Emergencies in General Practice

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Emergencies in General Practice
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(No Transcript)
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Overview of teaching

• 14.00 14.15
• Introduction to session / objectives
• 14.15 14.30
• Case studies work through in 4 small groups
• 14.30 15.30
• Brainstorming of case studies and presentations
  on 4 specific areas chest pain, collapse,
  shortness of breath and back pain
• 15.30-15.45
• Tea break
• 15.45 16.30
• Safety netting in general practice
• Summary of available resources
• 16.30 17.00
• Feedback

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How do we get emergency requests?

• Receptionists
• Practice nursing staff
• District nursing staff and Matrons
• How do we vet requests?
• Doctor on call taking all calls?
• Roving doctor doing home visits?
• Practice nurse triage?
• You decide all have pros and cons

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What information is essential ?

• Confirm
• Name, and Date of Birth
• Where the patient is staying
• Contact number
• Symptoms and duration
• Decide who should deal with this
• Protocol for practice available?

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Tool for reception staff to aid decision making
(example - seizures)

• Ambulance
• Head injury in last 48 hours
• Continuous fitting
• Speak to doctor urgently (within 10 mins)
• More than 1 fit in 24 hours
• First seizure
• Others could include
• Reduced GCS, Chest pain, Rash, or self harm

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Case Study One

• You are the GP on call in the middle of your
  morning surgery. Your receptionist puts a call
  through to you from Mr DH, a 72 year old man with
  chest pain. He is not known to you, but looking
  at his computer records, he suffers from angina
  and usually takes aspirin 75mg od, atenolol 50mg
  od and GTN spray.
• Please take a further history over the phone. We
  will decide as a group the most appropriate
  course of action.

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Chest Pain

• Site
• Onset
• Character
• Radiation
• Associated symptoms
• Timing
• Exacerbating/relieving factors

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Chest Pain

• Consider cardiac risk factors
• Previous cardiac history

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Management

• If MI suspected, call ambulance before/instead of
  visiting
• If possible, attend patient before ambulance
  called

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Management

• Aspirin 300mg po (unless contraindications)
• S/L GTN
• Oxygen if available
• Consider
• IV access
• IV analgesia eg diamorphine 2.5-5mg
• IV antiemetic eg metoclopramide 10mg
• Atropine if bradycardic

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Differential Diagnosis
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Case Study Two

• 72yr old calls with acute on chronic back pain.
  He has suffered with back pain for over 15 years
  and takes regular analgesia which normally helps.
  He has an appointment with the urologists
  tomorrow having been reffered urgently with
  prostatism and a raised PSA.

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Back Pain
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Back Pain cont

• Differential Diagnosis
• Mechanical
• Neurological
• Inflammatory
• Infective
• Sinister
• Referred

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Back Pain- examination

• MSK- Look, feel, move
• Abdomen- PR if indicated
• Neurological

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Back Pain- Red Flags
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Back Pain- management

• Analgesia
• Immediate referral if spinal cord compression or
  AAA
• Urgent referral if suspected malignancy
• Advice and reassurance for other, i.e. mechanical
  back pain

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NICE guidelines for referral

• Immediate referral
• Neurological features of cauda equina (sphincter
  disturbance, progressive motor weakness, saddle
  anaesthesia, bilateral nerve root involvement)
• Serious spinal pathology is suspected
• Urgent
• Progressive neurological deficit (weakness,
  anaesthesia)
• Nerve root pain not resolving after 6/52

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NICE guidelines for referral (2)

• Soon
• An underlying inflammatory disorder is suspected
• They have simple back pain and have not resumed
  normal activities in 3/12
• Effects of back pain will vary and could reduce
  QOL, function, independence or psychological
  well-being

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Case Study 3

• One of the receptionists sees that you are
  between patients and asks if you can speak to a
  man about his mother Mrs DC whom he has found
  collapsed. You have not met this patient
  before, but a quick check on the computer shows
  that she is an 89 year old lady with a background
  of hypertension, arthritis, depression and
  hypothyroidism. She takes aspirin, painkillers,
  citalopram, bendrofluazide, enalapril and
  thyroxine. She has not been into surgery for
  around 3 months.
• Please talk to her son about his concerns and
  decide as a group how you would manage this
  patient.

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Collapse

• Vague term, often used multiple causes.
• CV/Vascular MI, PE, Stroke, Arrthymias,
  Syncope, ?Card op
• CNS Seizure, Head injury, SDH, PD, Dementia
• Meds / Drugs Sedatives, Opiates, Alcohol,
  Solvents, OD
• Metabolic ??Glycaemia, ?Thermia, (hypo Ca, Hypo
  pit)
• Infection Septicaemia, Meningitis, LRTI, UTI.

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History

• Use access to info PMH, Drugs, Social
• Assess ABCs, GCS, Cognition
• - ?Talking, breathing, moving arms/legs, facial
  weak.
• When possible get a description of the event.
• - Recovery phase, precipitants or triggers.
• Consequences injury or fracture.

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Falls / Collapse
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Examination / Initial Rx

• ABCDE G
• Basics pulse, BP, Respiratory rate, Temp, BM.
• Full Exam - ?Injuries.
• Look for clues notes/repeat scripts.
• Initial Rx dependent on findings (glucagon,
  naloxone, benzylpenicillin)

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Disturbed behaviour

• If patient agitation, violent, overtly confused
  phone call from pt, relatives, friends or police.
• Causes
• Safety
• Action
• Drugs.

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Causes
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Safety

• If known to be violent consider police back-up.
• Inform somebody of entrance and expected exit
  time call for help if delayed.
• Dont get into vulnerable situation, have an exit
  strategy.
• Dont try to restrain the pt.

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Action

• May get very little info / exam from the patient.
• Use notes, relatives, neighbours.
• Any ? in meds, drugs/alcohol.
• Listen to the patient, talk calmly.
• Look for organic causes dont put yourself at
  risk.
• Discuss findings and plans w patient and
  relatives.

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? To admit

• Any Danger to pt, or others.
• If cause of behaviour is unclear.
• For treatment of causes found eg. UTI.
• Admit voluntarily / involuntarily.

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Sedating drugs

• Consider to cover transfer period or alleviate
  symptoms.
• Oral diazepam/lorazepam/chlopromazine.
• IM Chlopromazine, Haloperidol.
• Beware or sedation in COPD, Epilepsy, Alcohol
  excess or illicit drugs.

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Case 4

• You are working with the triage nurse and take a
  call from an asthmatic who is not known to you.
  Mr MN is a 27 year old woman whose asthma is
  usually managed with salbutamol and seretide
  inhalers. He is concerned about his breathing.
• Please discuss his symptoms with him over the
  phone, and as a group come up with an appropriate
  management plan.

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ASTHMA COPD HEART FAILURE ANAPHYLAXIS
FOREIGN BODY TUMOUR ANAPHYLAXIS TRAUMA
PE OD ACIDOSIS ANAEMIA HYPER-VENTILATION
SHOCK
HEART FAILURE PNEUMONIA FIBROSIS BRONCHIECTASIS
Consider Pneumothorax Effusion
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SOB Worrying features

• Cyanosis or low Oxygen saturations
• Co-existent chest pain
• New onset swollen leg (esp unilateral)
• Evidence of flash pulmonary oedema
• Recent chest injury exclude pneumothorax
• Stidor (esp in children)
• Facial swelling and new medication (or potential
  allergy history)
• Haemoptysis

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SOB Worrying features

• In the asthmatic
• Silent chest
• Tiredness and confusion
• Unable to complete sentences
• Lack of reversibility (other causes)
• Pulsus paradoxus (debatable)

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Acute asthma
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Management (1)

• Assess patient calmly
• Cardiac or respiratory history
• Chest pain
• Cough, sputum, haemoptysis
• Rate of change of symptoms
• Temp, pulse, bp, jvp, resp rate

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Management (2)

• Consider use of portable spirometry, with pef, or
  ecg
• Use oxygen saturations if possible
• Give oxygen if necessary (and cautiously in COPD)
• Look for risk factors
• previous failure
• admissions for asthma including ICU
• thromboembolic disease rf or history
• Give neb
• Wait for improvement or admit depending on status

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When to admit

• Severe asthma is recognisable
• Admission for moderate asthma is balance
• longer duration of symptoms
• poor response to initial therapy
• past history of admission for asthma
• comorbidity
• lack of social support

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Summary

• Good history will help decide on required action
• Red flags- remember to ask relevant questions
• Do you need help- ?paramedic, ?MHT, ?colleague
• Agree plan with patient