Thursday, April 12, 2012

Prehospital Abdominal Assessment Part 2

     Continuing the prehospital obdominal assessment we will look at the right lower quadrant.  In this area we are going to talk about the obvious acute appendicitis.  In order to help us differentiate an appendicitis in the presence of RLQ abdominal pain I would like to add two more assessment tools to your repertoire: tenderness over McBurney's point and obturator sign.  Positive results from these tests point toward appendicial irritation and possibly an acute appendicitis. McBurney's point  is a site of extreme sensitivity in acute appendicitis, situated in the normal area of the appendix one third the distance between the umbilicus and the anterior iliac spine in the right lower quadrant of the abdomen.  Finger pressure over McBurney's point in the presence of an acute appendicitis brings immediate and intense pain.  Tenderness over McBurney's point is one indicator of an irritated appendix.  

The next test you can do is called obturator sign.  The internal obturator muscle lies close to the appendix and flexation of this muscle in the presence of an acute appendicitis will cause an increase in pain in the lower right quadrant.  A picture is worth a thousand words so this test is best explained by watching the following video:

This brings us to the topic of rebound tenderness.  We have all learned that the presence of rebound tenderness in the LRQ could mean an appendicitis. Rebound tenderness is not an isolated test for an appendicitis.  Anytime the peritoneum is inflamed you will find rebound tenderness.  An inflamed and infected appendix will irritate the peritoneum thereby causing rebound tenderness in the area of the appendix.  Rebound tenderness can also be an early sign of abdominal bleeding even before rigidity as blood in the abdomen will cause peritoneal irritation as well.  So rebound tenderness in itself is not conclusive of an inflamed appendix.  Using the assessment tools I have described above is much more specific and useful.  When confronted with a patient with LRQ abdominal pain it is very important to determine the likelihood of an acute appendicitis as it is an emergent surgical case and a ruptured appendix can cause profound septicemia.

The most common signs and symptoms of an appendicitis are abdominal pain, loss of appetite, nausea, vomiting, and fever.  When you have this presentation along with tenderness over McBurney's point and a positive oburator sign...think acute appendicitis