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Fri, 11 Apr 2003 12:35:00 +0100

> This month's lead article in the American Journal of
> Surgery (Nissman SA, Kaplan LJ, Mann BD. Critically
> reappraising the literature-driven practice of
> analgesia administration for acute abdominal pain in
> the emergency room prior to surgical evaluation. Am J
> Surg 2003;185:291-96) addresses the once (still?)
> controversial practice of administering narcotics to
> patients suspected of harboring intraabdominal
> pathology before the arrival of the consulting
> surgeon. At best the
> supporting evidence comes from four studies that were
> flawed in design and/or examined insufficient numbers
> of patients.

Not a very systematic review. There is a vast body of evidence supporting
the hypothesis that analgesia is effective for acute abdominal pain. The
studies on diagnostic accuracy are too small to exclude a small improvement
or worsening of diagnostic accuracy with analgesia.

Thomas SH et al. Effects of morphine analgesia on diagnostic accuracy in
emergency department patients with abdominal pain: A prospective, randomized
trial. J Am Coll Surg 2003 Jan; 196: 18-31. is one more recent study
supporting the hypothesis that diagnostic accuracy is similar or improved in
patients given analgesia.

> I believe this is a relevant
> issue in trauma care as well, given the significant
> numbers of patients we are asked to see by the ER
> service who did not initially meet full trauma
> activation criteria yet in whom there is a question of
> intraabdominal injury.

Do we need to rehash the literature on diagnostic accuracy abdominal
examination in blunt trauma? Even in the alert orientated patient without
distracting injuries, the great majority of patients with a positive
abdominal exam have no significant intraabdominal injury, and a significant
minority of patients with a negative exam have a significant injury. 

> The point is that there is no good data
> that proves that premedicationg these patients does
> not affect the surgeons ability to render an accurate
> diagnosis. 

Equally, no good data that proves that premedicating does not improve
diagnostic accuracy. My personal experience is that it does.

Matt Dunn
Warwick

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Opiates & the Acute Abdomen