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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2738_Библиотеки_им_академика_М_И_Перельмана
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What to establish from the history
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• What taken, how much and when?
• Route of exposure
• Whether exposure is a single overdose, staggered or chronic
• Any other agent(s) involved, including co-agents (e.g. alcohol, paracetamol)
Investigations
Chapter 17: Emergency presentations 215
1. ABCDE – check for other wounds/
injuries, check pupils & GCS
2. ECG
3. Urine sample – drugs screen
4. Bloods – FBC, U&Es, LFTs, ABG +
specific toxin levels (e.g. salicylate)
Management
1. Stabilise with ABCDE
2. Consider activated charcoal
(reduced absorption if <1h)
3. Consider antidote if available
4. Increase elimination – multiple
doses of activated charcoal or urine
alkalinisation (salicylates) or dialysis
Poison Effects Management
Alcohol • Hypoglycaemia
• Coma
• Respiratory failure
Acids/alkalis • Inflammation & ulceration of GI tract • Early endoscopy
Ethylene glycol
(antifreeze)
• Tachycardia
• Metabolic acidosis
• Renal failure
Paracetamol 24–48h: abdo pain, vomiting
3–5d: liver failure (deranged LFTs, coagulopathy)
Aspirin
(salicylates)
Within 4h:
• N&V, drowsiness, blurred vision, tinnitus
• Hyperventilation (respiratory alkalosis →
metabolic acidosis)
• Acute renal failure
5. Monitoring & psychiatry
assessment
6. Consider discussion with Poisons
Centre in complex cases
• Check blood alcohol levels
• Monitor blood glucose (IV glucose if need)
• Ventilatory support
• Haemodialysis
• Measure plasma paracetamol levels after 4h
• Activated charcoal if <1h
• Measure plasma salicylate conc. (every 2h)
• Activated charcoal if <1h
• Urine alkalinisation
• Rapid BG, blood gases, Cr, FBC, ECG
• Supportive Tx: fluids, dialysis etc.
*use paracetamol nomogram to
determine if NAC is required. NAC is
started in all staggered overdoses.
Iron Initial: D&V, haematemesis, melaena, gastric ulcers
Methadone /
opioids
TCAs • Tachycardia, arrhythmias, hypokalaemia, wide QRS
BZDs • Sedation/drowsiness/coma
4
www.toxbase.org
Latent period
6h later: drowsy, coma, shock, convulse, liver fails
• Drowsiness, pinpoint pupils
• Hypotension, bradycardia
• Resp depression (respiratory acidosis)
• Dry mouth, blurred vision, urinary retention
• Agitation, confusion, convulsions, dilated pupils
• Respiratory depression
• Respiratory depression
• Hypotension, hyporeflexia
• Measure serum iron levels
• Gastric lavage if <1h not charcoal
• Activated charcoal even > 1h
• IV fluids
• Correct metabolic acidosis & hypokalaemia
• Ventilatory support
• Activated charcoal even if >1h
• Diazepam if convulsions
• Ventilatory support
• Consider IV flumazenil
Critical illness
216 Chapter 17: Emergency presentations
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5
Initial management
In all cases of seizure, must consider a
serious cause
• Infec tion / viral encephalitis
• Tumour
• Large stroke
• Venous sinus thrombosis
• Toxins (drugs/alcohol)
• Metabolic (hypoglycaemia/calcaemia/
magnesaemia)
• Autoimmune diseases
1. Secure airway if needed due to low GCS & give O
2
2. IV access to take bloods (FBC, U&Es, Ca, LFT, eGFR, ABG, AED levels)
3. Take a CBG: Don’t Ever Forget Glucose (r/o hypoglycaemia)
4. Confirm it is an epileptic seizure (Hx, features, blood results etc.)
Investigations
• Brain scans
• Lumbar puncture
• Bloods / septic screen
• AED levels
• Toxicology screen
Manage convulsion
1. IV lorazepam 4mg → repeat in 5–10min (10mg buccal midazolam / rectal
diazepam = 1st line in community)
2. Alert a senior for support
3. IV AED (e.g. sodium valproate / phenytoin / levetiracetam) → check Trust
guidelines
4. Alert critical care services (ICU/anaesthetics) for airway support
&escalation of care
5. Intubation & sedation
Status epilepticus6:
• A seizure lasting ≥5min OR
• >1 shorter seizure without resolution
between OR
• Repeated seizures for ≥30min
Ensure all AEDs are prescribed correctly
Critical illness
Obtain Hx including
IV lorazepam
medicationgiven so far
IV lorazepam
CALL FOR SENIOR HELP!
IV phenytoin/valproate/
GET AN ANAESTHETIST
Mechanical ventilation
levetiracetam
ICU & intubation
Transfer to ICU
Fig. 17.3
Post-seizure care
1. Start maintenance AED: valproate or levetiracetam
2. Continue patient’s current AEDs: if no oral route, give IV or via NG tube
3. Refer to neurology
5
Association of Anaesthetists (2022) Management of status epilepticus
6
Epilepsy Foundation definition of status epilepticus (www.epilepsy.com)
Septic shock: subset of sepsis where particularly profound circulatory, cellular
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• Signs: sepsis and hypotensive (<90mmHg) despite fluid resus and lactate
>2mmol/L
• Mx: SEPSIS 6 + vasopressors in ICU
Neutropenic sepsis: time-critical sepsis occurring in immunocompromised
• Signs: neutrophils <0.5×109/L ± usual signs (often occult)
• Mx: ABCDE & SEPSIS 6 ASAP (if suspect, don’t wait for blood results)
Chapter 17: Emergency presentations 217
20–24% mortality
When to trigger sepsis screen / assessment for red ags?
NEWS2 ≥5 combined with ≥1 of:
• Age >75y
• Impaired immunity (chemo, DM)
• Recent invasive procedure (surgery, trauma)
• Broken skin (indwelling lines, IVDU, cuts/burns)
Or otherwise unexplained concern from staff/carer:
• looks very unwell
• unexpected deterioration
• not responding to interventions
Risk stratication of sepsis
1. SOFA/qSOFA: official diagnostic criteria (increase of ≥2 from baseline)
2. Red ag criteria: not ‘formal diagnosis’ but suggests high likelihood of organ
dysfunction (pragmatic approach)
Red flags (any = start SEPSIS 6) Amber flags (any = need further review/Ix)
• Objective evidence of new/altered
mental state
• SBP ≤90mmHg
• HR ≥130bpm
• RR ≥25bpm
• Needs O2 for PaO2 ≥92% (≥88% COPD)
• Non-blanching rash / mottled skin
• Lactate ≥2mmol/L
• Oliguria <0.5ml/h or anuria for 18h
• Relatives concerned over mental state/
functioning
• SBP 91–100mmHg
• HR 91–130bpm
• RR 21–24bpm
• Temperature <36°C
• Clinical signs of wound infection
• Immunosuppressed
• Trauma/surgery in past 8w
Common sources of sepsis & associated
signs/symptoms:
• Pneumonia – consolidation, SOB, productive
cough
• UTI – dysuria, urine dip
• Abdomen – tenderness
• Skin / soft tissue, bone/joint – warmth,
swelling
Risk stratificaton tools help determine initial
management but do not replace clinical judgement
qSOFA score
Hypotension SBP <100
Altered mental state
Tachypnoeic >22
Managing sepsis7
SEPSIS 6 within 1h
1. Ensure senior clinician attends
2. Oxygen if sats <92%; aim for 94–98% (88–92% in known CO2 retention)
3. IV access: take bloods: culture ×2, glucose, lactate, FBC, U&Es, CRP, clotting;
consider sampling other sites
4. IV antibiotics: appropriate dose broad-spectrum therapy
5. IV fluids: bolus of 500ml; repeat if clinically indicated up to maximum 20ml/kg
6. Monitor: use NEWS2; urine output (catheterise) & fluid balance chart; repeat
ABG/VBG regularly if abnormal
7
NICE (2016, updated 2017) Sepsis [NG51]
Critical illness
218 Chapter 17: Emergency presentations
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General signs of shock
BP = CO × SVR
CO = StV × HR
Preload Compliance Contractility
Type of shock Hypovolaemic Cardiogenic Obstructive Distributive
Causes Reduced preload:
Compensation
Clinical signs Cool & mottled
Management High flow (15L) O2 via non-rebreather mask
*250ml only if risk of
fluid overload (renal/
heart failure, frail)
Afterload
1. Low BP
2. Signs of perfusion
3. Raised lactate
• Haemorrhage
• Dehydration
• GI losses
SVR by vasoconc.
HR
• Dehydration
sunken eyes, turgor
etc.
→ Fluid replacement
Like-for-like (blood/
saline)
• 500ml bolus*
• Further volume
given dependent on
clinical effect
cap refill
cool peripheries
RR
urine output
altered mental state
Types of shock
Pump failure:
• Arrhythmias
• Cardiomyopathy
• MI
SVR by vasoconc.
( contractility or HR)
• Fluid overload if HF
( JVP, crackles, RR)
General signs: B P, CRT, UO, altered mental state (+ lactate)
→ Depends on cause
• HR = cardioversion
• HR = chronotropes
• contract =
inotropes
Avoid fluids
Obstructed flow:
• Tension pneumothorax
• Massive PE
• Aortic dissection
• Cardiac tamponade
SVR by vasoconc.
HR
• Distended neck veins / raised JVP
Early IV access
Treat cause
→ Fluid therapy (carefully)
→ Remove obstruction
• Tension pneumothorax = needle
decompress & chest drain
• PE = thrombolysis
• Cardiac tamponade = pericardiocentesis
• Aortic dissection = surgery
Reduced SVR:
• Sepsis
• Anaphylaxis
• Neurogenic
(SC injury above T6)
HR
Contractility
• Fever if septic
• HR if neurogenic
• Rash if anaphylactic
→ Replace fluids
→ Vasopressors
± inotropes
Critical illness
Management of shock8
1. Monitoring
• ABCDE assessment (regularly repeat)
• Standard observations (RR, SpO2, HR,
BP, temp., AVPU)
• Hourly urine output (insert catheter)
2. Urgent investigations
• Blood gas (lactate, acid–base status)
• Bloods (FBC, U&Es, CRP, coag screen,
cultures, troponin/BNP)
• ECG
8
Frost PJ, Wise MP (2012) Early management of acutely ill ward patients. BMJ, 345:e5677
Advanced monitoring:
• Central venous pressure (CVC)
• Invasive BP (arterial line)
• Continuous cardiac monitoring
Other Ix:
• Mast cell tryptase if suspect
anaphylaxis
• X-match + G&S if haemorrhage
Classifying haemorrhagic shock
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Chapter 17: Emergency presentations 219
Class Blood loss
(ml)
Blood
loss (%)
Pulse rate
(/min)
Blood
pressure
Resp
rate
(/min)
Urine
output
(ml/h)
CNS /
mental
state
I <750 <15 <100 Normal 14–20 >30 Slightly
anxious
II 750–1500 15–30 100–120 Normal 20–30 20–30 Mildly
anxious
III 1500–2000 30–40 120–140 Decreased 30–40 5–15 Anxious/
confused
IV >2000 >40 >140 Decreased >35 Negligible Confused/
lethargic
Dehydration & hypovolaemia
Reduced intake – cognitive impairment e.g. dementia, children
Increased loss – exercise, hot environment, fever, vomiting, diarrhoea, diuretics,
high output stoma
Mild Moderate Severe
Symptoms • Thirst
• Light-headedness
• Nausea
Signs • Possible postural
hypotension
Management9Encourage oral
intake
• Apathy/tiredness
• Dizziness, headache
• Muscle cramps
• Dry tongue
• Sunken eyes
• Reduced skin turgor
• Postural hypotension
• Tachycardia
• Oliguria
Oral rehydration solution
IV fluids if cannot take
fluids orally
• Profound apathy &
weakness
• Confusion → coma
• Peripheral vasoconstriction
• Cold extremities
• Tachycardia
• Prolonged capillary
refill time
• Oliguria/anuria
• Hypotension/shock
IV fluids*:
1. Resuscitation bolus –
reassess after bolus
2. Maintenance
(total 25–30ml/kg/h)
Hypotension = late sign
9
NICE CKS (2020) Gastroenteritis + NICE (2013) Algorithms for IV uid therapy in adults
Critical illness
220 Chapter 17: Emergency presentations
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Types of arrhythmia
• Tachyarrhythmia e.g. VF, VT, SVT, fast AF
• Bradyarrhythmia e.g. heartblock, sinus node dysfunction
Management
1. Commence continuous cardiac monitoring: via an automated external
defibrillator & obtain a 12-lead ECG
2. Other investigations for cause: FBC, U&Es, blood gas
Features of instability:
1. Shock
2. Syncope
3. Myocardial infarction
4. Severe heart failure
3. Management depends on type:
• If no pulse = cardiac arrest protocol (shockable & non-shockable rhythms)
• If pulse but unstable = synchronised direct current cardioversion (DCC)
• If pulse and stable = pharmacological Mx or temporary transcutaneous
pacing (refractory bradycardia)
Atropine 500mcg IV
Satisfactory response?
No
Interim measures:
• Atropine 500mcg IV (repeat up
to 3mg)
• Isoprenaline 5mcg/min IV
• Adrenaline 2–10mcg/min IV
OR
Transcutaneous pacing
Yes / unstable
Yes
Yes No
ABCDE
O2 & IV access
Monitor: ECG, BP, SpO
2
Identify & treat reversible causes
Any adverse features?
Shock / syncope / MI / heart failure
No / stable
Risk of asystole?
• Recent asystole
• Mobitz II AV block
• Complete heart block + broad QRS
• Ventricular pause >3sec
Observe
Critical illness
Transvenous pacingSEEK EXPERT HELP
10
Resuscitation Council UK (2021) Adult bradycardias
Fig. 17.4
NARROW COMPLEX TACHYCARDIABROAD COMPLEX TACHYCARDIA
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Irregular
Chapter 17: Emergency presentations 221
Probable AF:
1. Rate: BB or CCB
2. If HF: digoxin/amiodarone
not restored
Sinus rhythm
SEEK EXPERT HELP
Possible ATRIAL FLUTTER
• Beta-blocker
ABCDE
& IV access
2
O
2
Monitor: ECG, BP, SpO
Identify & treat reversible causes
Any adverse features?
Shock / syncope / MI / heart failure
Yes / unstable
No / stable
Is QRS complex narrow? (<0.12s)
YesNo
Regular
Regular
If ventricular
• Vasovagal manoeuvres
• Adenosine 6mg IV (up to 3×)
• Continuous ECG monitoring
tachycardia:
amiodarone 300mg IV
restored
Sinus rhythm
Treat as regular
SVT (now with BBB):
If previously confirmed
Probable RE-ENTRY SVT:
• Record 12-lead ECG
(adenosine)
narrow complex tachy
• Give adenosine if recurs
Up to 3 attempts
Synchronised DC shock
Amiodarone 300mg IV
& repeat shock
SEEK EXPERT HELP
Irregular
Possibilities:
⇒ AF with BBB
(give magnesium)
⇒ Polymorphic VT
Fig. 17.5
Resuscitation Council UK (2021) Adult tachycardias
11
Critical illness
222 Chapter 17: Emergency presentations
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Causes of cardiac arrest:
Hypoxia
Hypo-/hyperthermia
Hypo-/hyperkalaemia
Hypovolaemia
Tension pneumothorax
Tamponade
Thrombosis
Toxins
4 Hs & 4 Ts
Rhythm check:
Shockable rhythms: VF & pulseless VT
Non-shockable rhythms: asystole & pulseless
electrical activity
MINIMISE DISRUPTION TO CHEST
COMPRESSIONS FOR RHYTHM CHECK & SHOCK
12
Adult basic life support (BLS)
1. Check for danger
2. Check for response
3. Call for help / pull alarm
4. Airway: check for obstruction → head tilt, chin lift (or jaw thrust)
5. Breathing: look, listen, feel (10s)
6. Circulation: feel for carotid pulse (at same time as breathing assessment)
7. Phone 999/2222
8. Start CPR: 30 to 2 (100–120/min)
9. Continue until help arrives
10. Attach automated external defibrillator (AED)
a) shout to stand back & remove O
b) rhythm check
c) shock if indicated
11. Assess & treat underlying cause
12. Post-arrest care: O2 (94–98% sats) + temperature control no higher
than37°C
2
Post-arrest Ix:
ABG + O
2
Bloods + glucose
CXR
Dispose to ICU
ECG
Mx of shockable rhythms: VF & pVT
• Shock ASAP
• Continue chest compressions
• Recheck cardiac rhythm every 2min
• Re-administer shock if indicated
• 1mg 1 in 10,000 IV adrenaline + 300mg
amiodarone
• Repeat adrenaline every 3–5min
Mx of non-shockable rhythms: PEA & asystole
Paediatric BLS
→ Head tilt, chin lift
→ 5 initial rescue breaths then check for signs of life including brachial pulse
→ Compressions 15:2 (100–120/min)
→ Use finger or one hand if small
Cardiac arrest rhythms
• 1mg IV adrenaline (10ml 1:10,000)
• Recheck cardiac rhythm every 2min
• Repeat adrenaline every 3–5min
• CPR until defib. is charged & ready to shock
Critical illness
12
Resuscitation Council UK (2021) Adult advanced life support guidelines
Chapter 17: Emergency presentations 223
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Acute asthma
Fig. 17.6
13
Assess severity of attack
Immediate management:
1. O2 via non-rebreather mask (aim for 94–98%)
2. 5mg salbutamol neb (SABA)
3. 0.5mg ipratropium neb (SAMA)
4. 40–50mg PO prednisolone / IV hydrocortisone
If severe / no improvement:
1. Senior review
2. + Ipratropium if not already given
3. + MgSO4 IV
4. Continue back-to-back nebs (every 15–30min)
Severe attack Life-threatening attack
• Incomplete sentences
• Accessory muscles
• Hyperinflated chest
• Pulsus paradoxus*
• PEF 33–50% of best
• RR >25
• HR >110
• Exhaustion/confusion
• Silent chest
• Cyanosis
• PEF <33% of best
• SpO2 <92%
• HR & BP
ABG: CO2, O2 <8, low pH
* SBP with inspiration
Oxygen (15L/min)
Salbutamol (5–10mg neb)
Hydrocortisone (100mg IV) or prednisolone (50mg PO)
Ipratropium (500microgram neb)
Purple steps are for severe cases
Acute COPD exacerbation14
1. Altered sputum volume/colour
2. Reduced exercise tolerance
3. Fever/malaise/lethargy
• Sputum sample if purulent
• ABG = T2RF (respiratory acidosis)
• FBC, U&Es
• CXR, ECG
insufficient response
13
SIGN (2019) British guideline on the management of asthma [158]
14
NICE (2018, updated 2019) Chronic obstructive pulmonary disease in over 16s [NG115]
retainer (92–96% if not)
2
Critical illness
224 Chapter 17: Emergency presentations
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Acute coronary syndrome15
M Morphine + metoclopramide 5–10mg
O Oxygen Target 92–96% sats
N Nitrates GTN spray (SL) or IV nitrate
A Antiplatelets
(see Chapter 1: Cardiology for further details)
1. 300mg chewable
2. Depends on Trust
guidelines
If STEMI =
PCI within
120min or
thrombolysis
Anaphylaxis
16
1. ABCDE (and call for help!)
via NRM + SABA if wheezy
2
2. IM adrenaline 1:1000
• ≤6m = 100–150mcg (0.10–0.15ml)
• <6y = 150mcg (0.15ml)
• 6–12y = 300mcg (0.30ml)
• >12y = 500mcg (0.50ml)
Hydrocortisone no longer given in routine
emergency treatment
→ repeat in 5min if no improvement
3. Further treatment options
• Monitor – pulse oximetry, ECG, BP (for at least 6h)
• Serum tryptase: on arrival then 1–4h later (s after 4h)
• Prednisolone PO: 3–5d
• ± EpiPen prescription & education
• Follow-up: with GP in 3–5d
• Allergy clinic referral
• Document in notes
1 in 1000
= FATAL
+ 24h after resolution
Critical illness
15
NICE (2020) Acute coronary syndromes [NG185]
16
Resuscitation Council UK (2021) Anaphylaxis guidance
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