Introduction

Emergency situations cause stress, especially if they are unfamiliar or present new and different challenges. Specific life threatening medical emergencies may only be experienced by most practitioners a few times in their career^1,2 and even experienced clinicians require training and practice to maintain confidence and skills. Using a system of care and assessment will improve consistency. This chapter aims to set out a system of assessment for the patient with emergency care needs. It can only offer a framework; proper application will require training, flexibility, common sense, and experience (Box 2.1).

Box 2.1 Objectives

To describe a system to identify immediately life threatening problems (the primary survey positive patient)

To provide guidance on the management of the primary survey positive patient

To introduce the SOAPC system for the full evaluation of a patient who might be suitable to treat and refer or treat and leave

Recognition of immediately life threatening problems

Most patients do not have an immediately life-threatening airway, breathing, circulation, or neurological problem. The patient who is talking normally, is fully orientated, is not pale or sweaty, has no dyspnoea, has a normal pulse, and is not breathless is unlikely to be in immediate danger. However the patient’s condition may change very quickly and some need careful monitoring and re-evaluation (for example, the patient with chest pain may have a sudden cardiac arrest). Making decisions about the presence or absence of an immediate threat to life can be difficult. There is evidence that important clinical signs of urgent airway, breathing, circulation, or neurological problems may be easily missed, misinterpreted, or mismanaged in the emergency setting in hospital practice;^1,2 the risk of clinical errors in pre-hospital practice is likely to be greater.

Fortunately, there are common presentations for most acute medical emergencies that can be anticipated. These include shortness of breath, chest pain, abdominal pain, collapse, coma, and seizures (Box 2.2).

Box 2.2 Common emergency presentations

Coma

Difficulty in breathing

Chest pain

Collapse with hypotension

Collapse with altered consciousness

Gastrointestinal bleeding

Abdominal pain

Headache

Seizures

The primary survey positive patient

A number of excellent reference texts and resources exist describing the priorities and immediate actions for assessing acutely unwell patients in the hospital and general practice setting.^3–10 The approach and techniques advocated are equally applicable in the resource limited community care environment and during transport to hospital. Similarly, the ABCDE approach taught on standard life support courses is as applicable to acute medical emergencies as it is to resuscitation from cardiac arrest and the management of major trauma. This structured approach is illustrated in Figure 2.1. This reflects the central doctrine of emergency care that immediate assessment and management of a life threatening condition does not require a precise diagnosis. It also illustrates the importance of considering early transport to definitive care with emergency treatment compared with resuscitation en route.

Fig. 2.1 Structured approach to identifying the primary survey positive patient.

After ensuring the scene is safe, the practitioner should aim to undertake a rapid primary survey (Box 2.3). In many patients, the primary survey may be completed very quickly. The common pathways to cardiac arrest in acute medical emergencies are airway obstruction, respiratory failure, circulatory failure, and neurological failure. The aim of the primary survey is to seek out evidence of these in order to target specific resuscitative interventions.

Box 2.3 Rapid primary survey

Airway Assessment

There is unlikely to be an immediately life threatening airway problem if:

the patient is talking normally and

there is no history of anaphylaxis or other airway problems

Breathing Assessment

There is unlikely to be a life threatening breathing problem if:

the patient is not dyspnoeic

the respiratory rate is less than 29 and greater than 10 breaths per minute

Circulation Assessment

There is unlikely to be an immediately life threatening circulation problem if:

the patient’s skin is not cold, clammy, sweaty

the pulse rate is >60 and <120 beats per minute

there is no evidence of a condition that might cause blood loss

there are no signs of sepsis

there is no clinical suspicion that the patient is having an acute myocardial infarct

Disability Assessment

There is unlikely to be an immediately life threatening neurological problem if:

the patient is fully alert and orientated

there are no localising neurological deficits (face or limbs)

there is n o history to suggest meningitis.

The patient’s condition can change and this assessment is a continuous process throughout the episode of care

If the patient is not talking normally then a more detailed airway assessment is required. Look for signs of obstruction and check that the patient is maintaining and protecting the airway. The unconscious patient is at significant risk of passive regurgitation and pulmonary aspiration even if the airway is maintained with simple techniques and positioning. Failure to clear blood, saliva or mucus from the oropharynx and absence of spontaneous swallowing indicate a failure of airway protection. Although the full range of basic and advanced airway management interventions should be available to manage such patients, simple adjuncts (especially nasopharyngeal airways), postural drainage, and head and neck positioning may be sufficient during the remainder of the primary survey and transfer to hospital.

To assess breathing, look for signs of increased respiratory effort, inadequate ventilation, and common physical signs associated with respiratory and cardiovascular disease. An increased respiratory rate, use of accessory muscles, splinting of the diaphragm, and recession of the chest wall are sensitive indicators of an increased work of breathing. Tachypnoea alone may reflect a very wide range of disease processes and it should not be assumed to reflect a breathing problem in the absence of other signs of respiratory distress. If wheeze is present, decide if the sound occurs mainly during inspiration (stridor) or expiration (most likely to be attributable to lower airways obstruction).

Detailed assessment of the circulation should identify the presence of shock and a systemic inflammatory response to infection. Shock is a failure of tissue oxygenation. The classic signs include prolonged capillary refill, tachycardia, tachypnoea, and sympathetic nervous system stimulation (pallor, sweating and peripheral vasoconstriction). ‘Sepsis’ refers to evidence of systemic infection (for example, pneumonia, meningococcal disease) accompanied by systemic inflammatory responses. These include a pulse rate greater than 90, a respiratory rate greater than 20, and a temperature above 38° C or below 36° C. Acute gastrointestinal haemorrhage may be missed if the clinical signs of bleeding are not assessed. Finally, assessment of the circulation in medical emergencies includes an assessment of heart rhythm and a search for evidence of heart failure and myocardial dysfunction (tachycardia, 3rd or 4th heart sounds, systolic murmur).

Detailed assessment of disability entails a mini-neurological examination starting with level of consciousness, mental state, pupil signs, localising signs, posture, and limb function (see below). The patient should also be exposed as much as practicable to look for evidence of a rash (urticaria or purpura), jaundice, anaemia, pitting oedema, and physical manifestations of chronic disease. An accurate assessment of temperature is essential in assessing whether the patient is feverish or hypothermic.

Patients with a serious illness requiring immediate transport to hospital

There are a number of common problems where the primary survey may confirm that the patient is ‘stable’ but they may still have a condition that needs immediate treatment, usually in hospital. Chest pain, vascular occlusions, severe shortness of breath, severe abdominal pain, and acute neurological deficit are examples. In such cases the focus of treatment is rapid transport to hospital with any necessary interventions being provided during the journey.

These patients are usually identified during the primary survey and often require little further examination. It is only once life threatening problems have been excluded or identified and treated that a conventional history and examination can be conducted.

The secondary survey

All acutely unwell patients should undergo a primary survey to identify their immediate resuscitation needs but most patients asking for assessment through their primary care service are not likely to need immediate life saving treatment or to be rushed to hospital. There is time to perform a more detailed secondary survey. This follows the more traditional medical model of history and examination.

Any further clinical examination should then be dictated by history and clinical suspicion. A differential diagnosis can then be reached and further decisions made regarding treatment, transportation and definitive care.

The SOAPC system

The system that we have adopted (Box 2.4) is based heavily on problem oriented methodology:¹¹

Subjective information: the history from the patient or carers

Objective information: examination findings, augmented when appropriate, by investigations and information from the patient record (for example, electronic record or patient held records)

Analysis: your opinion as to the probable cause of the problem and whether other serious problems need to be ruled out

Plan: the further care of the patient including advice, treatment with drugs, whether the patient requires another healthcare facility or can stay at home with appropriate follow up and ‘safety net’ advice

Communication with patients/carers/health team.

Box 2.4 The SOAPC system of care

Subjective information: the history

Objective information: the examination, tests, records

Analysis: working diagnosis or differential diagnosis

Plan: treatment and ongoing care

Communication: with the patient, carers and other healthcare professionals

S – The subjective assessment

TIP

Develop a system of appropriate history taking: ‘Ask the right questions, not every question’¹²

The history is the key to correct patient assessment.¹³

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