ACUTE MEDICAL EMERGENCIESPart 1

SYED RAZACardiologist & Acute Physician

Objectives

• 1. Rapid Assessment• 2.Intial timely management• 3.Asking for help• 4.Liasion with consultant• 5. Do NO Harm• 6.Arrangement for transfer• 7.Communication• 8.Documentation

Acute Coronary Syndrome

• ECG within 10 mins of arrival• Serial ECGs• Cardiac Troponin I/T > 6h from onset pain (± 12h

if negative, and still suspicious of cardiac pain)• CardioDetect• FBC, U+E, LFT, Glucose, Clotting, CRP• CXR (to exclude other diagnoses)• TIMI SCORE (for NSTEMI/UA) – Assess risk factors

Acute Coronary Syndrome• Top Tip: Put an IV cannula in ASAP, cardiac arrest is

possible• OXYGEN high flow, if hypoxic• IV (DIA)MORPHINE 2.5-10 mg + IV METOCLOPRAMIDE

10 mg, if pain severe• PO ASPIRIN 300 mg stat; then 75 mg od• PO CLOPIDOGREL 300 mg stat • (NSTEMI/UA) SC ENOXAPARIN 1 mg/kg bd.• (STEMI) Primary percutaneous intervention (PCI)

Contact BDF• Thrombolysis (if <12h); IV TENECTEPLASE 30-50 mg

• Key Management Decision• (STEMI) PCI or Thrombolysis (both <12h)

Acute Heart Failure

• Top Tip: Find out cause of heart failure (including exclusion of a MI)

• CXR, ECG (MI?)• O2 saturation ± ABG• Urinalysis (nephrotic?)• FBC, CRP, BNP• U+E, LFT, Clotting, Glucose, Troponin I (MI?)

Acute Heart Failure• Sit up• OYXGEN (high flow) if low SPO2• IV MORPHINE 2.5-5.0 mg• IV GTN infusion 10-200 mcg/min • IV FUROSEMIDE 40 mg od (80 mg if creat. 120-200; 120 mg if 200-

400; 250 mg, if 400+)• SC ENOXAPARIN 1 mg/kg (esp, if in AF)

± ?ACS protocol, if ?MI• Key Management Decisions• ECHO (not necessary acutely, will need later to exclude valvular

heart disease or cardiomyopathy)• CPAP• CCU/ITU - Transfer• DC Cardioversion (if new AF/flutter, and <24h)

Acute Kidney Injury• Key Investigations• Urinalysis (heavy proteinuria /microscopic

haematuria = glomerular disease)• U+E, LFT, Bone, Glucose, CK• FBC, ESR, CRP, INR, VBG/ABG• NGAL (Neutrophil Gelatinase associated

Lipocalin)• ECG, CXR• Renal US – exclude obstruction

Acute Kidney Injury• Top Tip: Rehydrate, exclude obstruction (ultrasound),

stop nephrotoxic drugs• Rx underlying cause (especially sepsis, stop drugs)• Assess fluid status• IV + FLUIDS (dry), or• ± PO/IV FUROSEMIDE 80-250 mg od/bd (wet)• ± IV INSULIN 10 units in 50 mls 50% DEXTROSE over 30

mins (if hyperkalaemic)• ± Urinary catheter• Key Management Decisions• IV fluids or diuretics• Dialysis

Severe Acute Asthma

• Assess severity • Peak flow meter• ABG, ECG, CXR• FBC, CRP, U+E, LFT, Bone, Glucose• Sputum culture Blood culture

Severe Acute Asthma• NEB SALBUTAMOL 5.0 mg qds (or continuously

until improvement noted)• NEB IPATROPIUM BROMIDE 500 mcg qds• IV HYDROCORTISONE 100 mg qds (severe) or PO

PREDNISOLONE 30 mg od (less)• OXYGEN, if hypoxic, to achieve saturation of 95-

97%• ± IV MAGNESIUM SULPHATE 2 g, over 20

minutes; can be repeated• +/- Antibiotics

Diabetic Ketoacidosis

• Glucose (BM) + Capillary Blood Test for ketones

• FBC, CRP• U+E, LFT, Glucose, HbA1C ± Troponin I• ECG, CXR• ABG, Blood Culture• Urinalysis (ketones?) ± MSU

Diabetic Ketoacidosis

• INSULIN (ACTRAPID, 50 units in 50 mls N saline), start infusion at 0.1 units/kg/hr

• SC ENOXAPARIN 40 mg od• IV Normal Saline 1 litre stat.500 ml 1st hour,

500ml in 2 hrs, 500 ml in 4 hours ,then as per I/O • + K supplement• Treat if any overt sepsis• Key Management Decision• ITU

Severe Sepsis

• Top Tip: Lack of temperature and/or normal/low WC can indicate a worse prognosis.

• lack of hypotension does not exclude diagnosis.

Severe Sepsis Oxygen if SPO2 < 94%• Blood Culture• IV antibiotics within one hour• Fluid resuscitation• Lactate and Hb• Catheterise, if necessary - and monitor urine output

• Key Management Decisions• ? Need for central IV access• ITU/ventilation – does patient need inotropic or ventilatory

support?• Source control (eg drainage of abscess or removal of foreign body)•

Severe Headache

• D/D Acute Meningitis Subarachnoid hemorrhage SOL

Severe Headache

• Analgesic• Keep NPO• I/V cannula• CBC, CRP, Blood culture if meningitis suspected• I/V Cefotaxime 2 gram stat if meningitis

suspected• Arrange for CT Brain• ? LP

Acute Upper GI Bleed

• Vitals/Postural BP• Rockall score• NPO• Urinary Cath. I/O charting• 2 Large bore (Brown/Grey) i/v cannula• CBC, Clotting, LFT, KFT• Cross match 6 units of blood

Acute Upper GI Bleed• Treat any clotting disorder i.e. FFP, Prothrombin Concentrate Complex, Vitamin K Urinary Cath.• Start volume expander : Gelofusine/N Saline

while awaiting Blood• Ensure if taking Aspirin/NSAIDs/Anticoagulant.• Known peptic ulcer disease• Alert Gastroenterologist

Do:• group and save all patients• act on vital signs• use large-bore cannulas• use CVP access in high risk patients• correct coagulopathy in patients with

cirrhosis. Don’t:• rely on Hb alone to guide red cell transfusion.

Acute Stroke

Key Initial Management

• Brief history• Vitals , examination(neurology),GCS• Gain I/V access. Urinary cath.• Lab: CBC, KFT, Clotting, LFT, BG & ECG ,CXR• Keep NPO until swallow is assessed/Aspirin

rectal if indicated.• Management of hypertension.• Urgent transfer for CT brain

Acute Pulmonary Embolism

• Sudden onset SOB• Pleuritic chest pain• Haemoptysis• Tachycardia /Tachypnea• SPO2 not very reliable• Risk factors for PE • Well’s Score

Initial Work Up

• CXR• ECG• ABG, D-DIMER, Clotting, CBC• Heparin if clinical suspicion is moderate/high

even before diagnosis is confirmed.• Arrange for urgent CTPA.• V-Q scan /US Doppler legs in special cases