COMMON EMERGENCY ACUTE PAINS

1. HEADACHE. 

Headache of non traumatic origin accounts for 0.5% of ED attendances of which 10-15 have serious underlying pathology. Patients typically present in one of the three ways:

1).   SEVERE HEADACHE, unlike any previous one (first severe or worse than ever)

2).    HEADACHE WITH ASSOCIATED WORRYING FEATURES-  e.g altered mental status, fever, focal neurology.

3).  Chronic severe headache unresponsive to treatment

Aetiology

Differentiating between potentially life-threatening and relatively non serious causes is difficult.

 Primary Headache

A,  migrane

B, tension headache

C, cluster headache

D, miscellaneous (benign cough headache, benign exertional headache, headache associated with sexual activity). 

Secondary Headache

a,  Head injury

b, Vascular (stroke, intracranial Haematoma, subarachnoid haemorrhage, venous thrombosis, hypertension)

c, substance misuse or withdrawal – including analgesia withdrawal or rebound

d,Non vascular intracranial disorder – increased CSF pressure, post LP, intracranial tumour.

e,  Infection – meningitis encephalitis

f,  Metabolic – hypoxia,  hypercapnia, hypoglycaemia, CO poisoning 

g,  Craniofacial disorder -  pathology of the skull, neck, eyes, nose, ears, sinuses, teeth, mouth, temporomandibular joint dysfunction

h,  Neuralgias- trigeminal occipital and other cranial nerves.

 

APROACH

Get detailed history and examination including vital signs- BP TPR and neurological examination. Look out for typical features in the brackets ():

i. subarachnoid haemorrhage: (sudden and severe onset, syncope).

 ii.  meningitis or enchaphalitis( fever, neck rigidity)

iii.  Head injury (history,or signs of trauma)

iv. increased ICP (papiloedema. Loss of retinal vein pulsation)

v. stroke (focal neurological signs)

vi. Acute glaucoma (painful redeye, irregular semi-dilated pupil)

HISTORY

Features in the history suggesting possible serious pathology are:

1. sudden onset headache

2. worst headache ever

3. dramatic change in pattern of headache

4. known immuno compromise or malignancy

5. headache coming on during exams

6. new onset of  headache in those aged > 50

Ask about drugs and the possibility of toxins (eg CO poisoning)

EXAMINATION

Assess vital signs, including GCS, pulse rate, respiratory rate, BP, temp,  sao2- perform a through examination to include:

1. Feel the head for muscular tenderness, look for evidence of head injury

2. Examine the eyes vision, pupil reactions, eye movements and papiloedema.

3. Palpate the sinuses for tenderness

4. Look in the forheamotympanum or infection.

5. Look for evidence purpura / rash of meningococcal  infection

6. check for oral cavity for infection

7. complete the neurological  examination.

Management

Investigationand emergency treatment will depend on the cause and the signs

 If cause not known / unclear - check FBC, ESR U& E, blood glucose, blood cultures

Consider - CT for patients with altered mental status, severe headache with vomiting

Admit if severe or suspecting meningitis

SUBARACHNOID HEAMORRHAGE

(consider subarachnoid  haemorrhage in any ‘worst ever or sudden onset headache)

Atraumatic subarachnoid haemorrhage can occur at any age and is an important cause of sudden collapse and death. Most of bleeds follow rapture of saccular (berry) aneurysm in the circle of willis. Other bleeds may be due to arterior-venous malformations. Tumours or connective tissue disorders.

HISTORY

Up to 70% of patients with subarachnoid haemorrhage report rapid onset or  worst ever headache

Patients will describe  the type of pain as a blow to the back of the head accompanied by neck pain, photophobia and vomiting.

The patient may be presented after an incidence of syncope/ or  fit

Drowsiness and confusion are common

Warning headaches may precede subarachnoid haemorrhage

Unilateral eye pain may occur

Examination

Check vital signs

Examine for neck stiffness – sign of meningitis

Investigation

1.blood sugar

2. FBC

3. Clotting time

4. E&U

5. CXR

6. EEG

7. CT

8. LP(12  hrs after the onset of headache)

TREATMENT

Will  depend on the cause and how they are presentation

 Give oxygen

Adequate analgesia

Assess AVP

CHEST PAIN

 

Common causes	Less common causes
Musculoskeletal	Aortic dissection
Myocardial ischemia/ infarction	Herpes zoster
Pneumothorax	Oesophageal rapture
Oesophagus	Pancreatitis
Pneumonia	Vertebral collapse
Pulmonary embolus

 HISTORY

a. Characterise the pain

b. Site

c. Severity

d. Time of onset and duration

e. character – (stabbing, tight/gripping or dull aching)

f. radiating – ( to the arms, & neck in myocardial infarction)

g. precipitating  and relieving factors (exercise/rest spray)

h. previous similar pains

Enquire about associated symptoms breathlessness, nausea and vomiting, sweating, cough haemoptysis, palpitations, dizziness, loss of consciousness.  Document past history, drug history and allergies.   Check old note and old ECG in available if not request for them. 

CHEST INJURIES  ( THORACIC INJURIES )

Chest injuries usually result from  major trauma such as gun shots, fall from height, assault, and RTA. A severe chest injury is  terrifying to a conscious patient.so the first aider must be tactful

·         Chest injury can be  blunt i.e  RTA or penetrating one from bullet or spear

The following are some of the chest injuries:

1.       Broken Ribs: A chest injury usually breaks the ribs of an older patient. But if the casualty is young,  the ribs may be so elastic that he can have severe internal injuries without #. Broken ribs heal spontaneously.

2.       Haemothorax – collection of blood in the pleural cavity. Blood may come from the chest wall or from injured lung.

3.       A  Pneumothorax : Air in the pleural cavity usually comes from the lungs, but it can also come from the trachea. A  small pneumothorax is usually harmless and resolves spontaneously.

4.       A Heamopneumothorax: presence of both air and blood in the  pleural cavity.

5.       Tension Pneumaothorax: the air in the pleural cavity may be under pressure when the injury on the lung or open chest wound, acts as a valve and allows air to get in but not out. More air is trapped each time he breathes.  The Lung on the injured side collapses, Mediastinum moves towards  the normal side, and restricts the movement of that lung too. The bronchi may kink and make his breathing even more difficult.  Unless air is rapidly let out, patient would die.

6.       A Flail chest: multiple #s of ribs can cause a large part of the chest wall to move independently of the rest of it, or allow it to be pushed inwards (stove in the chest). The danger of a flail chest is that the loose piece which should be moving outwards during inspiration, may be sucked inwards (paradoxical movement), and greatly impede his breathing. The mediastinum can also  move paradoxically as patients  breathes. The result is that air which should be replaced with each respiration, merely moves from one lung to the other (paradoxical breathing).

7.       A Sucking chest wound :allows a pleural cavity to communicate with the outside air. With the result that the lung on the injured side collapse, the patient’s mediastinum moves paradoxically and patient has paradoxical breathing. Closing his open wound may save life.

8.       Surgical emphysema: results from air escaping into the tissues, usually under the skin. Air in the mediastinum is much more serious and may indicate the rapture of the bronchus.

9.       Shocked lung:  is as a result of lung contusion by a shock wave. This is common and causes haemoptysis.

10.   Other injuries on patient’s thorax  include;

·        Abdomen injuries

·        Injuries to the diaphragm

·        Heart injuries

·        Injuries to the liver, spleen or spine.

·        Injuries to the Aorta are a common cause of death in RTA

 

 MANAGEMENT

1.      Secure the airway and encourage patient to cough and clear it.

2.      Remove air from the top of his pleural cavity

3.      Close the open chest wound

4.      Assist with ventilation

5.      Transfuse with blood

6.      Prevent infection

7.      Relieve  cardiac tamponade  by aspirating blood from the pericardium cavity

In severe injuries surgery to repair the organs is needed

DRAINING AIR AND FLUID FROM THE PLEURAL CAVITY

Drainage is all the patient with chest injury needs.

i.                    Air - Remove air by putting a tube into the pleural cavity, usually in the 3^rdintercostal space just lateral to his midclavicular line. 

ii.                  Blood and fluid or pus:  insert the tube from the bottom usually through his eighth or ninth space in his posterior axillary line.

The tubes to the bottle are put underthe surface of water in a large bottle.

Set for chest drain set

1.      Sterile bottle

2.      Trocar

3.      Adaptor

4.      Knife –surgical blade on a bp handle

5.      Soft rubber catheter

6.      Suturing material (needle and thread) forcepts

FLAIL CHEST FIRST AID MANAGEMENT

ABC

·        If chest is clear, casualty is breathing adequately no further aid is necessary

·        If not breathing adequately try the following:

i.                    Gently press with your hand

ii.                  Turn casualty on his side this will:

a.      Keep the flail segments still

b.      Keep the uninjured lung upper most

c.       Prevent blood from his injured lung draining downwards into it.

iii.                Support him with strapping or sandbags

CAUTION do not apply a pad or bandages, because this will only hide the abnormal movement, without stopping it. Intubate if necessary and inflate with a self –inflating  bag.

PARADOXICAL MOVEMENT IN FLAIL CHEST.

 Under local anaesthesia use any of the following methods to apply traction on one, or two or more points on the floating part of the patient’s rib cage’

i.                    Grip his ribs or sternum with several towel clips or suitable forceps, and then tie these together with string. The clips or forceps must have a ratchet so that they remain closed.

ii.                  Pass wire or strong sutures under the ribs or sternum

iii.                Screw some sterile cup hooks into his ribs or sternum

iv.                 Pass Steinmann’s pin under his pectoral muscles close to his ribs 

Examination 

 Evaluate ABC and resuscitate

-oxygen therapy

- IV access

-IV analgesia appropriately

- Listen to both lungs fields and check for tension pneumothorax 

 

Investigations

Depends on the presentation

ECG & CXR are usually required.

ABDOMINAL PAINS

Approach to abdominal pain

First aim to identify patients requiring resuscitation or urgent treatment. Thefor resuscitation is apparent in emergencies with associated hypovolaemia and or septic shock is less common.

 

History

Determine details of site, radiation, shift, character, timing, precipitating and relieving factors.

Vomiting record anorexia, nausea and vomiting. Ask about  the nature of vomit (blood, bile etc). vomiting which follows on set of abdominal pain tends to imply a surgical cause, whereas vomiting preceding pain is often non surgical.

Bowel disturbance – Enquire about recent change of bowel habits particularly any bleeding.

Other symptoms – do not forget that abdominal pain may be due to urological, respiratory, cardiovascular, or gynaecological disorders

Past history- Determine the nature of previous surgery, preferably by obtaining old notes

CAUSES OF ACUTE ABDOMINAL PAIN

The cause of abdominal pain is often unclear initially. Indeed many patients get better without definite cause being identified (non specific abdominal pain).

Surgical

·         Non specificabd pain

·         Acute appendicitis

·         Cholecystitis

·         Pancreatitis, peptic ulcer disease (including perfortion)

·         Raptured abdominal aortic aneurysm

·         Mesenteric infarction

·         Large bowel perforation

·         Intestinal obstruction from various causes

·         Ureteric culculi

·         Urinary retension

·         Testicular tortion

·         Intussusception

·         Cancer- colon