Abstract
This chapter is a brief overview of the approach to the care of adults presenting to urgent care with emergencies requiring rapid recognition, stabilization, and disposition.
Keywords
adult emergencies, altered mental status, anaphylaxis, chest pain, respiratory distress, stroke, seizures, syncope, sepsis
General Approach
1
What are the main priorities of an urgent care center in a true emergency?
In a true emergency, where delays can lead to increased risk of morbidity and mortality, the priorities of an urgent care facility are rapid recognition and disposition.
Recognition: Quickly identifying patterns is a necessity in urgent care medicine. Seeing a patient clutching the chest in pain, in respiratory distress, or unable to move half of his or her body should prompt immediate action.
Disposition: True emergencies require an emergency department. Call 911 or the closest possible ambulance to rapidly transport the patient to the nearest hospital.
2
How can an urgent care provider rapidly identify “sick” patients among many stable patients?
Recognition of “sick” versus “well” is a skill honed through experience and practice. Nevertheless, Table 51.1 shows some simple features to look out for.
| Sick | Not Sick | |
|---|---|---|
| Vital Signs |
|
|
| General Appearance |
|
|
3
What is an approach to stabilization and disposition of “sick” patients at an urgent care center presenting with common adult emergencies?
Stick to C-A-B (circulation, airway, breathing), according to Basic Life Support guidelines. Establish peripheral intravenous access and give fluids if patient is hypotensive. Hold pressure on any sites of ongoing bleeding. Give oxygen if the patient is in respiratory distress. Perform advanced cardiovascular life support and/or advanced airway techniques only if you and your staff are trained and experienced in doing so. If you cannot quickly stabilize the patient for transport to the nearest hospital, call 911 for additional assistance.
Chest Pain With Distress
4
What are the main priorities when a patient presents to urgent care with chest pain?
Any patient who appears acutely ill and complains of chest pain needs to be taken seriously. Focus on the basics first: Does the patient have a pulse? Is the patient talking and maintaining an airway? Is the patient breathing spontaneously? (In other words, perform C-A-B.) Next, obtain a set of vital signs. Finally, the most important step, quickly obtain a 12-lead electrocardiogram (ECG). If the patient has no contraindication (i.e., severe allergy), give 325 mg of aspirin. Call for immediate transportation to an emergency department.
5
What are the potentially life-threatening causes of chest pain?
Pulmonary embolism (PE), myocardial infarction (MI), pneumothorax, hemothorax, aortic dissection, esophageal rupture, and cardiac tamponade can cause life-threatening chest pain.
6
What are the criteria for ST-segment elevation myocardial infarction on ECG?
An ST-segment elevation myocardial infarction (STEMI) ( Fig. 51.1 ) is identified by ST-segment elevation in two or more contiguous leads. Threshold values vary based on age and gender, but in general, if the elevation is >1 mm in two leads on the ECG, there is a high index of suspicion for STEMI.
7
What actions should be taken for a patient with chest pain and a STEMI on ECG?
Arrange transportation to the nearest hospital with a cardiac catheterization laboratory (cath lab), where percutaneous coronary intervention (PCI) can be performed. Call ahead to the hospital to alert them of the incoming patient. Give a full 325-mg aspirin. Give nitroglycerin sublingual, and morphine to alleviate pain. Place the patient on a cardiac monitor for rapid transport.
8
What are the historical features that are more concerning for acute coronary syndrome (ACS)?
According to a large systematic review, the following features have the highest specificity for ACS in patients presenting with chest pain:
Symptoms:
Radiation to both arms: Sensitivity 11%, Specificity 96%
Diaphoresis: Sensitivity 24%–28%, Specificity 79%–82%
Exertion: Sensitivity 38%–53%
Vomiting: Specificity 77%–80%
Risk factors:
Prior abnormal stress test: Specificity 96%
Peripheral arterial disease (PAD): Specificity 97%
9
What is an approach to “ruling out” pulmonary embolism in the urgent care setting?
A pulmonary embolism (PE) is a serious and potentially a life-threatening diagnosis. Concern for this diagnosis should prompt evaluation in an emergency department setting. A patient with a pulmonary embolism may present with pleuritic chest pain, tachycardia, and hypoxia, but often the diagnosis is less clear. While there are no prospective trials of screening tools to “rule out” PE in an urgent care setting, the Pulmonary Embolism Rule-out Criteria (PERC rule) ( Box 51.1 ) has been validated to “rule out” PE in patients whom the clinician deems to be at low risk in the emergency department setting.
Rules out PE if no criteria are present and pretest probability is <15%
Age ≥50
HR ≥100
O 2 sat on room air <95%
Prior history of venous thromboembolism
Trauma or surgery within 4 weeks
Hemoptysis
Exogenous estrogen
Unilateral leg swelling
Chest Pain With Distress
4
What are the main priorities when a patient presents to urgent care with chest pain?
Any patient who appears acutely ill and complains of chest pain needs to be taken seriously. Focus on the basics first: Does the patient have a pulse? Is the patient talking and maintaining an airway? Is the patient breathing spontaneously? (In other words, perform C-A-B.) Next, obtain a set of vital signs. Finally, the most important step, quickly obtain a 12-lead electrocardiogram (ECG). If the patient has no contraindication (i.e., severe allergy), give 325 mg of aspirin. Call for immediate transportation to an emergency department.
5
What are the potentially life-threatening causes of chest pain?
Pulmonary embolism (PE), myocardial infarction (MI), pneumothorax, hemothorax, aortic dissection, esophageal rupture, and cardiac tamponade can cause life-threatening chest pain.
6
What are the criteria for ST-segment elevation myocardial infarction on ECG?
An ST-segment elevation myocardial infarction (STEMI) ( Fig. 51.1 ) is identified by ST-segment elevation in two or more contiguous leads. Threshold values vary based on age and gender, but in general, if the elevation is >1 mm in two leads on the ECG, there is a high index of suspicion for STEMI.
7
What actions should be taken for a patient with chest pain and a STEMI on ECG?
Arrange transportation to the nearest hospital with a cardiac catheterization laboratory (cath lab), where percutaneous coronary intervention (PCI) can be performed. Call ahead to the hospital to alert them of the incoming patient. Give a full 325-mg aspirin. Give nitroglycerin sublingual, and morphine to alleviate pain. Place the patient on a cardiac monitor for rapid transport.
8
What are the historical features that are more concerning for acute coronary syndrome (ACS)?
According to a large systematic review, the following features have the highest specificity for ACS in patients presenting with chest pain:
Symptoms:
Radiation to both arms: Sensitivity 11%, Specificity 96%
Diaphoresis: Sensitivity 24%–28%, Specificity 79%–82%
Exertion: Sensitivity 38%–53%
Vomiting: Specificity 77%–80%
Risk factors:
Prior abnormal stress test: Specificity 96%
Peripheral arterial disease (PAD): Specificity 97%
9
What is an approach to “ruling out” pulmonary embolism in the urgent care setting?
A pulmonary embolism (PE) is a serious and potentially a life-threatening diagnosis. Concern for this diagnosis should prompt evaluation in an emergency department setting. A patient with a pulmonary embolism may present with pleuritic chest pain, tachycardia, and hypoxia, but often the diagnosis is less clear. While there are no prospective trials of screening tools to “rule out” PE in an urgent care setting, the Pulmonary Embolism Rule-out Criteria (PERC rule) ( Box 51.1 ) has been validated to “rule out” PE in patients whom the clinician deems to be at low risk in the emergency department setting.
Rules out PE if no criteria are present and pretest probability is <15%
Age ≥50
HR ≥100
O 2 sat on room air <95%
Prior history of venous thromboembolism
Trauma or surgery within 4 weeks
Hemoptysis
Exogenous estrogen
Unilateral leg swelling
Seizures
16
What are the commonly encountered seizure types, and what do these look like to an observer?
Not all seizures look the same, and urgent care providers should be able to identify the common seizure patterns and mimics described in Table 51.3 .
| Convulsive status epilepticus | Clonic (repetitive, rhythmic movements) and tonic (stiffening) phases, lasting >5 minutes with associated loss of consciousness |
| Tonic-clonic seizures | Initial body and extremity stiffening followed by rhythmic contractions of muscle groups |
| Absence seizures | Staring episodes or an arrest in behavior |
| Myoclonic Clonic | Brief sudden muscular contractions Repetitive jerks |
| Simple partial seizure Complex partial seizure | Commonly motor or sensory symptoms isolated to one body part (facial twitching, unilateral arm clonus) Simple partial seizure + change in consciousness |
| Seizure mimics Syncope Psychogenic nonepileptiform events (pseudoseizures) Breath-holding spells | Sudden, brief loss of consciousness. Can be associated with brief episode of stiffening or jerking motions. Eyes closed, patient talking through the event, movements nonrhythmic, appear purposeful Children shaking/twitching after breath holding or crying |
17
What are the common causes of seizures?
While many of these seizure types can look similar, it is important to recognize that not all seizures are caused by epilepsy. Other common causes of seizures are listed in Table 51.4 .
