Common Medical Emergencies. Part 1

1. ACUTE MEDICAL EMERGENCIES
Part 1
SYED RAZA
Cardiologist & Acute Physician

2. 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

3. 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

4. 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

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

6. 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?)

7. 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)

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. Severe Sepsis
• Top Tip: Lack of temperature and/or
normal/low WC can indicate a worse
prognosis.
• lack of hypotension does not exclude
diagnosis.

15. 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)

16. Severe Headache
• D/D
Acute Meningitis
Subarachnoid hemorrhage
SOL

17. 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

18. 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

20. 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

21. 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.

22. Acute Stroke

23. 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

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

25. 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