Acute emergencies and pre-hospital care Flashcards
define acute abdomen
rapid onset of severe symptoms that may indicate life threatening intra abdominal pathology
what are the ddx for acute abdomen?
acute cholecystitis
acute appendicitis
meckel’s diverticulum
acute pancreatitis
ectopic pregnancy
diverticulitis
peptic ulcer
pelvic inflammatory disease
intestinal obstruction
gastroenteritis
acute intestinal infarction/ischaemia
Gi hameorhhage
UTI stones
acute urinary retention
abdominal aortic aneurysm
testicular torsion
MI
cholecystitis
cholangitis
PE
hernia obstruction/strangilation
haemorrage from solid organs - spleen
renal colic
mittelschmerz
ovarian cyst accident
pericarditis
penumonia
sickel cell crisis
hepatitis
IBD
opiate withdrawal
typhoid
HIv associated lymphadenopathy
how should a pt with acute abdomen be assessed?
initial impression - pt looks ill? lying still/peritonitic, rolling around (intestinal, biliary or renal colic)
assess ABC
hx - SQUITARS (worse by moving - peritonitis,relieved by sitting forward - pancreatitis)
associated sx - vomit, haematemesis, new lumps, E+D, bowel, fainting/dizzy/palpitations, fever, rash, urinary sx, weight loss
PMHx and surgical Hx
Gynacological - contraception, LMP, STI/PID, previous ectopic preg, vaginal bleeding
abdominal examination +/- DRE or pelvic/external genitalia
dipstick urine+/- culture, pregnancy test
any other appropriate examinations
how should a pt with acute abdomen be managed prehospital admission?
NBM
oxygen
IV fluids
send blood for group and crossmatch and other investigations
NG if vomit
analgesia?
anti emetic
abx if septic/peironitis/severe UTI - if peritonitis IV cephalosporin plus metronidazole
urgent surgical/gynae review
arrange investigations - ECG
what investigations can be arrnage din primary care for acute abdomen?
bloods - FBC, UE, LFT, amylase, glucose, clotting, calcium, ABG
group and crossmatch
blood culture
preg test
urinalysis
abdo x ray, CXR, IV pyelogram, CT, USS
ECG and cardiac enzymes
which pathologies occur at a sudden onset in acute abdomen?
vascular - dissection, bleeding or infarction
which pathologies migrate in acute abdomen?
periumbilical to RIF = appendicitis
intra abdominal conditions involving overlying peritoneum
which pathologies present as colicky?
obstruction of billiary tree - gall stones
which pathologies commonly radiate to the back?
pancreas or abdominal aorta
what is important to ask in the hx of a pt experiencing possible ACS?
history of pain - SQUITARS
CVS risk factors - HTN, smoking, hyperlipidaemia, DM, obesity
history of ischaemic heart disease
previous tx and investigations for chest pain
what sx indicate ACS?
pain in chest and/or arms, back, jaw lasting >15 mins
chest pain + N+V, marked sweating, breathlessness, haemodynamic instability, fatigue, palpitations, SOB
new onset chest pain or abrupt deterioration in stable angina, recurrent pain with little of no exertion + lasting >15 mins
why should you be cautious in assessing pts using GTN?
response to GTN should not be used to make a diagnosis
what advice is given to pts with pre existing angina be advised when an attack of angina occurs?
stop and rest
use GTN spray or tablets
second dose after 5 mmins
and third after another 5 mins
then call for ambulance if pain not easied or intensifyinh
what advice is given to pts with pre existing angina be advised when an attack of angina occurs?
stop and rest
use GTN spray or tablets
second dose after 5 mmins
and third after another 5 mins
then call for ambulance if pain not eased or intensifying
how can chest pain differ in terms of ddx?
cardiac ischaemia - retrosternal or epigastric, tight and crushing, radiates
aortic dissection - tearing
pericarditis and PE - pleuritic pain so worse on inspiration
reflux - burning
stable angina - if CP associated with effort, emotion, food or cold weather, sx relieved by rest/GTN and risk fx present
what are the atypical presentations of ACS and which groups of people do these occur in?
women, older men, DM, ethnic minorities
- abdo discomfort, jaw pain, altered mental state in elderly
what can aortic stenosis present with?
angina
what examination findings suggest cardiac v non cardiac CP?
cardiac - could have normal examination so can not exclude
non cardiac - tenderness of chest wall- MSK, epigastric tenderness - Peptic ulcer, focal lung signs - pneumonia
what are the ddx for chest pain?
Angina, ACS (in: MI)
acute pericarditis
pneumonia, PE, pneumothorax
GORD, oesophageal spasm
Peptic ulcer disease
gallstones, cholecystitis
acute pancreatitis
chest wall pain - tietze’s syndrome, trauma, shingles, rib secondaries, osteoporosis
aortic dissection
anxiety
depression
which condition results in immediate transfer to hospital?
suspected MI
which investigations should be considered in CP?
CXR = pneumonoa, aortic aneurysms, rib fractures
abdo USS = gallstones
serum amylase = acute pancreatitis
bloods - FBC, UE, cardiac enzymes, LFT, fasting lipids, fasting glucose
resting ECG
exercise tolerance test - diagnose or excluse stable angina
other: ehco, coronary angiography, V/Q scan, pulmonary angipgraphy, CT aortiography, OGD
how are patients with suspected coronary artery disease investigated?
- pre test probability of coronary artery disease - age, sex, risk fx, symptoms…https://qxmd.com/calculate/calculator_287/pre-test-probability-of-cad-cad-consortium
- if 10-29% - coronary artery calcium scoring using CT AND THEN CT coronary angiography if calcium 1-400
if 30-60% - functional cardiac imaging
if sx + 61-90% risk - invasive coronary angiography
if a pt with CP does not require hospital admission where can they be referred?
CP clinics
when can troponin testing be used?
pts who have been symptoms free between 24 hrs and 14 days previously and who have no high risk fx (ongoing or recurrent pain, syncope, HF, abnormal ECG)….but caution in primary care as high risk of adverse outcomes…defo in rural setting
what is the tx of choice for suspected ACS in primary care?
oxygen if <93%
GTN
IV fentanyl
..DOAC?
what is the tx of choice for suspected ACS in primary care?
oxygen if <93%
GTN
IV fentanyl
..DOAC?
name 3 cardiac and 3 non cardiac causes of raised serum troponin level
acute MI, acute or chronic HF, coronary artery spasm (due to methamphetamine use)
cardiotoxic agents (anthracyclines, CO), aortic dissection, severe hypo or hypertension, severe PE, dialysis, severe burns, sepsis, prolonged exercise
what should be ruled out in CP?
malignancy - lung
which clinical fx suggest a serious cause and admission to hospital for CP?
RR >30
HR >130
BP <90 SY <60 DI
O2 >92%
altered level of consciousness
temp
current chest pain
signs of complications - pulmonary oedema
abnormal ECG
how long and what is involved in the primary ABCDE assesment of a child?
<1 min
A+B= effort of breathing, RR, rhythm, stridor/wheeze, auscultation, skin colour
C - HR, pulse vol, CRT, skin temp
D - conscious level, posture, pupils
E- fever, rash, bruising
how is an airway assessment performed in a child?
look, listen and feel for airway patency
if unconscious - head tilt chin lift….neutral in infant and sniffing position in child
how is a breathing assessment performed in a child?
assess effort
RR - raised in airway/lung pathology or by metabolic acidosis ie DKA
<1 = 30-40
1-2 yrs= 25-30
2-5 = 25-30
5-12 = 15-25
>12 = 12-20
how is a breathing assessment performed in a child?
assess effort
RR - raised in airway/lung pathology or by metabolic acidosis ie DKA
<1 = 30-40
1-2 yrs= 25-30
2-5 = 25-30
5-12 = 15-25
>12 = 12-20
signs of resp distress - grunt, flaring of nostrils, accessory muscle us
gasp - late sign of severe hypoxia
may be no signs of resp effort but severely hypoxic in - life threatening asthma, neuromuscular disease, central resp depression
hypoxia - inititally tachycardia but if prolonged bradycardia
…give 15L high flow oxygen with oxygen mask with reservoir bag
if choking - encourage coughing, then 5 back blows + 5 thursts in abdomen
how is a circulation assessment performed on a child?
HR, pulse vol, CRT, BP, urine output, mottled skin, cool peripheries, altered mental state
hypotension will be late sign
20ml/kg bolus of 0.9% saline, in dka - 10mls/kg…may need intraosseous access
how is disability assessment performed on a child?
AVPU or GCS
floppy, stiff posturing (decorticate: flexed arms, extending legs, decerebrate: extended arms and legs) - brain dysfunction
pupil size and reflex
BM
consider intubation if P or \u
treat hypoglycaemia with 2ml/kg 10% glucose IV or IO + glucose infusion
if raised ICP - IV manntol
what clinical findings in A+B may indicate certain diagnoses?
bubbling - excessive secretion so suction
harsh stridor - croup so oral dexamethasone, neb budesnode and adrenaline
soft stridor, drooling and fever - bacterial tracheitis or epiglottitis - intubation +IV abx
sudden onset stridor and hx of inhalation - laryngoscopy for removal of foreign object
^ + known allergen - anaphylaxis so IM adrenaline
wheeze - acute ashtma - salbutamol
bronchial breathing - pneumonia so IV abx
how can closure of the ductus arteriosis present?
poor feeding, sleepiness, fast breathing, collapsed baby
give IV dinoprostone and then cardiology referral
what is the most common arrthymia in children?
SVT - palpitations, CP, dizziness
try vagal manoeuvres + rapid bolus of IV sdenosine or synchronised DC shock
how are seizures in children managed?
if seizure >20 mins or shorter with incomplete recovery = status epilepticus
supportive measures
how do children with sepsis present?
inexplicably unwell or not improve
hypothermia may occur, may not have fever
requires urine, blood and CSF cultures before abx unless unstable`
what temperature is considered high in children?
38 and above, listen to parents
what is important to ask in a hx of feverish child?
onset, duration, pattern and method of temp measurement
any associated sx - underlying cause
any perinatal complications - maternal fever or premature delivery
any medical condiitions - immunsupression
recent antipyrexic drug and/or abx
immunization hx
recent foreign travel
recent contact with infectious disease
parent beliefs about fever/family experience suggesting increased parental anxiety
how is an infant or child assessed with fever?
traffic light system - general appearance, temp, HR, RR, CRT, fluid status
red - ie sepsis - ambulance
amber - urgent face to face assessment
green - managed at home…assess for underlying cause, paracetamol, safety netting
how can breathlessness be classified?
acute (mins), subacute (hrs or days), chronic (weeks or mths)
what are the common cardiac causes of breathlessness?
silent MI
cardiac arrhythmias
acute pulmonary oedema
chronic HF
what are the common pulmonary causes of breathlessness?
asthma
COPD
pneumonia
PE
lung cancer
pleural effusion
what are the other common causes of breathlessness?
anaemia
diaphgramatic splinting (ascites, obesity or pregnancy)
psychogenic breathlessness
how should emergency or non emergency pt be managed?
emergency - ABC assessment
if not require emergency admission - CVS, resp, neurological examinations
when should emergency admission be arranged for a pt with breathlessness?
rapid onset or worsening sx of suspected HF
anaphylaxis
suspected sepsis
ECG suggesting cardiac arrhythmias or MI
clinical fx of PE or pneumothorax, pulmonary oedema, SVC obstruction or cardiac tamponade
severe or life threatening asthma or COPD
….<94% -> oxygen if not hypercapnic risk + underlying cause
how do you recognise the sx of stroke and TIA?
use tools such as FAST (face, arms, speech test)
exclude hypoglycaemia
how do you managed a pt with suspected TIA?
300mg aspirin daily immediately
refer immediately for specialist assessment within 24hrs of onset of sx
define stroke
clinical syndrome of presumed vascular origin characterised by rapidly developing signs of focal or global disturbance of cerebral functions which lasts longer than 24 hrs or leads to death
define TIA
transient (less than 24 hrs) neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without evidence of acute infarction
what are the two types of stroke?
85% are ischaemic, 15% are haemorrhagic
once had one…increased risk of further vascular event
what are some complications of stroke?
neurological problems, depression, anxiety, communication difficulties, difficulties with ADL’s
what are the clinical fx of stroke/TIA?
numbness, weakness, slurred speech, visual disturbance
when should TIA be suspected?
sudden onset, focal neurological deficit which has completely resolved within 24 hrs of onset
wehn should stroke be suspected?
sudden onset, focalneurological deficiti which is ongoing or has persisted for longer than 24 hrs
how is a suspected acute stroke or emegency TIA managed in primary care?
immediate emergency admission to stroke unit
adequate advanced information to ambulance control
avoidance of antiplatelet tx until haemorrhagic stroke has been excluded
when and why should there be follow up post stroke?
on discharge, 6 mnths and annually
- assess need for specialist review
- assess social and healthcare needs of pt and family
- optimise lifestyle measures and drug tx for secondary prevention
how is suspected TIA managed in primary care?
aspirin 300mg
referral to specialist within 24 hrs if occured within last week and within 7 days if cocured more than 1 wk previously
advise pt not to drive until guidance is given
follow up arranged to optimise secondary prevention
define bells palsy
unilateral facial nerve weakness or paralysis of rapid onset (less than 72 hrs) and unknown cause
most common between 15 and 45 yrs
what are the complications of bell’s palsy?
eye injury, facial pain, dry mouth, intolerance to loud noises, abnormal facial muscle contraction during voluntary muscles, psychological sequelae
what are teh sx of bell’s palsy?
rapid onset (<72 hrs)
facial muscle weakness - usually unilateral affecting upper and lower parts of face, reduction in movement and drooping of eyebrow and corner of mouth and loss of nasolabial fold
ear and postauricular region pain
difficulty chewing, dry mouth and changes in taste
incomplete eye closure, dry eye, eye pain, excessive tearing
numbness, tingling of cheek and/or mouth
speech articulations problems, drooling
hyperacusis
how is bell’s palsy managed?
eye lubricating drops during day and ointment at night
eye taped closed at bedtime using tape if can not close eye
if present within 72 hrs of onset - prednisolone
antiviral tx + corticosteroid - specialist advice
when is urgent referral of bell’s palsy required?
worsening of existing neurologic findings or new
fx of UMN signs
fx suggesting cancer
systemic or severe local infection
trauma
when should referral to a focial nerve specialist occur?
if doubt about diagnosis
or
no improvement after 3 weeks of tx, incomplete recovery 5 mths after, any atypical fx
where else may a pt with bell’spalsy need to be referred to?
opthalmologist
support/counselling
define anaphylaxis
when an allergen reacts with specific IgE antibodies on mast cells and basophils (type 1) triggering the release of histamine…capillary leakage, mucosal oedema and shock
what are some triggers of anaphylaxis?
foods - peanuts, pulses, fishes, eggs, milk
venom
drugs - abx, opiods, nsaids, IV contrast media, muscle relaxants
how does anaphylaxis present?
hx of sensitivity to allargen, recent exposure - ie to vaccine
skin - itching, urticaria, erythema,rhinitis, conjuncitivits and angio odema
airway involved - itching of palate or external auditary meatus, dyspnoea, stridor, wheezing
palpitations, tachycardia
N+V, abdo pain, faint, impending doom, collapse
what are some ddx of anphylaxis?
life threatening asthma
hypotension
vasovagal episode
panic attack
breath hold episode in child
idiopathic urticaria or angio oedema
how is anaphylaxis assessed?
A to E - including remove allergen, treat bromchospasm
give high flow oxygen with oxygen resevoir (>10L) so 94-98%
lay pt flat with raised legs
adrenaline IM in anterolateral aspect of middle third of thigh 0.5 mg, if child 6-12 = 0.3mg and <6 - 0.15mg
give 500 ml of warmed hartmanns or saline in 5-10 mins if normotesnive or 1L if hypotensive but smaller if HF
chlorphenamine 10mg IM or IV slowly
hydrocortisone - 200mg IM or IV slowly
may require broncodilator, ipratropium, IV aminophylline or MGSO4
reassess BP regularly
serum mast cell tryptase measured if ambiguity
how is anphylaxis managed?
review and inform pt and family and full hx
refer to allergist or allergy clinic
organise self use of pre loaded pen injections
self amangement plan
wear medical emergency identification bracelet
