HO medical - EMERGENCY management

Some of the notes seniors passed down which is very useful. I edited and add in some points i get during my posting as well. 

Big thumbs up to them who prepared the list and Thank You💕💖

1. Hypokalemia
2. Hyperkalemia
3. Hypoglycemia
4. Hyperglycemia
5. Chest Pain
6. Hypotension
7. Asystole
8. VT
9. Atrial Flutter
10. SVT
11. Fit
12. GCS drops
13. Aggressive behavior
14. Nausea/ vomiting
15. Diarrhea
16. Hematemesis
17. Shortness of Breath
18. Other electrolytes
19. UGIB
20. Anaphylaxis
21. Dengue

1. Hypokalemia (K+ <2.5)

- ECG STAT to look for hypokalaemic changes, check whether patient symptomatic.

- 1g KCL in 100cc NS in 1 hour

                or

    2g KCL in 200cc NS over 2hour (according to K+ level)

- with continuous cardiac monitoring

- Add KCl in drip (if patient on drip), mist kcl 15mls tds OR T. slow K 600mg/1.2g OD

- Check TFT, RP, VBG, UFEME

- Monitor v/s

- ECG (any ecg changes)

- Inform MO stat if symptomatic

- Off potassium supplements once K+ >4

- Repeat RP 1 hour post correction

- Daily RP until K+ stable

     

 2. Hyperkalemia (K+ >5.2)

- ECG STAT to look for hyperkalaemic changes, check whether patient symptomatic

- Off potassium supplements

- To serve lytic cocktail 

(10cc of 10% calcium gluconate in 10 minutes - slow bolus with cardiac monitoring + 50cc D50% glucose + 10 unit actrapid)

- If still high, repeat lytic cocktail 

Peritoneal dialysis?? Haemodialysis??

- T. kalimate 5-10g TDS

- Off kalimate once K+ <5

- Repeat RP 1 hour post correction

- Monitor RP daily till stable

3. Hypoglycemia (Reflo <4)

- Omit insulin

- Encourage patient to take orally (sweets, bread with jem, milo)

- If too low (<3.5) with symptoms, give 20-50cc D50% then repeat reflo 30mins

- If reflo 4-6, half the dose of next insulin

4. Hyperglycemia (Reflo >12)

- Serve S/C 6-10 unit actrapid STAT (depends on reflo) if patient not on insulin/insulin served earlier on.

- If patient already on insulin and not served yet, to serve usual dose.

- If persistently high despite insulin to start top up regime based on BMI. Take VBG, lactate and urine ketone dipstick TRO DKA.

5. Chest pain

- ECG STAT.

- If suspected ST elevation, to inform MO for referral to cardio KIV thrombolyse.

- S/L GTN, maximum 3 times. If persistent pain to start IV morphine with IV maxolon. If pain persists despite morphine to start IVI GTN.

- Oxygen

- Aspirin crush 300mg, Plavix 75mg

- Take cardiac enzymes(CK) and Trop T as baseline, to repeat at 6 hours later with ECG

6. Hypotension

- Determine cause (Septic, hypovolaemia, cardiogenic etc)

- Repeat manual BPx2 first to confirm

- Run 1 pint (250cc) NS fast 15-30minutes

     if no contraindication (watchout if patient have ROF).

     If still low, for another try.

- Inform MO is persistently low, KIV start IVI noradrenaline and adjust accordingly

- Regular BP monitoring (ideally every 15mins)

- KIV Gelafundin (colloid) @ inotrope

- Grey branula at neck/femoral line

- IV Noradrenaline 0.2mcg/kg/min

- KIV add another intropes if low despite high dose 1st intropes

7. Asystole

- Inform MO and call CRASH 

- Prepare Resus trolley and intubation kit

- Manual bagging 15L/m (even for ventilated patient)

- Straighten bed and commence CPR

- Transfer to acute bay

- Vital signs, reflo and cardiac monitoring

- Insert 2 large bore branula at least green at big veins (femoral/neck/cub fossa) and take all routine bloods including ABG, reflo and cardiac enzymes (run urgently)

- Run 1 pint NS fast if no contraindications

- Prepare IV adrenaline (1mg every 5 mins 3 cycles)

                IV Atropine 1mg every 3-5 mins (3x)

- If patient survive,

•     take ABG post intubation,
•     ECG,
•     septic workup (if infection is suspected),
•     D dimer (if PE is suspected)

- Keep BP >90/60, MAP >60.

- Insert CBD and strict IO monitoring (Keep U/O > 30cc/hr)

- Start inotropes if low BP

- IV panto 40mg OD to prevent gastric ulcer

- Insert Ryles tube, KIV start feeding later (refer to dietitian)

8. VT

- Inform MO

- Prepare resus trolley

- Vital signs and continuous cardiac monitoring

- If pulseless, for defib and 5 cycles of CPR. Repeat if unsuccessful.

- If pulse present but hemodynamically unstable, for urgent cardioversion and IV

lignocaine

- If pulse present, for IV amiodarone

9. Atrial flutter

- Inform mo

- Vital signs and continuous cardiac monitoring

- If hemodynamically unstable, for urgent DC shock and rate control meds.

9a. Fast AF

- Nasal prong O2 (NpO2)

-Continuous cardiac monitoring

- IV Digoxin (if HF) 0.25mg every 2hr, up to 1.5g within 24hr

- Metoprolol 25mg/100mg BD (absence of HF)

- KIV IVI Amiodarone 300mg over 30mins

- KIV cardioversion if hemodynamic not stable

>10. SVT

- Inform MO stat

- Vital signs monitoring and continuous cardiac monitoring

- If hemodynamically unstable, for cardioversion

- If stable for carotid massage (if no bruit) dan valsalva maneuver

- If persistent, need to give IV adenosine 6mg and flush with 20cc NS.

• then 12mg then 12mg
• if not reverted, IVI amiodarone 300mg over 30 minutes

Contraindicated for Asthma patient.

• Second bolus 12mg can be given after 5 mins with NS flush.

- If persist consider another drug (verapamil etc)

11. Fit

- Remove patient from dangerous objects

- Prepare IV diazepam 5mg STAT, if persist repeat dosage (max 3 doses with 10 mins gap)

- Put on HFM 10-15L/min

- Vital signs monitoring

- Put patient on left lateral position

- If fit persist, KIV IV phenytoin (loading and maintenance)

- Repeat bloods including electrolytes, KIV for CT brain/ LP

- If resolve, continue vitals monitoring, fit charting, - GCS charting

12. GCS drops

- Vital signs and reflo

- Inform mo

- Transfer to acute bay

- Refer CRASH KIV for intubation

- Determine cause

- Insert line and repeat bloods including ABG, septic workup Request for CT brain

-Treat according to cause

13. Aggressive behaviour

- Approach calmly

- Ask help from security guards or male staff

- IV haloperidol 5mg STAT

- 4 points restraints

- Repeat bloods TRO causes

- Refer psych if persistent aggressive behaviour

14. Nausea/vomiting

- IV maxolon 10mg STAT

- Start ORS

- If significant loss, start IVD maintenance

- Monitor RP

- Find the cause

15. Diarrhea

- ORS per purge

- KIV lomotil

- If significant loss, start IVD maintenance

- Monitor RP

- Find the cause

16. Hematemesis

- Inform MO

- Rule out UGIB (inspect vomitus)

- PR examination to look for melena

- Vital signs (look for compensated or decompensated shock)

- If significant blood loss to insert 2 large bore branula and repeat bloods

- IV tranexamic acid 1g STAT and 500mg TDS, IVI pantoprazole 8mg/hr.

17. SOB

- Examine lungs, check vitals

- Determine cause, repeat CXR if needed

- Refer CRASH if necessary (SpO2 unable to maintain with oxygen

supplementation or clinically worsening SOB)

- If intubated, check if ETT dislodged or too deep (if yes, to readjust)

- Start ocygen supplementation (according to SPO2 and clinical). If known case of

COPD to start VM.

- Watchout for respi distress, keep SpO2 >95%

- If significant SOB with Sp02 drop, take ABG, FBC (TRO anaemia), Cardiac

enzymes, Trop I (ACS is suspected), D dimer (TRO PE)

- If ronchi (asthma) - Neb AVN STAT, IV hydrocortisone 200mg STAT (if moderate

to severe). Reassess post neb, if worsening can try back to back neb.

- If PE is suspected, to take D- dimer KIV CTPA. Chest referral, KIV start clexane

- If pneumonia (HAP/aspiration) is suspected, to take septic workup and CXR and

start antibiotics.

- If fluid overload, to serve IV frusemide 20mg STAT (to check BP before serving),

adjust IVD and fluids intake

- If pleural effusion, KIV for tapping

>18. Other electrolyte deranged management

• Hypomagnesaemia:
• IVI MgSO4 1 ampule in 100cc NS over 1 hour
• Hypocalcaemia:
• - ECG
• - IVI CaCO3 1 ampule in 100cc NS 
• over 1 hour @
• - IVI Calcium Gluconate 1 ampule in 
• 100cc NS over 4 hours
• * Mild: Tab CaCO3 500mg BD/TDS

• Hypophosphatemia:
• - IVI KH2PO4 1 ampule in 100cc NS 
• over 4 hours

• Hyponatremia:
• - If no ROF, give IV drip NS 3-4  pints/24 hour

19. Upper GI Bleeding:

- 2 large bore branula 

- Run fluid 

- FBC, Coag profile, GXM 4pint blood

- IV Pantoprazole (PPI) 80mg stat 

and IVI 8mg/hr

- Inform MO

20. Anaphylaxis:

- IV Hydrocortisone 200mg

- IV Piriton 10mg

- IV Maxolon 10mg stat & TDS

- Oxygen 

- IV fluid

- If BP drop,IV/IM Adrenaline 1:1000

21. Dengue1:

- Dengue fever day __, __ warning signs, in __ phase (if defervescence phase point taken at__˚C), V/S, on drip __cc/kg/H, latest FBC reviewed. -

- Next FBC at __am/pm, cont drip __cc/kg/h

* WARNING SIGN: 

- Tender liver - Abdominal pain

- Mucosal bleed

- Persistent vomiting ≥3x + diarrhea  ≥3x/24 hr 

- Fluid accumulation(ascites/pleural E)

- Restlessness/altered conscious level

- Inc haematocrit, reduced platelet

Dengue2:

- N haematocrit: Male: >45; Female: >40

- Raised haematocrit in active smoker & obese pt is normal

- If pt took PCM, take Temp > 6hours after that, to count defervescence phase (< 38˚C)

- Dengue IgM & IgG positive high risk DHF (If systemic bleeding, give IV Traxenamic acid 500mg TDS)

- Ideal Body Weight in Dengue: 

Male: (Ht-152.4) x 0.91 + 50

Female: (Ht – 152.4) x 0.91 + 45