Original Contributions
Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain,☆☆,,★★

Abstract presented as a Poster at the 7th Connecticut College of Emergency Physicians Scientific Assembly Nov 17, 1999 and as an oral presentation at the 8th International Conference on Emergency Medicine, May 4-7, 2000.
https://doi.org/10.1053/ajem.2000.16315Get rights and content

Abstract

Giving an analgesic to patients with right lower quadrant (RLQ) pain causes greater alteration of abdominal signs predictive of appendicitis than placebo. A randomized double-blinded controlled trial of 68 patients who received either tramadol or placebo. Absence or presence of seven abdominal signs (tenderness on light and deep palpation, tenderness in the RLQ and elsewhere, rebound, cough, and percussion tenderness) and pain (100 mm Visual Analog Scale [VAS]) at 0 and 30 minutes were recorded. The predictive value of each physical finding (PF) was measured using an 11-point PF score weighted by likelihood ratios. There was significant reduction in mean VAS of 14.2 mm (95% CI 5.6 to 22.8) in analgesic group versus 6.5 mm (95% CI 1.6 to 11.4) in placebo group. The analgesic group had less normalization of signs as measured by the PF score in all patients [32 of 154 (20.8%) versus 40 of 121 (33.1%) (P = .031)] and in those with proven appendicitis [4 of 33 (12.1%) versus 10/22 (45.5%) (P = .014)]. Parenteral use of tramadol in emergency department patients with RLQ pain resulted in significant levels of pain reduction without concurrent normalisation of abdominal examination findings indicative of acute appendicitis. (Am J Emerg Med 2000;18:753-756. Copyright © 2000 by W.B. Saunders Company)

Section snippets

Methods

The study was conducted in Singapore at the National University Hospital, which provides urban tertiary care with an annual ED census of 85,000. A convenience sample of patients greater than 11 years of age who presented to our ED with right lower quadrant pain less than a week's duration (nontraumatic in origin) suggestive of acute appendicitis was included. Approval for the study was obtained from the hospital's Human Research Committee and patients were enrolled over a 6-month period from

Results

A total of 68 patients were randomized into two groups. There were 34 patients in the treatment group and 34 in the placebo group with one patient excluded from each group after randomization because of one having an incomplete record and the other absconding before study completion. Clinical findings in both groups (Table 1) were similar except for the greater representation of women in the treatment group.

. Demographics and Clinical Characteristics of Abdominal Pain Patients

Empty CellAnalgesic GroupEmpty Cell

Discussion

What constitutes a significant change in abdominal examination findings has not been precisely defined by prior studies. In three previous studies the investigators concluded that the administration of analgesics to abdominal pain patients resulted in some physical finding changes6, 8, 12 whereas in another study it was reported that there were “no changes in peritoneal signs.”7 The changes in abdominal signs reported were not quantified or qualified in any of these studies.

In our study we

Conclusions

Parenteral tramadol results in a decrease in the level of abdominal pain in patients with RLQ abdominal pain. This effect was achieved in this study without causing normalization of abdominal examination findings that were indicative of acute appendicitis.

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      Moreover, even an actual alteration of physical signs does not necessarily imply a variation of treatment strategy or predict a worse outcome. In fact some works revealed that changes on physical examination did occur, but concluded that diagnostic accuracy was not affected.12,14,15 Surgeon's confidence is not necessarily related to accuracy and delay of surgical intervention does not imply an incorrect treatment strategy unless it affects morbidity.

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      It was thought that analgesia could confuse the clinical examination. However, recent studies concluded that early analgesia inabdominal pain cases does not adversely affect treatment [1-11]. Yet, less attention has been given to actual outcomes than to other markers of diagnostic accuracy, such as physicians' diagnostic impressions or physical examination signs.

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    Returned January 26, 2000.

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    Address reprint requests to Malcolm Mahadevan, MD, 129 Hillcrest Road, Singapore 288999. E-mail: [email protected]

    Am J Emerg Med 2000;18:753-756

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