Emergency severity index book

The Emergency Severity Index (ESI) is a tool for use in emergency department (ED) triage. The
ESI triage algorithm yields rapid, reproducible, and clinically relevant stratification of patients into
five groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for
categorizing ED patients by both acuity and resource needs

! Main aim is to Avoid complications as possible

! Triage stabilization
! List Different dx at least closed dx
! classify patients in groups according to severity
! Start initial management then move patient to his department
! Prevent irreversible damage at any case ( compensated >> decompensated >> then irreversible
damage )

Triage systems
1. Emergency Severity index ESI
Level of triage for pt
** Who did triage ?
Nurse experience in triage
** Doctor has to be familial with the triage level
Initial assessment
1. ESI level
FIVE LEVEL OF ESI
1.level one : most sever urgent
" Is the Patient Dying?
" Any case need immediate Life saving interventions
" Like tension pneumothorax
" Or apnea air way management
" Arrested CPR

2.level two: High risk situation may became level one

" the patient should not wait
" Immediate physician involvement in the care of the patient is a key difference between ESI
level-1 and 2 patients. Level-1 patients are critically ill and require immediate physician
evaluation and interventions. Conversely, while level-2 patients are also very ill, the
emergency nurse can initiate care through protocols without a physician at the bedside.
" Level 2 like :
" STEMI
" CVA
" Eclampsia
" Peritonitis may cause septic shock(level 1 )
" DANGER VITAL SIGNS is level 2
" Not need immediate interventions
3. Levels 3,4 &5 : Complaining
" Like Abd pain
" Think about diff. Dx
" Before assigning a patient to ESI level 3, you need to look at the patient's vital signs and
decide whether they are outside the accepted parameters for age ( in dangerous zone ) . If the
vital signs are outside accepted parameters, then the triage level is ESI level 2.
" if VS are within normal range then ask : How many different resources do you think this
patient is going to consume in order for the physician to reach a disposition decision?
" If used more than one resource then: level 3
" One resource level4
" No resource level 5 just with history and physical examination

Resources like
# Lap (all lap ) is one resource
# All types of consultant is one resource
# Iv fluid as hydration is not a resource but when given with a medication is a resource
# ECG
# CT scan
# Ultrasound is not a resource
# ‫ﻟﻤﺎ اﻋﻤﻠﮭﺎ ﻓﻲ اﻟﻄﻮارئ‬bedside ‫ ﻻ ﺗﻌﺘﺒﺮ‬resource ‫ ﺑﻞ‬PEX ‫أﻣﺎ إذا اﻧﺎ ﺷﺎك ﺑﺎﺷﻲ وطﻠﺒﺖ اﻟﺘﺮاﺳﺎوﻧﺪ ﻛﻮﻧﺴﻠﺖ ھﺎي‬
resource
# Prophylactic tetanus
Management according to level triage :

$ Level one
# Immediate interventions are required!!
# All equipments should be ready, in crash cart
(Emergency trolley)
# The trolley must be Immediately ready after classified a
patient with level 1

! what dose crash cart contain?

" Alcohol swabs.
" Amiodarone 150 mg/3ml vial.
" Atropine 1mg/10 ml syringe.
" Sodium bicarbonate 50mEq/50 ml syringe.
" Calcium chloride 1gm/10 ml syringe.
" Sodium chloride 0.9% 10 ml vial Inj. 20 ml vial.
" Dextrose 50% 0.5 mg/ml 50 ml syringe.
" Dopamine 400 mg/250 ml IV bag
 # In general when present at
emergency:
I．Emergent .Hx and
physical exam should be
focused
II．Pt will be irritable

.......

Quick assessment
ABCDE
Don’t forget that if there is a defect treat it immediately then move to the next step of assessment

A: airway
# Look , listen , feel
# Look for chest rising breathing movements
# Listen for breathing sounds
# Feel breathing in front of mouth
# If appropriately answering questions, patient has a patent airway (at least for the moment)
# Observe patient for signs of respiratory distress
# Inspect mouth and larynx for injury or obstruction (e.g., blood, vomit, burns, soot)
# Assume cervical spine injury in blunt trauma patients until proven otherwise
# If patient is unconscious (and therefore unable to protect their airway) or in respiratory distress,
the threshold for intubation is very low.
# Patients with burn injuries; and evidence of respiratory involvement (e.g., soot in the
oropharynx) are often intubated out of precaution. [1]
# If orotracheal intubation is difficult, perform a cricothyrotomy.

B: breathing,
# Look for chest movements , symmetrical rising with respiration
# Using accessory muscles
# Assess oxygenation status with pulse oximetry.
# Inspect and auscultate chest wall for injuries (e.g., absent breath sounds, asymmetric or
 paradoxical movement)
# In unstable patients, do not delay treatment of tension pneumothorax or hemothorax in favor
of imaging.

C: circulation
# pulse palpation of central (carotid, femoral) and peripheral (radial, popliteal, posterior tibial,
dorsalis pedis) pulses
# Blood pressure
# Skin color
# Heart rate tachycardia or bradycardia
# Capillaries refill time
% Place two large-bore intravenous lines (at least 16 gauge).
% Intravenous line or intraosseus line.
% Control on-going hemorrhage with manual pressure or tourniquets.
% If patient is hypotensive, administer a bolus of intravenous saline.
% If history of hemorrhage or on-going hemorrhage, transfuse type O blood.
% If significant hemorrhage and persistent hemodynamic instability, transfuse plasma,
platelets and red blood cells at 1:1:1 ratio.
% (FAST) exam
% Remember hypovolemic shock due to hemorrhage requires loss of ∼ 1.5 L of blood.

# The compartments where large amounts of blood may go:

% Outside (external hemorrhage)
% Thoracic cavity
% Pelvic cavity
% Abdominal cavity

D: disability
# Assess patient's Glasgow Coma Scale score
# A GCS score ≤ 8 is an indication for intubation
# Assess pupillary size
# If patient is interactive, assess motor function and light
touch sensation.

# GCS for all acute disabilities

Pt with fever infections roll out sepsis using GCS

15 points
# 4 points eye opening
# 5 points verbal
- 5 for oriented ‫ﺻﺎﺣﻲ وﺑﺤﻜﻲ ﻛﻞ اﺷﻲ ﺻﺢ‬
- 4 confused ‫ﺑﺤﻜﻲ ﺟﻤﻞ ﻛﺎﻣﻠﺔ ﺑﺲ ﻣﺸﺘﺖ‬
 - 3 no sentences ‫ﺑﺤﻜﻲ ﻛﻠﻤﺎت ﺑﺲ ﻣﺎ اﻟﮭﺎ ﻋﻼﻗﺔ ﺑﺎﻟﻮاﻗﻊ‬
- 2 just sounds no words
- 1 no sound at all
# 6 points power Movements
- 6 Spontaneous on order ‫ ﺷﻮ ﺑﺘﺤﻜﯿﻠﮫ ﺑﻌﻤﻞ‬all movement,
exam be on unaffected limps
- 5 in pain stimulation
- 4 on pain stimulation withdrawal from the pain ‫ﺑﺒﻌﺪا ﯾﺪه ﻋﻦ اﻻﻟﻢ‬
- 3 spontaneous flection decorticate ‫ﺿﺎم ادﯾﮫ ﻋﺤﺎﻟﮫ‬
- 2 decerebrate ‫ زي ال‬، ‫ اﻟﻌﻜﺲ ادﯾﮫ ﻟﺒﺮا‬seizure ‫ﻋﺎﻣﻞ‬
- 1 no movement at all, relaxed

Lateralizing signed
Pupils symmetry, reaction weakness on one limp on side , a focal neurological assessment

! If GCS is 8 or LESS THAN 8 then DO INTUBATION, pt can't mantain airway

management is airway

E: exposure
# Undress patient completely.
# Examine body for signs of occult injury, including patient's back.
# If patient is hypothermic, cover with warm blankets and warm intravenous fluids.
# Palpate for vertebral tenderness and rectal tone.
# Avoid hypothermia
" General tips for applying an ABCDE approach in an emergency setting
include:
# Treat all problems as you discover them.
# Re-assess regularly and after every intervention to monitor a patient’s response to
treatment.
# Make use of the team around you by delegating tasks where appropriate.
# All critically unwell patients should have continuous monitoring equipment attached for
accurate observations.
# Clearly communicate how often would you like the patient’s observations relayed to you
by other staff members.

A:. Airway Management

" Position head tilt chin lift
If pt is traumatized then head tilt jaw thrust

This management is For patent airway not breathing

" Inspection
# If there is fluid suction
# If foreign body remove it only if you can see it
# If partial obstruction or low sat Use airway management
1. primary airway management

! Oropharyngeal airway
" ، ‫ﻗﯿﺎس اﻷداة ﻣﻦ طﺮف اﻟﻔﻢ ﻟﻄﺮف اﻻذن اذا ﺣﺠﻤﮭﺎ ﻣﻨﺎﺳﺐ ﻟﻠﻤﺮﯾﺾ‬
‫اﻟﻘﯿﺎس ﺑﻌﺪ اﻟﻠﻮن ﺑﺲ ﻟﻠﻄﺮف اﻟﻤﺎﺋﻞ‬
" ‫ﻛﯿﻒ ﺑﺪﺧﻠﮭﺎ؟‬
# For adult
‫اﻟﻜﯿﺮڤ ﻟﺘﺤﺖ وﻟﻤﺎ اﺻﻞ ﻟﻠﻨﺺ ﺑﻠﻔﮭﺎ ﻟﻔﻮق‬
# For pediatric or adult
‫ ﺑﺪﺧﻞ اﻷداة اﻟﻜﯿﺮڤ ﻟﻔﻮق ﻣﻦ اول اﻟﺪﻧﯿﺎ ﺑﻼش اﻋﻤﻞ‬injury

" Oropharyngeal airways come in a variety of sizes from

infant to adult and ensuring the correct size is important. If
it is too big it can obstruct the airway or cause trauma.
OPAs should only be used in an unconscious patient, as in
a conscious person their insertion can stimulate the gag
reflex and induce vomiting

! Nasopharyngeal airway
Contraindications is head trauma specially is there is a
BASAL SKULL FRACTURE

! Laryngeal Mask
Can be connected to ambu bag
In unconscious patients
Cover larynx give effective ventilation but air also enter
esophagus
2. definitive airway management
" Air just enter trachea, no air enter
esophagus.
1. Intubation
2. Surgical
- cricothyroidotomy
- tracheostomy

" Intubation types :

a. Elective intubation in operative
room
b. Rapid sequence intubation in ER
c. crush intubation In arrested or died
A-systole

B; breathing
" Think about tension pneumothorax And
treat it
# Chest tube at 5 or 6 intercostal
space (level of nipples in male) at
Anterior axillary line
# Larger tube is needed in case of
traumatic pneumothorax than
spontaneous pneumothorax
" O2 sources
# nasal cannula
# Face mask
# Non rebreather face mask more
effective (has a bag under the mask fill with O2 make
ventilation more effective
# CPAP or BIPAP
# Mechanical ventilator
" Definitive airway management
# Cricothyroidotomy
# Tracheostomy
# Need for mechanical ventilation
" Primary airway management: don't need mechanical ventilation

non rebreather face mask

C. Circulation management
" In traumatic pt think about bleeding
" External bleeding , internal bleeding
" If hemothorax treat as pneumothorax
" Place two large-bore intravenous lines (at least 16 gauge).
" Intravenous line or intraosseus line.
" Control on-going hemorrhage with manual pressure or tourniquets.
" If patient is hypotensive, administer a bolus of intravenous saline.
" If history of hemorrhage or on-going hemorrhage, transfuse type O blood.
" If significant hemorrhage and persistent hemodynamic instability, transfuse plasma, platelets
and red blood cells at 1:1:1 ratio.
" (FAST) exam
" Remember hypovolemic shock due to hemorrhage requires loss of ∼ 1.5 L of blood.

D. Disability management SOFA Score

" GCS done for any pt with acute
neurological deficit as neurological
assessment
" ‫ﻣﺮﯾﺾ ﻛﺎن ﺗﻤﺎم وﺧﻼل اﯾﺎم ﺻﺎر ﻋﻨﺪه ﺗﻐﯿﯿﺮ ﻣﺶ‬
‫ﻣﺮﯾﺾ زھﺎﯾﻤﺮ ﻣﻦ زﻣﺎن‬
" In sepsis quick sofa score in emergency
" Patient with infection should be evaluated
by sofa score which is
1. GSC
2. tachypnea
3. Low mean pressure; less than 65
" Don't forget to exam back examination
(using log roll )

E. Exposure management
" log roll Indication:
# To allow examination of patient’s back
Removal of spinal board
# If indicated rectal examination
" A minimum 5 people are involved in the
procedure
1. One person stands at the head, should be
 assigned as in charge and it is essential that all the others follow his/her orders
2. The person at the head will maintain manual control of patient’s head either with cervical
collar in place or MILS
3. Three assistants stand to the side of the patient onto which the patient to be turned
4. The fifth one is the examiner

" Complications:
• Lack of coordination and risk of injury
• Tubes and lines being displaced
• Fatigue of team members

! Stander management in trauma patient

1. ABCDE
2. Two large bore cannula (blood , 500 fluid)
3. Five fluid if No response
a) mean arterial blood pressure less than 65
b) long capillaries refill time then five blood
4. O2 supplement
5. Pain management is essential! because patient may
develop neurogenic shock, bradycardia and
hypotension.
6. Any trauma patient with hypotension is internal
bleeding until proven other wise
7. If suspected bleeding no NSAID
8. If head trauma give Morphin in sever , paracetamol tramadol
9. Antibiotics and antitetanus ( in penetrating trauma are required
10. Early consultant
11. Abd bleeding inspection penetration injury, Echimosis ...
12. In pelvis : Roll out Open book fracture in symphysis pubis
‫ﻣﻤﻨﻮع ﻧﻌﯿﺪ اﻟﻔﺤﺺ ﺑﺲ ﻣﺮة وﺣﺪة ﻛﻞ ﻣﺎ زاد اﻟﻔﺤﺺ ﯾﺰﯾﺪ اﻟﻨﺰف‬
Management by pelvic banded

Open book fracture

** Naloxone antidote of opioid
Need one minute to give effect but if didn't work Wait for 3 mins before second dose
Allowed Just Up to 3 doses

! Complete primary survey with portable chest, spine and / or pelvis x-ray
 Approach to CPR

" cardiac arrest then Start CAB not ABC

" ANY PATIENT SUDDEN COLLAPSE
% check pulse , response, call for help
% Start CPR
! do Adult 30 compression /2 breath if you are alone
! Pediatric 15/1
" Or If you are two at least do 15/1 adult
" Depth 2 inches adult
" Frequency 100-120 comp./min
" Full recoil of the chest is required
" Don't detach your head from the
chest
" Don't interrupt the CPR more than
10 seconds !!
" Keep the arms straight and do not
bend the elbow
" the shoulders should be directly
above the hands.
" Use full body weight to deliver rapid, firm compressions
" Team members
# Team leader Near foot
# Airway management in head of pt
# Medications + defibrillator
# Timer (recorder)
# CPR members two to three

" V tac + v fib pulseless shockable rhythms

" Resuscitation medications

! Obtain peripheral IV access or IO access for
medications
$ Shockable rhythms
! Epinephrine 1 mg IV/IO
# First dose: after second unsuccessful
defibrillation attempt
# Repeat every 3–5 minutes.
! Amiodarone 300 mg IV/IO (OR lidocaine 1–1.5 mg/kg
IV/IO)
# First dose: after third unsuccessful defibrillation
attempt
# An additional dose of
150 mg of
amiodarone or 0.5–
0.75 mg/kg of
lidocaine can be
given after 3–5
minutes.
$ Nonshockable
rhythms:
! administer epinephrine 1
mg IV/IO.
# Repeat every 3–5
minutes.
# First dose: as soon as
possible
! The 5 Hx and Ts for arrest
 Anaphylactic shock

" Anaphylaxis is an acute, potentially

life-threatening, type 1 hypersensitivity
reaction, involving the sudden
IgE-mediated release of histamine
mediators from mast cells and basophils
in response to a trigger (e.g., food, insect
stings, medication).

" Sign and symptoms:

" Skin or mucous membranes
# Flushing, erythema
# Urticaria, pruritus
# Swelling of the eyelids,
angioedema
# Nasal congestion, sneezing
" Respiratory
# Cough, hoarseness
# Chest tightness
# Dyspnea (due to bronchospasm or
laryngeal edema), tachypnea
# Stridor, wheezing
# Hypoxia, cyanosis
" Gastrointestinal
# Nausea, vomiting (especially in
food allergies)
# Abdominal pain, diarrhea
" Cardiovascular
# Hypotension
# Adults: SBP < 90 mm Hg OR
decrease ≥ 30% from baseline

" Management
1. Stabilize the patient (ABCDE approach).
2. Airway assessment and management
3. Rapid sequence intubation (RSI) for airway compromise
4. Oxygen: Provide FiO2 of 100% (e.g., high-flow O2 by nonrebreather mask).
5. Aggressive IV fluid resuscitation if hypotension present (large-bore IV access; administer 1–2
L 0.9% saline IV bolus)
6. Position the patient supine.
7. If anaphylaxis is likely , start initial treatment immediately
8. Remove inciting allergen
9. Administer epinephrine IM0.5 moof a 1:1,000 (1 mg/mL) into the anterolateral thigh
10. Repeat every 5–15 minutes as needed if not response give IV adrenaline (5ml 1:10000)only if
cardiac arrest!
11. IM epinephrine injections always require a more concentrated solution (1:1,000)
12. Once stabilized, consider adjunctive therapy with antihistamines; Chloramphenicol 10mg
IM or IV over 1-2 minutes , corticosteroids (e.g., methylprednisolone)
13. Continuous reassessment and subsequent management
14. Admit patient for observation (6-8 hours)
 Rapid sequence intubation

" Rapid sequence intubation (RSI) is an

airway management technique that produces
inducing immediate unresponsiveness
(induction agent) and muscular relaxation
(neuromuscular blocking agent) and is the
fastest and most effective means of
controlling the emergency airway
" INDICATIONS FOR RSI
# Lack of airway protection despite patency
(swallow, gag, cough, positioning , and
tone)hypoxia
# hypoventilation
# need for neuroprotection (e.g. target PaCO2
35-40 mmHg)
# impending obstruction (e.g. airway burn,
penetrating neck injury)
# prolonged transfer
# cervical spine injury (diaphragmatic
paralysis)
" PROCESS OF RSI
Remembered as the 9Ps:
# Plan
# Preparation (drugs, equipment, people,
place)
# Protect the cervical spine
# Positioning (some do this after paralysis and
induction)
# Preoxygenation
# Pretreatment (optional; e.g. atropine,
fentanyl and lignocaine)
# Paralysis and Induction
# Placement with proof
# Postintubation management
! LEMON Score
" Rapid sequence intubation depends on LEMON

Score
" LEMON score is for elective intubation
" One tool developed to determine which patients might
pose airway management difficulties is the LEMON
method
" The score, with a maximum of 10 points, was calculated
by assigning 1 point for each of the following LEMON
criteria:
# L=Look externally (facial trauma, large incisors,
beard or mustache, and large tongue)
# E=Evaluate the 3-3-2 rule (incisor distance <3 finger
breadths, hyoid/mental distance <3 finger breadths,
thyroid-to-mouth distance <2 finger breadths)
# M=Mallampati (Mallampati score ≥3)
# O=Obstruction (presence of any condition that could
cause an obstructed airway)
# N=Neck mobility (limited neck mobility).

" Contraindication medications in difficult intubation

% Paralytic agents cause paralysis so I won't be able to do intubation for the patient
" So in these patients do awake intubation with just sedation

" Steps
1. Prepare yourself : Protect yourself
2. Prepare instruments
# Laryngoscope: Handel +blade ( has different sizes)
# Tubes : all adult sizes are 7 - 8
# Some types are non- coughed, no balloon ( up to size 5) ,
because it may cause injury specially in long term intubation
# choose size according to age
# Size in non coughed 4+ (age/4)
# Size in coughed 3.5+ (age/4)
# Medications
# Suction

3. Prepare patient
Medications
! Sedation:
# Diazepam, Midazolam 0.1-0.3 mg/kg slow onset
# Etomidate 0.3-0.4 mg/kg
# Propofol 1-2.5 mg/kg hypotension, myocardial depression, reduced cerebral perfusion, pain
on injection, variable response, very short acting
# Ketamine 1.5-2 mg/kg ( increase ICP)caution in cardiovascular disease (hypertension,
tachycardia), laryngospasm (rare), raised intra-ocular pressure

NO paralytic agents until make sure the Patient’s intubation is not difficult

4. Oxygenation
Do hyperventilation
Face mask in high O2

5. Insertion the instrument

Listen the sound of breath to make sure the intubation reached both sides

" Capnography
# using to verify effective ventilation and proper tube placement
# no waveform = no tube!!!
# There is NO BETTER WAY to confirm proper tube placement than waveform
capnography
# Termination of Resuscitation
# EtCO2 measurements during a high quality resuscitation give you an accurate indicator
of survivability for patients under CPR
# Persistently low ETCO2 values < 10 mmHg in an intubated patient suggests that:
% ROSC is unlikely so you may terminate effort Inadequate & low quality chest
compressions
% Increase in CO2 to normal value to 35 – 40 mmHg during CPR can be an early
indicator of ROSC
# Main Uses of Capnography during resuscitation
% Tube placement confirmation: value more than 0
% Quality of chest compression: value between 10 & 20
% Termination of Resuscitation: constantly below 10 Entering ROSC stage: value
between 35 – 45
# But mostly we use O2 sat.

" Surgical intubation

1. Cricothyroidotomy in ER
2. Tracheostomy in OP

1. Cricothyroidotomy
A、Prepare yourself equipments and patient
B、put Thyroid cartilage superiorly
Cricoid cartilage inferiorly
C、incision vertical just to skin
a) Using your Little finger to dilation until feel
crico-thyroid membrane
D、Puncture ( horizontal incision )
 Tachycardia approach
! First ECG reading
1. Heart rate
300/Larg boxes regular HR
900/ 3 RR Larg boxes in irregular HR

2. regular or not
RR interval

3. Sinus
Present P wave before every QRS

4. Axis
# Both lead 1 & AVF are positive this is
normal Axis
# Lead 1 positive & AvF negative than this is
left Axis
# lead 1 negative but AvF positive then this is
Right Axis
# Both lead 1 & AvF are negative then this is
extremely left Axis

5. QRS
# Less than 3 small boxes
# Wide QRS like in hyperkalemia , LBBB ( indicated for Cath) , RBBB, toxin , digoxin toxicity,
tricyclic antidepressants

6. PR
# Short : Less than 0.2 second chanalopathy , WPW syndrome ( V4 .V5 V6 )
# Depression in pericarditis
# Prolonged in heart Block

6. ST segment
# Elevation causes:
a. Acute myocardial infarction.
b. Coronary vasospasm (Printzmetal's angina)
c. Pericarditis.but there should be no reciprocal ST depression (except in AVR and V1)
d. Benign early repolarization.
e. Left bundle branch block.
 f. Left ventricular hypertrophy.
g. Ventricular aneurysm.
h. Brugada syndrome
# Depressed
a. Severe hypertension.
b. Severe aortic stenosis.
c. Cardiomyopathy.
d. Anemia.
e. Hypokalemia.
f. Severe hypoxia.
g. Digitalis.
h. Sudden excessive exercise

7. T wave
# Inverted old wave or new
# Inverted With Q wave new MI

8. QT
# time taken for ventricular depolarisation and repolarisation.
# usually measured in either lead II or V5-6, however
# the normal QT interval is below 0.4 to 0.44 seconds.
# Less than half RR normal
Prolonged hypokalemia, Certain antifungal medications, Diuretics that cause an electrolyte
imbalance (low potassium, anti-arrhythmic medications

! Then tachycardia classification mainly depends on

these two questions:
1. Wide or narrow QRS complex?
Narrow QRS complex is 0.08 - 0.12 s
Wide QRS complex is more than 0.12 s

2. Is it regular or irregular?
! Narrow QRS complex
1. Sinus tachycardia
% is the most common regular SVT. It has an accelerated sinus rate that is a physiologic
response to a stressor. It is characterized by a heart rate faster than 100 beats per
minute (bpm) and generally involves a regular rhythm with p waves before all QRS
complexes.
% Mostly patient is asymptotic or mild palpitation
% No complications
% Treat the cause

2. MAT
! Multifocal atrial tachycardia (MAT) is a cardiac arrhythmia caused by multiple sites of
competing atrial activity.
! It is characterized by an irregular atrial rate greater than 100 beats per minute (bpm).
! Atrial activity is well organized, with at least 3 morphologically distinct P waves, irregular P-P
intervals, and an isoelectric baseline between the P waves. Within 10 seconds
! may be asymptomatic
or pt may complain
" Palpitations
" Shortness of breath
" Chest pain
" Lightheadedness
" Syncopal episode
! Pt mostly stable
! Mostly associated with chronic lung
disease
! Treat the underlying disease
3. supraventricular tachycardia
! high rate more than 180 BPM
! Regular
! No P wave
! Narrow complex
" Palpitations
" drawnness,
" Dizziness
" Syncope
" Chest pain
! Unstable Risk for Hypo-perfusion if
% mean pressure is less than 65 mean
% Or increase capillaries refill time,
patient usually looks ill pale
% Unstable because it may be as
complication of ACD ( with chest pain )
! Patients who are hemodynamically unstable should be resuscitated immediately with
cardioversion. An electrocardiogram (ECG) should be performed as soon as possible

! Management:
1 Pt unstable+ arrhythmia then he is triage level 2
synchronized Electrical cardioversion Around 100 jole
Give DC shock
If pt is conscious give sedation like
1- midazolam or diazepam 5mg IV push + must be intubated
2- Or second best medication is etomidate 3.5 mg/kg; is a short-acting intravenous anesthetic
indicated for the induction of anesthesia and supplementation of subpotent anesthesia during short
procedures

don’t give :
" ketamine with diazepam ( ketamine risk for hallucination ) but ketamine increase HR and
ICP so not good for tachycardia arrhythmia.
" propofol cardiac toxic

! Then continue the synchronized Electrical cardioversion

! Up to 3 trails in emergency ( increase the dose in every trail) then referred to cardiologist
! Give O 2
! Even it’s emergency you have to tell the patient “ it conscious “ and the family what you are
doing
! After giving the shock reassessment the pt
1. IF RETURN rhythm Full lead ECG to rule out STEMI and ischemic change
2. If not respond revive another DC shock if respond as above
3. If not respond give the last Dc shock
! ** rise the dose of shock in every trail until finishes three trails then referred to cardiologist If
not respond.

2 Pt is stable
! Stable mean good perfusion “ no hypo perfusion “
! No chest pain “ then no suspicious that is ischemia
! And pt is conscious
$ Start with non medical treatment
I．Cardiac massage : contraindication in pediatric, but in adult you have to
auscultation the carotid to roll out bruit sound “ rupture risk”
Absolute contraindications to carotid sinus massage include myocardial infarction,
transient ischemic attack or stroke within the preceding three months. A history of
ventricular fibrillation or tachycardia, or a previous adverse reaction to carotid sinus
massage are also absolute contraindications
And contraindication to be done bilaterally
Low response
II．valsalva maneuver
III．Squatting
$ Be sure the pt Is stable Start Adenosine IV push start with 6 mg, if no response
12mg, if no response 12mg via large pores cannula proximal as could be to heart ”
check stability of the pt after every dose if stable give the second if not move to
cardioversion shock”
$ How to give adenosine? Via three pore cannula and with flush , rise pt hand and
adenosine
$ Half life of Adenosine is just 4 seconds “ within 40 seconds adenosine removed
completely from body”
$ You have to tell the patient that he will feel sever chest pain burning dyspnea
drowsiness when give Adenosine
$ Aminophylline is the antidote for Adenosine
$ If not response after 3 trails go to electrical cardioversion shock “ despite pt Is
stable or not”

4. Atrial fibrillation ( is the same as atrial flutter in management)

" Narrow complex
" Wavy base line
" AFib Irregular irregularly
" Rate atrial rate higher than ventricular rate 3x
" A. Flutter regular
" If AFib present with RBBB n QRS complex will be wide not narrow
" New LBBB is indication for cath “ there is acute coronary “
! Management
A、First is pt is stable or not stable “ chest pain, hypo perfusion “
1,. If unstable go to synchronize electrical cardioversion shock Same dose , three trails , may give
rhythm control” lidocaine IV , amiodarone“ call cardiologist

2. if pt is stable
Then ask if the symptoms is start before 48 hours or less than 48 hours or unknown ‘ unknown
is classified with more than 48 hours “
Is important to thrombus formation risk or not “ CVA risk” ! Usually in left atrial appendage
because of
To do medical cardioversion or not , more risk in pt with symptoms more than 48 hours
" Less than 48 hours
Less risk for thrombus then Can do cardioversion safely
amiodaron 300 Mg/ 20 minutes, antiarhythmic class three : is heart safe but exrtacardiac toxic to
lung ..
Full dose of amiodaron is 1200 mg over 24 hours , give first 300 mg in 20 minutes then 900 mg over
the rest 24 hours , even the rhythms return normal , pt has to complete the full dose 1200 mg

" Is symptoms started before more than 48 hours

* Do trans-esophageal echocardiogram TEE “ not Trans thoracic echocardiogram “ to roll out
thrombus formation
* If could not be done then move to second choice
1. Give anticoagulant for three weeks with rate control “ B blockers Or calcium Chanel’s
blockers “
- Must have completely compliance for all three weeks for the anticoagulant , any forgotten dose
has to repeat the three full weeks all over
- Or if pt take warfarin, IN should be within therapeutic range ( 2-3).
** there is a risk to have an immediate normal rhythm after give rate control then risk for embolism
and CVA and this is medico legal risk
2. Then after three weeks do medical cardioversion
! for Prophylactic Use chads vasc score in general after the cardioversion and
treatment
# Maximum score is 9
# If patient’s score is 2 or more, then patient is in high risk zone and patient need anticoagulant
life long
# If patient’s score is less than 2 then patient then ask at presentation
" Is patient’s symptoms exceed 48 hours ? If yes then patient need for anticoagulant for 4
weeks
" If no then no need for anticoagulant after the cardioversion or may need one dose
# For example: pt presented with AFib
He was stable , chad vasc score was 3,
symptoms started before 24 hours , not
in warfarin
Stable then Do TEE or give him
anticoagulant for three weeks with rate
control like B Blockers
Then after three weeks do medical
cardioversion
after that, his chad vasc score we more
than 2 then give him anticoagulant life
long

CHAD VASC SCORE

! AFib Classification
1. Paroxysmal any patient had AFib that return to sinus within one week “ what ever
the method was used “ is paroxysmal
2. persistence: If AFib last for more than one week up to one month
3. Long standing persistent if AFib last more than one month up to three years
dispute continues treatment, this is irreversible and just give the patient rate control
 Six killers of chest pain

! Chest pain rise triage to level two, Then use PEX & Hx, Start with the most simple test

! Acute coronary
" Atherosclerosis diseases
" Any anginal pain is USA until proven other wise
" History typical of Myocardial ischemia "Angina
Pectoris" = Pain in the chest
" Central chest pressure, tightness, squeezing
" Intensity increases over a few minutes Radiation to
shoulders, arms, neck, jaw
" Worse with exertion
" Often not described as a "pain" but as
a. Pressure
b. Discomfort
c. Ache
d. Tightness
" Painless AMI common with age, women and diabetics, Prev stroke or heart failure also risks
By age 85 MAJORITY of AMI painless
" Basic investigations
% bloods
% CXR
% ECG: in Emergency Department an ECG in most if not all patients
$ More useful as 'rule in' than 'rule out'.
$ ECG in AMI 50% sensitivity, 90% specificity
$ No ECG change I n PE or aortic dissection

# USA unstable Angina:

" vital signs mostly normal in ER
" Not very High or very low
" Mild hypo or hyper
" ECG mostly normal but may have ST depression or T-wave inverted “not specific”
" Cheat X-ray normal
" Cardiac enzymes normal

" Management
% MONA
1. M: Morphin for sever pain not sever hypotension“ prevent neurogenic shock “
2. O: O2 when sat less than 95%
3. N: Nitroglycerin for HTN patient or normo-pressure ( cause hypotension, so not
given when patient is already hypotension “
4. A: Aspirin everyone 200-360 mg
% Put Patient in close cardiac monitor For high risk situation
" If pain continue more than 20min in pain then repeat 12 leads ECG for detection dynamic
change in ECG

# NSTEMI
" MORE sever pain
" Hx and VS mostly like USA “ normal or mild
change “
" ECG mostly normal“ the same as USA”
" Troponin positive
" management
% Start MONA
% Heparin 5000 -10000 IV push adult anticoagulation
% clopidogrel (plavix )300 mg loading dose (4 tablets orally), antiplatelet“don’t forget that
30% genetic of people has no effect of clopidogrel”
% Aspirin 300 Orally
 % Statin + b blocker
% Second antiplatelet
% within 72 hours patient should have
PCI/Cath

# STEMI
" lead 1 , .end 2 and AVF for inferior
" V2 V3 RECIPROCAL OF posterior
" Lead + avL lateral
" Lead1 , Avl + V5 V6 high lateral
completely full thickness
" reciprocal change lateral in inferior
" V2 V3 anterior
" V7, V8, V9 reciprocal change of
anterior
" V1 V2 ventricular septum

" PCI Cath should Within 120 min

" indications for primary catheterization:

% STEMI
% Posterior MI
% Chest pain with new completely LBBB
% patient who developed cariogenic shock after 6 hours of receiving TPI
" According to medscape
Patients with unstable angina and the following clinical characteristics should be referred for
immediate cardiac catheterization:
1. Cardiogenic shock
2. Severe left ventricular dysfunction
3. Angina refractory to medical therapy
4. Acute mitral regurgitation
5. New ventricular septal defect
6. Unstable tachyarrhythmias
# Aortic dissection
" is defined as separation of the layers within the
aortic wall. Tears in the intimal layer result in the
propagation of dissection (proximally or distally)
secondary to blood entering the intima-media
space.
" Anterior chest pain: Usually associated with
anterior arch or aortic root dissection
" Descending Dissection give pain mostly in back
" Neck or jaw pain: With aortic arch involvement
and extension into the great vessels
" Risk factors for Aortic Dissection
% HTN & tachycardia
% Aortic valve
$ Bicuspid
$ previous surgery
% Abnormal Aorta – mainly congenital Coarctation/ Marfan's/ Ehlers-Danlos
% Arteritis (Giant cell)
% PREGNANCY, COCAINE, TRAUMA
" Pressure on true legmen increase with increasing the dissection and may cause obstruction
" Aneurism is a major risk factor for aortic dissection
" Signs and symptoms are mainly
# Sudden onset of severe chest pain that often has a tearing or ripping quality (classic
symptom)
# Tearing or ripping intrascapular pain: May indicate dissection involving the descending
aorta
# No pain in about 10% of patients
# Syncope
# Altered mental status
# Numbness and tingling, pain, or weakness in the extremities
# Horner syndrome (ie, ptosis, myosis, anhidrosis)
# Flank pain (with renal artery involvement
# Abdominal pain (with abdominal aorta involvement

" patient gay to change position with no pain Improvement

" 17% of patients start with sever pain that cause neurogenic shock that cause loss of
consciousness then fallen down and trauma, so patient may be present as traumatic patient.
" nonspecific ECG change
% ST elevation without reciprocal change
" on CXR Widening of the mediastinum is the classic finding
# > 8.0-8.8 cm at the level of the aortic knob on portable anteroposterior chest radiographs
# Hemothorax may be evident if the dissection has ruptured
" On CT scan with arterial contrast enhancement (CTA) is the investigation of choice, able
not only to diagnose and classify the dissection but also to evaluate for distal complications. It
has reported sensitivity and specificity of nearly 100%
! double -lumen representing the true and false lumens
! dilatation of the aorta due to aortic insufficiency
! Mercedes-Benz sign in the case of a "triple-barreled" dissection
" true lumen
# often compressed by the higher pressure false lumen and the smaller of the two
# has outer wall calcifications (helpful in acute dissections)
# often contiguous with the aortic root
# the origins of the celiac trunk, SMA and right renal artery usually arise from the true
lumen
" false lumen
# often larger lumen size due to higher false luminal pressures (but size can be influenced
by phase of the cardiac cycle)
Beak sign
# often of lower contrast density due to delayed opacification
# at risk for rupture due to reduced elastic recoil and dilation
# typical location:
# right anterolateral aspect of the ascending aorta
# left posterolateral aspect of the descending aorta
# beak sign: is the acute angle formed at the edge of the false
lumen in aortic dissection in axial cross-section. It is formed
by the borders of the outer aortic wall and the intimal flap, and
may be partially thrombosed (blunted beak).
# cobweb sign (as slender linear areas of low attenuation
specific to the false lumen due to residual ribbons of media
that have incompletely sheared away during the dissection
process) 3
# maybe thrombosed and seen as mural low density only
(more common in chronic dissections)

" True lumen often has higher density on CTA

" Management
% Decreasing the blood pressure and the shearing forces of myocardial contractility
% Antihypertensive therapy, including beta blockers, is the treatment of choice for all
stable chronic aortic dissections Propranolol, Esmolol
% 10-20 mg IV labetalol (decrease HR ) Then 20 mg infusion/10-20 min
% Nitroprusside may be needed when BP doesn't decrease with labetalol
% Pain management: Narcotics and opiates are the preferred agents
 % Medications should be IV
% Emergency surgical correction is the preferred treatment for the following:
$ Stanford type A (DeBakey type I and II) ascending aortic dissection
$ Complicated Stanford type B (DeBakey type III) aortic dissections with specific
clinical or radiologic evidence

" Target
% Is decrease the mean pressure 20-30% within first hour
" mean pressure = diastole + 1/3 systole
" In acute dissection if not treated within 24 hours may cause death up to 95%

# Tamponade
" clinical syndrome in which there is an accumulation of fluid in the pericardial space,
resulting in reduced ventricular filling and subsequent hemodynamic compromise
"
" Mostly 200 cc is enough but rapid / age ... Is more important
" Dx. Is clinically
" Signs and symptoms
# Patients with acute tamponade may present with dyspnea, tachycardia, and tachypnea.
# Cold and clammy extremities from hypo-perfusion.
# Elevated jugular venous pressure
# Pulsus paradoxus
# Chest pressure
# Decreased urine output
# Confusion
# Dysphoria
# on physical examination patient is tried
# JVP is bilateral
# Hypotension
# Muffled heart Sound

" Confirm dx By echocardiogram

" Management
# O2
# Position
# rise leges
# Emergency subxiphoid percutaneous drainage
# Pericardiocentesis (with or without echocardiographic guidance
# Tension pneumothorax
" condition that develops when air is trapped in the pleural cavity under positive pressure,
displacing mediastinal structures and compromising cardiopulmonary function.
" Diagnosis made clinically hemodynamics disability
" most commonly seen after a traumatic chest injury or in individuals breathing through
mechanical ventilation.
" Traumatic tension pneumothorax
% Open chest wound, like a stab wound or a
gunshot
% Closed trauma, like a rib fracture
" Mechanical ventilation
High positive pressure during the inspiratory phase
can force air from the lungs into the pleural space.
Rarely, a spontaneous tension pneumothorax can
occur in the absence of any precipitating factors.
" Symptoms
% Severe shortness of breath
% Shallow breathing
% Acute chest pain
" Signs
% Low blood oxygen levels
% Increased heart rates
% Low blood pressure
% Altered mental status
% Decreased or absent breath sounds upon lung
auscultation
% Hyper-resonant chest percussion
% Asymmetrical expansion of the chest due to the
collapsed affected lung
" Cause obtrusive shock
" Unilateral pain
" Pleuritic pain
" JVD on same side
" A strong clinical suspicion of tension pneumothorax
is enough to initiate emergency treatment, which
should not be delayed by any imaging studies
" Management
% Sedation
% Chest tube at 5th - 6th intercostal specs at anterior axillary line
% Larger in traumatic than spontaneous
# Pulmonary embolism:

" Use wells score of PE

% 3 points if no alternative cause PE mostly the
diagnosis
% 3 points DVT confirm
% 1.5 points risk of DVT like immobilized patient
% 1.5 points Tachycardia
% 1.5 points if history of DVT or PE
% 1 malignant
% 1 Hemoptysis
# If result was Less than 2 then lower probability for PE and
move for D- dimmer ( D- diner only used in low Risk
patient)
# 2-6 moderate
# More than 6 high don't do D- dimmer
# Negative D- dimmer make PE Very unlikely
# Give anticoagulation heparin with close monitor

" Clinically
! Dyspnea ‫ﺣﺎﺳﺲ ﺣﺎﻟﻲ ﯾﺮﻛﺾ وﺑﻠﮭﺚ ﺑﺒﺬل ﺑﺠﮭﺪ‬
! abrupt onset of pleuritic chest pain On one side ,
shortness of breath, and hypoxia
! O2 Sat on border or lower
! Tachycardia
! Hypotension
! Obstruction shock right ventricle work against
resistance
! Hypotension
" High risk PE :Mean pressure less than 65 and
obstruction shock, unstable
" Intermediate high : biomarkers troponin positive,
bedside echo dilated right ventricle no Sock
" Intermediate low one is positive
" Low risk: non

" Management
# Immediate full anticoagulation is mandatory
for all patients suspected of having DVT or PE.
# Anticoagulation medications include the
following:
 % Unfractionated heparin
% Low-molecular-weight heparin
% Factor Xa inhibitors
% Fondaparinux
% Warfarin

" surgical management in high risk patients

% Catheter embolectomy and fragmentation or surgical embolectomy
% Placement of vena cava filters

# High Risk : surgical embolectomy

Trans Cath
TPA
# Intermediate high: heparin
# Intermediate low: heparin
# Low risk group: discharge on heparin
# Esophageal ruptured
" Ruptures due to developing a tear due to raised
intra-luminal pressure
" Classical triad is
% forceful emesis
% chest pain Retrosternal
% subcutaneous emphysema
" Prefer to sit up and may have chest signs CXR
usually abnormal on left side
" patient try to bend forward
" Clinical presentation
% Early: no fever sat good normal BP
% Late: fever leakage of esophagus cause
infections and sepsis, Tachycardia and
hypotension
" ECG normal
" CX-ray wide mediastinum ( in large leakage)
" Definitive diagnosis is CT, highly sensitive, gastrofren
" Tx fluid antibiotics
" Triple rule out CT done in emergency
# Complications
% acute mediastinitis
% esophagopleural fistula
% pneumonia
% empyema
% sepsis
Neck X-ray and CT
$ prevertebral soft tissue

The prevertebral component is measured on sagittal imaging as the distance

between the anterior border of the vertebral body and the air within the
pharynx/trachea.

Naturally there is a near-normal distribution of thickness in normal patients

depending on body build and expected variation. As such it is not possible to give a
definitive cut off that leads to perfect separation of patients with and those without
injury. It is merely a question of what sensitivity and specificity you are willing to
accept. For example in one study of plain radiographs yielded the following
measurements 7:

! C2/3: <7 mm
! C6/7: <21 mm

Values above these resulted in a true positive rate of 53% and false positive rate of
5% 7.

Similarly normal values for CT vary, but according to one of the larger series in
adults values the thickness of the prevertebral soft tissues are 6:

! C1: 8.5 mm
! C2: 6 mm
! C3: 7 mm
! C4/C5: variable due to variable height for cricoid/esophagus
! C6: 18 mm
! C7: 18 mm

$ The ABC’s of the cervical spine

A: Adequacy.
The C7/T1 junction must be visible

A: Alignment.
Ensure all 4 lines are contiguous/uninterrupted
1. Anterior longitudinal line
2. Posterior longitudinal line
3. Spinolaminal line
4. Spinous process line

B: Bones.
Each vertebrae must be examined for fracture/collapse/avulsion.
Parallel facet joints.

C: Cartilage (aka. disc spaces).

Examine for symmetry/normality of the
intervertebral discs between each
vertebrae

D: dens bone
The odontoid process (also dens or
odontoid peg) is a protuberance
(process or projection) of
the Axis (second cervical vertebra).

S: Soft tissue.
Prevertebral swelling of <2/3 of
adjacent vertebral width
Alternatively:
<7 mm anterior to C2
<2 cm anterior to C7

! Hyperkalemia
" 0.6 k increase In every 0.1 pH decrease
1.6 Na decrease every 100 increase in glucose

" Hyperkalemia is defined as a potassium level greater than 5.5

mEq/L.
" Initial emergency department care includes assessment of the
ABCs and prompt evaluation of the patient's cardiac status with
an electrocardiogram (ECG).

" Signs and symptoms of hyperkalemia

Patients with hyperkalemia may be asymptomatic, or they may

report the following symptoms
a. Weakness
b. Paresthesias
 c. Paralysis
d. Palpitations
e. diminished deep tendon reflexes or decreased motor strength
f. extrasystoles, pauses, or bradycardia
g. marked QRS widening

" Stages of hyperkalemia

Degrees of hyperkalemia are generally defined as follows
1. 5.5- < 6.5 mEq/L – Mild/ first stage
2. 6.5- <7.5 mEq/L – Moderate/ second stage
3. ≥7.5 mEq/L – Severe/ third stage

" Diagnosis of hyperkalemia

# Cause ECG change within 5 min

# ABG change: If acidosis is suspected
# Potassium level: The relationship between serum potassium level and
symptoms is not consistent; for example, patients with a chronically elevated
potassium level may be asymptomatic at much higher levels than other
patients; the rapidity of change in the potassium level influences the
symptoms observed at various potassium levels
# BUN and creatinine levels: For evaluation of renal status
# Ca level: If the patient has renal failure (because hypocalcemia can
exacerbate cardiac rhythm disturbances
# Glucose level: In patients with diabetes mellitus
# Digoxin level: If the patient is on a digitalis medication

# Urinalysis: To look for evidence of glomerulonephritis if signs of renal

insufficiency without a known cause are present
# Cortisol and aldosterone levels: To check for mineralocorticoid deficiency
when other causes

" ECG change

1. Stage one: peaked big T wave , narrow
complex
2. Stage two : p wave flattening + big T wave
3. Stage three : wide QRS ,flat p wave ,
may there is no big T wave
4. Then ventricle arrhythmia and arrest !

" Management
# Calcium (either gluconate or chloride):
Reduces the risk of ventricular
fibrillation caused by hyperkalemia,
 when k is 3 or more In stage Three
But in stage one or two without complications if hard to control hyperkalemia ( renal Dez)
may need for calcium gluconate

# Insulin+ glucose fast: Facilitates the uptake of glucose into the cell, which results in an
intracellular shift of potassium
- Pediatric 10% 20cc/kg
- 20-30 cc/kg dextrose 50% + 10 units insulin
- this method produces large amounts of ATP then can increase heart contractility so can be used as
an antidote in B blockers toxicity

# potassium oxalate in GI: need time

# Beta2-adrenergic agonists: Promote cellular reuptake of potassium (salbutamol), not use in
heart failure ( increase contractility)
# Alkalinizing agents: Increases the pH, which results in a temporary potassium shift from the
extracellular to the intracellular environment;
# Diuretics

" Urgent dialysis indication

1. Hyperkalemia with decrease urine out put

2. Pericardial effusion no out put + renal failure ( prevent tamponade)
3. Sever metabolic acidosis no chance for give high fluid + no out put
4. Pulmonary edema ( Lasix (furosemide failure)
 DKA emergency management
" DKA is characterized by:
# Hyperglycemia: blood glucose > 11.0 mmol/L or known diabetes mellitus
# Ketonemia: ketones > 3.0mmol/L or significant ketonuria (more than 2+ on standard
urine sticks)
# Acidosis: bicarbonate (HCO3-) < 15.0 mmol/L and/or venous pH < 7.3
" symptoms of DKA include:
# Palpitations
# Nausea
# Vomiting
# Sweating
# Thirst
# Weight loss
# Leg cramps
" clinical signs of DKA include:
# Tachycardia
# Hypotension
# Reduced skin turgor
# Dry mucous membranes
# Reduced urine output
# Altered consciousness (e.g. confusion, coma)
# Kussmaul breathing
" DKA pt
# Every . 0.1 pH decrease K decrease 0.6
# Every 100 glucose increase Na decrease 1.6

" Hyperglycemic may cause cardiac arrhythmia

" Most common abnormalities in DKA treatment is hypokalemia so give KCl when glucose
reach 200
" DKA patients usually presented with
pseudo-hyperkalemia, So treat
hyperglycemia then potassium will
decrease with the treatment
spontaneously

" So care about hypokalemia when treat

DKA patient
" Don't give bicarbonate In DKA/ metabolic acidosis unless one of the following :
a. HCO3- Less than 7
b. Or PH less than 6.9

" Steps of DKA management

# Correction of fluid loss with intravenous fluids
# Correction of hyperglycemia with insulin
# Correction of electrolyte disturbances, particularly potassium loss
# Correction of acid-base balance
# Treatment of concurrent infection, if present
 Hypoglycemia management

" Hypoglycemia is characterized by a

reduction in plasma glucose
concentration to a level that may
induce symptoms or signs such as
altered mental status
" mostly seen in diabetic patients, or
may be due to drugs like Ethanol
(including propranolol plus ethanol),
haloperidol, pentamidine, quinine,
salicylates, and sulfonamide
" Islet cell adenoma
" Glucose IV infusion
# 5%
# 10 % Glucose homeostasis
# 25%
# 50%
# 70%
" First start with 50% 20-30 cc/kg in adult for quick effect then move to lower dose
" In pediatric 10 % 2 cc/ kg
Hypertensive crises
" Hypertensive crises refer to acute increases in blood pressure (generally defined as ≥
180/120 mm Hg) that cause or increase the risk of end-organ damage:
# damage to the brain (e.g., encephalopathy, stroke)
# Eyes (e.g., retinopathy)
# Cardiovascular system (e.g., ACS, pulmonary edema, aortic dissection), and/or k
# Kidneys (e.g., acute renal failure).
" They can be due to primary hypertension or precipitated by underlying conditions (e.g.,
pheochromocytoma, pre-eclampsia, drug toxicity).
" Management
# Consists of rapidly identifying end-organ damage with patient history,
# Physical examination, and focused testing
# Determining whether the rapid lowering of the blood pressure with IV antihypertensives
is required.
% The ideal IV antihypertensive agent is determined by the underlying disorder,
end-organ systems affected
% In the absence of end-organ damage, hypertensive crises should be managed with
rapid follow-up and oral antihypertensives, as the prognosis is poor if they are left
untreated

! Hypertensive emergency
" ICU admission and immediate initiation of intravenous antihypertensive therapy.
" Continuous cardiac and intra-arterial blood pressure monitoring.
" Identify and treat any contributing comorbidities (e.g., chronic renal failure).
" IV fluids if signs of volume depletion
" Monitor Basic metabolic panel very 6 hours
" Reduce BP by max. 25% within the first hour to prevent coronary insufficiency and to ensure
adequate cerebral perfusion pressure.
" Reduce BP to patients baseline over 24–48 hours.
$ Intravenous antihypertensives drugsm
# Calcium channel blockers
% Nicardipine
% Clevidipine
# Nitric-oxide dependent vasodilators
% Sodium nitroprusside
% Nitroglycerin
# Direct arterial vasodilators: hydralazine
# Antiadrenergic drugs
% Selective beta-1 antagonist: esmolol
% Nonselective beta blocker with alpha-1 antagonism: labetalol
% Nonselective alpha antagonist: phentolamine
# D1 agonist: fenoldopam
# ACE inhibitor: enalaprilat