Acute Emergencies + Pre-hospital Care Flashcards
Explain the A in ABCDE
Airway:
Can they talk?
Obstruction-> vital organ damage and death. Signs include;
See-saw respirations, use of accessory muscles.
Central cyanosis
Complete- No breath sounds
Partial- Noisy and diminished air entry
Treat: Airway opening maneoverues, intubation, airway adjunct
Target: 94-98% or 88-92% if hypercapnia risk
Explain the B in ABCDE
Signs: Sweating, Central cyanosis, use of accessory muscles
Assess resp rythm, symmetry and rate (12-20 is normal)
Sats, breath sounds, percussion, auscultation
If needed provide O2 ventilation
Explain the C in ABCDE
Circulation:
Initial suspect should be Hypovolaemia
Look for: Pallor, Cyanosis, Distended neck veins
Feel for: Limb temp, pulse rate and rythm
Assess capillary refill time and BP
Give fluids if needed
Explain the D in ABCDE
Disability:
Assess consciousness AVPU and GCS
Look for pupil size and reaction to light
Fingerpick glucose (If under 4 mM give glucose)
Explain the E in ABCDE
Exposure:
Respect dignity and keep patient warm
Look for rash/ injuries
Assess surroundings
What is the Acute Abdomen? (Consider T Torsion and Ectopic)
“Rapid onset of severe symptoms that can indicate life threatening pathology”
USUALLY painful, but more likely to be pain-free in children & elderly
Pain may radiate, referred or migrate.
Outline the initial assessment of Acute Abdomen
- Do they look ill/ septic/ shocked?
- Lying still or moving around in pain?
- Asses and manage ABC
What do you ask in the history of Acute Abdomen
Pain features, Associated symptoms, PMx + Dx, Obs&Gyn history
Outline the Examination of an Acute Abdomen
- Look at patient, Vitals, Resp rate & pattern (Peritonitis-> shallow, rapid), AVPU/ GCS
- Inspection: Look for Jaundice, Anaemia, Abdominal distension, Visible peristalsis, Bruising around Umbilicus or Flanks (Cullen’s or Grey Turner’s), Signs of dehydration (dry mucous membranes, skin turgor)
- Auscultation: All quadrants, blood vessel sounds, bowel sounds
- Percussion: All quadrants, Liver & Spleen, Shifting dullness
- Palpation: All quadrants, Rebound tenderness, Liver & Spleen, Lymph nodes
How do you treat Acute Abdomen if there are signs of shock/ being acutely unwell?
Compare in hospital and in primary care
Primary: Transfer to hospital for further assesment and treatment
In Hospital: Investigations, Keep Nil-By-Mouth and treat symptoms (Fluids, O2, NG Tube, Antibiotics if needed
What investigations can be done for Acute Abdomen
Laparoscopy can be used in Diagnosis and Management
Investigations: USS, Urine dipstick, FBC (and perhaps blood cultures), LFTs, U&Es, Radiology
Outline the us of Analgesia and Anti-emetics in treating Acute Abdomen
- Previously, no pain relief was given until surgical review. One study and a Cochrane review showed that Morphine provides safe analgesia without compromising diagnostic accuracy
- Avoid using this to treat symptoms without considering a diagnosis
Outline the history taking of Chest Pain
Consider psychological cause- Anxiety, Depression
- If not in pain now, when was last episode (last 12 hours)?
- Nature, onset, duration, site, radiation. Exacerbating and relieving factors.
- Associated symptoms (Sweat, Pallor, N+V, SoB, Fatigue, Palpitations)
- PMx (Conditions, Scans, ECGs) and PDx
Cardia Ischaemia: Restrosternal/ Epigastric, Tight+crushing, Radiate-> Arm, Neck, Jaw, Shoulder
Outline Examination of Chest Pain
Many patients will be fully normal
- Full CVS, Auscultate for murmurs, Chest wall examination (tenderness, pain on movement)
- Abdomen (tender), Neck (tender and stiff), Legs (tender or swollen), Temp (infection
List Investigation for Chest Pain
If in Primary, don’t delay management to arrange for investigations
- ECG, Troponin testing, CXR
- FBC, Blood glucose, Lipid profiles (To asses CVD risk)
- Thyroid function tests, LFTs
- CTPA if PE is suspected
What criteria are needed to admit to hospital if presenting with chest pain?
• RR>30, HR>130, Systolic< 90, Diastolic< 60, O2< 92% or Central Cyanosis, Altered consciousness, High temp (especially> 38.5).
Suspected ACS with;
• Current chest pain, Signs of complications, Chest pain in last 12 hours + ECG abnormal or N/A
Outline Chest Pain referral if admission not required
- Urgent same-day Assesment: Suspected ACS + Pain-free, with chest pain in last 12 hours + Normal ECG + No complications (Alternatively, pain in last 12-72 hours + no complications)
- Within 2 weeks: Suspected ACS + Pain-free, with pain more than 72 hours ago + no complications
- Routinely: Suspected SA, non-specific chest pain, persistent symptoms despite management
Outline chest pain management in Primary care
- Arrange for hospital admission-> Sit patient up, Give O2 if needed
- If Suspected ACS: Aspirin, GTN/ Opioid (Fentanyl).
- If Suspected Acute Pulmonary Oedema: Diuretic, Opioid, Anti-emetic, Nitrate
- If Suspected Tension Pneumothorax: Large bore cannula in 2nd ICS at the Mid-Clavicular line
- Monitor Symptoms, Pulse/ BP/ Heart Rythm, SpO2, ECG, Pain relief
Why can chest pain come with cough?
Other than pulmonary cause
Small Intercostal Muscles get sore-> Bone pain
Normal RR ranges for ages;
<1:
1-2:
2-5:
5-12:
> 12:
<1: 30-40
1-2: 25-35
2-5: 25-30
5-12: 15-25
> 12: 12-20
Outline the 3 steps in the structured approach of assessing an acutely unwell child
- Primary ABCDE assessment and resuscitation
- Secondary assessment and emergency treatment
- Stabilisation and transfer
Outline Primary ABCDE assessment and resuscitation of an acutely unwell child
(Normal ABCDE)
Breathing;
- Effort: Resp rate, Grunting, Nostril flaring, Accessory muscle use
- Efficacy: Chest expansion, SpO2, Auscultation for air/ breathing sounds
- Effect: Hypoxia-> Tachycardia-> Bradycardia, Cyanosis, Agitation/ drowsiness
Provide high flow O2 (15L/min
Outline Secondary assessment and emergency treatment of an acutely unwell child
Reassess ABCDE, History, Examinations, Investigations
- Ask about Fever onset, duration, pattern and method of measurement.
- Associated symptoms? Perinatal complications? PMx and PDx, Recent travel? Vaccinations?
Use NICE ‘traffic light system” to assesses risk of serious illness;
- Life-threatening Red features: Arrange emergency ambulance to A&E
- Non-life threatening Red features: Arrange urgent F2F assessment within 2 hours
- Amber features: Arrange F2F assessment
- Green features: Child can be managed at home
Outline Stabilisation and Transfer of an acutely unwell child
Monitor SpO2, HR&R, BP, Urine output, Core temp
Outline the 3 classes of Dyspnea
Acute- Over mins
Subacute- Over hrs/days
Chronic- Over wks/mths
Outline history taking of a pt with SoB
- Pack years, Duration+ Severity of SoB, PMx + PDx + Family history
- Associated symptoms (Sputum, Breath sounds, Haemoptysis, Palpitations, DVT signs, Anxiety, Weight loss, Fatigue
Outline examination of a pt with SoB
• Resp and CVS exams, BP, SpO2, BMI, PEFR, Leg oedema, Heart sounds
What investigations for a pt presenting with SoB
• Sats, FBC, ECG, ABG, V/Q , D-Dimer, Spirometry, U&Es, Radiology (High-res CT, CXR, CTPA
How can unstable pts with SoB present?
Abnormal vitals, altered mental status, hypoxia, unstable Arrythmia
Breathing sounds, Effort without air movement, Tracheal deviation, Cyanosis, Low SpO2
Criteria for Emergency admission in a pt with SoB?
- ECG suggesting Cardiac Arrythmia/ MI
- Rapid onset of/ worsening symptoms of suspected Heart Failure
- Suspected PE, PT, Sepsis or Severe/ Life-threatening Asthma
- CURB65 score>0
Outline the Initial Management of a pt with SoB if Admission is needed
- ABCDE assessment, BP, Pulse, RR, Temp, SpO2, PEFR, ECG, Level of consciousness
- Give O2, Consider intubation, Give IV fluids, Treat any other symptoms
- If needed administer Diuretic, Nebulised Bronchodialtor or Perform needle thoracentesis in Tension PThorax
Outline History taking of a pt with Unilateral Weakness
- Neurological deficits, Associated symptoms, Risk Factors (CVD, DM, Hyperlipidiaemia, Smoking, Pregnancy, Trauma, Alcohol, PMx PDx and Fx- Family History)
- Time of Onset, Activity at onset, Symptom progression
- Features that may indicate alternate diagnosis (Migraine, GCA, Seizure
Outline Examination of a pt with Unilateral Weakness
- ABC, Vitals (BP, HR, Sats, Temp)
- Fundoscopy (Identify intraocular haemorrhage)
- CVS exam (HF, Arrythmia, Murmurs, Valvular pathology)
- Neuro exam (Unilateral weakness, Visual/speech disturbance, Sensory loss, Ataxia, Nystagmus)
- FAST test: Facial weakness, Arm weakness, Speech difficulty (Slurring/ naming objects
What investigations in a pt with Unilateral Weakness?
• Blood glucose to rule out Hypoglycaemia, ECG to rule out Arrhythmia
Outline Primary Care Management for Suspected Acute Stroke/ Emergent TIA
- Emergency admission to stroke unit (Include ToO, Symptom progression, Medications)
- Avoid antiplatelet treatment until haemorrhagic cause has been ruled out
- Monitor ABC, Vitals and Symptoms. Give O2 if <95% and safe
Outline Primary Care Management for Suspected TIA
300mg Aspirin unless contraindicated, regularly taken, coagulopathy or on an anticoagulant.
Arrange assessment by stroke specialist if a TIA occurred within last week
Advise not to drive until definitive guidance received from specialist
Outline Primary Care Management if TIA occured >1wk ago
- Refer for specialist assessment ASAP within 7 days
* Assess for AFib/ other arrhythmias
When to follow up a pt with Unilateral Weakness?
6mths and Annually after treatment
Outline Hospital Management of a pt with Unilateral Weakness
- If not Haemorrhagic, Thrombolysis (with Alteplase/tPA if within 4.5hrs of symptom onset)
- Thrombectomy ASAP within 6hrs of symptom onset (with TLysis if safe)
Outline Bell’s Palsy Management
If presenting within 72 hours of symptom onset, Prednisolone;
- 50mg daily for 10 days
- 60mg daily for 5 days followed by a daily 10mg reduction in dose
List signs of Anaphylaxis
- Sudden onset, rapid progression of symptoms
- Airway and/or Breathing and/or Circulation problems
- ACCOMPANYING Skin and/or mucosal changes (Flushing, Urticaria, Angioedema)
- ACCOMPANYING GI Symptoms
- Can have general symptoms (Palpitatons, TachyC, N+V, Ab Pain
Outline Anaphylaxis Management
IM Adrenaline in Anterolateral aspect of middle 1/3 of thigh;
- Adult dose: 500 micrograms
- Child >12 dose: 500 micrograms (300 if small or pre-pubertal)
- Child 6-12 dose: 300 micrograms
- Child <6: micrograms
- Repreat IM Adrenaline after 5 mins if no improvement
