Acute Emergencies & Pre-hospital Care Flashcards
Disucss how the A-E approach differs in primary care compared to in secondary care
In primary care:
- Less equipment/resources
- Staff less well trained (compared to e.g. A&E staff)
- Less support (e.g. in hospital you can put out a 2222 call and crash team will respond)
- May not have all medications you wish to give
- Some situations can be managed within primary care e.g. anphylaxis however a lot of emergencies will require escalation to hospital and GP will use A-E to keep pt stable
State some common medical and surgical emergencies seen in primary care
- Acute abdomen
- Assessment of acutely unwell child
- Chest pain
- SOB
- Unilateral weakness e.g. TIA, Bell’s palsy etc..
- Anaphylaxi
What is meant by the term ‘acute abdomen’?
Sudden onset of abodminal symtpoms presenting in roughly last 24hrs
*NOTE: common misconception that it is a sudden onset of abdo pain. Although abdo pain is the most common symptom, someone can still have an acute abdomen without any abdominal pain
Discuss how someone with an acute abdomen may present (state some examples- very broad variety of presentations)
- Abdo pain
- Shoulder tip pain
- N&V
- Diarrhoea
- Bleeding e.g. malaena or rectal bleeding
- Gyaecological symtoms e.g. bleeding, discharge
- Urinary symptoms e.g. cloudy urine, increased frequency
- Back pain
- Dizziness (hypotension related)
- Fever
- Tachycardia
State some potential causes of an acute abdomen; split your causes into:
- Gastrointestinal
- Urological
- Gynaecological
- Cardiovascular
- Other
*NOTE: lists are note exhaustive
Gastrointestinal:
- Appendicitis
- Pancreatitis
- Diverticulitis
- Bowel obstruction
- Mesenteric ischaemia
- Perforated bowel- peritonitis
- Strangulated hernia
- Volvulus, intussception…
- Gallbladder pathology e.g. biliary colic, acute cholecystitis, ascending cholangitis
- IBD flare
Urological
- UTI
- Pyelonephritis
Gynaecological
- Ectopic pregnancy
- Ovarian torsion
- Ovarian cyst bleed/rupture
Cardiovascular
- Aortic dissection
- Sickle cell crisis
- MI
Other
- Musuclar
- Spinal arthritis
- Ruptured spleen
- Testicular torsion
- DKA
The site of abdominal pain can help you to form differential diagnoses; for each of the 9 areas of the abdomen state what organs could cause pain in that area
State some questions you should ask someone presenting with an acute abdomen
- SQITARS/SOCRATES pain questions
- Nausea or vomitting
- Loss of appetite
- Diarrhoea
- Last open bowels/bowel habits
- Last passed urine
- Fever
- Chance of pregnancy
- Other menstrual symptoms
State some questions you should ask a woman presenting acute abdominal pain
- History of STIs
- History of PID
- Last menstrual period
- Chance of pregnancy
- History of ectopics
- Contraception e.g. IUD
- Any vaginal bleeding
For a ruptured spleen, discuss:
- Risk factors
- How it may present
- Management in primary care setting
Risk factors:
- History of abdo trauma (can occur days or weeks later)
- Diseased spleen e.g. glandular fever, malaria, leukaemia
Presentation:
- Abdo pain (left hypochondriac area)
- Tachycardia, hypotension, pallor, confusion (due to blood loss)
- Signs & symptoms of peritonitis: guarding, shoulder tip pain, rebound tenderness
Managment:
- Bluel-light to hospital for surgical emergency
For acute pancreatitis, discuss:
- Risk factors
- Symptoms
- Signs/examination findings
- Management in primary care setting
Risk Factors
- Alcohol
- Gallstones
- Recent surgery near pancreas
- Autoimmune conditions e.g. SLE
Symptoms
- Abdo pain: radiates to back, poorly localised, continuous, often worse lying down
- Nausea & vomitting
Signs
- Tachycardia
- Fever
- Jandice
- Epigastric tenderness or generalised tenderness
- Abdo distention
- Periumbilical & flank bruising= rare
Management in Primary Care
- Admit as acute surgial emergency
Delayed complications of pancreatitis may present in general practice; state some complications of acute pancreatitis that
Suspect complications if there is persistent pain or failure to regain appetite or weight. Complications include:
- Pancreatic necrosis
- Pseudocyst (localised collection of pancreatic secretions)
- Fistula/abscess formation
- Bleeding/thrombosis
Discuss how you can prevent further attacks of pancreatitis
- Avoid causative factors e.g. alcohol, drugs
- Low fat diet
- Treat reversible causes e.g. gallstones, hyperlipidaemia
How would you manage the following in primary care: intestinal obstruction, sigmoid volvulus, intussception, stragulated hernia, ischaemic bowel, abdominal perforation?
Admit as surgical emergency
State some common causes of abdominal perforation
- Peptic ulcers
- Diverticula
- Tumours
- IBD
Explain why signs & symptoms of perforated posterior gastric ulcer may present more insidiously
Can perforate into the lesser sac and the chemical peritonitis can be contained in the lesser sac resulting in signs & symptoms being more insidious
Patients with IBD may present to GP with acute exacerbations of IBD; discuss when you would admit an IBD pt, who is experiencing a flare, to hospital
Admit if:
- Severe abdo pai (especially if associated with tenderness)
- Severe diarrhoea (>8x day)
- Dramatic weight loss
- Fever
- Bowel signs
- Other signs of systemic disease e.g. tachycardia
For acute appendicitis, discuss:
- Peak age
- Presentation
- Examination findings
- Management iin primary care
- Peak age: 10-30yrs
Presentation
- Central abdo colic which then progresses and localises to RIF
- Worse on movement (especially coughing, laughing)
- Anorexia
- Dysuria
- N&V
Examination Findings
- Walk stooped due to discomfort
- Pyrexia
- Tenderness and guarding in RIF- particularly over McBurney’s point
- Pain in RIF on palpation of LIF (Rovsing’s sign)
- Furred tongue and/or foetor oris
Management in Primary Care
- Admit as surgical emergency if you suspect acute appendicitis (expect to be wrong ~1/2 time)
When would you admit a pt with diarrhoea & vomitting to hospital?
If dehydrated and unable to replace fluids
For acute diverticulitis, discuss:
- Presentation
- Management in primary care
- When you would consider admitting as surgical emergency
Presentation
- Colicky abdo pain- may becomem continous- usually left sided
- Altered bowel habit
- Fever
- Nausea
- Malaise
- Flatulence
Management in primary care
- Oral antibiotics e.g. co-amoxiclav
Admit as surgical emergency if:
- Suspicion of acute complications e.g. peritonitis, abscess, haemorrhage, post-infective stricture
- Uncertain of diagnosis
- Inadequete social support
- Severe or persistent symptoms depsite analgesia
Discuss the management of renal colic in priamry care
- Stones usually pass spontaenously hence give pain relief (NSAIDs are reccommended as first line e.g. dicofenac) and increase fluid intake to >3L /24hr (but not too much & avoid milk)
- Sieve urine to catch stones
- Monitor/review
If pts not admitted to hospital, the following investigations should be done (can wait until next working day):
- Urine dip
- Urine M,C&S
- KUB x-ray
- Blood tests e.g. U&Es
- Send recovered stones for analysis
- Refer to dietician for dietary advice dependent on stone composition
Signs & symptoms of acute appendicitis can be atypical in elderly, young or pregnant; discuss your management if unsure of diagnosis
- If pt unwell, admit to hospital
- If pt well, arrange to review a few hours later or ask them to contact you if any deterioration or change
For biliary colic, discuss:
- Presentation
- Examination findings
- Acute management in primary care
- When to admit to hospital
Presentation
- Upper abdo pain which becomes localised to RUQ, may radiate to back, shoulder tip or interscapula region. Last anywhere between 15 mins- 24hrs
- Post prandial association
- +/- jaundice
- +/- nausea & vomitting
Examination
- Tenderness & guarding in RUQ
- Murphy’s sign positive
Management in primary care
- Analgesia e.g. NSAID or paracetamol, NSAID IM if severe pain
- Antiemetic
- Follow up investigation for gallstones with abdo USS
When to admit to hospital
- Suspicion of complications e.g. gallstones ileus, pancreatitis
- Concomitant medical problems e.g. dehydration, pregnant
- Uncertain diagnosis
- Inadequete social support
For acute cholecystitis, discuss:
- Presentation
- Examination
- Acute management in primary care
- When to admit as surgical emergency
Presentation
- Pain in epigastrium, worse after fatty meal, later localise to RUQ, fever
Examination
- Tenderness & guarding in RUQ
- Murphy’s sign positive
- Fever
- +/-jaundice
Acute management in primary care
- Broad spectrum antibiotic e.g. ciprofloxacin
- Analgesia (NSAID or paracetamol or IM NSAID if severe)
- Antiemetic
- Follow up investigation for gallstones with abdo ultrasound
Admit as surgical emergency if:
- Signs of sepsis
- Generalised peritonism
- Concomitant problems e.g. pregnancy
- Not responding to treatment
If you are transferring a pt to hospital for acute abdo they should be NBM; true or false?
True
Haemolytic uraemic syndrome is the commonest cause of acute renal failure in children, discuss:
- Characteristic features
- Presentation
- Management
Characteristic features
- ARF
- Anaemia
- Thrombocytopenia
Presentation
- Usually follows bout of gastroenteritis (due to E-coli toxin)
- Dehydration, oliguria or polyuria, proteinuria, haematuria, bloody diarrhoea, fever, irritability, drowsiness, seizures
Management
- Admit as paediatric emergency
Discus how you can distinguish between a stroke/TIA and Bell’s palsy as a cause of unilateral facial weakness
When should you refer someone with Bell’s palsy immediately to secondary care?
State some potential diagnoses that may present with the following signs and suggest the emergency treatment:
- Bubbling sound
- Harsh stridor & a barking cough
- Soft stridor, drooling and fever in a sick looking child
- Sudden onset stridor with history of inhalation
- Stridor following ingestion or injection of a known allergen
- Wheeze
- Bronchial breathing
Describe the traffic light system for identifying risk of serious illness in a child
