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

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

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. Always remember ABC.

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

ROLE PLAY

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.

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: 0.5 ml > 12 y 0.3 ml 6-12 y 0.15 > 6m – 6 y 200 mg > 12 y 100 mg 6y – 12 y 50 mg 6 months – 6 y 25 mg < 6 months

Give chlorphenamine (piriton) IM or slow IV: 10 mg > 12 y 5 mg 6 y – 12 y 2.5 mg 6 months – 6 y 250 Microgram/kg < 6 months

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 mg Elderly 10-20 mg > 10 y 5-10 mg 2 – 10 y 5 mg 1 m – 2 y 1.25-2.5 mg neonates

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).

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).

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.

URGENT FOLLOW UP APPOINTMENT FOR BP IN FEW DAYS. 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.

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).

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).

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.

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.

If poor response  refer to medical casualty by ambulance. 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.

Thank you