Principles of Patient Assessment in EMS

1. Principles of Patient Assessment in EMS By: Bob Elling, MPA, EMT-P & Kirsten Elling, BS, EMT-P

2. Chapter 15 – Focused History and Physical Exam of the Patient with Abdominal Pain © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

3. Objectives • List and describe the three distinctive types of abdominal pain. • Describe specific information using OPQRST to ask the patient complaining of abdominal pain. • Describe specific information using SAMPLE pertinent to the patient complaining of abdominal pain. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

4. Objectives (continued) • Describe the steps to prepare a patient for physical examination of the abdomen. • List the normal and abnormal features to observe when examining the abdomen. • Describe the key feature of auscultation of bowel sounds for the EMS provider. • Describe the steps for light palpation, deep palpation and rebound tenderness of the abdomen. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

5. Objectives (continued) • Describe the normal percussion tones of the abdomen. • List the diagnostic tools the EMS provider may use during the examination of the patient with abdominal pain. • Describe why examination of the abdomen is different than examining other body parts. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

6. Objectives (continued) • Describe three reasons why the patient with severe abdominal pain may be difficult to assess. • List the most common causes of abdominal pain including intra-abdominal, extra-abdominal, metabolic and neurogenic causes. • List the causes of acute abdominal pain requiring surgery. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

7. Objectives (continued) • List the major gastrointestinal and genitourinary conditions the EMS provider may see in the prehospital setting. • Describe the clinical features associated with the major GI and GU conditions. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

8. Introduction • Abdominal pain has many etiologies. • Many causes are not life-threatening and require only supportive care. • Life-threatening causes include: • AMI • Ectopic pregnancy • Acute appendicitis © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

9. Introduction • The EMS provider should know clinical signs and symptoms and history taking unique to the patient with acute abdominal pain. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

10. Types of Abdominal Pain • Visceral – pain is caused by stretching of nerve fibers surrounding the organs. • Often poorly localized, diffuse and difficult to describe • Patient may complain of feeling crampy or gaseous • Patient may be guarding © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

11. Types of Abdominal Pain (Continued) • Somatic – pain is caused by irritation of nerve fibers in the parietal peritoneum. • Pain is usually more localized • Described as sharp and constant © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

12. Types of Abdominal Pain (continued) • Referred – pain that originates from one area of the body and is also sensed in another area. • There are several referral patterns associated with abdominal pain • Review Table 15-1 © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

13. Focused History • Be alert for clues to extra-abdominal causes of abdominal pain such as AMI and ectopic pregnancy. • Use OPQRST to elaborate on the chief complaint of abdominal pain. • Obtain a SAMPLE History on the patient. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

14. Physical Exam • Assess MS-ABCs, skin CTC, and signs of poor perfusion. • Assess patient’s level of distress as mild, moderate, or severe. • Abdominal distress usually produces autonomic nervous system reactions such as tachycardia and diaphoresis. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

15. Physical Exam • After the IA, focus the exam on the CC. • Assess each of the 4 quadrants. • Examine in this order: observe, auscultate, palpate, percuss. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

16. Observation • Note the following: • Symmetry • Skin tone • Masses • Bulges • Surgical scars • Rashes • Lesions • Transderm patches • Colostomy attachments © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

17. Observation (continued) • Cullen’s sign – periumbilical eccymosis. • Presacral edema – associated with limited mobility and cardiac history. • Pulsations from the abdominal aorta are normal in thin persons. • Pulsations from masses/bulges are abnormal. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

18. Observation (continued) • Ask the patient about bloating/distension as it is not always obvious. • Scaphoid abdomen – sinking, concave shape associated with dehydration or malnutrition. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

19. Auscultation • Listen for the presence or absence of bowel sounds (normal 5 to 30 times a minute). • The most significant finding is the absence of bowel sounds (obstruction, inflammation of peritonittis). • Assess only when time permits (2-5 minutes). • Auscultate prior to palpation. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

20. Palpation • Warm hands and position the patient on the back. • A normal abdomen should be soft, non-tender, without masses/bulges. • Note tenderness, temperature, guarding, and presence of abnormal structures. • Three types of palpation: • Light • Deep • Rebound © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

21. Palpation (continued) • Light palpation – using one hand to palpate approx. 1 cm in depth. • Deep palpation – using one or two hands, palpate 2-3 inches. (Do not perform deep palpation on masses). • Rebound tenderness – palpate one quadrant, then quickly remove hand. If the patient has pain with the release of pressure this is call rebound tenderness (associated with peritoneal irritation). © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

22. Percussion • Performed by touching and tapping the fingertips on various body parts. • Determines size, position, and consistency of underlying structures. • Most frequently used over the chest and abdomen. • Not routinely performed in the prehospital setting due to time constraints. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

23. Diagnostic Tools • Consider obtaining the following on the patient with abdominal complaints: • ECG • Pulse oximetry reading • Temperature © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

24. Features of Abdominal Pain • The location of pain is not always an accurate indication of the cause of the pain. • Suspect any pain above the umbilicus as cardiac until proven otherwise. • In females of child bearing age suspect ectopic pregnancy until proven otherwise. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

25. Features of Abdominal Pain • Consider the many possible referral patterns of pain. • Patients with severe pain may be difficult to assess. • Consider skin signs (CTC) • Level of distress • Position of comfort/ guarding © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

26. Common Causes of Abdominal Pain • Specific diagnosis is difficult, even in the ED. • Numerous causes: • Intra-abdominal • Extra-abdominal • Metabolic • Neurologic © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

27. Common Causes of Abdominal Pain • Inflammation, obstruction, infection, hemorrhage or any combination. • Conditions that require surgical intervention include: • Appendicitis, ectopic pregnancy, tumors • Cholecystitis, perforated peptic ulcer or viscus • Dissecting and rupture aneurysm or bowel infarction © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

28. Conclusion • The focused physical exam of the patient with abdominal pain should be performed quickly to identify any significant injury, potential hemorrhage or indications of a possible surgical abdomen. © 2003 Delmar Learning, a Division of Thomson Learning, Inc.

29. Conclusion • Specific diagnosis is not the objective. • Obtain a FH and PE, consider life-threatening conditions such as AMI and ectopic pregnancy early! © 2003 Delmar Learning, a Division of Thomson Learning, Inc.