Introduction

– All these syndromes involve severe abdominal, pelvic or loin pain with ‘collapse’ (i.e. inability to carry out normal activities). Patients may lie still, or may be restless with pain, depending on the cause. ‘Collapse’ is a potentially confusing medical term, as it may conjure up ideas of a patient in a heap on the floor. In a medical context, the term is used simply to suggest that the patient is unable to carry out daily activities. A patient so distracted by abdominal pain that their pain is all they can attend to at the time (and usually pain of this magnitude would cause them to lie down) would be considered to have abdominal pain with collapse, even if they are fully conscious.

– Rigidity, guarding and rebound tenderness are serious signs found on abdominal examination. Rigidity means that the abdominal muscles are in reflex spasm because of pain. Guarding describes a region of localised muscle spasm overlying a region of inflammation. Rebound tenderness describes the patient’s experience of discomfort when the pressure from an examining hand on the abdomen is released. Causes of these signs on examination of the abdomen include perforated viscus, peritonitis, appendicitis, bowel obstruction, ruptured aortic aneurysm, acute pancreatitis, bowel infarction and ectopic pregnancy.

– Failure of the bone marrow to produce the three cellular components of the blood leads to anaemia (due to low red blood cell count), bleeding (due to low platelet count) and intractable infections (due to low lymphocyte count). The patient will be pale, exhausted, may have purpura (dark purple macules on the skin), nosebleeds and fever.

– Bone marrow failure most commonly results from advanced secondary cancer or leukaemia or lymphoma. It can also be the result of reactions to drug therapy, including chemotherapy. The patient is at risk of succumbing to devastating bleeding or overwhelming infections and needs urgent medical assessment.

– Bleeding becomes an emergency situation if the blood loss is so severe as to threaten the development of the syndrome of shock (see A19.3). Shock is defined as any situation in which the circulation of the blood is not sufficient to meet bodily demands. The symptoms and signs of shock include feeling dizzy or faint with low blood pressure and collapse. As it is impossible to assess the exact volume of internal bleeding, refer all significant episodes of internal bleeding (e.g. in vomit, in stools, in pregnancy) as an emergency.

– If blood loss is the cause of shock, this is a form of hypovolaemic shock. In this case, the body responds by releasing the hormone adrenaline. This causes constriction of blood vessels and raises the heart rate. The patient will, therefore, have cold extremities and a racing pulse. The adrenaline may raise the blood pressure back to the normal range, and so the raised heart rate may be the cardinal red flag sign.

– Infection and allergic reaction can also cause shock, because in extreme cases the release of inflammatory chemicals can lead to widespread dilatation of the blood vessels and so cause a profound drop in blood pressure. The blood volume is normal in this case. The patient may seem warm and flushed, rather than cold, but the pulse rate will be increased, as it is with blood loss.

– Shock can also result from poor pumping efficiency of the heart (cardiogenic shock). This might occur after a heart attack, in heart failure or during an arrhythmia. In this case the prime features are faintness/collapse and low blood pressure.

– Simple fainting also results from a sudden drop in blood pressure, this time because of the release of hormones that cause a reduction in heart rate, and therefore a drop in blood pressure. Simple fainting is always characterised by a return to consciousness and normalisation of the pulse and blood pressure within a few seconds to minutes. Emotional factors and/or low blood sugar can trigger fainting. There is no need to refer a single episode of simple fainting. If the loss of consciousness is for more than a few seconds, then this is not characteristic of a faint and merits further investigations.

– Normal respiratory rate in an adult: 10–20 breaths/minute (one breath is one inhalation and exhalation).

– Moderate breathlessness in an adult: >30 breaths/minute.

– Severe breathlessness in an adult: >60 breaths/minute.

– Most situations in which the act of respiration is becoming insufficient to meet bodily requirements is characterised by rapid respirations (especially if >30 breaths/minute in adults), a sense of panic and, if severe, cyanosis (bluish coloration to the lips and tongue). The rapid respirations are a reflex response mediated by the respiratory centre in the brain stem which detect rising levels of carbon dioxide in the blood. Cyanosis is the visible sign that the haemoglobin in the blood is under-oxygenated. This pigment changes from red to purplish blue when the saturation of oxygen falls to less than 85%. In health, the saturation of oxygen of the blood is greater than 98%.

– In the cases of acute muscle weakness, or suppression of respiration resulting from stroke or drug intoxication, there can be insufficient respiration but without associated breathlessness. In this case, the red flag signs are shallow breathing, cyanosis and drowsiness. This is an emergency situation.

– Stridor is a harsh inspiratory and expiratory noise which comes from the upper airways, and indicates severe potential obstruction (either due to a swelling or a foreign body). A person in this situation will want to sit still and upright. The patient should not be asked to show his or her tongue in this situation, as this may worsen the obstruction.

– Causes of chest pain which merit emergency referral include myocardial ischaemia, pneumonia with pleurisy, dissecting aortic aneurysm, pulmonary embolus and pneumothorax.

– Serious chest pain of cardiac origin is characteristically heavy and radiates to the throat and upper arms. The patient may experience dread, breathlessness and palpitations. Serious chest pain of respiratory origin will be associated with breathing and breathlessness. The patient will be anxious.

– Chest pain is a common aspect of a panic attack. In this case, the pain may be more to one side and be described as stabbing in nature. It is more likely to occur for the first time in a young person. Breathlessness and tingling of the fingers may also be features. Although the best response is reassurance only, if you have any doubt, refer as if of cardiac origin.

– Possible causes of dehydration include excess climatic heat, prolonged fever, diarrhoea and vomiting, hyperglycaemia in diabetes mellitus and poor intake of fluids in a frail person or infant. Dehydration leads to concentration of the salts in the blood, ineffective removal of toxins by the kidneys and poor circulation to the brain and kidneys.

– Features of dehydration include dry mouth and skin, low blood pressure, weakness in adults, concentrated urine, floppiness, sunken eyes and fontanelle in infants, and loss of consciousness.

– Dehydration requires a rapid response in infants, in pregnancy and the elderly – these groups are more vulnerable to kidney damage and circulatory collapse.

– Possible causes of loss of consciousness include fainting, cardiac arrest, respiratory arrest, brain haemorrhage or infarction (stroke), drug intoxication, endocrine disorder (diabetes or Addison’s disease), brain infection (e.g. meningitis) and epileptic fit.

– All cases of continued measurable weakness (i.e a paralysis) or loss of consciousness are emergencies unless the cause is known.

– Anyone who has recovered from an episode of paralysis or loss of consciousness needs to be considered for high-priority referral for investigation if the cause is unknown.

– An altered mental state may be the result of a psychiatric condition, such as psychosis or extreme depression, or may have a physical (organic) basis. There are many organic causes of a confusional state, including drug intoxication, brain damage, epilepsy, high fever and a whole range of serious medical illnesses (e.g. pneumonia, diabetes, urinary infection). Confusion is more likely to develop in elderly people and young children in response to medical illness than is the case in older children and younger adults.

– There are two priorities to consider if a person is experiencing an altered mental state. First, that their behaviour may lead to harm to themselves or those around them; and second, that the underlying medical condition may merit urgent attention.

– A purpuric rash (non-blanching violaceous macules) in the presence of extreme malaise or headache or vomiting (suggest meningococcal septicaemia).

– A blistering rash on one side of the body, especially in an elderly person (suggests shingles, which can benefit from urgent treatment with antiviral drugs), and especially if affecting the region of the ophthalmic distribution of the trigeminal nerve, as ocular involvement can threaten sight.

– Angio-oedema: acute swelling of tissues, with urticaria and breathlessness (features of anaphylactic shock).

– Erythroderma: generalised inflammation of the skin wherein most of the skin surface is affected (due to eczema, psoriasis, sun exposure or drug reactions). There is a risk of circulatory collapse from poor fluid control. Refer urgently if any signs of shock are present.

– Headaches are common and are usually benign.

– In rare cases, headaches might signify a disorder of the brain, such as an infection, haemorrhage, thrombosis or a tumour. In all these situations there are characteristic features (see A23) which will help distinguish these headaches from benign headaches (i.e. tension headache and migraine).

– In only rare situations will a patient with a headache merit an emergency response. Emergency situations include brain haemorrhage, brain infection, malignant hypertension, arteritis and pre-eclampsia in pregnancy.

– The eyes are very vulnerable to infection and injury, and in some cases disease merits urgent referral for early treatment to prevent long-term damage.

– Visual disturbance may also be a red flag of disturbances of neurological function, such as stroke, malignant hypertension and toxaemia of pregnancy.

– The development of a blood clot in an artery is a serious condition, as the blood supply to the tissue supplied by the blocked artery will be cut off, and thus immediately threaten the life of that tissue. The red flags of infarction of the brain (stroke), coronary arteries (heart attack), lung (pulmonary embolism) and bowel (leading to acute abdomen and shock) have been described earlier under ‘loss of consciousness’ (C7), ‘chest pain’ (C5) and ‘acute abdominal pain’ (C1). Infarction of a limb is one other situation in which thrombosis of an artery merits an emergency response.

– The development of a blood clot in a vein is serious, not because the tissues are greatly threatened, but because a part of the blood clot may break off and travel to lodge in the pulmonary circulation. This event can cause a life-threatening pulmonary embolism.