Adult Medical Emergency Handbook - Scottish Intensive Care Society

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A GUIDE TO OBSERVATIONS AND INVESTIGATIONS FOR THE PATIENT WITH ACUTE POISONING Drug At risk of U&Es LFTs INR CK ABG Drug 12-lead Cardiac Detected Comment level ECG monitor in TOX screen? Amphetamine Hyperpyrexia � � � � � � /ecstasy Antihistamine ECG � � � changes Antipsychotic ↓BP, � � � � � Check CK ECG if ↑temp changes Aspirin Acid-base � � � Level at 2 disturbance if and/or severe 4 hours Benzodiazepine ↓GCS, � � ↓BP, ↓respiration Beta-blocker ↓HR, ↓BP � � � Calcium ↓HR, ↓BP, � � � channel arrhythmia blocker Carbamazepine Ataxia, � � � � Level not ↓GCS, normally ECG urgent changes Cocaine ↑BP, MI � � � � � Iron GI � � � � Level at 4 bleeding, hours acidosis Lithium ↓BP, � � � � Level immediately arrhythmia & at 6 hrs (not in Lithium sample tube) NSAIDs Renal � failure Opiates ↓GCS, � � � � ↓BP, ↓respiration Paracetamol Hepatic � � Level at 4 0-8 h and renal hours failure Paracetamol Hepatic � � � � Level 8-24 h and renal ASAP failure Paracetamol Hepatic � � � � >24 h and renal failure Phenytoin Ataxia, � � � Level not ↓GCS, normally ECG urgent changes Sodium ↓BP, � Level not valproate renal � � if normally failure severe urgent SSRI ↑temp, antidepressants ↑HR � � � � TCA ↑HR, antidepressants arrhythmia, � � � seizures ok if symptomatic ok if symptomatic adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11 259
MANAGEMENT OF COMMON POISONINGS Paracetamol Early features: usually none Late features: nausea, vomiting Toxicity: Ingestion of >150 mg/kg (or >12g) or >75 mg/kg in a high-risk patient may be fatal or cause severe toxicity PRESENTATION WITHIN 8 HOURS OF INGESTION • Give activated charcoal if >150 mg/kg ingested within 1 hour • Measure paracetamol concentration at 4 hours. There is no point in measuring the concentration before this. • Use paracetamol nomogram (shown below) to determine need for treatment. Remember to check if patients have any risk factors. • If paracetamol level is above treatment line, give N-acetylcysteine (NAC). Normally, N-acetylcysteine should not be given until paracetamol levels known. Plasma Paracetamol TREATMENT LINES Plasma Paracetamol (mgl/l) (mmol/l) 200 190 -1.3 180 -1.2 170 160 Normal treatment line -1.1 150 High risk treatment line -1.0 140 130 -0.9 120 -0.8 110 100 -0.7 90 -0.6 80 70 Prognostic accuracy -0.5 60 after 15 hours uncertain -0.4 50 40 -0.3 30 -0.2 20 10 -0.1 0 -0 0 2 4 6 8 10 12 14 16 18 20 22 24 Hours after ingestion 260 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,
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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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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 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
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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
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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
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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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