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