2 - Acute Emergencies and Pre-Hospital Care Flashcards
What is the ABCDE approach to emergency presentations?
- 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
What are some major causes of acute abdominal pain that may present to primary care?
- Shingles
- Hernia
- UTI/Pyelonephritis
If a patient described abdominal pain in each of the regions shown, what may be some differentials?
What are some important questions to ask a female presenting with acute abdominal pain?
- History of STIs or PID
- Contraceptive method e.g IUD
- LMP
- History of ectopic pregnancies
- Any vaginal bleeding
What pathologies can cause back pain as well as abdominal pain?
- Pancreas
- Abdominal aorta
How do you examine a patient that you have assessed/taken a history for with abdominal pain?
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
How do you manage a patient with acute abdominal pain?
- 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
How should you help a child who has respiratory difficulty or is choking?
- 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
What are some red flags with abdominal pain?
- Hypotension
- Confusion
- Dehydration
- Patient lying still or writhing
- Rebound tenderness
- Guarding
- Rigid abdomen
- Tenderness to percussion
- History of haematemesis or melaena
- Testicular pathology
What is the diagnosis and management for the following clinical findings in a child?
What is the traffic light system used for identifying a child’s risk of serious illness?
- 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
What are some major causes of acute chest pain?
- PE
- Pneumothorax
- Pericarditis
- Cardiac Tamponade
- Pneumonia
- Pleural effusion
What symptoms would make you think a patient’s acute chest pain is due to ACS?
What management should a patient with pre-existing angina be given when undergoing an angina attack?
How can chest pain be classified?
- Cause: cardiac/non cardiac
- Type: localised/poorly localised and pleuritic or non-pleuritic
How should you investigate and manage a patient with acute chest pain?
- Full CVS exam
- ECG 12 lead
- Cardiac enzymes/troponin
- Call 999 if urgent admission needed
If a patient presents with chest pain and does not require an immediate admission, where should they be referred to?
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
What should you do if you suspect a patients pain is due to ACS?
- Call 999
- Aspirin 300mg PO single loading dose chewed as antiplatelet
- Give clopidogrel 300mg PO loading
- Maintain sats >94% using oxygen if pulmonary oedema or hypoxia
- Offer morphine and antiemetics to relieve ischaemic pain
What signs associated with acute chest pain should encorage you to admit a patient to hospital urgently?
- Resp rate >30
- Tachycardia >130
- BP <90 <60 unless normal
- Temp >38.5
- Sats <92% or central cyanosis
Where do patients with suspected STEMIs go when they get to the hospital?
If had an ECG in the ambulance they go straight to the cardiology catheter lab
Why are patients given aspirin when ACS is suspected?
Lowers risk of myocardial infarction and stroke
How should you manage a patient in primary care that presents with a suspected PE?
- 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
What interim anticoagulation is given whilst awaiting results of a D-dimer test for a likely PE?
- Take FBC, renal and hepatic function, PT and APTT before commencing but do not wait for results
- Apixiban or Rivaroxiban first line for at least 5 days
- If not suitable use LMWH followed by dabigatran for 5 days OR LMWH with Vit K antagonist for 5 days
What are some differential diagnoses for acute shortness of breath in primary care?
- Silent MI
- Cardiac arrhythmia
- Acute pulmonary oedema/heart failure
- COPD
- Asthma
- Pneumona
- PE
- Lung cancer
- Pleural effusion
- Anaemia
- Diaphragmatic splinting
- Psychogenic breathlessness
What are some questions you would ask a patient presenting with an acute presentation of SOB?
- B.P
- Pulse
- Resp rate
- Sats
- ECG
- PEFR
- Temperature
What features would warrant an admission to hospital when a patient presents to primary care with SOB?
- 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
What would define whether asthma is severe asthma and life threatening asthma?
What is the management for acute asthma?
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 theophylline added by specialists
If life threatening hospital admission, if improved 24 hour follow up
How do you manage an acute exacerbaton of COPD?
What is the difference between a TIA and stroke?
Suspect stroke if the neurological deficit (e.g numbness, weakenss, slurred speech, visual disturbance) is ongoing or over 24 hours
How do you manage a suspected acute stroke in primary care?
- Emergency admission to stroke unit
- Give information to ambulance control and admitting hospital
- Avoid antiplatelet treatment until haemorraghic stroke excluded
How do you manage a suspected TIA?
- 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
How does Bell’s palsy present and what are some complications?
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
What differential diagnoses would you think of for unilateral facial weakness?
- TIA
- Stroke
- Bell’s Palsy
How would you distinguish between Bell’s Palsy and a stroke?
- 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
How would you manage Bell’s palsy in primary care?
- 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
When should you refer someone with Bell’s Palsy urgently to secondary care?
Should be no hearing loss with Bell’s
How would you treat suspected anaphylaxis in primary care?
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
How would you treat anaphylaxis once specialist help has arrived?
- 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
What dosage of IM adrenaline do you need to give in anaphylaxis?
- Adult or child>12: 0.5mg (500ug) IM
- Child 6-12 years or small>12: 0.3mg (300ug) IM
- Child <6: 0.15mg (150ug)
After emergency treatment for anaphylaxis what should the patient be offered?
- Referral to specialist allergy service
- Two autoinjectors and advice on how and when to use them
What signs would make you suspect anaphylaxis?
- Low b.p
- High HR
- High RR
- High temperature
- Using respiratory muscles
What type of drug is chlorphenamine?
Antihistamine
Symptomatic relief of hay fever, urticaria, food allergy, drug reactions,
Relief of itch associated with chickenpox
