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Emergency Station

Comprehensive guidelines and steps for handling medical emergencies including anaphylaxis, convulsions, MI, hypertensive urgency, HF, hypoglycemia, hyper/hypoglycemia, and asthma exacerbation. Useful for PGY3, Chief Residents, or medical professionals.

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Emergency Station

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  1. Emergency Station • Mohammad Alazemi - PGY3 • Chief Resident • 20/4/2019

  2. ANY REQUIREMNETS FOR THE OSCE • Stethoscope. • you can ask for any equipment THAT YOU NEED.

  3. WHAT EVER YOUR STATION IS? • H A N D W A S H I N G. • Call for help and ambulance. • Act, Act, Act !! • Talk to the patient. • Contact with the nurse. • When ever you give a medicine, mention the name of the drug, the dose and the route of administration.

  4. Initial Assessment • ABCD • GCS • Vitals • Pulse, BP, oxygen sats %, Resp Rate

  5. ROLE PLAY

  6. Anaphylaxis • Call ambulance. • Check: Airways  open airway (intubate if necessary). Breathing  assess effectiveness of ventilation + give O2 10l/min. Circulation  check pulse, BP, fix large bore IV cannula. Disability  assess consciousness level by Glasgow coma scale. Exposure  check skin changes, facial or lip swelling.

  7. Give IM Adrenaline 1:1000 (in the anterolateral aspect – middle 1/3 of the thigh) • Repeat after 5 min if no improvement. • Start IVF 0.9 % saline (adult 500 ml- 1 L in 5-10 min) / child 20 ml/kg. • Give hydrocortisone IM or slow IV:

  8. Give chlorphenamine (piriton) IM or slow IV:

  9. Convulsions • Call ambulance. • Check: ABCD similar to anaphylaxis. Put the patient in recovery position. Check temperature and blood sugar. If fit does not stop after 5 mins spontaneously  give Diazepam rectally If status epilepticus  repeat same dose every 15 mins until ambulance arrive.

  10. Myocardial infarction • Call ambulance. • Check: BP, RR, HR, O2, ECG. • GTN 300 Microgram sublingual (avoid if systolic BP < 90 mmHg or HR > 110). • Morphine IM/IV 5-10 mg stat (then 1-2 mg/min up to 15 mg until adequate response). If respiratory depression: Naloxone 0.4-2mg) repeat every 2-3 min (max 10 mg). • Aspirin 300 mg (if not contraindicated). • Metoclopramide IM/IV 10 mg. • If bradycardia: Atropine IV 500 Microgram (repeat if necessary to max 3mg).

  11. Hypertensive emergency • If systolic BP >/= 180 mmHg and/or Diastolic BP >/= 110 mmHg. • Asses ABCD. • Examine fundi (papilledema). • Do ECG (R/O ischemic change). • Do urinalysis if available (check for protein and RBCs).

  12. Hypertensive emergency: • If symptomatic with signs of end organ damage: • Headache or blurred vision. • Increasing chest pain or SOB. • Swelling or edema. • Confusion. 2. Call ambulance. 3. Open iv access. 4. Refer urgently to hospital to start iv medications to lower BP.

  13. Hypertensive urgency: • If asymptomatic and no signs of end organ damage. • If already on hypertensive medications  check compliance then restart optimize dose and Rx. • If not on hypertensive medications  • Oral captopril 12.5 mg (do not give if volume overload  edema, pounding pulse, tachycardia, respiratory crackles). • Oral furosemide (Lasix) 20 mg (do not give in volume depletion or dehydration  vomiting, diarrhea, excessive sweating, kidney failure). 4. Monitor the patient for drop of BP of 20-30 mmHg then send the patient home with longer acting hypertensive medication. URGENT FOLLOW UP APPOINTMENT FOR BP IN FEW DAYS.

  14. Acute left ventricular failure • Be calm and reassuring. • Call ambulance. • Position the patient upright. • Give: • Oxygen 100% aim for SpO2 94-98% (if COPD 24% O2 aim for SpO2 88-92%). • GTN sublingual (do not give if severe hypotension systolic <90 mmHg). • Fix an IV line and give: • IV furosemide 20-50 mg. • IV morphine 5-10 mg +/- IV mtachlopromide (can be mixed).

  15. Hypoglycemia • Conscious: Blood sugar < 4 mmol/l + hypoglycemic symptoms: • If the patient is oriented and able to swallow  give fast acting oral glucose juice (75 g dextrose) followed by long acting carbs (biscuits and milk). • If the patient is disoriented and unable to cooperate  give IM Glucagon 1 mg (if child weight , 25kg  0.5 mg).

  16. Unconscious: Call ambulance • Check ABCDE. • Give: • IM glucagon 1mg, SE nausea and vomiting  put the patient in recovery position, (if child weight < 25kg  0.5mg). • OR iv 50 ml 10% dextrose. • OR 20 ml 6g/20ml glucose. • Remeasure blood glucose after 15 min and repeat IV until blood sugar > 4 mmol/l. • If on sulfonylurea  refer to hospital in spite of correction of blood sugar.

  17. Hyperglycemia • Blood sugar > 20 mmol/l. • Urine test: if +ve for ketones  DKA, if –ve for ketones  hyperosmolar state. • Unconscious: • Check ABCD • Give 1 L of 0.9 % saline over 0.5-1 hr. (repeat up to 3X if needed. • Then 500 ml/hr for the next 2-3 hrs. • If child 10ml/kg. • Refer by ambulance.

  18. Asthma exacerbation • Check BP, RR, HR, O2. • Give: • O2 and high dose bronchodilator Salbutamol nebulizer (adult 5 mg = 1ml, child 2.5 mg = 0.5ml). Ipratropium bromide (adult 0.5 mg = 2 ampules, child 0.25 mg = 1 ampule). Assess response  repeat ventoline after 20 min if indicated. 2. Give corticosteroid Oral prednisolone (adult 40-50mg, child soluble 20mg < 2years, soluble 30-40mg 2-5 years0 3. Or give IV hydrocortisone (adult 100mg, child 50 mg <2y, 100mg 2-5 y). If poor response  refer to medical casualty by ambulance.

  19. Thank you

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