EMERGENCIES

Contents
 Sepsis, shock
 chest pain, MI
 arrhythmia
 Stroke
 fall/syncope
 meningitis
 upper GI bleed
 Bowel obstruction
 Haemoptysis
 diabetic emergencies
o Hypoglycemia
o DKA
o HHS
 status epilepticus
 PE
 delirium
 new headache
 Electrolytes
o Hyperkalemia
o Hypokalemia
o Hyponatremia
o Hypocalcemia
 post op fever or hypotension
 Post thyroidectomy
 ectopic pregnancy
 PET
 Alcohol withdrawal
 Osteomyelitis
 Urinary retention
 Ascending cholangitis
SEPSIS

Life threatening organ dysfunction caused by a dysregulated host response to infection

Scores
 NEWS
 qSOFA

Signs of sepsis
 Presentation of a specific infective source e.g. cough & dyspnoea - pneumonia
 Hypotension (SBP <90, MAP <70, or drop of SBP of >40)
 Temp >38.3 or <36
 HR >90
 RR>20
 Signs of poor perfusion to end organs
o Skin: initially warm and flushed, becomes cool, reduced CRT, cyanosis, mottling
o Altered mental status
 o Oliguria

SIRS criteria: 2+ need sepsis 6

 RR >20
 HR >90
 WCC <4 or >12
 Temp <36 or >38.2
 Glucose >7.7 in absence of DM

Sepsis 6
 Give 3
o Oxygen, IV fluids, antibiotics
 Take 3
o Blood cultures, urine output, blood tests incl lactate

Mgmt of ?sepsis
 ATLS
 Senior help if you think septic
 Sepsis 6
o 2 IV lines
o Fluids: 500ml bolus crystalloid
o Bloods: cultures, FBC, U&E, CRP, VBG for lactate, consider troponins
o Broad spec abx according to hospital guidelines
 ECG
 Further ix
o Urinalysis
o Cultures from any potential source
o Imaging e.g. CXR for pneumonia
 Monitor
o UO
o BP
o Lactate
 Further mgmt
o Source control
o Narrowing abx once susceptibility obtained

SHOCK

Causes of shock
 Hypovolaemic
o Blood loss
o Dehydration: vomiting, diarrhoea, poor oral intake
 Cardiogenic
o MI
o Arrhythmia
o PE
o Tension pneumo
 Distributive
o Septic shock
 o Neurogenic
o Anaphylactic
o Adrenal crisis

Examination
 Any active bleeding
 Peripheries
o Cool: hypovolaemic or cardiogenic shock
o Warm: distributive
 Assess volume status
o Dry: mucus membranes, UO, skin turgor
o Wet: periph or pulmonary oedema, ascites
 Heart & lungs

MI

STEMI
 = ACS w/ ST elevation or new onset LBBB or posterior changes
 ST elevation >1mm in 2 or more adjacent limb leads, or >2mm in 2 adjacent chest leads
 Posterior changes = deep ST depression and tall R waves in V1-3

STEMI mgmt
 Routine GTN now not recommended in acute setting unless acute HTN or LVF
 Aspirin 300mg & Ticagrelor 180mg
 Morphine 5-10mg as slow infusion + antiemetic e.g. metoclopramide 10mg IV
o Repeat morphine after 5 mins if needed
 O2 only if sats <94%
 Reperfusion
o PCI available in 120 mins
 Give ticagrelor
 Must have anticoagulant for PCI e.g. enoxaparin
o PCI not available in 120 mins
 Thrombolysis then transfer to PCI centre

NSTEMI
 Troponin + ACS w/o ST elevation
o ECG may show ST depression, T wave inversion, non-specific changes, or be
normal
 Exam- pulse, BP both arms, JVP, auscultate, signs of HF, periph pulses
 Mgmt
o Aspirin 300mg
o Morphine 5-10mg IV + antiemetic e.g. metoclopramide
 Can repeat morphine after 5 mins if needed
o Oxygen if sats <95, breathless, or acute LVF
o Measure troponin
 2nd antiplatelet
o Clopidogrel 300mg or ticagrelor
o Clopidogrel is often given first if ECG is non-diagnostic, before troponin results
 When ACS confirmed, can then give ticagrelor or prasugrel too
ARRHYTHMIA

Ix: FBC, U&E, glucose, Ca, Mg, TSH

SVT
 Vagal maneuvers: blow into 10ml syringe, carotid sinus massage
 IV Adenosine 6ml, up to 3 doses (flush quickly bc absorbs quickly into tissues)
 IV Diltiazem or B blocker
 If fails or pt is unstable, DC Cardioversion (synchronised)

Broad complex tachycardia mgmt

 No pulse: arrest protocol
 Pulse
o O2 if sats <90%
o Get IV access and ECG
o Adverse signs? Of so, call for help, give up to 3 synchronised DC shocks,
electrolyte correction, Amiodarone 300mg IV over 20 mins,
 Shock (BP<90, HR>100)
 Chest pain, or ischaemia on ECG
 Heart failure
 Syncope
o If no adverse signs
 Correct electrolyte disturbances
 Assess rhythm
 If VT or uncertain rhythm, give Amiodarone 300mg IV over 20
mins, then 900mg over 24h (all via central line)

Cardiac arrest rhythms

 Shockable rhythms
o Vfib
o VT
 Non-shockable
o Pulseless electrical activity
o Asystole

FAST CALL

Assessment
 When were they last seen well
 Get vitals on phone and ask for ECG
 ATLS
 Focused Hx
o Time of onset
o Sudden or gradual onset
o Symptoms - limb weakness, facial droop, change in speech, visual loss
o Mimics - headache, seizure, tongue biting, incontinence
  Hx of epilepsy, SOL, previous stroke
 Medications & when last took anticoagulant
 Vasc RFs

Make FAST call

Bedside Ix
 Vitals
 Glucose
 Point of care INR
 ECG ?afib
 Insert IV cannula, at least 20G(pink), should really have 18G (green) for CT
 Bloods
o U&E -renal function for contrast, hyponatremia can mimic stroke
o FBC - platelets for thrombolysis
o coag/INR
o Inflam markers if ?sepsis
 Check recent weight done

EXAM - NIHSS stroke scale

Mgmt
 Non-con CT brain to outrule haemorrhagic stroke and get ASPECTS score
 Multiphase (contrast) CT angio ?large occlusion suitable for thrombectomy
 CT perfusion ?suitable for thrombectomy
 Thrombolysis
o IV alteplase 0.9mg/kg up to max 90kg
o 10% IV bolus, 90% slow infusion

FALL/SYNCOPE

Syncope- rapid onset loss of consciousness of short duration

 As a result of global cerebral hypoperfusion
 With loss of postural tone
 Followed by a spontaneous and complete recovery

Syncope types
 Cardiogenic
o Arrhythmia
o Valve dz
o HOCM
o Rarely MI
 Orthostatic hypotension
 Neurally mediated
o Vasovagal
o Carotid sinus hypersensitivity

Fall causes
  Accidental - multifactorial slip & trip
 Epilepsy
 Hypoglycemia
 Intoxication
 Syncope

Fall mgmt
 Immediate
o Vitals
o ABCDE
o Blood glucose
 Get them onto bed or chair
 Hx
o Witnessed
o What whey were doing
o How they landed
o Pain
o Any cardiac symptoms - presyncope, chest pain
o Any limb weakness or changes in sensation
 PMH, falls RFs
 Medications - anticoagulants
 Exam
o GCS
o Look for injuries
o Take pulse
o Examine all major joints
o cardioresp

MENINGITIS

Hx
 Symptoms
o Headache
o Photophobia
o Fever
o Rash
o Neck stiffness
o SEIZURES or seizure like activity
 VACCINES
 Hx or fhx of TB
 Immune status

Can’t do LP before CT unless sure no raised ICP

Signs of raised ICP
 Altered consciousness
 Vomiting
 Papilloedema
 Focal neuro signs e.g. cranial nerve palsy
  Cushings triad - bradycardia, HTN, resp depression

Mgmt
 Give abx - VACA
o Vancomycin, cefotaxime, acyclovir
o Most likely organisms - neisseria meningitidis, strep pneumo
o Ampicillin if ?listeria e.g. age over 50, immunosupp
 And dexamethasone
 If see blood on LP
o Likely traumatic tap - take 3 samples
o Could be haemorrhage e.g. encephalitis, TB
 LP
o WCC & differential
o Protein
o Glucose
o Gram stain, C&S, PCR

UPPER GI BLEED

Ddx
 Variceal bleed
 Inflam
o PUD
o Oesophagitis, gastritis, duodenitis
 Meds: antiacoag, NSAIDs, steroids
 Trauma e.g. mallory weiss tear from coughing
 Malignancy - oesoph or gastric
 Aortoenteric fistula
 Epistaxis
 Rare: HHT, dieulafoy lesion

Hx - allergies, medication (anticoag), CLD

Exam ?CLD

Mgmt
 Call for help
 ATLS
o 100% O2
o 2 wide bore cannulae
o Take bloods
 FBC, U&E, LFTs, coag, crossmatch 6 units, glucose
 ABG
o Give crystalloids (avoid saline in liver dz, use dex)
 Manage medically
o If variceal - Iv terlipressin or octreotide, prophylactic abx
o IV PPI
 Correct coagulopathy, reverse meds
 Insert catheter to monitor urine output
  If unstable- massive haemorrhage protocol
o Balanced transfusion of RCC, platelets, plasma
o No TXA in upper GI bleed, doesn’t reduce mortality
 Urgent endoscopy if unstable, w/in 24h if stable
o Other options = CT angio, IR angio
 Transfuse if Hb <7 or <8 w/ CVD

Post endoscopy
 Omeprazole
 NPO for 24h, then clear fluids, try light diet after 48h
 Stop NSAIDs, steroids
 Daily bloods
 H pylori testing

Indications for surgery

 Rebleeding
 Bleeding despite transfusion of 6 units
 Rockall score >6
o Glasgow-blatchford used before treatment to decide who to admit and who t
discharge
 Tx: laparotomy, find vessel and underrun

Glasgow blatchford: predicts need for intervention

 If 0, pt can be safely D/C
Rockall score
 Pre and post endoscopy scores
o Pre: predicts mortality
o Post: predicts risk of rebleeding and mortality

BOWEL OBSTRUCTION

SBO causes
 Adhesions
 Hernia
 Stricture due to IBD
 Tumours rare
 Gallstone ileus
 Foreign body
 Adynamic ileus e.g. post-op

Hx
 Symptoms
o Acute onset
o Abdo pain
 Periumbilical
 Cramping, every 4-5 mins
 Focal and constant pain may indicate peritonitis
 Sudden severe pain may suggest acute intestinal perforation
o N&V
o Abdo distension
 o Obstipation
 Usually 12-24h after onset of symptoms
o Haematochezia - tumour, ischaemia, IBD, intussusception
 RFs
o Surgery
o Hernia
o IBD
o Hx or RFs for cancer
 Exam
o Signs of dehydration
o Fever is worrying for infection or bowel ischaemia
o Abdo distension
o Scars
o Hernia
o Auscultation
o Palpable mass - hernia, abscess, volvulus, tumour
o DRE - faecal impaction or rectal mass
 Blood suggests tumour, ischaemia, IBD, intussusception
 Ix
o Bloods
 FBC
 U&E - hypovolemia, hyponatremia, hypokalemia
 ABG - metabolic alkalosis from vomiting, metabolic acidosis from
ischaemic bowel
 Lactate = nonspecific, marker of ischaemia
 Cultures
o Imaging
 PFA - proximal bowel dilation >3cm w/ distal collapse
 Erect CXR ?free air
 Mgmt
o ABCDE - fluid resus, correct electrolytes
o NPO
o NGT decompression if significant distension, N or V
o Abx if bowel compromise suspected
o Analgesia - avoid opioids
 IV paracetamol
 Indications for immediate surgery
o Clinical or radiological signs of bowel compromise
o Closed loop obstruction
o Acute incarcerated hernia
o Intussusception
o Gallstone ileus
o FB ingestion
o Localised SB tumour
 Otherwise treat cause
o If ashdesions, attempt gastrograffin challenge
o Plan for surgery if pt deteriorates or obstruction lasts 3-5 days

Clinical signs of bowel compromise

  Continuous or worsening abdo pain
 Peritonitis
 Fever
 Tachycardia not responding to resus
 Leukocytosis
 Metabolic acidosis

HAEMOPTYSIS

Life-threatening haemoptysis = >150ml of blood in 24h

(roughly a half cup)

Causes
 Acute bronchitis
 Malignancy
 Bronchiectasis incl CF
 PE
 Infection - aspergillosis, TB, lung abscess
 Immune - goodpastures, SLE, GPA
 Trauma
 Bleeding d/os

Emergency mgmt
 ATLS
o ABG
o Bloods: FBC, U&E, coag, type & crossmatch, D dimer
o Fluids
 TXA
 Blood products
o PCC & vit K if on warfarin
o Dabigatran - praxbind
o Otherwise PCC & TXA
 Consider intubation w/ large bore ET tube
o Can’t give NIV, will aspirate blood
 Bronchoscopy and CT ideally w/in 24h
o Bronchoscopy
 Can be done bedside
 Can be therapeutic - guide balloon occlusion, suctioning and thrombus
removal, thermal ablation
o CT once stable
 Alert ICU

PE

Symptoms
 Dyspnoea
 Orthopnoea
 Pleuritic chest pain
 Cough
  Haemoptysis
 LL Swelling, pain, warmth

RFs
 Personal or family hx
 Recent surgery, immobility, obesity
 Older age
 Malignancy
 Pregnancy, COCP use
 Serious illness e.g. covid, IBD
 Long-distance flight

Exam
 Vitals
 Wheeze
 Decreased breath sounds

Ddx
 MI, Heart failure
 Pneumothorax
 Pneumonia
 Pericarditis

Ix
 ABG
o Unexplained hypoxemia and normal CXR = suspicious for PE
o Resp alkalosis, hypocapnia, Widened AA gradient
 Bloods
o D dimer
o Coag
o FBC, U&E, CRP
o BNP & Troponin
 ECG
o Usually sinus tachy
o Arrhythmias a/w poor px
 Imaging
o CXR
 Rule out other pathology
o CTPA
 Not indicated if stable, wells <6, and D dimer negative
 If wells >6 or D dimer positive, do CTPA

Mgmt
 ATLS
o O2 if low sats
o Fluid resus if unstable
 If unable to stabilise
o Thrombolysis, or surgical/catheter directed embolectomy if CI
o Alteplase 10mg over 10 mins, then infusion
  If stable
o Anticoag
 Start w/o imaging if low risk of bleeding and
 High clinical suspicion
 If Imaging will take 24h w/ low suspicion
 Can use LMWH, warfarin, or DOAC
 UFH preferred if unsable
o IVC filter if anticoagulant CI

HYPOGLYCEMIA

Symptoms: want them to be aware at 4, get symptoms at 3

 Neurogenic (sympathetic)
o Pallor, sweating, anxiety, hunger
 Neuroglycopenic
o Slurred speech, confusion, headache
 Severe: seizures, loss of consciousness

Mgmt
 If awake, give 15-20g glucose
o Recheck in 15 mins
o Keep doing this until glucose >4
 Emergency is <3.9
o Typically follows insulin OD or insulin not matched by food intake, or vomiting,
sulfonylureas e.g. gliclazide
o Mgmt of unconscious pt
 Glucagon injection IM if no access
 20% dex

HYPERKALEMIA

Causes
 Inc release from cells
o Pseudohyperkalemia (tourniquet on too long, sample left sitting)
o DKA
o Inc tissue catabolism - major surgery, rhabdo
o Metabolic acidosis
 Reduced excretion
o Acute and chronic kidney dz
o Hypoaldosteronism e.g. Addision’s
o Reduced effective circulating volume
 True volume depletion
 Heart failure
 cirrhosis
 Drug causes
o ACEis/ARBs
o K sparing diuretics e.g. spironolactone
o B blockers
 o Calcineurin inhibitors
o Excess in fluids or supplements

Ix
 Look for muscle weakness or paralysis
 Recheck K and do an ECG
 Assess renal function - hx, check eGFR
 Check glucose bc may be giving insulin
 Check Mg bc need to replace also if treating hyperkalemia

Hyperkalemia is an Emergency if
 Symptomatic: ECG changes or muscle weakness/paralysis
 K>6 w pseudohyperkalemia excluded
 K >5.5 w/ renal impairment and ongoing tissue breakdown
o Or >5.5 and need to be optimized for surgery

Hyperkalemia ECG changes

 Tall tented T waves
 Loss of p waves
 QRS complex broadening

If normal ECG and <6 - treat cause of hyperkalemia

Level <5.5
 Dietary modification
 Diuretics if appropriate
 Bicarb if metabolic acidosis

Emergency hyperkalemia mgmt

 Calcium gluconate to stabilise myocardium
o 10ml of a 10% solution IV over 2-3 mins
 Insulin dextrose to drive potassium into cells
o 10 units insulin followed by 50ml of 50% dextrose
o Don’t replace glucose if >14
o Then continuous infusion of 10% dextrose and close monitoring of glucose over
next 5-6h
 Calcium resonium -reduce oral absorption
 Treat cause
o Withdraw hyperkalemic drugs
o Haemodialysis if due to renal failure
o Loop diuretics if hypervolaemic and renal function is preserved