emergencies in gp
TRANSCRIPT
EMERGENCIES IN GENERAL PRACTICE
Dr. Chamath Fernando
Lecturer
Department of Family Medicine
Faculty of Medical Sciences
University of Sri Jayewardenepura
Sri Lanka
What is an emergency?
A highly volatile, dangerous situation requiring immediate remedial action.
“A physician can sometimes parry the scythe of death, but has no power over the sand in the hourglass”. Hester Piozzi, Mrs. Thrale (1741-1821). English writer.
Nature of GP emergencies
Who decides it is an emergency?patient / relatives / neighbours / health professionals
How does it differ from A & E work?• time pressures• social / psychological / physical problems• the primary care physician may be able
to provide complete solution
Home visit emergencies - should all requests for visits - even daytime - be screened by a doctor?
Area B: Modification of help-seeking behaviour
Area A: Management of presenting problems Area C: Management of continuing problems
Area D: Opportunistic health promotion
(Stott & Davies, The Exceptional Potential In Each Primary Care Consultation, JRCGP, 1979, 29, 201-205) - especially modification of help-seeking behaviour
What about the Stott & Davis model?
Cardiovascular emergencies
“Collapse“ - often vasovagal attackChest painLVFStrokeHaemorrhageAnaphylaxis
Diagnosis - should you carry an ECG machine?
Treatment Time of responseThrombolytic therapy
(Should GPs give thrombolytic therapy)CPR trainingWhy not just dial for Emergency care?
- referral without assessment can lead to breach of terms of service if there is subsequently a problem
Respiratory emergencies
SOB - Asthma/COPD Airway obstruction
- epiglottitis- FB
Surgical emergencies
Abdominal pain - common- acute abdomen is rare
TorsionStrangulation of herniaBleeding - also haematemesis / malaenaInjury etc
Orthopaedic emergencies
What is the correct assessment of bony injuries in practice?
Gynaecological emergencies
Pelvic pain – PIDBleedingEctopic pregnancy
Obstetric emergencies
Unexpected delivery at home- ergometrine?- equipment for iv infusion?
PPH
What if you undertake GP deliveries?What is your responsibility if you do not?
Contraception emergencies
Requests for emergency contraception
Dermatological emergencies/ Trauma
Rashes ? Urticarial rashesInjury / lacerationsBurns, scalds, sunburn
Neurological emergenciesConvulsionsStroke/ TIA – Hemipareisis, LOC, Loss of vision
Eyes / ENTOtalgiaInsect in Ear
Visual lossGlaucoma
Social / psychiatric emergencies
Somatisers / neurotic symptoms - somatic symptoms creating demand
- abdominal pain- those who cannot cope with viral illnesses - Distressed
Overdose / Deliberate Self Harm
True psychiatric emergencies - Mental Health Act
- possible harm to themselves or others- Agitated depression/ psychosis
Endocrine EmergenciesHypoglycaemiaDKAAddisonian CrisisMyxoedema coma, Thyrotoxic crisis
Urinary tract emergencies
UTI / pyelonephritis - do you administer antibiotics?analgesia?referral?
Ureteric colic - analgesia?referral?what about starting investigations in the middle of the night?
Paediatric emergencies
Earache - what about middle of the night call?AsthmaUpper airways obstruction / epiglottitisMeningismAbdominal painIngestion of poisonsIntussussceptionNAI
What equipment should GPs have?
Tongue depressorsExamination torchStethoscopeOphthalmoscopeAuriscopeExamination gloves & gel
Blood sugar testing equipment Urine dipsticks (Multistix)SphygmomanometerPatella hammerCusco's speculum?
Tape measureThermometer : normal reading?
low reading?
Specimen pots - blood / urine / stoolSyringes, needles
phlebotomy tourniquet?
Local anaestheticSutures / Steristrips / tissue glueStitch cutter / scalpel bladeDressings / scissors
Airway
Working transportAnswering facility - mobile 'phone / 'phonecard Pens - more than one which worksMap of locality
Visit log / diary / something to keep record of what you doSomething to keep clinical notes onList of 'phone nos. of nurses, hospital, social services, etc
Prescription padUrine test strips
Nebuliser?ECG machine?Urinary catheter?
Does it make a difference where you practice? - rural vs. urban
Good physical & mental healthmorale esp. over out-of-hours workdifferent from hospital work
Awareness of medicolegal responsibilities – especially trauma
What drugs should GPs have?
1: oral
Analgesics: Paracetamol?Oral opiate?Diclofenac
Anti-emetic / anti-vertigo
Antibiotics: treatment for urinary infection? After urine culture (in a rural set-up)
Others: sedatives / hypnoticprednisoloneoral diureticglucose tabletsoral rehydration sachetsanti-convulsants
2: rectal
Analgesics: NSAID - diclofenac suppositoryparacetamol
Anticonvulsants: diazepam - Rectules
Anti-emetic: prochlorperazine supp.
3: aerosol
GTN sprayBeta-agonist inhaler
4: injectable
Diuretic: frusemide Antiemetic: metoclopramide?
prochlorperazine? Analgesia: opiate +/- antiemetic Glucose / glucagon Anticonvulsant: diazepam
4: injectable (contd.)
Tranquilisers: diazepam NSAID: e.g. diclofenac Steroid: hydrocortisone Antibiotics: benzylpenicillin powder
( & water for injection)
Adrenaline Atropine Ergometrine Antidotes : Naloxone for?
Flumazenil for?
Telephones / message taking
Who does it? - receptionist?Primary Care Centre?
What do messages need to convey? - patient's detailsproblemurgencytelephone number
Medico-legal issues
Records - what to write and where?Responsibilities if drugs are given A high proportion of complaints come after "emergencies" - have to be sure that "all necessary treatment of the type usually provided by GPs" has been provided. The Family Doctor should do the initial management of the patient and stabilize before referral to the tertiary care unit is done.Confidentiality when relatives are around – chaperones?
Some Scenarios
TASK 3
When managing any kind of emergency….
A.B.C.D.
Value of approach and common sense in Family Practice!
1: You are in the middle of a busy morning surgery when an urgent telephone call is put through to you. A 65 year old woman whom you know well tells you that she has had crushing central chest pain for about an hour. She is a diabetic and has hypertension. You still have 16 patients to see in the Family Practice Centre. You are the only duty doctor. It is 09.50 hours. What are the management options (with benefits and disadvantages of each option identified)?
2: A hypertensive male patient aged 56 years with a history of angina was brought to your clinic complaining of a sudden onset central chest pain that the relatives attributed to have started during a quarrel at a party.Which causes crosses your mind? How do you manage?
3: It is 2 p.m. on Saturday afternoon. The mother of a male patient aged 22 'phones with the story that he has been "depressed" for several days and today has violently smashed up his room at home. What reactions might you have to this situation? Describe your management.
4: It is 2 p.m. on Saturday. Your answering service reports that an airline company wants your advice because they have had to turn a plane back after one of your patients became unwell after take-off. What would your management be?
5. 26 year old male patient with a history of Bronchial Asthma is rushed to your clinic with swollen lips and face accompanied by a severe shortness of breath. What will be your working diagnosis? How would you manage? Referrals…?
6. A 18 year old unmarried female was brought by her mother to the clinic complaining of intermittent cramping RIF pain for one week’s duration which worsened today. The girl is haemodynamically unstable. How would you assess and manage the patient.
7. A 10 year old child from the neighborhood of your clinic is brought to you while fitting, unconscious by his father.What important questions would you ask?How do you manage?
8. 37 year old Diabetic on Insulin was brought to your FPC complaining of abdominal pain, shortness of breath (fruity smelling) and faintishness. How do you investigate? Up to which extent do you manage?
9. Cord prolapse. What is the presentation? How would you manage?
10. Bronchial Asthma Mx?
1. Options include home visit, ask to rush the patient either to you or to the nearest hospital. The factors determine the decision….
2. ReassureShort historyExamination- Evaluation of the haemodynamic status.
Features of cardiac failure Investigations? ECG
Patient positioning – Comfortable position assumed by the patientO2 - ?Basic Monitoring?
Stat doses – Aspirin, ClopidogrelGTN – Repeat every five minutesAtenolol – C/I?Atorvastatin – Why?Captopril – Why?IV/IM Opioids 5-10mg of Morphine with?
Transfer to Emergency department of a tertiary care unit with a referral letter.
3. Most likely diagnosis? Agitated depressionDD: Illicit drugs, Delirium tremens, Thyrotoxicosis, Phaeochromocytoma, Hypoglycaemia, Electrolyte imbalance, Temporal Lobe Epilepsy)Consider your own safety – (Backup from Police, Try to calm the patient down, Ultimate resort is to obtain Help from staff/ relatives to restrain the patient)Talk calmlyTry to ascertain the cause
Mx: Tranquilize the patientIf corporative – Propranolol 20-40mg stat
Diazepam 5-10mg stat or Lorazepam 1mg orally with Chlorpromazine 25mgIf not IM Lorazepam 1.5mg/ Chlorpromazine 25mg / Haloperidol 1-3mgReferral
• What sinister complications can be expected from Phenothiazines (Chlorpromazine) and Buteophenones (Haloperidol)?
Acute Dystonic Reaction (Trismus, Ophisthotonus, Tongue protrusion, Grimacing)
Antidote?IM Procyclidine 5-10mg (repeated up to 20mg total in 20 min)Anticholinergic drug used for Parkinsonism
4. ConsiderationsCan you reach the airport/ healthcare facility which is closest
to the patient in a short time?Can you provide the health staff attending the patient
currently with patient’s health information?The efficiency of having a computer data base of patients’
clinical details that could be immediately shared among healthcare personnel.
5. Concerns:Airway and Breathing – Airway adjunct?CirculationDisability (Confusion, Coma)Exposure (For features of anaphylaxis)
Mx: Reassure and prompt historyQuick examination of vitals, Secure airwayPositioning? Head low, Raise the legsHigh flow oxygenLife saving drug? IM Adrenalin >12yrs = 0.5mg
6-12yrs = 0.3mg<6yrs = 0.15mg
Attach to monitors – SpO2, ECG, BP
IV Access Blood for FBC, SEIV Fluids – 500-1000ml in adult 20ml/kg bolus for childrenIV Chlorpheniramine 10mg (6-12yrs 5mg….)IV Hydrocortisone 200mg (6-12yrs 100mg…)Serum tryptase… Allergist….
6. DD: Appendicitis, Ectopic pregnancy, Twisted/ruptured ovarian cyst, caecal pathology e.g. amoebomaWhat investigation is must?
Mx:Short history – LMPExaminationHD stabilizationImmediate admission with referral letter
7. Important aspects in the history? Age 10yrs, Previous episodes, Duration, Involvement eg Bilateral, Fever
What is Status Epilepticus? >1 seizure without regaining of consciousness in between or single episode that lasts more than 5 minutes
Mx: Ensure airway patencyPut the child in ?recovery positionPrevent non-health staff from non-acceptable remediesObserve for 5 minutesIf continuesCall ambulanceRectal Diazepam 10mg (Lower for younger children)Alternatively - Gain IV access IV Lorazepam 100micg/kg Max 4mg)IV fluidsMonitoring?CBS stat
Admission necessary if Possibility of serious pathology e.g. Meningitis Incomplete recovery or Status
Followup necessary if Adult with first fit Child with first fit not related to fever or atypical features
Recovery Position
8. ABCD approachDiagnosis: Clinical
Biochemical: You may have ABG, Urine for KB, CBS
Mx: 4 Limbs. Can you manage all of them?1. IV fluids – NS followed by 5% Dextrose when Blood sugar is stable below 300mg/dl2. IV/IM Soluble Insulin infusion (Sliding scale)3. Correct K+ if <3.5 (20mmol of KCl to each 4. Correct pH – If Base excess is >-12 IV 8.4% NaHCO3 50-100ml
Keep monitoring – Vitals, UOP (important), and biochemical paramatersCorrect the cause – usually an infection
9. Presentation: The umbilical cord is presenting through the os of the cervix before the presenting part
Mx:ExplainMinimal Handling of the cordPut the mother on knee-chest positionHead down if possibleWear sterile glovePlace the cord within the warmth of the vagina with moist warm gauze packedPush the head (presenting part of the baby) above to release the squashing of the cordFill the bladder with 500ml of salineTransfer immediately to a tertiary care obstetric unit
10. Bronchial asthma?
Thank you!