1. Red Flags Dr. Ahmed A. Elbashir ED Consultant KFMC Assistant Prof. KSU

2. Objectives Discuss general principle in triage approach Discuss approach to common complaint To identify serious presentation

3. G General Principle Focused and systematic assessment Assume the most serious scenario Should have knowledge about red flags in each complaint Use only the available tools that can help you in taking a decision Ask for advice if you feel that you need

4. General Red Flags Extremes of age Symptoms or signs related to airway, breathing or circulation or affecting LOC Sudden onset of a complaint Short duration Severe mechanism of injury in trauma Decrease level of consciousness Serious signs as diaphoresis, Tachypnea, and cyanosis Abnormal vital signs

5. General Pain assessment Severity Character Localization Onset Duration Radiation Aggravating and relieving factors Associated symptoms

6. Red Flags in Airway problems Subjective : Difficulty of breathing Laryngeal pathology Airway trauma or burn Acute onset anterior neck swelling Allergic reaction with SOB Strider Acute change in voice with SOB

7. Red Flags in Airway problems Objective : Decrease LOC Respiratory distress Strider Tachypnea Sweating Cyanosis Abnormal vital signs

8. Red Flags in Chest pain Pain description Cardiac : Character : Pressure,heaviness,tightness, Localization : Substernal, and in the left Onset Acute recent or chronic with new changes Duration : If more than 20 min. significant Radiation : To the left arm, shoulder, jaw Aggravating, relieving factors may be by exertion Associated symptoms : Diaphoresis, nausea, Vomiting, SOB, syncope

9. Remember : Aortic dissection may occur in any age Usually the pain is abruptly sudden & acute, classically tearing and interscapular Red Flags in Chest pain

10. Remember Any patient with non traumatic chest pain ECG shall be done and interpreted within 10 minutes Red Flags in Chest pain

11. Other Risk indicators : Age PMH of IHD, HPT, DM, Hyperlipidemia Risk factors, smoking Red Flags in Chest pain

12. Non Cardiac but serious Pulmonary Causes : Pulmonary embolism Look for any high risk criteria Tensional pneumothorax, look for signs of distress Pain is usually sharp Localized and increase with respiration Red Flags in Chest pain

13. Criteria for high probability PE Clinical Signs and Symptoms of DVT? Immobilization at least 3 days, or Surgery in the Previous 4 weeks Previous, objectively diagnosed PE or DVT? Hemoptysis? Malignancy Treatment within 6 month,? Heart Rate > 100? Red Flags in Chest pain

14. Tensional pneumothorax  Severe respiratory distress or tachypnea  Distended neck veins  Hypotension  Hyperesonent chest percussion Red Flags in Chest pain

15. Old ages Severe pain Sudden onset Short duration Associated fever Associated hypotension Previous surgery Red Flags in abdominal pain

16. Remember Epigastric pain specially in elderly can be acute MI Red Flags in abdominal pain

17. Red Flags in non traumatic back pain AAA Old ages Previous history of Aortic aneurysm Severe acute onset Short duration Associated abdominal pain Week or Absent femoral pulses Associated hypotension, or sweating

18. Red Flags in non traumatic back pain Acute disc prolapse with cauda equina  Acute onset, short duration  Urinary or bowel incontinence or retention  Apparent acute LL weakness  Sensory level

19. Old ages Any decrease in LOC Severe acute onset Not a recurrent headache Anticoagulant medications Associated nausea or vomiting Associated photophobia Associated fever and no other symptoms of URTI Neck rigidity Any limb weakness Red Flags in patients with headache

20. Acute onset decrease LOC Old ages, no focus of infection Associated headache neck pain no URTI Photophobia Neck rigidity Chemotherapy Hypotension Red Flags in patients with fever

21. Old age Associated chest pain or SOB Associated syncope Any hypotension or hypoxia History of IHD or arrhythmias Important tools for Triage decision making : ECG – Glucometer Red Flags in patients with Palpitation

22.  Elderly age  Abrupt onset  Duration more than few seconds  Repeated episodes  Occurrence during sitting or supine  Associated symptoms, palpitation, chest pain  PMH Red Flags in patients with Syncope

23. Objective assessment  Bradycardia or tachycardia  Hypotension or hypertension  Pallor  Sweating  Focal neurological deficit  Apparent bleeding Red Flags in patients with Syncope

24. What is syncope  Transient loss of consciousness  Followed by inability to maintain postural tone  Followed by rapid complete return to baseline neurological function

25. Ischemic Limb :  Old age  Acute severe sudden pain  No trauma  Atherosclerotic diseases Examine the limb for  Color - Temperature - Pulsation Red Flags in patients with Limb pain

26. Potential limb threatening : Compartment syndrome History of trauma or post cast Hematoma became with increasing pain Increasing severe pain Swollen tense limb Painful passive stretching of tendons Red Flags in patients with Limb pain

27. Hypoglycemia Any decrease LOC Palpitation Sweating Recent intake of insulin or glucose lowering tab Important tools for Triage decision making : Glucometer Red Flags in Diabetic patients

28. Hyperglycemia Any decrease LOC Signs of dehydration Any abnormal vital signs Tachypnea Important tools for Triage decision making : Glucometer Red Flags in Diabetic patients

29. Remember Glugocheck shall be done for any patient with decrease LOC, Agitation, unexplained symptoms