Primary survey positive patient

The objectives of this chapter are listed in Box 14.1. Poisoning and self-inflicted trauma are two of the commonest causes of death and life-threatening emergencies in patients less than 40 years of age. These will present as primary positive patients for the reasons listed in Box 14.2. However be aware that these can be compounded by major trauma as part of the suicide attempt (e.g. falls, hanging and shootings). Recognition and management of these associated injuries are described elsewhere.

TIP

Request immediate back up when dealing with primary survey positive patients

Management

As you are assessing the ABCs, take a history or look for clues that might indicate the cause. Often it is obvious but in the unconscious patient it may not be.

The airway

The care of the airway is discussed in Chapter 2. Usually good basic techniques, such as airway opening procedures and patient positioning will be sufficient. Do the least to ensure a clear airway as in some types of drug overdose over aggressive intervention might induce vomiting or extreme bradycardia.

Breathing

Opiate overdose is the commonest cause of drug-induced hypoventilation. The initial management is to open the airway and ventilate using bag/valve mask techniques. Naloxone is a very effective antidote but can wear off before the opiate has been removed from the body. Consequently if the patient wakes up and then refuses to go to hospital, there is a risk that respiratory depression may re-occur once the naloxone is metabolised. As this has led to patients dying JRCALC recommends the titration of the naloxone to keep the patient in a ‘groggy state’. In such circumstances we recommend that naloxone is given slowly to bring the respiratory rate above 10 breaths per minute.

RED FLAG

Any patient given naloxone should be taken to hospital. If they refuse you must make all attempts to persuade them to go. Failing this, arrange for someone to observe them for 6 hours and make arrangements for a follow-up call within 2–3 hours

Carbon monoxide poisoning due to attempted suicide is usually diagnosed by the circumstances (e.g. a pipe from the car exhaust threaded through the vehicle’s side window). Accidental carbon monoxide poisoning can be very difficult to diagnose. Important clues are finding one or more people from the same enclosed space presenting with neurological signs such as headache, confusion and unconsciousness. In these circumstances have the area checked for a carbon monoxide source such as a room or water heater with poor ventilation. These patients must be removed from the poisonous environment, provided with high flow oxygen as part of basic ABC care and transported to hospital.

Circulation

Life-threatening haemorrhage occasionally occurs in those who have self harmed by cutting a major blood vessel. Management entails stemming the source of the bleeding by direct pressure and rapidly transporting the patient to hospital. During the journey IV access can be obtained but do not infuse large amounts of fluid as this is likely to increase the blood loss. Instead give enough fluid to maintain a radial pulse.

Many drugs can cause hypotension; Box 14.3 lists the commonest. The initial management is to obtain IV access, to give fluids and arrange transport to hospital. Simple measures such as raising the legs are also effective. The commonest drugs causing arrhythmia are listed in Box 14.4.

Box 14.3 Drugs causing hypotension