7.3 Acute Illness, Injury & Emergency Response

7.3 Acute Illness, Injury & Emergency Response

Quick Answer: In community pharmacy, recognise emergencies early, call 000 when airway, breathing, or circulation is threatened, and deliver first response within scope while waiting for ambulance care. High-yield scenarios: chest pain, severe shortness of breath/asthma attack, anaphylaxis, hypoglycaemia, opioid overdose (naloxone), major bleeding on anticoagulants, suspected stroke (FAST), and acute injury within first-aid limits. Do not delay emergency activation for a perfect history.

Standard 3.2.5 includes supporting people with acute illness or injury. Interns must know the difference between urgent self-care/GP referral and time-critical emergency response.

First principles: ABC before paperwork

Exam rule: If the stem shows collapse, severe respiratory distress, anaphylaxis features, unresponsiveness, or stroke/chest-pain emergency signs, the best first action is almost never "take a full medication history" or "recommend an OTC and review next week."

Chest pain

Treat new, severe, crushing, radiating, or associated chest pain (sweating, nausea, dyspnoea, syncope) as a potential acute coronary syndrome until proven otherwise.

Pharmacist actions:

1. Seat the patient, keep calm, call 000
2. Give aspirin 300 mg chewed if not contraindicated and local emergency protocols/first-aid guidance support it (confirm allergy, active major bleeding contraindications)
3. Assist with the patient’s own prescribed glyceryl trinitrate (GTN) if they have it and blood pressure/syncope cautions allow — do not invent doses beyond product/first-aid guidance
4. Be prepared for CPR/AED if collapse occurs
5. Handover: onset time, symptoms, medicines (especially antiplatelets, anticoagulants, GTN, PDE5 inhibitors — relevant to GTN), allergies

Do not drive the patient yourself as a substitute for ambulance when ACS is suspected. Do not dismiss pain as "just anxiety" or reflux without emergency assessment when red flags are present.

Severe shortness of breath and asthma attack

Red flags for emergency (call 000)

• Severe distress, inability to speak full sentences
• Cyanosis, exhaustion, confusion
• Little or no response to reliever
• Oxygen saturation low if measured and concerning
• Silent chest, collapsing posture
• Known brittle asthma with rapid deterioration

First response themes (within scope/training)

1. Sit the patient upright; reassure; do not leave alone if severe
2. Give reliever (salbutamol) via MDI with spacer if available — multiple puffs as per asthma first-aid plans (Australian Asthma Handbook first-aid style: salbutamol via spacer, repeat, call ambulance if not improving)
3. If the patient has a written asthma action plan, follow it
4. Oxygen only if trained/equipped and indicated
5. Prepare for deterioration → CPR pathway

Mild wheeze improving with reliever may be managed with plan review and urgent same-day medical care; severe attack is an emergency, not an OTC recommendation opportunity.

Anaphylaxis recognition

Anaphylaxis is a severe, life-threatening systemic hypersensitivity reaction.

Recognition cues:

• Acute onset after allergen/medicine exposure
• Skin/mucosal changes (urticaria, swelling) plus respiratory compromise and/or hypotension/collapse
• Isolated severe bronchospasm or hypotension after known allergen can still be anaphylaxis
• Throat tightness, stridor, tongue swelling, persistent cough/wheeze, dizziness, incontinence, sense of doom

Response:

1. Call 000
2. Lay flat; do not stand the patient if hypotensive (pregnant patients: left lateral as appropriate)
3. Give intramuscular adrenaline into mid-outer thigh without delay if anaphylaxis is likely and an adrenaline injector is available (patient’s own or pharmacy protocol/stock as authorised)
4. Repeat adrenaline per guidelines if no response (typically after ~5 minutes — follow current ASCIA-aligned first-aid guidance)
5. Salbutamol for ongoing wheeze after adrenaline if needed; antihistamines/steroids are adjuncts, not first-line replacements for adrenaline
6. Handover allergen, time of adrenaline, other medicines

Critical exam point: Antihistamine alone is not adequate treatment for anaphylaxis. Delay of adrenaline kills.

Hypoglycaemia

Common in insulin or sulfonylurea users; also consider other contexts.

Symptoms: sweating, tremor, hunger, confusion, irritability, drowsiness, seizure, coma.

If conscious and cooperative:

1. Give fast-acting carbohydrate (glucose tablets/gel, sugary drink per first-aid protocols)
2. Recheck symptoms; follow with longer-acting carbohydrate when recovered
3. Identify cause (missed meal, extra insulin, exercise, alcohol)
4. Advise medical review if on sulfonylurea, recurrent hypos, or unclear cause

If unconscious, seizing, or unable to swallow safely:

1. Call 000
2. Do not force oral fluids
3. Glucagon if available and trained to administer; recovery position as appropriate
4. Nil by mouth until safe swallow returns

Never send a severely hypoglycaemic patient home alone without recovery and a safety plan.

Opioid overdose awareness and naloxone

Opioid toxicity: pinpoint pupils, slow/absent breathing, deep sedation, cyanosis, snoring/gurgling, unresponsiveness.

Response principles:

1. Call 000; support airway/breathing; CPR if needed
2. Administer naloxone if available (intranasal or intramuscular formulations used in take-home and emergency programs) per product instructions
3. Naloxone may restore breathing; effect can wear off — monitor until ambulance care
4. Do not leave the person alone; be prepared to repeat naloxone if legally/protocol-supported
5. Counsel patients on high-dose opioids, history of overdose, or polydrug sedation about naloxone access (pharmacy supply pathways exist in Australia — know that take-home naloxone programs improve community safety)

Overdose response is not a moment for moralising. It is airway, oxygen/breathing support, naloxone, and emergency care.

Major bleeding on anticoagulants

Patients on warfarin or DOACs (e.g. apixaban, rivaroxaban, dabigatran) may present with:

• Uncontrolled external bleeding
• Black tarry stools, vomiting blood
• Large unexplained bruising, severe headache (possible intracranial bleed)
• Prolonged nosebleed, heavy haematuria

Actions:

1. Apply direct pressure to external bleeding; call 000 for major/uncontrolled bleeding or internal bleeding signs
2. Do not advise "just take another dose tonight" or stop/start anticoagulants casually without medical direction in an emergency
3. Identify the anticoagulant, last dose time, other antiplatelets/NSAIDs, and INR if known (warfarin)
4. Urgent hospital assessment for major bleed — reversal strategies are hospital-based
5. For minor bleeds that stop, still prompt timely medical review and medicine-use check (interacting OTC NSAIDs are a classic community trigger)

Suspected stroke: FAST

Additional signs: sudden severe headache, visual loss, imbalance with other neurological features. Do not give aspirin in undiagnosed stroke (haemorrhage possible). Do not let the patient drive. Record last known well time for handover — thrombolysis/endovascular windows are time-dependent in hospital systems.

Acute injury and first-aid limits

Community pharmacists commonly see cuts, sprains, burns, and eye injuries.

Within typical first-aid/pharmacy scope:

• Basic wound cleaning and simple dressings for minor injuries
• RICE/POLICE-style advice for mild soft-tissue injury; analgesia within S2/S3 rules when appropriate
• Chemical splash: immediate irrigation and urgent care referral as indicated
• Minor burns: cool running water guidance; refer extensive, electrical, airway, chemical, or circumferential burns

Refer / emergency — do not "manage in pharmacy only":

• Deep wounds, arterial bleeding, suspected fracture with deformity, head injury with red flags
• Eye injuries with vision loss, penetrating injury, or alkali burns after irrigation start
• Major trauma, amputation, spinal injury suspicion
• Infected wounds with systemic features

Know your limits: first aid stabilises; it does not replace emergency medicine or tetanus/surgical decisions.

Call emergency services: practical teamwork

• Designate a staff member to call 000 while another stays with the patient
• Use speakerphone; follow dispatcher instructions
• Clear space for paramedics; retrieve AED if collapse
• Prepare handover: identity, time of onset, observations, medicines given (adrenaline, salbutamol, aspirin, naloxone, glucose), allergies, next of kin if known
• Support bystanders and protect privacy as much as feasible in a crisis

Do not delay for complex history when ABC compromised

History still matters — after life threats are addressed, for handover and ongoing care.

After the event

• Document facts, times, medicines administered, and ambulance outcome if known
• Debrief staff; restock emergency kit (adrenaline injectors if used under protocol, spacers, gloves, glucose, naloxone where kept)
• Offer support to affected patients/staff
• Review whether pharmacy emergency protocols need update

Exam mindset

Intern Written acute-care items reward recognition + early 000 + correct first drug/device response + scope limits. Wrong answers usually over-investigate, under-call emergencies, choose antihistamine instead of adrenaline, or manage FAST-positive stroke with "rest at home."