Emergency Medicine Arjun Mehta, Catherine Culley
Chapter Notes

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  • Need for consideration of deep vein thrombosis (DVT) prophylaxis in every admitted patient in the hospital.
  • Hand washing and hand hygiene is crucial in every patient.
  • Consider the need for coagulation screen and blood grouping before undertaking any invasive procedure.
Consider and avoid hypoxia, hypovolemia, hyperkalemia, hypokalemia, hypocalcemia. For regular monitoring with pulse oximetry, blood pressure (BP) monitoring and electrocardiography (ECG).
Respiratory rate (RR) >35/min or <6/min, BP <90 mm Hg are at risk of cardiac arrest.
Machine derived BP is not accurate at extremes of BP or in fast tachycardia or in atrial fibrillation (AF).
  • Sepsis (Septic shock)
  • Myocardial infarction (MI) without any pain (early ECG changes though)
  • Occult blood loss
  • Poisoning
  • Pulmonary embolus (PE)
  • Anaphylaxis
  • Addison's disease
  • Cardiac tamponade
  • Autonomic dysfunctions.
2Septic Shock
Septic shock is, as a result of severe infection and sepsis and can cause multiple organ dysfunction and death. It is common in children, immune compromised individuals and elderly.
  • Systemic inflammatory response syndrome (SIRS) is present.
  • Any two of the following (tachypnea RR >20/min, white blood cells <4000 or >12000 cells/mm3, heart rate >90 beats/min, temperature >38.5°C (101.3°F) or <35°C (95°F).
  • There must be sepsis with evidence of infection like positive blood culture or sign of pneumonia on chest X-ray or other radiological or laboratory evidence of infection.
  • Signs of organ dysfunction such as renal failure, liver dysfunction or change in mental status or elevated serum lactate.
  • Finally refractory hypotension.
  • Begin resuscitation immediately if hypotension, or hypotension and serum lactate 4 or more. Goals—urine output >0.5 mL/kg/hr, mean arterial pressure >65 mm Hg.
  • Intravenous (IV) fluids—Crystalloids (normal saline or Hartmann's solution) 1 L or colloids (gelofusine) 300–500 mL over 30 minutes as fluid challenge, consider pack cells if hematocrit <30%.
  • Early antibiotics—Appropriate cultures before broad-spectrum antibiotics, at least 2 blood cultures (one percutaneous and other from vascular access) and imaging studies promptly to confirm or sample the source of infection and source control (abscess drainage or tissue debridement).
  • Use hospital guideline in Pseudomonas infections or neutropenic patient.
  • Vasopressors—Norepinephrine or dopamines are initial vasopressors administered centrally. Use dobutamine infusion maximum 25 µg/kg/min in patients with MI.
  • 3Hydrocortisone 300 mg/day IV if hypotension responds poorly to fluids challenges.
  • Blood transfusion if hemoglobin <7.0 g/dL, platelet transfusion if platelets <5000 (asymptomatic), <5000–30,000 (significant bleeding risk), <50,000 (invasive procedure or surgery).
  • Use IV insulin to control hyperglycemia, keeping BM 8.3 mmol/L (150 mg/dL).
  • Use bicarbonate if pH <7.15.
  • Use H2RA (H2 receptor antagonist), TEDS (stockings) or LMWH (low molecular weight heparin) or both (TEDS + LMWH) in view of high risk of DVT.
Acute Anaphylaxis
Acute allergic response to a substance to which the individual has been exposed previously results in mast cell degranulation and histamine release. Anaphylactic shock is twice as common in women and 1/3 suffer from atopy.
Nuts, fish, nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, anesthetics and stings.
Present as bronchospasm and/or cardiovascular collapse.
  • Airway, breathing and circulation (ABC)
  • Maintain airway and O2 by high flow O2 mask and reservoir bag, intubate if stridor.
  • Give adrenaline 500 µg (0.5 mL 1.1000) intramuscular (IM) and repeat in 5–10 min if no better.
  • Secure IV access and give IV fluids (Hartmann's solution or normal saline or gelofusine).
  • Monitor O2 saturation and BP.
  • Hydrocortisone 200 mg IV.
  • Antihistamine chlorpheniramine 10–20 mg IV slowly
  • Salbutamol 5 mg, nebulizer if wheeze present.
Disseminated Intravascular Coagulation
It is a systemic disorder in which hemorrhage (main problem 90%) and thrombosis can occur at the same time. 4It involves generation of intravascular fibrin and consumption of clotting factors and platelets. It can be acute or chronic. History—Bleeding—Extensive superficial bruising and oozing from venipuncture, IM injection sites, around indwelling catheters and tubes. Bleeding from mucosa, mouth, nose, gastrointestinal (GI), lungs, renal tract.
  • Sepsis—bacterial, viral, fungal, parasitic, malaria.
  • Major trauma, burns, surgery.
  • Toxins—venom.
  • Obstetric—placental abruption, eclampsia, and amniotic fluid embolism.
  • Cancer—metastatic carcinoma of stomach, colon, pancreas, breast, lung, mucin secreting adenocarcinoma, leukemia.
  • Severe pancreatitis.
  • Liver disease—acute liver failure.
  • Others—heat stroke, prosthetic devices, purpura fulminants, recreational drugs, severe transfusion reaction, transplant rejection, giant hemangioma and large vessel aneurysm (aortic).
  • Low platelet count
  • PT (prothrombin time) and activated PTT (partial thromboplastic time) both increased
  • FDP (fibrinogen degradation product) and/or D-dimer present or increased
  • AT3 (antithrombin 3) level reduced
  • Fibrinogen reduced
  • Thrombin time prolonged
  • Blood film—red cell fragmentation/microangiopathic hemolytic anemia.
  • Treat aggressively.
  • Broad-spectrum antibiotics for sepsis.
  • When established DIC diagnosed by laboratory then give FFP (fresh frozen plasma) (15 mL/kg or 1L = 4 units = 1 adult dose) to keep PT (prothrombin time) and PTT (partial thromboplastin time) <1.5 times upper limit of control value.
  • 5Give cryoprecipitate to keep fibrinogen >1 g/L (1–1.5 pack/10 kg = 10 units = 1 adult dose)
  • Give platelets (4–8 units) to keep platelets >50,000.
  • Give blood to keep hematocrit >0.30
  • Sepsis related DIC activated protein C can be used as 96 hrs infusion, provided platelet count > 30,000 × 109/L. Apart from acting as anticoagulant, it also has anti-inflammatory and anti-apoptotic properties.
  • If patient continues to bleed after 6 hr of treatment of underlying cause and supportive measures then with hematological advice consider AT3 and heparin 20–30,000 U/24 hr.
  • Used when thrombosis is main problem.
  • If hypotension or shock, consider an adrenal infarction (Waterhouse-Friderichsen syndrome) and give hydrocortisone 100 mg 6 hrly.
  • Amoxycillin 500 mg tds oral or IV, 1.0 g tds in pneumonia if CURB >2
  • Cefuroxime 1.5 g tds IV
  • Ciprofloxacin 750 mg bd IV
  • Clarithromycin 500 mg bd oral or IV
  • Co-amoxiclav 1.2 g tds IV
  • Flucloxacillin 1.0 g qid IV
  • Gentamycin 5 mg/kg IV
  • Penicillin G 1.2 g tds IV
  • Vancomycin 1.0 g bd IV
  • Tazocin 4.5 g tds IV
  • Doxycycline 200 mg stat and 100 mg oral daily
  • Levofloxacin 500 mg IV bd
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  • 6CURB-65 Score
    • C (confusion) AMT <8/10,
    • U (urea >7 mmol/L),
    • R (respiratory rate 30 or >30),
    • B (blood pressure systolic <90 mm Hg or diastolic 60 or <60 mm Hg),
    • Age 65 or >65.
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Chronic Obstructive Pulmonary Disease (COPD)
Amoxycillin 500 mg tds. If penicillin allergy or recent failure of amoxycillin—Doxycycline 200 mg stat and then 100 mg/day and if severe then ciprofloxacin to cover Pseudomonas.
Urinary Tract Infection (UTI)
  • Trimethoprim 200 mg bd for 3 days in females.
  • In males, trimethoprim failure, catheter associated, immune suppressed, hospital acquired, pyelonephritis, renal failure, recent urological surgery, co-amoxiclav 625 mg oral tds or IV 1.2 g tds + gentamycin 5 mg/kg for 2 doses. If penicillin allergy, ciprofloxacin 500 mg bd oral or IV 400 mg bd + stat dose of gentamycin for 7 days.
  • 7Gentamycin 80 mg IV or IM stat with in 30 minutes before catheter manipulation.
Nonlocalized Sepsis
  • <70 yrs: Penicillin G 1.2 g qid + flucloxacillin 1 g qid + ciprofloxacin 750 mg bid.
  • >70 yrs: Penicillin G + Flucloxacillin + Gentamycin or Tazocin 4.5 g IV + Gentamycin 5 mg/kg. If penicillin allergy then cefuroxime 1.5 g tid or vancomycin + ciprofloxacin + metronidazole or teicoplanin 400 mg IV 12 hrly 3 doses and then OD.
Biliary Sepsis or Spontaneous Bacterial Peritonitis (SBP)
  • Tazocin IV 4.5 g tds or ciprofloxacin + metronidazole or gentamycin + metronidazole.
  • Prophylaxis for SBP—Norfloxacin 400 mg daily life long.
  • <70 yrs: Cefuroxime 1.5 g tid + Metronidazole.
  • >70 yrs: Gentamycin + Metronidazole if creatinin >260 then ciprofloxacin 375 mg bid + metronidazole.
Acute Surgical Abdomen (Peritonitis)
Cefuroxime 1.5 g tid + Metronidazole or Gentamycin + Metronidazole or Tazocin 4.5 g tds.
Neutropenic Sepsis
If neutrophils <1 × 10 × 9/L, tazocin 4.5 g tid + gentamycin 4–6 mg/kg/day, if non-IgE penicillin allergy then Ceftazidime 2 g tid + gentamycin. If IgE penicillin allergy then ciprofloxacin IV 400 mg bd + gentamycin. Also consider granulocyte colony stimulating factor (GCSF). Add Teicoplanin IV 400 mg 12 hrly for 3 doses then od if central line infected.
Ceftriaxone IV 2 g/d for 7–10 days, add amoxycillin IV 2 g 4 hrly if over 55, immune suppressed or alcoholic. If penicillin allergy then vancomycin 1 g bd + IV chloramphenicol 25 mg/kg qds for 7–14 days. Add dexamethasone 810 mg qds IV for 4 days with IST dose of antibiotic unless septic shock or immune compromised or neurosurgery.
Septic Arthritis
Flucloxacillin 1 g qid + penicillin G 1.2 g 4 hrly 2 weeks. If penicillin allergy then teicoplanin IV 400 mg bd for 3 doses then od.
Septic Arthritis in Prosthetic Joint
Vancomycin 1 g bd + Rifampicin 600 mg od.
Flucloxacillin 2 g qid + Penicillin G 1.2 g qid for 6 weeks.
Ciprofloxacin 500 mg bd or Trimethoprim 200 mg bd for 28 days.
Indolent presentation—Penicillin G 1.2 g 4 hrly + Gentamycin 1 mg/kg tds maximum (80 mg), if penicillin allergy vancomycin 1 g bd + gentamycin 1 mg/kg tds.
Acute onset, intravenous drug users (IVDU), methicillin-resistant Staphylococcus aureus (MRSA), prosthetic valve—Vancomycin 1 g bd IV + Gentamycin + Rifampicin oral 600 mg bd.
  • Mild—Flucloxacillin 500 mg qid
  • Severe—Penicilin G 1.2 g qds + Flucloxacillin 1 g qds or if penicillin allergy or MRSA colonized then Teicoplanin 400 mg bd IV for 3 doses and then od or if non-IGE mediated penicillin allergy ceftriaxone 1.2 g od.
Diabetic Foot
  • If no systemic toxicity and no comorbidities then treat as mild cellulitis.
  • Otherwise teicoplanin IV 400 mg bd for 3 doses and then od + tazocin IV 4.5 g tds OR if penicillin allergy 9then teicoplanin + metronidazol IV 500 mg tds + gentamycin.
Orbital Cellulitis
Co-amoxiclav 1.2 g IV tds or if penicillin allergy clarithromycin 500 mg IV bd + metronidazole 500 mg IV tds.
Human or Animal Bites
Co-amoxiclav 625 mg tds oral or if penicillin allergy then doxycycline 100 mg bd + metronidazole 400 mg tds.