difficult to determine with some skin tones. The patient may also
present with uncontrollable shaking and uneasiness. In later stages there
will be shock and an altered mental status. If you have the above clinical
presentation along with hypotension and confusion then think ascending
cholangitis as this is a true medical emergency. Prehospital treatment is recognition,
pain management, fluids to increase the blood pressure and transport to
the nearest hospital with surgical services.
Perforated Duodenal
Ulcer
You should begin to
suspect a perforated duodenal ulcer when the patient is complaining of RUQ
abdominal pain and Murphy's sign is negative. Then check for a fever.
Unfortunately hypotension and high fever are late signs. The presentation
is usually a sudden acute onset of epigastric pain that will quickly become
generalized and may move to the RLQ. The patient may have a history of
recent surgery or previous ulcers. The abdomen may present with board-like
rigidity. Prehospital treatment is recognition,
pain management, fluid in the case of hypotension, and transport to the nearest
hospital with surgical services.
We are experts in
emergencies and abdominal emergencies are no exception. Just recognition of
these few conditions alone can save a life. So let's begin our journey
into the world of acute abdominal assessment by committing to memory Murphy's
sign, cholecystitis, ascending cholangitis, and perforated duodenal
ulcers.
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Nino-Murcia, M. and Jeffrey, R.B. Imaging the Patient with Right Upper Quadrant Pain.
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www.uptodate.com
Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed.
Cecil Textbook of Medicine 21st Edition
Saini, S. Imaging of the Hepatobiliary Tract. NEJM (1997) Volume 336:1889-1894
Hill AG. Management of perforated duodenal ulcer. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.
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