Adult Medical Emergency Handbook - Scottish Intensive Care Society

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REPERFUSION TERAPY STEMI PATHWAY - NHS LOTHIAN OPERATIONAL FRAMEWORK ST. JOHNS HOSPITAL Patient presents with Chest Discomfort • Immediate Clinical Assessment • 12 lead ECG within 5 minutes • Intravenous Access • Morphine 2.5mgs – 10 mgs IV + Metoclopramide 10mg IV • Oxygen + cardiac rhythm monitoring • Aspirin 300mgs po + Clopidogrel 300mg po • Metoprolol 5 -15mg IV followed immediately by 50 -100mg po • Blood Sampling: FBC, U&E, lipid profile, glucose, troponin Can the patient be transferred to the RIE cardiac lab (have left StJH) within 45mins of diagnostic ECG? Yes ST Segment Elevation of 2mm in 2 contiguous chest leads or 1mm in limb leads AND clinical suspicion of MI 50% fall in ST segment elevation or new onset of idioventricular rhythm No Contact Cardio SpR at RIE Transfer patient to RIE for rescue PCI if applicable adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11 103
LOTHIAN PRIMARY PCI/PRE-HOSPITAL THROMBOLYSIS INITIATIVE - NHS LOTHIAN AND NHS FORTH VALLEY OPERATIONAL FRAMEWORK SAS PRESENTERS Pt calls 999 with CP RIE CCU ask SAS “Can you be at the RIE Cath Lab within 60 minutes of diagnostic ECG?” YES YES Cath Lab staff hours • 0730 to 1730, Mon - Fri • SAS administer TNK + Heparin (if within JRCALC guidelines). • RIE CCU advise direct admission to RIE CCU Advise SAS • Give 5,000 unit bolus IV Heparin and 600mg Clopidogrel (unless contraindicated) • Proceed directly to relevant Cath Lab • Cascade CCU SHO + CP nurse or CCU nurse to meet patient at Cath Lab Telemetry transmission to receiving station, or (in event of transmission failure) SAS phonecall to RIE CCU? STEMI requiring reperfusion NO SAS ~ Assess ~ Rx: High flow O 2 , 300mg Aspirin po, Sublingual GTN, Intravenous Opiate ~ 12 lead ECG + telemetry 12 lead ECG showing ST segment elevation of >2mm in 2 contiguous leads and clinical suspicion of MI? NO Advise SAS • Give 5,000 unit bolus IV Heparin and 600mg Clopidogrel (unless contraindicated) • Proceed directly to A&E • Cascade CCU SHO + CP nurse or CCU nurse to meet patient at A&E • Cath Lab contact A&E as soon as available RIE CCU ask SAS “Can you be at the RIE A&E within 60 minutes of diagnostic ECG?” NO If not within JRCALC guidelines: RIE CCU advise admission to RIE for consideration of Primary PCI • Ascertain SAS ETA & keep on telephone • Contact Cath Lab via Primary PCI (red) phone and ask “Can you receive a Primary PCI at the ETA?” Out-of-Cath Lab staff hours • Ascertain SAS ETA • Cascade on -call Cath Lab team to RIE Advise SAS SAS transport to agreed destination unless the patient’s condition presents or deteriorates such that a crash-call to A&E resus should be considered. Should this be the case, SAS will phone RIE CCU at the earliest opportunity. YES • Give 5,000 unit Heparin bolus and 600mg Clopidogrel unless - cont indicated • Cascade CCU nurse - +/ HAN SHO to meet patient at A&E + inform A&E • Cath Lab contact A&E as soon as prepared 104 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11
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Adult Medical Emergencies EDITOR Dr
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WGH IN CARDIAC ARREST & LIFE THREAT
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RIE USEFUL BLEEP NUMBERS MED REG (w
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ST JOHN’S THEATRES 1-9 1 ........
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OTHER USEFUL TELEPHONE NUMBERS NAME
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Management of First Seizure in Adul
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Addison’s Disease ...............
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EDITOR’S INTRODUCTION The Adult M
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DISCLAIMER Every effort has been ma
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GENERAL POINTS Medicines • Doses
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i as far as is reasonably possible.
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i GOOD DOCUMENTATION • Write legi
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• Prescribe liquids by writing th
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Figure 1 Figure 2 Figure 3 Figure 4
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MAKING A DECISION ABOUT RESUSCITATI
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THE PATIENT WHO IS NOT COMPETENT TO
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i PATIENT DEATHS • See patients w
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CHECKLIST OF REQUIREMENTS This chec
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ORGAN DONATION Transplants are one
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i Always consider telephoning the G
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i review arrangements. Include: a)
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Immediate investigations are those
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i i NOTES ON INITIAL ASSESSMENT ALG
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i Exposure, evidence and examinatio
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i i 2b. ILLNESS SEVERITY ASSESSMENT
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Observation Chart Date chart commen
Page 53 and 54: i Illness Severity and Diagnosis (R
Page 55 and 56: i Watch for the development of card
Page 57 and 58: SHOCK Definition & Classification
Page 59 and 60: i Cuff BP by machine may be extreme
Page 61 and 62: If no bleeding and platelets
Page 63 and 64: TRANSFUSION REACTION Figure 1: Algo
Page 65 and 66: of infusing only 5-10mls of blood.
Page 67 and 68: Table 3: Drugs that may be required
Page 69 and 70: i i SEPSIS AND SEPTIC SHOCK Sepsis
Page 71 and 72: ANTIBIOTIC MINI-GUIDE FOR ADULTS
Page 73 and 74: i i • Remember to look for intra-
Page 75 and 76: i • Commence basic life support (
Page 77 and 78: ALGORITHM FOR FIRST MEDICAL RESPOND
Page 79 and 80: ACUTE PAIN MANAGEMENT The effective
Page 81 and 82: i DO YOU NEED HELP ? Contact the Ac
Page 83 and 84: i • Angina (rate related): treat
Page 85 and 86: DATE: Dear “FIRST SEIZURE” APPO
Page 87 and 88: Review Collapse Algorithm Identifie
Page 89 and 90: Loss of consciousness YES Perform:
Page 91 and 92: 07.00 to 17.00 Asymptomatic Normal
Page 93 and 94: i i ADULT ADVANCED LIFE SUPPORT: No
Page 95 and 96: i NON SHOCKABLE RHYTHMS Cardiac arr
Page 97 and 98: • Patients should be pain free an
Page 99 and 100: ACUTE CORONARY SYNDROMES In order t
Page 101 and 102: IMMEDIATE MANAGEMENT OF ACUTE CORON
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Page 107 and 108: i Thrombolysis Since the clinical b
Page 109 and 110: Reperfusion therapy not administere
Page 111 and 112: i i MILD-MODERATE LEFT VENTRICULAR
Page 113 and 114: i i Do not hesitate to seek a Cardi
Page 115 and 116: account any subsequently prescribed
Page 117 and 118: i rehab team or the BHF nurse, and/
Page 119 and 120: i i i Referral to ICU should follow
Page 121 and 122: ATRIAL FLUTTER Characterised by rap
Page 123 and 124: i Seek senior cardiology advice reg
Page 125 and 126: Causes • Bradycardia • Electrol
Page 127 and 128: i i In anterior infarction the deve
Page 129 and 130: abnormalities develop i.e. second o
Page 131 and 132: i VASCULAR EMERGENCIES ACUTE THORAC
Page 133 and 134: i ACUTE STROKE Stroke is a Medical
Page 135 and 136: STROKE DIFFERENTIAL DIAGNOSIS: COND
Page 137 and 138: ACUTE STROKE INTEGRATED CARE PATHWA
Page 139 and 140: ST JOHN’S HOSPITAL CARE PATHWAY A
Page 141 and 142: Role of D-dimer D-Dimer is helpful
Page 143 and 144: i Thrombolysis bolus alteplase (rtP
Page 145 and 146: i MANAGEMENT OF THE ACUTELY ISCHAEM
Page 147 and 148: i Chapter 4 RESPIRATORY EMERGENCIES
Page 149 and 150: i i • Decreased respiratory and h
Page 151 and 152: i i • Co-morbidity. • Multiloba
Page 153 and 154: other factors. Consult local antibi
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Antibiotics • Amoxicillin (amoxyc
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MANAGEMENT OF SPONTANEOUS PNEUMOTHO
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• Look at the CXR and mark intuba
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pack. Advance slowly along the infi
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Figure 1a - preparing to insert a c
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i i MANAGEMENT OF CHEST DRAINS •
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Features of a major bleed? • Tach
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i i Contact GI Registrar. ROCKALL S
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i i • Blood, urine and ascitic fl
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• For alcoholic liver disease: th
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Known IBD • Exclude infection. Mi
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• Are any drugs implicated e.g. o
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ACUTE PANCREATITIS Determine severi
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then it would be more appropriate t
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RIE/WGH ACUTE SURGICAL ADMISSION IN
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i i VASCULAR: renal artery disease
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• Examine the urine: proteinuria
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i 1. IMMEDIATE ACTION: STABILISATIO
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METABOLIC ACIDOSIS CAUSES OF METABO
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i MANAGEMENT OF DIABETIC KETOACIDOS
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i Electrolyte replacement • Despi
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• Screen for myocardial infarctio
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• Monitor respiratory rate, ECG,
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Consider Precipitating Factors: •
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likely to be either GKI or sliding
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• If capillary blood glucose is g
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COMMON SYMPTOMS OF HYPOGLYCAEMIA Au
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Always discuss with the metabolic r
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• Abdominal pain • Depression
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• Hypoparathyroidism, surgical.
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i TREATMENT Oral • Sando K 2-3 ta
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• Measurement of plasma renin act
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Flow Chart for the assessment and m
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Chapter 7 NEUROLOGICAL EMERGENCIES
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AETIOLOGY OF COMA Primary neurologi
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EPILEPTIC SEIZURES Epilepsy is a sy
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i DRUGS Initial treatment is with D
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INDICATIONS FOR INTUBATION AND VENT
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LIKELY ORGANISMS • Depend on age,
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TENTORIAL HERNIATION AND CONING •
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• CT scan if focal neurology, rai
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• Assessment of cognition can be
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ACUTE AGITATED CONFUSION IN AN OLDE
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• Drugs: - polypharmacy (>4 drugs
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i Chapter 9 EMEGENCIES IN HAEMATOLO
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on waking, and may be aggravated by
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EMERGENCIES IN PALLIATIVE CARE Emer
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SEIZURES IN PALLIATIVE CARE Seizure
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NALOXONE IN PALLIATIVE CARE Naloxon
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CARE OF THE DYING PATIENT If you th
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THE ROLE OF JUNIOR MEDICAL STAFF IN
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• Ensure adequate ventilation. Tr
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• Paracetamol and salicylate conc
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MANAGEMENT OF COMMON POISONINGS Par
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i i treatment schedule should be us
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i Toxicity Serious toxicity from pu
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conscious level. • Correct electr
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• Correct metabolic acidosis with
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i SEPSIS • Any age, any joint, ma
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Reactive Arthritis • Bed rest plu
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N.B. Remember spontaneous bacterial
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i ALCOHOL WITHDRAWAL MANAGEMENT Ens
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ACUTE DISTURBANCE Guide for medical
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detention certificate must state th
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a person there. Under an EDC, treat
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Appendix 1 SHARING DIFFICULT INFORM
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1. Write down or review what you ar
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CHECKLIST OF REQUIREMENTS This chec
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i • Reactions vary: distress, ang
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• Damaged syringes and siphonage:
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Start-up time (Syringe pumps) What
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• HR increases by 17% and stroke
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PAEDIATRIC FBAO TREATMENT Assess se
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CONSENT TO MEDICAL TREATMENT FOR CH
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CONTRACEPTION AND ABORTION It would
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c) Drugs and catheterisation pack -
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INSTRUCTIONS FOR ANAESTHETIST + ODP
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DRUGS - CIRCULATING NURSE 1. MAKE S
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HELP - NURSE / RESIDENT The followi
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RECOVERY & FURTHER TREATMENT With r
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MAJOR HAEMORRHAGE PROTOCOL 314 adul
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Useful links The Anaphylaxis campai
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