Dr Ibrahim Almoosa

EMERGENCIES IN
GENERAL PRACTICE
Emergencies in General
Practice
 Primary Health Care is entrance gate of
medical care
 Emergency guidelines deal with problems in
primary care that need immediate
intervention
 Aim of this lecture:
 IMPROVE THE EFFICACY OF PRIMARY
HEALTH CARE PHYSICIANS IN DEALING
WITH EMERGENCIES
Objectives

 Proper early diagnosis of emergency

conditions
 Appropriate intervention in clinic
 Implement measures to promote better
outcome
 Reduce discrepancy in management
Acute Chest Pain

 One of the most common presenting

complaints
 Range from simple self-limiting to life
threatening
Acute myocardial infarction
AMI
 Typical history
 Substernal chest pain:
 Nature: crushing
 Duration: several minutes – hours
 Radiation: neck, jaws, left arm
 Associated sympt: nausea, vomiting, sweating
(diaphoresis).
 NOTE! Beware of ATYPICAL presentation:
 ALWAYS consider cardiac cause. It can save lives!
Management of AMI
 Call ambulance
 Check vital signs – BP, pulse
 Keep vein open (fix IV cannula)
 Pain relief: morphine IV, 5mg stat (bolus)
 Then 1-2 mg/min until adequate analgesia
 Nalorphine in case of resp depression
 Metoclopramide 10 mg IV for antiemesis
 GTN sublingual
 Aspirin 300mg
 O2
 Atropine 0.6 mg IV if bradycaridia
Acute pulmonary edema
 c/o acute breathlessness, wheezing, looking anxious, profuse
sweating
 Cough w/ frothy blood tinged sputum
 Tachypnea, tachycardia, raised venous pressure, gallop rhythm
 Chest: crackles and wheeze
 Management:
 Sitting upright
 O2
 Morphine IV 5 mg stat, then 1-2mg/min
 Lasix IV (upto 100 mg)
 GTN subling. for vasodilat. effect.
 Digoxin and Aminophylline: NOT used outside hospital.
Hypertensive Urgency and
emergency
 Hypertensive urgency
 BP reduction within few hours
 Eg:
 Asymptomatic severe hypertension (HTN)
 SYS ≥ 240 mmHg, DIAS ≥ 130 mmHg
 Symptomatic moderately severe Hypertension
associated with headache, heart failure, or angina
(SBP ≥200, DBP ≥120)
 Hypertensive emergency
 BP reduction within 1 hour to avoid serious morbidity
or death
 Severe BP elevation, DBP >130 mmHg
 End organ damage is a major risk
 Encephalopathy: headache, irritability, confusion,
altered mental status
 Nephropathy: hematuria, protienuria, renal dysfunction
 Intra-cranial hemorrhage, arotic dissection, PE,
unstable angina, MI, pre-eclmapsia, eclampsia
 Malignant Hypertension
 Hypertensive emergency characterized by encephalopathy or
nephropathy with accompanying papilledema.
 Management:
 Parenteral therapy usu for HTN emergency only
 Abrupt BP reduction in asymptomatic HTN urgency NOT advised.
 HTN emergency: Reduction of SBP 20-30 mmHg, DBP 10-20 mmHg,
(achieve BP <180-200/110-120)
 Parenteral agents: Nirtoprusside Sodium, rapid BP lowering in
seconds via vasodilation (hospital)
 Oral agents:
 Captopril (capoten) 12.5-25mg orally, acts in 15-30 min.
 Caution! Response variable.
 Diuretics: IV loop diuretics
 Useful in signs of heart failure, fluid retention
 Response is slow, used as adjunct rather than primary agent.
Syncope
 Transient brief loss of consciousness due to decrease in cerebral perfusion
 Spontaneous recovery
 Affect any age, 3% ER visit, 1-6% hosp adm.
 30-50% cause not found
 Cardiac vs Non-cardiac cause
 Non-cardiac:
 Vasovagal syncope (simple faint)
 50% of cases
 Familial , rec.
 Ppt by emotional stress, fear, fatigue, pain, unpleasant sight, sound, or smell
 Due to vagal stimulation  pallor, BP, bradycard
 Situational syncope
 Micturition syncope
 Defecation syncope
 Cough syncope
 Swallowing syncope
 Carotid sinus hypersensitivity: carotid sinus stimulation  vagal stim
 Management:
 Recline pt to sitting or lying position, head down, leg up  spont recov
 Postural syncope
 Hypovolemia due to dehydration, medication,
bleeding
 Orthostatic syncope (old age, medical dis, DM)
 Treat underlying cause
 Cardiac causes
 Usually never benign
 A. Electric or Dysrhythmic (complete heart block, VT, etc)
 B. Mechanical or Obstructive (Aortic sten, tamponade, HOCM)
 Exertional sync
 Other causes: condition which  cardiac output (CHF, MI)
 Signs/sympt
 Syncope on exertion
 Assoc of chest pain, palpitation
 h/o cardiac dis.
 Elderly (>65y)
 Mortalitiy 18-33%
 Must differentiate from conditon which alter conc (siezure, stroke, coma, SAH).
 Unlike siezure: lack of aura, post-ictal, shaking
 Brief
 Complete recovery w/o neuro complications
 Diagnosis
 Good history v. imp
 Description of attack
 Precipitating fact
 Assoc sympt
 Recovery speed, post-attack state
 Past history
 Family history
 Physical examination: General, vitals, local ( CVS, CNS)
 ECG
 Management
 1. ABC (airway, breathing, circulation)
 2. Neurologic status, full history, ECG, refer (if needed)
 Referral if suspect cardiac cause or in elderly
 Coma
 State of unresponsiveness to external environmental stimuli, unarousable
 No O2 to brain 10 sec or no glu for 2 min unconc
 Timely diagnosis critical
 Causes (“TIPPS on vowels” (a e i o u))
 TIPPS:
 T: trauma, tumor, temperature
 I: Infection
 P: Psychiatric, porphyria
 P: Poison
 S: Space occupying lesion, shock, stroke, SAH
 VOWELS:
 A: Alcohol
 E: Electrolyte
 I: Insulin
 O: O2 (lack), opiates
 U: Uremia
 After ABC, one should obtain full hist from relative or eye witness
 Approach to critically ill patient in coma
Aim is first to: Stabilize, and after: find cause
 ABC
 Level of conc, vitals
 IV medication:
 Dextrose 50ml of 50% (adult), 2ml/kg 25% (child)
 Naloxone 20mg iv
 Thiamine 100mg iv
 Pupils
 Neck rigidity
 Eye movements
 Motor function
 CNS exam
 Fundus
Shock
 Inadequate tissue perfusion due to peripheral circulatory failure
 Types
 Hypovolemic, eg dehydration, burns, he
 Vasogenic (abnormal vasomotor tone), eg anaphylaxis, head injury, drugs, etc
 Cardiogenic (pump failure), eg, cong hrt dis, IHD, trauma, drugs
 Clinical features
 Unresponsive
 Poor response to painful stimuli
 Ashen look (greyish)
 Cold sweaty extermity
 Pulse weak, rapid
 Grunting
 BP low
 Hypotonia
 Management
 LOC, vitals
 Oxygen
 Expand intravascular volume
 Correct hypoglycemia
 Stop bleeding
Diabetic Ketoacidosis (DKA)
 Absolute insulin deficiency
 Acidemia, ketoacidosis, dehydration
 Fatal if untreated
 Signs/sympt
 Polyuria, polydipsia, wt loss, abd pain, vtg, weakness, blurring vision, dehydration
 Shock, Kussmal respiration
 Underlying illness
 Biochem
 BS > 11mmol/L
 Urine: ketone, glu
 Blood pH <7.3
 Bicarb <15mmol/L
 Management: correct:
 Dehydration
 Acidosis
 Hyperglycemia
 Insulin deficiency
 Underlying illness
 Fluid replacement: NS 0.9% 10ml/kg over 20-60 min
 Insulin: after treating shock
 Bicarb: NOT proven efficacy. Avoid.
Hypoglycemia

 Blood Sugar <2.5 mmol/L

 Signs: Trembling, sweating, pallor, tachycardia, hunger,
nausea/vtg, drowsiness, headache, weakness, confusion,
coma, siezures
 Treatment:
 Symptomatic:
 Bolus 25% Dext. 1-2ml/kg
 Glucose IV 7.5 mg/kg/min
 Asymptomatic: skip bolus dextrose.
Convulsion
 > 30 min  brain damage
 Causes:
 Birth trauma
 Febrile convulsions
 Infection
 Electrolyte disturbance
 Genetic
 Idiopathic
 Head trauma
 Management:- Aim: Control convulsions, treat cause (eg, Hypoglycemia)
 ABC, vitals
 Oxygen
 Turn pt on side, suction
 Benzodiazepine if > 5 min.
 Rectally: 0.5mg/kg. Can use syringe without needle if enema n/a
 IV: 0.2mg/kg, slowly, until eyelid drops or fitting stops, even if full dose not given
 If no effect in 5-10min: 2nd dose
 Caution re. apnea
Drowning and near-drowning

 Definition: death by suffocation due to immersion in liquid

 Wet: 80-90 % cases
 Dry: laryngospasm
 Children at greatest risk
 Presentation depends on when pt was rescued
 Management
 Airway protection, respiratory support
 CPR
 Oxygen 100%
 Manage hypothermia
 Other injury
 Cerbral hypoxia
 Diazepam
 Elevation of head
 Hyperventilation
 Refer all cases.
Multiple trauma

 Resucitation
 Call ambulance
 ABC
 Airway
 Neck support
 Suction, oxygen
 Splint for support
 CPR
CardioPulmonary Resucitation
CPR
 Approximately 700,000 cardiac arrests per
year in Europe
 Survival to hospital discharge presently
approximately 5-10%
 Bystander CPR vital intervention before
arrival of emergency services
 Early resuscitation and prompt defibrillation
(within 1-2 minutes) can result in >60%
survival
 Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths
 APPROACH SAFELY!

Approach safely
Scene Check response

Rescuer Shout for help

Open airway
Victim
Check breathing

Bystanders Call 112

30 chest compressions
2 rescue breaths
CHECK RESPONSE

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths
CHECK RESPONSE

Shake shoulders gently

Ask “Are you all right?”
If he responds
• Leave as you find him.
• Find out what is wrong.
• Reassess regularly.
SHOUT FOR HELP

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths
OPEN AIRWAY

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths
CHECK BREATHING

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths
CHECK BREATHING

 Look, listen and feel for

NORMAL breathing

 Do not confuse agonal

breathing with NORMAL
breathing
 AGONAL BREATHING

 Occurs shortly after the heart stops

in up to 40% of cardiac arrests

 Described as barely, heavy, noisy or gasping

breathing

 Recognise as a sign of cardiac arrest

30 CHEST COMPRESSIONS

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths
CHEST COMPRESSIONS

 Place the heel of one hand in the

centre of the chest
 Place other hand on top
 Interlock fingers
 Compress the chest
 Rate 100 min-1
 Depth 4-5 cm
 Equal compression : relaxation
 When possible change CPR
operator every 2 min
RESCUE BREATHS

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths
 CONTINUE CPR

30 2
 CPR IN CHILDREN

 Adult CPR techniques can

be used on children

 Compressions 1/3 of the

depth of the chest
 CPR demonstration
Acute Laryngeal Obstruction

 Anaphylaxis
 Symptoms
 Management
 O2
 Adrenaline
 KVO
 Vitals
 Refer
FB inhalation

 While eating
 Signs
 When to suspect
 Management
 ? Removal
 Shock
 Infants
 Proper position
 Heimlich Maneuver
 Needle crico-thyroidotomy
Acute Abdominal Pain

 Key symptoms
 Physical examination
 Bedside measures for diagnosis
 adult
 child
Abdominal pain (contd.)

 Peptic ulcer
 Acute appendicitis
 Testicular torsion
 Intussusception
 Meckel’s diverticulum
 Renal colic
 Biliary colic
Burns

 Burn wounds occur when there is contact

between tissue and an energy source, such as
heat, chemicals, electrical current, or
radiation.
 The resulting effects of the burn are
influenced by the:
 intensity of the energy
 duration of exposure
 type of tissue injured
Determine extent of injury

 Rule of nines
 Pt palm 1%
Determine depth of injury

 Treatment of burns is directly related to the

severity of injury
 Severity is determined by:
 depth of burn
 external of burn calculated in percent of total
body surface (TBSA)
 location of burn
 patient risk factors
Burn Management

 Clothing
 Cooling
 Cleaning
 Chemoprophylaxis
 Covering
 Comforting
When to refer?

 3rd deg, 2nd deg >5% child, >10% adult

 Area of involvement, type of burn, inhalation, pre-
existing medical disorder, age, family support
Poisoning

 Discussion
 History
 Examination
 Management
 Epicac
 Gastric lavage
 Activated charcoal
 Specific agents
 Fish
 paracetamol
Foreign Body (FB) Ingestion

 Management
 Indications for referral
FB in Ear

 Diagnosis
 Management
Eye Injury
 Eye injuries of all types occur at the rate of about 2000/day.

 10% to 20% of these injuries result in temporary or permanent vision

loss.

 Three out of five people who receive sustainable eye injuries were
not wearing eye protection.
 Flying objects – A survey conducted by the Bureau of Labor
Statistics, found that about 70% of eye injuries were caused by flying
debris or falling objects

 Contact with Chemicals

 Misuse of tools: improper guards, poor maintenance, poor safety

habits
Use of the appropriate
eyewear is important
Epistaxis – Acute Management

 Reassure patient
 􀂄 IV hydration depending on extent of bleed
 􀂄 control HTN
 􀂄 Bloodwork – CBC, INR/PTT, Group and Cross
 􀂄 Treatment
 - depends on etiology
 - those with systemic factors, conservative,
 noncauterizing, cartilage-sparing techniques for
 initial therapy -
 correct coags, d/c meds
Epistaxis

 Most common bleeding d/o of head and neck

 􀂄 Very common – 60% incidence through one’s life
 􀂄 10% seek medical attention; 6-10% ENT consult
 􀂄 Seasonal incidence – Winter > Summer
 􀂄 may be serious
 􀂄 Etiology – consider local and systemic factors
 􀂄 Site of bleed - Anterior 90%
 Posterior 10%
Thank you