Adult Medical Emergency Handbook - Scottish Intensive Care Society

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HYPOGLYCAEMIA INTRODUCTION • Complication of diabetes most feared by patients. • Mild hypoglycaemia common in diabetic patients on insulin and is usually managed by themselves. • Severe hypoglycaemia is that requiring help from another person to treat it. • Unconsciousness caused by hypoglycaemia in hospital setting requires parenteral treatment. • Hypoglycaemia is implicated in 4% of deaths in diabetics under the age of 50 years. RECOGNITION AND DIAGNOSIS • Defined arbitrarily as laboratory blood glucose < 3.5 mmol/l. • Always confirm hypoglycaemia with a laboratory measurement, but treat on basis of BM while awaiting lab result. • Symptoms of hypoglycaemia are age specific, with behavioural change being common in children and neurological symptoms prominent in the elderly - always check blood glucose in patients with suspected stroke or altered conscious level (including confusion). • Most patients presenting with hypoglycaemia will be on insulin or sulphonylurea drugs, e.g. gliclazide. AETIOLOGY In patients with diabetes mellitus on insulin or sulphonylureas (not biguanides i.e. metformin or thiazolidindione) common causes include: • Lack of food. • Unaccustomed exercise. • Alcohol • Excess insulin. • May be more than one of these factors. About 25% of Type 1 diabetic patients have reduced/lost awareness which increases the risk of severe hypoglycaemia. adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11 205
COMMON SYMPTOMS OF HYPOGLYCAEMIA Autonomic Neuroglycopenic Non-specific Sweating Weakness Headache Trembling Visual disturbance Nausea Pounding heart Difficulty speaking Anxiety Tingling Hunger Dizziness Difficulty concentrating Tiredness Drowsiness Confusion UNUSUAL ASSOCIATIONS AND PRESENTATION OF HYPOGLYCAEMIA Cardiovascular Neuropsychological General Prolongation of Focal/generalised Fracture of long QT-interval convulsions bones/vertebrae Atrial fibrillation Coma Joint dislocation Non-sustained Stroke; TIA’s Soft tissue injury ventricular ataxia, choreoathetosis Head injury tachycardia Focal neurological Burns Silent myocardial deficits Hypothermia ischaemia Decortication Road traffic accidents Angina Cognitive impairment Myocardial infarction Behavioural/ Sudden death personality change Automatism/aggressive behaviour Psychosis MANAGEMENT • Maintain ABCDE and oxygenation whilst correcting hypoglycaemia (especially airway). • ALWAYS confirm hypoglycaemia with a laboratory measurement, but treat on basis of BM whilst awaiting lab result. 206 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
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i i SEPSIS AND SEPTIC SHOCK Sepsis
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ANTIBIOTIC MINI-GUIDE FOR ADULTS
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i i • Remember to look for intra-
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i • Commence basic life support (
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ALGORITHM FOR FIRST MEDICAL RESPOND
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ACUTE PAIN MANAGEMENT The effective
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i DO YOU NEED HELP ? Contact the Ac
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i • Angina (rate related): treat
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DATE: Dear “FIRST SEIZURE” APPO
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Review Collapse Algorithm Identifie
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Loss of consciousness YES Perform:
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07.00 to 17.00 Asymptomatic Normal
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i i ADULT ADVANCED LIFE SUPPORT: No
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i NON SHOCKABLE RHYTHMS Cardiac arr
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• Patients should be pain free an
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ACUTE CORONARY SYNDROMES In order t
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IMMEDIATE MANAGEMENT OF ACUTE CORON
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CHEST PAIN PATHWAY - NHS LOTHIAN OP
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LOTHIAN PRIMARY PCI/PRE-HOSPITAL TH
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i Thrombolysis Since the clinical b
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Reperfusion therapy not administere
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i i MILD-MODERATE LEFT VENTRICULAR
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i i Do not hesitate to seek a Cardi
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account any subsequently prescribed
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i rehab team or the BHF nurse, and/
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i i i Referral to ICU should follow
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ATRIAL FLUTTER Characterised by rap
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i Seek senior cardiology advice reg
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Causes • Bradycardia • Electrol
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i i In anterior infarction the deve
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abnormalities develop i.e. second o
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i VASCULAR EMERGENCIES ACUTE THORAC
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i ACUTE STROKE Stroke is a Medical
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STROKE DIFFERENTIAL DIAGNOSIS: COND
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ACUTE STROKE INTEGRATED CARE PATHWA
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ST JOHN’S HOSPITAL CARE PATHWAY A
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Role of D-dimer D-Dimer is helpful
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i Thrombolysis bolus alteplase (rtP
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i MANAGEMENT OF THE ACUTELY ISCHAEM
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i Chapter 4 RESPIRATORY EMERGENCIES
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i i • Decreased respiratory and h
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i i • Co-morbidity. • Multiloba
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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
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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
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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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