Septic shock
Give 3
- oxygen
- broad spectrum antibiotics (within 1hr)
- IV fluids
Take 3
- blood cultures (urine, sputum, csf)
- urine output
- ABG (including lactate)
Haemorrhaging shock
- Stop bleeding (may require referral to surgery)
- Raise legs, give fluids (titrated to HR BP and urine output), lease with seniors regarding escalation
- haemorrhage estimated at >30% total blood volume = activate massive haemorrhage protocol (administering O Rh -ve blood until units are cross matched)
- lease with seniors/haematology regarding replacement of RBC and FFP
Anaphylaxis
ROHAS FC!!!
- Reassure patient
- Oxygen 15L 100% via NRB
- Help (call peri arrest team to secure airway)
- Adrenaline IM (adult 0.5ml 1:1000 IM in thigh) repeat every 5mins guided by BP, HR and RR
- Steroids (IV Hydrocortisone)
- Fluids (500ml 0.9% NaCl bolus over 15 mins)
- Chlorphenamine IV
Additionally, consider nebuliser adrenaline if wheeze. Measure mast cell tryptase at 1-6h and test for igE mediated reaction with RAST test
ACS
MONARTH!!!
Troponin, D-dimer, BNP
- Morphine (+metaclopramide)
- Oxygen (If sats are under 94% or SOB)
- nitrates (sublingual GTN)
- Asprin 300mg
- Reperfusion (refer for PCI if within 12h otherwise fibrinolysis - alteplase) - repeat ECG
- Ticagrelor 180mg
- Heparin
Secondary prevention (ABCES) Asprin, beta blocker, clopidogrel, ace inhibitor, statin
Acute pulmonary oedema
LMNOP!!
- loop diuretics (furosemide IV)
- diaMorphine (vasodilates)
- nitrates (venodilates)
- oxygen (15L 100% o2 NRB)
- position (sit patient upright)
Broad complex tachycardia
VT, SVT, AF
Pulseless VT > follow arrest protocol
Are there adverse signs? - HF, chest pain, shock
YES - immediate cardioversion (call anaesthetist)
NO - is QRS regular?
Regular = 300mg IV amiodarone Irregular = try IV adenosine (if polymorphic VT try IV mgso4)
Narrow complex tachycardia
Sinus tachycardia, atrial tachyarrhythmia
If irregular - manage as AF
Stable
<48h - synchronised dc shock
- pharmacological cardioversion with Flecainide (or amiodarone if structural abnormality - do echo)
> 48h
- electrical cardioversion if patient has been anticoagulated for 3 weeks on warfarin
- betablocker/calcium channel blocker/ digoxin - if patient is over 65 or has Hx of IHD
Unstable
- Heparinise + sedate + DC cardiovert
Regular
- valsalva manoeuvre or carotid massage
- adenosine (or verapamil if they have asthma)
- if adverse signs = DC cardiovert > amiodarone
- no adverse signs = b-blocker, Ca-b, amiodarone
Bradyarrythmia
If adverse features or risk of asystole:
- 1st: IV atropine
- 2nd: repeat IV atropine to max 3mg, transcutaneous pacing, IV isoprenaline or IV adrenaline
No adverse features - just observe
Asthma
OSHI(E)M!!!
- Oxygen 15L 100% NRB
- Salbutamol nebs
- IV hydrocortisone or prednisolone
- Ipratropium bromide nebs
- escalate to consider MgSo4
- warn ICU/ seniors
COPD
OSHI(E)T!!!
- Oxygen
- salbutamol nebs
- IV hydrocortisone
- ipratropium bromide nebs
- escalate for bipap (or intubation if severely acidotic)
- Theophylline - decided by seniors
- consider antibiotics if sputum is purulent
Pneumothorax
Primary pneumothorax
w/ SOB or >2cm rim of air on CXR?
- YES = senior advice + aspirate (if unsuccessful insert chest drain)
- NO = senior advice + send home/safety net + CXR 2-weekly until recovered
Secondary pneumothorax
- <1cm = Admit for 24hr observation
- 1-2cm = Admit and attempt aspiration
- 2cm+ or symptomatic = chest drain
Tension pneumothorax
- Immediate needle decompression 2nd ICS MCL
- Inform seniors for CXR + Chest drain
Pneumonia
- CURB-65 to assess severity 2 = hospital
- Oxygen (15L 100% NRB) if still hypoxic:
CPAP > NIV > Intubation - Antibiotics (local protocol/contact microbiology)
- Analgesia (paracetamol/ NSAID for pleuritic pain)
Pulmonary embolism
- Calculate Wells score
4 or less = D Dimer
5+ = CTPA - Oxygen
- IV morphine
- Warfarin + LMWH until INR 2.5 for >24hrs
Treatment duration 3 or 6 months (longer if unprovoked) then reassess
If massive PE (w/ haemodynamic compromise) thrombolysis - 50mg bolus Alteplase
Future management -investigate for thrombophilia and malignancy
Upper GI bleed
- calculate blatchford score
- Keep patient nil by mouth + notify surgeons
- Bleep endoscopist
- Give antibiotics and terlipressin if due to Varices
- If massive bleed activate major haemorrhage protocol
- Correct clotting abnormalities
- check for/eradicate H pylori - triple therapy
Meningitis
CT then LP (normal pressure = 10-20cmH2O
- IV Cefotaxime + Ampicillin
(Outside hospital administer IM Benpen) - IV fluids
- Escalate (seniors, ITU, microbiology)
- Consider IV dexamethasone
Encephalitis
Same as meningitis but with impaired consciousness/ odd behaviour
Acyclovir within 30mins for herpes simplex virus (for 2 weeks)
Adjust management following microbiology
Status epilepticus
Start clock and maybe put out early crash call
0 mins - ABCDE
5 mins - 1st dose IV lorazepam or PR diazepam or oral midazolam + senior review
15 mins - 2nd dose IV lorazepam or PR diazepam or oral midazolam
25 mins - IV phenytoin / IV phenobarbital / contact anaesthetists ready for next step
45 mins - rapid sequence induction with sodium thiopental and EEG monitoring in ITU
Raised ICP
LHOC!!!
Lie - elevate head to facilitate venous drainage
Hypotension - correct low BP
Osmotic agents - Mannitol (discuss with seniors)
Corticosteroids - IV dexamethasone (if tumour or vasculitis)
Consider craniotomy or burr hole if risk of coning
Head injury
- Look for battles sign / raccoon eyes / blood on otoscopy (all signs of basal skull fracture)
- CT head
- CT spine
Subarachnoid haemorrhage
- CT/MRI brain
- lumbar puncture to check for bilirubin (Xanthochromia)
- Liaise with seniors, request neurosurgical review, transfer to ICU if falling GCS
- Lie patient flat
- Opioids + anti-emetics
- Nimodipine (prevents arterial spasm)
- Dexamethasone if raised ICP
Stroke
- CT brain (look for haemorrhage)
- Asprin 300mg (if haemorrhage excluded)
- Thrombolysis if
Within 4.5 hours
Haemorrhagic stroke excluded
No contraindications - Also consider future anticoagulation, statin, clopidogrel
- carotid endarterectomy if stenosis >70%
Pheochromocytoma
Sudden onset fear, anxiety, sweating, headaches, hypertension
- Measure urinary metanephrine levels
- alpha blocker following by a beta blocker
- e.g. phentolamine, followed by labetalol
- adrenalectomy after 4-6 weeks (requires lifelong hormone replacement)
Pancreatitis
- Calculate modified Glasgow score PANCREAS (3+ = consider ITU)
- IV fluids titrated to adequate urine output
- Analgesia (pethidine or morphine)
- early threshold for escalation
