Chapter 7: Other Medical / Surgical Emergencies
Learning objectives for this chapter
By the end of this chapter, we would like you:
-To explain how to rapidly and accurately assess a variety of acute general medical and surgical problems in the emergency care setting.
-To describe the common presentation of acute general medical and surgical problems in the emergency care setting.
-To explain how to effectively manage a variety of acute general medical and surgical problems in the emergency care setting.
Complaints related to the gastrointestinal system are common reasons people present to emergency care setting in the UK. Usually, these are signs and symptoms of a mild and self-limiting gastrointestinal condition, such as indigestion, gastroenteritis or another minor gastric upset. However, these signs and symptoms may also indicate the presence of one of a number of other serious conditions related to the gastrointestinal system with which nurses working in emergency care settings must be familiar. If these conditions are poorly assessed and managed, disability and death may result. This section of the chapter will introduce you to emergency conditions related to the gastrointestinal system, and their assessment and management.
A focused assessment of the gastrointestinal system will involve:
- A detailed assessment of the gastrointestinal system. This begins with inspecting the abdomen for any obvious abnormal movement, masses, symmetry and / or surgical scars. The bowel sounds should be auscultated in all four abdominal quadrants to determine their frequency, quality and pitch, and to identify absent bowel sounds. The large abdominal organs may be percussed; dull sounds may be heard over distended organs. Finally, all four quadrants should be palpated; in particular, the nurse should assess for abnormal masses and tenderness, and note the patient's response.
- A detailed assessment of the patient's history. Most importantly, nurses must ask a patient about their recent food and fluid intake, any changes in their bowel pattern, and other symptoms they are experiencing.
- An assessment of the patient's gastrointestinal pain, if present. It is important to consider the anatomical location of the pain. However, in conducting a pain assessment, nurses should be aware that pain in the gastrointestinal region may radiate from the renal, genitourinary and / or gynaecologic regions, so differential diagnosis is important.
During assessment, a nurse may identify one or more of a variety of medical conditions related to the gastrointestinal system. The most common conditions, and their management in the emergency care setting, are described following:
- Gastrointestinal bleeding - bleeding may occur at any part of the gastrointestinal tract, and for a variety of reasons. A patient with gastrointestinal bleeding typically presents with bright red material and / or black material in the vomitus and / or stool, as well as changes in their vital signs if the bleeding is significant.
- Appendicitis - this is the acute inflammation of the appendix, caused most often by the obstruction of blood flow to, and bacterial invasion of, the appendix, a very small abdominal organ. Patients with appendicitis typically present with a range of non-specific symptoms - including pain, nausea, vomiting, malaise, anorexia and fever. If the appendix ruptures, acute pain and symptoms of acute infection will be seen. In most cases, appendicitis is treated by laparoscopic appendectomy.
- Cholecystitis - this is the acute inflammation of the gallbladder, caused most often by calculi obstructing the cystic duct within the gallbladder, resulting in an accumulation of bacteria. Patients with cholecystitis typically present with a range of non-specific symptoms - including severe pain, nausea, vomiting, anorexia, fever and flatulence. In most cases, cholecystitis is treated by laparoscopic surgery to remove the gallstones and / or the entire gallbladder.
- Acute pancreatitis - this is the acute inflammation of the pancreas. The exact pathophysiological mechanisms underpinning pancreatitis are unclear, however this condition is often associated with cholecystitis, alcohol abuse, infections, some drugs, and malignant structures obstructing the pancreatic duct.
- Bowel obstruction - the bowel may become obstructed for one of two reasons: (1) mechanical causes, or (2) non-mechanical reasons. Bowel obstruction may be partial or complete. In either case, the bowel contents accumulate above the obstruction, resulting in a rapid overgrowth of bacteria and abdominal distention. Patients may present with a variety of non-specific symptoms - including abdominal distention, wave-like colicky pain, nausea and vomiting, and constipation.
- Gastroenteritis - this is the inflammation of the stomach and / or intestinal lining, caused most often by viral or bacterial pathogen/s. Patients with gastroenteritis present with nausea, vomiting, diarrhoea and abdominal cramps, and occasionally fever.
Renal and genitourinary emergencies
Renal and genitourinary problems - including urinary tract infections (UTIs), pyelonephritis and acute kidney failure - are commonly seen in emergency care settings in the UK. If poorly managed, renal conditions can result in severe fluid and electrolyte imbalances and / or chronic kidney disease. It is important that nurses working in emergency care settings can assess and manage acute medical conditions related to the renal and genitourinary systems.
A focused assessment of the renal and genitourinary systems will involve:
- A detailed assessment of the patient's history. Nurses should ask a patient about common comorbid conditions affecting the renal / genitourinary systems, history of previous renal / genitourinary problems, any changes in urinary patterns, and any other symptoms experienced.
- An assessment of the patient's pain, if present.
- Additional assessments to assist with diagnosis - including urinalysis, X-rays or CT scans of the kidneys, blood assays, and post-void bladder ultrasonography to assess residual volume. In the UK, all female patients of childbearing age presenting to emergency care settings with renal and / or genitourinary symptoms are given a routine pregnancy test; this is done even if the patient assures nurses that she is not / cannot be pregnant.
During assessment, a nurse may identify one or more of a variety of medical conditions related to the renal and genitourinary systems. The most common conditions, and their management in the emergency care setting, are described following:
- Acute kidney injury (AKI) - AKI is an acute problem which results in impairment in the function of the kidneys. AKI may be due to one of a number of causes: (1) pre-renal, which decrease blood flow to the kidneys, (2) intra-renal, which damage the fragile structures within the kidneys, or (3) post-renal, which obstruct the urinary tract. A patient with AKI may present to an emergency care setting with a range of non-specific symptoms - including nausea, vomiting, changes in urinary patterns, and changes in neurological status.
In addition to patients with AKI, it is important to note that nurses working in emergency care settings will also care for patients with acute complications of chronic renal failure. These include, most commonly, dialysis access complications. Dialysis access complications are considered an emergency because patients with chronic renal failure rely on regular dialysis for their survival.
- Rhabdomyolysis - this occurs due to the destruction of the skeletal muscles, and the release of the waste product myoglobin into the blood. Rhabdomyolysis may result from a number of causes - including crush injuries, the ingestion of some toxins, major infections or burns, and general metabolic disturbances. Patients with rhabdomyolysis will present with myoglobinuria, generalised muscle pain, malaise and fever.
- Urinary tract infection (UTI) - the urinary tract may be infected by a variety of different bacteria, however most common are those originating in the gastrointestinal system. Patients with a UTI will present with symptoms of bladder irritability, discomfort and cloudy urine. If the bladder is infected and / or the kidneys are infected, the patient's symptoms may be more severe, and include haematuria, malodorous urine, fever, nausea and vomiting, and severe pain.
- Urinary calculi - these are formed when the urine is supersaturated with salt and minerals. Calculi may occur anywhere in the renal and / or genitourinary systems, but particularly the kidneys, ureters, bladder and urethra. Patients typically present with moderate to severe pain, the urge to void, dysuria and haematuria.
The endocrine system is a complex integration of hormone-secreting glands. The dysfunction of one gland in this system may have catastrophic systemic effects and result in severe disability or death. The majority of endocrine emergencies seen in emergency care settings in the UK are related to diabetes. However, it is also important for nurses in emergency care settings to be aware that endocrine emergencies can also relate to the pituitary gland, thyroid gland and / or adrenal glands, as well as other medical conditions.
A focused assessment of the endocrine system can then be undertaken; this will involve:
- A detailed neurological assessment. Changes in a patient's mental status are one of the key indicators of acute endocrine dysfunction.
- Additional assessments to assist with diagnosis - including blood assays, urinalysis and arterial blood gasses.
During assessment, a nurse may identify one or more of a variety of medical conditions related to the endocrine system. The most common conditions, and their management in the emergency care setting, are described following:
- Diabetic ketoacidosis (DKA) - this occurs when there is a depletion of insulin in a patient's body, often when a person with diabetes poorly manages their condition or when their system is exposed to stressors. Patients typically present with hyperglycaemia, polyuria, dehydration, electrolyte depletion, metabolic acidosis and fatigue.
- Hyperosmolar hyperglycaemic state (HHS) - this occurs when a patient with diabetes develops hyperglycaemia and hyperosmolarity. Patients may complain of a range of non-specific symptoms, including polydipsia and polyuria, but the condition often progresses to cause decreased levels of consciousness and seizures.
- Hypoglycaemia - this is defined as a pathologically low serum glucose level, and it occurs most often in patients with diabetes. Patients with hypoglycaemia often present with altered levels of consciousness, or even seizures and coma.
A person is considered to be intoxicated if a substance they have taken is impairing their capacity to act or reason. People may present to emergency care settings in the UK intoxicated with one or more of a variety of different types of substances - for example:
- Club drugs.
- Prescribed medications.
People may become intoxicated by substances intentionally or accidentally. The symptoms of intoxication vary depending on the substance taken; however, typically a patient will usually present with changes in their level of conscious, cognition, perception, affect, behaviour and motor coordination. In cases of severe intoxication, a patient may be significantly compromised and present with seizures or in a coma. Although it is impossible to be familiar with the effects of all the various substances on which a patient may become intoxicated, it is important that nurses know the effects of the substances most often seen in the emergency care setting and region where they work.
Care involves: (1) limiting the absorption of the substance, and (2) enhancing the elimination of the substance. This may involve strategies such as gastric lavage, the administration of activated charcoal or binding agents, whole bowel irrigation or even emergency haemodialysis. Some substances have antidotes which may be administered intravenously to reverse their effects; for example, overdoses of narcotics are frequently treated with naloxone, which acts to cancel their action.
In addition to acute intoxication, it is important to note that patients in emergency care settings may present with a variety of other substance-related complications. In particular, if a person takes a substance on which they have become dependent, the person may present with the signs of acute withdrawal from the substance. The exact symptoms experienced during withdrawal depend on the substance used, how the substance is taken, the dose taken, the length of time the patient has been dependent, and a variety of other physiological and psychological factors. It is important for nurses working in emergency care settings to be aware that patients may become dependent on prescribed medications, even if they are taking them correctly.
Mental health emergencies
It is very common for patients to present to emergency care settings in the UK with acute complications of mental illness. The most common types of mental illness in the UK are:
- Depression - a complex disorder where a person experiences prolonged melancholy. Patients with depression may present to emergency care settings with self-harm / suicidal ideologies, feelings that they may harm others, and / or psychosis.
- Anxiety disorders - a group of disorders where patients experience severe, disproportionate worry and / or phobias. Patients with an anxiety disorder may present to emergency care settings during or following an acute onset of their disorder, such as a panic attack.
- Psychotic disorders - including schizophrenia and bipolar disorder. Patients with psychotic disorders may present to emergency care settings during or following an acute onset of their disorder, particularly during or following a psychotic event.
It is essential for nurses working in emergency care settings to understand that intoxication emergencies and mental health emergencies often occur concurrently. Substance use may lead to a mental illness, and / or a person may choose to use substance/s in an attempt to manage their mental illness.
This chapter has introduced the knowledge and skills required to accurately and rapidly assess, and effectively manage, a variety of general, acute medical and surgical problems in the emergency care setting. You have also studied the most common emergency presentations of these problems. This chapter has provided a thorough grounding to prepare you to provide quality emergency care to patients with acute medical and surgical problems.
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