Adult Medical Emergency Handbook - Scottish Intensive Care Society

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Dose & Administration Prolonged or recurrent, opioid induced respiratory depression: • If repeated naloxone doses are required, start a continuous intravenous infusion of naloxone via an adjustable infusion pump. • Add 1mg of naloxone (= 2.5ml of 400 micrograms/ml naloxone injection) to 100ml of sodium chloride 0.9% to give a concentration of 10 micrograms/ml. • Calculate the dose requirement per hour by totalling the naloxone bolus doses and dividing by the time period over which all the doses have been given. • Start the IV infusion of naloxone at half this calculated hourly rate. • Adjust the naloxone infusion rate to keep the respiratory rate above 8 (do not titrate to the level of consciousness). • Continue to monitor the patient closely. • Continue the infusion until the patient’s condition has stabilised. • Additional IV boluses may need to be given using naloxone diluted in sodium chloride 0.9% as above. If in doubt, seek advice • Seek and treat the precipitating cause(s) of the opioid toxicity. • Review the regular analgesic prescriptions. Good Practice Point • Naloxone should be available in all clinical areas where opioids are used. (National Patient Safety Agency) • Naloxone is also available in disposable, pre-filled syringes. These doses may be too high for patients on regular opioid analgesics. Resources Professional Palliative Care Drug Information online http://www.palliativedrugs.com/ Community use • Naloxone may be administered IM when IV access is not immediately available • 100 micrograms (0.25ml) naloxone IM should be given and repeated after five minutes if there is no improvement with the first dose. • An IV line should be sited as soon as possible. Key references 1. Twycross R, Wilcock A. Palliative Care Formulary (3 rd Edition) 2007, Palliativedrugs.com Ltd., Nottingham 2. National Patient Safety Agency. Safer practice notice 2006/12 3. Adult Emergencies Handbook. NHS Lothian: University Hospitals Division. 4. Electronic Medicines Compendium. www.medicines.org.uk/naloxone http://emc.medicines.org.uk/emc/ industry/default.asp?page=displaydoc.asp&documentid=647 18/6/07 5. Lothian Joint Formulary. Section 15.1.7. www.ljf.scot.nhs.uk adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11 251
CARE OF THE DYING PATIENT If you think a patient is dying, consider the following points: 1. Discuss the issue with senior colleagues and document any decisions. If you agree that a patient is dying, document clearly in the notes: • “This lady/gentleman is probably dying” or similar: be explicit • Date and time • Who has made the diagnosis • What further action has been taken 2. Review: • Symptom control: Pain relief Relief of distress from breathing Psychological distress Relief of nausea and vomiting • Resuscitation status • Rationalisation of drugs • Hydration • Discussion with next of kin • Discussion with the patient if appropriate 3. Review the patient at least daily to check: • They are comfortable • Prescribed symptom relief is effective • Any issues they wish to discuss • Hydration 4. Speak to relatives regularly to update them about the patient’s progress. 252 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
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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,
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
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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: NALOXONE IN PALLIATIVE CARE Naloxon
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
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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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