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!