Emergencies

General Overview
L i f e s u p p o r t – A L S , AT L S , c h o k i n g
1. C a r d i o
2. R e s p
3. G a s t r o
4. E n d o
5. N e u r o
6. R e n a l
7. H a e m
8. Tr a u m a a n d O r t h o p a e d i c s
9. D e r m a t o l o g y
10.E y e s
 General overview
• A – patency, manoeuvres, adjuncts >>airway involve (e.g. burns) – ANAESTH
• B – no resp effort?> ARREST TEAM
• C – no palp pulse?> ARREST TEAM
• D – GCS<8 – ANAESTH

• *Senior help if: deteriorating/assess risk factors/’adverse signs’

• Position pt – sit up/lay flat with legs up

• 15 L/min O2
• Monitor vitals(pulse ox, defibr ECG, urinary catheter, art/CVP line)– take full set of obs
• Brief Hx/notes/drug chart & Ex (remember MSE) – consider likely and serious causes and Rx
• Analgesia
• Venous access (x2)– bloods (clotting, CXM, cultures, cardiac markers, betahcG…) and IV fluids
• Further Ix– ABG, ECG, urine dip, Imaging
• Rx causes if present
• Surgery: NBM, NGT, prophylactic abx, CXR, ECG
• Call seniors and sites (HDU/ITU/Theatres/HASU)
• Reassess starting with ABC……………
 ATLS
• Primary Survey
– Airway with C-spine protection
– Breathing
– Circulation with haemorrhage control
– Disability – brief neuro Ex
– Exposure/Environment
– REASSES ABCDE and consider transfer
• Secondary Survey
– AMPLE History (Allergies, Meds, Past Hx [med/surg/drugs], Last Meal,
Event details)
– Work your way down:
• Head/maxillofacial>Cspine/neck>Chest>Abdo>Perineum/rectum/
vagina>MSK>neuro
 1. Cardiovascular
Well’s Score – DVT – 1 point each:
• ACS Active Ca (Rx past 6mnths
Leg paralysed/plaster
• Pulmonary oedema Bed rest >3d or surgery within 4wks

• Aortic Dissection Collateral veins (non-varicose)

• Pitting oedema
Ruptured AAA Tenderness along veins
• Tachyarrhythmia >3cm calf swelling
Whole leg swollen
• Bradyarrhythmia
-2 point if other Dx as likely
• Hypertension
• Shock Score 0 – low (3%) – Ddimer, if +ve USS
Score 1 – mod (17%) – Rx as DVT
• Anaphylaxis Score 3 – high (75%) – Rx as DVT
• Acute limb pain
 Aortic Dissection
• Sx: splits media sequentially
– Aortic incomp > inf MI
– Carotids > hemiplegia
– Subclavian > Unequal arm pulses/bp
– Ant spinal artery > paraplegia
– Renal > Anuria

• Bloods: FBC, U&E, Clot, CXM-10units

• Fluids: Keep SBP <100 (IVI labetalol/esmolol – short t1/2)
• Further Ix: ECG, CXR, CT/MRI or ToE
• Rx:
– Type A (asc aorta involv) – tamponade risk – aortic root repl (Dacron) –
high mort (10-20%)
– Type B (no asc aorta involv) – conservative – Betablockers prevent
further extension, if 2ary ischaemia>revascularise
 Ruptured AAA
• Bloods: FBC, U&E, LFT, amylase, clot, CXM 10units
• Fluids: Oneg if desperate – keep SBP<100
• Further Ix: ECG, CT
• Call seniors: vasc surg, anaesth, warn theatre
 ACS Pharm
• ALL: • For STEMI: add…
– O2 rebreather – PCI
– Aspirin300mg PO + – Thrombolysis
Clopidogrel300mg PO • Strepto 1.5Mu in 100ml of
saline
– Diamorphine2.5mg IV +
• tPa with IV heparin
Metoclo10mg IV
• For NSTEMI: add…
– GTNspray – not if SBP≤/inf MI
– Enoxaparin 1 mg/kg bd sc if PCI
– Metoprolol IVSTEMI/PO NSTEMI -
> Δbisopstable
planned in next 24-36h
– High risktrop/ST/TIMI≥3/pain
– Insulin slid scale BG>11
• AbciximabGlypIIb/IIIa
– IV fluids
Next day: Aspirin75mg + Clopidogrel75mg + Simvastatin 40 mg od
When stable: Ramipril2.5 mg bd po + Bisoprolol 1.25 mg od
ASAP: wt, diet, exercise, smoking, DM
 Thrombolysis in MI
• TIMI Scoring (ASSARSE)
– Age >65
– Severe angina (≥2 epis in 24h)
– Stenosis (>50%)
– Aspirin use (last 7d)
– Risk factors (>3 of BP/DM/smok/Chol/FHx)
– ST seg change (>0.5mm)
– Elev troponin

• Early Invasive Rx for NSTEMI/USA? (angiography ± revasc within 48h)

– TACTICS-TIMI 18 trial
– Trop elev or ST seg change or TIMI ≥3
– Better long term outcome with early invasive (but inc in-hospital mort)
 Pulmonary oedema
• Sit up, 15L/min O2
• Life threatening? Anaesthetist, CPAP, ITU
• Furosemide40-120mg IV
• Diamorphine 1mg boluses (rep up to 5mg, watch RR) + Metoclopr 10mg

• Systolic >100: 2 sprays of S/L GTN then IVI GTN – keep SBP>100
• Systolic <100: shock Rx (MC cardiogenic), inotropes, senior help

• Wheezing: COPD Rx on top

• No improvement: Furosemide up to 120mg, CPAP, Urinary catheter and CVP line,
HDU/ITU
• When stable:
– Identify cause – arrhth,valve lesion, MI
– daily weights, fluid restriction
– Cardiac makers (>12h), Echo (LV function)
– ACEi, Bblocker, spironolactone (if high dose furosemide)
 Pharm: AF

N.B Give heparin for all

 Hypertension emergency
• Malignant Hypertension (>200/120, retinopathy, ↑ICP Sx, ↓GCS)
– Reduce DBP<100 over first 24h – if early feats use oral, late feats use IV
– No LVF? Labetalol
– LVF? Furosemide (40-80mg IV) + nitroprusside/hydralazine
– Consider ACEi to counteract circulating renin – BP can drop rapidly!
– Admission to monitored area (HDU/ITU)

• Hypertensive encephalopathy (as above, can be mild BP rise, seizures/coma)

– Reduce DBP<100 over first 1-2h
– Correct electrolyte abnorm and give Furosemide 40-80mg IV
– 1st line: Nitroprusside
– 2nd line: Labetalol and CCB (amlodipine or nifedipine MR not nifedipine IR_
– Consider ACEi to counteract circulating renin – BP can drop rapidly!
– Admission to monitored area (HDU/ITU)
Fluid Challenge – determines cause by response
- Note baseline obs (HR, BP, RR, sats, cap refill,
UO)
- Give 500ml of 0.9%sal over 5mins – repeat obs
- Good response? - ↑DBP,↓HR – consider rep
- Failed response? – grossly depleted/adequately
filled
 Shock - Hypovolaemic/Haemorrhagic

– Bloods:FBC, U&E (↑urea – GI bleed, ↓K+ - V/D) LFT, amylase,

clot, osmol, CXM (severe: 4 Oneg+4 type specific+4full match)
– ABG (acid:haem,DKA,panc; alk:vom), ECG
– CXR, pelvicXR, FAST scan(AAA, free intraperit fluid)
– Stool MC&S(ova,cyst,parasites,C.diff)
– Rx:
• O2, flat +legs up if dizzy, call senior, IL saline stat, stop
bleeding
• Another 1L saline if no improv – assess effect, Rx cause
• Early involvement of ITU
 Shock - Septic

– Bloods: FBC(Hb, WCC) CRP/ESR, U&E, LFT, glucose,

clot/fibrinogen, blood cultures (2-3 sets, diff sites)
– ABG (acidosis, ↓BE,↑lactate), ECG, urine dip(blood,prot,nit,leuk,C&S)
– Erect CXR(free air, consolid), Echo(valv lesion/veg – ToE more sens)
– Skin/wound swab(C&S) sputum(C&S)
– Rx:
• O2, flat +legs up if dizzy, call senior, IL saline stat, IV abx
• Another 1L saline if no improv – assess effect, Rx cause
• Central/art line to monitor CVP/multiple ABG
• Early involvement of ITU –inotropes/vent
– Early Goal Directed Therapy: restore tissue perfusion and O2 delivery with
early admin of abx – Surviving Sepsis Campaign
 Shock - Cardiogenic

– Immediate Echo(bleep on call cardio: dissect/tamponade/PE/LVF)

– ECG (isch, small complexes)CXR(pneumothorax, cardiomeg)
– ABG (hypox)
– Bloods: FBC, U&E, glucose, clot, CXM
– Rx:
• 15L/O2 min, treat cause
 Shock - neurogenic
• Symptoms: motor/sens dysf below lesion, bowel/bladder dysf
• Signs: hypoten, warm periph, if above T1-T4 cannot mount
tachy, upgoing plantars, loss of anal tone
– Rx:
• O2, flat +legs up if dizzy, call senior, IL saline stat, IV abx
• Catheterise
• Seniro help – spinal/ortho/anaesth(e.g. if epidural caused)
• Early inovlvement of ITU
 Anaphylaxis
• Sit up, unless hypotensive – lay flat legs up
• 15L/min O2, secure airway
• Hx/Drug chart/Ex: Remove precipitant
• 0.5mg adrenaline IM (0.5ml of 1:1000)
• Fluids: 1L 0.9% saline stat
• Chlorphenamine 10mg and hydrocort 200mg slow IV
• Neb salb 5mg or adrenaline 5mg
• Senior help
• FU: immunologist, epi pen
 Acute limb pain
• Ex: All limbs – vasc, neuro, joints
– Localised to joint/specific area?
– Distal sensation, pulses, cap refill? Ischaemia
– Doppler - pulses
• Ix:
– Bloods: FBC, ESR, U&E, CRP, CK, ±cardiac markers, ±sickle cell, Ddimer, clot, G&S
– ABG, ECGMI/AF analgesiaIV morph
• Senior help and reassess
• Causes:
– Acute isch – O2, analgesia, heparin, vasc surgeons
– Compartment syndrome – O2, remove plaster, ortho
– Septic arthritis – O2, joint aspiration, ortho
– Necrotising fasciitis – O2, fluids, IV abx, surgeons
– Gangrne – O2, fluids, IV abx, surgeons
 Acute limb ischaemia Irrevers after 6h
Worrying signs –
sens, purple/non-blanching mottling
• Causes:
– Thrombosis (60%): athero, graft stenosis, aneurysm, coag/thrombophilia
– Embolus (30%): AF, mural thrombus, valves (IE, RF, prosthetic),
atheroma/chol emboli, aneurysm, atrial myxoma
– Trauma: fracture, iatrogenic(arterial cannulation, IA drug admin)
• Sx: 6 Ps – confirm pulseless with Doppler probe
• Ix:
– Bloods: FBC(WCC) U&Erenal fail Ckrhabdo clot, thrombophil screen
– Urine: dip and urinalysismyoglobin
– ABGacidosis/lact ECGisch/AF
– Imaging: arterial duplex, angio, CT angio(AAA/aortic diss)
– Echo(cardiac source), 24hr HOLTER (later – arrhythmias)
• Rx:
– ABC, O2, analgesia
– Fluids, CVP line and catheter, NBM, IV heparin
– Thrombus suspected:
• angiography, IA thrombolysis (strepto/tPA: 4-24hrs), angioplasty/stent
• Unsalvageable: emergency reconstruction or amputation
– Embolus suspected:
• Embolectomy with Fogarty catheter and on table angiography, thrombolysis if unsuccess
• Emergency reconstruction ± fasciotomy, amputation
• Complications
– Reperfusion injury – Reintroduced O2 supply > O2 free radicals > endoth damage
• Leads to metabolic comps (acidosis, ARDS, myoglobinaemia) or compartment syndrome
 Gas (wet) gangrene
• Sx: shock, brown/black with blistering and oedema,
crepitus
• Ix:
– Bloods: FBC, U&E, LFT, CRP, CK, bld cultures, clot
– Gram stain of pus/necrotic tissue
– ABG, XR(gas)
• Rx:
– O2, fluids
– IV benpen, clinda, metro
– Surgical debridement
• Complications: amputation, sepsis, death
 Compartment syndrome
• Sx: pain (disproportion, passive stretch), neuro Sx,
pulse/pallor(late)
• Risks: long bone fracture/plaster cast, crush/vasc injury, anticoag,
burns
• Ix:
– Urine dip
– Bloods: FBC, U&E, CK, clot
– Comp pressure – Wick catheter – Δ30 from DBP
• Rx:
– Lie flat, elevate limb, O2, analgesia, IV fluids (monitor UO)
– Remove plaster cast
– Discuss with ortho re: fasciotomy
• Complications: rhabdo, K+, neuro damage, amputation
 2. Respiratory
PE risk scoring - BTS
Major
• Breathless/low sats overview Surgery, Fracture
Ca
Prev DVT/PE or v.v.
• Asthma Minor
Late preg

• COPD – acute exacerbation Oestrogens, obesity

Thrombotic disorder
Long distance travel
• Pneumonia Indwelling catheter

A. PE Sx
• PE B.
C.
Absence of alt explanation
Major risk factor

• Simple pneumothorax HIGH prob – A+B+C:

start LMWH and request imaging
• Tension pneumothorax INTERMEDIATE – A+ B or C:
Check D Dimer – if positive then LMWH
and request imaging
LOW - A only – see INTERMEDIATE Rx
 Breathless/ low sats overview
• Hx: Cardiac/Resp/Constitutional – inf/Ca
– PE risk factors
• Recent surgery/fracture/immobility/travel
• Oestrogen (female, preg, HRT, OCP), Obesity
• Malig
• Prev PE/DVT, varicose veins
• Central line
• Ix:
– PEFR, Sputum(physio help, inspect, MC&S)
– Bloods: FBC, U&E, LFT, CRP, Ddimer, Cardiac markers, blood cultures
– ABG, ECG, CXR
– Spirometry
• Rx:
– 15L/min O2(titrate for COPD later), sats, ECG then:
• Stridor – call anaesthetist
• Wheeze – nebs
• Shock, reduced air entry, unilat resonance – Rx tension pneumothorax
• Assym air entry and crackles – consider pneumonia
• Symm air entry and crackles, raised JVP – consider LVG
• Normal Ex – PE, cardiac, systemic cause
 Asthma

Chronic treatment – General Priniciples (ETAM)

1. Educate
- Resp nurse specialist and district nurse
- Pt:assess severity based on Sx
- Reinforce meds compliance
2. Technique - inhaler
3. Avoidance
- Allergens (smoke, carpet, grass in summer)
- Prophylactic (dust cover, synth pillows)
4. Monitor – PEFR (2-4/d), adjust drugs accordingly
 COPD
Acute: 24% O2 (sats 88-92%), neb bronchodil, abx, steroids and consider:
- Theophylline (if bronchodil not working), NIV(pH<7.35), ITU
- Discharge plan, resp nurse
Chronic
General
-MDT – pulm rehab, psych, nutrition
-Smoking, immunis, aggressive inf Rx (abx+steroids)
Inhaled
SABA or SAMA
FEV1≥50% - LABA or LAMA (stop SAMA)
FEV1≤50% - LABA+ICS or LAMA (stop SAMA)
LABA+LAMA+ICS
Mucolytics
LTOT – stop smoking
PaO2<7.3 or PaO2 7.3-8 at least one of :
2ary polycyth/pulm htn/ periph oedema/
noct hypoxia
Surgery
Bullectomy (SoB, FEV1≤50%, >1/3 of lung taken up)
Lung vol reduction
Lung tranplant (life exp ≥ 2yrs, no systemic probs/Ca –
improves QOL not survival
 Pneumonia
Ix:
- CXR
- O2 sats, ABG if SaO2<92%/severe pneumonia
- Bloods: FBC, U&ESIADH-atyp, LFT, CRP, blood filmcold
agglut
- Blood/sputumGram/MC&S cultures, atypical serology,
UrinePneum/Legion
- Pleural fluid aspirate – culture
- ECGAF/SVT - sepsis
- Bronchoscopy/BAL – immunocompromised

Rx: Legionella - clarithro±rifamp

- IV fluids, chest physio, abx Chlamydia – tetracycline
PCP – Co-trimoxazole
- Analgesia for pleuritic painparacetamol/NSAID HAP – aminoglyc IV + antipseud
- Tap any effusion/empyema and Aspiration – cef+met
Neutropenic (Gram+ve/Gram –ve/
sendph/prot/MC&S/AFP/cytology
fungal) – as HAP + antifungals
- Intubation/vent support in some patients (speak
to HDU/ITU if ≥3 on CURB-65)
 Tension Pneumothorax
• Surgical emergency, ATLS
• Immediate decompression – large bore cannula 2ics, MCL, affected side
• Chest Drain
– Consent, Check CXR (confirm side and pathology), 45oc position
– Aseptic tech, clean and drape, anaesth 5th ICS MAL
– 2cm transverse incision, above rib, safe triangle
– Dissect down to pleura, insert finger and sweep adhesions
– Remove trochar and insert drain (pneumothorax: towards apex; effusion: towards base)
– Tie drain in place with suture, purse string suture for skin closure
– Attach to underwater seal – water bubbling and tube swinging with each
breath
– Sterile dressing over wound siteImmediate decompression – large bore
cannula 2ics, MCL, affected side
• Repeat CXR – confirm position
 3. Gastro
• Abdo pain overview
• GI perforation
• Wound dehiscence
• Bowel obstruction
• Acute pancreatitis
• Upper GI bleed
• Acute Liver Failure and CLD
• Preparing for surgery
 Abdo pain overview
• Ix:
– Urine dip, MSU, β-hCG
– Bloods: FBC, U&E, LFT, amylase, Ca2+, gluc, ± cardiac markers,
clot, blood cultures
– ABG, ECG(exclude MI)
– Erect CXR, Plain AXR(bowel obstr) KUB/IVU, USSbiliary, CTabdo
– Rx: all get O2, analgesia+antiemetics, catheter, NBM
• Shocked – IV fluids, urgent senior
• Peritonitic – IV fluids, IV abx, urgent senior
• >50yr, sever pain - ?AAA, IV fluids, urgent senior
• Abdo pain and vom - ?obstruction, IV fluids, NG tube, AXR, urgent senior
• GI bleed – IV fluid, urgent senior
 GI Perforation
• Sx: Peritonism, ↑HR,↑RR, ±↓BP, red/absent BS
• Ix:
– Bloods: FBC(↓HB, ↑WCC) ↑amylase, CXMurgent :2-4U
– ABG(acidotic), erect CXR, AXR
• Rx:
– 15L/min O2, IV access – bloods & fluids
– Morphine 5-10mg IV with cyclizine 50mg/8h IV
– IV abx (cef 1.5mg/8h, met 500mg/8h), NGT, urinary catheter, NBM
– Prepare for emergency laparotomy
 Wound dehiscence
• Reassure, opiate analgesia, IV fluidsif deplete
• Cover bowel sterile swabs soaked sal
• Make CV stable > organise theatre
• Theatre
– Bowel insp/sal wash/ wound edge debrided
– Close w deep tension sutures (thick gauge, non
abs)
– Incisional hernia in 50-60%, mort – 20%
 Bowel obstruction
Ix:
- Bloods: FBC( ↑WCC) ↑amylase Causes of obstruction
- ABG(acidotic), erect CXR, AXRdilated bowel/ volvulus Extramural
Adhesions, herniae, masses,
volvulus
• SBO Intramural
Cong –atresia, Hirsch
– Cons: NBM, NGT+ fluids ‘drip and suck’ (1L sal 4-6h) replace lost Tumours, IBD, Divertic,
infarction
K+ Luminal
– Surg: if unwell Faeces, FB, intuss, strictures,
polyps
• LBO Pseudo-obstruction (paralytic ileus)
Post-op, electrolyte, uraemia,
– IV fluids, NBM, refer senior DM, anticholinergic drugs

– Urgent surgery if caecum >8cm otherwise do

colonoscopy/ water sol contrast enema
– Most require surgery except
• Sigmoid volv – sigmoidoscopy and flatus tube
• Faecal obstruction – laxative enema
• Paralytic ileus
– USS/contrast enema/CT – exclude mech obstr
– Cons: (as
Complications: for SBO)
strang, infarction, perforation, hypokal, hypovol
 Bowel ischaemia/infarction
• Sx: Cold extremities, ↑HR,↑RR, ↑T ±↓BP, generalised
tenderness
• Ix:
– Bloods: FBC(↑WCC) ↑amylase
– ABG(acidotic), ECGAF
• Rx:
– 15L/min O2, IV access – bloods & fluids
– Morphine 5-10mg IV with cyclizine 50mg/8h IV
– Anticoagulate with IV heparin, Rx AF if present
– IV abx (cef 1.5mg/8h, met 500mg/8h) NBM
– Prepare for emergency laparotomy
– Consider ITU – poor prognosis
 Appendicitis
• Sx: RIF pain+Rovsing, ↑HR, ↑T ±↓BP, ± peritonism
• Ix:
– Bloods: FBC(↑WCC) ↑ESR/CRP, blood cultures, G&S
• Rx:
– IV access – bloods & fluids
– Morphine 5-10mg IV with cyclizine 50mg/8h IV
– IV abx (cef 1.5mg/8h, met 500mg/8h) NBM
– Peritonitic? Immediate surgery. Otherwise reassess
regularly and wait for surgery
 Acute Pancreatitis
Oedematous – MC
Haemorrhagic –GT/Cullens
Necrotising
• Sx: Cold extremities, epigastricc pain+peritonism,
distention,↑HR, ↑T±↓BP, Cullen’s/Grey-Turner’s
• Ix: Glasgow Prognostic Score
– Bloods: FBC(↓Hb ↑WCC) LFT,↑gluc, ↓Ca2+,↑↑↑amylase, (Severity)
PaO2<8kPa
clot(±DIC) Age>55
– USS(gallstones) CT(pancreatic necrosis) Neuts>15
Calcium<2
• Rx: Raised Urea>16
– 15L/min O2, IV access – bloods & fluids, catheter, monitor Enzymes: AST>125 or LDH>600 IU
Albumin<32g/L
fluid Sugar>10
– Morphine 5-10mg IV with cyclizine 50mg/8h IV
1 – mild, 2 – mod, 3- severe
– IV abx (controversial – trust protocol/microbio) NBM, NGT CRP>150 - severe
– Attack severity – Glasgow Prog score ≥3 – ITU/HDU and
senior help
– Monitor: obs, gluc and daily FBC,U&E, CRP
– Prophylactic LMWH
Complications: DIC/haem/thrombosis, renal/resp fail, sepsis,
pseudocyst/abscess/chronic panc
• Ix
Upper GI bleed
– Bloods: FBC, U&E, LFT, clot, CXM 4-8 U
– ABG, ECGischaemia
– OGD(Dx,biopsy,Rx) – within 4h if variceal, within 12-24h if shocked/sig comorbidity
• Rx
– Protect airway, NBM, 15L/min O2,
– IV Saline stat or Oneg blood(until cross match avail) if shocked
– Monitor vitals every 15mins (CVP line/Swan-Ganz/urinary catheter)
– Assess severity(Rockall - ≤2=low risk; ≥9=high risk), Senior help and HDU/ITU
– Admit for OGD:
• Ulcers
– Cauterise and IV omeprazole80mg stat then 8mg/h for 72h
• Varices :
– Acute: glypressin, esomeprazole40mg PO, sclerotherapy/banding, Sengstaken-Blakemore/TIPS, IV abx(cef 1.5mg/8h)
– Bleeding controlled: glypressin for 3d, propranolol, Rx liver fail cause, TIPS

Rebleeds – 40% will die

In endoscopically proven cases give:
- IV omeprazole80mg stat then 8mg/h for
72h then 20mg/24h PO for 8wks

Signs of rebleed
- ↓:HR, JVP, UO,GCS, BP(late)
- Hametemesis/melaena
 Acute Liver Failure
• Airway: Look inside, suction of secretions, manoeuvres, oro/nasopharyngeal
if tolerated
• Breathing: 15L/min O2, monitor sats and RR Causes of decompensation
• Circulation: - Infection/SBP
– Acute Bloods: FBC(↑WCC), U&E, LFT↑bili, ↑INR, CRP, gluc, amylase, Ca2+, ↓Mg2+, - Drugs – paracetamol/NSAIDs
↓PO4-, blood cultures, paracetamol levels, viral serology
- GI bleed
– IV fluids1L 5%gluc over 4-6h
–
- HypoK+ - ↓renal NH3 clearance
Monitor vitals
• Disability: - HCC
– Glucose – Rx if <3.5
– GCS, pupil reflex, limb tone, plantars
West Haven Criteria
• Exposure:
–
Grade 0 – no pers change
Temp, Hx, Ex
– ABG(resp alk/met acid), ECG, CXR Grade 1 – altered mood/bv
Grade 2 – drowsy, confused,
• Rx: slurred speech
– ↑INR – one off vit K 10mg IV Grade 3 – stupor, v confused,
– Drugs – stop NSAIDS, aspirin, hepatotox; check doses for others restless, incoherent
– Abx prophylaxis cefotaxime±antifungal Grade 4 - coma
– Daily bloods - FBC, U&E, LFT, INR
– Lactulose30-50ml/8h – removes ammonia
– Hypotensive – IV fluids, avoid Na+ = salt poor albumin (blood bank)
– Hypoglycaemia – IV glucose
Complications- cerebral oedema, bleeding, sepsis, renal/resp fail,
hypoglyc/hypoK+, hyperNa+
 Chronic Liver disease
• Slow/reverse disease and prevent superimposed
– EtoH: abstinence Chronic Bloods:
– Viral: INF and rivabarin, immunisationhep A/B FBC, U&E, LFT, clot,
– Autoimmune: immunosup Iron, Ferritin,
• Prevent complications Caeruloplasmin(<50yrs),
– HCC – 6monthly USS and AFP Viral serology hepatitis, EBV, CMV
– Varices – Endoscopy, if med/large/Child Pugh C – Autoimmune screenANA,AMA,ASMA
Propranolol prophylaxis blood cultures
– SBP – prophylactic abx
• Liver transplant
Child-Pugh Severity Score
– Selection based on severity and comorbidities
Albumin, Bili, PT,Ascites, Encep
• 6months no EtoH, <65yrs
Grade A – 5-6 – 100% 1yr
– Independent of severity Grade B – 7-9 – 80% 1yr
• Intractable pruritus in PBC Grade C - >10 – 45% 1 yr
• Recurrent cholangitis in PSC
Complications of Cirrhosis
1. Portal htn > varics, ascites, hypersplenism/thrombocyt
2. Liver dysfunction> enceph, coag, jaundice, hypoalb
3. HCC
 Inpatient prep for surgery
• Consent
• Anaesthetist
• Site marked by surgeon
• Preop bloods in notes, ECG ±CXR, CXMavailable?
• Prophyl: DVTLMWH+TEDS and abx
• Bowel prep and NBM (no food<6h, sips clear<2h)
• Last minute ICE – happy to proceed?

• Booking emergency theatre

– Discuss case with ST1/2 or reg on call
– Enter pt details (theatre no, consultant, N/Sex/A/hosp no/loc)
– Special req (DM, ITU bed, bloods), op site, sign + bleep no
– Inform on call anaesth/reg/theatre coordinator
– Do above checklist
 4. Endo
• Hypoglycaemia
• DKA
• HONK
• Thyrotoxic Crisis
• Myxoedema
• Adrenal insufficiency
• Hypopituitary Coma
• Phaeochromocytoma
 Hypoglycaemic coma
• Sx: rapid onset of odd bv, sweating, pulse,
seizures
• Rx:
– 20-30g dextrose IV (200-300ml of 10%)
– Glucagon 1mg IV/IM (not as good on drunks)
– Dextrose IVI (prolonged hypo)
– When conscious: sugary drink and meal
 Type 1

DKA pH<7.3
ketonuria

• 15L/min O2
• Bloods: FBC, U&E, gluc, osmol, HCO3-, bld cultures
• Fluids: 1L sal stat (then 1,2,4,6h – tailor to pt)
– K+ only in first L if <3.5, when <5.5 - KCl 20mmol
• Finger prick gluc, urine dip for ketones
• Insulin: 6U/h IVI (10U IM until arrives)
– BG<15 - Δ 5%dex and start sliding scale
– Continue until ketones clear/ph N/ eating and drinking then switch
to sc regimen
• ABG, ECG and Monitorhourly – U&E, glucose, venous HCO3-
• NGTGCS<15 NBM12h LMWHuntil mob: comatose or hyperosm>350
• Other:Abx, preg test, bicarb, HDU/ITU
 T2DM

HONK
Plasma osm>340
Gluc>35
gluc/dehydr/confusion

• 15L/min O2
• Bloods: FBC, U&E, gluc, osmol, bld cultures
• Fluids: 1L sal over 30mins (then half rate of DKA)
– Less K+ needed, if Na>155 consider 0.45%sal
• Finger prick gluc, urine dip
• Insulin: Wait 1hr, then 1U/h as initial dose
– BG<15 - Δ 5%dex and start sliding scale
• ABG, ECG and Monitor2hourly – U&E, glucose, osmol
• NGTGCS<15 NBM12h LMWHalways-VTE risk
• Other: Abx
 Thyrotoxic Crisis
• Causes: compl w antithyroid, surg, inf, trauma MI
• Dx: Tc uptake – do not wait!
• O2, 0.9% saline IVI
• AF – Propranolol40mg tds PO/ Dilt + Digoxin + LMWH (DC not work until
euth)
• Thyroid – CBZ, Lugol’s soln4h after CBZ
• Hydrocortisone100mg QDS IV
• Other:
– Treat HF
– Abx
– Cooling – paracetamol, sponging
– Vom – NGT (avoid asp/drugs)
 Myxoedema Coma
• Sx: facies, thyroidectomy scar, goitre
• Treat preferably in ICU
• O2, 0.9% sal/ dexif hypo
• Liothyronine (T3)
• Hydrocortisone100mg QDS IV
• Other:
– Treat HF
– Warming – Bair Hugger
– Abx
– Vent/ICU
 Adrenal insufficiency
• Acute crisis – rapid steroid and fluid resus
– Dexameth (if unDx – no assay interference),
Hydrocotisone preferred (gluco/mineralo)
– Large vol of 0.9% saline (hypovol/hypoNa+)
• Long term–
– Dx with SynACTHen
– Glucocorticoid repl – hydrocort
– Mineralocorticoid repl – fludrocort
– Patient advice: compliance, steroids –illness/stress,
Medic Alert bracelet
 Hypopituitary Coma
• Sx:
– headache opthalmoplegia
– GCS/BP/T/glucose, hypopit Sx
• Dx:
– Bloods: T4,TSH,ACTH,cortisol,glucose
– CT/MRI pit fossa
• Rx:
– Hydrocortisone100mg IV/6h
– T310mcg/12h PO
– Surgery if pit apoplexy
 Phaeochromocytoma

• Hypertensive crisis from: stress, abdo palp,

parturition, GA, contrast media
• Ix:
– Glycosuria – during
– 24h urinary VMA/HMMA
• Rx
– Senior help
– Alpha blockerPhentolamine 2-5mg IV (repeat for safe BP)
– Alpha blockerPhenoxybenz>BblockerPropranolol>Surgery
 5. Neuro
• Coma/ ↓GCS
• Status Epilepticus
• CVA
• Cord compression/Cauda Equina
• Headache
Coma/ ↓GCS
 Neuro obs
CVA
Stroke Risk factors – CHADS VASC
+ smoking + cocaine GCS
Limb movements
Pupils – size, react
• Ix: Vitals – HR,BP,RR,T
– Bloods: FBC, ESR, gluc, U&E, LFT, lipids, cardiac markers, clot,
G&S Bamford classification
– ECGAF/arrhtm, prev inf CXRcardiomeg,aspir CT head TACS (60,35,5 at 1 yr)
– Causes – Echo, Dopplers, MRIdissectionMRAVST 1. Hemiplcontr,
• Acute Rx: 2. Homon hemiancontra
– Resus: 3. Higher cort dysfphasia/praxia/neglect
• O2, blood gluc, vitals (incl neuro obs) and monitor
PACS (15,30,55) – 2/3 TACS
• IV fluids, bloods, NBM, ECG
• Hx (Sx start, progression, thrombolysis Cis) and Ex
LACS (10,30,60) – motor ± sensory only
• Urgent CT POCS (sim to PACS/LACS)
– HASU: Isolated hemianopia
• MDT (physio, OT, SALT – NG/PEG) Brainstem Sx
• DVT prophylaxis Cerebellar
• Alteplase then aspirin300mg stat for 2wks then 75mg) +dipyr (if isch CT)
Parietal lobe Sx
• Surg: decompression/shunt
Dominant
• Chronic Rx: Dysphasia
– Nursing/social care Gerstmann’s
– Secondary prevention: I - Dysgraph/lex/calc
- L-R disorient
– Ischaemic:clopidogrel75mg ; TIA:Aspirin75mg + dipyr200mg/12h
- Finger agnosia
– AnticoagAF, antihtnnotBblock, statin, smoking, exercise
PICA(lateral medullary) Non-dominant
– Carotid endarterectomy Spinothal – contr - Apraxia – dress/construct
pain/T - Spatial neglect :
CN 5 – ipsil pain/T sens/visual inattention
CN 9/10 -
dysarth/dysphagia astereogenesis
Ipsil Horner’s graphaesthesia
 Thrombolysis
• Indications
– Cardiac: MI- within 12 hours of Sx
• CP>30 mins
• ST elev (>2mm in ≥2 chest leads, (>1mm in ≥2 limb leads)
• ST depr (>1mm in V1-V3)
• New LBBB
– Neuro: CVA- within 3 hours of Sx
• Sig Sx, not improving
• Non-haem on CT
• Contraindications
– Absolute: pt refusal, active bleed, prev ICH
– Relative
• Bleeding – anticoag, bleed dis, Hx GI bleed, active dyspepsia
• Trauma – surgery, prolonged CPR, head injury
• Other (the ‘P’s) – Prev CVA in last 3mnths, Pregnancy, Pericarditis
• Types
– Streptokinase: 1.5MU in 50ml 0.9% saline IVI
• Strepto before in last 4days/ SBP<110 – use rtPA
– rtPA( alt/ret/tenect) – give heparin
• Alt – bolus then infusion
• Ret – 2 boluses
• Ten – 1 bolus
Cord Compression/Cauda Equina
– Causes:tumour, trauma, abscess/TB, haematoma,
disc prolapse)
– Cord compression Sx: LMN at lesion, UMN below,
sensory level, spinal shock
– Cauda equina Sx: bilateral ↓weak/reflex(LMN)/sens
↓ anal tone / saddle anaesth
– Ix: MRI spine
– Rx: Ortho/neurosurg
– Complic: weak, ↓ sens, incontinence, impotence
 Headache overview
• Ix: Bloods: FBC, U&E, ESR/CRP, LFT, gluc, clot,
BC
– ABG – esp if ↓GCS
– CT head±LP – discuss with senior
– EEGencephalitis
• Ix: - exclude emergencies and give analgesia
 Headache - SAH
• Ix: CT head, if N – LPxanthochromia bili excludes bloody tap
• Rx – neurosurg help
– O2, lie flat, analgesia(5-10mg morphine + 10mg metoclop
IV/IM)
– Regular neuro obs
– Surgery: Craniotomy and Coiling aneurysm
– Medical:
» Keep systolic >100 but avoid sudden ↑BP
» Nimodipine – vasospasm
• Complications
– Cerebral isch, rebleeding, vasospasm, hydrocephalus
 Headache - Meningitis
• Ix:
– Bloods: FBC, U&E, LFT, gluc, coag screen
– BC, throat swab (1 bact, 1virol) stoolvirus
– CT head, CXR
– LP(see next slide) – meningococcal PCR
» CI: IC SOL, focal neuro, papilloedema, trauma, middle ear path, major coagulopathy
» Send for MC&S, Gram stain, Protein, Gluc, Virol
• Rx:
– ABC, fluids, regular neuro obs
– Septicaemic Sx predom (↓CRT, cold hand/feet, rash): do not LP, cefotaxime 2g iV, shock signs?
>take to ITU
– Meningitic Sx predom (neck stiff, photophobia): dexamethasone, no shock/↑ICP?>LP, cefotaxime
2g IV, ICP signs?>take to ITU
– Immunocompromised/ >55 – ampicillinListeria
– Cefotaxime2-4g/8h IVI for 10d Maintenance fluids, Isolationfirst 24h Intub/vent/inotropes
– Prophylaxis – household/close contacts – rifampicin or ciprofloxacin
• Complications
– ↑ICP, hydroceph, seizures, focal neuro
– Contact public healt – contact tracing
 Headache - Encephalitis
• Ix:
– Blood and viral culturethroat/ MSU
– Enhanced CT head, CXR
– LP – CSF for viral PCR
• Rx:
– ABC, fluids, regular neuro obs
– Aciclovir 10mg/kg/8h IV for 10d and abx as for meningitis
– Dexamethasone
• Complications
– ↑ICP, seizures
 Headache - ↑ICP
• Ix:
– Bloods: FBC, U&E, LFT, gluc, serum osmol, clot, BC
– CT head, CXR
– LP – opening pressure
• Rx:
– ABC, correct hypoten and Rx seizures
– Hx and Ex
– Intubate – hyperventilate to ↓PaCO2 to 3.5kPa
– Mannitol IV – rebound ↑ICP after prolonged
– Dexameth – only if tumour
– Fluid restrict <1.5L/d
– Close monitoring
• Complications
– Herniation
 Headache – Temporal Arteritis
• Ix: ↑↑ESR(>50mm) ↑CRP, FBC(↓Hb, ↑plts)
• Rx:
– Start pred 60mg/24h PO and strong analgesia
– Arrange temporal artery biopsy within 4d
– Liase with ophthalm – visual complic
– Osteoporosis prophylaxis
• Complications: blind, stroke, MI
 6. Renal
• Acute renal failure
• Acute urinary retention
• Rhabdomyolysis
• Tumour lysis syndrome
• Electrolyte abnormalities
 Acute Renal Failure TYPES
Prerenal hypoperfusion
Oliguria
urine osmol>500
• Hx: kidney probs, UO, fluid intake, other medical, urine Na+ <20
nephrotoxic drugs, rashes, bleeding Renal
Oliguria
• Ex: vol status, HR/BP/JVP, basal creps, gallop Haematuria
rhythm, oedema, palp bladder BP
CRF
• Ix: Small kidneys,
– Urine: colour, dip, MC&S, osmol and Na+ Prev abnormal
urea/creat
– Bloods: FBC, U&E, ESR, LFT, CK, CRP, osmol, clot HB, Ca2+, PO4-
– ABGacidosis, K+ ECGK+ signs CXR ATN
Olig/N/Polyuria
– USS: bladder ret/block cath renal, DopplerRAS Urine osmol<350
• Rx: Urine Na+>40
Obstructed
– General – Continue IV fluid unless overloaded (no Pain
KCl), stop nephrotoxic, refer to HDU/ITU for CVP Anuria
monitor, catheterise and monitor UO Palpable bladder
– Obstructed – palp bladder, bladder US, insert URGENT DIALYSIS
catheter Refr hyperkal (>7)
Refr pulm oedema
– Shocked - HR, BP, absent JVP, give fluids Severe met acid(ph<7.2, BE<10)
– Overloaded – oedema, basal creps, JVP, CXR; Uraemia (enceph/pericard)
furosemide
– Hyperkalaemia – ECG, ABG; Ca2+ gluconate,
 Acute Urinary Retention
• Causes: BPH, constip, post-op, pain, antichol,
spinal path/MS(painless) Preg, urethral stricture
• Ix: Bladder US if unsure/ just catheterise
• Rx:
– Urgent catheterisation:
• record urine vol(acute on chronic if >1L), dip, MC&S
– TWOC within 48hrs – recur? Reinsert > Rx as chronic
retention (urologists, TURP/self catheter/finasteride)
• Complications: ARF, chronic obstr
 Rhabdomyolysis
• Causes: lying on hard surface for long time,
crush injuries, strenuous exercise, burn
• Ix:
– Urine: dip, microscopy(no red cells c.f. myoglobin) urate
– Bloods: CK + N trop, Urea±Creat, K+
• Rx:
– As for ARF, may need Na bicarb/surg removal of
damaged tissue
• Complications: ARF, K+
 Tumour Lysis
• Sx: Muscle cramps, seizures, tingling, tetany, spasm, weakness,
syncope
• Bloods:
– LDH/K+/PO43-/urate/urea/creat
– Ca2+
• Rx:
– Hyperhydration with IV fluids, allopurinol, Na bicarb, K+ restrict, PO43- binders,
dialysis
• Prevent:
– Allopurionol24-48h before IV hydration prior to chemo
– Careful monitor of U&E, Ca2+, urate, LDH during
• Complications:
– AR, hyperkalaemia, arrhythmia, CCF
 <120 – irrit, confused
Hyponatraemia <110 – seizures, coma

• Causes:
– Plasma osmol (-MC, -hypergly/hyperton sal, N-Pseudohypo/TURP)
– ECF volume
• interstitial – failures, nephrotic, sepsis, anaphyl, preg
• Limited interstitial – SIADHCNSRespDrugsFluid excess/1ary polydipsia, intake,
hypothyr, Ca
– ECF volume
• urinary Na>20mmol/L – diuretics, Addison’s, bicarb/ketonuria, CWS
• urinary Na<20mmol/L – D&V, blood loss, sweat, 3rd spacing
• Rx:
– Na+ def = (140 – Na)M/2 > N.B. 1L 0.9%sal ≈150mmol/L
– Na<120 – get help, hypertonic sal
 Lethargy, weak, irrit, twitch,
Hypernatraemia seizures, coma
“Neuromusc irrit”

• Causes:
– Unreplaced Water loss
• Insuff drink – GI, sweat, diuresis, DI (central/nephro)
• Insuff thirst – Hypoth osmoR
• Into cells – severe exercise, seizures
– Na+ overload
• Fluids
• Diet
 Musc twitch/sapasm
Hypokalaemia Arrhytmia - 

• Causes:
– Losses
• GI – D&V, drains, laxatives
• Urinary – Diuretics, Conn’s/Cushings, HypoMg, Salt wasting (Bartler’s/Gitelman’s), Polyuria
• Sweat
• Dialysis/Plasmapharesis
– Entry into cells
• Alkalosis, insulin, Badrenergic, pseudohypo
• Hypothyr, Chloroquine
– Intake
• Rx: (K+<2.5 or <3 with ECG(arrhythm, PR, STdep, small T, U wave))
– O2, Monitor (defib ECG, vitals)
– Bloods: urgent U&E, Mg2+
– Replace K+: 40mmol/L KCL in 1L sal over 2hrs (≤20mmol KCL/h)
– ABG – severe alk
 Chest pain, palp, dizziness
Hyperkalaemia Burns, dark urine, sudden death

• Causes:
– release from cells
• Acidosis, insulin def, Bblockers, pseudohyper
• Tissue breakdown/exercise, Digoxin
– urinary excertion
• Hypoaldost, Renal fail/RTA Type 1, ureterojejunostomy
• Rx: (K+≥7 or >5.5 with ECG(arrhythm, flat P, wide QRS…))
– O2, Monitor (defib ECG, vitals)
– Bloods: urgent U&E, Mg2+
– 10ml of 10% Ca gluconate IV over 2 min, rep every 15mins (up to 5 doses) until
N ECG
– 10U of Actrapid in 50ml of 50% glucose over 10 mins
– Salbutamol neb 5mg
– Ion exchange resin – Ca resonium?
– Monitor blood gluc and K+ every 30mins for ≥6hrs
 ΔΔx in hospital:
Hypocalcaemia Injured PTH gland
Acute pancreatitis
Uncorrected Ca for
alb
• Causes:
– Loss from circ
• Hyperphos, pancr, mets, resp alk, complexing (citr/lact/EDTA/foscarnet)
– HypoPTH
• Idiopathic, Surg(PTH/neck/thyr), infiltr gland, HIV
• PsuedohypoPTH – PTH but resist – Albright’s
– Vit D def
– Other – sepsis, genetic, fluoride intox
• Rx:
– Determine Corrected Ca = Measured + (Δalb x 0.02)
– Treat arrhythmia (arrhthm, prolonged QT)
– Severe tetany > 10ml 10% Ca gluconate over 10 mins (slow)
– Prolonged Ca2+ > vit D and Ca2+ suppl (renal fail > α-cholecalc)
 ΔΔx in hospital :
Malig
Hypercalcaemia HyperPTH
Excess Ca2+/Vit D
Fracture
Bed rest
• Causes:
–  bone resorption
• 1/2ary HPTH, malig/mets, hyperthyr, Paget’s, Vit A intox
– Intestinal absorption
• Ca intake – renal fail suppl, milk alkali
• Vit D - intake, CGD – sarcoid, lymphoma, acromegaly
– Other – Lithium, thiazides, Phaeo, adrenal insuff, rhabdo, TPN, familial
hypocalciuric hypercalcaemia
• Rx:
– Determine Corrected Ca = Measured + (Δalb x 0.02)
– IV saline – continuous 1L/4-8h for 5d – rehydr (hyperCa polyuria/ vom)
– Furosemide if well hydr and pamidronate
– Extremely high – calcitonin IV
– Treat cause:
• Pred30-60mg PO – sarcoid, multiple myeloma, excess vit D
 7. Haematology
• Anticoagulants
• DIC
• Transfusions
 Anticoagulants - Heparin
• Potentiates antithrombin III
– Unfractionated: MW 40k, mix of sulph GAGs, IV or sc, monitor APTT(1.5-2.5)
– LMWH: MW 4-15k, heparin fragments, sc OD, no monitoring (if necessary – Fxa)
• CI: bleed risk – coagulopath, plts, PUD, recent ICH, severe liver dis/htn
• S: Immune (6d post), osteoporosis, hyperK+(inhib aldost), alopecia
• Int: antiplts

• APTT
– <1.5 –  infusion by 5000U/24h, retest 6h
– 1.5-2.4 – good
– 2.5-3.0 – stop infusion for 30 mins,  by 5000U/24h, retest 6h
– Higher values – stop infusion for 1 hr and retest 6h:
• 3.1-4 (  by 5000U/24h)
• 4.1-5 ( by 7000U/24h)
• >5.1 ( by 12000U/24h) – retest 3h
 Anticoagulants - Warfarin
Starting warfarin
• Vit K anatag, also prot C&S initially (procoag – give heparin) Day 1: 10mg PO at 1800
– Long t1/2 - 5d for N INR, highly prot bound/variable, CYP 450 Day 2: Measure INR at 0900 and 1800
• CI: preg, PUD, severe htn
INR<1.8 at 1800 : 10mg
PO
• S: Bleeding, skin necrosis (initial procoag>thrombosis), purple toe
(5mg if >60, CLD, cardiac
syndrome (3-8wks after, chol emboli, ‘trash foot’)
fail)
• Int: antiplatelets, CYP450 (inh, inducers effect) INR>1.8 at 1800 : 5mg PO
Daily INR for 5d and adjust till stable
• Monitor then weekly INR/anticoag/GP
– 2-3 (AF, mitral valve dis, DVT/PE :3/12 above knee, 6/12 no cause) Warfarin tablets
– 3-4 ( stroke prev, prosthetic valve, antiphospholipid) 0.5mg – white
1mg – brown
• INR
– 4.5-6: /STOP warfarin until INR<5 3mg – blue
– 6-8: STOP warfarin until INR<5 5mg - pink
– >8 + no/minor bleed: STOP warfarin until INR <5. Vit K 2mg PO. Daily INRadmit?
– >8 + major bleed: STOP warfarin until INR<5. PCC (50U/kg – discuss haem) +
Vit K 5mg IV. Daily INRadmit

Drugs interacting with Warfarin – Appendix 1

INR : EtoH, amiodarone, cimetidine, simvastatin, NSAIDs
INR: CBZ, phenytoin, rifampicin, oestrogens
 DIC
• Precipitants:
– Sepsis/trauma/burns/incompat blood transf
– Disseminated malig
– Liver fail
– Profound hypoxia
• Ix: plts, PT/INR, APTT, fibrinogen, D-dimer
• Rx:
– Senior help, discuss haematologist
– Treat cause (MC sepsis), supportive (BP/acidosis/hypox/normothermia)
– Blood transfusion > anaemia
– Correct coagulopathy
• FFP if INR or APTT >1.5ULN
• Plts and cyroprecipitate
• Complications: massive haem, MOF, death
 Transfusions
• Whole blood
– Rare, exchange transfusion and trauma Oneg
• Packed red cells (>HCt -70%)
– Anaemia or blood loss – 1U ≈ Hb 1g/dL
– 35d at 4oc, use within 4h of defridging
• Platelets
– Symptom/severe thromb, plt dysfunction – 1U≈
plts>20 X109
– Pooled from 4 donors, 5d at room temp
• FFP
– Coag factor def (if no safe single factor conc),
multiple coag deficiencies, DIC, liver, TTP
– 1 donor, store at -30, use within 4h thawed
• Cryoprecipitate
– Fibrinogen, vWF (first ddAVP), Factors 8 and 9
(emergency haemophil)
– Each from 5 donors, store at -30, use within 4h
thawed

• Packed red cell––immediately,

O Neg only one ABO+RhD crucial
Group specific – 15mins, Full CXM (ABO, RhD, Ab tested) – 45mins
• All the rest – RhD>ABO (N.B. ABO compat
reversed in non-RBC)
 Neutropenic sepsis
• Isolate pt
• Barrier nurse
• Full septic screenblood,urine,stool,sputum,CXR
• Rx
– IV broad spec abx – local guidelines, liase microbio
– Consider fungal in prolonged neutropenic
– G-CSF to increase WCC
 8. Trauma and Orthopaedics
• Head injury
• Neck injury
• Burns
 Head injury
• Request CT if:
– GCS: <13 1st assessed, <15 in A&E 2hrs after
– Fracture – suspected open/depressed, basal skull fracture signs
– ICP signs – seizure, LOC, focal neuro, >1 vom
– Amnesia – retrograde>30mins anterograde
– Age≥65
– Coagulopathy (bleeding HX, clot dis, anticoag)
– Dangerous injury
• Pedestrian/cyclist struck
• Ejection from car
• Fall from >1m/5 stairs
 Neck injury
• Request 3 view radiographs if:
– Cannot actively rotate neck 45O to R or L
– Cannot safely assess ROM
– Neck pain or midline tenderness and:
• Age ≥ 65 or
• Dangerous mechanism of injury
– Need definitive diagnosis (e.g. pre-surgery)
• Request CT if:
– GCS<13 on initial assess
– Intubated
– Plain films technically inadequate/suspicious/abnormal
– Continued clinical suspicion despite N XR
– Pt being scanned for multi-region trauma
 Wallace’s Rule of Nines

Burns
Trunk front 18%
Trunk back 18%
Each leg 9%
• A +C: Each arm 9%
– Collar, sandbags and tape Head 9%
– Look: face burns, singed eyebrows/nasal hair, soot Perineum 1%
– Listen: snoring/stridor/hoarse voice Palm ≈ 1%
– Intubate if inhalation inj suspected
• B:
Depth of thermal burn
– O2, RR (rapid RR suggests inh), Monitor(sats, RR)
1st degree (sup partial): painful, erythm
– Escharotomy if circumf chest burn restrictive
– heals in 7d
• C: 2nd degree (deep partial): into dermis,
– Bloods: FBC, U&E, gluc, clot, G&S, CoHb > ABG red, painful, blistering, oedema – heals
– IV sal 1L stat, IV morphine+cyclizine w/o scarring 2-3wks
– Monitor (defibr ECG, BP – look for shock Sx) 3rd degree (full thickness): painless,
waxy, leathery, charred. Heals with
• D contractures, requires grafting
– Full neuro obs and check glucose
• E
– Measure extent of burn, cover with cling film (analgesia), check T

Parklands formula -Fluid resus

• Further:
4 x wtkg x %SA burn = 24h volml
– Hx/Ex
– Fluid requirements, catheterise, NGT and PPIstress ulcer
– ABG, CXR Half over first 8hrs
– Senior help, reassess Other half over next 16hrs
 9. Dermatology
• Necrotising fasciitis
• Erythema multiforme
 Necrotising fasciitis
• Usually GAS (Type 2) or combination of aerobic and
anaerobic in DM and post abdo surgery pts (Type 1)
• Sx: blanching warm spreading erythema, blisters, LN,
crepitus over tissues
• Ix:
– Bloods: FBC(WCC, Neut) CRP, ESR, bld cultures
– Skin swabs/tissue aspiration
• Rx: do not wait for Ix – start abx immediately
– Senior help, surgeon to consult re: debridement
– IV fluclox/metro/cipro/clinda
• Prognosis – 25% mortality
 Erythema multiforme
• Hypersensitivity rash, inf (HSV,mycopl – minor) and
drugs (sulfon/penicill – major)
• 2 subtypes:
– Erythema multiforme minor: target lesions, red centre,
clear circular, outer red ring
– Erythema multiforme major (Steven’s-Johnsons): ≥2
mucous membranes – macules/papules/pustules
• Rx:
– Treat cause, supportive
– Steroids controversial – may mort
 10. Eyes
• Acute red eye
• Acute visual loss
 Acute red eye 1
• Foreign body sensation
– Conjunctivitis (assoc SLE and Reiter’s)
• Bacterial:sticky dx, one then both– Rx chloramphen
• Viral: watery dx, one then both, common cold – Rx abx to prevent 2ary
• Allergic: watery dx, very itchy, seasonal, hay fever – Rx cromoglicate,
viscotears
– + Sudden onset – Foreign body
• Local anaesth to Ex, cotton bud irrigate, shield eye until LA has worn off
• Chloramphenicol or ointment
– + Photophobia – Keratitis (gritty eyes, contact lens)
• One sector of cornea (c.f. bilat conj), fluorescein – corenal ulceration and
haze – Rx topical abx and steroid drops
 Acute red eye 2
• Pain
– + dilated pupil – Acute angle closure glaucoma
• Hazy cornea, oval shaped, tender globe
• acq prod(acetazol), acq outflow (mannitol, pilocarpine);
Surg – peripheral iridotomy
– + constricted pupil – Acute anterior uveitis
• HLA B27, blurred vision, photophobia, ±hypopyon
• Keratitic precip, post synechiae (iris sticks to cornea/lens)
• Rx topical steroids, dilating agents, immunosupr
– + engorged vessels – Scleritis (assoc RA)
• Perforation, tender globe Rx immunosupress
 Acute red eye 3
• Exclusion: Engorged vessels
– Yes? – Episcleritis (assoc PAN, SLE)
• May look blue, mid irritation, normal VA
• Rx steroids/NSAIDS
– No? – Subconj haemorrhage
• Incidental, benign, slight FB sensation initially
• Bright red blood under conj
• Rx Check BP and if recurrent FBC/clot
 Acute visual loss
• Hx (HELLP)
– Headache (GCA)
– Eye mvmts painful (optic neuritis)
– Lights/flashes before (retinal detach)
– Like curtain descending (amaurosis/GCA)
– Poor DM ctrl (vitreous haemorrhage)
 Optic neuritis
• Papillitis – nerve head involved – disc swollen
• Retrobulbar neuritis – inflamm behind nerve head – N disc
• Assoc :MS, LHON, DM, viral, vitamin def

• Acuity: sudden onset, prog worse over hrs-days

• Fields: Scotoma
• Reflexes: RAPD
• Fundoscopy: Optic atrophy
• Movement: Painful

• Usually recovery but some have visual loss or other signs above