Management of an acute sick patinet
ABC approach as part of ATLS protocol. AVPU.
A = assess for stridor + accessory muscles + central cyanosis → secure airway with head tilt/chin lift, then airway adjuncts e.g. NPA, OPA, I-gel, LMA, then alert anaesthetist if unsuccessful.
B = examine RR, SpO2, chest expansion; give high flow O2 via non-rebreather mask if low SpO2.
C = examine CRT, pulses + BP; 2 wide bore cannulae; cardiac monitor.
Take history (note if primary or secondary), examination + perform further investigations e.g. imaging.
Cardiovascular emergencies: STEMI
STEMI: ABC + O2 (15L) by non-rebreather mask (unless COPD) → Hx, O/E, Ix → Aspirin 300mg oral + Ticagrelor 180mg oral → Morphine 5-10mg IV + metoclopramide 10mg IV → GTN spray/tablet → primary PCI (preferred) or thrombolysis → B-blocker e.g. atenolol 5mg oral (unless LVF/asthma) → transfer CCU
Cardiovascular emergencies: NSTEMI
NSTEMI: ABC + O2 (15L) by non-rebreather mask (unless COPD) → Hx, O/E, Ix → Aspirin 300mg oral + Ticagrelor 180mg oral → Morphine 5-10mg IV + metoclopramide 10mg IV → GTN spray/tablet → LMWH OR Fondaparinux → B-blocker e.g. atenolol 5mg oral (unless LVF/asthma) → transfer CCU.
Cardiovascular emergencies: Acute LVF
Acute LVF: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → sit up → Morphine 5-10mg IV + metoclopramide 10mg IV → GTN spray/tablet → Furosemide 40-80mg IV → if inadequate, isosorbide dinitrate infusion + CPAP → CCU.
Cardiovascular emergencies: Tachycardia
>125bpm. Many just sick with non-cardiac disease i.e. sinus tachycardia, but consider algorithm if not sinus rhythm.
ABC + O2 (15L) by non-rebreather mask (if hypoxic)→ Hx, O/E, Ix:ECG/BP/electrolytes (IV access) → identify + treat reversible causes
- If adverse features (shock, syncope, MI, heart failure) → synchronised DC shock (up to 3x) → amiodarone 300mg IV over 10-20mins → repeat shock → amiodarone 900mg over 24h.
- If stable, note QRS complex.
- Narrow (<0.12s):
- Narrow complex + regular = vagal manoeuvres → adenosine 6mg rapid IV bolus → try 12mg again x 2 (monitor ECG continuously) → if sinus rhythm restored, probably re-entry paroxysmal SVT needing adenosine if re-currence + consider anti-arrhythmic prophylaxis. → If sinus rhythm not restored, possible atrial flutter (consider rate control e.g. B-blockers).
- Narrow complex + irregular = treat as AF → rate control (B-blocker or diltiazem), digoxin/amiodarone if HF.
- Broad (>0.12s)
- Broad complex + regular = VT → amiodarone 300mg IV over 20-60 minutes, then 900mg over 24h. OR SVT + BBB = treat as narrow (vagal/amiod)
- Broad complex + irregular = AF + BBB → treat as narrow; pre-excited AF → consider amiodarone; polymorphic VT = Mg2+ over 10mins.
- Narrow (<0.12s):
Cardiovascular emergencies: Anaphylaxis
Anaphylaxis: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → remove cause ASAP → adrenaline 0.5mg 1:1000 IM → chlorphenamine 10mg IV → hydrocortisone 200mg IV → asthma if wheeze + amend drug chart allergies.
Respiratory emergencies: acute exacerbation of asthma
Acute exacerbation of asthma: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → salbutamol 5mg + ipratropium 0.5mg nebulised → prednisolone 40-50mg oral and/or IV hydrocortisone 100mg IV → theophylline, magnesium sulphate, ITU.
Respiratory emergencies: acute exacerbation of COPD
Acute exacerbation of COPD: Same as asthma, but add antibiotics if infective exacerbations. T2RF more likely so give O2 via venturi mask at 24-28%, maintain SpO2 at 88-92%. NB: hypoxia kills quicker than hypercapnia so high-flow O2 if peri-arrest then review ABG.
ABC + O2 PERI-ARREST HIGH FLOW O2 AND REVIEW → Hx, O/E, Ix(ABG!)→ salbutamol 5mg + ipratropium 0.5mg nebulised → prednisolone 40-50mg oral and/or IV hydrocortisone 100mg IV +ABx! → theophylline, magnesium sulphate, ITU.
Respiratory emergencies: Pneumothorax
Primary… SOB + >2cm rim on CXR = aspirate x2 → chest drain; not SOB + <2cm discharge + OP follow-up in 4 weeks.
Secondary… always admit to treat; SOB + >2cm rim on CXR or >50 years old = chest drain; if not, then aspirate.
Tension… emergency aspiration, but will need chest drain quickly.
Respiratory emergencies: Pneumonia
Pneumonia: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → antibiotics (e.g. amoxicillin or co-amoxiclav) → paracetamol → if low BP, or raised HR, IV fluids as normal.
Respiratory emergencies: Pneumonia
Confusion; AMTS = 8
Ureal >7.5 mmol/L
Respiratory Rate >30/min
Blood pression (systolic) <90 mmHg
Age >/= 65yrs
0-1 = home treatment
2-3=Hospital with oral/IV Abx
Respiratory Emergency: Pulmonary embolism
Pulmonary embolism: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → morphine 5-10mg IV + metoclopramide 10mg IV → LMWH e.g. dalteparin → if low BP, IV gelofusine, then noradrenaline, then thrombolysis.
Gastrointestinal emergencies: Gastrointestinal bleeding
Gastrointestinal bleeding: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → 2 wide bore cannulae (TAKE FBC etc. + group and save + crossmatch 6U, GIVE colloid if low BP or O-negative blood if available) → catheter for strict fluid monitoring → correct clotting abnormalities (give FFP if PT/aPTT >1.5x N range, platelet transfusion if platelets abnormal) → camera (endoscopy) → stop CI drugs e.g. NSAIDs, aspirin, warfarin, heparin → call surgeons if severe.
Gastrointestinal emergency: GI bleed
Coloid vs crystaloid Rx Which fluid when?
give crystalloid (e.g. 0.9% saline) if normal/high, or a colloid (e.g. gelofusine) if BP low; once cross matched, give blood
Gastrointestinal emergency: GI bleed
Correcting clotting abnormalities: FFP/prothrombin/Platelets what/when?
If PT/aPTT >1.5xN => FFP
^ UNLESS due to warfarin => prothrombin complex e.g. beriplex
If platelets <50 x 109/L (and actively bleeding) => platelet transfusion
Neurological emergencies: Bacterial meningitis
Bacterial meningitis: If GP setting, give 1.2g benzylpenicillin if suspicion.
Give antibiotics after LP, unless undue delay. Do a CT scan not always required before LP.
ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → 2 wide bore cannulae (TAKE FBC, blood cultures, glucose etc. GIVE IV antibiotics e.g. 2g cefotaxime, IV fluids, IV dexamethasone) + LP (before antibiotics if possible, and after CT) → consider ITU.
Neurological emergencies: Seizures and status epilepticus
Seizures and status epilepticus:
initial: 1) ensure the airway is patent, (2) put in recovery position to prevent aspiration if patient vomits and (3) check for provoking factors (e.g. plastma glucose, electrolytes, drugs, sepsis)
Status= seizure >5 mins, Rx patient to stop the seizure (status is technically defined as seizure lasting >30mins)
ABC + O2 (15L) by non-rebreathe mask + airway manoeuvres/adjunct + recovery position (to prevent aspiration) → Hx, O/E, Ix →
if seizure for >5minutes, must give drugs → lorazepam 2-4mg IV or IV diazepam 10mg or buccal midazolam 10mg → if still fitting after 2 minutes, repeat diazepam → inform anaesthetist → phenytoin infusion → intubate then propofol.
Neurological emergencies: Stroke
ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix (including CT head) → if ischaemic stroke = thrombolysis if <4.5h ago + <80years old → aspirin 300mg oral → transfer to stroke unit.
If CT shows haemorrhage of any type, discuss with neurosurgery immediately and do not give aspirin or thrombolysis.
Metabolic emergencies: hyperglycaemia in T1 vs T2 DM
Hyperglycaemia in T1DM = DKA; in T2DM = HONK.
Metabolic emergencies: DKA
DKA… diagnose as hyperglycaemia, ketones in urine/blood, acidosis as low pH on ABG – watch out for raised K+.
ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → IV fluid 1L stat, 1L/1h, 1L/2h, 1L/4h, 1L/8h → sliding scale insulin/fixed infusion → find trigger (e.g. infection, MI, missed insulin) → monitor BM, K+ + pH.
Metabolic emergencies: HONK
HONK… diagnose as hyperglycaemia, hyperosmolar ((2 x (Na+ + K+)) + urea + glucose), non-ketotic (no ketones in blood or urine).
Same as DKA management, except half rate of fluids required.
ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → IV fluid 1L stat, 500mL/1h, 500mL/2h, 500mL/4h, 500mL/8h → sliding scale insulin → find trigger (e.g. infection, MI, missed insulin) → monitor BM, K+ + pH.
MEtabolic emergencies: Hypoglycaemia
Hypoglycaemia: <3mmol/L. Conscious = sugar-rich snack e.g. orange juice + biscuits.
Drowsy/vomiting = IV glucose via cannula e.g. 100ml 20% glucose. If no cannula, give IM glucagon 1mg
Metabolic emergencies: AKI
Acute kidney injury: ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → cannula + catheter for strict fluid monitoring → IV fluid 500ml STAT, then 1L 4-hourly → hunt for cause + complications → monitor U&Es + fluid balance.
causes: routine bloods, ABG, urinalysis, US kidneys, drug chart nephrotoxic
complications: fluid overload, hyperkalaemia, acidosis
Metabolic: Acute poisoning
ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → cannula + catheter for strict fluid monitoring → supportive measures (IV fluids + analgesia if appropriate) → correct electrolyte disturbances → reduce absorption (if within 1h e.g. gastric lavage, whole bowel irrigation, charcoal) → increase elimination (generous IV fluids) → psychiatric management.
Metabolic emergencies: Acute poisoning
Specific Rx for
- N-acetylcysteine for paracetamol over line of treatment after 4h on nomogram
- Naloxone if opiates been taken and now slow breathing or low GCS
- Fumazenil if benzodiazepines been taken.
Chronic CV condition: HTN
(management: who to treat/targets)
Hypertension: Treat after ambulatory or home BP monitoring.
Treat if BP >150/95mmHg or 135/85mmHg if any of following present: existing or high risk of vascular disease (IHD, stroke + PVD), hypertensive organ damage (intracerebral bleed, CKD, LVH + retinopathy).
Target BP: if <80 years, aim for <140/85mmHg in clinic and <135/85mmHg ambulatory; if >80 years, add 10mmHg to systolic values.
Target BP in DM
- if end-organ damage (e.g. renal disease, retinopathy) < 130/80 mmHg
- otherwise < 140/80 mmHg
Chronic CV: HTN
<55 = ACE-i;
>55 or black = CCBs
→ A + C
→ A + C + thiazide-like diuretic
→ K+<= 4.5 add spiro // K+>4.5 add high dose thiazide like Rx
--> consider alpha/beta blockers
C=CCB (nottol if oedema/evidence of HF, skip to D)
D=Thiazide: chlorthalidone (12.5-25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) preference to a conventional thiazide diuretic such as bendroflumethiazide
Chronic CV: Chronic heart failure
Chronic heart failure: ACE-i (e.g. Lisinopril 2.5mg daily) + B-blocker (e.g. bisoprolol 1.25mg daily) → increase doses as tolerated
mild/mod → add ARB ( e.g. candesartan 4mg daily)
mod-severe, black → add hydralazine (25mg 8-hourly) + ISMN (20mg 8-hourly)
mod/severe→ spironolactone (25mg daily).
Chronic CV: Atrial fibrillation
Atrial fibrillation: Prevent stroke + control rhythm OR rate.
- Prevent stroke
- Stroke prevention: use CHA2DS2VASc = CCF (or LVF alone), HTN, age > 75 = 2, diabetes, stroke or TIA = 2, vascular disease (e.g. IHD, PVD), age 65-74 = 1, sex – female = 1.
- Score 0 = no treatment; score 1 + male = condsider anticoagulation Aspirin is no longer recommended for reducing stroke risk in patients with AF– not if female; score 2 = warfarin/NOACs aiming for INR 2.5.
- Rhythm control:
- Who? If young/symptomatic AF/first episode/due to treated precipitant e.g. sepsis or electrolyte disturbance.
- How? Cardioversion = electrical or pharmacological (amiodarone 5mg/kg IV over 20-120minutes). Need AC if >48h since onset.
- Rate control:
- Who? Everyone else with HR > 90bpm.
- How? B-blocker (e.g. propranolol 10mg 6-hourly) or rate-limiting CCB (e.g. diltiazem 120mg daily) → add digoxin (1st line if others CI, 62.5-125ug daily).
Chronic CV: Stable angina
3 facets to first-line management:
- GTN spray as required (symptomatic relief)
- 2⁰ prevention (aspirin + statin +cv risks)
- one anti-angina drug (B-blocker – CI = hypotension, bradycardia, asthma & acute HF OR CCB – CI = hypotension, bradycardia & peripheral oedema)
→ increase dose of B-blocker or CCB
→ 2nd anti-angina drug (ISMN (long-acting nitrate), nicorandil (K+-channel activator)
→ urgent revascularisation therapy (PCI or CABG).
even if controlled with medical management, routinely refer for consideration of revascularisation
how to distinguish stable angina vs ACS
Features more likely to suggest N/STEMI: sweating + vomiting, at rest, >15 minutes, no response to GTN, raised troponin = N/STEMI so look at ECG to decide (NSTEMI can be ST depression or normal; NB – ST depression in V1-4 may be anterior ischaemia or posterior infarction),
if no troponin rise = unstable angina
occurs on exertion/emotion and ceases <15mins + responds to GTN, more likely stable angina
Chronic Resp: Chronic asthma
1. SABA + low dose ICS
2. SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
Continue LTRA depending on patient's response to LTRA
3. SABA + low-dose ICS + long-acting beta agonist (LABA) +/- LTRA
4. SABA + MART ( ICS + LABA in single inhaler) +/- LTRA
5. SABA + (medium dose ICS) MART (ICS + LABA) +/- LTRA
6. SABA +/- LTRA:
- + high dose ICS
- + e.g. LAMA/Theophyline
- + seak help
Chronic Resp: COPD Management
COPD: smoking cessation + NRT (bupropion or vareniciline) + annual influenza vaccine + one off pneumococcal vaccine
→ SABA or SAMA as required
→ assess FEV1…
- If FEV1 > 50%, LABA or LAMA (and discontinue SAMA).
- If FEV1 < 50%, add LABA + ICS or LAMA.
→ If still poorly controlled, add LABA + ICS (combination inhaler) OR LABA + ICS (combination inhaler) + LAMA.
- NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
- the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed
- Mucolytics should be 'considered' in patients with a chronic productive cough and continued if symptoms improve
Chronic DM (T1/T2)
T1+2DM: 4 components =
- education & dietary/exercise advice
- CV RF management (aspirin 75mg daily, simvastatin 20-40mg daily)
- annual review of complications (check albumin: creatinine ratio → give ACE-I if microalbuminuria)
- Blood glucose lowering therapy
in T1DM, start with insulin – never use oral hypoglycaemic drugs. e.g. long acting analogues glargine or NPH insulin humulin
In T2DM, if after trial of diet + exercise and HbA1c > 48mmol/mol…
- Metformin 500mg
- sulphonylurea (e.g. gliclazide)
- SGLT2 -inhibitor
- 3 agents OR Insulin therapy
- 4th line: (if not tolerated and BMI>35)
- metformin + sulphonylurea + GLP-1 mimetic
Chronic Neurological: Parkinson's disease
mild PD and worried about finite benefit from levodopa→ Da agonist (ropinirole) or MAO-O inhibitor (rasagiline).
OTHERWISE: co-beneldopa or co-careldopa (i.e. levodopa + peripheral dopa decarboxylase inhibitor – benserazide or carbidopa),
Chronic Neurological: Epilepsy
Epilepsy: means >2 seizures → most first seizures not treated with AED; choice reflects seizure type…
- Generalised TC = sodium valproate;
- absence = SV or ethosuximide;
- myoclonic = SV;
- tonic = SV;
- focal = carbamazepine or lamotrigine.
Each drug has multiple S/Es but if choice of 2 given, SV’s teratogenicity + lamotrigine’s rash should help select most appropriate.
Common SE of neuroelipeptic drugs
- SV = tremor, teratogenicity, tubby;
- lamotrigine = rash, rarely SJS;
- carbamazepine = rash, dysarthria, ataxia, nystagmus, ↓Na+;
- phenytoin = ataxia, peripheral neuropathy, gum hyperplasia, hepatotoxicity.
Chronic disease management: Alzheimer's disease
- Mild/mod = acetylcholinesterase inhibitors,
- only specialist can start
- e.g. donepezil, rivastigmine, alantamine.
- Mod/severe = NMDA antagonist e.g. memantine.
Chronic GI: Crohn's disease
Two principles; induce remission or maintain remission (prevent flare)
- mild = prednisolone 40mg daily oral
- severe = hydrocortisone 100mg 6-hourly IV + supportive (e.g. IV fluids, NBM, antibiotics)
- ^in either case, use rectal hydrocortisone too for rectal disease.
Azathioprine (check TPMT levels, risk of liver/BM toxicity) metabolised to 6-mercaptopurine. If TPMT low, use methotrexate.
Chronic Rheumatology: RA
- Combination of methotrexate + one other DMARD – usually sulfasalazine or hydroxychloroquine.
- After failure to respond to 2 DMARDs,
- severely active RA may be managed with TNF-alpha inhibitor e.g. infliximab.
- short-term glucocorticoids (e.g. IM methylprednisolone 80mg),
- short-term NSAIDs (e.g. ibuprofen 400mg 8-hourly) + gastro-protection (e.g. lansoprazole)
- re-instate DMARDs if dose previously reduced.
Symptom Management: Fever
treat underlying cause + paracetamol as antipyretic – same dose as for analgesia, maximum 4g in 24h.
Symptom Management: Constipation
treat underlying cause + laxative depending on cause and known Cis. Never give laxative if evidence of obstruction.
Stool softener = docusate sodium (high dose = stimulant), arachis oil (rectal);
- CI = arachis oil→ nut allergy;
- good for faecal impaction.
Bulking agents = isphagula husk;
- CI = faecal impaction, colonic atomy;
- can take days to develop effect.
Stimulant laxatives = senna, bisacodyl;
- CI = bisacodyl → acute abdomen;
- may exacerbate abdominal cramps.
Osmotic laxatives = lactulose, phosphate enema;
- CI = phosphate enema → acute abdomen;
- may exacerbate bloating.
Symptom Management: Diarrhoea
Diarrhoea: commonest cause GI infection (especially norovirus + C difficile) so don’t intentionally inhibit quick removal of infectious agents; chronic diarrhoea = loperamide 2mg oral up to 3-hourly or codeine 30mg oral up to 6-hourly (also relief of pain).
Symptom management: Insomnia
Insomnia: corticosteroids prevent sleep – so give in AM. Deal with aspects e.g. noisy environment first. Hypnotics can cause elderly to become very drowsy = risk of falls. If giving hypnotic, start with zopiclone 7.5mg oral nightly in adults (3.75mg in elderly).