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

• • 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