• Commonest by far is hypo
• Insulin
  
• Alcoholics
• Don't respond to glucagon (no reserves)
• Oral hypoglycaemics
• Neonates
• Management
• 200 ml 10% glucose
• Admit if on oral hypoglycaemics
• Long acting => Rebound hypo
• Can use octreotide (off-label)
• Send home for GP / clinic f/u if due to insulin
• If they don't wake up..
• Could be long hypo => neurological damage / cerebral oedema
  
• Could be Addisonian
• Cbeck cortisol
• Give IV hydrocortisone

DKA / HHS

• Management
• Fluids
• Replace 1/3 of deficit in first 24 hrs
• 1 L in first hour
• Add 20 mM K+ to second litre if K+ < 5 (as will fall rapidly)
• Twice-normal saline may be indicated in HHS, with senior input
  
• Insulin (actrapid)
  
• 6 U per hour while glucose >20
• 2 U per hour when glucose <20
• 2 U per hour + 10% dextrose when glucose <14, until ketones gone

Hyperkalaemia

• Causes
• Acidosis
• Addisons
• Renal failure
• Esp. pre-renal due to hypovolaemia
• Potassium-sparing diuretics
• Massive transfusion
• ACEi
• Rhabdomyolysis
• Haemolysis of sample
• Management
• 10 ml 10% calcium gluconate
• Repeat up to 30 ml if ECG changes persist
• 10 mg nebulised salbutamol, while you're drawing up the..
• 50mL of 50% dextrose with 10 units of soluble human insulin, over 15 mins
• Dialysis if required

PE

• Three (and only three) possible presentations
• Isolated SOB
• Pleuritic chest pain +/- haemoptysis
• Collapse
• They like to lie FLAT to better perfuse the lungs, unlike most other causes of SOB
• Give fluids (even if heart strain/raised JVP) for the same reason
  
• Risk factors
• Malignancy, Pregnancy, Obesity, Age, Immobilisation, >6 hr travel in last 4 weeks, Coagulopathy, Previous PE/DVT, FHx, Hormones
• Investigations
• CXR to exclude other causes
• May see wedge-shaped infarct
• ECG
• Sinus tachy.
• Non-specific ST/T wave abnormalities
• Right heart strain (RBBB, R axis deviation)
• ABG
• Type 1 resp. failure
• Wells score
• 0-2 => D dimer (i.e. ONLY if low pre-test probability)
• >2 straight to VQ scan (if CXR normal) or CTPA
• Management
• 5000 U heparin; Switch to LMW heparin once confirmed
• Thrombolysis for massive PE ONLY once you've done an echo:
• Confirm hypokinetic RV
• Exclude pericardial effusion

SAH

• TOP/ONLY DIAGNOSIS for sudden severe headache
• Sudden more important than severe (indicates vascular cause)
  
• CAREFUL not to miss it
• Investigations
• 95% show on CT (if within 6-12 hrs)
• Normal CT => Wait 12 hrs then LP for xanthochromia
• Give amlodipine + refer to neuro / interventional radiology for coiling
• Beware herald bleed
• Headache may get better; Still don't ignore

• Yankauer suction tip
• 2 types, one with a hole
• Supraorbital pressure as alternative to trapezius pinch
• 3rd CN pressure => Blown pupil
• SBP
• >50 => Central pulse
• >80 => Radial pulse
• 5 sites of blood loss
• Abdo
• Pelvis
• Thorax
• Long bones (esp. femur)
• External
• FAST scan
• Hepatorenal (Morison's) pouch
• Splenorenal pouch
• Pelvis
• Pericardial space
• +/- chest for pneumothorax
• Can see a large aorta on USS, but NOT blood (retroperitoneal)
  
• Can infer rupture if symptomatic
• Hartman's better than saline due to risk of hyperchloraemic acidosis