Professional Documents
Culture Documents
emergency medicine
for FRCophth exam
1 edition
st
Organized by
Dr.Waleed Badr
M.sc ophthalmology
2011
INDEX
Cardiovascular
CPR for Cardiorespiratory arrest
Shock
Acute chest pain
Acute coronary syndrome (ACS)
Severe pulmonary oedema
Broad complex tachycardia
Narrow complex tachycardia
Venous thromboembolic diseases (DVT & PE)
Cardio-vascular drugs
Appendix : Basics & abnormalities of ECG
Chest
Bed side tests in chest medicine
Acute breathless patient
Acute severe asthma
Acute exacerbation of COPD
Pneumonia
Tension pneumothorax
Neurology
Headache D.D
Coma
Meningitis , Encephalitis & Cerebral abscess
Status epilepticus
Stroke
ICP
Endocrine
Coma in diabetic patients
Thyroid function tests
Thyroid emergencies
Addisonian crisis
Hypopituitary coma
Pheochromocytoma emergencies
GIT : Acute GIT bleeding
Haematology
An approach to bleeding disorders
Drugs affecting haemostasis
Hyperviscosity syndrome
Nephrology : Acute renal failure
Acute poisoning
Burns
Hypothermia
Needle-stick injuries
Perioperative care
Severe local anaesthetic toxicity
Choking in children
3
10
15
17
20
21
22
24
28
32
37
39
42
43
45
47
49
51
54
56
58
60
61
64
65
66
67
67
68
73
76
79
80
82
85
89
90
91
93
95
Dr.Waleed Badr
2011
Usually results from an electrical disturbance in the heart e.g ventricular fibrillation, pulseless
ventricular tachycardia, Asystole or pulseless electrical activity that disrupts its pumping action &
causes blood to stop flowing to the rest of the body i.e loss of cardiac output.
Is different from a heart attack, which occurs when blood flow to a portion of the heart is blocked,
depriving the heart muscle of necessary oxygen. Like a heart attack, however, sudden cardiac arrest
almost always occurs in the context of other underlying heart problems, particularly coronary artery
disease.
Is a medical emergency. If not treated immediately, it is fatal, resulting in sudden cardiac death. With
fast, appropriate medical care, survival is possible. Administering cardiopulmonary resuscitation (CPR)
- or even just rapid compressions to the chest - can improve the chances of survival until emergency
personnel arrive.
These are the most common and most easily treatable cardiac arrest rhythms.
Can cause cardiac arrest if the ventricular rate is so rapid that effective mechanical contraction &
relaxation cannot occur, especially if it occurs in the presence of severe LT ventricular impairment.
Asystole :
This occurs when there is no electrical activity within the ventricles & is usually due to failure of the
conducting tissue or massive ventricular damage complicating MI.
When due to conducting tissue failure, permanent pacemaker implantation will be required if the
individual survives.
This occurs when there is no effective cardiac output despite the presence of organised electrical activity
i.e electromechanical dissociation (EMD) .
Dr.Waleed Badr
2011
e.g
semilateral
position
Dr.Waleed Badr
2011
In a second, confirm the diagnosis (unconscious, absent carotid pulse, apnoeic), then:
Shout for help (HOW? Ask someone to call the cadiac arrest team and bring the defibrillator (AED).
BLS aims to maintain a low level of circulation until more definitive treatment with advanced life support
"ALS" can be given.
BLS consists of ABC :
1. Prompt assessment & restoration of the airway.
2. Maintenance of breathing using rescue breathing ('mouth-to-mouth' breathing) .
3. Maintenance of the circulation using chest compressions
Chin lift.
Jaw thrust.
B: Breathing
Assess by Look, listen and feel (10 sec max.) (look for chest movements,
listen to breath sounds & feel for the breath from the mouth).
If breathing is compromised, give high concentration O2 & manage
according to the findings e.g. relieve tension pneumothorax.
If no respiratory effort, treat as arrest, give 2 breaths after
1st
set of
compressions
-
Use Ambu system (specialized bag& mask system; in place by thumbs pressing downwards
either side of the mouth-piece, palms against cheeks) if available and 2 resuscitators present.
Otherwise, mouth-to-mouth breathing.
Dr.Waleed Badr
2011
Then arrest team (not you except if you have the license) should have come to do:
Advanced life
D: Disability :
Assess level of consciousness by AVPU score or Glasgow coma scale if time allows (see P.53)
Check pupils (size, equality and reaction).
[
Dr.Waleed Badr
2011
1- VF/VT :
Immediate defibrillation must occur without delay: 360J monophasic or 150-360 J biphasic .
Immediately Resume CPR 30:2 for 2 minutes without attempting to confirm restoration of a pulse
(because restoration of mechanical cardiac output rarely occurs immediately after successful defibrillation).
If still VF/VT, repeat defibrillation . All shocks are 360J. Thereafter, additional shocks are given
every 2 minutes after each cycle of CPR .
2- A systole/PEA:
Immediately resume CPR 30:2 for 2 minutes continue until the victim starts to breathe normally .
Transverse cardiac pacing may be tried .
Correct reversible causes "4H, 4T" (see Algorithm) .
During CPR
Oxygen 100% .
Adrenaline 1mg/ml IV, every 3 min .
Amiodarone 300 mg IV . a futher 150 mg may be given, followed by an infusion of 1mg/min for
6h, then 0.5 mg/min for 6h (in resistant VF/VT) .
Atropine 3 mg IV (once) (in Asystole/PEA) .
Treat acidosis with good ventilation. Sodium bicarbonate may worsen intracellular acidosis &
precipitate arrhythmias, so use only in severe acidosis after prolonged resuscitation (e.g. 50 ml of
8.4 % solution by IVI).
Dr.Waleed Badr
2011
Dr.Waleed Badr
2011
NB :
Send someone to check patients notes & usual doctor, these may give clues to the cause of the
arrest .
If IV access fails, give drugs down tracheal tube (2-3 times the IV dose diluted in 10ml 0.9% saline
followed by 5 ventilations to assist absorption).
Dr.Waleed Badr
2011
Shock
Heat exhaustion.
3) Anaphylactic Shock.
4) Neurogenic shock : i.e related to a nervous system injury e.g. post spinal surgery.
5) Septic Shock : due to toxins or poisons released by an infection .
6) Iatrogenic : drugs e.g. anesthetics and antihypertensives.
7) Endocrine failure : e.g. Addisons ds or hypothyroidism.
Clinical picture :
1. Vital signs :
-
Bl.P : in early stages of shock as COP but rapidly as shock progresses i.e hypotension .
2. CNS: Early : change in personality & may progress to restlessness. Late : confusion & ultimately coma
may occur.
3. CVS : Chest pain. with profound acidosis, abnormal heart rhythms (cardiac dysrhythmias) are more
prevalent and are potentially fatal.
4. GIT problems : arise most often from the shunting of blood away from this system. Symptoms include :
abdominal pain, nausea, vomiting, or diarrhea + GIT bleeding with black/tarry stool .
5. Skin : cold, pale, clammy & cyanosed (if extreme low blood
O2
content) .
10
Dr.Waleed Badr
2011
Management:
If BP unrecordable, call the cardiac arrest team
Call for help + make the patient lie on hard surface with raised legs.
A ensure patent airway (remove any obstruction, chin elevation, head tilt) & adequate
ventilation.
B O2 100%.
C Circulation (IV access x 2 wide bore, get help if this takes > 2 min).
Identify & treat underlying cause if clear ( e.g check abdomen for signs of trauma or aneurysm.
GIT bleeding and melena). If unclear, ttt as Hypovolaemic (most common cause).
Consider: arterial line, central venous line & Foley's catheter.
Infuse crystalloids: fast to raise BP (unless cardiogenic shock) as dictated by BP, CVP & urine output
(aim for a urine flow > 30 mL/h).
NB.Dont overload with fluids if cardiogenic shock (exclude PE & RV infarct 1st).
Vital sign monitoring: pulse, BP, temperature, respiration & peripheral perfusion.
Do some investigations: FBC, U&E, ABG, glucose, cross matching, ECG.
Management:
o If the cause is MI, prompt thrombolysis or acute angioplasty.
o Manage in CCU or ICU if possible.
o Oxygen.
o Morphine (2.5 5 mg IV) for pain and anxiety.
o Investigations: ECG (every hour until diagnosis is made), Cardiac enzymes/troponins, U&E, CXR,
echo, ABG.
o Close monitoring: CVP, BP, ABG, ECG & urine output.
o Correct arrhythmia, U&E and acid base imbalance.
11
Dr.Waleed Badr
2011
o Consider a Swan Ganz catheter to assess pulmonary capillary wedge pressure (PCWP) and
cardiac output & an arterial line to monitor pressure.
PCWP < 15 mm Hg: give plasma expanders (100 mL every 15 min IV), aim for 15 20 mm Hg.
PCWP > 15 mm Hg: consider +ve inotropes e.g dopamine OR dobutamine (2.5 10 ug/kg/min
IVI), aim for systolic BP > 80 mm Hg.
o Look for and treat any reversible cause e.g. MI and PE (thrombolysis). Consider surgery for valvular
lesions.
Cardiac tamponade
Pericardial fluid collection intrapericardial pressure Heart cannot fill pumping stops.
Signs:
Investigations:
CXR: globular heart, Lt. heart border convex or straight, Rt. costophrenic angle < 90.
Echo is diagnostic.
Management:
Very difficult. With actual senior help and luck, prompt pericardiocentesis brings swift
relief.
While awaiting, give oxygen, monitor ECG and set an IVI. Take blood for group & save.
Cardiothoracic surgery (e.g CABG, ventricular repair, or pericardial window) may have
a role
Hypovolaemic shock:
Treat underlying cause e.g. control obvious hemorrhage, urgent laparotomy or thoracotomy.
Fluid replacement: Saline 0.9% or colloid initially; if bleeding, use cross matched blood transfusion or
group O Rh ve blood via large bore cannula.Titrate against BP, CVP & urine output.
12
Dr.Waleed Badr
2011
Anaphylactic shock:
Causes: drugs e.g. penicillin and contrast mediators in radiology (e.g FA). Stings and some kinds of
food e.g. strawberries, eggs, fish .
NB. Anaphlactoid reaction involves direct release of mediators from inflammatory cells without involving
antibodies e.g. with drugs.
Tachycardia, hypotension,
Syncope .
Differential diagnosis :
1. Causes of loss of consciousness :
Hypoglycaemia .
MI .
Treatment:
1. Remove cause, raise the feet + call for help .
2. ABC : Secure airway, 100% oxygen & Secure IV access.
3. Adrenaline 0.5 mg (0.5 mL of 1:1000) IM repeated every 5 min guided by BP, pulse and respiratory
function until better.
4. Antihistaminic e.g. chlorpheniramine 10 mg IV repeated every 6h if urticaria persists .
5. Hydrocortisone 200 mg IV (can be repeated if necessary) .
6.
If hypotensive : IVI 0.9 % saline 500 ml over 15 minutes (up to 2 L may be needed), titrated against BP.
7. If severe bronchospasm : Consider aminophylline & nebulized salbutamol 2.5 mg . titrated against
respiratory function .
8. if laryngeal edema is worsening (stridor) : refer to ICU & Intubation/ventilation.
NB: if patient is severely ill or has no pulse, consider IV adrenaline (1 mL of 1:10,000 solution per minute).
Stop as soon as a response has been obtained.
13
Dr.Waleed Badr
2011
patient is to be discharged only after 48hrs as
Skin- prick tests (showing specific IgE) helps in identifying which allergens to avoid.
Emergency tray equipped with Ambu bag with fascial fask, larnygyoscope, endotracheal tube,
oxygen cylinder
glucose) .
Septic shock:
Endotoxin-induced vasodilatation with shock & coma but with no signs of infection (fever and
WCC).
Antibiotics: is given (preferably after blood culture). if no clue to source IV cefuroxime 1.5 g / 8h or
gentamycin + antipseudomonal.
Vasovagal attack:
Treatment: raise legs, IVI fluids, Atropine 1mg IV & hydrocortisone 200 mg I.V .
14
Dr.Waleed Badr
2011
Pulmonary embolism.
Aortic dissection.
Tension pneumothorax.
Esophageal rupture.
Others :
Pericarditis.
Cervical spondylosis .
Sickle-cell crises.
Management:
15
ABC .
Level of consciousness.
Dr.Waleed Badr
2011
Site
Ischaemic
Aortic
Pericarditis/
cardiac
dissection
Pleurisy
Central,diffuse
Between
Retrosternal
Oesophageal
Musculoskeletal
shoulder
blades
Radiation
Jaw/neck/shoul
Back
der/arm/occasi
onally back
Character
Dull,constricting,
Sharp
choking,
tearing
&
Sharp
Can
mimic
squeezing,
constricting
crushing
or
pressure
Precipitated
Exercise,
by
emotion,
cold,
coughing
after
large
lying flat
Breathing,
or
Food,lying flat,hot
Movement
drinks,alcohol
(bending,
stretching,
meal
Relieved by
turning)
Rest, nitrates
leaning
Nitrates,antacids
forwards
Associated
Autonomic
symptoms &
over
signs
Breathlessness
costal cartilage
16
disturbance
e.g
Local tenderness
a
rib
or
Dr.Waleed Badr
2011
Unstable angina
[[
Heavy chest pain > 15min, radiating to the arm, neck and shoulder.
May present without chest pain (Silent MI) e.g in elderly or diabetics .
Investigations :
o
CK : 8 12 h till 72 h.
Management :
Brief history: previous attack & risk factors for IHD or any contraindications for thrombolysis.
Medications :
17
Dr.Waleed Badr
2011
Restore coronary perfusion either primary percutaneous coronary intervention (PCI) e.g angioplasty
(if available) or thrombolysis .
Primary PCI:
The treatment of choice if ongoing ischaemia & presentation is within 12h.
More effective than thrombolysis, with a greater reduction in the risk of death, recurrent MI or
stroke .
Not available in all locations .
Thrombolysis:
Greatest benefit if given < 12 h of onset, up to 24 h. thrombolysis is contraindicated beyond 24h
from the time of onset of symptoms .
Indications: ECG criteria for thrombolysis
1. ST elevation > 1 mm in 2 or more limb leads OR > 2 mm in 2 or more chest leads.
2. LBBB (unless known to have LBBB previously) .
3. Posterior changes : deep ST depression & tall R waves in leads V1 to V3 .
NB. Dont thrombolyze ST depression alone, T-wave inversion alone or normal ECG .
Contraindications: Internal bleeding, suspected aortic dissection, esophageal varices, active
peptic ulcer, recent surgery, trauma or hemorrhagic stroke. severe hypertension, pregnancy .
Choice of agent :
-
Streptokinase (SK): 1.5 million units in 100 mL 0.9 % saline IVI over 1h.
In cases of allergy to SK (rare) : Tissue plasminogen activator might be used e.g Alteplase
(human tPA), Tenecteplase & Reteplase ( tPA analogues) .
Complications:
-
18
Stroke .
Dr.Waleed Badr
2011
NSTEMI
Patients should be managed medically until symptoms settle and then investigated by angiography
with a view to possible angioplasty or surgery (CABG).
Assessment: brief history (previous attack, relief with rest/nitrates, risk factors for IHD, history of
cardiovascular diseases), examination (vital signs, signs of heart failure).
Investigations: ECG (ST depression, flat or inverted T or normal), cardiac enzymes, CXR, glucose,
lipids, U&E, FBC.
NB: measurement of cardiac troponin helps predict which patients are at risk of a cardiac event and
who can be discharged early (2 different forms: troponin T and troponin I).
Management:
BBlockers e.g. metoprolol 50-100 mg/8h . If contraindicated (asthma, COPD, LVF, bradycardia &
coronary artery spasm), give calcium channel antagonist e.g verapamil 80-120 mg/8h .
If symptoms fail to improve, refer to a cardiologist for urgent angiography angioplasty or CABG.
If improving (no further pain, normal ECG and negative troponin), treat medically, address risk factors
(DM, HTN, smoking), gentle mobilization and arrange further investigations (stress test & angiogram).
19
Dr.Waleed Badr
2011
Cardiovascular (LV failure post MI or IHD, mitral stenosis, arrhythmias & malignant hypertension).
Fluid overload.
DD:
1. asthma/COPD.
2. Pneumonia & pulmonary edema are often hard to distinguish especially in the elderly where they
may co-exist. Do not hesitate to treat all three simultaneously.
Treatment:
Oxygen 100%.
Start nitrate infusion e.g isosorbide dinitrate 2-10 mg/h IVI if systolic BP 100 mmHg.
Once stable and improving, do all investigations again and treat permanently accordingly.
20
Dr.Waleed Badr
2011
Management :
If in doubt, treat as ventricular tachycardia (the commonest cause).
Identify the underlying rhythm and treat accordingly.
If No pulse, treat as arrest.
Treatment of ventricular tachycardia:
Oxygen,
IV
access,
hypomagnesaemia,
if
unstable
amiodarone
(sedation,
or
lidocaine),
DC
shock,
correct
hypokalaemia
and
if
stable
(correct
hypokalaemia
and
After correction of VT: find the cause, anti-arrhythmic therapy, surgical isolation of arrythmogenic
area or implantable cardioverter defibrillator (ICD) may help.
21
Dr.Waleed Badr
2011
DD:
Atrial flutter: (rate 300 bpm, sawtooth baseline, ventricular rate 150 bpm (2:1 block)) .
Junctional tachycardia
Cardiac :
-
Hypertension .
Symptoms : may be asymptomatic or present with chest pain, palpitations & dysnea.
Signs :
Pulse : irregularly irregular* ( apical pulse rate (300-600 bpm) is greater than the radial rate) .
U&E, cardiac enzymes , thyroid function tests , D-dimer (if the patient has risk factors to pulmonary embolism)
22
Dr.Waleed Badr
2011
Anticoagulation is not required if AF of recent onset with normal echo but aspirin 300 mg PO
maybe given. Otherwise, give warfarin 3 wks before and 4 wks after DC cardioversion.
23
Dr.Waleed Badr
2011
Signs :
Calf warmth/tenderness/swelling/erythema
Pitting oedema.
Mild fever .
Homans' sign ( resistance/pain on forced foot dorsiflexion) : should not be tested for as it may
dislodge thrombus.
Differential diagnosis :
Ruptured knee (Bakers Cyst) : Usually occur in patients with rheumatoid arthritis .
Cellulitis : Infective cellulitis is usually distinguished by marked skin erythema & heat which is localised
within a well-demarcated area of the leg and may be associated with an obvious source of entry of
infection (e.g. an insect bite or leg ulcer).
Investigations :
1. FBC (WCC to help find infection; Hb to look for polycythaemia; platelet count look for
thrombocytosis) .
2. D-dimer blood tests (evidence of clot lysis) : High sensitivity but low specificity ( if thrombosis,
infection, malignancy & post-op) .
3. Compression U/S of calf & leg (ideally doppler U/S) : if ve, repeat at 1wK to catch those with
early but propagating DVTs ; this should also rule out ruptured knee
4. ECG; CXR; ABG; V/Q scan & CT pulmonary angiography (If pulmonary embolus a serious
concern).
24
Dr.Waleed Badr
2011
Complications :
1. Pulmonary embolism : range of severity from asymptomatic, to symptomatic, to sudden death
2. Chronic post-phlebitic leg problems (10-30%) :
Aspirin .
Management :
Anti-coagulants :
Start warfarin simultaneously with LMWH (as it is prothrombotic for the first 48h) .
Vena caval filters : may be used in active bleeding, or when anticoagulants fails, to minimize risk
of pulmonary embolus.
Calf swelling > 3cm compared to the other leg (measured 10cm below tibial tuberosity)
Active malignancy .
25
Dr.Waleed Badr
2011
Mechanism: Venous thrombi, usually from DVT, pass into the pulmonary circulation and block blood
flow to lungs. The source is often occult.
Risk factors: malignancy, long immobilization following surgery (especially pelvic), venous disease,
obesity, the PILL & HRT.
Investigations:
ECG:
-
Rt. ventricular strain pattern (V1 3), Rt. Axis deviation, RBBB .
AF.
Rarely, SI,QIII,TIIII pattern occurs : deep S waves in I, pathological Q waves in III, inverted T waves
in III.
CXR: often normal, vascular markings, small pleural effusion, wedge shaped area of infarction.
High sensitivity but low specificity as it also in infection, malignancy & post-op .
CT pulmonary angiography (CTPA): Better with helical (spiral) CT. It is sensitive & specific in
determining if emboli are in pulmonary artery. If unavailable, a ventilation-perfusion (V/Q) scan can
aid diagnosis. If equivocal, pulmonary angiography or bilateral venograms may help.
26
Dr.Waleed Badr
2011
Management
If still BP after 500 mL colloid, give dobutamine 2.5 10 ug/kg/min IV (aim for BP > 90 mmHg).
If still BP after 30 60 min of standard treatment with clinically definite PE and clinical
improvement, consider thrombolysis with streptokinase (loading dose 250,000 U IVI over 30 min,
maintenance 100,000 U/h for 12 72 h according to response).
27
Dr.Waleed Badr
2011
Cardiovascular drugs
1. B-blockers :
Classification :
1. 1st generation
(Non-selective blockers)
2. 2nd generation
(selective B1 blockers)
(cardioselective)
3. 3rd generation
(blockers with V.D action)
Propranolol
Sotalol
Timolol
Levobunolol
Metipranolol
Atenolol
Metapralol
Bisoprolol
Betaxolol
Dilevalol
Nebivolol
Mechanism of action : Block B-adrenoceptors, thus antagonizing the sympathetic nervous system. Blocking
B1-receptors is negatively inotropic and chronotropic (Pulse by firing of sinoatrial node), and B2receptors induce peripheral vasoconstriction and bronchoconstriction.
Indications :
1. Hypertension (2nd line).
2. Ischaemic heart diseases : Angina, post MI (mortality).
3. Cardiac arrythmias (antidysrhythmic).
4. Hyperthyroidism .
5. Prophylaxis of migraine .
6. Anxiety & tremors .
7. Glaucoma .
Side effects :
1. Bronchospasm (in susceptible patients) .
2. Hypotension & bradycardia (antidote to bradycardia is Atropine up to 3mg IV. Give glucagon 210mg IV bolus + 5% dextrose if atropine fails ( an atropine infusion of 50g/kg/h). If unresponsive,
consider pacing or an aortic balloon pump).
3. Peripheral ischaemia, intermittent claudication & cold extremities .
blood flow to liver & kidney metabolism & excretion of drugs .
4. Potentiation of the hypoglycaemic effect of insulin & oral hypoglycaemic drugs & masking of the
hypoglycaemic symptoms .
5. Hyperkalaemia in diabetic & uraemic patients .
28
Dr.Waleed Badr
2011
6. Miscellaneous S/E : night mares, depression, headache, nausea, vomiting, lipido & possible of
plasma HDL level .
Contraindications :
heart Block
Asthma/COPD .
Prinzmetal's angina (angina due to coronary spasm caused by hyperactivity of receptors in the
coronaries) .
2. Diuretics :
Mechanism
of action
Indications
Side effects
Loop diuretics
Thiazide diurectics
K+ sparing diuretics
(Furosemide)
(hydrochlorothiazide)
(Spironolactone)
Act mainly at limb of Act mainly at proximal Act mainly at distal part of
loop of henle .
part of DCT.
DCT & upper part of
Inhibit
Na+/K+/2CL- Inhibit Nacl cotransport collecting tubules .
cotransport Na+ &
Na+ & CL- reabsorption. Competitive inhibition with
CL- reabsorption .
aldosterone .
Acute pulmonary edema Congestive heart failure
Given
with
other
Hypertensive
Essential hypertension .
diuretics (to balance K+
emergencies .
Diabetes insipidus .
loss) .
Hyper Ca2+ & Hyper K+ .
Hyperaldosteronism
Hypokalaemia .
Hyperkalaemia .
Hypomagnesaemia .
Gynecomastia
&
Hyponatraemia .
impotence in males .
Hypocalcaemia .
Menstrual disorders &
Hyperuricaemia .
hirsutism in females
Ototoxicity .
2. Nondihydropyridines
29
Drugs
Nifedipine
Amlodipine
Lacidipine
Nimodipine
Nicardipine
Felodipine
Verapamil
Diltiazem
Indications
Hypertension
angina
Hypertension, angina
& arrhythmias .
&
Dr.Waleed Badr
2011
Mechanism of action : Work by blocking voltage-gated ca2+ channels in cardiac muscle & blood vessels. This
intracellular Ca2+ leading to a reduction in muscle contraction, thereby promoting coronary & peripheral
vasodilatation & reducing cardiac contractility and myocardial oxygen consumption (Bl.P ) .
Side effects :
1.
2.
3.
4.
5.
6.
4. Digitalis (Digoxin) :
Mechanism of action :
1. +ve inotropic action (Blocks the Na+/K+ pump free intracellular ca2+) improves myocardial
contractility & COP .
2. Slow the heart rate (used in fast AF to control ventricular rate. aim for pulse <100).
3. Conduction velocity : in small doses & in large doses .
Indications :
1. the major indication is CHG associated with atrial fibrillation .
2. other indications : heart failure not responding to diuretics, atrial fibrillation, atrial flutter & paroxysmal
atrial tachycardia .
Dosage :
PO:
-
loading dose : 0.5 mg PO twice daily (in AF, we give a large intial loading dose in 3-4 divided
doses at 6-hours intervals. A total dose of 1.25-1.5 mg is often necessary)
CI:
1. Possibility of digitalis toxicity .
2. Heart block .
3. Hypertrophic obstructive cardiomyopathy .
4. WPW syndrome .
5. Paroxysmal ventricular tachycardia .
30
Dr.Waleed Badr
2011
Never give I.V digitalizing dose before being sure that the patient has not received any digitalis
during previous 14 days to avoid digitalis toxicity .
Use lower digitalizing dose with elderly people , since toxic effects may be pronounced after
administration of the normal adult dose of digitalis .
SE (digitalis toxicity)
Hypokalaemia .
Digoxin-specific antibody fragments IVI (Digibind) : specific antibodies that permits high renal
clearance of digitalis complex by glomerular filteration .
5. Antiarrhythmic drugs
Classification :
1. Class I
31
Dr.Waleed Badr
2011
Rate:
-
At usual speed (25mm/s) each "big square" is 0.2s; each "small square" is 0.04s.
To calculate the rate, divide 300 by the number of big squares per R-R interval .
Rhythm:
-
If the cycles are not clearly regular, use the "card method": lay a card along ECG, marking
positions of 3 successive R waves. Slide the card to and fro to check that all intervals are equal. If
not, note if different rates are multiples of each other (i.e varying block), or is it 100% irregular (AF
or VF)?
Sinus rhythm is characterized by a P wave (upright in II, III, & aVF; inverted in aVR) followed by a
QRS complex.
AF has no discernible P waves and the QRS complexes are irregularly irregular.
Atrial flutter has a "sawtooth" baseline of atrial depolarization (~300/min) and regular QRS
complexes.
Nodal rhythm has a normal QRS complex but P waves are absent or occur just before or within
the QRS complex.
Ventricular rhythm has QRS complexes >0.12s with P waves following them.
Axis:
-
The mean frontal axis is the sum of all the ventricular forces during ventricular depolarization.
The axis lies at 90 to the isoelectric complex (ie the one in which positive and negative
deflections are equal).
Normal axis is between -30 and +90 .
As a simple rule of thumb, if the complexes in leads I and II are both "positive", the axis is normal.
Left axis deviation (LAD) is -30 and -90. Causes: left anterior hemiblock, inferior MI, VT from LV
focus, Wolff- Parkinson-White (WPW) syndrome (some types).
Right axis deviation (RAD) is +90 and +180 . Causes: RVH, PE, anterolateral MI, left posterior
hemiblock (rare), WPW syndrome (some types).
P wave:
-
P-R interval:
-
32
Dr.Waleed Badr
2011
QRS complex:
-
QT interval:
-
Measure from start of QRS to end of T wave. It varies with rate. Calculate corrected QT interval
(QTc) by dividing the measured QT interval by the square root of the cycle length, i.e
. Normal QTc: 0.38-0.42s
ST segment:
-
Usually isoelectric.
elevated (>1mm) in infarction .
depressed (>0.5mm) in ischaemia .
T wave:
-
33
Dr.Waleed Badr
2011
In LBBB, the following pattern is seen: QRS >0.12s, "M pattern" in V5, no septal Q waves, inverted T
waves in I, aVL, V5-V6. Causes: IHD, hypertension, cardiomyopathy, idiopathic fibrosis. NB: If there is
LBBB, no comment can be made on the ST segment or T wave.
Bifascicular block : is the combination of RBBB and left bundle hemiblock, manifest as an axis
deviation, eg LAD in the case of left anterior hemiblock.
Trifascicular block : is the combination of bifascicular block and 1st degree heart block.
Ventricular hypertrophy
There is no single marker of ventricular hypertrophy: electrical axis, voltage, and ST wave changes
should all be taken into consideration. Relying on a single marker such as voltage may be unreliable
as a thin chest wall may result in large voltage whereas a thick chest wall may mask it.
Suspect left ventricular hypertrophy (LVH) if the R wave in V6 >25mm or the sum of the S wave in V 1
and the R wave in V6 is >35mm .
Suspect right ventricular hypertrophy (RVH) if dominant R wave in V1, T wave inversion in V1-V3 or V4,
deep S wave in V6, RAD.
Other causes of dominant R wave in V1: RBBB, posterior MI, some types of WPW syndrome .
Causes of low voltage QRS complex: (QRS <5mm in all limb leads) Hypothyroidism, chronic
obstructive pulmonary disease (COPD), haematocrit (intra-cardiac blood resistivity is related to
haematocrit), changes in chest wall impedance (eg in renal failure, subcutaneous emphysema but
not obesity), pulmonary embolism, bundle branch block, carcinoid heart disease, myocarditis,
cardiac amyloid, adriamycin cardiotoxicity, and other heart muscle diseases, pericardial effusion,
pericarditis.
ECG abnormalities
Sinus tachycardia (Rate >100) : Causes: Anaemia, anxiety, exercise, pain, fever, sepsis, hypovolaemia,
heart failure, pulmonary embolism, pregnancy, thyrotoxicosis, beri beri, CO 2 retention, autonomic
neuropathy, sympathomimetics, e.g caffeine, adrenaline, and nicotine (may produce abrupt changes
in sinus rate, or other arrhythmia).
Sinus bradycardia (Rate <60) : Causes: Physical fitness, vasovagal attacks, sick sinus syndrome, acute MI
(esp. inferior), drugs (B-blockers, digoxin, amiodarone, verapamil), hypothyroidism, hypothermia,
intracranial pressure, cholestasis.
AF: Common causes: IHD, thyrotoxicosis, hypertension. (See before) .
A-V block :
-
1st degree : AV conduction is delayed so the PR interval is prolonged (> 0.20s). It rarely causes
symptoms.
2nd degree: In this condition dropped beats occur because some impulses from the atria fail to
conduct to the ventricles.
Mobitz type I : there is progressive lengthening of successive PR intervals, culminating in a
dropped beat. The cycle then repeats itself. It is usually due to impaired conduction in the
AV node itself.
Mobitz type II : the PR interval of the conducted impulses remains constant but some P
waves are not conducted (2:1or 3:1). it is usually caused by disease of the His-Purkinje
system and carries a risk of asystole.
Causes of 1st & 2nd degree: Normal variant, athletes, sick sinus syndrome, IHD, acute
carditis, drugs (digoxin, B-blockers).
34
Dr.Waleed Badr
2011
3rd degree (complete): When AV conduction fails completely, the atria and ventricles beat
independently (AV dissociation). Ventricular activity is maintained by an escape rhythm arising in
the AV node or bundle of His (narrow QRS complexes) or the distal Purkinje tissues (broad QRS
complexes).
Causes of 3rd degree: Idiopathic (fibrosis), congenital, IHD, aortic valve calcification,
cardiac surgery/trauma, digoxin toxicity, infiltration (abscesses, granulomas, tumours,
parasites).
Q waves: Pathological Q waves are usually >0.04s wide and >2mm deep. Usually as sign of infarction,
and may occur within a few hours of an acute MI.
ST elevation: Normal variant (high take-off), acute MI, Prinzmetal's angina , acute pericarditis (saddleshaped), left ventricular aneurysm.
ST depression: Normal variant (upward sloping), digoxin (downward sloping), ischaemic (horizontal).
T inversion: In V1-V3: normal (Blacks and children), right bundle branch block (RBBB), pulmonary
embolism. In V2-V5: subendocardial MI, HOCM, subarachnoid haemorrhage, lithium. In V 4-V6 and aVL:
ischaemia, LVH, associated with left bundle branch block (LBBB).
NB: ST and T wave changes are often non-specific, and must be interpreted in the light of the clinical
context.
MI:
-
Within hours, the T wave may become peaked and ST segments may begin to rise.
Within 24h, the T wave inverts, as ST segment elevation begins to resolve. ST elevation rarely
persists, unless a left ventricular aneurysm develops. T wave inversion may or may not persist.
Within a few days, pathological Q waves begin to form. Q waves usually persist, but may resolve
in 10%.
The leads affected reflect the site of the infarct: inferior (II, III, aVF), anteroseptal (V 1-4),
anterolateral (V4-6, I, aVL), posterior (tall R and ST in V1-2).
"Non Qwave infarcts" (formerly called subendocardial infarcts) have ST and T changes without Q
waves.
Pulmonary embolism:
- Sinus tachycardia is commonest.
- There may be RAD, RBBB , right ventricular strain pattern (R-axis deviation. Dominant R wave and T
wave inversion/ST depression in V1 and V2. Leads II, III and aVF may show similar changes).
- Rarely, the SIQIIITIII pattern occurs: deep S waves in I, pathological Q waves in III, inverted T waves
in III.
Metabolic abnormalities:
-
Digoxin effect: ST depression and inverted T wave in V 5-6 (reversed tick). In digoxin toxicity, any
arrhythmia may occur (ventricular ectopics and nodal bradycardia are common).
Hyperkalaemia: Tall, tented T wave, widened QRS, absent P waves, "sine wave" appearance .
Hypokalaemia: Small T waves, prominent U waves.
Hypercalcaemia: Short QT interval.
Hypocalcaemia: Long QT interval, small T waves.
35
Dr.Waleed Badr
2011
Contraindications:
Unstable angina
Recent Q wave MI (<5 days ago)
Severe AS
Uncontrolled arrhythmia, hypertension, or heart failure.
36
Dr.Waleed Badr
2011
Pulse oximetry : allows non-invasive assessment of peripheral O2 saturation . It provides a useful tool for
monitoring those who are acutely ill or at risk of deterioration. On most pulse oximeters, the alarm is set at
90%. A PaO2 80% is clearly abnormal and action is required (unless this is normal for the patient e.g in
COPD).
What is the difference between metabolic & respiratory acidosis & alkalosis ? SIMPLE RULES
-
37
Dr.Waleed Badr
2011
Acidosis
Metabolic
Alkalosis
HCO-3
Respiratory
pH
Lactic
acid
(shock,infection,hypoxia) .
Urate (renal failure) .
Ketones (D.M, alcohol) .
Salicylate poisoning .
pH CO2
Respiratory failure
pH HCO-3
Vomiting .
Burns .
K+ depletion (Diurectics) .
Ingestion of base .
pH CO2
A result of hyperventilation
CNS : stroke, subarachnoid
hge,meningitis.
Others
:
anxiety,
fever,
pregnancy, salicylate poisoning.
Causes
of
Hypoxia
ventilation/perfusion
(V/Q)
mismatch
"the
commonest
cause",
A PaCO2 < 4.5 kPa indicates hyperventilation and a PaCO2 > 6.0kPa indicates hypoventilation.
Type 1 respiratory failure is defined as PaO2 < 8 kPa and PaCO2 < 6.0 kPa, whereas type II respiratory
failure is defined as PaO2 < 8 kPa and PaCO2 > 6.0 kPa.
Signs of CO2 retention : bounding pulse, drowsy, tremor (flapping), headache, pink palms,
papilloedema .
38
Dr.Waleed Badr
2011
Acute asthma.
Heart failure.
Anaphylaxis.
Tumor or FB.
Acute epiglottitis.
Crepitations:
Heart failure.
Pneumonia.
Bronchiectasis.
Clear chest:
PE.
Anemia.
Shock.
CNS causes.
Others:
Pneumothorax.
Pleural effusion.
Workup:
History
H/O Associated cardiovascular symptoms (chest pain, palpitations, sweating and nausea) or
respiratory symptoms (cough, wheeze, haemoptysis, stridor) .
39
In the severely ill patient it may be necessary to obtain the history from accompanying relatives.
Dr.Waleed Badr
2011
In children, the possibility of inhalation of a foreign body or acute epiglottitis should always be
considered.
Clinical assessment :
Level of consciousness
Cardiovascular status (heart rate and rhythm, BP and degree of peripheral perfusion).
NB.Pulmonary oedema is suggested by pink frothy sputum and bi-basal crackles, asthma or COPD by
wheeze and prolonged expiration, pneumothorax by a silent resonant hemithorax, and pulmonary
embolus by severe breathlessness with normal breath sounds. The peak expiratory flow should be
measured whenever possible. Leg swelling may suggest cardiac failure or, if asymmetrical, venous
thrombosis.
Investigations : ABG, CXR & ECG ( to confirm the clinical diagnosis).
Management : look chest pain
40
Dr.Waleed Badr
2011
History
C/P
CXR
ABG
ECG
Pulmonary
oedema
Chest
pain,
palpitations,
orthopnoea,
cardiac history*
Central
cyanosis, JVP,
sweating, cool
extremities, pink
frothy
sputum
,basal crackles*
Cardiomegaly,
oedema/pleural
effusions*
PaO2
PaCO2
Sinus
tachycardia,
ischaemia*,
arrhythmia
pulmonary
embolism
Risk
factors,
chest
pain,
pleurisy,
syncope*,
dizziness*
Central
cyanosis, JVP*,
absence of signs
in
the
lung*,
shock
(tachycardia,
hypotension)
Often
normal
Prominent
hilar
vessels,
oligaemic
lung
fields*
PaO2
PaCO2
Sinus
tachycardia,
RBBB, S1Q3T3
pattern
T (V1-V4)
Acute severe
asthma
History
of
asthma,
asthma
medications,
wheeze*
Tachycardia,
pulsus
paradoxus,
cyanosis (late),
JVP *, peak
flow, wheeze*
Hyperinflation
only
(unless
complicated by
pneumothorax)*
PaO2
PaCO2
(PaCO2
extremis)
Sinus
tachycardia
(bradycardia in
extremis)
Acute
exacerbation
of COPD
Previous
episodes*,
smoker. If in
type
II
respiratory
failure may be
drowsy
Cyanosis,
hyperinflation*,
signs of CO2
retention
(flapping tremor,
bounding
pulses)*
Hyperinflation*,
bullae,
complicating
pneumothorax
or
PaO2
PaCO2 in type
II failure H+,
HCO3
in
chronic type II
failure
Normal, or signs
of right
ventricular
strain
Pneumonia
Prodromal
illness*, fever*,
rigors*, pleurisy*
Fever, confusion,
pleural
rub*,
consolidation*,
cyanosis
(if
severe)
Pneumonic
consolidation*
PaO2
PaCO2 (
extremis)
Tachycardia
Metabolic
acidosis
Evidence
of
DM or renal
disease, aspirin
or
ethylene
glycol
overdose
Fetor (ketones),
hyperventilation
without heart or
lung
signs*,
dehydration*, air
hunger
Normal
PaO2
normal
PaCO2, H+
Psychogenic
Previous
episodes,
digital or perioral
dysaesthesia
No cyanosis, no
heart or lung
signs,
carpopedal
spasm
Normal
PaO2 normal*
PaCO2, H+*
41
in
in
Dr.Waleed Badr
2011
Severe attack: Unable to complete sentences, respiratory rate > 25/min, pulse >110 beats/min, PEFR <
50% of predicted.
Life threatening attack: PEFR < 33% of predicted, silent chest, sweating, panic, speechless, using
accessory muscles, cyanosis, bradycardia, hypotension, confusion, coma.
Investigations: Peak expiratory flow rate (PEFR), ABG (high CO2, low O2 (<90%) + low pH), CXR, FBC & U&E.
Treatment:
Call for help .
Sit patient up & do not sedate.
ABC : Ensure patent airway, Give oxygen 100% & secure IV line .
Salbutamol (B2-agonist) 5 mg (or terbutaline 10 mg) plus ipratropium bromide 0.5 mg nebulized with
oxygen.
Hydrocortisone 100 mg IV or prednisolone 30 mg PO or both if very ill.
Monitor oxygen saturation (pulse oximeter), heart rate and respiratory rate. CXR to exclude
pneumothorax.
If still not improving (after 30 min), repeat salbutamol every 15min or 10mg continuously per hour &
give Hydrocortisone 100 mg IV or prednisolone 30 mg PO if not already given.
If still not improving, consider aminophylline (5 mg/kg IVI over 20 min) or give salbutamol IVI (3 20
ug/min).
NB.Dose of aminophylline is adjusted according to the individual patient e.g :
-
dose in : cardiac or liver failure, drugs that life of aminophylline e.g cimetidine, ciprofloxacin,
erythromycin & contraceptive steroids .
dose in : smoking, drugs that life e.g phenytoin, carbamazepine, barbiturates & rifampicin.
42
Dr.Waleed Badr
2011
If still not improving, consider transfer to ICU to intubate, give adrenaline and 500 mL colloid IVI.
Once patient is improving:
-
Continue to monitor PEFR with the above for 24h with rate > 75% of predicted or best with diurnal
variability < 25% (beware of early morning dips in PEFR).
therapy :
Dont leave patients hypoxic. However,in some patients, who rely on their hypoxic drive to
breathe; too much oxygen may lead to a reduced respiratory rate and hypercapnia with a
consequent fall in conscious level.
In case of evidence of CO2 retention, start with 24 28 % O2. Reassess after 30 min.
In case there is no retention, use 28-40% O2 but still monitor and repeat ABG.
43
Dr.Waleed Badr
2011
Consider respiratory stimulant drug e.g. doxapram (only for patients not suitable for mechanical
ventilation and as a short term measure only).
TTT of Stable COPD: Stop smoking, encourage exercise, proper nutrition, weight reduction and
influenza vaccination. Give short acting B2-agonist, ipratropium and corticosteroid inhalations
according to severity.
Consider long term oxygen therapy.
Surgery is indicated in selected cases e.g. recurrent pneumothorax or isolated bullous disease.
Assess social circumstances and support required. Identify and treat depression.
Air travel is hazards if O2 saturation is low, check availability of O2.
44
Dr.Waleed Badr
2011
Pneumonia
Others : staph.aureus, haemophilus influenza, legionella & chlamydia psittaci, G-ve bacilli e.g
pseudomonas (often hospital-acquired or immunocompromised) .
Symptoms : fever, rigors, malaise, anorexia, dyspnea, cough, purulent sputum, haemoptysis & pleuritic
chest pain.
Signs :
Signs of consolidation (diminished expansion, dull percussion note, tactile vocal fremitus/vocal
resonance, bronchial breathing) .
Pleural rub .
Severity :
score
Confusion .
Urea > 7mmol/L .
Respiratory rate 30/min .
BP < 90/60 .
Age 65 .
45
Dr.Waleed Badr
2011
Management :
B Oxygenation.
Investigations : CXR, ABG, FBC, U&E, LFT, CRP, blood culture, aspiration of pleural fluid for culture
& bronchoscopy (if immunocompromised)
Empirical antibiotics :
o
If atypical :
Complications : Pleural effusion, empyema, lung abscess, respiratory failure, septicaemia, pericarditis,
myocarditis, cholestatic jaundice & renal failure .
46
Dr.Waleed Badr
2011
Tension pneumothorax
This is a medical emergency, requires immediate relief. Do not delay management for obtaining a CXR.
Causes:
2ry : to underlying lung disease e.g asthma, COPD, TB, pneumonia, lung abscess, lung fibrosis &
carcinoma .
Trauma, iatrogenic (subclavian CVP line insertion, pleural aspiration or biopsy, percutaneous liver
biopsy & +ve pressure ventilation).
Pathophysiology : Air drawn inside the pleural space with each inspiration has no route to escape
during expiration, pushing the mediastinum to the opposite side, kinking and compressing great veins.
Unless the air is rapidly removed, cardio respiratory arrest will occur.
Clinical picture:
Symptoms : may be asymptomatic or sudden onset of dyspnea and/or pleuritic chest pain.
Signs:
-
47
Dr.Waleed Badr
2011
Aspiration of pneumothorax :
After infilterative anaesthesia, Insert a large bore (14 - 16 G) cannula (venflon) into the 2nd
intercostal space in the mid-clavicular line on the side of the suspected pneumothorax.
Connect the cannula to a 3-way tap and 50mL 0.9% saline. Aspirate up to 2.5 litres of air.
Request CXR to confirm resolution.if successful repeat CXR after 24h to exclude recurrence .
Advice to avoid air travel for 6 weeks after normal CXR. Diving should be permanently avoided.
May be removed 24h after the lung has re-expanded & air leak has stopped (i.e the tube stops
bubbling). This is done during expiration or a Valsalva manoeuvre.
If failed to re-expand lung (within 48h), suction or surgical intervention may be required
48
Dr.Waleed Badr
2011
Headache D.D
A. Life- or Vision-Threatening
1. Subarachnoid hemorrhage : Extremely severe headache, stiff neck, conscious level; rarely, subhyaloid
hemorrhages seen on fundus examination, usually from a ruptured aneurysm.
2. Structural abnormality of the brain e.g tumor, aneurysm, AV malformation ( conscious level, signs of
ICT, or neurologic signs during, and often after, the headache episode).
3. Epidural or subdural hematoma (follows head trauma; altered level of consciousness; may produce
anisocoria.).
4. Infectious CNS disorder e.g meningitis, encephalitis, brain abscess (fever, stiff neck, conscious level,
photophobia, neurologic signs).
5. Giant cell arteritis (GCA) : Age >50 years, ESR & CRP, scalp tenderness, ..etc
6. Acute angle-closure glaucoma
7. Ocular ischemic syndrome
8. Malignant hypertension
9. ICT e.g Papilloedema & ICH (headaches usually worse in the morning & worsened by Valsalva) .
B. Others
Migraine
Cluster headache
Tension headache
Herpes zoster ophthalmicus : headache or periocular pain may precede the herpetic vesicles .
Sinus headache : may be a serious headache in diabetic patients and immunocompromised hosts
because mucormycosis may be responsible .
Vertebral artery dissection (neck pain & cerebellar/medullary signs) .
Cervical spine disease .
Pagets disease ( Alk phos)
Trigeminal neuralgia :
-
Brief attacks of severe paroxysmal & sharp pain (like an electric shock) lasting a few seconds that
start in the distribution of one of the divisions of the trigeminal nerve
49
Dr.Waleed Badr
2011
Severe unilateral headache with periocular pain in the distribution of the 1 st division of trigeminal
nerve .
Tolosa-Hunt syndrome .
Convergence insufficiency & Accomodative spasm .
Drugs e.g nitrates, CCB & Carbon monoxide poisoning .
50
Dr.Waleed Badr
2011
Coma
Metabolic
Neurological
Trauma .
Hypoglycaemia, Hyperglycaemia .
Infection
Septicaemia .
Tumours .
Hypothermia .
Stroke .
Epilepsy .
Hepatic/uraemic encephalopathy .
e.g
meningitis,
encephalitis .
Management of coma
Call for help.
ABC .
Consider intubation if GCS < 8.
Stabilize cervical spine.
Vital signs monitoring.
Level of consciousness (document).
Blood glucose in all patients; give 50 mL 50% dextrose IV immediately if presumed hypoglycemia.
Control seizures.
Consider IV glucose, IV thiamine (alcohol, Wernickes encephalopathy), IV naloxone (opiate
intoxication) and IV flumazenil (benzodiazepine intoxication if airway compromised).
Brief examination:
51
Dr.Waleed Badr
2011
5. Fundus:
Papilloedma ICT.
52
Dr.Waleed Badr
2011
Glasgow coma scale
This gives a reliable, objective way of recording the conscious state of a person. It is used for initial
and continuing assessment. It also has value in predicting ultimate outcome. 3 types of response are
assessed
1) Best motor response:(6 grades) Obeying commands(6), Localizing response to pain (5), Withdrawal
to pain* (4), Flexor response to pain (decorticate posture)** (3), Extensor response to pain
(decerebrate posture)*** (2), No response to pain (1). Note that it is the best response of any limb
which should be recorded.
* omitted in some centers so GCS is 14 not 15 .
** Damage above the level of red nucleus in midbrain
*** damage below the level of red nucleus in midbrain
2) Best verbal response (5 grades): Oriented (5), Confused Conversation (4), Inappropriate speech (3),
Incomprehensive speech (2), None (1). Record level of best speech.
3) Eye opening (4 grades) : Spontaneous eye opening (4), Eye opening in response to speech (3), Eye
opening in response to pain (2), No eye opening (1).
Primary scale (AVPU): is sometimes used in the initial assessment primary survey
53
A alert.
P responds to pain.
U unresponsive.
Dr.Waleed Badr
2011
Meningitis
Clinical features :
Early : headache, leg pains, cold hands and feet, abnormal skin colour .
Later :
Signs of Meningism : neck stiffness, photophobia, kernigs sign (pain + resistance on passive knee
extension with hip flexed) .
conscious level & coma .
Seizures focal CNS signs opisthotonus .
Petechial rash (non blanching) .
Signs of septicaemia (capillary refill; DIC; BP) .
Investigations :
U&E, FBC, LFT, glucose, coagulation screen .
Blood culture & serology .
Lumbar puncture(LP): for opening pressure ( in meningitis) & CSF sample for microscopic
examination .
CSF PCR (in aseptic meningitis) .
CXR (for TB meningitis) .
Management :
A Adequate ventilation.
B Oxygenation.
C Circulation IV line.
54
If septicaemic signs :
o
Dont attempt LP .
If meningitic signs :
o
Dr.Waleed Badr
2011
Subsequent therapy :
o
Maintenance fluids .
Encephalitis
Organisms:
Viral : HSV-1&2, arboviruses, CMV, EBV, VZV, HIV, measles, mumps,rabies, japanese B encephalitis,
west nile virus, tick-borne encepahlitis .
Non-viral : any bacterial meningitis, TB, malaria, listeria, lyme disease, legionella, leptospirosis,
aspergillosis, cryptococcus, schistosomiasis .
Signs & symptoms: Confusion, coma, seizures, fever, headache, focal neurological signs history of
travel or animal bite .
Investigations:
U&E, FBC, LFT, glucose, coagulation screen .
Blood culture & serology .
CT (contrast-enhanced) or MRI :
-
Lumbar puncture (LP) & CSF PCR : CSF protein & lymphocytes and glucose
EEG
Cerebral abscess
Causes: it may follows ear, sinus, dental of periodontal infection; skull fracture; congenital heart disease;
endocarditis; bronchiectasis .
Signs & symptoms: seizures, fever, signs of ICP & signs of sepsis elsewhere
Investigations: CT/MRI, WBC, ESR .
Management: referral to neurosurgery treat the source infection + treat ICP .
55
Dr.Waleed Badr
2011
Status epilepticus
Definition: Seizures lasting > 30min or repeated without intervening consciousness. Mortality & risk of
permanent brain damage with the length of attack.
Causes of seizures:
1. Idiopathic .
2. Genetic : e.g tuberous sclerosis .
3. Cerebrovascular disease : stroke, SOL, AV malformation .
4. Infections : encephalitis, cysticerosis, AIDS .
5. Inflammatory : sarcoidosis, SLE, PAN .
6. Metabolic : hyperglycaemia, hypoglycaemia, hyponatraemia, hypocalcaemia, liver failure, renal
failure .
7. Drugs : phenothiazines, tricyclics, benzodiazepines (withdrawal), alcohol (withdrawal), inadequate
anticonvulsant dose .
Management
Treatment:
56
Dr.Waleed Badr
2011
Lorazepam :
-
Beware of respiratory arrest during the last part of the injection & Have full resuscitation
facilities around.
Alternatively use diazepam 10 mg IV over 2min;if needed, repeat at 5 mg/min, until seizures
stop or 20 mg given.
While waiting for this to work, prepare other drugs. If fits continue
Phenytoin infusion (18mg/Kg IVI at a rate of 50mg/min). Beware of hypotension and dont use in
case of bradycardia and heart block. Requires BP and ECG monitoring. If fits continue
General anesthesia.
57
Dr.Waleed Badr
2011
Stroke
Definition : ischemic infarction (or bleeding into) any part of the brain. It manifests by rapid onset (over
minutes) of focal CNS signs and symptoms (contralateral hemiplegia & sensory loss + homonymous
hemianopia) .
Causes:
1. Atherothromboembolism (e.g from carotid) .
2. Heart emboli (AF;IE;MI) .
3. CNS bleed (hypertension, trauma and aneurysm rupture).
Risk
factors:
hypertension,
smoking,
DM,
heart
disease
(AF,
valvular,
ischaemic)
&
hypercholesterolemia.
Management
A Adequate ventilation.
B Oxygenation.
C Circulation IV line.
Vital sign monitoring for hypertension, admit and control over days not hours.
Admission to stroke units for nursing/physio saves lives and is a great motivation.
Investigations:
Urgent CT/ MRI within a few days of stroke to differentiate hemorrhagic from ischemic if
considering anticoagulation.
Pointers to hemorrhagic strokes are meningism, severe headache, and coma within hours.
NB1. TIA : sudden onset of focal CNS signs (resolve within few minutes) due to temporary occlusion, usually
by emboli, of part of cerebral circulation .
NB2 : carotid bruit may signify stenosis (>30%), often near the internal carotid origin. It is heared best behind
the angle of jaw .
Other investigations: FBC, CXR, ECG, ESR, U&E, lipids, blood glucose, clotting tests, echo, carotid
doppler & carotid angiography .
58
Dr.Waleed Badr
2011
Treatment:
Unless there is strong suspicion of CNS bleeding, acute aspirin (300mg/24h PO) has a worthwhile
effect.
Turn regularly and keep dry (consider catheterization) to stop bed sores.
Passive limb movements, subcutaneous heparin and compressing stocking (DVT prophylaxis).
NB. some randomized trials suggest thrombolysis with alteplase within 3h of onset of symptoms might
decrease risk of adverse outcome. These hospitals have CNS thrombolysis teams with a dedicated
imaging service on 24h call. Howerever, this is still not recommended yet in the UK.
Prevention of stroke :
1. Control risk factors .
2. Exercise ( HDL) .
3. Life long anticoagulants " for those with rheumatic or prosthetic heart valves on lt side" .
4. Aspirin 75 mg/day for life .
59
Dr.Waleed Badr
2011
Hydrocephalus .
Head injury .
Cerebral oedema .
Status epilepticus .
Ophthalmic signs :
-
Papilloedema (NB. There is loss of previous spontaneous venous pulsation,if preserved exclude
papilloedema ) .
Investigations :
U&E, FBC, LFT, glucose, serum osmolarity, clotting, blood culture, CXR .
Management :
A Adequate ventilation (intubate if needed)
B Oxygenation.
C Circulation IV line.
Correct hypotension & treat seizures .
Brief history & examination .
Elevate the head of the bed 30- 40.
Osmotic agents e.g mannitol 20% 1-2g/kg IV over 10-20 min (5mL/kg) .clinical effect is seen after
20 min and lasts for 2-6h (Aim for serum osmolarity 300 mosmol/kg) .
Corticosteroids e.g dexamethasone 10 mg IV then 4 mg/6h IV/PO (if cerebral oedema) .
Fluid restriction to < 1.5L/d .
Close monitoring & monitor ICP .
Search for a cause and treat exacerbating factors e.g hyperglycaemia, hyponatraemia .
Refer to neurosurgeon for definitive treatment if possible .
60
Dr.Waleed Badr
2011
Hypoglycemic coma
Glucose level < 3.6 mmol/L sympathetic activity cold & sweaty skin.
Management :
Signs and symptoms: Gradual drowsiness, vomiting, dehydration, abdominal pain, polyuria,
polydepsia, lethargy, anorexia, ketotic breath, coma .
Precipitating factors: infection, surgery, MI, chemotherapy, non-compliance, or wrong insulin dose.
Investigations: The diagnosis requires hyperglycaemia + ketosis + metabolic acidosis (pH < 7.3)
Blood : blood sample (gluco-sticks) "glucose oxidase strip", lab glucose , U&E, HCO3, osmolarity,
ABG, FBC .
61
Dr.Waleed Badr
2011
Management:
ABC .
Level of consciousness.
Fluid replacement for correction of Dehydration : dehydation is more lethal than hyperglycemia, so
its correction takes precedence.
-
Give 1L stat, then 1L over the next hour, 1L over 2h, 1L over 4h, then 1L over 6h.
Dont stop the pump before routine SC insulin has been started .
If No pump, load with 20U IM, then give 4-6 U/h IM while glucose is > 10mmol/L (then to 2hourly) .
During DKA, the total body K+ is low because of osmotic diuresis, but the serum K + conc. is
raised because of the lack of insulin action, which allows K+ to shift out of the cells to
extracellular fluid, so hyperkalaemia.
During insulin treatment, K+ is shifted into the cells, which may lead to profound hypokalaemia
& dangerous irregularities in heart rate if not treated, therefore, continuous observation of the
heart rate is recommended, as well as repeated measurement of K + levels & addition of Kcl to
IV fluids depending on blood K+ levels .
Monitor urine output hourly;start adding K+ when urine flows at > 30ml/h .
62
Dr.Waleed Badr
2011
If acidosis is severe (pH < 7), give IV bicarbonate after discussing with your senior because of its
effects on Hb -dissociation and cerebral circulation.
Treatment:
63
Rehydration with 0.9% saline IVI over 48h at 1/2 the rate used on DKA.
Wait an hour before giving insulin, it may not be needed. If needed, give 1U/h .
Dr.Waleed Badr
2011
Thyroid emergencies
Basic tests
Measurement of free T4 and T3 levels is more useful than total T4 and T3 levels as the latter are
affected by TBG. Total T4 and T3 are when TBG is and vice versa. Free T3 and T4 levels are
unaffected.
TBG is in pregnancy, oestrogen therapy (HRT, oral contraceptive pill) and hepatitis. TBG is in
nephrotic syndrome and malnutrition (protein loss), drugs (e.g androgens, corticosteroids, phenytoin),
chronic liver disease and acromegaly.
Hyperthyroidism suspected: Ask for T3, T4, and TSH. In hyperthyroidism, all will have TSH (except for
the rare phenomenon of a TSH-secreting pituitary adenoma). Most have T4, but ~1% have only
T3.
Hypothyroidism suspected or monitoring replacement treatment: Ask for only T4, and TSH. Measuring
T3 does not add any extra information.
Interpretation of tests :
If TSH & T4
If TSH & normal T4
If TSH & T4
If TSH & T4 or T3
If TSH & normal T4 & T3
If TSH & T4 & T3
If normal TSH & T4 abnormal
64
:Primary hypothyroidism
:Subclinical hypothyroidism
: TSH secreting tumour, or thyroid hormone resistance
:Hyperthyroidism
:Subclinical Hyperthyroidism
:Pituitary disease
:Hormone-binding problems e.g prgnancy; thyroidbinding globulin; amiodarone; pituitary TSH tumour .
Dr.Waleed Badr
2011
Precipitated by : infection, recent trauma, MI or stroke, withdrawal of or non-compliance with antithyroid medication, recent thyroid surgery or radioiodine .
Investigations :
Thyroid function tests : T3, T4, TSH "Don't wait for test results if urgent treatment is needed"
Management : aimed at counteract peripheral effects of thyroid hormones, inhibit thyroid hormone
synthesis & treat systemic complications .
Resuscitation : IVI 0.9% saline, 500ml/4h (Adjust IV fluids as necessary;ideally guided by CVP). NG
tube if vomiting .
Antithyroid drugs :
Carbimazole 15-25 mg/6h PO; after 4h give Lugols solution 0.3 mL/8h PO well-diluted in
water for 1wK to block thyroid .
High-dose digoxin e.g 1mg over 2h IVI : may be needed to slow the heart . Cardioversion will not
be effective for AF until the patient is euthyroid .
Further thyroid management will depend on the progress of each individual patient & must be
under the care of an endocrinologist.
65
Dr.Waleed Badr
2011
Myxoedema coma
Signs & symptoms :
Coma & seizures (may have been psychotic myxoedema madness just before the coma) .
T3 5-20 ug/12h IV slowly with caution; you may precipitate manifestations of ischaemic heart
disease. Alternatively give Levothyroxine .
Addisonian crisis
66
Dr.Waleed Badr
2011
Hypopituitary coma
Hypothermia , refractory hypotension septic signs without fever associated with short stature or
loss of axillary/pubic hair gondal atrophy.
Investigations :
Take blood for cortisol, T4, TSH, ACTH & glucose dont wait for results & start ttt .
Management :
Hydrocortisone Na succinate 100 mg IV/6h .
Only after hydrocortisone begun, liothyronine 10 ug/12h PO or 5-20 ug/12h .
Prompt surgery is needed if the cause is pituitary apoplexy .
Pheochromocytoma
Pheochromocytoma is a rare catecholamine-producing tumour of the adrenal medulla.
Management :
67
Dr.Waleed Badr
2011
2. Stomach
3. Duodenum
4. Coagulopathy
Esophagitis
Esophageal varices
Esophageal cancer
Mallory Weiss tear (mucosal tear at gastro-esophageal junction due to retching)
Gastric ulcer (40%)
Gastritis
Gastric cancer
Duodenal ulcer
Aortoenteric fistula (if previous aortic graft)
Drugs (alcohol, aspirin, NSAIDS, thrombolytics & anticoagulants)
Renal disease
Liver disease
Symptoms:
Melena (black tarry stool) : usually due to upper GI bleeding. Occurs when blood comes in contact
with hydrochloric acid in the gut. Only need > 50 ml of blood loss .
Hematochezia (bright red or maroon rectal bleeding) : Usually a sign of a lower GI bleed & rarely
seen unless the patient is having a very large, brisk upper GI bleed ( > 1000 ml) .
Signs:
Vital signs :
Pulse : tachycardia .
68
Dr.Waleed Badr
2011
Management:
Assess whether patient is in shock
Cool and clammy.
If not shocked:
Insert 2 big cannulae (14-16G), start slow saline IVI (to keep lines patent), check bloods & monitor vital
signs + urine output.
If shocked:
Protect airway : endotracheal intubation to prevent aspiration in massive bleeding or mental status
change .
If still shocked, give group specific blood or group O Rh ve until cross matching is done (transfuse
as dictated by haemodynamics) .
NB.Avoid saline in patients with decompensated liver disease (ascites, peripheral oedema)
Keep NPO .
69
Dr.Waleed Badr
2011
Endoscopy :
Can identify the source of bleeding, estimate the risk of rebleeding +/- therapeutic intervention to
achieve hemostasis ( e.g varices ligation therapy, varices injection therapy, injection therapy for
ulcer bleeding, destroying visible vessel by heat probe thermocoagulation, hemoclip or laser) .
Risks for rebelling include spurting or oozing, visible vessel or fibrin clot
NB. If site of bleeding is not identified on endoscopy; bleeding site has healed; nose bleed
(swallowed blood); site distal to 3rd part of duodenum
NB. UGI barium studies are contraindicated in the setting of an acute UGI bleed as it will interfere with
subsequent endoscopy or surgery if needed .
Prognosis :
80% of UGIB stop spontaneously. Mortality is approximately 10%
Care for rebleeds: very serious event. 40 % of those patients will die.
Poor prognostic signs : Rockall scoring system
70
Age > 60 .
Signs of shock ( pulse > 100 bpm, SBP < 100 mmhg) .
Bleeding diathesis .
Dr.Waleed Badr
2011
2. Colon
3. Perianal
4. Coagulopathy
Neoplasm
Mockers diverticulum
Crohns disease
Aortoenteric fistula
Vascular problems
Diverticuli
Angiodysplasia
Inflammatory bowel disease (ulcerative colitis & crohn's disease) .
Ischemic gut
Neoplasm
Infectious
Hemorrhoids
Fissure
Fistula
Drugs, renal disease, liver disease
History:
1. Volume:
Small amounts on the tissue or surface of stool associated with hemorrhoids or fissures
Hematochezia
Massive blood loss likely due to either diverticulosis, angiodysplasia, or occasionally aortoenteric
fistula
Must always rule out a massive UGIB! Usually site is distal to the pylorus
2. Symptoms associated with inflammatory bowel disease or any other systemic disease
3. Constitutional symptoms or recent change in bowel habits suggesting a malignancy
4. Food intake which may give a false impression of rectal bleeding beets or iron
5. Infectious symptoms or recent ingestion of any poorly cooked meat
71
Dr.Waleed Badr
2011
If patients are hemodynamically unstable with rapid rates of blood loss other investigations can be
arranged.
1. Tagged red blood cell scan (TRBC scan)
RBCs labeled with 99mTc remain in circulation for as long as 48 hours and extravasate into the bowel
lumen with active bleeding
2. Angiography
Allows rapid localization and potential therapy of GI bleeding when bleeding rates exceed 0.5
ml/minute .
Identifies site in 60% of bleeds, 50-80% are a result of bleeding from the superior mesenteric artery
Allows for therapeutic intervention (When bleeding lesion is found, intra-arterial infusion of
3. Colonoscopy
Best performed in patients whose condition has clinically stabilized and who can tolerate an
adequate bowel purge
Barium enemas may detect proximal lesions not detected by colonoscopy, but interferes with
subsequent angiography and colonoscopy, thus there is no indication for urgent use.
4. Surgery : Consider in patients with ongoing bleeding and hemodynamic instability but with failure of
other therapeutic maneuvers.
72
Dr.Waleed Badr
2011
PT is the time it takes plasma to clot after addition of tissue factor (obtained from animals) . this
measures the quality of
coagulation i.e PT tests for abnormalities in factors I,II,V,VII,X . Normal range for PT is usually 11-16
seconds
INR : is the ratio of a patient's prothrombin time to a normal (control) sample. (INR was devised to
standardize the results, as The result (in seconds) for a prothrombin time performed on a normal
individual will vary according to the type of analytical system employed. This is due to the
variations between different batches of manufacturer's tissue factor used in the reagent to
perform the test) .
They are used to determine the clotting tendency of blood, in the measure of warfarin dosage,
liver damage & vitamin K status .
73
Dr.Waleed Badr
2011
The speed of the extrinsic pathway is greatly affected by levels of factor VII in the body. Factor VII
has a short half-life and its synthesis requires vitamin K. The prothrombin time can be prolonged as
a result of deficiencies in vitamin K, which can be caused by warfarin, poor factor VII synthesis
(due to liver disease) or increased consumption (in disseminated intravascular coagulation) .
A high INR level such as INR=5 indicates that there is a high chance of bleeding, whereas if the
INR=0.5 then there is a high chance of having a clot. Normal range for a healthy person is 0.91.3
and for people on warfarin therapy, 2.03.0, although the target INR may be higher in particular
situations, such as for those with a mechanical heart valve, or bridging warfarin with a lowmolecular weight heparin (such as enoxaparin) perioperatively.
coagulation i.e aPPT tests for abnormalities in factors I,II,V,VIII,IX,X,XI,XII . Normal range for aPPT is
usually 35-45 seconds .
TT is the time it takes a clot to form in the plasma of a blood sample to which an excess thrombin
has been added. This measures abnormality in the conversion of fibrinogen to fibrin . Normal
range for TT is usually 10-15 seconds .
D-dimers:
These are a fibrin degradation product (FDP), released from cross-linked fibrin during fibrinolysis i.e
tests the fibrinolytic system .
Bleeding time:
Carried out by making two small incisions into the skin of the forearm. The time it takes for
bleeding to stop (as thus the time it takes for a platelet plug to form) is measured.
74
Dr.Waleed Badr
2011
Antiplatelets e.g Aspirin and other cyclooxygenase inhibitors can prolong bleeding time
significantly. While warfarin and heparin have their major effects on coagulation factors .
NB: This test is seldom performed now, as results are very operator dependent.
Disorder
Heparin
DIC
Liver disease
Platelet defect
Vit K deficiency
Haemophilia
Von willebrand's
INR
--
-----
aPTT
--
TT
---------
Platelet count
--
---------
Bleeding time
--
----
Management :
depends on the degree of bleeding. If shocked, resuscitate. If bleeding continues, in the presence of a
clotting disorder, or a massive transfusion, discuss the need for fresh frozen plasma (FFP) and platelets with a
haematologist. In ITP , steroids IV immunoglobulin may be used. Especially in pregnancy , consult an
expert. Is there overdose with anticoagulants? In haemophiliac bleeds, consult early for coagulation factor
replacement. Never give IM injections.
75
Dr.Waleed Badr
2011
1)
2)
3)
4)
5)
Anticoagulants
Indications :
1. Therapeutic: Venous thromboembolic disease: DVT and PE.
2. Prophylactic:
Preparations :
Heparin
Characteristics
more
predictable
response
&
no
laboratory monitoring is usually required)
S/E
NB. HIT and osteoporosis are less common with LMWH than UFH. Beware hyperkalaemia.
C/I
Antidote
76
Dr.Waleed Badr
2011
Warfarin
Route & dosage
Mechanism
CI
Antidote
Vitamin K may take several hours to work, and can cause prolonged resistance when
restarting warfarin, so should be avoided if possible when long-term anticoagulation is
needed. Prothrombin complex concentrate contains a concentrate of Factor IX, and
provides a more complete and rapid reversal of warfarin than FFP.
Start infusion at 1000-2000iu/h IVI (2.8mL/h=1400iu/h). Check APTT at 6h, aim for aPTT ratio 1-2 (see
table) . Measure APTT 10h after dose change.
>5
APTT
4-5
3-4
2-3
1-2
1.2-1.4
Change rate (iu/h) by Stop* - 500 - 300
-100
-50
0
+ 200
*Stop for 1 hour then recheck APTT. Reduce dose by 500iu/h and restart if <5
<1.2
+400
Alternatively , use LMWH. Continue for 6 days & until adequately anticoagulated with warfarin.
If INR <1.8 (as is likely) the 2nd dose of warfarin is 5 or 10mg at 18.00 (24h after first dose). Give the
lower dose if >60yrs, liver disease, or cardiac failure. But if INR >1.8 (warfarin sensitivity; rare) give just
0.5mg.
Do INR daily for 5d and adjust dose (see table) (use 5mg, not 10mg dose3 if over 60, or liver disease,
or cardiac failure).
Measure INR on alternate days until stable, then weekly or less often.
Stop heparin after 5d and when INR >2 for 2d. Tell lab when stopped.
<2
INR
2
2.5
2.9
10mg
3rd dose
5mg
4mg
3mg
6mg
Maintenance
5.5mg
4.5mg
4mg
*Miss a dose; give 1-2mg the next day (if INR >4.5, miss 2 doses).
Lower doses are given in certain groups of patients .
77
3.3
2mg
3.5mg
3.6
0.5mg
3mg
4.1
0mg
*
Dr.Waleed Badr
2011
Prophylaxis of DVT
DVT or PE treatment .
Atrial fibrillation .
Recurrent DVT or PE .
Prosthetic heart valves
Very minor surgery has been undertaken without stopping warfarin (do INR within 24h: it may be safe to
proceed if <3.5).
In major surgery, drugs may be stopped for 2-5d pre-op. Risks and benefits are individual to each patient,
so exact rules are impossible. Discuss these issues when arranging consent.
One elective option is conversion to heparin (stop 6h prior to surgery, and monitor APTT perioperatively):
unfractionated heparin's short t1/2 allows swift reversal with protamine .When rewarfarinizing, don't stop
heparin cover until the INR is therapeutic, as warfarin is prothrombotic in the early stages.
The bleeding tendency effects of aspirin are reversed by 5d after stopping. but check with local policy to
see if cessation is required.
Antiplatelet drugs
Mechanism of action :
Aspirin (Acetylsalicylic acid) irreversibly acetylates & thus inactivates cyclo-oxygenase, preventing
production of thromboxane A2 & prostacyclin, thereby inhibiting platelet aggregation.
Indications : Used in low dose (e.g 75mg/24h PO) for secondary prevention following MI, TIA/stroke, and
for patients with angina or peripheral vascular disease. May have a role in primary prevention.
NB. Clopidogrel also block platelet aggregation, but may cause less gastric irritation. They have a role if truly
intolerant of aspirin, and post-coronary stent insertion
78
Dr.Waleed Badr
2011
Hyperviscosity syndrome
Definition : This occurs if the viscosity of blood rises enough to impair the microcirculation. It affects patients
with a very high RBCs count, WBCs count or plasma components (usually immunoglobulins).
Causes:
Waldenstorm's macroglobulinaemia (as IgM is larger and so viscosity more than the same amount
of IgG).
Presentation:
Spontaneous bleeding: GU or GI .
Plasmapheresis in myeloma & Waldenstorm's: blood is withdrawn via a plasma exchange machine,
the supernatant plasma from this is discarded, and the RBCs returned to the patient after being resuspended in a suitable medium.
79
Dr.Waleed Badr
2011
Definition : Acute (over hours or days) deterioration in renal function, characterized by in serum
creatinine & urea, often with oliguria or anuria .
Causes :
Management :
Assess intravascular volume BP, JVP, skin turgor, fluid balance sheet, weight, CVP, attach to
cardiac monitor. Consider inserting a central venous cannula .
Investigations :
o
U&E, Ca2+, PO-34, FBC, ESR, CRP, INR, LFT, CK, LDH, protein electrophoresis, hepatitis
serology, autoantibodies (ANA,ANCA, complement, anti-GBM, ASOT), blood cultures
ECG, CXR .
Sepsis antibiotics .
Causes : oliguric renal failure, metabolic acidosis (DM) & K+ sparing diuretics) .s
How to treat ?
-
10 mL Ca gluconate (10%) IV over 2min, repeated as necessary. This provides cardioprotection ( threshold potential); it does not change serum K+ levels .
Insulin + glucose (unless hyperglycaemic) e.g 50mL of 50% glucose + 10U of rapidly
acting insulin IV over 30 minutes, repeat if needed. (Insulin moves K+ into cells) .
80
Dr.Waleed Badr
2011
Dialysis .
Treatment of dehydration :
-
Give 250-500 mL of colloid or saline over 30min . Repeat if still dehydrated. Aim for a CVP
of 5-10 cm
Once fluid replete, continue fluids at 20 mL + previous hours urine output per hour .
Diet : high in calorics with adequate high-quality protein. Consider nasogastric or parentral
feeding if too ill .
Urgent diaysis if :
81
Pericarditis (in tamponade, only dialyse after pressure on the heart is relieved) .
Dr.Waleed Badr
2011
Acute poisoning
A Adequate ventilation.
B Oxygenation.
C Circulation IV line (if required) .
Level of consciousness (consider naloxone if conscious level) .
Vital signs monitoring.
Assess the patient : take history from patient, friends or family + examination .
Investigations :
Glucose, U&E, FBC, LFT, INR, ABG, ECG, paracetamol & salicylate levels .
Urine/serum toxicology.
Dont empty stomach if petroleum products or corrosives e.g acids or alkalis have
been ingested OR if the patient is unconscious OR unable to protect their airway
(unless intubated).
the absorption of many drugs from the gut when given as a single dose of 50g with
water e.g salicylates, paracetamol.
82
Antidote
Flumazenil
Atropine
Hydroxycobalamin
100% O2
Digoxin-specific antibody fragments (Digibind)
Desferrioxamine
Vit K + prothrombin
Naloxone
No specific antidote
N-acetylcysteine
Atropine (full atropinization)
Activated charcoal
Activated charcoal
Antivenom (IgG from venom-immunized sheep
Dr.Waleed Badr
2011
Salicylate poisoning
Dose-related
Rarely: lethargy or coma, seizures, BP and Heart block, pulmonary oedema, hyperthermia .
Respiratory alkalosis initially due to a direct stimulation of central respiratory centres then
metabolic acidosis .
Management :
Correct dehydration .
Serum glucose, urine output, U&E, LFT, INR, HCO3, FBC & salicylate level (repeated after 2h,
due to continuing absorption if a potentially toxic dose has been taken) .
83
Correct any metabolic acidosis with HCO3 . Aim to make the uring pH 7.5-8.5 .
Dr.Waleed Badr
2011
Paracetamol poisoning
150 mg/kg, or 12g in adults may be fatal.
Management :
Serum glucose, urine output, U&E, LFT, INR, HCO3, FBC & paracetamol level (at 4h post
ingestion) .
If < 8h since overdose & plasma paracetamol concentrations above normal treatment line
start N-acetylcysteine .
If > 8h & suspicion of large overdose start N-acetylcysteine, stopping it if level below
treatment line.
Dose of N-acetylcysteine :
Encephalopathy or ICT .
INR > 2 at <48h OR > 3.5 at <72h (so measure INR every 12h). if INR is normal at 48h, the
patient may go home .
84
Dr.Waleed Badr
2011
Burns
The most important as it influences the size of the inflammatory response (vasodilatation, vascular
permeability) & thus fluid shift from the intravascular volume .
85
Dr.Waleed Badr
2011
Rule of 9 in adults :
-
Back of trunk.18%
From birth to 1Y : head & neck is 18% and each leg is 14% .
For each year after, the head loses 1% & each leg gains 0.5%, so adult proportions are
reached by the age 10Y.
86
Dr.Waleed Badr
2.
2011
b) Full thickness
the whole skin
dermis
Appearance
Pain
Very painful
3. Site :
87
Burns in face & neck are serious oedema of glottis & disfigurement .
Dr.Waleed Badr
2011
Management :
B 100% O2 , exclude life-threatening chest injuries e.g tension pneumothorax & suspect CO 1
poisoning (history, cherry-red skin & carboxyhaemaglobin "CoHB" level) .
Cooling the burnt area using saline or tap water & warm the patient : Dont apply cold water to
extensive burns for long periods intensify shock .
Give antitetanic serum, Anti gas gangrene serum, antibiotics & morphine 10 mg.
Definitive dressings:
Partial thickness either biological (e.g pigskin, cadaveric skin) or synthetic (Mepitel,
Duoderm) + sulfadiazine cream .
Full thickness tangential excision & split-skin grafts .
88
Dr.Waleed Badr
2011
Hypothermia
In the young : usually from cold exposure e.g near-drowning or 2ry to impaired consciousness e.g
following excess alcohol or drug overdose .
exposure to cold .
Investigations : U&E, plasma glucose, thyroid function tests, FBC & ECG (show J-waves)
Management :
B Oxygenation.
Antibiotics for prevention of pneumonia (given routinely in patients > 65Y with T< 32C .
Slowly rewarm if too quickly V.D shock & death. Aim for a rise of 1/2 C/h. the 1st sign of
too rapid warming is BP.
Complications : Arrhythmias, pneumonia, pancreatitis, acute renal failure & intravascular coagulation
Prognosis : depends on age & degree of hypothermia. If age > 70Y & T<32 C then mortality > 50% .
89
Dr.Waleed Badr
2011
Needle-stick injuries
Needle-stick transmission rates from infected patients are :
Immediate management :
Encourage the injury to bleed & wash under running water; if body fluids splashed onto eyes irrigate
them copiously .
Report to the occupational health dept.(within 1h) OR accident & emergency dept. (if out-of-hours) .
If high risk of HIV transmission start post-exposure prophylaxis; this should be started within 1h by the
occupational health/A&E physician (see below)
Store blood from the donor & the recipient. Screening for hepatitis B & HIV where appropriate
generally arranged by the occupational health physician .
The Occupational Health/A&E physician will assess risk of HIV transmission based on patient history,
nature of body fluid & route of transmission .
High risk :
-
This
includes
exposure
to
blood/high-risk
body
fluids
(from
patient
with
PEP drugs starting within 1h (e.g zidovudine PO 250mg 2x/d + lamivudine PO 150mg
2x/d + indinavir PO 800mg 3x/d) .
If donor is HIV+
(already known or discovered on testing)
- Continue PEP for 4wKs.
- Test recipient for HIV seroconversion at
6wKs, 3mths & 6mths .
- Follow up with occupational health.
90
If donor is HIV-
Discontinue PEP .
Test
recipient
for
HIV
seroconversion at 3mths & 6mths .
Follow up with occupational
health .
Low risk :
-
Dr.Waleed Badr
2011
Uncontrolled hyperglycemia
Uncontrolled arrhythmias
Excessive INR
Preoperative management
Patients
for
general
anesthesia
Patients with diabetes
Patients
with
valvular
heart disease
Patients on aspirin
Patients on anticoagulants
ideally the INR should be <3 for intraocular and strabismus surgery but
<2 for orbital and oculoplastic surgery . This should be checked within
48 hours of surgery. If this is not compatible with their therapeutic
target, coordinate care with their hematologist or PCP. They may
consider changing to heparin in the perioperative period.
91
Dr.Waleed Badr
2011
Always try to put the patient first on the list (surgery, endoscopy, bronchoscopy, etc.). Inform the surgeon
and anaesthetist early.
Stop all long-acting insulin the night before. Get IV access before you need it urgently. If surgery is in the
morning, stop all SC morning insulin. If surgery is in the afternoon, have the usual short-acting insulin in the
morning at breakfast. No medium- or long-acting insulin.
Check U&E pre-op. Start an IVI of 1L of 5% dextrose with 20mmol KCl/8h. Dextrose saline can be given if
Na+ low, but do not give only saline; dextrose may need constant infusion to maintain blood glucose.
Start an infusion pump with 50U short-acting insulin (eg Actrapid) in 50mL 0.9% saline. Give according to a
sliding scale (see table) adjusted in the light of blood glucose.
Post-op, continue IV insulin + dextrose until patient tolerating food. Check fingerprick glucose every 2h.
Switch to usual SC insulin regimen .
IV soluble insulin*
None (50% glucose IV)
No insulin
1u/h
2u/h
3u/h
6u/h: get urgent diabetic review
Alternative SC insulin**
None (50% glucose IV)
No insulin
2u/h
5u/h
7u/h
These patients are usually controlled on oral hypoglycaemics . If diabetes poorly controlled (e.g fasting
glucose >10mmol/L), treat as for type 1 diabetes.
Do not give long-acting sulphonylureas (eg glibenclamide) on the morning of surgery, as they can cause
prolonged hypoglycaemia on fasting.
Beware lactic acidosis in patients on biguanides (eg metformin), especially if using IV contrast agents
and/or renal function poor (creatinine >150mol/L).
If the patient can eat post-operatively, simply omit tablets on the morning of surgery and give post-op with
a meal.
If the patient is having major surgery with restrictions to eating post-op, check fasting glucose on the
morning of surgery and start IV or SC insulin given according to sliding scale. Post-op, consult the diabetic
team as the patient may need a phase of insulin to supplement their oral hypoglycaemics.
92
Dr.Waleed Badr
2011
Cardiovascular
collapse:
sinus
bradycardia,
conduction
blocks,
asystole
and
ventricular
Local anaesthetic (LA) toxicity may occur some time after the initial injection
2) Immediate management
Give 100% oxygen and ensure adequate lung ventilation (hyperventilation may help by increasing pH
in the presence of metabolic acidosis)
Control seizures: give a benzodiazepine e.g midazolam, thiopental or propofol in small incremental
doses
3) Treatment
Management of cardiac arrest associated with LA injection:
Manage arrhythmias using the same protocols, recognising that they may be very refractory to
treatment
93
Dr.Waleed Badr
2011
Give an intravenous bolus injection of Intralipid 20% 1.5 ml.kg-1 over 1 min
o
Continue CPR
Repeat the bolus injection twice at 5 min intervals if an adequate circulation has not been restored
o
After another 5 min, increase the rate to 0.5 ml.kg-1.min-1 if an adequate circulation has not been
restored
o
Continue infusion until a stable and adequate circulation has been restored
Remember:
94
Dr.Waleed Badr
2011
Choking in children
Recognition of choking :
When a foreign body enters the airway the child reacts immediately by coughing in an attempt to
expel it. A spontaneous cough is likely to be more effective and safer than any manoeuvre a rescuer
might perform. However, if coughing is absent or ineffective, and the object completely obstructs the
airway, the child will become asphyxiated rapidly. Active interventions to relieve choking are
therefore required only when coughing becomes ineffective, but they then must be commenced
rapidly and confidently.
The majority of choking events in children occur during play or whilst eating, when a carer is usually
present. Events are therefore frequently witnessed, and interventions are usually initiated when the
child is conscious.
Choking is characterised by the sudden onset of respiratory distress associated with coughing,
gagging, or stridor. Similar signs and symptoms may also be associated with other causes of airway
obstruction, such as laryngitis or epiglottitis, which require different management. Suspect choking
caused by a foreign body if:
1. the onset was very sudden;
2. there are no other signs of illness;
3. there are clues to alert the rescuer, for example a history of eating or playing with small items
immediately prior to the onset of symptoms.
95
Dr.Waleed Badr
2011
Relief of choking :
If the child is coughing effectively, then no external manoeuvre is necessary. Encourage the child to
cough, and monitor continuously.
If the childs coughing is, or is becoming, ineffective, shout for help immediately and determine the
childs conscious level.
If the child is still conscious but has absent or ineffective coughing, give back blows.
If back blows do not relieve choking, give chest thrusts to infants or abdominal thrusts to children.
These manoeuvres create an artificial cough to increase intrathoracic pressure and dislodge the
foreign body.
96
Dr.Waleed Badr
2011
Back blows
In an infant:
Back blows are more effective if the child is positioned head down.
A small child may be placed across the rescuers lap as with an infant.
If this is not possible, support the child in a forward-leaning position and deliver the back blows
from behind.
If back blows fail to dislodge the object, and the child is still conscious, use chest thrusts for infants or
abdominal thrusts for children. Do not use abdominal thrusts (Heimlich manoeuvre) for infants.
97
Dr.Waleed Badr
2011
Identify the landmark for chest compression (lower sternum approximately a fingers breadth
above the xiphisternum).
Deliver up to 5 chest thrusts. These are similar to chest compressions, but sharper in nature and
delivered at a slower rate.
The aim is to relieve the obstruction with each thrust rather than to give all 5.
Grasp this hand with your other hand and pull sharply
inwards and upwards.
If the object has not been expelled and the victim is still conscious, continue the sequence of back blows
and chest (for infant) or abdominal (for children) thrusts.
If the object is expelled successfully, assess the childs clinical condition. It is possible that part of the object
may remain in the respiratory tract and cause complications. If there is any doubt, seek medical assistance.
98
Dr.Waleed Badr
2011
If the choking child is, or becomes, unconscious place him on a firm, flat surface.
Airway opening:
Rescue breaths:
Assess the effectiveness of each breath: if a breath does not make the chest rise, reposition
the head before making the next attempt.
Follow the sequence for single rescuer CPR (step 7B) for approximately 1 min before
summoning the EMS (if this has not already been done by someone else).
When the airway is opened for attempted delivery of rescue breaths, look to see if the foreign
body can be seen in the mouth.
If it appears that the obstruction has been relieved, open and check the airway as above.
Deliver rescue breaths if the child is not breathing and then assess for signs of life. If there are
none, commence chest compressions and perform CPR (step 7B).
If the child regains consciousness and is breathing effectively, place him in a safe side-lying
(recovery) position and monitor breathing and conscious level whilst awaiting the arrival of the
EMS.
99
Dr.Waleed Badr
2011
Step.7B
If there are no signs of life, unless you are CERTAIN that you can feela definite pulse of greater than 60
min-1 within 10 s
To avoid compressing the upper abdomen, locate the xiphisternum by finding the angle where
the lowest ribs join in the middle. Compress the sternum one fingers breadth above this.
Compression should be sufficient to depress the sternum by at least onethird of the depth of the
chest.
Release the pressure completely, then repeat at a rate of 100 - 120 min-1
After 15 compressions, tilt the head, lift the chin, and give two effective breaths.
The best method for compression varies slightly between infants and children.
The lone rescuer should compress the sternum with the tips of two fingers.
Place both thumbs flat, side by side, on the lower half of the sternum (as above), with the tips
pointing towards the infants head.
Spread the rest of both hands, with the fingers together, to encircle the lower part of the
infants rib cage with the tips of the fingers supporting the infants back.
Press down on the lower sternum with your two thumbs to depress it at least one-third of the
depth of the infants chest.
Place the heel of one hand over the lower half of the sternum (as above).
Lift the fingers to ensure that pressure is not applied over the childs ribs.
Position yourself vertically above the victims chest and, with your arm straight, compress the
sternum to depress it by at least one-third of the depth of the chest.
In larger children, or for small rescuers, this may be achieved most easily by using both hands with
the fingers interlocked.
------------------------------------------------------------------------------------------
GOOD LUCK
31/12/2011
100
Dr.Waleed Badr
2011
101
Dr.Waleed Badr