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14.01.09 Medical emergencies

Diabetes
  • 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

 DKA
HHS
Glucose
15 - 40
30 - 60
Fluid deficit 6 - 8 L
7 - 9 L
Total K+
Low
Low
Serum K+
High
Normal
Sodium
Normal
>155
pH
Very low
Slightly low
Ketones
+++
+

  • 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


Notes
  • 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
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