Emergency presentations + paeds Flashcards
What does acute abdomen mean?
rapid onset severe abdominal sx (usually with pain) that may indicate life-threatening intra-abdo pathology
How do you assess a pt p/w ?acute abdomen?
- Ask about pain, vomiting (bilious, undigested food, faeculent, haematemesis), melaena/bright bleeding/other stool changes, urinary changes, lumps in abdo/groin, whether they’re eating + drinking, bowels, feeling faint/dizzy/palps, fever/rigors, rash/itching, weight loss
- Check for signs of sepsis, dehydration
- Examine abdomen for jaundice, distension, bruising (around umbilicus Cullen’s sign of haemorrhagic pancreatits/ectopic pregnancy/flanks Grey Turner’s sign of retroperitoneal haematoma), bowel sounds, aortic/iliac bruits, ascites, tenderness, shifting dullness, fluid thrill, organomegaly, guarding, rebound tenderness, bladder distension
- Groin for herniae, DRE
- Men – scrotum, women – DVE if needed
Differentials for the acute abdomen
SURGICAL:
*Upper GI: cholecystitis, pancreatitis, peptic ulcer disease, gastroenteritis, GI haemorrhage, splenic rupture
*Lower GI: appendicitis, diverticulitis, Meckel’s diverticulum, SBO/LBO, acute intestinal ischaemia, vasculitis, lower GI haemorrhage, AAA
Mesenteric adenitis – dispute as to whether is an actual diagnosis
*Strangulated hernia
*Renal: acute retention, renal colic, pyelonephritis
*Psoas abscess
*Testicular torsion
*Ectopic pregnancy rupture
*PID, tubo-ovarian abscess
*Ovarian torsion, ovarian cyst torsion/rupture
MEDICAL:
- MI, pericarditis, pneumonia
- Sickle crisis
- Hepatitis, IBD exacerbation
- Opiate withdrawal
- Acute intermittent porphyria
Normal observations in children (RR, HR)
<1y - 30-40; 110-160 1-2y- 25-35; 100-150 2-5y-20-30; 95-140 5-12y-15-20; 80-12- >12y-12-16, 60-100
Causes of breathing difficulty in a child
- Lower airway obstruction: bronchiolitis, asthma, pneumonia, foreign body, viral-induced wheeze, whooping cough
- Upper airway obstruction: anaphylaxis, croup, epiglottitis, bacterial tracheitis, peritonsillar abscess, foreign body
- Cardiac: acute heart failure, SVT
- Panic disorders
What is a fever in a child?
Generally if temp 38C or higher, often hard to define and reported parental perception of fever should be accepted. In young children usually indicates an infection, with fever a natural response to this
Causes of fever in kids
- Serious infections like sepsis, meningitis, pyelonephritis, peritonitis, pneumonia, encephalitis
- Less serious infections like URTIs, EBV
- Fever without obvious source e.g. HPB infections, osteomyelitis, septic arthritis, abscess, pericarditis
- Travel-related like parasitic infections, TB, rheumatic fever, malaria
- Drug fever
- Kawasaki disease
- Malignancy – ALL, AML, lymphoma B symptoms
- Autoimmune – mixed connective tissue disease, RA, IBD, hyperthyroidism
What is the relevance of red and amber flags for fever in kids?
- If any red flags arrange emergency transfer for suspicion of things like sepsis, meningitis, encephalitis, pneumonia, severe dehydration
- If amber features see them and see if they need admission. E.g. infant <3m with suspected UTI needs hospital, significant parental anxiety etc
Amber flags in children with fever
Pallor of skin/lips/tongue reported by parent
Not responding normally, waking only with prolonged stimulation, reduced activity, not smiling
Nasal flaring
Tachypnoea: 6-12m RR>50, >12m RR >40
Sats 95% OA or less
Crackles on auscultation
Poor feeding in infants, dry MM, CRT >2s, reduced urine output, tachycardia >160 <1y, >150 1-2y, >140 2-5y
Fever for 5 days or more, rigors, temp 39 or more aged 3-6 months, swelling of limb/joint, non weight-bearing/not using a limb
Red flags in children with fever
Pale, mottled, ashen or blue skin/lips/tongue
Not responding, appears ill to HCP, unable to rouse/doesn’t stay awake, weak high pitched or continuous crying
Grunting, RR 60 or more, moderate-severe chest indrawing
Reduced skin turgor
Non-blanching rash, bulging fontanelle, neck stiffness, focal neurological signs focal seizures, status epilepticus
Roseola infantum
HSV 6/7: sudden onset high fever, coryza/sore throat/mild diarrhoea, then as fever goes down get rash on trunk + neck for couple of days
Slapped cheek syndrome
Erythema infectious. (Parvovirus B19): mild prodrome, 2-4d bright erythema on cheeks sparing nose + sparing around eyes/mouth, then erythematous macular-morbilliform eruption on extensor surfaces, then fades as a lacy pattern (reticulated). Children usually fine, can cause arthralgia in adults, can precipitate aplastic crisis
Measles
v contagious virus. Cough/coryza/sore red eyes/high fever, Koplik spots in mouth then morbilliform rash (macular, confluent)
Rubella
rubella virus
erythematous rash, may have mild constitutional sx or arthralgia in older children. Typically lasts 3 days
in pregnant women if exposed test them. if have rubella then if >20w prob fine, if <10w offer TOP as v high risk CRS, if 11-16w 10-20% chance
Bacterial maculopapular rash + fever
- Scarlet fever: tonsillitis, fine red rough-textured rash, fades and get desquamation, bright red tongue with strawberry appearance
- Erythema marginatum – rheumatic fever
- Erythema migrans – Lyme disease. target lesion
- rose spots of typhoid fever
Kawasaki disease
fever 5+ days not controlled with meds, conjunctival injection, rash, lymphadenopathy, red cracked lips/strawberry tongue, red palms/soles/desquamation.
Do Echo
M-high dose aspirin (to protect against coronary arteritis)
Vesicular/bullous rashes
- Viruses: HSV-1 (cold sores, eczema herpeticum), chickenpox (vesicules surrounded by erythematous halo, central umbilication + crusting), hand foot + mouth disease (high fever, coryza. Oral lesions red spots then yellow-grey ulcers, then spots on hands + soles that turn into blisters, lasts 7-10d)
- Bacterial: boils, impetigo (crusting), staphylococcal scalded skin syndrome, toxic epidermal necrolysis
Petechial + purpuric rashes in children
- Viruses: v common, from most like adenoviruses, enteroviruses
- Bacterial: meningococcal or other septic infection, may be initially erythematous/maculopapular then petechiae + purpura. Can also get in infective endocarditis
- HSP – headache/fever/anorexia, then rash on legs + buttocks, abdo pain/vomiting, joint pain (Esp knees + ankles), subcutaneous oedema, haematuria
- Thrombocytopenia – ITP, ALL
- Malaria
Complications of head injury
- Primary damage: neural tissue injury (focal contusions, lacerations, diffuse axonal injury), bv injury (extradural, subdural, subarachnoid haemorrhage), penetrating injury
- Secondary damage: cerebral oedema, hypotension, hypoxia, seizures, hypoglycaemia, later-onset infection
CVS causes of chest pain
o ACS (pain lasting >15 mins, a/w N+V/sweating/SOB, haemodynamic instability, new onset/abrupt deterioration; don’t use response to GTN to confirm/exclude)
o Stable angina
o Dissecting thoracic aneurysm (tearing pain, radiation to back, hypertension, different in both arms, inequality in pulses, new diastolic murmur (AR)
o Pericarditis/cardiac tamponade (sharp constant sternal pain, relief sitting forward, may radiate, worse lying on left/on inspiration/swallowing/coughing, may have fever/cough/arthralgia; tamponade may have dysphagia/sob; may hear pericardial friction rub, may have pulsus paradoxus, hypotension, muffled HS, jugular venous distension)
o Acute CCF (ankle swelling, tired, severe sob, orthopnoea, elevated JVP, coughing, gallop rhythm, inspiratory crackles at bases, wheeze)
o Arrythmias (palpitations, sob, syncope/near-syncope, brady or tachy)
Pulmonary causes of chest pain
o PE: acute sob, pleuritic CP, cough, haemoptysis, syncope, tachypnoea/tachycardia, signs of DVT, mild pyrexia
o Pneumothorax: acute pleuritic pain + sob, reduced chest wall movements, reduced breath sounds, increased resonance percussion
o CAP: cough and at least one of sputum/wheeze/dyspnoea/pleuritic CP; focal chest signs (dull percussion, bronchial breathing, coarse crackles), temp
o Asthma: wheeze, sob, cough, often triggers
o Lung/lobar collapse: localised CP, sob, cough, reduced chest wall movement, dull percussion, bronchial breathing, reduced BS
o Lung cancer: chest/shoulder pain, haemoptysis, dyspnoea, WL, appetite loss, hoarseness, cough
o Pleural effusion: localised CP, sob
MSK causes of chest pain
o Rib #: h/o trauma or coughing. u/l sharp chest pain worse on inspiration
o Costochondritis: u/l sharp anterior chest wall pain, worse with breathing/activity/postural, usually preceded by exercise/URTI, can last for months. Tender over costochondral junction, pain on palpation, tender swelling of costal cartilage at costochondral junction in Tietze’s syndrome
o Spinal disorders – disc prolapse, cervical spondylosis, facet joint dysfunction. Dull aching CP, worse with particular neck movements, radiates down arm/into head/shoulder/scapulae, may have headache/dizziness
GI causes of chest pain
o Acute pancreatitis: often h/o gallstones or high alcohol. Sudden onset pain, severe, continuous, boring, epigastric/generalised, may radiate to RUQ/chest/lower abdomen, relieved sitting up + leaning forward, N+V, tenderness, distension, Cullen’s sign (discolouration around umbilicus), Grey-Turner’s sign (discolouration around flank), hypotension
o Oesophageal rupture – CP, sob, odynophagia, h/o procedures/FB ingestion/oesophageal cancer
o PUD, GORD, oesophageal spasm, oesophagitis – substernal pain esp at night/after big meal, radiation to throat from epigastrium, worse bending/flat, acid/food reflux
o Acute cholecystitis – sudden onset severe RUQ pain, anorexia, N+V, sweating, low grade fever, Murphy’s sign (inspiration inhibited by pain on palpation), jaundice (stone in bile duct/external compression)
Psychological causes of chest pain
no identifiable case, often preceded by stressful event, usually in left sub-mammary position with no radiation, sharp continuous pain, worse with tiredness/stress, may get sx of hyperventilation (tingling extremities) and palps
What is precordial catch?
brief episodic left-sided CP, a/w bending/posture, relieved by single deep breath/straight posture, no radiation
How do you assess a pt p/w CP?
- History: if they currently have it, onset/nature/radiation (acute onset with central or band like CP radiating to jaw/arms/back suggests cardiac; persistent localised pain more likely lung/MSK), R+A factors (exertional CP – angina, pleuritic CP – MSK/pulmonary), sob (cardiac/lung), h/o CP or past ECG, CV risk factors, MSK/GI disorders, previous trauma, anxiety + depression
- Examination: CV (heart sounds [murmurs/pericardial rub], BP in both arms [aortic dissection], pulse rate + rhythm [shock/arrhythmias], chest wall (palpate for tenderness, does movement reproduce pain, listen to lungs for infection, check sats + RR), general appearance (signs of shock), abdo tenderness (gallstones, pancreatitis, peptic ulcer), neck tenderness/stiffness (cervical spondylosis, OA), leg swelling/tenderness (DVT), skin rashes (shingles), bruising (rib #), temp (infection, pericarditis, pancreatitis)
- May need admission to hospital
- Investigations to consider if not needing immediate admission:
o ECG – ventricular hypertrophy, arrhythmias, PE, stable angina, ACS
o CV bloods – glucose, lipid profiles, U+E
o FBC – anaemia may exacerbate stable angina
o TFTs
o LFT + amylase – cholecystitis, pancreatitis
o CRP/ESR for inflammation/infection
o CXR – signs of HF, pulmonary pathology
Acute SOB causes
- Pulmonary: acute asthma, acute COPD, pneumonia, PE, pneumothorax, pleural effusion, bronchiectasis, lung/lobar collapse (bronchial obstruction/compression by cancer/FB/secretions), acute pneumonitis, upper airway obstruction causing stridor
- Cardiac: acute HF, sudden onset arrhythmia e.g. SVT, IHD (including silent MI), acute valvular dysfunction, tamponade
- Other: metabolic (aspirin OD, DKA, renal failure), acute blood loss (pallor, tachycardia), thyrotoxicosis, NM e.g. GBS/MG, hyperventilation (hypertension, palpitations, paraesthesia, CP, choking sensation)
Signs that SOB is due to a lung issue?
wheeze, sputum, hyperinflated chest, purse lip breathing, ankle oedema from RHF, any focal chest sign, fever, signs of DVT, pleuritic CP, cough, haemoptysis, dizziness/syncope
Signs that SOB is due to a cardiac issue?
general malaise, collapse, upper body discomfort, nausea, abnormal rate pulse, sweating, hypotension, orthopnoea, coughing with frothy blood-stained sputum (acute pulmonary oedema), collapse/pulsus paradoxus/neck vein engorgement (tamponade)
Emergency management of pt with SOB in GP (whilst waiting for ambulance(
o Sit them up
o If sats 94% or less give O2 and continuously monitor – usually simple face mask at 5-10L/min, or nasal cannulae at 2-6L/min. For COPD/NM disorders/chest wall deformity/morbid obesity use 28% venturi mask at 4L/min
o MI – give aspirin 300mg
o Pulmonary oedema – give an IV diuretic, opioid + anti-emetic, and GTN spray
o SVT – attempt Valsalva/carotid sinus massage one side at a time
o Acute severe asthma/COPD – bronchodilator like neb/MDI salbutamol, oral prednisolone 40-50mg if available
o Tension pneumothorax – if diagnosis certain + life-threatening condition consider large bore
What is angio-oedema?
swelling of deep dermis, SC or SM tissue of face/genitalia/hands/face, sometimes bowel/airway. Most often occurs with urticaria but may be alone. Skin may look normal/have wheals/anther rash, skin swelling less well defined, assess for resp sx + circulatory collapse
What are the causes of angio-oedema?
Allergic: mast-cell mediated (usually IgE) and histamine-induced. Almost always a/w urticaria within 1-2h of exposue to the allergen. Likely if there is urticaria
Non-allergic: increased bradykinin. Likely if no urticaria
- Non-allergic drug reaction: days-months after taking the drug, e.g. ACEi
- Hereditary angio-oedema: rare inherited issue which causes overproduction of bradykinin. Spontaneous/triggered attacks
- Acquired angio-oedema: usually due to lymphoma/CT disorder. Presents from 40+ usually
How is angio-oedema (without anaphylaxis) managed?
- acutely - IV/IM chlorphenamine + hydrocortisone, arrange admission
- stable - find cause, stop the drug, non-sedating antihistamine, short course steroids, maybe refer to derm/immunology
What is anaphylaxis?
severe life-threatening generalised/systemic hypersensitivity reaction with rapidly developing A/B/C problems, usually a/w skin + mucosal problems
Features of anaphylaxis
o Sudden onset + rapid progression of sx – look + feel unwell, usually occur over minutes. Depends on trigger e.g. stings faster than ingested triggers
o Life-threatening A/B/C problems – airway swelling/difficulty breathing or swallowing/stridor etc, sob/wheeze/tiredness/confusion/low sats/resp arrest, signs of shock/tachycardia/hypotension/reduced GCS/cardiac arrest/myocardial ischaemia
o Skin and/or mucosal changes – often the first features, in >80% of anaphylactic reactions
May also have GI sx
Skin issues without life-threatening ABC usually doesn’t lead to anaphylaxis
How do you manage anaphylaxis in primary care?
o Call for ambulance + colleagues
o Assess – ABCDE, if not breathing normally + unresponsive do CPR, if don’t need CPR examine chest/pulse/BP/skin/inside mouth
o Sit them up if A+B problems, lie flat if hypotension
o IM adrenaline 1:1000 as per age-related guidelines. Repeat at 5 min intervals if needed
o Remove trigger if possible e.g. remove the stinger from a bee sting
o If possible give high flow O2, obtain IV access, rapid fluid challenge, monitor ECG + pulse oximetry
o Give slow IM/IV chlorphenamine and hydrocortisone, consider neb salbutamol/ipratropium if they are wheezy
Causes of the acute painful red eye
Scleritis Uveitis Corneal abrasion Corneal ulcer Viral keratitis Acute angle closure glaucoma Endophthalmitis Foreign body Chemical injury
Scleritis
50% a/w rheum condition, less common from surgery or infection. Urgent ophth will need to treat the cause.
CF: dull boring eye pain, headache, watering eye, painful movements, reduced VA is late. Usually a deep pinkish colour with more dilated brighter vessels superficially
Uveitis
inflammation of uveal tract, anterior uveitis most common. Usually idiopathic but can be a/w HLA-B27 positive conditions like AS/PA or some infections
CF: photophobic, red, watery, painful eye, VA often mildly reduced. May see hypopyon, irregular pupil (due to posterior synechiae where iris attaches to lens capsule), cloudy view cos of cells in aqueous humor + corneal oedema, circumciliary injection esp around cornea
M: ophth to control inflammation
Corneal abrasion
Break in the corneal epithelium
CF: v painful red watering eye, photophobia, VA may be mildly reduced if injury is in visual axis.
Stains brightly with fluorescein + blue light.
M: Chloramphenicol ointment reduces risk of bacteria entering + acts as a lubricant, may also use ocular lubricants/oral analgesics to help pain, avoid contact lenses until healed
Corneal ulcer
Similar sx to abrasion then pain very bad + worsened VA. Usually caused by infected abrasion e.g. extended contact lens wear. If severe need admission
Viral keratitis
o Pain, watering, photophobia, reduced VA, dendritic epithelial defect
o Herpes simplex e.g. from cold sores – usually in kids, looks like branching ulcer (like HZ) but with terminal bulbs (unlike HZ), patchy iris defect
o Herpes zoster – segmental iris defect, Hutchinson’s sign (rash on nose so is on the cornea as both supplied by nasociliary branch of CNV1)
o Refer to ophth-topical antivirals. Don’t give steroids to undiagnosed red eye as applying it to HSV keratitis can cause a geographic ulcer from impaired immune response
What is acute angle closure glaucoma?
obstructed anterior chamber (angle between cornea + iris where AH drainage usually takes place) causing a sudden rise in IOP because AH isn’t draining properly, though IOP may be normal, causes progressive optic neuropathy
RF for acute angle closure glacuoma
Hypermetropes - esp in reduced light
Women
CF of acute angle closure glaucoma
sudden onset red painful eye, blurred vision, N+V, headache, severe eye pain + tenderness, injection, eye feels hard, hazy cornea, semi-dilated pupil
Management of acute closed angle glaucoma
IV acetazolamide + pilocarpine drops (constrict pupil so better AH outflow). Analgesia + anti-emetics. Definitive is laser/surgical hole at peripheral of iris
Endophthalmitis
Overwhelming infection. Severe pain, photophobia, rapidly progressive LoV, hypopyon, injection, corneal oedema
Needs intravitreal ABx. Could lose sight.
Foreign bodies in the eye
Low speed e.g. gravel - irritation red/watering/FB sensation (even after cleared), may get photophobia/minor visual changes. Remove with LA eye drops + cotton bud, Abx drops for abrasions, lubricants for sx
High speed e.g. metal fragments -o More potential for injury. If having VA changes suggestive of corneal/retinal damage, flashes + floaters may indicate retinal damage. Penetrating injuries may cause blood in AC, visible holes in iris/distortion, plugged wound
Chemical injury to the eye
whatever it is irrigate + urgent r/v. Alkalis are the worst. Check pH, Abx drops, cytoplegics to help pain by paralysing iris
Causes of the acute painless red eye
Subconjunctival haemorrhage
Episcleritis
Conjunctivitis
Dry eye
Subconjunctival haemorrhage
common, usually just red but can feel gritty. Causes include trauma, sudden rise in intrathoracic pressure e.g. heavy lifting, rubbing eye; higher risk with HTN + anticoagulants/antiplatelets.
May give lubricants if feeling gritty but otherwise reassure will resolve in a few weeks (may go a faint yellow first)
Episcleritis
Uncomfortable not frank pain, sectoral area of hyperaemia + red dilated superficial vessels, blanches with phenylephrine. In 30% there is a systemic autoimmune condition e.g. UC. Self-limiting, adv analgesia + topical lubricants (sometimes top steroid/NSAID)
What is conjunctivitis?
inflammation over the sclera (bulbar) + inner (tarsal) eyelids. Usually b/l to some extent due to symmetrical pathologies/cross infection.
Causes general discomfort, watering, gritty feeling, DC, crusted eye shut, diffuse injection, chemosis, debris
Viral conjunctivitis
Viral e.g. adenoviral. V v contagious, eye watering, coryzal sx, pre-auricular LN. M-lubricants, cold compresses, hygiene
Bacterial conjunctivitis
Normal bacterial: resp pathogens like S pneumoniae. Often worse injection + DC. M – topical chloramphenicol drops/ointment or fusidic acid
Chlamydial: often u/l with serous dc, refer to GUM, may cause scarring. In babies usually a couple of weeks PP
Gonorrhoeal: severe swelling, hyperpurulent DC. Refer to GUM-can cause corneal ulcer. In babies usually within 48h PP
Allergic conjunctivitis
common esp when h/o atopy. Itchiness, swelling of eyelids/conjunctiva, coryzal sx. Can be seasonal or perennial.
M-cold compress, oral antihistamines, wash face after exposure, topical antihistamines/steroids/mast cell stabilisers for more severe
Dry eye
b/l ocular irritation worsened with exposure e.g. screen time/wind
May be:
*Evaporative e.g. blepharitis (inflamed eyelid margins – obstructed meibomian glands – tears evaporate more. May have crusting, matted eyelashes, chalazions) *Tear deficiency e.g. Sjogren’s syndrome
M: lid hygiene, warm compresses with lid massage, ocular lubricants (ointments at night)
