Generations of physicians learned from Dr. Zachary Cope, via his famous monograph, that the use of narcotic analgesia for patients with acute abdominal pain was absolutely verboten. The most recent edition of the great book cautiously permits the use of opiate analgesics, but only by the physician "responsible for the ultimate diagnosis and therapy" (i.e., the surgeon), lest "serious delay and error in decision-making" result.1 The present study questions this dictum.
Pace and Burke studied 71 adult patients presenting to the ED with severe, acute, atraumatic abdominal pain. The subjects were randomized in a double-blind fashion to receive either intravenous morphine or saline. Pain was assessed using a visual analog scale. The treating physicians were required to record the presence or absence of peritoneal signs and provisional diagnosis and disposition. The dose of morphine was 0.1 mg/kg initially, followed by 0.05 mg/kg boluses every 5-10 minutes until the patient reported that the pain was tolerable. Control patients received an equal volume of saline using the same guidelines. The final diagnosis was that eventually determined by surgical, radiographic, or endoscopic evaluation; the absence of such an ultimate diagnosis was considered "undifferentiated, self-limited illness."
The morphine and control groups were similar in age, sex, initial pain scores, incidence of peritoneal signs, need for operative management, and final diagnosis. The mean pain score following treatment was much lower in the group receiving narcotic analgesia than in the control group. There was no difference between the two groups in accuracy of the physician’s provisional diagnosis, although there was a consistent non-significant trend toward greater accuracy in the morphine-treated patients. No patient experienced resolution of peritoneal signs following treatment.
The authors conclude that morphine administration to patients with acute abdominal pain does not hinder the ability of physicians to reach a correct diagnosis and does not mask signs of peritoneal irritation. (Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996;3:1086-1092.)
COMMENT BY DAVID J. KARRAS, MD
Why should the doctrine proscribing narcotic analgesics for patients with acute abdominal pain be any less valid today than it has been over the past decade? While the differential diagnosis of acute abdominal pain has not changed much, the methods used to reach a provisional diagnosis have evolved dramatically. Specifically, laboratory and imaging studies have made serial examinations of the abdomen far less vital, and it is therefore less imperative that the patient be forced to endure severe, prolonged discomfort. This study contributes to the evidence that such stoicism may be unnecessary.2-3
The results of this study need to be replicated and disseminated in the surgical literature. Even after further confirmation of the "benign" effect of early narcotic administration for acute abdominal pain, I suspect that many surgeons will be displeased when informed that a patient has received analgesia prior to the surgeon’s examination. One reason for this displeasure is the inevitably slow pace with which dogma changes. A more vexing reason, I fear, is that it will be very tempting for a surgeon already frustrated by a difficult diagnosis to blame the emergency physician who administered narcotics for any error or delay in the patient’s diagnosis. Only time and strong convictions based on strong research can alter such inveterate convictions.
References
1. Cope Z. Early Diagnosis of the Acute Abdomen. 17th ed. New York: Oxford University Press; 1987:5-6.
2. Zoltie N, Cust MP. Analgesia and the acute abdomen. Ann R Coll Surg 1986;68:209-210.
3. Attard AR, et al. Safety of early pain relief for acute abdominal pain. BMJ 1992;305:554-556.
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