flag tables

Question 1

abdo pain red flags

Answer 1

• Severe pain.
• Abnormal vital signs.
• Pain radiating to the back.
• Loin or flank pain.
• Temperature > 40°C.
• Rigors.
• Female aged 14-50 years and last menstrual period (LMP) more than
  four weeks ago.
• Pregnant.
• Abdominal tenderness on palpation.
• Pain made worse by movement.
• Indigestion or epigastric pain.
• Persistent or recurrent vomiting.
• Aged < 5 years.
• Aged ≥ 65 years.
• Immunocompromised (for example on steroids or immunotherapy).

Question 2

abdo pain orange flags

Answer 2

• Dysuria.
• Frequency or urgency of urination.
• Recent unplanned weight loss.
• Haematuria.
• Temperature 38-40°C but other vital signs normal.
• New onset of constipation in the elderly.

Question 3

abdo pain green flags

Answer 3

Diarrhoea and vomiting with normal vital signs.
* Pain associated with menstruation.
* Recurrent constipation.

Question 4

A patient with abdominal pain who calls an ambulance should usually be assessed in an ED, unless there is….

Answer 4

unless there is an obvious benign cause such as urinary tract infection, menstruation or recurrent constipation.

Question 5

Abdominal pain radiating to the spine or flank may result from conditions such as….

Answer 5

pancreatitis, gastric or duodenal ulceration, cholecystitis, pyelonephritis, or a leaking abdominal aortic aneurysm.

Question 6

An abdominal aortic aneurysm is usually asymptomatic prior to….

Answer 6

leaking. Although many references describe a pulsating mass, this may not be palpable. A leaking abdominal aortic aneurysm usually presents with abdominal pain that radiates to the back and signs of shock.

Question 7

what is Rigors and what dose it indicate

Answer 7

Rigors indicate that bacteria may be present in the blood. episodes in which your temperature rises while experiencing severe shivering accompanied by a feeling of coldness.

Question 8

Perforated bowel (for example from cancer, diverticular disease or ulceration) usually presents with

Answer 8

non-specific abdominal pain for 1-2 days followed
by signs of peritonitis (abdominal tenderness with pain made worse by movement).

Question 9

All patients with upper abdominal (epigastric) pain should have a

Answer 9

12 lead ECG acquired, noting that a normal ECG does not rule out myocardial ischaemia.

Question 10

falls red flags

Answer 10

• Clinically significant injury.
• Clinically significant pain.
• Abnormal vital signs.
• Signs of stroke.
• Seizure without a history of epilepsy.
• Headache.
• New onset of visual disturbance.
• Unable to mobilise.
• Unstable medical condition contributing to the fall.

Question 11

orange flags for falls

Answer 11

• More than one fall in the last week.
• Postural hypotension.
• Seizure with a history of epilepsy.
• Recent change in medication.
• Minor injury requiring non-urgent treatment.
• New reduction in mobility but able to weight bear.

Question 12

green flags falls

Answer 12

• Minor soft tissue injury not requiring medical treatment.
• Able to mobilise in a manner that is normal for the patient.

Question 13

Have a raised index for suspicion of injury if the patient who has fallen is…

Answer 13

Has fallen a significant height, for example greater than one metre or five stairs in an adult, or
ū Is taking an anticoagulant or has a known bleeding disorder.

Question 14

Postural hypotension is present if there is a fall of greater than

Answer 14

20 mmHg in the systolic BP or greater than 10 mmHg in the diastolic BP when standing.

Question 15

falls risk assessment

Answer 15

• Ask the patient the following questions:
  ū Have you slipped, tripped or fallen in the last year?
  ū Do you need to use your hands to get out of a chair?
  ū Are there any activities you’ve stopped doing because you are afraid of
  falling?
• Perform Romberg’s test.
• Perform a timed up and go test.
• Refer the patient to a falls referral pathway if:
  ū The patient answered ‘yes’ to any of the questions, or
  ū Romberg’s test is abnormal, or
  ū The timed up and go test is abnormal, or
  ū Personnel consider the patient is at risk of falling.
• Examine the environment for hazards which may contribute to the risk of falling. Examples include rugs, mats, cords and poor footwear. Eliminate these hazards with the patient’s permission if feasible.

Question 16

Romberg’s test

Answer 16

• Stand beside the patient and be prepared to assist if they stumble.
• Ask the patient to stand with their feet together, place their arms by their side, get their balance and then close their eyes.
• Observe how long the patient can maintain the stance. A patient with normal balance should be able to maintain the stance without stumbling for more than 15 seconds.

Question 17

Timed up and go test

Answer 17

Seat the patient in a chair and mark a location three metres away. The patient should wear their regular footwear and use any regular walking aids.
* Give the patient the following instructions. “When I say go I want you to stand up, walk to the line, turn around, walk back and sit down again”.
* Begin timing on the word go and stop when the patient sits back down.
* The timed up and go test is abnormal if the time is longer than 12 seconds.
* During the timed up and go test observe the patient’s posture, gait and balance. Record any obvious abnormalities.

Question 18

treatment of fever under 12 months

Answer 18

Clearly recommend that all children aged less than 12 months with a fever are transported to an ED by ambulance.

Question 19

fever under 5 red flags

Answer 19

• Colour:
  ū Pale or ashen.
  ū Mottled.
  ū Cyanosed.
• Activity:
  ū No response to social cues.
  ū Difficult to rouse or does not stay awake when roused.
  ū Weak cry.
  ū Exhaustion.
• Respiratory: ū Grunting.
  ū Respiratory rate > 50/minute.
  ū Moderate or severe chest indrawing.
  ū SpO2 < 94% on air.
• Circulation and hydration:
  ū Reduced skin turgor.
  ū Severe tachycardia.
  ū Peripheral capillary refill time > three seconds.
  ū Bradycardia (an extremely late sign).
• Other:
  ū Temperature > 40°C.
  ū Neutropenia.
  ū Chemotherapy within the last four weeks.
  ū Pain in a single joint or a single muscle area.
  ū Rigors.
  ū Petechiae or purpura.
  ū Neck stiffness.
  ū Focal neurological signs.
  ū Significant concern regarding neglect or non-accidental injury.

Question 20

fever under 5 orange flags

Answer 20

• Colour: pallor reported by caregiver (but not seen by personnel).
• Activity:
  ū Not responding to social cues normally.
  ū Wakes only after physical stimulation.
  ū Decreased activity.
  ū Poor feeding.
• Respiratory:
  ū Nasal flaring.
  ū Respiratory rate 40-50/minute.
  ū Mild indrawing.
  ū Crackles audible on auscultation.
  ū SpO2 94-95% on air.
• Circulation and hydration:
  ū Dry mucous membranes.
  ū Tachycardia.
  ū Peripheral capillary refill time 2-3 seconds.
  ū Reduced urinary output or frequency.
• Other:
  ū Sore throat.
  ū Illness for longer than five days.
  ū Non-weight bearing or not mobilising appropriately.
  ū Immunocompromised (for example on steroids).
  ū Help from a healthcare provider has been sought more than once
  within 24 hours.

Question 21

fever under 5 green flags

Answer 21

• Colour: normal colour of skin, lips and tongue. * Activity:
  ū Responds normally to social cues.
  ū Wakes easily and stays awake.
  ū Strong/normal cry or not crying.
• Respiratory:
  ū Normal respiratory rate.
  ū No signs of indrawing.
  ū SpO2 ≥ 96% on air.
• Circulation and hydration:
  ū Normal skin and eyes.
  ū Moist mucous membranes.
  ū Normal heart rate.
  ū Peripheral capillary refill time < two seconds.

Question 22

Fever in patients aged five years and over red flags

Answer 22

• Significantly abnormal vital signs.
• Pain or tenderness in the flank or back.
• Rigors.
• Neutropenia.
• Chemotherapy within four weeks.
• Abdominal pain with tenderness on palpation.
• Pain in a single joint or a single muscle area.
• Severe muscle tenderness.
• Temperature > 40°C.
• Drowsiness.
• Severe or worsening headache.
• Neck stiffness.
• Petechiae or purpura.

Question 23

Fever in patients aged five years and over orange flags

Answer 23

• Cellulitis.
• Immunocompromised (for example on steroids or immunotherapy).
• Frequency or urgency of urination.
• Sore throat.
• Cough productive of purulent sputum.
• Pleuritic chest pain.
• Help from a healthcare provider has been sought more than once
  within 24 hours.

Question 24

five and over green flags

Answer 24

influenza with normal mobility and vitals

Question 25

headache red flags

Answer 25

• Headache or neck pain following neck manipulation.
• Neck pain or neck stiffness.
• Sudden onset of severe headache.
• Temperature > 38°C (in the absence of influenza symptoms).
• Persistent vomiting.
• Focal neurological signs.
• Altered level of consciousness, including a history of altered level of
  consciousness with the onset of the headache.
• New onset of an altered mental status.
• Worsening headache following recent trauma to the head.
• Taking an anticoagulant or has a known bleeding disorder.
• Signs of temporal arteritis.
• Hypertension during pregnancy.
• Previous history of intracranial bleeding.
• Family history of cerebral vascular abnormalities.
• Onset during sexual activity or exercise.
• Headache associated with seizure.

Question 26

headache orange flags

Answer 26

• Symptoms associated with sinusitis.
• Migraine with symptoms different to usual.

Question 27

headache green flags

Answer 27

• Symptoms associated with influenza.
• Known migraine with usual symptoms.
• Normal vital signs, normal assessment using the FAST test and able to
  walk normally.

Question 28

It is unusual for a patient with headache to call for an ambulance and the patient should usually be assessed in an ED, unless there is an obvious benign cause such as

Answer 28

a migraine, influenza, sinusitis, caffeine withdrawal, nicotine withdrawal or a hangover.

Question 29

migrane presentation

Answer 29

The pain is usually unilateral (but may be bilateral), throbbing, made worse by activity, associated with nausea and vomiting and may be associated with sensitivity to light and noise.

Question 30

opioates and migrants

Answer 30

Some patients with migraines call for an ambulance and request opiate pain relief. Opiates are strongly discouraged in this setting and should not be administered.

Question 31

cluster headache presentation

Answer 31

Cluster headaches are recurrent, unilateral headaches centred around one eye or the temporal area. They are often associated with watering of the eye and/ or congestion/running of the nose.

Question 32

treatment of cluster headache

Answer 32

A short period of inhalation of high concentration oxygen may resolve the headache. The theory is that this causes cerebral vasoconstriction and thus relieves the pain.If the provisional diagnosis is cluster headache and there are no red flags, administer 15 litres/minute of oxygen via a reservoir mask for 15-20 minutes and reassess:
ū Recommend self-care and subsequent follow up by their GP if the headache resolves.
ū Recommend the patient is seen by a doctor (preferably in primary care and preferably by their own GP) if their headache does not resolve.

Question 33

Subarachnoid haemorrhage may present with

Answer 33

sudden onset of severe headache (thunderclap headache) and/or headache associated with neck stiffness.

Question 34

Vertebral artery dissection may present with

Answer 34

sudden onset of neck pain and/or headache which may follow injury or neck manipulation.

Question 35

Meningitis may present with

Answer 35

headache, fever, neck stiffness, photophobia, nausea and vomiting.

Question 36

The symptoms of meningitis are similar to those of migraine, except that the pain from migraine:

Answer 36

ū Usually comes on over an hour or two, whereas the pain from meningitis usually comes on more slowly.
ū Is usually throbbing, whereas the pain from meningitis is usually more constant.
ū Usually lasts only for a few hours, whereas the pain from meningitis persists.

Question 37

Intracerebral haemorrhage usually presents with

Answer 37

sudden onset of severe headache and focal neurological signs. The patient will also have a falling level of consciousness if the intracerebral haemorrhage is severe.

Question 38

Anticoagulants include

Answer 38

warfarin and dabigatran, but not antiplatelet agents such as aspirin, clopidogrel or ticagrelor.

Question 39

what is Temporal arteritis

Answer 39

is an inflammatory condition affecting the blood vessels supplying the temporal area of the head. It is also sometimes called giant cell arteritis. It is an emergency because untreated it can lead to blindness. It most commonly occurs in patients over the age of 60 years and may present with any combination of:
ū Headache.
ū Fever.
ū Jaw pain (which may get worse with chewing).
ū Altered vision.
ū Scalp sensitivity.
ū Stiff aching joints.

Question 40

Opiate pain relief is discouraged for a patient with

Answer 40

headache is not reccomneded

Question 41

Non-traumatic lumbar back pain red flags

Answer 41

• Loss of bladder or bowel control.
• Temperature > 38°C.
• Rigors.
• Abnormal vital signs.
• Pain in the thoracic spine or chest.
• Abdominal pain or tenderness.
• Altered sensation in the saddle area.
• Altered sensation and/or power in both legs.
• Unable to mobilise.
• Signs or symptoms of generalised illness.
• Pain radiating down both legs.

Question 42

Non-traumatic lumbar back pain orange flags

Answer 42

• A history of cancer (other than skin cancer).
• Immunocompromised (for example on steroids or immunotherapy).
• Worsening pain, especially when lying down or at night.
• Recent unplanned weight loss.
• Pain radiating down one leg.
• Altered sensation or power in one leg.
• Osteoporosis.
• IV drug use.

Question 43

Non-traumatic lumbar back pain green flags

Answer 43

• Pain and/or muscle spasm isolated to the lumbar area.
• Able to walk.

Question 44

A prolapsed disc presentation

Answer 44

may compress a nerve root causing altered sensation and/
or motor power in one leg. Pain that radiates into one or both legs is usually
a sign of sciatic nerve involvement. If the altered sensation and/or power are only in one leg, the patient does not need immediate transport to ED provided no red flags are present.

Question 45

syncope red flags

Answer 45

• Abnormal vital signs.
• Failure to recover to normal.
• Chest pain.
• Abnormal 12 lead ECG with abnormalities of concern.
• New or unexplained shortness of breath.
• Clinically significant injury.
• Occurred during exertion.
• Pregnancy.
• Headache.
• Known valvular or congenital heart disease.

Question 46

syncope orange flags

Answer 46

• Aged < 15 years.
• Aged ≥ 75 years.
• Postural hypotension.
• Abnormal 12 lead ECG but no abnormalities of concern.
• Palpitations.
• Family history of sudden death.
• History of heart failure.

Question 47

syncope green flags

Answer 47

• Clearly benign. Factors associated with benign syncope include:
  ū Posture, for example prolonged standing.
  ū Provoking factors, for example pain or a procedure.
  ū Prodromal symptoms, for example sweating or feeling hot.

Question 48

syncope key questions

Answer 48

What was the patient’s posture before the syncope? Sometimes there will be a prolonged period of standing prior to benign syncope.
ū Were there any obvious provoking factors? Sometimes pain or a procedure (particularly injection) will provoke benign syncope.
ū Were there any obvious prodromal symptoms? Commonly the patient will complain of feeling sweaty or feeling hot prior to benign syncope.
ū What was the appearance and colour of the patient during the syncope? Most commonly the patient will be very pale as a result of low cardiac output.
ū Was there any twitching observed during the syncope? It is common for a patient to have some abnormal twitching during syncope, but rhythmic jerking movements suggest a seizure has occurred.
ū How long was the patient unconscious for? Most patients should recover to a normal level of consciousness within a few minutes. Failure to quickly regain a normal level of consciousness suggests a neurological cause.
ū Was the patient confused when they woke? A very brief period of disorientation may occur, but confusion that persists beyond a few minutes suggests a neurological cause.

Question 49

syncope examination

Answer 49

Examine for signs of injury.
ū Examine for signs of tongue biting and/or urinary incontinence. This
suggests a seizure has occurred.
ū Always perform a 12 lead ECG. Determining that abnormalities of
concern are present requires clinical judgement, but examples include
ST elevation in the absence of a clear STEMI mimic, ST depression in the absence of left ventricular hypertrophy, second or third degree heart block and a persistent heart rate of less than 50/minute. Any abnormality warrants medical follow up and personnel should have a low threshold for recommending transport to an ED by ambulance.
ū Measure a full set of vital signs, including a BP standing and sitting/lying. Postural hypotension is present if there is a fall of greater than 20 mmHg in the systolic or greater than 10 mmHg in the diastolic BP when standing.

Question 50

vertigo red flags

Answer 50

• Signs of stroke.
• Headache.
• Unable to walk unaided.
• Neck pain.
• Visual disturbance.
• Abnormal coordination during the finger-nose test.
• Nystagmus that persists for more than 10 seconds with the head still.
• Altered level of consciousness.
• Abnormal vital signs.
• History of recent trauma, especially head or neck injury.
• Symptoms that do not improve when the head is still.

Question 51

vertigo orange flags

Answer 51

• First episode of vertigo.
• Symptoms worsened by changes in head position.
• Symptoms improve, but do not completely settle when the head is
  kept still.
• Tinnitus or loss of hearing.

Question 52

vertigo green flags

Answer 52

• Symptoms totally resolve within 60 seconds when the head is kept still.
• Symptoms totally resolve following an Epley manoeuvre.

Question 53

The three main causes of vertigo are

Answer 53

cerebellar stroke, benign paroxysmal positional vertigo (BPPV) and vestibular neuritis. Cerebellar stroke is less common but much more serious and can easily be missed. BPPV and vestibular neuritis are both common and benign.

Question 54

The symptoms of cerebellar stroke usually come on suddenly (over a few minutes) and are associated with:

Answer 54

ū Vertigo that is not altered by head position.
ū Nausea and vomiting.
ū Loss of coordination with an abnormal finger-nose test.
ū Loss of balance with an inability to walk unaided.

Question 55

The Epley manoeuvre

Answer 55

There are several variations, but the following is recommended:
a) Sit the patient upright on a bed or stretcher and rotate their head to face one side, preferably toward the side that makes symptoms worse.
b) Assist the patient to lie back, keeping their head turned. Recline their head, using a pillow under their shoulders or with their head hanging off the end of the bed/stretcher, and their ear parallel with the floor.
c) Hold the patient’s head in this position for 60 seconds.
d) Quickly turn the patient’s head to face the opposite side and hold this
position for 60 seconds.
e) Turn the head further, so that the patient is facing downward (this may
require the patient to move their body to accommodate this). Hold this
position for 60 seconds.
f) Assist the patient into a sitting position and rotate their head forward.
* Repeat the Epley manoeuvre once if the symptoms do not resolve.