Healthcare Emergencies in Outpatient Settings

The primary assessment of a person with trauma in the field follows the ABCD prioritization mnemonic: Airway, Breathing, Circulation, and Disability (neurologic status). Depending on your training and equipment availability, you may be unable to implement these recommendations (Thim et al., 2012).

A - Airway 

The airway is the priority. Airway assessment should proceed while maintaining the cervical spine in a neutral position. The cervical spine is best maintained in a neutral position using a rigid cervical immobilization collar. Emphasis is given to using simple measures to protect the cervical spine when attending to the adequacy of the airway.

The airway should be assessed by determining the ability of air to pass unobstructed into the lungs. Critical findings include:

• Obstruction of the airway due to direct injury, edema, or foreign bodies.
• Inability to protect the airway because of a depressed level of consciousness.

B – Breathing

The adequacy of breathing should be assessed to determine the person's ability to ventilate and oxygenate. An assessment is most readily accomplished by:

• Visual inspection of thoracic cage movement.
• Palpation of thoracic cage movement.
• Auscultation of gas entry (over trachea and lungs).

C – Circulation/Hemorrhage Control

Emergent treatment of trauma persons with exsanguinating hemorrhage or shock can be lifesaving. An assessment includes identifying and managing rapid external hemorrhage, often achieved with a simple pressure dressing. Fracture alignment and stabilization are essential in limiting blood loss. Pelvic fractures may be initially stabilized with a pelvic binder or a wrapped sheet secured with a towel clip to reduce the pelvic volume, limiting hemorrhage.

D – Disability

During the acute resuscitation period, a brief assessment of disability and neurologic status should be performed. An assessment should include a global assessment of the trauma person's level of responsiveness and posture (i.e., any asymmetry, decerebrate, or decorticate posturing), pupil asymmetry, and pupillary response to light. A recommended system is the AVPU mnemonic:

• A = Person is awake, alert, and appropriate
• V = Person responds to voice
• P = Person responds to pain
• U = Person is unresponsive

E – Exposure/Environment

The final step in the primary assessment includes personal exposure and control of the immediate environment. Do not move the person in cases of severe injury due to trauma until EMS responds unless they are in danger. Moving a person who may have spinal injuries can result in paralysis. Efforts should be made to prevent significant hypothermia by providing cover if possible (Thim et al., 2012).

If a person loses consciousness, lay them flat, and raise their legs. People who lose consciousness may quickly awaken. If not, start oxygen (O₂) at 2 liters per nasal cannula. Monitor airway, breathing, and circulation until EMS responds. Loss of consciousness may indicate a cardiac or neurological problem.

The causes of seizures can include a high fever, epilepsy, or a stroke (Davis, 2004). With the medical history, obtain information about the nature of seizures, frequency, and degree of control. Signs and symptoms of seizures vary considerably. They can include:

• Aura or premonition of a seizure.
• The tonic phase includes loss of consciousness; the person becomes rigid, may fall, and become cyanosed.
• The clonic phase includes jerking movements of the limbs; accidental biting of the tongue may occur.
• Urinary incontinence.
• Frothing at the mouth.

Do not restrain the person. Do not try to put something in the person's mouth, as it may cause personal injury. Move obstacles away from the person so they do not hurt themselves. Time the length of the seizure. A seizure usually ends after a minute or two, followed by confusion and a slow return to awareness (Erich, 2020). Hypoglycemia may present as a seizure, so measure the blood glucose if possible. Individuals with recurrent seizures may know if they need EMS. Examples of when EMS response is needed include (Erich, 2020):

• First-time seizures
• When a second seizure quickly follows the initial seizure
• Impaired breathing
• Consciousness does not return 

People with seizures may carry midazolam, a medication often prescribed for seizures. It is given via the buccal or intra-nasal route. The buccal preparation is marketed as Epistatus. Parents may carry rectal diazepam for poorly controlled epilepsy in children to be used as a pre-treatment preparation. The parent must be on hand to administer this if needed (Boddu & Kumari, 2020).

People who have a stroke, also known as a cardiovascular accident (CVA), may not realize they are symptomatic. Therefore, that person may not be able to make a good decision about seeking emergency care. If in doubt and not in a hospital setting, call 911. Stroke symptoms are a time-sensitive crisis. Thrombolytics (clot-dissolving medicine) must be given quickly to prevent permanent disability due to blood clot damage.

Symptoms of a stroke include the sudden onset of (National Institute of Neurological Disorders and Stroke [NINDS], 2019):

• Numbness or weakness of the face, arm, or leg (especially on one side of the body)
• Confusion, trouble speaking or understanding speech
• Trouble seeing in one or both eyes
• Trouble walking, dizziness, loss of balance or coordination
• Severe, unusual headache

The most common symptoms in persons with a pulmonary embolism (PE) are:

• Dyspnea at rest or with exertion (this is the most common symptom)
  • The onset of dyspnea is frequently (but not always) rapid, usually within seconds or minutes.
  • Dyspnea may be less frequent in older persons with no previous cardiopulmonary disease.
  • Dyspnea is more likely present in persons with PE in the main or lobar vessels.
• Pleuritic pain (seen in 66% of cases)
  • Approximately 10% of persons present with the symptoms of an infarcted lung, usually due to smaller, more peripheral emboli.
  • Pleuritic pain is typical in this population due to inflammation of the pleura.
• Cough (seen in 37% of cases)
• Orthopnea (seen in 28% of cases)
• Calf or thigh pain or swelling (seen in 44% of cases)
• Wheezing (seen in 21% of cases)
• Hemoptysis (seen in 13% of cases)
  • Hemorrhage from the infarcted lung is also thought to be responsible for hemoptysis (Morrone & Morrone, 2018).

Risk factors can be classified as follows:

• Acquired
  • Provoking (e.g., recent surgery, trauma, immobilization, initiation of hormone therapy, active cancer)
  • Non-provoking (e.g., obesity, heavy cigarette smoking)
• Inherited (i.e., genetic)
  • Around 30 genetic risk factors have been identified, including factor V Leiden and the prothrombin gene mutation, or G20210-A (Morrone & Morrone, 2018)

Most emboli are thought to arise from lower extremity proximal veins (iliac, femoral, and popliteal), and more than 50% of persons with proximal deep vein thrombosis (DVT) have concurrent PE at presentation.

A calf vein DVT rarely embolizes to the lung, and two-thirds of calf vein thrombi resolve spontaneously after detection. However, if untreated, one-third of calf vein DVTs extend into the proximal veins, where they have greater potential to embolize. PE can also arise from DVTs in non-lower-extremity veins, including renal and upper-extremity veins, although embolization from these veins is less common (Waheed et al., 2023).

Asthma can be life-threatening. An attack may be precipitated by exertion, anxiety, infection, or exposure to an allergen. In obtaining a medical history, get some idea of the severity of attacks, precipitating factors, medication effectiveness, hospital admissions due to asthma, and the use of systemic steroids. People with asthma usually have their usual inhaler(s) with them. Asthma signs and symptoms include the following:

• Shortness of breath
• Tachypnea or more than 25 breaths per minute
• Expiratory wheezing
• Use of accessory muscles for respiration
• Tachycardia (Mayo Clinic, 2022)

Life-threatening asthma attack symptoms include the following:

• Cyanosis
• Slow respiratory rate of fewer than eight breaths per minute
• Bradycardia
• Decreased level of consciousness or confusion (Mayo Clinic, 2022). 

Most asthma attacks respond to an inhaler. Call EMS if there is no rapid response, or the attack becomes severe. High-flow O₂ should be given.

Anxiety is the common precipitating factor in hyperventilation. Breathing too quickly depletes the carbon dioxide that is necessary for normal ventilation. Hyperventilation leads to respiratory alkalosis. Symptoms of hyperventilation include the following:

• Dizziness or lightheadedness
• Shortness of breath
• Belching, bloating, dry mouth
• Weakness, confusion
• Sleep disturbances
• Numbness and tingling in the arms or around the mouth
• Muscle spasms in hands and feet, chest pain, and palpitations
• Loss of consciousness (Johns Hopkins Medicine, n.d.)

Be calm and reassure the person. Have the person rebreathe their own exhaled air to increase the carbon dioxide level. A paper bag or the person's cupped hands can be used.

Damage from a burn continues after the source of the burn is removed. The dominant priority is to stop the burning process. If a person is on fire, smother the fire with a large cover or have them roll on the ground to extinguish any flames. Running will increase the fire. The size and severity of the burn determine the level of care needed. Optimum first aid for burns and scalds is cool, running tap water for about 20 minutes; this action is effective up to three hours after the burn. Cool only the burned area, keeping the rest of the body warm. Do not apply toothpaste, butter, oil, eggs, turmeric, or ice to burn wounds. None of these are beneficial to wound healing. Oil-based substances can trap heat in the tissues, causing further damage. Ice can cause vasoconstriction and cold injuries, further damaging the skin (Stiles, 2018).

In cases of chemical burns, i.e., drain cleaner, bleach, battery fluid, etc., the continued contact of the agent with the person's skin may not be apparent. The process may require repeated testing of the person's skin, specific chemical neutralization, and extensive lavage of the affected areas.

If the clinical history or the physical examination suggests that upper airway burns or inhalation injury may be present, early intubation and mechanical ventilation are indicated. Persons with extensive burns require large volumes of intravenous (IV) crystalloid resuscitation fluids. While this resuscitation can be delayed briefly when lifesaving interventions are being performed, early commencement is beneficial. Treatment of burns is determined by the degree of burn and the percentage of body surface burned.

Burns are classified as first, second, third, or fourth-degree, depending on how deep and severe the damage penetrates the skin's surface.

1. First-degree (superficial) burns affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and has no blisters.
2. Second-degree (partial thickness) burns involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red and blistered and may be swollen and painful.
3. Third-degree (full-thickness) burns destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred.
4. Fourth-degree burns go through layers of the skin, underlying tissue, and deeper tissue, possibly involving muscle and bone. There is no pain in the area since the nerve endings are destroyed (Perez et al., 2020).

Although sometimes considered burn injuries, high-voltage electrical injuries (e.g., lightning strikes, power lines) present different problems. The tissue injury from electrical injuries may not be apparent on physical examination. Massive myonecrosis, soft tissue, and bone damage may be concealed beneath normal-appearing skin between the entrance and exit wounds. Continuous cardiac monitoring is needed because of the risks of direct myocardial injury and hyperkalemia arising from myonecrosis.

The classic description of chest pain is most commonly seen in the male, middle-aged population. Females, diabetics, and older adults often describe different or atypical sensations that may be cardiac.

Chest pain may be described as pressure, heaviness, squeezing, burning, or choking. The pattern and location of the discomfort are important.

Chronic cardiac chest pain is called angina. Angina may be a recurrent problem for some and is treated with nitroglycerin. People with chronic angina may not want EMS or emergency department care as they think nitroglycerin and rest will allow for recovery.

For cold injuries, the dominant priority is slowly rewarming, particularly in the case of systemic hypothermia, but it is equally applicable to cold injuries to the extremities (e.g., frostbite). While mild hypothermia is managed as described under the environment in the primary survey, severe cold injuries should be treated with immersion in water warmed to 40°C (Jin et al., 2021).

Type 1 diabetes, due to autoimmune β-cell destruction, usually leads to insulin deficiency. It often occurs in childhood or adolescence and requires diet control and insulin injections. Type 2 diabetes is due to a progressive loss of β-cell insulin secretion; this type usually results from insulin resistance and usually occurs in adults. It is possible to control it by diet and oral medication.

The acute complications of diabetes are hypoglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar syndrome (HHS). The latter two are acute but develop over a more extended period and are characterized by extremely high serum glucose. DKA and HHS are primarily caused by poor compliance with the diabetic medication regimen, acute infection, or illness. These complications' signs and symptoms are non-specific but include the following:

• Mental status changes
• Polydipsia
• Polyuria
• Weakness 

These are serious, life-threatening complications.

Hypoglycemia is much more common than DKA or HHS. A severe hypoglycemic event can cause death, and hypoglycemic events increase mortality risk. Hypoglycemia is most common with type 1 diabetes. The primary causes of hypoglycemia in a person with diabetes are too much insulin and a lack of sugar. Typical signs and symptoms of hypoglycemia include (but are not limited to) agitation, confusion, dizziness, drowsiness, irritability, palpitations, sweating, and weakness (Nakhleh & Shehadeh, 2021).

Hypoglycemia can occur without signs and symptoms. Some people can have significant hypoglycemia, but the body's response mechanisms fail to provide warning signs and symptoms, a condition called hypoglycemia unawareness. Hypoglycemia unawareness is not unusual, and it is very common in type 1 diabetics, affecting as many as 35% of persons with the disease. Treatment recommendations for hypoglycemia include (Nakhleh & Shehadeh, 2021):

• Symptomatic hypoglycemia: Ingest carbohydrates - 15-20 grams of glucose is preferred, and repeat the blood glucose measurement in 15 minutes.
• If the blood glucose is still low, ingest more glucose until the glucose level is normal, and then have a meal or a snack.
• Fats can prolong the glycemic response, and proteins can increase the insulin response without increasing the glucose level, so carbohydrates are preferred for treating hypoglycemia.
• Glucagon should be prescribed for anyone who has level 2 hypoglycemia.

Side effects are the secondary and undesired effects of a drug. These are expected reactions that occur with drug administration; every person receiving that drug is at risk of experiencing side effects. Examples of side effects include drowsiness with diphenhydramine administration and nausea with the administration of chemotherapeutic drugs.

Allergic reactions are aberrant immune responses to an antigen or an allergen. An antigen is a toxin or substance that incites an allergic reaction in the body, especially one that leads to antibody production. An allergen is defined as a substance that provokes an allergic reaction.

The term allergy implies an immediate hypersensitivity reaction mediated by immunoglobulin E (IgE) antibodies. However, many allergic reactions are not IgE-mediated. The subsequent reaction produces a wide range of clinical symptoms, from itching to anaphylaxis. Anaphylaxis is the most severe form of an allergic reaction, and it can occur suddenly and may, eventually, lead to death. The clinical symptoms of an allergic reaction to a drug may vary widely. A generalized allergic reaction may appear similar to serum sickness or immune-complex reactions (Hostoffer & Joseph, 2022).

Serum sickness and serum sickness-like reactions occur approximately 7-10 days after the primary exposure to an allergen, in this case, the drug, and are characterized by urticaria (hives), polyarthralgia (joint pain involving multiple joints), fever, and lymphadenopathy (swollen lymph nodes). Occasionally the persons may have systemic venalities' (inflammation of the veins during intravenous drug administration), which may progress into a full-blown systemic vasculitis. Serum sickness and serum sickness-like reactions can also occur after secondary exposure to heterologous proteins (classic serum sickness) or after secondary exposure to non-protein drugs such as sulfa or penicillin-based antibiotics (Rixe & Tavarez, 2022).

Epinephrine is the medication used to treat severe allergic reactions and anaphylaxis. It narrows blood vessels and opens airways in the lungs. These effects can reverse low blood pressure, wheezing, itching, hives, and swelling. Epinephrine is available in an EpiPen auto-injection. Highly sensitive people may carry an EpiPen. If an EpiPen is used, an EMS response is needed because the effects wear off in 10-20 minutes (Thornton, 2020).

Drug poisoning is the adverse effects experienced by exposure to chemicals, drugs, or otherwise innocuous substances. The reaction to a given toxin depends on the toxin dose. It varies in how each individual responds to the toxin, even with the same dose. The factors that affect an individual's reaction to a drug include; acquired tolerance, genetic predisposition, and other drugs in the system affecting enzymatic activation or inhibition. Depending on the route of exposure, poisoning may be local or systemic.

In most cases, the person may be confused, unconscious, or unwilling to cooperate. Any suspicious findings in the history should be further investigated. Suspicious findings include sudden unexplained illness in previously healthy persons, a history of psychiatric illness, and the onset of symptoms after ingesting foods or drinks, including alcohol or medications.

All healthcare facilities are required to have detailed information about the chemicals that are at the worksite. The information is in a standard format called a Safety Data Sheet (SDS). Help for suspected poisoning is available at POISONCONTROL.

The poison control phone number 1-800-222-1222 (U.S.) will route the call to your area's poison center.