Chapter 34: Acute Care and Out Of Hours

Section 1: GP Perspective & Introduction

Scope and Burden in General Practice

Acute care, both in-hours and out-of-hours (OOH), is a core component of general practice. It involves managing unscheduled, unpredictable presentations that require an urgent response. These consultations test a GP's diagnostic skills, ability to manage risk and uncertainty, and communication under pressure. The GP acts as the primary access point to the healthcare system for acutely ill patients, playing a crucial role as a gatekeeper to prevent unnecessary hospital admissions while ensuring those who are seriously ill receive timely, life-saving care. The GP's role involves:

• Triage and Assessment (OHLSP4A): Rapidly assessing the urgency of a situation, whether in person or over the phone, to determine the necessary course of action.
• Emergency Management (OHLPM3A): Recognising and providing immediate management for life-threatening conditions such as anaphylaxis, sepsis, myocardial infarction, and acute asthma.
• Managing Uncertainty: Making safe and effective decisions with limited information, often without access to the patient's full medical records, especially in the OOH setting (OHLSP5A).
• Coordination of Care: Liaising effectively with emergency services, secondary care colleagues, and community services to ensure a safe transition of care for the patient.
• Personal Safety and Resilience (OHLAC3A): Managing personal security during home visits or in OOH centres and developing coping strategies for the stress associated with high-stakes clinical decisions.

A mother presenting in a panic with her 4-year-old child who has hives, facial swelling, and hoarseness is a classic example of an acute emergency. This situation demands immediate recognition of anaphylaxis, rapid clinical intervention, and calm, clear communication with a distressed parent, encapsulating the high-pressure nature of acute care in general practice.

Section 2: Clinical Assessment of the Acutely Ill Patient

A structured, rapid assessment is essential to identify the seriously ill patient and prioritise management. The "ABCDE" approach is a universally recognised framework.

The ABCDE Approach (OHLPM1A)

• A - Airway: Is the airway patent? Look for signs of obstruction (e.g., stridor, hoarseness, paradoxical chest movements). If compromised, immediate intervention is needed.
• B - Breathing: Assess respiratory rate, effort (use of accessory muscles), and oxygen saturation (SpO2). Auscultate for wheeze, crackles, or a silent chest.
• C - Circulation: Assess heart rate, blood pressure, capillary refill time, and conscious level. Look for signs of shock (tachycardia, hypotension, cool peripheries).
• D - Disability: Assess conscious level using AVPU (Alert, Voice, Pain, Unresponsive) or GCS. Check blood glucose and pupil response.
• E - Exposure: Expose the patient to look for rashes (petechial, urticarial), injuries, or sources of infection, while respecting dignity and preventing heat loss.

Recognising the "Sick Child"

[HIGH-YIELD] GPs must be proficient in recognising the signs of serious illness in children. The "traffic light" system is a important framework:

• Green (Low Risk): Normal colour, activity, and response to stimuli. Smiling. Normal vital signs.
• Amber (Intermediate Risk): Pallor, reduced activity, nasal flaring, tachypnoea, tachycardia, reduced urine output. Requires close observation and potential referral.
• Red (High Risk / Sepsis): [RED FLAG] Mottled/ashen/cyanotic appearance, unresponsive, weak high-pitched cry, grunting, severe tachypnoea, signs of shock. Requires immediate emergency hospital admission.

Exam-Style Questions: Clinical Assessment

Section 3: Management of Acute Medical Emergencies

GPs must be competent in the immediate management of common life-threatening emergencies while awaiting transfer to hospital.

Anaphylaxis (OHLSP12A)

• Definition: A severe, life-threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing problems with Airway, Breathing, and/or Circulation.
• Recognition: Suspect anaphylaxis in a patient with acute onset of illness with typical skin features (urticaria, angioedema) AND respiratory and/or cardiovascular involvement. The 4-year-old child with hives, lip swelling, and hoarseness is a classic case.
• Management: [CRITICAL & HIGH-YIELD]
  1. Call 999 for an ambulance.
  2. Administer IM Adrenaline without delay. This is the single most important, life-saving step.
     • Dose: Use a 1:1000 solution.
     • Adult & child >12 years: 0.5ml (500 micrograms)
     • Child 6-12 years: 0.3ml (300 micrograms)
     • Child <6 years: 0.15ml (150 micrograms)
  3. Lay the patient flat and raise their legs (if breathing is not compromised). If they are breathless, allow them to sit up.
  4. Administer high-flow oxygen.
  5. Repeat adrenaline dose every 5 minutes if no improvement.

Acute Severe Asthma (OHLSP11A)

• Recognition of Severe Features: [RED FLAG]
  • PEFR 33-50% predicted.
  • Inability to complete sentences in one breath.
  • Respiratory rate ≥25/min.
  • Heart rate ≥110/min.
• Recognition of Life-Threatening Features:
  • PEFR <33%, SpO2 <92%, silent chest, cyanosis, exhaustion, confusion.
• Management:
  1. Call 999 for an ambulance.
  2. Sit the patient upright.
  3. Administer high-flow oxygen if SpO2 <94%.
  4. Administer high-dose Salbutamol via a spacer (e.g., 10 puffs). Nebulisers may be used by paramedics but are no more effective than a spacer.
  5. Administer oral Prednisolone (e.g., 40-50mg for adults) STAT.

Sepsis

• Definition: Life-threatening organ dysfunction caused by a dysregulated host response to infection.
• Recognition: [HIGH-YIELD] Suspect sepsis in any patient with evidence of infection and signs of organ dysfunction (altered mental state, tachypnoea >22, systolic BP <100 mmHg).
• Management: Sepsis is a time-critical emergency.
  1. Call 999 for an ambulance, stating "suspected sepsis".
  2. Administer oxygen to maintain SpO2 94-98%.
  3. In the community, the important interventions are recognition and rapid transfer. IV antibiotics and fluids will be administered by paramedics or in hospital.

Myocardial Infarction & Cardiopulmonary Resuscitation (CPR) (OHLSP7A)

• Management of ACS: See Chapter 6: Cardiovascular Health. Immediate actions are: Call 999, give Aspirin 300mg, give GTN, give O2 if hypoxic.
• Management of Cardiac Arrest:
  1. Confirm unresponsiveness and absence of normal breathing.
  2. Call 999 and send someone for the Automated External Defibrillator (AED).
  3. Commence chest compressions immediately (30 compressions to 2 rescue breaths).
  4. Attach the AED as soon as it arrives and follow the voice prompts.

Exam-Style Questions: Core Condition Management

Section 4, 5 & 6: Broader Competencies, Holistic Care & Scientific Features

Practice Preparedness (OHRPM2A, OHRPM3A)

• Emergency Equipment: A well-organised practice must have immediate access to essential emergency drugs and equipment. This includes a standardised "doctor's bag" and a practice emergency trolley. Important contents include: Adrenaline, Aspirin, GTN, Salbutamol, Prednisolone, Oxygen, an AED, and airway adjuncts. Regular checks of expiry dates and equipment function are mandatory.
• Training: All clinical and non-clinical staff should have up-to-date training in basic life support (BLS). Clinical staff require additional training in managing medical emergencies, often through courses like Immediate Medical Care.
• Protocols: The practice should have clear, written protocols for managing common emergencies (e.g., chest pain, collapse in the waiting room) so all team members know their role.

Out-of-Hours (OOH) Context (OHRAC1A)

• Working in OOH presents unique challenges:
  • Lack of Information: GPs often have no access to patient records, making assessment more reliant on focused history and examination skills (OHLSP5A).
  • Isolation: The GP may be working with unfamiliar colleagues or alone, requiring self-reliance and good clinical judgement.
  • Patient Expectations & Demand (OHRAS2A): OOH services often manage a high volume of lower-acuity problems alongside genuine emergencies, requiring excellent triage and communication skills.
• Telephone Triage (OHLSP4A): This is a core skill in OOH. It requires specific communication techniques to build rapport, obtain a focused history, assess risk remotely, and provide clear, safe advice and disposition.

Holistic and Person-Centred Care

• Communication under Pressure (OHRPC2A): In an emergency, it is vital to communicate in a calm, clear, and reassuring manner to the patient and their family. This reduces anxiety and facilitates cooperation.
• Carer Needs (OHLPC4A): The acutely ill patient is often accompanied by a distressed relative. The GP must attend to their needs, providing information and support while prioritising the patient's clinical care.
• Holistic Impact (OHRHA1A): After an acute event like anaphylaxis, the GP's role involves holistic follow-up. This includes exploring the psychological impact on the family, providing education on allergen avoidance, prescribing adrenaline auto-injectors, and training the family on their use.

Scientific Features & Evidence Base (OHLAS1A)

• The management of medical emergencies is protocol-driven and based on robust evidence from bodies like the Resuscitation Council (UK and European) and the Advanced Life Support Group (ALSG).
• GPs must maintain their knowledge and skills through regular, accredited training (e.g., BLS/ILS/ALS) to ensure their practice remains in line with current evidence-based guidelines.

Final Exam-Style Questions: Broader Competencies