Adult Medical Emergency Handbook - Scottish Intensive Care Society

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Acute Stroke ...................................................................................132 Thromboembolic Disease ...............................................................139 Suspected Pulmonary Embolism ...................................................141 Ruptured or Leaking Abdominal Aortic Aneurysm .........................142 Management of the Acutely Ischaemic Limb .................................144 Hypertension ..................................................................................145 CHAPTER 4 RESPIRATORY EMERGENCIES ...................................................146 Severe Acute Asthma ....................................................................146 Community-Acquired Pneumonia ..................................................148 Hospital-Acquired Pneumonia .......................................................151 Pneumothorax ................................................................................155 Spontaneous Pneumothorax ..........................................................155 Tension Pneumothorax ...................................................................157 Intercostal Drainage Tube Insertion ................................................157 CHAPTER 5 GASTROINTESTINAL EMERGENCIES ........................................165 Acute Upper Gastrointestinal Bleeding ..........................................165 Treatment and Assessment ............................................................166 Acute on Chronic Liver Failure .......................................................169 Acute Bloody Diarrhoea .................................................................172 Acute Diarrhoea ..............................................................................174 Constipation ...................................................................................175 Assessment of Acute Abdomen .....................................................176 Acute Pancreatitis ..........................................................................178 CHAPTER 6 RENAL, METABOLIC AND ENDOCRINE EMERGENCIES .........183 Acute Renal Failure ........................................................................183 Dangerous Hyperkalaemia .............................................................187 Metabolic Acidosis .........................................................................190 Management of Diabetic Ketoacidosis ..........................................192 Management of Diabetic Hyperosmolar Non-Ketotic Syndrome ...197 Hypoglycaemia ...............................................................................201 Sulphonylurea-induced Hypoglycaemia (SIH) ................................209 Hypercalcaemia ..............................................................................209 Hypocalcaemia - the 5 Common Causes ......................................211 Hypokalaemia .................................................................................213 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11 11
Addison’s Disease ..........................................................................214 Hyponatraemia ...............................................................................216 CHAPTER 7 NEUROLOGICAL EMERGENCIES ...............................................220 Coma ..............................................................................................220 Clinical Assessment of coma .........................................................223 Epileptic Seizures ...........................................................................224 Subarachnoid Haemorrhage ..........................................................227 Meningitis .......................................................................................229 Tentorial Herniation and Coning .....................................................232 Encephalitis ....................................................................................233 Spinal Cord Compression ..............................................................234 CHAPTER 8 ACUTE DETERIORATION IN THE ELDERLY ...............................235 Delirium ..........................................................................................235 Acute Agitated Confusion in an Older Patient ................................238 Falls and Immobility .......................................................................239 CHAPTER 9 EMERGENCIES IN HAEMATOLOGY, ONCOLOGY & PALLIATIVE CARE .............................................................................................242 Neutropenic Sepsis ........................................................................242 Superior Vena Cava Obstruction ....................................................243 Emergencies in Palliative care ....................................................246 Hypercalaemia in Palliative care .....................................................247 Seizures in Palliative care ...............................................................248 Spinal cord compression ................................................................249 Naloxone in Palliative care .............................................................250 <strong>Care</strong> of the dying patient .............................................................252 Standards of care for dying patients LUHT department of medicine for the elderly ..................................................................................253 The role of junior medical staff in the diagnosis of dying ...............254 CHAPTER 10 TOXICOLOGY ................................................................................255 A Guide to Observations and Investigations for the Patient with Acute Poisoning .............................................................................259 Management of Common Poisonings ............................................260 12 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11
Page 1 and 2: Adult Medical Emergencies EDITOR Dr
Page 3 and 4: WGH IN CARDIAC ARREST & LIFE THREAT
Page 5 and 6: RIE USEFUL BLEEP NUMBERS MED REG (w
Page 7 and 8: ST JOHN’S THEATRES 1-9 1 ........
Page 9 and 10: OTHER USEFUL TELEPHONE NUMBERS NAME
Page 11: Management of First Seizure in Adul
Page 15 and 16: EDITOR’S INTRODUCTION The Adult M
Page 17 and 18: DISCLAIMER Every effort has been ma
Page 19 and 20: GENERAL POINTS Medicines • Doses
Page 21 and 22: i as far as is reasonably possible.
Page 23 and 24: i GOOD DOCUMENTATION • Write legi
Page 25 and 26: • Prescribe liquids by writing th
Page 27 and 28: Figure 1 Figure 2 Figure 3 Figure 4
Page 29 and 30: MAKING A DECISION ABOUT RESUSCITATI
Page 31 and 32: THE PATIENT WHO IS NOT COMPETENT TO
Page 33 and 34: i PATIENT DEATHS • See patients w
Page 35 and 36: CHECKLIST OF REQUIREMENTS This chec
Page 37 and 38: ORGAN DONATION Transplants are one
Page 39 and 40: i Always consider telephoning the G
Page 41 and 42: i review arrangements. Include: a)
Page 43 and 44: Immediate investigations are those
Page 45 and 46: i i NOTES ON INITIAL ASSESSMENT ALG
Page 47 and 48: i Exposure, evidence and examinatio
Page 49 and 50: i i 2b. ILLNESS SEVERITY ASSESSMENT
Page 51 and 52: 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
Page 103 and 104:
CHEST PAIN PATHWAY - NHS LOTHIAN OP
Page 105 and 106:
LOTHIAN PRIMARY PCI/PRE-HOSPITAL TH
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
Page 155 and 156:
Antibiotics • Amoxicillin (amoxyc
Page 157 and 158:
MANAGEMENT OF SPONTANEOUS PNEUMOTHO
Page 159 and 160:
• Look at the CXR and mark intuba
Page 161 and 162:
pack. Advance slowly along the infi
Page 163 and 164:
Figure 1a - preparing to insert a c
Page 165 and 166:
i i MANAGEMENT OF CHEST DRAINS •
Page 167 and 168:
Features of a major bleed? • Tach
Page 169 and 170:
i i Contact GI Registrar. ROCKALL S
Page 171 and 172:
i i • Blood, urine and ascitic fl
Page 173 and 174:
• For alcoholic liver disease: th
Page 175 and 176:
Known IBD • Exclude infection. Mi
Page 177 and 178:
• Are any drugs implicated e.g. o
Page 179 and 180:
ACUTE PANCREATITIS Determine severi
Page 181 and 182:
then it would be more appropriate t
Page 183 and 184:
RIE/WGH ACUTE SURGICAL ADMISSION IN
Page 185 and 186:
i i VASCULAR: renal artery disease
Page 187 and 188:
• Examine the urine: proteinuria
Page 189 and 190:
i 1. IMMEDIATE ACTION: STABILISATIO
Page 191 and 192:
METABOLIC ACIDOSIS CAUSES OF METABO
Page 193 and 194:
i MANAGEMENT OF DIABETIC KETOACIDOS
Page 195 and 196:
i Electrolyte replacement • Despi
Page 197 and 198:
• Screen for myocardial infarctio
Page 199 and 200:
• Monitor respiratory rate, ECG,
Page 201 and 202:
Consider Precipitating Factors: •
Page 203 and 204:
likely to be either GKI or sliding
Page 205 and 206:
• If capillary blood glucose is g
Page 207 and 208:
COMMON SYMPTOMS OF HYPOGLYCAEMIA Au
Page 209 and 210:
Always discuss with the metabolic r
Page 211 and 212:
• Abdominal pain • Depression
Page 213 and 214:
• Hypoparathyroidism, surgical.
Page 215 and 216:
i TREATMENT Oral • Sando K 2-3 ta
Page 217 and 218:
• Measurement of plasma renin act
Page 219 and 220:
Flow Chart for the assessment and m
Page 221 and 222:
Chapter 7 NEUROLOGICAL EMERGENCIES
Page 223 and 224:
AETIOLOGY OF COMA Primary neurologi
Page 225 and 226:
EPILEPTIC SEIZURES Epilepsy is a sy
Page 227 and 228:
i DRUGS Initial treatment is with D
Page 229 and 230:
INDICATIONS FOR INTUBATION AND VENT
Page 231 and 232:
LIKELY ORGANISMS • Depend on age,
Page 233 and 234:
TENTORIAL HERNIATION AND CONING •
Page 235 and 236:
• CT scan if focal neurology, rai
Page 237 and 238:
• Assessment of cognition can be
Page 239 and 240:
ACUTE AGITATED CONFUSION IN AN OLDE
Page 241 and 242:
• Drugs: - polypharmacy (>4 drugs
Page 243 and 244:
i Chapter 9 EMEGENCIES IN HAEMATOLO
Page 245 and 246:
on waking, and may be aggravated by
Page 247 and 248:
EMERGENCIES IN PALLIATIVE CARE Emer
Page 249 and 250:
SEIZURES IN PALLIATIVE CARE Seizure
Page 251 and 252:
NALOXONE IN PALLIATIVE CARE Naloxon
Page 253 and 254:
CARE OF THE DYING PATIENT If you th
Page 255 and 256:
THE ROLE OF JUNIOR MEDICAL STAFF IN
Page 257 and 258:
• Ensure adequate ventilation. Tr
Page 259 and 260:
• Paracetamol and salicylate conc
Page 261 and 262:
MANAGEMENT OF COMMON POISONINGS Par
Page 263 and 264:
i i treatment schedule should be us
Page 265 and 266:
i Toxicity Serious toxicity from pu
Page 267 and 268:
conscious level. • Correct electr
Page 269 and 270:
• Correct metabolic acidosis with
Page 271 and 272:
i SEPSIS • Any age, any joint, ma
Page 273 and 274:
Reactive Arthritis • Bed rest plu
Page 275 and 276:
N.B. Remember spontaneous bacterial
Page 277 and 278:
i ALCOHOL WITHDRAWAL MANAGEMENT Ens
Page 279 and 280:
ACUTE DISTURBANCE Guide for medical
Page 281 and 282:
detention certificate must state th
Page 283 and 284:
a person there. Under an EDC, treat
Page 285 and 286:
Appendix 1 SHARING DIFFICULT INFORM
Page 287 and 288:
1. Write down or review what you ar
Page 289 and 290:
CHECKLIST OF REQUIREMENTS This chec
Page 291 and 292:
i • Reactions vary: distress, ang
Page 293 and 294:
• Damaged syringes and siphonage:
Page 295 and 296:
Start-up time (Syringe pumps) What
Page 297 and 298:
• HR increases by 17% and stroke
Page 299 and 300:
PAEDIATRIC FBAO TREATMENT Assess se
Page 301 and 302:
CONSENT TO MEDICAL TREATMENT FOR CH
Page 303 and 304:
CONTRACEPTION AND ABORTION It would
Page 305 and 306:
c) Drugs and catheterisation pack -
Page 307 and 308:
INSTRUCTIONS FOR ANAESTHETIST + ODP
Page 309 and 310:
DRUGS - CIRCULATING NURSE 1. MAKE S
Page 311 and 312:
HELP - NURSE / RESIDENT The followi
Page 313 and 314:
RECOVERY & FURTHER TREATMENT With r
Page 315 and 316:
MAJOR HAEMORRHAGE PROTOCOL 314 adul
Page 317:
Useful links The Anaphylaxis campai
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Adult Medical Emergency Handbook - Scottish Intensive Care Society

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