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
If you suspect AKI, what would be your management?
Refer to acute medical team
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
What is renal colic?
- Pain due to urolithiasis
- Severe pain that is always present but has waves of intensity
- Usually starts in flank the moves roudn to abdomen then to groin as stone progresses
- Pain may be referred to testis/tip of penis in man or labia majora in woman
- May be frank haematuria
When would you consider admitting someone with renal colic to hospital?
- Fever
- Oliguria
- Poor fluid intake
- Pregnant
- Uncertain diagnosis
- Analgesia ineffective or short lived
For ectopic pregnancy, discuss:
- Risk factors
- Presentation
- Examination findings
- How you would manage in primary care
Risk Factors
- PID
- IUCD
- Previous ectopic pregnancy
- POP
- Tubal surgery
- Age
- Smoking
Presentation
- Abdo pain (uni or bilateral), may radiate to shoulder tip, may increase on passing urine or opening bowels
- Amenorrhoea
- Irregular vaginal bleeding “prune juice”- dark brown, water- or fresh blood
Examination
- Abdo tenderness
- Rebound tenderness or guarding (71%)
- Cervical excitation
- Enlarged uterus
Management
Admit to hospital immediately for further investigation and management
State some potential causes of acute chest pain; group your causes into:
- Cardiovascular
- Respiratory
- Gastrointestinal
- Other
Cardiovascular
- ACS
- Stable angina
- Pericarditis
- Aortic dissection
- Cardiac tamponade
Respiratory
- Pulmonary embolism
- Pneumonia
- Pneumothorax
- Tension pneumothorax
- Pleural effusion
- Asthma
- COPD
Gastrointestinal
- Peptic ulcer
- GORD
- Gallstones
- Acute pancreatitis
Other
- Costochondritis
- Shingles
- Anxiety, depression
- Trauma
Which patients with suspected ACS would you admit to hospital? (3)
- Current chest pain
- Signs of complications e.g. pulmonary oedema
- Pain free but have had chest pain in last 12hrs and have an abnormal ECG or ECG not available
Which patients with suspected ACS would you refer for an urgent same-day assessment at rapid access chest pain clinic
Currently pain free but had chest pain in last 12hrs and have normal ECG and no complications
OR
chest pain in past 12-72 hours with no complications
Which patients with suspected ACS would you refer to rapid access chest pain clinic within 2 weeks?
Currently pain free and their chest pain was more than 72 hours ago and they have no complications, suspected underlying malignancy, lung or lobar collapse or pleural effusion
If you suspect a patients current pain is due to ACS what treatment should you give whilst waiting for ambulance?
- Morphine & antiemetic IV (therefore may leave for ambulance)
- Oxygen (if sats below 94%)
- GTN spray
- Aspirin 300mg PO chewable loading dose & antiplatelet e.g. clopidogrel 300mg PO
Discuss the difference between acute, subacute and chronic breathlessness
- Acute: develops over mins
- Subacute: develops over hours or days
- Chronic: develops over weeks or months
State some common causes of breathlessness, categorise your answers based on:
- Cardiac causes
- Respiratory causes
- Others
Cardiac
- Silent MI
- Cardiac arrhythmia
- Acute pulmonary oedema
- Chronic heart failure
Respiratory
- Asthma
- COPD
- Pneumonia
- PE
- Plerual effusion
- Lung cancer
- Pulmonary embolism
Others
- Anaemia
- Diaphragmatic splinting (due to ascites, obestiy or chest pain)
Discuss the management of a suspected PE
- Immediate admission if they are haemodynamically unstable or they are pregnant/given birth in past 6 weeks
- For all other pts, use two-level Wells score to estimate clinical probability of PE:
- >4 : arrange hospital admission for CTPA. If CTPA cannot be offered immediately offer interim anticoagulation (choose one that can be continued if PE confirmed)
- =/< 4 : offer D-dimer with result in 4 hours. If result can’t be obtained in 4hrs offter interim anticoagulation while awaiting results. If test is positive arrange admission to hospital for imediate CTPA. Again, if CTPA not immediatley available ensure you offer interim anticoagulation.
What interim anticoagulation is used in suspected PE?
- First line: apixaban or rivoraxaban
- If not suitable, use:
- LMWH for at least 5 days followd by dabigatran or edoxaban
- OR LMWH concurrently with warfarin for 5 days or until INR >2 for 24hrs
Briefly summarise the management of the following in primary care
- Asthma: depends on severity; acute severe or worse needs admission to hospital
- COPD: depends on severity and what they present with. Alter their normal medications, give antibiotics for infections… (see later weeks)
- Pneumonia: antibiotics. Use CURB65 score to help aid decision as to whether someone should be admitted to hospital
- Plerual effusion: depends on severity- refer for CXR
- Pneumothorax: depends on severity- refer for CXR
- Lung cancer: two week oncology referral
Discuss how you would manage a suspected stroke in primary care
- Call for an ambulance
- Be sure to explicitly state that you suspect a stroke so that stroke team at hospital are notified
Discuss the management of TIA in primary care setting in which the pt had the TIA within the last week
- 300mg of aspirin immediately
- Arrange urgent assessment by specialist stroke team within 24hrs
- You may also consider discussing the need for admission and observation in pts who have:
- Crescendo TIA
- Suspected cardioembolic source or severe carotid stenosis
- May be unable to attend for urgent review/lacks a reliable observer at home
Discuss the management of TIA in primary care in which the patient had the TIA more than a week ago
- Refer to specialist within 7 days
- Assess for AF and other arrhythmias
- Educate pt on signs of TIA/stroke and what to do (call 999)
- Advise not to drive until seen by a specialist
Discuss how you determine whether to manage a pt as a stroke or TIA in primary care
- If they have ongoing neurological symptoms MUST treat as stroke as you have no way of proving not a stroke until imaging or symptoms resolve within 24hrs
- If had neurological symptoms that stopped within 24hrs you can treat as a TIA
If a pt has had a TIA within 1 week of presentation the immediate treatment is 300mg of aspirin; state some circumstances in which aspirin would be contraindicated
- Bleeding disorder or are taking anticoagulation (requires immediate admission & imaging to exclude haemorrhage)
- Taking low dose aspirin already (continue this low dose until seen by specialist)
- Aspirin is contraindicated (in this case discuss with specialist team urgently to decide management)
For Bell’s palsy, discuss:
- Pathophysiology
- Presentation
- Complications
- Acute unlateral facial weakness or paralysis
- Symptoms & signs usually develop in less than 72hrs:
- Unilateral facial weakness
- Earache or preauricular pain
- Eye dryness
- Inability to close eye completely
- Bell sign (pt eye rolls when they try to close it)
- Hyperacusis
- Difficulty chewing
- Dry mouth
- Numbness in cheek or mouith
- Complications:
- Eye injury
- Corneal ulceration
- Facial pain & parasthesia
- Dry mouth
- Psychological impact of facial disfigurement
Discus how you can distinguish between a stroke/TIA and Bell’s palsy as a cause of unilateral facial weakness
Discuss the management of Bell’s palsy in primary care
- If onset of symptoms was within 72hrs, give 50mg of prednisolone for 10 days
- Antiviral treatment alone not recommended; speak to specialist before prescribing antivirals
- Reassurance
- Advice regarding eye care
- Consider referal to opthalmologist
- Refer to specialist if no improvement in 3 weeks or if pts develop symptoms of aberant reinnervation after 5 months
What advice, regarding eye care, can you give to pts with Bell’s palsy?
- Lubricating eye drops
- Tape eye shut at night time (with micropourus tape) if unable to close it
- Wear sunglasses outdoors
- Avoid irritationt to eye e.g. swimming, dust
- If they experience eye irritation, pain or vision changes seek specialist help
What reassurance can you give someone with Bell’s palsy?
Most pts make full recovery within 3-4 months
When should you refer someone with Bell’s palsy immediately to secondary care?
Disucss the management of anaphylaxis in primary care
- A-E assessment (and treat as you go along e.g. oxygen, lie pt flat with legs up)
- Call ambulance
- IM adrenaline 0.5mg/0.5ml of 1:1000 (into anterolateral aspect of middle third of thigh)
- Repeat adrenaline in 5 mins if no improvement
-
If have following can also give:
- Nebulised salbutamol
- IV fluids
- Chlorphenamine 10mg IV or IM
- Hydrocortisone 200mg IV
The adrenaline dose for an adult or child >12yrs in anaphylaxis is 0.5mL of 1:1000 solution (0.5mg); in what situations would you half the dose?
- Adult on tricyclic depressants, monoamine oxidase inhibitors or beta blockers
Additional notes on paediatric dosing:
- Child 6-12yrs give 1/2 dose (300mg/0.3mL)
- Child 6months-6yrs give 1/4 dose (150mg/0.15mL)
Following the acute management of anaphylaxis, what follow up should a patient have?
- Serumt tryptase within 6 hours
- Obervations
Later follow up:
- Refer to allergist or allergci clinic to try and identify allergen (if unknown)
- Provide with adrenaline EpiPens for future attacks and teach how to use
- Educate pt regarding anaphylaxis, including signs, symptoms & biphasic reaction
- Encourage pt to wear medical emergency identification bracelet or similar
State what the desirable degree of tilt in ‘head tilt chin lift’ manoeuvre is in:
- Child
- Infant
- Child= sniffing position
- Infant= neutral
State the normal respiratory rate for children aged:
- < 1yr
- 1-2 yr
- 2-5 yr
- 5-12 yr
- >12yr
- < 1yr = 30-40
- 1-2 yr = 25-35
- 2-5 yr = 25-30
- 5-12 yr = 15-25
- >12yr = 12-20
State soem signs of respiratory distress in a child
- Grunting
- Flaring of nostrils
- Tracheal tug
- Accessory muscle use
- Gasping= late sign of hypoxia
Children are very good at compensating for alterations in their physiology therefore hypotension is a late sign; true or false?
True
*HENCE, you should assess the adequecy of circulation by observing function of other organs e.g. respiratory rate (driven by metabolic acidosis from anaerobic respiration), reduced urine output, mottled skin with pale cool periheries, altered mental state
What bolus of fluids would you give to a child who has circulatory compromise?
20ml/kg of 0.9% NaCl. Consider inotropic support if more than 2 boluses needed.
*NOTE: in DKA initial bolus is 10ml/kg
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
Following assessment of an unwell child with the traffic light system, discuss the managment if child has:
- Red features
- Amber features
- Green features
- Red features
- Life threatening red= emergency transfer to A&E
- Other red features= urgent (within 2 hours) face to face assessment to decide whether hospital admission is needed
- Amber features
- Arrange face to face assessment (if assessmen was done over phone)
- Consider hospital admission in some circumstances
- Saftey net & follow up app if managing pt at home
- Green features
- Manage at home
