Acute medical emergencies


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Common Medical Emergencies.
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Acute medical emergencies

  1. 1. ACUTE MEDICAL EMERGENCIES Part 1 SYED RAZA Cardiologist & Acute Physician
  2. 2. Objectives• 1. Rapid Assessment• 2.Intial timely management• 3.Asking for help• 4.Liasion with consultant• 5. Do NO Harm• 6.Arrangement for transfer• 7.Communication• 8.Documentation
  3. 3. Acute Coronary Syndrome• ECG within 10 mins of arrival• Serial ECGs• Cardiac Troponin I/T > 6h from onset pain (± 12h if negative, and still suspicious of cardiac pain)• CardioDetect• FBC, U+E, LFT, Glucose, Clotting, CRP• CXR (to exclude other diagnoses)• TIMI SCORE (for NSTEMI/UA) – Assess risk factors
  4. 4. Acute Coronary Syndrome• Top Tip: Put an IV cannula in ASAP, cardiac arrest is possible• OXYGEN high flow, if hypoxic• IV (DIA)MORPHINE 2.5-10 mg + IV METOCLOPRAMIDE 10 mg, if pain severe• PO ASPIRIN 300 mg stat; then 75 mg od• PO CLOPIDOGREL 300 mg stat• (NSTEMI/UA) SC ENOXAPARIN 1 mg/kg bd.• (STEMI) Primary percutaneous intervention (PCI) Contact BDF• Thrombolysis (if <12h); IV TENECTEPLASE 30-50 mg
  5. 5. • Key Management Decision• (STEMI) PCI or Thrombolysis (both <12h)
  6. 6. Acute Heart Failure• Top Tip: Find out cause of heart failure (including exclusion of a MI)• CXR, ECG (MI?)• O2 saturation ± ABG• Urinalysis (nephrotic?)• FBC, CRP, BNP• U+E, LFT, Clotting, Glucose, Troponin I (MI?)
  7. 7. Acute Heart Failure• Sit up• OYXGEN (high flow) if low SPO2• IV MORPHINE 2.5-5.0 mg• IV GTN infusion 10-200 mcg/min• IV FUROSEMIDE 40 mg od (80 mg if creat. 120-200; 120 mg if 200- 400; 250 mg, if 400+)• SC ENOXAPARIN 1 mg/kg (esp, if in AF) ± ?ACS protocol, if ?MI• Key Management Decisions• ECHO (not necessary acutely, will need later to exclude valvular heart disease or cardiomyopathy)• CPAP• CCU/ITU - Transfer• DC Cardioversion (if new AF/flutter, and <24h)
  8. 8. Acute Kidney Injury• Key Investigations• Urinalysis (heavy proteinuria /microscopic haematuria = glomerular disease)• U+E, LFT, Bone, Glucose, CK• FBC, ESR, CRP, INR, VBG/ABG• NGAL (Neutrophil Gelatinase associated Lipocalin)• ECG, CXR• Renal US – exclude obstruction
  9. 9. Acute Kidney Injury• Top Tip: Rehydrate, exclude obstruction (ultrasound), stop nephrotoxic drugs• Rx underlying cause (especially sepsis, stop drugs)• Assess fluid status• IV + FLUIDS (dry), or• ± PO/IV FUROSEMIDE 80-250 mg od/bd (wet)• ± IV INSULIN 10 units in 50 mls 50% DEXTROSE over 30 mins (if hyperkalaemic)• ± Urinary catheter• Key Management Decisions• IV fluids or diuretics• Dialysis
  10. 10. Severe Acute Asthma• Assess severity• Peak flow meter• ABG, ECG, CXR• FBC, CRP, U+E, LFT, Bone, Glucose• Sputum culture Blood culture
  11. 11. Severe Acute Asthma• NEB SALBUTAMOL 5.0 mg qds (or continuously until improvement noted)• NEB IPATROPIUM BROMIDE 500 mcg qds• IV HYDROCORTISONE 100 mg qds (severe) or PO PREDNISOLONE 30 mg od (less)• OXYGEN, if hypoxic, to achieve saturation of 95- 97%• ± IV MAGNESIUM SULPHATE 2 g, over 20 minutes; can be repeated• +/- Antibiotics
  12. 12. Diabetic Ketoacidosis• Glucose (BM) + Capillary Blood Test for ketones• FBC, CRP• U+E, LFT, Glucose, HbA1C ± Troponin I• ECG, CXR• ABG, Blood Culture• Urinalysis (ketones?) ± MSU
  13. 13. Diabetic Ketoacidosis• INSULIN (ACTRAPID, 50 units in 50 mls N saline), start infusion at 0.1 units/kg/hr• SC ENOXAPARIN 40 mg od• IV Normal Saline 1 litre stat.500 ml 1st hour, 500ml in 2 hrs, 500 ml in 4 hours ,then as per I/O• + K supplement• Treat if any overt sepsis• Key Management Decision• ITU
  14. 14. Severe Sepsis• Top Tip: Lack of temperature and/or normal/low WC can indicate a worse prognosis.• lack of hypotension does not exclude diagnosis.
  15. 15. Severe Sepsis Oxygen if SPO2 < 94%• Blood Culture• IV antibiotics within one hour• Fluid resuscitation• Lactate and Hb• Catheterise, if necessary - and monitor urine output• Key Management Decisions• ? Need for central IV access• ITU/ventilation – does patient need inotropic or ventilatory support?• Source control (eg drainage of abscess or removal of foreign body)
  16. 16. Severe Headache• D/D Acute Meningitis Subarachnoid hemorrhage SOL
  17. 17. Severe Headache• Analgesic• Keep NPO• I/V cannula• CBC, CRP, Blood culture if meningitis suspected• I/V Cefotaxime 2 gram stat if meningitis suspected• Arrange for CT Brain• ? LP
  18. 18. Acute Upper GI Bleed• Vitals/Postural BP• Rockall score• NPO• Urinary Cath. I/O charting• 2 Large bore (Brown/Grey) i/v cannula• CBC, Clotting, LFT, KFT• Cross match 6 units of blood
  19. 19. Acute Upper GI Bleed• Treat any clotting disorder i.e. FFP, Prothrombin Concentrate Complex, Vitamin K Urinary Cath.• Start volume expander : Gelofusine/N Saline while awaiting Blood• Ensure if taking Aspirin/NSAIDs/Anticoagulant.• Known peptic ulcer disease• Alert Gastroenterologist
  20. 20. Do:• group and save all patients• act on vital signs• use large-bore cannulas• use CVP access in high risk patients• correct coagulopathy in patients with cirrhosis. Don’t:• rely on Hb alone to guide red cell transfusion.
  21. 21. Acute Stroke
  22. 22. Key Initial Management• Brief history• Vitals , examination(neurology),GCS• Gain I/V access. Urinary cath.• Lab: CBC, KFT, Clotting, LFT, BG & ECG ,CXR• Keep NPO until swallow is assessed/Aspirin rectal if indicated.• Management of hypertension.• Urgent transfer for CT brain
  23. 23. Acute Pulmonary Embolism• Sudden onset SOB• Pleuritic chest pain• Haemoptysis• Tachycardia /Tachypnea• SPO2 not very reliable• Risk factors for PE• Well’s Score
  24. 24. Initial Work Up• CXR• ECG• ABG, D-DIMER, Clotting, CBC• Heparin if clinical suspicion is moderate/high even before diagnosis is confirmed.• Arrange for urgent CTPA.• V-Q scan /US Doppler legs in special cases