Approach to abdominal pain

**Red flags**

• History
• collapse at toilet 
• lightheadedness
• ischaemic heart disease 
• progressive-vomiting pain, distension 
• menstrual abnomalities
• malignancy
• Signs
• Pallor and sweating 
• Hypotension 
• Atrial fibrillation or tachycardia
• Fever
• Prostration 
• Rebound tenderness and guarding 
• Decreased urine output

• Key history
• Dysphagia/odynophagia
• Nausea/vomiting
• Loss of appetite 
• Reflux
• Abdominal pain 
• Abdominal distension 
• Altered bowel habit
• systemic symptoms: malaise/fatigue/jaundice/fever

Murtagh Triad

• Pale child + severe colic + vomiting = acute intussusception
• intense pain + pale and 'shocked' +/- back pain = ruptured AAA
• Anxiety and prostration + intense central pain + profuse vomiting +/- bloody diarrhoea = mesenteric arterial occlusion 
• Localised RIF pain + a/n/v + guarding = acute appendicitis 
• Colicky central pain + vomiting + distension = SBO
• Colicky pain + distension +/- vomiting = LBO
• Sudden severe pain + anxious, still, 'grey', sweaty + deceptive improvement = perforated peptic ulcer
• Intense pain (loin) --> groin + microscopic haematuria = ureteric colic
• acute pain + left sided radiation + fever = acute diverticulitis

Burns

I am scared of burns. I don't know what to do but after seeing burns for a few times, I start to get some understandings of it. I tend to follow the following principles (hopefully most of the burns we see at GP clinic is just minor burns):

1.  Assess the whole person, follow the principle of ABC 

2.  Know when to refer, the burns unit is available 24/7 for you to get advice (please go to RCH website), refer 

• All full thickness burn
• Circumferential burns
• All burns to face, eyes, ears, hands, feet, genitalia, perineum or a major joint, even if less than 10 %
• Chemical burns
• Electrical burns
• Burns associated with significant fracture or other major injury 
• All inhalation or airway burns
• Burns in children under the age of 12 months
• It is out of your/your hospital's comfort zone 

3. Assess the TBSA of burns. In children, their palm size is around 1 % of their body surface area. In adults, you can use your palm to gauge

4. Categorize burns into the following 3 categories and treat accordingly:

• superficial: only epidermis is involved
• superfical partial thickeness: dermis is involved, forms blister, fixomull 
• superficial deep thickness: hist white slough, red mottled, sluggish capillary return
• Full thickness: dry, charred whitish, absent capillary return 

5. 

superficial burn --> can leave it open, in infants  use non adherent dressing

partial thickness burn --> mepilex Ag Tm with crepe bandage or acticoat 3/7

Full thickness burn --> refer 

Reference:

1. RCH burns guideline 

Otitis Externa

Condition

• Otitis Externa

Definition

• Inflammation of the ear canal
• Can be caused by bacterial (e.g. streptococcus or pseudomonas) or fungal (aspegillos niger or candida species) 

History

• pain 
• discharge
• no recent upper respiratory tract infection
• predisposing factors: swimming, trauma, known narrow ear canal and past history of exostoses
• itchiness and skin scaling from ear canals this could suggest underlying skin diseases e.g. eczema

Examination

• otoscope 

DDx

• Malignant otitis externa 
• potentially life threatening infection of the external ear and skull base
• most commonly presents in elderly patients, diabetic patients and the immunocompromised 
• usually presents with unrelenting otalgia over several weeks 
• examination will show ear discharge, granulation tissue visible in the floor of the external ear canal. 
• There may be facial nerve or other lower cranial nerve involvement
• needs urgent referral 

Treatment

• Ear canal debridment
• Keep ear dry 
• Ear drops
• Oral analgesia
• Treatment of underlying skin disorder

References

1. Hawke library

REST Course key points

REST COURSE 

I attended the REST (Rural emergency skills training) course over the weekend. It is decided for doctors who are not emergency physicians and want to have a structured approach to an emergency situation. 

Some key points I got from the course:

1. Use DRSABCD in all emergency situations. Write down this on a white board and try to be prepared as much as you can. 
1. D: Danger 
2. R: Response (AVPU) Response to pain = PU = may require intubation 
3. S: send for help! or SHAVE = Sugar, haemorrhage, adrenaline, VT/VF and Epilepsy
4. A: Airway + Cervical spine 
5. B: Breathing, Oxygen, Pulse oximeter, RR, Ausculation 
6. C: Circulation. Blood pressure, HR, Cap Refill, IV access
7. D: Disability. Pupil and spine 
2. Must know adrenaline dose 
1. only use IV adrenaline in someone who is dead 
2. Anaphylaxis: adult 0.5 ml in 1:1000
3. Anaphylaxis: paediatric 0.1ml/kg in 1: 10,000
4. Arrest: adult 1 ml in 1:1000
5. Arrest: paediatric 0.1 ml/kg in 10,000
3. Protecting the cervical spine is important. When in doubt, put the cervical spine collar on. 
4. Defibrillation: 200 J. Use it early in VT/VF
5. Protecting the airway is important but it doesn’t always require intubation to improve breathing. Try guedel or LMA. 
6. Fluid bolus formula is 20mg/kg
7. Paediatric weight calculation for 1 year or above (age +4) x 2 
8. Don’t forget to check sugar 
9. intraosseous can be placed medial to tibial tuberosity 1 cm below the articular surface
10. Don’t forget the 4Hs and 4Ts. Haemorrhage, hypoxia, Hypokalaemia/hyperkalaemia, Hypothermia. Tension pneumothorax, Tamponade, Toxins, Thrombosis