CARDIAC ARREST EM 01AssessmentCardiac arrest means No pulse No BP Unresponsive or deeply comatoseRespiration gasping; But pupils still reactingBegin immediatelyAdvanced Cardiac Life SupportStart external chest compressionsBasic Life Supporttilldefibrillation is availableCall colleagues for helpCall nurse to start medicationsCall nursing assistants to assistAttach monitor and defibrillator if availableStart oxygen by maskEndotracheal intubationPrecordial thumb inUnmonitored Cardiac arrest C2bMonitored Cardiac arrest C1Call attenders to start oxygenGive loud and clear instructionsBe the leader of the teamCheck for shockable rhythmOpen the patients airwayClear mouth, Remove denturesGive throat suctionExtent neck and intubateConnect oxygen by tubeStart artificial ventilationUse ambu bag or machineDelivered to the middle of chestwhen onset of VT VF is seenIt may convert VT VF to NSRDo not delay defibrillationIf unmonitored, can be harmfulEven precipitate a VT or VFDo not repeat the procedureShockableVF, PulselessVTNot ShockableAsystole PEAGive one shock and immediately resume CPRManual biphasic device –specific give 120-200jMonophasic device give 360 joulesImmediately resume CPR for 5 cyclesGive adrenaline 1mg mg IV repeat 3 dosesOr Vasopressin 40 U IV instead of adrenalineConsider Atropine 1 mg IV if asystole or PEARepeat 3 doses or till recoveryGive 5 cycles of CPR and check for shockable rhythmGive 5 cycles of CPR and check for Shockable rhythmContinue CPR while defibrillator is chargingGive one shock and resume CPRIf indicated try shockGive adrenaline 1mg mg IV repeat 3 doses

EXTERNAL CHEST CARDIAC MASSAGE EM 02Life saver (prolonger) techniqueStart immediatelyContinue unremittinglyPosition the patient on a hard cot, trolley or other surfaceRemove pillows and put the patient flat supineHigher levelLower head end if previously elevatedOpen the mouth of the takerGive two breaths If only 1 giver switch to compressionsGiver stands at a higher levelElbows kept at 1800Pressure shall come from shouldersPlace the left hand over the lower sternumPlace the right hand over the left handKeep the arms straight and give firm steady compressionsConsider endotracheal intubationAnd assisted ventilationCompressions of 4 cm depth Less will not be sufficient More may be harmfulOne cycle is 30 chest compressions and two breathsComplications of CPR:# ribs PneumothoraxHemopneumothoraxHemopericardiumAn effective CPR should be able to Restore the circulation to the brainAnd to the vital organs like the lungs and kidneysNever break the cycle of CPRExcept for giving DC shocksCPR - not a substitute for defibrillationShould not stand in the way CPR may be continued Indefinitely if indicatedGive 5 cycles of CPR or CPR for minimum of 2 minutesConsider discontinuing CPR only after 30 minutesGive adrenaline 1mg mg IV repeat 3 doses

VENTRICULAR FIBRILLATION / PULSELESS VT EM 03Arrive here fromCardiac arrest overviewMonitor showingVentricular Fibrillation/ TachycardiaAdrenaline 1 mg IV 10 ml of 1:10,000/2 mg 20 ml 1:10,000 ETFine Ventricular Fibrillation(lesser chance or correction)Coarse Ventricular FibrillationDefibrillate at 200 joules biphasic300 joules monophasicResume attempts to defibrillateGive 2 min CPR between defibrillationsLIDOCAINE 1 mg per kg IVThen 0.5mg per kg q 10 minif required to a maximum total dose of 3mg per kgPulseless Ventricular Tachycardia5 cycles of Cardiopulmonary ResuscitationConfirm A/W placementEffective oxygenation and ventilationResume attempts to defibrillateAssess rhythm only after 5 cycles/2m CPREstablish IVAssess rhythmIf Torsae des pointesMAGNESIUM IVASYSTOLE or Pulseless Electrical ActivityASYSTOLE or PEAso shock protocolResume attempts to defibrillateSinus Rhythm – OK Fine

DEFIBRILLATION EM 04Rhythm VF or Pulseless VTMaintain airway, OxygenateDefibrillation is a technique used to counter the onset of VF, the common cause of cardiac arrest, and pulseless VT, which sometimes precedes VF but can be just as dangerous on its own. In simple terms, the process uses an electric shock to stop the heart, in the hope that heart will restart with rhythmic contractions.SedatePatient is conscious and anxiousPress both buttons togetherOne electrode is placed on the right side of the front of the chest just below clavicle and the other electrode is placed on the left side of the chest just below the pectoral muscle or breast. Ensure no one touches the cotEnsure your body does not touch the cotCharge the defibrillator to chosen energyPlace both paddles in appropriate positionCheck monitor for rhythm VF or Pulseless VTIt is not effective for asystole(complete cessation of cardiac activity, ) and pulseless electrical activity (PEA). No Improvement?Cardiac arrest protocol

CARDIAC ASYSTOLE AND PEA [No shock advised] EM 05Arrive here from Cardiac arrest protocolEstablish IV line, Give 5 cycles of CPRConfirm airway placement, effective oxygenation and ventilationSearch forand treat possible causes, hypovolemia, hypoxia, hyperkalemia, hyokalemia, hypothermia, hydrogen ion acidosisTableta(Drug overdose) tamponade, tension pneumothorax, thrombosis (cardiac and pulmonary)Adrenaline 1 mg IVEndocratheal tubeAtropine 1 mg IV if PEA with rate <60Assess rhythmCardiac AsystoleVentricular FibrillationSee VF protocolConsider Sodium bicarbonateOnly if hyperkalemia

STABLE PATIENT WITH NARROW COMPLEX TACHYCARDIA EM 06AssessmentPatient stable/unstableLook for serious signs of instabilitySERIOUS SIGNSChest pain Shortness of breath Loss of conciousnessLow Blood pressure Cardiogenic shock Pulmonary edemaCongestive cardiac failureATRIAL FIBRILLATION /FLUTTERSINUS TACHYCARDIASUPRAVENTRICULAR TACHYCARDIAVAGAL COMPRESSIONSee procedureLook for and treat underlying Causes: Pain, Hypoxia, DehydrationDeteriorating serious signs or symptomsNot successful Try Digoxin + VerapamilSYNCHRONIZED CARDIOVERSIONStart at 100 joules Increase to 200, 300, 360Adenosine 6 mg IV pushRepeat the dose and Double the dose

STABLE WIDE COMPLEX TACHYCARDIA EM 07Arrive here from protocol Tachycardia OverviewMONOMORPHIC VTPOLYMORPHIC VTUNKNOWNSUPPORTIVE CARETRANSPORTSupportive CareTransportSUPPORTIVE CARETRANSPORTMAGNESIUM 1 gm IVLIDOCAINE 1 mg per kg IVThen 0.5mg per kg q 10 minif required to a maximum total dose of 3mg per kgLIDOCAINE 1 mg per kg IVThen 0.5mg per kg q 10 minif required to a maximum total dose of 3mg per kgDeteriorating symptoms or signsSYNCHRONIZED CARDIOVERSIONStart at 100 joules Increase to 200, 300, 360 TRANSPORT

BRADYCARDIA EM 08AssessmentHeart Rate less than 40 per minuteBP/Perfusion adequateSinus Bradycardia or I0 AV blockObserveNOType II second degree A V Block Or III degree Complete A V BlockNOAtropine0.5 mg q 5 minTranscutaneous Pacing if Symptoms developTemporaryTranscutaneouspacingNo response or easy reversions to CHBNot SuccessfulNOPermanent PacemakerDopamine 5-20 ug/kg/min IV

CARDIOGENIC SHOCK EM 09Assessment of ABCsOxygen 100% by mask Call for ALS team interceptEndotracheal intubation See airway management protocolPump versus rate problemIV access X 2Bradycardia with hypoperfusionSVT or VT with hypoperfusionMI with hypoperfusionAtropine 0.5mg IV pushRepeat to maximum 3 mgNormal saline 500 cc bolusSVT Narrow complexVT Wide complexSynchronized cardioversionNormal saline 500 cc bolusSTABLESTABLEDopamine IVStart at 5ug/kg/minuteAnd titrateEXTERNAL PACEMEAKERVagal manouereLidocaineDopamine IVStart at 5ug/kg/minuteAnd titrateAdenosineAdenosine TRANSPORT

CARDIAC FAILURE EM 10AssessmentHistory: MI, HTN, ASRaised JVP,Gallop, CracklesSEVERERespiratory distressCrackles throughoutOxygen saturation<92 NEAR DEATHInsufficient Respiratory driveCyanosis Dropping saturationDecreased LOC MILD/ MODERATEAble to speak sentencesCrackles base onlyOxygen saturation>92 Oxygen to maintain sat >92High flow qxygen100% OxygenNitroglycerine SL repeat q5mNitroglycerine SL repeat q5mNitroglycerine SL repeat q5mIV saline lockSalbutamol [only if wheeze]Salbutamol [only if wheeze]IV Morphine2.5-5 mgIV Morphine2.5-5mg DeterioratingIV FrusemideOnly if on diureticsIV FrusemideOnly if on diureticsDeteriorating

BRONCHIAL ASTHMA EM 11AssessmentLess than 50 yearsHistory of AsthmaEnvironmental exposureSevereDecreased a/e throughoutWith expiratory wheezeExpiratory wheezeOxygen saturation <92%Mild to moderateDecreased a/e throughoutExpiratory wheezeSpeaking in sentencesOxygen saturation >92%Near DeathDecreased level of conciousnesIneffective respiratory effectUnable to speak CyanosisOxygen saturation <92%Oxygen to maintain sat >92%Oxygen 100% BVM prnOxygen to maintain sat >92%Salbutamol 5mg nebulizationSalbutamol 5mg nebulizationEpinephrine 0.3mg SCIV Aminophylline 250 mg in 100mlSee suspected cardiac origin protocolIpratropium bromide 0.3mg aerosol IV saline LockIV Aminophylline 250 mg in 100mlSee suspected cardiac origin protocolAdenosine 6 mg IV pushRepeat the dose and Double the dose

DIABETIC KETOACIDOSIS EM 12ASSESSMENT: History and PE, RBS, Urea, S Cr, SE, Urine , CBC, ECG Blood gases, CXRDiagnostic criteria for DKARBS >250mg%, Arterial pH < 7.3m, S Bicarbonate < 15mg%, Moderate ketouriaStart IV fluid 0.9% Saline 1L per hour initally(15-20 ml/kg/hourInsulinPotassiumIV FluidsDetermine hydration statusIV RouteSC / IM routeIf Serum K+ level is <3.3 meq/LHold insulin and give K+40meq/hr2/3rd as Pot Chloride and 1/3rd as Pot phosphateHypovolemic shock:Administer 0.9% Sodiunm chloride1L / hour and or plasma expanderAdminister Regular Insulin 0.5 U /kg as IV bolusAdminister 0.3 U /kg as IV bolusAnd ½ given SC or IMCardiogenic shock: Hemodynamic monitoringAdminister Regular Insulin 0.1 U /kg as IV infusionAdminister 0.1 U /kg per hourAnd ½ given SC or IMIf Serum K= level is . 5.5meq/L do not give K+but check level every 2 hMild hypotension:Evaluate corrected serum Na levelHigh or Normal: Administer 0.45% Na clIf RBS dose not fall by 50-70mg in the 1st hourIf Serum K+ level is >3.3 meq/L but < 5.5meq/L give 20-30 meq in each liter of IV fluid2/3rd as Pot Chloride and 1/3rd as Pot phosphateDouble insulin infusionHourly until RBSFalls by 50-70mg/hGive hourly IV insulinBolus until RBSFalls by 50-70mg/hSerum Na low:Administer 0.9% Na ClDepending on hydration statusWhen Serum Glucose reaches 250mg/Dl[13.3mmol/LChange to 5% Dextrose0.45% Saline administered at 100-200ml per hour, with adequate insulin0.05-0.1 U/kg/has IV infusion or 10 U SC 2 hours given to keep glucose level between 150 and 200mg%Check chemistry every 4 hours until patient is stableLook again for precipitating causesAfter resolution of diabetic ketosis obtain blood glucoseEvery 4 hours and give sliding scale regular insulin

ACUTE ISCHEMIC STROKE EM 13AssessmentNew onset of Neurological DeficitStroke or Transient Ischemic AttackNon contrast Head CT scanAcute cerebral edema cause obtundation herniationPeaks on 2nd day but mass effect till 10th dayLarger the infarct more the cerebral edemaCan directly compress the brainstemBlood pressure to be lowered ifMalignant HypertensionConcomitant Myocardial IschemiaBlood Pressure >180/110 mmHgCare of comatose patientsRyles tube feedingAdequate calorie & fluid intakeIntravenous Mannitol 100 ml 8 hourly for 3 daysOral Glycerine 30 ml TID orally or via Ryles tubeWater restriction but avoiding hypovolemiaStart Amlodipine 2.5mg BID orTablet Nifedipine 10mg BIDTitrate to keep BP At 150/90Consider catheterizationEnsure good urine outputFrequent change of positionIntravenous rtPA 0.9mg/kg to a90mg maximumIn selected patients within 3 hours of the onsetAttention directed towards Common complications of bedridden patientsRespiratory tract infectionsUrinary tract infectionsPressure soresDVT and Pulmonary EmbolismMonitor Blood Sugar regularlyKeep RBS value below 200mg%Fever detrimental Use antipyretics as indicatedIf unmonitored, can be harmfulEven precipitate a VT or VFDo not repeat the procedureAspirin 300mg dailyThe role of Anticoagulation is uncertainSearch for evidence of cardioembolic strokeInvestigate with ECG, Chest X Ray and EchoConsider anticoagulation with PTT INR controlConsider Neuroprotective agentsGive adrenaline 1mg mg IV repeat 3 dosesOr Vasopressin 40 U IV instead of adrenalineRehabilitation of stroke patientsPhysical, speech, and occupational therapyEducation of the patient and familyPrevention of complications of immobilitySearch for risk factors for strokeHypertension, Diabetes, Smoking, DyslipidemiaAsymptomatic or symptomatic carotid stenosisRelative risk reduction with treatmentBalloon Angioplasty with Stenting is the alternativeSurgical treatment restricted to Carotid Endartectomy

ACUTE EMBOLIC STROKE EM 14AssessmentNew onset of Neurological DeficitStroke or Transient Ischemic AttackNon contrast Head CT scanAnticoagulation to keep INR ranging from 2 to 3Warfarin reduces the risk by 67%1% risk per year of a major bleeding complicationCan directly compress the brainstemNon rheumatic Atrial FibrillationChronic Obstructive Lung DiseaseEssential HypertensionMitral Valve ProlapseArtery to artery embolic strokeThrombus formation onAtherosclerotic plaque in carotidAnticoagulation also reduces risk of embolism after acute Anterior wal Q wave MI A three month course is recommendedRecent Myocardial InfarctionPost Infarction Mural thrombosisTransmural Anteroapical MIProphylactic anticoagulationIntracranial atherosclerosisIn situ thrombosis or embolizationWarfarin sodium and aspirinIntravenous Mannitol 100 ml 8 hourly for 3 daysOral Glycerin 30 ml TID orally or via Ryles tube Paradoxical embolization:Venous thromboses migrate to Arterial circulation viaCardiac Right to left shuntAtrial Septal DefectPatent Foramen OvaleUrinary tract infectionsValvular EndocarditisValvular Vegetations Multifocal symptoms and signsSmall microscopic infarcts orLarge septic infarcts brain abscessHemorrhagic InfarctsA greater degree of anticoagulation is indicated for Prosthetic valve ThrombosisCombination of antiplatelets advantageousSearch for evidence of cardio embolic strokeInvestigate with ECG, Chest X Ray and EchoConsider anticoagulation with PTT INR controlConfirmation by Trans esophageal EchocardiographyPresence of a venous source of embolusof right to left cardiac shunting Rehabilitation of stroke patientsPhysical, speech, and occupational therapyEducation of the patient and familyPrevention of complications of immobilitySearch for risk factors for strokeHypertension, Diabetes, Smoking, DyslipidemiaAsymptomatic or symptomatic carotid stenosisRelative risk reduction with treatmentBalloon Angioplasty with Stenting is the alternativeSurgical treatment restricted to Carotid Endartectomy

ACUTE HEMORRHAGICIC STROKE EM 15AssessmentNew onset of Neurological DeficitHeadache, projectile vomitingNon contrast Head CT scanHypertensive Intra-parenchymal hemorrhageSpontaneous rupture of a small penetrating arteryCommon sites are basal ganglia, putamen, thalamusSometimes the pons and the cerebellumBlood pressure to be lowered ifMalignant HypertensionConcomitant Myocardial IschemiaBlood Pressure >180/110 mmHgCare of comatose patientsRyles tube feedingAdequate calorie & fluid intakeIntravenous Mannitol 100 ml 8 hourly for 3 daysOral Glycerine 30 ml TID orally or via Ryles tubeWater restriction but avoiding hypovolemiaStart Amlodipine 2.5mg BID orTablet Nifedipine 10mg BIDTitrate to keep BP At 150/90Consider catheterizationEnsure good urine outputFrequent change of position50% of patients die<30ml Good, 30-60ml intermediate, >30ml poor Attention directed towards Common complications of bedridden patientsRespiratory tract infectionsUrinary tract infectionsPressure soresDVT and Pulmonary EmbolismMonitor Blood Sugar regularlyKeep RBS value below 200mg%Fever detrimental Use antipyretics as indicatedIf unmonitored, can be harmfulEven precipitate a VT or VFDo not repeat the procedureEvacuation of hematoma helpful only in cerebellarSub Arachnoid HemorrhageNeurosurgical intervention is necessary by craniotomy and external clipping of the bleeding vessel or aneurysmDuring this waiting period medical treatments to control blood pressure, bed rest, and a quiet environment reduce the risk of rebleed. Nimodipine is an oral calcium channel blocker, that has been shown to reduce the chance of a bad outcome, even if it does not significantly reduce the amount of angiographic vasospasm. Or by interventional radiology (neuroradiology), which employs transfemoral angiography and inserting of metal coils to stem the bleeding (which is especially useful in aneurysmatic hemorrhage). Balloon Angioplasty with Stenting is the alternativeSurgical treatment restricted to Carotid Endartectomy

ACUTE SUBARACHNOID HEMORRHAGE EM 16AssessmentSudden onset of severe headacheLethargy, coma, low back painNo focal neurological deficit in the beginningNuchal rigidity, positive Kerning signRetinal hemorrhages ( sub-hyaloid)Rebleeding 20% at two weeksVasospasm and neurological deficits (days 4-14)Blood pressure to be lowered ifMalignant HypertensionConcomitant Myocardial IschemiaBlood Pressure >180/110 mmHgCare of comatose patientsRyles tube feedingAdequate calorie & fluid intakeNon contrast CT scan headLumbar puncture: Uniformly blood stainedXanthochromia on immediate centrifugationStart Amlodipine 2.5mg BID orTablet Nifedipine 10mg BIDTitrate to keep BP At 150/90Consider catheterizationEnsure good urine outputFrequent change of positionIntravenous Mannitol 100 ml 8 hourly for 3 daysOral Glycerine 30 ml TID orally or via Ryles tubeWater restriction but avoiding hypovolemiaAttention directed towards Common complications of bedridden patientsRespiratory tract infectionsUrinary tract infectionsPressure soresDVT and Pulmonary EmbolismRuptured berry aneurysmFusiform aneurysmssecondary to atherosclerosisMycotic aneurysmResulting from septic embolismHypertensive hemorrhageArteiovenous malformationsContrast CT or MRI useful in demonstratingCerebral angiography (DSA) needed pre-surgicallyNeurosurgical intervention is necessary for Berry aneurysmTiming of surgery after SAH is controversialDepends on clinical conditionDuring this waiting period medical treatments to control blood pressure, bed rest, laxatives and a quiet environment reduce the risk of rebleed. Nimodipine is an oral calcium channel blocker, that has been shown to reduce the chance of a bad outcome, even if it does not significantly reduce the amount of angiographic vasospasm. Or by interventional radiology (neuroradiology), which employs transfemoral angiography and inserting of metal coils to stem the bleeding (which is especially useful in aneurysmatic hemorrhage). Nimodipine Dose is 60 mg PO QIDSurgical treatment restricted to Carotid Endartectomy

SEIZURES EM 17AssessmentABCs / Vital signs/ OximetryContinuos ECG monitoringPlace a soft plastic airwayAdminister oxygen by maskInsert a large bore IV lineIdeally two one being dextrose freeGlucometer <60mg%Administer Thiamine 100mg IVfolloewed by 50ml 50% dextroseLaboratory analysis:Blood sugar, Urea, CreatinineSerum ElectrolytesUrine analysis, and drug screenAntiepileptic drug levelsRBSParenteral anticonvulsants indicated if status epilepticusPatient pregnant High BP See pre-eclamsia protocolHigh BPLorazepam 0.1mg/kg at 2mg Per minute up to 4mgDiazepam 0.2mg/kg at 5mg per minute up to 10 mgORShort duration of action of These drugs necessitate maintenance anticonvulsantsPhenytoin SodiumPreferred maintenance drugLoading dose 20mg/kgWatch for arrhythmias and hypotensionBenzodiazepine infusionA preferable option in somemaintenance anticonvulsantsSee shock protocolsThe maximum rate of infusion is 50mg per minute and a large bore IV line with dextrose free fluid used to prevent precipitationRespiratory depression may require intubationAnd assisted ventilationPhenobarbitone 20mg/kg at the rate of 50mg/minute

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