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ANAPHYLACTIC SHOCK
Causes: drugs (penicillin, contrast media, sulphonamides), latex (e.g. gloves), stings (bees, wasps etc), food (eggs, peanuts, fish), semen, pollen etc.

Signs and symptoms: itching, erythema, urticaria, hives, oedema, angioedema, wheeze, cyanosis, laryngeal obstruction, hypotension, tachycardia.

NOTE: ANAPHYLACTOID REACTION is a reaction that occurs when we have direct release of mediators from inflammatory cells, contrary to anaphylactic reaction, without involving IgE antibodies. Usually it occurs as a response to a drug (classically N-acetylcysteine which is antidote for paracetamol overdose or used for cough).

ALGORITHM ON ALAPHYLAXIS ABCs Secure airway, give 100% oxygen, intubate if airway is not patent and obstruction is imminent (stridor/ angioedema check the mouth for obstruction is the uvula enlarged?/ exclude foreign body obstruction).

Remove the cause (e.g. sting you can remove it with a hard card e.g. ID or VISA or phone card). Raise the patients feet!

Administer epinephrine IM 0.5 mg (0.5 ml of 1:1.000 solution). Repeat every 5 min if needed (according to BP, HR and respiration) until the patient improves. Childrens dose is < 6 months years old: 0.05ml adrenaline 1: 1.000 6 months 6 years: 0.12 ml 6 years 12 years: 0.25 ml >12 years: 0.5 ml

Establish IV/ access Administer chlorphenamine 10mg IV (or diphenhydramine 25 50 mg IM/IV) and hydrocortisone 200 mg IV. Give also IVI NS (normal saline) e.g. 500 ml over 15 min, titrating t BP. You may need to give up to 2 L.

In case the patient has wheezing treat as for asthma (see asthma algorithm below). May need intubation & mechanical ventilation.

If still hypotensive, transfer to ICU. May be needed IV adrenaline, +_ aminophylline and nebulized salbutamol. Call expert. The dose of IV adrenaline is 100 g /min titrating to BP (0.5 1 ml/ min of 1: 10.000 solution). NOTES In case the patient takes blockers consider salbutamol IV instead of epinephrine. In case of hereditary angioedema give c1 esterase inhibitor or FFP (Fresh Frozen Plasma).

ACUTE SEVERE ASTHMA

Differential Diagnosis: acute infective exacerbation of COPD (ask the patient if is or was smoker), pulmonary edema (cardiac asthma!), anaphylaxis (see above; history? any precipitant?), pulmonary embolus (risk factors?), upper respiratory tract obstruction (stridor?), pneumothorax (if you suspect it, do expiratory CXR chest X Ray). Check peak expiratory flow rate PEFR (PEF). Ask previous measurements and the patients best PEF. Life threatening asthma: peak expiratory flow rate PEFR (PEF) < 33% of predicted or best, silent chest, cyanosis, bradycardia, hypotension, feeble respiratory effort, exhaustion, confusion, coma, ABGs (arterial blood gases) hypercapnia, hypoxaemia, axidosis.

ALGORITHM FOR ACUTESEVERE ASTHMA

Sit the patient up! Give 100% oxygen high flow via a mask with a non rebreathing bag. Check PEF (Peak Expiratory Flow rate PEFR) and check the patients best PEF.

Administer short acting agonist: salbutamol 5 mg (or terbutaline 10 mg or albuterol 0.2 0.3 ml in 3 ml normal saline nebulized every 20 30 min) + ipratropium 0.5 mg nebulized with oxygen. You can repeat ipratropium. Side effects of salbutamol (and generally of agonists) are tachycardia, arrhythmias, hypokalaemia, tremor. Check K.

Give hydrocortisone 100 mg IV or methylprednisolone 125 mg IV, or prednisolone 50 mg PO (per oral) or both (IV & PO) if severe asthma.

Check the PEF 15 30 min after the initial treatment. Perform CXR (chest X Ray). Exclude pneumothorax. If suspected pneumothorax, ask also an expiratory CXR! Turn the film lateral to see better the gap. Check ABGs (arterial blood gases). Recheck them within 2 h. Also check SaO2 (oxygen saturation) Keep it > 92% with high flow oxygen. Labs: CBC/FBC (complete/ full blood count), UN (), Electrolytes. Check especially for hypokalaemia from salbutamol or aminophyline.

On life threatening asthma call ICU and experts. Add MgSO4 magnesium sulphate 1.2 2 g IV over 15 30min (not bolus!). Also give salbutamol nebulizers every 15 min or 10 mg continuously / h.

A. If the patient is improving give 40 60 % oxygen, administer prednisolone 50 mg/ 24 h PO (continue for at least 5 days), give nebulized salbutamol every 4h and monitor oxygen saturations SaO2 and PEF (peak expiratory flow rate PEFR).

B. If the patient is not improving after 15 30 min continue 100% high flow oxygen and steroids, administer hydrocortisone 100 mg IV or methylprednisolone 125 mg IV +_ prednisolone 30 60 mg PO, if not already given.

Administer salbutamol nebulized every 15 min (or 10 mg continuously /h) plus ipratropium 0.5 mg nebilized every 4 6 h.

If the patient is still no improving call the ICU, repeat salbutamol nebulized every 15min, give MgSO4 magnesium sulphate 1.2 2 gr over 20 min (if not already given). The paediatric dose of MgSO4 is 40 mg/kg. Antidote for magnesium overdose is calcium chloride or calcium gluconate. The adult dose is 10 ml (500 1000 mg) VERY slowly IV (over 10min). When you administrate MgSO4 check deep tendon reflexes and RR respiratory rate. Stop infusion if absent reflexes or decreased RR respiratory rate.

Also on severe asthma consider aminophylline. The loading dose, if NOT already on theophylline, is 5 mg/kg IVI over 20min and then 500 g (0.5 mg) / kg/ h (as Kg here we have the ideal body weight; so the dose for a small adult is 750 mg/24 h and for a large adult the dose is 1200 mg/ 24h). If already on theophylline preparations the last 24h, then the loading dose is 3 mg/kg. Check plasma theophylline and adjust the dose. Do levels if infusion is given > 24 h. Aim for plasma concentration 10 20 g/ ml (55 110 mole/ L). With blood concentration >_ 25 g/ ml toxicity can occur with hypotension, seizures (!), arrhythmias and cardiac arrest! Also theophyllines may cause hypokalaemia (check potassium!). Alternative to aminophylline is salbutamol IVI 3 20 g / min (better in ICU).

Also on severe asthma you may administer adrenaline 0.2 0.3 ml 1: 1.000 Sc (subcutaneous), every 20 30min, or terbutaline 0.25 mg Sc every 2 4 h.

The patient may need IPPV (intermittent positive pressure ventilation).

In case of no improvement or life threatening asthma the patient may need intubation and mechanical ventilation. ketamine is very helpful as anesthetic in asthma (give also atropine to prevent secretions from ketamine).

ACUTE EXACERBATION OF COPD

Symptoms: cough, SOB shortness of breath, or wheeze. Ask the patient if he/she is or was a smoker for years! Differential Diagnosis: asthma, pneumothorax (do expiratory CXR chest X Ray if suspected), upper respiratory tract obstruction (stridor?), anaphylaxis (history? Precipitant?), pulmonary embolus (risk factors?), acute left ventricular failure/ pulmonary edema (cardiac asthma). ACUTE COPD ALGORITHM Start Oxygen at 24 28%, according to ABGs (arterial blood gases) and monitor for hypercapnia.

Administer nebulized salbutamol 5 mg/ 4h + ipratropium 0.5 mg/ 6h.

Administer IV hydrocortisone 200 mg + prednisolone PO (orally) 30 40 mg.

If there is evidence of infection as a precipitating cause of COPD exacerbation give antibiotics e.g. amoxicillin 500 mg/ 8h PO (ask if allergic on it).

If no response, repeat salbutamol and ipratropium nebulized and consider IV aminophylline! The loading dose, if NOT already on theophylline, is 5 mg/kg IVI (e.g. 250 mg IVI) over 20min and then 500 g (0.5 mg) / kg/ h (as Kg here we have the ideal body weight, so the dose for a small adult is 750 mg/24 h and for a large adult the dose is 1200 mg/ 24h).

If already on theophylline preparations the last 24h, then the loading dose is 3 mg/kg. Check plasma theophylline and adjust the dose. Do levels if infusion is given > 24 h. Aim for plasma concentration 10 20 g/ ml (55 110 mole/ L). With blood concentration >_ 25 g/ ml toxicity can occur with hypotension, seizures (!), arrhythmias and cardiac arrest! Also theophyllines may cause hypokalaemia (check potassium!).

If still no response, consider NIPPV (nasal intermittent positive pressure ventilation) if RR (respiratory rate) > 30 or acidosis. If still acidosis and hypercapnia, consider intubation and mechanical ventilation. For patients not suitable for mechanical ventilation consider the respiratory stimulant doxapram (1.5 4 mg/min). NOTE Some patients rely on their hypoxic drive to breathe and high oxygen concentration (>30%) on them may lead to reduced respiratory rate, hypercapnia and decrease the level of consciousness. So, if ABG (arterial blood gases) show carbon dioxide CO2 retention start with 24 28% oxygen and reassess after 30 min. Monitor the patient and check if raising of PaO2 causes hypercapnia. In patients without evidence of CO2 retention start oxygen at 28 40% concentration and monitor ABGs.

COMA
Coma is unrousable unresponsiveness Metabolic causes: drugs, poisoning (carbon monoxide CO, alcohol, TCAs tricyclics antidepressants, barbiturates etc), hypo/hyperglycemia (DKA diabetic ketoacidosis or HONK hyperosmotic non ketotic coma), hypoxia, CO2 retention (COPD), sepsis, hypo/ hyperthermia, myxedema, Addisonian crisis, hepatic encephalopathy, uremia. Neurological causes: head trauma, meningitis, encephalitis (give IV acyclovir if HSV encephalitis is suspected), malaria (do blood thick films), typhus/ typhoid, parasitosis (e.g. trypanosomiasis), rabies, head tumor (primary or metastatic), stroke, sabdural/ subarachnoid hemorrhage, hypertensive encephalopathy, epilepsy (may be non convulsive), postictal state.

COMA ALGORITHM ABCs (stabilize Cervical spine if suspected trauma always stabilize it on head trauma)

IV access

Check blood glucose (finger stick test and Labs).

Control seizures (see seizures algorithms)

Treat reversible causes. If glucose levels are unknown, give glucose 50 ml of 50% dextrose IV (in adults) over 5 min and in a large vein (flush it with normal saline after the administration because dextrose is harmful to the veins. Also give thiamine (vitamin B1), especially if suspected malnutrition and Wernickes encephalopathy (e.g. on alcoholics). The dose of thiamine is 100 mg IV slowly, prior to, or at the same time with glucose. Give also naloxone 0.4 2 mg IV (if small pupils or possible opiate abuse; bilateral small pupils may occur from other causes such as pontine hemorrhage or organophosphate poisoning). Also in case of suspected benzodiazepine OD (overdose) give flumazenil 0.2 mg slowly (over 15 sec) IV, repeated at 0.1 mg at 1 min intervals, as needed. Usual dose is 0.3 0.6 mg IV over 3 6 min. Max dose is 1 mg (2 mg if in ICU).

Brief history and examination. Check AMPLE (Allergies, Medications, Past medical history, Last meal and Environment). Also ask if other members of family or other close contacts with same symptoms (e.g. carbon monoxide CO poisoning).

ABGs (arterial blood gases), CXR (chest X Ray), head (initially non contrast) CT.

Labs: CBC/ FBC (full/ complete blood count), UREA, creatinine, electrolytes (K, Na, Calcium, Magnesium, Phosphate), LFT (liver function tests), ESR, CRP, toxicology, ethanol, drug levels (e.g. aspirin & acetaminophen paracetamol), blood & urine cultures, blood thick films (if malaria suspected).

SHOCK
For causes of shock see APPENDIX (I) SHOCK ALGORITHM

ABCs high flow oxygen. Raise foot of the bed! IV access, 2 wide bore IV lines (ask help if they take > 2 min)

Treat underlying cause.

Infuse crystalloids fast to raise BP (unless cardiogenic shock)

ABGs (arterial blood gases), ECG, CXR (chest X Ray), SaO2 (oxygen saturation), Echo, abdominal CT, ultrasound. Place Foley, CVP line and arterial line. Replace fluids titrated to BP, CVP and urine output. Aim for urine output > 30 ml/h. If cardiogenic shock, dont overload with fluids! Exclude PE (pulmonary embolism) and Right ventricular infraction (in RV infarction dont give nitrates!). Consider inotropes on persistent hypotension. Most common cause of shock is hypovolaemia. On abdominal aortic aneurysm (palsatile abdominal mass, perform ultrasound) aim for Systolic BP about 90 mmHg. Check glucose (finger prick test and labs). Labs: CBC/ FBC (complete/ full blood count), ESR, CRP, CK, CK MB, urea, creatinine, Electrolytes, blood type & crossmatch, pregnancy test, blood & urine cultures, drug levels, toxicology, alcohol, lactate. NOTES

SIRS (systemic inflammatory response syndrome) is characterized >_ 2 of the following: temperature > 38 or < 36 degrees C, RR (respiratory rate) > 20 (or PaCO2 < 4.3 KPa or < 33 mmHg), HR (heart rate) > 90 bpm, WCC (WBC) > 12 X 109 / L or < 4 x 109 / L or > 10% immature forms (bands). Sepsis is SIRS with infection. On heat exhaustion perform tepid sponging and fanning (avoid ice and immersion to cold water), administer NS norman saline +_ hydrocortisone (!) 100mg IV and chlorpromazine 25 mg IM (for shivering). Stop cooling when temperature < 39 degrees C!

On septic shock give antibiotics within 1 h (better take blood cultures first). If unknown microbial origin give initially IV amoxicillin + clavulate 1.2g/8h or meropenem 1g/ 8h or gentamycin (caution in renal failure, do levels) + antipseudomonal penicillin e.g. ticarcillin. Also give colloid/ crystalloids IVI +_ inotropes. Aim for CVP 8 12 mmHg, MAP (mean arterial pressure) > 65 mmHg and urine output > 35 ml/h. Low dose steroids (on persistent hypotension despite fluids and vasopressors) and also recombinant human activated protein C (Drotrecogin alfa) may help. Mean BP = (SBP + 2 DBP)/ 3

ACUTE LEFT VENTRICULAR PULMONARY OEDEMA

FAILURE

(LVF)/

Causes: cardiovascular (LVF left ventricular failure, valvular heart disease, arrhythmias, malignant hypertension!), ARDS (many causes e..g. trauma, infection, drugs, sepsis, post operative), fluid overload, neurogenic! (e.g. head trauma), renal failure (!).

Differential diagnosis: asthma, COPD exacerbation, pneumonia, PE pulmonary embolus. It may be difficult to distinguish especially in the elderly in which asthma/ COPD exacerbation, pneumonia and acute LVF may coexist and cardiac asthma with wheeze may be difficult to be distinguished from asthma/ COPD exacerbation. You may need to treat all of them (e.g. with nebulized salbutamol, furosemide IV, morphine IV and amoxicillin)! Other diagnostic possibilities are hypertensive crisis, aortic dissection, tension pneumothorax and anaphylaxis. Perform an ECG! Connect to monitor.

BNP (brain natriuretic peptide) may be very helpful in distinguish LVF from other causes of shortness of breath e.g. COPD. If BNP is > 100 pg/dL then we have possible heart failure. Take also a CXR (chest X Ray) to check for signs of LVF: kerley B lines, fluid in lung fissures, small effusions at costophrenic angles, shadowing usually billateral bat wings, interstitial edema, increased cardiothoracic ratio. The last may not appear in acute LVF! Also, a supine or AP CXR may show a falsely enlarged heart. The only CXR that is accurate for the hearts size is the erect PA. If suspected pneumothorax, take also an expiratory CXR. Symptoms: SOB (shortness of breath), orthopnea, paroxysmal nocturnal dyspnea, pink frothy sputum. Ask for recent drugs and recent health problem (asthma, COPD, pneumonia, MI myocardial infarction, LVF). Signs: distressed, pale, sweaty (!), tachycardia, tachypnea, pink frothy sputum, pulsus alterans (alternating strong and weak pulse), fine lung crackles/ end respiratory crepitations or rales (especially at lung bases), gallop rhythm (S3 +_ S4), wheeze (cardiac asthma!). The patient is sitting up and leaning forward. ACUTE LEFT ALGORITHM VENTRICULAR FAILURE (LVF)/ PULMONARY EDEMA

Sit the patient up (raise the head of the bed)!

Give 100% oxygen (unless COPD with EVIDENCE of CO2 retention, see above COPD)

IV access, connect to monitor, ECG

Treat any underlying arrhythmia

Give morphine 2 4 mg slowly IV (with metoclopramide 10 mg IV). You may repeat after 5 10 min. Alternative is diamorphine 2.5 5 mg slowly IV (caution in COPD for respiratory drive compromise and also caution on liver failure). CI

(contraindications) to morphine are hypersensitivity to it or other opiates and also signs of CNS depression (e.g. respiratory depression, decreased BP or decreased HR).

Give furosemide (Lasix) 0.5 1 mg/kg (e.g. for 80 kg patient give 40 80 mg) IV slowly (it is preferred to start with 40 mg IV Lasix, reassess and repeat; monitor BP!). Give larger dose in renal failure. If on diuretics or renal failure, give Lasix e.g. 80 160 mg IV.

Give GTN (nitroglycerine) spray of 0.4 mg 2 puffs or 2 tablets of 0.3 or 0.4 mg (each puff or each tablet needs to be taken 5 min apart!). CI (contraindications) to NTG is SBP (systolic BP) < 90 mmHg or BP< 30 mmHg below baseline, HR < 50 or > 100, erectile drugs (Sildenafil Viagra or Vardenafil Levitra the last 24 h or tadafil Cialis the last 48 h), intracranial bleeding, aortic or mitral stenosis or HOCM (hypertrophic obstructive cardiomyopathy) and also on Right Ventricular myocardial Infarction!

Investigations, examination, history. ECG (MI myocardial infarction? Arrhythmia?), SaO2 (oxygen saturation), ABGs (arterial blood gases), +_ Echo. Labs: Tropinins T&I, CK- MB, myoglobin, UREA, creatinine, electrolytes and plasma BNP.

If Systolic BP >_ 100mmHg start nitrate infusion e.g. isosorbite dinitrate 2 10 mg/h or NTG 5 10 g/ min. Keep Systolic BP > 90mmHg.

In case the patient is worsening give further Lasix 40 80 mg, consider CPAP (5 10 mmHg, use it if not hypotension and not need for intubation) or intubation and mechanical ventilation. Also consider increasing nitrate infusion. u may also try (especially if hypotension) inotropics (short term) such as milrinone or dobutamine. Rarely, you may try to venesect 500 ml of blood.

If systolic BP is < 100 mmHg, treat as cardiogenic shock (see next algorithm). Consider inotropes (dobutamine/ dopamine) and Swan Ganz catheter and intra aortic balloon pump.

If the patient doesnt respond consider a different diagnosis such as hypertensive crisis, aortic dissection, pneumonia, PE pulmonary embolism, asthma, COPD exacerbation, tension pneumothorax, anaphylaxis.

Neseritide is rh BNP (recombinant human brain natriuretic peptide) may be useful in decompensated cardiac failure and improves hamodynamicaly the patients. The dose is 0.01 g / kg/ min. It may cause hypotension. It is contraindicated in cardiogenic shock, right ventricular myocardial infarction, aortic stenosis, HOCM (hypertrophic obstructive cardiomyopathy), constrictive pericarditis.

You may also give an ACE inhibitor such as enalapril 1.25 mg IV over 5 min. CI (contraindications) are pregnancy, hyperkalaemia and hypotension. Long term therapy includes ACE Inhibitors and blockers.

CARDIOGENIC SHOCK
Causes: MI (myocardial infarction), dysrhythmias, PE pulmonary embolus, tension penumothorax, cardiac tamponade (the 3 last are obstructive causes of shock), myocarditis, myocardial depression (drugs such as opiates; acidosis, sepsis, hypoxia), endocarditis with valve destruction, aortic dissection.

CARDIOGENIC SHOCK ALGORITHM

Give 100% oxygen. Maintain oxygen saturation > 90%.

IV access, connect to monitor, perform 12 lead ECG, CXR (chest X Ray), take SaO2 (oxygen saturation) and perform cardiac Echo. Labs (UREA, creatinine, Electrolytes, cardiac enzymes such as CK MB & markers such as troponin I & T & myoglobin repeat cardiac markers also 12 h later). Correct any electrolyte abnormality. Check ABGs (arterial blood gases) and correct any acid base abnormality

In case you suspect aortic dissection perform trans-oesophagal Echo (TOE) or CT of thorax (if stable or if TOE unavailable). If you suspect PE (pulmonary embolus) perform CT of thorax or V/Q scan. Monitor CVP, BP, ABGs (arterial blood gases), ECG and urine output (insert Foley). Consider a Swan Ganz catheter to assess PCWP (pulmonary capillary wedge pressure) and cardiac output and also consider an arterial line to monitor BP.

Give morphine 2 4 mg slowly IV (with metoclopramide 10 mg IV) or diamorphine 2.5 5 mg slowly IV for pain and anxiety (caution in COPD for respiratory drive compromise and also caution on liver failure). CI (contraindications) to morphine are hypersensitivity to it or other opiates and also signs of CNS depression (e.g. respiratory depression, decreased BP or decreased HR). On decreased BP you may try fentanyl, instead of morphine or diamorphine!

Measure PCWP (pulmonary capillary wedge pressure) with a Swan Ganz catheter. A. If PCWP is < 15 mmHg load with fluid. Give colloid or crystalloids 100 ml IV every 15 min. Aim for PCWP of 15 20 mmHg. If there is no evidence of pulmonary edema administer 250 500ml of crystalloids over 30 min. If BP improves, maintain rate at 100 200 ml/h. B. If PCWP is > 15 mmHg OR severe shock or pulmonary edema give inotropes e.g. dobutamine 2.5 10 g / kg/ min IVI. Aim for Systolic BP > 80 mmHg.

Consider renal dose of dopamine. Initially give 2 5 g/ kg/min IV, only via central line. Also consider dobutamine.

Consider intra aortic balloon pump. This may buy time in case surgery is needed.

Treat underlying reversible causes such as MI (heart attack). On massive PE (pulmonary embolism) consider thrombolysis or embolectomy. Consider surgery for mitral or aortic incompetence and acute VSD (ventricular septal defect). A new drug which decrease mortality from 67% to 27% is L NMMA (N monomethyl L arginine), a NO (nitrous oxide) synthase inhibitor.

CARDIAC TAMPONADE
Causes: chest trauma, lung or breast cancer, pericarditis, MI (myocardial infarction), TB, renal failure, radiation, myxedema, SLE, aortic dissection. Signs: hypotension, increasing JVP (JVD jugular veins distension) and muffled heart sounds (Becks triad). Also Kussmauls sign (increasing JVP on inspiration), pulsus paradoxus (weaker pulse on inspiration), electrical alternans on ECG and small QRS complexes on ECG. Suspect it on blunt or penetrating chest trauma. Echocardiography or FAST on trauma is diagnostic. CXR (chest X Ray) on pericarditis may show globular heart, convex or straight left heart border, right cardiophrenic angle < 90 degrees. Management: give oxygen, monitor ECG and administer IV fluids (crystalloids) immediately. Call expert. Prepare for emergency pericardiocentesis, better with the guidance of ultrasound (FAST). On trauma you may need to perform troracotomy (if an OR operating room is immediately available).

PNEUMOTHORAX
Causes: spontaneous (especially young thin men) after a rapture of a subpleural bulla; asthma, COPD, pneumonia, cancer, lung abscess, lung fibrosis, cystic

fibrosis, sarcoidosis, Marfans, Ehlers Danlos, trauma, iatrogenic (subclavian central vein line, pleural aspiration, pleural biopsy, liver biopsy and positive pressure ventilation!) Symptoms: may be no symptoms (especially if young fit and if small pneumothorax) or sudden SOB (shortness of breath) and/ or pleuritic chest pain (on inspiration). Mechanical ventilated patients may present with hypoxia or increased ventilation pressures. In case of ventilation with self inflating bag there may be difficulty and decreased compliance on ventilating. Also on a patient with COPD or asthma may appear with sudden deterioration. Signs: reduced expansion of the hemithorax, hyper resonance/ tympany on the affected side on percussion, diminished/ absent breath sounds on the affected side. On tension pneumothorax a late sign is tracheal shift away from the affected side. Perform immediately an EXPIRATORY CXR (chest X Ray) and check for an area devoid of lung markings peripheral to the edge of the collapsed lung (it may be helpful if you turn the film laterally). Be careful to distinguish a large emphysematous bulla from pneumothorax! Check ABGs (arterial blood gases).

ACUTE PNEUMOTHORAXALGORITHM A. PRIMARY PNEUMOTHORAX Dyspnea and / or rim of air > 2cm on CXR (chest X Ray)

No: consider discharge (after excluding other causes of dyspnea) Yes: aspiration.

Successful: consider discharge. Non successful: repeat aspiration. If still no successful insert chest drain.

B. SECONDARY PNEUMOTHORAX (asthma, COPD, etc) Dyspnea and age > 50 and rim of air > 2 cm on CXR (chest X Ray).

Yes: insert chest drain. No: perform aspiration. If successful admit for 24h. If not successful, insert a chest drain.

TENSION PNEUMOTHORAX
On tension pneumothorax the air, with each inspiration, is drawn into the pleural space, but it cant escape during expiration so the mediastinum is pushed into the contralateral hemithorax compressing the superior vena cava and causing cardiorespiratory collapse and arrest. Signs: respiratory distress, SOB (shortness of breath), tachycardia, hypotension, JVD (jugular vein distension), tracheal deviation away from the side of pneumothorax (late sign!), hyper-resonance tympany on percussion and reduced/ absent breath sounds at the affected side. Management: DONT WAIT FOR CXR (chest X Ray)! Tension pneumothorax is a clinical diagnosis. Insert a large bore (14 16 G) needle into the 2nd intercostal interspace, in the midclavicular line of the hemithorax of the suspected side of pneumothorax. After this, insert a chest tube to drain the pneumothorax.

PULMONARY EMBOLISM (PE)

Risk factors: surgery (especially pelvis, hip), malignancy, immobility, the Pill & HRT (hormone replacement therapy at menopause slight risk), previous TE (thromboembolism) and inherited thrombophilia. Signs & Symptoms: acute SOB (shortness of breath), pleuritic chest pain (on inspiration), hemoptysis, syncope, collapse, hypotension, tachycardia, tachypnea, cyanosis gallop rhythm, JVD (jugular vein distension), loud P2 at heart auscultation (!), right ventricular heave (at chest palpation), pleural rub (!), AF (atrial fibrillation). However, signs are often non specific. Suspect PE if risk factors. Pulmonary embolism presents classically 10 days post operative with sudden dyspnea and collapse while straining at stool (on sudden collapse at straining at stool also exclude subarachnoid hemorrhage). However often the only sign is breathlessness and/or tachycardia! Check for DVT (deep vein thrombosis) swollen legs!

Investigations: Labs: UREA, creatinine, CBC/FBC (complete/full blood count), coagulation studies (including Platelets, PT, aPTT and especially D Dimers). D Dimers have high sensitivity but low specifity for PE. They may increase in thrombosis, inflammation, infection, malignancy and post operative. NORMAL D DIMERS EXCLUDE PE. ECG: any of the following: normal, sinus tachycardia, right ventricular strain on V1 V3, right axis deviation, RBBB, AF, S1Q3T3 (rare; deep S in I, Q waves in III, inverted T in III). CXR: normal or decreased vascular markings, small pleural infusion, atelectasis, wedge shaped areas of infarction). ABGs (arterial blood gases): hypoxemia, hypocapnia (!), PH may be increased. In metabolic alkalosis exclude causes such as PE before attributing it in hysteria! ECHO (echocardiogram) shows right ventricular hypokinesis and dilation. CTPA (CT Pulmonary Angiography) has high sensitivity and specifity. If not available, perform V/Q scan. If V/Q scan is equivocal, perform pulmonary angiography or bilateral venograms. Alternatives are MRI venography or plethysmography. Dont forget leg/ pelvis Doppler for DVT (deep vein thrombosis). LARGE PULMONARY EMBOLISM (PE) ALGORITHM

Give 100% oxygen

Administer morphine 5 10 mg with metoclopramide 10 mg IV in case the patient has pain or is distressed. CI (contraindications) to morphine are hypersensitivity to it or other opiates and also signs of CNS depression (e.g. respiratory depression, decreased BP or decreased HR).

On massive PE with unstable patient consider immediately thrombolysis (e.g. alteplase rTPA give 10 mg IV over 2 min and then 90mg infusion over 2 h) or surgery (embolectomy, consult a thoracic surgeon)

IV access. Administer LMWH (low molecular weight heparin) such as tinzaparin 175 units/kg/24 h Sc or enoxaparin 1 mg/kg Sc every 12h or give UH unfractioned heparin 80 units / kg (give e.g. 10.000 units) bolus IV, followed by 18 units/kg/h guided by aPTT (target APTT is 1.5 2.5). The bolus of UH unfractioned heparin may be preferred from LMWH because its fast onset. Dont give heparin if suspected septic embolism e.g. from right sided endocarditis!

Check the BP!

A.

BP < 90 mmHg

Start rapid crystalloids or colloid infusion: saline) over 20 30 min.

250 to 500 ml NS (normal

If BP is still low after 500 ml crystalloids or colloids, then give dobutamine 2.5 10 g/kg/min IV, titrating to BP (aim for BP > 90mmHg). Consider also dopamine.

If still hypotensive, consider IV noradrenaline (always via central vein)

If still BP< 90 after 30 min 1 h of treatment, clinical definite PE and no CI (contraindications), consider thrombolysis (if not already given). e.g. alteplase rTPA give 10 mg IV over 2 min and then 90 mg infusion over 2 h).

B. BP > 90 mmHg

Start warfarin 10 mg/24h PO. Confirm diagnosis.

PNEUMONIA
Symptoms: fever, cyanosis, rigors, malaise, dyspnea, cough, purulent sputum (rusty with pneumoniococcus), pleuritic chest pain (on inspiration), +_ haemoptysis. Signs: fever, cyanosis, confusion, tachycardia, tachypnea, herpis labialis (pneumococcus), hypotension, pleural rub, diminished expansion, dull on percussion (stony dull on pleural fluid), increased tactile vocal fremitus and vocal resonance, bronchial breathing. Severity of pneumonia is estimated by the CURB 65 score where C is confusion, U is urea> 7 mmol/L, R is respiratory rate RR >_ 30, B is BP< 90/60 and 65 is age >_65. Score: 0 1: may do home treatment; 2: hospital therapy; >_3: severe pneumonia, may need ICU. Other risk factors are co-existing disease, hypoxemia, SaO2 oxygen saturation < 92% and bilateral or multilobar involvement. Ask if air condition, bird exposure, aspiration (gastroesophagal reflux?) & if other in the family with the same symptoms.

PNEUMONIA ALGORITHM Give oxygen (caution if COPD, see COPD algorithm)

Treat shock and hypotension

SaO2 (oxygen saturation), CXR (chest X Ray), ABGs (arterial blood gases). Labs: CBC/ FBC (full/ complete blood count), urea, creatinine, electrolytes, LFTs (liver function tests), atypical serology, blood/ sputum cultures, pleural fluid aspiration culture. On immunocompromised patients or patients in ICU (and also if HIV or suspected HIV + with pneumocystis jiroveci (carinii)), you may perform bronchoscopy and broncoalveolar lavage for diagnosis.

Antibiotics. For mild pneumonia give amoxicillin 500 mg 1gr/8h PO (orally) or clarithromycin 500 mg/12h PO. Give them both on moderate pneumonia (if you chose IV dose, give amoxicillin 500 mg/8h IV plus clarithromycin 500 mg/ 12h IV). For severe community acquired pneumonia give co amoxiclav 1.2 gr/8h IV, or cefuroxime 1.5 g/8h IV PLUS Clarithromycin 500 mg/12h IVI. Add flucloxacillin if you suspect staphylococcus. Add vancomycin if you suspect MRSA. Treat for 10 days (14 21bdays if you suspect staphylococci, legionella or Gram negative enteric bacteria). If you suspect legionella pneumophilia give clarithromycin +_ rifampicin or levofloxacin and treat for 14 21 days; for Chlamydia add tetracycline; for pneumocystis jiroveci (carinii) add co trimoxazole. For hospital acquired or neutropenic patients consider gentamicin IV + ticarcillin (it will cover pseudomonas) or a 3rd generation cephalosporine (e.g. cefotaxime). For neutropenia consider antifugals after 48h. For aspiration pneumonia, give cefuroxime IV + metronidazole 500 mg/8h IV.

IV fluids as required (anorexia, dehydration)

Paracetamol (acetaminophen) 1g/6h or NSAID for pleuritic chest pain

May be needed intubation & mechanical ventilation

ACUTE UPPER GASTROINTESTINAL (GI) BLEEDING

Causes: peptic ulcer (40%), Mallory Weiss tearing (after reching; 15%), gastroduodenal ulcer (10%), oesophagitis (10%), varices (7%), malignancy, vascular malformations, Dieulafoys lesion (rapture from unusual big arteriole e.g. in the fundus of the stomach), nose bleeding & haemoptysis (swallowed blood). Ask for past medical history (especially on GI system), medication and alcohol.

Signs & symptoms: hematemesis, melaena, dizziness, loss of consciousness, abdominal pain, postural hypotension, hypotension, tachycardia (if not on blockers!), decreased JVP, cool & clammy skin, decreased urine output, prolonged capillar refill time, signs of liver disease such as askites, porphyra and telangiectasias. If the patient is shocked, then has cool and clammy skin (e.g. nose, toes, fingers), tachycardia (> 100 bpm), increased capillary refill time, JVP < 1 cmH2O, hypotension (Systolic BP < 90), postural hypotension (drop of Systolic BP> 20 mmHg or increase of HR >_ 30 bpm or Systolic BP < 90 on standing for 1min after being supine for 3 min), confusion, urine output < 30 ml/h.

UPPER GI BLEEDING ALGORITHM

ABCs, secure airway, give high flow oxygen, keep NBM (Nil by mouth), Insert 2 large bore cannulae (14 16G) and take blood for Labs (CBC/FBC complete/ full blood count, UREA, creatinine, electrolytes, LFT liver function tests, amylase, lipase, coagulation studies. Blood type & cross match 6 units!

Place a NG (nasogastric) tube. Perform gastric lavage with warm normal saline. If it is positive for blood, call a gastroenterologists and a surgeon. Emergency endoscopy or surgery may be needed. In case of negative blood on gastric effluent, suspect lower GI bleeding and notify a gastroenterologist to consider emergency colonoscopy.

Rapid crystalloids infusion (up to 1 L)

If still shocked, give blood group specific (if not fast available and if the patient is unstable give O Rh negative) If the patient is haemodynamically stable and not shocked, give slow saline infusion to keep IV lines open. Keep Hb (hemoglobin) > 8. Note: on patients with decompensated liver failure with ascites and peripheral oedema avoid saline because the patients, despite low serum sodium, have high body sodium! In that case use whole blood or albumin (salt poor) and

use D5W (5% dextrose) for maintenance. Correct clotting defects. Consider FFP (fresh frozen plasma) and vitamin K for coagulation defects (e.g. liver problems or warfarin overdose). Consider also platelet concentrate.

Place a CVP line to guide fluid replacement. Aim for CVP > 5 cmH2O. In case of ascites or CCF (congestive heart failure), CVP may be misleading! Consider then a Swan Ganz catheter.

Place a Foley. Aim for urine output > 30 ml/h.

Monitor vitals every 15 min until stable. When stable, monitor vitals hourly. Notify surgeons if severe bleeding. Also notify the gastroenterologists, as urgent endoscopy may needed for diagnosis and bleeding control. Specific treatment. Give in all patients omeprazole 80 mg stat (immediately) IV and then 8 mg/h for 72 h. On variceal bleeding consider terlipresin 2mg Sc (subcutaneously) qds (4 times daily consult BNF) (caution if peptic ulcer). On a bleeding peptic ulcer or variceal bleeding consider octreotide 50 100 g bolus followed by 25 50 g /h infusion. For variceal bleeding notify a gastroenterologist for emergency endoscopy and band ligation or sclerotherapy. If unavailable, consider Sengstaken Blakemore or Minessota tube. Gine also omeprazole 40 mg PO.

MENINGITIS
Early symptoms: headache, cold hands & feet, abnormal skin color. Later: neck stiffness, kernings (pain & resistance on passive knee extension with the hip fully flexede) & Brudzinski signs, photophobia, decreased LOC (level of consciousness), opisthotonus, seizures (20%), focal neurological signs (20%),

coma, petechiae (non blanching e.g. on placing an empty glass of water; petechiae may be 1 2 spots or none). Sepsis: increased capillary refill time, hypotension, tachycardia (may not occur), DIC, pyrexia (or normal temperature!). MENINGITIS ALGORITHM

ABCs, high flow 100% oxygen, IV access, fluids IVI.

A. Septaemic signs predominate: cool hands and feet, increased capillary refill time, hypotension etc.

Dont perform LP (lumbar puncture)! Give cefotaxime 2 gr IV. Call ICU. 1. If signs of shock occur, then transfer to ICU for fluid resuscitation, inotropes/ vasopressors, intubation and mechanical ventilation and perhaps activated protein C drotrecogin alfa (controversial). Aim for BP> 80 mmHg and urine output > 30 ml/h. 2. If no signs of shock, monitor the patient.

B. Meningitic signs predominate: neck stiffness, Kernings and Brudzinski signs, photophobia etc.

Give dexamethasone 4 10 mg/6h, IVI (0.15 mg/kg/6h). Give it just before the antibiotic. Administer it if suspected pneumococcal meningitis and on children. Avoid it in known meningococcal meningitis, septic shock, immunocompromised, TB and post operative meningitis!

If the patient has signs of increased ICP (intracranial pressure), transfer to ICU. Dont perform LP (lumbar puncture)! If there is no shock and no signs of increased ICP, then do a LP. LP is CI (contraindicated) in suspected intracranial mass lesion, focal neurological signs, papilloedema, trauma, major coagulopathy, middle ear pathology (!), suspected increased ICP (e.g. decreased level of consciousness) and septemic signs of meningitis! Papillioedema is a late sign. Also CT may not rule out increased ICP! In case there is contraindication for LP, perform first a CT head scan! However, before the CT scan give antibiotics!

Give cefotaxime 2 gr IV, immediately post LP (lumbar puncture). However, if LP is about to delay more than 30 min, give the antibiotic pre (before) LP!

Nurse the patient at 30 degrees level. Give fluids, however avoid over or underhydration. Isolate the patient for the 1st 24 h. Also notify the CCDV (consultant in communicable disease control in the UK).

Commonly used antibiotic for meningitis is cefotaxime 2 4 gr/ 8h IVI for 10 days (decrease dose in renal failure). Alternatives are ceftriaxone and vancomycin. In suspected Listeria and on patients > 55 years old & alcoholics add ampicillin 2 gr/ 6h.

ENCEPHALITIS
Signs & symptoms: odd behavior, confusion, decreased LOC (level of consciousness), coma, fever, headache, focal neurological signs, seizures. Suspect it if history of travel or animal bite! Also suspect it if odd behavior, decreased LOC, focal neurological signs or seizures preceded by an infectious prodrome with fever, rash, lymphadenopathy, conjuctivitis and meningeal signs! If this infectious prodrome does not occur, then exclude encephalopathy, hypoglycemia, DKA (diabetic ketoacidosis), hypoxia, drugs, uremia, SLE, Wernickes syndrome (alcoholic, malnurished) and hepatic encephalopathy! Investigations: Labs (blood culture, viral serology, PCR, throat swab, MSU mid stream urine culture, urine analysis, toxoplasma serology, malaria (blood thick films), contrast enhanced CT (do it before the LP lumbar puncture!), LP (lumbar puncture), EEG (electroencephalography).

Management: start empirically acyclovir within 30 min of the presentation! Dose is 10 mg/kg/ 8h IV over 1 h, for 2 weeks (3 weeks if immunocompromised) to cover HSV (herpes simplex virus). Adjust the dose according to the eGFR. For CMV encephalitis give ganciclovir IV; and for toxoplasma give pyrimethamine and sulfadiazine. For seizures give phenytoin. The patient may be needed to be transferred to the ICU.

CEREBRAL ABCESS.
Signs: fever, seizures, localizing signs or signs of increased ICP (intracranial pressure), coma. Suspect it in any patient with increased ICP, especially with fever and increased WCC (WBC)! It may occur after ear (Bacterioides fragilis or other anaerobes are common culprits if ear abscess), sinus, dental, or periodontal infection (in dental or frontal sinuses infection, the culprit is commonly Streptococcus milleri or anaerobes); also it may occur at congenital heart disease, skull fracture, endocarditis and bronciectasis! Exclude immunesuppression. In toxoplasma the lesions on CT are deeper (e.g. on basal ganglia). Investigations: CT/ MRI. Labs (increased ESR and WCC). Biopsy! Management: call neurosurgeon, treat increased ICP (see below).

STATUS EPILEPTICUS
Status epilepticus occurs when seizures last more than 30 min, without regaining consciousness. Mortality is high and therefore seizures lasting more than a few minutes need to be managed. Status epilepticus may be NON CONVULSIVE (e.g. continue partial seizures with preservation of consciousness or absence status epilepticus) and in that case look for subtle signs such as eye or lid movement or a single twitch! An EEG (electroencephalography) is very helpful. Also exclude pregnancy and eclampsia as a cause of seizures (check BP, urine protein and for oedema)!

Investigation: glucose finger stick test (!), ABGs (arterial blood gases), SaO2 (oxygen saturation), ECG/ monitor, EEG, Labs (UREA, creatinine, electrolytes including calcium and magnesium, LFTs liver function tests, FBC/ CBC full/complete blood count, anticonvulsant levels !, toxicology including carbon monoxide levels, drug levels (aspirin, acetaminophen, theophyllines!), +_blood & mid stream urine culture, +_ LP (lumbar puncture) +_ head CT. STATUS EPILEPTICUS ALGORITHM

ABCs, open & maintain the airway, place in recovery position, remove dentures (if poor fitting), insert nasopharyngeal airway, intubate if necessary. Give 100% high flow oxygen & suction (if required).

IV access, Labs (see above), glucose (finger stick ward test & official Lab test)

Give 250mg thiamine malnourishment.

IV

over

10min

in

suspected

alcoholism

and

If glucose isnt fast known, give glucose 50 ml of 50% solution. Also give naloxone 0.4 2 mg IV if opiate overdose is suspected (e.g. pin point pupils). Repeat every 2 min. Max 10 mg.

Give fluids if hypotensive

A. Slow IV bolus phase for stopping seizures: give lorazepam 2 4 mg slowly (over 30 sec) IV into a large vein (repeat in 10 min if no response). Beware respiratory arrest during the last part of injection (have full resuscitation facilities bedside). Alternative is diazepam (but is less long acting than lorazepam) which dose is 0.15 mg/kg e.g. 10 mg IV, slowly, over 2 min. If no response, repeat a dose of 5 mg every 3 4 min, until seizures stop or 20 mg dose have been given as total dose or if respiratory depression occurs.

If IV access is difficult, diazepam may be given rectally, endotracheally or IO (intraosseously). Diazepam, alternatively, may be given rectally, if IV access is difficult. The dose with rectal tubes is 0.5 mg/kg stat (immediately) e.g. give 3 tubes of 10mg PR (per rectum). If still no response after 10 min, then try another last 10 mg tube. The dose for the elderly is half. Buccal midazolam is also an alternative. Dose for >_ 10 years old is 10 mg (1 ml); 1 4 years old is 0.5 ml; 6 12 months old is 0.25 ml. Squirt half of the volume between lower gum and the cheek on each side. Prepare other drugs while waiting this to work. In case you dont have buccal midazolam, you may try IV or (if IV access hasnt been obtained) IM midazolam at dose of 0.2 mg/kg. B. IV infusion phase if seizures continue: give phenytoin 20 mg/kg IVI (1.2 g if 60 kg and 1.6 g if 80kg) at a rate of <_ 50 mg/min. If seizures still persist, an additional dose of 10 mg/kg may be given. Monitor BP and ECG! Beware hypotension! Dont give if the patient has heart block or bradycardia! Maintenance dose is 100 mg/ 6 8 h (check blood levels). Dont administer diazepam at the same line! If the patient is already taking phenytoin, consider lower dose: 10 mg/kg IVI (500 mg 1 gr total) or give valproate (see below). Safer than phenytoin is fosphenytoin. Dose is 20 mg PE (phenytoin equivalents)/ kg IV/IM at rate of 150 PE/min. NOTE: phenytoin is harmful to the veins, so flush the line after the infusion! Alternative is diazepam infusion: mix 100 mg diazepam in 500 ml of 5% dextrose and infuse at rate of about 40 ml/h (3mg/ kg/ 24h). Beware respiratory depression (have resuscitation facilities available). If seizures recur after this, consider if they are pseudo seizures, especially if odd (pelvic thrusts, resisting on eye lids opening, resisting on passive movements, arms and legs falling apart). NOTE: give 10 mg dexamethasone IV if vasculitis or cerebral edema (e.g. from tumor) are possible.

Valproic acid is another agent used for refractory seizures. It is safer than the other drugs. Loading dose is 15 20 mg/kg. Intubation may be avoided by using this agent! For refractory seizures you may also try midazolam at loading dose, as mentioned above, 0.2 mg/kg IV, followed by infusion of 0.05 2 mg/kg/h. Hypotension is rare compared to propofol.

C.

General anesthesia phase: call anesthesiologist for paralysis and mechanical ventilation and monitoring in the ICU.

Propofol may be given (better by an anesthetist) at loading dose of 3 5 mg/kg, followed by infusion of 1 15 mg/kg/h. Monitor for hypotension!

HEAD TRAUMA
Call early a neurosurgeon, check pulse, BP temperature (!), respiration, pupils (size and reaction to light) every 15 min. Assess for anterograde (post traumatic) amnesia and retrograde amnesia (it occurs with anterograde amnesia). ABCs, Secure airway, Nurse semi prone (if no suspected spinal trauma), place Foley. Ventilate if coma (GCS <_8), hypoxemia, hyperventilation and irregular respiratory pattern. hypercapnia, spontaneous

CT scan is needed immediately in any of the following: patients with GCS< 13 at any time or GCS 13 or 14 at 2 h after the injury, focal neurological deficit, post traumatic seizures, vomiting (more than once), suspected open or depressed skull fracture or basal skull fracture. Also CT is needed if loss of consciousness and any of the following: age >_ 65, coagulopathy, anterograde amnesia (post traumatic) > 30 min and positive severe mechanism of injury (e.g. road traffic accident or fall from height). Drowsy patients with GCS < 15 and > 8, smelling alcohol. Alcohol is unlikely to cause coma if plasma levels < 44 mmol/L. Alcohol levels can be also estimated by the osmolar gap. If osmolar gap is 40 mmol/L, then plasma alcohol is about 40 mmol/L. NOTE: osmolar gap = measured osmolality plasma osmolality. Plasma osmolality= 2 (K+Na) + urea+ glucose. Normal plasma osmolality is 280 300 mosmol/ kg.

Dont attribute signs to alcohol and illicit drugs without excluding a head trauma and increased ICP (intracranial pressure). You may need to perform a CT. Also, on a multitrauma patient, head trauma is unlikely to cause hypotension. Exclude hemorrhage (e.g. chest, abdominal, pelvis, major fracture) first.

HEAD TRAUMA ALGORITHM

ABCs, immobilize neck if cervical spine injury is suspected, give 100% high flow oxygen, intubate and ventilate if necessary. If GCS is <_ 8 (coma), intubate.

Stop bleeding, treat for shock if needed.

Treat seizures with lorazepam +_ phenytoin.

Assess GCS (Glasgow coma scale), pupils size & reaction to light, abnormal postures (flexion or extension posture), and also for anterograde (post traumatic) or retrograde amnesia and vomiting (more than once).

ABGs (arterial blood gases), SaO2 (oxygen saturation). Labs: UN (), creatinine, electrolytes, glucose, FBC/CBC (full/ complete blood count), blood alcohol, toxicology, coagulation studies. Place a Foley.

Give tetanus immunization, if external trauma.

Brief history: AMPLE (Allergy, ,Medication, Past medical history, Last meal & Environment/ injury mechanism). Ask when, where and how did the trauma occur, if the patient had any seizures, if there was a lucid interval and if alcohol or drug abuse.

Check the lacerations of face or scalp. Palpate deep wounds and check for step deformity! Check for depressed skull fracture. Note any obvious skull or facial fracture.

Check also for CSF leakage from nose (CSF rhinorrhea), or ear (check the fluid for glucose, also see if it creates a halo when placing some drops on a newspaper). Check if there is any blood behind the ear drum (haemotympanium) and for blood from the ear canal (e.g. petrous bone fracture). Check also for periorbital ecchymoses (raccoon or pandas eyes) or postauricular ecchymoses (Battles sign). If any of the above occur, suspect basilar skull fracture. Perform a CT, give Tetanus immunization and refer to neurosurgeons.

Palpate the cervical area for tenderness and deformity. If detected, or if the patient has head trauma or injury above the clavicle with loss of consciousness, immobilize the neck with a collar and take C spine X Rays.

Image tests: head CT, CXR (chest X Ray), C (cervical) spine X Rays.

RAISED ICP (INTRACRANIAL PRESSURE)

Causes: head trauma, tumors (primary or metastatic), hemorrhage (subdural, extradural, subarachnoid, intracerebral, intraventricular), hydrocephalus, infection (meningitis, encephalitis, brain abscess), cerebral edema, status epilepticus, severe metabolic abnormality. Signs & symptoms: headache, obtundation, drowsiness, vomiting, seizures, listlessness, irritability, Cushing triad (rising BP, falling pulse rate and irregular respirations), pupil changes (initially constriction, later dilation; dont use pupil dilating eye drops for fundoscopy, at least not before the neurological examination), anisokorian (unequal pupils), decreased visual aquity, visual fields loss, pupilloedema (unreliable sign). Venous pulsation at the optic disc may be absent; remember that is absent in about 50% of normal population; but loss is a sign and retinal vein pulsation in fundoscopy may exclude increasing of ICP. Investigations: UREA, creatinine, glucose, FBC/ CBC (full/ complete blood count), serum osmolality, LFTs liver function tests, coagulation studies, blood culture.

Plasma osmolality= 2 (K+Na) + urea+ glucose. Normal plasma osmolality is 280 300 mosmol/ kg.

Place a Foley (urinary catheter). CXR (chest X Ray), SaO2 (oxygen saturation), head CT, LP (after the head CT! Also measure the opening pressure!). RAISED ICP ALGORITHM

ABCs. Maintain airway. High flow oxygen.

Correct hypotension with fluids. Treat seizures. You may need to give seizure prophylaxis.

Brief history: AMPLE (Allergy, Medication, Past medical history, Last meal & Environment/ injury mechanism). Brief examination. Check for rash (meningitis?). Any tumor?

Elevate the head of bead to 30 40 degrees (if not hypotension!)

If intubated and neurological deterioration/ impending herniation (Cushing triad: rising BP, falling pulse rate and irregular respirations; also pupil changes (initially contralateral dilation, anisokoria implying III cranial nerve entrapment), hyperventilate to decrease PaCO2 (target is Pa CO2 25 30 mmHg), for a short time! This causes cerebral vasoconscriction and will fast decrease ICP.

If not hypotensive, use osmotic agents such as mannitol 1 2 gr/kg of 20% solution (e.g. 5 ml/kg) over 10 20 min. Effect is seen after about 20 min and lasts 2 6 h. However, prolonged use for 12 24 h may lead to rebound ICP increase. Check serum osmolality. Aim for plasma osmolality about 300 mosmol/kg, but dont exceed 310 molsmol/kg! NOTE: plasma osmolality= 2 (K+Na) + urea+ glucose. Normal plasma osmolality is 280 300 mosmol/ kg.

If not hypotensive, you may also try Lasix (furosemide) 0.3 0.5 mg/kg. Check potassium.

For increased ICP from focal causes (e.g. haematoma from trauma) call a neurosurgeon. Craniotomy or burr holes may be needed. However, surgery doesnt help on ischemic or anoxic brain injury.

For edema surrounding head tumors give dexamethasone 10 mg IV and continue with 4 mg/6h IV/PO.

If not hypotensive, restrict fluids to < 1.5 L/day.

Consider invasive ICP monitoring. Normal ICP (intracranial pressure) is 0 10 mmHg.

Treat exacerbating factors e.g. hypoglycemia or hyponatraemia!

Definite treatment. In persistent ICP increase, a barbiturate (inducing) coma in the ICU may be tried.

DIABETIC KETOACIDOSIS (DKA)

Signs symptoms: gradual decrease of LOC (level of consciousness), vomiting, dehydration, abdominal pain (!), polyuria, polydipsia, ketotic breath (!), anorexia, drowsiness, lethargy, coma, deep sighing Kussmauls respirations (hyperventilation). Almost always involves DM (diabetes mellitus) type 1 (rarely on type 2). Diagnosis is acidosis (PH< 7.3), serum bicarbonate <_ 15 mEq /L, hyperglycemia (glucose > 20 mmol/L or > 250 mg/dL), Ketosis! (ketonuria or serum ketones).

Precipitating factors for DKA are infection (lung, skin, urine, perineum), surgery, MI (myocardial infarction), pancreatitis, antipsychotics, chemotherapy, wrong insulin dose, non compliance to DM therapy. Tests: Urine (ketones, mid stream urine for glucose). ABGs (arterial blood gases), SaO2 (oxygen saturation), CXR (chest X Ray). Labs - blood: glucose, CBC/ FBC (complete/ full blood count), UREA, creatinine, electrolytes, amylase, bicarbonates HCO3, cardiac markers & enzymes, osmolality, blood (+_ urine) cultures. Plasma osmolality= 2 [Na +K] + [urea] + [glucose] mmol/L. Normal is 280 300mosmol/kg.

DKA (DIABETIC KETOAXIDOSIS) ALGORITHM

DKA may manifest with abdominal pain! Check plasma glucose. It is > 20 mmol/L (250 mg/dL). Usually is > 360 mg/dL. If so, give 4 8 units soluble insulin IV (Actrapid or Humalin S). The insulin dose is 0.1 0.15 units/kg. Check potassium! If potassium is low (< 3.3 mmol/L) dont give insulin because it will decrease it!! In that case, first replace fluids and potassium.

IV access. Tests (see above)

Fluid replacement. Give 1 L of 0.9% saline stat (immediately). Then give 1 L over the next hour, 1 L over 2 h, 1 L over 4 h and then 1 L over 6h. Adjust according to urine output. When glucose is < 10mmol/L (180 mg/dL) use D5W (5% dextrose). Caution on the elderly and patients with CCF (congestive heart failure). These patients need less saline, with caution (a CVP line would be helpful).

K (Potassium) replacement Total body K is low and plasma K falls as K enters into the cells with the insulin treatment. Do not add K at the 1st bag (which is given immediately)! Monitor urine

output hourly. Add K when urine flow is > 30 ml/h! Check UREA and electrolytes hourly, initially.

Serum K (mmol/L).Amount of KCl added per L of fluid < 3 ...40 mmol 3 430 mmol 4 520 mmol In renal failure and oliguria, less K will be needed.

Place a NG (nasogastric) tube if nausea, vomiting or unconscious. Place also a Foley (especially if no urine passes after 3 h or if the patient is in coma).

Insulin is given via a pump diluted to 1 unit/mL (add 50 units of soluble insulin Actrapid/ Humalin S to 50 ml normal saline in a syringe). See the sliding scale of insulin (below) e.g. for severe DKA start at about 6 Units/h for adults. Expect blood glucose to fall by 5 mmol/L/h (90 mg/ dL/ h). If poor response, double or quadruple the rate. When blood glucose is < 10 mmol/L (180 mg/dL), decrease the rate to 3 units/ h and continue until food by mouth is possible. Dont stop the pump until routine Sc (subcutaneous) insulin has been initiated. Check the ABGs if the acidosis has been corrected.

Sliding scale of insulin via IVI pump in DKA Hourly glucose.Soluble insulin (U/h) Insulin if ............................................infection ...or insulin resistance mmol/l (mg/ dL)... 0 3.9 (0 70)0.5...1 4 7.9 (71 143)...1..2 8 11.9 (144 216).2.4 12 16 (217 290)...3.6 >16 (> 290)4.8

In case you dont have a pump, give loading dose 20 units IM, then give 4 6 units IM, while glucose is > 10 mmol/L (180 mg/dL). Then decrease to 2/ h.

Check GCS (Glasgow Coma Scale), glucose, UREA, creatinine, electrolytes and bicarbonate HCO3 often (initially hourly). Check also vitals, urine output, urine ketones. CVP monitoring may help fluid replacement (especially in the elderly and if CHF congestive heart failure).

Continue fluid and potassium replacement. Treat any precipitant infection (lung, skin, urine, perineum), after taking cultures. Give LMWH (low molecular weight heparin) until the patient is mobile. Change to Sc (subcutaneous) insulin when ketones are <_ 1+ and the patient can eat.

Check what precipitated the DKA in order to prevent a new one. Complications: cerebral oedema (CNS deterioration), hypokalaemia, aspiration, hypomagnesaemia, hypophosphataemia, TE (thromboembolism) & PE (pulmonary embolism)! NOTES: Plasma glucose may not be high at presentation if insulin is continued! High WCCs (WBCs) in DKA may occur without infection! Infection can occur without fever! Perform blood & MSU (midstream urine) cultures. Perform a CXR (chest X Ray). Give broad spectrum antibiotics (e.g. co - amoxiclav) at suspected infection. Clasma creatinine may be unreliable because some assays for creatinine cross react with ketone bodies! Hyponatraemia is common (osmolar compensation with hyperglycemia)! Increased or stable Na (sodium) indicates severe dehydration. During treatment, sodium raises as water enters the cells. Sodium may also be low as artifact! Corrected plasma sodium: Na + 2.4 [(glucose mmol/L 5.5)/ 5.5].

Ketonuria ++ may occur after an overnight fast. If glucose is normal, check alcohol. Test also plasma ketones. On acidosis without elevated glucose exclude other causes e.g. drug overdose (e.g. aspirin) and lactic acidosis (e.g. in elderly diabetics). Serum amylase may be up to 10 fold raised with non specific abdominal pain, in the absence of pancreatitis. Maintaining a constant rate of insulin (e.g. 4 5 units/h) IVI and coinfusing 10% or 20% dextrose to keep plasma glucose at 6 10 mmol/L (108 180 mg/ dL) will prevent recurrent DKA.

HYPERGLYCAEMIC HYPEROSMOLAR NON KETOTIC COMA (HONK)

It typically occurs in patients with DM (diabetes mellitus) type 2. There is a prolonged period of dehydration (e.g. 1 week) and glucose > 35 mmol/L (636 mg/dL), but without acidosis, neither urine ketones. The patient is usually old, with DM type II and usually presenting for the 1st time. Osmolality is> 340 mossmol/kg. Note: Plasma osmolality= 2 [Na +K] + [urea] + [glucose] mmol/L. Normal is 280 300mosmol/kg. Precipitants are MI (myocardial infarction), drugs, mesenteric ischemia, GI bleeding etc. Labs: CBC/FBC (complete/full blood count), UREA, creatinine, electrolytes, plasma osmolality, blood & urine cultures, cardiac markers & enzymes, bicarbonate HCO3, urine ketones, urinalysis. Also ECG, SaO2 (oxygen saturation), ABGs (arterial blood gases), CXR (chest X Ray). There is also risk for DVT (deep vein thrombosis), focal CNS signs, stroke, DIC, leg ischemia and rhabdomyolysis! Heparin prophylaxis is needed. Give e.g. 5000 units IV over 30 min. Management: rehydration with e.g. 9 L of normal saline 0.9% over 48 h. Use half the dose of DKA fluid replacement. Place a Foley. Wait urine to flow and then replace potassium! Wait 1 h before you give insulin which it may not be needed.

Avoid rapid changes that may precipitate pontine myelinolysis! However, if insulin is needed, give e.g. 1 unit/h.

Hyperlactataemia

is a rare complication of DM (diabetes mellitus) after metformin therapy or sepsis. Blood lactate is > 5 mmol/L. Give oxygen. Treat sepsis. Call ICU.

HYPOGLYCAEMIC COMA
Usually has fast onset. Initial symptoms are odd behavior (e.g. aggressiveness), sweating, tachycardia (may not occur if on blockers!). Untreated it will lead to seizures and coma. It may also cause hemiparesis and mimic stroke! Causes: insulin or hypoglycaemics wrong dose, insulinoma, Addisonian crisis, myxedema, hypopituitarism, liver failure, IgF1 tumors, Hodgkins disease, poisoning (e.g. salicylates) and alcoholism intoxication. Therapy: give immediately 50 100 ml of 50% dextrose, slowly (e.g. over 5 min). However this is harmful for the veins (so use a large vein and after the infusion flush it with normal saline), so you may alternatively give 20 30 gr dextrose IV for example you can give 200 300 ml of 10% dextrose. Glucagon 1mg IV/IM is an alternative, but will not work on intoxicated (drunk) patients and generally in patients with low glucogen stores (starvation, chronic hypoglycemia, adrenal insufficiency Addisons). In that case give also dextrose. When the patient regains his/her consciousness, give drinks with sugar and bread.

MYXOEDEMA COMA
Often occurs on patients > 65 years old. Signs & symptoms include hypothermia (!), decreased reflexes, hypoglycemia, bradycardia (!), non pitting oedema (puffy eye lids, hands, feet), goitre, cyanosis, hypotension (cardiogenic), heart failure (!), pericarditis, psychosis (myxoedema madness!), seizures, coma. Signs of hypothyroidism: BRADYCARDIC: Bradycardia, decreased Reflexes, cerebellar Ataxia, Dry thin hair/ skin, Yawning/ drowsy/ coma, Cold hands, +_hypothermia, Ascites, +_non pitting edema on lids/ hands, feet, +_ pericardial/ pleural effusion, Round puffy face/ obese/ double chin, Defeated demeanour, Immobile, +_ illeus, CCF congestive heart failure; also neuropathy, myopathy, +_ goiter.

Precipitants are: prior surgery (thyroidectomy) or radioiodine therapy for hyperthyroidism, hypopituitarism (!), MI (myocardial infarction), stroke, infection, trauma. Complications: hypoglycemia(!), pancreatitis, arrhythmias, MI, pericarditis.

MYXOEDEMA COMA ALGORITHM

Consider transferring to ICU.

High flow oxygen if cyanosis. Consider intubation and mechanical ventilation.

Labs: 3, 4, fT3, fT4, TSH, UREA, creatinine, electrolytes (check for hyponatraemia!), glucose, cortisol (blood 10 ml heparin or clotted), ACTH (blood 10 ml heparin, transfer immediately to Lab), cardiac enzymes & markers, amylase, blood/ urine cultures. CXR (chest X Ray), ABGs (arterial blood gases), ECG.

Correct hypoglycemia!

Administer 5 20 g/ 12h T3 (liothyronine) slowly IV (caution in suspected ischemic heart disease you may precipitate cardiac ischemia!). Alternative drug is levothyroxine T4. Also give hydrocortisone 100 mg/8h IV. It will help in suspected hypopituitarism (no goiter, no previous therapy with radioiodine, no previous thyroidectomy).

Give 0.9% normal saline (caution if LVF left ventricular failure).

In suspected infection give cefuroxime 1.5 g/8h IVI.

Treat heart failure. Consider vasopressors if hypotension.

Treat hypothermia (warm blankets in warm room & warm drinks if conscious) Therapy is continued with 5 20 g T3 every 4 12 h IV for 2 3 days, and then levothyroxine T4 50 g/ 24 h PO. Give also hyodrocortisone & fluids. Hyponatraemia is dilutional.

HYPERTHYROID CRISIS (THYROTOXIC STORM)

Signs & symptoms: women : men = 4 : 1, pyrexia/ hyperthermia (!), agitation, tachycardia, AF (atrial fibrillation), diarrhea, vomiting, goitre, thyroid bruit, abdominal pain (! exclude surgical causes), heart failure, hypotension (cardiogenic), confusion, coma.

Signs of hyperthyroidism: fast/ irregular pulse (SVT supraventricular tachycardia or AF atrial fibrillation, rare VT ventricular tachycardia), warm moist skin, palmar erythema, fine tremor, thin hair, lid lag, lid retraction, +_ goiter, +_ thyroid nodules or bruit. On Graves: exophthalmos, ophthalmoplegia, pretibial myxedema, thyroid acropachy. Precipitants: recent thyroid surgery, radioiodine, MI (heart attack), infection, trauma. Confirm diagnosis with 99mTc (technetium) uptake scan. HYPERTHYROID CRISIS (THYROTOXIC STORM) ALGORITHM

Administer IVI 0.9% saline 500 ml/4h. Put NG (nasogastric) tube if the patient is vomiting.

Labs: 3, 4, fT3, fT4, TSH, blood & urine cultures in suspected infection

ECG, cardiac enzymes & markers, ABGs (arterial blood gases), SaO2 (oxygen saturation).

Sedation if needed (e.g. chlorpromazine 50 mg PO/IM). Monitor BP. For dysrhythmias, If no CI (contraindication) and if normal cardiac output, give propranolol 40 mg/8h PO (orally). IV dose of propranolol is 1 mg IV slowly over 2 5 min. You may repeat propranolol at >_ 2 min intervals to a total max IV dose 0.1 mg/kg. If asthma or low cardiac output dont give propranolol, but consider the short acting blocker esmolol. Dose of esmolol is 250 300 mcg (g)/ kg/min. Blockers are contraindicated in severe CHF (congestive heart failure), asthma/ COPD, bradycardia, 2nd or 3rd degree AV (atrioventricular) block, hypotension and cardiogenic shock.

On tachyarrhythmia you may also need to administer high dose digoxin e.g. 1 mg over 2 h IVI.

Administer carbimazole 15 25 mg/ 6h PO (orally) or via NG tube (if vomiting). After 4 h give Lugol solution 0.3 ml/8h PO diluted in water. Continue Lugol for 1 week. After 5 days reduce carbimazole to 15 mg/8h PO.

Administer hydrocortisone sodium succinate 100mg/ 6h or dexamethasone 4 mg/6h PO.

Treat any suspected infection e.g. with cefuroxime 1.5 gr/8h IVI.

If hyperthermia, cool with tepid sponging +_ paracetamol (acetaminophen).

If no improvement in 24 h, consider thyroidectomy. Consult an expert anesthetist & surgeon.

ADDISONIAN CRISIS (ADRENAL INSUFFICIENCY)

Signs & symptoms: may present with shock, with tachycardia, postural hypotension (!), oliguria, confusion, coma! May occur in a patient taking steroids and discontinuing them abruptly or forgetting to take them, or not increasing them in stress such as infection, trauma or surgery! Also may be caused by bilateral adrenal hemorrhage e.g. on Waterhouse Friderichsen syndrome from meningococcaemia. Signs of adrenal insufficiency (Addisons disease): lean, tanned, tired, weakness, anorexia, faints, dizzy, myalgia, arthralgia, flue like, lassitude, depression, psychosis, nausea, vomiting!, abdominal pain!, diarrhea/ constipation, vitiligo!, pigmented palmar creases & buccal mucosa!, postural hypotension. In deterioration: shock, hypotension, tachycardia, pyrexia, coma. Also hyponatraemia and hyperkalaemia!

ADDISONIAN CRISIS ALGORITHM

If suspected, treat before biochemical results. Give hydrocortisone sodium succinate 100 mg IV stat (immediately).

Labs: cortisol (blood 10 ml heparin or clotted) and ACTH (blood 10 ml heparin, transfer immediately to Lab).

Also blood, MSU (mid stream urine) & sputum culture.

Administer IV normal saline 0.9%

Monitor blood glucose for hypoglycemia! Give glucose if hypoglycemic.

Give antibiotics in suspected infection (after cultures have been taken) such as cefuroxime 1.5 gr/8h IVI.

Continue IV fluids guided by clinical state. Correct electrolyte abnormalities. Check for hyponatraemia and hyperkalaemia!

Continue hydrocortisone sodium succinate 100 mg/ 6h IV or IM. Change to oral steroids after 72 h, if the patient has been improved.

You cant do the tetracosactrin Synacthen test while on hydrocortisone. In case you initially treated the patient with dexamethasone, you may still do the test.

You may need to give fludrocortisones (e.g. 50 200 g daily PO) in adrenal disease.

Treat any underlying cause. Consult early an endocrinologist.

HYPOPITUITARY COMA
It may manifest with hypothermia, refractory hypotension & septic signs without fever. The patient may have short stature, loss of axillary and pubic hair, and gonads atrophy. It usually develops gradually in a patient with known hypopituitarism e.g. from pituitary tumor. It may occur rapidly after a pituitary infarction e.g. at Sheehans syndrome (post partum). Symptoms include meningism & headache and often is misdiagnosed as subarachnoid haemorrhage! Causes: a. ypothalamus: Kallmans syndrome: (gonadotropin releasing hormone deficiency with anosmia and color blindness), tumor, inflammation, infection (such as meningitis or TB), ischemia. b. Pituitary stalk: trauma, surgery, craniopharyngioma, meningioma, carotid artery aneurysm. c. Pituitary: tumor, inflammation, irradiation, autoimmune causes, infiltration on hemochromatosis, amyloidosis, metastases; ischemia: pituitary apoplexy, DIC, Sheehans syndrome postpartum.

Signs & symptoms: headache, ophthalmoplegia, decreased LOC (level of consciousness), hypotension, hypothermia, hypoglycemia and signs of hypopituitarism. Specifically, signs of deficiency of: GH: central obesity, dry wrinkly skin, lassitude, decreased balance, decreased cardiac output!, decreased exercise ability, hypoglycemia!, osteoporosis); Gonadotropins FSH/ LH: a. women: oligomenorrhoea/ amenorrhoea, decreased fertility and libido, breast atrophy, osteoporosis, dyspareunia. b. men: erectile dysfunction, decreased libido, decreased muscle bulk, hypogonadism with decreased hair of body, small testes, decreased ejaculate volume and spermatogenesis. Thyroid: hypothyroidism: BRADYCARDIC: Bradycardia, decreased Reflexes, cerebellar Ataxia, Dry thin hair/ skin, Yawning/ drowsy/ coma, Cold hands, +_hypothermia, Ascites, +_non pitting edema on lids/ hands, feet, +_ pericardial/ pleural effusion, Round puffy face/ obese/ double chin, Defeated demeanour, Immobile, +_ illeus, CCF congestive heart failure; also neuropathy, myopathy, +_ goiter. Corticotrophin: as adrenal insufficiency: lean, tanned, tired, weakness, anorexia, faints, dizzy, myalgia, arthralgia, flue like, lassitude, depression, psychosis, nausea, vomiting!, abdominal pain!, diarrhea/ constipation, postural hypotension; no skin pigmentation! Prolactin PRL: rare; absent lactation. Labs: cortisol (blood 10 ml heparin or clotted), ACTH (blood 10 ml heparin, transfer immediately to Lab), T3, T4, fT3, fT4, TSH, glucose.

Imaging tests: pituitary fossa CT/ MRI. HYPOPITUITARY COMA ALGORITHM

Dont wait Lab results for treatment. Start treatment stat (immediately).

Administer hydrocortisone sodium succinate e.g. 100 mg IV/ 6h.

Only after administering hydrocortisone, you may give liothyronine (3) e.g. 10 g/ 12h PO (orally) or 5 20 g/ 12h slowly IV (initially may be needed 4 hourly).

In pituitary apoplexy consult a neurosurgeon, as emergency surgery may be needed.

PHAEOCHROMOCYTOMA WITH HYPERTENSIVE CRISIS

Pheochromocytoma is a catecholamine secreting tumor, typically at the adrenal medulla. Usually presents as paroxysmal or sustained hypertension in young to middle aged patients! Signs & symptoms of hypertensive crisis from pheochromocytoma: flushing, palpitations, pallor, pulsating headache, profuse diaphoresis, hypertension!, feeling about to die, pyrexia, LVF (left ventricular failure), ST elevation on ECG, VT (ventricular tachycardia), cardiogenic shock. Also chronic weight loss, orthostatic hypotension !! & impaired glucose tolerance. Precipitating factors: stress, abdominal palpation (!), parturition (labor), general anesthetic, contrast media (except IV contrast media with low osmolality). Labs: 24 h urine catecholamine metabolites and/or and plasma free metanephrines. Diagnosis: MIBG isotope scan, CT/MRI, angiography. Treatment: for a adrenergic blockage give Phentolamine 1 2 mg IV. You may repeat every 5 min until BP has decreased. Alternative drug is labetalol with dose 10 20 mg IV boluses every 10 min.

In severe tachyarrhythmias use blockers. However, give the blockers only after sufficient a blockage is initiated, otherwise the blockers may cause severe hypertension! When BP is controlled, give the a blocker phenoxybenzamine 10 mg/ 24 h PO (increase by 10 mg/ day as needed, up to 30 mg bd twice daily PO per os i.e. orally). It may cause idiosyncratic severe BP drop after 1st dose. You need to increase the dose until BP is controlled, but without severe postural hypotension. A 1 blocker may then be given to control tachycardia or myocardial ischemia or arrhythmias. Surgery is done electively after 4 6 weeks, after full a blockage and volume expansion.

ARF (ACUTE RENAL FAILURE)

It is defined as acute (hours to days) renal function deterioration with rise in serum creatinine, ureaand usually with oliguria or anuria. Causes: hypovolaemia/ low cardiac output, sepsis, drugs, glomerulonephritis, obstruction (stones, blood, clot, tumor, sloughed papilla, abdominal/ pelvic mass/ tumor, retroperitoneal fibrosis) vasculitis, hepatorenal syndrome etc. ARF ALGORITHM

Priorities: Check immediately BP, urinary protein, urinary sediment, serum potassium K, urea, creatinine & electrolytes. Also perform ultrasound.

IV access, catheterize the bladder (Foley), check hourly urine output and write complete fluid charts. Consider central venous cannula for CVP. Also check fluid balance sheet.

Assess BP, ABGs (arterial blood gases), SaO2 (oxygen saturation), JVP, CVP, skin turgor, weight. Attach to cardiac monitoring and take a 12 Lead ECG. Take a CXR (chest X Ray).

Examine for masses PR (per rectum) and PV (per vaginum), and for palpable bladder. On PR examination feel the prostate. If obstruction is suspected, perform an urgent US (ultrasound) and consider bilaterally nephrostomies to relieve obstruction, to take urine for culture and perform anterograde pyelography.

Labs: urea, creatinine, electrolytes (including calcium & phosphate), CBC/FBC (complete/full blood count), ESR, CRP, LFT liver function tests, LDH, coagulation studies including INR, CK, hepatitis serology, protein electrophoresis, blood & urine cultures, autoantibodies: ANAs, c & p ANCAs, anti GBM, ant LKM, complement such as c3 & c4; ASO.

Urgent urine microscopy and cultures. Check urine for white cell casts (infection, interstitial nephritis) and red cell casts (inflammatory glomerular condition).

Indentify & treat hyperkalaemia! (see below)

Treat any precipitating cause such as blood transfusion for hypovolaemia, antibiotics for sepsis, nephrostomy for obstruction etc.

In case of pulmonary edema, pericarditis or cardiac tamponade consider urgent dialysis. If pulmonary edema, but no dieresis is established, consider removing 1 unit of blood, before dialysis!

A. If the patient is dehydrated, give 250 500 ml of saline over 30 min. Use a large bore line in a large vein (central vein access may be risky in volume depletion).

Reassess. If still the patient is dehydrated, repeat fluids. Aim for CVP 5 10 cm.

When fluids are repleted, give fluids 20 ml PLUS the previous hour urine output/h.

B. If there is volume overload, consider urgent dialysis. Consider nitrate infusion, furosemide (Lasix 120 500 mg IV; if oliguric or anuric give 120 250 mg IV and then 5 10 mg/h), or renal dose of dopamine (2 5 mcg/kg/min).

Correct acidosis with sodium bicarbonate 8.4% 1 ml/kg (1 mEq/kg) e.g. 50 ml of 8.4% IV. C. Consider urgent dialysis on persistent hyperkalaemia (K > 6 mmol/L), acidosis (PH<7.2), pulmonary edema without established diuresis, pericarditis and also in high catabolic state. In cardiac tamponade first perform needle decompression!

If sepsis is suspected, take cultures and give antibiotics (avoid nephrotoxic drugs such as gentamycin or sulfamethoxasole tremethoprim SMX TMP). Check first the GFR. Also remove possible sources of sepsis e.g. non essential IV lines.

Avoid nephrotoxic drugs such as gentamicin, amphotericin or NSAIDs.

Check all drugs that have been administered. Is there any drug responsible for the impaired renal function.

Treat also pulmonary edema, pericarditis & cardiac tamponade with dialysis (on tamponade first do percardiocentesis!). If pulmonary edema without established diuresis, consider removing 1 unit of blood before dialysis!

Consider renal biopsy.

In renal failure there is a high catabolic state. Diet should be with high calories (2000 4000 Kcal daily), with adequate high quality protein. In severe cases, nutrition may be given by NG (nasogastric) rout or parenterally.

HYPERKALAEMIA (e.g. on renal failure)

Normal potassium (K) is 3.5 5 mmol/L. Potassium > 6.5 mmol/L needs urgent treatment. Causes: oliguric renal failure, potassium sparing diuretics (e.g. spironolactone, amiloride), rhabdomyolysis, compression syndrome (trauma), metabolic acidosis, excess K administration, Addisons disease (see above), massive blood transfusion, burns, drugs (e.g. ACE inhibitors, suxamethonium), artifact. In artifact hyperkalaemia the patient doesnt look unwell and also ECG is normal. Repeat the Lab test for K! Artifact hyperkalaemia may occur from hemolysis (difficulty on venepunctrure, the patient has the fist clenched), contamination with potassium EDTA anticoagulant in FBC/CBC (full/ complete blood count) bottles (so do FBC/CBC analysis after the urea& electrolytes estimation), delayed analysis (long time to reach the Lab, the K exits the RBCs) and also in thrombocythaemia (K exits the platelets during clotting). ECG: tall tented T waves, may have small or flat P waves and increased PR interval. On severe hyperkalaemia the QRS widens and there untreated leads to VT (ventricular tachycardia)/ VF (ventricular fibrillation). HYPERKALAEMIA ALGORITHM

Monitor ECG. Treat the underlying cause! Review the medications!

In severe hyperkalaemia administer 10 ml calcium gluconate 10% or calcium chloride KCl over 2 min into a large vein with a large cannula (it may cause skin necrosis if extravasated). Calcium protects the heart, but does not affect the K levels!

If not severely hyperglycaemic, administer 10 units rapid acting insulin (e.g. insulin Actrapid) with 50 ml of 50% glucose (dextrose) into a large vein, over 30 min. Check glucose levels to avoid hypoglycemia. You may repeat the above regimen. Insulin moves the K into the cells.

Administer sodium bicarbonate 1 ml/kg (1 mEq/kg) 8.4% IV e.g. 50 mmol (50 ml) of 8.4% solution IV over 5 min.

Administer furosemide (Lasix) 1 mg/kg slowly IV.

Administer nebulized salbutamol 2.5 mg. It also moves the K into the cells. Give polystyrene sulphonate resin (e.g. Calcium Resonium 15g/ 6 8h diluted in water) PO (orally) or (if vomiting) as enema 30 gr, followed by bowel irrigation after 9 h, in order to remove the K from the colon.

Consider dialysis if K is persistently high (> 6 mmol/L).

ACUTE POISONING GENERALLY

Signs and culprit drug OD (overdose)/poison/toxin: Tachycardia or irregular pulse: salbutamol (high doses), TCAs (tricyclic antidepressants), quinine, phenothiazines, anticholinergics. Respiratory depression: barbiturates, phenothiazines, opiates. Coma: usually from barbiturates, benzodiazepines, alcohol, opiates, TCAs (tricyclic antidepressants). Seizures: theophyllines(!), hypoglycaemics, illicit drug abuse, TCAs (tricyclic antidepressants), phenothiazines. Hyperthermia: amphetamines, MAO inhibitors, cocaine, ecstasy, aspirin(!) Hypothermia: barbiturates, phenothiazines. Also exclude hypothyroidism. Dilated pupils: cocaine, amphetamines, quinine, TCAs (tricyclic antidepressants).

Constricted pupils: opiates, organophosphates (insecticides). Also exclude pontine hemorrhage. Hyperglycemia: MAO inhibitors, theophylines, organophosphates. Hypoglycemia: insulin, oral antidiabetic agents, alcohol, salicylates (!) Metabolic acidosis: alcohol (ethanol), methanol, ethylene glycol, paracetamol (acetaminophen), CO (carbon monoxide). Increased plasma osmolality: alcohol (ethanol), methylen alcohol, ethylene glycol. NOTE: plasma osmolality= 2 (K+Na) + urea+ glucose. Normal plasma osmolality is 280 300 mosmol/ kg. Renal failure: salicylates, ethylene glycol, paracetamol (acetaminophen). Visual impairment/ blindness: methanol. ACUTE POISONING ALGORITHM Consider decontamination (skin, GI gastrointestinal tract, eyes etc). Remove cloths. Wash with copious water.

ABCs, establish airway. Consider RSI (rapid sequence intubation) and mechanical ventilation if RR (respiratory rate) < 8/min, or GCS <_ 8. If the patient is unconscious, place him /her semi prone! Keep eye lids closed (to avoid keratitis).

Phone immediately the POISON INFORMATION SERVICE (UK: 0844 892 0111; USA: call 911; International: 112).

Treat shock (raise legs, administer fluids +_ inotropes/ vasopressors place a CVP line especially if elderly or with CHF congestive heart failure)

Assess the patient. History from the patient, relatives, friends, neighbors, EMS crew.

Examination. Dont forget to perform PR (per rectum) & PV (per vaginum) examination in suspected smugglers. Check also pupils (size & reaction to light). Labs: glucose (initially ward finger stick, then official Lab test), UREA, creatinine, electrolytes, CBC/ FBC (complete/ full blood count), LFT (liver function tests), coagulation studies (including INR), paracetamol & salicylate levels, plasma osmolality, urine & serum toxicology including recreational drugs, specific drug levels, anticonvulsunt levels.

ECG, CXR (chest X Ray), ABGs (arterial blood gases) check anion gap!!!

Monitor HR (heart rate), RR (respiratory rate), BP, SaO2 (oxygen saturation), T (temperature), urine output (place Foley), glucose (ward finger stick test & official Lab test). Continue monitoring ECG.

Specific therapy: e.g. specific antidote if indicated, gastric lavage +_ activated charcoal, whole bowel irrigation, chelating agents, dialysis.

Assess the patients intentions to suicide: Planned act? Were there any precautions for not to be found? Left suicide note? Asked for help after the attempt? Realizes the severity of the attempt? Is present intention still to die? Wishes to have been dead? Was the attempt helped by someone? Does the problems that led to the attempt still exist? Is there any psychiatric disorder (depression, mania, schizophrenia etc) or any other medical problem (e.g. dementia, terminal ill) or alcoholism or illicit drug abuse? What are his/her resources (family, friends, work, neighbors)? If needed, consult a psychiatrist. The patient may be needed to be admitted and retained against his/her will, if it is possible that he/she can harm his/her self and/or the others (consult the hospitals legal counselor for it).

PLASMA & URINE TOXICOLOGY

If the patient is unconscious check paracetamol (acetaminophen) & aspirin levels & plasma glucose. Other toxicology tests include digoxin, iron, lithium, methanol, theophylline, recreational illicit drugs, heavy metals, COHb (carboxyhemoglobulin), anticonvulcant levels (check also compliance) etc.

Gastric lavage: used < 60 min after poisoning! Contraindicated if petroleum

products or corrosives (such as acid, alkali, bleach, discalers) have been ingested!!! Exception is paraquat! Dont induce vomiting! Consider airway protection (intubation). Gastric emptying & lavage: if coma or no gag reflex, consider intubation! Monitor SaO2 (oxygen saturation). Have suction on hand! Position the patient on his/her left lateral position. Raise the foot of bed by 20 cm. Pass a lubricated tube 14 mm external diameter via the mouth, asking the patient to swallow. To confirm if the tip of the tube is in the stomach, blow air into the tube and auscultate the stomach to hear the bubbling. Aspirate the gastric contents. Check the PH of the fluids with a litmus paper. Perform gastric lavage with 300 600 ml tepid water at a time. Massage the left hypochondrium. Repeat until clear effluent/ no tablets in the siphoned fluid! Give activated charcoal (see below) in the stomach, unless alcohol, ethylene glycol, iron, Lithium (Li) have been ingested (in that case it is ineffective). When pulling the tube out, occlude its end to prevent aspiration from the remaining fluid in the tube!!

Activated charcoal: it reduces the absorption of many drugs. Given at a

dose of 50 gr in 200 ml water. It doesnt absorb metal salts (such as iron & lithium), alcohol or ethylene glycole. It is contraindicated in petroleum products, corrosives, alcohols, malathion, and clofenotane! It may be given in repeated doses (50 gr/ 4h) for drugs such as dapsone, carbamazepine, theophyllines, paraquat, phenobarbital, theophyllines, quinine. Use lower dose in children: 1 2 g/kg (max 50 gr) in 200 ml water.

Whole bowel irrigation

Give polyethylene glycol solution (Colyte) via a NG (nasogastric) tube 1 2 L/h (400 500 ml in children) until the rectal effluent is clear (in 3 5 hours).

Indication for whole bowel irrigation includes large ingestion of sustained release products, large ingestion of chemicals not absorbed by charcoal (e.g. lithium and iron), foreign bodies or drug filled packers (e.g. smugglers).

SPECIFIC POISONS AND ANTIDOTES BENZODIAZEPINE POISONING

The antidote is flumazenil (for respiratory arrest) 200 g over 15 sec, then 100 g at 60 sec intervals if needed. Usual dose is 300 600 g over 3 6min. Max dose is 1mg (2 mg in ICU). It may provoke fits. It may also cause uncontrolled seizures if used in TCA (tricyclic antidepressants) overdose with seizures.

B BLOCKER POISONING
May cause severe bradycardia and/or hypotension. Give atropine 3 mg IV. If ineffective, give 2 10 mg IV glucagon bolus + D5W (5% dextrose). If still unresponsive, consider pacing or intra aortic pump.

CALCIUM CHANNEL BLOCKERS POISONING

It may cause hypotension, bradycardia, CNS depression, drowsiness, AV (atrioventricular) block and asystole. Combination with blockers increases toxicity! Generally, avoid this combination on treating a patient. Therapy includes activated charcoal, whole bowel irrigation (if sustained release preparation), leg elevation (for hypotension), atropine (0.01 0,03 mg/kg), calcium chloride CaCl2 or calcium gluconate 10 ml of 10% solution (0.1 0.2 ml/kg or 10 20 mg/kg on children) slowly (over 5 10 min). Also give 2 5 mg glucagon bolus. It may be repeated to total dose of 10 mg.

DIGOXIN/ DIGITOXIN POISONING

Symptoms include confusion, yellow green visual halos (!), arrhythmia, nausea & vomiting. Check for hypokalaemia! Treatment: correct hypokalaemia! In severe poisoning give digoxin specific antibodies fragments (Digibind). For unknown dose give 20 vials (800 mg) for adults or children > 20 kg. Dilute in water for injection 4ml/ 38 mg vial and normal

saline. Administer the Digibind IVI over 30 min, via a 0.22 m pore filter. f ingested dose is known give e.g. 10 vials Digibind for 25 ingested tbs (tablets) of 0.25 mg; 20 vials for 50 tablets; 40 vials for 100 tablets. Specifically, to inactivate 1 mg of digoxin or digitoxin we need 60mg of Digoxin Specific antibody fragment. 1 vial contains 40 mg antibody fragment. To estimate the amount of digoxin (in mg) in the body we use the formula concentration in plasma (ng/ml) x 0.0056 x body weight (kg). To estimate the amount of digitoxin (in mg) in the body we use the formula concentration in plasma (ng/ml) x 0.00056 x body weight (kg). For the amount that the patient has ingested we subtract 20% because absorption is not complete.

CN (CYANIDE) POISONING
It may be caused by burning plastics, nitropruside overdose, wild bitter almonds etc. Initially causes anxiety, dizziness, headache and confusion, followed by tachycardia and dyspnea, that give way to bradycardia, seizures, shock, coma, apnea and death. Treatment: give 100% oxygen and perform gastric decontamination. If LOC (level of consciousness) is decreased give sodium nitrite and sodium thiosulfate. Dose is 10 ml sodium nitrate (or 300 mg IV) over 3 min. After 5 min give 50 ml of 25% sodium thiosulfate IV (or 500 mg IV) over 10 min. If symptoms recur, repeat the above scheme at half dose. Alternative is dicobalt edate 300 mg IV over 1 5 min and then 50 ml of 50% dextrose IV over the same line (repeat once if needed). Give it only if certain cyanide poisoning, as it may have severe side effects. Another alternative is hydroxycobalamin (vitamin B12A) 5 gr over 30 min (70 mg/kg) repeated once if needed. After treatment for cyanide overdose, prevent methemoglobinaemia! Goal is 25 30% methemoglobin. For mild poisoning give 100% oxygen and amyl nitrate: break 1 2 aspirols (administer 0.3 0.6 ml dose) under the patients nose or via the Ampu mask (mask for bag mask ventilation).

CO (CARBON MONOXIDE) POISONING

Skin is pink (cherry red!) or pale, despite hypoxaemia. Symptoms are headache (!), nausea, vomiting, tachycardia, tachypnea; and if COHb (carboxyhaemoglobulin)> 50%: fits, coma, arrest. SaO2 (oxygen saturation) is unreliable! Confirm diagnosis with heparinized blood sample (COHb > 10%). Treatment: give 100% oxygen. Severe CO poisoning may cause cerebral oedema! Treat it with IV mannitol. Consider hyperbaric oxygen if the patient is or was unconscious, has CNS signs, is pregnant, and if COHb is > 20% or it is not decreasing. Note: COHb levels do not correlate well with the severity of poisoning and may be influenced from smoking cigarettes or living in a polluted city. Use better a nomogram.

OPIATE POISONING
Suspect if pin point pupils and also in respiratory depression and pulmonary edema (especially on young). Opioids may be contained in many analgesics (e.g. codeine), drugs for cough and for diarrhea (loperamide)! Antidote to opiates is naloxone 0.4 2 mg IV, repeated every 2 min until breathing is sufficient. It has a short life, so may be needed to be given often, or IM. Max dose is 10 mg. If withdrawal symptoms (with diarrhea and abdominal cramps) occur, treat with diphenoxylate & atropine (Lomotil). High dose abuse may need methadone to counteract withdrawal symptoms. Consult an expert. For agitation consider aloperidol 2 mg IM. Give up to 10 mg IM (max daily dose is 18 mg). Monitor pulse, BP, temperature (it may cause hyperthermia!) and glucose.

ORAL ANTICOAGULANTS (such as warfarin) POISONING

May cause echymosis, hematuria, hematemesis, melena, epistaxis, hemoptysis, uterine bleeding. Coagulation defects may occur delayed 2 3 days after ingestion. Treatment includes GI (gastrointestinal) decontamination. In severe bleeding give fluids & vitamin K, 5 10 mg slowly IV. Also treat with prothrombin complex concentrate 50 units / kg IV, or if unavailable give FFP (fresh frozen plasma) 15 ml/kg IVI. Warfarin if necessary may be started again after 2 3 days.

HEPARIN OVERDOSE
For heparin overdose with bleeding, antidote is protamine sulfate. 1mg of protamine sulfate inactivates about 100 units of heparin, if given 15 min after the overdose. The max dose of protamine is 50 mg over 10min.

IRON POISONING
Give desferrioxamine 15 mg/kg/h IVI (max 80 mg/kg/day). Perform gastric lavage if ingestion < 1h. Also, consider whole bowel irrigation.

HEAVY METAL POISONING

Dimercaprol (BAL) is antidote for poisoning from mercury (Hg), arsenic (As), bismuthium (Bi), gold (Au), antimonium and Thallium (Th). It is contraindicated in liver failure and may cause haemolysis in G6PD deficiency. Dose is 3 4 mg/kg IM every 4 h the first 2 days; followed by 3 mg/kg every 6 h for 2 days; followed by 3 mg/kg every 12 h for 1 week. Give max dose for severe poisoning. Ethylenededeiamine Disodium Ethylenediamine Tetra Acetate is antidote for lead (Pb), Zinc (Zn), iron, magnesium, beryllium and copper (Cu) poisoning, and also may be used in hypercalcaemia. Usually this antidote is given for lead. Dose is 15 25 mg/kg IV in 250ml of NS (normal saline) or D5W (5% dextrose) infusion over 1 2 h, 2 times daily (max daily dose is 40 50 mg/kg) for 5 days. This scheme may be repeated after 2 days from the 1st scheme. The antidote may be given IM at dose of 50 mg/kg in 2 doses (mix every dose with equal volume of procain 1 %). Note: lead poisoning may be suspected from a blue line at the gum tooth margin! Lead may also cause constipation, pappenheimer bodies and cabot ring in peripheral blood film and also neurological problems, abdominal pain (!), headache, irritability, joint pain, fatigue, anemia (!), motor neuropathy (!), memory deficits and rarely encephalopathy. In children it can cause impaired cognition, abdominal pain, lethargy, anorexia, ataxia, anemia, slurred speech and in severe cases may cause convulsions, coma, cerebral edema and renal failure. Usually chronic exposure causes the above symptoms. Treatment is with oral succimer or IM edentate calcium disodium.

CCl4 (CARBON TETRACHLORIDE) POISONING

It is a solvent used in industry and also on correction fluids for typos. It causes nausea & vomiting, abdominal pain, diarrhea, seizures, coma, renal and liver failure (tender enlarged liver with jaundice). N acetylcysteine may help.

PARAQUAT POISONING
It is contained in weed killers. It causes nausea & vomiting, painful oral ulcers, alveolitis and renal failure. Perform urine test for diagnosis. Give activated charcoal 100 gr followed by laxative. Then give 50 gr/ 3 4 h activated charcoal. Avoid using early oxygen because it promotes lung damage! Antidote is bentonite with PO (oral) dose 250 500 ml oral solution 7% every 2 4 h for 48 h; plus a saline laxative.

PHENOTHIAZINE POISONING
These are neuroleptics (such as chlorpromazine) or drugs for nausea (stomach prokinetics). They may cause dystonia (torticollis or retrocollis, glossopharyngeal dystonia, opisthotonus). Treat with procyclidine 5 10 mg IM or IV. Treat shock by raising the legs, fluids +_ dopamine. Monitor ECG. In arrhythmias, avoid lidocaine! For prolonged fits give lorazepam IV.

Neuroleptic malignant syndrome

is a reaction caused by neuroleptics and is characterized by labile BP, tachycardia, sweating, urinary incontinence, mutism, hyperthermia, confusion, coma. Labs: increased WCCs (WBCs) and CK (CPK). Treat with cooling. Consider dantrolene 1 mg/kg IV. Max dose of dantrolene is 10 mg/kg IV.

MALIGNANT HYPERTHERMIA FROM HALOTHANE AND SIMILAR ANAESTHETICS

Treated also with dantrolen 1 mg/kg (max 10 mg/kg) IV. Also treated with procaine hydrochloride.

EXTRAPYRAMIDAL SYMPTOMS FROM DRUGS

Give biperiden 2.5 5 mg IM or slowly IV. It may be repeated every 30 min, max 4 times (i.e. max dose 20 mg).

ORGANOPHOSPHATES POISONING
These inactivate cholinesterase, increasing Ach (acetylcholine). The SLUD response consists of Salivation, Lacrimation, Urination, and Diarrhea. Also

symptoms/ signs are sweating, small pupils (miosis), muscle fasciculation, bronchorrea, emesis, seizures, respiratory distress, bradycardia and coma. Management: wear gloves, remove soiled clothes and wash skin /eyes. Take blood to check CBC/ FBC (complete/ full blood count) and serum cholinesterase activity. Give atropine 2 mg IV every 10 min until full atropinization (with dry skin, pulse > 70 and dilated pupils). You may need to treat with atropine for 3 days. You may also give pralidoxime 30 mg/ kg slowly (min over 2 min) IV, diluted with >_ 10 ml water for injection. Repeat, if needed, every 30min. Max dose is 12 gr in 24 h. Diazepam 5 10 mg slowly (over 2 min) IV is another drug that helps, even if no fits.

SEVERE HYPERMAGNESAEMIA, SEVERE HYPERKALAEMIA, SEVERE HYPOCALCAEMIA (WITH TETANY), CALCIUM CHANNEL BLOCKER POISONING & SODIUM POLYPHOSPHATE (DETERGENT) POISONING
For these the antidote is calcium gluconate or calcium chloride CaCl2 10%. The adult dose is 10 ml (500 1000 mg) VERY slowly IV (over 10min). The children dose is 10 20 mg/kg (0.1 0.2 ml/kg) calcium chloride 10% VERY slowly IV/IO (over 10 min). Dont give it with NaHCO3 (sodium bicarbonate).

ETHYLENE GLYCOL (ANTIFREEZER FOR CARS) & METHANOL (CONTAMINATED ALCOHOL BEVERAGES) POISONING
Check anion gap! Give 4 methylpyrazole (10 20 mg/kg day orally) or if unavailable give ethanol infusion (however it may cause CNS depression). Give ethanol IV as 10% solution in D5W (5% dextrose) or NS (normal saline) (take 50 ml from a 500 ml bag NS or D5W and replace with 50 ml ethanol). Give a loading dose of 10 ml/kg followed by infusion of 0.15 ml/kg/h for non drinkers or 0.3 ml/kg/h for regular drinkers. Titrate to plasma ethanol levels 1 1.5 gr/L (21.7 32.6 mmol/L). Continue the infusion for at least 48 h. Correct metabolic acidosis with bicarbonate (for methanol). Severe acidosis, renal failure, visual impairment (for methanol; it may cause blindness) or severe poisoning needs dialysis (haemodialysis, for ethylene glycol prefer peritoneal dialysis).

ECSTASY POISONING
Used at rave parties. It is a semi synthetic hallucinogenic drug MDMA (3, 4 methylenedioxymethamphetamine). It causes nausea, muscle pain, blurred vision, amnesia, fever hyperthermia, confusion, ataxia, tachyarrhythmias, hypertension or hypotension, water intoxication (with hyponatraemia), hyperkalaemia, rhabdomyolysis, ARF (acute renal failure), liver failure, cardiovascular collapse, fits, DIC, ARDS. Labs: CBC/ FBC (complete/full blood count), LFT (liver function tests), UREA, creatinine, electrolytes, CK, coagulation studies. ABGs (arterial blood gases), SaO2 (oxygen saturation). Treatment: give activated charcoal. Monitor HR (heart rate), BP, ECG and temperature, urine output (Foley). For metabolic acidosis give bicarbonate. For anxiety give diazepam 0.1 0.3 mg/kg PO or you may give it IV. For narrow complex tachycardia give metoprolol 5 10 mg IV. For hypertension give nifedipine 5 10 mg PO or phentolamine 2 5 mg IV. Hyperthermia is akin to serotonin syndrome. For hyperthermia, if rectal temperature is > 39 degrees C, attempt rapid cooling and consider dantrolene 1 mg/kg IV which it may be repeated max dose is 10 mg/kg. Also propranolol, muscle relaxants, intubation & mechanical ventilation may be needed (avoid succinycholine as neuromuscular blocker on RSI rapid sequence intubation if suspected rhabdomyolysis with hyperkalaemia). For rhabdomyolysis with myoglobinuria, treat with IV fluids (place a CVP line if oliguric), mannitol IV & urine alkalization with sodium bicarbonate (see aspirin poisoning below).

COCAINE POISONING
It may cause severe hypertension, hyperthermia, myocardial ischemia (ECG may be normal!), aortic dissection, intracranial hemorrhage (!), psychosis, seizures, tachycardia, dysrhythmias. On cocaine OD (overdose) maintain airway, perform intubation & mechanical ventilation if needed; give activated charcoal if cocaine was ingested within 1 h; perform whole bowel irrigation on body packers (e.g. smugglers); monitor ECG; give diazepam for convulsions & agitation; give NTG (nitroglycerine), aspirin & diazepam for chest pain. Exclude MI (myocardial infarction). The patient may have normal ECG with cardiac ischemia! Avoid blockers! For hyperthermia with T (temperature) > 40

degrees C consider cooling (e.g. fanning), diazepam & dantrolene 1 mg/kg (it may be repeated, max dose is 10 mg/kg). Perform CT if new onset of seizures. Exclude intracranial hemorrhage. For rhabdomyolysis with myoglobinuria, treat with IV fluids (place a CVP line if oliguric), mannitol IV & urine alkalization with sodium bicarbonate (see aspirin poisoning below).

GAMMA HYDROXYBUTYRATE
Gamma hydroxybutyrate is a CNS depressant and can cause coma. It is called date rape drug and it is used often on rave parties. Treatment is supportive and includes endotracheal intubation if airway is compromised.

PCP (PHENCYCLIDINE) POISONING

PCP is an illicit drug of abuse that has rapid onset of action (smoked or snorted). The drug is manufactured from marijuana, amphetamines and hallucinogens. So it is sympathomimetic and hallucinogenic. Symptoms may fluctuate from severe agitation and paranoid/violent behaviour to stupor. Symptoms also include vertical & horizontal nystagmus (!), agitation, stupor, coma, hyperthermia, rhabdomyolysis, myoglobinuria (which may cause ARF acute renal failure), violent behavior, large or small pupils, hypertension, tachycardia, and muscle rigidity. Treatment includes GI (gastrointestinal) decontamination. For agitation or violent behavior give diazepam 2 5 mg IV over 2 min. If no response, repeat the dose every 10 min, until sedation or 20 mg dose have been given as total dose or if respiratory depression occurs. For rhabdomyolysis with myoglobinuria, treat with IV fluids (place a CVP line if oliguric), mannitol IV & urine alkalization with sodium bicarbonate (see aspirin poisoning below).

TCA (TRICYCLIC ANTIDEPRESSANT) OVERDOSE

Toxic dose is 5 mg/kg. Overdose causes mydriasis, agitation, seizures, coma, QRS widening, hypotension, AV (atrioventricular) block, VT (ventricular tachycardia) and Torsades! Treatment includes active charcoal (within 1 h from ingestion), ECG monitoring, diazepam or Phenobarbital for seizures and sodium bicarbonate 50 100 mEq (1 2 mEq/Kg) 8.4% IV bolus. For dysrrhytrhmias try lidocaine 1 2 mg/kg. For refractory hypotension try adrenaline or noradrenalin infusion (consult an expert from ICU). Generally, adrenalin has to be given in lower dose on patients taking

TCAs. For rhabdomyolysis with myoglobinuria, treat with IV fluids (place a CVP line if oliguric), mannitol IV & urine alkalization with sodium bicarbonate (see aspirin poisoning below). On TCA OD (overdose) avoid propranolol & physostigmine! Also administration of flumazenil (antidote to benzodiazepine overdose) may also cause uncontrolled seizures if used in TCA (tricyclic antidepressants) overdose with seizures.

REVERSAL OF NON NEUROMUSCULAR BLOCKERS PANCURONIUM, ROCURONIUM)

DEPOLARIZING (VECUROINIUM,

Give atropine 1.2 1.5 mg and next give neostigmine 2 3 mg slowly IV. Repeat after 8 12 min neostigmine 1 2 mg slowly IV. max dose is 4 mg. Alternative to neostigmine is pyridostigmine. Give 0.016 0.02 mg/kg atropine plus 0.1 0.16 mg/kg pyridostigmine.

ATROPINE & SIMILAR ALKALOIDS OVERDOSE

Give physostigmine salicylate 1 2 mg IM or slowly IV. For children give 0.5 mg. If recurrence, repeat until total dose of 4 6 mg for adults and 2 mg for children.

SALICYLATE POISONING
150 mg/kg cause mild toxicity, 250 mg/kg cause moderate toxicity and 500 mg/kg cause severe toxicity. Signs & symptoms include nausea, vomiting, dehydration, tinnitus (!), hyperventilation, vertigo, sweating. Severe poisoning causes nausea, vomiting, heart block, hypoglycemia or hyperglycemia, pulmonary edema (!), hyperthermia (!), hypotension, lethargy, coma. Patients initially present with respiratory alkalosis (from stimulation of the respiratory center) and then develops metabolic acidosis. Labs: paracetamol (acetaminophen) & salicylates levels, glucose, urea, creatinine, electrolytes, LFT lever function tests, bicarbonates, CBC/ FBC (complete/ full blood count), coagulation studies (including INR). Repeat salicylate levels after 2 h, if toxic dose has been taken.

ABGs (arterial blood gases), SaO2 (oxygen saturation). Monitor HR (heart rate), BP, urine output (Foley) & blood glucose. Monitor urine PH. Treatment: give fluids for dehydration, perform gastric lavage if < 1 h ingestion, give activated charcoal (you may repeat it). Beware of hypoglycemia. Correct metabolic acidosis with 1.26% sodium bicarbonate HCO3. If plasma salicylates are > 500 mg/L (3.6 mmol/L) consider alkalization of the urine with e.g. 1.5 L of 1.26 % HCO3 with 40mmol KCl IV over 3 h. Aim for urine PH 7.5 8.5. Beware hypokalaemia from treatment! Dialysis may be needed if salicylate level is > 700 mg/L with renal or heart failure, seizures, severe acidosis or persistent increased salicylate level. Monitor ECG.

PARACETAMOL (ACETAMINOPHEN) POISONING

150 mg/kg (75 mg/kg if malnourished) or 12 g in adults may be fatal. Treat promptly. Signs & symptoms: initially none, or may have vomiting +_ right upper quadrant pain. Later: jaundice, hepatic encephalopathy +_ renal failure. Labs: paracetamol (acetaminophen) levels 4 h post ingestion. Also check glucose, urea, creatinine, electrolytes, LFT lever function tests, bicarbonates CO3, CBC/ FBC (complete/ full blood count), coagulation studies (including INR). ABGs (arterial blood gases), SaO2 (oxygen saturation). Monitor HR (heart rate), BP, urine output (Foley) & blood glucose. Treatment: gastric lavage if > 12 g were ingested (> 150 mg/kg) and < 1h of ingestion. Give activated charcoal if < 1h since ingestion. Check the plasma concentration of paracetamol vs time graph. Patients with plasma paracetamol concentration above the NORMAL TREATMENT LINE should be treated with N acetylcysteine IV or if the overdose was taken within 10 12 h with methionine PO (orally). However, patients taking enzyme inducing drugs (e.g. carbamazepine, phenobarbitale, phenytoin, rifampicin), or with pre existing liver disease, alcoholics, or malnourished (e.g. from anorexia, alcoholism or HIV +), or are HIV + (decreased hepatic glutathione) and patients with pre existed liver disease

should be treated if their plasma paracetamol concentration are above the HIGH RISK TREATMENT LINE. The graph may be misleading if long acting paracetamol has been ingested or if HIV positive (decreased hepatic glutathione), or on pre-existing liver disease or induction of liver enzymes from drugs. Beware hypoglycemia! Test hourly (with ward finger prick test). Also test INR every 12 h. If <8 h since overdose and plasma paracetamol is above the treatment line graph, start N acetylcystein. If > 8 h since overdose and if there is suspicion of severe overdose (> 7.5 g) start N acetylcystein and stop it if levels are below treatment line and INR/ ALT (sGPT) are normal. N acetylcystein is given IVI: 150 mg/kg in 200 ml of D5W 5% dextrose over 15 min. Then give 50 mg/kg in 500 ml of D5W 5% dextrose over 4h. Then give 100 mg/kg over 16 h, in 1 L of D5W 5% dextrose. Rash is common side effect. Treat with chlorphenamine and observe. Stop infusion only if anaphylactoid reaction (<_ 10%) with shock, vomiting and wheezing). Alternative to N- acetylcysteine is methionine 2.5 g/ 4h PO (oraly) for 16 h (total 10 g), but absorption is unreliable if vomiting or if concurrent activated charcoal has been administered. If ingestion time is unknown, or staggered or presentation is > 15 h from ingestion, you can still give N acetylcysteine. Beware hypoglycemia! The next day do Labs (INR, LFTs liver function tests, urea, creatinine and electrolytes). If INR is increasing, continue N acetylcysteine until INR < 1.4. If the deterioration continues, consult a liver unit. Transfer to a liver unit if encephalopathy or increased ICP intracranial pressure (signs of CNS edema include sustained BP> 160/90, or brief rises, systolic BP > 200 mmHg, bradycardia, decerebrate posture (extensor posture), poor pupil response, extensor spasm monitor ICP), INR > 2 at < 48 h or > 3.5 at < 72 h (measure INR every 12 h, peak elevation: 72 96 h, Liver Function Tests are not good markers for liver damage; if INR is normal at 48h the patient may be

discharged home), renal damage (creatinine > 200 mol/L) (monitor urine output and daily urea, creatinine and electrolytes; do hemodialysis if creatinine > 400 mole/L), blood PH <7.3, Systolic BP < 80 mmHg.

SNAKE ENVENOMING
May cause anaphylaxis, hypotension, diarrhea & vomiting, swelling (spreading proximally within 4 h of bite), bleeding gums, bleeding venepuncture sites, ptosis, rhabdomyolysis, trismus, pulmonary edema. Labs: increased WCC (WBCs), clotting abnormalities, decreased platelets, urine RBCs, increased CK, hypoxemia. Do ECG, connect to monitor and also check urea & creatinine and electrolytes. Management: avoid active movement of affected limb (immobilize with splints or slings)! Avoid incisions or tourniquets! If IgG antivenom is indicated, give e.g. 10 ml of European Viper antiserum over 15 min IV for adults and children. Have resuscitation drugs such as adrenaline to hand in case of anaphylaxis. Monitor ECG.

HYPOTHERMIA
Use a low reading thermometer or an IR (infrared) ear thermometer. It is defined as core (rectal) T (temperature) < 35 degrees C. Elderly patients may not complaint or may not feel cold (e.g. from autonomy neuropathy), neither may have tried to warm up. Causes: impaired homeostatic mechanism (e.g. elderly), impaired thermoregulation (e.g. pneumonia, MI myocardial infarction, heart failure), low room temperature (e.g. poverty), heat loss (e.g. psoriasis), reduced metabolism (hypothyroidism, hypopituitarism, pituitary apoplexy, DM diabetes mellitus, immobility), autonomy neuropathy (DM, Parkinsons), cold awareness (dementia, confusion), exposure to cold (falls, especially at night), drugs (tranquillizers, diuretics, antidepressants), alcohol. Signs: For T (temperature) > 32 but < 35: there may be pallor +_ apathy. For Temperature < 32 degrees C, the sequence is hypotension, coma, bradycardia, AF (atrial fibrillation), VT (ventricular tachycardia), VF (ventricular fibrillation).

Investigations: urea, creatinine, electrolytes, amylase (pancreatitis is a complication), glucose, TFTs (thyroid function tests), CBC/FBC (complete/ full blood count), blood cultures. ECG (may show J waves!). ABGs (arterial blood gases).

HYPOTHERMIA ALGORITHM

ABCs. Intubate and ventilate if coma or respiratory insufficiency.

Warm (40 degrees C) IVI fluids. Correct electrolyte disturbances. Dont give RL (Ringers Lactated) fluids on hypothermia!

Cardiac monitoring. Beware AF atrial fibrillation and VT ventricular tachycardia during rewarming.

Place a Foley to monitor urine output.

Slowly rewarming! Beware that fast reheating may cause peripheral vasodilation, shock and death! Aim for rise of temperature of 0.5 degrees C per hour. The first signs of rapid rewarming is falling BP. So avoid rapid rewarming. On an old conscious patient nurse in a warm room and offer hot drinks (not alcohol!). Thermal blankets may cause rapid warming in the elderly. However, for sudden hypothermia with temperature < 30 degrees C from immersion accompanied by cardiac arrest, the patient needs fast rewarming with pleural warm lavage (via chest tube), warm IV fluids, warm fluids thru Foley, peritoneal warm lavage, hemodialysis and cardiopulmonary bypass (dont give heparin on trauma). One way of rapid core rewarming is thoracic cavity lavage with 2 thoracostomy tubes and infusion of fluids warmed to 41 C0 (105.8 F0 ) thru one tube and drainage thru the other one.

On arrest perform only 1 defibrillation and withhold drugs if temperature < 30 degrees C! Also dont pronounce a patient dead, unless the patient is > 33

degrees C. Rewarm and re-examine. Erica Nordy eventually survived 2 hours after cardiac arrest with core temperature 16 degrees C.

Monitor pulse, RR respiratory rate, BP, core (rectal) temperature every 30 min.

Complications: dysrhythmias, pneumonia, pancreatitis, acute renal failure, DIC, coma

Consider antibiotics for pneumonia prevention, especially in pts > 65 years old with temperature < 32 degrees C.

BURNS
Resuscitate and transfer to burn center all major burns (> 25% partial thickness in adults, > 20% in children). Refer also full thickness burns > 5%, partial thickness burns > 10% (> 5% in children and elderly), burns in special sites (genitals, hands, face etc), chemical burns, electrical burns and burns with inhalational injury. Burn size estimation: it may be difficult. For the estimation ignore erythema! A partial thickness burn is painful, red and blistered. A full thickness burn is grey/ white & insensate/ painless! Burns can evolve, especially after 48 h. The rule of nines (% BSA body surface area) for people >_ 10 years old: arm 9%, front of trunk 18%, head & neck 9%, leg 18%, back of trunk 18%, perineum 1%. For children from birth to 1 years old head & neck surface is 18% and each leg is 14%. For each year after, the head loses 1% and each leg gains 0.5%, so adult proportions are reached by 10 years old. ABCs: Airway: beware upper airway obstruction after inhalation injury from hot gases. Suspect it if history of fire in an enclosed space, soot in oral/ nasal cavity, singed nasal hair, hoarse voice. Consider early intubation!! Also consider flexible laryngo/ bronchoscopy. Obstruction can develop in the first 24h! Call early an anesthetist. For smoke inhalation consider repeated bronchoscopic lavage.

Breathing: decompress with escharotomy any constricting circumferential burns that impair thorax expansion! Give 100% oxygen. Suspect CO (carbon monoxide) and CN (cyanide) poisoning (see above). Circulation: partial thickness burns > 15% in adults and > 10% in children require IV fluids. Place 2 large bore (14 or 16G) IV lines (if it cant be avoided, you may still place them on burned skin) or use IO rout (e.g. in babies). For fluid resuscitation use the Parkland formula: 4 x weight (kg) x % burn as ml of Ringers Lactated given in 24 h (give the half dose in the first 8 hour from the time of burn not from the time of presentation; give the rest fluid the rest 16 h). You can use also the Muir & Barclay formula: [weight (kg) x % burn] /2 as ml of colloids per 4h, 4h, 4h, 6h, 6h and 12 h. Replace the fluids from the time of burn, not the time of presentation in hospital. Adjust fluids according to clinical response and urine output. Place a Foley. Aim for urine output 0.5 ml/kg/h (1 ml/kg/h on children; 50% more in electrical burns and inhalation injury). Avoid overhydration that may cause pulmonary edema or abdominal or limb compartment syndrome! Monitor pulse, BP, urine output and temperature (core & surface). Dont apply cold water to extensive burns for long time. Beware that circumferential full thickness burns of the limbs may cause compartment syndrome, especially after fluid resuscitation! In that case decompress with escharotomy and fasciotomy. Dont burst any blisters. Dont apply any cream. Use on burns simple saline gauze or Vaseline gauze. Cling film is useful temporally measure and relieves pain. Use morphine titrated for good analgesia. Dont forget tetanus immunization. Definite dressings in a burn unit include biological skin, synthetic skin, silver sulfadiazine cream alone or in combination with cerium nitrate. Major full thickness burns benefit from early tangential excision and split skin grafts, because burns cause SIRS and sepsis!

APPENDIX(I): ARTERIAL BLOOD GASES (ABGs) ACID BASE BALANCE AT A GLANCE

Normal values are: PH is 7.35 7.45, PaCO2 is 35 45 mmHg, HCO3 (bicarbonates) are 22 26 mEq/L, SaO2 (oxygen saturation) is 96 100%, PaO2 is 85 100 mmHg and BE (base) excess is 2 to +2 mmol/L.

In venous blood normal values are PH 7.31 7.41, PaCO2 41 51 mmHg, HCO3 (bicarbonates) is 22 29 mEq/L, SaO2 is 60 85%, PaO2 is 34 40 mmHg and BE is 0 to + 4 mmol/L. So, PH of venous blood is usually 0,04 lower than the arterial blood PH. Also PCO2 is 6 mmHg higher and bicarbonate is 2 meq/L higher by using venous blood. ANION GAP is calculated by the difference between (Na + K) cations and anions (Cl + HCO3). So, anion gap is ([Na] + [K]) ([Cl] + [HCO3]). Normally it is 10 18 mmol/L. It is a measure of fixed or organic acids such as phosphate, ketones and lactate. Increased osmolar gap may occur in DKA (diabetic ketoacidosis), ethylene glycole or methanol or ethanol or isopropanol poisoning. Osmolar gap Osm = measured Osm Calculated Osm. Plasma osmolality= 2 [Na +K] + [urea] + [glucose] mmol/L. Normal is 280 300mosmol/kg. 1. Look at the PH. PH< 7.35 is acidosis and PH> 7.45 is alkalosis. 2. Look if the PaCO2 is increased or decreased? Is this change in keeping with the PH (e.g. an acidosis with raised PaCO2)? If yes, its a respiratory problem (respiratory acidosis). If not, or if there is opposite, then the change is compensatory. 3. Look if the HCO3 (bicarbonates) are increased or decreased? Is this change in keeping with the PH (e.g. an acidosis with decreased HCO3)? If yes, its a metabolic problem (metabolic acidosis). If not, or if there is opposite, then the change is compensatory.

Henderson Hasselbuch equation PH=6.1 + log[HCO3]/ PaCO2 x 0.03. N=normal, decr= decreased, incr= increased PH......PaCO2HCO3..ACID BASE BALANCE Decreased.Increased.NormalRespiratory acidosis IncreasedDecreased...NormalRespiratory alkalosis DecreasedNormalDecreased/decr BE...metabolic acidosis Increased..NormalIncreased/incr.BE...metabolic alkalosis N/DecreasedIncreasedIncreased..respiratory acidosis ..with metabolic compensation N/Increased..IncreasedIncreased...metabolic alkalosis

with respiratory compensation Decreased.IncreasedDecreased..mixed metabolic & ..................respiratory acidosis IncreasedDecreased..Increasedmixed metabolic& ...respiratory alkalosis On metabolic acidosis check the potassium (K) for hyperkalaemia. CAUSES OF ACID BASE ABNORMALITY a. Causes of metabolic acidosis (PH decreased, HCO3 decreased / decreased BE) & INCREASED anion gap: it is due to an increased production of fixed or organic acids. HCO3 decreases, and unmeasured anions associated with the acids are increased. 1. Lactic acid: shock, infection, hypoxia, hypoxemia. 2. Urate: renal failure. 3. Ketones: DKA (diabetic ketoacidosis), alcohol, starvation. 4. Biguanides (such as metformin, for DM). 5. Exogenous toxins metabolized to lactate (cyanide CN, carbon monoxide CO, ibuprofen, strychnine, toluene, iron Fe, INH isoniazide). 6. Exogenous toxins metabolized to acids (aspirin - salicylates, methanol, ethanol, ethylene glucol, paraldeyde and rarely with isopropanol). 7. Severe hypotension. 8. Seizures.

b.

Causes of metabolic acidosis (PH decreased, HCO3 decreased / decreased BE) & normal anion gap: it is due to loss of HCO3 (bicarbonate) or ingestion of H+ ions. 1. Renal tubular acidosis. 2. Drugs such as acetazolamide (diuretic, used for glaucoma). 3. Addisons disease. 4. Pancreatic fistula. 5. Ingestion of ammonium chloride.

c. Causes of metabolic alkalosis (increased PH, increased HCO3): 1. Vomiting 2. Burns. 3. Potassium (K) depletion (diuretics).

4. Ingestion of base. d. Causes of respiratory acidosis (decreased PH, Increased PaCO2): 1. Respiratory failure (lung disease, neuromuscular disease, physical cause). Check if PaO2 is low. If yes, is oxygen therapy required? In case of COPD use oxygen with care. Some patients rely on their hypoxic drive to breathe and high oxygen concentration (>30%) on them may lead to reduced respiratory rate, hypercapnia and decrease the level of consciousness. So, if ABG (arterial blood gases) show carbon dioxide CO2 retention start with 24 28% oxygen and reassess after 30 min. Monitor the patient and check if raising of PaO2 causes hypercapnia. In patients without evidence of CO2 retention start oxygen at 28 40% concentration and monitor ABGs.

e. Causes of respiratory alkalosis (increased PH, decreased PaCO2): 1. CNS problems (stroke, meningitis, subarachnoid hemorrhage). 2. Altitude. 3. Anxiety/ panic attack. 4. Pyrexia. 5. Pregnancy. 6. Drugs such as salicylates (initial phase of poisoning; then the patients develop metabolic acidosis). 7. Pulmonary Embolus (hyperventilation)!

APPENDIX (II): COMMON CAUSES OF SHOCK

What to rule out on a shock:
a)Traumatic blood loss. Check for bleeding in chest. Perform CXR, FAST. Check for pelvic or long bone fracture. If so, do immobilization and consider PAST antishock trousers.

b)Non traumatic blood loss. Rule out abdominal aortic aneurysm (e.g. palsatile abdominal mass). Do USS/ FAST. Is there hematemesis or melena? Is fluid on Levine (NG tube) bloody? Perform endoscopy if high suspected GI bleeding. c)Dysrhythmia. Perform an ECG. d)Tension pneumothorax. Are there any decreased unilateral breath sounds, tracheal deviation (away from the pneumothorax), hyper-resonant hemithorax on percussion or distended neck veins (if not hypotensive with blood loss)? Dont wait CXR. Perform needle decompression and next insert a chest tube. e)Cardiac Tamponade.Are there distended JVD (jugular veins distension), muffled heart sounds, low ECG voltage and electrical alterance, or pulsus paradoxus? Perform FAST/ USS (ultrasound). f)Massive pulmonary embolism. Is there hypoxemia with right ventricular strain on ECG? g)Anaphylaxis. Is there angioedema, laryngeal edema with stridor, wheezing, hives on skin? h)Spinal Cord Injury Neurogenic shock with decreased HR. Check for a motor/ sensory level of paralysis and anesthesia. Take cervical spine protections. Check rectal tone and check for blood. i)Warm skin? If so, consider sepsis, neurogenic shock, anaphylactic shock, medication overdose (e.g. or Ca blockers). j)Also rule out Poisons/ medication overdose or SEs (Side Effects)/ illicit drug abuse, Sepsis and Adrenal Insufficiency.

APPENDIX (III): GCS Eye Opening (E4)

4 0 1 years old: spontaneously; > 1 years old: spontaneously 3 0 1 years old: to shout; > 1 years old: to verbal command (not necessarily to open your eyes) 2 all ages: to pain 1 all ages: no response

Response to pain is checked by pressing the patients nails bed with a pen. If not response, try supraorbital pressure and sternal pressure.

Best Verbal Response (V5)

5 0 2 years old: appropriate cry, smiles; 2 5 years old: appropriate words and phrases; > 5 years old: oriented, converses 4 0 2 years old: cries; 2 5years old: inappropriate words; > 5 years old: confused 3 0 2 years old: inappropriate cry; 2 5 years old: cries, screams; > 5 years old: inappropriate words 2 0 2 years old: grunts; 2 5 years old: grunts, sounds; > 5 years old: incomprehensible e.g. moans 1 all ages: no response

Best Motor Response (M6)

6 0 1 years old: moves spontaneously and adequately; > 1 years old: obeys command 5 all ages: localizes pain 4 all ages: flexion withdrawal 3 all ages: decorticate (stereotypical flexion) 2 all ages: decerebrate (stereotypical extension) 1 all ages: no response Motor response may be e.g. raise your hand. It is the better response of any limb. Decorticate posture is characterized by flexion of upper extremities. Decerebrate posture is characterized by internal rotation of shoulder & arm pronation and limb extension.

Score: min 3, max 15. If GCS<_8 the patient needs intubation (RSI rapid sequence intubation if GCS > 3). GCS <_8 severe injury, GCS 9 12 moderate injury, GCS 1315 minor injury.