Emergency medicine in surgery

 

Management of addisionian crisis

• hydrocortisone 100mg IM or IV

• • 1-liter normal saline infused over 30-60 min or with dextrose if hypoglycaemic

• • Continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol

• exerts weak mineralocorticoid action

• • Oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days

Management of anaphylactic shock

• Remove allergen

• • ABCD

• • Drugs:

• o Adrenaline 1:1000 0.5ml INTRAMUSCULARLY (not IV). Repeat after 5 min if no response.

• o Then Chlorpheniramine 10mg IV

• o Then Hydrocortisone 100-200mg IV

Management of Acute coronary syndrome

NICE produced guidelines in 2010 on the management of unstable angina and non-ST elevation myocardial infarction

(NSTEMI). They advocate managing patients based on the early risk assessment using a recognized scoring system such

as GRACE (Global Registry of Acute Cardiac Events) to calculate predicted 6-month mortality.

All patients should receive

• Aspirin 300mg

• Nitrates or morphine to relieve chest pain if required

Whilst, commonly, non-hypoxic patients receive oxygen therapy there is little evidence to support this approach.

The 2008 British Thoracic Society oxygen therapy guidelines advise not giving oxygen unless the patient is hypoxic.

Antithrombin treatment. Low molecular weight heparin should be offered to patients who are not at a high risk of

bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a

patient’s creatinine is > 265 mmol/l unfractionated heparin should be given.

Clopidogrel 300mg should be given to patients with a predicted 6-month mortality of more than 1.5% of patients who

may undergo percutaneous coronary intervention within 24 hours of admission to the hospital. Clopidogrel should be

continued for 12 months.

Intravenous glycoprotein IIb/IIIa receptor antagonists(eptifibatide or tirofiban) should be given to patients who have an

intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are

scheduled to undergo angiography within 96 hours of hospital admission.

Coronary angiography should be considered within 96 hours of the first admission

to the hospital to patients who have predicted 6-month mortality above 3.0%. It should also be performed as soon as

possible in clinically unstable patients.

Ventricular Tachycardia: Management

Whilst a broad complex tachycardia may result from a supraventricular rhythm with aberrant conduction, the European

Resuscitation Council advise that in a peri-arrest situation it is assumed to be ventricular in origin

If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure or rate > 150 beats/min) then immediate

cardioversion is indicated. In the absence of such signs antiarrhythmics may be used. If these fail, then electrical

cardioversion may be needed with synchronised DC shocks

Drug therapy

• Amiodarone: ideally administered through a central line

• Lidocaine: use with caution in severe left ventricular impairment

• Procainamide

Verapamil should NOT be used in VT

If drug therapy fails

• Electrophysiological study (EPS)

• Implant able cardioverter-defibrillator (ICD) - this is particularly indicated in patients with significantly impaired

LV function