Adult Medical Emergency Handbook - Scottish Intensive Care Society

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TACHYCARDIA ALGORITHM (with pulse) • Support ABCs: give oxygen; cannulate a vein • Monitor ECG, BP, SpO2 • Record 12-lead ECG • Identify and treat reversible causes (e.g. electrolyte abnormalities) Is Patient stable? Signs of instability include: 1. Reduced conscious level 2. Chest pain 3. Systolic BP< 90 mmhg 4. Heart failure (Rate related symptoms uncommon at less than 150 beats min-1 ) unstable Synchronised DC Shock* Up to 3 attempts • Amiodarone 300mg IV over 10-20 min and repeat shock; followed by; • Amiodarone 900mg over 24h Stable Narrow Is QRS narrow (
ATRIAL FLUTTER Characterised by rapid regular or irregular narrow QRS complexes with a saw-tooth appearance to the baseline. A regular, narrow complex (unless BBB pattern present) tachycardia of 150 bpm should be suspected to be atrial flutter with a 2:1 block irrespective of whether or not flutter waves are obvious on the ECG. Management • Carotid sinus massage/vagal manoeuvres may slow the ventricular response revealing underlying flutter waves and assisting the diagnosis. • Adenosine may also be used to help assist the diagnosis by slowing AV conduction and revealing flutter waves. Rapid IV bolus of 6mg followed by saline flush, up to 12mg IV a total of twice at 1-2 minute intervals may be given if tolerated. Do not use in asthmatics (bronchoconstriction) or those taking dipyridamole, carbamazepine or with denervated (transplanted) hearts (effects prolonged and potentiated). Administration may be accompanied by flushing and/or chest tightness but the half life is short (20 seconds) with clinical effects resolving in about 2 minutes. WARN THE PATIENT. Always run an ECG rhythm strip during administration. Adenosine is contraindicated in 2nd or 3rd degree AV block. • Atrial flutter tends to be sustained and does not respond readily to AV node blocking drugs. Therefore, every patient with persistent atrial flutter should be considered for early cardioversion. • For immediate management consider using the management guideline for atrial fibrillation. • Note that IV Flecainide cardioversion should NOT be used for atrial flutter. It can slow the flutter rate and cause a paradoxical rise in the heart rate to >200bpm. (Increased rate of conduction through a-v node). SUPRAVENTRICULAR TACHYCARDIA Characterised by regular narrow QRS complexes. Three types exist: 1. AV Node re-entry tachycardia. Usually presents in young adults. Commoner in women. Usually no ‘P’ waves visible. 2. AV re-entry tachycardia (the tachycardia associated with WPW). Also presents in young adults. Inverted ‘P’ waves may be seen after the QRS and a pseudo-RBBB pattern in V1. 3. Atrial tachycardia due to enhanced automaticity in an atrial focus. ‘P’ waves visible before the QRS but with abnormal P wave morphology. 120 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
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i Illness Severity and Diagnosis (R
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i Watch for the development of card
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SHOCK Definition & Classification
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i Cuff BP by machine may be extreme
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If no bleeding and platelets
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TRANSFUSION REACTION Figure 1: Algo
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of infusing only 5-10mls of blood.
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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: i i i Referral to ICU should follow
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
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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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Adult Medical Emergency Handbook - Scottish Intensive Care Society

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