10. Emergencies – 101

Technically this domain is called Identifying and Managing the Patient with Significant Illness. The key competencies are:

  1. A patient with significant illness (red flags) is identified.
  2. Has confidence in, and takes ownership of, own decisions while being aware of own limitations (dealing with emergencies)

Red flags in a medical context are warning signs that suggest a potentially serious underlying condition and may require immediate attention. Identifying these signs is crucial as they often indicate the need for urgent evaluation and possibly rapid intervention. Here are common red flags for significant illness across various medical domains:

Significant Illness and Red Flags

General Red Flags

These can be remembered with the mnemonic RASCAL FACTS WIN.

  1. Representation or failure to improve
  2. Acute onset
  3. Severe pain
  4. Cancer hx
  5. Altered bowel/urine habit or severe vomiting/dysphagia
  6. Loss of Weight
  7. Fever > 37.8
  8. Age > 50
  9. Cognitive deficits
  10. Travel overseas
  11. Syncope on the toilet
  12. White (Pallor)
  13. Immunocompromised, i.e. steroids, biologicals, methotrexate, carbimazole
  14. Narcotic, drug or alcohol abuse

Cardiovascular Red Flags

  • Chest pain or discomfort
    • This is particularly true if it is persistent or associated with nausea, sweating, or radiation to other areas like the arm or jaw.
  • Shortness of breath
    • With or without exertion, which could indicate heart failure, severe asthma, or pulmonary embolism.
  • Palpitations
    • Particularly if they are accompanied by dizziness, fainting, or chest discomfort.
  • Sudden swelling of the legs or ankles
    • Potentially indicating heart failure or deep vein thrombosis.

Neurological Red Flags

  • Sudden severe headache
    • A headache that feels like the “worst ever,” which could suggest a hemorrhagic stroke or aneurysm.
  • Changes in mental status
    • Confusion, decreased alertness, or altered consciousness.
  • Sudden vision changes
    • Loss of vision, double vision, or new onset of “floaters” in the vision.
  • Weakness or numbness on one side of the body
    • Could signal a stroke or other neurological disorder.

Gastrointestinal Red Flags

  • Severe abdominal pain
    • Especially if it is acute and localized, could indicate appendicitis, perforation, or other surgical emergencies.
  • Blood in the stool or black, tarry stools
    • This could indicate gastrointestinal bleeding.
  • Jaundice
    • Points to liver dysfunction or biliary obstruction.
  • Persistent vomiting or diarrhea
    • Especially when it leads to significant dehydration or electrolyte imbalances.

Respiratory Red Flags

  • Difficulty breathing or rapid breathing
    • Could suggest pneumonia, asthma exacerbation, or pulmonary embolism.
  • Blue tint to lips or face (cyanosis)
    • Indicating severe hypoxia or respiratory failure.
  • Persistent cough with blood (hemoptysis),
    • Potentially indicative of lung cancer or an infection like tuberculosis.

Urological Red Flags

  • Severe flank pain
    • Might indicate kidney stones or pyelonephritis.
  • Blood in urine (hematuria)
    • A possible sign of urinary tract infections, kidney stones, or bladder/kidney cancers.
  • Inability to urinate with a full bladder
    • A sign of an obstructive uropathy or severe urinary tract infection.

Musculoskeletal Red Flags

  • Severe back pain
    • Especially with fever, unexplained weight loss
    • If it’s severe enough to wake the patient from sleep, this could suggest a spinal infection, fracture, or malignancy.
  • Sudden severe joint pain and swelling
    • Could indicate a septic joint, particularly in the presence of fever.

Oncological Red Flags

  • New lumps or swelling
    • Particularly those that are rapidly growing, especially if they are hard or immovable.
  • Unexplained bleeding or discharge
    • From any part of the body, including abnormal vaginal bleeding or unusual nipple discharge.

Identifying these red flags requires a thorough patient history and physical examination. When any of these signs are present, further investigation, often urgently, is required to determine the underlying cause and initiate appropriate management.

Dealing with Emergencies

The ability to deal with emergencies is a key GP skill. In general, it boils down to DRS ABCDEFG, where “Send for Help” is a key component!

Primary Survey

The primary survey in emergency medicine is a critical initial assessment aimed at identifying and managing life-threatening conditions. It follows the ABCDE approach: Airway, Breathing, Circulation, Disability, and Exposure. This rapid assessment ensures that immediate threats to life are recognized and treated swiftly. The airway is checked for obstructions, breathing is assessed for adequacy, and circulation is evaluated to identify major bleeding or shock. Disability involves a quick neurological evaluation, primarily focusing on the level of consciousness using tools like the Glasgow Coma Scale. Exposure requires the patient to be fully undressed to identify any hidden injuries, while maintaining body temperature to prevent hypothermia. The primary survey is designed to stabilize the patient quickly and prepare for further detailed evaluation.

Secondary Survey

Following the primary survey, the secondary survey is conducted once the patient is stabilized, with the goal of identifying all potential injuries or medical issues. This detailed assessment includes a complete, head-to-toe physical examination and a thorough patient history, including the patient’s AMPLE information (Allergies, Medications, Past medical history, Last meal, and Events leading to the injury or illness). This stage also involves a more comprehensive neurological assessment and closer inspection of each body system. Additional diagnostic tools such as X-rays, CT scans, and lab tests are commonly utilized during this phase to aid in diagnosing injuries or conditions that were not immediately life-threatening but may require medical intervention.

Tertiary Survey

The tertiary survey is typically conducted within 24 hours of admission, especially in a trauma setting, to catch any injuries or conditions that were missed in earlier assessments. This thorough review includes a repeated and detailed physical examination and a comprehensive review of the patient’s clinical course and all diagnostic tests performed since admission. It aims to ensure a complete understanding of the patient’s overall health status and to address any complications that may have arisen. This step is crucial for preventing delayed diagnosis and management of injuries or conditions, thereby enhancing recovery outcomes and minimizing the risks of long-term complications. The tertiary survey often involves multidisciplinary input and may lead to additional diagnostic testing or revisions in the treatment plan based on the findings.

Primary Survey

DRS ABCDEFG is an acronym used to guide the initial response to an unconscious person, particularly in situations where life-threatening emergencies are suspected. It stands for Danger, Response, Send for help, Airway, Breathing, CPR, Defibrillation and Don’t Ever Forget Glucose.

This sequence is a fundamental part of first aid training, designed to systematically prioritize actions to ensure the safety of the rescuer and the best possible outcome for the victim. Here’s a breakdown of each step:

  • D – Danger:
    • Before approaching the casualty, check the surrounding area for any potential dangers to yourself, the casualty, or others. This includes traffic, fire, gas, electricity, or any other hazards. Ensure the scene is safe before proceeding.
  • R – Response:
    • Check if the casualty is responsive. Gently tap their shoulders and ask loudly, “Are you okay?”
    • Look for any response, including movement, sounds, or attempts to open their eyes.
    • This helps determine the level of consciousness.
    • AVPU and GCS
  • S – Send for help:
    • If the casualty is unresponsive or their life appears to be in danger, call for emergency medical services immediately.
    • Provide them with as much information as possible about the casualty’s condition and your location.
    • In a rural location on/off-duty nurses, doctors, and paramedics may all need to be recruited.
  • A – Airway:
    • Open the casualty’s airway by tilting their head back and lifting their chin.
    • This maneuver helps remove any obstruction from the airway, ensuring it is clear for breathing.
    • Check for any visible blockages, such as food or foreign objects, and remove them if safely possible.
  • B – Breathing:
    • Look, listen, and feel for normal breathing for no more than 10 seconds. Watch for chest movements, listen for breathing sounds at the mouth and nose, and feel for breath on your cheek.
    • If the patient is not breathing normally, prepare to start CPR.
  • C – CPR (Cardiopulmonary Resuscitation):
    • If the patient is not breathing or not breathing normally (only gasping), start CPR immediately.
    • Push hard and fast in the centre of the chest, allowing full recoil between compressions at a rate of 100 to 120 compressions per minute.
    • If trained and willing, give 2 rescue breaths after every 30 compressions. If not, continue with chest compressions alone.
  • D – Defibrillation:
    • If an Automated External Defibrillator (AED) is available, turn it on and follow its voice prompts.
    • The AED will assess the casualty’s heart rhythm and advise whether a shock is needed.
    • Defibrillation can be crucial in the case of sudden cardiac arrest, as it may restore a normal heart rhythm.
  • DEFG – Don’t Ever Forget Glucose!

Secondary Survey

After addressing all life-threatening issues in the primary survey and stabilizing the patient, the secondary survey is performed. This is a thorough, head-to-toe examination to identify all injuries, including those that are not immediately life-threatening. The secondary survey also includes a detailed patient history using the AMPLE mnemonic:

  • Allergies
  • Medications currently used
  • Past medical history/Pregnancy
  • Last meal
  • Environment of the injury/event and Events leading to the injury

The secondary survey focuses on a complete physical examination, including inspection, palpation, auscultation, and neurological assessment. It also involves ordering appropriate diagnostic tests, such as X-rays, CT scans, or blood tests, to further evaluate the patient’s injuries and condition.

Tertiary Survey

The tertiary survey is a critical component of the patient evaluation process, particularly in trauma care. It is typically conducted after the primary and secondary surveys have been completed, and it aims to identify any injuries or conditions that may have been missed during the initial assessments. The tertiary survey is usually performed within 24 hours after admission but can be done later, especially in patients who were initially unstable or required immediate intervention.

Purpose of the Tertiary Survey

The main purpose of the tertiary survey is to perform a thorough and systematic evaluation to identify all injuries and complications that could affect the patient’s recovery. This comprehensive assessment helps in improving clinical outcomes by ensuring that no significant injuries or health issues go untreated.

Components of the Tertiary Survey

The tertiary survey involves several key components:

  1. Detailed History and Review:
    • Review of Circumstances: Detailed re-evaluation of the patient’s medical history and the circumstances surrounding their current medical situation or injury. This includes reviewing pre-hospital reports, initial assessments, and any changes in the patient’s condition.
    • Complete Medical History: Includes reviewing past medical records, previous surgeries, ongoing treatments, and any known allergies or chronic diseases.
  2. Comprehensive Physical Examination:
    • A head-to-toe examination is conducted again with special attention to areas not thoroughly assessed previously or that could have developed new signs or symptoms. This might include a more detailed neurological examination, careful inspection and palpation of all body regions, and reassessment of all organ systems.
  3. Diagnostic Review:
    • Review all diagnostic tests performed, including laboratory results, X-rays, CT scans, MRIs, and any other imaging done. It’s crucial to ensure that all previously ordered tests have been completed and reviewed and to determine if additional diagnostic tests are needed based on the new comprehensive assessment.
    • It often includes re-evaluation of radiographs by a radiologist, as initial films may have been reviewed under emergent or suboptimal conditions.
  4. Consultations:
    • Consultations with various specialists may be necessary depending on the findings of the tertiary survey. This could include neurologists, orthopedic surgeons, general surgeons, or other specialists who can provide additional insights or management options for specific injuries or conditions identified.
  5. Documentation:
    • Detailed and systematic documentation of all findings from the tertiary survey is essential. This documentation should include any discrepancies or new findings compared to the initial assessments.
    • Plans for ongoing monitoring, additional tests, or interventions should be updated based on the tertiary survey results.

Importance in Clinical Care

The tertiary survey is particularly important in trauma care, where the patient’s initial condition may prevent a complete assessment or injuries may evolve over time. It ensures a comprehensive management plan that addresses all aspects of the patient’s health and injuries. This survey reduces the incidence of missed injuries and complications, which are crucial for patients who have undergone significant initial resuscitation and may have multiple complex injuries.

In summary, the tertiary survey is a systematic and detailed re-evaluation to ensure no significant injuries or conditions are overlooked in the acute care setting. This meticulous process is critical for improving patient outcomes, particularly in complex cases such as multi-trauma patients.