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Ovid: Oxford Handbook of General Practice

Editors: Simon, Chantal; Everitt, Hazel; Kendrick, Tony Title: Oxford Handbook of General Practice, 2nd Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 29 – Emergencies Chapter 29 Emergencies Andrea L. Zuckerman Being prepared This chapter contains information on conditions in which immediate action is essential. For the sake of brevity, it does not contain all acute situations a GP might face—most are dealt with in their appropriate sections within the book. Before being on-call for emergencies

  • Ensure you have a reliable car with a full tank of petrol
  • Have a good street map of the area ± an Ordinance Survey map
  • Carry a large, strong torch in the car
  • Carry a mobile telephone and make sure it is charged
  • Check the drug box is fully stocked and all items are in date
  • Check all equipment carried is operational and you have spare batteries
  • Carry a list of emergency telephone numbers
  • Know which chemists have extended opening hours and carry the chemist’s rota.

When on-call for emergencies In all cases:

  • Record—the time of any calls, full name, date of birth or age, telephone number, address of the patient and current location.
  • Give the patient or the person making the call a clear idea of what you will do (e.g. if you will call an ambulance, when you will be visiting) and what you expect them to do.
  • If only advice is given, then make full notes to be filed in the patient’s notes.
  • If visiting, take directions from the person making the request for a visit if the area is unfamiliar to you.
  • Keep a full record of the consultation with the patient, any actions taken, and drugs administered (including expiry date, manufacturer, and batch number).
  • Don’t go alone to suspected violent patients—call the police to accompany you.
  • Ensure someone knows where you are and when to expect you back, at all times.

The doctor’s bag p.54

Useful telephone numbers:
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

P.1017
P.1018
Managing a resuscitation attempt outside hospitalG Ventricular fibrillation complicating acute Ml is the most common cause of cardiac arrest that members of the primary healthcare team will encounter. Success is greatest when the event is witnessed and attempted defibrillation is performed with the minimum of delay. Resuscitation equipment See Table 29.1

  • Resuscitation equipment is used relatively infrequently. Staff must know where to find equipment at the time it is needed and should be trained to use the equipment to the expected level.
  • Each practice should have a named individual with responsibility for checking the state of all resuscitation drugs and equipment, on a regular basis—ideally once a week. In common with drugs, disposable items like the adhesive electrodes have a finite shelf-life and will require replacement from time to time, if unused.

Training Training and practice are necessary to acquire skill in resuscitation techniques. Resuscitation skills decline rapidly and updates and retraining, using manikins, are necessary every 6–12mo. to maintain adequate skill levels. Level of resuscitation skill needed by different members of the primary healthcare team differs according to the individual’s role:

  • All those in direct contact with patients should be trained in BLS and related resuscitation skills such as the recovery position.
  • Doctors, nurses, and other paramedical workers (e.g. physiotherapists) should also be able to use an automatic external defibrillator (AED) effectively.

Other personnel (e.g. receptionists) may also be trained to use an AED. It is unacceptable for patients who sustain a cardiopulmonary arrest to await the arrival of the ambulance service before basic resuscitation is performed and a defibrillator is available. Performance management Accurate records of all resuscitation attempts and electronic data stored by most AEDs during a resuscitation attempt should be kept for audit, training, and medico-legal reasons. The responsibility for this rests with the most senior member of the practice team involved. Process and outcome of all resuscitation attempts should be audited—both at practice and PCO level—to allow deficiencies to be addressed and examples of good practice to be shared. Ethical issues

  • It is essential to identify individuals in whom cardiopulmonary arrest is a terminal event and where resuscitation is inappropriate.
  • Overall responsibility for a ‘Do not attempt to resuscitate (DNAR)’ decision rests with the doctor in charge of the patient’s care.
  • Seek opinions of other members of the medical and nursing team, the patient, and any relatives in reaching a DNAR decision.
  • Record the patient should not be resuscitated in the notes, the reasons for that decision, and what the relatives have been told.
  • P.1019

  • Ensure all members of the multidisciplinary team involved with the patient’s care are aware of the decision and have it recorded in their notes.
  • Review the decision not to attempt resuscitation, regularly, in the light of the patient’s condition.

Essential reading Resuscitation Council (UK) (2001) Cardiopulmonary resuscitation guidance for clinical practice and training in primary care http://www.resus.org.uk BMA, RCN, and Resuscitation Council (UK) (2001) Decisions relating to cardiopulmonary resuscitation http://www.resus.org.uk

Table 29-1 Resuscitation equipment needed
Equipment Notes
Defibrillator with electrodes and razor
  • An automated external defibrillator should be available wherever and whenever sick patients are seen
  • Regular maintenance is needed even if the machine has not been used
  • After the machine is used, the manufacturers instructions should be followed to return it to a state of readiness with the minimum of delay
Pocket mask with 1-way valve
  • All personnel should be trained to use one
Oropharyngeal airway
  • Suitable for use by those appropriately trained—keep a range of sizes available
Oxygen and mask with reservoir bag
  • Should be available wherever possible
  • Oxygen cylinders need regular maintenance—follow national safety standards
Suction
  • Simple, mechanical, portable, hand-held suction devices are recommended
Drugs Epinephrine/adrenaline—1mg iv
Atropine—3mg iv (give once only)—for bradycardia, asystole, and pulseless electrical activity
Amiodarone—300mg iv for VF resistant to defibrillation
Naloxone—for suspected cases of respiratory arrest due to opiate overdose
images There is no evidence for the use of alkalizing agents, buffers, or calcium salts before hospitalization

  • Drugs should be given by the intravenous route, preferably through a catheter placed in a large vein (e.g. in the antecubital fossa) and flushed in with a bolus of iv fluid
  • Many drugs may be given via the bronchial route if a tracheal tube is in place; for epinephrine/adrenaline and atropine, the dose is double the iv dose
Other
  • Saline flush, gloves, syringes and needles, iv cannulae, iv fluids, sharps box, scissors, tape

P.1020
Basic life supportG

Figure 29.1 Basic life support algorithm

Basic life support Basic life support (BLS) is a holding operation— sustaining life until help arrives. BLS should be started as soon as the arrest is detected—outcome is less good the longer the delay.

  • Danger: Ensure safety of rescuer and patient.
  • Response: Check the patient for any response.
    • Is the patient Alert? Yes/No
    • Does he respond to Vocal stimuli? Yes/No
    • Does he respond to a Painful stimulus (pinching the lower part of the nasal septum)? Yes/No
    • Is the patient Unconscious? Yes/No
  • If he responds by answering or moving: Don’t move the patient unless in danger. Get help. Reassess regularly.
  • If he does not respond: Shout for help; turn the patient on to his back; remove any visible obstructions from the patient’s mouth—leave well fitting dentures in place.
  • Airway: Open the airway—gently tilt the head back and lift the chin.
  • Breathing: With airway open, look, listen, and feel for breathing.
  • If breathing normally: Turn the patient into the recovery position (p.1022), get help, and check for continued breathing. If not breathing: Or only making occasional gasps/weak attempts at breathing—get help; start rescue breathing.
  • P.1021

  • Give 2 slow, effective rescue breaths
    • Ensure head tilt and chin lift.
    • Pinch the soft part of the nose closed with your index finger and thumb. Open the mouth a little.
    • Take a deep breath and place your lips around the patient’s mouth (or nose/mouth and nose), making sure you have a good seal.
    • Blow steadily into the patient’s mouth for ~2 sec. to make the chest rise (1–1.5sec. for a child <8y.). Take your mouth away and watch the chest fall.
    • Repeat the sequence to give 2 effective breaths (max. 5 attempts).
  • Circulation: Check the carotid pulse (max. 10 sec.).
  • If circulation is present: Continue rescue breathing until the patient starts breathing alone; check signs of circulation every 10 breaths. If the patient starts to breath alone but remains unconscious, turn into the recovery position (p.1022) and reassess frequently.
  • If there are no signs of a circulation or you are unsure: Start chest compressions:
    • Place the heel of one hand on top of the other over the lower 1/2 of the sternum (use one hand only in a child <8y. and 2 fingers in an infant <1y.); extend or interlock the fingers of both hands.
    • Position yourself vertically above the patient’s chest and, with arms straight, press the sternum down 4–5cm (1/3–1/2 the depth of the chest in children <8y.). Release the pressure without losing contact between hand and sternum. Compression and release should take an equal amount of time.
    • Repeat at a rate of ~100 compressions/min.
  • After 15 compressions: Tilt the head, lift the chin, and give 2 effective breaths. Then without delay, give 15 further compressions, continuing compressions and breaths in a ratio of 15:2 (5:1 if child <8y.).

Try to avoid head tilt if trauma to the neck is suspected. Only stop to recheck for signs of a circulation if the patient makes a movement or takes a spontaneous breath; otherwise resuscitation should not be interrupted. When to go for assistance It is vital for rescuers to get assistance as quickly as possible.

  • When >1 rescuer is available: One should start resuscitation while another rescuer goes for assistance.
  • Lone rescuer: The rescuer must decide whether to start resuscitation or to go for assistance first.
  • If the likely cause of unconsciousness is trauma; drowning; or if the victim is an infant or a child the rescuer should perform resuscitation for 1min. before going for assistance (and may take a young child/infant with him).
  • Otherwise, go for help immediately it has been established the victim is not breathing.

Essential reading Resuscitation Council (UK) (2000) Resuscitation guidelines http://www.resus.org.uk P.1022
Recovery positionG When circulation and breathing have been restored, it is important to:

  • Maintain a good airway
  • Ensure the tongue does not cause obstruction
  • Minimize the risk of inhalation of gastric contents

For this reason, the victim should be placed in the recovery position. This allows the tongue to fall forward, keeping the airway clear. Action See Figure 29.2

  • Remove the patient’s glasses
  • Kneel beside the patient and make sure that both legs are straight
  • Place the arm nearest to you out at right angles to the body, elbow bent, with the hand palm uppermost
  • Bring the far arm across the chest, and hold the back of the hand against the patient’s cheek nearest to you
  • With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground
  • Keeping the patient’s hand pressed against his cheek, pull on the leg to roll the patient towards you, onto his side
  • Adjust the upper leg so that both the hip and knee are bent at right angles
  • Tilt the head back to make sure the airway remains open
  • Adjust the hand under the cheek, if necessary, to keep the head tilted
  • Check breathing regularly.

Monitor the peripheral circulation of the lower arm. If the patient has to be kept in the recovery position for >30min., turn him onto the opposite side. The unconscious child

  • The child should be in as near a true lateral position as possible with his mouth dependant, to allow free drainage of fluid.
  • The position should be stable. In an infant, this may require the support of a small pillow or rolled up blanket placed behind the back to maintain the position.

Cervical spine injury

  • If spinal cord injury is suspected (e.g. if the victim has sustained a fall, been struck on the head or neck, or has been rescued after diving into shallow water), take particular care during handling and resuscitation to maintain alignment of the head, neck, and chest in the neutral position.
  • A spinal board and/or cervical collar should be used if available.
Figure 29.2 Recovery position

P.1023
P.1024
Automated external defibrillatorsG

Figure 29.3 Automatic external defibrillator algorithm (Reproduced from Resuscitation guidelines (2000) with permission of Resuscitation Council (UK). Full version available from http://www.resus.org.uk)

Use of automated external defibrillators (AEDs)

  • Modern AEDs have simplified the process of defibrillation considerably.
  • ECG interpretation and charging of the machine in preparation to shock are now automated. This has greatly reduced training requirements and extended the range of personnel who can attempt defibrillation.
  • The use of such machines should be within the capabilities of all medical and nursing staff working in the community—so ALL practices should have an AED.
  • Increasingly, trained lay persons are successfully employing AEDs and it is quite appropriate for reception, administrative, and secretarial staff to be trained in their use.

P.1025
Cardiac arrest in adults A high proportion of adults who suffer cardiac arrest in the community will have a VF arrest. Their best chance of survival is to be shocked as soon as possible. If a patient arrests:

  • Perform basic life support until the defibrillator arrives (p.1020)
  • Make sure someone has called an ambulance
  • Prepare the patient for defibrillation:
    • Expose the chest
    • Shave any chest hair (there should always be a special razor for this purpose stored with the defibrillator)—it is essential there is good contact between the skin and the electrodes
    • Remove any GTN patches visible—if a patch is present and you’re not sure what it is, remove it
    • Remove jewellery or move it away from the electrodes
    • Apply the pads—pads should be stored flat, should be unopened, and in date.
  • Pad position: The pads are marked to show where they should be placed—one on the right side of the chest with the top right corner in the angle between the clavicle and sternum; the other, along the line of the bottom left rib pointing into the axilla
  • Switch the defibrillator on and follow the instructions
  • Before delivering a shock check:
    • Top—any oxygen has been moved away from the patient and the person looking after the airway is standing clear
    • Middle—the person performing cardiac massage and you are standing clear
    • Bottom—anyone else in the vicinity is standing clear
  • Announce you are delivering a shock in a clear, loud voice; check briefly again that everyone is standing clear; and then shock the patient
  • Follow the instructions from the defibrillator.

Cardiac arrest in children Ventricular fibrillation is a less common presentation of cardiopulmonary arrest in children, but the same treatment principles apply.

  • Children >8y.: Modern AEDs designed for use in adults can be used.
  • Children <8y.: Special infant electrodes are advised—they are available from some manufacturers.

Essential reading Resuscitation Council (UK) http://www.resus.org.uk

  • Resuscitation guidelines (2000)—guidelines for the use of automated external defibrillators
  • The use of biphasic defibrillators and AEDs in children (revised 2003)

P.1026
Adult advanced life supportG

Figure 29.4 Adult advanced life support algorithm (Reproduced from Resuscitation guidelines (2000) with permission of Resuscitation Council (UK). Full version available from http://www.resus.org.uk)

P.1027
Notes Precordial thump Appropriate if arrest is witnessed and defibrillator is not to hand. Basic life support (BLS) algorithm p.1020 or inside back cover. BLS should be started if there is any delay in obtaining a defibrillator, but must not delay shock delivery. Automated external defibrillator protocol p.1024 or inside back cover. Drugs

  • Drugs administered by the iv route must be followed by a flush of ≥20ml of saline to assist delivery.
  • Adrenaline (epinephrine)—dose 1mg iv or 2–3mg (diluted in at least 10ml of sterile water) via endotracheal (ET) tube. Give every 3min. during resuscitation but avoid giving within 1min. of defibrillation.

VF/VT arrest

  • Paddle position: Place 1 paddle under the right clavicle and the other on the left axillary line.
  • Defibrillation: Up to 3 shocks with energies of 200J, 200J, 360J may be used in any cycle of resuscitation. When all 3 shocks are needed—aim to administer them in <1min. During 1min. after defibrillation, do not administer adrenaline (epinephrine), as it may be harmful. Successful defibrillation is usually followed by at least a few seconds of true asystole.
  • Amiodarone: Consider, following epinephrine, to treat shock-refractory cardiac arrest due to VF or pulseless VT. Amiodarone 300mg (made up to 20ml with dextrose, or from a prefilled syringe) may be administered into a peripheral vein. A further dose of 150mg may be given for recurrent or refractory VT/VF.

Non-VT/VF arrest

  • Asystole
    • Check ECG for the presence of P waves or slow ventricular activity—it may respond to cardiac pacing. Repeated precordial blows, lateral to the lower left sternal edge (70/min.), can be used to stimulate the myocardium (percussion pacing).
    • Atropine 3mg iv or 6mg via ET tube (in a volume of 10–20ml of water) may be helpful.
    • If there is any doubt about diagnosis of asystole, treat for VF.
  • Pulseless electrical activity/electromechanical dissociation: Best chance of survival is prompt identification and treatment of any underlying cause.

Essential reading Resuscitation Council (UK) (2000) Resuscitation guidelines http://www.resus.org.uk P.1028
Paediatric advanced life supportG

Figure 29.5 Paediatric advanced life support algorithm (Reproduced from Resuscitation guidelines (2000) with permission of Resuscitation Council (UK). Full version available from http://www.resus.org.uk)

P.1029
Basic paediatric life support Follow the algorithm on p.1020 or inside the back cover. Notes Unable to ventilate? Consider foreign body in the airway and initiate airway obstruction sequence—p.1052. Checking the pulse

  • Child—feel for the carotid pulse in the neck
  • Infant—feel for the brachial pulse on the inner aspect of the upper arm.

Adrenaline (epinephrine) dose

  • Intravenous or interosseous access—10mcg/kg epinephrine (0.1 ml/kg of 1:10,000 solution).
  • Via endotracheal (ET) tube—100mcg/kg (1 ml/kg of 1 in 10,000 or 0.1 ml/kg of 1 in 1000 solution).
  • Consider using higher doses (e.g. 100mcg/kg iv or io) if vasodilatation contributed to cardiac arrest (e.g. septicaemia, anaphylaxis).

VF/pulseless VT Less common in paediatric life support.

  • Defibrillation: Use up to 3 shocks/resuscitation cycle:
    • 2J/kg, 2J/kg, 4J/kg on the first occasion
    • 4J/kg, 4J/kg, 4J/kg on subsequent occasions.
  • Electrode/paddle position: Child: Place the defibrillator pads or paddles on the chest wall—one just below the right clavicle, the other at the left anterior axillary line. Infant: Apply the pads or paddles to the front and back of the infant’s chest.
  • After each drug, CPR should continue for up to a minute to allow the drug to reach the heart before a further defibrillation attempt.
  • For shock resistant VF/pulseless VT, try amiodarone 5mg/kg via rapid iv bolus.

Intravenous fluids In situations where the cardiac arrest has resulted from circulatory failure, a standard (20ml/kg) bolus of crystalloid fluid should be given if there is no response to the initial dose of epinephrine. Essential reading Resuscitation Council (UK) (2000) Resuscitation guidelines http://www.resus.org.uk P.1030
Resuscitation of the newbornG Follow the algorithm opposite (Figure 29.6). Rapid assessment of the infant at birth A healthy baby

  • Born blue
  • Good tone
  • Cries within a few seconds of delivery
  • Good heart rate (120–150bpm)
  • Rapidly becomes pink during the first 90sec.

A less healthy baby

  • Blue at birth
  • Less good tone
  • ± slow heart rate (<100bpm)
  • ± inadequate breathing by 90–120sec.

An ill baby

  • Born pale
  • Floppy
  • Slow/very slow heart rate (<100bpm)
  • Not breathing

Notes Heart rate Best judged by listening with a stethoscope—in many cases it can also be felt by gently palpating the umbilical cord or by feeling for the apex beat over the anterior chest. Feeling for peripheral pulses is not helpful. Meconium Screaming babies have an open airway; floppy babies—have a look. Airway Open the airway by placing the head in a neutral position—where the neck is neither extended nor flexed. If the occiput is prominent and the neck tends to flex, place a support under the shoulders. It may be necessary to apply jaw thrust or chin lift if the baby is very floppy. Breathing Inflation breaths are breaths with pressures of ~30cms of water for 2–3sec.

  • If the heart rate ↑ from its previous rate—you have successfully inflated the chest. If the baby does not then start breathing alone, continue to provide regular breaths at a rate of ~30–40breaths/min. until the baby starts to breathe on its own.
  • If the heart rate does not ↑ following inflation breaths, then either you have not inflated the chest or the baby needs more help. By far the most likely is that you have failed to inflate the chest (the chest does not move).

Chest compressions Only commence after inflation of the lungs. Grip the chest in both hands in such a way that the thumbs of both hands can press on the sternum at a point just below an imaginary line joining the nipples and with the fingers over the spine at the back. Compress the chest quickly, reducing the AP diameter of the chest by ~1/3 with each compression. The ratio of compressions to inflations is 3:1. Essential reading Resuscitation Council (UK) (2000) Resuscitation guidelines http://www.resus.org.uk

Figure 29.6 Newborn life support algorithm

P.1031
P.1032
Coma Patients in coma/pre-coma nearly always require emergency admission. When you receive the call for assistance

  • Advise the attendant (unless history of possible spinal injury) to turn the patient onto his/her side
  • Call an ambulance to meet you at the scene.

On reaching the patient

  • Assess the need for basic life support:
    • Airway patent?
    • Breathing satisfactory?
    • Circulation adequate?
  • Turn into the recovery position (p.1022) if no contraindications (e.g. spinal injury)
  • Call for ambulance support if you have not already done so
  • Ensure the patient is warm.
  • Record baseline level of responsiveness either using Glasgow Coma Scale (below) or as AVPU Score (p.1020). Ensure you note the time the score was recorded.
  • Try to establish a diagnosis (see assessment)

As soon as possible

  • Insert an airway
  • Give oxygen
  • Establish iv access
  • Transfer to hospital (unless the condition has resolved e.g. hypoglycaemia, fit)

Possible causes

  • Drugs: Sedatives or hypnotics, opiates, alcohol, solvents, carbon monoxide poisoning
  • Vascular: Stroke, low cardiac output e.g. post Ml, ruptured AAA
  • CNS: Fit or post-ictal state; hydrocephalus (e.g. blocked shunt); cerebral oedema (e.g. meningitis, SAH, head injury); concussion; extradural or subdural haematoma
  • Metabolic: Hypo- or hyperglycaemia; hypothermia; hypopituitarism
  • Infection: Meningitis or septicaemia; pneumonia

Assessment and management See Figure 29.7

Table 29-2 The Glasgow Coma Scale
Eye opening Spontaneous 4 To pain 2
To voice 3 None 1
Best verbal response Oriented 5 Incomprehensive 2
Confused 4 None 1
Inappropriate words 3
Best motor response Obeys command 6 Flexion 3
Localizes pain 5 Extension 2
Withdraw 4 None 1
Total score = Eye opening + best verbal + best motor response scores
Figure 29.7 Assessment and management of the unconscious patient

P.1033
P.1034
Anaphylaxis Severe systemic allergic reaction. Common causes

  • Foods: nuts, fish and shellfish, sesame seeds and oil, milk, eggs, pulses (beans, peas)
  • Insect stings: wasp or bee
  • Drugs: antibiotics, aspirin and other NSAIDs, opiates
  • Latex

Essential features 1 or both of:

  • Respiratory difficulty e.g. wheeze, stridor—may be due to laryngeal oedema or asthma
  • Hypotension—can present as fainting, collapse, or loss of consciousness

Other features All or some of the following:

  • Erythema
  • Angio-oedema
  • Itching of palate
  • Itching of external auditory meatus
  • Generalized pruritus
  • Rhinitis
  • Nausea
  • Palpitations
  • Urticaria
  • Conjunctivitis
  • Vomiting
  • Sense of impending doom

Examination

  • Airway—mouth/tongue for oedema
  • Breathing—chest (wheeze), PEER
  • Circulation—pulse, BP
  • Skin—check for rashes

Action

  • If suspected when the initial call for help comes in, call an emergency ambulance immediately—then visit.
  • Ask when the initial call is taken if the patient has had a similar event before. If so, ask if he/she has an Epipen or similar. If yes, advise the caller to use it immediately.

On arrival

  • Ensure the patient is comfortable—lie down flat ± leg elevation if ↓BP; sit up if breathing difficulty.
  • If available, give oxygen at high flow rates (10–15l/min.).
  • Give im adrenaline (epinephrine) to all patients with clinical signs of shock, airway swelling, or breathing difficulty. Dose:
    • Adult or child > 12y.: 0.5ml epinephrine (adrenaline) 1:1000 solution (500µg) im. Give half dose if: pre-pubertal or adult on tricyclic antidepressants, monoamine oxidase inhibitors, or β blockers.
    • Child 6–12y.: 1/2 adult dose—0.25ml of 1:1000 epinephrine (adrenaline) solution (250µg) im.
    • Child 6mo.–6y.: 1/4 adult dose—0.12ml of 1:1000 epinephrine (adrenaline) solution (120µg) im.
    • Child <6mo.: 0.05ml 1:1000 epinephrine (adrenaline) solution (50µg) im. Absolute accuracy of dose is not necessary.
  • P.1035

  • Repeat after ≥5min. if improvement is transient, no improvement, or deterioration after initial treatment. May need several doses.
  • Give an antihistamine: Dose of chlorpheniramine:
    • Adults and children > 12y.—10–20mg im
    • Children 6–12y.—5–10mg im
    • Children 1–6y.—2.5–5mg im
  • Give hydrocortisone by im or slow iv injection. Dose:
    • Adults and children >12y.—100–500mg
    • Children 6–11y.—100mg
    • Children 1–6y.—50mg
  • Give salbutamol if bronchospasm
  • If severe hypotension does not respond rapidly, start an iv infusion (if available) and rapidly infuse 1–2l of saline until BP ↑ (children 20ml/kg rapidly, then another similar dose if not responding)
  • Admit the patient to hospital until ill effects have settled.

The preferred site for im injection is the midpoint of the anterolateral thigh. Algorithm for management of anaphylaxis in adults Figure 29.8 (p.1036). Algorithm for management of anaphylaxis in children Figure 29.9 (p.1037). Follow-up

  • Warn patients or parents of the possibility of recurrence.
  • Advise sufferers to wear a device (e.g. Medic Alert bracelet) that will inform bystanders or medical staff should a future attack occur.
  • Refer all patients after their first anaphylactic attack to a specialist allergy clinic.
  • Consider supplying sufferers (or parents) with an Epipen or similar which can be used to administer im epinephrine (adrenaline) immediately should symptoms recur.
  • If you supply an Epipen, teach anyone likely to need to use it, how to operate the device. Intramuscular epinephrine is very safe.

Further Information Resuscitation Council (UK) Emergency Medical treatment of anaphylactic reactions for first medical responders and community nurses (Revised 2005) http://www.resus.org.uk

Figure 29.8 Anaphylactic reactions: treatment algorithm for adults (Reproduced with permission of Resuscitation Council UK.)
Figure 29.9 Anaphylactic reactions: treatment algorithm for children (Reproduced with permission of Resuscitation Council UK.)

P.1036
P.1037
P.1038
Shock Due to inadequate blood flow to the peripheral circulation. Usually → ↓ BP (± tachycardia), peripheral cyanosis, and ↓ urinary output. Hypovolaemic shock Usually due to haemorrhage e.g. Gl bleeding (p.1040), ruptured AAA (p.1042). Signs

  • Initially—tachycardia (pulse >100bpm), pallor, sweating > restlessness.
  • Later—decompensation—(sudden fall in pulse rate and BP). Young people may decompensate very rapidly. If tachycardic, treat as a medical emergency—speed could be lifesaving.

Action

  • Lie the patient down flat and raise legs above waist height
  • Call for ambulance assistance
  • Control bleeding by applying pressure, if obvious bleeding point (e.g. nose bleed, laceration)
  • Gain iv access and (if possible) take blood for FBC and cross-matching—try to insert 2 large bore cannulae
  • If available, start plasma expander/iv fluids; give rapidly over 10–15min.
  • If available, give 100% oxygen (unless COPD, when give 24%)

Anaphylactic shock p.1034 Cardiogenic shock Due to heart pump failure e.g. Ml, arrythmia, tamponade. Signs

  • Hypotension—systolic BP <80–90mmHg
  • Pulse rate may be normal, ↑, or ↓
  • Severe breathlessness ± cyanosis

Action

  • Sit the patient up if possible
  • Call for ambulance assistance
  • Treat any underlying cause found e.g. atropine for bradycardia; diamorphine, frusemide, and GTN spray for acute LVF
  • Gain iv access if possible
  • If available, give 100% oxygen (unless COPD, when give 24%)

Septic shock Due to toxins from bacterial infection e.g. meningococcus. Signs

  • Hypotension
  • Tachycardia
  • Peripheral vasodilation or shut down (peripheral pallor and cyanosis, cool extremities)
  • Pyrexia
  • Tachypnoea
  • ± purpuric rash

P.1039
Action

  • Lie the patient down flat and raise legs above waist height
  • Call for ambulance assistance
  • Give iv/im benzylpenicillin immediately while awaiting transport. Dose:
    • Adult and child ≥10y.—1.2g
    • Child 1–9y.—600mg
    • Infant <1y.—300mg
  • If possible, gain iv access whilst awaiting the ambulance and take blood for cultures
  • If available, start plasma expander/iv fluids; give rapidly over 10–15min.
  • If available, give 100% oxygen (unless COPD, when give 24%)

Other rarer causes of shock Admit as medical emergencies.

  • Neurogenic—due to cerebral trauma or haemorrhage e.g. head injury, subarachnoid haemorrhage
  • Poisoning
  • Liver failure

P.1040
Gastrointestinal (Gl) bleeding Causes of Gl bleeding Upper Gl bleed

  • Peptic ulcer
  • Gastritits
  • Mallory-Weiss tear
  • Oesophagitis
  • Oesophageal or gastric cancer
  • Oesophageal varices
  • Drugs—NSAIDs, steroids, anticoagulants
  • Angiodysplasia
  • Haemangioma
  • Bleeding disorders
  • Swallowed blood from nosebleed

Lower Gl bleed

  • Diverticulitis
  • Colitis—infectious or inflammatory
  • Large bowel tumour or polyp
  • Haemorrhoids
  • Anal fissure
  • Angiodysplasia (arterio-venous malformations are common)
  • Haemangioma
  • Bleeding disorders
  • Blood from upper Gl bleed

Risk factors Upper Gl bleed

  • History of alcohol abuse
  • History of chronic liver disease
  • History of NSAID use
  • History of oral steroid use

Lower Gl bleed

  • Change in bowel habit
  • History of diverticulitis
  • History of UC

All Gl bleeds

  • Anticoagulant use
  • Serious medical conditions (e.g. cardiovascular, respiratory, or renal disease)
  • Recent tiredness (? due to anaemia)

Presentation Upper Gl bleeding Typical presentation:

  • Haematemesis—vomiting of blood
  • Melaena—passage of black, offensive, tarry stool consisting of digested blood, per rectum (PR)

Iron tablets may cause black stools. Lower Gl bleeding Typical presentation:

  • Passage of fresh blood, PR

Very heavy upper Gl bleeds can present with fresh red bleeding, PR. Other features that may be present

  • Faintness or dizziness, especially on standing
  • Patient feels cold or clammy
  • Collapse ± cardiac arrest

Examination

  • Pulse—tachycardia
  • BP—↓ and/or postural drop
  • JVP—↓
  • Vomitus

Young people can lose a lot of blood before their BP drops. Be worried if a young person is tachycardic. P.1041
Action

  • When the call for help is received—arrange immediate emergency transfer of the patient to hospital if a significant acute Gl bleed is suspected.
  • Attend the patient if diagnosis from history is unclear or (if possible) once the ambulance has been called to assist.
  • Regard as an emergency until proved otherwise.

On arrival Briefly assess the severity of the bleed from history and examination. If a significant Gl bleed is suspected:

  • Lie the patient flat and lift legs higher than body (e.g. feet on a pillow).
  • Insert a large bore iv cannula—the opportunity may be lost by the time the ambulance crew arrive. If possible, take a sample for FBC and X-match on insertion.
  • If available, give oxygen.
  • If available, start plasma expander/iv fluids.
  • Transfer as rapidly as possible to hospital.

Coffee-grounds vomit

  • Vomiting of altered blood—looks like coffee granules
  • Implies upper Gl bleeding—though less severe than fresh red blood
  • History and examination as for acute Gl bleed
  • Always admit to hospital for further assessment

P.1042
Other bleeds Bleeding aneurysms Ruptured abdominal aortic aneurysm (AAA)

  • In the community setting, death rate from ruptured AAA ≈ 90% (80% die before reaching hospital and 50% that get to hospital die during surgery).
  • Consider a ruptured AAA in any patient with ↓BP and atypical abdominal symptoms (especially if there is a pulsatile abdominal mass).

In a patient with a known AAA, abdominal pain represents a ruptured AAA unless proven otherwise. Dissecting thoracic aneurysm

  • Consider in any patient with ↓BP and chest pain (especially if the pain radiates through to the back).
  • Typically presents with sudden tearing chest pain radiating to the back.
  • As the dissection progresses, branches of the aorta are sequentially occluded causing:
    • Hemiplegia—carotid artery
    • Unequal pulses and BP in the two arms—subclavian artery
    • Paraplegia—spinal arteries
    • Acute renal failure—renal arteries
  • Proximal extension may cause aortic incompetence and MI (cardiac arteries).

Action

  • Obtain venous access with 2x large bore iv cannulae.
  • Admit as ‘blue light’ emergency, keeping the patient flat in the ambulance.
  • Warn relatives of poor prognosis.

Nose bleed/epistaxis Usually from ruptured blood vessels on the nasal septum (vein behind the comella or Little’s area). Causes

  • Elderly: Degenerative arterial disease, ↑ BP, nose picking, coryza, allergic rhinitis, blood dyscrasias, teleangiectasia, and tumours. Often no cause is found.
  • Young: Nose picking, coryza, allergic rhinitis, blood dyscrasias.

Action

  • Check if the patient is on anticoagulants, aspirin, or NSAIDs and enquire about bleeding problems.
  • Check BP—often high at time of bleed, so review prior to considering treatment Watch for signs of shock and airway problems.

Most bleeds can be stopped by:

  • Pinching the soft tip of nose for ≥10min.
  • If available, applying an ice pack to the bridge of the nose.
  • Leaning the patient forward to prevent blood entering the post nasal space.

P.1043
If the bleeding is not settling and an anterior bleeding point is visualized:

  • Try cautery with a silver nitrate stick after application of lignocaine on a piece of cotton wool.
  • Prescribe antiseptic cream e.g. naseptin bd for 1wk.

Admit: As an emergency to A&E or ENT if shocked or heavy bleeding cannot be stopped after 30min. Hospital management

  • The anterior nares can be packed to try and stop bleeding using ribbon gauze in paraffin or a nasal tampon. The pack is usually left in place for 24h.
  • Posterior nasal packs (e.g. using a foley catheter) are also used.
  • Blood transfusion is rarely required.
  • Occasionally, surgical exploration is required to find and cauterize the bleeding point or perform arterial ligation.

Referral: Refer recurrent minor bleeds to ENT for non-urgent assessment. P.1044
Meningitis and encephalitis Meningitis May be preceded with prodrome of fever, vomiting, malaise, poor feeding, and lethargy which is often indistinguishable from a viral infection. Usually rapid onset (<48h.) with signs of:

  • Meningism
    • Headache
    • Photophobia
    • Stiff neck—can’t put chin on chest
    • Kernig’s sign +ve—with hips fully flexed, resists passive knee extension
  • ↑ICP
    • Irritability
    • Drowsiness and/or ↓ conscious level
    • Fits
    • Vomiting
    • ↓ pulse rate
    • ↑ BP
    • Bulging fontanelle (baby)
    • Abnormal tone/posturing
  • Septicaemia
    • Rash—petechiae suggest meningococcus
    • Fever
    • Arthritis
    • Tachycardia
    • Peripheral shut down—cool peripheries, mottled skin, cyanosis
    • Tachypnoea

Small children, the elderly, or immunocompromised may not present with typical signs. Go on gut feeling. Action

  • Call an 999 ambulance and get the patient to hospital as soon as possible.
  • Give iv/im benzylpenicillin immediately while awaiting transport. Dose:
    • Adult and child >10y.—1.2g
    • Child 1–9y.—600mg
    • Infant <1y.—300mg
  • Cefotaxime is an alternative for patients allergic to penicillin.
  • If possible, gain iv access whilst awaiting the ambulance and take blood for cultures.

Contact tracing/prophylaxis

  • Undertaken by the local public health department.
  • For a single case, only very close contacts (‘kissing contacts’ e.g. immediate family members) require prophylactic antibiotics.
  • Prophylaxis is with rifampicin 600mg bd for 2d. (child 10mg/kg bd for 2d. unless <1y. when dose is 5mg/kg bd for 2d.) or ciprofloxacin 500mg as a single dose (not licensed for this indication and not suitable for children) Rifampicin colours urine red.

P.1045
Meningitis vaccination

  • Group C strains are responsible for 40% of meningococcal disease
  • Group B strains are responsible for most of the rest
  • Group A strains are common in other parts of the world but rare in the UK.

Meningococcal A&C vaccine: Confers no protection against Group B organisms. Meningitis C conjugate vaccine

  • Confers no protection against group A or group B organisms.
  • For infants, doses are given at 2, 3, and 4mo. as part of the routine childhood vaccination programme (p.480).
  • For infants >4mo., 2 doses are required; and >1y. of age, only 1 dose is necessary to confer lasting immunity.
  • Vaccine may be given to HIV +ve patients.
  • A gap of 6mo. is recommended between a dose of the meningococcal A&C vaccine, usually given for travel purposes, and meningitis C conjugate vaccine.
  • Do not use meningitis C conjugate vaccine for travel purposes as the greatest risk is from group A infection.
  • Immunize individuals travelling abroad to high-risk areas with the meningococcal A&C vaccine, even if they have received the meningitis C conjugate vaccine beforehand.

Helplines for families Meningitis Research Foundation Tel: 080 8800 3344 http://www.meningitis.org.uk Meningitis Trust Tel:0845 6000 800 http://www.meningitis-trust.org Encephalitis Inflammation of brain parenchyma. Usually viral in origin. Typically presents with:

  • Fever
  • Symptoms and signs of meningitis (see opposite)
  • Altered consciousness
  • Focal neurological signs/symptoms
  • Convulsions
  • Psychiatric symptoms

Action

  • Admit immediately for further investigation/treatment.
  • Treat blind with antibiotics if symptoms/signs of meningitis—see opposite.

P.1046
Chest pain On receiving the call for assistance Ask:

  • Nature and location of the pain
  • Duration of the pain
  • Other associated symptoms—sweating, nausea, shortness of breath, palpitations
  • Past medical history (particularly heart disease, high cholesterol)
  • Family history (particularly heart disease)
  • Smoker?

Action

  • Consider differential diagnosis (Table 29.3).
  • If MI is suspected, call for ambulance assistance before (or instead of) visiting.
  • Otherwise visit, assess, and treat according to cause.
  • If a patient is acutely unwell with chest pain, and the cause is not clear, err on the side of caution and admit for further assessment.

Further information Chest pain (p.251)

Table 29-3 Possible causes of acute chest pain
Diagnosis Page reference Features
MI p.1048 Band-like chest pain around the chest or central chest pressure.
± radiation to shoulders, arms (L > R), neck, and/or jaw.
Often associated with nausea, sweating, and/or short-ness of breath.
Unstable angina p.1048 As for MI.
Pericarditis p.351 Sharp, constant sternal pain relieved by sitting forwards.
May radiate to left shoulder ± arm or into the abdomen.
Worse lying on the left side and on inspiration, swallowing, and coughing.
Dissecting thoracic aneurysm p.1042 Typically presents with sudden tearing chest pain radiating to the back.
Consider in any patient with chest pain (especially if radiates through to the back) and ↓BP.
PE p.1054 Acute dyspnoea, sharp chest pain (worse on inspiration), haemoptysis, and/or syncope.
Pleurisy p.252 Sharp, localized chest pain-worse on inspiration.
May be associated with symptoms and signs of a chest infection.
Pneumothorox p.392 Sudden onset of pleuritic chest pain or ↑ breathlessness ± pallor and tachycardia.
Oesophageal spasm, oesophagitis p.434 Central chest pain. May be associated with acid reflux (though not always).
May be described as burning but often indistinguishable from cardiac pain.
May respond to antacids.
Musculo-skeletal pain p.253 Localized pain-worse on movement.
May be a history of injury.
Shingles p.494 Intense, often sharp, unilateral pain.
Responds poorly to analgesia.
May be present several days before rash appears.
Costochondritis p.584 Inflammation of the costochondral junctions— tenderness over the costochondral junction and pain in the affected area on springing the chest wall.
Bornholm’s disease Unilateral chest and/or abdominal pain, rhinitis.
Coxsackie virus infection. Treat with simple analgesia.
Idiopathic chest pain p.253 No cause apparent. Common.
Affects young people > elderly people; ♀ > ♂.

P.1047
P.1048
Myocardial infarct (MI) and unstable angina Myocardial infarct Typical presentation Sustained central chest pain not relieved by sublingual GTN. Other features that may be present

  • Collapse ± cardiac arrest
  • Breathlessness
  • Anxiety/fear of dying
  • Nausea ± vomiting
  • Sweating
  • Pain in 1 or both arms, jaw, back, or upper abdomen.

May occasionally be silent, especially in patients with DM. Examination Pulse, BP, JVP, heart sounds, chest (? pulmonary oedema). Investigation ECG—ST elevation or R waves and ST depression in leads V1–V3 (posterior infarction) or new LBBB. Action When the call for assistance is made If MI is suspected, arrange immediate transfer to hospital—for throm-bolysis to be effective, it must be given as soon as possible after the onset of pain. Seeing the patient before arranging transfer introduces unnecessary delays. If possible, attend the patient once the ambulance has been called to assist—there is a lot a GP can do that an ambulance crew cannot If the patient is seen:

  • Give aspirin 300mg po (unless contraindicated)
  • Insert iv cannula
  • Give iv analgesia (diamorphine 2.5–5mg); repeat in 15min. as necessary
  • Give iv antiemetic (metoclopramide 10mg)
  • Give sublingual GTN to act as a coronary artery vasodilator (if systolic BP >90 and pulse <100bpm)
  • If available, give oxygen
  • If bradycardia, give atropine 300mcg iv and further doses of 300mcg, if needed, to a maximum of 1.2mg.

Thrombolysis in general practice: May be appropriate in places where transfer to hospital takes >1/2 h. Special training and equipment is necessary. P.1049
Late calls

  • If the patient is seen <24h. after an acute episode, admit for specialist assessment.
  • If the patient is seen >24h. after an acute episode but still has residual pain or other symptoms, admit
  • If the patient is seen >24h. after an acute episode and is well, start regular aspirin, supply with GTN spray, warn what to do if any further episodes of acute chest pain, and follow-up as for MI post-discharge (p.332).

Follow-up care p.332 Unstable angina Defined as rapid acceleration of pre-existing exertional angina or the occurrence of prolonged episodes of ischaemic pain at rest. It is difficult to tell the difference between acute MI and unstable angina in general practice. Treat as for acute MI. P.1050
Choking—adultG If blockage of the airway is only partial, the victim will usually be able to dislodge the foreign body by coughing. If obstruction is complete, urgent intervention is required to prevent asphyxia. Victim is unconscious

  • Tilt the victim’s head and remove any visible obstruction from the mouth
  • Open the airway further by lifting the chin
  • Check for breathing by looking, listening, and feeling
  • Attempt to give 2 effective rescue breaths (p. 1020)

If effective breaths can be achieved in ≤5 attempts

  • Check for signs of a circulation
  • Start chest compressions and/or rescue breaths as appropriate (p. 1020)

If effective breaths cannot be achieved in ≤5 attempts

  • Start chest compressions immediately, to relieve the obstruction—do not check for signs of a circulation
  • After 15 compressions, check the mouth for any obstruction, then attempt further rescue breaths
  • Continue to give cycles of 15 compressions, followed by attempts at rescue breaths

If, at any time, effective breaths can be achieved

  • Check for signs of a circulation
  • Continue chest compressions and/or rescue breaths as appropriate (p. 1020)

Victim shows signs of exhaustion or becomes cyanosed but is conscious Carry out back blows.

  • Remove any obvious debris or loose teeth from the mouth
  • Stand to the side and slightly behind him
  • Support the chest with one hand and lean the victim well forwards
  • Give up to 5 sharp blows between the scapulae with the heel of the other hand; each blow should be aimed at relieving the obstruction, so all 5 need not necessarily be given

If the back blows fail, carry out abdominal thrusts

  • Stand behind the victim and put both your arms around the upper part of the abdomen
  • Ensure the victim is bending well forwards so that the obstructing object comes out of the mouth when dislodged
  • Clench your fist and place it between the umbilicus and the xiphisternum. Grasp it with your other hand
  • Pull sharply inwards and upwards. Repeat up to 5 times. The obstruction should be dislodged.

If the obstruction is still not relieved

  • Recheck the mouth for any obstruction that can be reached with a finger
  • Continue alternating 5 back blows with 5 abdominal thrusts

P.1051
Victim is conscious and breathing, despite evidence of obstruction Encourage him to continue coughing but do nothing else. Foreign body in the throat Occurs after eating—fish bone or food bolus are most common. Can cause severe discomfort, distress, and inability to swallow saliva. Management Refer immediately to A&E or ENT for investigation (lateral neck X-ray ± laryngoscopy). Most fish bones have passed and the discomfort comes from mucosal trauma. Food boluses often pass spontaneously (especially if the patient is given a smooth muscle relaxant) but occasionally need removal under GA.

Figure 29.10 Algorithm for the management of choking in adults. (Reproduced with permission of the Resuscitation council (UK) http://www.resus.org.uk)

Further information Resuscitation Council (UK) http://www.resus.org.uk P.1052
Choking—childG If the child is breathing spontaneously, his own efforts to clear the obstruction should be encouraged. Intervention is necessary only if these attempts are clearly ineffective and breathing is inadequate. Do not perform blind finger sweeps of the mouth or upper airway as these may further impact a foreign body or cause soft tissue damage. Step 1: Perform up to 5 back blows

  • Hold the child in a prone position and try to position the head lower than the chest with the airway in an open position
  • Deliver up to 5 smart blows to the middle of the back between the shoulder blades
  • If this fails to dislodge the foreign body, proceed to chest thrusts

Step 2: Perform up to 5 chest thrusts

  • Turn the child into a supine position with the head lower than the chest and the airway in an open position
  • Give up to 5 chest thrusts to the sternum
  • The technique for chest thrusts is similar to that for chest compressions but chest thrusts should be sharper and more vigorous and carried out at a rate of ~20/min.

Step 3: Check the mouth

  • After 5 back blows and 5 chest thrusts, check the mouth
  • Carefully remove any visible foreign bodies

Step 4: Open the airway

  • Reposition the airway by the head tilt and chin lift (jaw thrust) manoeuvre
  • Reassess breathing

Step 5 If the child is breathing

  • Turn the child on his side
  • Check for continued breathing

If the child is not breathing

  • Attempt up to 5 rescue breaths to achieve 2 effective breaths, each of which makes the chest rise and fall. The child may be apnoeic or the airway partially cleared. In either case, you may be able to achieve effective ventilation at this stage.

If the airway is still obstructed For a child (>1y.)

  • Repeat the cycle (steps 1–5 above) but substitute 5 abdominal thrusts for 5 chest thrusts
  • Abdominal thrusts are delivered as 5 sharp thrusts directed upwards towards the diaphragm
  • Use the upright position if the child is conscious; kneel behind a small child
  • Unconscious children should be laid supine and the heel of one hand placed in the middle of the upper abdomen
  • P.1053

  • Alternate chest thrusts and abdominal thrusts in subsequent cycles
  • Repeat the cycles until the airway is cleared or the child breathes spontaneously

For an infant (<1y.)

  • Abdominal thrusts are not recommended in infants because they may rupture the abdominal viscera
  • Perform cycles of 5 back blows and 5 chest thrusts only
  • Repeat the cycles until the airway is cleared or the infant breathes spontaneously.

Further information Resuscitation Council (UK) http://www.resus.org.uk P.1054
Acute breathlessness (1) Attend as soon as possible after receiving the call for help. If there is likely to be any delay, call for emergency ambulance assistance. On arrival Be calm and reassuring. Breathlessness is frightening and panic only adds to the sensation of being breathless. Consider possible causes

  • Asthma: p. 1058
  • Anaphylaxis: p. 1036
  • Acute left ventricular failure: p. 1056
  • Arrythmia: p.342
  • Pneumonia: p.390
  • Acute exacerbation of COPD: p.386
  • Hyperventilation: p. 1056
  • Pulmonary embolism: See below
  • Spontaneous pneumothorax: See opposite and p.392
  • Choking: p. 1050
  • Air hunger due to shock: p. 1038

Direct history and examination to finding the cause as quickly as possible. Treat according to the cause. If no cause can be found—don’t delay. Admit to hospital as an acute medical emergency. Pulmonary embolus Venous thrombi (usually from a DVT) pass into the pulmonary circulation and block blood flow to the lungs. Fatal in ~1:10 cases. Risk factors

  • Immobility—long flight or bus journey, post-op, plaster cast
  • Smoking
  • COC pill
  • Pregnancy or puerperium
  • Malignancy
  • Past history or FH of DVT or PE

Presentation

  • Symptoms: Acute dyspnoea, pleuritic pain, haemoptysis, syncope
  • Signs
    • Hypotension
    • Tachycardia
    • Cyanosis
    • Tachypnoea
    • Pleural rub
    • ↑ JVP
  • Look for a source of emboli—though often DVT is not clinically obvious

Differential diagnosis

  • Pneumonia and pleurisy
  • Ml
  • Other causes of acute breathlessness (above)
  • Acute intra-abdominal emergencies (p. 1066)

Action Give oxygen as soon as possible. Admit as an acute medical emergency. P.1055
Further management After initial anticoagulation in hospital, patients are usually discharged home on oral anticoagulants. Target INR 2.5 (range 2–3). Continue anticoagulation for 3mo. unless on-going risk factors. Tension pneumothorax

  • Complication of traumatic pneumothorax; rare after spontaneous pneumothorax.
  • A valvular mechanism develops—air is sucked into the pleural space during inspiration but cannot be expelled during expiration. The pressure within the pleural space ↑, the lung deflates further, the mediastinum shifts to the opposite side of the chest and venous return ↓.
  • Can be rapidly fatal.

Clinical features

  • Agitated and distressed patient, often with a history of chest trauma
  • Tachycardia
  • Sweating
  • Signs of a large pneumothorax—↓ breath sounds and ↓ chest movement on the affected side
  • Mediastinal shift—trachea deviated away from the side of the pneumothorax

Action: If suspected

  • Sit the patient upright if possible;
  • Insert a large bore cannula through the 2nd intercostal space of the chest wall in the mid-clavicular line on the side of the pneumothorax to relieve the pressure in the pleural space;
  • Transfer as an emergency to hospital.

P.1056
Acute breathlessness (2) Acute left ventricular failure (acute LVF) Severe acute breathlessness due to pulmonary oedema. Urgent treatment is needed to save life. Presenting features

  • Sudden acute breathlessness
  • Fatigue
  • Cough ± haemoptysis (usually pink and frothy)
  • Tends to occur at night
  • Some relief gained from sitting/standing

Signs

  • Dyspnoea
  • Tachycardia—gallop rhythm may be present
  • Coarse wet sounding crackles at both bases
  • Ankle/sacral oedema if right heart failure also present
  • ± hypotension

Differential diagnosis Other causes of acute breathlesness (especially asthma)—p. 1054. Action

  • If severe, call for ambulance support
  • Sit the patient up
  • Be reassuring—it is frightening to be very short of breath
  • Give 100% oxygen if available and no history of COPD (24% if history of COPD)
  • Give iv furosemide 40–80mg slowly (or bumetanide 1–2mg)
  • Give iv diamorphine 2.5–5mg over 5min.
  • Give metoclopramide 10mg iv (can be mixed with diamorphine)
  • Give GTN spray 2 puffs sublingually

Admission Depends on severity and cause of attack, response to treatment, and social support. Always admit if:

  • Alone at home
  • Inadequate social support
  • Suspected cause of acute LVF warrants admission (e.g. acute Ml)
  • Very breathless and no improvement over 1/2 h. with treatment at home
  • Hypotension or arrythmia.

Further information Heart failure—(p.334) Hyperventilation Features Fear, terror, and feeling of impending doom accompanied by some or all of the following:

  • Palpitations
  • Shortness of breath
  • Choking sensation
  • Dizziness
  • Paraesthesiae
  • Chest pain/discomfort
  • Sweating
  • Carpopedal spasm

P.1057
Differential diagnosis

  • Dysrhythmia
  • Asthma
  • Anaphylaxis
  • Thyrotoxicosis
  • Temporal lobe epilepsy
  • Hypoglycaemia
  • Phaeochromocytome (very rare)

Action Talking down Explain the nature of the symptoms to the patient.

  • Racing of the heart is due to adrenaline produced by the panic.
  • Paraesthesiae and feelings of dizziness are due to overbreathing due to panic.

Count breaths in and out, gently slowing breathing rate. Rebreathing techniques

  • Place a paper bag over the patient’s mouth and ask him to breath in and out through the mouth. A connected but not switched on O2 mask or nebuliser mask is an alternative in the surgery.
  • This raises the partial pressure of CO2 in the blood and symptoms due to low CO2 (e.g. tetany, paraesthesiae, dizziness) resolve. It also demonstrates the link between hyperventilation and the symptoms to the patient.

Propranolol 10–20mg stat may be helpful—DON’t USE for asthmatics or patients with heart failure or on verapamil. Recurrent panic attacks p.962 P.1058
Acute asthma in adults Many deaths from asthma are preventable. Delay can be fatal. Factors leading to poor outcome include:

  • Doctors failing to assess severity by objective measurement
  • Patients or relatives failing to appreciate severity
  • Underuse of corticosteroids

Regard each emergency asthma consultation as acute severe asthma, until proven otherwise. Risk factors for developing fatal or near fatal asthma A combination of severe asthma recognized by ≥ 1 of:

  • Previous near fatal asthma definition opposite
  • Previous admission for asthma—especially if within 1y.
  • Requiring ≥3 classes of asthma medication
  • Heavy use of β2 agonist
  • Repeated attendances at A&E for asthma care—especially if within 1y.
  • Brittle asthma

And adverse behavioural or psychosocial features recognized by ≥1 of:

  • Non-compliance with treatment or monitoring
  • Failure to attend appointments
  • Self-discharge from hospital
  • Psychosis, depression, other psychiatric illness or deliberate self-harm
  • Current or recent major tranquillizer use
  • Denial
  • Alcohol or drug misuse
  • Obesity
  • Learning difficulties
  • Employment problems
  • Income problems
  • Social isolation
  • Childhood abuse
  • Severe marital, legal, or domestic stress

Assess and record

  • Peak expiratory flow (PEF)
  • Symptoms and response to self-treatment
  • Heart and respiratory rates
  • Oxygen saturation by pulse oximetry (if available)

Patients with severe or life-threatening attacks may not be distressed and may not have all the characteristic abnormalities of severe asthma. The presence of any should alert the doctor. Levels of severity of acute asthma exacerbations Moderate asthma exacerbation

  • Increasing symptoms
  • PEF >50–75% predicted
  • No features of acute severe asthma

Acute severe asthma Any one of:

  • PEF 33–50% best or predicted
  • Respiratory rate ≥25 breaths/min.
  • Heart rate ≥110/min.
  • Inability to complete sentences in 1 breath

P.1059
Life-threatening asthma Any 1 of the following with severe asthma:

  • PEF <33% best/predicted
  • O2 saturation <92%
  • Silent chest
  • Cyanosis
  • Feeble respiratory effort
  • Bradycardia
  • Dysrhythmia
  • Hypotension
  • Exhaustion
  • Confusion
  • Coma

Near fatal asthma Respiratory acidosis and/or requiring mechanical ventilation with ↑ inflation pressures. Brittle asthma

  • Type 1: Wide PEF variability (>40% diurnal variation for >50% of the time for a period of >150d.) despite intense therapy.
  • Type 2: Sudden severe attacks on a background of apparently well controlled asthma.

Management Figure 29.11—p.1060 Admit to hospital if

  • Life-threatening features
  • Features of acute severe asthma present after initial treatment
  • Previous near fatal asthma

Lower threshold for admission if

  • Afternoon or evening attack
  • Recent nocturnal symptoms or hospital admission
  • Previous severe attacks
  • Patient unable to assess own condition
  • Concern over social circumstances

If admitting the patient to hospital

  • Stay with the patient until the ambulance arrives
  • Send written assessment and referral details to the hospital
  • Give high-dose β2 bronchodilator via an oxygen-driven nebuliser in the ambulance

Follow-up after treatment or discharge from hospital

  • GP review within 48h.
  • Monitor symptoms and PEF
  • Check inhaler technique
  • Written asthma action plan
  • Modify treatment according to guidelines for chronic persistent asthma
  • Address potentially preventable contributors to admission

Management of chronic asthma p.376,p.377,p.378,p.379,p.380,p.381 Essential reading BTS/SIGN (2004) British guidelines on the management of asthma http://www.sign.ac.uk

Figure 29.11 Management of acute severe asthma in adults (Reproduced from the British guideline on the management of asthma (2004) with permission of SIGN/British Thoracic Society.)

P.1060
P.1061
P.1062
Acute asthma in children Assess and record

  • Pulse rate—increasing heart rate generally reflects ↑ severity
  • Respiratory rate and breathlessness
  • Use of accessory muscles—best noted by palpation of neck muscles
  • Amount of wheezing
  • Degree of agitation and conscious level

Levels of severity Child >5y Figure 29.12 (p.1063) Child 2–5y Figure 29.13 (p.1064) Child <2y Assessment of children <2y. can be difficult

  • Moderate wheezing
    • O2 saturation ≥92%
    • Audible wheezing
    • Using accessory muscles
    • Still feeding
  • Severe wheezing
    • O2 saturation <92%
    • Cyanosis
    • Marked respiratory distress
    • Too breathless to feed
  • Life-threatening
    • Apnoea
    • Bradycardia
    • Poor respiratory effort

If a patient has signs and symptoms across categories, always treat according to the most severe features. Management Child >5y Figure 29.12 (p.1063) Child 2–5y Figure 29.13 (p.1064) Child <2y Intermittent wheezing attacks are usually in response to viral infection and response to bronchodilators is inconsistent.

  • If mild/moderate wheeze
    • A trial of bronchodilators can be considered if symptoms are of concern—use a metred dose inhaler and spacer with a face mask.
    • If no response, consider alternative diagnosis (aspiration pneumonitis, pneumonia, bronchiolitis, tracheomalacia, CF, congenital anomaly) and/or admit.
  • If severe wheezing: Admit to hospital.
  • If any life-threatening features: Admit immediately as a blue light emergency.

Follow-up after treatment or discharge from hospital

  • GP review within 1 week
  • Monitor symptoms, PEF, and check inhaler technique
  • Written asthma action plan
  • Modify treatment according to guidelines for chronic persistent asthma
  • Address potentially preventable contributors to admission

P.1063
Management of chronic asthma

  • Children <12y.: p.860,p.861,p.862,p.863,p.864,p.865
  • Children >12y. and adults: p.376,p.377,p.378,p.379,p.380,p.381

Essential reading BTS/SIGN (2004) British guideline on the management of asthma http://www.sign.ac.uk

Figure 29.12 Management of acute asthma in children >5y. (Reproduced from the British guideline on the management of asthma (2004) with permission of SIGN/British Thoracic Society.)

P.1064
Lower threshold for admission if

  • Attack in late afternoon or at night
  • Recent hospital admission or previous severe attack
  • Concern over social circumstances or ability to cope at home
Figure 29.13 Management of acute asthma in children 2–5y. (Reproduced from the British guideline on the management of asthma (2004) with permission of SIGN/British Thoracic Society.).

Lower threshold for admission if:

  • Attack in late afternoon or at night
  • Recent hospital admission or previous severe attack
  • Concern over social circumstances or ability to cope at home

P.1065
P.1066
Acute abdominal pain Signs may be masked in elderly patients or those on corticosteroids. Small children with abdominal pain are difficult to assess. Consider Gl causes

  • Appendicitis (p.464)
  • Gastritis (p.437)
  • Perforated peptic ulcer (p.438)
  • Acute pancreatitis (p.448)
  • Biliary colic (p.447)
  • Acute cholecystitis (p.447)
  • Intestinal obstruction (p.466)
  • Intussusception (p.858)
  • Strangulated hernia (p.462)
  • Ischaemic bowel (p.466)
  • Diverticulitis (p.467)
  • Volvulus (p.466)
  • Impacted faeces (p.472)
  • Inflammatory bowel disease e.g. Crohn’s, UC (p.456)
  • Irritable bowel syndrome (p.460)
  • Gastroenteritis (p.452)

Gynaecological causes

  • Ovarian torsion (p.712)
  • Bleed into or rupture of an ovarian cyst (p.712)
  • Ectopic pregnancy (p.738)
  • Dysmenorrhoea (p.726)
  • Pelvic inflammatory disease (p.720)
  • Uterine abruption (p.796)
  • Endometriosis (p.722)

Other causes

  • MI (p.1048)
  • CCF (p.334)
  • Leaking or ruptured AAA (p.1042)
  • Pneumonia (p.390)
  • Sickle cell crisis (p.527)
  • Diabetic ketoacidosis (p.1068)
  • Renal disease (p.678)
  • UTI (p.692)
  • Henoch-Schonlein purpura (p.284)
  • Mesenteric adenitis opposite
  • Ruptured spleen below
  • Torsion of the testis (p.698)
  • Herpes zoster (p.494)
  • Porphyria (p.663)

Management Treat the cause—if unsure, admit as a surgical emergency to hospital. Do not give analgesia prior to surgical assessment as it may mask vital diagnostic signs. Ruptured spleen May occur immediately following trauma or present days/weeks later. Diseased spleens (e.g. glandular fever, malaria, leukaemia) rupture more easily. Presentation

  • History: of abdominal trauma
  • Signs of blood loss: tachycardia, ↓ BP ± postural drop, pallor
  • Signs of peritoneal irritation: guarding, abdominal rigidity, shoulder tip pain
  • Signs of paralytic ileus: abdominal distention, lack of bowel sounds

Action: If suspected, admit as a surgical emergency via ‘999’ ambulance. P.1067
Mesenteric adenitis Pain due to mesenteric lymphadenopathy in children. Usually associated with URTI. Treat with simple analgesia and fluids. Review if the pain becomes more severe or changes. Further information

  • Abdominal pain (p.246)
  • Epigastric pain (p.259)
  • Right upper quadrant pain (p.288)
  • Right iliac fossa pain (p.287)
  • Left iliac fossa pain (p.273)
  • Left upper quadrant pain (p.273)
  • Pelvic pain (p.720)

P.1068
The fitting patient and delirium tremens When the call for assistance is received Instruct the attendant:

  • to stay with the fitting patient
  • to move anything from the vicinity of the patient that might cause injury
  • to turn the patient onto his/her side

If the patient is a child, suspect a febrile cause and advise the attendant to cool the child by stripping off layers of clothing and by tepid sponging. Management of a major fit

  • Ensure that the airway is clear
  • Turn the patient into the recovery position—p.1022
  • Prevent onlookers from restraining the fitting patient
  • Do not give drugs for the 1st 10min.—the fit is likely to stop spontaneously
  • After 10min.; treat with diazepam 5–10mg iv or pr (5mg if 2–3y. or elderly; 2.5mg if <2y.)
  • If the fit is not controlled, treat as status epilepticus

Admit any patient with a fit if

  • There is suspicion that the fit is 2° to other illness e.g. meningitis, subdural haematoma
  • The patient doesn’t recover completely after the fit (other than feeling sleepy)
  • Status epilepticus

Status epilepticus If >1 seizure without the patient regaining consciousness or fitting continues >20min.

  • Give diazepam 5–10mg iv or pr (5mg if 2–3y. or elderly; 2.5mg if <2y.)
  • Repeat every 15min. until fits are controlled
  • Check BM to exclude low blood sugar
  • Arrange immediate admission, even if fits are controlled

Follow-up

  • Refer any adult who has a first fit to neurology for assessment
  • Refer any child who has a first fit not related to fever to paediatrics for assessment

Delirium tremens (DTs) Major withdrawal symptoms. Usually occur 2–3d. after an alcoholic has stopped drinking. Features:

  • General: Fever, tachycardia, ↑BP, ↑ respiratory rate
  • Psychiatric: Vivid visual and tactile hallucinations, acute confusional state, apprehension
  • Neurological: Tremor, fits, fluctuating level of consciousness

Action DTs have 15% mortality and always warrant emergency hospital admission. Further information

  • Epilepsy: p.618–21
  • Febrile convulsions: p.867
  • Alcoholism: p.236–9

P.1069
P.1070
Endocrine emergencies Hypoglycaemic coma History

  • Short history
  • Known diabetic on oral or insulin therapy
  • May or may not have been warning signs/symptoms—sweating, hunger, tremor

Examination May present with coma, fits or odd/violent behaviour, tachycardia ±↑ BP. Investigation Blood sugar (on blood testing strip) <2.5mmol/l.. Action

  • Give:
    • Glucagon 1mg, sc, im, or iv (0.5mg in children)—takes ≤5min. to act. May have poor effect if the patient is starved or drunk. or
    • iv glucose (20–50ml of 20% solution).
  • Once the patient has regained consciousness, supplement with oral glucose.
  • Monitor frequent blood sugars over the next 4h. (hourly) and 4 hourly for the following 24h. Review reasons for hypoglycaemia— p.413.
  • Maintain a high glucose intake for several hours if the patient has a severe episode of hypoglycaemia due to a sulphonylurea.

Hyperglycaemic ketoacidotic coma Only occurs in patients with type 1 DM—though may be the way in which it presents (i.e. can occur in young patients not known to be diabetic). History 2–3d. deterioration which may have been precipitated by infection. Examination Dehydration, hyperventilation, breath smells ketotic, ↓BP + postural drop, tachycardia. Investigation Finger prick blood sugar test using reagent strip—usually >20mmol/l. Dipstick of urine is +ve for ketones (if urine available). Action Admit immediately to hospital. Hyperglycaemic hyperosmolar non-ketotic coma Only occurs in patients with type 2 DM. History Up to 1wk. history of deterioration. Often precipitated by other illness e.g. infection, Ml. May be a presenting feature of type 2 DM. Examination ↓ level of consciousness, dehydration ++, ↓ BP with postural drop. Investigation Blood sugar (on blood testing strip) >35mmol/l. Action Admit immediately to hospital. P.1071
Myxoedema coma Presentation

  • >65y. old
  • History of thyroid surgery/radioactive iodine
  • May be precipitated by Ml, stroke, infection, or trauma
  • Looks hypothyroid
  • Hypothermia
  • Hyporeflexia
  • Heart failure
  • Cyanosis
  • Bradycardia
  • Coma
  • Seizures

Investigation Finger prick blood glucose may be ↓ Action

  • Keep warm
  • Treat heart failure with diuretics ± opiates and nitrates—p.1056
  • Admit as an emergency to hospital

Hyperthyroid crisis (thyrotoxic storm) Risk factors

  • Recent thyroid surgery/radioactive iodine
  • Infection
  • Trauma
  • Ml

Presentation

  • Fever
  • Agitation and/or confusion
  • Coma
  • Tachycarida/AF
  • D&V
  • Acute abdomen
  • May have goitre ± thyroid bruit.

Action Admit as an emergency to hospital. P.1072
Obstetric emergencies Obstetric shock: Causes

  • Haemorrhage—remember that in abruption, bleeding may be internal and not seen pv
  • Ruptured uterus
  • Inverted uterus
  • Amniotic fluid embolus
  • Pulmonary embolus
  • Septicaemia

Action

  • Call for help
  • Arrange immediate admission to the nearest specialist obstetric unit or failing that, A&E department
  • Gain iv access and start iv fluids (if available)
  • Treat the cause if apparent

Shoulder dystocia Affects <1% deliveries but is a life-threatening emergency. Occurs when the anterior shoulder impacts upon the symphysis pubis after the head has delivered, and prevents the rest of the baby following. Most cases of shoulder dystocia are unanticipated. Clues:

  • Prolonged 1st or 2nd stage of labour
  • ‘Head bobbing’—the head consistently descends then returns to its original position during a contraction or while pushing in the 2nd stage

If shoulder dystocia occurs in the community, there is usually not time to transfer a woman to a specialist unit. Action: Call for help. Consider episiotomy. Then try any of these procedures (no particular order):

  • Roll the mother onto hands and knees and try delivering posterior shoulder first.
  • Flex the mother’s legs up to her abdomen (upside down squatting position)—try delivery again.
  • Deliver the posterior arm—put a hand in the vagina in front of the baby—ensure the posterior elbow is flexed in front of the body and pull to deliver the forearm. The anterior shoulder usually follows.
  • External pressure—ask an assistant to apply suprapubic pressure with the heel of the hand—a rocking movement can help.
  • Adduction of the most accessible (preferably anterior) shoulder. Simultaneously put pressure on the posterior clavicle to turn the baby. If unsuccessful, continue rotation through 180 degrees and try again.

Uterine inversion: Rare. Action

  • If noted early, try to replace the uterus. Otherwise, admit by emergency ambulance to the nearest obstetric unit.

The mother may become profoundly shocked so set up an iv infusion before transfer and give O2 via face mask. P.1073
Retained placenta 3rd stage is complete in <10min. in 97% labours. If the placenta has not delivered within 30min. it will probably not deliver spontaneously. PPH is a risk—p.792. Action

  • Avoid excessive cord traction.
  • Check the placenta is not in the vagina—remove if it is.
  • Check the uterus—if well contracted, the placenta has probably separated but become trapped in the cervix. Wait for the cervix to relax and remove the placenta.
  • If the uterus is bulky, the placenta may have failed to separate. Try:
    • Rubbing up a uterine contraction per abdomen
    • Putting the baby to the breast (stimulates uterine contraction)
    • Giving a further dose of syntometrine
    • If the placenta still will not deliver, transfer as an emergency to a specialist obstetric unit for manual removal

Foetal distress Signifies hypoxia. Signs:

  • Passage of meconium during labour
  • Foetal tachycardia (>160bpm at term)
  • Foetal bradycardia (<100bpm)—seek urgent obstetric assistance

Action

  • Give the mother oxygen via a face mask
  • Turn the mother on her side
  • Transfer immediately to a specialist obstetric unit for further assessment ± delivery

Resuscitation of the newborn p.1030 P.1074
Road traffic accidents (RTAs) and trauma Road accidents Doctors are not legally obliged to attend an accident they happen to pass—but most feel morally obliged to do so. Immediate action

  • Assess the scene.
  • Ensure police and ambulance have been called.
  • Take steps to ensure your own safety and that of others—park your vehicle defensively; turn on hazard lights; use warning triangles.
  • Ensure all vehicle ignitions are turned off.
  • Triage casualties into priority groups—decide who to attend first.
  • Forbid smoking.

Immediate treatment

  • Check the need for basic resuscitation:
    • Airway patent?
    • Breathing adequate?
    • Circulation intact?
  • Resuscitate as necessary (p.1020 or inside back cover).
  • Control any haemorrhage with elevation and pressure.
  • DO NOT attempt to move anyone who potentially could have a back or neck injury until skilled personnel and equipment are available.
  • Do not give anything by mouth.
  • Use coats and rugs to keep victims warm.
  • If available, give analgesia (e.g. opiates—but not if significant head injury or risk of intraperitoneal injury; entonox—from ambulance).
  • If shocked, set up iv fluids.
  • Take directions from the paramedics—they are almost certainly more experienced than you in these situations.

Medicolegal issues

  • Ensure your medic-legal insurance covers emergency treatments.
  • Keep full records of events, action taken, drugs administered, origin of drugs, batch numbers, and expiry dates.
  • A GP can charge a fee to the victims for any assistance given.

Burns and scalds p.1076 Drowning Most common in drunk adults and children poorly supervised around water. Children can drown in a few centimetres of water. Action

  • Call for help
  • Start basic life support (Airway, Breathing, Circulation)—p.1020

Attempted resuscitation of a seemingly dead child is worthwhile as cooling ↓ metabolic rate and recovery can occur after prolonged immersion. Prevention p.162 P.1075
Fractures Presentation

  • Symptoms: Pain at the affected site made worse by movement; loss of function.
  • Signs: Swelling; bruising; deformity; local tenderness; impaired function; crepitus; abnormal mobility.

Action

  • Immobilize the affected part and give analgesia.
  • If available and the patient is shocked, start an iv infusion of plasma expander.
  • Refer to A&E for assessment, X-ray and treatment.

Fracture complications

  • Often occur after the patient has been discharged from hospital and may present to the GP.
  • Patients should not have persistent pain—beware of compartment syndrome (p.197).
  • Refer back to the fracture clinic or A&E if:
    • Persistent pain
    • Limb swelling that is not settling
    • Offensive odour or discharge
    • If cast edges are abrading the skin or if the cast has deteriorated in structural strength e.g. from getting wet

P.1076
Scalds and burns Assessment

  • Cause, size, and thickness of the burn.
  • Use the ‘rule of nines’ to assess extent of burns (see box).
  • Partial thickness burns are red, painful, and blistered; full thickness burns are painless and white or grey.
  • Always consider non-accidental injury in children—p.886.
    Rule of nines: Ignore areas of erythema only.
    Palm 1%
    Arm (all over) 9%
    Leg (all over) 18% (14% children)
    Front 18%
    Back 18%
    Head (all over) 9% (14% children)
    Genitals 1%
    images The Rule of Nines is inaccurate for children <10y. For children and for small burns, an alternative method is to estimate the extent of the burn by comparison with the area of the patient’s hand. The area of the fingers and palm ≈1% total body surface area burn.

Action:

  • Remove clothing from the affected area and place under cold running water for >10min. or until pain is relieved.
  • Do not burst blisters.
  • Prescribe/give analgesia.
  • Refer all but the smallest (<5%) partial thickness burns for assessment in A&E.
  • Refer all electrical burns for assessment in A&E.
  • Refer all chemical burns for assessment in A&E unless burn area is minimal and pain-free.
  • Consider referral to A&E for smoke inhalation.

If managing the burn in the community

  • Check tetanus immunity and give immunization ± prophylaxis as necessary—p.484.
  • Apply silver sulfadiazine cream (flamazine) or vaseline impregnated gauze and non-adherent dressings and review for healing and infection every 1–2d.
  • Cover burns on hands in flamazine and place in a plastic bag—elevate the hand in a sling and encourage finger movement.
  • Refer if burns are not healed in 10–12d.

P.1077
Special situations Chemical burns

  • Usually caused by strong acids or alkalis.
  • Wear gloves to remove contaminated clothing.
  • Irrigate with cold running water for ≥20min.
  • Do not attempt to neutralize the chemical—this can exacerbate injury by producing heat.
  • Refer all burns to A&E unless the burn area is minimal and pain free.

Electric shock

  • Causes thermal tissue injury and direct injury due to the electric current passing through the tissue.
  • Skin burns may be seen at the entry and exit site of the current.
  • Muscle damage can be severe, with minimal skin injury.
  • Cardiac damage may occur and rhabdomyolysis can lead to renal failure.
  • Refer all patients for specialist management.

Smoke inhalation

  • Refer all patients who have potentially inhaled smoke for assessment—a seemingly well patient can deteriorate later.
  • Smoke can cause thermal injury, carbon monoxide poisoning, and cyanide poisoning.
  • Airway problems occur due to thermal and chemical damage to the airways, causing oedema—suspect if singed nasal hairs, a sore throat, or a hoarse voice.
  • Carbon monoxide poisoning may result in the classic cherry-red mucosa—but this may be absent.
  • Cyanide poisoning is commonly due to smouldering plastics and causes dizziness, headaches, and seizures.

Prevention of scalds and burns

  • Prevention through public education is important.
  • Children often sustain burns by pulling on the flex of boiling kettles or irons, pulling on saucepan handles, or climbing onto hot cookers.
  • Refer any children who have sustained accidental burns to the health visitor for follow-up.

P.1078
Poisoning and overdose On receiving the call for assistance

  • Try to establish what has happened—substances involved, ongoing dangers, state of the patient.
  • Advise the caller to stay with the patient until you arrive.
  • If the patient is unconscious, arrange for an ambulance to meet you at the scene.
  • Arrange for the patient to be removed from any source of danger e.g. contaminated clothing or inhaled gases. DO NOT put yourself or anyone else in danger attempting to do this. If necessary, call the fire brigade, who have protective clothing and equipment, to help remove a patient from a dangerous environment.

Assessment of the unconscious patient Assess the need for basic life support

  • Airway patent?
  • Breathing satisfactory?
  • Circulation adequate?

Resuscitation (p.1020) takes priority over everything else. Additionally

  • If breathing is depressed and opiate overdose is a possibility, give naloxone 0.8–2mg iv every 2–3min. to a maximum of 10mg..
  • Check BM—if low, give 50mls 50% glucose iv.

General examination

  • BP
  • Pulse
  • Temperature
  • Level of coma (p.1032)
  • Pupil responses
  • Evidence of iv drug abuse
  • Obvious injury

The coma may not be due to poisoning/overdose If unconscious, turn into the recovery position p.1022. Check no contraindications first e.g. spinal injury. Note down any information about the exposure

  • Product name—as much detail as possible. If unidentified tablets, see if any are left and send them to the hospital in their own container (if there is one), with the patient.
  • Time of the incident
  • Duration of exposure/amount ingested
  • Route of exposure—swallowed, inhaled, injected, etc.
  • Whether intentional or accidental
  • Take a general history from any attendant—medical history, current medication, substance abuse, alcohol, social circumstances.

P.1079
Assessment of the conscious patient

  • Note down any information about the exposure, as for the unconscious patient.
  • Record symptoms the patient is experiencing as a result of exposure.
  • Examine—pulse, BP, temperature (if necessary), level of consciousness or confusion, evidence of iv drug abuse, any injuries.
  • If non-accidental exposure, assess suicidal intent (p.1080).
  • Take a general history from the patient and/or any attendant—medical history, current medication, substance abuse, alcohol, social circumstances.

Children Peak incidence of accidental poisoning is at 2y.—mainly household substances, prescribed or OTC drugs, or plants. Teenagers may take deliberate overdoses—especially of OTC medication e.g. paracetamol. Poisoning can be a form of non-accidental injury (p.886). Action Consider admission if

  • The patient’s clinical condition warrants it: unconsciousness, respiratory depression, etc.
  • The exposure warrants admission for treatment or observation:
    • Symptomatic poisoning: Admit to hospital.
    • Agents with delayed action: Aspirin, iron, paracetamol, tricyclic antidepressants, Lomotil (co-phenotrope), paraquat, and modified-release preparations. Admit to hospital even if the patient seems well.
    • Other agents: Consult poisons information.
  • You judge there is serious suicidal intent (p.1080), the poisoning is suspected to be a non-accidental injury to a child, or the patient has another psychiatric condition which warrants acute admission.
  • There is a lack of social support.

Poisons information UK National Poisons Information Service Tel: 0870 600 6266 TOXBASE—poisons database http://www.spib.axl.co.uk P.1080
Threatened suicide GPs are frequently called to patients who have deliberately self-harmed themselves, are threatening suicide, or if relatives are worried about risk of suicide. Action If any self-harm Assess the situation and admit to A&E as needed. Ask about suicidal ideas and plans In a sensitive but probing way. It is a common misconception that asking about suicide can plant the idea into a patient’s head and make suicide more likely. Evidence is to the contrary. Useful questions:

  • Do you feel you have a future?
  • Do you feel that life’s not worth living?
  • Do you ever feel completely hopeless?
  • Do you ever feel you’d be better off dead and away from it all?
  • Have you ever made any plans to end your life (if drug overdose—have you handled the tablets)?
  • Have you ever made an attempt to take your own life—if so, was there a final act e.g. suicide note?
  • What prevents you doing it?
  • Have you made any arrangements for your affairs after your death?

Ask about present circumstances

  • What problems are making the patient feel this way?
  • Does s/he still feel like this?
  • Would the act of suicide be aimed to hurt someone in particular?

What kind of support does the patient have from friends and relatives and formal services (e.g. CPN)? Assess suicidal risk Ask the patient and any relatives/friends present. Risk factors:

  • ♂ > ♀
  • ↑ with age
  • Divorced > widowed > never married > married
  • Certain professions: vets, pharmacists, farmers, doctors.
  • Admission or recent discharge from psychiatric hospital
  • Social isolation
  • History of deliberate self-harm (100x ↑ risk)
  • Depression
  • Alcohol or substance abuse
  • Personality disorder
  • Schizophrenia
  • Serious medical illness (e.g. cancer)

Assess psychiatric state Features associated with ↑ suicide risk are:

  • Presence of suicidal ideation (see above)
  • Hopelessness—good predictor of subsequent and immediate risk
  • Depression
  • Agitation
  • Early schizophrenia with retained insight—especially young patients who see their ambitions restricted
  • Presence of delusions of control, poverty, and/or guilt.

P.1081
Refer for psychiatric evaluation High risk of suicide

  • Direct statement of intent
  • Severe mood change
  • Hopelessness
  • Alcohol or drug dependence
  • Abnormal personality
  • Living alone

Admit as a psychiatric emergency, using the Mental Health Act for compulsory admission (p.986) if voluntary admission is declined. Lower risk of suicide Arrange for someone to stay with the patient until follow-up. Remove all potentially harmful drugs. Liaise with the psychiatric services, according to the individual patient, about psychiatric follow-up. Mothers of young children: ↑ risk of child abuse. Assess risks, offer support, arrange for health visitor or social services to visit. Compulsory admission under the Mental Health Act p.986 P.1082
Disturbed behaviour When a patient becomes very agitated or violent or starts to behave oddly, the GP is usually called—by the patient, relatives or friends, or police attending the disturbance. After assessing the problem, decide if hospitalization is required and whether this can be done on a voluntary or involuntary basis. Look after your own safety

  • If the patient is known to be violent, get back-up from the police before entering the situation.
  • Tell someone you are going in and when to expect an ‘exit’ call. Advise them to call for help if that call is not made.
  • Do not put yourself in a vulnerable situation—sit where there is a clear, unimpeded exit route.
  • Do not make the patient feel trapped.
  • Do not try to restrain the patient.

Causes of acutely disturbed behaviour

  • Physical illness—infection (e.g. UTI, chest infection); hypoglycaemia; hypoxia; head injury; epilepsy.
  • Drugs—alcohol (or alcohol withdrawal); prescribed drugs (e.g. steroid psychosis); illicit drugs (e.g. amphetamines).
  • Psychiatric illness—schizophrenia; mania; anxiety/depression; dementia; personality disorder (e.g. attention-seeking; uncontrolled anger).

Action

  • Before seeing the patient, gather as much information as possible from notes, relatives, and even neighbours.
  • Ask the patient and family for any history of drugs or alcohol excess.
  • Listen to the patient and talk calmly—choose your words carefully.
  • Try to look for organic causes—this can be difficult in the heat of the moment. Physical examination, except from a distance, may be impossible. Don’t put yourself at risk.
  • Suspect an organic cause where there are visual hallucinations.
  • Discuss and explain your suggested management with the patient and any attendants.
  • If the patient is an immediate danger to himself or others, admission is warranted.
  • If the cause of the behaviour is unclear, admission for investigation is needed.
  • Instigate management of treatable causes identified e.g. admit if MI suspected; treat UTI.
  • Consider sedation to cover the period before admission or to alleviate symptoms if admission is inappropriate.

Acute confusion p.976 Compulsory admission under the Mental health Act p.986 P.1083
Suitable drugs to use for sedation

  • Oral: diazepam 5–10mg po or lorazepam 1mg po/s/ling; chlorpromazine 50–100mg po.
  • Intramuscular: chlorpromazine 50mg; haloperidol 1–3mg.

Avoid sedating patients with COPD, epilepsy, or if the patient has been taking illicit drugs, barbiturates, or alcohol. Acute dystonia can occur soon after giving phenothiazines or butyophenones. Signs:

  • torticollis
  • tongue protrusion
  • grimacing
  • opisthotonus

Dystonia can be relieved with procyclidine 5–10mg im (repeated prn after 20min. to a maximum dose of 20mg). P.1084
Miscellaneous emergencies Acute limb ischaemia Causes

  • Acute thrombotic occlusion of pre-existing stenotic segment (60%)
  • Embolus (30%)
  • Trauma e.g. compartment syndrome or traumatic vessel damage

Presentation

  • Pain
  • Pallor
  • Paraesthesia
  • Pulselessness
  • Paralysis
  • Perishing cold

Action Admit acutely under the care of a vascular surgeon. Treatment can be surgical (e.g. embolectomy) or medical (e.g. thrombolysis). Hypothermia Defined as a core temperature of <35°C. Causes

  • Not feeling the cold e.g. neuropathy, confusion, dementia
  • Inadequate heat in the home e.g. poor housing, poverty and fear of high fuel bill
  • Immobility
  • Hypothyroidism
  • DM
  • ↑ heat loss e.g. psoriasis, erythroderma
  • Inadequate protection from the cold e.g. unsuitable clothing whilst doing outdoor sports
  • Alcohol
  • Drugs—antipsychotics, antidepressants, barbiturates, tranquilizers may lower the level of consciousness and ↓ ability to shiver
  • Falls—if unable to rise from the floor may remain still and cold until discovered
  • Unconsciousness e.g. overdose, stroke

Presentation

  • Skin pale and cold to touch
  • Puffy face
  • Listlessness, drowsiness, and/or confusion

When severe

  • ↓ breathing—slow and shallow
  • ↓ pulse volume—faint and irregular
  • Stiff muscles
  • Loss of consciousness

Investigation

  • Rectal temperature on low-reading thermometer <35°C
  • ECG-‘J’ wave on the end of the QRS complex

P.1085
Action

  • Remove from the cold environment
  • Wrap in blankets—including head
  • Do not use direct heat (e.g. hot water bottles) as this can cause rapid fluid shifts and potentially fatal pulmonary oedema.
  • Transfer to hospital.
  • Consider the cause of the incident and liaise with the hospital, primary healthcare team, and social services to prevent recurrence in the future.

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apply_now Pepperstone Group Limited