Dr Haymesh Patel

Dr Adil Ibrahim

 19 year old male comes into A+E with shortness of breath Nurses have told you that hes finding it hard to breath. He has no significant PMH Obs done Sats 92%, RR 26, HR 105, BP N, Apyrexial What would you do?

 A - Patent B equal chest expansion, resonant, wheeze ausculation, Sats 92%. C normal, tachycardia D GCS and pupils N; BM 5 Your immediate actions

Oxygen Nebs IV access (inc bloods) ABG CXR

Frequent monitoring??

 Bloods sent off ABG pH 7.4; pO2 9.8; pCO2 5; HCO3 + BE N CXR no consolidation, no pneumorthorax

Diagnosis? PEFR 300 (35% expected) You give him some steroids type? Route? Amount? How many nebs? Patient not improving still tight chest and wheeze. Sats not improving.

 MgSO4 how much? route? Anything else?? Senior help Resp/ICU input - aminophylline

Symptoms: SOB Wheeze Tight chest Coughing

History and examination Investigations: PEFR Bloods (WCC, CRP) ABG CXR Sputum

Moderate

Severe

Life threatening

PEFR <75%
Worsening symptoms

PEFR <50%
HR > 110 RR > 25 Incomplete sentences

PEFR <33%
Poor resp effort Cyanosis Silent chest Exhaustion

Altered consciousness
Sats < 92% Pa02<8kPa NEAR FATAL CO2 RETENTION Normal PaCO2

Sit them up High flow oxygen Salbutamol nebuliser (5mg) oxygen driven Ipratropium bromide (500mcg) Prednisolone (40mg)/ Hydrocortisone(200mg IV)

Continually reassess Sats (and PEFR)

 Signs of infection antibiotics If further deterioration/ no improvement: MgSO4 2g IV over 20-30mins

Call for senior help Consider Leukotriene Antagonist/ Aminophylline (IV) Consider ICU input

Symptoms have improved Off nebulisers for 24hours PEFR > 75% Steroids

 Check inhaler technique Discuss potential triggers/ allergen avoidance PEFR diary Action plan: PEFR <80% - recommence/ increase inhaled steroids PEFR <60% - start emergency course of steroids PEFR <40% - seek emergency medical care O/P F/U within 3-4/52 of discharge

Symptoms SOB Wheeze Cough sputum Reduced ET

History and Examination: Normal and current ET Treatment Home O2 / Home Nebs Number of exacerbations/ hospital admissions Investigation: Sats Bloods + ABG Sputum Blood cultures Theophylline level CXR

 Controlled oxygen (Venturi) sats 88-92%; Nebulisers (Salbutamol/Ipratropium) Steroids Signs of infection: Antibiotics: 1st line amoxicllin/ doxycyline 2nd line ciprofloxacin ?associated risk

PaO2: 8-10kPa

Worsening hypoxaemia: Repeat ABG acidosis Consider NIV ABG at 1hr, 4hr and 24hr when NIV commenced

http://www.draeger.co.uk/sites/en_uk/Pages/Hospital/Reduction-of-Complications.aspx?navID=1025

Smoking cessation Review of current management plan Spirometry O/P F/U

Need for LTOT: PaO2 <7.3kPa PaO2 7.3-7.9kPa and peripheral oedema/ secondary polycythaemia/ noturnal hypoxaemia/ pulmonary hypotension

 16 girl presents to A+E with N+V, general abdominal pain - over last 12-18 hours You go to see her. What should you do first?

A patent B RR 22, breathing deep and laboured chest N C HR 100, BP 91/68; CRT 3-4s; High UO; HS I+II+0 D GCS 15; pupils N. Apyrexial, Sats 100% BM 26

Working diagnosis? What would you do next? IV access and Fluids Bloods, Urine dip MSU, CXR, ECG

Glucose: Known DM Blood glucose > 11mmol/L Ketones: Ketonuria - > ++ urine dip Or Ketonaemia - > 3mmol

Acidosis: Venous bicarb < 15mmol/L Or Venous pH <7.3

1. Fluid and Electrolyte replacement

Type? Amount? Infusion time? Electrolytes?
Bloods Na 130, K 6, Ur 8, Creat 200, HCO3 11, Glucose 28

2. Insulin
Types? Amount? Mixed with what component? Rate of infusion?

 T1DM Insulin deficiency hyperglycaemia and dehydration Causes: Infection MI Pregnancy Unknown DM

Low Insulin Glucagon, GH, Cortisol Hyperglycaemi a Osmotic diuresis Fluid and electrolyte loss Lipolysis increases

Ketone formation

Metabolic acidosis

Symptoms: N+V Polyuria Pronounced thirst Abdominal pain Confusion, lethargy, reduced GCS

Signs: Kussmauls respiration Evidence of dehydration Tachycardia, hypotension Ketotic odour

Glucose: Known DM Blood glucose > 11mmol/L Ketones: Ketonuria - > ++ urine dip Or Ketonaemia - > 3mmol

Acidosis: Venous bicarb < 15mmol/L Or Venous pH <7.3

Capillary and venous glucose Bloods Blood cultures ECG CXR MSU

ABCD Replace fluid and electrolyte deficit Correct acidosis Correct hyperglycaemia

Regular monitoring BMs, venous bicarb, electrolytes ABG ?necessary

Fluid replacement: Aggressive if in shock, young Careful in older patient

Aim to replace fluid loss gradually over 24 hours

Fluid replacement (0.9% Saline): 1L stat 2L over 4 hour (K+) 2L over 8 hours (K+)

Check K+ and Na+ 2-hourly Change to 0.45% Saline (Na+ >150mmol/L) or 5%-10% Dextrose (plasma glucose <14mmol/L)

Insulin IVI: 0.1units/kg body weight/ hour

E.g. 70kg man 7 units/hour

Soluble insulin saline (0.9%) 1unit/ml Keep glucose between 5-14mmol/L Reduce rate of insulin when glucose <12mmol/L

Failure to improve/ reduced GCS: Senior help Contact ICU/ diabetiologist

Complications: Hypokalaemia Acute pancreatitis Cerebral oedema Hypo-hyperglycaemia Pulmonary oedema

DKA: o ? > 5.5 o ? 3.5-5.5 o ? <3.5 Never inject neat; cannot add to Hartmanns Max 40mmol in 1L bag Maximum infusion rate never more than 20mmol/hour 3-3.4 oral supplementation <3 IV replacement; ECG

Hyperglycaemia : severe and uncontrolled Severe dehydration Residual insulin: little ketoacidosis Uraemia

Causes: ppt infection, diuretics, high glucose intake

Presentation: Gradual onset several days >> 1-2 week Confusion/coma Mental obtundation Moribund at admission

Na K Urea Creat HCO3Glucose

HHS 146 6 50 420 18 >35

DKA 130 6 9 200 11 20

Diagnosis: Raised plasma osmolality (>340mmol/L) Hyperglycaemia (usually > 30mmol/L)

ABCD Fluid replacement Electrolyte replacement Insulin infusion

Correction made gradually

Monitoring: Blood glucose slow decline in BM Electrolytes Urine output catheter

Fluid replacement: Aim to replace fluid lost over 48-72 hours Similar types of fluid used in DKA

K+ replacement: Similar to DKA

Insulin: Fluid will lower glucose level Not always necessary

If required at a lower rate than DKA

 Slow recovery Complications: Death Cerebral oedema VTE

 Bleeped by a nurse at 9pm bloods have come back for Mr Smith on ward 15 Potassium is 6.4. But the patient seems ok You come to see the patient What would you do?

 ABCD all normal. Asymptomatic. Has a cannula. ECG no changes What would you do?
History, PMH, DH Renal Disease Fluid prescription

Repeat ECG 20 mins later changes present i.e. ... What would you do now?

 Calcium gluconate
How much, route..., max dose

Insulin Dextrose
How much, over how long

If struggling with IV access? When to re-check K+? Any further interventions?

Causes Haemolysed samples, renal failure, K+ sparing diuretics, ACEI, burns, iatrogenic, mineralocorticoid deficient Symptoms Palpitations, CP, dizziness, weakness Signs Irregular pulse

Changes on ECG Peaked T-waves, Broad QRS, diminished/flat P waves Sine wave pattern, asystole

http://lifeinthefastlane.com/2010/01/hyperkalemia/

 40 y.o woman presents to A+E she admits to taking a paracetamol overdose. Also been drinking alcohol. Vague on details around 25 tablets in the last 6 hours. You examine her (ABCD..) slight abdominal discomfort, some nausea. Obs stable What would you do?

 IV access bloods what specifically?

Paracetamol and salicylate level INR ALT (U+Es)

(25 tablets in the last 6 hours) N-acetylcysteine

Dose, infusion rate?

 Metabolised by liver When in overdose toxic metabolite inactivated by glutathione Glutathione depletion necrosis of liver cell and kidney tubules

High risk patients: Enzyme inducing drugs (rifampicin, phenytoin, carbemazepine) Malnourished HIV Alcohol/ other liver disease

Early (<24hour) Asymptomatic Mild N+V Later (24-72hour): RUQ pain Hypoglycaemia Oliguria Liver failure - coagulopathy Renal failure - acidosis Recovery

Paracetamol (and salicylate) level: At 4 hours ASAP if >4h or staggered overdose

Bloods: Esp. INR, ALT

Venous bicarb/ ABG

Recent changes to treatment guideline: One single treatment line N-acetylcysteine (NAC; Parvolex) Paracetamol level > 100mg/L at 4hours

http://www.mhra.gov.uk/home/groups/pl-p/documents/drugsafetymessage/con184396.pdf

 Start treatment (NAC) within 8 hours Significant overdose - >10g If presents within 1 hour of overdose PO activated charcoal If close to 8hr mark have a low threshold for intervention

8-24 hours: Detailed history Urgent paracetamol level ALT and INR ? NAC >24 hours: Unlikely to have detectable level Same as above Refer to Toxbase

Change in treatment guidance: Initial dose is now given over 60 minutes (not 15mins) 1. 150mg/kg in 200ml 5% glucose over 60min 2. 50mg/kg in 500ml 5% glucose over 4hr 3. 100mg/kg IV in 1L 5% glucose over 16hr

 40 y.o. woman started on Parvolex within a few minutes urticaria, lips swell, tachycardic, hypotensive. What has happened? Management?

Causes: Latex, nuts, seafood, insect bites, antibiotics.... Symptoms/signs: A B C Itching, erythema, urticaria, oedema (facial, lips) Wheeze, laryngeal oedema, Tachycardia, hypotension

 Exacerbation of Asthma Septic Shock

ABCD Oxygen / Intubation Raise the feet Adrenaline (0.5mg: 0.5ml of 1 in 1000 IM) IV access Chlorphenamine Hydrocortisone Fluids give accordingly Still hypotensive - ITU (?Adrenaline in Cardiac Arrest)

 http://www.diabetes.nhs.uk/our_publications Oxford Handbook of Clinical Medicine Oxford Handbook for the Foundation Programme

Questions?
haymeshpatel@gmail.com

 30 Year old man presents with haematemesis. His obs are:

HR 110, BP 80/40, Sats 94%, T 37C, RR 24

What do you do!!!

 Dont Panic and Remember ABC!!! Is the airway patent?

Are the talking?

Oxygen
Nasal cannula if they are vomiting lots

Breathing
Agonal breathing Not really breathing Be aware of aspiration

 Circulation
They may have lost a lot of blood and it needs to be replaced When inserting a cannula, take blood at the same time FBC, UnE, LFT, Clotting, X-Match, CRP?? Can give 0-ve blood if required urgently otherwise X-match 4 units. Crystalloid versus Colloid? Doesnt matter in the acute setting, just dont use dextrose Give 1L STAT if they have lost a lot!

Dont forget to call for help!!

 Chest X-ray not always needed

Can show rupture of oesaphagus Air is around the arch of the aorta

OGD needs to be done as soon as

 Stop blood pressure tablets and any medications that can cause vasodilation! The aim is to maintain the blood pressure If they are on warfarin, will it need reversing? Does the patient have acute kidney injury? Are they on anything which could of caused the bleed?

 Upper GI often medical problems

bleeding ulcer Known history of ulcers or reflux Started Aspirin or NSAIDs Mallorry Weiss Tear History of forceful vomiting Oesophageal varices Dilated Veins History of chronic liver disease Others Epistaxis Gastric cancers Vascular malformations

How much? Over how long? Colour? Associated Symptoms

Pain (Chest or abdo) Bleeding from other sites Dizziness or syncope

Obs Stable?
HR, BP, GCS

Examination
Pale or cold extremities Reduced JVP Abdominal Tenderness

 Use common sense!!

In other words, do they look ill? Did they just vomit 5L in front of you?

Use Blatchford scoring system before the OGD Use Rockall Risk Scoring system after Depends on where you work as some places use both at the same time

 30 Year old man presents with rectal bleed His obs are:
HR 110, BP 80/40, Sats 94%, T 37C, RR 24

What do you do!!!

 Practically the same management! Its that simple

 Lower GI often surgical problems

Polyps Diverticular Disease Hemorrhoids or anal fissure Are they constipated IBD Cancer Upper GI Bleed Others Aorto-enteric fistulae

 45 year old Male comes in with abdominal pain. Obs

T 37C HR 110, RR 20 sats 96% BP 90/50

What do you think it is? What do you do? Firstly, ABC!!!!

 Pain?
Socrates Generalised, acute onset

History?
Has been out drinking

Examination
Generalised tenderness, more severe in epigastric and umbilical region.

 Imaging
ERECT CXR!!! Abdominal x-ray

Bloods
FBC, UnE, CRP, LFT, Amylase, Clotting, GnS

What if amylase is borderline?

Urinary amylase or Lipase

 Do a jackson 5
ABC!!!

A lot of third space fluid loss

Give a 2 hourly, 4 hourly, and then 6 hourly

Keep them Nil Use the Pancreatitis scoring system. Analgesia!!!!

Remember, most places do not like to give IV morphine. If you need to give morphine, give it IM

 CT to confirm GET SMASHED

The ones you need to remember are Alcohol, Gallstones and ERCP

Modified Glasgow Score for Pancreatitis Variable age pO2 WCC Ca2+ (uncorr.) ALT LDH glucose urea albumin Score one point if present >55 years <8.0 kPa >15x109/litre <2.0 mmol/L >100 IU >600 IU >10 mmol/L >16 mmol/L <32g/L

RIF Pain? Male or female? Ovarian Cyst or appendicitis Ovarian cyst will be sharp sudden onset Cyst would not start as generalised pain Appendicitis will put you off food so ask if they are hungry. Make sure you do a PR!! Rebound tenderness Rovsings (Pain in RIF when palpating LIF) Imaging??

38 Year old female Vomitting brown liquid for the past 2 days Not opened bowels since 3 days No Flatus Generalised Abdominal pain PMH
Cesarean 2 years ago

 ABC!!! Bloods Dont forget amylase!! Imaging

Erect chest X-ray Abdominal X-ray

Large Bowel

Small Bowel

 SBO
Nil by Mouth Drip and Suck i.e. IV fluids, NG tube

LBO
Surgery unless Sigmoid volvulus sigmoidoscopy and flatus tube Faecal obstruction enemas

Paralytic Ileus
Can be caused by surgery or pancreatitis Treatment similar to SBO

 Hernias Masses

Adhesions!!! (this lady had a cesarean)

 40 year old male post op from a Hartmanns procedure Spikes a temperature You are on the phone to the staff nurse SBAR
Situation, Background, Assessment, Recommendation

 Obs
HR 110, RR 20, BP 90/50, Sats 95% T 39C

What are you going to do? Hint, it rhymes with PVC ABC!!!

 Bloods
FBC, UnE, CRP, ABG, Cultures

Swabs TTU X-ray imaging ECG Paracetamol and Empirical Antibiotics

24 Year old male Pain in testicle Nil PMH Not sexually active (Hes waiting for the one!) What are you thinking?

 Pain in testes, possibly suprapubic area If you suspect this get senior review within 4 hours as the testes can become necrotic! Pain in testicles not relieved by raising testes (Prehns sign, if +ve could suggest epididymitis)

 ABC!!! Bloods Imaging???

Can use USS doppler but that can delay treatment

Exploratory surgery!

Stop over thinking!!!! ABC ABC ABC