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.
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
