A cardinal sign of hemorrhage within the peritoneal cavity, Kehr’s sign is referred left shoulder pain due to diaphragmatic irritation by intraperitoneal blood. The pain usually arises when the patient assumes the supine position or lowers his head. Such positioning increases the contact of free blood or clots with the left diaphragm, involving the phrenic nerve.

Kehr’s sign usually develops right after the hemorrhage; however, its onset is sometimes delayed up to 48 hours. A classic symptom of a ruptured spleen, Kehr’s sign also occurs in ruptured ectopic pregnancy.

After you detect Kehr’s sign, quickly take the patient’s vital signs. If the patient shows signs of hypovolemia, elevate his feet 30 degrees. In addition, insert a large-bore I.V. catheter for fluid and blood replacement and an indwelling urinary catheter. Begin monitoring intake and output. Draw blood to determine hematocrit, and provide supplemental oxygen.

A reliable early indicator and tool used to diagnose meningeal irritation, Kernig’s sign elicits both resistance and hamstring muscle pain when the examiner attempts to extend the knee while the hip and knee are both flexed 90 degrees. However, when the patient’s thigh isn’t flexed on the abdomen, he’s usually able to completely extend his leg. (See Eliciting Kernig’s sign, page 416.) This sign is usually elicited in meningitis or subarachnoid hemorrhage. With these potentially life-threatening disorders, hamstring muscle resistance results from stretching the blood- or exudate-irritated meninges surrounding spinal nerve roots.

Kernig’s sign can also indicate a herniated disk or spinal tumor. With these disorders,
sciatic pain results from disk or tumor pressure on spinal nerve roots.