Adult Medical Emergencies

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Adult
Medical
Emergencies
Handbook
EDITOR
Dr Graham R. Nimmo MD FRCPE FFARCSI
Consultant Physician
Intensive Care and Medical Education
WGH and The University of Edinburgh
NHS LOTHIAN - UNIVERSITY HOSPITALS DIVISION | 2007/2009
NOTES
i
Any protocols, guidelines, algorithms are subject to review and
updating. Ensure you are using the current version.
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
NOTES
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
ADULT ADVANCED LIFE SUPPORT ALGORITHM
Adult Advanced Life Support Algorithm
Unresponsive ?
Open airway
Look for signs of life
Call 222
Resuscitation Team
CPR 30:2
Whilst defibrillator / monitor
attached
Assess
rhythm
Shockable
Non-Shockable
(VF / pulseless VT)
(PEA / Asystole)
1 Shock
150-360 J biphasic
or 360 J monophasic
Immediately resume
CPR 30:2
for 2 min
During CPR:
• Correct reversible causes*
• Check electrode position
and contact
• Establish / verify:
IV access
airway and oxygen
• Give uninterrupted
compressions when
airway secure
• Give adrenaline 1mg IV
every 3-5 min
• Consider: amiodarone,
atropine, magnesium
Immediately resume
CPR 30:2
for 2 min
* Reversible Causes
Hypoxia
Hypovolaemia
Hypo/hyperkalaemia/metabolic
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis (coronary or pulmonary)
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
WGH
IN CARDIAC ARREST & LIFE THREATENING EMERGENCY CALL 222
HOSPITAL AT NIGHT OFFICE/COORDINATOR 33322
USEFUL TELEPHONE NUMBERS
BIOCHEMISTRY
HAEMATOLOGY
MICROBIOLOGY
CARDIOLOGY/ECG
CORONARY CARE UNIT
STROKE
DCN (ALL HEAD &
GENERAL ENQUIRIES............. 31900/31901
EMERGENCIES (<6PM)............ 31985
>6PM ....................................... Bleep: 8452
GENERAL ENQUIRIES............. 31910/31911
COAGULATION......................... 31171
BLOOD BANK........................... 31912
SPECIMEN RECEPTION.......... 31936
RESULTS.................................. 27777
CLINICAL ENQUIRIES.............. 26027/26048
ECG/ECHO............................... 31852/32330
BLEEP....................................... 8206/8536
.................................................. 33552
REGISTRAR.............................. Bleep: 8699
SECRETARIES.......................... 32022 (X-ray appts.)
SPINE CT/ MRI)
(FOR URGENTS & RESULTS)
MAIN X-RAY (EVERYTHING ELSE... BODY CT/ USS etc)
INTENSIVE CARE
ANAESTHETIST DCN
NEW STICKIES (ADMISSIONS)
ARAU
BED MANAGEMENT
FOOD
DAY BED AREA
COMPUTERS
PATHOLOGY
PORTERS
NUCLEAR MEDICINE
THEATRES
PHARMACY
PSYCHIATRY
AIR TUBE
INFECTION CONTROL
MORTUARY WGH
MRI........................................... 32026
CT SCANNING..........................
CT SECRETARY........................ 32066
REPORTING ............................ 32058 (Main CT)
EMERGENCY (ALL DAY).......... Bleep: 8204
.................................................. 31664/31665
IN AN EMERGENCY................ 8112
.................................................. 8519
ADMISSIONS OFFICE.............. 31342/31343
RECEPTION.............................. 31330/31331
TROLLEYS................................ 31335
DOCTORS ROOM.................... 31334/31313
RESUS...................................... 31336
WARD.......................................
OFFICE..................................... FAX: 32565
BLEEP/ PAGE........................... 8245
DINING ROOM/MANAGER....... 31373/31364
NURSES STATION.................... 31329
WHEN THEY GO WRONG........ 32343/31394
ENQUIRIES............................... 31962
ROOM/BLEEP.......................... 31534/5116
DCN BLEEP.............................. 8252
V/Q OR BONE SCAN................ 32038/Fax: 32039
MAIN (RECEPTION).................. 31669
ENDOSCOPY............................ 31695
DCN.......................................... 31693/31694
DRUG INFO.............................. Bleep: 5426
SATURDAY................................ Bleep: 5423
REFERRAL SECRETARY.......... 31834
PROBLEMS.............................. 31446 (Estates)
.................................................. 26089
.................................................. 31972
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
RIE
IN CARDIAC ARREST & LIFE THREATENING EMERGENCY CALL 222
HOSPITAL AT NIGHT OFFICE/COORDINATOR 23888
USEFUL TELEPHONE NUMBERS
CARDIOLOGY
ECG.........................................21814
CORONARY CARE UNIT
................................................21141 Bleep:1581 (SHO)
X-RAY PORTABLE X-RAYS.................Bleep:2155
MAIN........................................23716
A&E..........................................21300
CT............................................23800
SCANNING..............................23797
FILM STORE............................23728
ULTRASOUND SEC. (Wilma)....23759
MEDICINE OF THE ELDERLY/
STROKE
................................................26927
OPHTHALMOLOGY A&E
................................................63751
RECORDS
ADMISSIONS .........................23029/23028
LIBRARY..................................23037
A&E
PORTERS................................21329
TROLLEYS..............................21314
IC.............................................21345
RADIOLOGY............................23801
CAA
TROLLEYS..............................21422
INTENSIVE CARE
................................................21187/21188
HDU
WARD 116...............................21161/21164
. ................................................ Bleep:5198 (SHO)
ALCOHOL PROBLEMS
................................................21392
IMMUNOASSAY
................................................62710
ENDOSCOPY
................................................21600
DERMATOLOGY
APPOINTMENTS.....................62059 OPD: 62060
PATHOLOGY
MORTUARY RIE......................27177
PORTERS
................................................21329
DENTIST (RIE)
................................................63708
SURGERY................................63709
THEATRES
1...............................................63877/63878
2...............................................63880
3...............................................63882/64161
4 (COFFEE ROOM)..................63885
(THEATRE)............................63886
Trauma 1..................................63888
Trauma 2..................................63890
(REST ROOM).......................63891
Vascular...................................63892
PHARMACY: 22911
DRUG INFO.............................22918
PSYCHOLOGICAL MEDICINE................................................21392
SOCIAL WORK
................................................27852
SALT
................................................26915
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
RIE
USEFUL BLEEP NUMBERS
MED REG (ward referrals)
................................................2112
MED REG (A&E/trolleys)
................................................2242
MEDICAL HDU SHO
................................................5198
SURGICAL SHO (ET)
................................................2254
SURGICAL REG (ET)
................................................#6435
ORTHO SHO/REG
................................................2181
VASCULAR REG
................................................#6440
ANAESTHETIC SHO
................................................2140
ICU REG
................................................2306
CCU SHO
................................................1581
RESPIRATORY REG
................................................#6408
CARDIOLOGY REG
................................................#6816
GI REG
................................................#6361
RENAL REG
................................................#6394
HAEMATOLOGY REG
................................................#6466
MEDICINE OF ELDERLY REG.................................................#6770
DIABETIC REG
................................................#6800
GYNAE REG
................................................1625/4001
PAIN TEAM CLINICAL NURSE
SPECIALIST
................................................5247
TISSUE VIABILITY NURSE ................................................5541
INFECTION CONTROL
NURSE
................................................2201
LABORATORIES TELEPHONE AND BLEEP NUMBERS
COMBINED LABORATORIES
ENQUIRIES
................................................27777
BIOCHEMISTRY ................................................Bleep:2221
HAEMATOLOGY
................................................Bleep:#6550
ON CALL ................................Bleep: #6466
BACTERIOLOGY ENQUIRIES.................................................66910
BLOOD TRANSFUSION
................................................27501/27502
PATHOLOGY ENQUIRIES
................................................27148/27170
MICROBIOLOGY
ENQUIRIES..............................27777 Bleep:2900
CLINICAL ENQUIRIES.............26027/26048
INFECTION CONTROL............26089
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
ST JOHN’S
IN CARDIAC ARREST & LIFE THREATENING EMERGENCY CALL 222
HOSPITAL AT NIGHT OFFICE/COORDINATOR 52210
USEFUL TELEPHONE NUMBERS
ST JOHN’S SWITCHBOARD ................................................0
BIOCHEMISTRY
GENERAL ENQUIRIES............53160/53161
ON CALL.................................Bleep:728
HAEMATOLOGY
GENERAL ENQUIRIES............53353
BLOOD BANK.........................53354
ON CALL.................................Bleep:729
MICROBIOLOGY
GENERAL ENQUIRIES............53075/53077
ON CALL.................................aircall via switchboard
PATHOLOGY
GENERAL ENQUIRIES............52016
MORTUARY.............................52022
CARDIOLOGY
ECG/Echo................................53851 Bleep:655
CORONARY CARE UNIT.........3024
RADIOLOGY
X-Ray (plain film)......................54345
CT............................................54343
ON CALL.................................Bleep:657
MEDICAL PHYSICS
................................................52148
INTENSIVE CARE
................................................54063/54056
ANAESTHETIST (ICU)
................................................Bleep:561
DUTY ANAESTHETIST
(Theatres)
................................................Bleep:886
PAIN (acute)
................................................53065 Bleep:934
ON CALL.................................Bleep:561(Anaesthetics)
RESUSCITATION OFFICERS ................................................53892 Bleep 909
ADMISSIONS
................................................53173
MEDICAL RECORDS
................................................53570/53571
A&E
................................................53012
MEDICAL DIRECTORATE COORDINATOR.............................Bleep:584
SURGICAL DIRECTORATE COORDINATOR...........................Bleep:624(day), 584 (night)
ENDOSCOPY
. .................................................. 53935
PHARMACY
DISPENSARY (and weekend no.).....52037
MEDICINES INFORMATION....52035
ASEPTIC..................................52046
PORTERS
................................................52084
DOMESTIC SUPERVISOR
................................................52169
CATERING MANAGER
................................................53137
INFECTION CONTROL
................................................53088
HEALTH & SAFETY
................................................52159
COMPUTERS
IT HELP DESK.........................53496
WARDS
................................................541 plus ward number
STROKE UNIT
................................................54104
LABOUR WARD
................................................54125
THEATRES
RECEPTION............................52182
ANAESTHETICS OFFICE........53052
RECOVERY..............................54244
THEATRE COORDINATOR......Bleep:541
CEPOD COORDINATOR.........Bleep:002 (541out of hours)
ODA ON CALL........................... Bleep:656
cont...
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
ST JOHN’S
THEATRES 1-9
1.................................................. 54233
2.................................................. 54234
3.................................................. 54235
4.................................................. 54236
5.................................................. 54237
6.................................................. 54238
7.................................................. 54239
8.................................................. 54240
9.................................................. 54241
USEFUL EXTERNAL NUMBERS
SHORT CODES
RIE SWITCHBOARD
RIE NUMBERS
WGH SWITCHBOARD
WGH NUMBERS
................................................7050
................................................705 plus extn
................................................7910
................................................791 plus extn
RIE LABORATORIES
ENQUIRIES..............................extn 27777
PROCURATOR FISCAL
(Linlithgow for St John’s
patients)
................................................01506 844556
................................................short code 62174
................................................Out of hours: via police
POLICE
................................................short code 62148
TRANSPLANT COORDINATOR...............................................0131 536 3946
HSDU
................................................0131 242 6105
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
COMMON or SHARED CONTACT NUMBER
IN CARDIAC ARREST & LIFE THREATENING EMERGENCY CALL 222
RESUSCITATION OFFICERS
RIE.................................... 21760 Page:#6459/#6498
WGH................................ 32496 Bleep: 8355/8113
SJH.................................. 53892
INTENSIVE CARE
WARD 118 RIE................. 21187/21188
WARD 20 WGH................ 31664/31665
ICU SJH........................... 54063/54056
PROCURATOR FISCAL
EDINBURGH.................... #6118
WEST LOTHIAN............... short code 62174
MEDICINES INFORMATION
SERVICE RIE/WGH.......................... 22918/22920
SJH.................................. 52035
Bleep:909
NATIONAL POISONS
INFORMATION SERVICE (NPIS)......................................... 0870 600 6266 (24hr)
VIROLOGY
RESULTS......................... 27777
CLINICAL ENQUIRIES..... 26027/26048
......................................... 705 extn from SJH
EEG (WGH)
......................................... 32097
......................................... 791 32097 from SJH
NEUROLOGY REGISTRAR
......................................... Bleep: via WGH switchboard
RHEUMATOLOGY REGISTRAR ......................................... Bleep: via WGH switchboard
SHORT CODES from WGH/RIE AAH.................................. 7550
LIBERTON........................ 7390
RVH.................................. 7780
REH.................................. 7600
St John’s.......................... 7340
Edinburgh University........ 7740
WARDS in RIE
NURSES........................... 2 (ward number) 1
DOCTORS........................ 2 (ward number) 2
SISTER............................. 2 (ward number) 3
OCCUPATIONAL HEALTH ......................................... 0131 537 6000
ON CALL.......................... (NEEDLESTICKS)
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
OTHER USEFUL TELEPHONE NUMBERS
NAME
LOCATION
TEL/BLEEP NUMBER
10 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
Contents
ALS Algorithm..................................................................................... 3
Useful phone and bleep numbers....................................................... 4
CHAPTER 1
GOOD CLINICAL PRACTICE.......................................................... 19
Introduction....................................................................................... 19
General Points................................................................................... 20
Professional Responsibilities............................................................. 23
Good Documentation........................................................................ 24
Good Prescribing.............................................................................. 24
Practical Procedures......................................................................... 29
Talking with Patients and Relatives................................................... 29
Patient Deaths................................................................................... 34
Organ Donation................................................................................. 38
Discharges: Good Practice............................................................... 39
Guide to Good Discharge Summaries............................................... 41
CHAPTER 2
RESUSCITATION AND EMERGENCY MANAGEMENT................. 43
Initial Assessment and Management of the Acutely Ill Adult............ 43
Primary Assessment and Management:
Approach to the Acutely Ill Patient.................................................... 45
Identification of the Acutely Ill Patient Requiring Intensive Care or
High Dependency Unit Referral......................................................... 55
Shock................................................................................................ 58
Shock Management Summary.......................................................... 59
Blood and Blood Components.......................................................... 60
Transfusion Reactions....................................................................... 64
Sepsis and Septic Shock.................................................................. 69
Anaphylaxis....................................................................................... 74
Algorithm for First Trained Responder to Anaphylaxis...................... 77
Urticaria and Angio-oedema............................................................. 78
Life-threatening Upper Airway Obstruction....................................... 78
Acute Pain Management................................................................... 79
Summary of Principles of Acute Care............................................... 81
Approach to the patient with............................................................. 82
• Chest Pain.................................................................................... 82
• Acute Shortness of Breath........................................................... 83
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
11
First Seizure in Adults........................................................................ 84
Management of First Seizure in Adults............................................. 86
Management of Syncope.................................................................. 87
Management of Unexplained Syncope in Adults.............................. 88
Management of Collapse.................................................................. 89
Management of Renal Colic.............................................................. 90
Resuscitation................................................................................... 92
Adult Advanced Life Support Algorithm............................................ 93
Algorithm for Automated External Defibrillation................................ 95
CHAPTER 3
ACUTE CARDIOLOGY AND VASCULAR EMERGENCIES............ 97
Based on Coronary Care Therapeutic Schedule (RIE & WGH)
General Administrative Policy........................................................... 98
Acute Coronary Syndromes ........................................................... 101
Management of St Elevation Acute Coronary Syndrome................ 104
Management of Non-St Elevation Acute Coronary Syndrome....... 110
Hypertension in the patient requiring Thrombolysis........................ 111
Non-ST Elevation Myocardial Infarction (NSTEMI).......................... 112
Management of other Acute Coronary Syndromes......................... 112
Management of Complications Associated with
Myocardial Infarction....................................................................... 113
Severe Left Ventricular Failure......................................................... 114
Cardiogenic Shock.......................................................................... 116
Diabetic Control in the setting of Acute Myocardial Infarction........ 118
Late Management of Acute Myocardial Infarction.......................... 119
Other Potential Problems in the Peri-infarct Period........................ 120
Other Medical Emergencies Admitted to CCU............................... 121
Out of Hospital Cardiac Arrest........................................................ 121
Management of Arrhythmias........................................................ 122
Tachyarrhythmias............................................................................ 122
Atrial Fibrillation Algorithm.............................................................. 122
Narrow Complex Tachycardia Algorithm......................................... 123
Broad Complex Arrhythmias........................................................... 125
Diagnosis of Broad Complex Tachycardia...................................... 126
Management of Bradyarrhythmias.................................................. 129
Bradycardia Algorithm..................................................................... 130
External Cardiac Pacing.................................................................. 131
Specific Drug Points........................................................................ 132
12 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
Vascular Emergencies................................................................... 134
Acute Thoracic Aortic Dissection.................................................... 134
Investigation Algorithm for Acute Aortic Dissection........................ 135
Acute Stroke.................................................................................... 136
Thromboembolic Disease................................................................ 142
Suspected Pulmonary Embolism.................................................... 144
Ruptured or Leaking Abdominal Aortic Aneurysm.......................... 145
Management of the Acutely Ischaemic Limb.................................. 147
Hypertension................................................................................... 148
CHAPTER 4
RESPIRATORY EMERGENCIES.................................................... 149
Severe Acute Asthma . ................................................................... 149
Community-Acquired Pneumonia................................................... 151
Hospital-Acquired Pneumonia........................................................ 155
Pneumothorax................................................................................. 158
Spontaneous Pneumothorax........................................................... 158
Tension Pneumothorax.................................................................... 158
Intercostal Drainage Tube Insertion................................................. 159
CHAPTER 5
GASTROINTESTINAL EMERGENCIES......................................... 164
Acute Upper Gastrointestinal Bleeding........................................... 164
Treatment and Assessment............................................................. 165
Acute on Chronic Liver Failure........................................................ 168
Acute Bloody Diarrhoea.................................................................. 171
Acute Diarrhoea............................................................................... 173
Constipation.................................................................................... 174
Assessment of Acute Abdomen...................................................... 176
Acute Pancreatitis........................................................................... 177
CHAPTER 6
RENAL, METABOLIC AND ENDOCRINE EMERGENCIES.......... 183
Acute Renal Failure......................................................................... 183
Dangerous Hyperkalaemia.............................................................. 187
Metabolic Acidosis.......................................................................... 190
Management of Diabetic Ketoacidosis........................................... 192
Management of Diabetic Hyperosmolar Non-Ketotic Syndrome.... 197
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
13
Hypoglycaemia................................................................................ 205
Sulphonylurea-induced Hypoglycaemia (SIH)................................. 209
Hypercalcaemia............................................................................... 209
Hypocalcaemia - the 5 Common Causes....................................... 211
Hypokalaemia.................................................................................. 213
Addison’s Disease........................................................................... 214
Hyponatraemia................................................................................ 216
CHAPTER 7
NEUROLOGICAL EMERGENCIES................................................ 220
Coma............................................................................................... 220
Clinical Assessment of coma.......................................................... 223
Epileptic Seizures............................................................................ 224
Subarachnoid Haemorrhage........................................................... 227
Meningitis........................................................................................ 229
Tentorial Herniation and Coning...................................................... 232
Encephalitis..................................................................................... 233
CHAPTER 8
ACUTE DETERIORATION IN THE ELDERLY................................ 235
Delirium........................................................................................... 235
Acute Agitated Confusion in an Older Patient................................. 238
Falls and Immobility........................................................................ 239
CHAPTER 9
HAEMATOLOGY AND ONCOLOGY EMERGENCIES.................. 242
Neutropenic Sepsis......................................................................... 242
Spinal Cord Compression............................................................... 243
Superior Vena Cava Obstruction..................................................... 244
CHAPTER 10
TOXICOLOGY................................................................................. 246
A Guide to Observations and Investigations for the Patient with
Acute Poisoning.............................................................................. 250
Management of Common Poisonings............................................. 251
14 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
CHAPTER 11
ACUTE RHEUMATOLOGY............................................................ 259
Acute Mono or Oligoarthritis........................................................... 259
CHAPTER 12
PSYCHOLOGICAL MEDICINE...................................................... 263
Alcohol............................................................................................. 263
Management of Alcohol Withdrawal............................................... 264
Alcohol Withdrawal Management Guideline................................... 265
Alcohol Liaison Service................................................................... 266
Acute Disturbance........................................................................... 267
APPENDIX 1
Sharing Difficult Information with Patients/Relatives...................... 274
APPENDIX 2
End of Life Care............................................................................... 277
APPENDIX 3
General Principles of Good Practice: Infusion Devices................... 281
APPENDIX 4
Resuscitation: Specialised Information........................................... 285
Pregnancy....................................................................................... 285
APPENDIX 5
Paediatric Basic Life Support.......................................................... 287
Foreign Body Obstruction Sequence.............................................. 289
Consent to Medical Treatment for Children in Scotland................. 290
APPENDIX 6
Malignant Hyperthermia Action Sheets NRIE/WGH........................ 293
Major Haemorrhage Protocol.......................................................... 301
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
15
EDITOR’S INTRODUCTION
The Adult Medical Emergencies Handbook was first developed for the
Western General Hospital in Edinburgh in 1996 and first appeared in
1998. Over the following three years hospitals in Edinburgh became a
Trust and a Lothian University Hospitals Trust edition was produced.
This was greatly strengthened by the development of management
plans agreed across the city by specialists in both the Royal Infirmary
and the Western General and has been in use up until this edition. In this
edition The Lothian Hospitals are working under the aegis of Lothian
Health. So this edition of this evolving work (the 4th) is the Adult Medical
Emergencies Handbook for Lothian Health and specifically for RIE, St
John’s Hospital and WGH. I hope that it has improved with revision.
We have built on the strong foundations laid by all who have contributed
to the previous editions and they are accredited in the intranet version.
Many new colleagues have helped with this version and I hope that
they have all been acknowledged, but if not I apologise to them and
thank them for their contributions.
This kind of project is dynamic. I am extremely grateful to Nicky
Greenhorn of the Medical Illustration Department, Learning Technology
Section of the University of Edinburgh who has been a major partner
in the production of this book. I also acknowledge the great support
and help I have had from colleagues but wish to particularly thank
Emma Williamson, Cathy Kelly, Simon Maxwell, Ben Shippey, Susan
Nimmo, Neil McGowan and Robin Mitchell who have all contributed
detailed reviews of the manuscript with multiple helpful comments
and suggestions. I would also like to thank Jane Pearson and Morag
Naysmith for their contributions and also for co-ordinating the proof
reading by specialist pharmacists.
I would also like to encourage any “users” to feed back with comments,
suggestions and criticisms so that we can continue to improve this
work. On a lighter note copies of the handbook have been sighted
around the world! Basra, Sydney and Kirkcaldy! The editor would be
interested in receiving notice (or photos) of future sitings.
ACKNOWLEDGEMENT
We are grateful to the Resuscitation Council (UK) for permission to
include algorithms from the Advanced Life Support teaching materials.
We are also grateful to the American College of Surgeons for permission
to reproduce a table from the ATLS manual.
16 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
LIST OF CONTRIBUTORS TO 4th EDITION
EDITORIAL COMMITTEE
B Chapman, C Kelly, S Maxwell, M McKechnie, G Nimmo, M Naysmith,
E Olsen, J Pearson, B Shippey, E Williamson,
CONTRIBUTORS TO THIS EDITION OF THE HANDBOOK
Dr K Adamson, Dr N Amft, Mr D Anderson, Dr I Arnott, Prof J Bell, Dr C Blair,
Dr B Chapman, Dr N Colledge, Dr P Dale, Dr J Dave, Dr R Davenport,
Prof M Dennis, Dr A Dennison, Dr M Denvir, Dr V Dhillon, Dr A Elder, K Farrer,
Dr M Ford, Dr A Gibb, Dr P Gibson, Miss T Gillies, Dr C Goddard, Dr I Grant,
Prof A Greening, Dr E Halloran, Mr S Hartley, Prof P Hayes, Dr G Howard,
Dr P Johnson, Mr M Johnstone, Dr P Kalima, Dr S Keir, Dr C Kelly,
Dr C Leen, Dr M Logan, Dr V Macaulay, Dr S MacKenzie, Dr A MacLullich,
Dr N McGowan, Dr M McKechnie, Dr J McKnight, Dr E McRorie,
Dr M Mackie, Dr C Maguire, Dr L Manson, Dr S Maxwell, Dr S Midgley,
Dr R Mitchell, Dr S Moultrie, Dr G Nimmo, Dr S Nimmo, Dr E Olson,
Dr A Patrick, Dr P Padfield, Dr K Palmer, Prof S Ralston, Dr S Ramsay,
Mr Z Raza, Dr P Reid, Dr P Riches, Dr Rustam Al-Shahi Salman, Dr J Spiller,
Dr I Starkey, Dr M Strachan, Dr J Stone, Dr N Uren, Mrs L Waite, Dr J Walker,
Dr S Waring, Dr W Whiteley, Dr D Wilks, Dr A Williams, Dr E Williamson
PHARMACISTS WHO PROOF READ SPECIALITY SECTIONS
J Blythe, A Kinnear, C Mathieson, J McKidd, H Paterson, J Scott, S Selkirk,
L Shaw, A Thomson, L Thomson, H Veitch,
ENTIRE TEXT PROOF READERS
Dr C Kelly, Dr S Maxwell, Dr B Shippey, Dr S Nimmo, Dr E Williamson,
Dr N McGowan
Grateful acknowledgement is made to authors of:
•
CCU therapeutic schedule
•
Palliative care guidelines
•
Acute care algorithms
•
Infusion devices guidelines
•
Alcohol withdrawal guideline
•
Agitation/confusion in the elderly guideline
•
Major Haemorrhage protocol
•
Malignant Hyperpyrexia protocol
•
Acute pain guidelines
•
Lothian DNAR group
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
17
DISCLAIMER
Every effort has been made by the editors and contributors to the handbook to
ensure accuracy of information. Users are advised to refer to drug and product
information and to detailed texts for confirmation.
COPYRIGHT STATEMENT FOR LOTHIAN AMEH - MARCH 2007
ALL RIGHTS RESERVED. No part of this publication may be copied,
modified, reproduced, stored in a retrieval system or transmitted in any
material form or used for commercial purposes except in accordance with the
provisions of the Copyright, Designs and Patents Act 1988. It is permissible
to use this information for non-profit, educational purposes with the written
permission of the copyright owner.
© 2007 Lothian Health - University Hospitals Division
18 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
Chapter 1
GOOD CLINICAL PRACTICE
INTRODUCTION
The purpose of this handbook is to provide management guidelines for
adult medical emergencies in your hospital. The handbook has been
written by specialists who deal with these emergencies on a daily basis.
It has been edited to standardise the approach and has been reviewed
and approved by colleagues. Contents are evidence and best-practice
based as far as is possible and are aligned with National and International
guidelines where appropriate.
i It is designed to advise staff in training and in practice on the
management of most common adult medical emergencies, and
in the management of unusual but important clinical conditions.
However, the book is intended as a guide and is not a substitute
for immediate expert help when this is needed: if in doubt ask for
senior advice or assistance.
The book is divided into three sections:
Section 1
General information
Section 2
Clinical Management
Section 3
Appendices
The handbook should be used in conjunction with
• Local and Divisional protocols and guidelines.
• The Lothian Joint Formulary,
• Divisional guidelines for anti-microbial therapy (Sepsis section Chapter 2)
• Divisional Acute Pain Guidelines offer detailed information which is
complimentary to this text.
Medicine doses are being continually revised and novel adverse effects
of drugs may be discovered over time. Every effort has been made to
ensure that recommended dose ranges are appropriate and evidence
based at the time of going to press but prescribers are advised to
consult the BNF and where necessary the product data sheets.
Throughout the text useful clinical information is highlighted as ‘key
points’ identified by the notation below.
i KEY POINT these are useful, often practical, pieces of information.
Comments and suggestions relating to the book are welcomed and
should be addressed to: Dr Graham Nimmo Consultant Intensive Care and Clinical Education at WGH
E-mail: [email protected]
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GENERAL POINTS
Medicines
• Doses are for adults unless otherwise indicated.
• While every effort has been made to check doses, if doubt exists
consult the BNF.
• The Lothian Joint Formulary should be consulted for local
prescribing advice/guidance. All adverse events involving black
triangle (recently marketed) and serious adverse events involving
any drugs should be reported to the MHRA using yellow cards
which are available in paper form in all BNF’s and also online via
the Trust intranet or at http://www.mhra.gov.uk
• European law requires the use of the Recommended International
Nonproprietary Name (rINN) for medicinal substances. In most cases
the British Approved Name (BAN) and rINN were identical. Where
the two differed, the BAN was modified to accord with the rINN with
the important exceptions of adrenaline and noradrenaline. The new
BANs are used in this text.
Infections
• The University Hospitals Division and St John’s antimicrobial
guidelines offer excellent advice on treatment choice: these are
updated regularly. (Sepsis section Chapter 2).
• Clinical Microbiological advice is available 24/7.
Specialist Referral
• Throughout the text advice on criteria for specialist referral is given,
along with contact numbers for specific hospital sites.
• If the patient is pregnant discuss with the Obstetric registrar on call.
• Consider early referral for ICU or HDU care (see assessing illness
severity Chapter 2) when appropriate.
Decisions to be made for every admission
• Medicines: consider which long term medicines should be continued
and which with-held eg vasodilators in sepsis or in hypovolaemia,
diuretics in dehydrated.
• Remember to assess the need for DVT prophylaxis in all admissions.
Consult Divisional guideline for venous thromboembolism prophylaxis
and treatment, or local protocol where appropriate.
• Consider the resuscitation status of each patient at admission:
discuss with the consultant responsible. Document on the specific Do
Not Attempt Resuscitation (DNAR) sheet and include in casenotes.
Always discuss with next of kin.
20 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
• Incapacity: see below.
• Diagnosis: review the evidence. The diagnostic “label” may be
inaccurate or incomplete. Don’t make assumptions and “don’t
give up the search” for alternative explanations for the patient’s
presentation especially if they do not respond to initial treatment.
ADULTS WITH INCAPACITY ACT
General Principles
• Under the Act an adult is defined as a person who has attained 16
years of age.
• All adults are considered capable of making their own medical
decisions unless proven otherwise.
• Without consent for any procedure or treatment the health care
professional carrying out the procedure or treatment could be liable
for assault.
• It is the doctor primarily responsible for the patient’s medical
treatment who is responsible for assessing the patient’s capacity to
consent to treatment.
Legal capacity requires that an individual be capable of:
• understanding why treatment or a procedure is necessary.
• retaining information given before making a decision.
• being able to communicate a decision.
• understanding implications of refusing or allowing treatment and
being able to retain this information.
Incapacity may be short lived e.g. acute confusional state or more
longstanding e.g. dementia.
MEDICAL TREATMENT
Medical treatment is defined as:
• ‘any treatment that is designed to promote or safeguard physical or
mental health’.
The treatment must be clinically indicated and must:
• promote or safeguard physical or mental health.
• take account of present and past wishes e.g. advance directive or
living will.
• take account of the views of any relevant others including health
care professionals involved in the patient’s care, relatives or carers
as far as is reasonably possible.
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• minimise the restriction of the patient’s freedom - for example if it
was considered unlikely that the patient’s clinical condition would
be compromised by waiting until the patient regained the capacity
to give consent, then the treatment should be delayed until such
time.
• respect the patient’s residual autonomy, thereby empowering them
as much as possible.
Therefore any medical, surgical or nursing intervention, diagnostic
study or physiotherapy is covered under the act.
How does this work in practice?
• Every adult patient who is incapable of making decisions with
regard to their medical treatment or care should have a completed
Certificate of Incapacity filed in the front of their medical notes. The Certificate will replace consent forms unless the patient has a
legally appointed proxy decision maker.
i Any immediate treatment to save life or prevent serious
deterioration in the patient’s medical condition is exempt from
the procedures laid down in the act.
• In all other cases the doctor primarily responsible for the patient
can authorise the provision of medical treatment according to the
general principles of the Act. However if a proxy decision maker
has been nominated consent must be obtained from them prior to
any procedure, other than emergency treatment.
Proxy decision makers include:
• Welfare attorney. The patient, in anticipation of their becoming
incapacitated, nominates this power of attorney. The power of
attorney must be registered with The Public Guardian who should
issue a certificate in the prescribed form.
• Welfare Guardian. This proxy is appointed by a sheriff when an
individual has become incapacitated or has never had the capacity
to make decisions pertaining to their medical treatment.
• Intervention Order. Representation is provided by the courts on
behalf of the incapacitated adult.
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PROFESSIONAL RESPONSIBILITIES
• All staff and students must be identifiable by wearing an appropriate
name badge at all times.
• In all interactions with patients, relatives and colleagues, courtesy
and common sense should be exhibited.
• All staff and students should wear appropriate clothing at all times.
i Documentation: quality notes are crucial for good patient
management and as a lasting record of ward rounds,
decisions, procedures and communication. Guidelines on
following page.
• Practical procedures: from the simple and mundane to highly
complex invasive procedures adherence to the guidelines below
will optimise efficacy and minimise complications.
• Procedure for Cardiac Arrest Management and Do Not Attempt
Resuscitation Orders for all sites are available in all clinical areas,
from the Resuscitation Officers (see ‘phone list) and on the Intranet.
Cardiac arrest audit forms are available widely and should be
completed for every cardiac arrest call. These provide invaluable
information on process and outcome and influence planning of
resuscitation training and equipment acquisition.
• Clinical Risk/Clinical Governance: in order to minimise adverse
events a Lothians wide system is in place to allow any staff member
to report a near-miss or a critical incident occurring in patient care.
This can be anonymous and is intended to alert senior staff to areas
where improvements in the system will result in better outcomes for
our patients. You should familiarise yourself with the Datix system
on the hospital intranet home page. Dr A Arnstein chairs the Clinical
Risk group and can be contacted via Department of Anaesthetics,
St John’s Hospital.
• Major Incident procedure: in the event of a Major Incident being
declared large numbers of casualties may be transported to the Royal
Infirmary and St John’s Hospital. SJH and the RIE are DESIGNATED
RECEIVING HOSPITALS for a major incident occurring in the
Lothian Region. The RIE would act as the CONTROL HOSPITAL
(responsible for co-ordinating all medical activity) and SJH would
act in a SUPPORT capacity in all circumstances. SJH’s role will
manage minor/intermediate injuries, medical cases, and isolated
(i.e. without other major injuries) burns. Staff there should be familiar
with the local policies available in the Medical Staff Handbook and
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RIE or SJH Major Incident Plans. At the time of the Major Incident
the role of WGH will be to take all Medical and Surgical emergencies
from both the North Zone (WGH) and South Zone (RIE). Details of
WGH local policy can be found in the WGH Major Incident Plan.
GOOD DOCUMENTATION
• Write legibly, preferably in black ink (so it can be legible when
photocopied).
• The medical case record is a legal document to which patients and
relatives have right of access.
• All entries into case records should be legible, have a date and time
assigned to them, and be signed in a way that allows the writer to
be identified.
• Keep notes in chronological order: if writing in retrospect make this
obvious.
• Keep clear progress notes both for inpatients and outpatients.
• Make clear your reasoning for clinical decisions.
• Any typed notes should be checked, corrected and signed.
• Cross out errors and write a corrected entry, dated and signed.
• Record details of discussions with patients or relatives.
• Record discussion of the patient’s condition or about risk/benefit of
therapy.
• Any untoward or unexpected events and action taken in response
to them should be adequately documented.
• At all times remember that the written record documents your
thoughts for others to read.
• Write the patient’s name, date of birth, CHI number at the top of
each page (each side).
GOOD PRESCRIBING
i When a patient is admitted as an emergency consider which
medicines may worsen the acute problem and omit until it is
appropriate to restart.
Good Practice in Writing Prescriptions on the Prescription and
Administration Record (Drug Kardex)
A clearly written prescription:
24 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
• saves everybody’s time.
• reduces the risk of medication errors.
• help ensures the right patient receives the right medicine in the right
form and right dose by the right route at the right time.
• provides a clear record of the patient’s drug therapy.
GOLDEN RULES FOR PRESCRIPTION WRITING
1. Select the correct Prescription and Administration Record
There are three versions available in RIE and WGH:
• a standard 14 day record
• a standard 14 day record with a warfarin chart
• a 28 day record
(SJH have 14 day, 28 day and 120 day records - all with separate
warfarin chart)
2. Write clearly in block capitals, using a black ballpoint pen.
i Note any allergies or adverse effects of medicines. Document
what happens eg rash, anaphylaxis.
3. Complete all the required patient details on the front of the
Record
• Hospital/ward
• patient name*
• consultant
• patient number*
• weight
• date of birth*
• height
*A printed label will suffice for these 3 details
Write the patient name and date of birth on each page of the record (ie
each side). Include any previous adverse drug reactions, if known.
4. Use approved (generic) names of medicines
Rare exceptions include drugs where a specific brand is necessary
due to variation of response between brands e.g. theophylline,
lithium, diltiazem, nifedipine, and verapamil, and combination
products with no generic name e.g. Rifinah®.
5. Write the drug dose clearly
• The dose of medicine must be specified. Prescribing a dose range e.g 10-20mg, is not acceptable.
• The only acceptable abbreviations are
g - gramme
All other dose units must be written out in full e.g. micrograms
mg - milligram
ml - millilitre
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• Avoid decimal points write 100 micrograms (not 0.1 mg). If not
avoidable, write zero in front of the decimal point e.g. 0.5 ml (not .5 ml).
• Prescribe liquids by writing the dose in milligrams, except where the strength is not expressed in weight e.g adrenaline 1 in 1000, where the dose should be written in millilitres (ml).
• For ‘as required’ medicines, include the symptoms to be relieved, the minimum time interval between doses, and the maximum daily dose. (Figure 1)
6. Route of administration
The only acceptable abbreviations are:
IV - intravenous
SL - sublingual NG - nasogastric
IM - intramuscular
PR - per rectum ID - intradermal
TOP - topical
SC - subcutaneous
PV - per vagina
ETT - endotracheal
INHAL - inhaled
NJ - nasojejunostomy
NEB - nebulised
PEG - percutaneous endoscopic gastrostomy
Never abbreviate ORAL or INTRATHECAL.
Always specify RIGHT or LEFT for eye and ear preparations.
7. Enter the start date (Figure 2)
For courses of treatment, write only the dates therapy is required
and discontinue as described below.
For alternate day treatment, put a horizontal line through the boxes in
the administration section on the days the medicine is not given.
8. For once only prescriptions (Figure 3)
•
•
Medicines intended to be given once only must be prescribed in the ‘once only’ section of the medicine chart (Figure 3).
Medicines that are to be given once weekly must be prescribed in the regular section of the chart. A line must be drawn through the days that the medicine is not to be given and an instruction must be written in the notes section ‘Once a week on a ...day’.
9. Sign the prescription
Initials are not acceptable. Sign and print your name.
10.If the patient also has a supplementary chart in use (Figure 4)
Enter the details in the ‘other charts in use’ section on the Record.
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11.Never alter prescriptions
Cancel completely and rewrite.
12.Discontinue medicines by - (Figure 5)
Drawing a diagonal line through the prescription box, but do not
obliterate what has been written. Drawing a vertical line down the
last administration time, then a double diagonal line, the signing
and dating it.
13.When the discharge prescription has been written
Enter date and initial on the box on the front page of the Record.
Prescription and Administration Charts must be re-written when
required as follows:
• Any item no longer required must be cancelled, and a diagonal line drawn across each page of the old chart.
• The original start date for each medicine must be written in the new chart.
• The word ‘re-written’ and the date of re-writing, must be written at the top of the new chart.
• Ensure no medicines have been accidentally omitted from the new chart.
i Good prescribing information can also be found in the
British National Formulary
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27
Figure 1
Specimen Drug Kardex Prescriptions
Figure 2
Figure 3
Figure 4
Figure 5
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PRACTICAL PROCEDURES
Details of practical techniques for a number of emergency procedures
are contained in this handbook. These notes are not meant to
substitute for practical instruction in the correct method of carrying out
these procedures. They will however be useful reminders and should
ensure that details are not overlooked.
• Never undertake a procedure unsupervised when inexperienced.
• If difficulties are encountered, stop and call for help. • Before starting consider the need for a coagulation screen and
blood grouping.
• Explain the procedure to the patient and prepare the patient
appropriately (see chest drain insertion as an example). Familiarise
yourself with the patient’s anatomy and position the patient before
scrubbing up.
• Always record details of the time of day and nature of the procedure in
the notes together with the required monitoring asked of nursing staff.
• In the event of an unexpected change in the patient’s clinical
condition remember possible complications especially hypoxia,
vasovagal effects, haemorrhage, anaphylaxis and infection.
i Peripheral IV access: antecubital cannulation is painful, irritant
and potentially dangerous. Avoid unless no alternative.
TALKING WITH PATIENTS AND RELATIVES
• Talking with, and listening to, patients and their relatives is
important.
• Be open and honest.
• Do not be afraid to say you don’t know the answer to a question.
• Seek advice from a senior member of staff when unsure.
• Record details of the interview in the case notes with written details
of the information transmitted and the names of those present
(doctor, nurse, relatives).
• Try to see relatives as soon as possible after admission to seek
and document important information about the medical and social
aspects of the acutely ill or confused patient.
i Guidelines on the approach to breaking bad news can be found
in Appendix 1.
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MAKING A DECISION ABOUT RESUSCITATION
Lothian Framework for
Resuscitation Decisions
(See policy document for full details)
Can a cardiac or
respiratory arrest
be anticipated?
For example:
• Progressive cardiac or
respiratory compromise
• Previous life-threatening
event or condition in which
cardiac arrest is likely
• Patient dying from
irreversible condition e.g.
advanced cancer
NO
Is there anything about
the patient that makes you
think they may not wish
to be resuscitated in the
event of an unexpected
cardiac arrest?
For example:
NO
• Severe incurable
neurodegenerative condition
YES
YES
CPR should
be carried out
NO
• Do not burden the patient or
relevant others with a CPR
decision
• Continue to communicate
and assess any concerns
of the patient and relevant
others. This may involve
discussion on CPR and its
outcome
• Review only when
circumstances change
• In the event of cardiopulmonary arrest, carry out
CPR
Advanced Decision on CPR is possible
Are you as certain as
you can be that CPR
would realistically
have a medically
successful outcome?
NO
NO
Are you as certain as
you can be that CPR
would realistically
NOT have a medically
successful outcome?
NO
Seek advice
YES
• Sensitive exploration of the patients wishes regarding
resuscitation should be undertaken by the most experienced
staff available
• If the patient is competent for this decision, discuss options
of CPR and DNAR with patient. Involve relevant others* if
appropriate (with patient’s permission).
• If the patient is not competent to understand the implications
of this discussion, the medical team should make this decision
based on available information regarding patient’s previous
wishes (from relevant others*, other healthcare professionals
or members of the multidisciplinary team). Relevant others*
should never be asked to make the decision unless they are
the legally appointed proxy/welfare guardian for the patient.
• Document the decision and any discussion around that
process
• Continue to communicate and assess any concerns of the
patient and relevant others*
• Ongoing review to assess any change in circumstances
• In the event of a cardio-pulmonary arrest, act in accordance
with the documented decision
CPR inappropriate
• As CPR would not be successful it cannot be offered as a
treatment option. A DNAR form should be completed and
used to communicate this information to those involved in the
patient’s care.
• Allow natural death with good palliative care and support for
patient and relevant others
• Do not burden the patient or relevant others* with a CPR
decision
• Document decision and review fortnightly or if the patient’s
situation changes
• Continue to communicate and assess any concerns of the
patient and relevant others (which may include discussion
about why CPR is inappropriate)
• Ongoing review to assess any change in circumstances
*Relevant others refers to the patient’s relatives, carers, guardian etc
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A decision about the appropriateness of CPR can only be made if the
situation(s) where CPR might be required can be anticipated for the
particular patient (e.g. recent MI, pneumonia, advanced cancer etc.).
If such a situation can’t be thought through then there is no medical
decision to make and there is no need to burden patients with
resuscitation decisions.
Advanced statements - The exception to this would be where a
patient has some chronic and /or irreversible condition such that they
would not wish resuscitation in the event of any unexpected cardiorespiratory arrest from any unexpected cause. This would be a quality
of life issue and therefore the patient’s decision rather than a medical
decision. Such patients may have their wishes sensitively explored and
a DNAR form +/- advanced statement completed if this is appropriate
(see Lothian DNAR policy Appendix 2).
MEDICAL DECISIONS ABOUT DNAR
• The role of the medical team is to decide if CPR is realistically
likely to have a medically successful outcome. Such decisions do
not involve quality of life judgements.
• It may help in making a medical decision to decide whether the
patient would be appropriate for Intensive Care treatment (likely
outcome of a “successful” prolonged resuscitation).
• The consultant/GP responsible for the patient’s care has the authority
to make the final decision, but it is wise to reach a consensus with
the patient, staff and relevant others.
• It is not necessary to burden the patient with resuscitation decisions
if the clinical team is as certain as it can be that CPR realistically
will not have a medically successful outcome and the clinician is
not obliged to offer CPR in this situation. This must never prevent
continuing communication with the patient and relevant others about
their illness, including information about CPR, if they wish this.
PATIENTS DECISIONS ABOUT RESUSCITATION ISSUES
• Where CPR is realistically likely to have a medically successful
outcome consideration of a DNAR order for quality of life reasons
must be discussed with the patient and their wishes must be given
priority in this situation.
• Doctors cannot make a DNAR decision for a competent
patient based on a quality of life judgement unless the patient
specifically requests that they do this.
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THE PATIENT WHO IS NOT COMPETENT TO MAKE A DECISION
ABOUT RESUSCITATION
• Enquire about previous wishes from the relevant others to help
the clinical team make the most appropriate decision. Continue to
communicate progress to them.
• A Treatment Plan under Section 47 of the Adults with Incapacity
(Scotland) Act must be completed prior to a DNAR decision being
made.
• Continue to communicate progress to the relevant others.
THE ROLE OF THE RELATIVES/RELEVANT OTHERS
• A competent patient’s permission must be sought before any
discussion takes place with the relevant others.
• Relatives should never be given the impression that their wishes
override those of the patient. They can give information about the
patient’s wishes but should not be burdened with the decision unless
their status as proxy for the patient has been legally established.
PATIENTS WITH A DNAR ORDER AT HOME OR BEING
DISCHARGED HOME
• It is the medical and nursing team’s responsibility to ensure that the
family are aware of the existence of the DNAR form and know what
to do in the event of the patient’s death.
• Where it is felt it may be harmful to the patient to have the DNAR
form in the home the GP should keep the form in the front of the
medical notes and ensure that all the healthcare professionals
involved in the patient’s care are aware of this.
• The OOH service must be made aware of the existence of the DNAR
order. Every effort must be made to ensure the emergency services
are not called inappropriately where a patient’s death is expected.
PATIENTS WITH A DNAR ORDER BEING TRANSPORTED BY
AMBULANCE
• The ambulance section of the DNAR form must be completed for
any such patient form being transported in Lothian by the Scottish
Ambulance Service.
• Ambulance control must be informed of the existence of the DNAR
order at the time of booking the ambulance.
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WHERE NO DNAR DECISION HAS BEEN MADE AND A PATIENT
ARRESTS
• The presumption is that staff would attempt to resuscitate a patient
in the event of a cardio-pulmonary arrest. However, it is unlikely to
be considered reasonable for medical staff or senior nursing staff to
attempt to resuscitate a patient who is in the terminal phase of an
illness.
NOTES
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PATIENT DEATHS
• See patients without delay after being informed of their death.
• Inform the GP and the relevant consultant within 24 hours of the
death of all patients.
• Guidelines for ‘When Death Occurs’ are found in Appendix 2.
• Sudden or unexpected deaths should be reported to the Procurator
Fiscal. The Fiscal should be consulted in the event of any death
associated with sudden unexplained ill health, occupational
disease, medical accident or suspicion of foul play, drug overdose,
suicide or neglect.
DEATH AND THE PROCURATOR FISCAL
If there is doubt about the cause of death discuss the patient with
your seniors, and if necessary the Procurator Fiscal. In the following
circumstances you MUST refer the case to the Fiscal. DO NOT issue
any certificates without first talking to the Fiscal.
INDICATIONS FOR REFERRAL TO PROCURATOR FISCAL:
summarised from circular MEL (1996) 33 which gives full details
i •
•
•
•
•
•
•
•
•
•
•
Duty Procurator Fiscal (Edinburgh: for WGH or RIE) can be contacted
during office hours at the deaths’ enquiries office on #6118, and at
weekends via Fettes Police switchboard on #6100 (311 3131).
Procurator Fiscal Linlithgow: for SJH short code 62174, at weekends
via police short code 62148.
Death due to an accident.
Death resulting from an accident at work or industrial disease.
Any death of a person while at work.
Death due to poisoning.
Death where suicide is a possibility.
Death due to medical mishap.
Deaths which occur unexpectedly having regard to the clinical
condition of the deceased prior to his receiving medical care.
Deaths which are clinically unexplained.
Death seemingly attributable to therapeutic or diagnostic hazard.
Deaths which are apparently associated with lack of medical care.
Deaths which occur during the actual administration of general or
local anaesthetic.
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• Deaths which may be due to the anaesthetic.
• Death following abortion.
• Deaths where the circumstances indicate neglect on the part of
another person.
• Deaths while under legal custody.
• Any death where the deceased’s residence is unknown.
• Death due to drowning.
• Death due to food poisoning or any notifiable infectious disease.
• Death due to fire or explosion.
• Death of a foster child.
• Any other death due to violent, suspicious or unexplained cause.
• Any death where a complaint is received from the next of kin
about the medical treatment given to the deceased, and where the
medical treatment may have contributed to the death.
THE DEATH CERTIFICATE
• Detailed advice on completion of the death certificate is contained
in the certificate booklet.
• Ensure that both the counter foil and the death certificate proper
have the patient’s name written legibly on them.
• Ensure the date is correct, and that it is neat, legible and signed.
• When speaking to the family explain what the technical terms
mean, if this is appropriate.
• Document what has been written on the certificate in patient case
record.
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35
CHECKLIST OF REQUIREMENTS
This checklist is used at ward level to ensure that all important steps
are taken to document timing and responsible individuals.
Initials
Yes No
Patient’s death confirmed by doctor?
Senior nurse in charge informed of patient’s death?
Next of kin notified of death?
(see breaking bad news guidelines) Appendix 1
Procurator Fiscal Notification - inform as appropriate
Death certificate prepared? (see instructions in Deaths
booklet)
Death certificate given to family?
Family returning later for death certificate?
(if yes please record at the bottom of the page)
Bereavement booklet given to family?
Valuables/belongings returned to the family?
Valuables held in cashier office?
Post Mortem if required - Patient’s family must sign
Copy of signed post mortem consent given to family?
Cremation Form B (if appropriate) completed?
Cremation Form B (if appropriate) sent to mortuary?
Infection Certificate for undertaker sent to mortuary?
Consultant informed - within 24 hours
GP contacted - within 24 hours
Medical records informed - within 24 hours
Cancel any follow-up appointments if already booked
prior to death
Arrangements to collect death certificate: Date / /
Other comments:
Determine family’s
wishes regarding
jewellery?
To remain on patient
Time:
Yes/No
Comments:
Initials
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THE CREMATION FORM
i Incomplete cremation forms can delay funeral arrangements,
cause distress to bereaved relatives and cause major
difficulty for mortuary staff. It is sensible to complete a Form
B cremation form for every death unless it is known for
certain a burial is planned.
• If there is no post mortem examination Form C is completed by
a senior clinician (usually arranged by the mortuary). This is
coordinated by Medical Unit secretary at SJH.
• If a post mortem examination is to be done, only Form B is required
and should be completed (Q8a) after speaking to the pathologist.
• Cremation forms are not given to the family but are sent to the
mortuary.
POST MORTEM EXAMINATION
• If a post mortem examination is considered desirable or is requested
by the family, a clinician of F2/SHO grade or higher, or other suitably
trained person, should explain to the family before requesting
authorisation.
• Ensure the authorisation form is fully completed, signed and
witnessed. One copy of this form is given to the family with the
information booklet, one copy is filed in the medical notes and the
third copy is for pathology.
• A post mortem request form is completed and countersigned by a
clinician of SpR grade and upwards.
• Send the pathology copy of the authorisation form and the request
form to the mortuary.
• The mortuary will invite clinical staff to view the post mortem
findings.
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37
ORGAN DONATION
Transplants are one of the most miraculous achievements of modern
medicine, but they depend entirely on the generosity of donors and
their families who are willing to make this life-saving gift to others.
At present the number of people awaiting transplantation greatly
exceeds the number of organs available. It is therefore essential to
maximise the potential number of organs available from the existing
potential donor pool.
Typically donation is from a variety of clinical settings:
Organ donation - is from patients in the intensive care unit following
confirmation of death by brain stem death tests or from
Non-heart Beating Donation - patients are certified dead following
cardio-respiratory arrest within the intensive care unit.
Tissue – can be donated following either the confirmation of death
by brain stem tests or cardio-respiratory death. Tissue does not
deteriorate immediately following cessation of the heartbeat due to
its low metabolic requirements, allowing more time for retrieval and
therefore may be offered in a variety of clinical settings.
All potential donors should be referred to the local donor transplant
coordinator/tissue coordinator as early as possible for consideration
for organ/tissue donation (Department of Health Working Party-Code of
Practice for the Diagnosis of Brain Stem Death 1998). In cases of organ
donation the donor transplant coordinator will be present throughout
the organ donation process.
Donated organs/tissues and the families that donate them are a precious
resource. The lives of hundreds of transplant patients are saved each
year as a result of this gift. It is important that, where appropriate, the
option of donating organs and/or tissue is offered to the next of kin/
person closest in life.
To discuss organ or tissue donation call switchboard at RIE asking for
the transplant coordinator on call.
38 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
GOOD PRACTICE FOR DISCHARGING PATIENTS
• Discharge is an extremely important part of patient care.
• Planning of discharges should begin early in the patient’s admission.
A patient’s suitability for discharge will depend on:
• Medical Condition: is the patient stable and can further investigation
or treatment be completed as an out‑patient?
• Functional Ability: is the patient independent or dependent on
others?
• Social Situation: does the patient live alone or are there carers?
i If there is any doubt about a patient’s ability to manage at home, a
MULTIDISCIPLINARY ASSESSMENT should be performed. This will
usually involve physiotherapy, occupational therapy and social work.
Procedure
• An expected date of discharge form is in use across Lothian.
• At least 6 hours before discharge of any patient you should use
the patient’s Prescription and Administration Record and Case
Notes to help complete the Summary Form.
• Fill in the Patient Discharge Information Summary with as much
information as you can.
• Fill in an OPD Appointment Card with Clinic Name and approximate
date of attendance.
• In some units the ward secretary or housekeeper will arrange
appointments.
• Write in the Case Notes: Date of admission (DOA)
Date of discharge (DOD)
Diagnoses
Any other relevant details
Relevant Ix, Rx, changes to Rx
Follow‑up
• The medication on Discharge (see below) should be checked with
a more senior member of medical staff. You must complete this
accurately.
• Leave in the agreed place for checking by a Pharmacist where this
service is available.
• Give the nurses the discharge letter to arrange supply of discharge
medications where appropriate and place the notes with summary form
in the appropriate place. Give appointment card to ward clerkess.
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i Always consider telephoning the G.P. This is ESSENTIAL for
frail elderly patients and for other patients where further
medical intervention will be required e.g. patients being
commenced on warfarin.
If you are in any doubt, pick up the telephone.
DISCHARGE PRESCRIPTION WRITING
• Adhere to previous guidance on good prescription writing.
• The Patient Discharge Information Summary must be used to
prescribe all current medicines. The information required must be
accurately transcribed from the inpatient prescription chart and the
patient’s medical notes.
• The doctor responsible for the patient’s care must ensure that the
Patient Discharge Information Summary is completed in adequate time,
taking account of the patient’s planned time and date of discharge.
• At least a seven day supply of medicines must be provided, unless
a longer or shorter course of treatment is appropriate. The duration
of therapy for antibiotic or steroid courses MUST be specified.
• Review all inpatient medicines and whether they need to be
continued. Recommend review of changes to GP.
• Include (IN CAPITAL LETTERS)
Name - (Patient’s name, GP’s name, Consultant’s name)
Address - (Patient and GP’s address)
Ward / Department
Date
Signature - (name printed beside signature)
• If the patient already has his or her own supply of required medicines at
home or stored in the ward an additional supply should not be issued
from the hospital. However, the doctor who writes the prescription,
or the pharmacist, nurse or other professional who checks the
prescription, must satisfy himself or herself that the patient’s own
supply is of an adequate quantity, quality and is correctly labelled with
the current dosage instructions. The Patient Discharge Information
Summary must be endorsed ‘patient’s own supply’.
• If the medicines are to be dispensed in the pharmacy, the Patient
Discharge Information Summary must be delivered to the pharmacy
at least 4 working hours before the patient is due to be discharged,
to allow adequate time for dispensing and delivery to the ward.
40 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
i Always review analgesic and sedative medication prior to discharge
Outpatient and discharge prescriptions for controlled drugs must
comply with legal requirements. The prescription must:
• Include the name and address of the patient
• be written in indelible ink
• include the form (e.g. tablets) and if appropriate strength of the
preparation e.g. morphine sulphate modified release tablets 10 mg
• include the total quantity of the preparation, or the number of dose
units, in both words and figures e.g. 28 (twenty-eight) tablets, or
280 (two hundred and eighty) mg
• include the dose
• be signed and dated by the prescriber
i For Warfarin: fully complete the yellow anticoagulation booklet
and give to the patient.
Further information available on the Lothian Joint Formulary
website: www.ljf.scot.nhs.uk
GUIDE TO GOOD DISCHARGE SUMMARIES
• The Discharge Summary is of vital importance.
• It is a summary of the in­patient stay.
• It is the main method of communication with the GP as well as
being a summary for the case records.
Discharge summaries must include:
• The main diagnosis for that admission.
• Any important concurrent diagnoses.
• Important social factors e.g. living alone.
• Details of operations or major procedures e.g. central venous lines,
endoscopy.
• Drugs on discharge including dietary advice.
i Highlight any changes to treatment.
• Community Services arranged e.g. Home Help, District Nurse etc.
• Follow-up: arrangements at hospital or with GP.
• Information given/not given to patient and relatives.
How to do it
• Text should be relatively brief and detail changes in treatment and
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41
review arrangements. Include:
a) drugs stopped (and reason why).
b) new treatments (which should be justified).
• Concentrate on selected details to indicate the disease and its
severity.
• Unexpected findings, complications and relevant results should be
included.
• Check the format preferred in your unit.
• The best summaries are accurate, brief and timely.
• The GP should have the full summary within ten days of discharge,
thus it is essential you dictate promptly.
You should try to:
• Dictate summaries daily, or at most within 3 days of discharge.
• Give the date of dictation.
• Speak clearly and slowly.
• Include all the details listed above.
• Use precise diagnoses ‑ ask your Consultant or Specialist Registrar
if in doubt.
• Send copies of the summary where appropriate e.g. to other
hospitals, to specialist units within the Division (e.g. Diabetes,
Endocrine, Haematology, Neurosciences, Oncology, Orthopaedics,
PAEP, Renal, Surgery), to other Consultants, and to Medical Officers
of Nursing Homes.
• Sign your summaries (and other letters) promptly.
You should NOT:
• leave your summaries until a weekend on ‑ this is unfair to the
patient and secretary, and renders it much less effective as a means
of communicating.
• use symptom diagnosis e.g. chest pain if a more precise one is
available.
• give all clinical details and normal results ‑ be selective.
• repeat all the past history ‑ include relevant details under concurrent
diagnoses.
i Dictation can seem a chore, but it is MUCH EASIER to do if the
patient is fresh in your mind, and MUCH HARDER if you leave it
and cannot remember who the patient was.
42 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
Chapter 2
RESUSCITATION & EMERGENCY MANAGEMENT
INITIAL ASSESSMENT AND MANAGEMENT OF
THE ACUTELY ILL ADULT
GENERAL POINTS
• Acutely ill patients require rapid but careful assessment.
• Initiation of treatment often precedes definitive diagnosis but
diagnosis should be actively pursued.
• Aim to prevent further deterioration and stabilise the patient.
i Early involvement of experienced assistance is optimal
i.e. GET HELP.
• The general principles of emergency management described here
can be applied to the majority of acutely ill adults irrespective of
underlying diagnosis or admitting speciality.
• Sepsis, shock and respiratory failure can occur in any clinical area.
There may be life-threatening abnormalities of physiology present
e.g. hypoxia or hypovolaemia, or the patient may have a specific
condition which is at risk of rapid de-stabilisation e.g. acute
coronary syndrome, GI bleed.
The approach to the acutely ill adult requires four elements to proceed
almost in parallel:
THE FOUR KEY ELEMENTS OF EMERGENCY MANAGEMENT
1.
Acute
assessment
& primary
treatment with
immediate
targeted
examination,
investigations &
support
2.
Monitoring
with
frequent
re-assessment
3.
Illness
severity
assessment
4.
Definitive
diagnosis &
treatment:
full exam
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43
Immediate investigations are those which will influence the acute
management of the patient and include;
•
•
•
•
•
•
•
•
Arterial blood gas
Glucose
Potassium
Haemoglobin
Clotting screen (where indicated).
Twelve lead ECG.
CXR (where indicated).
Remember to take appropriate cultures including venous blood
cultures before administering antibiotics (if practical).
• Consider sending blood for screen, group and save or cross-matching.
1. ACUTE ASSESSMENT, PRIMARY TREATMENT & INVESTIGATIONS
Acute assessment is designed to identify life-threatening physiological
abnormalities and diagnoses so that immediate corrective treatment
can be instituted (see algorithm). Patient observations and SEWS score
are critical to the process. Within NHS Lothian an early warning scoring
system (SEWS) has been developed to alert staff to severely ill patients.
It is a decision support tool that compliments clinical judgement and
provides a method for prioritising clinical care. An elevated SEWS
score correlates with increased mortality and it is recommended
that a patient with a SEWS of 4 or greater requires urgent review and
appropriate interventions commenced. Think: Do they need specialist/
critical care input NOW?
44 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
PRIMARY ASSESSMENT & MANAGEMENT:
APPROACH TO THE ACUTELY ILL PATIENT
See explanatory notes below
Approach: Hello, how are you?
What is the main problem? Do you have any allergies? What medicines
are you on? PMH?
Get a clear history to assist definitive diagnosis
CLINICAL ASSESSMENT
ACTION
*GET HELP NOW
INVESTIGATIONS
IN ASSESSMENT
A Airway and Conscious Level
Clear and coping? Stridor*
Chin lift, head tilt
Call for help early
Breathing
Look, listen and feel Rate and volume
B and symmetry
WOB2/pattern
RR > 30*
Paradoxical breathing*
High concentration ABG3, PEFR, CXR
60-100% oxygen1
Monitor ECG, BP, SpO2
Ventilate
if required
Circulation
Pulse4
No pulse: 12 lead ECG
Rate/volume
cardiac massage
IV access5 and
C Rhythm/character
Skin colour and temp
fluids
Capillary refill6 and warm/
cold interface
Blood pressure (BP)
HR < 40 >140*
BP < 90 SBP*
CNS and Conscious Level
D GCS/AVPU
Fall in GCS 2 points*
Pupils, focal neurological signs
ABC & Consider
the cause
Management of coma
Glucose
Examine & Assess Evidence Look at SEWS chart, Standard bloods
E & Environment
results, drug &
Temperature
fluid charts
If not breathing, get help and give two effective rescue breaths.
WOB: work of breathing.
3
Always record inspired oxygen concentration.
4
If collapsed carotid, if not start with radial.
5
Take blood for x-match and immediate tests (see text).
6
Should be <2 seconds.
1
2
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45
NOTES ON INITIAL ASSESSMENT ALGORITHM
Airway and Breathing
• See BLS guidelines for cardiac arrest.
• By introducing yourself and saying hello you can rapidly assess the
airway, breathing difficulties and the conscious level. If the patient
is talking A is clear and B isn’t dire.
• AMPLE: ask about allergies, medicines, past history, last food/fluid,
events at home or in ward e.g. drug administration.
• If any patient with known or suspected chronic respiratory disease
arrives in A&E, CAA or ARAU on high concentration oxygen check
ABG immediately and adjust oxygen accordingly.
• When assessing breathing think of it in the same way as you think
of the pulse: rate, volume, rhythm, character (work of breathing),
symmetry. Look for accessory muscle use, and the ominous sign of
paradoxical chest/abdomen movement: “see-saw”.
• High concentration oxygen is best given using a mask with a
reservoir bag and at 15l can provide nearly 90% oxygen.
i The concentration of oxygen the patient breathes in is determined
by the type of mask as well as the flow from the wall and the
breathing pattern. By using a fixed performance system (Venturi)
you can gauge the percentage much more accurately.
• The clinical state of the patient will determine how much oxygen to
give, but the acutely ill should receive at least 60% oxygen initially.
• ABG should always be checked early to assess oxygenation,
ventilation (PaCO2) and metabolic state (HCO3 and base deficit).
Always record the FiO2 (oxygen concentration).
• Oxygen therapy should be adjusted in the light of ABGs: O2
requirements may increase or decrease as time passes.
Circulation
• IV access is often difficult in sick patients.
• The gauge of cannula needed is dictated by the required use:
- large bore cannulae are required for volume resuscitation. Ideally
insert 2 large bore (at least 16G grey) cannulae, one in each arm
in the severely hypovolaemic patient.
- an 18 gauge green cannula is usually adequate for drug
administration.
• The femoral vein offers an excellent route for large bore access and
an 8.5F Swan-Ganz introducer is ideal.
46 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
• If there is major blood loss speak to the labs & BTS: you may need
coagulation factors as well as blood. Consider activating the Major
Haemorrhage protocol dial 222. Call Senior help.
• Use pressure infusors and blood warmers for rapid, high volume
fluid resuscitation.
i If the patient is very peripherally vasoconstricted and hypovolaemic
don’t struggle to get a 14G (brown) cannula in. Put in two 18G cannulae (green) and start fluid resuscitation through both.
CALL FOR HELP
• Machine derived cuff blood pressure is inaccurate at extremes of
BP and in tachycardias (especially AF).
• Manual sphygmomanometer BP is more accurate in hypotension.
• In severe hypotension which is not readily corrected with fluid
early consideration should be given to arterial line insertion and
vasoactive drug therapy: GET HELP.
Disability
• Glasgow coma scale (GCS): document all three components
accurately with best eye, best verbal and best motor responses.
Glasgow Coma Scale to record conscious level
Eye Opening (E)
Verbal Response (V)
Motor Response (M)
4=Spontaneous
5=Normal conversation
3=To voice
4=Disoriented conversation
2=To pain
3=Words, but not coherent
1=None
2=No words......only sounds
1=None
6=Normal
5=Localizes to pain
4=Withdraws to pain
3=Decorticate posture
2=Decerebrate
1=None
Total = E+V+M
• Check pupil size, symmetry and reaction to light.
Exposure, evidence and examination
• Targeted examination should be performed and information sought
from any recent investigations, prescription or monitoring charts.
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47
LOOK AT
ABNORMALITIES
SOUGHT
Trachea
Deviation
Chest
Lateralising signs, wheeze,
creps, dull PN
CXR
CTPA
JVP and HS I + II
➔
INVESTIGATIONS
JVP, III + IV HS,
murmurs
ECG, Echocardiograph
Abdomen
Distension, peritonism,
pulsation, bowel sounds
USS, AXR
CNS
Pupils, lateralising signs,
neck stiffness
CT
Skin
Rashes, purpura
Blood cultures
PREVENTING DETERIORATION & CARDIAC ARREST
• Around 80% of our in-hospital cardiac arrests are in non-shockable
rhythms.
• In ventricular fibrillation/pulseless ventricular tachycardia the
onset is abrupt, and an at-risk group with acute coronary syndromes
can be identified and monitored. Early defibrillation results in optimal
survival.
• In contrast, in-hospital cardiac arrest in asystole or pulseless
electrical activity or PEA has a survival rate of around 10% and there
is no specific treatment. There are usually documented deteriorations
in physiology prior to the arrest. These are often treatable and reversible
so the aim is to recognise decline early and to provide early corrective
management in order to PREVENT CARDIAC ARREST. ( See SEWS
section).
i Causes of preventable asystole and PEA can also cause VF.
• Hypoxaemia and hypovolaemia are common and often co-exist
e.g. in sepsis, anaphylaxis, trauma or haemorrhage such as GI
bleeding.
• Electrolyte abnormalities, notably hyperkalaemia, hypokalaemia
or hypocalcaemia are easily detected and readily correctable.
• Drug therapy or poisoning/toxins may contribute to instability.
N.B. β-blockers and calcium channel blockers.
48 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
Physiological abnormalities
How to pick them up
Hypoxaemia, hypercarbia, acidosis
Do an early blood gas
Hypovolaemia, hypervolaemia
Assess circulation (see algorithm)
Hypokalaemia, hyperkalaemia
Early bloods
Hypothermia
Assess context, core temp
Tension pneumothorax
Clinical context and signs
Toxins
Clinical context, (chart in chapter 10)
Cardiac tamponade
Clinical context, early echo
Thromboembolic
Clinical context, PE/CTPA
• Hypothermia, tension pneumothorax, cardiac tamponade
(particularly after thrombolysis, cardiac surgery or chest trauma) and
thrombo-embolic disease must all be considered (in context).
2. MONITORING & REASSESSMENT
• Real-time continuous monitoring is invaluable in the acutely ill.
• Pulse oximetry, ECG and cuff BP monitoring should be instituted
immediately in all patients.
• Monitoring is an integral part of the treatment/re-assessment/
treatment/re-assessment loop.
• The place of urgent investigation is detailed previously.
• In order to make a definitive diagnosis other blood tests or imaging
techniques may be required.
i Do not move unstable patients e.g. to x-ray until stabilised, and
then only with adequate support, vascular access, monitoring
and appropriate escort.
Assessment and re-assessment
Assess response to treatment by constant clinical observation,
repeated assessment of airway, breathing, circulation and disability
(conscious level) as above with uninterrupted monitoring of ECG and
oxygen saturation. Reassess regularly to see the effects of intervention,
or to spot deterioration.
i If the patient is not improving consider:
1. Is the diagnosis secure?
2. Are they so ill help is needed now?
3. Is there a new problem or diagnosis?
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49
3. ILLNESS SEVERITY ASSESSMENT
• Working out how ill the patient is and what needs to happen to them
next underpins the effective, safe management of all adult medical
emergencies.
Specific scoring systems are included in specialist sections. The
Scottish Early Warning Scoring System is being used in Lothian (QV).
Illness severity assessment informs four key decisions:
i) What level and speed of intervention is required? e.g. urgent
ventilation, immediate surgery.
ii) Is senior help required immediately, and, if so, whom?
iii)Where should the patient be looked after? This is a decision about
nursing care, monitoring and treatment level. The choices include:
- General wards.
- Intermediate care facility (Coronary Care Unit: CCU or High
Dependency Unit: HDU).
- Theatre
- Intensive Care Unit (ICU).
i Placing the patient in a monitored HDU bed without increasing
the level of appropriate medical input and definitive treatment
will not improve outcome on it’s own.
Senior advice should be sought early .
iv)What co-morbidity is present? (including drugs which blunt
compensatory changes in physiology).
i If you are called to a sick patient GO AND SEE THEM. Five
seconds critically looking at the patient will tell you more than
10 minutes on the phone.
SEWS PARAMETERS AND SCORING SYSTEM
Parameter
321
Score
0123
Respiratory rate
≥ 36
31-35
21-30
9-20
SaO2 (%)
< 85
85-89
90-92
≥ 93
≤8
Temperature
≥ 39
38-38.9
36-37.9
35-35.9
34-34.9
≤ 33.9
BPS (mm Hg)
≥ 200
100-199
80-99
70-79
≤ 69
≥ 130
110-129
100-109
50-99
40-49
30-39
≤ 29
Alert
Verbal
Pain
None
HR
AVPU Response
Case example Patient presents in respiratory distress.
RR 32, SaO2 90%, T° 38.9, BPS 160/70, HR 105, AVPU: Verbal
SEWS score = 6
Patient requires increased frequency of observations and urgent medical review.
50 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
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51
TEMP
Inspired 02%
Sp02
RESP.
RATE
1
2
SEWS
9-10
6-8
4-5
1-3
0
Bowels
SEWS SCORE (with all obs)
9-10
6-8
4-5
1-3
0
Bowels
Severe
Severe
Moderate
Mild
None
NEURO
RESPONSE
Alert
Verbal
Pain
Unresp
U0<30
BM
35°
34°
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
>140
130
120
110
100
90
80
70
60
50
40
30
34°
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
>140
130
120
110
100
90
80
70
60
50
40
30
Alert
Verbal
Pain
Unresp
UO<30mls/hr (3 hrs+)
BM
HEART
RATE
BLOOD
PRESSURE
36°
37°
35°
38°
37°
36°
39°
38°
ADMISSION DATE:
39°
D.O.B:
36+
31-35
26-30
21-25
15-20
9-14
b8
93+
90-92
85-89
<85
%
NAME:
36+
31-35
26-30
21-25
15-20
9-14
b8
<93+
90-92
85-89
<85
%
DATE:
TIME:
3
SEWS KEY
0
SEWS SCORE
uses Systolic BP
ASU:
PAIN
Observation Chart
Date chart commenced:
This is chart number
Attach a patient Addressograph here
this admission
Actual or estimated patient weight
How
•
Do
•
Rec
•
Not
•
Add
•
Act
If RR >2
If Sp02
kgs
If Temp
An Early Warning Score (SEWS) must be calculated every time patient observations are recorded.
If SEWS score 4 or more then call the appropriate doctor and nurse in charge using the guidelines below.
Increased frequency of observations (minimum hourly) should be commenced and a detailed report in
the patient’s medical notes should be completed.
Early Warning Score 4 or more
or concern with a patients condition.
Early Warning Score 6 or more
or rapidly deteriorating patient.
If Systo
Consid
Consid
If Pulse
Call Junior Doctor & Senior Nurse/Nurse Practitioner
If Dr cannot attend within 20 mins,
they should arrange a Deputy.
If respo
or unre
Practitioner/Dr unable to attend within 20 mins or
SEWS increased by 2 or patient deteriorating.
If BM <
Call appropriate SHO/Registrar & Senior Nurse/Nurse Practitioner
Dr unable to attend within 10 mins or
SEWS increased by 2 or patient deteriorating.
Pain
How t
Call appropriate Registrar/Consultant
Consider ICU referral/review of treatment plan
Cancer
Acute p
Pain S
0
Persistent Pain – 6 or above and unresponsive to guidelines
Call Medical Staff/Senior Nurse/Nurse Practitioner
1-3
4-5
6-10
Loth
For further advice contact:
Cancer
ACUTE
CANCER-RELATED
Mon- Fri: Bleep Acute Pain Team
Out of hours: On-call anaesthetist
Mon- Fri: Bleep Palliative Care Team
Out of hours: via switchboard
Acute p
P
© Quality
52 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
rded.
low.
ort in
How to calculate SEWS Score
•
Do not add pain score to SEWS Score.
•
Record standard observations (RR, Sp02, Temp, BP, HR, AVPU).
•
Note whether observation falls in shaded “At Risk Zone”. Score as per SEWS key.
•
Add points scored and record total “SEWS Score” in bottom row of chart.
•
Action as per guidelines on front of chart.
If RR >24
Review patient / CXR +/- gases / PEF (Peak Expiratory Flow) etc �
If Sp02 sats <93%
Review probe ? accurate
Review patient � prescribe oxygen on drug chart if indicated, consider ABGs.
If Temp >38
Blood cultures Other cultures Start antibiotic therapy if indicated.
If Systolic BP<100
Review monitoring (cardiac / oximetry / urine output / invasive BP etc).
IV Access
Review patient / drug kardex.
Consider:
IV Fluid �
Consider:
Hypovolaemia Cardiac
Obstructive
Distributive
Dehydration
Blood loss
PE
Tamponade
Sepsis
Anaphylaxis
Arrhythmia
Pump failure
Review monitoring (cardiac monitor indicated)
If Pulse >130
IV Access
Review patient / ECG / electrolytes �
If responds to pain only
or unresponsive
Assess airway, BM, GCS, consider neuro observation chart, review patient / kardex.
If BM <4
Give Oral Carbohydrate / IV Dextrose. Consider checking urgent laboratory blood glucose.
Pain Assessment & Management Guidelines
How to score pain:
Cancer-related pain:
Acute pain:
Always score worst pain in last 24 hours or since last assessment.
Score current pain e.g. on movement/deep breathing.
Pain Score:
Action:
0
NONE
Continue to assess pain daily or with observations.
1-3
MILD
Continue to assess pain daily or with observations.
4-5
MODERATE
Assess. Using guidelines, prescribe analgesia as appropriate for the patient. Review.
6-10
SEVERE
Assess. Using guidelines, prescribe analgesia as appropriate for the patient. Review.
Lothian Guidelines
Cancer-related pain:
Acute pain
Initiate Edinburgh Pain Assessment Tool (EPAT©) for pain score of 4 or above.
Use Palliative Care Guidelines.
Use Acute Pain Guidelines.
PERSISTENT MODERATE OR SEVERE PAIN, WHICH DISTRESSES PATIENT:
REFER. SEE FLOW CHART OVER.
© Quality Improvement Scotland (QIS) Illness Severity Criteria Subgroup, February 2005.
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53
Illness Severity and Diagnosis (Risk of Deterioration)
• As the ABCD is secured a specific diagnosis is sought with the
‘Secondary Examination’ and specific treatment can then be
instituted.
• Explanation, reassurance and analgesia are integral parts of acute
care. Always keep the patient, family and/relevant others informed
about progress.
• Objective information on severity of illness may be obtained from
blood tests e.g. acidosis and oxygenation, K+, renal dysfunction,
liver failure and DIC.
• If acidosis is due to tissue hypoxia, base deficit can be followed as
a guide to response to treatment (unless metabolic acidosis is due
to e.g. renal failure).
i BASE DEFICIT is very important.
+3 to -3
-5 to -10
-10 or worse
normal
moderately ill
severely ill
Arterial blood lactate
• If elevated has prognostic significance - the higher the worse.
N.B. However, patient’s may have tissue hypoxia with a normal
lactate.
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IDENTIFICATION OF THE ACUTELY ILL PATIENT REQUIRING
INTENSIVE CARE OR HIGH DEPENDENCY UNIT REFERRAL
CRITERIA FOR EARLY REFERRAL TO INTENSIVE CARE
Threatened or obstructed airway
Stridor
Respiratory arrest
Tachypnoea >35/min, respiratory distress
Respiratory
SpO2 <90% on high concentration (>60%) oxygen
Failure
Rising PaCO2
(generally >8 kPa or >2 kPa above patient’s
normal level, with respiratory acidosis)
Cardiac arrest (unless circulation restored
rapidly by defibrillation and with return of
consciousness)
Shock: tachycardia and/or hypotension not
responsive to volume resuscitation
Shock
Evidence of tissue hypoperfusion/hypoxia
Clinically poor peripheral perfusion
Metabolic acidosis
Hyperlactataemia
Diminished conscious level
Poor urine output
Renal
Oliguria
Failure
Hyperkalaemia
Uraemia
➔
Diminished conscious level
Threatened
airway
GCS
Absent gag/cough
Failure to maintain normal PaO2 and PaCO2
Status epilepticus
Gastro-intestinal/ Liver failure
Liver
GI bleeding
Sepsis
Severe sepsis and septic shock.
Even in the absence of a specific diagnosis of concern or greatly
impaired physiology early ICU involvement may be appropriate: seek
senior advice.
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i Watch for the development of cardiovascular, respiratory and
other organ system failure, particularly in patients known to be at
risk because of their illness.
INVOLVE ICU EARLY
These guidelines are intended to facilitate referral of acutely ill patients
for consideration of Intensive Care, High Dependency care and
treatment of major organ system failure.
Mechanism of referral:
ICU
RIE - Ward 118: 21187/21188
SJH - 54063/54056 BLEEP 561
WGH - Ward 20: Call ICU Consultant
HDU (Level 2)
RIE - Ward 116 HDU: 21161
(SHO 5198 for medical referrals or med.HDU consultant)
SJH - 54063/54056 BLEEP 561
WGH - Ward 20: Call ICU Consultant
EXAMPLES OF PATIENTS
Surgical problems
• Perforated, ischaemic or infarcted bowel (both upper and lower).
• Acute pancreatitis.
• Sepsis from the gastro-intestinal, biliary or urinary tract.
• Respiratory or cardiorespiratory failure after any operation.
• Significant cardiovascular or respiratory disease in patients undergoing
major surgery.
Medical problems
• Pneumonia, acute exacerbation of COPD, severe acute asthma.
• Sepsis.
• Cardiovascular failure e.g. severe LVF, post-MI.
• Post cardiac arrest (unless rapid return of circulation, ventilation
and consciousness) usually go to CCU.
• GI bleed with haemodynamic instability.
• Severe diabetic ketoacidosis
• Poisoned patients at risk of airway or haemodynamic compromise.
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Patients with Neurological disease with:
• Inability to breathe adequately.
• Inability to protect their airway.
• These include patients with reduced conscious level or brain-stem
dysfunction.
4. DEFINITIVE DIAGNOSIS & TREATMENT
• Immediate life-saving treatment often prevents further decline
or effects improvement while the diagnosis is made and specific
therapy applied e.g. thrombolysis in MI, endoscopic treatment of
an upper GI bleeding source. Outcome is better in patients where a
definite diagnosis has been made and definitive therapy started.
FULL EXAMINATION & SPECIALIST INVESTIGATIONS
• Get a good history: useful information is always available.
• Relatives, GP, neighbours, ambulance staff may all be helpful.
i If the patient is not improving consider:
1. Is the diagnosis secure?
2. Is the illness severity so great help is needed?
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SHOCK
Definition & Classification
• Shock is an acute metabolic emergency where compromised oxygen
transport leads to cellular oxygen utilisation which is insufficient to
sustain normal aerobic metabolism.
• The common denominator in all types of shock is inadequate tissue
oxygen availability.
• The aim of therapy in shock is to optimise tissue oxygen delivery
in relation to oxygen requirements, whilst making a specific
diagnosis and treating the underlying problem.
• Shock may result from inadequate oxygen delivery to the tissues
(hypovolaemia, anaemia, low cardiac output), maldistribution of
blood flow (sepsis, anaphylaxis) or the inability of the cells to utilise
oxygen (sepsis).
TRADITIONAL CLASSIFICATION (aetiological):
• Hypovolaemic
• Septic
• Cardiogenic
• Anaphylactic
• Obstructive
• Neurogenic
FUNCTIONAL CLASSIFICATION (pathophysiological):
Intact oxygen utilisation
Abnormal (low
(low flow: low stroke volumes)
oxygen utilisation low systemic vascular resistance)
• Cardiogenic
• Septic
• Hypovolaemic
• Anaphylactic
• Obstructive
• Late low flow shock
e.g. pulmonary embolism,
tensionpneumothorax, tamponade
Clinical Presentation
Clinical evidence of organ dysfunction:
• Tachypnoea
• Tachycardia
• Hypotension
• Poor peripheral perfusion
• Abnormal mental state
• Oliguria
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i Hypotension is a sign of advanced shock in hypovolaemic/
cardiogenic/low flow shock, implying decompensation of
cardiovascular defence mechanisms.
Management
• Assess ABCDE and treat accordingy as detailed above.
• Get help.
• Correct hypoxaemia with high concentration oxygen by mask.
• Secure adequate IV access: this may be difficult.
• Correct hypovolaemia with colloid, crystalloid and blood as
appropriate maintaining haemoglobin around 100g/l.
• Take blood and other samples for culture and give appropriate
antibiotics. Early surgical intervention may be crucial e.g. laparotomy
for perforated bowel, control of haemorrhage, abscess drainage.
SHOCK MANAGEMENT SUMMARY
i
In sepsis large volumes of fluid may be required and clinically
important anaemia may result from haemodilution . Even if the
patient is not bleeding blood transfusion may be necessary.
Monitoring
• Pulse oximetry, continuous ECG, non-invasive blood pressure
(NIBP) should be used routinely.
i Cuff BP by machine may be extremely inaccurate in sick patients.
Treatment
• The management of cardiogenic, hypovolaemic or septic shock
unresponsive to the above measures can be very difficult.
• Tracheal intubation and ventilation, vasoactive drug therapy, invasive
haemodynamic monitoring or mechanical circulatory support may
be required.
• In acute coronary syndromes thrombolysis, PCI or other interventions
may be needed.
• Persisting hypotension with impaired organ perfusion despite
oxygenation and correction of volume status may necessitate vasoactive drug support.
• The drug of first choice is adrenaline (short term) as it has inotropic
and vasoconstrictor effects, the latter predominating at higher
doses.
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• An arterial line should be used to monitor BP.
• Adrenaline should be infused via a central venous catheter.
i Adrenaline 6mg is diluted in 100ml dextrose 5% and run initially
at 3-10ml/hr.
 GET EXPERT HELP EARLY: contact numbers for ICU, Cardiology,
Anaesthetics, Respiratory, GI & other specialists in appropriate
chapters of the book and in telephone lists.
BLOOD AND BLOOD COMPONENTS
Comprehensive notes on the use of blood and its products can be
found in the comprehensive Stationary Office Handbook of Transfusion
Medicine 3rd Edition March 2001 and in the Divisional Blood
Components Clinical Procedures Manual.
The Major Haemorrhage protocol is at the back of this book.
Blood
• Blood is usually supplied as red cell concentrates, unless otherwise
requested (volume 280-350mls).
• In general fully cross-matched blood should be used.
• In an emergency this can be provided within 40 minutes of receipt
of the sample.
• In an extreme emergency group specific blood can be used.
• ORhD negative uncrossmatched blood is available in A&E, Labour
Ward and blood bank on RIE/Simpsons NRIE site and in WGH in
Blood Bank and in blood bank (Haematology lab) at SJH.
• Please note that if a patient is found to have red cell antibodies
there will be some delay in finding compatible blood.
• In the context of an acute bleed, blood may be transfused as
quickly as required to attain haemodynamic stability.
• When transfusing anaemic patients with no acute bleed then it is
given more slowly, in general 2 to 4 hourly. In these patients with
poor cardiac reserve give blood 4 hourly and “cover” with oral
furosemide (frusemide) e.g. 40 mg with alternate bags.
• Large transfusions may impair clotting and cause thrombocytopenia.
After 5 units check FBC, PTR and APTT, and correct with fresh
frozen plasma (FFP) and platelet transfusions if clinically appropriate
i.e. PTR >1.5 x normal, APTT >2 x normal, platelets <50.
• If an additional transfusion is required more than three days later, then
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•
•
•
•
•
a new sample must be sent for cross match (this is not necessary if
more blood is requested within 72 hours of initial cross-match).
If a reaction e.g. rigors, hypotension, loin pain occurs, STOP the
transfusion, take down blood bag and giving set and send the
blood bag, and a serum sample with EDTA and serum tubes to
Blood Bank and citrate and EDTA tubes and urine specimen to
the Haematology lab. Check coagulation screen, blood cultures,
electrolytes.
Contact the BTS or Haematologist for advice.
Some patients e.g. bone marrow transplant, multiply transfused,
renal patients require ‘special’ e.g. CMV -ve blood, irradiated,
genotyped or filtered blood. These requests must be arranged in
advance.
Planned transfusion (top up or for surgery). Sample should be sent
at least 24 hours ahead.
If in doubt ask.
Platelets
• Check indication with a Haematologist.
• Given to correct a low platelet count (except when due to peripheral
consumption e.g. ITP).
• In general transfuse if active bleeding and platelet count <50x109/l. If
no bleeding and platelets <20x109/l consider transfusion. Transfuse
if <10x109/l.
• 4 units of platelets are usually given over 30 to 60 minutes (a 250ml
pooled or apheresis bag).
• Check platelet count 1 hour post transfusion for increment if presurgery or procedure.
• In general blood group specific platelets are given. If these are not
available group compatible will be given. Rhesus negative platelet
concentrates should be used for Rhesus negative patients.
Fresh Frozen Plasma
• Discuss with Haemotologist.
• Used to correct some coagulation defects e.g. over anticoagulation
with warfarin, DIC.
• Usual dose is 10-15ml/kg i.e. 1 litre for 70kg adult.
• Must be compatible blood group i.e. AB universal, O only to O
recipient.
• The units have a short half-life. Once defrosted use immediately if
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61
possible and certainly within 4 hours.
• Infuse over <15mins.
• Use immediately pre procedure.
• Reactions may occur: contact the haematologist for advice.
Reactions to blood products
• Transfusion reactions with fever/rigors can be managed with
paracetamol.
• Allergic reactions such as urticaria or bronchospasm may
require hydrocortisone, chlorphenamine (chlorpheniramine),
bronchodilators as detailed in anaphylaxis chapter.
Sites with blood fridges
RIE
WGH
RHSC
SJH
A&E
Ward 1
Theatre Haematology
Orthopaedic recovery
Ward 8
Laboratory
GI/Liver/Renal recovery
DCN theatre
Cardiothoracic recovery
Main theatre
Adjacent to Obstetrics recovery
General HDU
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SAFE PATIENT IDENTIFICATION
Mandatory Data Set Requirements for Blood Transfusion Requests
Dangerous or fatal transfusion errors are usually caused by failing to keep to
standard procedures. Inadequate patient identification or sample labelling may
lead to ABO-incompatible transfusions.
As a result, the transfusion laboratory has to reject requests that arrive where
the sample or request form do not comply with the mandatory data set.
i Please remember to always seek positive identification of the
patient before drawing the sample (‘Please tell me your name and
date of birth’) and never write on the sample tube before drawing
the sample.
Mandatory Data Set
Mandatory information required on the SAMPLE TUBE (handwritten at the
bedside – patient identification sticky label must not be used):
1. Surname
2. First name
3. Patient identification number (hospital number or CHI number)
4. Date of birth
5. Sample date
6. Signature of person taking sample
7. If the patient identification number is unavailable, please include postcode
Mandatory information required on the REQUEST FORM (patient identification
sticky label may be used):
1. Patient identification number (hospital number or CHI number)
2. Surname
3. First name
4. Date of birth
5. Gender
6. Location
7. Signature of requesting doctor (or appropriately trained nurse practitioner)
8. Name of person taking sample (if different from above)
9. If the patient identification number is unavailable, please include postcode
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63
TRANSFUSION REACTION
Table 1: Guidelines for Recognition and Management of Acute
Transfusion Reactions
CATEGORY SIGNS
SYMPTOMS
POSSIBLE CAUSE
Category 1: Localised Pruritis Hypersensitvity
Mild
cutaneous
Febrile non-haemolytic
reactions:
transfusion reactions:
• Urticaria
•Antibodies to white
• Rash blood cells, platelets
• Mild Fever
•Antibodies to proteins,
including IgA
Category 2: • Flushing
Anxiety
Hypersensitivity
Moderately • Urticaria
Pruritis
(moderate-severe)
Severe
• Rigors
Palpitations
Febrile non-haemolytic
• Fever
Mild dyspnoea transfusion reactions:
• Restlessness
Headache
•Antibodies to white
• Tachypnoea
blood cells, platelets
• Tachycardia
•Antibodies to proteins,
including IgA
Possible contamination with pyrogens and/or bacteria
Category 3: • Rigors
Anxiety
Life
• Fever
Chest pain
Threatening • Restlessness
Pain near
• Hypotension
infusion site
(fall of >20% in Respiratory
systolic BP)
distress/
• Tachypnoea +++ shortness of • Tachycardia breath
(rise of >20% in Loin/back pain
heart rate)
Headache
• Haemoglobinuria
• Unexplained
bleeding (DIC)
Acute intravascular
haemolysis
Bacterial contamination
and septic shock
Fluid overload
Anaphylaxis
Transfusion related
acute lung injury (TRALI)
Transfusion associated
Graft versus Host
Dyspnoeadisease
(TA-GvHD)
Note: If an acute transfusion reaction occurs as you are treating the
patient, as you are starting to treat the patient check the blood pack
labels and the patient’s identity. These events should happen at the
same time. If there is any discrepancy, stop the transfusion immediately
and consult the hospital transfusion laboratory.
In an unconscious or anaesthetised patient, hypotension and uncontrolled
bleeding may be the only signs of an incompatible transfusion.
In a conscious patient undergoing a severe haemolytic transfusion
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reaction, signs and symptoms may appear very quickly - within minutes
of infusing only 5-10mls of blood. Close observation at the start of the
transfusion of each unit is essential.
Table 2: Immediate Management of Acute Transfusion Reactions
IMMEDIATE REACTION
CATEGORY 1: MILD
1. Slow the transfusion.
2. If required, administer antipyretic/antihistamine.
3. If no clinical improvement within 30 minutes or if signs and
symptoms worsen, treat as Category 2.
CATEGORY 2: MODERATELY SEVERE
1. Stop the transfusion. Replace the giving set and keep the IV line
open with saline 0.9%.
2. Notify the doctor and the Hospital Transfusion Laboratory
immediately.
3. Send the blood unit with the giving set, freshly collected blood
samples (including blood cultures) with appropriate request form
to the Hospital Transfusion Laboratory for investigations.
4. Administer antipyretic/antihistamine (avoid aspirin in
thrombocytopenic patients).
5. Treat as per anaphylaxis protocol: stridor, wheeze and hypotension
will require treatment with oxygen and im adrenaline. Call
experienced help early: ICU/Anaesthetics.
6. Collect urine for next 24 hours for evidence of haemolysis and
send to laboratory.
7. If clinical improvement, restart transfusion slowly with new blood
unit and observe carefully.
8. If no clinical improvement within 5-10 minutes or if signs and
symptoms worsen, treat as Category 3 and ensure help is
coming.
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65
Table 2 continued
IMMEDIATE REACTION
CATEGORY 3: LIFE-THREATENING
1. Maintain airway and give high concentration (60-100%) oxygen
by mask.
2. Stop the transfusion. Replace the giving set and keep the IV line
open with 0.9% saline.
3. Manage as anaphylaxis protocol and ensure help is coming:
stridor, wheeze and hypotension require treatment with oxygen
and im adrenaline. Critical care admission will be necessary.
4. Notify the Consultant Haematologist and the Hospital Transfusion
Laboratory immediately.
5. Send the blood unit with the giving set, freshly collected blood
samples with appropriate request form to the Hospital Transfusion
Laboratory for investigations.
6. Check a fresh urine sample visually for signs of haemoglobinuria.
7. Commence a 24 hour urine collection and fluid balance chart and
record all intake and output. Maintain fluid balance.
8. Assess for bleeding from puncture sites or wounds, if DIC
suspected seek expert advice.
9. Reassess:
• Treat bronchospasm and shock as per protocol.
• Acute renal failure or hyperkalaemia may require urgent renal
replacement therapy.
10.If bacteraemia is suspected (rigors, fever, collapse, no evidence
of a haemolytic reaction), take blood cultures and give broad
spectrum antibiotics with Pseudomonas cover: Tazocin 4.5G tds
IV plus gentamicin 7mg/kg od IV (ideal bodyweight). Discuss with
haematologist on call.
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Table 3: Drugs that may be required in the management of Acute
Transfusion Reactions
RELEVANT
EFFECTS
DRUGS & DOSES
Name
Route & Dosage
Oxygen
60-100%
NOTES
1st line
Bronchodilator Adrenaline
Vasopressor
500 micrograms
im repeated after
5 mins if no
better, or worse
1st line
Expand blood
0.9% -
volume
Saline,
Gelofusine
If patient
hypotensive,
20ml/kg over
5 minutes
1st line
Reduce fever
Paracetamol Oral or rectal and inflamm-
10 mg/kg
atory response
2nd line
Avoid aspirin
containing
products if
patient has low
platelet count
Inhibits
histamine
mediated
responses
IV 0.1 mg/kg
2nd line
By 5mg nebuliser
2nd line
Chlorphen-
amine
(Chlorpheniramine)
Inhibits
Salbutamol
immune
mediated
Amino-
bronchospasm phyllline
Vasopressor
Bronchodilator
Use under
expert guidance
Adrenaline 5-10ml/hr
6mg in 100ml
5% dextrose
(6%)
Use only under
expert guidance
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67
Table 4: Investigating Acute Transfusion Reactions
INVESTIGATING ACUTE TRANFUSION REACTIONS
1. Immediately report all acute transfusion reactions with the
exceptions of mild hypersensitvity and non-haemolytic febrile
transfusion reactions, to the Consultant Haematologist and the
Hospital Transfusion Laboratory
2. Record the following information on the patient’s notes:
• Type of transfusion reaction
• Length of time after the start of the transfusion and when the
reaction occurred
• Volume, type and pack numbers of the blood components
transfused
3. Take the following samples and send them to the Hospital
Transfusion Laboratory:
• Immediate post transfusion blood samples from a vein in the
opposite arm:
- Group & Antibody Screen
- Direct Antiglobulin Test
- Return blood unit and giving set containing residues of the
transfused donor blood
4. Take the following samples and send them to the Haematology/
Clinical Chemistry Laboratory for:
• Full blood count
• Coagulation screen
• Urea
• Creatinine
• Electrolytes
• Blood culture in an appropriate blood culture bottle
5. Complete a transfusion reaction report form.
6. Record the results of the investigations in the patient’s records for
future follow-up, if required.
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SEPSIS AND SEPTIC SHOCK
Sepsis is a systematic response to infection and a useful clinical
definition allows early identification and treatement of patients before
organ dysfunction or failure occurs.
For sepsis to be diagnosed two or more of the following should be
present:
• Respiratory rate >20 breaths/min or PaCO2 <4.3 kPa.
• Heart rate >90 beats/min.
• Temperature >38ºC or <36ºC.
• WBC>12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature
forms.
Plus suspected or confirmed infection.
i A low diastolic and wide pulse pressure eg 110/40mmHg may
indicate sepsis
Severe sepsis is present when organ dysfunction, hypoperfusion
(e.g. lactic acidosis, oliguria, or an acute alteration in mental status) or
hypotension (systolic BP <90mmHg) has supervened.
Septic shock is broadly defined as the development of hypotension
and organ failure as a result of severe infection. Septic shock is
a clinical diagnosis, confirmed by positive blood cultures in only a
proportion of cases.
See Identifying Sepsis Early materials:
www.scottishintensivecare.org.uk education section
CLINICAL FEATURES
General clinical features
Fever and rigors.
Hypothermia is common and indicates poor prognosis.
Change in mental state: confusion or coma can occur.
Where is the source? Specific clinical freatures:
• Auscultation may reveal evidence of pneumonia or endocarditis.
• Abdomen - tenderness, peritonitis.
• Skin - rash, petechiae in meningoccaemia.
• Skin: cellulitis, evidence of IVDA.
• CNS: Photophobia and neck stiffness in meningitis.
• Urinary tract symptoms? Loin pain?
• Lines - Intravascular
• Trauma
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Assessment
• Airway: usually secure unless reduced conscious level.
• Breathing: tachypnoea is common - early.
• Circulation: tachycardia and hypotension may occur. In early shock
there is peripheral vasodilatation and increased cardiac output. The
patient is hypotensive, with warm peripheries. In advanced septic
shock cardiac output falls due to hypovolaemia (+/- myocardial
depression) and the skin becomes cold, cyanotic and mottled with
increased capillary refill time. If unresponsive to volume resuscitation
the patient is at high risk of death.
• Disability - GCS, pupils, focal neurological signs.
Organisms
• Community-acquired
sepsis:
Coliforms,
Streptococcus
pneumoniae, Neisseria meningitidis, Staphylococcus aureus. Group
A Streptococcus.
• In hospital patients or recently discharged patients MRSA is
increasingly encountered as are multi-resistant gram negatives.
• In patients with abdominal sepsis, mixed infection with coliforms,
anaerobes.
• In patients with neutropenia, Pseudomonas aeruginosa must be
covered.
• Splenectomised patients are at particular risk from capsulated
organisms (Streptococcus pneumoniae, Haemophilus influenzae,
Neisseria meningitidis) and severe malaria.
• Seek advice from ID or Microbiology if unusual freatures - travel
history, animal contact, IVDU.
Investigations
i Take blood cultures x2 before giving antibiotics. Administration
of antibiotics should not be delayed in severely unwell patients
until after other investigations including lumbar puncture.
• Blood cultures. Send at least 2 sets. At least 10ml of blood should
be cultured per set
• Chest X-ray
• Urine: dipstick for WCC and nitrites (urgent laboratory micoscopy is
not usually necessary)
• Pus, wound swabs
• Sputum
• CSF
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• Blood (EDTA or clotted) PCR if meningitis suspected
• Stool if diarrhoea
• FBC,CRP
i Neutropenia secondary to sepsis is an ominous finding
indicating advanced sepsis.
ANTIBIOTIC
MINI-GUIDE FOR ADULTS
ANTIBIOTIC MINI-GUIDE FOR ADULTS
Take cultures prior to start of antibiotics. INTRAVENOUS TREATMENT SHOULD BE REVIEWED DAILY.
See Full Guidelines for duration of therapy and IV to oral switching.
THERAPY SHOULD BE REVIEWED WHEN CULTURE RESULTS AVAILABLE
1. BACTERIAL MENINGITIS
CEFTRIAXONE 2 g bd IV
•
If patient is > 60 yo or immunocompromised, add
AMOXICILLIN 2 g 4-hrly IV to cover Listeria.
•
Consider DEXAMETHASONE 10 mg qds IV if
pneumococcal meningitis likely and patient has not
already received antibiotics.
2a. COMMUNITY-ACQUIRED PNEUMONIA
Not seriously ill: AMOXICILLIN 500 mg tds ORAL
•
If atypical organism suspected:
add CLARITHROMYCIN 500 mg bd ORAL
Penicillin allergy (not seriously ill):
CLARITHROMYCIN 500 mg bd ORAL
Severe illness: CEFTRIAXONE 1-2 g od IV plus
CLARITHROMYCIN 500 mg bd ORAL or IV
2b. ASPIRATION PNEUMONIA
CO-AMOXICLAV 625 mg tds ORAL or 1.2 g tds IV
Penicillin allergy: seek advice
2c. ACUTE EXACERBATION OF COPD
1st line: AMOXICILLIN 500 mg tds ORAL
2nd line: CO-AMOXICLAV 625 mg tds ORAL
Penicillin allergy CLARITHROMYCIN 500mg bd ORAL
2d. HOSPITAL-ACQUIRED PNEUMONIA
Seek specialist advice: choice of antibiotic will depend on
patient’s previous antibiotic therapy, local prevalence of
MRSA etc.
3a. ENDOCARDITIS: native valve
BENZYLPENICILLIN 1.2 g 4-hourly IV plus GENTAMICIN
80 mg bd IV
•
If patient is an IVDU or has skin sepsis, Staph
aureus may be present, therefore add to the above:
FLUCLOXACILLIN 2 g 4 hourly IV
3b. ENDOCARDITIS: prosthetic valve
or If patient is known to be MRSA-colonised,
or patient with penicillin allergy:
Seek advice from Cardiology and Microbiology.
3c. Antibiotic prophylaxis to prevent endocarditis is
indicated for certain procedures: see full guidelines.
4. STAPH AUREUS BACTERAEMIA
Any S aureus bacteraemia is a life-threatening condition and
should be treated with FLUCLOXACILLIN 1 – 2 g qds IV (or
see 8a for MRSA) for at least TWO WEEKS.
5. SOFT TISSUE INFECTION
Mild: FLUCLOXACILLIN 500 mg qds ORAL
Moderate -severe: FLUCLOXACILLIN 1-2 g qds IV
plus BENZYLPENICILLIN 1.2 – 2.4 g qds IV
Penicillin allergy:
CLINDAMYCIN 450 mg qds ORAL (mild infection)
CLINDAMYCIN 600 mg – 1.2 g qds IV (severe infecn)
Life- or limb- threatening infection: this is a surgical
emergency. Seek urgent advice from Surgeon and
Microbiology.
6a. INTRA-ABDOMINAL SEPSIS including hepato-biliary
CEFTRIAXONE 1-2 g od IV plus METRONIDAZOLE
500mg 8-hrly IV
6b. INFECTIVE DIARRHOEA (GASTROENTERITIS)
Antibiotics are usually contraindicated. If patient severely ill/
septicaemic, CIPROFLOXACIN 500 mg bd ORAL (or 400 mg
bd IV only if oral not possible)
6c. C. DIFFICILE DIARRHOEA
Stop other antibiotics - this may lead to resolution
of symptoms. If still symptomatic, then:
METRONIDAZOLE 400 mg tds ORAL (or 500 mg tds IV only if
oral not possible)
7a. LOWER URINARY TRACT INFECTION (CYSTITIS)
TRIMETHOPRIM 200mg bd ORAL
or CO-AMOXICLAV 625 mg tds ORAL
7b. UPPER URINARY TRACT INFECTION
(PYELONEPHRITIS)
Not seriously ill: CO-AMOXICLAV 625 mg tds ORAL
If patient vomiting: CO-AMOXICLAV 1.2 g tds IV
Penicillin allergy: CIPROFLOXACIN 500 mg bd ORAL
Severe illness/septicaemia:
CIPROFLOXACIN 400 mg bd IV
7c. CATHETERISED PATIENTS WITH ?UTI
If no systemic symptoms, NO ANTIBIOTIC
If antibiotics are initiated, catheter should be changed/
removed.
Systemic illness/septicaemia: GENTAMICIN
160 mg IV once, with catheter change
8. HOW TO TREAT MRSA
8a. BACTERAEMIA or SEVERE PNEUMONIA
or SEVERE SOFT TISSUE INFECTION:
VANCOMYCIN (at WGH and RIE, dose as local policy) or,
SJH only, TEICOPLANIN 10mg/kg IV to nearest 200 mg (i.e.
generally 600 mg or 800 mg), 3 loading doses 12 hours apart
then once daily.
Consider adding RIFAMPICIN 300 mg bd ORAL/IV
8b. MODERATE MRSA INFECTIONS:
DOXYCYCLINE 100 - 200 mg od ORAL
Consider adding RIFAMPICIN 300 mg bd ORAL for more
severe infection.
• MRSA lower urinary tract infection only: TRIMETHOPRIM
200mg bd ORAL or NITROFURANTOIN 500 mg qds
ORAL
9. NEUTROPENIC SEPSIS
TAZOCIN 4.5g qds IV plus GENTAMICIN 7mg/kg od IV.
Calculate dose using ideal body weight and monitor using
Hartford nomogram.
Penicillin allergy: seek Microbiology advice
10. SEPSIS OF UNKNOWN ORIGIN
If patient too unstable to delay giving antibiotic pending
investigation:
CEFTRIAXONE 2 g od IV and seek senior opinion
There may be some minor local variations: check individual policies.
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71
i If life-threatening penicillin allergy, discuss alternative antibiotics
promptly with on call consultant in Microbiology or ID.
Differential diagnosis
Remember other causes of hypotension and shock:
Unexplained Hypotension - think of:
•
•
•
•
•
•
•
•
•
Sepsis (including Toxic Shock Syndrome)
Myocardial infarct with no chest pain (early ECG).
Occult blood loss
Poisoning
Pulmonary embolism
Anaphylaxis
Addison’s disease
Autonomic dysfunction
Cardiac tamponade
Supportive management
i Call ICU early
• High concentration oxygen by face mask: 60-100% aiming for SpO2
>96%.
• Secure adequate IV access and commence volume replacement.
Insert a large bore peripheral venous line and administer saline 0.9% or
colloid. If the patient is hypotensive give 250ml boluses of Gelofusine.
• Volume replacement is a priority, and should be monitored
scrupulously.
• Take blood cultures x2, and other Microbiology samples, then
choose and start appropriate IV antibiotics.
• Draw venous blood for FBC, U&Es, glucose, clotting.
• Check arterial blood gases and blood lactate.
• Make a full assessment of the patient’s condition and the likely
aetiology as above.
• Insert a urinary catheter.
• Observe carefully for fluid overload and be aware of the possibility
of acute renal failure.
• Remove or drain any obvious source of infection such as an abscess
or infected IV line.
72 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
• Remember intra-abdominal sources, severe cellulitis, necrotising fasciitis
or gangrene and if suspected seek urgent surgical opinion.
i Septic shock unresponsive to oxygen therapy and initial volume
loading has a high mortality. Invasive monitoring and vasopressor
therapy are likely to be necessary.
CALL ICU EARLY.
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73
ANAPHYLAXIS
Anaphylaxis is an acute allergic process where a substance to which
the individual has been previously exposed results in mast cell
degranulation and massive mediator release. Anaphylactic shock is
twice as common in women and atopy is present in about a third of
cases.
Aetiology
• Foods: nuts, fish.
• Drugs: NSAIDs, antibiotics, anaesthetics.
• Stings
• Idiopathic
Presentation
There is a spectrum of severity from mild to catastrophic, and treatment
must be tailored to the individual situation.
Clinical features
• Airway compromise and breathing difficulties: stridor, wheeze,
tachypnoea.
• Circulatory collapse: hypotension, tachycardia.
• Itch, skin rash, angio-oedema - may be completely absent.
• In about 20% abdominal or muscle pain or GI upset are major
symptoms.
ACUTE ANAPHYLAXIS
i
Bronchospasm and/or cardiovascular collapse.
Adrenaline should be given to all patients with respiratory
difficulties and/or hypotension.
1. Immediate action
O2 + Help
Adrenaline
IV Fluids
• Discontinue administration of suspect drug, blood transfusion or IV fluid.
• GET HELP - call 222.
• ABC: maintain airway and give 100% oxygen by high flow with
oxygen mask and reservoir bag or bag/mask/valve apparatus.
Intubation may be required early, particularly if stridor is present.
74 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
•
•
•
•
Commence basic life support (CPR) if no pulse present.
Secure adequate IV access if not already.
Monitor oxygen saturation and BP.
ECG must be continuously monitored, and a defibrillator immediately
available.
• Give adrenaline 500 micrograms intramuscular (0.5ml of 1 in 1000
solution). Repeat in 5-10 mins if no better or getting worse.
• Give IV fluids. Hartmann’s solution, 0.9% saline or Gelofusine 10ml/
kg (about 500ml to 1 litre) can be used initially. Colloid may be more
efficient at restoring blood volume especially in severe cases.
2. Supplementary action to damp down inflammation/prevent
recurrence
• Give hydrocortisone 200mg IV (slowly).
• Give Antihistamines: chlorphenamine (chlorpheniramine) 10-20mg
IV slowly.
• Give salbutamol 5mg nebuliser if wheeze present.
• Measure arterial blood gases and coagulation.
i VERY SEVERE ANAPHYLAXIS
Most cases will resolve with the above treatment. However in
the most severe cases with life-threatening shock or airway
compromise, particularly in association with general anaesthesia,
adrenaline should be given intravenously as described here.
• This is a rapidly life-threatening condition requiring experienced
clinical management. Intravenous adrenaline boluses should only
be given by, or under the direct supervision of, an appropriately
experienced clinician.
• Give ADRENALINE INTRAVENOUSLY (especially in the presence
of stridor or wheeze) starting with 50 to 100 micrograms (0.5-1 ml
of 1 in 10,000 i.e. Minijet), with further 50 to 100 microgram aliquots
as required. • Adrenaline dose in cardiac arrest is 1 mg (10ml of 1 in 10,000).
SUBSEQUENT ACTION
Record allergy prominently in notes and explain to patient and family.
CONTINUING PROBLEMS (requiring ICU referral for:)
Severe and resistant bronchospasm
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75
• Salbutamol 5mg nebulised in 100% oxygen, repeated as
necessary.
i Always maintain oxygen therapy during administration of
bronchodilators.
• Salbutamol 250 micrograms slowly IV (4micrograms/kg over at
least 10 mins) as a loading dose followed by 5-20 micrograms/min
infusion (directed by Senior Clinicians).
N.B. Can cause tachyarrhythmias, hypotension, hypokalaemia.
Alternatively (as directed by Senior Clinicians)
• Adrenaline by infusion 6mg diluted in 100ml of dextrose 5% at
3-10 ml per hour.
• Aminophylline 250mg IV over 20 mins by volumetric pump or syringe
driver. This is usually sufficient but up to 6-8mg/kg can be used.
N.B. Can cause tachyarrhythmias, myocardial ischaemia and
hypokalaemia. Caution in the elderly, IHD or if on oral theophylline.
Half loading dose if on theophylline or level unavailable.
i Refractory hypotension and/or pulmonary oedema and/or
bronchospasm requires ICU referral.
FURTHER MANAGEMENT
Even if stabilised and improving:
• admit to ICU or HDU or appropriate monitored area.
• monitor respiratory rate, ECG, BP, SpO2.
• continue steroids and anti-histamines orally or IV.
Follow up is crucial: over 60% of patients will have repeated
attacks.
• Patients should be advised to wear a medic-alert type bracelet or
talisman. Information on this is available from:
Anaphylaxis Campaign
01252 542029 [email protected]
British Allergy Foundation
02083 038792 www.allergyfoundation.com
email: [email protected]
• In food, insect or unknown allergies provide an Epipen or Anapen
adrenaline injector and training in use.
• Referral to allergist is ideal but in Lothian this service is not available.
76 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
ALGORITHM FOR FIRST MEDICAL RESPONDER TO ANAPHYLAXIS
Figure 1 AnaphylacticAdvanced
Reactions: Treatment
Algorithm
for Adults
by First Medical Responders
Life Support
(UK)
Algorithm
Consider when compatible history of severe allergic-type
reaction with respiratory difficulty and/or hypotension
especially if skin changes present
Oxygen treatment
when available
Stridor, wheeze,
respiratory distress or
clinical signs of shock1
Adrenaline (epinephrine ) 2,3
1:1000 solution
0.5 mL (500 micrograms) IM
Repeat in 5 minutes if no clinical
improvement
Antihistamine (chlorphenamine)
10-20 mg IM/or slow IV
IN ADDITION
For all severe or recurrent
reactions and patients
with asthma give
Hydrocortisone
100-500 mg IM/or slowly IV
If clinical manifestations of shock
do not respond to drug treatment
give 1-2 litres of IV fluid.4
Rapid infusion and/or one repeat
dose may be necessary
1.
An inhaled beta 2-agonist such as salbutamol may be used as an adjunctive measure
if bronchospasm is severe and does not respond rapidly to other treatment.
2.
If profound shock judged immediately life threatening give CPR/ALS if necessary. Consider
slow IV adrenaline (epinephrine) 1:10,000 solution. This is hazardous and is recommended
only for an experienced practitioner who can also obtain IV access without delay.
Note the different strength of adrenaline (epinephrine) that may be requiredfor IV use.
3.
If adults are treated with an Epipen, the 300 micrograms will usually be sufficient. A second
dose may be required. Half doses of adrenaline (epinephrine) may be safer for patients on
amitriptyline, imipramine or a beta blocker.
4.
A crystalloid may be safer than a colloid.
Updated May 2005
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77
URTICARIA AND ANGIO-OEDEMA
• These conditions are sub-acute or chronic unless they accompany
anaphylaxis or the airway is involved by swelling.
• Sudden total airway obstruction can result and is rapidly fatal
unless oxygenation is maintained.
Management
• Airway compromise: if stridor is present and airway obstruction
imminent endotracheal intubation is mandatory (GET HELP).
• Give high concentration oxygen. Intubation may be difficult: fast
bleep (222) anaesthetics and ICU.
• In severe cases of urticaria/angio-oedema adrenaline should be
given as for anaphylaxis: 500 micrograms im (0.5ml 1 in 1000
solution) or using the IV schedule detailed above.
• If total upper airway obstruction occurs oxygenation must be
maintained via emergency cricothyrotomy. Kit in A&E, ARAU,
Theatres and ICUs.
• May be more resistant to drug treatment than anaphylaxis and need
early intubation. Often a very difficult procedure.
• Nebulised adrenaline may be effective.
• Antihistamines and steroids are used as for anaphylaxis.
LIFE-THREATENING UPPER-AIRWAY OBSTRUCTION
Inability to get gas in by patient or by attendants.
• Causes include foreign body, swelling (anaphylaxis, angio-oedema
see above), trauma, burns and peri-anaesthetic (laryngospasm).
• Administer 100% oxygen via BMV and call for Anaesthetic/ICU
HELP.
• May need to contact ENT surgeons for definitive airway.
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ACUTE PAIN MANAGEMENT
Appropriate acute pain management is dependent on assessment
of the severity of pain followed by appropriate prescription and
administration of multimodal analgesia. This should be prescribed
and given at a dose, route and frequency appropriate to the individual
patients condition and the effect of each intervention reassessed.
Assess pain in the context of the whole patient, remember to consider
why they have lost control of their acute pain e.g. is there a new
pathology ?
Pain score/ level of distress
Intervention
Prescription
0 to 3 None required
mild undistressing pain
Mild analgesics should be available as required if pain is anticipated
Paracetamol, NSAID & a weak opioid such as codeine or a combination e.g. cocodamol should be prescribed as appropriate
3 to 6
moderate pain
&/or distress
Rescue analgesia
required
Usually an opioid titrated to effect
orally or parenterally
Review of
prescribed analgesia required
Is the patient on:
• regular paracetamol?
• regular NSAID?
• regular opioid?
7 to 10
Urgent rescue
severe and analgesia required
distressing pain
Review of
prescribed
analgesia required
Intravenous morphine or equivalent titrated to effect.
Is the patient on:
• regular paracetamol?
• regular NSAID?
• regular opioid of appropriate strength?
PAIN MANAGEMENT BASIC PRINCIPLES
• Pain management regimens must be tailored to individual patient
requirements. Where appropriate the combined use of different
analgesics (multimodal analgesia) should be used. This is more
effective, limits the dose of any one therapy and helps to minimise
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79
serious side effects. It is necessary to review the patient’s response
to therapy and then tailor ongoing analgesia to their needs.
• In acute pain it is anticipated that the worst pain will be present
initially and steadily improve with time. It is therefore essential to
have an appropriate level of maximum therapy instituted at the
outset of treatment and gradually stepped down.
• Regular assessment of pain scores and the side effects of therapy
is necessary to ensure effective and safe treatment.
• Pain management should aim to control pain to a tolerable level.
Remember it should be possible with appropriate interventions as
above to control acute pain for most hospital patients to a level with
which the patient is comfortable. However, it is inappropriate to aim
for complete analgesia in all patients since this is likely to lead to
problems with treatment side effects.
• Pain relief from any analgesic regime is balanced against side
effects. In some situations a compromise is necessary, where less
effective analgesia is acceptable to avoid complications of therapy
which may be distressing or which may lead to morbidity and even
mortality.
• Regular analgesia is more effective than “as required” dosing. “As
required” prescribing should only be used for the mildest pain or to
relieve breakthrough pain in addition to regular analgesia.
• When converting from a more complex analgesic regime eg epidural,
adequate step down analgesia must be prescribed.
• Analgesic prescriptions should be reviewed regularly, giving
consideration to changing requirements and possible drug
interactions.
ACUTE PAIN GROUPS : CONTACT NUMBERS
Western General - 08.00-17.00: contact the Clinical Nurse Specialists
for Pain on bleep 5292 or ext. 31670. Out of hours and at weekends
contact the duty anaesthetist on bleep 5112.
Royal Infirmary - 08.00-17.00: contact the Clinical Nurse Specialists
for Pain on bleep 5247 or ext. 23205. Out of hours and at weekends
contact the duty anaesthetist on bleep 2140.
St John’s Hospital - 08.00-17.00: contact the Clinical Nurse Specialists
for Pain on bleep 934 or ext. 53065. Out of hours and at weekends
contact the duty anaesthetist on bleep 561
Further Information: Lothian Acute Pain Guidelines Site (Intranet)
80 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
SUMMARY OF PRINCIPLES OF ACUTE CARE
• Assess and treat simultaneously.
• Give enough oxygen to correct hypoxaemia.
• Establish adequate IV access. Take blood for urgent tests, including
ABG and cross-match.
• Commence continuous monitoring.
• Perform llness severity assesment: SEWS scoring and look at the
patient!
? risk of deterioration/cardiac arrest.
? where to admit.
? co-morbidity.
• Get help as indicated.
• Write in notes and prescribe drugs (incuding oxygen and fluids).
• Communicate with patient, family and significant others.
• Re-assess repeatedly and act on findings.
• Treat pain, nausea and other symptoms appropriately.
• Make a diagnosis, institute definitive treatment and assess response.
• Communicate the above and the plan with the patient, the ward
team and the patient’s relatives.
i Many of these elements should happen at the same time.
THE FOUR KEY ELEMENTS OF EMERGENCY MANAGEMENT
1.
Acute
assessment
& primary
treatment with
immediate
targeted
examination
investigations &
support
2.
Monitoring
with
frequent
re-assessment
3.
Illness
severity
assessment
4.
Definitive
diagnosis &
treatment: full
exam
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81
APPROACH TO THE PATIENT WITH …
CHEST PAIN
You have been called to see the patient…
• Ensure P, BP, temp and RR are recorded while you are getting there.
On your way to the ward work through a differential diagnosis:
• Angina or MI
• Pleurisy or Pericarditis.
• Oesophageal/dyspepsia
• Musculoskeletal pain
i On arrival use the initial assessment process described in Chapter 2.
Give oxygen and establish IV access if appropriate.
Make your clinical assessment and take an ECG.
Draw bloods if appropriate.
Make your own assessment of the need for analgesia and prescribe
it/administer it as necessary.
• Pulse oximetry and ECG monitoring may be indicated.
• Decide on illness severity, the need for senior opinion and further
treatment/investigations.
• Write in notes and prescribe drugs including oxygen.
•
•
•
•
A ROUGH GUIDE
• STEM I: call CCU and initiate treatment; see Cardiology section.
• Acute Coronary Syndrome: initiate treatment and consider need for
monitoring, d/w Cardiology bleep #6816 RIE, 5689 at WGH, #630
at SJH (the on call medical middle grade).
• Angina (rate related): treat rate (will depend on cause and rhythm).
• Oesophageal reflux: gaviscon or mucogel.
• Musculoskeletal pain: prescribe appropriate analgesia.
• Pleurisy: treat cause (PE, pneumonia) and give analgesia.
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ACUTE SHORTNESS OF BREATH
Use the initial assessment process previously described.
• Give oxygen and establish IV access if appropriate.
• Pulse oximetry is essential and ECG monitoring may be indicated.
i Remember if RR > 30 &/or paradoxical breathing - it is serious.
GET HELP EARLY.
•
•
•
•
Ensure temp, P, BP, RR, PEFR are all done.
Organise a CXR.
Do ECG, take bloods and ABG’s on O2 recording FiO2.
Based on your clinical judgement commence treatment e.g.
nebulised bronchodilators.
Have a different diagnosis in mind, such as:
- Asthma
- LVF
- PE
- Pneumonia
- Pneumothorax
- Sepsis
- Metabolic acidosis
• Get bloods etc sorted.
• Write in notes and prescribe drugs including oxygen.
• Reassess when all the information is to hand, and consider response
to initial therapy: better, the same or worse?
TREATMENT
Get help if necessary
Asthma
LVF
see appropriate
PE
sections
Pneumothorax
Pneumonia
Sepsis
Metabolic acidosis
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83
PROTOCOLS FOR SPECIFIC PROBLEMS
(based on RIE protocols)
FIRST SEIZURE IN ADULTS
NO
Wasthisaseizure?
Consider causes of non-epileptic attacks e.g.
Syncope, panic attacks, pseudoseizures
YES
Has hypoglycaemia been
excluded?
NO
Treat hypoglycaemia,
address underlying cause and then reassess
NO
Consider poor compliance with medication,
intercurrent illness or infection, alcohol or drug
ingestion, or part of normal seizure pattern
YES
Is this the first adult
generalised seizure?
YES
DoesthispatientrequireanurgentCT?
Indications for CT scan prior to disposition:
- New focal neurological deficits
- Persistent altered mental status
- Fever or persistent headache
- Recent head trauma
- History of cancer or HIV infection
- Patients with new focal onset seizure
- Patients whose follow up cannot be ensured
- Anticoagulation or bleeding diathesis
YES
Emergency CT head.
IsCTnormal?
NO
Refer to “first seizure
clinic”
NO
YES
AretheECG/bloodresultsallnormal?Consider:
Uraemia, hyponatraemia, hypoglycaemia,
hypercalcaemia, prolonged QT interval
NO
ADMIT
YES
Doespatientmeetdischargecriteria?
(See Discharge Table)
YES
Give written advice about driving and lifestyle
Inform patient of their duty to notify the DVLA.
Discharge/arrange follow up at first fit clinic
File notes, investigations and assessment
page with referral at reception.
Provide patient with a copy of “first seizure
clinic” appointment letter.
Produced by Protocol Group October 2003
84 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
“FIRST SEIZURE” APPOINTMENT LETTER
DATE:
Patient ID sticker
Dear
We think it is possible that you have had an epileptic seizure (fit) to account
for your recent symptoms. We are therefore referring you to a specialist for a
further opinion regarding the diagnosis, possible investigations and treatment
if necessary.
In order to make your appointment, you need to telephone the Medical
Outpatient Department 2 on 0131 242 1368 or 1369. The department is
open Monday-Thursday 0900-1700, and Fridays 0900 to 1600. You should ask
the receptionist to book you an appointment in Dr Davenport’s First Seizure
clinic and we recommend that you have a pen and piece of paper handy to
note the date and time of your appointment. The clinic is currently held on a
Monday morning in MOPD 2 in the Royal Infirmary of Edinburgh.
•
•
•
If someone witnessed your collapse or funny turn, then please bring
them with you to the clinic, or arrange for them to be contactable by
phone, as the doctor may wish to speak to them.
Please bring any prescription medications that you are taking with
you, in their packaging, or a list of the medications you are taking and
their doses.
If you hold a driving licence, we would advise you that should not
drive until you have been seen in the clinic.
Doctor’s name (printed):……………………………
Responsible doctor should document in ED record that patient has been
given this letter and forward the ED sheet together with completed first
seizure protocol to Dr Davenport, Consultant Neurologist, MOPD 2, RIE
Doctor’s signature:…………………………………
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85
MANAGEMENT OF FIRST SEIZURE IN ADULTS
Inclusion
Criteria
•
•
•
Exclusion
Criteria
Patients >16yrs <60yrs
Clear history of first generalised seizure
Seizures related to drug or alcohol ingestion or withdrawal
Patients with non-epileptic attacks
(e.g. syncope, pseudoseizures)
• Patients with known seizure or metabolic disorder
• Seizures related to recent trauma
• Eclampsia
Name
DoB
•
Address
Tel No
History Table (please tick if relevant)
Witness history
Type of seizure (generalised, partial)
Previous history of seizures, febrile fits, birth trauma, meningitis, head injuries
Family history of seizures
Possible precipitating events (alcohol, drugs, sleep deprivation)
Clinical Findings (enter findings)
Temperature
Pulse
GCS
BP
Pupils
Right
E
M
Resp Rate
V
Size
Reaction
Breath Alcohol
Limb Movement
Left
Size
BM
R Arm
L Arm
R Leg
L Leg
Reaction
Investigations Table (enter result)
ECG
Urea
Creat
Na
K
CO2
Ca
Alb
Glu
Hb
MCV
WCC
PLT
Bil
GGT
ALT
Alk Ph
CT
Discharge Table (all boxes MUST be ticked before discharge)
Patient fully recovered with no persistent neurological symptoms/signs
(include headache)
Normal observations and investigations (include temperature)
Patient has been given written advice about driving and lifestyle changes and their duty to
notify the DVLA
Patient has a responsible adult to stay with following discharge
Patient will attend follow up
First fit clinic letter with copies of all notes and investigations forwarded to Dr Davenport’s
secretary at MOPD , RIE
86 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
MANAGEMENT OF SYNCOPE
ECG abnormalities @
• Bifascicular block
• Second or complete heart block
• Sinoatrial block
• QRS > 120ms
• QTc > 450ms
• Bradycardia <50/min
•Previous?MI
• RBBB with ST elevation V1-3
(Brugada syndrome)
Review
Collapse
Algorithm
Yes
Identified cause for syncope
Manage appropriately
No
Does the patient have:
• Cardiac Failure
• Ischaemic Heart Disease
• History VT/VF
• Valvular Heart Disease
• ECG abnormality
• Exertional syncope
• Significant assoc injury
Yes
No
Does the patient have:
• Associated chest pain
• Associated palpitations
• Family history of sudden death
•Frequentsyncopalepisodes
• No presyncopal warning
Organise Echo/24
hour tape +/- ETT
Admit to monitored bed
Yes
Yes
Consider admission
D/W senior colleague
No
Refer MOPD
No
Age more than 60
CSM@ not contraindicated
Yes
CSMfor5seconsequential
sides results in:
• Ventricular pause >3 sec
• Fall in systolic BP >50 mmHg
Yes
No
Frequentepisodes
No
No
Yes
Refer cardiology
@Carotid
Sinus Massage contraindicated if:
Carotid Bruit present; recent CVA, TIA or MI (6 months)
Discharge GP
Produced by Protocol Group October 2003
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
87
MANAGEMENT OF UNEXPLAINED SYNCOPE IN ADULTS
Inclusion
Criteria
• Patients >16yrs
• Confirmed history of unexplained loss of consciousness
Name
Exclusion
Criteria
• Any of the following after assessment for collapse
(Fit, hypoglycaemia, postural hypotension, arrhythmia, PE,
CVA, vasovagal event, GTN syncope, situational syncope,
structural cardiac cause)
DoB
FOLLOW COLLAPSE ALGORITHM
Indications for admission
•
•
•
•
•
•
•
Congestive Cardiac Failure
Ischaemic Heart Disease
History of ventricular arrhythmia
Significant Valvular heart disease
ECG abnormality (see algorithm)
Exertional syncope
Significant injury associated with syncope
Clinical Findings (enter findings)
Temperature
Pulse
Lying BP
Standing BP
Address
Tel No
Indications for MOPD follow up
• Syncope associated with chest pain or
•
•
•
•
palpitations
Family history of sudden death
Frequentepisodes
No presyncopal warning
Syncope while supine
O2 saturations
BM
Breath Alcohol
Carotid Sinus Massage
Investigations Table (enter result)
ECG
(see list)
Urea
Creat
Na
K
CO2
Ca
Alb
Glu
Hb
MCV
WCC
PLT
Bil
GGT
ALT
Alk Ph
Other
Discharge Table (all boxes MUST be ticked before discharge)
Is the patient fully recovered and appropriate for discharge? (see admission criteria above)
Is the patient fit for discharge i.e. consider social support, mobility and age
Has MOPD referral form been completed and relevant documents included (see follow up
criteria above)
Patient has a responsible adult to stay with following discharge
Arrange Echo and 4 hour tape for all patients attending MOPD. Other investigations e.g. ETT
and Tilt table will be organised AFTER MOPD review
Advice has been given regarding driving, hobbies and occupation
88 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
MANAGEMENT OF COLLAPSE
NO
Loss of consciousness
YES
Consider:
• Simple fall
• Intoxication
• Drop attacks
• Narcolepsy
Perform:
• BM stix
• ECG
• Erect and supine BP
• Oxygen saturation
YES
YES
BM low
Treat hypoglycaemia
Send lab glucose
NO
• Witnessed seizure
• Possible history of seizure
• Tongue biting
• Incontinence
YES
Manage and follow
seizure algorithm
NO
• Arrhythmia
• Structural cardiac cause
• Pulmonary embolism
• Cerebrovascular event
• Vascular steal syndrome
YES
Manage as appropriate
NO
Postural drop in systolic BP
>20 mm Hg or systolic BP
< 90 mm Hg
YES
Check FBC and U+E
Consider:
• Blood loss - inc occult
• Dehydration
• Drug therapy
• Addison's disease
• Autonomic neuropathy
• Sepsis
NO
• Vasovagal episode
• GTN syncope
• Related to micturition,
defaecation, coughing,
emotional stress
YES
Discharge if fully recovered
and investigations normal
Nofollowuprequired
NO
Unexplained syncope
(Follow syncope algorithm)
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
89
MANAGEMENT OF RENAL COLIC
Based on RIE Procedure
Compatible history
No
Consider/manage other diagnoses
Yes
How to arrange a CT
Contact radiology directly 9-5.
Patient should attend radiology with notes and
return with report and film.
History meets inclusion/exclusion
criteria for renal colic
Out of hours if asymptomatic the patient can be
discharged and return to CAA base 1 the next day
and CT organised.
Yes
If symptomatic the patient will be admitted to CAA.
IV access: Send FBC, U/Es, Ca, Urate
Send MSU
Check pregnancy test
Provide analgesia (Morphine IV titrated +/Diclofenac 50mg PO/100mg PR/75mg IM)
Ensure hydration with oral/IV fluids
07.00 to 17.00
If recent CT/IVU discuss with radiology regarding Ix.
17.00 to 07.00
Asymptomatic
(discharge)
Continued Symptoms
Admit CAA
Arrange CT
Continued
Symptoms
Asymptomatic
Normal CT
Abnormal CT
Normal CT
Abnormal CT
Discharge GP
Refer
Lithotripsy
Reassess and
manage
appropriately
Refer Urology
90 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
MANAGEMENT OF RENAL COLIC
MANAGEMENT OF RENAL COLIC
Inclusion
Criteria
Exclusion
Criteria
•
•
Age <60y
Typical pain with (microscopic) haematuria
•
•
•
Age >60y
Temperature > 38C
Known Vascular Disease
Name
DoB
Address
Tel N o
Clinical Findings (enter findings)
Temperature
Pulse
BP
Resp Rate
BM
Urinalysis
Urine _HCG
Investigations Table (enter result)
Urea
Creat
Na
K
CO2
Ca
KUB
Glu
Urate
Hb
WCC
Platelets
CT
IVU
Indications for admission
Intractable pain and vomiting
Known single kidney
Renal transplant
Chronic renal failure
CT reveals proximal stone or >8 mm stone and patient symptomatic (refer urology)
Discharge from CAA (all boxes MUST be ticked before discharge)
Patient fully recovered with controlled symptoms/signs
Normal observations and investigations (include temperature), MSU sample sent
Normal U+Es
Regular analgesia prescribed
If discharged at night patient able to attend RIE CAA base 1 or ARAU WGH 09.00 following
morning for Ix.
If discharged during day CT normal
Lithotripsy Unit follow up
Abnormal CT
Lithotripsy referral form completed
Full length CT and KUB sent by courier to Lithotripsy Unit with referral form
Patient aware Lithotripsy Unit will make contact within 3 working days
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
91
RESUSCITATION
ADULT BASIC LIFE SUPPORT
UNRESPONSIVE?
Shout for help
Open airways
NOT BREATHING NORMALLY?
Call 222
30 chest compressions
2 rescue breaths
30 compressions
• If he is breathing turn into recovery position, monitor for continued
breathing and get/send for help.
• If he is not breathing send someone for help or, if you are on your
own, leave the victim and telephone for help using 222.
• Return and immediately commence chest compressions at a ratio
of 30 compressions to 2 ventilations at rate of 100/minute.
• Continue until the victim shows signs of life or the advanced life
support techniques can be applied.
• Do not interrupt CPR unless the patient responds, help takes over
or you are exhausted.
• In respiratory only arrest continue to ventilate the patient at a rate of
10-12 breaths per minute.
i i If the victim is an adult and the cause of unconsciousness is not
trauma or drowning, the rescuer should assume that the victim
has a heart problem and go for help immediately it has been
established that the victim is not breathing.
www.resus.org.uk/siteindex.htm
Training sessions can be arranged by contacting:
In WGH/RVH Stephen Hartley RO or Dina Johnston RO on 32496.
In RIE Marilyn Mathers RO or Denise Peden RO on 21670.
In St John’s Stephen Short (Shorty) RO 53892 or bleep 909
92 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
ADULT ADVANCED LIFE SUPPORT ALGORITHM
Unresponsive?
Open Airway
Look for signs of life
Call : Cardiac Arrest team
CPR 0:
Until defibrillator/monitor attached
Assess
rhythm
Non Shockable
PEA/Asystole
Defibrillate x 360j monophasic
150j biphasic
Immediately
resume
CPR for minutes
•
•
•
•
•
•
•
•
During CPR
Shockable
VF/VT
Correct reversible causes
If not already:
• Check: electrode/paddle
positions & contact
• Attempt/verify: airway &
O2, IV access
• Give uninterrupted
compressions when
airway secured
• Give adrenaline mg every
-5 minutes
• Consider: Amiodarone,
(Magnesium)
Atropine/pacing/buffers
Immediately resume
CPR
min cycles
Hypoxia
Hypovolaemia
Hyper/hypokalaemia & metabolic disorders
Hypothermia
Tension pneumothorax
Tamponade, Cardiac
Toxic/therapeutic disturbances
Thrombosis (coronary or pulmonary)
The ALS Algorithm for the management of cardiac arrests in adults.
NOTE that each successive step is based on the assumption that the one before has
not resulted in restoration of circulation.
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
93
ADULT ADVANCED LIFE SUPPORT: Notes on Algorithm
• Basic life support is commenced in unmonitored situations while
the monitor/defibrillator is obtained and attached. • In witnessed collapse a single precordial thump can be administered
by trained personnel.
• In monitored patients the clinical and ECG detection of cardiac
arrest should be simultaneous.
i In the presence of VF/pulseless VT defibrillation must occur as
soon as possible.
• Once the airway is secured (endo-tracheal tube) chest compressions
are performed at 100/min and asynchronous ventilations at 10/min.
VENTRICULAR FIBRILLATION/
PULSELESS VENTRICULAR TACHYCARDIA
VF/Pulseless VT section
Defibrillation: The first shock is given at 150j biphasic or 360j
monophasic ensuring good contact with the chest wall. Use of gel
pads or hands free pads as applicable ensuring correct positioning
and pressure application.
• The second and all subsequent shocks are delivered using the
same energy level.
• A pulse check is no longer performed unless the patient responds
to treatment.
• A two minute period of CPR immediately follows defibrillation.
• Adrenaline 1mg should be given IV every 3-5 minutes (alternate
cycles = every 4 minutes). If no IV access give adrenaline 2mg via
the ET Tube.
• Adrenaline should be administered just prior to shock.
Drug therapy
• In refractory cases amiodarone can be considered: prefilled 10ml
syringe of 300mg or 300mg made up in 20 mls 5% dextrose over
2-5 mins in a large/central vein. A generous flush should be used if
using a peripheral vein.
• Expert advice should be sought.
• The use of IV sodium bicarbonate should be limited to patients with a
severe metabolic acidosis, hyperkalaemia or tricyclic antidepressant
overdose.
i The mainstay of the correction of acidosis in cardiac arrest is
adequate ventilation and oxygenation with rapid restoration of a
perfusing cardiac rhythm.
94 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
ALGORITHM FOR AUTOMATED EXTERNAL DEFIBRILLATION
Unresponsive
Call for help
Open airway
Not breathing normally
Send or go for AED
Call 222
CPR 30:2
Until AED is attached
AED
assesses
rhythm
Shock advised
No shock advised
1 Shock
150 J biphasic or
360 J monophasic
Immediately resume
CPR 30:2
for 2 min
Immediately resume
CPR 30:2
for 2 min
Continue until the victim starts
to breathe normally
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
95
NON DEFIBRILLATABLE RHYTHMS
Cardiac arrest in asystole and PEA may result from a number of causes
other than ischaemic heart disease (see table on previous page).
These are potentially reversible causes of cardiac arrest. They should
also be regarded as preventable causes of cardiac arrest, in that
their recognition and treatment prior to cardiac arrest can prevent
deterioration.
• On this side of the algorithm CPR is conducted for 2 minute periods
whilst considering and treating any of the above.
• The airway should be secured, IV access obtained and adrenaline
1mg given IV every 3-5 minutes. (Alternate cycles every 4 minutes)
Drugs
• A single dose of Atropine 3mg IV is given asystole to block vagal
activity, and in PEA with a ventricular rate under 60 beats per
minute.
• Adrenaline is given 1mg IV at least every 3-5 minutes (as above).
Pacing
External or transvenous pacing is unsuccessful in asystole but may
be effective in ventricular asystole where p waves are still evident.
Percussion pacing may also be effective.
i An external pacing defibrillator can be obtained from ARAU,
CCU, ICU all HDUs, Wd 8 unit, wd 12, wd43 (ID), C.I.S in WGH
and A&E or ICU in RIE and in SJH.
• After 3 minutes of CPR the ECG rhythm is re-assessed.
• If a rhythm compatible with cardiac output is present check the
pulse.
• If VF/pulseless VT is present follow that side of the algorithm.
Otherwise, continue with loops of the right hand path of the
algorithm for as long as it is appropriate to continue active
resuscitation.
96 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
Chapter 3
ACUTE CARDIOLOGY AND
VASCULAR EMERGENCIES
CONTACT NUMBERS
RIE fast bleep non cardiac arrest........................ 1111
RIE cardiac arrest................................................ 222
WGH fast bleep non cardiac arrest..................... 222
WGH cardiac arrest............................................. 222
SJH cardiac arrest............................................... 222
CARDIOLOGY: MEDICAL CONTACT NUMBERS
Office
Bleep
Secretary
Dr Nick Boon................................... 21849...........5090............21848
Dr Peter Bloomfield......................... 21864...........5091............21864
Dr Martin Denvir.............................. 31846...........5432............ 31733
Dr Andrew Flapan........................... 21865...........5203............ 21847
Professor Keith Fox......................... 26350...........5089............21844
Dr Neil Grubb.................................. 21840...........2334............21845
Dr Ashok Jacob (SJH)..................... 53868............763.............53869
Professor David Newby................... 26422..........#6537...........21844
Dr David Northridge........................ 31848...........5489............31849
Dr Stuart Shaw................................ 31842........... 5153............31843
Dr Ian Starkey.................................. 31841........... 5159............31845
Dr Neil Uren..................................... 21842..........#6680...........21046
Registrars Room (WGH)................. 31850...........5689
Registrars Rooms (RIE)................... 21910.......... #6816
Cardiology bed coordinator (RIE).... 5606
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
97
GENERAL ADMINISTRATIVE POLICY (RIE/WGH)
i
CCU services are changing in Lothian: seek up to date
operational detail.
ADMISSIONS TO CCU
The following patients should be considered for admission to CCU:
• Patients with an acute coronary syndrome within the preceding 24
hours.
• Patients with life threatening, or haemodynamically unstable
arrhythmias.
• Heart failure, pulmonary oedema or cardiogenic shock where
intensive management/monitoring is required.
• Patients requiring monitoring after interventional cardiology
procedures.
• Following cardiac arrest.
TRANSFERS/DISCHARGES
• After an uncomplicated ACS the patient may be transferred to a
non-monitored cardiology or general medical bed after 24 hours. If
there is a pressure on CCU beds transfer could take place sooner.
• Patients should be pain free and haemodynamically stable for at
least 12 hours prior to transfer.
• Uncomplicated, stable infarct patients may be transferred from
CCU to a monitored bed in the general cardiology ward within 24
hours of admission.
• The consultant with responsibility for CCU patients for the week
will decide which patients are suitable for transfer out at each ward
round in discussion with CCU charge nurse.
• Ideally all transfers should take place before 20.00hrs. Transfers
should ideally be accompanied by a letter or written clinical summary
when transferring out-with cardiology. Transfers within cardiology
should at least involve a handover by verbal clinical summary for
the team taking over care of the patient. This summary should
include details of diagnosis, treatment at time of transfer/discharge
and consultant responsible for the patient.
• Discharges home should be planned according to hospital discharge
planning policy (for discharge pathway see the MI integrated care
pathway).
98 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
CARDIOLOGY SUPPORT
There is an organised 24 hour rota for Consultant/Registrar cardiology
opinion.
Out of hours the appropriate person can be contacted by bleep,
radiopage (via switchboard), mobile phone or at home.
A copy of the rota is available in CCUs, cardiac catheter labs and
switchboards.
HANDOVER OF CLINICAL CARE
When required, it is the responsibility of the medical and nursing team
to ensure there is a hand-over to the team on the ward (letter or verbal).
Outwith normal working hours (i.e.: from 5pm & at weekends) CCU
nursing staff will inform the appropriate nursing and medical team of
the transfer.
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
99
SUMMARY OF MANAGEMENT OF
ACUTE CORONARY SYNDROME
Immediate Clinical Assessment
Electrocardiogram
 Intravenous access
 Morphine 2.5 -10 mg iv + metoclopromide 10 mg iv
Oxygen + cardiac rhythm monitoring
Aspirin 300 mg po +
Clopidogrel 300 mg po in unstable angina, clopidogrel 600 mg if for PCI
Metoprolol 5-15 mg iv  Blood sampling: FBC, U&E, lipid profile, glucose,troponin
Transfer to a Specialist Cardiology Unit
Yes
Reperfusion Therapy
Yes
Rapid
Primary
PCI
Available?
GP IIb/IIa receptor
antagonist ivi +
Emergency PCI
No
No
ST Segment
Elevation ACS
Presenting <12h
FromOnset?
No
Pentasaccharide sc
Consider nitrate ivi
Thrombolysis contraindicated
and no primary PCI available
Yes
Medium
To High
RiskACS?
No
Consider
GP IIb/IIa receptor
antagonist ivi
Yes
 Recurrent
Thrombolysis iv +
Pentasacharide or LMW
heparin sc in unstable angina,
iv if for PCI
Yes
Successful
Reperfusion?
No
Symptoms?
Early coronary
angiography with view
to PCI or CABG
Maintenance In-hospital Medication Aspirin, clopidogrel,
pentasaccharide/LMW heparin4, statin, beta-blocker and ACE inhibitor therapy
TIMI risk score
(Death, MI, recurrent ischaemia)
Low risk ≤ 2
Medium risk 3-4
High risk ≥ 5
GRACE score (Death)
Low risk ≤ 4.9%
Medium risk 5-9.9%
High risk ≥ 10%
i
Killip class 1 in the absence of bradycardia
(heart rate <65/min) or hypotension
(systolic blood pressure <105 mmHg).
2
Within 90 minutes of diagnosis or if thrombolysis is
contra-indicated.
3
Patients presenting within six hours of symptom onset.
4
Continued for eight days, or until hospital discharge or
coronary revascularisation.
1
Myocardial Ischaemia may be caused by anaemia, particularly
with an acute bleed. In this case blood transfusion and cessation
of bleeding are appropriate and most of the above therapy is
contraindicated ie heparin, GTN, antiplatelet agents and b-blockers.
100 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
ACUTE CORONARY SYNDROMES
In order to make a presumptive diagnosis of ACS the patient should
exhibit symptoms consistent with acute myocardial ischaemia and
have one of the following:
• electrocardiographic changes consistent with an ACS
• serial increases in biochemical markers of myocardial necrosis, and/or
• documentation of coronary artery disease.
IMMEDIATE MANAGEMENT
In combination with the clinical presentation, an ST segment elevation
acute coronary syndrome is defined by the presence of ≥1mm ST
elevation in at least two adjacent limb leads, ≥ 2 mm ST elevation in
at least two contiguous precordial leads, or new onset bundle branch
block. In absence of ST segment elevation (non-ST segment elevation
acute coronary syndrome), patients are initially managed without
emergency reperfusion therapy.
The categories of ACS, unstable angina or myocardial infarction, are
defined by the serum concentration of cardiac enzymes and markers.
The cardiac markers, troponin I and troponin T are extremely sensitive
to myocardial injury and damage. Very small amounts of damage can
be detected allowing identification of ‘micro-infarcts’ where there is
an elevation in the troponin concentration without a significant rise
in creatine kinase or other cardiac enzymes. One consequence of
the availability of troponin measurement has been a blurring of the
distinction between unstable angina and myocardial infarction.
Cardiac Marker Concentrations
Troponin T
(ng/mL), BCS
<0.01
≥0.01 and <1.0
≥1.0
Troponin I (ng/mL), RIE
<0.2
≤0.2 and <1.0
≥1.0
Troponin I (ng/mL), WGH
<0.2
≤.02 and <2.0
≥2.0
Troponin I (ng/mL), SJH
<0.034
≤ 0.034 and <1.0
≥1.0
BCS
definition
ACS with
unstable angina
ACS with
ACS with clinical
myocyte necrosis myocardial infarction
ESC/ACC definition
unstable angina
unstable angina
myocardial infarction
WHO definition
unstable angina
unstable angina
myocardial infarction
30-Day Mortality
4.5%
10.4%
12.9%
6-Month Mortality
8.6%
18.7%
19.2% adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
101
DIAGNOSIS AND RISK STRATIFICATION OF PATIENTS WITH
ACUTE CORONARY SYNDROME
Many treatments, especially for ST elevation acute coronary syndrome,
are critically time-dependent and the immediate clinical assessment of
all patients with a suspected acute coronary syndrome is essential.
The electrocardiogram should be repeated
• with recurrent or persistent pain
• the day after admission
• prior to discharge
• with any change in the patient’s symptoms
i Patient’s with suspected acute coronary syndrome require
immediate clinical assessment and 12 lead electrocardiogram.
To establish a diagnosis in patients with acute coronary syndome, a
serum troponin concentration should be measured 12 hours from the
onset of symptoms.
Troponin concentration provides one measure of risk that should not
be relied upon in isolation. For example, patients with unstable angina
and a troponin concentration within the reference range at 12 hours,
can have a high risk of future cardiovascular events (30 day risk of
death up to 4-5%). Elevated troponin concentrations are associated
with adverse outcomes in many different clinical settings including
congestive heart failure, sepsis, pulmonary disease, acute pulmonary
embolism and chronic renal failure.
i
In patients presenting with chest pain, serum troponin
concentration should be measured on arrival at hospital to
guide appropriate management and treatment.
A fasting lipid profile should be determined within the first 24 hours
of symptom onset. Investigations - electrolytes, urea, creatinine, liver
function tests, glucose, full blood count and cholesterol.
Risk stratification using clinical scores should be conducted to identify
those patients with an acute coronary syndrome who would benefit
from early therapeutic intervention.
102 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
IMMEDIATE MANAGEMENT OF ACUTE CORONARY SYNDROME
This section refers to all categories of ACS including those patients
with ST segment elevation. In the event of unstable angina or acute
MI including STEMI occurring in the wards, theatres or other clinical
areas at WGH or SJH treatment should be initiated as described in this
chapter and the Cardiology Registrar should be contacted.
Typical history of ACS
Establish continuous ECG monitoring
• Oxygen to keep SpO2>97%
• IV access (2 for those receiving TNK)
• Anti-emetic: metoclopramide 10mg IV standard
• Morphine 2.5-10mg IV initially
• In the absence of bradycardia (<65 /min) or hypotension (systolic blood pressure <105 mmHg), patients with an acute coronary syndrome in Killip class I should be considered for immediate intravenous and oral beta-blockade.
• Aspirin 300mg to chew (unless already given by ambulance crew)
and clopidogrel 300mg in unstable angina and 600mg if ECG ischaemic or elevation of cardiac markers or for PCI.
• Blood sampling for U+Es, lipid profile, glucose, FBC
• CK level if pain started >6 hours prior to presentation
• TpI
STEMI DEFINITIONS FULFILLED
IMMEDIATE REPERFUSION
TRANSFER TO CCU WITH CONTINUOUS MONITORING
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103
IMMEDIATE MANAGEMENT OF ST ELEVATION ACUTE
CORONARY SYNDROME
All patients with ST segment elevation acute coronary syndrome
presenting within 12 hours of symptom onset should be considered
for immediate reperfusion therapy.
If the ECG is normal, immediate reperfusion therapy should not be
given, even if the history is suggestive of MI. ‘T’ wave inversion and
widespread ST depression is not an indication for immediate reperfusion
therapy. If there is diagnostic doubt then consider:
• Posterior ECG leads [ST elevation in 2 or more contiguous leads
V7-V9]
• Repeat ECG after 10 minutes + nitrate administration
• Echocardiography
• Early Cardiology opinion
Primary Percutaneous Coronary Intervention (PCI)
When compared with thrombolysis, primary PCI reduces short and
long-term mortality, stroke, re-infarction, recurrent ischaemia and the
need for coronary artery bypass graft (CABG) surgery as well as the
combined end points of death or non-fatal re-infarction. This benefit
is consistent across all patient subgroups and is independent of the
thrombolytic agent used. The greatest benefit is seen in those patients
treated within 12 hours of symptom onset.
i
Where available, patients with ST elevation acute coronary
syndrome should be treated immediately with primary
percutaneous coronary intervention.
Patients undergoing primary percutaneous coronary intervention
should be treated with a glycoprotein IIb/IIIa receptor antagonist and
undergo intracoronary stent implantation.
i
When primary percutaneous coronary intervention cannot
be provided within 90 minutes of diagnosis, patients with ST
elevation acute coronary syndrome should receive immediate
thrombolytic therapy.
104 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
LOTHIAN PRIMARY PCI INITIATIVE - NHS LOTHIAN OPERATIONAL
FRAMEWORK SELF PRESENTERS (WGH)
Lothian Primary PCI initiative - NHS Lothian Operational Framework
Self presenters (WGH)
Pt arrives in
ARAU with CP
ARAU ~ Assess, Cardiac Monitor, IV Access
~ 12 lead ECG within 5 minutes
~ Rx: O2,300mg Aspirin, GTN, Intravenous Opiate,
600mg Clopidogrel
12 lead ECG showing ST segment elevation of > 2mm
in 2 contiguous leads or new BBB and clinical suspicion of MI?
CCU SHO on - duty?
0900 to 1630 , Monday to Friday
CCU SHO not on - duty?
Bleep CCU SHO (8102)/CP Nurse (8755), stating
STEMI patient in ARAU possibly for PPCI
Weekend daytime
0830-1630, Sat&Sun
Out-of-hours
1630- 0830, Mon-Sun
CCU SHO & CP/CCU Senior Nurse go
immediatelyt o ARAU with STEMI kit-bag
Phone Cardiology SpR (8689), requesting
cascade of the Cath Lab on-call team
Patient eligible for immediate PPCI?
NO
EG unable to lie flat,
refuses consent
Discuss with
Consultant Cardiologist
consider thrombolysis
YES
Cath Lab contact ARAU as
soon as prepared
Phone Cath Lab (31855)
and ascertain
estimated time of
availability
Cath Lab available immediately
Transfer patient to Cath Lab
Cath Lab available within 60 minutes
Cath Lab contact ARU as soon as available
Cath Lab not available within 60 minutes eg
equipment failure, ongoing complex case,
on-call team at RIE
Discuss with Consultant Cardiologist
Consider thrombolysis and admit CCU
Consider while awaiting Cath Lab availability
Repeat ECG. Chest X-Ray.
Secure IV access, 2nd cannula if uncertain
Discuss with family
Routine biochemistry, haematology, group & save
Document peripheral pulses
5,000 units IV Heparin
High dose Tirofiban bolus + infusion
5-10mg IV Metoprolol
IV Opiate
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105
LOTHIAN PRIMARY PCI/PRE-HOSPITAL THROMBOLYSIS
INITIATIVE - NHS LOTHIAN OPERATIONAL FRAMEWORK SELF
PRESENTERS (RIE)
ED ~ Assess, Cardiac Monitor, IV Access
~ 12 lead ECG within 5 minutes
~ Rx: O2, 300mg Aspirin, GTN, Intravenous Opiate,
600mg Clopidogrel
Pt arrives in ED
with CP
12 lead ECG showing ST segment elevation of > 2mm in 2
contiguous leads or new BBB and clinical suspicion of MI?
CP Nurse on-duty?
0730 to 1930
7 days per week unless
otherwise stated
CP Nurse not on-duty?
1930 to 0730
or, CP Nurse not on duty
ED Bleep 1581 (either CCU Senior Nurse
or CCU SHO on as part of HAN) stating
STEMI patient in ED possibly for PPCI
ED Bleep CP Nurse (5834) stating
STEMI patient in ED possibly for PPCI
CP Nurse, CCU SHO or CCU Senior Nurse go immediately to ED
with STEMI kit-bag
EG unable to lie flat, refuses consent
Discuss with Consultant Cardiologist,
consider thrombolysis
NO
Patient eligible for immediate PPCI
YES
YES
Cath Lab staff hours
0830 to 1630,
Mon – Fri
Phone CCU, remain on line while
CCU contact Cath Lab via Primary
PCI (red) phone and ascertain
estimated time of availability
Cath Lab available immediately
Transfer patient to Cath Lab
Cath Lab available within 60 minutes
Cath Lab contact ED as soon as available
Out-of-Cath Lab staff
hours
Phone CCU, requesting
cascade of the Cath Lab
on-call team
Cath Lab contact ED as
soon as prepared
Cath Lab not available within 60 minutes
eg equipment failure, ongoing complex case,
on-call team at WGH
Discuss with Consultant Cardiologist
Consider thrombolysis and admit CCU
Consider while awaiting Cath Lab availability
Repeat ECG. Chest X-Ray.
Secure IV access, 2nd cannula if uncertain
Discuss with family
Routine biochemistry, haematology, group & save
Document peripheral pulses
5,000 units IV Heparin
High dose Tirofiban bolus + infusion
5-10mg IV Metoprolol
IV Opiate
106 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
LOTHIAN PRIMARY PCI/PRE-HOSPITAL THROMBOLYSIS
INITIATIVE - NHS LOTHIAN OPERATIONAL
FRAMEWORK SAS PRESENTERS
~ Assess
ax flow O , 300mg Aspirin po, Sublingual GTN,
~ Rx: High
2
Intravenous Opiate
~ 12 lead ECG + telemetry
SAS
Pt calls 999 with CP
12 lead ECG showing ST segment elevation of
> 2mm in 2 contiguous leads and clinical suspicion of MI?
Telemetry transmission to receiving station, or (in event
of transmission failure) SAS phonecall to RIE CCU?
Cath Lab staff hours
0830 to 1630,
Mon- Fri
STEMI requiring
reperfusion
Out-of-Cath Lab staff hours
Out-of-hours
1630-0830,
Mon-Sun
RIE CCU ask SAS
“Can you be at the nearest Cath
Lab (RIE or WGH) within 60 minutes
of diagnostic ECG?”
Weekend daytime
0830-1630,
Sat & Sun
NO
YES
SAS administer TNK + Heparin (if within JRCALC guidelines).
RIE CCU advise direct admission to nearest appropriate CCU:
RIE(24/7), StJH(24/7) or WGH (0830 to 1630, Mon – Fri)
If WGH/StJH, pre-alert + forward ECG to CCU fax.
If not within JRCALC guidelines: RIE CCU advise
admission to nearest appropriate Cath Lab hospital
(RIE/WGH).
Ascertain SAS ETA & keep on telephone
Contact relevant Cath Lab via Primary PCI
(red) phone and ask
“Can you receive a Primary PCI at the ETA?”
YES
NO
NO
RIE CCU ask SAS
“Can you be at the RIE
A&E within 60 minutes
of diagnostic ECG?”
YES
Ascertain SAS ETA
Advise SAS
Give 5,000 unit bolus IV
Heparin (unless
contraindicated)
Proceed directly to
relevant Cath Lab
If WGH, forward fax ECG
to WGH CCU
Cascade CCU SHO + CP
nurse or CCU nurse to
meet Cath Lab patient at
Cath Lab
Advise SAS
Give 5,000 unit bolus IV
Heparin (unless contraindicated)
Proceed directly to
relevant A&E/ARAU
If WGH, forward fax ECG
to WGH CCU
Cascade CCU SHO + CP
nurse or CCU nurse to
meet patient at
A&E/ARAU Cath Lab
contact A&E/ARAU as
soon as available
SAS transport to agreed destination unless the
patient’s condition presents or deteriorates such that
a crash-call to A&E/ARAU resus should be
considered. Should this be the case, SAS will phone
RIE CCU at the earliest opportunity.
Cascade on-call
Cath Lab team to RIE
Advise SAS
Give 5,000 unit Heparin
bolus unless
cont-indicated
Cascade CCU nurse +/HAN SHO to meet
patient at A&E
Cath Lab contact A&E
as soon as prepared
NO
RIE CCU ask SAS
“Can you be at the
nearest Cath Lab (RIE
or WGH) within 60 of
diagnostic ECG?”
minutes
YES
Ascertain SAS ETA
Cascade on-call
Cath Lab team to
RIE/WGH
Advise SAS
Give 5,000 unit Heparin
bolus unless
cont-indicated
If WGH, forward fax ECG
to WGH CCU
Cascade CCU nurse +/SHO to meet patient at
A&E/ARAU
Cath Lab contact
A&E/ARAU as soon as
prepared
If the Cath Lab on-call team are on-site at either
RIE/WGH performing a procedure, the Cath Lab Nurse
will call RIE CCU to alert them both on arrival and
departure. In this case the patient must be directed to
the site where the team are at the time.
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107
Thrombolysis
Since the clinical benefits of thrombolysis are time-dependent with an
increase of 1.6 deaths per hour of delay per 1,000 patients treated,
various strategies have been employed to minimise the delay between
diagnosis and administration of thrombolysis. Pre-hospital thrombolysis
should be used where possible because it shortens the time between
the call for help and the administration of thrombolysis.
Significant improvements in door-to-needle times are achieved by
administration of thrombolysis within the Emergency Department. This
can be facilitated by an experienced cardiology nurse and accomplished
without compromising the appropriateness of its administration. Doorto-needle time should be less than 30 minutes.
Contra-indications to thrombolysis:
• Known/suspected intracranial tumour, aortic dissection,
pericarditis.
• Recent [within last 3 months] stroke of any type, GI or GU
bleeding.
• Major surgery [including dental surgery], trauma, biopsy or head
injury within 6 weeks.
• Severe hypertension – systolic > 180 mmHg and/or diastolic > 110
mmHg (see below)
• Bleeding diathesis, including uncontrolled anticoagulation.
• Puncture of a non-compressible vessel.
• Prolonged (> 10 minutes) cardiopulmonary resuscitation.
• Impaired consciousness following cardiac arrest.
• Pregnancy
• Neurosurgery (within last year).
Choice of thrombolytic:
i
Tenectplase is the thrombolytic agent of choice.
Ease of use favours a bolus fibrin-specific agent on practical
grounds, particularly in the pre-hospital setting.
108 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
Tenecteplase dosing: weight adjusted
<60kg 60-69kg 70-79kg 80-89kg
> 90kg
30mg 35mg 40mg 45mg 50mg 6000 units
7000 units
8000 units
9000 units
10000 units
Heparin is commenced following this
<67kg 4000 units IV unfractionated (heparin bolus)
Then 800 iv/hr
>67kg 5000 units IV unfractionated (heparin bolus)
Then 1000 iv/hr
Check APTT at 6 hrs aiming for 1.5-2.5
From WGH CCU: check your local policy
Hypertension. All patients should already have received intravenous
opiate analgesia and beta-blockade. Repeated dosing should be given
if appropriate. Further hypertension can be managed with intravenous
nitrate infusion. Thrombolysis can be commenced once systolic blood
pressure <180 mmHg and diastolic blood pressure <110 mmHg.
Anticoagulation following thrombolysis:
Patients with ST elevation acute coronary syndrome who receive
thrombolytic therapy should be treated immediately with either a
pentasaccharide (fondaparinux 2.5 mg iv then sc daily) or low molecular
weight heparin (enoxaparin 1 mg/kg bd sc). This should be continued for
eight days, or until hospital discharge or coronary revascularisation.
Failure to reperfuse following thrombolysis:
Rescue PCI is undertaken within 12 hours of thrombolysis administration
when there is an apparent failure to reperfuse the infarct-related artery.
Reperfusion is taken to have occurred when there is a >50% fall in ST
segment elevation or new onset of idioventricular rhythm.
i
Patients presenting with ST elevation acute coronary
syndrome within six hours of symptom onset, who fail to
reperfuse following thrombolysis, should undergo rescue
percutaneous coronary intervention.
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109
Reperfusion therapy not administered
Some patients may not reach the full electrocardiographic criteria
for reperfusion therapy, have a delayed presentation (>12 hours from
symptom onset) or have significant contra-indications or co-morbidity
that limits the administration of reperfusion therapy.
Patients with ST elevation acute coronary syndrome who do not
receive reperfusion therapy should be treated immediately with a
pentasaccharide (Fondaparinux 2.5 mg sc). This should be continued for
eight days, or until hospital discharge or coronary revascularisation.
IMMEDIATE MANAGEMENT OF NON-ST SEGMENT ELEVATION
ACUTE CORONARY SYNDROMES
Patients with non-ST elevation ACS should be treated immediately
with a pentasaccharide (fondaparinux 2.5 mg sc daily). This should
be continued for eight days, or until hospital discharge or coronary
revascularisation.
Patients with an ACS who have dynamic ST segment changes,
haemodynamic compromise or acute heart failure are at particularly
high risk. Such patients benefit from early invasive intervention. “Up
stream” use of glycoprotein IIb/IIIa receptor antagonism reduces events
and improves outcomes particularly where the patient has diabetes
mellitus or an elevated troponin.
High-risk patients with non-ST elevation acute coronary syndrome
should be treated with an intravenous glycoprotein IIb/IIIa receptor
antagonist and considered for urgent PCI.
110 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
HYPERTENSION IN THE PATIENT REQUIRING THROMBOLYSIS
The following is suggested where there is persistent hypertension prior
to administration of thrombolysis.
Assessment of pain and pain control
MORPHINE
Slow IV injection at a rate of 2mg/min. until pain relief achieved
•
•
•
•
•
Exclude the following:
Bradycardia HR <60
Heart block
Cardiac failure
Asthma
Critical limb ischaemia
Excluded
IV betablocker
IV metopropol
• 1-2mg/min. up to 5mg
• Repeat after 5 min if required
- Total dose 10-15mg
- Give oral dose 25-50mg
at same time
Not excluded
Nitrate
• IV GTN infusion
• GTN Spray
• Buccal nitrates
Commence thrombolysis once systolic BP <180 and diastolic <110mmHg
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111
FURTHER MANAGEMENT OF ACUTE CORONARY
SYNDROMES
Following ACS all patients should be considered for:
• aspirin
• clopidogrel for three months (for six months if drug-eluting stent
implanted)
• statin
• ACE inhibition
• beta-blockade
PATIENTS WITH CLINICAL MYOCARDIAL INFARCTION
Patients with clinical myocardial infarction and diabetes mellitus
or marked hyperglycaemia (>11.0 mmol/L) should have immediate
intensive blood glucose control using intravenous insulin and glucose.
This should be continued for at least 24 hours.
Where possible, patients with clinical myocardial infarction should be
commenced on long-term angiotensin-converting enzyme inhibitor
therapy within the first 36 hours.
Patients with clinical myocardial infarction complicated by left
ventricular dysfunction or heart failure should be commenced on
long-term angiotensin receptor blocker therapy if they are intolerant of
angiotensin-converting enzyme inhibitor therapy.
Patients with clinical myocardial infarction complicated by left
ventricular dysfunction (ejection fraction <35%) in the presence of
either heart failure or diabetes mellitus should be commenced on longterm aldosterone receptor antagonist therapy.
RISK STRATIFICATION AND INVASIVE INVESTIGATION
• Risk stratification using clinical scores should be conducted to
identify those patients with ACS who would benefit from early
therapeutic intervention.
• Assess cardiac function to identify patients at high risk (those who
benefit from selected therapeutic interventions, such as aldosterone
receptor antagonism).
Patients with ST elevation ACS treated with thrombolytic therapy
should be considered for coronary angiography and revascularisation
during their index hospital admission.
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MANAGEMENT OF COMPLICATIONS ASSOCIATED
WITH MYOCARDIAL INFARCTION
RECURRENT ISCHAEMIC PAIN
• ECG should be recorded during pain if possible.
The following may be required, depending on the circumstances:
• Additional opiate.
• Buccal nitrates 2-5mg as required.
• Optimisation of beta blockade (heart rate<70 bpm).
• Consideration of IV glycoprotein IIb/IIa a receptor antagonist
• Consideration of urgent coronary angiography.
PERICARDIAL PAIN
A friction rub may or may not be heard. Mild pain can be controlled by
paracetamol 1g qds or dihydrocodeine 30mg qds. Non-steroidal antiinflammatory drugs such as ibuprofen may be considered but avoided
in the presence of extensive infarction, renal failure or cardiac failure.
More severe pain should be treated with IV opiate.
NAUSEA AND VOMITING
Metoclopramide 10mg IV 8 hourly is the first line drug of choice.
MILD-MODERATE LEFT VENTRICULAR FAILURE/PULMONARY OEDEMA
The following features either together or in isolation should raise
clinical suspicion of heart failure in the setting of an acute coronary
syndrome:
• Mild breathlessness at rest or on minimal exertion.
• Persistent tachycardia.
• Elevated JVP.
• Basal crepitations.
• Upper lobe diversion on CXR.
• Pulmonary oedema on CXR.
i After a myocardial infarction an elevated JVP as an isolated
feature may reflect right ventricular infarction particularly in the
setting of an inferior or posterior infarction. Diuretic therapy
may worsen the situation.
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113
Management
• Oxygen (high concentration >60%).
• Blood gases are not always required but should be performed if
shock or COPD also present.
• Monitor O2 saturation and ECG.
• Consider reducing or stopping beta-bocker temporarily.
• Ensure the patient is on an ACE inhibitor such as lisinopril or ramipril
unless contra-indicated.
• Consider oral diuretics such as furosemide or bumetanide. Assess
the need for diuretics daily. Be careful not to over-treat.
• Assess cardiac structure and function by echocardiography prior to
hospital discharge.
• Use intravenous glyceryl trinitrate if systolic blood pressure
>90mmHg.
• Once the patient is stable with no signs of pulmonary oedema or
salt and water excess consider starting a low dose beta-blocker
such as bisoprolol 1.25mg od or Carvedilol 3.125mg bd.
SEVERE LEFT VENTRICULAR FAILURE (LVF)
Patient breathless at rest. Sinus tachycardia is usual, or possibly rapid atrial
fibrillation (BP often high). A gallop rhythm and widespread crepitations
are often present. CXR shows features of pulmonary oedema.
i
If a patient looks “shocked”: tachypnoeic and tachycardic
but with a high BP LVF is the likely problem
Management
• Give high concentration oxygen 60% or greater via a venturi mask
or non-rebreathing mask/reservoir system.
• Give sublingual GTN, 2 puffs immediately if SBP > 100mm Hg.
• All patients with severe LVF should receive an intravenous infusion
of nitrates (GTN 0.3-10mg/hr starting dose depending on baseline
BP between 0.3mg/hr and 1mg/hr).
• Consider titrating morphine -1-5mg IV over 5-10 minutes preceded
by prophylactic anti-emetic (metoclopromide 10mg IV). Reduce
morphine dose in frail, elderly, chronic respiratory disease: give
1mg increments.
• If bronchospasm is a major component nebulised salbutamol 2.5mg
or 5mg may be benefically improving oxygenation and reducing
work of breathing.
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i Morphine 10mg made up to 10ml with water for injection titrated
slowly IV in 1mg increments, 2mg/minute.
• IV diuretic: If normal renal function and diuretic naive use furosemide
20mg: if currently on diuretic or in renal failure may require higher
doses e.g. 50-100mg. Slow IV < 4mg/minute.
• Consider arterial blood gases (caution with thrombolysis).
• Consider CPAP early for refractory hypoxia and respiratory fatigue.
• Consider early HDU/ICU referral.
• Monitor urine output: insert a urinary catheter.
Investigations
• ECG
• CXR
• Early Echocardiography
• Review the cardiac rhythm and blood pressure, treating tachy/
bradyarrhythmias and hypertension appropriately.
• Consider and exclude mechanical causes e.g. acquired VSD,
mitral regurgitation, left ventricular aneurysm, cardiac tamponade.
i Echocardiography is of particular value in this situation and
should be obtained as early as possible.
If patient becomes drowsy or obtunded, or if CO2 retention is present,
give an opiate antagonist and, if there is no immediate response,
consider ventilatory support. Maintain high concentration oxygen
therapy throughout.
i Do not hesitate to seek a Cardiology opinion if there is no
improvement and refer to ICU early.
• In severe or resistant cases support with intra-aortic balloon pump
maybe life saving.
• Consider insertion of an arterial line and pulmonary artery catheter
to measure cardiac output, guide the administration of inotropes,
and assess response. Particularly useful in hypotension.
• Vasoactive drugs may be required and should be administered
under expert guidance.
• Digitalisation, for its inotropic effect, may be beneficial but 3-6 hours
may elapse before there is any appreciable effect. Loading doses
as per AF (caution in renal impairment).
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115
RIGHT VENTRICULAR INFARCTION/FAILURE
Diagnosis
• Right Ventricular Failure (Hypotension and elevated JVP/hepatic
congestion) in the absence of clinical /radiological evidence of
pulmonary congestion suggests the possibility of right ventricular
infarction. This is more likely in association with acute inferior/
infero-posterior infarctions.
• The right ventricular leads on the 12 lead ECG (V3R & V4R placed in
the equivalent positions but to the right of the sternum as V3 & V4)
may show ST elevation, confirming RV Infarction.
• Echocardiogram and/or the insertion of a pulmonary artery catheter
will confirm the diagnosis.
Management
• Diuretics or vasodilators/GTN should be avoided as right
ventricular function is dependent upon high filling pressures.
• If hypotension/oliguria persists, administer IV fluids and consider
haemodynamic monitoring using a PA catheter.
• In the event of persistent hypotension/low cardiac output inotropic
therapy may be required. Seek expert advice.
CARDIOGENIC SHOCK
i Combined Cardiology and ICU referral early is appropriate.
Diagnosis
Cardiogenic shock should be considered if the following features are
present:
• Hypotension
• Tachycardia or profound bradycardia.
• Poor peripheral perfusion.
• Oliguria
• Absence of haemorrhage or hypovolaemia.
Management
• High concentration oxygen, 60-100% humidified (35% initially in
patients with severe COPD).
• Seek expert help (above).
• Treat any arrhythmias appropriately, wherever possible restoring
sinus rhythm. Many anti arrhythmics are myocardial depressant.
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• In the setting of acute myocardial infarction consider the option of
immediate PCI possibly with support from the intra aortic balloon pump.
• A urinary catheter should be inserted to monitor urine output.
• Check electrolytes and blood gases.
• Consider early insertion of a pulmonary artery catheter and arterial
line.
• Vasoactive therapy may be required and is titrated to effect.
• An immediate echocardiogram should be performed to assess LV
and RV function and to exclude cardiac tamponade, acute mitral
regurgitation, ventriculo-septal defect.
• Consider other causes e.g. haemorrhage (especially retroperitoneal
in anticoagulated patients), volume depletion or RV infarction.
i 1. Seek cardiology advice regardless of the time of day or night.
2. Make ICU referral early.
DVT
There is a policy for the prevention and treatment of DVT in ambulant
patients. See the Prescribing Bulletin (on Intranet).
HYPOKALAEMIA
Potassium supplementation should be instituted in the following
circumstances:
• Potassium <3.5mmol/l associated with any acute coronary syndrome.
• Any arrhythmia associated with hypokalaemia or low normal
potassium.
• During insulin infusion in a diabetic patient.
• Take care to review drug therapy on a daily basis taking into account
any subsequently prescribed potassium-sparing diuretics or ACEinhibitors.
• For intravenous replacement of potassium always use a preprepared bag for infusion.
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117
DIABETIC CONTROL IN THE SETTING OF ACUTE
MYOCARDIAL INFARCTION
Background:
Prospective randomised study of intensive insulin treatment on long
term survival after acute myocardial infarction in patients with diabetes
mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute
Myocardial Infarction) Study Group. BMJ. 1997 May 24; 314 (7093):
1512-5.
DIGAMI Protocol:
• All patients admitted with an acute myocardial infarction within the
preceding 24 hours who are known to have diabetes mellitus or,
although not known to have diabetes, who have a random blood
glucose concentration >11 mmol/l should be started on an IV
insulin/dextrose regimen for 24-48 hours.
• The diabetes team should be consulted regarding advice on
management of diabetes/impaired glucose tolerance thereafter.
Infusion regime (RIE/WGH)
• Dextrose: start a drip infusion of 5% dextrose and run at 500mls per
12 hours.
• Insulin: use 50 i.u. of human actrapid or humulin S in 50mls of
saline (0.9% NaCl) equivalent to 1u/ml via a syringe driver at a rate
determined by the table below.
• Blood glucose levels monitored hourly by BM stix until stable, then
4-6 hourly during infusion.
• Potassium levels may fall rapidly and should be monitored closely
during insulin infusion.
Blood glucose (mmol/l)
Insulin infusion rate (iu/hr)
0-4
0 (0.5 if known diabetic)
4.1-6.9
1
7.0-10.9
2
11.0-15.0
3
>15
6 (check pump + connections) + IV access
• This scale is flexible and should be adjusted according to individual
patient response.
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LATE MANAGEMENT OF ACUTE MYOCARDIAL
INFARCTION
DRUG THERAPY AT THE TIME OF DISCHARGE
All patients with acute coronary syndrome should be discharged on:
• Aspirin 75 mg od
Clopidogrel 75 mg od for 3 months (6 months where drug-eluting
stent has been implanted)
• Statin (see below), such as simvastatin 40 mg daily
• Beta-blocker, titrated to achieve HR <70 /min
• ACE Inhibitor, up titrated to evidence based dose, such as ramipril
10 mg od or lisinopril 10 mg od. Patients intolerant of ACE inhibitor
therapy should be considered for an angiotensin receptor blocker,
such as valsartan 40-160mg bd or candesartan 4-16 mg od.
• All patients should be given a GTN spray to use as required for
chest pain.
i If any of these drugs are not prescribed, reasons for this should be
clearly documented in the casenotes.
CARDIAC REHABILITATION
Additional secondary prevention strategies addressed as part of the
rehabilitation program include:
• Smoking cessation.
• Dietary advice.
• Exercise
• Alcohol intake.
These are incorporated in the HEART MANUAL that is received by all
patients with clinical myocardial infarction.
• Cardiac Rehabilitation Programme should be considered for all
patients suffering clinical myocardial infarction. There is no age limit
for referral. The cardiac rehabilitation co-ordinators are contactable
by page and should be informed of all patients admitted with
clinical MI regardless of the perceived need for rehab. Frail and
infirm patients will be offered information and support.
• The Lothian Hospitals offer lifestyle education, smoking cessation
advice and, for those who are suitable, group exercise programs.
The majority of patients are given the ‘Heart Manual’: a six week
home based program with support during the time by the hospital
rehab team or the BHF nurse, and/or the community heart manual
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119
facilitators. As a rough guide, patients referred for group exercise
should be able to complete stage 1 (3 minutes) of full Bruce protocol.
Treadmill testing.
Phase III programmes are offered at Astley Ainslie Hospital, Western
General Hospital and St John’s Hospital.
OTHER POTENTIAL PROBLEMS IN THE
PERI-INFARCT PERIOD
ALCOHOL WITHDRAWAL
There is an alcohol withdrawal policy (see Lothian Joint Formulary) and
chapter 12.
NICOTINE WITHDRAWAL
Evidence suggests that transdermal nicotine, and nicotine gum should
not be withheld from patients who suffer an MI unless there is evidence
of ongoing ischaemia (Goldstein, Niaura, 2000). The safety of NRT
in those with unstable angina or post MI within 2 weeks has not yet
been studied but cardiac complications should be lower than with
smoking.
A risk/benefit assessment should be made with each individual patient.
Patients struggling with the withdrawal effects of nicotine should be
offered treatment for the first 48 hours, or until haemodynamically
stable, using benzodiazepines, as for alcohol withdrawal. The risks of
NRT should be explained using written information about the specific
product they will use. They should sign a statement in the case
notes indicating that they have read this information and accept
responsibility for its use. They should also agree not to smoke
whilst on NRT.
i Patients should be seen by the smoking cessation nurse when
considering starting NRT in the setting of a recent acute coronary syndrome.
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OTHER MEDICAL EMERGENCIES ADMITTED TO CCU
OUT OF HOSPITAL CARDIAC ARREST
Acute myocardial infarction is the underlying cause in 40% of cases
and the general principles of its management should be followed.
Emergency coronary angiography and reperfusion therapy should be
considered if the patient has recovered consciousness. Reperfusion
therapy may also be considered in patients with impaired consciousness
who show signs of awakening provided there is no evidence of head
injury arising from the collapse.
In cases without definite evidence of acute myocardial infarction
investigations should be directed towards other causes of ventricular
arrhythmia:
•
•
•
•
Electrolyte disturbance.
Underlying bradycardia.
Pro-arrhythmic effect of medication.
Drug overdose (tricyclic antidepressants, amphetamines, cocaine).
Coma is present in approximately half of cases admitted to CCU with
an out-of-hospital cardiac arrest. Coma is compatible with meaningful
survival even if it persists for up to 72 hours. Management should be
directed at maintaining oxygenation, circulation and renal fuction during
this period. Patients should be considered for therapeutic hypothermia
and this is indicated in the presence of:
•
•
•
•
•
coma (unresponsive to voice, GCS <9)
intubation and ventilation
no other cause of coma
negative pregnancy test
haemodynamically stability
Mechanical ventilation should be considered for:
•
•
•
•
•
i
Maintenance of oxygenation
Normalisation of CO2
Shock
Seizures
Worsening acidosis
Intubation with spontaneous breathing is not ideal for
optimisation of coronary and cerebral oxygen delivery.
Mechanical ventilation is often appropriate.
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121
Referral to ICU should follow discussion with the duty cardiologist.
Late management should include assessment of left ventricular function
and exercise testing. In those without acute myocardial infarction the
indications for an ICD should be discussed.
MANAGEMENT OF ARRHYTHMIAS
The following are guidelines only. Any complex problems or
arrhythmia unresponsive to treatment should be discussed
with the Cardiologist on call at any time.
i
TACHYARRHYTHMIAS
NARROW COMPLEX TACHYCARDIAS
Sinus Tachycardia
Characterised by a narrow QRS (3 small squares or less, unless
bundle branch block present) and normal ‘P’ waves. Rate >100bpm at
rest. Consider other supraventricular tachycardias for any rate above
140bpm. Carotid sinus massage may help to differentiate.
i Sinus tachycardia commonly results from underlying
pathology outwith the heart e.g. sepsis, hypovolaemia, pain.
Management
• Treat possible causes (e.g. pain, anxiety, fever, cardiac failure,
pericarditis).
• In acute coronary syndromes, consider beta-blocker unless
contraindicated.
• Consider echocardiography to assess LV function.
ATRIAL FIBRILLATION
Characterised by irregular, narrow QRS complexes with no discernable
P-waves.
i AF may result from underlying pathology outwith the heart
e.g. sepsis, hypovolaemia, pneumonia, pulmonary embolism.
Management
• For management refer to UK Resuscitation Council guidelines
(see algorithm).
• Atrial fibrillation often accompanies left ventricular failure. Therapy
may be ineffective unless it is given in conjunction with effective
treatment of cardiac failure.
• Check TFTs.
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123
unstable
Broad QRS
Is QRS regular?
If previously confirmed SVT with
bundle branch block:
• Give adenosine as for regular
narrow complex tachycardia
• Adenosine
Probable re-entry PSVT:
• Record 12-lead ECG in sinus rhythm
• If recurs, give adenosine again &
consider choice of anti-arrhythmic
prophylaxis
Yes
No
Narrow QRS
Is rhythm regular?
vagal manoeuvres
6 mg rapid IV bolus;
if unsuccessful give 12 mg;
if unsuccessful give further 12 mg;
• Monitor ECG continuously
• Use
Regular
Narrow
Normal sinus rhythm restored?
Is QRS narrow (<0. sec)?
Stable
If Ventricular Tachycardia
(or uncertain rhythm);
• Amiodarone 300 mg IV over 20-60
min; then 900 mg over 24 h
Regular
Is Patient stable?
Signs of instability include:
1. Reduced conscious level
2. Chest pain
3. Systolic BP< 90 mmhg
4. Heart failure
(Rate related symptoms uncommon
at less than 150 beats min-1)
*Attempted electrical cardioversion is
always undertaken with sedation or general
anaesthesia
Possibilities include:
• AF with bundle branch block
treat as for narrow complex
• Pre-excited AF
consider amiodarone
• Polymorphic VT (e.g.torsade
de pointes - give magnesium 2g
over 10 min)
Seek expert help
Irregular
Broad
300mg IV over 10-20
min and repeat shock; followed by;
900mg over 24h
• Amiodarone
• Amiodarone
Syncronised DC Shock*
Up to 3 attempts
•
•
ABCs: give oxygen; cannulate a vein
Monitor ECG, BP, SpO2
Record 12-lead ECG
• Identify and treat reversible causes (e.g. electrolyte abnormalities)
• Support
Irregular
Possible atrial flutter
Control rate (e.g.B-Blocker)
Seek expert help
Irregular Narrow Complex Tachycardia
Probable atrial fibrillation
Control rate with:
• -Blocker IV or digoxin IV
If onset <48 h consider: via a large Cannula in a large vein
• Amiodarone 300 mg IV 20-60 min; then 900 mg over 24 h
Continuous infusion of amiodarone should be administered
via a central venous catheter using an appropriate infusion
device
TACHYCARDIA ALGORITHM (with pulse)
ATRIAL FLUTTER
Characterised by rapid regular or irregular narrow QRS complexes with
a saw-tooth appearance to the baseline. A regular, narrow complex
(unless BBB pattern present) tachycardia of 150 bpm should be
suspected to be atrial flutter with a 2:1 block irrespective of whether or
not flutter waves are obvious on the ECG.
Management
• Carotid sinus massage/vagal manoeuvres may slow the ventricular
response revealing underlying flutter waves and assisting the diagnosis.
• Adenosine may also be used to help assist the diagnosis by
slowing AV conduction and revealing flutter waves. Rapid IV bolus
of 6mg followed by saline flush, up to 12mg IV a total of twice
at 1-2 minute intervals may be given if tolerated. Do not use in
asthmatics (bronchoconstriction) or those taking dipyridamole,
carbamazepine or with denervated (transplanted) hearts (effects
prolonged and potentiated). Administration may be accompanied by
flushing and/or chest tightness but the half life is short (20 seconds)
with clinical effects resolving in about 2 minutes. WARN THE
PATIENT. Always run an ECG rhythm strip during administration.
Adenosine is contra-indicated in 2nd or 3rd degree AV block.
• Atrial flutter tends to be sustained and does not respond readily to
AV node blocking drugs. Therefore, every patient with persistent
atrial flutter should be considered for early cardioversion.
• For immediate management consider using the management
guideline for atrial fibrillation.
• Note that IV Flecainide cardioversion should NOT be used for atrial flutter.
It can slow the flutter rate and cause a paradoxical rise in the heart rate
to >200bpm. (Increased rate of conduction through a-v node).
SUPRAVENTRICULAR TACHYCARDIA
Characterised by regular narrow QRS complexes.
Three types exist:
1. AV Node re-entry tachycardia. Usually presents in young adults.
Commoner in women. Usually no ‘P’ waves visible.
3. AV re-entry tachycardia (the tachycardia associated with WPW).
Also presents in young adults. Inverted ‘P’ waves may be seen
after the QRS and a pseudo-RBBB pattern in V1.
3. Atrial tachycardia due to enhanced automaticity in an atrial focus. ‘P’
waves visible before the QRS but with abnormal P wave morphology.
124 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
BROAD COMPLEX ARRHYTHMIAS
VENTRICULAR PREMATURE BEATS - VPBs
Ventricular premature beats occurring in the early phase of acute
myocardial infarction, are common and are not in themselves predictors
of serious ventricular arrhythmias. However, in the presence of frequent
VPBs combined with significant left ventricular impairment (ejection
fraction <35%) consider a 24 hour ECG recording prior to discharge to
exclude non-sustained VT.
IDIOVENTRICULAR RHYTHM
Characterised by regular, broad complex arrhythmia at a rate <120
bpm (a rate >120 bpm indicates VT). It is common during reperfusion
after thrombolysis.
• Idioventricular rhythms are usually self-terminating and do not
require anti-arrhythmic therapy.
BROAD COMPLEX TACHYCARDIA
Treat as ventricular tachycardia until proven otherwise. Characterised by
regular broad QRS complexes >120 bpm. Differentiation between VT and
SVT with a bundle branch block is aided by the diagnostic algorithm.
Diagnosis
• Where possible compare previous ECGs in sinus or previous arrhythmia.
• In a patient with previous myocardial infarction, IHD, cardiomyopathy,
age >60 years, a broad complex tachycardia is nearly always
ventricular in origin.
• Adenosine may be used in an effort to assist diagnosis.
i Do not use verapamil if VT is not excluded. It can cause haemodynamic collapse or asystole.
Management
• See algorithms
• Treatable factors should be identified e.g. persistent cardiac failure,
hypokalaemia, hypomagnesaemia.
• Pro-arrhythmic effect of anti-arrhythmic drugs or inotropic agents
may necessitate their reduction or cessation.
• Occasionally mechanical causes are responsible e.g. central lines
or pacing wires.
i Seek senior cardiology advice regardless of the time of the day
or night and before proceding further through the algorithm.
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125
DIAGNOSIS OF BROAD-COMPLEX TACHYCARDIA
Broad complex Tachyarrhythia
Irregular
Consider atrial fibrillation with bundle
branch block, or pre-excitation
Regular
Yes
Clinical evidence of AV dissociation
Ventricular Tachycardia
No
Yes
ECG shows AV dissociation, blocked VA
conduction, capture or fusion beats?
Ventricular Tachycardia
No
Yes
Is there an ECG showing sinus
rhythm available?
Does it show?
No
Assume patient does not have bundle
branch block when in sinus rhythm
Remember to reapply algorithm after
restoring sinus rhythm
Narrow QRS <120ms?
Ventricular
Tachycardia
Yes
Pre-excitation
Is QRS >140ms
during tachycardia?
Consider Intracardiac study
No
Ventricular
Tachycardia
Yes
Bundle branch block?
Is QRS morphology Yes
unchanged during
tachycardia?
Supra-ventricular
tachycardia
No
Is axis <-300 during
tachycardia?
Has axis altered
to <-450 during
tachycardia?
No
Yes
Is QRS >140ms
during tachycardia?
No
No
Is QRS >180ms
during tachycardia?
Yes
Ventricular
Tachycardia
No
Yes
Are there previous records of broad complex
tachycardia with different morphologies?
No
Ventricular
Tachycardia
Yes
Is there ventricular concordance?
No
Yes
Is there Rsr’ in V1 or QS or rS in V6 in patients with
right bundle branch block configuration?
No
1.
Detailed analysis of morphology
2.
Oesophageal/right atrial electrode
3.
Intracardiac study
126 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
• Maintenance anti-arrhythmic therapy following restoration of sinus
rhythm depends on the arrhythmia substrate for SVT prophylaxis.
VT prophylaxis centres around the use of beta-blockers and/or
amiodarone. Some patients may require ICD implantation. Longterm management of these patients should always be discussed
with a consultant cardiologist.
• Most anti-arrhythmic drugs can cause sinus bradycardia or AV
block. For patients with impaired LV function, beta-blockers should
be introduced at a low dose (e.g bisoprolol 1.25-2.5mg daily) and
titrated gradually. Amiodarone is effective for VT treatment and
prophylaxis in these patients. Class Ic drugs such as flecainide
and propafenone are contraindicated in heart failure/LV
impairment.
• Overdrive pacing may be considered for resistant or recurrent
arrhythmias.
VT or VF are commonly triggered within the first 48 hours of acute
MI. In this situation recurrence after the acute event is uncommon
and no specific prophylaxis is needed. VT or VF occurring more
than 48 hours after acute MI is more sinister; this may indicate the
development of a chronic arrhythmia substrate. These patients
need assessment with a view to revascularisation and either antiarrhythmic drug treatment or an ICD.
i Do not hesitate to seek a senior cardiology opinion in the case
of troublesome dysrhythmias - ‘cocktails’ of anti-arrhythmics
cause more problems than they solve.
TORSADE-DE-POINTES TACHYCARDIA
Characterised by rapid, broad QRS complexes twisting around the
baseline giving the appearance of changing QRS morphology and
axis. It is a form of polymorphic VT and can be mistaken for VF. It
is often self terminating and recurrent. Its recognition is important
because the aetiology and treatment differs from monomorphic VT.
Diagnosis
Consider Torsade when the following are present:
• Polymorphic VT.
• Prolonged QT interval.
• Initiation of tachycardia with long-short coupling intervals.
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127
Causes
• Bradycardia
• Electrolyte disturbances - hypokalaemia/hypomagnesaemia/
hypocalcaemia.
• Tricyclic antidepressants.
• Certain anti-psychotics (e.g. thioridazine).
• IV erythromycin.
• Antihistamines (e.g. terfenadine).
• Anti-arrhythmic drugs - amiodarone, sotalol, disopyramide,
procainamide etc.
• Myocardial ischaemia.
• Inherited long QT syndrome (may be family history of synocope, sudden death or “epilepsy” in association with any of the above).
Management
• The primary treatment of drug induced Torsade is intravenous
magnesium infusion
• Withdraw any drug known to prolong QT interval
• Consider the use of temporary atrial or ventricular pacing.
• Intavenous isoprenaline (2.25 mg isoprenaline sulphate in 500 mL
5% dextrose infused at 10-30ml per hour) is an effective short-term
treatment. Use with caution in patients with angina or heart failure,
and discuss management with cardiologist.
VENTRICULAR FIBRILLATION
Characterised by a chaotic electrical pattern with no discernible cardiac
rhythm.
Follow cardiac arrest algorithm.
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MANAGEMENT OF BRADYARRHYTHMIAS
SINUS BRADYCARDIA, JUNCTIONAL RHYTHM
Characterised by rate <60 bpm, ‘P’ wave present (sinus brady). ‘P’ wave
inverted or buried within or after QRS in the case of junctional rhythm.
Management - see bradycardia algorithm. (Always consider
and treat the cause e.g. hypothermia, drugs, intracranial
pressure, hypothyroidism etc).
i
FIRST DEGREE ATRIOVENTRICULAR (AV) BLOCK
Characterised by one ‘P’ wave per QRS but with a PR interval >0.2
secs, is not uncommon especially after inferior MI. Those on betablockers may have an acceptable, marginal first degree AV block.
i If a prolonged PR interval is associated with either new
bifascicular block (RBBB +LAD or RBBB +RAD) or with complete
LBBB DISCUSS WITH A CARDIOLOGIST, as a prophylactic
pacing electrode may be required.
SECOND & THIRD DEGREE (COMPLETE) AV BLOCK
Second degree heart block
• Type I (Wenckebach) - characterised by lengthening PR interval with
each successive beat until failure of conduction of the atrial impulse
through the AV node occurs; this tends to occur in a cyclical pattern.
• Type 2 (usually 2:1 block) - characterised by a constant PR interval
and the sudden failure of conduction of an atrial impulse through
the AV node; this tends to occur in a cyclical pattern.
Third degree heart block
• Characterised by complete dissociation of atrial and ventricular
activity with all atrial impulses blocked within the conducting
system.
In inferior infarction only requires treatment if associated with
hypotension, syncope, cardiac failure or ‘escape’ ventricular rhythms.
Initially, IV atropine 500 micrograms should be given and repeated, if
necessary, up to a maximum of 3mg. If AV block recurs a temporary
pacing electrode should be inserted. AV block associated with inferior
MI usually resolves within 10 days, therefore permanent pacing is not
normally necessary.
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129
i In anterior infarction the development of second degree or
complete heart block is an indication for insertion of a temporary
pacing electrode. A permanent DDD system may be required
before discharge.
• Transutaneous pacing can be used as a “safety net” until a pacing
wire has been inserted.
BRADYCARDIA ALGORITHM
(includes rates inappropriately slow for haemodynamic state)
Yes
•
•
•
•
Adverse signs?
Systolic BP <90mm Hg
Heart rate <40 beats min-1
Ventricular arrhythmias compromising BP
Heart failure
No
Atropine
500 mcg IV
Satisfactory
Response?
Yes
No
•
•
•
•
Interim measures:
Atropine 500 mcg IV
repeat to maximum of 3 mg
Adrenaline 2-10 mcg min-1
Alternative drugs*
OR
Transcutaneous pacing
•
•
Yes
•
•
Risk of asystole?
Recent asystole
Moblitz II AV block
Complete heart block
with broad QRS
Ventricular pause>3s
No
Seek expert help
Arrange transvenous pacing
Observe and Monitor
*Alternatives include:
• Aminophylline
• Isoprenaline
• Dopamine
• Glucagon (if beta-blocker or calcium-channel blocker overdose)
• Glycopyrronium can be used instead of atropine
i
If bradycardia is a “secondary” phenomenon treat the cause
hypothermia, hypothyroidism
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EXTERNAL CARDIAC PACING
GET HELP
Main Indications (as below pending transvenous pacing)
• Complete heart block.
• Ventricular standstill.
• Symptomatic bradycardia unresponsive to atropine.
• Risk of asystole: see algorithm.
Equipment
• External pacing defibrillators are located in:
WGH:- ARAU, HDU’s Ward 21, Ward 26 and some other wards.
RIE:- A&E, ICU, CCU Ward 114 and some other wards.
SJH:- A&E, CCU (spare machines are located in the recusitation
department and Medical Physics).
See current cardiac arrest trolley list for full location list.
Method
• Appropriate gel pads are applied to the chest in the defibrillator
paddle sites on front and back. There is a diagram on the outside
of the bag in which they are provided.
• The ECG electrodes from the defibrillator monitor must be attached
to the patient or it will not pace.
• The starting default settings which appear when you press the on
button are below.
• Mode is demand: don’t change this.
• Rate 70bpm: can be increased or decreased to achieve the optimal
haemodynamic condition.
• Power: 30mA: can be increased to gain capture. The lowest level
which is effective should be selected.
• External pacing can be uncomfortable, painful and distressing. Titrate
IV morphine for comfort and add 0.5-1mg midazolam if distressed.
Be careful with this potentially destabilising combination. Monitor
continuously (ECG, SpO2 and BP) and re-assess frequently.
INTRAVENTRICULAR OR BIFASICULAR BLOCK
Right bundle branch block plus left or right axis deviation (-300 or > +900)
constitutes bifasicular block. Following anterior myocardial infarction,
unless known to be long-standing, it is an indication for considering
insertion of a temporary pacing electrode. If more severe conduction
abnormalities develop i.e.: second or third degree AV block a permanent
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131
pacemaker is indicated prior to discharge. New left bundle branch block
associated with first degree heart block should be treated similarly.
INTRA-AORTIC BALLOON PUMP (IABP)
May be useful in severe acute valvular disease, in severe unstable
angina or in cardiogenic shock. Prior to insertion there should be a
clearly agreed clinical management strategy. Discuss with senior
cardiologist.
SPECIFIC DRUG POINTS
A full account of all drugs mentioned in the schedule is available in the BNF,
which should be consulted. Further detail in CCU Therapeutic Schedule.
ACE-INHIBITORS
Reduce mortality after AMI by approximately 20-30%.
Most frequently used drugs: ramipril, lisinopril, enalapril.
• Following AMI, therapy is normally commenced when the patient is
stable, within 24-36 hours after the acute event.
• Where significant hypotension might occur (e.g. pre-existing
hypotension, reno-vascular disease), a test dose of captopril
6.25mg is normally used. The blood pressure and pulse should be
monitored every 30 minutes for 2 hours following this.
• Where hypotension is unlikely to be a problem, low dose ramipril,
lisinopril or enalapril are equally appropriate as initial therapy.
• It is important to titrate ACE inhibitors to appropriate doses as used
in clinical trials - lisinopril 10mg od, ramipril 5mg bd (especially if
signs of heart failure present), enalapril 10-20mg bd.
• Effects of potassium supplements or potassium sparing diuretics
should be monitored closely by checking plasma potassium and
adjusting prescription accordingly.
BETA BLOCKERS
Reduce mortality after AMI by ~25%
• Contra-indicated in asthma.
• Prescribe with caution in COPD.
• Stable chronic peripheral vascular disease is NOT a contraindication.
• Beta blockers should also be considered in patients with heart
failure associated with AMI once stabilised.
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DIGITALIS TOXICITY
Digitalis toxicity is most often associated with bradycardia, ventricular
bigeminy, paroxysmal atrial tachycardia (often with variable AV block),
accelerated idioventricular rhythm and AV block, but almost any
arrhythmia can be provoked. Visual disturbance, anorexia, nausea
and vomiting are also common features - level should be measured.
CONTACT THE POISONS BUREAU AT RIE FOR ADVICE: 0131 242 1389.
ANTI-PLATELET THERAPIES
Clopidogrel
The CURE (Clopidogrel in Unstable Angina to Prevent Recurrent
Ischaemic Events) study, demonstrated that initiating oral therapy
with clopidogrel early, and continuing its use long- term, reduces the
relative risk of heart attack, stroke and cardiovascular death by 20% in
patients with acute coronary syndromes (unstable angina and non-Q
wave myocardial infarction).
Indications: Patients with non-ST segment elevation myocardial
injury (including non-Q MI) and unstable angina with troponin or
ECG changes - 300mg loading followed by 75mg daily for 12 months +
aspirin 75-300mg.
Following insertion of intra-coronary stent in elective PCI (300mg
loading dose followed by 75mg daily for 1 month combined with aspirin
75-300mg daily thereafter).
Cautions: Check FBC 7 days after initiation of combination therapy.
N.B. STOP treatment at least 7 days prior to major surgery including
coronary by-pass.
Integrilin (Eptifibatide)
Indications: acute coronary syndromes (i.e. unstable angina or non Qwave MI) regardless of whether they ultimately undergo PCI.
Tirofiban
Tirofiban is a non-peptide inhibitor of the platelet glycoprotein (GP) IIb/
IIIa receptor, the final common pathway for platelet aggregation.
Abciximab (REOPRO)
• Indications: in association with high risk percutaneous coronary
intervention.
• Abciximab: (c7E3) is a monoclonal antibody directed against the
GP IIb/IIIa receptor.
For details of pharmacology, dosing and administration please refer to
the Coronary Care Unit Therapeutic Schedule.
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133
VASCULAR EMERGENCIES
ACUTE AORTIC DISSECTION
Acute aortic dissection is a medical emergency and should be
investigated and treated with the same urgency as acute MI. Always
discuss management with a senior cardiologist at first opportunity.
Risk factors are hypertension, Marfans syndrome, pregnancy, aortitis,
coarctation of the aorta.
Presenting features include:
• Very severe anterior chest pain.
• Very severe posterior chest pain.
• Ischaemic syndromes - coronary, cerebral, upper limbs, renal, lower
limbs.
• Syncope
• Cardiac tamponade.
• Acute aortic regurgitation.
• Unequal limb pulses and blood pressures.
Management
• Oxygen 60-100%
• IV access
• IV opiate analgesia and anti-emetic therapy
• Transfer to CCU if imaging assessment is delayed
• Urinary catheter
• Transfer immediately to cardiac surgery if diagnosis of Type A
dissection is confirmed. Mortality is as high as 5% per hour.
• Intensive BP control with IV beta-blocker, such as labetolol. In
patients with contraindication to beta-blocker, IV verapamil should
be used. Additional vasodilators may need to be considered such
as IV GTN or sodium nitroprusside. Target blood pressure should
be to maintain systolic blood pressure <120 mmHg.
i Get expert help.
Investigations
• CXR - look for widened mediastinum, pleural effusions.
• ECG - may show ischaemia
• Transthoracic echocardiography as a rapid initial evaluation for type
A dissections but has low sensitivity and cannot be relied upon.
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• Emergency multislice computed tomography, magnetic resonance
imaging or transoesophageal echocardiography should be
considered to diagnose and define the extent of the dissection.
i Early mortality in acute aortic dissection of the ascending aorta
is 10% per hour. Surgery can be life saving and should not be
delayed. Never transfer a patient for surgery without adequate
BP control with IV therapy.
INVESTIGATION ALGORITHM FOR ACUTE AORTIC
DISSECTION
Suspected acute aortic dissection
Transthoracic echocardiography
Aortic dissection
confirmed
Dissection limited
to arch and/or
descending aorta
(type B)
Echo normal or
inconclusive
Conservative
management
Involves ascending
aorta (type A)
Further noninvasive imaging
TOE, CT or MRI
Urgent surgical
opinion
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135
ACUTE STROKE
i Stroke is a Medical Emergency: TIME IS BRAIN.
An acute stroke integrated care pathway should be initiated immediately
on arrival at hospital. It will guide you through the initial management of
the patient. If there is a known time of onset of symptoms, the patient
presents within 2.5 hours of onset and there are no contraindications
to thrombolysis, ring the stroke team immediately for consideration for
immediate thrombolysis.
If onset within 5.5 hours, ring stroke team immediately for consideration
for randomisation into IST 3 (thrombolysis trial).
During day, bleep the WGH Stroke SpR page 8699, out of hours the
Neurology registrar.
Service at RIE from 9-5.
At SJH page Stroke Liason Nurse on 986.
In any patient presenting with an apparent stroke, your management
should centre on answering the following questions:
• Where is the brain lesion?
• Has this patient had a vascular event or not?
• If this is a vascular event is it a haemorrhage or an infarct?
• Why has this patient had a stroke?
• What are this patient’s problems?
MANAGEMENT
• If possible, all patients admitted with an acute stroke should be
directed to the Acute Stroke Unit in Ward 55 WGH or Ward 101 in
RIE and at SJH to the Medical Admissions Unit in wards 23 & 24 or
to CCU if thrombolysis is being administered.
• Perform standard acute initial assessment to ensure that the patient
is maintaining an adequate airway, is breathing and has an adequate
circulation.
• Check swallowing prior to allowing free fluids. Nursing staff on the
acute stroke units have a protocol for swallowing assessment. A
formal swallowing assessment may be organised within normal
working hours by contacting a speech and language therapist on
bleep 5221 WGH, ext. 21967 RIE or at SJH SALT on ext 54191.
• If there are doubts about the patient’s ability to swallow safely
the patient should be placed nil by mouth and given intravenous
fluids.
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• Urinary catheterisation should be avoided in the acute phase unless
there is urinary retention, a high risk of pressure sores or unless the
urine output needs to be monitored. Discuss with Nursing staff.
• DVT Prophylaxis: avoid Heparin.
INVESTIGATION
•
•
•
•
•
•
i Immediate BM to exclude hypoglycaemia
U&E’s, and glucose
LFTs, cholesterol
FBC, ESR
ECG
CXR
CT scan should be requested immediately in all patients. These
can normally wait until the next day.
• If clinical evidence of a cardiac source of embolism e.g. atrial fibrillation
or significant cardiac murmur, request an echocardiogram.
• If the patients has had a minor stroke or TIA affecting the carotid territory
arrange a carotid duplex to screen for significant carotid stenosis.
INDICATIONS FOR IMMEDIATE CT SCANNING
• Coma or reducing conscious level.
• Likelihood of important non-stroke diagnosis (e.g. subdural
haematoma, subarachnoid haemorrhage).
• Patient on or requiring anticoagulants.
• Patient eligible for thrombolysis.
• Unusual presentation? Basilar artery thrombosis.
STROKE DIFFERENTIAL DIAGNOSIS: CONDITIONS WHICH MAY
MIMIC OR BE MIS-DIAGNOSED AS STROKE
Toxi-metabolic derangements
• Hypoglycaemia
• Alcohol intoxication
• Drugs e.g. tricyclic antidepressants
• Hyponatraemia
Other CNS disease
• Meningitis/encephalitis
• Subarachnoid haemorrhage
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137
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Sub-dural haematoma
Todd’s paresis
Tumour
Cerebral vasculitis
All patients with stroke who have not been admitted to the stroke
units should be notified to Professor Dennis or Dr Keir (WGH) or
Drs Hart, Mead, Chapman or Coull ext 26927 (RIE) or the stoke unit
on ext 54104 or stoke liason nurse on bleep 986 (SJH) as early as
possible.
Once a cerebral haemorrhage has been excluded (by CT brain), a
single dose of aspirin should be prescribed at a dose of 300 mg oral
od. If patient cannot swallow give by suppository. After that 75mg
per day should be given (minimise GI side effects).
Thrombolysis is available 24/7 at WGH and 9-5 at RIE and
SJH. Contact Stroke Registrar or Consultant via appropriate
switchboard.
If already on aspirin leave on aspirin until CT result known.
For patients with ischaemic stroke dipyridamole MR 200mg daily
should be given in addition to aspirin.
If the total cholesterol is greater than 3.5mmol/l start patient on
simvastatin 40 mg nocte (consider pravastatin if on warfarin and
digoxin). See Lothian lipid guidelines.
Antihypertensive medication may be continued if the patient is able
to swallow.
New antihypertensive medication should not be initiated within
the first week of an acute stroke unless there is accelerated phase
hypertension.
After the first week blood pressure lowering with an ACE inhibitor
and thiazide diuretic should be considered even if blood pressure is
“normal”.
Patients with a proven ischaemic stroke who are in atrial fibrillation
should be considered for anticoagulation after 2 weeks.
If AF is symptomatic (e.g. palpitations or breathlessness)
consideration should also be given to subsequent chemical or
electrical cardioversion.
All patients with ischaemic stroke who are shown to have a severe
stenosis (>70%) of the ipsilateral internal carotid artery on the
carotid duplex should be referred to Professor Dennis or Dr Keir
(WGH), Dr Chapman or Dr Hart (RIE) or Dr S Ramsay (SJH) on ext
53846 for further consideration of carotid endarterectomy.
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ACUTE STROKE INTEGRATED CARE PATHWAY (WGH version)
ICP for Acute Admission following SUSPECTED STROKE v3.5, post mdt 25/08/06
NHS Lothian
Addressograph or
CRITERIA: Initiate for ALL PATIENTS
Name
Dob
ATTENDING with a SUSPECTED STROKE
Address
date initiated: ___/____/___
site : St.John’s , RIE , WGH
Unit number
CHI
INSTRUCTIONS Insert information into appropriate spaces as required.
Circle Y or N to indicate status of patient or your actions. Do not initial until actually done!
This ICP is an immediate action checklist & a clinical record, & also requires a Kardex & SEWS chart
PHASE 1 - IMMEDIATE PATIENT ASSESSMENT – complete with Y or N
Facial weakness:
Arm weakness:
Speech problems:
FAST
criteria:
[__] Can the person smile?
[__] Can the person
raise both arms?
[__] Can the person speak clearly
& understand what you say?
Test all 3: If NO to any question, a Stroke is probable, continue with ICP
initial
date&time
If YES to all three, continue with full Medical Clerking & devise a Medical management Plan
Time of Arrival
date ____/____/____
time ____:____hrs
Symptom Onset
date ____/____/____
time ____:____hrs
Time difference
____:____ hrs
If Time Difference is < 3h call Stroke Consultant URGENTLY bl………….
Eligible for
Yes - initiate Thrombolysis ICP
Thrombolysis?
No – state reason
GLASGOW COMA SCALE: on arrival: EYES ……. , MOTOR ……. , SPEECH …….. : total ……..
Is airway compromised
& / or GCS < 9
Blood Pressure: SBP >210 or <90
Airway:
Cardiac rhythm: In Atrial Fibrillation?
Oxygenation:
CT BRAIN
SCAN:
date
___/____/___
time ___:___
RESULT
date
___/____/___
time ___:___
Is O2 sats. < 95%
IF YES, d/w HDU/ICU
N Y
IF YES, control hyper- / hypo-tension
initial
N Y
IF YES, control heart rate
initial
N Y
IF YES, prescribe O2 & check ABG
initial
time: ……………..
Arrange scan NOW (completed a request card & sent to X-Ray dept. Y / N )
Anticoagulated (INR>1.4) or Coagulopathy
Suspected subarachnoid haemorrhage (SAH)
Eligible for thrombolysis
Deteriorating GCS or ??intracranial infection
Intracerebral Haemorrhage N Y
Infarction
Posterior Fossa bleed,
Hydrocephalus, or
Malignant MCA infarct
SAH
N Y
?
? N Y
?
N Y
N
N
N
N
Y
Y
Y
Y
IF YES to any question,
ring Radiologist NOW
for immediate scan
(day or night)
IF YES, if INR>1.4 - reverse anticoagulation NOW
(NHSL VTE Guideline) & STOP all antithrombotics
initial
initial
initial
initial
IF YES, give Aspirin 300mg stat oral/pr NOW
(must be given < 48 hrs of presenting to hospital)
& continue with 75mg daily Clopidogrel only if Aspirin allergic
IF YES,
d/w Stroke consultant [bl ……] NOW
initial
IF YES, d/w Neurology Sp.Reg in DCN
give Nimodipine 60mg oral 4hrly [iv if no swallow]
once REQUESTED these ROUTINE INVESTIGATIONS (if in bold to be performed in all patients)
FBC
ESR
If > 50mmHg
N Y: IF YES, consider endocarditis or arteritis
U & E’s, LFT’s
If urea raised
N Y: IF YES, adjust fluid regime
If LFT > x
N Y If YES, do NOT prescribe a statin
Random Glucose
If >7.0mmol/l
N Y: IF YES, arrange fasting glucose
If in AF
ECG
N Y: IF YES, control HR
Chest X-ray
initial
N Y
initial
initial
initial
initial
initial
initial
initial
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139
ICP for Acute Admission following SUSPECTED STROKE v3.5, post mdt 25/08/06
Phase 2 – planning for transfer to ward
Hydration
Drowsy or unsafe swallow
N Y
NHS Lothian
IF YES TO ANY QUESTION
initial when done
initial
Prescribe IV 0.9% Saline depending on state of
hydration. Avoid Dextrose in first 48hrs: 2/4/6 rule
o
Temperature Temp > 37.5 C
N Y
Prescribe Paracetamol 1g 4-6 hrly oral / IV / PR
Take blood cultures, look for & treat infection
initial
Blood Sugar Glucose >11mmol/L
(4hrly BM’s)
N Y
Prescribe dextrose / potassium / insulin infusion (see
GKI ICP)
initial
Not mobilising independently N Y Consider CLOTS trial enrolment (unless PVD,
DVT
neuropathy or ulcers). Avoid Heparin
prophylaxis
initial
Swallow
screen
Swallow screen failed
N Y
Referral to S. & L. T., consider need for medications,
fluid & food
initial
Continence
Incontinent of urine
N Y
Avoid urinary catheterisation unless renal failure, skin
broken or acute urinary retention
initial
Positioning
Perform Moving & Handling
Assessment
Nurse 30o Head-up if drowsy or NG fed, & Physio
referral prior to transfer (if not for transfer on bed)
initial
Nutritional
screen
Complete nutrition screen
Document weight
Consider Modified diet or NG feeding at 24 hrs and
referral to Dietitian
Initial
Clinical
Trials
consider : CLOTS - Y /
Trial C - Y / N/A
IF ISCHAEMIC STROKE
Carotid Duplex scan
Transthoracic
Echocardiogram
24 Hour ECG
Secondary
prevention
N/A
Trial B - Y /
Trial D - Y /
N/A
N/A
or
Initial
& include date / time sent
If TIA or minor non-disabling stroke & considering endarterectomy
initial
If in AF, recent MI, cardiac murmur or bilateral infarcts
Bubble contrast echo if <55 yrs
If arrhythmia suspected
initial
75mg Aspirin, once daily + 200mg Dipyridamole, twice daily
initial
If ischaemic & total
chol>3.5mmol/l
initial
N Y
initial
prescribe Simvastatin* 40mg first choice
* (Pravastatin if already stabilised on warfarin, as Simvastatin interacts)
IF <55yrs old consider the following investigations
or
& include date / time sent
Lupus anticoagulant
3 Green & 1 Red tubes to Haematology RIE
sent
Auto-antibody screen
1 White tube to Immunology RIE
sent
Syphilis serology
1 White tube to Microbiology
sent
Fasting Homocysteine
1 Red tube to Royal Hospital for Sick Children Biochemistry
sent
Trans-oesophageal Echo
d/w stroke consultant
sent
, initial
, initial
, initial
, initial
, initial
TRANSFER to ward & initiation of ‘Continuing Stroke care’ ICP: date ……/ ………/ …….. time …. : ……
Print name
Designation
Initials
Signature
date
1
2
3
4
5
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141
Commence rt-PA Bolus
Admit to CCU
Final Decision to give rt-PA
Yes
CT Scan Suitable for Thrombolysis?
Urgent CT Request
Alert CCU / Bed Manager
Yes
Suitable for Thrombolysis?
• Confirm Time of Onset
• Check NIH Stroke Score
Page Acute Stroke Team
• Stroke Nurse
• SGR
• KJ
FAST Protocol
Yes
No
Acute Stroke Monitoring Protocol
rt-PA Infusion
Avoid Aspirin / Heparin / NG Tube / Urinary Catheter
Dr S G Ramsay November 2006
If TIA:
• Refer to Neurovascular OPC
• Discharge with TIA Pack
Probable TIA
Consent / Assent from Patient / Relatives
• Provide Information Leaflet
No
Admit MAU via Med. Reg.
No
Time of Onset <3hrs
Acute Stroke Patient
ST JOHN’S HOSPITAL CARE PATHWAY
THROMBOEMBOLIC DISEASE
DVT and pulmonary embolism are a spectrum of the same disease
and often co-exist. There are about 20,000 deaths per year from
thromboembolic disease in the UK. The clinical diagnosis is difficult. It
is therefore helpful to follow a process to assess clinical probability and
have an agreed investigative pathway which includes:
Recognition of the symptom complex
• Breathlessness
• Pleuritic chest pain
• Cough
• Haemoptysis
• Syncope (usually indicates major PE).
• The symptoms in isolation are not diagnostic and merely help
support the diagnosis or differential diagnosis.
Determination of the risk factors for thrombosis (risk increases
with age)
Major (5-20)
Surgery
Pregnancy
Orthopaedic
Malignancy
Immobility, e.g. hospital
Previous VTE
FH of VTE
Minor (2-4)
Cardiovascular disease
Oral contraceptive pill
Hormone replacement therapy
Obesity
Travel (>5-6hrs)
Baseline investigations
All patients with suspected pulmonary embolism should have standard
bloods, chest X-ray, ECG and arterial blood gases on admission.
The clinical probability of PE can then be determined:
High probability patients (>80% likelihood of PE)
• Risk factor present.
• Unexplained dyspnoea, tachypnoea or pleurisy.
• Unexplained radiographic changes or gas exchange abnormality.
Low probability (<20%)
• No risk factors.
• Dyspnoea, tachypnoea or pleurisy with possible alternative cause.
• Alternative explanation for radiographic changes or gas exchange.
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Role of D-dimer
D-Dimer is helpful if used according to protocol.
It is not a routine screening test and is best used when there is
suspicion of PE but this is low probability.
Only a negative result is of value and a Vidas D-dimer test < 500 is
negative.
D-dimer tests should not be performed if there is a history of:
• Malignancy
• Recent trauma or surgery
• Active infection
• Pregnancy
• Bleeding
In patients with low probability of PE and a negative D-dimer then PE
can be excluded and an alternative diagnosis determined.
DIAGNOSTIC ALGORITHM
The commonest tests undertaken are CT pulmonary angiography and
perfusion lung scan (occasionally plus ventilation lung scan). In patients
with equivocal results particularly from perfusion lung scanning then
leg imaging or CTPA should be considered to confirm or refute the
diagnosis. CTPA has the advantage of providing an alternative cause
for symptoms in a proportion of patients.
Echocardiography in massive PE may help confirm the diagnosis and
support treatment stratification to thrombolysis if there is evidence of
right ventricular strain.
Pulmonary angiography is now rarely performed and only after
consultation with radiology and the Consultant involved with patient
care.
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SUSPECTED PULMONARY EMBOLISM
Assess Clinical Risk
Symptom Complex
Risk Factors
Chest X-ray, ECG and ABG
Massive PE
Rx
CTPA
Echocardiogram
Positive Rx
PE unlikely
D-dimer
Vidas
PE likely
Chest X-ray
Abnormal
Normal
CTPA
Q-Scan
Negative
Alternative
Diagnosis
Equivocal
Positive Rx
Negative
Alternative
Diagnosis
Negative
Alternative
Diagnosis
Further Ix
Lower limb
TREATMENT
The current recommended approach in uncomplicated PE is initiation
of LMWH - currently weight adjusted S/C Enoxaparin 1.5 mg/kg once
daily and oral warfarin (Fennerty regime). LMWH Heparin should be
started immediately.
For patients with a high risk of bleeding eg post major surgery or in
renal failure then unfractionated heparin should be considered because
of the shorter half life. When unfractionated heparin is used then APTT
must be measured regularly according to protocol.
Oral warfarin can be initiated on the first day and heparin should
be overlapped for a minimum of 5-6 days and until INR has been
therapeutic (>2.0) for 2 days.
Warfarin should be continued for 3 months in patients with PE with a
precipitating factor eg surgery and for 6 months in those with idiopathic
PE or extensive thromboembolic disease. Target INR is 2.5.
Patients with thrombophilia or recurrent disease should be referred to
Haematology for ongoing management.
Thrombolysis should be considered in patients with massive pulmonary
embolism after consultation with a Consultant and the patient should
be managed in a critical care environment.
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Thrombolysis bolus alteplase (rtPA) 10mg IV over 1-2 minutes followed
by an infusion of 90mg over 2 hours (max dose 1.5 mg/kg if weight
is <65kg). Start IV unfractionated heparin once APTT <2.0 at rate if
1000u/hour. Check APTT after 6 hours and aim for ratio of 1.5-2.5.
In the cardiac arrest or peri arrest scenario 50mg of alteplase can be
administered while resuscitation is on-going and attempts to confirm
or refute the diagnosis are arranged.
Outlook is bleak but there are individual patients who have survived.
RUPTURED OR LEAKING ABDOMINAL AORTIC
ANEURYSM
Presentation
• Severe back pain or abdominal pain.
• History of collapse (often with brief recovery).
• Hypotension.
• Large pulsatile mass in the abdomen.
Misdiagnosis
• Renal colic.
• Acute Pancreatitis.
• Perforated intra-abdominal viscus.
i In older patients presenting with renal colic for the first time or
after many years disease free think of AAA.
Risk factors
• Elderly.
• Male sex.
• History of hypertension.
Initial Management
• Radiopage the Vascular Registrar (#6440).
• High concentration oxygen; analgesia - titrate IV morphine in 1mg
increments.
• IV access in the upper limb (femoral lines should be avoided).
• Low volume resuscitation; aim for a systolic pressure of between 60
to 80mmHg (or enough to maintain conciousness).
• Monitoring ECG, BP and pulse oximetry.
• Bloods including x-match (The Vascular Registrar shall initiate the
Major Haemorrhage Protocol).
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145
i WGH blood bank phone is 32419.
RIE blood issue phone is #27501/27502/27503.
SJH bloodbank phone is 53354
Investigations
• Plain CXR and AXR (loss of psoas shadow, calcified aneurysm).
• Portable ultrasound scan if there is any element of doubt regarding
the diagnosis.
(The use of CT scanning to establish the diagnosis of a ruptured/
leaking AAA is both time-consuming and unhelpful.)
Prognosis
Overall >75% mortality and 50% operative mortality.
Hardmans Criteria (guide to overall prognosis)
• Age >76
• Loss of consciousness
• Haemoglobin <9
• Creatinine >180
• ECG ischaemia
3 or more of the above on admission indicates a very poor outcome.
Transfer from WGH or SGH
• The patient should be transferred by the most senior middle-grade
doctor of the receiving speciality. For patients referred to the
waiting Surgeons this will be the SHO or SpR on call for General
Surgery. For patients referred to Medicine (e.g. as renal colic) this
will be the SHO or Specialist Registrar on call for Acute Medicine.
• If a patient requires transfer to the Royal Infirmary, there should
be no delay and all transfers should be ‘blue lighted’ with an
appropriate SHO/Registrar.
i The only definitive management of these patients is early
surgery. It is our aim to maintain cardiovascular stability using
low volume resuscitation to allow transfer, but speed is pivotal to
good outcome.
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MANAGEMENT OF THE ACUTELY ISCHAEMIC LIMB
Presentation
• Pain
• Paraesthesia
• Pulseless
• Power reduced
• Pallor
• Perishing with cold
(all of the above may not be present simultaneously)
Initial Management
• Assessment of the affected and contralateral limb and pattern of
pulses.
• IV access and analgesia - morphine titrated.
• Doppler asssessment.
• Discuss with Vascular Registrar regarding heparinisation and further
investigation.
(In the absence of paraesthesia, significant pain and loss of power
to the limb, many patients may be heparinised and avoid surgical
embolectomy).
Investigations
• FBC, U & E’s, CK, Clotting screen and G & S.
• Duplex examination.
• Angiogram.
(Imaging is avoided if the site of the embolus can be determined
clinically)
Further Management
• Correction of cause (if appropriate) e.g. atrial fibrillation
Prognosis
• Depends on ischaemia time and aetiology.
i The diagnosis of an acutely ischaemic limb is a surgical
emergency. A favourable outcome depends on the speed of limb
reperfusion. Call Vascular Registrar #6440.
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147
HYPERTENSION
Hypertension is common and most patients do not require admission.
The key to its correct management is a slow reduction, even in
hypertensive emergencies. Rapid reduction may result in cerebral
infarction. Hypertension immediately following intracerebral events is
not uncommon, and may aid cerebral perfusion. It does not usually
warrant intervention. Seek expert advice on treatment. See the Lothian
Guidelines for the treatment of hypertension.
Moderate Hypertension: diastolic BP 105-115mmHg
• Secondary hypertension is rare and should not be pursued unless
there are clear clinical or biochemical clues.
• Check fundi, creatinine, ECG for end organ damage.
• Urine dipstick.
• Check for radiofemoral delay, and renal bruits.
• Identify cardiovascular risk factors and treat if necessary e.g.
diabetes, hypercholesterolaemia smoking.
• Follow Lothian Hypertension guidelines.
• Most patients will require more than one agent.
SEVERE: diastolic BP >115mmHg
• Management is similar to that for moderate hypertension although
repeat measurement is less important.
• Patients with accelerated phase (‘malignant’) hypertension should
be admitted to hospital.
• They have evidence of end organ damage.
• Atenolol 50mg oral od if no contraindication, an alternative would
be Nifedipine LA 30mg orally od. The second drug could be added
after 24 hours.
• Ix and Rx as above.
ENCEPHALOPATHY OR INTRACEREBRAL BLEED
• Seek expert opinion.
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Chapter 4
RESPIRATORY EMERGENCIES
SEVERE ACUTE ASTHMA
Presentation
Breathlessness, wheeze, chest tightness and cough. Often in a patient
known to have asthma, but first episode can occur at any age and may be
severe. Onset may be rapid (minutes/hours) or gradual over a few days.
Severe Episode
• Too breathless to complete sentences in one breath.
• Respiratory rate of 25 or more.
• Heart rate of 110 or more.
• PEF <50% of predicted normal or best known (see table in ARAU,
A&E and BTS guidelines).
• Oxygen saturation <92% (depends on FiO2).
Life-threatening Attack
• Unable to talk.
• Sweaty, pale or cyanosed.
• Silent chest on auscultation.
• Feeble respiratory efforts.
• Bradycardia
• Hypotension
• Confusion
• Exhaustion
Management
i Immediate treatment with oxygen, salbutamol nebulised with
8l/min oxygen and systemic corticosteroids (see below) should
be given during assessment with ABGs etc. Aim for SpO2 at least
92%. Contact Respiratory Registrar/Consultant IMMEDIATELY.
• High concentration humidified oxygen 60% via mask initially and
adjust according to ABG.
• IV access.
• Arterial blood gas on oxygen in all patients with severe asthma
(record inspired oxygen concentration).
• Management decisions depend upon clinical state and ABGs.
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149
• Check peak flow and compare to predicted or previous best PEFR:
may be too ill to do this.
i PaCO2
PaO2
[H+]
SEVERITY
Low
Normal
High
Low
Low
Low
Low
Normal
High
Moderate
Severe
Life-threatening
Immediately contact Respiratory Registrar/Consultant and alert
ICU if ABGs indicate life-threatening attack.
• Salbutamol 5mg nebulised in oxygen 8l/minute, repeated every 1015 mins if necessary.
• Prednisolone 40mg orally or
• Hydrocortisone succinate 200mg IV (slowly) if unable to take
orally.
• If no response give salbutamol 5mg plus ipratropium bromide
500micrograms nebulised in oxygen at 8l/minute.
• If no response to repeated nebulised bronchodilators, Respiratory/
Medical Registrar or ICU staff could consider IV magnesium sulphate
2.0g over 20 minutes or IV aminophylline 250mg (maximum 5mg/
kg) by controlled infusion over 20 mins followed by a continuous
infusion.
i Do not use aminophylline without the advice of Respiratory or
Intensive Care specialists.
i Do not give loading dose of aminophylline to patients on oral
therapy. Check the theophylline blood concentration.
i Caution: Magnesium is a powerful vasodilator and may cause
dangerous hypotension in the hypovolaemic or septic patient.
• Chest x-ray - all severely ill patients. Urgent if clinical signs suggest
pneumothorax.
• Calm reassurance throughout is highly beneficial.
• U&Es, FBC, 12 lead ECG should be performed.
ASSESSMENT OF RESPONSE
Clinical Improvement
• Less distressed.
• Decreased respiratory and heart rates.
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• Able to talk in sentences.
• Louder breath sounds on auscultation (may be more wheezes).
• Arterial blood gases must be repeated within 30 minutes if no or
poor response to treatment.
i ABGs should be regarded as a monitor and repeated early
and again if required.
• Pulse oximetry may be used to assess response in patients who
have clinically improved and did not have a high PaCO2 initially. Aim
for SpO2 >92%.
• PEF: repeat 15 and 30 minutes after starting treatment.
• Monitor heart rate and oxygen saturation continuously and measure
blood pressure frequently.
Contact ICU if:
• Deteriorating or not improving.
• ABG worsening.
• Exhaustion
• Confusion, drowsiness, coma.
i Transfer to ICU if respiratory acidosis worsens or develops in
spite of treatment.
Further Management if Improved
• Continue oxygen titrating concentration against saturation/PaO2.
Aim for SpO2 >92%.
• Continue prednisolone 40mg daily orally.
• Regular nebulised salbutamol e.g. 2.5mg-5mg 4 hourly +/ipratropium 6 hrly.
• If immobile thromboprophylaxis with subcutaneous heparin should
be given: see local protocols.
COMMUNITY-ACQUIRED PNEUMONIA
IMMEDIATE MANAGEMENT GUIDELINES
Definition - Acute lower respiratory infection with recently developed
radiological signs.
Diagnosis
Symptoms
• Specific: dyspnoea, chest pain (peripheral/pleuritic or dull central),
cough, sputum (often absent early), wheeze.
• General: malaise, fever, rigors, myalgia.
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Signs
• Tachypnoea
• Tachycardia
• Focal signs: dullness, crackles, bronchial breathing, pleural rub.
• Cough
• Sputum (mucopurulent, rusty or bloodstained).
• Cyanosis
LIKELY UNDERLYING CAUSES
i Type
Organism
Approx. % cases
Typical
Streptococcus pneumoniae
Haemophilus influenzae
Influenza virus
Staphylococcus aureus
Gram negative eg Klebsiella
31
7
7
2
2
Atypical
Mycoplasma pneumonia
Chlamydia psittica
Legionella pneumophilia
10
4
2
No organism found
(most probably pneumococcal)
35
Travel history and animal contact may point to less common
pathogens: seek advice from Respiratory/ID/Microbiology.
ASSESSMENT OF SEVERITY: CURB 65
Prognostic indicators (on admission) of high mortality:
C - new onset confusion.
U - Urea over 7 mmol/l.
R - Respiratory rate 30/minute or above.
B - BP systolic <90mmHg and diastolic <60mmHg.
• Age >65
Two or more of these gives 36 x risk of death: predicts requirement for Intensive Care or High Dependency Care.
• Co-morbidity.
• Multilobar involvement.
• Atrial fibrillation.
If none of these, consider outpatient treatment.
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IMMEDIATE INVESTIGATIONS
•
•
•
•
•
•
ABG (record inspired oxygen concentration).
CXR
FBC, urea & electrolytes.
Blood cultures.
Sputum culture.
If atypical pneumonia suspected, serum for antibodies, urine for
Legionella antigen.
• Throat swab (for virology in viral transport medium)
INITIAL TREATMENT
• Oxygen - high concentration is normally safe in pneumonia; use
enough to relieve hypoxaemia. (monitor arterial pCO2 in patients
with pre-existing COPD and in those worsening).
• IV fluids to correct hypovolaemia and total body fluid deficits and
prevent renal dysfunction.
i Antibiotics: should be started immediately and related to likely
organism and severity of illness.
• Amoxicillin 500mg orally tds suitable for those with CURB-65 score
0-2 who would have been sent home but for social or other reasons
and for elderly patients (as atypical organisms uncommon).
• If not seriously ill but unable to tolerate oral medication: amoxicillin
500 mg tds IV.
• If penicillin allergy: Clarithromycin 500 mg bd oral or IV.
• If severely unwell Ceftriaxone 2g od IV plus Clarithromycin 500mg
bd IV.
• If Staphylococcus is cultured or suspected Flucloxacillin 1-2g 6hourly IV plus Clarithromycin 500mg 12-hourly IV.
• If Mycoplasma or Legionella is suspected Clarithromycin 500mg
12-hourly orally or IV or
• If Legionella is suspected Rifampicin 600mg 12-hourly IV in severe
cases.
Severe CAP
• Clarithromycin 500mg 12-hourly IV or
Co-amoxiclav 1.2g 8-hourly IV or
Ceftriaxone 1-2g daily IV or
Cefuroxime 1.5g 8-hourly IV or
Amoxicillin 1g 6-hourly IV plus flucloxacillin 2g 6-hourly IV
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153
i Clarithromycin must be diluted to 250ml in 5% dextrose or 0.9%
saline and given IV over 1 hour.
i Signs and symptoms do not reliably distinguish
pneumococcal pneumonia from “atypical” pathogens
Legionella or Mycoplasma. Therefore patients with severe
pneumonia CURB 65>3 should receive dual therapy. Dual
therapy is not necessary in mild illness.
• If the patient has already had antibiotics from GP find out what and
for how long. May need to modify treatment accordingly.
• If patient has unusual travel or animal contact history, seek advice
from microbiology or ID.
i Primary resistance to amoxicillin (amoxycillin) in S pneumoniae
is very rare in Lothian (<1%). H.Influenzae causes relatively few
cases and beta-lactamase resistance in this organism remains
uncommon (around 7%), so the routine initial use of antibiotics
stable to beta lactamase (e.g. Co-amoxiclav) is not justified.
• Intravenous therapy is expensive in materials, nursing and medical
time and should only be used when oral therapy cannot be taken
and in severely ill.
i Consult Respiratory Registrar regarding appropriate further
management and transfer to Respiratory Unit care.
REASON FOR FAILURE OF TREATMENT
• Incorrect diagnosis.
• Incorrect antibiotic, or too low a dose.
Not treated for long enough: it takes 48-72h for antibiotics to start
to improve pneumococcal pneumonia.
• Unusual or resistant pathogen: check laboratory report.
• Immunocompromised patient: have less common pathogens, eg
has pneumocystis been considered?
• Complication:
- empyema
- lung abscess
- pulmonary embolism
- cardiac failure (LVF, RVF, both)
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HOSPITAL - ACQUIRED PNEUMONIA
Likely pathogen will depend on previous antibiotic therapy, whether the
patient is MRSA - colonised and other factors. Consult local antibiotic
guidelines or microbiologist for advice.
ACUTE EXACERBATIONS OF COPD
Chronic obstructive pulmonary disease (COPD) is the preferred term.
Acute exacerbations of COPD present as a worsening of the previous
stable situation.
Symptoms
• Increased breathlessness.
• New or increased sputum purulence.
• Increased sputum volume.
• Increased wheeze.
• Chest tightness.
• New or increased ankle oedema.
Important features in the history
• Previous exercise tolerance.
• Social circumstances and quality of life, especially whether living
alone/alone with support/with family; whether housebound.
• Current treatments, including home nebulisers and oxygen
therapy.
• Number of previous admissions in past five years.
• Number of admissions to ICU.
• Previously ventilated?
• Time course of current exacerbation.
• Smoking history.
IMPORTANT SIGNS
• Frankly purulent sputum
• Tachypnoea, wheeze and use of accessory muscles with increased
work of breathing.
• Pyrexia
• Cyanosis
• Confusion
• Peripheral oedema
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Initial Investigations
Priority
• ABGs (record inspired O2 concentration).
• CXR (exclude pneumothorax).
Less urgent investigations
• PEFR and start PEFR chart.
• FBC, U&Es.
• Sputum and blood cultures.
• 12 lead ECG.
INITIAL TREATMENT
• Oxygen: do not give an inspired O2 of more than 28% via Venturi mask
or 2l/min via nasal prongs until arterial blood gases are known.
• Check ABG within 20 mins of starting O2 and within 20 mins of
changing inspired O2. Aim to achieve a PaO2 of >6.6 kPa and H+
of <55. If the PaO2 is responding and the effect on H+ is modest
increase the inspired O2 to achieve a PaO2 >7.5 kPa.
i This applies to this particular group of COPD patients and must
not be extrapolated to other acute conditions such as asthma,
pneumonia, LVF, sepsis and so on.
Bronchodilators
• Nebulised salbutamol 5mg and ipratropium bromide 500
microgrammes should be given on arrival and repeated 4-6 hourly.
• Consider using air compressor and 2l nasal O2.
• For distressed patients more frequent salbutamol nebulisers may
be given.
• For the improving patient the ipratropium may be discontinued.
• If the patient is not responding to repeated nebulised bronchodilators
IV aminophylline may be considered by the Respiratory/Intensive
Care Specialist. Controlled IV infusion of 250mg (maximum 5mg/
kg) aminophylline over 20 mins only if patient NOT receiving oral
theophyllines).
• NIV - non-invasive positive pressure ventilation via face mask - should
be considered for decompensated patients with hypercapnoea and
acidosis H+>55nmol/l: discuss with Respiratory/ Intensive Care
Specialist.
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Antibiotics
• Amoxicillin (amoxycillin) 500mg oral tds (clarithromycin 500mg oral
bd in penicillin allergic subjects).
If patient has severe infection, or has bronchiectasis: seek specialist
advice.
Other measures
• Prednisolone 40mg oral daily should be given unless there are
contraindications to steroids.
• Hydrocortisone 200mg IV may be given initially if the oral route is
not appropriate.
• Diuretics are indicated if there is peripheral oedema and/or raised
JVP.
• Atrial fibrillation with an uncontrolled ventricular rate should be
treated with digoxin.
• If immobile thromboprophylaxis with subcutaneous heparin should
be given: see local protocols.
THE SICK PATIENT
The Respiratory Registrar (and as appropriate, Consultant) on call
should be involved in the management of these patients. Ventilation
(IPPV - intermittent positive pressure ventilation via ET tube - on ICU or
NIPPV on the Respiratory Unit or HDU of WGH or in HDU at RIE and
SJH) may be required for patients with a H+ >55nmol/l and/or a rising
PaCO2.
FACTORS TO ENCOURAGE USE OF IPPV
• Demonstrable, remedial reason for current decline (e.g. pneumonia).
• First episode of respiratory failure.
• Acceptable quality of life or habitual level of activity.
FACTORS TO DISCOURAGE USE OF IPPV
• Previous severe COPD, fully assessed but unresponsive to
therapy.
• Poor quality of life (e.g. housebound) despite maximal therapy.
• Severe co-morbidities.
Discuss with Respiratory and ICU Consultant on call if any doubt.
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PNEUMOTHORAX
i Tension pneumothorax is an EMERGENCY and requires immediate
treatment by inserting a 14G cannula in the 2nd intercostal space
in the mid-clavicular line on the affected side. A formal chest drain
can then be sited. Otherwise treatment is based on the symptoms,
degree of pneumothorax, and underlying pathology.
SPONTANEOUS PNEUMOTHORAX
If the lungs are normal:
• Aspirate if complete collapse - aspirate in 2nd intercostal space,
mid-clavicular line with an 18G cannula, 50ml syringe and 3 way tap.
This should follow explanation, skin cleansing and infiltration of the
site with adequate 2% lidocaine (lignocaine). If the pneumothorax
resolves or is rendered small the procedure has been successful.
Repeat once only.
• Moderate collapse (degree of collapse: small = a rim of air; <2 cm
air moderate = 2cm rim; complete = airless lung).
• Admit to Respiratory Unit for observation. May be discharged within
24 hours.
• If small, uncompromised and a sensible patient discharge and
review with CXR within one week. Must be advised to return
immediately if less well or more breathless.
If the lungs are abnormal:
• Aspirate if moderate/complete collapse, or if smaller pneumothorax
but breathless or compromised. Compromise includes tachypnoea,
hypoxaemia/low SpO2 and/or signs of tension.
• If <50% collapse and patient not dyspnoeic or compromised
observe as an inpatient (refer to Respiratory Unit).
STOP aspiration if:
• More than 2.5 litres aspirated.
• Resistance is felt.
• Excessive coughing.
Chest drains are required for the following:
• Tension pneumothorax.
• Symptomatic patient with underlying lung disease.
• Failed aspiration (unsatisfactory resolution of pneumothorax or
breathlessness).
• History of chest trauma (includes CVP line and CPR related
pneumothorax).
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TENSION PNEUMOTHORAX
This is a clinical diagnosis associated with:
• Chest trauma including CPR.
• Positive pressure ventilation, especially with poorly compliant lungs.
• Rib fractures.
• CVP line insertion (and attempts) and insertion of pacemaker.
• Severe airways obstruction e.g. asthma.
Signs
• Cyanosis/low SpO2/low PaO2.
• Hypotension with raised JVP or CVP.
• Raised airway pressures (if ventilated).
Diagnosis is NOT radiological but is clinical
• Tracheal deviation away from side of other signs.
• Reduced air entry, reduced expansion and hyper-resonance to
percussion on side of pneumothorax.
Action
• 100% oxygen.
• 14G cannula inserted perpendicular to skin in 2nd intercostal space,
mid-clavicular line.
• Give analgesia.
• Formal intercostal drain insertion.
• CXR to check position and re-expansion. Adjust position of chest
tube if required.
INTERCOSTAL DRAINAGE TUBE INSERTION
i Respiratory Unit staff can be contacted for insertion of
intercostal drain.
• Oxygen and IV access. Atropine should be available as profound
vagal stimulation, with resulting bradycardia, can occur during
pleural manipulation.
• Explain the procedure to the patient.
• Premedicate anxious patients with midazolam 1mg to 2.5mg IV
or diazepam 5mg to 10mg sublingually (ordinary tablets dissolve)
unless the patient is in respiratory failure. Flumazenil should be
immediately available.
• Analgesia including morphine should be considered.
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• Look at the CXR and mark intubation site (4th or 5th ICS in midaxillary line) with pen on patient’s chest.
• Place the patient supine (20-30 degrees) with the patient’s ipsilateral
arm behind head.
• Wash hands and put on gown and gloves.
• Clean the lateral chest wall, drape it and infiltrate skin then down to
parietal pleura with 1% lidocaine (lignocaine) 10-20ml, using a blue
then subsequently a green needle aspirating intermittently (look for
air in syringe to confirm that the pleural space has been entered).
• In many patients insertion of a small chest drain by the Seldinger
technique using, for example, the Sims-Portex system may be
appropriate: see product inserts and video for details of technique.
• Select a 20-24 French guage chest drain tube (adult) using a smaller
size for pneumothoraces and larger for fluid. • Check all drain connections and make sure the underwater bottle is
prepared with fluid before inserting the chest drain.
• Make a small transverse incision into skin and subcutaneous fat at
the intercostal space below that selected for insertion of the tube.
• Using blunt dissection afforded by spreading forceps between
the skin and chest wall, a subcutaneous track is developed to the
level of the selected intercostal space. The intercostal muscles
are separated over the edge of the rib below (remember the
neurovascular bundle runs in a groove on the inferior surface of the
rib) and the parietal pleura is gently penetrated (Fig 1).
• The tip of the finger is then inserted through the skin incision and
pleural penetration is verified, and a gentle finger sweep ensures
that the lung is not adherent to the chest wall.
• Insert the clamped chest drainage tube (with the trocar removed)
through the prepared track using forceps to guide it apically (Fig 2).
• Never force the chest drain in.
• Connect drain to underwater seal bottle, release clamp (look for
bubbling and swinging of water column confirming position in the
pleural space) and secure drain with 2/0 suture (one loop through
skin and at least four ties on tube).
• Apply dressing (swabs and elastoplast), loop tube and secure with
further plaster (Fig 2).
• CXR
• Instruct the patient to keep water bottle below waist level, and
prescribe adequate analgesia.
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PLEURAL DRAINAGE - FIGURE 1
SALIENT POINTS OF CHEST DRAIN INSERTION
Reassure and prepare
the patient (note position of suture)
Lung
Visceral
pleura
Rib
Incision
Lower end
of suture
Parietal
pleura
Intercostal
muscle
Form dissection
with forceps
See
next
page
'Load' chest drain
onto forceps
Ensure that there is a
space between the visceral
and parietal pleura
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161
PLEURAL DRAINAGE - FIGURE 2
Use the forceps to
guide the chest drain
through the dissection
into the pleural space
Apply dressing along the
line the line of the ribs
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MANAGEMENT OF CHEST DRAINS
• CXR post-insertion to check position and ensure re-expansion.
• Once bubbling has stopped for 24hrs AND CXR shows lung reexpansion remove the drain.
i NEVER routinely clamp a chest drain: only clamp a chest drain if
the bottle breaks or the tube becomes disconnected.
• Repeat CXR after removal and if lung collapsed again discuss with
Respiratory Registrar (if not already).
• If lung not re-expanded repeat CXR next morning. If still not reexpanded and drain bubbling discuss with Respiratory team.
• If drain not swinging or bubbling then it has either come out or is
blocked: check the drain. If drain has come out and is still needed
the drain tube should be removed and a new drain inserted with full
aseptic technique.
i Never replace the drain through a previous insertion site.
• If still bubbling at 24hrs consult Respiratory Registrar. Consider
low-grade suction (5-10cm H2O). Do not use a standard wall kPa
suction pump.
• If subcutaneous emphysema check the drain is not blocked.
• Great care should be taken to insure that tubing between the chest
drain and the underwater seal bottle does not disconnect.
TROUBLESHOOTING
Fails to swing
• Check connections.
• Check CXR and if drain blocked or outside pleural cavity remove.
• Replace only if lung not up.
Bubbling at 24hrs
• Check position (as above).
• Check connections.
• Check entry wound is not sucking in air.
If a patient with a chest drain in situ requires transfer by ambulance a
trained nurse with experience in the management of chest drains must
be part of the escort.
Discuss with Respiratory team if requiring suction or any
problems.
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Chapter 5
GASTROINTESTINAL EMERGENCIES
ACUTE UPPER GASTROINTESTINAL BLEEDING
• Common emergency.
• 10% mortality in the UK.
• Presentation with haematemesis and/or melaena, and with shock
or collapse.
• Syncopal symptoms such as dizziness or weakness may be
present.
AETIOLOGY
• Peptic ulcer
• Varices
• Oesophagitis
• Mallory-Weiss tear
• Vascular malformation
• Gastritis
FREQUENCY
50%
5-10%
10% *
5%*
5%*
15%*
* usually respond to conservative therapy and are not life-threatening.
MANAGEMENT OF HAEMATEMESIS AND MELAENA
Standard initial assessment and management of the ill patient as
described in Chapter 2.
Immediate action for all
• Oxygen
• Secure adequate IV access.
• IV fluids: 0.9% saline or colloid.
• Avoid saline in liver disease.
• Send bloods (below) including cross-match.
• 12 lead ECG in elderly/history of cardiac disease.
• Keep NBM. Consent for endoscopy will be obtained by endoscopist
or other GI staff. Note any previous history of DU or GU, NSAID,
anticoagulants, liver disease or dyspeptic symptoms.
• Look for evidence of chronic liver disease such as jaundice or
spider naevi. If present refer to the GI Registrar and commence
resuscitation (below).
i In all patients ascertain the severity of the bleed and at risk
factors: risk stratify.
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Features of a major bleed?
• Tachypnoea
• Tachycardia >100 bpm.
• Hypotension SBP <100mmHg supine or postural drop at any stage.
Relate BP to the patient’s normal e.g. hypertensive.
• Clammy, cold and peripherally shutdown.
• Conscious level reduced/confusion.
• History of syncope.
Is the patient at Significant Risk of Death?
• Hypotensive after initial resuscitation.
• Variceal bleed likely.
• Obvious signs of chronic liver disease or deranged clotting indicative
of liver disease.
• Continuing melaena, haematemesis, or rebleed.
• Existing co-morbidity e.g. IHD, renal failure, disseminated
malignancy.
• Age >60 years.
Complicating factors
• Co-morbid disease e.g. cardiovascular, respiratory, renal, malignancy.
• Rate limiting drugs prevent compensatory tachycardia
e.g. ß-blockers, verapamil.
• Vasodilators prevent compensatory vasoconstriction, e.g. ACE
inhibitors.
TREATMENT AND ASSESSMENT
SHOCKED PATIENT
• High concentration oxygen, at least 60%.
• IV access with two large bore cannulae 16G or bigger.
• Draw blood for FBC, PTR/clotting, U&E, LFTs, blood for CROSS
MATCH at least 4 units of red cells. Alert BTS: consult Major
Haemorrhage protocol (Appendix 3).
• Commence IV fluids: 0.9% saline or Gelofusine 10-20 ml/kg (5001000ml).
• Use O negative blood if patient exsanguinating or unable to keep
BP above 100mmHg systolic, and more than 1 litre of colloid given
(see next page).
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165
• Monitor closely: ideally ECG and pulse oximeter for continuous heart
rate and oxygen saturation readings with frequent BP measurement
e.g. every 5 mins. Consider need for HDU/ICU referral and invasive
monitoring: elderly, co-morbid disease and severe bleed are
indications.
i A large bore femoral venous line can be invaluable for rapid fluid
infusion.
• Refer to GI Registrar.
• ABG for oxygenation and base deficit (i.e. the severity of bleed). • Get Hb and K+ results early.
• A urinary catheter should be inserted.
• Nasogastric intubation is not necessary.
If features of circulatory compromise persist after the initial bolus of
fluid commence blood transfusion. If available use type-specific or
cross-matched blood. If not, use O Negative blood: this is kept in
the blood fridge in clinical chemistry, WGH and in A&E in RIE and in
Haematology laboratory at SJH. Inform Blood Transfusion that it is a
significant bleed: consider triggering Major Haemorrhage protocol.
• Use a blood warmer if large volumes are to be given. A ‘Level One’
blood warmer is available from main theatre WGH, and A&E and
Theatres, RIE; A+E and Theatres at SJH.
• Coagulopathy should be corrected using FFP.
• Early endoscopy should be performed for all large bleeds and suspected
varices but the patient must be adequately resuscitated first. Guidelines
for endoscopy in high risk patients are available in theatre.
i Rebleeding is a major predictor of death.
Modified Rockall Score is a means of assessing risk of rebleed
and mortality following non-variceal upper GI bleeding. Total (preendoscopic + endoscopic) score of 0 or 1 implies 0% mortality and
therefore discharge should be safe. Calculation of the pre-endoscopic
score is as follows: (add scores for each line).
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0123
Age
<60
Shock
Systolic>100 Systolic>100 Systolic<100
Pulse<100
Pulse>100
60-79
Co-morbidity None
>=80
Heart failure
IHD
Major
Cormorbidity
Renal failure
Liver failure
Disseminiated
Malignancy
• A Rockall score of 1-2 suggests a mild bleed and a score of greater
than 2 a major or severe bleed. There is 50% mortality with a Rockall
score of 7.
• In SJH if Rockall score is 0 or 1 the patient is admitted there and
OGD performed at the latest the next day. If the Rockall score is 2
or greater the patient is transferred to RIE (following appropriate
assessment and resuscitation).
VARICEAL BLEEDING
i Contact GI Registrar.
• Resuscitate as above: avoid saline, use colloid and IV dextrose 5%
and FFP as required.
• Monitor cardiac rate and rhythm, BP and oxygen saturation.
• Give terlipressin 2mg IV then 1-2mg IV every 6 hours until bleeding
is controlled, for up to 72 hours. Caution in ischaemic heart disease,
peripheral vascular disease and unresuscitated patients.
• A Sengstaken-Blakemore tube may be necessary for massive or
ongoing bleeding. It is available in the Resuscitation room in A&E
and ARAU.
i Sengstaken-Blakemore tube is only for use in dire situations.
It should be placed only by the GI team or other senior
staff experienced in its use, therefore get help. The patient
should be discussed with anaesthetics re intubation prior
to placement of tube if possible. In general patients with
Sengstaken tubes in situ, should not be transferred between
hospitals unintubated.
• The gastric balloon is inflated with 300mls of air and the tube held
in place with two tongue depressors taped together and padded
(to avoid pressure on lips). CXR should be performed to confirm
correct position.
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• Inadequate placement of Sengstaken tube confers no benefit but
has risk of major complications e.g. oesophagael perforation.
• Prophylactic antibiotic: Ceftriaxone 1g od IV
• Discuss further interventions e.g. TIPSS with GI Registrar/Consultant
if not already referred.
MANAGEMENT OF UPPER GI HAEMORRHAGE: SUMMARY
MAJOR BLEED: HIGH RISK
Pulse > 100
Systolic BP < 100mm Hg
Hb < 100 g/L
EMERGENCY (OUT OF
HOURS) ENDOSCOPY
Contact GI Registrar
RESUSCITATE
As above
LIKELY VARICEAL: HIGH RISK
Stigmata of liver disease
Abnormal LFTs, clotting
RESUSCITATE
As above
EMERGENCY (OUT OF
HOURS) ENDOSCOPY
Contact GI Registrar
MINOR BLEED: LOW RISK
Pulse < 100
Systolic BP > 100mm Hg
Hb > 100 g/L
OBSERVE
2 hrly observations
i ENDOSCOPY ON NEXT
ELECTIVE LIST
Contact GI Registrar
An intravenous proton pump inhibitor is only indicated in
patients who have active bleeding or stigmata of recent
haemorrhage at endoscopy.
ACUTE ON CHRONIC LIVER FAILURE
General points
• Avoid hypoxaemia, hypotension, and hypoglycaemia (2-4hrly BM
measurement).
• Lactulose 30ml oral tds is beneficial in early encephalopathy. Titrate
to produce 2 to 3 bowel movements daily. Use phosphate enemas
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in more severe cases or if unable to take lactulose.
• Blood, urine and ascitic fluid cell count and culture if encephalopathic
and in all cases on admission.Cell count: WBC>250/microlitre is
suggestive of spontaneous bacterial peritonitis.
• Establish if there is a history of drug misuse, blood product transfusions,
hepatotoxic drug ingestion, alcohol abuse or foreign travel.
• Clinical assessment: note the presence of jaundice, ascites,
encephalopathy, spider naevi, pruritis, bruising, splenomegaly,
rashes or arthritis.
• Try to ascertain what has precipitated this episode.
Consider: bleeding
infection
drugs, particularly diuretics or sedatives
electrolyte disturbances e.g. hyponatraemia, hypokalaemia
Investigations to consider
• FBC, U&E, glucose, phosphate, LFT, PT, AFP.
• Venous blood cultures, MSSU.
• Viral hepatitis screen.
• Autoantibody profile.
• Paracetamol level.
• Ascitic tap for bacteriology (Gram stain, cell count and culture), protein.
• USS of abdomen.
FULMINANT HEPATIC FAILURE
i Always check for PARACETAMOL OVERDOSE in patients presenting
with acute liver failure or unexplained metabolic acidosis.
The commonest causes of acute liver failure are paracetamol poisoning
and viral hepatitis. Patients with liver failure may present in a variety
of ways. They may show non-specific features such as confusion,
sepsis, or shock. Specific modes of presentation are with ascites or
encephalopathy, and the management of these is detailed below.
i Early ICU involvement for airway protection, ventilation,
haemodynamic monitoring and resuscitation may be
necessary. At the same time early referral to the Scottish Liver
Transplantation Unit is crucial (22068 in RIE). GI/Liver registrar
on bleep #6361 or via switchboard RIE. Referral criteria in ARAU/
WGH, A&E and Combined Assessment Units.
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DEFINITIONS
Hepatocellular failure is the result of impairment of hepatocyte function,
which manifests itself in a variety of ways, either encephalopathy, in
acute liver failure, or encephalopathy or ascites in chronic liver failure.
Acute liver failure
• Presents as hepatocellular jaundice, elevated transaminases, and
prolongation of the INR, in the context of acute liver injury, e.g.
acute viral hepatitis.
• This is complicated by hepatic encephalopathy.
• Encephalopathy occurs within 8 weeks of onset of jaundice (first
illness).
• Risk of hypoglycaemia and raised intra-cranial pressure (ICP).
Chronic hepatocellular failure occurs when there is decompensation
in a chronic liver disease, presenting either with ascites or
encephalopathy.
ENCEPHALOPATHY: Grading of Hepatic Encephalopathy
• Grade 1 Mildly drowsy with impaired concentration/number
connection test.
• Grade 2 Confused but able to answer questions.
• Grade 3 Very drowsy and able to respond only to simple
commands.
• Grade 4 Unrousable.
DECOMPENSATED CHRONIC LIVER DISEASE
•
•
•
•
•
Hypoglycaemia and raised ICP uncommon.
Causes and management differ.
Repeated assessment and documentation of GCS is very useful.
Identify and treat infection or bleeding, and stop precipitant drugs.
Paracentesis or diuretics can precipitate encephalopathy
(hypokalaemia, hyponatraemia).
• Diagnostic paracentesis to exclude spontaneous bacterial peritonitis
(i.e. >250 polymorphs per microlitre) of ascites.
• In patients with encephalopathy treat with lactulose 30ml oral
tds titrated to produce 2 to 3 bowel movements daily, and use
phosphate enemas if patient unable to take oral lactulose.
• Ensure good nutrition, correction of hypoxaemia and electrolyte
abnormalities (including hypophosphataemia).
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• For alcoholic liver disease: thiamine 300mg oral daily is given. In acute/
imminent Wernicke’s encephalopathy or Korsakoff’s psychosis, and in
patients unable to take orally, IV vitamins are given as Pabrinex IV two
pairs (No1 and No2 mixed) by IV infusion in 100ml 5% dextrose over
15-30 mins 8 hourly.
N.B. Risk of anaphylaxis.
• In patients with altered conciousness exclude focal neurology e.g.
subdural haematoma.
• Sedation should be avoided if possible. Small doses of haloperidol
e.g. 1-2mg IV may be used in severe agitation.
• Monitor renal function closely as there is a high risk of renal failure.
TENSE ASCITES
• Large volume paracentesis can be performed with IV 20% Albumin
‘cover’, 6g per litre drained or 400ml 4.5% Human Albumin solution
every 3 litres ascites drained.
• Correct intravascular volume before paracentesis: stop diuretics.
• Close monitoring of renal function is required: hourly urine volumes,
daily U&Es.
• Exclude spontaneous bacterial peritonitis by diagnostic paracentesis
cell count, Gram stain, culture and protein.
ACUTE BLOODY DIARRHOEA
Bloody diarrhoea tends to occur in two groups of patients: those with
known inflammatory bowel disease and those in whom bleeding arises
de novo.
• In severe cases hypovolaemia and/or sepsis may result in shock
which should be managed as described in Chapter 2.
• A history of inflammatory bowel disease should be sought. If this is
positive refer to the GI registrar having secured adequate IV access
and sent blood for FBC, ESR, U&E, glucose, albumin, CRP and
LFTs.
• Duration of symptoms: this is an important point as a history of less than
7-10 days suggests an infective aetiology. Ascertain the frequency of
motions/amount of blood, any recent foreign travel, a similar history
amongst friends and family, any recent antibiotic or NSAID use (in last
2 weeks) or abdominal pain. Take a sexual history.
• Examine for abdominal tenderness or distension, arthritis, erythema
nodosum and iritis.
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INITIAL MANAGEMENT
• IV access.
• FBC, ESR, U&Es, glucose, albumin, CRP, LFTs. Group, screen and
save or cross match if appropriate.
• Stool culture
• C. difficile toxin if
a. any antibiotic in last eight weeks or
b. hospitalised within last eight weeks.
SPECIFIC MANAGEMENT
Infective
• Short history, no antibiotic usage.
• Isolate patient.
• FBC and culture stool (and C. diff toxin).
• Maintain “hydration” and observe.
• Ciprofloxacin 500mg oral bd if unwell. Use antibiotics with caution
in probable infective diarrhoea (may worsen outcome in E Coli 0157
infection).
Pseudomembranous Colitis (likely if antibiotic therapy in last eight
weeks)
• FBC and bloods as above.
• Isolate patient.
• Sigmoidoscopy and biopsy.
• Stool culture and C. difficile toxin.
• Monitor pulse, BP, temperature oxygen saturation.
• If ‘toxic’ do AXR looking for toxic dilatation.
• Consider empirical metronidazole 400mg oral tds or 500mg tds
IV if not tolerated orally (alternative is vancomycin 125mg oral
qds only if metronidazole not tolerated or if recently treated with
metronidazole).
• Stop other antibiotics if possible: seek microbiology advice if
antibiotics need to be continued.
• Seek early surgical review if very unwell.
Known IBD
• Exclude infection.
Mild colitis (<4 stools per 24 hours)
• Apyrexial, pulse <90/min, Hb >120g/l, ESR <10mm/hr, small amount
of blood in motion.
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• Known IBD: steroid enemata.
• Diagnosis uncertain: await histology and stool cultures; consider
flexible sigmoidoscopy or colonoscopy.
• DVT prophylaxis (exclude coagulopathy first).
Severe colitis - Refer to GI Unit( >8 stools per 24 hours)
• Febrile >37.5 C, pulse >100/min, Hb <110g/l, ESR >30mm/hr, blood
in motion +++.
• Inform GI Registrar.
• AXR
• Sigmoidoscopy
• Stool cultures.
• IV methylprednisolone 60mg/24hr, given by continuous IV infusion
(can cause dysrhythmias) in WGH or hydrocortisone 100mg IV QDS
in RIE.
• DVT prophylaxis as per local policy.
ACUTE DIARRHOEA
CAUSES
•
•
•
•
•
•
•
•
•
•
•
Infective
Inflammatory bowel disease
Irritable bowel syndrome
Overflow
Antibiotic associated
Clostridium difficile
Malabsorption
Thyrotoxicosis
Laxative abuse
Alcohol
Other drugs e.g. NSAIDs, PPIs
INVESTIGATIONS
• FBC, U&E’s, LFT’s, ESR, CRP; endomysial antibodies, and
haematinics if coeliac disease suspected.
• Stool culture
• Cl difficile toxin if recent antibiotics or hospitalisation. Microscopy
for amoebae and other GI pathogens, (if at risk 3 samples).
• Blood cultures if febrile or features of sepsis.
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•
•
•
•
i •
•
•
•
•
•
Plain abdominal x-ray
Rectal examination
Sigmoidoscopy and rectal biospy
Thyroid function tests
Travel history and suspected food sources must be stated
on lab request form - some pathogens eg Vibrio cholerae are
only looked for if appropriate clinical information
MANAGEMENT
Rehydrate, replacing sodium, potassium, and chloride loss using
oral rehydration fluids.
Isolate if infection is suspected.
Notify suspected food poisoning cases to Lothian Public Health:
7720.
In general infective diarrhoea is not treated with antibiotics.
Consider metronidazole or vancomycin for pseudomembranous
colitis: see above.
If inflammatory bowel disease - refer to GI.
CONSTIPATION
•
•
•
•
•
•
•
A rectal examination must be performed
Evidence of obstruction?
Clinical examination
Plain abdominal X-ray only if suggestion of intestinal obstruction.
Is this acute/recent or chronic?
Check U&E’s, calcium, TFT’s.
Are any drugs implicated e.g. opiates?
Refer to surgeons if obstruction (clinical evidence or on abdominal
X-ray). AVOID stimulants. Use lactulose.
• Barium enema to exclude megacolon.
• Refer to GI team for advice.
• Disimpact with
Glycerine suppositories
Phosphate enema
Arachis oil enema
Picolax
Manual disimpaction (with care)
• Maintain with
Fybogel or lactulose
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• Stimulate with
(Stimulants are best avoided
except in terminal care)
• In refractory cases PEG-
based agents
Senna
Codanthrusate (Potentially
carcinogenic. So only use long-term
in the elderly, or terminally ill)
Movicol 1/2-1 sachet/day titrated
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175
ASSESSMENT OF THE ACUTE ABDOMEN
• Definitions vary but a general one would be disabling abdominal
pain of less than two weeks duration.
• Take a careful history about the onset and progression of pain,
site and radiation, exacerbating and relieving factors, associated
symptoms.
• In general visceral pain is ill-localised and felt in the area
corresponding to the organ’s origin- foregut, midgut or hindgut.
• Irritation of the parietal peritoneum is well localised and responsible
for features of peritonism found on examination-guarding and
rebound or percussion tenderness.
• Any inflammatory pathology will give rise to symptoms of peritoneal
irritation e.g. pain exacerbated by movement; obstruction of a
tubular structure gives rise to colic type symptoms.
• Examine carefully for signs of shock- increased respiratory rate is a
useful early indicator.
• Lie the patient flat and expose the whole abdomen, watching for
excursion with respiration.
• Remember to include examination of hernial orifices and genitalia
and PR.
If the patient is shocked, begin resuscitation at the same time as
undertaking investigations- O2, fluids and iv access, analgesia, catheter
as necessary and call for senior help. See chapter 2.
i
Diagnosis and resuscitation are simultaneous processes in
the shocked patient
Baseline investigations : • Fbc, U&E, glucose, LFTs, amylase, G&S
• ABG, lactate- if unwell
• Urinalysis
• Exclude pregnancy if relevant
• Erect CXR- if possibility of perforation
(only positive in 50%)
• AXR- if obstructed
• CRP- remember can lag behind clinical features
Decisions to be made
• Does the patient require a laparotomy?
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• Is more resuscitation or investigation required?
If the patient is bleeding this will usually need surgical control, but if
the patient is obstructed with metabolic derangement there is normally
time for fluid replacement. This process of preoptimisation needs to be
actively managed and will benefit from management in HDU/ICU.
PITFALLS
• Medical causes of abdominal pain including DKA, pneumonia and
Herpes Zoster.
• Much of the abdominal cavity is not easily accessible to palpation
– the pelvis and much of the supracolic compartment
URGENT SURGERY
• Ensure blood is cross matched if required.
• Operating surgeon should liase with theatre and anaesthetist and
obtain consent from patient if appropriate.
• Make plans for post op care early- will the patient need management
in ICU or HDU.
i ICU and Anaesthetics opinions should be sought early to
allow planning of and delivery of optimal perioperative care.
ACUTE PANCREATITIS
Determine severity of pancreatitis on all patients using modified
Glasgow Score* (see below).
The following investigations should be undertaken daily on all patients
with SEVERE PANCREATITIS for at least 3 days:
•
•
•
•
•
•
•
•
FBC
U&E’s, creatinine
Blood glucose
Serum calcium
LFT’s (LDH must be specified)
Serum albumin
Arterial blood gas (on air initially) only if well enough to tolerate this.
CRP
Initial management in all patients involves:
• nil by mouth
• IV fluids
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177
• urinary catheter and measurement of hourly urine volumes.
Patients with severe pancreatitis may need to be managed in HDU/ICU
and often warrant invasive haemodynamic monitoring.
FURTHER INVESTIGATIONS
• U/S Scan as soon as possible after admission.
• CT Scan is usually needed in all patients with severe pancreatitis
within 10 days of admission and must be a dynamic contrastenhanced scan.
• ERCP should be considered in all patients with severe pancreatitis
thought to be due to the gallstones who do not settle promptly on
conservative management and have evidence of cholangitis.
* modified GLASGOW criteria: a severe attack is predicted if
3 or more criteria are positive.
AGE
arterial PO2
albumin
calcium
WBC
LDH
ALT
glucose
urea
> 55 years
<8.0 kPa (on air)
<32 g/L
<2.0 mmol/l
>15 x 109/l
>600 U/l
>100 U/l
>10 mmol/l (in absence of diabetes)
>16 mmol/l
(A C-reactive protein level over 100 mg/l may also reflect the presence
of a severe attack and can be used to monitor progress and the need
for CT scan).
INTER HOSPITAL TRANSFER BETWEEN UPPER GI (RIE)
AND LOWER GI (WGH) UNITS IN EDINBURGH
• Both units receive “General Surgery” where the diagnosis is either
uncertain or out with the GI tract. Allocation will depend on bed
availability and patient location. Bed Bureau will usually decide
destination.
• Patients assessed in either hospital should have appropriate first
line investigations carried out in that hospital, if feasible, to confirm
diagnosis before transfer, e.g. abdominal ultrasound for suspected
biliary colic and CT abdo/pelvis for acute diverticular disease etc.
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i Discussion must take place at Registrar or Consultant level
only.
• Patients must be stable before transfer and the “transfer form”
(attached) must be completed in all cases. Between arranging
transfer and the patient leaving, the referring team must continue
to ensure resuscitation and ongoing monitoring is taking place, with
regular review and reassessment.
• Patients who are unstable and therefore unsuitable for transfer
should be discussed between consultants.
• In-patient emergencies arising in St John’s Hospital outside those
hours where there are surgeons on site (8am – 6 pm Monday –
Thursday and 8 am – 2 pm Friday) should be discussed initially with
the consultant on-call at the Western General Hospital. Clearly if the
problem is upper gastrointestinal/biliary pancreatic then it would be
more appropriate to contact the consultant at the Royal Infirmary. If
the patient is considered unsuitable for transfer then the consultant
at the Western General Hospital will arrange for that patient to be
seen and assessed at St John’s Hospital. At times discussion may
need to take place between the consultant at the Western General
Hospital and the consultant at the Royal Infirmary to ascertain who
would be best to go to St John’s and what cover we would put in
place in Edinburgh while that consultant is at St John’s.
• Stable patients should not be transferred (where possible)
overnight.
GUIDELINES FOR THE ASSESSMENT OF SURGICAL PATIENT
SUITABILITY FOR TRANSFER BETWEEN RIE AND WGH
Patients present to RIE and WGH. To ensure optimal management and
avoid morbidity some of these should not be transferred but should
be resuscitated, analgesed and operated on where they present e.g
perforated intra-abdominal viscus.
Remember : Identification of the sickest patient is usually straightforward,
but the patient who is ‘compensating’ physiologically may appear
much better than he/she really is.
TRANSFER GUIDELINES FOR ILL PATIENTS
Patient Assessment
• Respiratory rate
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179
•
•
•
•
•
•
Pulse
BP and peripheral perfusion
SpO2
Metabolic state: potassium, base excess/deficit, lactate
Haemoglobin, presence of active bleeding
Pain
ASSESS USING CRITERIA IN BOX BELOW:
IF ALL ACHIEVED OK TO TRANSFER
• RR >10 and <25/min
• Pulse <110/min BP > 110mm Hg systolic Hg (systolic no more than 30
mmHg lower than normal for patient), not peripherally shutdown
• SpO2>96% (on <60% oxygen)
• K+ 3 to 5.5mmol/l
• Base deficit better than -7 (if unwell arterial blood gases should be done)
• Pain controlled adequately
• Appropriate IV access
• Hb>100g/l, not actively bleeding
• The patient should be cardiovascularly stable
If not achieved not ok to transfer
Can correct to figures in box
Do so then Senior opinion about safety of transfer (qv)
Cannot correct easily to
figures in box. Senior
assessment and keep in
that hospital, resuscitate and operate there as appropriate.
Minimum treatment and monitoring
• Oxygen to achieve sats >96%
• IV access and fluids to restore perfusion; x-match and transfuse as
required
• Adequate analgesia with iv opioids and iv anti-emetic
• Correction of potassium imbalance
• Monitor ECG, pulse oximetery, cuff BP, urinary catheter and
output.
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i
•If the patient is considered unstable enough to require the
above then it is questionable that they should be transferred.
•If diagnosis is unclear transfer is unwise.
•A senior surgical opinion should always be sought before
transfer.
•If you are not 100% happy don’t transfer the patient.
•A specific protocol for management of AAA presenting to
WGH is in chapter 3.
Guideline developed by Dr Graham Nimmo with surgical and anaesthetic
cross site group RIE/WGH 1998.
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181
RIE/WGH ACUTE SURGICAL ADMISSION INTERHOSPITAL
TRANSFER PROFORMA
Must be completed by clinician arranging transfer
PATIENT ID
DATE:
Assessing hospital: RIE / WGH
DIAGNOSIS
Criteria to be achieved for transfer
Patient
Criteria fulfilled?
Temp
<40C, no rigors
Pulse
pulse <110
BP systolic >110
Peripheral perfusion warm
Resp Rate
RR>10 or <20
SpO2 SpO2>96% on <60% O2
Hb
K
BM
BHCG
>100g/l
3-5.5
4-10
Negative
H+
pO2
pCO2
BE
>35 or <45
>9 on air
<6 on air
-2 to +2
Adequate IV access? Yes (18G or greater)
Y/N
Fluids running? Yes
Y/N
Pain controlled?
Yes
Y/N
Active bleeding?
No
Y/N
Anticoagulated?
INR<4
Y/N
Perforation?
No
Y/N
Time of transfer
GUIDELINES FOR TRANSFER
IF CRITERIA ACHIEVED, for transfer after discussion specialist registrars at
each hospital or consultants.
IF CRITERIA NOT ACHIEVED, NOT FOR TRANSFER
Can correct parameters to acceptable
range. Then Consultant Opinion
about safety of transfer
Cannot correct parameters easily
Senior assessment
Keep in original hospital
Resuscitate & operate as appropriate
Clinician accepting transfer:
Name
Designation
Clinician arranging transfer:
Name
Designation
Signature
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Chapter 6
RENAL, METABOLIC AND ENDOCRINE EMERGENCIES
ACUTE RENAL FAILURE
Acute renal failure (ARF) is an abrupt decline in renal function
which is usually reversible. It is recognised by the accummulation of
waste products (urea, creatinine), with the development of electrolyte
disturbance (hyperkalaemia) and metabolic acidosis. A decline in urine
output (oliguria) is usually found. ARF is commonly caused by acute
cardiovascular failure.
CLASSIFICATION OF ARF
PRERENAL: compromise to renal perfusion and oxygen supply
commonly due to hypovolaemia or hypotension. Reversible with early
resuscitation. Effects can be potentiated by a number of medicines
including non-steroidal agents and ACE inhibitors or AII antagonists
which should be stopped. If strong indication for ACE consider restarting
following recovery with close monitoring of renal function.
OBSTRUCTIVE: blockage to urinary flow. • Ureteric/urethral as in prostatic hypertrophy or bladder/ureter
blockage as a result of tumour, stone, clot or stricture.
• Renal tubules/pelvis, ureters with myoglobinuria, haemoglobinuria,
crystal formation, myeloma and papillary sloughing (e.g. diabetes).
Uncommon.
INTRINSIC: damage to the renal parenchyma.
Intrinsic Causes of ARF
Nephrotoxins
• Drugs: NSAIDs, aminoglycosides, paracetamol in overdose.
• Poisons: methanol, ethylene glycol.
• Contrast media.
Specific conditions
• Vasculitis/glomerulonephritis: is there a history of skin rash,
arthralgia/arthritis, rigors?
• Accelerated phase hypertension.
• Interstitial nephritis: follows a period of drug exposure in most
instances.
• Infections: legionella, leptospirosis, malaria.
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VASCULAR: renal artery disease and aortic atheroma/cholesterol
emboli. Cholesterol emboli commonly follow intervention e.g.
angiography or on commencement of anticoagulation.
MANAGEMENT
Approach to ARF
• Stabilise the patient whilst trying to improve or protect renal function
by identifying potentially reversible factors.
• Seek underlying cause of ARF.
• Immediate concerns are hypoxaemia, blood volume abnormalities
(hypovolaemia or fluid overload), hyperkalaemia, metabolic acidosis.
IMMEDIATE TREATMENT
• Correct hypoxaemia.
• IV access. Remember sites in upper limbs may be required for
fistulae and consider using only one arm for cannulae and blood
sampling (remembering potential pitfalls of blood dilution).
• Treat hyperkalaemia (see below).
• Correct volume status. If shocked commence resuscitation and
refer to ICU.
i The combination of shock and acute renal failure has a high
mortality.
• Insert a urinary catheter and measure hourly volumes.
• CVP measurement may help in monitoring volume replacement.
i Do not give loop diuretics unless there is a positive reason such
as severe fluid overload.
• Stop nephrotoxins including drugs which may be a factor in ARF
and hyperkalaemia.
• Treat metabolic acidosis: discuss with senior medical staff.
• In WGH/SJH if hyperkalaemia requires urgent renal replacement
therapy (haemodialysis/haemofiltration) the first treatment should
be performed in ICU before transfer to Renal Unit RIE. Contact
ICU.
Indications for urgent dialysis or haemofiltration: the clinical state
of the patient should be taken into account before commencing
renal replacement therapy.
• Refractory and severe hyperkalaemia.
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•
•
•
•
i Fluid overload with pulmonary oedema, refractory to diuretics.
Severe metabolic acidosis.
Pericarditis
Renal replacement also indicated if urea and/or creatinine are
markedly elevated. Discuss with the renal registrar.
Call Renal Registrar page #6394 in RIE, ICU in WGH or SJH
- seek advice early.
INVESTIGATIONS
• U&E (including total CO2), creatinine, glucose, FBC, clotting screen,
group, screen and save, blood cultures.
• Plasma CK and urinary myoglobin (if available).
• ABGs
• Blood film for red cell fragments.
• Ca, PO4, LFTs, albumin.
• Urate
• Glomerulonephritis screen where appropriate.
• Viral screen.
• Urinalysis
• Urine sodium and osmolality: interpretation is complicated by prior
administration of IV fluids or diuretics.
• Urgent ultrasound of kidneys: size, number, obstruction, aorta.
i All patients with acute renal failure should have USS of renal
tract. Timing will depend on clinical presentation.
FURTHER MANAGEMENT
• If oliguria persists or biochemistry worsens renal replacement
therapy (haemodialysis or haemofiltration) may be required: discuss
with the Renal Registrar RIE or ICU in WGH/SJH.
• Scrutinise the notes, drug charts and review the history.
• Fully examine the patient.
• Look for infection and treat it.
i Remember rhabdomyolysis. Muscle signs and symptoms are only
seen in 50%, and myoglobin is absent from urine in about 30%.
Causes include trauma, burns, compartment syndrome, epilepsy,
drugs (including self-poisoning), coma with hypotension, falls and
ischaemic limbs.
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185
• Examine the urine: proteinuria and haematuria may indicate
glomerulonephritis and urgent renal referral is obligatory. Look for
skin rash, nail changes, arthralgia and history of rigors.
• Don’t delay referral as early diagnosis and appropriate treatment
such as immunosuppression/plasma exchange may save renal
function. GN bloods include anti-nuclear factor, anti neutrophil
cytoplasmic antibody, anti-glomerular basement membrane
antibody, rheumatoid factor.
• Fluid balance: once volume depletion corrected, and in the
absence of fluid overload, give previous hour’s output (urine and
other losses) plus insensible (about 20-40ml/hr).
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DANGEROUS HYPERKALAEMIA
May cause sudden death with no warning features. Symptoms include
paraesthesiae, circumoral tingling, muscle weakness, malaise. There
may be no clinical signs.
Diagnosis: elevated potassium: absolute level and rate of rise are
important. An abrupt rise of 2 mmol e.g. from 4 mmol/l to 6 mmol/l may
cause arrhythmias whilst some patients with chronic renal failure tolerate
higher levels. Consider level >6mmol/l as potentially dangerous.
i ECG changes may provide the first clue to hyperkalaemia and
its severity. ECG may be NORMAL in presence of dangerous
hyperkalaemia.
CAUSES OF HYPERKALAEMIA
1. Reduced excretion
• Renal failure
Drugs:
• Potassium sparing diuretics: Spironolactone, Triamterene, Amiloride
• ACE inhibitors, angiotensin II antagonists
• NSAIDs
• Hypoaldosteronism: adrenal insufficiency
2. Shift of K+ from cells
• Tissue damage: rhabdomyolysis, trauma, burns, haemolysis, internal
bleeding
• Drugs: suxamethonium, digoxin, ß-blockers
• Acidosis
• Others: hyperosmolality, insulin lack, periodic paralysis
3. Excessive intake
4. Pseudohyperkalaemia
• Thrombocytosis, leukocytosis
• Haemolysis: in vitro or sampling
• Delayed analysis
ECG CHANGES OF HYPERKALAEMIA
•
•
•
•
Prolonged PR interval.
Peaked T waves.
Widening of QRS interval and flattening/loss of P waves.
Sine wave proceeding to ventricular fibrillation or asystole.
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1. IMMEDIATE ACTION: STABILISATION
•
•
•
•
•
•
Assess ABCDE and treat accordingly.
Correct hypoxaemia.
IV access.
Continuous ECG monitoring is mandatory.
Monitor oxygen saturation.
Specific treatment depends on ECG changes and potassium
concentration.
• If ECG shows peaked T waves or more severe changes titrate IV
calcium gluconate 10% or calcium chloride 10% in 1 ml aliquots
watching the ECG. The trace will normalise as the calcium takes
effect. If too much IV calcium is given it can result in cardiac arrest
in asystole. The required amount varies from 2 or 3 mls to 20mls. This simply stabilises the myocardium giving time to institute
therapy to reduce the potassium. This may need to be repeated.
• In cardiac arrest follow ALS algorithm and give 10mls 10% calcium
chloride IV. VF will be resistant to defibrillation if calcium not
given.
2. REDUCING THE POTASSIUM
• Bolus IV dextrose 50ml 50% solution with 5-10iu Actrapid (or
equivalent e.g. Humulin S). Takes 20-30 mins to work.
• This can be followed with a slow infusion of 10% or 20% dextrose
running at between 10ml/hr and 50ml/hr. Monitor blood sugar
regularly and add insulin as required.
• Nebulised salbutamol 5mg and repeated.
• Sodium bicarbonate 1.26% IV infusion. Start at 100ml/hr and titrate
to HCO3 and K+ levels. Not for routine use. May help: discuss with
renal registrar RIE or ICU, WGH/SJH.
3. ELIMINATING THE POTASSIUM
• The best way of removing potassium is to restore urine output and
recover renal function.
• Failing this potassium removal by haemodialysis or haemofiltration
may be required. i Stop dextrose and insulin infusions to allow potassium to
re-enter the blood, thus making it available for removal in the
dialyser.
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• In WGH or SJH haemofiltration should be arranged with ICU pretransfer to Renal Unit RIE if the level is high or the patient at risk.
• In potassium poisoning with normal renal function give IV fluids and
furosemide (frusemide) to secure renal potassium loss.
• Ion exchange resins are difficult to administer orally or pr in the
ill patient and take several hours to work. Most useful in chronic
situations or if the patient needs to be transferred a long distance.
Calcium resonium 15g stat oral, then 15g 2 to 3 times daily. An oral
laxative should be prescribed at the same time.
i Use the femoral vein for insertion of dialysis access as cardiac
arrest in VF can be precipitated by the guidewire when using the
internal jugular or subclavian routes.
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189
METABOLIC ACIDOSIS
CAUSES OF METABOLIC ACIDOSIS (MA)
• Tissue hypoxia:
• No tissue hypoxia:
• Anion gap:
shock with lactic acidosis.
loss of or impaired generation of bicarbonate.
acid accumulation (other than lactate).
Na+ + K+ - (Cl- + HCO-3): normal up to
18mmol.
RAISED ANION GAP MA: ‘KUSSSMALE’
•
•
•
•
•
•
•
•
•
Keto-acidosis
Uraemia
Salicylate poisoning, paracetamol poisoning
Severe losses of bicarbonate e.g. diarrhoea, GI fistulae
Starvation
Methanol poisoning
Alcohol i.e. ethanol
Lactic acidosis
Ethylene glycol poisoning
Severe elevation of anion gap >35mmol is usually due to:
• Toxin ingestion e.g. methanol, ethylene glycol.
• Severe shock or cardiac arrest (lactic acidosis).
NORMAL ANION GAP MA
•
•
•
•
•
•
Subsiding DKA.
Renal tubular abnormalities (renal tubular acidosis).
Hypoaldosteronism.
Acute diarrhoea.
Ureterosigmoidostomy.
Acetazolamide.
CLINICAL FEATURES
•
•
•
•
Hyperventilation of Kussmaul type.
Circulatory insufficiency: may be a late feature e.g. in DKA.
Confusion, stupor, coma.
Signs and symptoms of underlying cause.
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Diagnosis
H+ >45 pH <7.35, standard base deficit > -5mmol/l.
Diagnostic investigations: will depend on circumstances
• Glucose
• U&Es
• Blood for ketones.
• Blood lactate.
• Toxins: ethylene glycol, methanol, paracetamol, salicylate, ethanol.
MANAGEMENT
•
•
•
•
•
ABCDE
Correct hypoxia.
Correct circulatory abnormalities: see Chapter 2.
Treat specific causes (see below) e.g. infection, DKA.
Poisoning: methanol, ethylene glycol, salicylate, paracetamol seek
expert advice.
• IV sodium bicarbonate is seldom indicated unless renal failure or
specific poisoning.
• Bicarbonate loss from gut or in renal tubular acidosis: correct
cause, replace fluid and electrolyte losses (especially potassium)
and infuse sodium bicarbonate 1.26% titrated.
i Sodium bicarbonate use should be limited to patients WITHOUT
tissue hypoxia as it has many detrimental effects in anaerobic
lactic acidosis.
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MANAGEMENT OF DIABETIC KETOACIDOSIS
DIAGNOSIS
• Elevated plasma and/or urinary ketones.
• Metabolic acidosis (raised H+/low serum bicarbonate).
Remember that hyperglycaemia, although usually marked, is not a
reliable guide to the severity of acidosis, and in children, pregnant
women, malnourished or alcoholic patients, blood glucose may not be
very raised.
i The degree of hyperglycaemia is not a reliable guide to the
severity of the metabolic disturbance in DKA.
The presence of the following features should alert you to the possibility
of DKA:
• Intra- and extra-vascular volume depletion with reduced skin turgor,
tachycardia and hypotension (late feature).
• Rapid and deep sighing respirations, smell of ketones.
• Ketonuria
• Vomiting/abdominal pain.
• Drowsiness/reduced conscious level.
Remember:
• Consider DKA in any unconscious or hyperventilating patient.
• Patients with adverse clinical signs (on the SEWS chart) or
signs of cerebral oedema (see below) should be discussed
immediately with senior medical staff.
• These guidelines refer to adult patients. All patients under the
age of 16 should be discussed with the paediatric diabetes
team at the Sick Children’s hospital and arrangements made
for transfer when clinically appropriate.
RIE/WGH/SJH have an integrated care pathway which should be
adhered to. The following is the RIE/WGH protocol. The SJH protocol
differs slightly.
IMMEDIATE MANAGEMENT - WITHIN THE FIRST HOUR
Initial Assessment and Treatment
• Airway and breathing - correct hypoxaemia.
• IV access.
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• Monitor respiratory rate, ECG, O2 saturations, pulse rate, BP,
respiratory rate, conscious level and fluid balance.
• Perform laboratory blood glucose, bedside BM, urea and electrolytes,
serum bicarbonate, arterial blood gases.
Fluid Replacement
• Commence fluid therapy with 0.9% saline 1 litre over 1 hour. A
specimen IV fluid regime is shown below.
Intravenous Insulin
• Prepare intravenous insulin infusion (see below) and commence at
6 units/hr.
Other Interventions/Actions
• 12 lead ECG
• NG tube if impaired consciousness or protracted vomiting.
• Urinary catheter if oliguric.
• Admit patient to a high dependency area.
• Consider central line if clinically indicated.
• Call the diabetes registrar and/or senior medical staff.
ONGOING MANAGEMENT - HOURS 2-4
Reassess patient regularly and monitor vital signs
Intravenous fluids
• Aim to rapidly restore circulating volume and then gradually correct
interstitial and intracellular fluid deficits.
• Use isotonic saline (see example below) - infusion rates will vary
between patients, remember risk of cardiac failure in elderly patients.
• If hypotension (SBP <100mmHg) or signs of poor organ perfusion
are present, use colloid to restore circulating volume.
1000mls 0.9% NaCl over 2nd hour
500 mls 0.9% NaCl over 3rd hour
500 mls 0.9% NaCl over 4th hour
• Add in 10% dextrose once blood glucose ≤14mmol/l. Infuse at 100
mls/hr. Do not alternate saline and dextrose.
• Measure U&Es and venous bicarbonate at the end of hour 2 and
hour 4.
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Electrolyte replacement
• Despite a considerable total body potassium deficit (300 - 1000
mmol/l), plasma potassium levels are usually normal or high at
presentation because of acidosis, insulin deficiency and renal
impairment.
• Potassium concentration will fall following commencement of
treatment; expect to have to give plenty of potassium.
• Target potassium concentration is 4.0-5.0mmol/l.
i Severe hypokalaemia complicating treatment of DKA is
potentially fatal and is avoidable.
Potassium Replacement
No potassium in the first litre unless known to be < 3.0 mmol/l.
Thereafter, replace potassium as below:
plasma potassium
< 3.5 mmol/l
3.5 – 5.0 mmol/l
>5.0 mmol/l, or anuric
potassium added
40* mmol/l
20 mmol/l
No supplements
*must be given in one litre of fluid; avoid infusion rates of KCL
>10mmol/hr
• Occasionally Infusion rates of over 10mmol/hr may be required. If
so senior medical staff should decide this and ECG monitoring is
mandatory.
• 40mmol of potassium should be diluted in 1 litre of fluid if given by
peripheral cannula. Use pre-prepared bags with KCl.
Blood Glucose and Insulin
• Hourly laboratory glucose.
• Aim to ensure a gradual reduction in blood glucose over the first
12-24 hours. There is no specific evidence to avoid rapid rates
of fall (e.g. >5mmol/hr), but there are some observational data to
suggest that excessive rates of fall may be associated with cerebral
oedema.
• The target blood glucose concentration for the end of the first day
is 9-14 mmol/l.
• Make up an infusion of 50 units of soluble insulin (e.g. Humulin S
or Actrapid) in 50 mls 0.9% saline (1 unit/ml) and infuse using a
syringe driver.
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Rate of Insulin Infusion
• 6 units/hr initially.
• 3 units/hr when blood glucose ≤14 mmol/l.
If plasma glucose does not fall in the first hour, the rate of infusion
needs increased - phone the diabetes registrar and/or senior
medical staff for advice.
• If blood glucose falls below target (i.e. <9 mmol/l) on 3 units/hr,
reduce insulin infusion to 2 units/hr. Do not reduce the insulin
infusion rate below this. If glucose continues to fall, increase the
infusion rate of dextrose or the concentration. Discuss with the
diabetes registrar and/or senior medical staff.
• Remember that intravenous insulin has a half-life of 2.5 minutes. It
is important that the insulin infusion is not interrupted.
Consider Precipitating Factors:
If indicated check:
• FBC
• CXR
• ECG
• urine gram stain and culture
• blood cultures and other infection screen
Correction of acidosis
• Volume resuscitation and insulin infusion will correct metabolic
acidosis in the majority.
• Ketonaemia typically takes longer to clear than hyperglycaemia.
i Intravenous sodium bicarbonate should not be used routinely
and certainly not without discussing with a senior doctor (no
evidence that it is effective).
Other measures
• Urinary catheter: if cardiac failure, persistent hypotension, renal
failure or no urine passed after 2 hours.
• CVP line: consider if elderly with concomitant illness, cardiac failure
or renal failure.
• Give standard venous thromboembolism prophylaxis according to
local protocols: exclude coagulopathy.
• Antibiotics: only if infection is proven or strongly suspected. Remember
that raised WBC and fever occur with metabolic acidosis.
• Screen for myocardial infarction if > 40 years old.
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SUBSEQUENT MANAGEMENT - 4 HOURS+
Fluids and Electrolytes
• Allow oral intake if swallowing safe and bowel sounds present.
• Measure U&Es and venous bicarbonate twice daily, until bicarbonate
within the normal reference range.
• Continue with 0.9% saline ≤250ml/hour until bicarbonate is in the
reference range and the patient is eating.
• Continue potassium infusion until target is maintained.
Insulin and Dextrose
• A blood glucose meter can be used to monitor blood glucose
concentration if the previous laboratory blood glucose is <20 mmol/l.
• Pre-meal subcutaneous soluble insulin should be administered to
patients who are eating, even when on intravenous insulin. Discuss
the doses with the diabetes team.
• Maintain IV insulin (minimum rate 2 units/hr) and 10% dextrose
infusion (100ml/hr) until biochemically stable and patient has eaten
at least two meals. In such circumstances, stop IV insulin 30
minutes after subcutaneous insulin.
CONTINUING CARE
• Ensure patient is reviewed by the diabetes team on the day
following admission (at the very latest), so that the cause of the
DKA can be elucidated, appropriate education be given and follow
up arranged.
• Patient should not be discharged until biochemically normal, eating
normally and established on subcutaneous insulin.
• Ensure that a copy of the discharge summary is sent to the diabetes
team.
ACUTE COMPLICATIONS OF DKA
• Hypokalaemia: due to inadequate potassium replacement and
predictable due to insulin and fluid administration and resolution of
acidosis. Avoid by regular monitoring of electrolytes and appropriate
potassium replacement.
• Hypoglycaemia: due to over treatment with insulin.
• Hyperglycaemia: due to interruption or discontinuation of
intravenous insulin after recovery without subsequent coverage by
subcutaneous insulin - always ask advice of diabetes team.
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• Cerebral oedema: rare but potentially fatal. More common in children,
but is seen in young adults. Characteristically, the patient has initially
responded well to treatment prior to the development of severe
headache and neurological deterioration. Get urgent senior help:
call ICU. Treatment depends on clinical state and includes mannitol
0.5 - 2 g/kg body weight.
• ARDS: suspect if dyspnoea, tachypnoea, central cyanosis and nonspecific chest signs. Manage ABCDE and call ICU.
• Thromboembolism - prevention and management as standard.
MANAGEMENT OF DIABETIC HYPEROSMOLAR
NON-KETOTIC SYNDROME
• Common in frail elderly.
• High mortality (30%).
• May be previously undiagnosed diabetes, but can also develop in
people with known type 2 diabetes.
• Significant hyperglycaemia: ketonuria and acidosis are usually
absent.
• Acute intercurrent illness is common.
DIAGNOSIS
Typical features include:
• Severe hyperglycaemia (>50 mmol/l).
• Hyperosmolarity (>320 mosmol/kg) with profound dehydration and
prerenal uraemia.
• Depression of the level of consciousness; coma is well recognised.
Plasma osmolality
2 x (Na + K) + urea + glucose (all mmol/l)
normal range is 280 – 300 mosmol/kg
IMMEDIATE MANAGEMENT - WITHIN THE FIRST HOUR
Initial Assessment
• Airway and breathing ensure airway and correct hypoxaemia.
• IV access.
• Monitor respiratory rate, ECG, O2 saturations, pulse rate, BP,
conscious level and fluid balance.
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• Laboratory blood glucose, bedside BM, urea and electrolytes,
serum bicarbonate, arterial blood gases.
Fluid Replacement
• Commence rehydration with 0.9% saline 1000 ml over one hour.
Intravenous Insulin
• Prepare intravenous insulin infusion (see below) and commence at
3 units/hr.
Other Interventions/Actions
• Admit patient to a high dependency area.
• Call the diabetes registrar/senior medical staff.
• NG tube if impaired consciousness or protracted vomiting.
• Catheter if oliguric.
• Consider central line if clinically indicated.
ONGOING MANAGEMENT - HOURS 2-4
Reassess patient regularly and monitor vital signs
Intravenous fluids
• Aim to rapidly restore circulating volume and then gradually correct
interstitial and intracellular fluid deficits.
• Use isotonic saline (see example below) - infusion rates will vary
between patients, remember risk of cardiac failure in elderly
patients.
• If serum sodium exceeds 155mmol/l, use 0.45% saline instead of
isotonic. Discuss with diabetes registrar/senior medical staff.
500 mls saline over 2nd hour
500 mls saline over 3rd hour
500 mls saline over 4th hour
• If hypotension (SBP <100 mmHg) or signs of poor organ perfusion
are present, use colloid to restore circulating volume.
• Add in 10% dextrose once blood glucose ≤15mmol/l. Infuse at
125-250 mls/hr. Do not alternate saline and dextrose.
• Measure U&Es and serum osmolality at the end of hour 2 and hour 4.
Electrolyte Replacement
• Target potassium concentration is 4.0-5.0mmol/l.
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Potassium Replacement
No potassium in the first litre unless known to be < 3.0 mmol/l.
Thereafter, replace potassium as below:
plasma potassium
< 3.5 mmol/l
3.5 – 5.0 mmol/l
>5.0 mmol/l, or anuric
potassium added
40* mmol/l
20 mmol/l
No supplements
*must be given in one litre of fluid; avoid infusion rates of KCL
>10mmol/hr
Occasionally infusion rates of >10 mmol/l are required if so ECG
monitoring is manditory.
Blood Glucose and Insulin
• Hourly laboratory glucose
• Aim to ensure a gradual reduction in blood glucose over the first
12-24 hours. There is no specific evidence to avoid rapid rates
of fall (e.g. >5 mmol/hr), but there are some observational data to
suggest that excessive rates of fall may be associated with cerebral
oedema.
• The target blood glucose concentration for the end of the first day
is 10-20 mmol/l.
• Make up an infusion of 50 units of soluble insulin (e.g. Humulin S
or Actrapid) in 50 mls 0.9% saline (1 unit/ml) and infuse using a
syringe driver.
• 3 units/hr initially
If plasma glucose does not fall in the first hour, the rate of infusion
needs increased - phone the metabolic registrar for advice.
• If blood glucose falls below target (i.e.<10 mmol/l) on 3 units/hr, the
insulin infusion can be reduced to a minimum of 1 unit/hr. Do not
reduce the insulin infusion rate below this. If glucose continues
to fall, increase the infusion rate of dextrose or the concentration.
Discuss with the metabolic/diabetes registrar.
• Remember that intravenous insulin has a half-life of 2.5 minutes. It
is important that the insulin infusion is not interrupted.
Consider Precipitating Factors:
• FBC
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•
•
•
•
CXR
ECG/MI screen
Urine gram stain and culture.
Blood cultures and other infection screen.
Other measures
• Urinary catheter: if cardiac failure, persistent hypotension, renal
failure, no urine passed after 4 hours or impaired consciousness.
• CVP line: consider if elderly with concomitant illness, cardiac failure
or renal failure.
• Thromboembolic complications are common, however full
anticoagulation has been associated with a high risk of GI bleeding.
Patients should receive DVT prophylaxis with LMWH, rather than
unfractionated heparin (unless renal impairment) and should have
TED stockings (unless contra-indicated).
• Nasogastric tube: if consciousness is impaired, to avoid aspiration
of gastric contents.
• Antibiotics: low threshold for use.
SUBSEQUENT MANAGEMENT - 4 HOURS+
Fluids and Electrolytes
• Allow oral intake if swallowing safe and bowel sounds present.
• Measure U&Es twice daily, until within the normal reference range
(or back to usual baseline for that patient).
• Continue with isotonic saline ≤250ml/hour until U&Es back to
baseline and the patient is eating.
• Continue potassium infusion until target is maintained.
Insulin and Dextrose
• A blood glucose meter can be used to monitor blood glucose
concentration if the previous laboratory blood glucose is <20
mmol/l.
• Maintain IV insulin (minimum rate 2 units/hr) and 10% dextrose
infusion (250ml/hr) until biochemically stable and patient has eaten
at least two meals. It is not necessarily the case that the patient
will require subcutaneous insulin; the need for sc insulin or oral
hypoglycaemic therapy should be discussed with the diabetes
team.
Continuing Care
• Ensure patient is reviewed by the diabetes team prior to discharge,
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so that the cause of the HONK can be elucidated, appropriate
education be given and follow up arranged.
• Patient should not be discharged until biochemically normal, eating
normally and established on appropriate therapy.
• Ensure that a copy of the discharge summary is sent to the diabetes
team.
HYPOGLYCAEMIA
PERI-OPERATIVE MANAGEMENT OF DIABETIC PATIENTS
General Principles
Plan Ahead
Admit 1 day before elective surgery for:
• full assessment of risk factors, baseline biochemistry, glucose
profile, ECG.
• optimisation of metabolic control
• formulation of peri-operative management plan with Diabetic
Registrar
• Schedule the patient for surgery (whenever possible) early in the
morning and first on the list.
• Discuss all patients with the anaesthetist and remember that the
Diabetes Team are ALWAYS available to give you help/advice (Page
#6800 RIE, WGH via switchboard, SJH Diabetes consultants).
• If patients have poor metabolic control but require emergency
surgery, discuss with the Diabetes Team.
WHICH PATIENTS NEED PERI-OPERATIVE INSULIN?
• All outpatients being treated with insulin
• All patients having major surgery (most abdominal and thoracic
procedures)
• Any traumatic procedure especially in poorly controlled patients
• All patients undergoing emergency surgery
• All who are acutely ill
HOW SHOULD THE INSULIN BE ADMINISTERED?
GKI or Sliding Scale
The precise method should be discussed with the anaesthetist but is
likely to be either GKI or sliding scale.
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Continuous infusion of glucose (G), potassium (K), and insulin (I) i.e. a
GKI regimen - according to the guidelines set out below.
Proforma for GKI regimen
(1) On the morning of operation, omit breakfast and do not give
subcutaneous insulin.
(2) Before 0800hr measure blood glucose on the ward and send an
urgent blood sample to Clinical Chemistry for plasma urea, electrolytes
and glucose determinations.
(3) If blood glucose < 10 mmol/l commence infusion with
16 units soluble insulin e.g. Human ACTRAPID
10 mmol/l KCl
in 500 ml 10% Dextrose at 100 ml/hr
(4) Less insulin (i.e. start with 12 units) is required in
thin elderly patients
those on less than 30 units/day at home
those who have had previous total pancreatectomy
(5) More insulin (i.e. begin with 20 units) is required in
patients requiring high insulin doses previously ( > 1 unit/kg/day)
patients with intercurrent infection
some endocrine (e.g. acromegaly) and metabolic disorders
(6) If the blood glucose is > 12 mmol/l and rising, the insulin in the infusion
should be increased by 4 units (THIS REQUIRES A NEW BAG)
(7) If the blood glucose is 6 mmol/l and falling the insulin in the infusion
should be reduced by 4 units (THIS REQUIRES A NEW BAG).
If GKI is continued beyond 18 hours
• monitor Urea and Electrolyte levels daily
• adjust K supplement to maintain normokalaemia
• watch for water overload causing dilutional hyponatraemia
• less fluid can be given if 20% dextrose is used with double the
insulin dose but local phlebitis may occur.
• Long term GKI is therefore best given through a central venous
catheter.
Stopping the GKI
• The infusion should be continued until one hour after patient’s first
post-operative meal.
• Subcutaneous insulin is given with this meal - with at least as
intensive a regimen as pre -operatively.
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INTRAVENOUS INSULIN SLIDING SCALE REGIMEN
i Remember, intravenous insulin has a half-life of only 2.5
minutes, so if intravenous insulin is disconnected for any
appreciable length of time, hyperglycaemia will quickly ensue
(unless subcutaneous insulin has been given).
The insulin infusion is prepared by adding 50 Units of Actrapid insulin
to 0.9% saline in a syringe to a total volume of 50ml. Thus, 1ml of the
solution contains 1 unit of insulin. The doses of insulin are adjusted
according to a sliding scale, which is prescribed as below.
BG (mmol/l)
>16
13-15.9
10-12.9
7.0-9.9
5.0-6.9
4.0-4.9
<4
Insulin infusion (Units actrapid/hour = ml/hour)
6 (test urine for ketones, call Dr as the sliding scale may need revision)
4
3
2
1
0.5
off (call Dr, the sliding scale may need revision)
• Capillary blood glucose should be tested every hour. It is crucial
that medical staff monitor the pattern of blood glucose every 2-4
hours as the sliding scale may require modifications to ensure that
blood glucose concentrations remain between 5 and 10mmol/l.
• Commence glucose infusion with 20 mmol/l of KCI - infusion
should run at 50ml/hr. Usually this will be 5% or 10% glucose,
but in some special circumstances (e.g neurosurgery) an infusion
of 5% glucose/0.45% saline is preferred. The anaesthetist will
advise which glucose infusion should be used. If the patient is very
hyperglycaemic, the glucose infusion should be deferred until the
intravenous insulin has lowered the blood glucose to <14 mmol/l.
• The insulin and glucose infusions should both be given through the
same IV cannula, rather than separate cannulae, to avoid the danger
of a blocked cannula resulting in only one of the two being given.
• The insulin syringe should be attached to a ‘PCA giving set’,
incorporating a Y-connector with a one-way valve for attaching the
glucose infusion. The one-way valve prevents insulin being pumped
backwards into the glucose giving set.
• Inform anaesthetist if blood glucose is less than 4 mmol/l or greater
than 16 mmol/l.
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• If capillary blood glucose is greater than 20 mmol/l, take blood
for urgent laboratory glucose and U&E’s (including venous
bicarbonate).
• If blood glucose concentrations are stable and in the desired range,
the frequency of monitoring may be reduced, e.g.to 2 hrly.
• U&E’s and a laboratory glucose should be checked daily while the
patient is on intravenous insulin/glucose.
• Be prepared to vary the KCI content of the intravenous fluids
according to plasma K+ levels. Be especially careful in patients with
renal impairment.
• If patient is on intravenous insulin and glucose for greater than
24hrs, ensure that Hartman’s solution is also given to avoid
hyponatraemia. Remember 10% glucose is hypertonic. This
glucose infusion is not designed for volume replacement, but
glucose control. Extra fluids such as Hartmann’s will invariably be
required and these can be piggy-backed in through a separate IV
infusion line. However, if patients are volume overloaded, discuss
management with the anaesthetist and/or diabetes registrar.
DIABETIC PATIENTS NOT REQUIRING INSULIN
Patients undergoing relatively minor procedures (e.g. hernia repair,
laparoscopic cholecystectomy)
• Treatment is simpler if insulin is not required but frequent blood
glucose monitoring is still essential.
• Check blood glucose pre-operatively to confirm that level < 10
mmol/L (lab analysis).
• Omit usual oral hypoglycaemic agent(s).
• Avoid IV glucose infusion
• On return from theatre repeat blood glucose. If > 15 mmol/l, insulin
may be required.
CAUTION Diabetic patients on metformin are at risk of acute renal failure from
radiological investigations where intravascular contrast material is
given. (CT scan, IVP, angiogram, CTPA etc). Metformin should be
omitted before the procedure and for 48 hours after. Careful watch is
to be kept on the renal function and it should be ensured that patients
remain well hydrated.
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HYPOGLYCAEMIA
INTRODUCTION
• Complication of diabetes most feared by patients.
• Mild hypoglycaemia common in diabetic patients on insulin and is
usually managed by themselves.
• Severe hypoglycaemia is that requiring help from another person to
treat it.
• Unconsciousness caused by hypoglycaemia in hospital setting
requires parenteral treatment.
• Hypoglycaemia is implicated in 4% of deaths in diabetics under the
age of 50 years.
RECOGNITION AND DIAGNOSIS
• Defined arbitrarily as laboratory blood glucose < 3.5 mmol/l.
• Always confirm hypoglycaemia with a laboratory measurement, but
treat on basis of BM while awaiting lab result.
• Symptoms of hypoglycaemia are age specific, with behavioural
change being common in children and neurological symptoms
prominent in the elderly - always check blood glucose in patients
with suspected stroke or altered conscious level (including
confusion).
• Most patients presenting with hypoglycaemia will be on insulin or
sulphonylurea drugs, e.g. gliclazide.
AETIOLOGY
In patients with diabetes mellitus on insulin or sulphonylureas (not
biguanides i.e. metformin or thiazolidindione) common causes
include:
• Lack of food.
• Unaccustomed exercise.
• Alcohol
• Excess insulin.
• May be more than one of these factors. About 25% of Type 1
diabetic patients have reduced/lost awareness which increases the
risk of severe hypoglycaemia.
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COMMON SYMPTOMS OF HYPOGLYCAEMIA
Autonomic
Sweating
Trembling
Pounding heart
Anxiety
Hunger
Neuroglycopenic
Non-specific
Weakness
Visual disturbance
Difficulty speaking
Tingling
Dizziness
Difficulty concentrating
Tiredness
Drowsiness
Confusion
Headache
Nausea
UNUSUAL ASSOCIATIONS AND PRESENTATION OF HYPOGLYCAEMIA
Cardiovascular
Neuropsychological
General
Prolongation of
Focal/generalised
Fracture of long
QT-interval
convulsions
bones/vertebrae
Atrial fibrillation
Coma
Joint dislocation
Non-sustained
Stroke; TIA’s
Soft tissue injury
ventricular
ataxia, choreoathetosis
Head injury
tachycardia
Focal neurological
Burns
Silent myocardial
deficits
Hypothermia
ischaemia
Decortication
Road traffic accidents
Angina
Cognitive impairment
Myocardial infarction
Sudden death
Behavioural/
personality change
Automatism/aggressive
behaviour
Psychosis
MANAGEMENT
• Maintain ABCDE and oxygenation whilst correcting hypoglycaemia
(especially airway).
• ALWAYS confirm hypoglycaemia with a laboratory measurement,
but treat on basis of BM whilst awaiting lab result.
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• If patient not known to have diabetes, or deliberate overdose of
insulin/sulphonylurea suspected, take blood for assay for insulin
and c-peptide concentrations.
Mild or severe
but conscious
Hypoglycaemia
• 2-4 dextrose tablets or
• small glass of carbonated
sugar-containing drink
• If no improvement within 5-10
mins, repeat
• If next meal not imminent,
longer acting carbohydrate
should be administered, e.g.
biscuit, sandwich, fruit
Severe and
unconscious
• IV dextrose
125mls 20% dextrose, 250mls
10% dextrose or 500mls 5%
dextrose*
OR
• Glucagon 1 mg IM (not if liver
disease/alcoholism)
• Glucagon is effective almost as quickly as dextrose but may not work
in alcohol related hypoglycaemia, in liver disease or in prolonged
hypoglycaemia. Occasionally causes vomiting, abdominal pain,
diarrhoea. Dextrose infusion 10-20% IV may be needed especially when
a long acting insulin or oral hypoglycaemic agent is responsible.
i Give oral starchy carbohydrate within 10-30 mins of glucagon to
replenish liver glycogen stores and prevent recurrent
hypoglycaemia.
• In the situation of a massive insulin overdose with a long acting
preparation the injection site can (occasionally) be surgically
removed.
Recovery from hypoglycaemia may be delayed if:
• hypoglycaemia has been prolonged or severe.
• an alternative cause for impairment of consciousness co-exists,
e.g. stroke or drug overdose.
• patient is post-ictal (convulsion caused by hypoglycaemia).
Follow up
• Think of the causes of hypoglycaemia.
• Why has it occurred?
• If patient recovers quickly then admission is rarely indicated (unless
sulphonylurea induced hypoglycaemia) but ensure that adequate
follow up is arranged through the diabetes team.
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Always discuss with the metabolic registrar the management and
follow up of patients admitted with hypoglycaemia. However, it
is important to elucidate the reason for hypoglycaemia. The most
common cause for hypoglycaemia is patient error, i.e. too much insulin
or not enough carbohydrate. Others include:
• Excessive exercise (hypoglycaemia can be early or occur the
following day).
• Excess alcohol (inhibits hepatic gluconeogenesis).
• Renal failure (insulin and sulphonylureas undergo renal clearance).
• Development of coincidental endocrine disease, e.g. Addison’s disease
(weight loss, anorexia, skin pigmentation, postural hypotension,
hyponatraemia, hyperkalaemia etc), hypopituitarism, hypothyroidism.
• Malabsorption and gastroparesis, e.g. coeliac disease (weight loss,
abdominal pain, bloating, loose stools, glossitis, apthous ulceration,
anaemia, hypoalbuminaemia etc).
Risk factors for severe hypoglycaemia
Intensive insulin therapy
Low HbA1c
Previous history of severe hypoglycaemia
Long duration of diabetes
Impaired awareness of hypoglycaemia
Irregular life style
Alcoholism or binge drinking
Risk factors for sulphonylurea-induced hypoglycaemia
Age (not dose of drug)
Impaired renal function
Previous history of cardiovascular disease or stroke
Reduced food intake; diarrhoea
Alcohol
Adverse drug interactions
Use of long-acting sulphonylureas
Recent hospital admission
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SULPHONYLUREA-INDUCED HYPOGLYCAEMIA (SIH)
• Mild SIH is treated in a similar way to insulin-induced hypoglycaemia
(see above).
• Sulphonylurea-induced hypoglycaemic coma requires intravenous
dextrose and treatment in hospital because relapse after initial treatment
is well recognised. An intravenous bolus of glucose stimulates insulin
secretion, especially in individuals who have retained pancreatic betacell function, and many people will require an ongoing intravenous
infusion of 10% dextrose to sustain the blood glucose concentration
above 5.0 mmol/l. Inform diabetes team.
i All of these patients should be admitted.
HYPERCALCAEMIA
Severe hypercalcaemia (corrected calcium >3.0mmol/L) is uncommon,
and usually due to hyperparathyroidism, or malignancy (e.g. myeloma).
Symptoms may be masked by underlying malignancy. In any unwell
patient with known malignancy check the serum calcium, and albumin.
CAUSES OF HYPERCALCAEMIA
• Primary hyperparathyroidism.
• Malignancy: solid tumours with metastases to bone; tumours
secreting PTH or PTHRP (usually squamous carcinomas);
haematological malignancy.
• These two causes account for >80% of cases.
• Familial hypocalciuric hypercalcaemia.
• Sarcoidosis, granulomatous disease.
• Endocrine: thyrotoxicosis; Addison’s disease; phaeochromocytoma.
• Milk-alkali syndrome.
• Immobilisation (<16 yr old).
• Meds: Vit D analogues, anti-oestrogens, lithium, thiazides.
SYMPTOMS
•
•
•
•
•
Thirst
Polyuria
Constipation
Nausea and anorexia
Abdominal pain
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• Depression
• Confusion
COMPLICATIONS
•
•
•
•
•
•
Peptic ulceration
Acute pancreatitis
Muscle weakness
Psychosis, drowsiness, coma
Corneal calcification
Short QT interval on ECG
INVESTIGATIONS
All patients
• FBC, ESR
• U&Es
• Ca++, PO4-, Mg++, ionised Ca++, albumin
• ALP, LFT’s
• ECG
• CXR
• Parathyroid hormone
Specific depending on the history.
• Myeloma screen and skeletal survey.
• Bone scintigraphy.
• Thyroid function tests.
• Serum ACE.
• 24hr urine for calcium and creatinine.
• Short Synacthen test.
TREATMENT
Calculate corrected calcium or refer to ionised value. Emergency
treatment is required if corrected calcium >3.5 mmol/l (ionised>1.8
mmol/l). Between 3 and 3.5mmol/L may not require emergency
treatment, but this depends on signs and symptoms.
For each 1g the albumin is below 40g/L add 0.02mmol/L to the
uncorrected calcium e.g. calcium 2.62mmol/L with an albumin of 30g/
L gives a corrected calcium of 2.62 + (10 x 0.02)= 2.82mmol/L.
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Fluid
• Urgent fluid replacement with 0.9% saline (add potassium chloride
as required) will lower calcium, and enhance renal clearance.
• Check U&E’s and calcium twice daily.
Diuretics
• Loop diuretics (e.g. furosemide 40mg IV bd) will enhance calcium
loss in the urine. DO NOT start until fluid deficits rectified.
• NEVER use thiazides as they cause calcium retention.
Bisphosphonates
• Ensure fluid deficit corrected first.
• A single infusion of pamidronate (see table) will lower calcium levels
within 2 to 4 days (but not acutely).
• Maximal effect is at about 1 week.
• Recurrent hypercalcaemia may be treated with repeated IV infusions
of pamidronate.
Other
• If patient is on digoxin, discontinue. • Steroids should not be used routinely. May be helpful in sarcoidosis,
myeloma and hypervitaminosis-D (prednisolone 60-80mg oral daily).
PAMIDRONATE DOSE TABLE
Serum calcium (mmol/L)
Dose of pamidronate
<3.0
3.0-3.5
3.6-4.0
>4.0
15mg
30mg
60mg
90mg
If creatinine clearance >30ml/min infuse at rates up to 60mg/hr. If
creatinine clearance <30ml/min administer maximum rate of 20mg/
hour (4 hr 30mins for 90mg) but do not reduce dose.
HYPOCALCAEMIA - THE 5 COMMON CAUSES
• Spurious hypocalcaemia, that is failure to correct for low albumin
(check ionised calcium). Add 0.02 mmol/l to the total calcium for
each g/l albumin is below 40 g/l.
• Hypoparathyroidism, surgical.
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• Renal failure.
• Vitamin D deficiency.
• Hypomagnesaemia.
CLINICAL FEATURES
Mild hypocalcaemia may be asymptomatic.
Early features
• Anxiety and nervousness.
• Paraesthesiae around the mouth, in toes and fingers.
Late features (esp. if total Ca++ <1.9 mmol/l)
• Convulsions
• Prolonged QT interval on ECG.
• Papilloedema
• Muscle cramps
• Muscle twitches
• Chvostek’s sign
• Trousseau’s sign (carpal spasm).
INVESTIGATIONS
• Total and ionised calcium, albumin, phosphate, magnesium.
• U&Es
• 25(OH)2D3 and 1,25(OH)2D3, PTH and alkaline phosphatase may
help establish aetiology.
EMERGENCY TREATMENT
• Required for severe complications e.g. fits, dysrrhythmias, tetany.
• Monitor ECG.
• 5-10mls calcium chloride 10% or calcium gluconate 10% IV over 15
minutes will reverse tetany. Calcium chloride is immediately available
in minijet form, but ampoules of calcium gluconate are available for
injection and the preparation of infusions.
• Follow up: slow IV infusion at 0.5-2mg Ca/kg/hr (0.06 -0.22mls/kg/hr)
as calcium gluconate 10%; dilute 60mls calcium gluconate in 1 litre
5% dextrose. (10% calcium gluconate contains 8.9 mg elemental
Ca++/ml).
• Oral calcium: introduce as below +/- vitamin D as soon as
possible.
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• Hypomagnesaemia may be the cause. Emergency treatment is with
IV magnesium. Hypomagnesemia is caused by chronic alcoholism,
malabsorption, cyclosporin treatment, prolonged parenteral nutrition
or diuretic therapy.
• Treat convulsions and arrhythmias with magnesium sulphate IV: 8
mmols magnesium sulphate diluted in 100 ml 0.9% NaCl and infused
over 20 minutes. Monitor ECG. May cause hypotension.
TREATMENT OF MILD AND MODERATE CASES
• Mildly symptomatic or asymptomatic patients with chronic
hypomagnesaemia, oral replacement can be tried but may be
unsuccessful due to diarrhoea. Magnesium glycerophosphate is
used most commonly, however this is an unlicensed medicine and
should be discussed with the appropriate consultant first.
• Primary hypocalcaemia: oral or IV calcium +/- vitamin D will be
required. Therapeutic target is low normal calcium. Oral calcium is
administered as calcichew (2-3 tablets daily) or sandocal 400 (1-4
tablets daily) or sandocal 1000 (1-2 tablet daily). Vitamin D as Alfa
calcidol usual dose is 0.25 - 1 microgram per day.
• Chronic asymptomatic hypocalcaemia: may need larger doses of
oral calcium up to 7g per day in multiple divided doses. Vitamin
D usually needed (0.25-1 microgram per day). Use shorter-acting
vitamin D analogues as that will make reversal easier if any toxicity/
hypercalcaemia.
HYPOKALAEMIA
Potassium <3.5mmol/l
GENERAL
• Common
• Rarely an emergency, except in diabetic ketoacidosis, or
arrhythmias.
• Common causes are GI losses, vomiting and diuretics.
• Oral replacement is preferred.
• IV treatment required if patient vomiting, NBM, or with cardiac
arrhythmia.
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TREATMENT
Oral
• Sando K 2-3 tablets oral bd, or tds. Avoid Slow K, especially in the
elderly as it can cause oesophageal erosions and ulcers.
• Add a potassium sparing diuretic if diuretic induced.
• Monitor potassium levels daily and review dose regularly.
Intravenous
i NEVER administer stat or undiluted.
• Maximum concentration is 40 mmol/L usually over 4hrs.
• Higher concentrations (e.g. 80 mmol/L) may be given centrally,
but the rate must not exceed 20 mmol/hr (with continuous ECG
monitoring).
• Caution: monitor serum potassium levels to ensure hyperkalaemia
does not occur, especially in patients with renal impairment.
• Use pre-prepared bags to minimise risk of error (wherever
possible).
• Serum potassium concentration is a poor reflection of total body
potassium (frequently much lower). Seemingly large quantities may
be required e.g. in DKA.
• If difficulty replacing potassium is experienced, check serum
magnesium. May be low, especially in alcoholics, and patients on
diuretics.
• Hypomagnesaemia impairs potassium retention by the kidney.
ADDISON’S DISEASE
SYMPTOMS AND SIGNS
•
•
•
•
•
•
•
Weight loss
Pigmentation
Abdominal pain
Vomiting, diarrhoea
Fatigue
Postural hypotension
Shock
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LABORATORY INVESTIGATIONS
•
•
•
•
•
•
•
Low Na+
High K+
Metabolic acidosis
High urea
Hypoglycaemia
Hypercalcaemia
These changes occur late in the disease.
TESTING FOR ADDISON’S DISEASE
i A short Synacthen test is useful to confirm the diagnosis and
only takes 30 mins. However do not do short Synacthen test in
the very ill. Take blood to check cortisol and ACTH then start
hydrocortisone treatment.
•
•
•
•
SHORT SYNACTHEN TEST
Venous blood sample for baseline cortisol and ACTH.
Give 250 micrograms Synacthen im (IV if peripherally shutdown).
Recheck cortisol at 30 minutes.
A normal response is a 30min cortisol >460nmol/L.
TREATMENT
•
•
•
•
•
•
•
•
•
•
•
•
Correct hypoxaemia.
Establish IV access.
Take a sample for serum cortisol/ACTH.
0.9% saline IV with 10% dextrose IV if hypoglycaemic.
200mg hydrocortisone IV.
Then 100mg hydrocortisone IV qds for 48hrs.
Decrease hydrocortisone dose to 50mg qds the following day and
continue to derease at daily intervals as follows
Then 50mg bd iv or oral if well enough
Then 25mg bd oral
Then 20mg am and 10mg pm (no later than 6pm) oral
Then 10mg am and 5mg pm (usual maintenance dose)
Fludrocortisone 50-100 micrograms oral per day may be required
(when total daily hydrocortisone dose is <30mg), as determined by
plasma electrolytes, and blood pressure.
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• Measurement of plasma renin activity can also be helpful in
assessing mineralocorticoid deficiency.
• Discuss with Endocrinology registrar.
• Patients should be advised to wear a medic-alert type bracelet or
talisman and should be given a steroid card. Further details can be
found in the BNF.
• Advise not to stop steroids unless told to by a doctor. If become
unwell steroid dose should be doubled. If vomiting, or diarrhoea
contact GP at once.
Management of intercurrent illness in patients requiring
glucocorticoid replacement
• Patients with Addison’s disease or ACTH deficiency secondary to
pituitary failure are unable to mount an increased cortisol reponse
to stress.
• In mild or moderate illness, patients should double or triple their
glucocorticoid replacement for the duration of the illness.
• In severe illness or if vomiting/diarrhoea, iv hydrocortisone is
required. 100mg iv qds. NB replace fluid deficit with iv saline as
appropriate.
• Decrease back down to usual dose gradually as outlined above.
HYPONATRAEMIA
Seen in 1.5% of hospital admissions.
Mechanism
Dilutional (impaired renal water clearance) or depletional. Often a
combination.
Dilutional commoner and seen in:
• Cirrhosis
• Cardiac failure
• Nephrotic syndrome
• Hypothyroidism
• ACTH deficiency
• SIADH: check plasma and urine osmolality urinary sodium, TFT,
synacthen test, CXR
Depletional causes:
• Vomiting/ diarrhoea
• Diuretics
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• Addison’s disease.
• Renal salt wasting.
HISTORY, EXAMINATION & INVESTIGATIONS
• Accurate history to establish rate of onset of symptoms, any obvious
cause eg diuretics.
• Assess hydration status.
• Check urine sodium concentration before giving any IV therapy.
i Patients with urinary sodium >30mmol/l are more likely to have
dilutional hyponatraemia (exceptions are Addison’s disease and
renal salt-wasting and patients receiving diuretic therapy).
• Symptoms and signs relate to the rate of onset more than the
degree of fall in sodium.
• Na+ <130 mmol/l may give headache with nausea and vomiting
and lead to fits, coma and respiratory arrest. This is more likely in
women of child-bearing age (16-45 yrs).
• Na+ <120 mmol/l is associated with 50% mortality. Chronic
development has much lower morbidity and mortality. If chronic
even severe hyponatraemia may be asymptomatic.CHRONIC
i Chronic fall to 110mmol/l can be well tolerated, acute fall to
127mmol/ has been fatal.
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Flow Chart for the assessment and management of a
patient with hyponatraemia*
Hyponatraemia
Hypovolaemic
Euvolaemic
Hypervolaemic
Clinical signs of
Clinical state may
volume depletion not help diagnostically
Plasma urea tends
Plasma urea tends to be Usually easier to
to be high rather
low rather than high
diagnose clinically e.g.
than low Urine sodium >30 mmol/l
Heart failure
Urine sodium < 30 mmol/l
but may be <30 if
Cirrhosis with ascites
but may be > 30 dietary access to salt
Nephrotic
if IV saline has already restricted syndrome
been administered
Correct volume depletion
IV 0.9% saline
Fluid restriction (≤ 1litre/d)
+/-Demeclocycline (600 - 1200 mg/d)
IV 3% (hypertonic) saline
if severe symptoms and of acute onset (< 48 hrs)
Discuss with senior clinician
Treat underlying
condition
Fluid deprivation
and/or
demeclocycline
may help
• *Most difficulty arises in differentiating mild hypovolaemia from
euvolaemic, dilutional, hyponatraemia. In both hypovolaemic
and euvolaemic hyponatraemia plasma osmolality will be low
and the urine will be less than maximally dilute (inappropriately
concentrated). Posm/Uosm will rarely help clinical management.
• Monitor the sodium concentrations carefully (every hour if necessary
during iv therapy).
• In a sick individual consider Addison’s disease and give parenteral
hydrocortisone (100mg) after taking blood for plasma cortisol as
glucocorticoids are anticipated to have little toxicity in this acute
setting and may be life-saving.
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MANAGEMENT
• Depends on degree and rate of fall: in patients with a severe abrupt
fall in sodium associated with symptoms rapid correction is well
tolerated and beneficial.
• In more chronic onset and without symptoms correction should be
much slower.
• Depends on body salt and water status.
EMERGENCY TREATMENT
i Prompt treatment is required for patients with neurological
signs, and sodium less than 120mmol/L. EMERGENCY treatment
is required for seizures. Discuss all such cases with Endocrine
Registrar. Consider high dependency or intensive care
management early.
• Hyponatraemic encephalopathy: symptomatic and Na <120mmol/l
use hypertonic saline aiming to raise the sodium by 3-5mmol in
the first instance over 4-6 hours: get senior advice. Sodium should
not rise more than 12mmol in 24 hours. In chronic cases, the Na+
increment should be no greater than 8mmol in 24 hours. Hypertonic
saline should only be given on advice of endocrine or ICU Reg/Cons.
Caution in renal and cardiac disease.
• Treat fits as standard with diazemuls and refer early to ICU.
• Remove cause.
• Fluid restriction ± Demeclocycline where appropriate. Cardiac
failure, cirrhosis and nephrotic syndrome: water restrict, diuretics,
no improvement with hypertonic saline (can make worse).
• In volume depleted patient give 0.9% saline, and correct
hypokalaemia (may benefit from hypertonic saline, but usually
respond to isotonic).
• Treat hypothyroidism and Addison’s disease with appropriate
hormones.
CRITERIA FOR SIADH
•
•
•
•
Plasma sodium <130 mmol/L, urine sodium >30 mmol/L.
No oedema or hypovolaemia.
Normal renal, thyroid, and adrenal function.
No diuretic useage.
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Chapter 7
NEUROLOGICAL EMERGENCIES
NON-TRAUMATIC COMA
This guideline relates to the unrousable, unresponsive patient. There
are many causes of coma, (GCS<8) but the initial approach is similar
for all of them
IMMEDIATE MANAGEMENT
Assess the airway and breathing
• Open airway and stabilise the cervical spine if there is a history of
head or neck trauma.
• Give high concentration oxygen and if no breathing ventilate with a
bag-valve-mask and 100% oxygen
• Intubation will often be necessary - seek expert help from an
anaesthetist early.
Assess the circulation
• Check pulse, perfusion, oxygen saturation and blood pressure
• Correct hypovolaemia or arrhythmias
• Obtain large bore IV access
• Immdediate investigation: take blood for BM, full blood count,
glucose, electrolytes and toxicology screen
Look for evidence of hypoglycaemia
• Measure glucose rapidly
• If you believe hypoglycaemia is present give 200-500ml 5% dextrose
• Give Pabrinex IV HP 1+2 (20ml in 100ml 5% glucose or 0.9%
sodium chloride over 30mins, as per LUHD guidelines) to alcoholics
or malnourished patients at the same time as glucose
IMMEDIATE ASSESSMENT
• Obtain history from ambulance crew, relatives, partner, friends or GP.
• Record the level of consciousness using the Glasgow Coma Scale,
and reasses it frequently.
• Examine pupils, look at eye movements, and look for unilateral
weakness (suggesting an intracranial cause such as stroke) by
giving a painful stimulus to each limb.
• Examine the rest of the patient carefully looking for pointers to a
diagnosis.
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FURTHER TREATMENT TO CONSIDER
If you suspect an OPIATE OVERDOSE (drug paraphernalia at scene,
track marks, pinpoint pupils, reduced respiratory rate) give NALOXONE
as per Toxicology chapter.
If you suspect a BENZODIAZEPINE OVERDOSE (previous prescriptions
of benzodiazepines, empty drug boxes, reduced respiratory rate).
manage as per Toxicology chapter.
If you suspect MENINGITIS (neck stiffness, rash or fever) give
INTRAVENOUS ANTIBIOTICS: Ceftriaxone 2g IV. See meningitis
section.
FURTHER INVESTIGATIONS TO CONSIDER
If the cause of the coma is not immediately evident, further investigation
is usually required. Consider;
• CT brain: once circulation is stable and the airway is secure
• Drug levels: toxicology screen
• Lumbar puncture: cell count, protein, glucose, culture.
i Early advice from a neurologist and/or neurosurgeon and/or
intensive care physician may be crucial.
ONGOING CARE OF THE UNCONSCIOUS PATIENT
• Monitoring of conscious level, blood pressure, pulse, ECG and
oxygen saturations
• DVT prophylaxis: heparin may be contraindicated
• pressure sore prevention
• nutrition
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AETIOLOGY OF COMA
Primary neurological disease
• Trauma
• Intra-cranial haemorrhage: SAH, intra-cerebral, sub/
extradural
• Arterial/venous infarction
• Infection: meningitis, encephalitis, cerebral abscess
• Other structural: tumours
• Epilepsy: postictal non-convulsive status epilepticus
• Psychogenic
Secondary to systemic disease
• Toxic (drugs/alcohol)
• Liver or renal failure
• Hypoxia/hypercarbia
• Wernicke’s encephalopathy
Metabolic
• Hypertensive encephalopathy
• Hypoglycaemia
• Hyperglycaemia
• Hyponatraemia
• Hypocalcaemia
GLASGOW COMA SCALE
Eye Opening
Best verbal response
Best motor response
1 None
1 None
1
2 To pain
2 Sounds only
2
3 To voice
3 Incoherent Words
3
4 Spontaneous 4 Confused speech
4
5 Normal conversation 5
6
None
Abnormal
extension
response to pain
Abnormal flexion response to pain
Withdrawal from a painful stimulus
Localises a painful stimulus
Normal
Add up the score for each component of the scale, and report them
separately.
Localisation to pain is defined as reaching above the clavicle to a
painful stimulus given above the neck.
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CLINICAL ASSESSMENT
General medical assessment
Raised intracranial pressure leads to bradycardia and hypertension
(Cushing response). Once haemodynamically stable, look for:
• Neck stiffness in flexion of neck: may be absent in deep coma
despite meningeal irritation.
• Skin rash: remember conjunctivae, hands and feet (soles).
• Pyrexia
• Medic-alert bracelets.
• Evidence drug abuse (needle tracks).
• Cranial trauma (feel over whole head).
Neurological assessment
• Use sternal and nail bed pressure to elicit response, if no response
to verbal stimuli.
• If asymmetrical, score best side, but note asymmetry (lesion
localisation).
Pupil size/reactions:
• Pinpoint pupils = opioid OD or pontine structural lesion.
• Asymmetry pupil size: lesion localisation, especially emerging third
nerve palsy.
Reflex asymmetry:
• Lesion localisation.
• Bilateral extensor plantar response common in coma.
Further management
If diagnosis obvious from initial assessment/blood tests (e.g. metabolic),
treat appropriately and reassess (should improve after correction, if
not, why not?).
If primary neurological cause suspected:
• Brain imaging (CT usually), but ensure patient stable first. Airway
protection, correction of hypoxaemia and abnormal CO2 may
necessitate intubation. Get help early.
• Consult neurological advice (Neurology SpR via WGH
switchboard).
Further investigation will depend on the above clinical assessment.
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EPILEPTIC SEIZURES
Epilepsy is a syndrome characterised by two or more unprovoked
epileptic seizures.
Epileptic seizures may be:
• Generalised (most commonly tonic-clonic).
• Focal.
CAUSES
First seizure:
• Patients presenting with suspected first ever seizure should be
managed as per the ‘First seizure in adults’ protocol. See Chapter 2.
• Further investigations/treatment should only be undertaken after
consultation with a neurologist.
Symptomatic seizures in a person known to have epilepsy:
• Subtherapeutic drug concentration (poor compliance, drug
interaction).
• Primary CNS disease (infection, stroke, trauma etc.).
• Encephalopathy due to toxic/metabolic disturbances.
• Intercurrent illness, infection, fatigue, stress.
Isolated presentation:
Patients presenting with suspected first ever seizure must have:
• ECG, FBC, glucose, U&Es, (toxicology if indicated) LFTs, calcium,
magnesium.
• If recovered may be discharged, and referred to “first seizure” clinic
(Dr Davenport, Consultant Neurologist, RIE): see referral sheet in
Chapter 2.
• Inform patient and document advice regarding DVLA (patients have
legal obligation to inform DVLA regarding any suspected epileptic
seizures or episode of disturbed consciousness not explained
by vasovagal syncope). The patient should not drive until further
assessment.
• Further investigations/treatment should only be undertaken after
consultation with neurologist.
STATUS EPILEPTICUS
Defined as more than 30 minutes of:
• continuous seizure activity or;
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• two or more sequential seizures without full recovery of
consciousness between seizures.
• This summary is for tonic/clonic status.
i In 50% of patients it is the first seizure. The longer status goes
on the harder it is to control and the greater the cerebral damage
and systemic effects.
COMPLICATIONS OF STATUS EPILEPTICUS
•
•
•
•
•
•
•
Systemic and cerebral hypoxia
Neurogenic pulmonary oedema
Rhabdomyolysis, acute renal failure, hyperkalaemia
Lactic acidosis
Hepatic necrosis
DIC
Death
MANAGEMENT
• Airway: assess, open and maintain, high concentration oxygen.
Naso-pharyngeal airway may be helpful.
• Breathing: assess and support.
• Circulation: assess, IV access (check blood glucose), IV fluids. Use
0.9% sodium chloride and avoid 5% dextrose.
• Drugs: abolish seizure activity (below).
• Monitoring: pulse oximeter, ECG, BP, GCS, pupils.
Urgent investigations
• Blood glucose.
• U&Es, Ca++, Mg++, CK.
• ABG
• LFTs
• FBC and coagulation screen.
• The specific cause may be crucial e.g. meningitis, subarachnoid
haemorrhage and so on. See below for details of these.
• Discuss with Neurology Registrar: contact via switchboard WGH.
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DRUGS
Initial treatment is with DIAZEPAM emulsion (Diazemuls).
• 2mg increments IV initially up to 10mg over 5 minutes.
• Alternative is IV lorazepam 4mg slow IV into a large vein.
• Benzodiazepines may cause respiratory depression and
hypotension.
• Repeat Diazepam once 15 minutes later up to total 20mg if
required.
• Repeat lorazepam once 15mins later up to a total of 8mg, if
required.
• Usually effective but wears off allowing recurrent seizures in many.
Second line therapy for seizures persisting despite benzodiazepines is
PHENYTOIN.
For patients NOT already on phenytoin:
• Give by IV infusion diluted in 100ml 0.9% sodium chloride.
Recommended maximum concentration is 10mg/ml. Sodium chloride
is the ONLY suitable diluent.
• For otherwise fit adults a loading dose of 15mg/kg given no faster
than 50mg/min is used.
• The solution is liable to precipitation and a 0.2µm filter should be
used in the line.
• To avoid local venous irritation flush cannula with 0.9% sodium
chloride before and after infusion.
• Monitor ECG continuously as heart block may occur.
• Measure BP frequently as phenytoin causes hypotension. • Maintenance: IV 100mg phenytoin 8 hourly (or 300mg phenytoin
od orally/NG) until the need for ongoing anti-epileptic treatment is
reviewed by a neurologist.
i In the elderly or in patients with cardiac disease a lower loading
dose should be used e.g. 10mg/kg and can be divided into two
separate doses.
• Refractory status, continuing for >30 mins despite the above therapy
requires expert involvement from Intensive Care and Neurology.
• Call the duty anaesthetist and inform the ICU Consultant on call.
The next line of therapy involves the use of IV general anaesthetic
drugs, tracheal intubation and assisted ventilation.
• Remember specific causes especially meningitis, encephalitis and
other intra-cranial pathology.
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i If cranial CT scan is required secure ABCD first. This will involve
invasive monitoring and ventilation.
SUBARACHNOID HAEMORRHAGE
Acute bleed into the subarachnoid space, may also have intracerebral
component.
• 80%: aneurysmal
• 10%: no known vascular cause (perimesencephalic)
• 5%: avms, tumours etc.
PRESENTATION
• Acute onset (severe) headache (usually maximal instantly or within
few minutes).
• Transient or persisting loss of consciousness.
• Epileptic seizures.
• Vomiting
• Focal neurological signs.
• Meningism is uncommon in the early stages; irritability common.
• Fever is uncommon in the early stages.
• Limb and cranial nerve signs; subhyaloid retinal haemorrhages.
• Hypertension and tachycardia.
• Pulmonary oedema may occur early.
• 20% SAH present with headache alone.
i Contact the Neurology Registrar on-call via switchboard WGH.
MANAGEMENT
• Airway: assess, maintain, give high concentration oxygen if
hypoxic.
• Breathing: assess and support. Laryngoscopy and intubation cause
severe hypertension and may precipitate rebleeding. Unless the
patient has arrested or cannot be ventilated intubation should not
be attempted except with an appropriate anaesthetic technique by
an experienced clinician.
• Circulation: assess, support, gain IV access. Most patients will be
hypertensive: no attempt should be made to reduce blood pressure
as it is critical to maintenance of cerebral perfusion pressure.
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INDICATIONS FOR INTUBATION AND VENTILATION IN SAH
•
•
•
•
•
Airway or breathing compromised.
Hypoxaemia not corrected by high concentration oxygen.
GCS 8 or less.
Hypoventilation and PaCO2 >6kPa.
Hyperventilation and PaCO2 <3.5kPa.
• Disability
Neurological assessment: grading of subarachnoid haemorrhage
is by the World Federation of Neurological Surgeons Classification
and is based on Glasgow Coma Scale.
WFNS GRADING SAH
Grade 1: GCS 15
Grade 2: GCS 13-14
Grade 3: GCS 13-14 with deficit
Grade 4: GCS 7-12
Grade 5: GCS 3-6
• Lower grades may be due to convulsions or hydrocephalus as well
as the magnitude of the bleed.
• Management depends on grade: CT brain scanning should be
performed early. If negative, lumbar puncture must be performed
(unless contra-indicated). Timing is crucial (not before 6-12 hours
since symptom onset) and xanthochromia is sought biochemically
(bilirubin on spectrophotometry).
• Discuss Grade I-2 with Neurology Registrar WGH and discuss
Grades 3-5 with Neurosurgery Registrar WGH.
PRIORITIES
• Resuscitation as previous.
• Analgesia: oral paracetamol 1g 6 hourly, oral/IM codeine phosphate
30mg 6 hourly, and lactulose 10ml bd. Subcutaneous/intravenous
morphine 10mg 2 hourly can be used with care, preceded by an antiemetic.
• Investigation: CT scan head. Transport only after appropriate
stabilisation and with adequate monitoring and escort.
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PREVENTION & TREATMENT OF COMPLICATIONS OF SAH
• Standard preventive measures for delayed ischaemic
neurological deficit/vasospasm: usually occurs day 4-12. Good
fluid intake and oral nimodipine 60mg 4hrly for 21 days. Nimodipine
may cause hypotension necessitating halving of dose to 30mg, or
omission of doses until BP recovers. Do not treat hypertension.
• Rebleeding: peak of up to 20% in first 24 hours, and 40% in
1st month if left untreated. Definitive treatment is to occlude the
aneurysm by endovascular ‘coiling’, or sometimes neurosurgical
‘clipping’.
• Raised intracranial pressure: haematoma and hydrocephalus
may be treatable surgically.
• Epileptic seizures.
• Neurogenic Pulmonary Oedema (NPO): in the patient with SAH
if BP is normal or low, they are poorly perfused and oxygenation is
poor with crackles in the chest NPO is likely. Involve ICU early for
specific treatment.
MENINGITIS
Suspect meningitis in every patient with a fever, headache, meningism, or
neurological signs. Optimal management requires a rapid assessment,
diagnosis, and treatment.
FEATURES OF MENINGITIS
• Meningism- photophobia, neck stiffness in 70%, headache, Kernig’s
sign.
• Fever
• Decreased level of consciousness.
• Seizures in about 20%.
• Focal neurological signs, especially cranial nerve palsies in about
20%.
• Petechial rashes in meningococcal septicaemia. However, a similar
rash can occur in staphylococcal and pneumococcal septicaemia.
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LIKELY ORGANISMS
• Depend on age, and a large number of other factors e.g.
immunological state.
The commonest bacterial pathogens are:
• <60yrs Streptococcus pneumoniae, Neisseria meningitidis.
• >60yrs Streptococcus pneumoniae, Neisseria meningitidis, Listeria
monocytogenes.
INITIAL MANAGEMENT
• Full ABCDE assessment and treatment: see Chapter 2.
• Take blood cultures and start antibiotics immediately. Do not delay
while awaiting a CT scan or LP.
• Careful examination for neurological signs and rashes.
• Check vital signs: if shocked treat as for septic shock at once with
high concentration oxygen and IV fluids.
• Document GCS.
• Signs of raised ICP give mannitol 20% 200ml, furosemide 20mg
and Alba 200ml IV stat and call ICU and Neurosurgery.
• CT scan with appropriate escort, resuscitation and monitoring.
ANTIBIOTICS
• If <60 yrs ceftriaxone 2g IV bd.
• If >60 yrs or immunocompromised ceftriaxone 2g IV bd and
amoxicillin 2g IV qds to cover Listeria.
• Seek urgent microbiological advice re antibiotics and duration of
treatment, once organism is known.
• Contact ID middle grader.
• Consider IV aciclovir (10mg/kg tds) if LP is delayed (see
encephalitis).
• Discuss use of dexamethasone 10mg 6 hourly IV or oral for 4 days
if pneumococcol meningitis likely (eg no purpuric rash) and it can
be started before or at same time as antibiotics. There is no benefit
in giving steroids after antibiotics.
INVESTIGATIONS
• FBC
• U&E’s and glucose.
• Blood cultures.
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• EDTA blood sample for PCR (pink tube, as FBC).
• Coagulation screen.
• Throat swabs. One for bacteria, and one in viral transport medium
for viral culture. State clearly on request form “meningitis”.
• Stool for viral culture.
• If clinical features suggest recent mumps, parotid duct swab in viral
transport medium.
• Lumbar puncture: see below re CT scanning. A CT scan may be
required first if a mass lesion, or abscess is suspected, i.e. focal
neurological signs, papilloedema, middle ear pathology, or a history
suggestive of a neoplasm or if profoundly immunosuppressed
eg HIV positive. Check opening pressure, if >35 cmH2O, remove
only the fluid in the manometer and refer to ICU urgently (see next
page). Otherwise try and send at least 5ml to Microbiology (greatly
increases diagnostic yield). One sample to microbiology for MC&S,
one to biochemistry for glucose, protein, and xanthochromia if
subarachnoid haemorrhage is a possibility, and one to Virology.
• Contemporaneous blood glucose.
i • Contraindications to lumbar puncture include signs of raised
intracranial pressure, (including reduction in conscious level,
focal neurological signs) or major coagulopathy.
• CXR
Normal CSF is gin-clear. Any haze/turbidity is an indication for
immediate antibiotic if not already given.
i Cerebro-spinal Fluid Findings
BACTERIAL VIRAL
Cell count
Cell type
Polymorphs
TUBERCULOUS
Lymphocytes Lymphocytes
(normal up to 5 lymphocytes)
Protein
(normal <0.4g/L)
Glucose
(0.5-2.0)
(0.4-0.8)
(1.0-3.0)
<40% serum >50% serum <40% serum
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TENTORIAL HERNIATION AND CONING
• Raised ICP can cause this.
• Rapidly fatal but it is potentially reversible if identified and treated early.
• May occur post lumbar puncture but this is rare in patients with no focal neurology or raised ICP
Diagnosis
• Intra-cranial pathology e.g. recent lumbar puncture in meningitis or
SAH, haematoma.
• Pupil(s) dilate abruptly, and fix.
• Respiration periodic or stertorous.
• Bradycardia and hypertension.
• Coma
Action
• Call 222 then ICU and Neurosurgeon.
• Bag, mask, valve hyper-ventilate with high concentration oxygen.
• IV access.
• Mannitol 20% 200ml IV, furosemide 20mg IV, ALBA 200ml all stat.
• Require intubation and ventilation with anaesthetic.
• Further management will be decided by ICU and Neurosurgical
specialists.
FURTHER MANAGEMENT OF MENINGITIS
• Analgesia.
• IV fluids if dehydrated.
• Infection control for suspected meningococcal disease, isolate
patient for first 48h.
• Notify the on-call consultant in Public Health of all meningococcal
and Haemophilus influenzae infections. They will arrange prophylaxis
for all contacts, including the patient’s immediate household
contacts and any significantly exposed staff contacts (mouth-tomouth resuscitation or other close prolonged contact; prophylaxis
rarely necessary for staff).
ICU referral if:
• Shock unresponsive to initial fluid resuscitation.
• Respiratory failure.
• GCS <11.
Prophylaxis Don’t forget to give the patient prophylaxis before
discharge (if they have not received ceftriaxone during admission).
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ENCEPHALITIS
VIRAL ENCEPHALITIS
Viral encephalitis is inflammation of the brain due to viral infection, with
Herpes simplex being the most destructive but potentially treatable
causative agent. Currently, Herpes simplex encephalitis is estimated
to occur in approximately 1 in 250,000 to 500,000 individuals a year. It
occurs throughout the year and in patients of all ages, 1/3 in those aged
less than 20 years and approximately one half in those aged over 50
years. In pre aciclovir (acyclovir) days, the mortality was over 70%.
Other viral causes of acute encephalitis include:
• Enterovirus, mumps, influenza, EBV, VZV, CMV.
• In patients with travel history: arboviruses, rabies.
Presentation
• Signs of meningeal inflammation: e.g. fever, headache, neck
stiffness.
• Altered mentation/personality change.
• Decreasing conscious level.
• Focal neurology.
• Seizures
INITIAL MANAGEMENT
• Careful clinical examination including full neurological examination
and Glasgow Coma Score.
• ABCDE as Chapter 2.
• Ask for travel history.
• If patient needs a CT head scan, do not delay antibiotics (see
Meningitis chapter) and aciclovir (10mg/kg tds IV).
• Ensure the patient is stable enough for transfer to CT scan.
INVESTIGATIONS
•
•
•
•
•
FBC, U+E’s, glucose, LFT, Ca, clotting screen.
Blood cultures X3.
Blood for serology.
Throat swabs in viral transport medium.
Stool for Virology
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• Parotid duct swab (for mumps) in viral transport medium.
• Swab any lesion suggestive of Herpes simplex.
• CT scan if focal neurology, raised intracranial pressure, mass lesion.
Lumbar puncture if CT shows no features to contraindicate this.
CSF to microbiology for microscopy, cell count and gram stain.
CSF also to biochemistry for sugar and protein (a contemporaneous
plasma sugar is also required). CSF should be sent to Virology for
culture and PCR (min. volume 1ml).
• CXR
• EEG
• CT/MRI
FURTHER MANAGEMENT
• Analgesia
• Glasgow Coma Scale and other vital signs should be carefully
monitored. Seizures should be treated with anticonvulsants.
• IV fluids to maintain euvolaemia.
• Notify Infectious Diseases and Neurology SpR on call via
switchboard WGH.
SPECIFIC ANTIMICROBIAL THERAPY
• Antibiotics as per meningitis of unknown aetiology (see
meningitis).
• IV aciclovir (acyclovir) 10mg/kg tds depending on renal function.
DIFFERENTIAL DIAGNOSIS
There is a wide spectrum of conditions that may mimic viral encephalitis,
including brain abscess/empyema, partially treated bacterial
meningitis, tuberculous meningitis, tumour, vasculitis, connective
tissue disorders and toxic/metabolic causes. Consult Neurology or
Infectious Diseases.
SUPPORTIVE CARE
If raised ICP, depressed conscious level, shock or respiratory failure
early ICU referral is appropriate. See Chapter 2.
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Chapter 8
ACUTE DETERIORATION IN THE ELDERLY
DELIRIUM
i Delirium is a medical emergency and needs prompt
assessment and treatment.
Delirium (‘acute confusional state’) is an acute deterioration in cognition,
often with altered arousal (drowsiness, stupor, or hyperactivity) and
psychotic features (eg. paranoia). The main cognitive deficit in delirium
is ‘inattention’, eg. the patient is distractable, cannot consistently
follow commands, and loses the thread during a conversation. Delirium
is different from dementia, where there is a much slower decline in
cognition and inattention is much less prominent, but the two conditions
commonly co-exist.
Delirium affects 1 in 5 of older patients in hospital. It is important
because it frequently indicates serious illness – NB ‘confusion’ in the
CURB-65 score. The outcome is frequently poor.
CAUSES OF DELIRIUM
• Three main groups:
1. physical and psychological stress: any acute illness, trauma, surgery, etc.
2. drugs: drugs with anticholinergic activity (eg. amitriptyline, oxybutinin), opiates, benzodiazepines, steroids; also drug withdrawal (eg. benzodiazepines, alcohol)
3. metabolic, eg. hyponatraemia, hypercalcaemia, hypoglycaemia
• Note that a higher number predisposing factors (old age,
baseline cognitive impairment, multiple comorbidities) mean that
an apparently minor insult, eg. a UTI or a change of drugs, can
precipitate delirium.
INITIAL ASSESSMENT
• Delirium should be suspected in any patient with (a) cognitive
impairment and/or altered arousal and (b) evidence that the altered
mental status is of recent onset (hours, days, weeks).
• Therefore, to screen for delirium you need to assess cognition
and arousal, and seek a third party history regarding the patient’s
baseline state.
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• Assessment of cognition can be done formally using the Abbreviated
Mental Test, and through clinical observation (eg. inability to converse
normally, distractibility, inability to follow commands, etc.)
• Note other features, such as irritability, paranoia, lability of mood,
apathy, etc.
• Agitation is not necessary to make the diagnosis: more than 50% of
patients will not show this.
• Once you have made the diagnosis you need to consider the
predisposing and precipitating factors.
• In older patients delirium may be the presenting feature of acute
illness, for example pneumonia, UTI, cholecystitis, etc. Often
patients will lack other obvious features of the illness. Thus, initial
examination is directed at looking for an acute cause.
• Do not neglect examination of the nervous system (stroke can
cause delirium), joints, and skin.
ABBREVIATED MENTAL TEST SCORE (AMT)
SCORE
OUT OF 10 COMMENTS
1. What is your present age (± 1 year)?
2. What is the time just now (± 1 hour)?
3. What year is it?
4. What is the name of this place?
Please memorise this address - 42 West St
5. When is your birthday (date and month)?
6. When did the First World War begin?
7. What is the Queen’s name?
8. Can you recognise 2 people?
9. Count backwards from 20 to 1?
10.Can you remember the address I just gave you?
INVESTIGATIONS
•
•
•
•
•
•
•
•
•
Exclude hypoglycaemia and hypoxia at the bedside.
U&Es, Ca
LFTs
FBC
ESR & CRP
Troponin
Glucose
Blood cultures if any evidence of infection
ABGs if tachypnoeic, low 02 sats (<96%), possibility of C02 retention
or metabolic acidosis
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•
•
•
•
•
Urinalysis +/- MSU
CXR
ECG
Abdo USS if LFTs deranged – eg. to investigate possible cholecystitis
Consider CT brain +/- LP if delirium persists without known precipitant.
Further investigations should be under the supervision of a specialist.
MANAGEMENT
• Because delirium is usually due an interaction between multiple
predisposing factors and precipitating factors, management should
be aimed at not just finding and treating the assumed cause, but
also optimising all aspects of care:
1. optimise physiology: correct hypoxia and hypoglycemia, treat anaemia, dehydration, hyponatraemia, malnourishment, etc.
2. treat any possible precipitants
3. stop or reduce deliriumogenic drugs (amitriptyline, etc.) – consult pharmacist if unsure
4. minimise mental stress – provide repeated re-orientation, involve family/carers, and provide care in as quiet and stable an environment as possible (eg. side room)
5. avoid prolonged bedrest: mobilisation can help recovery
• Management is best carried out on specialist units: transfer to
Acute Medicine of the Elderly ward early. Appropriate nursing care
can often avoid sedation (quiet, well lit environment).
• If agitation causes severe distress or immediate danger of injury
consider using drug treatment. The first line drug is haloperidol
0.5mg oral or im, at intervals of 20 min – 1 hr until agitation is reduced
to acceptable levels. If in any doubt contact a senior colleague for
advice or seek specialist help. See below for further details
ADDITIONAL POINTS
• Benzodiazepines prolong delirium and may worsen outcome. Do
not use unless under specialist supervision, alcohol withdrawal is
suspected, or the patient has Parkinson’s disease or dementia with
Lewy Bodies.
• Delirium is very common in dying patients – treat cause(s) if possible
and consider antipsychotics
• Differentiation between depression, dementia and delirium can be
difficult, and where the delirium persists seek specialist advice.
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ACUTE AGITATED CONFUSION IN AN OLDER PATIENT
PRESCRIBING GUIDELINE
Look for possible precipitants
Metabolic problems - sodium, calcium, hypoxia, hypoglycaemia?
Is your patient in pain?
Is there infection in chest, urine, skin, joints, or meninges?
Is alcohol withdrawal
a possibility?
Is benzodiazepine withdrawal
Is urinary retention a possibility?
a possibility?
Drugs - be suspicious of all prescribed drugs and check
that none have been suddenly stopped.
Can you modify the environment?
One to one nursing - discuss extra staff with the directorate manager.
Try to find a quiet, well lit,
side room.
Can family stay with the patient for Provide an understanding nurse.
some of the time?
Is your patient too hot, too cold, or hungry?
Drug Treatment
N.B. Only use drugs if your patient is at risk of causing
harm to themselves or others.
If alcohol or benzodiazepine withdrawal is a possibility refer to the
alcohol withdrawal guideline.
In other cases use:
1. Haloperidol
0.5-1mg orally if possible Wait 20 mins at least
2. If no response
0.5-2mg orally or IM
Wait 20 mins at least
repeat Haloperidol
3. If no response discuss with a senior member of your team
4.If agitation remains an acute problem discuss with on-call psychiatric
staff. (Out of hours contact via REH switchboard on Ext.7600)
An alternative to haloperidol in patients in whom this is unsuitable (eg. Parkinson’s
disease, dementia with Lewy Bodies) is lorazepam 0.5mg orally or im, using
same regime as for haloperidol. Use as little as possible: benzodiazepines
prolong delirium and may be associated with a worse outcome.
REMEMBER
This is a general guideline - your patients have individual problems
Seek and treat participants
Try to modify the environment
Give drugs time to work
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FALLS AND IMMOBILITY
Falls and unsteadiness are very common in older people. Although
only 10-15% of falls result in serious injury, they are the cause of 92%
of hip fractures in older women. There is now a good evidence base for
falls and fracture prevention.
PROBLEMS THAT MAY PRESENT AS A “FALL” OR “OFF LEGS”
Bear in mind that many patients will be in more than one of these
categories:
• Loss of consciousness: syncope or seizure.
• Acute illness e.g. infection, stroke, metabolic disturbance.
• Simple trip.
• Chronic neurological and locomotor disease (see below).
ASSESSMENT
Full history and examination are required:
• Ask about the circumstances of the fall, and frequency if they are
recurrent
• Try to establish if the patient lost consciousness e.g. “do you
remember hitting the ground?”. A witnesses account is best.
• Check for symptoms or signs of acute illness, especially infection.
• Find out the past history - if necessary ask the relatives and GP.
Conditions associated with falls:
- Stroke and vascular dementia.
- Parkinson’s disease.
- Alzheimer type dementia.
- Disease of weight bearing joints e.g. OA, joint replacement or
previous fracture.
- Depression.
• Look for the known risk factors for falls (many patients will have
several):
- Impaired cognitive function: check the AMT.
- Poor balance: ask and examine the patient’s gait.
- Reduced strength: grade 1-5 and look for wasting.
- Poor vision: ask and check eyesight.
- Postural hypotension: ask about dizziness on standing up and
check erect and supine blood pressure and drug treatment.
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•
•
•
Drugs:
- polypharmacy (>4 drugs).
- sedatives and anti-psychotics.
- antidepressants including SSRIs.
- hypnotics
Exclude serious injury e.g. hip or vertebral fracture, head injury.
Assess osteoporosis risk e.g. previous low trauma fracture, low
BMI, steroid use, smoker and consider DEXA scan.
Admission is required in those who:
• cannot walk without help
• are acutely unwell
• are falling so frequently that they can’t manage at home.
INVESTIGATION
•
•
•
•
•
•
•
•
FBC
U&E, glucose, LFTs, CRP, Ca & PO4.
Digoxin level if on this.
Urinalysis and MSU if features of sepsis, pyrexial or raised WBC and
CRP.
ECG (24 hour ambulatory ECG is not helpful unless the patient is
having recurrent syncopal episodes).
Chest X-ray.
If the patient has impaired cognitive function unexplained by known
pathology:
- CT brain, B12 and folate, TFTs.
If the patient has impaired balance or strength unexplained by known
pathology, consider CT brain if focal neurological signs, X ray if
abnormal joints. Occasionally other investigations are required such
as nerve conduction studies to confirm a peripheral neuropathy, or
Vitamin D levels in proximal myopathy. (Osteomalacia).
MANAGEMENT
This has to be tailored to the individual patient’s problems and requires
input from a multidisciplinary team.
• Treat any acute illness.
• Optimise the management of any chronic pathology e.g.:
- Pain control and physiotherapy for degenerative joint disease.
- Adjust anti-Parkinsonian medication to achieve best control.
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•
- Ensure 20 stroke prevention and treatment measures are in place.
Multifactorial intervention for falls prevention in all:
- Exercise and balance training by physiotherapy.
- Reduce medication as far as possible and reduce or stop any
contributing drugs e.g. diuretics, antithypertensives, SSRI or
anti-anginals.
- Reduce postural hypotension:
• ensure not anaemic
• reduce or stop any contributing drugs
• teach the patient to rise carefully from bed or chair
• consider TED stockings
• in extreme cases, seek expert advice regarding drug treatment
to maintain or raise BP
- Safety education and home hazard assessment by OT
- Correct visual impairment
• Refer to Lothian Joint Formulary guidelines on osteoporosis.
• Commence treatment with a weekly bisphosphonate and Adcal
D3 in those with proven osteoporosis and those with 2 or more
previous fragility fractures.
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Chapter 9
HAEMATOLOGY & ONCOLOGY EMERGENCIES
1. NEUTROPENIC SEPSIS
Definitions
Neutropenia: neutrophil count of less than 1.0 x 109/l.
Fever: isolated temperature greater than 38.5oC or 2 recordings greater
than 38.0oC two hours apart.
Presenting features
• Generalised constitutional symptoms are common (lethargy,
rigors, confusion). Patients can go from being well to being in life
threatening septic shock in just a few hours. Neutropenia markedly
alters the host’s immune response and makes infection more
difficult to detect.
• Ask about respiratory, urinary, oropharyngeal and lower GI
symptoms. Enquire about recent instrumentation/dental work.
• Does the patient have a Hickman Line? Ask about recent line use
and whether there is pain around the line.
i Patients with febrile neutropenia MUST receive antibiotics
even if there are no localising signs of infection.
Assessment
Look for:
• Signs of shock e.g. tachypnoea, tachycardia, hypotension, altered
mental state.
• Fever
• Detailed examination for any localising signs of infection.
Management
• Assess ABCDE. Treat as in Chapter 2.
• Give high concentration oxygen by mask.
• Gain IV access and resuscitate with colloid if hypotensive.
• Check full blood count, electrolytes, renal function, LFT’s, calcium,
lactate, ABG & CRP.
• Take blood cultures, peripheral and from all line lumens.
• Urine for culture (even if dipstick - negative).
• Stool for culture and C difficile toxin if patient has diarrhoea.
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•
•
•
•
•
Sputum if available.
Other microbiology samples depending on symptoms and signs eg throat swab, mouth swab, ear swab.
Viral throat swab and serology.
Perform chest x-ray.
Monitor respiratory rate, SpO2, pulse/BP every 15 mins until
stable.
• Monitor urine output.
Anti-microbial therapy
Information available: WGH Haematology handbook on LUHD intranet - microsites - haematology-WGH
• Tazocin 4.5g IV QDS & IV gentamicin 7mg/kg OD (ideal bodyweight)
(see guideline for administration and monitoring).
• Add clarithromycin if chest infection.
• Add metronidazole if lower GI symptoms.
Replace gentamicin with vancomycin if a) patient MRSA colonised;
b) long term central line. In latter consider removing the line.
2. SPINAL CORD COMPRESSION
• 20% of patients with vertebral metastases develop spinal cord
compression.
• Early recognition is vital.
• Pre-treatment neurological status is the most powerful predictor of
functional outcome.
Presenting features
• Back pain (local or radicular) in 90% of cases.
• Weakness (80%) which is usually progressive over days/weeks.
• Sensory loss or paraesthesia, which may ascend to the level of
compression.
• Autonomic dysfunction (urinary retention, constipation) occurs late
& is associated with a worse prognosis.
Assessment
Careful neurological examination. There are two broad syndromes.
1. Spinal cord compression (above L2) - increased tone (reduced if
acute syndrome), weakness, hyper-reflexia & extensor plantors.
Sensory level to pinprick (spinothalamic tracts) & proprioceptive
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loss (posterior columns). The bladder may be palpable. Local spinal
tenderness.
2. Cauda equina syndrome (L2 down) weakness, variable sensory
loss, characteristically perianal sensory loss.
Management
• Early identification and treatment are vital.
• Give adequate pain relief.
• Give dexamethasone 16mg IV on clinical suspicion (helps pain &
reduces pressure on cord).
• Contact on call Clinical Oncology registrar via WGH switchboard.
Neurosurgical referral may be appropriate.
• X-ray spine (85% are abnormal). Look for pedicular erosion (“winking
owl” sign) on AP films & collapse on lateral films.
• Urgent MRI spine (discuss with on-call Neuroradiologist).
• Catheterise, if in urinary retention.
• Anti-thrombotic measures (heparin prophylaxis as per local policy,
TEDS).
• Bedrest until further advice.
Definitive Treatment
Steroids followed by neurosurgical decompression/stabilisation or
palliative radiotherapy.
3. SUPERIOR VENA CAVA OBSTRUCTION
90% of cases have a malignant cause. The commonest is lung cancer
(65%) followed by lymphoma, metastatic lymphadenopathy, germ cell
tumours & thymoma.
Presenting features
Usually insidious onset with progressive dyspnoea, facial swelling,
head fullness, arm swelling & cough. Symptoms may be present only
on waking, and may be aggravated by lying down.
Assessment
• Distended neck veins, distended chest wall veins & facial oedema
are the commonest signs. Cyanosis, facial plethora and arm oedema
can also be seen.
• Examine for neck nodes.
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Management
• Sit upright.
• Give high concentration oxygen by mask.
• Arrange chest x-ray (60% have superior mediastinal widening).
• Discuss with on-call Clinical Oncology registrar via WGH
switchboard.
• 60% of patients have no known malignant diagnosis. Consider
sputum cytology, biopsy of neck nodes or bronchoscopy.
• Where at all possible histological diagnosis should be made
prior to treatment:
- Discuss with Chest Physician, Thoracic Surgeon.
Treatment
Depends on:
1. Aetiology of obstruction (extrinsic compression vs. SVC
thrombus).
2. Histology of tumour.
CT thorax and/or venography add more information.
• Dexamethasone 4mg qds.
• SVC stent + or - thrombectomy (discuss with interventional
Radiologists at RIE).
• Radiotherapy (if no histology or non small cell lung carcinoma).
• Chemotherapy (lymphoma, small cell lung cancer, germ cell
tumours).
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Chapter 10
TOXICOLOGY
National Poisons Information Service (NPIS)
NPIS (Edinburgh) is one of four UK centres commissioned by the
Health Protection Agency that contribute to the TOXBASE® website.
This provides guidance on the management of poisoning by any one
of a large number of different drugs, chemicals and plants. TOXBASE®
is a standard reference for advice on the features and treatment of
poisoning cases, and is updated on a daily basis. It can be accessed
from the Combined Assessment Area (Base 6) and A&E departments
at the Royal Infirmary, ARAU at the WGH, the A&E department of St.
John’s Hospital, and the critical care areas on all three sites. Additional
information related to unusual or severe poisoning can also be obtained
by telephone.
NPIS : 0870 600 6266
24-hour information service for more severe and complex
poisoning cases
ADMISSION POLICY
• Patients who present after drug overdose or deliberate self-harm
(e.g. self-cutting) normally require admission to hospital. In some
cases this may be for psychiatric assessment alone, rather than
ongoing medical care. The preferred site for admission in Edinburgh
is CAA Base 6, Royal Infirmary (0131-242-1443).
• Patients who are unconscious or at high risk of airway or
haemodynamic compromise should normally be admitted to a
critical care area (e.g. HDU, ICU).
• Patients expressing suicidal thoughts but who have not actually
harmed themselves or taken a drug overdose do not usually need
admission to a medical unit, and should be discussed with the oncall duty Psychiatrist.
• At SJH patients are managed in A&E.
IMMEDIATE MANAGEMENT
• Maintain airway using nasopharyngeal or oropharyngeal airway if
conscious level is reduced
• Endotracheal intubation is required if unresponsive and loss of
protective airway reflexes. Make ICU referral early
• Give oxygen if drowsy aiming to maintain SpO2 > 92%
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• Ensure adequate ventilation. Treat underlying cause if applicable or
consider need for intubation and ventilation. NB. Opiate overdose
may lead to respiratory depression with hypoventilation
• Consult TOXBASE®; contact NPIS if further advice needed
0870 6006266 (24hr)
• Consider need for activated charcoal or gastric lavage
• Record pulse, blood pressure, oxygen saturation, respiratory rate
and temperature
• Monitor cardiac rhythm if drug likely to have haemodynamic effects
or cause arrhythmia
GENERAL MANAGEMENT
• Manage in an appropriate care area eg HDU/ICU
• Correct underlying hypoxia to reduce risk of seizures or
arrhythmias
• If hypotensive administer IV fluids to ensure adequate hydration
and elevate the legs. If blood pressure remains low then inotropes
may be required.
• Metabolic acidosis increases the risk of seizures and arrhythmia after
overdose with certain drugs. If acidosis persists despite correction
of hypoxia and hydration status then IV sodium bicarbonate
may be administered. 1.26% sodium bicarbonate 250 ml can be
administered and repeated as necessary. Seek expert advice.
• Control agitation with oral or IV diazepam (0.1-0.3mg/kg body
weight). Repeated administration may be needed. Large doses
may be needed in patients using recreational drug such as cocaine
or amphetamines.
• Treat seizures with IV lorazepam 2-4 mg or diazepam 5-10 mg;
repeated doses might be needed. Management of persistent
seizures should be discussed with the NPIS; some anticonvulsants
can increase toxicity of a number of drugs.
• If cardiac arrhythmias occur ensure that hypoxia and metabolic
acidosis are corrected. Arrhythmias due to tricyclic antidepressant
overdose should be treated with IV sodium bicarbonate, which
should be given as 50 ml 8.4% sodium bicarbonate or 250ml
1.26% sodium bicarbonate via a central or large peripheral vein.
• Torsade de pointes arrhythmia (polymorphic ventricular tachycardia)
can be caused by some drugs that prolong the QTc interval. This
should be treated with IV magnesium sulphate 8-10 mmol, given over
1-2 minutes. This may be repeated after 5-10 minutes if necessary.
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• Use antidotes where indicated in TOXBASE®.
GUT DECONTAMINATION/DRUG ELIMINATION
• Induced vomiting is of no benefit, is potentially hazardous, and
should be avoided.
• Absorption of many drugs may be reduced by oral activated charcoal
(50 g) within the first hour post ingestion. Activated charcoal must
not be given without adequate airway protection.
• Some substances including iron, lithium, methanol and ethylene
glycol are not bound to charcoal.
• Repeated doses of activated charcoal enhance elimination of
certain drugs, and can be beneficial beyond 1 hour post-ingestion:
carbamazepine, phenobarbitone, quinine and theophylline.
• Gastric lavage is rarely necessary, and should be considered only
if a life-threatening dose of chemical or drug have been ingested
within 1 hour.
• Gastric lavage should NOT be undertaken in patients with reduced
conscious level or inadequate airway protection, or after ingestion
of petroleum distillates or corrosives due to the risk of aspiration. If
in doubt discuss with the NPIS.
• Whole bowel irrigation with osmotic laxatives may reduce absorption
of some drugs that are not adsorbed by charcoal. It is occasionally
necessary for patients who have ingested packages of illicit drugs
(e.g. ‘body-stuffers’).
• Urinary alkalinisation may increase elimination of some drugs (e.g.
salicylate), and can protect against renal impairment in patients
who have rhabdomyolysis.
• Haemodialysis can improve outcome in some cases of severe
toxicity, e.g. digoxin, ethylene glycol, lithium, methanol and
salicylates. Further information is available from TOXBASE® and
NPIS.
EMERGENCY INVESTIGATIONS
• See table for suggested investigations
• Perform arterial blood gas if airway is compromised, hypoventilation
or metabolic acidosis is suspected. Carboxyhaemoglobin should
also be measured in cases of suspected carbon monoxide
poisoning.
• Chest X-ray should be performed if the patient is persistently
248 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
hypoxic or after inhalational exposure.
• Paracetamol and salicylate concentrations should be measured if
there is suspected ingestion of either, or the ingested drugs are
unknown. The timing of sample collection is important.
• Plasma concentrations of certain other drugs can be helpful, e.g.
carbamazepine, digoxin, iron, lithium, phenytoin, theophylline and
thyroxine.
• In cases of severe unexplained metabolic acidosis, consider
measurement of ethanol, methanol and ethylene glycol
concentrations (discuss with local laboratory).
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249
A GUIDE TO OBSERVATIONS AND INVESTIGATIONS FOR THE
PATIENT WITH ACUTE POISONING
Drug
At risk of U&EsLFTs INRCK ABG Drug12-lead Cardiac Detected Comment
level ECG monitor in TOX
screen?
Amphetamine Hyperpyrexia    


/ecstasy
Antihistamine ECG 

changes
Antipsychotic ↓BP,  

ECG changes
Aspirin
Acid-base 
 
disturbance
if severe
Benzodiazepine ↓GCS,
↓BP,
↓respiration Beta-blocker ↓HR, ↓BP 


Calcium
↓HR, ↓BP, 


channel arrhythmia
blocker
Carbamazepine Ataxia,  


↓GCS, ECG
changes
Cocaine
↑BP, MI

 


Iron
GI 

bleeding, acidosis
Lithium
↓BP, 



Check CK
if ↑temp
Level at 2
and/or
4 hours
Level not
urgent
Level at 4
hours
Level immediately
arrhythmia
& at 6 hrs
(not in Lithium sample tube)
NSAIDs
Renal 
failure
Opiates
↓GCS, 

↓BP,
↓respiration Paracetamol Hepatic


Level at 4
0-8 h
and renal hours
failure
Paracetamol Hepatic
  

8-24 h
and renal
failure
Paracetamol Hepatic
  

>24 h
and renal
failure
Phenytoin
Ataxia, 


Level if on
↓GCS, regularly
ECG
changes
Sodium ↓BP,

valproate
renal

 if
failure severe
SSRI ↑temp,
antidepressants ↑HR

 

TCA ↑HR,
antidepressants arrhythmia, 


seizures
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MANAGEMENT OF COMMON POISONINGS
Paracetamol
Early features: usually none
Late features: nausea, vomiting
Toxicity: Ingestion of >150 mg/kg (or >12g) or >75 mg/kg in a high-risk
patient may be fatal or cause severe toxicity
PRESENTATION WITHIN 8 HOURS OF INGESTION
• Give activated charcoal if >150 mg/kg ingested within 1 hour
• Measure paracetamol concentration at 4 hours. There is no point in
measuring the concentration before this.
• Use paracetamol nomogram (shown below) to determine need for
treatment. Remember to check if patients have any risk factors.
• If paracetamol level is above treatment line, give N-acetylcysteine
(NAC). Normally, N-acetylcysteine should not be given until
paracetamol levels known.
Plasma
Paracetamol
(mgl/l)
Plasma
Paracetamol
(mmol/l)
TREATMENT LINES
200
-1.3
190
180
-1.2
170
160
Normal treatment line
-1.1
150
High risk treatment line
-1.0
140
130
-0.9
120
-0.8
110
-0.7
100
-0.6
90
80
-0.5
70
Prognostic accuracy
after 15 hours uncertain
60
50
-0.4
-0.3
40
-0.2
30
20
-0.1
10
0
-0
0
2
4
6
8
10
12
14 16
18
20
22
24
Hours after ingestion
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251
HIGH RISK FACTORS
A number of factors increase the risk of toxicity after paracetamol
ingestion, either because they are associated with hepatic enzyme
induction (more rapid formation of toxic metabolite), or glutathione
depletion (inability to detoxify toxic metabolite):
•
•
•
•
•
•
•
•
Carbamazepine
Phenobarbitone
Phenytoin
Primidone
Rifampicin
St John's Wort
Regular alcohol excess
Malnutrition (e.g. eating disorders, cystic fibrosis, Muscular
dystrophies, AIDS)
N-ACETYLCYSTEINE (NAC)
• Treatment is most effective if started within 8 hours of ingestion.
Adult dosing schedule for N-acetylcysteine:
• 150mg/kg IV in 200mls 5% dextrose over 15 minutes, then:
• 50mk/kg IV in 500mls 5% dextrose over 4 hours, then:
• 100 mg/kg in 1000mls 5% dextrose over 16 hours
ANAPHYLACTOID REACTIONS TO N-ACETYLCYSTEINE
• A histamine-mediated reaction occurs in 10% of patients, usually
within 30 min: features include flushing, vomiting, rash, and rarely
bronchospasm and hypotension. True anaphylaxis does not tend to
occur.
• Infusion should be stopped, and symptoms often subside within
20-30 minutes. In some cases, antihistamines may be needed (e.g.
IV chlorphenamine 10-20 mg). Occasionally, bronchodilators are
required (e.g. nebulised salbutamol 5 mg) and, rarely, IM adrenaline
and IV hydrocortisone are required for severe hypotension. See
chapter 2.
• When symptoms have resolved the NAC infusion should be
recommenced at 50% of the normal administration rate.
• Reactions to NAC do not necessarily recur. Therefore, the normal
treatment schedule should be used even if patients have a history
of a reaction to a previous N-acetylcysteine infusion.
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PRESENTATION 8-15 HOURS POST INGESTION
• If >150 mg/kg (or >12g) or >75 mg/kg in a high risk patient has
been ingested start N-acetylcysteine immediately (see Adult Dosing
Schedule above)
• Check FBC, U&Es, LFTs and prothrombin time (INR) and paracetamol
concentration
• If paracetamol concentration is below treatment line, ALT and INR
are normal and the patient is asymptomatic discontinue NAC.
• Otherwise continue with the normal infusion protocol.
PRESENTATION 15 –24 HOURS
i Patients presenting late are at greatest risk of developing
liver damage.
• If >150 mg/kg (or >12g) or >75 mg/kg in a high risk patient has been
ingested start N-acetylcysteine immediately
• Check FBC, U&Es, LFTs and prothrombin time (INR) and paracetamol
concentration
• The paracetamol concentration is less reliable at this time, and
the presence of an elevated prothrombin time and ALT are better
markers of possible liver damage
• If blood tests are all normal and the patient is asymptomatic, Nacetylcysteine can be discontinued otherwise continue with the
normal infusion protocol.
PRESENTATION >24 HOURS
i Patients presenting late are at greatest risk of developing
liver damage.
• Check FBC, U&Es, LFTs and prothrombin time (INR)
• If investigations are normal, and the patient is asymptomatic no
further medical treatment is required
• If abnormal give N-acetylcysteine
• Patients require frequent monitoring of U&Es (including bicarbonate),
LFTs, INR, lactate and glucose
• Progressively rising INR and ALT, metabolic acidosis, renal
impairment, hypoglycaemia and hepatic encephalopathy are poor
prognostic indicators and the patient should be discussed with
the NPIS and on-call gastroenterology/ liver team (via switchboard
RIE).
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253
STAGGERED OVERDOSE
• If >150 mg/kg (or >12g) or >75 mg/kg in a high risk patient has been
ingested within a 24-hour period, then N-acetylcysteine infusion
should be given
• Check FBC, U&Es, LFTs and prothrombin time (INR)
• Plasma paracetamol concentration will confirm ingestion but cannot
be used to determine the need for treatment
• If repeat blood tests are normal 24-hours after ingestion of the last
tablets, and the patient is asymptomatic, then N-acetylcysteine can
be discontinued
COMPLETION OF N-ACETYLCYSTEINE
• Check U&Es, ALT and prothrombin time (INR) at the end of the
infusion.
• If ALT and creatinine are normal, and INR ≤1.3, then the patient
can be discharged after appropriate psychiatric review (N.B. Nacetylcysteine directly causes a rise in INR that is not related
to liver function).
• If ALT or creatinine are abnormally high, or INR >1.3, or there is
metabolic acidosis, then N-acetylcysteine should be continued at
150 mg/kg over 24 hours. Coagulation and LFTs should be checked
every 8-12 hours. When there is a sustained improvement the Nacetylcysteine can be discontinued.
• In a small number of cases, INR and ALT continue to rise despite
N-acetylcysteine therapy. Patients may develop liver failure, renal
failure, hypoglycaemia and metabolic acidosis. These patients may
need consideration for liver transplant, and should be discussed
with senior staff urgently.
BENZODIAZEPINES
Features
Drowsiness, hypotension, coma and respiratory depression. Toxicity is
worse when co-ingested with alcohol or other CNS depressants, e.g.
opioids.
Toxicity
Serious toxicity from pure benzodiazepines is uncommon
Management
• Consider need for gut decontamination if present within 1 hour of
ingestion
254 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
• If significantly reduced conscious level or respiratory depression,
then call 222 for urgent endotracheal intubation and ventilatory
support in a critical care area
• Flumazenil (Anexate®), a benzodiazepine antagonist, may be used
if immediate access to critical care is not available. It has a short
half-life (around 1 hour) and can provoke seizures, especially in
patients with:
1. Pre-existing epilepsy
2. Benzodiazepine-dependence
3. Mixed overdose, particularly common after tricyclic antidepressants
i FLUMAZENIL should not be used as a ‘diagnostic test’.
SALICYLATES
Features
Vomiting, tinnitus, deafness. In severe cases confusion, seizures,
metabolic acidosis, pulmonary oedema and coma may occur.
Toxicity
Likely if >250 mg/kg ingested; >500 mg/kg can cause severe toxicity/
death.
Management
• Give activated charcoal if >120 mg/kg ingested less than 1 hour
ago.
• It can take several hours to reach peak plasma concentrations.
Salicylate concentrations should be checked in patients who have
ingested >120 mg/kg.
• In symptomatic patients: check at 2 hours post-ingestion, then
repeat after further 2 hours in case of on-going drug absorption.
• In asymptomatic patients: check at 4 hours post-ingestion.
• In patients with features of toxicity, a repeat level should be checked
in case of prolonged drug absorption, and repeated until levels are
falling.
• Poisoning severity is indicated by plasma salicylate concentrations
taken together with clinical and biochemical features. Concentrations
>350 mg/l (2.5 mmol/l) are associated with toxicity, and
concentrations >700 mg/l (5.1 mmol/l) are associated with severe
toxicity and may be fatal. Confusion, impaired consciousness,
metabolic acidosis and high salicylate concentrations all indicate
severe poisoning.
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255
• Check U&Es, prothrombin time (INR) and blood glucose. If serum
potassium is low this must be corrected first. After correction of
serum potassium, metabolic acidosis should be corrected with IV
sodium bicarbonate.
• If salicylate >500 mg/l, then IV 1.26% sodium bicarbonate 1500
ml should be administered over 2 hours to enhance salicylate
clearance. This should be repeated as necessary to obtain optimal
urine pH 7.5-8.5. It is important to monitor electrolytes and acidbase status closely (particularly to avoid hypokalaemia).
• Patients with plasma salicylate level >700 mg/l, those with renal
failure, severe metabolic acidosis, pulmonary oedema or CNS
toxicity should be considered for haemodialysis (discuss with NPIS
for further information).
ANTIDEPRESSANTS
Features
• Tricyclic antidepressants (TCAs) e.g amitriptyline, dosulepin
Tachycardia, dilated pupils, urinary retention, hyperreflexia, divergent
squint, hypotension, seizures, coma, arrhythmias, prolonged QRS
duration, metabolic acidosis.
• Selective serotonin reuptake inhibitors (SSRIs) e.g. paroxetine,
sertraline. Nausea, vomiting, tremor, prolonged QTc, serotonergic
syndromes.
• Selective norepinephrine reuptake inhibitors (SNRIs) e.g.
venlafaxine. Tachycardia, tremor, agitation, prolonged QRS and
QTc duration, arrhythmia, seizures, coma.
• Mirtazapine. Drowsiness, nausea, vomiting.
Toxicity
• In general the most toxic in overdose are venlafaxine and tricyclics
(particularly dosulepin) due to the risk of seizures and arrhythmia.
• Toxicity greatest when two or more antidepressants taken together.
Management
• Consider activated charcoal if within 1 hour of ingestion.
• Organise early intubation and intensive care admission if reduced
conscious level.
• Correct electrolyte or acid-base disturbance, ensure adequate hydration.
• Perform ECG and monitor cardiac rhythm.
• If QRS >120 ms after TCA overdose, administer IV 8.4% sodium
bicarbonate 50 ml (=50 mmol) via central or large peripheral vein,
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even in the absence of acidosis, to reduce risk of arrhythmia and
seizure. Repeat as necessary.
• Arrhythmias are best treated by correction of hypoxia and acidosis
(metabolic and respiratory). Torsade de pointes should be treated
with IV magnesium sulphate 8-10 mmol over 1-2 minutes. Consult
TOXBASE® or contact NPIS for further advice.
• Treat seizures with IV lorazepam (2-4 mg) or diazepam 5-10mg;
repeated doses may be required.
• Serotonin syndrome may occur after ingestion of 2 or more drugs
with serotonergic effects e.g. TCAs, SSRIs, monoamine oxidase
inhibitors, tramadol. Features include alteration of mental status,
neuromuscular hyperactivity and autonomic instability. If suspected,
monitor temperature and check serum creatinine kinase (CK).
Discuss management with NPIS.
OPIOIDS
For example codeine, diamorphine, dihydrocodeine, fentanyl,
methadone, morphine, pethidine, tramadol.
Features Reduced conscious level, respiratory depression, pinpoint pupils and
hypotension. (N.B. opioids and their active metabolites accumulate in
patients with renal impairment: opioid toxicity should be suspected
in any patient with unexplained type-2 respiratory failure)
Management
• ABCDE as Chapter 2.
• Monitor respiratory rate and ensure adequate airway and support
ventilation.
• If reduced conscious level or respiratory depression, then administer
IV naloxone 0.4-2.0 mg: repeat the dose if inadequate response
after 2 minutes.
• Naloxone (Narcan®) is a competitive antagonist and large doses
(>4 mg = 10 ampoules) may be required in severe cases.
• Naloxone can be administered by the IM route if IV access is not
possible, or if the patient is threatening to self-discharge when its
effects might be more prolonged.
i The plasma half-life of naloxone is shorter than that of
most opioids, so repeated doses are often required. This
is especially true of long-acting opiates (e.g. MST or
methadone), where a naloxone infusion might be needed.
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257
• Naloxone infusion is usually started at around 60% of the initial dose
per hour. A solution containing 5 mg (12.5 ampoules) reconstituted
in 25 mls dextrose gives a 200 micrograms/ml solution for IV infusion
via a syringe driver.
• Measure U&Es and CK. N.B. patients who have reduced
conscious level are at high risk of rhabdomyolysis, pressure
injuries and compartment syndromes.
RECREATIONAL DRUGS
Features
• Stimulants such as MDMA (ecstasy), amphetamines, cocaine,
lysergic acid diethylamide (LSD) may cause severe agitation,
tachycardia, sweating, pyrexia, dilated pupils, hypertension,
arrhythmia and seizures. Severe cases result in coma,
rhabdomyolysis, renal failure, subarchnoid haemorrhage, myocardial
infarction, refractory seizures and death.
Specific features
• Cocaine also causes coronary artery spasm, myocardial ischaemia
and infarction and aortic dissection.
• Ecstasy may cause severe hyponatraemia.
• Gamma hydroxybutyrate (GHB) may cause bradycardia,
hypotension, reduced conscious level and coma.
Management
• Measure U&Es, LFTs and CK.
• Perform ECG and monitor cardiac rhythm.
• Control agitation and seizures with diazepam. Large doses and
repeated administration may be required.
• Hypertension usually settles after administration of diazepam. If
hypertension persists despite diazepam, then consider intravenous
nitrates (e.g. glyceryl trinitrate 1-2 mg/hour) and gradually increase
the dose until blood pressure is controlled.
• Treat cocaine induced chest pain and ECG changes with aspirin,
diazapem and nitrates.
• Tachycardia usually responds well to adequate sedation and
control of agitation, and specific therapy is not normally needed.
• Correct metabolic acidosis with sodium bicarbonate.
• Hyperthermia should be treated with passive cooling and sedation with
intravenous diazepam (large doses may be required). However, when
body temperatures exceed 40ºC, then more active cooling is preferable,
and the patient should be transferred to a critical care area.
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Chapter 11
ACUTE RHEUMATOLOGY
ACUTE MONO OR OLIGOARTHRITIS
i Commonest causes are summarised by the abbreviation
GRASP. Acute arthritis in > 1 joint should be considered to be
sepsis until proven otherwise.
• Every effort should be made to aspirate involved joints, involving onsite orthopaedic teams/radiology for ultrasound guided aspiration if
necessary.
• It is imperative to send blood cultures on admission.
• Once aspirates and blood cultures are sent, empirical IV antibiotics
(see below) should be commenced. Err on side of diagnosis of
sepsis until proven otherwise.
GOUT
•
•
•
•
•
•
1st MTPJ > ankle > knee > upper limb: tophi.
Middle age to elderly.
Men > women.
Polyarticular in 10%.
Can mimic sepsis: see above.
Atypical subacute onset in hands in elderly women with renal
impairment on diuretics.
• History of previous attacks, alcohol or diuretic intake, obesity, renal
disease.
• Family history.
REACTIVE ARTHRITIS
•
•
•
•
•
•
Young male > female.
Large joint, lower limb: usually more than one.
Can mimic sepsis: see above.
History must include GI, Genito-urinary and sexual information.
Balanitis, keratoderma blenorrhagicum, nail changes.
Conjunctivitis, iritis.
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SEPSIS
•
•
•
•
•
Any age, any joint, may be more than one joint.
General symptoms: malaise, fever.
Skin infection may be seen e.g. pustules, boils.
Staphylococcus aureus is most common organism in adults.
Is there reduced immunity? e.g. Rheumatoid arthritis, steroids,
NSAID, liver or renal disease.
• Gonococcal athritis should be considered in young adults. Patients
are usually female with polyarticular disease. There may be no
clinical evidence of concurrent STD.
PSEUDOGOUT
•
•
•
•
•
Middle aged or elderly.
Knee or wrist.
Can mimic gout/sepsis.
Previous attacks likely.
May have chondrocalcinosis on x-ray.
OTHER CAUSES
Other causes include: haemarthrosis, monoarticular presentation of
polyarticular disease, mechanical.
INVESTIGATIONS
For All
i
Every effort should be taken to aspirate involved joints:
Involve on-site orthopaedic teams/radiology for ultrasound
guided aspiration if necessary.
• Record colour, viscosity and turbidity.
• Microscopy for cell count, differential and Gram stain (Microbiology);
polarising microscopy for crystals (Histopathology lab).
• Culture.
• Blood cultures x3.
• FBC and diff, ESR and CRP.
• X-ray joint on admission.
Selective Investigations
• Gout: serum urate (but a poor discriminator).
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• Reactive: stool for Salmonella, Campylobacter, Shigella,Yersinia.
• STDs: endocervical swab or first pass urine for chlamydia.
Endocervical, urethral, rectal and throat swabs (as applicable on
history) for culture for gonococcus.
• Yersinia serology (if stool culture negative).
• Serology in polyarthralgia: parvovirus, ASOT, mycoplasma.
Consider also, if possible exposure history, Lyme.
MANAGEMENT
i Seek rheumatological advice early in suspected septic or reactive arthritis via WGH switchboard.
i If gonorrhoea confirmed, contact tracing should be arranged via
Genito Urinary Medicine.
i GUM do not contact trace for chlamydia: arrange yourself or via
patient’s GP.
Analgesia
• Paracetamol
• NSAIDs
• Others
i In cases with infected joint prosthesis obtain specialist
Orthopaedic or Rheumatological advice.
Gout
• Bed rest plus high dose indometacin (indomethacin) 50mg qds oral
or alternative NSAID e.g. diclofenac 50mg oral bd to maximum
dose. Colchicine (0.5 mg oral od-tds depending on tolerance) is
useful in patients in whom NSAIDs are contraindicated (e.g. renal
failure, allergy, GI complications). Should be used under expert
supervision. Leave 3 clear days between courses, halve dose if
creatinine clearance <10ml/min.
• Intra-articular steroid may be used in difficult cases: consult
Rheumatologist.
• Do not use allopurinol until attack has settled for at least 2 weeks
and only introduce with NSAID or colchicine (0.5mg bd) cover.
Adjust dose of allopurinol if renal function impaired: normal renal
function 300mg od oral, creatinine clearance 30-60ml/min 200mg od
oral, creatinine clearance <30ml/min 100mg od oral.
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261
Reactive Arthritis
• Bed rest plus NSAID in adequate dose +/- intra-articular steroid.
Treat associated/triggering infection. If active arthritis persists
consult Rheumatologist.
Septic Arthritis
• Rest joint in appropriate position.
• Antibiotic therapy
a) First line therapy: flucloxacillin 2 g iv 6 hourly
b) In circumstances where there is increased likelihood of Gram
negative infection (chronic or acute urinary tract infection, chronic
prostate symptoms, recent intra-abdominal surgery)
use flucloxacillin 2 g iv 6 hourly plus ciprofloxacin 500mg oral bd
(ciprofloxacin 400mg iv bd if unable to take oral).
c) Seek Microbiological advice if suspected (risk factors present)
MRSA or confirmed MRSA positive.
• Treatment will vary locally e.g. Orthopaedic patients may be different
to others. Discuss with rheumatologist/orthopaedic surgeon and
specialist microbiologist.
• Once cultures available treat according to sensitivities and on
microbiology advice.
• Duration of antibiotic therapy: minimum of 2 weeks IV, then
prolonged oral or IV therapy depending on whether prosthetic joint,
whether patient immunosuppressed and pathogen. Seek specialist
advice ( from Rheumatology/ID/Microbiology).
Pseudo-gout
• Bed rest, joint aspiration, single injection of intra-articular steroid
usually sufficient. NSAID may be used.
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Chapter 12
PSYCHOLOGICAL MEDICINE
ALCOHOL
PRESENTATION
•
•
•
•
•
Acute intoxication.
Withdrawal “DT’s” see below.
Seizures: withdrawal or intoxication, or hypoglycaemia.
Associated problem e.g. pneumonia, rhabdomyolysis.
Incidental e.g. admission for unrelated problem.
MANAGEMENT
• Check plasma alcohol level, FBC, U&E’s, glucose, LFT’s, clotting,
and other tests indicated e.g. amylase if abdominal pain.
• Start thiamine 300mg od oral.
• Pabrinex may be required if NBM, actual or incipient Wernicke’s
encephalopathy or Korsakoff’s psychosis (see below).
• Indications for Pabrinex:
- Acute confusion
- Reduced conscious level
- Memory problems
- Ataxia
- Opthalmoplegia
- Hypoglycaemia
• Pabrinex IVHP (No1 and No2 mixed) by IV infusion in 100ml 5%
dextrose over 30mins then 8 hourly for 48 hours.
N.B. Risk of anaphylaxis - facilities for treating this must be readily
available.
• Alcohol withdrawal management guidelines are detailed below
and updates are available on the Intranet.
• Never prescribe hypnotics as discharge drugs.
i High dependency or intensive care and nursing observation is
required with IV sedatives.
• Treat any associated problems. Screen for infection including CXR.
N.B. Remember spontaneous bacterial peritonitis and tap any ascites
and send for culture (in blood culture bottles), and urgent Gram stain
and cell count, WCC (>250 per microlitre suggestive of SBP). Check
cytology on ascitic tap.
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• Consider a referral to the liaison psychiatrist/alcohol dependence
team/social worker.
NOTE
• Myelo-suppression, with a reduced platelet count is not uncommon,
as is folate deficiency.
• In chronic pancreatitis the amylase may be normal. A raised CRP is
the best guide.
• TB is more common in alcoholics. Request AFB’s on sputum sample
x3 (preferably early morning).
• Don’t assume alcohol is responsible for a fit. Could the patient have
meningitis, or intra-cerebral pathology following a fall?
• Check for hypoglycaemia.
• Encephalopathic patients may have flap, LOC, signs of chronic
liver disease. Distinguish from DT’s (tremor, restlessness).
• Common precipitating causes of encephalopathy are infection, GI
bleed, electrolyte disturbance, constipation.
• Withdrawal may occur two to three days after hospitalization.
MANAGEMENT OF ALCOHOL WITHDRAWAL
Alcohol dependence and withdrawal are associated with significant
morbidity and mortality. People who admit to drinking more than 10
units a day are likely to have withdrawal symptoms. Delirium tremens
is rare at a consumption of less than 15 units per day. Hypoglycaemia,
hypokalemia, hypocalcaemia and fever may predispose patients to
seizures or delirium tremens.
INITIAL ASSESSMENT
History
Ask the patient ‘Do you take a drink sometimes?’ or ‘What have you
had to drink in the last week?’ Make a note of alcohol consumption
in units wherever possible. If you suspect alcohol dependence ask
‘have you experienced tremor or shakiness in the morning - and taken
a drink to relieve this?’ Ask when they last had a drink. Try to take a
history from an informant if the patient is unable to co-operate.
Examination
Look for excessive capillarisation of the conjunctivae or facial skin,
palmar erythema, and alcohol on the breath.
Key investigations: alcohol level or breathalyser, Gamma GT and liver
function tests, MCV.
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ALCOHOL WITHDRAWAL MANAGEMENT
Ensure patients are cared for in a well-ventilated, adequately lit, quiet area
PRESCRIBING GUIDELINE
MILD SYMPTOMS
Tense, irritable, poor
concentration.
If there is suspicion of
withdrawal then review
regularly
Alcoholintake?
<50 units/week
Encourage fluids
Continue to observe
MODERATE SYMPTOMS
Tachycardia, nausea, tremor,
sweats, anxious, headache,
irritable, flu-like
symptoms, seizures
SEVERE SYMPTOMS
Confusion, visual or auditory
hallucinations, irrational thought/fears,
bizarre, aggressive or
unco-operative behaviour
>50 units/week or
previous history of
alcohol withdrawal
. GAIN CONTROL
IV diazemuls by slow injection. Up to
40mg in divided doses during the first 30
minutes whilst monitored
Adjunctive therapy - haloperidol 5-10mg
IM or IV. If still symptomatic contact
SYMPTOMS Oral diazepam 10-40mg up to four SYMPTOMS admitting consultant for advice (see
notes).
NOT
NOT
times daily and hourly (if
RESOLVING
RESOLVING Options
necessary) are required (max
(i) IM paraldehyde (5-10ml) max 20ml
160mg/24 hours) titrated to
(ii) Midazolam infusion (0.03-0.2 mg/kg/hr)
response.
Consider transfer to higher
If no response after 160mg,
dependency unit. Call ICU consultant or
stop diazepam and go to Step 2
anaesthetist if appropriate.
of Severe Symptoms.
NB: syrup form available
. TO MAINTAIN CONTROL
Haloperidol (oral) 5mg twice daily
increasing to 5mg four times daily if
required.
No medication required
on discharge
VITAMIN SUPPLEMENTATION
ORAL - Thiamine 300mg stat dose then 300mg once daily.
IV - Indications: i) Vomiting/malabsorption/general debility,
ii) Risk of Wernicke/Korsakoff Dose of Pabrinex (2 pairs) up to 8 hourly
untiloralintakeadequate.Ifindoubt-givePabrinexwithoutdelay.
See CSM advice below.
CSM Advice - Pabrinex
I - 1. Restrict to patients in whom enteral treatment is not possible
II - 2. Administer over at least 10 minutes
III - 3. Facilities for treating anaphylaxis should be available
REVIEW PATIENT TWICE DAILY
Signs of major toxic side effects of treatmentmedication?
(a) IV benzodiazepine - monitor pulse, oximetry and respiratory rate. Reversed with flumazenil.
II - • Reductioninmedication? (b) Haloperidol extrapyramidal side effects. Reversed with procyclidine.
I - • Increaseinmedication?
• Continue to observe and review patient
• Reduce the dose of diazepam or
haloperidol according to response
CONTINUATION THERAPY
Convert to oral diazepam as soon as
possible or reduce dose of haloperidol
On discharge prescribe:
• Thiamine 300mg once daily if chronic alcohol problem (GP to review need)
• Diazepam 2-3 days reducing course if committed to abstinence and if under
appropriate review.
Strengths/Preparations available:
SPECIAL NOTES
Diazepam tablets mg, 5mg, 0mg
. Dose with caution in the elderly.
Diazepam syrup mg/5ml, 5mg/5ml
. Thiamine/Pabrinex should always be given before the administration of dextrose
Diazepam injection 5mg/ml
fluids to avoid precipitating Wernicke Syndrome.
Haloperidol ampoule(s) 0mg/ml
. Reality orientation and reassurance is encouraged.
Haloperidol capsule(s) 500mcg
4. Transfer patients to oral medication as soon as possible.
Haloperidol liquid mg/ml
5. For complicated cases or cases that are difficult to control seek specialist advice:
At RIE - consult Psychiatric Team, Medical Registrar/Consult on call at RIE or the
duty psychiatrist (REH).
At WGH - consult consultant on-call or in charge.
At SJH - contact Psychiatry SHO on-call, radio page via switchboard.
6. For follow up contact the Alcohol Liaison Service, RIE ext 21396, WGH contact ext 31834.
. These guidelines may not be appropriate in the peri-operative period.
i Consider referral to Intensive Care if requiring more sedation.
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ALCOHOL LIAISON SERVICE
The service operates at the Royal Infirmary Monday to Friday 09:0017:00.
Direct referral should be made by telephone to extension 21396/21398
or by bleeping Sr Leslie (#6426).
If patients are admitted and discharged over a weekend, referrals
can be made via the service answerphone (as above) or complete a
weekend referral form kept in doctors’ rooms in CAA.
The following details are required when making a referral:
Referrer
Patient name
Address
DOB
Reason for admission
PATIENT’S PERMISSION MUST BE SOUGHT PRIOR TO REFERRAL
N.B. For patients to be seen promptly, referrals must be made as early in
the day as possible. Where possible, a same day service is offered.
There is currently no alcohol liaison service at the WGH. Referrals from
the WGH should go either to psychiatry or the Alcohol Problem Service
at the Royal Edinburgh Hospital.
St John’s: radiopage via switchboard
Alcohol Withdrawal Seizures
Initial treatment with 10mgs diazepam (as Diazemuls) by intravenous
injection over two minutes may be given. Status epilepticus should be
treated according to the guidelines.
Fluid and Electrolyte Balance
Examine for features of fluid depletion and check U&Es. Oral fluid
intake of 2-2.5 litres per day should be given. Intravenous replacement
of fluid and electrolytes may be required; potassium and magnesium
supplementation should be tailored according to blood chemistry.
Hypoglycaemia should be excluded by blood sugar measurements
and treated accordingly.
Vitamin Supplementation: see above.
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ACUTE DISTURBANCE
Guide for medical practitioners on the granting of an emergency
detention certificate under section 36 of the Mental Health (Care and
Treatment) (Scotland) Act 2003.
Registered medical practitioner (see notes 1) carries out a medical examination and
recommends hospital admission.
Patient Agrees to Admission
Patient Refuses Admission
The patients must meet these grounds for detention:
1. You consider it likely that conditions (a) and (b) are met:
(a) the person has a mental disorder (see notes 2) : and
(b) because of that mental disorder, the person’s ability to
make decisions about the provision of medical treatment
for that mental disorder is significantly impaired.
AND
2. You are satisfied that conditions (a) to (c) are met:
(a) it is necessary as a matter of urgency to detain the
patient in hospital for the purpose of determining what
medical treatment requires to be provided to the patient:
(b) if the patient were not detained in hospital there would
be a significant risk to the health, safety or welfare of the
patient or to the safety of any other person if the patient
were not detained in hospital.
(c) making arrangements with a view to granting a
short-term detention certificate would involve undesirable
delay.
AND
3. Immediately before the medical examination, the patient
was not detained in hospital by way of certain provisions
of the Act (see note 3).
AND
4. There was no conflict of interests in relations to the
medical examinations (see note 4).
Detention criteria
are met
Patient
subsequently
decides to leave
Non-AMP
available to
examine patient
Continue hospital
treatment
AMP* available
to examine
patient
No medical
practitioner
available
Consider using
nurse’s holding
power under
section 299
Consider whether
criteria for an
emergency detention
certificate are met
Consider whether
criteria for a
short-term detention
certificate are met
Detention criteria are not met: emergency
detention certificate may not be granted.
You must, where practicable, consult a mental health officer (MHO) and obtain their consent to the
granting of the certificate. See notes 5 and 6.
MHO consent obtained.
Impracticable to consult and obtain the
consent of an MHO.
1. Inform patient of decision to grant the certificate
2. Complete and sign the emergency detention on certificate within prescribed
timescales (see notes 7,8 and 9)
3. Ensure that arrangements are in place for the patient’s transfer to hospital
where this is required.
4. Ensure that the detention certificate is passed to the relevant hospital managers
(see note 10).
MHO consent refused.
Emergency detention
certificate may not be
granted and the patient
may not be detained.
Throughout the process of granting an emergency detention certificates, you are bound to have regard to the
principles of the legislation as laid out in sections 1 to 3 of the Act.
*AMP: approved medical practitioner
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This section is still under development. Please refer to the final version
on the Intranet.
Note 1: Any registered medical practitioner may grant an emergency
detention certificate. You do not have to be an approved medical
practitioner.
Note 2: Section 328(1) of the Act defines “mental disorder” as “mental
illness, personality disorder or learning disability, however caused or
manifested”. Section 328(1) further states that a person is not mentally
disordered by reason only of sexual orientation, sexual deviancy: transsexualism: transvestism: dependence on, or use of alcohol or drugs:
behaviour that causes, or likely to cause harassment, alarm or distress
to an other person: or acting as no prudent person would act.
Note 3: The relevant provisions are set out at section 36(2) of the Act
and they are: an emergency detention certificate: a short-term detention
certificate: an extension certificate issued under section 47 of the Act
pending an application for a CTO: section 68 of the Act (i.e. the extension
to the detention period authorised once a CTO application has been
submitted to the Tribunal): a certificate granted under sections 114(2)
or 115(2) of the Act (i.e. a certificate issued subsequent to a patients
non-compliance with the terms of a community-based interim CTO or
a CTO).
Note 4:[DN - conflict of interest material to be added once regs/Code
of Practice material has been finalised]
Note 5: The medical practitioner must consult and seek the consent
of an MHO to the granting of the certificate. All reasonable efforts
should be made to contact a MHO. However, where the urgency of the
situation is so great that it would not be practible for this consultation
to take place then it is permissible for the practitioner to grant the EDC
without consent. [DN -Add best practice material about consulting and
discussing the situation with other members of the multi-disciplinary
team depending on what the final version of the Code says.]
Note 6: Best practice would be that if one MHO refuses to grant consent,
then.... [DN - revise according to the final version of the Code]
Note 7: A valid emergency detention certificate can be issued on
any document if form [x] is not available. However, it is strongly
recommended that form [x] be used in all circumstances. If form
[x] is not used, the emergency detention certificate must state the
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practitioner’s reasons for believing the conditions mentioned at points
1 and 2 on the blue box overleaf to be met and must be signed by the
medical practitioner.
Note 8:The emergency detention certificate must be completed either
by the end of the day on which the medical examination takes place
(if the examination takes place before 8pm) or within 4 hours of the
medical examination being completed (if it takes place after 8pm).
Note 9: The emergency detention certificate authorises first the
patient’s transfer to hospital within 72 hours of the certificate being
granted:and secondly, the patient’s detention in hospital for 72 hours.
Note 10: Section 36(7) of the Act states that the patient’s detention
in hospital is only authorised if the emergency detention certificate is
given to the managers of the hospital before the patient is admitted to
hospital under the authority of the certificate. If the patient is already
in hospital when the certificate is granted, then the certificate must
be given to the hospital managers as soon as practicable after it was
granted [DN - clarification of “hospital managers’ required? depends
on final content of Code on this point.]
The purpose of the above information is to act as a guide only. It does
not provide full and comprehensive coverage of everything you ought
to know about emergency detentions. For fuller information please
consult the Act and its Code of Practice.
OBTAINING INFORMED CONSENT POLICY/PROCEDURE
Care for patients in general as well as psychiatric hospital settings.
Commonest problem area that is covered by the Adults with Incapacity
Act. However, other areas such as the inability to manage money or to
agree to discharge arrangements may be important.
Frequently asked questions and answers
Q1 Why use the Mental Health Act in general hospital?
A1 If someone with a mental disorder is at risk of self-harm, self-neglect
or of harming others they may be prevented from leaving hospital by
use of the Act. Sometimes the Act is used to authorise restraint of
a violent person. Authorisation of compulsory treatment for mental
illness may occasionally be required.
Q2 Who could be detained?
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A2 Someone who has a mental disorder and impaired judgement
about the treatment of that disorder could be detained on a short-term
detention certificate (STDC). If using a STDC would involve ‘undesirable
delay’ an emergency detention certificate (EDC) may be used.
Detention may be necessary to allow for full assessment of suicidal
intent. Violent behaviour is not a mental disorder but may be a sign of
underlying mental disorder such as mania or schizophrenia. Similarly,
violence associated with drug or alcohol intoxification or dependence
is not a mental disorder but delerium or a confusional state may result
from drug or alcohol withdrawal and may justify detention. Psychotic
illnesses may result from drug or alcohol use. Intoxication may increase
the risk of harm to self or others and this should be taken into account
when considering the detention of someone with an underlying mental
disorder.
Q3 How can someone be detained uner the Mental Health Act?
A3 Only a senior psychiatrist, who is an Appoved Medical Practitioner,
can grant a STDC, which is effective for up to 28 days. The consent
of a specialised social worker (Mental Health Officer/MHO) is required.
An AMP may not be available out of hours in smaller hospitals. A fully
registered medical practitioner can grant an EDC, normally with the
consent of an MHO. If it is impossible to consult the MHO consent
can be dispensed with. Under the previos Mental Health Act 1984 a
relative could give consent, but this is no longer permitted. An EDC
may be justified when detention in hospital is needed urgently in order
to assess the need for treatment and where this is a risk to the person’s
health, safety or welfare or the safety of others. A form called DET1 will
need to be completed. Forms can be downloaded from the Scottish
Executive website. The form must be passed to the Medical Records
Department after completion for it to take effect. It should not be filed
in case notes.
Q4 What measures are authorised by an EDC?
A4 If the person is not an inpatient, admission to hospital is authorised
(within 72 hours) and detention in hospital is then authorised for up to
72 hours. A person in an Accident and Emergency department is not
usually an inpatient and an EDC will not usually authorise detention of
a person there. Under an EDC, treatment for mental disorder may be
given if the person is able to consent and does so. Without consent,
only urgent treatment may be given. There are some restrictions on
the type of treatment that may be given e.g. treatment that entails
significant physical hazard may not be given. The Mental Welfare
Commission must be informed within 7 days, using form T4.
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Q5 When does an EDC end?
A5 A person who is subject to an EDC should be assessed by an
Approved Medical Practitioner as as possible. Normally the EDC will
be rescinded and the person will either become informal or made
subject to a STDC. An EDC should not usually remain in force for
the full 72 hours. Occasionally a person may need to leave hospital
temporarily during the period of detention. The EDC can be suspended
by the doctor in charge of the patient’s care, the Responsible Medical
Officer.
Q6 What measures are authorised by a STDC?
A6 Compulsory treatment for a mental disorder is authorised in addition
to detention. Treatment can be given without the patient’s consent but
with reference to the principles.
Q7 What is a Compulsory Treatment Order?
A7 This is a long-term order, with provisions similar to a STDC.
Compulsory treatment under these orders can be given in hospital or
in the community. A Compulsion Order is similar but is granted by a
court. Occasionally patients subject to these orders are admitted to
general hospital for treatment of a physical condition. A psychiatrist
(AMP) must be responsible for mental health care. Liaison between
the relevant psychiatric and general medical records departments is
essential to ensure that the necessary legal arrangements are made
to allow the patient to be admitted to the general hospital. If the
psychiatric unit is in the same hospital, no special arrangements are
necessary. There is no requirement under the Act that such patients
should be cared for by mental health nurses but local arrangements
may be made if this is appropriate.
Q8 Who is responsible for the patient’s treatment under a
compulsory order?
A8 Hospital managers must appoint an AMP to be the patient’s
Responsible Medical Officer. He or she is responsible for the
patient’s mental health care on the general ward but responsibility
for the treatment of the patient’s physical disorder remains with the
appropriate physician or surgeon. If the patient’s detention has been
suspended, the psychiatric hospital is still responsible for appointing
an AMP. However, if the patient’s order has been transferred to the
general hospital, its managers are responsible for appointing the AMP.
There should be clear arrangements for liaison between the AMP and
the medical/surgical team.
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Q9 Can treatment for a physical condition be given without
consent?
A9 The Mental Health (Care & Treatment) Scotland Act authorises
treatment for mental disorder or for conditions that are a consequence
of mental disorder. Treatment of conditions that are a direct cause of
mental disorder, such as infection causing delirium, is authorised, as is
treatment of conditions directly resulting from mental disorder, such as
self-poisoning resulting from a depressive illness. Artificial feeding of a
person with anorexia nervosa or severe depression may be authorised
by the Act although a second opinion is required.
Where a person is unable to consent to treatment because of mental
disorder, treatment can be authorised under the Adults with Incapacity
Act by completing a Section 47 certificate, providing that person does
not object or resist. In an emergency, if a person objects or resists,
treatment can be given under common law, but the AWIA procedure
should be used if time allows.
Another person may by authorised to give consent under AWIA. This
may be through Power of Attorney, an intervention Order or Welfare
Guardianship. The consent of the person delegated to make a decision
should always be sought whenever practicable. Occasionally consent
may be withheld. In these circumstances treatment may not be given.
The AWIA includes arrangements to resolve such disputes, including a
second opinion procedure.
Where treatment is not urgent and the patient objects or resists, there
is no simple procedure to authorise treatment. Guardianship or an
intervention order may be approved by a court, and an enforcement
order applied for subsequently, but the Commission does not know of
any examples of this leading to successful treatment.
Further information about the Mental Health and Incapacity Law in
Scotland is available from the Commission’s website
www.mwcscot.org.uk
The website provides links to the Acts and their Codes of Practice.
Mental Health Act forms can be downloaded from the Scottish Executive
website. A link to forms is also provided from the Commission site.
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Other useful information sources:
www.gmc-uk.org
www.bma.org.uk
www.nmc-uk.org
Guidelines for Continuing Care
• Nurse in good lighting, a cool ambient temperature with good
ventilation and supportive staff. Augment psychosocial and alcohol
history.
• Perform a detailed physical examination looking for the stigmata of
alcohol abuse.
• Feed back diagnosis to the patient, with the results of tests, in an
open, but helpful manner.
• Abstinence should be advised if there is alcohol dependence with
physical damage.
• Follow up should be arranged to aid this. Possibilities include: their
GP, the Department of Psychological Medicine at the Western
General, Social Work department, the Alcohol Problems Clinic at the
Royal Edinburgh Hospital, Alcoholics Anonymous, Lothian Council
on Alcoholism. In any event, always inform the GP by letter.
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Appendix 1
SHARING DIFFICULT INFORMATION WITH
PATIENTS/RELATIVES
Be truthful but sensitive to the amount of information wanted.
The communication process should be two way.
PREPARE FOR THE INTERVIEW
• Plan the meeting - a relative/close friend should be present, if
possible:
- allow enough time; not too early or late in the day.
- ensure the patient is awake and comfortable.
- in hospital, avoid giving bad news at the bedside if possible.
- ensure you have all the relevant information.
• Place - quiet, private, equipped with tissues, notes/results, written
information, booklets etc.
• Protect against interruption.
• Clinical staff who know the patients should give the results of tests;
preferably in person not by phone.
• A nurse who knows the family should be involved.
GIVING INFORMATION
• Manage the whole interview by summarising, clarifying what has
been understood and checking for outstanding issues/concerns.
Use clear, simple, unambiguous language.
• Check how much the patient/relative knows already,
e.g. “Can you tell me what you understand about the illness?”
• Check how much they want to know,
e.g. “Are you the sort of person that likes to know exactly what
is happening?”
• Clarify the current situation and give any new information, tailored
to the person’s needs.
BUT, if the person is unaware of the situation - give a warning shot,
e.g. “I’m afraid things are not so good”
- break the news slowly in small steps - pause after each.
Coping with patient’s/relative’s reactions & distress:
• A slow pace, with pauses, allows the person to take the information in.
• Avoid premature advice/reassurance - it may be misinterpreted or
not heard.
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• Acknowledge/empathise with distress and encourage the person to
talk about their feelings, e.g. “It sounds as if you feel .....”
• Help the person identify specific concerns resulting from the
information given, e.g. “Can I ask you what exactly worries you
about…?”
• Summarise and prioritise the person’s concerns.
• Take the person’s concerns in order of priority and give appropriate
information/advice.
• Give reassurance of ongoing support and agree a joint plan of
action.
At the end of the interview
• Summarise the conversation and offer to write down key
information.
• Offer relevant written information/booklets.
• Arrange a later opportunity to ask further questions or go over the
information again.
• Check if there is anything else they need now.
• Offer the patient/relative time alone if they wish.
After the interview
• Record details of: the information given
any resulting concerns/issues
follow-up arrangements
• Ensure that other key staff including the patient’s GP/consultant are
aware of what has been said.
GIVING DIFFICULT INFORMATION BY TELEPHONE
This should be avoided, if possible, but may be necessary
e.g. to inform relatives of a death.
In advance:
• Find out if the family want to be informed of changes in the
patient’s condition by phone.
• Do the family want to be contacted overnight or not?
• Is one family member to be contacted first?
Record these details clearly in the patient’s record with
contact numbers.
• If the death is “sudden and unexpected” it is always better if the
GP, emergency social work service or the police go and break
the news to relatives.
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1. Write down or review what you are going to say before you
phone.
2. Speak slowly
3. Check if you are speaking to the right person.
4. State who you are and where you are phoning from.
5. Warn them you have some bad news and check if they are alone.
PAUSE.
6. Give the person the opportunity to phone you back later if they
wish.
7. Give the information slowly, simply and clearly.
If the patient has died, it is better to tell the truth.
(Avoid euphemisms e.g. passed away).
8. Express your regret. PAUSE.
9. IF ALONE - offer to phone a relative/friend to be with them.
IF NOT ALONE - offer to speak to the relative/friend who is there.
10. Check when and how relatives will be coming into the unit. They do
not need to rush.
11. Assure them medical and nursing staff will be available to talk to
them.
12. Phone and inform the GP of a patient’s death.
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Appendix 2
END OF LIFE CARE
WHEN DEATH OCCURS - CARE GOALS
If you have a bleep, ask someone to hold it while you speak with the family. Turn off mobile phone.
GOAL
Family feel supported in
the decision to be alone
with the patient
•
•
•
•
GOAL
Religious/cultural issues
are identified
• Ask family if they would welcome support of minister/priest/other.
Religious/Cultural issues?
• Have they been identified?
(see “What to do after a death in Scotland Booklet” - Chapter 10)
GOAL
Family supported and
advice given if they are
waiting for the Death
Certificate to be issued
• Medical staff will pronounce life extinct (PLE).
• Provide tea/coffee in separate room, to allow medical staff to confirm
death and issue death certificate to the family in private.
• Medical staff will assess whether the Procurator Fiscal should be
informed. The death certificate cannot be issued by hospital staff in
the event of the fiscal taking over the case.
• Using professional judgement as to the appropriateness, sensitively
ascertain if any arrangements have been made/discussed re burial
or cremation. If cremation is chosen, or if intentions are not clear, a
Cremation Form part B should be completed and sent to the mortuary.
It should not be handed to relatives. The mortuary will arrange for
Form C to be completed if a post mortem is not undertaken and will
give the cremation form to the undertaker.
• Ward staff return belongings as per policy* and give bereavement
booklet and invitation for bereavement support.
GOAL
Arrangements for
organ donation or post
mortem if appropriate
Reassure them that they will be given all the time they need.
Continue to make regular contact to provide support, but do not imply haste.
Provide a separate private area to enable the family to be together.
After a period of time ascertain if family still comfortable staying,
sometimes they are at a loss as to what to do or what happens next.
• If there is a possibility of organ donation or a post mortem
examination is thought desirable, discuss with the family.
• A cremation Form C is not required if a post mortem examination
has been undertaken but consultation with pathologist is necessary
for completion of Q8a in Form B.
GOAL
Declaration of serious
infection hazard to
undertaker.
Complete a care of the deceased form (infection certificate) and send
to mortuary.
GOAL
Family advised what
to do next (if they do
not wish to wait for the
death certificate)
• Advise to return at a mutually convenient time the next day.
• Inform them that any member of the family / friend can do this as it
is often too difficult for the immediate family.
GOAL
Advice given to the family
about what to do next
Explain steps in booklet pertaining to registering the death and about
the role of the funeral directors.
GOAL
Enquire whether the person
has support at home
Discuss whether contact with family /friends or GP is required for support.
If appropriate accompany to the end of the ward or to the car.
*If all the above have been addressed perform Last Offices identifying cultural beliefs and
spiritual needs (refer to manual if required)
Ensure remaining patients concerns are addressed
Initials
Yes
No
Above Goals met
If “No” record
a variance
(Code …)
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CHECKLIST OF REQUIREMENTS
This checklist is used at ward level to ensure that all important steps
are taken and to document timing and responsible individuals.
Initials Yes
No
Initials Yes
No
Initials Yes
No
Patient’s death confirmed by doctor?
Senior nurse in charge informed of patient’s death?
Next of kin notified of death? (See breaking bad news guidelines)
Procurator Fiscal Notification - inform as appropriate
Death certificate prepared? (See instructions in Deaths Book)
Death certificate given to family?
Family returning later for death certificate? (if yes please record
at the bottom of the page)
Bereavement booklet given to family?
Valuables/belongings returned to family?
Valuables held in cashier office?
Post Mortem If required - Patient’s family must sign
Copy of signed post mortem consent given to family?
Cremation Form B (if appropriate) completed?
Cremation Form B (if appropriate) sent to Mortuary?
Infection Certificate for undertaker sent to Mortuary?
Consultant informed - within 24hrs
GP contacted - within 24hrs
Medical records informed - within 24hrs
Cancel any follow up appointments if already booked prior
to death
Arrangements to collect death certificate: Date:
/
/
Time:
Other comments:
Determine families
wishes regarding
jewellery?
To remain on the patient? Yes / No
Comments:
Initials:
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BREAKING BAD NEWS TO BEREAVED RELATIVES
FOLLOWING ATTEMPTED RESUSCITATION
Bereaved relatives
• Despite good quality intervention, it is inevitable that resuscitation will
not always be successful. Appropriate handling of the situation can
help relatives and friends to cope, to start the grieving process and
to initiate the practical process relating to funeral arrangements.
• Insensitivity or poor communication at this time may cause longlasting psychological distress.
Contacting the relatives
• Personal communication is best. Use the Police rather than
giving the news by telephone, but if it has to be done by phone
an experienced person should do it, and arrange for immediate
support e.g. neighbour. Face-to-face communication is the best.
Who should tell them?
• The appropriate person may be a member of the medical team, the
named nurse or another. There are no hard and fast rules. It is often
appropriate for a doctor and nurse to see the family together.
Practical points
• If you have a bleep or mobile phone, ask someone to hold it while
you are speaking with the family.
• Prepare yourself: make sure any blood or other fluid which has been
around during resuscitation is cleaned up. Wash your hands, take a
big breath in to steady yourself. Plan what you will say.
• Involve a nurse who may know the family.
• CONFIRM they are the correct relatives, who’s who, introduce
yourself, find out what they know.
• Physical proximity is important. Sit down, don’t look rushed (even if
you are), give them time.
• Make eye contact. Holding hands may be appropriate. Talk clearly
in a simple straightforward way getting to the point quickly. Use the
word died or death.
• Do not use euphemisms e.g. passed away.
• Emphasise and repeat. Give time for reactions and questions (i.e.
be quiet).
• Be truthful, direct, compassionate and empathise. The only thing
you may be able to offer is a hug, if this is accepted. If it feels right
it usually is right.
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• Reactions vary: distress, anger, denial, guilt, numbness. Allow
and encourage crying. Ask if there are questions: be sympathetic,
honest but non-judgmental. Reassure them that pain and other
distressing symptoms were dealt with.
• Physical comfort e.g. tea.
• Do not be afraid to show emotion.
Where to tell them?
• A quiet room.
Facilities which should be available
• Paper tissues. Comfortable chairs, a telephone to call out on (not
an internal one which may ring at any time). A sink, drinks.
Seeing the patient or body
• Try to get the relatives in before death.
• Warn about equipment and any deformity.
• Encourage them to get close.
• Some relatives will want to help with cleaning the body.
• Remember Religious and Ethnic requirements. Involvement of
the Chaplain, Minister, Priest or other religious officals may be
welcomed.
Communication
• Contact the GP.
• Notify the Procurator Fiscal if required.
• Religious officers.
• Information on what to do next. Write the death certificate neatly
and explain what it says.
• Leaving the hospital: ensure family or friends are available for support.
• Follow up: give the relatives contacts. They may wish to come back
to discuss events at a later stage.
• Staff support and debriefing is to be encouraged.
Gaining experience of breaking bad news
i Try to accompany experienced members of staff when they are
speaking to relatives.
Thanks to the authors of the Lothian Palliative Care Guidelines
for the sections on ‘sharing difficult information with patients &
relatives’ and ‘giving difficult information by phone’.
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Appendix 3
GENERAL PRINCIPLES OF GOOD PRACTICE:
INFUSION DEVICES
“Health Professionals are personally accountable for their use of
medical devices and must therefore ensure that they have
appropriate knowledge and training”
Medical Devices Agency 2001
What causes infusion device adverse incidents?
• Free-flow and siphonage.
Example of poor practice
Bandaged ‘temporary’ repair
• Incorrect setting of or failure to set
infusion rate.
• Use of inappropriate accessories.
• Calculation errors.
• Lack of knowledge of infusion therapy.
• Patient/Visitor tampering.
• Using damaged devices.
Report mechanical or fluid spillage damage.
NEVER use damaged medical devices.
Free-flow and Siphonage
What is it?
• Uncontrolled fluid flow from container
(syringe or fluid bag).
What causes it?
• Gravity: Fluid containers empty if
raised above the infusion site and
there is nothing to prevent flow (e.g.
outflow tube is open).
• Volumetric set: A fluid bag empties if
the roller clamp is not closed or the
line is not clamped before removal
from the pump.
• Syringe pump: Siphonage can occur
if: (1) syringe is not properly inserted
in pump, (2) the pump is located too
high above patient or (3) the syringe is
damaged.
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• Damaged syringes and siphonage: Air leaks can occur if the seal
between barrel and plunger is broken or if the syringe is cracked.
Siphonage then occurs without movement of syringe plunger.
What are the consequences?
• Free-flow and syphonage can cause over-infusion – in severe cases
this can lead to death.
What steps should be taken to prevent free-flow? Syringe pumps:
• Use anti-siphon valve where possible. Use Luer-lock syringes.
• Check that the syringe is not damaged.
• Clamp the syringe securely in the pump (plunger and barrel secured
and syringe lip in pump groove) before attaching the line to the
patient.
• Pump Height. Ideally, mount syringe pumps and drivers at or below
the height of the infusion site.
Never mount higher than 2 feet above the infusion site.
• Clamp the infusion line before removing the syringe from a syringe
pump or driver.
Volumetric pumps
• Ensure that the correct infusion line is selected for use with
volumetric pumps.
• Clamp the line before opening the door and removing the line from
the pump.
What checks to make before starting an infusion?
• Check infusion rate. Does it match the prescription? Ask a
colleague to tell you the rate.
• After an end-of-infusion alarm, don’t Ask a colleague to confirm rate.
restart the pump before checking
Don’t prompt the answer.
if the prescribed volume has been
Ye
o
What rate is
Is the rate
infused.
this pump
20ml/hr?
• Syringe pumps: Check that the pump
setto?
correctly registers the syringe size
being used (Graseby 3000 series and
Alaris Asena series pumps).
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Why should you carry out regular checks and what are you
looking for?
Infusion devices are very reliable and rarely give problems. However,
occasionally they do fail. It is also important to regularly check the
infusion site for signs of extravasation or infiltration.
Regular checks
When:
• First check after
15-20 minutes
• Hourly thereafter
What: Patient
• Infusion site.
Swelling, pain
• Patient comfort
Infusion devices don’t measure flow rate
Infusion devices do not measure the flow
rate - they record the pumping action.
If the peristaltic fingers don’t press correctly on the giving set (incorrect set or
door not fully closed) the flow rate will be
incorrect.
A syringe pump can record flow with an
empty syringe.
Infusion System - pump, giving set and fluid container
• Infusion rate
• Volume left in bag or syringe - also check totaliser.
• The line. Has the line been left clamped.
When things go wrong:
Safety Action/Hazard Notices and Incident reporting
Safety Action Bulletins and Hazard notices
What are they? Issued by Scottish Healthcare Supplies to inform
users of potential dangers involving medical devices, often following
problems experienced in other hospitals.
Where do you find these safety warnings? These should be kept in
a file in the clinical area. They are issued by e-mail and through the
Messenger. If in doubt, contact the Clinical Skills Co-ordinators or
Medical Physics.
Incident reporting
If an adverse event or a near miss occurs, fill in the incident report
according to Trust protocol. You should also directly inform Medical
Physics (x 22352 - RHSC and RIE; x 32167 - WGH; x 52148 - SJH).
The giving set should not be removed from the pump (unless clinical
care requires otherwise). The pump, together with the giving set and a
copy of the infusion chart should be sent to Medical Physics.
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Start-up time (Syringe pumps)
What is it? The time delay between
starting an infusion and the patient
receiving infusion at the prescribed
rate. (Analogous to the time for a car
to reach say 60mph from standstill.)
What causes it? Mechanical slack
between the syringe and the pump and
within the mechanism of the pump.
?? Question ??
Have you ever commenced an infusion and found
that, after an hour, the pump’s totaliser display
indicates that the hourly rate has been delivered
butthesyringevolumehasnotaltered?
Cause: Start-up time delay.
Prevention: Purge to remove slack.
PURGE
How can it be prevented or at least minimised?
• Prime line before installing syringe in the pump.
• Install the syringe correctly and firmly in the pump.
• Before connecting line to patient, use the pump’s PURGE facility.
This takes up the pump’s mechanical slack, minimising start-up
time delay.
Occlusion Alarm Pressure
What is it? Infusion pumps generate sufficient pressure to deliver the
infusion at the set rate. If the line becomes fully or partially blocked, the
pressure in the line will rise. For example, phlebitis in the vein can increase
the resistance to flow causing the pump to increase the delivered pressure
to overcome the increased resistance. When the pressure rises above the
occlusion alarm pressure the pump alarms OCCLUSION.
What is the limit? Recommended at less than 500mmHg for adult
and 300mmHg for paediatric infusions. Some pumps enable the user
to adjust the limit - with in-line pressure-monitoring users can adjust
the alarm pressure to about 30mmHg above the pressure needed to
deliver the infusion.
What should you do if the alarm sounds?
1. Determine the cause of the occlusion,
Pressure increase in line
checking the venflon site.
rising to an occlusion alarm
2. Check that the line is not clamped
Occlusion Alarm Pressure
or kinked.
Pressure
in the line
3. Release the syringe plunger clamp
in order to avoid a post-occlusion
Time
bolus.
Does the occlusion alarm prevent infiltration/extravasation?
No, it is not sufficiently sensitive. Always check clinical signs (redness,
swelling, and pain).
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Appendix 4
RESUSCITATION: SPECIALISED INFORMATION
PREGNANCY
Introduction
Resuscitation in pregnancy is complicated by a number of important
factors.
• There are at least two patients.
• The physiological changes of pregnancy alter the response to acute
illness, and to treatment.
• There are a number of diseases unique to pregnancy which may
result in collapse.
• In view of these factors although the standard approach to
resuscitation is applied, there are specific modifications.
i Most of the causes of cardiac arrest in pregnancy are identifiable
at a time when cardiac arrest should be preventable: e.g. hypoxaemia, hypovolaemia, and the aim is to avoid cardiac arrest.
Physiology
Changes in anatomy and physiology affect the approach to management
of the pregnant patient.
Airways
• Oedema.
• Anatomical changes.
• Nasal congestion.
Breathing
• At 10 weeks 40% increase in tidal volume and normal respiratory
rate with minute ventilation rising from 7.5 to 10.5 litres.
• PaCO2 falls to 4kPa, and at term PaO2 rises from 11.3 to 12.3kPa.
• FRC falls by about 30%.
Circulation
• Total body water rises by about 7 litres.
• Blood volume increases from 65 ml/kg to 80-85 ml/kg.
• Hb falls from 140g/l - 120g/l.
• Cardiac output increases by 1.5 l/min at 12 weeks, and by 44% in
the third trimester.
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• HR increases by 17% and stroke volume by 27%.
• Blood pressure and peripheral resistance fall.
• The combination of ventilatory and circulatory changes means
that the ability to mount a compensatory response to acute illness
(sepsis, hypovolaemia, haemorrhage) is diminished as the system
is already working way beyond normal capacity.
GI
•
•
•
•
Lower oesophageal sphincter tone falls.
Intra-abdominal pressure rises.
Gastric emptying may be delayed.
Risk of regurgitation of stomach contents greater than normal, and
increases the risks of pulmonary aspiration in situations where
conscious level is depressed (including general anaesthesia).
Resuscitation peri-arrest and during arrest
• Call for help early: anaesthetist, obstetrician and paediatrician as
appropriate.
• ABCDE
• High concentration oxygen: is the airway secure? Get anaesthetic
help early.
• Large bore IV access and fluids: 20ml/kg colloid. Activate Major
Haemorrhage protocol as appropriate.
• Left lateral tilt: as required.
• Refinements to BLS and ALS: see ALS manual in A&E/ARAU.
Specific problems: Haemorrhage; embolism; anaesthetics, eclampsia.
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Appendix 5
PAEDIATRIC BASIC LIFE SUPPORT
PAEDIATRIC BASIC LIFE SUPPORT
Resuscitation Council (UK)
Paediatric Basic Life Support
(Healthcare professionals
with a duty to respond)
UNRESPONSIVE ?
Shout for help
Open airway
NOT BREATHING NORMALLY ?
5 rescue breaths
STILL UNRESPONSIVE ?
(no signs of a circulation)
15 chest compressions
2 rescue breaths
If alone after After
1 minute
callcall
resuscitation
team
CPR. If rescuers
1 minute
resuscitation
teamthen
then continue
continue CPR
activate 222 call immediately stating paediatric cardiac arrest.
Note: Compress the chest by approx. one-third of its depth. Use 2 fingers
for an infant under 1 year; use 1 or 2 hands for a child over 1 year as
needed to achieve an adequate depth of compression.
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PAEDIATRIC FBAO TREATMENT
Assess severity
Ineffective cough
Effective cough
Unconscious
Conscious
Encourage cough
Open airway
5 breaths
Start CPR
5 back blows
5 thrusts
(chest for infant)
(abdominal for
child >1 year)
Continue to check
for deterioration to
ineffective cough or
relief of obstruction
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289
Infant
(<1 year)
5 Abdominal
Thrusts
5 Back Blows
5 Chest
Thrusts
5 Back Blows
Open Airway
Reassess for
Breathing
Check Mouth
CHILD
(1-8 years)
If not
breathing
- Attempt 5
Breaths
Resuscitation Guidelines 2000-Resuscitation Council (UK), Marie Elen January 2001
Check Mouth
Open Airway
Reassess for
Breathing
If not
breathing
- Attempt 5
Breaths
FOREIGN BODY OBSTRUCTION SEQUENCE
CONSENT TO MEDICAL TREATMENT FOR
CHILDREN IN SCOTLAND
This information is concerned with young people under the age of 16.
Once a child reaches 16, he or she has full adult legal rights to decide
whether to consent to treatment or not.
Child Health in Scotland operates within the framework of Scots law,
which differs from the law in England and Wales.
MEDICAL CONSENT IN GENERAL
Medical treatment is lawful, either:
• With consent
• Or in cases of urgent necessity (when consent cannot be
immediately obtained).
It is important to remember that consent to medical treatment,
whatever the age and capacity of the patient, is a matter that qualified
medical practitioners must always make a decision about.
In some cases where emergency treatment is required, the practitioner
may decide that the situation is so urgent that the treatment cannot
wait for consent. It is the practitioner who is making a judgement.
CONSENT FOR YOUNG PEOPLE OF 16 AND OVER
Scots Law treats the 16 year old as a full adult. He or she has the
right to consent or refuse to consent to all medical, dental or surgical
treatments or procedures.
CONSENT FOR YOUNG PEOPLE UNDER 16
(4) A person under the age of 16 years shall have legal capacity to
consent on his own to any surgical, medical or dental procedure or
treatment where, in the opinion of a qualified medical practitioner
attending him, he is capable of understanding the nature and
possible consequences of the procedure or treatment.
This means that for any child under 16 there is a right to consent to any
form of treatment if the medical or dental practitioner considers that
the child has capacity to understand:
• what the treatment or procedure is
• and its possible consequences.
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For example it may be considered appropriate for a child to consent
to a straight forward procedure such as setting a broken limb but not
when considering treatments for more complex illnesses.
If a doctor, dentist or other medical practitioner takes the view that the
child has the capacity to consent, then only the child can consent or
refuse consent. Although it would always be considered good practice
for parents and if appropriate other family members to be included in
the decision process.
It is important that all professionals who work with children are aware
of the rights of the child rather than thinking that adults are the only
people who have rights and whose views matter.
Who consents if not the child or young person?
If the medical practitioner does not think that the child is legally
capable of consenting, the adults who could give consent would be
as follows:
• Birth parents who have not lost their rights and responsibilities
through adoption. A court could overrule the parents rights to
consent or not to medical care, but this is very rare.
• Unmarried fathers do not automatically have parental responsibilities
but carers rights.
• People who normally “care” for the child may also consent to
medical treatment in certain circumstances. This is if the carer is
over 16 years of age and the child is not capable of consenting and
the carer has no knowledge that a parent of the child would refuse
consent.
• School teachers and those under the age of 16 cannot give
consent. It is also usual that in the event of the child being in care
the local authority will have asked parents to sign a consent form,
consenting to any required treatment. • If the child is awaiting adoption then the local authority has all
parental responsibilities for the child and the birth parents have no
rights.
CONFIDENTIALITY
This is always a difficult area. The general opinion is that if a child is
considered able to consent or refuse treatment, the child must also be
entitled to patient confidentiality. It would always be considered good
practice that the child and parents were included in any discussion.
This would have to be done only if the child gave consent to it.
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CONTRACEPTION AND ABORTION
It would be a breach of confidentiality if a doctor told a parent that their
child had sought advice on contraception without the prior consent of
the child.
The only exception is where the child is at risk and information may
be disclosed in order to protect the child. When the girl is under 16, it
could be argued that in seeking contraception she is “at risk” of being
a victim of a sexual offence, but it is not always appropriate to inform
the police or social services.
Similarly with abortion, consent to abortion or refusal of such consent
is a matter for the young person, unless the girl has severe learning
difficulties. Considerable support and counselling would be considered
good practice and reasonable attempts to involve the family only if the
child agrees. It is ultimately up to the girl to decide for herself and not
up to her parents.
Bibliography
British Agencies for Adoption and Fostering (1998) Practice Note 38.
Consent to Medical Treatment for Children in Scotland.
Lothian Health (1998) Children and Young People’s Health Strategy.
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Appendix 6
MALIGNANT HYPERTHERMIA ACTION SHEETS - LUHD
RIE/WGH 2005-2007
TO BE KEPT IN THEATRE PROTOCOL FOLDER & MH BOX
DIAGNOSIS
Clinical
Tachycardia + Tachypnoea / Raised EtCO2
Masseter Muscle Spasm after Suxamethonium.
Rigidity / Fasciculations
Arrhythmias
Cyanosis / Low SpO2
Skin Mottling
Temperature rise ( Approx 10 / 5mins)
Soda Lime hot & Rapidly Consumed
Sweating +++
Blood pressure unstable
Monitoring/laboratory
SpO2 decrease/Central Venous Hypoxia
Hypercarbia
Metabolic Acidosis
Hyperkalaemia
Myoglobinaemia
Creatine Phosphokinase increase
Clotting Screen Abnormality
ACTION
1. DISCONTINUE ANAESTHETIC IMMEDIATELY WHEN
POSSIBLE.
Withdraw trigger agents immediately ie. All volatile agents.
Use new breathing system
2. INTUBATE PATIENT & HYPERVENTILATE WITH 100% O AT 3
2
x Vmin
(Aim for EtCO2 of 3.5‑4KPa)
3. Distribute “action sheets”:
a) Treatment/Monitoring
- Yourself + ODP‑ Page 1‑3
b) Malignant Hyperthermia Box
- Anaesthetic Room Nurse
‑ Page 4
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c) Drugs and catheterisation pack - Circulating Nurse‑ Page 5
d) Cooling (cooled iv fluids)
e) Help
- Assistant Surgeon + ODO/
Resident‑Page 6
- Nurse/Resident‑Page 7
4. Ask the surgeon to :
A. Abandon the operation rapidly.
B. Insert urinary catheter.
5. INJECT DANTROLENE.
6. COMMENCE BODY SURFACE COOLING WITH COOL WATER.
7. INFORM CONSULTANT IN CHARGE.
TREATMENT - OVERVIEW
THE ORDER WILL DEPEND ON AVAILABILITY OF DRUGS
AND EQUIPMENT SPEED IS MORE IMPORTANT THAN ORDER.
HYPERVENTILATION : 100% Oxygen (Use new breathing system, NO volatile agents)
Intubate
3 x Vmin approx.
Aim for ETCO2 of 3.5 ‑ 4 kPa.
IV CANNULA : Large bore
DANTROLENE
: 1‑2mg kg -1 IV rapidly.
(i.e. 4 ‑ 6 x 20mg vials for average adult)
Vial Preparation :
Add 60 mls sterile water for injection to each vial
Further titrated Dantrolene up to 10 mg kg-1 may be required.
COOLING : 1. Stop warming devices – fluid warmers, warming blankets/mattresses.
2. Surface cooling with cool water sponging
(Ice cooling is no longer recommended as it can cause intense
vasoconstriction which retains body heat and can raise the core
body temperature even more.)
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3. IV cooled fluids : (4 x 1000ml N/saline minimum stored in fridge)
RIE : Cardiothoracic theatre (Th 4-8),
Or Orthopaedic Theatre Clean Utility Area fridge.
WGH : Blood fridges in main theatre (outside Theatre 3), DCN theatre & Theatre 14.
Consider using a cardiac bypass pump heat exchanger in cooling mode.
SUPPORTIVE TREATMENT TO COMBAT INCREASED METABOLIC
RATE DUE TO SUSTAINED MUSCLE CONTRACTION:
Na BICARBONATE : 1‑2 mmols/Kg (100‑200ml 8.4%)
+
Reduces acidosis & serum K
Repeat cautiously according to blood gas results.
DIURESIS : MANNITOL 20% (at room temp) 2ml/Kg/hr up to 500mls.
FRUSEMIDE 40 mg
Volume replacement as necessary (cold fluids)
+
K REDUCTION
: Dextrose & Insulin infusion ‑ 50ml 50% dextrose + 10 units Actrapid
(Monitor Blood Glucose levels)
ARRHYTHMIAS
: Usually secondary to acidosis & hyperkalaemia. Treat as appropriate. ß‑Blockers frequently required. (Avoid the use of calcium channel blockers with dantrolene as hyperkalaemia can occur)
BLOOD TESTS
: Blood gases. K+. Glucose. Clotting screen (DIC is common),
Creatinine Kinase (repeat at 24 hrs)
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INSTRUCTIONS FOR ANAESTHETIST + ODP
1. STOP ADMINISTRATION OF VOLATILE AGENTS.
2. USE NEW BREATHING SYSTEM
If a circle system must be used the CO2 absorbent must be replaced
with new fresh granules to avoid absorbed volatile agents being
released back into the system.
3. ARRANGE FOR MALIGNANT HYPERTHERMIA BOX TO BE
COLLECTED FROM :
RIE : GENERAL / Orthopaedic Theatre Recovery
Clean Utility Area – lower shelf.
or ICU (Wd 118) WGH : ICU – Drug cupboard No 5
WGH ICU also keeps another 12 vials of Dantrolene and 8x100ml vials of sterile water for reconstitution as a back up. Take them with you to save a second journey.
SJH: In the Theatre Suite – Recovery Room on dedicated trolley.
4. ARRANGE FOR ON-CALL PHARMACST TO SEND A FURTHER
12 VIALS OF DANTROLENE & 8X 100ML VIALS STERILE WATER
URGENTLY.
Dosage: 1-2mg kg-1 IV rapidly.
(i.e. 4 ‑ 6 x 20mg vials for average adult)
Vial Preparation :
Add 60 mls sterile water for injection to each vial
Further titrated Dantrolene up to 10 mg kg-1 may be required.
5. INTUBATE patient & hyperventilate with 100% O2 at 3 x Vmin
( Aim for ETco2 of 3.5 ‑ 4kPa )
6.
•
•
•
•
•
•
•
•
SET UP:‑
ECG
SpO2
Et CO2
Large bore IV cannula
Thermometer (Naso‑pharyngeal/oesophageal/rectal)
Arterial line
Urine output ‑ Surgeon will insert catheter (with urimeter)
Central Venous Pressure line
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7. BLOOD SAMPLES:‑
•
•
•
•
Blood gases
Potassium
Clotting screen
10ml lithium heparin ‑ for later analysis of creatine phosphokinase
and myoglobin (At start / height / end of crisis)
• 20ml urine ‑ for myoglobin (At start / height / end of crisis)
ANAESTHETIC ROOM NURSE
( OR OTHER FAST RUNNER )
GET MALIGNANT HYPERTHERMIA BOX
LOCATIONS –
RIE : GENERAL/Orthopaedic Theatre Recovery - Clean Utility Area – lower shelf or ICU (Ward 118) Clean Utility Area – Work surface
corner
WGH : ICU - Drug cupboard No 5.
WGH ICU also keeps another 12 vials of Dantrolene and 8x100ml
vials of sterile water for reconstitution as a back up. Take them with
you to save a second journey.
PAEP : Central Drug Store opposite Theatre 1 Anaesthetic room.
RHSC : Main Theatre – The middle of the recovery room by the
emergency trolley.
ROODLANDS HOSPITAL : Main Theatre – in the safe in the ‘back
corridor’
St. JOHN’S HOSPITAL LIVINGSTON : In the Theatre Suite –
Recovery Room on dedicated trolley.
Contents
Dantrolene Sodium : 12 Vials x 20mg
Water for injection : 8 bottles x 100ml
1 bottle opener
: For rapid filling of syringes using a quill
4 drawing up quills
12 luer lock 60 ml syringes
12 white needles
2 sponges for surface cooling
1 set Malignant Hyperthermia Protocol sheets
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DRUGS ‑ CIRCULATING NURSE
1.
•
•
•
MAKE SURE THAT THE FOLLOWING ARE HANDY :‑
Emergency drug box
Syringes needles and giving sets
0.9% Normal Saline (NOT RINGER LACTATE), 5% Dextrose, 8.4%
Bicarbonate
• Foley catheter and equipment for urinary catheterisation
• Basin / bucket to hold cool water for use with the sponges in the
MH kit
2. Remind the anaesthetist to ask the surgeon to insert a urinary
catheter when he has finished sewing up.
3.
Take charge of the MALIGNANT HYPERTHERMIA BOX when it arrives:
Make up Dantrolene 1-2 mg kg-1 (SPEED IS IMPORTANT) :‑
Add 60ml sterile water for injection to each vial.
The box contains quills and a bottle opener to speed up filling the
syringes
Shake vials well to dissolve the dantrolene.
(Average initial adult dose is 4 - 6 ampoules rapidly IV.)
4. Check that you have in theatre:
•
•
•
•
Mannitol 20%
Dextrose 20% or 50%
Insulin
Furosemide
5. Frequently ensure that stocks of IV fluids are not running out.
6. Arrange for more DANTROLENE to be brought to theatre from
pharmacy .
Note : You will need another 800ml (8 x100ml bottles) of sterile
water for injection per box of 12 Dantrolene vials.
Dispensary open hours:
RIE
Monday to Friday 0830‑1830
Saturday
0830-1500
Sunday
1000-1400
WGH Monday to Friday 0845‑1700
Saturday
0900-1230
Ext 22911
Ext 22911
Ext 22911
Ext 31461 (or page #6421 or bleep 5535)
Ext 31210
Outwith these times contact the on‑call pharmacist via the switchboard
If necessary more Dantrolene can be mobilised from other hospitals.
(See page 8.) - Ask Pharmacist to co-ordinate
298 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
COOLING ‑ ASSISTANT SURGEON / RESIDENT / ODP
SPEED IS VITAL
Cool patient by sponging with cool water over as much of the body as
possible.
This cools the patient by an evaporative heat loss process.
Two sponges are in the MH box.
(The anaesthetist may arrange cardiac bypass pump cooling if
required.)
Important Further Information :
The following are no longer recommended for the treatment malignant
Hyperthermia :
1. Ice cooling is no longer recommended as it can cause intense
vasoconstriction which retains body heat and can raise the core
body temperature even more. Frostbite with loss of extremities
could also occur.
2. Gastric or peritoneal lavage.
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
299
HELP ‑ NURSE / RESIDENT
The following people should be contacted :
RIE :
1. Supervising Consultant / On Call Consultant
2. Contact ward 118 ICU team in RIE (ext 2118) to arrange emergency
transfer and admission.
3. The Assistant Operations Manager to report that the Malignant
Hyperthermia policy plan has been actioned (RIE Bleep 2118 )
WGH :
1. WGH Consultant on call. Emergency Anaesthetist (Bleep 8155)
2. ICU Consultant on call. ICU team to arrange emergency transfer
and admission (ext 31664/31665)
3. SHO on call (Bleep No 8112)
4. Theatre Assistant Operations Manager to report that the Malignant
Hyperthermia policy plan has been actioned (Bleep # 6122)
PAEP :
1. Contact ward 118 ICU team in RIE (ext 2118) to arrange emergency
transfer and admission.
2. Inform Clinical Lead.
3. Theatre Assistant Operations Manager to report that the Malignant
Hyperthermia policy plan has been actioned (Bleep # 1600)
ROODLANDS HOSPITAL :
1. Contact ward 118 ICU team in RIE (ext 2118) to arrange emergency
transfer and admission.
2. Inform Clinical Lead.
3. Theatre Assistant Operations Manager to report that the Malignant
Hyperthermia policy plan has been actioned.
300 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
LOCATIONS OF SUPPLIES OF DANTROLENE IN
THE LOTHIAN AREA
Large back-up supplies are available from the pharmacies in RIE,
WGH & St Johns
- Pharmacy will mobilise these sources if necessary
ROYAL HOSPITAL FOR SICK CHILDREN
12 vials of 20mg
In Main Theatre ‑ Middle of recovery room by emergency trolley.
WESTERN GENERAL HOSPITAL
12 vials of 20mg
12 vials of 20mg
12 vials of 20mg
In ICU - in MH Box in‘Drug Cupboard No 5’.
In ICU - in‘Drug Cupboard No 5’ as back-up.
WGH Pharmacy
ROODLANDS HOSPITAL
12 vials of 20mg
In Main Theatre ‑ in safe in ‘back corridor’.
ROYAL INFIRMARY OF EDINBURGH
96 vials of 20mg
12 vials of 20mg
12 vials of 20mg
In Pharmacy Dept ‑ Drug store, injection store.
ICU Ward ‑ At Nurses Station, top shelf.
General/Orthopaedic Theatre Recovery Room - Clean Utility Area - lower shelf.
St. JOHN’S HOSPITAL LIVINGSTON
12 vials of 20mg
In Theatre Suite ‑ Recovery Room on dedicated trolley.
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
301
RECOVERY & FURTHER TREATMENT
With rapid diagnosis and treatment most cases of Malignant Hyperthermia
will recover. After the initial crisis has been stabilised the patient should
be admitted to an intensive care unit noting the following :
RETRIGGERING
-
May occur.
Oral Dantrolene ( if possible ) should be given for 48hours :
4mg/kg/day in divided doses.
Unnecessary stress should be avoided as this can trigger Malignant Hyperthermia.
HYPOTHERMIA ‑ Can be induced by overvigorous cooling during recovery.
DIURESIS
‑ Should be maintained to reduce the possibility of myoglobin induced renal failure.
BLEEDING DISORDERS
‑ A DIC type coagulopathy is common.
PULMONARY OEDEMA
‑ Is common.
MUSCLE OEDEMA ‑ Compartment Syndrome may require fasciotomy.
(Spinal anaesthesia is often the method of choice for this)
Consider other diagnoses - Myopathy / Ecstasy ingestion / Neuroleptic Malignant Syndrome
Patients suspected of having Malignant Hyperthermia and their blood
relatives should be referred later for formal investigation to :‑
Malignant Hyperthermia Services
University Dept. of Anaesthesia
St. James’s University Hospital
Leeds LS9 7TF
Leeds Malignant Hyperthermia Hotline : 07947 609 601
302 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
MAJOR HAEMORRHAGE PROTOCOL
• WGH/RIE: Attending clinicians should telephone switchboard on
the emergency number (222), informing them that there is major
haemorrhage, the name and location of the patient and a contact
telephone number (and individual where possible).
SJH: Telephone/bleep blood bank (as below) and porters (ext 2120)
not 222.
• Switchboard will inform:
- Blood Bank /Haematology Laboratory (by bleep).
- Haematology/BTS duty doctor (by bleep).
- Porter to go to the clinical area (porter will remain until stood
down by clinical team).
• Blood Issue (WGH Ext. 31912, SJH Ext. 53354/bleep 729, NRIE Ext.
27501/27502) should be rung directly to clarify the following:
- How urgent the need for blood is.
- Patient’s minimum data set (full name, date of birth, hospital number
if available, A&E number or Major Incident number if necessary).
- The number and nature of blood components requested (a
standard pack for an adult will consist of 10 units of red cell
concentrate, 1 pool of platelets and 3 units of FFP. For children
the normal dose is 10-15 ml/kg for these components).
- The exact location of the patient.
• If required, emergency O negative stock is held in the RIE and WGH
blood banks, and also in the fridges in the Acute Receiving Unit
at WGH, A & E at RIE, Simpsons Centre for Reproductive Health
Labour Ward, RHSC, and Roodlands. If required please use the
nearest available stock.
• In order to speed up the coagulation screen, the fibrinogen will be
done first and phoned to the clinical team and Haematology/BTS duty
doctor. If this is less than 0.8g/l the PTR and APTT will be prolonged
and fresh frozen plasma and cryoprecipitate are likely to be required.
• When the full blood count and coagulation screen are available they
will be phoned to both the clinical team and to the Haematology/
BTS duty doctor. The Haematology/BTS duty doctor will liaise with
the attending clinicians with regard to the haematological results
and further blood component requirements.
For further FBC/coagulation or blood components, the clinical team
should liaise direct with the appropriate laboratories on the emergency
numbers. There is no requirement to go through the Haematology/BTS
duty doctor, though he/she will be available as required.
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
303
MAJOR HAEMORRHAGE PROTOCOL
304 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
CONTRIBUTORS TO PREVIOUS EDITIONS
LIST OF CONTRIBUTORS TO 1st WGH EDITION 1998
Editors: Dr G Nimmo, Dr D Northridge, Prof D Webb, Dr I Wilkinson.
Dr N Bateman, Dr R Benediktsson, Dr GK Crompton, Dr M Dennis,
Dr M Denvir, Dr R Ellis, Dr M Ford, Dr S Ghosh, Sister F Good,
Dr IS Grant, Dr A Greening, Dr G Howard, Dr N Hurst, Dr JA Innes,
Mr M Johnstone, Dr C Leen, Dr R Lindley, Dr M Mackie,
Dr SJ Maxwell, Dr J McKnight, Dr C Mumford, Ms L Murray,
Dr GR Nimmo, Dr D Northridge, Prof G Nuki, Mr M O’Sullivan,
Ms R Oughton, Dr P Padfield, Dr K Palmer, Dr I Penman,
Prof L Prescott, Dr PWH Rae, Ms Jenny Scott, Dr K Slatford,
Dr A Webster, Prof DJ Webb, Dr I Wilkinson, Dr D Wilks.
LIST OF CONTRIBUTORS TO 1st LUHNT EDITION
Dr T Beattie, Dr D Bell, Prof J Bell, Dr B Chapman, Prof M Dennis,
Dr M Denvir, Dr M Ford, Dr P Gibson, Dr I Grant, Dr A Greening,
Dr G Howard, Mr M Johnstone, Dr C Kelly, Dr S MacKenzie,
Dr M Mackie, Dr C Maguire, Dr SJ Maxwell, Dr R Mitchell, Dr G Nimmo,
Dr S Nimmo, Dr A Patrick, Dr P Padfield, Dr K Palmer, Dr D Wilks,
Dr D Wright and all contributors to CCU Therapeutic Schedule.
SPECIALIST PHARMACISTS WHO PROOF READ CHAPTERS
Morag Naysmith, Anne Balfour, Julie Blythe, Alistair Brand, Carole Callaghan,
Jenny Carson, Heather Dalrymple, Katherine Harrington, Anne Kinnear,
Lesley Pacitti, Heather Paterson, Carol Philip, Karen Reid, Maureen Reid,
Jenny Scott, Sheila Selkirk, Laura Shaw, Lorna Thomson, Helen Veitch,
Susan Wilson, Sherry Wright.
LIST OF CONTRIBUTORS TO 2004/2006 EDITION
EDITORIAL COMMITTEE
B Chapman, C Kelly, S Maxwell, R Mitchell, G Nimmo, R Paterson,
J Pearson, M Watson.
CONTRIBUTORS TO THIS EDITION OF THE HANDBOOK
Dr J Amoore, Dr S Balata, Dr T Beattie, Dr D Bell, Prof J Bell,
Dr B Chapman, Dr N Colledge, Dr R Davenport, Prof M Dennis,
Dr M Denvir, K Farrer, Dr M Ford, Dr P Gibson, Dr I Grant, Dr A Gray,
Prof A Greening, Prof P Hayes, Dr G Howard, Mr M Johnstone,
Dr S Keir, Dr C Kelly, Mike Logan, Dr V Macaulay, Dr S MacKenzie,
Dr M Mackie, Dr C Maguire, Dr L Manson, Dr S Maxwell,
Dr S Midgley, Dr R Mitchell, Dr G Nimmo, Dr S Nimmo, Dr A Patrick,
Dr P Padfield, Dr K Palmer, Mr Z Raza, Dr M Strachan, Mrs L Waite,
Dr D Wilks, Dr R Winney, Dr D Wright
PHARMACISTS WHO PROOF READ SPECIALITY SECTIONS
J Blythe, H Dalrymple, L Goundry, C Hannah, A Kinnear, M Naysmith,
H Paterson, J Pearson, S Petrie, K Reid, L Shaw, C Stein
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
305
NOTES
306 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2007/09
The Anaphylaxis campaign:
[email protected]
Meningitis Research Foundation:
www.meningitis.org
British Thoracic Society :
www.brit.thoracic.org.uk
Resuscitation Council (UK):
www.resus.org.uk
The British Toxicology Society:
www.thebts.org
National Poison Information Service:
www.npis.org/NPIS/uk%20npis.htm
British Society Gastroenterology
www.bsg.org.uk
Scottish Intensive Care Society:
www.scottishintensivecare.org.uk
In the education section you will find this handbook as a pdf and also
sections on critical decision making EDM in intensive care and teaching
materials for Identifying Sepsis Early.

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