Emergency

Sepsis
➢ Life-threatening organ dysfunction caused by a dysregulated host response to infection

Questions to be asked when dealing with sepsis:

1. Is the patient acutely unwell or it there any clinical concern?
2. Does the total NEWS (National Early Warning Score) score 5 or more?
3. Is there a single NEWS score indicator of 3?

If any of the above questions were yes → then ask yourself, could this be an infection? If yes → look for RED FLAGS
• Systolic blood pressure <90 (or >40 mmHg fall from baseline)
• Heart rate >130 bpm
• O2 saturation <91% (<88% in COPD) Rigors: episodes of shaking or exaggerated shivering, caused
• RR >25 bpm mainly by:
1. Bacteremia (seen in biliary sepsis or pyelonephritis)
• Responds only to voice or pain/unresponsive
2. Malaria
• Lactate >2.0 mmol
• Urine output <0.5 ml/kg/h for ≥2h

If 1 or more RED FLAGS present → complete the SEPSIS SIX within 60 minutes
SEPSIS SIX → Take 3, Give 3
Take 3
Septic shock
- Blood cultures 1. Low BP unresponsive to IV fluids
- FBC, U&E, clotting, lactate 2. Requires Vasopressors to maintain a mean
- Start monitoring urine output arterial pressure ≥65 mmHg
3. Serum lactate ≥2
Give 3
Severe sepsis
- High flow O2 • Sepsis + organ hypoperfusion (hypoxemia,
- IV fluids oliguria, lactic acidosis or altered cerebral
- IV antibiotics function)

How’s organ dysfunction identified?

• At the bedside, organ dysfunction is identified by an increase in the SOFA score of 2 or more
1. RR ≥22
2. Altered mentation
3. Systolic blood pressure ≤100 mmHg

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Sepsis vs SIRS

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Acute upper GI bleeding

Blatchford score
- For the initial assessment, to determine who are at “low risk” and candidates for outpatient management:
• Urea <5-6 mmol/L
• Hemoglobin >130 g/L (men) or >120 g/L (women)
• Systolic blood pressure ≥110 mmHg
• Pulse <100 bpm
• Absence of melena, syncope, cardiac failure or liver disease

Rockall score
- Assessment for admission and early endoscopy
• Age ≥60 years (all patients >70 years should be admitted)
• Witnessed hematemesis or hematochezia (suspected continued bleeding)
• Hemodynamic disturbance (systolic blood pressure <100 mmHg, pulse ≥100 bpm)
• Liver disease or known varices
• Other significant comorbidity (cardiac disease, malignancy) should also lower the threshold for admission

Management for upper GI bleeding

• 1st → IV fluid + Terlipressin (ADH analogue)
• 2nd → Endoscopy + band ligation (in most patients who are unstable or with persistent bleeding)
• TIPS should be considered of bleeding from esophageal varices isn’t controlled by band ligation
- Always remember, upper GI bleeds are referred to the medical team not surgeons
- PPIs (omeprazole) should NOT be used prior to endoscopy

Post GIT bleeding due to Mallory-Weiss $

If patient is stable
• Discharge with advice
• Repeat FBC
• Observe his vitals

If hemodynamically unstable
• Resuscitation (maintain airway, high flow O2, IV fluid)
• Endoscopy immediately after resuscitation

Indications for Fresh frozen plasma (FFP)

• Replacement of isolated factor deficiency
• Platelet count <50 x109/L
• Reversal of warfarin effect
• Patient has clotting disorder (e.g. due to liver disease)
• Prolonged INR
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• Massive blood transfusion (>1 blood volume within several hours)
• Treatment of TTP

Hypovolemic shock
Early changes
• Hypovolemia → stretch receptors in the atria and baroreceptors in the aorta become activated →
vasomotor center triggers efferent output → increase in catecholamine → arteriolar constriction,

venoconstriction, tachycardia

Late changes
• Reduced GFR → secretion of Aldosterone and ADH → salt and water reabsorption → thirst center becomes
triggered

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Look for the heart rate and memorize the blood loss %

Stage 4: over 40% blood loss, 140bpm, marked hypotension

Stage 3: over 30% blood loss, >120bpm, hypotension
Stage 2: 15-30% blood loss, >100bpm, postural hypotension
Stage 1: normal

Stage 1-2 → IV fluids

Stage 3-4 → Blood transfusion, you might need to give IV fluid initially until the bloods arrive to prevent shock

Anaphylaxis features
➢ The speed of onset and severity vary with the nature and amount of the stimulus, but the onset is usually in
minutes/hours
Respiratory
• Swelling of lips, tongue, pharynx, and epiglottis → may lead to complete upper airway occlusion
• Lower airway involvement is similar to acute severe asthma e.g. dyspnea, wheeze, chest tightness, hypoxia,
and hypercapnia
Skin
• Pruritus, erythema, urticaria, and angio-edema (swelling of the deeper layers of the skin)
Cardiovascular
• Peripheral vasodilation and increased vascular permeability → plasma leakage from the circulation →
hypotension, and shock
Management
1. ABC
2. High-flow O2
3. Lay patient flat
4. Adrenaline (epinephrine) IM, in the anterolateral aspect of the middle third of the thigh
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- <6 years → .15ml 1 in 1,000
- 6-12 years → .3ml 1 in 1,000
- >12 years → .5ml 1 in 1,000
5. Hydrocortisone and chlorpheniramine (antihistamine)

Signs and symptoms of smoke inhalation injury

• Persistent cough
• Stridor
• Wheezing
• Black sputum (excessive exposure to soot)
• Use of accessory muscles of respiration
• Blistering or edema of the oropharynx
• Hypoxia or hypercapnia
Management
- Summon the anesthetic for intubation
- If airway is obstructed → Cricothyroidotomy

Choking and foreign body airway obstruction (FBAO) in infants

• In a seated position, support the infant in a head-downwards, prone position to let gravity aid removal of the
foreign body
• Perform five sharp blows with the heel of the hand to the middle of the back (between the shoulder blades)
• After five unsuccessful back blows, use chest thrusts: turn the infant into a supine position and deliver five
chest thrusts. These are similar to chest compressions for CPR, but sharper in nature and delivered at a
slower rate
• If respiratory distress → anesthetic removes the foreign body with Magill’s forceps under direct
laryngoscopy

<1y/o → Back blows then chest thrusts

>1y/o → Heimlich maneuver
Carbon dioxide poisoning
➢ Tasteless and odorless gas, may occur from car exhausts, fires, faulty gas heaters or painting products
Early features
• Headache malaise
• Nausea and vomiting
Severe toxicity
• “Pink” skin and mucosa
• Hyperpyrexia
• Arrythmia
• Coma with hyperventilation
Investigation
• Carboxyhemoglobin level (COHb)
Management
• Clear the airway
• Maintain ventilation with high concentration of O 2
• For a conscious patient → use a tight-fitting mask with an O2 reservoir, but if unconscious → intubate and
provide IPPV on 100% O2

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Indications for hyperbaric oxygen therapy (HBOT) -- NOPE
- COHb level >20%
- Loss of consciousness
- Neurological signs other than headache
- Myocardial ischemia/arrythmia diagnosed by ECG
- The patient is pregnant

Tricyclic antidepressant (TCA) overdose (Amitriptyline)

Features [3Cs → Convulsions, Coma, Cardiotoxicity]
• Dilated pupil
• Dry mouth, Dry flushed skin
• Dry urethra: Urinary retention
• Drowsiness and altered mental state leading to coma
• Decreased blood pressure
ECG monitoring is essential → Sinus tachycardia and signs of hyperkalemia
Broad complex tachycardia can occur which are life threatening
ABGs → Metabolic acidosis
Management
• ABCDE protocol
• If within 1h of ingestion and >4 mg/kg → activated charcoal
• IV fluid as bolus
• Sodium bicarbonate, if prolonged QRS >120ms or hypotension unresponsive to fluids (even if not acidotic)

Tricyclic antidepressant overdose →

Unilateral space occupying lesions such as tumors, hematomas or abscesses →

Opiate (heroin) overdose or a cerebrovascular accident affecting the brainstem →

Paracetamol overdose → Liver toxicity

Features
• Initially → Nausea, vomiting, pallor
• After 24h → Hepatic enzymes rise
• After 48h → Jaundice, an enlarged, tender liver
• Hypoglycemia, hypotension, encephalopathy, coagulopathy, coma may also occur
Management
• <24 tablets (>150mg), serum paracetamol is normal and no hepatic risk factors) → Refer to psychiatry
• >24 tablets or unknown amount / within 8h of ingesting → Admit to medical ward and measure
paracetamol level every 4h post-ingestion (calculated from the time of ingestion not the hospital visit)
• >8h or staged overdose, doubt over the time, increased plasma paracetamol (above the line on the
nomogram) → N-acetylcysteine
<1h → Charcoal
1-4 → Delay blood sample until 4h post-ingestion
>4h → Do serum PCM levels and give NAC if indicated
>8h → NAC immediately
150mg 24 tablets =
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Alcohol consumption reduces the effect, chronic alcohol drinking worsens the condition
Criteria for liver transplantation (paracetamol liver failure)
➢ Arterial pH <7.3, 24h after ingestion OR all of the following:
- PT >100s
- Creatinine >300
- Grade III or IV encephalopathy

Aspirin overdose
➢ Toxic to the brain → Encephalopathy
➢ Toxic to the brainstem → Hyperventilation
➢ Metabolic acidosis later on
Common drugs cause metabolic acidosis [I2A2 MD]
• Metformin
• Alcohol
• Isoniazid
• Iron
• Aspirin
• Digoxin
ACEIs and NSAIDs → Metabolic alkalosis
Benzodiazepine, organophosphates (active ingredient in insecticides) → Respiratory acidosis

Benzodiazepines over dose → [CRASH]

• C-Cognitive problems
• R-Respiratory depression → life threatening
• A-Anteretrograde amnesia → loss of ability to create new memory
• S-Sedation
• H-Hypotension
Heroin overdose → flu-like symptoms (e.g. runny nose, muscle aches), agitation, sweating and sleep disturbance
CT scan after a head injury
For adults who have sustained a head injury and have any of the following → perform CT head with 1h of the risk
factor being identified:
• GCS <13 on initial assessment in the emergency department
• GCS <15 at 2h after the injury on assessment in the emergency department
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture (hemotympanum, panda eyes, CSF leakage from ear or nose, Battle’s sign →
can take several days to appear)
• Post-traumatic seizure
• Focal neurological deficit
• >1 episode of vomiting

For adults with any of the following who have experienced some loss of consciousness or amnesia since the injury →
perform CT head within 8h of the head injury
• Age 65 years or older
• Any history of bleeding or clotting disorders
• A patient on warfarin

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• Dangerous mechanism of injury (a pedestrian struck by a
motor vehicle, an occupant ejected from a motor vehicle or a
fall from height >1m or 5 stairs)
• >30 minutes retrograde amnesia of events immediately
before the head injury

Management for stabbed injury in the RUQ with

shock features and suspected liver injury
1. IV fluids
2. Call the surgeons
3. Cross match for packed RBCs
4. CT abdomen
5. Laparotomy

Indications for FAST

• BAT (blunt abdominal trauma)
• Stable penetrating injuries
• Assessment of intraperitoneal free fluid (2ry to perforation/hemorrhage
due to trauma)

Renal trauma
Features
• Severe loin or back pain
• Hypotension
• Macroscopic hematuria → due to tearing of blood vessels at the renal
pedicle or rupture of the ureter at the pelvi-ureteric junction
Investigations
• Most initial diagnostic tool → Urgent abdominal CT
• If CT is not available → IVU

Patients should be hemodynamically stable before performing CT

Parkland formula
• Used to count the fluids required after burns, this is calculated from the time of burn
• Fluid requirements = Body area burned (%) x Wt. (kg) x 4mL (use Hartmann’s)
• Give ½ of total requirement in 1st 8h, then give 2nd half over the next 16h

Types of burns or scalds (due to hot water/steam)

Superficial (epidermal) burns
• Red and painful but don’t blister
• Managed with → wound dressing, bandage and discharge

Partial thickness burn

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• Ranges from blistering to deep dermal burn
• The appearance is shiny and sensation is intact
• Capillary refill blanches

Full thickness burn

• Has a leathery or waxy appearance
• May be white, brown or black in color
• There are no blisters
• Sensation is lost so they don’t feel any pain
• There’s no capillary refill
Management
1. Analgesia
2. IV fluid if burn >15% in adults, >10% in children (disregard superficial burn)
3. Referring to a specialized burn service
- >3% of total body surface partial thickness burn
- Burns involving the face, hands, feet, genitalia, perineum or major joints
- All deep dermal and full thickness burns
- All burns associated with electrical shock or chemical burns
- All burns associated with no-accidental injury
- All burns with inhalation injury

Blisters should be left intact to reduce the risk of infection however large blisters (>1cm) can be de-roofed or
aspirated under aseptic techniques

A significant percentage of burns are due to child abuse; if the story doesn’t match or there’s a delay in presenting →
contact child protection and refer to the specialized burn service

You may check tetanus status and give tetanus toxoid if required

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CPR

<1 y/o, blow air through the nose and mouth

>1 y/o, nose pinched

For cardiac arrest → CAB (Compressions, Airway, Breathing)

For any non-cardiac arrest → ABC

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Flail chest
➢ A flail chest occurs as a result of a trauma to the chest, leading to at least 3 ribs becoming fractured or
broken, close together, with pieces of bone detaching from the chest wall
➢ These segments of bone start to move independently of the chest wall and in the opposite direction because
of lung pressure. The result is a “paradoxical respiration”
Causes
• Fall (for example, off a bicycle or a horse)
• Blunt trauma to the chest
• Car accident
Diagnosis
• Paradoxical respiration + shortness of breath + chest pain in a patient who has just had blunt chest trauma
raises the suspicion of a flail chest
• Diagnosis is usually clinical with the help of chest X-ray → rib fractures
Management
1. High flow oxygen
2. Analgesia → paracetamol / NSAIDS / Opiates / intercostal block / thoracic epidural (up to T4) + splinting of
injury
3. If worsening fatigue and RR → Intubation / mechanical ventilation

Diaphragmatic rupture (diaphragmatic injury or tear)

➢ It is usually secondary to blunt trauma due to a car accident where the seat belt compression causes a burst
injury directed to the diaphragm
➢ The pressure within the abdomen raises so quickly with a sudden blow to the abdomen causing a burst in
the diaphragm. It is commonly on the left side
Features
• Chest and abdominal pain
• Respiratory distress
• Diminished breath sounds on the side of the rupture
• Bowel sounds may be heard in the chest
Investigation
• Chest X-ray to diagnose diaphragmatic rupture is actually quite unreliable and has low sensitivity and low
specificity. However, there are specific signs detectable on X-ray which should raise suspicion:
- Raised left hemi diaphragm
- Air fluid levels in the chest may also be seen
- A nasogastric tube is seen curled into the chest → Pathognomonic but rare
• Thoracoabdominal CT scan is usually diagnostic

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Hemothorax
➢ Blood accumulates in the pleural cavity
Features
Similar to that seen in traumatic pneumothorax, except the following:
• Dullness to percussion over the affected lung
• Signs and symptoms of hypovolemia if massive hemothorax
Investigations
• Chest X-ray → increased shadowing on a supine X-ray, with no visible fluid level
Treatment
• Oxygen
• Insert 2 large venous cannula and send blood for cross matching
• Evacuation of blood may be necessary to prevent development of empyema; thus, chest tube is needed and
is often placed low. Usually the lung will expand and the bleeding will stop after a chest tube is inserted
• Surgery to stop the bleeding is seldom required. The lung is the usual the source of bleeding

Homogenous opacity = white = fluid or gas = Hemothorax or pleural effusion

In blunt trauma → could be both hemopneumothorax

Hemothorax Pneumothorax

• Usually sharp trauma (stabbing) • Usually blunt trauma

• Dullness to percussion • Hyperresonance over the affected lung
• JVP not raised • Raised JVP
• CXR → Homogenous opacity • CXR → Hyperlucency

Toxic shock syndrome

➢ Caused by Staphylococcus aureus typically manifests in otherwise healthy individuals with high fever,
accompanied by low blood pressure, malaise and confusion, which can rapidly progress to stupor, coma,
and multiple organ failure
➢ The characteristic rash → often seen early in the course of illness, resembles a sunburn, and can involve any
region of the body, including the lips, mouth, eyes, palms and soles
➢ In patients who survive the initial phase of the infection, the rash desquamates, or peels off
➢ High WBC and low platelets (platelet count < 100,000 / mm³)
Features
• Fever > 38.9 °C
• Hypotension: Systolic blood pressure < 90 mmHg
• Diffuse macular erythroderma
• Desquamation (especially of the palms and soles) 1–2 weeks after onset
Involvement of three or more organ systems
• Gastrointestinal (vomiting, diarrhea)
• Muscular: severe myalgia or creatine phosphokinase level elevation
• Mucous membrane hyperemia
• Kidney failure
• Liver inflammation

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Orbital blowout fracture
➢ Most common bone affected in an → Maxilla (orbital
floor)
➢ Followed by → Ethmoid (medial wall)

Signs of maxilla (orbital floor) fracture

• Periorbital ecchymosis
• Enophthalmos
• Diplopia, as inferior rectus is trapped preventing the eye
from going up → Upward gaze whenever the patient try
to look up

Hereditary angioedema (C1 esterase inhibitor deficiency)

• Rare genetic causing episodes of angioedema which includes life-threatening laryngeal edema
• Positive family history
• Onset from childhood of episodes of angioedema affecting the larynx
• Abdominal pain and vomiting
• Confirmed by → Low levels of C1-esterase inhibitor and complement studies during the acute episode
• Treated by → C1-INH (C1-esterase inhibitor) concentrate

Urethral injuries
• Often associated with pelvic fractures + perineal bruising + blood at the
external urethra
• Rectal examination → High-riding prostate or inability to palpate the
prostate imply urethral injury
• Retrograde urethrogram might be used to assess urethral injury
• Suprapubic catheterization is needed to empty the bladder

Compartment syndrome [5Ps]

➢ Often occurs after a traumatic injury such as a car crash
➢ Causes severe high blood pressure in the compartment which results in insufficient blood supply to muscles
and nerves
➢ If left untreated, it might lead to permanent muscle and nerve damage and can result in the loss of function
of the limb
➢ Managed by → Fasciotomy
Features
• Pain
• Pallor
• Paresthesia (feeling of numbness)
• Pulselessness
• Paralysis

- Acute limb ischemia is similar to Compartment $ except it develops gradually in the latter

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Notes
• In mixed acidosis, HCO3 is given when → pH <7 and HCO3 <10 mmol/L
• Commonest cause of mixed respiratory and metabolic acidosis → Cardiac arrest, patient is retaining carbon
dioxide as he’s not breathing and his kidneys aren’t perfusing due to low cardiac output, managed by →
Increase ventilation
• Sharp/aching pain, aggravated by movement such as deep inspiration, coughing or sneezing + tenderness on
the side of the sternum → Costochondritis
• Costochondritis + swelling over the affected joints of the anterior chest wall → Tietze’s $
• Autonomic nervous system responsible for “fight or flight” and VC of bl. Vessels → Sympathetic
• Autonomic nervous system responsible for “rest and digest” and VD of bl. Vessels → Parasympathetic
• A professional doing CPR for adults, compression with rescue breaths → 30:2
• A professional doing CPR for children, compression with rescue breaths → 15:2
• A layman doing CPR → 30:2
• Pressing depth in an infant should be → 4cm, Aim for rate → 100/min
• Mydriasis + nystagmus + tachycardia + hypotension → Carbamazepine toxicity
• Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness, confusion, delirium, vision disturbance
(blurred or yellow vision) + cardiac abnormalities (VT, VF, heart block) → Digoxin toxicity
• Bradycardia, hypotension, hypothermia, hypoglycemia (especially in children) → Propranolol toxicity
• Hypotension, fever, frequent urination, muscle cramps and twitching → Thiazide toxicity
• Bleeding occurs at the time of surgery or immediately after an injury or an operation → 1ry hemorrhage →
Replace blood, if severe → return to theatre for adequate hemostasis
• Bleeding within the first 24h following trauma/surgery, usually caused by slipping of ligatures, dislodgement
of clots, patient warming up after surgery causing vasodilation, on top of normalization of blood pressure →
Reactionary hemorrhage → Replace blood and explore the wound
• Caused by necrosis of an area of blood vessel, related to previous repair and is often precipitated by wound
infection, it occurs 1-2 weeks post-op → 2ry hemorrhage → Admission and IV antibiotics
• Main concern in fracture femur → Blood loss into compartment, so initial action after ABCD → Thomas’s
splint
• RTA, trauma to left side of the chest + abdominal distension + falling blood pressure + rising pulse +
abdominal tenderness and diminished bowel sounds → Splenic fracture, initially → X-ray abdomen (loss of
left psoas shadow), confirmed by → CT abdomen
• Initial investigation for abdominal trauma in hemodynamically stable patient → CT
• Initial investigation for abdominal trauma in hemodynamically unstable patient → FAST
• FAST in splenic fracture → Free peritoneal fluids → Immediate laparotomy
• Stable patient with upper GI bleeding after excessive alcohol ingestion → Mallory-Weiss tear → Endoscopy
• An alcoholic seeking help to quit but lacks social support → Refer to social services
• If there’s any medical concerns → Admit
• Crackles at the lung could be due to → Pulmonary edema or infection
• Most common site for tearing in traumatic aortic rupture → Proximal descending aorta
• Calf swelling with a positive Homan’s sign (pain with ankle dorsiflexion) → DVT or Popliteal cyst ruptures
• Popliteal cyst ruptures → usually starts behind the knee (popliteal fossa)
• To differentiate between DVT and popliteal cyst rupture → US
• Asymptomatic swelling behind the knee that may cause discomfort → Baker’s cyst
• History of popping sound around the ankle with pain and decreased plantar flexion → Achilles Tendon
rupture
• DNR allows to withhold CPR not treatment
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