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Emergencies checklist
ARV associated lactic acidosis
Suspect: in patients on ARVs or who have recently stopped ARVs, with abdominal or muscle pain, ‘flu’, malaise or abnormal breathing.
Check: pulse rate, respiratory rate, BP, lactate, and pH/bicarbonate.
Treat: STOP ARVs, treat intercurrent infections (manage as possibly septicaemic), give thiamine 100 mg IM daily.
ARV associated renal failure or hypokalaemia
Suspect in patients on tenoforvir and presenting with signs and symptoms of dehydration, or generalised weakness or fluid overload in a setting of tenofovir use. Check the serum potassium and creatinine and manage accordingly. Acute gastroenteritis can cause life-threatening hypokalaemia in these patients
Asthma
Check: pulse rate, BP and pulsus paradoxus, peak flow rate, and record these.
Consider: (other causes of wheeze – see text); pneumothorax – mobile CXR; mitral stenosis
Treat:
- Salbutamol 1ml nebuliser solution with 4 ml saline at oxygen flow rate of 6l/min. Give nebs every 20 minutes initially, then drop to hourly or two hourly.
- hydrocortisone 200 mg IV stat then prednisone 30 mg PO daily.
- Only give an antibiotic if strongly suspect associated chest infection – usually either oral amoxycillin 500 mg 8 hourly or intravenous ceftriaxone 1 g daily
Acute confusional states
Suspect: hypoglycaemia, frontal lobe CVA, meningitis, thiamine deficiency
Sedate: haloperidol 0.5-5 mg IM depending on age and frailty. If very robust and very aggressive, may require 5 mg of haloperidol with either a benzodiazepine – e.g. clonazepam 1 mg IM – or promethazine 25mg IM. The principle of good sedation is regular doses in modest amounts rather than erratic excessive dosages. Clonazepam or lorazepam are both suitable (lorazepam 2 to 4 mg) but the latter requires refrigeration for the parenteral formulation.
Congestive cardiac failure
Check: cyanosed? Pulse rate and rhythm, BP, JVP, apex, murmurs, rub.
Suspect: cardiomyopathy (displaced apex, S3), cor pulmonale (cyanosed, hyperinflated), valvular heart disease (murmur), pericardial disease (clear lungs)
Treat: 40% oxygen (beware in cor pulmonale) Furosemide 40 to 80 mg IV is a usual starting dose. Give thiamine 100mg IM if beriberi is suspected. Further management according to cause. If available and tolerated, CPAP may help.
Diabetic ketoacidosis
Check: missed medication? Source of sepsis – urine dip sticks, throat, ears, chest. Blood chemistry and venous pH and bicarbonate.
Treat: normal saline 1 litre over 1 hour, second litre over 2 hours, then 4 hourly. Short acting insulin IV infusion (or IM) 5-6 units/hour. Watch the potassium as it drops rapidly with what is essentially a ‘potassium shift’ regimen
Fits
Check: fingerprick glucose, evidence of head injury, temperature.
Treat: Clonazepam 1-2 mg IM: for status also start phenytoin 20 mg/kg in saline over 45 minutes, then 300 mg daily orally, with first dose 12 hours after infusion.
Hypoglycaemia
Consider: excessive oral anti-diabetic agents in context of deteriorating renal function; intercurrent infections, Addison’s (random cortisol)
Treat: 20-50 ml of dextrose 50% IV, and check the sugar comes up and stays up.
Hypokalaemia
If the patient is vomiting or has diarrhoea, this usually requires intravenous therapy, the magic cut-off (not evidence based) being less than 2.8 to 3.0 mmol/L but this also depends on cause and predicted direction and speed of movement of the level. If replacing intravenously, and IV fluid likely to be tolerated, one option is to prescribe 40 mmol (two 20 ml amps of KCl containing 20 mmol in each amp) mixed thoroughly in 1 L of normal saline and infused over 6 to 8 hours, repeating as needed (a single bag is rarely enough if serum [K] is less than 3 and there is ongoing loss.)
Myocardial infarction
Treat: 40% oxygen if clinically hypoxaemic. Aspirin 300 mg stat, the 150 mg daily. Clopidogrel 300 mg load then 75 mg daily if available. Streptokinase 1.5 MU in 200 ml saline IV if less than six hours post-event. Heparin if not given streptokinase.
Paralysis
Consider: Guillain-Barre, TB spine, cord ischaemia, cobra bite, hypokalaemia..
Measure: FVC 2 hourly (>1.5 okay) until clearly stabilised. If worsening may warrant ventilation.
Stroke
Check:
- can swallow water from a syringe?
- continence issues addressed?
- if febrile, look for sepsis source.
- turn patient looking for bed sores, and document carefully if found.
- adequate hydration and nutrition.
- don’t drop BP abruptly.
- tell the patient/relatives what is going on.