Based on the very good manual book of Longmore M., Wilkinson I.B, Davidson E.H., Foulkes A., Mafi A.R., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 8th edition, 20010. www.oup.com  and the very good medical book of Stone C.K., Humphries R.L., Current Diagnosis and Treatment in Emergency Medicine, McGraw Hill - LANGE, 6th edition, 2008. mcgraw-hillmedical.com

 

NOTE

All the medical procedures and drug administration mentioned in this text should be done only under a senior doctor’s consultancy. Some information in this text is empirical and its reliability can’t be ascertained. It is suggested to search official medical articles, books and guidelines in order to ascertain the medical information & drug doses of this text.

 

ADVANCED LIFE SUPPORT, ACLS (ADVANCED CARDIAC LIFE SUPPORT – INCLUDING STROKE), ADVANCED PAEDIATRIC (INCLUDING NEWBORN) LIFE SUPPORT AND ADVANCED LIFE SUPPORT IN OBSTETRICS ALGORITHMS AND ALSO CAUSES OF SHOCK ARE DESCRIBED ON DIFFERENT TEXTS AT www.aboutmedicine.tk

  

 

ANAPHYLACTIC SHOCK

Causes: drugs (penicillin, contrast media, sulphonamides), latex (e.g. gloves), stings (bees, wasps etc), food (eggs, peanuts, fish), semen, pollen etc.

 

Signs and symptoms: itching, erythema, urticaria, hives, oedema, angioedema, wheeze, cyanosis, laryngeal obstruction, hypotension, tachycardia.

 

NOTE: ANAPHYLACTOID REACTION is a reaction that occurs when we have direct release of mediators from inflammatory cells, contrary to anaphylactic reaction, without involving IgE antibodies. Usually it occurs as a response to a drug (classically N-acetylcysteine which is antidote for paracetamol overdose or used for cough).

 

 

ALGORITHM ON ALAPHYLAXIS

ABCs Secure airway, give 100% oxygen, intubate if airway is not patent and obstruction is imminent (stridor/ angioedema – check the mouth for obstruction – is the uvula enlarged?/ exclude foreign body obstruction).

Remove the cause (e.g. sting – you can remove it with a hard card e.g. ID or VISA or phone card). Raise the patient’s feet!

 Administer epinephrine IM 0.5 mg (0.5 ml of 1:1.000 solution). Repeat every 5 min if needed (according to BP, HR and respiration) until the patient improves.

Children’s dose is

< 6 months years old: 0.05ml adrenaline 1: 1.000

6 months – 6 years: 0.12 ml

6 years – 12 years: 0.25 ml

>12 years: 0.5 ml

 

 

Establish IV/ΙΟ access

Administer chlorphenamine 10mg IV (or diphenhydramine 25 – 50 mg IM/IV) and hydrocortisone 200 mg IV.

Give also IVI NS (normal saline) e.g. 500 ml over 15 min, titrating tο BP. You may need to give up to 2 L.

In case the patient has wheezing treat as for asthma (see asthma algorithm below). May need intubation & mechanical ventilation.

If still hypotensive, transfer to ICU. May be needed IV adrenaline, +_ aminophylline and nebulized salbutamol. Call expert.

 

The dose of IV adrenaline is 100 μg /min titrating to BP (0.5 – 1 ml/ min of 1: 10.000 solution).

 

NOTES

Ø      In case the patient takes β’ blockers consider salbutamol IV instead of epinephrine.

 

Ø      In case of hereditary angioedema give c1 esterase inhibitor or FFP (Fresh Frozen Plasma).

 

 

 

ACUTE SEVERE ASTHMA

 

Differential Diagnosis: acute infective exacerbation of COPD (ask the patient if is or was smoker), pulmonary edema (cardiac asthma!), anaphylaxis (see above; history? any precipitant?), pulmonary embolus (risk factors?), upper respiratory tract obstruction (stridor?), pneumothorax (if you suspect it, do expiratory CXR chest X’ Ray).

 

Check peak expiratory flow rate PEFR (PEF). Ask previous measurements and the patients best PEF.

 

Life threatening asthma: peak expiratory flow rate PEFR (PEF) < 33% of predicted or best, silent chest, cyanosis, bradycardia, hypotension, feeble respiratory effort, exhaustion, confusion, coma, ABGs (arterial blood gases) hypercapnia, hypoxaemia, axidosis.

 

ALGORITHM FOR ACUTESEVERE ASTHMA

Sit the patient up! Give 100% oxygen high flow via a mask with a non rebreathing bag. Check PEF (Peak Expiratory Flow rate PEFR) and check the patient’s best PEF.

Administer short acting β’ agonist: salbutamol 5 mg (or terbutaline 10 mg or albuterol 0.2 – 0.3 ml in 3 ml normal saline nebulized every 20 – 30 min) + ipratropium 0.5 mg nebulized with oxygen. You can repeat ipratropium.

 

Side effects of salbutamol (and generally of β’ agonists) are tachycardia, arrhythmias, hypokalaemia, tremor. Check K.

Give hydrocortisone 100 mg IV or methylprednisolone 125 mg IV, or prednisolone 50 mg PO (per oral) or both (IV & PO) if severe asthma.

 

Check the PEF 15 – 30 min after the initial treatment.

Perform CXR (chest X’ Ray). Exclude pneumothorax. If suspected pneumothorax, ask also an expiratory CXR! Turn the film lateral to see better the gap.

Check ABGs (arterial blood gases). Recheck them within 2 h. Also check SaO2 (oxygen saturation) Keep it > 92% with high flow oxygen.

Labs: CBC/FBC (complete/ full blood count), ΒUN (), Electrolytes. Check especially for hypokalaemia from salbutamol or aminophyline.

On life threatening asthma call ICU and experts. Add MgSO4 magnesium sulphate 1.2 – 2 g IV over 15 – 30min (not bolus!).

Also give salbutamol nebulizers every 15 min or 10 mg continuously / h.

 

A.    If the patient is improving give 40 – 60 % oxygen, administer prednisolone 50 mg/ 24 h PO (continue for at least 5 days), give nebulized salbutamol every 4h and monitor oxygen saturations SaO2 and PEF (peak expiratory flow rate PEFR).

 

B.     If the patient is not improving after 15 – 30 min continue 100% high flow oxygen and steroids, administer hydrocortisone 100 mg IV or methylprednisolone 125 mg IV +_ prednisolone 30 – 60 mg PO, if not already given.

 

Administer salbutamol nebulized every 15 min (or 10 mg continuously /h) plus ipratropium 0.5 mg nebilized every 4 – 6 h.

 

If the patient is still no improving call the ICU, repeat salbutamol nebulized every 15min, give MgSO4 magnesium sulphate 1.2 – 2 gr over 20 min (if not already given). The paediatric dose of MgSO4 is 40 mg/kg. Antidote for magnesium overdose is calcium chloride or calcium gluconate. The adult dose is 10 ml (500 – 1000 mg) VERY slowly IV (over 10min). When you administrate MgSO4 check deep tendon reflexes and RR respiratory rate. Stop infusion if absent reflexes or decreased RR respiratory rate.

Also on severe asthma consider aminophylline. The loading dose, if NOT already on theophylline, is 5 mg/kg IVI over 20min and then 500 μg (0.5 mg) / kg/ h (as Kg here we have the ideal body weight; so the dose for a small adult is 750 mg/24 h and for a large adult the dose is 1200 mg/ 24h).

 

If already on theophylline preparations the last 24h, then the loading dose is 3 mg/kg.

 

Check plasma theophylline and adjust the dose. Do levels if infusion is given > 24 h. Aim for plasma concentration 10 – 20 μg/ ml (55 – 110 μmole/ L). With blood concentration >_ 25 μg/ ml toxicity can occur with hypotension, seizures (!), arrhythmias and cardiac arrest! Also theophyllines may cause hypokalaemia (check potassium!).

 

Alternative to aminophylline is salbutamol IVI 3 – 20 μg / min (better in ICU).

Also on severe asthma you may administer adrenaline 0.2 – 0.3 ml 1: 1.000 Sc (subcutaneous), every 20 – 30min, or terbutaline 0.25 mg Sc every 2 – 4 h.

The patient may need IPPV (intermittent positive pressure ventilation).

In case of no improvement or life threatening asthma the patient may need intubation and mechanical ventilation.  ketamine is very helpful as anesthetic in asthma (give also atropine to prevent secretions from ketamine).

 

 

 

ACUTE EXACERBATION OF COPD

Symptoms: cough, SOB shortness of breath, or wheeze.

 

Ask the patient if he/she is or was a smoker for years!

 

Differential Diagnosis: asthma, pneumothorax (do expiratory CXR chest X’ Ray if suspected), upper respiratory tract obstruction (stridor?), anaphylaxis (history? Precipitant?), pulmonary embolus (risk factors?), acute left ventricular failure/ pulmonary edema (cardiac asthma).

 

ACUTE COPD ALGORITHM

Start Oxygen at 24 – 28%, according to ABGs (arterial blood gases) and monitor for hypercapnia.

Administer nebulized salbutamol 5 mg/ 4h + ipratropium 0.5 mg/ 6h. 

Administer IV hydrocortisone 200 mg + prednisolone PO (orally) 30 – 40 mg.

If there is evidence of infection as a precipitating cause of COPD exacerbation give antibiotics e.g. amoxicillin 500 mg/ 8h PO (ask if allergic on it).

If no response, repeat salbutamol and ipratropium nebulized and consider IV aminophylline! The loading dose, if NOT already on theophylline, is 5 mg/kg IVI (e.g. 250 mg IVI) over 20min and then 500 μg (0.5 mg) / kg/ h (as Kg here we have the ideal body weight, so the dose for a small adult is 750 mg/24 h and for a large adult the dose is 1200 mg/ 24h).

 

If already on theophylline preparations the last 24h, then the loading dose is 3 mg/kg.

 

Check plasma theophylline and adjust the dose. Do levels if infusion is given > 24 h. Aim for plasma concentration 10 – 20 μg/ ml (55 – 110 μmole/ L). With blood concentration >_ 25 μg/ ml toxicity can occur with hypotension, seizures (!), arrhythmias and cardiac arrest! Also theophyllines may cause hypokalaemia (check potassium!).

If still no response, consider NIPPV (nasal intermittent positive pressure ventilation) if RR (respiratory rate) > 30 or acidosis. If still acidosis and hypercapnia, consider intubation and mechanical ventilation. For patients not suitable for mechanical ventilation consider the respiratory stimulant doxapram (1.5 – 4 mg/min).

 

NOTE

Some patients rely on their hypoxic drive to breathe and high oxygen concentration (>30%) on them may lead to reduced respiratory rate, hypercapnia and decrease the level of consciousness. So, if ABG (arterial blood gases) show carbon dioxide CO2 retention start with 24 – 28% oxygen and reassess after 30 min. Monitor the patient and check if raising of PaO2 causes hypercapnia.

In patients without evidence of CO2 retention start oxygen at 28 – 40% concentration and monitor ABGs.

 

 

 

COMA

Coma is unrousable unresponsiveness

 

Metabolic causes: drugs, poisoning (carbon monoxide CO, alcohol, TCAs tricyclics antidepressants, barbiturates etc), hypo/hyperglycemia (DKA diabetic ketoacidosis or HONK hyperosmotic non ketotic coma), hypoxia, CO2 retention (COPD), sepsis, hypo/ hyperthermia, myxedema, Addisonian crisis, hepatic encephalopathy, uremia.

 

Neurological causes: head trauma, meningitis, encephalitis (give IV acyclovir if HSV encephalitis is suspected), malaria (do blood thick films), typhus/ typhoid, parasitosis (e.g. trypanosomiasis), rabies, head tumor (primary or metastatic), stroke, sabdural/ subarachnoid hemorrhage, hypertensive encephalopathy, epilepsy (may be non convulsive), postictal state.

 

 

 

COMA ALGORITHM

ABCs (stabilize Cervical spine if suspected trauma – always stabilize it on head trauma)

IV access

Check blood glucose (finger stick test and Labs).

 

Control seizures (see seizures algorithms)

Treat reversible causes. If glucose levels are unknown, give glucose 50 ml of 50% dextrose IV (in adults) over 5 min and in a large vein (flush it with normal saline after the administration because dextrose is harmful to the veins.

 

Also give thiamine (vitamin B1), especially if suspected malnutrition and Wernicke’s encephalopathy (e.g. on alcoholics). The dose of thiamine is 100 mg IV slowly, prior to, or at the same time with glucose.

 

Give also naloxone 0.4 – 2 mg IV (if small pupils or possible opiate abuse; bilateral small pupils may occur from other causes such as pontine hemorrhage or organophosphate poisoning).

 

Also in case of suspected benzodiazepine OD (overdose) give flumazenil 0.2 mg slowly (over 15 sec) IV, repeated at 0.1 mg at 1 min intervals, as needed. Usual dose is 0.3 – 0.6 mg IV over 3 – 6 min. Max dose is 1 mg (2 mg if in ICU).

Brief history and examination. Check AMPLE (Allergies, Medications, Past medical history, Last meal and Environment). Also ask if other members of family or other close contacts with same symptoms (e.g. carbon monoxide CO poisoning).

ABGs (arterial blood gases), CXR (chest X’ Ray), head (initially non contrast) CT.

Labs: CBC/ FBC (full/ complete blood count), UREA, creatinine, electrolytes (K, Na, Calcium, Magnesium, Phosphate), LFT (liver function tests), ESR, CRP, toxicology, ethanol, drug levels (e.g. aspirin & acetaminophen – paracetamol), blood & urine cultures, blood thick films (if malaria suspected). 

 

 

 

SHOCK

For causes of shock see APPENDIX (I)

 

SHOCK ALGORITHM

ABCs – high flow oxygen. Raise foot of the bed!

IV access, 2 wide bore IV lines (ask help if they take > 2 min)

Treat underlying cause.

Infuse crystalloids fast to raise BP (unless cardiogenic shock)

ABGs (arterial blood gases), ECG, CXR (chest X’ Ray), SaO2 (oxygen saturation), Echo, abdominal CT, ultrasound. Place Foley, CVP line and arterial line.

 

Replace fluids titrated to BP, CVP and urine output. Aim for urine output > 30 ml/h. If cardiogenic shock, don’t overload with fluids! Exclude PE (pulmonary embolism) and Right ventricular infraction (in RV infarction don’t give nitrates!). Consider inotropes on persistent hypotension. Most common cause of shock is hypovolaemia. On abdominal aortic aneurysm (palsatile abdominal mass, perform ultrasound) aim for Systolic BP about 90 mmHg.

 

Check glucose (finger prick test and labs). Labs: CBC/ FBC (complete/ full blood count), ESR, CRP, CK, CK MB, urea, creatinine, Electrolytes, blood type & crossmatch, pregnancy test, blood & urine cultures, drug levels, toxicology, alcohol, lactate.

 

 NOTES

·        SIRS (systemic inflammatory response syndrome) is characterized >_ 2 of the following:  temperature > 38 or < 36 degrees C, RR (respiratory rate) > 20 (or PaCO2 < 4.3 KPa or < 33 mmHg), HR (heart rate) > 90 bpm, WCC (WBC) > 12 X 10⁹ / L or < 4 x 10⁹ / L or > 10% immature forms (bands). Sepsis is SIRS with infection.

·        On heat exhaustion perform tepid sponging and fanning (avoid ice and immersion to cold water), administer NS norman saline +_ hydrocortisone (!) 100mg IV and chlorpromazine 25 mg IM (for shivering). Stop cooling when temperature < 39 degrees C!

·        On septic shock give antibiotics within 1 h (better take blood cultures first). If unknown microbial origin give initially IV amoxicillin + clavulate 1.2g/8h  or meropenem 1g/ 8h or gentamycin (caution in renal failure, do levels) + antipseudomonal penicillin e.g. ticarcillin. Also give colloid/ crystalloids IVI +_ inotropes. Aim for CVP 8 – 12 mmHg, MAP (mean arterial pressure) > 65 mmHg and urine output > 35 ml/h. Low dose steroids (on persistent hypotension despite fluids and vasopressors) and also recombinant human activated protein C (Drotrecogin alfa) may help. Mean BP = (SBP + 2 DBP)/ 3

 

 

 

 

ACUTE LEFT VENTRICULAR FAILURE (LVF)/ PULMONARY OEDEMA

Causes: cardiovascular (LVF left ventricular failure, valvular heart disease, arrhythmias, malignant hypertension!), ARDS (many causes e..g. trauma, infection, drugs, sepsis, post operative), fluid overload, neurogenic! (e.g. head trauma), renal failure (!).

 

Differential diagnosis: asthma, COPD exacerbation, pneumonia, PE pulmonary embolus. It may be difficult to distinguish especially in the elderly in which asthma/ COPD exacerbation, pneumonia and acute LVF may coexist and cardiac asthma with wheeze may be difficult to be distinguished from asthma/ COPD exacerbation. You may need to treat all of them (e.g. with nebulized salbutamol, furosemide IV, morphine IV and amoxicillin)! Other diagnostic possibilities are hypertensive crisis, aortic dissection, tension pneumothorax and anaphylaxis. 

 

Perform an ECG! Connect to monitor.

 

BNP (brain natriuretic peptide) may be very helpful in distinguish LVF from other causes of shortness of breath e.g. COPD. If BNP is > 100 pg/dL then we have possible heart failure. 

 

Take also a CXR (chest X’ Ray) to check for signs of LVF: kerley B lines, fluid in lung fissures, small effusions at costophrenic angles, shadowing – usually billateral ‘bat wings’, interstitial edema, increased cardiothoracic ratio. The last may not appear in acute LVF!

Also, a supine or AP CXR may show a falsely enlarged heart. The only CXR that is accurate for the heart’s size is the erect PA.

 

If suspected pneumothorax, take also an expiratory CXR.

 

Symptoms: SOB (shortness of breath), orthopnea, paroxysmal nocturnal dyspnea, pink frothy sputum. Ask for recent drugs and recent health problem (asthma, COPD, pneumonia, MI myocardial infarction, LVF).

 

Signs: distressed, pale, sweaty (!), tachycardia, tachypnea, pink frothy sputum, pulsus alterans (alternating strong and weak pulse), fine lung crackles/ end respiratory crepitations or rales (especially at lung bases), gallop rhythm (S3 +_ S4), wheeze (cardiac asthma!). The patient is sitting up and leaning forward.

 

ACUTE LEFT VENTRICULAR FAILURE (LVF)/ PULMONARY EDEMA ALGORITHM

 

Sit the patient up (raise the head of the bed)!

Give 100% oxygen (unless COPD with EVIDENCE of CO2 retention, see above COPD)

IV access, connect to monitor, ECG

Treat any underlying arrhythmia

Give morphine 2 – 4 mg slowly IV (with metoclopramide 10 mg IV). You may repeat after 5 – 10 min. Alternative is diamorphine 2.5 – 5 mg slowly IV (caution in COPD for respiratory drive compromise and also caution on liver failure). CI (contraindications) to morphine are hypersensitivity to it or other opiates and also signs of CNS depression (e.g. respiratory depression, decreased BP or decreased HR).

Give furosemide (Lasix) 0.5 – 1 mg/kg (e.g. for 80 kg patient give 40 – 80 mg) IV slowly (it is preferred to start with 40 mg IV Lasix, reassess and repeat; monitor BP!). Give larger dose in renal failure. If on diuretics or renal failure, give Lasix e.g. 80 – 160 mg IV.

Give GTN (nitroglycerine) spray of 0.4 mg 2 puffs or 2 tablets of 0.3 or 0.4 mg (each puff or each tablet needs to be taken 5 min apart!). CI (contraindications) to NTG is SBP (systolic BP) < 90 mmHg or BP< 30 mmHg below baseline, HR < 50 or > 100, erectile drugs (Sildenafil – Viagra or Vardenafil – Levitra the last 24 h or tadafil – Cialis the last 48 h), intracranial bleeding, aortic or mitral stenosis or HOCM (hypertrophic obstructive cardiomyopathy) and also on Right Ventricular myocardial Infarction!

Investigations, examination, history.

ECG (MI myocardial infarction? Arrhythmia?), SaO2 (oxygen saturation), ABGs (arterial blood gases), +_ Echo.

Labs: Tropinins T&I, CK- MB, myoglobin, UREA, creatinine, electrolytes and plasma BNP. 

If Systolic BP >_ 100mmHg start nitrate infusion e.g. isosorbite dinitrate 2 – 10 mg/h or NTG 5 – 10 μg/ min.  Keep Systolic BP > 90mmHg.

In case the patient is worsening give further Lasix 40 – 80 mg, consider CPAP (5 – 10 mmHg, use it if not hypotension and not need for intubation) or intubation and mechanical ventilation. Also consider increasing nitrate infusion. Υοu may also try (especially if hypotension) inotropics (short term) such as milrinone or dobutamine. Rarely, you may try to venesect 500 ml of blood.

If systolic BP is < 100 mmHg, treat as cardiogenic shock (see next algorithm). Consider inotropes (dobutamine/ dopamine) and Swan – Ganz catheter and intra – aortic balloon pump. 

 

If the patient doesn’t respond consider a different diagnosis such as hypertensive crisis, aortic dissection, pneumonia, PE pulmonary embolism, asthma, COPD exacerbation, tension pneumothorax, anaphylaxis. 

 

Neseritide is rh – BNP (recombinant human brain natriuretic peptide) may be useful in decompensated cardiac failure and improves hamodynamicaly the patients. The dose is 0.01 μg / kg/ min. It may cause hypotension. It is contraindicated in cardiogenic shock, right ventricular myocardial infarction, aortic stenosis, HOCM (hypertrophic obstructive cardiomyopathy), constrictive pericarditis.

 

You may also give an ACE inhibitor such as enalapril 1.25 mg IV over 5 min. CI (contraindications) are pregnancy, hyperkalaemia and hypotension. Long term therapy includes ACE Inhibitors and β’ blockers.

 

 

CARDIOGENIC SHOCK

Causes: MI (myocardial infarction), dysrhythmias, PE pulmonary embolus, tension penumothorax, cardiac tamponade (the 3 last are obstructive causes of shock), myocarditis, myocardial depression (drugs such as opiates; acidosis, sepsis, hypoxia), endocarditis with valve destruction, aortic dissection. 

 

CARDIOGENIC SHOCK ALGORITHM

 

Give 100% oxygen. Maintain oxygen saturation > 90%.

IV access, connect to monitor, perform 12 lead ECG, CXR (chest X’ Ray), take SaO2 (oxygen saturation) and perform cardiac Echo.

 

Labs (UREA, creatinine, Electrolytes, cardiac enzymes such as CK – MB & markers such as troponin I & T & myoglobin – repeat cardiac markers also 12 h later). Correct any electrolyte abnormality. Check ABGs (arterial blood gases) and correct any acid base abnormality

 

 

In case you suspect aortic dissection perform trans-oesophagal Echo (TOE) or CT of thorax (if stable or if TOE unavailable).

 

If you suspect PE (pulmonary embolus) perform CT of thorax or V/Q scan.

 

Monitor CVP, BP, ABGs (arterial blood gases), ECG and urine output (insert Foley). Consider a Swan – Ganz catheter to assess PCWP (pulmonary capillary wedge pressure) and cardiac output and also consider an arterial line to monitor BP.

Give morphine 2 – 4 mg slowly IV (with metoclopramide 10 mg IV) or diamorphine 2.5 – 5 mg slowly IV for pain and anxiety (caution in COPD for respiratory drive compromise and also caution on liver failure). CI (contraindications) to morphine are hypersensitivity to it or other opiates and also signs of CNS depression (e.g. respiratory depression, decreased BP or decreased HR).

On decreased BP you may try fentanyl, instead of morphine or diamorphine!

Measure PCWP (pulmonary capillary wedge pressure) with a Swan – Ganz catheter.

 

A.     If PCWP is < 15 mmHg load with fluid. Give colloid or crystalloids 100 ml IV every 15 min. Aim for PCWP of 15 – 20 mmHg. If there is no evidence of pulmonary edema administer 250 – 500ml of crystalloids over 30 min. If BP improves, maintain rate at 100 – 200 ml/h.

 

B.    If PCWP is > 15 mmHg OR severe shock or pulmonary edema give inotropes e.g. dobutamine 2.5 – 10 μg / kg/ min IVI. Aim for Systolic BP > 80 mmHg.

 

Consider renal dose of dopamine. Initially give  2 – 5 μg/ kg/min IV, only via central line.  Also consider dobutamine.

Consider intra – aortic balloon pump. This may buy time in case surgery is needed.

Treat underlying reversible causes such as MI (heart attack). On massive PE (pulmonary embolism) consider thrombolysis or embolectomy. Consider surgery for mitral or aortic incompetence and acute VSD (ventricular septal defect).

 

A new drug which decrease mortality from 67% to 27% is L – NMMA (N – monomethyl L arginine), a NO (nitrous oxide) synthase inhibitor.

 

 

CARDIAC TAMPONADE

Causes: chest trauma, lung or breast cancer, pericarditis, MI (myocardial infarction), TB, renal failure, radiation, myxedema, SLE, aortic dissection.

 

Signs: hypotension, increasing JVP (JVD jugular veins distension) and muffled heart sounds (Beck’s triad). Also Kussmaul’s sign (increasing JVP on inspiration), pulsus paradoxus (weaker pulse on inspiration), electrical alternans on ECG and small QRS complexes on ECG. Suspect it on blunt or penetrating chest trauma. Echocardiography or FAST on trauma is diagnostic. CXR (chest X’ Ray) on pericarditis may show globular heart, convex or straight left heart border, right cardiophrenic angle < 90 degrees.

 

Management: give oxygen, monitor ECG and administer IV fluids (crystalloids) immediately. Call expert. Prepare for emergency pericardiocentesis, better with the guidance of ultrasound (FAST). On trauma you may need to perform troracotomy (if an OR operating room is immediately available).

 

 

PNEUMOTHORAX

Causes: spontaneous (especially young thin men) after a rapture of a subpleural bulla; asthma, COPD, pneumonia, cancer, lung abscess, lung fibrosis, cystic fibrosis, sarcoidosis, Marfan’s, Ehlers – Danlos, trauma, iatrogenic (subclavian central vein line, pleural aspiration, pleural biopsy, liver biopsy and positive pressure ventilation!) 

 

Symptoms: may be no symptoms (especially if young fit and if small pneumothorax) or sudden SOB (shortness of breath) and/ or pleuritic chest pain (on inspiration). Mechanical ventilated patients may present with hypoxia or increased ventilation pressures. In case of ventilation with self inflating bag there may be difficulty and decreased compliance on ventilating. Also on a patient with COPD or asthma may appear with sudden deterioration.

 

Signs: reduced expansion of the hemithorax, hyper – resonance/ tympany on the affected side on percussion, diminished/ absent breath sounds on the affected side. On tension pneumothorax a late sign is tracheal shift away from the affected side.

 

Perform immediately an EXPIRATORY CXR (chest X’ Ray) and check for an area devoid of lung markings peripheral to the edge of the collapsed lung (it may be helpful if you turn the film laterally). Be careful to distinguish a large emphysematous bulla from pneumothorax!

 

Check ABGs (arterial blood gases).

 

 

ACUTE PNEUMOTHORAXALGORITHM

A.     PRIMARY PNEUMOTHORAX

Dyspnea and / or rim of air > 2cm on CXR (chest X’ Ray)

No: consider discharge (after excluding other causes of dyspnea)

Yes: aspiration.

Successful: consider discharge.

Non successful: repeat aspiration. If still no successful insert chest drain.

 

 

B.    SECONDARY PNEUMOTHORAX (asthma, COPD, etc)

Dyspnea and age > 50 and rim of air > 2 cm on CXR (chest X’ Ray).

Yes: insert chest drain.

No: perform aspiration. If successful admit for 24h. If not successful, insert a chest drain. 

 

 

TENSION PNEUMOTHORAX

 

On tension pneumothorax the air, with each inspiration, is drawn into the pleural space, but it can’t escape during expiration so the mediastinum is pushed into the contralateral hemithorax compressing the superior vena cava and causing cardiorespiratory collapse and arrest.

 

Signs: respiratory distress, SOB (shortness of breath), tachycardia, hypotension, JVD (jugular vein distension), tracheal deviation away from the side of pneumothorax (late sign!), hyper-resonance – tympany on percussion and reduced/ absent breath sounds at the affected side.

 

Management: DON’T WAIT FOR CXR (chest X’ Ray)! Tension pneumothorax is a clinical diagnosis. Insert a large bore (14 – 16 G) needle into the 2^nd intercostal interspace, in the midclavicular line of the hemithorax of the suspected side of pneumothorax. After this, insert a chest tube to drain the pneumothorax.

 

 

PULMONARY EMBOLISM (PE)

Risk factors: surgery (especially pelvis, hip), malignancy, immobility, the Pill & HRT (hormone replacement therapy at menopause – slight risk), previous TE (thromboembolism) and inherited thrombophilia.

 

Signs & Symptoms: acute SOB (shortness of breath), pleuritic chest pain (on inspiration), hemoptysis, syncope, collapse, hypotension, tachycardia, tachypnea, cyanosis gallop rhythm, JVD (jugular vein distension), loud P2 at heart auscultation (!), right ventricular heave (at chest palpation), pleural rub (!), AF (atrial fibrillation). However, signs are often non specific. Suspect PE if risk factors.

 

Pulmonary embolism presents classically 10 days post operative with sudden dyspnea and collapse while straining at stool (on sudden collapse at straining at stool also exclude subarachnoid hemorrhage). However often the only sign is breathlessness and/or tachycardia!

 

Check for DVT (deep vein thrombosis) – swollen legs!

 

Investigations:

Labs: UREA, creatinine, CBC/FBC (complete/full blood count), coagulation studies (including Platelets, PT, aPTT and especially D’ Dimers).

 

D’ Dimers have high sensitivity but low specifity for PE. They may increase in thrombosis, inflammation, infection, malignancy and post operative. NORMAL D’ DIMERS EXCLUDE PE.

 

ECG: any of the following: normal, sinus tachycardia, right ventricular strain on V1 – V3, right axis deviation, RBBB, AF, S1Q3T3 (rare; deep S in I, Q waves in III, inverted T in III).

 

CXR: normal or decreased vascular markings, small pleural infusion, atelectasis, wedge shaped areas of infarction).

 

ABGs (arterial blood gases): hypoxemia, hypocapnia (!), PH may be increased. In metabolic alkalosis exclude causes such as PE before attributing it in hysteria! 

 

ECHO (echocardiogram) shows right ventricular hypokinesis and dilation.

 

CTPA (CT Pulmonary Angiography) has high sensitivity and specifity. If not available, perform V/Q scan. If V/Q scan is equivocal, perform pulmonary angiography or bilateral venograms. Alternatives are MRI venography or plethysmography. Don’t forget leg/ pelvis Doppler for DVT (deep vein thrombosis).

 

LARGE PULMONARY EMBOLISM  (PE) ALGORITHM

Give 100% oxygen

Administer morphine 5 – 10 mg with metoclopramide 10 mg IV in case the patient has pain or is distressed. CI (contraindications) to morphine are hypersensitivity to it or other opiates and also signs of CNS depression (e.g. respiratory depression, decreased BP or decreased HR).

On massive PE with unstable patient consider immediately thrombolysis (e.g. alteplase rTPA give 10 mg IV over 2 min and then 90mg infusion over 2 h) or surgery (embolectomy, consult a thoracic surgeon)

IV access. Administer LMWH (low molecular weight heparin) such as tinzaparin 175 units/kg/24 h Sc or enoxaparin 1 mg/kg Sc every 12h or give UH unfractioned heparin 80 units / kg (give e.g. 10.000 units) bolus IV, followed by 18 units/kg/h guided by aPTT (target APTT is 1.5 – 2.5). The bolus of UH unfractioned heparin may be preferred from LMWH because its fast onset. Don’t give heparin if suspected septic embolism e.g. from right sided endocarditis!

 Check the BP!

A.      BP < 90 mmHg

Start rapid crystalloids or colloid infusion:  250 to 500 ml NS (normal saline) over 20 – 30 min.

If BP is still low after 500 ml crystalloids or colloids, then give dobutamine 2.5 – 10 μg/kg/min IV, titrating to BP (aim for BP > 90mmHg). Consider also dopamine.

If still hypotensive, consider IV noradrenaline (always via central vein)

If still BP< 90 after 30 min – 1 h of treatment, clinical definite PE and no CI (contraindications), consider thrombolysis (if not already given). e.g. alteplase rTPA  give 10 mg IV over 2 min and then 90 mg infusion over 2 h).

 

 

B.    BP > 90 mmHg

Start warfarin 10 mg/24h PO. Confirm diagnosis.

 

 

PNEUMONIA

 

Symptoms: fever, cyanosis, rigors, malaise, dyspnea, cough, purulent sputum (‘rusty’ with pneumoniococcus), pleuritic chest pain (on inspiration), +_ haemoptysis.

 

Signs: fever, cyanosis, confusion, tachycardia, tachypnea, herpis labialis (pneumococcus), hypotension, pleural rub, diminished expansion, dull on percussion (stony dull on pleural fluid), increased tactile vocal fremitus and vocal resonance, bronchial breathing.

 

Severity of pneumonia is estimated by the CURB – 65 score where C is confusion, U is urea> 7 mmol/L, R is respiratory rate RR >_ 30, B is BP< 90/60 and 65 is age >_65. Score: 0 – 1: may do home treatment; 2: hospital therapy; >_3: severe pneumonia, may need ICU. Other risk factors are co-existing disease, hypoxemia, SaO2 oxygen saturation < 92% and bilateral or multilobar involvement.

Ask if air condition, bird exposure, aspiration (gastroesophagal reflux?) & if other in the family with the same symptoms.

 

 

PNEUMONIA ALGORITHM 

Give oxygen (caution if COPD, see COPD algorithm)

Treat shock and hypotension

SaO2 (oxygen saturation), CXR (chest X’ Ray), ABGs (arterial blood gases).

 

Labs: CBC/ FBC (full/ complete blood count), urea, creatinine, electrolytes, LFTs (liver function tests), atypical serology, blood/ sputum cultures, pleural fluid aspiration culture. On immunocompromised patients or patients in ICU (and also if HIV or suspected HIV + with pneumocystis jiroveci (carinii)), you may perform bronchoscopy and broncoalveolar lavage for diagnosis.

Antibiotics.

 

For mild pneumonia give amoxicillin 500 mg – 1gr/8h PO (orally) or clarithromycin 500 mg/12h PO. Give them both on moderate pneumonia (if you chose IV dose, give amoxicillin 500 mg/8h IV plus clarithromycin 500 mg/ 12h IV).

 

For severe community acquired pneumonia give co – amoxiclav 1.2 gr/8h IV, or cefuroxime 1.5 g/8h IV PLUS Clarithromycin 500 mg/12h IVI. Add flucloxacillin if you suspect staphylococcus. Add vancomycin if you suspect MRSA. Treat for 10 days (14 – 21bdays if you suspect staphylococci, legionella or Gram negative enteric bacteria).

 

If you suspect legionella pneumophilia give clarithromycin +_ rifampicin or levofloxacin and treat for 14 – 21 days; for Chlamydia add tetracycline; for pneumocystis jiroveci (carinii) add co – trimoxazole.  For hospital acquired or neutropenic patients consider gentamicin IV + ticarcillin (it will cover pseudomonas) or a 3^rd generation cephalosporine (e.g. cefotaxime). For neutropenia consider antifugals after 48h. For aspiration pneumonia, give cefuroxime IV + metronidazole 500 mg/8h IV.

IV fluids as required (anorexia, dehydration)

Paracetamol (acetaminophen) 1g/6h or NSAID for pleuritic chest pain

May be needed intubation & mechanical ventilation 

 

 

 

ACUTE UPPER GASTROINTESTINAL (GI) BLEEDING

Causes:  peptic ulcer (40%), Mallory Weiss tearing (after reching; 15%), gastroduodenal ulcer (10%), oesophagitis (10%), varices (7%), malignancy, vascular malformations, Dieulafoy’s lesion (rapture from unusual big arteriole e.g. in the fundus of the stomach), nose bleeding & haemoptysis (swallowed blood).

 

Ask for past medical history (especially on GI system), medication and alcohol.

 

Signs & symptoms: hematemesis, melaena, dizziness, loss of consciousness, abdominal pain, postural hypotension, hypotension, tachycardia (if not on β’ blockers!), decreased JVP, cool & clammy skin, decreased urine output, prolonged capillar refill time, signs of liver disease such as askites, porphyra and telangiectasias. If the patient is shocked, then has cool and clammy skin (e.g. nose, toes, fingers), tachycardia (> 100 bpm), increased capillary refill time, JVP < 1 cmH2O, hypotension (Systolic BP < 90), postural hypotension (drop of Systolic BP> 20 mmHg or increase of HR >_ 30 bpm or Systolic BP < 90 on standing for 1min after being supine for 3 min), confusion, urine output < 30 ml/h. 

 

 

UPPER GI BLEEDING ALGORITHM

 

ABCs, secure airway, give high flow oxygen, keep NBM (Nil by mouth), Insert 2 large bore cannulae (14 – 16G) and take blood for Labs (CBC/FBC complete/ full blood count, UREA, creatinine, electrolytes, LFT liver function tests, amylase, lipase, coagulation studies. Blood type & cross match 6 units!

 

Place a NG (nasogastric) tube. Perform gastric lavage with warm normal saline. If it is positive for blood, call a gastroenterologists and a surgeon. Emergency endoscopy or surgery may be needed. In case of negative blood on gastric effluent, suspect lower GI bleeding and notify a gastroenterologist to consider emergency colonoscopy.

Rapid crystalloids infusion (up to 1 L)

 

If still shocked, give blood group specific (if not fast available and if the patient is unstable give O Rh negative)

If the patient is haemodynamically stable and not shocked, give slow saline infusion to keep IV lines open. Keep Hb (hemoglobin) > 8.

 

Note: on patients with decompensated liver failure with ascites and peripheral oedema avoid saline because the patients, despite low serum sodium, have high body sodium! In that case use whole blood or albumin (salt poor) and use D5W (5% dextrose) for maintenance. Correct clotting defects. Consider FFP (fresh frozen plasma) and vitamin K for coagulation defects (e.g. liver problems or warfarin overdose). Consider also platelet concentrate.

Place a CVP line to guide fluid replacement. Aim for CVP > 5 cmH2O. In case of ascites or CCF (congestive heart failure), CVP may be misleading! Consider then a Swan – Ganz catheter.

 

Place a Foley. Aim for urine output > 30 ml/h.

Monitor vitals every 15 min until stable. When stable, monitor vitals hourly.

 

Notify surgeons if severe bleeding. Also notify the gastroenterologists, as urgent endoscopy may needed for diagnosis and bleeding control.

 

Specific treatment. Give in all patients omeprazole 80 mg stat (immediately) IV and then 8 mg/h for 72 h. 

 

On variceal bleeding consider terlipresin 2mg Sc (subcutaneously) qds (4 times daily – consult BNF) (caution if peptic ulcer).

 

On a bleeding peptic ulcer or variceal bleeding consider octreotide 50 – 100 μg bolus followed by 25 – 50 μg /h infusion.

 

For variceal bleeding notify a gastroenterologist for emergency endoscopy and band ligation or sclerotherapy. If unavailable, consider Sengstaken – Blakemore or Minessota tube. Gine also omeprazole 40 mg PO.

 

 

 

MENINGITIS

Early symptoms: headache, cold hands & feet, abnormal skin color.

Later: neck stiffness, kerning’s (pain & resistance on passive knee extension with the hip fully flexede) & Brudzinski signs, photophobia, decreased LOC (level of consciousness), opisthotonus, seizures (20%), focal neurological signs (20%), coma, petechiae (non blanching – e.g. on placing an empty glass of water; petechiae may be 1 – 2 spots or none).

 

Sepsis: increased capillary refill time, hypotension, tachycardia (may not occur), DIC, pyrexia (or normal temperature!).

 

MENINGITIS ALGORITHM

ABCs, high flow 100% oxygen, IV access, fluids IVI.

 

A.     Septaemic signs predominate: cool hands and feet, increased capillary refill time, hypotension etc.

 

Don’t perform LP (lumbar puncture)! Give cefotaxime 2 gr IV. Call ICU.

 

1.      If signs of shock occur, then transfer to ICU for fluid resuscitation,

inotropes/ vasopressors, intubation and mechanical ventilation and perhaps activated protein C drotrecogin alfa (controversial). Aim for BP> 80 mmHg and urine output > 30 ml/h.

2.      If no signs of shock, monitor the patient.

 

B.    Meningitic signs predominate: neck stiffness, Kerning’s and Brudzinski signs, photophobia etc.

 

Give dexamethasone 4 – 10 mg/6h, IVI (0.15 mg/kg/6h). Give it just before the antibiotic. Administer it if suspected pneumococcal meningitis and on children. Avoid it in known meningococcal meningitis, septic shock, immunocompromised, TB and post operative meningitis!

If the patient has signs of increased ICP (intracranial pressure), transfer to ICU. Don’t perform LP (lumbar puncture)! If there is no shock and no signs of increased ICP, then do a LP. LP is CI (contraindicated) in suspected intracranial mass lesion, focal neurological signs, papilloedema, trauma, major coagulopathy, middle ear pathology (!), suspected increased ICP (e.g. decreased level of consciousness) and septemic signs of meningitis!

 

Papillioedema is a late sign. Also CT may not rule out increased ICP! In case there is contraindication for LP, perform first a CT head scan! However, before the CT scan give antibiotics!

Give cefotaxime 2 gr IV, immediately post LP (lumbar puncture). However, if LP is about to delay more than 30 min, give the antibiotic pre (before) LP!

 

Nurse the patient at 30 degrees level. Give fluids, however avoid over or underhydration. Isolate the patient for the 1^st 24 h. Also notify the CCDV (consultant in communicable disease control in the UK). 

Commonly used antibiotic for meningitis is cefotaxime 2 – 4 gr/ 8h IVI for 10 days (decrease dose in renal failure). Alternatives are ceftriaxone and vancomycin. In suspected Listeria and on patients > 55 years old & alcoholics add ampicillin 2 gr/ 6h.

 

 

ENCEPHALITIS

Signs & symptoms: odd behavior, confusion, decreased LOC (level of consciousness), coma, fever, headache, focal neurological signs, seizures.

 

Suspect it if history of travel or animal bite! Also suspect it if odd behavior, decreased LOC, focal neurological signs or seizures preceded by an infectious prodrome with fever, rash, lymphadenopathy, conjuctivitis and meningeal signs! If this infectious prodrome does not occur, then exclude encephalopathy, hypoglycemia, DKA (diabetic ketoacidosis), hypoxia, drugs, uremia, SLE, Wernicke’s syndrome (alcoholic, malnurished) and hepatic encephalopathy!

 

Investigations: Labs (blood culture, viral serology, PCR, throat swab, MSU mid stream urine culture, urine analysis, toxoplasma serology, malaria (blood thick films), contrast enhanced CT (do it before the LP lumbar puncture!), LP (lumbar puncture), EEG (electroencephalography).

 

Management: start empirically acyclovir within 30 min of the presentation! Dose is 10 mg/kg/ 8h IV over 1 h, for 2 weeks (3 weeks if immunocompromised) to cover HSV (herpes simplex virus). Adjust the dose according to the eGFR. For CMV encephalitis give ganciclovir IV; and for toxoplasma give pyrimethamine and sulfadiazine. For seizures give phenytoin. The patient may be needed to be transferred to the ICU.

 

 

CEREBRAL ABCESS.

Signs: fever, seizures, localizing signs or signs of increased ICP (intracranial pressure), coma. Suspect it in any patient with increased ICP, especially with fever and increased WCC (WBC)! It may occur after ear (Bacterioides fragilis or other anaerobes are common culprits if ear abscess), sinus, dental, or periodontal infection (in dental or frontal sinuses infection, the culprit is commonly Streptococcus milleri or anaerobes); also it may occur at congenital heart disease, skull fracture, endocarditis and bronciectasis!

 

Exclude immunesuppression.

 

In toxoplasma the lesions on CT are deeper (e.g. on basal ganglia).

 

Investigations: CT/ MRI.

Labs (increased ESR and WCC).

Biopsy!

 

Management: call neurosurgeon, treat increased ICP (see below).

 

 

STATUS EPILEPTICUS

Status epilepticus occurs when seizures last more than 30 min, without regaining consciousness. Mortality is high and therefore seizures lasting more than a few minutes need to be managed.

 

Status epilepticus may be NON – CONVULSIVE (e.g. continue partial seizures with preservation of consciousness or absence status epilepticus) and in that case look for subtle signs such as eye or lid movement or a single twitch! An EEG (electroencephalography) is very helpful. Also exclude pregnancy and eclampsia as a cause of seizures (check BP, urine protein and for oedema)!

 

Investigation: glucose finger stick test (!), ABGs (arterial blood gases), SaO2 (oxygen saturation), ECG/ monitor, EEG, Labs (UREA, creatinine, electrolytes – including calcium and magnesium, LFTs liver function tests, FBC/ CBC full/complete blood count, anticonvulsant levels !, toxicology – including carbon monoxide levels, drug levels (aspirin, acetaminophen, theophyllines!), +_blood & mid stream urine culture, +_ LP (lumbar puncture) +_ head CT.

 

STATUS EPILEPTICUS ALGORITHM

ABCs, open & maintain the airway, place in recovery position, remove dentures (if poor fitting), insert nasopharyngeal airway, intubate if necessary. Give 100% high flow oxygen & suction (if required).

IV access, Labs (see above), glucose (finger stick ward test & official Lab test)

Give 250mg thiamine IV over 10min in suspected alcoholism and malnourishment.

 

If glucose isn’t fast known, give glucose 50 ml of 50% solution. 

 

Also give naloxone 0.4 – 2 mg IV if opiate overdose is suspected (e.g. pin point pupils). Repeat every 2 min. Max 10 mg.

Give fluids if hypotensive

 

A.     Slow IV bolus phase for stopping seizures: give lorazepam 2 – 4 mg slowly (over 30 sec) IV into a large vein (repeat in 10 min if no response). Beware respiratory arrest during the last part of injection (have full resuscitation facilities bedside).

 

Alternative is diazepam (but is less long acting than lorazepam) which dose is 0.15 mg/kg e.g. 10 mg IV, slowly, over 2 min. If no response, repeat a dose of 5 mg every 3 – 4 min, until seizures stop or 20 mg dose have been given as total dose or if respiratory depression occurs. 

 

If IV access is difficult, diazepam may be given rectally, endotracheally or IO (intraosseously).

 

Diazepam, alternatively, may be given rectally, if IV access is difficult. The dose with rectal tubes is 0.5 mg/kg stat (immediately) e.g. give 3 tubes of 10mg PR (per rectum). If still no response after 10 min, then try another last 10 mg tube. The dose for the elderly is half.

 

Buccal midazolam is also an alternative. Dose for >_ 10 years old is 10 mg (1 ml); 1 – 4 years old is 0.5 ml; 6 – 12 months old is 0.25 ml. Squirt half of the volume between lower gum and the cheek on each side. Prepare other drugs while waiting this to work.

 

In case you don’t have buccal midazolam, you may try IV or (if IV access hasn’t been obtained) IM midazolam at dose of 0.2 mg/kg.

 

B.    IV infusion phase if seizures continue: give phenytoin 20 mg/kg IVI (1.2 g if 60 kg and 1.6 g if 80kg) at a rate of <_ 50 mg/min. If seizures still persist, an additional dose of 10 mg/kg may be given. Monitor BP and ECG! Beware hypotension! Don’t give if the patient has heart block or bradycardia! Maintenance dose is 100 mg/ 6 – 8 h (check blood levels). Don’t administer diazepam at the same line!

 

If the patient is already taking phenytoin, consider lower dose: 10 mg/kg IVI (500 mg – 1 gr total) or give valproate (see below).

 

Safer than phenytoin is fosphenytoin. Dose is 20 mg PE (phenytoin equivalents)/ kg IV/IM at rate of 150 PE/min.

 

NOTE: phenytoin is harmful to the veins, so flush the line after the infusion!

 

Alternative is diazepam infusion: mix 100 mg diazepam in 500 ml of 5% dextrose and infuse at rate of about 40 ml/h (3mg/ kg/ 24h). Beware respiratory depression (have resuscitation facilities available). If seizures recur after this, consider if they are pseudo – seizures, especially if odd (pelvic thrusts, resisting on eye lids opening, resisting on passive movements, arms and legs falling apart).

 

NOTE: give 10 mg dexamethasone IV if vasculitis or cerebral edema (e.g. from tumor) are possible.

 

Valproic acid is another agent used for refractory seizures. It is safer than the other drugs. Loading dose is 15 – 20 mg/kg. Intubation may be avoided by using this agent!

 

For refractory seizures you may also try midazolam at loading dose, as mentioned above, 0.2 mg/kg IV, followed by infusion of 0.05 – 2 mg/kg/h. Hypotension is rare compared to propofol. 

 

 

C.    General anesthesia phase: call anesthesiologist for paralysis and mechanical ventilation and monitoring in the ICU.

 

Propofol may be given (better by an anesthetist) at loading dose of 3 – 5 mg/kg, followed by infusion of 1 – 15 mg/kg/h. Monitor for hypotension!

 

 

HEAD TRAUMA

Call early a neurosurgeon, check pulse, BP temperature (!), respiration, pupils (size and reaction to light) every 15 min. Assess for anterograde (post traumatic) amnesia and retrograde amnesia (it occurs with anterograde amnesia). ABCs, Secure airway, Nurse semi – prone (if no suspected spinal trauma), place Foley.

 

Ventilate if coma (GCS <_8), hypoxemia, hypercapnia, spontaneous hyperventilation and irregular respiratory pattern.

 

CT scan is needed immediately in any of the following: patients with GCS< 13 at any time or GCS 13 or 14 at 2 h after the injury, focal neurological deficit, post traumatic seizures, vomiting (more than once), suspected open or depressed skull fracture or basal skull fracture. Also CT is needed if loss of consciousness and any of the following: age >_ 65, coagulopathy, anterograde amnesia (post traumatic) > 30 min and positive severe mechanism of injury (e.g. road traffic accident or fall from height).

 

Drowsy patients with GCS < 15 and > 8, smelling alcohol. Alcohol is unlikely to cause coma if plasma levels < 44 mmol/L. Alcohol levels can be also estimated by the osmolar gap. If osmolar gap is 40 mmol/L, then plasma alcohol is about 40 mmol/L.

NOTE: osmolar gap = measured osmolality – plasma osmolality. Plasma osmolality= 2 (K+Na) + urea+ glucose. Normal plasma osmolality is 280 – 300 mosmol/ kg. 

 

Don’t attribute signs to alcohol and illicit drugs without excluding a head trauma and increased ICP (intracranial pressure). You may need to perform a CT. Also, on a multitrauma patient, head trauma is unlikely to cause hypotension. Exclude hemorrhage (e.g. chest, abdominal, pelvis, major fracture) first.

 

 

HEAD TRAUMA ALGORITHM

 

ABCs, immobilize neck if cervical spine injury is suspected, give 100% high flow oxygen, intubate and ventilate if necessary. If GCS is <_ 8 (coma), intubate.

Stop bleeding, treat for shock if needed.

Treat seizures with lorazepam +_ phenytoin.

Assess GCS (Glasgow coma scale), pupils size & reaction to light, abnormal postures (flexion or extension posture), and also for anterograde (post traumatic) or retrograde amnesia and vomiting (more than once).

ABGs (arterial blood gases), SaO2 (oxygen saturation).

Labs: ΒUN (), creatinine, electrolytes, glucose, FBC/CBC (full/ complete blood count), blood alcohol, toxicology, coagulation studies.  Place a Foley.

Give tetanus immunization, if external trauma.

Brief history: AMPLE (Allergy, ,Medication, Past medical history, Last meal & Environment/ injury mechanism). Ask when, where and how did the trauma occur, if the patient had any seizures, if there was a lucid interval and if alcohol or drug abuse.

Check the lacerations of face or scalp. Palpate deep wounds and check for step deformity! Check for depressed skull fracture. Note any obvious skull or facial fracture.

Check also for CSF leakage from nose (CSF rhinorrhea), or ear (check the fluid for glucose, also see if it creates a halo when placing some drops on a newspaper). Check if there is any blood behind the ear drum (haemotympanium) and for blood from the ear canal (e.g. petrous bone fracture). Check also for periorbital ecchymoses (raccoon or panda’s eyes) or postauricular ecchymoses (Battle’s sign). If any of the above occur, suspect basilar skull fracture. Perform a CT, give Tetanus immunization and refer to neurosurgeons.

Palpate the cervical area for tenderness and deformity. If detected, or if the patient has head trauma or injury above the clavicle with loss of consciousness, immobilize the neck with a collar and take C – spine X’ Rays.

Image tests: head CT, CXR (chest X’ Ray), C (cervical) spine X’ Rays. 

 

 

 

RAISED ICP (INTRACRANIAL PRESSURE)

Causes: head trauma, tumors (primary or metastatic), hemorrhage (subdural, extradural, subarachnoid, intracerebral, intraventricular), hydrocephalus, infection (meningitis, encephalitis, brain abscess), cerebral edema, status epilepticus, severe metabolic abnormality. 

 

Signs & symptoms: headache, obtundation, drowsiness, vomiting, seizures, listlessness, irritability, Cushing triad (rising BP, falling pulse rate and irregular respirations), pupil changes (initially constriction, later dilation; don’t use pupil dilating eye drops for fundoscopy, at least not before the neurological examination), anisokorian (unequal pupils), decreased visual aquity, visual fields loss, pupilloedema (unreliable sign). Venous pulsation at the optic disc may be absent; remember that is absent in about 50% of normal population; but loss is a sign and retinal vein pulsation in fundoscopy may exclude increasing of ICP.

 

Investigations: UREA, creatinine, glucose, FBC/ CBC (full/ complete blood count), serum osmolality, LFTs liver function tests, coagulation studies, blood culture. 

 

Plasma osmolality= 2 (K+Na) + urea+ glucose. Normal plasma osmolality is 280 – 300 mosmol/ kg. 

 

 

Place a Foley (urinary catheter).

 

CXR (chest X’ Ray), SaO2 (oxygen saturation), head CT, LP (after the head CT! Also measure the opening pressure!).

 

RAISED ICP ALGORITHM

ABCs. Maintain airway. High flow oxygen.

Correct hypotension with fluids. Treat seizures. You may need to give seizure prophylaxis.

Brief history: AMPLE (Allergy, Medication, Past medical history, Last meal & Environment/ injury mechanism).

Brief examination. Check for rash (meningitis?). Any tumor?

Elevate the head of bead to 30 – 40 degrees (if not hypotension!)

If intubated and neurological deterioration/ impending herniation (Cushing triad: rising BP, falling pulse rate and irregular respirations; also pupil changes (initially contralateral dilation, anisokoria – implying III cranial nerve entrapment), hyperventilate to decrease PaCO2 (target is Pa CO2 25 – 30 mmHg), for a short time! This causes cerebral vasoconscriction and will fast decrease ICP.

If not hypotensive, use osmotic agents such as mannitol 1 – 2 gr/kg  of 20% solution  (e.g. 5 ml/kg) over 10 – 20 min. Effect is seen after about 20 min and lasts 2 – 6 h. However, prolonged use for 12 – 24 h may lead to rebound ICP increase. Check serum osmolality. Aim for plasma osmolality about 300 mosmol/kg, but don’t exceed 310 molsmol/kg!

NOTE: plasma osmolality= 2 (K+Na) + urea+ glucose. Normal plasma osmolality is 280 – 300 mosmol/ kg. 

If not hypotensive, you may also try Lasix (furosemide) 0.3 – 0.5 mg/kg. Check potassium.

For increased ICP from focal causes (e.g. haematoma from trauma) call a neurosurgeon. Craniotomy or burr holes may be needed. However, surgery doesn’t help on ischemic or anoxic brain injury.

For edema surrounding head tumors give dexamethasone 10 mg IV and continue with 4 mg/6h IV/PO.

If not hypotensive, restrict fluids to < 1.5 L/day.

Consider invasive ICP monitoring. Normal ICP (intracranial pressure) is 0 – 10 mmHg.

 

Treat exacerbating factors e.g. hypoglycemia or hyponatraemia!

Definite treatment.  In persistent ICP increase, a barbiturate (inducing) coma in the ICU may be tried.

 

 

 

DIABETIC KETOACIDOSIS (DKA)

Signs symptoms: gradual decrease of LOC (level of consciousness), vomiting, dehydration, abdominal pain (!), polyuria, polydipsia, ketotic breath (!), anorexia, drowsiness, lethargy, coma, deep sighing – Kussmaul’s respirations (hyperventilation). Almost always involves DM (diabetes mellitus) type 1 (rarely on type 2).

 

Diagnosis is acidosis (PH< 7.3), serum bicarbonate <_ 15 mEq /L, hyperglycemia (glucose > 20 mmol/L or > 250 mg/dL), Ketosis! (ketonuria or serum ketones).

 

Precipitating factors for DKA are infection (lung, skin, urine, perineum), surgery, MI (myocardial infarction), pancreatitis, antipsychotics, chemotherapy, wrong insulin dose, non compliance to DM therapy.

 

Tests: Urine (ketones, mid stream urine for glucose).

ABGs (arterial blood gases), SaO2 (oxygen saturation), CXR (chest X’ Ray). 

 

Labs - blood: glucose, CBC/ FBC (complete/ full blood count), UREA, creatinine, electrolytes, amylase, bicarbonates HCO3, cardiac markers & enzymes, osmolality, blood (+_ urine) cultures. Plasma osmolality= 2 [Na +K] + [urea] + [glucose] mmol/L. Normal is 280 – 300mosmol/kg. 

 

 

DKA (DIABETIC KETOAXIDOSIS) ALGORITHM

DKA may manifest with abdominal pain!

 

Check plasma glucose. It is > 20 mmol/L (250 mg/dL). Usually is > 360 mg/dL. If so, give 4 – 8 units soluble insulin IV (Actrapid or Humalin S). The insulin dose is 0.1 – 0.15 units/kg.

 

Check potassium! If potassium is low (< 3.3 mmol/L) don’t give insulin because it will decrease it!! In that case, first replace fluids and potassium.

IV access. Tests (see above)

Fluid replacement. Give 1 L of 0.9% saline stat (immediately).

Then give 1 L over the next hour, 1 L over 2 h, 1 L over 4 h and then 1 L over 6h. Adjust according to urine output. When glucose is < 10mmol/L (180 mg/dL) use D5W (5% dextrose). Caution on the elderly and patients with CCF (congestive heart failure). These patients need less saline, with caution (a CVP line would be helpful).

K (Potassium) replacement

Total body K is low and plasma K falls as K enters into the cells with the insulin treatment. Do not add K at the 1^st bag (which is given immediately)! Monitor urine output hourly. Add K when urine flow is > 30 ml/h! Check UREA and electrolytes hourly, initially.

 

Serum K (mmol/L)………………….……Amount of KCl added per L of fluid

< 3 …………………………………………………………………………...40 mmol

3 – 4…………………………………………………………………………30 mmol

4 – 5…………………………………………………………………………20 mmol

In renal failure and oliguria, less K will be needed.

 

Place a NG (nasogastric) tube if nausea, vomiting or unconscious. Place also a Foley (especially if no urine passes after 3 h or if the patient is in coma).

Insulin is given via a pump diluted to 1 unit/mL (add 50 units of soluble insulin Actrapid/ Humalin S to 50 ml normal saline in a syringe). See the sliding scale of insulin (below) e.g. for severe DKA start at about 6 Units/h for adults. Expect blood glucose to fall by 5 mmol/L/h (90 mg/ dL/ h). If poor response, double or quadruple the rate. When blood glucose is < 10 mmol/L (180 mg/dL), decrease the rate to 3 units/ h and continue until food by mouth is possible. Don’t stop the pump until routine Sc (subcutaneous) insulin has been initiated. Check the ABGs if the acidosis has been corrected.

Sliding scale of insulin via IVI pump in DKA

 

Hourly glucose……….Soluble insulin (U/h)………………………… Insulin if  

 

………………………………………………............................................infection ………………………………………………………………...or insulin resistance 

mmol/l (mg/ dL)……………………………………………………………………...

 

0 – 3.9 (0 – 70)…………………0.5………………………………………………...1

4        – 7.9 (71 – 143)………...1…………………………………………………..2

8– 11.9 (144 – 216)…………….2………………………………………………….4

12   – 16 (217 – 290)………...3………………………………………………….6

>16 (> 290)………………4………………………………………………….8

 

 

 

In case you don’t have a pump, give loading dose 20 units IM, then give 4 – 6 units IM, while glucose is > 10 mmol/L (180 mg/dL). Then decrease to 2/ h.

 

Check GCS (Glasgow Coma Scale), glucose, UREA, creatinine, electrolytes and bicarbonate HCO3 often (initially hourly).

Check also vitals, urine output, urine ketones. CVP monitoring may help fluid replacement (especially in the elderly and if CHF congestive heart failure).

Continue fluid and potassium replacement. Treat any precipitant infection (lung, skin, urine, perineum), after taking cultures.

Give LMWH (low molecular weight heparin) until the patient is mobile.

Change to Sc (subcutaneous) insulin when ketones are <_ 1+ and the patient can eat.

Check what precipitated the DKA in order to prevent a new one.

 

Complications: cerebral oedema (CNS deterioration), hypokalaemia, aspiration, hypomagnesaemia, hypophosphataemia, TE (thromboembolism) & PE (pulmonary embolism)!

 

 NOTES:

·        Plasma glucose may not be high at presentation if insulin is continued!

·        High WCCs (WBCs) in DKA may occur without infection!

·        Infection can occur without fever! Perform blood & MSU (midstream urine) cultures. Perform a CXR (chest X’ Ray). Give broad spectrum antibiotics (e.g. co - amoxiclav) at suspected infection. 

·        Clasma creatinine may be unreliable because some assays for creatinine cross react with ketone bodies!

·        Hyponatraemia is common (osmolar compensation with hyperglycemia)!

·        Increased or stable Na (sodium) indicates severe dehydration. During treatment, sodium raises as water enters the cells. Sodium may also be low as artifact! Corrected plasma sodium: Na + 2.4 [(glucose mmol/L – 5.5)/ 5.5].

·        Ketonuria ++ may occur after an overnight fast. If glucose is normal, check alcohol.

·        Test also plasma ketones.

·        On acidosis without elevated glucose exclude other causes e.g. drug overdose (e.g. aspirin) and lactic acidosis (e.g. in elderly diabetics).

·        Serum amylase may be up to 10 fold raised with non specific abdominal pain, in the absence of pancreatitis. 

·        Maintaining a constant rate of insulin (e.g. 4 – 5 units/h) IVI and co-infusing 10% or 20% dextrose to keep plasma glucose at 6 – 10 mmol/L (108 – 180 mg/ dL) will prevent recurrent DKA.

 

 

 

 

HYPERGLYCAEMIC HYPEROSMOLAR NON – KETOTIC COMA (HONK)

It typically occurs in patients with DM (diabetes mellitus) type 2. There is a prolonged period of dehydration (e.g. 1 week) and glucose > 35 mmol/L (636 mg/dL), but without acidosis, neither urine ketones. The patient is usually old, with DM type II and usually presenting for the 1^st time. Osmolality is> 340 mossmol/kg.

Note: Plasma osmolality= 2 [Na +K] + [urea] + [glucose] mmol/L. Normal is 280 – 300mosmol/kg. 

 

Precipitants are MI (myocardial infarction), drugs, mesenteric ischemia, GI bleeding etc.

 

Labs: CBC/FBC (complete/full blood count), UREA, creatinine, electrolytes, plasma osmolality, blood & urine cultures, cardiac markers & enzymes, bicarbonate HCO3, urine ketones, urinalysis.

 

Also ECG, SaO2 (oxygen saturation), ABGs (arterial blood gases), CXR (chest X’ Ray). 

 

There is also risk for DVT (deep vein thrombosis), focal CNS signs, stroke, DIC, leg ischemia and rhabdomyolysis! Heparin prophylaxis is needed. Give e.g. 5000 units IV over 30 min.

 

Management: rehydration with e.g. 9 L of normal saline 0.9% over 48 h. Use half the dose of DKA fluid replacement. Place a Foley. Wait urine to flow and then replace potassium! Wait 1 h before you give insulin which it may not be needed. Avoid rapid changes that may precipitate pontine myelinolysis! However, if insulin is needed, give e.g. 1 unit/h.

 

Hyperlactataemia is a rare complication of DM (diabetes mellitus) after metformin therapy or sepsis. Blood lactate is > 5 mmol/L. Give oxygen. Treat sepsis. Call ICU.

 

 

HYPOGLYCAEMIC COMA

Usually has fast onset. Initial symptoms are odd behavior (e.g. aggressiveness), sweating, tachycardia (may not occur if on β’ blockers!). Untreated it will lead to seizures and coma. It may also cause hemiparesis and mimic stroke!

 

Causes: insulin or hypoglycaemics wrong dose, insulinoma, Addisonian crisis, myxedema, hypopituitarism, liver failure, IgF1 tumors, Hodgkins disease, poisoning (e.g. salicylates) and alcoholism – intoxication.

 

Therapy: give immediately 50 – 100 ml of 50% dextrose, slowly (e.g. over 5 min). However this is harmful for the veins (so use a large vein and after the infusion flush it with normal saline), so you may alternatively give 20 – 30 gr dextrose IV – for example you can give 200 – 300 ml of 10% dextrose. Glucagon 1mg IV/IM is an alternative, but will not work on intoxicated (drunk) patients and generally in patients with low glucogen stores (starvation, chronic hypoglycemia, adrenal insufficiency – Addison’s). In that case give also dextrose.

When the patient regains his/her consciousness, give drinks with sugar and bread.  

 

 

MYXOEDEMA COMA

Often occurs on patients > 65 years old. Signs & symptoms include hypothermia (!), decreased reflexes, hypoglycemia, bradycardia (!), non pitting oedema (puffy eye lids, hands, feet), goitre, cyanosis, hypotension (cardiogenic), heart failure (!), pericarditis, psychosis (myxoedema madness!), seizures, coma. 

 

Signs of hypothyroidism: BRADYCARDIC: Bradycardia, decreased Reflexes, cerebellar Ataxia, Dry thin hair/ skin, Yawning/ drowsy/ coma, Cold hands, +_hypothermia, Ascites, +_non pitting edema on lids/ hands, feet, +_ pericardial/ pleural effusion, Round puffy face/ obese/ double chin, Defeated demeanour, Immobile, +_ illeus, CCF congestive heart failure; also neuropathy, myopathy, +_ goiter.

 

Precipitants are: prior surgery (thyroidectomy) or radioiodine therapy for hyperthyroidism, hypopituitarism (!), MI (myocardial infarction), stroke, infection, trauma. 

 

Complications: hypoglycemia(!), pancreatitis, arrhythmias, MI, pericarditis. 

 

 

MYXOEDEMA COMA ALGORITHM

 

Consider transferring to ICU.

High flow oxygen if cyanosis. Consider intubation and mechanical ventilation.

Labs: Τ3, Τ4, fT3, fT4, TSH, UREA, creatinine, electrolytes (check for hyponatraemia!), glucose, cortisol (blood 10 ml heparin or clotted), ACTH (blood 10 ml heparin, transfer immediately to Lab), cardiac enzymes & markers, amylase, blood/ urine cultures.

 

CXR (chest X’ Ray), ABGs (arterial blood gases), ECG. 

Correct hypoglycemia!

Administer 5 – 20 μg/ 12h T3 (liothyronine) slowly IV (caution in suspected ischemic heart disease – you may precipitate cardiac ischemia!). Alternative drug is levothyroxine T4. Also give hydrocortisone 100 mg/8h IV. It will help in suspected hypopituitarism (no goiter, no previous therapy with radioiodine, no previous thyroidectomy).

Give 0.9% normal saline (caution if LVF left ventricular failure).

In suspected infection give cefuroxime 1.5 g/8h IVI.

Treat heart failure. Consider vasopressors if hypotension.

Treat hypothermia (warm blankets in warm room & warm drinks if conscious)

 

Therapy is continued with 5 – 20 μg T3 every 4 – 12 h IV for 2 – 3 days, and then levothyroxine T4 50 μg/ 24 h PO. Give also hyodrocortisone & fluids. Hyponatraemia is dilutional.

 

 

 

HYPERTHYROID CRISIS (THYROTOXIC STORM)

Signs & symptoms: women : men = 4 : 1, pyrexia/ hyperthermia (!), agitation, tachycardia, AF (atrial fibrillation), diarrhea, vomiting, goitre, thyroid bruit, abdominal pain (!  exclude surgical causes), heart failure, hypotension (cardiogenic), confusion, coma.

 

 

Signs of hyperthyroidism: fast/ irregular pulse (SVT supraventricular tachycardia or AF atrial fibrillation, rare VT ventricular tachycardia), warm moist skin, palmar erythema, fine tremor, thin hair, lid lag, lid retraction, +_ goiter, +_ thyroid nodules or bruit. On Graves: exophthalmos, ophthalmoplegia, pretibial myxedema, thyroid acropachy.

 

Precipitants: recent thyroid surgery, radioiodine, MI (heart attack), infection, trauma.

 

Confirm diagnosis with 99mTc (technetium) uptake scan. 

 

HYPERTHYROID CRISIS (THYROTOXIC STORM) ALGORITHM

Administer IVI 0.9% saline 500 ml/4h. Put NG (nasogastric) tube if the patient is vomiting.

Labs: Τ3, Τ4, fT3, fT4, TSH, blood & urine cultures in suspected infection

 

ECG, cardiac enzymes & markers, ABGs (arterial blood gases), SaO2 (oxygen saturation).

Sedation if needed (e.g. chlorpromazine 50 mg PO/IM). Monitor BP.

For dysrhythmias, If no CI (contraindication) and if normal cardiac output, give propranolol 40 mg/8h PO (orally). IV dose of propranolol is 1 mg IV slowly over 2 – 5  min. You may repeat propranolol at >_ 2 min intervals to a total max IV dose 0.1 mg/kg. If asthma or low cardiac output don’t give propranolol, but consider the short acting β’ blocker esmolol. Dose of esmolol is 250 – 300 mcg (μg)/ kg/min.

 

β’ Blockers are contraindicated in severe CHF (congestive heart failure), asthma/ COPD, bradycardia, 2^nd or 3^rd degree AV (atrioventricular) block, hypotension and cardiogenic shock. 

On tachyarrhythmia you may also need to administer high dose digoxin e.g. 1 mg over 2 h IVI.

 

Administer carbimazole 15 – 25 mg/ 6h PO (orally) or via NG tube (if vomiting). After 4 h give Lugol solution 0.3 ml/8h PO diluted in water. Continue Lugol for 1 week. After 5 days reduce carbimazole to 15 mg/8h PO.

Administer hydrocortisone sodium succinate 100mg/ 6h or dexamethasone 4 mg/6h PO.

Treat any suspected infection e.g. with cefuroxime 1.5 gr/8h IVI.

If hyperthermia, cool with tepid sponging +_ paracetamol (acetaminophen).

If no improvement in 24 h, consider thyroidectomy. Consult an expert anesthetist & surgeon.

 

 

 

ADDISONIAN CRISIS (ADRENAL INSUFFICIENCY)

Signs & symptoms: may present with shock, with tachycardia, postural hypotension (!), oliguria, confusion, coma! May occur in a patient taking steroids and discontinuing them abruptly or forgetting to take them, or not increasing them in stress such as infection, trauma or surgery! Also may be caused by bilateral adrenal hemorrhage e.g. on Waterhouse Friderichsen syndrome from meningococcaemia.

 

Signs of adrenal insufficiency (Addison’s disease): lean, tanned, tired, weakness, anorexia, faints, dizzy, myalgia, arthralgia, flue like, lassitude, depression, psychosis, nausea, vomiting!, abdominal pain!, diarrhea/ constipation, vitiligo!, pigmented palmar creases & buccal mucosa!, postural hypotension. In deterioration: shock, hypotension, tachycardia, pyrexia, coma. Also hyponatraemia and hyperkalaemia!

 

ADDISONIAN CRISIS ALGORITHM

If suspected, treat before biochemical results. Give hydrocortisone sodium succinate 100 mg IV stat (immediately). 

Labs: cortisol (blood 10 ml heparin or clotted) and ACTH (blood 10 ml heparin, transfer immediately to Lab).

Also blood, MSU (mid stream urine) & sputum culture.

Administer IV normal saline 0.9%

Monitor blood glucose for hypoglycemia! Give glucose if hypoglycemic.

Give antibiotics in suspected infection (after cultures have been taken) such as cefuroxime 1.5 gr/8h IVI. 

Continue IV fluids guided by clinical state. Correct electrolyte abnormalities. Check for hyponatraemia and hyperkalaemia!

Continue hydrocortisone sodium succinate 100 mg/ 6h IV or IM. Change to oral steroids after 72 h, if the patient has been improved.

 

You can’t do the tetracosactrin – Synacthen test while on hydrocortisone. In case you initially treated the patient with dexamethasone, you may still do the test.

You may need to give fludrocortisones (e.g. 50 – 200 μg daily PO) in adrenal disease.

Treat any underlying cause. Consult early an endocrinologist. 

 

 

HYPOPITUITARY COMA

It may manifest with hypothermia, refractory hypotension & septic signs without fever. The patient may have short stature, loss of axillary and pubic hair, and gonads atrophy.  It usually develops gradually in a patient with known hypopituitarism e.g. from pituitary tumor. It may occur rapidly after a pituitary infarction e.g. at Sheehan’s syndrome (post partum). Symptoms include meningism & headache and often is misdiagnosed as subarachnoid haemorrhage!

 

Causes:

a. Ηypothalamus: Kallman’s syndrome: (gonadotropin releasing hormone deficiency with anosmia and color blindness), tumor, inflammation, infection (such as meningitis or TB), ischemia.

b. Pituitary stalk: trauma, surgery, craniopharyngioma, meningioma, carotid artery aneurysm.

c. Pituitary: tumor, inflammation, irradiation, autoimmune causes, infiltration on hemochromatosis, amyloidosis, metastases; ischemia: pituitary apoplexy, DIC, Sheehan’s syndrome postpartum.

 

Signs & symptoms: headache, ophthalmoplegia, decreased LOC (level of consciousness), hypotension, hypothermia, hypoglycemia and signs of hypopituitarism.

 

Specifically, signs of deficiency of:

 

GH: central obesity, dry wrinkly skin, lassitude, decreased balance, decreased cardiac output!, decreased exercise ability, hypoglycemia!, osteoporosis);

 

Gonadotropins FSH/ LH:

a. women: oligomenorrhoea/ amenorrhoea, decreased fertility and libido, breast atrophy, osteoporosis, dyspareunia.

b. men: erectile dysfunction, decreased libido, decreased muscle bulk, hypogonadism with decreased hair of body, small testes, decreased ejaculate volume and spermatogenesis.

 

Thyroid: hypothyroidism: BRADYCARDIC: Bradycardia, decreased Reflexes, cerebellar Ataxia, Dry thin hair/ skin, Yawning/ drowsy/ coma, Cold hands, +_hypothermia, Ascites, +_non pitting edema on lids/ hands, feet, +_ pericardial/ pleural effusion, Round puffy face/ obese/ double chin, Defeated demeanour, Immobile, +_ illeus, CCF congestive heart failure; also neuropathy, myopathy, +_ goiter.

 

Corticotrophin: as adrenal insufficiency: lean, tanned, tired, weakness, anorexia, faints, dizzy, myalgia, arthralgia, flue like, lassitude, depression, psychosis, nausea, vomiting!, abdominal pain!, diarrhea/ constipation, postural hypotension; no skin pigmentation!

 

Prolactin PRL: rare; absent lactation.

 

Labs: cortisol (blood 10 ml heparin or clotted), ACTH (blood 10 ml heparin, transfer immediately to Lab), T3, T4, fT3, fT4, TSH, glucose.

 

 

Imaging tests: pituitary fossa CT/ MRI.

 

HYPOPITUITARY COMA ALGORITHM

Don’t wait Lab results for treatment. Start treatment stat (immediately).

Administer hydrocortisone sodium succinate e.g. 100 mg IV/ 6h.

Only after administering hydrocortisone, you may give liothyronine (Τ3) e.g. 10 μg/ 12h PO (orally) or 5 – 20 μg/ 12h slowly IV (initially may be needed 4 hourly).

In pituitary apoplexy consult a neurosurgeon, as emergency surgery may be needed.

 

 

 

PHAEOCHROMOCYTOMA WITH HYPERTENSIVE CRISIS

Pheochromocytoma is a catecholamine secreting tumor, typically at the adrenal medulla. Usually presents as paroxysmal or sustained hypertension in young to middle aged patients!

 

Signs & symptoms of hypertensive crisis from pheochromocytoma: flushing, palpitations, pallor, pulsating headache, profuse diaphoresis, hypertension!, feeling about to die, pyrexia, LVF (left ventricular failure), ST elevation on ECG, VT (ventricular tachycardia), cardiogenic shock. Also chronic weight loss, orthostatic hypotension !! & impaired glucose tolerance.

 

Precipitating factors: stress, abdominal palpation (!), parturition (labor), general anesthetic, contrast media (except IV contrast media with low osmolality).

 

Labs: 24 h urine catecholamine metabolites and/or and plasma free metanephrines.

 

Diagnosis: MIBG isotope scan, CT/MRI, angiography.

 

Treatment: for a – adrenergic blockage give Phentolamine 1 – 2 mg IV. You may repeat every 5 min until BP has decreased.

 

Alternative drug is labetalol with dose 10 – 20 mg IV boluses every 10 min.

 

In severe tachyarrhythmias use β’ blockers. However, give the β’ blockers only after sufficient a – blockage is initiated, otherwise the β’ blockers may cause severe hypertension!

 

When BP is controlled, give the a – blocker phenoxybenzamine 10 mg/ 24 h PO (increase by 10 mg/ day as needed, up to 30 mg bd twice daily PO per os – i.e. orally). It may cause idiosyncratic severe BP drop after 1^st dose. You need to increase the dose until BP is controlled, but without severe postural hypotension. A β1 blocker may then be given to control tachycardia or myocardial ischemia or arrhythmias.

 

Surgery is done electively after 4 – 6 weeks, after full a – blockage and volume expansion. 

 

 

 

ARF (ACUTE RENAL FAILURE)

It is defined as acute (hours to days) renal function deterioration with rise in serum creatinine, ureaand usually with oliguria or anuria.

 

Causes: hypovolaemia/ low cardiac output, sepsis, drugs, glomerulonephritis, obstruction (stones, blood, clot, tumor, sloughed papilla, abdominal/ pelvic mass/ tumor, retroperitoneal fibrosis) vasculitis, hepatorenal syndrome etc.

 

ARF ALGORITHM

Priorities: Check immediately BP, urinary protein, urinary sediment, serum potassium K, urea, creatinine & electrolytes. Also perform ultrasound.

IV access, catheterize the bladder (Foley), check hourly urine output and write complete fluid charts. Consider central venous cannula for CVP. Also check fluid balance sheet.

Assess BP, ABGs (arterial blood gases), SaO2 (oxygen saturation), JVP, CVP, skin turgor, weight. Attach to cardiac monitoring and take a 12 Lead ECG. Take a CXR (chest X’ Ray).

Examine for masses PR (per rectum) and PV (per vaginum), and for palpable bladder. On PR examination feel the prostate. If obstruction is suspected, perform an urgent US (ultrasound) and consider bilaterally nephrostomies to relieve obstruction, to take urine for culture and perform anterograde pyelography.

Labs: urea, creatinine, electrolytes (including calcium & phosphate), CBC/FBC (complete/full blood count), ESR, CRP, LFT liver function tests, LDH, coagulation studies including INR, CK, hepatitis serology, protein electrophoresis, blood & urine cultures, autoantibodies: ANAs, c & p ANCAs, anti – GBM, ant LKM, complement such as c3 & c4; ASO.

Urgent urine microscopy and cultures. Check urine for white cell casts (infection, interstitial nephritis) and red cell casts (inflammatory glomerular condition). 

Indentify & treat hyperkalaemia! (see below)

Treat any precipitating cause such as blood transfusion for hypovolaemia, antibiotics for sepsis, nephrostomy for obstruction etc. 

In case of pulmonary edema, pericarditis or cardiac tamponade consider urgent dialysis. If pulmonary edema, but no dieresis is established, consider removing 1 unit of blood, before dialysis!

 

A.     If the patient is dehydrated, give 250 – 500 ml of saline over 30 min. Use a large bore line in a large vein (central vein access may be risky in volume depletion).

Reassess. If still the patient is dehydrated, repeat fluids. Aim for CVP 5 – 10 cm.

When fluids are repleted, give fluids 20 ml PLUS the previous hour urine output/h.

 

B.    If there is volume overload, consider urgent dialysis. Consider nitrate infusion, furosemide (Lasix 120 – 500 mg IV; if oliguric or anuric give 120 – 250 mg IV and then 5 – 10 mg/h), or renal dose of dopamine (2 – 5 mcg/kg/min).

Correct acidosis with sodium bicarbonate 8.4% 1 ml/kg (1 mEq/kg) e.g. 50 ml of 8.4% IV.

 

C.    Consider urgent dialysis on persistent hyperkalaemia (K > 6 mmol/L), acidosis (PH<7.2), pulmonary edema without established diuresis, pericarditis and also in high catabolic state. In cardiac tamponade first perform needle decompression!  

If sepsis is suspected, take cultures and give antibiotics (avoid nephrotoxic drugs such as gentamycin or sulfamethoxasole – tremethoprim SMX TMP). Check first the GFR.

Also remove possible sources of sepsis e.g. non essential IV lines.

Avoid nephrotoxic drugs such as gentamicin, amphotericin or NSAIDs.

Check all drugs that have been administered. Is there any drug responsible for the impaired renal function.

Treat also pulmonary edema, pericarditis & cardiac tamponade with dialysis (on tamponade first do percardiocentesis!). If pulmonary edema without established diuresis, consider removing 1 unit of blood before dialysis!

Consider renal biopsy.

In renal failure there is a high catabolic state. Diet should be with high calories (2000 – 4000 Kcal daily), with adequate high quality protein. In severe cases, nutrition may be given by NG (nasogastric) rout or parenterally.

 

 

 

HYPERKALAEMIA (e.g. on renal failure)

Normal potassium (K) is 3.5 – 5 mmol/L. Potassium > 6.5 mmol/L needs urgent treatment.

 

Causes: oliguric renal failure, potassium sparing diuretics (e.g. spironolactone, amiloride), rhabdomyolysis, compression syndrome (trauma), metabolic acidosis, excess K administration, Addison’s disease (see above), massive blood transfusion, burns, drugs (e.g. ACE inhibitors, suxamethonium), artifact.

 

In artifact hyperkalaemia the patient doesn’t look unwell and also ECG is normal. Repeat the Lab test for K! Artifact hyperkalaemia may occur from hemolysis (difficulty on venepunctrure, the patient has the fist clenched), contamination with potassium EDTA anticoagulant in FBC/CBC (full/ complete blood count) bottles (so do FBC/CBC analysis after the urea& electrolytes estimation), delayed analysis (long time to reach the Lab, the K exits the RBCs) and also in thrombocythaemia (K exits the platelets during clotting). 

 

ECG: tall tented T waves, may have small or flat P waves and increased PR interval. On severe hyperkalaemia the QRS widens and there untreated leads to VT (ventricular tachycardia)/ VF (ventricular fibrillation).

 

HYPERKALAEMIA ALGORITHM

Monitor ECG. Treat the underlying cause! Review the medications!

In severe hyperkalaemia administer 10 ml calcium gluconate 10% or calcium chloride KCl over 2 min into a large vein with a large cannula (it may cause skin necrosis if extravasated). Calcium protects the heart, but does not affect the K levels!

If not severely hyperglycaemic, administer 10 units rapid acting insulin (e.g. insulin Actrapid) with 50 ml of 50% glucose (dextrose) into a large vein, over 30 min. Check glucose levels to avoid hypoglycemia. You may repeat the above regimen. Insulin moves the K into the cells.

Administer sodium bicarbonate 1 ml/kg (1 mEq/kg) 8.4% IV e.g. 50 mmol (50 ml) of 8.4% solution IV over 5 min.

Administer furosemide (Lasix) 1 mg/kg slowly IV.

Administer nebulized salbutamol 2.5 mg. It also moves the K into the cells.

 

Give polystyrene sulphonate resin (e.g. Calcium Resonium 15g/ 6 – 8h diluted in water) PO (orally) or (if vomiting) as enema 30 gr, followed by bowel irrigation after 9 h, in order to remove the K from the colon.

Consider dialysis if K is persistently high (> 6 mmol/L).

 

 

 

ACUTE POISONING – GENERALLY

 

Signs and culprit drug OD (overdose)/poison/toxin:

 

Tachycardia or irregular pulse: salbutamol (high doses), TCAs (tricyclic antidepressants), quinine, phenothiazines, anticholinergics.

 

Respiratory depression: barbiturates, phenothiazines, opiates.

 

Coma: usually from barbiturates, benzodiazepines, alcohol, opiates, TCAs (tricyclic antidepressants).

 

Seizures: theophyllines(!), hypoglycaemics, illicit drug abuse, TCAs (tricyclic antidepressants), phenothiazines. 

 

Hyperthermia: amphetamines, MAO inhibitors, cocaine, ecstasy, aspirin(!)

 

Hypothermia: barbiturates, phenothiazines. Also exclude hypothyroidism.

 

Dilated pupils: cocaine, amphetamines, quinine, TCAs (tricyclic antidepressants).

 

Constricted pupils: opiates, organophosphates (insecticides). Also exclude pontine hemorrhage.

 

Hyperglycemia: MAO inhibitors, theophylines, organophosphates.

 

Hypoglycemia: insulin, oral antidiabetic agents, alcohol, salicylates (!)

 

Metabolic acidosis: alcohol (ethanol), methanol, ethylene glycol, paracetamol (acetaminophen), CO (carbon monoxide).    

 

Increased plasma osmolality: alcohol (ethanol), methylen alcohol, ethylene glycol.

NOTE: plasma osmolality= 2 (K+Na) + urea+ glucose. Normal plasma osmolality is 280 – 300 mosmol/ kg. 

 

Renal failure: salicylates, ethylene glycol, paracetamol (acetaminophen).

 

Visual impairment/ blindness: methanol.