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