ADD ON...PRE-HOSPITAL CARE Immediate Assessment And Management Of Acute Medical Emergencies

Pre-hospital immediate care is ‘the provision of skilled medical help at the scene of an accident or medical emergency and during transportation to hospital’ (1). Although this widely accepted definition places equal emphasis on both traumatic injury and medical emergencies, trauma tends to dominate training courses and discussions (2). Medical emergencies generally only feature in the context of cardio-pulmonary resuscitation (3).While this may seem appropriate when working with pre-dominantly young and healthy individuals (such as soldiers on operational deployment), knowledge of the immediate care of medical emergencies is an essential component of immediate care practice. Acute medical emergencies are far more common than major trauma. Given this, it might be assumed that doctors, paramedics and nurses will be confident in the immediate management of the full range of acute medical emergencies simply by virtue of their training and practice. However, there is evidence that clinical signs of life threatening dysfunction of the airway, breathing, circulation or consciousness may be easily missed, misinterpreted, or mis-managed in the emergency setting (4,5) and specific lifethreatening medical emergencies may only occur a few times in a career (6,7). Even experienced doctors require training and revision to maintain confidence and skills in recognising and treating the full range of emergencies quickly and correctly. In addition, General Practitioners (GPs) provide much of the pre-hospital care in this context and there is often little opportunity for other immediate care practitioners to develop experience in the pre-hospital assessment and management of these patients. When considering the immediate care for a medical emergency, it is useful to think in terms of common presentations and common underlying conditions or diagnoses. Shortness of breath, chest pain, abdominal pain, collapse, coma and seizures are typical examples of common emergency presentations (Box 1). They are not diagnoses. In contrast, acute coronary syndromes, pulmonary embolism, pneumonia, pneumothorax, appendicitis and sub-arachnoid haemorrhage are typical examples of conditions or diagnoses that lead to acute presentations. Although knowledge of the underlying medical condition or disease process will clearly influence management, this may not be known at the time of the emergency.The essence of immediate care is the ability to manage such presentations without the certainty of a diagnosis. In this first of two articles on acute medical emergencies, the emphasis is placed on a safe and effective systematic approach to the assessment and immediate management of the common acute medical presentations. The detailed management of specific disease processes will be discussed in the second article.