Emergencies in general practice

Patients attending the surgery can become acutely unwell while on the premises, so practice nurses need to have the skills to cope with any emergency situation

Some of the best features of general practice - that it is familiar, nearby and accessible - mean that people often visit the surgery as the first port of call when they feel unwell. This may then mean that they can become acutely unwell while in the practice and require emergency care. Other emergencies may occur unexpectedly during a standard appointment, such as fitting an intrauterine device. This means that nurses working in general practice should have the necessary skills to be able to cope with such an eventuality. In this article, we will consider the key skills required to deal with an emergency. In subsequent articles, we will discuss specific emergency situations and how to act safely and effectively in each situation.

EMERGENCY SITUATIONS

Some of the areas where emergency action may be required include:

• Acute asthma attack
• Bleeding
• Collapse
• Cardiac arrest
• Suspected stroke
• Hypoglycaemia
• Choking
• Anaphylaxis
• Status epilepticus
• Breath-holding attack (child)
• Panic attack
• Someone being assaulted in the surgery

Each specific situation will require particular skills and interventions; however, there are key elements which are central to ensuring the best outcome in an emergency.

BASIC LIFE SUPPORT

Basic life support involves maintenance of the airway, breathing and circulation until recovery or death. The phrase 'DR ABC' will be familiar with many people in this respect as a mnemonic for what needs to be done in an emergency.¹

D - danger
R - response
A - airway
B - breathing
C - circulation
D - danger

Before anything else, a swift, mental 'risk assessment' of possible danger should be carried out. Potential dangers include those related to the patient, the health care providers involved and the environment. For example, a young man enters the surgery bleeding heavily from a leg wound. He has been stabbed. He is accompanied by a gang of young men who are shouting at another group of people outside the surgery. In this situation, there is obvious danger facing the patient because of his wound, plus there is a bodily fluid spillage risk to the environment and there is a risk of further violence which could involve everyone - staff and patients. Immediate action is required to safeguard the health and well-being of all of these people.

R - response

Check to see if the patient is responsive by gently shaking their shoulders and shouting a phrase such as 'Can you hear me?' Try this in both ears in case the patient has a hearing impediment. If there is no response to this, it is important to call loudly for help or alternatively, to activate any emergency system that may be in place in the practice. This means that there is support available for any attempt at resuscitation and to dial 999 if and when required.

A - airway

Assess whether the airway is patent by extending the head backwards and bringing the jaw forwards. (Figure 1) If anything is blocking the airway (tongue, foreign body, vomit) try to clear it.

B - breathing

It is important to assess for normal breathing, as in a stressful, emergency situation agonal breathing (laboured, irregular breathing which may be seen in the dying patient) can be misinterpreted as a sign that the patient is breathing.² A hand in front of the mouth may be all that is needed to assess for the presence of normal breathing; observing for regular chest movements is also useful.

C - circulation

The advice is that signs of the presence of a circulation should be looked for and feeling for the carotid pulse may be one way to do this. However, according to the Resuscitation Council2 time has been wasted on occasion by looking for a carotid pulse, especially by members of the public who may not have the skills to do this. Health care professionals should be able to check for the presence of a carotid pulse, using two fingers positioned between the trachea and the sternocleidomastoid muscle.

If the patient has a palpable pulse and is breathing, he should be put into the recovery position whilst awaiting an ambulance.

If the pulse and/or breathing are absent, then emergency life support should commence.

CPR: STAYING ALIVE

Cardiopulmonary resuscitation (CPR) involves supporting breathing and/or circulation to allow vital organs to be perfused with blood and oxygen when the heart and lungs are unable to function normally. This has been the subject of a recent British Heart Foundation (BHF) campaign to increase public understanding of how and when to carry out CPR.³ In the BHF advertisement, fronted by Vinnie Jones, the advice is to carry out chest compressions to the rhythm of the Bee Gees tune 'Staying Alive'. The purpose of the campaign was to remove any concerns people had about performing mouth to mouth resuscitation, either due to confusion over timing and ratio of breaths to compressions or just general squeamishness. The message is that compressions are more important than full CPR: in an emergency, chest compressions can save lives. This may be important if you need to involve members of the public in any resuscitation attempt and they have concerns about performing mouth to mouth.

To view the BHF 'Staying Alive' advertisement, go to http://www.youtube.com/watch?v=ILxjxfB4zNk

However, hands-only CPR is for the general public only; for health care professionals, the advice is to continue combining chest compressions with mouth to mouth resuscitation. The current recommended rate is two breaths, pinching the nose closed and watching the chest to check it is rising with each breath, to thirty compressions, with the hands joined and pressing over the sternum (Figure 3) at a rate of approximately 100 per minute.²

OTHER KEY EMERGENCY SKILLS

In the next article we will consider some case studies based on emergencies, which may present in the general practice setting and discuss the best way to approach them, using the latest evidence and advice. However, there are some key tools which may be used in these situations, which it might be useful to revisit here.

The electrocardiogram (ECG)

ECGs can provide useful information about heart rate and rhythm and evidence of possible ischaemic changes. However, in an acute situation, it may be more important to get the patient to hospital than to record an ECG. Acute changes, such as those seen in acute coronary syndrome, may not be evident initially and there is a danger that people may be inappropriately reassured by an apparently normal ECG.⁴ In other circumstances, such as suspected atrial fibrillation, it is important to get an ECG as soon as possible, when it is more likely that an arrhythmia will be recorded. As with any other skill, the person who records the ECG should have had appropriate training, as should the person who interprets it.

Automated External Defibrillator

In cases of cardiac arrest, the use of an automated external defibrillator (AED) can significantly increase the chances of survival, especially if used within the first five minutes of a person collapsing.⁵ It is thought that having a defibrillator in the surgery can increase the chances of surviving a cardiac arrest by up to 60%. In theory, anyone can use an AED as the machines 'talk' the user through the process, advising how to apply the pads and when to activate the current. However, if there is an AED in the practice, staff should have been taught how to use it.

Nebuliser

In situations such as an acute asthma attack, delivering high dose bronchodilators is an important part of emergency care. In many cases this can be done safely and effectively by using a pressurised metered dose inhaler (pMDI) with a spacer device such as a Volumatic.⁶ A basic dose schedule of four puffs of salbutamol given every 15 minutes can be adapted for the individual patient so that higher or more frequent doses can be given if deemed necessary. In children, failure to respond to 10 puffs of salbutamol means that they should be sent to the hospital for further assessment and management. In the case of a severe or even life-threatening acute exacerbation, the patient may not have the requisite inspiratory flow rate for a pMDI and spacer, and a nebuliser may be required. Nebulised salbutamol at a dose of 2.5-5mg should be given via oxygen-driven nebuliser until the patient can be fully assessed by the emergency team. Emergency oxygen administration is discussed in more detail below.

Pulse oximetry

Pulse oximetry is a crude way of assessing the level of oxygen in an individual's blood through the use of a finger clip. The pulse oximeter measures oxygen saturation levels but does not give information about carbon dioxide levels or possible acidosis. Normal readings vary between 95-99%. A general rule is that if readings are below this, and certainly if they reach 92% or less, the patient may need supplemental oxygen and admission for arterial blood gases.⁶ Pulse oximetry should always be used alongside more holistic assessment of the individual and the user should bear in mind the fact that people with chronic obstructive pulmonary disease (COPD) may be chronically hypoxic and may even rely on this to stimulate their respiratory drive.⁷

Oxygen administration

Decisions about when and how to deliver oxygen to patients in acute situations can be complex. In acute coronary syndrome and stroke, for example, oxygen may be unnecessary or even harmful; this is also the case in pregnancy and in COPD. In cases of hypoxaemia, as defined by pulse oximetry carried out in the surgery, giving 5-10l/min via a simple face mask or 15l/min via a reservoir mask is suggested.⁸ A full guideline on emergency oxygen use in adults is available from the British Thoracic Society.

Heimlich manoeuvre

The Heimlich manoeuvre is a technique to help to dislodge a foreign body in a case of choking.⁹

The Heimlich manoeuvre should focus on the action of the fist which is positioned between the ribs and under the stomach. The fist should be forced upwards, avoiding crushing the ribs at the same time if possible, with a view to dislodging any foreign body stuck in the trachea. Attempts to dislodge a foreign body using fingers are discouraged unless it is easily visible and can be removed with a simple finger sweep.

SUMMARY

A thorough but swift assessment of any emergency situation will ensure that the correct procedures are carried out, including basic life support, assessment and treatment of hypoxia, delivery of life saving treatments such as high dose bronchodilators and the appropriate use of aids to diagnosis such as ECGs.

In the next articles, we will look at specific situations where interventions, such as those described above, might be needed. More detailed discussion of how to manage each acute presentation will be included. Scenarios which will be discussed next time are:

• Acute asthma attack
• Suspected heart attack
• Suspected stroke
• Hypoglycaemic collapse
• Anaphylaxis

REFERENCES

1. St John Ambulance (2012) DR ABC Available from http://www.sja.org.uk/sja/first-aid-advice/lifesaving-procedures/primary-survey.aspx Accessed October 2012

2. Resuscitation Council (2010) Basic Life Support Available from http://www.resus.org.uk/pages/bls.pdf Accessed October 2012

3. British Heart Foundation (2012) Hands-only CPR Available from http://www.bhf.org.uk/heart-health/life-saving-skills/hands-only-cpr.aspx Accessed October 2012

4. Bostock B. Assessing chest pain in primary care. Practice Nurse 21 September 2012;42(14):34-39

5. British Heart Foundation (2012) Defibrillators. Available from http://www.bhf.org.uk/heart-health/life-saving-skills/defibrillators-save-lives.aspx Accessed October 2012

6. BTS/SIGN (2012) British Guideline on the management of asthma Available from http://www.brit-thoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/sign101%20Jan%202012.pdf Accessed October 2012

7. International COPD Coalition (2010) Clinical Use of Pulse Oximetry Available from http://www.copd-alert.com/OximetryPG.pdf Accessed October 2012

8. BTS (2008) Emergency oxygen use in adult patients Available from http://www.brit-thoracic.org.uk/guidelines/emergency-oxygen-use-in-adult-patients.aspx (note later revisions to recommended flow rates) Accessed October 2012

9. International Consensus On Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (2005) Circulation 112 (III): 5-16. Available from http://circ.ahajournals.org/cgi/content/full/112/22_suppl/III-5 Accessed October 2012