• Medical Emergencies and Essential Management

    by  • 18/06/2013 • Medical Emergencies and Essential Management

    Medical Emergencies and Essential Management:

    1. Anaphylaxis
    2. Shock (secondary to large GI bleed)
    3. Pulmonary Embolus
    4. Cardiac arrest
    5. Myocardial Infarction
    6. Paracetamol OD
    7. Opiate OD
    8. Benzodiazepine OD
    9. Beta-blocker OD
    10. Iron OD
    11. Organophosphate Insecticide OD
    12. Warfarin OD
    13. Wide-complex tachycardia
    14. Narrow-complex tachycardia
    15. Asthma ‘Attack’
    16. Tension pneumothorax
    17. Status Epilepticus

     

    Anaphylaxis

    1. PROTECT airway
    2. Fluids (up BP)
    3. ADRENALINE 0.3-1.0ml/1000 solution IM. Repeat at 10-20 minute intervals
    4. HYDROCORTISONE 100mg IV
    5. CHLORPHENIRAMINE (anti-histamine) 10-20mg IV

     

    Shock (secondary to large GI bleed)

    1. PROTECT AIRWAYS
    2. KEEP NBM
    3. Insert 2 large bore cannulae (one in each arm)
    4. X-MATCH 6 UNITS
    5. Take bloods (=FBC, U&E, LFTs, BM, clotting)
    6. HIGH FLOW OXYGEN
    7. CRYSTALLOID INFUSION 1L IV stat
    8. If still shocked –
    9. Give BLOOD (TRANSFUSE)
    10. Correct clotting abnormalities
    11. Set up a CVP line (aim >5cmH2O)- use a Swan Ganz catheter to monitor
    12. Catheterise and monitor urine output (>30mls/hr [0.5ml/kg/hr])
    13. Monitor vital signs every 15 mins
    1. Notify surgeons of all serious bleeds
    2. URGENT ENDOSCOPY FOR DIAGNOSIS

     

    Pulmonary Embolus

    1. HIGH FLOW OXYGEN 100%
    2. MORPHINE 10mg IV and METCLOPRAMIDE 10mg IV
    3. Critically ill = THROMBOLYSIS (=50mg bolus ALTEPLASE)
    4. Start HEPARIN
    5. If SBP <90 = COLLOID INFUSION 500mls stat,. If still no improvement = NOADRENALINE DOBUTAMINE 2.5-10ug/kg/min IV
    6. IF SBP >90 = WARFARIN

     

    Cardiac arrest

    1. SHOCKABLE (pulseless VT/VF) = IV access and CPR 200J shock CPR 2 mins 200J shock 2 mins CPR ADRENALINE 2mg IV 360J shock AMIODARONE 300mg 360J shock.
    2. NON-SHOCKABLE (PEA/asystole) = ADRENALINE immediately 1mg. In asystole = ATROPINE

     

    Myocardial Infarction

    MONA’

    1. OXYGEN 2-4L (target >95% PO2 sats) – caution COPD!
    2. ASPIRIN 300mg PO and CLOPIDOGREL 300mg PO
    3. MORPHINE 5-10mg IV and METCLOPRAMIDE 10mg IV
    4. GTN 2 PUFFS S/L
    5. Later: ATENOLOL 5mg IV, DVT prophylaxis (HEPARIN), ATORVASTATIN 80mg

     

    Paracetamol OD

    1. <6 hours after ingestion in everyone >6yo: ACTIVATED CHARCOLE FIRST! (50g for adults)
    2. Wait 4 hours and take venous blood sample and compare results to paracetamol OD chart
    3. If 8-24 hours after ingestion and above treatment line: give N-acetylcysteine (usual dose = 150mg/kg in 200mls of 5% DEXTROSE over 5-15 mins)

    Opiate OD

    1. Tx: NALOXONE 0.4 to 2 mg/dose IV.
    2. Repeat every 2 to 3 minutes until breathing adequately.
    3. Therapy may need to be reassessed if no response is seen after a cumulative dose of 10 mg.

     

    Benzodiazepine OD

    1. Tx: FLUMAZENIL 0.2 mg IV one time over 15-30 seconds
    2. Repeat with 0.5 mg may be given every minute
    3. Maximum total dose 3 mg. But for patients who respond partially at 3 mg may receive additional doses up to 5 mg

     

    Beta-blocker OD:

    1. Tx = ATROPINE 3mg IV OR GLUCAGON 2-10mg IV and 5% DEXTROSE

     

    Iron OD

    1. Tx = DESFERRIOXAMINE 15mg/kg/hr

     

    Organophosphate Insecticide OD

    1. Tx = ATROPINE 2mg IV every 10 mins

     

    Warfarin OD

    1. Tx = VIT K 5mg IV slow, then if needed PROTHROMBIN COMPLEX CONCENTRATE (‘OCTOPLEX’) 50u/kg IV

     

    Wide-complex tachycardia (ie VT)

    1. Sedation
    2. Synchronised DC shock (100J200J360J)
    3. AMIODARONE 300mg IV over 20-60 mins, then 900mg over 24 hours
    4. CORRECT K and Mg
    5. Refractory = consider – LIDOCAINE/PROCAINAMIDE/FLECAINIDE

     

    Narrow-complex tachycardia (ie AF)

    1. VAGAL MANOEUVRES – avoid carotid massage – risk of releasing embolus
    2. ADENOSINE 6mg bolus IV, then 12mg, then further 12mg
    3. No response – sedate

     

    1. Synchronised DC shock (100J200J360J)
    2. AMIODARONE 300mg IV over 20-60 mins, then 900mg over 24 hours
    3. Consider anti-coagulation = HEPARIN / WARFARIN (CHA2DS2-VASc score)

     

    Asthma ‘attack’

    1. Sit patient upright
    2. HIGH DOSE OXYGEN 100% via NON-REBREATHER BAG
    3. SALBUTAMOL 5mg or TERBUTALINE 10mg
    4. IPRATROPIUM BROMIDE 0.5mg nebulised
    5. HYDROCORTISONE 100mg or PREDNISOLONE 40-50mg PO – IF VERY ILL = GIVE BOTH!
    6. MAGNESIUM SULPHATE 1.2-2.0g IV over 20 mins
    7. SALBUTAMOL nebs every 15 minutes (max 10mg/hr)
    8. CXR (pneumothorax), ECG (arrhthymias)

     

    Tension pneumothorax

    1. Insert a large-bore venflon / needle (14/16 gauge) into the 2nd IC space MIDCLAVICULAR LINE.
    2. Place ABOVE 3rd rib at a 90o angle - to avoid neurovascular bundle

     

    Status Epilepticus (GENERALISED CONVULSION >30 mins)

    1. OPEN and MAINTAIN AIRWAY
    2. Lay in recovery position, remove dentures, INTUBATE if necessary.
    3. HIGH FLOW OXYGEN 100% and SUCTION
    4. IV access and bloods (check also tox levels/anticonvulsant levels)
    5. If ALCOHOL/MALNOURISHMENT = THIAMINE 250mg IV over 10 mins
    6. If HYPOGLYCAEMIA = GLUCOSE 50mls 50% IV
    7. If HYPOTENSION = FLUIDS
    8. Active management:
    9. SLOW LORAZEPAM infusion IV 2-4mg
    10. No response in 2 mins – REPEAT LORAZEPAM infusion
    11. No response – PHENYTOIN 18mg/kg/IVI, rate <50mg/min
    12. Monitor ECG/BP
    13. OR
    14. DIAZEPAM infusion 100mg in 500mls 5% dextrose, rate ~40ml/hr
    15. If no response = GENERAL ANAETHSTHETICS (+ventilation/EEG/ITU)

     

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