This document provides guidance on managing various cardiac and medical emergencies that may present to the emergency department. It addresses treatments for tachycardias, bradycardias, ventricular fibrillation, seizures, coma, analgesia, abdominal issues, gynecological emergencies, and managing shifts, patients, and self-care as an emergency physician. Senior support is advised when needed and respect for nursing staff is emphasized.
10. Tachycardias
Chronic AF, CP
Seek and treat precipitant eg CCF, sepsis, hypovolaemia
Rate control eg diltiazem 10mg IV, 20mg 15 min later if needed
½ dose if hypotensive. May need diltiazem + phenylephrine
Check BP before each dose
17. Hyper K with widened QRS
Salbutamol 10mg neb
Calcium gluconate 10mmol = 1 amp
Urgent dialysis
If delay to dialysis d/w renal unit re insulin
and glucose, HCO3, frusemide.
18. Renal failure patients
ECG on arrival – look for hyperK
Fentanyl for analgesia rather than morphine or
tramadol
CAPD patients with belly pain or any signs of
sepsis -> eyeball the dialysate -> cloudy =
peritonitis -> intraperitoneal Abs +/- Sepsis
Pathway
23. Bradycardia
CPR if needed (no pulse, losing consciousness)
Fluid load if not overloaded
Transcutaneous pacing -> Transvenous pacing.
Isoprenaline infusion
24. D
Seizures
You are called to a room where a febrile child
has been seizing for 1 minute
What are you going to do?
25. Seizures
Reassure everybody
Turn the child on his/her side
Suction if necessary
Oxygen
Wait for seizure to stops
If seizure last 3 minutes what are you going to do?
26. Seizures
Check blood sugar (2 ml/kg of 10% dextrose,
recheck BSL after 15 minutes)
Benzodiazepine
We usually use midazolam 0.15mg/kg IV or
0.2mg/kg IM. Can also use IN, buccal, rectal.
Repeat if still seizing after 5 minutes.
27. … still seizing …
IV phenytoin 15mg/kg over 20 minutes
Antibiotics eg ceftriaxone 100mg/kg to max of 2g
Call paeds
Wait
The brain won’t fry from a prolonged seizure
Usually better to wait for the seizure to stop than to
intubate – especially in our context where we don’t
have 24/7 medical cover in critical care
29. Coma
Go through ABCDEG including a glucose
Then use eg AEIOUTIPS
Alcohol and other drugs
Electrolytes, encephalopathy (hepatic, hypercapnic, hypertensive (NB kids), infective, endocrine)
Inborn errors, intestinal disaster
Overdose
Uraemia
Trauma, toxins
Infection
Psychiatric
Seizure (including non-convulsive and post ictal), Stroke, SOL, snake or spider bite (not in NZ!)
30. Coma
In practice:
Firm stimulus eg triceps pinch
Physical exam including basic neuro
Look for eg deviated eyes as sign of non-convulsive
status
Blood sugar
ECG
Urine
Labs including a venous gas, LFT.
31. Coma
Usually intubation by ED senior unless fairly
sure just drunk or poor prognosis in
elderly -> recovery position
CT brain
Reassess with results
32. Analgesia
Fentanyl for moderate - severe pain
Less itch, hypotension, nausea than morphine
1μg/kg IV/IO, 1.5-3μg/kg IN, repeat PRN
No diamorph in NZ
Convert to morphine (longer acting than fentanyl) if
needed when pain under control
Paracetamol load 20mg/kg then 15mg/kg
thereafter
Ibuprofen 10mg/kg
33. Analgesia
Ketamine eg 5-30mg as analgesic
50% or 70% nitrous oxide
Long acting local anaesthetics (eg bupivocaine
2.5mg/kg) – wrists, ribs, clavicles, wrist
blocks, ring blocks, femoral nerve, fascia
iliaca/triple block.
Local anaesthetic toxicity
Intralipid
34. Analgesia
Consider a PCA on the ward
Charted by an emergency physician or anaesthetist
Ketamine infusions eg 0.3mg/kg/hour titrated
to pain / confusion
35. G: Glucose, Guts (abdo), Gynae
Hypoglycaemia
3-4 Oral glucose tabs then food
If unable to eat: 2ml/kg 10% glucose +/-
infusion if still unable to eat
36. G
Abdo pain in the elderly (> 50 male > 60
female)
Be afraid
Low threshold for bedside u/s for AAA
Low threshold for CT abdo
37. Gynae
ßHCG in almost every female of childbearing
age who is in ED
Shock in early pregnancy = ectopic till proven
otherwise.
Bedside ultrasound for free fluid in abdo.
If +ve call gynae, transfuse, tranexamic acid
38. Gynae shock
If unable to do bedside ultrasound
-> PV exam - remove POC from cervix
If no products is internal os open?
Yes -> miscarriage – see next slide
No -> call gynae +/- urgent ultrasound
39. If shocked + miscarrying in early pregnancy
Remove POC from Cx
Misoprostal 800mg PR or buccally
Tranexamic acid 1g IV
If still bleeding ++ -> transfuse and call
gynae + theatre (rare)
40. POC
Many women from many cultures want to
keep/bury products of conception - don't
just throw POC is the rubbish.
42. Managing your day
Don't take too many patients at once
To start with don't have more than 3 active patients
Take breaks
Have a lunch break
43. Managing your day
As you get used to the job aim to take 3
patients in the first 20 minutes of your shift.
See them quickly
Write a very brief note eg sudden onset
headache, CGS 15 P: analgesia, CT, review
after CT ? for LP
Order the tests
Then see the next patient
44. Managing your day
Don't take on new patients in your last hour: tidy up your
remaining patients, sign off some labs or XRays and
check work emails.
Handover any remaining patients before you go
Trust that your colleagues will be taking good care of your
patients and let them go.
45. Treat the nurses with the
respect they deserve
Nurses out-rank you in our ED
They have more experience than you
They will protect their patients … and therefore you
They will give you great advice and may help with lines and bloods if
they have time
Listen to them
Ask for help
When requesting they do a job say “Please would you …” not “Could
we please …”
47. Managing your night
Have a nap
If that little voice says don't send that patient
home -> keep 'em, especially after 3am
Pick the nurses brains
If you think you should ring a consultant /
registrar -> ring 'em
48. If you need senior help, and you are fairly sure
which speciality the patient will be
admitted under please call that registrar
(ortho, surg) or consultant (other
specialities)
If you are not sure which speciality the patient
comes under or you need ED specific skills
call the ED consultant
Better to overcall than undercall
49. I expected to be called once a night on your
first set of nights
If in doubt ask a nurse
If a nurse thinks you need help s/he will call
us
50. Managing your night
You will feel your performance improves over
your set of nights
It doesn't
You get worse
If in doubt talk to the boss or keep the patient
in
51. Self care
Information overload
We can't know everything
We are human and make mistakes
Accept yourself and work to improve
52. Self care / being a better doc
Meditation
http://emtutorials.com/2013/04/mindfulness-for-health-
professionals/
Sleep
http://emtutorials.com/2013/04/insomnia-and-sleep/
53. Study
45 minutes then take a 15 minute break
http://lifeinthefastlane.com/ Links to all free EM teaching
http://embasic.org/
http://www.emrap.org/ $
http://emcrit.org/ EM/intensive care
http://ekgumem.tumblr.com/ ECG video tutorials
http://emtutorials.com/
54. Real time on-line resources
eMedicine
UpToDate
Blue Book
Starship Paediatric Guidelines
Links on the RMO page on the intranet
55. Teaching sessions / case discussions
Monday 8:15 X-ray meeting
Tuesday 9am Dept meeting / Case discussions
Tuesday 1pm ED RMO teaching sessions
Thursday 1pm RMO teaching sessions
1st Tuesday of each month 5pm Journal Club
