Emergencies

Very Brief Summaries of some common emergencies: (MS Word version)

(For more detail please see: Assessment of the Acutely Ill Patient, by Jon Silversides.)

1. Cardiac Arrest

Basic Life Support (BLS):
   Call for Help
  A: Head tilt + chin lift/jaw thrust. Clear mouth.
  B: If not breathing - give 2 breaths
  C: If no pulse - give 15 chest compressions at 100/minute, per 2 breaths.

Advanced Life Support (ALS):
  If witnessed arrest - give Precordial thump.
  BLS.
  Attach defib/monitor.
  If VF or pulseless-VT => DC Shock 200, 200, 360 joules; CPR 1 minute; reaccess rhythm & pulse; reshock 3 x 360 joules.
  If non-VF or VT-with-pulse => 3 minutes CPR; reaccess rhythm & pulse.
  During CPR: correct reversible causes, IV access, give 1mg IV Adrenaline each 3 minutes, consider intubation.
  Consider amiodarone, atropine, pacing, buffers.

Reversible causes:
  Hypoxia
  Hypovolaemia
  Hypokalaemia, hyperkalaemia
  Hypothermia
  Tension pneumothorax
  Tamponade
  Toxic/therapeutic disturbance
  Thromboembolic/mechanical obstruction.

2. Myocardial Infarction

Management: (BOOMASS)
  Bed rest
  Oxygen
  Opiates
  Monitor rhythm (ECG)
  Aspirin (300mg) (GTN and Beta-blockers can help)
  Steptokinase (if within 12hr and elevated ST, but no contraindications)
  Stop smoking (exercise, diet, physio)

In more detail:
  ECG Monitor
  O2 (High flow)
  IV Access.
  FBP, U+E, Glucose, Lipids, Cardiac enzymes.
  Aspirin 300mg
  Morphine (5-10mg IV) or Diamorphine (2-5mg IV) + Antiemetic, eg: Metoclopramide (10mg IV)
  GTN (unless hypotensive)
  Beta-blocker (eg. atenolol 5mg IV, unless asthma or LVF)
  Thrombolysis (Streptokinase or Alteplase, rt-PA) - if within 12 hrs (still may help upto 24 hrs) and ST elevation, BUT no internal bleeding, no surgery in past 2 weeks, BP not over 200/120mmHg, previous allergic reaction, pregnancy, don't give streptokinase if it is 5 days to 1 year since last administration. If there are thrombolysis contra-indications, consider urgent angioplasty instead.
  CXR
  Prophylaxis - Management of any existing Diabetis, DVT Prophylaxis
  Stop Calcium channel antagonists

3. Acute severe Asthma

Signs of Severe attack:
  Cannot complete sentences
  Resp rate > 25/minute
  Pulse > 110/minute
  Peak flow < 50% of predicted or best

Signs of Life-threatening attack:
  Peak flow < 33% of predicted or best
  Silent chest, cyanosis, feeble respiratory effort
  Bradycardia or Hypotension
  Exhaustion, confusion, or coma
  Normal or high PaCO2, Low PaO2, Low pH.

Treatment:
  Sit patient up,
  100% O2
  Salbutamol (5mg) with O2
  Hydrocortisone (200mg IV)
  Condider Ipratropium or Aminophylline (but risk of arrhythmia side effects)
  If severe, warn ITU.
  CXR - exclude pneumothorax.

4. Anaphylactic Shock

Symptoms & signs:
  Skin: Itching, Erythema, Urticaria, Oedema.
  Breathing: Wheeze, Laryngeal obstruction.
  Heart: Tachycardia, Hypotension.

Management:
  Secure Airway
  100% Oxygen
  Intubate if respiratory obstruction imminent
  Adrenaline IM, 0.5ml of 1:1000 (=0.5mg), repeat each 5 minutes if needed
  IV Access
  Chlorpheniramine 10mg IV
  Hydrocortisone 200mg IV
  IV saline (eg 500ml per 15 minutes, upto 2 litres) monitoring BP.
  If wheeze, treat for asthma.
  May need ventilatory support, and Intensive care.

5. Diabetic Ketoacidosis

Dehydration is more life threatening than any hyperglycaemia.

Signs & symptoms:
Polyuria, lethargy, hyperventilation, ketotic breath, dehydration, vomiting, abdominal cramp, coma.

Management:
  IV access
  IV Fluids (Saline 1 litre stat, 1L over 1hr, 1L over 2hr, 1L over 4hr. Careful if >65years or CCF. Dextrose saline when glucose<15mmol/L)
  Plasma glucose. If > 20mmol/L give 10 units soluble insulin (actrapid) IV.
  Tests: Lab glucose, U+E, HCO3, osmolality, blood gases, FBP, blood culture, urine ketones & MSU.
  NG Tube if nausea/vomiting/unconscious.
  Insulin sliding scale with hourly blood glucose tests.
  Potassium replacement

6. Acute upper GI bleed

Access for shock:
  Cold nose and fingers
  Slow capillary refill
  Pulse>100/min
  Systolic BP > 100mmHg
  Urine output < 30ml/hr

If shocked:
  Protect airway. Nil by mouth.
  2 large cannulae.
  Draw bloods (FBP, U+E, LFT, glucose, clotting screen).
  Cross-match 6 units.
  High-flow O2.
  Rapid IV colloids (upto 1 litre).
  If still shocked: group specific or O-ive blood until cross-match.
  (If not still shocked and not liver failure, IV saline to keep lines open).
  Correct clotting: Vit K, FFP.
  Monitor vitals each 15 minutes, and urine output (>30ml/hr).
  Notify surgeons (Endoscopy for diagnosis/control bleeding).

Self test questions on Emergencies.

State what you would do in the following emergencies. Send 40 seconds on each question, then look at the suggested answers above.

1. Cardiac Arrest - give the Basic Life Support algorithm, Advanced Life Support algorithm, Reversible causes of cardiac arrest.

2. Myocardial Infarction - give the Management

3. Acute severe Asthma - give the Signs of severe attack, Signs of Life-threatening attack, Treatment

4. Anaphylactic Shock - give the Signs and Management

5. Diabetic Ketoacidosis - give the Signs & symptoms, and Management.

6. Acute upper GI bleed - give the Management