Acute emergencies and pre-hospital care Flashcards
How does acute appendicitis present ?
Central abdominal colic progresses and localises in the right iliac fossa.
Worsens on movement and coughing, laughing
May have :
Dysuria
Nausea + - vomiting
Rarely diarrhoea
What is seen on examination in acute appendicitis ?
Discomfort on walking
Flushed and unwell - pyrexia
Tenderness and guarding in the right iliac fossa
What is seen in investigations in acute appendicitis ?
Urinalysis - NAD or trace of blood
What is the management of an acute appendicitis ?
Admit as a surgical emergency
What are some differential diagnoses for acute abdominal pain that aren’t GI causes ?
Renal colic
UTI
Pyelonephritis
Hydronephrosis
Ectopic pregnancy
Ovarian torsion
Dysmenorrhea
Ruptured spleen
Testicular torsion
What are some differential diagnoses of acute abdominal pain that is GI causes ?
IBS
Constipation
Diverticular disease
Gallbladder disease - biliary colic, cholecystitis
Liver disease
Crohn’s
UC
Peptic ulcer
Appendicitis
GI malignancy
What conditions may increase the risk of rupturing spleen ?
Glandular fever
Malaria
Leukaemia
How does a ruptured spleen present ?
History of abdominal trauma
Blood loss - tachycardia, low BP+/- postural drop, pallor
Peritoneal irritation : guarding, abdo rigidity, shoulder tip pain
Paralytic ileus - abdominal distension, lack of bowel sounds
What to do if a ruptured spleen is suspected ?
Admit as a blue-light surgical emergency
How does biliary colic present ?
Clear cut attacks of severe upper abdominal pain that may radiate - - back / shoulder tip, lasting under 30 minutes and causes restlessness +/- jaundice, nausea and vomiting
what is seen on examination of biliary colic ?
Tenderness and guarding in the RUQ
Increased on deep inspiration - Murphy’s sign
What is the acute management of biliary colic ?
Treat with pethidine or Diclofenac + prochlorperazine or Domperidone for nausea
When should biliary colic be admitted as a surgical emergency ?
Uncertain of diagnosis
Inadequate social support
Persistent symptoms despite analgesia
Suspicion of complications
What follow up investigations should be performed for biliary colic ?
Abdominal USS
How does acute cholecystitis present ?
Pain and tenderness in the RUQ/ epigastrium +/- vomiting
What is seen on examination in acute cholecystitis ?
Tenderness +/- guarding in the RUQ +/- fever or jaundice
What is the acute management on acute cholecystitis ?
Treat with broad spectrum antibiotics ( ciprofloxacin ) and analgesia for biliary colic
When should a person with acute cholecystitis be admitted for emergency surgery ?
Generalised peritonism or very toxic
Diagnosis uncertain
Other medical conditions such as dehydration, DM, addisons or pregnancy
Not responding to medication
How does acute pancreatitis present ?
Poorly localised, continuous, boring epigastric pain that increases over an hour period - often worse when lying down and may radiate to the back. Accompanied by nausea and vomiting.
What is seen on examination in acute pancreatitis ?
Tachycardia
Fever
Shock
Jaundice
Localised epigastric pain or generalised abdominal tenderness
Abdominal distension
Decreased bowel sounds
What is the management of acute pancreatitis ?
Admit as an acute surgical emergency
What are some complications of acute pancreatitis ?
Persistent pain
Failure to regain weight
Pancreatic necrosis
Pseudocyst
Fistula / abscess formation
Bleeding or thrombosis
How can a person prevent further attacks of acute pancreatitis ?
Avoid risk factors such as alcohol and drugs
Advise patients to follow a low fat diet
Treat reversible causes - Hyperlipidaemia or gallstones
What is an intestinal obstruction ?
Blockage of the bowel due to either a mechanical obstruction or failure of peristalsis
What are some causes of intestinal obstruction ?
Adhesions
Malignancy
Hernia
IBD
Diverticulitis
Constipation
Medications
How does intestinal obstruction present ?
Anorexia
Nausea and vomiting
Colicky central abdominal pain + distension
Absolute constipation
What is seen on examination in intestinal obstruction ?
Uncomfortable and restless
Abdominal distension +/- tenderness
Active tinkling sounds or quiet/ silent sounds ( later )
What is the management of intestinal obstruction ?
Admit as a surgical emergency
What is a sigmoid volvulus ?
It occurs in people who have a redundant colon on a long mesentery with a narrow base. The sigmoid loop twists causing intestinal obstruction. This causes the loop to be ischaemic
What are some risk factors for a sigmoid volvulus ?
Constipation
Laxatives
Tranquillisers
How does a sigmoid volvulus present ?
Acute onset of abdominal distension and colicky abdominal pain with complete constipation and absence of flatulence. There may be a history of repeated attacks.
What is the management of a sigmoid volvulus ?
Admit acutely to hospital
Treat by passing a flatus tube and / or surgery
What should be done following treatment of a sigmoid volvulus ?
To decrease recurrence prevent constipation and stop tranquillisers
What is intussusception ?
The invagination of one part of the bowel into the lumen of the immediately adjoining bowel. It is the commonest cause of intestinal obstruction in young children and usually occurs in previously healthy children. Peak age 5-8 months old
How does intussusception present ?
Abdominal colic - paroxysms of pain during which the child draws up their legs - the child usually screams in pain and becomes pale.
Vomiting is an early sign
Rectal bleeding or slime
Sausage shaped mass in the abdomen usually RUQ
What is a risk of not treating intussusception quickly ?
The child becomes rapidly worse and can become toxic. An obstructive picture can occur when the abdomen becomes distended and there is faeculent vomiting.
What are some other differentials for intussusception ?
Gastroenteritis
Constipation
Haemolytic uraemic syndrome
What is an ischaemic bowel ?
Interruption of the blood supply of the bowel.
What is the difference between primary and secondary ischaemic bowel ?
Primary - usually due to wither a mesenteric embolus from the right side of the heart or a venous thrombosis an usually presents in elderly people with pre-existing heart conditions
Secondary. Usually due to an intestinal obstruction
How does ischaemic bowel present ?
Sudden onset of abdominal pain that rapidly becomes severe
There may be a history of pain after meals prior to the event.
What can be seen on examination in ischameic bowel ?
Very unwell
In shock
May be in AF
Generalised tenderness but normally no guarding or rebound
What is the management of ischameic bowel ?
Give opiate analgesia
Admit as a surgical emergency
How does acute diverticulitis present ?
Altered bowel habit
Colicky left sided abdominal pain - may cause guarding
Fever
Malaise +/ nausea
Flatulence
What is the management for acute diverticulitis ?
Treat with oral antibiotics - co-amoxiclav or ciprofloxacin
There may also be some benefit from a low residue diet
What are some complications of acute diverticulitis ?
Diverticular abscess
Haemorrhage
Perforation
Fistula formation
Post-infective stricture
What are some causes of a perforated bowel ?
Peptic ulcers
Diverticula
Tumours
IBD
How does a perforated peptic ulcer present ?
Ill patient in pain
History of sudden onset epigastric pain +/- haematemesis
What is seen on examination in someone with a perforated peptic ulcer ?
Tachycardia
Shallow respiration
Abdominal tenderness with guarding
Absent bowel sounds
How does someone with a more distal bowel perforation present ?
Ill patient in pain
History of sudden onset abdominal pain
what is seen on examination of someone with a distal bowel perforation ?
Toxic - fever, tachycardia, low BP
Abdomen tender with guarding
Absent bowel sounds
What is the management of a perforated bowel ?
In all cases admit as an acute surgical emergency
What are some causes of pyrexia ?
Childhood infections
Consider cancer ( lymphoma and leukaemia )
Sarcoidosis
Drugs - antibiotics
How do childhood urinary tract infections present ?
Infants and toddlers - usually non-specific including vomiting, irritability, fever, abdominal pain and failure to thrive and prolonged jaundice
Older children - dysuria, urinary frequency, abdominal pain, haematuria and enuresis
What to do if you suspect a UTI in a child ?
Send urine for M, C and S in any child with urinary symptoms or any infant with a fever over 38.5 degrees with no definite cause.
what is the management of a UTI in children ?
Treat symptomatic infection without waiting for laboratory confirmation with trimethoprim for 7-10 days
What should be done as a follow up for a UTI in children ?
Start prophylactic antibiotics after the first infection and continue until further investigations are complete. Refer all children to a paediatrician after the first proven UTI.
What is acute suppurative otitis media ?
It is the prescience of infected middle ear fluid and inflammation of the mucosa lining. It is caused by viral or bacterial infection or a bacterial infection complicating a viral illness such as URTI or measles.
How does suppurative otitis media present ?
Ear pain - usually unilateral and often accompanied by fever and systemic upset. There may also be ear discharge associated with relief on pain if there is a spontaneous perforation of the ear drum.
What is seen on examination in acute suppurative otitis media ?
A red bulging drum
If perforated the external canal may be full of pus obscuring the drum.
What is the acute management of acute suppurative otitis media ?
In most people, Symptoms resolve within 3 days without treatment
Advise fluids and paracetamol +/- ibuprofen for analgesia and fever control.
Most GPs prescribe antibiotics on presentation - amoxicillin tds for 5-7 days if a perforation is present.
What are some preventative measures for acute suppurative otitis media ?
Parental smoking increases the child’s risk of otitis media
Encourage parents to stop smoking
What is the most common bacterial cause of a sore throat ?
Group A beta - haemolytic streptococci
How does a sore throat present ?
Pain on swallowing
Fever
Headache
Tonsillar exudates
Nausea and vomiting
Abdominal pain
What are some differentials for a sore throat ?
Glandular fever especially in teenagers with peristaltic sore throat
What is the management of a sore throat ?
90 % of patients recover in less than 1 week without treatment.
Advise analgesia and antipyretics
Increase fluid intake and salt-water gargles
Consider delayed prescription for antibiotics if no improvement in 2-3 days.
What are some complications of a sore throat ? ( all rare )
Quinsy ( peritonsillar abscess ) - unilateral peritonsillar swelling, difficulty swallowing - admit for IV antibiotics + incision and drain
Retropharyngeal abscess ( occurs in children ) - inability to swallow and fever - admit for IV antibiotics + incision and drain
Rheumatic fever
Glomerulonephritis
What is scarlet fever ?
Group A haemolytic streptococci infection with 2-4 day incubation period
How does scarlet fever present ?
Fever
Malaise
Headache
Tonsillitis
Rash-fine punctate erythema sparing face
Scarlet facial flushing
Strawberry tongue
What is the management of scarlet fever ?
Penicillin V for 10 days
What are the complications of scarlet fever ( very rare ) ?
Rheumatic fever
Glomerulonephritis
What is glandular fever ?
It is caused by the Epstein Barr virus and is spread by droplets and direct contact - it has a 4-14 day incubation period.
Consider in teenagers or young adults presenting with a sore throat for longer than 1 week
How does glandular fever present ?
Sore throat
Malaise
Fatigue
Lymphadenopathy
Enlarged spleen
Palatal petechiae
Rash
What is the management of glandular fever ?
Advise rest, fluids and Renault paracetamol
Try salt water gargles
Consider a short term of prednisolone for severe symptoms
Treat secondary infection with antibiotics
What shouldn’t be given for the treatment of glandular fever ?
DONT prescribe amoxicillin as it causes a severe rash
what are some complications of glandular fever ?
Secondary infections
Rash with amoxicillin
Hepatitis
Jaundice
Pneumonitis
Neurological disturbances ( rare )
What is sudden infant death syndrome ?
Babies are found unexpectedly dead in the first year of their life in the UK. Most common in winter and at night. If there is no identifiable cause then it is called cot death.
What are some risk factors for cot death ?
Baby sleeping face down
Smoking ( mother or other family members )
Overheating
Minor inter current illness
Twin or multiple pregnancy
Low birth weight
Social disadvantage
Young mother
Large number of siblings
What to ask when someone if having chest pain ?
Nature and location of the pain
Duration
Other associated symptoms - sweating, nausea, SOB or palpitations
Past medical history
Family history
Smoker ?
What would you assess in an examination when a patient presents with chest pain ?
Check BP in both arms
General appearance - distress, sweating, pallor
JVP and carotid pulse
RR
Apex beat
Heart sounds
Lung fields
Local tenderness
Pain on movement of chest
Skin rashes
Swelling or tenderness in the legs
What investigations should be ordered for chest pain ?
ECG
CXR
What are some features of an MI ?
Sustained central chest pain not relieved by sublingual GTN
Collapse
Breathlessness
Anxiety
Nausea +/- vomiting
Sweating
Radiating pain
What should be assessed for on examination in an MI ?
Pulse
BP
JVP
Heart sounds
Chest for pulmonary oedema
What investigations should be performed if suspecting an MI ?
ECG - ST elevation or ST depression
Troponin levels
What actions should be done if suspecting an MI ?
Immediate transfer to hospital for thrombolysis to be given as soon as possible.
Give aspirin 300mg po
Insert iv cannula and give analgesia, antiemetics
Give sublingual GTN
If bradycardic give atropine 300 micrograms IV and further doses.
what is unstable angina ?
Pain on minimal or no exertion, pain at rest or angina which is rapidly worsening in intensity, frequency or duration
What is the management of unstable angina ?
It is often difficult to tell the difference between unstable angina and an MI in general practice
Treat as an acute MI and admit is attacks are severe, occur at rest or last more than 20 mins even with GTN spray.
What differentials should be thought of when someone presents with chest pain ?
MI
PE
Dissecting aneurysm
Pericarditis
What are some features of an MI ?
Band like chest pain or central pressure / dull ache +/- radiation to shoulders or left arm, neck o jaw.
Often associated with nausea, sweating and or SOB
What are some features of pericarditis ?
Sharp, constant sternal pain relieved by sitting forward. Many radiate to left shoulder +/- arm into the abdomen.
Worse on lying on the left side and on inspiration, swallowing or coughing.
What are some features of a dissecting thoracic aneurysm ?
Typically presents with sudden tearing chest pain radiating to the back.
Consider in any patient with chest pain and decreased BP - especially if pain radiates to the back
What are some features of a PE ?
Acute dyspnoea
Sharp chest pain
Haemoptysis
Syncope
Tachycardia and mild pyrexia
What are some features of pleurisy ?
Sharp localised chest pain worse on inspiration
What are some features of a pneumothorax ?
Sudden onset of pleuritic chest pain or increased breathlessness +/- pallor and tachycardia
What are some features of Costochondritis ?
Inflammation of the Costochondral junctions - tenderness over the costochondral junction and pain in the affected area on springing the chest wall
What are some causes of acute breathlessness ?
Asthma
Anaphylaxis
Acute left ventricular failure
Arrhythmia
PE
Acute exacerbation of COPD
Pneumonia
Pneumothorax
SVC obstruction
What are some features of asthma ?
Breathlessness and wheeze
Past history of asthma
Severe attack :
- inability to complete sentences
- Tachycardia
- Increased RR
- Use of accessory muscles
- Drowsiness or exhaustion
What are some features of anaphylaxis ?
Respiratory distress - wheeze, stridor
Hypotension
Erythema
Angio-oedema
Pruritis
Rhinitis
Nausea and vomiting
Palpitations
Urticaria
What are some signs and symptoms of acute left ventricular failure ?
Sudden acute breathlessness
Fatigue
Cough +/- haemoptysis
Tends to occur at night
Dyspnoea
Tachycardia
Coarse crackles at bases
Ankle/sacral oedema if right heart failure
What are some features of arrhythmias ?
Usually palpitations - chest pain
Collapse
Sweating
Breathlessness
What are some features of a PE ?
Acute dyspnoea
Sharp chest pain
Haemoptysis +/- syncope
Tachycardia
Mild pyrexia
What are some features of acute exacerbation of COPD ?
Worsening of previously stable COPD
Increased dyspnoea, decreased exercise tolerance, increased fatigue, increased fluid retention, increased wheeze and chest tightness, increased cough, increased sputum volume, acute confusion
What are some features of pneumonia ?
Breathlessness
Cough
Fever
Sputum
Localised chest pain worse on inspiration
What are some features of pneumothorax ?
Sudden onset of pleuritic chest pain or increased breathlessness +/- pallor and tachycardia
What is a PE ?
A venous thrombi usually from a DVT in the leg - pass into the pulmonary circulation and block blood flow to the lungs.
What are some risk factors for a PE ?
Immobility
Smoking
COC pill
Pregnancy
Malignancy
Past history of DVT or PE
What immediate management is given for a PE ?
Give oxygen as soon as possible
What further management is given for a PE ?
In all cases of proven PE anti coagulation is started in hospital.
Warfarin should be continued for 6 months
( aim to keep INR between 2-3 )
What are some risk factors for a pneumothorax ?
Previous pneumothorax
Smoking
Ascent in an aeroplane
Diving
What is the management for a pneumothorax ?
Refer to CXR
If confirmed seek specialist advice
Small pneumothoraces resolve spontaneously
Larger pneumothoraces may require admission for aspiration or a chest drain
Smoking cessation to decrease recurrence
What is a tension pneumothorax ?
A valvular mechanism develops - air is sucked into the pleural space during inspiration but cannot be expelled during expiration. This causes the pressure to increase in the pleural space and lung deflates further, the mediastinum shifts to the opposite side of the chest and venous return decreases. This can be fatal.
What are some clinical features of a tension pneumothorax ?
Agitated and distressed patient often with a history of chest trauma
Tachycardia
Sweating
Decreased breath sounds and chest movement
Mediastinal shift - trachea deviated away from the side affected
What action should be taken if you are suspecting a tension pneumothorax ?
Sit the patient upright
Insert a large bore cannula through the 2nd intercostal space of the pneumothorax to relieve the pressure
Transfer as an emergency to hospital
What is bronchiolitis ?
Usually occurs in the winter months
Caused by respiratory syncitial virus infection.
What are some symptoms of bronchiolitis ?
Irritable cough
Rapid breathing
Feeding difficulty
What is seen on examination in someone with bronchiolitis ?
Tachypnoea
Tachycardia
Widespread crepitations over the lung fields +/- high pitched wheeze
What is the management of bronchiolitis ?
Depends on severity of the symptoms
If mild then paracetamol and fluids. Bronchodilators may be given for short term relief.
If more severe admit as a paediatric emergency for oxygen +/- feeding.
Ventilation is rarely required.
How does pneumonia present ?
Cough
New focal chest signs such as coarse crackles
Sweating
Fever
What investigations should be performed for pneumonia ?
Pulse oximetry
CXR
Sputum culture
Bloods - FBC
What are some differentials for pneumonia ?
Pneumonitis
Pulmonary oedema
PE
Acute bronchitis
Exacerbation of COPD
Lung cancer
Bronchiectasis
What is the management for pneumonia ?
At home treatment - advise not to smoke, start antibiotics - amoxicillin
Analgesia
What are some possible reasons why patients may not improve with treatment for pneumonia ?
Elderly
Incorrect diagnosis
Incorrect antibiotics
Non-bacterial cause
TB
Impaired immunity
What is influenza ?
Sporadic respiratory illness during autumn and winter
What are the causes of influenza and how does it spread ?
Influenza virus A,B or C
Droplet infection, person to person contact, to contact with contaminated items
How does influenza present ?
In mild cases symptoms present as a common cold.
In more severe cases fever begins suddenly accompanied by aches and pains
Headache, sore throat, cough
What is the management of influenza ?
Rest, fluids and paracetamol for fever / symptom control
Antivirals if severe - zanamivir
How to prevent influenza ?
Influenza vaccine
Oseltamivir for prophylaxis in high risk patients
What are some features of an acute exacerbation of COPD ?
Increased dyspnoea
Decreased exercise tolerance
Fatigue
Wheeze
Cough
Sore throat
What are some causes of an acute exacerbation of COPD ?
Infection
Pollutants
What are some investigations for acute exacerbation of COPD ?
Pulse oximetry
CXR
Sputum culture
What is the home treatment for an acute exacerbation of COPD ?
Add or increase bronchodilators
Start antibiotics - use broad spectrum antibiotics - erythromycin
Oral corticosteroids
What is the follow up for an acute exacerbation of COPD ?
Reassess if necessary
Check FEV1
Emphasise the potential benefit for lifestyle modification - smoking cessation, exercise, weight loss if obese
What is a febrile convulsion ?
A seizure occurring in a child aged 6 months to 5 years associated with fever arising from infection or inflammation outside the CNS in a child who is neurologically normal.
What are some causes of a febrile convulsion ?
Viral infections
Otitis media
Tonsillitis
UTI
Gastroenteritis
Meningitis
What are the features of a simple febrile convulsion ?
Isolated, generalised, tonic clonic seizures lasting less than 10-15 minutes
What are the features of a complex febrile convulsion ?
Last 15-30 mins
Or are focal
Not followed by full consciousness after 1 hour
What are some differentials of febrile convulsions ?
Epilepsy
Poisoning
Hypoglycaemia
Meningitis
What is a stroke ?
A syndrome typified by rapidly developing signs of focal or global disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than vascular.
What are some risk factors of a stroke ?
Age
High BP
DM
AF
Previous stroke or MI
Smoking
Obesity
How does a stroke present ?
Sudden onset of CNS features such as :
Face droop
Slurred speech
Unable to lift arms
dizziness
Blurry vision
What is the acute management for a stroke ?
Admit all patients who have suffered an acute stroke to hospital
Do not give aspirin prior to admission
What is a TIA ?
Presents with a history of sudden onset focal neurological deficit
Recovery takes place within 24 hours
What are the most common focal symptoms of a TIA ?
Hemiparesis or weakness
Speech and language problems
Sensory symptoms
What are some non-focal symptoms of a TIA ?
Light-headedness
Feeling faint
Blackouts
Confusion
What are the risk factors of a stoke following a TIA ?
Over 60
High BP
Having unilateral weakness or speech disturbance
Having symptoms longer than 10 minutes
What investigations are done for a TIA ?
ECG
CXR
Bloods - FBC, ESR, U&E, creatinine
Consider clotting screen
What is the management of a TIA ?
Once all symptoms have stopped start aspirin 50-300 mg
Start treatment for risk factors
Refer for assessment and further investigation to a specialist service
What is Amaurosis fugax ?
A form of TIA due to an emboli passing through the retina.
Causes brief loss of vision - like a curtain
What is anaphylaxis ?
Severe systemic allergic reaction
What are the common causes of anaphylaxis ?
Foods : nuts, fish and shellfish, sesame seeds and oils, milk, eggs, pulses
Insect stings
Drugs
Latex
What are some essential features of anaphylaxis ?
Wheeze, stridor
Hypotension
What are some other features of anaphylaxis ?
Erythema
Angio-oedema
Itching of the palate
Generalised Pruritus
Nausea
Urticaria
What is examined in a suspected anaphylaxis ?
Airway - mouth/tongue for oedema
Breathing - chest, PEFR
Circulation - pulse, BP
Skin - check for rashes
What action needs to be taken in someone suffering from anaphylaxis ?
If suspected call an ambulance immediately
If patient has an Epi-Pen advise to use it.
Lie patient down and elevate legs
Give IM adrenaline an repeat if no improvement in symptoms
Give anti-histamine 10-20mg IM
