3. Glasgow Coma Score
Eye MotorVerbal
Doesn’t open eyes Makes no movementMakes no sound
Pain Extension to painIncomprehensible
Voice Abnormal Flexion to PainInnappropriate
Flexion to painConfused, disorientated
Localises
Spontaneously
Orientated
Obeys
1
2
3
4
5
6
4. Paediatric Glasgow Coma Score
Eye MotorVerbal
Doesn’t open eyes Makes no movementMakes no sound
Pain Extension to painInconsolable, agitated
Voice Abnormal Flexion to PainInconsistently Inconsolable
Withdraws from painCries but is consolable
Withdraws from touch
Spontaneously
Smiles, orients to
sounds and interacts
Moves spontaneously
1
2
3
4
5
6
6. Important Immediate Considerations
• Support circulation if required
• Give 100% O2 and treat any seizures
• Give 50ml 50% Dextrose IV stat if hypoglycaemia present
• IV thiamine if there is any suggestion of Wernicke’s encephalopathy
• IV naloxone/flumazine for opiate/benzodiazepine respectively
7. Examination
• OBSERVATIONS
• A patient in sepsis or shock will DIE
• Evidence of trauma
• Stigmata
• Skin
• Smell breath
• Opisthotanus
• Meningism
• Pupils
• Chest, Abdo exam
HR - 123
RR - 34
Temp - 38.8°C
BP - 98/63
SaO2 - 89% on air
8. HISTORY!!!
• From whoever is around
• Ask how they were found
• Mechanism of any injury
• Recent medical history
• Past medical history
• Drug or toxin exposure
21. Management
• ABC!!!
• IV fluid challenge
500mL-1L in adult
20mL/kg in child
Adrenaline Hydrocortisone Chlorphenamine
< 6 months
150 mcg (0.15ml 1 in
1,000)
25 mg 250 mcg/kg
6 months - 6
years
150 mcg (0.15ml 1 in
1,000)
50 mg 2.5 mg
6-12 years
300 mcg (0.3ml 1 in
1,000)
100 mg 5 mg
Adult and
child > 12
years
500 mcg (0.5ml 1 in
1,000)
200 mg 10 mg
22. Acute Coronary Syndrome – with ST elevation
• Aspirin 300mg
• Nitrates or Morphine to relieve chest pain
• Primary PCI or Thrombolysis
23. Thrombolysis
• ST elevation >1mm in 2 or more limb leads OR
• >2mm in 2 or more chest leads
• New LBBB
• Posterior changes
• Deep ST depression
• Tall R waves in V1-V2/3
25. Acute Coronary Syndrome – with ST elevation
• Aspirin 300mg
• Nitrates and Morphine to relieve chest pain
• Primary PCI or Thrombolysis
• Beta blocker
• CXR
• Consider DVT prophylaxis
• Continue medication EXCEPT Ca2+ channel antagonists
26. Acute Coronary Syndrome – with ST elevation
• M
• O
• N
• A
• R
• C
• H
• S
-orphine
-xygen
-itrates
-spirin and atenolol
-eperfusion and ramipril
-lopidogrel
-eparin/LMWH
-imvastatin
27. Acute Coronary Syndrome – without ST elevation
• Early Risk Assessment – GRACE scoring
• Predicts risk of MI/Death in hospital and Death at 6 months
• ALL patients receive Aspirin 300mg and nitrates or morphine
• Lowest risk – conservative management
• Low risk – single 300-mg loading dose clopidogrel and continue for 12
months
• Then conservatively manage
• If recurrent ischaemia then angiography
28. • Intermediate risk & above
• Offer 300mg clopidogrel and continue for 12 months
• Add a glycoprotein inhibitor
• Coronary angiography with PCI if indicated
• Optimise antihypertensive and antilipid medication
Acute Coronary Syndrome – without ST elevation
29. Severe Pulmonary Oedema – Cardiac in Origin
Check patency
Listen to lung fields, check O2 sats
Cap. refill, pulse, blood pressure, heart sounds, hydration
GLUCOSE, Glasgow Coma Scale
Temperature, secondary survey
Airway
Breathing
Circulation
Disability
Exposure
31. Management
• Sit upright
• 100% O2 if no pre-existing lung disease
• IV access & ECG
• Diamorphine 2.5-5mg IV VERY SLOWLY
• Furosemide 40-80mg IV SLOWLY
• GTN spray UNLESS HYPOTENSIVE
• Consider ventilation
32. Broad Complex Tachycardia
• If in doubt treat as VT
• Try to identify the underlying rhythm
• Give high flow-O2
• Connect to cardiac monitor and have defibrillator nearby
• Correct electrolyte abnormalities
• Check for adverse signs
• Obtain 12-lead EC and request CXR
• Obtain IV access
34. Arrest Protocol – Major Points
• 30:2 ratio chest compressions to ventilation
• Continue whilst defibrillator is charging
• During VF/VT arrest give adrenaline 1mg once compressions have
restarted after the 1st shock then every 3-5 minutes
• Amiodarone 300mg also given after first shock
• Single shocks are given followed by chest compressions
• After resuscitation titrate O2 to SaO2 of 94-98% to prevent potential
harm from hyperoxaemia
36. • Give O2 and get IV access
• Assess for adverse signs
• If present, resuscitate
• If not:-
• Correct electrolyte problems
• Assess rhythm
• Get expert help
• Sedation and cardioversion
38. Management
• If haemodynamically compromised DC cardioversion
• Otherwise identify underlying rhythm and treat accordingly
• Consider vagal manoeuvres or giving adenosine
39. Acute Severe Asthma
Severe Attack Life-Threatening Attack
Unable to complete sentences Peak expiratory flow <33% of
predicted or best
Resp rate >25/min Silent chest, cyanosis, feeble
respiratory effort
Pulse rate >110 beats/min Bradycardia/hypotension
Peak expiratory flow <50% of
predicted
Exhaustion, confusion, coma
Respiratory acidosis, Hypoxia
40. Management – General Points
• Nebulised Salbutamol and prednisolone 30mg PO
• Repeat salbutamol if PEF remains <75%
• Monitor vital signs
• For discharge ensure:
• Been stable on medication for 24h
• Had inhaler technique
• Steroid and bronchodilator therapy
• Own PEF meter and have management plan
• GP appointment within 1 week
• Respiratory clinic appointment in 4 weeks
41. Management – General Points
• Sit patient upright and give high-dose O2 via non-rebreathing mask
• Salbutamol 5mg + ipratropium bromide
• Hydrocortisone 100mg IV or prednisolone 50mg PO or both
• CXR to exclude pneumothorax
42. Management – Life-threatening
• Inform ITU
• Add MgSO4 1.2-2g IV over 20 mins
• Give nebulisers every 15 minutes
• Monitor ECG
43. Further Management
If Improving
• 40-60% O2
• Prednisolone 50mg PO for at
least 5 days
• Nebulised salbutamol every 4
hours
• Monitor PEF and O2 saturations
If Not Improving
• Continue 100% O2 and steroids
• Hydrocortisone if not already
given
• MgSO4 if not already given
• Consider aminophylline
44. Acute Exacerbation of COPD
• Presents with increasing cough, breathlessness or wheeze.
• History – ensure you ask
• Usual treatment
• Smoking status
• Exercise capacity
47. Oxygen Therapy
• ALWAYS GIVE OXYGEN
• Amount depends on retention of CO2
• Hence why ABG is so important
• If severely hypoxic 100% O2 and titrate down
• Otherwise controlled O2 therapy
• 24-28% venture mask
• Aim for PaO2 >8.0kPa with a rise in PaCO2 <1.5kPa
48. Management
• Nebulised salbutamol and ipratropium
• IV hydrocortisone and oral prednisolone 30-40mg
• Give antibiotics ONLY if evidence of infection
• Amoxicillin, clarithromycin or doxycycline
• Chest physiotherapy
49. If no response…
• Consider nasal intermittent positive pressure ventilation (NIPPV) if
acidotic or tachypnoeic
• Consider intubation & ventilation if severely acidotic and PaCO2 is
rising
50. Tension Pneumothorax
• DO NOT PERFORM A CXR TO CONFIRM
• Insert either a needle with a syringe partially filled with saline OR a
large-bore Venflon it 2nd intercostal space midclavicular line
• Then request a CXR
• Insert a chest drain
51. Pneumothorax
Primary
• Symptomatic or rim of air >2cm
on CXR?
• If no discharge and follow-up in
outpatients
• If yes aspirate. If successful
discharge and follow-up in
outpatients
• If unsuccessful repeat. If still
unsuccessful put in a chest drain
Secondary
• Symptoms AND >50 AND rim of
air >2cm on CXR?
• If no aspirate then if successful
admit for 24hrs
• If yes (or aspiration
unsuccessful) then put a chest
drain in
54. Management
• ABCs
• High flow oxygen
• Treat hypotension and shock
• Investigate
• Antibiotics
• FOLLOW local guidelines
• But in general co-amoxiclav or cefuroxime AND clarithromycin
• Analgesia
55. Pulmonary Embolism
• USE WELLS SCORE
• Predicts likelihood
• But keep in mind treat the patient not the score/test
• If ‘likely’ CTPA
• If ‘unlikely’ D-dimer, then CTPA if necessary
• Give LMWH as cover if there is any delay
• Use V/Q scan ONLY if allergic to contract media, renal impairment,
they don’t have major cardiopulmonary co-morbidities and there is
availability
56. Treatment
• Assess ABCs and treat accordingly
• If critically ill consider thrombolysis or surgery
• Otherwise IV access and start LMWH or unfractionated heparin
• If systolic BP >90 start warfarin and confirm the diagnosis if not
already done
• If systolic BP <90 treat as such
• Fluids
• Dobutamine
• Noradrenaline
57. Acute Upper GI Bleed
• ABCs
• If not shocked
• Insert 2 big cannulae
• Start slow saline IVI
• Check bloods
• Observations & urine output
• If shocked resuscitate
• Endoscopy
58. Rockall Scoring System for Prognosis
Score
Variable 0 1 2 3
Age <60 60-80 >80
Shocked? No SBP >100
Pulse >100
SBP <100
Pulse >100
Co-morbidity None Any major Renal/liver
failure or
malignancy
Diagnosis Mallory-
Weiss or
normal
All other
diagnoses
Malignancy
Bleeding Visible? None/spot Visible
blood/clot/
spurting vessel
Score >3 means excellent prognosis. >8 means a high risk of mortality
59. Meningitis
• ABCs & Septic 6
• FOLLOW LOCAL POLICIES FOR ANTIBIOTICS
• In general:
• <55yrs cefotaxime 2g/6h slow IV
• >55 years cefotaxime + ampicillin 2g IV/4h
• Aciclovir if virus suspected
60. Lumbar Puncture
• Perform after CT unless mass lesion or raised ICP not evident
CSF in Meningitis Pyogenic Tuberculous Viral
Appearance Turbid Fibrin web Usually clear
Predominant cell Polymorphs Mononuclear Mononuclear
Glucose <1/2 plasma <1/2 plasma >1/2 plasma
Protein >1.5 1-5 <1
Bacteria In smear & culture Often none in smear None seen or cultured
62. Status Epilepticus
• ABCs
• Thiamine if alcoholism or malnourishment suspected
• Glucose 50mL 50% IV unless glucose known to be normal
• IV bolus phase
• Lorazepam 2-4mg
• Give 2nd dose if no response within 2 mins
• IV infusion phase
• If continuing start phenytoin IV and monitor ECG/BP
• Alternative diazepam in 500mL 5% dextrose
• General anaesthesia if required
63. Head Injury
ABC
100% O2
Intubate &
hyperventilate
Immobilise neck
Stop blood loss
Support circulation
Treat seizures
with lorazepam
± phenytoin
Assess GCS
Rapid
examination
survey
Investigations -
U&Es, glucose,
FBC, alcohol,
toxicology, ABG
& clotting
History & Neuro
examination
Evaluate lacerations
Check CSF leak from
nose
Blood behind ear
drum
Palpate neck
posteriorly
for deformity
Radiology
64. Raised ICP
• Elevate head
• Hyperventilate to reduce PaCO2
• Give dexamethasone/mannitol
• Fluid restrict
• Monitor and diagnose
• Definitive treatment = urgent neurosurgery
• Craniotomy or burr hole
67. Insulin & Potassium
• 0.1mg/kg bolus and adjust Insulin
• MONITOR K+
Serum K Amount of KCl to add per
litre of IV fluid
<3.0 40mmol
3-4 30mmol
4-5 20mmol
68. Other Diabetic Emergencies
• Hypoglycaemic coma
• Give 20-30g dextrose IV
• Once conscious give sugary drinks and a meal
• Hyperglycaemic hyperosmolar non-ketotic (HONK) coma
• Suspect in T2DM
• At risk of thrombotic events so heparinise
• Rehydrate with 9L 0.9% saline over 48 hours (1/2 the rate of DKA)
• Replace K+ when urine begins to flow
• Insulin may not be needed
• Hyperlactataemia
• Rare effect of metformin use
• Seek expert help give O2 and treat sepsis
69. Addisonian Crisis
• Patient with known Addison’s in shock
• Oral steroid not increased to cover stress OR
• Forgotten tablets
• OR sepsis causing adrenal haemorrhage
• Measure cortisol and ACTH urgently
• Hydrocortisone sodium succinate 100mg IV stat
• IV fluids and monitor for hypoglycaemia
• Continue hydrocortisone every 6hrs and change to oral steroids once
recovered
• Get specialist advice
70. Acute Renal Failure
• CATHETERISE
• ASSESS HYDRATION STATUS
• INVESTIGATE
• IDENTIFY/TREAT HYPERKALAEMIA
• IF DEHYDRATED FLUID CHALLENGE
• REASSESS
• IF VOLUME OVERLOADED CONSIDER DIALSIS
• CORRECT ACIDOSIS
• TREAT CAUSE
71. Managing Hyperkalaemia
• 10mL Calcium Gluconate IV over 2 min, repeated as necessary
• Insulin + glucose
• Nebulised salbutamol
• Calcium resonium
• Dialysis
90. Classification of Burns
• Superficial
• Superficial partial thickness
• Deep partial thickness
• Full-thickness
Involves only the epidermal layer
Does not blister
Painful, dry, red, blanch with pressure
Involves epidermis and portions of
dermis
Blisters within 24 hours
Painful, red, weeping, blanch with
pressure
Extend into deeper dermis
Damages hair follicles and glandular
tissue
Painful to pressure only
Always blister
Wet or waxy dry
Variable mottled colourisation
Extend through and destroy all layers
of dermis
Injure underlying subcutaneous tissue
Can compromise a limb if
circumferential
Painless
Does not blister
Skin does not blanch
Use streptokinase for non-anterior MI. Tenecteplase if Anterior MI. Alteplase in LBBB.
CXR features – interstitial oedema, bat wing appearance, upper lobe diversion, Kerley B lines, pleural effusion, cardiomegaly if cardiac
Use arrest protocol
Use arrest protocol
Hypotension, chest pain, heart failure, tachycardia >150bpm
If rhythm regular – amiodarone 300mg over 20-60 mins then 900mg over 24hrs. If irregular – AF, treat as AF. Polymorphic VT e.g. torsades des pointes give Mg2+ and beta blockers.
Re-entry circuits
Score 0-1 = home treatment if possible, 2 hospital therapy, >3 = severe pneumonia
Bloods to do:- FBC, U&E, LFT, Glucose, Clotting screen, cross-match 6 units
Mitsuaka Uchikoshi hibernated for 24 days on Mount Rokko with a core body temp of 22 degrees and was still alive. Erica Nordby, a Canadian infant, came to life 2 hours after her heart stopped having a core temperature of 16 deg.
‘J waves, AF, PR elongation, QRS widening, QT elongation
