2 - Acute Emergencies and Pre-Hospital Care

Question 1

What is the ABCDE approach to emergency presentations?

Answer 1

• LOOK LISTEN FEEL ensuring personal safety
• Check patients drug chart for disability for any changes in consciousness
• Respect patients dignity when exposing and prevent uneccessary heat loss

Question 2

What are some major causes of acute abdominal pain that may present to primary care?

Answer 2

• Hernia
• UTI/Pyelonephritis

Question 3

If a patient described abdominal pain in each of the regions shown, what may be some differentials?

Answer 3

Question 4

What are some important questions to ask a female presenting with acute abdominal pain?

Answer 4

• History of STIs or PID
• Contraceptive method e.g IUD
• LMP
• History of ectopic pregnancies
• Any vaginal bleeding

Question 5

What pathologies can cause back pain as well as abdominal pain?

Answer 5

• Pancreas
• Abdominal aorta

Question 6

How do you examine a patient that you have assessed/taken a history for with abdominal pain?

Answer 6

Inspection: look for anaemia or jaundice, Grey-Turners and Cullens, ab distension, visible peristalsis, assess hydration

Auscultation: listen for absent bowel sound, bruit

Percussion: shifting dullness, fluid thrill, organomegaly

Palpitation: start away from pain and move towards it, rebound tenderness, look for hernia in groin, examine scrotum, look at groin and supraclavicular lymph nodes

Extra: urine, pregnancy test, lower limb pulse, rectal or pelvic exam

Question 7

How do you manage a patient with acute abdominal pain?

Answer 7

• Admit if likely surgical cause or IV antibiotics needed
• Nil by mouth if transfer
• IV fluids if in shock and check blood group
• Antibiotics if sepsis, UTI, peritonitis
• Analgesia and antiemetic

Urgent surgical/gynaecological review

Arrange investigations e.g ECG

Question 8

How should you help a child who has respiratory difficulty or is choking?

Answer 8

- Resp difficulty: High flow oxygen (15L/min) or bag valve mask if poort effort

- Choking: Encourage coughing, if not 5 back blows then 5 chest thrusts

Question 9

What are some red flags with abdominal pain?

Answer 9

• Hypotension
• Confusion
• Dehydration
• Patient lying still or writhing
• Rebound tenderness
• Guarding
• Rigid abdomen
• Tenderness to percussion
• History of haematemesis or melaena
• Testicular pathology

Question 10

What is the diagnosis and management for the following clinical findings in a child?

Answer 10

Question 11

What is the traffic light system used for identifying a child’s risk of serious illness?

Answer 11

• Any red features that are a life threatening cause of febrile illness (e.g sepsis) need emergency ambulance to A+E
• Any red non-life threatening need face to face assessment within two hours
• Any amber face to face assessment on clinical judgment
• Any green can be managed at home with support e.g hydrate and ibuprofen, and safety net

CARCO

Question 12

What are some major causes of acute chest pain?

Answer 12

• PE
• Pneumothorax
• Pericarditis
• Cardiac Tamponade
• Pneumonia
• Pleural effusion

Question 13

What symptoms would make you think a patient’s acute chest pain is due to ACS?

Answer 13

Question 14

What management should a patient with pre-existing angina be given when undergoing an angina attack?

Answer 14

• Stop what they are doing and rest.
• Use their glyceryl trinitrate spray or tablets as instructed.
• Take a second dose after 5 minutes if the pain has not eased.
• Call 999 for an ambulance if the pain has not eased 5 minutes after the second dose, or earlier if the pain is intensifying or the person is unwell.

Question 15

How can chest pain be classified?

Answer 15

- Cause: cardiac/non cardiac

- Type: localised/poorly localised and pleuritic or non-pleuritic

Question 16

How should you investigate and manage a patient with acute chest pain?

Answer 16

• Full CVS exam
• ECG 12 lead
• Cardiac enzymes/troponin
• Call 999 if urgent admission needed

Question 17

If a patient presents with chest pain and does not require an immediate admission, where should they be referred to?

Answer 17

REFER TO CHEST PAIN CLINIC

- Urgent same day assessment: if suspected ACS but pain-free with chest pain in the past 12 hours and a normal ECG or chest-pain in past 12-72 hours with no complications

- 2 Weeks: suspected ACS with pain in past 72 hours, suspected malignancy, suspected pleural effusion, suspected lobar/lung collapse

- Routinely if stable angina or unknown chest pain

Question 18

What should you do if you suspect a patients pain is due to ACS in primary care?

Answer 18

• Call 999
• Exacerbations of pain and other symptoms.
• Pulse, blood pressure, and heart rhythm.
• Oxygen saturation (using pulse oximetry).
• Resting 12-lead ECG (repeat if necessary).
• Pain relief (and review for efficacy).
• Treat pain with glyceryl trinitrate (GTN) and/or an opioid (for example intravenous diamorphine 2.5 mg to 5.0 mg, given slowly over 5 minutes).
• Give aspirin 300 mg PO (unless there is clear evidence that the person is allergic to it). Send a written record with the person that aspirin has been given.
• Take a resting 12-lead ECG (electrocardiogram) and send the recording with the person to the hospital. Recording and sending the ECG should not delay transfer to hospital.
• Maintain sats >94% using oxygen
• Offer morphine and antiemetics to relieve ischaemic pain

Question 19

What signs associated with acute chest pain should encorage you to admit a patient to hospital urgently?

Answer 19

• Resp rate >30
• Tachycardia >130
• BP <90 <60 unless normal
• Temp >38.5
• Sats <92% or central cyanosis

Question 20

Where do patients with suspected STEMIs go when they get to the hospital?

Answer 20

If had an ECG in the ambulance they go straight to the cardiology catheter lab

Question 21

Why are patients given aspirin when ACS is suspected?

Answer 21

Lowers risk of myocardial infarction and stroke

Question 22

How should you manage a patient in primary care that presents with a suspected PE?

Answer 22

- Immediate admission for anyone who is haemodynamically unstable or pregnant/given birth in past 6 weeks

• If none of these then do the Well’s criteria. If >4 admit to hospital for CTPA, if <4 offer D-dimer test with result in 4 hours with interim anticoagulation if takes longer. If test positive send for CTPA

Wells score

Question 23

What are some differential diagnoses for acute shortness of breath in primary care?

Answer 23

• Silent MI
• Cardiac arrhythmia
• Acute pulmonary oedema/heart failure
• COPD
• Asthma
• Pneumona
• PE
• Lung cancer
• Pleural effusion
• Anaemia
• Diaphragmatic splinting
• Psychogenic breathlessness

Question 24

What are some questions you would ask a patient presenting with an acute presentation of SOB?

Answer 24

• B.P
• Pulse
• Resp rate
• Sats
• ECG
• PEFR
• Temperature

Question 25

What features would warrant an admission to hospital when a patient presents to primary care with SOB?

Answer 25

- If **sats less than 94%** **oxygen should be given** and monitored while awaiting transfer to hospital, unless at risk of hypercapnia - Only admit chronic breathlessness, e.g COPD, if exacerbation

Question 26

What would define whether asthma is severe asthma and life threatening asthma?

Answer 26

Question 27

What is the management for acute asthma?

Answer 27

**OSHIT** **- O₂** 5l to maintain sats between 94-98% **- Salbutamol 5mg** or **Terbutaline 10mg** nebulised with O₂ **- IV hydrocortisone 100mg** or **40-50mg PO prednisolone** - Add ipratropium bromide 0.5mg/6h to nebuliser is life threatening - Magnesium sulfate and amino/theophylline added by specialists If life threatening hospital admission, if improved 24 hour follow up

Question 28

How do you manage an acute exacerbaton of COPD?

Answer 28

Question 29

What is the difference between a TIA and stroke?

Answer 29

Suspect stroke if the neurological deficit (e.g numbness, weakenss, slurred speech, visual disturbance) is ongoing or over 24 hours

Question 30

How do you manage a suspected acute stroke in primary care?

Answer 30

- Emergency admission to stroke unit - Give information to ambulance control and admitting hospital - Avoid antiplatelet treatment until haemorraghic stroke excluded

Question 31

How do you manage a suspected TIA?

Answer 31

- Give **aspirin 300mg** unless contraindicated or taking aspirin regularly **- Arrange assessment by TIA clinc within 24 hours** if TIA occured in last week, if more than a week ago refer to specialist within 7 cays - Arrange **urgent admission** if patient has had **more than one TIA**, if patient lacks reliable observer at home or if patient has bleeding disorder/taking anticoagulant - **Advise patient not to drive** until review by specialist - After TIA have **follow up with GP** to discuss lifestyle changes and drug therapies

Question 32

How does Bell's palsy present and what are some complications?

Answer 32

Acute unilateral facial nerve weakness or paralysis of rapid onset (\<72 hrs) **Presentation:** rapid onset, difficulty chewing, dry mouth, numbness in cheek or mouth, drooling, hyperacusis, facial weakness so drooping **Complications:** eye injury, facial pain, dry mouth, psychological sequele, abnormal facial muscle contractions, hyperacusis

Question 33

What differential diagnoses would you think of for unilateral facial weakness?

Answer 33

- TIA - Stroke - Bell's Palsy

Question 34

How would you distinguish between Bell's Palsy and a stroke?

Answer 34

- Bell's often has longer acute onset with peak in hours or days but stroke is in minutes - Stroke often can wrinkle forehead as central lesion but cannot in Bell's - Bell's will have absence of other neurological symptoms

Question 35

How would you manage Bell's palsy in primary care?

Answer 35

- If presenting **within 72 hours** of onset prescribe **prednisolone** **50mg for 10 days** - Possible antiviral treatment **aciclovir** as herpes and v.zoster could be involved - Keep eye lubricated with eye drops, sunglasses and tape eye shut at night. Consider referal to opthalmologist - Use straw - Refer to facial nerve specialist if no improvement after 3 weeks of treatment or incomplete recovery in 5 months

Question 36

When should you refer someone with Bell's Palsy urgently to secondary care?

Answer 36

Should be no hearing loss with Bell's

Question 37

How would you treat suspected anaphylaxis in primary care?

Answer 37

ABCDE assessment - Call ambulance - High flow oxygen \>10L - Lay patient flat and raise legs (if pregnant left lateral tilt) - IM adrenaline into anterolateral aspect of middle third of thigh - Repeat IM after 5 minutes if no improvement

Question 38

How would you treat anaphylaxis once specialist help has arrived?

Answer 38

**- Constantly monitor** pulse, sats, bp and ECG **- Establish airway** **- IV fluid challenge** with 500ml 0.9% saline in 5-10 minutes if normotensive, 1000ml if hypotensive - **Chlorphenamine** **- Hydrocortisone** - If still breathing difficulty give IV or inhaled bronchodilators etc

Question 39

What dosage of IM adrenaline do you need to give in anaphylaxis?

Answer 39

**- Adult or child\>12:** 0.5mg (500ug) IM **- Child 6-12 years or small\>12**: 0.3mg (300ug) IM **- Child \<6:** 0.15mg (150ug)

Question 40

After emergency treatment for anaphylaxis what should the patient be offered?

Answer 40

- Referral to specialist allergy service - Two autoinjectors and advice on how and when to use them

Question 41

What signs would make you suspect anaphylaxis?

Answer 41

- Low b.p - High HR - High RR - High temperature - Using respiratory muscles

Question 42

What type of drug is chlorphenamine?

Answer 42

**Antihistamine** Symptomatic relief of hay fever, urticaria, food allergy, drug reactions, Relief of itch associated with chickenpox