ACUTE EMERGENCIES

in
Medicine

Dr. Vithoosan

MB.BS (Hons), MD (Medicine)

MRCP (UK), MRCP (LOND), MRCPE (Edinburgh)

Senior Registrar in Neurology, Institute of Neurology, National Hospital of Sri Lanka

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Dr. Vithoosan
 1. Acute ST elevation of MI and other Acute Coronary Syndrome (ACS)
Mr. A 50 year old known patient with Diabetes mellitus for 10 years and hypertension for 5 years ,
having family history of ischaemic heart disease presented with sudden onset retrosternal chest pain
for 30 min ,sweating ,nausea and vomiting . You are the house officer. How will you manage?

The management given

 Acute side bed

 Small rapid history - Acute chest pain is almost always ACS until proven otherwise
Differential diagnosis –
ACS
Dissection of aorta ( asymmetrical pulses and unequal blood pressure in
both arms)
Pulmonary embolism
Tension pneumothorax
Acute pericarditis
 Check Airway ,Breathing ,Circulation
 Administer oxygen if SpO2 < 94%
 Connect to cardiac monitor
 Take blood for FBC , SE , S.Cr ,BU , Lipid profile
 After 6 hours of onset of pain take blood for Troponin I(Quantitiative troponin)
 Drugs given immediately
Aspirin 300mg stat (tablet 75mg,150mg,300mg)
Clopidogrel 300mg(tablet 75mg)
Atorvastatin 40mg stat
Morphine 5mg(0.1mg/kg) with IV metochlopromide 10mg/ Sublingual GTN
 Arrange for urgent 12 lead ECG
STEMI Streptokinase(SK)
LBBB
ACS NSTEMI Primary PCI
Unstable angina LMWH
 Reperfusion Options- Primary PCI or Thrombolysis depend on the availability
 If PCI is possible should be performed within 60 minutes. If the patient can be transferred
to a PCI capable centre within 120 minutes PCI should be considered. If fibrinolysis is
contraindicated PCI should be considered irrespective of the time.

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Dr. Vithoosan
  Fibrinolysis – Tenectaplase ( better reperfusion rate and less complication than
Streptokinase), Streptokinase
 Criteria for Fibrinolysis

1. STEMI

2. new onset LBBB

3. True posterior MI
4. patient comes within 12 hours

left bundle branch block

 Then i will call the cardiology unit and ask for the availability of Primary PCI , if not available then
we have to give SK after excluding the contraindications

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Dr. Vithoosan
 Absolute contra indications
 Active internal bleeding
 Suspected aortic dissection
 Recent head trauma
 Intracranial neoplasms
 Past hx of haemorrhagic shock

How to give SK- 1.5mU in 100 ml of normal saline over 1 hour( Target to give thrombolytic within 30
minutes of medical contact)

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Response in ST elevation
Patient clinically well and haemodynamically stable
Reduction in ST elevation > 50% in 90minutes

 Failed Thrombolysis?
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 Look for Complications- LVF/ Right Ventricular infarct( in patients with inferior STEMI . Do ECG
with V4R. Administer Fluid Challenge)/ Heart blocks in inferior STEMI
 Later – Start the below mentioned medications once the emergency management is over
ACEI – Enalapril 2.5mg nocte
Aspirin 150mg nocte
Clopidogrel 75mg nocte
Atorvastatin 20mg nocte
GTN 20ng nocte
B-Blockers

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Dr. Vithoosan
  Once the patient is stable Do
Echo
Exercise ECG

 The reasons for SOB after MI

Arrythmias
Acute LVF
Chordae tendinae rupture and resulting Mitral regurgitation

 The differentiation between NSTEMI and Unstable angina is positive troponin I in NSTMI

 For these both conditions Enoxaparin (LMWH) 1mg/kg bd for NSTMI and

******* READ ABOUT TIMI SCORE , GRACE SCORE, KILLIP SCORE*******

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Dr. Vithoosan
 2. Acute Left Ventricular Failure
 Mr.Y a 60 year old patient with Ischaemic heart disease, presented to medical casuality with
acute onset SOB he is also having past history of similar symptoms and also complaining of
progressive cough with frothy sputum which is stained by tinge of blood.
 Ex – B/L coarse basal crepitations /LV gallop
 Management
 Acute side bed, Prop up the patient
 The DD for the similar episodes are
Acute exacerbation of bronchial asthma
Acute exacerbation of COPD
Pulmonary embolism – clear chest , loud P2
Pneumothorax
Metabolic acidosis
If not sure about the diagnosis BNP or pro BNP can be sent.
 Give high flow oxygen to maintain saturation>94%
 Assess the tissue perfusion and
congestion……………………………………………………………………………………………………………………………………
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 Gain IV access .Take blood for routine investigations (FBC , SE , S.Cr ,BU , Lipid profile)
 Connect with cardiac monitor – look for ischaemic changes MI can precipitate Heart failure
 Give IV frusemide 80-120 mg IV bolus if the BP stable (can repeat every 2 hrs depend on
symptoms, doubling the dose if the patient does not respond max dose 400 mg. if the patient is
very symptomatic then start infusion)
 Give IV morphine 5mg and metochlopramide 10mg
 If blood pressure is high or normal can start GTN infusion 10-20 g/min can increase the dose up
to 200g/min . Aim to keep BP around 100mmhg
 IV GTN indicated in HT  LVF
HT  ACS
 If no response go for CPAP(Continuous positive airway pressure) in patients with respiratory
distress( RR> 25/min, SpO2< 90%) ( Non invasive positive pressure ventilation can reduce BP and
should be used with caution in hypotensive patients)
 Intubation need to be considered if cannot be managed with non invasive ventilation

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Dr. Vithoosan
 
 Later can do Dialysis with ultrafiltration or venesection
 Cardiogenic shock
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Dr. Vithoosan
3. Hypertensive Emergencies

Category Definition Management

Hypertensive emergency Severe hypertension with evidence Reduction of MAP by 25% in 1

of new or progressive target organ st hour or
damage( hypertensive
encephalopathy/ ICH/ acute DBP to 100 -110 mmHg within
LVF/renal failure/ aortic dissection 1-2 hours
/Eclampsia
IV antihypertensives

Sodium nitroprusside (0.25-

10mcg/kg/min)

GTN (5-200micg/min)

Labetalol – used in aortic

dissection, neurological
emergencies, pre eclampsia
and eclampsia) ( IV bolus 20
mg over 2 min can repeat
every 5 Min or IV infusion 1-2
mg/min max 300mg)

Hypertensive urgency Severe hypertension without Reduction in MAP by 25%

evidence of new or progressive within hours to a day
target organ damage Oral antihypertensives

 Should be managed in ICU /HDU with complete bed rest

 Sudden drop may precipitate hypoperfusion resulting in ischaemic infarction of vital organs
 Get an IV access and should catherterise to monitor UOP and give oxygen
 take blood for (FBC , SE , S.Cr ,BU , Blood picture, CXR and Echo
 Reduction of mean arterial pressure by 25% of initial value in the first hour of treatment is the
target of treatment

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Dr. Vithoosan
4. Acute severe asthma
Mr.Z, a 25 year old patient was admitted with severe Shortness of breath. On admission his respiratory
rate was 32/min , and he was unable to speak a full sentence and he has a history of cough and sputum
production few days ago.

Differential diagnosis – Acute severe asthma

Pneumonia
Pneumothorax

Pulmonary oedema

Acute severe asthma Life threatening asthma

Inability to complete a single sentence in one Exhausted , Confused , Comatose

breath

RR > 25/min Poor respiratory effort

HR >115 /min Brady cardia & Hypotension, arrhythmias

PEFR 50 -33 % Cyanosis

Silent chest

PEFR < 33% SpO2 < 92%

Management

 Admit in acute side bed and assess A,B,C

 Connect to the Monitor , measure SpO2 and give high flow oxygen (100%)( face mask or non
rebreathing mask with reservoir bag for high flow Oxygen)
 Give oxygen driven salbutamol nebulisation 5mg every 15 to 30 minutes (1ml salbutamol plus
1ml 0.9% N.saline)(3 times back to back nebulisation)
 Add iptratropium bromide 500µg and nebulise every 6 hour ( 2ml iptratropium bromide plus
1ml 0.9% N.saline)
 Monitor the response
 Give hydrocortisone 100mg continue 6 hourly – upto 24 hours , then the patient should be
started on oral prednisolone 40mg stat for 10 – 14 days

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Dr. Vithoosan
 If the patient is not responding do an ABG ( Life threatening asthma PaO2< 8 kPa 60 mmHg
despite O2 , Acidosis)
 Give IV MgSO4 , 1.2 to 2g in 50ml N.saline as an infusion over 20 minute
 IV salbutamol
 ( aminophyline IV bolus 5mg/kg (250mg for a 50kg person) over 20 minutes, then infusion
1mg/kg/hr- can cause cardiac arrhythmias and electrolyte abnormalities So usually not used )
 CXR to exclude pneumothorax

 Give IV salbutamol with cardiac monitoring

 Non invasive ventilation
 Invasive ventilation

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Dr. Vithoosan
5.Infective exacerbation of COPD
History will be similar to acute severe asthma

 Acute side bed

 Prop up
 Connect with cardiac monitor & pulse oximetry
 Give 24 – 28% via venturi mask. Target saturation of 88-92%
 Give nebulised salbutamol 5mg and Ipratropium 0.5 mg over 15 to 30 minutes
 Give IV hydrocortisone 100mg 6hourly for 24 hours , later oral prednisolone 40mg/daily for
14days
 Start IV antibiotics Eg IV co amoxyclav

 If the patient does not improve do an ABG
 If does not improve try non invasive ventilation( indications- respiratory acidosis arterial pH <
7.35 and/or PaCO2 > 6.0kPA, 45 mmHg, severe dyspnoea with signs of respiratory muscle
fatigue – accessory muscle use, paradoxical motion of the abdomen , intercostal recession)
 If the patient unstable or cannot tolerate NIV , consider invasive ventilation.

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Dr. Vithoosan
6.Paracetamol(PCM) poisoning
A 20 year old girl presents to the casuality ward after ingestion of 20 tablets of paracetamol 5 hours
back. She denies a history of vomiting and other discomforts. On examination she is asymptomatic

The dose taken 150mg/kg – toxic dose(20 tablets and above can be toxic)
200mg/kg is fatal dose

Gastric lavage is indicated if >150mg/kg is taken within 1 hour

activated charcol

Give activated charcol if less than 1 hour of ingestion (50g of activated charcol in 200ml of water)

Get an IV line and take blood for LFT, INR, ABG, FBC, HCO3- and blood PCM level at 4 hours after
ingestion

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Dr. Vithoosan
 High risk

a. Positive for HIV infection

b.Pre existing liver disease
c.Induction of liver enzymes

Carbamazepine
Phenobarbitone
Phenytoin
Rifampicin
Alcohol

 If < 8 hours since overdose & plasma PCM level is above the line then start N-Acetylcysteine
 If > 8 hours , and there is a suspicion of large overdose start N-Acetylcysteine(NAC) & stop it if
the level is below the treatment line and INR /ALT is normal
 N-Acetylcysteine is given by IV infusion first 150mg/kg in 200ml of 5% dextrose over 15 minutes
and then 50mg/kg in 500ml of 5% dextrose over 4 hour and lastly by 100mg/kg in 1l of 5%
dextrose over 16 hours
 Rash is a common side effect treat with chlorpheniramine and observe
 Alternative is methionine 2.5g/4hour for 16 hours (total of 10g over 16 hurs)
 Do INR, S.Cr/ S.E, LFT
 If INR is rising continue NAC untill it become <1.4 (the NAC infusion should be continued in a
rate of 150mg/kg/24 hours)
 Check for hypoglycemia and treat
 Look for enchephalopathy and treat ( the organs involved are Liver,Kidney,Pancreas)

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Dr. Vithoosan
Paracetamol metabolism in liver

Conjugation with Glucuronide 60%

Sulphate 30%
Oxidation 5-10%

Then forms NABQI then it conjugates with Glutathione and get deactivated rapidly .but when excess
amount of NABQI formed glutathione reserves become unable to handle that. So then NABQI oxidises
the thiol and sulfar components in vital organs

T ½ of PCM in therapeutic doses – 2hour but in toxic doses it is 4-8 hours

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Dr. Vithoosan
 7. Hyperkalemia
Normal range of serum K -3.5 – 5.1 mmol/dl

If it is >6.0mmol/dl or keep on persistently raising repeat the test frequently

Causes of Hyperkalemia
Renal failure
Drugs(Spirinolactone, ACEI ,NSAID)
Addison’s disease
Rhabdomyolysis
Digoxin

Clinical features

Muscle weakness
Bradycardia
Arrythmia – Palpitations
Hypotension
Asystolic cardiac arrest
Paraesthesia

ECG changes

Tall tented T waves

Flattened “P” wave Increased or widened QRS complex

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Dr. Vithoosan
Sine wave pattern

A patient who had a snake bite is having decreased urine output , a serum electrolytes showed
increased serum K level of 6.6mmol/dl. ECG showed tall T waves

Management

 Admit
 Keep in the Acute side bed and check A,B,C
 Connect with cardiac monitor and continuosly monitor the ECG
 Get an IV access and take blood for –S,Cr,BU,CBS,ABG(metabolic acidosis)
 Give 10ml of 10% Ca gluconate over 10 minutes (Ca gluconate is a cardiac membrane stabilizer,
it raises the threshold of the membranes .but it does not change the K level
 Give salbutamol nebulization 5mg undiluted (actually salbutamol act on the B receptors and
enhance the K entry into the cells
 Give 10 units of soluble insulin with 50ml of 50% dextrose over 30 minutes (this also increase
the K entry into the cells)

 All the above measures only decrease the serum K but not the total body K. .So later on
measures must be taken to eliminate the excess K from the body

a. K binding resins – calbind

b. Lactulose - is an laxative so it will produce diarrhoea and K will be lost in stolls(mucus
contains a lot of K )
c. K loosing diuretics (loop diuretics , thiazides)
d.Haemodialysis – the definitive management

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Dr. Vithoosan
 8. ACUTE KIDNEY INJURY
Additional Points For AKI

Look for haemodynamic stability , fluid over load

Catheterise if needed

Monitoring ………………………………………………………………………………………………………………………………………

Investigations - ………………………………………………………………………………………………………………………………..

Look for the cause- ? Pre renal ? Renal ? Post renal

Antibiotics in UTI, Leptospirosis ETC

ABG- ? Acidosis ? K+

If dehydrated consider fluid challenge – carefully look for fluid over load

IV Furosemide 40-80 mg bolus for pulmonary oedema. But no value if anuric

Manage hyperkalemia as above

Correct acidosis with IV NaHCO3

Consider RRT if indications are present.

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Dr. Vithoosan
 9. Haematemesis
A 55 year old patient presents with sudden onset vomiting of blood for the past one hour. He is having
past medical history of chronic liver cell disease complicated by portal hypertension but he is not
complaining of faintishness , palpitations and abdominal pain.

Management

 Give acute side bed

 Assess A,B,C- make sure airway is patent
 Assess the haemodynamic status
 Give 100% oxygen
 Insert 2 wide bore cannula and insert a NG tube & keep nil by mouth
 Take blood for grouping and cross matching, FBC /DC , LFT ,RFT
 Monitor Pulse rate, Blood pressure , Urine output ½ hourly
 Give crystalloid depend on the shock as a bolus
 If remain shocked aft er1l of crystalloid give blood -Give blood if Hb < 7 . in high risk patients
target Hb of 9. Fully cross matched or Group specific
or O(-)ve
 Avoid over transfusion since this will cause further bleeding.
 IV omeprazole 80mg stat over 5 minutes followed by 8mg/hr infusion for 72 hour
 Give IV vasopressin 20U (2 vials) over 20 minutes. Alternative is octreotide(50µg IV bolus
followed by continuous infusion of 25-50 µg /hr( the best is IV terlipressin 2 mg stat and 1 mg 4
hourly)
 If coagulopathy correct coagulopathy with FFP 15 ml/kg
 IV tranexamic acid 500mg tds
 IV vit K 10mg stat
 Commence hepatic encephalopathy prophylaxis and IV antibiotics- IV ceftriaxone or cefotaxime
 Urgent Upper GI endoscopy – Sclerotheraphy , Band ligation , Balloon tamponade with
sengstaken blackmore tube Band ligation

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Dr. Vithoosan
Balloon tamponade with Sengstaken Blakemore tube

Rockall score for prognosis in UGI bleeding

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Dr. Vithoosan
9. Management of acute stroke
A 55 year old woman with hypertension presents with right sided hemiparesis associated with
dysphasia. Her blood pressure was 170/100 mmhg .CT scan of the brain shows an ischaemic stroke in
the middle cerebral artery territory.

 Check A,B,C
 Quick history and examination- Exclude Differential diagnosis
 “ TIME IS BRAIN”
 Check CBS- hypoglycaemia can present with focal neurological signs
 URGENT NCCT brain – ischaemic stroke may be looking like a normal image at the earlier
stage(ischaemic changes appear later only early findings- hypodensity , loss of grey white
demarcation) but in haemorrhagic stroke the changes will appear immediately so the reason for
taking NCCT is to exclude haemorrhagic stroke.
 Take blood for FBC , SE , SCr , LFT , clotting profile (PT/INR)
 If there is no haemorrhage , Options For Reperfusion
1. IV thrombolysis – rTPA- Alteplase
2.endovascular reperfusion- limited availability
 Consider thrombolysis
Indication -
1. Age > 18 years
2.Clinical diagnosis of ischaemic stroke causing a measurable neurological deficit – Formal
Assessment with NIHSS score
3.Onset < 4.5 hours
( Additional warning for treatment from 3-4.5 hours
1. Age> 80 years
2. Oral anticoagulant use regardless of the INR
3. Severe stroke – NIHSS > 25
4. Combination of both previous ischemic stroke and DM

Contra indications
a. Minor or rapidly resolving stroke symptoms
b.Other strokes or head trauma within 3 months
c.Known history of Intracranial haemorrhage
d.Sustained BP > 185 mmhg DBP >100mmhg at the time treatment is begun
e.symptoms suggestive of Sub arachnoid haemorrhage
f.Gastrointestinal or Genitourinary tract haemorrhage within past 3 weeks
g.Arterial puncture in the compressible sites within 7 days
h.Patient received heparin within last 8 hours and has elevated APTT
i.Platelet < 100,000/ml

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Dr. Vithoosan
 Thrombolysis with rTPA Alteplase 0.9mg/kg maximum 90mg over 1 hour.(10 % as a bolus and
rest as infusion over 1 hour .
Should be given as early as possible
If rTPA given keep the patient off other anti thrombotic therapy for 24 hours.
Monitor BP frequently while and after giving rTPA and look for reduction in consciousness-
Beware of the risk of bleeding

If not giving rTPA give Aspirin 300 mg stat and continue for 2 weeks. If rTPA is given delay
aspirin By 24 hours.

Mechanical thrombectomy is indicated in acute ischemic stroke due to large artery

occlusion in the anterior circulation who can be treated within 24 hours of symptom
onset regardless of whether they received alteplase

GENERAL SUPPORTIVE MANAGEMENT

 Fluid- intravascular volume depletion common- isotonic saline agent of choice
 Treatment of hyperglycaemia to keep 140-180 mg/dl- Strict control no benefit
 Keep head in neutral position. Cerebral perfusion maximum in horizontal position. Elevate to 30
degree in pt with increased ICP, risk of aspiration, cardio pulmonary decompensation.
 Avoid hyperthermia- induced hypothermia is not currently recommended
 Stroke unit care
 Arterial blood pressure is usually elevated in acute stroke. ( May be due to chronic HT, acute
sympathetic response or stroke mediated mechanism) This hypertensive effect is transient. Fall
by 20/10 within 10 days.
 Adverse effect of reducing the BP in the first 24 hrs.
 Before thrombolytic therapy BP <=185/110 the BP should be stabilized and maintained at or
below 180/105 for at least 24 hours after thrombolytic therapy.
 Start treatment if SBP >220 or DBP >120. When tx needed 15 % lowering in the first 24 hrs.
 IV labetalol nicardipine and clevidipine are first line.
 If cerebral oedema – IV mannitol, Decompressive cranictomy

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Dr. Vithoosan
Haemorrhagic stroke

Most important management is BP control

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Correct clotting abnormalities if present
Neurosurgical referral if indicated

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Dr. Vithoosan
 10. Sub arachnoid haemorrhage

sudden onset worst ever headache is sub arachnoid haemorrhage until proven otherwise

 Often associated with exertion

Aetiology

 85% ruptured saccular aneurysm

 AVM
 Bleeding disorders
 Anticoagulant therapy

Risk factors – HT, Smoking, Alcohol

Investigations

1) NCCT – First line

2) LP

3) DSA

Prognosis – Poor

Complications

1) Rebleeding

2) Vasospasm and delayed cerebral ischaemia

3) Hydrocephalus

4) Increased ICP

5) Seizures

6) Hyponatraemia

7) Cardiac abnormalities

8) Hypothalmic dysfunctions and pituitary insufficiency

Mx – Aim – Tx of source of bleeding and treat complications of SAH

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Dr. Vithoosan
 Monitoring GCS, Pupil size and reaction PR, BP

General measures

1) Reduce rerupture and rebleed, bed rest, avoid straining, analgesia, avoid BP fluctuations

2) Adequate hydration to prevent delayed ischaemia

3) CCBs – Nimodipine 60mg 4hourly

4) Anti-fibrinolytic therapy

5) High dose statin

6) Monitor, identify and treat complications

7) DVT prophylaxis

Definitive treatment

Aneurysm repair – Clipping, Endovascular coiling

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Dr. Vithoosan
10. Pulmonary embolism
How to diagnose

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*****Scoring system – Well’s score- READ*****

Management

 High flow O2
 Do the following investigations ASAP –
ECG(……………………………………………………………………………………………….) , CXR , ABG , D.Dimer level(
to exclude pulmonary embolism in patients with low probability) , CT pulmonary angiogram-
Gold standard in pulmonary embolism ,
ECHO(…………………………………………………………………………………………)

 Admit the patient to ICU or HDU

 High flow O2
 Give analgesics NSAID
 Monitor the SaO2
 IV cannula
 Give colloid if Blood pressure is low – Consider the need for ionotropes
 If the patient is critically ill with massive Pulmonary embolism – Should be started on UFH
immediately as preferred therapy (5000 IU bolus and 1000 IU/hr infusion target APTT 1.5-2.0 0f
normal) combined with thrombolysis (SK-250,000 IU loading dose over 30 minutes followed by
100,000 IU/hr over 24 hours)
 Otherwise start heparin

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Dr. Vithoosan
 S.C LMWH – 1.0 mg/kg bd
Un fractionated heparin 100u/kg – loading dose. Followed by 1000u/hr infusion)

Also start on warfarin once the diagnosis is confirmed 5mg daily adjust with stabilised INR 2.5 –
3.5 ,continue the dose for upto 6 months

 Heparin is used concurrently with warfarin then stopped when the INR is >2

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Dr. Vithoosan
 11. DHF-Shock with narrow pulse pressure and hypotension

 Symptoms of shock
Sweating
Abdominal pain
Persistent vomiting
Postural dizziness
Restlessness / altered conscious level
Decreased urine output (OUP)

 Signs of shock
-Cold extremities
-Prolonged capillary refill time >2 seconds
-Unexplained tachycardia
-Increasing diastolic pressure
-Narrowing of pulse pressure ≤ 20 mmHg
-Postural drop ≥ 20 mmHg of systolic blood pressure
-Hypotension < 20% from patient’s baseline or SBP

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 12. Management of anaphylaxis
Clinical features

Pharyngeal oedema
Bronchial spasm
Tachycardia
Hypotension
Shock
Loss of consciousness
Urticaria
Angioedema
Pruritus

Angioedema Urticaria

Management

 Acute side bed

 Airway – give 100% O2 Intubate if respiratory obstruction is imminent
 Give adrenaline IM 0.5mg (i.e 0.5ml 1:1000) repeat every 5 minutes if needed (ampoul –
1mgl/ml) as guided by BP , PR , RR untill they get better
 Secure IV access
 Give chlorpheniramine 10mg IV and Hydrocortisone 200mg IV
 IV fluids – IV N/S 500ml over ¼ hr upto 2l may be needed ,titrate against BP
 For wheezing we have to treat it as Bronchial asthma
 Monitor PR , BP , SPO2
 If severe hypotension ,and no response with the above intervention IV infusion of adrenaline in
a rate of 100g/min can be given. Till the patient recovers.(1ml of 1:10,000 solution/minute)
should be stopped as soon as the response occured.
 Continue chlorpheniramine 4mg bd oral , prednisolone 40mg mane oral for about 24 -48 hours
( Anaphylaxis- Acute onset illness with involvement of skin, mucous membrane or both and at least one
of the following- respiratory compromise, reduced BP or symptoms of end organ dysfunction)

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Dr. Vithoosan
13. Snake bite
Management

 Assurance
 Identify the snake by various methods- ( Site of the bite- Krait- head to toe, Cobra and Russel’s
viper-below elbow and below knee ,Saw scaled and hump nosed viper-fingers, hand ankle and
foot) Time of the bite – Krait at night, Season – Krait- rainy season, Circumstances- Paddy field,
road , foot paths at dawn and dusk-Russel’s viper, sleeping in the floor – Krait, near water
reservoirs or inside dwellings – Cobra, Estates, damp places, home gardens- Hump nosed viper)
 Wash the bite site with soap and water
 Immediately remove rings and bangles
 Give pain relief (Only PCM) don’t give aspirin
 Observe the site for fang marks. If there is any fang marks give anti tetanus prophylaxis
 If there is swelling , cellulitis ,any signs of infection give antibiotics . Eg: cloxacillin 500mg 6hourly
 Take blood for investigations – S.Cr, S.E ,FBC ,PT/INR , APTT , LFT
 General supportive care measures
IV fluids as volume expanders for hypotension
Diazepam for anxiety
 Monitoring – Level of consciousness , PR ,BP , RR ,Temperature, UOP
 Most Important Investigation: 20 minutes Whole blood clotting time- if it is >20 minutes that
means there is coagulopathy THE 20WBCT
 The 20 minute whole blood clotting test is performed at the bedside as follows:
1. Collect 2 ml of blood into a clean, dry test tube, gently rotate and leave it undisturbed for 20
minutes.
2. At the end of 20 mins. tilt the tube: observe whether the blood has clotted or not.
3. Conclusions
a) If the blood flows (i.e. no clot), there is coagulopathy (envenomed).
b) If the blood does not flow (i.e. clotted), there is no coagulopathy (not envenomed).

Detect coagulopathy in viper bites by performing the 20 minute whole blood clotting test
(20WBCT) 1 to 2 hourly during the first 6 hours and then 6 hourly

Then antevenom has to be given

- If the patient has features of systemic envenomation (coagulopathy or neurotoxicity)

- If WBCT > 20 min
- or for local envenomation only following cobra bite if half of the limb is involved or if
ascending swelling

 Antivenom can be given for snakes like Cobra , Common krait , Sri Lankan Krait , Russel’s viper
bites and Saw scaled viper
 Not given for Hump nosed viper , green pit viper , Sea snake bites
 It is never too late to give antivenom provided the indications are present:

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Dr. Vithoosan
 -Only if features of systemic envenoming are present for bites of snakes in the red box
-Do not give for local envenoming alone, except for cobra bites, if half the limb is involved, or in
ascending swelling in other snake bite

How to give antivenom

-Take informed written consent
-Insert 2 wide bore cannula
-Prepare adrenaline tray

 Dose: 100-200 ml (10-20 ampoules) or more* of Indian polyspecific antivenom in 400 ml of

normal saline infused intravenously over one hour.
 The dose of antivenom depends on the severity of envenoming—in acute, severe coagulopathy
following Russell’s viper bites up to 30 ampoules could be given.
 In viper bites — antivenom may be repeated in 6 hours in a dose of 100 ml (10 ampules) if
coagulopathy persists; the endpoint of antivenom therapy is reversal of coagulopathy as
determined by serial performance of the 20WBCT
 Do not continue anti venom administration for persistent neurotoxicity, provided the
coagulopathy has been reversed
 In cobra & krait bites — Usually one dose (the first dose) of antivenom is sufficient
 In viper bites, monitor the efficacy of antivenom by repeatedly performing the 20 min. whole
blood clotting test (20WBCT) at the bedside. Repeat 20 WBCT in 6 hours—if the blood does not
clot in 20 minutes, repeat antivenom infusion and perform 20WBCT 6 hours later. Continue the
cycle till the blood clots
 TREAT REACTIONS IMMEDIATELY WITH
 Adrenaline: 0.5 ml of 1:1000 solution • if not in shock and collapsed, give by intramuscular
injection
 if the patient is in shock and collapsed, intravenous administration may be considered
* Chlorpheniramine: 10 mg intravenously If unavailable, give Promethazine 25 mg
intravenously
* Hydrocortisone: 200 mg intravenously
In severe shock, severe dyspnoea, compromised airways or in deteriorating patients,
intravenous infusion of adrenaline is recommended in the following dosage: Adults: 10-20
micrograms (1-2 ml of a 1:100,000 solution) per minute intravenously (or 0.75-1.5 micrograms /
kg body weight of 1:100,000 solution intravenously).

PREMEDICATION

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14. Organophosphate poisoning
Organophosphate inactivate cholinesterase

Features- SLUD response

1. Salivation
2. Lacrimation
3. Urination
4. Diarrhoea
Also sweating, small pupils, muscle fasciculations, coma, respiratory depression

Management

A, B, C- important to protect the airway – may need to intubate- avoid suxamethonium during
intubation.

Wash the skin , remove contaminated clothes

Gastric decontamination may have a place upto two hrs of ingestion but it should be embarked once the
patient is adequately stabilized airway protected either fully conscious or intubatedand atropinisation is
commenced

Give IV atropine as soon as possible 1.8-3 mg- rpt the dose until 3/5 parameters are corrected

1. Clear chest with no wheeze

2. Dry axillae
3. HR between 80-110 bpm
4. SBP more than 90
5. Pupils no longer pin point
Consider atropine infusion- 10-20 % of the total dose as an hourly infusion

Pralidoxime infusion 30 mg/ kg loading dose followed by infusion of 8-10 mg/kg

Watch for intermediate syndrome- look for neck muscle weakness

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Dr. Vithoosan
 15. ASSESSMENT OF UNCONSCIOUS PATIENT/ COMA/ACUTE
MENINGITIS/ENCEPHALITIS

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Dr. Vithoosan
 16. Status epilepticus
Defined as seizure lasting for more than 30 minutes or repeated attacks of seizure without regaining
consciousness. ***Working Diagnosis 5 minutes

Includes both convulsive and non convulsive seizure disorders

Aim of the treatment

Diagnosis
Protect the brain
Treat complications
Identify underlying aetiology or precipitating causes
Prevent further seizures

Once the seizure exceeds 5 minutes working diagnosis of status should be taken.

0-5 minutes

 Maintain A(suction and remove foreign body),B,C

 High flow oxygen via face mask
 Insert IV cannula ,Take blood for U&E ,S.Cr , glucose (Hypoglycemia) and S.Ca2 ( Give IV
thiamine 100mg with50% 50 cc dextrose if CBS < 60 mg/dl)
Initial Therapy 5-20 minutes

 Then give IV diazepam 5mg stat(lorazepam 0.15 mg/kg- maximum 10 mg/dose may
repeat the dose once)
(If no IV access- Rectal diazepam 0.5mg/kg or IM Midazolam 0.15 mg/kg or Buccal midazolam
0.3mg/kg)
Recurrent attacks repeat 5 mg every 5 min upto 20mg (Caution with diazepam)

Second phase 20-40 minutes

If seizure continues IV phenytoin ( 20 mg/kg over 30 minutes) or IV phenobarbital 15 mg/kg

If seizure continues 40-60 minutes

IV midazolam 5mg/hr -15 mg/hr

Rapid sequence of induction & anaesthesia with thiopentone Na

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 36
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 18. DIABETIC KETO ACIDOSIS (DKA)

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 38
Dr. Vithoosan
 19. SEPSIS
 Quick initial assessment
 A, B, C
 Hydration- IV normal saline- 30ml/kg over 1 hour with the rate adjusted to the response
 If cannot achieve the MAP> 65 mmHg with Hydration , start IV inotropes- IV noradrenaline is the
preferred agent- 0.05-2 microg/kg/min
 ( 2nd option IV Vasopressin 0.03U/min)
 Refractory shock IV hydrocortisone 50 mg 6 hourly
 Inotropes ideally via central line
 3 Sets of blood cultures as soon as possible and other sputum, urine cultures and basic blood
tests like FBC, CRP, LFT and RFT, ABG
 Start IV broad spectrum antibiotics – Eg : IV meropenem
 If there is a septic foci remove the source
 Catheterise monitor UOP
 Monitor vital parameters frequently
 Control sugar with IV soluble insulin infusion (110-180)
 Serum lactate will help to guide the therapy

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Dr. Vithoosan
20.Plant poisoning
Yellow oleander poisoning (Kaneru)
 Thevetia peruviana, Tamil - Manchal alari
 Commonest plant poison in Sri Lanka
 Fruits are highly toxic, several cardiac toxins presence including Thevetin A

Clinical features
 Burning sensation in the mouth
 Nausea ,vomiting and diarrhoea due to local irritation of stomach
 Cardiotoxicity – bradycardia, hypotension, heart block / tachyarrhythmia, atrial and ventricular
ectopics
 yellow vision (xanthopsia)
 convulsions and coma

Investigations
 Serum electrolytes - regularly
 ECG frequently or continuous cardiac monitoring
 Blood for assay of toxic substance

Management

1. Asymptomatic patients observe in hospital for 24 hours

2. Symptomatic patient
 Gastric lavage for adults, induce emesis for children
 Monitor - BP, pulse, respiratory rate
 Bradycardia - Atropine 0.5mg IV
 3rd degree heart block – transvenous pacing catheter
 Fluid balance chart and replace losses

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Dr. Vithoosan
  Correct electrolyte imbalances, check 4 hourly
i. If the serum potassium is below 3 mEq/L, 500 ml of Hartmann’s solution should be infused over
4 hours. Serum potassium levels greater than 5.5 mEq/L is seen with acute toxicity and is an
indication for treatment with anti-digoxin antibodies, if available.
 In convulsions – Diazepam 5 – 10mg IV (Paediatric dose 0.2 mg/kg)
 The decision whether to give Kanerutab will depend on the level of risk. This decision should be
taken on an individual basis, by the Physician /Cardiologist. Level 1 would be a definite indiction
for Kanerutab. Kanerutab should be considered in level 2. Level 3 patients could be kept under
observation and reviewed every 2 hours. Kanerutab is provided in vials of 40 mg. The
recommended dose is 800 mg (20 vials), irrespective of age, sex or body weight.
i. Contraindications are known allergy to Kanerutab or ovine products and pregnancy. However in
situations where the mother’s life is at risk, Kanerutab may be used.
ii. 800 mg of Kanerutab is dissolved in 100 ml of 0.9% sodium chloride, given by IV infusion over 20
minutes.
iii. Side effects are uncommon, and a test dose is not required. Urticarial reactions and
bronchospasm should be watched for, but prophylactic adrenaline or hydrocortisone is not
required.

Gloriosa superba poisoning (Niyangala)

 All parts of the Niyangala plant are poisonous
 Toxicity due to alkaloid colchicine
Clinical features
1. Within 6 -12 hours
 Nausea, vomiting, diarrhoea with blood, abdominal pain
 Hypovolaemia, hypotension and shock
2. After 24 hours
 Granulocytopenia, thrombocytopenia, clotting defects with bleeding manifestations
 Polyneuropathy
 Hepatic insufficiency
 Acute renal failure
3. In severe poisoning
 Respiratory depression / acute respiratory distress syndrome
 Confusion
 Convulsions & coma
 Disseminated intravascular coagulation can occur

Investigations
 Full blood count
 Clotting time
 Prothrombin time
 Serum electrolytes
 Serum creatinine
 Blood urea

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Dr. Vithoosan
Management
 Induce emesis or gastric lavage
 Give activated charcoal
 If respiratory depression - Oxygen and assisted ventilation
 IV fluids and correct electrolyte imbalances
 Forced diuresis within 24 hours to eliminate colchicine
 IgG goat colchicine Fab fragments and filgrastin, a granulocyte colony stimulating factor, have been
used to treat colchicine overdose. Their value in the management of ‘niyangala’ poisoning is not
tested. However, these Fab fragments are not available in Sri Lanka.
Autopsy
 Gastric lavage – Govt analysis
 Blood tests

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Dr. Vithoosan
21. Treatment of shockable rhythms (VF/VT)
1. Confirm cardiac arrest – check for signs of life and normal breathing, and if trained to do
so check for breathing and a pulse simultaneously.
2. Call resuscitation team.
3. Perform uninterrupted chest compressions while applying self-adhesive
defibrillation/monitoring pads – one below the right clavicle and the other in the V6
position in the midaxillary line.
4. Plan actions before pausing CPR for rhythm analysis and communicate these to the
team.
5. Stop chest compressions; confirm VF/pVT from the ECG. This pause in chest
compressions should be brief and no longer than 5 seconds.
6. Resume chest compressions immediately; warn all rescuers other than the individual
performing the chest compressions to “stand clear” and remove any oxygen delivery
device as appropriate.
7. The designated person selects the appropriate energy on the defibrillator and presses
the charge button. Choose an energy setting of at least 150 J for the first shock, the
same or a higher energy for subsequent shocks, or follow the manufacturer’s guidance
for the particular defibrillator. If unsure of the correct energy level for a defibrillator
choose the highest available energy.
8. Ensure that the rescuer giving the compressions is the only person touching the patient.
9. Once the defibrillator is charged and the safety check is complete, tell the rescuer doing
the chest compressions to “stand clear”; when clear, give the shock.
10. After shock delivery immediately restart CPR using a ratio of 30:2, starting with chest
compressions. Do not pause to reassess the rhythm or feel for a pulse. The total pause
in chest compressions should be brief and no longer than 5 seconds.
11. Continue CPR for 2 min; the team leader prepares the team for the next pause in CPR.
12. Pause briefly to check the monitor.
13. If VF/pVT, repeat steps 6–12 above and deliver a second shock.
14. If VF/pVT persists, repeat steps 6–8 above and deliver a third shock. Resume chest
compressions immediately. Give adrenaline 1 mg IV and amiodarone 300 mg IV while
performing a further 2 min CPR. Withhold adrenaline if there are signs of return of
spontaneous circulation (ROSC) during CPR.
15. Repeat this 2 min CPR – rhythm/pulse check – defibrillation sequence if VF/pVT
persists.
16. Give further adrenaline 1 mg IV after alternate shocks (i.e. approximately every 3–5
min).
17. If organised electrical activity compatible with a cardiac output is seen during a rhythm
check, seek evidence of ROSC (check for signs of life, a central pulse and end-tidal

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Dr. Vithoosan
 CO2 if available).

1. If there is ROSC, start post-resuscitation care.

2. If there are no signs of ROSC, continue CPR and switch to the non-shockable
algorithm.
18. If asystole is seen, continue CPR and switch to the nonshockable algorithm.

22. Treatment of PEA and asystole

1. Start CPR 30:2
2. Give adrenaline 1 mg IV as soon as intravascular access is achieved
3. Continue CPR 30:2 until the airway is secured – then continue chest compressions
without pausing during ventilation
4. Recheck the rhythm after 2 min:
a. If electrical activity compatible with a pulse is seen, check for a pulse and/or signs of life
i. If a pulse and/or signs of life are present, start post resuscitation care
ii. If no pulse and/or no signs of life are present (PEA OR asystole):
1. Continue CPR
2. Recheck the rhythm after 2 min and proceed accordingly
3. Give further adrenaline 1 mg IV every 3–5 min (during alternate 2-min
loops of CPR)
b. If VF/pVT at rhythm check, change to shockable side of algorithm.

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Dr. Vithoosan
 45
Dr. Vithoosan
 Adult Advanced Life Support

Unresponsive and not

breathing normally

Call resuscitation
team

CPR 30:2
Attach defibrillator/monitor
Minimise interruptions

Assess rhythm

Shockable Return of spontaneous Non-shockable

(VF/Pulseless VT) circulation (PEA/Asystole)

1 Shock Immediate post cardiac

Minimise interruptions
Immediately resume
CPR for 2 min
Minimise interruptions
arrest treatment
 Use ABCDE approach
 Aim for SpO2 of 94-98%
 Aim for normal PaCO2
 12-lead ECG
 Treat precipitating cause Immediately resume
 Targeted temperature CPR for 2 min
management Minimise interruptions

During CPR Treat Reversible Causes Consider

 Ensure high quality chest compressions  Hypoxia  Ultrasound imaging
 Minimise interruptions to compressions  Hypovolaemia  Mechanical chest
 Give oxygen  Hypo-/hyperkalaemia/metabolic compressions to facilitate
 Use waveform capnography  Hypothermia
transfer/treatment
 Continuous compressions when
advanced airway in place  Thrombosis - coronary or  Coronary angiography and
 Vascular access (intravenous or pulmonary percutaneous coronary
intraosseous)  Tension pneumothorax intervention
 Give adrenaline every 3-5 min  Tamponade – cardiac  Extracorporeal CPR
 Give amiodarone after 3 shocks  Toxins

2010 Resuscitation
Guidelines
Adult tachycardia (with pulse)
algorithm
Synchronised DC Shock
Up to 3 attempts
 Amiodarone 300 mg IV over 10-20 min
and repeat shock; followed by:
 Amiodarone 900 mg over 24 h
Irregular
Is rhythm regular?
!
Seek expert help
Possibilities include:
AF with bundle branch block
treat as for narrow complex
Pre-excited AF
consider amiodarone
Polymorphic VT
(e.g. torsade de pointes -
give magnesium 2 g over 10 min)
Resuscitation Council (UK)
 Assess using the ABCDE approach
 Give oxygen if appropriate and obtain IV access
 Monitor ECG, BP, SpO2 , record 12-lead ECG
 Identify and treat reversible causes (e.g. electrolyte abnormalities)
Adverse features?
Yes / Unstable  Shock
 Syncope
 Myocardial ischaemia
 Heart failure
No / Stable
Broad Is QRS narrow (< 0.12 s)? Narrow
Broad QRS Regular Regular Narrow QRS Irregular
Is rhythm regular?
 Use vagal manoeuvres Irregular Narrow Complex
 Adenosine 6 mg rapid IV bolus; Tachycardia
if unsuccessful give 12 mg;
Probable atrial fibrillation
if unsuccessful give further 12 mg.
 Monitor ECG continuously Control rate with:
 -Blocker or diltiazem
 Consider digoxin or amiodarone
Sinus rhythm restored? if evidence of heart failure
If ventricular tachycardia
Yes No
(or uncertain rhythm):
 Amiodarone 300 mg IV
!
Seek expert help
over 20-60 min;
then 900 mg over 24 h Probable re-entry paroxysmal SVT:
 Record 12-lead ECG in sinus
If previously confirmed rhythm
SVT with bundle branch block:  If recurs, give adenosine again &
 Give adenosine as for regular consider choice of anti-arrhythmic Possible atrial flutter
narrow complex tachycardia prophylaxis  Control rate (e.g. -Blocker)
 Proposed Algorithm for Convulsive Status Epilepticus
From “Treatment of Convulsive Status Epilepticus in Children and Adults,” Epilepsy Currents 16.1 - Jan/Feb 2016
Interventions for emergency department, in-patient setting,
Time Line or prehospital setting with trained paramedics

1. Stabilize patient (airway, breathing, circulation, disability - neurologic exam)

2. Time seizure from its onset, monitor vital signs
3. Assess oxygenation, give oxygen via nasal cannula/mask, consider intubation if respiratory assistance
0-5 Minutes needed
Stabilization 4. Initiate ECG monitoring
Phase 5. Collect finger stick blood glucose. If glucose < 60 mg/dl then
Adults: 100 mg thiamine IV then 50 ml D50W IV
Children ≥ 2 years: 2 ml/kg D25W IV Children < 2 years: 4 ml/kg D12.5W IV
6. Attempt IV access and collect electrolytes, hematology, toxicology screen, (if appropriate) anticonvulsant
drug levels

Does Seizure
YES Continue? NO

A benzodiazepine is the initial therapy of choice (Level A): If patient at baseline,

Choose one of the following 3 equivalent first line options with dosing and frequency: then symptomatic
• Intramuscular midazolam (10 mg for > 40 kg, 5 mg for 13-40 kg, single dose, medical care
Level A) OR
5-20 Minutes • Intravenous lorazepam (0.1 mg/kg/dose, max: 4 mg/dose, may repeat dose
Initial Therapy once, Level A) OR
Phase • Intravenous diazepam (0.15-0.2 mg/kg/dose, max: 10 mg/dose, may repeat dose
once, Level A)
If none of the 3 options above are available, choose one of the following:
• Intravenous phenobarbital (15 mg/kg/dose, single dose, Level A) OR
• Rectal diazepam (0.2-0.5 mg/kg, max: 20 mg/dose, single dose, Level B) OR
• Intranasal midazolam (Level B), buccal midazolam (Level B)

Does Seizure
YES Continue? NO

There is no evidence based preferred second therapy of choice (Level U): If patient at baseline,
Choose one of the following second line options and give as a single dose then symptomatic
• Intravenous fosphenytoin (20 mg PE/kg, max: 1500 mg PE/dose, single dose, medical care
20-40 Minutes Level U) OR
Second Therapy • Intravenous valproic acid (40 mg/kg, max: 3000 mg/dose, single dose,
Phase Level B) OR
• Intravenous levetiracetam (60 mg/kg, max: 4500 mg/dose, single dose, Level U)
If none of the options above are available, choose one of the following (if not given
already)
• Intravenous phenobarbital (15 mg/kg, single dose, Level B)

Does Seizure
YES Continue? NO

40-60 Minutes There is no clear evidence to guide therapy in this phase (Level U): If patient at baseline,
Third Therapy Choices include: repeat second line therapy or anesthetic doses of either thiopental, then symptomatic
Phase midazolam, pentobarbital, or propofol (all with continuous EEG monitoring) medical care

Disclaimer: This clinical algorithm/guideline is designed to assist clinicians by providing an analytic framework for evaluating and treating
patients with status epilepticus. It is not intended to establish a community standard of care, replace a clinician’s medical judgment, or
establish a protocol for all patients. The clinical conditions contemplated by this algorithm/guideline will not fit or work with all patients.
Approaches not covered in this algorithm/guideline may be appropriate.
2016 © Epilepsy Currents