Emergencies Handbook NHS

1. EMERGENCIES
HANDBOOK
First Edi on, May 2015
Dr Jessica Ball & Dr Karina Baxter

2. East Kent Hospitals Emergencies Handbook – 1st
Edition
NB: This is intended as a GUIDE only and is not extensive – always seek senior advice
if you are concerned about a patient.
Full guidance can be found on Sharepoint or as stated in the handbook
1. Anaphylaxis 1
2. Respiratory Medicine Asthma
COPD
Pneumonia
Pneumothorax
PE
2
3
4
6
8
3. Cardiology STEMI / NSTEMI
Pulmonary oedema
Bradyarrhythmias
Tacharrythmias
Atrial fibrilla on
9
11
13
14
15
4. AKI and Electrolytes Hyperkalemia
Hypercalcaemia
Hypernatraemia
Hypermagnaesmia
High phosphate
Hypokalemia
Hypocalcaemia
Hyponatraemia
Low magnesium
Low phosphate
Acute Kidney Injury
16
17
18
19
19
20
21
22
24
25
26
5. Neurology TIA
Prolonged convulsive seizures
ETOH withdrawal
Wernicke’s encephalopathy
Delirium
27
29
31
32
33
6. Endocrinology Hypoglycaemia
Diabe c ketoacidosis
35
36
7. Upper GI bleed 39
8. An coagula on 42
9. Warfarin reversal 43
10. Pain management 44
11. Sepsis 46
12. Useful numbers 47

3. Recognising anaphylaxis: Sudden onset and rapid progression of symptoms, characteristically within one hour of
exposure to speci ic antigen
ABCDE assessment
Airway: Throat and tongue swelling , stridor, hoarse voice
CALL FOR URGENT MEDICAL ASSISTANCE WITH ANAESTHETIST
Breathing: Dyspnoea, Tachypnoea, Wheeze ,Fatigue, Confusion caused by hypoxia, Cyanosis, Respiratory arrest
Circulation: Signs of shock – pale, clammy, tachycardia, Hypotension – dizziness, collapse, Decreased conscious level
or loss of consciousness, Myocardial ischaemia and ECG changes, Cardiac arrest
Skin or mucosal changes: Flushing, Urticarial, Angioedema, Pruritus, Rhinitis
Gastrointestinal: Nausea, Vomiting, Cramping, Abdominal pain
Remove trigger if possible
Oxygen - High low oxygen (using reservoir bag) – If intubated- ventilate with high concentration
using a self-in lating bag
IV ,luids - Rapid IV luid challenge (Adults: 500-1000ml; Child: 20ml/kg)
Monitor response and further doses as necessary
Stop IV colloid (this may be the cause)
Antihistamine (chlorphenamine) - after initial resuscitation
>12 years and adults: 10 mg IM or IV slowly
Steroids (hydrocortisone)-after initial resuscitation
>12 years and adults: 200 mg IM or IV slowly
Con nue observa ons: oximetry, HR, BP. DO CXR, ABG, BLOODS
INCLUDING mass cell tryptase
Cautions
Beta blockers may increase the severity of an anaphylaxis reaction and antagonise the response to
adrenaline
Patients taking tricyclic antidepressants or monoamine oxidase inhibitors should only receive 50% of
the usual dose of adrenaline, as an interaction is potentially dangerous
Patients receiving systemic anti-cancer therapy antibodies may experience during infusion related
reaction 2-24 hours post dose and 1-2% experience severe allergic reaction
1. ANAPHYLAXIS
1
Adrenaline - Should be given to all patients with life threatening features
IM adrenaline (1:1000)
Adults and children > 12: 0.5mg IM (0.5mL of 1:1000) adrenaline
Repeat the IM dose if there is no improvement at 5-minute intervals

4. Management of Acute Asthma
Classi,ication of Asthma
IF SEVERE OR LIFE THREATENING AT ANY TIME CONTACT ITU TO MAKE THEM AWARE OF
THE PATIENT
ABCDE approach. Do ABG and peak low (reduced in acute setting compared with best or predict-
ed.)
1) SUPPLEMENTARY O2
Start with 15L/min non-rebreathe mask and titrate down to maintain SpO2 ≥94%
2) Β2 AGONIST
Salbutamol nebs: 5mg repeatedly every 15-30 minutes.
3) MONITOR SIDE EFFECTS: hypokalaemia/hyperglycaemia/tachycardia/arrhythmia/tremors
4) ANTICHOLINERGICS
Ipratropium (Atrovent) nebs: 0.5mg every 6 hours
5) STEROID THERAPY
Prednisolone : 40mg orally if they can swallow
OR
Hydrocortisone 200mg IV (then 100mg QDS)
Depending on the severity steroids should be continued for 5 days.
6) IF NO IMPROVEMENT OR LIFE THREATENING FEATURES PRESENT AT THIS STAGE THEN
DISCUSS WITH A SENIOR PHYSICIAN OR ICU
7) MAGNESIUM SULPHATE
1.2-2g IV over 20 minutes
8) IV BRONCHODILATORS
There is little evidence that these will be bene icial, and are not in the BTS guidelines, however they
can be used when nebulised bronchodilators can not be used readily. Be aware, lactic acidosis will
develop within 2-4 hours in 70% of patients if used.
IV salbutamol: 5-20 micrograms/min or 250 microgram bolus over 1 minute
Moderate asthma Increasing symptoms
PEF 50-75% of best or predicted
No features of acute severe asthma
Acute severe asthma Any one of:
PEF 33-50% of best or predicted
RR ≥ 25/min
HR ≥ 110/min
Inability to complete sentences in one breath
Life threatening asthma Any one of the following with acute severe asthma:
Decreased conscious level
Exhaustion
Arrhythmia
Hypotension
Cyanosis
Silent chest
Poor respiratory effort
PEF< 33%
SpO2 <92%
PaO2<8 kPa
Near fatal asthma CO2 retention – CALL ITU
2. RESPIRATORY MEDICINE
2

5. Management of COPD Exacerbation
ABCDE assessment
Take a history and establish their baseline respiratory function. Are they on home BiPAP or home
O2? Check previous EDN’s and clinic letters. How frequently are they admitted with an exacerba-
tion? Any haemoptysis, purulent sputum?
Investigations: Arterial blood gas to assess the severity of respiratory impairment (Type I or type
II respiratory failure). Repeat after 30 minutes in seriously ill patients. Chest X-ray hyperin lated,
lat hemi-diaphragm (look for evidence of infection, pneumothorax or bullae).
If you suspect chest SEPSIS make sure you initiate the sepsis 7.
Acute exacerbation of COPD: Sit the patient up ad give them the minimum amount of O2 to main-
tain sats between 88% and 92% (Aim for PaO2 ~ 8kPa). Give salbutamol 5mg +/- ipratropium 500
microgram NEBS (driven by air leaving nasal O2 cannulae on under mask if necessary) and predni-
solone 30mg PO or hydrocortisone 200mg IV. Sputum for MC&S. Get an ABG and CXR (portable if
unwell). Use ABG results and clinical observations to guide further management.
Normal ABG (for them) continue current O2 and give regular NEBS QDS.
Worsening hypoxaemia -FiO2, repeat ABG <30 mins, assess for confusion which should prompt a
repeat ABG sooner, consider NIV, call outreach or ITU.
-CO2, retention or ¯GCS request senior help urgently; consider:
ITU input assessment
Aminophylline 5mg/kg bolus (loading dose) over 20 mins unless the patient is on oral aminophyl-
line or theophylline. Remember to check levels and keep in therapeutic range.
NIV
Prescribe antibiotics as per trust guidelines for pneumonia if the patient has increased SOB, fevers,
worsening cough, purulent sputum or local changes on CXR.
If simple infective exacerbation of COPD: Doxycycline 200mg PO STAT, then 100mg BD for 5 days.
Non-Invasive Ventilation:
BiPAP is the NIV of choice for type II respiratory failure in COPD. CPAP more commonly used for cardiogenic
pulmonary oedema.
*PLEASE FOLLOW NIV GUIDELINES
Indications for BiPAP:
Acute exacerbation of COPD with respiratory acidosis (pH <7.35), hypercapnia PaCO2 ≥6 kPa who have failed
to respond to initial medical therapy. BiPAP has been shown to reduce mortality and length of admission in
these patients.
Contact outreach and/or ITU if patient is unwell enough to require NIV
3

6. Management of Pneumonia
Symptoms – cough, purulent sputum/haemoptysis, pleuritic chest pain, shortness of breath, pyrex-
ia, confusion, anorexia.
Signs ↑ RR, ↑ temp, tachycardia, ↓ SpO2, dullness to percussion, bronchial breathing, unequal/↓ air
entry, reduced expansion, crackles on auscultation.
History:
Be sure to take a thorough history to establish cause and type of pneumonia in order to guide ap-
propriate management. Is it community acquired (most common), hospital acquired (recent dis-
charge/inpatient?), aspiration (Hx stroke/↓ GCS/oesophageal pathology/neuro history including
dementia, MS, Parkinson’s/OGD, NG tube, bronchoscopy), ventilation (ITU admission/recently on
ventilator.)
CURB 65 severity score. 1 point for each:
Confusion
Urea > 7mmol/L
Respiratory rate >30
Blood pressure (SBP <90, DBP <60)
65 or older
Score = 0-1 can go home with oral antibiotics if no other reason to be admitted. >2 see management
below.
Investigations
Bloods – WCC, U+Es, CRP, blood cultures if CURB 65 >2. Serology for atypical and viral if suspected.
Sputum – cultures if CURB65 >3 or CURB65 = 2 and not had Antibiotics.
Urine – if CURB65 >2 test for pneumococcal antigen, if >3 or suspicion test for legionella antigen.
ABG – may see ↑PaO2 (+/- ↓PaCO2 due to hyperventilation but not if tiring/COPD.)
CXR – look for focal consolidation. May have pleural effusions. May have 2° pneumothorax as result
of coughing or underlying lung disease (e.g. COPD (bullae) + coughing.)
Management
ABCDE assessment.
Sit up and give O2 as required. Give IV luids if dehydrated (likely in infection as abnormal ongoing
losses due to fever/tachypnoea). Give antibiotics, see table below.
Chest Physiotherapy
Give antibiotics as soon as possible within 1 hour of diagnosis, either in A&E or CDU, as mortality
rises with every hour of delay with antibiotics given. (See table below).
4

7. TRUST GUIDELINES
Infection First Line Penicillin Allergic/Alternative
Sepsis ?RTI/UTI Amoxicillin 1g TDS IV
+Gentamicin as per policy
Clarithromycin 500mg BD IV/PO+
Gentamicin as per policy
Community Acquired
Pneumonia (CAP)
CURB65 <2
• Evidence of consolidation on
CXR
• CXR indings and CURB65
score must be documented
-----------------------------------
CURB65 score >2
Doxycycline 200mg PO STAT
then 100mg PO BD
OR
Amoxiclillin 1g TDS PO for 5-7
days
-----------------------------------------
Amoxicillin 1g TDS IV
+ Clarithromycin 500mg BD IV
Clarithromycin 500mg PO BD
------------------------------------------
RASH:
Cefuroxime 1.5gTDS IV + Clarithro-
mycin 500mg BD IV
OR
ANAPHYLAXIS:
Levo,loxacin 500mg BD IV
Hospital Acquired
Pneumonia (HAP) <5 days
admission
Evidence of consolidation
on CXR
>5 days admission or after
ventilation
Treat as per CAP regime for 7 days
------------------------------------------
Mild HAP
Amoxicillin 500mg TDS PO + Met-
ronidazole 400mg TDS PO
Severe HAP
Co-amoxiclav 1.2g TDS IV for 5-7
days (IV to PO switch: co-
amoviclav 625mg TDS PO)
VAP:
Piperacillin/Tazobactam 4.5g
TDS IV
Treat as per CAP regime for 7 days
------------------------------------------
Clarithromycin 500mg BD PO + Met-
ronidazole 400mg TDS PO
Cefuroxime 1.5g TDS IV (rash)
OR
Levo,loxacin 500mg BD IV/PO
(anaphylaxis) for 5-7 days. If risk of
aspiration add:
Metronidazole 500mg TDS IV (IV to
PO switch option: Doxycycline 200mg
PO STAT, then 100mg BD +/- metroni-
dazole 400mg TDS PO)
Cefuroxime 1.5g TDS IV (rash) OR
Levo,loxacin 500mg BD IV/PO
(anaphylaxis)
If risk of aspiration add: Metronida-
zole 500mg TDS IV
Aspiration Pneumonia Amoxicillin 500mg TDS IV + Met-
ronidazole 500mg TDS IV
Calrithromycin 500mg BD IV + Metro-
nidazole 500mg TDS IV
5

8. Management of Pneumothorax
Management will depend on whether it is a primary or secondary pneumothorax and how big it is
and the age of the patient.
Primary pneumothorax: no underlying lung disease or known cause. Risk factors: tall, thin, male,
Marfan’s or other connective tissue disorder, recent central line, pleural aspiration or chest drain.
Secondary pneumothorax: Underlying lung disease or clear cause. Risk factors: COPD, asthma,
infection, trauma, mechanical ventilation.
Symptoms: breathlessness +/- chest pain.
Signs: ↑RR, ↓SpO2, ↓air entry on affected side, hyper resonant percussion note, may have tracheal
deviation or fractured ribs.
CXR – lung markings extending away from peripheries, pleural line away from periphery. Measure
how many cm from peripheries to guide Rx.
Treatment: Sit up and give 15L/min O2. Chest drain/aspiration as directed by BTS guidelines (See
next page.) ALWAYS USE THE PLEURAL CHECKLIST TO ENSURE THE CORRECT SIDE IS ASPIRAT-
ED/DRAINED AND PATIENT POSITIVELY IDENTIFIED.
TENSION PNEUMOTHORAX
If air trapped in the pleural space is under positive pressure (e.g. in mechanical ventilation or
trauma) then it may expand and compress/shift the contents of the pleural cavity including heart,
contralateral lung trachea. This may reduce venous return and cause circulatory collapse, rapid
deterioration and death. This is an EMERGENCY and needs immediate treatment.
The patient may be tachycardic, hypotensive, tachypnoeic with unilateral hyper-resonance and
reduced air entry. JVP may be - due to compression of vena cava causing reduced venous return,
tracheal deviation may be present.
Treatment
Sit up and give 15L/min O2. There is no time to do a CXR. Insert a large bore cannula on affected
side (grey or orange) in to the 2nd intercostal space, mid-clavicular line. Listen for a hiss and leave
it in situ.
Insert a chest drain on the same side. The air under positive pressure will come out and pressure
will reduce in the pleural cavity and the lung will re-in late. This is life saving treatment and it is
imperative that it is done as quickly as possible after tension pneumothorax is suspected.
If after inserting the cannulae there is no hiss, try and place another one or consider alternative
diagnosis.
6

9. 7

10. Management of Pulmonary Embolism
Symptoms
Shortness of breath, pleuritic chest pain, palpitations, collapse, haemoptysis, dizziness, leg pain or
swelling/erythema.
Signs
Tachycardia, tachypnoea, hypotension, ↑JVP, ↑RR, RV heave, pleural rub, pyrexia. Consider PE in all
cases of unexplained hypoxia.
Risk Factors
Malignancy, Recent critical care admission, Dehydration, Recent long haul light, Smoking, Throm-
botic disorder, Obesity, Chronic illness e.g. Crohn’s, SLE. Previous PE/DVT, First degree relative
history of DVT/PE, Pregnancy (esp. 2nd/3rd trimester), Recent immobility e.g. inpatient stay, Recent
surgery especially pevlic/ortho
Assessment
Wells Score
PE likely score >4, PE unlikely score ≤4
Assess clinical probability of PE. If you suspect massive PE the patient should be transferred to re-
sus for further management.
If PE unlikely (Wells score <4) check D-dimer. If D-dimer +ve then order immediate CTPA. If this is
not immediately available give treatment dose enoxaparin until result available to con irm or ex-
clude PE.
If PE likely (Wells score >4) then order immediate CTPA. If this is not immediately available give
treatment dose enoxaparin until result available to con irm or exclude PE.
When CTPA result is available, use this to guide further management. If PE is present, anticoagu-
late. If there is no PE, seek alternative diagnosis.
CTPA is contraindicated in the following patients:
• Patients with a contrast media allergy
• Pregnant patients or those whose risk from irradiation is high
• Renal impairment.
• In these cases opt for V/Q scan instead (on patient centre order ventilation AND perfusion
scans).
Treatment
Acute: ABCDE approach. 15 L/min O2. Mainstay of treatment is low molecular weight heparin
(enoxaparin 1.5mg/kg/day). See PE stickers for complex/variable section o drug chart. Consider
analgesia to relieve pain.
* Seek immediate senior support if patient haemodynamically unstable, consider ECHO if no time
for CTPA. Consider thrombolysis for haemodynamically unstable patient / saddle emboli.
Will need anti-coagulation for at least 6 months following acute episode as guided by senior.
Clinical signs of DVT 3
Alternative diagnosis less likely than PE 3
Heart Rate >100 1.5
Immobilisation/surgery <90 days 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Cancer 1
8

11. MANAGEMENT OF ACUTE CORONARY SYNDROMES (ACS)
Patients with chest pain suggestive of myocardial ischaemia (central or retrosternal pressure, tight-
ness, heaviness, radiating to neck, shoulder or jaw, associated with breathlessness, nausea or vom-
iting) require an immediate 12-lead ECG and medical assessment including brief history and ex-
amination. Attach a cardiac monitor to detect arrhythmias, obtain IV access and immediately take
bloods for FBC, U+Es, glucose, troponin, CK, clotting and lipids. A chest x-ray should be done, but
should not delay therapy unless suspecting aneurysm. Troponin should be repeated 12 hours after
initial onset of pain.
Management of STEMI
If SUSPECTING STEMI (even if suspected but not de,inite), discuss urgently with:
A&E senior or on-call physician
Phone the Coronary Care Unit (723- 6869/8386) and Cardiac Catheter Lab (723- 8063)
Fax ECG with a patient label to the Cardiac Catheter Lab on 723-6831
The ECG changes diagnostic of STEMI are:
· ST elevation of > 0. 2mm in leadsV1-V3 or > 0.1mm in other leads.
· Left bundle branch block that is new or presumably new, in the context of a convincing history.
1) Refer the patient immediately to Cardiology for Primary Percutaneous Intervention (1° PCI);
the target door-balloon time is within 60mins. This is done by faxing the ECG to the Cath lab
(numbers above).
2) Aspirin: 300mg soluble aspirin to be chewed at point of irst contact. Followed by Aspirin
75mg OD. If the patient is allergic to aspirin seek advice medicines information (ext 6001)
3) Clopidogrel: 300mg at point of irst contact. Followed by clopidogrel 75mg OD. If the patient
is allergic to clopidogrel seek advice medicines information (ext 6001)
(The decision to switch Clopidogrel to Ticagrelor or Prasugrel should be made by
cardiologist
4) Morphine 2.5-5mg by slow IV injection (1mg/min) followed by a further 2.5-5.0mg IV if pain
persists (and then every 4 hrs as required). Given with anti-emetic cover (eg. metoclopramide
(10mg IV over 2 minutes) or cyclizine 50mg IV).
5) Oxygen: In patients at no risk of hypercapnic respiratory failure controlled oxygen should be
administered if oxygen saturation (SpO2) is < 94%. In COPD patients, or those at risk of hy-
percapnic respiratory failure, the target is 88-92% until blood gas is available
6) Nitrites: GTN 400microgram spray sub lingually initially for pain. If continued chest pain or
pulmonary oedema, consider IV glyceryl trinitrate infusion at a dose of 1-10mg per hour if
the systolic blood pressure is >90mmHg and the patient hasn’t received a phosphodiesterase
inhibitor (eg. sildena il) within 24 hours.
7) Blood glucose management:
a. Only stop metformin if eGFR <60 and/or in cardiogenic shock
b. If Glucose >11 Start variable insulin infusion (aka sliding scale)
c. Refer newly diagnosed diabetic patients to the diabetes nurse specialist.
8) ACE inhibitors, Beta blockers and statins will be initiated by the cardiology consultant
post PCI. PCI consultant will also be responsible for anticoagulation if required
9) Arrange for an echo-cardiogram to be done within 24 hrs of admission. If there are clinical
signs of heart failure and the left ventricular ejection fraction is <40%, consider an Aldoste-
rone receptor antagonists such as Eplerenone 25mg od (contraindicated if the creatinine
clearance is <50 mL/min or potassium is >5 mmol/L). Refer to heart failure nurse via PAS
and upon discharge via eDN.
10) Gastroprotection: Either ranitidine 300mg bd or lansoprazole 30 mg od.
3. CARDIOLOGY
9

12. MANAGEMENT OF NSTE-ACS
Non ST-segment elevation acute coronary syndromes (NSTE-ACS) include unstable angina (UA)
and non ST-segment elevation myocardial infarction (NSTEMI).
Patients with NSTE-ACS may complain of rapidly worsening, prolonged and increasingly frequent
episodes of cardiac chest pain, of cardiac pain occurring at rest, or of pain of recent onset occurring
with trivial provocation.
ECG changes: The ECG changes diagnostic of NSTE-ACS are:
· Symmetrical deep T wave inversion ≥ 2 mm.
· Transient ST elevation
· Deep T wave inversion V1-V4/LAD syndrome
· Persistent ST depression ≥1 mm
If normal or equivocal ECG, with a convincing history and a troponin rise after 12 hours, consider
treatment as NSTEMI. Seek senior advice if uncertain.
NOTE: always repeat ECG if the patient’s symptoms change or if the initial ECG is non-diagnostic
but clinical suspicion remains high.
1) Aspirin 300mg on admission (unless previously taking aspirin, or aspirin contraindicated),
and 75mg daily thereafter.
2) Clopidogrel 300mg followed by clopidogrel 75mg od.
3) Morphine 2.5-5.0mg for continued pain by slow IV injection and repeat if pain persists. To
reduce the likelihood of vomiting, give either metoclopramide (10mg IV over 2 mins) or cy-
clizine (50mg over 3 mins).
4) Controlled oxygen therapy if appropriate (see STEMI guideline).
5) Anticoagulation: Enoxaparin s/c 1mg/kg BD (review dose poor renal function)
6) ACE inhibitors: Consider in all patients with NSTEMI except those with renal failure or hypo-
tension. Ramipril can be started at a dose of 1.25mg ON. Dosage can be slowly titrated up-
wards, taking care to avoid a fall in BP or reduction in renal function. Other maintenance
agents include lisinopril and perindopril
7) Beta-blockade recommended for all patients except those with heart failure requiring thera-
py, second or third degree heart block, cardiogenic shock, allergy/hypersensitivity to β-
blockers
8) Statins and lipid-lowering agents: All patients should be started on Atorvastatin 40mg ON
titrated to 80mg before discharge. Reduce dose or use Pravastatin 40mg od in patients re-
ceiving interacting drugs (clarithromycin, cyclosporin, protease inhibitors, diltiazem, vera-
pamil).
9) Blood glucose management: Patients with diabetes mellitus and/or a blood sugar of >11
should be started on IV insulin (see STEMI section)
10) Nitrites: Intravenous GTN can be given for continuous chest pain or pulmonary oedema (see
STEMI sections for dose and contra-indications)
11) Aim for cardiac catheterisation within 72 hours (more urgent if sudden drop in BP) This will
be guided by cardiologist. Relevant patient referrals should be faxed.
12) Gastroprotection
10

13. Management of Pulmonary Oedema
Signs and symptoms: SOB, orthopnoea (needing to sleep on more pillows), frothy sputum,
tachypnoea, fine inspiratory crackles (these are all very non-specific so keep a wide DDx in mind.)
Inves ga ons:
• Bloods: FBC (anaemia/infec on?), U&Es (renal func on), CRP, (BNP<100 = normal, BNP 100-
400 = some degree of HF likely, >400 = 95% chance of heart failure)
• Chest X-ray – cardiomegaly, upper lobe diversion, bat wing alveolar oedema, Kerley B lines
• ABG – ?hypoxia (DDx COPD?)
• ECHO – Poor LV func on, ↓ejec on frac on. Check pa ent centre, old EDNs and EPR for old
ECHO reports.
• ECG – may show arrhythmia, acute STEMI, old infarcts, LV hypertrophy or strain. Normal
ECG makes heart failure unlikely.
Acute treatment: Sit up and give O2 to maintain SpO2 >94%. If severe call ITU ASAP as input may be
needed. Monitor obs including HR, RR, BP and SpO2 whilst giving 40-120mg IV furosemide (start at
40mg and work up) +/- diamorphine 1mg boluses IV (up to 5mg). Watch RR and SpO2 as can cause
resp depression. Further management should be guided by BP;
• Systolic BP >100 – give 2 sprays of sub-lingual GTN (400mcg per dose) followed by IV GTN
infusion, star ng at 4mg/hour and increasing by 2mg/hour every 10 minutes usual range 4-
10mg/hour. Aim to keep systolic BP >100.
• Systolic BP <100 (unless BP normal for them. Ask pt, heart failure book, old EDNs, GP rec-
ords etc.)– the pa ent may be in cardiogenic shock. Call ITU as inotropes usually required if
in cardiogenic shock. Do NOT give nitrates.
If no improvement give furosemide up to 120mg total and consider CPAP. Insert catheter for fluid
balance +/- CVP monitoring. Call outreach/ITU.
• Don’t stop B blockers in pa ents already taking them unless heart rate <50bpm.
• If usually on diure cs, give usual dose but IV e.g 1mg bumetanide = 40mg furosemide IV.
• Once condi on stabilised start or restart B blockers in hospital.
• Offer ACEi or ARB if intolerable side effects in those with acute heart failure and ↓LVEF.
Offer aldosterone antagonist if ACEi or ARB not tolerated.
CPAP – applica on of con nuous posi ve airway pressure prevents alveolar and small airway
collapse. The pa ent must s ll ini ate a breath and have sufficient muscular power to inhale and
exhale. Outreach will organise CPAP for pa ent.
Indica ons
• Cardiogenic pulmonary oedema – must be authorised by senior physician.
Contraindica ons
• ↓GCS
• Cardio/resp arrest
• Exacerba on of COPD or asthma/SOB secondary to pneumonia
• Recent upper GI or cranio-facial surgery
• Facial/airway burns
• Aspira on risk/excess bronchial secre ons.
11

14. Ongoing management:
Daily weights
Fluid balance chart
? fluid restric on if heart failure (1.5L/day)
document LV func on with ECHO and op mise Rx of heart failure if present (If no ECHO in last 12
months needs inpa ent ECHO)
Op mise heart failure medica on
Monitor renal func on
12

15. 13

16. 14

17. Management of Atrial Fibrillation
Symptoms and signs – palpitations, shortness of breath, dizziness/lightheadedness, fatigue, chest
pains, irregularly irregular pulse (may be tachycardic), hypotension if CVS compromise, signs of
concurrent precipitating disease e.g. PE, thyroid disease, infection/sepsis.
Risk factors - Increasing age, ischemic heart disease, mitral and other valve disease, dilated left
atria, alcohol intoxication/withdrawal, drugs such as cocaine/amphetamines, acute illness.
Investigations – ECG (absent p waves, irregular rhythm (usually narrow complex unless aberrant
conduction), TFTs, FBC, U+Es, CXR (pulmonary oedema, pneumonia, cardiomegaly), ECHO (LV
structure/function, valvular lesion).
Treatment
Haemodynamic compromise – resuscitate/treat shock, give high low O2. Call for senior help. Gain
IV access. The patient may need DC cardioversion. If this is not successful then amioderone 5mg/kg
over 20 minutes may be given with ECG monitoring +/- further cardioversion. Chronic AF is unlike-
ly to cause compromise so do not shock but do consider other causes of compromise.
Haemodynamically stable
Treat obvious precipitants in new onset AF (e.g. infection, electrolyte abnormalities.) This may be
all that is needed for AF to revert to sinus rhythm as long as the patient remains monitored and sta-
ble.
Rate control
Controlling the heart rate reduced risk of heart failure and reduces cardiac metabolic demand. Use
beta blockers (cardio-selective) such as bisoprolol, metoprolol or atenolol or rate limiting calcium
channel blocker such as diltiazem (more effective than verapamil). Be cautious not to use a cardio-
selective B blocker in combination with non-dihydropyridine calcium channel blocker such as vera-
pamil or diltiazem due to risk of complete heart block. Digoxin can be added but should not be used
as irst line therapy unless in sedentary elderly, co-existing heart failure and those in whom AF is
unlikely to revert to sinus rhythm (e.g. elderly, established AF, mitral valve disease, dilated left atri-
um).
Rhythm control
Younger patients and those with AF onset <48 hours may be suitable for cardioversion. If no struc-
tural/ischemic heart disease lecainide may be used in those with heart disease amiodarone should
be used. DC cardioversion may also be used if chemical cardioversion is unsuccessful. Maintenance
of sinus rhythm can be achieved using B-blockers or sotalol, lecainide or amiodarone if BB not tol-
erated or not effective (Sotalol and lecainide not suitable in those with structural heart disease).
Anticoagulation:
In patients whom rate control is used assess for risk of stroke and appropriate choice of
anticoagulation using the CHA2DS2VASc score*:
*A score of 0 points indicated low
risk and anti-coagulation may not be
required, a score of >1 indicated
moderate risk and patient may re-
quire anti-coagulation with aspirin
or other anti-platelet and a score or
>2 indicates intermediate/high risk
and anti-coagulation with warfarin
or NOAC should be considered.
CCF 1
HTN 1
Age >75 2
Diabetes 1
Stroke / TIA 2
Vascular disease 1
Age 65-75 1
Sex category Female 1
15

18. MILD
K⁺ 5 - 5.9 mmol/L
SEVERE
K⁺ > - 6.0 mmol/L
EMERGENCY MANAGEMENT OF
HYPERKALAEMIA
1. Repeat K⁺ within 6 hours if unwell then daily if
stable.
2. Review medica ons.
3. In ‘well’ pa ents with CKD refer to NICE CKD
guidelines.
ASSESSMENT
-ABCDE and EWS
-CONSIDER CAUSE: AKI, medica ons, digoxin
toxicity, metabolic acidosis, adrenal crisis,
rhabdomlyolsis, trauma, tumour lysis syndrome,
burns
PREVENT FURTHER K⁺ ACCUMULATION
-Medica on Review: ACEi, ARBs, K⁺ sparing diu-
re cs
-Low K⁺ diet: avoid bananas, crisps, fruit juice,
chocolate. Die cian review.
1. ECQ before treatment
2. CARDIAC MONITOR if K⁺ > 6.5 mmol/L or acute ECH
changes
If K⁺ > mmol/L do step 3 if < 7.0 do step 4
3. PROTECT THE HEART if K⁺ > 7.0 mmol/L or acute ECG
changes
-Calcium Gluconate 10% 10 ml IV over 3-4 mins
-Repeat every 10 mins if ECG changes persist to max
dose 50mL
4. EARLY SENIOR REVIEW & ESCALATION
-Medical / Renal SPR assessment
-Inform outreach
-Discuss escala on with renal and ITU team
-Consider dialysis early
5. MOVE K⁺ INTO CELLS
-10 units Actrapid in 50 mL 50% glucose via syringe
driver over 15-30 mins
-Monitor blood glucose for 6 hours every half hour for
2 hours then hourly
-Do not use 50% Glucose in DKA
-Adjunct nebulised Salbutamol 2 x 5mg nebs back to
back
FAILURE OF RESPONSE TO TREATMENT
K⁺ > 6.5mmol/L or acute ECG changes persist or
rebound within 4 hours:
- Liaise with Renal team and ITU
- Dialysis
- No cross site transfer unless consultant to
consultant agreement
K⁺ 6 -6.5mmol/L and no acute ECG changes:
- con nue to check K⁺
- Repeat insulin and salbutamol up to 3 x in 24
hours
MONITORING K⁺
- Send a repeat K⁺ ASAP but do not delay treatment
- Repeat K⁺ 1, 2, 4, 6 and 24 hours aLer treatment
16
4. ELECTROLYTES

19. High Calcium – Ca++ (reference range 2.2 – 2.6 mmol/L)
Adjusted calcium = serum calcium + 0.02 (40 – serum albumin)
Causes:
Drugs e.g. calcium resonium, thiazides, oestrogens, androgens, tamoxifen, lithium, supplements -
calcium, vitamin D, vitamin A.
Hyperparathyroidism (cause in 50% of patients), multiple myeloma/ malignancy, dehydration.
Symptoms:
Nausea and vomiting, constipation, abdominal pain, confusion, depression, weight loss, tiredness,
weakness, polydipsia, hypotension, arrhythmias.
Emergency Treatment:
Rehydrate with 4-6 litres 0.9% NaCl over 24 hrs (reduce volumes in CCF and elderly
patients to avoid luid overload).
And
Forced diuresis with IV furosemide to maintain adequate urine output (200-300ml/hr)
increasing Ca++ loss
Monitor electrolytes and creatinine, correct other abnormalities (K+, Mg++).
Recheck serum calcium & if still elevated give pamidronate.
N.B. Check renal function and PTH before initiating pamidronate.
The total dose may be administered as a single infusion or as multiple infusions over 2-4 consecutive
days.
Max rate: 60 mg/hr.
Caution in renal impairment: max rate 20mg/hr.
Serum levels begin to fall within 24 – 48 hours but can take up to 5 days to have a maximal effect.
Dose can be repeated after 4 – 5 days.
Moderate
Hypercalcaemia
> 3.0 mmol/L IV - rehydrate,
diuresis, pamidronate
Severe Hypercalaemia > 3.4 mmol/L IV - rehydrate, diuresis, pamidronate
Adjusted Ca++
(mmol/L)
Pamidronate Total Dose (usually given in 0.9% NaCl). Max concentration
60 mg/250 ml
2.7 – 3.0 15 mg in 100 ml or 30 mg in 250 ml over 30 mins
3.0 – 3.5 30 mg in 250 ml over 30 mins or 60 mg in 250 ml over 1hr
3.5 – 4.0 60 mg in 250 ml over 1 hr or 90 mg in 500 ml over 2 hrs
> 4.0 90 mg in 500 ml over 2 hrs
17

20. High Sodium – Na+ (reference range 133 – 146 mmol/L)
Causes:
Drugs e.g. mineralocorticosteroids.
Excessive luid loss, diabetes insipidus, osmotic diuresis (hyperglycaemia), primary aldosteronism,
dehydration & iatrogenic use of saline.
Symptoms:
Intense thirst, altered mental status, lethargy, irritability, seizures, restlessness, muscle twitching,
fever, nausea, hypotension, tachycardia.
Treatment:
Treat underlying cause.
Amount of luid de icit should be estimated clinically and this is not covered in this guideline. Fluid
replete hypernatraemia is rare. Oral hydration with water when possible as part of management
plan.
Only if hyperglycaemic rehydrate with IV 0.45% NaCl until normoglycaemia is achieved.
Otherwise rehydrate IV with 5% glucose.
Nasogastric tube hydration with water may also be appropriate and 5% glucose subcutaneously
may be better than nothing at all.
Correction of severe hypernatraemia should aim at being no more than a decrease in serum Na+ of
0.5 mmol/litre/hour.
Mild hypernatraemia >146 mmol/L and no
major symptoms
Treat cause , oral hydration +/- IV 5%
glucose
Severe hypernatraemia >155 mmol/L and
major symptoms
Treat cause and either IV 5% glucose or if
hyperglycaemic 0.45% NaCl
18

21. High Magnesium – Mg++ (reference range 0.70-1.00 mmol/L)
Mg++ levels often follow same trend as Ca++ and K+
Causes:
Drugs: magnesium products in renal impairment, picolax.
Acute kidney injury, haemodialysis with hard water.
A special case is iatrogenic high magnesium during therapeutic treatment. Protocols exist for
monitoring for this complication for example in premature labour and also see low magnesium
section of this booklet.
Symptoms:
Usually asymptomatic unless > 2.50 mmol/L. Absent patella re lex usually irst sign of toxicity,
followed by nausea and vomiting, muscle weakness, impaired consciousness, neuromuscular
transmission and cardiac conduction.
Treatment:
Rarely required
Treat underlying cause
Calcium gluconate injection can be used to treat Mg++ toxicity if not hypercalcaemic.
High Phosphate (reference range 0.80 – 1.50 mmol / L)
Causes:
Kidney disease (CKD stage 3b, 4 and 5), hypervitaminosis D, hypoparathyroidism or pseudohy-
poparathyoidism, hypersecretion of growth hormone.
Symptoms:
Rarely symptomatic.
Treatment:
Calcium or non-calcium based phosphate binders if associated with renal failure. The timing of
these binders in relation to food depends on the type of binders. Discuss with renal team/
pharmacy for management.
19

22. Low Potassium K+ (reference range 3.5 – 5.3 mmol/L)
Causes:
Drugs e.g. loop or thiazide diuretics, beta 2 agonists, insulin, amphotericin, gentamicin, cortico-
steroids, theophylline
.
Vomiting, diarrhoea, severe burns, low Mg++.
Symptoms:
Muscle weakness, constipation, abdominal discomfort, depression, confusion, arrhythmias.
Exacerbates digoxin toxicity. Reduces effectiveness of anti-arrhythmic drugs.
Emergency Treatment:
Caution if using K+ supplements in renal impairment or with potassium sparing diuretics/ACEi.
Oral
Sando K (effervescent, 12 mmol/tab) 2 tds for 2-3 days.
OR
Kay-Cee-L liquid (1 mmol/ml) 20 ml tds for 2-3 days.
OR
Slow-K (MR: 8 mmol/tablet) 2 tds/qds for 2-3 days but is very irritant to stomach. Use only if
intolerant to above.
Intravenous
80-100 mmol/day.
0.9% NaCl preferred to 5% glucose.
Use ‘ready-made bags’ - always administer via pump.
Rate
10 mmol/hr - without ECG monitoring
20 mmol/hr - with ECG monitoring
40 mmol/hr – emergencies only with ECG monitoring.
Maximum concentration peripherally 40 mmol/L.
Exceptionally via large peripheral vein 80 mmol/L (irritant to veins).
Higher concentrations must always be given centrally.
Mild hypokalaemia 2.5 -3.4 mmol/L and
asymptomatic
Oral
Severe hypokalaemia <2.5 mmol/L or symptoms IV
20

23. Low Calcium Ca++
(corrected calcium reference range 2.2 – 2.6 mmol/L)
Corrected calcium = serum calcium + 0.02 (40 – serum albumin)
Causes:
Hypoparathyroidism, hypomagnesaemia, malignancy, rhabdomyolysis, kidney disease, acute
pancreatitis, septic shock, vitamin D de iciency, over-hydration.
Increased serum phosphate complexes with serum Ca++ leading to reduced Ca++.
Symptoms:
Tetany, paraesthesia, neuromuscular excitability, carpopedal spasm, seizures.
Emergency Treatment:
Correct Ca++ before H+ in metabolic acidosis.
Administration of Ca++ can potentiate digoxin toxicity.
Correct low Mg++ if present.
Check PTH before starting treatment.
Oral
Sandocal 1000 (25 mmol/tab) 1 od – bd.
Best between meals: chelates with dietary phosphate.
Intravenous
Give 1) Calcium gluconate 10% - 10 ml (2.25mmol) over 5-10 mins.
Repeat as needed.
Then 2) Calcium gluconate 10% - IV infusion of 40 ml (9 mmol) diluted in 100 ml 5%
dextrose or 0.9% NaCl over 1 hour. Until Ca++ returns to normal.
Need to monitor potassium and magnesium.
Mild hypocalcaemia >1.6 and < 2.0 mmol/L and
asymptomatic
Oral
Severe hypocalcaemia < 1.6 mmol/L or severe symp- IV
21

24. Low sodium Na+ (reference range 133 – 146 mmol/L)
Important to determine whether caused by low body Na+ or too much luid by
Clinical assessment
Measure plasma osmolality (to exclude pseudohyponatraemia) & urine osmolality and sodium
to establish renal losses
Assess volume status
Determine whether acute (developed within 48 hours) or chronic hyponatraemia
Use diagnostic algorithm:
Hypovolaemia: ↓Total body water (TBW) + ↓↓ Total body Na (TBNa).
If Urine Na+ > 20 mmol/L then possible causes are thiazide diuretic excess, mineralocorticoid
de iciency, salt-losing nephropathy, bicarbonaturia with renal tubular acidosis and metabolic
acidosis, ketonuria or osmotic diuresis.
Hypovolaemia: ↓ TBW + ↓↓ TBNa.
If Urine Na+ < 20 mmol/L then possible causes are vomiting, diarrhoea, burns, pancreatitis and
trauma.
Euvolaemia: no oedema, ↑TBW + ↔ TBNa.
Urine Na+ > 20 mmol/L then possible causes are glucocorticoid de iciency, hypothyroidism,
stress, postsurgery, medications e.g thiazide and loop diuretics, potassium-sparing diuretics,
SSRIs, amitriptyline, carbamazepine or SIADH.
Hypervolaemia: ↑↑TBW + ↑TBNa.
If urine Na+ > 20 mmol/L then possible causes are acute or chronic kidney failure.
Hypervolaemia: ↑↑TBW + ↑TBNa.
If urine Na+ < 20 mmol/L then possible causes are nephritic syndrome, cirrhosis, cardiac failure.
Accurate diagnosis is key to proper management. If necessary endocrinology should be consult-
ed prior to initiating therapy.
Symptoms:
Depend on level and rate of onset. > 125 mmol/L, symptoms rare.
< 125 mmol/L predominantly neuropsychiatric.
General principles for treatment: please consult endocrinology:
Correct hyperglycaemia if present
Oral salt replacement very rarely appropriate
Treat acutely if acutely acquired (last 48 hours) and more slowly if chronically acquired. Heat
stroke is a special case.
Chronic asymptomatic, hypervolaemic
Fluid restriction to 0.5 – 1L/day
Consider furosemide 40 – 80 mg IV or oral daily to remove excess water.
Monitor K+ depletion.
Chronic asymptomatic, euvolaemic
Fluid restriction to 0.5 – 1L/day
SIADH - (urine osmolarity > 100 mosmol/kg in presence of a dilute plasma & random urine Na+
> 20 mmol/L)
Identify cause of SIADH and treat/remove.
If Na+ 125-132 mmol/L: Fluid restriction for 3-4 days.
Acute hyponatraemia < 120 mmol/L with symptoms 1.8% NaCl IV
Chronic Hyponatraemia <125 mmol/L and asymptomatic Determine cause
22

25. If no improvement and asymptomatic, consider demeclocycline up to 300 mg bd but note takes 3-4 days to
work & requires monitoring of renal function and for photosensitivity
If Na+ 115-125 mmol/L - restrict luids to 0.5-1L/day
If Na+ <115 or <125 mmol/L and symptomatic or non-responsive to luid restriction for 3 days then use
Tolvaptan only with consultant endocrinologist recommendation.
Acute, symptomatic, Na < 120 mmol/L:
Aim to raise serum Na+ by no more than 0.5 mmol/litre/hour.
Correct K+ de iciency.
1.8% NaCl IV infusion until serum level reaches 125 mmol/L and patient is asymptomatic. Max 500 ml of
1.8% over 2 hours (consider ITU admission).
23

26. Low Magnesium Mg++
(reference range 0.70- 1.00 mmol/L)
Mg++ levels follow same trend as those of Ca++ and K+
Causes:
Drugs e.g. diuretics, alcohol, aminoglycoside antibiotics, PPIs.
Diarrhoea, extensive bowel resection, acute pancreatitis, severe malnutrition, diabetic ketoaci-
dosis, phosphate depletion, long-term TPN – refeeding syndrome (see trust policy), alcoholism.
Symptoms:
Neuromuscular hyperexcitability including: irritability, tremor, paraesthesia, seizures, tetany,
arrhythmias.
Emergency Treatment:
Check and correct other electrolyte de iciencies.
Oral
First choice - Magnesium L Aspartate 10mmol Mg++ per sachet.
1 sachet bd
Dissolve in 200ml water.
Not recommended where luid load is signi icant.
Second choice - Magnesium glycerophosphate 4 mmol tablets 1-2 tds, (Unlicensed).
Dose limiting side effect – diarrhoea (give with or after food).
Care in renal failure and hyperphosphataemia.
Intravenous
8mmol Mg+ + in 250ml 0.9% NaCl or 5% glucose over 4 hours, up to 20 mmol Mg+ + in minimum
50 ml 0.9% NaCl or 5% glucose over at least 2.5 hours or 40 mmol Mg++ in minimum 100 ml
over at least 5 hours, daily for up to 5 days & measure electrolytes: Mg++ & Ca++ (allows for uri-
nary loss). N.B licensed dose is 20mmol Mg++ in 1L over 3 hrs.
Magnesium Sulphate 50%, contains 2 mmol Mg++ (0.5g)/ml.
Contra-indicated in AV block and severe bradycardia, caution in renal failure (reduce dose to
lower range above).
If symptoms severe e.g. serious arrhythmias (especially if hypokalaemic), 8 mmol (2 g) over 10-
15 mins. Repeat if necessary. Monitor deep tendon re lexes at 15 minutes and continuous ECG.
Mild – moderate hypomag- 0.40 – 0.69 mmol/L and asymp- Oral
Severe hypomagnesaemia <0.40 mmol/L or symptomatic IV
24

27. Low Phosphate (reference range 0.80 – 1.50 mmol/L)
Causes:
Drugs: phosphate binding preparations.
Vitamin D de iciency, chronic diarrhoea, hyperparathyroidism, metabolic or respiratory acidosis,
renal transplant, refeeding syndrome – see nutrition guidelines for treatment advice.
Symptoms:
Rarely symptomatic, may affect calcium metabolism. Symptoms may include muscle weakness,
anorexia, seizures, haemolytic anaemia. Hypoxic respiratory failure if severe
Treatment:
Oral
Phosphate Sandoz 4-6 tabs daily in divided doses with plenty of water (diarrhoea is a dose limiting
side effect).
Each tablet: 16.1 mmol phosphate, 20.4 mmol Na, 3.1 mmol K.
Intravenous – for severe or if oral treatment not suitable.
Addiphos 9 – 18 mmol phosphate in 250ml(9mmol) – 500 ml (18mmol) 5% glucose over 6 – 12
hours via peripheral IV line (0.9% NaCl can be used).
20ml vial contains Phosphate 40 mmol (2 mmol/ml)
Sodium 30 mmol (1.5 mmol/ml)
Potassium 30 mmol (1.5 mmol/ml).
Phosphate Polyfusor 50mmol in 500ml can be used for high dose regime when the calculated
phosphate requirement is 50mmol.
This may be administered undiluted via peripheral line over 12 – 24 hours.
Each 500ml polyfusor contains 50 mmol phosphate,
81 mmol sodium,
9.5 mmol potassium
Extreme caution with high Ca++ because tissue calci ication more likely & can cause hypotension,
organ failure & acute kidney injury.
Low phosphate < 0.65 mmol/L and symptomatic Oral or IV
25

28. Management of AKI
Ins tute in all pa ents with a 1.5 X rise in crea nine or oliguria
(0.5mls/kg/hour) for >6 hours
This is a medical emergency!
Full set of physiologically observa ons
Assess for signs of shock/hypoperfusion
If MEWS triggering give oxygen, begin resuscita on and contact cri cal care
outreach team
Fluid therapy in AKI
If hypovolaemic give bolus fluids (e.g. 250-500mls) un l volume replete with regular review of response.
If the pa ent is euvolaemic give maintenenance fluids (es mated output plus 500mls) Assess heart rate, blood
pressure, jugular venous pressure, capillary refill (should be <3 secs), conscious level.
Middle grade review if >2 litres filling in oliguria.and set daily fluid target.
Monitoring in AKI
Do arterial blood gas and lactate if venous bicarbonate is low or evidence of severe sepsis or
hypoperfusion. at least daily while crea nine rising.
Measure daily weights, keep a fluid chart and perform a minimum of 4 hourly observa ons.
Consider inser on of urinary catheter and measurement of hourly urine volumes.
Measure urea, crea nine, bone, other electrolytes and venous bicarbonate
Perform regular fluid assessments and check for signs of uraemia.
Inves ga on of AKI
Urine dips ck. If proteinuria is present perform urgent spot urine protein crea nine ra o (PCR). USS should be per-
formed within 24 hours unless AKI cause is obvious or AKI is recovering Check liver func on (hepatorenal), CRP and
CK (rhabdomyolysis). If platelets low do blood film/LDH/Bili/re cs (HUS/TTP).
If PCR high, consider urgent Bence Jones protein & serum free light chains.
Inves gate the cause of all AKI unless mul -organ failure or obvious precipitant or within 6 hours if obstruc on with
infec on (pyonephrosis) is suspected
Suppor ve AKI care
Treat sepsis - in severe sepsis intravenous an bio cs should be administered within 1 hour of recogni on.
Stop an -hypertensives if rela ve hypotension. If hypovolaemic consider stopping diure cs.
Stop NSAID/ACE/ARB/meNormin/K-sparing diure cs and review all drug dosages. Give proton pump inhibitor and
perform diete c assessment. Avoid radiological contrast if possible. If given follow prophylaxis protocol.
Causes
Sepsis and hypoperfusion, Toxicity (drugs/contrast), Obstruc on, Parenchymal kidney disease
(acute GN) 26

29. Management of TIA
Following a TIA:
• The overall risk of stroke is approximately 10-11% in the first 7 days
• In high risk individuals the risk of stroke is 30% in the first 7 days, andis greatest in the first
48hrs.
• Pa ents with a clinical diagnosis of suspected TIA should be prescribed Aspirin 300mg and be referred to
the TIA clinic on the referral formaSached immediately (including weekends and evenings)
• Pa ents with more than one definite TIA in the same week should be admiSed to the Stroke Unit
• High risk TIA pa ents (ABCD score ≥ 6) should be admiSed to the StrokeUnit; with a view to evoking the
thrombolysis pathway should they developpersistent symptoms (i.e. > 10mins)
• All pa ents taking Warfarin, need an emergency CT head even if INR innormal range.
• Remember TIA is a diagnosis which may only be made in retrospect and ifthe pa ent s ll has symptoms
when you see them they are to be classified asa stroke (even if the symptoms are rapidly improving) and
treated as perthe stroke pathway
Management Targets
Score ≥ 6 Immediate Aspirin, admit to the Stroke Unit
Score 5- 4 Immediate Aspirin, very urgent TIA clinicassessment Score 1-3 Immediate Aspirin,
urgent TIA clinic assessment (<7days)
ABCD Score
A -
B -
Age > 60
Blood pressure, systolic >140
And/or diastolic >90
Score
1
1
C -
Clinical features
- Unilateral weakness
- Speech disturbance, noweakness
- Other
2
1
0
D -
Dura on of symptoms >60
(in minutes) >10-59
<10
2
1
0
D - Diabetes 1
5. NEUROLOGY
27

30. ALGORITHM FOR MANAGEMENT OF TIA
Sudden, all symp-
toms occur at
once: may worsen
or get better
Symptom On set
Gradual,
progressive
Consider:
Epilepsy
Migraine
Cardiac problems
Positive Symptoms
• Shaking
• Fitting
• Disturbed, not loss of Visual field
• Dizzy, light headedness
• Confusion
• Black outs
• Vertebrobasilar eg.
• Diplopia
• Dysarthria
• Crossed sensory signs
• Facial numbness
• Facial Weakness
• Mal co ordination
Seek a further opinion
ABCD2 score ≥6
Transient Nega ve
• Caro d eg.
• Hemiplegia
• Hemianopia Dysphasia
If occurring alone, the following may
not suggest a TIA, and require sup-
por ng
• Ver go
• Balance loss
• Dysarthria
No
Immediate referral (Faxed)
To TIA Clinic:
WHH: 01233 616009
KCH: 01227 868612
QEQM: 01843 234377
Prescribe Aspirin 300mg
Prescribe Aspirin 300mg
Admit to Stroke Unit, and prepare to
evoke the thrombolysis pathway if
persistent symptoms return (ie. >10
mins)
Diagnosis Confirmed by
Stroke Team
Yes
Yes
Score
A: Age > 60 1
B: Blood Pressure
Systolic > 140 or diastolic > 90 1
C: Clinical Features
Unilateral weakness 2
Speech disturbance without weakness 1
Other symptoms 0
D: dura on >60mins 2
10-59 1
<10 0
Diabetes 1
ABCD²
MRI DWI with Contrast Enhanced MRA
(consultant stroke physician request)
28

31. If fitting for
> 5mins:
First choice:
•IV Lorazepam; Usual dose bolus 2 to 4mg (maximum rate 2 mg/min). If necessary
repeat up to a total maximum dose of 0.1mg/kg.
•IV Diazepam; Usual dose 5 to 10mg titrate for effect, up to 20 mg if necessary. Do
not give too fast to avoid respiratory depression (maximum rate 5mg/min).
Diazepam is rapidly redistributed and may accumulate with repeated dosing.
If IV difficult/not possible:
•Buccal Midazolam; Usual dose 10mg (Caution: Give 5mg in the elderly or pa-
tients less than 50kg). Repeat dose once after 10 minutes if necessary.
If buccal preparation not available use 10mg/2ml injection administered via buccal route (if
available).
If IV and buccal not possible:
•IM Midazolam; Usual dose 10mg (Caution: Give 5mg in the elderly or patients
less than 50kg). Repeat dose once after 10 minutes if necessary. (If 10mg/2ml is
available)
If IV, buccal and IM not possible:
•Rectal Diazepam; Usual dose 10mg (Caution: Give 5mg in elderly patients or pa-
In-Hospital Emergency Drug Management of Convulsive Status Epilepticus inAdults
See page 2 for essential parallel generalmeasures
STEP 1:
Benzodiazepine
If seizures stop, recurrence rate is high; the majority of patients need an intravenous stage 2
anti- epileptic drug (see below for doses) to prevent further seizures.
If no response to step 1
WITHIN 10 MINUTES
move to step 2
Step 2 antiepileptic drug administered IV & inform anaesthetist/neurointensivist
See loading dose proformas for administration guidance
If no specific contraindication or clear preference for alternative:
Phenytoin; 18mg/kg (range 15 to 20mg/kg); maximum rate 50mg/min. Infuse into large or cen-
tral vein (with filter if diluted) with ECG & BP monitoring (caution hypotension). Check concomi-
tant drugs (phenytoin is an enzyme inducer – the effect of enzyme induction on half life of affected
drugs is not immediate). For patients already on regular phenytoin see note on page 2* before
administering.
OR
Levetiracetam; 30mg/kg (range 20 to 70mg/kg). Infuse over 15 minutes; no interactions; good
side-effect profile in this setting but comparative efficacy remains to be established; renal excre-
tion. OR
Sodium Valproate; 30mg/kg (range 15 to 30mg/kg); infuse over 5 minutes
Contraindicated in mitochondrial disease & status of unknown cause in young people. Caution:
in pregnancy or acute liver failure where an alternative is preferable. Check concomitant drugs
(valproate is an enzyme inhibitor, with immediate effect on half life of other drug if affected).
OR
Phenobarbital; 10mg/kg (range 10 to 15mg/kg); maximum rate 100mg/min. Monitor BP, ECG
& respiratory function (Caution: respiratory depression may occur – only give if respiratory sup-
port can be provided). Check concomitant drugs (Phenobarbital is an enzyme inducer – the effect
of enzyme induction on half life of affected drugs is not immediate).
STEP 2:
Give anti-epileptic
&
INFORM
ANAESTHETIST /
NEURO
INTENSIVIST
ENSURE ANAESTHETIST/NEUROINTENSIVIST IS AWARE OF THE PATIENT
If seizures recur in patients who are haemodynamically stable, optimise dose of initial second stage
.
If no response to step 2 within 30 minutes patient needs ITU
29

32. General Management - In Parallel to Drug Management
General Medical Measures
Secure airway and resuscitate
Administer oxygen
Assess cardiorespiratory function
Check temperature
Establish intravenous access (large veins if possible)
BM stick for glucose and immediately correct hypoglycaemia.
Give 75mls 20% glucose IV over 5 minutes
If no IV access 1mg IM Glucagon
Check blood glucose again after 15 minutes
Check blood gases.
If poor nutrition/alcohol abuse suspected give:
Pabrinex ONE PAIR intravenously over 10 minutes
OR
Thiamine 100mg intravenously in 100ml 0.9% sodium chloride over 30 minutes
Take blood for:
Electrolytes
Glucose Cal-
cium Magne-
sium
Full Blood Count
Liver Function Tests & INR
Anti-epileptic Drug Levels
Creatine Kinase
Alcohol and toxicology screen
Culture as appropriate
NOTE
Do not treat psychogenic non-epileptic seizures ‘pseudostatus’ with sedation or anti-
epileptic drugs
Consider urgent EEG and seek senior opinion
Mandatory Seizure Related Measures
• Investigate the cause of status and treat accordingly
• Reinstate any recently withdrawn anti-epileptic drug
• Continue existing anti-epileptic drugs
• Start maintenance anti-epileptic drug therapy promptly (usually the second line drug given
• – see above).
*For those on phenytoin, full loading is not appropriate but ‘top-up’ dose is given as per following
formula:
Target level (mg/l) – actual level obtained urgently (mg/l) x 0.7 x weight in kg
Example: If desired level=20mg/l, actual level=5mg/l and weight=70 Kg, then Dose = 20-
5=15; 15x0.7x70=735 mg rounded up to 750mg 30

33. Management algorithm for the alcohol withdrawal
Characteristic symptoms of DTs Impaired attention / Marked anxiety
Characteristic symptoms of DTs
overactivity
Auditory / visual illusions / hallucina-
tions Clouding of consciousness
Confusion / disorientation
Delusions
Plus symptoms of autonomic
Impaired attention / Marked anxiety
Paranoid ideas
Systolic hypertension
Tachypnoea
Insomnia
No Yes = DTs
Chlordiazepoxide 50mg po every 2
hours or
diazepam 10mg IV every 30-60
Obtain expert advice
Alcohol withdrawal symptoms/
signs
Anxiety / Agitation / Irritability
Tremor of hands, tongue,
eyelids
Sweating
Nausea / Vomiting / Retching
Insomnia
Fever, with or without infection
Tachycardia
Mild systolic hypertension
Mild Moderate / Severe
Oral Chlordiazepoxide **
with *
Risk factors for progression to severe withdrawal
High alcohol intake (> 15 units/day)
Sweating (palms)
History of severe withdrawal inc. seizures / DTs
Insomnia
High levels of anxiety
Hypoglycaemia
Hypokalaemia
No
No treatment
Yes
Oral chlordiazepoxide**
with *
Admit and continue
Day
1
2
3
Morning
30mg
20mg
10mg
5mg
5mg
Midday
30mg
20mg
10mg
5mg
After-
noon
30mg
20mg
Night Total
30mg 120mg
30mg 90mg
20mg 50mg
10mg 25mg
**Oral chlordiazepoxide sedation regimen
Breakthrough symptoms: chlordiazepoxide 5mg to 10mg prn
Some Consultants use Diazepam as an alternative – seek
senior advice
*Administration of Pabrinex IVHP
*Administration of Pabrinex IVHP
Amp pairs diluted in 50ml to 100ml
N saline or 5% w/v glucose.
Infuse over 30 minutes.
Note: Small risk of anaphylaxis.
Facilities to manage should be
available
Admit and con nue

34. Management algorithm for Wernicke’s
Management algorithm for Wernicke’s
Known / suspected alcohol
Known / suspected alcohol
misuser
• Acute confusion
• Decreased consciousness level / unconscious-
ness / coma
• Memory disturbance
Ataxia / unsteadiness
Ophthalmoplegia
Nystagmus
Any one or more from:
No
Risk factors for Wernicke’s
encephalopathy
• Intercurrent illness
• DTs / treatment for DTs
• Alcohol related seizures /
treatment for alcohol relat-
ed seizures
• IV glucose administration
• Significant weight loss
Yes
Wernicke’s
Start:
Pabrinex IVHP*
1 amp pair daily
for 3 to 5 days
Pabrinex not
Indicated (unless
Indicated by alcohol
Start:Pabrinex
IVHP*
2 amp pairs tds for 3 days
if no improvement stop.
If improvement then 2
amp pairs daily for as
long as improvement
continues
Admit and con nue
Wernicke’s
encepthalopathy
*Administration of Pabrinex IVHP
Ampoule pairs diluted in 50ml to 100ml N saline or 5% w/v
Note: Small risk of anaphylaxis. Facilities to manage should be available.
32

35. • Worsening Confusion
• Disturbance of Consciousness (more alert/
sleepy)
• Change in cognition/attention over hours to days
• Fluctuating course
• Advanced Age
• Severe Illness
• Known Dementia
• Frailty
• Dehydration/Infection
• Visual/hearing Impairment
• Surgery
• Medications (eg opiates), withdrawal (incl. alco-
hol)
• Infection
• Constipation, urine retention
• Pain
• Dehydration/electrolyte imbalance
• Drugs
• Indwelling devices (cannulas, catheters etc)
Management of Confusion
DOES YOUR PATIENT SHOW SIGNS OF:
DOES YOUR PATIENT SHOW SIGNS OF:
DOES YOUR PATIENT SHOW SIGNS OF: CONFUSION PATHWAY:
HIGH RISK
HIGH RISK PATIENTS:
COMMON CAUSES:
THINK REVERSIBLE CAUSES
• Screen & treat common causes of delirium
• Use Confusion Assessment Method (CAM - see
below) to help diagnose delirium.
THINK GOOD CARE
• Calm environment
• Reorientation
• Avoid unnecessary moves (esp at night)
• Provide reassurance and explanation
• Fluid/food chart
• Stool chart
• Pain charts
THINK PATIENT SAFETY
• Harm prevention strategies
• ABC chart
• De-escalation techniques
THINK COMMUNICATION
• Involve patients in decisions where possible
• Early discussion with carers/relatives
• Use Patient Passport, or “This Is Me”
document
33

36. Rapid Tranquillisa on for Disturbed/ Violent Behaviour in the Emergency
Department-Follow NICE Guidelines.
• The aim of rapid tranquillisa on is to achieve a state of calm sufficient to minimise
the risk posed to the pa ent and others
• Any interven on used must be a reasonable and propor onate response to the risk it
seeks to address
• Give medica on orally if possible
• Use reduced doses in the elderly and debilitated
• Be aware of increased cardio-respiratory effects of medica on in those with high
arousal, possible drug misuse, dehydra on and physical illness
• Use IV medica on in excep onal circumstances only ,under senior guidance
• Monitor vital signs as soon as pa ent’s condi on allows-Temp,HR,BP,RR,Sats
Non Psycho c Context Psycho c Context
1st
Line
Oral Lorazepam 1mg – 2mg
Oral Lorazepam 1mg – 2mg
plus
Oral Haloperidol 0.5mg – 3mg
(Up to 5mg if symptoms severe)
Consider 2nd
line therapy if oral therapy is refused, not a propor onate response or not
indicated by previous clinical response
2nd
Line
IM Lorazepam 1.5mg – 2.5mg
IM Lorazepam 1.5mg - 2.5mg
plus
IM Haloperidol 2mg – 10mg
If 2nd
line treatment fails call for senior help
For full details and alterna ve drug regimes refer to Nice
Guidelines 25 quick reference guide- Violence p12-13 or BNF
For acute dystonic reac ons to haloperidol
give Procyclidine 5mg – 10mg IM/IV
34

37. Management of Hypoglycaemia
Hypoglycaemia is most likely to occur in diabetic patients taking hypoglycaemic agents such as
insulin or oral hypoglycaemic medications. Occasionally it is induced by these drugs in suicide
attempts. Aspirin and alcohol may also cause hypoglycaemia especially if the patient has not
eaten. Metabolic and malignant factors such as carcinoid, insulinoma and sepsis can also cause
hypoglycaemia.
Hypoglycaemia = blood glucose ≤ 4mmol/L. If patient is asymptomatic, repeat test. Ideally con-
irm with lab sample, however do NOT wait for lab results. Treat immediately.
Mild - blood glucose 3-4mmol/L* and/or patient conscious and able to swallow. May be trem-
bling, sweating, hungry, tingling, headache, anxiety, palpitations, nausea, confusion.
Give 15-20g fast acting glucose: 4 x glucotabs (4g glucose per tab), a single dose of Hypostop gel
(GlucoGel) orally, 1x 59ml bottle of GlucoJuice, 120ml Lucozade or 200ml fruitjuice.
Moderate – blood glucose 2-3mmol/L* and/or patient conscious and able to swallow, but in
need of assistance. Dif iculty concentrating, speaking, confusion, weakness, guiddiness, drowsi-
ness, unsteady, headache.
Cooperative: Give 4 x glucotabs, one dose of oral Hypostop gel, 1x 59ml bottle of GlucoJuice,
120ml Lucozade or 200ml fruit juice.
Uncooperative: give 2 x tubes of GlucoGel – ensure patient has gag re lex.
NB: Mild and moderate hypoglycaemia – If NBM on insulin sliding scale, adjust as per regimen. If
not on insulin infusion give 100ml of 10% glucose IV/1mg glucagon IM. wait 15 mins, re-check
BM. If reading still <4mmol/L or if no physical improvement, repeat STEP 1. If reading still be-
low 3 escalate to senior.
Severe – blood glucose <2 mmol/L* and/or patient unconscious, unable to swallow or itting.
Check airway (ABC) and place in recovery position. If no palpable pulse or no respiratory effort
put out cardiac arrest call on 2222. If GCS < 8 call anaesthetist. NO oral luids. If on insulin infu-
sion stop immediately. Put out medical emergency/cardiac arrest call. Call ITU.
Give high low O2. Establish venous access and give IV glucose STAT (50ml of 50%, 100ml of
20% or 200ml of 10%) or 1mg glucagon SC/IM/IV. If hypoglycaemia is cause of episode, GCS
should return to 15 in <10min. If still unconscious assess for other causes.
Start 1L 10% glucose 4-8hourly IV, adjust rate to keep glucose over 5mmol/L. If patient was on
sulphonylureas consider octreotide 50 micrograms 12 hourly SC.
Once patient conscious give sips of GlucoJuice or Lucozade. Check blood glucose every 15
minutes to ensure increase at least to 5mmol/L.
Always follow up with starchy carbohydrate foods. Once recovered patient should eat slowly
digested/starchy carbohydrate e.g. a slice of bread or sandwich made from low GI bread (ideally
granary/wholemeal/multigrain), digestive biscuits, glass of milk or normal meal if due. Check
glucose after 15 minutes. Identify possible cause of hypoglycaemia. NEVER omit insulin after
episode. Follow up with diabetic review of the patient if appropriate. Refer to diabetes/
endocrine team.
*Ranges of blood glucose levels only a guide. Poorly controlled diabetics can have symptoms of
hypoglycaemia with blood glucose >3.5mmol/L. Be guided by clinical picture as well as glucose
level.
6. ENDOCRINOLOGY
35

38. The Management of Diabetic Ketoacidosis in adults
Diagnostic criteria:
Capillary blood gluce >11mmol/L AND
Capillary ketones >3mmol OR urine ketones ++ or more AND
Venous pH <7.3 and/or bicarbonate <15mmol/L
IMMEDIATE MANAGEMENT: time 0-60minutes
OBTAIN IV ACCESS – if IV access cannot be obtained request critical support immediately!!
1) FLUIDS commence 0.9% sodium chloride (See luid replacement box for rate)
2) INSULIN commence a ixed rate intravenous insulin infusion (IVII) (0.1unit/kg/hour) made up with 50 units
actrapid insulin made up to 50ml with 0.9%saline
NOTE: if patient normally takes long acting insulin analogue (ie Lantus) continue at usual dose and time!
3) ASSESSMENT - OBS, GCS, full clinical examination
4) INVESTIGATIONS – capillary and laboratory gloucose, venous blood gas, U+Es, FBC, blood cultures, ECG, CXR,
MSU
5) ESTABLISH MONITORING REGIMEN - Hourly capillary blood glucose, Capillary ketone measurement if
available, Venous bicarbonate and potassium at 60 minutes, 2 hours and 2 hourly thereafter, 4 hourly plas-
ma electrolytes, Continuous cardiac monitoring if required, Continuous pulse oximetry if required
6) ESTABLISH CAUSE -Consider precipitating causes and treat appropriately
HDU/level 2 facility and/or insertion of central line may be required in following circumstances(request
urgent senior review)
Young people aged 18-25 years, the Elderly, Pregnant patients, Heart or kidney failure or Other serious co-
morbidities
Severe DKA by following criteria - Blood ketones above 6 mmol/L, Venous bicarbonate below 5 mmol/L,
vernous pH <7.1, hypokalaemia on admission (<3.5mmol/L), GCS <12, O2 saturations <92% on air (arterial
blood gas required), systolic BP <90mmHg, HR >100 or <60 bpm, anion gap >16 [anion Gap = (Na + K) – (Cl+
HCO3)]
Initial ,luid replacement - Restoration of circulating ,luid balance is a priority!
If Systolic BP (SBP) < 90mmHg – (Likely to be due to low circulating volume, but consider other causes such as
heart failure, sepsis, etc.)
Give 500ml of 0.9% sodium chloride solution over 10-15 minutes. If SBP remains< 90mmHg - repeat - request
senior input. Most patients require between 500 to 1000ml given rapidly.
Consider involving the ITU/outreach
Once SBP > 90mmHg (or if SBP >90mmHg on admission) give 1000ml 0.9% sodium chloride over next 60 minutes.
Addition of potassium likely to be required if this is the second litre of luid
Potassium replacement
if potassium level >5.5, no potassium replacement required
if 3.5-5.5, 20mmol per litre of infusion solution indicated
If K level <3.5 patient will need senior review – additional potassium required
36

39. EARLY MANAGEMENT - 60 minutes to 6 hours:
Aim: Rate of fall of ketones of at least 0.5 mmol/L/hr OR bicarbonate rise 3 mmol/L/hr and blood glucose
fall 3 mmol/L/hr; Maintain serum potassium in normal range; Avoid hypoglycaemia
1: Re-assess patient, monitor vital signs - Hourly blood glucose (lab blood glucose if meter reading ‘HI’);
Hourly blood ketones if meter available; Venous blood gas for pH, bicarbonate and potassium at 60 minutes, 2
hours and 2 hourly thereafter.
If Potassium outside normal range, reassess potassium replacement, check hourly. If abnormal after fur-
ther hour, seek senior advice.
2: Continue ,luid replacement via infusion pump as follows:
0.9%sodium chloride 1L with potassium chloride over next 2 hours
0.9%sodium chloride 1L with potassium chloride over next 2 hours
0.9%sodium chloride 1L with potassium chloride over next 4 hours
Add 10% glucose 125ml/hr if blood glucose falls below 14 momol/L
More cautious luid replacement in young people aged 18-25 years, elderly, pregnant, heart or renal failure.
(Consider HDU and/or central line)
3: Assess response to treatment - Capillary ketones should fall by at least 0.5 mmol/L/hr, Venous bicar-
bonate should rise by at least 3 mmol/L/hr, Plasma glucose should fall by at least 3 mmol/L/hr
If so, Continue ixed rate IVII until ketones less than 0.3 mmol/L, venous pH over 7.3 and/or venous bicarbonate
over 18 mmol/L.
If ketones and glucose are not falling as expected always check for pump malfunction. If equipment
working but response to treatment inadequate, increase insulin infusion rate by 1 unit/hr increments hourly until
targets achieved
REMEMBER: review OBS regularly including O2 saturdations, accurate luid balance chart, consider NG
tube if vomiting AND REMEMBER THROMBOPROPHYLAXIS
INTERMEDIATE MANAGEMENT - 6 to 12 hours
Aims: Ensure clinicaland biochemical parameters improving, Continue iv luid replacement, Avoid hypoglycaemia,
Assess for complications of treatment e.g. luid overload, cerebral oedema,Treat precipitating factors as necessary
1: Re-assess patient as per criteria above- If patient not improving by criteria in Box 3 seek senior advice. Con-
tinue iv luid via infusion pump at reduced rate
0.9% sodium chloride 1L with potassium chloride over 4 hours
0.9% sodium chloride 1L with potassium chloride over 6 hours
Add 10% glucose 125ml/hr if blood glucose falls below 14 momol/L
Reassess cardiovascularstatus at 12 hours; further luid may be required. Check for luid overload
2: Review biochemical and metabolic parameters - At 6 hours check venous pH, bicarbonate, potassium, ca-
pillary ketones and glucose.Resolution is de ined as ketones less than 0.3 mmol/L, venous pH over 7.3 (do not
use bicarbonate as a surrogate at this stage). Ensure referral has been made to consultant diabetes team
If DKAnot resolved review insulin infusion as previous.
37

40. Ongoing management - 12-24 hours
Expectation: By 24 hours the ketonaemia and acidosis should have resolved. Request senior review if not im-
proving. Identify and treat reasons for failure to respond.
Aim:
• Ensure that clinicaland biochemical parameters – pH, bicarbonate, potassium, capillary ketones and glu-
cose are continuing to improve or are normal - Resolution is de ined as ketones <0.3 mmol/L, venous pH>7.3
If patient not eating and drinking continue iv luid replacement
• If ketonaemia cleared and patient is not eating and drinking move to a variable rate IVII as per local guidelines
Re-assess for complications of treatment e.g. luid overload, cerebral oedema and continue to treat precipitat-
ing factors
If patient eating and drinking normally transfer to subcutaneous regime as below
Resolution of DKA
Convert to subcutaneous regime when biochemically stable (capillary ketones less than 0.3 mmol/L, pH over 7.3)
and the patient is ready and able to eat. Do not discontinue intravenous insulin infusion until 30
minutes after subcutaneous short acting insulin has been given
Conversion to subcutaneous insulin should be managed by the Specialist Diabetes Team. If the patient is
newly diagnosed it is essential they are seen by the specialist team a n d I P D N S prior to discharge. Specialist
team will arrange follow up with Community DSN and follow up in OPD
38

41. Algorithm for the initial management of upper gastrointestinal (GI) haemorrhage
Presen ng features of upper GI haemorrhage
Melaena
Haematemesis
Coffee ground vomit
Fresh blood per rectum and shock
Calculate Blatchford Score (p. 2) &
plan endoscopy ming.
Inves ga ons
All pa ents - FBC, urea, crea nine
and electrolytes, LFTs, cloYng,
ECG, chest X-ray Group and save.
Selected pa ents - X-match.
Ini al Resuscita on
• IV access – 2 large bore cannulae if significant bleed.
• IV fluids – colloid or 0.9% saline while awai ng cross match.
• Transfuse red blood cells if Hb ≤ 70g/L at me of presenta on or if there are other indica-
ons e.g. shock, con nuing bleed, co-morbid condi ons affected by anaemia. Repeat Hb 8
hours a[er admission.
• Platelets if < 50 x 109
and ac vely bleeding.
• Correct INR if >1.5x normal or PT >3 seconds prolonged in those ac vely bleeding.
• Warfarin users – give prothrombin complex concentrate to pa ents ac vely bleeding or
manage in line with Trust protocol (2012) for those who have stopped bleeding.
Outpa ent endoscopy for low risk
Consider early discharge and early outpa-
ent endoscopy for pa ents with Blatch-
ford score 0 (that is the 20% of pa ents
presen ng with upper GI haemorrhage
who are at low risk)
*
Urgent endoscopy (Unit or 24/7 bleed rota)
In ac vely bleeding pa ents who remain haemody-
namically unstable a[er ini al resuscita on. In pa-
ents with a high probability of variceal bleeding
(clinical evidence of liver disease and abnormal liver
biochemistry) assess a[er pre-endoscopy treatment.
All others
Endoscopy usually within
24 h. At weekends contact
endoscopy unit to see if rou-
ne list running or ‘base en-
doscopy unit’**
to arrange
transfer for next available list.
Pre-endoscopy therapy
In suspected variceal bleeding
• Take blood cultures (55% have infec on)
• Prevent infec on: co-amoxiclav
(ciprofloxacin if allergic)
• Terlipressin 2 mg 4 x daily (NB: vasopres-
sor, monitor for peripheral and cardiac
ischaemia)
• In all pa ents: Oral PPI, No benefit in i.v.
PPI pre-endoscopy unless delay to
endoscopy.
Post endoscopy management of common causes.
Complete full Rockall Score for prognos ca on
Pep c ulcer bleed
• For pa ents with ‡
SRH: I.V. esomeprazole 80
mg stat then 8 mg/h for 72 h, inform on call
surgeons.
• Oral PPI for pa ents without SRH.
• Management of re-bleeds depends on pa-
ent and ulcer site – op ons are further
endoscopic therapy, surgery, angiographic
embolisa on,
• Aspirin users – con nue in secondary pre-
ven on of vascular events when haemosta-
sis achieved.
• Clopidogrel users – discuss with pa ent and
cardiology.
• Aspirin/clopidogrel users – con nue long
term only in combina on with PPI
Oesophageal variceal bleeding
• Con nue terlipressin (2-5 days) + an bio cs
(5 days).
• Ac vely search for associated complica-
ons: sepsis (par cularly spontaneous bac-
terial peritoni s. diagnose with asci c neu-
trophil count > 200), renal failure, encepha-
lopathy.
• Management of re-bleeds includes further
endoscopic treatment, Sengstaken tube or
TIPPS.
• Start 2o
prophylaxis prior to discharge -
propranolol and request repeat banding for
1 – 2 weeks, then repeat scope at 1, 3, 6
and 12 months.
Other
• Oesophagi s & Mallory
Weiss tear usually low risk
and stop spontaneously. If
deep tear examine CXR (?
pneumomedias num)
• For normal endoscopy
repeat scope (?missed
lesions) if re bleeds and/or
colonoscopy for melaena
Post-endoscopy therapy
• Transfuse if Hb ≤ 70 g/L unless
other indica on as above.
• NSAIDS – stop in acute phase
• FFP and Platelets – indica ons
as pre endoscopy
7. UPPER GI BLEED
39

42. *Arranging an urgent endoscopy
Registrar must discuss with their own Consultant prior to calling on-call Endoscopist (via switch-
board). Following minimum details to be available: time of onset of GI bleed, Blatchford Score
with score breakdown and details of any previous endoscopy (via Unisoft reporting tool, notes
or patient history).
Request OGD on ISOFT.
Once need for urgent out of hours endoscopy agreed with on-call endoscopist, site-manager to call
on-call endoscopy nurse for that site with the following details: patient name, age, ward, patient
pulse and BP. Endoscopy nurse informed if endoscopy taking place in main theatres.
For patients with encephalopathy, some haemodynamically unstable patients the endoscopy will
need to take place in main theatres. On site team to call for anaesthetic assistance and arrange
theatres.
For all other patients who are to be scoped in the endoscopy units a member of staff (ward nurse,
site coordinator, doctor) who is trained in airway management must accompany the patient to
the unit and stay with them throughout the procedure. This is in order that the on-call endosco-
py nurse is free to assist with haemostasis e.g. clips, adrenaline injection, variceal banding.
**Base endoscopy unit
On-call endoscopist does a Saturday & Sunday (9.00 – 14.00) endoscopy list at their base hospital
(KCH, WHH, QEQM). For ‘all other patients’ who are admitted between 5.00pm Friday and 8.00am
Sunday contact ‘base’ endoscopy unit during working hours to arrange an endoscopy on this Satur-
day or Sunday list. The patient will need to be transferred to the ‘base’ site by ambulance. Request
OGD on ISOFT.
‡SRH (stigmata of recent haemorrhage) is an actively spurting vessel, visible vessel or clot overly-
ing an ulcer. SRH indicates the need for endoscopic therapy and indicates a higher risk of re-
bleeding than ulcers with a clean base.
Glasgow-Blatchford Score
Admission risk marker Score component value
Blood Urea
≥6·5 <8·0 2
≥8·0 <10·0 3
≥10·0 <25·0 4
≥25 6
Haemoglobin (g/L) for men
≥12.0 <13.0 1
≥10.0 <12.0 3
<10.0 6
Haemoglobin (g/L) for women
≥10.0 <12.0 1
<10.0 6
Systolic blood pressure (mm Hg)
100–109 1
90–99 2
<90 3
40

43. The Glasgow-Blatchford score is used
to identify low risk patients who do not
require any intervention (blood transfu-
sion, endoscopic therapy, surgery).
Approximately 20% of patients present-
ing with UGIH have a Blatchford score of
zero. Such patients can largely be man-
aged safely in the community as the
mortality in this group is 0.
The Rockall scoring system
Other markers
Pulse ≥100 (per min) 1
Presentation with melaena 1
Presentation with syncope 2
Hepa c disease 2
Cardiac failure 2
Score
Variable 0 1 2 3
Age < 60 60–79 >/= 80
Shock
No shock
Systolic BP > 100
mm Hg
Pulse < 100
beats/min
Tachycardia
Systolic BP > 100
mm Hg
Pulse > 100 beats/
min
Hypotension
Systolic BP < 100
mm Hg
Comorbidity Nil major
Cardiac failure, is-
chemic heart dis-
ease, any major
comorbidity
Renal failure, liver failure,
disseminated malignancy
Diagnosis at
OGD
Mallory–Weiss
tear, no lesion,
and no SRH
All other diagnoses
Malignancy of up-
per-GI tract
Major SRH at
OGD
None, or dark
spot
Blood in upper-GI
tract, adherent clot,
visible or spurting
vessel
• Calculate Rockall score from sum of above
• Mortality increases with increasing Rockall score and is mainly due to deterioration of co-morbid
conditions rather than blood loss.
• Full Rockall score 0 – 4, mortality 0 – 5.3%
• Full Rockall score 8 +, mortality 41% +
41

44. Drug Indication MoA Monitoring/interpreting
bloods
Reversal/bleeding*
Warfarin AF, metallic heart valves,
recurrent DVT/PE, TIA
Vitamin K
antagonist→
factors II, VII, IX, X
inhibited
INR. To calculate: (INR =
PT patient/PT normal)ISI)
*ISI = international sensi-
tivity index.
See below
Enoxaparin Thromboprophylaxis in
medical and surgical pa-
tients. Rx of DVT/PE,
NSTEMI.
Accelerates the
activity of an-
tithrombin III, po-
tentiating inhibi-
tion of factors Xa +
IIa.
No routine monitoring.
APTT varies according to
laboratory and other pa-
tent factors. Anti-factor Xa
levels can be used to moni-
tor.
No reversal. Consid-
er RFVIIa in haemor-
rhage.
Apixaban Prevention of stroke /
systemic embolism in
non-valvular AF + 1 of
previous stroke/TIA, HF,
DM, HTN or age >75. VTE
prophylaxis in total hip/
knee replacement
Direct factor Xa
inhibitor
No monitoring. There is
currently no validated as-
say to measure affect how-
ever, prolongs PT and
APTT. PT may be normal
even at therapeutic levels
so not reliable way to
monitor.
No reversal. Consider
IV tranexamic acid
(1g bolus over 10min)
then 1g over 8 hours,
consider FFP 4 units
in moderate severe
bleeding. Consider
FFP if bleeding is post
-procedure within 24
hours of last dose in
life threatening bleed-
ing.
Rivaroxaban Rx of DVT/PE and
prophylaxis of recurrent
DTV/PE. Prevention of
stroke /systemic embo-
lism in non-valvular AF +
1 of; CCF, HTN,previous
stroke or TIA, age ³75 or
DM.
VTE Prophylaxis in total
hip/knee replacement
Direct factor Xa
inhibitor
No monitoring. PT (or
APTT) can be used for the
urgent determination of
the relative intensity of
anticoagulation due to
rivaroxaban. PT usually
more sensitive. It cannot
be used to determine the
drug level.
No reversal. Consider
IV tranexamic acid
(1g bolus over 10min)
then 1g over 8 hours,
consider FFP 4 units
in moderate severe
bleeding. Consider
PCC, rFVIIa in life
threatening bleeding.
Dabigatran Prevention of stroke /
systemic embolism in
non-valvular AF + 1 of;
previous stroke, TIA or
systemic embolism, LVEF
<40%, HF, age ³75, or
age >65 +DM, coronary
artery disease or HTN.
VTE Prophylaxis in total
hip/knee replacement.
Direct thrombin
(factor IIa) inhibi-
tor
No monitoring. APTT can
be used with most rea-
gents for urgent determi-
nation of the relative in-
tensity of dabigatran. The
APTT cannot be used to
deter- mine the drug level.
A normal TT means the
level of dabigatran must be
very low.
No reversal. Consider
IV tranexamic acid
(1g bolus over 10min)
then 1g over 8 hours,
consider FFP 4 units
in moderate severe
bleeding. Consider
PCC, rFVIIa or haemo-
dialysis in life threat-
ening bleeding.
In all cases of bleeding on NOAC: stop NOAC, assess and resuscitate as appropriate, initiate massive
haemorrhage if appropriate, use local haemostatic measures to control bleeding, consider surgical inter-
vention, request FBC, renal pro ile, calcim, group and save ad cross match, clotting screen for PT, APTT, TT
and ibrinogen (state when last dose given), consider oral activated charcoal esp in overdose if ingesgion
<2 hours ago. Monitor Hb and transfuse red cells in accordance with haemorrhage protocol (approx. 1unit
packed red cells per 10g/l drop in Hb).
In mild bleeding delay next dose of NOAC or discontinue Rx if appropriate. Consider risk/bene it and CI’s
to re-starting anti-coagulation. Check renal function. In cases of dabigatran or apixaban consider re-
starting at lower licenced dose if appropriate.
In all moderate/severe bleeding contact haematology for advice. Give luid replacement to maintain
good urine output. Blood products support to keep: Hb >80g/L, platelets >50 x 109/L, ibrinogen >1.0g/L,
APTT <1.5 x normal.
8. ANTICOAGULATION
42

45. High thrombotic risk patients, target INR 3.0-4.0 such as:
Recurrent VTE, anti-phospholipid syndrome, mechanical heart valves, TIA/CVA with AF.
If no bleeding or minor bleeding/bruising:
INR 4.5-5.9 – omit one warfarin dose. Reduce warfarin dose by 10-15%.
INR 6.0-7.9 – omit two doses of warfarin. Reduce warfarin by 20%.
INR 8.0-9.9 – 1mg oral vitamin K. Omit at least 2 doses of warfarin. Repeat INR next day or as soon as
practical. Once INR <4.5: re-start warfarin with 25% dose reduction.
INR >10 – 2mg oral vitamin K. Omit at least 2 doses of warfarin. Repeat INR next day or as soon as practi-
cal. Once INR <4.5: re-start warfarin with 30% dose reduction.
Low thrombotic risk patients, target INR 2.0-3.0 such as in AF.
If no bleeding or minor bleeding/bruising:
INR 4.5-5.9 – omit two doses of warfarin. Reduce warfarin dose by 15%.
INR 6.0-7.9 – omit two doses of warfarin. Reduce warfarin dose by 20%.
INR >8 – omit warfarin. 2mg oral vitamin K. Repeat INR 24-48 hours later or as soon as practical. Re-
start warfarin at 25% reduction in dose once INR <3.0.
NB consider where there has been a transient risk factor for over-anticoagulation which has now resolved
e.g. anti-biotics/alcohol.
Omit appropriate number of doses, retest INR, when INR back in range continue at previous stable dose.
Major bleeding on warfarin* (high and low risk thrombotic risk patients):
Stop warfarin
Admit patient urgently to CDU or A&E
If INR supra-therapeutic give prothrombin complex concentrate (beriplex or octaplex) 20 units/kg
(treatment of choice). FFP 10-15ml/kg should only be used if there is a contra-indication to pro-
thrombin complex concentrate (e.g. known hypersensitivity, DIC, pregnancy/breastfeeding).
Give vitamin K 2mg oral or IV in addition to prothrombin complex concentrate.
NB vitamin K IV can cause anaphylaxis and should only be given when full resuscitation facilities are availa-
ble including adrenaline, steroids and oxygen.
*As well as above in major bleeding initiate major haemorrhage protocol and monitor Hb and replace blood
(be guided by Hb) as well as blood products and resuscitation.
9. WARFARIN REVERSAL
43

46. Pain assessment
• Identify any Red lags!
◊ Pain related to serious pathology e.g. ischemia, pulmonary embolism, infection,
acute abdomen, metastases
Nociceptive Pain treatment – pharmacology
• WHO Pain relief ladder:
A note on tramadol: in elderly, epileptic patient s and those on anti-depressants. If adequate control
on regular dose consider SR/MR formulation 100-200mg BD
A note on morphine: consider other options: oxycodone, tapentadol, fentanyl, buprenorphine
(Transtec). Short acting: Sevredol 10mg.
DO NOT Prescribe more than one opioid, Use more than 120mg/day morphine equivalent day
without specialist advise.
BE CAUTIOUS Prescribing opioids for elderly patients, Using codeine or morphine if eGFR <
30mls/min
Be aware Common side effects! (see full guidance)
Consider
• Non pharmacological treatments
• Fentanyl/buprenorphine patches for people who have dif iculty with compliance with
oral opioids, Long-term use, Cannot tolerate codeine products and suggest musculoskeletal
pain, Dif iculty swallowing or absorption problems
Driving - Advice patient to inform DVLA and insurance companies when taking strong opioids , Advice
10. PAIN MANAGEMENT
44

47. taken extra break through or rescue doses or feel sleepy or start taking other drugs that cause
drowsiness
See Equivalence doses when adjusting dose or medication (BNF/full guidance)
Neuropathic pain:
Management
Treatment for neuropathic pain (except trigeminal neuralgia)
• Low dose tricyclic antidepressants
◊ Amitriptyline/Nortriptyline
• 10-75mg nocte
◊ Dosulepin
• 25-75mg nocte
• Titrate upwards over 4-5 weeks
• Trial for at least 6-8 weeks
◊ Patient who do not bene it from one TCA may bene it from alterative
◊ If TCA fail switch to Duloxetine or Gabapentin or Pregablin
• Duloxetine
• Gabapentin
◊ Start at 100-300mg OD for 3-7 days, then titrate up
◊ 100-300mg BD for 3-7 days
◊ 100-300mg TDS for 3-7 days
◊ If tolerated titrate to 600mg TDS
◊ Trial for at least 608 weeks
◊ Equal spacing between doses
• Pregabalin
◊ 25-75mg nocte for 3-7 days
◊ 25-75mg BD for 3-7 days
◊ 75-150mg BD for 3-7 days
◊ Standard dose 150 mg bd, Max dose 300 mg bd
◊ (twice daily prescribing, not tds)
Speci ic condition considerations:
• Diabetic neuropathy
◊ duloxetine +/- gabapentinoid
• Widespread body pain
◊ gabapentinoid, duloxetine & magnesium supplements
• Trigminal neuralgia
◊ Carbarmazepine
• Hand/Knee OA
◊ Topical NSAID or capsaicin cream 0.025%
◊ Post herpetic neuralgia or discrete focal areas of cutaneous neuropathy
• Capsaicin cream 0.075%
45

48. 11. Sepsis
Sepsis
Iden fying sepsis:
Severe sepsis = Sepsis + Signs of organ
dysfunc on
Sep c shock = Sepsis + Hypotension despite
adequate fluid resuscita on and perfusion
abnormali es.
Managing sepsis:
Sepsis of unknown origin
Empirical treatment:
- Amoxicillin 1g TDS IV
AND
- Gentamicin OD IV (as per dose calculator)
Give the first dose of gentamicin in a sep c pa ent prior to
knowing the renal func on to prevent delay.
If penicillin allergic:
- Vancomycin IV (as per dose calculator)
AND
Author: Dr Alice Rendall (Junior Doctor)
References 1) Iden fying sepsis EKHUFT Intranet 2) Sepsis seven EKHUFT intranet 3) An microbial
guidelines: EKHUFT Intranet hSp://www.ekhu[.nhs.uk/staff/clinical/an microbial-guidelines/sepsis
-of-unknown-origin/
46

49. Bleeps
Hot Registrar
Cold Registrar
Hot F1
Cold F1
Surgical Registrar on call
Surgical SHO on call
Surgical F1 on call
Outreach
Anaesthe cs SHO
Anaesthe cs SpR
ENT SHO
Orthopaedics SHO
Gynaecology SHO
MaxFax SHO
Urology SpR
Urology SHO
Hospital @ home
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8506
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8500
8504
8772
8771
8770
8460
8508
8511
8010
8807
8777
7510
7604
7602
8891
Numbers / extensions
03300100177
0845956700
7236001
7238004 / 5
7238226
7238997
7238921
07951 1445621 or 07554 110887
Fax numbers (put a 9 in front of fax numbers unless using extension)
ECHO
Cardiology
Respiratory
Gastroenterology
Endocrinology
01233 616011
01233 616011
01233 616044
01233 616044
Crossroads care geYng older people home from hospital ………………..
Crossroads carers support …………………………………………………………………
Medicines Informa on ………………………………………………………………………
Pharmacy ………………………………………………………………………………………….
X-Ray …………………………………………………………………………………………………
CT ……………………………………………………………………………………………………..
Endoscopy …………………………………………………………………………………………
Vascular Access …………………………………………………………………………………
12. Useful Numbers
47

50. Written and produced by Dr Jessica Ball and Dr Karina Baxter
(FY1 Doctors at William Harvey Hospital 2014-2015)
With thanks to all contributors:
Dr Jessica Ball
Dr Karina Baxter
Dr Malaz Elsadig
Dr Lauren Hookham
Dr Vithya Nagendram
Dr Jayne Lee
Dr Alice Rendall
Acknowledgements
Dr Bandipalyam Prathibha
Dr Jonathon Hawkins
Maggie Batchelor