All the medical procedures and drug administration mentioned in this text should be followed only under a senior doctor’s consultance.

 

 

CHAPTERS

ABCDEs – PRIMARY SURVEY

VITALS & BRIEF CLINICAL EXAMINATION

BRIEF HISTORY

LAB TESTS

STANDARD EMERGENCY PROCEDURES

EMERGENCY MEDICINE DRUGS

ENDOTRACHEAL INTUBATION AT A GLANCE

ECG & CARDIOLOGY AT A GLANCE

MISC ON EMERGENCY MEDICINE

NOTE

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor’s consultance.

I)      ABCDEs – PRIMARY SURVEY

 

SAFETY

Safety comes firsts. Is the scene safe? If not, call police/ fire brigade/ coast guard/ security staff.

 

Initially you must have a ready prepared team with distinguished roles and a team leader – coordinator. The roles are e.g. on ALS 1^st EMT member is a team leader, 2^nd handles the airway, 3^rd administrates drugs/fluid and records the time, 4^th handles the defibrillator, 5^th gives chest compressions. The person with the chest compression is changed every 2 min in order to achieve good quality chest compressions (which can’t be achieved if the provider gets tired).

Without a good and prepared team, proper resuscitation can be difficult.

 

If many patients arrive, perform triage (e.g. based on ABCs)!

 

A: ΑIRWAY & C spine immobilization. Also Ask for help.

1)     Do you suspect cervical spine trauma?

 

With a cervical collar immobilize the C (cervical) spine (the neck) in case you suspect trauma (e.g. road car accident). If you haven’t got a collar then stabilize the neck manually with both your hands.

In case of isolated head trauma always immobilize the spine.

On suspected spinal trauma immobilize the spine on a long board.

 

2)     Open the airway (jaw thrust or chin lift, on suspected neck trauma: 1^st rescuer jaw thrust and 2^nd rescuer immobilizing the neck). 

 With your finger remove any VISIBLE foreign object (e.g. broken or dislocated denture), but don’t move non visible objects. The stable denture must be left on its position to help the airway remain open and assist the ventilation. If available, put a oropharyngreal airway. 

 

a)     Is the airway patent? (e.g. when the patient is talking the airway is patent)

b)     Is the airway threatened? (snoring, stridor, voice hoarseness).

c)     Is the airway obstructed?

d)     Is the airway lost?

 

Stridor is an indication of imminent upper airway obstruction and it caused by foreign body partial airway obstruction or laryngeal edema on anaphylaxis (or angioedema).

 

If ventilation (e.g. BMV, Bag Mask Ventilation) is not effective then reposition the head!

 

If airway is patent and the patient is breathing and ventilations aren’t needed, but level of consciousness is decreased, position the patient on recovery position (if not suspected spinal trauma).

 

In case of resistance on ventilation, exclude pnemothorax.

 

In case of airway obstruction by a foreign body, ventilation may be difficult or impossible. If the patient is conscious and responsive and cough is effective, just encourage coughing.

 

In case the patient is conscious, but can’t talk, or has stridor or cyanosis and cough is ineffective,  you have to perform 5 back blows (with the head positioned down) / 5 abdominal thrusts (Heimlich maneuver) for patients > 1 years old or 5 chest thrusts for infants (< 1 years old). If unsuccessful, call help, open the airway, remove any visible object with a single sweep. Ventilate with 2 breaths. If unsuccessful, reposition the head. If still unable to ventilate, start chest compressions (30:2). Consider laryngoscopy and removal of the foreign body with a Mafill’s forceps. 

 

If unconscious and unresponsive, call for help, position the patient supine, open airway, remove any visible object with a single sweep and attempt to ventilate. I unsuccessful reposition the head and attempt to ventilate. If still unsuccessful, perform chest compressions (30:2) and re-estimate the airway. Consider direct laryngoscopy and remove the foreign object with a Magill’s forceps.

If you can’t still ventilate may need to perform needle or surgical cricothyroidotomy or surgical tracheotomy.

 

In case the airway is threatened or lost perform jaw thrust (on trauma, or without trauma; on trauma another rescuer should perform also manual neck immobilization during jaw thrust) or chin lift (if not trauma), perform suction of the oropharynx and place an oropharengeal airway (if no gag reflex: if placing the airway does not cause cough or vomiting) or a nasopharyngeal airway (if not apnea, not ethmoid (cribriform) bone or basal skull fracture or facial trauma) or perform RSI (rapid sequence intubation). The oropharengeal airway size is 2, 3, or 4 for small, medium and large adult, respectively.

 

Also give oxygen with a non rebreathing mask with high flow and with reservoir (it may achieve about 90% oxygen concentrations), connected to oxygen supply. If the patient is not breathing, ventilate with BMV bag mask ventilation (bag mask with reservoir and better with connected oxygen supply) or perform endotracheal intubation. On suspected cervical trauma immobilize the head during intubation!

 

3)      Check the trachea. Tracheal deviation occurs (late) on tension pneumothorax (the tracheal deviation is away from the side of pneumothorax). Also check for surgical emphysema (laryngeal trauma, pneumothorax, bronchial rapture, oesophagal rapture etc) and laryngeal trauma (crepitus, surgical emphysema, open wound, air leakage).

 

4) Check for JVD (jugular vein distension) e.g. LVF (left ventricular failure), tension pneumothorax, cardiac tamponade etc. 

 

 

 

B: BREATHING.

1)     Is breathing normal/ shallow/ deep/ rhythmic? Are breaths labored?

2)     Check respiratory rate (RR). If RR is > 30/ min or < 10/ min on adults, use bag mask ventilation (with reservoir and better with oxygen supply) or perform RSI (rapid sequence intubation).

 

3)     Chest examination:

a)     Look the chest. Is the chest expanded normally or there is unequal expansion between right and left chest during respiration, indicating flail chest on trauma? (More than 2 rib fractures may cause paradox respiration).

 

b)    Auscultate with your stethoscope the patients’ lungs (bases & apices) and check if breath sounds are normal or diminished (on pneumothorax, pleural infusion and lung collapse – atelectasis and consolidation).

 

Also check for extra (added) sounds such as wheezing (if ‘polyphonic’: COPD or asthma – exclude cardiac asthma; if ‘monophonic’ may indicate foreign body obstruction or cancer), crackles (fine and coarse), ronchi and rub (rub is a creaking sound like the creak of a footstep in fresh snow, heard at the height of inspiration, caused by pleural infusion on pneumonia, but may occur and in pulmonary embolism).

 

Crackles are heard in inspiration. Coarse crackles are caused by fluid (e.g. CHF congestive heart failure/ pulmonary oedema – especially if heard on the bases) or infection (e.g. consolidation). Fine crackles occur later on inspiration (are heard like rolling your hair between your thumb and forefinger in front of your ear) and is caused from fluid (e.g. CHF/ pulmonary oedema), infection (e.g. consolidation) or fibrosis (especially at bases). Crackles early on inspiration may indicate asthma and chronic bronchitis/ COPD.

 

Auscultate also the heart. Are heart sounds muffled (e.g. on cardiac tamponade)? Are S1 and S2 normal, or is any of them increased or decreased? Do you hear any S3 and/or S4 (e.g. heart failure)?

 

c)     Percuss the thorax to check for hyperesonance or ‘tympany’ (on ‘tympany’ suspect large/ tension pneumothorax, hyperesonance occurs also on emphysema) or normal percussion note or for dullness on percussion (on dullness suspect haemothorax on trauma, or lobar pneumonia; if ‘stony’ dull suspect pleural infusion).

 

4)     Check the oxygenation.

 

a)     Check if there is cyanosis. For central cyanosis see if the patient’s tongue and lips are blue. For peripheral cyanosis check if the patient’s finger nails are blue. Central cyanosis is always combined with peripheral. Most common causes of cyanosis are cardiopulmonary. Asymptomatic cyanosis (without breathlessness) may caused by methemoglobinemia (e.g. drug induced).

 

b)     Check the oxygen saturation (SpO2). Is SpO2> 95%? The oxygen saturation is unreliable on CO carbon monoxide poisoning (then check Hb - CO carboxyhemoglobin) or methemoglobinemia (e.g. drug induced).

 

c)     Check if the work of breathing is increased and the patient uses accessory respiratory muscles (such as sternocleidomastoid). Check also for see – saw ‘rocking’ respiration (the abdomen expands and the chest wall retracts during contraction of the diaphragm on inspiration) and for subcostal and intercostals recession, xiphoid retraction, nasal flaring and also head bobbing on babies (head bobs up and down with each breath) and grunting on babies. These show decompensated respiratory failure (which is the commonest cause of cardiac arrest on children).

 

 

On patients WITHOUT significant hypoxia (SpO2 Oxygen saturation, ABGs Arterial Blood Gases) and WITH ADEQUATE breathing give oxygen with nasal cannula 2 – 4 L/min.

On patients WITH significant hypoxia but ADEQUATE breathing give O2 (oxygen) with non rebreathing mask with reservoir and flow 15 L/min.

In case of INADEQUATE breathing or APNEA perform BMV bag mask ventilation with reservoir and oxygen supply and flow 15 L/min.

Keep always SpO2 oxygen saturation > 90%.

 

In case the work of breathing is increased, and the patient has respiratory distress, give oxygen with a non rebreathing mask with reservoir and better connected with an oxygen supply (it can offer more than 90% oxygen) and consider NIV non invasive ventilation (CPAP with facial mask, BiPap with facial/nasal mask) or RSI rapid sequence intubation and mechanical ventilation. On suspected cervical trauma immobilize the head during intubation!

 

ΝΟΤΕ: Before ET (endotracheal) intubation pre-oxygenate the patient with BMV (Bag Mask Ventilation) (with 100% oxygen supply) at least for 2 – 3 min.

 

 

 

 

C: CIRCULATION.

 

1)      Check pulse. Check radial pulse. If no radial pulse check femoral pulse. If it is absent check carotid pulse.

 

On adults if > 100 bpm we have tachycardia (exclude shock e.g. from hemorrhage) and if <60 bpm we have bradycardia. Infants and neonates develop bradycardia as response to hypoxia.

 

Is pulse fast or slow, weak or fast and thready (e.g. on shock)?

2)     Check the pulse pressure (systolic pressure – diastolic pressure).

 

3)     Check for shock.

 

Mildly increased HR (heart rate) and RR (respiratory rate), normal or increased (!) pulse pressure, cool/pale skin and mild agitation are the first that occur on shock and show less than 15% circulating blood volume loss on adults.

If there is 15 – 30% of circulating blood volume loss on adults, then HR is > 100, RR respiratory rate is increased, pulse pressure is reduced (diastolic pressure increases) and skin is cool/pale (check e.g. hands and feet), there is decreased urine output and the patient is moderately agitated.

 

On children on < 25% of circulating blood volume loss there is mildly increased HR, moderate increased RR, normal or increased peripheral pulse volume, normal or increased capillary refill time, cool/pale skin and mild agitation.

 

In shock, systolic BP will fall if more than 30% of circulation blood volume is reduced on adults, and > 40% on children!

 

4)     Check the peripheral circulation:

 

a)     Check capillary refill time by pressing the patient’s finger pulp for 5 sec (or the sternum on babies, or on black people the hand’s thenar or the forehead). Normally it is < 2 sec.

 

b)     Check for cyanosis (see above).

 

 

c)     Check skin color. Is it normal, or pale or mottled or cyanosis?

 

d)     Check skin temperature and texture. Is the skin cold and clammy (e.g. on shock)? If outside the hospital consider if the ambient temperature is cold.

 

 

e)     Check peripheral pulses. Are they diminished? Is this from central reasons (e.g. shock) or peripheral (e.g. vascular injury from fracture, trauma, compartment or crushing syndrome).

 

NOTE

On the acute ischemic limb remember the rule of 5Ps. First the ischemic limb is painful, then becomes, painless (numb), pale, paralyzed and pulseless. This shows that peripheral pulses and capillary refill time are initially unreliable for diagnosing vascular injury.

 

In case you suspect compartment syndrome measure the intra-compartment pressures! On compartment syndrome the symptoms are pain (bigger than expected which increased with the passive muscle stretching), paresthesia, decreased sensory sense or loss of function from nerve damage and also oedema. Loss of pulse and weakness or paralysis appear later!

 

5)     Check the preload. Check for JVD jugular (neck) vein distension, legs oedema (or sacral/ scrotal if bedridden, also may have ascites), lung crackles and on children check also for liver enlargement. JVD (if the patient is not hypovolaemic) may occur from tension penumothorax, cardiac tamponade and heart failure.

 

Place a peripheral IV cannulae (if trauma put 2 grey 16G or 2 orange 14G catheters) and give fluids (crystalloids, colloids, blood) and/or drugs as indicated.

 

On trauma on a patient with shock give 1 – 2 L normal saline or RL (Ringers Lactated).

 

On children give 20 ml/Kg crystalloids. On neonates give 10 ml/Kg on 5 – 10 min. On children if no response on 20 ml/Kg, repeat once. If not response, give 15 ml/Kg RBCs (packed red blood cells) added to 10ml/kg crystalloid and reheated to body temperature or give 10ml/kg whole warmed blood. If still no response, give other 10 – 15 ml/Kg RBCs.

 

Fluids on trauma need to be warmed on 40 degrees C (104 degrees F). Do not use a microwave oven to heat blood!

 

6)     Is there any obvious hemorrhage? If yes, press the bleeding area and elevate the limb (if not fracture). Consider also pressing pressure points.

 

On pelvis fracture consider placing a PASG (MAST) or immobilizing it with a sheet. 

 

On pregnant, if the pregnancy is > 24 weeks, put a pillow under the pregnant’s pelvis (or if on a stretcher, put a wedge below the stretcher) in order to move the uterus to a left position on an incline of 15 – 30 degrees. This maneuver decompresses the aorta and the inferior vena cava from the uterus. On case of CPR, an EMS member may put his legs like a wedge below the pregnant’s pelvis in order to move the uterus on a left position. In case of suspected spinal trauma, don’t move the uterus right, but instead place a wedge below the stretcher.

 

 

 

D: DISABILITY

 

1)     Check GCS (see below),

2)     Check the pupils (reaction to light and size).

3)     Check any abnormal posture (e.g. stereotypical extension or flexion of the limbs – see below).

 

If GCS<_8 intubate. Use RSI (rapid sequence intubation) if GCS>3!

During the intubation immobilize the neck if you suspect cervical trauma!

In case you can’t remember GCS check AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) & pupils’ reaction to light and irregularities).

On patients with altered mental status, intoxicated and under drug influence exclude head trauma!

 

Avoid attributing decreased BP on head trauma. Exclude other (e.g. abdominal) trauma.

Head trauma with increased ICP intracranial pressure manifests with Cushing’s triad: decreased HR heart rate, increased BP and irregular respirations.

Neurogenic shock from spinal trauma is characterized by decreased HR and decreased BP (however you still need to exclude major bleeding source first e.g. abdominal).

‘Spinal’ shock isn’t a real shock, but transient spinal cord dysfunction after injury that manifests with loss of spinal reflexes (such as the bulbocavernosus).

 

GCS

 

Eye Opening (E4)

4  0 – 1 years old: spontaneously; > 1 years old: spontaneously

3  0 – 1 years old: to shout; > 1 years old:  to verbal command (not 

 necessarily to ‘open your eyes’)

2  all ages: to pain

1  all ages: no response  

Response to pain is checked by pressing the patient’s nail’s bed with a pen. If not response, try supraorbital pressure and sterna pressure. 

 

Best Verbal Response (V5)

5  0 – 2 years old: appropriate cry, smiles;  2 – 5 years old: appropriate words and phrases; > 5 years old: oriented, converses

4  0 – 2 years old: cries; 2 – 5years old: inappropriate words; > 5 years old:  confused

3  0 – 2 years old: inappropriate cry; 2 – 5 years old: cries, screams; > 5 years old:  inappropriate words

2  0 – 2 years old: grunts; 2 – 5 years old: grunts, sounds; > 5 years old:   incomprehensible e.g. moans

1  all ages: no response

 

Best Motor Response (M6)

6  0 – 1 years old: moves spontaneously and adequately; > 1 years old:  obeys command

5  all ages: localizes pain  

4  all ages: flexion withdrawal

3  all ages: decorticate (stereotypical flexion)

2  all ages: decerebrate (stereotypical extension) 

1  all ages: no response 

 

Motor response may be e.g. ‘raise your hand’. It is the better response of any limb. Decorticate posture is characterized by flexion of upper extremities. Decerebrate posture is characterized by internal rotation of shoulder & arm pronation and limb extension.

 

 

Score: min 3, max 15. If GCS<_8 the patient needs intubation (RSI rapid sequence intubation if GCS > 3). GCS <_8 severe injury, GCS 9 –12 moderate injury, GCS 13–15 minor injury. 

 

 

 

E: EXPOSURE – ENVIRONMENT. Also Expert call.

Remove the patients’ clothes. Check the back (Log Roll if trauma). Check for trauma, rash, urticaria, erythema, and cyanosis. Next prevent hypothermia with blankets.

 

 

NEXT

 

Give oxygen if needed.

 

Connect to cardiac monitor, check vitals (Temperature, BP, pulse, SpO2 Oxygen Saturation, RR respiratory rate, ABGs arterial blood gases, stick blood glucose, dip stick urine test). On breathing, check for labored or shallow breaths, decreased breath sounds and hyper-resonance on chest percussion (on the last 2 clues, exclude pneumothorax). Check for JVD (see above), calf edema, liver distension and lung rales (e.g. on LVF left ventricular failure).

 

Place IV line with saline.

Take blood for FBC (CBC complete blood count), biochemistry, urea & electrolytes, glucose, CK – MB and Troponins (on chest or upper abdominal or upper back pain or discomfort or abnormal ECG), coagulation studies, pregnancy test and toxicology. Also take blood for type and cross match.

Perform 12 lead ECG. Take all the necessary X Rays: neck, chest & pelvis on trauma, non trauma: {PA (posterroanterior) erect if feasible} CXR chest X’ Ray to all emergencies, and abdominal erect and supine X Ray if abdominal pain.

Consider also abdominal ultrasound (e.g. biliary/kidney colici, appendixitis etc) and Doppler (on suspected DVT Deep Vein Thrombosis).

 

On trauma perform FAST/ ultrasound (exclude abdominal aneurysm rupture and cardiac tamponade!). You may also need to perform DPL (on trauma).

 

Also put urinary catheter (Foley) to check urine output and perform urin stick and urinalysis.

If needed perform blood/urine/ feces/ sputum/ wound/ lesions / vaginal/ rectal/ pharyngeal smear Gram stain & cultures.

 

Give drugs/ fluids as indicated. In suspected LVF left Ventricular Failure don’t give initially more than 500 ml fluids (place a CVP line!).

 

Consider Levine NG (nasogastral) tube if decreased level of consciousness and aspiration risk (especially on children, pregnant, diaphragmatic hernia and stroke) or poisoning (consider gastric lavage) or upper GI (gastrointestinal) bleeding (perform NG lavage to check for blood).

 

Consult an Expert.

 

 

PERFORM SECCONDARY SURVEY

Examine the patient from toes to head(e.g. ask the patient to grip your hands, to move his/her legs, check for paralysis and paresthesia, check peripheral pulses etc.). You have to examine the head, the face and mandible, the neck, the cervical spine, the chest, the abdomen, the perineum, the rectum, the vagina, the locomotor system and the neurological system. 

 

Don’t forget to perform a PR per rectum examination (on children has to be performed better by the team leader trauma surgeon).

On per – rectum PR examination high riding prostate, urethral meatus blood, scrotal hematoma, vaginal lacerations, perineal hematoma and pelvic injury/ fracture indicate a strong suspicion for urethral trauma. Don’t place then a Foley (urinary catheter). Perform a retrograde urethrogram.

 

CT/MRI belong to secondary survey! Don’t rush to do them before you finish the primary survey .

 

Also, other than essential X’ Rays (essential X’ Rays are neck, chest and pelvis on trauma, CXR on all emergencies, and abdominal X' Rays erect & supine on abdominal pain), urethrography, angiography, limb X’ Rays, transesophageal echo, bronchoscope and oesophagoscope, all belong to secondary survey.

 

Transesophagal Echo may be very useful on diagnosing aortic dissection!

 

Medical history – AMPLE (see below chapter) also belongs to secondary survey. 

 

Ask the patient (if alert and not confused) or the relatives for consent where and when indicated (e.g. invasive procedure).

 

 

REASSESS THE PATIENT FREQUENTLY!

 

TRANSFER FOR DEFINITE THERAPY

If needed, transfer the patient to other suitable hospital or send the patient for CT/MRI as soon as the patient is stabilized. On trauma don’t postpone surgical intervention pending for CT and not postpone transfer to another hospital waiting Lab or image tests. On trauma, if the patient is unstable, then emergency operation is indicated. Don’t send an unstable patient to perform a CT/ MRI before stabilizing him/her.

 

On trauma, in case of disagreement between neurosurgeon and trauma surgeon about who will operate first the patient remember that the patient needs to be operated from what it will kill him/her first. This may be intrabdominal bleeding or a patient with increased ICP (intracranial pressure) and impending herniation. So even operations need triage!  

 

 

 

 

APPENDIX I : COMMON CAUSES OF SHOCK

 

 What to rule out on a shock:

a)Traumatic blood loss. Check for bleeding in chest. Perform CXR, FAST. Check for pelvic or long bone fracture. If so, do immobilization and consider PAST antishock trousers.

b)Non traumatic blood loss. Rule out abdominal aortic aneurysm (e.g. palsatile abdominal mass). Do USS/ FAST. Is there hematemesis or melena? Is fluid on Levine (NG tube) bloody? Perform endoscopy if high suspected GI bleeding.

c)Dysrhythmia. Perform an ECG.

d)Tension pneumothorax. Are there any decreased unilateral breath sounds, tracheal deviation (away from the pneumothorax), hyper-resonant hemithorax on percussion or distended neck veins (if not hypotensive with blood loss)? Don’t wait CXR. Perform needle decompression and next insert a chest tube.

e)Cardiac Tamponade.Are there distended JVD (jugular veins distension), muffled heart sounds, low ECG voltage and electrical alterance, or pulsus paradoxus? Perform FAST/ USS (ultrasound).

f)Massive pulmonary embolism. Is there hypoxemia with right ventricular strain on ECG?

g)Anaphylaxis. Is there angioedema, laryngeal edema with stridor, wheezing, hives on skin?

h)Spinal Cord Injury – Neurogenic shock with decreased HR. Check for a motor/ sensory level of paralysis and anesthesia. Take cervical spine protections. Check rectal tone and check for blood.

i)Warm skin? If so, consider sepsis, neurogenic shock, anaphylactic shock, medication overdose (e.g.β’ or Ca blockers).

j)Also rule out Poisons/ medication overdose or SEs (Side Effects)/ illicit drug abuse, Sepsis and Adrenal Insufficiency.

• PH of venous blood is usually 0,01 – 0,03 lower than the arterial blood PH. Also PCO2 is 6 mmHg higher and bicarbonate is 2 meq/L higher by using venous blood.

• Anion gap is ([Na] + [K]) – ([Cl] + [HCO3]) and normal values are 12 – 16 mEq/L (usually 10 -1 2mEq/L).  Increased anion gap occurs on DM (diabetes melitus), alcoholics, starvation, lactic acidosis, renal failure, exogenous toxins metabolized to lactate (cyanide – CN, CO, ibuprofen, strychnine, toluene, iron – Fe and INH - isoniazide), or exogenous toxins metabolized to acids (aspirin, methanol, ethanol, ethylene glucol, paraaldeyde and rarely with isopropanol), severe hypotension, seizures and hypoxemia.

• Increased osmolar gap may occur in DKA, ethylene glycole or methanol or ethanol or isopropanol poisoning. Osmolar gap ΔOsm = measured Osm – Calculated O.

 

APPENDIX II : STROKE ASSESSMENT

Check vitals, give oxygen, check ABGs arterial blood gases, check glucose. Hypoglycemia may mimic stroke (also liver failure as well as  hypoglycemia may cause focal signs e.g. hemiparesis). Treat hyper or hypoglycemia. Treat if glucose < 70 mg/dl with signs & symptoms. Perform 12 lead ECG. Exclude AF (atrial fibrillation)! Give oxygen if hypoxemic. Start IV line with saline, take blood samples (for the usual studies, see above).

Don’t give D5W (5% dextrose) fluids!

CINCINNATE PREHOSPITAL STROKE SCALE

At least 1 of the following indicates high probability for stroke:

1)     Facial droop (1 side of the face does not move).

2)     Arm drift (with closed eyes!): 1 arm drifts.

3)     Speech slurring or inappropriate words or mute.

Fibrinolytic therapy is used in the USA but is controversial in the UK. It can be given max 3 hours after the symptoms onset. Check contraindications!

 

 

II)    VITALS & BRIEF CLINICAL EXAMINATION

 

·       First impression. Does the patient look comfortable or distressed? Well or ill? Well nourished or malnourished? Hydrated or dehydrated? Do you recognize any syndrome (e.g. Turner’s, or Marfan’s – may indicate aortic dissection) or facies (e.g. moon face on Cushing’s).

·       Vital signs. Temperature, BP (don’t forget BP and pulses: postural, difference between arms, difference between ipsilateral arm and leg), pulse (check and peripheral pulses), SpO2 (Oxygen Saturation), RR (respiratory rate), ABGs (arterial blood gases), stick blood glucose, dip stick urine test.

·       Normal vitals:

 

a)   RR (respiratory rate)

Neonates (until 6^th week) min 30/min and max 50/min.

Infants until preschool age min 20/min and max 30/min.

Teenagers min 12/min and max 20/min.

 

b)  HR (heart rate)

 Neonates min 100bpm and max 150 bpm.

 Infants min 80 bpm and max 120 bpm.

 Preschool age until school age min 60 bpm and max 110 bpm.

 Teenagers/adults min 60 bpm and max 100 bpm.

 

c)   Systolic BP:

 

Neonates until preschool age min is 70 mmHg.

School age and adolescents min is 80 – 90 mmHg.

Adults 90mmHg

 

d)  Urine Output

Infants 2 ml/kg/hour.

Children 1ml/kg/h.

Adults 0.5 ml/kg/h.

 

 e) Weight on children

W (Kg)= (age (years) + 4 ) x 2.

 

·        On a deteriorating patient or a patient on arrest check ABCDs and consider the 4 Hs and 4 Ts whish are hypoxia, hypovolaemia, hepo/hyperkalaemia/metabolic problems and Hypothermia. The 4 Ts are Tension pneumothorax, Tamponade cardiac, Toxins (poisoning/drugs/ medication) and Thrombosis (cardiac or pulmonary). The 4 Hs and 4 Ts are reversible causes of sudden deterioration and cardiac arrest.

·       Check jugular veins distension (JVD): e.g. cardiac tamponade, tension pneumothorax (if not hypotensive), heart failure etc.

·       Check for pulmonary crepitations/ rales (especially on bases) e.g. heart failure.

·       Check for peripheral edema e.g. heart/lever/ renal failure.

·       AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) & pupils reaction to light and irregularities) or (if time)

·       GCS

·       ABGs (arterial blood gases), SpO2 (Oxygen saturation), stick blood glucose and urine dip stick, CXR (chest X’Ray) and ECG (12 lead).

·       Temperature normally is 36 – 37 on axilla, important is said to be the morning temperature and also the temperature diurnal pattern. Normal oral temperature is 37 degrees C. Rectal temperature is 0.5 degrees C higher and axillary 0.5 degrees C lower.

·       BP Normal BP is maximum 139/89. Check any difference on BP and pulses on both arms and also on the ipsilateral arm and leg (exclude aorta’s coarctation, aortic dissection, and aortic aneurysm or aortic branches aneurysm). If BP of the arm is bigger than femoral BP then exclude coarctation of aorta. If there is difference between the BP of the 2 upper extremities exclude thoracic outlet syndrome! It will also be decreased about 45 mmHg on the left if stenotic subclavian artery!

·       Check for postural hypotension. Ask the patient to stay supine for 3 minutes and then to stand up for 1 min. We have postural hypotension when HR has increased equal or more than 30 bpm or SBP (systolic BP) has decreased equal or more than 20 or SBP <90.Check for hemorrhage (including internal bleeding, use FAST/USS and oesophago – gastroscopy/colonoscopy – exclude aortic aneurysm rupture!).

·       In case difference of BP between arm and femoral is more than 15 mmHg (measure it on both sides) exclude aortic aneurysm or aortic dissection or aortic coarctation.

·       Check for pulsus paradoxus (difference more than 10mmHg between the Korotkoff sounds or doubling of the the Korotkoff sounds or weaker pulse during inspiration) on cardiac tamponade, constrictive pericarditis, or status asthmaticus.

·       Check for pulsus alternans (alternating strong and weak pulsation) on LVF left ventricular failure.

·       Check for Kussmaul’s sign (the JVP jugular vein pressure rises during inspiration) on cardiac tamponade, constrictive pericarditis or right ventricular infraction.

·       If pulse in adults is more than 100 we have tachycardia and if <60 bradycardia.

·       Check pulses on both femoral arteries. If decreased or absent suspect coarctation of aorta. If there is difference between the 2 pulses suspect rupture of aortic aneurysm.

·       Check also the systolic BP and the pulse on both upper extremities. If there is difference suspect aortic rupture (if trauma) or aortic arc aneurysm rupture, or aortic dissection or subclavian steal syndrome. On difference > 15 mmHg, exclude aortic dissection.

 

·        DOPES (Displacement of the tube – accidental extubation or tube in the right main bronchus, Obstruction of the tube, Pneumothorax, Equipment failure, Stomach distension) should be checked if respiratory distress occurs on an intubated patient. The first thing is to extubate the patient and ventilate him/her for a while with BMV (Bag Mask Ventilation) until you figure out the reason of the respiratory compromise. About the Equipment failure check Oxygen, bag mask, ventilator etc. Stomach distension happens frequently on children, pregnant and patients (e.g. neonates) with diaphragmatic hernia.

·        CPR: 100 compressions/min (some do it too slow!) and 10 – 12 ventilations/min with rhythm 30 compressions : 2 ventilations, or unsynchronized if the patient is intubated. 

·        On defibrillation don’t forget GEL – JOULE –PADDLES. Remove any oxygen mask or oxygen nasal cannula or oxygen supply to ventilator at least 1 m (40 inches) far away from the patient, before the defibrillation.

·       On an emergency exclude poisoning (CHECK ANION GAP!), illicit drug abuse (toxicology), medication overdose or SEs (side effects), electrolyte defects and endocrinological diseases.

·       On women exclude ectopic pregnancy.

·       NG (Nasogastral) tube is essential on children and pregnant with decreased GCS/ decreased gag reflex (high aspiration risk) and other patients at risk of aspiration (e.g. stroke, diaphragmatic hernia – e.g. on neonates, bulbar paralysis etc).

·        If GCS is equal or less than 8 or respiration rate is more than 30 or less than 10, then intubate the patient or at least use BMV (bag mask ventilation – e.g. Ampu)!

·       Symptoms occurring on more than one persons, or on a family may indicate poisoning.

 

·        In case you suspect poisoning, but you haven’t any clues, ask the family, paramedics, friends or neighbours. If still no clues, ask the police to go at the place (e.g. home) in which the victim was found.

 

·        On poisoning don’t forget decontamination, skin and eyes cleaning, clothes removal, gastric lavage, activated charcoal and/or whole bowel irrigation. Also think antidotes! 

 

·        On neurological problems do not forget fundoscopy (however do not install mydriatic eye drops before the neurological examination and GCS is completed). Retinal vein pulsation at fundoscopy may exclude increased ICP (intracranial pressure), however it is absent in 50% of normal population! But absence of venous pulsation at the disc is a useful sign. On the other hand, papilloedema isn’t always a reliable sign.

 

·        A pregnant woman may appear with a sudden problem that is irrelevant with her pregnancy.

 

·        A psychiatric patient may also appear with a sudden problem that is irrelevant with his/her mental illness or may occur from their medications e.g. antipsychotic/ neuroleptic drugs increase the risk for TE thromboembolism about 3 fold (the atypical drugs probably do not do that)! Also TCAs (tricyclic antidepressants), lithium and neuroleptic drugs prolong QT interval and may cause severe cardiac arrhythmias (including torsades de points) on overdose or if combined with drugs that prolong QT (e.g. procainamide, quinidine, disopyramide, sotalol, amiodarone, co-trimoxazole, IV erythromycin, and phenytoin). These drugs must be avoided to be prescribed together because they will prolong QT!

 

·        On neurological (and psychiatric) problems exclude CNS problems metabolic abnormalities, liver or renal failure, hypoglycaemia, Lyme disease, syphilis (VDRL/ RPR/ FTA-Abs tests), sarcoidosis, DM (diabetes mellitus), chronic alcohol abuse (!), opioids and other illicit drugs of abuse, medication overdose or SE (side effects), malnutrition, poisoning (Pb – Lead, As – Arsenic, organophosphates, parathion, carbamate etc), Wilson disease (inherited disorder of copper metabolism), CO poisoning (headache!), botulism (! eating home tins, babies eating honey), paralytic shell fish poisoning (!), tick paralysis (remove the tick!), malnutrition (thiamine - alcoholics, Vitamin B12), hypokalemic periodic paralysis, amyloidosis, stroke/ cerebral hemorrhage (perform non contrast CT), TIA – Transient Ischemic Attack (amaurosis fugax?), hypoglycaemia (!), hepatic/ renal insufficiency (CBC/FBC – Complete/Full Blood Count), epilepsy (even without convulsions, or very fine e.g. on a finger, perform EEG), brain tumours, migraine (!), old stroke, delirium(confusional state), endocrinological disorders (esp. Thyroid) etc. Do FBC (CBC complete blood count), biochemistry, toxicology screening and pregnancy test (exclude eclampsia with brain haemorrhage) and call the poisoning center if you suspect poisoning.

 

·        Patient’s Exposure is very important and don’t avoid it because you or the patient feel embarrassed. It may give you diagnostic clues such a trauma on the back or a rash that indicates allergy (e.g. urticaria) or meningitis (e.g. 1 or 2 or more petechia that don’t blanch on glass).

 

·        On chest pain don’t forget to the abdomen (e.g. duodenal ulcer perforation). Also on epigastric pain don’t forget to do an ECG (MI) and a CXR (Chest X’ Ray e.g. pneumonia of the bases).

 

·        Always consider allergy/ anaphylaxis on your differential diagnosis (especially on shock and breathlessness). A stridor (or wheezing) has to alarm for an anaphylaxis (or angioedema) or airway obstruction by a foreign body (especially on a child or a mentally incapacitated or a psychiatric patient or a patient with a stroke).

 

·        Exclude anaphylaxis if wheezing, urticaria/ rash/ erythema/ itching, angio/oedema (larynx, lids, lips, tongue, uvula), laryngeal obstruction – stridor (exclude foreign body obstruction e.g. child, mental ill, stroke), cyanosis, hypotension/ shock and tachycardia.  Give immediately adrenaline IM 0.3 – 0.5 mg (0.3 – 0.5 mL 1:1000) on adults or 0.01 mg/kg on children.

 

·        Differential diagnosis of acute breathlessness includes pulmonary oedema/ heart failure, (tension) pneumothorax, asthma/ COPD, pneumonia, PE pulmonary embolism (here we may have haemoptysis), metabolic acidosis (e.g. DKA diabetic ketoacidosis), drug poisoning (e.g. salicylates), anaphylaxis (wheezing/ stridor), foreign body airway obstruction (child, mental ill, stroke), pneumonia etc.

 

 

 

 

III) BRIEF HISTORY

• AMPLE (Allergy, Medication, Past medical history, Last meal, Environment/Events that brought him/her to the hospital) should be asked in ALL the patients that arrive on the ER (A&E).

Medication includes prescribed or over the counter drugs (OTC), herbs, aspirin, paracetamol (acetaminophen), ibuprophen and other agents used wrongly as ‘muscle relaxants’ (and have side effects such as interstitial nephritis), sleeping pills, inhalers, eye – drops, illicit – recreational drug abuse and ‘proteins’ for body building or drugs to lose weight (some products contain caffeine, amphetamines, thyroxin, iodine, ephedrine, diuretics etc), oral contraception (the Pill) and estrogen replacement therapy after menopause, tranquilizers and laxatives.

Ask also about alcohol and illicit drug abuse, smoking & last menstruation (women).

 
Ask also family members or friends or neighbours with similar symptoms (exclude poisoning or bioterrorism if many people arrive on the ER – A&E with the same symptoms).

Ask details about kinetics and biomechanics on a car or motorbike accident (e.g. a spider break of the wind screen shows high energy to the head and neck and necessitates neck protection).

Also, if there is time, ask about hobbies, pets/ animal exposure, family history and child diseases. Environment and event is what happened that brought the patient to the hospital.

• On last meal exclude also food poisoning, toxins/poisons (e.g. fruits with organophosphates), botulism and paralytic fish/ shellfish poisoning. Consider stomach emptying with NG tube if altered mental status and risk for aspiration (which is great on obese, children, pregnant and pts with reflux or diaphragmatic hernia).

 

·        Asking AMPLE and taking a brief history (from the patient, the relatives, the paramedics, the patient’s GP and perhaps neighbours or the police) is essential.

 

 

 

IV)            LAB TESTS

• Standard Lab tests include CBC – Complete Blood Count (FBC – Full Blood Count), coagulation studies (Plts – Platelets, PT, aPTT, D –Dimers, INR), Blood Urea Nitrogen (BUN) & Cr (creatinine), glucose (initially blood finger stick test), LFTs [liver functional tests ALT (sGPT), AST (sGOT) & γGT], CRP, CK, CK-MB, Troponins (T&I), BNP, urinalysis, amylase & lipase, LDH, bilirubin (total, conjugated and unconjugated), ALP (alkaline phosphatase), albumin, total protein, iron, ferritin, urate (uric acid), electrolytes (potassium, sodium, magnesium calcium – ionized & total for calcium take blood sample uncuffed i.e. remove the tourniquet after the needle is in vein, but before taking the blood sample; also correct calcium for albumin: add 0.1 mmol/L to calcium level for every 4 g/L that albumin is below 40 g/L; do a similar subtraction for a raised albumin), BNP, and ABGs (Arterial Blood Gases). Also consider blood/ urine cultures, smears/ swabs gram Stain & cultures, pregnancy test, blood type & crossmatch (ask 4 units packed RBCs) and toxicology tests (e.g. blood/ urine drug screen, blood alcohol). Also consider blood reticulocyte count.

• Special Lab tests to consider include stool occult blood, faecal cultures/ WBCs/ova/ parasites, urine WBCs (white blood cells)/ RBCs (red blood cells)/ casts/ nitrites/ leukocyte esterase, TFTs (Thyroid Function Tests), peripheral blood smear & reticulocyte (anaemia), CK (myopathy, rabdomyolisis), serum lactate, toxicology – blood or urine (illicit drugs), medication levels (acetaminophen (paracetamol), anticonvulsants, digoxin etc), serum cortizol & Cosyntropin test (Addison’s), 24h urine metanephrines & plasma free metanephrines (pheochromocytoma), serum lactate, serum & urine osmolality (SIADH – Syndrome of Inappropriate ADH release, Diabetes insipidus), PTH (increased or decreased Ca or phosphate), ammonia, urine specific gravity, ADH, urine myoglobulin, HbCO carboxyhemoglobulin (burns, smoke inhale) and lead/ arsenic (e.g. neurological problems) and serum seruloplasmine & urine cooper (Cu, Wilson’s disease, neurologic or psychiatric problems especially in young, also eye examination).

V)   STANDARD EMERGENCY PROCEDURES

Neck/ spine immobilizing (if neck trauma suspected and always in head trauma), 100% Oxygen (non rebreathing mask with reservoir or bag – with reservoir – mask ventilation), 2 IV lines (warm on trauma 40⁰ C or 104⁰ F) 16 G or bigger (initially give saline or RL – don’t give RL in hypothermia), SpO2 (Oxygen saturation but does not show CO poisoning or methemoglobinemia), GCS, ECG 12 Lead & continue monitoring, ABGs (arterial blood gases), Lab tests (including lactate), toxicology, CXR (Chest X’ Ray – Face, Profile/ prefer erect, also decubitus lateral, supine patient), perhaps AXR (Abdominal X’ Ray upright – preferred and/or supine), perhaps spinal X’ Ray studies if trauma suspected (but X’ Rays do not exclude spinal trauma 100%, perform MRI/CT), USS (ultrasound), FAST/DPL (trauma), perhaps TTE (Trans – oesophageal Echo, it can show aortic dissection), CT (if decreased GCS and/or head trauma and in other occasions), Foley urinary catheter, and perhaps NG tube (Nasogastral tube – Levine).

 

·        Administration of medications (such as adrenaline) on peripheral lines on emergencies should be followed immediately by flush with normal saline (at least 20 ml on adults, 2 – 5 ml on children) and elevation of the extremity for 10 – 20 sec to facilitate drug delivery to the central circulation.

• To exclude brain problems perform initially a non contrast CT. Also perform LP (lumbar puncture) to exclude meningitis, meningoencephalitis, subarachnoid haemorrhage. However, be cautious on LP contraindications. On subarachnoid haemorrhage it may take 2 – 4 hours for CSF xanthochromia after the bleeding! Increased bilirubin – jaundice, elevated CSF protein and hypercarotonemia may also cause xanthochromia! Don’t forget to take a CSF specimen for a VDRL study. Also measure opening pressure!

• Contraindications to LP (lumbar puncture) are suspected intracranial mass lesion, papilloedema, focal neurological signs, trauma, middle ear pathology, major coagulopathy and septemic signs of meningitis with shock, hypotension, rash (initially may have decreased capillary refill >2sec and cold hands & feet). Be aware of the above contraindications, because if you perform a LP the patient may die from herniation!

• On poisoning don’t forget decontamination, skin and eyes cleaning, clothes removal, gastric lavage, activated charcoal and/or whole bowel irrigation. Also think antidotes!

 
VI)            EMERGENCY DRUGS

Administration of medications (such as adrenaline) on peripheral lines on emergencies should be followed immediately by flush with normal saline (at least 20 ml on adults, 2 – 5 ml on children) and elevation of the extremity for 10 – 20 sec to facilitate drug delivery to the central circulation.

 

Many of the drugs referred below, as well as fluids, can be administrated via IO (intra - osseous) rout, especially on children.

 

IO rout is the rout of choice on children with PEA (pulseless electrical activity), asystole and also if 3 attempts of IV access have failed or take more than 90 sec.  

 

Endotracheal doses (e.g. epinephrine, lidocaine, atropine, naloxone, amiodarone) is 2 – 2.5 times the recommended IV/IO dose. Glucose (dextrose) is NEVER given endotrachel route. Also DON’T give it with blood.

 

a)     Adrenaline (epinephrine) Used on cardiac arrest 1mg IV/ IO (intra-osseous) every 3 – 5 min (1ml of 1:1000 solution or 10 ml of 1:10.000).

 

 If endotracheal rout is used, give 3 mg diluted to 10 – 20 ml sterile water. However, absorption via tracheal rout is unreliable.

 

On children with cardiac arrest give 10 mcg/kg adrenaline (0.1 ml/kg of 1:10.000 solution) (1mg/10ml) IV or IO. If tracheal route is used on children, give 100 mcg/kg (0.1 ml/kg) of 1:1000 solution (1mg/1ml). However, this rout is not recommended because of the unrealiable dose.

 

Adrenaline is also used:

 

For second line treatment of cardiogenic shock give 0.05 – 1 mcg/kg/min IV (adults).

 

As alternative to external pacing in bradycardia give 2 – 10 mcg/min IV (adults).

 

On symptomatic severe bradycardia with adverse signs or severe hypotension give adrenaline 2 – 10 mcg/min. Add 1 mg epinephrine (1 ml of 1:1000 solution) to 500 ml NS (normal saline) and infuse at rate 1 – 5 ml/min.

 

For anaphylaxis give 0.5 ml (500mcg) IM 1:1000 solution. Repeat in 5 min if no improvement. On life threatening profound shock consider slow IV adrenaline 1:10.000 solution (consult an expert).

 

On children with anaphylaxis the dose of IM adrenaline 1:1000 solution is:

Infants < 6 month 50 mcg IM (0.05 ml)

>6 months – 6 years 120mcg IM (0.12ml)

6 – 12 years old 250 mcg IM (0.25 ml)

Ø      12 years old 500 mcg IM (0.5 ml)

 

Relative CI (contraindications) of adrenaline (not for the above indications where is used as an emergency drug) are tachycardia and hypertension

 

Don’t mix adrenaline with sodium bicarbonate!

 

 

 

b)  Amiodarone

 

Indications are VF ventricular fibrillation and pulseless VT ventricular tachycardia (refractory to defibrillation), polymorphic VT ventricular tachycardia, wide complex tachycardia of uncertain origin, stable VT (when cardioversion is unsuccessful), as an adjunct to synchronized cardioversion in SVT supraventricular tachycardia, termination of ectopic atrial tachycardia, rate control in AF atrial fibrillation and atrial flutter resistant to other therapies. Also used in pre-excitation tachycardia e.g. in WPW. 

 

CI (contraindications) are known sensitivity, SN (sinus node) disease with severe bradycardia and 2^nd or 3^rd degree AV atrioventricular block. 

 

For ventricular fibrillation VF or pulseless VT ventricular tachycardia give 300 mg IV rapid (diluted in 20 ml D5W 5% dextrose ) over a large peripheral or via a central vein. Repeat dose of 150 mg (diluted in 20 – 30 ml D5W 5% dextrose) via rapid IV push, 3 – 5min later.

 

On children with refractory (to defibrillation) VF give 5 mg/kg amiodarone IV bolus.It may be repeated up to 15 mg/kg/day.

 

On SVTs (supraventricular tachycardia) amiodarone must be injected slowly, over 20 – 60 min, to avoid hypotension. Hypotension occurs less often if you use the aqueous solution!

 

Amiodarone prolonges QT, so don’t combine it with drugs that prolong the QT (e.g. procainamide).

 

For unstable (haemodynamically) tachycardia unresponded to electrical cardioversion give over a large peripheral vein or a central vein 300 mg IV over 10 – 20min followed by infusion of 900 mg over 24 h. 

 

The ALS (ERC) mentions that for haemodynamically stable SVT (supraventricular tachycardia), polymorphic VT, broad complex tachycardia of uncertain origin, paroxysmal SVT uncontrolled by adenosine, vagal manoeuvres or AV node blockage, and also to control rapid ventricular rate caused by accessory pathway conduction in pre-excited atrial arrhythmias (e.g. WPW) you should give 300 mg IV over 20 – 60 min followed by infusion of 900 mg over 24h.  

However, the ACLS protocol mentions that for stable VT and AF atrial fibrillation the dose is 150 mg (diluted in 20 – 30 ml D5W 5% dextrose) via IV push over 10 min (may be repeated every 10 min – max 2.2 g/24h).

 

24 hour maintenance infusion dose for amiodarone is 360mg via IV infusion over the first 6 hours (1 mg/min) and next 540 mg via IV infusion over the remaining 18 hours (0.5 mg/min).  Max dose is 2.2 g/ 24 hours.

 

c)     Lidocaine  

 

CI (contraindications) to lidocaine are hypersensitivity to it or the ‘caine’ drugs (e.g. novocaine), sinus bradycardia and AV atrioventricular block.

 

ALS (ERC) mentions that for refractory to 3 defibrillations VF (ventricular fibrillation)/ pulseless VT (ventricular tachycardia) when amiodarone is unavailable; give 100 mg IV. Give additional bolus 50 mg if no response. Max on the 1^st hour 3 mg/kg.

 

However, ACLS protocol mentions that for VF and pulseless VT the dose is 1 – 1.5 mg/kg (rapid V push) which may be repeated at 0.5 – 0.75 mg/kg every 5 – 10min (if refractory arrhythmia) to max 3 mg/kg.

 

 

ALS (ERC) also mentions that for haemodynamically stable VT, as alternative to amiodarone, you can give 50 mg IV lidocaine.

 

However, ACLS protocol mentions that the dose for stable VT and wide complex tachycardia of unknown origin the dose is 1 – 1.5 mg/kg rapid IV push, that may be repeated at 0.5 – 0.75 mg/kg every 5 – 10 min to max 3 mg/kg.

 

Maintenance infusion is 1 – 4 mg/min titrated to desired effect.

 

d)     MgSO4 Magnesium sulphate ALS (ERC) protocol mentions that for refractory VF ventricular fibrillation with hypomagnesaemia you should give 2 gr bolus (4ml, 8 mmol) of 50% MgSO4. For VT ventricular tachyarrhythmias with hypomagnesaemia, Torsades de pointes, AF (atrial fibrillation) and digoxin toxicity; give 2 g over 10min IV.

 

The ACLS protocol mentions that for arrest with hypomagnesemia or Torsades without pulse the dose of MgSO4 50% is 1 – 2 gr (2 – 4 ml) diluted in 10ml D5W 5% dextrose IV. For Torsades with pulse the dose is 1 – 2 g of 10% MgSO4 diluted in 50 – 100 ml D5W 5% dextrose over 5 – 60 min and followed by infusion of 0.5 – 1 g/h IV. 

 

 

e)     Atropine For asystole or PEA (pulseless electrical activity) with HR < 60 give 3 mg IV only once. On children give 20 mcg/kg IV/IO with min dose 100 mcg. Max dose is 3 mg. If endotracheal rout is used, give triple dose. 

 

For sinus/atrial /nodal bradycardia with adverse signs give 0.5 mg (rapid IV) increments IV every 3 – 5 min to a max of 3 mg.

 

Contraindications of atropine are glaucoma, tachycardia and  transplanted heart (will not work – give instead catecholamines or perform transcutaneous pacing).

 

f)     Calcium For PEA caused by hyperkalaemia, hypocalcaemia, hypermagnesaemia and overdose of calcium channel blockers; give 10 ml of 10% CaCl2 (calcium chloride) or calcium gluconate IV over 10min (rapid in arrest).

 

g)     Sodium Bicarbonate For severe hyperkalaemia, cardiac arrest from hyperkalaemia or TCAs (tricyclic antidepressants) overdose or prolonged arrest (> 10min); give 50 ml (1 mEq/kg) of 8.4% sodium bicarbonate IV over 2 – 5 min (rapid IV in arrest). Don’t give it routinely on cardiac arrest or ROSC.

On children the dose is 1 mEq/kg (1mMole/kg) (1 ml/kg of 8.4% solution) IV/IO. On neonates and infants <3 months use the 4.2% solution (1mMole or 1 mEq= 2ml).

 

Sodium Bicarbonate is contraindicated in hypercarbic acidosis.

 

Ventilate the patient after administration!

 

Don’t give sodium bicarbonate simultaneously with catecholamines (e.g. adrenaline or dopamine) at the same vascular access (at least give the drugs separated by a bolus of normal saline).

 

 

h)    Thrombolytics For non traumatic cardiac arrest caused by suspected pulmonary embolus. If you give thrombolytic consider prolonging CPR at least 60 – 90 min before termination of resuscitation. Also as fibrilolytics on acute MI myocardial linfraction < 12 h old (from the symptoms onset), acute ischemic stroke < 3 h old (from the symptoms onset) and acute pulmonary embolism (massive).

 

 Check contraindications!

 Tenecteplase 500 – 600 mcg (μg)/kg IV over 10 sec.

 

 Alteplase (r-tPA) ALS (ERC) protocol mentions that dose is 10 mg IV over 1 – 2 min followed by IV infusion of 90 mg over 2 h.

 

 ACLS guidelines mention that for acute MI the dose is 100mg IV over 3 h. Mix in 100 ml sterile water for 1 mg/ml. For accelerated 1.5 h infusion the dose is 15 mg IV bolus (15 ml) over 2 min followed by 0.75 mg/kg (max 50mg) over the next 30 min; followed by 0.5 mg/kg (max 35 mg) over the next hour. 

 

 Alternative dose scheme is the 3 h infusion: give 10mg IV bolus (10 ml) over 2 min, followed by 50mg (50ml) over the 1^st hour; followed by 20 mg/h (20ml/h) the next 2 h.

 

 For acute ischemic stroke < 3h the dose, according to ACLS, is 0.9 mg/kg IV (max 90mg) over 1 h. Give 10% of the dose as IV bolus over 1 min and next give the remaining 90% over the next hour.

 

 For acute PE the dose is 100 mg IV over 2 h. Give 10 mg IV over 2 min, followed by 90 mg IV infusion over 2 h.

 

 

 

i) Adenosine For stable regular narrow complex tachycardia or a broad complex tachycardia known to be SVT (supraventricular tachycardia) that is not terminated by vagal manoeuvres give 6 mg rapid bolus IV, if no response give further 12 mg and if no response give other 12 mg. The interval between the administrations is 1 – 2 min. Follow each infusion with 20 ml 0.9% NS normal saline flush and extremity elevation for 10 – 20 sec. Chose a large vein near the heart and warn the patient for the side effects (flushing, sense that dies etc).

 

 On children adenosine dose is 100 mcg (=0.1mg)/kg IV/IO bolus, max 6 mg, followed by 3 – 5 ml saline flush. If no response, you may give after 1 – 2 min a 2^nd dose of 200 mcg (=0.2 mg)/kg, max 12 mg, followed by 3 – 5 ml saline flush. 

 

 CI (contraindications) are toxin induced tachycardia, 2^nd or 3^rd degree AV atrioventricular block, AF atrial fibrillation, atrial flutter, wide QRS tachycardia and rapid pre-excitation tachycardia in WPW.  

 

j)        Aspirin For ACS (acute coronary syndrome) give 300 – 325 mg PO (orally) followed by 75 mg daily. Contraindications are allergy, active peptic ulcer, recent GI gastrointestinal bleeding and other bleeding disorders (e.g. haemophilia). Use with caution in asthma.

 

k)     β’ blockers For  narrow complex regular tachycardia not terminated by vagal maneuvers or adenosine on patient with preserved ventricular function. Also to control rate in AF (atrial fibrillation) and atrial flutter with duration < 48h and with preserved the ventricular function (don’t give it in rapid ventricular rate caused by accessory pathway in pre-excited arrhythmias such as WPW). 

 

 CI (contraindications): heart failure (IV category), asthma –bronchospasm/ COPD (with bronchospasm), AV block/ bradycardia and brittle insulin depended DM (IDDM), rapid ventricular rate caused by pre- excited tachycardia e.g. WPW.

 

 Don’t give concomitantly a Calcium blocker with a β’ blocker, because they may cause severe hypotension and bradycardia.  

  Atenolol (β1) 5mg slowly (1 mg/min) over 5 min. May be repeated 

 10 min later at same dose (5 mg) slowly (1mg/min) over 5 min.

 IV infusion in dysrythmias is 150 μg/ kg over 20min. May be repeated 

 after 12 h.  For early phase (<12 h) of MI (heart attack) the dose is 5 – 

 10 mg slowly (1mg/min) IV, and then PO (orally): 50 mg after 15 min; 50

 mg after 12 h; 100 mg after 12 h; and then 100 mg 1 dose daily. 

Metoprolol (β1) 2 – 5 mg slow IV at 5 min intervals. Total dose 15mg.

 

Propanolol (β1&β2) 100 mcg (μg) (=0.1 mg)/kg in 3 divided doses at 2 min intervals. Because of β2 blockage, usually used in hyperthyroidism at thyrotoxic crisis (there exclude AF atrial fibrillation!).

 

Esmolol (β1 short acting!) 500 mcg (μg) (=0.5mg)/kg over 1 min followed by infusion of 50 – 200 mcg/kg/min.

 

l)        Calcium channel blockers.

 Indications: control of ventricular rate in AF atrial fibrillation and atrial flutter (consider anticoagulation!). Also, for stable narrow complex tachycardia that is not terminated by vagal manoeuvres or adenosine.  Also, verapamil is used in ectopic atrial tachycardias.

 

 Verapamil 2.5 – 5 mg  IV over 2 min Repeat dose at 5 – 10 mg IV every 15 – 30 min to max 20 mg. The max 24 h dose is 100 mg.

 

 Alternative is

 

 Diltiazem 15 – 20 mg (0.25 mg/kg) IV over 2 min. It may be repeated after 15 min at 20 – 25 mg (0.35 mg/kg) over 2 min. Maintenance dose is 5 – 15 mg/h titrated to HR and BP.

 

To control ventricular rate in patients with AF or atrial flutter (usually when the arrhythmia is < 48h) give Diltiazem 15 – 20mg IV over 2 min.

 

 CI (contraindications) to calcium blockers are wide complex tachycardia of uncertain origin, poison or drug induced tachycardia, pre – excited tachycardia e.g. rapid atrial flutter or AF and generally rapid ventricular rate caused by pre- excited tachycardia e.g. WPW.

 Also CI are SN sinus nodal disease, AV (atrioventricular) block without pacemaker, and perhaps on CHF (congestive heart failure), because of negative inotropic action (especially of verapamil). Give them with caution if LV (left ventricular) dysfunction. Use sustained long acting formula, because short acting increases the risk for ACS/ MI (acute coronary syndrome/ myocardial infarction)!

Verapamil is a negative inotropic agent so avoid it in patients with left ventricular impairment or heart failure, even they are stable! Also, avoid it on 2^nd or 3^rd degree heart block, sick sinus syndrome.

 Don’t give concomitantly a Calcium blocker with a β’ blocker, because they may cause severe hypotension and bradycardia.  

m)    Digoxin. ALS (ERC) protocol mentions that for AF or atrial flutter  with fast ventricular response give 500 mcg (=0.5 mg) IV over 30 min.

 

 ACLS protocol mentions that dose of digoxin is 0.5 – 1mg (10 – 15 mcg/kg) over 5 min.

 

 The loading dose is followed by 0.25mg/24 h digoxin, under ECG monitoring.

 

 The ALS protocol says that for AF (atrial fibrillation) the dose is 0.75 – 1 mg in 0.9% normal saline IV.

 

 For thyroid storm give 1 mg over 2 h, IVI.

 

 

 If on digoxin, and cardioversion is needed, start cardioversion with 5 J.

 

 Digoxin toxicity increases if hypokalaemia, hypomagnesaemia, or hypercalcaemia.

 

 Contraindications to digoxin are VF, VT, HR < 60 bpm, rapid ventricular rate caused by pre- excited tachycardia e.g. WPW. Use with caution in renal failure.

 

 

n)     Dobutamine For hypotension (not caused by hypovolaemia) or cardiogenic shock give 2 – 20 mcg/kg/min IV.

 

o)     Dopamine For hypotension (not caused by hypovolaemia) give 1 – 10 mcg/kg/min IV.  

 Renal dose is 2 – 5 mcg/kg/min

 Inotropic dose is 5 – 10 mcg/kg/min

 Vasopressor dose is > 10mcg/kg.

 

 Add 400 mg dopamine in 250 ml NS  (normal saline), RL (Ringers - Lactated) or D5W (5% dextrose).

 

 For severe symptomatic bradycardia it is 1^st choice drug (according to ACLS) with dose 2 – 10 mcg/kg/min. For profound hypotension (but not hypovolaemic) the dose is 10 – 20 mcg/kg/min.

 

 Don’t give sodium bicarbonate at the same line with dopamine.

 

 In case you can’t exclude hypovolaemia, give 500 ml normal saline before dopamine administration. Dopamine is dangerous on a hypovolaemic – fluid depleted patient.

 

 Contraindications are hypovolaemia, hypersensitivity to it, use of MAO I (inhibitor), tachyarrhythmias, VF ventricular fibrillation and pheochromocytoma.

 

p)     Noradrenaline. Use only central vein! For severe hypotension associated with low peripheral resistance (e.g. septic shock), in the absence of hypovolaemia. Also, alternatively to adrenaline in the treatment of cardiogenic shock. Give 0.05 – 1 mcg/kg/min IV via central vein.

 

q)     Naloxone For opioid overdose 400 – 800 mcg (0.4 – 0.8 mg) IV. Repeat every 2 – 3min, if necessary up to 10 mg.

 On children the initial dose is 100 mcg/kg in children < 5 years old (max 2 mg) and 2 mg on children > 5 years old IV/IO/IM. If necessary repeat every 3 min. If large amount of opioids has taken you may use an infusion of 10 – 160 mcg/kg/h titrated to response. 

 

r)       Opioids for analgesia or acute LVF (left ventricular failure) – pulmonary oedema (with systolic BP >90) give morphine 2 – 5 mg IV/IM SQ  (on increments of 2 – 4 mg administered slowly over 1 – 5 min, every 5 min, to total 10 mg) or diamorphine 2.5 – 10 mg IV.

 

 ACLS protocol mentions that morphine sulphate is given for chest pain not completely releaved by NTG (nitroglycerine), and also for cardiogenicpulmonary edema with systolic BP> 90. Dose for ACS (acute coronary syndrome) is 2 – 4 mg increments slowly – over 1 – 5 min. May be repeated every 5 – 30 min up to 10 mg (max total dose).

 

 CI (contraindications) are hypersensitivity to it or other opiates, CNS depression (e.g. respiratory depression, hypotension, bradycardia).

 

s)     Nitrates – Nitroglycerine (NTG)

 

 Indications: chest pain (cardiac) or cardiogenic pulmonary oedema.

 

 Contraindications are Systolic BP <90 (OR > 30 mmHg below baseline), HR < 50 or HR> 100, intracranial bleeding, Aortic stenosis, right ventricular infraction and use of erectile agents and specifically use of Viagra (sildenafil) or Levitra (vardenafil) the past 24 h or Cialis (tadalafil) the past 48 h. 

 

 ΑLS protocol mentions the following doses:   for prophylaxis or relief of angina give GTN 300 – 600 mcg sublingual.

For UA (unstable angina) give 400 mcg (0.4 mg) sublingual, buccal tablets 1 – 5 mg.

For MI (heart attack) give buccal 5 mg, transdermal 5 – 15 mg.

For acute or chronic LVF give 10 – 200 mcg/min IV. Alternatively use isosobide mononitrate or dinitrate 10 – 60 mg PO (orally).

 

ACLS protocol doses for ACS (acute coronary syndrome) for NTG are

SL tbs (sublingual tablets) 0.3 – 0.4 mg (1 tablet) or SL (sublingual;) spray 1 dose (0.4 mg), repeated 3 times in 5 min intervals between each dose.

 

IV dose is 10 – 20 mcg/min titrated to desired effects and BP.

Check frequently the BP!

 

t)       Glucose On adults on severe hypoglycaemia give 50 – 100 ml of 50% dextrose. However it is irritant to veins, so alternatively give 20 – 30 gr dextrose IV e.g. 200 – 300 ml of 10% dextrose. Alternative to glucose is glucagon 1mg IV/IM, but it will not work in drunk patients! On children (with documented hypoglycaemia) the dose is 5 – 10 ml/kg of 10% dextrose (5 ml= 0.5 G glucose) and on newborn 2.5 ml/kg.

 Don’t give RBC (red blood cells) with glucose together.

 Don’t give glucose via tracheal rout.

 Also bolus(es) of hypertonic solutions (such as glucose) may cause intraventricular haemorrhage in premature neonates.

 

u) Procainamide

 

 Indications are recurrent VF ventricular fibrillation or pulseless ventricular tachycardia, stable SVT supraventricular tachycardia (uncontrolled with adenosine), stable wide complex tachycardia of uncertain origin and AF with rapid ventricular rate in pre – excitation tachycardia  – e.g. on WPW!

 

 CI (contraindications are known sensitivity to it or similar drugs, 3^rd degree AV atrioventricular block without pacemaker, digitalis toxicity, prolongation of QRS and QT (e.g. Torsades), myasthenia gravis and SLE (systemic erythematosus lupus).

 

 Do not combine procainamide with other drugs that prolong the QT (e.g. amiodarone).

 

 For recurrent VF ventricular fibrillation and pulseless VT ventricular tachycardia give 20mg/min procainamide IV (max: up to 50mg/min). For SVT supraventricular tachycardia, AF atrial fibrillation and wide complex trachycardia of uncertain origin give 20 mg/min procainamide IV.

 

 Maintenance dose is 1 – 4 mg/min titrated to the desired effect. Stop infusion if 1 of the following occurs: arrhythmia is converted (terminated), hypotension, wide QRS (> 50% before treatment), OT prolongation, or max dose of 17 mg/kg.

 

v) Furosemide (Lasix). For CHF (congestive heart failure) with pulmonary oedema or hypertensive crisis give 0.5 – 1 mg/kg IV slowly. Max total dose is 2 mg/kg. Children dose is 1 mg/kg slowly IV/IO. For hyperkalaemia give 1 mg/kg IV slowly. If on diuretics or renal failure, give 80 – 160 mg. For acute renal failure the dose is 120 – 250 mg IV, if oliguric or anuric. For volume overload on renal failure give 120 – 500 mg IV, and then 5 – 10 mg/h (consult a nephrologist).

 

 Contraindications are hypokalaemia, hypotension (systolic BP <90) and dehydration.

 

 

w) Bretylium

 

 For VF/VT 5 mg/kg IVP (IV push), repeat with 10mg/kg IVP every 15 min up to 30 mg/kg. For VT with a pulse give 5 – 10 mg/kg IV over 8 – 10 min (diluted in 50 ml). Drip: mix 1000 mg in 250 ml D5W 5 %dextrose and run at 1 – 2 mg/min.

 

 CI (contraindications) are AV atrioventricular block and digitalis toxicity. It may cause hypotension and initially worsen dysrhythmia.

 

x) Vasopressin

 

 For cardiac arrest replacing the 1^st dose of epinephrine.

 Also used for oesophagal varices rupture, however because of its side effects today we use terlipresin for variceal bleeding. .

 

 CI (contraindications) are known sensitivity to it, ACS (acute coronary syndrome), hypertension, children, migraine, epilepsy, CHF congestive heart failure, asthma, pregnancy, lactation and chronic nephritis with nitrogen retention.

 

 Dose for arrest (replacing the 1^st dose of adrenaline) is 40 units IVP (IV push), one dose. Give epinephrine 10min after vasopressin, not earlier. 

 

 

y) Oxytocin

 

 For labor induction and PPH post partum hemorrhage.

 

 Contraindications are multiple fetuses.

 

 It may cause hypertension, dysrhythmias, hyponatraemia and increased uterine tone.

 

 For preventing PPH (postpartum hemorrhage) give 10 units IM prior the placenta delivery. For uterine bleeding mix 10 – 40 units in 1 L RL (Ringers Lactated) and titrate to control the uterine bleeding (e.g. 10 units/h).

 

z) Atosiban

 For preterm labor (premature baby is the one born < 37 weeks). It may buy time for corticosteroid therapy for lung maturation (if 24 – 34 weeks).

 

 Dose is 6.75 mg rapid IV followed by IV infusion 18 mg/h for 3 h; next 6 mg/h for 48 h (max therapy is for 48 h).

 

 

 

 Sedation before synchronized cardioversion

 Give diazepam 5 – 10 mg IV slowly or midazolam 1 – 2.5 mg (0.1 mg/kg – max 5 mg) slowly IV.

 

VII)         ENDOTRACHEAL INTUBATION AT A GLANCE

In case of suspected cervical trauma do not forget to  immobilize the head during intubation.

 

Ventilation is tidal volume 6 – 7 ml/kg (about 500 ml per breath), with 10 – 12 respirations/min. Ventilation duration with BMV bag mask ventilation is 1 sec.

 

After ET endotracheal intubation, successful intubation must be confirmed with auscultation of chest – axillae and stomach for equal bilateral breath sounds and no gastric bubbles, respectively. The most reliable confirmation is with CXE chest X’ Ray (the tube is just above the carina). Other method is the end tidal CO2 carbon dioxide detector (capnographer). If the colometric paper turns yellow on expiration, then the ET tube is in the trachea. If it turns purple, the tube is likely in the oesophagus. Another method is the oesophageal detector. In that method, when the bulb connected with the ET tube is squeezed and refills with air, then the ET tube is in the trachea. If not, it is likely in the oesopohagus. 

 

a)     Laryngeal mask. Don’t forget to use lubricate spray. We usually use size 5 for most men and size 4 for most women. The volume of air (ml) we inflate the cuff is empirically tube size x 10 -10 e.g. for tube size 4 we inflate with 4 x 10 – 10 = 30 cc. For a size 5 we inflate with 40 ml. If insertion is satisfactory, the tube will lift 1 – 2 cm out of the mouth as the cuff finds its correct position. 

 

b)     Orotracheal intubation in adults. The tube size is usually for men size 8 – 9 (usually 8) and for women 7- 8 (usually 7) mm ID (internal diameter).

We inflate the cuff with 5 – 8 cc of air. The depth of the tube is usually 24 cm (9.45 inch) on men and 22cm (8.66 inch) on women.

If GCS is > 3 we use RSI.

 

Don’t forget to pre oxygenate with 100% O2.

On arrest, pre –oxygenate the patient with BMV bag mask ventilation (with 100% oxygen supply) at least 2 – 3 min before ET endotracheal intubation.

Use a curved blade – size 3 will be adequate for most patients. Don’t forget the lubricating jelly. Have also suction on hand, exhaled CO2 detector & Magill’ s forceps.

 

Confirm the right position of the ET (endotr. tube) by asculating the lungs (chest + axillae), the stomach, using a CO2 detector (or an esophageal detector) and taking an X’Ray.

Don’t forget Sellick maneuver (cricoid pressure). If you remove the cuff deflate the cuff! In case the left chest on auscultation has more distant breath sounds than the right chest (something that suggests right main stem bronchus intubation), then withdraw the tube 1 – 2 cm (3/8 – 3/4 inches) and ventilate again.

c)     Paediatric orotracheal intubation.

 

The tube size is

for pre-term neonates 2.5 – 3 mm ID (internal diameter) or gestational weeks/10. 

For term neonates it is 3 – 3.5 mmID.

For infants < 1 year old it is 4 – 4.5 mmID.

For children > 1 year old use the formula: (age (years)/4 ) +4 e.g. for 8 years old kid use a size 8/4 + 4 = 6mmID.

 

Use uncuffed tubes on children < 8 years old (up to 5.5 mmID). To estimate the length of the tube, use the formulas: oral tube length (cm) = (age (years)/2) + 12. Nasal tube length (cm) = age (years)/2 + 15.

On RSI use atropine (to prevent bradycardia).

About the laryngoscope, use a straight blade (No 0 or 1) for infants (< 1year old) and neonates. On children and adolescents use curved blades (No 0, 1, 2 for infants and children; No 3 or 4 for adolescent& adults).

Don’t forget Sellick maneuver (cricoid pressure). Nasotracheal intubation is not applicable for children < 3 years old.

Neonatal orotracheal intubation. The insertion depth at the upper lip (cm) = Weight (Kg) + 6 cm.

Use an uncuffed straight blade (size0 for premature and size 1 for term newborn).

About the tracheal tube size use the below guidance. GA is gestational age.

 

Tracheal tube size 2.5 mmID, Weight <1000gr, GA <28 weeks,  Insertion depth 6.5 – 7cm

Size 3 mmID, Weight 1000 – 2000 gr,  GA28 – 34 weeks,  Insertion depth 7 – 8 cm

Size 3 – 3.5 mmID, Weight  2000 – 3000 gr, GA 34 – 38 weeks, Insertion depth  8 – 9 cm

Size 3.5 – 4 mmID, Weight  >3000 gr, GA >38 weeks, Insertion depth >9 cm

 

Tracheal tube size (mm)= gestational age (weeks)/10.

Insert the tube about 1.5 – 2 cm into the larynx, so that the black mark on the tip of the tube is just visible thru the cords.

·        DOPES (Displacement of the tube – accidental extubation or tube in the right main bronchus, Obstruction of the tube, Pneumothorax, Equipment failure, Stomach distension) should be checked if respiratory distress occurs on an intubated patient.

The first thing is to extubate the patient and ventilate him/her for a while with BMV (Bag Mask Ventilation) until you figure out the reason of the respiratory compromise. About the Equipment failure check Oxygen, bag mask, ventilator etc. Stomach distension happens frequently on children, pregnant and patients (e.g. neonates) with diaphragmatic hernia.

 

 

 

DRUGS USED IN INTUBATION

 

a)     Succinylcholine (suxamethonium, depolarizing neuromuscular blocker) 1 – 1.5 mg/kg in adults and 1.5 – 2 mg/kg in children.

Contraindications are risk for hyperkalaemia (sabacute burns, sabacute crash injuries, tetanus, upper & lower motor neuron disease, renal failure), hereditary pseudocholinesterase deficiency), glaucoma, penetrating ocular trauma and hypersensitivity to this drug. The 3 below drugs are non deporalizing neuromuscular blockers.

 

b)     Vecuronium 0.1 mg/kg. For rapid intubation give 0.25 mg/kg.

Contraindications are known hypersensitivity to it.

 

c)Rocuronium (rapid onset, short acting) 0.6 mg/kg.  

 Contraindication is known hypersensitivity to it.

 

d)     Pancuronium (longer acting) 0.05 – 0.2 mg/kg.

Contraindications are known hypersensitivity to it and also cardiovascular instability or CHF (congestive heart failure).

 

 Non depolarizing neuromuscular blockage can be reversed with neostigmine or pyridostigmine. Neostigmine dose is usually 2 – 3 mg slowly IV with concomitant administration of atropine (may be administered before neostigmine). Neostigmine may be repeated after 8 – 12 min at dose of 1 – 2 mg. Don’t give more than 4 mg!

 

 

e)     Atropine. Used immediately before the sedative, preventing the vagal bradycardia from succinylholine. Used especially in children and also in adults with bradycardia and before the  2^nd dose of succinylcholine. Dose 0.01 – 0.02 mg/kg (min 0.1 mg). Also used to prevent secretions from ketamine.

 

f)       Lidocaine. Dose 1.5 mg/kg. Given 1 min before intubation, may prevent the elevations of ICP associated with succinylcholine and intubation. Especially helpful on head trauma. Also may protect from laryngospasm and ventricular arrhythmias during intubation.  Etomidate and fentanyl are also useful on preventing elevations on ICP. On head injury ketamine is contraindicated.

 

 

g)     Etomidate is a short acting sedative/hypnotic. Dose is 0.3 mg/kg IV.

 

Contraindications are known hypersensitivity to it, pregnancy and adrenal insufficiency. Etomidate may cause hypotension in the hypovolaemic patient. Etomidate lowers ICP intracranial pressure and it is useful in head trauma.

 

h)      Midazolam is a short acting benzodiazepine. Dose is 0.1– 0.3 mg/kg IV.

 

Contraindications are known hypersensitivity to midazolam or bendodiazepines, pregnancy, acute narrow angle glaucoma. Adverse affects include respiratory depression or arrest. Cardiovascular effects are usually minimal with bigeminy, nodal rhythms and premature ventricular contractions.

 

Antidote to midazolam and the rest benzodiazepines is flumazenil. Initial dose is 0.2 mg IV (0.3 mg in ICU), over 15 sec. May be repeated every 1 min until max total dose of 1 mg (2 mg in ICU). Usual dose is 0.3 – 0.6 mg. In case of recurrence you may give infusion of 0.1 – 0.4 mg/h. Contraindications are lactation, pregnancy, situations that benzodiazepines had been used (e.g. status epilepticus) (in that case the symptoms will recurrent), and also TCA (tricyclic antidepressants) overdose!

 

i)        Fentanyl is a short acting narcotic analgesic. Dose is 1 – 5 mcg (μg)/kg IV.

 

Contraindications are known hypersensitivity to it and pregnancy. It may cause respiratory depression and apnea. However bradycardia and cardiovascular depression are rare. Antidote is naloxone 1 – 4 mg IV. It does not cause histamine release (contrary to other opioids) and also it blunts intracranial pressure response during intubation.

 

j)        Ketamine is a dissociative anesthetic. Dose is 1 – 2 mg/kg. It is very useful for sedation and analgesia on RSI, especially in hypotension! It is also very useful in status asthmaticus.

 

Contraindications are hypersensitivity to it, head injury, severe hypertension, age < 2 months, pregnancy, inceased intraocular pressure and pre/ eclampsia. It may elevate BP and HR (so use with caution on an irritable myocardium). It also increases secretions, so pretreat with atropine. To prevent hallucinations you may combine it with a benzodiazepine.

 

 

 

 

VIII)       ECG & CARDIOLOGY AT A GLANCE

 

ECG

·        Emergency ECG: In Europe Red lead on Right arm, YeLLow lead on Left arm, GrEEn on the lower left chest wall (splEEn).

·        Alternatively, you can check the ECG with the defibrillator’s paddles (quick look)!

·        Emergency defibrillation: 1 electrode below the Right clavicle. The other one in the midaxillary line (at the level of V6 ECG lead or the breasts if woman – but not on breast tissues).

 

·        ECG (on emergency monitor check II lead): Ask your self

1.      Is there any electrical activity?

Initially, increase the GAIN and also assure that the electrodes and the leads are connected properly to the patient and the monitor.

If still no electrical activity, we have asystole (or fine VF). Defibrillation isn’t indicated. Start CPR/ ALS.

2.      What is the ventricular rate?  

QRS = 300 / large squares between RR or

QRS = 1500/ small squares between RR.

If we have irregular QRS we can count on 6 sec (equal with 30 large squares) how many QRS we have and we multiply it with 10 e.g. if we have 21 QRS complexes on the distance of 30 big squares, then the ventricular rhythm is 210 bpm (beats per min).

If pulse in adults is more than 100 we have tachycardia and if <60 bradycardia.

3.      Is the QRS rhythm regular or irregular?

We have irregular QRS on AF (atrial fibrillation). With a caliper, ruler or a small paper estimate the length of R-R (on the paper mark with a pen the tips of the R waves) and compare it with the rest R-R distances.

If QRS are irregular check

a)     Is it totally irregular, with no recognizable pattern of R-R interval? If so, then the most likely rhythm is AF (atrial fibrillation).

b)     Is the basic rhythm regular with intermittent irregularity? A regular rhythm may be made irregular by extrasystoles (ectopic beats). If the QRS of the ectopic beats is narrow (< 0.12 sec or 3 small squares) then the ectopic originates from the atrium or the EV node. If they are wide, then they come from the ventricles or they are supraventricular with a bundle branch block. 

c)     Is there a recurring cyclical variations in the RR intervals? An arrhythmia that occurs intermittely, interspersed with periods of normal sinus rhythm, is described as paroxysmal.

Atrial flutter is characterized by ‘saw – tooth’ appearance of baseline and normal appearance of QRS (but if QRS are wide we have a bundle brunch/ AV block) and its causes are similar to AF. The AV (atrioventricular) node is unable to conduct impulses faster than 200/min, so atrial contraction faster than 200/min leads to impulses failing to conduct, so we have a block which may be 2:1 or 4:1 etc. On 2:1 block the atrial rate of 300/min gives a ventricular rate and pulse of 150 bpm. Using a vagal maneuver (e.g. ipsilateral carotid massage) may unmask the atrial flatter and show on the ECG the ‘saw tooth’ appearance.

4.      Is the QRS complex width normal or prolonged?

ECG has speed 25 mm/sec. One sec is represented by 5 large squares or 25 small squares.

Normally QRS width is less than 0.12 sec or 3 small squares.

A prolonged QRS (> 3 small squares) may occur it may be ventricular tachycardia or supraventricular with bundle branch block! 

5.      Is atrial activity present?

Is there a P? Check leads II and V1.

Normally PR is less than 0.2 sec or 1 big square (5 small squares). If PR is > 0.2 sec (1 large square or 5 small squares) then we have 1^st degree AV (atrioventricular) block. On 2^nd degree AV block Mobitz II we have constant PR distance, however some of P waves are not followed by QRS complexes.

If atrial activity is not present we may have a AF (atrial fibrillation), or atrial flutter or a supraventricular tachycardia (SVT), or a sustained tachycardia.

6.      Is atrial activity related to ventricular activity and, if so, how?

Is every P followed by a QRS? If yes, it is likely that the conduction between atrium and ventricle is intact. If no relationship between P and QRS we may have a complete (3^rd degree) AV block, or a VT (ventricular tachycardia – check for wide QRS), or AF (atrial fibrillation) with or without an AV block (with a block the QRS will be wide).

 

 

Also check if  PR is short with or without δ (delta) wave? If yes, suspectshort PR  syndrome (WPW or LGL).

Call expert! In case of pre- excited tachycardia on WPW most drugs are contraindicated (you can give amiodarone or procainamide or do electrical synchronized cardioversion).  For WPW syndrome check lead V1 for upright delta wave and QRS (type A WPW), or downward delta wave and QRS (type B WPW). WPW is characterized by short PR, wide QRS and delta wave, Differential Diagnosis from LBBB and MI (myocardial infarction)! Another short PR syndrome is Lown – Ganong – Levine which is characterized by short PR, but normal QRS (without delta waves and with normal width).

 

 

Also on ECG:

·        QT normally is 0.35 – 0.44 sec.

·        For P wave look V1 and II leads.

·        VT (ventricular tachycardia) is >_ 3 susceptible ventricular contracts with HR> 100. 

 

 

 

 CARDIOLOGY

 

·       Use paediatric paddles for < 10 Kg (< 1 years old) child.

·        Alternatively you can use the anteroposterior placement of the paddles on an infant, if infant paddles are unavailable.

·        For children < 8 years old use an AED with attenuator, if applicable.

·        For children < 1 years old AED isn’t recommended!

·        Before the defibrillation check if the patient has implanted pacemaker or implantable cardiac defibrillator (ICD) device. Ask the patient/ the relatives/ the GP. Also check for scars. In case of an implantable device, during defibrillation keep the paddles 12 cm away from the device, otherwise electrocution of the heart may occur!

 

·         Bradycardia on children occurs if we have HR<100 on neonates, HR< 80bpm on infants (< 1 year old); and if HR< 60 bpm for > 1 year old (children, adolescents, adults).

·        SVT on children has HR > 220 bpm on infants (< 1year old); and > 180 bpm on children > 1 year old.

·        Sinus tachycardia on children has HR < 220 bpm on infants (< 1year old); and < 180 bpm on children > 1 year old.

·        Don’t use verapamil for SVT because it may cause hypotension.

·        In case a patient with tachycardia (> 100 bpm) is unstable (reduced conscious level, chest pain, systolic BP< 90 mmHg, heart failure) perform synchronized DC shock (with the defibrillator, sedate if conscious, start 120, next 200, next 200 J) up to 3 attempts. Next give amiodarone 300 mg IV (over a central or a large vein) over 10 – 20min, repeat DC shock and give amiodarone 900 mg over 24 h.

·        In case of bradycardia (<60 bpm) if the patient has adverse signs (systolic BP<90, HR<40 bpm, heart failure, ventricular arrhythmias compromising BP) give atropine 500mcg (0.5 mg) IV. If no response, repeat atropine to max of 3 mg, consider adrenaline (2 – 10 mcg/ min) or perform transcutaneous pacing.

Asystole, AV block Mobitz II, complete AV block (3^rd degree) and ventricular standstill > 3 sec, are indications for emergency (transcutaneous or transvenous) temporary pacing (such as a symptomatic severe bradycardia) and not response to atropine. Don’t give atropine in a transplated heart.

·        We have AMI (acute myocardial infarction) with indication for thrombolytic therapy if:

1.      ST segment elevation > 0.2 mV in 2 adjacent chest leads or > 0.1mV in 2 or more adjacent limb leads (ACLS protocol: ST elevation >_ 1 mm in >_ 2 contiguous leads) or

2.      Dominant R waves and ST depression in V1 – V3 leads (posterior infraction) or

3.      New onset (or presumed new onset) LBBB (left bundle branch block).

LBBB is characterized by notched/ slurred R waves (like letter ‘M’) in I, or V5, or V6, and QS wave (like letter ‘W’) in V1. LBBB has also negative (reversed) T on V5 and V6.

To check LBBB remember the acronymioum WiLLiaM: the QRS in V1 looks like letter ‘W’ and in V6 lead it looks like ‘M’. LL in WiLLiaM means Left BBB.

 4. Symptoms < 12h (Fibrinolytics are available max 12 h from the 

 symptoms onset). 

 

 

Check cardiac troponins T & I (high specific for MI, but elevate also in other conditions such as myocarditis, acute or chronic heart failure, sustained tachyarrhythmia, PE pulmonary embolism, acute sepsis and renal failure !) and also CK – MB, AST & LDH.

 

·        Exclude CI (contraindication) for thrombolytic therapy! Absolute contraindications are previous haemorrhagic stroke, ischemic stroke during the last 6 months, CNS damage (and also AV malformation, aneurysm, tumour, surgery) or neoplasm, recent (within 3 weeks) major surgery, head injury or other major trauma. Also CI are active internal bleeding (not menses) or GI (gastrointestinal) bleeding within the last month, known or suspected aortic dissection, known bleeding disorder e.g. haemophilia.

 

Relative contraindications are: refractory hypertension (systolic BP> 180, diastolic BP > 110), TIA (transit ischemic attack) the last 6months, oral anticoagulation, pregnancy or < 1 week postpartum, traumatic CPR (prolonged > 10 min with evidence of thoracic trauma), non compressible vascular (especially arterial) puncture, active peptic ulcer, infective endocarditis, advanced liver disease or advanced cancer or severe renal disease and previous allergic reaction to the thrombolytic to be used. If streptokinase has been given > 4 days previously, give a different thrombolytic (because of antibodies to it). 

 

 

·        Aortic dissection is a contraindication to thrombolytics. Consider it if the patient has high BP and/or marfanoid features or Ehlers – Danlos (may appear with joint & collagen hyperelasticity). Suspect it if asymmetry of carotid or branchial pulses! Other signs are sinus tachycardia, cardiac tamponade (+_ pulsus paradoxus, pericardial rub, hypotension), aortic regurgitation, and/or neurologic abnormalities. CXR (chest X’ Ray) may show widening of mediastinum. Confirm the diagnosis with CT, MRI, ultrasound (esp. transesophagal Echo help’s fast diagnosis!), or aortography.

·        STEMI (ST elevation myocardial infarction) or MI (myocardial infarction) with new LBBB (left bundle branch block) is treated with PCI (percutaneous coronary intervention) and/or thrombolytic drugs (check for contraindications!). Also therapy is with MONA (morphine, Oxygen, nitroglycerine and aspirin), ACE inhibitors (within 24 h, check contraindications!) and β’ blockers (check contraindications).

·        On an ACS measure the electrolytes (esp. potassium K and magnesium Mg) and correct any abnormality.

·        NSTEMI (non ST elevation MI) and UA (unstable angina) are treated with MONA (morphine, Oxygen, nitroglycerine and aspirin), LMWH (low molecular weight heparin) Sc, β’ blockers, aspirin, clopidogrel, GPIIb/IIIa antagonists, but NOT with fibrinolytic therapy!

·        AV (atrioventricular) block on acute anterior MI has usually broad QRS (!) and slow HR, resistant to atropine. Temporary cardiac pacing is usually required.

·        AV block on acute inferior MI has usually narrow QRS and HR is not excessively too slow. Use atropine for symptomatic bradycardia. Complete AV block is usually transient and permanent cardiac pacing is rarely necessary.

·        Ventricular aneurysm is a complication of MI. The presence of thrombus within the aneurysm, or a large aneurismal segment due to anterior MI, warrants oral anticoagulation with warfarin for 3 – 6 months.

·        Right ventricular infarction is confirmed by ST elevation in RV3/ RV4 (V3 and V4 are placed in the RIGHT side of the chest) and/or Echo. Treat hypotension and oliguria with fluids. Avoid nitrates and diuretics, because they may increase hypotension! Transfer to ICU and consider inotropes.

·        Pericarditis is also a complication of MI (manifested with pleuritic positional pain and pericardial rub, perform an ultrasound). Avoid then anticoagulants, because they may cause cardiac tamponade!

·        On severe arrhythmia don’t forget to check electrolytes (potassium, sodium, calcium, and magnesium), urea & creatinine and also consider digoxin toxicity! Also consider thyroid function tests. ABGs may give a fast calculation of potassium.

·        Do not give concomitantly calcium blockers with β’ blockers because may decrease seriously the HR (heart rate).

·        In ACS (ACS (Acute Coronary Syndrome) give MONA (Morphine, Oxygen, Nitroglycerine – initially sublingual spray and also Aspirin 300 mg chewed). Don’t give it with the order of MONA, but with the order of OANM (i.e. Oxygen, aspirin, NTG and last morphine)!

 

 Give oxygen with nasal cannula 1 – 4 L/min in mild cases or for more severe cases 15 L/min with non rebreathing mask with reservoir. Keep SpO2 oxygen saturation > 90%.

 

 Give (if not contraindicated) aspirine 160 – 325 mg

 Contraindications to aspirine are allergy, active peptic ulcer, recent GI gastrointestinal bleeding and other bleeding disorders (e.g. haemophilia).  Use with caution in asthma.

 

 Next give NTG (nitroglycerine) up to 3 SL sublingual tablets of 0.3 or 0.4 mg per tablet or up to 3 SL sprays of 0.4 mg per spray.

 Contraindications to NTG  are Systolic BP <90 (OR > 30 mmHg below baseline), HR < 50 or HR> 100, intracranial bleeding, Aortic stenosis, right ventricular infraction and use of erectile agents and specifically use of Viagra (sildenafil) or Levitra (vardenafil) the past 24 h or Cialis (tadalafil) the past 48 h. 

 

  If pain is not relieved by NTG, give 2 – 4 mg morphine slowly IV over 1 – 5 min. It may be repeated every 5 – 30 min up to 10mg. Antidote is naloxone. 

 CI (contraindications) to morphine are hypersensitivity to it or other opiates, CNS depression (e.g. respiratory depression, hypotension, bradycardia).

 

·        If pulse in adults is more than 100 we have tachycardia and if <60 bradycardia.

·        On defibrillation don’t forget GEL – JOULE –PADDLES. Remove any oxygen mask or nasal cannula or oxygen supply to ventilator at least 1 m (40 inches) far away from the patient, before the defibrillation.

·        CPR: 100 compressions/min (some do it too slow!) and 10 – 12 ventilations/min with rhythm 30 compressions : 2 ventilations, or unsynchronized if the patient is intubated. 

·        Defibrillation on children is 4 Joule/kg.

·        The synchronized cardioversion on children e.g. for unstable SVT, wide QRS tachycardia or VT with pulse is 1^st shock 1Joule/kg, 2^nd 2 Joule/kg, next amiodarone IV/IO and next 3^rd shock.

·        The synchronized cardiovesrion on adults on unstable monomorphic VT ventricular tachycardia with pulse is 75 J, next 120 J, next 150 J and next 200 Joule for biphasic (for monophasic is 100, next 200 J, next 300 J, next 360 J). For unstable  polymorphic VT with pulse is 120J, next 200 J with biphasic or 360 J with monophasic.

 For unstable AF atrial fibrillation, atrial flutter and or PSVT (paroxysmal supraventricular tachycardia) is 30 J, next 50 J, next 75 J and next 120 J with biphasic. With monophasic for AF the dose is 100 J, next 200 J, next 300 J, next 360 J, and for PSVT or atrial flutter with monophasic is 50 J, next 100 J, next 200J, next 300 J, next 360 J.

·        Cardioversion should be performed on an unstable conscious patient only with sedation and should be synchronized (unless VF/ pulseless VT)!

·        Administration of medications (such as adrenaline) on peripheral lines on emergencies should be followed immediately by flush with normal saline (at least 20 ml on adults, 2 – 5 ml on children) and elevation of the extremity for 10 – 20 sec to facilitate drug delivery to the central circulation. 

·        On a patient with a pacemaker you can’t diagnose cardiac ischemia on the ECG!

·        In cardiac problems e.g. acute myocardial infarction the beneficial effect of morphine is due to the release of histamine. For this reason, do not use concomitantly an antiemetic that is antihistamine or phenothiazine drug!!!

·        Rapid (>250 bpm) wide QRS associated with AF – Atrial Fibrilation (on pre- excitation syndrome e.g. WPW syndrome): if patient stable, give IV procainamide or amiodarone (if Congestive Heart Failure, CHF), but DO NOT GIVE digoxin or Calcium blockers or β’ blockers or adenosine, because they may degenerate it to VT (ventricular tachycardia)/VF (Ventricular Fibrillation)! If pt is unstable perform cardioversion!

·        β’ blockers CI (contraindications): heart failure (IV category), bronchospasm/ COPD (with bronchospasm), asthma, AV block/ bradycardia and brittle insulin depended DM (IDDM).

·        Nesiritide is a new drug, BNP analogue, used in NON compensated CHF (Congestive Heart Failure).  

·       On sustained atrial fibrillation or flutter consider anticoagulation before cardioversion. Consider especially anticoagulation on high risk patients (e.g. DM).

 

 AF (atrial fibrillation) and atrial flutter: In acute AF/ atrial flutter (<_48 hours) treat associated illness (usual causes are MI, pneumonia, heart failure, heart ischemia, hypertension, PE pulmonary embolism, mitral valve disease, alcohol, hyperthyroidism, decreased magnesium, hypokalaemia), control ventricular rate and start full coagulation with heparin (5000 – 10.000 U IV) to keep options for cardioversion even if the 48 hour time limit is running out. If the 48 hours period has elapsed, then cardioversion without coagulation is OK only if trans – oesophageal Echo shows no intracardiac thrombus! Cardioversion is electrical and/or with drugs such as amiodarone IV. Alternative (if stable, if not structural heart disease, if not IHD ischemic heart disease, if not WPW) is flecainide (be careful because it is a negative inotropic agent!). On chronic AF give warfarin (always check contraindications such as bleeding diathesis). Rate control drugs in acute or paroxysmal AF are diltiazem or verapamil or metoprolol. For chronic AF use IV β’ blocker or a rate limiting Calcium blocker IV. In paroxysmal AF try a β’ blocker. If it fails try sotalol (if no LV dysfunction and if not increased QT – avoid concomitant use of other drugs that increase QT such as amiodarone) or amiodarone (better if LV dysfunction) and also anticoagulate.   You can also control rate with digoxin, IV.

 

 On AF & flutter use warfarin (target INR 2.5, range 2 – 3) on high risk for emboli: past ischemic stroke, TIA or emboli, age >_75 years with hypertension, DM (diabetes mellitus), CHD (coronary heart disease), peripheral arterial disease, evidence of valve disease or decreased LV (left ventricular) function/ CCF – congestive heart failure ( if unsure perform Echo). 

·        In cardiac problems e.g. acute myocardial infarction the beneficial effect of morphine is due to the release of histamine. For this reason, do not use concomitantly an antiemetic that is antihistamine or phenothiazine drug!!!

·        Flecainide is an alternative drug for rhythm control if there isn’t any structural heart disease (Myocardial Infarction, Heart Failure, structural cardiac abnormality).

·        CI (contraindications) to calcium blockers are AV (atrioventricular) block and perhaps on CHF (congestive heart failure), because of negative inotropic action (especially of verapamil). Give them with caution if LV (left ventricular) dysfunction. Use sustained long acting formula, because short acting increases the risk for ACS/ MI (acute coronary syndrome/ myocardial infarction)!

 

·        Patients with fixed cardiac output (e.g. HOCM hypertrophic obstructive cardiomyopathy or aortic stenosis or mitral stenosis) avoid drugs that may lower BP (such as nitrates or ACE inhibitors).

 

·        When starting an ACE inhibitor withdraw diuretics 24 – 48 hours before, otherwise severe hypotension may occur. They can be restarted once treatment has been initiated (usually in lower dose). Give initially a small dose of ACE inhibitor (e.g. 6.25 mg captopril or 2.5 mg enalapril) only when the patient is on bed, because the initial dose may cause, within 4 hours of the administration, a transient severe fall in BP.

 

·        Verapamil is a negative inotropic agent so avoid it in patients with left ventricular impairment or heart failure, even they are stable! Also, avoid it on 2^nd or 3^rd degree heart block, sick sinus syndrome. Don’t give concomitantly a Calcium blocker with a β’ blocker, because they may cause severe hypotension and bradycardia.  

 

·        Do not combine drugs that prolong QT. Examples of drugs that prolong QT are procainamide, quinidine, disopyramide, sotalol, amiodarone, co-trimoxazole, IV erythromycin, and phenytoin, lithium, neuroleptic drugs and TCAs (tricyclic antidepressants). These drugs must be avoided to be prescribed together because they will prolong QT!

 

 

 

 

IX)           MISC ON EMERGENCY MEDICINE

• To exclude brain problems perform initially a non contrast CT. Also perform LP (lumbar puncture) to exclude meningitis, meningoencephalitis, subarachnoid haemorrhage. However, be cautious on LP contraindications. On subarachnoid haemorrhage it may take 2 – 4 hours for CSF xanthochromia after the bleeding! Increased bilirubin – jaundice, elevated CSF protein and hypercarotonemia may also cause xanthochromia! Don’t forget to take a CSF specimen for a VDRL study. Also measure opening pressure!

• Contraindications to LP (lumbar puncture) are suspected intracranial mass lesion, papilloedema, focal neurological signs, trauma, middle ear pathology, major coagulopathy and septemic signs of meningitis with shock, hypotension, rash (initially may have decreased capillary refill >2sec and cold hands & feet). Be aware of the above contraindications, because if you perform a LP the patient may die from herniation!

• On poisoning don’t forget decontamination, skin and eyes cleaning, clothes removal, gastric lavage, activated charcoal and/or whole bowel irrigation. Also think antidotes!

·        On patients with type II respiratory failure you should usually give initially 24% and if no improvement 28% oxygen! These patients have hypoxemia (low oxygen concentration) and hypercapnia (increased CO2). An example is the COPD patients. These patients are chronically hypoxic and it is hazardous (with respiratory suppression and even apnoea!) to raise their oxygen concentration to normal. An oxygen saturation around 85% may be adequate! If no improvement, consider doxapram stimulation, or NIPPV (assisted ventilation – Non Invasive Positive Pressure Ventilation) and if still no improvement consider intubation and mechanical ventilation. Seek early an expert’s advice!

Causes of type II respiratory failure include asthma, COPD, pneumonia, pulmonary fibrosis, obstructive sleep apnoea, sedative drugs, CNS (central nerve system) tumour, CNS trauma, cervical cord lesion, diaphragmatic paralysis, polio (poliomyelitis), myasthenia gravis, Guillain Barre, flail chest (trauma) and kyphoscoliosis.

On COPD patients start oxygen at 24 – 28%. Check ABGs (arterial blood gases). Some patients rely on their hypoxic drive to breathe, so oxygen more than 30% may lead to reduced RR (respiratory rate) and hypercapnia which will cause decreased conscious level and respiratory failure with cardiac arrhythmias. So, in case on ABGs is evidence of CO2 retention, start with 24 – 28% oxygen in the above patients and reassess after 30 min. In case the patient has not evidence of CO2 retention, then start with 28 – 40% oxygen and monitor next the ABGs.

 

·        Avoid 5% dextrose D5W fluids on patients with stroke. Avoid normal saline on patients with liver failure. Avoid RL (Ringers Lactated) on patients with hypothermia. 

 

·        Ketamine’s CI (contraindications) are head injury, allergy on this agent, pregnancy and also severe hypertension. It is useful in status asthmaticus. Also it can be used out of hospital and in low doses is analgesic with minimal cardiovascular compromise.  Ketamine is dissociative anaesthetic. To avoid hallucinations you may combine it with a benzodiazepine.

·        Etomidate is a useful anaesthetic on head trauma. On RSI (rapid sequence) also use lidocaine on head trauma. Barbiturate coma is used in severe increased ICP (intracranial pressure). Also on children use atropine on RSI to prevent bradycardia. On a patient with hypotension first control hypotension (e.g. with fluids/ blood). Most anaesthetics will lower BP, however consider giving midazolam or ketamine (some say that etomidate is safe, however in fact it may lower BP in hypovolemic patients). Never give propofol or barbiturates  in hypotension.

·        On status epilepticus or coma of unknown etiology, give glucose (50 ml dextrose 50% IV over 5 min, via a large vein!), thiamine (in suspected malnutrition/alcoholics 100 mg IV slowly) and naloxone (0,4 – 2mg IV). Also consider flumazenil (IV bolus 0.2 mg followed by further bolus of 0.1 mg every 2 min until the patient is rousable) if severe benzodiazepine overdose (e.g. coma) is suspected (but don’t give it as a routine, because it may cause intractable seizures especially on chronic benzodiazepine abusers).  50% dextrose is irritant to veins, so alternatively you can give 20 – 30 gr dextrose IV e.g. 200 – 300 ml of 10% dextrose. Alternative to glucose is glucagon 1mg IV/IM, but it will not work in drunk patients! On children (with documented hypoglycaemia) the dose is 5 – 10 ml/kg of 10% dextrose (5 ml= 0.5 G glucose).

 

·        On status epilepticus give initially lorazepam 2 – 4 mg (0,1 mg/kg) IV every 3 – 4 min (max 8 mg). The above doses involve adults.

·        Fosphenytoin is safer than phenytoin and can be given more rapidly.

·        Phenytoin is given on status epilepticus via a large peripheral vein or a central vein (it can cause venous irritation). Phenytoin can cause cardiovascular and CNS depression. Don’t give it on patients with 2^nd degree or complete heart block. On status epilepticus give phenytoin IV (not IM, its unreliable) 15 mg/kg slowly (less than 50mg /min). Also have continued cardiac monitoring.

·        Hyperthermia has many causes including drugs (cocaine, amphetamines, etc), poisoning (salycilates, anticholinergics, TCAs and other antidepressants), halothane (anesthetic), neuroleptics (malignant neuroleptic syndrome), heat stroke, infection/ sepsis, hyperthyroidism, head trauma, status epilepticus/ prolonged seizures, subarachnoid haemorrhage. As antidote think dantrolene (e.g. for halothane or neuroleptics). Do not forget cooling techniques such as using a fan, sponge with cool water (e.g. face, axillae, ingual areas), cold fluids IV/ peritoneal/ pleural or via Foley – urinary catheter, extracorporeal circulation (by pass)!

·        Elevate limb in case of haemorrhage, burns or oedema.

·        Don’t forget on trauma/ burns to remove watch & jewellery!

·        Extremity examination (e.g. on trauma or burns) includes pulses, capillary refill (normal less than 2 sec on pressing the nail pulp 5 sec), paresthesias, vibratory sense, pinpoint sense. Also in high suspicion perform Doppler!

·        Do not forget Td (tetanus prophylaxis) and perhaps antibiotics for trauma, burns, frost bite, human or animal bites, stings, snake bites, insect bites.

·        Don’t forget tetanus prophylaxis on pregnant!

·        Don’t forget to give anti D immunoglobulin to Rh negative mothers in hemorrhage, chorionic villus sampling, external cephalic version, antepartum hemorrhage, amniocentesis (and other uterine procedures such as fetal blood sampling), abdominal trauma, ectopic pregnancy, intrauterine death and stillbirth, spontaneous abortion followed with instrumentation, spontaneous complete abortion after 12 weeks gestation, threatened abortion after 12 weeks, threatened miscarriage before 12 weeks (if viable fetus, heavy or repeated bleeding and abdominal pain) and all surgical or medical terminations of pregnancy. Perform a Kleihauer test! In case of ABO incompatibility the Kleihauer test may be negative.

·        Extravasation of IV drugs such as barbiturates, phenytoin, vasopressors (esp. noradrenalin), glucose (e.g. 50% dextrose) and chemotherapeutics (e.g. doxorubicin), may cause arterial spasm and tissue necrosis! Consider that many drugs need central vein or at least a large peripheral vein plus saline flushing.

·        To access a vascular injury (trauma, crash/ compartment syndrome, electrocution, fracture) check the extremity for pulses, murmurs/bruits, paresthesias, cool/pale color and swelling. Use Doppler USS (ultrasound), contrast CT or official angiography (arteriography).

·        Vascular injuries of neck include 3 zones that are defined by the clavicle, the cricoids cartilage and the angle of the mandible. In case of rapid expanding hematoma perform intubation.

 Zone I trauma needs surgical exploration!

 Zone II trauma needs surgical exploration or imaging first!

 Zone III trauma needs imaging first. A ENT specialist will decide.

·        Avoid saline on patients with decompensated liver failure (e.g. ascites, oedema) because it worsens ascites (patients have high body sodium despite the low serum sodium). Use instead salt poor albumin or whole blood for resuscitation and 5% dextrose for maintenance.

 

 

 

NOTE

All the medical procedures and drug administration mentioned in this text should be followed only under a senior doctor’s consultance.

 

NOTE

About PE (pulmonary embolism), negative D - Dimers are helpful and may rule out only low risk patients. On high risk patients perform a spiral CT or V/Q scan.

 

BIBLIOGRAPHY FOR EMERGENCY & ACUTE MEDICINE

1) Stone C.K., Humphries R.L., Current Diagnosis and Treatment in Emergency Medicine, McGraw Hill - LANGE, 6th edition, 2008.

2) Wyatt J.P., Illingworth R.N., Graham C.A., Clancy M.J., Robertson C.E., Oxford Handbook of Emergency Medicine, Oxford Medical Publications, 3rd edition, 2006.

3) Ramrakha P., Moore K., Oxford Handbook of Acute Medicine, Oxford Medical Publications, 2nd edition, published 2004, reprinted 2005.

4) ALS (Advanced Life Support), European Resuscitation Council, 5th edition, The Image Factory, Belgium,2006.

5) EPLS (European Paediatric Life Support), European Resuscitation Council, 3rd edition, The Image Factory, Belgium, 2006.

6) Llewelyn H., Aun Ang H., Lewis K., Al – Abdulla A., Oxford Handbook of Clinical Diagnosis, Oxford Medical Publications, 2006.

 

7) Thomas J., Monaghan T., Oxford Handbook of Clinical Examination and Practical Skills, Oxford Medical Publications, 2008.

8) Richards D., Aronson J., Oxford Handbook of Practical Drug Therapy, Oxford Medical Publications, 2008.

9) ATLS (Advanced Trauma Life Support), American College of Surgeons – Committee on Trauma, Students Course Manual, First Impression, 7th edition, 2002.

10) PHTLS (Prehospital Trauma Life Support, basic & advanced), Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in association with The Committee of Trauma of the American College of Surgeons, 5th edition (revised), Mosby, inc, 2003.

11) ALSO (Advanced Life Support in Obstetrics), American Academy of Family

Physicians, 4th edition (revised), 2006.

12) Kasper D.L., Braunwald E., Fauci A.S., Hauser S.L., Longo D.L., Jameson J.L., Harrison’s Manual of Medicine, McGraw – Hill, 16th edition, 2005.

13) Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.

14) Longmore M., Wilkinson I., Turmezei T., Kay Cheung C., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 7th edition, 2008.

15) Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.

 

16) ACLS (Advanced Cardiac Life Support), American College of Emergency Physicians, Study Guide, 2^nd edition, Jones and Bartlett Publishers, 2007.