CHAPTER 2 Acute medical and surgical problems 116 Acute myocardial infarction Symptoms As for unstable angina, but: - Pain likely to be more severe - Sweating, nausea, and vomiting likely to be more marked. Signs As for unstable angina, but also: - Bradycardia/tachycardia - Cardiac failure/shock ( JVP, murmurs, basal crepitations, BP). ECG abnormalities May be absent in early stages. - Peaked T waves and ST elevation. Followe d by - ST elevation and \200\230mirror \200\231 ST depression. Followed by - Development o f Q waves. Followed by - T wave inversion. Location of changes: - Inferior MI II, III aVF (may extend laterally or posteriorly). Anterior MI V1 \200\223V3 (may extend to V4, anteroseptal or to V6, anterolateral). Posterior MI ST depression and R wave changes in V1 \200\223V2 (mirror image of anterior changes). Immediate management - Rest - High-flow O2 - Monitor pulse oximetry, ECG, pulse respiratory rate, and BP - Aspirin 300mg (unless recent major GI bleed or aspirin allergic) - Nitrate (buccal or sublingual) - Diamorphine up to 5mg with metoclopramide 10mg - CONSIDER thrombol ysis (see p.117) - Urgent evacuation to hospital for further management Therapy with betablockers or ACE inhibitors should be commenced following arrival in hospital. MYOCARDIAL ISCHAEMIA1 117 Pre-hospital thrombolysis In the majority of cases, thrombolysis or acute percutaneous coro nary intervention (PCI) will be carried out after arrival in hospital and the aim of pre-ho spital care must be to expedite arrival at hospital. In some circumstances, geographical lo cation or conditions will mean that pre- hospital thrombolysis is appropriate and thromboly sis is increasingly provided by ambulance service personnel. If this is likely to be the ca se in a particular area, appropriate protocols should be in place. Indications - Ischaemic chest pain (onset within 12 hours) AND 1mm ST elevation in 2 or more adjacent limb leads OR 2mm ST elevation in 2 or more adjacent chest leads. New left bundle branch block is also an indication for thrombolysis in the presence of chest pain, but old notes and ECGs are unli kely to be available in pre-hospital care. Contraindications See Table 2.2 Table 2.2 Contraindications to thrombolysis Absolute Stroke in last six months - Trauma with risk of major bleeding - Bleeding diathesis - Sever e liver disease - Coma - Lumbar puncture, visceral biopsy, or dental extraction in last mon th Active peptic ulcer disease - Recent GI bleeding - Acute pancreatitis - Oesophageal varices - Known aortic dissection - Abdominal, eye, or neuro- surgery in last month Relative Active menstruation - Pregnancy - Hypertension (systolic >200mmHg, diastolic >100mmHg) - Anticoagulant therapy - Abdominal aortic aneurysm - Traumatic CPR CHAPTER 2 Acute medical and surgical problems 118 Thrombolytic agents The thrombolytic agent of choice in pre-hospital care is tenectaplase w hich activates plasminogen to form plasmin which degrades fibrin and breaks up thrombi. Dos e 500 \200\223600g/kg (maximum 50mg) by intravenous injection over 10 sec Side-effects - Nausea and vomiting - Bleeding - Reperfusion arrhythmias - Hypotension. MYOCARDIAL ISCHAEMIA1 119 Fig. 2.26 Acute inferior MI. Reprinted with permission from Myerson SG et al. (2005). Emerg encies in Cardiology. Oxford University Press, Oxford. CHAPTER 2 Acute medical and surgical problems 120 Fig. 2.27 Acute anterior MI. Reprinted with permission from Myerson SG et al. (2005). Emerg encies in Cardiology. Oxford University Press, Oxford. This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 122 Pericarditis Etiology Causes include viruses, bacteria including tuberculosis, fungi, malig nancy, autoimmune disease, and post myocardial infarction. Many cases are idio- pathic. A r ecent history of a flu-like illness is suggestive of viral pericarditis. Symptoms Retrosternal or left-sided chest pain; may be pleuritic. Radiates to neck. Worse w ith coughing, lying flat, inspiration, or swallowing. May be associated with shortness of b reath. Other symptoms may reflect the underlying cause. Signs A pericardial rub may be heard in full inspiration or expiration with the patient lea ning forward. ECG abnormalities Concave upwards ST segment elevation. Immediate management Admission to hospital for investigation and management. No other immed iate treatment required. In the absence of contraindications, a NSAID can be given for anal gesia (ibuprofen 400 \200\223600mg tds). PERICARDITIS1 123 I III aVR aVL aVF II V2 V1 V3 V4 V5 V6 Fig. 2.28 Pericarditis: ECG abnormalities. Reprinted with permission from Myerson SG et al. (2005). Emergencies in Cardiology. Oxford University Press, Oxford. CHAPTER 2 Acute medical and surgical problems 124 Shingles (Herpes zoster) Shingles results from reactivation of herpes virus in sensory root ganglia. Symptoms and signs - Pain in distribution of one or more sensory dermatomes May precede - V esicular rash in the distribution of one or more sensory dermatomes. Rash may be disseminated in immunocompromised individuals. Management - The patient will need an oral antiviral agent such as acyclovir 800mg 5 x day. Shingles involving the face may cause eye complications. Exclude keratitis with fluorescein staining. If any evidence of decreased visual acuity or any othe r eye involvement, refer for specialist opinion. This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 126 Acute pulmonary oedema Symptoms - Breathlessness (acute or acute on chronic) - Cough - Frot hy sputum (may be lightly blood stained) - Collapse - Shock, sweating, pallor, peripheral c oldness. Other symptoms reflect the underlying cause: - Chest pain - Palpitation. Signs - Patient dyspnoeic at rest and sitting upright - Bilateral basal pulmonary crepitati ons - Patient may be cold, clammy, and sweaty in severe cases - Tachycardia - Tachypnoea - Elevated JVP (in congestive failure). Immediate management - Rapid evacuation to hospital - Monitor pulse, respiratory rate, BP, O2 saturation, ECG - Give high-flow oxygen (care in COPD) - Give frusemide 40 \200\223120mg IV (40mg boluses) - Consider morphine 5 \200\22310mg IV with an antiemetic - Consider bucc al GTN 2 \200\2235mg - Consider 12-lead ECG to exclude MI. Signs indicating SEVERE pulmonary oedema Inability to speak, BP <100mmHg, severe dyspnoea, copious frothy (pink) sputum This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 128 Acute exacerbations of asthma Classification A classification of asthma (adapted for pre-ho spital use ) is given in Table 2.3. Transportation to hospital is mandatory if any of the m arkers of near fatal, life-threatening, or acute severe asthma are present. Management. - Sit patient up, administer high-flow oxygen (15L/min) - Give salbutamol 5mg b y nebulizer (on oxygen); repeat if necessary - Gain IV access and give 200mg hydrocortisone - Monitor pulse, BP, respiratory rate, and O2 saturation (maintain above 95%) Consider IV magnesium 1.2 \200\2232g - Be prepared to provide ventilatory support if the pa tient deteriorates - Evacuate urgently to hospital (warn A&E to call an anesthetist if required). Always consider pneumothorax or tension pneumothorax as a cause of deterioration in an asth matic. ACUTE EXACERBATIONS OF ASTHMA1 129 Table 2.3 Classification of asthma for pre-hospital use Near fatal - Immediate requirement for ventilation Life-threatening - Severe airways obstruction - PEF <33% predicted - Silent chest - Feeble respiratory effort - Increased work of breathing Exhaustion - Systolic BP <100mmHg - Bradycardia or arrhythmia - Ventilation perfusion misma tch Cyanosis - Hypoxia (SpO2 <92%) Ventilatory failure Confusion or coma (suggestive of rising PaCO2) Acute severe asthma - PEF 33 \200\22350% predicted - Respiratory rate >25/min - Tachycardia (>110 bpm) - Inability to complete sentence in one breath Moderate asthma - PEF 50 \200 \22375% predicted - No features of acute severe asthma - Increasing symptoms CHAPTER 2 Acute medical and surgical problems 130 Chronic obstructive pulmonary disease (COPD) Presenting features - Wheeze unresponsive to i nhaler therapy - Production of purulent sputum/increased sputum production - Increasingly s evere breathlessness - Respiratory failure. Signs - Increased respiratory rate (>25/min suggests a significant exacerbation) - Cyanosis - Use of accessory muscles - CO2 retention flap, confusion (indicative of hypercapnoea) - Bilateral widespread wheezes (beware the silent chest) - Peripheral oedema. Initial management - Oxygen 24 \200\22328% via face mask - Salbutamol 5mg nebulized - Consi der hydrocortisone 200mg IV - Consider oral antibiotics if the patient does not require adm ission - Be prepared to provide respiratory support in the event of progressive respiratory failure In extreme circumstances, institute BVM ventilation with high-flow oxygen. This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 132 Pulmonary embolism Presenting features - The clinical picture of pulmonary embolism may var y from apparently minor non-specific chest pain to acute cardio-respiratory collapse. Sudden onset pleuritic chest pain - Shortness of breath - Haemoptysis - Cardiac arrest, typ ically with PEA (massive PE). Signs - Tachycardia and tachypnoea - Raised JVP - Cyanosis - Pleural rub - Signs of DVT. Signs may be of little help in establishing the diagnosis and the history may be of little more than chest pain and mild dyspnoea. Immediate management - Have a high index of suspicion; if the diagnosis is a possibility, r efer to A&E urgently for further investigation and management Give oxygen 15L/min via a non-rebreathing mask - 12-lead ECG may demonstrate the S1T3Q3 pat tern but is far more likely to show tachycardia and non-specific ST and T wave changes Monitor pulse, BP, respiratory rate, ECG, and pulse oximetry - Give analgesia (NSAID or sma ll dose of opiates). Cardiac arrest In the event of cardiac arrest, manage according to appropriate protocol. Vi gorous CPR may dislodge embolus and produce effective cardiac out- put. There is currently no established place for pre-hospital thrombolysis in pulmonary embolism. PULMONARY EMBOLISM1 133 Common risk factors for DVT Prolonged bed rest - Prolonged travel - Recent surgery - Pregnancy or recent childbirth - M orbid obesity - Previous/family history of DVT/PE CHAPTER 2 Acute medical and surgical problems 134 Pneumothorax (See also Chapter 3, Trauma) Spontaneous primary pneumothorax is rare, with a male to female ratio of 4:1. It occurs in previously normal lungs and is characteristically a disease of young men. Pneumothorax may also occur secondary to pre- existing lung diseas es, most commonly asthma and COPD. Presenting features - Shortness of breath (usually sudden onset) - Chest pain (non-specific , often pleuritic) - Acute severe exacerbation of asthma or COPD - Increasing difficulty in manually ventilating a patient or deteriorating hypoxia despite effective ventilation. Types of pneumothorax Simple Simple pneumothorax occurs when there is a leakage of air into the pleural space through a hole in the visceral pleura. No valve is formed and the pressu re within the pleural space remains atmospheric. Symp- toms and signs may be absent or subt le but will be related to the degree of pneumothorax. Tension Tension pneumothorax (which is rare in non-traumatic conditions) is a life-threaten ing emergency and a cause of cardiac arrest. Air enters the pleural space either through a hole in the chest wall or, more commonly, through a hole in the visceral pleura. A flap val ve effect develops and air which enters the pleural space is unable to leave during expirat ion. As a result, an increasingly positive pressure builds up in the pleural space, compres sing the great vessels and the heart, shifting the mediastinum, and compressing first the i psilateral and then the contralateral lung. Although initially subtle, untreated, the patient will rapidly progress to severe respiratory distress, then cardiorespiratory arrest and death. Signs Other signs of tension pneumothorax include a weak thready pulse, elevated JVP, and c yanosis (very late). Tracheal deviation is a late sign. PNEUMOTHORAX1 135 Table 2.4 Signs of pneumothorax Ipsilateral percussion note Ipsilateral breath sounds Chest expansion Trachea Simple Hyper-resonant Reduced Central May be reduced Tension Hyper-resonant Reduced or Reduced, then over expanded Central, then deviated to opposite side absent Immediate management Simple pneumothorax No pre-hospital treatment is required. Monitor res piratory rate and O2 saturation and transportation to hospital for investigation and manage ment. Tension pneumothorax Decompress urgently by inserting a large-bore IV cannula into the seco nd intercostal space, midclavicular line. Once the cannula has been inserted, the needle is removed and the cannula secured in place. Presence of a tension pneumothorax is confirmed by the escape of air under pressure. Even if there is no evidence of a tension pneumothorax , the cannula must be left in place until the patient arrives in hospital. Formal chest drainage (tube thoracostomy) Insertion of a formal chest drain is very rarely indicated in pre-hospital care. It is a complex, painful procedure with serious complicatio ns and, whenever possible, should be carried out after arrival in hospital. Situa- tions wh en insertion of a chest drain should be considered include: - Predicted prolonged entrapmen t - Very prolonged or delayed evacuation - Before transfer by air - In the artificially ven tilated patient with a known pneumothorax. The technique is described on the following page. Increasing difficulty in manually ventilating a patient or deteriorating hypoxia despite ef fective ventilation is STRONGLY SUGGESTIVE of the possibility of pneumothorax. CHAPTER 2 Acute medical and surgical problems 136 Insertion of a chest drain 1. Prepare the drainage system (a bag/valve system is most appropriate). 2. If possible, position the patient with their arm (on the side of the pneumothorax) abduc ted with the forearm behind their head. 3. Identify and mark the 5th intercostal space midclavicular line. 4. Clean and prepare the area with antiseptic solution. 5. If the patient is conscious, inject 1% or 2% lignocaine down to the pleura. The needle should be inserted just above the lower rib in order to miss the neurovascular bundle which lies under the lower border of each rib. 6. Fixing the skin firmly between thumb and forefinger, make a 3cm incision along the line of the intercostal space with a scalpel 7. Using the scalpel (carefully!) and then a forceps, create a track down to and through the pleura. 8. Insert a finger (usually the little finger) through into the pleural. space and sweep ro und the hole to ensure that there is no lung stuck to the inside of the chest wall (care in trauma \200\224there may be sharp ends of fractured ribs). 9. Grip the proximal end of the chest drain (through one of the side drainage holes) with f orceps and clamp the distal end of the tube. 10. Using the forceps, insert the drain, directing the tip towards the lung apex. 11. Connect the drain to the drainage bag; check for bubbling. 12. Close the incision with mattress sutures and stitch the drain in place with a \200\230garter \200\231 stitch or equivalent. 13. Dress the wound using 10 cm x 10 cm swabs with a cut in one side to accommodate the drain (making sure it is not kinked) and cover the drain/tube junct ion with tape. 414. Ensure that the lung is ventilating. This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 138 Hyperventilation syndrome Presenting features - Anxiety/panic - Hyperventilation - Per-oral tingling - Carpo-pedal spasm - Tinnitus - Chest tightness. Management Either Get the patient to breathe slowly and shallowly into a paper (not plastic !) bag Or Instruct the patient to take slower and slower breaths Whilst quietly reassuring them and gradually calming them down. It is often necessary to be firm and insistent on gra dual slowing of the breathing whilst ensuring that the breaths become shallower and not dee per. Once the symptoms have resolved, it may be worth getting the patient to reproduce them by a rtificially hyperventilating. This confirms the diagnosis and demonstrates to the patient t hat they have control over their own symptoms. This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 140 The unconscious patient Differential diagnosis Common causes of loss of consciousness inclu de: - Hypoglycaemia - Drug/alcohol intoxication - Head injury - Intracerebral catastrophe ( subarachnoid hemorrhage, stroke, etc) - Epilepsy Approach to the unconscious patient Responsiveness The first priority must be to ensure tha t the patient is unconscious! A gentle shake of the shoulder accompanied by \200\230Are yo u alright? \200\231 is appropriate. Airway and breathing Open the airway, remove any obvious foreign material, consider inserti ng an airway, and check for breathing. If respiration is absent or inadequate, ventilatory support with high-flow oxygen will be required. Circulation Assess the circulation using the pulses; if there is no pulse, commence CPR. Ga in intravenous access. Monitor pulse, BP, ECG, and pulse oxi- metry. Check the blood glucos e. Disability Perform a simple assessment of the conscious level using the AVPU system and ass essment of papillary responses. A Glasgow Coma Scale Score can be performed during transfer to hospital, if there is time. NEVER forget the blood glucose in an unconscious patient THE UNCONSCIOUS PATIENT1 141 Table 2.5 Assessment of pupils Equal Unequal Large Reactive Tricyclics Holmes \200\223Adie Sympathomimetics Hypothermia Unreactive Tentorial herniation Mydriatics Local injury Small Reactive Opiates Argyll Robertson Unreactive Pontine hemorrhage Miotics Horner \200\231s syndrome CHAPTER 2 Acute medical and surgical problems 142 Diagnostic clues in the unconscious patient Diagnostic clues from simple assessment of the patient are given in Table 2.6. Table 2.6 Diagnostic clues in the unconscious patient Breathing Tachypnoea Cheyne \200\223Stokes Kussmaul Bradypnoea Salicylates CVA DKA Opiates Hypovolaemia Raised intracranial pressure Tricyclic antidepressants Circulation Hypotension Hypertension Opiates Rising intracranial pressure Tricyclic antidepressants DKA Hypovolaemia Tachycardia Bradycardia DKA Rising intracranial pressure Hypovolaemia Beta blockers Disability Large pupils Small pupils Unequal Tricyclics Opiates Local trauma Hypothermia Pontine hemorrhage Head injury (very late) General appearance \200\224Look out for: Injection marks \200\224opiates Urinary incontinence \200\224epilepsy Signs of assault or serious injury Smell of alcohol Smell of ketones Medic-Alert bracelet Meningitic rash This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 144 Cerebrovascular events Cerebro vascular accident (CVA) \200\224stroke Presenting features S udden onset of abnormal cerebral function including: - Unilateral weakness/paraesthesia - D ysphasia - Convulsions - Headache - Reduced level of consciousness/coma - Abnormal respirat ory pattern - Abnormal eye movements. If the neurological symptoms and signs last less than 24 hours, the diagnosis is transient ischaemic attack (TIA). This distinction can rarely b e made pre-hospital. An alternative diagnosis (space-occupying lesion, demyelination, encep halitis, etc) is more likely in younger patients Immediate management - All patients should be transported urgently to hospital for assessme nt - Aspiration is a significant risk, therefore establish and maintain an open airway (use the recovery position) Give high-flow oxygen - Check a BM stix . CEREBROVASCULAR EVENTS1 145 Sub-arachnoid hemorrhage (SAH) Presenting features - Sudden onset of occipital headache ( \200\230like a blow \200\231) - Neck stiffness - Nausea and vomiting - Impaired conscious l evel/coma - Fits - Focal neurological signs. Notes: onset of headache during sexual interco urse is a classical but rare feature of SAH. Many patients will report lesser headaches in the days leading up to their presentation ( \200\230herald bleeds \200\231). Immediate management - Monitor pulse, BP, respiratory rate, pulse oximetry - If the patient is drowsy /unconscious, establish and maintain a patent airway (use the recovery position) Maintain a quiet environment as far as possible - Give high-flow oxygen - Treat fits with d iazemuls (p.146) - Evacuate immediately, preferably to a hospital with neurosurgical facilities - BM stix CHAPTER 2 Acute medical and surgical problems 146 Status epilepticus Most patients with epilepsy and their families are experienced at dealin g with single seizures. They are only likely to call for help when the fitting appears to b e lasting longer than normal. Pre-hospital care personnel may also, more rarely, be asked t o treat a patient having their first fit. Definition Status epilepticus is defined as fitting lasting 30 min or longer, or multiple s hort seizures with so little time between them that no recovery occurs before the new attac k commences. Immediate management - Ensure a safe environment. - Fits lasting 5 min or less require no t reatment. - Give high-flow oxygen if possible. - Stop fitting with IV diazemuls (see box). - Establish and maintain a clear airway (an oral or nasal airway and the recovery position is usually adequate); ensure effective suction is available. Transfer urgently to hospital. - If control is not achieved, transportation the patient to hospital for further management. DO NOT give dangerous doses of diazemuls. Doses of diazemuls Adults 10 \200\22320mg by slow IV injection in aliquots to effect Rectally, 500g/kg Children Rectal \200\224children over 10kg, 500g/kg maximum 30mg IV \200\224200 \200\223300 g/kg or 1mg per year of age This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 148 Meningococcal meningitis and meningococcal septicaemia Meningococcal disease may present wi th a predominantly meningitic or with a septicaemic picture. Meningitis Presenting features - Neck stiffness - Pyrexia - Headache - Photophobia - Drowsi ness - Non-specific flu-like symptoms. Meningococcal septicaemia Any or all of the above plus: - Petechial rash - Ecchymotic/purpu ric rash (due to enlargement and confluence of petechiae) Non-purpuric maculopapular rash - Shock - Respiratory distress. Notes A suggestive rash, even in the absence of other symptoms, should be treated as mening ococcal septicaemia until proven otherwise. The rash may not always be present on presentat ion. Meningism may be absent even in the presence of a rash. Immediate management - Intravenous access - Give benzyl penicillin (see box) - Commence IV fluids - Establish and maintain a patent airway - Transfer to hospital without delay. Consi der intramuscular antibiotics if IV access is difficult: DO NOT DELAY TRANSFER. Alternative therapy, suitable also for those genuinely allergic to penicillin, is cefotaxime 2g or cef triaxone 2g (adult doses). Meningococcal meningitis and septi- caemia MENINGOCOCCAL MENINGITIS AND SEPTICAEMIA1 149 Benzyl penicillin in meningococcal disease Adult 1.2g (2.4g in established disease) by IV injection (preferred) or intra- muscular inj ection Children - Under 1 year:300mg - 1 \200\2239 years: 600mg - 10 years and over: adult dose Contact prophylaxis in meningococcal disease The following will need antibiotic prophylaxis : - Household \200\230kissing contacts \200\231 - Institutional contacts (nursing home res idents, etc) - Clinical personnel \200\224only if involved in close patient contact (e.g. r esuscitation) or risk of body fluid (sputum, blood) contamination Seek advice from local consultant in communicable disease regarding medication. CHAPTER 2 Acute medical and surgical problems 150 Poisoning (including drugs and alcohol) See Chapter 6. Hypothermia See pp.554 \200\2237. This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 152 Diabetic emergencies Hypoglycaemia Presenting features - Tachycardia/palpitation - Sweating - Anxiety - Headache - Pallor and cold extremities - Tremor - Confusion - Aggression - Com a. Immediate management If the patient is still conscious and aware of likely diagnosis, co nsider oral treatment such as hot sweet drinks (milk and sugar, sweet tea, etc), Hypostop , or confectionery. If patient unconscious, check BM stix then give 10% dextrose via a large IV cannula. If IV access is difficult, give glucagon 1mg by intramuscular injection. Glucagon will not work in cachetic patients, those with chronic liver disease, or alcoholics. Any BM stix result of 4 or less should be treated. Ketoacidosis Diabetic ketoacidosis is much more insidious in onset than hypoglycaemia. It m ay result from non-compliance with treatment, be precipitated by infection, or be the prese ntation of previously undiagnosed diabetes. Presenting features - Polyuria, polydipsia - We ight loss - Weakness - Shortness of breath - Abdominal pain - Vomiting - Confusion - Coma - Signs and symptoms of underlying infection (eg pneumonia, urinary tract infection). The diagnosis is made by BM stix \233\232 which will usually demonstrate an elevated blood glucose. Immediate management - The priority is urgent transfer to hospital. - Establish an d maintain a clear airway (vomiting is a significant risk). - Give oxygen 15L/min. - If tra nsfer is prolonged or delayed (or during transit) obtain iv access and give normal saline s tat(care in patients with cardiac disease); consider administering a short-acting insulin d epending on BM result. This page intentionally left blank CHAPTER 2 Acute medical and surgical problems 154 The acute abdomen The pre-hospital practitioner will not always be able to make a precise d iagnosis in the case of a patient with an acute abdomen. Sometimes (e.g. food poisoning) th e history will give the probable diagnosis; in other cases, the patient may present the cla ssical history and examination findings of, for example, acute appendicitis or cholecystiti s. Very often, however, it will be more useful to answer these two questions: - Is there a possibility (however small) that this patient has a serious condition requiring operative i ntervention or further investigation? - Does the patient require care or symptom relief whi ch cannot be provided at home? If the answer to either of these questions is yes, the patient requires transfer to A&E for further assessment and management. Differential diagnosis Nevertheless, it is often possible to reach at least a working diagn osis for the patient with abdominal pain. This depends on the identification of characteris tic symptom patterns for each condition. Use of Table 2.7 allows matching of symptoms and p ossible diagnoses. It may also be helpful to consider the age of the patient when attempt- ing to reach a diagnosis (see Table 2.8). Abdominal aortic aneurysm (AAA) Presenting features - Sudden onset abdominal or back pain - Pulsatile mass (may be tender) - Hypotension (following rupture) - Syncope (following rupt ure) Notes: - The aneurysm may be difficult to palpate (especially in the obese). - Ruptured AAA should always be considered as a cause of syncope in the elderly. Any patient with a history and findings suggestive of the diagnosis should be referred urgently for assessment. Immediate management - Immediate transfer to hospital - Oxygen 15L/min - DO NOT waste time attempting IV access \200\224do this en route. - If fluids are necessary, maintain a BP of approximately 90mmHg. DO NOT attempt to achieve normotension. THE ACUTE ABDOMEN1 155 Table 2.7 Matching of symptoms and possible diagnoses Finding Possible diagnoses Page Aortic aneurysm 154 Severe abdominal pain radiating to back Acute cholecystitis 158 Acute pancreatitis 159 Peptic ulcer disease 160 Active labor 664 Renal/ureteric colic 161 Flank pain radiating to the groin Pyelonephritis 162 Testicular torsion Aortic aneurysm 154 Aortic aneurysm 154 Collapse or signs of shock Ectopic pregnancy 646 Gastrointestinal bleed Myocardial infarction 116 Bowel obstruction 164 Distension Pregnancy 644 Ascites Mass Trauma 218 Abdominal bruising Aortic aneurysm 154 Acute pancreatitis 159 Aortic aneurysm 154 Pain out of proportion to examination findings Mesenteric infarction 165 Renal colic 161 Ulcer 160 Haematemesis or melaena Diverticular disease 166 Angiodysplasia Malignancy Varices Bowel ischaemia 275 Constipation Bowel obstruction 164 Diverticular disease 166 CHAPTER 2 Acute medical and surgical problems 156 Table 2.7 Diagnosis of the acute abdomen by age. Reprinted from Greaves I and Porter K (199 9). Pre-hospital medicine \200\224the principles and practice of immediate care. Hodder Arn old Children under 2 years Non-specific 61% Appendicitis 32% Intussusception 1.3% Adolescents Acute appendicitis Ectopic pregnancy Adults under 50 years Non-specific 39% Appendicitis 2% Cholecystitis 6.3% Bowel obstruction 2.5% Pancreatitis 1.6% Diverticular disease <0.1% Hernia <0.1% Cancer <0.1% Vascular <0.1% Adults over 50 years Cholecystitis 21% Non-specific 15.7% Appendicitis 15.2% Bowel obstruction 12.5% Pancreatitis 7.3% Diverticular disease Malignancy 4.1% Hernia 3.1% Vascular 2.3% THE ACUTE ABDOMEN1 157 Acute appendicitis Presenting features - Dull peri-umbilical pain which migrates to the rig ht iliac fossa, becoming sharp Anorexia - Nausea and vomiting - Right iliac fossa tenderness (signs of peritonitis suggest perforation) - Mild pyrexia - Coated tongue and hallitosis. Other symptoms (variable) - Previous similar attacks - Urinary frequency and dysuria - Diar rhea. Notes Older patients and women tend to present with less \200\230classical \200\231 sympto ms. Immediate management - Transfer to hospital for assessment and surgery - Give antiemetic if required. CHAPTER 2 Acute medical and surgical problems 158 Gallbladder disease Gallbladder disease is more common amongst patients who are obese, fema le, and middle aged, although it can occur in either sex and any age group. Presenting features - Biliary colic Short episodes of right upper quadrant pain or epigastric pain which may radiate to the bac k, usually constant in nature (not truly collicky). Usually less than 30 min duration. Nausea and vomiting (mild) - Murphy \200\231s sign* usually negative, no abdominal tenderne ss - Fever absent - Acute cholecystitis Nausea and vomiting (more marked) - More prolonged than biliary colic - Localized right upp er quadrant pain radiating to the epigastrium or scapula Low-grade fever - Local peritonism - Murphy \200\231s sign \210\227 usually positive - Pati ent looks \200\230unwell \200\231. Gallbladder perforation Usually in the elderly, infirm, or diabetic - Jaundice - Fever/rigors - Right upper quadran t pain. These symptoms suggest the presence of ascending cholangitis. Immediate management - Urgent transfer to hospital - Give analgesia (NSAID or opiate), pref erably IV - Give oxygen 15L/min - Monitor pulse, pulse oximetry, BP, and ECG (myocardial is chaemia is a differential of gallbladder disease). Place the hand lightly in the right upper quadrant and ask the patient to take a deep breat h. If the patient experiences discomfort (when the inflamed gallbladder jars against the ex amining hand), Murphy \200\231s sign is positive. THE ACUTE ABDOMEN1 159 Acute pancreatitis A careful history is important in the diagnosis of acute pancreatitis in order to identify potential causes. The most common (>80%) are gall- stones and alcohol. O ther cause include viral infections such as mumps and hepatitis, drugs, and trauma. Acute p ancreatitis can also be familial. Presenting features - Severe abdominal pain, usually rapid onset Poorly localized in the epigastrium and left upper quadrant - Radiating to back - Aggravate d by lying down, relieved by sitting forwards Vomiting (may be severe) - Patient looks unwell - Jaundice - Shock more common in the elder ly - Abdominal tenderness, usually diffuse; guarding and rebound - Rarely, bruising may be noted in the flanks (Gray \200\223Turner \200\231s sign) or around the umbilicus (Cullen \200\231s sign). Immediate management - Transfer urgently to hospital - Establish and maintain a clear airwa y - Give oxygen 15L/min - IV access in transit, commence normal saline. If the patient is n ot shocked, time may be spent in gaining iv access for analgesia. Give antiemetic and analgesia (opiate) - Monitor pulse, BP, respiratory rate, ECG, and puls e oximetry - Check BM stix - Nil by mouth. CHAPTER 2 Acute medical and surgical problems 160 Peptic ulcer disease Presenting features - Severe epigastric pain; radiation to the back su ggests posterior perforation Signs of peritonitis are absent unless perforation has occurred - If perforation has occurr ed, the patient will try to lie as still as possible - Haematemesis and melaena - Shock (fr om perforation or bleeding). Immediate management - Transfer to hospital for investigation and management - IV access en route - IV fluids to maintain a radial pulse if the patient is shocked and transfer prolonged Monitor pulse, BP, ECG, and pulse oximetry - Give high-flow oxygen - Give analgesia (opiate ) - Nil by mouth. THE ACUTE ABDOMEN1 161 Ureteric colic (renal stones) Presenting features - Often very severe loin and flank pain, radiating to groin and genitalia - Patient may writhe around in an attempt to gain some eas e from the pain Nausea and vomiting - Sweating - Frank haematuria is usually absent - Loin tenderness (guar ding may be present). Immediate management - Give analgesia (NSAID, opiate) - Entonox may be useful whilst other analgesia takes effect - Refer to hospital for pain control, diagnosis, and further managem ent - Monitor pulse, BP, ECG, and pulse oximetry - Recurrent attacks: urgent admission may not be required. CHAPTER 2 Acute medical and surgical problems 162 Acute pyelonephritis Presenting features - High fever - Sweating - Vomiting (not always pre sent) - Loin pain - Urinary frequency and dysuria - Haematuria. Immediate management - The decision to refer urgently to hospital will depend on the clinic al condition of the patient. Urinary tract investigation will be necessary in all new cases. Analgesia - Increased fluid intake (oral or IV \200\224severe cases will require admission) - Urine for microscopy culture and sensitivity - Antibiotic therapy (trimethoprim, amoxyci llin, or a cephalosporin are usually suitable). THE ACUTE ABDOMEN1 163 Gynecological causes of abdominal pain See Chapter 12. CHAPTER 2 Acute medical and surgical problems 164 Bowel obstruction Presenting features Most bowel obstructions are secondary to adhesions fr om previous surgery. Other causes include malignancy, herniae, and diverticular disease. Ex amination may reveal evidence of such a cause or features of a careful history may suggest the diagnosis. The common presenting features of bowel obstruction are: - Abdominal pain - Nausea and vomiting (vomiting may be absent in distal small bowel and large bowel obstruction) Abdominal distension - Abdominal tenderness - Constipation and inability to pass flatus (va riable) - The hernial orifices must be carefully examined and note taken of scars from previous surgery. Immediate management - Urgent transfer to hospital for assessment and further management - Give oxygen 15L/min - Nil by mouth - During transit, gain IV access and start crystalloid - Give analgesia (opiate) - Monitor pulse, BP, ECG, and pulse oximetry. THE ACUTE ABDOMEN1 165 Mesenteric infarction Mesenteric infarction with bowel ischaemia and necrosis has a high mo rtality. The patient is often desperately unwell, but by the time the diagnosis is apparent , it is very often too late to intervene. Presenting features - Previous history of cardiac disease such as IHD or atrial fibrillatio n - Abdominal pain (sudden onset) - Nausea and vomiting - Blood in stool or vomit - Abdomin al tenderness - Patient looks disproportionately ill - Shock (may be severe). Management - High-flow oxygen - Urgent transfer to hospital - IV access en route - Analgesi a - Nil by mouth. CHAPTER 2 Acute medical and surgical problems 166 Diverticular disease Diverticular disease (which is rare under age 35) is usually relativel y benign with little more than cramping left iliac fossa pain which is often improved by pa ssing feces, in an otherwise well patient. Symptoms of acute diverticulitis are usually mor e florid, with the patient looking obviously unwell. Presenting features - Left iliac fossa pain (may be longstanding) - History of irregular bo wel habit - Localized peritonism - Nausea and vomiting - Fever and tachycardia - Rectal ble eding (can be massive) - Mass in left iliac fossa (not always present). Immediate management (severe or previously undiagnosed cases) - Urgent transfer to hospital for assessment and management - Give oxygen 15L/min - Nil by mouth - During transit, gain IV access - Give analgesia (opiate) - Monitor pulse, BP, ECG, and pulse oximetry. THE ACUTE ABDOMEN1 167 Medical causes of abdominal pain A number of medical diagnoses may present with abdominal p ain, these include: - Myocardial infarction - Pneumonia - Diabetic ketoacidosis - Poisoning (more commonly in children) - Patients with abdominal pain from these causes do not have s igns of peritonism. This page intentionally left blank Chapter 3 169 Trauma Patient assessment and treatment 170 Primary survey 172 Secondary survey 190 Head and neck injuries 192 Skull fractures 198 Localized brain injury 200 Neck injuries 202 Faciomaxillar y injuries 204 Chest injuries 208 Abdominal and genitourinary trauma 218 Bone and joint inj uries 224 Regional injuries: upper limb 228 Regional injuries: the thorax 246 Regional inju ries: the pelvis 250 Regional injuries: lower limb 254 The complications of fractures 272 S oft tissue injuries 274 Spinal injuries 280 Amputation 284 Blast and gunshot injuries 286 B urn injury 296 CHAPTER 3 Trauma 170 Patient assessment and treatment The assessment and management of the trauma victim is divi ded into the following stages: - Pre-hospital Primary survey Resuscitation Secondary survey Definitive care Hospital In time, critical trauma pre-hospital care involves undertaking a rapid primary survey and instituting life-saving measures only. A detailed secondary survey and definitive care can be undertaken at an appropriate time in hospital. This page intentionally left blank CHAPTER 3 Trauma 172 Primary survey The primary survey is a rapid structured assessment designed to identify inj uries which are immediately life-threatening. When a problem is identi- fied, it must be re ctified straightaway. For example: Airway obstruction \207\222 Airway maneuver \207\222 Airway opened Therefore, the primary survey and resuscitation are performed simulta- neously. The primary survey follows the following ABCDE sequence: A Airway with cervical spine control B Breath ing with ventilation and oxygen therapy C Circulation and control of external hemorrhage D Disability E Exposure and Environment.