Medical Emergencies

Question 1

Immediate mx UGIB

Answer 1

Inspection: AVPU, around bedside, pallor

A

B:
IPPA
tachypnoea if large volume blood loss
auscultate: for aspiration (R base) - be ready to remove mask if haematemesis (might aspirate)

C: 
IPPA
tachycardia likely, hypotension if v severe
Inspect: pallor, reduced JVP
Palpate: pulse, cool peripheries, CRT
Insert 2 large-bore cannulae - take Hb, U&Es, clotting, Group + Cross-match
Fluid resus
Fluid balance chart

D

E: PR

Contact: GOD
V unstable: endoscopy + surgeon in attendance
High risk/ stable: endoscopy within 12h
Low risk: next routine list

Ask about: PPI (NICE advise NOT prior to endoscopy for non-variceal bleed), abx prophylaxis (Co0amox or cipro for 7 days), plan for re-bleed

Senior decision:
platelets and FFP
terlipressin (unless strongly suspect variceal bleed: 2 mg IV initially)

Question 2

Immediate mx DKA

Answer 2

A

B: Kussmaul breathing
auscultate: focus of infection?

C: tachycardia is common (bradycardia usually before arrest)
hypotension

2 large-bore cannulae
bloods: VBG, FBC, U&Es, CRP, LFTs, glucose
Fluid resus: NaCl 1 litre stat + 1 litre over 1 hour (after this can start fluids with KCl)

Catheterise if oliguric

ECG

D:
AVPU (GCS would be better): call HDU/ ICU if impairment
blood glucose
Actrapid 50 units in 0.9% NaCl - 6 units/ hour
(If BG less than 14, consider 3 units/ hour + additional 10% glucose at 100 mL/hr)

E

Request urinalysis
CXR
Hourly EWS + BG
2-4 hourly VBG

Inform senior/ diabetes team

BG should fall by at least 3 mmol/hr (if not, increase rate by 1 unit/hour)

Once blood glucose is below 14, can return to s/c insulin and can E+D - see chart

Question 3

Acute mx hypoglycaemia

Answer 3

Mild (4):
have some sugar! (4 x gluco tabs), 200 mL fruit juice etc.

Moderate (2-3):
if co-operative: sugar!
if uncooperative: glucogel (needs gag reflex)

Severe/ unconscious:
10% glucose 100 mL stat (repeat if remains unconscious)

If pt was on sulphonylurea - consider octreotide

Consider sending bloods/urine for insulin/ sulphonylurea screen if may be iatrogenic

Question 4

Mx Addisonian Crisis

Answer 4

Take bloods

Start NaCl (to reverse hypotension/ hypnatraemia)

Correct hypoglycaemia

100 mg IV hydrocortisone bolus
(+6-hourly QDS for 24-48h)

Question 5

Ix suspected stroke

Answer 5

CT head within 1 hour (can repeat if initially -ve)

Bloods: FBC, U&Es, LFTs, coag screen, glucose, cholesterol
Blood cultures if ?endocarditis
ECG (possibly echo for ?embolus)
CXR

If ischaemic stroke, should have Doppler study (carotid + vertebral)
If young ischaemic, consider thrombophilia screen

Question 6

Mx status epilepticus

Answer 6

First 0-5 minutes
Padded bed rails
Get obs + ECG
Measure out 4 mg lorazepam

A
insert airway inter-ictal period (not during convulsions)
4 mg lorazepam over 2 minutes [IF NOT AVAILABLE 10 mg DIAZEPAM or 10 mg buccal midazolam]

Repeat after 10-20 minutes

B

C:
IV access: VBG, FBC, U&Es, LFTs, bone profile, clotting, anti-convulsant drug, blood toxicology

D: if alcohol abuse/ malnutrition give Pabrinex before hypoglycaemia

E

After 2 doses, call anaesthetist - consider second-line therapy
Phenytoin needs cardiac monitor
Valproate not in women of child-bearing age
Levetiracetam

CXR after ?aspiration

Question 7

Mx anaphylaxis

Answer 7

Remove allergen

High-flow oxygen and preserve airway

0.5 mg adrenaline IM (antero-lateral middle-third of thigh)
Repeat after 5 mins if no improvement

Fluid challenge

Give chlorphenamine 10 mg by IM or slow IV

(Consider CS/ salbutamol as per asthma)

Mast cell tryptase after emergency treatment and 1-2 hours later

Question 8

Mx hyperkalaemia

Answer 8

If ECG abnormal, or K above 6.5:
Give 10 mL 10% calcium gluconate (over 5 mins)
Can repeat up to 4 times - would ideally want cardiac monitoring

Dextrose/insulin infusion:
50 mL of 50% dextrose with 10 units of actrapid over 15 mins
CHECK BLOOD GLUCOSE HOURLY
Can be repeated but would warrant discussion with reg/ renal team

Do blood gas. If acidotic and not fluid overloaded, may need to give bicarb.

Question 9

Meds for acute agitation

Answer 9

0.5-1 mg lorazepam (in old) and 1-2 mg (in young)
can try 10 mg buccal midazolam

if lorazepam contra-indicated, can try haloperidol (not in Parkinson’s or cardiac disease - ideally needs baseline ECG), or other stuff