Most important presentations to A&E

Most important presentations to A&E

There is not a single most important one, and different ones are triaged and sent to different parts of A&E.

Anyway. In this article we will go through some of the most important presentations to A&E. It is largely for health professionals (especially junior doctors).

Chest pain

The causes of chest pain can be broken down according to the body system involved:

• Cardiac – e.g. acute coronary syndrome, aortic dissection and pericarditis
• Respiratory – e.g. pulmonary embolism, pneumothorax and pneumonia
• Gastrointestinal – e.g. gastro-oesophageal reflux, gastritis and peptic ulcer disease
• Musculoskeletal – e.g. costochondritis, rib fractures or muscular injuries.

Top Tips (all causes of chest pain)

1. There are FOUR important causes of acute chest pain to consider in every patient: ACS (especially MI), PE, aortic dissection (hard to diagnose) and pneumothorax – we will go through them
2. All FOUR are serious but treatable
3. Do a CXR, ECG and ABG, then think, especially if no obvious diagnosis.

Acute coronary syndrome

This umbrella term includes ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina.

ACS definitions

• STEMI: ST elevation and a raised troponin
• NSTEMI: Normal ECG or T wave inversion associated with a raised troponin
• Unstable angina: Normal ECG and normal troponin but with cardiac-sounding chest pain on minimal exertion or at rest.

Top Tips – chest pain

1. All patients with cardiac-sounding chest pain should have an ECG as soon as possible after arrival
2. The ECG can be normal in ACS (and PE, aortic dissection and pneumothorax) – i.e. a normal ECG doesn’t mean all is OK.

Pulmonary embolism (PE)

Pulmonary emboli can range in clinical severity from small subsegmental clots, to a massive saddle embolus, causing right heart strain and haemodynamic instability. It is essential to consider a PE in anyone with pleuritic chest pain, sudden onset shortness of breath or collapse.

Risk factors include active cancer, recent surgery, obesity, DVT, prolonged period of immobility, pregnancy and medication such as the combined oral contraceptive pill.

Note. ECG findings in pulmonary emboli are not always present. When present, the most common ECG findings are sinus tachycardia or signs of right heart strain (right bundle branch block and right axis deviation), or normal. Unlike in medical exams, the classic ‘S1Q3T3’ pattern is rarely seen!

Aortic dissection

An aortic dissection describes a tear in the intimal layer of the aortic wall, creating a false lumen. This is a catastrophic diagnosis associated with a high mortality rate.

The classical presentation is that of a severe, sudden onset, tearing chest pain which is maximal at the point of onset and which radiates through to the back. However, patients do not always present typically.

Note. Listen for the soft diastolic murmur of aortic regurgitation (AR) at the lower left sternal edge, with the patient sitting forward in expiration. But its absence does not exclude aortic dissection.

Top Tip
Aortic dissections are diagnostically challenging and associated with a high mortality. Senior input must be sought for all cases of severe, sudden onset chest pain, shock or unexplained neurology.

Pneumothorax

Pneumothoraces can be spontaneous or traumatic. Spontaneous pneumothoraces can be subdivided further into primary or secondary depending on the patient’s age and the presence or absence of underlying lung disease.

A tension pneumothorax can develop from a spontaneous pneumothorax or, more commonly, a traumatic pneumothorax. The trapping of air in a tension pneumothorax results in compression of the mediastinal great vessels, causing haemodynamic compromise.

Top Tip
Rapid deterioration of a patient with a known or suspected pneumothorax should raise the suspicion of a tension pneumothorax.

A tension pneumothorax is managed by immediate decompression of the affected side.

Shortness of breath

Pulmonary embolism (again)

Pulmonary embolism (discussed above) is an important differential for patients presenting with shortness of breath, pleuritic chest pain, syncope, collapse or haemoptysis.

Top Tip
A patient with unexplained SOB and a normal CXR has a PE(s) until otherwise proven, and should be treated as such.

Asthma / COPD

Asthma
Asthma exacerbations are usually non-infective and may be triggered by environmental factors or a viral illness. It is essential to gauge the severity of asthma. Severe asthmatics who have previously required ITU admission can deteriorate quickly and should be managed aggressively.

COPD
Patients with COPD often have ‘rescue packs’ at home, and they may come in after having tried a course of antibiotics and steroids already. I.e. if they are in hospital, they are ill.

Gauging the severity of the patient’s COPD is important. You should enquire about the patient’s baseline oxygen saturation, whether or not they use ambulatory oxygen therapy at home and if they have required non-invasive ventilation (NIV) in the past.

Pneumonia

Pneumonia should be near the top of your differential for anyone presenting with shortness of breath, cough and a fever, sepsis or a PUO.

SOB is not always present. There is alot of respiratory reserve. So a simple lobar pneumonia (in one lobe) in someone with previously normal lungs will not cause SOB.

Remember pneumonia (and through in pneumonitis) is not only caused by bacteria. It can be caused by viruses (including COVID-19, and CMV), fungi, parasites, protozoans (including PCP), and other organisms.

Be alert for atypical presentations. For example, consolidation at the base of the lungs due to lower lobe pneumonia can sometimes present with abdominal pain.

Top Tip
Sending a sputum sample and checking for previous sensitivities can help guide treatment, especially in cases where empirical antibiotic treatment has failed.

Other causes of shortness of breath

There are many other causes of shortness of breath (SOB) to consider, such as pleural effusion, congestive cardiac failure, and anaemia.

Performing a thorough history and examination is always the first step to getting the correct diagnosis. If you are unsure, discuss the patient with a senior.

Note. Dont forget metabolic acidosis as a cause of SOB. Renal tubular acidosis is very (very) rare but AKI (and to a lesser extent, lactic acidosis) are not rare.

Abdominal pain

There are many organs in the abdomen and, consequently, many potential causes of abdominal pain.

A thorough abdominal pain history and examination is your most valuable tool in differentiating between these causes.

Top Tips (all causes of abdominal pain)

1. There are many possible causes of acute abdominal pain, and atypical presentations are well recognised
2. Involve the surgical team early if the patient is presenting with signs of peritonitis, or you do not know what’s going on
3. Elderly patients with abdominal pain are at high risk of significant pathology and should always be discussed with a senior.

The ‘acute abdomen’

Whilst it may take you a while before you get to the underlying cause of the patient’s pain, one crucial distinction you can make early on is whether or not, the patient has an acute surgical abdomen.

Guarding, rebound or percussion tenderness are all signs of peritonitis and indicate an acute pathology requiring input from the surgical team. You should involve the surgical team early in cases where the above signs are elicited. It is unnecessary to wait for the results of blood tests or imaging before contacting them.

Be aware that a high body mass index (BMI) can make it more difficult to elicit signs of peritonitis due to the quantity of adipose tissue between your hands and the inflamed peritoneum.

Top Tip
All women of childbearing age who present with acute abdominal pain should have a urine pregnancy test.

Appendicitis

Appendicitis is a common acute surgical presentation. It can affect people of any age, especially younger patients. It has an overall lifetime risk of 7-8%.

The main symptom of appendicitis is abdominal pain. Classically, this starts as dull colicky peri-umbilical pain that is poorly localised; but later migrates to the right iliac fossa, becoming localised and constant.

But atypical presentations of appendicitis are well recognised. Patients, especially children and the elderly, can present in many different ways. Other associated symptoms include vomiting (typically after the pain, not preceding it), anorexia, nausea, or diarrhoea.

Note. For example, retrocaecal appendicitis is an inflamed appendix behind the caecum. Its features are different from those of classical appendicitis associated with a normally sited appendix.

Top Tip
Call a surgeon and take the appendix out.

Bowel obstruction

You should suspect bowel obstruction in all patients who present with abdominal pain and a cessation in bowel motions or flatus. Bowel obstruction is usually associated with poor appetite, nausea and (sometimes faeculent) vomiting.

It has many causes including an obstructed hernia. So feel the hernial orifices.

Hernias

The examination of common hernia sites (umbilical, inguinal and femoral) is essential to the abdominal examination.

Ensure the patient is lying flat when examining them and that the femoral and inguinal areas are exposed.

Obstructed or incarcerated hernias will be firm, irreducible and tender. All patients with an obstructed or incarcerated hernia require an urgent surgical review.

Ruptured abdominal aortic aneurysm (AAA)

This is a life-threatening condition which has a pre-hospital mortality of 50%, and an untreated mortality approaching 100%.

A high index of suspicion is needed to make the diagnosis as only 25-50% of patients present with the classic triad of abdominal pain radiating to the back, hypotension and a pulsatile mass.

Renal colic

Renal colic is extremely painful. You can often spot these patients queueing to book themselves in as they will be doubled over and holding onto their flank. The classic presentation is a severe colicky loin-to-groin pain.

Most of these patients will have microscopic haematuria due to the trauma caused by the passing stone.

Giving adequate analgesia is a priority, and PR diclofenac is very effective for this type of pain.

Don’t forget testicular torsion

Don’t forget the genitals! Testicular torsion can also cause lower abdominal pain, especially in children where the pain is more poorly localised.

Torsion may occur in all age groups but is most common soon after birth and between 12-18 years. Clinical signs include a tender, high-riding testicle with an absent cremasteric reflex. You should discuss all suspected cases with a senior or the on-call urology team.

 .. or gynaecological causes

Gynaecological causes of acute abdominal pain include ruptured ovarian cyst, ectopic pregnancy, pelvic inflammatory disease (PID), ovarian torsion and endometriosis.

Specific points to remember in gynaecological history taking include gravidity and parity (remembering to ask about previous abortions, ectopics or miscarriages), last menstrual period, vaginal bleeding, discharge and a sexual history (including sexually transmitted infections and dyspareunia).

Approach these topics delicately and with empathy. However, do not shy away from asking all the important questions.

Ectopic pregnancy

This should be considered in any woman with abdominal pain in early pregnancy who has not yet had a confirmed intrauterine pregnancy on the initial dating scan. Unilateral lower abdominal pain associated with vaginal bleeding is the most common presentation.

Risk factors include smoking, increased maternal age, use of an IUD, previous ectopic pregnancy, tubal damage and previous pelvic infections.

Medical causes of abdominal pain

There are many medical causes of abdominal pain which should be considered. This includes gastroenteritis, peptic ulcer disease, inflammatory bowel disease, lower lobe pneumonia and diabetic ketoacidosis.

Gastritis and peptic ulcer disease

Gastritis and gastro-oesophageal reflux disease (GORD) are common conditions. However, they are overdiagnosed in A&E.

If the patient is in severe pain or there are signs of gastrointestinal bleeding, then you should consider perforation from a peptic ulcer.

A rectal examination is important in all cases of suspected GI bleeding to look for melaena. In any patient with non-specific abdominal pain, the presence of melaena or frank blood on a PR exam can provide a vital clue to the underlying cause.

Falls in the elderly

There are two key questions to consider in an elderly patient who has fallen:

• Why did they fall? – the medical question
• What injuries (especially fractures) have they sustained? – the surgical question

Why did they fall?

Falls in the elderly are multifactorial, and you should not label the fall as ‘mechanical’ until you have fully considered other causes.

A VBG is a quick way of looking for any significant physiological abnormalities (lactate, pH, electrolyte abnormalities and blood glucose).

Routine blood tests may also be helpful in a falls ‘MOT’, including a full blood count, CRP, U+Es, and creatinine kinase (CK) if there was a long lie (due to the risk of rhabdomyolysis).

What injuries have they sustained?

‘Silver trauma’ = older people can sustain significant injuries  (including fractures) despite a relatively benign mechanism, such as falling from standing.

They are often very tough, don’t complain of much pain and can walk on a fractured neck of femur.

Older patients respond to trauma differently. Osteoporotic fractures are possible following only minor injuries, and medications such as beta-blockers may mask a tachycardic response to internal bleeding.

Have a low threshold for obtaining an x-ray of the pelvis and hips. A fractured neck of femur is common in the elderly and associated with poor outcomes if missed. It needs surgery in 24 hours.

Head injury

Head injuries can range from minor bumps to major trauma. Understanding the mechanism of injury is key to gaining an appreciation of the severity of the injury.

Important features in the history include whether or not there was a loss of consciousness, amnesia, drowsiness, seizures, focal neurology, nausea or vomiting.

Top Tip
If in doubt, get a CT head

Other important A&E presentations and conditions

• Stroke
• Headache
• Meningitis/SAH/encephalitis
• Pericarditis
• Upper GI bleed
• Diabetes – hypo and hyper-glycaemia
• Pulmonary oedema (including acute heart failure)
• AKI, and other biochemical abnormalities (especially sodium, potassium and calcium)
• Sepsis.

Top Tips (all patients)

1. Do an ABG and CRP. Take a lactate above 2, or acidosis very seriously
2. Get a senior to see the patient
3. If no clear diagnosis on day 3, get a CT CAP (CT chest, abdomen, pelvis).

Summary

We have described what is the most important presentations to A&E. There isn’t one. But we have described the most important A&E presentations and conditions.

We hope it has been helpful.