Chapter 4 C tables
Red flags requiring urgent referral
Introduction
The red flags are referenced to those found in the A tables in Chapter 2 so that the reader can access more information about these symptoms and signs and their underlying medical conditions.
The order of the C tables can be found in the contents pages of this text.
TABLE C1 Red flags of acute abdominal pain
| Symptoms suggestive of: | Priority | For more detail and definitions go to: |
|---|---|---|
| Severe abdominal pain with collapse (‘the acute abdomen’): the pain can be constant or colicky (coming in waves) | ***/** | A6. Red flags of diseases of the stomach A10. Red flags of diseases of the small and large intestines |
| Acute pancreatitis: presents as the acute abdomen, with severe central abdominal and back pain, vomiting and dehydration | ***/** | A7. Red flags of diseases of the pancreas |
| Obstructed gallstone: right hypochondriac pain (pain under the right ribs) which is very intense and comes in waves. May be associated with fever and vomiting, and jaundice | ***/** | A9. Red flags of diseases of the gallbladder |
| Obstructed kidney stone: acute loin pain (pain in the flanks radiating round to pubic region) which comes in waves. May be associated vomiting, agitation and collapse | *** | A30. Red flags of diseases of the ureters, bladder and urethra |
| Acute testicular pain (torsion of testis): radiates to groin, scrotum or lower abdomen. May be associated vomiting and collapse | ***/** | A36. Red flags of structural disorders of the reproductive system |
| Pelvic inflammatory disease (acute form): lower abdominal pain with collapse and fever | *** | A35. Red flags of sexually transmitted diseases |
| Ruptured aortic aneurysm: acute abdominal or back pain with collapse and features of shock | *** | A11. Red flags of diseases of the blood vessels |
| Sustained severe abdominal pain in pregnancy: may be ruptured ectopic pregnancy, placental abruption, pre-eclampsia or premature labour | ***/** | A37. Red flags of pregnancy |
| Premature labour: periodic mild cramping sensations in later pregnancy (lasting no more than a few seconds) are likely to be Braxton Hicks contractions, but if becoming regular and intensifying, beware that these might signify premature labour (by definition, before week 36 of pregnancy) | ***/** | A37. Red flags of pregnancy |
| Pre-eclampsia/HELLP (hemolysis, elevated liver enzymes, low platelet count) syndromes in pregnancy: headache, abdominal or epigastric pain, visual disturbance, nausea and vomiting and oedema (in middle to late pregnancy) | ***/** | A37. Red flags of pregnancy |
Notes
– 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.
TABLE C2 Red flags of bone marrow failure
| Symptoms suggestive of: | Priority | For more detail and definitions go to: |
|---|---|---|
| Bone marrow failure: symptoms of progressive anaemia, recurrent progressive infections, and progressive bruising, purpura and bleeding | ***/** | A1. Red flags of cancer A20. Red flags of leukaemia and lymphoma |
Notes
– 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.
TABLE C3 Red flags of blood loss and shock
| Symptoms suggestive of: | Priority | For more detail and definitions go to: |
|---|---|---|
| Continuing blood loss: any situation in which significant bleeding is continuing for more than a few minutes without any signs of abating (e.g. nosebleed), except within the context of menstruation, is potentially serious | ***/** | A19. Red flags of haemorrhage and shock |
| Vomiting of fresh blood or altered blood (haematemesis): if blood is altered, it looks like dark gravel or coffee grounds in the vomit. Refer urgently if any signs of shock (see A19.3) are present | ***/** | A6. Red flags of diseases of the stomach A8. Red flags of diseases of the liver |
| Altered blood in stools (melaena): stools look like black tar. Suggests large amount of bleeding from stomach. Refer urgently if any signs of shock (see A19.3) are present | ***/** | A6. Red flags of diseases of the stomach |
| Bleeding: refer any episode of vaginal bleeding in pregnancy as an emergency if any signs of shock (see A19.3) are apparent | ***/** | A37. Red flags of pregnancy |
| Post-partum (after delivery of baby) haemorrhage with a bleed of >500 ml or the symptoms of shock (see A19.3) | ***/** | A38. Red flags of the puerperium |
| A very rapid pulse of 140–250 beats/minute: most likely to be supraventricular tachycardia or atrial fibrillation. Refer urgently if ongoing, and as a high priority if has settled down but was first ever episode | ***/** | A14. Red flags of heart failure and arrhythmias |
| A very slow pulse of 40–50 beats/minute (complete heart block): refer if either of recent onset or if associated with features of shock (see A19.3), such as dizziness, light-headedness or fainting | ***/** | A14. Red flags of heart failure and arrhythmias |
Notes
– 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.
First-aid measures for blood loss and shock
• Call for medical assistance.
• Ensure the patient is kept comfortable and warm.
• Stem any sources of external blood loss by firm pressure, and raise any limbs which are bleeding.
• If there are features of shock (low blood pressure and feelings of faintness), first check there are no breathing difficulties. If not, then ensure the patient is lying down.
• Place in recovery position if there is possibility of vomiting or if there is loss of consciousness.
• Continue to check airway, breathing and circulation (ABC). If no breathing, then call the emergency services and be prepared to perform cardiopulmonary resuscitation (CPR).
TABLE C4 Red flags of acute difficulty in breathing
| Symptoms suggestive of: | Priority | For more detail and definitions go to: |
|---|---|---|
| Severe asthma. At least two of the following: rapidly worsening breathlessness, >30 respirations/minute (or more if a child1), heart rate >110 beats/minute, reluctance to talk because of breathlessness, need to sit upright and still to assist breathing. Cyanosis is a very serious sign | *** | A17. Red flags of lower respiratory disease |
| Infection of the lower respiratory tract (pneumonia): cough, fever, malaise, >30 respirations/minute (or more if a child1), heart rate >110 beats/minute, reluctance to talk because of breathlessness, need to sit upright and still to assist breathing. Cyanosis is a very serious sign | ***/** | A17. Red flags of lower respiratory disease |
| Central cyanosis: cyanosis seen on the tongue suggests poor oxygenation of the blood and merits urgent referral if of recent onset in an unwell person | *** | A17. Red flags of lower respiratory disease |
| Pulmonary embolism: sudden onset of pleurisy (chest pain exacerbated by breathing in), with breathlessness, cyanosis, collapse, and blood in sputum | *** | A17. Red flags of lower respiratory disease |
| Sudden lung collapse (pneumothorax): onset of severe breathlessness, may be some pleurisy (chest pain exacerbated by breathing in), and collapse if very severe | *** | A17. Red flags of lower respiratory disease |
| Stridor (harsh noisy breathing heard on both the inbreath and outbreath): suggests obstruction to upper airway. Patient will want to sit upright and still. Do not ask to examine the tongue | ***/** | A16. Red flags of upper respiratory disease |
| A single, grossly enlarged tonsil and difficulty in breathing: if the patient is unwell and feverish and has foul-smelling breath, this suggests quinsy. This is a surgical emergency, as breathing may be compromised | ***/** | A16. Red flags of upper respiratory disease |
| Acute heart failure: sudden onset of disabling breathlessness and watery cough | *** | A14. Red flags of heart failure and arrhythmias |
| Any sudden or gradual onset of muscle weakness that might be affecting muscles of respiration: needs to be referred urgently as the condition may progress to respiratory failure | *** | A25. Red flags of diseases of the spinal cord and peripheral nerves |
– 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.
Categorisation of respiratory rate in children
The normal range for respiratory rate in children varies according to age.
The following rates indicate moderate to severe breathlessness:
1Categorisation of respiratory rate in adults
| newborn (0–3 months) | >60 breaths/minute |
| infant (3 months to 2 years) | >50 breaths/minute |
| young child (2–8 years) | >40 breaths/minute |
| older child to adult | >30 breaths/minute. |
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