Emergency Medicine

EMERGENCY MEDICINE
1 DR. MOHCEN AL. HAJ

Index
CARDO-VASCULAR SYSTEM EMERGENCY:

Acute Pulmonary Edema ----------------------------------------------------------------------------------- 3, 4
Malignant Hypertension --------------------------------------------------------------------------------------- 5
Unstable Angina & Non STEMI ------------------------------------------------------------------ 6, 7, 8
STEMI ---------------------------------------------------------------------------------------- 9, 10, 11, 12, 13
Atrial Fibrillation ----------------------------------------------------------------------------------------- 14, 15
Ventricular Tachycardia & Ventricular Fibrillation ---------------------------------------------- 16
RESPIRATORY SYSTEM EMERGENCY:

Acute Exacerbation of Asthma -------------------------------------------------------------------- 17, 18
Acute Exacerbation of COPD ----------------------------------------------------------------------- 19, 20
Pneumothorax ------------------------------------------------------------------------------------- 21, 22, 23
Pulmonary Embolism ------------------------------------------------------------------------------------------ 24
GASTRO INTESTINAL TRACT SYSTEM EMERGENCY:

Upper GIT Bleeding -------------------------------------------------------------------------- 25, 26, 27
Hepatic Encephalopathy ------------------------------------------------------------------------------------ 27
NEUROLOGICAL SYSTEM EMERGENCY:

Status Epilepticus --------------------------------------------------------------------------------------------- 28
Stroke ------------------------------------------------------------------------------------------------------ 29, 30
ENDOCRINE SYSTEM EMERGENCY:

Diabetic Keto Acidosis ------------------------------------------------------------------------------ 31, 32
Hyperglycemic Hyperosmolar State -------------------------------------------------------------------- 33
Hypoglycemia ---------------------------------------------------------------------------------------------------- 34
Thyrotoxic Crisis ----------------------------------------------------------------------------------------------- 35
Myxedema Coma ------------------------------------------------------------------------------------------------ 36
Acute Adrenal Crisis ----------------------------------------------------------------------------------------- 37
MISCELLANEOUS EMERGENCY:
Hyperkalemia ----------------------------------------------------------------------------------------------------------------- 38
Hypercalceamia -------------------------------------------------------------------------------------------------------------- 39
Coma ----------------------------------------------------------------------------------------------------------------------- 40, 41

CARDIO-VASCULAR SYSTEM EMERGENCY
 Acute Pulmonary Edema (Pulmonary Congestion)

Definition: It is an Acute Left Side Heat Failure.
Causes: Most Common Cause of Acute Pulmonary Edema is  Myocardial Infarction.

Also Acute Pulmonary Edema Caused By  Atrial Fibrillation with Mitral Stenosis.
 Symptoms & Signs of Acute Pulmonary Edema:
Symptoms of Acute Pulmonary Edema Signs of Acute Pulmonary Edema
1. Sudden Dyspnea at Rest. 1. Agitation & Distressed.

2. Orthopnea. 2. Pale Periphery & Central Cyanosis.
3. Proxysmal Nocturnal Dyspnea (PND). 3. Hypotension & Tachycardia.
4. Cough with Frothy Sputum + Blood (Heamoptysis) 4. Bilateral Basal Crackles.
5. Wheeze. 5. Raised Jugular Venous Pressure.
 Management of Acute Pulmonary Edema:
 Call For Help + Admission In Coronary Care Unit (CCU) +

Patient On Sitting Position + Full Monitoring (Blood Pressure, ECG,
Heart Rate, Respiratory Rate, O2 Saturation).
 A.B.C:
A= Air Way  Oxygen Poly Mask High Concentration.
B= Breathing  Asses Breathing By Counting the Respiratory Rate (Tachypnic Pt).
C= Circulation  Insert Two Large IV Canula and Take Blood For Investigations;
(CBC  For Base Line Hemoglobin, Urea Electrolytes  to Asses Renal Function).
 Stabilize the Patient By:

IV Morphin (5mg)
*Best Choice to Decrease Anxiety & Agitation of the Patient.
*Also Morphin Decrease Dyspnea & Can Lead to Vasodilatation.
Note: Give Anti-Emetic (Metoclopramide 10mg) Because Morphin Cause Vomiting.

 Check the Systolic Blood Pressure of the Patient:
If the Systolic Blood Pressure More If the Systolic Blood Pressure Less
than 90 mmHg: than 90 mmHg:
Give the Patient IV Furesmaide 40-80 mg. Give the Patient IV Dobutamine 2.5-10
mg/kg/Minute.
If There is No Response:
Give the Patient 2nd Dose IV Furesmaide 40-80 mg. If the Systolic BP Became More than 90 mmHg:
Give the Patient IV Furesmaide 40-80 mg
If There is No Response: (and Repeat First Cycle)
Check From Systolic Blood Pressure; If It Was More
than 110mmHg  Give the Patient IV Nitrate If There is No Response:
(Isosorbid Di-Nitrate 2-10 mg/Hour). Give the Patient 2nd Dose IV Furesmaide 40-80
mg.
Note:
Nitrate is Vasodilator Drug (Veno-Dilator) Lead to If There is No Response:
Dilation of Veins & Decrease Venous Return  Check From Systolic Blood Pressure; If It Was
Improve Pulmonary Congestion. More than 110mmHg  Give the Patient IV
Nitrate (Isosorbid Di-Nitrate 2-10 mg/Hour).
 Investigations of Acute Pulmonary Edema:

Investigations For Cause Investigations For Diagnosis Investigations For
Hypoxia
Chest X Ray  Detect Pulm Congestion.

1. Echo Cardio Graphy Arterial Blood Gas.
(ECG). *Features of Pulmonary Congestion (ABCDE):
2. Cardiac Enzyme. A  Alveolar Edema  Butter Fly Opacity. * Detect  Hypoxia &
B  B- Line  Due to Interstitial Edema. Type of Hypoxia.
* Detect  Myocardial C  Cardiomegaly.
Infarction (MI). D  Dilated Upper Lobe Vessels.
E  Pleural Effusion.

 Malignant Hypertension (Accelerated Hypertension):
Also Called Hypertensive Crisis;

Rare Condition Characterized By Very High Blood Pressure & End Organ Damage.
(Blood Pressure Will Be More than  230/140mmHg).
 Management of Hypertensive Crisis:
 Call For Help + Admission In Coronary Care Unit (CCU) +

Bed Rest + Oxygen Poly Mask High Concentration + Full
Monitoring (Blood Pressure, ECG, Heart Rate, Respiratory Rate).
 Now According to:

  
If Malignant HTN Without Organ If Malignant HTN With Organ

Damage (Urgent Case): Damage (Emergency Case):
Give Oral Anti-Hypertensive Drugs: Give Parental (I.V) Anti-Hypertensive Drugs:
1. Diuretics. 1- I.V Diuretics  Furesmide 40 – 80mg.

2. β- Blockers. 2- I.V β- Blockers  Labetalol 50mg.
3. ACE Inhibitors. 3- I.V Sodium Nitroprusside 0.5 Microgram/kg.
 Other Anti-Hypertensive Treatment Could Be Used:

Hydralazne  I.M.
Nitrates  I.V.
Note:
Lowering of Blood Pressure Should Be Slowly;
Because  Lowering Blood Pressure Rapid Lead to
Cerebral Edema & Hypotension.

Unstable Angina (UA) &

Partial Thickness Myocardial Infarction OR
Non ST Segment Elevation MI (Non STEMI)
Definition: They are an Acute Coronary Syndrome Caused By Partial Occlusion of

Coronary Artery Which Clinically Presented with Retro-Sternal Chest Pain Due to
Myocardial Ischemia.
 Symptoms of UA & Non STEMI  Chest Pain;

Site: Retro-Sternal (Central).
Onset: Sudden.
Character: Pressure, Squeezing, Compression, Tightness, Heaviness.
Radiate: Lower Jaw, Neck, Left Shoulder, Left Arm and Upper Abdomen.
Relieving Nitrate  Sub Lingual Glyceryl Tri Nitrate (GTN).
Aggravating: Even at Rest.
Associated Symptoms: Dyspnea, Nausea, OR Vomiting.
Time of Pain: More Than 30 Minutes.
 Management of UA & Non STEMI:
 Call For Help + Admission In Coronary Care Unit (CCU) + Bed

Rest + Full Monitoring (ECG, Blood Pressure, Heart Rate, Respiratory Rate).
 A.B.C:
B= Breathing  Asses Breathing By Counting the Respiratory Rate.
(Cardiac Enzyme, CBC For Base Line Hemoglobin & Leukocytosis ).

 Give the Patient Nitrate (Sub-Lingual GTN) as First Aid.
 Do Serial ECG Every Half Hour.
 Give 4 Anti;
Anti Pain: Anti Platelets: Anti Coagulant: Anti Angina:

(Analgesia)
*I.V Morphin *Aspirin 300mg. *Heparin. *I.V β–Blockers.

Crushed Tablet Orally. Within First 12 Hours.
5-10mg. Advantages:
&
Advantages:
Give Anti-Emetic *Clopidogrel. 1. Decrease Thombo- 1. Decrease Pain.
(Metoclopramide 10mg); Embolic Complications 2. Prevent Arrhythmia.
Because Morphin Cause Decrease Mortality in (DVT).
Vomiting. 25% of Patients. *If there is
Better in First 12 2. Prevent Formation Contraindication of
Hours. of New Thrombus. Beta Blockers Use 
IV Nitrate OR Calcium
Note: 3. Prevent Thrombus to Channel Antagonist.
IV Glycoprotein Increase in Size.
IIb/IIIa Antagonist Note:
(Abcximab); Don’t Use Nifedipine or
Continue Giving Heparin
Can Be Given to High Amlodipine Alone
Until Discharge OR
Risk Patients According Because They Lead to
For 8 Days.
to GRACE Score. Tachycardia.
So Give B- Blockers
with Nifedipine OR
Amlodipine.
Don’t Use Thrombolytic Therapy in Patients with Unstable Angina & Non STEMI
 Now Do Risk Stratification According to  GRACE Score:
If  Low Risk GRACE Score: If  High Risk GRACE Score:
Patient Should Do Exercise ECG After 4 Weeks: Do Early Coronary Angiography Followed
By Revascularization (PCI or CABG) within
If Exercise ECG was Negative Good Prognosis. First 48 Hours.
If Exercise ECG was Positive Do Coronary Angiography.

High Risk GRACE Score are:
1. Recurrent Ischemia.
2. High Serum Troponin.
3. ST Segment Depression.
4. Left Ventricular Failure OR Low BP.
5. Ventricular Tachycardia OR Previous CABG.
 Long Term Treatment of UA & Non STEMI:

1. β–Blockers.
2. Satins
3. ACE Inhibitors Long Life.
4. Anti Platelet Therapy Combination  Aspirin and Clapidogrel for 9, 12 Months,
Then Continue with Aspirin Only.
 Investigations of UA & Non STEMI:
1. ECG:
Show  ST Depression and/OR T-wave Inversion,
No Pathological Q wave.
2. Cardiac Enzyme: CK-MB and/OR Troponin

Elevated in  Non STEMI,
Normal in  Unstable Angina Except Troponin May Slightly High.

Full Thickness Myocardial Infarction OR

ST Segment Elevation Myocardial Infarction
(STEMI)
Definition: It is an Acute Coronary Syndrome Caused By Persistent & Complete
Occlusion of Coronary Artery.
 Symptoms of Full Thickness MI (STEMI):

1. Sever Retro-Sternal (Central) Chest Pain Lasting for More Than 30 Minutes.
2. Sweating + Nausea & Vomiting.
3. Syncope  Due to Sever Hypotension OR Arrhythmia.
4. Breathlessness  Due to Left Side Heart Failure (Pulmonary Congestion).
5. Abdominal Pain  Due to Inferior MI.
6. Sudden Death  Due to Ventricular Tachycardia & Ventricular Fibrillation.
7. Asymptomatic OR Silent OR Painless MI  Due to Diabetic Neuropathy,
Elderly, Transplanted Heart & Patient Under Anesthesia OR Coma.
 Sings of Full Thickness MI (STEMI):

1. Sweating & Tachycardia Due to Sympathetic Activation (25% of Anterior MI).
2. Vomiting & Bradycardia  Parasympathetic Activation (50% of Inferior MI).
3. Raised JVP & Wheeze  Due to Left Side Heart Failure (Pulmonary Congestion).
4. Fever  Due to Myocardial Tissue Damage.
5. Sudden Death  Due to Ventricular Tachycardia & Ventricular Fibrillation.
 Diagnosis of Full Thickness MI (STEMI):
1. Typical Chest Pain (Retrosternal)  Lasting For More Than 30 Minutes.

2. Typical ECG Finding  ST Segment Elevation.
3. Elevated Cardiac Enzyme  High Troponin & Creatin Kinase MB.
   
At Least 2 From 3 Diagnose Myocardial Infarction.

 Management of Full Thickness MI (STEMI):

 A.B.C:
(Cardiac Enzyme, Blood Sugar, CBC For Base Line Hemoglobin & Leukocytosis ).
 Give the Patient Nitrate (Sub-Lingual GTN) as First Aid.
 Do Serial ECG Every Half Hour.
 Give 4 Anti;
Anti Pain: Anti Platelets: Anti Coagulant: Anti Angina:

(Analgesia)
*I.V Morphin *Aspirin 300mg. *Heparin. *I.V β–Blockers.

Crushed Tablet Orally. Within First 12 Hours.
5-10mg. Advantages:
&
Advantages:
Give Anti-Emetic *Clopidogrel. 1. Decrease Thombo- 1. Decrease Pain.
(Metoclopramide 10mg);
Embolic Complications 2. Prevent Arrhythmia.
Because Morphin Cause Decrease Mortality in
(DVT).
Vomiting. 25% of Patients. *If there is
Better in First 12 Contraindication of
2. Prevent Formation
Note: Hours. Beta Blockers Use 
of New Thrombus.
Don’t Give Morphin I.M IV Nitrate OR Calcium
Note:
Because It Lead to Channel Antagonist.
IV Glycoprotein 3. Prevent Thrombus to
Heamaturea If Given
IIb/IIIa Antagonist Increase in Size.
I.M with Thrombolytic. Note:
(Abcximab) Given to; Don’t Use Nifedipine or
1. High Risk Patients Continue Giving Heparin
Amlodipine Alone
According to GRACE Until Discharge OR
Because They Lead to
Score. For 8 Days.
Tachycardia.
2. If We Will Do PCI. So Give B- Blockers
3. Recurrent Symptoms. with Nifedipine OR
Amlodipine.

 Re-Perfusion:
To Restore Coronary Patency, Improve Survival &
Decrease Mortality (25% – 50%).
1- Primary Per-Cutaneous Coronary Intervention (1ry PCI):

It’s the Treatment of Choice If Readily Available.
Best Result If Used with Glycoprotein IIb/IIIa Antagonist.
More Effective than Thrombolytic Therapy.
Decrease Risk of Death More Than Thrombolytic By 50%.
If 1ry PCI Can’t Achieved within 2 Hours of Diagnosis; Then Give Thrombolytic.
2- Thrombolytic Therapy (Fibrinolysis):

They Increase Activity of Fibrinlytic System.
Types of Thrombolytic:
Streptokinase: Alteplase
(Tissue Plasminogen Activator):
It is a Foreign Protein (Bacterial Enzyme
Streptococcus); So May Induce Allergic It is Human Tissue Plasminogen Activator But is
Reaction & Hypotension. a Recombinant Protein; So Not Allergic.
Given I.V Infusion. Given I.V Infusion.
Side Effect: Side Effect:

1- Bleeding & Reperfusion Arrhythmia. 1- Bleeding & Reperfusion Arrhythmia.
2- Allergic Reaction (Antibody Production). 2- High Risk of Cerebral Heamorrhage.
Note: Note:
 Streptokinase If Given Once  Antibody  Ateplase Has Better Survival Rate than
Formation; So You Can’t Give It More. Streptokinase.
 Rehabilitation Post Full Thickness MI:
*Patient Can Mobilize From 2nd Day If No Complications.

*Patient Can Be Discharged From 3rd to 5th Day If No Complications.
*Patient Can Do Walking Activity From 1st to 2nd Week If No Complications.
*Patient Can Return to Work From 4th to 6th Week If No Complications.
*Patient Can Drive From 4th to 6th Week If No Complications.

 Secondary Prevention Post Full Thickness MI:
Life Style Control: Drugs:
1. Stop Smoking. 1. Anti Platelet Therapy Combination:

Aspirin and Clapidogrel for 9, 12 Months,
Then Continue with Aspirin Only,
2. Control Hypertension, Diabetes Mellitus & They Decrease Risk of Recurrent MI (25%)
Serum Cholesterol.
2. Statin : (Simvastatin OR Atrovastatin).
3. Decrease Weight & Regular Exercise. 3. β–Blockers: Given for at Least 2 Years; If
There is No Contraindication,
(Decrease Mortality in 25% of Patients).
4. Decrease Saturated Animal Fat.
4. ACE Inhibitors: Given Long Life to All Patients
with MI; Because They Prevent Remodeling, Heart
5. Increase Vegetables Fruits & Omega 3 in Failure &  Risk of Ventricular Aneurysm,
Diet. Also Decrease Risk of Recurrent MI & Decrease
Hospitalization.
They Improve Survival Also.
 Investigations of Full Thickness MI:
1. Electro Cardio Graphy (ECG):

Diagnostic For 80% to 85% of Cases,
The Remaining 15% to 20% of MI Don't Have Clear Evidence on ECG,
So  Normal ECG Doesn’t Exclude MI.
ECG Changes in MI:

 ST Segment Elevation.
 Pathological Q Wave.
 New Left Bundle Branch Block.

2. Plasma Cardiac Enzymes:
Troponin (I & T): It is the Most Sensitive Markers of Myocardial Cell Damage.
Released Within  4 – 6 Hours.
Reach to the Peak Within  12 – 24 Hours.
Return to Normal Within  10 – 14 Days.
Other Differential Diagnosis For High Troponin:

1. Congestive Heart Failure.
2. Myocarditis.
3. Pulmonary Embolism.
Creatine Kinase Released Within First  4 – 6 Hours.
Reach to the Peak Within  12 Hours.
MB:
(CK MB)
Types of Creatine Kinase (CK):
Creatine Kinase MB (CK MB)  Found in Hear Muscle.
Creatine Kinase MM (CK MM) Found in Skeletal Muscles.
Creatine Kinase BB (CK BB)  Found in Brain.
*Differential Diagnosis of High Creatine Kinase:

1. Intra Muscular Injection.
2. Vigorous Physical Exercise.
3. Post Trauma (Fall Down).
4. Defibrillation (DC Shock).
Myoglobin: Released Within First  1 – 2 Hours (First to Rise).

Reach to the Peak Within  6 - 8 Hours.
*Myoglobin is Not Specific.
3. Chest X Ray:
To Detect  Pulmonary Congestion.
To Exclude  Pneumothorax & Aortic Dissection.
4. Echo Cardiography:
To Detect  Ventricular Function (EF%).
To Detect  Complications of MI.

 Atrial Fibrillation
Definition: It is a Multiple Re-Entry of Impulses in Atrium Leading to Spontaneous,

Rapid, Ineffective Atrial Contraction, (Atrial Rate > 350 Beat/Minute).
Characterized By Irregular R-R Interval.
*During Atrial Fibrillation:

1. Atrium Contraction is Ineffective (Leading to Atrial Thrombus).
2. Ventricles Activated Irregularly.
 Clinical Pictures of Atrial Fibrillation:

Symptoms: 1. Palpitation.
2. Dizziness.
3. Dyspnea.
4. Symptoms of Underling Cause.
5. Thrombo-Embolic Symptoms  Stroke, Renal Infarction, Limb Ischemia, MI.
Signs: 1. Irregular Irregular Pulse.

2. Absent a-wave on JVP.
3. Signs of Heart Failure.
 Types of Atrial Fibrillation:

Paroxysmal Atrial Fibrillation Persistent Atrial Fibrillation Permanent Atrial Fibrillation
Short, Recurrent Episodes Prolonged, Multiple Episodes. Continuous Atrial Fibrillation

(≥2 Episodes). Episodes.
The Episodes Can Be
The Episodes Terminate Terminated By Cardioversion. The Episodes Cannot Be
Spontaneously. Cardioverted.
β-Blockers is Drug of Choice So; Target of Treatment is Control

in This Type. Rate & Prevent Thrombo-Embolism.

 Management of Atrial Fibrillation:
1. Rate Control  Done For All Patients with Atrial Fibrillation:
(A, B, C, D)  Amiodarone, β- Blockers, Calcium Channel Blockers, Digoxin.
* Amiodarone: Can Be Give For All Patients.
* β-Blockers: First Line Drug, But Not Given to Patient with Heart Failure.
*Calcium Channel Blocker: Verapamil OR Dilitiazem (Not Given to Heart Failure Patient)
* Digoxin: Used First If the Patient Has Heart Failure.
2. Restore Sinus Rhythm By  Electrical Cardioversion (DC Shock) OR

Chemical Cardoversion (Drugs);
If Atrial Fibrillation Less Than 2 Days: If Atrial Fibrillation More Than 2 Days:
Do Trans-Esophageal Echo:
*If Echo Didn’t Detect Thrombus:
Do Electrical Cardioversion (DC Shock) with Do Electrical Cardioversion (DC Shock) with I.V Heparin.
I.V Heparin. *If Echo Detect Thrombus:
Give Warfarin Until INR Become 2-3, For 3 Weeks,
Then Do Electrical Cardioversion (DC Shock).
-------------------------------------------------
If DC Shock Failed; Give Chemical Cardioversion
(Amiodarone OR Sotalol).
Warfarin Must Be Continue for at Least 4 Weeks.
3. Prevent Recurrence By:

Amiodarone  Drug of Choice for Patients with Cardiac Disease.
Flecainide  Drug of Choice for Patients without Cardiac Disease.
4. Cure Persistent Cases By  Radio-Frequency Ablation.
5. Prevent of Thrombo-Embolism By  Aspirin OR Warfarin.

Choice of Thrombo-Embolism Drug s is According to  CHDS2 VASC Score;
C  Congestive Heart Failure = 1 Point.
H  Hypertension = 1 Point.
D  Diabetes Miletus = 1 Point.
S  Stroke OR TIA = 2 Points.
V  Vascular Diseases (Aortic Atherosclerosis, PVD) = 1 Point.
A  Age From 65 to 74 Years = 1 Point and >= 75 Years = 2 Points.
S  Sex  Male = No Points and Female = 1 Point.
If Score  Zero  No Treatment.

If Score  1  Give Aspirin.
If Score  2 OR More  Give Warfarin (Target INR  2-3).

 Ventricular Tachycardia & Ventricular Fibrillation (VT & VF):
Most of The Patients of VT & VF Has History of Myocardial Infarction.
 Management of VT & VF:

 A.B.C:
(Cardiac Enzyme, Blood Sugar, CBC For Base Line Hemoglobin & Leukocytosis ).
If Un-Stable Patient OR Systolic Blood If Stable Patient OR Systolic Blood

Pressure Less Than 90 mmHg: Pressure More Than 90 mmHg:
 
DC Shock Give  I.V Lidocaine 50-100mg.

st 
1  150 Joel.
 *If Not Respond  Repeat I.V Lidocaine.
If There is No Response  150 Joel. 
 *If Not Respond  Give I.V Amiodarone.
If There is No Response  200 Joel, 
Then Insert  Implantable Cardiac Defibrillator *If Not Respond  Do DC Shock.
(ICD).
 Prevention of Ventricular Tachycardia:
1. β- Blockers with OR without Amiodarone.

2. Implantable Cardiac Defibrillator (ICD).
 ECG of VT & VF Shows:

1. Tachycardia (180-240 Beat/Minutes), with No P- Wave.
2. Wide, Regular QRS in VT, and Wide, Irregular, Bizzar QRS in VF.
3. Capture Beats and/OR Fusion Beats Only in VT.

RESPIRATORY SYSTEM EMERGENCY
 Acute Exacerbation of Asthma (Status Asthmaticus)
Acute Sever Asthma Life Threatening Asthma Near Fatal Asthma
1. PEFR 50% - 33% 1. PEFR < 33%. 1. Low PaO2 and Saturation.
2. RR > 25 Cycle/Minute 2. Silent Chest. 2. High PaCO2.
3. HR > 110 Beat/Minute 3. HR < 60 B/Minute (Bradycardia). 3. Low PH (Acidosis).
4. Pulsus Paradoxus. 4. Low Blood Pressure (Hypotension).
5. Inability to Complete 5. Patient Can’t Speak. 
Sentence in One Breath. 6. Decrease in O2 Saturation (< 92%) This Patient Need
But Normal C02. Mechanical Ventilation.
7. Central Cyanosis.
8. Confusion
 Management of Acute Exacerbation of Asthma:
 Admission (in Case of Near Fatal Asthma Admission in ICU) + Bed Rest +
Full Monitoring (ECG, Blood Pressure, Heart Rate, Respiratory Rate,
O2 Saturation, Temperature).
 A.B.C:
A= Air Way  Oxygen By Poly Mask High Concentration 60%-100% (Except in
Case of Near Fatal Asthma Give Him Low Concentration O2 By Venti Mask).
(CBC  For Base Line Hemoglobin & Leukocytosis, Don’t Forget to Collect  ABG).
 Give  Bronchodilators:
Nebulized Salbutamol 5mg Repeat Every 15 Minutes +
Nebulized Ipratropium bromide 0.5mg (Atrovent) Every 15 Minutes.

 Give  Steroids:
IV Hydrocortisone 100-200mg Every 6 Hours OR Oral Prednisolone 40mg.
If There is No Improvement within 15-30 Minutes;  Add  Single Dose

IV Magnesium Sulphate 1.2-2g/Kg Over 20 Minutes.
If There is No Response;  Do  Chest X- Ray To Exclude Pneumothorax.
Note:
You Have to Do Close Monitoring For Vital Signs (Heart Rate, ECG, O2 Saturation).
Also You Have to Do ABG & Check from Serum K Level (Because Salbutamol May
Lead to Alkalosis and Decrease Serum K level).
Note:
In Old Version Way IV Aminophylline was Giving  250mg Over 20 Minutes.
(But When You Gave Aminophylline; You Should Do Close Monitoring For ECG;
Because Aminophylline Lead to Arrhythmia).
But Now Aminophylline is Not Recommended.

 Acute Exacerbation of COPD
Definition: It is an Increasing in Symptoms of COPD & Deterioration of lung

Function Leading to Decrease of Health Status in COPD Patient.
The Most Common Cause of Acute Exacerbation of COPD is  Infection

(Pneumonia Especially Streptococcal Pneumonia).
Note:
Patient with COPD Can Be Managed at Home By Increasing Dose of
Bronchodilators & Steroids.
But the Patient Should Be Referred to the Hospital If Presented with:
1. Cyanosis.
2. Altered of Conscious Level.
3. Peripheral Edema.
 Management of Acute Exacerbation of COPD :
 Admission + Bed Rest + Full Monitoring (ECG, Blood Pressure,

Heart Rate, Respiratory Rate, O2 Saturation, Temperature).
 A.B.C:
A= Air Way  Oxygen By Venti Mask Low Concentration 24%-28%.
(CBC  For Base Line Hemoglobin & Leukocytosis For Infection, CRP and
Don’t Forget to Collect  ABG).
 Give  Bronchodilators:
Nebulized Salbutamol 5mg Repeat Every 15 Min +
Nebulized Ipratropium bromide 0.5mg (Atrovent) Every 15 Minutes.
 Give  Steroids:
IV Hydrocortisone 100-200mg Every 6 Hours OR Oral Prednisolone 40mg.

 Give  Anti Biotic:
Especially If Sputum is Purulent & Large in Amount & Febrile Patients.
 Give  Heparin:
As a Prophylaxis For DVT (Because Patients with COPD Has Polycythemia).
 If Respiratory Rate Less than 20 Cycle/Min;

Give  Doxapram:
It is a Respiratory Center Stimulant Used to Increase Respiratory Rate.
 If the Patient Has Lower Limb Edema OR Has Heart Failure;

Give  Diuretics
 If All Failed and PH < 7.35 & the Patient was Conscious;
Do  Non Invasive Intermittent Positive Pressure
Ventilation (NIPPV):
NIPPV Has Two Types:
1. C-PAP  Continuous Positive Airway Pressure: Used If the Patient Has
Respiratory Failure Type I.
2. Bi-PAP  Bi-Phasic Positive Airway Pressure: Used If the Patient Has
Respiratory Failure Type II.
 If PH < 7.26 OR High PaCO2 & the Patient was Unconscious;

Do  Mechanical Ventilation

 Pneumothorax
Definition: Presence of Air in Pleural Space.
Closed Pneumothorax Open Pneumothorax Tension Pneumothorax
The Communication between the Persistent Communication Occurs when the Leak Remains
Lung and Pleural Space is Closed, between the Lung and Pleural Open and Act as One-way Valve
No More Air Leak. Space (Broncho pleural fistula), between the Lung and Pleural
Persistent Air Leaking. Space,
Pleural Pressure Remains Progressive Increase of Air in
Negative & Resolution will Occur The Air Enters and Gets Out of Pleural Space.
Even without Treatment. Pleural Space.
Positive Pleural Pressure.
Pleural Pressure Equal to
Atmospheric Pressure, Pleural Pressure More than
Atmospheric Pressure.
Patient Has High Risk of
Infection (Empyema). Compression of the Underlying
Lung with Heart and Mediastinal
Shifting.
 Management of Pneumothorax:

 A.B.C:
A= Air Way  Oxygen By Poly Mask High Concentration.
(CBC  For Base Line Hemoglobin, and Don’t Forget to Collect  ABG).
 Do Chest X- Ray (Only If the Patient Stable).

In Case of Young to Middle Age Patient (<50) without Any Chronic Lung Disease;
Measure the Rim in Chest X Ray;

If the Rim Less than 2cm: If the Rim More than 2cm:
 
Observation of the Patient For 6 Hours Then Do Percutenous Needle Aspiration

Discharge the Patient. (By Using Large Canula at 2nd Intercostal Space in
 Mid Clavicular Line).
and You Have to Do Chest X Ray.
If There is No Improvement & the Rim Increased; 

If There is No Improvement;
Do Percutenous Needle Aspiration 
(By Using Large Canula at 2nd Intercostal Space
in Mid Clavicular Line). Repeat Percutenous Needle Aspiration.
and You Have to Do Chest X Ray. 

If There is No Improvement;
If There is No Improvement; 

Insert Chest Tube;
Repeat Percutenous Needle Aspiration. (By Using Chest Tube at 5th Intercostal Space in
 Mid Axillary Line and Connect it to the
Under Water Seal).
If There is No Improvement; and You Have to Do Chest X Ray.

Insert Chest Tube; Chest Tube Can Be Removed after 24 Hours From
(By Inserting Chest Tube at 5th Intercostal Stopping of Air Bubbling in Under Water Seal.
Space in Mid Axillary Line and Connect it to the
Under Water Seal). If Under Water Seal Continuo Bubbling
and You Have to Do Chest X Ray. From 5 to 7 Days;

Chest Tube Can Be Removed after 24 Hours From Transfer the Patient to Thoracic Surgery.
Stopping of Air Bubbling in Under Water Seal.
If Under Water Seal Continuo Bubbling

From 5 to 7 Days;

Transfer the Patient to Thoracic Surgery.

In Case of Middle to Old Age Patient (>50) with Chronic Lung Disease;
Measure the Rim in Chest X Ray;

If the Rim Less than 2cm: If the Rim More than 2cm:
 
Do Percutenous Needle Aspiration Insert Chest Tube;

(By Using Large Canula at 2nd Intercostal Space (By Using Chest Tube at 5th Intercostal Space in
in Mid Clavicular Line), Mid Axillary Line and Connect it to the Under
and You Have to Do Chest X Ray. Water Seal).

and You Have to Do Chest X Ray.
If There is No Improvement; ---------------------------------------------------------
 Note:
Make Sure If the Under Water Seal Working By
Insert Chest Tube; Asking the Patient to Cough to Watch If There
(By Inserting Chest Tube at 5th Intercostal is the Air Bubbles OR Not.
Space in Mid Axillary Line and Connect it to the ---------------------------------------------------------
Under Water Seal).
and You Have to Do Chest X Ray. Chest Tube Can Be Removed after 24 Hours From
Stopping of Air Bubbling in Under Water Seal.
Chest Tube Can Be Removed after 24 Hours From
Stopping of Air Bubbling in Under Water Seal. If Under Water Seal Continuo Bubbling
From 5 to 7 Days;
If Under Water Seal Continuo Bubbling 
From 5 to 7 Days;
 Transfer the Patient to Thoracic Surgery.
Transfer the Patient to Thoracic Surgery.
In Case of Tension Pneumothorax Immediate Chest Tube Insertion.
 Symptoms of Tension Pneumothorax:

Sudden Onset Dyspnea and Chest Pain.
NOTE:
Patients with Pneumothorax Should Not Fly for 3 Months; Because the Pressure
Changes Can Lead to Expansion of the Gas in Pleural Space and Lead to  Tension
Pneumothorax.

 Pulmonary Embolism (PE)
80% of Pulmonary Embolism Caused By Deep Venous Thrombosis (DVT).
 Management of Pulmonary Embolism:

 A.B.C:
(D- Dimer, Coagulation Profile (APTT, PT, INR) and Don’t Forget  ABG).
 Immediately Give  Anti Coagulant:

Better to Give Heparin (Fractionated OR LMWH) and Give Warfarin in Same Time.
Heparin Types & Doses:

 Un-Fractionated Heparin:  Fractionated Heparin:
7500 to 10,000 Units Bollus Followed by Enoxaparin 1mg/Kg S.C.
Continuous IV Infusion of about:
30,000-40,000 U/Day (1500-2000 U/Hour).
Heparin & Warfarin Give Together Until INR Become 2-3 OR Given at For 5 Days,
Then after INR Become 2-3; Stop Heparin and Continuo Warfarin Only,
Duration of Warfarin:
 If the Cause was Known; Given For  3 Months.
 If the Cause was Unknown; Given For  6 Months.
 If the Patient Has Anti Phospholipid Syndrome; Given  Long Life.
NOTE:
*If the Blood Pressure was < 90/60:
Start IV Infusion of Crystalloids OR Colloids and Give the Patient
Dobutamine 2.5-10 um/kg/min.
*If Anti Coagulants Are Contraindicated OR in Recurrent Pulmonary Embolism Even

When the Patient Taking Anti Coagulants; Then  Do Caval Filter (Placed in IVC).

GIT SYSTEM EMERGENCY
 Upper GIT Bleeding
Definition: Bleeding Proximal to Ligament of Treitz.
 Clinical Picture of Upper GIT Bleeding:

1. Heamatemesis: Vomiting of Fresh Blood.
2. Coffee Ground Vomiting.
3. Melena: Black Tarry, Offensive, Sticky Stool.
4. Heamatochezia: Sever Upper GIT Bleeding Associated with Bleeding Per Rectum.
5. Syncope: Due to Hypovolemic Shock & Low Blood Pressure.
 Management of Upper GIT Bleeding:

 A.B.C:
(CBC  For Base Line Hemoglobin, Blood Group, Cross Match, Coagulation Profile,
Liver Function Test).
In Case of Low Hemoglobin (< 10g/dl) OR Hypovolemic Shock (BP < 90/60mmHg)
 Give IV Fluid with Blood Transfusion.
 Do  Urgent Upper GT Endoscopy: to Identify Source of Bleeding
If the Endoscopy Shows  Esoghagitis, Gasrtitis, OR Mallory Weiss

Syndrome; Then Do  Conservative Treatment (Spontaneous Healing).

If the Endoscopy Shows  Peptic Ulcer, OR Cancer; Then Do:
Adrenaline Injection.
Heater Probe OR Laser Photocoagulation.
If the Endoscopy Shows  Esophageal Varices; Then Do:
1. Endoscopic Band Ligation OR Sclerotherapy:

 It is the Most Widely Initial Treatment, It Stops 80% of Bleeding.
 Banding Ligation Better than Sclerotherapy; Because Sclerotherapy Can Lead to
Esophageal Stricture and Also Lead to Abdominal & Chest Pain.
 Banding Ligation Can Be Repeated in 1-2 Weeks Especially If Re-bleeding Occurs.
2. Medical Treatment: Used Only in Active Bleeding.

They Decrease Portal Blood Flow By Causing Splanchnic Arterial Vasoconstriction.
They are:
 Terlipressin: (Vasopressin) 2mg / 6Hourly, Has Shown to Decrease Mortality
and It is Used with Nitroglycerin to Prevent Coronary & Renal Vasoconstriction.
 Octreotide: (Somatostatin Analog) Used when Terlipressin is Contraindicated.
3. Balloon Tamponade: By Using Sengstaken-Blakemore Tube.

Done If Endoscopic Banding Failed to Stop Bleeding (Uncontrolled Heamorrhage).
 Sengstaken-Blakemore Tube (Mineosota Tube):

 Has Two Balloon; One For Funds of the Stomach and the Other For Esophagous,
and Has Two Suction; Gastric Suction and Esophageal Suction.
 The Tube Inserted From Nose OR Mouth, Check it in Stomach By Auscultation

the Stomach While Inject Air in Stomach, OR Checked By X- Ray.
 First Inflate Gastric Balloon (200-250ml of Air) and Do Traction,

If the Bleeding Not Stopped; Then Inflate Esophageal Balloon.
 If You Inflated Esophageal Balloon; You Have to Deflate it 10Minutes/3Hours;

To Avoid Esophageal Ischemia OR Rupture.
4. Transjugular Intrahepatic Porto-Systemic Shunt (TIPPS):

Used Only If All Other Treatment Failed to Control the Bleeding.

5. Prophylactic Antibiotic: Cephalosporin OR Ciprofloxacin.
6. IV Proton Pump Inhibitors: To Prevent Peptic Ulcer OR Gastric Erosion.
7. Lactulose: To Prevent Hepatic Encephalopathy.
8. Prevention of Recurrent Bleeding:

 Drug  Propranolol 60-180 mg/Day, OR Nadolol.
They Reduces Portal Pressure & Used to Prevent Recurrent Variceal Bleeding.
 Non-pharmacological  TIPS, Endoscopic Band Ligation OR Sclerotherapy.
 Hepatic Encephalopathy
Definition: It is a Reversible State of Disordered CNS Function Associated with

Severe Acute OR Chronic Liver Disease.
 Clinical Picture of Hepatic Encephalopathy:

Mild Confusion  Moderate Confusion  Marked Confusion  Coma.
Others: Sleeping Disorder, Lethargy, Drowsiness, Convulsion, Flapping Tremor.
 Management of Hepatic Encephalopathy:
1. Remove the Precipitating Factors (Prevent Portal HTN By  Propranolol).
2. Decrease Ammonia (NH3) By:

 Decrease Protein in Diet.
 Oral Lactulose: Decrease PH of Colon  Decrease Ammonia Absorption From
Colon, Produce Diarrhea, Alters Bowel Flora.
Lactulose Given Until Bowel Motion Become 2 Times /Day.
3. If the Patient Can Not Tolerate Lactulose; Give Him  Neomycin.

NEUROLOGICAL SYSTEM EMERGENCY
 Status Epilepticus
Definition: It is a Series of Seizures Occurs without the Patient Return to

Awareness Between Attacks Lasting For More than 30 Minutes.
 Causes of Status Epilepticus:

• Sudden Withdrawal of Anti-Convulsant Drugs.
• Acute Metabolic Disturbance (Electrolyte Disturbance).
• Presence of Major Structural Lesion.
 Management of Status Epilepticus:

 A.B.C:
(Urea Electrolyte (Serum Na, K), Blood Glucose, Calcium, Magnesium, LFT).
 Give Diazepam 10mg IV OR Rectally OR Give; Lorazepam 4mg IV

   
If Seizures Continue After 15 Minutes; Repeat Diazepam OR Lorazepam IV.

   
If Seizures Continue After 30 Minutes; Give Pheytoin 15mg/Kg IV Infusion.

   
If Seizures Continue After 15 Minutes; Give Phenobarbital 10mg/Kg IV Infusion.

   
If Seizures Continue After 15 Minutes; Give Phenobarbital 10mg/Kg IV Infusion.

   
If Seizures Continue After 30-60 Minutes; Do Intubation & Ventilation and

Give General Anesthesia (Propofol OR Thiopental OR Medazolam).

 Stroke OR CVA (Ischemic & Heamorrhagic)
Definition: It is a Sudden Onset Neurological Deficit Lasting For > 24 Hours.
 Management of Stroke:

 A.B.C:
(CBC, ESR, Coagulation Profile, Blood Glucose, Urea Electrolytes, Lipid Profile).
 NPO & Do  Urgent Brain CT Scan & Then;
If the Brain CT Doesn’t Show Any Lesion OR Shows Black Lesion;
Then It is an Ischemic Stroke; Then:
If the Ischemic Stroke at First 3 Hours: If the Ischemic Stroke at After 3 Hours:
Give the Patient  Thrombolytic (Tissue Give the Patient  Aspirin 300mg Crushed
Plasminogen Activator). Orally.
 Don’t Lower the Blood Pressure in the First Week; Because

My Lead to Decrease of Cerebral Perfusion and Increase the
Infarction.
 You Should Lowering the Blood Glucose If It Was High;

Because High Blood Glucose May Increase Size of Infarction.
 You Should Lowering the Temperature If It Was High;

Because Fever May Increase Size of Infarction.

After Stabilizing the Patient;

 Asses the Swallowing and Gag Reflex;

If +ve Chocking  NPO & Insert Naso-Gastric Tube (NGT).
If -ve Chocking  No Need For NGT.
 Secondary Prevention of Stroke;

Give the Patient Aspirin Low Dose & Statin.
 Turn the Patient Side to Side to Avoid Bed Pressure Sore.
 Avoid DVT By Elastic Stokes.
 Treat and Control Any Risk Factor For Atherosclerosis.
 Treat Any Infection (Especially UTI).
 Pschycological Support.
 Physiotherapy.
----------------------------------------------------------------------
If the Brain CT Shows White Lesion;
Then It is a Heamorrhagic Stroke; Then:
 Avoid Aspirin and Avoid Thrombolytic.
 You Can Lower the Blood Pressure But Gradually.
 Neuro-Surgical Opinion.
The Neurosurgeon Will Advice Mannitol to Decrease the Edema.

ENOCRINE SYSTEM EMERGENCY
 Diabetic Keto Acidosis (DKA)
Definition: It is a Clinical Case Result From Sever Insulin Deficiency with High
Blood Sugar (250-600mg/dl).
 Clinical Feature:
• Polyuria, Polydepsia & Weight loss.
• Anorexia, Nausea, Vomiting and Abdominal pain.
• Kussmaul Respirations and an Acetone Odor on the Patient's Breath.
• Vital Signs: High Heart Rate, Low Blood Pressure, high Respiratory Rate, ± Fever.
• Altered Mental Function OR Even Coma.
 Management of Diabetic Keto Acidosis (DKA):

 A.B.C:
(Blood Sugar, Urea Electrolytes (Serum K & Na), Don’t Forget to Collect  ABG).
 Give  IV Fluid Replacement:

0.9 Normal Saline
One Liter Over 30 Minutes.
One Liter Over 1 Hour.
One Liter Over 2 Hours.
One Liter Over Next 4 Hours.
When Blood Glucose Reach to 270mg/dl; Switch to  5% Dextrose Saline

One Liter Over 8 Hours; to Decrease Risk of Brain Edema.
Typical Recruitment of IV Fluid are  6 Liters in First 24 Hours.

 Give  Insulin:
Regular (Soluble) Insulin
50 I.U Soluble Insulin in 50ml of 0.9 Normal Saline Via Infusion Pump.
6 I.U/Hour Initially.
 When Blood Glucose Reach  270mg/dl; Change to  3 I.U/Hour.
 When Blood Glucose Reach  180mg/dl; Change to  2 I.U/Hour.
Don’t Forget to Check Blood Glucose Hourly (in the First 24 Hours).
 Now Check Potassium Level in the Blood (K):
If Potassium Level Less than 3.5mmol/L;

Give  20mmol Potassium Chloride (KCL).
If Potassium Level Between 3.5 - 5mmol/L;
Give  10mmol Potassium Chloride (KCL).
If Potassium Level More than 5mmol/L;
Don’t Give Potassium Chloride (KCL).
Don’t Forget to Check Serum K Level Every 4 Hours (in the First 24 Hours).
Note:
Insulin Decrease Potassium Level in Blood; Because Insulin Take Potassium From
Blood to Inside the Cells, That’s Why We to Check From Potassium Level in Blood
and If it was Low OR Eve Normal; You Can Give Potassium (KCL).
 Now Check PH:
If PH Less than 7; Give  IV Sodium Bicarbonate (NaHco3)  1.4%.
Don’t Forget to Check PH Every 4 Hours (in the First 24 Hours).
 Give  Anti Biotic:  If Infection is Suspected.
 Finally  When the Patient Start Eating; Stop Insulin Infusion & Give:
Sub Cutaneous Intermediate OR Long Acting Insulin.

 Hyperglycemic Hyperosmolar State (HHS)
[Hyperosmolar Non-Ketotic Diabetic Coma (HNKDC)]
Typically an Elderly Patient with Polyuria, Thirst, Weight Loss ± Decreased Level
of Consciousness, Presented with Vomiting & Abdominal Pain.
 Management of Hyperglycemic Hyperosmolar State (HHS):

 A.B.C:
(Blood Sugar, Urea Electrolytes (Serum K & Na), Don’t Forget to Collect  ABG).
 Give  Insulin:
Similar to DKA But Half Insulin Dose; Because Patient is More Sensitive to Insulin.
Regular (Soluble) Insulin

50 I.U Soluble Insulin in 50ml of 0.45 Normal Saline Via Infusion Pump.
3 I.U/Hour.
Don’t Forget to Check Blood Glucose Hourly (in the First 24 Hours).
 Give  Prophylactic Heparin:

It is Recommended For Thrombo-Embolism.
 Prognosis of HHS:
Mortality Rate about 40% Due to Presence of Other Disease. (Ex; IHD).

 Hypoglycemia
Definition: Blood Glucose Level Less than 50 mg/dl.
 Causes of Hypoglycemia:
Missed OR Inadequate Meal, Poor Insulin Regimen,
Malabsorption (Cealiac Disease), Gastroparesis (Delay Gastric Emptying),
Lipodystrophy at Site of Injection, Unusual Exercise, Alcohol.
1. Increase of Sympathetic Activity:
• Sweating •Tremor • Tachycardia • Anxiety • Hunger.
2. Neuroglycopenic Symptoms:
• Dizziness • Headache • Confusion.
3. When Blood Glucose Become Below 40mg/dl:

CNS: Seizures • Neurological Deficit (CVA or TIA) • Coma & Death If Prolonged.
CVS: Arrhythmia • Myocardial Infarction.
Eyes: Vitreous Hemorrhage.
 Management of Hypoglycemia:
According to the Patient State:

  
If the Patient Was Conscious and Able to Drink;

Give Him  Oral Glucose (Glucose Drink OR Honey).

If the Patient Came with Decrease of Conscious Level;

Give Him  75ml 50% Dextrose IV.

If the Patient Came with Decrease of Conscious Level and There is No Vein
Can Be Canulated;
Give Him  IM Glucagon 1mg.

 Thyrotoxic Crisis (Thyroid Storm)
Definition: It is a Life Threatening Thyrotoxicosis Precipitated by Infection OR

Post-Subtotal Thyroidectomy OR Post Radio-Active Iodine with Mortality Rate 10%
Fever, Irritability, Confusion, Vomiting, Diarrhea Tachycardia & Atrial Fibrillation.
 Management of Thyrotoxic Crisis (Thyroid Storm):

 A.B.C:
(TFT, Urea Electrolytes, CBC, Blood Glucose).
 Give  IV Fluid (Rehydrate the Patient).
 Give  Antibiotic.
 Give  β-blockers (Propranolol) For Symptoms.
 Give Propylthiouracil OR Carbimazole (Carbimazole Can Given Rectally)
Propylthiouracil is Better; Because It Decrease Peripheral Conversion of T4 to T3.
 Give Sodium Ipodate:

It Restore Serum T3 to Normal in 48-72 Hours.
 Give  Dexamethasone:
Inhibit Release and Conversion of T4 to T3.

 Myxedema Coma
Definition: It is a Rare Medical Emergency with Mortality Rate of 50%.
 Clinical Feature: (4Hypo):

1. Hypothyroidism.
2. Hypothermia.
3. Hypoglycemia.
4. Hypoventilation.
5. Decrease of Conscious Level.
 Management of Myxedema Coma:

 A.B.C:
(TFT, Urea Electrolytes, CBC, Blood Glucose, Don’t Forget to Collect  ABG).
 Worm the Patient Gradually.
 Give  IV Fluid (Rehydrate the Patient).
 Give  IV Glucose.
 Give  Antibiotic.
 Give  IV T3:
Given 20 µg For 48-72 Hours, Then Change to Oral Thyroxin 50 µg Daily.
 Give  Hydrocortisone:
Because It May 2ry Hypothyroidism & Associated with  Cortisone.

 Acute Adrenal Crisis (Acute Addison Crisis)
Definition: Severe Hypotension with Hyponatremia, Hyperkalemia & Hypoglycemia.

Presented with Abdominal Pain, Vomiting, Diarrhea.
 Causes of Acute Adrenal Crisis:

1. Infection.
2. Any Stress Especially  Surgery.
3. Sudden Stoppage of Treatment (Steroid Stoppage).
 Management of Acute Adrenal Crisis:

 A.B.C:
(CBC, Urea Electrolyte (Serum Na, K), Blood Glucose, ACTH).
 Now Give  3S:

Saline + Sugar + Steroid.
Saline  IV Fluid  0.9 Normal Saline.

Sugar  IV Fluid  10% Dextrose Saline.
Steroid  Hydrocortisone 200mg IV Stat Then 100mg 8 Hourly
 Remove Precipitating Factors:

Give  Antibiotic For Infection.

MISCELLANEOUS EMERGENCY
 Hyperkalemia
Definition: Serum Potassium Level More than 5mmol/L.

If Serum Potassium Level More than 7mmol/L; It is Dangerous Condition; Because
It is Leading to Cardiac Arrest (VT, VF) Due to Marked Sowing of Action Potential.
 Causes of Hyperkalenia:
1• Increase of Exogenous K (Increase Intake): Diet, IV Fluid.
2• Increase of Endogenous K: Heamolysis, IV Fluid.
3• Disease: Chronic Kidney Disease (CKD), Renal Tubular Acidosis Type 4 (RTA),
Addison’s disease (Low Aldosterone), Diabetic Keto Acidosis (DKA), Any Acidosis.
4• Drugs: Spironolactone, ACE Inhibitors, Beta Blockers, NSAID, Digoxin Toxicity.
 Management of Sever Hyperkalemia:
 Admission + Bed Rest + ECG Monitoring.
 A.B.C:
(Urea Electrolyte (Serum K, Na), Blood Glucose, Don’t Forget to Collect  ABG).
 Protect the Heart Give IV Ca Gluconate 10%/ 10ml Over 10 Minutes.

  
 Shift K From Serum into Cells By Giving:

1. Insulin: 5 Units IV with 50ml/50% Dextrose Water.
2. Inhaler Beta2 Agonist (Ventolin).
3. If PH Less than 7; Give Sodium Bicarbonate (NaHco3) 1.4%.
  
 Remove K From the Body By Giving:

Calcium Resonium (Orally OR Rectally): Bind to K in GIT & Prevent Absorption.
  
 If All Measures Failed; Do  Heamodialysis.

 Hypercalcaemia
Definition: Serum Calcium Level More than 11mg/dl.
 Causes of Hypercalcaemia:
1• Hyperparathyroidism (Primary & Tertiary).
2• Malignancy: Multiple Myeloma, Ca Lung, Ca Breast, Ca Kidney, Ca Thyroid.
3• Vitamin D Intoxication (Excess Vitamin D).
4• Sarcoidosis.
5• Thyrotoxicosis.
6• Addison’s Disease.
7• Drugs: Thiazide.
 Management of Sever Hypercalcaemia:
 Admission + Bed Rest + ECG Monitoring.
 A.B.C:
(Serum Calcium, Parathyroid Hormone).
 Give  IV Fluid Normal Saline 0.9%  2-4 L/Day.
 Give  IV Bisphosphonate: (Pamidronate, Zolendronate, Clodronate)

They Inhibit Osteoclast Activity.
 Give  Calcitonin IV OR S/C:

Especially in Life Threatening Hypercalcaemia.
 In Case of Sarcoidosis, Malignancy; GiveSteroid (Prednisolone)
 If All Measures Failed; Do  Heamodialysis.

 Coma
Definition: It is a State in Which the Patient Unresponsive to Environmental

Stimuli and Unable to Communicate in Any Manner.
 Causes of Coma:
1• Metabolic Causes:
• Systemic Failure: Respiratory Failure, Liver Failure, Renal Failure, Hypothyroidism.
• DM Complications: Hypoglycemia, DKA, Hyperglycemic Hyerosmolar Coma.
• Hypo OR Hypernatremia, Acidosis, Hypothermia.
• Drugs & Toxins: Opioids, Alcohol, Organophosphate.
• Thiamin Deficiency (Wernicke’s Encephalopathy).
2• Trauma:
• Subdural Heamatoma.
• Epidural Heamatoma.
3• Infarction:
• Cerebral Infarction.
• Brainstem Infarction.
• Sub-Arachnoid Heamorrhage (SAH).
4• Infection:
Meningitis, Encephalitis, Brain Abscess, Generalized Sepsis.
5• Tumor.
 Quick Assessment For Comatose Patient By:

Glasgow Coma Scale and Pupils.
Glasgow Coma Scale

Eye Opening Verbal Response Motor Response
• Spontaneous = 4 • Oriented to Sounds = 5 • Obeys Commands = 6
• To Speech = 3 • Confused = 4 • Move to Localize the Pain = 5
• To Pain = 2 • Inappropriate Words = 3 • Flex to Withdraw From Pain = 4
• Non = 1 • Incomprehensible Sounds = 2 • Abnormal Flexion = 3
• Non = 1 • Abnormal Extension = 2
• Non = 1
Complete Score  15, Compensated  8-3, Unresponsive  3

Pupils
Pin-Point Large Non-Reactive
Differentia Diagnosis: Differentia Diagnosis:
• Pontine Heamorrhage. • Third Cranial Nerve Palsy (III Nerve Palsy).

• Opiate Overdose. • Barbiturate Overdose.
• Organophosphate Poisoning.
 Management of Coma:

 A.B.C:
(Blood Glucose, Urea Electrolytes (Serum Na, K), LFT, CBC, Don’t Forget  ABG).
 Give  Coma Cocktail;

50ml/50% Dextrose + 100mg Thiamine + 0.4mg Naloxone
 Definitive Treatment Will Depend on the Cause.

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EMERGENCY MEDICINE

1 DR. MOHCEN AL. HAJ

CARDO-VASCULAR SYSTEM EMERGENCY:

RESPIRATORY SYSTEM EMERGENCY:

GASTRO INTESTINAL TRACT SYSTEM EMERGENCY:

NEUROLOGICAL SYSTEM EMERGENCY:

ENDOCRINE SYSTEM EMERGENCY:

2 DR. MOHCEN AL. HAJ

 Acute Pulmonary Edema (Pulmonary Congestion)

Causes: Most Common Cause of Acute Pulmonary Edema is  Myocardial Infarction.

 Symptoms & Signs of Acute Pulmonary Edema:

Symptoms of Acute Pulmonary Edema Signs of Acute Pulmonary Edema

1. Sudden Dyspnea at Rest. 1. Agitation & Distressed.

 Management of Acute Pulmonary Edema:

 Call For Help + Admission In Coronary Care Unit (CCU) +

 Stabilize the Patient By:

3 DR. MOHCEN AL. HAJ

 Investigations of Acute Pulmonary Edema:

Chest X Ray  Detect Pulm Congestion.

4 DR. MOHCEN AL. HAJ

Also Called Hypertensive Crisis;

 Management of Hypertensive Crisis:

 Call For Help + Admission In Coronary Care Unit (CCU) +

 Now According to:

If Malignant HTN Without Organ If Malignant HTN With Organ

Give Oral Anti-Hypertensive Drugs: Give Parental (I.V) Anti-Hypertensive Drugs:

1. Diuretics. 1- I.V Diuretics  Furesmide 40 – 80mg.

 Other Anti-Hypertensive Treatment Could Be Used:

5 DR. MOHCEN AL. HAJ

Definition: They are an Acute Coronary Syndrome Caused By Partial Occlusion of

 Symptoms of UA & Non STEMI  Chest Pain;

Character: Pressure, Squeezing, Compression, Tightness, Heaviness.

Relieving Nitrate  Sub Lingual Glyceryl Tri Nitrate (GTN).

Aggravating: Even at Rest.

Associated Symptoms: Dyspnea, Nausea, OR Vomiting.

Time of Pain: More Than 30 Minutes.

 Management of UA & Non STEMI:

 Call For Help + Admission In Coronary Care Unit (CCU) + Bed

6 DR. MOHCEN AL. HAJ

 Do Serial ECG Every Half Hour.

Anti Pain: Anti Platelets: Anti Coagulant: Anti Angina:

*I.V Morphin *Aspirin 300mg. *Heparin. *I.V β–Blockers.

 Now Do Risk Stratification According to  GRACE Score:

If  Low Risk GRACE Score: If  High Risk GRACE Score:

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 Long Term Treatment of UA & Non STEMI:

 Investigations of UA & Non STEMI:

2. Cardiac Enzyme: CK-MB and/OR Troponin

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 Symptoms of Full Thickness MI (STEMI):

 Sings of Full Thickness MI (STEMI):

 Diagnosis of Full Thickness MI (STEMI):

1. Typical Chest Pain (Retrosternal)  Lasting For More Than 30 Minutes.

At Least 2 From 3 Diagnose Myocardial Infarction.

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 Call For Help + Admission In Coronary Care Unit (CCU) + Bed

 Give the Patient Nitrate (Sub-Lingual GTN) as First Aid.

 Do Serial ECG Every Half Hour.

Anti Pain: Anti Platelets: Anti Coagulant: Anti Angina:

*I.V Morphin *Aspirin 300mg. *Heparin. *I.V β–Blockers.

I.V Morphin Aspirin 300mg. Heparin. I.V β–Blockers.

I.V Morphin Aspirin 300mg. Heparin. I.V β–Blockers.