Oxford Handbook of Acute Medicine 2nd Edition

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Editors: Ramrakha, Punit S.; Moore, Kevin P. T itle: Oxford Handbook of Acute Medicine, 2nd Edition Copyri ght 1997,2004 Oxford Uni vers i t y Pres s (Copyri ght 1997, 2004 by Puni t S Ramrakha and Kevi n P Moore)
> Front of Book > Edit ors
Editors
Punit S. Ramrakha Cons ul t ant Cardi ol ogi s t St oke Mandevi l l e Hos pi t al , Ayl es bury Hammers mi t h Hos pi t al , London, UK Kevin P. Moore Profes s or of Hepat ol ogy and Honorary Cons ul t ant Phys i ci an Royal Free and Uni vers i t y Col l ege Medi c al Sc hool , Uni vers i t y Col l ege London, London, UK
Contributors to the second edition

Dr Ed Beveridge Li ai s on Ps ychi at ri s t Royal Free Hos pi t al , London Dr Ian Cropley Cons ul t ant i n Infect i ous Di s eas es Royal Free Hos pi t al , London Dr Narbeh Melekian Speci al i s t Regi s t rar Dept of Cardi ol ogy, Hammers mi t h Hos pi t al , London Dr David T aylor Cons ul t ant Phys i ci an Buc ki nghams hi re Hos pi t al s NHS T rus t , Hi gh Wyc ombe, Buc ks Dr David Pao Speci al i s t Regi s t rar Dr Martin Fisher Cons ul t ant Depart ment of HI V/GUM, Bri ght on and Sus s ex Uni vers i t y Hos pi t al s NHS T rus t Dr Masud Husain Reader i n Nerol ogy Dr Parashkev C Nachev
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Cl i ni cal Res earch Fel l ow Depart ment Di vi s i on of Neuros c i enc es and Ps yc hol ogi c al Medi c i ne, I mperi al Col l ege London (Chari ng Cros s Hos pi t al ) Dr Paresh Malhotra I CN, London Dr Helen Eagleton Cons ul t ant Haemat ol ogi s t St oke Mandevi l l e Hos pi t al , Buc ks .
Advice on chapter revisions was also given by the following

Robbie Rakhit Cons ul t ant Cardi ol ogi s t Royal Free Hos pi t al Martina Hennessy Cons ul t ant Cl i ni cal Pharmacol ogi s t Royal Free Hos pi t al Jonathan Robbin Cons ul t ant Phys i ci an Royal Free Hos pi t al Andrew Davenport Cons ul t ant Nephrol ogi s t Royal Free Hos pi t al Marc Lipman Cons ul t ant i n Res pi rat ory Medi ci ne and HIV di s eas e Royal Free Hos pi t al Barbara Bannister Cons ul t ant i n i nfect i ous di s eas es Royal Free Hos pi t al Anne Dunleavy SpR i n Res pi rat ory Medi c i ne, Royal Free Hos pi t al Amir H. Sam Medi cal St udent & Aut hor Royal Free & Uni vers i t y Col l ege Medi c al Sc hool Paul Kooner Gas t roent erol ogy SpR, Royal Free Hos pi t al
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Richard Stratton Cons ul t ant Rheumat ol ogi s t Royal Free Hos pi t al Cate Orteu Cons ul t ant Dermat ol ogi s t Royal Free Hos pi t al
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> Front of Book > Disc laimer
Disclaimer
Oxford Uni vers i t y Pres s makes no repres ent at i on, expres s or i mpl i ed, t hat t he drug dos ages i n t hi s book are correct . Readers mus t t herefore al ways check t he product i nformat i on and cl i ni cal procedures wi t h t he mos t up-t o-dat e publ i s hed product i nformat i on and dat a s heet s provi ded by t he manufact urers and t he mos t recent codes of conduct and s afet y regul at i ons . The aut hors and t he publ i s hers do not accept res pons i bi l i t y or l egal l i abi l i t y for any errors i n t he t ext or for t he mi s us e or mi s appl i cat i on of mat eri al i n t hi s work.
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> Front of Book > Prefac e t o t he sec ond edit ion
Preface to the
second edition
There has been a rapi d expans i on and change of cl i ni cal pract i ce over t he l as t 56 years , and t he need for a det ai l ed handbook t hat educat es , reas s ures , and hel ps i n t he management of acut el y i l l peopl e has not di mi ni s hed. The t as k of updat i ng t he t ext for t hi s new edi t i on woul d not have been pos s i bl e wi t hout t he hel p of col l eagues and s peci al i s t s who have t aken t he t i me t o read, advi s e and i n s ome cas es revi s e l arge s ect i ons of t hi s book t o ens ure t hat i t i s i n l i ne wi t h modern management . W e t hank t hem mos t s i ncerel y. The mos t obvi ous changes i ncl ude a new chapt er on ps ychi at ri c emergenci es , i ni t i al l y draft ed by Dr Ed Beveri dge. Managi ng pat i ent s who are confus ed or ps ychi at ri cal l y di s t urbed i s fri ght eni ng t o many juni or doct ors , and t hi s chapt er i ncl udes s t rai ght forward advi ce on management , t he l aw and t he res t rai nt of pat i ent s . Al t hough no chapt er has es caped revi s i on, we have radi cal l y revi s ed t he chapt ers on cardi ac emergenci es , HIV di s eas e and i nfect i ous di s eas es . W e have added a new s ect i on of col our Pl at es s howi ng eye and s ki n condi t i ons . The t ext now i ncorporat es al l t he major advances i n medi cal care s i nce t he fi rs t edi t i on was publ i s hed, and we hope t hat readers wi l l cont i nue fi nd t hi s book us eful and i nformat i ve. P S R K P M June 2004
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> Front of Book > F oreword t o t he first edit ion by Professor John Ledingham
Foreword to the first edition by Professor John Ledingham

A profes s or of medi ci ne at Edi nburgh i n t he more l ei s urel y days of 1862 t aught t hat an acut e i l l nes s was one t hat ran i t s cours e i n 14 days . A s t udent courageous l y i ncl i ned t o di s put e t hi s defi ni t i on ret ort ed t hat an omni bus ran from Edi nburgh t o Lei t h i n 20 mi nut es , but t hat was not a defi ni t i on of an omni bus . Acut e i n t he cont ext of t hi s book s ugges t s rat her more urgency t han was t he concept i n 1862! There i s a need for juni or doct ors (and s eni or ones t oo) t o have at t hei r fi nger t i ps t he es s ent i al s of management of al l acut e emergenci es . Thi s book wi l l s urel y be a great hel p i n achi evi ng t hat ai m. The aut hors have s ucceeded i n produci ng an admi rabl y s ucci nt and yet comprehens i ve account of t he management of a huge vari et y of condi t i ons requi ri ng urgent t reat ment and have done s o wi t hout bei ng t oo t i res omel y di dact i c. Handbooks i n t he s eri es from Oxford Uni vers i t y Pres s are al ready i n t he pocket s of mos t cl i ni cal s t udent s al l over t he worl d. Thi s one i s s ure t o be t here t oo and wi l l , I s us pect , al s o be i n t he pocket s of juni or doct ors and even (perhaps covert l y) readi l y avai l abl e t o more s eni or phys i ci ans . Such a pract i cal book as t hi s needs t o have been wri t t en by aut hors t horoughl y and recent l y fami l i ar wi t h t he whol e fi el d of acut e medi ci ne. It has been and has been done very wel l . I am del i ght ed t o provi de a Foreword t o an excel l ent book whi ch real l y does fi l l an i mport ant gap.
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> Front of Book > Prefac e t o t he first edit ion
Preface to the
first edition
As every doct or s oon di s covers , t he management of acut e medi cal emergenci es i s t he mos t demandi ng and s t res s ful as pect of medi cal t rai ni ng. Mos t handbooks of cl i ni cal medi ci ne can onl y go i nt o general det ai l about t he management of medi cal probl ems and t he s peci fi c advi ce needed t o manage acut el y i l l pat i ent s i s us ual l y i ns uffi ci ent i n t hes e t ext s . The ai m of t hi s handbook i s t o gi ve confi dence t o doct ors t o manage acut e medi cal probl ems effect i vel y and s afel y, and i s i nt ended t o compl ement t he Oxford Handbook of Cl i ni c al Medi c i ne . Many books on acut e medi ci ne are wri t t en by s eni or s t aff, who have not been at t he front l i ne for s ome t i me, and cert ai n as pect s of care are as s umed or overl ooked. Thi s book was wri t t en by juni or doct ors wi t h fi rs t -hand experi ence of t he pract i cal probl ems and di l emmas faced i n cas ual t y. The l ayout of t he book refl ect s cl i ni cal pract i ce: as s es s ment , di fferent i al di agnos i s , i mmedi at e management , and s ome as pect s of l ong-t erm t herapy. W e have i ncl uded an ext ens i ve s ect i on on pract i cal procedure as wel l as a s ect i on on pharmacot herapy t o provi de i nformat i on on t he us e of cert ai n common and unus ual drugs t o compl ement t hat provi ded t he Bri t i s h Nat i onal Formul ary (BNF). Throughout t he book t he t ext commonl y exceeds t hat requi red for t he management of s peci al i s t probl ems by t he general i s t . W e make no apol ogy for t hi s . Thi s i s i nt ended t o provi de t he doct or wi t h an unders t andi ng of s peci al i s t i nt ervent i ons s o t hat t hey are more convers ant wi t h what i s pos s i bl e and what i s happeni ng t o t hei r pat i ent .
Acknowledgements
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W e woul d l i ke t o t hank al l of t he cont ri but ors and part i cul arl y Mas ud Hus ai n (Neurol ogy), Bi l l Lynn (Infect i ous Di s eas es ), and Amanda Perry (Haemat ol ogy) for bei ng prompt , comprehens i ve, and adheri ng t o t he format of t he book. Thanks al s o go t o Jan Fos t er and Kat i e Darl i ng for t hei r art work. W e woul d al s o l i ke t o t hank OUP for t hei r encouragement duri ng t hei r i ncept i on and wri t i ng of t hi s book. PSR i s i ndebt ed t o Vandana and hi s parent s for t hei r s upport and mot i vat i on. KPM i s i ndebt ed t o Janet , Al i ce, and Thomas for t hei r cont i nued pat i ence when t he port abl e comput er accompani ed fami l y hol i days . Fi nal l y, we woul d l i ke t o acknowl edge t he envi ronment at t he Hammers mi t h Hos pi t al where acut e medi ci ne i s bot h i nt eres t i ng and fun. P S R K P M Oct ober, 1997
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> Front of Book > Oxford Handbook List
Oxford Handbook
List

Oxford Handbook of Ps ychi at ry (OHPS) - 1s t Edi t i on Oxford Handbook of Tropi cal Medi ci ne (OHTM) - Second Edi t i on Oxford Handbook of Acci dent and Emergency Medi ci ne (OHAE) - Second Edi t i on Oxford Handbook of Pal l i at i ve Care (OHPC) - Fi rs t Edi t i on Oxford Handbook of Cl i ni cal Dent i s t ry (OHCD) - Fourt h Edi t i on Oxford Text book of Ps ychot herapy (OTPT) - Fi rs t Edi t i on Oxford Handbook of Acut e Medi ci ne (OHAM) - Second Edi t i on Oxford Handbook of Cri t i cal Care (OHCC) - 2nd edi t i on
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> Front of Book > Symbols and abbreviat ions
Symbols and
abbreviations
Abbreviations
~ approxi mat el y -ve negat i ve +ve pos i t i ve decreas ed i ncreas ed normal degrees A&E acci dent and emergency AAA abdomi nal aort i c aneurys m Ab ant i body ABC ai rway, breat hi ng, and ci rcul at i on ABG art eri al bl ood gas es ACE angi ot ens i n-convert i ng enz yme
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ACEI angi ot ens i n-convert i ng enz yme i nhi bi t ors AChR acet yl chol i ne recept or ACLS advanced cardi ac l i fe s upport ACS acut e coronary s yndrome ACT H adrenocort i co s t i mul at i ng hormone AD adrenal i ne ADH ant i -di uret i c hormone AF at ri al fi bri l l at i on AIDS acqui red i mmunodefi ci ency s yndrome ALI acut e l ung i njury ALL acut e l ymphobl as t i c l eukaemi a ALP al kal i ne phos phat as e ALT al ani ne t rans ami nas e AMA ant i -mi t ochondri al ant i body AMI acut e myocardi al i nfarct i on AML acut e myel oi d l eukaemi a ANA ant i -nucl ear ant i body ANCA ant i -neut rophi l cyt opl as mi c ant i body
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AP ant eropos t eri or aPC act i vat ed prot ei n C APSAC ani s t repl as e APT T act i vat ed part i al t hrombopl as t i n t i me AR aort i c regurgi t at i on ARDS adul t res pi rat ory di s t res s s yndrome ARF acut e renal fai l ure AS aort i c s t eros i s ASA acet yl s al i cyl i c aci d ASD at ri al s ept al defect ASOT ant i -s t rept ococcal t i t re AST as parat e t rans ami nas e AT N acut e t abul ar necros i s AT P aderos i ne t ri phos phat e AV at ri ovent ri cul ar AVNRT at ri ovent ri cul ar-nodal re-ent ry t achycardi a AVR aort i c val ve repl acement AVRT acces s ory pat hway t achycardi a
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AXR abdomi nal X-ray AZT z i dovudi ne BAL bronchoal veol ar BBB bundl e branch bl ock BC bl ood cul t ures BLS bas i c l i fe s upport BM bone marrow BMT bone marrow t rans pl ant BNF Bri t i s h Nat i onal Formul ary BOOP bronchi ol i t i s obl i t erans organi zi ng pneumoni a BP bl ood pres s ure Ca carci noma CABG coronary art ery bypas s graft CAD coronary art ery di s eas e cAMP cycl i c AMP CAVM cont i nuous art eri ovenous haemofi l t rat i on CAVHD Haemodi afi l t rat i on CBD Common bi l e duct
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CCDC Cons ul t ant i n Communi cabl e Di s eas e Cont rol CCF Conges t i ve cardi ac fai l ure CCHF Cri mean-Congo haemorrhagi c fever CCU Coronary care uni t CEA Carci noembryoni c ant i gen CI cardi ac i ndex CK creat i ne phos phoki nas e CMV cyt omegal ovi rus CNS cent ral nervous s ys t em CO cardi ac out put COP crypt ogeni c organi zi ng pneumoni a COPD chroni c obs t ruct i ve pul monary di s eas e CPAP cont i nuous pos i t i ve ai rways pres s ure CPK creat i ni ne phos phoki nas e CPR cardi opul monary res us ci t at i on CrAg crypt ococcal ant i gen CRF Chroni c renal fai l ure CRP C-reat i ve prot ei n
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CSF cerebros pi nal fl ui d CSM carot i d s i nus mes s age CT comput eri s ed t omography CT PA CT pul monary angi ography CVA cerebrovas cul ar acci dent CVP cent ral venous pres s ure CVVH or CVVHD cont i nuous venovenous haemofi l t rat i on CVS cardi ovas cul ar s ys t em CXR ches t X-ray D&V di arrhoea and vomi t i ng DA dopami ne DAT di rect ant i gen t es t DBP di as t ol i c bl ood pres s ure DC di rect current DDAVP des mopres s i n DI di abet es i ns i pi dus DIC di s s emi nat ed i nt ravas cul ar coagul at i on DKA di abet i c ket oaci dos i s
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DM di abet es mel l i t us DNA deoxyri bos e nucl ei c aci d DSH del i berat e s el f-harm DT del eri um t remens DT PA di et hyl enet ri ami nepent aacet i c aci d DU duodenal ul cer DVT deep vei n t hrombos i s E ecs t as y EBV Ebs t ei n Barr Vi rus EC ext racel l ul ar ECG el ect rocardi ogram Echo echocardi ogram ECV ext racel l ul ar vol ume EEG el ect roencephal ogram EF eject i on fract i on EG et hyl ene gl ycol EM el ect ron mi cros copy EMD el ect romechani cal di s s oci at i on
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EMG el ect romyogram ENT ear nos e and t hroat EP el ect rophys i ol ogi cal EPS el ect rophys i ol ogi cal s t udi es ERCP endos copi c ret rograde chol angi opancreat ography ESR eryt hrocyt e s edi ment at i on rat e ET endo t racheal FBC ful l bl ood count FDP fi bri nogen degredat i on product s FEIBA Fact or VIII i nhi bi t or bypas s i ng act i vi t y FEV1 forced expi rat ory vol ume (1 mi nut e) FFP fres h froz en pl as ma FH fami l y hi s t ory FSH fol l i cul er s t i mul at i ng hormone FVC forced vi t al capaci t y G6PD gl ucos e-6-phos phat e dehydrogenas e G&S group and s ave GB gal l bl adder
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GBM gl omerul ar bas ement membrane GBS Gui l l ai nBarr s yndrome GCS Gl as gow coma s cal e GCSF granul ocyt e col ony-s t i mul at i ng fact or GFR gl omerul ar fi l t rat i on rat e GH growt h hormone GHB gammahydroxybut yri c aci d GI gas t roi nt es t i nal GIT gas t roi nt es t i nal t rack glc gl ucos e GP general pract i t i oner GP gl ycoprot ei n GT N gl yceryl t ri ni t rat e GU geni t ouri nary GUM geni t ouri nary medi ci ne GVHD graft vs . hos t di s eas e HAART hi ghl y act i ve ant i -ret rovi ral t herapy HACEK Haemophi l us , Aci nt obaci l l us , cardi obact eri um, Ei kenel l a and
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Ki ngel l a s pp. (caus es of cul t ure negat i ve endocardi t i s ) HAIgM Hepat i t i s A Ig M HAPO hi gh-al t i t ude pul monary oedema HAV Hepat i t i s A Vi rus HBc Hepat i t i s B core HbS Hepat i t i s B Surface HBsAg Hepat i t i s B Surface Ant i gen HBV Hepat i t i s B Vi rus HCG Human chori oni c ganadot rophi n HCV Hepat i t i s C Vi rus HDL hi gh-dens i t y l i poprot ei n HDU hi gh dependency uni t HIV human i mmunodefeci ency vi rus HLA human l ymphocyt e ant i gen HMG-CoA hydroxy met hyl gl ut aryl -Coenzyme A HOCM hypert rophi c obs t ruct i ve cardi omyopat hy HONC hyperos mol ar non-ket ot i c coma HR heart rat e HRT
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hormone repl acement t heraphy HSV Herpes Si mpl ex vi rus HT hypert ens i on HT LV human-T-l ymphot ropi c vi rus HUS haemol yt i curaemi c s yndrome (I:E) i ns pi rat ory:exporat ory rat i o IABP i nt ra aort i c bal l oon pump IBD i nfl ammat ory bowel di s eas e ICD i mpl ant abl e cardi overt er defi bri l l at or ICP i nt racrani al pres s ure ICU i nt ens i ve care uni t ID i nfect i ous di s eas e IE i nfect i ve endocardi t i s IgA i mmunogl obul i n A IgE i mmunogl obul i n E IgG i mmunogl obul i n G IgM i mmunogl obul i n M IHD i s chaemi c heart di s eas e IJV
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i nt ernal jugul ar vei n INR i nt ernat i onal normal i zed rat i o (prot hrombi n rat i o) IPPV i nt ermi t t ent pos i t i ve pres s ure vent i l at i on IT P i di opat hi c t hrombocyt opani c purpura IT U i nt ens i ve t herapy uni t IVC i nferi or vena cava IVI i nt ravenous i nfus i on IVU i nt ravenous urogran JPS joi nt pos i t i on s ens e JVP jugul ar venous pres s ure KS kapos i 's s arcoma LA l eft at ri um LAD l eft ant eri or des cendi ng coronary art ery LBBB l eft bundl e branch bl ock LDH l act at e dehydrogenas e LDL l ow-dens i t y l i poprot ei n LFT l i ver funct i on t es t LH l eut i ni z i ng harmone LHRH
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l eut i ni z i ng harmone rel eas i ng harmone LMN l ower mot or neurone LMS l eft mai n s t em LMWH l ow-mol ecul ar-wei ght hepari n LP l umbar punct ure LSD l ys ergi c aci d di et hyl ami de LV l eft vent ri cul ar LVEDP l eft vent ri cul ar end di as t ol i c pres s ure LVF l eft vent ri cul ar fai l ure LVH l eft vent ri cul ar hypert rophy MACE major cardi ac event s MAI Myc obac t eri um avi um i nt rac el l ul are MAOI monoami ne oxi das e-i nhi bi t or MAP mean art eri al pres s ure MAT mul t i focal at ri al t achycardi a MC&S mi cros copy, cul t ure and s ens i t i vi t y MCA mi ddl e cerebral art ery MCT D mi xed connect i ve t i s s ue di s eas e MCV
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mean corpus cul ar vol ume MDMA ecs t acy MI myocardi al i nfarct i on MOF mul t i pl e organ fai l ure MR magnet i c res onance MR mi t ral regurgi t at i on MRA magnet i c res onance angi ography MRCP magnet i c res onance chol angi o-pancreat ography MRI magnet i c res onance i magi ng MRSA met hi ci l l i n res i s t ant St aphyl oc oc c us aureus MS mul t i pl e s cl eros i s MSU mi ds t ream uri ne MV mi t ral val ve MVP mi t ral val ve prol aps e MVR mi t ral val ve repl acement MVT monomorphi c vent ri cul ar t achycardi a N&V naus ea and vomi t i ng NA noradrenal i ne NABQI
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N -acet yl -benz oqui nonei mi ne NAC N -acet yl -cys t ei ne NANB non-A, non-B NBM ni l by mout h NBT V non-bact eri al t hrombot i c veget at i on NCS nerve conduct i on s t udi es NG nas ogas t ri c NIV non-i nvas i ve vent i l at i on NPV negat i ve pres s ure vent i l at i on NQ-MI non-Q-wave MI NR normal range NSAID non-s t eroi dal ant i -i nfl ammat ory drug NST EMI/UA non-ST el evat i on myocardi al i nfarct i on OCP oral cont racept i ve pi l l OD overdos e OER oxygen ext ract i on rat i o OPG ort hopent amogram PA pul monary art ery PACI
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part i al ant eri or ci rcul at i on i nfarct PAN pol yart eri s t s nodos a pANCA ant i neut rophi l cyt opl as mi c ant i body t ype-p Pa O 2 part i al pres s ure of oxygen i n art eri al bl ood PAWP pul monary art ery wedge pres s ure PBC pri mary bi l i ary ci rrhos i s PCA pat i ent -cont rol l ed anal ges i a PCI percut aneous coronary i nt ervent i on PCP Pneumoc ys t i t i s c ari ni i pneumoni a PCR pol ymeras e chai n react i on PCV packed cel l vol ume PCWP pul monary capi l l ary wedge pres s ure PDA pat ent duct us art eri os us PE phenyt oi n equi val ent PE pul monary embol i s m PEA pul s el es s el ect ri cal act i vi t y PEEP pos i t i ve end expi rat ory pres s ure PEF peak expi rat ory fl ow PEFR
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peak expi rat ory fl ow rat e PEG percut aneous endos copi c gas t ros t ony PEP pos t -expos ure prophyl axi s PET pos i t ron emi s s i on t omography PFO pat ent foramen ovel e PHI pri mary HIV i nfect i on PMH pas t medi cal hi s t ory PML progres s i ve mul t i -focal l eucoencephal opat hy PMN pol ymarphonucl ear cel l s (neut rophi l s ) PMR pol ymyal gi a rheumat i ca PPI prot on pump i nhi bi t or PR per rect um PSA pros t at e-s peci fi c ant i gen PSC pri mary s cl eros i ng chol argi t i s PT prot hrombi n t i me PT H parat hyroi d harmone PUO pyrexi a of unknown ori gi n PVE pros t het i c val ve endocardi t i s PVR
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pul monary vas cul ar res i s t ance PVT pol ymorphi c vent ri cul ar t achycardi a Qw-MI Q-wave MI RA ri ght at ri um RAD ri ght axi s devi at i on rAPC recombi nant act i vat ed prot ei n C RAS reni n angi ot ens i n s ys t em RBBB ri ght bundl e branch bl ock RBC red bl ood cel l RCA ri ght coronary art ery RCP Royal Col l ege of Phys i ci ans RF rheumat i c fever RNA ri bos e nucl ei c aci d RNP ri bo nucl ei c prot ei n RR res pi rat ory rat e RS res pi rat ory s ys t em RSV res pi rat ory s yncyt i al vi rus rt-PA recombi nant t i s s ue pl as mi nogen act i vat or RT A
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road t raffi c acci dent RUQ ri ght upper quadrant RV ri ght vent ri cul ar RVDP ri ght vent ri cul ar end di as t ol i c pres s ure RVF ri ght vent ri cul ar fai l ure RVOT ri ght vent ri cul ar out fl ow t ract SAH s ub arachnoi d haemorrhage SARS s evere acut e res pi rat ory s yndrome SBE s ubacut e bact eri al endocardi t i s SBP s ys t ol i c bl ood pres s ure SCU s ubcl avi ew vei n SIADH s yndrome of i nappropri at e ADH s ecret i on SK s t rept oki nas e SL s ubl i ngual SLE s ys t emi c l upus eryt hemat os us SOB s hort of breat h SOL s pace-occupyi ng l es i on SR s l ow rel eas e SSRI
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s el ect i ve s erot oni n reupt ake i nhi bi t or SSS s t aphyl ococcal s cal ded s ki n s yndrome ST EMI ST el evat i on myocardi al i nfarct i on ST S s erol ogi cal t es t s for s yphi l i s SVC s uperi or vena cava SVR s ys t emi c vas cul ar res i s t ance SVT s upravent ri cul ar t achycardi a SXR s kul l X-ray TB t ubercul os i s T BG t hyroi d-bi ndi ng T EN t oxi c epi dermal necrol ys i s T FT t hyroi d funct i on t es t T IA t rans i ent i s chaemi c at t ack T IBC t ot al i ron bi ndi ng capaci t y T IPS t rans venous i nt rahepat i c port os ys t emi c s hunt i ng T nI t roponi n I T nT t roponi n T T OE t rans oes ophageal echocardi ogram tPA
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t i s s ue pl as mi nogen act i vat or T PHA Treponema Pal l i dum haemaggl ut i nat i on T PN t ot al parent ral nut ri t i on T PR t emperat ure, pul s e and res pi rat i ons TR t ri cus pi d regurgi t at i on T RALI t rans fus i on-rel at ed acut e l ung i njury T RH t hyrot ropi n rel eas i ng hormone T SH t hyroi d s t i mul at i ng harmone TT t hrombi n t i are TTP t hrombot i c t hrombocyt openi c purpura T URBT t rans uret hral res ect i on of bl adder t umour T URP t rans uret hral res ect i on of pros t at e U&Es urea and el ect rol yt es UA uns t abl e angi na UC ul cerat i ve col i t i s UFH unfract i onat ed hepari n UMN upper mot or neuron URT I upper res pi rat ory t ract i nject i on US
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ul t ras ound USS ul t ras ound s can UT I uri nary t ract i nfect i on UV ul t ravi ol et VC vi t al capaci t y VE vent ri cul ar ext ras ys t ol e VF vent ri cul ar fi bri l l at i on VMA vani l l yl mandel l i c aci d VOR ves t i bul o-ocul ar refl ex VPB vent ri cul ar premat ure beat s VQ vent i l at i on (v)-perfus i on (Q) VSD vent ri cul o-s ept al defect VT vent ri cul ar t achycardi a vW von W i l l ebrand VZIG vari cel l a zos t er i mmunogl obul i n VZV vari cel l a zos t er vi rus WBC whi t e bl ood cel l WCC whi t e cel l count WPW
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W ol ffParki ns onW hi t e ZN Zi ehl Ni eel s on s yndrome
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Table of Contents
[-] Chapter 1 - Cardiac emergencies [+] Adult basic life support [+] Adult advanced life support [+] Universal treatment algorithm [+] Acute coronary syndrome ( [+] ST elevation myocardial infarction ( [+] STEMI: diagnosis 1 [+] STEMI: diagnosis 2 [+] STEMI: general measures [+] STEMI: reperfusion therapy (thrombolysis) 1 [+] STEMI: thrombolysis 2 [+] STEMI: reperfusion by primary percutaneous coronary intervention ( Surgery for acute STEMI STEMI: additional measures [+] Right ventricular ( [+] STEMI: predischarge risk stratification [+] STEMI: complications [+] Ventricular septal defect post myocardial infarction (
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[+] Acute mitral regurgitation post MI Pseudoaneurysm and free wall rupture [+] Cocaine-induced MI Ventricular tachyarrhythmia post MI Atrial tachyarrhythmia post MI Bradyarrhythmias and indications for pacing Bradyarrhythmias post MI [+] Hypotension and shock post MI [+] Cardiogenic shock [+] Non-ST elevation myocardial infarction (NSTEMI)/unstable angina ( NSTEMI/UA: diagnosis [+] NSTEMI/UA: risk stratification NSTEMI/UA: late risk stratification [+] NSTEMI/UA: medical management 1 [+] NSTEMI/UA: medical management 2 NSTEMI/UA: invasive versus non-invasive strategies Discharge and secondary prevention [+] Arrhythmias: general approach [+] Tachyarrhythmias heart rate (
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Treatment options in tachyarrhythmias [+] Broad complex tachycardia: diagnosis [+] Monomorphic ventricular tachycardia ( [+] Polymorphic ventricular tachycardia ( [+] Polymorphic [+] Ventricular tachycardia: drugs [+] Narrow complex tachyarrhythmias ( [+] Atrial fibrillation: assessment [+] Atrial fibrillation: management 1 [+] Atrial fibrillation: management 2 [+] Atrial fibrillation: rate control [+] Atrial flutter [+] Multi-focal atrial tachycardia ( [+] Accessory pathway tachycardia (A-V re-entrant tachycardia, Atrioventricular-nodal re-entry tachycardia ( [+] Bradyarrhythmias: general approach [+] Sinus bradycardia or junctional rhythm [+] Intraventricular conduction disturbances [+] Types of atrioventricular (
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[+] Pulmonary oedema: assessment [+] Pulmonary oedema: causes [+] Pulmonary oedema: management 1 [+] Pulmonary oedema: management 2 [+] Pulmonary oedema: management 3 [+] Pulmonary oedema: specific conditions [+] Infective endocarditis ( [+] Infective endocarditis: diagnosis Infective endocarditis: investigations [+] Infective endocarditis: antibiotics [+] Infective endocarditis: monitoring treatment [+] Culture-negative endocarditis Right-sided endocarditis Prosthetic valve endocarditis ( [+] Surgery for infective endocarditis [+] Endocarditis prophylaxis [+] Acute aortic regurgitation [+] Acute mitral regurgitation [+] Deep vein thrombosis (
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[+] Deep vein thrombosis: management [+] Pulmonary embolism ( [+] Pulmonary embolism: investigations 1 [+] Pulmonary embolism: investigations 2 [+] Pulmonary embolism: management 1 [+] Pulmonary embolism: management 2 [+] Fat embolism [+] Hypertensive emergencies [+] Hypertensive emergencies: management 1 [+] Hypertensive emergencies: management 2 [+] Hypertensive emergency with retinopathy (accelerated and malignant hypertension) [+] Hypertensive encephalopathy [+] Aortic dissection: assessment [+] Aortic dissection: investigations [+] Aortic dissection: management 1 [+] Aortic dissection: management 2 [+] Acute pericarditis: assessment [+] Acute pericarditis: management [+]
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Bacterial pericarditis [+] Cardiac tamponade: presentation [+] Cardiac tamponade: management [+] Congenital heart disease in adults 1 [+] Congenital heart disease in adults 2 [-] Chapter 2 - Respiratory emergencies [+] Acute pneumonia: assessment [+] Acute pneumonia: investigations [+] Acute pneumonia: management [+] Acute pneumonia: specific situations [+] Acute pneumonia: complications Mycoplasma pneumonia Legionella pneumonia Viral pneumonia Chlamydia pneumonia Psittacosis Miscellaneous conditions [+] Acute asthma: assessment [+] Acute severe asthma: immediate therapy [+]
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Acute severe asthma: further management [+] Mildmoderate asthmatic attacks [+] Acute exacerbation of chronic obstructive pulmonary disease ( Acute exacerbation of COPD: management [+] Acute exacerbation of COPD [+] Respiratory failure: assessment [+] Respiratory failure: investigations [+] Respiratory failure: management [+] Adult Respiratory Distress Syndrome 1 [+] Adult Respiratory Distress Syndrome 2 [+] Adult Respiratory Distress Syndrome 3 [+] Pneumothorax: assessment [+] Pneumothorax: management [+] Acute pneumothorax: management [+] Tension pneumothorax [+] Haemoptysis: assessment [+] Haemoptysis: further management [+] Pleural effusions [+] Chronic massive effusion [+]
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Empyema [+] Acute upper airway obstruction: assessment [+] Acute upper airway obstruction [+] Chapter 3 - Shock [+] Chapter 4 - Infectious diseases [+] Chapter 5 - Emergencies in [+] Chapter 6 - Renal emergencies [-] Chapter 7 - Neurological emergencies [+] Coma: assessment [+] Coma: immediate management [+] Coma: clues from examination 1 [+] Coma: clues from examination 2 [+] Coma: management [+] Limb weakness: assessment Limb weakness: localizing the lesion [+] Acute dizziness: assessment [+] Acute dizziness: management [+] Acute loss of vision [+] Approach to acute/sub-acute visual loss [+]
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Painful red eye: assessment [+] Painful red eye: management [+] Acute bacterial meningitis: assessment [+] Acute bacterial meningitis: immediate management [+] Acute bacterial meningitis: continuing therapy Acute bacterial meningitis: complications and their treatment [+] Meningitis with lymphocytic CSF [+] Acute viral encephalitis [+] Head injury: presentation [+] Head injury: assessment [+] Head injury: immediate management [+] Head injury: further management [+] Raised intracranial pressure ( [+] Raised intracranial pressure: immediate management [+] Raised intracranial pressure: further management [+] Intracranial space-occupying lesion [+] Extradural haemorrhage [+] Intracerebral haemorrhage [+] Subdural haematoma [+]
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Subarachnoid haemorrhage: assessment [+] Subarachnoid haemorrhage: immediate management [+] Subarachnoid haemorrhage: further management [+] Status epilepticus (tonicclonic) 1 [+] Status epilepticus (tonicclonic) 2 [+] Status epilepticus (tonicclonic) 3 [+] Stroke: overview [+] Stroke: haemorrhage or infarct? Stroke: other investigations [+] Stroke: complications [+] Stroke: secondary prevention [+] Cerebral infarction syndromes [+] Brainstem stroke [+] Cerebellar stroke [+] Transient ischaemic attacks ( [+] Confusional states and delirium 1 [+] Confusional states and delirium 2 [+] Acute alcohol withdrawal [+] Neuromuscular respiratory failure: assessment [+]
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Neuromuscular respiratory failure 2 [+] Myasthenic crises [+] Spinal cord compression: assessment Spinal cord compression: management [+] GuillainBarr Syndrome ( [+] GuillainBarr syndrome 2 [+] Botulism [+] Tetanus [+] Glasgow Coma Scale ( [+] Examination of brainstem function 1 [+] Examination of brainstem function 2 [+] Examination of brainstem function 3 [+] Examination of brainstem function 4 [+] Oculocephalic and oculovestibular responses [+] Brain death [+] Chapter 8 - Psychiatric emergencies [-] Chapter 9 - Endocrine emergencies [+] Diabetic ketoacidosis ( [+] Diabetic ketoacidosis: management [+]
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Diabetic ketoacidosis: complications [+] Hyperosmolar non-ketotic coma ( [+] Hypoglycaemic coma: assessment [+] Hypoglycaemic coma: management [+] Urgent surgery in patients with diabetes [+] Hyponatraemia: assessment [+] Hyponatraemia: causes [+] Hyponatraemia: management [+] Hypernatraemia [+] Acute hypocalcaemia [+] Hypercalcaemia [+] Hypophosphataemia [+] Addisonian crisis: assessment [+] Addisonian crisis: management [+] Myxoedema coma [+] Thyrotoxic crisis: assessment [+] Thyrotoxic crisis: management [+] Pituitary apoplexy [+] Hypopituitary coma [+]
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Phaeochromocytomas: assessment Phaeochromocytomas: management [+] Polyuria [+] Malignant hyperthermia [+] Neurolepetic malignant syndrome [-] Chapter 10 - Gastroenterological emergencies [+] Acute upper gastrointestinal bleeding 1 [+] Acute upper gastrointestinal bleeding 2 [+] Acute upper gastrointestinal bleeding 3 [+] Peptic ulcer disease [+] Erosive gastritis/oesophagitis [+] Variceal haemorrhage: medical management [+] Variceal haemorrhage: further management [+] MalloryWeiss tear [+] Acute gastroenteritis: assessment Bacterial gastroenteritis Viral gastroenteritis Pseudomembranous colitis Giardiasis [+]
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Travellers' diarrhoea [+] Bloody diarrhoea [+] Bacterial dysentery [+] Amoebic dysentery [+] Inflammatory bowel disease ( [+] Inflammatory bowel disease 2 [+] Inflammatory bowel disease 3 [+] Jaundice: assessment Viral hepatitis [+] Alcoholic hepatitis Drug-induced hepatitis Autoimmune hepatitis Acholuric jaundice Sepsis [+] Ischaemic hepatitis [+] Obstructive jaundice [+] Gallstone disease [+] Acute cholecystitis [+] Biliary obstruction [+]
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Ascites [+] Acute liver failure: assessment [+] Acute liver failure: investigations [+] Acute liver failure: management [+] Acute-on-chronic liver failure Hepatic encephalopathy [+] Liver abscesses [+] Acute pancreatitis: assessment [+] Acute pancreatitis: management [-] Chapter 11 - Haematological emergencies Blood transfusion reactions: assessment [+] Blood transfusion reactions: management [+] Sickle cell crisis: presentation [+] Sickle cell crisis: management [+] Bleeding disorders: general approach [+] Abnormal coagulation 1 [+] Abnormal coagulation 2 [+] Circulating inhibitors of coagulation [+] Abnormal platelets 1 [+]
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Abnormal platelets 2 [+] Anti-coagulant therapy Bleeding with fibrinolytic therapy [+] Bleeding in liver disease [+] Bleeding in uraemia [+] Massive transfusion/cardiopulmonary bypass [+] Haemophilia and related disorders 1 [+] Haemophilia and related disorders 2 Combined thrombotic and haemorrhagic disorders [+] Disseminated intravascular coagulation ( [+] Thrombotic thrombocytopenic purpura ( [+] Microangiopathic haemolytic anaemia [+] Heparin-associated thrombocytopenia [+] Acute leukaemias: presentation [+] Acute leukaemias: management [+] Acute leukaemias: treatment [+] Early complications of bone marrow transplantation ( [+] Complications of bone marrow transplantation [+] The febrile neutropenic patient 1 [+]
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The febrile neutropenic patient 2 [+] The febrile neutropenic patient 3 Infections in the transplant patient [+] Cytomegalovirus ( [+] Hyperviscosity syndrome [+] Tumour lysis syndrome [+] Hypercalcaemia of malignancy [+] Superior vena cava obstruction [+] Massive mediastinal mass [+] Chapter 12 - Rheumatological emergencies [+] Chapter 13 - Dermatological emergencies [+] Chapter 14 - Drug overdoses [+] Chapter 15 - Disorders due to physical agents [+] Chapter 16 - Practical procedures
Back of Book
[-] Resources [-] Appendices [+] Reference intervals [+] Useful telephone numbers -
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Change in names of certain medicinal substances [+] ECG Ruler [+] Color Plates
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Adult basic life support
Adult basic life support

Bas i c l i fe s upport i s t he backbone of effect i ve res us ci t at i on fol l owi ng a cardi ores pi rat ory arres t . The ai m i s t o mai nt ai n adequat e vent i l at i on and ci rcul at i on unt i l t he underl yi ng caus e for t he arres t can be revers ed. 34 mi nut es wi t hout adequat e perfus i on (l es s i f t he pat i ent i s hypoxi c) wi l l l ead t o i rrevers i bl e cerebral damage. The us ual s cenari o i s an unres pons i ve pat i ent found by s t aff who al ert t he cardi ac arres t t eam. The i ni t i al as s es s ment des cri bed bel ow s houl d have al ready been performed by t he pers on fi ndi ng t he pat i ent . The s ame pers on s houl d have al s o s t art ed CPR. Occas i onal l y you wi l l be t he fi rs t t o di s cover t he pat i ent and i t i s i mport ant t o rapi dl y as s es s t he pat i ent and begi n CPR. The vari ous s t ages i n bas i c l i fe s upport are des cri bed bel ow and s ummari zed i n t he al gori t hm oppos i t e.
Assessment of the patient

o o
Ensure safety of rescuer and victim Check whether the patient is responsive. Gent l y s hake vi ct i m and as k l oudl y are you al l ri ght ?
If vi ct i m res ponds pl ace t hem i n t he recovery pos i t i on and get hel p. If vi ct i m i s unres pons i ve s hout for hel p and move on t o as s es s ai rway (s ee bel ow).
Airway assessment
o
Open the airway. W i t h t wo fi ngert i ps under t he poi nt of t he chi n, t i l t t he head up. If t hi s fai l s pl ace your fi ngers behi nd t he angl es of t he l ower jaw and appl y s t eady pres s ure upwards and forwards . Remove i l l -fi t t i ng dent ures and any obvi ous obs t ruct i on. If t he pat i ent s t art s
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breat hi ng, rol l t he pat i ent over i nt o t he recovery pos i t i on and t ry t o keep t he ai rway open unt i l an orophyrangeal ai rway can be i ns ert ed (s ee P6).
o
Keep airway open, look, listen, and feel for breathing. Look for ches t movement s , l i s t en at t he vi ct i m's mout h for breat hi ng s ounds and feel for ai r on your cheek (for no more t han 10 s econds ).
If pat i ent i s breat hi ng t urn pat i ent i nt o t he recovery pos i t i on, check for cont i nued breat hi ng and get hel p.
If pat i ent i s not breat hi ng or maki ng occas i onal gas ps or weak at t empt s at breat hi ng s end s omeone for hel p (or go for hel p i f al one). (On ret urn) St art res cue breat hs by gi vi ng t wo s l ow effect i ve breat hs each res ul t i ng i n a vi s i bl e ri s e and fal l i n t he ches t wal l .
Assessment of circulation
o
As s es s s i gns of ci rcul at i on by feel i ng t he carot i d pul s e for no more t han 10 s econds .
If t here are s i gns of ci rcul at i on but no breat hi ng cont i nue res cue breat hs and check for s i gns of breat hi ng every 10 breat hs (approxi mat el y 1 breat h a mi nut e).
If t here are no s i gns of ci rcul at i on s t art ches t compres s i on at a rat e of 100 t i mes per mi nut e. Combi ne res cue breat hs and compres s i on at a rat e of 15 compres s i ons t o t wo effect i ve breat hs .
The rat i o of compres s i ons t o l ung i nfl at i on remai ns t he s ame for res us ci t at i on wi t h t wo pers ons .
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Send or go for hel p as s oon as pos s i bl e t o gui del i nes For furt her i nformat i on s ee t he Res us ci t at i on Counci l (UK) webs i t e ( ht t p://www.res us .org.uk/pages /bl s .ht m)
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Adult advanc ed life support
Adult advanced life support
It i s unl i kel y t hat an effect i ve s pont aneous cardi ac act i vi t y wi l l be res t ored by bas i c l i fe s upport wi t hout more advanced t echni ques (i nt ubat i on for effect i ve vent i l at i on, drugs , defi bri l l at i on, et c.). Do not was t e t i me. As s oon as hel p arri ves , del egat e CPR t o s omeone l es s experi enced i n ACLS, s o t hat you are abl e t o cont i nue. At t ach t he pat i ent t o a cardi ac moni t or as s oon as pos s i bl e t o det ermi ne t he cardi ac rhyt hm and t reat appropri at el y (s ee P8 for uni vers al t reat ment al gori t hm). Oropharyngeal (Guedel ) or nas opharyngeal ai rways hel p mai nt ai n t he pat ency of t he ai rway by keepi ng t he t ongue out of t he way. They can caus e vomi t i ng i f t he pat i ent i s not comat os e. ET i nt ubat i on i s t he bes t met hod of s ecuri ng t he ai rway (P5). Do not at t empt t hi s i f you are i nexperi enc ed . Es t abl i s h venous acces s . Cent ral vei n cannul at i on (i nt ernal jugul ar or s ubcl avi an) i s i deal but requi res more t rai ni ng and pract i ce and i s not for t he i nexperi enced. If venous acces s fai l s , drugs may be gi ven vi a an ET-t ube i nt o t he l ungs (except for bi carbonat e and cal ci um s al t s ). Doubl e t he dos es of drugs i f us i ng t hi s rout e, as abs orpt i on i s l es s effi ci ent t han i v.
Post resuscitation care
Try t o es t abl i s h t he event s t hat preci pi t at ed t he arres t from t he hi s t ory, s t aff, wi t nes s es , and t he hos pi t al
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not es of t he pat i ent . Is t here an obvi ous caus e (MI, hypoxi a, hypogl ycaemi a, s t roke, drug overdos e or i nt eract i on, el ect rol yt e abnormal i t y, et c.)? Record t he durat i on of t he arres t i n t he not es wi t h t he i nt ervent i ons and drugs (and dos es ) i n chronol ogi cal order.
Exami ne t he pat i ent t o check bot h l ung fi el ds are bei ng vent i l at ed. Check for ri bs t hat may have broken duri ng CPR. Li s t en for any cardi ac murmurs . Check t he neck vei ns . Exami ne t he abdomen for an aneurys m or s i gns of peri t oni s m. Ins ert a uri nary cat het er. Cons i der an NG-t ube i f t he pat i ent remai ns uncons ci ous . Record t he Gl as gow Coma Score (P520) and perform a bri ef neurol ogi cal as s es s ment (s ee P406). Inves t i gat i ons : ECG [l ooki ng for MI, i s chaemi a, t al l T-waves (K )]; ABG [mi xed met abol i c and res pi rat ory aci dos i s i s common and us ual l y res ponds t o adequat e oxygenat i on and vent i l at i on once t he ci rcul at i on i s res t ored. If s evere, cons i der bi carbonat e]; CXR (check pos i t i on of ET-t ube, l ook for pneumot horax); U&Es ; and gl uc os e . Aft er earl y and s ucces s ful res us ci t at i on from a pri mary cardi ac arres t , t he pat i ent may rapi dl y recover compl et el y. The pat i ent mus t be t rans ferred t o HDU or CCU for moni t ori ng for 1224h. Commonl y t he pat i ent i s uncons ci ous pos t arres t and s houl d be t rans ferred t o ITU for mechani cal vent i l at i on and haemodynami c moni t ori ng and s upport for 24 hours . Change any venous l i nes t hat were i ns ert ed at t he t i me of arres t for cent ral l i nes i ns ert ed wi t h s t eri l e t echni que. Ins ert an art eri al l i ne and cons i der PA cat het er (SwanGanz ) i f requi ri ng i not ropes . Remember t o t al k t o t he rel at i ves . Keep t hem i nformed of event s and gi ve a real i s t i c (i f bl eak) pi ct ure of t he arres t and pos s i bl e out comes . W hen appropri at e cons i der t he pos s i bi l i t y of organ
+
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donat i on and do not be fri ght ened t o di s cus s t hi s wi t h t he rel at i ves . Even i f di s cus s i on wi t h t he rel at i ves i s del ayed, remember corneas and heart val ves may be us ed up t o 24 hours aft er deat h. Brai n s t em deat h (s ee P532).
Jaw l i ft t o open t he ai rway
Jaw t hrus t (t hrus t t he angl e of t he mandi bl e upwards )
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Ins ert i on of oropharyngeal ai rway
Ins ert i on of nas opharyngeal ai rway
Page 86
> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Universal t reat ment algorit hm
Universal treatment algorithm
Cardi ac rhyt hms of cardi ac arres t can be di vi ded i nt o t wo groups :

o o
(VF/VT) Ot her cardi ac rhyt hms , whi ch i ncl ude as ys t ol e and PEA.
The pri nci pl e di fference i n t reat ment of t he t wo groups of arrhyt hmi as i s t he need for at t empt ed defi bri l l at i on i n t he VF/VT group of pat i ent s . The fi gure oppos i t e s ummari zes t he al gori t hm for management of bot h groups of pat i ent s .
VF/VT
VF/VT are t he mos t common rhyt hms at t he t i me of cardi ac arres t . Succes s i n t reat ment of VF/VT i s dependent on t he del i very of prompt defi bri l l at i on. W i t h each mi nut e t he chance of s ucces s ful defi bri l l at i on decl i nes by 710%. Precordial thump. If arres t i s wi t nes s ed or moni t ored a s harp bl ow wi t h a cl os ed fi s t on t he pat i ent 's s t ernum may convert VF/VT back t o a perfus i ng rhyt hm. It i s part i cul arl y effect i ve i f del i vered wi t hi n 30 s econds aft er cardi ac arres t . Shock cycl es are general l y i n groups of t hree. Ini t i al l y 200J, 200J, and 360J, wi t h s ubs equent cycl es at 360J. Aft er each s hock (or s equence) t he carot i d pul s e s houl d be pal pat ed onl y i f t he waveform changes t o one us ual l y capabl e of provi di ng a cardi ac out put . Shock cycl e i s repeat ed every mi nut e i f VF/VT pers i s t s . Myocardi al and cerebral vi abi l i t y mus t be mai nt ai ned
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aft er each s hock cycl e wi t h ches t compres s i ons and vent i l at i on of l ungs as des cri bed on P2.
In bet ween cycl es of defi bri l l at i on revers i bl e fact ors mus t be i dent i fi ed and correct ed, t he pat i ent i nt ubat ed (i f pos s i bl e) and venous acces s obt ai ned. Adrenal i ne s houl d be gi ven every 3 mi nut es (1mg i v and 23mg vi a endot racheal rout e).
Non-VF/VT rhythms
The out come from t hes e rhyt hms i s general l y wors e t han for VF/VT unl es s a revers i bl e caus e can be i dent i fi ed and t reat ed prompt l y. Ches t compres s i ons and vent i l at i on s houl d be undert aken for 3 mi nut es wi t h each l oop of t he al gori t hm (1 mi nut e i f di rect l y aft er a s hock). W i t h each cycl e at t empt s mus t be made t o i nt ubat e t he pat i ent , gai n i v acces s , and gi ve adrenal i ne.
Asystole
At ropi ne 3mg i v s houl d be gi ven t o bl ock al l vagal out put . In t he pres ence of P-waves on t he s t ri p/moni t or, paci ng (ext ernal or t rans venous ) mus t be cons i dered.
PEA
Ident i fi cat i on of t he underl yi ng caus e (s ee P9) and i t s correct i on are bot h vi t al for s ucces s ful res us ci t at i on. Res us ci t at i on mus t be cont i nued whi l s t revers i bl e caus es are bei ng s ought .
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(for furt her det ai l s s ee t he Res us ci t at i on Counci l (UK) webs i t e ht t p://www.res us .org.uk/pages /al s .ht m)
Page 89
> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Ac ut e c oronary syndrome (
Acute coronary syndrome
(ACS)
ACS i s an operat i onal t erm us ed t o des cri be a cons t el l at i on of s ympt oms res ul t i ng from acut e myocardi al i s chaemi a. An ACS res ul t i ng i n myocardi al i njury i s t ermed MI. ACS i ncl udes t he di agnos i s of UA, NSTEMI, and STEMI. The t erm ACS i s general l y as s i gned by anci l l ary/t ri age pers onnel on i ni t i al cont act wi t h t he pat i ent . Gui del i nes for i dent i fi cat i on of ACS are s ummari zed on P46.
Definition
The current nomencl at ure di vi des ACS i nt o t wo major groups , on t he bas i s of del i vered t reat ment modal i t i es (s ee fi gure).
STEMI. An ACS where pat i ent s pres ent wi t h i s chaemi c ches t di s comfort and ST-s egment el evat i on on ECG. Thi s group of pat i ent s mus t undergo reperfus i on t herapy on pres ent at i on. NSTEMI and UA. ACS where pat i ent s pres ent wi t h i s chaemi c ches t di s comfort as s oci at ed wi t h t rans i ent or permanent non ST-el evat i on i s chaemi c ECG changes . If t here i s bi ochemi cal evi dence of myocardi al i njury t he condi t i on i s t ermed NSTEMI and i n t he abs ence i f bi ochemi cal myocardi al i njury t he condi t i on i s t ermed UA (s ee P11). Thi s group of pat i ent s i s not t reat ed wi t h t hrombol ys i s .
Initial management of ACS
Al l pat i ent s wi t h s us pect ed ACS s houl d be pl aced i n an envi ronment wi t h cont i nuous ECG moni t ori ng and defi bri l l at i on capaci t y.
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The referri ng doct or s houl d be i ns t ruct ed t o gi ve as pi ri n (300mg po i f no cont rai ndi cat i ons ) and not t o gi ve any i m i nject i ons (caus es a ri s e i n t ot al CK and ri s k of bl eedi ng wi t h t hrombol ys i s /ant i coagul at i on).
Immedi at e as s es s ment s houl d i ncl ude Rapi d exami nat i on t o excl ude hypot ens i on and not e t he pres ence of murmurs and t o i dent i fy and t reat acut e pul monary oedema. Secure i v acces s . 12-l ead ECG s houl d be obt ai ned and report ed wi t hi n 10 mi nut es . Gi ve Oxygen (i ni t i al l y onl y 28% i f hi s t ory of COPD) Di amorphi ne 2.510mg i v prn for pai n rel i ef Met oc l oprami de 10mg i v for naus ea GT N s pray 2 puffs (unl es s hypot ens i ve) Take bl ood for: FBC/U&Es Gl ucos e May be acut el y pos t MI, even i n non-di abet i cs , and refl ect s a s t res s -cat echol ami ne res pons e, whi ch may res ol ve wi t hout t reat ment . Bi ochemi cal markers of cardi ac i njury. Li pi d profi l e Tot al chol es t erol , LDL, HDL, t ri gl yceri des Serum chol es t erol and HDL remai n cl os e t o bas el i ne for 2448 hours but fal l t hereaft er and t ake 8 weeks t o ret urn t o bas el i ne. Port abl e CXR t o as s es s cardi ac s i ze, pul monary oedema and t oexcl ude medi as t i nal enl argement . General exami nat i on s houl d i ncl ude peri pheral pul s es , fundos copy, abdomi nal exami nat i on for organomegal y, and aort i c aneurys m. P.11 Suppl ement K
+
t o keep i t at 45mmol /L.
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Conditions mimicking pain in ACS

Peri cardi t i s Di s s ect i ng aort i c aneurys m Pul monary embol i s m Oes ophageal refl ux, s pas m, or rupt ure Bi l i ary t ract di s eas e Perforat ed pept i c ul cer Pancreat i t i s
Nomencl at ure of ACS: Pat i ent s wi t h ACS may pres ent wi t h or wi t hout ST el evat i on on t he ECG. The majori t y of pat i ent s wi t h ST el evat i on (l arge arrows ) ul t i mat el y devel op QwMI whereas a mi nori t y (s mal l arrow) devel op a NQ-MI. Pat i ent s wi t hout ST-el evat i on are experi enci ng ei t her UA or an NSTEMI dependi ng on t he abs ence or pres ence of cardi ac enz ymes (e.g. t roponi n) det ect ed i n t he bl ood.
1
Footnote
1
Adapt ed from Ant man, EM (1997) Acut e myocardi al i nfarct i on. In Braunwal d EB, ed. Heart Di s eas e: A T ext book of c ardi ovas c ul ar medi c i ne ; Saunders , Phi l adel phi a.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST elevat ion myoc ardial infarc t ion (
ST elevation myocardial
infarction (STEMI)
Pat i ent s wi t h an ACS who have ST-s egment el evat i on/LBBB on t hei r pres ent i ng ECG benefi t s i gni fi cant l y from i mmedi at e reperfus i on and are t reat ed as one group under t he t erm STEMI.
Presentation
Ches t pai n us ual l y s i mi l ar i n nat ure t o angi na, but of great er s everi t y, l onger durat i on and not rel i eved by SL GTN. As s oci at ed feat ures i ncl ude naus ea and vomi t i ng, s weat i ng, breat hl es s nes s , and ext reme di s t res s . The pai ns may be at ypi cal s uch as epi gas t ri c or radi at e t hrough t o t he back. Di abet i cs , t he el derl y, and hypert ens i ves may s uffer pai nl es s (s i l ent ) i nfarct s and/or at ypi cal i nfarct i on. Pres ent i ng feat ures i ncl ude breat hl es s nes s from acut e pul monary oedema, s yncope or coma from dys rrhyt hmi as , acut e confus i onal s t at es (mani a/ps ychos i s ), di abet i c hypergl ycaemi c cri s es , hypot ens i on/cardi ogeni c s hock, CNS mani fes t at i ons res embl i ng s t roke s econdary t o s udden reduct i on i n cardi ac out put , and peri pheral embol i zat i on.
Management
Di agnos i s i s normal l y made on pres ent at i on fol l owed by rapi d s t abi l i z at i on t o ens ure i ns t i t ut i on of reperfus i on t herapy wi t hout del ay. Thi s i s i n cont ras t t o NSTEMI/UA where di agnos i s may evol ve over peri od of 2472 hours (s ee P46). The management pri nci pl es of t he vari ous s t ages are out l i ned bel ow and expanded on s ubs equent l y.
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St abi l i zi ng meas ures are general l y s i mi l ar for al l ACS pat i ent s (s ee P10)
o
Al l pat i ent s wi t h s us pect ed STEMI s houl d have cont i nuous ECG moni t ori ng i n an area wi t h ful l res us ci t at i on faci l i t i es . Pat i ent s s houl d recei ve i mmedi at e as pi ri n 300mg po (i f no cont rai ndi cat i ons ), anal ges i a, and oxygen. Secure i v acces s . Rapi d exami nat i on t o excl ude hypot ens i on and not e t he pres ence of murmurs and t o i dent i fy and t reat acut e pul monary oedema. RVF out of proport i on t o LVF s ugges t s RV i nfarct i on (s ee P28). Bl ood for FBC, bi ochemi cal profi l e, markers of cardi ac i njury, l i pi d profi l e, gl ucos e and port abl e CXR.
Diagnosis mus t be made on t he bas i s of hi s t ory, ECG (ST el evat i on/new LBBB), and bi ochemi cal markers of myocardi al i njury (NB i f ECG changes di agnos t i c, reperfus i on mus t not be del ayed t o wai t for bi ochemi cal markers ) (P16). T reatment :
o o
General medi cal meas ures (P18) Reperfus i on (pp2025).
All patients with STEMI should be admitted to CCU . Discharge and risk prevention (P30).
P.13
Factors associated with a poor prognosis

Age >70 years Previ ous MI or chroni c s t abl e angi na Ant eri or MI or ri ght vent ri cul ar i nfarct i on Left vent ri cul ar fai l ure at pres ent at i on Hypot ens i on (and s i nus t achycardi a) at pres ent at i on
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Di abet es mel l i t us Mi t ral regurgi t at i on (acut e) Vent ri cul ar s ept al defect
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST EMI: diagnosis 1
STEMI: diagnosis 1
Thi s i s bas ed on a combi nat i on of hi s t ory, ECG, and bi ochemi cal markers of cardi ac i njury. In pract i ce hi s t ory and ECG changes are normal l y di agnos t i c res ul t i ng i n i mmedi at e reperfus i on/medi cal t reat ment . Bi ochemi cal markers of cardi ac i njury us ual l y become avai l abl e l at er and hel p reconfi rm di agnos i s as wel l as provi de prognos t i c i nformat i on (magni t ude of ri s e).
ECG changes
ST -segment elevation occurs wi t hi n mi nut es and may l as t for up t o 2 weeks . ST el evat i on of 2mm i n adjacent ches t l eads and 1mm i n adjacent l i mb l eads i s neces s ary t o ful fi l t hrombol ys i s cri t eri a. Pers i s t i ng ST el evat i on aft er 1 mont h s ugges t s format i on of LV aneurys m. Infarct i on s i t e can be l ocal i zed from ECG changes as i ndi cat ed i n t he t abl e oppos i t e. Pathological Q-waves i ndi cat e s i gni fi cant abnormal el ect ri cal conduct i on, but are not s ynonymous wi t h i rrevers i bl e myocardi al damage. In t he cont ext of a t rans mural i nfarct i on t hey may t ake hours or days t o devel op and us ual l y remai n i ndefi ni t el y. In t he s t andard l eads t he Q-wave s houl d be 25% of t he R-wave, 0.04s i n durat i on, wi t h negat i ve T-waves . In t he precordi al l eads , Q-waves i n V4 s houl d be >0.4mV (4 s mal l s q) and i n V6 >0.2mV (2 s mal l s q), i n t he abs ence of LBBB (QRS wi dt h <0.1s or 3 s mal l s q). ST -segment depression (ischaemia at distance) i n a s econd t erri t ory (i n pat i ent s wi t h ST-s egment el evat i on) i s s econdary t o i s chaemi a i n a t erri t ory ot her
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t han t he area of i nfarct i on (oft en i ndi cat i ve of mul t i ves s el di s eas e) or reci procal el ect ri cal phenomena. Overal l i t i mpl i es a poorer prognos i s .
PR-segment elevation/depression and al t erat i ons i n t he cont our of t he P-wave are general l y i ndi cat i ve of at ri al i nfarct i on. Mos t pat i ent s wi l l al s o have abnormal at ri al rhyt hms s uch as AF/fl ut t er and wanderi ng at ri al pacemaker and AV nodal rhyt hms . T -wave inversion may be i mmedi at e or del ayed and general l y pers i s t s aft er t he ST el evat i on has res ol ved. Non-diagnostic changes , but ones t hat may be i s chaemi c, i ncl ude new LBBB or RBBB, t achyarrhyt hmi as , t rans i ent t al l peaked T-waves or T-wave i nvers i on, axi s s hi ft (ext reme l eft or ri ght ), or AV bl ock.
P.15
Conditions that may mimic ECG changes of a STEMI

Left or ri ght vent ri cul ar hypert rophy LBBB or l eft ant eri or fas ci cul at ar bl ock W ol ffParki ns onW hi t e s yndrome Peri cardi t i s or myocardi t i s Cardi omyopat hy (hypert rophi c or di l at ed) Trauma t o myocardi um Cardi ac t umours (pri mary and met as t at i c) Pul monary embol us Pneumot horax Int ra-crani al haemorrhage Hyperkal aemi a Cardi ac s arcoi d or amyl oi d Pancreat i t i s
Localization of infarcts from ECG changes
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Anterior Anteroseptal Anterolateral Lateral
ST el evat i on and/or Q-waves i n V1V4/V5 ST el evat i on and/or Q-waves i n V1V3 ST el evat i on and/or Q-waves i n V1V6, I, and aVL. ST el evat i on and/or Q-waves i n V5V6 and T-wave i nvers i on/ST el evat i on/Q-waves i n I and aVL
Inferolateral Inferior Inferoseptal T rue posterior
ST el evat i on and/or Q-waves i n II, III, aVF, and V5V6 (s omet i mes I and aVL) ST el evat i on and/or Q-waves i n II, III, and aVF ST el evat i on and/or Q-waves i n II, III, aVF, and V1V3 Tal l R-waves i n V1V2 wi t h ST depres s i on i n V1V3 T-waves remai n upri ght i n V1V2. Thi s can be confi rmed wi t h an oes ophageal l ead i f avai l abl e (met hod s i mi l ar t o an NG t ube). Us ual l y occurs i n conjunct i on wi t h an i nferi or or l at eral i nfarct
RV infarction
ST-s egment el evat i on i n t he ri ght precordi al l eads (V3RV4R). Us ual l y found i n conjunct i on wi t h i nferi or i nfarct i on. Thi s may onl y be pres ent i n t he earl y hours of i nfarct i on
Page 98
> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST EMI: diagnosis 2
STEMI: diagnosis 2
Biochemical markers of cardiac injury
Seri al meas urement s eval uat i ng a t emporal ri s e and fal l s houl d be obt ai ned t o al l ow a more accurat e di agnos i s . CK and CK-MB from a s kel et al mus cl e s ource t end t o remai n el evat ed for a great er t i me peri od i n compari s on t o a cardi ac s ource.
CK
Level s t wi ce upper l i mi t of normal are t aken as bei ng abnormal . Serum l evel s ri s e wi t hi n 48 hours pos t STEMI and fal l t o normal wi t hi n 34 days . The peak l evel occurs at about 24 hours but may be earl i er (12 hours ) and hi gher i n pat i ent s who have had reperfus i on (t hrombol ys i s or PCI). Fal s e pos i t i ve rat es of ~15% occur i n pat i ent s wi t h al cohol i nt oxi cat i on, mus cl e di s eas e or t rauma, vi gorous exerci s e, convul s i ons , i m i nject i ons , hypot hyroi di s m, PE, and t horaci c out l et s yndrome.
CK-MB i s oenzyme i s more s peci fi c for myocardi al di s eas e. Level s may be el evat ed des pi t e a normal t ot al CK. However, CK-MB i s al s o pres ent i n s mal l quant i t i es i n ot her t i s s ues (s kel et al mus cl e, t ongue, di aphragm, ut erus , and pros t at e) and t rauma or s urgery may l ead t o fal s e pos i t i ve res ul t s . If t here i s doubt about myocardi al i njury wi t h CK-MB l evel s obt ai ned a cardi ac t roponi n mus t be meas ured.
Cardiac troponins (TnT, TnI)
Bot h TnI and TnT are hi ghl y s ens i t i ve and s peci fi c markers of cardi ac i njury.
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Serum l evel s s t art t o ri s e by 3 hours pos t MI and el evat i on may pers i s t up t o 714 days . Thi s i s advant ageous for di agnos i s of l at e MI. In mos t STEMI cas es t he di agnos i s can be made us i ng a combi nat i on of t he cl i ni cal pi ct ure and s eri al CK/CK-MB l evel s . In t he event of normal CK-MB l evel s and s us pect ed non-cardi ac s ources of CK, t roponi ns can be us ed. Troponi ns can al s o be el evat ed i n non-i s chaemi c myocyt e damage s uch as myocardi t i s , cardi omyopat hy, and peri cardi t i s .
Other markers
There are mul t i pl e ot her markers , but wi t h i ncreas i ng cl i ni cal avai l abi l i t y of t roponi ns , meas urement s are not recommended. Thes e i ncl ude AST (ri s e 1836 hours pos t MI) and LDH (ri s e 2436 hours pos t MI). The t i me cours e of t he vari ous markers i s s een i n t he fi gure oppos i t e.
Graph of t he appearance of cardi ac markers i n t he bl ood vers us t i me of ons et of s ympt oms Peak A : earl y rel eas e of myogl obi n or CK-MB i s oforms aft er AMI. Peak B : cardi ac t roponi n aft er AMI. Peak C : CK-MB aft er AMI. Peak D : cardi ac t roponi n aft er uns t abl e angi na.
1
Footnote
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1
Adapt ed from W u AH et al . (1999) Cl i n Chem 45 : 11041121. P.17
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST EMI: general measures
STEMI: general measures
Immediate stabilizing measures are as out l i ned on P10 Control of cardiac pain
o
Diamorphine 2.510mg i v i s t he drug of choi ce and may be repeat ed t o ens ure adequat e pai n rel i ef, unl es s evi dence of emergi ng t oxi ci t y (hypot ens i on, res pi rat ory depres s i on). Naus ea and vomi t i ng s houl d be t reat ed wi t h met ocl oprami de (10mg i v) or a phenot hi azi ne. Oxygen t o be admi ni s t ered at 25L/mi n for at l eas t 23 hours . Hypoxaemi a i s frequent l y s een pos t MI due t o vent i l at i onperfus i on abnormal i t i es s econdary t o LVF. In pat i ent s wi t h refract ory pul monary oedema, CPAP, or vi a formal endot racheal i nt ubat i on may be neces s ary. Beware of CO 2 ret ent i on i n pat i ent s wi t h COPD. Nitrates may l es s en pai n and can be gi ven provi di ng t hat pat i ent i s not hypot ens i ve (s ubl i ngual or i nt ravenous ). They need t o be us ed caut i ous l y i n i nferi or STEMI, es peci al l y wi t h ri ght vent ri cul ar i nfarct i on, as venodi l at i on may i mpai r RV fi l l i ng and preci pi t at e hypot ens i on. Ni t rat e t herapy has no effect on mort al i t y (ISIS-4).
Correction of electrolytes Bot h l ow pot as s i um and magnes i um may be arrhyt hmogeni c and mus t be s uppl ement ed es peci al l y i n t he cont ext of arrhyt hmi as .
Strategies to limit infarct size (-blockade, ACE-I,
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and reperfusion)
-blockade
Earl y -bl ockade i n l i mi t i ng i nfarct s i ze, reduci ng mort al i t y, and earl y mal i gnant arrhyt hmi as . Al l pat i ent s (i ncl udi ng pri mary PCI and t hrombol ys i s pat i ent s ) s houl d have earl y -bl ockade, but t hos e wi t h t he fol l owi ng feat ures wi l l benefi t mos t :
o o o
Hyperdynami c s t at e (s i nus t achycardi a, BP) Ongoi ng or recurrent pai n/rei nfarct i on Tachyarrhyt hmi as s uch as AF.
Abs ol ut e cont rai ndi cat i ons : HR <60, SBP <100mmHg, moderat e t o s evere heart fai l ure, AV conduct i on defect , s evere ai rways di s eas e. Rel at i ve cont rai ndi cat i ons : as t hma, current us e of cal ci um channel bl ocker and/or -bl ocker, s evere peri pheral vas cul ar di s eas e wi t h cri t i cal l i mb i s haemi a, l arge i nferi or MI i nvol vi ng t he ri ght vent ri cl e. Us e s hort -act i ng agent i v i ni t i al l y (met oprol ol 12mg at a t i me repeat ed at 12 mi nut e i nt erval s t o a maxi mum dos e of 1520mg) under cont i nuous ECG and BP moni t ori ng. Ai m for a pul s e rat e of 60 and SBP of 100110mmHg. If haemodynami c s t abi l i t y cont i nues 1530 mi nut es aft er l as t i v dos e s t art met oprol ol 50mg t ds . Es mol ol i s an ul t ra-s hort -act i ng i v -bl ocker, whi ch may be t ri ed i f t here i s concern whet her t he pat i ent wi l l t ol erat e -bl ockers .
ACE inhibitors
Aft er recei vi ng as pi ri n, -bl ockade (i f appropri at e), and reperfus i on, al l pat i ent s wi t h STEMI/LBBB i nfarct i on s houl d recei ve an ACE i nhi bi t or wi t hi n t he fi rs t 24 hours of pres ent at i on. P.19
Pat i ent s wi t h hi gh-ri s k/l arge i nfarct s part i cul arl y wi t h an ant eri or STEMI, a previ ous MI, heart fai l ure, or
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i mpai red LV funct i on on i magi ng (ECHO) or t hos e who are el derl y wi l l benefi t mos t .
The effect of ACE-I appears t o be a cl as s effect : us e t he drug you are fami l i ar wi t h (e.g. rami pri l 1.25mg od).
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST EMI: reperfusion t herapy (t hrombolysis) 1
STEMI: reperfusion
therapy (thrombolysis) 1
Rapi d reperfus i on i s t he corners t one of current management of STEMI and i s marked by normal i zat i on of ST s egment s on ECG. Pri mary PCI and t hrombol ys i s are t he mai n reperfus i on modal i t i es . The bes t l ong-t erm out come i s achi eved wi t h pri mary PCI. Reperfus i on occurs i n 5070% of pat i ent s who recei ve t hrombol ys i s wi t hi n 4 hours of ons et of pai n (cf. ~20% of cont rol s ). As wi t h pri mary PCI, t hrombol ys i s al s o res ul t s i n reduced mort al i t y, LV dys funct i on, heart fai l ure, cardi ogeni c s hock, and arrhyt hmi as . However, t he magni t ude of t he benefi t s obt ai ned are s mal l er. Furt hermore, pat i ent s mus t undergo cardi ac cat het eri zat i on t o del i neat e t hei r coronary anat omy before revas cul ari zat i on (achi eved at t he s ame t i me wi t h pri mary PCI). Ti me i s once agai n of paramount i mport ance and t hrombol ys i s s houl d be admi ni s t ered as s oon as pos s i bl e.
Indications for thrombolysis
Typi cal hi s t ory of cardi ac pai n wi t hi n previ ous 12 hours and ST el evat i on i n 2 cont i guous ECG l eads (>1mm i n l i mb l eads or >2mm i n V1V6). Cardi ac pai n wi t h new/pres umed new LBBB on ECG. If ECG i s equi vocal on arri val , repeat at 1530 mi nut e i nt erval s t o moni t or progres s i on. Thrombol ys i s s houl d not be gi ven i f t he ECG i s normal , or i f t here i s i s ol at ed ST depres s i on (mus t excl ude t rue pos t eri or i nfarct ) or ST el evat i on wi t h no precedi ng hi s t ory of pai n.
Timing of thrombolysis
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Great es t benefi t i s achi eved wi t h earl y t hrombol ys i s (es peci al l y i f gi ven wi t hi n 4 hours of ons et of fi rs t pai n). Pat i ent s pres ent i ng bet ween 1224 hours from ons et of pai n s houl d be t hrombol ys ed onl y wi t h pers i s t i ng s ympt oms and ST-s egment el evat i on. El derl y pat i ent s (>65 years ) pres ent i ng wi t hi n t he 1224 hour t i me peri od wi t h s ympt oms are bes t managed by pri mary PCI as t hrombol ys i s has demons t rat ed i ncreas ed cardi ac rupt ure. Pat i ent s pres ent i ng wi t hi n 1224 hours from t he ons et of pai n whos e cl i ni cal pi ct ure appears t o have s et t l ed s houl d be managed i ni t i al l y as an NSTEMI fol l owed by earl y cat het eri zat i on.
Choice of thrombolytic agent
Thi s i s part l y det ermi ned by l ocal t hrombol ys i s s t rat egy. Al l ergi c react i ons and epi s odes of hypot ens i on are great er wi t h SK. Bol us agent s are eas i er and qui cker t o admi ni s t er wi t h a decreas e i n drug errors i n compari s on t o fi rs t -generat i on i nfus i ons . rt PA has a great er reperfus i on capaci t y and a margi nal l y hi gher 30-day s urvi val benefi t t han SK, but an i ncreas ed ri s k of haemorrhage. More recent rPA deri vat i ves have a hi gher 90-mi nut e TIMI-III fl ow rat e, but s i mi l ar 30-day mort al i t y benefi t t o rt PA. P.21
An rt PA deri vat i ve s houl d be cons i dered for any pat i ent wi t h

o
Large ant eri or MI es peci al l y i f wi t hi n 4 hours of ons et
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ABC Ambe r CHM Conve rte r Tria l ve rsion, http://w w w .proce sste x t.com/a bcchm.html o
Previ ous SK t herapy or recent s t rept ococcal i nfect i on Hypot ens i on (s ys t ol i c BP <100mmHg) Low ri s k of s t roke (age <55 years , s ys t ol i c BP <144mmHg). Rei nfarct i on duri ng hos pi t al i zat i on where i mmedi at e PCI faci l i t i es are not avai l abl e.
o o
The charact eri s t i cs of t he major t hrombol yt i c agent s are gi ven on P23.
Patients who gain greatest benefit from thrombolysis

Ant eri or i nfarct Marked ST el evat i on Age >75 years Impai red LV funct i on or LBBB, hypot ens i ve Sys t ol i c BP <100mmHg Pat i ent s pres ent i ng wi t hi n 1 hour of ons et of pai n
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST EMI: t hrombolysis 2
STEMI: thrombolysis 2
Complications of thrombolysis
Bl eedi ng i s s een i n up t o 10% of pat i ent s . Mos t are mi nor at s i t es of vas cul ar punct ure. Local pres s ure i s s uffi ci ent but occas i onal l y t rans fus i on may be requi red. In ext reme cas es , SK may be revers ed by t ranexami c aci d (10mg/kg s l ow i v i nfus i on). Hypot ens i on duri ng t he i nfus i on i s common wi t h SK. Lay pat i ent s upi ne and s l ow/s t op i nfus i on unt i l t he bl ood pres s ure ri s es . Treat ment wi t h caut i ous (100500ml ) fl ui d chal l enges may be requi red es peci al l y i n i nferi or/RV i nfarct i on. Hypot ens i on i s not an al l ergi c react i on and does not warrant t reat ment as s uch. Al l ergi c react i ons are common wi t h SK and i ncl ude a l ow-grade fever, ras h, naus ea, headaches , and fl us hi ng. Gi ve hydrocort i s one 100mg i v wi t h chl orpheni rami ne 10mg i v. Int racrani al haemorrhage i s s een i n ~0.3% of pat i ent s t reat ed wi t h SK and ~0.6% of t hos e wi t h rt -PA. Reperfus i on arrhyt hmi as (mos t commonl y a s hort , s el f-l i mi t i ng run of i di ovent ri cul ar rhyt hm) may occur as t he met abol i t es are was hed out of t he i s chaemi a t i s s ue. See pp4042 for management . Sys t emi c embol i zat i on may occur from l ys i s of t hrombus wi t hi n t he l eft at ri um, l eft vent ri cl e, or aort i c aneurys m.
Absolute contraindications to thrombolysis

Act i ve i nt ernal bl eedi ng Sus pect ed aort i c di s s ect i on
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Recent head t rauma and/or i nt racrani al neopl as m Previ ous haemorrhagi c s t roke at any t i me Previ ous i s chaemi c s t roke wi t hi n t he pas t 1 year Previ ous al l ergi c react i on t o fi bri nol yt i c agent Trauma and/or s urgery wi t hi n pas t 2 weeks at ri s k of bl eedi ng
Relative contraindications to thrombolysis

Trauma and/or s urgery more t han 2 weeks previ ous l y Severe uncont rol l ed hypert ens i on (BP >180/110) wi t h/wi t hout t reat ment Non-haemorrhagi c s t roke over 1 year ago Known bl eedi ng di at hes i s or current us e of ant i coagul at i on wi t hi n t herapeut i c range (INR 2 or over) Si gni fi cant l i ver or renal dys funct i on Prol onged (>10 mi n) of cardi opul monary res us ci t at i on Pri or expos ure t o SK (es peci al l y previ ous 69 mont hs ) Pregnancy or pos t part um Lumbar punct ure wi t hi n previ ous 1 mont h Mens t rual bl eedi ng or l act at i on Hi s t ory of chroni c s evere hypert ens i on Noncompres s i bl e vas cul ar punct ures (e.g. s ubcl avi an cent ral venous l i nes )
P.23
Doses and administration of thrombolytic agents SK
Gi ve as 1.5 mi l l i on uni t s i n 100ml normal s al i ne i v over 1 hour There i s no i ndi cat i on for rout i ne hepari ni zat i on aft er SK as t here i s no cl ear mort al i t y benefi t and t here i s a s mal l i ncreas e i n ri s k of haemorrhage
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rtPA (alteplase)
The GUSTO t ri al s ugges t ed t hat front -l oaded or accel erat ed rt PA i s t he mos t effect i ve dos age regi men Gi ve 15mg bol us i v t hen 0.75mg/kg over 30 mi nut es (not t o exceed 50mg), t hen 0.5mg/kg over 60 mi nut es (not t o exceed 35mg). Thi s s houl d be fol l owed by i v hepari n (s ee t ext )
Reteplase
Gi ve t wo i v bol us dos es of 10 uni t s 10 mi nut es apart
Tenecteplase
Gi ve as i nject i on over 10 s econds at 3050mg accordi ng t o body wei ght (500600g/kg) Maxi mum dos e i s 50mg
APSAC (anistreplase)
Gi ve as an i v bol us of 30mg over 25 mi nut es
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST EMI: reperfusion by primary perc ut aneous c oronary int ervent ion (
STEMI:
reperfusion by primary percutaneous coronary intervention (PCI)

Ti me i s of t he es s ence for reperfus i on and each i ns t i t ut i on s houl d have i t s recommended prot ocol . It i s i mperat i ve t hat t here are no del ays i n bot h t he deci s i on-maki ng and i mpl ement at i on proces s es for reperfus i on. If pri mary PCI i s chos en one t el ephone cal l s houl d ens ure a rapi d res pons e.
Primary PCI
Pri mary PCI i s t he current gol d s t andard reperfus i on s t rat egy for t reat ment of STEMI. Pri mary PCI requi res s i gni fi cant coordi nat i on bet ween t he emergency s ervi ces , communi t y hos pi t al s , and i nvas i ve cent res . It mus t onl y be performed i f (1) a pri mary PCI programme i s avai l abl e and (2) t he pat i ent pres ent s t o an i nvas i ve cent re and can undergo cat het eri zat i on wi t hout del ay.
Indications for primary PCI
Al l pat i ent s wi t h ches t pai n and ST-s egment el evat i on or new LBBB ful fi l pri mary PCI cri t eri a (compare wi t h i ndi cat i ons for t hrombol ys i s ). Thi s wi l l i ncl ude a group of pat i ent s where ST-s egment el evat i on may not ful fi l t hrombol ys i s cri t eri a. In general pat i ent s i n whom t hrombol ys i s i s cont rai ndi cat ed s houl d be managed by pri mary PCI.
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Cas es where t here i s s i gni fi cant ri s k of bl eedi ng mus t be managed i ndi vi dual l y.
Outcome in primary PCI
Dat a from over 10 l arge randomi zed t ri al s demons t rat e a s uperi or out come i n pat i ent s wi t h STEMI who are t reat ed wi t h pri mary PCI i n compari s on t o t hrombol ys i s . There i s a s i gni fi cant s hort -t erm, as wel l as l ong-t erm reduct i on i n mort al i t y and major cardi ac event s (MACE) (deat h, non-fat al rei nfarct i on, and non-fat al s t roke) i n STEMI pat i ent s t reat ed wi t h pri mary PCI. Furt hermore, pri mary PCI pat i ent s have overal l bet t er LV funct i on, a hi gher ves s el pat ency rat e, and l es s recurrent myocardi al i s chaemi a. Mul t i pl e s t udi es (i ncl udi ng PRAGUE-2 and DANAMI-2) have al s o demons t rat ed t hat i nt erhos pi t al t rans port at i on for pri mary PCI (communi t y hos pi t al t o i nvas i ve cent re) i s s afe and pri mary PCI cont i nues t o remai n s uperi or t o t hrombol ys i s des pi t e t he t i me del ays i nvol ved.
Complications
Thes e i ncl ude bl eedi ng from art eri al punct ure s i t e, s t roke, recurrent i nfarct i on, need for emergency CABG, and deat h, whi ch are s i mi l ar t o hi gh-ri s k PCI cas es (~1%). The bes t res ul t s are obt ai ned from hi gh-vol ume cent res wi t h experi ence of pri mary PCI. Each pri mary PCI cent re wi l l have i t s own pol i cy for management of cas es i ncl udi ng t he us e of LMW H/UFH, and ant i -pl at el et agent s P.25
(e.g. IIb/IIIa). It i s general l y accept ed t hat i n t he acut e phas e onl y t he cul pri t l es i on(s )/ves s el (s ) wi l l be t reat ed. The pat t ern of di s eas e i n t he remai nder of t he
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ves s el s wi l l det ermi ne whet her t ot al revas cul ari zat i on s houl d be performed on t he pers on as an i n-pat i ent or as an el ect i ve cas e i n t he fut ure.
STEMI pat i ent s t reat ed wi t h pri mary PCI can be di s charged s afel y wi t hi n 72 hours of admi s s i on wi t hout t he need for furt her ri s k s t rat i fi cat i on. Pri mary PCI i s more cos t effect i ve i n t he l ong t erm wi t h s i gni fi cant s avi ngs from fewer days i n hos pi t al , a l ower need for readmi s s i on, and l es s heart fai l ure. Pos t -di s charge care, s econdary prevent i on, and rehabi l i t at i on remai n i dent i cal t o ot her MI cas es .
Rescue PCI
As an adjunct t o t hrombol ys i s , PCI s houl d be res erved for pat i ent s who remai n s ympt omat i c pos t t hrombol ys i s (fai l ure t o reperfus e) or devel op cardi ogeni c s hock (s ee P44). W e recommend al l pat i ent s who do not s et t l e pos t t hrombol ys i s (on-goi ng s ympt oms and on-goi ng ST-el evat i on wi t h/wi t hout s ympt oms ) s houl d be di s cus s ed wi t h t he l ocal cardi ac cent re for urgent cat het eri zat i on and revas cul ari zat i on.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Surgery for ac ut e ST EMI
Surgery for acute STEMI
Emergency s urgi cal revas cul ari zat i on (CABG) cannot be wi del y appl i ed t o pat i ent s who s uffer a MI out s i de of t he hos pi t al . CABG i n uncompl i cat ed STEMI pat i ent s aft er 6 hours from pres ent at i on i s cont rai ndi cat ed s econdary t o s i gni fi cant haemorrhage i nt o areas of i nfarct i on. Uns t abl e pat i ent s have a very hi gh peri -operat i ve mort al i t y. CABG i n t he cont ext of an acut e STEMI i s of val ue i n t he fol l owi ng s i t uat i ons
Pers i s t ent or recurrent ches t pai n des pi t e t hrombol ys i s /pri mary PCI Hi gh-ri s k coronary anat omy on cat het eri zat i on (LMS, LAD os t i al di s eas e) Compl i cat ed STEMI (acut e MR, VSD) Pat i ent s who have undergone s ucces s ful t hrombol ys i s but wi t h s urgi cal coronary anat omy on cat het eri zat i on Pat i ent s known t o have s urgi cal coronary anat omy on cat het eri zat i on performed pri or t o admi s s i on wi t h STEMI.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST EMI: addit ional measures
STEMI: additional measures

o
Low molecular weight and unfractionated heparin UFH
There i s no i ndi cat i on for rout i ne i v hepari n fol l owi ng SK i v hepari n (4000U/max i v bol us fol l owed by 1000U/h max adjus t ed for an aPTT rat i o of 1.52.0 t i mes cont rol ) s houl d be us ed rout i nel y fol l owi ng rt -PA and i t s deri vat i ves for 2448 hours .
LMWH
There are t ri al dat a for t he us e of LMW H and t hrombol ys i s (e.g. enoxapari n 30mg i v bol us , t hen 1mg/kg s c q12h)
LMW H can be us ed at a prophyl act i c dos e t o prevent t hromboembol i c event s i n pat i ent s s l ow t o mobi l i ze as an al t ernat i ve t o UFH.
Clopidogrel
o
Shoul d be admi ni s t ered t o al l pat i ent s undergoi ng pri mary PCI (l oadi ng dos e 300mg po fol l owed by 75mg od) If coronary s t ent s are depl oyed pat i ent s houl d remai n on cl opi dogrel for at l eas t 1 mont h for bare met al s t ent s and 3 mont hs for coat ed s t ent s More dat a are requi red t o s ee whet her l onger-t erm t reat ment may be of benefi t fol l owi ng t hrombol ys i s al one.
Glycoprotein IIb/IIIa inhibitors

o
There are mul t i pl e on-goi ng t ri al s t o eval uat e t hei r rol e i n combi nat i on wi t h t hrombol ys i s and/or
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LMW H
o
Are recommended rout i nel y i n t he cont ext of STEMI pat i ent s t reat ed wi t h pri mary PCI. Lower dos es of LMW H/UFH s houl d be us ed (cons ul t manufact urer's i nformat i on s heet for i ndi vi dual agent s ) They can al s o be us ed i n t he cont ext of res cue PCI s ubs equent t o fai l ed t hrombol ys i s al t hough t here i s a great er ri s k of bl eedi ng. Each cas e mus t be judged on i t s meri t s .
Magnesium
o
Earl i er t ri al s gi vi ng Mg
2+
before or wi t h
t hrombol yt i cs s howed s ome benefi t i n mort al i t y. ISIS-4 s howed no benefi t from t he rout i ne us eof i v magnes i um pos t MI. However Mg prot ect i ve effect of Mg
2+ 2+
was gi ven l at e
(6 hours ) aft er t hrombol ys i s by whi ch t i me t he on reperfus i on i njury may

2+
have been l os t . Tri al s are on-goi ng

o
Current accept ed rol e for Mg
i s confi ned t o Mg
2+
-depl et e pat i ent s and pat i ent s wi t h reperfus i on, s upravent ri cul ar, and vent ri cul ar arrhyt hmi as
o
Dos e: 8mmol i n 20ml 5% dext ros e over 20 mi nut es fol l owed by 65mmol i n 100ml 5% dext ros e over 24 hours (cont rai ndi cat i ons : s erum Cr >300mol /L, 3 AV bl ock).
Calcium antagonists
o
Bes t avoi ded, es peci al l y i n t he pres ence of LV i mpai rment Di l t i azem and verapami l s t art ed aft er day 45 i n pos t -MI pat i ent s wi t h normal LV funct i on have a s mal l benefi ci al effect Aml odi pi ne i s s afe t o be us ed i n pat i ent s wi t h poor LV pos t MI Ni fedi pi ne has been s hown t o i ncreas e mort al i t y and s houl d be avoi ded.
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Digoxin
o
Has l i t t l e rol e i n management of an acut e STEMI and heart fai l ure compl i cat i ng an acut e MI Can be us ed s afel y i n management of arrhyt hmi as and HR.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Right vent ric ular (
Right ventricular (RV) infarction
RV i nfarct i on res ul t s i n el evat ed ri ght -s i ded pres s ures (RA, RVEDP) and l ow l eft -s i ded pres s ures (BP, CO). It i s common i n i nferi or STEMI.
Diagnosis
Cl i ni cal : s i gns of ri ght heart fai l ure (JVP, Kus s maul 's s i gn, pul s us paradoxus ) wi t h abs ence of pul monary oedema i n t he cont ext of a l ow out put s t at e (BP, col d peri pheri es ). ECG: i n pat i ent s wi t h i nferi or STEMI a 0.1mV (>1mm) ST-s egment el evat i on i n any one of l eads V4RV6R i s hi ghl y s ens i t i ve and s peci fi c for RV i nfarct i on. See fi gure for di fferent ECG pat t erns i dent i fi ed i n ri ght -s i ded precordi al l eads . Changes may be t rans i ent and pres ent i n t he earl y s t ages onl y. Echo: l ooki ng for RV di l at i on and wal l -mot i on abnormal i t i es .
Management
Ai m t o mai nt ai n a hi gh RV prel oad

o o
Ini t i al l y gi ve 12L of col l oi d rapi dl y Avoi d us e of ni t rat es and di uret i cs as t hey reduce pre-l oad and can wors en hypot ens i on In pat i ent s requi ri ng paci ng AV s ynchrony mus t be mai nt ai ned t o ens ure maxi mal CO (at ri al and vent ri cul ar wi res ) Cardi overt any arrhyt hmi as (SVT, AF/fl ut t er, or vent ri cul ar rhyt hms ).
Reduce aft erl oad

o
Thi s i s part i cul arl y i mport ant i f t here i s
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concomi t ant LV dys funct i on

o o
Ins ert IABP Art eri al vas odi l at ors (Na ni t roprus s i de, hydral azi ne) or ACE i nhi bi t ors can be us ed wi t h caut i on.
Inot ropi c s upport s houl d i deal l y be avoi ded and us ed onl y i f al l ot her meas ures fai l t o res t ore haemodynami c s t at us . Reperfus i on of t he RCA (PCI and t hrombol ys i s ) has been demons t rat ed t o i mprove RV funct i on and reduce mort al i t y.
P.29
ST elevation and T -wave configuration in lead V4R in inferoposterior AMI . Proxi mal occl us i on of t he RCA produces ST el evat i on 1mm and a pos i t i ve T-wave. Di s t al occl us i on i s charact eri zed by a pos i t i ve T-wave but no ST el evat i on. Occl us i on of t he ci rcumfl ex art ery produces a negat i ve T-wave and ST depres s i on of at l eas t 1mm.
1
Footnote
1
Adapt ed from W el l ens HJ (1999) N Engl J Med 340 : 1383.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST EMI: predisc harge risk st rat ific at ion
STEMI: predischarge risk
stratification
It i s i mport ant t o i dent i fy t he s ubgroup of pat i ent s who have a hi gh ri s k of re-i nfarct i on or s udden deat h. They s houl d undergo coronary angi ography wi t h a vi ew t o revas cul ari zat i on pri or t o di s charge (i f not t reat ed wi t h pri mary PCI) and/or el ect rophys i ol ogi cal i nves t i gat i ons as neces s ary.
Primary PCI group
STEMI pat i ent s t reat ed wi t h pri mary PCI are at a much l ower ri s k of devel opi ng pos t MI compl i cat i ons . There i s on-goi ng debat e whet her pat i ent s t reat ed wi t h pri mary PCI s houl d have t ot al revas cul ari zat i on as an i n-pat i ent or whet her t hi s can be achi eved aft er funct i onal t es t i ng on an out -pat i ent bas i s . Fol l ow your l ocal pol i cy. Pat i ent s who s houl d have el ect rophys i ol ogi cal as s es s ment pri or t o di s charge are l i s t ed bel ow.
Thrombolysis group
Pat i ent s t reat ed wi t h t hrombol ys i s s houl d be ri s k s t rat i fi ed pri or t o di s charge and hi gh-ri s k pat i ent s s houl d have i n-pat i ent (or earl y out -pat i ent ) angi ography. Hi gh-ri s k pat i ent s i ncl ude t hos e wi t h
o o
Si gni fi cant pos t -i nfarct angi na or uns t abl e angi na Pos i t i ve exerci s e t es t (modi fi ed Bruce prot ocol ) wi t h angi na, >1mm ST depres s i on or fal l i n BP Cardi omegal y on CXR, poor LV funct i on on Echo (EF <40%) Document ed epi s odes of regul ar VEs and VT 24
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hours pos t i nfarct i on

o
Frequent epi s odes of s i l ent i s chaemi a on Hol t er moni t ori ng.
Electrophysiological study
Al l STEMI pat i ent s wi t h (1) non-s us t ai ned VT and document ed EF <40% or (2) s us t ai ned/pul s el es s VT/VF (regardl es s of EF) s houl d undergo el ect rophys i ol ogi cal t es t i ng pri or t o di s charge (MADIT and MUSTT t ri al s ) wi t h a vi ew t o defi bri l l at or i mpl ant at i on.
Discharge and secondary prevention
Lengt h of hos pi t al s t ay i n uncompl i cat ed pat i ent s . The t hrombol ys i s group need t o undergo ri s k s t rat i fi cat i on pri or t o di s charge and t end t o have a mean hos pi t al s t ay of 57 days . The pri mary PCI group have a s hort er hos pi t al s t ay bet ween 34 days . Pri or t o di s charge an agreed pl an bet ween pat i ent (pat i ent 's fami l y) and phys i ci an i s neces s ary t o addres s modi fi abl e ri s k fact ors , benefi ci al medi cat i on, and rehabi l i t at i on programme. Modi fi abl e ri s k fact ors i ncl ude
o o o o o
Management of l i pi ds and us e of s t at i ns Det ect i on and t reat ment of di abet es Ens uri ng bl ood pres s ure i s adequat el y cont rol l ed Couns el l i ng t o di s cont i nue s moki ng Advi ce on a heal t hy di et and wei ght l os s .
P.31
It i s vi t al pat i ent s unders t and t he medi cal regi me and i n part i cul ar t he i mport ance of l ong-t erm prognos t i c medi cat i on. Unl es s t here are cont rai ndi cat i ons al l pat i ent s s houl d be on a mi ni mum of
o
As pi ri n 75mg od (i f t rue al l ergy, us e cl opi dogrel 75mg od)
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ABC Ambe r CHM Conve rte r Tria l ve rsion, http://w w w .proce sste x t.com/a bcchm.html o o o
ACE i nhi bi t or at t he recommended dos age St at i n at t he recommended dos age The rol e of l ong-t erm formal ant i -coagul at i on i s cont rovers i al .
Al l pat i ent s mus t be pl ugged i nt o a rehabi l i t at i on programme.
Sugges t ed s t rat egy pos t STEMI i n pat i ent s who have undergone t hrombol ys i s t o det ermi ne t he need for i n-pat i ent angi ography/EPS.
1
Footnote
1
Adapt ed from
nd
Ant man EM (2000) Cardi ovas cul ar Therapeut i cs 2
edi t i on.
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Saunders , Phi l adel phi a.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > ST EMI: c omplic at ions
STEMI: complications
Complications include

Cont i nui ng ches t pai n Fever A new s ys t ol i c murmur: VSD, acut e MR, or peri cardi t i s Dys rrhyt hmi a (VT, AV bl ock ect opi cs , and bradycardi a) Pump fai l ure: hypot ens i on, cardi ac fai l ure, and cardi ogeni c s hock.
Compl i cat i ons are encount ered more commonl y i n pat i ent s pos t STEMI, but can al s o be found i n NSTEMI pat i ent s (s ee next s ect i on). In NSTEMI pat i ent s compl i cat i ons are more common where mul t i pl e cardi ac event s have occurred.
Further chest pain
Ches t pai n pos t MI i s not neces s ari l y angi na. Careful hi s t ory i s needed t o charact eri ze pai n. If t here i s doubt about t he aet i ol ogy of pai n i n t he abs ence of ECG changes s t res s /t hal l i um i magi ng may ai d di agnos i s . A brui s ed s ens at i on and mus cul os kel et al pai ns are common i n t he fi rs t 2448 hours , es peci al l y i n pat i ent s who have recei ved CPR or repeat ed DC s hock. Us e t opi cal agent s for s ki n burns . Recurrent infarction i s an umbrel l a t erm i ncl udi ng bot h ext ens i on of i nfarct i on i n t he ori gi nal t erri t ory and repeat ed i nfarct i n a s econd t erri t ory.
o o
Us ual l y as s oci at ed wi t h recurrent ST el evat i on If cardi ac enzymes not yet back t o normal , a s i gni fi cant change i s a t wo-fol d ri s e above t he previ ous nadi r Pat i ent s s houl d i deal l y undergo i mmedi at e PCI.
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Thrombol ys i s i s an al t ernat i ve, but a l es s at t ract i ve approach. St andard t hrombol ys i s cri t eri a mus t be met (s ee P20). Bl eedi ng i s a ri s k (NB: SK s houl d not be us ed on a s econd occas i on).
Post infarction angina (angi na devel opi ng wi t hi n 10 days of MI) s houl d be t reat ed wi t h s t andard medi cal t herapy. Al l pat i ent s wi t h angi na pri or t o di s charge s houl d undergo cardi ac cat het eri zat i onand revas cul ari zat i on as an i n-pat i ent . Pericarditis pres ent s as s harp, pl euri t i c, and pos i t i onal ches t pai n, us ual l y 13 days pos t i nfarct . It i s more common wi t h STEMI. A peri cardi al fri ct i on rub may be audi bl e. ECG changes are rarel y s een. Treat wi t h hi gh-dos e as pi ri n (600mg qds po) coveri ng wi t h a prot on pump i nhi bi t or (e.g. l ans oprazol e 30mg od po). Ot her NSAIDs have been as s oci at ed wi t h hi gher i nci dence of LV rupt ure and i ncreas ed coronary vas cul ar res i s t ance and are probabl y bes t avoi ded. Pericardial effusion i s more common wi t h ant eri or MI es peci al l y i f compl i cat ed by cardi ac fai l ure. Tamponade i s rare and t he res ul t of vent ri cul ar rupt ure and/or haemorrhagi c effus i ons . Det ect i on i s wi t h a combi nat i on of cl i ni cal feat ures and echocardi ography. Mos t res ol ve gradual l y over a few mont hs wi t h no act i ve i nt ervent i on. Pulmonary thromboembolism can occur i n pat i ent s wi t h heart fai l ure and prol onged bed res t . Rout i ne us e of prophyl act i c LMW H and UFH combi ned wi t h earl y mobi l i zat i on have reduced i nci dence of PE. Sources i ncl ude l ower l i mb vei ns and/or RV (s ee P146).
P.33
Fever
Oft en s een and peaks 34 days pos t MI
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As s oci at ed wi t h el evat ed W CC and rai s ed CRP Ot her caus es of fever s houl d be cons i dered (i nfect i on, t hrombophl ebi t i s , venous t hrombos i s , drug react i on, peri cardi t i s ).
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Vent ric ular sept al defec t post myoc ardial infarc t ion (
Ventricular septal
defect post myocardial infarction (MI)
Cl as s i cal l y s een 24 hours (hi ghes t ri s k) t o 10 days pos t MI and affect s 24% of cas es . Clinical features i ncl ude rapi d det eri orat i on wi t h a hars h pan-s ys t ol i c murmur (maxi mal at t he l ower l eft s t ernal edge), poor perfus i on, and pul monary oedema. The abs ence of a murmur i n t he cont ext of a l ow out put s t at e does not rul e out a VSD.
Diagnosis
Echocardi ography: t he defect may be vi s ual i zed on 2D-Echo and col our fl ow Doppl er s hows t he pres ence of l eft -t o-ri ght s hunt . Ant eri or i nfarct i on i s as s oci at ed wi t h api cal VSD and i nferi or MI wi t h bas al VSD. Fai l ure t o demons t rat e a s hunt on Echo does not excl ude a VSD. PA cat het er (es peci al l y i n abs ence of Echo or i nconcl us i ve Echo res ul t s ): a s t ep-up i n oxygen s at urat i on from RA t o RV confi rms t he pres ence of a s hunt , whi ch may be cal cul at ed by
Management
St abal i z at i on meas ures are al l t empori zi ng unt i l defi ni t i ve repai r can t ake pl ace. Hypot ens i on (s ee P42) and pul monary oedema
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(P112) s houl d be managed as des cri bed el s ewhere. Import ant pri nci pl es are gi ven bel ow.
Invas i ve moni t ori ng (PA cat het er and art eri al l i ne) t o di ct at e haemodynami c management . RA and PCW P di ct at e fl ui d admi ni s t rat i on or di uret i c us e. Cardi ac out put , mean art eri al pres s ure, and art eri al res i s t ance det ermi ne t he need for vas odi l at or t herapy. If SBP >100mmHg, caut i ous us e of vas odi l at or t herapy, general l y wi t h ni t roprus s i de, wi l l l ower t he s ys t emi c vas cul ar res i s t ance and reduce t he magni t ude of t he s hunt . Ni t rat es wi l l caus e venodi l at at i on and i ncreas e t he s hunt and s houl d be avoi ded. Not be us ed wi t h renal i mpai rment . Inot ropes i f s everel y hypot ens i ve (i ni t i al l y dobut ami ne but adrenal i ne may be requi red dependi ng on haemodynami c res pons e). Increas i ng s ys t emi c pres s ure wi l l wors en s hunt . In mos t cas es i nt ra-aort i c bal l oon s houl d be i ns ert ed rapi dl y for count er pul s at i on. Li ai s e wi t h s urgeons earl y for pos s i bl e repai r. Operat i ve mort al i t y i s hi gh (2070%) es peci al l y i n t he cont ext of peri -operat i ve s hock, i nfero-pos t eri or MI, and RV i nfarct i on. Current recommendat i ons are for hi gh-ri s k earl y s urgi cal repai r combi ned wi t h CABG MV repai r/repl acement . If pat i ent has been weaned off pharmacol ogi cal and/or mechani cal s upport i t may be pos s i bl e t o pos t pone s urgery for 24 weeks t o al l ow for s ome l evel of i nfarct heal i ng. P.35
Pat i ent s s houl d i deal l y undergo cat het eri zat i on pri or t o s urgi cal repai r t o ens ure cul pri t ves s el (s ) are graft ed. Cl os ure of t he VSD wi t h cat het er pl acement of an umbrel l a-s haped devi ce has been report ed t o s t abi l i ze
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cri t i cal l y i l l pat i ent s unt i l defi ni t i ve repai r i s pos s i bl e.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Ac ut e mit ral regurgit at ion post MI
Acute mitral regurgitation
post MI
MR due t o i s chaemi c papi l l ary mus cl e dys funct i on or part i al rupt ure i s s een 210 days pos t MI. Compl et e rupt ure caus es t orrent i al MR and i s us ual l y fat al . More commonl y as s oci at ed wi t h i nferi or MI (pos t ero-medi al papi l l ary mus cl e) t han ant eri or MI (ant erol at eral papi l l ary mus cl e). Si l ent MR i s qui t e frequent and mus t be s us pect ed i n any pos t MI pat i ent wi t h unexpl ai ned haemodynami c det eri orat i on. Di agnos i s i s by Echo. In s evere MR, PA cat het eri zat i on wi l l s how a rai s ed pres s ure wi t h a l arge v wave.
Management (P140)
Treat ment wi t h vas odi l at ors , general l y ni t roprus s i de, s houl d be s t art ed as earl y as pos s i bl e once haemodynami c moni t ori ng i s avai l abl e. Mechani cal vent i l at i on may be neces s ary. Li ai s e wi t h s urgeons earl y for pos s i bl e repai r.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pseudoaneurysm and free wall rupt ure
Pseudoaneurysm and free
wall rupture
Demons t rat ed i n up t o 6% of STEMI pat i ent s and l eads t o s udden deat h i n t wo-t hi rds . A proport i on pres ent s ub-acut el y wi t h cardi ogeni c s hock al l owi ng t i me for i nt ervent i on. Di agnos i s of s ub-acut e cas es can be made on a combi nat i on of cl i ni cal feat ures of peri cardi al effus i on, t amponade, and Echo. Pat i ent s who have undergone earl y t hrombol ys i s have a l ower chance of wal l rupt ure. St abi l i zat i on of t he pat i ent fol l ows s i mi l ar l i nes t o cardi ogeni c s hock (P44). Cas e mus t be di s cus s ed wi t h s urgeons i mmedi at el y wi t h vi ew t o repai r.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Coc aine- induc ed MI
Cocaine-induced MI
The i nci dence of cocai ne-i nduced MI, LV dys funct i on, and arrhyt hmi as are on t he i ncreas e. It has been es t i mat ed t hat 1425% of young pat i ent s pres ent i ng t o urban emergency depart ment s wi t h non-t raumat i c ches t pai n may have det ect abl e l evel s of cocai ne and i t s met abol i t es i n t hei r ci rcul at i on. Of t hi s group 6% have enzymat i c evi dence of MI (fi gures are from t he USA). Mos t pat i ent s are young, non-whi t e, mal e ci garet t e s mokers wi t hout ot her ri s k fact ors for i s chaemi c heart di s eas e.
Diagnosis
Can be di ffi cul t and mus t be s us pect ed i n any young i ndi vi dual wi t h ches t di s comfort at l ow-ri s k of devel opi ng i s chaemi c heart di s eas e. Chest pain occurs mos t commonl y wi t hi n 12 hours of cocai ne us e. Effect s can ret urn up t o 2436 hours l at er s econdary t o l ong-l as t i ng act i ve met abol i t es . ECG i s abnormal wi t h mul t i pl e non-s peci fi c repol ari zat i on changes i n up t o 80% of cas es and approxi mat el y 40% may have di agnos t i c changes of STEMI qual i fyi ng for reperfus i on t herapy (s ee P14). Biochemical markers of cardiac injury can be mi s l eadi ng, as mos t pat i ent s wi l l have el evat ed CK l evel s s econdary t o rhabdomyol ys i s . TnT and TnI are vi t al t o confi rm myocardi al i njury.
Management
General measures
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Thes e are t he s ame as for anyone pres ent i ng wi t h an MI. Oxygen: hi gh-fl ow 510L unl es s t here i s a cont rai ndi cat i on; anal ges i a; as pi ri n 75mg od GTN: t o be gi ven at hi gh dos es as i v i nfus i on (>10mg/h fi nal l evel s ) and dos e t i t rat ed t o s ympt oms and haemodynami c res pons e (s ee STEMI) Benzodi azepi nes : t o reduce anxi et y. Verapamil i s gi ven i n hi gh dos es and has t he dual funct i on of reduci ng cardi ac workl oad, hence res t ori ng oxygen s uppl y and demand, as wel l as revers i ng coronary vas ocons t ri ct i on. Shoul d be gi ven caut i ous l y as 12mg i v bol us at a t i me (up t o 10mg t ot al ) wi t h cont i nuous haemodynami c moni t ori ng. Thi s s houl d be fol l owed by a hi gh-dos e oral preparat i on t o cover t he 24-hour peri od for at l eas t 72 hours pos t l as t dos e of cocai ne (80120mg po t ds ). Phentolamine i s an -adrenergi c ant agoni s t and readi l y revers es cocai ne-i nduced vas ocons t ri ct i on (25mg i v and repeat ed i f neces s ary). It can be us ed i n conjunct i on wi t h verapami l . Labetalol has bot h - and -adrenergi c act i vi t y and can be us ed aft er verapami l and phent ol ami ne i f pat i ent remai ns hypert ens i ve. It i s effect i ve i n l oweri ng cocai ne-i nduced hypert ens i on, but has no effect on coronary vas ocons t ri ct i on. Reperfusion therapy evi dence for us e of t hrombol ys i s i s l i mi t ed and general l y as s oci at ed wi t h poor out come s econdary t o P.39
Second-line agents
o
hypert ens i on-i nduced haemorrhagi c compl i cat i ons . If pat i ent fai l s t o s et t l e aft er i mpl ement i ng fi rs t -l i ne
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meas ures , verapami l , and phent ol ami ne t hey s houl d undergo i mmedi at e coronary angi ography fol l owed by PCI i f appropri at e (evi dence of t hrombus /ves s el occl us i on). In t he event t hat angi ography i s not avai l abl e t hrombol yt i c t herapy can be cons i dered.
Caut i on : - blockers must be avoided (e.g. propranolol) . They exacerbat e coronary vas ocons t ri ct i on by al l owi ng unoppos ed act i on of t he -adrenergi c recept ors .
Cocaine-induced MI Pathogenesis
The caus e of myocardi al i njury i s mul t i fact ori al i ncl udi ng an i ncreas e i n oxygen demand (HR, BP, cont ract i l i t y) i n t he cont ext of decreas e i n s uppl y caus ed by a combi nat i on of i nappropri at e vas ocons t ri ct i on (i n areas of mi nor at heroma), enhanced pl at el et aggregat i on, and t hrombus format i on The effect s can be del ayed as t he met abol i t es of cocai ne are pot ent act i ve vas ocons t ri ct ors and can remai n i n t he ci rcul at i on for up t o 36 hours (or l onger) res ul t i ng i n a recurrent wave of s ympt oms
Other complications
Cocaine-induced myocardial dysfunction i s mul t i fact ori al and i ncl udes MI, chroni c damage s econdary t o repet i t i ve s ympat het i c s t i mul at i on (as i n pheochromocyt oma), myocardi t i s s econdary t o cocai ne i mpuri t i es /i nfect i on, and unfavourabl e changes i n myocardi al /endot hel i al gene expres s i on Cocaine-induced dysrrhythmias i ncl ude bot h at ri al and vent ri cul ar t achyarrhyt hmi as , as wel l as as ys t ol e and heart bl ock [s ee pos t -MI arrhyt hmi as (P40) and cardi opul monary res us ci t at i on (P4)] Aortic dissection (s ee P170)
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Vent ric ular t ac hyarrhyt hmia post MI
Ventricular
tachyarrhythmia post MI
Accelerated idioventricular rhythm

o
Common (up t o 20%) i n pat i ent s wi t h earl y reperfus i on i n fi rs t 48 hours . Us ual l y s el f l i mi t i ng and s hort l as t i ng wi t h no haemodynami c effect s If s ympt omat i c, accel erat i ng s i nus rat e wi t h at ri al paci ng or at ropi ne may be of val ue. Suppres s i ve ant i -arrhyt hmi c t herapy (l i gnocai ne, ami odarone) i s onl y recommended wi t h degenerat i on i nt o mal i gnant vent ri cul ar t achyarrhyt hmi as .
VPB
o
Common and not rel at ed t o i nci dence of s us t ai ned VT/VF General l y t reat ed cons ervat i vel y. Ai m t o correct aci d-bas e and el ect rol yt e abnormal i t i es (ai m K >4.0mmol /L and Mg
2+ +
>1.0mmol /L)
Peri -i nfarct i on -bl ockade reduces VPB. As s oci at ed wi t h a wors e cl i ni cal out come Correct revers i bl e feat ures s uch as el ect rol yt e abnormal i t i es and aci d-bas e bal ance DC cardi overs i on for haemodynami c i ns t abi l i t y Non-s us t ai ned VT and haemodynami cal l y s t abl e VT (s l ow HR <100bpm) can be t reat ed wi t h ami odarone (300mg bol us i v over 30 mi nut es , fol l owed by 1.2g i nfus i on over 24 hours ). Li gnocai ne i s no l onger recommended as fi s t l i ne.
Non-sustained and monomorphic VT

o o
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Procai nami de i s an effect i ve al t ernat i ve, but i s arrhyt hmogeni c

o
For i nces s ant VT on ami odarone cons i der overdri ve paci ng.
Ventricular fibrillation and polymorphic VT

o
A medi c al emergenc y and requi res i mmedi at e defi bri l l at i on In refract ory VF cons i der vas opres s i n 40U i v bol us Ami odarone 300mg i v bol us t o be cont i nued as an i nfus i on (s ee above) i f out put res t ored.
o o
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > At rial t ac hyarrhyt hmia post MI
Atrial tachyarrhythmia post MI
Incl udes SVT, AF, and at ri al fl ut t er If pat i ent i s haemodynami cal l y uns t abl e mus t undergo i mmedi at e s ynchroni zed DC cardi overs i on Haemodynami cal l y s t abl e pat i ent s can be t reat ed wi t h di goxi n, -bl ockers , and/or cal ci um channel bl ockers (s ee P82) Ami odarone can be us ed t o res t ore s i nus rhyt hm. However, i t i s not very effect i ve i n cont rol l i ng rat e. Cl as s I agent s s houl d general l y be avoi ded as t hey i ncreas e mort al i t y In AF and fl ut t er pat i ent s s houl d undergo ant i -coagul at i on t o reduce embol i c compl i cat i ons i f t here are no cont rai ndi cat i ons .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Bradyarrhyt hmias and indic at ions for pac ing
Bradyarrhythmias and
indications for pacing

Al t ernat i ng or i s ol at ed RBBB/LBBB do not need paci ng (unl es s haemodynami cal l y uns t abl e or progres s i on t o hi gher l evel s of bl ock). New bi fas i cul ar bl ock (RBBB wi t h ei t her LAD or RAD) or BBB wi t h fi rs t -degree AV bl ock may requi re prophyl act i c paci ng dependi ng on t he cl i ni cal pi ct ure. Indi cat i ons for paci ng s houl d not del ay reperfus i on t herapy. Venous acces s (femoral or i nt ernal jugul ar vei n) s houl d be obt ai ned fi rs t and paci ng wi re i ns ert ed l at er. Ext ernal t emporary cardi ac paci ng, at ropi ne (300g t o 3mg i v bol us ), and i s oprenal i ne can be us ed t o buy t i me.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Bradyarrhyt hmias post MI
Bradyarrhythmias post MI
First-degree AV block
o o
Common and no t reat ment requi red Si gni fi cant PR prol ongat i on (>0.20s ) i s a cont rai ndi cat i on t o -bl ockade.
Second-degree AV block Thi s i ndi cat es a l arge i nfarct i on affect i ng conduct i ng s ys t ems and mort al i t y i s general l y i ncreas ed i n t hi s group of pat i ent s
o
Mobi t z t ype I i s s el f-l i mi t i ng wi t h no s ympt oms . General l y, requi res no s peci fi c t reat ment . If s ympt omat i c or progres s i on t o compl et e heart bl ock wi l l need t emporary paci ng Mobi t z t ype II, 2 : 1, 3 : 1 s houl d be t reat ed wi t h t emporary paci ng regardl es s of whet her i t progres s es t o compl et e heart bl ock.
T hird-degree AV block
o
In t he cont ext of an i nferi or MI can be t rans i ent and does not requi re t emporary paci ng unl es s t here i s haemodynami c i ns t abi l i t y or an es cape rhyt hm of <40bpm Temporary paci ng i s requi red wi t h ant eri or MI and uns t abl e i nferi or MI.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Hypot ension and shoc k post MI
Hypotension and shock post MI
(See cardi ogeni c s hock P44). The i mport ant pri nci pl es i n managi ng hypot ens i ve pat i ent s wi t h myocardi al i nfarct i on are
If t he pat i ent i s wel l perfus ed peri pheral l y, no pharmacol ogi cal i nt ervent i on i s requi red. Cons i der l yi ng t he pat i ent fl at wi t h l egs el evat ed i f neces s ary, provi ded t here i s no pul monary oedema Try t o correct any arrhyt hmi a, hypoxi a, or aci dos i s Arrange for an urgent Echo t o excl ude a mechani cal caus e for hypot ens i on (e.g. mi t ral regurgi t at i on, VSD, vent ri cul ar aneurys m) t hat may requi re urgent s urgery.
P.43
Patients may be divided into two sub-groups
Hypotension with pulmonary oedema (al s o s ee P108)

o
Secure cent ral venous acces s : i nt ernal jugul ar l i nes are preferabl e i f t he pat i ent may have recei ved t hrombol yt i c t herapy. Commence inotropes (s ee P44, cardi ogeni c s hock). Furt her i nvas i ve haemodynami c moni t ori ng as avai l abl e (PA pres s ures and wedge pres s ure moni t ori ng, art eri al l i ne). Ens ure opt i mal fi l l i ng pres s ures , gui ded by phys i cal s i gns and PA di as t ol i c or wedge pres s ure. Si gni fi cant mi t ral regurgi t at i on wi l l produce l arge v
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waves on t he wedge t race and gi ve s puri ous l y hi gh es t i mat es of LVEDP.

o
Ens ure rapi d coronary reperfus i on (i f not al ready done), ei t her wi t h t hrombol yt i c t herapy or pri mary PCI where avai l abl e. Int ra-aort i c bal l oon count er pul s at i on (s ee P898) may al l ow s t abi l i zat i on unt i l PCI can be performed.
Hypotension without pulmonary oedema Thi s may be due ei t her t o RV i nfarct i on or hypovol aemi a.
Diagnosis
Check t he JVP and ri ght at ri al pres s ure. Thi s wi l l be l ow i n hypovol aemi a and hi gh i n RV i nfarct i on. RV i nfarct i on on ECG i s s een i n t he s et t i ng of i nferi or MI and ST el evat i on i n ri ght -s i ded ches t l eads (V3RV4R).
Management
In ei t her cas e cardi ac out put wi l l be i mproved by caut i ous pl as ma expans i on. Gi ve 100200ml of col l oi d over 10 mi nut es and reas s es s . Repeat once i f t here i s s ome i mprovement i n bl ood pres s ure and t he pat i ent has not devel oped pul monary oedema. Invas i ve haemodynami c moni t ori ng wi t h a PA cat het er (SwanGanz) i s neces s ary t o ens ure hypot ens i on i s not due t o l ow l eft -s i ded fi l l i ng pres s ures . Ai m t o keep PCW P 1215mmHg. St art i not ropes i f bl ood pres s ure remai ns l ow des pi t e adequat e fi l l i ng pres s ures . Us e i v ni t rat es and di uret i cs wi t h caut i on as venodi l at at i on wi l l compromi s e RV and LV fi l l i ng and exacerbat e hypot ens i on. See P28 for management of RV i nfarct i on.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Cardiogenic shoc k
Cardiogenic shock
Effect s bet ween 520% of pat i ent s and up t o 15% of MI pat i ent s can pres ent wi t h cardi ogeni c s hock. Management i nvol ves a compl ex i nt eract i on bet ween many medi cal , s urgi cal , and i nt ens i ve care t eams wi t h mul t i pl e i nvas i ve and non-i nvas i ve meas ures . Des pi t e s i gni fi cant advances prognos i s remai ns poor. Therefore, t he abs ol ut e wi s hes of t he pat i ent wi t h regard t o s uch an i nvas i ve s t rat egy s houl d be res pect ed from t he out s et .
Diagnosis
A combi nat i on of cl i ni cal and phys i ol ogi cal meas ures :
Cl i ni c al : marked, pers i s t ent (>30mi n) hypot ens i on wi t h SBP <8090mmHg. Phys i ol ogi c al : l ow cardi ac i ndex (<1.8L/mm/m ) wi t h el evat ed LV fi l l i ng pres s ure (PCW P >18mmHg).
2
Management

Compl ex and mus t be qui ck. Correct revers i bl e fact ors i ncl udi ng
o o o
Arrhyt hmi as and ai m t o res t ore s i nus rhyt hm Aci dbas e, el ect rol yt e abnormal i t i es Vent i l at i on abnormal i t i es : i nt ubat e i f neces s ary.
Rapi d haemodynami c, echocardi ographi c, and angi ographi c eval uat i on

o
Haemodynami c: t o ens ure adequat e moni t ori ng and acces s i ncl udi ng cent ral venous l i nes , SwanGanz, art eri al l i ne i ns ert i on, uri nary cat het er Echocardi ographi c: t o as s es s vent ri cul ar s ys t ol i c
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funct i on and excl ude mechani cal l es i ons , whi ch may need t o be deal t wi t h by emergency cardi ac s urgery i ncl udi ng mi t ral regurgi t at i on (NB: t al l v waves on PCW P t race), VSD, and vent ri cul ar aneurys m/ps uedoanuerys m
o
Angi ographi c: wi t h a vi ew t o PCI or CABG i f appropri at e.
Ai m t o i mprove haemodynami c s t at us achi evi ng a SBP 90mmHg gui ded by phys i cal s i gns and LV fi l l i ng pres s ures . As a general gui de:
o
PCWP <15 mmHg: caut i ous of i v fl ui ds (col l oi ds ) i n 100200ml al i quot s PCWP >15 mmHg: i not ropi c s upport di uret i cs (i f pul monary oedema).
Inot ropes s houl d be avoi ded i f at al l pos s i bl e i n acut el y i s chaemi c pat i ent s . The ai m s houl d be t o rapi dl y res t ore/maxi mi ze coronary fl ow and off-l oad LV. Earl y revas cul ari zat i on i s vi t al and has been s hown t o decreas e mort al i t y. IABP wi l l part i al l y hel p achi eve aforement i oned goal s . If haemodynami c s t at us does not i mprove pos t revas cul ari zat i on and IABP i ns ert i on, i not ropes s houl d be us ed. Choi ce of agent can be P.45
di ffi cul t and s houl d part l y be gui ded by l ocal prot ocol s and expert i s e. General l y accept ed choi ces depend on t he cl i ni cal pi ct ure and i ncl ude
o
If pat i ent i s hypot ens i ve ( pul monary oedema): s t art wi t h dopami ne (up t o 15g/kg/mi n) and i f i neffect i ve s ubs t i t ut e wi t h epi nephri ne and/or norepi nephri ne If pat i ent has adequat e bl ood pres s ure ( pul monary oedema): dobut ami ne t o i ncreas e cardi ac out put (s t art i ng at 2.55g/kg/mi n and
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i ncreas i ng t o 20g/kg/mi n) t i t rat i ng t o HR and haemodynami cs . Phos phodi es t eras e i nhi bi t ors can be us ed as an al t ernat i ve. If hypot ens i on and t achycardi a compl i cat e dobut ami ne/PDI i nhi bi t or t reat ment , (nor)epi nephri ne can be added as a s econd agent t o achi eve des i red haemodynami c effect .
Us e of di uret i cs , t hrombol ys i s , GP IIb/IIIa ant agoni s t s , and LMW H/UFH s houl d fol l ow normal pri nci pl es and be bas ed on t he cl i ni cal pi ct ure.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Non- ST elevat ion myoc ardial infarc t ion (NST EMI)/unst able angina (
Non-ST
elevation myocardial infarction (NSTEMI)/unstable angina (UA)

UA and NSTEMI are cl os el y rel at ed condi t i ons wi t h s i mi l ar cl i ni cal pres ent at i on, t reat ment , and pat hogenes i s but of varyi ng s everi t y. If t here i s bi ochemi cal evi dence of myocardi al damage t he condi t i on i s t ermed NSTEMI and i n t he abs ence of damage, UA. Unl i ke pat i ent s wi t h a STEMI where di agnos i s i s general l y made on pres ent at i on i n t he emergency depart ment , di agnos i s of NSTEMI/UA may not be defi ni t i ve on pres ent at i on and evol ves over t he s ubs equent hours t o days . Therefore, management of pat i ent s wi t h NSTEMI/UA i s a progres s i on t hrough a number of ri s k-s t rat i fi cat i on proces s es dependent on hi s t ory, cl i ni cal feat ures , and i nves t i gat i ve res ul t s , whi ch i n t urn det ermi ne choi ce and t i mi ng of a number of medi cal and/or i nvas i ve t reat ment s t rat egi es . The fi gure oppos i t e i s a s ummary of a recommended i nt egrat ed c are pat hw ay i l l us t rat i ng a management pl an for di agnos i s and ri s k-di rect ed t reat ment of a pat i ent wi t h STEMI/UA.
Clinical presentation
There are 3 di s t i nct pres ent at i ons

Rest angina (angi na when pat i ent i s at res t ) New-onset severe angina Increasing angina (previ ous l y di agnos ed angi na whi ch has become more frequent , l onger i n durat i on, or l ower i n t hres hol d).
General exami nat i on (as i ndi cat ed for al l ACS (s ee P10) mus t be undert aken i n part i cul ar t o rul e out pul monary oedema, and as s es s haemodynami c s t abi l i t y, cardi ac val ve abnormal i t i es , and
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di aphores i s .
Integrated management plan

W e recommend t hat al l pat i ent s fol l ow a l ocal i nt egrat ed care pat hway on pres ent at i on. The vari ous s t ages are broadl y out l i ned bel ow. See rel evant pages for furt her i nformat i on.
Initial stabilization (s ee al s o ACS P10)

o
Trans fer pat i ent t o area wi t h cont i nuous ECG moni t ori ng and defi bri l l at or faci l i t y St ri ct bed res t Gi ve oxygen, as pi ri n 300mg po, SL ni t rat e and mi l d s edat i on i f requi red If pai n pers i s t s gi ve di amorphi ne 2.55mg i v prn wi t h met ocl oprami de 10mg i v.
o o
General investigations : s i mi l ar t o STEMI pat i ent s (s ee P1217) i ncl udi ng bl ood for FBC, bi ochemi cal profi l e and markers of myocardi al i njury, l i pi d profi l e, as wel l as CRP and TFT (i f pers i s t ent t achycardi a). Arrange port abl e CXR (rul e out LVF, medi as t i nal abnormal i t i es ). Confirm diagnosis (s ee P48). Risk stratification (s ee P50) i n order t o det ermi ne appropri at e medi cal and i nvas i ve t reat ment s t rat egi es . Hi gh-ri s k pat i ent s s houl d be admi t t ed t o CCU and l ow/i nt ermedi at e pat i ent s t o moni t ored beds i n s t ep-down uni t . P.47
T reatment i s bas ed on pat i ent 's ri s k and i ncl udes

o
Medical Strategies

ant i -i s chaemi c (P56) ant i pl at el et (P58) ant i -t hrombi c (P58)
Invasive strategies (P60).
Secondary prevention and discharge .
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NSTEMI/UAi nt egrat ed care pat hway
Page 147
> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > NST EMI/UA: diagnosis
NSTEMI/UA: diagnosis
Di agnos i s i n NSTEMI/UA i s an evol vi ng proces s and may not be cl ear on pres ent at i on. A c ombi nat i on of hi s t ory, s eri al c hanges i n ECG, and bi oc hemi c al markers of myoc ardi al i njury (us ual l y over a 2448 hour peri od) det ermi ne t he di agnos i s . Once a pat i ent has been des i gnat ed a di agnos i s of ACS wi t h probabl e/pos s i bl e NSTEMI/UA t hey wi l l requi re t he fol l owi ng.
Serial ECGs : changes can be t rans i ent and/or fi xed es peci al l y i f a di agnos i s of NSTEMI i s made. See P15 for l ocal i zat i on of i s chaemi c areas .
o
ST-s egment depres s i on of 0.05mV i s hi ghl y s peci fi c of myocardi al i s chaemi a (unl es s i s ol at ed i n V1V3 s ugges t i ng a pos t eri or STEMI). T-wave i nvers i on i s s ens i t i ve but non-s peci fi c for acut e i s chaemi a unl es s very deep (0.3mV). Rarel y Q-waves may evol ve or t here may be t rans i ent /new LBBB.
Serial biochemical markers of cardiac injury are us ed t o di fferent i at e bet ween NSTEMI and UA, as wel l as det ermi ne prognos i s . W e recommend l evel s at 6, 12, 24, and 48 hours aft er l as t epi s ode of pai n. A pos i t i ve bi ochemi cal marker (CK, CK-MB, or t roponi n) i n t he cont ext of one or more of t he aforement i oned ECG changes i s di agnos t i c of NSTEMI. If s eri al markers over a 2472 hour peri od from t he l as t epi s ode of ches t pai n remai n negat i ve, UA i s di agnozed.
o
Cardi ac t roponi n T and I: are bot h are hi ghl y cardi ac s peci fi c and s ens i t i ve, can det ect mi croi nfarct i on i n t he pres ence of normal CK-MB, are not affect ed by s kel et al mus cl e i njury,
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and convey prognos t i c i nformat i on (wors e prognos i s i f pos i t i ve). Troponi ns can be rai s ed i n non-at heros cl erot i c myocardi al damage (cardi omyopat hy, myocardi t i s , peri cardi t i s ) and s houl d t herefore be i nt erpret ed i n t he cont ext of t he cl i ni cal pi ct ure. Bot h TnT and TnI ri s e wi t hi n 3 hours of i nfarct i on. TnT may pers i s t up t o 1014 days and TnI up t o 710 days . Res ul t s mus t be i nt erpret ed wi t h caut i on i n pat i ent s wi t h chroni c renal fai l ure. See fi gure on P17.
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CK l evel s do not al ways reach t he di agnos t i c t wi ce upper l i mi t of normal and general l y have l i t t l e val ue i n di agnos i s of NSTEMI. CK-MB has l ow s ens i t i vi t y and s peci fi ci t y CK-MB i s oforms i mprove s ens i t i vi t y (CK-MB2 >1U/L or CK-MB2/CK-MB1 rat i o >1.5), but i s oform as s ays are not wi del y avai l abl e cl i ni cal l y. Myogl obi n i s non-cardi ac s peci fi c, but l evel s can be det ect ed as earl y as 2 hours aft er ons et of s ympt oms . A negat i ve t es t i s us eful i n rul i ng out myocardi al necros i s .
Continuous ECG monitoring can det ect epi s odes of s i l ent i s chaemi a and arrhyt hmi a. Bot h have been s hown t o be more prol onged i n NSTEMI t han i n UA.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > NST EMI/UA: risk st rat ific at ion
NSTEMI/UA: risk stratification
NSTEMI/UA are a het erogeneous group of condi t i ons wi t h vari abl e out comes . An as s es s ment of ri s k for advers e out come i s vi t al t o ens ure format i on of an adequat e management pl an. Ri s k s t rat i fi c at i on s houl d begi n on i ni t i al eval uat i on and c ont i nue t hroughout t he hos pi t al s t ay . At each s t age pat i ent s wi t h a hi gh chance of a poor out come s houl d be i dent i fi ed and managed appropri at el y. W e recommend at l eas t t wo formal ri s k-s t rat i fi cat i on proces s es .
Early risk stratification (s ee t abl e, P52): t hi s s houl d t ake pl ace on pres ent at i on and forms part of t he i ni t i al as s es s ment us ed t o make a di agnos i s . It i nvol ves a combi nat i on of cl i ni cal feat ures , ECG changes , and bi ochemi cal markers of cardi ac i njury as demons t rat ed on P52. Pat i ent s are di vi ded i nt o hi gh ri s k and i nt ermedi at e/l ow ri s k.
o
High-risk pat i ent s s houl d be admi t t ed t o CCU, fol l ow an earl y i nvas i ve s t rat egy , and be managed wi t h a combi nat i on of

ASA, cl opi dogrel , LMW H (UFH), IIb/IIIa Ant i -i s chaemi c t herapy (fi rs t -l i ne -bl ocker, GTN) Earl y i nvas i ve s t rat egy (i n-pat i ent cat het eri zat i on and PCI wi t hi n 48 hours of admi s s i on).
Intermediate/low-risk pat i ent s s houl d be admi t t ed t o a moni t ored bed on a s t ep-dow n uni t and undergo a s ec ond i n-pat i ent ri s k s t rat i fi c at i on once t hei r s ympt oms have s et t l ed t o det ermi ne t i mi ng of i nvas i ve i nves t i gat i ons . Ini t i al
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management s houl d i ncl ude

ASA, cl opi dogrel , LMW H (UFH) Ant i -i s chaemi c t herapy (fi rs t -l i ne -bl ocker, GTN) Undergoi ng a l at e ri s k s t rat i fi c at i on i n 4872 hours from admi s s i on.
Late risk stratification : (P54) i nvol ves a number of non-i nvas i ve t es t s t o det ermi ne t he opt i mal t i mi ng for i nvas i ve i nves t i gat i ons i n i nt ermedi at e/l ow-ri s k pat i ent s . Sugges t ed gui del i nes are s ummari zed on P54. It i s general l y performed i f t here have been no furt her epi s odes of pai n/i s chaemi a at 2448 hours aft er admi s s i on.
o
Int ermedi at e/l ow-ri s k pat i ent s who devel op recurrent pai n and/or i s chaemi c ECG changes at any poi nt duri ng t hei r admi s s i on, heart fai l ure, or haemodynami c i ns t abi l i t y i n t he abs ence of a non-cardi ac caus e s houl d be managed as a hi gh-ri s k pat i ent (IIb/IIIa and earl y i nvas i ve s t rat egy). The fi gure on P47 i s a s ummary of a recommended i nt egrat ed care pat hway combi ni ng di agnos i s , ri s k s t rat i fi cat i on, and t reat ment . There are ot her ri s k-s t rat i fi cat i on as s es s ment s cores i ncl udi ng Braunwal d and TIMI. As recommended above, hi gh-ri s k pat i ent s from t hes e as s es s ment s s houl d al s o fol l ow an earl y i nvas i ve s t rat egy and i nt ermedi at e/l ow-ri s k pat i ent s a more cons ervat i ve s t rat egy.
P.51
P.52
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Short-term risk of death non-fatal MI in patients with UA 1

Feature High risk (At least 1 of the following features must be present) Intermediate risk (No high-risk have 1 of the following) Low risk (No high- or sk feature but may have any of the following features) Hi s t ory Accel erat i ng t empo of i s chaemi c s ympt oms i n precedi ng 48 hours Charact er of Prol onged pai n ongoi ng (> 20 mi nut es ) res t pai n Pri or MI, peri pheral or cerebrovas cul ar di s eas e, or CABG, pri or as pi ri n us e Prol onged (>20 mi nut es ) res t angi na, now res ol ved, wi t h moderat e or hi gh New-ons et or progres s i ve CCS Cl as s III or IV angi na t he pas t 2 weeks wi t hout
feature but must intermediate-ri
Cl i ni cal fi ndi ngs
Pul monary oedema, mos t l i kel y due t o i s chaemi a New or wors eni ng MR murmur S 3 or new/wors eni ng ral es Hypot ens i on,
l i kel i hood of CAD prol onged (>20 Res t angi na (<20 mi nut es ) res t mi nut es ) or pai n but wi t h rel i eved wi t h res t moderat e or or s ubl i ngual NTG hi gh l i kel i hood Age>70 years of CAD
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bradycardi a, t achycardi a Age >75 years Angi na at res t wi t h t rans i ent ST-s egment
ECG
T-wave i nvers i ons Normal or >0.2mV Pat hol ogi cal unchanged ECG duri ng an epi s ode of ches t di s comfort
changes >0.05mV Q-waves Bundl e-branch bl ock, new or pres umed new Sus t ai ned vent ri cul ar Cardi ac markers
1
t achycardi a El evat ed (e.g. TnT or TnI
Sl i ght l y el evat ed (e.g. TnT >0.01
Normal
>0.1ng/mL) but <0.1ng/mL) Adapt ed from Ameri can Col l ege of Cardi ol ogy Pract i ce Gui del i nes .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > NST EMI/UA: lat e risk st rat ific at ion
NSTEMI/UA: late risk
stratification
The hi ghes t ri s k of advers e out come i n pat i ent s who are des i gnat ed as i nt ermedi at e/l ow ri s k on pres ent at i on i s duri ng t he earl y phas e of admi s s i on. Therefore, i t i s i mport ant t hat t he s econd ri s k-s t rat i fi cat i on proces s occurs wi t hi n 2448 hours of admi s s i on i f t he pat i ent i s s t abl e. Lat e ri s k s t rat i fi cat i on i s bas ed on one of t he fol l owi ng non-i nvas i ve i nves t i gat i ons . A pat i ent i s regarded as bei ng at hi gh ri s k of advers e out come i f t hey ful fi l one of t he feat ures l i s t ed bel ow. Thes e pat i ent s s houl d have i n-pat i ent cardi ac cat het eri zat i on.
Exercise ECG test

o o o o o
Horizontal/down-sloping ST depression with Ons et at HR <120bpm or <6.5 METS Magni t ude of >2.0mm Pos t -exerci s e durat i on of changes >6 mi nut es Depres s i on i n mul t i pl e l eads refl ect i ng mul t i pl e coronary di s t ri but i ons .
Abnormal systolic BP response

o
Sus t ai ned decreas e of >10mmHg or fl at BP res pons e wi t h abnormal ECG.
Other
o o o
Exerci s e i nduced ST-s egment el evat i on VT Prol onged el evat i on of HR. Abnormal t racer di s t ri but i on i n more t han one t erri t ory
2 Stress radionuclide myocardial perfusion imaging

o
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Cardi ac enl argement .
3 LV imaging Stress echocardiography

o o
Res t EF <35% W al l mot i on s core i ndex >1. Res t EF <35% Fal l i n EF >10%.
Stress radionuclide ventriculography

o o
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > NST EMI/UA: medic al management 1
NSTEMI/UA: medical
management 1
Anti-ischaemic therapy
Al l pat i ent s s houl d be t reat ed wi t h a combi nat i on of t he bel ow agent s t o ens ure adequat e s ympt om cont rol and a favourabl e haemodynami c s t at us (SBP 100110mmHg, PR 60). Al l pat i ent s s houl d be t reat ed w i t h adequat e anal ges i a, i v ni t rat es , -bl oc kers , and s t at i ns (i f no cont rai ndi cat i ons ). Ot her agent s can al s o be added dependi ng on t he cl i ni cal pi ct ure.
Analgesia: di amorphi ne 2.55mg i v (wi t h met ocl oprami de 10mg i v). Act s as anxi ol yt i c. Reduces pai n and s ys t ol i c bl ood pres s ure t hrough venodi l at at i on and reduct i on i n s ympat het i c art eri ol ar cons t ri ct i on. Can res ul t i n hypot ens i on (res pons i ve t o vol ume t herapy) and res pi rat ory depres s i on (revers al wi t h nal oxone 400g t o 2mg i v). Nitrates: GTN i nfus i on (50mg i n 50ml ni t rat e s al i ne at 110ml /h) t i t rat ed t o pai n and keepi ng SBP >100mmHg. Tol erance t o cont i nuous i nfus i on devel ops wi t hi n 24 hours and t he l owes t effi caci ous dos e s houl d be us ed. Common s i de-effect s are headache and hypot ens i on, bot h of whi ch are revers i bl e on wi t hdrawal of medi cat i on. Abs ol ut e c ont rai ndi c at i on i s us e of s i l denafi l (Vi agra) i n t he previ ous 24 hours . Thi s can res ul t i n exaggerat ed and prol onged hypot ens i on. -blockers: s houl d be s t art ed on pres ent at i on. Ini t i al l y us e a s hort -act i ng agent (e.g. met oprol ol 12.5100mg po t ds ), whi ch i f t ol erat ed, may be
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convert ed t o a l onger-act i ng agent (e.g. at enol ol 251000mg od). Rapid -bl ockade may be achi eved us i ng s hort -act i ng i v agent s s uch as met oprol ol (s ee -bl ockade for STEMI). Ai m for HR of ~5060bpm. Mi l d LVF i s not an abs ol ut e cont rai ndi cat i on t o -bl ocker t herapy. Pul monary conges t i on may be s econdary t o i s chaemi c LV s ys t ol i c dys funct i on and/or reduced compl i ance. If t here i s overt heart fai l ure -bl ockade i s cont rai ndi cat ed and a cal ci um ant agoni s t (aml odi pi ne 510mg od) can be us ed. By reduci ng heart rat e and bl ood pres s ure, -bl ockers reduce myocardi al oxygen demand and t hus angi na. W hen ei t her us ed al one or i n combi nat i on wi t h ni t rat es and/or cal ci um ant agoni s t s , -bl ockers are effect i ve i n reduci ng t he frequency and durat i on of bot h s ympt omat i c and s i l ent i s chaemi c epi s odes .
Calcium antagonists: di l t i azem 60360mg po, verapami l 40120mg po t ds . Thei r us e ai ms t o reduce HR and BP and i s a us eful adjunct t o t reat ment s 13 above. Aml odi pi ne/fel odi pi ne 510mg po od can be us ed wi t h pul monary oedema and i n poor LV funct i on. Cal ci um ant agoni s t s al one do not appear t o reduce mort al i t y or ri s k of MI i n pat i ent s wi t h UA. However when combi ned wi t h ni t rat es and/or -bl ockers t hey are effect i ve i n reduci ng s ympt omat i c and s i l ent i s chaemi c epi s odes , non-fat al MI, and t he need for revas cul ari zat i on. Statins (HMG-CoA reductase inhibitors): hi gh-dos e s t at i ns (at orvas t at i n 80mg od) have been s hown t o reduce mort al i t y and recurrent MI i n t he acut e s et t i ng. The rol e of s t at i ns i n pri mary and s econdary prevent i on of cul t ure cardi ovas cul ar event s i s wel l document ed. ACE inhibitors: unl i ke pat i ent s wi t h STEMI where earl y i nt roduct i on of an ACE i nhi bi t or has s i gni fi cant prognos t i c benefi t s , s peci fi c t rai l s i n t he NSTEMI/UA s et t i ng are l acki ng. However, t here i s good evi dence
Pa g e 1 5 7
t hat bot h pat i ent s wi t h l ow and hi gh ri s k of cardi ovas cul ar di s eas e wi l l benefi t from l ong-t erm ACE i nhi bi t i on (HOPE and EUROPA Tri al s ).
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > NST EMI/UA: medic al management 2
NSTEMI/UA: medical
management 2
Anti-platelet therapy
Al l pat i ent s s houl d be gi ven as pi ri n and c l opi dogrel (unl es s c ont rai ndi c at i ons ). I I b/I I I a ant agoni s t s t o hi gh-ri s k pat i ent s onl y .
Aspirin (75300mg po) s houl d be admi ni s t ered i mmedi at el y i n t he emergency depart ment and cont i nued i ndefi ni t el y (unl es s cont rai ndi cat i ons ). It has been s hown t o cons i s t ent l y reduce mort al i t y and recurrent i s chaemi c event s i n many t ri al s . In pat i ent s wi t h as pi ri n hypers ens i t i vi t y or major gas t roi nt es t i nal i nt ol erance cl opi dogrel 75mg od s houl d be us ed. T hienopyidines. Cl opi dogrel (75mg od) s houl d be gi ven on admi s s i on t o al l pat i ent s wi t h proven NSTEMI/UA, regardl es s of ri s k and be cont i nued for at l eas t 1 mont h, i deal l y for 9 mont hs . Cl opi dogrel s houl d be wi t hhel d i n pat i ent s requi ri ng CABG for 57 days t o reduce haemorrhagi c compl i cat i ons . Cl opi dogrel i s preferred over t i cl opi di ne becaus e of i t s rapi d ons et of act i on and bet t er s afet y profi l e. Glycoprotein IIb/IIIa antagonists. There are mul t i pl e s hort - and l ong-act i ng commerci al l y avai l abl e mol ecul es . Thes e agent s s houl d be us ed i n conjunct i on wi t h as pi ri n, cl opi dogrel , and LMW H (or UFH). Ept i fi bat i de and t i rofi ban s houl d be us ed i n hi gh-ri s k pat i ent s wi t h on-goi ng i s chaemi a and el evat ed t roponi n i n whom an earl y i nvas i ve management s t rat egy i s not pl anned/avai l abl e (<24 hours ). In pat i ent s wi t h an
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earl y i nvas i ve s t rat egy al l IIb/IIIa ant agoni s t s can be us ed. Infus i on i s general l y cont i nued for 12 hours pos t PCI. Taken as a group t hes e agent s prot ect NSTEMI/UA pat i ent s from deat h and non-fat al MI duri ng t he acut e phas e of t hei r pres ent at i on and 24 hours pos t i nt ervent i on. See t abl e for dos es and admi ni s t rat i on regi me.
Anti-thrombotic therapy
Al l pat i ent s s houl d be gi ven a LMWH (UFH) .
LMWHs have been s hown t o be as good as or s uperi or t o UFH i n s hort -t erm reduct i on of deat h, MI, and revas cul ari zat i on i n pat i ent s wi t h NSTEMI/UA. They s houl d be us ed i n conjunct i on wi t h as pi ri n and cl opi dogrel i n al l pat i ent s on pres ent at i on and be cont i nued for 25 days aft er t he l as t epi s ode of pai n and i s chaemi c ECG changes . Ot her advant ages over UFH i ncl ude s ubcut aneous admi ni s t rat i on, l ack of moni t ori ng, and reduced res i s t ance and t hrombocyt opaeni a. The t abl e oppos i t e l i s t s t he dos es of vari ous agent s i n us e for t reat i ng NSTEMI/UA. UFH. Mul t i pl e t ri al s have demons t rat ed t he reduct i on of ri s k of deat h and MI i n pat i ent s wi t h UA/NSTEMI. UFH s houl d be s t art ed on pres ent at i on as an al t ernat i ve t o LMW H i n conjunct i on wi t h as pi ri n and cl opi dogrel . Infus i on s houl d be cont i nued for 25 days s ubs equent t o t he l as t epi s ode of pai n and/or i s chaemi c ECG changes . An Ini t i al bol us of 6070U/kg (maxi mum 5000U) s houl d be fol l owed by an i nfus i on of 1215U/kg/h (1000U/h). The infus i on rat e s houl d be al t ered t o achi eve an aPTT val ue of 1.52.0 t i mes cont rol . Coagul at i on s houl d be checked i ni t i al l y every 6 hours fol l owed by once every 24 hours aft er 2 cons i s t ent val ues have been obt ai ned.
P.59
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Thrombolysis
There i s no evi dence t o s ugges t t hat combi ng t hrombol yt i c agent s wi t h as pi ri n, LMW H, and convent i onal ant i -i s chaemi c t herapy i s of benefi t . In t he TIMI IIIB t ri al t he rt -PA group had a wors e out come at 6 weeks and ri s k of bl eedi ng was al s o great er wi t h t he t hrombol yi s group.
Doses of LMWH and GP IIb/IIIa antagonists for treating NSTEMI/UA LMWH

Dal t epari n Enoxapari n 120U/kg bd (max 10 000U t wi ce dai l y) 1mg/kg bd (100U/kg t wi ce dai l y)
GP IIb/IIIa antagonists
Abci xi mab (Reopro) Bol us 250mcg/kg over 1 mi nut e fol l owed by i v i nfus i on 125ng/kg/mi n
Ti rofi ban (Aggras t at ) 400ng/kg/mi n for 30 mi nut es fol l owed by i v i nfus i on 100ng/kg/mi n
Ept i fi bat i de (Int egri l i n) Bol us 180mcg/kg fol l owed by i v i nfus i on 2mcg/kg/mi n
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > NST EMI/UA: invasive versus non- invasive st rat egies
NSTEMI/UA: invasive
versus non-invasive strategies

The current evi dence s upport s earl y angi ography and revas cul ari zat i on i n pat i ent s who pres ent wi t h ei t her hi gh-ri s k feat ures or i nt ermedi at e- l ow-ri s k feat ures wi t h on-goi ng s ympt oms . Furt hermore, l ow- and i nt ermedi at e-ri s k pat i ent s who s et t l e on medi cal t herapy s houl d undergo s ympt om-l i mi t ed, non-i nvas i ve s t res s t es t i ng t o i dent i fy a cohort of pat i ent s wi t h an i ncreas ed ri s k of advers e out come. Thi s s econd group wi l l al s o benefi t from an earl y i nvas i ve management . Pat i ent s managed wi t h an earl y cons ervat i ve s t rat egy t end t o have an i ncreas ed need for ant i -angi nal t herapy and rehos pi t al i zat ai on for angi na and many undergo coronary angiography wi t hi n t he year. The fol l owi ng groups are recommended t o benefi t from an earl y i nvas i ve s t rat egy (i n-pat i ent cardi ac cat het eri zat i on and PCI).
Patients with high-risk features of NST EMI/UA

o
Recurrent angi na/i s chaemi c ECG changes des pi t e opt i mal medi cal t herapy El evat ed t roponi n New/pres umed new ST-s egment depres s i on Ches t pai n wi t h cl i ni cal feat ures of heart fai l ure (pul monary oedema, new/wors eni ng MR, S3 gal l op) Haemodynami c i ns t abi l i t y Sus t ai ned vent ri cul ar t achycardi a
o o o
o o
Poor LV systolic function (EF <40%) Patients allocated to low/medium risk in whom subsequent non-invasive testing demonstrates high-risk features PCI in previous 6 months
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Previous CABG Patients with other comorbidities (e.g. mal i gnancy, l i ver fai l ure, renal di s eas e) i n whom ri s ks of revas cul ari zat i on are not l i kel y t o out wei gh benefi t s .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Disc harge and sec ondary prevent ion
Discharge and secondary
prevention
Length of hospital stay wi l l be det ermi ned by s ympt oms and t he rat e of progres s i on t hrough t he NSTEMI/UA pat hway. General l y pat i ent s are hos pi t al i zed for 37 days . Secondary prevention remai ns of paramount i mport ance and i s s i mi l ar i n pri nci pl e t o STEMI pat i ent s (s ee P30).
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Arrhyt hmias: general approac h
Arrhythmias: general approach
Bot h t achyarrhyt hmi as and bradyarrhyt hmi as may pres ent wi t h s i gni fi cant s ympt oms and haemodynami c compromi s e. The approach t o pat i ent s wi t h arrhyt hmi as depends upon

The effect s of t he rhyt hm on t he pat i ent The di agnos i s from t he ECG and t he rhyt hm Any underl yi ng cardi ac abnormal i t y or i dent i fi abl e preci pi t ant .
Effects of the rhythm on the patient
Patients with signs of severe haemodynamic compromise

o o o o
Impendi ng cardi ac arres t Severe pul monary oedema Shock: s ys t ol i c BP <90mmHg Depres s ed cons ci ous nes s .
Treat i mmedi at el y wi t h uns ynchroni zed ext ernal defi bri l l at i on for t acharrhyt hmi a and t emporary paci ng for bradyarrhyt hmi a (s ee P100).
Patients with mildmoderate compromise

o o
Mi l d pul monary oedema Low cardi ac out put wi t h cool peri pheri es and ol i guri a Angi na at res t .
Try t o record an ECG and l ong rhyt hm s t ri p before gi vi ng any pharmacol ogi cal agent s and/or defi bri l l at i on. Thi s wi l l be i nval uabl e for l ong-t erm management . If t hey det eri orat e, t reat as above.
Diagnosing the arrhythmia

The mai n di s t i nct i ons t o make are
Tachy- (>120/mi n) vers us brady- (<60/mi n) arrhyt hmi a
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Narrow (120ms or 3 s mal l s q.) vers us broad QRS compl ex Regul ar vers us i rregul ar rhyt hm.
Multiple, common precipitating factors

Underlying cardiac disease

Is chaemi c heart di s eas e Acut e or recent MI Angi na Mi t ral val ve di s eas e LV aneurys m Congeni t al heart di s eas e Abnormal i t i es of res t i ng ECG Pre exci t at i on (s hort PR i nt erval ) Long QT (congeni t al or acqui red) Ant i -arrhyt hmi cs Sympat homi met i cs (2 agoni s t s , cocai ne) Ant i -depres s ant s (t ri cycl i c) Adenyl at e cycl as e i nhi bi t ors (ami nophyl l i ne, caffei ne) Al cohol or K Mg
2+ + 2+
Drugs

Metabolic abnormalities

or Ca P a O 2 P a CO 2 Aci dos i s
Endocrine abnormalities

Thyrot oxi cos i s Phaeochromocyt oma Febri l e i l l nes s Emot i onal s t res s Smoki ng Fat i gue
Miscellaneous

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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > T ac hyarrhyt hmias heart rat e (
Tachyarrhythmias heart rate (HR)

History : Previ ous cardi ac di s eas e, pal pi t at i ons , di z z i nes s , ches t pai n, s ympt oms of heart fai l ure and recent medi cat i on. As k s peci fi cal l y about condi t i ons known t o be as s oci at ed wi t h cert ai n cardi ac arrhyt hmi as (e.g. AF: al cohol , t hyrot oxi cos i s , mi t ral val ve di s eas e, IHD, peri cardi t i s ; VT: previ ous MI, LV aneurys m). Examination : BP, heart s ounds and murmurs , s i gns of heart fai l ure, carot i d brui t s . Investigations (i f pat i ent i s haemodynami cal l y s t abl e, before t reat ment i n uns t abl e pat i ent s , aft er res t orat i on of a s t abl e rhyt hm):
>120bpm
12 l ead ECG and rhyt hm s t ri p Bl ood t es t s W here appropri at e Ches t X-ray
Regul ar vers us i rregul ar rhyt hm Narrow vers us broad QRS compl ex. FBC, bi ochemi s t ry, gl ucos e (urgent l y) Ca , Mg
2+ 2+
(es peci al l y i f on di uret i cs )
Bi ochemi cal markers of myocardi al i njury.
Bl ood cul t ures , CRP, ESR Thyroi d funct i on t es t s Drug l evel s Art eri al bl ood gas es .
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Heart s i ze Evi dence of pul monary oedema Ot her pat hol ogy (e.g. Ca bronchus AF, peri cardi al effus i on s i nus t achycardi a, hypot ens i on AF).
Management
Haemodynamically unstable patients Arrhyt hmi as caus i ng s evere haemodynami c compromi s e (cardi ac arres t , s ys t ol i c BP <90mmHg, s evere pul monary oedema, evi dence of cerebral hypoperfus i on) requi re urgent correct i on, us ual l y wi t h ext ernal defi bri l l at i on. Drug t herapy requi res t i me and haemodynami c s t abi l i t y.
The onl y except i on i s a pat i ent i n chroni c AF wi t h an uncont rol l ed vent ri cul ar rat e: defi bri l l at i on i s unl i kel y t o cardi overt t o SR. Rat e cont rol and t reat ment of preci pi t ant i s fi rs t l i ne. Sedat e awake pat i ent s wi t h mi dazol am (2.510mg i v) di amorphi ne (2.55mg i v + met ocl oprami de 10mg i v) for anal ges i a. Beware res pi rat ory depres s i on and have an anaes t het i s t , fl umazeni l , and nal oxone t o hand. Formal anaes t hes i a wi t h propofol i s preferred, but remember t he pat i ent may not have an empt y s t omach and precaut i ons s houl d be t aken t o prevent as pi rat i on (e.g. cri coi d pres s ure, ET i nt ubat i on). St art at 200 J. s ynchroni zed s hock and i ncreas e as requi red.
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If t achyarrhyt hmi a recurs or i s unres pons i ve t ry t o correct P a O 2 , P a CO 2 , aci dos i s , or K . Gi ve Mg (8mmol i v s t at ) and s hock agai n. Ami odarone 150300mg bol us i v may al s o be us ed. Gi ve s peci fi c ant i arrhyt hmi c t herapy (s ee P66). P.65
+ 2+
Haemodynamically stable patients

o
Admi t and arrange for cont i nuous ECG moni t ori ng and 12-l ead ECG. Try vagot oni c manoeuvres (e.g. Val s al va or carot i d s i nus mas s age P78). If di agnos i s i s cl ear i nt roduce appropri at e t reat ment . If t here i s doubt regardi ng di agnos i s , gi ve adenos i ne 6mg as fas t i v bol us fol l owed by 5 ml s al i ne fl us h. If no res pons e, t ry 9, 12, and 18mg i n s ucces s i on wi t h cont i nuous ECG rhyt hm s t ri p. Defi ni t i ve t reat ment s houl d s t art as s oon as di agnos i s i s known (pp6699).
Narrow complex tachycardias ori gi nat e i n t he at ri a or AV node (i .e. SVT; s ee fi gure, P79). Irregular, narrow-complex tachycardia i s mos t commonl y AF or at ri al fl ut t er wi t h varyi ng AV bl ock. Broad complex tachyarrhythmias may ori gi nat e from ei t her t he vent ri cl es (VT) or from t he at ri a or AV node (SVT) wi t h aberrant conduct i on t o t he vent ri cl es (RBBB or LBBB confi gurat i on). If t he pat i ent has previ ous document ed arrhyt hmi as , compare t he morphol ogy of t he current arrhyt hmi a t o ol d ECGs . The di agnos i s of VT vers us SVT and t herapy may be evi dent from t he l as t admi s s i on.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > T reat ment opt ions in t ac hyarrhyt hmias
Treatment options in
tachyarrhythmias
Sinus tachycardia
Look for caus e. -bl ockade i f anxi ous Rate control (AV node)
o o o
Atrial fibrillation Atrial flutter SVT (P78)
Di goxi n -bl ockade Cal ci um bl ocker (e.g. verapami l Fl ecai ni de Ami odarone Sot al ol Di s opyrami de Synchroni zed DC s hock Ami odarone Sot al ol Qui ndi ne Procai nami de
Version to SR
o o o o o
Prevention
o o o o
Junctional tachycardias (AVNRT ) (P98)

o o o o o o
Adenos i ne -bl ockade Verapami l (Vagal s t i mul at i on) Di goxi n Fl ecai ni de
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Synchroni zed DC s hock
Accessory pathway tachycardias (i.e. AVRT ) (P96)
At AV node
o o
Adenos i ne -bl ockade Sot al ol Fl ecai ni de Di s opyrami de Qui ni di ne Ami odarone Synchroni zed DC Shock
At accessory pathway
o o o o o
T ermination only
o o
Ventricular tachycardia (P68)
T ermination and prevention

o o o o o o o o o
Li gnocai ne Procai nami de Amoi darone Magnes i um DC s hock Fl ecai ni de Di s opyrami de Propafenone -bl ockade Bret yl i um
T ermination only
o
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Broad c omplex t ac hyc ardia: diagnosis
Broad complex
tachycardia: diagnosis
(QRS wi dt h >120ms or >3 s mal l s q.)
Diagnostic approach
The fol l owi ng pri nci pl es can be us ed t o di s t i ngui s h bet ween di fferent forms of broad compl ex t achyarrhyt hmi a.
Examine the rhythm strip. Is it regular or irregular? Regular

o o o
VT (mono/pol ymorphi c) SVT or at ri al fl ut t er wi t h bundl e branch bl ock At ri al fl ut t er or SVT wi t h pre-exci t at i on (e.g. W PW )
Irregular
o
AF, at ri al fl ut t er, or mul t i focal at ri al t achycardi a wi t h bundl e branch bl ock Pre-exci t ed AF (e.g. W PW ) Tors ades de poi nt es (PVT)
o o
Are there any features on the 12-lead ECG that help distinguish VT from SVT with aberrancy? Factors favouring SVT
o
A gros s l y i rregul ar broad compl ex t achycardi a wi t h rat es 200/mi n s ugges t s AF wi t h conduct i on over an acces s ory pat hway Sl owi ng or t ermi nat i on by vagot oni c manoeuvres Evi dence of at ri al and vent ri cul ar coupl i ng (e.g. wi t h 1 : 2 AV bl ock).
o o
Factors favouring or diagnostic of VT
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ABC Ambe r CHM Conve rte r Tria l ve rsion, http://w w w .proce sste x t.com/a bcchm.html o o
Cycl e l engt h s t abi l i t y (< 40ms R-R vari at i on) QRS >140ms (3.5 s mal l s q.) es peci al l y wi t h normal durat i on when compared wi t h previ ous ECG i n s i nus rhyt hm Marked l eft axi s devi at i on (negat i ve i n l ead II) QRS concordance i n ches t l eads . If t he predomi nant defl ect i on of t he QRS i s pos i t i ve t hi s i s hi ghl y s ugges t i ve of VT In pat i ent s wi t h previ ous LBBB or RBBB, i t i s di ffi cul t t o di s t i ngui s h VT from SVT wi t h aberrancy. A di fferent QRS morphol ogy i n t achycardi a s ugges t s VT (ot her cl ues are gi ven i n t he t abl e oppos i t e) Fus i on or capt ure beat s Independent at ri al act i vi t y (s een i n ~25%). The t rans i ent AV bl ock produces one of t hree res ul t s : T he tachycardia terminates . Thi s s ugges t s an SVT wi t h aberrancy or RVOT t achycardi a (t echni cal l y a form of VT). T he ventricular rate slows unmasking atrial activity. Ei t her fl ut t er waves (at ri al fl ut t er wi t h bl ock or i nt ra-at ri al t achycardi a) or AF. The t achycardi a t ypi cal l y cont i nues aft er a few s econds once t he adenos i ne wears off. No effect on the rhythm. Check t hat t he pat i ent recei ved a t herapeut i c dos e of adenos i ne (and experi enced ches t t i ght nes s wi t h t he i nject i on). Hi gher dos es are requi red i n pat i ent s on t heophyl l i nes . The di agnos i s i s mos t l i kel y t o be VT.
o o
o o
What are the effects of adenosine?

o
I f t here i s any doubt about di agnos i s i n t he ac ut e s et t i ng t he pat i ent mus t be t reat ed as VT unt i l proven ot herw i s e . P.69
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Morphologic rules
For any broad compl ex t achycardi a wi t h bundl e branch bl ock morphol ogy, as s ume i t i s VT unl es s RBBB Lead V1 rSR' wi t h R' > r RS wi t h R >S Lead V6 If a Q-wave i s pres ent , i t mus t be 40ms and <0.2mV Sens i t i vi t y 90%, Speci fi ci t y 6785%.
1 1
LBBB rS or QS wi t h t i me t o S-wave nadi r <70ms R-wave wi t h no Q-wave
Gri ffi t h et al . (1994) Lancet 343 : 386388.
Page 174
> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Monomorphic vent ric ular t ac hyc ardia (
Monomorphic ventricular
tachycardia (MVT)
Management
Assess airway, breathing, and circulation immediately If patient is haemodynamically unstable

o
Del i ver precordi al t hump: t hi s can i nduce a mechani cal premat ure vent ri cul ar compl ex i nt errupt i ng VT ci rcui t and t ermi nat i ng arrhyt hmi a. Immedi at e uns ynchroni zed ext ernal defi bri l l at i on (200J, 200J, 360J). Pat i ent i s oft en uncons ci ous and i f s o, no s edat i on i s requi red.
If patient is haemodynamically stable

o
Pat i ent s houl d i ni t i al l y be t reat ed wi t h i v pharmacol ogi cal agent s . If t hi s i s uns ucces s ful t hey can be el ect ri cal l y cardi overt ed under s edat i on/anaes t hes i a. Chemi c al c ardi overs i on i s empi ri c and t he choi ce of agent depends on l ocal pol i cy and expert i s e. W e recommend i v s ot ol ol , proc ai nami de, or ami odarone as fi rs t -l i ne agent s . Ami odarone i s t he agent of choi ce i n t he cont ext of poor LV funct i on. Second-l i ne agent s i ncl ude l i gnoc ai ne and -bl oc kers (t he l at t er i s part i cul arl y val uabl e i n t he s et t i ng of MI/acut e i s chaemi a). Gi ve IV magnes i um (8mmol bol us over 25 mi nut es fol l owed by 60mmol i n 50ml dext ros e over 24 hours ) for al l pat i ent s , es peci al l y i f t here i s a
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ri s k of hypomagnes aemi a (e.g. di uret i cs , exces s i ve et hanol i nt ake). W i t h recurrent VT bol us dos e can be repeat ed s afel y. Save a s erum s ampl e for anal ys i s l at er.
Correct reversible factors

o
I s c haemi a mus t be t reat ed es peci al l y i n t he cont ext of pos t -i nfarct i on VT. Thi s can i ni t i al l y be achi eved wi t h -bl ockers . Pat i ent s s houl d undergo revas cul ari zat i on at t he earl i es t opport uni t y (s ee STEMI, P24). El ec t rol yt e abnormal i t i es mus t be correct ed (ai m K
+
4.04.5, Mg
2+
1.0).
Ac i dos i s : i f s evere (pH 7.1) gi ve bi carbonat e (8.4% s odi umbi carbonat e 50ml vi a a cent ral l i ne over 20 mi nut es ).
If there is recurrent or persistent VT

o
Sync hroni zed DC s hoc k under s edat i on or anaes t hes i a, wi t h an anaes t het i s t pres ent i n cas e of s udden det eri orat i on. Overdri ve pac i ng us i ng a t emporary t rans venous wi re may be us ed t o t ermi nat e VT. The combi nat i on of prol onged t emporary paci ng and ant i arrhyt hmi cs for recurrent VT i s part i cul arl y effect i ve i n s i t uat i ons where t he VT i s provoked by bradycardi a. If pos s i bl e rhyt hm s t ri ps of ons et of runs of VT mus t be anal ys ed l ooki ng for bradycardi a, heart bl ock, or s i ck s i nus s yndrome. Dual -chamber t emporary paci ng may i mprove cardi ac out put by res t ori ng AV s ynchrony.
Maintenance therapy i s us ual l y oral and depends on aet i ol ogy of VT. Pat i ent mus t be di s cus s ed wi t h cardi ac el ect rophys i ol ogi s t earl y and opt i ons for el ect rophys i ol ogi cal s t udy, radi ofrequency abl at i on of VT focus , and/or ICD i mpl ant at i on expl ored. Pat i ent wi l l need Hol t er moni t or, exerci s e t es t i ng, or more i nvas i ve s t i mul at i on t es t s t o moni t or effect i venes s of t herapy.
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P.71
Monomorphic VT: Teaching points
Defi ned as 3 cons ecut i ve vent ri cul ar ect opi cs at a rat e 100/mi n Common earl y pos t MI (up t o 40%). If s el f-l i mi t i ng, wi t hout haemodynami c compromi s e, does not requi re t reat ment Sus t ai ned VT i n t he s et t i ng of acut e MI ( LV dys funct i on) i s as s oci at ed wi t h a poor prognos i s (s hort and l ong t erm) and requi res urgent t reat ment . Pat i ent s s houl d undergo el ect rophys i ol ogi cal as s es s ment ICD i ns ert i on Accel erat ed i di ovent ri cul ar rhyt hm or s l ow VT (rat e 50100/mi n) requi res t reat ment i f hypot ens i ve (from l os s of at ri al cont ri but i on)
Investigation of ventricular tachycardia

ECG CXR U&Es Mg , Ca Cardi ac enz ymes ABG Echo ?Hypoxi a, aci dos i s For LV funct i on and t o excl ude s t ruct ural abnormal i t y (e.g. aneurys m)
2+ 2+
Acut e MI, prol onged QT i nt erval Cardi omegal y, pul monary oedema Hypokal aemi a, renal i mpai rment ?defi ci ency Smal l ri s es common aft er DC s hock
Once acut e epi s ode i s over, cons i der referral t o cardi ol ogi s t for

Hol t er moni t ori ng Exerci s e t es t i ng Coronary angi ography
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VT s t i mul at i on (provocat i on) t es t i ng
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Polymorphic vent ric ular t ac hyc ardia (
Polymorphic ventricular
tachycardia (PVT) 1
General management pri nci pl es are i dent i cal as for monomorphi c VT. Mos t pat i ent s wi l l be haemodynami cal l y uns t abl e and mus t undergo ext ernal defi bri l l at i on. PVT occurri ng i n t he fol l owi ng ci rcums t ances requi res s peci fi c t herapy:

Is chaemi c PVT i n t he cont ext of MI Non-i s chaemi c PVT wi t h QT prol ongat i on (Tors ades de Poi nt es ) PVT as s oci at ed wi t h Brugada s yndrome.
Ischaemic PVT
Occurs i n conjunct i on wi t h acut e MI and chroni c myocardi al i s chaemi a MVT i n t he cont ext of MI can convert t o PVT Pri mary t reat ment i s compl et e revas cul ari zat i on. Thi s mus t be fol l owed by Hol t er, exerci s e ECG, and EP eval uat i on t o det ermi ne arrhyt hmi a t hres hol d A s ub-s et of pat i ent s es peci al l y wi t h poor LV funct i on, or where MVT degenerat es i nt o PVT, may requi re ICD i mpl ant at i on.
Non-ischaemic PVT with prolonged QT interval (Torsades de Pointes)

Thi s i s an i rregul ar pol ymorphi c VT (oft en s el f-l i mi t i ng), whi ch appears t o t wi s t about t he i s oel ect ri c l i ne. It occurs i n t he s et t i ng of prol ongat i on of t he QT i nt erval (QTc >500ms ) but t he rel at i ons hi p bet ween degree of prol ongat i on and ri s k of s eri ous arrhyt hmi as i s unpredi ct abl e. It may pres ent as recurrent s yncope
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or di z z i nes s . Qui t e oft en pat i ent s are mi s t aken as havi ng s ei zures .
Brugada syndrome 1
Brugada s yndrome i s charact eri zed by t he t ri ad of

o o o
ST el evat i on i n V1V3 RBBB Sudden deat h (or fami l y hi s t ory of s udden deat h) from VF.
It i s common i n Japan and i n SE As i a. Men are affect ed more t han women. The i nheri t ance pat t ern i s aut os omal domi nant and s ome fami l i es have a mut at i on i n t he cardi ac s odi um channel SCN5A. Mus t obt ai n s peci al i s t advi ce from cardi ac el ect rophys i ol ogi s t . Pat i ent s wi l l requi re EP s t udi es wi t h vi ew t o ICD i mpl ant at i on. Di agnos i s i s made by s eri al ECGs aft er admi ni s t rat i on of fl ecani de 2mg/kg body wei ght i v i n 10 mi nut es or procanami de 10mg/kg i v i n 10 mi nut es . The t es t i s pos i t i ve i f an addi t i onal 1mm ST el evat i on appears i n l eads V1, V2, and V3. Al l pos i t i ve i ndi vi dual s s houl d undergo EP s t udi es and furt her s peci al i s t eval uat i on.
Footnote
1
Ramon Brugada Seni or Foundat i on. ht t p://www.crt i a.be
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Polymorphic
Polymorphic VT 2
Causes of prolonged QT interval Acquired
Drugs Ant i -arrhyt hmi cs (qui ni di ne, procai nami de, di s opyrami de ami odarone, s ot al ol ) Ant i -ps ychot i cs Ant i -hi s t ami nes (pi mozi de, t hi ori dazi ne) (t erfenadi ne, as t emi zol e, es peci al l y i f ot her pres cri bed drugs i nt eract wi t h t hem (e.g. ket oconazol e, eryt hromyci n) Ant i -mal ari al s Organophos phat e poi s oni ng

(es peci al l y hal ofant ri ne)
El ect rol yt e abnormal i t i es (K , Mg , and Ca ) Severe bradycardi a (compl et e heart bl ock or s i nus bradycardi a) Int ri ns i c heart di s eas e (IHD, myocardi t i s ) Int racrani al haemorrhage (es peci al l y s ub-arachnoi d)
2+
2+
Congenital long QT syndromes

Jervel l , LangeNei l s en s yndrome (AR, wi t h deafnes s ) RomanoW ard s yndrome (AD, normal heari ng) NB: Al t hough ami odarone and s ot al ol prol ong QT i nt erval , pol ymorphi c VT from t hes e drugs i s rare.
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Management
Congenital long QT
PVT i n congeni t al QT prol ongat i on i s adrenergi cal l y dri ven and t reat ment mus t i ncl ude l ong-t erm -bl ockade (e.g. propanol ol ). Ot her adjunct i ve t reat ment i ncl udes pacemaker i mpl ant at i on and l eft s t el l at e gangl i onect omy. Pat i ent s s houl d be cons i dered for ICD t herapy. On occas i ons deci s i ons may be di ffi cul t becaus e of t he young age of pat i ent s .
Acquired long QT

The pri mary pri nci pl e i s t o correct QT prol ongat i on. Offendi ng agent (s ) mus t be i dent i fi ed and di s cont i nued i mmedi at el y. PVT i n acqui red QT prol ongat i on i s oft en s econdary t o prol onged paus es , whi ch mus t be avoi ded. Al l pat i ent s s houl d recei ve i v magnes i um (8mmol as a bol us over 25 mi nut es fol l owed by a 60mmol i nfus i on over 24 hours ) Overdri ve t emporary paci ng [ei t her vent ri cul ar or at ri al ] t ermi nat es t he arrhyt hmi a. Cont i nued paci ng prevent s recurrence of PVT. Is oprenal i ne may be us ed whi l e preparat i ons are bei ng made for paci ng. Thi s accel erat es t he at ri al rat e and capt ures t he vent ri cl es . Ai m for rat e of 110120bpm.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Vent ric ular t ac hyc ardia: drugs
Ventricular tachycardia: drugs
Dosages of selected anti-arrhythmics for the acute treatment of VT

Drug Magnes i um s ul phat e Dosage Loading dose 8mmol (2g) i v over 215 mi nut es (repeat once i f neces s ary) Maintenance dose 60mmol /48ml s al i ne at 23 ml /h Loading dose 100mg i v over 2 mi nut es (repeat once i f neces s ary) Maintenance dose 4mg/mi n for 30 mi nut es 2mg/mi n for 2 hours 12mg/mi n for 1224 hours Loading dose 100mg i v over 2 mi nut es . Repeat every 5 mi nut es t o max of 1g Maintenance dose 24mg/mi n i v i nfus i on 250mg q6h po Loading dose 300mg i v over 60 mi nut es vi a cent ral l i ne fol l owed by 900mg i v over 23 hours 200mg po t ds 1 week t hen 200mg po bd 1 week Maintenance dose 200400mg od i v or po Loading dose 50mg i v over 5 mi nut es repeat ed up t o maxi mum of 150mg i v 200mg po Maintenance dose 25mg/mi n i v i nfus i on 100200mg q6h po Loading dose 2mg/kg i v over 10 mi nut es (max 150mg) Maintenance dose
Li gnocai ne
Procai nami de
Ami odarone
Di s opyrami de
Fl ecai ni de
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1.5mg/kg i v over 1 hour t hen 100250g/kg/h i v for 24 hours or Bret yl i um 100200mg po bd Loading dose 510mg/kg (~500mg) i v over 1015 mi nut es Maintenance dose 12mg/mi n i v i nfus i on
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Narrow c omplex t ac hyarrhyt hmias (
Narrow complex
tachyarrhythmias (SVT)
Thes e ori gi nat e wi t hi n t he at ri um or t he conduct i on s ys t em above t he bundl e of Hi s . The i mport ant di s t i nct i on t o make i s bet ween regul ar and i rregul ar t achyarrhyt hmi as (s ee t abl e on faci ng page). Feat ures of t he di fferent arrhyt hmi as are s hown on P80. The di agnos i s not t o mi s s i s AVRT (t achycardi as i nvol vi ng an acces s ory pat hway) as di goxi n and verapami l are cont rai ndi cat ed.
Making the diagnosis

Thi s can be done by careful exami nat i on of t he 12-l ead t achycardi a ECG rhyt hm s t ri p and t he effect of i nduci ng AV bl ock.
Examination of ECG. Import ant feat ures t o demons t rat e are whet her rhyt hm i s regul ar or i rregul ar and t o exami ne for pres ence/abs ence and morphol ogy of P-waves .
o
Irregular rhythm
No P-waves visible
Irregul ar rhyt hm wi t h no di s cerni bl e P-wave (chaot i c bas e l i ne wi t h f -waves ): t reat as at ri al fi bri l l at i on (P84).
Irregul ar rhyt hm wi t h no di s cerni bl e P-wave and s aw-t oot h fl ut t er waves (es peci al l y i n i nferi or l eads and V1): t reat as at ri al fl ut t er w i t h vari abl e bl oc k (P92).
P-waves visible
Irregul ar rhyt hm wi t h mul t i pl e P-wave
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morphol ogi es (>3) and varyi ng PR i nt erval s : t reat as mul t i focal at ri al t achycardi a (P94).
o
Regular rhythm
No P-waves visible
No di s cerni bl e P-wave and s aw-t oot h fl ut t er waves (es peci al l y i n i nferi or l eads and V1): t reat as at ri al fl ut t er w i t h bl oc k (P92).
P-waves visible
P-waves wi t h normal morphol ogy: t reat as s i nus t ac hyc ardi a or s i nus node re-ent ry t ac hyc ardi a .
P-waves wi t hi n or di s t ort i ng t he s t art or end of QRS compl ex: t reat as AVNRT (s ee P98).
QRS compl ex may/may not be fol l owed by P-waves wi t h di fferent morphol ogy t o s i nus P-waves : t reat as AVRT (s ee P96).
Induce AV block by vagot oni c manoeuvres (e.g. val s al va, carot i d s i nus mas s age) and i f uns ucces s ful , wi t h adenos i ne. [Adenos i ne 6mg fas t i v bol us (3mg i f vi a cent ral l i ne) fol l owed by 5ml s al i ne fl us h. If no res pons e t ry 9, 12mg, and t hen 18mg]. Check t hat t he pat i ent has recei ved a t herapeut i c dos e of adenos i ne (and experi enced ches t t i ght nes s wi t h t he i nject i on). Hi gher dos es are requi red i n pat i ent s on t heophyl l i nes .
o o
AVNRT and AVRT may t ermi nat e wi t h adenos i ne. Trans i ent AV bl ock wi l l unmas k AF, fl ut t er, and at ri al t achycardi a, but wi l l not t ermi nat e. The exact di agnos i s may be l eft t o an experi enced cardi ol ogi s t . P.79
I f t here i s degenrat i on of t he rhyt hm i nt o a broad
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c ompl ex t ac hyarrhyt hmi a and/or haemodynami c c ompromi s e pat i ent mus t be el ec t ri c al l y c ardi overt ed i mmedi at el y . It i s i mport ant t o remember t hat SVT wi t h previ ous BBB/aberrancy or AVRT wi t h pre-exci t at i on can pres ent wi t h a broad compl ex t achycardi a. Di fferent i at i on from VT may be di ffi cul t and i f i n doubt pat i ent mus t be t reat ed as VT unt i l proven ot herwi s e. ECG feat ures t o di s t i ngui s h bet ween t he t wo are out l i ned on P68. Regular tachycardia

Si nus t achycardi a At ri al fl ut t er (wi t h 2 : 1 or great er bl ock) AVRT (i .e. wi t h acces s ory pat h, e.g. W PW ) AVNRT Int ra-at ri al re-ent ry t achycardi a AF At ri al fl ut t er wi t h vari abl e bl ock Mul t i -focal at ri al t achycardi a
Irregular tachycardia

Types of s upravent ri cul ar t achycardi a
Differential diagnosis of SVT
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A P Ef C rr w fe o h a ct m yt v of m h e a e m c d nt ia o e nf n ig o u si r n at e io n Si N Tr n or a u mn s al s i ta P e c w nt h a A y v V c e bl a s oc r di a (1 0 0 2 0 0/ k
Page 188
m in ) A f Tr Ir tr - a re ia w n g l a s i ul fi v e ar b e nt rh ril s . A yt la C V h ti h bl m o a oc . n ot k A ( ic < 2 0 0/ m in ) d e n o si n e ca u s e s ra te to sl o w br ie fl
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y. F a st A F wi th br o a d Q R S s e e n in A V R T (e .g . W P W ) A Fl Tr A tr ut a d ia t e n e l r si n fl w e o
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ut a nt s i te v A n r e V e (7 s bl m 5 (s oc a a k y w 1 -t 7 o 5/ ot m h) i n (I ) I, II I, a V F a n d VI ) A In T M V v er o N er m s t R t e i n co T d, at m (1 b e m 4 ur s o 0 ie d i n 2 Q 0 R n re cu rr e co n v er t to A F
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0/ S m (u in s ) u al ly n ot s e e
nt S V T in a d ul ts
n) A In T N V v er or R er m m T t e i n al (e d, at Q .g af e R . te s S Wr P Q WR or S ac (i ce nf s s er or i o y r p le at a h d w s, a R y) P (1 > if a nt e gr a d e d o w n A V n o
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5 P 0 R in t e 2 rv 5 al 0/ ) m in )
d e; br o a d Q R S if a nt e gr a d e d o w n p at h w a
y A A Tr Di tr b a g ia n n t o l or s i xi ta m e ci c al nt t y h P A , y w V lu
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c a bl n a v oc g r e k di di (P a R (i < nt R ra P) at 2 ri : al 1 re A -e V nt bl ry oc ) k (1 m 0 a 0 y b e 2 s 0 e 0/ e mn in ) M M Tr A ul ul a s s ti t i n oc fo pl s i . c e e wi al P nt t h at m A l u ri or V n s e a s e or g a ni c h e ar t di s e a s e
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al h bl g ta ol oc di c o k s h gi y e c s a r di a ) (1 0 0 1 3 0/ m in Not e: Any of t hes e may be as s oci at ed wi t h broad QRS compl ex es ei t her from pre-exi s t i ng bundl e e a s e a n d h y p o x a e m ia
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branch bl ock, or rat e-rel a t ed i nt ravent ri cul ar conduct i on abnorma l i t y.
P.80
P.81
P.82
Dosages of selected anti-arrhythmics for SVT
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Dr Do ug sa ge Di g Lo oxi adi n ng do se iv 0.7 5 1 mg in 50 ml s al i ne ove r 1 2 ho urs po 0.5 mg q1 2h for 2 dos es t he n
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0.2 5m g q1 2h for 2 day s Ma int en an ce do se 0.0 62 5 0 .25 mg dai ly (i v or po) Pro i v pra 1m nol g ol ove r 1m i n, rep
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eat ed eve ry 2 mi nut es up to ma xi m um 10 mg po 10 40 mg 3 4 tim es a day At e i v nol 5 ol 1 0m g by slo w i nj
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ect i on po 25 10 0m g dai ly Sot i v al o 20 l 60 mg by slo w i nj ect i on po 80 16 0m g bd Ver i v ap 5m am g il ove r 2m i nu
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t es ; rep eat ed eve ry 5 mi nut es up to ma xi m um 20 mg po 40 12 0m g t ds Pro i v cai 10 na 0m mi g de ove r 2m i n; rep eat
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ed eve ry 5 mi nut es up to ma xi m um 1g po 25 0m g q6 h Am Lo i od adi aro ng ne do se iv 30 0m g ove r 60 mi n vi a cen
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t ral lin e fol l ow ed by 90 0m g iv ove r 23 ho urs OR po 20 0m g t ds 1 we ek t he n 20 0m g po bd
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1 we ek Ma int en an ce do se 20 0 4 00 mg od iv or po Di s i v opy 50 ra mg mi ove de r 5m i n; rep eat ed eve ry 5 mi nut es
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up to ma xi m um 15 0m g iv 10 0 2 00 mg q6 h po Fl e 2m cai g/k ni d g e iv ove r 10 mi n (m ax 15 0m g) or 10 0 2
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00 mg po bd
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > At rial fibrillat ion: assessment
Atrial fibrillation: assessment
Presentation
Thi s may pres ent wi t h pal pi t at i ons , ches t pai n, breat hl es s nes s , col l aps e, or hypot ens i on. Les s commonl y, i t may pres ent wi t h an embol i c event (s t roke, peri pheral embol us ) or be as ympt omat i c. It occurs i n 1015% of pat i ent s pos t MI. Look for s i gns of an underl yi ng caus e (s ee t abl e). Try t o es t abl i s h t he durat i on of t he AF: t hi s wi l l det ermi ne t he s ubs equent management (s ee bel ow).
Investigations
Thes e s houl d be di rect ed at l ooki ng for a preci pi t ant and underl yi ng heart di s eas e. Al l pat i ent s s houl d have ECG Broad QRS i f aberrant conduct i on; ST-T-wave changes may be due t o rapi d rat e, di goxi n, or underl yi ng cardi ac di s eas e CXR U&Es Cardi ac enz ymes Thyroi d funct i on Drug l evel s Es peci al l y i f t aki ng di goxi n Mg , Ca ABG Echo TOE
2+ 2+
Cardi omegal y, pul monary oedema, i nt rat horaci c preci pi t ant , val ve cal ci fi cat i on (MS) Hypokal aemi a, renal i mpai rment ?MI. Smal l ri s e aft er DC s hock Thyrot oxi cos i s may pres ent as AF onl y
If hypoxi c, s hocked, or ?aci dot i c For LV funct i on and val ve l es i ons and t o excl ude i nt racardi ac t hrombus pri or t o vers i on t o SR
Ot her i nves t i gat i ons depend on s us pect ed preci pi t ant .

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Immediate management Stabilize the patient
General meas ures (P64) are as for any pat i ent wi t h an arrhyt hmi a. Obt ai n venous acces s . Send bl oods (P64) and i f pos s i bl e check t he K machi ne.
+
i mmedi at el y on an ITU
Correct any el ec t rol yt e abnormal i t y. If s evere ac i dos i s (pH 7.1) gi ve s odi um bi carbonat e 50ml of 8.4% s l owl y i v over 20 mi nut es . CSM or i v adenos i ne may hel p confi rm t he di agnos i s , reveal i ng chaot i c at ri al act i vi t y. Thi s i s part i cul arl y hel pful i n pat i ent s wi t h a rat e of 150/mi n where at ri al fl ut t er s houl d al ways be cons i dered. CSM or adenos i ne wi l l s l ow t he vent ri cul ar rat e and reveal fl ut t er waves . Does t he ECG i n AF s how i nt ermi t t ent or cons t ant del t a waves ? Thi s s ugges t s W PW and di goxi n and verapami l are cont rai ndi cat ed.
Further management

Cardi overt t o s i nus rhyt hm i f appropri at e. Cont rol t he vent ri cul ar res pons e rat e. Try t o prevent furt her epi s odes of AF.
P.85
Causes of atrial fibrillation

Underlying cardiac disease pathology

Is chaemi c heart di s eas e Mi t ral val ve di s eas e Hypert ens i on Heart fai l ure Cardi omyopat hy Peri cardi t i s Endocardi t i s
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Myocardi t i s At ri al myxoma Pos t cardi ac s urgery Pneumoni a Mal i gnancy (1 or 2) Pul monary embol us Trauma El ect rol yt es (K , Mg ) Aci dos i s Thyrot oxi cos i s Drugs (al cohol , s ympat homi met i cs )
+ 2+
Separate intrathoracic

Metabolic disturbance

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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > At rial fibrillat ion: management 1
Atrial fibrillation:
management 1
Rate control versus cardioversion
Import ant pri nci pl es requi red t o make a deci s i on are

o
Are t here advant ages i n i mmedi at e cardi overs i on? (e.g. on-goi ng i s chaemi a wi t h fas t vent ri cul ar rhyt hm, pul monary oedema, haemodynami c i ns t abi l i t y). If t he pat i ent i s cardi overt ed wi l l t hey remai n i n s i nus rhyt hm? (e.g. underl yi ng s eps i s /t hyroi d di s eas e, l arge LA, poor LV, MV di s eas e). W hat are t he ri s ks of t hromboembol i c compl i cat i ons and i s ant i -coagul at i on requi red?
Cardi overs i on can be achi eved chemi cal l y or wi t h ext ernal defi bri l l at i on.
Haemodynamically unstable patients
Al l hypot ens i ve pat i ent s s houl d undergo ext ernal defi bri l l at i on us i ng a s ynchroni zed s hock of i ni t i al l y 200J (s ee P894). Do not at t empt t o defi bri l l at e hypot ens i ve pat i ent s wi t h known chroni c AF or a known underl yi ng caus e dri vi ng a fas t vent ri cul ar res pons e. Chances of s ucces s are very l ow (e.g. mi t ral s t enos i s , s evere LV dys funct i on, hypert hyroi d, s ept i c). Rel at i ve cont rai ndi cat i ons t o defi bri l l at i on need t o be wei ghed agai ns t t he pat i ent 's cl i ni cal condi t i on. If pos s i bl e, ai m t o opt i mi ze cl i ni cal pi ct ure before cardi overs i on:
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Hypokal aemi a may be qui ckl y correct ed by gi vi ng 20mmol over 1 hour i n 100ml ni t rat e s al i ne vi a a cent ral l i ne. If di gi t oxi ci t y i s a pos s i bi l i t y, ens ure K i s 4.55mmol /L and gi ve magnes i um s ul phat e 8mmol i n 50ml ni t rat e s al i ne over 15mi nut es , before at t empt i ng defi bri l l at i on at l ow energi es i ni t i al l y (e.g. 2050J). AF >48 hours durat i on carri es a s i gni fi cant ri s k of t hromboembol i c compl i cat i ons unl es s pat i ent i s on l ong-t erm ant i -coagul at i on and INR has been t herapeut i c. Cons i der performi ng a TOE fi rs t .
+
The procedure i s det ai l ed on P894. If DC s hock fai l s i ni t i al l y

o
Gi ve i v ami odarone 300mg over 30 minut es vi a a cent ral l i ne (fol l owed by i v i nfus i on of 9001200mg over 24 hours ) Correct hypokal aemi a (ai m for K 4.55.0mmol /L) At t empt furt her DC s hock.
+
The i ni t i al ai m s houl d be rapi d pharmacol ogi cal rat e cont rol fol l owed by a deci s i on regardi ng res t orat i on of s i nus rhyt hm i f appropri at e. W hen maki ng a deci s i on regardi ng res t orat i on of s i nus rhyt hm current evi dence mus t be t aken i nt o account :
o
Management of AF wi t h a rhyt hm-cont rol s t rat egy al one has no s urvi val benefi t over a rat e-cont rol s t rat egy as l ong as hi gh-ri s k pat i ent s are ant i -coagul at ed. Rat e cont rol i s not i nferi or t o rhyt hm cont rol for prevent i on of deat h and cardi ovas cul ar morbi di t y i n pat i ent s wi t h pers i s t ent AF aft er el ect ri cal cardi overs i on.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > At rial fibrillat ion: management 2
Atrial fibrillation:
management 2
AF >2 days duration
Cont rol vent ri c ul ar rat e us i ng one of or a combi nat i on of di goxi n and cl as s II, III, and IV agent s (i ncl udi ng: -bl ockers , verapami l , di l t i azem, or ami odarone). Can be gi ven as i v preparat i on t o achi eve rapi d rat e cont rol fol l owed by oral preparat i ons (s ee t abl e, P82 for dos es ). If pat i ent not ant i -coagul at ed s t art LMWH/UFH (UFH: gi ve bol us of 5000U fol l owed by i nfus i on ai mi ng for an aPTT rat i o of 23) unt i l warfari ni zat i on i s adequat e (ai m INR 23). Si nus rhyt hm may be res t ored by cl as s Ia, Ic, and III agent s (we recommend ami odarone, s ot al ol , qui ni di ne, di s opyrami de, and fl ecai ni de). If pat i ent needs t o be el ect ri cal l y cardi overt ed, mus t perform T OE t o l ook for i nt ra-cardi ac t hrombus or s pont aneous cont ras t (a marker of very s l uggi s h fl ow). If negat i ve, DC cardi overs i on may be performed s afel y. Gi ve bol us of LMW H/UFH before cardi overs i on i f not al ready on LMW H/UFH. Di s charge when s t abl e. Cons i der readmi s s i on fol l owi ng 46 weeks of warfari n for DC cardi overs i on.
AF <2 days duration
Al t hough ri s k of embol i s m i n new ons et AF i s l ow, we recommend ant i -coagul at i on at pres ent at i on wi t h LMW H/UFH and s ubs equent l y warfari n (s ee above).
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At t empt chemi cal cardi overs i on i f t here are no cont rai ndi cat i ons t o pot ent i al agent s . Chances of s ucces s are much hi gher wi t h s hort er durat i on of AF. Pos s i bl e agent s i ncl ude
o
Flecainide 2mg/kg i v over 10 mi nut es (maxi mum dos e, 150mg). Mus t be avoi ded i n pat i ent s wi t h known IHD and/or poor LV funct i on. Disopyramide 50100mg i v. Vent ri cul ar rat e may i ncreas e and fi bri l l at ory waves coars en before revert i ng t o s i nus rhyt hm, s o l oad wi t h di goxi n/-bl ocker/verapami l before gi vi ng t hi s . Amiodarone may be us ed i v/po. Dos i ng requi res cent ral l i ne and i t may t ake 2448 hours for s i nus rhyt hm t o be achi eved. Ami odarone has rel at i vel y poor rat e-cont rol propert i es and may need t o be combi ned wi t h -bl ocker or verapami l i ni t i al l y.
If cardi overs i on i nappropri at e or uns ucces s ful , achi eve rat e cont rol as i ndi cat ed above. DC cardi overs i on can be at t empt ed i f rat e cont rol i s di ffi cul t . Di s charge when s t abl e. Ant i -coagul at i on may be achi eved on an out -pat i ent bas i s i f appropri at e.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > At rial fibrillat ion: rat e c ont rol
Atrial fibrillation: rate control
Controlling the ventricular response rate
Check t hat t here i s no hi s t ory of W PW and t hat no del t a waves are vi s i bl e on t he ECG. W e recommend - bl oc kers and c al c i um c hannel bl oc kers (verapami l and di l t i azem) as fi rs t -l i ne agent s for rat e cont rol . They bot h have t he advant age of mai nt ai ni ng vent ri cul ar rat e duri ng exert i on. If s i ngl e agent i s not adequat e ei t her (1) combi ne -bl ockers and cal ci um channel bl ockers (i f BP adequat e) or (2) add di goxi n or ami odarone. Di goxi n i s an al t ernat i ve drug and can equal l y be us ed as fi rs t -l i ne agent . Pat i ent s s houl d i ni t i al l y be gi ven a ful l l oadi ng dos e. The mai nt enance dos e vari es (0.06250.25mg od) dependi ng on body mas s , renal funct i on, age, et c. Di goxi n i s poor at cont rol l i ng vent ri cul ar rat e duri ng exert i on. In pat i ent s wi t h poor LV funct i on, -bl ockers and cal ci um channel bl ockers may not be appropri at e, i nduci ng heart fai l ure and hypot ens i on. Di goxi n wi t h or wi t hout ami odarone i s a good combi nat i on (ami odarone wi l l i ncreas e t he pl as ma di goxi n l evel s o hal ve t he mai nt enance di goxi n dos e). Ot her drugs t hat may be t ri ed t o cont rol t he vent ri cul ar rat e are l i s t ed i n t he t abl e on P82. If cont rol l i ng vent ri cul ar rat e i s di ffi cul t , cons i der al t ernat i ve di agnos i s , i n part i cul ar MAT. Di goxi n may make t he arrhyt hmi a wors e (s ee P94).
Long-term management
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Look for caus es (s ee t abl e on P85) and arrange an Echo. Pat i ent s s ucces s ful l y cardi overt ed acut el y s houl d be commenced on a prophyl axi s regi me us i ng cl as s Ia, Ic, or III agent s (e.g. s ot al ol , ami odarone, fl ecai ni de, propafenone). The choi ce of agent mus t be i ndi vi dual i zed:
o
Lone AF: us e cl as s Ic agent s fi rs t , fol l owed by cl as s III or Ia i f i t fai l s . Poor LV funct i on: ami odarone i s t he agent of choi ce. IHD: cl as s III agent s and -bl ockers (prevent i s chaemi a and as a res ul t i s chaemi a-dri ven AF) are agent s of choi ce.
If s ubs equent l y cons i dered t o be at l ow ri s k, t reat ment may be s t opped at 1 mont h. Seek cardi ac opi ni on i f i n doubt .
Pat i ent s cardi overt ed el ect i vel y s houl d remai n on warfari n and rhyt hm prophyl axi s for 1 mont h pendi ng out -pat i ent revi ew. Pat i ent s wi t h paroxys mal AF requi re l ong-t erm t herapy t o t ry t o mai nt ai n s i nus rhyt hm (cl as s III, cl as s Ic, and cl as s Ia). Di goxi n onl y cont rol s t he vent ri cul ar rat e and does not prevent AF. Thes e pat i ent s may need l ong-t erm ant i -coagul at i on dependi ng on (1) frequency and l engt h of AF paroxys ms , (2) pres ence of underl yi ng s t ruct ural , cardi ac abnormal i t i es , and (3) ot her s ys t emi c ri s k fact ors of t hromboembol i c compl i cat i ons .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > At rial flut t er
Atrial flutter
Thi s i s rarel y s een i n t he abs ence of underl yi ng coronary di s eas e, val ve di s eas e, pri mary myocardi al di s eas e, peri cardi t i s , or t hyrot oxi cos i s . The at ri al rat e i s 280320/mi n and at ri al act i vi t y i s s een as fl ut t er waves i n t he i nferi or l eads and V1 on t he ECG. The AV node conduct i on i s s l ower (mos t commonl y 2 : 1 bl ock, s omet i mes 3 : 1 or 4 : 1) and t hi s det ermi nes t he vent ri cul ar rat e. Vagot oni c manoeuvres and adenos i ne i ncreas e t he AV bl ock and reveal t he fl ut t er waves but onl y very rarel y t ermi nat e t he arrhyt hmi a.
Management
DC c ardi overs i on i s t he t herapy of c hoi c e as fl ut t er can be res i s t ant t o pharmacol ogi cal t herapy.
o o
Lower energi es are needed (20100J). If fl ut t er has been pres ent >48 hours perform TOE and t hen cardi overt wi t h LMW H/UFH cover (as for AF).
Medi c al management
o
Pharmacol ogi cal agent s recommended are s i mi l ar t o AF. Rat e cont rol and revers i on rat es can be l ow. Di goxi n, verapami l , and -bl oc kers can al l be us ed t o s l ow vent ri cul ar res pons e. i v preparat i ons can be us ed for more rapi d act i on. The overal l res pons e can be poor. i v verapami l (2.55mg over 12 mi nut es repeat ed every 5 mi nut es t o a maxi mum dos e of 20mg) wi l l s l ow t he res pons e
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rat e and occas i onal l y res t ore s i nus rhyt hm i n 1520% of pat i ent s .
o
I but i l i de and dofet i l i de have been report ed t o have revers i on rat es of 50% and 70% res pect i vel y. Al t ernat i ve agent s are ami odarone, fl ec ai ni de, qui ni di ne, and proc ai nami de . NB: Cl as s Ia drugs can enhance AV conduct i on and mus t al ways be us ed aft er rat e cont rol has been achi eved (s ee above).
Fl ut t er abl at i on can be performed i n res i s t ant and/or recurrent at ri al fl ut t er. Di s cus s wi t h cardi ac el ect rophys i ol ogi s t .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Mult i- foc al at rial t ac hyc ardia (
Multi-focal atrial tachycardia
(MAT)
Commonl y occurs i n cri t i cal l y i l l pat i ent s es peci al l y wi t h obs t ruct i ve ai rways di s eas e who may be hypoxaemi c and hypercapni c. Theophyl l i ne t oxi ci t y i s an i mport ant fact or. Charact eri zed by at l eas t 3 di fferent P-wave morphol ogi es wi t h varyi ng PP and PR i nt erval s . At ri al nodal rat e i s 120180 wi t h 1 : 1 conduct i on. Rapi d regul ar rhyt hm may be di ffi cul t t o di fferent i at e from at ri al fi bri l l at i on. However, di fferent i at i on i s very i mport ant as MAT i s not res pons i ve t o DC cardi overs i on and i s exacerbat ed by di goxi n.
Management
The onl y t rue effec t i ve t reat ment i s t o t reat t he underl yi ng i l l nes s . If as s oci at ed wi t h l ung di s eas e ai m t o i mprove P a O 2 and P a CO 2 . El ect rol yt e abnormal i t i es mus t be correct ed. Hi gh-dos e Mg
2+
i v may res t ore s i nus rhyt hm (15g over 5 hours ).
There i s i ncreas i ng evi dence from s mal l t ri al s t hat met oprol ol i s t he mos t effect i ve t herapy. Us e caut i ous l y i v. However, mos t pat i ent s wi t h MAT and COPD may not t ol erat e even a cardi o-s el ect i ve -bl ocker. Verapami l i s an al t ernat i ve agent (5mg i v over 2 mi nut es and repeat ed every 5 mi nut es up t o a maxi mum of 20mg; t hen 40120mg po t ds ) i f t he vent ri cul ar rat e i s cons i s t ent l y over >100/mi n and t he
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pat i ent i s s ympt omat i c.
DC s hock and di goxi n are i neffect i ve.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Ac c essory pat hway t ac hyc ardia (A- V re- ent rant t ac hyc ardia,
Accessory
pathway tachycardia (A-V re-entrant tachycardia, AVRT)
The t hree mos t common acces s ory pat hways t hat produce paroxys mal t achycardi as are l i s t ed bel ow. Duri ng re-ent ry t achycardi a, t he del t a wave i s l os t as t he acces s ory pat hway i s onl y conduct i ng ret rogradel y. AF may produce very rapi d vent ri cul ar rat es as t he acces s ory pat h has rapi d ant egrade conduct i on (unl i ke t he AV node). The ECG wi l l s how t he del t a wave i n s ome or al l of t he QRS compl exes .
Management
DC cardi overs i on s houl d be us ed earl y i f t he t achycardi a i s poorl y t ol erat ed. Cl as s Ia, Ic, and II agent s are s ui t abl e for chemi cal cardi overs i on. W e recommend i v fl ecai ni de or di s opyrami de. -bl ocker may al s o be gi ven es peci al l y i f ot her agent s are cont rai ndi cat ed (s ee t abl e, P82). Di goxi n and verapami l s houl d be avoi ded as t hey may accel erat e conduct i on down t he acces s ory pat hway. Ami odarone i s dangerous unl es s gi ven very s l owl y (e.g. 300mg i v over 24 hours ). If recurrent s ympt oms , pat i ent s houl d be referred for el ect rophys i ol ogi cal as s es s ment and RF abl at i on. Seek s peci al i s t advi ce for l ong-t erm medi cal management .
Types of accessory pathways Kent bundle (WolffParkinsonWhite

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syndrome)
ECG Short PR i nt erval and del t a wave Type A Pos i t i ve -wave i n V1V6 Negat i ve i n l ead I (Pos t eri or l eft at ri al pat hway) Type B Bi phas i c or negat i ve wave i n V1V3 Pos i t i ve i n l ead I (Lat eral ri ght at ri al pat hway) Conceal ed As s oci at ed wi t h No -wave vi s i bl e as pat hway onl y, conduct s ret rogradel y. Ebs t ei n's , HOCM, mi t ral val ve prol aps e.
Mahaim pathway (rare)
Pat hway connect s AV node t o ri ght bundl e res ul t i ng i n a t achycardi a wi t h LBBB morphol ogy.
James pathway (LownGanongLevine syndrome) (rare)

Short PR i nt erval but no del t a wave. Pat hway connect s at ri a t o AV node, Hi s , or fas ci cl es .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > At riovent ric ular- nodal re- ent ry t ac hyc ardia (
Atrioventricular-nodal
re-entry tachycardia (AVNRT)
AVNRT occurs s econdary t o a mi cro re-ent errant ci rcui t i n t he AV node. General pri nci pl es as out l i ned on P64 appl y. Rat e cont rol can be achi eved wi t h (i v and po) di goxi n, -bl ockers , and cal ci um channel bl ockers . -bl ockers and cal ci um channel bl ockers can al s o promot e revers i on i nt o s i nus rhyt hm. Cl as s Ic and Ia agent s (we recommend fl ecai ni de) can al s o be us ed for chemi cal cardi overs i on and mai nt ai nance of s i nus rhyt hm l ong t erm. If arrhyt hmi a i s res i s t ent t o t reat ment cons i der el ect ri cal cardi overs i on. Pat i ent s wi t h recurrent s ympt oms s houl d be referred for el ect rophys i ol ogi cal as s es s ment and pos s i bl e RF abl at i on.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Bradyarrhyt hmias: general approac h
Bradyarrhythmias: general
approach
As k s peci fi cal l y about previ ous cardi ac di s eas e, pal pi t at i ons , bl ackout s , di zzi nes s , ches t pai n, s ympt oms of heart fai l ure, and recent drugs . Exami ne careful l y, not i ng t he BP, JVP waveform (?cannon waves ), heart s ounds and murmurs , and s i gns of heart fai l ure.
Investigations
12-l ead ECG & Look s peci fi cal l y for t he rel at i ons hi p bet ween rhyt hm s t ri p P-waves and QRS compl ex. A l ong rhyt hm s t ri p i s s omet i mes neces s ary t o det ect compl et e heart bl ock i f at ri al and vent ri cul ar rat es are s i mi l ar Bl ood t es t s FBC, bi ochemi s t ry, gl ucos e (urgent l y) Ca , Mg
2+ 2+
(es peci al l y i f on di uret i cs )
Bi ochemi cal markers of cardi ac i njury Bl ood cul t ures , CRP, ESR Thyroi d funct i on t es t s Drug l evel s Art eri al bl ood gas es Ches t X-ray Heart s i ze, ?s i gns of pul monary oedema
Management Haemodynamically unstable patients
Gi ve oxygen vi a facemas k i f t he pat i ent i s hypoxi c on
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ai r.
Keep NBM unt i l defi ni t i ve t herapy has been s t art ed t o reduce t he ri s k of as pi rat i on i n cas e of cardi ac arres t or when t he pat i ent l i es s upi ne for t emporary wi re i ns ert i on. Secure peri pheral venous acces s . Bradyarrhyt hmi as caus i ng s evere haemodynami c c ompromi s e (cardi ac arres t , as ys t ol e, SBP <90mmHg, s evere pul monary oedema, evi dence of cerebral hypoperfus i on) requi re i mmedi at e t reat ment and t emporary paci ng (t he t echni que i s des cri bed on P882).
o
Gi ve at ropi ne 1mg i v (Mi n-I-Jet ) bol us ; repeat i f neces s ary up t o a maxi mum of 3mg. Gi ve i s oprenal i ne 0.2mg i v (Mi n-I-Jet ) i f t here i s a del ay i n paci ng and t he pat i ent remai ns uns t abl e. Set up an i nfus i on (1mg i n 100ml bag ni t rat e s al i ne s t art i ng at 1ml /mi n t i t rat i ng t o HR). Set up ext ernal pac i ng s ys t em i f avai l abl e and arrange for t rans fer t o a s creeni ng room for t rans -venous paci ng. If fl uoros copy i s not avai l abl e, bl i nd t rans -venous paci ng us i ng a bal l oon-t i pped paci ng wi re may be at t empt ed.
Bradycardi a i n s hock i s a poor prognos t i c s i gn. Look for a s ource of bl ood l os s and begi n aggres s i ve res us ci t at i on wi t h fl ui ds and i not ropes .
P.101

Admi t t o CCU wi t h cont i nuous ECG moni t ori ng. Keep at ropi ne drawn up and ready i n cas e of acut e det eri orat i on. Does t he pat i ent requi re a t emporary wi re i mmedi at el y? It may be of val ue t o have appropri at e cent ral venous acces s (femoral or i nt ernal jugul ar vei n) i n pl ace i n
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cas e of t he need for emergency t emporary wi re i ns ert i on.
Refer t he pat i ent t o a cardi ol ogi s t .
External cardiac pacing
In emergenci es , ext ernal cardi ac paci ng may be us ed fi rs t but t hi s i s pai nful for t he pat i ent and i s onl y a t emporary meas ure unt i l a more defi ni t i ve t rans -venous paci ng wi re can be i ns ert ed. Ext ernal cardi ac paci ng i s us eful as a s t andby i n pat i ent s pos t myocardi al i nfarct i on when t he ri s ks of prophyl act i c t rans -venous paci ng aft er t hrombol ys i s are hi gh. Haemodynami cal l y s t abl e pat i ent s wi t h ant eri or myocardi al i nfarct i on and bi fas i cul ar bl ock may be managed s i mpl y by appl i cat i on of t he ext ernal paci ng el ect rodes and havi ng t he pul s e generat or ready i f neces s ary. Fami l i ari ze yours el f wi t h t he machi ne i n your hos pi t al when you have s ome t i me: a cardi ac arres t i s not t he t i me t o read t he manual for t he apparat us !
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Sinus bradyc ardia or junc t ional rhyt hm
Sinus bradycardia or
junctional rhythm
(Heart rat e <50/mi n)
Causes

Y oung at hl et i c i ndi vi dual Drugs (-bl ockers , morphi ne) Hypot hyroi di s m Hypot hermi a Increas ed vagal t one
o o o o
vas ovagal at t ack naus ea or vomi t i ng carot i d s i nus hypers ens i t i vi t y acut e MI (es peci al l y i nferi or)
Is chaemi a or i nfarct i on of t he s i nus node Chroni c degenerat i on of s i nus or AV nodes or at ri a Chol es t at i c jaundi ce Rai s ed i nt racrani al pres s ure
Management
If hypot ens i ve or pre-s yncopal t reat as on P100:

o
At ropi ne 600g3mg i v bol us repeat i ng as neces s ary. Is oprenal i ne 0.510g/mi n i v i nfus i on. Temporary paci ng. Avoi d and t ake s t eps t o correct preci pi t ant s (s ee above). St op any drugs t hat may s uppres s t he s i nus or AV nodes .
o o o
Long-t erm t reat ment :
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If al l pos s i bl e underl yi ng caus es removed and i f s ympt omat i c bradycardi a remai ns , refer for permanent paci ng. Cons i der Hol t er moni t ori ng i n pat i ent s wi t h pos s i bl e epi s odi c bradycardi a. R-R i nt erval s >2.5 s econds may requi re permanent paci ng, es peci al l y i f as s oci at ed wi t h s ympt oms .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Int ravent ric ular c onduc t ion dist urbanc es
Intraventricular
conduction disturbances
Common causes of bundle branch block

Is chaemi c heart di s eas e Hypert ens i ve heart di s eas e Val ve di s eas e (es peci al l y aort i c s t enos i s ) Conduct i on s ys t em fi bros i s (Lev and Lenegre s yndromes ) Myocardi t i s or endocardi t i s Cardi omyopat hi es Cor pul monal e (RBBB) (acut e or chroni c) Trauma or pos t -cardi ac s urgery Neuromus cul ar di s orders (myot oni c dys t rophy) Pol ymyos i t i s .
Management

General pri nci pl es (P100) appl y. Int ervent ri cul ar conduct i on di s t urbances on t hei r own do not requi re t emporary paci ng. However, when as s oci at ed wi t h haemodynami c di s t urbance or progres s i on t o hi gher l evel s of bl ock (even i f i nt ermi t t ent ), mus t cons i der i ns ert i on of a t rans venous paci ng wi re. The need for l onger-t erm paci ng i s dependent on t he pers i s t ence of s ympt oms and underl yi ng caus e. Cons ul t a cardi ol ogi s t . See P882 for s i t uat i ons where t emporary paci ng i s i ndi cat ed.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > T ypes of at riovent ric ular (
Types of atrioventricular
(AV) conduction block
First-degree heart block

o
Prol ongat i on of t he PR i nt erval (>0.22s , >5 s mal l s q.)
Second-degree heart block

o
Mobitz type 1 (Wenckebach): progres s i ve i ncreas e i n PR i nt erval wi t h i nt ermi t t ent compl et e AV bl ock (P-wave not conduct ed). Mobitz type 2: The PR i nt erval i s cons t ant but t here i s i nt ermi t t ent fai l ure t o conduct t he P-wave. Oft en occurs i n t he pres ence of broad QRS compl ex. 2 : 1, 3 : 1 etc.: As i n mobi t z t ype 2, PR i nt erval i s cons t ant but every s econd (i n 2 : 1) or t hi rd (i n 3 : 1) P-wave i s not conduct ed on a regul ar bas i s .
T hird-degree (complete) heart block

o
Compl et e AV di s s oci at i on. If t he P and QRS rat es are s i mi l ar, a l ong rhyt hm s t ri p or exerci s e (t o s peed up t he at ri al rat e) wi l l hel p demons t rat e di s s oci at i on.
Causes

As s oci at ed wi t h acut e i nfarct i on or i s chaemi a Drugs (-bl ockers , di gi t al i s , Ca -bl ockers ) Conduct i on s ys t em fi bros i s (Lev and Lenegre s yndromes ) Increas ed vagal t one Trauma or fol l owi ng cardi ac s urgery
2+
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Hypot hyroi di s m (rarel y t hyrot oxi cos i s ) Hypot hermi a Hyperkal aemi a Hypoxi a Val vul ar di s eas e (aort i c s t enos i s , i ncompet ence, endocardi t i s ) Myocardi t i s (di pht heri a, rheumat i c fever, vi ral , Chagas ' di s eas e) As s oci at ed wi t h neuromus cul ar di s eas e, i .e. myot oni c dys t rophy Col l agen vas cul ar di s eas e (SLE, RA, s cl eroderma) Cardi omyopat hi es (haemochromot os i s , amyl oi dos i s ) Granul omat ous di s eas e (s arcoi d) Congeni t al heart bl ock Congeni t al heart di s eas e (ASD, Ebs t ei n's , PDA).
Management

Pri nci pl es are l i s t ed on P100. In s ummary al l s ympt omat i c pat i ent s mus t have t emporary paci ng. The hi gher t he l evel of bl ock (i rres pect i ve of s ympt oms ) t he great er t he progres s i on t o compl et e heart bl ock and/or chances of as ys t ol e. See P882 for s i t uat i ons when t emporary paci ng i s i ndi cat ed.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pulmonary oedema: assessment
Pulmonary oedema:
assessment
Presentation
Acut e breat hl es s nes s , cough, frot hy bl ood-s t ai ned (pi nk) s put um. Col l aps e, cardi ac arres t , or s hock. As s oci at ed feat ures may refl ect underl yi ng caus e:
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Ches t pai n or pal pi t at i ons : ?IHD/MI, arrhyt hmi a Precedi ng hi s t ory of dys pnoea on exert i on: ?IHD, poor LV Ol i guri a, haemat uri a: ?acut e renal fai l ure (P378) Sei zures , s i gns of i nt racrani al bl eed.
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Causes
A di agnos i s of pul monary oedema or heart fai l ure i s not adequat e. An underl yi ng caus e mus t be s ought i n order t o di rect t reat ment appropri at el y. Thes e may be di vi ded i nt o

Increas ed pul monary capi l l ary pres s ure (hydros t at i c). Increas ed pul monary capi l l ary permeabi l i t y. Decreas ed i nt ravas cul ar oncot i c pres s ure.
Oft en a combi nat i on of fact ors are i nvol ved (e.g. pneumoni a, hypoxi a, cardi ac i s chaemi a) s ee t abl e on P110. The mai n di fferent i al di agnos i s i s acut e (i nfect i ve) exacerbat i on of COPD (previ ous hi s t ory, qui et breat h s ounds wheeze, fewer crackl es ). It may be di ffi cul t t o di fferent i at e t he t wo cl i ni cal l y.
Principles of management
St abi l i ze t he pat i ent : rel i eve di s t res s and begi n defi ni t i ve t reat ment .
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Look for an underl yi ng caus e. Addres s haemodynami c and res pi rat ory i s s ues . Opt i mi ze and i nt roduce l ong-t erm t herapy.
Initial rapid assessment
If t he pat i ent very unwel l (e. g. unabl e t o s peak, hypoxi c, s ys t ol i c BP <100mmHg), i nt roduce s t abi l i zi ng meas ures and begi n t reat ment i mmedi at el y before det ai l ed exami nat i on and i nves t i gat i ons (P109). If t he pat i ent i s s t abl e and/or i f t here i s doubt as t o t he di agnos i s , gi ve oxygen and di uret i c, but awai t t he out come of cl i ni cal exami nat i on and CXR before deci di ng on defi ni t i ve t reat ment .
Urgent investigations for all patients

ECG Si nus t achycardi a mos t common ?any cardi ac arrhyt hmi a (AF, SVT, VT) ?evi dence of acut e ST change (STEMI, NSTEMI, UA) ?evi dence of underl yi ng heart di s eas e (LVH, p mi t ral e). CXR To confi rm t he di agnos i s , l ook for i nt ers t i t i al s hadowi ng, enl arged hi l a, promi nent upper l obe ves s el s , pl eural effus i on, and Kerl ey B l i nes . Cardi omegal y may or may not be pres ent . Al s o excl ude pneumot horax, pul monary embol us (ol i gaemi c l ung fi el ds ), and cons ol i dat i on. ABG Typi cal l y P a O 2 . P a CO 2 l evel s may be (hypervent i l at i on) or dependi ng on s everi t y of pul monary oedema. Pul s e oxi met ry may be i naccurat e i f peri pheral l y s hut down. U&Es ?pre-exi s t i ng renal i mpai rment . Regul ar K meas urement s (once on i v di uret i cs ). FBC ?anaemi a or l eukocyt os i s i ndi cat i ng t he preci pi t ant . abnormal i t i es , VSD, or peri cardi al effus i on. P.109
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Echo As s oon as pract i cal t o as s es s LV funct i on, val ve
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Investigations for patients with pulmonary oedema All patients should have

FBC, U&Es , CRP Seri al bi ochemi cal markers of myocardi al i njury (CK, CK-MB, t roponi ns ) LFTs , al bumi n, t ot al prot ei n ECG CXR Echo ( TOE) Art eri al bl ood gas es
Where appropriate consider

Sept i c s creen (s put um, uri ne, bl ood cul t ures ) Hol t er moni t or (?arrhyt hmi as ) Coronary angi ography (?IHD) Ri ght and l eft heart cat het er (i f Echo unabl e t o provi de adequat e i nformat i on on pres s ures , s hunt s , val ve di s eas e) Endomyocardi al bi ops y (myocardi t i s , i nfi l t rat i on) MUGA s can Cardi opul monary exerci s e t es t wi t h an as s es s ment of peak oxygen cons umpt i on
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pulmonary oedema: c auses
Pulmonary oedema: causes
Look for an underl yi ng c aus e for pul monary oedema
Increased pulmonary capillary pressure (hydrostatic)

Left at ri al pres s ure

Mi t ral val ve di s eas e Arrhyt hmi a (e.g. AF) wi t h pre-exi s t i ng mi t ral val ve di s eas e
Left at ri al myxoma Is chaemi a Arrhyt hmi a Aort i c val ve di s eas e Cardi omyopat hy Uncont rol l ed hypert ens i on Peri cardi al cons t ri ct i on Fl ui d overl oad Hi gh out put s t at es (anaemi a, t hyrot oxi cos i s , Paget 's , AV fi s t ul a, beri -beri )
LVEDP
Reno-vas cul ar di s eas e L R s hunt (e.g. VSD) Veno-occl us i ve di s eas e
Pul monary venous pres s ure
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Neurogeni c
Int racrani al haemorrhage Cerebral oedema Pos t i ct al See P858
Hi gh-al t i t ude pul monary oedema
Increased pulmonary capillary permeability

Acut e l ung i njury
ARDS, s ee P230
Decreased intravascular oncotic pressure

Hypoal bumi naemi a
l os s es (e.g. nephrot i c s yndrome, l i ver fai l ure)
product i on (e.g. s eps i s ) Di l ut i on (e.g. crys t al l oi d t rans fus i on)
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NB: The cri t i cal LA pres s ure for hydros t at i c oedema = s erum al bumi n (g/L) 0.57.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pulmonary oedema: management 1
Pulmonary oedema:
management 1
Stabilize the patient
Pat i ent s wi t h acut e pul monary oedema s houl d i ni t i al l y be cont i nuous l y moni t ored and managed where ful l res us ci t at i on faci l i t i es are avai l abl e. Si t t he pat i ent up i n bed. Gi ve 60100% oxygen by facemas k (unl es s cont rai ndi cat ed, COPD). If t he pat i ent i s s everel y di s t res s ed, s ummon t he on-cal l anaes t het i s t and i nform ITU. If dys pnoea cannot be s i gni fi cant l y i mproved by acut e meas ures (bel ow) t he pat i ent may requi re CPAP or mechani cal vent i l at i on. Treat any haemodynami cal l y uns t abl e arrhyt hmi a [urgent s ynchroni zed DC s hock may be requi red. Gi ve
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Di amorphi ne 2.55mg i v (caut i on abnormal ABGs ) Met ocl oprami de 10mg i v Frus emi de 40120mg s l ow i v i nject i on.
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Secure venous acces s and s end bl ood for urgent U&Es , FBC, and cardi ac enzymes (i ncl udi ng t roponi n). Unl es s t hrombol ys i s i s i ndi cat ed t ake ABG. If t he s ys t ol i c bl ood pres s ure i s 90mmHg and t he pat i ent does not have aort i c s t enos i s
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Gi ve s ubl i ngual GTN s pray (2 puffs ) St art i v GTN i nfus i on 110mg/h, i ncreas e t he
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i nfus i on rat e every 1520 mi nut es , t i t rat i ng agai ns t bl ood pres s ure (ai mi ng t o keep s ys t ol i c BP ~100mmHg).
If t he s ys t ol i c bl ood pres s ure i s <90mmHg t reat pat i ent as cardi ogeni c s hock (P44). Ins ert a uri nary cat het er t o moni t or uri ne out put . Repeat ABG and K
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i f t he cl i ni cal condi t i on
det eri orat es /fai l s t o i mprove, or aft er 2 hours i f t here i s i mprovement and t he ori gi nal s ampl e was abnormal .
Moni t or pul s e, BP, res pi rat ory rat e, O 2 s at urat i on wi t h a pul s e oxi met er (i f an accurat e readi ng can be obt ai ned) and uri ne out put .
Further management
The s ubs equent management of t he pat i ent i s ai med at ens uri ng adequat e vent i l at i on/gas exchange, ens uri ng haemodynami c s t abi l i t y, and correct i ng any revers i bl e preci pi t i ns of acut e pul monary oedema. Assess the patient' s respiratory function Does t he pat i ent requi re res pi rat ory s upport ? Assess the patient' s haemodynamic status Is t he pat i ent i n s hock? Look for an underlying cause Conditions that require specific treatment Acut e aort i c and mi t ral regurgi t at i on Di as t ol i c l eft vent ri cul ar dys funct i on Fl ui d overl oad Renal fai l ure Severe anaemi a Hypoprot ei naemi a pp138141 P118 P118 P118 P118 P118. P258 P118 P902
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Pulmonary oedema:
management 2
If t he pat i ent remai ns uns t abl e and/or det eri orat es t ake t he fol l owi ng s t eps .
Assess the patient's respiratory function
W heeze may be caus ed by i nt ers t i t i al pul monary oedema. If t here i s a hi s t ory of as t hma, gi ve nebul i zed s al but amol (2.55mg), nebul i zed i prat ropi um bromi de (500g), and hydrocort i s one (200mg) i v. Cons i der commenci ng ami nophyl l i ne i nfus i on. Thi s wi l l rel i eve bronchos pas m, as wel l as off-l oad by s ys t emi c vas odi l at at i on (P213). However, i t may wors en t achycardi a and i t can be arrhyt hmogeni c and l ower K (s uppl ement t o ens ure K 45mmol /L).
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I ndi c at i ons for furt her res pi rat ory s upport i nc l ude
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Pat i ent exhaus t i on or cont i nui ng s evere breat hl es s nes s Pers i s t ent P a O 2 <8kPa Ri s i ng P a CO 2 Pers i s t ent or wors eni ng aci dos i s (pH <7.2).
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CPAP : Thi s may be t ri ed for co-operat i ve pat i ent s , who can prot ect t hei r ai rway, have adequat e res pi rat ory mus cl e s t rengt h, and are not hypot ens i ve. The pos i t i ve pres s ure reduces venous ret urn t o t he heart and may compromi s e BP. Endot rac heal i nt ubat i on and mec hani c al vent i l at i on may be requi red and s ome pos i t i ve end expi rat ory pres s ure (PEEP) s houl d be us ed (P902).
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Di s cus s t he pat i ent wi t h t he on-cal l anaes t het i s t or ITU t eam earl y.
Assess the patient's haemodynamic status

It i s i mport ant t o di s t i ngui s h bet ween cardi ogeni c and non-cardi ogeni c pul monary oedema, as furt her t reat ment i s di fferent bet ween t he t wo groups . Thi s may be di ffi cul t cl i ni cal l y. A PA (SwanGanz) cat het er mus t be i ns ert ed i f t he pat i ent 's condi t i on wi l l al l ow.
Non-c ardi ogeni c pul monary oedema occurs when t he hydros t at i c pres s ure wi t hi n t he capi l l ary s ys t em overcomes t he pl as ma oncot i c pres s ure. In pat i ent s wi t h hypoal bumi naemi a t hi s wi l l occur at PCW P l es s t han 15mmHg. The cri t i cal PCW P may be es t i mat ed by s erum al bumi n (g/L) 0.57. Thus a pat i ent wi t h a s erum al bumi n of 15g/L wi l l devel op hydros t at i c pul monary oedema at a LA pres s ure of 8mmHg; a s erum al bumi n of 30g/L wi l l requi re an LA pres s ure of >17mmHg, et c. Cardi ogeni c pul monary oedema i s oft en as s oci at ed wi t h s i gni fi cant s ys t emi c hypot ens i on or l ow out put s t at es . Cont ri but i ng fact ors i ncl ude condi t i ons where t here i s mechani cal i mpai rment t o forward fl ow [e.g. val vul ar heart di s eas e (es peci al l y i f acut e), VSD] or s evere myocardi al di s eas e (l arge MI, myocardi t i s , cardi omyopat hy). The gradi ent bet ween PA di as t ol i c pres s ure and PCW P (PADPCW P) i s general l y <5mmHg i n cardi ogeni c and >5mmHg i n non-cardi ogeni c pul monary oedema (e.g. ARDS). The pul s e and BP are mos t commonl y el evat ed due t o ci rcul at i ng cat echol ami nes and over act i vi t y of t he reni nangi ot ens i n s ys t em. Exami nat i on reveal s s weat i ng, cool s hut -down peri pheri es , hi gh pul s e vol ume (as s es s carot i d or femoral pul s es ).
P.115
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Management
The general approach i nvol ves combi nat i on of di uret i cs , vas odi l at ors i not ropes . Pat i ent s may be di vi ded i nt o t wo groups :
Pat i ent s i n s hock (wi t h s ys t ol i c BP <100mmHg) (s ee P116) Haemodynami cal l y s t abl e pat i ent s wi t h s ys t ol i c BP >100mmHg (s ee P117).
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Pulmonary oedema:
management 3
Patients with systolic BP <100mmHg
The pat i ent i s i n i nci pi ent (or overt ) s hock. The mos t common aet i ol ogy i s cardi ogeni c s hock but remember non-cardi ogeni c caus es (e.g. ARDS, s ept i c s hock, P258). Opt i mal moni t ori ng and ac c es s : cent ral l i ne PA cat het er (SwanGanz ), uri nary cat het er, art eri al l i ne (moni t ori ng BP and ABGs ). Int ernal jugul ar l i nes are preferabl e as t he ri s k of pneumot horax i s l ower. Ens ure pat i ent i s not under fi l l ed us i ng PCW P as a gui de (<10mmHg) (mi s t aken di agnos i s , e.g. s ept i c s hock from bi l at eral pneumoni a). I s t here a mec hani c al c aus e t hat may requi re emergenc y s urgery?
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Arrange an urgent Echo t o rul e out
VSD and acut e MR i n al l pat i ent s wi t h recent MI wi t h/wi t hout new murmur (P32) Pros t het i c heart val ve dys funct i on (e.g. dehi s cence, i nfect i on) or pre-exi s t i ng nat i ve aort i c or mi t ral di s eas e t hat may requi re s urgery.
Di s cus s pat i ent earl y on wi t h cardi ol ogi s t /cardi ac s urgeon.
The c hoi c e of i not ropi c agent depends on t he cl i ni cal condi t i on of t he pat i ent and t o s ome ext ent , t he underl yi ng di agnos i s .
Treat ment of s ept i c s hock i s di s cus s ed el s ewhere (P270).
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Sys t ol i c BP 80100mmHg and cool peri pheri es : s t art dobut ami ne i nfus i on at 5g/kg/mi n, i ncreas i ng by 2.5g/kg/mi n every 1015 mi nut es t o a maxi mum of 20g/kg/mi n unt i l BP >100mmHg. Thi s may be combi ned wi t h dopami ne (2.55g/kg/mi n). However, t achycardi a and/or hyopt ens i on s econdary t o peri pheral vas odi l at i on may l i mi t i t s effect i venes s . Phos phodi es t eras e i nhi bi t ors (enoxi mone or mi l ri none) s houl d be cons i dered where dobut ami ne fai l s . Sys t ol i c BP <80mmHg : gi ve a s l ow i v bol us of epi nephri ne (25ml of 1 i n 1000 s ol ut i on Mi n-I-Jet ) and repeat i f neces s ary.
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Dopami ne at dos es of >2.5g/kg/mi n has a pres s or act i on i n addi t i on t o di rect and i ndi rect i not ropi c effect s and may be us ed at hi gher dos es (1020g/kg/mi n) i f t he bl ood pres s ure remai ns l ow. However i t t ends t o rai s e t he pul monary capi l l ary fi l l i ng pres s ure furt her and s houl d be combi ned wi t h vas odi l at ors (e.g. ni t roprus s i de or hydral azi ne) once t he bl ood pres s ure i s res t ored (s ee bel ow). Beware of arrhyt hmi as at t hes e dos es . Epi nephri ne i nfus i on may be preferred t o hi gh-dos e dopami ne as an al t ernat i ve i not rope. Once t he bl ood pres s ure i s res t ored (>100mmHg), vas odi l at ors s uch as ni t roprus s i de/hydral azi ne or GTN i nfus i on s houl d be added t o count eract t he pres s or effect s . Epi nephri ne can be combi ned wi t h dobut ami ne and/or a phos phodi es t eras e i nhi bi t or, es peci al l y i n t he cont ext of a poor vent ri cl e.
I nt ra-aort i c bal l oon c ount er pul s at i on s houl d al s o be us ed wi t h/wi t hout i not ropes i n t he cont ext of a pot ent i al l y revers i bl e caus e for t he pul monary oedema and s hock (e.g. on-goi ng myocardi al i s chaemi a, VSD, acut e MR) (s ee P34). Furt her dos es of di uret i c may be gi ven.
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P.117
Patients with systolic BP 100mmHg
Furt her dos es of di uret i c may be gi ven [frus emi de 4080mg i v q34h or as a cont i nuous i nfus i on (2080mg/h)]. Cont i nue t he GTN i nfus i on, i ncreas i ng t he i nfus i on rat e every 1520 mi nut es up t o 10mg/h, t i t rat i ng agai ns t bl ood pres s ure (ai mi ng t o keep s ys t ol i c BP ~100mmHg). ACE i nhi bi t ors can be us ed i f BP i s adequat e and t here are no ot her known cont rai ndi cat i ons (e.g. RAS, renal fai l ure). Art eri ol ar vas odi l at ors (ni t roprus s i de or hydral azi ne) may al s o be added i n or us ed i ns t ead of GTN (ACE i nhi bi t or) i n pat i ent s wi t h adequat e BP. Art eri al pres s ure s houl d be moni t ored cont i nuous l y vi a an art eri al l i ne t o prevent i nadvert ent hypot ens i on.
Unl es s a cont rai ndi cat i on exi s t s , s t art an ACE i nhi bi t or, i ncreas i ng t he dos e t o as near t he recommended maxi mal dos e as pos s i bl e. In t he cont ext of LV i mpai rment , ACE i nhi bi t ors have s i gni fi cant prognos t i c benefi t . If ACE i nhi bi t ors are cont rai ndi cat ed or not t ol erat ed, cons i der t he us e of hydral azi ne and l ong-act i ng oral ni t rat e i n combi nat i on. If t he pat i ent i s al ready on hi gh dos es of di uret i cs and ACE i nhi bi t ors cons i der t he addi t i on of s pi ronol act one (2550mg) (NB: moni t or renal funct i on and s erum pot as s i um). In t he cont ext of s t abl e pat i ent s (no cl i ni cal feat ures of fai l ure) and poor LV funct i on -bl ockers have s i gni fi cant mort al i t y and s ome s ympt omat i c benefi t (NB: s t art at a very s mal l dos e and i ncreas e gradual l y every 2 weeks wi t h regul ar moni t ori ng). Bi s oprol ol ,
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carvedi l ol , and met oprol ol can al l be us ed.

Ens ure al l arrhyt hmi as are t reat ed (s ee P64). Di goxi n can be us ed for s ympt omat i c i mprovement . Cons i der mul t i -s i t e paci ng (bi vent ri cul ar) i n t he cont ext of s evere LV dys funct i on, broad QRS compl ex MR on Echo. Pat i ent s wi t h AF or poor LV funct i on s houl d be cons i dered for l ong-t erm ant i -coagul at i on. Pat i ent s <60 years wi t h s evere i rrevers i bl e LV dys funct i on and debi l i t at i ng s ympt oms mus t be cons i dered for cardi ac t rans pl ant at i on.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pulmonary oedema: spec ific c ondit ions
Pulmonary oedema: specific
conditions
Diastolic LV dysfunction
Thi s t ypi cal l y occurs i n el derl y hypert ens i ve pat i ent s wi t h LV hypert rophy, where t here i s i mpai red rel axat i on of t he vent ri cl e i n di as t ol e. There i s marked hypert ens i on, pul monary oedema, and normal or onl y mi l d s ys t ol i c LV i mpai rment . W i t h t achycardi a, di as t ol i c fi l l i ng t i me s hort ens . As t he vent ri cl e i s s t i ff i n di as t ol e, LA pres s ure i s i ncreas ed and pul monary oedema occurs (exacerbat ed by AF as fi l l i ng by at ri al s ys t ol e i s l os t ). Treat ment i nvol ves cont rol of hypert ens i on wi t h i v ni t rat es (and/or ni t roprus s i de), cal ci um bl ockers (verapami l or ni fedi pi ne), and even s el ect i ve -bl ockers (e.g. carvedi l ol ).
Fluid overload

St andard meas ures are us ual l y effect i ve. In ext reme ci rcums t ances venes ect i on may be neces s ary. Check t he pat i ent i s not anaemi c (Hb 10g/dl ). Remove 500ml bl ood vi a a cannul a i n a l arge vei n and repeat i f neces s ary. If anaemi c (e.g. renal fai l ure) and acut el y unwel l , cons i der di al ys i s (P378).
Known (or unknown) renal failure
Unl es s t he pat i ent i s permanent l y anuri c, l arge dos es
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of i v frus emi de may be requi red (up t o 1g gi ven at 4mg/mi n) i n addi t i on t o s t andard t reat ment .
If s uch t reat ment fai l s , or t he pat i ent i s known t o be anuri c, di al ys i s wi l l be requi red. In pat i ent s not known t o have renal fai l ure, an underl yi ng caus e s houl d be s ought (P378).
Anaemia
Cardi ac fai l ure may be wors ened or preci pi t at ed by t he pres ence of s i gni fi cant anaemi a. Sympt oms may be i mproved i n t he l ong t erm by correct i ng t hi s anaemi a. General l y t rans fus i on i s unneces s ary wi t h Hb >9g/dl unl es s t here i s a ri s k of an acut e bl eed. Treat ment of pul monary oedema wi l l res ul t i n haemoconcent rat i on and a ri s e i n t he Hb. If t he anaemi a i s t hought t o be exacerbat i ng pul monary oedema, ens ure t hat an adequat e di ures i s i s obt ai ned pri or t o t rans fus i on. Gi ve s l ow t rans fus i on (34 hours per uni t ) of packed cel l s , wi t h i v frus emi de 2040mg before each uni t .
Hypoproteinaemia
The cri t i cal LA pres s ure at whi ch hydros t at i c pul monary oedema occurs i s i nfl uenced by t he s erum al bumi n and approxi mat es t o [s erum al bumi n concent rat i on (g/L) 0.57] (s ee P282). Treat ment i nvol ves di uret i cs , caut i ous al bumi n repl acement , s pi ronol act one (i f t here i s s econdary hyperal dos t eroni s m), and t reat ment of t he underl yi ng caus e for hypoprot ei naemi a.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Infec t ive endoc ardit is (
Infective endocarditis (IE)

Cl i ni cal pres ent at i on of IE i s hi ghl y vari abl e and dependent on a combi nat i on of i nt ra-cardi ac pat hol ogy, evol ut i on of t he i nfect i on, and pos s i bl e ext ra cardi ac i nvol vement . Pres ent at i on can be i ns i di ous as i n s t rept ococcal i nfect i ons wi t h s t ri ki ng cons t i t ut i onal s ympt oms , s uch as S. aureus . Pres ent i ng feat ures can i ncl ude t he fol l owi ng.
Symptoms and signs of the infection. Thes e i ncl ude mal ai s e, anorexi a, wei ght l os s , fever, ri gors , and ni ght s weat s . Long-s t andi ng i nfect i on produces anaemi a, cl ubbi ng, and s pl enomegal y Cardiac manifestations of the infection. Conges t i ve cardi ac fai l ure, pal pi t at i ons , t achycardi a, new murmur, peri cardi t i s , or AV bl ock. Symptoms and signs due to immune complex deposition
Ski n
Pet echi ae (mos t common), s pl i nt er haemorrhages Os l er's nodes [s mal l t ender nodul es (pul p i nfarct s ) on hands and feet , whi ch pers i s t for hours t o days ] Janeway l es i ons (non-t ender eryht hemat ous and/or haemorrhagi c areas on t he pal ms and s ol es ) Rot h s pot s (oval ret i nal haemorrhages wi t h a pal e cent re l ocat ed near t he opt i c di s c), conjunct i val s pl i nt er haemorrhages , ret i nal fl ame haemorrhages Mi cros copi c haemat uri a, gl omerul onephri t i s , and renal
Eye
Renal
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i mpai rement Cerebral Toxi c encephal opat hy Mus cul os kel et al Art hral gi a or art hri t i s
Complications of the infection Local effects

o
Val ve des t ruct i on res ul t s i n a new or changi ng murmur. Thi s may res ul t i n progres s i ve heart fai l ure and pul monary oedema. A new hars h pans ys t ol i c murmur and acut e det eri orat i on may be due t o perforat i on of t he i nt ervent ri cul ar s ept um or rupt ure of a s i nus of Val s al va aneurys m i nt o t he ri ght vent ri cl e. Hi gh degree AV bl ock (24% of IE) occurs wi t h i nt ra-cardi ac ext ens i on of i nfect i on i nt o t he i nt ervent ri cul ar s ept um (e.g. from aort i c val ve endocardi t i s ). Int ra-cardi ac abs ces s may be s een wi t h any val ve i nfect i on (2550% of aort i c endocardi t i s , 15% of mi t ral but rarel y wi t h t ri cus pi d) and i s mos t common i n pros t het i c val ve endocardi t i s .
Embolic events
o
Sept i c embol i are s een i n 2045% of pat i ent s and may i nvol ve any ci rcul at i on [(brai n, l i mbs , coronary, ki dney, or s pl een; pul monary embol i wi t h t ri cus pi d endocardi t i s . 4045% of pat i ent s who have had an embol i c
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event wi l l have anot her.

o
The ri s k depends on t he organi s m (mos t common wi t h G - ve i nfect i ons , S. aureus or c andi da ) and t he pres ence and s i ze of veget at i ons (embol i i n 30% of pat i ent s wi t h no veget at i on on Echo, 40% wi t h veget at i ons <5mm, and 65% wi t h veget at i ons >5mm).
P.121
As k s peci fi cal l y for a hi s t ory of dent al work, i nfect i ons , s urgery, i v drug us e, or i ns t rument at i on, whi ch may have l ed t o a bact eraemi a. Exami ne for any pot ent i al s ources of i nfect i on, es peci al l y t eet h or s ki n l es i ons . Ri s k fact ors for endocardi t i s are s hown i n t he t abl e bel ow.
Risk factors for infective endocarditis

High risk Pros t het i c val ves Previ ous bact eri al endocardi t i s Aort i c val ve di s eas e Mi t ral regurgi t at i on or mi xed mi t ral di s eas e Cyanot i c congeni t al heart di s eas e Pat ent duct us art eri os i s Uncorrect ed L R s hunt Int ra-cardi ac and s ys t emi cpul monary s hunt s Moderate risk MVP wi t h regurgi t at i on or val ve t hi ckeni ng Is ol at ed mi t ral s t enos i s Tri cus pi d val ve di s eas e Pul monary s t enos i s Hypert rophi c cardi omyopat hy Bi cus pi d aort i c val ve di s eas e Degenerat i ve val ve di s eas e i n t he el derl y Mural t hrombus (e.g. pos t i nfarct i on) Low risk MVP wi t hout regurgi t at i on Tri cus pi d regurgi t at i on wi t hout s t ruct ural val ve abnormal i t y Is ol at ed ASD Surgi cal l y correct ed L R s hunt wi t h no res i dual s hunt Cal ci fi cat i on of MV annul us Is chaemi c heart di s eas e and/or previ ous CABG Permanent pacemaker
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At ri al myxoma
Other predisposing factors

Art eri al pros t hes es or art eri ovenous fi s t ul ae Recurrent bact eraemi a (e.g. i v drug us ers , s evere peri odont al di s eas e, col on carci noma) Condi t i ons predi s pos i ng t o i nfect i ons (e.g. di abet es , renal fai l ure, al cohol i s m, i mmunos uppres s i on) Recent cent ral l i ne
In many cases no obvious risk factor is identified
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Infec t ive endoc ardit is: diagnosis
Infective endocarditis:
diagnosis
Cl i ni cal feat ures can be non-s peci fi c and di agnos i s di ffi cul t . A hi gh i ndex of s us pi ci on mus t be mai nt ai ned i f pat i ent s pres ent wi t h unexpl ai ned fever, a predi s pos i ng cardi ac l es i on, bact eraemi a, and embol i c phenomenon. The Duke cl as s i fi cat i on has been devi s ed t o hel p di agnos i s : Definite endocarditis Possible endocarditis 2 major cri t eri a, or 1 major and 3 mi nor cri t eri a, or 5 mi nor cri t eri a. Fi ndi ngs whi ch fal l s hort of defi ni t e endocardi t i s but are not reject ed. res ol ut i on of cl i ni cal feat ures wi t h <4 days of ant i bi ot i c t herapy.
Rejected diagnosis Fi rm al t ernat i ve di agnos i s , or s us t ai ned
Major criteria
Positive blood culture Typi cal mi croorgani s m for IE from t wo s eparat e bl ood cul t ures Pers i s t ent l y pos i t i ve bl ood cul t ure.
2 1
Evidence of endocardial involvement Pos i t i ve echocardi ogram

o o
Os ci l l at i ng i nt ra-cardi ac mas s (veget at i on) Abs ces s
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New part i al dehi s cence of pros t het i c val ve New val ve regurgi t at i on.
Minor criteria

Predi s pos i ng condi t i on or drug us e Fever >38C Vas cul ar phenomena: art eri al embol i , s ept i c pul monary i nfarct s , mycot i c aneurys m, i nt racrani al and conjunct i val haemhorrhage, Janeway l es i ons Immunol ogi c phenomena: gl omerul onephri t i s , Os l er's nodes , Rot h s pot s , rheumat oi d fact or Mi crobi ol ogi cal evi dence: pos i t i ve bl ood cul t ures but not meet i ng major cri t eri a or s erol ogi cal evi dence of organi s m cons i s t ent wi t h IE Echo: pos i t i ve for IE but not meet i ng major cri t eri a.
Common organisms in IE
5060% 10% 25% St rept ococci (es peci al l y St rep. vi ri dans group) Ent erococci St aphyl ococci S. aureus = coagul as e +ve S. epi dermi di s = coagul as e -ve 510% <1% <1% <1% <1% Cul t ure negat i ve Gram negat i ve baci l l i Mul t i pl e organi s ms Di pt heroi ds Fungi
Footnote
1
St rep. vi ri dans , St rep. bovi s , HACEK group, communi t y-acqui red Bl ood cul t ures drawn 12 hours apart or 3 more cul t ures wi t h fi rs t
St aph. aureus or ent eroc oc c i i n t he abs ence of pri mary focus .

2
and l as t drawn 1 hour apart .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Infec t ive endoc ardit is: invest igat ions
investigations
Bl ood cul t ures Take 34 s et s of cul t ures from di fferent s i t es at l eas t an hour apart and i nocul at e a mi ni mum of 10ml /bot t l e for t he opt i mal pi ck-up rat e. Bot h aerobi c and anaerobi c bot t l es mus t be us ed. Lab s houl d be advi s ed t hat IE i s a pos s i bi l i t y es peci al l y i f unus ual organi s ms are s us pect ed. In s t abl e pat i ent s on ant i bi ot i c t herapy dos es mus t be del ayed t o al l ow cul t ure on s ucces s i ve days . As k for prol onged (fungal ) cul t ures i n i v drug FBC us ers . May s how normochromi c, normocyt i c anaemi a (excl ude haemat i ni c defi ci ency), neut rophi l U&Es LFTs l eukocyt os i s , and perhaps t hrombocyt openi a. May be deranged (t hi s s houl d be moni t ored t hroughout t reat ment ). May be deranged, es peci al l y wi t h an i ncreas e i n
ALP and -GT. ESR/CRP Acut e phas e react i on. Uri nal ys i s Mi cros copi c haemat uri a prot ei nuri a. Immunol ogy Pol ycl onal el evat i on i n s erum Igs , compl ement ECG l evel s . May have changes as s oci at ed wi t h any underl yi ng caus e. There may be AV bl ock or conduct i on defect s (es peci al l y aort i c root abs ces s ) and rarel y CXR (embol i c) acut e MI. May be normal . Look for pul monary oedema or mul t i pl e i nfect ed or i nfarct ed areas from s ept i c embol i (t ri cus pi d endocardi t i s ).
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Echo
Trans t horaci c Echo may confi rm t he pres ence of val ve l es i ons and/or demons t rat e veget at i ons i f >2mm i n s i ze. TOE i s more s ens i t i ve for aort i c root and mi t ral l eafl et i nvol vement . A normal Echo does not excl ude t he di agnos i s . Us eful i n i nves t i gat i on of paraval vul ar ext ens i on, aort i c root aneurys m, and fi s t ul as . Al l pat i ent s s houl d have an OPG (ort hopent amograma panorami c dent al X-ray) and a dent al opi ni on. Any pot ent i al s i t es of i nfect i on (s ki n l es i ons ). In cas es where ri ght -s i ded endocardi t i s i s s us pect ed t hi s may s how mul t i pl e mi s mat ched
MRI Dent i t i on
Swabs V/Q s can
defect s . Save s erum As pergi l l us preci pi t i ns Candi da ant i bodi es (ri s e i n for t i t re) Q fever ( Coxi el l a burnet t i ) compl ement fi xat i on t es t Chl amydi a compl ement fi xat i on t es t Bruc el l a aggl ut i ni ns Legi onel l a ant i bodi es Bart onel l a s p.
Page 255
> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Infec t ive endoc ardit is: ant ibiot ic s
antibiotics
Blind treatment for endocarditis
Infect i ve endocardi t i s i s us ual l y a cl i ni cal di agnos i s and mus t be cons i dered i n any pat i ent wi t h a t ypi cal hi s t ory, fever, and a murmur wi t h no ot her expl anat i on. Oft en ant i bi ot i cs need t o be s t art ed before t he cul t ure res ul t s are avai l abl e. Be gui ded by t he cl i ni cal s et t i ng (s ee t abl e ). Presentation Choice of antibiotic Benzyl -peni ci l l i n + Gent ami ci n Fl ucl oxaci l l i n + Gent ami ci n t ei copl ani n) + Gent ami ci n + Ri fampi ci n Vancomyci n
1
Gradual ons et (weeks ) Acut e ons et (days ) or hi s t ory of s ki n t rauma di pt heroi d, Kel bs i el l a , corynebact eri um or nos ocomi al s t aphyl ococci ) i v drug us er
Recent val ve pros t hes i s (pos s i bl e MRSA, Vancomyci n (or
Suggested antibiotic doses

Benz yl peneci l l i n Fl ucl oxaci l l i n Vancomyci n Gent ami ci n 4MU (2.4g) q4h i v 2g qds i v 15mg/kg q12h i v over 60 mi nut es , gui ded by l evel s 3mg/kg di vi ded i n 13 dos es gui ded by
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Ri fampi ci n Ci profl oxaci n
l evel s 300mg q12h po 300mg q12h i v for 1 week, t hen 750mg q12h po for 3 weeks
Ident i fi cat i on of an organi s m i s i nval uabl e for furt her management and bl ood cul t ures s houl d be t aken before ant i bi ot i cs wi t h met i cul ous at t ent i on t o det ai l . Ant i bi ot i cs s houl d be admi ni s t ered i v, preferabl y vi a a t unnel l ed cent ral (Hi ckman) l i ne. If an organi s m i s i s ol at ed, ant i bi ot i c t herapy may be modi fi ed when s ens i t i vi t i es are known. Sugges t ed ant i bi ot i c combi nat i ons are s hown i n t he t abl e above; however i ndi vi dual uni t s may have s peci fi c pol i ci es . Pat i ent s s houl d be di s cus s ed wi t h your l ocal mi crobi ol ogi s t .
Footnote
1
Oakl ey CM (1995) Eur Heart J 16 ( s uppl . B ): 9093. P.127
Duration of treatment
Thi s i s cont rovers i al wi t h a t rend t oward s hort er cours es . Mi crobi ol ogy and ID opi ni on i s i mport ant es peci al l y i n res i s t ant and/or uncommon organi s ms . The box bel ow s hows one s ugges t ed prot ocol . The durat i on of t reat ment vari es dependi ng on t he
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s everi t y of i nfect i on and t he i nfect i ng organi s m. i v t herapy i s us ual l y for at l eas t 2 weeks and t ot al ant i bi ot i c t herapy i s for 46 weeks .
If t he pat i ent i s wel l fol l owi ng t hi s peri od, ant i bi ot i c t reat ment may be s t opped. Provi ded no s urgery i s i ndi cat ed (P134), pat i ent may be di s charged and fol l owed up i n out -pat i ent cl i ni c. Pat i ent s s houl d be advi s ed of t he need for endocardit i s prophyl axi s i n t he fut ure (s ee t abl e, P136). Pat i ent s wi t h val vul ar damage fol l owi ng i nfect i on s houl d be fol l owed l ong t erm and pat i ent s wi t h vent ri cul ar s ept al defect s s houl d be cons i dered for cl os ure. Vi ri dans s t rept ococci and St rept oc oc c us bovi s (peni ci l l i n s ens i t i ve)
o o o o
Benzyl peni ci l l i n onl y (4 weeks ) Vancomyci n or t ei copl ani n (4 weeks ) Peni ci l l i n + ami nogl ycos i de (2 weeks ) Ceft ri axone 2g (4 weeks )
Group B, C, G s t rept ococci , St rep. pyogenes , St rep. Pneumoni ae

o o
Peni ci l l i n (4 weeks ) + ami nogl ycos i de (2 weeks ) Vancomyci n (4 weeks ) + ami nogl ycos i de (2 weeks ) Peni ci l l i n (4 weeks ) Vancomyci n (4 weeks ) Peni ci l l i n + ami nogl ycos i de (46 weeks ) Vancomyci n + ami nogl ycos i de (46weeks ) Peni ci l l i n (4 weeks ) + ami nogl ycos i de (2 weeks ) Vancomyci n (4 weeks ) + ami nogl ycos i de (2 weeks )
Group A s t rept ococci

o o
Ent erococci
o o
Ext ra-cardi ac i nfect i on from s ept i c embol i

o o
St aphyl oc oc c us aureus and coagul as e negat i ve s t aphyl ococci

o
Left -s i ded endocardi t i s
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Fl ucl oxaci l l i n (46 weeks ) + ami nogl ycos i de (2 weeks ) If MRSA: Vancomyci n + ri fampi ci n (6 weeks ) ami nogl ycos i de (2 weeks ) Ri ght -s i ded endocardi t i s Fl ucl oxaci l l i n (2 weeks ) + ami nogl ycos i de (2 weeks ) Ci profl oxaci n (4 weeks ) + ri fampi ci n (3 weeks ) If MRSA: Vancomyci n (4 weeks ) + ri fampi ci n (4 weeks )
o o
o o
Fungi
o
Amphot eri ci n B i v t o a t ot al dos e of 2.53g
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Infec t ive endoc ardit is: monit oring t reat ment
monitoring treatment
Pat i ent s need careful cl i ni cal moni t ori ng bot h duri ng and for s everal mont hs aft er t he i nfect i on. Re-appearance of feat ures s ugges t i ve of IE mus t be i nves t i gat ed t horoughl y t o rul e out recurrent i nfect i on or res i s t ance t o t reat ment regi me.
Clinical features
Si gns of cont i nued i nfect i on, pers i s t ent pyrexi a, and t he pers i s t ence of s ys t emi c s ympt oms . Pers i s t ent fever may be due t o drug res i s t ance, concomi t ant i nfect i on (cent ral l i ne, uri ne, ches t , s ept i c embol i t o l ungs or abdomen) or al l ergy (?eos i nophi l i a, ?l eukopeni a, ?prot ei nuri a: common wi t h peni ci l l i n but may be due t o any ant i bi ot i c; cons i der changi ng or s t oppi ng ant i bi ot i cs for 23 days ). Changes i n any cardi ac murmurs or s i gns of cardi ac fai l ure. The devel opment of any new embol i c phenomena. Ins pect venous acces s s i t es dai l y. Change peri pheral cannul ae every 34 days .
Echo
Regul ar (weekl y) t rans t horaci c echocardi ograms may i dent i fy cl i ni cal l y s i l ent , but progres s i ve val ve des t ruct i on and devel opment of i nt ra-cardi ac abs ces s es or veget at i ons . The t i ps of l ong-s t andi ng cent ral l i nes may devel op s t eri l e fi bri nous fronds , whi ch may be vi s i bl e on TOE: change t he l i ne and s end t he t i p for cul t ure.
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Veget at i ons need not be due t o i nfect i on (s ee t abl e on P131).
ECG
Looki ng s peci fi cal l y for AV bl ock or conduct i on abnormal i t i es s ugges t i ng i nt ra-cardi ac ext ens i on of t he i nfect i on. A dai l y ECG mus t be performed.
Microbiology
Repeat ed bl ood cul t ures (es peci al l y i f t here i s cont i nued fever). Regul ar ami nogl ycos i de and vancomyci n l evel s (ens uri ng t he abs ence of t oxi c l evel s and t he pres ence of t herapeut i c l evel s ). Gent ami ci n ot ot oxi ci t y may devel op wi t h prol onged us e even i n t he abs ence of t oxi c l evel s . Back t i t rat i on t o ens ure t hat mi ni mum i nhi bi t ory and bact eri ci dal concent rat i ons are bei ng achi eved.
Laboratory indices

Regul ar (dai l y) uri nal ys i s Regul ar U&Es and l i ver funct i on t es t s Regul ar CRP (ESR every 2 weeks ) FBC: ri s i ng Hb and fal l i ng W CC s ugges t s s ucces s ful t reat ment ; wat ch for -l act am as s oci at ed neut ropeni a. Serum magnes i um (i f on gent ami ci n).
P.129
Causes of culture-negative endocarditis 1

Previ ous ant i bi ot i c t herapy Fas t i di ous organi s m Nut ri t i onal l y defi ci ent vari ant s of St rep. vi ri dans Bruc el l a, Nei s s eri a, Legi onel l a Noc ardi a
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Mycobact eri a The HACEK group of oropharyngeal fl ora Cel l -wal l defi ci ent bact eri a and anaerobes
Cel l -dependent organi s ms Chl amydi a , ri cket t s i ae ( Coxi el l a )
Fungi
HACEK = Haemophi l us , Ac i nt obac i l l us , Cardi obac t eri um, Ei kenel l a , and Ki ngel l a s p.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Cult ure- negat ive endoc ardit is
Culture-negative endocarditis
The commones t reas on for pers i s t ent l y negat i ve bl ood cul t ures i s pri or ant i bi ot i c t herapy and t hi s effect s up t o 15% of pat i ent s wi t h a di agnos i s of IE. If t he cl i ni cal res pons e t o t he ant i bi ot i cs i s good t hes e s houl d be cont i nued. For a pers i s t i ng fever
o o
W i t hhol d ant i bi ot i cs i f not al ready s t art ed Cons i der ot her i nves t i gat i ons for a PUO (s ee P296) If cl i ni cal s us pi ci on of IE i s hi gh, i t warrant s furt her i nves t i gat i on Repeat ed phys i cal exami nat i on for any new s i gns Regul ar Echo and TOE. Veget at i ons need not be due t o i nfect i on (s ee t abl e) Repeat ed bl ood cul t ures , es peci al l y when t he t emperat ure i s rai s ed. Di s cus s wi t h mi crobi ol ogy about prol onged cul t uri ng t i mes (4+ weeks ) and s peci al cul t uri ng and s ub-cul t uri ng t echni ques . Mos t HACEK group organi s ms can be det ect ed.
o o
Cons i der unus ual caus es of endocardi t i s

o
Q-fever ( Coxi el l a burnet i i ). Compl ement fi xat i on t es t s i dent i fy ant i bodi es t o phas e 1 and 2 ant i gens . Phas e 2 ant i gens rai s ed i n t he acut e i l l nes s , phas e 1 ant i gens rai s ed i n chroni c i l l nes s es s uch as endocardi t i s . PCR can be performed on operat i ve s peci mens . Treat wi t h i ndefi ni t e (l i fe-l ong) oral doxycycl i ne co-t ri moxazol e, ri fampi ci n, or qui nol one. Chl amydi a ps i t t ac i . Commonl y t here i s a hi s t ory of
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expos ure t o bi rds and t here may be an as s oci at ed at ypi cal pneumoni a. Di agnos i s i s confi rmed us i ng compl ement fi xat i on t es t s t o det ect rai s ed ant i body t i t res .
o
Brucellosis. Bl ood cul t ures may be pos i t i ve t hough organi s ms may t ake up t o 8 weeks t o grow. Serol ogy us ual l y confi rms t he di agnos i s . Fungi. Candi da i s t he mos t common s peci es and may be cul t ured. The det ect i on of ant i bodi es may be hel pful t hough l evel s may be rai s ed i n normal s . The det ect i on of a ri s i ng t i t re i s of more us e. Ot her fungal i nfect i ons (e.g. hi s t opl as mos i s , as pergi l l os i s ) are rare but may be di agnos ed wi t h cul t ure or s erol ogy, t hough t hes e are commonl y negat i ve. Ant i gen as s ays may be pos i t i ve, or t he organi s m may be i s ol at ed from bi ops y mat eri al . Fungal IE i s more common i n pat i ent s wi t h pros t het i c val ves and i v drug us ers . Bul ky veget at i ons are common. Treat ment i s wi t h amphot eri ci n B fl ucyt os i ne. Pros t het i c val ves mus t be removed. Mort al i t y i s >50%.
P.131
Causes of vegetations on Echo 1

Infect i ve endocardi t i s St eri l e t hrombot i c veget at i ons

o o o
Li bman Sacks endocardi t i s (SLE) Pri mary ant i -phos phol i pi d s yndrome Marant i c endocardi t i s (adenocarci noma)
Myxomat ous degenerat i on of val ve (commonl y mi t ral ) Rupt ured mi t ral chordae Exuberant rheumat i c veget at i ons (bl ack Afri cans ) Thrombus (pannus ) on a pros t het i c val ve A s t i t ch or res i dual cal ci um aft er val ve repl acement
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Footnote
1
Mi chel PL & Acar J (1995) Eur Heart J 16 ( s uppl B ): 26.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Right - sided endoc ardit is
Right-sided endocarditis
Al ways cons i der t hi s di agnos i s i n i v drug us ers (or pat i ent s wi t h venous acces s ). Endocardi t i s on endocardi al permanent pacemaker l eads i s a rare but recogni zed caus e. Pat i ent s mos t commonl y have s t aphyl ococcal i nfect i on and are unwel l , requi ri ng i mmedi at e t reat ment and oft en earl y s urgery. Les i ons may be s t eri l i zed wi t h i v ant i bi ot i cs . Surgery may be requi red for
o
Res i s t ant organi s ms ( St aph. aureus , Ps eudomonas , Candi da , and i nfect i on wi t h mul t i pl e organi s ms ) Increas i ng veget at i on s i ze i n s pi t e of t herapy Infect i ons on pacemaker l eads (s urgi cal removal of l ead and repai r or exci s i on of t ri cus pi d val ve) Recurrent mycot i c embol i
o o
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Prost het ic valve endoc ardit is (
Prosthetic valve endocarditis
(PVE)
Convent i onal l y di vi ded i nt o earl y (<2 mont hs pos t operat i vel y) and l at e (>2 mont hs pos t operat i vel y). Early prosthetic valve endocarditis
o
Mos t commonl y due t o s t aphyl ococci , gram negat i ve baci l l i , di pt heroi ds , or fungi . General l y i nfect i on has begun ei t her per-operat i vel y or i n t he i mmedi at e pos t -operat i ve peri od. Oft en a hi ghl y des t ruct i ve, ful mi nant i nfect i on wi t h val ve dehi s cence, abs ces s format i on, and rapi d haemodynami c det eri orat i on. Di s cus s wi t h t he s urgeons earl y. They commonl y requi re re-operat i on. Mort al i t y i s hi gh (4575%).
Late prosthetic valve endocarditis

o
The pat hogenes i s i s di fferent . Abnormal fl ow around t he pros t het i c val ve ri ng produces mi crot hrombi and non-bact eri al t hrombot i c veget at i ons (NBTVs ), whi ch may be i nfect ed duri ng t rans i ent bact eraemi a. The s ource i s commonl y dent al or urol ogi cal s eps i s or i ndwel l i ng venous l i nes . Common organi s ms are coagul as e negat i ve s t aphyl ococci , St aph. aureus , St rep. vi ri dans , or ent erococci . Frequent l y needs s urgi cal i nt ervent i on and t hi s carri es a hi gh mort al i t y, but l es s t han for earl y PVE.
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It may be pos s i bl e t o s t eri l i ze i nfect i ons on bi opros t hes es wi t h i v ant i bi ot i cs onl y. Surgery (s ee P134) may t hen be deferred.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Surgery for infec t ive endoc ardit is
Surgery for infective
endocarditis
Di s c us s earl y w i t h t he regi onal c ardi ot horac i c c ent re: i mmedi at e i nt ervent i on may be appropri at e .
Surgi cal i nt ervent i on may be neces s ary ei t her duri ng act i ve i nfect i on or l at er becaus e of degree of val ve des t ruct i on. Opt i mal t i mi ng depends on a number of fact ors :
o o o
Haemodynami c t ol erance of l es i on Out come of t he i nfect i on Pres ence of compl i cat i ons .
Choi ce of ant i -mi crobi al t herapy s houl d be modi fi ed dependi ng on mi crobi ol ogi cal res ul t s from i nt raoperat i ve s peci mens . Sampl es s houl d be s ent for cul t ure, s t ai ni ng, i mmunol ogi cal t es t i ng, and PCR dependi ng on s us pect ed organi s m. Durat i on of ant i -mi crobi al t reat ment i s dependent on t he cl i ni cal pi ct ure:
o
Cul t ure-negat i ve operat i ve s peci mens : 23 weeks for val ve i nfect i on and 34 weeks for abs ces s . Cul t ure-pos i t i ve operat i ve s peci mens : 34 weeks for val ve i nfect i on and 46 weeks for abs ces s .
Ti mi ng i s di ct at ed by cl i ni cal pi ct ure. Indi cat i ons for urgent s urgery are l i s t ed bel ow. In pat i ent s wi t h neurol ogi cal i njury s urgery s houl d be del ayed t o avoi d i nt racrani al haemhorrage i f cardi ac funct i on permi t s (embol i c i nfarct : del ay 1014 days , haemorrhage:
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2128 days and when rupt ured mycot i c aneurys ms have been repai red).
Tabl e oppos i t e s ummari zes t he abs ol ut e and rel at i ve i ndi cat i ons for s urgery.
Haemodynamic tolerance of lesion
If t he pat i ent i s haemodynami cal l y s t abl e, s urgery may be del ayed unt i l aft er ant i bi ot i c cours e i s compl et ed. The fi nal management depends on t he val ve affect ed, t he degree of des t ruct i on, and i t s effect on vent ri cul ar funct i on. Severe aort i c and mi t ral regurgi t at i on us ual l y requi re s urgery; t ri cus pi d regurgi t at i on, i f wel l t ol erat ed, i s managed medi cal l y. Decompens at i on (s evere conges t i ve cardi ac fai l ure or l ow cardi ac out put s yndrome wi t h funct i onal renal fai l ure) may res pond t o s urgery but t he mort al i t y i s hi gh. Met as t abl e pat i ent s who have been s ucces s ful l y t reat ed aft er an epi s ode of acut e decompens at i on s houl d be cons i dered for earl y operat i on aft er 23 weeks ant i bi ot i c t herapy.
Outcome of the infection
Pers i s t ence or rel aps e of i nfect i on (cl i ni cal and l aborat ory i ndi ces ) des pi t e appropri at e ant i bi ot i cs at an adequat e dos e may ei t her be due t o a res i s t ant organi s m or an abs ces s (paraval vul ar, ext ra-cardi ac). Cons i der val ve repl acement i f no ext ra-cardi ac focus found. The organi s m may i nfl uence t he deci s i on: cons i der earl y s urgery for fungal endocardi t i s or pros t het i c endocardi t i s wi t h E. c ol i or St aph. aureus .
P.135
Presence of complications
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Urgent s urgery i ndi cat i ons compri s e

Hi gh degree AV bl ock Perforat i on of i nt ervent ri cul ar s ept um Rupt ure of s i nus of Val s al va aneurys m i nt o RV Int racardi ac abs ces s Recurrent s ept i c embol i Pros t het i c endocardi t i s es peci al l y as s oci at ed wi t h an uns t abl e pros t hes i s .
Indications for surgery in infective endocarditis

Absolute indications
Moderat e t o s evere heart fai l ure s econdary t o val ve regurgi t at i on Uns t abl e pros t hes i s Uncont rol l ed i nfect i on: pers i s t ent bact eraemi a, i neffect i ve ant i mi crobi al t herapy [IE s econdary t o fungi , Bruc el l a , Ps eudomonas aerogi nos a (es peci al l y aort i c and mi t ral val ve)] St aph. aureus pros t het i c i nfect i on wi t h an i nt racardi ac compl i cat i on
Relative indications

Peri val vul ar ext ens i on of i nfect i on Poor res pons e t o St aph. aureus nat i ve val ve i nfect i on Rel aps e aft er adequat e t reat ment Large (>10mm) hypermobi l e veget at i ons Pers i s t ent unexpl ai ned fever i n cul t ure-negat i ve endocardi t i s Endocardi t i s s econdary t o ant i bi ot i c-res i s t ant ent erococci
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Endoc ardit is prophylaxis
Endocarditis prophylaxis
prophylaxis
Dent al Upper res pi rat ory t ract Gas t roi nt es t i nal Al l procedures
Procedures that require antibiotic
Tons i l l ect omy, adenoi dect omy Oes ophageal di l at at i on or l as er t herapy Oes ophageal s urgery Scl eros i s of oes ophageal vari ci es ERCP Abdomi nal s urgery Bari um enema Si gmoi dos copy bi ops y
Urol ogi cal
Ins t rument at i on of uret er or ki dney Bi ops y or s urgery of pros t at e or bl adder
Procedures for which the risk of IE is controversial

Upper res pi rat ory t ract Gas t roi nt es t i nal Geni t al Bronchos copy Endot racheal i nt ubat i on Upper GI endos copy bi ops y Vagi nal hys t erect omy or del i very
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The t abl e on P121 s hows cardi ac condi t i ons at ri s k of IE. Hi gh and moderat e ri s k requi res prophyl axi s ; l ow ri s k does not . The regi men may be modi fi ed dependi ng on t he degree of ri s k (bot h pat i ent and procedure rel at ed) as i n t abl e bel ow.
Antibiotic prophylaxis Minimal regimen

1h before No peni ci l l i n al l ergy Al l ergy t o peni ci l l i n Amoxyci l l i n 3g po Cl i ndamyci n 300600mg po 6h after No 2nd dos e No 2nd dos e
Flexible modifications depending on the degree of risk

Addi t i onal dos es aft er procedure Addi t i onal ami nogl ycos i des Parent eral admi ni s t rat i on
Maximal regimen
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1h 6h bef aft or er e No Am 1 pe oxy 1.5 ni ci ci l l g llin in al l 2g erg i v y + Ge nt a mi c in 1.5 mg /kg i m/ iv Va No nco 2n my d ci n dos 1g e iv 1g ove i v r 1 at ho 12 ur h Al l + No erg Ge 2n y nt a d e t o mi c dos pe i n po
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ni ci 1.5 l l i n mg /kg i m/ iv
Footnote
1
Thi s i s one regi me [aft er Leport C et al . (1995) Eur Heart J 16 ( s uppl . B ): 126131]. Refer t o your l ocal pol i cy.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Ac ut e aort ic regurgit at ion
Acute aortic regurgitation
Presentation
Sudden, s evere aort i c regurgi t at i on pres ent s as cardi ogeni c s hock and acut e pul monary oedema. The haemodynami c changes are markedl y di fferent from t hos e s een i n chroni c AR. The previ ous normal -s i zed LV res ul t s i n a s mal l er effect i ve forward fl ow and hi gher LVEDP for t he s ame degree of aort i c regurgi t at i on. Pat i ent s are oft en ext remel y unwel l , t achycardi c, peri pheral l y s hut down, and oft en have pul monary oedema. Unl i ke chroni c AR, pul s e pres s ure may be near normal . If avai l abl e, as k for a hi s t ory of previ ous val vul ar heart di s eas e, hypert ens i on, feat ures of Marfan's s yndrome, and ri s k fact ors for i nfect i ve endocardi t i s (P121). Phys i cal s i gns of s evere AR i ncl ude a qui et aort i c cl os ure s ound (S2); an eject i on s ys t ol i c murmur over aort i c val ve (t urbul ent fl ow); hi gh-pi t ched and s hort earl y di as t ol i c murmur (AR); qui et S1 (premat ure cl os ure of t he mi t ral val ve). Exami ne s peci fi cal l y for s i gns of an underl yi ng caus e. W here t here i s no obvi ous underl yi ng caus e (e.g. acut e MI), as s ume i nfect i ve endocardi t i s unt i l proven ot herwi s e.
Causes

Infect i ve endocardi t i s As cendi ng aort i c di s s ect i on Col l agen vas cul ar di s orders (e.g. Marfan's ) Connect i ve t i s s ue di s eas es (l arge- and medi um-ves s el
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art eri t i s )

Trauma Dehi s cence of a pros t het i c val ve.
Diagnosis
Bas ed on a combi nat i on of cl i ni cal feat ures and t rans t horaci c and/or t rans oes ophageal Echo.
Management
Acut e AR i s a s urgi cal emergency and al l ot her management meas ures are onl y ai med at s t abal i zi ng pat i ent unt i l urgent AVR can t ake pl ace. Pat i ent 's cl i ni cal condi t i on wi l l det ermi ne t he urgency of s urgery (and mort al i t y). Li ai s e i mmedi at el y wi t h l ocal cardi ol ogi s t s .
General measures

Admi t t he pat i ent t o i nt ens i ve care or medi cal HDU. Gi ve oxygen, begi n t reat i ng any pul monary oedema wi t h di uret i cs . Moni t or bl ood gas es ; mechani cal vent i l at i on may be neces s ary. Bl ood cul t ures 3 are es s ent i al . Ot her i nves t i gat i ons as on P124. Seri al ECG: wat ch for devel opi ng AV bl ock or conduct i on defect s .
P.139
Specific measures
Every pat i ent mus t be di s cus s ed wi t h t he regi onal cardi ot horaci c cent re. In t he cont ext of good s ys t emi c BP, vas odi l at ors s uch as s odi um ni t roprus s i de or hydral azi ne may t emporari l y i mprove forward fl ow and rel i eve pul monary oedema. Inot ropi c s upport may be neces s ary i f hypot ens i ve. However, i not ropes are bes t avoi ded as any i ncreas e i n
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s ys t emi c pres s ures may wors en AR.
Al l pat i ent s wi t h haemodynami c compromi s e s houl d have i mmedi at e or urgent aort i c val ve repl acement . Infect i ve endocardi t i s : i ndi cat i ons for s urgery are gi ven on P134. IABP mus t be avoi ded as i t wi l l wors en AR.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Ac ut e mit ral regurgit at ion
Acute mitral regurgitation
Presentation
Pat i ent s mos t commonl y pres ent wi t h acut e breat hl es s nes s and s evere pul monary oedema. Sympt oms may be l es s s evere, or s pont aneous l y i mprove, as l eft at ri al compl i ance i ncreas es . There may be a hi s t ory of previ ous murmur, angi na, or myocardi al i nfarct i on. The s i gns are di fferent t o t hos e s een i n chroni c MR becaus e of t he pres ence of a non-di l at ed and rel at i vel y non-compl i ant LA. Acut e MR res ul t s i n a l arge LA s ys t ol i c pres s ure wave ( v -wave) and hence pul monary oedema. Pat i ent s may be acut el y unwel l wi t h t achycardi a, hypot ens i on, peri pheral vas ocons t ri ct i on, and pul monary oedema and a pan-s ys t ol i c murmur of MR. Lat er i n t he i l l nes s , probabl y becaus e of s us t ai ned hi gh l eft at ri al and pul monary venous pres s ures , ri ght heart fai l ure devel ops . Exami ne for s i gns of any underl yi ng condi t i ons (s ee t abl e). The i mport ant di fferent i al di agnos i s i s a VSD. Trans t horaci c Echo and Doppl er s t udi es can readi l y di fferent i at e bet ween t he t wo condi t i ons . Al t ernat i vel y, i f Echo i s not avai l abl e, pul monary art ery cat het eri zat i on i n acut e MR wi l l excl ude t he pres ence of a l eft t o ri ght s hunt and t he PCW P t race wi l l demons t rat e a l arge v -wave. W here t here i s no obvi ous underl yi ng caus e (e.g. acut e
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MI), as s ume t he pat i ent has i nfect i ve endocardi t i s unt i l proven ot herwi s e.
Diagnosis
Bas ed on a combi nat i on of cl i ni cal feat ures and Echo. Trans t horaci c Echo can readi l y di agnos e and quant i fy MR. It al s o provi des i nformat i on on LV s t at us (i n part i cul ar regi onal wal l -mot i on abnormal i t i es whi ch can gi ve ri s e t o MR). TOE can provi de s peci fi c i nformat i on about aet i ol ogy of val ve dys funct i on i ncl udi ng papi l l ary mus cl e rupt ure and MV l eafl et (ant eri or and pos t eri or) s t ruct ural abnormal i t i es . Thi s i nformat i on wi l l be vi t al for a deci s i on regardi ng defi ni t i ve management .
General measures

Admi t t he pat i ent t o i nt ens i ve care or medi cal HDU. Gi ve oxygen, begi n t reat i ng any pul monary oedema wi t h di uret i cs . Moni t or bl ood gas es ; mechani cal vent i l at i on may be neces s ary. Bl ood cul t ures 3 are es s ent i al . Ot her i nves t i gat i ons as on P124. If pres ent , MI s houl d be t reat ed i n t he s t andard manner.
Specific measures

Pul monary oedema may be very res i s t ant t o t reat ment . In t he pres ence of good BP, reduct i on i n prel oad [GTN i nfus i on] and aft erl oad es peci al l y wi t h ACE i nhi bi t ors i s i mport ant . Sys t emi c vas odi l at ors s uch as hydral azi ne (12.5100mg t ds ) can al s o be added i n. An IABP wi l l hel p decreas e LVEDP and al s o i ncreas e coronary bl ood fl ow. P.141
Pat i ent s may requi re i not ropi c s upport . There are mul t i pl e combi nat i ons and aet i ol ogy of MR,
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haemodynami c s t at us , and l ocal pol i cy/expert i s e s houl d di ct at e choi ce of agent .
CPAP and i nt ubat i on and pos i t i ve pres s ure vent i l at i on are ext remel y us eful and mus t be cons i dered i n al l s evere and/or res i s t ant cas es . Haemodynami c di s t urbance and s evere pul monary oedema i n t he cont ext of acut e MR i s a s urgi cal emergency. Infect i ve endocardi t i s . Indi cat i ons for s urgery are gi ven on P134. Pos t -i nfarct MR. Management depends upon t he pat i ent 's condi t i on fol l owi ng res us ci t at i on. Pat i ent s who are s t abi l i zed may have MVR deferred becaus e of t he ri s ks of s urgery i n t he pos t -i nfarct pat i ent . Thei r pre-operat i ve management s houl d cons i s t of di uret i cs and vas odi l at ors , i ncl udi ng ACE i nhi bi t ors i f t ol erat ed. Advi s e pat i ent s regardi ng endocardi t i s prophyl axi s .
Causes of acute mitral regurgitation

Infect i ve endocardi t i s Papi l l ary mus cl e dys funct i on or rupt ure (pos t MI, P36) Rupt ure of chordae t endi nae (e.g. i nfect i on, myxomat ous degenerat i on, SLE) Trauma (t o l eafl et s , papi l l ary mus cl e or chordae) Pros t het i c val ve mal funct i on (e.g. s econdary t o i nfect i on) Left at ri al myxoma Acut e rheumat i c fever Col l agen vas cul ar di s orders (e.g. Marfan's ) Connect i ve t i s s ue di s eas es (l arge- and medi um-ves s el art eri t i s )
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Deep vein t hrombosis (
Deep vein thrombosis (DVT): assessment

Presentation
Mos t commonl y as ympt omat i c. Mi nor l eg di s comfort or i s ol at ed s wel l i ng (>65%) i n t he effect ed l i mb are t he mos t common cl i ni cal feat ures . Breat hl es s nes s or ches t pai n may be s econdary t o pul monary embol i s m. Si gns i ncl ude eryt hema and s wel l i ng of t he l eg, di l at ed s uperfi ci al vei ns , and cal f di s comfort on dors i fl exi on of t he foot (Homan's s i gn). The t hrombus may be pal pabl e as a fi brous cord i n t he popl i t eal fos s a. Confi rm t he pres ence of s wel l i ng (>2cm) by meas uri ng t he l i mb ci rcumference 15cm above and 10cm bel ow t he t i bi al t uberos i t y. In al l cas es of l eg s wel l i ng, abdomi nal and rect al (and pel vi c i n women) exami nat i on mus t be carri ed out t o excl ude an abdomi nal caus e.
Risk factors for DVT

Pro-coagulant states Congeni t al Fact or V Le i d e n Ant i t hrombi n III defi ci ency Prot ei n C defi ci ency Prot ei n S defi ci ency Ac qui red Mal i gnant di s eas e (~5%) Ant i phos phol i pi d s yndrome Myel oprol i ferat i ve di s orders Oral cont racept i ve pi l l (es peci al l y wi t h Fact or V Le i d e n mut at i on) Nephrot i c s yndrome (vi a renal AT III l os s es ) Homocys t i nuri a
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Venous stasis
Miscellaneous
Paroxys mal noct urnal haemogl obi nuri a Immobi l i t y (e.g. l ong journeys ) Recent s urgery Pel vi c mas s Pregnancy or recent chi l dbi rt h Severe obes i t y Hypervi s cos i t y s yndromes (P728) Previ ous DVT or PE Fami l y hi s t ory of DVT/PE
Investigations
Real t i me B-mode venous compres s i on ul t ras onography of l eg vei ns i s l argel y repl aci ng venography as t he i ni t i al i nves t i gat i on of choi ce. It i s qui ck, and non-i nvas i ve, wi t h s ens i t i vi t y and s peci fi ci t y of over 90% and does not carry t he ri s k of cont ras t al l ergy or phl ebi t i s . It can s i mul t aneous l y as s es s ext ent of proxi mal progres s i on of t he t hrombus i n part i cul ar ext ens i on i nt o pel vi c ves s el s . D-Di mers have a hi gh negat i ve predi ct i ve val ue for DVT. A l ow cl i ni cal probabi l i t y of DVT and a negat i ve D-Di mer does not requi re furt her i nves t i gat i on. A pos i t i ve D-Di mer res ul t s houl d be fol l owed by ul t ras onography. Venography: Us e i f res ul t s uncert ai n and cl i ni cal s us pi ci on i s hi gh. P.143
Cons i der bas el i ne i nves t i gat i ons [FBC, U&Es , ECG, CXR, uri nal ys i s , and pul s e oxi met ry ( ABG)] on al l pat i ent s . If appropri at e, l ook for an underl yi ng caus e (s ee above).
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Coagul at i on s creen Pro-coagul ant s creen: refer t o l ocal s creeni ng pol i cy and get haemat ol ogy advi ce (e.g. CRP, ESR, Prot ei n C and S, Ant i t hrombi n III l evel s , Fact or V
Le i d e n
mut at i on, aut o-Ab s creen, i mmunogl obul i ns
and i mmunoel ect rophoret i c s t ri p, ant i cardi ol i pi n ant i body, Ham t es t , et c.).
o
Screen for mal i gnancy: ul t ras ound CT (abdomen and pel vi s ), CXR, LFTs , PSA, CEA, CA-125, CA-19.9, -HCG, et c.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Deep vein t hrombosis: management
Deep vein thrombosis:
management
If t here i s a hi gh cl i ni cal s us pi ci on of DVT (t he pres ence of ri s k fact ors and abs ence of an al t ernat i ve di agnos i s ), s t art empi ri c ant i -coagul at i on wi t h LMW H. Thi s may be s t opped i f s ubs equent i nves t i gat i ons are negat i ve. Bel ow-knee DVT: t hrombi l i mi t ed t o t he cal f have a l ower ri s k of embol i zat i on and may be t reat ed wi t h compres s i on s t ocki ngs and s ub-cut aneous prophyl act i c dos es of LMW H unt i l mobi l e t o det er proxi mal propagat i on of t hrombus . A bri ef peri od of s ys t emi c ant i -coagul at i on wi t h LMW H may l es s en t he pai n from bel ow-knee DVT. Above-knee DVT: t hrombi wi t hi n t he t hi gh vei ns warrant ful l ant i -coagul at i on wi t h LMW H/UFH and s ubs equent l y warfari n.
Anti-coagulation
Heparin
o
LMW Hs have now s upers eded UFH for management of bot h DVT and PE. They require no moni t ori ng on a dai l y bas i s and al s o al l ow out -pat i ent t reat ment . There mus t be peri od of overl ap bet ween LMW H/UFH t herapy and ant i -coagul at i on wi t h warfari n unt i l INR i s wi t hi n t herapeut i c range and s t abl e. LMW H are admi ni s t ered pri mari l y as a once-dai l y
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s c i nject i on and dos age i s det ermi ned by pat i ent wei ght .
Warfarin
o
Al ways ant i -coagul at e wi t h LMW H/UFH before s t art i ng warfari n. Prot ei n C (a vi t ami n K-dependent ant i -coagul ant ) has a s hort er hal f-l i fe t han t he ot her coagul at i on fact ors and l evel s fal l s ooner res ul t i ng i n a t rans i ent pro-coagul ant t endency. If DVT i s confi rmed commence warfari n and mai nt ai n on LMW H/UFH unt i l INR >2. Ant i -coagul at e (INR 22.5) for 3 mont hs . If recurrent DVT, or pat i ent at hi gh-ri s k of recurrence, cons i der l i fel ong ant i -coagul at i on.
o o
Thrombolysis
Thi s s houl d be cons i dered for recurrent , ext ens i ve, proxi mal venous t hrombos i s (e.g. femoral or i l i ac vei ns ), as i t i s more effect i ve t han ant i -coagul at i on al one i n promot i ng cl ot di s s ol ut i on and produces a bet t er cl i ni cal out come. Cat het er-di rect ed t hrombol yt i c t herapy (rt -PA or SK) i s s uperi or t o s ys t emi c t hrombol ys i s . One approach i s s t rept oki nas e 250 000U over 30 mi nut es t hen 100 000U every hour for 2472 hours (s ee dat a s heet ). See P22 for cont rai ndi cat i ons t o t hrombol ys i s .
Further management
W omen t aki ng t he combi ned OCP s houl d be advi s ed t o s t op t hi s . If t here are cont rai ndi cat i ons t o ant i -coagul at i on, cons i der t he i ns ert i on of a caval fi l t er t o prevent PE. Al l pat i ent s s houl d be t reat ed wi t h t hi gh-hi gh compres s i on s t ocki ngs t o t ry t o reduce s ympt omat i c venous di s t ens i on when mobi l i zi ng.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pulmonary embolism (
Pulmonary embolism (PE): assessment

Symptoms
Cl as s i cal l y pres ent s wi t h s udden ons et , pl euri t i c ches t pai n, as s oci at ed wi t h breat hl es s nes s and haemopt ys i s . Addi t i onal s ympt oms i ncl ude pos t ural di zzi nes s or s yncope. Mas s i ve PE may pres ent as cardi ac arres t (part i cul arl y wi t h el ect romechani cal di s s oci at i on) or s hock. Pres ent at i on may be at ypi cal , i .e. unexpl ai ned breat hl es s nes s or unexpl ai ned hypot ens i on or s yncope onl y. Pul monary embol i s houl d be s us pect ed i n al l breat hl es s pat i ent s wi t h ri s k fact ors for deep vei n t hrombos i s (DVT) or wi t h cl i ni cal l y proven DVT (P144). Recurrent PEs may pres ent wi t h chroni c pul monary hypert ens i on and progres s i ve ri ght heart fai l ure.
Signs
Exami nat i on may reveal t achycardi a and t achypnoea onl y. Look for pos t ural hypot ens i on (i n t he pres ence of rai s ed JVP). Look for s i gns of rai s ed ri ght heart pres s ures and cor pul monal e (rai s ed JVP wi t h promi nent a wave, t ri cus pi d regurgi t at i on, paras t ernal heave, ri ght vent ri cul ar S3, l oud pul monary cl os ure s ound wi t h wi de s pl i t t i ng of S2, pul monary regurgi t at i on). Cyanos i s s ugges t s a l arge pul monary embol i s m. Exami ne for a pl eural rub (may be t rans i ent ) or
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effus i on.

Exami ne l ower l i mbs for obvi ous t hrombophl ebi t i s . Mi l d fever (>37.5C) may be pres ent . There may be s i gns of co-exi s t i ng COPD.
Causes
Mos t frequent l y s econdary t o DVT (l eg >> arm; s ee P144). Ot her caus es

o
Rarel y s econdary t o ri ght vent ri cul ar t hrombus (pos t MI) Sept i c embol i (e.g. t ri cus pi d endocardi t i s ) Fat embol i s m (pos t fract ure) Ai r embol i s m (venous l i nes , di vi ng, s ee P850) Amni ot i c fl ui d Paras i t es Neopl as t i c cel l s Forei gn mat eri al s (e.g. venous cat het ers ).
o o o o o o o
Prognostic features
The prognos i s i n pat i ent s wi t h pul monary embol i vari es great l y, as s oci at ed i n part wi t h any underl yi ng condi t i on. General l y wors e prognos i s i s as s oci at ed wi t h l arger pul monary embol i ; poor prognos t i c i ndi cat ors i ncl ude

Hypot ens i on Hypoxi a ECG changes (ot her t han non-s peci fi c T-wave changes ).
P.147
Practice point
A normal D-di mer excl udes pul monary embol us wi t h ~95% accuracy, but a pos i t i ve D-di mer can be s econdary t o ot her di s orders .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pulmonary embolism: invest igat ions 1
Pulmonary embolism:
investigations 1
General investigations
ABG Normal ABG does not excl ude a PE. P a O 2 i s i nvari abl e wi t h l arger PEs . Ot her changes i ncl ude mi l d res pi rat ory al kal os i s and P a CO 2 (due t o t achypnoea) and met abol i c aci dos i s (2 t o ECG s hock). Commonl y s hows s i nus t achycardi a non-s peci fi c ST- and T-wave changes i n t he ant eri or ches t l eads . The cl as s i cal changes of acut e cor pul monal e s uch as S 1 Q 3 T 3 , ri ght axi s devi at i on, or RBBB are onl y s een wi t h mas s i ve PE. Les s common fi ndi ngs i ncl ude CXR AF. May be normal and a near-normal ches t fi l m i n t he cont ext of s evere res pi rat ory compromi s e i s hi ghl y s ugges t i ve of a PE. Les s commonl y may s how focal pul monary ol i gaemi a (W es t ermark's s i gn), a rai s ed hemi di aphragm, s mal l pl eural effus i on, wedge-s haped s hadows bas ed on t he pl eura, s ub-s egment al at el ect as i s , or di l at ed proxi mal Bl ood t es t s pul monary art eri es . There i s no s peci fi c t es t . FBC may s how neut rophi l l eukocyt os i s ; mi l dl y el evat ed CK, t roponi n, and
bi l i rubi n may be s een. Echo/TOE Ins ens i t i ve for di agnos i s but can excl ude ot her caus es of hypot ens i on and rai s ed ri ght -s i ded pres s ures (e.g. t amponade, RV i nfarct i on, P28). In PE i t wi l l s how RV di l at at i on and gl obal hypoki nes i a
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[wi t h s pari ng of apex (McConnel l 's s i gn)] and pul monary art ery di l at i on. Doppl er may s how t ri cus pi d/pul monary regurgi t at i on al l owi ng es t i mat i on of RV s ys t ol i c pres s ure. Rarel y, t he t hrombus i n t he pul monary art ery may be vi s i bl e.
Specific investigations D-dimer

A hi ghl y s ens i t i ve, but non-s peci fi c t es t . Us eful i n rul i ng out PE i n pat i ent s wi t h l ow or i nt ermedi at e probabi l i t y. Res ul t s can be affect ed by advanci ng age, pregnancy, t rauma, s urgery, mal i gnancy, and i nfl ammat ory s t at es .
Ventilation/perfusion (V/Q) lung scanning

A perfus i on l ung s can (wi t h i v Technet i um-99 l abel l ed al bumi n) s houl d be performed i n al l s us pect ed cas es of PE. A vent i l at i on s can (i nhal ed Xenon-133) i n conjunct i on i ncreas es t he s peci fi ci t y by as s es s i ng whet her t he defect s i n t he vent i l at i on and perfus i on s cans mat ch or mi s mat ch. Pre-exi s t i ng l ung di s eas e makes i nt erpret at i on di ffi cul t .

A normal perfus i on s can rul es out s i gni fi cant -s i zed PE. Abnormal s cans are report ed as l ow, medi um, or hi gh probabi l i t y:
o
A hi gh probi l i t y s can i s s t rongl y as s oci at ed wi t h a PE, but t here i s a s i gni fi cant mi nori t y of fal s e pos i t i ves P.149
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A l ow probabi l i t y s can wi t h a l ow cl i ni cal s us pi ci on of PE s houl d prompt a s earch for anot her caus e for t he pat i ent 's s ympt oms If t he cl i ni cal s us pi ci on of PE i s hi gh and t he s can i s of l ow or medi um probabi l i t y, al t ernat i ve i nves t i gat i ons are requi red.
Investigations for an underlying cause for PEs

Ul t ras ound deep vei ns of l egs USS abdomen and pel vi s (?occul t mal i gnancy/pel vi c mas s ) CT abdomen/pel vi s Screen for i nheri t ed pro-coagul ant t endency (e.g. Prot ei n C, S, ant i t hrombi n III, Fact or V Le i d e n ) Aut oi mmune s creen (ant i cardi ol i pi n ant i body, ANA) Bi ops y of s us pi ci ous l ymph nodes /mas s es
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pulmonary embolism: invest igat ions 2
Pulmonary embolism:
investigations 2
CTPA
Thi s i s t he recommended i ni t i al l ung i magi ng modal i t y i n pat i ent s wi t h non-mas s i ve PE. Al l ows di rect vi s ual i zat i on of embol i as wel l as ot her pot ent i al parenchymal di s eas e, whi ch may expl ai n al t ernat i ve expl anat i on for s ympt oms . Sens i t i vi t y and s peci fi ci t y are hi gh (>90%) for l obar pul monary art eri es but not s o hi gh for s egment al and s ub-s egment al pul monary art eri es . A pat i ent wi t h a pos i t i ve CTPA does not requi re furt her i nves t i gat i on for PE. A pat i ent wi t h a negat i ve CTPA i n t he cont ext of a hi gh/i nt ermedi at e probabi l i t y of a PE s houl d undergo furt her i nves t i gat i on.
Evaluation of leg veins with ultrasound
Not very rel i abl e. Al mos t hal f of pat i ent s wi t h PE do not have evi dence of a DVT and t herefore a negat i ve res ul t cannot rul e out a PE. Us eful s econd-l i ne i nves t i gat i on as an adjunct t o CTPA/V/Q s can. Out come s t udi es have demons t rat ed t hat i t woul d be s afe not t o ant i -coagul at e pat i ent s wi t h a negat i ve CTPA and l ower l i mb US who have an i nt ermedi at e/l ow probabi l i t y of a PE.
Pulmonary angiography
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Is t he gol d s t andard i nves t i gat i on. It i s i ndi cat ed i n pat i ent s i n whom di agnos i s of embol i s m cannot be es t abl i s hed by non-i nvas i ve means . Look for s harp cut -off of ves s el s or obvi ous fi l l i ng defect s . Invas i ve i nves t i gat i on and can be as s oci at ed wi t h 0.5% mort al i t y. If t here i s an obvi ous fi l l i ng defect , t he cat het er or a gui de wi re pas s ed t hrough t he cat het er may be us ed t o di s obl i t erat e t he t hrombus . Aft er angi ography, t he cat het er may be us ed t o gi ve t hrombol ys i s di rect l y i nt o t he affect ed pul monary art ery (s ee P152). The cont ras t can caus e s ys t emi c vas odi l at at i on and haemodynami c col l aps e i n hypot ens i ve pat i ent s .
MR pulmonary angiography
Res ul t s are comparabl e t o pul monary angi ography i n prel i mi nary s t udi es . It can s i mul t aneous l y as s es s vent ri cul ar funct i on.
The Fl ow di agram oppos i t e s ummari zes one propos ed pat hway for i nves t i gat i on on pot ent i al PE pat i ent s .
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Propos ed pat hway for i nves t i gat i on of pat i ent s wi t h s us pect ed PE
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pulmonary embolism: management 1
Pulmonary embolism:
management 1

o
Unl es s an al t ernat i ve di agnos i s i s made t he pat i ent s houl d be t reat ed as for a pul monary embol us unt i l t hi s can be excl uded. Moni t or cardi ac rhyt hm, pul s e, BP, res pi rat i on rat e every 15 mi nut es wi t h cont i nuous pul s e oxi met ry and cardi ac moni t or. Ens ure ful l res us ci t at i on faci l i t i es are avai l abl e. Obt ai n venous acces s and s t art i v fl ui ds (crys t al l oi d or col l oi d). Gi ve maxi mal i ns pi red oxygen vi a facemas k t o correct hypoxi a. Mechani cal vent i l at i on may be neces s ary i f t he pat i ent i s t i ri ng (beware of cardi ovas cul ar col l aps e when s edat i on i s gi ven for endot racheal i nt ubat i on). Gi ve LMWH or UFH t o al l pat i ent s w i t h hi gh or i nt ermedi at e ri s k of PE unt i l di agnos i s i s c onfi rmed . Met a-anal ys i s of mul t i pl e t ri al s has s hown LMW H t o be s uperi or t o UFH wi t h a reduct i on i n mort al i t y and bl eedi ng compl i cat i ons . For dos es cons ul t l ocal formul ary. If t here i s evi dence of haemodynami c i ns t abi l i t y (s ys t emi c hypot ens i on, feat ures of ri ght heart fai l ure) or cardi ac arres t , pat i ent s may benefi t from t hrombol ys i s wi t h rt PA or s t rept oki nas e [s ame dos es us ed for t reat ment of STEMI (s ee bel ow].
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Analgesia
o o
Pat i ent s may res pond t o oral NSAIDs . Opi at e anal ges i a t o be us ed wi t h caut i on. The vas odi l at at i on caus ed by t hes e drugs may preci pi t at e or wors en hypot ens i on. Gi ve s mal l dos es (12mg di amorphi ne i v) s l owl y. Hypot ens i on s houl d res pond t o i v col l oi d. Avoi d i m i nject i ons (ant i -coagul at i on and pos s i bl e t hrombol ys i s ).
Investigations with a view to a definite diagnosis (s ee previ ous s ect i on) Anti-coagulate
o
Pat i ent s wi t h a pos i t i ve di agnos i s mus t undergo ant i -coagul at i on wi t h warfari n. There s houl d be peri od of overl ap wi t h LMW H/UFH unt i l INR val ues are t herapeut i c. Target INR i s 23 for mos t cas es (s ee bel ow). St andard durat i on of ant i -coagul at i on i s

46 weeks for t emporary ri s k fact or 3 mont hs for fi rs t i di opat hi c cas es At l eas t 6 mont hs for ot her cas es W i t h recurrent event s and underl yi ng predi s pos i t i on t o t hromboembol i c event s (e.g. ant i -phos phol i pi d ant i body s yndrome), l i fel ong ant i -coagul at i on may be needed (as wel l as hi gher t arget INR >3).
Dosage of thrombolytic agents for pulmonary embolus

rtPA 100mg over 2 hours or 0.6mg/kg over 15 mi nut es (maxi mum of 50mg) fol l owed by Streptokinase hepari n 250 000U over 30 mi nut es fol l owed by 100 000U/h i nfus i on for 24 hours
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NB: cont rai ndi cat i ons for t hrombol ys i s i dent i cal t o t hos e for STEMI (P22)
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Pulmonary embolism: management 2
Pulmonary embolism:
management 2
Cardiac arrest (also see P8)
Mas s i ve PE may pres ent as cardi ac arres t wi t h EMD. Excl ude t he ot her caus es of EMD (s ee P8). Ches t compres s i ons may hel p break up t he t hrombus and al l ow i t t o progres s more di s t al l y, t hereby res t ori ng s ome cardi ac out put . If cl i ni cal s us pi ci on of PE i s hi gh and t here i s no abs ol ut e cont rai ndi cat i on t o t hrombol ys i s , gi ve rt -PA [s i mi l ar i n dos e t o STEMI wi t h a maxi mum of 50mg (s ee P152) fol l owed by hepari n]. If cardi ac out put ret urns , cons i der pul monary angi ography or i ns ert i ng a PA cat het er t o t ry t o mechani cal l y di s rupt t he embol us .
Hypotension
The acut e i ncreas e i n pul monary vas cul ar res i s t ance res ul t s i n ri ght vent ri cul ar di l at at i on and pres s ure overl oad, whi ch mechani cal l y i mpai rs LV fi l l i ng and funct i on. Pat i ent s requi re a hi gher t han normal ri ght -s i ded fi l l i ng pres s ure, but may be wors ened by fl ui d overl oad.
Ins ert an i nt ernal jugul ar s heat h pri or t o ant i -coagul at i on. Thi s can be us ed for acces s , l at er i f neces s ary. If hypot ens i ve, gi ve col l oi d (e.g. 500ml Haemacel l s t at ). If hypot ens i on, pers i s t s i nvas i ve moni t ori ng and/or i not ropi c s upport i s requi red. The JVP i s a poor
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i ndi cat or of t he l eft -s i ded fi l l i ng pres s ures i n s uch cas es . Adrenal i ne i s t he i not rope of choi ce.
Femoro-femoral cardi opul monary bypas s may be us ed t o s upport t he ci rcul at i on unt i l t hrombol ys i s or s urgi cal embol ect omy can be performed. Pul monary angi ography i n a hypot ens i ve pat i ent i s haz ardous as t he cont ras t may caus e s ys t emi c vas odi l at at i on and cardi ovas cul ar col l aps e.
Pulmonary embolectomy
In pat i ent s who have cont rai ndi cat i ons t o t hrombol ys i s and are i n s hock requi ri ng i not ropi c s upport , t here may be a rol e for embol ect omy i f appropri at e s ki l l s are on s i t e. Thi s can be performed percut aneous l y i n t he cat het eri zat i on l aborat ory us i ng a number of devi ces or s urgi cal l y on cardi opul monary bypas s . Percut aneous procedures may be combi ned wi t h peri pheral or cent ral t hrombol ys i s . Seek s peci al i s t advi ce earl y. Bes t res ul t s are obt ai ned before ons et of cardi ogeni c s hock. Radi ol ogi cal confi rmat i on of ext ent and s i t e of embol i s m i s preferabl e before t horacot omy. Mort al i t y i s ~2530%.
IVC filter
Infrequent l y us ed as l i t t l e t o s ugges t i mproved s hort or l ong-t erm mort al i t y. Fi l t ers are pos i t i oned percut aneous l y and i f pos s i bl e pat i ent s mus t remai n ant i -coagul at ed t o prevent furt her t hrombus format i on. P.155
Mos t are pos i t i oned i nfra-renal l y (bi rd's nes t fi l t er), but can al s o be s upra-renal (Greenfi el d fi l t er). Indi cat i ons for IVC fi l t er us e i ncl ude
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Ant i -coagul at i on cont rai ndi cat ed: e.g. act i ve bl eedi ng, hepari n-i nduced t hrombocyt openi a, pl anned i nt ens i ve chemot herapy Ant i -coagul at i on fai l ure des pi t e adequat e t herapy Prophyl axi s i n hi gh-ri s k pat i ent s : e.g. progres s i ve venous t hrombos i s , s evere pul monary hypert ens i on.
o o
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Fat embolism
Fat
embolism
Commonl y s een i n pat i ent s wi t h major t rauma. There i s embol i z at i on of fat and mi cro-aggregat es of pl at el et s , RBCs , and fi bri n i n s ys t emi c and pul monary ci rcul at i on. Pul monary damage may res ul t di rect l y from t he embol i (i nfarct i on) or by a chemi cal pneumoni t i s and ARDS (s ee P230).
Clinical features
There may be a hi s t ory of fract ures , fol l owed (2448 hours l at er) by breat hl es s nes s , cough, haemopt ys i s , confus i on, and ras h. Exami nat i on reveal s fever (3839C), wi des pread pet echi al ras h (2550%), cyanos i s , and t achypnoea. There may be s cat t ered crepi t at i ons i n t he ches t , t hough exami nat i on may be normal . Changes i n ment al s t at e may be t he fi rs t s i gn wi t h confus i on, drows i nes s , s ei z ures , and coma. Exami ne t he eyes for conjunct i val and ret i nal haemorrhages ; occas i onal l y fat gl obul es may be s een i n t he ret i nal ves s el s . Severe fat embol i s m may pres ent as s hock.
Investigations
ABG FBC Coagul at i on U&Es and gl ucos e 2+ Ca Hypoxi a and a res pi rat ory al kal os i s (wi t h l ow P a CO 2 ) as for t hromboembol i c PE Thrombocyt openi a, acut e i nt ravas cul ar haemol ys i s Di s s emi nat ed i nt ravas cul ar coagul at i on Renal fai l ure, hypogl ycaemi a May be l ow
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Uri ne ECG CXR
Mi cros copy for fat and di ps t i ck for haemogl obi n Us ual l y non-s peci fi c (s i nus t achycardi a; occas i onal l y s i gns of ri ght heart s t rai n Us ual l y l ags behi nd t he cl i ni cal cours e. There may be pat chy, bi l at eral , ai r s pace opaci fi cat i on. Effus i ons are rare Cons i der i f t here i s a pos s i bi l i t y of head i njury wi t h expandi ng s ubdural or epi dural bl eed.
CT head
Differential diagnosis
Pul monary t hromboembol i s m, ot her caus es of ARDS (P231), s ept i c s hock, hypovol aemi a, cardi ac or pul monary cont us i on, head i njury, as pi rat i on pneumoni a, t rans fus i on react i on.
Management
Treat res pi rat ory fai l ure (P228). Gi ve oxygen (maxi mal vi a facemas k; CPAP and mechani cal vent i l at i on i f neces s ary). Ens ure adequat e ci rcul at i ng vol ume and cardi ac out put . CVP i s not a good gui de t o l eft -s i ded fi l l i ng pres s ures and a PA cat het er (SwanGanz ) s houl d be us ed t o gui de fl ui d repl acement . Try t o keep PCW P 1215mmHg and gi ve di uret i cs i f neces s ary. Us e i not ropes t o s upport ci rcul at i on as requi red (P234). As pi ri n, hepari n and Dext ran 40 (500ml over 46 hours ) are of s ome benefi t i n t he acut e s t ages , but may exacerbat e bl eedi ng from s i t es of t rauma. Hi gh-dos e s t eroi ds (met hyl predni s ol one 30mg/kg q8h for 3 dos es ) have been s hown t o i mprove hypoxaemi a but s t eroi ds are probabl y mos t effect i ve i f gi ven prophyl act i cal l y.
1
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Footnote
1
Li ndeque BG et al . (1987) J Bone Joi nt Surg 69 : 128131.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Hypert ensive emergenc ies
Hypertensive emergencies
Hypertensive crisis
Hypert ens i ve cri s i s i s defi ned as a s evere el evat i on i n bl ood pres s ure (SBP >200mmHg, DBP >120mmHg). Rat e of change i n BP i s i mport ant . A rapi d ri s e i s poorl y t ol erat ed and l eads t o end-organ damage, whereas a gradual ri s e i n a pat i ent wi t h exi s t ent poor BP cont rol i s t ol erat ed bet t er. Hypert ens i ve cri s i s i s cl as s i fi ed as
Hypertensive emergency , where a hi gh BP i s compl i cat ed by acut e t arget -organ dys funct i on (s ee t abl e) and i ncl udes
o
Hypertensive emergency with retinopathy , where t here i s marked el evat i on i n BP (cl as s i cal l y DBP >140mmHg) wi t h ret i nal haemorrhages and exudat es (previ ous l y cal l ed accel erat ed hypert ens i on) and Hypertensive emergency with papilloedema , wi t h a s i mi l arl y hi gh BP and papi l l oedema (previ ous l y cal l ed mal i gnant hypert ens i on).
Hypertensive urgency , where t here i s a s i mi l ar ri s e i n BP, but wi t hout t arget organ damage.
Conditions which may present with hypertensive emergency

Es s ent i al hypert ens i on Renovas cul ar hypert ens i on: at heroma, fi bromus cul ar dys pl as i a, acut e renal occl us i on Renal parenchymal di s eas e: acut e gl omerul onephri t i s , vas cul i t i s , s cl eroderma Endocri ne di s orders : phechromocyt oma, Cus hi ng's
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s yndrome, pri mary hyperal dos t eroni s m, t hyrot oxi cos i s , hyperparat hyroi di s m, acromegal y, adrenal carci noma

Ecl amps i a and pre-ecl amps i a Vas cul i t i s Drugs : cocai ne, amphet ami nes , MAOI i nt eract i ons , cycl os pori ne, -bl ocker and cl oni di ne wi t hdrawal Aut onomi c hyperact i vi t y i n pres ence of s pi nal cord i njury Coarct at i on of t he aort a.
Presentation
Occas i onal l y mi ni mal non-s peci fi c s ympt oms s uch as mi l d headache and nos e bl eed. A s mal l group of pat i ent s pres ent wi t h s ympt oms res ul t i ng from BP-i nduced mi crovas cul ar damage:
o
Neurol ogi cal s ympt oms : s evere headache, naus ea, vomi t i ng, vi s ual l os s , focal neurol ogi cal defi ci t s , fi t s , confus i on, i nt racerebral haemorrhage, coma. Ches t pai n (hypert ens i ve heart di s eas e, MI, or aort i c di s s ect i on) and conges t i ve cardi ac fai l ure. Sympt oms of renal fai l ure: renal i mpai rment may be chroni c (s econdary t o l ong-s t andi ng hypert ens i on) or acut e (from t he necrot i zi ng vas cul i t i s of mal i gnant hypert ens i on).
P.159
Pat i ent s may pres ent wi t h hypert ens i on as one mani fes t at i on of an underl yi ng di s eas e (renovas cul ar hypert ens i on, chroni c renal fai l ure, CREST s yndrome, phaeochromocyt oma, pregnancy). Exami nat i on s houl d be di rect ed at l ooki ng for evi dence of end-organ damage even i f t he pat i ent i s as ympt omat i c (heart fai l ure, ret i nopat hy, papi l l oedema, focal neurol ogy).
Hypertensive emergencies
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Hypert ens i ve emergency wi t h ret i nopat hy/papi l l oedema Hypert ens i ve encephal opat hy Hypert ens i on-i nduced i nt racrani al haemorrhage/s t roke Hypert ens i on wi t h cardi ovas cul ar compl i cat i ons
o o o
Aort i c di s s ect i on (P170) MI Pul monary oedema (P108)
Pheochromocyt oma (P598) Pregnancy-as s oci at ed hypert ens i ve compl i cat i ons Ecl amps i a and pre-ecl amps i a
Acut e renal i ns uffi ci ency Hypert ens i ve emergency s econdary t o acut e wi t hdrawal s yndromes (e.g. -bl ockers , cent ral l y act i ng ant i -hypert ens i ves )
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Hypert ensive emergenc ies: management 1
Hypertensive
emergencies: management 1
Priorities in management

Confi rm t he di agnos i s and as s es s t he s everi t y. Ident i fy t hos e pat i ent s needi ng s peci fi c emergency t reat ment . Pl an l ong-t erm t reat ment .
Diagnosis and severity
As k about previ ous BP recordi ngs , previ ous and current t reat ment , s ympat homi met i cs , ant i -depres s ant s , non-pres cri pt i on drugs , recreat i onal drugs . Check t he bl ood pres s ure yours el f, i n bot h arms , aft er a peri od of res t and i f pos s i bl e on s t andi ng. Moni t or t he pat i ent 's bl ood pres s ure regul arl y whi l e t hey are i n A&E. Exami ne careful l y for cl i ni cal evi dence of cardi ac enl argement or heart fai l ure, peri pheral pul s es , renal mas s es or focal neurol ogi cal defi ci t . Al ways exami ne t he fundi : di l at e i f neces s ary.
Investigations
Al l pat i ent s s houl d have FBC U&E Coag. s creen Mi croangi opat hi c haemol yt i c anaemi a wi t h mal i gnant HT + Renal i mpai rment and/or K (di ffus e i nt ra-renal i s chaemi a and 2 hyperal dos t eroni s m) DIC wi t h mal i gnant HT
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CXR Uri nal ys i s
Cardi ac enl argement Aort i c cont our (di s s ect i on?) Pul monary oedema Prot ei n and red cel l s cas t s .
Ot her i nves t i gat i ons , dependi ng on cl i ni cal pi ct ure and pos s i bl e aet i ol ogy i ncl ude 24-hour uri ne col l ect i on Creat i ni ne cl earance Free cat echol ami nes , met anephri nes , or VMA Echo LVH, aort i c di s s ect i on s t enos i s MR renal angi ogram CT/MR brai n Drug s creen Renal art ery s t enos i s Int racrani al bl eed Cocai ne, amphet ami ne, ot hers .
Renal USS and Doppl er Si ze of ki dneys and renal art ery
Indications for admission

Di as t ol i c bl ood pres s ure pers i s t ent l y 120mmHg Ret i nal haemorrhages , exudat es or papi l l oedema Renal i mpai rment .
P.161
Voltage criteria for LVH
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Tal l es t R (V4V6) + deepes t S (V1V3) >40mm Tal l es t R (V4V6) >27mm Deepes t S (V1V3) >30mm R i n aVL >13mm R i n aVF >20 mm QRS compl ex >0.08s (2 s mal l s q.) Abnormal ST depres s i on or T i nvers i on i n V4V6
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Hypert ensive emergenc ies: management 2
Hypertensive
emergencies: management 2
Treatment principles
Rapi d reduc t i on i n BP i s unnec es s ary, mus t be avoi ded, and c an be very dangerous . Thi s can res ul t i n cerebral and cardi ac hypoperfus i on (an abrupt change of >25% i n BP wi l l exceed cerebral BP aut oregul at i on). Ini t i al BP reduct i on of 25% t o be achi eved over 14 hours wi t h a l es s rapi d reduct i on over 24 hours t o a DBP of 100mmHg. The onl y t wo s i t uat i ons where BP mus t be l owered rapi dl y are i n t he cont ext of aort i c di s s ect i on and MI.
Treatment
The majori t y of pat i ent s who are al ert and ot herwi s e wel l may be t reat ed wi t h oral t herapy t o l ower BP gradual l y. Fi rs t -l i ne t reat ment s houl d be wi t h a -bl ocker (unl es s cont rai ndi cat ed) wi t h a t hi azi de di uret i c, or a l ow-dos e cal ci um ant agoni s t . Urgent i nvas i ve moni t ori ng (art eri al l i ne) pri or t o drug t herapy i s i ndi cat ed for pat i ent s wi t h
o o
Evi dence of hypert ens i ve encephal opat hy Compl i cat i ons of hypert ens i on (e.g. aort i c di s s ect i on, acut e pul monary oedema, or renal fai l ure) Treat ment of an underl yi ng condi t i on (e.g. gl omerul onephri t i s , phaeochromocyt oma, CREST cri s i s )
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Pat i ent s wi t h pers i s t ent di as t ol i c BP 140mmHg Ecl amps i a.
Subl i ngual ni fedi pi ne mus t be avoi ded.
Condi t i ons requi ri ng s peci fi c t reat ment are l i s t ed i n t abl e bel ow.

Inves t i gat e as appropri at e for an underl yi ng caus es . Sel ect a t reat ment regi me t hat i s t ol erat ed and effect i ve. Tel l t he pat i ent why l ong-t erm t herapy i s i mport ant . Try t o reduce al l cardi ovas cul ar ri s k fact ors by advi s i ng t he pat i ent t o s t op s moki ng, appropri at e di et ary advi ce (chol es t erol ), and ai m for opt i mal di abet i c cont rol . Moni t or l ong-t erm cont rol and l ook for end-organ damage (regul ar fundos copy, ECG, U&Es ). Even poor cont rol i s bet t er t han no cont rol .
Conditions requiring specific treatment

Accel erat ed and mal i gnant hypert ens i on (P166) Hypert ens i ve encephal opat hy (P168) Ecl amps i a Phaeochromocyt oma (P598) Hypert ens i ve pat i ent s undergoi ng anaes t hes i a
P.163
P.164
Drugs for the treatment of hypertensive emergencies: IV therapy

Drug Dosage Onset of action Comments
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Labet al ol
2080mg i v bol us q10mi n
25 mi nut es
Drug of choi ce i n s us pect ed phaeochromocyt oma (P598) or aort i c di s s ect i on (P170). Avoi d i f t here i s LVF May be cont i nued oral l y (s ee bel ow) Drug of choi ce i n LVF and/or encephal opat hy. Mai nl y venodi l at at i on. Us eful i n pat i ent s wi t h LVF or angi na. May provoke angi na
20200mg/mi n by i v i nfus i on i ncreas i ng Ni t roprus s i de every 15 mi n. 0.2510g/kg/mi n Seconds i v i nfus i on (P698) GTN 110mg/hr i v i nfus i on 25 mi nut es
Hydral azi ne
510mg i v over 20 1015 mi n 50300g/mi n i v mi nut es
Es mol ol HCl
i nfus i on 500g/kg/mi n i v l oadi ng dos e 50200g/kg/mi n
Seconds
Short act i ng -bl ocker al s o us ed for SVTs
i v i nfus i on Phent ol ami ne 25mg i v over 25 mi nut es prn
Seconds
Drug of choi ce i n phaeochromocyt oma (P598) fol l owed by l abet al ol (po) when
BP cont rol l ed NB: It i s dangerous t o reduce t he bl ood pres s ure qui ckl y. Ai m t o reduce t he di at ol i c BP t o 100110mmHg wi t hi n 24 hours . Unl es s t here are good reas ons t o commence i v t herapy, al ways us e oral medi ci nes P.165
Drugs for the treatment of hypertensive
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emergencies: Oral therapy

D D O C r o n o u s s m g a et m g of e e a nt ct io n At 5 3 T e 0 0 h n er d e ol 1 6 ar 0 0 e 0 mn m in u g ut m p e er o s o o d u s al te rn at iv e -b lo ck er
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s s e e B N F Ni 1 1 A fe 0 5 v di oi pi d n 2 2 s e 0 0 u m m bl g in in p ut g o e u q s al 8 h (q 1 2 h if sl o w re le a s e) a s th e fa ll in b p is v er y ra pi
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d. L 1 3 U a 0 0 s b 0 e et i f al 6 p ol 4 0 h 0 ma 0 in e m ut oc g e hr p s o o q 1 2 h m oc yt o m a s u s p ec te d. S af e in pr e g n a nc
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y H 2 2 S y 5 0 af dr e al i n a 5 4 pr zi 0 0 e n mmg e g in n p ut a o e nc q s y 8 h Mi 5 3 M n 0 a o y xi 1 ca di 0 6 u l m0 s g me p in m o ut ar o e k d s e d s al t a n d w at er
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re te nt io n C o m bi n e wi th a lo o p di ur et ic (e .g . fr u s e m id e 4 0
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2 4 0 m g d ai ly ) Cl 0.2 S o mg e ni po d di fol l o at n wed i o e by n 0.1 co mg m hour m ly . o D max n. 30 o 60 n mi n ot ut es s t 0.8 o mg p t ot a a l for br urge u nt pt t her ly apy, a or s
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0.05 h 0 er .1m e g po q8h i ncr eas i ng ever y 2 day s is a hi g h in ci d e nc e of re b o u n d h y p er te n si v e cr is is NB: Ai m to
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reduce di as t ol i c bp t o 1001 10mmHg i n 24 hours and normal i z e bp i n 23 days
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Hypert ensive emergenc y wit h ret inopat hy (ac c elerat ed and malignant hypert ension)
Hypertensive emergency with retinopathy (accelerated and malignant hypertension)

Thi s i s part of a cont i nuum of di s orders charact eri zed by hypert ens i on (DBP oft en >120mmHg) and acut e mi crovas cul ar damage (s een bes t i n t he ret i na but pres ent i n al l organs ). It may be di ffi cul t t o deci de whet her t he damage i n s ome vas cul ar beds i s t he caus e or effect of hypert ens i on. An exampl e i s i n t he cont ext of an acut e gl omerul onephri t i s .
Accel erat ed hypert ens i on (Grade 3 ret i nopat hy) may progres s t o mal i gnant hypert ens i on, wi t h wi des pread necrot i zi ng vas cul i t i s of t he art eri ol es (and papi l l oedema). Pres ent at i on i s commonl y wi t h headache or vi s ual l os s and varyi ng degrees of confus i on. More s evere cas es pres ent wi t h renal fai l ure, heart fai l ure, mi croangi opat hi c haemol yt i c anaemi a, and DIC.
Management

Trans fer t he pat i ent t o medi cal HDU/ITU. Ins ert an art eri al l i ne and cons i der cent ral venous l i ne i f t here i s evi dence of necrot i zi ng vas cul i t i s and DIC. Cat het eri ze t he bl adder. Moni t or neurol ogi cal s t at e, ECG, fl ui d bal ance. Ai m t o l ower t he DBP t o 100mmHg or by 1520mmHg, whi chever i s hi gher, over t he fi rs t 24 hours . Thos e wi t h earl y feat ures may be t reat ed s ucces s ful l y wi t h oral t herapy (-bl ockers , cal ci um channel
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bl ockers ).
Pat i ent s wi t h l at e s ympt oms or who det eri orat e s houl d be gi ven parent eral t herapy ai mi ng for more rapi d l oweri ng of BP. If t here i s evi dence of pul monary oedema or encephal opat hy gi ve frus emi de 4080mg i v. If t here i s no LVF, gi ve a bol us of l abet al ol fol l owed by an i nfus i on. For pat i ent s wi t h LVF, ni t roprus s i de or hydral azi ne are preferabl e. Cons ul t renal t eam for pat i ent s wi t h acut e renal fai l ure or evi dence of acut e gl omerul onephri t i s (>2+ prot ei nuri a, red cel l cas t s ). ARF i s managed as on P378. Dopami ne s houl d be avoi ded as i t may wors en hypert ens i on. Cons i der gi vi ng an ACE i nhi bi t or. Hi gh ci rcul at i ng reni n l evel s may not al l ow cont rol of hypert ens i on, whi ch i n t urn caus es progres s i ve renal fai l ure. ACE i nhi bi t ors wi l l bl ock t hi s vi ci ous ci rcl e. There may be marked fi rs t -dos e hypot ens i on s o s t art caut i ous l y. Haemol ys i s and DIC s houl d recover wi t h cont rol of BP.
Hypertension in the context of acute stroke/intracranial bleed
St roke/bl eed may be t he res ul t of hypert ens i on or vi ce vers a. In t he acut e s et t i ng t here i s i mpai red aut oregul at i on of cerebral bl ood fl ow and aut onomi c funct i on. Smal l changes i n s ys t emi c BP may res ul t i n cat as t rophi c fal l s i n cerebral bl ood fl ow. Sys t emi c BP s houl d not be t reat ed unl es s DBP >130mmHg and/or pres ence of s evere cerebral oedema (wi t h cl i ni cal mani fes t at i ons ). P.167
In mos t cas es BP t ends t o s et t l e over 2436 hours . If
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t reat ment i s i ndi cat ed, above BP reduct i on pri nci pl es mus t be adhered t o and a combi nat i on of ni t roprus s i de, l abet al ol , and cal ci um channel bl ockers can be us ed.
Cent ral l y act i ng agent s mus t be avoi ded as t hey caus e s edat i on. In pat i ent s wi t h SAH, a cerebros el ect i ve cal ci um channel bl ocker, s uch as ni modi pi ne, i s us ed t o decreas e cerebral vas os pas m. Sys t emi c BP mus t al s o be t reat ed i f i t qual i fi es wi t h t he above pri nci pl es and/or i f i t remai ns el evat ed aft er 24 hours . There i s no evi dence t hat t hi s reduces furt her event s i n t he acut e phas e.
Hypertensive retinopathy
Grade 1 Grade 2 Grade 3 Grade 4 Tort uous ret i nal art eri es , s i l ver wi ri ng AV ni ppi ng Fl ame-s haped haemorrhages and cot t on Papi l l oedema
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Hypert ensive enc ephalopat hy
Hypertensive encephalopathy
Caus ed by cerebral oedema s econdary t o l os s of cerebral aut oregul at ory funct i on. Us ual l y gradual ons et and may occur i n previ ous l y normot ens i ve pat i ent s at bl ood pres s ures as l ow as 150/100. It i s rare i n pat i ent s wi t h chroni c hypert ens i on and pres s ures are al s o much hi gher.
Symptoms
Headache, naus ea and vomi t i ng, confus i on, grade III and IV hypert ens i ve ret i nopat hy. Lat e feat ures cons i s t of focal neurol ogi cal s i gns , fi t s , and coma.
Diagnosis
A di agnos i s of excl us i on and ot her di fferent i al di agnos i s mus t be rul ed out (e.g. s t roke, encephal i t i s , t umours , bl eedi ng, vas cul i t i s ). Hi s t ory i s hel pful , part i cul arl y of previ ous s ei zures , SAH us ual l y bei ng s udden i n ons et and s t rokes bei ng as s oci at ed wi t h focal neurol ogi cal defi ci t . Al ways excl ude hypogl ycaemi a. St art i ng hypot ens i ve t reat ment for hypert ens i on as s oci at ed wi t h a s t roke can caus e ext ens i on of t he s t roke. An urgent MRI or CT brai n mus t be obt ai ned t o rul e out s ome of t he di fferent i al di agnos i s .
Management
The pri mary pri nci pl e of bl ood pres s ure cont rol i s t o reduc e DBP by 25% or reduc e DBP t o 100mmHg,
Pa g e 3 2 4
w hi c hever i s hi gher, over a peri od of 12 hours .
Trans fer t he pat i ent t o ITU for i nvas i ve moni t ori ng (s ee previ ous s ect i on). Moni t or neurol ogi cal s t at e, ECG, fl ui d bal ance. Correct el ect rol yt e abnormal i t i es (K , Mg , Ca ). Gi ve frus emi de 4080mg i v. Ni t roprus s i de i s t he fi rs t -l i ne agent as i t al l ows eas y cont rol of BP changes , des pi t e i t s t endency t o i ncreas e cerebral bl ood fl ow. Labet ol ol and cal ci um channel bl ockers are s econd-l i ne agent s and s houl d be added i n i f neces s ary. It i s vi t al t o avoi d agent s wi t h pot ent i al s edat i ve act i on s uch as -bl ockers , cl oni di ne, and met hyl dopa. In s el ect ed pat i ent s who are s t abl e and pres ent at t he very earl y s t ages , oral t herapy wi t h a combi nat i on of -bl ockers and cal ci um bl ockers may be s uffi ci ent .
+ 2+ 2+
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Aort ic dissec t ion: assessment
Aortic dissection: assessment
Aort i c di s s ect i on i s a s urgi cal /medi cal emergency and unt reat ed has a >90% 1-year mort al i t y. Di s s ect i on begi ns wi t h format i on of a t ear i n t he i nt i ma and t he force of t he bl ood cl eaves t he medi a l ongi t udi nal l y t o vari ous l engt hs . Predi s pos i ng fact ors are s ummari z ed i n t abl e oppos i t e.
Classification
There are t hree cl as s i fi cat i ons as i l l us t rat ed i n fi gure on P173 (DeBakey, St anford, and Des cri pt i ve). Di s s ect i ons i nvol vi ng t he as cendi ng and/or aort i c arch are s urgi cal emergenci es and t hos e excl us i ve t o t he des cendi ng aort a are t reat ed medi cal l y.
Presentation
Chest pain. Cl as s i cal l y abrupt ons et of very s evere, mos t commonl y ant eri or ches t pai n radi at i ng t o t he i nt ers capul ar regi on. Us ual l y t eari ng i n nat ure and unl i ke t he pai n of myocardi al i nfarct i on mos t s evere at i t s ons et . Pai n fel t maxi mal l y i n t he ant eri or ches t i s as s oci at ed wi t h as cendi ng aort i c di s s ect i on, whereas i nt ers capul ar pai n s ugges t s di s s ect i on of t he des cendi ng aort a. Pat i ent s oft en us e adject i ves s uch as t eari ng, ri ppi ng, s harp, and s t abbi ng t o des cri be t he pai n. Sudden death or shock. Us ual l y due t o aort i c rupt ure or cardi ac t amponade. Congestive cardiac failure. Due t o acut e aort i c i ncompet ence and/or myocardi al i nfarct i on. Pat i ent s may al s o pres ent wi t h s ympt oms and s i gns of occl us i on of one of t he branches of t he aort a. Exampl es i ncl ude
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St roke or acut e l i mb i s chaemi a: due t o compres s i on or di s s ect i on Parapl egi a wi t h s ens ory defi ci t s : s pi nal art ery occl us i on Myocardi al i nfarct i on: us ual l y t he ri ght coronary art ery Renal fai l ure and renovas cul ar hypert ens i on Abdomi nal pai n: coel i ac axi s or mes ent eri c art ery occl us i on.
o o
Aort i c di s s ect i on may be pai nl es s . As k s peci fi cal l y about hi s t ory of hypert ens i on, previ ous heart murmurs or aort i c val ve di s eas e, and previ ous ches t X-rays t hat may be us eful for compari s on.
Examination

Thi s may be normal . Mos t pat i ent s are hypert ens i ve on pres ent at i on. Hypot ens i on i s more common i n di s s ect i ons of t he as cendi ng aort a (2025%) and may be due t o bl ood l os s , acut e aort i c i ncompet ence (whi ch may be accompani ed by heart fai l ure), or t amponade (di s t ended neck vei ns , t achycardi a, pul s us paradoxus ). Ps eudohypot ens i on may be s een i f fl ow t o ei t her or bot h s ubcl avi an art eri es i s compromi s ed. Look for unequal bl ood pres s ure i n t he arms and document t he pres ence of peri pheral pul s es careful l y. Abs ent or changi ng pul s es s ugges t ext ens i on of t he di s s ect i on. P.171
Aus cul t at i on may reveal aort i c val ve regurgi t at i on and occas i onal l y a peri cardi al fri ct i on rub. Des cendi ng aort i c di s s ect i ons may rupt ure or l eak i nt o t he l eft pl eural s pace and t he effus i on res ul t s i n dul l nes s i n t he l eft bas e. Neurol ogi c defi ci t s may be due t o carot i d art ery
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di s s ect i on or compres s i on (hemi pl egi a) or s pi nal art ery occl us i on (parapl egi a wi t h s ens ory l os s ).
Conditions associated with aortic dissection

Hypertension Connective tissue disorders Smoki ng, dys l i pi daemi a, cocai ne/crack Marfan's s yndrome
1
Ehl ers Danl os s yndrome Hereditary vascular disorders Bi cus pi d aort i c val ve Vascular inflammation Coarct ai on Gi ant cel l art eri t i s Takayas u art eri t i s Behet 's di s eas e Syphi l l i s Decceleration trauma Chest trauma Pregnancy Iatrogenic
1
Car acci dent Fal l s
Cat het eri zat i on Cardi ac s urgery
Marfan's s yndrome [arm s pan > hei ght , pubi s t o s ol e > pubi s t o
vert ex, depres s ed s t ernum, s col i os i s , hi gh-arched pal at e, upward l ens di s l ocat i on, t horaci c aort i c di l at i on/aort i c regurgi t at i on, i ncreas ed uri nary hydroxyprol ene (s ome)].
The ches t pai n may be mi s t aken for acut e MI and acut e MI may compl i cat e aort i c di s s ect i on. Al ways l ook for ot her s i gns of di s s ect i on (s ee above), as t hrombol ys i s wi l l be fat al . Severe ches t pai n and col l aps e may al s o be due t o pul monary embol i s m, s pont aneous pneumot horax, acut e pancreat i t i s , and penet rat i ng duodenal ul cer. Pul s e defi ci t s wi t hout backache s houl d s ugges t ot her di agnos es : at heros cl erot i c peri pheral vas cul ar di s eas e,
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art eri al embol i s m, Takayas u's art eri t i s , et c.
Acut e cardi ac t amponade wi t h ches t pai n i s al s o s een i n acut e vi ral or i di opat hi c peri cardi t i s and acut e myocardi al i nfarct i on wi t h ext ernal rupt ure.
Practice point
Uni l at eral t ongue weaknes s aft er a car cras h wi t h whi pl as h i njury s ugges t s carot i d art ery di s s ect i on.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Aort ic dissec t ion: invest igat ions
Aortic dissection:
investigations
General
ECG. May be normal or non-s peci fi c (LVH, ST/T abnormal i t i es ). Look s peci fi cal l y for evi dence of acut e MI (i nferi or MI i s s een i f t he di s s ect i on compromi s es t he ri ght coronary art ery os t i um). Chest X-ray. May appear normal , but wi t h hi nds i ght i s al mos t al ways abnormal . Look for wi dened upper medi as t i num, hazi nes s or enl argement of t he aort i c knuckl e, i rregul ar aort i c cont our, s eparat i on (>5mm) of i nt i mal cal ci um from out er aort i c cont our, di s pl acement of t rachea t o t he ri ght , enl arged cardi ac s i l houet t e (peri cardi al effus i on), pl eural effus i on (us ual l y on l eft ). Compare wi t h previ ous fi l ms i f avai l abl e. Bloods. Bas e FBC, U&E, cardi ac enz ymes as wel l as cros s mat ch. A novel monocl onal ant i body as s ay t o s moot h mus cl e myos i n heavy chai ns can accurat el y di fferent i at e an acut e di s s ect i on from a MI.
Diagnostic
Echocardiography. T rans t horac i c Ec ho may be us eful i n di agnos i ng aort i c root di l at at i on, aort i c regurgi t at i on, and peri cardi al effus i on/t amponade. T rans oes ophageal Ec ho (TOE) i s t he i nves t i gat i on of choi ce as i t al l ows bet t er eval uat i on of bot h as cendi ng aort a and des cendi ng aort a, may i dent i fy ori gi n of i nt i mal t ear, al l ows eval uat i on of t he ori gi ns of t he coronary art eri es i n rel at i on t o t he di s s ect i on fl ap, and
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provi des i nformat i on on aort i c i ns uffi ci ency. It i s not good at i magi ng t he di s t al as cendi ng aort a and proxi mal arch.
MRI angiography. Is t he gol d s t andard for di agnos i ng aort i c di s s ect i on. It has al l t he pos i t i ve feat ures of TOE and i n part i cul ar al s o provi des accurat e i nformat i on on al l s egment s of as cendi ng/arch/des cendi ng aort a, ent ry/exi t s i t es , and branch ves s el s . Images can be di s pl ayed i n mul t i pl e vi ews as wel l as recons t ruct ed i n t hree di mens i ons . However, t here are a number of di s advant ages i ncl udi ng (1) avai l abi l i t y of s ervi ce out of hours and cos t , (2) pres ence of met al l i c val ves or pacemakers may precl ude pat i ent from havi ng an MRI, (3) moni t ori ng of uns t abl e pat i ent s i n t he s canner can be di ffi cul t and uns afe. Spiral (helical) CT with contrast. Al l ows t hree-di mens i onal di s pl ay of al l s egment s of aort a and adjacent s t ruct ures . True and fal s e l umen are i dent i fi ed by di fferent i al cont ras t fl ow, ent er and exi t s i t e of i nt i mal fl ap, as wel l as pl eural and peri cardi al fl ui d. However i t cannot demons t rat e di s rupt i on of t he aort i c val ve, whi ch may be as s oci at ed wi t h as cendi ng aort i c di s s ect i on. Angiography. Us i ng t he femoral or axi l l ary approach may demons t rat e al t ered fl ow i n t he t wo l umens , aort i c val ve i ncompet ence, i nvol vement of t he branches , and t he s i t e of t he i nt i mal t ear. It i s i nvas i ve and as s oci at ed wi t h a hi gher ri s k of compl i cat i ons i n an al ready hi gh-ri s k pat i ent . It has l argel y been s upers eded by CT/MRI and TOE.
P.173
Selecting a diagnostic modality
Confi rm or refut e a di agnos i s of di s s ect i on.
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Is t he di s s ect i on confi ned t o t he des cendi ng aort a or does i t i nvol ve t he as cendi ng/arch? Ident i fy ext ent , s i t es of ent er and exi t , and pres ence and abs ence of t hrombus . To s ee whet her t here i s aort i c regurgi t at i on, coronary i nvol vement or peri cardi al effus i ons .
Selecting a diagnostic modality
W here avai l abl e, TOE s houl d be t he fi rs t -l i ne i nves t i gat i on. It i s s afe and can provi de al l t he i nformat i on neces s ary t o t ake t he pat i ent t o t he operat i ng t heat re If TOE i s not avai l abl e or i f i t fai l s t o provi de t he neces s ary i nformat i on a s pi ral cont ras t CT s houl d be performed MRI s houl d general l y be res erved for fol l ow-up i mages Angi ography i s rarel y us ed, but i s of val ue i f ot her modal i t i es have fai l ed t o provi de a di agnos i s and/or ext ens i ve i nformat i on i s needed on branch ves s el s
Cl as s i fi cat i on of aort i c di s s ect i on
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Aort ic dissec t ion: management 1
Aortic dissection:
management 1
If t he di agnos i s i s s us pect ed, t rans fer t he pat i ent t o an area where ful l res us ci t at i on faci l i t i es are readi l y avai l abl e. Secure venous ac c es s wi t h l arge-bore cannul as (e.g. grey venfl on). T ake bl ood for FBC, U&Es , and cros s mat ch (10 uni t s ). W hen t he di agnos i s i s confi rmed or i n cas es wi t h cardi ovas cul ar compl i cat i ons , t rans fer t o I T U , i ns ert an art eri al l i ne (radi al unl es s t he s ubcl avi an art ery i s compromi s ed when a femoral l i ne i s preferred), c ent ral venous l i ne , and uri nary c at het er . Immedi at e meas ures s houl d be t aken t o correct bl ood pres s ure (s ee bel ow). Adequat e anal ges i a (di amorphi ne 2.510mg i v and met ocl oprami de 10mg i v).
Plan the definitive treatment

Thi s depends on t he t ype of di s s ect i on (s ee fi gure on P173) and i t s effect s on t he pat i ent . General pri nci pl es are
Pat i ent s wi t h i nvol vement of t he as cendi ng aort a s houl d have emergenc y s urgi c al repai r and BP c ont rol Pat i ent s wi t h di s s ect i on l i mi t ed t o t he des cendi ng aort a are managed i ni t i al l y medi cal l y wi t h aggres s i ve bl ood pres s ure cont rol .
However, t hi s may change i n t he near fut ure wi t h emergi ng encouragi ng dat a from depl oyment of endovas cul ar s t ent -graft s .
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Indications and principles for surgery

Invol vement of t he as cendi ng aort a Ext ernal rupt ure (haemoperi cardi um, haemot horax, effus i ons ) Art eri al compromi s e (l i mb i s chaemi a, renal fai l ure, s t roke) Cont rai ndi cat i ons t o medi cal t herapy (AR, LVF) Progres s i on (cont i nued pai n, expans i on of haemat oma on furt her i magi ng, l os s of pul s es , peri cardi al rub, or aort i c i ns uffi ci ency).
The ai m of s urgi cal t herapy i s t o repl ace t he as cendi ng aort a, t hereby prevent i ng ret rograde di s s ect i on and cardi ac t amponade (mai n caus e of deat h). The aort i c val ve may need recons t ruct i on and res us pens i on unl es s i t i s s t ruct ural l y abnormal (bi cus pi d or Marfan's ), where i t i s repl aced.
Indications and principles for medical management

Medi cal t herapy i s t he t reat ment of choi ce for

Uncompl i cat ed t ype B di s s ect i on St abl e i s ol at ed arch di s s ect i on Chroni c (>2 weeks ' durat i on) s t abl e Type B di s s ect i on.
In al l but t hos e pat i ent s who are hypot ens i ve, i ni t i al management i s ai med at reduci ng s ys t emi c bl ood pres s ure and myocardi al cont ract i l i t y. The goal i s t o s t op t he s pread of t he i nt ramural haemat oma and t o prevent rupt ure. The bes t gui de i s cont rol of pai n. St ri ct bed res t i n a qui et room i s es s ent i al .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Aort ic dissec t ion: management 2
Aortic dissection:
management 2
Control blood pressure. Reduce s ys t ol i c BP t o 100120mmHg.
St art on i v -bl ocker (i f no cont rai ndi cat i ons ) ai mi ng t o reduce t he heart rat e t o 6070/mi n (s ee t abl e). Once t hi s i s achi eved, i f bl ood pres s ure remai ns hi gh, add a vas odi l at or s uch as s odi um ni t roprus s i de (s ee t abl e). Vas odi l at ors i n t he abs ence of -bl ockade may i ncreas e myocardi al cont ract i l i t y and t he rat e of ri s e of pres s ure (d P /d t ). Theoret i cal l y t hi s may promot e ext ens i on of t he di s s ect i on. Furt her ant i -hypert ens i ve t herapy may be neces s ary and ot her convent i onal agent s s uch as cal ci um channel bl ockers , -bl ockers , and ACE i nhi bi t ors can be us ed. In pat i ent s wi t h aort i c regurgi t at i on and conges t i ve cardi ac fai l ure, myocardi al depres s ant s s houl d not be gi ven. Ai m t o cont rol bl ood pres s ure wi t h vas odi l at ors onl y.
Hypotension. May be due t o haemorrhage or cardi ac t amponade.
Res us ci t at e wi t h rapi d i nt ravenous vol ume (i deal l y col l oi d or bl ood, but crys t al l oi d may be us ed al s o). A pul monary art ery wedge cat het er (SwanGanz ) s houl d be us ed t o moni t or t he wedge pres s ure and gui de fl ui d repl acement . If t here are s i gns of aort i c regurgi t at i on or t amponade, arrange for an urgent Echo and di s cus s wi t h t he s urgeons .
Emerging indications and principles for interventional therapy. There are i ncreas i ng report s and s hort cas e s eri es demons t rat i ng
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favourabl e out come (prognos t i c as wel l as s ympt omat i c) dat a on us i ng endovas cul ar s t ent -graft s i n management of pri mari l y Type B and al s o t o a l es s er ext ent Type A aort i c di s s ect i ons . On t he bas i s of t he current evi dence endovas cul ar s t ent -graft s s houl d be cons i dered t o s eal ent ry t o fal s e l umen and t o enl arge compres s ed t rue l umen i n t he fol l owi ng s i t uat i ons :

Uns t abl e Type B di s s ect i on Mal perfus i on s yndrome (proxi mal aort i c s t ent -graft and/or di s t al fenes t rat i on/s t ent i ng of branch art eri es ) Rout i ne management of Type B di s s ect i on (under eval uat i on).
Cardiac tamponade. If t he pat i ent i s rel at i vel y s t abl e peri cardi ocent es i s may preci pi t at e haemodynami c col l aps e and s houl d be avoi ded. The pat i ent s houl d be t rans ferred t o t he operat i ng t heat re for di rect repai r as urgent l y as pos s i bl e. In t he cont ext of t amponade and EMD or marked hypot ens i on peri cardi ocent es i s i s warrant ed. Long-term treatment. Mus t i nvol ve s t ri ct bl ood pres s ure cont rol .
Prognosis
The mort al i t y for unt reat ed aort i c di s s ect i on i s roughl y 2030% at 24 hours and 6575% at 2 weeks . For di s s ect i ons confi ned t o t he des cendi ng aort a, s hort -t erm s urvi val i s bet t er (up t o 80%) but ~3050% wi l l have progres s i on of di s s ect i on des pi t e aggres s i ve medi cal t herapy and wi l l requi re s urgery. Operat i ve mort al i t y i s of t he order of 1025% and depends on t he condi t i on of t he pat i ent pre-operat i vel y. Pos t -operat i ve 5-year act uari al s urvi val of up t o 75% may be expect ed.
P.177
Medical therapy of aortic dissection

-blockade (aim for HR 6070/min)
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Labet al ol
2080mg s l ow i v i nject i on over 10 mi nut es t hen 20200mg/h i v, i ncreas i ng every 15 mi nut es 100400mg po q12h
At enol ol Propranol ol
510mg s l ow i v i nject i on t hen 50mg po aft er 15 mi nut es and at 12 hours , t hen 100mg po dai l y 0.5mg i v (t es t dos e), t hen 1 mg every 25 mi nut es up t o max. 10 mg; repeat every 23 hours 1040mg po 34 t i mes dai l y
When HR 6070/min (or if -blocker contraindicated) add Ni t 0.2 rop 5 rus 1 s i d 0 e g/ kg/ mi n iv i nf us i on Hy 5 dra 1 l az 0m i ne g iv ove r 20 mi nut
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es 50 30 0 g/ mi n iv i nf us i on 25 50 mg po q8 h GT 1 N 1 0m g/h iv i nf us i on Am 5 l od 1 i pi 0m ne g po od
Page 338
> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Ac ut e peric ardit is: assessment
Acute pericarditis: assessment
Presentation
Typi cal l y pres ent s as cent ral ches t pai n, oft en pl euri t i c, rel i eved by s i t t i ng forward and can be as s oci at ed wi t h breat hl es s nes s . Ot her s ympt oms (e.g. fever, cough, art hral gi a, ras h, fai nt nes s /di zzi nes s s econdary t o pai n/HR) may refl ect t he underl yi ng di s eas e (s ee bel ow). A peri cardi al fri ct i on rub i s pat hognomoni c. Thi s may be pos i t i onal and t rans i ent and may be confus ed wi t h t he murmur of TR or MR. Venous pres s ure ri s es i f an effus i on devel ops . Look for s i gns of cardi ac t amponade (P184).
Investigations ECG

May be normal i n up t o 10%. Saddl e-s haped ST -s egment el evat i on (concave upwards ), wi t h vari abl e T i nvers i on (us ual l y l at e s t ages ) and PR-s egment depres s i on (oppos i t e t o P-wave pol ari t y). Mi ni mal l ead i nvol vement t o be cons i dered, t ypi cal l y i ncl udi ng I, II, aVL, aVF, and V3V6. ST s egment i s al ways depres s ed i n aVR, frequent l y depres s ed or i s oel ect ri c i n V1, and s omet i mes i n depres s ed i n V2. May be di ffi cul t t o di s t i ngui s h from acut e MI. Feat ures s ugges t i ng peri cardi t i s are
o
Concave ST el evat i on (vers us convex)
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Al l l eads i nvol ved (vers us a t erri t ory, e.g. i nferi or) Fai l ure of us ual ST evol ut i on and no Q-waves No AV bl ock, BBB, or QT prol ongat i on.
Earl y repol ari zat i on (a normal vari ant ) may be mi s t aken for peri cardi t i s . In t he former, ST el evat i on occurs i n pre-cordi al and rarel y i n V6 or t he l i mb l eads and i s unl i kel y t o s how ST depres s i on i n V1 or PR s egment depres s i on. Us ual l y not hel pful i n di agnos i ng peri cardi t i s pos t MI. The vol t age drops as an effus i on devel ops and i n t amponade t here i s el ect ri cal al t ernans , bes t s een i n QRS compl exes .
Echo

May demons t rat e a peri cardi al col l ect i on. Us eful t o moni t or LV funct i on i n cas e of det eri orat i on due t o as s oci at ed myoperi cardi t i s . W e recommend every pat i ent has an Echo pri or t o di s charge t o as s es s LV funct i on.
Other investigations depend on the suspected aetiology

Al l pat i ent s s houl d have

FBC and bi ochemi cal profi l e ESR and CRP (l evel s ri s e proport i onat e t o i nt ens i t y of di s eas e) Seri al cardi ac enzymes (CK, CK-MB, t roponi n). El evat i ons i ndi cat e s ub-peri cardi al myocardi t i s CXR (heart s i ze, pul monary oedema, i nfect i on). Vi ral t i t res (acut e + 2 weeks l at er) and obt ai n vi rol ogy opi ni on P.179
Where appropri at e
Bl ood cul t ures
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Aut oant i body s creen (RF, ANA, ant i -DNA, compl ement l evel s ) Thyroi d funct i on t es t s Fungal preci pi t i ns (i f i mmunos uppres s ed), Mant oux t es t Sput um cul t ure and cyt ol ogy Di agnos t i c peri cardi al t ap (cul t ure, cyt ol ogy).
Causes of acute pericarditis

Idi opat hi c Infect i on (vi ral , bact eri al , TB, and fungal ) Acut e myocardi al i nfarct i on Dres s l er's s yndrome, pos t -cardi ot omy s yndrome Mal i gnancy (e.g. breas t , bronchus , l ymphoma) Uraemi a Aut oi mmune di s eas e (e.g. SLE, RA, W egner's , s cl eroderma, PAN) Granul omat ous di s eas es (e.g. s arcoi d) Hypot hyroi di s m Drugs (hydral azi ne, procai nami de, i s oni azi d) Trauma (ches t t rauma, i at rogeni c) Radi ot herapy
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Ac ut e peric ardit is: management
Acute pericarditis:
management
General measures
Admit? Depends on cl i ni cal pi ct ure. W e recommend admi s s i on of mos t pat i ent s for obs ervat i on for compl i cat i ons es peci al l y effus i ons , t amponade, and myocardi t i s . Pat i ent s s houl d be di s charged when pai n free. Bed rest Analgesia. NSAIDs are t he mai ns t ay. Ibuprofen i s wel l t ol erat ed and i ncreas es coronary fl ow (200800mg qds ). As pi ri n i s an al t ernat i ve (600mg qds po). Indomet haci n s houl d be avoi ded i n adul t s as i t reduces coronary fl ow and has marked s i de-effect s . Us e PPI (l ans opraz ol e 30mg od) t o mi ni mi ze GI s i de-effect s . Opoi d anal ges i a may be requi red. Col chi ci ne us ed as monot herapy or i n addi t i on t o NSAIDs may hel p s et t l e pai n acut el y and prevent recurrence. Steroids. Thes e may be us ed i f t he pai n does not s et t l e wi t hi n 48 hours (e.g. predni s ol one EC 4060mg po od for up t o 2 weeks , t aperi ng down when pai n s et t l es ). Us e i n conjunct i on wi t h NSAID and t aper s t eroi ds fi rs t before s t oppi ng NSAID. It i s al s o of val ue i f peri cardi t i s s econdary t o aut oi mmune di s orders . Colchicine. Anecdot al evi dence s ugges t s t hat ei t her us ed as monot herpay or i n conjunct i on wi t h NSAIDs i t may hel p t o s et t l e pai n acut el y and prevent rel aps es (1mg/day di vi ded dos es ). St op i f pat i ent devel ops
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di arrhoea, naus ea. (1mg s t at , 500mcg q6h for 48 hour).
Pericardiocentesis. Thi s s houl d be cons i dered for s i gni fi cant effus i on or i f t here are s i gns of t amponade (P184). Antibiotics. Thes e s houl d be gi ven onl y i f bact eri al i nfect i on i s s us pect ed. Oral anticoagulants. Shoul d be di s cont i nued (ri s k of haemo-peri cardi um). Pat i ent s houl d be gi ven i v UFH, whi ch i s eas i er t o revers e (i v prot ami ne) i f compl i cat i ons ari s e.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Bac t erial peric ardit is
Bacterial pericarditis
The commones t pat hogens are pneumococcus , s t aphyl ococci , s t rept ococci , Gram -ve rods , and Nei s s eri a s peci es . Ri s k fact ors i ncl ude pre-exi s t i ng peri cardi al effus i on (e.g. uraemi c peri cardi t i s ) and i mmunos uppres s i on (i at rogeni c, l ymphoma, l eukaemi a, HIV). The i nfect i on may have s pread from medi as t i ni t i s , i nfect i ve endocardi t i s , pneumoni a, or s ub-di aphragmat i c abs ces s . Sus pect i n pat i ent s wi t h hi gh fever, ni ght s weat s , dys pnoea, and rai s ed JVP (ches t pai n may be mi l d or abs ent ); t here may be ot her i nt ra-t horaci c i nfect i on (e.g. pneumoni a). If s us pect ed, t ake bl ood cul t ures and s t art i v fl ucl oxaci l l i n (2g qds ) and i v gent ami ci n or i v cefot axi me (2g t ds ). Adjus t t reat ment when s ens i t i vi t i es known. Si gni fi cant -s i zed peri cardi al col l ect i ons s houl d be drai ned t o drynes s i f pos s i bl e. Send fl ui d for Gram and ZN s t ai n, fungal s mear, and cul t ure. Surgi cal drai nage may be requi red for recurrent effus i ons . Pat i ent s wi t h TB peri cardi t i s are very prone t o devel opi ng cardi ac cons t ri ct i on. St eroi ds have not been s hown t o prevent t hi s but t hey do prevent progres s i on once cons t ri ct i ve s ympt oms devel op. Surgi cal peri cardect omy may be requi red. Take advi ce from cardi ol ogi s t s and i nfect i ous di s eas es t eam.
Viral pericarditis
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Pat hogens i ncl ude Coxs acki e A + B, echovi rus , adenovi rus , mumps , EBV, VZV, CMV, hepat i t i s B, and HIV. Us ual l y a s el f-l i mi t i ng i l l nes s (13 weeks ) and can be s eas onal . Common i n young i ndi vi dual s wi t h no as s oci at ed cardi ac hi s t ory. 2030% devel op recurrent peri cardi t i s . Compl i cat i ons i ncl ude recurrent peri cardi t i s (2030%), myocardi t i s , di l at ed cardi omyopat hy, peri cardi al effus i on and t amponade, and l at e peri cardi al cons t ri ct i on. Treat ment i s s upport i ve (s ee above).
Uraemic pericarditis
Thi s i s an i ndi cat i on for urgent di al ys i s (P385).
Dressler's syndrome, post-cardiotomy syndrome
Compl i cat es ~1% of acut e MI and 1015% pat i ent s fol l owi ng cardi ac s urgery pres ent i ng 24 weeks l at er (up t o 3 mont hs l at er). Cons i s t s of recurrent peri cardi t i s , fever, anaemi a, hi gh ESR, neut rophi l l eukocyt os i s , pl eural effus i ons , and t rans i ent pul monary i nfi l t rat es on CXR. Treat wi t h bed res t , NSAIDs (as pi ri n 600mg po qds ) and s t eroi ds for pers i s t i ng s ympt oms (s ee above). Peri cardi t i s fol l owi ng acut e MI (s ee P32).
Neoplastic pericarditis
The 1-year s urvi val of pat i ent s wi t h mal i gnant effus i ve peri cardi t i s i s 25%. The approach t o t reat ment depends on t he underl yi ng mal i gnancy and s ympt oms . P.183
As ympt omat i c peri cardi al effus i ons do not requi re
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drai nage. Treat t he underl yi ng mal i gnancy ( medi as t i nal radi ot herapy). Recurrent effus i ons may need format i on of s urgi cal peri cardi al wi ndow.
Drai nage i s i ndi cat ed for cardi ac t amponade.
Myopericarditis
Al t hough i t can occur wi t h al l cas es of peri cardi t i s i t i s more common i n t he cont ext of AIDS, vas cul i t i s /connect i ve t i s s ue di s orders , rheumat i c fever, and TB i nfect i on. Cl i ni cal s us pi ci on s houl d be hi gher i n t he cont ext of peri cardi t i s accompani ed by s i gni fi cant arrhyt hmi a (es peci al l y vent ri cul ar) and feat ures of LV dys funct i on and s i nus t achycardi a out of proport i on t o cl i ni cal pi ct ure (fever, pai n, pers i s t ence >56 days ). Bi ochemi cal markers of myocardi al i njury are oft en pos i t i ve (s peci al l y TnT or TnI). In t he abs ence of heart fai l ure, t reat ment i s as uncompl i cat ed peri cardi t i s . St eroi ds s houl d be avoi ded unl es s i ndi cat ed as part of t reat ment for underl yi ng caus e. Heart fai l ure s houl d be t reat ed convent i onal l y. Int erferon can be us ed t o t reat ent erovi ral i nfect i ons and gl obul i ns for CMV. Peri cardi al effus i ons mus t be drai ned wi t h care as t he effus i on may be s pl i nt i ng a di l at ed/myocardi t i c heart . Drai nage can l ead t o rapi d di l at i on and cardi ovas cul ar col l aps e. Prognos i s i s general l y good and mos t recover unl es s t here i s s evere LV i mpai rment .
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Cardiac t amponade: present at ion
Cardiac tamponade:
presentation
Cardi ac t amponade occurs when a peri cardi al effus i on caus es haemodynami cal l y s i gni fi cant cardi ac compres s i on. The pres ent at i on depends on t he s peed wi t h whi ch fl ui d accumul at es wi t hi n t he peri cardi um. Acut e t amponade may occur wi t h 100200ml i n a rel at i vel y res t ri ct ed peri cardi al s ac. Chroni c peri cardi al col l ect i ons may cont ai n up t o 1000ml of fl ui d wi t hout cl i ni cal t amponade.
Causes
Acute tamponade

Cardi ac t rauma Iat rogeni c

o o o
Pos t cardi ac s urgery Pos t cardi ac cat het eri zat i on Pos t paci ng/EP s t udy
Aort i c di s s ect i on Spont aneous bl eed

o o o
Ant i -coagul at i on Uraemi a Thrombocyt openi a
Cardi ac rupt ure pos t MI Mal i gnant di s eas e Idi opat hi c peri cardi t i s
o
Sub-acute tamponade

Uraemi a Bact eri al Tubercul os i s
Infect i ons
o o
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Radi at i on Hypot hyroi di s m Pos t peri cardot omy SLE
Presentation
Pat i ent s commonl y pres ent ei t her wi t h cardi ac arres t (commonl y el ect ri cal mechani cal di s s oci at i on) or wi t h hypot ens i on, confus i on, s t upor, and s hock. Pat i ent s who devel op cardi ac t amponade s l owl y are us ual l y acut el y unwel l , but not i n ext remi s . Thei r mai n s ympt oms i ncl ude
o o
Breat hl es s nes s , l eadi ng t o ai r hunger at res t There may be a precedi ng hi s t ory of ches t di s comfort Sympt oms res ul t i ng from compres s i on of adjacent s t ruct ures by a l arge effus i on (i .e. dys phagi a, cough, hoars enes s , or hi ccough) There may be s ympt oms due t o t he underl yi ng caus e Ins i di ous devel opment may pres ent wi t h compl i cat i ons of t amponade i ncl udi ng renal fai l ure, l i ver and/or mes ent eri c i s chaemi a, and abdomi nal pl et hora.
Important physical signs

Mos t phys i cal fi ndi ngs are non-s peci fi c. They i ncl ude

Tachycardi a (except i n hypot hyroi di s m and uraemi a). Hypot ens i on ( s hock) wi t h pos t ural hypot ens i on. Rai s ed JVP (oft en >10cm) wi t h a promi nent s ys t ol i c x des cent and abs ent di as t ol i c y des cent (s ee fi gure). If t he JVP i s vi s i bl e and ei t her remai ns s t at i c or ri s es wi t h i ns pi rat i on i t i ndi cat es concomi t ant peri cardi al cons t ri ct i on (Kus s maul 's s i gn). Aus cul t at i on may reveal di mi ni s hed heart s ounds . Peri cardi al rub may be pres ent and s ugges t s a s mal l
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peri cardi al col l ect i on.
Look for pul s us paradoxus (a decreas e i n t he pal pabl e pul s e and s ys t ol i c BP of >10mmHg on i ns pi rat i on). Thi s may be s o marked t hat t he pul s e and Korot koff s ounds may be compl et el y l os t duri ng P.185
i ns pi rat i on. Thi s can be meas ured us i ng a BP cuff or art eri al cat het er i f i n s i t u al ready. Ot her condi t i ons t hat can caus e a pul s us paradoxus i ncl ude: acut e hypot ens i on, obs t ruct i ve ai rways di s eas e, and pul monary embol us .
Ot her phys i cal s i gns i ncl ude cool ext remi t i es (ears , nos e) t achypnoea, hepat omegal y, and s i gns of t he underl yi ng caus e for t he peri cardi al effus i on.
Causes of hypotension with a raised JVP

Cardi ac t amponade Cons t ri ct i ve peri cardi t i s Res t ri ct i ve peri cardi t i s Severe bi vent ri cul ar fai l ure Ri ght vent ri cul ar i nfarct i on Pul monary embol i s m Tens i on pneumot horax Acut e s evere as t hma Mal i gnant SVC obs t ruct i on and s eps i s (e.g. l ymphoma)
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Ri ght at ri al pres s ure (RAP) t raci ng i n t amponade. There i s a paradoxi cal ri s e i n RAP duri ng i ns pi rat i on
Footnote
1
T eaching point. To es t abl i s h pres ence of pul s us paradoxus
non-i nvas i vel y, i nfl at e BP cuff t o 15mmHg above hi ghes t s ys t ol i c pres s ure. Defl at e cuff gradual l y unt i l fi rs t beat s are heard and hol d pres s ure at t hat l evel concent rat i ng on di s appearance and reappearance of s ounds wi t h res pi rat i on (bumpbump, s i l ences i l ence, bumpbump, where noi s e refl ect s expi rat i on). Cont i nue t o defl at e s l owl y, payi ng at t ent i on t o s ame pat t ern unt i l al l beat s are audi bl e. The di fference bet ween t he i ni t i al and fi nal pres s ure s houl d be great er t han 10mmHg.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Cardiac t amponade: management
Cardiac tamponade:
management
Tamponade s houl d be s us pect ed i n pat i ent s wi t h hypot ens i on, el evat ed venous pres s ure, fal l i ng BP, HR and RR (wi t h cl ear ches t ), pul s us paradoxus es peci al l y i f predi s pos i ng fact ors are pres ent .
Investigations
Chest X-ray. The heart s i ze may be normal (e.g. i n acut e haemoperi cardi um fol l owi ng cardi ac t rauma). W i t h s l ower accumul at i on of peri cardi al fl ui d (>250ml ) t he cardi ac s i l houet t e wi l l enl arge wi t h a gl obul ar appearance. The s i ze of t he effus i on i s unrel at ed t o i t s haemodynami c s i gni fi cance. Look for s i gns of pul monary oedema. ECG. Us ual l y s hows a s i nus t achycardi a, wi t h l ow vol t age compl exes and vari abl e ST-s egment changes . W i t h l arge effus i ons el ect ri cal al t ernans may be pres ent wi t h beat -t o-beat vari at i on i n t he QRS morphol ogy res ul t i ng from t he movement of t he heart wi t hi n t he peri cardi al effus i on. Echocardiography. Confi rms t he pres ence of a peri cardi al effus i on. The di agnos i s of t amponade i s a cl i ni cal one. Echo s i gns hi ghl y s ugges t i ve of t amponade i ncl ude (1) chamber col l aps e duri ng di as t ol e (RA, RV, RV out fl ow t ract ), (2) marked vari at i on i n t rans val vul ar fl ow, (3) di l at ed IVC wi t h l i t t l e or no di amet er change on res pi rat i on. If avai l abl e, exami ne t he cent ral venous pres s ure t race
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for t he charact eri s t i c exaggerat ed x des cent and abs ent y des cent .
Management
Fol l owi ng confi rmat i on of t he di agnos i s :
W hi l e prepari ng for drai nage of t he peri cardi al fl ui d, t he pat i ent 's ci rcul at i on may t emporari l y be s upport ed by l oadi ng wi t h i v col l oi d (5001000ml s t at ) and s t art i ng i not ropes (i .e. adrenal i ne). In pat i ent s wi t h an adequat e bl ood pres s ure, caut i ous s ys t emi c vas odi l at at i on wi t h hydral azi ne or ni t roprus s i de i n conjunct i on wi t h vol ume l oadi ng may i ncreas e forward cardi ac out put . Thi s i s not t o be recommended rout i nel y as i t may caus e acut e det eri orat i on. The effus i on s houl d be urgent l y drai ned (s ee P890 for peri cardi ocent es i s ) gui ded by Echo or fl uoros copy. I n t he event of c i rc ul at ory c ol l aps e drai nage mus t happen i mmedi at el y w i t hout i magi ng . Surgi cal drai nage i s i ndi cat ed i f t he effus i on i s s econdary t o t rauma. Avoi d i nt ubat i on and pos i t i ve pres s ure vent i l at i on as t hi s reduces CO. In pat i ent s wi t h cardi ac arres t ches t compres s i on has l i t t l e or no val ue, as t here i s no room for addi t i onal fi l l i ng. Uraemi c pat i ent s wi l l al s o need di al ys i s . The caus e of t he effus i on s houl d be es t abl i s hed (s ee P179). Peri cardi al fl ui d s houl d be s ent for cyt ol ogy, mi crobi ol ogy i ncl udi ng TB, and i f appropri at e Hb, gl ucos e, and amyl as e.
P.187
Furt her management i s of t he underl yi ng caus e.
Special cases
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Recurrent pericardial effusion

In s ome cas es peri cardi al effus i on recurs . Thi s requi res ei t her a change i n t he t reat ment of t he underl yi ng caus e or a formal s urgi cal drai nage procedure s uch as a s urgi cal peri cardi al wi ndow or peri cardi ect omy.
Low pressure tamponade

Seen i n t he s et t i ng of dehydrat i on. The JVP i s not rai s ed, ri ght at ri al pres s ure i s normal , and t amponade occurs even wi t h s mal l vol umes of peri cardi al fl ui d.

The pat i ent may res pond wel l t o i v fl ui ds . If t here i s a s i gni fi cant peri cardi al col l ect i on t hi s s houl d be drai ned.
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Congenit al heart disease in adult s 1
Congenital heart disease in
adults 1
Extra-cardiac complications
Polycythaemia. Chroni c hypoxi a s t i mul at es eryt hropoi et i n product i on and eryt hrocyt os i s . The i deal Hb l evel i s ~1718g/dl ; s ome cent res advocat e venes ect i on t o cont rol t he haemat ocri t and prevent hypervi s cos i t y s yndrome (P728). Fol l ow l ocal gui del i nes . General l y cons i der phl ebot omy onl y i f moderat e or s evere s ympt oms of hypervi s cos i t y are pres ent and haemat ocri t >65%. Remove 500ml of bl ood over 3045 mi nut es and repl ace vol ume s i mul t aneous l y wi t h 5001000ml s al i ne, or s al t -free dext ran (i f heart fai l ure). Avoi d abrupt changes i n ci rcul at i ng vol ume. If hypervi s cos i t y s ympt oms are t he res ul t of acut e dehydrat i on or i ron defi ci ency venes ect i on i s not requi red and pat i ent mus t be rehydrat ed and/or t reat ed wi t h i ron. Renal disease and gout. Hypoxi a affect s gl omerul ar and t ubul ar funct i on res ul t i ng i n prot ei nuri a, reduced urat e excret i on, i ncreas ed urat e reabs orpt i on and reduced creat i ni ne cl earance. Overt renal fai l ure i s uncommon. Try t o avoi d dehydrat i on, di uret i cs , radi ographi c cont ras t . As ympt omat i c hyperuri caemi a does not need t reat ment . Col chi ci ne and s t eroi ds are fi rs t -l i ne agent s for t reat ment of acut e gout . NSAIDs s houl d be avoi ded. Sepsis. Pat i ent s are more prone t o i nfect i on. Ski n acne
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i s common wi t h poor heal i ng of s cars . Ski n s t i t ches for operat i ve procedures s houl d be l eft i n for 710 days l onger t han normal . Dent al hygi ene i s very i mport ant due t o t he ri s k of endocardi t i s . Any s i t e of s eps i s may res ul t i n cerebral abs ces s es from met as t at i c i nfect i on or s ept i c embol i .
T hrombosis and bleeding. Mul t i fact ori al and caus ed by a combi nat i on of abnormal pl at el et funct i on, coagul at i on abnormal i t i es , and pol ycyt haemi a. PT and aPTT val ues may be el evat ed and s econdary t o a fal l i n Fact ors V, VII, VIII, and X. Bot h art eri al venous t hrombos es and haemorrhagi c compl i cat i ons (e.g. pet echi ae, epi s t axes , haemopt ys es ) can occur. Dehydrat i on or oral cont racept i ves are ri s k fact ors for t hrombot i c event s . Spont aneous bl eedi ng i s general l y s el f-l i mi t i ng. In t he cont ext of s evere bl eedi ng general meas ures are effect i ve i ncl udi ng pl at al et t rans fus i on, FFP, cryopreci pi t at e, and Vi t K. As pi ri n and ot her NSAIDs s houl d general l y be avoi ded t o decreas e chances of s pont aneous brui s i ng/bl eedi ng. Primary pulmonary problems. Incl ude i nfect i on, i nfarct i on, and haemorrhage from rupt ured art eri ol es or capi l l ari es . Stroke. Can be bot h t hrombot i c as wel l as haemorrhagi c. Art eri al t hrombos i s , embol i c event s (paradoxi cal embol i i n R L s hunt ) and i njudi ci ous phl ebot omy l ead t o s pont aneous t hrombos i s . Haemos t as i s probl ems (as i ndi cat ed above) es peci al l y when combi ned wi t h NSAIDs or formal ant i -coagul at i on can l ead t o haemorrhagi c s t roke. Any i njured brai n t i s s ue i s al s o a ni dus for i nt racrani al i nfect i on/abs ces s format i on. Complications secondary to drugs, investigations, surgery. Avoi d abrupt changes i n bl ood pres s ure or s ys t emi c res i s t ance (s ee above). Cont ras t agent s may provoke s ys t emi c vas odi l at at i on and caus e acut e
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decompens at i on. They may al s o preci pi t at e renal fai l ure. Before non-cardiac s urgery, t ry t o opt i mi ze haemat ocri t and haemos t as i s P.189
by cont rol l ed phl ebot omy and repl acement wi t h dext ran. Hi gh-fl ow oxygen i s i mport ant before and aft er s urgery. Ext reme precaut i on wi t h i v l i nes (s ee bel ow).
Arthralgia. Mai nl y due t o hypert rophi c os t eoart hropat hy. In pat i ent s wi t h R L s hunt megakaryocyt es bypas s t he pul monary ci rcul at i on and become t rapped i n s ys t emi c vas cul ar beds , promot i ng new bone format i on.
Cardiac complications
Congestive cardiac failure. The aet i ol ogy can be compl ex and i s oft en di rect l y dependent on t he underl yi ng abnormal i t y. Pos s i bi l i t i es i ncl ude val ve dys funct i on (cal ci fi cat i on of an abnormal val ve or s econdary t o s upra- or s ub-val vul ar fi bros i s and s t enos i s ), vent ri cul ar dys funct i on (hypert rophy, fi bros i s , and fai l ure), dys funct i oni ng s urgi cal s hunt , or pul monary art eri ol ar di s eas e and s hunt revers al . Treat as us ual t aki ng s peci al care not t o dehydrat e t he pat i ent or preci pi t at e acut e changes i n bl ood pres s ure (s ee bel ow). Endocarditis. The ri s k depends on t he cardi ac l es i on and t he pat hogen. See t abl e, P121. The recommended ant i bi ot i c prophyl axi s regi men i s gi ven on P136. Pat i ent s s houl d be advi s ed on careful s ki n care (e.g. acne) and ant i bi ot i c prophyl axi s t o prevent l ocal i nfect i ons t hat may met as t as i ze t o heart or brai n. Arrhythmias. Treat i n t he s t andard way (pp64106).
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> T able of Cont ent s > Chapt er 1 - Cardiac emergenc ies > Congenit al heart disease in adult s 2
Congenital heart disease in
adults 2
Management
Pat i ent s can be very compl ex and mus t be di s cus s ed wi t h t hei r regul ar cardi ol ogi s t and/or l ocal congeni t al adul t heart cent re.
General measures
Cont act and t ake advi ce from t he cardi ol ogi s t normal l y i nvol ved i n t he pat i ent 's care. i v l i nes are pot ent i al l y very hazardous due t o t he ri s k of s eps i s and s ys t emi c embol i zat i on (ai r and part i cul at e mat t er). Us e an ai r fi l t er i f avai l abl e. Remove i v cannul ae i f t here are any l ocal s i gns of t hrombophl ebi t i s . Avoi d s udden changes i n ci rcul at i ng vol ume (e.g. vomi t i ng, di arrhoea, haemorrhage, venes ect i on). Any acut e fal l i n SVR may preci pi t at e i nt ens e cyanos i s and deat h and an acut e ri s e i n SVR may abrupt l y reduce s ys t emi c bl ood fl ow and caus e col l aps e. Moni t or for neurol ogi cal s i gns and s ympt oms from cerebral t hromboembol i s m or s ept i c embol i s m.
Specific measures
Haemoptysis. Common. Mos t epi s odes are s el f-l i mi t i ng and preci pi t at ed by i nfect i on. Di fferent i at i on from pul monary embol i s m may be di ffi cul t . Try t o keep t he pat i ent cal m and ens ure adequat e BP cont rol . Gi ve hi gh-fl ow oxygen by mas k. If t here i s cl i ni cal s us pi ci on of i nfect i on (fever, s put um product i on, l eukocyt os i s ,
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rai s ed CRP, et c.) s t art broad-s pect rum ant i bi ot i cs . VQ s can may hel p i n t he di agnos i s of pul monary embol i s m (P146) but i s oft en equi vocal . Avoi d as pi ri n and NSAIDs as t hes e exacerbat e t he i nt ri ns i c pl at el et abnormal i t i es . There i s anecdot al evi dence for t he us e of l ow-dos e i v hepari n, Dext ran 40 (500ml i v i nfus i on q46h), acri d (Arvi n, reduces pl as ma fi bri nogen by cl eavi ng fi bri n), or l ow-dos e warfari n t herapy for reduci ng t hrombot i c t endency i n t hes e pat i ent s . Severe pul monary haemorrhage may res pond t o aprot i ni n or t ranexami c aci d.
Breathlessness. May be due t o pul monary oedema or hypoxi a (i ncreas ed s hunt ) s econdary t o ches t i nfect i on or pul monary i nfarct i on. Do not gi ve l arge dos es of di uret i cs or ni t rat es as t hi s wi l l drop s ys t emi c pres s ures and may preci pi t at e acut e col l aps e. Compare ches t X-ray t o previ ous fi l ms t o t ry t o as s es s i f t here i s radi ol ogi cal evi dence of pul monary oedema. The JVP i n pat i ent s wi t h cyanot i c CHD i s t ypi cal l y hi gh and s houl d not be us ed as a s ol e marker of heart fai l ure. Overal l pat i ent s need a hi gher fi l l i ng pres s ure t o mai nt ai n pul monary bl ood fl ow. Gi ve hi gh-fl ow oxygen by mas k. St art ant i bi ot i cs i f t here i s a cl i ni cal s us pi ci on of i nfect i on (P198). Gi ve oral di uret i cs i f t here i s evi dence of pul monary oedema or s evere ri ght heart fai l ure. Moni t or haemat ocri t and renal funct i on cl os el y for s i gns of over-di ures i s . Effort syncope. Shoul d prompt a s earch for arrhyt hmi as , i n part i cul ar VT (Hol t er moni t or), s evere val ve di s eas e, or s i gns of overt heart fai l ure. Treat as appropri at e. P.191
Chest pain. May be s econdary t o pul monary embol i s m or i nfarct i on (s pont aneous t hrombos i s ), pneumoni a,
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i s chaemi c heart di s eas e, or mus cul os kel et al caus es . It requi res careful eval uat i on wi t h t he convent i onal di agnos t i c modal i t i es al ready des cri bed.
Congenital defects with survival to adulthood

Common

Bi cus pi d aort i c val ve Coarct at i on of t he aort a Pul monary s t enos i s Os t i um s ecundum ASD Pat ent duct us art eri os us Aneurys m of Si nus of Val s al va Dext rocardi a (s i t us s ol i t us or i nvert us ) Congeni t al compl et e heart bl ock Congeni t al l y correct ed t rans pos i t i on Ebs t ei n's anomal y Vent ri cul ar s ept al defect Fal l ot 's t et ral ogy
Rarer

Congenital defects with good prognosis after surgery

Causes of cyanosis in adults with congenital heart disease
Ei s enmenger react i on: R L s hunt t hrough VSD, ASD or pat ent foramen oval e wi t h pul monary hypert ens i on (pul monary hypert ens i on may be s econdary t o pul monary vas cul ar di s eas e, pul monary art ery s t enos i s or bandi ng, pul monary val ve s t enos i s , t ri cus pi d at res i a) Abnormal connect i on: t rans pos i t i ons , IVC or SVC t o l eft at ri um, t ot al anomal ous pul monary venous drai nage Pul monary AV fi s t ul ae
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e pneumonia: assessment
Acute pneumonia: assessment
Presentation
Cl as s i cal l y cough (product i ve or non-product i ve), fever, breat hl es s nes s , ches t pai n, abnormal CXR. There may be prodromal s ympt oms of coryz a, headache, and mus cl e aches . The aet i ol ogi cal agent cannot be predi ct ed from t he cl i ni cal feat ures . Immunocompromi s ed pat i ent s may pres ent wi t h agi t at i on, fever, t achypnoea, decreas ed rout i ne oxi met ry readi ngs . CXR abnormal i t i es may be s ubt l e. Pat i ent s wi t h ri ght -s i ded endocardi t i s (e.g. i v drug us ers ) may pres ent wi t h haemopt ys i s , fever, pat chy cons ol i dat i on cavi t at i on.
Adverse prognostic features in acute pneumonia 1

Pre-existing

Age 50 years Co-exi s t i ng di s eas e (IHD, cancer, et c.). Confus i on Urea >7mmol /L Res pi rat ory rat e >30/mi n SBP <90mmHg and/or DBP 60mmHg. Hypoxi a (Sat s <92%; P a O 2 <8kPa) regardl es s of Fi O 2 W CC <4 or >20 10
9
Core clinical features

Additional features

Bi l at eral or mul t i -l obar i nvol vement on CXR 2
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core feat ures carri es a hi gh mort al i t y: cons i der admi s s i on t o ITU.
Management General resuscitation and investigations
Chec k ABC (ai rw ay, breat hi ng, and c i rc ul at i on) . Arrange for urgent CXR . Sec ure venous ac c es s : i f t here are s i gns of dehydrat i on, s t art i v crys t al l oi ds ; exami ne regul arl y for s i gns of fl ui d overl oad. Send bl oods : FBC, U&Es , LFT, CRP. Chec k ABG : Correct hypoxi a ( P a O 2 10kPa) wi t h oxygen , at l eas t 35%. If hypoxi a fai l s t o correct des pi t e maxi mum i ns pi red O 2 or t here i s hypercapnoea ( P a CO 2 6kPa) t he pat i ent i s l i kel y t o requi re vent i l at i on. Arrange for urgent CXR . Cul t ure bl ood and s put um : Urgent s put um mi cros copy wi t h Gram-s t ai n i s occas i onal l y us eful but s houl d not be rel i ed upon rout i nel y. Pai n rel i ef : Paracet amol or a NSAID us ual l y s uffi ce. Morphi ne may be requi red; res pi rat ory depres s i on i s unl i kel y t o be a probl em i f t he P a CO 2 i s l ow or normal and i t may be revers ed wi t h nal oxone.
Footnote
1
From BTS Gui del i nes for t he management of communi t y acqui red pneumoni a i n adul t s (2001) T horax 56 (s uppl . IV): P.195
Indications for intensive care

>2 core feat ures from t abl e above. Si gns of hypoperfus i on (SBP <90mmHg, ol i guri a, confus i on) not res pondi ng t o t herapy.
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Res pi rat ory fai l ure ( P a O 2 8kPa P a CO 2 6kPa). Si gni fi cant aci dos i s (pH 7.25, bas e exces s < -8). Progres s i ve exhaus t i on.
Causes of acute pneumonia in-patients admitted to hospital

Community acquired

St rep. pneumoni ae (40%) H. i nfl uenzae (5%) St aph. aureus (2%) Moraxhel l a c at arrhal i s (2%) Gram -ve bact eri a/anaerobes 1% Infl uenz a A&B (11%) Ot her vi rus es (2%) Mi xed pat hogens (14%) No organi s m i dent i fi ed (30%) Myc opl as ma (11%) Legi onel l a pneumophi l a (4%) Chl amydi a pneumoni ae (13%) Ot her Chl amydi a s peci es (4%) Al l of t he above Al l of t he above
Atypicals

Hospital acquired
Immunocompromised
Who may be discharged from A&E?

Have a l ow t hres hol d for admi s s i on. If pat i ent i s young, wi t h no advers e prognos t i c feat ures , a s i ngl e l obe i nvol ved on CXR, and no compl i cat i ons (e.g. cavi t at i on or effus i on) t hen cons i der di s charge from A&E. Arrange for earl y out -pat i ent revi ew (23 days ).
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e pneumonia: invest igat ions
Acute pneumonia:
investigations
Investigations
Al l pat i ent s s houl d have

Art eri al bl ood gas es (on ai r and oxygen) FBC, U&Es , l i ver funct i on t es t s , ESR, CRP ECG Ches t X-ray (s ee fi gure bel ow) Bl ood cul t ures Sput um cul t ure, Gram s t ai n, ZN s t ai n (i f s us pi ci ous of TB), cyt ol ogy Pl eural fl ui d as pi rat i on (i f pres ent ) for MC&S, prot ei n, and pH Pneumoc oc c al ant i gen: uri ne, s put um, or bl ood Serol ogy (acut e and conval es cent ) Col d aggl ut i ni ns ( Myc opl as ma day 714) Uri ne for Legi onel l a ant i gen, s put um for Legi onel l a cul t ure, and di rect i mmunofl uores cence.
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Fi gure. No capt i on avai l abl e. W here appropri at e cons i der
Bronchos copy (BAL) (i f i mmunocompromi s ed, or i f fai l s t o res pond t o fi rs t -l i ne ant i bi ot i cs and no organi s m i dent i fi ed) Echo (?ri ght heart endocardi t i s , P122) VQ s can (t o excl ude i nfect ed pul monary i nfarct ) Trans -bronchi al or open l ung bi ops y As pi rat i on of pl eural fl ui d for MC&S Vi ral t i t res .
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e pneumonia: management
Acute pneumonia:
management
Treatment
Bl i nd t reat ment s houl d be s t art ed as s oon as appropri at e cul t ures have been s ent (t abl e, oppos i t e). Modi fy t herapy i n t he l i ght of s ubs equent i nves t i gat i ons or pos i t i ve cul t ures . St art on i v t herapy for at l eas t 48 hours ; adjus t accordi ng t o cl i ni cal condi t i on and res pons e (s ee t abl e). In pat i ent s wi t h COPD or as t hma, cons i der t reat ment wi t h s al but amol (2.55mg nebul i zed q46h) t o rel i eve bronchos pas m. Thi s may al s o l oos en s ecret i ons and i mprove mucoci l l i ary act i on. Cont i nue i v fl ui ds as neces s ary t o keep t he pat i ent wel l hydrat ed. Moni t or res pons e t o t herapy wi t h
o o o
FBC, CRP Pul s e oxi met ry or bl ood gas es CXR at day 35 (s ooner i f det eri orat i ng).
Tot al durat i on of t herapy us ual l y 10 days . Fol l ow-up CXR 46 weeks aft er di s charge mandat ory t o excl ude an underl yi ng endobronchi al l es i on.
Choice of antibiotics
In s everel y i l l pat i ent s , t he hi s t ory may poi nt t o a l i kel y pat hogen: COPD S. pneumoni ae, H. i nfl uenzae, M. c at arrhal i s
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Al cohol i s m
S. pneumoni ae, S. aureus , H. i nfl uenzae , Kl ebs i el l a , TB, anaerobes , Gram -ve bact eri a S. aureus , S. pneumoni ae, H. i nfl uenzae Anaerobes , Gram -ve bact eri a C. ps i t t ac i St rept ococci , S. aureus , l ung abs ces s , necrot i zi ng Gram -ve bact eri a, i nvas i ve as pergi l l os i s Legi onel l a Mycopl as ma, anaemi a/col d aggl ut i ni ns
Recent fl u Ri s k of as pi rat i on Cont act wi t h bi rds Haemopt ys i s
Di arrhoea, abdomi nal pai n Pharyngi t i s /ot i t s
medi a Ri s k fact ors for HIV S. pneumoni ae, H. i nfl uenzae , CMV, PCP, Hos pi t al acqui red Neut ropeni a Drug addi ct s Nurs i ng home pat i ent s P.199 Crypt oc oc c us Gram -ve bact eri a, S. aureus P. aerugi nos a , Gram -ve bact eri a, As pergi l l us S. aureus , Candi da Hi gher ri s k of as pi rat i on: anaerobes , Gram -ve bact eri a
Blind treatment of pneumonia 1
Mos t pat i ent s can be adequat el y t reat ed wi t h oral ant i bi ot i cs . Cons i der i v ant i bi ot i cs i f advers e prognos t i c feat ures (s ee P194) pres ent .
Co Am mm oxy uni ci l l t y- i n acq + ui r Ery ed t hr
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pn om eu yci mo n , ni a at ypi cal fea t ur es Ho Cef s pi ot a t al xi m -ac e qui (or red Cef pn t az eu i di mo me ni a ) Me t ro ni d az o le Pos Cef t -i uro nfl xi m ue e nz a (or
2 3
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pn Am eu oxy mo ci l l ni a i n ( + St a Ery ph. t hr aur om eus yci pos n

2
sib + l e) Fl u cl o xac illi If n Swi
MR t ch SA Fl u i s o cl o l at xac ed i l l i or n s us t o pec Va t ed nco my ci n As Cef pi r uro at i xi m on e + pn Me eu t ro mo ni d
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ni a az o le or Be nz y l pe ni ci llin + Ge nt a mi c in + Me t ro ni d az o le Pat As i en for t h k CA hi g os e wi t P + ri s h-d fac i v t or Cos t ri for mo HI xaz V an d ol e
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s us pi ci on of PC P
2
Al t ern at i vel y cl ari t hr omyci n .

3
If
i nt ol er ant of -l act am or macrol i de, us e fl uoroq ui nol o ne wi t h act i vi t y agai ns t S. pneum oni ae (e.g. l evofl o xaci n).
Suggested antibiotic dosages
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Am 50 oxy 0m ci l l g in 1 g iv t ds Be 1.2 nz y l 2.4 pe g ni ci i v l l i n qds Cef 75 uro 0m xi m g e 1 .5g iv t ds Cef 1 ot a 2 xi m g e iv t ds Cef 1 t az 2 i di g me i v t ds Co- 1.2 am g oxi i v cl a t ds v Co- 5m
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t ri g/k mo g xaz q6 ol e h of t ri me t ho pri m co mp on ent Ery 50 t hr 0m om g yci 1 n g iv (or po) qds Fl u 1 cl o 2 xac g illi iv n qds Ge l oa nt a di n mi c g in dos e (12 0m
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g i v) t he n 1-2 .5 mg /kg q8 12 h gui de d by l ev el s Me 50 t ro 0m ni d g az o i v l e t ds Va 20 nco 0 my 4 ci n 00 mg od iv for MR SA 1g iv
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bd gui de d by l ev el s Tei 20 cop 0 l an 4 in 00 mg od iv for MR SA NB: i v eryt hromyci n caus es s evere phl ebi t i s . Us e cent ral l i ne i f avai l abl e or change t o oral preparat i on aft er 23 days . Cl ari t hromyci n i s an al t ernat i ve t o eryt hromyci n.
Footnote
1
In pat i ent s wi t h a good hi s t ory of peni c i l l i n al l ergy (anaphyl axi s ,
urt i cari a) al t ernat i ves i ncl ude eryt hromyci n, cl ari t hromyci n, l evofl oxaci n (NB: ci profl oxaci n i s not very act i ve agai ns t S. pneumoni ae ). Al t ernat i ves for fl ucl oxaci l l i n i ncl ude vancomyci n, t ei copl ani n, or ri fampi ci n: cons ul t BNF for dos ages .
2 3
Al t ernat i vel y cl ari t hromyci n. If i nt ol erant of -l act am or macrol i de, us e fl uoroqui nol one wi t h
act i vi t y agai ns t S. pneumoni ae (e.g. l evofl oxaci n).
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e pneumonia: spec ific sit uat ions
Acute pneumonia: specific
situations
Community-acquired pneumonia
Ei t her amoxyc i l l i n 1g i v q8h or c efuroxi me 750mg1.5g i v q8h pl us eryt hromyc i n 500mg1g po/i v q6h t o cover at ypi cal s pl us fl uc l oxac i l l i n 12g i v q6h i f St aph. aureus i s s us pect ed. Peni c i l l i n al l ergy: cephal os pori ns are us ual l y s afe where t here i s a hi s t ory of ras hes wi t h peni ci l l i n. If t here i s hi s t ory of anaphyl axi s cons i der cl ari t hromyci n 500mg bd po as s ol e t herapy, or i f unwel l s eek res pi rat ory/mi crobi ol ogi cal advi ce.
Aspiration pneumonia
Ri s k fact ors i ncl ude s ei zures , reduced cons ci ous l evel , s t roke, dys phagi a, peri odont al di s eas e, down-and-out , general anaes t hes i a. Al ways admi t . Cl i ni cal feat ures i ncl ude wheez e and frot hy non-purul ent s put um (as s oon as 24 hours aft er as pi rat i on), t achypnoea, cyanos i s , and res pi rat ory di s t res s . Gas t ri c aci d des t roys al veol i res ul t i ng i n i ncreas ed capi l l ary permeabi l i t y and pul monary oedema. Haemorrhage i s common. Severe necrot i zi ng pneumoni a may res ul t . T reat ment : Cefuroxi me (as above) + met roni dazol e (500mg i v q8h). Amoxyci l l i n + met roni dazol e + gent ami ci n.
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Hospital-acquired pneumonia
Mos t l i kel y organi s ms are ent eri c Gram negat i ve anaerobes . T reat ment : broad-s pect rum cephal os pori n (e.g. c efot axi me 2g t ds i v) met roni dazol e (500mg i v t ds ). If i nt ubat ed 48 hours us e ant i -ps eudomonal ant i bi ot i c (e.g. c eft azi di me 2g t ds , modi fy dos e i n renal fai l ure).
Pneumonia in the immunocompromised
Al l rout i ne pat hogens are pos s i bl e; ot her i nfect i ons depend on t he nat ure of i mmunos uppres s i on. TB and at ypi cal mycobact eri a are more common. Si nce t he i nt roduct i on of combi nat i on ant i -ret rovi ral t reat ment opport uni s t i c i nfect i ons are l es s common and pul monary Kapos i 's s arcoma or l ymphoma rarel y s een. However, pul monary opport uni s t i c i nfect i on may be t he fi rs t mani fes t at i on of HIV before i t i s di agnos ed, t he mos t common bei ng Pneumoc ys t i s c ari ni i . Fungal and vi ral (CMV) pneumoni t i s may al s o occur. Des at urat i on on exerci s e i n t he pres ence of a normal CXR or one wi t h a di ffus e i nt ers t i t i al s hadowi ng i s hi ghl y s ugges t i ve of PCP. Reci pi ent s of organ t rans pl ant s have depres s ed cel l -medi at ed i mmuni t y due t o ant i -reject i on i mmunos uppres s i ve t herapy. Addi t i onal pat hogens t o whi ch t hey are s us cept i bl e i ncl ude PCP, vi rus es (e.g. CMV, RSV, i nfl uenz a and parai nfl uenz a, adenovi rus ), and fungi ( As pergi l l us s pp., Candi da s pp.). The CXR abnormal i t i es t end not t o be s peci fi c for t he pat hogen and t reat ment s houl d cover al l pos s i bl e pat hogens . In general earl y bronchos copy and bronchoal veol ar l avage i s i ndi cat ed for di agnos i s ; management s houl d be di s cus s ed earl y wi t h a res pi rat ory/i nfect i ous di s eas e/mi crobi ol ogy t eam.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e pneumonia: c omplic at ions
Acute pneumonia:
complications
Community-acquired pneumonia that fails to respond
Revi ew t he di agnos i s (?PE, pul monary oedema, pul monary vas cul i t i s , al veol ar haemorrhage, cavi t at i on, organi zi ng pneumoni a, eos i nophi l i c pneumoni a, bronchi ect as i s ). Repeat CXR and arrange for CT ches t t o l ook for cavi t at i on or empyema. Repeat cul t ure of rel evant s peci mens (e.g. s put um, bl ood). Cons i der pos s i bl e res i s t ant organi s m or underl yi ng di s eas e, e.g. bronchi al carci noma. Cons i der bronchos copy t o excl ude TB, PCP, or an obs t ruct i ng l es i on. Revi ew ant i bi ot i c dos ages and i nt ens i fy (e.g. i nadequat e oral eryt hromyci n for Myc opl as ma pneumoni a).
Parapneumonic pleural effusion or empyema
Parapneumoni c pl eural effus i ons devel op i n up t o 50% of pat i ent s wi t h bact eri al pneumoni a admi t t ed t o hos pi t al . Di agnos t i c t ap s houl d be performed on al l parapneumoni c effus i ons t o excl ude an empyema. Sent pl eural fl ui d for MC&S, urgent Gram s t ai n, and pH anal ys i s .
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Empyema (vi s i bl y cl oudy fl ui d, pus , or organi s ms on Gram s t ai n) or compl i cat ed parapneumoni c effus i on (vi s i bl y cl ear fl ui d wi t h pH <7.2) s houl d be removed wi t h pl eural s pace drai nage. Di s cus s wi t h res pi rat ory phys i ci ans . Ul t ras ound may hel p l ook at t he l evel of t he effus i on and demons t rat e l ocul at i on wi t h an empyema. If an empyema fai l s res ol ve wi t h pl eural s pace drai nage, arrange ches t CT and di s cus s wi t h cardi ot horaci c s urgeons (P249).
Cavitation or abscess
Any s evere pneumoni a may cavi t at e, but part i cul arl y St aph. aureus , Kl ebs i el l a s pp., TB, as pi rat i on pneumoni a, bronchi al obs t ruct i on (forei gn body, t umour) or pul monary embol i (t hrombus or s ept i c embol i , e.g. from DVT wi t h s uper-added i nfect i on or t ri cus pi d endocardi t i s , P132).
Treatment
Seek advi ce from res pi rat ory t eam. Mos t res pond t o appropri at e ant i bi ot i cs but may requi re more prol onged cours e. Surgi cal drai nage or CT-gui ded percut aneous as pi rat i on may be neces s ary. Bl i nd t reat ment : c efuroxi me 1.5g t ds i v (or c efot axi me 2g t ds i v) + fl uc l oxac i l l i n 12g qds i v + gent ami c i n l oadi ng dos e (100120mg i v) t hen 67mg/kg od (accordi ng t o renal funct i on and l evel s ) met roni dazol e 500mg i v t ds . Long-t erm ant i bi ot i cs (46 weeks ) l i kel y t o be requi red.
Other complications
Res pi rat ory fai l ure Rhabdomyol ys i s DIC (es peci al l y Legi onel l a ) P224 P392 P702.
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Page 379
> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Myc oplasma pneumonia
Mycoplasma pneumonia
Di s eas e of young adul t s . Low-grade fever, dry cough, headache, and myal gi a. Eryt hema mul t i forme may be s een i n ~25%. ~5% have a meni ngoencephal i t i s . W CC i s oft en normal , ESR i s hi gh, s peci fi c IgM i s s een earl y t hen l evel s decl i ne. ~50% devel op col d aggl ut i ni ns (al s o s een i n meas l es , EBV) whi ch may caus e haemol ys i s . CXR may s how ret i cul onodul ar s hadowi ng (l ower l obe > upper l obe) whi ch may t ake over 6 weeks t o res ol ve (unl i ke bact eri al pneumoni a). Treat ment i s wi t h eryt hromyc i n 500mg qds po/i v, c l ari t hromyc i n 500mg bd po/i v, or t et rac yc l i ne 500mg qds po/i v.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Legionella pneumonia
Legionella pneumonia
Il l nes s of mi ddl e-aged men; more s evere i n s mokers . Incubat i on 210 days fol l owed by hi gh fever, ri gors , headache, myal gi a, dry cough, progres s i ve res pi rat ory di s t res s , and confus i on. Abdomi nal pai n, di arrhoea, naus ea and vomi t i ng, and pal pabl e hepat omegal y are s een i n ~30%. Compl i cat i ons i ncl ude peri cardi t i s ( effus i on), encephal opat hy (CSF i s us ual l y normal ) and rarel y renal fai l ure. Moderat e l eukocyt os i s (20 10 /L, neut rophi l i a, l ymphopeni a), hyponat raemi a, deranged LFTs , prot ei nuri a, haemat uri a, and myogl obi nuri a. Di agnos i s : ri s e i n s peci fi c IgM and IgG t i t res (uri ne, bl ood, s put um). CXR may s how anyt hi ng from di ffus e pat chy i nfi l t rat es t o l obar or s egment al changes and us ual l y det eri orat es i n s pi t e of t reat ment . Pl eural effus i ons are s een i n ~50%. Treat ment i s wi t h c l ari t hromyc i n 500mg bd po/i v. Cont i nue t herapy for 1421 days . Add ri fampi c i n (600mg bd po/i v) i f s ympt oms do not s et t l e wi t hi n 72 hours . Pont i ac fever i s s el f-l i mi t i ng (25 days ) acut e non-pneumoni c Legi onel l a i nfect i on wi t h hi gh fever, ri gors , myal gi a, headache, and t racheo-bronchi t i s .
9
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Viral pneumonia
Viral pneumonia
Cl i ni cal feat ures res embl e Myc opl as ma pneumoni a (s ee P204). Di agnos i s i s by 4 i ncreas e i n s peci fi c ant i body t i t res . CMV. Commones t vi ral i nfect i on i n AIDS and fol l owi ng s ol i d organ or bone marrow t rans pl ant at i on, pres ent i ng as fever, dry cough, and progres s i ve res pi rat ory di s t res s wi t h hypoxi a and bi l at eral crackl es . CXR s hows di ffus e i nfi l t rat es ; a mi l i ary pat t ern i s as s oci at ed wi t h rapi d progres s i on and poor out come whereas an i nt ers t i t i al pat t ern has a bet t er prognos i s (s ee fi gure, P196). Treat wi t h ganci cl ovi r 5mg/kg i v q12h for 23 weeks . Coxsackie and Echovirus. Ti t res oft en ri s e i n epi demi c pl eurodyni a (Bornhol m's di s eas e), a s el f-l i mi t i ng i l l nes s wi t h ches t pai n exacerbat ed by coughi ng and deep breat hi ng, myal gi a, and mus cl e t endernes s . Treat ment : anal ges i a (paracet amol , NSAIDs ). Varicella pneumonia. More common i n s mokers and i mmunos uppres s ed pat i ent s . Al l pat i ent s wi t h vari cel l a pneumoni t i s s houl d be t reat ed wi t h acycl ovi r 10mg/kg i v 8 hourl y.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Chlamydia pneumonia
Chlamydia pneumonia
Chl amydi a pneumoni ae pres ent s i n ol der adul t s wi t h headaches and l onger durat i on of s ympt oms before hos pi t al admi s s i on. Ext ra-pul monary mani fes t at i ons may i ncl ude meni ngoencephal i t i s , Gui l l i anBarre s yndrome, art hri t i s , and myocardi t i s . Treat ment : eryt hromyc i n 500mg qds po/i v, c l ari t hromyc i n 500mg bd po/i v, or t et rac yc l i ne 500mg qds po/i v.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Psit t ac osis
Psittacosis
Chl amydi a ps i t t ac i produces fever, cough, myal gi a, and i n s evere cas es , del i ri um (ps i t t acos i s ). Compl i cat i ons i ncl ude peri cardi t i s , myocardi t i s , and hepat os pl enomegal y. Di agnos i s i s by s erol ogy. Treat wi t h t et racycl i ne 500mg po qds for 23 weeks .
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Misc ellaneous c ondit ions
Miscellaneous conditions
Extrinsic allergic alveolitis may mi mi c vi ral pneumoni a and pres ent as breat hl es s nes s , dry cough, myal gi a, and fever wi t h neut rophi l i a (eos i nophi l s us ual l y normal acut el y) and pat chy radi ographi c changes . There i s us ual l y hi s t ory of expos ure t o t he al l ergen and s erum preci pi t i ns are det ect abl e. BAL s hows predomi nance of mas t cel l s and l ymphocyt es . Treat ment i s wi t h s t eroi ds . Pulmonary eosinophilia: t hi s i s a het erogenous group of di s orders charact eri zed by eos i nophi l i c pul monary i nfi l t rat es produci ng res pi rat ory s ympt oms , CXR s hadowi ng, and bl ood and s put um eos i nophi l i a. The caus e may be unknown as i n crypt ogeni c eos i nophi l i c pneumoni a, or i t may be due t o drugs (e.g. ni t rofurant oi n, phenyt oi n, and ampi ci l l i n), hel mi nt h i nfect i ons (e.g. As c ari s l umbroc oi des , hookworms , St rongyl oi des s t erc oral i s ), t ropi cal pul monary eos i nophi l i a (l ymphat i c fi l ari al i nfect i on), or t he s mal l -ves s el s ys t emi c vas cul i t i s (ChurgSt raus s ). Allergic bronchopulmonary aspergillosis i s a hypers ens i t i vi t y react i on of ai rways col oni zed by As pergi l l us s p. produci ng pul monary eos i nophi l i a. It t ypi cal l y occurs i n as t hmat i cs wi t h repeat ed epi s odes of bronchi al obs t ruct i on, i nfl ammat i on, and mucus i mpact i on res ul t i ng i n bronchi ect as i s and upper l obe fi bros i s . Such pat i ent s are us ual l y as pergi l l us s ki n-pri ck t es t (IgE) and s erum preci pi t i ns (IgG) pos i t i ve. Treat ment depends on t he underl yi ng condi t i on. COP may pres ent wi t h fever, mal ai s e, cough, breat hl es s nes s , and pul monary s hadows on CXR.
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Charact eri zed by exces s i ve prol i ferat i on of granul at i on t i s s ue wi t hi n s mal l ai rways and al veol i , COP i s t he i di opat hi c form of bronchi ol i t i s obl i t erans organi zi ng pneumoni a (BOOP). Organi zi ng pneumoni a can al s o be as s oci at ed wi t h col l agen vas cul ar di s eas es (rheumat oi d art hri t i s , l upus , dermat omyos i t i s ), chroni c i nfect i on ( Legi onel l a , CMV, Myc opl as ma ), and drugs (ami odarone, bl eomyci n). Treat ment i s wi t h s t eroi ds .
Alveolar haemorrhage: i nt rapul monary haemorrhage may pres ent wi t h cough, fever, and breat hl es s nes s . Haemopt ys i s may be abs ent i n 30%. The CXR may s how di ffus e al veol ar opaci t i es . BAL s hows predomi nant l y RBCs . Caus es i ncl ude s ys t emi c vas cul i t i s (e.g. W egener's granul omat os i s , mi cros copi c pol yangi i t i s ), col l agen vas cul ar di s eas es (e.g. SLE), Goodpas t ure's s yndrome, ARDS, and i di opat hi c pul monary haemos i deros i s . Treat ment depends on t he caus e. Bronchoalveolar cell carcinoma may mi mi c an acut e pneumoni a radi ol ogi cal l y al t hough t ypi cal s ympt oms of pneumoni a are us ual l y not pres ent unl es s t here i s s uperadded i nfect i on. Di agnos i s i s made by l ung bi ops y.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e ast hma: assessment
Acute asthma: assessment
Presentation
The cl as s i cal t ri ad i s w heeze, breat hl es s nes s , and c ough . Pl euri t i c pai n may be due t o di aphragmat i c s t ret ch, pneumot horax, or acut e i nfect i on. Acut e at t acks may bui l d up over mi nut es , hours , or days and t he pat i ent s may det eri orat e very rapi dl y and pres ent as res pi rat ory or cardi o-res pi rat ory arres t . Fact ors i ncreas i ng t he ri s k of s evere l i fe-t hreat eni ng as t hma i ncl ude previ ous vent i l at i on, hos pi t al admi s s i on for as t hma i n t he l as t year, heavy res cue medi cat i on us e, >3 cl as s es of as t hma medi cat i on, repeat ed at t endances at A&E for as t hma care, bri t t l e as t hma.
Precipitants
No cl ear preci pi t at i ng caus e can be i dent i fi ed i n over 30% of pat i ent s Expos ure t o known al l ergen or i rri t ant (e.g. pol l ens , ani mal s , dus t s , ci garet t e s moke) Upper res pi rat ory t ract i nfect i on (commonl y vi ral ) Ches t i nfect i on: vi ral or bact eri al Negl ect or poor compl i ance wi t h regul ar i nhal ed or oral s t eroi ds Emot i onal s t res s Col d ai r or exerci s e-i nduced as t hma.
Markers of severity

For as s es s ment of t he s everi t y of as t hma, s ee t abl e. The s everi t y of an at t ack may be eas i l y underes t i mat ed. As s es s
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The degree of ai rfl ow obs t ruct i on The effect of i ncreas ed work of breat hi ng on t he pat i ent The ext ent of vent i l at i onperfus i on mi s mat ch Any evi dence of vent i l at ory fai l ure.
o o
(Pat i ent s wi t h marked morni ng di ps i n PEF are at ri s k of s udden s evere at t acks .)
Investigations
ABG Hypoxaemi a on room ai r i s al mos t i nvari abl e. In at t empt i ng t o mai nt ai n al veol ar vent i l at i on i ni t i al l y t here i s hypocapnoea and res pi rat ory al kal os i s . P a CO 2 s ugges t s i nci pi ent res pi rat ory fai l ure due t o exhaus t i on; cont act ITU i mmedi at el y. Poorl y cont rol l ed as t hma over s everal days may be recogni zed by a mi l d non-ani on gap aci dos i s (s erum bi carbonat e 2024mmol /L). A l act i c aci dos i s s een wi t h s evere as t hma. Pulse oximetry Chest X-ray ECG Cont i nuous oxi met ry i s es s ent i al ; ai m for 92%. Excl ude pneumot horax and t o di agnos e any parenchymal i nfect i on. Us ual l y normal ; i n s evere as t hmat i cs , s i gns of ri ght heart s t rai n may be pres ent . FBC, U&E, As s es s for s i gns of i nfect i on; K may be l owered by CRP P.211 hi gh dos es of -agoni s t s .
+
Assessment of severity of acute asthma 1
Near-fat al as t hma
o
Rai s ed P a CO 2 or i mmedi at e requi rement for vent i l at i on wi t h rai s ed i nfl at i on pres s ures
Li fe-t hreat eni ng as t hma
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Severe ai rways obs t ruct i on

PEF <33% bes t or predi ct ed Soft breat h s ounds or s i l ent ches t Feebl e res pi rat ory effort
Increas ed work of breat hi ng and haemodynami c s t res s

Exhaus t i on Hypot ens i on (s ys t ol i c BP <100mmHg) Bradycardi a or arrhyt hmi a Cyanos i s Hypoxi a (SpO 2 <92% and/or P a O 2 <8kPa i rres pect i ve of i ns pi red O 2 concent rat i on)
Vent i l at i on-perfus i on mi s mat ch

Vent i l at ory fai l ure
Ri s i ng P a CO 2 s ugges t s near-fat al as t hma Confus i on or coma
Acut e s evere as t hma

o o o o
PEF 3050% bes t or predi ct ed Res pi rat ory rat e >25/mi n Tachycardi a: heart rat e >100/mi n Inabi l i t y t o compl et e s ent ences i n one breat h Type 1: wi de PEF vari at i on des pi t e i nt ens i ve and regul ar t herapy Type 2: s udden s evere as t hma at t acks on background of apparent l y wel l -cont rol l ed as t hma
Bri t t l e as t hma
o
Admi s s i on i s mandat ory i f any of t he markers of s evere, l i fe-t hreat eni ng, or near-fat al as t hma are pres ent .
Footnote
1
Adapt ed from BTS/SIGN Bri t i s h gui del i nes on management of as t hma (2003) T horax 38 (s uppl . 1)
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e severe ast hma: immediat e t herapy
Acute severe asthma:
immediate therapy
Priorities

Treat hypoxi a Treat bronchos pas m and i nfl ammat i on As s es s t he need for i nt ens i ve care Treat any underl yi ng caus e i f pres ent (e.g. i nfect i on, pneumot horax).
o
Pat i ent s may det eri orat e rapi dl y and s houl d not be l eft unat t ended. Remai n c al m: reas s urance i s i mport ant i n reduci ng t he pat i ent 's anxi et y whi ch may furt her i ncreas e res pi rat ory effort .
Severe or life-threatening attack
Ini t i al t reat ment

o o
Si t t he pat i ent up i n bed. Oxygen : t he hi ghes t percent age avai l abl e, i deal l y at l eas t 60% or 15L/mi n wi t h a hi gh-fl ow mas k. CO 2 ret ent i on i s not a probl em i n as t hmat i c pat i ent s . Mai nt ai n O 2 s at s >92%.
Nebul i zed bronc hodi l at ors : gi ve nebul i zed s al but amol 5mg or t erbut al i ne 10mg, admi ni s t ered vi a O 2 and repeat up t o every 1530 mi nut es i f requi red. Cons i der cont i nuous nebul i zat i on of s al but amol 510mg/h i f i nadequat e res pons e t o i ni t i al t reat ment . Add i prat ropi um bromi de 0.5mg 46 hourl y i f i ni t i al res pons e t o 2 -agoni s t s i s poor.
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Obt ai n i v ac c es s . St art s t eroi ds : 200mg of hydrocort i s one i nt ravenous l y (s t eroi ds s houl d s t i l l be us ed i n pregnant women as t he ri s k of foet al anoxi a from t he as t hma i s hi gh). Cont i nue ei t her hydrocort i s one 100mg qds i v or predni s ol one 3050mg od po. Ant i bi ot i c s s houl d be gi ven i f t here i s evi dence of ches t i nfect i on (purul ent s put um, abnormal CXR, rai s ed W CC, fever). Y el l ow s put um may jus t be due t o eos i nophi l s and a rai s ed W CC may be due t o s t eroi ds . See P199 for choi ce of ant i bi ot i cs . Adequat e hydrat i on i s es s ent i al and may hel p prevent mucus pl uggi ng. Ens ure an i nt ake (i v or po) of 23L/day, t aki ng care t o avoi d overl oad. Suppl ement pot as s i um as requi red.
Moni t ori ng progres s

o o
Pre- and pos t -nebul i zer peak fl ows . Repeat ed art eri al bl ood gas es 12 hourl y or accordi ng t o res pons e es peci al l y i f SaO 2 <93%.
If res pons e t o above t reat ment not bri s k or i f t he pat i ent 's condi t i on i s det eri orat i ng
o
Cont i nue oxygen and nebul i z ed 2 -agoni s t every 15 mi nut es . Gi ve a s i ngl e dos e of i v magnes i um s ul phat e (s ee t abl e). Cons i der s t art i ng an i v ami nophyl l i ne i nfus i on (s ee t abl e). Cons i der s t art i ng an i v s al but amol i nfus i on (s ee t abl e). Summon anaes t het i c hel p .
P.213
Intravenous bronchodilators for asthma

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Magnes i um s ul phat e
1.22g i f i nfus ed over 20 mi nut es
Gi ve as a s i ngl e dos e onl y. Repeat ed dos es may l ead t o hypermagnes aemi a wi t h mus cl e weaknes s and res pi rat ory fai l ure. Sal Loa but di n am g ol dos e: 10 0 3 00 g ove r 10 mi nut es Mai nt e na
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nc e i nf us i on : 5 2 0 g/ mi n (5 mg in 50 0m l s al i ne at 1 3 ml / mi n) Si de Effect s : t remor, t achycardi a, hypokal aemi a, hypergl ycaemi a common. Lact i c aci dos i s may occur and res ponds wi t hi n hours t o reduct i on i n s al but amol i nfus i on rat e. Am Loa i no di n phy g l l i n dos e e: 25
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0m g (4 5 mg /kg ) iv ove r 20 mi nut es Mai nt e na nc e i nf us i on : 0.5 0.7 mg /kg /h (25 0m g in 1 litr e N s al i ne
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at 2 4 ml / kg/ h)
Do not gi ve t he l oadi ng dos e i f t he pat i ent i s on oral t heophyl i nes wi t hout checki ng a l evel . Hal ve t he dos e i n pat i ent s wi t h ci rrhos i s or CCF, or i n t hos e recei vi ng eryt hromyci n, ci met i di ne, or ci profl oxaci n. Moni t or l evel s every 24 hours (ai m for l evel s of 1020mg/L).
Indications for admission to intensive care unit

Hypoxi a ( P a O 2 <8kPa (60mmHg) des pi t e Fi O 2 of 60% Ri s i ng P a CO 2 or P a CO 2 >6kPa (45mmHg) Exhaus t i on, drows i nes s , or coma Res pi rat ory arres t Fai l ure t o i mprove des pi t e adequat e t herapy
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e severe ast hma: furt her management
Acute severe asthma:
further management
Cautious CPAP may hel p reduce t he work of breat hi ng i n pat i ent s wi t h res pi rat ory mus cl e fat i gue but may not i ncreas e t he funct i onal res i dual capaci t y furt her. Ketamine (a di s s oci at i ve anaes t het i c agent ) may be us eful i n vent i l at ed pat i ent s (13mg/mi n) probabl y by i ncreas i ng ci rcul at i ngcat echol ami nes by bl ocki ng upt ake i nt o adrenergi c nerve endi ngs . Inhalational anaesthetic agents (e.g. hal ot hane, enfl urane, i s ofl urane) have been report ed t o i mprove bronchos pas m and may be us eful when i ni t i at i ng vent i l at i on. Mechanical ventilation may be l i fe s avi ng but has a hi gh ri s k of compl i cat i ons and an overal l mort al i t y of ~13%. Barot rauma i s s een i n ~14% (e.g. pneumot horax, pneumo-medi as t i num, or s ubcut aneous emphys ema) and hypot ens i on i n ~38% (us ual l y a combi nat i on of i ncreas ed i nt rat horaci c pres s ure, i nt ravas cul ar fl ui d depl et i on due t o dehydrat i on, and di l at i ng effect of anaes t het i c agent s ). Seek expert advi ce from your i nt ens i ve care phys i ci an for t he pract i cal management of vent i l at i on of t he as t hmat i c pat i ent .
General principles

Adequat e humi di fi cat i on and warmi ng of i ns pi red gas es Low frequency vent i l at i on (610 breat hs /mi n) Low t i dal vol umes (610ml /kg) Long expi rat ory phas e of t he cycl e (I : E rat i o 1 : 3 or
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l onger)
Mi ni mi ze ai rway pres s ures (ai m for <50cm H 2 O, normal <25) Mai nt ai n P a O 2 >8.0 kPa; al l ow P a CO 2 t o ri s e provi ded pH >7.2 Adequat e s edat i on and paral ys i s t o overcome res pi rat ory dri ve Avoi d opi at es and at acuri um (may rel eas e hi s t ami ne) Cons i der benzodi azepi ne, ket ami ne, vecuroni um, i s ofl urane, et c.
On-going therapy
Once i mprovement es t abl i s hed cont i nue nebul i zed 2 -agoni s t , reduci ng t hi s t o 4-hourl y and prn aft er 2448 hours Peak fl ow rat e s houl d be meas ured before and aft er each nebul i zer Mai nt ai n O 2 s at s >92% Cont i nue nebul i zed i prat ropi um bromi de 6-hourl y unt i l t he condi t i on i s i mprovi ng Cont i nue s t eroi ds , hydrocort i s one 100mg q6h i v s wi t chi ng t o 3060mg od oral predni s ol one when abl e t o s wal l ow, and cont i nue for 1014 days Moni t or i nt ravenous ami nophyl l i ne l evel s every 24 hours Moni t or s erum K dai l y whi l s t unwel l and s uppl ement as neces s ary.
+
P.215
Discharge after hospital admission
The PEF s houl d be 75% of bes t wi t hout s i gni fi cant morni ng di ppi ng (di urnal vari abi l i t y 25%) and wi t h no noct urnal s ympt oms The pat i ent s houl d be es t abl i s hed on i nhal ers wi t h no requi rement for nebul i zers for 2448 hours pri or t o
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di s charge. Check i nhal er t echni que
Di s charge drugs :
o
Predni s ol one po 30mg od for 13 weeks (pl an gradual dos e reduct i oni f t reat ment >14 days ) I nhal ed c ort i c os t eroi ds at hi gh dos e (us ual l y 10001500g becl omet has one vi a s pacer) or equi val ent Res t art i nhal ed l ong-ac t i ng 2 - agoni s t s i f pres cri bed pri or t o admi s s i on Inhal ed prn 2 - agoni s t Oral t heophyl l i nes i f requi red (confi rm drug l evel s before di s charge)
o o
Provi de PEFR met er and chart and arrange fol l ow-up wi t h GP or pract i ce nurs e (wi t hi n 2 days ) and ches t cl i ni c (wi t hi n 1 mont h)
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Mildmoderat e ast hmat ic at t ac ks
Mildmoderate asthmatic
attacks
Mild asthmatic attack
No s evere feat ures , PEF 75% of predi ct ed (or of bes t when wel l ).
Admi ni s t er t he pat i ent 's us ual bronchodi l at or (e.g. 2 puffs s al but amol by met ered dos e i nhal er). Obs erve for 60 mi nut es . If PEF remai ns 75% of predi ct ed val ue, t hen di s charge. Ens ure pat i ent i s on at l eas t 1000g i nhal ed becl omet has one or equi val ent per day. Advi s e t he pat i ent t o get earl y GP fol l ow-up, moni t or PEF, and ret urn t o hos pi t al earl y i f t he as t hma det eri orat es .
Moderate asthmatic attack

No acut e s evere feat ures , PEF 5175% of predi ct ed (or of bes t when wel l )
Admi ni s t er nebul i zed -agoni s t (s al but amol 5mg or t erbut al i ne 10mg) and oral predni s ol one 3060mg. Re-as s es s aft er 30 mi nut es . If wors e or PEF 50% of predi ct ed t hen admi t and as s es s as bel ow for s evere as t hma. If PEF 5175% predi ct ed t hen repeat nebul i zer and obs erve for a furt her 60 mi nut es . The pat i ent may be di s charged from A&E i f s t abl e aft er 12 nebul i zers and PEFR 75%. If aft er s econd nebul i zer and a furt her 60 mi nut es ' obs ervat i on t hepat i ent i s cl earl y i mprovi ng and PEFR
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50%, t hen di s charge may be cons i dered.
Di s charge on
o
Oral predni s ol one (us ual dos e 3040mg od for 7 days ) Inhal ed cort i cos t eroi d (1000g/day i nhal ed becl omet has one) Inhal ed -agoni s t .
Advi s e t he pat i ent t o s eek GP fol l ow-up wi t hi n 48 hours and t o ret urn earl y t o A&E i f t here i s any det eri orat i on. Cons i der referral t o ches t cl i ni c.
Sending people home from A&E
Mi l d-moderat e exacerbat i ons may be fi t t o be di s charged from A&E. If t here are any feat ures of acut e s evere as t hma (s ee t abl e, P211) t hen admi s s i on i s mandat ory. A hi s t ory of bri t t l e as t hma or previ ous at t acks requi ri ng mechani cal vent i l at i on i s al ways a requi rement for admi s s i on.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e exac erbat ion of c hronic obst ruc t ive pulmonary disease (
Acute
exacerbation of chronic obstructive pulmonary disease (COPD): assessment

Presentation
Det eri orat i on of pre-exi s t i ng s ympt oms of exert i onal breat hl es s nes s , cough (s omet i mes wi t h dai l y s put um product i on) and wheez e. Res pi rat ory fai l ure (s ee P224): May be Type 1 (normal P
a
CO 2 , l ow P a O 2 ) or Type 2 (hi gh P a CO 2 , l ow P a O 2
refl ect i ng s evere bronchos pas m and/or al veol ar hypovent i l at i on).

W heeze unrel i eved or part i al l y rel i eved by i nhal ers . Increas ed product i on of purul ent s put um (i .e. i nfect i on as a preci pi t ant ). Pos i t i ve s moki ng hi s t ory (i f not t hen l at e-ons et as t hma i s l i kel y). Confus i on/i mpai red cons ci ous nes s (exhaus t i on, CO 2 ret ent i on).
Causes
I nfec t i ve exac erbat i on (No new CXR changes ): Typi cal l y H. i nfl uenzae, S. pneumoni ae, Moraxel l a c at arrhal i s . Commonl y vi ral . Communi t y acqui red pneumoni a (new CXR changes ): See P196. Expos ure t o know n al l ergen: COPD may co-exi s t wi t h
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al l ergi c as t hma.
Pneumot horax (s ee P236, di fferent i at e from l arge bul l ae). Expans i on of l arge bul l ae. Sput um ret ent i on wi t h l obar or s egment al col l aps e (at el ect as i s ): pneumoni a, exces s i ve s edat i on or opi oi d anal ges i a (t rauma, pos t -s urgery), i mpai red cons ci ous nes s . Confoundi ng or c ont ri but i ng fac t ors : myocardi al i s chaemi a, pul monary oedema, cor pul monal e, pul monary embol i s m.
Investigations
Al l pat i ent s s houl d have: U&Es FBC Look for dehydrat i on, renal fai l ure. Moni t or K . Look for l eukocyt os i s or anaemi a (chroni c res pi rat ory fai l ure may produce a s econdary pol ycyt haemi a). Pul s e oxi met ry To as s es s degree of res pi rat ory fai l ure and pH. and ABG Sept i c s creen And gui de appropri at e oxygen t reat ment . Sput um s houl d be s ent for cul t ure. Bl ood cul t ures i f febri l e or CXR changes s ugges t pneumoni a. Peak fl ows Ches t X-ray ECG As k what i s normal for pat i ent . Focal changes s ugges t pneumoni a (s ee P196). Myocardi al i s chaemi a or arrhyt hmi a.
+
Assessment of severity
Hi s t ory: As s es s t he s everi t y of COPD when s t abl e and compare wi t h current exacerbat i on. As k about s ympt oms and funct i onal capaci t y when wel l (di s t ance wal ked on fl at , s t ai rs cl i mbed, frequency of exacerbat i ons , previ ous admi s s i ons , ever vent i l at ed?). As s es s l evel of us ual t reat ment (regul ar nebul i zed bronchodi l at ors or oral s t eroi ds , home O 2 ) and
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concurrent i l l nes s es (IHD, renal i mpai rment ). Any previ ous document at i on (PFTs , ABG).
Exami nat i on: As s es s for s everi t y of res pi rat ory di s t res s (RR >25/mi n, us e of acces s ory mus cl es or paradoxi cal ches t wal l movement s ), hypoxi a (cyanos i s ), hypercapnoea (CO 2 ret ent i on fl ap, confus i on), cor pul monal e (peri pheral oedema).
P.219
Criteria for hospital admission 1

Marked i ncreas e i n s ympt oms Bas el i ne of s evere COPD New phys i cal s i gns , e.g. cyanos i s , peri pheral oedema Fai l ure t o res pond t o i ni t i al management at home Si gni fi cant co-morbi di t i es Di agnos t i c uncert ai nt y Age >70 years Ins uffi ci ent home s upport
Footnote
1
Adapt ed from
Gl obal i ni t i at i ve for chroni c obs t ruct i ve pul monary di s eas e 1993.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e exac erbat ion of COPD: management
Acute exacerbation of
COPD: management
T reat hypoxia and respiratory failure

o
The di s t i nct i on bet ween pi nk puffers (breat hl es s t o mai nt ai n P a O 2 and s o keep P a CO 2 down) and bl ue bl oat ers (l os e breat hl es s dri ve t o mai nt ai n P a O 2 and s o P a CO 2 ri s es ) i s unhel pful as mos t pat i ent s have feat ures of bot h. Commence oxygen therapy. Uncont rol l ed O 2 t herapy may wors en CO 2 ret ent i on i n s ome pat i ent s . W hi l e awai t i ng ABGs gi ve cont rol l ed 2428% O 2 vi a a vent ure mas k. Nas al canul ae gi ve unrel i abl e i ns pi red O 2 concent rat i on and may be dangerous . Once ABG res ul t s avai l abl e, adjus t Fi O 2 accordi ngl y. Arterial blood gases
If pat i ent i s not ret ai ni ng CO 2 ( P a CO 2 < 6kPa) and i s hypoxi c ( P a O 2 <10kPa) t hen gi ve oxygen 2840%. Repeat ABGs 30 mi nut es l at er (s ooner i f cons ci ous l evel det eri orat es ) t o ens ure correct i on of hypoxi a and excl ude ri s i ng P a CO 2 . Ai m t o mai nt ai n s at s 92%. If CO 2 ret ent i on i s pres ent t hen us e 2428% oxygen and repeat bl ood gas es aft er 1530 mi nut es . Ai m t o keep P a O 2 7.3kPa and P a CO 2 7.5kPa, but t hes e l i mi t s may not be achi evabl e. Bal ance hypoxi a (whi ch may be fat al ) agai ns t cons ci ous l evel , art eri al pH, and res pi rat ory
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effort . Cons i der non-i nvas i ve vent i l at i on, mechani cal vent i l at i on, or doxapram.
o
NIV. Thi s i s t he fi rs t -l i ne t reat ment of choi ce for COPD exacerbat i ons wi t h t ype 2 res pi rat ory fai l ure i n pat i ent s who fai l t o res pond t o i ni t i al t herapy. It al l ows t he admi ni s t rat i on of hi gher O 2 concent rat i ons wi t hout an uncont rol l ed ri s e i n P a CO 2 . NIV reduces t he need for i nt ubat i on, decreas es mort al i t y and hos pi t al s t ay, and s houl d be cons i dered i n al l pat i ent s wi t h COPD exacerbat i ons wi t h P a CO 2 6.0kPa and pH 7.35 who have fai l ed t o res pond t o i ni t i al bronchodi l at or t herapy. Mechanical ventilation. Thi s s houl d be cons i dered i n pat i ent s unl i kel y or unabl e t o t ol erat e NIV (s ee P906). Respiratory stimulants. Thes e have general l y been s upers eded by NIV. However where NIV i s not avai l abl e or has not been s ucces s ful and mechani cal vent i l at i on i s not cons i dered appropri at e, a t ri al of doxapram may be wort hwhi l e. It i s not benefi ci al i n t ype 2 res pi rat ory fai l ure due t o poor res pi rat ory effort .
T reat bronchospasm and obstruction

o
Nebul i zed -agoni s t s (s al but amol 5mg or t erbut al i ne 10mg q4h and prn) vi a oxygen or ai r i f CO 2 ret ai ni ng. (If pat i ent i s very hypoxi c, gi ve 2L/mi n oxygen vi a nas al cannul ae whi l s t nebul i zer i n progres s .) Pat i ent s wi t h COPD may have rel at i vel y fi xed bronchos pas m, but where t he pat i ent i s very unwel l t hen cons i der i v ami nophyl l i ne and/or i v -agoni s t s as for s evere as t hma (P213). Incl ude nebul i zed i prat ropi um bromi de 500g 6 hourl y.
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Gi ve s t eroi ds : 200mg hydrocort i s one i v or 3040mg predni s ol one po. Urgent phys i ot herapy may hel p cl eari ng bronchi al s ecret i ons .
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e exac erbat ion of COPD
Acute exacerbation of COPD
Mechanical ventilation
COPD per s e i s not a cont rai ndi cat i on t o vent i l at i on i n appropri at el y s el ect ed pat i ent s . Vent i l at i on s houl d be cons i dered where res pi rat ory fai l ure i s pres ent ( P a O 2 7.3kPa) regardl es s of CO 2 l evel s and i n t hos e pat i ent s who have fai l ed t o res pond t o fi rs t -l i ne t reat ment (i ncl udi ng NIV), or who are very s everel y unwel l and unl i kel y t o res pond t o any ot her i nt ervent i on. Di s cus s wi t h a s eni or col l eague or ITU s t aff pri or t o i nt ubat i on.
In favour of a good outcome from ventilation
Acut e res pi rat ory fai l ure (normal bi carbonat e, acut e hi s t ory) Rel at i vel y young pat i ent Obvi ous remedi abl e caus e (e.g. pneumoni a) Good recent exerci s e t ol erance and qual i t y of l i fe Not previ ous l y known t o ret ai n CO 2 when wel l .
Against a good outcome from ventilation

Rel at i vel y ol d Ot her co-morbi d condi t i ons (e.g. IHD, renal fai l ure) Previ ous di ffi cul t y weani ng from vent i l at or On maxi mal t herapy at home (home nebul i zer, l ong-t erm oxygen t herapy) Poor qual i t y of l i fe or poor exerci s e t ol erance.
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Management of gas exchange during ventilation
Pat i ent s who are chroni cal l y hypoxi c or CO 2 ret ai ners wi l l t ol erat e poor bl ood gas es bet t er t han t hos e pat i ent s wi t h ot her caus es of res pi rat ory fai l ure. W hen vent i l at i ng pat i ent s wi t h COPD, achi evi ng a normal P a CO 2 and P a O 2 may not be appropri at e. Thos e who are chroni cal l y hypoxi c or who chroni cal l y ret ai n CO 2 (as evi denced by previ ous abnormal gas es or a rai s ed bi carbonat e wi t h a normal or near-normal pH) are unl i kel y t o breat h s pont aneous l y or wean from t he vent i l at or unl es s t hei r bl ood gas es are al l owed t o mi rror what i s probabl y t hei r chroni c s t at e. Thus a pat i ent wi t h chroni c t ype 2 res pi rat ory fai l ure may need a P a CO 2 of 67.5kPa mi l d hypoxi a even on t he vent i l at or t o achi eve s ucces s ful weani ng.
Treat cause of exacerbation

Infective exacerbation
Sugges t ed by purul ent s put um or i ncreas e i n s put um product i on. For l obar cons ol i dat i on or bronchi al pneumoni a fol l ow gui del i nes on pP198200. Ot herwi s e t reat wi t h amoxyc i l l i n 500mg1g t ds po/i v; i f unwel l or fai l ure t o res pond t reat c efuroxi me 750mg t ds i v for i mproved cover of res i s t ant Haemophi l us s p. Fol l ow l ocal prot ocol s .
Pneumothorax. Unl es s very s mal l , cons i der as pi rat i on drai n, P236. Pulmonary oedema. P108. Pulmonary embolism. P146.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Respirat ory failure: assessment
Respiratory failure:
assessment
Res pi rat ory fai l ure i s pres ent when gas exchange becomes s i gni fi cant l y i mpai red. Cl i ni cal l y, i t i s not pos s i bl e t o predi ct t he P a O 2 or P a CO 2 and s o t hi s di agnos i s rel i es on ABG anal ys i s . There are t wo t ypes : T ype 1. Hypoxi a P a O 2 8kPa on ai r or oxygen wi t h normal or l ow P a CO 2 (i .e. mai nl y vent i l at i onperfus i on mi s mat ch). T ype 2. Hypoxi a P a O 2 8kPa on ai r or oxygen wi t h rai s ed P a CO 2 (>6kPa) (i .e. predomi nant l y al veol ar hypovent i l at i on). In pract i ce, bot h t ypes may co-exi s t .
Presentation
Short nes s of breat h i s t he commones t pres ent at i on. As k about t he s peed of ons et (s udden ons et may s ugges t pneumot horax, pul monary embol us , or cardi ac fai l ure). Res pi rat ory fai l ure may pres ent wi t hout dys pnoea, part i cul arl y exacerbat i ons of COAD wi t h hypovent i l at i on (bl ue bl oat ers ), and non-res pi rat ory caus es s uch as Gui l l ai nBarr s yndrome (P572) or drug overdos e. Neuromus cul ar res pi rat ory fai l ure i s di s cus s ed on P502. Confus i on may be t he s ol e pres ent at i on i n t he el derl y. Hi s t ory of as t hma/chroni c bronchi t i s and s moki ng. Hi s t ory of ot her chroni c l ung di s eas e (e.g. fi bros i ng al veol i t i s , s arcoi dos i s ). Sput um product i on and fevers (pneumoni a).
T he hi s t ory may poi nt t o t he caus e of res pi rat ory fai l ure:

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Swol l en l egs due t o t he devel opment of cor pul monal e or hypoxi c/hypercapni c renal fl ui d ret ent i on i n pat i ent s wi t h chroni c l ung di s eas e. Haemopt ys i s (pneumoni a, PE). Cardi ac hi s t ory i ncl udi ng pal pi t at i ons and/or ches t pai n. Drug and/or overdos e hi s t ory. Neurol ogi cal s ympt oms i ncl udi ng pai nful l egs and paraes t hes i ae (Gui l l ai nBarr s yndrome). Al l ergi es . Try t o as s es s t he funct i onal capaci t y when wel l , e.g. di s t ance wal ked on fl at , s t ai rs cl i mbed wi t hout s t oppi ng, frequency of at t acks , previ ous admi s s i ons , ever vent i l at ed?, concurrent i l l nes s es (heart di s eas e, renal i mpai rment , l i ver i mpai rment ), et c.
Physical examination
Li s t en t o t he breat hi ng (s t ri dor, wheeze, coars e crackl es ). Look for wheez e (ai rfl ow l i mi t at i on, ei t her l ocal i zed (l ocal obs t ruct i on) or general i zed (e.g. as t hma, COPD, pul monary oedema), coars e crackl es (i nfect i on, pul monary oedema, or fi bros i s ), bronchi al breat hi ng (i ndi cat es cons ol i dat i on or col l aps e, but may al s o occur wi t h fi bros i s or above a pl eural effus i on), s i gns of pneumot horax (hyper-res onance, decreas ed breat h s ounds ), or pl eural effus i on (s t ony dul l , decreas ed breat h s ounds ). Pal pat e t he upper ches t and neck for crepi t us (pneumot horax or pneumomedi as t i num). Look for s i gns of a DVT (s wol l en hot l eg pai n, s ee P142).
P.225
Causes of respiratory failure

Common
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Acut e as t hma (P210) Exacerbat i on of COPD (P218) Pneumoni a (P194) Pul monary oedema (P108) Pul monary embol us (P146) Infect i on compl i cat i ng kyphos col i os i s or ot her chroni c l ung di s eas e Pl eural effus i on (P248) Pneumot horax (P236) ARDS/ALI (P230) Res pi rat ory depres s i on Drugs e.g. opi at es Lung col l aps e/at el ect as i s (t umour, forei gn body, s put um pl ug, i nfect i on) Acut e res pi rat ory mus cl e weaknes s [Gui l l ai nBarr s yndrome (P512), myas t heni a gravi s (P506), pol i omyel i t i s ] Upper ai rway obs t ruct i on (forei gn body, t umour, epi gl ot t i t i s ) (P256) Ches t t rauma Anaphyl axi s (P264)
Rarer
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Respirat ory failure: invest igat ions
investigations
Urgent investigations
ABG On ai r i mmedi at el y, or i f very unwel l whi l s t on oxygen (not e Fi O 2 ) Ches t X ray ECG Look for s i gns of PE (t achycardi a, RBBB, ant eri or T-wave changes , RAD, rarel y S 1 Q 3 T 3 , P146), t achyarrhyt hmi as , or myocardi al i s chaemi a Bl ood t es t s Ins pect s put um FEV 1 and FVC Sept i c s creen If s us pect ed mus cl e weaknes s (e.g. Gui l l ai nBarr) Sput um cul t ure, bl ood cul t ures i f febri l e or i f CXR s ugges t s i nfect i on. Y el l ow, green, mucoi d, s t reaky, or frank bl ood FBC (anaemi a, l eukocyt os i s ), U&Es , gl ucos e (s ee fi gure, P196)
Where indicated consider

As pi ri n and paracet amol l evel s Pl as ma and uri ne for t oxi col ogy Uri nal ys i s for gl ucos e and ket ones Exami ne t he CXR s ys t emat i cal l y for any abnormal i t y.
CXR assessment
Cons ol i dat i on/al veol ar s hadowi ng: may be l obar or pat chy. Pres ence of an ai r bronchogram s ugges t s
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pneumoni a.
Pul monary oedema due t o l eft vent ri cul ar fai l ure (cardi ogeni c): t ypi cal l y peri hi l ar (bat s -wi ng), upper l obe venous conges t i on, Kerl ey B l i nes i n peri pheral l ung fi el ds , pl eural effus i ons , cardi omegal y. Non-cardi ogeni c pul monary oedema (ARDS/ALI): t ypi cal l y peri pheral al veol ar s hadowi ng ai r bronchogram, no upper l obe venous conges t i on, Kerl ey B l i nes , pl eural effus i ons , or cardi omegal y. Pl eural effus i ons . Mas s es s ugges t i ng bronc hogeni c c arc i noma . Pul monary embol i s m: wedge-s haped peri pheral opaci t i es , s mal l pl eural effus i ons , l ocal i zed areas of ol i gaemi a, enl arged pul monary art ery. Pneumot horax (di s t i ngui s h from l arge bul l ae). Trauma/ri b fract ures . Di ffus e l ung di s eas e (e.g. fi bros i ng al veol i t i s ): s mal l l ung fi el ds , i nt ers t i t i al ret i cul o-nodul ar s hadowi ng, peri pheral l y and bas al l y.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Respirat ory failure: management
management
See P502 for neuromus cul ar res pi rat ory fai l ure. The s everi t y of res pi rat ory fai l ure depends upon res pons e t o oxygen. Fai l ure of hypoxi a t o correct on 4060% oxygen or progres s i ve hypercapnoea i mpl i es t hat non-i nvas i ve or mechani cal vent i l at i on may be neces s ary dependi ng on t he cl i ni cal condi t i on and underl yi ng caus e.
Poor prognostic signs on presentation include

Inabi l i t y t o s peak due t o dys pnoea Res pi rat ory rat e (>40) Peak fl ow 33% of predi ct ed i n acut e as t hma Tachycardi a HR 100 or bradycardi a HR 60 Exhaus t i on or coma (vent i l at ory s upport i s requi red urgent l y) St ri dor (t hi s i ndi cat es upper ai rway obs t ruct i on, s ee P254) Pul s e oxi met ry s at urat i on of <90% Shock (t achycardi a + hypot ens i on). May i ndi cat e t ens i on pneumot horax (P242), s evere LVF (P108), s evere pneumoni a (P198), or l arge PE (P146).
Hypercapnoea i s t he end res ul t of many caus es of res pi rat ory fai l ure (i ncl udi ng as t hma and pneumoni a), not jus t COPD, and i ndi cat es a t i ri ng pat i ent . Even i f rel at i vel y el derl y t he pat i ent may res pond wel l t o vent i l at i on wi t h a s at i s fact ory fi nal out come dependi ng on t he di s eas e and premorbi d condi t i on.
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General resuscitation (ABC)

Ens ure t he ai rway i s pat ent and t he mout h i s cl ear. If s t ri dor i s pres ent reques t anaes t het i c and/or ENT as s i s t ance urgent l y (P254). Si t t he pat i ent up (unl es s hypot ens i ve) and admi ni s t er oxygen at 60% unl es s t here i s a hi s t ory of COPD (us e 2428% oxygen). Ens ure t hat res pi rat ory effort i s adequat e and effect i ve (meas ure res pi rat ory rat e and as s es s dept h of res pi rat i on), us e pul s e oxi met ry t o moni t or t he P aO 2 . If t he pat i ent i s exhaus t ed wi t h a fai l i ng res pi rat ory dri ve, cal l for anaes t het i c as s i s t ance and cons i der urgent t rans fer t o ITU. In comat os e pat i ent s wi t h poor res pi rat ory effort cons i der drug overdos e wi t h opi at es (pi npoi nt pupi l s ) or benzodi azepi nes . Gi ve nal oxone 200400g (24g/kg) i v bol us fol l owed by i nfus i on dependi ng on res pons e and/or i v fl umazeni l (200g over 15 s econds t hen 100g at 60-s econd i nt erval s i f requi red [max. t ot al dos e 1mg (2mg i f on ITU)]. Met hods of res pi rat ory s upport are di s cus s ed on P902. Secure i v acces s . Meas ure t he BP and heart rat e, l ook for s i gns of cardi ac fai l ure (rai s ed JVP, i ns pi rat ory crackl es , oedema) or s i gns of pul monary embol i s m (rai s ed JVP, t achycardi a, hypot ens i on, normal breat h s ounds pl eural rub).
P.229
Indications for intensive care

Progres s i ve exhaus t i on or i mpai red cons ci ous l evel Shock not res pondi ng rapi dl y t o i ni t i al res us ci t at i on Res pi rat ory fai l ure not res pondi ng rapi dl y t o i ni t i al t herapy
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Adult Respirat ory Dist ress Syndrome 1
Adult Respiratory Distress
Syndrome 1
ALI and i t s more s evere s ub-s et , ARDS, i s a common cl i ni cal di s order charact eri zed by i njury t o t he al veol ar epi t hel i al and endot hel i al barri ers of t he l ung, acut e i nfl ammat i on, and prot ei n-ri ch pul monary oedema l eadi ng t o acut e res pi rat ory fai l ure. Oft en occurs i n t he s et t i ng of MOF.
Diagnostic criteria
Acut e ons et of res pi rat ory fai l ure wi t h one or more ri s k fact ors (t abl e, oppos i t e) Hypoxaemi a
o o
ALI: Rat i o P a O 2 (kPa) : Fi O 2 <40 ARDS: Rat i o P a O 2 (kPa) : Fi O 2 <27
Bi l at eral i nfi l t rat es on CXR Pul monary capi l l ary wedge pres s ure <19mmHg, wi t h normal col l oi d oncot i c pres s ure (i n pat i ent s wi t h hypoal bumi naemi a, t he cri t i cal PCW P i s approx. s erum al bumi n (g/l ) 0.57, s ee P282) or cl i ni cal excl us i on of cardi ac fai l ure.
Investigations

CXR ABG (cons i der art eri al l i ne as regul ar s ampl es may be requi red) Take bl ood for FBC, U&Es , LFTs and al bumi n, coagul at i on, X-mat ch, and CRP Sept i c s creen (cul t ure bl ood, uri ne, s put um) ECG Cons i der drug s creen, amyl as e i f hi s t ory s ugges t i ve
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Pul monary art ery cat het er t o meas ure PCW P, cardi ac out put , mi xed venous oxygen s at urat i on and t o al l ow cal cul at i on of haemodynami c paramet ers Ot her i nves t i gat i ons i f appropri at e
o o
CT ches t Bronchoal veol ar l avage for mi crobi ol ogy and cel l count (?eos i nophi l s ) Carboxy-haemogl obi n es t i mat i on.
Management
Al mos t al l c as es of ALI al one w i l l requi re HDU/I CU c are: l i ai s e earl y The mai n ai m i s t o i dent i fy and t reat t he underl yi ng caus e whi l s t provi di ng s upport for organ fai l ure:
o
Res pi rat ory s upport t o i mprove gas exchange and correct hypoxi a Cardi ovas cul ar s upport t o opt i mi ze oxygen del i very t o t i s s ues Revers e or t reat t he underl yi ng caus e.
P.231
Disorders associated with the development of ARDS

Direct lung injury
As pi rat i on
o o
Gas t ri c cont ent s Near drowni ng Noxi ous gas es Smoke Any organi s m PCP
Inhal at i on i njury
o o
Pneumoni a
o o
Pul monary vas cul i t i des
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Pul monary cont us i on Drug t oxi ci t y or overdos e

o o o o
Oxygen Opi at e overdos e Bl eomyci n Sal i cyl at es
Indirect (non-pulmonary) injury

Shock Sept i caemi a Amni ot i c or fat embol i s m Acut e pancreat i t i s Mas s i ve haemorrhage Mul t i pl e t rans fus i ons DIC Mas s i ve burns Major t rauma Head i njury
o o
Rai s ed ICP Int racrani al bl eed
Cardi o-pul monary bypas s Acut e l i ver fai l ure
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Syndrome 2
Respiratory support Spontaneously breathing patient
In very mi l d ALI, hypoxi a can be correct ed wi t h i ncreas ed i ns pi red oxygen concent rat i ons (Fi O 2 4060%). However, s uch pat i ent s are rarel y recogni zed as havi ng ALI as a caus e of t hei r res pi rat ory fai l ure. Pat i ent s i nvari abl y requi re hi gher oxygen concent rat i ons (non-rebreat her mas ks wi t h res ervoi r Fi O 2 ~6080%) or CPAP (s ee P904). Cons i der t rans fer t o HDU/ICU. Indi cat i ons for mechani cal vent i l at i on
o o o
Inadequat e oxygenat i on ( P a O 2 <8kPa on Fi O 2 >0.6) Ri s i ng or el evat ed P a CO 2 (>6kPa) Cl i ni cal s i gns of i nci pi ent res pi rat ory/cardi ovas cul ar fai l ure.
Mechanical ventilation
Thi s i s t he real m of t he ICU phys i ci an. Mai n ai m i s t o i mprove oxygenat i on/ vent i l at i on whi l e mi ni mi zi ng t he ri s k of furt her vent i l at or-i nduced l ung i njury; t ermed l ung prot ect i ve vent i l at i on.
General principles
Cont rol l ed mechani cal vent i l at i on wi t h s edat i on ( neuromus cul ar bl ockade). Ai m for t i dal vol ume ~6ml /kg. Recent evi dence has confi rmed t hat vent i l at i on wi t h s mal l er t i dal vol umes i s as s oci at ed wi t h i mproved out come compared t o t he
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t radi t i onal approach (~1012ml /kg).
St art wi t h Fi O 2 = 1.0. Subs equent adjus t ment s are made t o achi eve oxygen s at urat i on >90% wi t h Fi O 2 < 0.6. Pos i t i ve end expi rat ory pres s ure (PEEP) i mproves oxygenat i on i n mos t pat i ent s and al l ows reduct i on i n Fi O 2 . Us ual s t art i ng l evel , 510cm H 2 O, wi t h opt i mal l evel s i n t he range 1015cm H 2 O. Beware hypot ens i on due t o reduct i on i n venous ret urn. The us e of s mal l er t i dal vol umes may i mpai r CO 2 cl earance wi t h res ul t i ng aci dos i s des pi t e hi gh vent i l at ory rat es (2025 breat hs /mi nut e). Furt her i ncreas es i n rat e or t i dal vol ume ri s k wors eni ng vent i l at or-i nduced l ung i njury. Gradual i ncreas es i n pCO
2
(up t o ~13kPa) are wel l t ol erat ed i n mos t pat i ent s
and aci dos i s (pH <7.25) can be t reat ed wi t h i nt ravenous bi carbonat e, s o-cal l ed permi s s i ve hypercapni a.
If oxygenat i on/vent i l at i on cannot be i mproved des pi t e t hes e meas ures , t he fol l owi ng can be cons i dered;
o
Invers e rat i o vent i l at i on (P906): may i mprove oxygenat i on, but pCO 2 may ri s e furt her
Prone pos i t i oni ng: i mproves oxygenat i on i n ~70% of pat i ent s wi t h ARDS Inhal ed vas odi l at ors (ni t ri c oxi de, nebul i zed pros t acycl i n): may i mprove oxygenat i on
Hi gh-frequency vent i l at i on: onl y avai l abl e i n s peci al i s t cent ers .
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Syndrome 3
Cardiovascular support
Art eri al l i ne es s ent i al for cont i nuous bl ood pres s ure meas urement s . Ot her i nvas i ve moni t ori ng i s i nvari abl y us ed (PA cat het er, Pi CCO, oes ophageal Doppl er), but t hei r i ndi vi dual rol es and effect s on out come are uncl ear. Mos t pat i ent s are haemodynami cal l y compromi s ed due t o t he underl yi ng condi t i on and/or vent i l at ory management , and benefi t from fl ui d res us ci t at i on. Thi s may ri s k wors eni ng capi l l ary l eak i n t he l ung and compromi s e oxygenat i on/vent i l at i on. Ai m for a l ow-normal i nt ravas cul ar vol ume whi l s t mai nt ai ni ng cardi ac i ndex and mean art eri al pres s ure. Inot rope and/or vas opres s or s upport i s commonl y requi red and t he choi ce of agent i s us ual l y deci ded on a combi nat i on of cl i ni cal eval uat i on and i nvas i ve haemodynami c moni t ori ng (cardi ac i ndex, oxygen del i very, mi xed venous /cent ral venous s at urat i on, l act at e). Agent s commonl y empl oyed i ncl ude dobut ami ne, dopami ne, epi nephri ne, norepi nepheri ne. Repeat ed as s es s ment i s es s ent i al .
On-going management

Look for and t reat a preci pi t ant (s ee t abl e, P231) Sepsis

o
Fever, neut rophi l i a, and rai s ed i nfl ammat ory markers are common i n ALI/ARDS and do not
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al ways i mpl y s eps i s

o
A t ri al of empi ri c ant i bi ot i cs gui ded by pos s i bl e pat hogens , and fol l owi ng an appropri at e s ept i c s creen (cons i der bronchoal veol ar l avage once i nt ubat ed and s t abl e), s houl d be cons i dered. Ant i bi ot i cs s houl d be modi fi ed or di s cont i nued i n l i ght of mi crobi ol ogi cal res ul t s Indwel l i ng CVP cat het ers are a common s ource of s eps i s Cons i der l ow-dos e s t eroi d i nfus i on i f (s ee bel ow) Cons i der act i vat ed prot ei n C, whi ch has been s hown t o i mprove s urvi val i n pat i ent s wi t h s ept i c s hock wi t h mul t i -organ fai l ure.
o o
Renal failure. Common and may requi re renal repl acement t herapy t o cont rol fl ui d bal ance and bl ood bi ochemi s t ry. Enteral feeding. Hel ps mai nt ai n i nt egri t y of t he gut mucos a and i s as s oci at ed wi t h a l ower ri s k of s ys t emi c s eps i s when compared t o parent eral feedi ng (TPN). Del ayed gas t ri c empt yi ng and reduced gut mot i l i t y i s common i n ICU pat i ent s and may res pond t o pro-ki net i c drugs (met ocl oprami de, eryt hromyci n) or may requi re nas ojejunal feedi ng. St res s ul cer prophyl axi s (H 2 -bl ockers ) s houl d be cons i dered i f mechani cal vent i l at i on >48 hours , or mul t i -organ fai l ure. Coagulopathy. Common and i f mi l d does not requi re t herapy. If s evere/DIC, expert advi ce s houl d be s ought . Steroid therapy
o
ALI/ARDS: no benefi t i n t he acut e s t age. Treat ment (2mg/kg/day of met hyl predni s ol one) l at er i n t he cours e of t he di s eas e (710 days ) may i mprove prognos i s but furt her s t udi es are awai t ed. P.235
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Seps i s : evi dence s ugges t s t hat s ome pat i ent s wi t h refract ory s ept i c s hock (ongoi ng/i ncreas i ng vas opres s or requi rement s ) may have rel at i ve or funct i onal adrenal i ns uffi ci ency and may benefi t from s upraphys i ol ogi cal s t eroi d repl acement (200300mg/day hydrocort i s one). Ident i fi cat i on of pat i ent s l i kel y t o benefi t uncl ear at pres ent , but ACTH s t i mul at i on t es t may hel p di s cri mi nat e.
Causes of sudden deterioration in ARDS

Respiratory

Pneumot horax Bronchi al pl uggi ng Di s pl aced ET t ube Pl eural effus i on (haemot horax) As pi rat i on (e.g. NG feed) Arrhyt hmi a Cardi ac t amponade Myocardi al i nfarct i on GI bl eed (s t res s ul cer) Sept i caemi a
Cardiovascular

Outcome
The out come for ALI/ARDS has i mproved i n recent years , wi t h overal l mort al i t y rat es of ~40%. Pat i ent s wi t h ALI/ARDS and s eps i s , l i ver di s eas e, non-pul monary organ dys funct i on, or advanced age have hi gher mort al i t y rat es . In s urvi vors , al t hough formal l ung funct i on t es t s are abnormal , res pi rat ory compromi s e at 12 years i s unus ual . There i s i ncreas i ng evi dence t hat s urvi vors s uffer cons i derabl e neuromus cul ar and ps ychol ogi cal di s abi l i t y. Thi s may refl ect t he peri od of prol onged cri t i cal i l l nes s rat her t han be s peci fi c for ALI/ARDS.
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Footnote
1
The pul monary phys i ci an i n cri t i cal care (2002) Thorax 57 .
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Pneumot horax: assessment
Pneumothorax: assessment
Presentation
Mos t i ndi vi dual s pres ent i ng t o hos pi t al wi t h a s pont aneous pneumot horax have no recogni zed underl yi ng l ung di s eas e. The commones t pres ent i ng s ympt oms are
Breat hl es s nes s : us ual l y abrupt i n ons et (young, fi t pat i ent s may have very l i t t l e, but pat i ent s wi t h COPD or as t hma may pres ent wi t h a s udden det eri orat i on) Ches t pai n: dul l , cent ral , heavy; or t here may be a pl euri t i c el ement In an i n-pat i ent , cons i der t he di agnos i s i n anyone who is
o
Breat hl es s aft er an i nvas i ve t horaci c procedure (e.g. s ubcl avi an vei n cannul at i on) Increas i ngl y hypoxi c or has ri s i ng i nfl at i on pres s ures on mechani cal vent i l at i on.
Causes
Pri mary/s pont aneous Heal t hy s ubject s , no known underl yi ng l ung di s eas e. More common i n t al l , young, s moki ng men aged 2040 years . Probabl y due t o rupt ure of api cal s ubpl eural bl ebs /bul l ae Secondary/s pont aneous Pl eural rupt ure due t o underl yi ng l ung di s eas e: emphys ema, fi bros i ng Infect i on al veol i t i s , cys t i c fi bros i s , s arcoi dos i s Cavi t at i ng pneumoni a, e.g. s t aphyl ococcal , l ung abs ces s ,
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Trauma Iat rogeni c
t ubercul os i s , PCP Part i cul arl y ches t t rauma i n RTA Aft er pl eural bi ops y or as pi rat i on, t rans bronchi al bi ops y, percut aneous l ung bi ops y, s ubcl avi an vei n cannul at i on, mechani cal vent i l at i on wi t h hi gh ai rway pres s ures .
Investigations: the chest radiograph

The cl as s i cal cl i ni cal s i gns may not al ways be pres ent . In a s upi ne pat i ent a pneumot horax mot not be eas y t o s ee. Look for hyperl ucency of one l ungfi el d, and us ual l y cl ear heart border, or a l i ne paral l el t o t he ches t wal l (caus ed by ret ract i on of t he R mi ddl e l obe). If a pat i ent has COPD and marked bul l ous di s eas e, t ake care t hat t he s us pect ed pneumot horax i s not a l arge t hi n-wal l ed bul l us : wi t h a pneumot horax t he pl eural l i ne i s us ual l y convex t o t he l at eral ches t wal l ; wi t h a bul l us , t he apparent pl eural l i ne i s us ual l y concave t o t he l at eral ches t wal l . If t here i s any doubt , CT ches t wi l l be abl e t o di s t i ngui s h bet ween t he t wo.
P.237
Signs of a significant pneumothorax
Tens i on pneumot horax: mi d-l i ne s hi ft away from t he pneumot horax, rai s ed or obs t ruct ed JVP, hypot ens i on, t achycardi a, s hock. Si z e of pneumot horax: percent ages of pneumot horax are hard t o es t i mat e; cl as s i fy accordi ng t o t he s i ze of
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t he vi s i bl e ri m bet ween t he l ung margi n and t he ches t wal l on CXR:

o o
Smal l pneumot horax: vi s i bl e ri m <2cm Large pneumot horax: vi s i bl e ri m >2cm (NB: a l arge pneumot horax approxi mat es t o a 50% l os s of l ung vol ume).
Hypoxi a: P a O 2 10kPa on ai r (may s i mpl y refl ect underl yi ng l ung di s eas e). Severe dys pnoea.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Pneumot horax: management
Pneumothorax: management
See al gori t hm, P240.
Who to discharge from A&E

o
Smal l s pont aneous pri mary pneumot horax, ri m pf ai r <2cm on CXR, no s i gni fi cant dys pnoea, and no underl yi ng chroni c l ung di s eas e. Large s pont aneous pri mary pneumot horax fol l owi ng s ucces s ful as pi rat i on (<2cm ri m of ai r on repeat CXR), no s i gni fi cant dys pnoea or underl yi ng l ung di s eas e. Fol l ow up i n ches t cl i ni c i n 1014 days wi t h a repeat CXR. Advi s e t he pat i ent t o ret urn t o A&E i f breat hl es s or i ncreas i ng ches t pai n.
Who to admit for observation

o
Al l pat i ent s wi t h pneumot horax s econdary t o t rauma or wi t h underl yi ng l ung di s eas e even i f as pi rat i on has been s ucces s ful : di s charge aft er 24 hours i f fol l ow-up CXR s hows no recurrence. Pat i ent s i n whom as pi rat i on has fai l ed t o re-expand t he l ung ful l y. Gi ve oxygen (>35% unl es s t here i s cl i ni cal evi dence of COPD, i n whi ch cas e s t art wi t h 2428% and check ABGs ). Thi s accel erat es t he reabs orpt i on of t he pneumot horax up t o 4 fol d. Mos t of t he pneumot horax i s N 2 (ai r) and s uppl ement al O 2 decreas es t he part i al pres s ure of N 2 i n t he bl ood, i ncreas i ng t he gradi ent for i t s reabs orpt i on. Once t he ai r l eak i s s eal ed, t he pneumot horax
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reabs orbs at a rat e of ~1.25% of t he vol ume of t he hemi t horax per day. A 15% pneumot horax wi l l t ake approx. 3 weeks t o reabs orb.
Attempt chest aspiration in patients with

o
Pri mary pneumot horax: al l l arge pri mary pneumot horaces , whet her s ympt omat i c or not . Repeat as pi rat i on i s s ucces s ful i n up t o 50%. Secondary pneumot horax: al l s mal l s econdary pneumot horaces , onl y i f as ympt omat i c and <50 years . Admi t for obs ervat i on and i f t here i s mi ni mal or no pneumot horax on CXR aft er 24 hours , di s charge wi t h fol l ow-up i n ches t cl i ni c i n 1014 days wi t h CXR.
Proceed to intercostal chest tube drainage in patients with

o
Pri mary pneumot horax: fai l ed as pi rat i on aft er 12 at t empt s . Secondary pneumot horax: s mal l pneumot horax i f s ympt omat i c or >50 years ; fai l ed as pi rat i on aft er 1 at t empt . Mi s cel l aneous : As s oci at ed hydro- or haemopneumot horax, al l mechani cal l y vent i l at ed pat i ent s wi t h a pneumot horax, al l pat i ent s wi t h a pneumot horax requi ri ng i nt er-hos pi t al t rans fer. The t echni que for i ns ert i on of an i nt ercos t al s drai n i s des cri bed on P920.
If t he l ung has re-expanded and t he drai n i s not bubbl i ng, wai t 24 hours and repeat CXR t o excl ude recurrence, and remove t he drai n.
A col l aps ed l ung and bubbl i ng drai n s ugges t s pers i s t ent ai r l eakand s uct i on may be requi red. Us e l ow-pres s ure s uct i on (25kPa) P.239
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vi a appropri at e pump or modi fi ed wal l s uct i on: di s cus s wi t h ches t t eam.
A col l aps ed l ung and no bubbl i ng s ugges t s t he drai n i s bl ocked, di s pl aced, or cl amped. If a new drai n i s requi red i t s houl d be t hrough a new i nci s i on.
If t here i s a pers i s t ent ai r l eak or fai l ure of t he l ung t o re-expand aft er 35days cons i der s urgi cal pl eurodes i s (cons ul t t he ches t t eam and/or cardi ot horaci c t eam). Open t horacot omy and pl eurect omy, or s urgi cal t al c pl eurodes i s , are more effect i ve t han medi cal pl eurodes i s (wi t h t al c, bl eomyci n, or t et racycl i ne), whi ch s houl d onl y be cons i dered for t hos e unwi l l i ng or unabl e t o undergo s urgery.
Practice points
There are NO i ndi cat i ons i n t he s t andard management for a pneumot horax for cl ampi ng ches t drai ns . If pat i ent s are t o be moved, keep t he drai n bot t l e bel ow ches t hei ght but DO NOT CLAMP NEVER cl amp a ches t drai n unl es s you know what you are doi ng
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e pneumot horax: management
Acute pneumothorax:
management
Adapt ed from BTS gui del i nes for t he management of s pont aneous pneumot horax, (2003) T horax 58 (s uppl . 11): 11391152.
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Secondary pneumot horax: Management
Page 432
> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > T ension pneumot horax
Tension pneumothorax
Us ual l y s een i n pat i ent s recei vi ng mechani cal vent i l at i on or pos t CPR Pat i ent i s us ual l y di s t res s ed, t achypnoei c wi t h cyanos i s , profus e s weat i ng, and marked t achycardi a and hypot ens i on Thi s requi res i mmedi at e at t ent i on.
Management
Do not l eave t he pat i ent unat t ended. Gi ve maxi mal i ns pi red oxygen t o revers e hypoxi a. Ins ert an 18G (green) cannul a (or t he l arges t avai l abl e) perpendi cul ar t o t he ches t wal l i nt o t he s econd i nt ercos t al s pace i n t he mi d-cl avi cul ar l i ne on t he s i de wi t h t he pneumot horax on cl i ni cal exami nat i on (reduced breat h s ounds and t rachea devi at ed away). Rel i ef s houl d be al mos t i mmedi at e. Leave t he cannul a i n pl ace unt i l t he ai r ceas es t o rus h out . Improvi ze an underwat er s eal us i ng an i v l i ne at t ached t o t he cannul a wi t h t he free end hel d under a bowl of wat er, unt i l a formal i nt ercos t al drai n can be s et up. Ins ert a ches t drai n as s oon as pos s i bl e. If no ai r rus hes out when t he cannul a i s i ns ert ed, t he pat i ent does not have a t ens i on pneumot horax and t he cannul a s houl d be removed.
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Haemopt ysis: assessment
Haemoptysis: assessment
Presentation
Haemopt ys i s i s t he coughi ng up of bl ood from t he l ungs or t racheobronchi al t ree (s ee t abl e). Mas s i ve haemopt ys i s i s defi ned as 400ml over 3 hours or 600ml over 24 hours . The common caus es of mas s i ve haemopt ys i s are bronchi ect as i s , bronchi al carci noma, i nfect i on (e.g. TB, l ung abs ces s , or as pergi l l oma), or t rauma. Oft en t he caus e i s obvi ous from t he hi s t ory. Pat i ent s wi t h l arge bl eeds may be abl e t o l ocat e t he s i t e of bl eedi ng by a gurgl i ng wi t hi n t he ches t . As k s peci fi cal l y for s moki ng and drug hi s t ory. Exami ne for an underl yi ng caus e (s ee t abl e) and t o as s es s t he haemodynami c and res pi rat ory effect s of t he bl eed. Cons i der t hat t he bl ood may be comi ng from s omewhere ot her t han t he l ungs : upper res pi rat ory t ract , GI t ract , nas opharynx.
Poor prognostic factors

Thes e i ncl ude

Increas i ng age Pre-exi s t i ng l ung or cardi ac di s eas e Res pi rat ory compromi s e (rat e, cyanos i s ) Hypoxi a ( P a O 2 10kPa on ai r) On-goi ng haemopt ys i s of l arge amount s of fres h bl ood Shock (pos t ural or s upi ne hypot ens i onrare).
Initial management
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Mas s i ve haemopt ys i s s houl d us ual l y be managed at a hos pi t al wi t h cardi ot horaci c s urgi cal back-up, and urgent t rans fer s houl d be cons i dered i f t hi s i s not avai l abl e. Gi ve hi gh i ns pi red oxygen. Pl ace pat i ent i n t he recovery pos i t i on, wi t h t he bl eedi ng l ung down (i f i t i s known whi ch s i de t he bl eedi ng i s from) t o t ry t o keep t he unaffect ed l ung free of bl ood. If as pi rat i on of bl ood i s t hreat ened, get anaes t het i c hel p urgent l y; anaes t het i ze, i nt ubat e, and vent i l at e. A doubl e-l umen endot racheal t ube may be us ed t o i s ol at e t he l ungs but t he narrow l umen may make s ubs equent fl exi bl e bronchos copy di ffi cul t . Ins ert a l arge-bore peri pheral cannul a, fol l owed by a cent ral l i ne i f i ndi cat ed; i nt ernal jugul ar rout e i s preferred t o mi ni mi ze t he ri s k of pneumot horax. Support t he ci rcul at i on: haemopt ys es are rarel y s evere enough t o warrant t rans fus i on. If t he pat i ent has pos t ural or s upi ne hypot ens i on us e i nt ravenous col l oi d unt i l bl ood i s avai l abl e. Moni t or t he uri ne out put , pul s e, BP, and i f appropri at e CVP.
P.245
Investigations
Al l pat i ent s s houl d have t he fol l owi ng

Bl ood for FBC, U&Es , coagul at i on s t udi es , X-mat ch Art eri al bl ood gas es ECG CXR ( l at eral ) Sput um (mi cros copy and cul t ure, cyt ol ogy) Fl exi bl e bronchos copy.
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Common causes of haemoptysis

Lung disease

Bronchi ect as i s ( i nfect i on) Bronchogeni c carci noma Infect i on

o o o o
Tubercul os i s Pneumoni a Lung abs ces s As pergi l l oma
Bronchi t i s Trauma AV mal format i on Pul monary embol us Left vent ri cul ar fai l ure Mi t ral s t enos i s Congeni t al heart di s eas e wi t h pul monary hypert ens i on Aort i c aneurys m SLE W egner's Goodpas t ure's Mi cros copi c pol yangi i t i s
Cardiovascular

Systemic vasculitis

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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Haemopt ysis: furt her management
Haemoptysis: further
management
Diagnose the source of bleeding
CXR. Thi s s houl d be exami ned s ys t emat i cal l y for a mas s l es i on hi l ar nodes , bronchi ect as i s (t ram-l i ne s hadows ), ol d or new cavi t i es whi ch may s ugges t as pergi l l omas . Look for caus es of mi nor haemopt ys i s , i f t hi s i s t he current probl em. Fibre-optic or rigid bronchoscopy. Thi s s houl d be performed urgent l y i n al l cas es of mas s i ve haemopt ys i s . Thi s i s unl i kel y t o l ocal i ze t he exact s ource, but may hel p l ocal i ze t he l ung or l obe affect ed t o gui de s urgeons or radi ol ogi s t s . Bl eedi ng may be arres t ed by endos copi cal l y admi ni s t ered adrenal i ne (1ml 1 : 10 000) or, i n mas s i ve haemopt ys i s , a bal l oon cat het er may be i nfl at ed for 2448 hours wi t hi n a s egment al or s ub-s egment al bronchus . Selective pulmonary angiography. Can i dent i fy t he bl eedi ng s ource i n 90% of pat i ent s and, when combi ned wi t h embol i zat i on, i s effect i ve i n cont rol l i ng bl eedi ng i n up t o 90%. Mul t i pl e procedures may be neces s ary. High resolution CT chest. May hel p i dent i fy parenchymal l es i ons and peri pheral endobronchi al l es i ons .
Specific therapeutic interventions
Correct coagul opat hy: If t he haemopt ys i s i s rel at i vel y mi nor i t may be s uffi ci ent t o correct an exces s i vel y el evat ed INR t o a t herapeut i c range (INR 1.52.0)
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wi t h FFP. In pat i ent s wi t h a pros t het i c val ve and mas s i ve haemopt ys i s , t he cl ot t i ng mus t be normal i zed as bes t as pos s i bl e. Di s cus s wi t h your l ocal haemat ol ogi s t s or cardi ol ogi s t s . Support pl at el et s i f <50 10 /L.
Cons i der nebul i zed -agoni s t and/or i v ami nophyl l i ne as a mucoci l l i ary s t i mul ant and t o rel i eve bronchos pas m i n pat i ent s wi t h as t hma and COPD. Pat i ent s wi t h mi nor haemopt ys i s s houl d be ful l y i nves t i gat ed (s ee t abl e). No caus e i s found i n ~10%. Pat i ent s wi t h mas s i ve haemopt ys i s s houl d undergo urgent fi bre-opt i c bronchos copy t o l ocat e t he bl eedi ng s ource. Angi ography and embol i zat i on s houl d be cons i dered for al l pat i ent s wi t h mas s i ve haemopt ys i s pri or t o s urgery. If angi ography i s not avai l abl e, pat i ent s who cont i nue t o bl eed >600ml /day or who have an i dent i fi abl e l es i on (e.g. l ung abs ces s , as pergi l l oma, t rauma) s houl d have defi ni t i ve s urgery. Di s cus s al l cas es of haemopt ys i s wi t h t he ches t t eam. Pat i ent s wi t h mas s i ve haemopt ys i s s houl d be managed i n a s peci al i s t cent re wi t h appropri at e cardi ot horaci c and radi ol ogi cal back-up. Trans fer t he pat i ent (vent i l at ed i f uns t abl e) i f t he pat i ent i s fi t enough. Infect i on i s a common preci pi t ant (e.g. i n bronchi ect as i s ). Cons i der ant i bi ot i cs (e.g. co-amoxi cl av 1g i v q68h or cefot axi me 2g i v q8h) aft er appropri at e cul t ures . TB or l ung paras i t es wi l l requi re s peci fi c ant i mi crobi al t herapy.
P.247
Further investigation of haemoptysis

Aut oant i bodi es (ANA, ANCA, ant i -GBM ant i body) Serum for Legi onel l a s erol ogy
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As pergi l l us preci pi t i ns CT ches t VQ s can Echo Pul monary and bronchi al art ery angi ogram Lung bi ops y Pul monary funct i on t es t s wi t h t rans fer fact or
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Pleural effusions
Pleural effusions
Presentation

Dys pnoea Ches t di s comfort or s ens at i on of heavi nes s Sympt oms of mal i gnancy: l os s of appet i t e, wei ght , energy Sympt oms of i nfect i on: fever, cough, s put um, ni ght s weat s .
Severity depends on

Speed of ons et (e.g. t raumat i c or pos t -procedural ) Haemodynami c compromi s e (hypot ens i on, t achycardi a) Hypoxi a or res pi rat ory fai l ure Pres ence of underl yi ng di s eas e (e.g. heart fai l ure, COPD).
Causes
T ransudate (protein <30g/L) Rai s ed venous pres s ure Cardi ac fai l ure Cons t ri ct i ve peri cardi t i s Fl ui d overl oad Hypoprot ei naemi a Nephrot i c s yndrome Ci rrhos i s wi t h as ci t es Prot ei n-l os i ng ent eropat hy Exudate (protein <30g/L) I nfec t i on Pneumoni a Empyema (bact eri al or TB) Sub-phreni c abs ces s Mal i gnanc y Pri mary bronchi al Mes ot hel i oma Secondary (and l ymphoma) Lymphangi t i s carci nomat os a Mi s c el l aneous Hypot hyroi di s m Mei gs s yndrome Y el l ow nai l s yndrome Mi s c el l aneous Haemot horax (t rauma, i at rogeni c) Chyl ot horax (t horaci c duct t rauma) Aut oi mmune (RA, SLE, Dres s l er's ) Pancreat i t i s
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Management
If acut e t hen s t abi l i ze t he pat i ent and i ns ert a ches t drai n. If effus i on i s chroni c t hen reach a di agnos i s and t reat accordi ngl y.
Acute massive effusion

Gi ve oxygen. i v acces s : vi a a wi de-bore cannul a or i nt ernal jugul ar cent ral l i ne. If cent ral acces s i s di ffi cul t t hen avoi d at t empt i ng unl es s peri pheral acces s i s cl earl y i nadequat e. At t empt t o cannul at e (i nt ernal jugul ar vei ns onl y) on t he normal s i de. A bi l at eral pul monary probl em wi l l be a di s as t er. Take bl ood: for FBC, cl ot t i ng, and urgent cros s -mat ch (6 uni t s ). Correct coagul opat hi es . Res t ore ci rcul at i ng vol ume: i f BP l ow or t achycardi c, t hen gi ve a pl as ma expander 500ml s t at ., accordi ng t o s i z e of effus i on drai ned and res pons e. Ins ert a ches t drai n (s ee P920). The drai n s houl d be l eft uncl amped and al l owed t o drai n freel y, t he amount drai ned s houl d be recorded.
P.249
Indications for specialist referral
Traumat i c haemot horax s houl d be referred t o t he cardi ot horaci c s urgeons . Haemot horax s econdary t o procedures s houl d be referred i f t he pat i ent i s s hocked and/or t here i s on-goi ng s i gni fi cant bl ood l os s requi ri ng t rans fus i on at a rat e 1 uni t every 4 hours (approx.). W hen i n doubt di s cus s t he cas e wi t h t he s urgi cal t eam.
Practice point
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If t here i s decreas ed movement of one s i de of t he ches t , t hat i s t he s i de of pat hol ogy (eg fl ui d, i nfect i on, pneumot horax).
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Chronic massive effusion
Chronic massive effusion
A uni l at eral chroni c effus i on wi l l us ual l y have accumul at ed over weeks or perhaps even mont hs . The commones t caus es are mal i gnancy, empyema, TB, aut oi mmune di s eas es (e.g. rheumat oi d), and ci rrhot i c as ci t es wi t h t rans di aphragmat i c movement .
Investigation
Di agnos t i c as pi rat i on: i deal l y, t he ches t s houl d be s canned and marked by ul t ras ound pri or t o t appi ng t he effus i on as underl yi ng col l aps e may caus e s i gni fi cant el evat i on of t he hemi di aphragm. A s ampl e s houl d t hen be wi t hdrawn (50ml ) and s pl i t i nt o t hree for
Bi ochemi s t ry
Prot ei n 30g/L i mpl i es an exudat e Prot ei n <30g/L i mpl i es a t rans udat e LDH t o as s es s Li ght 's cri t eri a (s ee oppos i t e) pH <7.2 s ugges t s a pos s i bl e empyema Gl ucos e <3.3mmol s ugges t s a pos s i bl e empyema (al s o s een i n TB and aut oi mmune-rel at ed effus i ons ) Amyl as e i f acut e pancreat i t i s s us pect ed Tri gl yceri des i f chyl ot horax s us pect ed Turbi d fl ui d wi t h neut rophi l s i mpl i es i nfect i on Bl ood-s t ai ned fl ui d i mpl i es mal i gnancy but may be a haemot horax (check fl ui d haemat ocri t : i f >1/2 bl ood haemat ocri t , s us pect haemot horax) ZN s t ai ni ng for AFB (+ve i n onl y 20% of pl eural TB) Cul t ure for TB and rout i ne cul t ure For pri mary and s econdary t umours .
Mi cros copy mi crobi ol ogy
Cyt ol ogy
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Pos i t i ve i n 60%, s o negat i ve does not excl ude mal i gnancy.
Pl eural bi ops y s houl d be performed i f mal i gnancy or TB i s s us pect ed. Ches t CT wi t h cont ras t may hel p di fferent i at e beni gn from mal i gnant di s eas e, pl eural t hi ckeni ng, mes ot hel i oma, or i nt rapul monary pat hol ogy.
Management
The fl ui d may be drai ned by repeat ed as pi rat i ons of 1L/day unt i l dry, or by t he i ns ert i on of a s mal l -bore i nt ercos t al drai n (s ee P920), whi ch s houl d be cl amped and rel eas ed t o drai n 1.5L/day (t hi s i s t he onl y i ns t ance when a ches t drai n may be cl amped). Drai nage of >1.5L/day may res ul t i n reperfus i on pul monary oedema. If t he mal i gnant effus i on reaccumul at es rapi dl y, cons i der chemi cal or s urgi cal pl eurodes i s .
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Empyema
Empyema
Thi s i s a s eri ous compl i cat i on of bact eri al ches t i nfect i on (P202). Al l effus i ons as s oci at ed wi t h a pneumoni a (parapneumoni c) s houl d be t apped.
To avoi d l ong-t erm s carri ng and l ocul at ed i nfect i on t he empyema requi res urgent drai nage by ul t ras ound gui dance and us ual l y t he pos i t i oni ng of an i nt ercos t al drai n. Frequent l y drai nage fai l s as t he empyema organi zes wi t h dens e adhes i ons produci ng l ocul at i ons . Thi s can be as s es s ed by ul t ras ound. Surgi cal drai nage i s t he onl y opt i on i n t hi s s i t uat i on. The rol e of i nt rapl eural t hrombol yt i cs remai ns uncl ear. Empyema s houl d al ways be di s cus s ed wi t h a res pi rat ory phys i ci an or cardi ot horaci c s urgeon.
Light's criteria for pleural fluid analysis

The pl eural fl ui d i s an exudat e i f one or more of t he fol l owi ng cri t eri a are met :

Pl eural fl ui d prot ei n di vi ded by s erum prot ei n >0.5 Pl eural fl ui d LDH di vi ded by s erum LDH >0.6 Pl eural fl ui d LDH more t han t wo-t hi rds t he upper l i mi t of normal s erum LDH l evel
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e upper airway obst ruc t ion: assessment
Acute upper airway
obstruction: assessment
Presentation
St ri dor: i ns pi rat ory noi s e. Generat ed by t he col l aps e of t he ext ra-t horaci c ai rway duri ng i ns pi rat i on Breat hl es s nes s Dys phagi a Inabi l i t y t o s wal l ow s ecret i ons (hunched forward, drool i ng) Cyanos i s Col l aps e.
As k c ol l eagues t o c al l a s eni or anaes t het i s t and ENT as s i s t anc e i mmedi at el y w hi l e you c ont i nue your as s es s ment .
Identify the cause

(s ee t abl e)
History. Sudden ons et , s omet hi ng i n mout h or chi l d pl ayi ng wi t h uns afe t oy (forei gn body), fever (epi gl ot t i t i s , di pht heri a, t ons i l l i t i s ), hoars e voi ce (epi gl ot t i t i s ), s ore t hroat (i nfect i ve as l i s t ed), t ravel (Eas t ern Europedi pht heri a), s moker + l onger hi s t ory + s ys t emi c s ympt oms (?carci noma), t rauma. Examination. W here i nfect i ve caus e i s s us pect ed t hen exami nat i on of oropharynx mus t be undert aken i n area where pat i ent may be i mmedi at el y i nt ubat ed, wi t h an anaes t het i s t s t andi ng by. Fever, drool i ng, s t ri dor. Bul l neck, l ymphadenopat hy, ps eudomembrane over oropharynx (di pht heri a). Swol l en t hroat + epi gl ot t i s on di rect /i ndi rect l aryngos copy
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(epi gl ot t i t i s ).
Investigations. Do not del ay t reat ment i f t he pat i ent i s i n di s t res s . If t he pat i ent i s rel at i vel y s t abl e, perform a ches t X-ray (forei gn body), l at eral neck X-ray (s wol l en epi gl ot t i s ). FBC, U&E's , bl ood gas es .
Indications for ITU/surgical referral
Pri or t o exami nat i on of oropharynx i f i nfect i ve caus e s us pect ed Fai l ure t o mai nt ai n adequat e ai rway or oxygenat i on Inabi l i t y t o s wal l ow s ecret i ons Vent i l at ory fai l ure ( P a O 2 10kPa, P a CO 2 6kPa) Col l aps e Severe dys pnoea.
Management
If s evere, l i ai s e i mmedi at el y wi t h ITU and ENT or general s urgeons (pot ent i al for urgent t racheos t omy). Pri ori t i es are
o o o
St abi l i ze t he pat i ent : ens ure adequat e ai rway Ident i fy caus e of obs t ruct i on Speci fi c t reat ment meas ures .
Take art eri al bl ood gas es and gi ve hi gh percent age oxygen (60%) If cl ear caus e of obs t ruct i on (forei gn body, pos t -operat i ve t hyroi d s urgery), t hen t ake appropri at e meas ures t o gai n pat i ent ai rway (s ee bel ow). P.255
If pat i ent i s becomi ng i ncreas i ngl y exhaus t ed or t here i s acut e fai l ure of vent i l at i on t hen s ummon col l eagues as above and be prepared t o i nt ubat e or perform t racheos t omy.
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Causes of acute stridor
Infect i ve: acut e epi gl ot t i t i s , di pht heri a, t ons i l l i t i s , or adenoi di t i s (chi l dren) Inhal at i on of forei gn body Tumour of t rachea or l arynx Trauma Pos t -operat i vel y (t hyroi d s urgery)
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> T able of Cont ent s > Chapt er 2 - Respirat ory emergenc ies > Ac ut e upper airway obst ruc t ion
Acute upper airway obstruction
Foreign body
W i t h t ot al upper ai rway obs t ruct i on, perform Hei ml i ch manoeuvre (s t and behi nd pat i ent , gri p wri s t s acros s t he pat i ent 's upper abdomen and t ug s harpl y t o rai s e i nt rat horaci c pres s ure and expel forei gn body). Ot herwi s e perform ches t X-ray, l i ai s e wi t h res pi rat ory/ENT/cardi ot horaci c t eams for ret ri eval under di rect vi s i on.
Epiglottitis
Us ual l y Haemophi l us i nfl uenzae t ype b, al s o St rep. pneumoni ae . Treat wi t h 3rd-generat i on cephal os pori n, e.g. cefot axi me 2g t ds (adul t s ). Chi l dren more l i kel y t o requi re i nt ubat i on, but i f any concerns over ai rway t hen pat i ent (adul t or chi l d) s houl d be moni t ored on ITU aft er anaes t het i c as s es s ment .
Diphtheria
Uncommon i n UK, occas i onal l y s een i n pat i ent s ret urni ng from abroad. Toxi n-medi at ed probl ems i ncl ude myocardi t i s and neuri t i s . Treat wi t h di pht heri a ant i -t oxi n + ant i bi ot i c eradi cat i on of organi s m (cons ul t mi crobi ol ogy).
Tumour obstruction
Unl i kel y t o caus e l i fe-t hreat eni ng obs t ruct i on wi t hout warni ng s ympt oms over few days . If s i gni fi cant s t ri dor pres ent t hen admi ni s t er 200mg hydrocort i s one and t hereaft er predni s ol one 40mg od po. If l aryngeal ori gi n l i ai s e wi t h ENT regardi ng t racheos t omy. Lung cancer i n t rachea, or ext ri ns i c cancer erodi ng i nt o t he t rachea, wi l l requi re urgent radi ot herapy (or occas i onal l y l as er or cryot herapy vi a bronchos cope).
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> T able of Cont ent s > Chapt er 3 - Shoc k
Chapter 3
Shock
P.258
Shock
Shock i s defi ned as i nadequat e perfus i on of vi t al organs . Concurrent hypot ens i on need not neces s ari l y be pres ent . The drop i n bl ood pres s ure i s a l at e fi ndi ng, part i cul arl y i n young, fi t peopl e, s o res us ci t at i on s houl d i deal l y commence before t hi s poi nt i s reached.
Priorities
I f t he bl ood pres s ure i s unrec ordabl e, c al l t he c ardi ac arres t t eam . Begi n bas i c l i fe s upport and es t abl i s h venous acces s . Seek s peci al i s t hel p earl y. The caus e of hypot ens i on i s oft en apparent . If i t i s not , t hen one can us ual l y make a rapi d cl i ni cal as s es s ment of l i kel y caus es :
o o o o o
Cardi ac pump fai l ure Hypovol aemi a Sys t emi c vas odi l at at i on Anaphyl axi s Obs t ruct i on (e.g. PE, t ens i on pneumot horax, t amponade).
Differential diagnosis of shock
Cardi ac pump fai l ure

o o
Myocardi al i nfarct i on (p12) Di s s ect i on of t horaci c aort a (p170)
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ABC Ambe r CHM Conve rte r Tria l ve rsion, http://w w w .proce sste x t.com/a bcchm.html o o o o
Cardi ac dys rhyt hmi as (p62) Acut e val vul ar regurgi t at i on or acut e VSD (p34) Drug overdos e (cardi ac depres s ant s , s ee p792) Myocardi t i s Haemorrhage [GI t ract (p608), aort i c di s s ect i on or l eaki ng AAA, pos t t rauma (s pl eni c rupt ure)] Fl ui d l os s es (di arrhoea, vomi t i ng, pol yuri a, or burns ) 3rd s pace fl ui d l os s es [acut e pancreat i t i s (p670), as ci t es ] Adrenal fai l ure (p584) Seps i s (p266) Li ver fai l ure (p658) Drug overdos e (cal ci um ant agoni s t s or ot her vas odi l at ors , drugs caus i ng mul t i -organ fai l ure, e.g. paracet amol , paraquat ) Adrenal fai l ure (may be bot h hypovol aemi c and vas odi l at ed)
Hypovol aemi a
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Sys t emi c vas odi l at at i on

o o o
Anaphyl axi s
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Recent drug t herapy Food al l ergy (e.g. peanut ) Ins ect s t i ngs (p862) Cardi ac t amponade (p184) Pul monary embol us (p146) Tens i on pneumot horax (p242)
Obs t ruct i on
o o o
P.259
P.260
Shock: assessment
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I f t he BP i s unrec ordabl e t hen c al l t he c ardi ac arres t t eam . Begi n bas i c l i fe s upport (Ai rway, Breat hi ng, and Ci rcul at i on) and es t abl i s h venous acces s . If t he caus e of hypot ens i on i s not obvi ous , perform a rapi d cl i ni cal exami nat i on l ooki ng s peci fi cal l y for t he fol l owi ng.
Check t he ai rway i s unobs t ruct ed phys i cal l y and cl ear of vomi t or bl ood. Gi ve hi gh-fl ow (60100%) oxygen by mas k ( res ervoi r bag) or ET t ube i f ai rway unprot ect ed or breat hi ng i nadequat e. Check bot h l ungs are bei ng vent i l at ed (?t ens i on pneumot horax). Not e t he res pi rat ory rat e (us ual l y i ncreas ed i n aci daemi a, pneumot horax, embol us , and cardi ac fai l ure, except at end s t age). Check t he cardi ac rhyt hm and t reat i f abnormal (s ee pp62p106). Is t he JVP el evat ed (s ee t abl e)? Is t he BP t he s ame i n bot h arms (t horaci c aort i c di s s ect i on)? Are t here any unus ual cardi ac murmurs ? (Acut e val vul ar l es i on, fl ow murmurs may be heard i n vas odi l at ed pat i ent s .) Is t he pat i ent col d and cl ammy? Thi s s ugges t s cardi ac pump fai l ure or hypovol aemi a; however pat i ent s wi t h s evere s eps i s s hock may al s o be peri pheral l y s hut down. Check for fever (NB: t emperat ure may be s ub-normal , es peci al l y i n t he el derl y and chi l dren) and pal pat e t he forearms (boundi ng pul s es of proxi mal art eri al vas odi l at at i on). Is t he pat i ent warm and s ys t emi cal l y vas odi l at ed (feel fi nger pul p and feet ). Pal pat e t he forearm mus cl es for boundi ng pul s es . Exami ne t he abdomen. Is t here a ful l nes s or pul s at i l e mas s i n t he abdomen (rupt ured aneurys m)? Is t here evi dence of an acut e abdomen (aneurys m, pancreat i t i s , perforat ed vi s cus )? Is t he pat i ent cl i ni cal l y dehydrat ed or hypovol aemi c
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(s ki n t urgor, mucous membranes , pos t ural fal l i n BP)?
Is t here evi dence of haemat emes i s (bl ood around mout h) or mel aena (PR exami nat i on)? Is t here any evi dence of urt i cari a s uch as wheezi ng, s oft t i s s ue s wel l i ng (e.g. eyel i ds or l i ps ) s ugges t i ve of anaphyl axi s ? Is cons ci ous l evel i mpai red?
Investigations
Acu G te arr hyt hm i as , PE (ri g ht he art str ai n wi t h S1, Q3, T3) Pn R eu t ho rax , CX mo EC MI,
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PE, di s s ec tio n, ta mp on ad e, pl e ura l eff us i on U& Es Bl o (re od nal t es i m ts pai rm ent , adr en al fai l ure ), FB C (ha em
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orr ha ge, or WB C in s ep sis , pl a t el et s in liv er di s eas e an d s ep sis ), gl u c os e, clo tti ng stu
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di e s (l i v er di s eas e, DI C), LFT s, Xma tch Aci da AB em Gs i a (re nal , l ac t i c, ket oac i do sis ) Cul t ur Se e pt i bl o c od, s cr uri ee ne,
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s pu tu
m W h c. ere pro pri at e con sid er art eri al bl o od l ac t at e, Ech o (s u s pe ct e d ta mp on ad e, di s s ec tio n, Mi s ap
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val ve dys fun ct i on) , LP, US S or CT ab do me n he ad P.261
Causes of hypotension with a raised CVP

Pul monary embol us (p146) Cardi ac t amponade (p184) Cardi ogeni c s hock (p44) Fl ui d overl oad i n s hocked vas odi l at ed pat i ent s Ri ght vent ri cul ar i nfarct i on (p28) Tens i on pneumot horax (p242)
P.262
Shock: management
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General measures
Check t he ai rway and gi ve hi gh-fl ow oxygen (60100%) by face mas k t o opt i mi ze O 2 s at urat i on. If cons ci ous l evel i s i mpai red (GCS <8), ai rway i s unprot ect ed, and/or breat hi ng i s i nadequat e, cons i der i nt ubat i on. Li e t he pat i ent fl at and rai s e t he feet t o t ry t o res t ore BP. Ins ert 2 l arge-bore i nt ravenous cannul ae and commence i nfus i on of col l oi d (e.g. Haemaccel ) or bl ood. In mos t cas es of s hock, i ncl udi ng cardi ac caus es , i t i s us ual l y benefi ci al and s afe t o gi ve col l oi d (200ml over 510 mi nut es ) whi l e a more det ai l ed as s es s ment i s bei ng carri ed out . If t he fl ui d chal l enge bri ngs i mprovement , cons i derat i on s houl d be gi ven t o more chal l enges . Send bl ood for U&Es , gl ucos e, FBC, X-mat ch and bl ood cul t ures . Ins ert cent ral venous l i ne t o moni t or CVP, and for i not rope i nfus i ons i f neces s ary. Ins ert art eri al l i ne for more accurat e as s es s ment of BP. Cat het eri ze t he bl adder t o moni t or uri ne out put . Ti t rat e fl ui d repl acement accordi ng t o BP, CVP, and uri ne out put . Over-ent hus i as t i c fl ui d admi ni s t rat i on i n pat i ent s wi t h cardi ac pump fai l ure wi l l preci pi t at e pul monary oedema wi t h l i t t l e gai n or fal l i n s t roke vol ume or cardi ac out put (s ee p282). Pers i s t ent hypot ens i on i n s pi t e of adequat e fi l l i ng i s an i ndi cat i on for i not ropi c s upport . The choi ce of fi rs t -l i ne agent vari es t o s ome ext ent dependi ng upon t he underl yi ng di agnos i s . Treat t he underl yi ng condi t i on and enl i s t s pec i al i s t hel p earl y . Ens ure s omeone t akes t i me t o t al k t o t he rel at i ves t o expl ai n t he pat i ent i s s eri ous l y i l l and may di e. Di s cus s
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res us ci t at i on s t at us .
Cardiogenic shock (cardiac pump failure)

Correct any cardi ac arrhyt hmi as and U&E i mbal ance. Opt i mi ze fi l l i ng, gui ded by phys i cal s i gns and res pons e i n s t roke vol ume and fi l l i ng pres s ures t o fl ui d chal l enges . Pos s i bl e concurrent hypovol aemi a? i v fl ui ds are t he i ni t i al t reat ment . Gi ve col l oi d chal l enges (100200ml ) and as s es s res pons e. Adequat e fi l l i ng? If bl ood pres s ure al l ows , s t art a ni t rat e i nfus i on (e.g. GTN 5mg/h). If very hypot ens i ve, s t art an i v i not rope i nfus i on. Commence epi nephri ne(adrenal i ne) (110g/mi n) or dobut ami ne (520g/kg/mi n), t i t rat i ng t he dos e accordi ng t o res pons e (s ee p290 for det ai l s ). A s mal l amount of di amorphi ne (e.g. 2.5mg) i s benefi ci al as i t vas odi l at es , reduces anxi et y, and l owers met abol i c rat e. Non-i nvas i ve or i nvas i ve vent i l at i on s houl d be cons i dered i n pat i ent s wi t h s evere heart fai l ure as t hi s decreas es t he work of breat hi ng and provi des benefi ci al effect s on bot h l eft vent ri cul ar aft erl oad and prel oad. If t here i s a pot ent i al l y revers i bl e caus e for cardi ogeni c s hock, cons i der i nt ra-aort i c bal l oon count erpul s at i on (p898).
P.263
Hypovolaemic shock
Fl ui d repl acement i s t he mai ns t ay. There i s no cl ear evi dence t o favour ei t her col l oi ds or crys t al l oi ds and i n pract i ce a mi xt ure i s us ed. Gi ve bl ood t o mai nt ai n Hb 8g/dl . Na and K abnormal i t i es s houl d be t reat ed i n t he us ual way. The met abol i c aci dos i s us ual l y res ponds t o fl ui d
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repl acement onl y.
If t he pat i ent remai ns hypot ens i ve i n s pi t e of fl ui ds , cons i der ot her pat hol ogy (s eps i s , t amponade, t ens i on pneumot horax, et c.). A reperfus i on i njury may occas i onal l y mani fes t i t s el f as a hypot ens i ve, vas odi l at ed ci rcul at i on. If fl ui d repl et e, commence i not ropes : adrenal i ne or dobut ami ne i f a l ow cardi ac out put s t at e i s s us pect ed, or norepi nephri ne i f t here i s a hi gh out put , vas odi l at ed ci rcul at i on. If ol i guri a pers i s t s i ns pi t e of adequat e res us ci t at i on, frus emi de (1020mg i v) may be t ri ed. The onl y ai m here i s t o mai nt ai n a uri ne out put as t hi s makes fl ui d management much eas i er.
Practice point
In one major s t udy i nvol vi ng ~7000 pat i ent s , s al i ne was equal l y effect i ve as al bumi n for fl ui d res us ci t at i on (Fi nfer et al . , NEJM , 2004, 350, 22946, SAFE St udy).
P.264
Anaphylaxis
At opi c i ndi vi dual s are part i cul arl y at ri s k, but i t may be a feat ure i n s ome pat i ent s wi t hout any pas t hi s t ory. Preci pi t ant s i ncl ude

Ins ect bi t es (es peci al l y was p and bee s t i ngs , s ee p862) Foods and food addi t i ves (e.g. peanut s , fi s h, eggs ) Drugs and i nt ravenous i nfus i ons (bl ood product s and i nt ravenous i mmunogl obul i n, vacci nes , ant i bi ot i cs , as pi ri n and ot her NSAIDs , i ron i nject i ons , hepari n).
Presentation
Cut aneous feat ures i ncl ude s ki n rednes s , urt i cari a, conjunct i val i nject i on, angi oedema, and rhi ni t i s . More s evere mani fes t at i ons i ncl ude l aryngeal obs t ruct i on (choki ng s ens at i on, cough, s t ri dor), bronchos pas m, t achycardi a, hypot ens i on, and s hock.
Management
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Sec ure t he ai rw ay : i f res pi rat ory obs t ruct i on i s i mmi nent , i nt ubat e, and vent i l at e or cons i der emergency cri cot hyroi dot omy (s ee p914). A 14G needl e and i ns uffl at i on wi t h 100% O 2 can t empori ze unt i l t he anaes t het i s t arri ves . Gi ve 100% oxygen : i f t here i s refract ory hypoxaemi a, i nt ubat e, and vent i l at e. Li e t he pat i ent fl at wi t h head-down t i l t i f hypot ens i ve. Gi ve i nt ramus c ul ar epi nephri ne 0.51mg (0.51ml of 1 i n 1000 adrenal i ne i nject i on) and repeat every 10 mi nut es accordi ng t o BP and pul s e. Admi ni s t er t hi s before s earchi ng for i nt ravenous acces s s o as not t o was t e t i me. I f i v ac c es s i s pres ent , us e s mal l i v dos es of epi nephri ne (0.10.2mg) t hen revi ew res pons e . Subcut aneous epi nephri ne s houl d not be gi ven i n anaphyl act i c s hock due t o vari abl e abs orpt i on. Es t abl i s h venous acces s and s t art i v fl ui ds (col l oi d i f hypot ens i ve). Pers i s t ent hypot ens i on requi res a cont i nuous epi nephri ne i nfus i on t i t rat ed t o a BP res pons e. Gi ve i v hydrocort i s one 100200mg and chl orpheni rami ne 10mg. Cont i nue H 1 -ant agoni s t (e.g. chl orpheni rami ne 4mg q4 6h) for at l eas t 24 48 hours l onger i f urt i cari a and pruri t i s pers i s t . Add an H 2 -ant agoni s t (rani t i di ne 50mg i v t ds ). If t he bronchos pas m does not s ubs i de, t reat as s evere as t hma (i ncl udi ng s al but amol , nebul i zed or i nt rat racheal epi nephri ne, ami nophyl l i ne).
Angioneurotic oedema (C1-esterase inhibitor deficiency)

See p768. P.265
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P.266
Shock with systemic vasodilatation 1

Pat i ent s s houl d be moni t ored i n ei t her an ICU or HDU. Ideal l y, bot h an art eri al l i ne for cont i nuous BP moni t ori ng and i nt ermi t t ent bl ood s ampl i ng and a moni t or for meas uri ng cardi ac out put [e.g. oes ophageal Doppl er, pul monary art ery (SwanGanz ) cat het er] s houl d be us ed. A cent ral venous cat het er al one i s oft en not adequat e t o moni t or t hes e pat i ent s . Recent s t udi es have cas t doubt on t he us e of PA cat het er moni t ori ng of ICU pat i ent s and pros pect i ve t ri al s are on-goi ng. W hi l s t PA l i nes may be as s oci at ed wi t h i ncreas ed mort al i t y, t he cas e agai ns t t hei r us e i s not yet proven; i f us ed di l i gent l y, wi t h removal as s oon as t hei r us eful nes s has expi red, we bel i eve t hat cent ral moni t ori ng of haemodynami cs can be us eful i n t he management of s uch cri t i cal l y i l l pat i ent s . Oes ophageal Doppl er moni t ori ng i s a mi ni mal l y i nvas i ve haemodynami c as s es s ment t ool , whi ch provi des t he abi l i t y for on-goi ng real -t i me haemodynami c as s es s ment of t he cri t i cal l y i l l or compromi s ed pat i ent . Thi s s i mpl e-t o-us e t echnol ogy requi res t hat a probe be i ns ert ed i nt o t he oes ophagus t o obt ai n meas urement of bl ood fl ow i n t he des cendi ng aort a. Haemodynami c vari abl es s uch as cardi ac out put , prel oad, aft erl oad, and cont ract i l i t y are meas ured or deri ved from t he oes ophageal Doppl er moni t ori ng waveform.
Aims of management

Correct i on of underl yi ng caus e Opt i mi ze organ perfus i on Opt i mi ze oxygen del i very t o t i s s ues .
There have been s everal new devel opment s over recent years t hat are bel i eved t o i mprove out come i n s uch pat i ent s :
Early goal directed therapy (<6 hours ) t o obt ai n a CVP of 812mmHg, a MAP of >65mmHg, a uri ne
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out put of >0.5ml /kg/h, and a cent ral venous O 2 s at urat i on (ScvO 2 ) >70%. Thi s ent ai l s us i ng more i v fl ui ds and more i not ropes earl y i n cri t i cal i l l nes s ; i n one s t udy i t has been s hown t o decreas e mort al i t y from 47% t o 31%.
Intravenous hydrocortisone Many phys i ci ans are nervous about gi vi ng s t eroi ds t o pat i ent s wi t h s ept i c s hock. However, rel at i ve adrenal i ns uffi ci ency occurs i n 5075% of s uch pat i ent s . One mul t i -cent re s t udy found t hat i v hydrocort i s one (200mg/day) t oget her wi t h fl udrocort i s one (50g/day) decreas ed mort al i t y from 63% t o 53% i n pat i ent s wi t h es t abl i s hed refract ory s hock. The benefi t was s een i n non-res ponders t o an ACTH s t i mul at i on (Synact hen) t es t . Activated protein C Severe s eps i s i s as s oci at ed wi t h a decreas e i n act i vat ed prot ei n C (aPC). A recombi nant aPC t hat has ant i -i nfl ammat ory, ant i -coagul ant (i ncl udi ng i nact i vat i on of fact or V and VIIIA), and profi bri nol yt i c propert i es , can be gi ven wi t h s ome out come benefi t .In one s t udy, aPC (Drot recogi n ) decreas ed mort al i t y from 31% t o 25%, but doubl ed t he ri s k of major bl eedi ng from 1% t o 2%. Low tidal volumes in ARDS Pat i ent s wi t h ARDS were t radi t i onal l y vent i l at ed t o a t i dal vol ume of 1015ml /kg i deal body wei ght . However, s t udi es have s hown t hat decreas i ng t he t i dal vol ume t o 68ml /kg/i deal body wei ght res ul t s i n a decreas e i n mort al i t y from 40% t o 31%.
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P.268
Shock with systemic vasodilatation 2
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It i s i mport ant i n t he management of s uch cri t i cal l y i l l pat i ent s not t o l os e s i ght of t he needs of t he pat i ent . It i s eas y i n an ICU s et t i ng not t o exami ne pat i ent s but t o l ook at chart s . Al ways exami ne t he pat i ent at l eas t t wi ce a day and det ermi ne whet her t he cl i ni cal paramet ers mat ch t hos e on t he ICU chart .
Ask yourself twice a day
Fl ui d requi rement s (what i s t he fl ui d bal ance, i s t he pat i ent cl i ni cal l y dry or oedemat ous ?) Is t he ci rcul at i on adequat e? Not e t he BP (and MAP), fi l l i ng pres s ures , and cardi ac out put . Exami ne t he peri pheri es (are t hey cool and s hut down, or warm). Is t he uri ne out put s at i s fact ory? Is t here a marked s wi ng on t he art eri al t race, whi ch can s ugges t hypovol aemi a? Is t here a devel opi ng met abol i c aci dos i s , whi ch may i ndi cat e t i s s ue hypoperfus i on? Is gas exchange s at i s fact ory? W at ch cl os el y for devel opi ng ARDS (p230). Exami ne t he ches t dai l y for det eri orat i on t hat may be mas ked (on ABG) by adjus t ment s of mechani cal vent i l at i on and do a CXR as appropri at e. Are t here s i gns of s eps i s ? Is t here any new focus of i nfect i on? W hat do t he t es t s s how (U&Es , LFTs , Ca , PO 4 , Mg , CRP, cul t ures (bl ood, uri ne, s put um, l i ne t i ps , et c.)? Is t he pat i ent recei vi ng adequat e nut ri t i on (TPN or ent eral )? Al ways gi ve ent eral nut ri t i on i f pos s i bl e. Even ent eral nut ri t i on at 10ml /h wi l l benefi t t he gut mucos a. Gi ve wi t h TPN i f gut funct i on i s i n doubt .
2+ 32+
Optimizing oxygen delivery to tissues and oxygen consumption
Ai m for a MAP of at l eas t 5560mmHg. Such a pres s ure i s us ual l y requi red for good renal funct i on. If t he pat i ent remai ns ol i guri c, es peci al l y i n previ ous l y hypert ens i ve pat i ent s , t hen cons i der rai s i ng t he MAP by
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1020mmHg us i ng vas opres s or agent s or i not ropes (s ee bel ow).
Vas opres s or and i not ropi c agent s : i f cardi ac out put i s l ow, epi nephri ne (adrenal i ne) or dobut ami ne s houl d be us ed, and i f t he pat i ent i s hypot ens i ve wi t h a hi gh cardi ac out put (i .e. SVR i s l ow), t hen norepi nephri ne (noradrenal i ne) s houl d be us ed (t hi s has rel at i vel y l i t t l e i not ropi c effect ). Al t ernat i ves t hat are favored i n l i ver di s eas e i ncl ude t erl i pres s i n gi ven as a bol us i v at 0.5mg, repeat ed every 30 mi nut es t o a maxi mum of 2mg. Hi gher dos es res ul t i n a much hi gher i nci dence of di gi t al i s chaemi a. Not e t he effect s any manoeuvre has on s ys t emi c haemodynami cs and oxygen met abol i s m: e.g. i nfus i on of noradrenal i ne may i mprove BP, but decreas e oxygen ext ract i on; i ncreas i ng t he PEEP on t he vent i l at or may decreas e cardi ac out put . Fl ui d repl acement : expandi ng t he ci rcul at i on wi l l oft en i ncreas e t he cardi ac out put , but exces s i ve fl ui d l oadi ng i n t he pres ence of l eaky pul monary capi l l ari es carri es t he pot ent i al ri s k of det eri orat i on of gas exchange. If t he pat i ent i s anaemi c, us e bl ood. Ai m for a haemogl obi n of 7g/dl , t hough pos s i bl y hi gher i n pat i ent s wi t h cardi ores pi raot ry compromi s e.
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P.270
Sepsis syndrome and septic shock Definitions

Ba Pos
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cte i t i v ra e em bl o ia od cul t ur es . Se Evi psi de s nce of i nf ect i on pl u s s ys te mi c i nfl am ma t or y res po ns e s uc h as pyr exi a or t ac
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hyc ard i a. Se Sys psi t e s mi c sy res nd po ro ns e me t o i nf ect i on pl u s evi de nce of org an dys fun ct i on: con fus i on , hyp oxi a, ol i gur i a,
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me t ab ol i c aci dos is. Se Se pti ps i c s sh s yn oc dro k me pl u s hyp ot e ns i on refr act ory to vol um e rep l ac em ent .
Presentation
General symptoms. Sweat s , chi l l s , or ri gors . Breat hl es s nes s . Headache. Confus i on i n 1030% of pat i ent s , es peci al l y t he el derl y. Naus ea, vomi t i ng, or di arrhoea may occur. Examination. Hypot ens i on (s ys t ol i c BP <90mmHg or a 40mmHg fall
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from bas el i ne), t achycardi a, wi t h peri pheral vas odi l at at i on (warm peri pheri es , boundi ng peri pheral pul s e, boundi ng pul s es i n forearm mus cl es ) are t he hal l marks of s ept i c s hock, but pat i ent s do become s hut down event ual l y. SVR i s reduced and cardi ac out put i s i ncreas ed i ni t i al l y but s evere myocardi al depres s i on may occur. Ot her feat ures i ncl ude fever >38 C or hypot hermi a <35.6C (i mmunocompromi s ed or el derl y pat i ent s may not be abl e t o mount a febri l e res pons e), t achypnoea and hypoxi a, met abol i c aci dos i s , ol i guri a. Focal phys i cal s i gns may hel p t o l ocal i ze t he s i t e of i nfect i on.
Investigations
Blo Bl o od od tes cul ts t ur es , U& Es , bl o od s ug ar, FB C, coa gul at i on stu di e s, LFT s, CR
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P, gro up an d s av e s er um , l ac t at e, AB Gs . Am yl a s e, CK an d acu te ph as e titr es or ant i ge n t es ts if
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ap pro pri at e . Cul Bl o tur od, e s pu tu m, uri ne, lin e-t i ps , wo un d sw abs , t hr oat sw ab, dra in fl ui d, sto ol , CS F (as
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i nd i ca t ed ). Im CX agi R, ng US S or CT bra i n, che st, ab do me n, an d pel vi s for col l ect i on s. Ech o if en doc ard itis s us pec
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t ed .
Prognosis
The i nci dence of bact eraemi a i s 7/1000 admi s s i ons t o hos pi t al . Of t hes e 20% devel op s ept i c s hock and approxi mat el y 50% of t hes e di e. Mo rta lity Bac 15 t er ae 20 mi % a Bac 30 t er ae 40 mi % a pl u s s ho ck Sh 40 ock
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pl u 60 s AR DS %
P.271
Poor prognostic features in sepsis syndrome

Age >60 Mul t i -organ fai l ure Renal fai l ure Res pi rat ory fai l ure (ARDS) Hepat i c fai l ure Hypot hermi a or l eukopeni a Hos pi t al -acqui red i nfect i on Di s s emi nat ed i nt ravas cul ar coagul at i on Underl yi ng di s eas e (e.g. i mmunocompromi s ed, poor nut ri t i onal s t at us , mal i gnancy)
P.272
Sepsis syndrome: management 1

Pat i ent s wi t h es t abl i s hed s hock requi re adequat e haemodynami c moni t ori ng and hi gh-dependency faci l i t i es . The t reat ment i s mai nl y s upport i ve, t ryi ng t o opt i mi z e bl ood pres s ure and t i s s ue
Pa g e 4 7 5
oxygenat i on and pres erve vi t al organ perfus i on unt i l t he i nfect i on i s overcome by ant i bi ot i cs and hos t defences . Succes s ful management requi res cl os e l i ai s on bet ween s everal di fferent t eams (i nt ens i vi s t s , phys i ci ans , s urgeons , mi crobi ol ogi s t s , et c.).
Resuscitation
Check t he ai rway i s cl ear. Gi ve hi gh-fl ow oxygen: i f t here i s refract ory hypoxi a, i nt ubat e and vent i l at e. Treat res pi rat ory fai l ure (p224). Ins ert a l arge-bore peri pheral venous cannul a t o begi n fl ui d res us ci t at i on. Ins ert cent ral l i ne and art eri al l i ne. Cons i der cardi ac out put meas urement . Vol ume repl acement i s es s ent i al , and bl ood i f haemogl obi n i s <710g/dl . Opt i mi ze fi l l i ng pres s ures , wat chi ng gas exchange cl os el y; wors eni ng may s ugges t exces s l eakage from pul monary capi l l ari es . If t hi s occurs , cons i der us e of vas ocons t ri ct i ng i not ropes (e.g. epi nephri ne, norepi nephri ne) i f requi red t o i mprove t he ci rcul at i on. Ai m t o keep mean art eri al pres s ure >5560mmHg. If cardi ac out put i s l ow, epi nephri ne s houl d be us ed and i f cardi ac out put i s hi gh (and SVR l ow), t hen norepi nephri ne s houl d be us ed. Sugges t ed s t art i ng dos es are
o o
Norepi nephri ne (noradrenal i ne) 112mg/mi n. Epi nephri ne (adrenal i n) 112mg/mi n. Terl i pres s i n 0.5mg i v every 24 hours t o a maxi mum of 2mg, t hough moni t or cl os el y for di gi t al i s chaemi a and wors eni ng aci dos i s (dobut ami ne may exacerbat e vas odi l at at i on i n s ept i c s hock (or decompens at ed l i ver di s eas e) and i s general l y bes t avoi ded.
Al t ernat i ves i ncl ude

o
Optimize haemodynamics and oxygen delivery
Pa g e 4 7 6
Convent i onal management i nvol ves t ryi ng t o normal i ze t he haemodynami c paramet ers (s ee bel ow). However, i t has been argued t hat i n t he s et t i ng of s eps i s , as t he oxygen ext ract i on and ut i l i z at i on by t he t i s s ues are i mpai red, one s houl d ai m for s upra-normal ci rcul at i on t o t ry t o i mprove oxygen del i very. No rm I al de ra al ng e in se psi s Car 2.8 >4. di a 5 c i nd ex (L/ mi n/ m ) SV 17 >1 R 60 46 i nd 0 ex 26 (dy 00 nes /S/ cm
5 2
3.6
) Ox 52 >8 yge 0 00 n 7
Pa g e 4 7 7
del 20 i ve ry ( DO
2
ml / mi n) Ox 11 >1 yge 0 70 n su mp tio n ( VO 2 ml / mi n) See p280 for formul ae for haemodynami c cal cul at i ons P.273 1 con 40
P.274
Sepsis syndrome: management 2 Antibiotics

Ant i bi ot i c choi ce i s di ct at ed by t he s us pect ed s i t e of i nfect i on and probabl e mi crobe, hos t fact ors s uch as age, i mmunos uppres s i on, and hos pi t al i zat i on, and l ocal ant i bi ot i c-res i s t ance pat t erns . A s ugges t ed empi ri c regi men i n pat i ent s wi t h s eps i s s yndrome and t he fol l owi ng s ource of i nfect i on i s as fol l ows :
Pa g e 4 7 8
Pneu monia Co Comm am uni oxi t y- cl a acq v ui r or ed Cef ot a xi m e + cl a ri t h ro my ci n Ho Cef s pi t az t al i di -ac me qui al o red ne or Pi p era ci l l in + ge nt a mi c in NB :
Pa g e 4 7 9
if St a ph. aur eus s us pec t ed , us e t ei cop l an in or van co my ci n (i f MR SA) , fl u cl o xac illi n (i f MS SA) Int Cef raot a ab xi m do e +
Pa g e 4 8 0
mi me nal t ro se ni d psi az o s le or Pi p t az ob act am ge nt a mi c in Bi l i Pi p ary t az t ra ob ct act am ge nt a mi c in Urinar y tract Co Comm am uni oxi t y- cl a acq v ui r or ed cef
Pa g e 4 8 1
ot a xi m e Ho Cef s pi t az t al i di -ac me qui or red Pi p t az ob act am ge nt a mi c in Ski Con d t am cl a or an oxi sof v tis Am su oxy e ci l l in + fl u cl o xac illi n So Be
Pa g e 4 8 2
re nz y thr l pe oat ni ci llin Mu Va ltip nco le my or ci n ga + nis ge ms nt a (an mi c aer i n ob + es , me E. i, t ro az o c ol ni d St r l e ep or .) Cl i nd am yci n ge nt a mi c in Me Cef nin ot a giti xi m s e or
Pa g e 4 8 3
(i f pe n. an d cef . al l erg i c) Va nco my ci n ri fa mp i ci n Ma ny no w s ug ges t chl ora mp he ni c ol NB: cons ul t your mi crobi ol ogi s t s for l ocal ant i bi ot i c pol i cy.
Removal of infective foci

It i s es s ent i al t o i dent i fy and drai n focal s i t es , e.g. obs t ruct ed uri nary t ract or bi l i ary t ree, drai n abs ces s es , and res ect dead
Pa g e 4 8 4
t i s s ue.
Causes of treatment failure

Res i s t ant or unus ual i nfect i ng organi s m Undrai ned abs ces s Infl ammat ory res pons e (rai s ed CRP, rai s ed W CC) may pers i s t des pi t e adequat e ant i -mi crobi al t herapy Advanced di s eas e.
P.275
P.276
Toxic shock syndrome
Di s t i nct cl i ni cal i l l nes s caus ed by t oxi n-produci ng Gram-pos i t i ve bact eri a, us ual l y s t aphyl ococci or s t rept ococci . Infect i on i s oft en l ocal i zed and i l l nes s i s mani fes t by t he t oxi ns . 85% of cas es are femal e. As s oci at i on wi t h mens t ruat i on i n femal es t he us e of t ampons . May occur wi t h any focal i nfect i ons due t o a t oxi n-produci ng s t rai n, i ncl udi ng pos t operat i ve wound i nfect i ons .
Clinical features

Fever: >38.9C Ras h: di ffus e macul ar (s een i n 95%), mucous membrane i nvol vement common. Des quamat i on 12 weeks l at er, pal ms and s ol es (cons i der drug react i on i n di fferent i al di agnos i s ) Hypot ens i on: s ys t ol i c <90mmHg, or pos t ural hypot ens i on Di arrhoea frequent
Pa g e 4 8 5
DIC and pet echi al ras h Mul t i -organ fai l ure may fol l ow.
Laboratory findings
Normochromi c normocyt i c anaemi a (50%) and l eukocyt os i s (>80%) Renal /hepat i c fai l ure (2030%) El evat ed CPK i s very common DIC Pyuri a CSF pl ei ocyt os i s (s t eri l e) Bl ood cul t ures rarel y pos i t i ve Vagi nal s wabs , t hroat s wab, and wound s wabs Toxi n-produci ng St aph. aureus i n 98% of mens es -as s oci at ed cas es .
Therapy

Li mi t t oxi n product i on/rel eas e Drai n any focal col l ect i ons and remove forei gn bodi es Ant i -s t aphyl ococcal ant i bi ot i cs (hi gh-dos e fl ucl oxaci l l i n or t ei copl ani n i v) Support i ve care as for any pat i ent wi t h s hock.
P.277
P.278
Lactic acidosis
Lact i c aci dos i s i s a met abol i c aci dos i s due t o exces s product i on or reduced met abol i s m of l act i c aci d. It may be di vi ded i nt o t wo t ypes , t ype A (due t o t i s s ue hypoxi a) and t ype B (non-hypoxi c).
Presentation
Pat i ent s are us ual l y cri t i cal l y i l l . Cl i ni cal feat ures i ncl ude
Shock (oft en BP <80/40)
Pa g e 4 8 6
Kus s maul res pi rat i on Tachypnoea Det eri orat i ng cons ci ous l evel Mul t i -organ fai l ure i ncl udi ng hepat i c, cardi ac, and renal fai l ure Cl i ni cal s i gns of poor t i s s ue perfus i on (col d, cyanot i c peri pheri es ).
Investigations

ABGs (pH <7.34, s evere i f pH <7.2) Serum el ect rol yt es i ncl udi ng bi carbonat e and chl ori de t o cal cul at e ani on gap, i f l act at e unavai l abl e. Rai s ed ani on gap >16mmol /L [ani on gap = (Na + K )-(Bi carbonat e + chl ori de)] FBC (anaemi a, neut rophi l i a) Bl ood gl ucos e Bl ood l act at e l evel >5mmol /L (us e a fl uori de t ube) Screen for s eps i s (bl ood cul t ures , CRP, MSU, et c.) Spot uri ne (50ml ) for drug s creen i f caus e unknown CXR l ooki ng for cons ol i dat i on or s i gns of ARDS.
+ +
Severi t y i s as s es s ed by t he bl ood l act at e concent rat i on and t he degree of aci daemi a. Thi s may be confounded by t he pres ence of acut e renal fai l ure. In t he earl y s t ages , t he art eri al pH may be normal or even rai s ed as el evat ed l act at e l evel s i n t he CNS caus e hypervent i l at i on wi t h a compens at ory res pi rat ory al kal os i s . The bes t predi ct or of s urvi val i s t he art eri al pH. Pat i ent s pres ent i ng wi t h a l act at e of great er t han 5mmol /L and a pH <7.35 have a mort al i t y >50%.
Management
The pri nci pl e of management i s di agnos i s and t reat ment of t he caus e, and amel i orat i on of t he underl yi ng pat hophys i ol ogy. Al l pat i ent s s houl d be managed i n a hi gher dependency area.
Sepsis. St art broad-s pect rum ant i bi ot i cs (e.g. cefot axi me pl us met roni dazol e, or amoxyci l l i n,
Pa g e 4 8 7
gent ami ci n, and met roni dazol e).
Diabetic lactic acidosis. Ins ul i n and fl ui ds as appropri at e (s ee p556). Shock. Cons i der i nvas i ve haemodynami c moni t ori ng. Treat as on p262. Renal failure. Treat by cont i nuous haemofi l t rat i on. Thes e pat i ent s are us ual l y t oo uns t abl e t o t ol erat e haemodi al ys i s . If haemodi al ys i s i s us ed, i t i s now convent i onal t o us e bi carbonat e di al ys i s . Methanol. Infus e et hanol (compet i t i ve met abol i s m, s ee p824). Acidaemia. The rol e of bi carbonat e i s cont rovers i al as i t may l ower CSF pH and al t er t he oxygen di s s oci at i on curve unfavourabl y. There i s no benefi t of bi carbonat e over equi mol ar s al i ne i n cont rol l ed t ri al s .
P.279
Causes of lactic acidosis

Ty Ty pe pe A B Ti s Se s ue ps i hyp s op erf us i on (s h ock ) Sev Re ere nal
Pa g e 4 8 8
an /he ae pat mi i c a fai l ure Sev Di a ere bet hyp es oxi me a llit (s a us me (un as con
) t rol l ed
) Cat Mal ech i gn ol a anc mi y ne (l e exc uka es s em (e. i a, g. l ym ph ph ae om ocr a) om Acu ocy t e t o pa ma ncr or eat exo i t i s ge
Pa g e 4 8 9
no us ) Sev Par ere ace exe t a rci s mo e l (ac et a mi no ph en) ove rdo se Drug-i nduce d (met fo rmi n, met ha nol , et hano l, s al i cyl at es , and cyani d e) Rare cause s Heri di t ary enz ym
Pa g e 4 9 0
e defect s s uch as Gl ucos e-6-ph os phat as e and fruct os e 1,6 di phos phat as e defi ci e ncy P.280
Haemodynamic calculations
In general mos t s ys t ems t hes e days cal cul at e al l t he paramet ers t hat you requi re, and t he formul ae bel ow s houl d not be neces s ary. It i s i mport ant t o di s t i ngui s h bet ween i ndexed (modi fi ed for body s urface area) and non-i ndexed val ues . Indexed val ues are s i gni fi ed by t he l et t er I. Thus cardi ac out put (CO) becomes CI and s ys t emi c vas cul ar res i s t ance (SVR) becomes SVRI. Mean arteri al pressu re (MAP) MAP =
Pa g e 4 9 1
Di as t ol ic pres s u re + 1/3 (Sys t ol ic Di as t ol ic pres s u re) e.g. BP 120/60 = MAP of 60 + 1/3 (120 60) = 80mm Hg R. N 1 at R ri al pr es su 7 m m H
re g R. N 1 ve R 5 nt r. sy st 2 5
Pa g e 4 9 2
ol ic pr es su
m m H g
re R. N 1 ve R nt r. di as to lic pr es su re P N 2 A R 0 sy st ol ic pr es su 2 5 m m H 7 m m H g
re g P N 3 A R di as to lic pr 1 2 m m
Pa g e 4 9 3
es su
H g
re M N 9 e R a n P A pr es su 1 6 m m H g
re P N 3 ul R m o n ar y ar te ry w e d g e pr es su re The PAW P i s i ncreas ed i n mi t ral regurgi t at i on, and i t may be di ffi cul t or i mpos s i bl e t o obt ai n a t ypi cal wedged t raci ng. 1 2 m m H g
Pa g e 4 9 4
Cardiac output (CO)
N 4. R 0 6. 2 L/ m in
Cardiac index (CI) N 2. R 8 3. 6 L/ m in / m

2
Systemic vascular resistance (SVR) and SVRI N 8 R 0 0 1 5 0 0 dy n e/
Pa g e 4 9 5
S/ c m
5
N 1 R 7 6 0 2 6 0 0 dy n e/ S/ c m
5
/ m
2
Pulmonary vascular resistance (PVR) N 2 R 0 1 2 0 dy n e/
Pa g e 4 9 6
S/ c m
5
O 2 delivery D O 2 = CO CaO 2
N 9 R 0 0 1 0 0 0 m l/ m in
O 2 consumption: V O 2 = (CaO 2 -CvO 2 ) CO
N 2 R 3 0 2 5 0 L/ m in
C aO 2 = oxygen cont ent of art eri al bl ood (meas ured by haemogl obi nomet er or deri ved from art eri al gas es ) C vO 2 = oxygen cont ent of mi xed venous bl ood (obt ai ned from PA di s t al l i ne)
Pa g e 4 9 7
Oxygen content = Hb (g/L) 1.34 oxygen sat. Oxygen extraction ratio (OER) OER = V O 2 / D O 2 N 0. R 2 2 0. 3 (2 2 3 0 % ) P.281
P.282
Appendices
Appendix 1: Understanding circulatory failure

Int el l i gent mani pul at i on of t he fi l l i ng pres s ures and i not ropi c s upport of a pat i ent wi t h s hock or heart fai l ure requi res a bas i c unders t andi ng of t he way i n whi ch t he l eft and ri ght vent ri cl es res pond t o changes i n fi l l i ng pres s ure and what effect di fferent cl i ni cal condi t i ons have on t hei r funct i on. The fol l owi ng i s a s omewhat s i mpl i fi ed approach.
Pa g e 4 9 8
The s t roke vol umes of t he ri ght and l eft vent ri cl es are i dent i cal but as t he res i s t ance of t he pul monary bed i s much l ower t han t hat of t he s ys t emi c bed, t he ri ght vent ri cl e i s abl e t o do t hi s at a l ower fi l l i ng pres s ure t han t he l eft vent ri cl e. Rai s i ng t he ri ght at ri al pres s ure wi t h i v fl ui ds wi l l i ncreas e t he s t roke vol ume of t he ri ght vent ri cl e. The l eft at ri al pres s ure (and t hus t he LVEDP) wi l l ri s e, keepi ng t he s t roke vol ume of bot h s i des of t he heart mat ched. Seps i s , aci dos i s , K , Ca , Na , MI or i s chaemi a, and cert ai n drugs (e.g. -bl ockers ) are known t o i mpai r myocardi al funct i on. Inot ropes wi l l i mprove cardi ac funct i on. Expandi ng t he ci rcul at i on wi t h i v fl ui ds becomes progres s i vel y l es s effect i ve i n i ncreas i ng t he s t roke vol ume (and s o cardi ac out put ) as t he funct i on become more depres s ed, i .e. t he i ncreas e i n s t roke vol ume per uni t t rans fus ed becomes progres s i vel y l es s . Furt hermore i t i ncreas es t he ri s ks of preci pi t at i ng pul monary oedema (s ee bel ow). Pul monary oedema occurs when t he hydros t at i c pres s ure wi t hi n t he capi l l ary overcomes t he pl as ma oncot i c pres s ure (t he major det ermi nant of whi ch i s t he s erum prot ei ns and al bumi n). The cri t i cal PCW P for hydros t at i c pul monary oedema i s approx. = s erum al bumi n (g/L) 0.57 (i .e. wi t h an al bumi n of 40g/L, cri t i cal PCW P = 22mmHg. The l ungs wi l l of cours e get s t i ffer as t he PCW P ri s es and t he pat i ent may get breat hl es s before t hi s pres s ure i s reached. Thus , even i n normal pat i ent s , cont i nued i v t rans fus i on wi l l event ual l y rai s e t he ri ght - and l eft -s i ded fi l l i ng pres s ures s uffi ci ent l y t o preci pi t at e pul monary oedema.
+ 2+ +
Circulation in sepsis
Seps i s produces a s ys t emi c i nfl ammat ory res pons e t hat res ul t s i n l eaky capi l l ari es , i n t he l ungs and el s ewhere, as wel l as hypoal bumi naemi a from a combi nat i on of i mpai red product i on and l os s i nt o ext ravas cul ar s paces . Thus pat i ent s are at ri s k of pul monary oedema at l ower val ues of PCW P. Furt hermore, t he cardi ac funct i on i s depres s ed s o t hat i v fl ui ds wi l l produce l es s i ncreas e i n s t roke vol ume and cardi ac out put . It i s more prudent t o
Pa g e 4 9 9
s upport t he ci rcul at i on wi t h vas ocons t ri ct i ng i not ropes (e.g. adrenal i ne) t han fl ui ds al one, rememberi ng t hat when t he capi l l ari es are no l onger l eaky, t he fl ui d defi ci t mas ked by adrenal i ne wi l l need t o be repl aced as t he adrenal i ne i s t urned down. P.283
P.284
Appendix 2: inotrope support

Inotropes General points
Ens ure al l pat i ent s gi ven i not ropes have an adequat e i nt ravas cul ar vol ume (CVP or Swan-Ganz cat het er). The ai m of i not ropi c s upport i s t o maxi mi ze t i s s ue oxygenat i on (e.g. as as s es s ed by pl as ma l act at e and mi xed venous oxygenat i on) and not cardi ac out put . The i not ropes i n wi des pread cl i ni cal us e are cat echol ami nes or t hei r deri vat i ves . Thei r haemodynami c effect s are compl ex and refl ect t he rel at i ve i mport ance of a and b adrenergic effect s for each agent . They are s ummari zed i n t he t abl e bel ow: H S M C C R V A O P
R P Is + - + + o + p + r e n /
Pa g e 5 0 0
al in e A + + + + + d r e n al in e Dopamine (l + - + + o w d o s e ) ( + + + + hi + + + + g h d o s e ) D + o + b ut a m in -/ + + + + + + +
Pa g e 5 0 1
e N - + + -/ -/ o r a d r e n al in e Abbrevi at i ons : HR, heart rat e; SVR, s ys t emi c vas cul ar res i s t ance; MAP, mean art eri al pres s ure; CO, cardi ac out put ; CP, coronary perfus i on; +, i ncreas e; -, decreas e; , no change. + + + +
Isoprenaline Pharmacology
Is oprenal i ne i s a s ynt het i c -adrenocept or agoni s t ( 1 & 2 ) wi t h no act i vi t y on a-recept ors . It i s a bronchodi l at or, act s as a cardi ac s t i mul ant i n heart bl ock by s t i mul at i ng t he s i no-at ri al node,
Pa g e 5 0 2
i ncreas i ng conduct i on vel oci t y and s hort eni ng t he refract ory peri od of t he AV node. It has a pos i t i ve i not ropi c effect . It al s o act s on s kel et al mus cl e and bl ood ves s el s . It has a pl as ma hal f l i fe of 5 mi nut es .
Drug interaction

Tri cycl i c ant i depres s ant s enhance t he effect s Bet a-bl ockers anat goni s e t he effect s Sympat homi met i c ami nes may produce an addi t i ve effect Anaes t het i c gas es s es ns i t i ze t he myocardi um an may t ri gger arrhyt hmi as Di goxi n i ncreas ed ri s k of t achyarrhyt hmi as
P.285
Preparation of inotrope infusions for a typical 70kg patient

Ino For Vol St a Mai t ro mu um rt i n nt e pe l at i e g na on t o i nf nce ad us i dos d on e t o rat 50 e 0m l 5% De xt r os e Adr 1:1 2m 15 15
Pa g e 5 0 3
en 00 l al i 0 n
ml / 18
(2 h )
ne s ol mg (1 0m g/ l /h mi (1 n) 1 2 g/ mi n) Do 40 20 6m pa mg ml l /h R mi /ml (80 (2. en ne 0m 25 al g) g/k dos g/ e mi 25 n) 13 ml / h (1 5 g/k g/ mi n) C ard i ac
Pa g e 5 0 4
dos e 13 26 ml / h (5 1 0 g/k g/ mi n) Do 12. 40 10 10 but 5m ml ml / am g/ (50 h 60 i ne ml 0m (2. ml / g) 5 h g/ (2. kg/ 5 mi 1 n) 5 g/ kg/ mi n) Nor 2m 2m 15 7.5 adr g/ l al i ne ml / en ml (4 hr 90 mg (2 ml / ) g/ h mi (1 n) 1
Pa g e 5 0 5
2 g/ mi n) Is o 1m 5m 3m 3 pre g/ l i ne l /h 6 nal ml (5 (0. 0m mg 5 l /h ) g/ (0. mi 5 n) 1 0 g/ mi n) P.286
Adrenaline Pharmacology
Adrenal i ne i s a 2 s el ect i ve agoni s t (10-fol d over 1 ) but makes l i t t l e di s t i nct i on bet ween 1 and 2 recept ors . It has general l y l i t t l e effect on MAP except i n t he pres ence of a non-s el ect i ve -bl ocker, when t he l os s of 2 -medi at ed vas odi l at at i on: convert s adrenal i ne i nt o an ext remel y pot ent pres s or agent ( 1 s el ect i ve bl ockers do not produce t hi s effect ).
Uses
Anaphyl act i c s hock angi oedema and acut e al l ergi c react i ons The us e of adrenal i ne as an i not rope i s l argel y res t ri ct ed t o s ept i c s hock were i t may have advant ages
Pa g e 5 0 6
over dobut ami ne (s ee p688). It caus es , however, a marked reduct i on i n renal bl ood fl ow (up t o 40%) and s houl d onl y be us ed wi t h a renal dos e of dopami ne.

Cardi ac arres t Open angl e gl aucoma Adjunct i ve wi t h l ocal anaes t hei c agent s
Doses
0.21mg i m for acut e al l eri c react i ons and anaphyl axi s , res pect i vel y 1mg (10ml of 1:10,000, or 1ml of 1:1000) for cardi ac arres t In s hock i nfus e dos es of 110g/mi n.
Pharmacokinetics
It i s ext ens i vel y met abol i zed wi t h 50% prot ei n bi ndi ng and a t 1 / 2 of 3 mi nut es , bei ng met abol i zed by t he l i ver and neuronal t i s s ue.
Side-effects

Cardi ac arrhyt hmi as Cerebral haemorrhage (overdos e) Pul monary oedema (overdos e) Local i s chaemi c necros i s Anxi et y, dys pnoea, pal pi t at i ons , t remors , weaknes s , col d ext remi t i es
Drug interactions

Tri cyl cl i c ant i depres s ant s Anaes t het i c agent s b-bl ockers Qui ni di ne and dogoxi n (cardi ac dys rt hmi as more common) a-ant agoni s t s bl ock t he -effect s
Contraindications

Hypert hyroi di s m Hypert ens i on Is chaemi c heart di s eas e
Pa g e 5 0 7
Cl os ed angl e gl aucoma
P.287
P.288
Dopamine Pharmacology
Dopami ne act s on di fferent recept ors . At l ow dos es D 1 and D 2 recept ors are act i vat ed. D 1 recept ors are found i n vas cul ar s moot h mus cl e, and caus e vas odi l at at i on i n t he renal , mes ent eri c, cerebral , and coronary vas cul ar beds . D 2 recept ors are found on pos t gangl i oni c s ympat het i c nerve endi ngs , and aut onomi c gangl i a. At t he next dos e, 1 recept ors are act i vat ed wi t h a pos t i ve chronot ropi c and i not ropi c effect , and at hi gher dos es 1 and 2 recept ors are al s o act i vat ed, whi ch i nhi bi t renal vas odi l at at i on.
Uses
To i ncreas e renal bl ood fl ow i n pat i ent s wi t h i mpai red renal perfus i on, us ual l y i n t he s et t i ng of mul t i -organ fai l ure. There i s l i t t l e evi dence t hat dopami ne affect s cl i ni cal out come.
Dosing
Dopami ne at l ow i nfus i on rat es (0.52g/kg/mi n) s el ect i vel y vas odi l at es t he renal (and mes ent eri c) vas cul ar beds , i ncreas i ng renal bl ood fl ow and GFR. At hi gher rat es (25g/kg/mi n) t here i s act i vat i on of 1 and recept ors , and s ubs equent decreas e of renal bl ood fl ow.
Pharmacokinetics
Dopami ne i s rapi dl y di s t ri but ed by act i ve upt ake i nt o s ympat het i c nerves . The t 1 / 2 i s 9 mi nut es wi t h a V d of 0.9 l /kg, but s t eady s t at e i s achi eved wi t hi n 10 mi nut es (i .e. more rapi dl y t han predi ct ed). It i s met abol i zed by t he l i ver.
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Side-effects

Cardi ac arrhyt hmi as rarel y Hypert ens i on i f dos i ng t oo hi gh Ext ravas at i on may caus e s ki n necros i s . The ant i dot e i s i nfi l t rat i on of phent ol ami ne i n t he i s haemi c area Naus ea, vomi t i ng, headache, pal pi t at i ons , and mydri as i s Increas ed cat abol i s m
Drug interactions

Monoami ne oxi das e i nhi bi t ors -bl ockers may exacerbat e vas odi l at at i on -bl ockers may exacerbat e hypert ens i on Ergot al kal oi ds exacerbat e peri pheral vas ocons t ri ct i on
Contraindications

Phaeochromocyt oma Tachyarrhyt hmi as (unt reat ed)
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Dobutamine Pharmacology
Dobut ami ne i s an i s oprenal i ne deri vat i ve act i ng on 1 , 2 , and 1 recept ors . It i s us ed as a racemat e wi t h t he d-i s omer s howi ng 1 (+ 2 ) s el ect i vi t y and t he l -i s omer 1 s el ect i vi t y. The 2 effect s (vas odi l at i on of mes ent eri c and s kel et al mus cl e bed) and 1 effect s (vas ocons t ri ct i on) t end t o cancel each ot her out , s o t hat i t has l i t t l e effect on bp unl es s hi gh dos es are us ed. It i s l es s arryt hmogeni c t han dopami ne.
Uses
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Inot ropi c s upport for cardi ac fai l ure Inot ropi c s upport for s ept i c s hock and l i ver fai l ure i s cont rovers i al s i nce i t may caus e vas odi l at at i on. Pharmacol ogi cal cardi ac s t res s t es t i ng
Dosing
It i s admi ni s t ered i nt ravenous l y at a dos e of 2.510 g/kg/mi nut e (rarel y up t o 40 g/kg/mi n). The ons et of act i on i s wi t hi n 2 mi nut es , wi t h a peak effect at 10 mi nut es . In conges t i ve cardi ac fai l ure i t may i ncreas e PCW P, t hrough an unknown mechani s m.
Pharmacokinetics
The drug i s ext ens i vel y met abol i zed by t he l i ver. It has a t 1 / 2 of 2.5 mi nut es , and V d of 0.21/kg.
Side-effects

Cardi ac arrht hmi as Myocardi al i s chaemi a may occur i f cardi ac out put i ncreas es Hypot ens i on may be mi ni mi zed by cocomi t ant us e wi t h dopami ne at a dos e t o caus e vas ocons t ri ct i on. May occur i n pat i ent s wi t h s eps i s or l i ver di s eas e. Al l ergi es are very rare Ti s s ue necros i s at s i t e of admi ni s t rat i on
Drug interactions
-ant agoni s t s may execerbat e vas odi l at at i on caus i ng hypot ens i on
Contraindications

Low cardi ac fi l l i ng pres s ures Cardi ac arrhyt hmi as Cardi ac t amponade Val vul ar heart di s eas e (AS, ASTIP, MS, HOCM) Known hypers ens i t i vi t y
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Noradrenaline Pharmacology
Noradrenal i ne has s i mi l ar 1 effect s t o adrenal i ne but i t i s s l i ght l y l es s pot ent on mos t 1 recept ors , and has very l i t t l e 2 act i vi t y. Thi s l ack of 2 -medi at ed vas odi l at at i on makes i t a much more pot ent pres s or agent t han adrenal i ne. It i s s omet i mes empl oyed i n acut e hypot ens i on, but i t has rel at i vel y l i t t l e effect on cardi ac out put and t he i nt ens e vas ocons t ri ct i on act ual l y wors ens t i s s ue i s chaemi a (es peci al l y i n ki dney, s ki n, l i ver, and s kel et al mus cl e). If a noradrenal i ne i nfus i on i s us ed i t s houl d be never be s t opped abrupt l y becaus e of t he ri s k of a s udden col l aps e of t he bp.
Drug interactions
Tri cyl i c ant i depres s ant s (whi ch bl ock re-upt ake i nt o cat echol ami ne nerve t ermi nal s ) caus e a 24-fol d i ncreas e i n s ens i t i vi t y t o adrenal i ne or noradrenal i ne i nfus i ons . MAO i nhi bi t ors (e.g. t ranyl cypromi ne and pargyl i ne) markedl y pot ent i at e t he effect s of dopami ne i nfus i ons whi ch s houl d be s t art ed at one-t ent h t he us ual i nfus i on rat e, i .e. 0.2g/kg/mi n. Dobut ami ne i s not a s ubs t rat e for MAO.
Milrinone
Mi l ri none i s a pot ent i nhi bi t or of phos phodi es t eras e (t ype III) and caus es a concent rat i on dependent i ncreas e i n cel l ul ar cAMP. It act s as a pos i t i ve i not rope and vas odi l at or, wi t h l i t t l e chronot ropi c act i vi t y. It s cardi ac act i ons probabl y i nvol ve effect s on cal ci um channel s or fas t ent ry s odi um channel s . The pos i t i ve i not ropi c effect s are enhanced by -agoni s t s . It has a t 1 / 2 of ~ 1h. It i s us ed i n t he s hort t erm t reat ment of s evere heart fai l ure unres pons i ve t o ot her t herapy and acut e heart fai l ure fol l owi ng cardi ac s urgery.
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Doses (for 70kg patient)

Add 10mg t o 40ml 5% dext ros e (50ml fi nal vol ume) Loadi ng dos e 17.5 ml (50g/kg) over 10 mi nut es Mai nt enance dos e 615ml /hr (0.30.8 g/kg/mi n): max 24mg/kg/day
Side-effects
Hypot ens i on and/or cardi ovas cul ar col l aps e i n hypovol aemi c pat i ent s
Enoximone
Enoxi mone i s a pot ent i nhi bi t or of phos phodi es t eras e (t ype IV) and caus es a concent rat i on dependent i ncreas e i n cel l ul ar cAMP. It act s as a pos i t i ve i not rope and vas odi l at or, wi t h l i t t l e chronot ropi c act i vi t y; t hes e effect s are not as s oci at ed wi t h i ncreas ed myocardi al oxygen cons umpt i on. It i s over 20 t i mes more pot ent t han t heophyl l i ne, and has a t 1 / 2 of ~ 1.5 hours . It i s met abol i s ed t o an act i ve met abol i t e whi ch has 10% of pot ency and a hal f l i fe of 15 hours . It i s us ed i n t he t reat ment of conges t i ve cardi ac fai l ure, and can be gi ven ei t her oral l y or i nt ravenous l y.
Doses (for 70kg patient)

Add 50mg t o 40ml normal s al i ne (50ml fi nal vol ume) Loadi ng dos e 63ml (90g/kg/mi n) over 10 mi nut es Infus i on of 2080ml /hr (520g/kg/mi n): max. 24mg/kg/day
Side-effects
Hypot ens i on and/or cardi ovas cul ar col l aps e i n hypovol aemi c pat i ent s
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Sodium bicarbonate Pharmacology

Sodi um bi carbonat e i s an i mport ant bufferi ng mechani s m i n vi vo . It s effect s are s hort l i ved. The admi ni s t rat i on of s odi um bi carbonat e res ul t i n bot h a s odi um l oad and generat i on of carbon di oxi de. It caus es i nt racel l ul ar aci dos i s , and i s negat i vel y i not ropi c, and for t hes e reas ons s houl d be us ed caut i ous l y. It may al s o produce a l eft s hi ft i n t he oxygen di s s oci at i on curve, and decreas e effect i ve oxygen del i very. Mi l d aci dos i s al s o caus es cerebral vas odi l at at i on, and t hus correct i on coul d compromi s e cerebral bl ood fl ow i n t hos e wi t h cerebral oedema.
Uses
Severe met abol i c aci daemi a (us e i n DKA i s cont rovers i al ) Severe hyperkal aemi a It s us e i s bes t avoi ded i n cardi ac res us ci t at i on, s i nce adequat e vent i l at ai on and ches t compres s i on us ual l y s uffi ce.
Dosing
It i s avai l abl e as ei t her an 8.4% s ol ut i on (hypert oni c, cont ai ns 1mmol e HCO 3 /ml ) or a 1.26 % s ol ut i on (i s ot oni c). It i s us ual l y admi ni s t ered as i nt ermi t t ent bol us es of 50100ml , and t he effect on art eri al pH and haemodynami cs moni t ored. Accordi ng t o t he UK Res us ci t at i on Counci l Gui del i nes , t he approxi mat e dos e of 8.4% s ol ut i on requi red can be cal cul at ed as fol l ows :-2
Thus a pat i ent of 60kg wi t h a bas e exces s of -20, woul d requi re 400ml . of 8.4% bi carbonat e t o normal i ze t he pH. Thi s cont ai ns t he equi val ent of 400mmol e of s odi um. Our pers onal vi ew i s t hat t hi s i s t oo much, and one s houl d t ry t o correct t he art eri al pH t o 7.07.1 by gi vi ng 50100ml s odi um bi carbonat e fol l owed by repeat art eri al bl ood gas es , and repeat i ng t he bi carbonat e as neces s ary.
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Thi s s houl d buy enough t i me for more effect i ve and s afer meas ures t o be empl oyed t o t ry t o correct t he underl yi ng caus e for t he aci dos i s .
Side-effects
Ti s s ue ext ravas at i on caus es s evere necros i s . Gi ve vi a a cent ral l i ne where pos s i bl e. It preci pi t at es i n t he l i ne when gi ven wi t h cal ci um chl ori de, and can caus e mi croembol i .
Drug interactions
Preci pi t at es wi t h cal ci um s al t s
Contraindications
Art eri al pH >7.2
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> T able of Cont ent s > Chapt er 4 - Infec t ious diseases
Chapter 4
Infectious diseases
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Fever in a traveller 1 Assessment
It i s i mport ant t o obt ai n a very accurat e hi s t ory of what count ri es were vi s i t ed and what areas wi t hi n t hos e count ri es and t he act i vi t i es of t he i ndi vi dual whi l s t t hey were t here (i .e. vi s i t s t o rural areas or urban t ravel onl y, campi ng vers us l uxury hot el s et c.) t oget her wi t h dat es i n rel at i on t o ons et of i l l nes s , what drugs were t aken, and what were forgot t en. Do not forget t hat al t hough t he pat i ent has t ravel l ed t hey may have common i nfect i ons s uch as pneumoni a or pyel onephri t i s .
Initial investigations
See t abl e.
Management
The epi demi ol ogy and drug-res i s t ance pat t erns of many t ropi cal pat hogens are cons t ant l y changi ng and expert advi ce can be eas i l y obt ai ned from l ocal regi onal i nfect i ous di s eas es uni t . The t el ephone numbers of t he s chool s of t ropi cal medi ci ne are gi ven on p961. Pat i ent s s houl d onl y be s ent home i f t here i s no evi denc e of s eri ous bac t eri al i nfec t i on, t hey are afebri l e, and a mal ari a fi l m i s negat i ve. A s i ngl e
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mal ari a fi l m does not exc l ude mal ari a and t he pat i ent mus t be revi ew ed i mmedi at el y i f a furt her fever oc c urs .
I s ol at i on . If t here i s a hi s t ory of t ravel t o rural W es t Afri ca (part i cul arl y rural Ni geri a, Si erra Leone, Gui nea, or Li beri a) and t he pat i ent i s febri l e cons i der Las s a fever (p322). Di s cus s t he cas e i mmedi at el y wi t h t he regi onal i nfect i ous di s eas es uni t . Onl y a mal ari a fi l m and ot her i mmedi at el y rel evant bl ood t es t s s houl d be performed aft er di s cus s i on wi t h t he on-s i t e l abs . Unl es s cl earl y s ufferi ng from a haemorrhagi c i l l nes s , t he pat i ent i s kept on s i t e unt i l mal ari a has been excl uded and t hen t rans ferred t o a s upra-regi onal hi gh-s ecuri t y i nfect i ous di s eas es uni t capabl e of nurs i ng pat i ent s wi t h vi ral haemorrhagi c fevers . If mal ari a i s di agnos ed, management can proceed as des cri bed on p354. Al l ot her pat i ent s s houl d be nurs ed i n a s i de room unt i l a di agnos i s i s es t abl i s hed. Cl i ni cal rabi es i s rare i n t he UK but s houl d be cons i dered i n t ravel l ers wi t h s evere encephal i t i s comi ng from a rabi es -endemi c area. A more common probl em i s t hat pat i ent s qui t e frequent l y pres ent havi ng s uffered an ani mal bi t e when t ravel l i ng i n an endemi c area. Pos t -bi t e prophyl axi s can prevent rabi es i n vi rt ual l y al l cas es (s ee p328). T B s houl d be cons i dered when eval uat i ng al l pat i ent s , part i cul arl y from t he Indi an s ubcont i nent or Afri ca. TB i s a frequent pres ent i ng i l l nes s i n advanced HIV i nfect i on, es peci al l y i n s ub-Saharan Afri can pat i ent s and may be ext ra-pul monary (e.g. TB meni ngi t i s , mi l i ary TB, abdomi nal TB). Al l pat i ent s wi t h TB s houl d be offered HIV t es t i ng. Cons i der drug-res i s t ant TB es peci al l y i f pat i ent previ ous l y t reat ed for TB or has been i n pri s on i n eas t ern Europe.
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Investigations for febrile travellers

FBC Look for anaemi a (mal ari a, hookworm, mal abs orpt i on, l ei s hmani as i s ), l eukocyt os i s (bact eri al i nfect i ons , amoebi c l i ver abs ces s ) or l eucopoeni a (mal ari a, t yphoi d, dengue fever, acut e HIV s eroconvers i on), eos i nophi l i a (hel mi nt h/worm i nfect i on), t hrombocyt openi a (mal ari a, t yphoi d, dengue fever) Bl ood fi l ms Thi n fi l ms s houl d be exami ned by t he haemat ol ogi s t s for mal ari a. Thi ck fi l ms can al s o be exami ned, but need expert i s e t o i nt erpret . Mal ari a ant i gen di ps t i ck t es t s on bl ood are now commerci al l y avai l abl e, qui ck, and requi re mi ni mal t rai ni ng U&Es LFTs Renal fai l ure may be s een wi t h P. fal c i parum , vi ral haemorrhagi c fevers (p322), and bact eri al s eps i s Jaundi ce and abnormal l i ver funct i on are s een wi t h hepat i t i s AE, mal ari a, l ept os pi ros i s , yel l ow fever, t yphoi d, l i ver abs ces s es , and many ot hers Cl ot t i ng s t udi es Deranged wi t h vi ral haemorrhagi c fevers (p322), P. fal c i parum , bact eri al s eps i s , vi ral hepat i t i s
Bl ood cul t ures Mandat ory for al l febri l e pat i ent s Uri nal ys i s CXR For bl ood and prot ei n, and a s peci men for cul t ure For pneumoni a. Rai s ed ri ght hemi di aphragm i n amoebi c l i ver abs ces s Other investigations to consider: s erol ogy (hepat i t i s AE), CXR, USS abdomen, Sput um MC&S P.298
Fever in a traveller 2
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Pr Dia es gn ent osi ing s fea to tur co e nsi de r Jau Mal ndi ari ce a, he pat itis A E , l ep t os pi r os i s, yel l ow fev er, t yp hoi d, liv er abs ces s
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Spl Mal en ari om a, eg l ei al y s h ma ni a sis He Mal pat ari os p a, l en s ch om i s t eg os o al y mi as i s, t yp hoi d, bru cel l os i s, l ei sh ma ni a sis Di a E. rrh c ol oe i , a d Sal nel an mo
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vo l a, mi t Shi i ng gel l a, Ca mp yl o bac t er , Gi a rdi a, E. hi s t ol yt i ca, cho l er a, V. par ah ae mo l yt i c us , vi r al gas t ro ent
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eri t is Ski Ery n t he l es ma i on no s dos um (TB , l ep ros y, fun gi , pos t -s t re pt o coc cal i nf ect i on ) Bur row s (s c abi es ) Pai nfu l no
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dul e wi t h pu nct um (cu t an eo us myi as i s, i .e. ma gg ot s ) Der ma titi s (on cho cer ci a sis ) Ul c ers (s y phi lis,
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l ep ros y, l ei sh ma ni a sis ) Sca bs , es c har s (t y ph us , ant hra x) Ery t he ma chr oni ca mi gra ns (Ly me di s eas e)
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Ab W i t do h mi di a nal rrh pai oe n a in dys ent ery , per for at i on of bo wel (t y ph oi d , dys ent ery ) Ha Vi r em al at u ha ri a em orr ha gi c fev ers
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(p3 22) , s ch ist os o mi as i s, ha em ogl obi nur ia in P. fal cip aru m Me Me ni n ni n gi s goc m/ occ con al fus an i on d ot h er bac t eri al me ni n
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gi t i s, vi r al enc ep hal itis Bl e Me edi ni n ng goc t en occ de al ncy s ep tic ae mi a, ha em orr ha gi c fev ers , l ep t os pi r os i s RU Am Q n, oe liv pai bi c
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i nt er erc abs os t ces al t en der nes s R pl e ura l eff us i on Pl e TB, ura l i v l er eff abs us i ces on s P.299 s
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Malaria: assessment
Mal ari a i s a common caus e of deat h from t ravel -acqui red i nfect i on i n t he UK. Excl ude t hi s i n al l febri l e pat i ent s ret urni ng from an endemi c z one.
Organism
Pl as modi um fal c i parum i s t he caus at i ve agent of t he
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mos t s evere and pot ent i al l y fat al or mal i gnant form of mal ari a.
P. vi vax, P. oval e , and P. mal ari ae may caus e chroni c, recurrent di s eas e but are not l i fe-t hreat eni ng. There are no rel i abl e cl i ni cal gui des t o di s t i ngui s h each t ype of i nfect i on. The di fferent s peci es can be di s t i ngui s hed by t hei r morphol ogy on a bl ood fi l m but t hi s may need expert i nt erpret at i on. Mal ari a ant i gen bl ood di ps t i ck t es t i ng can di fferent i at e rel i abl y bet ween P. fal c i parum and P. vi vax . Mi xed i nfect i ons can occur. If i n doubt t herapy s houl d be di rect ed agai ns t P. fal c i parum .
Symptoms
Incubat i on peri od from 7 days mi ni mum up t o 1 year (but us ual l y wi t hi n 3 mont hs ) for P. fal c i parum , up t o 2 years for P. vi vax and P. oval e , up t o 20 years for P. mal ari ae . Hi gh fever, chi l l s , and ri gors fol l owed by s weat i ng. Al t ernat e day fever i s des cri bed but many pat i ent s do not exhi bi t t hi s . Headache i s a very common s ympt om. If as s oci at ed wi t h i mpai rment i n cons ci ous nes s , behavi oural change, or s ei zure act i vi t y, cons i der hypogl ycaemi a. Cerebral mal ari a i s defi ned as unrous abl e coma (GCS 9). Ret i nal haemorrhages , drows i nes s , and ot her neurol ogi cal s i gns may i ndi cat e l es s er cerebral i nvol vement , whi ch may progres s . General i zed fl u-l i ke s ympt oms , mal ai s e, and myal gi a. Abdomi nal s ympt oms : anorexi a, pai n, vomi t i ng, and di arrhoea.
Examination

No s peci fi c feat ures Pyrexi a i n mos t , but not al l cas es , oft en up t o 40C duri ng paroxys ms Spl enomegal y
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Haemol yt i c jaundi ce.
Indicators of severity in P. falciparum malaria
Neurol ogi cal feat ures (deep comas , s ei zures , decerebrat e ri gi di t y) Ret i nal haemorrhages Hypogl ycaemi a Paras i t aemi a >2% Schi zont s on bl ood fi l m Pul monary oedema W CC >12 10 /L Hb <7g/dl Coagul opat hy (DIC) Renal fai l ure (creat i ni ne >250M) Lact i c aci daemi a (>6mmoY l )
9
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P.302
Malaria: investigations
An C ae a, no n-i mm un e ha em FB mi
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ol y sis , l eu kop eni a, an d t hr om bocyt op eni a s ug ges t P. fal cip aru m. Blo Re od pe fil at e ms d bl o od sa mp l es ove r
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s ev era l ho urs s ho ul d be exa mi ne d by an exp eri enc ed i nd i vi du al if t he pat i en t is un wel l an d ma l ari
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a not fou nd on t he i ni t i al bl o od fi l m. A ma l ari a ant i ge n bl o od di p sti ck t es t for P. fal cip aru m s ho ul d
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al s o be per for me d (t h is is as s en siti ve as a bl o od fi l m rea d by an exp eri enc ed mi c ros cop ist an d
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can ai d s pe ci a tio n). If in do ubt , t re at for ma l ari a an d s en d t he fi l ms to a ref ere nce l ab ora t or y for
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a def i ni t i ve opi ni o n. Thi ck fi l ms are mo re s en siti ve. Thi n fi l ms ma ke s pe ci a tio n eas i er an d are us e d
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to cal cul at e t he par as i t ae mi a. Pa Mi l ras d: ita <2 em % ia par as i t ae mi a, te mp . <3 9 C, an d pat i en t am bul ant wi t h
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no co mp l i ca tio ns ; s ev ere : >2 % par as i t ae mi a or s ch izo nt s on fi l m or co mp l i ca tio ns . G6 Ca PD us e sta s tus ha em ol y
Pa g e 5 3 7
sis in G6 PD def i ci e ncy . Glu Hy cos po e gl y cae mi a ma y occ ur wi t h P. fal cip aru m or iv qui ni n e t he rap y, es p eci
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al l y dur i ng pre gn anc y. U& Acu Es, t e LF ren T s al fai l ure an d ha em ogl obi nur ia ma y occ ur in s ev ere P. fal cip aru m. El e
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vat ed unc onj ug at e d bi l i rub i n, AS T, an d LD H refl ect ha em ol y sis . Blo Eve od n i f cul ma tur l ari es a is con fi r me d. Ot her
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i nf ect i on s s uc h as a Gra mne gat i ve s ep tic ae mi a ma y al s o be pre s en t. He Ma ad y CT be sca req n d ui r in pec an ed LP s us
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t ed cer ebr al ma l ari a to exc l ud e ot h er pat hol ogi es . AB Me G t ab ol i c aci dos is i nd i ca t es s ev ere ma l ari a. P.303
P.304
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Malaria: management General measures
Admi s s i on i s mandat ory as rapi d progres s i on and deat h can occur wi t hi n hours . Lower fever wi t h t epi d s pongi ng and paracet amol . If s evere mal ari a or cerebral mal ari a admi t t o HDU/ITU. Fi t s can be cont rol l ed wi t h di azepam. In s evere cas es cat het eri ze t he bl adder t o moni t or uri ne out put and i ns ert a CVP l i ne t o hel p manage fl ui d bal ance, as ARDS can eas i l y be preci pi t at ed i n t hes e pat i ent s . Renal s upport may be requi red. 2-hourl y bl ood gl ucos e es t i mat i ons . Regul ar TPR, BP, uri ne out put . Pre-t reat ment ECG requi red for i v qui ni ne (caus es QT prol ongat i on). In s evere cas es repeat bl ood fi l ms at l eas t t wi ce dai l y unt i l paras i t aemi a cl earl y fal l i ng and t hen perform dai l y. Dai l y U&Es , FBC, LFTs . Thrombocyt openi a i s us ual and rarel y needs s upport unl es s pl at el et count <20 10 /L or bl eedi ng.
9
Di s cus s any s evere or compl i cat ed mal ari a wi t h ID uni t earl y. P. fal c i parum acqui red on t he Thai borders and i n nei ghbouri ng count ri es may be qui ni ne res i s t ant and need addi t i onal t reat ment wi t h ant i -mal ari al s not general l y avai l abl e (e.g. parent eral art emet her or art es unat e).
P.305
P.306
Pa g e 5 4 3
Malaria: anti-malarial therapy 1 P. falciparum

Uncomplicated, non-severe P. falciparum in adults
Qui ni ne oral l y, 600mg 8 hourl y, reduced t o 12 hourl y i f pat i ent devel ops s evere ci nchoni s m (naus ea, t i nni t us , deafnes s ). For 57 days unt i l afebri l e and bl ood fi l m negat i ve fol l ow ed by ei t her a s i ngl e dos e of 3 t abl et s of Fans i dar (pyri met hami ne and s ul fadoxi ne) or, i f Fans i dar res i s t ant (part i cul arl y areas of Eas t Afri ca) or Fans i dar al l ergi c, gi ve doxycycl i ne 100mg bd for 7 days . Mal arone (at ovaquone/proguani l ) and Ri amet (art emet her/l umefant ri ne) have bot h been l i cens ed for t he t reat ment of non-s evere P. fal c i parum . The dos es for adul t s are Mal arone, 4 t abl et s once dai l y for 3 days ; Ri amet , 4 t abl et s i ni t i al l y, fol l owed by 5 furt her dos es of 4 t abl et s each gi ven at 8, 24, 36, 48, and 60 hours (t ot al 24 t abl et s over 60 hours ).
Complicated or severe P. falciparum in adults
If paras i t aemi a >2% gi ve qui ni ne di hydrochl ori de i v 10mg/kg (max 700mg) in 250ml of normal s al i ne over 4 hours . Repeat 12 hourl y. Convert t o oral regi me above as s oon as pos s i bl e. (If s everel y i l l or paras i t aemi a >5% may cons i der gi vi ng fi rs t dos e of qui ni ne di hydrochl ori de at 20mg/kg (max 1.4g) over 4 hours fol l owed 12 hourl y by 10mg/kg. NB: us e 10mg/kg fi rs t dos e i f recent mefl oqui ne, hal ofant ri ne, or Ri amet becaus e of pos s i bl e t oxi ci t y.) Qui ni ne dos e can be gi ven 8 hourl y, but need t o wat ch careful l y for t oxi ci t y (QT prol ongat i on). Mefl oqui ne may al s o be effect i ve but res i s t ance i s emergi ng and i t i s bes t t o cont act a mal ari a expert for
Pa g e 5 4 4
advi ce on t he bes t regi menfor t he count ry of ori gi n.
Chl oroqui ne res i s t ance i s now wi des pread and cannot be cons i dered as t reat ment for P. fal c i parum i n t he UK.
Adjunctive therapy

St eroi ds are not recommended for cerebral mal ari a. Exchange t rans fus i on remai ns s omewhat cont rovers i al but may be i ndi cat ed for ext reme paras i t aemi as (>10%). Seek s peci al i s t advi ce. Dai l y bl ood fi l ms unt i l t rophozoi t es cl eared. Rout i ne fol l ow-up not i ndi cat ed unl es s compl i cat i ons . W arn of s mal l ri s k of rel aps e and i mport ance of repeat i ng bl ood t es t s i f furt her fever. Advi s e on fut ure prophyl axi s .
Footnote
For advi ce i n t he UK phone London: 020 7387 9300 (t reat ment ); 020 7388 9600 (t ravel prophyl axi s ). See BNF Sect i on 5.4 for det ai l s of ot her cent res . P.307
P. vivax, P. ovale, and P. malariae
Admission. If di agnos i s s ecure and t he pat i ent i s s t abl e, admi s s i on may not be neces s ary, however many wi l l requi re admi s s i on for s hort s t ay. General meas ures are as above. Acute therapy. Chl oroqui ne remai ns t he drug of choi ce wi t h onl y very l i mi t ed res i s t ance report ed for P. vi vax . Gi ve chl oroqui ne: 600mg (bas e) s t at fol l owed by 300mg 6 hours l at er and 300mg dai l y for 2 days . Radical cure. Rel aps e due t o pers i s t ent hepat i c hypnozoi t e occurs wi t h P. vi vax and P. oval e . Pri maqui ne gi ven aft er cours e of chl oroqui ne. Treat ment i s wi t h pri maqui ne 15mg dai l y for 14 days . Check G6PD l evel s before gi vi ng pri maqui ne as i nduces
Pa g e 5 4 5
s evere haemol ys i s i n t hes e pat i ent s , s eek advi ce.
Patient advice. Avoi d cont act s port s for 1 mont h becaus e of t he ri s k of s pl eni c rupt ure.
P.308
Infections presenting with fever and rash Rashes table: Features of the common childhood exanthems
Inf Mo Dis Inc As Co ect rp tri ub soc mp ion hol but ati iat lica og ion on ed tio y fea ns tur es Va Cl e Les 10 Pyr Bac ric ar i on exi t eri ell ves s a (ch s 21 a al i cl e occ day 1 i nf ur s 2 ect day i on s Var fl u- i cel lik la e pn pro eu dro mo me ni a Enc ep hal itis
i ck on i n pe ery cro np t he ps , ox) ma s t a t ou rt s e on nk bas t ru (5 an 1 d 2m s pr m), ea
Pa g e 5 4 6
evo d l vi per ng i ph i nt era o l l y. pus Mu t ul cos es al t ha i nv t st d ol v ent mm bur em an co cru on
Re act i va t es as her pes zos t er
st Me Ma St a 10 Cor Ot i asl cul rt s yza t i s es op on 14 , ul a ad s r, an mo d rbi l nec l i fo k rm s pr ea di n g per i ph era lly me ap he day con di a jun , ct i bac vi t i t eri s, al cou pn gh, eu l ym mo ph ni a ad , en me op as l at h es y. pn Ko eu pl i mo
Pa g e 5 4 7
k's ni a s po , ts in e enc ep itis
l at hal pro (1 dro : me 10 00) , de afn es s , s ub -ac ut e s cl ero sin g pa nec ep hal itis (SS PE) Ru Pi n Pro 14 Ly Art bel k la gre mp hri t day de i n no ad pat ul t ma s s e 21 ha i s
(Ge cul s an m
rm ar fro s
Pa g e 5 4 8
me as l es )
t ru nk ove r 2 4 day s, ma y be ver y mi l d or abs
hy s es p Enc eci ep al l hal y itis s ub rar occ e i pi t al
ent Pa Fac Fac 5 Ly Art rvo i al i al 1 mp hri t vir ery ras 0 us t he h (s l ma i n ap i n d chi l pe chi l dre dre n (s l che n. s ha i s no ad pat ul t hy s Art Foe hra t al l gi l os a s in pre gn anc y (hy day de i n
ek, Ma ap ery cul pe t he ar d ma or che i nf ma ek) ect cul Ge i os o- ner um pa al i
Pa g e 5 4 9
, h
pul zed mo ad
dro ps ) An ae mi a in pat i en ts wi t h ha em ogl obi no pat hi e s Chr oni c i nf ect i on in im mu noc om pro mi s ed
fi ft ar, i n di s rbi l ul t eas l i fo s e) rm or an nul ar
P.309
Pa g e 5 5 0
P.310
Primary varicella infection (chickenpox)

The cl as s i cal ras h i s des cri bed on p308. At ypi cal pres ent at i ons may occur i n t he i mmunocompromi s ed hos t who may have ful mi nant cut aneous i nvol vement wi t h haemorrhagi c chi ckenpox or convers el y can devel op s ys t emi c i nvol vement wi t h mi ni mal ras h.
Complications
Sys t emi c compl i cat i ons are rare i n t he i mmunocompet ent chi l d but more frequent i n adul t s and t he i mmunocompromi s ed. In t he UK chi ckenpox i s res pons i bl e for about 20 deat hs per year i n ot herwi s e heal t hy adul t s .
Secondary bacterial infections. Mos t frequent compl i cat i on, 2050% of hos pi t al i zed adul t s , and res pons i bl e for approxi mat el y 50% of chi ckenpox-as s oci at ed deat hs . Super-i nfect i ons wi t h group A s t rept ococcal s ept i caemi a i n chi l dren and s t aphyl ococcal s ki n i nfect i ons (i ncl udi ng t oxi c s hock s yndrome) or bact eri al pneumoni a predomi nat e. Viral pneumonia. Approxi mat el y 1 : 400 adul t cas es wi t h 20% mort al i t y. Commoner i n s mokers . Charact eri zed by cough, breat hl es s nes s , and hypoxi a wi t h di ffus e pneumoni t i s on CXR. Hepatitis. Severe hepat i t i s rare except i n s everel y i mmunocompromi s ed. Modes t el evat i on i n t rans ami nas es i s us ual . Encephalitis. Inci dence of 0.1 % i n adul t s , 2030 % mort al i t y. Cerebellar ataxia. 71 : 4000 cas es i n chi l dren, general l y s el f-l i mi t ed. Reyes syndrome. Epi demi ol ogi cal as s oci at i on i n chi l dhood wi t h concomi t ant as pi ri n us e.
Pa g e 5 5 1
Management
Anti-viral and anti-microbial therapy
Immunocompetent children. Ant i -vi ral t herapy not i ndi cat ed. Have a hi gh i ndex of s us pi ci on for bact eri al i nfect i on i f i l l enough t o requi re hos pi t al i zat i on. Immunocompetent adult moderately unwell. W i t hi n fi rs t 24 hours of t he ons et of ras h may benefi t from oral aci cl ovi r 800mg fi ve t i mes per day wi t h reduct i on i n fever and number of l es i ons . Immunocompetent adult with evidence of pneumonitis. i v aci cl ovi r 10mg/kg q8h and ant i -s t aphyl ococcal and s t rept ococcal ant i bi ot i c cover (e.g. cefuroxi me). Pregnancy. Aci cl ovi r i s not l i cens ed for us e i n pregnancy, but appears t o be s afe and non-t erat ogeni c. Pregnant women are at i ncreas ed ri s k of s evere di s eas e and i f pres ent i ng wi t hi n 24 hours of ons et of ras h, t he us e of aci cl ovi r s houl d be di s cus s ed wi t h an expert . Immunocompromised adult or child. Aci cl ovi r i ndi cat ed i n al l cas es . If mi l d di s eas e and mi ni mal i mmunos uppres s i on, oral t herapy wi t h 800mg fi ve t i mes per day may be s uffi ci ent . In more s evere i mmunos uppres s i on, e.g. pos t t rans pl ant , or any evi dence of di s s emi nat i on, t reat wi t h i v 10mg/kg q8h (adul t dos e).
P.311
Prophylaxis for high-risk susceptible patient
Hyperi mmune i mmunogl obul i n (VZI G) i s effect i ve i n prevent i ng or modi fyi ng vari cel l a when gi ven up t o 10 days aft er expos ure. VZIG s houl d be gi ven t o al l
Pa g e 5 5 2
s us cept i bl e (i .e. abs ent s erum VZV IgG, res ul t us ual l y avai l al e i n 48 hours i f di s cus s ed wi t h l ab) i mmunocompromi s ed i ndi vi dual s as s oon as pos s i bl e aft er expos ure t o chi ckenpox or z os t er. VZIG i s i ndi cat ed for VZV IgG-negat i ve pregnant women cont act s and s houl d al s o be gi ven t o newborn i nfant s whos e mot hers have had pri mary vari cel l a 7 days before t o 7 days aft er t he bi rt h. Prophyl act i c aci cl ovi r (t aken from days 714 aft er expos ure) i s al s o effect i ve i n cert ai n groups , but i s not l i cens ed for t hi s i ndi cat i on.
VZIG s uppl i es are l i mi t ed and t i ght l y cont rol l ed. Y our cons ul t ant vi rol ogi s t or mi crobi ol ogi s t s houl d be cont act ed i n t he fi rs t i ns t ance. Vari cel l a vacci ne i s now l i cens ed and can be cons i dered for s us cept i bl e non-i mmune adul t s at ri s k and ot hers fel t t o be at i ncreas ed ri s k. It i s a l i ve vacci ne and s houl d not be gi ven t o t he i mmunocompromi s ed.
P.312
Herpes zoster (shingles)

React i vat i on from l at ent vi rus i n t he s ens ory root gangl i a. Ri s k i ncreas es wi t h age and i mmunodefi ci ency. Ves i cul ar ras h devel opi ng i n crops i n a s i ngl e dermat ome, mul t i pl e dermat omes , or di s s emi nat i on i n i mmunocompromi s ed (up t o 20 di s s emi nat ed ves i cl es are normal i n t he i mmunocompet ent ). Sus pect i mmunodefi ci ency i n recurrent and mul t i -dermat omal zos t er.
Complications
Thes e are more frequent i n i mmunocompromi s ed pat i ent s .

Secondary bact eri al i nfect i on. Pos t -herpet i c neural gi a. Eye compl i cat i ons : kerat i t i s occurs i n 10% of pat i ent s wi t h i nvol vement of t he t ri gemi nal nerve (opht hal mi c z os t er). Rarel y t here may be ret i nal necros i s . As ept i c meni ngi t i s : CSF pl eocyt os i s i s common and
Pa g e 5 5 3
general l y as ympt omat i c.
Cerebral angi i t i s l eadi ng t o a cont ra-l at eral hemi pares i s . Trans vers e myel i t i s : mai nl y i n i mmunocompromi s ed pat i ent s . Cut aneous di s s emi nat i on: i n exces s of 20 ves i cl es out s i de of t he affect ed dermat ome s ugges t s a hi gh ri s k of s ys t emi c di s s emi nat i on. Sys t emi c di s s emi nat i on: l ung, l i ver, and brai n s pread occurs , mai nl y i n i mmunocompromi s ed pat i ent s .
Management
Immunocompetent adult. Val aci cl ovi r 1g t ds , famci cl ovi r 250mg t ds , and aci cl ovi r 800mg 5 t i mes a day appears t o reduce t he durat i on of pos t -herpet i c neural gi a i f gi ven wi t hi n 48 hours of ons et . Ophthalmic zoster. St ai n cornea wi t h fl uoros cei n t o det ect kerat i t i s ; opht hal mol ogy opi ni on vi t al i f decreas ed vi s ual acui t y or any evi dence of eye i nvol vement . If kerat i t i s pres ent t reat wi t h t opi cal , aci cl ovi r, or t ri fl uori di ne oi nt ment and i v aci cl ovi r or oral val aci cl ovi r or famci cl ovi r. Uncomplicated zoster in immunocompromised. Gi ve aci cl ovi r t o prevent di s s emi nat i on. Oral aci cl ovi r, famci cl ovi r, or val aci cl ovi r for pat i ent s wi t h mi l d i mmunos uppres s i on (e.g. on l ong-t erm s t eroi d t herapy). i v aci cl ovi r (10mg/kg q8h) for pat i ent s wi t h s evere i mmunos uppres s i on. Disseminated zoster. Gi ve i v aci cl ovi r 10mg/kg q8h.
Varicella infection control

Chi ckenpox i s i nfect i ous from 48 hours before t he ons et of t he ras h unt i l about 5 days aft er t he ons et . Pat i ent s s houl d be nurs ed by i mmune s t aff us i ng cont act precaut i ons i n a neut ral - or negat i ve-pres s ure s i de room on a ward wi t hout i mmunocompromi s ed pat i ent s . Shi ngl es i s much l es s i nfect i ous unl es s i t i nvol ves t he face or ot her uncovered part of t he body.
Pa g e 5 5 4
P.313
P.314
Meningococcal infection: assessment Rashes

Pupuri c l es i ons are t he hal l mark of meni ngococcal di s eas e but s everal di fferent pat t erns may be s een ei t her s eparat el y or t oget her.
Petechial. Ini t i al l y 12mm di s cret e l es i ons frequent l y on t runk, l ower body and conjunct i vae. Enl arge wi t h di s eas e progres s i on and correl at e wi t h t hrombocyt opaeni a and DIC, whi ch are poor prognos t i c s i gns . Ecchymoses. The pet echi al l es i ons coal es ce and enl arge t o form wi des pread purpura and ecchymos es part i cul arl y on t he peri pheri es . Purpura fulminans. In ext reme cas es ent i re l i mbs or s ect i ons of t he body become purpuri c and t hen necrot i c due t o t he combi nat i on of DIC and vas cul ar occl us i on. Maculopapular. Non-purpuri c and eas i l y mi s t aken for a vi ral ras h occurs earl y i n s ome pat i ent s . May l ook l i ke fl ea bi t es .
Presentation
Predominantly septicaemia. Sympt oms and s i gns of s ept i caemi a, s hock, res pi rat ory di s t res s . May progres s from fi rs t s i gns t o deat h wi t hi n a coupl e of hours . Purpuri c ras h al mos t al ways devel ops but may be abs ent at pres ent at i on. Pat i ent oft en not meni ngi t i c. Gi ve ant i bi ot i cs i mmedi at el y aft er bl ood cul t ures . Cal l ICU i mmedi at el y. Do not perform LP or CT s can. Predominantly meningitis. No s hock, no res pi rat ory
Pa g e 5 5 5
di s t res s . Neurol ogi cal s i gns predomi nat e and ras h may or may not be pres ent .
Bacteraemia without meningitis or sepsis. Non-s peci fi c fl u-l i ke s ympt oms wi t h or wi t hout ras h. Pos i t i ve bl ood cul t ures come as a s urpri s e. Ras h l es s oft en pres ent . May devel op focal s pread s uch as s ept i c art hri t i s , peri cardi t i s . Chronic meningococcaemia. Low-grade fever, purpuric ras h, and art hri t i s , oft en confus ed wi t h gonococcaemi a. Seps i s and meni ngi t i s do not devel op and t he i l l nes s may l as t for weeks unl es s recogni zed. Recurrent meningococcaemia. Sus pect i mmunocompromi s e, part i cul arl y compl ement defi ci ency.
Antibiotics
See p316.
Investigations
Bl ood c ul t ures . Immedi at el y. Al s o t ake EDTA bl ood s ampl e for PCR and t hroat s wab. FBC, U & Es , gl ucos e, LFT, cl ot t i ng. Brai n CT s c an. Shoul d be performed pri or t o l umbar punct ure i n al l cas es of predomi nant l y meni ngi t i s wi t h depres s ed cons ci ous nes s or focal neurol ogi cal s i gns (CGS <12 or fl uct uat i ng GCS, focal neurol ogy, papi l l oedema, fi t s , bradycardi a, and hypert ens i on). Gi ve ant i bi ot i cs before CT Scan. Do NOT del ay t reat ment . Do not perform i n pat i ent s w i t h predomi nat l y s ept i c aemi adel ays I CU c are. P.315
LP: Do not perform i n pat i ent s w i t h predomi nant l y s ept i c aemi a (del ays t hei r vi t al i mmedi at e management and may be dangerous i f DIC). In general , a CT head s can i s advi s abl e i n al l pat i ent s wi t h s us pect ed meni ngi t i s pri or t o Lumbar punct ure. However, t hi s
Pa g e 5 5 6
i nt roduces del ays and recent gui del i nes from t he Bri t i s h Infect i ous Soci et y recommends t hat an LP can be performed wi t hout a head CT i n pat i ent s wi t h s i mpl e meni ngi t i s l i e not s ept i caemi c and no focal neurol ogi cal s i gns and no decreas e i n cons ci ous l evel . Do NOT del ay ant i bi ot i cs beyond 30 mi nut es .
Differential diagnosis of purpuric rash and fever

Gonococcaemi a Bact eri al s ept i caemi a wi t h DIC Haemat ol ogi c mal i gnancy wi t h s eps i s HenochSchnl ei n purpura In t ravel l ers cons i der Rocky mount ai n s pot t ed fever (USA) Vi ral haemorrhagi c fevers (s ee p322)
LP findings in meningococcal infections

Op Oft eni en ng el e pr. vat ed W B El e C vat ed in al mo st 10 0% : me
Pa g e 5 5 7
di a n 12 00 cel l / l, ma i nl y PM N but ma y be mi x ed if par t i al ly t re at e d Pro El e t ei vat n ed in 90 % Gl u Re cos duc e ed in
Pa g e 5 5 8
75 80 % Gra Pos m- i t i v sta e in wi t h a ne gat i ve cul t ur e in 10 15 % Cul Pos t ur i t i v e e in 50 80 % of me ni n gi t i s Ant Pos i ge i t i v
Pa g e 5 5 9
t es i n t i n 50 g % an d cor rel at e s wi t h gra msta in P.316
Meningococcal infection: management Antibiotic therapy
Treat ment mus t be s t art ed i mmedi at el y i f t he di agnos i s of predomi nant l y meni ngoc oc c al s ept i c aemi a i s s us pect ed. If t he di agnos i s i s predomi nant l y meni ngi t i s wi t h no evi dence of s ept i caemi a, perform LP i f no cont rai ndi cat i ons , but do not del ay more t han 30 mi nut es before ant i bi ot i cs are gi ven. If cal l ed by a GP t hen i ns t ruct t he GP t o admi ni s t er peni ci l l i n 2mi u (1.2g) i m/i v or a t hi rd-generat i on cephal os pori n before arrangi ng t rans fer t o hos pi t al .
Treatment

Cefot axi me 2g 4 hourl y or ceft ri axone 2g bd. If t he pat i ent has had defi ni t e anaphyl axi s or near
Pa g e 5 6 0
anaphyl axi s t o peni ci l l i n, t hen chl orampheni col 25mg/kg 6 hourl y (max 1g qds ) may be cons i dered i ni t i al l y.
If t here i s a pos s i bi l i t y t hat t he pat i ent has pneumococcal meni ngi t i s and i s s everel y obt unded s t art dexamet has one 10mg 6 hourl y for 4 days wi t h or jus t before t he fi rs t dos e of ant i bi ot i cs : t hi s has been s hown t o reduce mort al i t y s ubs t ant i al l y.
Prophylaxis

Not i fy t he cas e i mmedi at el y t o t he l ocal CCDC. CCDC wi l l advi s e on ant i bi ot i c prophyl axi s . Cl os e cont act s onl y, i .e. hous ehol d, ki s s i ng cont act s , cl os e fami l y, i ns t i t ut i onal cont act s (i f from a nurs i ng home) et c. i n previ ous 710 days . St aff members onl y i f i nvol ved i n res us ci t at i on or endot racheal i nt ubat i on and s uct i oni ng wi t hout a mas k on. Adul t s : Ci profl oxaci n 500mg as a s i ngl e dos e (unl i cens ed i ndi cat i on) or ri fampi ci n 600mg bd for 2 days or ceft ri axone 250mg i m s t at .
Chi l dren: Ri fampi ci n 10mg/kg bd for 2 days .
Supportive therapy
Int ens i ve care moni t ori ng i s es s ent i al i n any s hocked pat i ent or i f s i gni fi cant i mpai rment of cons ci ous nes s . If s hocked, urgent fl ui d repl acement , ai ded by i nvas i ve moni t ori ng, i s es s ent i al . Support i ve care for s ept i c s hock i s di s cus s ed on p270. Treat ment of DIC i s s upport i ve. Rol e of drot recogi n al fa (rAPC) i s not yet cl ear: may be cont rai ndi cat ed becaus e of t hrombocyt openi a, haemorrhage.
Prognosis
Meni ngi t i s wi t hout s hock: mort al i t y approxi mat el y 10%, neurol ogi cal s equel ae uncommon. Coma i s a poor
Pa g e 5 6 1
prognos t i c s i gn.
Ful mi nant meni ngococcaemi a: mort al i t y rel at ed t o organ fai l ure bet ween 2080%.
P.317
P.318
Enteric fever (typhoid) 1. Presentation
Non-s peci fi c s ympt oms , e.g. anorexi a, myal gi a, headache, mal ai s e, fever, chi l l s , and s weat s common. Remi t t ent t emperat ure gradual l y ri s i ng duri ng t he fi rs t week t o ~40C wi t h a rel at i ve bradycardi a. Abdomi nal pai n (3040%), D&V (4060%), or cons t i pat i on (1050%) may al l be s een. Acut e abdomen occurs i n l at er s t ages (perforat i on of bowel ). Spl enomegal y (4060%) and hepat omegal y (2040%). Res pi rat ory s ympt oms common i ncl udi ng s ore t hroat and cough. Neurol ogi cal mani fes t at i ons i ncl udi ng encephal opat hy, coma, meni ngi s m, and/or s ei zures are s een i n 510%. Ros e s pot s are 24mm eryt hemat ous macul opapul ar l es i ons , bl anch wi t h pres s ure, and occur i n crops of ~10 l es i ons on upper abdomen l as t i ng onl y a few hours . Pres ent i n 1030% and eas i l y mi s s ed.
A ful mi nant , t oxaemi c, form occurs i n about 510% of cas es wi t h rapi d det eri orat i on i n cardi ovas cul ar, renal , hepat i c, and neurol ogi cal funct i on. In ot her pat i ent s , ons et may be qui t e i ns i di ous . In t he fi rs t 710 days aft er i nfect i on bact eraemi a occurs wi t h s eedi ng i nt o t he Peyer's pat ches of t he gut l eadi ng t o ul cerat i on and necros i s (weeks 23).
Pa g e 5 6 2
Investigations
Initial week of illness. Normal Hb, W CC or , el evat ed hepat i c enzymes . Bl ood cul t ures pos i t i ve i n 8090%. 2nd3rd weeks. dHb, W CC, and pl at el et s due t o marrow s uppres s i on. Bl ood cul t ures become negat i ve, uri ne and s t ool cul t ures become pos i t i ve. Marrow cul t ure pos i t i ve. Abdomi nal X-rays and i magi ng i s i ndi cat ed i f t here i s abdomi nal pai n. Serology. Unhel pful at di s cri mi nat i ng act i ve i nfect i on from pas t expos ure or vacci nat i on.
Complications
Al l uncommon wi t h prompt di agnos i s and t herapy.
T oxaemia. Acut e compl i cat i ons i ncl ude hyperpyrexi a, renal and hepat i c dys funct i on, bone marrow fai l ure, and myocardi t i s . Gastrointestinal. Lat e compl i cat i ons due t o breakdown i n Peyer's pat ches i ncl udi ng gas t roi nt es t i nal haemorrhage and perforat i on. Metastases. Meni ngi t i s , endocardi t i s , os t eomyel i t i s , l i ver/s pl een. Chronic carriage. 13% beyond 1 year.
P.319
P.320
Enteric fever (typhoid) 2 Management
Supportive care. If t oxaemi c admi t t o ITU. Uri nary cat het er and CVP or SwanGanz l i ne t o manage fl ui d bal ance. May need renal s upport .
Pa g e 5 6 3
Antibiotics. Mul t i pl e drug res i s t ance has become a probl em and ampi ci l l i n can no l onger be us ed for empi ri cal t reat ment . Qui nol ones , e.g. ci profl oxaci n, 750mg bd oral l y for 14 days or 400mg bd i v, are current l y t he agent s of choi ce but res i s t ance has been des cri bed and ceft ri axone 2g od i s an al t ernat i ve unt i l s ens i t i vi t i es are known. Steroids. Indi cat ed for t he s evere t oxaemi c form and have reduced acut e mort al i t y al t hough wi t h a s mal l i ncreas e i n rel aps es . Gi ve hi gh-dos e dexamet has one 3mg/kg fol l owed by 1mg/kg 6 hourl y for 8 dos es . Surgery. Es s ent i al for bowel perforat i on (add met roni dazol e). Infection control. Not i fy t he cas e t o CCDC. Spread i s faecal /oral and i ndi vi dual s s houl d not prepare food unt i l fol l ow-up s t ool cul t ures (off ant i bi ot i cs ) are negat i ve. Sal monel l a ent eri c a s erot ype t yphi and s erot ype parat yphi (l es s s evere) have a wi des pread di s t ri but i on i ncl udi ng Afri ca, Sout h Ameri ca, and Indi an s ub-cont i nent Incubat i on peri od i s 721 days and i t i s very rare >1 mont h aft er ret urn from an endemi c area Unt reat ed mort al i t y 1015%; wi t h adequat e t herapy mort al i t y i s l es s t han 1% i n t he UK Rel aps e rat e 17% Chroni c carri er s t at e: i ncreas ed i nci dence i n el derl y, i mmunocompromi s ed, and wi t h gal l -s t ones . Ampi ci l l i n or amoxyci l l i n (46g/day + probeni ci d 2g/day) or ci profl oxaci n (750mg bd) for 4 weeks wi l l cl ear 8090% of pat i ent s , fal l i ng t o 2050% i f t he pat i ent has gal l s t ones . Chol ecys t ect omy may eradi cat e carri age, but not us ual l y i ndi cat ed i f carri age i s as ympt omat i c
P.321
Pa g e 5 6 4
P.322
Viral haemorrhagic fevers

Dis Cli Ou ea nic tco se al me fea /m tur an es ag em ent De Fi r Is o ng s t l at i ue exp on fev os u not er re : req (s e hi g ui r rot h s ed ype pyr Mor exi t al i ty I a, )
IV he l ow ad i n n-s Tro ach no pi c e, al / joi hoc s ub nt k -t r pai cas opi ns , es cal ma Tre z on cul at es , op me
Pa g e 5 6 5
Am ap nt eri ul a s up cas r , Car h por e ras t i v
i bb on Ser ea t ru ol o n, nk, gi c Oc al ea W C di a ni a C , a, As i d gn s an os i (ac
Afri pl a ut e ca t el an T ra et s d ns Sec con mi s on val sio d es c n : exp ent mo os u s er s qu re a) i t o t o PC di ff R ma ere us e n nt ful Hu s er i n ge ot y fi rs epi pe : t 5 de De day mi c ng s s ue of I nc ha i l l n
Pa g e 5 6 6
ub em es s at i orr onl on : ha y 3 gi c 1 s ho 5 s ck 15 day i n (us ual 25 ly % 4 cas 7 es day s) Yel Sev St a lo w ere nd cas ard
fev es : bl o er he od/ Tro ad bo pi c ach dy al e, fl ui Afri my d ca, al g i s o Ce i a, l at i nt r hi g on, al d h adv an fev i s e er, s t a on So an ff ut h d Am vo vac eri mi t ci n ca i ng at i
Pa g e 5 6 7
T ra 3 on ns 4 Ca mi s day s e sio s. fat n : 1 al i t mo 2 y s qu day 5 ito s 2 l at 0% hu er Tre ma s y at n mp me I nc t o nt ub ms s up at i ret por on : urn t i v 3 wi t e 1 h 4 s Di a jau gn ce, s ha by em PC orr R ha an ge, d an s er d al fai l ure , rel ol o ren gy
day ndi os i
Pa g e 5 6 8
at i ve bra dyc ard i a, l eu kop eni a, DI C, an d ab nor ma l liv er fun ct i on La Fev Ref ssa er, er fev ph s us er ary pec Rur ngi t ed al t i s , cas di s ret es t ri c ros t o ts of st t er hi g nal h-s n, ri t y
W e pai ecu
Pa g e 5 6 9
Afri an i s o ca d l at i (es pro on pec t ei fac i al l nur i l i t y ia y Si e Ha Mor rra em t al i Leo orr t y ne, ha 1 Gui gi c 2 ne co %, a, mp ri s i Li b l i ca ng eri t i o t o a, ns 15 Ni g 20 eri 20 a) 30 % T ra % i n ns of ha mi s t ho em s i o s e orr n : ad ha rod mi t gi c ent t ed cas ma n ma n I nc ub es Ri b avi ri n eff ect i ve t re
Pa g e 5 7 0
at i on : 3 2 1 day s Pos sib ly 30 0 00 0 cas es / yea r in We st Afri
at me nt an d pro phy l ax is Di a gn os i s by PC R an d s er ol o gy
ca Eb Fev Ref ola er, er vir he s us us ad pec Rur ach t ed al e, cas are joi es as nt t o of pai hi g Ce ns , h-s nt r s or ecu al , e ri t y Eas t hr i s o
Pa g e 5 7 1
t, d
oat l at i on ab fac
(an ,
pos do i l i t s i b mi y ly nal Ca fat y W e pai s e s t ) n, ca d in Afri an al i t vo 50
out mi t % bre i ng Tre aks . at aff Ma me ect cul nt i ng op s up up ap por t o ul a t i v a r e gn few ras Di a hu h. ndr Ha os i ed em s pe orr by opl ha PC e gi c R T ra ma an ns ni f d mi s es t s er s i o at i ol o n : ons gy per co s on mm
Pa g e 5 7 2
on per 3 s on 4 I nc day ub s at i aft on : er 2 ons 2 et 1 day s Mar bur g vi r us sim i l ar Dis Cli Ou ea nic tco se al me fea /m tur an es ag em ent Cri Fev Ref me er, er an ma s us -C l ai pec on s e, t ed go i rri cas ha t ab es
Pa g e 5 7 3
em i l i t t o orr y, hi g ha he h-s gic ad ecu fev ach ri t y er e, iso (C s ev l at i CH ere on F) pai fac W i ns i l i t de i n y di s t he Ca t ri b l i m s e ut i bs fat on, an al i t cen d y t ral l oi 30 As i ns , a, fol l 50 s ou ow % t he ed Tre rn by at Afri an me ca ore nt T ra xi a wi t ns , h mi s na ri b s i o us e avi n : a, ri n per vo Di a s on mi t gn -pe i ng os i rs o , n, s an by
Pa g e 5 7 4
con d t h
PC
t ac ab R do an nal s er gy wi t mi d bl o pai ol o od n of Ha i nf em ect orr ed ha l i v gi c es t ma ock ni f , es t con at i t ac ons t h on 4 wi t day i nf 5 ect of ed i l l n t i c es s k CN I nc S ub i nv at i ol v on: em 1 ent 1 10 2 s P.323 % day 25
Pa g e 5 7 5
Dengue fever i s commonl y i mport ed i nt o t he UK (es t i mat ed at 100150 cas es /year) and pres ent s wi t h fever, headache, and ras h. Cas es of t he ot her haemorrhagi c fevers are i mport ed onl y once every few years Recogni t i on i s i mport ant becaus e Las s a, Ebol a, Marburg, and CCHF have been t rans mi t t ed t o heal t h care workers of pat i ent s (i ncl udi ng l aborat ory s t aff). Di s cus s s us pect ed cas es urgent l y wi t h s peci al i s t hi gh-s ecuri t y i nfect i ous di s eas es cent res regardi ng i nves t i gat i on and pos s i bl e t rans fer Sus pect ed cas es i ncl ude pat i ent s wi t h t he ons et of t hei r fever wi t hi n 21 days of l eavi ng an endemi c area, part i cul arl y i f a mal ari a fi l m i s negat i ve Li mi t l ocal haemat ol ogi cal i nves t i gat i ons t o an abs ol ut e mi ni mum i f one of t hes e four VHFs i s s us pect ed (but al w ays perform mal ari a fi l m fi rs t )
P.324
Rickettsial infections
Thes e pres ent wi t h fever, headache, and ras h and s houl d be i ncl uded i n t he di fferent i al di agnos i s of febri l e t ravel l ers . Recogni t i on i s i mport ant becaus e t he ri cket t s i al i l l nes s es have s i gni fi cant mort al i t y i f l eft unt reat ed. Is ol at i on i s not neces s ary. Incubat i on i s about 514 days . R. c onori i and R. afri c ae are probabl y t he t wo commones t of t he group t o be i mport ed i nt o t he UK, us ual l y from Afri ca, but Ri c ket t s i ae are wi del y di s t ri but ed acros s t he worl d. Mol ecul ar and di rect i mmunofl uores cent di agnos t i c t echni ques are not wi del y avai l abl e, s o t reat ment has t o be gi ven on cl i ni cal s us pi ci on. Serol ogy i s not pos i t i ve unt i l t he s econd week of t he i l l nes s at t he earl i ers t and may t ake 34 weeks t o become
Pa g e 5 7 6
pos i t i ve (and may be modi fi ed by t reat ment ). Fi rs t -l i ne t reat ment i s wi t h doxycycl i ne 100mg bd up t o 7 days (ot her t et racycl i nes , chl orampeni col , or qui nol ones have al s o been us ed). Dis Cli ea nic se al fea tur es T yphu s group Epi Fev de er, mi c s ev t yp ere hus he : ad Ri c ach ket es , t s i ma a cul pro op w a ap zek ul a i r ras h on t ru nk s pr ea di n
Pa g e 5 7 7
g to ext re mi t i es . Co mp l i ca tio ns i ncl ud e pn eu mo ni t i s, enc ep hal itis an d my oca rdi t is Mur R. i ne t yp t yp hi hus l es : s
Pa g e 5 7 8
Ri c s ev ket ere t s i t ha a hi n pro wa zek ii Spotte d fever group Bo Fev ut o er, nn s ev eus ere e he fev ad er: ach Ri c e, ket es c t s i har a (bl c on ack ori i s ca Afri b can wi t tic h k s ur t yp rou us : ndi Ri c ng ket ery tsi t he t yp R.
Pa g e 5 7 9
ma
afri ) c ae at (pl s i t us e ot h of ers bi t ) e, s pa rs e pa pul ar ras h Roc Fev ky er, mo he unt ad ai n ach s po e, t t e con d fus fev i on er an (N d Am nec eri k ca) s t i f : fne Ri c s s , ket joi t s i nt a pai ri c k ns ,
Pa g e 5 8 0
et t ma s i a l ai e s e. Ma cul ar ras h sta rt s at wri sts an d ank l es s pr ea di n g to t ru nk, ma y be pet ech i al or pur pur i c.
Pa g e 5 8 1
Si mi l ar to me ni n goc occ al s ep i ca em i a. Mor t al i ty 30 % unt rea t ed Scrub typhus SE Es c As i har a: , Ori pai ent nfu ia l t s u reg t ug i on am al i s h l ym i ph ad
Pa g e 5 8 2
en op at h y, fev er, he ad ach e, ma l ai s e, ma cul op ap ul a r ras h in 60 % P.325
P.326
Q fever
Coxi el l a burnet i i i s a di s eas e of rural areas (res ervoi rs i n s heep and cat t l e) and t rans mi t t ed by i nhal at i on of i nfect i ous part i cl es i n dus t , cont act wi t h i nfect ed carcas s es (e.g. i n abat t oi rs ) and by t i ckbi t es .
Pa g e 5 8 3
Pres ent at i on: non-s peci fi c s ympt oms , fever, myal gi a, mal ai s e, s weat s ; dry cough and feat ures of at ypi cal pneumoni a; hepat i t i s ; PUO and s pl enomegal y. I nves t i gat i ons : Pat chy CXR s hadowi ng (l ower l obes ), hepat i c granul omat a. Compl ement fi xat i on t es t s i dent i fy ant i bodi es t o phas e 1 ant i gens (chroni c i nfect i on, e.g. endocardi t i s p122) and Phas e 2 ant i gens (acut e i nfect i on). T reat wi t h oral doxycycl i ne (t o t ry t o prevent chroni c i nfect i on) co-t ri moxazol e, ri fampi ci n, or qui nol one
Human bites
Superfi c i al abras i ons : Cl ean t he wound. Re-dres s t he area dai l y. Gi ve t et anus prophyl axi s as needed. Check hepat i t i s B s t at us and i mmuni ze i f neces s ary (s ee p646). HIV couns el l i ng and urgent PEP i f i ndi cat ed (s ee p374). HCV has al s o been t rans mi t t ed by human bi t e, s o appropri at e fol l ow-up needed (t here i s no HCV PEP). Have a l ow t hres hol d for admi s s i on t o hos pi t al and i v ant i bi ot i c t herapy: t he human mout h cont ai ns a number of aerobi c and anaerobi c organi s ms t hat may produce aggres s i ve necrot i zi ng i nfect i on, part i cul arl y i f t he cl os ed s paces of t he hand or feet are i nvol ved. Ant i bi ot i c t herapy : Al l wounds t hat penet rat e t he dermi s requi re ant i bi ot i cs . Aerobi c and anaerobi c cul t ures s houl d be t aken pri or t o t reat ment wi t h ant i bi ot i cs . A s ugges t ed regi men i s co-amoxi cl av 500/125mg t ds po (or i v cefuroxi me and met roni dazol e). Cons ul t your l ocal mi crobi ol ogi s t s . Fac i al bi t es : Cos met i cal l y s i gni fi cant bi t es s houl d be referred t oa pl as t i c s urgeon. Punct ure wounds s houl d be cl eaned t horoughl y and t reat ed wi t h prophyl act i c ant i bi ot i cs (s ee above). Pat i ent s s houl d be i ns t ruct ed t o re-open t he wound and expres s any purul ent or bl oody mat eri al 34 t i mes a day for t he fi rs t few days .
Pa g e 5 8 4
Hand bi t es : Shoul d be referred t o t he ort hopaedi c t eam; expl orat i on i s recommended. Cl ean t he wound t horoughl y. Gi ve t he fi rs t dos e of ant i bi ot i cs i v and s ubs equent dos es po unl es s t here are s i gns of s ys t emi c ups et .
P.327
P.328
Non-human mammalian bites
General management i s as for human bi t es (s ee above). Cl ean t he wound, s wab for aerobi c and anaerobi c cul t ure, t et anus prophyl axi s as needed, and prophyl act i c ant i bi ot i cs as above. Rabi es prophyl axi s (vacci ne pl us rabi es -s peci fi c i mmunogl obul i n) s houl d be cons i dered i n al l cas es i f t he bi t e occurred out s i de t he UK, or i f t he bi t e was from a bat w i t hi n t he UK or from an ani mal i n a quarant i ne faci l i t y. For up-t o-dat e advi ce and s uppl i es of vacci ne and i mmunogl obul i n cont act t he dut y doct or, Vi rus Reference Di vi s i on, Heal t h Prot ect i on Agency, Col i ndal e, London NW 9 5HT (Tel . 020 8200 4400). See ht t p://www.hpa.org.uk/i nfect i ons /defaul t .ht m Rabi es i s t rans mi t t ed by i nfect ed s al i va i nocul at ed t hrough t he s ki n or by i nhal at i on of aeros ol i zed vi rus (from i nfect ed bat s ). Pres ent i ng feat ures are a vi ral prodrome fol l owed by paras t hes i ae and fas ci cul at i ons . Agi t at i on, confus i on, mus cl e s pas ms , l ocal i zed paral ys i s , and brai ns t em dys funct i on fol l ow. There i s no effect i ve t reat ment once s ympt oms appear; prevent i on i s es s ent i al . Rabi es vac c i ne s houl d be gi ven prophyl act i cal l y (i n t he del t oi d) t o t hos e at ri s k of bi t es from i nfect ed ani mal s
Pa g e 5 8 5
(vet s , ani mal handl ers , fi el d workers , UK bat handl ers ).
Some Ol d W orl d monkeys , part i cul arl y rhes us and cynomol gus macaques are i nfect ed wi t h herpes B vi rus (caus es a s i mi l ar i l l nes s i n monkeys as HSV does i n humans ). It can be t rans mi t t ed by bi t e and s al i va and has caus ed fat al di s s emi nat ed i nfect i on i n humans . If t he bi t e i s from a macaque from a col ony cl ear of t he vi rus , cons i der s t art i ng val aci cl ovi r 1g t ds 14 days pendi ng furt her i nves t i gat i on.
Infections in intravenous drug users

In UK majori t y are HCV pos i t i ve. Mi nori t y are HIV and HBs Ag pos i t i ve. St aphyl ococcus aureus bact eraemi a and s ept i caemi a i s common. Pat i ent s wi t h murmurs s houl d have echocardi ography t o i nves t i gat e pos s i bi l i t y of endocardi t i s . Mul t i pl e round l ung i nfi l t rat es are charact eri s t i c of t ri cus pi d endocardi t i s wi t h s ept i c embol i . P.329
P.330
Necrotizing fasciitis

Pat i ent us ual l y ext remel y unwel l Eryt hemat ous , exqui s i t el y t ender area, s omet i mes wi t h underl yi ng crepi t us . X-ray may s how gas i n s ubcut aneous t i s s ues . Mai ns t ay of t reat ment i s urgent debri dement of al l necrot i c t i s s ue by s eni or s urgeon. Furt her i magi ng pri or t o t heat re merel y del ays procedure wi t hout provi di ng furt her t herapeut i c i nformat i on. Oft en pol ymi crobi al . Cl i ndamyci n s eems t o be an i mport ant component of any ant i mi crobi al t herapy. One s ugges t ed t reat ment regi me i s ci profl oxaci n 400mg bd i v, cl i ndamyci n 600mg
Pa g e 5 8 6
qds i v, benzyl peni ci l l i n 1.22.4g 4-hourl y.
Pat i ent s us ual l y requi re dai l y debri dement i n t heat re fol l owed by recons t ruct i ve s urgery.
Severe acute respiratory syndrome (SARS)
Thi s i s a new coronavi rus i nfect i on i n man wi t h a hi gh t rans mi s s i on rat e t o cl os e res pi rat ory cont act s , part i cul arl y heal t h care workers . Al s o probabl e t rans mi s s i on by faeco-oral rout e and fomi t es . Caus es fever, myal gi a, and vari abl e pneumoni c i l l nes s wi t h rapi d det eri orat i on i n s econd week of i l l nes s . Very l ow morbi di t y i n pre-adol es cent s . Hi gh mort al i t y i n pat i ent s >60 years . St ri ct i s ol at i on and ri gorous enforcement of i nfect i on cont rol es s ent i al . At t he t i me of wri t i ng (Jul y 2003), epi demi c wani ng, but may reappear. Treat ment as yet undefi ned. Hi gh-dos e s t eroi ds may be of s ome benefi t i n s everel y i l l . Ri bavi ri n i s probabl y of no val ue. See ht t p://www.who.i nt /cs r/s ars /en/i ndex.ht ml
P.331
P.332
Bioterrorism
There i s i ncreas i ng awarenes s of t he pos s i bi l i t y of a del i berat e rel eas e of bi ol ogi cal and chemi cal agent s . Hi s t ori cal l y pl ague, Sal monel l a and ant hrax have al l been us ed, as have nerve gas es and bi ol ogi cal t oxi ns . The mos t recent l arge s cal e rel eas es have been Sari n gas (a nerve gas ) on t he Tokyo underground i n 1995, and ant hrax s pores (as whi t e powder i n t he mai l ) i n t he USA i n 2001.
Pa g e 5 8 7
Rel eas es are l i kel y t o be ei t her ai rborne or food and wat er cont ami nat i on. Cl ues t hat a del i berat e rel eas e may have occurred woul d be t he unexpect ed appearance of an i nfect i on out s i de i t s normal range (e.g. ant hrax i n a ci t y), an i nfect i on appeari ng i n a pat i ent unl i kel y t o cont ract t he di s eas e or a s udden cl us t er of pat i ent s wi t h t he s ame pat t ern of s ympt oms . W hi t e powder i nci dent s al s o cont i nue t o caus e concern. Any s us pi ci on of a del i berat e rel eas e s houl d be communi cat ed urgent l y t o t he cons ul t ant mi crobi ol ogi s t and t he CCDC (Cons ul t ant i n Communi cabl e Di s eas e Cont rol ). Speci fi c gui del i nes on di agnos i s , management and prophyl axi s can be found on t he HPA webs i t e ht t p://www.hpa.org.uk/i nfect i ons /t opi cs _az/del i berat e_ rel eas e/menu.ht m Current organi s ms of part i cul ar concern i ncl ude s mal l pox, pl ague, t ul araemi a, mel i oi dos i s , bot ul i s m, gl anders (an i nfect i ous di s eas e caus ed by t he bact eri um Burkhol deri a mal l ei ), and vi ral haemorrhagi c fevers al t hough ot her agent s may be i nvol ved.
P.333
P.334
Ag Cli Pe T r Pr ent nic rso eat op al n me hyl to nt axi pe rso n s
Pa g e 5 8 8
tra ns mis sio n ris k Sm Ini Y e Su Vac al l t i al s pox l y ma cul es , t he n de ep ves i cl e s pre do mi na nt l y on per i ph eri es (of chi cke np pp ci n ort i at i ve on (po stexp os u re vac ci n at i on eff ect i ve )
Pa g e 5 8 9
ox s up erfi ci al ves i cl e s pre do mi na nt l y on t ru nk) Pl a Li k Y e Ge Ci p gu el y s e to be pn eu mo ni c wi t h s ev ere s ep sis in i nh al a tio nal nt a rofl mi c oxa i n, ci n str , ept dox om ycy yci cl i n n, ci p rofl oxa ci n e
Pa g e 5 9 0
pl a gu e Tul Li k Ver Ge Ci p ara el y y ia nt a rofl em t o l ow mi c oxa be pos i n, ci n fl u- s i b ci p , l i k i l i t rofl dox e y, oxa ycy e or but ci n cl i n pn res eu pi r mo at o ni c ry wi t pre h cau s ep t i o s i s ns in adv i nh i s a al a bl e tio nal t ul ara em ia Ant Se Hi g Ci p Ci p hra ps i hl y rofl rofl x s, unl oxa oxa , , ha i ke ci n ci n i nh em l y al a orr t i o ha dox dox ycy ycy
Pa g e 5 9 1
nal gi c me di s t i ni tis (wi de ne d me di a sti nu m), ma y be mi ni ma l pn eu mo ni t i
cl i n cl i n e e, vac ci n at i on
s Ant Ne Hi g Ci p Ci p hra cro hl y rofl rofl x t i c unl oxa oxa , , ul c i ke ci n ci n cut er l y an wi t eo h us ma rke dox dox ycy ycy cl i n cl i n e e,
Pa g e 5 9 2
d s ur rou ndi Ant hra x whi te po wd er i nci de ng oe de ma If po wd er con t ai ns ant hra x s po
vac ci n at i on Ci p rofl oxa ci n , dox ycy cl i n e, vac ci n
nt res at i Mel Li k Cef t he on i oi el y t az n dos t o i di hi g i s pre me hl y s en , i nf t me ect as rop i ou s ep en s. tic em Co ae nt r mi c ol l illn ed es s dec , ont but am s pe i na ct r tio um n of es s
Pa g e 5 9 3
i l l n ent es s i al Bot Mul No Ant ul i t i pl sm e cra ni a l ner ve pal sie s, ot h er pal sie s. No al t era tio n in con s ci ous l ev el VH Ha Y e Ri b Ri b Fs em s orr ha gi c illn avi avi ri n ri n for for l as l as sa sa ito xi n gi v en on cl i n i cal s us pi ci on
Pa g e 5 9 4
es s wi t h fev
an an d d CC ?C HF CH
er F Ner Ant Y e Su ve i ch s pp gas ol i i f ort i es nes cl o ve, t er t hi at r as e ng opi i nh con ne, i bi t t a pra ors mi l i d , nat oxi s al ed me i va (t r , t i o ans di a n, cut zep bro an am nch eo orr us ho abs ea, orp sw tio eat n) i ng , bro nch os p as m, bra dyc
Pa g e 5 9 5
ard i a, ab do mi nal cra mp s, di a rrh oe a, me i os is, mu s cl e fas ci c ul a tio n, we akn es s , res pi r at o ry par al y
Pa g e 5 9 6
sis , t ac hyc ard i a, hyp ert ens i on , em ot i on al l ab ilit y, con fus i on , at a xi a , con vul sio ns , co ma , cen t ral
Pa g e 5 9 7
res pi r at o ry de pre ssi on
Page 598
> T able of Cont ent s > Chapt er 5 - Emergenc ies in
Chapter 5
Emergencies in HIV positive patients

P.338
Emergency presentations of HIV infection

Pat i ent s wi t h human i mmunodefi ci ency vi rus (HIV) i nfect i on may pres ent t o acut e medi cal s ervi ces i n a vari et y of ci rcums t ances :
Pat i ent s wi t h undi agnos ed HIV i nfect i on pres ent i ng wi t h HIV-rel at ed or -unrel at ed probl ems Pat i ent s wi t h known HIV i nfect i on pres ent i ng wi t h HIV-rel at ed or -unrel at ed probl ems Pat i ent s wi t h HIV i nfect i on pres ent i ng wi t h t oxi ci t y rel at ed t o ant i -HIV t herapy [ant i ret rovi ral t herapy; hi ghl y act i ve ant i ret rovi ral t herapy (HAART)] Pat i ent s pres ent i ng wi t h pri mary HIV i nfect i on (s eroconvers i on).
Cl i ni ci ans provi di ng acut e medi cal care may be i n a pos i t i on t o di agnos e HIV i nfect i on i n i ndi vi dual s i n whom t hi s has been previ ous l y unrecogni zed. In addi t i on, cl i ni ci ans provi di ng emergency care may encount er i ndi vi dual s (heal t hcare workers and t he general publ i c) who may have been expos ed t o HIV and i n whom PEP may be cons i dered. The s peci fi c management i s s ues for t he above are cons i dered i n t he fol l owi ng s ect i ons . W here t here i s l ocal expert i s e i n t he management of HIV i nfect i on, i t i s recommended t hat care i s provi ded i n cons ul t at i on wi t h t he appropri at e t eam. Thi s i s part i cul arl y rel evant where t he pres cri bi ng of t herapy may requi re cons i derat i on of co-pres cri bed ant i ret rovi ral t herapi es .
Pa g e 5 9 9
General principles
The us e of combi nat i on ant i ret rovi ral t herapy has been ext raordi nari l y s ucces s ful i n i mprovi ng t he prognos i s for HIV-i nfect ed i ndi vi dual s , wi t h HIV now cons i dered a chroni c manageabl e di s eas e. Succes s ful ant i ret rovi ral t herapy s i gni fi cant l y i ncreas es t he CD4 count and reduces t he ri s k of opport uni s t i c compl i cat i ons . In over 95% HAART wi l l reduce HIV RNA l oad t o undet ect abl e l evel s (e.g. <50copi es /ml pl as ma). Pat i ent s wi t h known or s us pect ed HIV i nfect i on s houl d t herefore be i nves t i gat ed and managed aggres s i vel y, as t he out l ook may be far bet t er t han many cl i ni ci ans may ant i ci pat e from hi s t ori cal experi ence. Unus ual opport uni s t i c i nfect i ons and mal i gnanci es are oft en s een and can occur s i mul t aneous l y or s equent i al l y. Rel aps e i s common. Toxi ci t y from ant i ret rovi ral t herapy may pres ent t o acut e medi cal s ervi ces . Drug i nt eract i ons wi t h ant i ret rovi ral t herapy requi re cons i derat i on. Common di s eas es s t i l l affect HIV-pos i t i ve i ndi vi dual s and may pres ent at ypi cal l y.
P.339
Exami nat i on of t he mout h can reveal a great deal of i nformat i on regardi ng t he l evel of i mmuni t y (e.g. oral t hrus h, hai ry l eucopl aki a s ugges t s reduced i mmuni t y and i ncreas ed ri s k of s evere opport uni s t i c i nfect i on; Kapos i s arcoma s ugges t s i ncreas ed ri s k of vi s ceral KS). P.340
Factors influencing presentation in HIV

Pa g e 6 0 0
disease Degree of immunosuppression
6 3
The normal CD4 count i s 5001500 10 cel l s /mm and gradual l y decreas es duri ng t he cours e of HIV i nfect i on. The CD4 count i s us ed as a gui de t o a pat i ent 's s us cept i bi l i t y t o compl i cat i ons of HIV i nfect i on (s ee fi gure). For exampl e, Pneumoc ys t i s ji rovec i (formerl y
known as P. Cari ni i ) pneumoni a (PCP) i s uncommon wi t h a CD4 count >200. Pat i ent s (who are aware of t hei r HIV s t at us ) are us ual l y fami l i ar wi t h t hes e meas ures and are l i kel y t o be aware of t hei r mos t recent res ul t s .
Risk group and predisposition to different complications

HIV i n t he UK i s predomi nant l y s een i n s peci fi c pat i ent groups , and t he i nci dence of HIV-rel at ed compl i cat i ons vari es bet ween t hes e groups .
Homos exual men have a hi gher i nci dence of Kapos i 's s arcoma t han ot her Caucas i ans . Inject i ng drug us ers are more l i kel y t o be co-i nfect ed wi t h hepat i t i s C, and are more l i kel y t o experi ence s eps i s rel at ed t o i nject i ng. Indi vi dual s of Afri can or As i an ori gi n are more l i kel y t o pres ent wi t h TB (whi ch may be at ypi cal and/or ext ra-pul monary i n pres ent at i on). Indi vi dual s of Afri can ori gi n are more l i kel y t o experi ence crypt ococcal i nfect i on.
Travel history
Many i nfect i ons i n t he HIV-i nfect ed pat i ent repres ent react i vat i on of l at ent pat hogens and a comprehens i ve t ravel hi s t ory i s hel pful i n t he di fferent i al di agnos i s , part i cul arl y for i ndi vi dual s pres ent i ng wi t h pyrexi a.
Pa g e 6 0 1
Hi s t opl as mos i s : t ravel t o cent ral Ameri ca and t he eas t ern USA. Cocci di omycos i s : t ravel t o t he SW USA and part s of Sout h Ameri ca. Peni ci l l i nos i s : t ravel t o count ri es i n SE As i a and Indones i a. St rongyl oi des hyperi nfect i on: previ ous t ravel i n t he t ropi cs . Lei s hmani as i s : t ravel i n medi t erranean and t ropi cs .
Antiretroviral therapy
Pat i ent s who are res pondi ng wel l t o ant i ret rovi ral t herapy (i .e. who are vi rol ogi cal l y s uppres s ed and have achi eved a s i gni fi cant i ncreas e i n CD4 count ) are much l es s at ri s k from opport uni s t i c compl i cat i ons of HIV i nfect i on. General medi cal /s urgi cal condi t i ons s houl d be cons i dered i n s uch pat i ent s (as i n t he unt reat ed i ndi vi dual wi t h HIV i nfect i on and a hi gh CD4 count ). However, t oxi ci t i es of ant i ret rovi ral t herapy may pres ent t o t he emergency cl i ni ci an (s ee p370), and caut i on s houl d be exerci s ed when co-pres cri bi ng.
Fi gure. No capt i on avai l abl e. P.341
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P.342
HIV testing
In mos t s i t uat i ons , HIV t es t i ng s houl d be carri ed out wi t h i nformed cons ent and i s us ual l y undert aken i n GUM/STI cl i ni cs , i n pri mary care, or as part of rout i ne ant enat al care. However, t he pres ent at i on of i ndi vi dual s wi t h pot ent i al l y HIV-rel at ed compl i cat i ons or at pot ent i al ri s k of previ ous HIV expos ure t o t he emergency cl i ni ci an may provi de t he opport uni t y t o di agnos e i nfect i on. W hi l s t many i ndi vi dual s may choos e t o have an HIV t es t wi t hi n t he confi dent i al s et t i ng of a s peci fi c HIV-t es t i ng s ervi ce, any heal t hcare provi der s houl d pos s es s t he es s ent i al s ki l l s for appropri at e di s cus s i on of HIV t es t i ng.
Pre-test discussion
The fol l owi ng i s s ues s houl d be i ncl uded i n a pre-t es t di s cus s i on

Rat i onal e for t es t i ng Benefi t s of knowi ng s t at us W hen and by whom t he res ul t wi l l be gi ven W i ndow peri od of i nfect i on (i .e. may t ake up t o 3 mont hs from expos ure for HIV ant i body t es t t o become pos i t i ve) Confi dent i al i t y (a negat i ve t es t may not requi re di s cl os ure t o a GP and does not have i mpl i cat i ons for i ns urance/mort gages , et c.; a pos i t i ve res ul t does not neces s ari l y need t o be di s cl os ed t o t hi rd part i es wi t hout cons ent but wi l l have i mpl i cat i ons for i ns urance/mort gages ).
Post-test discussion
The fol l owi ng pri nci pl es s houl d be fol l owed i n a pos t -t es t di s cus s i on
Pa g e 6 0 3
Gi vi ng a pos i t i ve res ul t s houl d fol l ow t he normal pri nci pl es of breaki ng bad news If a res ul t i s pos i t i ve, earl y referral t o an HIV cl i ni ci an i s recommended If a res ul t i s negat i ve, t he wi ndow peri od s houl d be rei nforced (part i cul arl y i n s i t uat i ons where s eroconvers i on i s s us pect ed: s ee bel ow) If a res ul t i s negat i ve, t he opport uni t y for fut ure ri s k reduct i on s houl d be cons i dered.
HIV testing without consent

It i s rarel y neces s ary t o t es t for HIV i nfect i on wi t hout cons ent . However, t hi s i s jus t i fi ed i n t he fol l owi ng s et t i ngs .

Tes t i ng of organ t rans pl ant at i on donors . Tes t i ng of t he uncons ci ous /confus ed pat i ent where HIV i nfect i on i s s us pect ed and t he management of t he pat i ent wi l l be mat eri al l y changed by knowl edge of t hei r HIV s t at us . Tes t i ng of t he uncons ci ous pat i ent who i s t he donor i n a s i gni fi cant needl es t i ck/s pl as h i njury. In t hi s s i t uat i on, t es t i ng i s jus t i fi ed i f t he pat i ent i s unl i kel y t o regai n cons ci ous nes s for 48 hours , but s houl d onl y be performed on a bl ood s peci men t hat has been previ ous l y t aken for anot her purpos e. Gi ven t he pot ent i al l i t i gat i on ari s i ng from HIV t es t i ng wi t hout cons ent , i t i s advi s abl e t o s eek a s econd opi ni on (preferabl y from a phys i ci an wi t h HIV experi ence) t hat s uch t es t i ng i s jus t i fi ed.
P.343
P.344
Primary HIV infection (PHI)

PHI (al s o known as HIV s eroconvers i on i l l nes s ) i s eas i l y
Pa g e 6 0 4
overl ooked. Int ervent i on may hel p prevent furt her s pread of HIV (i ndi vi dual s recent l y i nfect ed wi t h HIV are t hought t o be hi ghl y i nfect i ous , part i cul arl y i f unaware of t hei r s t at us ).
Risk of recent infection

A s i gni fi cant hi s t ory of expos ure t o a pot ent i al HIV s ource wi t hi n t he l as t 3 mont hs (s exual , percut aneous , or mucocut aneous ) i n conjunct i on wi t h any of t he feat ures bel ow warrant s performi ng s peci fi c di agnos t i c t es t s for PHI.
Symptoms and signs
Typi cal l y wi t hi n 24 weeks of expos ure but can be up t o 3 mont hs Fl u-l i ke i l l nes s (fever, myal gi a, headache, l ymphadenopat hy, ret ro-orbi t al pai n) Macul opapul ar ras h (di fferent i al di agnos i s of s econdary s yphi l i s ) Pharyngi t i s /oral ul cerat i on Concomi t ant s exual l y t rans mi t t ed i nfect i ons (e.g. pri mary or s econdary s yphi l i s , gonorrhoea, geni t al ul cer di s eas e).
Laboratory findings
HIV ant i body t es t s may be negat i ve at t he t i me of s eroconvers i on and an HIV RNA vi ral l oad t es t may be requi red t o confi rm t he di agnos i s Lymphopaeni a, t hrombocyt opaeni a, and rai s ed ALT/AST may occur.
Sequelae of acute immunosuppression
CD4 count may t rans i ent l y fal l t o <200 cel l s /mm PCP)
(t herefore ri s k of opport uni s t i c i nfect i ons , part i cul arl y Candi di as i s , vi ral wart s , VZV.
Management
The di agnos i s of PHI wi l l enabl e appropri at e part ner not i fi cat i on, s creeni ng for ot her s exual l y t rans mi t t ed
Pa g e 6 0 5
i nfect i ons , and s t rat egi es t o reduce onward t rans mi s s i on.
The ut i l i t y of ant i ret rovi ral t herapy i n t hi s s et t i ng remai ns cont rovers i al and under s t udy. Up t o 25% of new i nfect i ons may have pri mary res i s t ance t o one or more ant i ret rovi ral agent s : knowl edge of l ocal res i s t ance rat es i s needed before i ni t i at i ng ant i ret rovi ral t herapy. Earl y referral t o an HIV s peci al i s t i s recommended.
P.345
P.346
Acute neurological conditions in HIV positive patients: assessment

Opport uni s t i c i nfect i ons and mal i gnanci es , t he di rect effect of HIV i t s el f, and ant i ret rovi ral drugs can al l caus e di s eas e of t he cent ral or peri pheral nervous s ys t em. The pres ent i ng feat ures of di fferent condi t i ons are oft en vari ed and non-s peci fi c and t end t o i nvol ve t he s ame di agnos t i c approach and i nves t i gat i ons .
Key symptoms and signs
General. Look for evi dence of advanced i mmunos uppres s i on (s ee fi gure, p341). Unconsciousness. As s es s and manage as on p406. Seizure. Requi res urgent cont ras t CT or preferabl y MRI head s can t o det ect SOL and, i f none det ect ed, s ui t abi l i t y for di agnos t i c LP. Cons i der ant i -epi l ept i cs but be aware of ant i ret rovi ral and ot her drug i nt eract i ons (s odi um val proat e commonl y recommended i f recei vi ng prot eas e or non-nucl eos i de t herapy). Headache. El uci dat e s ympt oms of rai s ed i nt racrani al pres s ure s ugges t i ve of a SOL s uch as naus ea, earl y
Pa g e 6 0 6
morni ng headache, and i ncreas ed i nt ens i t y on coughi ng. Di s t i ngui s h from faci al pai n caus ed by dent al , s i nus or herpet i c neural gi a (check for herpet i c ras h).
Meningism. May be reduced or abs ent due t o reduced i nfl ammat ory res pons e. As ept i c meni ngi t i s can occur duri ng pri mary HIV i nfect i on (s eroconvers i on i l l nes s ). W i t h advanci ng i mmunos uppres s i on, vi ral , bact eri al , t ubercul ous , and fungal (crypt ococcal ) meni ngi t i des are more common and may not mani fes t t ypi cal s i gns of meni ngi s m. Paraparesis. Cons i der vi ral t rans vers e myel i t i s (HIV, CMV, VZV, or HSV) or cord compres s i on by i nfect i on or mal i gnancy. Requi res urgent MRI s pi ne and s ubs equent LP i f not cont rai ndi cat ed. Cognitive impairment. W i de di fferent i al . If as s oci at ed wi t h any focal neurol ogi cal s i gns cons i der SOL, PML, HIV dement i a, l at e s yphi l i s . Psychiatric disturbances. An organi c caus e i s oft en found. May be a res ul t of ant i ret rovi ral drug i nt eract i ons wi t h ant i -ps ychot i c and recreat i onal drugs . If aggres s i ve, ens ure pat i ent has no acces s t o cont ami nat ed s harps . Peripheral neuropathy. Typi cal l y of gradual ons et and caus ed by cert ai n ant i ret rovi ral s or HIV i t s el f. Myopathy. Zi dovudi ne (AZT) can caus e myopat hy or even rhabdomyol ys i s (check creat i ne ki nas e and renal funct i on), ari s i ng from mi t ochondri al t oxi ci t y (s ee p370). It may al s o be due t o t he concomi t ant us e of l i pi d-l oweri ng agent s . Rapid visual deterioration. Cons i der CMV-rel at ed ret i ni t i s (oft en apparent on fundos copy), uvei t i s , endopht hal mi t i s , and i nt racerebral caus es . Ret i nal det achment may be a cons equence of t reat ment . Immedi at e referral t o opht hal mol ogi s t .
P.347
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P.348
Acute neurological conditions in HIV positive patients: investigations Blood tests
Baseline (us eful i f al ready donepat i ent wi l l oft en know res ul t s ): CD4 cel l count , HIV RNA vi ral l oad, s erol ogy for t oxopl as ma IgG (pos i t i ve i n >90% of pat i ent s wi t h cerebral t oxopl as mos i s , i ndi cat i ve of ri s k of react i vat i on), CMV IgG, s erol ogi cal t es t s for s yphi l i s (STS). Routine: FBC (l ow l ymphocyt e count may gi ve a cl ue t o CD4 depl et i on), U&Es , LFTs . Acute: i nfl ammat ory markers (CRP and ESR), STS, LDH (may be rai s ed i n l ymphoma), bl ood cul t ures (bact eri al , mycobact eri al (46 weeks )). Cons i der CMV Di rect Ant i gen Tes t (DAT) and crypt ococcal ant i gen (CrAg) i f CD4 count <200 cel l s /mm (pos i t i ve i n >80% wi t h crypt ococcal meni ngi t i s ).
3
Specific

Stool, urine and throat cultures Chest X-ray. Cons i der TB at any CD4 count . Para-aort i c and hi l ar l ymphadenopat hy mi ght s ugges t MAI or l ymphoma. Contrast CT or MRI scan of head
o
Cont ras t es s ent i al , MRI more s ens i t i ve t han CT (ri s k of mi s s i ng brai ns t em di s eas e, T oxopl as ma cys t s and PML by CT). Cont ras t enhanci ng SOL very l i kel y t o be ei t her cerebral t oxopl as mos i s (t ypi cal l y mul t i pl e, wi t h ri ng enhancement , as s oci at ed wi t h oedema, at t he
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bas al gangl i a or grey-whi t e mat t er i nt erface) or cerebral l ymphoma (t ypi cal l y fewer l es i ons , wi t h i rregul ar enhancement , as s oci at ed wi t h oedema, peri vent ri cul ar). Poor res pons e t o empi ri cal t oxopl as mos i s t reat ment s ugges t s l ymphoma. Les s commonl y cons i der bact eri al (e.g. s t rept ococcus , nocardi a), mycobact eri al (e.g. t ubercul oma), or fungal (e.g. crypt ococcoma) l es i ons . Mycobact eri al di s eas e i s on t he i ncreas e es peci al l y i n hi gh ri s k popul at i ons e.g. pat i ent s from hi gh preval ence TB areas .
o
Meni ngeal enhancement and hydrocephal us can occur i n t ubercul ous , crypt ococcal or s yphi l i t i c meni ngi t i s . PML: non-enhanci ng, mul t i focal , s ubcort i cal whi t e mat t er changes . No mas s effect . HIV-as s oci at ed dement i a: non-enhanci ng, di ffus e, deep whi t e mat t er hyperi nt ens i t i es wi t h promi nent cerebral at rophy. No mas s effect . Vi ral encephal i t i s (t ypi cal l y CMV, HSV, VZV) may di s pl ay vari abl y enhanci ng confl uent changes but oft en normal .
Brain biopsy. If di s eas e s t age and general prognos i s fai r, cons i der performi ng when no res pons e t o empi ri cal t reat ment . EEG. Us eful t o confi rm s ei zure act i vi t y and res pons e t o t reat ment but oft en non-s peci fi c for HIV encephal opat hy and opport uni s t i c i nfect i ons . Contrast MRI of spine. The bes t modal i t y for s pi nal cord and nerve root i magi ng. Nerve conduction studies/electromyogram. Us eful i f unus ual or t reat ment -unres pons i ve s ens ory or mot or s ympt oms and s i gns .
P.349
Pa g e 6 0 9
Lumbar puncture
Arrange for cont ras t CT or MRI head before any LP and ens ure t hat t here are no cl ot t i ng abnormal i t i es Al ways meas ure openi ng pres s ure Col l ect 68ml of CSF and di vi de i nt o 4 uni vers al cont ai ners and 1 fl uori de t ube for gl ucos e (al ways t ake pai red bl ood for gl ucos e) Bot t l es 1 and 4 t o mi crobi ol ogy for
o o o
RBC and W BC es t i mat i on Bac t eri al : mi cros copy, cul t ure, and s ens i t i vi t y Myc obac t eri al : Zi ehl Ni eel s on mi cros copy, cul t ure and cons i der PCR Vi ral : PCR for CMV, HSV, VZV, JC vi rus (PML), EBV (l ymphoma) Ot her: Indi an i nk mi cros copy and CrAg (near 100% s ens i t i vi t y and s peci fi ci t y for neurol ogi cal crypt ococcal di s eas e), fungal cul t ure, and STS
Bot t l e 2 and bot h fl uori de t ubes t o bi ochemi s t ry for prot ei n and pai red gl ucos e meas urement Bot t l e 3 t o cyt ol ogy (rarel y di agnos t i c) or i mmunol ogy i f i ndi cat ed Rai s ed CSF cel l count and prot ei n (upt o 1g/L) can be an i nci dent al fi ndi ng i n as ympt omat i c HIV i nfect i on; convers el y, t here may be l i t t l e i nfl ammat ory res pons e, e.g. i n crypt ococcal meni ngi t i s
P.350
Acute neurological conditions in HIV-infected patients: treatment

C P Di T reatme o o a nt
Pa g e 6 1 0
n ss g di ib n ti le o o p st n r ic e te s st e s nt at io n s H E Di Hi ghl y IV nc a act i ve e g ant i ret rov p n i ral h o t herapy al s i (HAART) iti s s of or e a xc s lu e si pt o ic n m e ni n gi ti s D Br
Pa g e 6 1 1
e ai mn e bi nt o ia p /p s y s y di ch a ia g tr n ic o pr s t e ic s b e ut nt n at ot io p n er S fo ei r z m ur e e d s fo r th is re a s o n T S 9 o O 0
Sul p
Pa g e 6 1 2
x L % S o a ei pl nt z a iur s to e m x s o o si s a nt ib o d y p o si ti v e b ut d o n ot di sc ri m in at e ac ti
hadi azi n e 1 2g i v/p o qds + pyri met hami ne 100 mg po od on fi rs t day t hen 75m g po od + fol i n ic aci d 15m g po od for 4 6 wee
Pa g e 6 1 3
v e fr o m in ac ti v e di s e a s e C C o T: nf ri u n si g o e n n h a nc in g le si o n s E Br nc ai

ks Cl i n dam yci n 1.2g po/i v qds + pyri met hami ne 100 mg po od on fi rs t day t hen 75m g po od fol i n ic aci d 15m g po od At ov aquo ne
Pa g e 6 1 4
e n p bi h o al p iti sy c g i l l ol n d e st ss a n d ar d, p er fo r m if n o re s p o n s e to e m pi ri
750 mg po t ds for 21 days (con s i de r us e of dexa met has o ne to redu ce cere bral oede ma)
Pa g e 6 1 5
ca l th er a p y Cr H C y e S pt a F: oc d pl oc ac ei co h oc s i e yt s o si ms e wi ni t h n lo gi w s gl m uc S o O s L e (c b ry ut pt m oc a oc y co b m e a) n S or
Amp hot e ri ci n 0.25 mg 1 mg/ kg i v od for up to 6 wee ks fl ucy t os i ne 100 mg/ kg po/i v qds for 2 wee ks
Pa g e 6 1 6
ei m z al ur i n e 2 s 0 3 0 % . In di a in k st ai n, cu lt ur e, a n d cr y pt oc oc ca l a
(l i po s om al form ul at i ons may be us ed if conc erns rega rdi n g neph rot o xi ci t y Fl uc onaz ol e 400 mg bd
Pa g e 6 1 7
nt ig e n C S o er nf u u m s i cr o y n pt oc oc ca l a nt ig e n p o si ti v e 9 5 % M H C Obt ai n yc e S s peci al i s t o a F: mi crobi ol b d pl ogi cal ac ac ei advi ce; t e h oc i ni t i at e
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ri e yt t herapy u o wi t h at m s i l eas t 4 m s agent s e wi (preferabl ni t h y n l o i ncl udi ng gi w t hos e s gl wi t h CNS m uc penet rat i o on, i .e. s i s oni azi d e + i n pyraz i na m mi de) and o cons i der s t s t eroi ds ca i f fi t s or s wors eni ng e neurol ogi s cal s i gns Z N st ai n p o si ti v e in o
Pa g e 6 1 9
nl y 1 0 2 0 % . C S F cu lt ur e ta k e s 4 6 w e e ks N H Br Combi nat i oc e ai on of at ar a n l eas t 2 of di d bi cot ri moxa a ac o zol e, h p ami kaci n,
Pa g e 6 2 0
e s y s t rept omy /c ci n, ul i mi penem m t u (or e re meropene ni n gi s m S O O ft L e (t n u co b -e er xi cu s t lo in mg a) p S ul ei m z o ur n e ar s y C di o s nf e u a si s o e n C E Vi yt nc ra m) and mi nocycl i ne
Ganc
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o e l mp d e h et g al ec al i t i t i o s o Tr vi n a ru in n s C sv S er F s or e n m e y ur el al iti ti s ss P u ol e. yr P a C di R, cu cu lit lt is ur e, or i m m u n o
i cl ov ir 5mg /kg iv bd for 2 3 wee ks
Val g anci cl ovi r 900 mg po bd
Fos c arne t 90m g/kg bd iv for 2 3 wee ks
Pa g e 6 2 2
hi st oc h e m is tr y V E Vi ar nc ra ic e l el p d l a h et z al ec o iti ti st s o Tr er n a in n C sv S er F s or e n m e y ur el al iti ti s ss P u ol e. yr C a ul di tu cu re
Aci cl ovi r 10m g/kg iv t ds for 10 days
Aci cl ovi r 800 mg 5 t i me s dai l y for 5 10 days
Val a ci cl o vi r
Pa g e 6 2 3
lit , is i m m u n o hi st oc h e m is tr y, or P C R H E Vi er nc ra p e l e p d s h et s i al ec m iti ti pl s o R e n a x in di C cu S lit F is or S n
1g po t ds for 1 wee k
Aci cl ovi r 5mg /kg iv t ds for 10 days
Aci cl ovi r 200 40 0mg
Pa g e 6 2 4
ei e z ur ur al e ti s ss u e. C ul tu re , i m m u n o hi st oc h e m is tr y, or P C
5 t i me s dai l y for 5 10 days Val a ci cl o vi r 500 mg po bd for 5 10 days
R P M C HAART M ot S L or F: (J d a
Pa g e 6 2 5
C ys nt vi fu i ru nc JC s ) t i vi o ru n s a nt ib o di e s P C R Cr Br a ai ni n al bi n o er p v sy e p al si e s D W e hi m te e m nt at ia te
Pa g e 6 2 6
r M RI /C T ch a n g e s Ly S C HAART + m O S chemot he p L F rapy h o m a cy (t reat men t o t or l o pal l i at i ve g ) + y i nt racrani M Br al al ai i rradi at i o ig n n n bi a o nt p m sy e ni n gi ti s Is ol at
Pa g e 6 2 7
e d n er v e or s pi n al co rd le si o n Check BNF for Cont rai ndi cat i on s , caut i ons , s i de-effect s , and i nt eract i ons P.351
P.352
Respiratory emergencies in HIV positive patients: assessment

Caut i on: HIV-i nfect ed pat i ent s pres ent i ng wi t h cough warrant a hi gh i ndex of s us pi ci on for Myc obac t eri um t uberc ul os i s (TB) or mul t i -drug res i s t ant TB. Such pat i ent s s houl d wear a fi l t er mas k and be admi t t ed t o a s i de-room. If on a ward wit h ot her
Pa g e 6 2 8
i mmunocompromi s ed pat i ent s , t hi s s houl d be wi t h negat i ve-pres s ure i s ol at i on faci l i t i es .
General. Look for evi dence of advanced i mmunos uppres s i on and ext ra-pul monary cl ues t o aet i ol ogy (e.g. cut aneous KS, neurol ogi cal s i gns due t o crypt ococcos i s or ret i ni t i s due t o CMV). Remember mul t i pl e pat hol ogi es can co-exi s t . Cough productive of sputum. Purul ent s put um s ugges t i ve of bact eri al or mycobact eri al aet i ol ogy (i nci dence of S. pneumoni ae, H. i nfl uenzae and TB up t o 100-fol d hi gher t han i n HIV-negat i ve cont rol s ). Al s o cons i der S. aureus (i n IVDUs ), Gram-negat i ve organi s ms (e.g. P. aerugi nos a ). Non-productive cough. In pat i ent s wi t h CD4 cel l count <200 cel l s /mm t he mai n concern i s Pneumoc ys t i s c ari ni i pneumoni a (PCP, a fungus ), whi ch t ypi cal l y has a chroni c, progres s i ve hi s t ory as s oci at ed wi t h breat hl es s nes s (s ee Tabl e). PCP can occas i onal l y occur i n pat i ent s duri ng pri mary HIV i nfect i on (s eroconvers i on i l l nes s ) and can be s een i n pat i ent s des pi t e good adherence t o cot ri moxazol e (Sept ri n) prophyl axi s . Ot her caus es of non-product i ve cough i ncl ude vi ral URTIs (any CD4 count ), KS, l ymphoma, and rarel y l ymphocyt i c i nt ers t i t i al pneumoni t i s (any CD4 count but t ypi cal l y rai s ed CD8 cel l count wi t h Sjgren's s ympt oms ). Haemoptysis. Sugges t i ve of mycobact eri al or fungal caus es , pul monary embol us , or KS. Breathlessness. If s udden ons et , cons i der pneumot horax (s econdary t o PCP), pul monary oedema, or pul monary embol i s m. If gradual and progres s i ve need t o excl ude PCP. Chest pain. More common i n bact eri al i nfect i ons , KS, pneumot horax and pul monary embol us . HIV-i nfect ed
3
Pa g e 6 2 9
pat i ent s are more at ri s k of t hromboembol i c di s eas e. Pneumot horax may compl i cat e up t o 10% of pat i ent s wi t h PCP. P.353
Clinical, laboratory, and CXR findings that may distinguish PCP from bacterial pneumonia
Fi P B n n a di e ct n u er g m ia s o l cy st is c ar in ii C < A D 2 ny 4 0 ce 0 l l ce co l l u s/ nt m m
3
Sy N Pr m o o
Pa g e 6 3 0
pt n- d o pr uc m o ti s d ve uc co ti u ve g co h P u ur g ul h e nt sp ut u m Sy A 3 m fe pt w o w 5 m e d d ek ay ur s s at io n Si O Fo g cc ca ns as l io lu n n al g ly si bi g
Pa g e 6 3 1
l a ns te ra l fi n e cr ac kl es (u su al ly m in i m al si g ns ) La W W b B B or C C at va fr or ri e y a q t e bl u st e e s nt ly el
Pa g e 6 3 2
ev at e d Chest radiog raph findin gs Di Di Fo s t ff ca ri us l b e > ut > di i o fo ff n ca us l e Lo Bi U ca l a ni ti te la o ra t e n l , ra P l, er s e ih g il m ar e i n nt i t i al al /l ly o b ar P Di Of at ff t e t e us n
Pa g e 6 3 3
rn e, l o in b t e ar rs or t i fo t i ca al l i n co fi l ns t r ol at i d es at io n C 1 5 ys 0 t s 1 1 0 5 % % (K le bs ie ll a, St a p hy lo co cc al )
Pa g e 6 3 4
Pl V 2 e er 5 ur y al ra ef re 3 fu si o ns 0 %
Practice points
Beware normal CXR: res pi rat ory hi s t ory i s t he mos t i mport ant . If CD4 count <200 cel l s /mm and hi s t ory i s compat i bl e, cons i der PCP as t he mos t l i kel y res pi rat ory i nfect i on and s t art empi ri cal t herapy. Di agnos t i c i nves t i gat i ons can be deferred for s everal days unt i l t he pat i ent i s cl i ni cal l y s t abl e. TB i s on t he i ncreas e i n t he UK.
3
P.354
Respiratory emergencies in HIV positive patients: investigations Non-invasive investigations

NB: vi ral and fungal i nfect i ons may caus e few s ympt oms and s i gns i f s us pect ed, reques t vi ral PCR or cul t ure and fungal mi cros copy and cul t ure i n addi t i on t o t he i nves t i gat i ons l i s t ed bel ow.
Baseline (useful if already done). CD4 cel l count , HIV RNA vi ral l oad.
Pa g e 6 3 5
Radiology. Ches t X-ray (s ee t abl e). Ot her radi ol ogy s uch as ul t ras ound, CT, or hi gh-res ol ut i on CT performed as needed. FBC. Leucopeni a s ugges t s poor prognos i s i n bact eri al i nfect i ons and i f pre-exi s t i ng can gui de choi ce of empi ri cal t herapy. U&Es. Low Na or renal i mpai rment s ugges t s poor prognos i s . LFT s. Abnormal i t i es s ugges t di s s emi nat ed di s eas e or ot her pat hol ogy. Serology . For Legi onel l a, Myc opl as ma , and ot her at ypi cal pat hogens . Cryptococcal antigen. A t es t wi t h a >90% s ens i t i vi t y and >95% s peci fi ci t y for s ys t emi c crypt ococcaemi a. ABGs. Hypoxi a can occur i n any pneumoni c proces s but mos t charact eri s t i c of PCP. Heaf test (tuberculin skin testing). Res ul t s can be mi s l eadi ng or unhel pful as anergy i s common. Onl y us ed i n s peci fi c ci rcums t ances . Exercise oxygen saturation. Si gni fi cant exerci s e des at urat i on very s ugges t i ve of a di ffus e pneumoni t i s s uch as PCP. Us eful i n pat i ent s wi t h normal CXR and SaO 2 >93% at res t . Lung function tests. If avai l abl e t hes e may be us eful as i mpai red gas t rans fer (KCO) has t he s ame s i gni fi cance as oxygen des at urat i on. Blood cultures. Oft en pos i t i ve i n S. pneumoni ae i nfect i ons . Mycobact eri al bl ood cul t ures may be us eful (46 weeks ). Sputum cultures. For mi cros copy and cul t ure (bact eri al and mycobact eri al ). Induced sputum. Nebul i zed hypert oni c s al i ne admi ni s t ered by s peci al i s t nurs e or phys i ot herapi s t . Si l ver s t ai n or i mmunofl uores cence has a maxi mum of 8590% s ens i t i vi t y for PCP compared wi t h gol d s t andard fi bre opt i c bronchos copy (t ypi cal l y 5060%).
+
Pa g e 6 3 6
Al s o s end s ampl es for mi cros copy and cul t ure (bact eri al and mycobact eri al ). Do not perform on an open ward.
Invasive investigations
Fibre optic bronchoscopy. Us ual l y i ndi cat ed i f no res pons e t o t reat ment or s econd pat hol ogy s us pect ed. Look careful l y for KS l es i ons (t rans bronchi al bi ops i es not rout i nel y t aken as ri s k of pneumot horax and haemorrhage). Send BAL s ampl es for mi cros copy (i ncl udi ng s t ai ns for pneumocys t i s ) and cul t ure (bact eri al , fungal , and mycobact eri al ), vi rus es and PCR. Pleural aspiration. Cel l count , prot ei n, mi cros copy and cul t ure (bact eri al and mycobact eri al ), cyt ol ogy, pl eural bi ops y of al l s i gni fi cant effus i ons . Lung biopsy. t rans bronchi al , percut aneous , or open l ung bi ops y. Seek s peci al i s t s urgi cal advi ce.
P.355
CXR patterns in HIV-associated disease

X-r Disease ay process fin din g Nor ma l
PCP, vi ral pneu moni a (i f hypo xi c onex erci s
Pa g e 6 3 7
e) Foc al i nfi l t ra te
Bact eri al ( S. pneu moni ae, H. i nfl u enza e)
Myco bact eri a (TB or MAI)
Fung al orga ni s m s (cry pt oc occu s, hi s t opl a s mo sis, as pe rgi l l us ,
Pa g e 6 3 8
cand i da)
Noca rdi a or Rho doc o c c us equi (rare )
Pul m onar y KS or l ymp hom a
PCP (api cal i f on nebu l i zed pent ami d i nep roph yl axi s)
Ca vi t at i
Bact eri al
Pa g e 6 3 9
ng
(s t a phyl ococ cal , s t re pt oc occa l, noca rdi a, anae robe s)
Myco bact eri a
Fung al orga ni s m s
PCP may prod uce t hi nwal l ed cys t s (pne uma
Pa g e 6 4 0
t oco el es ) Pn eu mo t ho rax
PCP: occa s i on al l y whe n pneu mat ocoe le rupt ures
TB PCP, cl as s i cal pres ent a t i on
Di f fus e i nfi l t ra te
Res p i rat o ry vi rus es (RSV , aden ovi r us ,
Pa g e 6 4 1
para i nfl u enza )
CMV (oft en di ffi cul t to deci de whet her pat h ogen ic rol e)
Mi l i a ry t ube rcul o sis
Fung al orga ni s m s
Toxo pl as mos i s
Pa g e 6 4 2
Lym phoc yt i c i nt er stiti al pneu moni tis
Pl e ura l eff us i on
Bact eri al (mai nl y S. pneu moni ae )
Myco bact eri a (mai nl y TB)
Lym pho ma
Hear t fai l u re
KS
Pa g e 6 4 3
Me di a sti nal l ym ph ad en op at h y
Not a feat ure of HIVrel at ed l ymp hade nopa t hy
Myco bact eri a, fung al i nfec t i on
Lym pho ma and KS
P.356
Respiratory emergencies in HIV positive patients: management General measures
Moni t or pul s e, BP, and t emperat ure regul arl y.
Pa g e 6 4 4
Pul s e oxi met ry s houl d be us ed wi t h s uppl ement ary oxygen t o mai nt ai n s at urat i ons above 90%.
Assisted ventilation
Bei ng HIV-i nfect ed i s not i n i t s el f a cont rai ndi cat i on t o as s i s t ed vent i l at i on or i nt ens i ve care. Indeed, many acut e res pi rat ory i nfect i ons requi ri ng s uch s upport achi eve excel l ent out comes . It i s t he i ndi vi dual 's s t age of di s eas e and general prognos i s t hat deems s uch management appropri at e or i nappropri at e, as wel l as t he vi ews of t he pat i ent and t hei r next of ki n.
Specific treatment of respiratory conditions:

Cont act l ocal mi crobi ol ogy s ervi ces i f uncert ai n. Co Dosage, ndi n Co mm uni t yacq ui r ed pn eu mo ni a (C D4 cou nt >2
route, y, duration Co-a mox ycl a v 600 mg t ds i v/p o or ceft r i axo ne 2g od iv
tio frequenc
Pa g e 6 4 5
00 cel l s/ mm
3
for 7 days azi t hro myci n 500 mg od i v/p o for 3 days
Co If any mm s ugges t i o uni n of PCP t y- t reat as acq PCP + ui r ed pn eu mo ni a (C D4 cou nt <2 00 cel l s/ mm
Azi t hro myci n 500 mg od/i v po for 3 days
Pa g e 6 4 6
) Pn eu mo c ys tis ji ro vec i pn eu mo ni a (i f Pa O2 <8 kPa ad d pre dni s ol on e 75 mg od po for 5 day s, t he n
Cot ri mox azol e 120 mg/ kg in 2 4 di vi d ed dos e s i v/p o for 14 21 days . Red uce to 100 mg/ kg aft er 7 days if res p ons i ve
Pa g e 6 4 7
50 mg od for 5 day s, t he n 25 mg od for 5 day s) Ho s pi t al -ac qui red pn eu mo ni a
( ri s k of t oxi c i t y) Cl i n dam yci n 600 mg 1. 2g qds po/i v + pri m aqui ne 15 30 mg od po for 14 21 days
Pent ami d i ne i s et i onat e
Pa g e 6 4 8
4mg /kg od iv for 14 21 days + nebu l i zed 600 mg od for fi rs t 3 days
At ov aquo ne 750 mg po bd for 21 days
Cefo t axi me 1 2g
Pa g e 6 4 9
t ds i v or ci pro fl ox aci n 500 mg bd po/i v for 7 days +
Azi t hro myci n 500 mg od i v/p o for 3 days
Int Cefot axi m rav e 12g en t ds i v + ous fl ucl oxaci l dru l i n g r 12g for 7 days + az i t hromy us e qds po/i v
Pa g e 6 5 0
ci n 500mg od i v/po for 3 days or ceft ri azon e + fl ucl oxaci l lin Ne If any ut r s ugges t i o op n of PCP eni t reat as c pat i en t (du rat i on of t re at me nt gui de d by mi c rob i ol ogi st) PCP +
Ceft azi di me 1 2g t ds iv for 7 14 days + azi t hro myci n 500 mg od i v/p o
Pa g e 6 5 1
Pi pe raci l lin 4g qds iv + gent ami c in (2m g/kg iv l oad i ng dos e t hen 3mg /kg iv in di vi d ed dos e acco rdi n g to l evel s + azi t hro myci n 500 mg od
Pa g e 6 5 2
Ci pr ofl o xaci n 500 mg 1g bd i v+ amo xyci l lin 2g t ds iv + azi t hro myci n 500 mg od
Ka HAART pos i 's chemot he s ar rapy co ma Ly HAART mp ho chemot he ma rapy P.357
Pa g e 6 5 3
P.358
Gastrointestinal (GI) presentations in HIV positive patients: assessment

Opport uni s t i c i nfect i ons , mal i gnanci es , and ant i ret rovi ral drug t oxi ci t y can al l frequent l y mani fes t as s ympt oms /s i gns i n t he GI t ract .
General. As s es s hydrat i on, wei ght , and nut ri t i onal s t at us . Diarrhoea. Can be caus ed by mul t i pl e pat hogens : bot h common and opport uni s t i c (s ee t abl e p364), drug t herapy, or advanced HIV per s e . The pres ence of as s oci at ed s ympt oms (fever, abdomi nal pai n, bl ood, per rec t um ) s houl d be es t abl i s hed. An awarenes s of CD4 count wi l l as s i s t i n di rect i ng management . Weight loss. Can be caus ed by advanced HIV i nfect i on, may be t he res ul t of chroni c di arrhoea/mal abs orpt i on, may be t he pres ent i ng s ympt om of underl yi ng mal i gnancy or opport uni s t i c i nfect i on, or may repres ent t oxi ci t y t o ant i ret rovi ral t herapy (part i cul arl y s ubcut aneous fat l os s ). Abdominal pain. Can be a feat ure of GI i nfect i ons (s ee p364), bi l i ary t ree di s eas e, or pancreat i t i s (whi ch may be drug i nduced, not abl y by nucl eos i de anal ogues , part i cul arl y ddI [di danos i ne]). Lact i c aci dos i s and hepat i c s t eat os i s are rare compl i cat i ons of ant i ret rovi ral t herapy t hat may pres ent as vague abdomi nal pai n. Loin pain/nephrolithiasis. A wel l -recogni zed s i de-effect of i ndi navi r t herapy. St ones are unl i kel y t o be s een on pl ai n X-rays and us ual l y res pond t o cons ervat i ve management wi t h fl ui d i nput wi t hout need
Pa g e 6 5 4
t o di s cont i nue t he offendi ng agent . W i t h s evere epi s odes (haemat uri a and confi rmed cal cul i on renal t ract i nves t i gat i on) change t herapy as t here i s ri s k of furt her epi s odes and progres s i ve renal damage.
Jaundice. May be t he res ul t of vi ral hepat i t i s (acut e or chroni c), bi l i ary t ract di s eas e, drug-i nduced hepat i t i s , or hepat i c i nvol vement by ot her opport uni s t i c i nfect i ons or t umours . Dysphagia. Mos t commonl y caus ed by candi dal i nfect i on (oral Candi da i s us ual l y pres ent ), and l es s commonl y by ul cerat i on s econdary t o HSV, VZV, CMV, or i di opat hi c (apht hous ). Oral lesions. Oral C andi da (us ual l y i n a ps eudomembranous form, appeari ng as whi t e pl aques , but may be eryt hemat ous or hyperpl as t i c) and oral hai ry l eucopl aki a (whi t e pl aques on t he s i de of t he t ongue) are common s i gns i n i ndi vi dual s wi t h HIV i nfect i on and may be t he fi rs t pres ent i ng feat ures of advanci ng i nfect i on. KS may pres ent as red/purpl e macul es on t he pal at e or gi ngi val margi n.
P.359
Practice point
There i s an epi demi c of acut e hepat i t i s C and s yphi l i s i n s exual l y act i ve gay mal es i n t he UK. Al ways t es t for t hes e organi s ms i f t here are concerns or s ympt oms .
P.360
GI presentations in HIV positive patients: investigations General investigations
Pa g e 6 5 5
FBC, U&Es, LFT s. Check for evi dence of anaemi a, dehydrat i on, hepat i c dys funct i on. Blood cultures. Bact eri al GI i nfect i ons are more l i kel y t o be accompani ed by s ys t emi c i nfect i on i n t he i mmunocompromi s ed hos t . Mycobact eri al bl ood cul t ures (part i cul arl y cons i deri ng at ypi cal mycobact eri a i n i ndi vi dual s wi t h CD4 count s <100 cel l s /mm ).
3
Amylase. Check for pancreat i t i s i n i ndi vi dual s pres ent i ng wi t h abdomi nal pai n. Uncuffed serum lactate. Cons i der t he pos s i bi l i t y of l act i c aci dos i s i n t he unwel l pat i ent recei vi ng ant i ret rovi ral t herapy wi t h non-s peci fi c abdomi nal s ympt oms . Send t o a l ab rapi dl y for an accurat e res ul t . Hepatitis serology. Cons i der acut e hepat i t i s A/B i n t he jaundi ced pat i ent and chroni c hepat i t i s B/C i n pat i ent s wi t h evi dence of chroni c l i ver di s eas e. New ons et of abnormal LFTs may be due t o hepat i t i s C.
Specific investigations
Stool specimens. Shoul d be exami ned/cul t ured for bact eri a and ova, cys t s , and paras i t es . At l eas t 3 s t ool s peci mens s houl d be s ent . Cl os t ri di um di ffi c i l e t oxi n s houl d be reques t ed i n i ndi vi dual s who have t aken or are t aki ng ant i bi ot i cs . In an i ndi vi dual wi t h s evere i mmunos uppres s i on (CD4 <100) and negat i ve convent i onal s t ool anal ys i s , exami nat i on for Mi c ros pori di al s peci es s houl d be performed. Abdominal X-ray. Look for evi dence of t oxi c di l at at i on i n t he pat i ent pres ent i ng wi t h di arrhoea/abdomi nal pai n. The major caus es are CMV (wi t h CD4 count s <100 cel l s /mm ) and bact eri al i nfect i ons ( Sal monel l a, Shi gel l a, Campyl obac t er ) at hi gher CD4 count s . Ultrasound scanning. Look for evi dence of hepat i c/bi l i ary abnormal i t y i n pat i ent s wi t h jaundi ce/abnormal LFTs , evi dence of as ci t es i n pat i ent s wi t h abdomi nal di s t ens i on, and abdomi nal
3
Pa g e 6 5 6
mas s es /l ymphadenopat hy i n i ndi vi dual s wi t h opport uni s t i c i nfect i ons /t umours .
CT scanning. Look for evi dence of mas s es /l ymphadenopat hy i n i ndi vi dual s wi t h abdomi nal pai n, whi ch may repres ent i nvol vement by underl yi ng opport uni s t i c i nfect i ons or t umours . Upper gastrointestinal endoscopy. Look for oes ophageal l es i ons i n pat i ent s wi t h dys phagi a, gas t ri c l es i ons i n pat i ent s wi t h abdomi nal pai n. Perform duodenal bi ops i es i n i ndi vi dual s wi t h chroni c di arrhoea where no pat hogen has been i s ol at ed. Sigmoidoscopy/colonoscopy. Look for evi dence of i nvol vement by opport uni s t i c pat hogens /t umours i n pat i ent s wi t h chroni c di arrhoea or abdomi nal pai n. Rect al /col oni c bi ops i es s houl d be performed i n pat i ent s wi t h chroni c di arrhoea where no pat hogen has been i s ol at ed. ERCP/MRCP. Shoul d be cons i dered i n i ndi vi dual s wi t h evi dence of obs t ruct i ve jaundi ce where no caus e has been found, or i n i ndi vi dual s wi t h chroni c abdomi nal pai n l ooki ng for any evi dence of as cendi ng chol angi t i s .
P.361
P.362
GI presentations in HIV positive patients: Management
General pri nci pl es of rehydrat i on, anal ges i a, and nut ri t i onal s upport s houl d appl y. Speci fi c t herapy s houl d be di rect ed t owards t he s us pect ed/proven underl yi ng caus e (s ee t abl e, p364). Cons i der empi ri c t reat ment wi t h ant i bact eri al agent s (ci profl oxaci n met roni dazol e) i n t he unwel l pat i ent wi t h
Pa g e 6 5 7
di arrhoea and addi t i onal ant i -cyt omegal ovi rus t herapy (us ual l y ganci cl ovi r) i f t he CD4 count i s <100 cel l s /mm .
Ant i ret rovi ral t herapy s houl d not be di s cont i nued or modi fi ed wi t hout di s cus s i on wi t h an experi enced HIV cl i ni ci an.
P.363
P.364
GI pathogens in HIV positive patients

Pa ge n Ca ndi da Clinical Diagnosis T reatme nt tion
tho presenta
Oral : us ua lly whi t e pl aq ues . Us u al l y CD4 <35 0
Us u al l y bas e d upon cl i ni cal appe aran ce
Oral : us ua lly wi t h fl uco nazo le (50 mg 5 days ) or 400 mg s t at
Can be confi rme d by bi op
Oes opha geal
Pa g e 6 5 8
: dys p hagi a or odyn opha gi a. Us u al l y CD4 <20 0
s y/c ul t ur e
Oes opha geal : fl uco nazo le 100 mg od 14 days
Hi gh er dos e s of fl uco nazo l e or al t er nat i ve agen ts may be reco mme nded in cas e s of
Pa g e 6 5 9
s us p ect e d/pr oven a zol e res i s t anc e Sal mo nel la
Di arr hoea feve r, abdo mi na l pai n , and bl oo d per rec t um ; Col o ni c di l at at i o n . Any CD4
Conf i rme d by s t oo l ( bl oo d) cul t ures
Ci pr ofl o xaci n 500 mg bd 7 14 days
Empi ri c t rea t me nt may be cons i der ed in t he unw
Cep hal o s por in if ci pro fl ox aci n i nt ol eran t
Pa g e 6 6 0
coun t Shi gel la
el l pat i ent
Di arr hoea feve r, abdo mi na l pai n , and bl oo d per rec t um ; Col o ni c di l at at i o n . Any CD4 coun t
Conf i rme d by s t oo l ( bl oo d) cul t ures
Ci pr ofl o xaci n 500 mg bd 7 14 days
Empi ri c t rea t me nt may be cons i der ed in t he unw el l pat i ent
Tri m et ho pri m if ci pro fl ox aci n i nt ol eran t
Ca mp yl o bac t er
Di arr hoea feve
Conf i rme d by s t oo
Ci pr ofl o xaci n
Pa g e 6 6 1
r, abdo mi na l pai n , and bl oo d per rec t um ; Col o ni c di l at at i o n . Any CD4 coun t Cry t os por i di a

l ( bl oo d) cul t ures Empi ri c t rea t me nt may be cons i der ed in t he unw el l pat i ent

500 mg bd 7 14 days Eryt hro myci n if ci pro fl ox aci n i nt ol eran t
May pres ent acut el y as t rave l l ers di arr hoea
Dem ons t rat i o n of orga ni s m on s t oo l anal ys i s
No effe ct i ve ant i mi cr obi a l t her apy (con s i de
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at any CD4 coun t whi c h us ua lly cl ear s s pon t ane ous l y, or chro ni cal l y as wat e ry di arr hoea wi t h CD4 <10 0
and/ or bi op sy
r ni t a zoxa ni de ). Acut e cryt os po ri di a l i nfec t i on us ua lly res o l ves s pon t ane ous l y; t rea t chro ni c i nfec t i on wi t h HAA RT
Mi c ros por i di
W at ery di arr hoea
Dem ons t rat i o n of
Al be ndaz ol e is
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in i ndi v i dua ls wi t h CD4 <10 0
orga ni s m s by s pec i fi c s t oo l anal ys i s or on bi op s y/e l ect r on mi cr os co py
bene fi ci a l in s om e s t ud i es . Effe ct i ve HIV t rea t me nt res u lts in cl i ni cal i mpr ove men t
I so s po ra
W at ery di arr hoea in i ndi v i dua ls wi t h CD4 <10 0
AFB s me ar of s t oo l
Cot ri mox azol e us ua lly effe ct i ve
Pa g e 6 6 4
Ent am oe ba hi s t ol yt i ca
Di arr hoea bl oo d and abdo mi na l pai n . Any CD4 coun t
OC& P of s t oo l
Met r oni d azol e 500 mg t ds or t i ni d azol e t hen di l ox ani d e
Gi a rdi a
W at ery di arr hoea . Any CD4 coun t
OC& P of s t oo l
Met r oni d azol e 250 50 0mg t ds for 10 days or t i ni d azol e
Cyt om eg al o
Oes opha geal :
Dem ons t rat i o n of
Spec i fi c CMV t her
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vi r us
dys p hagi a wi t h ul cer at i o n
orga ni s m s by i mm unoc yt oc hemi s t ry of bi op sy s pec i men s
apy (us u al l y ganc i cl ov ir 5mg /kg bd for 3 4 wee ks ). Effe ct i ve ant i HIV t her apy s hou ld redu ce ri s k of recu rren ce/o t her endorga n
Gas t ri c/u pper GI: abdo mi na l pai n
Col o ni c: di arr hoea abdo mi na l pai n . Toxi c di l at at i o n may occu r.
Pa g e 6 6 6
CD4 <10 0
di s e as e
Her pes sim pl e x Her pes zos t er My c ob ac t eri um avi um co mp l ex
Oes opha geal ul cer at i o n, or proc titis /col i tis
Dem ons t rat i o n of orga ni s m s on bi op s y/c ul t ur e
Aci cl ovi r 200 80 0mg 5 /day or 5mg /kg iv for 2 3 wee ks
Oes opha geal ul cer at i o n
Dem ons t rat i o n of orga ni s m s on bi op s y/c ul t ur e
Chro ni c, wat e ry di arr hoea abdo mi na l pai n . Us u al l y
Aci cl ovi r 400 80 0mg 5 /day or 5 10m g/kg iv for 2
Bl oo d cul t ures (s pe ci fi c myc obac
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s ys t emi c s ym pt o ms (fev er, wei g ht l os s , panc yt op aeni a). CD4 <50
t eri a l cul t ure: may t ake s eve ral wee ks ), or dem ons t rat i o n of orga ni s m s on bi op sy
3 wee ks 3 agen ts (us u al l y ri fab ut i n, et ha mbu t ol , and cl ari t hro myci n or azi t hro myci n)
Effe ct i ve ant i HIV t her apy is as s o ci at ed wi t h
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cl i ni cal res p ons e Cl o s t ri di u m di ff icil e
W at ery di arr hoea . Hi s t ory of ant i bi ot i cs Any CD4 coun t
St oo l t oxi n as s a y
Met r oni d azol e 250 50 0mg qds 10 14 days
Vanc omy ci n 125 mg qds 10 14 days
P.365
P.366
Pyrexia of unknown origin
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Assessment

Look for s i gns /s ympt oms of focal i nfect i on Check for neut ropeni a Cons i der l i ne s eps i s i f i ndwel l i ng i nt ravenous cannul ae Cons i der drug-rel at ed fever (det ai l ed drug hi s t ory, i ncl udi ng ant i ret rovi ral agent s ) Cons i der underl yi ng l ymphoma Det ai l ed t ravel hi s t ory es s ent i al .
Investigations

Us ual i nves t i gat i on of fever Crypt ococcal ant i gen Mycobact eri al bl ood cul t ures (MAI i f CD4 <100) Cons i der
o o o
CT s can head CT s can ches t and abdomen Lymph node bi ops y (i f s i gni fi cant l ymphadenopat hy) Bone marrow exami nat i on Gal l i um/whi t e cel l s can.
o o
Treatment
Unl es s cl i ni cal l y unwel l , mos t cl i ni ci ans woul d recommend wi t hhol di ng empi ri c ant i mi crobi al t herapy. Speci fi c ant i mi crobi al (or ot her) t herapy s houl d be di rect ed agai ns t s us pect ed underl yi ng pat hogen/proces s .
Dermatological presentations
Cons i der drug-rel at ed caus es (i ncl udi ng ant i ret rovi ral agent s ), but do not di s cont i nue ant i ret rovi ral agent s (unl es s es s ent i al ) wi t hout di s cus s i on wi t h an HIV cl i ni ci an. In part i cul ar, pat i ent s recent l y havi ng commenced nevi rapi ne t herapy may be at ri s k of St evens Johns on s yndrome or t oxi c epi dermal necrol ys i s , and pat i ent s havi ng recent l y commenced
Pa g e 6 7 0
abacavi r may be at ri s k of a hypers ens i t i vi t y s yndrome (s ee, p370).
Mos t dermat ol ogi cal compl ai nt s can behave at ypi cal l y and more s everel y i n i ndi vi dual s wi t h HIV i nfect i on.
o
Shi ngl es ( Vari c el l a zos t er ) may pres ent wi t h mul t i -dermat omal l es i ons and/or neurol ogi cal i nvol vement . Herpes s i mpl ex may pres ent wi t h more s evere l es i ons and/or neurol ogi cal i nvol vement and requi res hi gher dos es of aci cl ovi r t han us ed i n i mmunocompet ent pat i ent s . Seborrhoei c dermat i t i s may pres ent more aggres s i vel y i n t he HIV pos i t i ve pat i ent and may be recal ci t rant t o convent i onal t herapy. Earl y s yphi l i s s houl d be cons i dered i n any HIV pos i t i ve pat i ent wi t h dermat ol ogi cal l es i ons .
P.367
P.368
Haematological presentations
Cyt opaeni as may be t he res ul t of HIV i nfect i on per s e , ant i ret rovi ral (or ot her drug) t oxi ci t y, or bone marrow i nvol vement by opport uni s t i c i nfect i ons or t umours .
Mi l dmoderat e t hrombocyt openi a i s a common fi ndi ng i n t he HIV-i nfect ed pat i ent ; a s evere ITP pi ct ure i s wel l recogni zed. Us ual l y res ponds t o ant i ret rovi ral t herapy, but s t eroi ds /i mmunogl obul i n may be requi red i n s evere cas es . Anaemi a i s a recogni zed s i de-effect of ant i ret rovi ral t herapy [not abl y zi dovudi ne (AZT) t herapy]. Neut ropeni a i s a recogni zed s i de-effect of zi dovudi ne (AZT), ganci cl ovi r t herapy and occurs more frequent l y i n
Pa g e 6 7 1
t he HIV-i nfect ed pat i ent recei vi ng chemot herapy for mal i gnancy. St andard management of neut ropeni a s houl d appl y. P.369
P.370
Antiretroviral toxicity 1
Many cl i ni ci ans are unfami l i ar wi t h t he agent s us ed t o t reat HIV i nfect i on. They are as s oci at ed wi t h mul t i pl e t oxi ci t i es , s ome of whi ch may pres ent t o t he emergency cl i ni ci an. Al ways cons i der di s cus s i ng t he cas e wi t h a cl i ni ci an experi enced i n us e and t oxi ci t y of t hes e drugs . The key pri nci pl es of management are t o recogni ze t he pos s i bi l i t y of i at rogeni c i l l nes s and t o exert caut i on i n management . In order t o mi ni mi ze t he ri s k of devel opment of res i s t ance and t o pres erve fut ure t reat ment opt i ons , ant i ret rovi ral agent s can be di s cont i nued wi t h di s cus s i on wi t h an HIV cl i ni ci an. If neces s ary, t he t oxi c agent i s s wi t ched and t he wi t hdrawal of one or t wo of a combi nat i on of agent s (t hus l eavi ng an i ndi vi dual on s ubopt i mal t herapy) s houl d be avoi ded. In i ndi vi dual s recei vi ng ant i ret rovi ral t herapy who pres ent s ys t emi cal l y unwel l , t he pos s i bi l i t y of l act i c aci dos i s s houl d al ways be cons i dered (s ee bel ow).
Rash and hypersensitivity
Abac avi r hypers ens i t i vi t y react i on (4%) can pres ent as a fever or macul opapul ar ras h (us ual l y i n fi rs t 2 mont hs of t reat ment ) oft en as s oci at ed wi t h one or more ot her s ympt oms or s i gns (fever; s ore t hroat , GI or res pi rat ory s ympt oms , l aborat ory abnormal i t i es ). If s t rongl y s us pect ed, abacavi r s houl d be di s cont i nued and t he
Pa g e 6 7 2
pat i ent never re-chal l enged (ri s k of fat al hypers ens i t i vi t y react i on). Thi s deci s i on s houl d be t aken by an experi enced HIV cl i ni ci an.
Non-nuc l eos i de revers e t rans c ri pt as e i nhi bi t ors (efavi renz and nevi rapi ne): macul opapul ar ras h (~10%) peaki ng at 2 weeks oft en as s oci at ed wi t h abnormal LFTs . Somet i mes can be pus hed t hrough wi t h ant i hi s t ami nes (cet i ri zi ne) but needs cl os e moni t ori ng (as s oci at ed s evere or l i fe-t hreat eni ng hepat ot oxi ci t y not uncommon). St even's Johns on s yndrome and t oxi c epi dermal necrol ys i s are wel l recogni zed but uncommon s i de-effect s of nevi rapi ne ( ri s k i n women).
Mitochondrial toxicity
Us ual l y at t ri but ed t o t he unwant ed i nhi bi t i on of mi t ochondri al DNA pol ymeras e gamma by t he nucl eos i de revers e t rans cri pt as e i nhi bi t ors (part i cul arl y s t avudi ne and di danos i ne). Over mont hs t hi s can l ead t o mi t ochondri al dys funct i on whi ch can mani fes t as
Lac t i c ac i dos i s /hepat i c s t eat os i s res ul t i ng from general mi t ochondri al dys funct i on. If s us pect ed (general mal ai s e, abdomi nal pai n, met abol i c aci dos i s , abnormal LFTs ), an uncuffed bl ood s ampl e s houl d be s ent for i mmedi at e l act at e meas urement and i f hi gh (>5mmol /L) wi t h as s oci at ed aci dos i s t he offendi ng drug(s ) s t opped. Thi s condi t i on can be rapi dl y fat al and admi s s i on t o i nt ens i ve care i s occas i onal l y requi red. Ac ut e panc reat i t i s : part i cul arl y as s oci at ed wi t h di danos i ne (ddI) (al s o preci pi t at ed by al cohol , gal l s t ones , pent ami di ne, and s ome OIs ). Myopat hy (mus cl e bi ops y di agnos t i c): zi dovudi ne (AZT). Ant i ret rovi ral -i nduc ed peri pheral neuropat hy: part i cul arl y as s oci at ed wi t h zal ci t abi ne, s t avudi ne, and di danos i ne. Renal t ubul ar ac i dos i s /Fanc oni 's s yndrome have been rarel y report ed wi t h t enofovi r.
P.371
Pa g e 6 7 3
Practice point
Al ways di s cus s t reat ment i ni t i at i on/change wi t h an experi enced HIV-cl i ni ci an.
P.372
Antiretroviral toxicity 2 Metabolic disturbances

Hyperl i pi daemi a and gl ucos e i nt ol erance (i ncl udi ng frank di abet es ) have been as s oci at ed wi t h t he us e of ant i ret rovi ral t herapy, part i cul arl y t he prot eas e i nhi bi t ors . The as s oci at i on wi t h premat ure cardi ovas cul ar di s eas e current l y remai ns uncert ai n but i s s ugges t ed by s ome cohort s t udi es . The pres cri pt i on of s t at i ns i n t hi s pat i ent group s houl d be made wi t h care gi ven t he pot ent i al drugdrug i nt eract i ons ; s i mvas t at i n i s cont rai ndi cat ed i n pat i ent s recei vi ng prot eas e i nhi bi t ors (pravas t at i n or at orvas t at i n are preferred).
Haematological toxicity
Nucl eos i de anal ogues [part i cul arl y zi dovudi ne (AZT)] are as s oci at ed wi t h haemat ol ogi cal t oxi ci t y es peci al l y anaemi a and neut ropeni a whi ch us ual l y occurs duri ng t he fi rs t few weeks /mont hs of t herapy.
Hepatotoxicity
Al l of t he avai l abl e ant i ret rovi ral agent s have been as s oci at ed wi t h hepat ot oxi ci t y, part i cul arl y i n t hos e i ndi vi dual s co-i nfect ed wi t h hepat i t i s C/B. Nevi rapi ne has been rarel y as s oci at ed wi t h ful mi nant hepat i t i s (wi t hi n t he fi rs t 6 weeks of t herapy). Hepat i c s t eat os i s (as part of a s yndrome of mi t ochondri al dys funct i onas out l i ned above) i s a wel l -recogni zed t hough rare compl i cat i on of nucl eos i de anal ogue t herapy. Mos t HIV phys i ci ans woul d cl os el y moni t or LFTs wi t hout di s cont i nuat i on unl es s t here i s evi dence of cl i ni cal hepat i t i s or an ALT/AST of >510 t i mes t he upper l i mi t of normal .
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Neurological toxicity
Efavi renz (and occas i onal l y nevi rapi ne) can caus e s i gni fi cant neurops ychi at ri c di s eas e. In t he majori t y of pat i ent s t hi s occurs i n t he fi rs t 4 weeks of t herapy and can pres ent as mood s wi ngs or depres s i on. reat ment i s di s cont i nued by 510% of i ndi vi dual s , t hough upt o 50% wi l l experi ence s ome s ympt oms of muzzy head or ni ght mares .
Drug interactions with antiretroviral therapy

The prot eas e i nhi bi t ors and non-nucl eos i de revers e t rans cri pt as e i nhi bi t ors are met abol i zed t hrough t he cyt ochrome p450 s ys t em and exhi bi t a wi de vari et y of drug i nt eract i ons , many of whi ch have pot ent i al l y s eri ous cons equences . It i s recommended t hat co-admi ni s t rat i on of ot her P450-medi at ed agent s s houl d be wi t h caut i on. Furt her i nformat i on i s avai l abl e i n t he Bri t i s h Nat i onal Formul ary (BNF) or can be acces s ed vi a t he Li verpool Uni vers i t y webs i t e (ht t p://www.hi v-drugi nt eract i ons .org). P.373
P.374
Post-exposure prophylaxis (PEP)

Evi dence t hat PEP may be effect i ve can be drawn from bot h ani mal and vert i cal t rans mi s s i on s t udi es . The mos t compel l i ng dat a are from a cas e-cont rol l ed s t udy of heal t hcare workers where t he admi ni s t rat i on of zi dovudi ne (AZT) monot herapy was s hown t o be as s oci at ed wi t h approxi mat el y 80% reduct i on i n HIV t rans mi s s i on. Mos t hos pi t al s /emergency depart ment s wi l l have es t abl i s hed prot ocol s for t he management of PEP. However, t he fol l owi ng general pri nci pl es appl y.
The ri s k of HIV t rans mi s s i on i s t he product of t he ri s k
Pa g e 6 7 5
of t he donor bei ng HIV and t he ri s k of HIV i nfect i on from t he expos ure.
To es t i mat e t he ri s k of t he donor bei ng HIV pos i t i ve, an unders t andi ng of t he epi demi ol ogy of t he ri s k group of t he i ndi vi dual i s hel pful l .
o
For exampl e, t he ri s k of a homos exual man i n t he UK bei ng HIV i s es t i mat ed at 1015% i n London and 2.5% el s ewhere. The ri s k of an i nt ravenous drug us er bei ng HIV i s <5%. The ri s k of a het eros exual bei ng HIV requi res a knowl edge of t he HIV preval ence i n t he count ry i n whi ch t hey have been s exual l y act i ve (as hi gh as 2050% i n s ome s ub-Saharan Afri can count ri es ).
Needlestick/Splash injury
The ri s k of HIV t rans mi s s i on from expos ures has been es t i mat ed at

Needl es t i ck i njury: 1 i n 300 Spl as h i njury (t o eyes or di s eas ed s ki n): <1 i n 1000.
Factors associated with increased risk include

Donor: advanced HIV i nfect i on; hi gh vi ral l oad Injury: hol l ow-bore needl e; i ns ert i on of needl e i nt o art ery or vei n of pat i ent ; vi s i bl e bl ood on devi ce; deep i njury.
Fol l owi ng as s es s ment of t he ri s k, cons i der PEP. NB: Do not forget t hat opt i mal management of s harps i njuri es i ncl udes i mmedi at e wound management (bl eedi ng and s i mpl e was hi ng) and cons i derat i on of expos ure t o hepat i t i s B (as s es s vacci nat i on s t at us and cons i der accel erat ed vacci nat i on or i mmunogl obul i n) and hepat i t i s C.
Sexual exposure
The ri s k of HIV t rans mi s s i on t hrough s exual expos ure i s es t i mat ed as
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Unprot ect ed vagi nal s ex (mal e t o femal e): 1 i n 1000 Unprot ect ed vagi nal s ex (femal e t o mal e): 1 i n 1000 Unprot ect ed anal s ex (ri s k t o i ns ert i ve part ner): 1 i n 1000 Unprot ect ed anal s ex (ri s k t o recept i ve part ner): 1 i n 1000 t o 1 i n 30 Oral s ex wi t h ejacul at i on: <1 i n 25 000.
Gi ven t he pot ent i al opport uni t i es for fut ure ri s k reduct i on and concerns regardi ng PEP effi cacy, HIV res i s t ance, and drug t oxi ci t y i n t hi s s et t i ng, i t i s recommended t hat t he deci s i on t o admi ni s t er PEP aft er s exual expos ure i s t aken i n conjunct i on wi t h cl i ni ci ans experi enced i n GUM/HIV medi ci ne. P.375
PEP
A ri s k as s es s ment s houl d be carri ed out fi rs t . If t he ri s k of i nfect i on i s cons i dered s i gni fi cant , PEP s houl d be commenced as earl y as pos s i bl e, i deal l y wi t hi n 1 hour and cert ai nl y wi t hi n 72 hours Mos t hos pi t al s recommend t he admi ni s t rat i on of t hree agent s :
Zi dovudi ne and l ami vudi ne (co-admi ni s t ered as combi vi r, 1 t abl et bd) A prot eas e i nhi bi t or (nel fi navi r 1250mg bd or i ndi navi r 800mg t ds )
Notes
The admi ni s t rat i on of PEP i s as s oci at ed wi t h s i gni fi cant s i de-effect s . The i ni t i al di s cus s i on and s ubs equent fol l ow-up s houl d be under t he s upervi s i on of a cl i ni ci an experi enced i n t he us e of t hes e agent s If t he donor i s known t o be HIV i nfect ed pos i t i ve, as k about t hei r ant i ret rovi ral t herapy hi s t ory, as t hi s may al t er t he choi ce of PEP agent s If t he reci pi ent i s pregnant or t aki ng medi cat i ons , be aware of t he s afet y of t hes e drugs i n
Pa g e 6 7 7
pregnancy and pot ent i al drugdrug i nt eract i ons
W here pos s i bl e, t he donor i n s uch an i njury s houl d be encouraged t o t es t for HIV t o al l ow t he di s cont i nuat i on of PEP where pos s i bl e. It i s permi s s i bl e t o t es t s uch a donor for HIV wi t hout cons ent i f t hey are deceas ed or uncons ci ous (and unexpect ed t o regai n cons ci ous nes s wi t hi n 48 hours ), t hough i n t he l at t er s i t uat i on t hi s s houl d be performed on a previ ous bl ood s peci men (s ee HIV t es t i ng, p342)
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> T able of Cont ent s > Chapt er 6 - Renal emergenc ies
Chapter 6
Renal emergencies
P.378
Acute renal failure (ARF) Presentation
El evat ed creat i ni ne (or urea) duri ng bi ochemi cal s creeni ng Det ect i on of ol i guri a by nurs i ng s t aff. Mal ai s e, confus i on, s ei zures , or coma Naus ea, anorexi a, or vomi t i ng Ol i guri a or abnormal uri ne col our Haemat uri a (pi nk rat her t han frank bl ood) Drug overdos e (e.g. paracet amol ) Cons t i t ut i onal s ympt oms (art hral gi a, rhi ni t i s , res pi rat ory s ympt oms ) Vas cul i t i c ras h Mul t i -organ fai l ure.
Occas i onal l y t he pat i ent may pres ent t o t he A&E depart ment wi t h

In t he majori t y of cas es , t hei r renal i mpai rment can be res ol ved by adequat e vol ume repl acement , t reat ment of s eps i s , and s t oppi ng nephrot oxi c drugs . There are many caus es of acut e renal i mpai rment , s ome of whi ch, s uch as mul t i -s ys t em vas cul i t i s or rhabdomyol ys i s , are i mport ant as t hei r earl y di agnos i s and t reat ment may have a profound effect on out come (s ee t abl e).
Pat i ent s wi t h acut e renal fai l ure have a hi gh mort al i t y (~50%). The fol l owi ng hi s t ory i s i mport ant .
Pa g e 6 7 9
Hi s t ory of fl ui d l os s (D&V, di uret i cs , bl eedi ng, fever). Di arrhoea may s ugges t haemol yt i c uraemi c s yndrome or hypovol aemi a. Hi s t ory of s eps i s (e.g. UTI, fever or hypot hermi a, bact eri al endocardi t i s . Sympt oms may be non-s peci fi c i n el derl y). Drug hi s t ory NSAIDs , ACE-I, ant i bi ot i cs i n part i cul ar ami nogl ycos i des and amphot eri ci n, drugs for HIV di s eas e. Non-s peci fi c s ympt oms (e.g. myal gi a, art hral gi a), neurol ogi cal s i gns , opht hal mi c compl i cat i ons , s i nus i t i s , and s ki n ras hes may s ugges t vas cul i t i s . Pas t hi s t ory of BP, DM, renovas cul ar di s eas e, pros t at i s m, or haemat uri a. Pat i ent s wi t h di abet es or myel oma have an i ncreas ed ri s k of cont ras t i nduced renal i mpai rment (avoi d dehydrat i on). Are t here s ympt oms or s i gns of l i ver di s eas e? Back ache may s ugges t pel vi -uret eri c obs t ruct i on. W hi l s t t hi s may affect a s i ngl e ki dney i ni t i al l y t he ot her ki dney i s l i kel y t o become i nvol ved. Cons i der aort i c aneurys m. Chol es t erol embol i (aneurys ms , abs ent pul s es , ras h). Pos t part um (HELLP s yndrome, HUS, fat t y l i ver, pre-ecl amps i a). Look for s i gns of fl ui d overl oad (dys pnoei c wi t h s i gns of pul monary oedema, hi gh JVP or CVP, peri pheral oedema, gal l op rhyt hm) or dehydrat i on (pos t ural hypot ens i on, t i s s ue t urgor).
Poor prognostic features include

Age >50 years Infect i on (es p. s ept i caemi a) Burns (>70% s urface area) Ri s i ng urea (>16mmol /24h) Ol i guri c for >2 weeks
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Mul t i -organ fai l ure (>3) Jaundi ce.
The mai n pri ori t y i s t o t ry t o prevent cardi ovas cul ar col l aps e and deat h, and t o s t abi l i ze for t rans fer t o a renal uni t . P.379
Assessment of patients with acute renal failure
Is t here l i fe-t hreat eni ng hyperkal aemi a or pul monary oedema? W hat i s t he l i kel y caus e? Is t he pat i ent s t i l l pas s i ng uri ne? Does i t l ook normal ? ECG Urgent U&Es + ABGs CXR Check pos t ural BP, HR As s es s vol ume s t at us , meas ure CVP Seps i s s creen Uri nal ys i s and mi cros copy for bl ood/cas t s Vas cul i t i s s creen Drug hi s t ory CPK/myogl obi n i n uri ne May have compl et e ces s at i on of uri ne (anuri a)
Pre-renal (75%)

Renal (20%)

Post renal (5%)
P.380
Acute renal failure: causes Causes of acute renal failure
Pa g e 6 8 1
Pre renal

Hypovol aemi a Hypotension, shock (p258) Renal art ery embol i Renal art ery s t enos i s + ACEI Hepat orenal s yndrome Renal vei n t hrombos i s Increas ed i nt ra-abdomi nal pres s ure HIV drugs (i ndi navi r) Int rat ubul ar (uri c aci d crys t al s ) Uret eri c St ones Ret roperi t oneal fi bros i s /t umour Uret hral Pros t at i c hypert rophy Vas cul i t i s (SLE, PAN) Glomerulonephritis Acut e t ubul ar necros i s Is chaemi a (e.g. hypot ens i on) Sept i caemi a Toxi ns (myogl obi n, BJ prot ei ns ) Drugs (e.g. gent ami ci n), cont ras t Prol onged pre-renal ol i guri a Mal ari a Thrombot i c mi croangi opat hy Accel erat ed hypert ens i on HUS/TTP (p704) Scl eroderma cri s i s Seps i s Int ers t i t i al nephri t i s Drugs (NSAIDs , ant i bi ot i cs ) Infect i ons ( St rep., St aph., Lept os pi ros i s , Bruc el l a , G -ve s eps i s , Legi onel l a ) Cal ci um, urat e, oxal at e overl oad
Post renal(obstructive)

Renal (parenchymal)

Pa g e 6 8 2
Tumour l ys i s s yndrome (p730)
Causes of immune-mediated ARF and vasculitis

Mi cros copi c pol yangi i t i s W egener's granul omat os i s ChurgSt raus s s yndrome Pol yart eri t i s nodos a SLE Rheumat oi d art hri t i s (and t reat ment ) Goodpas t ure's s yndrome Cryogl obul i naemi a HenochSchnl ei n purpura Acut e prol i ferat i ve gl omerul onephri t i s Acut e i nt ers t i t i al nephri t i s HIV Myel oma Lept os pi ros i s (i nt ers t i t i al nephri t i s ) or Hant a vi rus (pul monaryrenal s yndrome) Infect i ve endocardi t i s IgA nephropat hy (rarel y) Drugs (peni ci l l ami ne or amphet ami nes )
P.381
Urgent investigations for patients with ARF

U&Es FBC and bl ood fi l m Coagul at i on s t udi es (PT, APTT, TT, fi bri nogen, FDPs ) CPK, uri nary myogl obi n Hapt ogl obi n Bl ood cul t ures Uri ne MC&S Uri ne Na ECG
+
and os mol al i t y
Pa g e 6 8 3
CXR USS ki dneys (s i ze of ki dneys , obs t ruct i on) Cons i der ot her i nves t i gat i ons t o ai d i n di agnos i s (s ee p382)
P.382
Acute renal failure: investigations Blood tests

Ure a U& i s Es di s pro por tio nat el y rai s ed in pre -re nal ura em i a, GI bl e eds , cat ab
Pa g e 6 8 4
ol i c sta t es Aci
2+
da , ia rea s es i on ize d Ca
Ca em PO 4 i nc
3-
. An C ae a s ug ges ts chr oni c or acu te on chr oni c ren al fai l FB mi
2+
Pa g e 6 8 5
ure . pl a t el et s : liv er di s eas e, HE LLP , s ep sis . wi t h MC V, bl o od fi l m (H US, my el o ma , l eft s hi
Pa g e 6 8 6
ft ). Pl a t el et s : vas cul i tis (e. g. We ge ner 's ) eos i no phi l i a, Ch urg St r aus s s yn dro me , i nt ers titi al ne
Pa g e 6 8 7
phr itis Ab nor Co ma ag l i n ul a DI t i o C, n liv er di s eas e, SLE , HE LLP s yn dro me , HU S Acu s te pat itis , par ace ta mo l ove LFT he
Pa g e 6 8 8
rdo s e, ci rr hos is. Al k al i ne ph os p hat as e oft en in vas cul i tis Inc rea LD s ed H/ i n HB HU D S Ver K y h in rha bd om yol ys i CP hi g
Pa g e 6 8 9
s Sh oul Bl o d od be cul t ak t ur en es fro m al l pat i en ts wi t h AR F AN CA, Im ant mu i -G nol BM ogy , Igs , C3/ C4, Rh fac t or , AN A, EN A,
Pa g e 6 9 0
ds DN A, cry ogl ob ul i ns , ant i -c ard i ol i pi n an d ant i - 2-g l yc opr ot e i n1 ant i bo di e s (an tiph os p hol i pi d
Pa g e 6 9 1
s yn dro me ) CR P ES i s R/C oft RP en nor ma l, ES R hi g h in SLE For par Pro apr t ei ot e n p i ns yel om a, lig ht cha in di s eas e) Ser s t ri (m
Pa g e 6 9 2
ol o
HI gy V, req HB ui r s A ed g, for HC di a VA l ys i b s.
Urine
Ins pect t he uri ne yours el f. Cont act t he renal regi s t rar or mi crobi ol ogy t echni ci an on cal l t o arrange urgent mi cros copy. Save uri ne for cyt ol ogy i f haemat uri a i s t he domi nant s ympt om. Send a s peci men t o mi crobi ol ogy for mi cros copy and cul t ure. RBC c as t s s ugges t gl omerul onephri t i s (refer t o renal phys i ci an urgent l y), pi gment c as t s s ugges t myogl obi nuri a, WBC c as t s s ugges t acut e pyel onephri t i s . Exc es s eos i nophi l s i n t he uri ne are as s oci at ed wi t h i nt ers t i t i al nephri t i s . Save a s peci men for BenceJones prot ei n i f myel oma i s s us pect ed. Uri ne el ec t rol yt es and os mol al i t y: t hes e may hel p but do not repl ace careful cl i ni cal exami nat i on and are unrel i abl e when di uret i cs have been gi ven. They may be l es s rel i abl e i n t he el derl y when s ub-cl i ni cal renal i mpai rment may be pres ent . See t abl e.
P.383
Other investigations
Pa g e 6 9 3
Al l S pat ts wi t h AR F s ho ul d hav e an urg ent ul t r as o un d to exc l ud e obs t ru ct i on an d to as s es s ki d ney US i en
Pa g e 6 9 4
siz e (s ma ll in acu t eonchr oni c fai l ure ), an d bl o od fl o w on Do ppl er im agi ng. CX Loo R k at t he he art siz
Pa g e 6 9 5
e (di l at e d, per i ca rdi al eff us i on) , pul mo nar y vas cul at u re (pu lm on ary oe de ma , Ker l ey lin es ) , l un
Pa g e 6 9 6
g fi el ds ( fl uff y s ha do ws : oe de ma , ha em orr ha ge of Go od pas t ur e's or We gn er' s, i nf ect i on
Pa g e 6 9 7
). EC Loo G k for cha ng es of hyp erk al a em ia (t e nt e d Twa ves , QR S bro ad eni ng) an d sig ns of my oca rdi al
Pa g e 6 9 8
isc ha em ia or per i ca rdi t is.
Urinary electrolytes and osmolality in renal failure

Pr Re e-r nal en ( al AT N ) Uri <1 >4 ne 0 Na (m mo l /l ) Uri >4 <2 ne/ 0 s er um cre at i ni n e Uri >5 <3 0
+
Pa g e 6 9 9
ne 00 50 os mo l al i ty Uri >1. <1. ne/ 2 s er um os mo l al i ty NB: The t abl e above as s umes t hat t he pat i ent i s not t aki ng di uret i cs . P.384 2
Acute renal failure: management Hyperkalaemia

In general t erms t he abs ol ut e K concent rat i on i s l es s i mport ant t han t he effect on t he cardi ac conduct i ng t i s s ue (t ent ed T-waves , broad QRS, fl at t ened P-wave), but i f t he K
+ +
i s >7mmol /L t hen t reat

+
urgent l y. If t he hyperkal aemi a i s an unexpect ed i s ol at ed fi ndi ng, and t here are no ECG s i gns of hyperkal aemi a, t hen repeat K urgent l y. I f t here are ECG c hanges or K > 7mmol /L , cont act t he renal t eam and arrange for urgent di al ys i s i f appropri at e. W hi l e t hi s i s bei ng s et -up

+
Record 12-l ead ECG, at t ach t o cardi ac moni t or. Gi ve 10ml of 10% c al c i um gl uc onat e i v , repeat ed every 1020 mi nut es unt i l ECG normal i zes (pat i ent s may requi re up t o 50ml ). i v cal ci um does not l ower t he pot as s i um l evel but reduces cardi ac exci t abi l i t y.
Pa g e 7 0 0
Gi ve nebul i zed s al but amol (510mg) t o dri ve K i nt racel l ul arl y (us e l ower dos es i n pat i ent s wi t h i s chaemi c heart di s eas e).
50ml 50% dext ros e w i t h 10U ac t rapi d i ns ul i n over 1530 mi nut es (moni t or bl ood gl ucos e); t hi s s houl d l ower K for s everal hours .
+
50100ml 8.4% bi c arbonat e i v vi a c ent ral l i ne over 30 mi nut es (or 400ml 2.1% peri pheral l y): repres ent s a Na
+
l oad of 50100mmol .
250mg frus emi de or 5mg bumet ani de i v over 1 hour. Pol ys t yrene s ul phonat e res i n enema ( c al c i um res oni um ) 30g i ncreas es gut l os s es of pot as s i um. Fol l ow wi t h 15g po t ds wi t h regul ar l act ul os e. Thi s t akes 24 hours t o work. Moni t or s erum K frequent l y t o as s es s res pons e t o t reat ment .
+
Fluid balance

Manage on HDU or ITU Meas ure wei ght , BP (s upi ne and s i t t i ng or upri ght ), and pul s e rat e As s es s hydrat i on (cent ral s ki n t urgor, mucous membranes , and JVP) Ins ert cent ral venous l i ne and meas ure CVP. Moni t or PCW P i n pat i ent s who are hypoxi c or s everel y compromi s ed Exami ne fl ui d and wei ght chart s , and operat i on not es i f appl i cabl e.
If vol ume depl et ed
If t he pat i ent has a l ow or normal CVP pos t ural hypot ens i on gi ve a t ri al of vol ume expans i on (500ml of col l oi d or N s al i ne) over 30 mi nut es . Moni t or res pons e of uri ne out put and venous pres s ure. Cont i nue fl ui ds unt i l CVP i s 510cm at mi d-cl avi cul ar l i ne. W hen adequat el y fi l l ed (CVP >10 and/or PCW P >15) reas s es s uri ne out put . If ol i guri c or anuri c gi ve
Pa g e 7 0 1
frus emi de 120mg250mg IVI (max. 4mg/mi n), fol l owed by a frus emi de i nfus i on of 510mg/h. It i s much eas i er t o manage a pat i ent pas s i ng uri ne t han one who i s ol i go-anuri c.
If hypot ens i on pers i s t s (MAP <60mmHg) i n s pi t e of adequat e vol ume repl acement (i .e CVP of >10cm), commence i not ropi c s upport (s ee p263).
If fl ui d overl oaded
Cons i der urgent haemofi l t rat i on or di al ys i s . Cons i der venes ect i on i f t here i s a del ay for di al ys i s ; remove 250500ml . Gi ve oxygen t o mai nt ai n SaO 2 >95%. Cons i der CPAP (p904). P.385
St art i nt ravenous ni t rat es (e.g. GTN 210mg/h i v). Gi ve i v frus emi de: 120mg500mg, fol l owed by i nfus i on (510mg/h). Paracent es i s i f t ens e as ci t es i s pres ent (p926). Avoi d opi at es , al t hough a s i ngl e dos e (e.g. 2.5mg di amorphi ne i v) may hel p rel i eve anxi et y and t he s ens at i on of breat hl es s nes s .
Indications for dialysis

Pers i s t ent hyperkal aemi a (K >7mmol /L) Fl ui d overl oad (e.g. refract ory pul monary oedema) Peri cardi t i s (heral ds t he ri s k of t amponade, p178) Aci dos i s (art eri al pH <7.1, bi carbonat e <12mmol /L) Sympt omat i c uraemi a (t remor, cogni t i ve i mpai rment , coma, fi t s , urea t ypi cal l y >45mmol /L)
Pa g e 7 0 2
ECG changes i n hyperkal aemi a P.386
Acute renal failure: further management

Treat ment of l i fe-t hreat eni ng hyperkal aemi a, s evere fl ui d overl oad, or dehydrat i on t ake pri ori t y (p384).
Correct other abnormalities
Acidaemia. Cl as s i cal l y produces s i ghi ng res pi rat i ons (Kus s maul 's breat hi ng) and may wors en hypot ens i on (i mpai red cardi ac funct i on):
o
If pH i s <7.2 gi ve 100ml of 8.4% bi carbonat e vi a cent ral l i ne over 1530 mi nut es (or 400ml 2.1% bi carbonat e peri pheral l y) Arrange urgent di al ys i s Correct i on can caus e s ympt omat i c hypocal caemi a.
o o
Hyponatraemia. Us ual l y di l ut i onal (rel at i ve wat er exces s ). Management i s di s cus s ed on p594. Hyperphosphataemia. If t he product of [Ca ] [PO 4
32+
] i s >4.6 t he ri s k of met as t at i c preci pi t at i on i s

33-
hi gh. Ai m t o l ower PO 4 t o 0.61.4mmol /L. Gi ve oral PO 4 bi nders (e.g. cal ci um carbonat e 3001200mg q8h po). The PO 4
3-
us ual l y fal l s wi t h di al ys i s or
haemofi l t rat i on. A new agent , Seval emer, wi l l al s o
Pa g e 7 0 3
l ower PO 4 concent rat i ons (us e 806mg t ds ).
3-
Nutrition. There i s no rol e for prot ei n res t ri ct i on. Ins t i t ut e ent eral or parent eral feedi ng earl y. In pat i ent s wi t h di abet es , i ns ul i n requi rement s fal l wi t h renal i mpai rment . Sepsis. Common preci pi t ant /compl i cat i on of ARF. Cul t ure bl ood, uri ne, and s peci mens from ot her pot ent i al s i t es of i nfect i on. Treat wi t h appropri at e ant i bi ot i cs rememberi ng t o adjus t t he dai l y dos e i n vi ew of t he renal i mpai rment (s ept i c s hock i s covered on p270).
Further measures
The caus es of ARF are l i s t ed on p380. Mos t cas es are mul t i -fact ori al wi t h vol ume depl et i on or hypot ens i on, s eps i s , and drugs (e.g. i njudi ci ous us e of ACE-I and NSAIDs ), uri nary t ract obs t ruct i on and/or pre-exi s t i ng chroni c renal di s eas e. It i s es s ent i al t o i dent i fy t reat abl e condi t i ons . In pract i cal t erms i t i s probabl y mos t s i mpl i s t i c t o di vi de pat i ent s i nt o t hos e wi t h pre-renal , renal , and pos t -renal acut e renal fai l ure us i ng c l i ni c al as s es s ment , fi l l i ng pres s ures (CVP, PCW P), and USS. W hi l s t s eps i s i s i ncl uded as a renal caus e, much of t he earl y del et eri ous effect s (i .e. hypot ens i on) are pot ent i al l y revers i bl e wi t h appropri at e management . The pri nci pl es of furt her management are as fol l ows .
Opt i mi ze fl ui d bal anc e : t here i s no s ubs t i t ut e for pai ns t aki ng phys i cal exami nat i on. Careful fl ui d bal ance chart s and dai l y wei ght s gui de repl acement . Li mi t fl ui d i nt ake t o t ot al fl ui d out put pl us 500ml /day. The bes t s i gn of i nt ravas cul ar vol ume depl et i on i s pos t ural drop i n BP. I nt ri ns i c renal di s eas e : ol i guri a i s revers ed by res t orat i on of ci rcul at i ng vol ume or bl ood pres s ure, but t akes up t o 8 hours t o res pond ful l y. It i s i mport ant t hat fl ui d bal ance i s opt i mi zed (CVP of 510cm, MAP of >75mmHg). If di uret i cs fai l t o i mprove uri ne out put ,
Pa g e 7 0 4
ATN i s l i kel y t o be es t abl i s hed, and t he pat i ent wi l l requi re renal s upport . P.387
Pat i ent s wi t h s evere port al hypert ens i on and as ci t es may have marked ol i guri a (~250ml uri ne per day), and mai nt ai n a normal creat i ni ne. Thei r uri ne i s very concent rat ed and vi rt ual l y devoi d of s odi um. They are us ual l y res i s t ant t o di uret i cs , but may res pond t rans i ent l y t o vol ume expans i on. Beware of preci pi t at i ng el ect rol yt e or renal dys funct i on by over-di ures i s .
P.388
Anuria
Anuri a i mpl i es t hat t here i s no uri ne out put .
Causes
Obs t ruct ed uri nary t ract (bi l at eral uret eri c or bl adder out fl ow) Renal i nfarct i on (e.g. prol onged hypot ens i on i n pat i ent s wi t h at heros cl erot i c s t enos i s of renal art eri es ) Acut e renal fai l ure (p378).
Assessment
As s es s as for ARF. However, al s o
As k s peci fi cal l y about s ympt oms of pros t at i s m, or haemat uri a (t umour) and back ache (s t ones , aneurys m) Drug hi s t ory (ACE i nhi bi t ors ) as a pos s i bl e caus e of renal i nfarct i on, recent ant i bi ot i cs , NSAIDs (i nt ers t i t i al nephri t i s ) Recent renal angi ography or angi opl as t y (renal i nfarct i on, cont ras t nephropat hy) Cons t i t ut i onal s ympt oms s ugges t i ve of
Pa g e 7 0 5
gl omerul onephri t i s
Has t he pat i ent previ ous l y l os t a ki dney?
Management
(s ee acut e renal fai l ure, p384) If pat i ent i s anuri c
Exami ne for pal pabl e bl adder, enl arged pros t at e, or ot her pel vi c mas s es . Ins ert uri nary cat het er t o excl ude ret ent i on If t he bl adder i s empt y, an urgent ul t ras ound i s needed t o excl ude bi l at eral obs t ruct i on (or obs t ruct i on of s ol i t ary funct i oni ng s ys t em). Treat bi l at eral hydronephros i s wi t h nephros t omi es . Ant egrade i magi ng can det ermi ne t he l evel of obs t ruct i on If t he USS i s negat i ve arrange a CT s can of t he abdomen If obs t ruct i on i s abs ent (one cannot excl ude acut e obs t ruct i on on USS) an i s ot ope renogram wi l l det ermi ne whet her t here i s renal perfus i on. If t here i s renal perfus i on, t hen a ret rograde uret erogram wi l l det ermi ne whet her t here i s obs t ruct i on. Abs ent renal perfus i on s ugges t s renal i nfarct i on.
P.389
P.390
Interstitial nephritis
Thi s i s caus ed by i nfl ammat ory cel l i nfi l t rat i on of t he renal parenchyma, us ual l y i nduced by drugs (NSAIDs , peni ci l l i n, cephal os pori ns , s ul phonami des , al l opuri nol , ri fampi ci n, mes al azi ne, i nt erferon), s ome i nfect i ons (e.g. Legi onel l a, Lept os pi ros i s , vi ral ), granul omat ous i nt ers t i t i al nephri t i s (e.g. s arcoi dos i s ). Ot her caus es i ncl ude DM, s i ckl e cel l di s eas e, refl ux nephropat hy, renal t rans pl ant reject i on.
Pa g e 7 0 6
Presentation. Acut e renal fai l ure, fever, eos i nophi l i a, and uri nary eos i nophi l s . Preci pi t at i ng caus e us ual l y precedes renal i mpai rment by a few days t o 2 weeks (very vari abl e). Diagnosis. Renal bi ops y. T reatment . St op offendi ng drug. The us e of s t eroi ds i n t hi s s et t i ng remai ns cont rovers i al .
Indications for renal biopsy

Caus e i s unknown Heavy prot ei nuri a (>2g/day) Feat ures of s ys t emi c di s eas e Act i ve uri nary s edi ment Immune medi at ed ARF Prol onged renal fai l ure (>2 weeks ) Sus pect ed i nt ers t i t i al nephri t i s (drug i nduced)
P.391
P.392
Rhabdomyolysis
Thi s i s t he devel opment of ARF s econdary t o ext ens i ve mus cl e damage and rel eas e of myogl obi n. Approx. 7% of al l cas es of ARF.
Presentation
Mos t cas es occur fol l owi ng mus cl e t rauma (e.g. crus h s yndrome) or s evere phys i cal exert i on [e.g. marat hon runni ng or mi l i t ary t rai ni ng (s quat jump s yndrome)]. Prol onged i mmobi l i t y (e.g. aft er drug overdos e and coma) may res ul t i n pres s ure necros i s of t he mus cl es . Sympt oms i ncl ude s wol l en t ender mus cl es , di rt y red-brown uri ne (l i ke Coca-Col a mi xed wi t h uri ne) and/or ol i guri a. Mal i gnant hypert hermi a or mal i gnant neurol ept i c
Pa g e 7 0 7
s yndrome.
Myogl obi n i s pres ent i n mus cl e as ferrous myogl obi n (Fe

2+
), and myogl obi n i s depos i t ed i n t he ki dney as ferri c

3+
myogl obi n (Fe ). Furt her oxi dat i on of myogl obi n by hydroperoxi des generat es a pot ent oxi di zi ng s peci es ferryl -myogl obi n (Fe ) t hat caus es renal i njury. Al kal i ni zat i on works by s t abi l i zi ng t he ferryl -myogl obi n and maki ng i t l es s react i ve.
4+
Investigations
Typ i cal U& l y Es K , cre at i ni n e : ure a rat i o
2+ +
,
3-
Ca PO 4 , PO 4 i ni t
3-
i al Ca
2+
(as
Pa g e 7 0 8
it ent ers da ma ge d mu s cl e) fol l ow ed by re bo un d Ca

2+
Us ual Ura l y t e wi t h tis s ue nec ros is,
Pa g e 7 0 9
al s o exc ret i on AS s T y hi g h: fro m s ke l et al mu s cl e Ver K y h (up to 1 mi l lio n u/L ) Me t ab AB ol i c CP hi g LFT ver
Pa g e 7 1 0
aci dos is, hyp oxi c if her e is as s oci at e d acu te l un g i nj ury (t r au ma ) or i nf ect
i on Th e Uri uri ne ne l oo ks red -br
Pa g e 7 1 1
ow n. Uri nal ys i s is pos itiv e for bl o od (m yog l ob in t es ts pos itiv e), but no RB C s ee n on mi c ros cop y. Uri
Pa g e 7 1 2
nar y my ogl obi n is di a gn os t ic aC, c. gl u e, bl o od cul t ur es , ES R, CR P, s er um for t ox i col ogy vi r ol o gy, pl a Mi s cos
Pa g e 7 1 3
sm a my ogl obi n, EC G. Ser um l oo ks cl e ar (cf. ha em ol y sis ) as my ogl obi n do es not bi n d ha pt o gl o bi n
Pa g e 7 1 4
s an d is rap i dl y cl e are d by ki d ney s.
Management
Pat i ent s are oft en febri l e, dehydrat ed, and unwel l . The pri ori t i es are

Hyperkal aemi a needs urgent t reat ment (s ee p384) Rehydrat i on: i n el derl y pat i ent s or i f t he pat i ent i s ol i guri c, i ns ert a cent ral l i ne and be gui ded by CVP. W at ch for fl ui d overl oad Al kal i ne di ures i s (s ee p834): al kal i ni zat i on s t abi l i zes t he oxi di zi ng form of myogl obi n. It i s us ual l y effect i ve wi t hi n t he fi rs t 8 hours . Tes t uri ne regul arl y wi t h pH s t ri ps t o moni t or t reat ment Anal ges i a: avoi d NSAIDs : us e opi at e anal ges i a i f requi red Avoi d frus emi de: t hi s may preci pi t at e myogl obi n i n t he renal t ubul es Refer for a s urgi cal opi ni on. Fas ci ot omi es or debri dement of necrot i c t i s s ue may be needed for compart ment s yndrome P.393
Pa g e 7 1 5
Avoi d Ca
2+
i nfus i on t o t reat hypocal caemi a: i t may

2+
caus e met as t at i c cal ci fi cat i on i n damaged mus cl e and caus e furt her t i s s ue necros i s . However, i v Ca Treat t he underl yi ng caus e (s ee t abl e) Di al ys i s or haemofi l t rat i on may be neces s ary for t he s hort t erm but ful l recovery of renal funct i on i s l i kel y. is i ndi cat ed for pat i ent s wi t h s evere hyperkal aemi a

Causes of rhabdomyolysis

Crus h i njury Severe exert i on, heat s t roke Prol onged convul s i ons Prol onged i mmobi l i t y Pol ymyos i t i s or vi ral myos i t i s Mal i gnant hyperpyrexi a (p606) Acut e al cohol i c bi nge McArdl e's s yndrome Hypokal aemi a CO poi s oni ng (p802) Burns Di abet i cs ket oaci dos i s (p556) Ecs t as y abus e (p810) Snakebi t e (p864) El ect ri c s hock (p854) Neurol ept i c mal i gnant s yndrome
P.394
Hepatorenal syndrome
Thi s i s defi ned as t he ons et of renal fai l ure i n pat i ent s wi t h s evere l i ver di s eas e i n t he abs ence of renal pat hol ogy. It may occur i n ei t her ci rrhos i s or acut e l i ver fai l ure. It may be charact eri zed by a l ow uri ne s odi um (<10mM), but t hi s i s not a cri t eri on i n t he di agnos i s .
Pa g e 7 1 6
Presentation
Renal fai l ure i s mos t commonl y found as i nci dent al fi ndi ng duri ng bi ochemi cal s creeni ng of pat i ent s wi t h as ci t es (ci rrhos i s ), acut e l i ver fai l ure, or jaundi ce (mos t common i n al cohol i c hepat i t i s ). Preci pi t ant s of hepat orenal s yndrome i n pat i ent s wi t h advanced l i ver di s eas e i ncl ude i njudi ci ous di uret i c us e, paracent es i s , port o-s ys t emi c s hunt s urgery, and cont ras t radi ography (es p. bi l i ary).
There are many caus es of renal fai l ure and l i ver di s eas e whi ch are not s ynonymous wi t h hepat orenal s yndrome. Thes e i ncl ude
Hypovol aemi a: caus ed by bl eedi ng, over-di ures i s , or pos t paracent es i s ci rcul at ory dys funct i on Seps i s Nephrot oxi c drugs gi ven t o pat i ent s wi t h l i ver di s eas e (e.g. gent ami ci n) Chroni c vi ral hepat i t i s (HBV or HCV) caus i ng gl omerul onephri t i s Lept os pi ros i s (marked hyperbi l i rubi naemi a, ot her l i ver enz ymes vi rt ual l y normal ) Paracet amol overdos e.
Investigations
See acut e renal fai l ure, p382.
Management
Excl ude ot her caus es of renal fai l ure i n l i ver di s eas e (s ee above). Ins ert a uri nary cat het er and moni t or uri ne out put . Vol ume chal l enge (500ml Haemaccel fol l owed by 1L N s al i ne over 2 hours . St op al l di uret i cs . Broad-s pect rum ant i bi ot i cs (e.g. cefot axi me + met roni dazol e, or ci profl oxaci n + amoxyci l l i n). If mean art eri al pres s ure [di as t ol i c pres s ure + (s ys t ol i c - di as t ol i c pres s ure) 3] i s <75mmHg admi ni s t er a vas opres s or agent aft er vol ume expans i on. The mos t
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appropri at e agent i s gl ypres s i n at 0.51mg i v bol us every 46 hours , or noradrenal i ne (110g/mi n). Mi dodri ne t oget her wi t h oct reot i de has al s o been us ed.
N-acet yl cys t ei ne 100mg/kg bd by i v i nfus i on may i mprove renal funct i on i f al l el s e fai l s . Cont rol l ed t ri al s are needed. If t here i s t ens e as ci t es , a t ot al paracent es i s wi l l decreas e t he renal venous pres s ure and enhance renal bl ood fl ow (s ee p926). Haemofi l t rat i on or di al ys i s : pat i ent s t ol erat e haemofi l t rat i on bet t er t han haemodi al ys i s . There i s no val ue i n di al ys i ng a pat i ent wi t h end-s t age ci rrhos i s and renal fai l ure unl es s t he pat i ent i s goi ng t o have a l i ver t rans pl ant . It i s , however, reas onabl e t o di al ys e a pat i ent wi t h a revers i bl e caus e of l i ver fai l ure (i .e. acut e l i ver fai l ure or acut e al cohol i c hepat i t i s ). Hyperkal aemi a and aci dos i s are rarel y a probl em. Al l pat i ent s s houl d be di s cus s ed wi t h a l i ver t rans pl ant cent re. Hepat orenal s yndrome can be revers ed by l i ver t rans pl ant at i on, but t he prognos i s from l i ver t rans pl ant at i on i s wors e i n t hi s group.
P.395
P.396
Acute upper urinary tract infections

Infect i on of t he upper uri nary t ract may res ul t i n acut e pyel onephri t i s , renal abs ces s , pyonephros i s , or peri nephri c abs ces s (s ee fi gure). Infect i on wi t h obs t ruct i on caus es rapi d t i s s ue des t ruct i on unl es s t he obs t ruct i on i s rel i eved.
Predisposing factors
Ei t her an as cendi ng i nfect i on or haemat ogenous s pread. Organi s ms : E. c ol i 60%, Prot eus 20%, S. faec al i s 10%, Kl ebs i el l a
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5%.

Femal e (s hort uret hra) Renal s t ones Bl adder cat het er Chroni c l i ver di s eas e St ruct ural abnormal i t y of renal t ract Pregnancy Di abet es mel l i t us Int ravenous drug abus e Infect i ve endocardi t i s
Presentation

Cl as s i cal s ympt oms are l oi n pai n, fever, and ri gors . Non-s peci fi c s ympt oms may predomi nat e: e.g. naus ea, vomi t i ng, anorexi a, mal ai s e, confus i on, or weaknes s . Up t o 75% have precedi ng l ower uri nary t ract s ympt oms (frequency, dys uri a). There may be as s oci at ed haemat uri a. Severe, bi l at eral pyel onephri t i s or acut e-on-chroni c pyel onephri t i s may res ul t i n acut e renal fai l ure. A precedi ng hi s t ory of i nt ermi t t ent l oi n pai n may i mpl y i nt ermi t t ent obs t ruct i on wi t h pyonephros i s . Renal parenchymal abs ces s es are s een wi t h i v drug us e, endocardi t i s , or s ki n i nfect i ons . As k s peci fi cal l y about any predi s pos i ng fact ors (s ee above). Si gns i ncl ude fever, abdomi nal or l oi n t endernes s , a pal pabl e mas s i n t he l oi n, and wi t h s evere i nfect i on, s col i os i s concave t owards t he affect ed s i de, hypot ens i on, and s hock (s ept i caemi a). The s ympt oms and s i gns may be di ffi cul t t o di s t i ngui s h from pneumoni a (pl euri t i c pai n and s hal l ow breat hi ng on affect ed s i de) or ot her caus es of an acut e abdomen (e.g. chol ecys t i t i s , di vert i cul i t i s ).
Investigations
Uri nal ys i s commonl y s hows bl ood and prot ei n. Uri ne
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ni t ri t e i s oft en pos i t i ve. W hi t e cel l s , bact eri a, W BC cas t s may be s een on mi cros copy. Cul t ure may be negat i ve i n i nfect i ons confi ned t o t he renal cort ex.
Al l pat i ent s s houl d have U&Es (for renal dys funct i ondehydrat i on, acut e-on-chroni c fai l ure), gl c, FBC (anaemi a, l eukocyt os i s ) and bl ood cul t ures . AXR: s t ones , s oft t i s s ue mas s , or l os s of ps oas l i ne on affect ed s i de. USS t o excl ude obs t ruct i on and del i neat e renal and peri -renal col l ect i ons . Arrange CT i f s urgery i s pl anned.
Management
St abi l i ze t he pat i ent : res us ci t at e s everel y i l l pat i ent s wi t h i v fl ui ds i not ropes , gui ded by CVP and BP. Gi ve i v ant i bi ot i cs , e.g. cefuroxi me 750mg t ds and modi fy t reat ment i n l i ght of res ul t s of cul t ures . Cont i nue ant i bi ot i cs for t ot al 714 days . P.397
Fl ui d bal ance: mai nt ai n hi gh fl ui d i nt ake (e.g. 3L/24h). Moni t or fl ui d bal ance and uri ne out put careful l y for t he fi rs t 4872 hours . Anal ges i a: t ry NSAID i f renal funct i on i s normal .(e.g. di cl ofenac s odi um 75mg i m). Al t ernat i vel y t ry i m pet hi di ne 5075mg q3h prn. Pyonephros i s , renal or peri nephri c abs ces s : requi res urgent advi ce: cont act t he urol ogi s t s . Remember t o s ave a s ampl e for MC&S. Inves t i gat e for any underl yi ng caus e: IVU, DMSA, and DTPA s cans wi l l det ermi ne anat omy, ext ent of renal damage, and remai ni ng funct i on.
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Pat t erns of renal i nfect i ons P.398
Renal colic and renal stones

Spas modi c pai n radi at i ng from l oi n t o groi n us ual l y due t o s t ones or bl ood cl ot s . ~23% of popul at i on have a s t one i n t he upper uri nary t ract .
Presentation
Pai n: t he s i t e of t he pai n may vary, s t ones i n t he renal pel vi s caus e dul l l oi n ache, uret eri c s t ones produce s evere col i cky pai n oft en of s udden ons et radi at i ng from l oi n t o groi n, bl adder s t ones caus e s uprapubi c and peri neal or t es t i cul ar ache and s t rangury. Haemat uri a (oft en frank) may be t he onl y feat ure. W i t h s evere pai n t he pat i ent wi l l be res t l es s , s weat y, pal e, naus eat ed, and very di s t res s ed. Try t o obt ai n a hi s t ory of previ ous epi s odes , UTIs , fl ui d i nt ake, occupat i on, peri ods of res i dence i n hot cl i mat es , s ympt oms of hypercal caemi a, or fami l y hi s t ory of s t one di s eas e.
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On exami nat i on not e any fever, abdomi nal t endernes s (es peci al l y l oi n or s ubcos t al ), pal pabl e ki dneys . Do not mi s s a l eaki ng abdomi nal aort i c aneurys m t hat may be produci ng s i mi l ar s ympt oms .
Investigations
Acut el y, t he t es t s requi red are
Bl oods : U&Es (for renal dys funct i on) and gl ucos e, FBC (for Hb, W CC) Uri ne: di ps t i ck uri nal ys i s for bl ood and formal mi cros copy for crys t al s , pyuri a, and bact eri a. Cul t ure for i nfect i on AXR: t he pl ai n AXR fi l m wi l l det ect >90% of s t ones CT s can or USS wi l l s how obs t ruct i on.
Ot her i nves t i gat i ons t o det ermi ne t he underl yi ng caus e of t he renal col i c (s t one format i on, papi l l ary necros i s , or cl ot ) can us ual l y be performed once t he acut e epi s ode has been deal t wi t h. Tes t s t o cons i der i ncl ude s erum Ca
2+
and urat e (s ee p580 for i nves t i gat i on of

2+
hypercal caemi a) and 24-hour uri ne for Ca , phos phat e, oxal at e, urat e t o det ect a s t one-formi ng met abol i c defect .
Management of acute renal colic
Anal ges i a: di cl ofenac s odi um 75mg i m repeat ed aft er 30 mi nut es . If needed pet hi di ne 50100mg i m q4h prn wi t h an ant i emet i c. Hi gh fl ui d i nt ake. Beware of i nfect i on above t he s t one and pyonephros i s (p397). If t here i s fever, bact uri a, or obs t ruct i on t reat empi ri cal l y unt i l cul t ure res ul t s are known (e.g. cefuroxi me 750mg i v t ds ) and decompres s any obs t ruct i on. Large-s i zed s t ones wi t h i nfect i on or obs t ruct i on requi re urol ogi cal management s uch as uret eros copi c ext ract i on or ext racorporeal s hock wave l i t hot ri ps y, or s urgery.
Prognosis
~60% of al l s t ones wi l l pas s (hal f of t hes e wi t hi n 48 hours ). ~30%
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wi l l requi re s urgi cal removal . The ri s k of s t one recurrence may be reduced by di et ary advi ce (e.g. avoi d hi gh-oxal at e foods s uch as rhubarb, s pi nach), a hi gh fl ui d i nt ake, cont rol l i ng hypercal ci uri a (l ow-cal ci um di et , t hi azi de di uret i cs , bran), t reat i ng t he caus e i f hypercal caemi c (p580), uri nary al kal i ni zat i on (hyperuri caemi a, renal t ubul ar aci dos i s , cys t i nuri a), uri nary aci di fi cat i on t o pH <5.5 ureas e i nhi bi t ors (s t ruvi t e s t ones ), al l opuri nol (urat e s t ones ) or d-peni ci l l ami ne (cys t i ne s t ones ). P.399
Causes of renal colic Renal stones

Us ual l y di vi ded i nt o Radi o-opaque (90%) : cont ai n Ca
2+ 2+
or Mg , e.g.
cal ci um oxal at e (hypercal ci uri a, hypercal caemi a, dehydrat i on, renal t ubul ar aci dos i s , medul l ary s ponge ki dney, hyperoxal uri a), cal ci um phos phat e (as before and UTIs ), magnes i um ammoni um phos phat e (UTIs wi t h ureas e-pos i t i ve organi s ms , e.g. Prot eus ). Cys t i ne s t ones are s emi -opaque due t o t hei r s ul phur cont ent Luc ent : (Urat e or xant hi ne or rarel y 2,8 di hydroxyadeni ne)
Indinavir crystal deposition (HIV drug) Renal papillary necrosis

DM, s i ckl e cel l di s eas e, anal ges i c nephropat hy. Pai n occurs when a papi l l a s l oughs i nt o t he uret er
Blood clots
Due t o t rauma, t umour (parenchymal or urot hel i al ), bl eedi ng di at hes i s , or pol ycys t i c ki dney di s eas e P.400
Haematuria History
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As k s peci fi cal l y about
Severi t y of haemat uri a: pi nk uri ne, frank bl ood, or cl ot s ? The t i mi ng of haemat uri a: bl eedi ng occurs at s t art or end of mi ct uri t i on s ugges t s bl adder neck, pros t at e, or uret hral s ource. Bl ood mi xed wi t h t he s t ream s ugges t s a s ource hi gher i n t he uri nary t ract . Hi s t ory of t rauma: even s eemi ngl y mi nor t rauma can caus e bl eedi ng from congeni t al l es i ons of t he uri nary t ract . Uni l at eral l oi n pai n: cons i der cal cul i , t umour, cys t i c di s eas e, or hydronephros i s . Pai nl es s haemat uri a s ugges t s neopl as m. Di s t urbance of mi ct uri t i on: frequency, urgency, dys uri a, hes i t ancy, poor s t ream, and dri bbl i ng s ugges t cys t i t i s . Bl eedi ng and pai n at t he end of t he s t ream i s t ypi cal of a bl adder s t one. Cons t i t ut i onal s ympt oms : s ore t hroat s , art hral gi a, mal ai s e, and ras h may i ndi cat e gl omerul onephri t i s . AF i s as s oci at ed wi t h renal embol i . Fever, dys uri a, or abdomi nal pai n may i ndi cat e i nfect i on. Brui s i ng or ot her bl eedi ng may i ndi cat e a bl eedi ng di at hes i s .
Physical examination
General examination. Hypert ens i on (chroni c or acut e renal di s eas e i ncl . pol ycys t i c di s eas e), i rregul ar pul s e or heart murmurs (s ource of embol i ), anaemi a, brui s i ng or purpura, oedema or pl eural effus i ons . Urinary tract examination. Loi n or abdomi nal t endernes s , renal mas s , pel vi c mas s , pros t at e enl argement , t es t es . Ins pect t he uri ne.
Investigations
Pos itiv
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Uri e nal res ys i ul t s s ee n wi t h my ogl obi nur ia (p3 92) an d ha em ogl obi nur i a. Pro t ei nur ia s ug ges ts ren al pat hol ogy
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RB C Mi c cas ros t s cop or y dys mo rph ic red cel l s s ug ges t gl o me rul ar ori gi n . WB C cas ts s ug ges t pye l on ep hri t is.
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Ot her fi n di n gs i ncl ud e cry sta ls (s t on e di s eas e), ova (s c hi s t os om i as i s ), an d ma lig na nt cel l s Thr om FB boc
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yt o pe ni a an ae mi a (ha em ol y sis , l eu ke mi a), l eu koc yt o sis ma y i nd i ca te i nf ect
i on For ren U& al Es fun ct i on For
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coa
Cl o gul t t i op ng at h y If S pos t ra um at i c or s ev ere If gl o AS me OT, rul C on ep hri t is is s us pec t ed . Co ns i der me as u ri n g G& t
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aut oa nt i bo di e s. Ref er to ren al t ea m Ma y Ul t di a ras gn ou os e nd pol ycy sti c di s eas e, ure t eri c obs t ru ct i on by sto ne
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or tu mo ur, or gro ss ren al ab nor ma liti es Ma y CT de Sca mo n ns t rat e sto nes , hyd ron ep hro sis , ren al i nj ury or
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tu mo ur, cys tic di s eas e, or uro t he l i al tu mo ur To exc Cys l ud t os e cop ot h y er cau s es of bl e edi ng fro m t he l ow er uri nar y
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t ra ct .
P.401
Management
Admi t pat i ent s wi t h

o o
Pos t -t raumat i c haemat uri a (refer t o urol ogy) Severe unexpl ai ned haemat uri a (i ncl . bl eedi ng di at hes i s ) es p. i f t here i s cl ot ret ent i on. Ins ert a l arge (22G) t ri pl e l umen uri nary cat het er for cont i nuous bl adder i rri gat i on t o was h out cl ot s Haemat uri a and renal i mpai rment (?gl omerul onephri t i s ). Arrange for urgent renal referral and bi ops y Severe i nfect i on, e.g. pyel onephri t i s . Commence ant i bi ot i cs (e.g. cefuroxi me gent ami ci n) aft er t aki ng appropri at e cul t ures .
Pai n rel i ef (pet hi di ne 2550mg i v wi t h an ant i -emet i c). Pro-Bant hi ne (propant hel i ne bromi de) 15mg t ds po rel i eves pai nful bl adder s pas m of haemorrhagi c cys t i t i s and cl ot ret ent i on (may caus e uri nary ret ent i on). Correct any bl eedi ng di at hes i s (FFP Vi t K for warfari n).
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Causes of haematuria
Tra Bl u um nt a an d pe net rat i ng i nj uri es , i at r og eni c (e. g. rec ent TU RP, TU RB T, or ren al bi o ps y ), s ev ere exe
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rci s e ( j og ger s ha em at u ri a ), for ei g n bo dy St o Re nes nal , ure t eri c, or bl a dd er Inf Pye ect l on i on ep s hri t is, ha em
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orr ha gi c cys titi s, acu te pro sta titi s: bac t eri al , TB, or par as i tic (e. g. s ch ist os o mi as i s) Tu Uro mo t he urs l i al , ren al par
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enc hy ma l, pro sta tic Bl e Ha edi em ng op di a hi l i t he a, s es t hr om boc yt o pe ni a Re Gl o nal me pat rul hol on ogy ep hri t is, ren al art eri al em bol i, ren al
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vei n t hr om bos is Dru Ant gs i -c oa gul ant s, cyc l op hos ph am i de , d-p eni ci l l am i ne Co Pol ng ycy eni s t i t al c di s eas e, sic kl e cel l di s
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eas e (pa pi l l ary nec ros i s ), Al p ort ' s s yn dro me , hyd ron ep hro sis . NB: Di s col oured uri ne may al s o be due t o beet root , porphyri a, ri fampi ci n, co-dant hramer, and veget abl e dyes . P.402
Renovascular disease
Renal art ery s t enos i s may be at heros cl erot i c (common i n t he el derl y and di abet i cs ) or fi bromus cul ar hyperpl as i a (general l y younger pat i ent wi t hout vas cul ar di s eas e el s ewhere). It s houl d be cons i dered i n al l pat i ent s wi t h

Fl as h pul monary oedema (s udden unexpect ed ons et ) Peri pheral vas cul ar di s eas e, aort i c di s s ect i on, t ype 2 di abet es
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Unequal ki dneys on USS Impai red renal funct i on i n cont ext of ACE i nhi bi t or us e Hypert ens i on/coronary or carot i d art ery di s eas e Compl et e anuri a i n a pat i ent who has previ ous l y l os t a ki dney.
Investigations
Ul t ras ound s can: t o l ook as renal s i ze and Doppl er fl ow t hrough t he renal art eri es . Is ot ope renogram: Done before and aft er gi vi ng an ACE i nhi bi t or (capt opri l ); GFR fal l s on t he s i de wi t h t he s t enos i s . MRA i s t aki ng over from angi ography as t he gol d s t andard i nves t i gat i on i n s ome hos pi t al s : be gui ded by your l ocal radi ol ogi s t s . Ens ure t he pat i ent i s wel l hydrat ed pre, and mai nt ai ns a good fl ui d i nt ake pos t procedure. Di gi t al s ubt ract i on angi ography i s s omet i mes us ed.
Management
Opt i mi ze fl ui d s t at us (s ee p384). There i s oft en a fi ne bal ance bet ween pul monary oedema and pre-renal uraemi a. Avoi d ACE i nhi bi t ors and NSAIDs . Refer t o a dedi cat ed t eam of i nt ervent i onal radi ol ogi s t s and vas cul ar s urgeons . General l y s peaki ng i f t he ki dney i s >8cm t hen s al vage may be pos s i bl e. If t he ki dney i s s mal l (<8cm), t hen i nt ervent i on i s probabl y hazardous and wi t hout benefi t . Treat ment may be by angi opl as t y, s t ent i ng, or bypas s s urgery. Remember BP cont rol and t reat ment of ot her ri s k fact ors ; t he majori t y of pat i ent s wi t h at heromat ous renovas cul ar di s eas e di e from t hei r as s oci at ed i s chaemi c heart di s eas e.
P.403
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P.404
Cholesterol embolism
Mos t commonl y s een i n art eri opat hs aft er mani pul at i on of vas cul at ure (e.g. angi ography) and i s fol l owed by acut e renal fai l ure. Us ual l y s i l ent . There i s part i al occl us i on of s mal l - and medi um-s i zed art eri es res ul t i ng i n i s chaemi c at rophy. More fl ori d pres ent at i on i ncl udes wi des pread purpura, dus ky and cyanot i c peri pheri es wi t h i nt act pedal pul s es , GI bl eedi ng, myal gi a, and acut e renal fai l ure. It can be s pont aneous or fol l ow t herapy wi t h hepari n or warfari n. Diagnosis. Eos i nophi l i a, renal i mpai rment , hypocompl ement aemi a, ESR, ANCA negat i ve. Uri nary s edi ment i s us ual l y beni gn; mi l d prot ei nuri a may be s een. Renal bi ops y s hows chol es t erol cl eft s . Management. The renal i mpai rment i s us ual l y i rrevers i bl e or onl y part i al l y revers i bl e (i n cont ras t t o ATN). Ant i -coagul at i on i s cont rai ndi cat ed. Treat ment i s s upport i ve.
Contrast nephropathy
Thi s i s acut e i mpai rment of renal funct i on, whi ch fol l ows expos ure t o radi o-cont ras t mat eri al s . Inci dence i n an uns el ect ed popul at i on i s 27% but t hi s i ncreas es t o 25% i f renal funct i on i s al ready i mpai red. It res ul t s from a combi nat i on of afferent art eri ol ar vas ocons t ri ct i on, i nt erference wi t h t ubul o-gl omerul ar feedback, t ubul ar hypoxi a, and di rect nephrot oxi ci t y of t he cont ras t agent . Remember MRI s cans do not empl oy t oxi c cont ras t agent s .
Risk factors
Pre-exi s t i ng renal di s eas e (i nci dence up t o 60% i f Cr >400M) Renovas cul ar di s eas e Prot ei nuri a (i ncreas es ri s k 3 fol d) DM (ri s k depends on renal funct i on; i nci dence of ARF ~100% i f Cr >400M) Conges t i ve cardi ac fai l ure (i nci dence 78%)
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Mul t i pl e myel oma Pancreat i t i s Mul t i pl e cont ras t s t udi es Dehydrat i on Jaundi ce.
Management
There i s no s peci fi c t reat ment . Prevent i on i s t he bes t pol i cy.

Moni t or U&Es , creat i ni ne. Try t o ens ure good hydrat i on pre procedure (gi ve pat i ent s who are at ri s k i v fl ui ds i f t hey are t o be kept NBM for t he procedure). Mai nt ai n hi gh uri ne out put . St op nephrot oxi c drugs (es p. NSAIDs ) peri procedure. Out come i n one s t udy: 68% regai n normal renal funct i on, 14% had part i al recovery, 18% deat h, di al ys i s , or t rans pl ant at i on. N-acet yl cys t ei ne (50mg/kg bd by i v i nfus i on peri procedure) may prot ect agai ns t cont ras t -i nduced nephropat hy.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Coma: assessment
Coma: assessment
Presentation
Coma i s a s t at e of unarous abl e unres pons i venes s .
No evi denc e of arous al : t here i s no s pont aneous eye openi ng, comprehens i bl e s peech, or vol unt ary l i mb movement . Unres pons i ve t o ext ernal s t i mul i and s urroundi ng envi ronment , al t hough abnormal pos t ures may be adopt ed, eyes may open, or grunt s may be el i ci t ed i n res pons e t o pai n. I nvol unt ary movement s , e.g. s ei zures or myocl oni c jerks , may occur. GCS (P520) i s a us eful way of as s es s i ng and moni t ori ng l evel of cons ci ous nes s . Si gns of brai n s hi ft (P526) may accompany decreas i ng l evel of cons ci ous nes s .
Causes
For pract i cal purpos es , i t i s bes t t o di vi de t hes e i nt o

Met abol i c Toxi c Infect i ve St ruct ural l es i ons wi t h or wi t hout
Focal brai ns t em s i gns Lat eral i zi ng cerebral s i gns
Meni ngeal i rri t at i on.
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In general , t oxi c and met abol i c caus es us ual l y do not produce focal s i gns (except rarel y wi t h hypogl ycaemi a, l i ver, or renal fai l ure), whereas i nfect i ons and s t ruct ural l es i ons do. Meni ngi s m offers a very us eful cl ue about t he caus e of coma (s ee bel ow).
Coma without focal/lateralizing neurological signs

Anoxi a/hypoperfus i on Met abol i c: e.g. hypo-/hypergl ycaemi a, aci dos i s /al kal os i s , hypo- or hypernat raemi a, hypercal caemi a, hepat i c or renal fai l ure Int oxi cat i ons : e.g. al cohol , opi at es , benz odi azepi nes , t ri cycl i cs , neurol ept i cs , l i t hi um, barbi t urat es , carbon monoxi de Endocri ne: hypot hyroi di s m Hypo- or hypert hermi a Epi l eps y Hypert ens i ve encephal opat hy.
Coma with focal/lateralizing neurological signs (due to brainstem or cerebral dysfunction)

Vas cul ar: cerebral haemorrhage or i nfarct i on Supra- or i nfrat ent ori al s pace-occupyi ng l es i on: t umour, haemat oma, abs ces s . In order t o produce coma t hes e ei t her have t o be wi t hi n t he brai ns t em or compres s i t by produci ng brai n s hi ft (P526).
Coma with meningism

Meni ngi t i s , encephal i t i s Subarachnoi d haemorrhage.

GCS (P520) Si gns of brai n s hi ft (P526) and/or brai ns t em compromi s e.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Coma: immediat e management
Coma: immediate management
Priorities
St abi l i ze t he pat i ent (ai rway, breat hi ng, ci rcul at i on). Gi ve oxygen. Cons i der gi vi ng t hi ami ne, dext ros e, nal oxone, or fl umazeni l . Exami ne pat i ent . Is t here meni ngi s m? Es t abl i s h Gl as gow Coma Scal e s core. Is t here evi dence of brai ns t em fai l ure? Are t here focal or l at eral i zi ng s i gns ? Pl an for furt her i nves t i gat i ons . Obs erve for s i gns of det eri orat i on and at t empt t o revers e t hem.
Open t he ai rw ay by l ayi ng t he pat i ent on t hei r s i de. Not e t he pat t ern of breat hi ng (s ee s i gns of brai n s hi ft , P526). If t here i s apnoea or l aboured or di s t urbed breat hi ng, i nt ubat i on and vent i l at i on s houl d be cons i dered. Meas ure art eri al bl ood gas es . Support t he c i rc ul at i on . Correct hypot ens i on wi t h col l oi d and/or i not ropes . If prol onged t herapy i s requi red, bot h requi re careful and frequent moni t ori ng of cent ral venous pres s ure and/or pul monary art ery wedge pres s ure. Search for any occul t s ource of bl eedi ng, e.g. i nt ra-abdomi nal . T reat s ei zures wi t h us ual drugs (P472) but beware of over-s edat i on and hypot ens i on. Take bl ood for gl uc os e, U&Es , c al c i um, l i ver enzymes , al bumi n, c l ot t i ng s c reen, FBC, t oxi c ol ogy (i ncl udi ng urgent paracet amol and s al i cyl at e l evel s ). Uri ne s houl d
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be s aved for t oxi c ol ogy s c reen .
Give thiamine, dextrose, naloxone, or flumazenil
Check BM s t i x. There i s a good argument for gi vi ng 50ml of 50% dext ros e i mmedi at el y for pres umed hypogl ycaemi a becaus e t hi s wi l l us ual l y not caus e any harm. The onl y concern i s t hat gl ucos e may preci pi t at e W erni cke's encephal opat hy i n mal nouri s hed i ndi vi dual s . Some cl i ni ci ans t herefore favour gi vi ng a bol us of t hi ami ne 100200mg i v beforehand. Nal oxone s houl d onl y be gi ven i f opi at e i nt oxi cat i on i s l i kel y (s mal l pupi l s ) and t he pat i ent i s i n coma or has a markedl y reduced res pi rat ory rat e. In adul t s nal oxone 0.82.0mg i v s houl d be gi ven at i nt erval s of 23 mi nut es t o a maxi mum of 10mg. Fl umazeni l s houl d onl y be admi ni s t ered i f benzodi azepi ne i nt oxi cat i on i s l i kel y; i t i s cont rai ndi cat ed i n epi l ept i cs who have recei ved prol onged benzodi azepi ne t herapy. In adul t s fl umazeni l 200g s houl d be gi ven over 15 s econds ; furt her 100g bol us es may be gi ven at 1-mi nut e i nt erval s (us ual dos e i s 300600g maxi mum t ot al dos e out s i de i nt ens i ve care s et t i ng i s 1mg). Bot h nal oxone and fl umazeni l may be gi ven as i nt ravenous i nfus i ons i f drows i nes s recurs but i nt ens i ve care moni t ori ng i s advi s abl e.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Coma: c lues from examinat ion 1
Coma: clues from examination
1
History
If avai l abl e, t he as s es s ment may be made eas i er. Even i f t he hi s t ory i s not ext ens i ve, a wi t nes s may hel p t o es t abl i s h whet her coma commenced s uddenl y (s ugges t i ve of a vas cul ar event ) or whet her t here was a gradual decl i ne i n l evel of cons ci ous nes s over hours or even days . Indi vi dual s known t o s uffer from s peci fi c di s eas es may be weari ng a Medi cal ert bracel et or carryi ng t hei r regul ar medi cat i on. An enormous amount may be l earned from a rapi d but t horough exami nat i on.
General examination 1, 2
Thi s s houl d es t abl i s h t he fol l owi ng.
Core temperature. A fever us ual l y i ndi cat es i nfect i on but s omet i mes res ul t s from di encephal i c l es i ons . Hypot hermi a i s oft en forgot t en as a caus e for coma; t he pos s i bi l i t y of myxoedema s houl d be cons i dered. Heart rate and rhythm. May i ndi cat e a dys rhyt hmi a as t he reas on for poor cerebral perfus i on. Blood pressure. Prol onged hypot ens i on of any caus e wi l l l ead t o anoxi a and i s chaemi a. Apart from a cardi ac caus e, occul t bl eedi ng, a caus e of s eps i s , and drug i nt oxi cat i on need t o be cons i dered. Respiratory pattern. Shal l ow, s l ow breat hi ng s houl d al ert t he exami ner t o t he pos s i bi l i t y of drug i nt oxi cat i on, e.g. opi at es . Deep, rapi d Kus s maul breat hi ng s ugges t s aci dos i s . Brai ns t em compromi s e can caus e di s t i nct i ve pat t erns of breat hi ng (P525).
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Breath. Al cohol , ket ones , hepat i c, or uraemi c foet or? Skin. There may be s i gns of t rauma t o t he head. Brui s i ng over t he s cal p or mas t oi ds , bl ood i n t he nos t ri l s , or ext ernal audi t ory meat us rai s es t he pos s i bi l i t y of a bas al s kul l fract ure. A ras h s ugges t s t he pos s i bi l i t y of meni ngi t i s . Look for s i gns of chroni c l i ver di s eas e or s al l ow di s col orat i on of uraemi a. Int ravenous drug abus e may be s ugges t ed by needl e t racks . Heart. Occas i onal l y bact eri al endocardi t i s or vas cul i t i des as s oci at ed wi t h heart murmurs pres ent wi t h coma. Abdomen. Look for enl argement of organs whi ch may gi ve cl ues t o t he caus e of coma. It i s i mport ant not t o mi s s an acut e i nt ra-abdomi nal event s uch as perforat i on of a vi s cus or a l eaki ng aort i c aneurys m. Fundi. Papi l l oedema i ndi cat es rai s ed i nt racrani al pres s ure but i t s abs ence does not excl ude t hat pos s i bi l i t y. Subhyal oi d haemorrhages are pat hognomoni c of s ubarachnoi d haemorrhage but are rare. Changes of di abet i c or hypert ens i ve ret i nopat hy s ugges t t he pos s i bi l i t y of encephal opat hy s econdary t o t hes e condi t i ons .
Is there meningism?
Neck s t i ffnes s s houl d be as s es s ed onl y i f i t i s cert ai n t hat t here has been no t rauma t o t he cervi cal s pi ne. Increas ed s t i ffnes s s ugges t s meni ngeal i rri t at i on, ei t her becaus e of i nfl ammat i on or i nfi l t rat i ve proces s es affect i ng t he meni nges , or becaus e of t he pres ence of bl ood. Meni ngi s m rai s es t he pos s i bi l i t y of meni ngi t i s , encephal i t i s , or s ubarachnoi d haemorrhage. St art ant i bi ot i cs i mmedi at el y i f meni ngi t i s i s s us pect ed.
Footnote
1
Pl um F & Pos ner JB (1980) T he Di agnos i s of St upor and Coma , 3rd edn; FA Davi s , Phi l adel phi a.
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2
Bat es (1993) J Neurol Neuros urg Ps yc hi at 56 : 589598.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Coma: c lues from examinat ion 2
Coma: clues from examination
2
Assess the GCS
Thi s may reveal brai ns t em dys funct i on or l at eral i zi ng s i gns . W hen t es t i ng t he mot or res pons e decort i cat e or decerebrat e pos t uri ng may become evi dent (P522). If t here i s a change i n t hes e s i gns , i t may i ndi cat e brai n s hi ft (P526).
Look for evidence of brainstem dysfunction?

See P522 for det ai l s .
Tes t and obs erve

o o o o o
Pupi l l ary res pons e Corneal refl ex Res t i ng pos i t i on of eyes Spont aneous eye movement s Ocul ocephal i c res pons e/Dol l 's head manoeuvre (i f no C-s pi ne i njury) Ocul oves t i bul ar res pons e/cal ori c s t i mul at i on Swal l owi ng Res pi rat ory pat t ern.
o o o
There wi l l be evi dence of brai ns t em fai l ure ei t her becaus e t here i s s t ruct ural damage (i nt ri ns i c l es i on or ext ri ns i c compres s i on due t o brai n s hi ft , P526) or becaus e of met abol i c coma s uch as drug i nt oxi cat i on wi t h di ffus e, us ual l y revers i bl e, dys funct i on. If t here i s focal brai ns t em dys funct i on t he caus e i s mos t l i kel y s t ruct ural or i nt ri ns i c brai ns t em di s eas e.
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If t here i s ros t ro-caudal progres s i on of brai ns t em s i gns cons i der a herni at i on s yndrome (P526). If t here appears t o be di ffus e brai ns t em dys funct i on, i t may not be eas y t o di s t i ngui s h bet ween s t ruct ural and met abol i c aet i ol ogi es . The mos t i mport ant cl ue i s t hat i n met abol i c coma, i rres pect i ve of t hei r s i ze, t he pupi l s cont i nue t o react except i n very few except i onal cas es (at ropi ne, s copol ami ne, or gl ut et hi mi de i nt oxi cat i on wi l l depres s brai ns t em funct i on and produce pupi l l ary abnormal i t i es ).
Are there lateralizing signs?

Tes t i ng of brai ns t em refl exes , as s es s i ng t he GCS, and general exami nat i on may reveal faci al as ymmet ry, and di fferences i n mus cl e t one, refl exes , and pl ant ar res pons es bet ween t he t wo s i des . Al l t hes e feat ures poi nt t oward t he pos s i bi l i t y of a s t ruct ural l es i on, al t hough occas i onal l y met abol i c coma i s as s oci at ed wi t h focal neurol ogi cal s i gns .
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Coma: management
Coma: management
Plan for further investigations
The hi s t ory, phys i cal exami nat i on, and/or l aborat ory s t udi es may hel p make t he di agnos i s . Oft en, however, a di agnos i s cannot be reached s o rapi dl y. The pract i cal approach i s t o di vi de pat i ent s accordi ng t o t he fol l owi ng s cheme.
Brainstem function intact

Urgent CT head s can. Thi s wi l l reveal one of t he fol l owi ng
Operabl e l es i ons (e.g. s ubdural haemat oma, s ubarachnoi d or i nt racerebral haemorrhage); refer as appropri at e. Inoperabl e l es i ons (e.g. bi l at eral cort i cal i nfarct s ); t reat ment i s s upport i ve. Normal : a l umbar punct ure s houl d be performed. CSF anal ys i s may s ugges t an i nfect i ve proces s (e.g. meni ngi t i s , encephal i t i s ) (P432). If t he CSF i s normal , t he mos t l i kel y di agnos i s i s a met abol i c coma.
Brainstem function not intact

Cons i der whet her t here are s i gns of brai n s hi ft (P526). If a herni at i on s yndrome appears t o be progres s i ng rapi dl y, manni t ol s houl d be gi ven, hypervent i l at i on commenced, and a s urgeon cont act ed urgent l y (s ee rai s ed ICP, P452). If t he t empo of event s i s not s o rapi d, manni t ol may be gi ven and an urgent CT s can arranged. Even i f t he brai ns t em s i gns appear t o be non-progres s i ve, a CT s can s houl d be arranged t o excl ude t he pos s i bi l i t y of an operabl e pos t eri or fos s a
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mas s or haemorrhage (e.g. cerebel l ar haemorrhage).
If t he CT i s normal , a l umbar punct ure s houl d be performed t o excl ude i nfect i on. If t hi s t oo i s normal t he di agnos t i c pos s i bi l i t i es are i nt ri ns i c brai ns t em di s eas e not det ect ed by CT, met abol i c coma, or pos s i bl y i nfect i on, e.g. encephal i t i s , wi t hout l eukocyt i c res pons e. MRI i s more s ens i t i ve i n det ect i ng i nt ri ns i c brai ns t em pat hol ogy. Lumbar punct ure s houl d be repeat ed t he next day i f t here i s no i mprovement i n t he pat i ent 's condi t i on. Treat ment i s s upport i ve.
Monitoring progress
Thi s requi res regul ar obs ervat i ons of vi t al s i gns and neurol ogi cal s t at e (i ncl udi ng GCS s core). An i mport ant caus e of det eri orat i on i n s t ruct ural brai n l es i ons i s brai n s hi ft l eadi ng t o herni at i on s yndromes (P526). The emergency t reat ment of rai s ed i nt racrani al pres s ure i s di s cus s ed on P454. Ot her reas ons for det eri orat i on are el ect rol yt e or met abol i c changes , hypovol aemi a, or fl ui d overl oad. Pl as ma el ect rol yt es and fl ui d bal ance need t o be regul arl y as s es s ed t o avoi d s uch probl ems .
Prognosis
In coma due t o head i njury, prognos i s i s cl earl y rel at ed t o GCS s core. Pat i ent s s cori ng 8 or l es s have a very poor prognos i s . In non-t raumat i c coma, GCS al one i s not a very good predi ct or. Pat i ent s wi t h drug i nt oxi cat i ons may have very l ow s cores on admi s s i on but , i n general , have good out comes . As s es s ment of prognos i s i n non-t raumat i c coma i s ai ded by s i mpl e feat ures of t he exami nat i on. For exampl e, i f aft er 24 hours i t i s s t i l l not pos s i bl e t o el i ci t pupi l l ary res pons es , corneal refl exes , and ocul oves t i bul ar res pons e, s urvi val i s ext remel y unl i kel y.
1
Footnote
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1
Levy et al . (1981) Arc h I nt Med 94 : 293301.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Limb weakness: assessment
Limb weakness: assessment
History
The hi s t ory s houl d es t abl i s h i f t here has been

Sudden ons et or gradual progres s i on W eaknes s or i ncoordi nat i on Upper l i mb or faci al weaknes s As ymmet ri cal or s ymmet ri cal weaknes s As s oci at ed s ens ory s ympt oms , e.g. paraes t hes i ae or numbnes s Di ffi cul t y wi t h s wal l owi ng, s peech, mi ct uri t i on, or defecat i on Back or neck pai n Sys t emi c s ympt oms , e.g. mal ai s e, fever, di arrhoea and vomi t i ng, art hral gi a Recent t rauma Previ ous medi cal hi s t ory, e.g. hypert ens i on, i s chaemi c heart di s eas e, s t roke, di abet es , connect i ve t i s s ue di s eas es , i mmunos uppres s i on Drug hi s t ory, e.g. phenyt oi n, i s oni azi d, vi ncri s t i ne, met roni dazol e.
Examination
What is the pattern of weakness? Some common pat t erns , t oget her wi t h as s oci at ed feat ures , are i l l us t rat ed on P41819. Thi s s houl d hel p t o l ocal i ze t he l evel of t he l es i on i n t he nervous s ys t em. Is the weakness upper or lower motor neurone/combination? If upper motor neurone, is it pyramidal? i .e. ext ens or more t han fl exor weaknes s i n upper l i mbs ; fl exor
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great er t han ext ens or weaknes s i n l ower l i mbs .
Is there fatiguable weakness with repetitive effort? As i n myas t heni a. Are there any involuntary movements? Tremor, myocl oni c jerks , or fi t s may be not ed. What is the gait like? Thi s i s i mport ant t o t es t i f at al l pos s i bl e. It may demons t rat e, for exampl e, a hemi pl egi c gai t , at axi a (cerebel l ar or s ens ory), a waddl i ng (myopat hi c) gai t , s t eppage (l ower mot or neurone) gai t , fes t i nat i ng movement s of t he Parki ns oni an pat i ent . Is there any sensory loss? Where? Is there a sensory level? Sens ory changes are oft en t he mos t di ffi cul t t o el i ci t . Do not forget t o t es t al l modal i t i es or t o t es t t he back of t he l egs up t o t he anal s phi nct er. What modalities of sensation are lost? Dors al col umn l os s produces a di s cri mi nat ory l os s wi t h i mpai red t wo-poi nt di s cri mi nat i on, joi nt -pos i t i on and vi brat i on l os s , as t ereognos i s , and s ens ory at axi a. Spi not hal ami c l os s us ual l y produces a l ack of awarenes s of pai n and t emperat ure.
The hi s t ory and exami nat i on s houl d hel p t o l ocal i ze t he l es i on and, t oget her wi t h t he pat i ent 's age, gi ve an i ndi cat i on of t he l i kel y pat hol ogi cal proces s i nvol ved.
1
Footnote
1
Adapt ed from
Li nds ay KW , Bone I, and Cal l ander R (1991) Neurol ogy and Neuros urgey I l l us t rat ed , 2nd edn; pp.191194; Churchil l Li vi ngs t one, London. P.417
Investigations
The i ni t i al i nves t i gat i on of choi ce depends upon t he l i kel y
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di agnos i s . Inves t i gat i ons t o cons i der are gi ven i n t he t abl e oppos i t e.
Diagnoses not to miss

Spi nal cord compres s i on Gui l l i anBarr s yndrome Subdural haemat oma St roke P508 P512 P464 P478
Diagnoses to consider

Demyel i nat i on (mul t i pl e s cl eros i s , pos t i nfect i ous , et c.) Mal i gnancy (carci nomat ous meni ngi t i s , i nt racrani al mas s ) Syri ngomyel i a Mot or neurone di s eas e Vi t ami n defi ci ency (s ub-acut e combi ned degenerat i on-B
12
Peri pheral neuropat hy (t oxi c, DM, aut oi mmune, amyl oi d, et c.) TB, s yphi l i s
Investigations to consider
Bl ood t es t s : FBC, U&Es , LFTs , ESR, CRP, pros t at e s peci fi c ant i gen, B 1 2 /fol at e, prot ei n s t ri p, s yphi l i s s erol ogy CT s can MRI brai n s pi ne CSF anal ys i s : prot ei n, cel l s , ol i gocl onal bands Vi s ual evoked pot ent i al s
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EMG NCS Tens i l on t es t Mus cl e bi ops y
Practice point
A pat i ent who can cycl e eas i l y, but onl y wal k yards , us ual l y has l umbar s t enos i s .
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Limb weakness: loc alizing t he lesion
Limb weakness: localizing
the lesion
Monoplegia Arm face Lesion site Cont ral at eral cort ex
Other features
Vi s ual fi el d defect Dys phas i a (domi nant hemi s phere l es i on)
Cort i cal s ens ory l os s (JPS and 2-poi nt di s cri mi nat i on)
Leg onl y
Cont ral at eral cort ex Ips i l at eral s pi nal l es i on
W i t h i ps i l at eral s ens ory defi ci t
Cont ral at eral pai n and t emperat ure l os s
JPS l os t on s ame s i de UMN VII i nvol vement Impai red conci ous nes s Vi s ual fi el d defect Dys phas i a (i f domi nant hemi s phere l es i on)
Hemi pl egi a Les i on s i t e Face + arm + l eg Cont ral at eral hemi s phere
Ot her feat ures

Cont ral at eral i nt ernal caps ul e
UMN VII i nvol vement Al ert No dys phas i a (even wi t h
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a domi nant hemi s phere l es i on) Cont ral at eral mi d-brai n l es i on

Cont ral at eral IIIrd pal s y Impai red upgaze VII unaffect ed Vi s ual fi el d defect Dys phas i a (i f domi nant hemi s phere l es i on)
Arm ( face) or Cont ral at eral l eg al one cort ex
Cort i cal s ens ory l os s (JPS and 2-poi nt di s cri mi nat i on)
Cont ral at eral medul l ary
Ips i l at eral pai n and t emperat ure l os s
Cont ral at eral Horner's s yndrome
Cont ral at eral pal at al and t ongue weaknes s
Ips i l at eral s pi nal l es i on
Pai n and t emperat ure l os s i n cont ral at eral l eg
Ips i l at eral l os s of JPS Ips i l at eral Horner's LMN face i nvol vement on oppos i t e s i de t o weak l i mbs
Arm, l eg, and oppos i t e face
Cont ral at eral pons
Conjugat e gaze devi at i on t owards weak s i de
UMN = upper mot or neurone; JPS = joi nt pos i t i on s ens e P.419
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H L mi si pl o eg n ia si te Ar M m e an d d ul op l a po ry sit le e g si n le o
Other
e e features
Pal a t al and t ong ue wea knes s on t he s i de of arm wea knes s
Pa L Other ra e features pl si eg o ia n si te Mi dli n e
Cort i cal s ens ory
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co rt i ca l le si o n
l os s (JPS and 2-po i nt di s cr i mi n at i o n)
F ront al i nco nt i n ence
Nor mal pai n and t em pera t ure
T h or ac ic sp in e
S ens o ry l evel
Acut e uri n ary
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ret e nt i o n or hes i t anc y of mi ct uri t i on T e L Other tr e features ap si le o gi n a si te Fa P ce o an nt d in al l e fo l e ur s i li o m n bs in vo lv ed
L ocke d-i n s ynd rom e: onl y vert i cal eye mov eme nt s pos s i bl e
Fa C ce er
No crani
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s p vi ar ca ed l sp in e le si o n
al nerv e l es i o n Hi gh l es i o ns (C1 3) requ i re vent i l at i on
Les i ons at C4 have i nt a ct di ap hrag mat i c brea t hi n g
M e d ul
No pal a t al or
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la ry le si o n
t ong ue mov eme nt or s pee ch but i nt a ct faci a l mov eme nt s
Combined UMN and LMN signs
The LMN s i gn s poi n t to t he l evel of t he l es i o n
Two l es i o ns (e.g.
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cervi cal and l umb ar s pon dyl o sis) may prod uce mi xe d s i gn s in l i mb s LMN limb weakness (Unilateral or Bilateral)
Nerv e root di s t r i but i on?
Pl ex opat hy?
Peri pher al
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nerv e di s t r i but i on (mo novers us pol y neur opat hy)
Pres ence of refl e xes s ugg es t s a myo pat h y (cf. neur opat hy)
Spec i fi c di s t r i but i on
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s een in e.g. fas ci os ca pul o hum oral dys t roph y
Fat i guab ility s ugg es t s neur omu s cul ar junc t i on di s e as e
LMN = Lower mot or neurone
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ac ut e dizziness: assessment
Acute dizziness: assessment
History
Det ermi ne whet her
T here i s t rue vert i go , i .e. a hal l uci nat i on t hat ei t her t he pat i ent or t hei r envi ronment i s rot at i ng. Sympt oms s t art ed ac ut el y , are progres s i vel y wors eni ng, or are t rans i ent (s ee vert ebrobas i l ar TIAs , P494). Ves t i bul ar neuri t i s t ypi cal l y begi ns over a peri od of a few hours , peaks i n t he fi rs t day, and t hen i mproves wi t hi n days . Infarct i on caus es a ves t i bul ar s yndrome t hat t ypi cal l y has an abrupt ons et . Trans i ent i s chaemi c at t acks oft en l as t for l es s t han 30 mi nut es . Abrupt ons et of vert i go for s econds aft er a change i n head pos i t i on i s charact eri s t i c of beni gn pos i t i onal vert i go.
1
Sympt oms w ors e w i t h c ert ai n pos t ures . Vert i go i s wors e wi t h cert ai n head pos i t i ons i n beni gn pos i t i on vert i go and s ome cas es of cent ral nys t agmus (s ee bel ow). Pos t ural hypot ens i on i s frequent l y caus ed by drugs and can be caus ed by acut e bl ood l os s ; uncommonl y i t i s due t o aut onomi c fai l ure. Neck movement s i n cervi cal s pondyl os i s or carot i d s i nus hypers ens i t i vi t y may al s o l ead t o di zzi nes s . T here i s as s oc i at ed t i nni t us (as i n Mni re's di s eas e). Heari ng l os s i s pres ent i n Mni re's di s eas e, cerebel l opont i ne angl e l es i ons , e.g. acous t i c neuromas . Ear di s c harge may occur wi t h mi ddl e ear di s eas e. As s oc i at ed foc al neurol ogi c al s ympt oms , e.g. uni l at eral
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weaknes s , cl ums i nes s , paraes t hes i ae, or numbnes s .
Headac he: s udden ons et i n i nt racerebral haemorrhage; progres s i ve wi t h feat ures of ICP i n mas s l es i ons (e.g. acous t i c neuroma). Any rec ent head i njury ? Sys t emi c s ympt oms , e.g. weaknes s and l et hargy i n anaemi a. Previ ous medi c al /ps yc hi at ri c hi s t ory , e.g. hypert ens i on, i s chaemi c heart di s eas e, di abet es , ri s k fact ors for s t roke or TIAs (P494), epi s odes of neurol ogi cal di s t urbance, pani c at t acks , and anxi et y. Drug hi s t ory i s pert i nent t o bot h t rue vert i go (e.g. phenyt oi n, gent ami ci n, frus emi de) and di zzi nes s (e.g. ant i -hypert ens i ves , ant i -depres s ant s , drugs for Parki ns on's di s eas e, hypogl ycaemi cs ).
Examination
Ear . Is t here a di s charge? Is t he t ympani c membrane normal ? Neurol ogi c al exami nat i on s houl d di s cover whet her t here are any focal s i gns due t o brai ns t em or cerebel l ar di s eas e (P522). Non-cont i guous brai ns t em pat hol ogy may be due t o pat chy demyel i nat i on. Do not forget t o as s es s t he c orneal refl ex , t he abs ence of whi ch i s one of t he earl i es t s i gns of an i ps i l at eral acous t i c neuroma. Obs erve t he gai t i f pos s i bl e; i t may be at axi c. Exami ne ext raoc ul ar eye movement s . Is t here an i nt ranucl ear opht hal mopl egi a (vas cul ar/demyel i nat i ng brai ns t em di s eas e)? Exami ne careful l y for nys t agmus (s ee t abl e). Hal l pi ke manoeuvre i nvol ves pos i t i oni ng t he pat i ent 's head over one s i de of t he bed and wat chi ng for nys t agmus . Beni gn pos i t i onal vert i go: nys t agmus devel ops aft er a bri ef del ay, but i t fat i gues and, wi t h repet i t i on, adapt s . Cent ral nys t agmus : no i ni t i al del ay, fat i gueabi l i t y, or adapt at i on. Fundos c opy may reveal papi l l oedema (s ugges t i ve of i nt racrani al s pace-occupyi ng l es i on) or opt i c at rophy (whi ch occurs wi t h previ ous demyel i nat i on i n mul t i pl e s cl eros i s ). General exami nat i on: meas ure BP (l yi ng and s t andi ng). Pos t ural hypot ens i on i s a common caus e of di zzi nes s .
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P.421
Classification of nystagmus
First degree nys t agmus occurs onl y when t he eyes are devi at ed t o one s i de. If i t occurs i n t he mi d-l i ne pos i t i on as wel l , i t i s second degree . Nys t agmus i n al l di rect i ons of gaz e i s t ermed third degree Vestibular nystagmus i s due t o dys funct i on of t he l abyri nt h or ves t i bul ar nerve. The s l ow phas e i s t owards t he l es i on; t he qui ck phas e i s away from t he l es i on. There may be rot at ory nys t agmus Central nystagmus i s due t o brai ns t em dys funct i on (ves t i bul ar nucl ei or t hei r connect i ons ); t here may no vert i go as s oci at ed wi t h t hi s form of nys t agmus . The nys t agmus may be hori zont al , vert i cal , or rot at ory; s omet i mes i t i s pres ent i n one eye onl y. The qui ck phas e i s det ermi ned by di rect i on of gaze: i t i s mul t i -di rect i onal Positional nystagmus may occur i n beni gn pos i t i onal vert i go but wi t h repeat ed t es t i ng i t adapt s (s ee bel ow). It may al s o occur wi t h pos t eri or fos s a, e.g. cerebel l ar l es i ons (qui ck phas e t ends t o be t oward t he l es i on) i n whi ch t here i s no adapt at i on
Footnote
1
Hot s on JR & Bal oh RW (1998) New Engl J Med 339 : 680685.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ac ut e dizziness: management
Acute dizziness: management
Investigations
Thes e depend upon t he l i kel y di agnos i s .
Cerebel l opont i ne angl e l es i ons s uch as acous t i c neuroma may be i maged by CT w i t h c ont ras t but , i n general , pos t eri or fos s a and brai ns t em di s eas e i s bet t er apprai s ed by MRI s c anni ng . Pure t one audi omet ry i s a s ens i t i ve way of det ect i ng s ens ori neural l os s . Cervi c al s pi ne fi l ms may reveal degenerat i ve di s eas e compromi s i ng vert ebral art ery ci rcul at i on. Meas ure blood sugar and FBC i f i ndi cat ed.
Approach to dizziness/vertigo
True vert i go Acut e l abyri nt hi t i s Management

Bed res t Cons i der cycl i zi ne or prochl orperaz i ne
Beni gn pos i t i onal vert i go
Avoi d preci pi t at i ng pos i t i on Epl ey manoeuvre or Cawt horneCooks ey exerci s es
Mni re's di s eas e (s ens ori neural deafnes s and t i nni t us )
Bed res t Cons i der cycl i zi ne or prochl orperaz i ne
Pure t one audi omet ry
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ENT referral
Mi ddl e ear di s eas e Brai ns t em/cerebel l ar di s eas e (s t roke, P478, demyel i nat i on, vert ebrobas i l ar i ns uffi ci ency, mi grai ne, vas cul i t i s ) Cerebel l opont i ne angl e l es i ons (e.g. acous t i c neuroma)
ENT referral Cons i der CT/MRI
Pure t one audi omet ry CT, MRI s can
Page 773
> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ac ut e loss of vision
Acute loss of vision

History
Det ermi ne whet her
Vi s ual l os s i s or w as monoc ul ar or bi noc ul ar, c ompl et e or i nc ompl et e , e.g. hemi anopi a, cent ral or peri pheral l os s , hazi nes s or compl et e obs curat i on of vi s i on. Los s of ac ui t y oc c urred i ns t ant l y as i n amauros i s fugax. Peri od for w hi c h i t l as t ed . T here w ere any ot her as s oc i at ed vi s ual s ympt oms , e.g. s ci nt i l l at i ons (fl as hi ng l i ght s and s hapes ) occur i n ret i nal mi grai ne. T he eye i s pai nful red . Headac he or fac i al pai n: uni l at eral or bi l at eral . As s oc i at ed foc al neurol ogi c al s ympt oms , e.g. uni l at eral weaknes s , cl ums i nes s , paraes t hes i ae, or numbnes s . Any rec ent t rauma? Sys t emi c s ympt oms , e.g. mal ai s e, aches , and pai ns . Previ ous medi c al hi s t ory , e.g. hypert ens i on, i s chaemi c heart di s eas e, di abet es , ot her ri s k fact ors for s t roke or TIAs (P494), mi grai ne, connect i ve t i s s ue di s eas es .
Examination
Ext ernal appearanc e of t he eye . Is i t red (P428)? Is t here corneal cl oudi ng? Vi s ual ac ui t y s houl d be meas ured for each eye wi t h a Snel l en chart . Near vi s i on s houl d be t es t ed (wi t h news pri nt i f neces s ary). If none of t hes e are pos s i bl e, t he pat i ent 's acui t y for count i ng number of fi ngers , or percei vi ng hand movement or l i ght s houl d be not ed. Ideal l y, col our vi s i on s houl d al s o be exami ned wi t h
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Is hi hara pl at es .
Pl ot t he vi s ual fi el ds . Oft en careful beds i de examnat i on i s s uffi ci ent , al t hough peri met ry avai l abl e i n opht hal mol ogi cal depart ment s may be more s ens i t i ve. The l os s of vi s i on may be i ncompl et e. I s t here an afferent pupi l l ary defec t ? (Swi ngi ng t orch t es t .) Fundos c opy may reveal a ret i nal embol us , changes of cent ral /branch ret i nal art ery occl us i on, s wol l en or pal e opt i c nerve head, papi l l oedema, or hypert ens i ve changes . I s t he t emporal art ery t ender? It need not be i n t emporal art eri t i s . Compl et e neurol ogi c al exami nat i on i s neces s ary t o di s cover i f t here are any ot her as s oci at ed s i gns . Li s t en for c arot i d brui t s al t hough t hey may not be pres ent i n pat i ent s wi t h s ympt omat i c carot i d s t enos i s . As s es s heart rhyt hm (i nc l udi ng ECG) and c ardi ovas c ul ar s ys t em for pos s i bl e cardi ogeni c s ource of embol us . Meas ure BP (l yi ng and s t andi ng) and bl ood s ugar . Hypot ens i on i n t he pres ence of art eri os cl eros i s can l ead t o occi pi t al l obe i s chaemi a. Hypert ens i on and di abet es are ri s k fact ors for TIAs .
Investigations
See P4802. NB: An ESR s houl d be performed i n any pat i ent aged >50 years who pres ent s wi t h monocul ar bl i ndens s and uni l at eral headache. It i s rarel y normal i n t emporal art eri t i s . If t he ESR i s el evat ed and t he pres ent at i on i s compat i bl e wi t h t emporal art eri t i s , hi gh-dos e cort i cos t eroi d t herapy s houl d be cons i dered (i ni t i al l y 60mg/day oral l y) becaus e t he ot her eye i s al s o at ri s k of ant eri or i s chaemi c opt i c neuropat hy (s ee P760).
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Approac h t o ac ut e/sub- ac ut e visual loss
Approach to
acute/sub-acute visual loss

1 Monocular transient loss without prominent unilateral headache
Amauros i s fugax (s ee TIAs , P494). In t he el derl y t hi s may be due t o embol i s m. In s ome younger pat i ent s i t i s probabl y due t o vas os pas m (a di agnos i s of excl us i on). Hypervi s cos i t y s yndrome (e.g. pol ycyt haemi a, myel oma, s i ckl e cel l anaemi a), hypercoagul abl e s t at e, vas cul i t i s : bl ood fi l m, prot ei n el ect rophores i s , aut oi mmune s creen, ot her haemat ol ogi cal i nves t i gat i ons as requi red (P728). Pos t ural hypot ens i on (may exacerbat e vert ebrobas i l ar i s chaemi a): s t op any exacerbat i ng drugs . Excl ude aut onomi c neuropat hy.
2 Monocular transient loss with prominent headache
Mi grai ne (us ual l y t here are pos i t i ve phenomena, e.g. s ci nt i l l at i ons ): obs erve, gi ve anal ges i cs /ergot deri vat i ve. Arrange neurol ogi cal cons ul t at i on.
3 Monocular sustained loss with red eye
Acut e gl aucoma (di l at ed pupi l and corneal cl oudi ng): urgent opht hal mol ogy referral . Acut e uvei t i s (i nfl ammat i on of i ri s and ci l i ary body wi t h s mal l pupi l ), kerat i t i s (corneal i nfl ammat i on), endopht hal mi t i s (i nvol vent of vi t reous , uvea, and ret i na
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wi t h cel l ul ar debri s /pus i n ant eri or chamber), or ocul ar t rauma. Urgent opht hal mi c referral .
4 Monocular sustained loss without red eye Central visual loss with relative afferent pupillary defect
Opt i c neuri t i s orbi t al pai n exacerbat ed by eye movement . The commones t caus e i s demyel i nat i on but cons i der t he pos s i bi l i t y of mas s l es i ons compres s i ng t he opt i c nerve (cons i der evoked pot ent i al s , CT orbi t ) Ant eri or i s chaemi c opt i c neuropat hy due t o pres umed at heros cl eros i s of pos t eri or ci l i ary art eri es or t o t emporal art eri t i s (cons i der s t eroi ds , perform ESR, t emporal art ery bi ops y).
Central scotoma without relative afferent pupillary defect

Vi t reous haemorrhage Macul ar di s order: macul ar degenerat i on, haemorrhage, or exudat e Branch ret i nal vei n/art ery occl us i on.
Peripheral visual field loss

Ret i nal det achment Chori oret i ni t i s Int raocul ar t umour Ret i nal vas cul ar occl us i on.
5 Binocular sustained loss
Fi el d l os s (e.g. quadrant onopi a, hemi anopi a, bi t emporal ) CT s can Hypot ens i on (e.g. cardi ac fai l ure) l eadi ng t o pos t eri or ci rcul at i on i ns uffi ci ency. Dys rhyt hmi as or vert ebrobas i l ar i ns uffi ci ency may produce t rans i ent epi s odes of bi nocul ar vi s ual l os s . CT s can Toxi c opt i c neuropat hi es (e.g. t obacco, al cohol ,
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met hanol ).
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Painful red eye: assessment
Painful red eye: assessment
History
Thi s s houl d es t abl i s h i f t here has been
Oc ul ar t rauma or forei gn body (i nc l udi ng c ont ac t l ens ) i n t he eye . Sudden or gradual ons et of s ympt oms , nat ure, and l oc at i on of pai n . Irri t at i on, s orenes s , or gri t t y s ens at i ons may occur wi t h conjunct i vi t i s but t he pai n i s s evere i n acut e gl aucoma. Di mi nut i on of vi s ual ac ui t y occurs wi t h condi t i ons affect i ng t he cornea (vari abl e reduct i on), i ri s (mi l d reduct i on), and gl aucoma (s evere reduct i on of acui t y). Di s c harge (not s i mpl y l acri mat i on) from eyes may be mucopurul ent wi t h bact eri al or chl amydi al conjunct i vi t i s . It may be muci d and s t ri ngy wi t h al l ergi c condi t i ons or dry eyes . Headac he or fac i al pai n i s common wi t h orbi t al cel l ul i t i s . It may precede cavernous s i nus t hrombos i s or herpes zos t er opht hal mi cus . Phot ophobi a s ugges t s corneal i nvol vement or i ri t i s . Sys t emi c s ympt oms , e.g. mal ai s e/fever, may occur wi t h orbi t al cel l ul i t i s and cavernous s i nus t hrombos i s , vomi t i ng i s a feat ure of acut e gl aucoma, art hral gi a + uret hral di s charge s ugges t s Rei t er's or chl amydi al i nfect i on. Previ ous hi s t ory . Recurrent red eyes may occur wi t h epi s cl eri t i s , i ri t i s , herpes s i mpl ex corneal ul cer. As k s peci fi cal l y about BP, heart di s eas e, di abet es , connect i ve t i s s ue di s eas es , and at opy.
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Examination
What i s red? The conjunct i va, i ri s , s cl era, or epi s cl era (whi ch l i es jus t beneat h t he conjunct i va and next t o t he s cl era), eye l i d, s ki n around orbi t ? Is t here a vi s i bl e haemorrhage, ei t her s ub-conjuct i val or i n t he ant eri or chamber (hyphaema)? In conjunct i vi t i s t here i s i nject i on or i ncreas ed fi l l i ng of exi s t i ng l i ght red ves s el s , wi t h i ndi vi dual branches di s t i nct l y vi s i bl e; t he ves s el s can be moved wi t h t he conjunct i va over t he s cl era. Ci l i ary or ci rcumcorneal i nject i on refers t o a bl uered di s col ourat i on, mos t cons pi cuous at t he l i mbus (corneas cl eral border) and occurs i n ant eri or uvei t i s or i ri t i s and kerat i t i s (corneal i nfl ammat i on). Mi xed i nject i on (conjunct i val + ci l i ary) al s o occurs i n uvei t i s . I s t here propt os i s ? Sugges t s a ret ro-orbi t al /i nt raori bt al mas s or cavernous s i nus t hrombos i s i n whi ch i t may become bi l at eral . I s i t pul s at i l e? As i n a carot i co-cavernous fi s t ul a, wi t h an audi bl e brui t . I s t here opht hal mopl egi a? Any mas s l es i on or cavenous s i nus t hrombos i s . I s vi s ual ac ui t y di mi ni s hed? A Snel l en chart s houl d be us ed and near vi s i on t es t ed (wi t h news pri nt i f neces s ary). In acut e gl aucoma, t here i s marked reduct i on i n acui t y; i n acut e i ri t i s or kerat i t i s , acui t y i s onl y modes t l y di mi ni s hed; i n conjunct i vi t i s i t i s normal . What i s t he s i ze of t he pupi l ? Fi xed and di l at ed i n acut e gl aucoma; s mal l wi t h reduced react i on t o l i ght i n i ri t i s ; normal i n conjunct i vi t i s . I s t he red refl ex normal ? I f i t i s , does t he c ornea appear normal ? The red refl ex may be i mpai red i n kerat i t i s , cent ral corneal ul cer or oedema, ant eri or chamber hyphaema (bl ood i n ant eri or chamber aft er bl unt t rauma), ant eri or uvei t i s , gl aucoma, or endopht hal mi t i s (i nvol vent of vi t reous , uvea, and ret i na wi t h cel l ul ar debri s /pus i n ant eri or chamber). Fundos c opy may not be pos s i bl e as wi t h t he corneal cl oudi ng of acut e gl aucoma. Are t here any ant eri or c hamber abnormal i t i es ? In acut e ant eri or uvei t i s t here are exudat es i n t he ant eri or chamber.
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I s t here a ras h or ves i c l es on t he fac e, nos e, or eyel i d? Herpes z os t er can l ead t o conjunct i vi t i s , i ri t i s , corneal ul cerat i on, and 2 gl aucoma. P.429
Differential diagnosis of red-eye

Conjunc tiva Iris Pupil Corne Anteri Intraoc Appearance a or ular e Very hi gh chamb pressur Acut e Bot h and conjunct i val ves s el s i nject ed Ent i re eye i s Iri t i s red Rednes s Inject e Smal l , Normal Turgi d Normal mos t marked around cornea Col our does not bl anch on pres s ure Conjunct i v Conjunct Normal Normal Normal Normal Normal itis i val ves s el s i nject ed, d fi xed er Inject e Di l at ed St eamy Very d , fi xed, , hazy s l ow oval
gl aucoma ci l i ary
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great es t t oward forni ces Bl anch on pres s ure. Mobi l e over s cl era Subconjun Bri ght ct i val ge red wi t h whi t e ri m around l i mbus Aft er RD Judge, GD Zui dema, FT Fi rzgeral d 1989 Cl i ni c al di agnos i s 5 ed, Li t t l e Brown, Bos t on. haemorrha s cl era Normal Normal Normal Normal Normal
Page 782
> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Painful red eye: management
Painful red eye: management
W i t h a careful hi s t ory and exami nat i on, t he di agnos i s may become cl ear. Unl es s you are abs ol ut el y s ure of t he di agnos i s , di s c us s t he pat i ent w i t h an opht hal mol ogi s t .
Diagnosis of painful red eye in non-traumatic cases With prominent ocular discharge
Vi ral /bact eri al conjunct i vi t i s (wat ery/mucopurol ent di s charge, normal red refl ex, normal pupi l ) Bact eri al /fungal kerat i t i s (mucopurol ent di s charge, opaque cornea wi t h i mpai red red refl ex, normal or s l i ght l y reduced pupi l ) Kerat oconjunct i vi t i s s i cca or at opi c res pons e (dry eye, mucoi d s t rands ).
Without prominent discharge and normal red reflex Normal cornea

Epi s cl eri t i s , s cl eri t i s , or s ub-conjunct i val haemorrhage Orbi t al cel l ul i t i s (s ki n around orbi t eryt hemat ous and t ender) Carot i co-cavernous fi s t ul a (di l at ed conjunct i val ves s el s , forehead vei ns , and choroi dal ves s el s becaus e of art eri al i zat i on, reduced acui t y becaus e of opt i c nerve i s chaemi a, pul s at i l e propt os i s , and brui t ) Cavernous s i nus t hrombos i s [fever, acut e ons et pai nful opht hal mopl egi a, conjunct i val oedema and conges t i on,
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propt os i s , oedema over mas t oi d (emi s s ary vei n) may progres s t o meni ngi t i s ].
Abnormal cornea
Corneal abras i on or ul cer (NB: herpes s i mpl ex and herpes zos t er).
Without prominent discharge and impaired red reflex
Acut e gl aucoma (s evere pai n, markedl y reduced acui t y, cl oudy cornea, purpl e conges t i on at l i mbus , fi xed di l at ed pupi l , rockhard gl obe) Acut e ant eri or uvei t i s (mal ai s e, cl ear cornea, bl uered conges t i on at l i mbus , ant eri or chamber exudat e, i ri s muddy and i nject ed, s mal l pupi l wi t h reduced res pons e t o l i ght ) Endopht hal mi t i s (reduced acui t y, eyel i d s wel l i ng, conjunct i val i nject i on, ant eri or chamber cel l ul ar debri s , vi t reous cl oudi ng, ret i nal haemorrhages ) Kerat i t i s (red conges t i on at l i mbus , pupi l normal or reduced i n s i ze, cornea opaque) Cent ral corneal ul cer.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ac ut e bac t erial meningit is: assessment
Acute bacterial
meningitis: assessment
Presentation
Headac he, fever, nec k s t i ffnes s (abs ent i n 18% of pat i ent s ) , phot ophobi a (oft en over hours t o days ).
1
Ras h . Meni ngococcal meni ngi t i s i s mos t commonl y as s oci at ed wi t h a macul ar ras h progres s i ng t o pet echi ae or purpura (s ee P314) but ot her organi s ms may al s o caus e a ras h. Confus i on, ps yc hi at ri c di s t urbanc e (e.g. mani a) or al t ered l evel of c ons c i ous nes s . In t he el derl y (es peci al l y t hos e wi t h di abet es mel l i t us or cardi opul monary di s eas e) and t he i mmunocompromi s ed or neut ropeni c, t here may be l i t t l e ot her t han confus i on. Foc al neurol ogi c al s i gns compl i cat e meni ngi t i s i n at l eas t 15% cas es . Thes e can s ugges t cerebral damage (e.g. hemi pares i s fol l owi ng venous i nfarct i on or art eri t i s ) or i ndi cat e crani al nerve and brai ns t em i nvol vement by bas al exudat i on and i nfl ammat i on (e.g. i n Li s t eri a monoc yt ogenes meni ngi t i s ). They can al s o i ndi cat e brai n s hi ft s econdary t o rai s ed i nt racrani al pres s ure (s ee P526). Cons i der t he pos s i bi t y of brai n abs ces s or encephal i t i s i f focal s i gns or s ei zures are promi nent . Papi l l oedema i s uncommon (<1%) and s houl d s ugges t an al t ernat i ve di agnos i s . Sei zures are t he pres ent i ng feat ure i n up t o 30%.
2
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Us ual l y none, but acut e ot i t i s medi a, mas t oi di t i s , pneumoni a, head i njury, s i ckl e cel l di s eas e, al cohol i s m, and i mmunocompromi s ed s t at es are al l as s oci at ed.
Causes in adults
Common Nei s s eri a meni ngi t i di s St rep. pneumoni ae Rarer Gram negat i ve baci l l i (i n el derl y) Li s t eri a (i n el derl y)
Mort al i t y i ncreas es as cons ci ous nes s decreas es (~55% for adul t s i n coma). How ever , meni ngi t i s can proceed wi t h al armi ng rapi di t y even i n t he mos t al ert pat i ent s .
Management
St abi l i ze t he pat i ent (Ai rway, Breat hi ng, Ci rcul at i on); gi ve oxygen. Commence ant i bi ot i cs . It i s not neces s ary t o awai t CSF anal ys i s . CT s can pri or t o l umbar punct ure (t hi s i s t he s afes t opt i on). Make a defi ni t i ve di agnos i s wi t h l umbar punct ure. Recons i der ant i bi ot i c regi men aft er CSF anal ys i s . Cons i der adjunct i ve cort i cos t eroi d t herapy. Arrange for cont act s (i ncl udi ng medi cal /nurs i ng s t aff) t o have prophyl axi s . Not i fy t he publ i c heal t h s ervi ce. Obs erve for and, i f neces s ary, t reat compl i cat i ons .
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Footnote
1
Cons ens us St at ement on Di agnos i s , Inves t i gat i on, Treat ment and Prevent i on of Acut e Bact eri al Meni ngi t i s i n Immunocompet ent Adul t s (1999) J I nfec t 39 : 115.
2
Anders on M (1993) J Neurol Neuros urg Ps yc hi at 56 : 12431258.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ac ut e bac t erial meningit is: immediat e management
Acute bacterial
meningitis: immediate management

1 Antibiotic therapy: follow your hospital guidelines if available
Adul t pat i ent s wi t h a t ypi cal meni ngococcal ras h s houl d be gi ven i v benzyl peni c i l l i n 2.4g (4MU) every 4 hours . Adul t s bet ween 18 and 50 wi t hout a ras h s houl d recei ve c efot axi me 2g q8h or c eft ri axone 2g every 12 hours . For adul t s over 50 wi t hout a ras h cons i der addi t i on of 2g ampi ci l l i n every 4 hours t o cefot axi me or ceft ri axone as above (t o cover Li s t eri a ). If t he pat i ent comes from an area of t he worl d where peni ci l l i n and cephal os pori n-res i s t ant pneumococci are common (e.g. medi t erranean count ri es ) t hen add i v vanc omyc i n 500mg every 6 hours . If t he i ndi vi dual i s al l ergi c t o peni ci l l i n, cons i der i v c hl orampheni c ol 25mg/kg every 6 hours wi t h vanc omyc i n 500mg every 6 hours . Addi t i onal co-t ri moxazol e s houl d be gi ven i n t hos e over 50. Di s cus s t he cas e wi t h your mi crobi ol ogi s t .
1
Bl ood c ul t ures s houl d be t aken but i t i s dangerous t o wi t hol d i nt ravenous ant i bi ot i cs unt i l t hes e are t aken or l umbar punct ure i s performed. Mos t organi s ms wi l l be di agnos ed from bl ood cul t ures . Meni ngococcal i nfect i ons are di s cus s ed on P316.
2 CT scan
Our pol i cy i s t hat al l pat i ent s s houl d have a CT s can pri or t o l umbar punct ure. Ot hers s ugges t t hi s need be
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performed onl y i f t here i s decreas ed l evel of conci ous nes s , focal s i gns , papi l l oedema (very unus ual i n meni ngi t i s ), or s i gns s ugges t i ng i mpendi ng cerebral herni at i on P526. Y ou s houl d di s cus s t he pat i ent wi t h a s eni or member of your t eam.
3 Lumbar puncture
Meas ure openi ng pres s ure . CSF pres s ure i s oft en rai s ed (>14cm CSF) i n meni ngi t i s and t here are onl y a few report s of cerebral herni at i on (coni ng) fol l owi ng t he procedure. If t he pres s ure i s rai s ed t he pat i ent mus t be obs erved cl os el y at no l es s t han 15-mi nut e i nt erval s . A CT s can i s requi red t o excl ude a compl i cat i on of meni ngi t i s or a s pace-occupyi ng l es i on, e.g. cerebral abs ces s . Anal ys i s of CSF s ee t abl e oppos i t e bact eri al meni ngi t i s charact eri s t i cal l y demons t rat es a hi gh (us ual l y >1000/mm ) W CC wi t h predomi nance of neut rophi l s . A l ow CSF W CC (020/mm ) wi t h hi gh bact eri al count on Gram s t ai n i s as s oci at ed wi t h a poor prognos i s
3 3
CSF W CC
CSF gl ucos e CSF prot ei n Gram s t ai n
us ual l y reduced (CSF : bl ood gl ucos e rat i o <0.31 i n ~70%) but may be normal usual l y el evat ed (>1.0 g/l ) i s pos i t i ve i n 6090% but may not be i f t here has been a del ay bet ween s t art i ng ant i bi ot i cs and l umbar punct ure. Al s o t he yi el d of CSF cul t ure fal l s t o <50% from 7085%.
Thi s CSF profi l e may al s o occur wi t h vi ral and TB meni ngi t i s i n t he earl y phas e, but repeat CSF anal ys i s s hows t rans format i on t o a l ymphocyt i c predomi nance. Pat i ent s wi t h a CSF profi l e charact eri s t i c of bact eri al meni ngi t i s s houl d be t reat ed as i f t hey have t hi s condi t i on unt i l proven ot herwi s e. P.435
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CSF composition in meningitis

Bacterial Appearance
3
Viral Cl ear 5500 Lymphocyt e Normal 0.50.9 PCR
T B meningitis Cl ear 51000 Lymphocyt e Low Oft en >1.0 Zi ehl Neel s en Fl uores cent t es t PCR
Turbi d
Cel l s (per mm ) 52000 Mai n cel l t ype Gl ucos e (mM) Prot ei n (g/L) Ot her t es t s Neut rophi l Very l ow Oft en >1.0 Gram s t ai n Bact eri al ant i gen
See P952 for reference i nt erval s for CSF anal ys i s
Footnote
1
Cons ens us St at ement on Di agnos i s , Inves t i gat i on, Treat ment and Prevent i on of Acut e Bact eri al Meni ngi t i s i n Immunocompet ent Adul t s (1999) J I nfec t 39 : 115.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ac ut e bac t erial meningit is: c ont inuing t herapy
Acute bacterial
meningitis: continuing therapy

Reconsider antibiotics? Adjunctive steroids?
CSF l ymphoc yt os i s . If t he CSF pl eocyt os i s i s predomi nant l y l ymphocyt i c t he di agnos i s i s unl i kel y t o be bact eri al meni ngi t i s . Thi s i s di s cus s ed furt her on P440. CSF pol ymorphs >50 000/mm s ugges t s pos s i bi l i t y of cerebral abs ces s . A CT brai n s can s houl d be performed. CSF Gram s t ai n: i f Gram -ve di pl ococci are vi s i bl e cont i nue wi t h 2.4g benzyl peni c i l l i n i v every 4 hours or 2g ampi c i l l i n i v 4 hourl y. Di s cus s t he cas e wi t h your mi crobi ol ogi s t . If Gram +ve di pl ococci are vi s i bl e gi ve 2g c efot axi me i v 6 hourl y and cons i der addi ng vanc omyc i n 500mg i v 6 hourl y. If Gram +ve cocco-baci l l i s ugges t i ve of Li s t eri a monoc yt ogenes are vi s i bl e gi ve ampi c i l l i n 2g 4 hourl y i v and gent ami c i n 5mg/kg/24h i v as a s i ngl e dai l y dos e or di vi ded i nt o 8 hourl y dos es . Adjunc t i ve c ort i c os t eroi d t herapy has been s hown t o reduce t he i nci dence of neurol ogi cal s equel ae i n adul t s and chi l dren, es peci al l y i n pneumococcal meni ngi t i s and many neurol ogi s t s now favour i t s us e t o reduce i nfl ammat i on. In pat i ent s wi t h rai s ed ICP, s t upor, or i mpai red ment al s t at us , gi ve 10mg dexamet has one i v l oadi ng dos e, fol l owed by 46mg po q6h.
1 3
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Prophylaxis for contacts should be given immediately
Publ i c heal t h s ervi c es s houl d be not i fi ed of any cas e of bact eri al meni ngi t i s . They wi l l be abl e t o gi ve advi ce on current prophyl act i c t reat ment and vacci nat i on (pos s i bl e wi t h s ome s t rai ns of meni ngococcus ); t hey wi l l al s o as s i s t i n cont act t raci ng. Pat i ent s wi t h meni ngococcus are i nfect i ous and can s pread organi s ms t o ot hers . Li ai ze wi t h your l ocal mi crobi ol ogi s t s . Prophyl axi s s houl d be gi ven as s oon as t he di agnos i s of bact eri al meni ngi t i s i s s us pect ed. In t he UK, for adul t cont act s , ri fampi ci n 600mg bd for 2 days i s recommended. The al t ernat i ve for adul t s i s ci profl oxaci n 750mg as a s i ngl e dos e (for chi l dren ol der t han 1 year: 10mg/kg bd for 2 days ; for chi l dren 3 mont hs 1 year: 5mg/kg bd for 2 days ).
Footnote
1
De Gans J et al . (2002) New Engl J Med 347 : 15491556. Van de Beek D et al . (2003) Coc hrane Dat abas e Sys t Rev 2003 : CD004505.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ac ut e bac t erial meningit is: c omplic at ions and t heir t reat ment
Acute bacterial
meningitis: complications and their treatment
Rai s ed i nt rac rani al pres s ure may res pond t o s t eroi ds and, as di s cus s ed above, s ome neurol ogi s t s gi ve t hi s rout i nel y t o reduce i nfl ammat ory react i on. In t he acut e s i t uat i on, i f t here i s evi dence of brai n s hi ft or i mpendi ng t rans t ent ori al herni at i on (P526) manni t ol s houl d be gi ven 1g/kg over 1015 mi nut es (~250ml of 20% s ol ut i on for an average adul t ) and t he head of t he bed el evat ed t o 30 (s ee P448). Oral gl ycerol has al s o been s hown t o be effect i ve i n s ome s mal l t ri al s . Hydroc ephal us (di agnos ed by CT) may requi re an i nt ravent ri cul ar s hunt and s houl d be di s cus s ed urgent l y wi t h neurol ogi s t s . It can occur becaus e of t hi ckened meni nges obs t ruct i ng CSF fl ow or becaus e of t he adherence of t he i nfl amed l i ni ng of t he aqueduct of Syl vi us or fourt h vent ri cul ar out fl ow. Papi l l oedema may not be pres ent . Sei zures s houl d be t reat ed as s ei zures of any ot her aet i ol ogy (s ee P474). Pers i s t ent pyrexi a s ugges t s t hat t here may be an occul t s ource of i nfect i on. The pat i ent s houl d be careful l y re-exami ned (i ncl udi ng oral cavi t y and ears ). Foc al neurol ogi c al defi c i t may occur becaus e of art eri t i s or venous i nfarct i on or s pace-occupyi ng l es i on, e.g. s ubdural empyema. Infl ammat ory react i on at t he bas e of t he s kul l may l ead t o crani al nerve pal s i es . A CT
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s can s houl d be reques t ed i f i t has not al ready been performed. Ant i -coagul at i on i s not of benefi t for t reat ment of t hrombos es .
Subdural empyema i s a rare compl i cat i on. Focal s i gns , s ei z ures , and papi l l oedema s ugges t t he di agnos i s . It requi res urgent s urgi cal drai nage. Di s s emi nat ed i nt ravas c ul ar c oagul at i on i s an omi nous s i gn. Pl at el et and fres h frozen pl as ma may be requi red. The us e of hepari n s houl d be di s cus s ed wi t h a haemat ol ogi s t and neurol ogi s t . Syndrome of i nappropri at e ADH may occur. Fl ui d bal ance and el ect rol yt es need t o be checked regul arl y.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Meningit is wit h lymphoc yt ic CSF
Meningitis with lymphocytic
CSF
Presentation
Vi ral meni ngi t i s may be i ndi s t i ngui s habl e on cl i ni cal grounds from acut e earl y bact eri al meni ngi t i s but i t i s us ual l y s el f-l i mi t i ng. TB meni ngi t i s i s us ual l y preceded by a hi s t ory of mal ai s e and s ys t emi c i l l nes s for days t o weeks before meni ngeal feat ures devel op. However, i t may pres ent very acut el y. TB meni ngi t i s may be as s oci at ed wi t h bas al archnodi t i s , vas cul i t i s , and i nfarct i on l eadi ng t o focal neurol ogi cal s i gns , e.g. crani al nerve pal s i es , obs t ruct i ve hydrocephal us wi t h papi l l oedema. Crypt ococcal or s yphi l i t i c meni ngi t i s i n t he i mmunocompromi s ed pres ent wi t h feat ures i ndi s t i ngui s habl e from TB meni ngi t i s .
Causes
Viral Coxs acki e Echo Mumps Herpes s i mpl ex t ype 1 Vari cel l a zos t er HIV Lymphocyt i c Non-viral TB Crypt ococcus Lept os pi ros i s Lyme di s eas e Syphi l i s Brucel l os i s Parameni geal i nfect i on wi t h a
chori omeni ngi t i s vi rus
CSF react i on
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CSF findings
The CSF us ual l y demons t rat es a l ymphocyt os i s but t he CSF i n vi ral meni ngi t i s may i ni t i al l y demons t rat e predomi nant l y neut rophi l s . It i s i mport ant not t o di s mi s s t he pos s i bi l i t y of TB meni ngi t i s i f CSF gl ucos e i s normal ; i t may be i n ~20% of cas es and t he t uberci l i n t es t may al s o be negat i ve i ni t i al l y i n a s i mi l ar percent age. M. t uberc ul os i s i s s een i n t he i ni t i al CSF of approxi mat el y 40% of pat i ent s wi t h t ubercul ous meni ngi t i s . Send CSF for vi ral and TB PCR.
Treatment regimens

Vi ral meni ngi t i s : us ual l y s upport i ve t reat ment onl y. T B meni ngi t i s : pyrazi nami de 30mg/kg/day and i s oni azi d 10mg/kg/day (up t o a max of 600mg/day) achi eve bes t CSF penet rat i on. Gi ve pyri doxi ne 10mg dai l y as prophyl axi s agai ns t i s oni azi d neuropat hy. For t he fi rs t 3 mont hs , add ri fampi ci n (450mg/day i f wt <50kg or 600mg/day i f wt >50kg) and et hambut ol (25mg/kg/day) i f t he pat i ent i s not uncons ci ous . Thereaft er, for t he next 710 mont hs , gi ve i s oni azi d (at a l ower dos e of 300mg/day) and ri fampi ci n. Cons ul t your l ocal res pi rat ory/ID s peci al i s t s for advi ce. There are s everal ot her regi mens i n us e for M. t uberc ul os i s meni ngi t i s ; M. avi um i nt rac el l ul are requi res a di fferent combi nat i on of drugs .
1
Cort i c os t eroi ds are oft en pres cri bed i f t here are focal s i gns , rai s ed i nt racrani al pres s ure, or very hi gh l evel s of CSF prot ei n (s ee adjunct i ve t herapy for acut e bact eri al meni ngi t i s , P436).
Crypt oc oc c al meni ngi t i s : s everal regi mens are us ed. Amphot eri ci n B 0.61.0mg/kg/day al one or at a l ower dos e of 0.5mg/kg/day i n conjunct i on wi t h fl ucyt os i ne 150mg/kg/day for 6 weeks appears effect i ve. Fl uconazol e (400mg/day i ni t i al l y, t hen 200400mg/day for 68 weeks ) i s an al t ernat i ve whi ch appears t o be as effect i ve i n AIDS.
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Footnote
1
Berger JR (1994) Curr Opi n Neurol 7 : 191200.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ac ut e viral enc ephalit is
Acute viral encephalitis
Presentation

Change i n pers onal i t y . Confus i on, ps yc hi at ri c di s t urbanc e or al t ered l evel of c ons c i ous nes s . Headac he, fever and s ome nec k s t i ffnes s . Meni ngi s m i s us ual l y not promi nent : s ome i ndi vi dual s have a meni ngo-encephal i t i s . Foc al neurol ogi c al s i gns . Hemi pares i s or memory l os s (us ual l y i ndi cat i ve of t emporal l obe i nvol vement ) i s not uncommon. Sei zures are common; s ome are compl ex part i al i n nat ure. Rai s ed i nt rac rani al pres s ure and s i gns of brai n s hi ft (P526). Predi s pos i ng Fac t ors : i mmunocompromi s ed pat i ent .
Management
Antibiotic therapy If t here i s any s us pi ci on t hat t he i l l nes s i s meni ngi t i s , s t art ant i bi ot i cs (P434). It i s not neces s ary t o awai t CSF anal ys i s .
Specific anti-viral therapies Acycl ovi r has dramat i cal l y reduced mort al i t y and morbi di t y i n HSV encephal i t i s . Mos t cl i ni ci ans t herefore gi ve i t i n s us pect ed encephal i t i s wi t hout wai t i ng for confi rmat i on t hat t he pat hogen i s herpes s i mpl ex.
o
Ac yc l ovi r 10mg/kg i v (i nfus ed over 60 mi nut es ) every 8 hours (reduced dos e i n renal i ns uffi ci ency) i s gi ven for 1014 days .
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Ganc i c l ovi r 2.55.0mg/kg i v (i nfus ed over 60 mi nut es ) every 8 hours s houl d be gi ven i f cyt omegal ovi rus i s a pos s i bl e pat hogen (more l i kel y i n renal t rans pl ant pat i ent s or t hos e wi t h AIDS). Treat ment i s us ual l y for 1428 days dependi ng upon res pons e.
CT scan: scan all patients prior to LP In a pat i ent wi t h focal neurol ogi cal s i gns , focal s ei zures , or s i gns of brai n s hi ft a CT s can mus t be arranged urgent l y. CT may not demons t rat e any abnormal i t i es . In herpes s i mpl ex encephal i t i s t here may be l ow at t enuat i on areas , part i cul arl y i n t he t emporal l obes , wi t h s urroundi ng oedema. MR i magi ng i s more s ens i t i ve t o t hes e changes .
Lumbar puncture
o
Meas ure openi ng pres s ure . CSF pres s ure may be rai s ed (>14cm CSF) i n whi ch cas e t he pat i ent mus t be obs erved cl os el y at 15-mi nut e i nt erval s . Anal ys i s of CSF us ual l y reveal s a l ymphocyt i c l eukocyt os i s (us ual l y 5500/mm ) i n vi ral encephal i t i s , but i t may be ent i rel y normal . The red cel l count i s us ual l y el evat ed. PCR on CSF i s s ens i t i ve and s peci fi c. CSF prot ei n i s onl y mi l dl y el evat ed and gl ucos e i s normal .
3
Further investigations
o
Serol ogy: s ave s erum for vi ral t i t res (IgM and IgG). If i nfect i ous mononucl eos i s i s s us pect ed a monos pot t es t s houl d be performed. EEG: s houl d be arranged even i n t hos e wi t hout s ei zures . There may be general i zed s l owi ng and, i n herpes s i mpl ex encephal i t i s , t here may be burs t s of peri odi c hi gh-vol t age s l ow wave compl exes over t emporal cort ex.
P.443
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Complications
Neurol ogi cal obs ervat i ons s houl d be made regul arl y. Two compl i cat i ons may requi re urgent t reat ment .
Rai s ed i nt rac rani al pres s ure s econdary t o cerebral oedema may requi re t reat ment wi t h dexamet has one (s ee i nt racrani al s pace-occupyi ng l es i on, P458). There i s s ome experi ment al evi dence t hat s t eroi ds may pot ent i at e s pread of herpes vi rus , s o dexamet has one s houl d not be gi ven prophyl act i cal l y wi t hout a s peci fi c i ndi cat i on. In t he acut e s i t uat i on, i f t here i s evi dence of brai n s hi ft , manni t ol may be us ed (s ee rai s ed i nt racrani al pres s ure, P452). Anot her caus e of rai s ed ICP i s hameorrhage wi t hi n necrot i c t i s s ue. Perform a CT i f t here i s any det eri orat i on i n t he pat i ent and di s cus s wi t h neuros urgeons . Sei zures may be di ffi cul t t o cont rol but are t reat ed as s ei z ures of any ot her aet i ol ogy.
Causes in UK

Herpes s i mpl ex Vari cel l a zos t er Coxs acki e Cyt omegal ovi rus (i n i mmunocompromi s ed) Mumps Eps t ei nBarr vi rus Echovi rus
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Head injury: present at ion
Head injury: presentation
Vari es from t rans i ent s t unni ng for a few s econds t o coma. A fract i on of pat i ent s who at t end A&E need t o be admi t t ed for obs ervat i on (i ndi cat i ons for admi s s i on are gi ven i n on P449).
In t he al ert pat i ent , det ermi ne t he fol l owi ng.
Circumstances surrounding injury. W as i t caus ed by endogenous fact ors , e.g. l os s of cons ci ous nes s whi l s t dri vi ng? Or exogenous fact ors , e.g. anot her dri ver? W as t here ext racrani al t rauma? Period of loss of consciousness. Thi s rel at es t o s everi t y of di ffus e brai n damage. Period of post-traumatic amnesia. The peri od of permanent memory l os s aft er i njury al s o refl ect s degree of damage (NB: peri od of ret rograde amnes i a or memory l os s for event s pri or t o i njury does not correl at e wi t h s everi t y of brai n damage). Headache/vomiting. Common aft er head i njury but i f t hey pers i s t rai s ed i nt racrani al pres s ure s houl d be cons i dered (P452). GCS score. Skull fracture present? Neurological signs. Are t here any focal neurol ogi cal s i gns ? Extracranial injury. Is t here evi dence of occul t bl ood l os s ?
The drows y or uncons ci ous pat i ent needs t he fol l owi ng.
Urgent assistance from senior A&E staff and anaesthetists.
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Protection of airway. The pat i ent who has det eri orat i ng l evel of cons ci ous nes s or i s i n coma s houl d be i nt ubat ed becaus e hypocarbi a and adequat e oxygenat i on are effect i ve means of reduci ng i nt racrani al pres s ure rapi dl y. If t he pat i ent i s neurol ogi cal l y s t abl e and prot ect i ng t hei r ai rway, i nt ubat i on may not be neces s ary. As s ume t here i s a cervi cal s pi ne i njury unt i l an X-ray (of al l s even cervi cal vert ebrae) demons t rat es ot herwi s e. Hyperventilation. The pat t ern of breat hi ng s houl d be not ed (P524). Hypervent i l at i on of i nt ubat ed pat i ent s wi t h t he ai m of l oweri ng P a CO 2 i s cont rovers i al : cons ul t an i nt ens i vi s t . Support of circulation. Hypot ens i on s houl d be t reat ed i ni t i al l y wi t h col l oi d. If pers i s t ent or s evere, excl ude a cardi ac caus e (ECG) and occul t haemorrhage (e.g. i nt ra-abdomi nal ). T reatment of seizures. Di azepam 510mg i v/rect al l y whi ch may be repeat ed t o a maxi mum of 20mg. If s ei z ures cont i nue, cons i der i v phenyt oi n (P474). Rapid survey of chest, abdomen, and limbs. Looki ng for a fl ai l s egment or haemo/pneumot horax, pos s i bl e i nt ra-abdomi nal bl eedi ng (i f t here are any doubt s peri t oneal l avage may be requi red), l i mb l acerat i ons , and l ong bone fract ures . Brief history. Shoul d be obt ai ned from ambul ance crew or rel at i ves . The pat i ent may have l os t cons ci ous nes s jus t before t he i njury, e.g. due t o s ubarcahnoi d haemorrhage, s ei zure, or hypogl ycaemi a. The t empo of neurol ogi cal det eri orat i on s houl d be es t abl i s hed. Guidelines for performing skull X-rays and CT scans are on P446.
P.445
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Symptoms following head injury

Symptoms associated with minor head injury Headache, di zzi nes s , fat i gue, reduced concent rat i on, memory defi ci t , i rri t abi l i t y, anxi et y, i ns omni a, hyperacus i s , phot ophobi a, depres s i on, and general s l owed i nformat i on proces s i ng Symptoms associated with moderate to severe head injury As above, but al s o Behavi oural probl ems i ncl ude i rri t abi l i t y, i mpul s i vi t y, egocent ri ci t y, emot i onal l abi l i t y, i mpai red judgment , i mpat i ence, anxi et y, depres s i on, hyper- or hypo-s exual i t y, dependency, euphori a, aggres s i venes s , apat hy, chi l di s hnes s , and di s i nhi bi t i on Cogni t i ve i mpai rment i ncl udes defi ci t s of memory, di ffi cul t y i n abs t ract t hi nki ng, general s l owed i nformat i on proces s i ng, poor concent rat i on, s l ow react i on t i me, i mpai red audi t ory comprehens i on, reduced verbal fl uency, anomi a, and di ffi cul t y pl anni ng or organi zi ng
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Head injury: assessment
Head injury: assessment
Examination Rapid neurological assessment should take only a few minutes
The l evel of cons ci ous nes s mus t be not ed wi t h GCS s core (P520). Not e t he s i ze, s hape, and react i ons of pupi l s t o bri ght l i ght . Res t i ng eye pos i t i on and s ponat eous eye movement s s houl d be obs erved. If t he l at t er are not ful l and t he pat i ent unres pons i ve, t es t ocul ocephal i c and/or ocul oves t i bul ar res pons es (P530). The dol l 's head manoeuvre s houl d not be at t empt ed i f cervi cal s pi ne i njury has not been excl uded. Tes t t he corneal refl ex (crani al nerves V and VII). Mot or funct i on s houl d be as s es s ed (s ee P520); any as ymmet ry s houl d be not ed. Look for feat ures s ugges t i ng brai n s hi ft and herni at i on (P526).
Head and spine assessment
The s kul l s houl d be exami ned for a fract ure. Ext ens i ve peri orbat al haemat omas , brui s i ng behi nd t he ear (Bat t l e's s i gn), bl eedi ng from t he ear, and CSF rhi norrhoea/ot orrhoea s ugges t a bas al s kul l fract ure. Look for faci al (maxi l l ary and mandi bul ar) fract ures . Onl y 1% of pat i ent s wi l l have a s kul l fract ure. Thi s great l y i ncreas es t he chances of an i nt racrani al haemat oma (from 1 : 1000 t o 1 : 30 i n al ert pat i ent s ;
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from 1 : 100 t o 1 : 4 i n confus ed/comat os e pat i ent s ). NB: pot ent i al l y fat al i njuri es are not al ways as s oci at ed wi t h s kul l fract ure.
Cons i der t he pos s i bi l i t y of s pi nal cord t rauma. Log-rol l t he pat i ent and exami ne t he back for t endernes s over t he s pi nous proces s es , paras pi nal s wel l i ng, or a gap bet ween t he s pi nous proces s es . The l i mbs may have been found t o be fl acci d and unres poni ve t o pai n duri ng t he neurol ogi cal as s es s ment . There may be pai nl es s ret ent i on of uri ne.
Indications for skull X-ray

Hi s t ory of hi gh-i mpact i njury Decreas ed l evel of cons ci ous nes s Amnes i a Naus ea/vomi t i ng Neurol ogi cal s i gns /s ympt oms CSF/bl ood from nos e/ear Scal p brui s i ng/s wel l i ng Sus pect ed penet rat i ng i njury Di ffi cul t y i n cl i ni cal as s es s ment (e.g. al cohol , drugs , very young/el derl y) Sei z ures I f GCS <12/15, arrange an urgent head CT
Things to look for on skull X-rays

Li near s kul l fract ure (s ee above) Depres s ed s kul l fract ure (requi res el evat i on i f depres s ed by more t han t he vaul t t hi cknes s ) >3mm s hi ft of a cal ci fi ed pi neal (i f pres ent ) Int egri t y of crani ocervi cal junct i on Fl ui d l evel i n s phenoi d s i nus
P.447
Definite indications for CT scan 1
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Skul l fract ure and pers i s t ent neurol ogi cal dys funct i on Depres s ed l evel of cons ci ous nes s and/or neurol ogi cal dys funct i on (i nc. s ei zures ) Coma aft er res us ci t at i on Sus pect ed compound fract ure of vaul t or bas e of s kul l (e.g. CSF l eak) Skul l fract ure Confus i on/neurol ogi cal di s t urbance pers i s t i ng >12 hours Sei z ure Si gni fi cant head i njury requi ri ng general anaes t haes i a
Things to look for on C-spine films

Check al l 7 C-s pi n e vert ebr ae and C7-T1 junct i o n are vi s i bl e Ch ant eck eri al i or gn an me d nt pos t eri or of
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ver t eb ral bo di e s pos t eri or ma rgi n of s pi nal can al s pi no us pro ces s es A s t ep of >25% of vert ebral body s ugges t s facet joi nt di s l ocat i on Ch out eck l i n con es t ou of
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rs
ver t eb ral bo di e s out lin es of s pi no us pro ces s es
Look for avul s i on fract ures , wedge fract ures (>3mm hei ght di fference bet ween ant eri or and pos t eri or body hei ght ) Ch op eck en od mo ont ut h oi d an d l at era l vi e ws
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Th di s di s s pa t an ces ce bet s pa we ce en bet ant we . en arc ant h eri C1 or an C3 d an od d ont bac oi d k s ho ph ul d ary be ng <3 eal mm s ha di s do c w s pa >5 cea mm nd s ug od ges ont ts oi d ret rop Ch har
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eck yng s of eal t ma tis ss s ue (e. s g. abs ces s or ha em at o ma fro m fra ct u re of C2)
Footnote
1
Adapt ed from
Report of t he W orki ng Part y on t he Management of wi t h Head Injuri es (1999) Royal Col l ege of Surgeons of Engl and, London.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Head injury: immediat e management
Head injury: immediate
management
Aft er res us ci t at i on, t ake bl ood for FBC, G&S, U&Es , art eri al bl ood gas es and i f t he ci rcums t ances of i njury are not cl ear or t here i s a s us pi ci on of drug i nt oxi cat i on, t oxi c ol ogy s c reen . Subs equent management depends upon t he pace of event s and t he cl i ni cal s i t uat i on. >40% comat os e pat i ent s wi t h head i njury have i nt racrani al haemat omas and i t i s not pos s i bl e defi ni t i vel y t o di s t i ngui s h bet ween t hes e pat i ent s and t hos e who have di ffus e brai n i njury and s wel l i ng on cl i ni cal exami nat i on al one. Urgent CT s c an . Thi s i s t he next s t ep i n mos t pat i ent s who have depres s ed l evel of cons ci ous nes s or focal s i gns (s ee t abl e, P447). The s peed wi t h whi ch t hi s needs t o be arranged depends upon t he t empo of neurol ogi cal det ri orat i on (rel at i ve change i n GCS s core, P520) and/or t he abs ol ut e l evel of cons ci ous nes s (GCS <8). If CT s canni ng i s not avai l abl e at your hos pi t al you mus t di s cus s wi t h your regi onal neuros urgi cal cent re. T reat ment of rai s ed i nt rac rani al pres s ure i s di s cus s ed on P452; cort i cos t eroi ds have no proven benefi t . Di s cus s wi t h your neuros urgi cal cent re. In a rapi dl y det eri orat i ng s i t uat i on i t may be neces s ary t o proceed di rect l y t o s urgery. It may be deci ded t o hypervent i l at e and t o gi ve manni t ol (1g/kg over 1015 minut es or ~250ml of 20% s ol ut i on for an average adul t ) and frus emi de (2040mg i v) whi l e obt ai ni ng an urgent CT
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s can.
Surgery may be i ndi cat ed for ext radural (P460), s ubdural (P464), and pos s i bl y s ome i nt racerebral haemorrhages (P462) and compl ex head wounds s uch as compound depres s ed s kul l fract ures .
o
A general rul e i s urgent evacuat i on i s requi red of ext radural haemat omas whi ch produce mi d-l i ne s hi ft of 5mm or more and/or 25ml i n cal cul at ed vol ume. If t he ext raduaral haemorrhage i s cons i dered t oo s mal l t o warrant s urgery on a CT s can performed wi t hi n 6 hours of i njury, t he s can s houl d be repeat ed aft er a few hours i rres pect i ve of whet her t here has been a det eri orat i on i n t he pat i ent 's condi t i on.
Non-operat i ve management . Brai n cont us i on may be evi dent as areas of i ncreas ed or decreas ed dens i t y but CT i s not a s ens i t i ve way t o det ect pri mary di ffus e brai n i njury. Effacement of t he cavi t y of t he t hi rd vent ri cl e and of t he peri mes encephal i c ci s t erns s ugges t s rai s ed i nt racrani al pres s ure but t he abs ence of t hes e s i gns i s not t o be t aken as an i ndi cat or or normal i nt racrani al pres s ure. Many cent res t herefore proceed t o i nt racrani al pres s ure moni t ori ng (P948) al t hough t hi s i s a cont rovers i al s ubject .
P.449
Indications for admission following head injury

Confus i on Abnormal CT s can Decreas ed l evel of cons ci ous nes s (<15/15) Cl i ni cal or radi ol ogi cal evi dence of s kul l fract ure Neurol ogi cal s i gns or s evere headache + vomi t i ng
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Di ffi cul t y i n as s es s ment (e.g. al cohol , drugs , very young/el derl y) Concurrent medi cal condi t i ons (e.g. cl ot t i ng di s orders , di abet es ) Poor s oci al ci rcums t ances /l i vi ng al one
NB: Very bri ef l os s of cons ci ous nes s or pos t -t raumat i c amnes i a are not abs ol ut e i ndi cat ors for admi s s i on but each pat i ent needs t o be as s es s ed on t hei r own meri t s .
If patients are discharged they should be sent home with
A res pons i bl e adul t who wi l l be wi t h t hem over t he next 24 hours A head i njury card whi ch des cri bes pot ent i al s i gns and s ympt oms (e.g. undue s l eepi nes s , headache, vomi t i ng, or di zzi nes s ) of del ayedneurol ogi cal dys funct i on
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Head injury: furt her management
Head injury: further
management
The ai m of s ubs equent management i s t o mi ni mi ze s econdary i njury t o t he brai n ot her t han i nt racrani al haemat omas (s ee t abl e). Management may be bet t er undert aken at a neuros urgi cal cent re and i f t hi s i s arranged t he gui del i nes oppos i t e s houl d be fol l owed for t rans fer. The pri nci pl es of management are
Regul ar and frequent neurol ogi c al obs ervat i on . If t here i s det eri orat i on cons i der whet her t here may be a s econdary caus e of brai n i njury cont ri but i ng t o t hi s (s ee t abl e). If t here are new s i gns of rai s ed i nt racrani al pres s ure, decl i ni ng l evel of cons ci ous nes s , or s i gns of t rans t ent ori al herni at i on (P526), t he pat i ent requi res i nt ubat i on and hypervent i l at i on i f t hi s has not al ready been performed. Manni t ol may be s t art ed or a repeat bol us may need t o be gi ven (s ee P454) and repeat CT s canni ng may be neces s ary. Regul ar moni t ori ng of BP, bl ood gas es , el ec t rol yt es , uri nary out put . Pre-empt i ve t reat ment of a decl i ne i n any of t hes e may prevent neurol ogi cal det eri orat i on. Hypot ens i on i s commonl y due t o s edat i ve agent s and/or hypovol aemi a. But fl ui d t herapy needs t o be conduct ed wi t h care becaus e overgenerous admi ni s t rat i on may exacerbat e rai s ed i nt racrani al pres s ure. Moni t or CVP. Prompt t reat ment of s ei zures (P474). Nas ogas t ri c t ube t o admi ni s t er nut ri t i on and drugs i ncl udi ng rani t i di ne 150mg bd for prophyl axi s agai ns t gas t ri c ul cerat i on.
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A bow el regi men of s t ool s oft eners s houl d be s t art ed.
Before transfer to Neurosurgical Unit 1
As s es s cl i ni cal l y for res pi rat ory i ns uffi ci ency, s hock, and i nt ernal i njuri es . Perform CXR, art eri al bl ood gas es t i mat i on, cervi cal s pi ne X-ray. Appropri at e t reat ment mi ght be t o
o o
i nt ubat e (e.g. i f ai rway obs t ruct ed or t hreat ened) vent i l at e (e.g. cyanos i s , P a O 2 <7.9kPa, P a CO 2 >5.9kPa) commence i v fl ui ds careful l y gi ve manni t ol , aft er cons ul t at i on wi t h neuros urgeon appl y cervi cal col l ar or cervi cal t ract i on.
o o
Pat i ent s houl d be accompani ed by pers onnel abl e t o i ns ert or t o repos i t i on endot racheal t ube, t o i ni t i at e or mai nt ai n vent i l at i on, t o admi ni s t er oxygen and fl ui ds , and t o us e s uct i on.
P.451
Indications for neurosurgical referral (and/or urgent CT head scan) following head injury 1a

Recent i nt racrani al l es i on s een on CT Pers i s t i ng coma (<9/15) aft er i ni t i al res us ci t at i on Confus i on whi ch pers i s t s for >4 hours Progres s i ve focal neurol ogi cal s i gns Sei z ure wi t hout ful l recovery Depres s ed s kul l fract ure Defi ni t e or s us pect ed penet rat i ng i njury CSF l eak or ot her s i gn of a bas al s kul l fract ure Urgent CT i ndi cat ed but no l ocal faci l i t i es avai l abl e
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Causes of secondary brain injury 2

Systemic Hypoxaemi a Hypot ens i on Hypercarbi a Severe hypocapnoea Pyrexi a Hyponat raemi a Anaemi a DIC i nt racerebral ) Brai n s wel l i ng/oedema Rai s ed ICP Cerebral vas os pas m Epi l eps y Int racrani al i nfect i on Intracranial Haemat oma (ext radural , s ubdural , or
Footnote
1
Mendel ow AD & Teas dal e G (1991) In Swas h M & Oxbury J, ed. Cl i ni c al Neurol ogy , Sect i on 14, p. 698.
1a
Adapt ed from Report of t he W orki ng Part y on t he Management of wi t h Head Injuri es (1999) Royal Col l ege of Surgeons of Engl and, London.
2
Mi l l er JD (1993) J Neurol Neuros urg Ps yc hi at 56 : 440447.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Raised int rac ranial pressure (
Raised intracranial pressure
(ICP)
Presentation
Normal ICP i n adul t s i s 010mmHg at res t . Treat ment i s requi red when i t exceeds 1520mmHg for >5 mi nut es . Sympt oms and s i gns s ugges t i ve of rai s ed ICP i ncl ude
Headac he and Vomi t i ng wors e i n morni ngs ; exacerbat ed by bendi ng. Foc al neurol ogi c al s i gns may occur i f t here i s a s pace-occupyi ng l es i on and i n s ome met abol i c condi t i ons (e.g. l i ver fai l ure). But t here may al s o be fal s e l ocal i zi ng s i gns , e.g. VIt h crani al nerve pal s y. Sei zures may occur wi t h s pace-occupyi ng l es i ons , CNS i nfect i on, or met abol i c encephal opat hi es as s oci at ed wi t h rai s ed ICP. Papi l l oedema i s pres ent onl y i f t here i s CSF obs t ruct i on. I mpai red l evel of c ons c i ous nes s : from mi l d confus i on t o coma. Si gns of brai n s hi ft may accompany decreas i ng l evel of cons ci ous nes s . They are di s cus s ed wi t h exami nat i on of brai ns t em funct i on (P524). Lat e s i gns : bradyc ardi a and hypert ens i on (Cus hi ng res pons e) probabl y res ul t s from di rect medul l ary compres s i on. It s cl i ni cal val ue i s probabl y overemphas i zed i n compari s on t o ot her s i gns of brai n s hi ft (P526).
1
Causes
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Head i njury i nt racrani al haemat oma/brai n s wel l i ng/cont us i on St roke (haemorrhagi c, major i nfarct , venous t hrombos i s ) Met abol i c (hepat i c or renal fai l ure, DKA, hyponat raemi a, et c.) CNS i nfect i on (abs ces s , encephal i t i s , meni ngi t i s , mal ari a) CNS t umour St at us epi l ept i cus Hydrocephal us (of any caus e) Beni gn i nt racrani al hypert ens i on.

GCS (P524) Si gns of brai n s hi ft and brai ns t em compromi s e (P526).
Management

St abi l i ze t he pat i ent Cons i der act i ve means of reduci ng ICP At t empt t o make a di agnos i s Treat fact ors whi ch may exacerbat e rai s ed ICP Obs erve for s i gns of det eri orat i on and at t empt t o revers e t hem Cons i der s peci fi c t herapy.
W hat fol l ows i s t he management for s t abi l i zi ng a pat i ent pres ent i ng acut el y wi t h rai s ed ICP and may not be appropri at e for many pat i ent s wi t h a l ong progres s i ve hi s t ory of det eri orat i on. P.453
Practice point
A morni ng occi pi t al headache may i ndi cat e rai s ed ICP or cervi cal s pondyl os i s .
1a
Footnote
1
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1a
Hawkes C (2002) Hos p Med 63 :73242.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Raised int rac ranial pressure: immediat e management
Raised intracranial
pressure: immediate management

Open t he ai rw ay by l ayi ng t he pat i ent on t hei r s i de. Gi ve oxygen. Meas ure art eri al bl ood gas es . Int ubat i on and mechani cal vent i l at i on may be neces s ary becaus e of res pi rat ory compromi s e. It may al s o be neces s ary t o reduce ICP by hypervent i l at i ng t he pat i ent (s ee bel ow) t o keep P a CO 2 bet ween 3.34.0kPa (2530mmHg). Correc t hypot ens i on . Vol ume expans i on wi t h col l oi ds or i nfus i ons of i not ropes needs t o be conduct ed wi t h careful and frequent moni t ori ng of CVP and/or pul monary art ery wedge pres s ure. In general , pat i ent s wi t h rai s ed ICP s houl d be fl ui d res t ri ct ed t o 1.52.0L/day. So i f vol ume expans i on i s requi red i t s houl d be kept t o t he mi ni mum requi red t o res t ore BP. T reat s ei zures (P474). Exami ne rapi dl y for s i gns of head i njury (P444). If t he pat i ent i s hypot ens i ve, exami ne careful l y for any occul t s i t e of bl eedi ng. If t here i s a ras h, cons i der t he pos s i bi l i t y of meni ngococcal meni ngi t i s ; t ake bl ood cul t ures and gi ve ant i bi ot i cs (P434). Take bl ood for gl uc os e (t hi s may be rai s ed i n di abet i c ket oaci dos i s or hyperos mol ar non-ket ot i c s t at es , i t may be very l ow i n l i ver fai l ure), U&Es (bi ochemi cal as s es s ment of dehydrat i on and renal funct i on, pot as s i um for s us cept i bi l i t y t o dys rhyt hmi a, hyponat raemi a from i nappropri at e ADH, or
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hypernat raemi a from aggres s i ve di uret i c-i nduced dehydrat i on), LFT s , al bumi n, c l ot t i ng s t udi es and ammoni um (t o as s es s l i ver funct i on), FBC , and bl ood c ul t ure .
Measures to reduce ICP

The val ue of ICP moni t ori ng i s a cont rovers i al s ubject . Irres pect i ve of whet her or not your pat i ent 's ICP i s moni t ored, t he fol l owi ng i nt ervent i ons s houl d be cons i dered.
El evat e head of bed t o ~30 (once cervi cal s pi ne i njury has been excl uded) t o promot e venous drai nage. Hypervent i l at i on s o t hat P a CO 2 i s kept bet ween 3.73.9kPa wi l l promot e cerebral vas ocons t ri ct i on and l ower cerebral bl ood vol ume: t hi s requi res i nt ubat i on and paral ys i s . It wi l l al s o l ower t he BP and may compromi s e cerebral ci rcul at i on. In pat i ent s wi t h l i ver fai l ure t hi s i s no l onger recommended. Di s cus s wi t h your l ocal ITU. Manni t ol : 0.51g/kg over 1015 mi nut es (~250ml of 20% s ol ut i on for an average adul t ) reduces ICP wi t hi n 20 mi nut es and i t s effect s s houl d l as t for 26 hours . Frus emi de 2040mg i v may be gi ven wi t h manni t ol t o pot ent i at e i t s effect . If requi red furt her bol us es of s mal l er dos es of manni t ol (0.250.5g/kg) may be gi ven every few hours . U&Es and s erum os mol al i t y s houl d be moni t ored as a profound di ures i s may res ul t . Serum os mol al i t y s houl d not be al l owed t o ri s e over 320mOs m/kg. Cort i c os t eroi ds are of benefi t i n reduci ng oedema around s pace-occupyi ng l es i ons (P458) but are not hel pful i n t he t reat ment of s t roke or head i njury. Dexamat has one i s gi ven as a l oadi ng dos e of 10mg i v. It may be fol l owed by 46mg q6h po/vi a NG t ube. P.455
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Fl ui d res t ri c t i on t o 1.52.0L/day. U&Es mus t be checked frequent l y. Cool i ng t o 35 C reduces cerebral i s chaemi a. Avoi d/t reat hypergl yc aemi a becaus e i t exacerbat es i s chaemi a.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Raised int rac ranial pressure: furt her management
Raised intracranial
pressure: further management

Attempt to make a diagnosis
Oft en t he hi s t ory makes t he di agnos i s obvi ous and us ual l y rai s ed ICP i s a s econdary di agnos i s . If a hi s t ory i s not avai l abl e, focal neurol ogi cal s i gns or focal s ei zures s ugges t an underl yi ng s t ruct ural cerebral l es i on (al t hough s uch s i gns may occur wi t h hepat i c or renal fai l ure). Meni ngi s m rai s es t he pos s i bi l i t y of s ubarachnoi d haemorrhage or meni ngi t i s . A CT s c an s houl d be performed i n al l pat i ent s s us pec t ed of havi ng rai s ed I CP before l umbar punc t ure i s c ons i dered . (Lumbar punct ure s houl d be di s cus s ed wi t h a s eni or col l eague and/or Neurol ogi s t .) Bl ood s ent for anal ys i s on admi s s i on may hel p t o det ect met abol i c caus es of rai s ed ICP.
Benign intra-cranial hypertension

Beni gn i nt racrani al hypert ens i on (BIH) i s a s yndrome of rai s ed i nt racrani al pres s ure i n t he abs ence of an i nt racrani al mas s l es i on or hydrocephal us . Al t hough rarel y l i fe-t hreat eni ng, BIH can caus e permanent vi s ual l os s due t o opt i c nerve damage. Thi s di s order affect s 1 i n 100 000 of t he popul at i on overal l , but t hi s i ncreas es t o 1 : 5000 obes e women of chi l d-beari ng age. There i s a predomi nance i n women over men (4 : 1), aged 1745 years .
Presentation

Cons t ant but vari abl e headaches Vi s ual di s t urbances (i ncl . di pl opi a, vi s ual obs curat i ons , s cot oma) naus ea Probl ems wi t h bal ance, memory
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Ti nni t us Neck and back pai ns The pres ence of focal neurol ogy i ncl . epi l eps y does NOT occur i n BIH. Pres ervat i on of cerebral funct i on di s t i ngui s hes BIH from acut e vi ral encephal i t i s or bact eri al meni ngi t i s . Fundos copy al mos t i nvari abl y s hows papi l l oedema (maybe uni l at eral ).
Associations

Obes i t y i s pres ent i n >90% Mens t rual probl ems Drugs (t et racycl i ne, i s oret i noi n and et ret i nat e, nal i di xi c aci d, ni t rofurant oi n, and l i t hi um) Oral cont racept i ve pi l l St eroi d wi t hdrawal Increas ed s pont aneous abort i on
Investigations

CT head s can or MRI are us ual l y normal . Lumbar punct ure reveal s an el evat ed CSF pres s ure (>20cm, but may i ncreas e i n obes i t y anyway).
P.457
Treatments (seek advice)

Los i ng wei ght Repeat ed t herapeut i c LP every 25 days Predni s ol one (4060mg/day) i s effect i ve i n rel i evi ng t he headache and vi s ual obs curat i on due t o papi l l oemea. However, s t eroi ds are t o be avoi ded l ong t erm. acet azol ami de +/- frus emi de, s urgi cal s hunt i ng (l umboperi t oneal s hunt s ).
Treat factors which exacerbate raised ICP 1
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Hypoxi a/hyperc apni a . Art eri al bl ood gas es need t o be meas ured regul arl y. I nadequat e anal ges i a, s edat i on, or mus c l e rel axat i on l ead t o hypert ens i on. NB: hypert ens i on s houl d not be t reat ed aggres s i vel y. Pai n, e.g. from uri ne ret ent i on, may be t he caus e. Rapi d l oweri ng of BP may l ead t o wat ers hed/border zone cerebral i nfarct s . Sei zures are not al ways eas y t o i dent i fy i n paral yzed pat i ent s . Pyrexi a i ncreas es cerebral met abol i s m and, as a cons equence, cerebral vas odi l at at i on. It al s o appears t o i ncreas e cerebral oedema. The caus e of pyrexi a s houl d be s ought but paracet amol (gi ven rect al l y) and act i ve cool i ng s houl d be commenced. Hypovol aemi a . Hyponat raemi a i s us ual l y t he res ul t of fl ui d overl oad but may be caus ed by a s yndrome of i nappropri at e ADH s ecret i on. Treat wi t h DDAVP 14g i v dai l y (s ee P572).
Consider specific therapy
Once a di agnos i s i s es t abl i s hed i t may be appropri at e t o cons i der s urgery i n order t o decompres s brai n or i ns ert a vent ri cul ar s hunt t o drai n CSF. Int racrani al i nfect i ons need t o be t reat ed wi t h t he mos t s ui t abl e ant i bi ot i cs . Hypergl ycaemi a (ket ot i c/non-ket ot i c) and l i ver or renal fai l ure have t hei r own s peci fi c management (s ee rel evant s ect i ons ). Oft en, however, t here may not be a s peci fi c i nt ervent i on t hat i s appropri at e, e.g. cont us i on fol l owi ng head i njury, and management i s confi ned t o opt i mi zi ng a pat i ent 's condi t i on whi l s t awai t i ng recovery.
Footnote
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1
Pi ckard JD & Cz os nyka M (1993) J Neurol Neuros urg Ps yc hi at 56 : 845858.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Int rac ranial spac e- oc c upying lesion
Intracranial
space-occupying lesion
Presentation
Sympt oms of rai s ed i nt rac rani al pres s ure : headache, naus ea, and vomi t i ng (s ee P452). Papi l l oedema i s pres ent i n t he mi nori t y of cas es . Foc al neurol ogi c al s ympt oms and s i gns . Thes e depend upon l ocat i on of t he l es i on, i t s ext ent and t hat of s urroundi ng cerebral oedema, and compres s i on of l ong t ract fi bres or crani al nerves . Some l es i ons , part i cul arl y t hos e i n t he front al l obe, are rel at i vel y s i l ent and may produce no s i gns or s i mpl y change i n pers onal i t y. Sei zures . I mpai red l evel of c ons c i ous nes s rangi ng from confus i on t o coma. Si gns of brai n s hi ft (P526) may be pres ent . Fever s ugges t s an i nfect i on. There may be a recent hi s t ory of ear ache/di s charge, t oot h ache, forei gn t ravel , or i mmune compromi s e. Ac ut e ons et of s ympt oms s ugges t s t he pos s i bi l i t y of a vas cul ar event , ei t her pri mary or bl eedi ng i nt o anot her t ype of l es i on, e.g. t umour.
Management
Depends upon t he di agnos i s . In a comat os e i ndi vi dual wi t h known i noperabl e brai n met as t as es i t i s us ual l y not appropri at e t o i nt ervene. On t he ot her hand, i f a pat i ent pres ent s for t he fi rs t t i me wi t h s i gns s ugges t i ve of a s pace-occupyi ng l es i on t he
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di agnos i s needs t o be es t abl i s hed.
As s es s s everi t y
o
If comat os e, prot ect t he ai rway and manage as on P408. If t here are s i gns of brai n s hi ft whi ch s ugges t i mpendi ng t rans t ent ori al herni at i on (P526) gi ve manni t ol 0.51g/kg over 1015 mi nut es (100250ml of 20% s ol ut i on for an average adul t ) and hypervent i l at e t o keep P a CO 2 bet ween 3.73.9kPa. Thi s may be fol l owed by s mal l er dos es of manni t ol every few hours (P454). If t he pat i ent i s al ert and s t abl e i t i s bes t t o awai t CT s can and i n t he i nt eri m make regul ar neurol ogi cal obs ervat i ons .
If t he pat i ent i s pyrexi al or t he hi s t ory i s s ugges t i ve of i nfec t i on , bl ood, s put um, and uri ne cul t ures s houl d be s ent . An urgent CT s can s houl d be arranged for t hes e cas es ; CSF anal ys i s may be neces s ary but l umbar punct ure s houl d not be performed before t he s can or di s cus s i on wi t h neurol ogi s t s /neuros urgeons . If a vas c ul ar event i s s us pect ed a CT s houl d al s o be arranged urgent l y becaus e decompres s i on may be pos s i bl e. Sei zures s houl d be t reat ed. If t hey are recurrent , t he pat i ent may requi re l oadi ng wi t h i v phenyt oi n. Many neuros urgeons , gi ve oral phenyt oi n prophyl act i cal l y t o pat i ent s (300mg/day; t herapeut i c l evel s are not reached for at l eas t 5 days ). St eroi d t herapy i s gi ven i f i t i s t hought t hat s ome of t he s ympt oms /s i gns are due t o t umour-rel at ed brai n oedema. Gi ve dexamet has one 10mg i v (l oadi ng dos e), fol l owed by 46mg po or ng q6h. Thi s i s a l arge dos e of s t eroi d (NB: dexamet has one 20mg/day equi val ent t o predni s ol one 130mg/day) and uri ne/bl ood gl ucos e s houl d be moni t ored. Durat i on of t herapy i s gui ded by res pons e t o s t eroi d and t he pat i ent 's general condi t i on.
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Neuros urgery/radi ot herapy may be of s ome benefi t i n s ome i ndi vi dual s : di s cus s wi t h your regi onal neuros urgi cal cent re.
P.459
Common causes of intracranial space-occupying lesions

Cerebral t umour (1/2) Subdural haemat oma Int racerebral haemorrhage Tubercul oma Cerebral abs ces s Ext radural haemat oma Subdural empyema Toxopl as mos i s (i mmunocompromi s ed)
Practice point
Hemi -s ens ory l os s i nvol vi ng t he t runk i s l i kel y t o be due t o a deep l es i on i nvol vi ng t he t hal amus . Compl et e hemi -s ens ory l os s may be s een i n funct i onal di s orders , and can be di s t i ngui s hed by pl aci ng a t uni ng fork on each s i de of t he forehead and t he s t ernum. Pat i ent s wi t h funct i onal di s eas e report t hat vi brat i on i s l es s on t he affect ed s i de, whi ch i s anat omi cal l y not pos s i bl e.
1
Footnote
1
Hawkes C (2002) Hos p Med 63 :73242.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ext radural haemorrhage
Extradural haemorrhage
Presentation
There are no s peci fi c di agnos t i c feat ures . Cons i der t he di agnos i s i n any head-i njured pat i ent who fai l s t o i mprove or cont i nues t o det eri orat e.

Head i njury i s al mos t i nvari abl e. Skul l frac t ure pres ent i n over 90% of adul t cas es . Headac he and vomi t i ng may occur. I mpai red l evel of c ons c i ous nes s . There may be an i ni t i al l uci d i nt erval fol l owi ng head i njury but ext radural haemat omas may be pres ent i n pat i ent s who have been i n coma cont i nuous l y aft er t he i njury. Uncommonl y, i f t he caus e i s a dural venous s i nus t ear (rat her t han s heari ng of a meni ngeal art ery) l uci d i nt erval may ext end for s everal days . Sei zures . Cont ral at eral hemi pares i s and ext ens or pl ant ar may be el i ci t ed. Si gns of brai n s hi ft (P526).
Causes
Common Head i njury t eari ng of meni ngeal art ery (commonl y mi ddl e meni geal ) Rare Head i njury dural s i nus t ear Int racrani al i nfect i on (s i nus es , mi ddl e ear, orbi t ) Ant i -coagul ant s /bl ood dys cras i a
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Bi l at eral ext ens or pl ant ars or s pas t i ci t y, ext ens or res pons e t o pai nful s t i mul i , and coma are s evere effect s of an ext radural haemorrhage.
Management
Depends upon t empo of pres ent at i on. Pri ori t i es are
St abi l i ze t he pat i ent : prot ect t he ai rway; gi ve oxygen, s upport t he breat hi ng and ci rcul at i on. As s ume C-s pi ne i njury t i l l excl uded. T reat s ei zures (P474). Urgent CT s c an
o
Haemat omas wi t h >5mm mi d-l i ne s hi ft on CT and/or >25ml cal cul at ed vol ume requi re urgent evacuat i on. If t he ext raduaral haemorrhage i s cons i dered t oo s mal l t o warrant s urgery on a CT s can performed wi t hi n 6 hours of i njury, t he s can s houl d be repeat ed aft er a few hours i rres pect i ve of whet her t here has been a det eri orat i on i n t he pat i ent 's condi t i on.
Cl os el y moni t or neurol ogi c al s t at e (i nc. GCS)

o
If t he pat i ent s l i ps i nt o coma and s i gns of t ent ori al herni at i on (P526) are progres s i ng rapi dl y, gi ve 1g/kg of 20% manni t ol as a bol us and i nform on-cal l s urgeons . If t here i s evi dence of brai n s hi ft , di s cus s wi t h neuros urgeons : i nt racrani al pres s ure s houl d be reduced wi t h manni t ol (0.51.0g/kg 20% manni t ol ) and hypervent i l at i on (P454).
Al l pat i ent s mus t be di s c us s ed w i t h neuros urgeons . Neurol ogi cal i mpai rment i s pot ent i al l y revers i bl e i f t he ext radural haemat oma i s t reat ed earl y.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Int rac erebral haemorrhage
Intracerebral haemorrhage
Presentation
Headac he , naus ea, and vomi t i ng of s udden ons et i s common. Foc al neurol ogi c al defi c i t : t he nat ure of t hi s depends upon l ocat i on of haemorrhage. Put ami nal haemorrhages (~30% of cas es ) or l obar bl eeds (~30% of cas es ) may l ead t o cont ral at eral hemi pares i s and s ens ory l os s , vi s ual fi el d di s t urbance, dys phas i a (l eft hemi s phere), or s pat i al negl ect (more s evere wi t h ri ght hemi s phere l es i ons ). In ot her words , t hey may pres ent l i ke a mi ddl e cerebral art ery i nfarct (P488) but oft en t here i s a great er al t erat i on i n t he l evel of cons ci ous nes s . Thal ami c haemorrhages (~10% cas es ) may res ul t i n eye s i gns (forced downgaze, upgaze paral ys i s , or s kew devi at i on) as wel l as cont ral at eral s ens ory l os s and hemi pares i s . Cerebeal l ar haemorrhage i s deal t wi t h on P492 and pont i ne bl eeds on P490. Sei zures may occur. Gl obal neurol ogi c al defi c i t wi t h decreas i ng l evel of cons ci ous nes s progres s i ng t o coma. There may be s i gns of brai n s hi ft (P526). Hypert ens i on .
Common predisposing factors

Hypert ens i on (4050%). Ant i -coagul ant s . Met as t at i c neopl as m: bl eeds may occur wi t hi n l es i on. Drug abus e (al cohol , cocai ne, ps eudoephedri ne, amphet ami nes ).
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A l ow GCS (<9), a l arge-vol ume haemat oma, and t he pres ence of vent ri cul ar bl ood on t he i ni t i al CT are fact ors t hat are predi ct i ve of a hi gh mort al i t y rat e.
Management
Pri ori t i es are
St abi l i ze t he pat i ent : prot ect t he ai rway, gi ve oxygen i f requi red, s upport t he ci rcul at i on i f neces s ary or appropri at e, commence general meas ures for t reat i ng comat os e pat i ent (P408) i f neces s ary. If t here i s evi dence of rai s ed i nt racrani al pres s ure, i t s houl d be reduced (s ee P454). Correct bl eedi ng t endency or effect s of ant i -coagul ant s . Make a defi ni t i ve di agnos i s wi t h urgent CT s can. Li ai ze wi t h regi onal neuros urgery uni t earl y as s urgi cal i nt ervent i on may be of benefi t . W het her aggres s i ve i nt ervent i on i s appropri at e s houl d be deci ded earl y. If appropri at e, i nt ens i ve care/hi gh dependency ward nurs i ng obs ervat i ons are requi red for t he drows y or comat os e pat i ent i f t hey are not t rans ferred t o neuros urgi cal cent re i mmedi at el y. Surgi cal decompres s i on may be benefi ci al : us ual l y for acces s i bl e bl eeds wi t hi n t he pos t eri or fos s a (s ee P492), put amen, or t hal amus . Pat i ent s who have a s ei zure at t he ons et of t he haemorrhage s houl d recei ve i v ant i -convul s ant s . Hypert ens i on i s common. If s ys t ol i c BP >200 or di as t ol i c >120mmHg fol l owi ng a haemorrhagi c s t roke, i t probabl y s houl d be t reat ed t o l i mi t vas ogeni c oedema, but t hi s i s cont rovers i al , Subl i ngual ni fedi pi ne i s bes t avoi ded as i t may caus e a profound fal l i n BP. W e recommend at enol ol 2550mg po i f neces s ary.
1 2
Footnote
1
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O'Connel l JE & Gray C (1994) BMJ 308: 15231524.

2
Lavi n P (1986) Arc h I nt Med 146: 6668.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Subdural haemat oma
Subdural haematoma
Presentation
Thi s may pres ent i n one of t wo ways : acut e or chroni c. Bot h are us ual l y t he res ul t of t eari ng of bri dgi ng vei ns (bet ween cort i cal s urface and venous s i nus es ). Acut e haemorrhage i nt o t he s ubdural s pace fol l ows head i njury and can be i mpos s i bl e t o di s t i ngui s h on cl i ni cal grounds from ext radural haemorrhage (P460). A chroni c haemat oma i s al s o preceded i n mos t cas es by head i njury but t hi s i s oft en s o t ri vi al t hat pat i ent s are unabl e t o recol l ect i t . Bot h t ypes of pat i ent may pres ent wi t h
o o o
Skul l frac t ure (more common i n acut e cas es ) Headac he I mpai red and fl uc t uat i ng l evel of c ons c i ous nes s rangi ng from mi l d confus i on, t hrough cogni t i ve decl i ne (e.g. i mpai red memory) t o coma. The di agnos i s s houl d be cons i dered i n any i ndi vi dual , part i cul arl y el derl y, who pres ent s wi t h i nt el l ect ual det eri orat i on or dement i a of rel at i vel y recent ons et Foc al neurol ogi c al s i gns (hemi pares i s , dys phas i a, hemi anopi a, et c.) Sei zures occur i n a mi nori t y of pat i ent s Si gns of brai n s hi ft (P526) or papi l l oedema .
o o

Head i njury: i n young or ol d Ol d age: cort i cal at rophy s t ret ches bri dgi ng vei ns . Long-s t andi ng al cohol abus e
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Ant i -coagul ant us e.
The fol l owi ng are s evere effect s of an s ubdural haemorrhage

Bi l at eral ext ens or pl ant ars or s pas t i ci t y Ext ens or res pons e t o pai nful s t i mul i Coma.
Management
Depends upon t empo of pres ent at i on.
In s us pect ed chronic cases , a CT s can i s requi red l es s urgent l y unl es s t here has been an acut e det eri orat i on on a background of s t eady neurol ogi cal decl i ne. Chroni c haemat omas become i s odens e wi t h brai n and are t herefore s omet i mes di ffi cul t t o di s t i ngui s h; magnet i c res onance i magi ng may be bet t er. In acute cases , pri ori t i es are
o
Prot ect i on of ai rway, gi ve oxygen, s upport t he breat hi ng and ci rcul at i on as neces s ary. Li ai s on wi t h neuros urgi cal t eam earl y. Cl os e moni t ori ng of neurol ogi cal s t at e (GCS). Cons i der met hods t o reduce i nt racrani al pres s ure i f rai s ed (P454): i f t he pat i ent s l i ps i nt o coma and s i gns of t ent ori al herni at i on (P526) are progres s i ng rapi dl y, gi ve 1g/kg of 20% manni t ol as a bol us , i nform on-cal l s urgeon, and very urgent CT s can. Treat s ei zures (P474).
o o o
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Subarac hnoid haemorrhage: assessment
Subarachnoid
haemorrhage: assessment
Presentation
Headac he : cl as s i cal l y s udden and s evere (t hundercl ap), radi at i ng behi nd t he occi put wi t h as s oci at ed neck s t i ffnes s . Oft en, t he t i me from ons et t o peak of headache i s onl y a few s econds , but l es s dramat i c pres ent at i ons are common. Cons i der t he di agnos i s i n any unus ual l y s evere headache, es peci al l y i f t he pat i ent does not have a previ ous hi s t ory of headaches and i s over 40 years . Approx. 4% of aneurys mal bl eeds occur at /aft er s exual i nt ercours e, but mos t coi t al headaches are not s ubarachnoi d haemorrhages . 10% of pat i ent s wi t h s ubarachnoi d bl eeds are bendi ng or l i ft i ng heavy object s at ons et of s ympt oms . Naus ea, vomi t i ng, di zzi nes s may be t rans i ent or prot ract ed. I mpai red l evel of c ons c i ous nes s : t here may be i ni t i al t rans i ent l os s of cons ci ous nes s fol l owed by vari abl e i mpai rment . Pat i ent s may pres ent i n coma. Earl y foc al neurol ogi c al s i gns may occur, es peci al l y i f t here has been a concomi t ant i nt racerebral haemorrhage. Thi rd nerve pal s y rai s es pos s i bi l i t y of pos t eri or communi cat i ng aneurys m. Sei zures are uncommon, but s ubarachnoi d haemorrhage i n a pers on known t o have fi t s s ugges t s underl yi ng AV mal format i on.
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Heral d bl eed : Bet ween 20 and 50 % of pat i ent s wi t h document ed SAH report a di s t i nct , unus ual l y s evere headache i n t he days or weeks before t he i ndex bl eed. Thes e are oft en mi s di agnos ed as s i mpl e headaches or mi grai ne, s o a hi gh degree of s us pi ci on i s requi red. Pat i ent s may pres ent wi t h s econdary head i njury fol l owi ng col l aps e. Bl ood s een on CT s canni ng may be at t ri but ed t o t rauma.
1
Causes
Common Aneurys m (70%) AV mal format i on (5%) 20% Rare Cl ot t i ng di s order/ant i -coagul ant s Tumour
No known caus e i n up t o Vas cul i t i s As s oci at ed wi t h pol ycys t i c ki dney di s eas e
Assessment of severity (prognostic features)
Hunt & Hess Scale al l ows gradi ng at pres ent at i on and t hereaft er:
Grade 1 Grade 2
As ympt omat i c or mi ni mal headache + s l i ght neck s t i ffnes s Moderat e or s evere headache wi t h neck s t i ffnes s , but no neurol ogi cal defi ci t ot her t han crani al nerve pal s y Drows i nes s wi t h confus i on or mi l d focal neurol ogy St upor wi t h moderat e t o s evere hemi pares i s or mi l d decerebrat e ri gi di t y Deepl y comat os e wi t h s evere decerebrat e ri gi di t y.
Grade 3 Grade 4 Grade 5
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Prognos i s i s bes t i n Grade 1 (mort al i t y <5%), wors t i n Grade 5 (mort al i t y 5070%), and i nt ermedi at e i n bet ween. Neurol ogi cal det eri orat i on fol l owi ng pres ent at i on has a wors e prognos i s . Pat i ent s s houl d be re-graded on t he Hunt & Hes s Scal e.
P.467
Practice points
Fi rs t and wors t headache i n s omeone not prone t o headaches s houl d s ugges t vas cul ar t umours or expandi ng aneurys m
1
Thundercl ap headache may be due t o a rupt ured i nt ra-crani al aneurys m

1a
Pat i ent s who wake, oft en at t he s ame t i me, wi t h s evere uni l at eral orbi t al pai n wi l l us ual l y have cl us t er headache. Mos t l y mi ddl e-aged mal es .
1a
Footnote
1
Edl ow JA & Capl an LR (2000) New Engl J Med 342 : 2935.

1a
Hawkes C (2002) Hos p Med 63 :73242.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Subarac hnoid haemorrhage: immediat e management
Subarachnoid
haemorrhage: immediate management
Once t he di agnos i s i s confi rmed, di s cus s wi t h regi onal neuros urgeons . Trans fer Grade 1 and 2 pat i ent s as s oon as pos s i bl e. Surgery wi l l prevent rebl eedi ng and al t hough opt i mal t i me for operat i on i s debat ed (2 days vers us 710 days pos t bl eed), out come i s probabl y i mproved by earl y t rans fer. Surgery on poor prognos i s pat i ent s i s unrewardi ng; t hey are us ual l y managed cons ervat i vel y. However, s ui t abi l i t y for s urgery s houl d be re-as s es s ed i f t hei r condi t i on i mproves .
Prot ec t t he ai rw ay by l ayi ng t he drows y pat i ent i n t he recovery pos i t i on. Gi ve oxygen. Cons i der meas ures t o reduc e i nt rac rani al pres s ure i f s i gns s ugges t i t i s rai s ed (P452) but avoi d dehydrat i on and hypot ens i on. T reat s ei zures wi t h us ual drugs (P474) but beware of over-s edat i on and hypot ens i on. Correc t hypot ens i on i f neces s ary wi t h col l oi d or i not ropes . T o avoi d hypert ens i on t he pat i ent s houl d be nurs ed i n a qui et room, s edat i ves may be requi red, and s t ool s oft eners s houl d be gi ven t o avoi d s t rai ni ng. Once t he di agnos i s i s es t abl i s hed, ni modi pi ne i s us ual l y gi ven t o
Pa g e 8 4 0
reduce vas os pas m; i t hel ps al s o t o reduce bl ood pres s ure.
ECG moni t ori ng and t reat dys rhyt hmi as i f t hey compromi s e bl ood pres s ure or t hreat en t hromboembol i s m. Rarel y s ubarachnoi d haemorrhage i s as s oci at ed wi t h (neurogeni c) pul monary oedema. Take bl ood for c l ot t i ng s c reen (i f bl eedi ng di at hes i s s us pect ed) and U&Es (bi ochemi cal as s es s ment of dehydrat i on, pot as s i um for s us cept i bi l i t y t o dys rhyt hmi a, hyponat raemi a from i nappropri at e ADH or hypernat raemi a from aggres s i ve di uret i c-i nduced dehydrat i on).
Confirm the diagnosis
Urgent hi gh-res ol ut i on CT s c anni ng i s requi red. Thi s wi l l cl i nch t he di agnos i s i n 95% of pat i ent s s canned wi t hi n 24 hours . Furt hermore, i t gi ves val uabl e i nformat i on regardi ng pos s i bl e l ocat i on of aneurys m and may even demons t rat e AV mal format i on. It may al s o di s pl ay concomi t ant i nt racerebral and/or i nt ravent ri cul ar bl eeds . Lumbar punc t ure i s not us ual l y requi red, unl es s CT s can i s normal but t he hi s t ory i s hi ghl y s ugges t i ve. It i s i mport ant t o exami ne t he CSF for bl ood under t hes e ci rcums t ances ; t he pres ent i ng event may be a warni ng l eak. Bl ood i n t he CSF may res ul t from a t raumat i c t ap. If t hi s i s t he cas e t here s houl d be di mi ni s hi ng numbers of red cel l s i n each s ucces s i ve t ube of CSF (al t hough t hi s i s not al ways rel i abl e). If t he bl ood has been pres ent for >6 hours , t he s upernat ant s houl d be xant hochromi c aft er cent ri fugat i on.
Footnote
1
Kopi t ni k TA & Sams on DS (1993) J Neurol Neuros urg Ps yc hi at 56 : 947959.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Subarac hnoid haemorrhage: furt her management
Subarachnoid
haemorrhage: further management

Specific therapies
Ni modi pi ne i s a cal ci um channel bl ocker whi ch works preferent i al l y on cerebral ves s el s t o reduce vas os pas m (and cons equent cerebral i s chaemi a). It has been s hown t o reduce morbi di t y and mort al i t y fol l owi ng SAH. Gi ve 60mg po (or i n t he comat os e pat i ent ) every 4 hours ; i nt ravenous t herapy i s cos t l y and requi res cent ral venous acces s . Ant i -fi bri nol yt i c s were i nt roduced t o prevent l ys i s of cl ot and rebl eedi ng. They have been as s oci at ed wi t h i ncreas ed t hrombot i c compl i cat i ons and are not advi s ed at pres ent . Appropri at e anal ges i a (codei ne phos phat e 3060mg every 4 t o 6 hours ) and ant i -emet i cs s houl d be gi ven for awake pat i ent s .
2 1
Observe for deterioration. Attempt to reverse it

Neurol ogi c al obs ervat i ons s houl d be performed regul arl y. If t here i s a det eri orat i on, e.g. l oweri ng of t he l evel of cons ci ous nes s , a CT s can s houl d be performed. There are s everal pos s i bl e mechani s ms for det eri orat i on:
Cerebral i s c haemi a i s us ual l y i ns i di ous and mul t i -focal . It may gi ve ri s e t o focal and/or gl obal neurol ogi cal det eri orat i on. Vol ume expans i on wi t h col l oi d or i nduced hypert ens i on wi t h i not ropes have been at t empt ed but
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t hes e procedures have not been properl y s t udi ed.
Rebl eedi ng may be i mmedi at el y fat al or l ead t o apnoea. It i s report ed t hat as s i s t ed vent i l at i on for 1 hour may be al l t hat i s neces s ary for s pont aneous breat hi ng t o ret urn t o t he majori t y of apnoei c i ndi vi dual s . Pat i ent s who rebl eed are at hi gh ri s k of furt her bl eedi ng and s houl d be cons i dered for emergency aneurys m cl i ppi ng. Ac ut e hydroc ephal us may be t reat ed wi t h vent ri cul ar drai nage. Thi s can l ead t o dramat i c i mprovement i n t he pat i ent 's condi t i on.
3
Refer for definitive treatment

Unl es s t he pat i ent has a poor prognos i s (s ee Hunt & Hes s s cal e, P466), t hey s houl d be cared for at a neuros urgi cal cent re. The compl i cat i ons l i s t ed above s houl d be managed by cl i ni ci ans experi enced i n t reat i ng t hem.
Footnote
1
Pi ckard JD et al . (1989) BMJ 298 : 636642.

2
Ki rkpat ri ck PJ (2002) J Neurol Neuros urg Ps yc hi at 73 (s uppl . 1): i 28i 33.

3
van Gi jn J (1992) Lanc et 339 : 653655.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > St at us epilept ic us (t onic c lonic ) 1
Status epilepticus
(tonicclonic) 1
Presentation
General i z ed t oni ccl oni c s t at us epi l ept i cus i s ei t her cont i nuous t oni ccl oni c convul s i ons (30 mi nut es or l onger) or convul s i ons s o frequent t hat each at t ack begi ns before t he previ ous pos t -i ct al peri od ends .
Causes

Cerebral t umour (1/1) Int racrani al i nfect i on Hypogl ycaemi a Head i njury El ect rol yt e di s t urbance (l ow s odi um, cal ci um, or magnes i um) Drug overdos e (e.g. t ri cycl i cs ) Drug wi t hdrawal (e.g. al cohol ) Hypoxi a (e.g. pos t cardi ac arres t ) Sequel a of s t roke Ant i -epi l ept i c non-compl i ance/wi t hdrawal
NB: mos t epi s odes of s t at us do not occur i n known epi l ept i c pat i ent s .
Management Priorities

St abi l i ze t he pat i ent . Gi ve oxygen Ant i -epi l ept i c drug t herapy At t empt t o i dent i fy aet i ol ogy Ident i fy and t reat medi cal compl i cat i ons
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Ini t i at e l ong-t erm mai nt enance t herapy i f appropri at e.
Open t he ai rw ay by l ayi ng t he pat i ent on s i de i n a s emi prone pos i t i on wi t h t he head s l i ght l y l ower t o prevent as pi rat i on. Us ual l y an oral ai rway wi l l s uffi ce and endot racheal i nt ubat i on i s rarel y neces s ary. Gi ve oxygen . Correc t hypot ens i on wi t h col l oi d i f neces s ary. Obt ai n an ECG i f t he pat i ent i s hypot ens i ve. CVP moni t ori ng may be neces s ary. Take bl ood for U&Es , gl uc os e, c al c i um, magnes i um, l i ver enzymes , FBC (i nc . pl at el et s ) ; i f rel evant , bl ood s houl d al s o be s ent for t oxi c ol ogy s c reen (i f drug overdos e or abus e s us pect ed) and ant i -c onvul s ant l evel s . T hi ami ne 250mg i v s houl d be gi ven i f al cohol i s m or ot her mal nouri s hed s t at es appear l i kel y. If hypogl ycaemi a i s s us pect ed 50ml of 50% gl uc os e s houl d be admi ni s t ered i v. Becaus e gl ucos e i ncreas es t he ri s k of W erni cke's encephal opat hy, t hi ami ne 12mg/kg i v s houl d be admi ni s t ered beforehand i n any pat i ent s us pect ed of al cohol exces s .
Anti-epileptic drug therapy

A number of agent s may be us ed:

Benzodi azepi nes (di azepam, l orazepam) Phenyt oi n Fos phenyt oi n Mi s cel l aneous (general anaes t hes i a, paral dehyde).
P.473
Practice point
Int ermi t t ant ol fact ory hal l uci nat i ons may i ndi cat e a mal i gnant gl i oma of t he ant eromedi al t emporal l obe
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(uncus ) l eadi ng t o unci nat e fi t s .
Footnote
1
Hawkes C (2002) Hos p Med 63 :73242.
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Status epilepticus
(tonicclonic) 2
Anti-epileptic drug therapy 1
Di azepam 1020mg i v or rect al l y, repeat ed once 15 mi nut es l at er i f neces s ary. Int ravenous i nject i on s houl d not exceed 25mg/mi n. Di azepam i s rapi dl y redi s t ri but ed and t herefore has a s hort durat i on of act i on. W i t h repeat ed dos i ng, however, as peri pheral l i pi d compart ment s become s at urat ed, t here i s l es s redi s t ri but i on and bl ood di azepam l evel s i ncreas e. W hen t hi s happens t here i s a ri s k of s udden cent ral nervous and res pi rat ory depres s i on as wel l as cardi ores pi rat ory col l aps e. If s ei zures cont i nue, gi ve l orazepam 0.07mg/kg i v (us ual l y 4mg bol us whi ch may be repeat ed once aft er 10 mi nut es ). Becaus e l orazepam does not accumul at e i n l i pi d s t ores and has s t rong cerebral bi ndi ng and a l ong durat i on of act i on, i t has di s t i nct advant ages over di azepam i n earl y s t at us epi l ept i cus . If s ei zures cont i nue, gi ve phenobarbi t al 10mg/kg i v at a rat e of 100mg/mi n (i .e. about 70mg i n an average adul t over 7 mi nut es ). If s ei zures cont i nue 30 mi nut es aft er fi rs t admi ni s t rat i on of an ant i -epi l ept i c agent , s t art an i nfus i on of phenyt oi n at 1518mg/kg at a rat e of 50mg/mi n (e.g. 1g over 20 mi nut es ). NB: 5% dext ros e i s not compat i bl e wi t h phenyt oi n. The pat i ent s houl d have ECG moni t ori ng becaus e phenyt oi n may i nduce
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cardi ac dys rhyt hmi as ; pul s e, BP, and res pi rat ory rat e s houl d al s o be moni t ored. i v phenyt oi n i s rel at i vel y cont rai ndi cat ed i n pat i ent s wi t h known heart di s eas e, part i cul arl y t hos e wi t h conduct i on abnormal i t i es .
An al t ernat i ve i s fos phenyt oi n gi ven as an i nfus i on of 15mg PE (phenyt oi n equi val ent s ) at a rat e of 100mg PE/mi n (i .e. about 1000mg PE i n an average adul t over 10 mi nut es ). In refract ory s t at us (s ei zures cont i nui ng for 6090 mi nut es aft er i ni t i al t herapy), t he pat i ent s houl d be t rans ferred t o i nt ens i ve care.
o
General anaes t hes i a wi t h ei t her propofol or t hi opent one s houl d be admi ni s t ered. Paral dehyde (510ml i m) i s an al t ernat i ve but requi res gl as s s yri nges as i t corrodes rubber and pl as t i c. T reat rai s ed i nt rac rani al pres s ure (P452). EEG moni t ori ng s houl d be commenced. The anaes t het i c agent s houl d be cont i nued for 1224 hours aft er t he l as t cl i ni cal or el ect rographi c s ei zure; t he dos e s houl d t hen be t apered down.
o o o
I f t reat ment i s fai l i ng t o c ont rol s ei zures , c ons i der w het her

Ini t i al drug dos e i s adequat e Mai nt enance t herapy has been s t art ed and i s adequat e Underl yi ng caus e of s t at us epi l ept i cus has been correct l y i dent i fi ed Compl i cat i ons of s t at us adequat el y t reat ed (s ee bel ow) Co-exi s t i ng condi t i ons have been i dent i fi ed (e.g. hepat i c fai l ure) There has been a mi s di agnos i s : i s t hi s ps eudo s t at us ?
Footnote
1
Shorvon SD (2001) J Neurol Neuros urg Ps yc hi at 70 (s uppl . 2):
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i i 22i i 27.
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Status epilepticus
(tonicclonic) 3
Attempt to identify aetiology
A hi s t ory of previ ous ant i -convul s ant us e, drug abus e/wi t hdrawal (i ncl udi ng al cohol ), di abet es , t rauma, or recent s urgery (e.g. hypocal caemi a pos t t hyroi d or parat hyroi d s urgery) i s obvi ous l y hel pful . Exami ne t he pat i ent for s i gns of head t rauma, meni ngi s m, focal neurol ogi cal defi ci t (t he s ei zures may al s o have s ome focal charact eri s t i cs ), needl e t racks , or i ns ul i n i nject i on s i t es . Cons i der urgent CT s can i f head i njury may be a preci pi t ant ; a l umbar punct ure may be neces s ary i f CSF i nfect i on i s l i kel y. Al t hough hypogl ycaemi a and hypocal caemi a s houl d be correct ed prompt l y, hyponat raemi a s houl d be revers ed caut i ous l y becaus e of t he pos s i bi l i t y of preci pi t at i ng pont i ne myel i nos i s .
Identify and treat medical complications of status

Treat ment i s requi red for

Hypoxi a Lact i c aci dos i s Hypogl ycaemi a Dys rhyt hmi as Rhabdomyol ys i s El ect rol yt e di s t urbance (es peci al l y hyponat raemi a,
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hypo/hyperkal aemi a)

Hypot ens i on/hypert ens i on Rai s ed i nt racrani al pres s ure Hyperpyrexi a Pul monary oedema Di s s emi nat ed i nt ravas cul ar coagul at i on
Thes e compl i cat i ons are managed as i n ot her cont ext s .
Initiate long-term therapy (if appropriate)

Some di s orders , e.g. hypogl ycaemi a i n a di abet i c t aki ng i ns ul i n, do not requi re l ong-t erm ant i -convul s ant t herapy, but rat her correct i on of t he underl yi ng probl em. Ot her condi t i ons may need ant i -convul s ant t reat ment for a s hort whi l e, e.g. al cohol wi t hdrawal , or i ndefi ni t el y, e.g. repeat ed s t at us epi l ept i cus i n mul t i -i nfarct dement i a.
Sodi um val proat e i s now cons i dered fi rs t -choi ce t reat ment , wi t h c arbamazepi ne as an al t ernat i ve. Ini t i al l y, s odi um val proat e s houl d be gi ven 400600mg/day oral l y i n t hree di vi ded dos es (i nt ravenous t herapy can al s o be gi ven). It s houl d be i ncreas ed by 200mg/day at 36-day i nt erval s ; t he mai nt enance dos e i s 2030mg/kg/day (us ual adul t dos e i s 12g/day). Carbamazepi ne s houl d be s t art ed at 100200mg 12 t i mes dai l y; t he mai nt enance dos e i s 715mg/kg/day di vi ded i n 23 dos es (200800mg/day for adul t s ). Phenyt oi n may be cont i nued aft er i nt ravenous l oadi ng at dai l y dos ages of 5mg/kg (about 300mg for an average adul t ) ei t her oral l y or vi a a nas ogas t ri c t ube or s l ow i nt ravenous i nfus i on. Dos age s houl d be gui ded by phenyt oi n l evel meas urement s . Pl as ma concent rat i on for opt i mum res pons e i s 1020mg/L (4080mol /L). Phenyt oi n i s di s advant ageous becaus e i t requi res moni t ori ng.
1
P.477
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Driving advice
In t he UK, pat i ent s s houl d i nform t he Dri vi ng and Vehi cl e Li cens i ng Agency (Swans ea). Dri vi ng l i cences are revoked unt i l t he pat i ent has been free of dayt i me s ei zures for 1 year, t reat ed or unt reat ed. Dri vers of l arge goods or pas s enger carryi ng vehi cl es us ual l y have t hos e l i cences revoked permanent l y. For current medi cal s t andards of fi t nes s t o dri ve go t o ht t p://www.dvl a.gov.uk/at _a_gl ance/cont ent .ht m
Footnote
1
Smi t h D & Chadwi ck D (2001) J Neurol Neuros urg Ps yc hi at 70 (s uppl . 2): i i 15i i 21.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > St roke: overview
Stroke: overview
Presentation
Sudden-ons et focal defi ci t of cerebral funct i on i s t he mos t common pres ent at i on. Al t ernat i ve pres ent at i ons i ncl ude apparent confus i on (e.g. due t o dys phas i a or vi s uos pat i al i mpai rment ), s ei z ures , decl i ni ng l evel s of cons ci ous nes s or gl obal l os s of brai n funct i on and coma. If t he s ympt oms l as t for >24 hours (or l ead t o deat h) and t here i s no apparent caus e ot her t han a vas cul ar event , t he di agnos i s i s mos t l i kel y t o be a s t roke. If t he s ympt oms l as t <24 hours and, aft er adequat e i nves t i gat i on, are pres umed t o be due t o t hrombos i s or embol i s m, t he di agnos i s i s a TIA.
Causes
Thrombos i s or embol i s m caus i ng cerebral i nfarct i on (~80% cas es ) Pri mary i nt racerebral haemorrhage (~15% cas es ) Subarachnoi d haemorrhage (~5% cas es ) Cerebral venous t hrombos i s (1%).
Risk factors
See t abl e.
Many condi t i ons may mas querade as a s t roke:

Cerebral t umour (1 or 2) Brai n abs ces s Demyel i nat i on Focal mi grai ne
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Subdural haemat oma Todd's pares i s (pos t s ei zure) Hypogl ycaemi c at t ack Encephal i t i s . Pat i ent s l es s t han 45 Pres ence of s ei zures Pres ence of papi l l oedema Prol onged and/or di s cont i nuous evol ut i on of s ympt oms . Abs ence of ri s k fact ors Fl uct uat i ng l evel of cons ci ous nes s Pyrexi a (at pres ent at i on)
An al t ernat i ve di agnos i s t o s t roke i s more l i kel y i n

In general , a s t roke commences s uddenl y and t he defi ci t i s at i t s peak and es t abl i s hed wi t hi n 24 hours . If t he evol ut i on of s ympt oms i s l onger or progres s es i n a s t ut t eri ng way over days or weeks , a s pace-occupyi ng l es i on mus t be s us pect ed. If t here i s a vari abl e depres s i on of cons ci ous nes s , t he di agnos i s of a s ubdural haemat oma s houl d be ent ert ai ned, and pyrexi a at pres ent at i on s houl d al ert one t o t he pos s i bi l i t y of a cerebral abs ces s . Sei z ures occur i n 510% of s t rokes at t hei r ons et al t hough t hey are frequent s equel ae. Papi l l oedema woul d be ext remel y unus ual i n art eri al s t rokes but may occur i n cerebral venous s i nus t hrombos i s . Cons i der t hi s di agnos i s part i cul arl y i n pat i ent s who may have become dehydrat ed and a young women (part i cul arl y duri ng t he puerperi um) wi t h headache and s ei zures focal s i gns . Di s s ect i on of t he i nt ernal carot i d or vert ebral art eri es s houl d al ways be cons i dered, part i cul arl y i n younger pat i ent s who may have experi enced onl y mi l d neck t rauma. Oft en, however, t here may be no cl ear hi s t ory of precedi ng t rauma. Carot i d di s s ect i on may be accompani ed by a Horner's s yndrome; vert ebral di s s ect i on pres ent s wi t h s ympt oms as s oci at ed wi t h brai ns t em s t roke. P.479
Risk factors for stroke
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Global

Increas i ng age Hypert ens i on Di abet es Fami l y hi s t ory Increas ed l i pi ds Homocys t ei naemi a Drug abus e Smoki ng OCP HRT Di vi ng (Cai s s on's di s eas e) Neck t rauma/mani pul at i on Cerebrovas cul ar di s eas e Berry aneurys ms Cerebral amyl oi d Cerebral AV mal format i on At ri al fi bri l l at i on Myocardi al i nfarct i on Left vent ri cul ar aneurys m Is chaemi c heart di s eas e Cyanot i c heart di s eas e Pat ent foramen oval e Endocardi t i s Carot i d s t enos i s Pul monary AV mal format i ons Ehl ers Danl os Type IV (carot i d di s s ect i on) Hypercoagul abl e s t at es Pol ycyt haemi a Si ckl e cel l di s eas e
Lifestyle

Cerebral

Cardiac

Peripheral vascular

Haematological

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W arfari n (haemorrhage) Thrombol ys i s
OCP = Oral cont racept i ve Pi l l HRT = Hormone repl acement t herapy
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > St roke: haemorrhage or infarc t ?
Stroke: haemorrhage or
infarct?
Int racerebral haemorrhage oft en has an apopl ect i c ons et wi t h a combi nat i on of headache, neck s t i ffnes s , vomi t i ng, and l os s of cons ci ous nes s of acut e ons et . Cons ci ous l evel can be depres s ed for over 24 hours , t here may be bi l at eral ext ens or pl ant ar res pons es and t he bl ood pres s ure i s more l i kel y t o be rai s ed 24 hours aft er admi s s i on. But al t hough feat ures s uch as t hes e have been i nt egrat ed i nt o s cori ng s ys t ems , i t i s not pos s i bl e wi t h cert ai nt y t o di fferent i at e i s chaemi c from haemorrhagi c s t roke on cl i ni cal grounds al one. A CT s can i s requi red.
When to scan?
Al l pat i ent s s us pect ed of havi ng a s t roke s houl d be s canned wi t hi n 48 hours of ons et . CT i s t he i nves t i gat i on of choi ce i n t he majori t y of cas es becaus e i t i s bet t er at det ect i ng haemorrhage i n t he earl y s t ages compared wi t h MRI. Aft er t he fi rs t 24 hours , and i n cas es where t he s t roke i s s us pect ed t o i nvol ve brai ns t em or cerebel l um, MRI i s s uperi or. W here t he CT s can i s normal , di ffus i on-wei ght ed MRI may reveal areas of cerebral i s chaemi a or i nfarct i on. Urgent CT s houl d be performed i n t he pres enc e of

Depres s ed l evel of cons ci ous nes s Hi s t ory of ant i -coagul ant t reat ment or known coagul opat hy No avai l abl e hi s t ory Feat ures s ugges t i ng an al t ernat i ve di agnos i s requi ri ng i mmedi at e act i on, i n part i cul ar
o
Subarachnoi d haemorrhage (s evere headache, depres s ed l evel of cons ci ous nes s , neck s t i ffnes s )
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Subdural haemorrhage (headache, hi s t ory of mi nor t rauma, progres s i ve or fl uct uat i ng s i gns and s ympt oms ) Space-occupyi ng l es i on (depres s ed l evel of cons ci ous nes s , progres s i ve s i gns , papi l l oedema) Cerebral i nfect i on (headache, fever, neck s t i ffnes s , crani al nerve pal s i es )
Indi cat i ons for t hrombol ys i s or earl y ant i -coagul at i on.
Brai n i magi ng s houl d al ways be undert aken before ant i -coagul ant t reat ment i s s t art ed.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > St roke: ot her invest igat ions
Stroke: other investigations
Apart from a CT s can, t here are s ome bas i c t es t s t hat mos t pat i ent s s us pect ed of havi ng a s t roke s houl d have.
FBC , t o det ect pol ycyt haemi a, t hrombocyt haemi a, or t hrombocyt openi a. ESR and CRP , t o s creen for vas cul i t i s , endocardi t i s , hypervi s cos i t y. El ec t rol yt es and c al c i um (neurol ogi cal defect may be non-vas cul ar and caus ed by hyponat raemi a, hypercal caemi a, or renal fai l ure). Gl uc os e t o excl ude hypogl ycaemi a and non-ket ot i c hypergl ycaemi a (whi ch can mi mi c s t roke) and di abet es mel l i t us (a ri s k fact or). Chol es t erol (i f t aken wi t hi n 1224 hours of s t roke). Syphi l i s s erol ogy (l ow yi el d but t reat abl e condi t i on). NB: VDRL (but not TPHA) may be pos i t i ve i n SLE and t he pri mary ant i -cardi ol i pi n s yndrome. TPHA (but not VDRL) i s pos i t i ve i n pat i ent s previ ous l y expos ed t o non-s yphi l i t i c t reponemes (e.g. yaws ). Prot hrombi n t i me / I NR i f t he pat i ent i s t aki ng warfari n. ECG t o det ermi ne cardi ac rhyt hm and excl ude acut e myocardi al i nfarct i on. Carot i d Doppl er ul t ras ound t o excl ude hi gh-grade (>70%) s t enos i s or di s s ect i on. Thi s s houl d be performed i n pat i ent s who woul d be s ui t abl e for carot i d endart erect omy or angi opl as t y. A brui t need not be pres ent ! Cardi ac ec hoc ardi ography may demons t rat e t he pres ence of val vul ar di s eas e or i nt racardi ac cl ot or may det ect s ome rare caus es of s t roke s uch as at ri al
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myxoma or pat ent foramen oval e. Some pat i ent s , part i cul arl y young ones wi t hout common ri s k fact ors (s ee above), s houl d be i nves t i gat ed furt her. Pos s i bl e t es t s i ncl ude
Serum prot ei n, el ec t rophores i s , vi s c os i t y . In hypervi s cos i t y s yndromes t he ESR i s us ual l y rai s ed but not al ways . Aut oant i body s c reen . (part i cul arl y for SLE). Haemos t at i c profi l e . In haemorrhagi c s t roke not apparent l y s econdary t o hypert ens i on, meas urement of PT, APTT, bl eedi ng t i me, and fi bri n degradat i on product s may be i ndi cat ed. In cerebral i nfarct s , bl ood s houl d be t aken for prot ei n S, C, ant i -t hrombi n III, and ant i -cardi ol i pi n ant i bodi es . APTT may be prol onged i n ant i cardi ol i pi n s yndrome. Cons i der t es t i ng for s i ckl e cel l i n bl ack pat i ent s . The Fact or V Le i d e n mut at i on may be an i mport ant ri s k fact or for t he devel opment of venous t hrombos i s . T oxi c ol ogy s c reen on admi s s i on s ampl e i f drug abus e (e.g. cocai ne, ps eudoephedri ne, or amphet ami nes ) s us pect ed. Uri ne t es t s may det ect homocys t i nuri a (wi t hout ot her cl i ni cal mani fes t at i ons ) or porphyri a. If BP i s l abi l e cons i der phaeochromocyt oma and meas ure uri nary cat echol ami nes . CSF anal ys i s may be neces s ary i f t he di agnos i s of s t roke i s not wel l es t abl i s hed, e.g. normal CT s can and no ri s k fact ors . Cerebral angi ography i s al s o res erved for cas es where t he di agnos i s i s not wel l es t abl i s hed and i n t hos e i n whom cerebral vas cul i t i s or mal format i on i s s us pect ed. MRI i s more s ens i t i ve at det ect i ng s mal l i nfarct s , cerebral venous t hrombos i s , and l es i ons i n t he pos t eri or fos s a. In expert hands magent i c res onance angi ography may be comparabl e t o convent i onal angi ography.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > St roke: c omplic at ions
Stroke: complications
Cerebral complications
Furt her neurol ogi cal det eri orat i on may be caus ed by t he fol l owi ng.
T rans t ent ori al herni at i on (P526) i s t he commones t caus e of deat h wi t hi n t he fi rs t week and carri es a mort al i t y of 80%. It i s due t o rai s ed i nt racrani al pres s ure (P452) s econdary t o cerebral oedema, and i n i s chaemi c s t roke i s commones t aft er l arge MCA i nfarct s . Cort i cos t eroi ds do not i mprove out come; manni t ol and hypervent i l at i on may be us eful t emporary meas ures (P454); s urgi cal decompres s i on may be i ndi cat ed i n l arge haemorrhages , part i cul arl y cerebel l ar ones . Haemorrhagi c t rans format i on occurs i n ~30% of i s chaemi c s t rokes (and up t o ~70% of cardi oembol i c s t rokes ), us ual l y 12 hours t o 4 days aft er t he event . Neurol ogi cal det eri orat i on, i t i s us ual l y due t o a mas s effect . Ac ut e hydroc ephal us due t o compres s i on of t he aqueduct of Syl vi us by oedema or bl ood may occur. Vent ri cul ar s hunt i ng may be of val ue. Sei zures compl i cat e ~10% of i nfarct s and are commones t i n l arge, haemorrhagi c, and cort i cal s t rokes . They us ual l y res pond t o monot herapy (e.g. phenyt oi n). I nappropri at e ADH s ec ret i on occurs i n 1015% s t rokes . It may i ni t i at e or wors en cerebral oedema and i s t reat ed by fl ui d res t ri ct i on. Depres s i on occurs i n ~50% and may requi re t herapy i f i t pers i s t s .
Systemic complications
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As pi rat i on i s common. Dys phagi a occurs i n at l eas t hal f of al l cas es of s t roke , t he i nci dence i s hi gher i n t hos e wi t h brai ns t em i nvol vement or pre-exi s t i ng cerebrovas cul ar di s eas e. It i s oft en undet ect ed at beds i de and us ual l y l eads t o as pi rat i on. Tes t i ng t he gag refl ex i s not a s uffi ci ent as s es s ment ; s wal l owi ng mus t be obs erved and i f t here i s any s us pi ci on vi deo-fl uoros copy may be us ed. Pat i ent s s houl d general l y be fed upri ght . I nfec t i on i s a common caus e of deat h fol l owi ng s t roke. Pneumoni a (i ncl udi ng as pi rat i on) and UTIs are t he us ual probl ems . Fever us ual l y occurs as a res ul t of i nfect i on or DVT. Occas i onal l y, i t i s a di rect res ul t of cerebral damage. Venous t hromboembol i s m: t he i nci dence of DVT fol l owi ng s t roke i s comparabl e t o t hat fol l owi ng hi p or knee art hropl as t y. Pul monary embol i s m account s for up t o 25% of earl y deat hs fol l owi ng s t roke. The us e of prophyl act i c ant i -coagul ant s reduces t he i nci dence of venous t hromboembol i s m but i t i s as s oci at ed wi t h an i ncreas ed ri s k of haemorrhagi c t rans format i on whi ch may out wei gh any benefi t . Many phys i ci ans us e prophyl act i c l ow mol ecul ar wei ght hepari n, al t hough t he RCP gui del i nes recommend compres s i on s t ocki ng onl y. In t he abs ence of i nt racrani al haemorrhage, s ub-cl i ni cal or overt proxi mal DVT s houl d be t reat ed wi t h s t andard t herapy. Bel ow-knee DVT s houl d be managed wi t h compres s i on s t ocki ngs and s eri al USS moni t ori ng for evi dence of proxi mal ext ens i on. Pres s ure s ores occur eas i l y unl es s pat i ent s are regul arl y t urned.
2
P.485
Practice point: Hypertension post stroke
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Hypert ens i on i s apparent i n 75% of pat i ent s at t he t i me of admi s s i on

3
BP us ual l y fal l s over t he fi rs t week and s t abi l i zes t o reveal underl yi ng hypert ens i on i n about hal f of al l pat i ent s Al t hough earl y hypert ens i on (BP >180mmHg) appears t o be as s oci at ed wi t h a poor out come t here i s no evi dence t hat l oweri ng BP i n t he acut e phas e of s t roke i s of any benefi t W e recommend t hat pat i ent s s houl d be t reat ed i f BP >180/120 t o 240/130, t here are s i gns of accel erat ed hypert ens i on, or t here are compl i cat i ng medi cal probl ems requi ri ng urgent t reat ment s uch as s evere heart fai l ure or aort i c di s s ect i on Drugs t hat may l ower BP prec i pi t ous l y (e.g. s hort -act i ng cal ci um ant agoni s t s ) s houl d be avoi ded Many neurol ogi s t s do not t reat hypert ens i on aggres s i vel y i n pat i ent s who are known t o have a s i gni fi cant carot i d or bas i l ar art ery s t enos i s as t hi s may preci pi t at e fres h cerebral i nfarct i on
Footnote
1
Oppenhei mer S & Hachi ns ki V (1992) Lanc et 339 : 721724.

2
Perry L & Love CP (2001) Dys phagi a 16 : 718.

3
Bat h (1992) Br Med Bul l 56 : 422435.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > St roke: sec ondary prevent ion
Stroke: secondary prevention
Attempt to modify risk factors. (See ri s k fact ors , P478). Target BP s houl d be bel ow 140/85 (l ower i n di abet i cs ). There i s l i t t l e t o choos e bet ween t he di fferent cl as s es of drugs : al l reduce t he ri s k of furt her event s . Cons i der s t at i ns , es p. i n t hos e wi t h co-exi s t i ng IHD. Anti-platelet drugs. As pi ri n reduces recurrence of s t roke and deat h from ot her caus es . In t he abs ence of abs ol ut e cont rai ndi cat i ons as pi ri n (300mg i ni t i al l y and 75300mg od t hereaft er) s houl d be gi ven i mmedi at el y aft er t he ons et of s t roke s ympt oms i f haemorrhage i s cons i dered unl i kel y; ot herwi s e i t s houl d be del ayed unt i l brai n i magi ng has been performed. Pat i ent s i nt ol erant of as pi ri n s houl d be t reat ed wi t h cl opi dogrel (75mg od), whi ch may be more effect i ve t han as pi ri n, part i cul arl y i n hi gh-ri s k pat i ent s . Pat i ent s i n whom i s chaemi c s t roke has recurred des pi t e as pi ri n s houl d be t reat ed wi t h as pi ri n and cl opi dogrel i n combi nat i on, or as pi ri n and di pyri damol e i n combi nat i on (al t hough t he l at t er i s cont roveri s al ). Anti-coagulants. To prevent recurrence of i s chaemi c s t roke, warfari n i s s uperi or t o as pi ri n i n val vul ar, non-val vul ar, and paroxys mal at ri al fi bri l l at i on but i t i s as s oci at ed wi t h i ncreas ed ri s k of major bl eedi ng. The bal ance of benefi t may depend on pat i ent group but general l y favours warfari n, part i cul arl y i n val vul ar AF. Ai m for an INR of 23 provi ded t here are no cont rai ndi cat i ons and regul ar checks of INR are pract i cabl e. There i s no cons ens us on when t o i ni t i at e
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warfari n and whet her a repeat CT i s requi red t o rul e out l at e haemorrhagi c t rans format i on. Current pract i ce i s t o del ay t he warfari ni zat i on for 12 weeks aft er t he event , and t o repeat t he s can where t he i nfarct i s very l arge, or where t here i s cl i ni cal s us pi ci on of haemorrhagi c t rans format i on. There i s no pl ace for ei t her unfract i onat ed hepari n or l ow mol ecul ar wei ght hepari ns . In s uch cas es , i t i s bes t t o di s cus s management wi t h a s eni or col l eague. Int ravenous hepari ni zat i on s houl d be commenced i mmedi at el y i n pat i ent s wi t h proven cerebral venous t hrombos i s (regardl es s of pres ence of haemorrhagi c change on CT), and many neurol ogi s t s woul d al s o do t he s ame for carot i d/bas i l ar di s s ect i on.
Carotid endarterectomy. Shoul d be cons i dered i n al l pat i ent s wi t h >70% i ps i l es i onal s t enos i s . The operat i on has an appreci abl e morbi di t y (i ncl udi ng furt her s t roke) and mort al i t y but appears t o i mprove overal l prognos i s i n s el ect ed pat i ent s . In cent res wi t h experi ence of t he procedure carot i d angi opl as t y may be an al t ernat i ve part i cul arl y i n pat i ent s who are cons i dered poor s urgi cal candi dat es . Patent foramen ovale. Some advocat e cl os ure us i ng an endovas cul ar devi ce but t here i s onl y anecdot al evi dence of i t s effect i venes s . Current pros pect i ve evi dence s ugges t s t hat s t roke pat i ent s wi t h PFOs t reat ed wi t h as pi ri n or warfari n onl y do not have an i ncreas ed ri s k of recurrent s t roke or deat h compared wi t h cont rol s .
2
HRT and the oral contraceptive pill. Combi ned HRT i ncreas es t he ri s k of i s chaemi c s t roke and s houl d be s t opped. The combi ned, but not t he proges t agen onl y, oral cont racept i ve pi l l al s o appears t o be as s oci at ed wi t h an i ncreas ed ri s k of s t roke. Swi t ch t o a proges t agen- onl y formul at i on, or al t ernat i ve forms of cont racept i on.
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Footnote
1
Mars hal l RS & Mohr JP (1993) J Neurol Neuros urg Ps yc hi at 56 : 616.

2
Homma S et al . (2002) Ci rc ul at i on 105 : 26252631.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Cerebral infarc t ion syndromes
Cerebral infarction syndromes
Anterior (carotid territory) circulation Middle cerebral artery syndrome
Tot al occl us i on of t he mi ddl e cerebral art ery (us ual l y embol i c) l eads t o cont ral at eral hemi pl egi a, hemi anaes t hes i a, homonymous hemi anopi a, and devi at i on of t he head and eyes t oward t he s i de of t he l es i on. Left -s i ded l es i ons l ead t o gl obal dys phas i a; ri ght -s i ded ones are more l i kel y t o l ead t o uni l at eral negl ect of cont ral at eral s pace. Branch occl us i ons of t he mi ddl e cerebral art ery are more common and l ead t o i ncompl et e s yndromes : e.g. occl us i on of upper branches l eads t o Broca's (non-fl uent or expres s i ve) dys phas i a and cont ral at eral l ower face and arm weaknes s ; l ower branch occl us i on, on t he ot her hand, may caus e W erni cke's (fl uent or recept i ve) dys phas i a.
Anterior cerebral artery syndrome

Occl us i on of t hi s art ery (oft en embol i c) can l ead t o paral ys i s of t he cont ral at eral l eg, gegenhal t en ri gi di t y, pers everat i on, al i en l i mb s yndrome, gras p refl ex i n t he oppos i t e hand, and uri nary i ncont i nence.
Posterior circulation Posterior cerebral artery syndrome

Occl us i on by t hrombus or embol us may l ead t o combi nat i ons of cont ral at eral homonymous hemi anopi a/upper quadrant onopi a, mi l d
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cont ral at eral hemi pares i s and/or hemi s ens ory l os s , dys l exi a, and memory i mpai rment .
Lacunar infarction
Infarct s i n s mal l penet rat i ng ves s el s , oft en t he cons equence of hypert ens i on, l ead t o a number of s yndromes : pure mot or s t roke or pure s ens ory s t roke, or pure s ens ori mot or s t roke, at axi c hemi pares i s (combi ned cerebel l ar and pyrami dal s i gns i n t he s ame l i mb).
Prognostic significance 1
The t ype of s t roke appears t o be a s i gni fi cant fact or i n a pat i ent 's prognos i s .
Tot al ant eri or ci rcul at i on i nfarct s , i .e. i nfarct s i n t he carot i d t erri t ory l eadi ng t o mot or and s ens ory defi ci t , hemi anopi a, and new di s t urbance of hi gher cerebral funct i on have t he wors t prognos i s i n t erms of deat h or di s abi l i t y. Pos t eri or ci rcul at i on i nfarct s , PACIs , and l acunar i nfarct s have bet t er prognos es , al t hough pat i ent s wi t h PACI have a hi gh ri s k of recurrent s t roke wi t hi n 3 mont hs .
Footnote
1
Bamford et al . (1991) Lanc et 337: 15211526.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Brainst em st roke
Brainstem stroke
Presentation
Sudden ons et of

Headac he , naus ea, vomi t i ng, vert i go Weaknes s : bi l at eral or uni l at eral Sens ory s ympt oms (e.g. paraes t hes i ae) may be confi ned t o face and i f uni l at eral , may be cont ral at eral t o weaknes s Opht hal mopl egi a, gaze devi at i on, or dys c onjugat e eye movement s . In uni l at eral pont i ne l es i ons conjugat e gaz e devi at i on i s di rect ed away from t he l es i on and t oward t he s i de of t he hemi pares i s i f t here i s one. The revers e obt ai ns for front al cort i cal s t rokes Horner's s yndrome Pt os i s caus ed by a mi d-brai n i nfarct i n t he abs ence of an accompanyi ng t hi rd nerve pal s y or Horner's s yndrome i s al ways bi l at eral Nys t agmus Heari ng l os s caus ed by damage t o t he VIIt h nerve nucl eus or fas ci cl e Dys art hri a or dys phagi a At axi a whi ch may be uni - or bi l at eral due t o dys funct i on of cerebel l ar connect i ons I mpai red l evel of c ons c i ous nes s ranges from t rans i ent l os s of cons ci ous nes s t o coma Al t ered pat t ern of res pi rat i on .
Si gns as s oci at ed wi t h brai ns t em dys funct i on are expl ai ned on P522. They res ul t becaus e of damage ei t her t o t he nucl ei (i ncl udi ng crani al nerve nucl ei ) wi t hi n t he brai ns t em, t o t he crani al nerves , or
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t o t he l ong t ract s whi ch t ravers e and/or decus s at e wi t hi n t he brai ns t em. Cros s ed s i gns may occur i n brai ns t em s t rokes , e.g. part of t he l at eral medul l ary/W al l enberg's s yndrome cons i s t s of l os s of pai n and t emperat ure s ens at i on from t he cont ral at eral t runk and l i mbs (cros s ed s pi not hal ami c) and i ps i l at eral l os s of t he s ame s ens ory modal i t i es from t he face (uncros s ed t ri gemi nal t ract ). There are a l arge number of ot her eponymous s yndromes as s oci at ed wi t h damage t o part i cul ar z ones wi t hi n t he brai ns t em. Learni ng t hes e i s not part i cul arl y rewardi ng; bet t er t o concent rat e on t he pri nci pl es of brai ns t em anat omy.
1
Causes
Thrombos i s , embol i s m, haemorrhage, or vert ebral art ery di s s ect i on (es peci al l y fol l owi ng neck mani pul at i on).
Reduced l evel of cons ci ous nes s and coma carry wors e prognos i s Ext ent of brai ns t em dys funct i on may be appreci at ed from s ys t emat i c exami nat i on of brai ns t em funct i on (P522) Bas i l ar occl us i on carri es a very poor prognos i s (approx 80% mort al i t y).
Management
Cons ul t a neurol ogi s t . The i magi ng modal i t y of choi ce i s MRI; t hi s s houl d be performed urgent l y t o rul e out ot her di agnos es . Some cent res may cons i der i nt ra-art eri al t hrombol ys i s i n pat i ent s wi t h bas i l ar occl us i on i f t he pat i ent i s referred s wi ft l y. Urgent i nt ervent i on i s requi red for. P.491
Met abol i c coma wi t h brai ns t em depres s i on, e.g. opi at es (P826) Trans t ent ori al herni at i on progres s i ve brai ns t em compres s i on (P526)
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Pos t eri or fos s a mas s wi t h t ons i l l ar herni at i on brai ns t em compres s i on Cerebel l ar haemorrhage wi t h/wi t hout brai ns t em compres s i on (P526).
Footnote
1
Rowl and (1991) In Kandel , Schwart z, & Jes s el l , ed. Pri nc i pl es of Neural Sc i enc e , pp. 711730.
Pa g e 8 7 1
> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Cerebellar st roke
Cerebellar stroke
Presentation
Tri ad of headache, naus ea/vomi t i ng, and at axi a i s t he cl as s i cal s yndrome. But i t occurs i n <50% of cas es and, of cours e, i s common i n a number of ot her condi t i ons . Pat i ent s pres ent wi t h s ympt oms and s i gns , whi ch are oft en at t ri but ed t o brai ns t em or l abyri t hi ne caus es . Al ways cons i der t he pos s i bi l i t y of a cerebel l ar s t roke as a s eri ous al t ernat i ve di agnos i s becaus e s urgi cal decompres s i on can be l i fe s avi ng i f t here i s a mas s effect wi t hi n t he pos t eri or fos s a. If t he di agnos i s i s a pos s i bi l i t y, as k for an urgent CT s can, or bet t er s t i l l , an MRI.
1 2
Headache, nausea/vomiting. Sudden or progres s i ve over hours t o days . Locat i on of headache vari es wi del y Dizziness or true vertigo. Occurs i n ~30% of cas es Visual disturbance. Di pl opi a, bl urred vi s i on, or os ci l l ops i a. Gait/limb ataxia. Mos t al ert pat i ent s report or demons t rat e t hi s Nystagmus or gaze palsy Speech disturbance. Dys art hri a or dys phoni a i n ~50% of al ert pat i ent s Loss of consciousness. May be t rans i ent but many pres ent i n coma Hypertension.

Hypert ens i on (>50%) Ant i -coagul ant s : t here i s a di s proport i onat el y hi gher ri s k of cerebel l ar haemorrhage (cf. i nt racerebral haemorrhage) i n pat i ent s t aki ng warfari n
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Met as t at i c neopl as m.
Pat i ent s who pres ent i n coma, or s ubs equent l y devel op i t , wi l l di e unl es s t hey recei ve s urgi cal t reat ment . There i s debat e about t he prognos i s of t hos e who remai n al ert .
Management
Make a defi ni t i ve di agnos i s wi t h urgent CT s can. (Is t here a haemorrhage/ i nfarct ? Is t here di s t ort i on of fourt h vent ri cl e and aqueduct wi t h di l at at i on of l at eral vent ri cl es ?) Li ai s e wi t h regi onal neuros urgery uni t earl y.
Priorities
St abi l i ze t he pat i ent and prot ect t he ai rway. See coma P408 Correct bl eedi ng t endency or effect s of ant i -coagul ant s Int ens i ve care/hi gh dependency ward nurs i ng obs ervat i ons i f pat i ent i s not t rans ferred t o neuros urgi cal cent re i mmedi at el y Defi ni t i ve s urgi cal decompres s i on i f neces s ary and pos s i bl e.
Footnote
1
Dunne JW et al . (1987) Quart J Med 64 : 739754.

2
Edi t ori al (1988) Lanc et i: 10311032.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > T ransient isc haemic at t ac ks (
Transient ischaemic attacks
(TIAs)
Presentation
Sudden-ons et focal defi ci t of cerebral funct i on or monocul ar bl i ndnes s res ol vi ng wi t hi n 24 hours . The s ympt oms s houl d have devel oped wi t hi n a few s econds and i f s everal part s of t he body (e.g. face, arm, l eg) are i nvol ved t hey s houl d have been affect ed s i mul t aneous l y wi t hout any march or progres s i on.
Symptoms of carotid T IA. Hemi pares i s , dys phas i a, or t rans i ent monocul ar bl i ndnes s (amauros i s fugax). See ant eri or ci rcul at i on s t rokes (P488) Symptoms of posterior circulation/vertebrobasilar T IA. Bi l at eral or al t ernat i ng hemi pl egi a or s ens ory s ympt oms , cros s ed mot or/s ens ory s i gns (i ps i l at eral face, cont ral at eral arm, t runk or l eg defi ci t ), quadri pl egi a. Sudden bi l at eral bl i ndnes s . Two or more of vert i go, di pl opi a, dys phagi a, at axi a, and drop at t acks i f t hey occur s i mul t aneous l y. Symptoms of uncertain arterial territory origin. Hemi anopi a al one or dys art hri a al one. Symptoms not acceptable as T IA. Syncope, l os s of cons ci ous nes s or confus i on, convul s i on, i ncont i nence of uri ne or faeces , di zzi nes s , focal s ympt oms as s oci at ed wi t h mi grai nous headache, s ci nt i l l at i ng s cot oma.
Causes
Thrombos i s or embol i s m (s ee P478 for ri s k fact ors ).
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Many condi t i ons may appear at fi rs t t o be a TIA, e.g.

Cerebral t umour (1 or 2) Brai n abs ces s Demyel i nat i on Focal mi grai ne Subdural haemat oma Todd's pares i s (pos t s ei zure) Hypogl ycaemi c at t ack Encephal i t i s .
Investigation
A CT s can s houl d be performed as ~5% of pat i ent s wi l l have an ot herwi s e uns us pect ed caus e (e.g. mas s l es i on). Ot herwi s e, i nves t i gat i on i s t he s ame as i s chaemi c s t roke (s ee P482).
Management
The object i ve i s t o prevent recurrence or compl et e s t roke. The general pri nci pl es of management are t hos e us ed i n t reat i ng i s chaemi c s t roke (P4808). Perhaps t he onl y di fference l i es i n t reat ment of recurrent TIAs not cont rol l ed by as pi ri n. In t he acut e s i t uat i on, i f major s t roke i s t hreat ened by a cres cendo of recurri ng TIAs

Gi ve hi gh-dos e as pi ri n (300mg/day) Add cl opi dogrel (75mg od) Expedi t e i nves t i gat i ons of underl yi ng caus e (carot i d s t enos i s , cardi ac embol i et c.) Cons ul t a neurol ogi s t .
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Confusional st at es and delirium 1
Confusional states and
delirium 1
Up t o 10% of acut e medi cal admi s s i ons are compl i cat ed by acut e confus i on or del i ri um. The hal l mark of ac ut e c onfus i onal s t at es i s di s ori ent at i on i n t i me and pl ace, i mpai red s hort -t erm memory, and i mpai red cons ci ous nes s l evel . Typi cal l y, t he pat i ent i s drows y wi t h a poor at t ent i on s pan and s l owed ment at i on. In del eri um , t here are, i n addi t i on, di s orders of percept i on s uch as hal l uci nat i ons (s eei ng or heari ng t hi ngs not t here) or i l l us i ons (mi s i nt erpret i ng s hadows s een or s ounds heard) and t hes e may produce res t l es s nes s , agi t at i on, and hyperact i vi t y. The mai n pri ori t y i s t o i dent i fy t he caus e of any t reat abl e or l i fe-t hreat eni ng condi t i on. Onl y a s mal l mi nori t y (<10%) of pat i ent s wi l l have a pri mary neurol ogi cal di s order and commonl y t here are mul t i pl e fact ors t hat may appl y; t hes e pat i ent s carry a good prognos i s .
Assessment
As s es s t he ment al s t at e: check for di s ori ent at i on and memory i mpai rment wi t h t he mi ni -ment al t es t . An anxi et y s t at e can us ual l y be di s t i ngui s hed by t al ki ng t o t he pat i ent . Vi vi d hal l uci nat i ons i n t he abs ence of hi s t ory of ment al i l l nes s s ugges t s al cohol wi t hdrawal . Revi ew t he pat i ent 's not es and t ry t o obt ai n hi s t ory from fri ends /rel at i ves of previ ous ment al s t at e or epi s odes of confus i on. Pat i ent s wi t h dement i a are prone t o confus i on wi t h i nt ercurrent i l l nes s . Revi ew t he drug chart : benzodi azepi nes and narcot i cs may caus e acut e confus i on i n t he el derl y. Ot her drugs
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t hat may be i nvol ved are s t eroi ds , NSAIDs , -bl ockers , and ps ychot ropi c medi cat i ons .
As s es s t he pat i ent for acut e i l l nes s : excl ude faecal i mpact i on and uri nary ret ent i on. Rel evant i nves t i gat i ons are l i s t ed i n t he t abl e on P498. Exami ne for any focal neurol ogi cal s i gns (pupi l s , l i mb power, refl exes , and pl ant ar res pons es ). In pat i ent s wi t h pri or hi gh al cohol i nt ake, exami ne for s i gns of l i ver di s eas e, l i ver fl ap, and pos s i bl e W erni cke's encephal opat hy (nys t agmus , at axi a, VI nerve pal s y).
Mini-mental examination for the elderly

Age Ti me (neares t hour) 42 W es t St reet : addres s for recal l at t he end of t he t es t (make t he pat i ent repeat t he addres s t o check) Y ear Pl ace (name of hos pi t al ) Recogni t i on of t wo peopl e (doct or, nurs e, et c.) Dat e of bi rt h (day and mont h) Y ear of W orl d W ar 1 (or 2) W ho i s on t he t hrone at t he moment ? Count backwards from 20 t o 1
Each correct ans wer s cores 1 poi nt . Heal t hy el derl y peopl e s core 8 P.497
Practice point
Pat i ent s who repeat edl y prot rude t hei r t ongue have t ardi re dys ki nes i a.
1
Footnote
1
Hawkes C (2002) Hos p Med 63 :73242.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Confusional st at es and delirium 2
Confusional states and
delirium 2
Systemic disorder Differential diagnosis

Seps i s Al cohol wi t hdrawal Met abol i c di s order

o o o
or gl c, Na, or Ca Vi t ami n defi ci ency Endocri ne di s eas e (t hyroi d, adrenal cort ex)
Myocardi al i s chaemi a Organ fai l ure (renal , res pi rat ory, l i ver, cardi ac)
Drug toxicity CNS disorder

Dement i a CVA (es p. non-domi nant pari et al l obe) Int racrani al bl eed (SAH, s ubdural ) Infect i on (encephal i t i s , meni ngi t i s ) Trauma Mal i gnancy (1 or 2) Pos t i ct al ; non-convul s i ve s t at us Cerebral vas cul i t i s (SLE, PAN)
Malignancy Investigations
Check uri ne, bl ood cul t ures , W BC, CRP, ches t X-ray, U&Es , gl c, LFTs , Ca , art eri al gas es , pH, ECG, cardi ac enz ymes Cons i der magnes i um, amyl as e, porphyri ns , t hi ami ne, B 1 2 , fol at e, TSH, free T4
2+
Pa g e 8 7 8
Check pres cri bed medi cat i on s erum al cohol /drug s creen Cons i der CT s can wi t h cont ras t , l umbar punct ure, EEG, bl ood cul t ures , CRP, s yphi l i s s erol ogy, Lyme s erol ogy Check ches t X-ray CT ches t , s erum cal ci um, CT brai n
Management
Treat t he caus e. Nurs e i n a moderat el y l i t room wi t h repeat ed reas s urance. See i f a fami l y member can s t ay wi t h t he pat i ent . If t he pat i ent i s agi t at ed and aggres s i ve, s edat i on may be neces s ary. Benzodi azepi nes may exacerbat e confus i on: us e major t ranqui l l i zers (e.g. hal operi dol 210mg i m po or chl orpromaz i ne 2550mg i m/po). Obs erve t he effect on t he pat i ent for 1520 mi nut es and repeat i f neces s ary. In pat i ent s wi t h cardi ac or res pi rat ory fai l ure, correct i ng hypoxi a may cal m t he pat i ent by i t s el f. Chl ormet hi azol e i s i ndi cat ed for confus i on due t o al cohol wi t hdrawal (s ee P500).
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Ac ut e alc ohol wit hdrawal
Acute alcohol withdrawal
Mi nor s ympt oms may be managed at home by t he GP but oft en a s hort admi s s i on i s more effect i ve and al l ows obs ervat i on for compl i cat i ons and ps ychos oci al as s es s ment rehabi l i t at i on.
Presentation
Ini t i al s ympt oms i ncl ude anxi et y and t remor, hyperact i vi t y, s weat i ng, naus ea and ret chi ng, t achycardi a, hypert ens i on, and mi l d pyrexi a. Thes e s ympt oms peak at 1230 hours and s ubs i de by 48 hours . General i zed t oni ccl oni c s ei zures (rum fi t s ) may al s o occur duri ng t hi s peri od, but s t at us epi l ept i cus i s unus ual . Typi cal l y t hes e do not s how t he EEG charact eri s t i cs of epi l eps y and may be preci pi t at ed by fl i ckeri ng l i ght s or ot her phot i c s t i mul at i on. Del i ri um t remens (DTs ) occurs i n <5% of i ndi vi dual s , us ual l y aft er 34 days of ces s at i on of al cohol i nt ake. It i s as s oci at ed wi t h an unt reat ed mort al i t y of 15%. Feat ures i ncl ude
o
Coars e t remor, agi t at i on, confus i on, del us i on, and hal l uci nat i ons Fever (occas i onal l y s evere), s weat i ng, t achycardi a Rarel y l act i c aci dos i s or ket oaci dos i s Al s o l ook for hypogl ycaemi a, W erni ckeKors akoff ps ychos i s , s ubdural haemat oma, and hepat i c encephal opat hy.
o o o
Management
General meas ures

o
Nurs e i n a wel l -l i t room t o prevent di s ori ent at i on.
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Rehydrat e (i v fl ui ds i f neces s ary; avoi d s al i ne i n pat i ent s wi t h known chroni c l i ver, di s eas e). Moni t or uri ne out put .
o
Vi t ami n s uppl ement s : i v t herapy (e.g. Parbi nex 23 pai rs of amps . i v s l ow l y 8 hourl y; wat ch for s i gns of anaphyl axi s ) for 5 days or oral t herapy [t hi ami ne 100mg po bd, vi t ami n B t abl et s (compound s t rong) 2 t abl et s t ds , and vi t ami n C 50mg po bd] for 1 week. Moni t or BMs for hypogl ycaemi a and t reat i f neces s ary. Severe hypophos phat aemi a may compl i cat e al cohol wi t hdrawal and s houl d be t reat ed wi t h i nt ravenous phos phat es (pol yfus or phos phat es ) i f s erum phos phat e i s <0.6mM (s ee P582). Excl ude i nt ercurrent i nfect i on (pneumoni a, s ki n, uri ne).
Sedat i on
o
Long-act i ng benzodi azepi nes s uch as chl ordi azepoxi de (Li bri um) or di azepam (Val i um) are commonl y us ed; l orazepam i s not met abol i zed by t he l i ver and may be us ed i n l i ver di s eas e. Carbamazepi ne i s as effect i ve as benzodi azepi nes but s i de-effect s l i mi t i t s us e. For s evere agi t at i on, hal operi dol 10mg i m may be us ed.
Werni c keKors akoff s yndrome

o
W erni cke's di s eas e compri s es t he t ri ad of opht hal mopl egi a (nys t agmus , VI nerve pal s y), at axi a (cerebel l ar t ype), and confus i onal s t at e. In Kors akoff's s yndrome, confus i on predomi nat es , oft en wi t h overt ps ychos i s , amnes i a (ant egrade and ret rograde), and confabul at i on. W i t hdrawal s ympt oms may al s o occur. Di agnos i s : reduced red-cel l t rans ket ol as e act i vi t y.
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Treat wi t h i v t hi ami ne (s ee above) whi l e wai t i ng for res ul t s .
P.501
Sei zures
o
W i t hdrawal s ei zures are t ypi cal l y s el f-l i mi t i ng; i f needed, us e i v di azepam (Di azemul s ) 10mg over 5 mi nut es (s ee P474). Treat t he pat i ent wi t h chl ordi azepoxi de (rat her t han chl ormet hi az ol e or carbamaz epi ne). Phenyt oi n i s l es s effect i ve but s houl d be added i f t here i s a hi s t ory of epi l eps y or recurrent s ei zures .
Fol l ow -up
o
Arrange referral t o an al cohol dependence cl i ni c.
Sedation regimens in delerium tremens: a guide

Chlordiazepoxide t hen t hen t hen 30mg q6h for 2 days 20mg dai l y (di vi ded dos es ) for 2 days 10mg dai l y (di vi ded dos es ) for 2 days 5mg dai l y for 2 days .
St art women on 20mg (i ns t ead of 30mg) and t aper as above. Reduce t he dos e i n l i ver di s eas e, i n el derl y, and i n s l i ght i ndi vi dual s . Carbamazepine As effect i ve as benzodi azepi nes and no abus e pot ent i al .
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St art wi t h 200mg/day i n di vi ded dos es i ncreas i ng t o 400mg/day over t he next 23 days and t aper off by day 8.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Neuromusc ular respirat ory failure: assessment
Neuromuscular
respiratory failure: assessment

Presentation
A number of di s orders of peri pheral nerve, neuromus cul ar junct i on, or mus cl e may pres ent wi t h hypercapni c (t ype II) res pi rat ory fai l ure, or i mpendi ng fai l ure. There are many di fferences bet ween t hes e condi t i ons but cons i der t he di agnos i s i n t he pres ence of t he fol l owi ng feat ures .
Li mb w eaknes s progres s i ng over hours or days wi t h di mi ni s hed/no refl exes but no upper mot or neurone s i gns Mus c ul ar t endernes s or pai n may be a feat ure Fac i al w eaknes s Pt os i s Bul bar dys func t i on i s a part i cul arl y omi nous s i gn becaus e i t may l ead t o i mproper cl earance of s ecret i ons and as pi rat i on Paradoxi c al abdomi nal movement : i f t he di aphragm i s paral ys ed i t moves pas s i vel y i nt o t he t horax wi t h t he fal l i n i nt rapl eural pres s ure produced by expans i on of t he ri bcage i n i ns pi rat i on. As a res ul t , t he ant eri or abdomi nal wal l al s o moves i n (rat her t han out ) duri ng i ns pi rat i on Dys pnoea or di s t res s i n s upi ne pos i t i on: i f t he di aphragm i s paral ys ed movement of abdomi nal cont ent s t owards t he t horax i s more promi nent when t he pat i ent l i es fl at becaus e gravi t y no l onger act s t o count eract t hi s pas s i ve movement . As a res ul t , t he
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vol ume of ai r i ns pi red i s reduced. Thi s i s a rare but i mport ant caus e of ort hopnoea
Sens ory s ympt oms may be pres ent wi t h or wi t hout gl ove-and-s t ocki ng s ens ory l os s Aut onomi c i ns t abi l i t y may be a promi nent feat ure of Gui l l ai nBarr s yndrome and may l ead t o cardi ac arres t Pneumoni a i n known neuromus cul ar di s eas e Res pi rat ory arres t : a common pi t fal l i s t o cons i der t he degree of res pi rat ory di s t res s uni mpres s i ve. Peri pheral weaknes s i n combi nat i on wi t h an expres s i onl es s myopat hi c faci es may l ead t o a fal s e s ens e of wel l -bei ng when t he pat i ent may i n fact be confront i ng i mpendi ng res pi rat ory arres t .
The meas urement of forced vi t al capaci t y i s mandat ory (meas ured wi t h W ri ght res pi romet er avai l abl e from anaes t het i c nurs e or i nt ens i ve care uni t ). Not e t hat oxygen s at urat i ons , peak fl ow rat e, and FEV1 do not c orrel at e wi t h t he degree of neuromus cul ar i mpai rment . Forced vi t al capaci t y <30ml /kg caus es i mpai red cl earance of s ecret i ons . Forced vi t al capaci t y <15ml /kg s ugges t s vent i l at ory fai l ure and i s an i ndi cat i on for i mmedi at e i nt ubat i on and vent i l at i on regardl es s of ot her paramet ers of res pi rat ory funct i on. Art eri al bl ood gas es : hypercapni a occurs rel at i vel y l at e. CXR t o det ermi ne ext ent of cons ol i dat i on i f t here i s concomi t ant as pi rat i on or i nfect i ve pneumoni a. Subt l e l i near at el ect as i s i s oft en s een as a di rect res ul t of reduced l ung vol ume.
Pa g e 8 8 5
> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Neuromusc ular respirat ory failure 2
Neuromuscular respiratory
failure 2
Investigations for neuromuscular respiratory failure

FBC, U&Es , CPK, ESR, CRP Forced vi t al capaci t y Art eri al bl ood gas es Ches t X-ray NCS EMG Ant i -AChR ant i body/Tens i l on t es t CT/MRI s can for brai ns t em pat hol ogy Nerve bi ops y, mus cl e bi ops y Uri ne/pl as ma t oxi n s creen (s ee t abl e)
Management

As s es s s everi t y and meas ure FVC frequent l y. Cons i der i nt ubat i on and vent i l at ory s upport i f i n adul t s FVC <1L or 15ml /kg. Do not us e s uxamet honi um as a mus cl e rel axant . It may caus e a s udden ri s e i n pot as s i um i n pat i ent s wi t h denervat ed mus cl es . Li ai s e wi t h neurol ogi s t earl y. Cons i der t rans fer t o regi onal neurol ogy uni t i f t he pat i ent i s wel l and FVC >25ml /kg and s t abl e. If t he pat i ent i s unwel l and FVC <15ml /kg or fal l i ng preci pi t ous l y from a hi gher l evel , i nt ubat e el ect i vel y and t hen cons i der t rans fer. Al l pat i ent s s houl d be accompani ed by an anaes t het i s t . Inves t i gat i ons (s ee t abl e). Mos t of t hes e condi t i ons
Pa g e 8 8 6
wi l l not come i nt o t he di fferent i al but i t i s advi s ed t hat bl ood be t aken for vi rol ogy s creen and aut oi mmune profi l e, and 20ml be s aved for ret ros pect i ve anal ys i s i f requi red.
ECG moni t ori ng and frequent obs ervat i on of BP and pul s e i s requi red i f Gui l l ai nBarr i s s us pect ed becaus e t here i s a hi gh i nci dence of aut onomi c i ns t abi l i t y. Cons i der s peci fi c t herapi es (s ee t abl e) and P512 P505 P516 P505 P505 P505 P392.
Gui l l ai nBarr Myas t heni a gravi s Bot ul i s m Heavy met al i nt oxi cat i on Organophos phat e expos ure Porphyri a Rhabdomyol ys i s
Subcut aneous hepari n prophyl axi s for deep vei n t hrombos i s . Ent eral nut ri t i on s houl d be cons i dered earl y.
P.505
Condition Investigation Central nervous system disease Brai ns t em di s eas e MRI s can
Specific treatments

Reduce ICP Decompres s Decompres s
Spi nal cord di s eas e
MRI s can
Peripheral neuropathies
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GBS (s ee P512)
NCS
i v i mmunogl obul i n Pl as ma exchange At ropi ne Pral i doxi me
Organophos phat es
Red cel l chol i nes t eras e
Pl as ma ps eudo-chol i n es t eras e
Heavy met al s : l ead, t hal l i um, gol d, ars eni c Drugs (e.g. vi ncri s t i ne) Mal i gnancy Vas cul i t i s (e.g. SLE) Met abol i c (porphyri a) Di pht heri a
Bl ood and uri ne l evel s
Speci fi c ant i dot e (s ee p797)
St op drug Cyt ot oxi cs Immunos uppres s ant s Avoi d preci pi t ant s i v gl c/haemat i n Ant i t oxi n St eroi ds Pl as ma exchange
Nerve bi ops y Nerve bi ops y Uri nary porphyri ns
Throat s wab
Neuro-muscular junction disease Myas t heni a gravi s Ant i -AChR Ab
Tens i l on t es t
Ant i -chol i nes t eras e overdos e
-ve Tens i l on t es t
St op drug
Hypermagnes aemi a Bot ul i s m (s ee P516) Muscle disease Hypokal aemi a Hypophos phat aemi a Pol ymyos i t i s
Pl as ma Mg
i v cal ci um Ant i t oxi n K repl acement PO

34 +
Pl as ma K
34
Pl as ma PO EMG
repl acement
St eroi ds
Pa g e 8 8 8
Mus cl e bi ops y EMG Mus cl e bi ops y

Acut e rhabdomyol ys i s (s ee P392)
i v hydrat i on Uri ne al kal i ni zat i on
Page 889
> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Myast henic c rises
Myasthenic crises
Presentation
General i zed w eaknes s us ual l y wors e proxi mal l y, and cl as s i cal l y pai nl es s and fat i guabl e. There may be pt os i s and di pl opi a. Refl exes and s ens at i on are normal . Dys pnoea . The pat i ent may not at fi rs t gl ance appear very di s t res s ed. An expres s i onl es s myopat hi c faci es t oget her wi t h weak mus cl es of res pi rat i on may gi ve a fal s e s ens e of wel l -bei ng. Bul bar dys func t i on i s pot ent i al l y dangerous as i t may l ead t o i mpai red cl earance of s ecret i ons and as pi rat i on pneumoni a. Exhaus t i on and vent i l at ory fai l ure l eadi ng t o coma. Hi s t ory of peni ci l l ami ne us e (may caus e a s yndrome i dent i cal t o i di opat hi c myas t heni a gravi s ).
Infect i on, s urgery, drugs (s ee t abl e). NB: cort i cos t eroi ds us ed t o t reat myas t heni a can i ni t i al l y l ead t o an acut e cri s i s .
Vi t al capaci t y i s t he mos t us eful i ndi cat or. Art eri al bl ood gas es are not s ens i t i ve enough and demons t rat e hypercarbi a l at e. Bul bar dys funct i on.
Cholinergic crisis
It may not be pos s i bl e on cl i ni cal eval uat i on t o di s t i ngui s h bet ween wors eni ng myas t heni a and exces s i ve ant i -chol i nes t eras e t reat ment (whi ch l eads t o weaknes s by produci ng depol ari zat i on bl ock).
Pa g e 8 9 0
Cons i der wi t hdrawi ng ant i -chol i nes t eras es onl y aft er cons ul t i ng a neurol ogi s t . Not e t hat chol i nergi c cri s i s i s very rare compared t o myas t heni c cri s i s .
Management
St abi l i ze t he pat i ent : prot ect t he ai rway; i nt ubat e and vent i l at e i f neces s ary. Ens ure t here are no el ect rol yt e di s t urbances (K , Ca , Mg ) or drugs pres cri bed whi ch exacerbat e weaknes s . Cons i der Tens i l on (edrophoni um) t es t (s ee t abl e). Ant i -chol i nes t eras e t reat ment may be hel pful i f chol i nergi c cri s i s i s excl uded. If t here i s no effect wi t h Tens i l on, recons i der t he di agnos i s . W i t hhol d al l ant i -chol i nes t eras e medi cat i ons for 72 hours . The Tens i l on may be repeat ed at i nt erval s . Immunos uppres s i on s houl d be s upervi s ed by a neurol ogi s t : predni s ol one 120mg/day on al t ernat i ng days produces i mprovement aft er 1012 days , but s houl d be i nt roduced wi t h care becaus e t here may be i ni t i al wors eni ng of weaknes s . Hi gh-dos e s t eroi ds are gi ven unt i l remi s s i on occurs . Azat hi opri ne (2.5mg/kg) has al s o been us ed for mai nt enance t herapy but t akes mont hs t o have an effect . Pl as mapheres i s i s us ed t o remove ci rcul at i ng ant i body. It us ual l y i nvol ves exchange of 50ml /kg/day over s everal days . Many cent res now favour i v i mmunogl obul i n t herapy. P.507
+ 2+ 2+
Regul ar ant i -chol i nes t eras e i nhi bi t or t herapy s houl d be di rect ed by a neurol ogi s t . Therapy depends upon res pons e but one i ni t i al s t rat egy i s t o commence wi t h pyri dos t i gmi ne 60mg q4h. Thi s can be gi ven by NG-t ube or, i f neces s ary, i m neos t i gmi ne can be us ed i ns t ead (1mg neos t i gmi ne s houl d be gi ven for every 60mg
Pa g e 8 9 1
pyri dos t i gmi ne).
Drugs which may exacerbate myasthenia

Antibiotics Gent ami ci n Neomyci n Col i s t i n Cardiac drugs Qui ndi ne Propranol ol Local anaesthetics Li gnocai ne Anti-convulsants/psychotropic drugs Phenyt oi n Li t hi um Chl orpromaz i ne Muscle relaxants Suxamet honi um Analgesics Pet hi di ne Hormones Cort i cos t eroi ds (i ni t i al l y) Others Magnes i um s al t s Thyroxi ne Morphi ne Curare Barbi t urat es Procai ne Qui ni ne Procai nami de Tet racycl i ne Tobramyci n Cl i ndamyci n St rept omyci n Kanamyci n Li ncomyci n
Tensilon (edrophonium) test
A hi s t ory of as t hma or cardi ac dys rhyt hmi as are rel at i ve cont rai ndi cat i ons . At ropi ne s houl d be drawn up pri or t o t he t es t i n cas e edrophoni um (an i nhi bi t or of acet yl chol i nes t eras e) produces a s evere chol i nergi c react i on, e.g. s ympt omat i c bradycardi a. Prepare and l abel t wo 1ml s yri nges : one cont ai ni ng s al i ne, t he ot her 10mg of edrophoni um. Sel ect a mus cl e t o obs erve for t he t es t and as k a col l eague t o as s es s i t s s t rengt h pri or t o t he t es t .
Pa g e 8 9 2
Inject , i n s t ages , t he cont ent s of ei t her s yri nge, keepi ng bot h pat i ent and col l eague bl i nded t o t he cont ent s of each s yri nge. As k t he obs erver t o reas s es s mus cl e s t rengt h aft er t he cont ent s of each s yri nge have been i nject ed. Edrophoni um s houl d fi rs t be gi ven as a bol us of 2mg (0.2ml ) and unt oward chol i nergi c effect s s houl d be obs erved for. If i t i s t ol erat ed t he remai ni ng 0.8ml can be gi ven 1 mi nut e l at er. Improvement i n mus cl e s t rengt h fol l owi ng edrophoni um s ugges t s t he pat i ent i s s ufferi ng a myas t heni c, not chol i nergi c, cri s i s .
Footnote
1
Thomas CE et al . (1997) Neurol ogy 48 : 12531260.
Pa g e 8 9 3
> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Spinal c ord c ompression: assessment
Spinal cord compression:
assessment
Presentation
Bac k pai n i s us ual l y t he fi rs t s ympt om. It oft en s t art s weeks before ot her feat ures and becomes progres s i vel y unremi t t i ng keepi ng t he pat i ent awake at ni ght . There may al s o be radi c ul ar pai n whi ch i s mi s i nt erpret ed and l eads t o a l ong and unrewardi ng s earch for t he caus e of ches t or abdomi nal pai n. Sens ory s ympt oms s uch as paraes t hes i ae or a s ens at i on of l i mb heavi nes s or pul l i ng may t hen occur. Sens ory l os s may be apparent as a s ens ory l evel on t es t i ng. It i s wi s e t o t es t for pi n pri ck (s pi not hal ami c funct i on) and joi nt pos i t i on s ens e/ vi brat i on s ens e (dors al col umn funct i on): ant eri or or pos t eri or port i ons of t he cord may be s el ect i vel y compres s ed. Sacral s pari ng refers t o pres ervat i on of s ens at i on i n (us ual l y) S3S5 dermat omes ; i t i s a rel at i vel y rel i abl e s i gn of an i nt ramedul l ary l es i on (s ee caus es ) whi ch i ni t i al l y s pares l at eral l y pl aced s pi not hal ami c t ract fi bres s ubs ervi ng s acral s ens at i on. Not e t hat a s ens ory l evel onl y i ndi cat es t he l owes t pos s i bl e l evel of t he l es i on: i t may wel l be s everal s egment s hi gher. Weaknes s i s oft en fi rs t des cri bed as cl ums i nes s but s oon progres s es t o cl ear l os s of power. Aut onomi c dys func t i on: i f t he s ympat het i c pat hways are i nvol ved, es peci al l y i n hi gh t horaci c or cervi cal l es i ons , hypot ens i on, bradycardi a, or s omet i mes cardi ac
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arres t may occur. Thi s may be t ri ggered by noxi ous s t i mul i s uch as pai n, uri nary t ract i nfect i on, or abdomi nal di s t ens i on caus ed by cons t i pat i on or bl adder out fl ow obs t ruct i on.
Sphi nc t er dys func t i on commences as hes i t ancy or urgency of mi ct uri t i on and may progres s t o pai nl es s uri nary ret ent i on wi t h overfl ow. Cons t i pat i on i s anot her cons equence of cord compres s i on. Fever s houl d al ert one t o t he pos s i bi l i t y of an i nfect i ous caus e. Res pi rat ory fai l ure occurs wi t h hi gh cervi cal cord compres s i on and i s one caus e of acut e neuromus cul ar res pi rat ory paral ys i s (P502). Conus medul l ari s l es i ons compres s t he s acral s egment s of t he cord and l ead t o rel at i vel y earl y di s t urbance of mi ct uri t i on and cons t i pat i on, i mpot ence, reduced peri anal s ens at i on and anal refl ex; rect al and geni t al pai n occurs l at er. Pl ant ar res pons es are ext ens or. Cauda equi na l es i on: l es i ons at or bel ow t he fi rs t l umbar vert ebral body may compres s t he s pi nal nerves of t he cauda equi na l eadi ng t o a fl acci d, arefl exi c, oft en as ymmet ri c parapares i s . Lumbos acral pai n occurs earl y; bl adder and bowel dys funct i on appear rel at i vel y l at e. A s ens ory l evel i s found i n a s addl e di s t ri but i on up t o L1 (corres pondi ng t o root s carri ed i n cauda equi na). Combi ned c onus and c auda l es i ons produce a combi nat i on of l ower and upper mot or neurone s i gns . General exami nat i on : remember t hat l i kel i es t caus e i s mal i gnant compres s i on from met as t at i c di s eas e. Perform a careful exami nat i on, i ncl udi ng breas t and t hyroi d i f appropri at e.
The degree of weaknes s , s ens ory l os s , and s phi nct er dys funct i on are us eful i ndi cat ors of s everi t y.
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P.509
Causes of non-traumatic spinal cord compression

T umours Pri mary: i nt radural + ext ramedul l ary: s chwannoma, meni ngi oma; i nt radural + i nt ramedul l ary: as t rocyt oma, ependymoma. Met as t at i c (us ual l y ext radural ) : breas t , pros t at e, l ung, t hyroi d, GI t ract , l ymphoma, myel oma Infection : s t aphyl ococcal abs ces s , t ubercul oma, i nfect ed dermoi d Prolapsed intervertebral disc (cent ral ) Cyst : arachnoi d, s yri ngomyel i a Haemorrhage Skeletal deformity : kyphos col i os i s , achondropl as i a, s pondyl ol i s t hes i s
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Spinal c ord c ompression: management
Spinal cord
compression: management
Thi s depends on t he di agnos i s and t he condi t i on of t he pat i ent . If t he di agnos i s i s unknown i t i s i mperat i ve t o make i t s wi ft l y and di s cus s t he cas e wi t h t he regi onal neuros urgi cal cent re. If t he pat i ent i s known t o have neopl as t i c di s eas e and mal i gnant compres s i on i s very l i kel y, urgent radi ot herapy i s fi rs t -l i ne t herapy i n mos t but not al l cas es . In s ome pat i ent s wi t h di s s emi nat ed di s eas e i t may not be appropri at e t o make any i nt ervent i on apart from anal ges i a. Al ways cons ul t a s eni or oncol ogi s t .
Pl ai n X-rays of t he s pi ne s houl d be obt ai ned i mmedi at el y. Thes e may s how vert ebral col l aps e, l yt i c l es i ons , or s cl eros i s . Perform a CXR t o l ook for mal i gnancy. Magnet i c res onance i magi ng or CT myel ography i s t he next i nves t i gat i on of choi ce. Thi s s houl d be arranged urgent l y. If faci l i t i es are not avai l abl e l ocal l y, di s cus s wi t h regi onal neuros urgi cal Cent re. The us e of hi gh-dos e s t eroi ds i s cont rovers i al : t here i s no defi ni t e evi dence of benefi t i n mal i gnancy and i n s ome cas es of hi gh-grade l ymphoma t hey may t ri gger a fat al t umour l ys i s s yndrome. Di s cus s wi t h your s eni or col l eagues . If t he caus e of compres s i on appears t o be i nfect i ve (fever, neut rophi l i a, rai s ed CRP, et c.), bl ood, s put um, and uri ne cul t ures s houl d be s ent . Moni t or haemodynami cs and wat ch for aut onomi c dys funct i on. Cont rol pai n and act t o prevent cons t i pat i on.
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If t here i s bl adder dys funct i on, uri nary cat het eri zat i on may be neces s ary. If i mmobi l e, s t art prophyl act i c s ubcut aneous hepari n (5000U t ds ). If t here i s hi gh cervi cal compres s i on or i f vent i l at i on appears t o be compromi s ed, FVC and art eri al bl ood gas es s houl d be meas ured. The i ndi cat i ons for i nt ubat i on (i f t hi s i s appropri at e) are di s cus s ed i n acut e neuromus cul ar res pi rat ory paral ys i s (P502). If a di agnos i s i s not apparent and i mmedi at e neuros urgi cal act i on i s not i ndi cat ed di s cus s wi t h radi ol ogy wi t h a vi ew t o CT-gui ded bi ops y.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > GuillainBarr Syndrome (
GuillainBarr Syndrome
(GBS) 1
Presentation
Progres s i ve w eaknes s of more t han one l i mb i n an i ndi vi dual who may recent l y have experi enced a mi l d res pi rat ory or gas t roi nt es t i nal febri l e i l l nes s . W eaknes s i s as commonl y proxi mal as di s t al . It i s us ual l y s ymmet ri cal but may be as ymmet ri cal . Di mi ni s hed t endon refl exes /arefl exi a i s common. Sens ory s ympt oms . Paraes t hes i ae oft en precede weaknes s . Sens ory l os s i s not us ual l y profound al t hough t here may be a gl ove-and-s t ocki ng di s t ri but i on i mpai rment of t wo-poi nt di s cri mi nat i on, joi nt pos i t i on, and vi brat i on s ens e. If t here i s a s ens ory l evel , s pi nal cord compres s i on (P510) s houl d be t he di agnos i s unt i l proved ot herwi s e. Li mb or bac k pai n i s a major s ympt om i n ~30%. Crani al nerve dys func t i on occurs i n 50%. Bul bar funct i on and mus cl es of mas t i cat i on are affect ed i n 30%; ocul ar mus cl es i n 10% of pat i ent s . Vent i l at ory fai l ure . See acut e res pi rat ory fai l ure (P502). Aut onomi c dys func t i on i s common: s weat i ng, t achycardi a, s udden s wi ngs of BP, dys rhyt hmi as , and cardi ac arres t . Bl adder or bowel dys funct i on occurs but i f i t i s pres ent from t he out s et or i f i t i s pers i s t ent , recons i der t he di agnos i s . Mi l l erFi s her vari ant : opht hal mopl egi a (gi vi ng ri s e t o
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di pl opi a), at axi a, and arefl exi a wi t hout s i gni fi cant weaknes s or s ens ory s i gns . As s oci at ed wi t h ant i -GQ1b ant i bodi es i n t he s erum.
Causes
GBS probabl y repres ent s an i mmune-medi at ed at t ack on peri pheral nerves . Infect i ons whi ch may precede i t i ncl ude cyt omegal ovi rus , Campyl obac t er jejuni , Eps t ei nBarr vi rus , hepat i t i s B, Myc opl as ma , and herpes s i mpl ex vi rus .
Poor prognos t i c feat ures on pres ent at i on i ncl ude

Rapi d ons et Requi rement for vent i l at i on (bul bar compromi s e, reduci ng VC, res pi rat ory fai l ure) Age >40 Reduced ampl i t ude of compound mus cl e act i on pot ent i al (<10% of cont rol ) and ext ens i ve s pont aneous fi bri l l at i on i n di s t al mus cl es s ugges t i ng denervat i on (NB: el ect rophys i ol ogi cal s t udi es may be normal i n earl y GBS) Pres ence of aut onomi c dys funct i on Axonal vari ant (oft en wi t h precedi ng Campyl obac t er jejuni i nfect i on).
A gradi ng s ys t em has been devi s ed t o fol l ow a pat i ent 's progres s :

Grade 1: Abl e t o run Grade 2: Abl e t o wal k 5m but not t o run Grade 3: Abl e t o wal k 5m wi t h as s i s t ance Grade 4: Chai r/bed bound Grade 5: Vent i l at ed.
P.513
Practice point
Acut e ons et of bi l at eral faci al pal s y i s us ual l y due t o Gui l l ai n-Barr s yndrome. Long-s t andi ng bi l at eral
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faci al weaknes s i s us ual l y due t o Sarcoi d or Lyme di s eas e.

1
Footnote
1
Hawkes C (2002) Hos p Med 63 :73242.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > GuillainBarr syndrome 2
GuillainBarr syndrome 2
Management
It i s i mport ant t o appreci at e t hat GBS i s a di agnos i s of excl us i on wi t h an ext ens i ve di fferent i al (s ee acut e res pi rat ory paral ys i s P502). The pace at whi ch al t ernat i ve di agnos es need t o be excl uded depends upon t he hi s t ory and fi ndi ngs . The management of t he pat i ent wi t h GBS i s t hat of any pat i ent wi t h neuromus cul ar paral ys i s (P502), al t hough t here are a few i mport ant s peci fi c meas ures :

Moni t or FVC t wi ce dai l y Aut onomi c i ns t abi l i t y i s a common feat ure, s o ECG moni t ori ng and frequent as s es s ment of BP and pul s e i s advi s abl e, part i cul arl y i n any pat i ent wi t h bul bar or res pi rat ory i nvol vement (NB: t racheal s uct i on may l ead t o bradycardi a or as ys t ol e) CSF anal ys i s may be requi red. CSF prot ei n may be normal i ni t i al l y but charact eri s t i cal l y ri s es markedl y and peaks i n 46 weeks St eroi ds are of no benefi t i n GBS Pl as ma exc hange i s current l y t he onl y t reat ment t hat i s proven t o be bet t er t han s upport i ve t reat ment al one. I nt ravenous i mmunogl obul i n (0.4g/kg for 5 days ) has never been adequat el y compared wi t h pl acebo but appears t o be as effect i ve as pl as ma exchange and i s current l y t he s t andard t reat ment . Therapy s houl d not be commenced wi t hout pri or di s cus s i on wi t h a neurol ogi s t . DVT prophyl axi s .
Prognosis
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Around 65% are abl e t o res ume manual work, 8% di e i n t he acut e s t age (us ual l y from aut onomi c dys funct i on or pul monary embol i s m), and t he remai nder are l eft wi t h res i dual di s abi l i t y. The prognos i s i s wors e i n t hos e wi t h more s evere di s eas e.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Bot ulism
Botulism
Presentation
Bot ul i s m i s caus ed by exot oxi ns of Cl os t ri di um bot ul i num . There are t hree s yndromes : food-borne, s ubcut aneous drug us ers wound, and i nfant i l e. The l at t er t wo caus es are rare and wi l l not be di s cus s ed here. The mos t common form of bot ul i s m i s food-borne wi t h out breaks us ual l y at t ri but ed t o canned food. Pat i ent s pres ent wi t h s ympt oms us ual l y wi t hi n 18 hours of i nges t i on of t he t oxi n:

Sore t hroat , fat i gue, di zzi nes s , bl urred vi s i on Naus ea, vomi t i ng, c ons t i pat i on Rapi dl y progres s i ve w eaknes s oft en begi nni ng i n t he ext raocul ar and/or pharyngeal mus cl es and des cendi ng s ymmet ri cal l y i n s evere cas es t o gi ve upper and l ower l i mb paral ys i s and res pi rat ory fai l ure (s ee acut e res pi rat ory paral ys i s , P502) Paraes t hes i ae may occur but t here are no s ens ory s i gns Paras ympat het i c dys func t i on caus es a dry mout h, i l eus , and di l at ed non-react i ve pupi l s i n an al ert pat i ent . Thi s pupi l l ary res pons e may hel p t o di s t i ngui s h bot ul i s m from ot her neuromus cul ar di s orders ; however, i n mos t cas es t he pupi l s remai n react i ve.
W ound bot ul i s m i s s i mi l ar, except gas t roi nt es t i nal ups et does not occur.
Li mb weaknes s and vent i l at ory fai l ure are i ndi cat ors of s evere di s eas e. Pat i ent s wi t h t hes e feat ures have a wors e prognos i s , as do pat i ent s over 20 years , and t hos e who have i nges t ed t ype A t oxi n.
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Management
As s es s s everi t y, meas ure FVC frequent l y , and at t empt t o excl ude ot her i mport ant caus es of neuromus cul ar fai l ure (s ee P502). In part i cul ar, a T ens i l on t es t s houl d be performed t o excl ude myas t heni a gravi s (P507); nerve c onduc t i on s houl d be normal but i t i s i mport ant t o excl ude Gui l l ai nBarr s yndrome (P512); el ec t romyography i s frequent l y abnormal i n bot ul i s m (decrement of compound mus cl e act i on pot ent i al at s l ow rat es of repet i t i ve s t i mul at i on of 3s
-1 -1
and faci l i t at i on of mot or res pons e at rapi d rat es of 50s ). Serum and s t ool s houl d be as s ayed for t oxi n and C. bot ul i num .

General management i s des cri bed el s ewhere (P502). Spec i fi c t reat ment : i f bot ul i s m i s s us pect ed 10 000 uni t s of t ri val ent (A, B, E) ant i -t oxi n s houl d be admi ni s t ered i v i mmedi at el y and at 4 hourl y i nt erval s . Approxi mat el y 20% pat i ent s have mi nor al l ergi c react i ons t o t hi s and requi re cort i cos t eroi d and ant i -hi s t ami nes as for anaphyl axi s (for s uppl i es out s i de normal worki ng hours cont act Depart ment of Heal t h Dut y Offi cer, t el : 020 7210 3000). Guani di ne hydroc hl ori de (an acet yl chol i ne agoni s t ) may be of benefi t i n s ome pat i ent s (3540mg/kg/day oral l y i n di vi ded dos es ). Gas t ri c l avage, emet i cs , cat hart i cs , and enemas may be us ed wi t h caut i on t o accel erat e el i mi nat i on of t oxi n from t he gas t roi nt es t i nal t ract . The fi rs t t wo i nt ervent i ons are cont rai ndi cat ed i f bul bar weaknes s i s pres ent ; magnes i um-cont ai ni ng cat hart i cs s houl d not be us ed as t here i s a ri s k t hat magnes i um may enhance t oxi n act i vi t y.
P.517
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Pathophysiology of botulism
Preformed bot ul i num t oxi n i s a pot ent pres ynapt i c bl ocker of acet yl chol i ne rel eas e at t he neuromus cul ar junct i on, pos t -gangl i oni c paras ympat het i c t ermi nal s , and aut onomi c gangl i a. There are 6 ant i geni cal l y di s t i nct t oxi ns (AF) but onl y A, B, and E appear t o be as s oci at ed wi t h human i l l nes s .
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > T et anus
Tetanus
Presentation
Tet anus i s caus ed by t he effect s of exot oxi ns produced by Cl os t ri di um t et ani . It occurs aft er C. t et ani s pores have gai ned acces s t o t i s s ues . The wound may be very t ri vi al and i n 20% of cas es t here i s no hi s t ory or evi dence of i njury. Incubat i on of s pores may t ake weeks but mos t pat i ent s pres ent wi t hi n 15 days wi t h

Pai n and s t i ffnes s of jaw Ri gi di t y and di ffi c ul t y i n openi ng mout h: t ri s mus or l ockjaw General i zed ri gi di t y of fac i al mus c l es l eadi ng t o t he cl as s i cal ri s us s ardoni cus or cl enched t eet h expres s i on Ri gi di t y of body mus c ul at ure l eadi ng t o neck ret ract i on and s pi nal ext ens i on Refl ex s pas ms are pai nful s pas ms el i ci t ed by s t i mul i s uch as pres s ure or noi s e. Thes e us ual l y occur 13 days aft er t he i ni t i al s ympt oms and are pot ent i al l y very dangerous as t hey may endanger res pi rat i on and preci pi t at e cardi ores pi rat ory col l aps e Convul s i ve s ei zures Aut onomi c dys func t i on wi t h bot h s ympat het i c (s weat i ng, hypert ens i on, t achycardi a, dys rhyt hmi as , hyperpyrexi a) and paras ympat het i c (bradycardi a, as ys t ol e) i nvol vement .
Cause
Exot oxi n bl ocks i nhi bi t ory pat hways wi t hi n t he cent ral nervous s ys t em.
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Rapi dl y progres s i ng feat ures and t he ons et of s pas ms s i gni fy wors e di s eas e and prognos i s .
Management
As s es s s everi t y . In s evere s pas ms /res pi rat ory fai l ure vent i l at i on wi l l be requi red. Ot herwi s e pat i ent s s houl d be nurs ed i n a qui et , dark room (t o reduce refl ex s pas ms ) under cl os e obs ervat i on. Sedat i on wi t h di az epam may be neces s ary but beware of res pi rat ory depres s i on. General management as di s cus s ed on P502. Spec i fi c t reat ment : human hyperi mmune gl obul i n 300010 000 uni t s i v or i m s houl d be gi ven t o neut ral i ze ci rcul at i ng t oxi n. Thi s wi l l not amel i orat e exi s t i ng s ympt oms but wi l l prevent furt her bi ndi ng of t oxi n t o CNS. Peni ci l l i n i v (1.2g qds ), or al t ernat i vel y t et racycl i ne 500mg qds , s houl d be pres cri bed t o t reat C. t et ani . Wound c are and debri dement as appropri at e: s wabs s houl d be s ent for cul t ure but oft en do not grow t he organi s m. Prophyl axi s i n pat i ent s w ho have previ ous l y been i mmuni zed: for any wound, gi ve a boos t er dos e of t et anus t oxoi d i f t he pat i ent has not recei ved a boos t er i n t he l as t 10 years . If t he wound appears di rt y and i nfect ed, or t he pat i ent has never been i mmuni zed/cannot recal l /unabl e t o gi ve hi s t ory, gi ve human ant i t oxi n (250 uni t s i m) i n addi t i on t o t oxoi d.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Glasgow Coma Sc ale (
Glasgow Coma Scale (GCS)
Devel oped t o as s es s dept h and durat i on of i mpai red cons ci ous nes s i n a s t andard fas hi on. The t ot al i s out of 15 (s ee t abl e); t he wors t pos s i bl e s core i s 3 (whi ch even t he dead can achi eve). The s cal e has a hi gh rat e of i nt er-obs erver agreement and GCS s core i s one us eful way of moni t ori ng cons ci ous l evel .
Eye opening
If s pont aneous , i ndi cat es brai ns t em arous al mechani s ms are probabl y i nt act , but t he pat i ent need not be aware of t hei r s urroundi ngs . Eye openi ng t o s peech i s not neces s ari l y a res pons e t o a verbal command t o open t he eyes ; any verbal approach, e.g. cal l i ng t he name of t he pat i ent , may el i ci t t hi s . Eye openi ng t o pai n i s bes t t es t ed by us i ng a s t i mul us i n t he l i mbs becaus e s upra-orbi t al or s t yl oi d proces s pres s ure can l ead t o gri maci ng wi t h eye cl os ure.
Verbal responsiveness
An ori ent at ed pat i ent knows who t hey are, where t hey are, and why t hey are t here; t hey can recol l ect t he mont h and year. A confus ed pat i ent wi l l convers e but t hei r res pons es i ndi cat e varyi ng degrees of di s ori ent at i on and confus i on. An i ndi vi dual wi t h i nappropri at e s peech cannot s us t ai n a convers at i on; t hei r ut t erances are excl amat ory or random and may cons i s t of s hout i ng or s weari ng. Incomprehens i bl e s peech does not cons i s t of any recogni zabl e words but i nvol ves moani ng and groani ng.
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Motor response
See fi gure.
Pat i ent s who obey commands s how t he bes t pos s i bl e mot or res pons e but be careful not t o mi s i nt erpret pos t ural adjus t ment s or t he gras p refl ex. If t here i s no res pons e t o command, a pai nful s t i mul us may be appl i ed i ni t i al l y by appl yi ng pres s ure t o t he fi ngernai l bed. If t hi s el i ci t s fl exi on at t he el bow, pres s ure may be appl i ed t o t he s t yl oi d proces s , s upra-orbi t al ri dge, and t runk t o s ee i f t here i s l ocal i zat i on. If pai n at t he nai l bed el i ci t s a rapi d wi t hdrawal wi t h fl exi on of t he el bow and abduct i on at t he s houl der i t i s s cored 4. If i ns t ead i t produces a s l ower fl exi on of t he el bow wi t h adduct i on at t he s houl der, i t i s cons i dered an abnormal fl exi on res pons e (s omet i mes cal l ed dec ort i c at e pos t uri ng ). If pai n el i ci t s ext ens i on of t he el bow, adduct i on, and i nt ernal rot at i on of t he s houl der wi t h pronat i on of t he forearm, t hi s i s not ed as an ext ens or res pons e (s omet i mes cal l ed dec erebrat e pos t uri ng ).
Prognosis
The GCS i s a val uabl e t ool i n predi ct i ng l i kel y out come from coma, but i t has l i mi t at i ons and s houl d not be t he onl y fact or us ed t o as s es s prognos i s . Pat i ent s wi t h GCS 38 general l y have far wors e prognos es t han t hos e wi t h >8. But t he caus e of coma i s al s o an i mport ant predi ct or, e.g. met abol i c coma (es peci al l y due t o drug i nt oxi cat i on) general l y has a bet t er out l ook t han ot her caus es , i rres pect i ve of GCS. P.521
GCS
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Eye opening Spont aneous l y To s peech To pai nful s t i mul us No res pons e Best verbal response Ori ent at ed Di s ori ent at ed Inappropri at e words Incomprehens i bl e s ounds No res pons e Best motor response Obeys verbal commands Local i z es pai nful s t i mul i W i t hdrawal t o pai n Fl exi on t o pai n Ext ens i on t o pai n No res pons e 6 5 4 3 2 1 5 4 3 2 1 4 3 2 1
Pos t uri ng i n coma
Page 911
> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Examinat ion of brainst em func t ion 1
Examination of brainstem
function 1
As s es s ment of brai ns t em funct i on i s vi t al t o t he management of coma (P406), rai s ed i nt racrani al pres s ure (P452), brai ns t em s t rokes (P490), and brai n deat h (P532). It i s not neces s ary t o have a det ai l ed knowl edge of brai ns t em anat omy. Some s i mpl e obs ervat i ons reveal a great deal about funct i on at di fferent l evel s of t he brai ns t em.
Examination of the eyes
Pupillary reactions. The s i ze of t he pupi l s and t hei r react i ons t o bri ght l i ght s houl d be as s es s ed. Thi s t es t s t he pat hway from each eye (IInd crani al nerve) t hrough t he s uperi or col l i cul us (mi d-brai n), i t s connect i on t o t he nearby Edi ngerW es t phal IIIrd nerve nucl eus (al s o i n t he mi d-brai n), and efferent paras ympat het i c out fl ow of t he IIIrd nerve. The pupi l l ary refl ex i s cons ens ual s o l i ght i n one eye s houl d el i ci t cons t ri ct i on of bot h pupi l s . Thus obs ervat i ons of t he pupi l l ary res pons e can i nt errogat e brai ns t em funct i on at t he l evel of t he mi d-brai n. Corneal reflex. Thi s t es t s t he i nt egri t y of t he afferent pat hway (Vt h nerve) t hrough t o t he efferent pat hway (VIIt h nerve). The corneal refl ex i s al s o a cons ens ual refl ex. Thi s refl ex al l ows one t o i nt errogat e brai ns t em funct i on at t he l evel of t he pons . Resting eye position. Thi s may gi ve a us eful cl ue t o as ymmet ri c brai ns t em dys funct i on. If t he eyes are dys conjugat e t here mus t be a di s order of t he nucl ei of
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t he IIIrd, IVt h, or VIt h nerves , t hei r connect i ons , or t he nerves t hems el ves . Not e t he IIIrd and IVt h nucl ei are l ocat ed i n t he mi d-brai n, whereas t he VIt h nucl eus i s l ocat ed i n t he pons .
Spontaneous eye movements. If t here are s pont aneous fas t (s accadi c) hori zont al and vert i cal conjugat e eye movement s t he brai ns t em mechani s m for generat i ng s accades i s i nt act and t here i s no need t o t es t for t he ocul ocephal i c or ocul oves t i bul ar res pons e becaus e
o
Hori zont al s accades requi re t he i nt egri t y of t he paramedi an pont i ne ret i cul ar format i on (pons ), t he IIIrd nerve nucl eus , t he VIt h nerve nucl eus , and t he medi al l ongi t udi nal fas ci cul us connect i ng t hes e. Vert i cal s accades requi re t he dors al mi d-brai n t o be i nt act . Dys conjugat e eye movement s rai s e t he pos s i bi l i t y of uni l at eral damage t o brai ns t em ocul omot or nucl ei , t hei r connect i ons , or crani al nerves i nnervat i ng t he ext raocul ar mus cl es . In t hi s cas e t he res t i ng pos i t i on of t he eyes may al s o be dys conjugat e. A number of ocul omot or s i gns as s oci at ed wi t h brai ns t em dys funct i on have been i dent i fi ed; none are abs ol ut el y s peci fi c but t hey may provi de us eful cl ues t o s i t e of l es i on.
1
Oculocephalic response. The dol l 's head manoeuvre (P530) s houl d be performed onl y i f cervi cal i njury has been excl uded. Bot h i t and cal ori c s t i mul at i on as s es s t he i nt egri t y of t he ves t i bul o-ocul ar refl ex whi ch i s a t hree-neurone arc from t he s emi ci rcul ar canal s vi a t he ves t i bul ar nucl ei t o t he IIIrd and VIt h nerve nucl ei . Oculovestibular response. Cal ori c s t i mul at i on (P530).
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Footnote
1
Lewi s & Topel (1992) In W ei ner W J, ed. Emergent and Urgent Neurol ogy , pp. 125.
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function 2
The swallowing reflex
Thi s may be t es t ed by i nject i ng 10ml of wat er i n a s yri nge i nt o t he mout h of t he pat i ent . Refl ex s wal l owi ng requi res , amongs t ot her t hi ngs , t hat t he s wal l owi ng cent re i n t he ret i cul ar format i on of t he medul l a, very cl os e t o t he s ol i t ary nucl eus , be i nt act .
Respiratory pattern
Thi s i s s omet i mes us eful i n l ocal i zat i on but oft en i s not . Cent ral neurogeni c hypervent i l at i on , for exampl e, has no l ocal i zat i on val ue. It i s rapi d, regul ar deep cont i nuous breat hi ng at ~25/mi n whi ch i s not produced by aci dos i s or hypoxaemi a. It s us eful nes s i s t hat i ncreas i ng regul ari t y of t hi s pat t ern s i gni fi es i ncreas i ng dept h of coma and wors eni ng prognos i s . Apneus t i c breat hi ng (prol onged i ns pi rat i on fol l owed by a peri od of apnoea), on t he ot her hand, i mpl i es damage t o t he pons , as does c l us t er breat hi ng (cl os el y grouped res pi rat i ons fol l owed by a peri od of apnoea). Damage t o t he medul l ary res pi rat ory cent res i s s ugges t ed by at axi c breat hi ng and gas pi ng breat hi ng (Bi ot 's res pi rat i ons ). The former are charact eri zed by a chaot i c pat t ern of res pi rat i on; t he l at t er cons i s t of gas ps fol l owed by apnoei c peri ods of vari abl e durat i on. Bot h are us ual l y s oon fol l owed by res pi rat ory arres t . Shal l ow, s l ow breat hi ng may be due t o medul l ary depres s i on caus ed by drugs , e.g. opi at es .
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CheyneSt okes res pi rat i on may be caus ed by bi l at eral deep hemi s pheri c and bas al gangl i a damage but i s more us ual l y due t o non-neural caus es , e.g. pri mary cardi ovas cul ar or res pi rat ory dys funct i on.
Long t rac t s i gns . Fi nal l y, s t ruct ural damage t o t he brai ns t em may produce l ong t ract s i gns wi t h dys funct i on of des cendi ng pyrami dal /ext rapyrami dal t ract s or as cendi ng s ens ory pat hways . There may be cros s ed s i gns becaus e of decus s at i on of pat hways wi t hi n t he brai ns t em.
Abnormal res pi rat ory pat t erns as s oci at ed wi t h pat hol ogi c l es i ons (s haded areas ) at vari ous l evel s of t he brai n. (a) Cheyne-St okes res pi rat i on. (b) Cent ral neurogeni c hypervent i l at i on. (c) Apneus i s . (d) Cl us t er breat hi ng (e) At axi c breat hi ng. (From Pl um F & Pos ner JB (1980) T he Di agnos i s of St upor and Coma 3rd ed; FA Davi s , Phi l adel phi a, wi t h permi s s i on.)
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function 3
Signs of brain shift 1
Rai s ed i nt racrani al pres s ure may produce a number of dis t i nct progres s i ve brai ns t em s yndromes as s oci at ed wi t h brai n s hi ft :

Cent ral herni at i on s yndrome Lat eral (uncal ) herni at i on s yndrome Fal s e l ocal i zi ng s i gns Tons i l l ar herni at i on. Obs ervat i on of res pi rat ory pat t ern Pupi l l ary react i on Ocul ocephal i c/ocul oves t i bul ar res pons e (s ee above) Mot or res pons e at res t or t o pai n (s ee P520).
As s es s ment i nvol ves

Central herniation syndrome
Vert i cal di s pl acement of t he brai ns t em due t o a s uprat ent ori al mas s . The fi rs t s i gn i s not of brai ns t em but rat her di enc ephal i c i mpai rment . The pat i ent becomes l es s al ert and t here may be CheyneSt okes breat hi ng. The pupi l s are s mal l (perhaps due t o hypot hal ami c s ympat het i c dys funct i on) but react i ve. There may i ni t i al l y have been uni l at eral hemi pl egi a due t o t he s uprat ent ori al mas s . Charact eri s t i cal l y i n t he earl y di encephal i c s t age, parat oni c res i s t ance ( gegenhal t en ) devel ops i n t he cont ral at eral l i mbs and bot h pl ant ar res pons es become ext ens or. Event ual l y t here i s a decort i cat e res pons e t o pai n (P520).
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Mi d-brai nupper pont i ne dys funct i on becomes evi dent wi t h fl uct uat i ons i n t emperat ure, ons et of cent ral neurogeni c hypervent i l at i on, apneus t i c or cl us t er breat hi ng (s ee above), unreact i ve pupi l s whi ch are mi d-pos i t i on and oft en i rregul ar i n s hape, l os s of vert i cal eye movement s (whi ch may be t es t ed wi t h t he dol l 's head manoeuvre), i ncreas i ng di ffi cul t y i n el i ci t i ng hori zont al ocul ocephal i c and ocul oves t i bul ar res pons es whi ch may become dys conjugat e (P530). Mot or res pons es progres s from decort i cat e (fl exor) ri gi di t y t o decerebrat e (ext ens or) ri gi di t y i n res pons e t o pai n (P520). Low er pont i neupper medul l ary compromi s e i s reveal ed by oft en at axi c breat hi ng, fi xed mi d-pos i t i on pupi l s , and fai l ure t o el i ci t ocul ocephal i c and ocul oves t i bul ar res pons es . The pat i ent i s fl acci d at res t ; pai nful s t i mul i may not el i ci t any mot or res pons e except occas i onal fl exor res pons es i n t he l ower l i mbs . Medul l ary dys func t i on i s t ermi nal . Breat hi ng i s at axi c or gas pi ng. The pul s e rat e may dec reas e and BP i nc reas e (Cus hi ng res pons e). Aft er a few gas ps , breat hi ng s t ops and pupi l s oft en di l at e and become fi xed.
Footnote
1
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function 4
Lateral (uncal) herniation syndrome
Due t o l es i ons i n t he l at eral mi ddl e fos s a or t emporal l obe pus hi ng t he medi al edge of t he uncus and hi ppocampal gyrus over t he free l at eral edge of t he t ent ori um. The fi rs t s i gn i s a uni l at eral l y di l at i ng pupi l (due t o compres s i on of t he IIIrd nerve at t he t ent ori al hi at us ), whi ch i s i ni t i al l y s l uggi s h i n res pons e t o l i ght . Thi s may s oon be fol l owed by pt os i s and a compl et e IIIrd nerve pal s y wi t h a fi xed, di l at ed pupi l . Ocul ocephal i c and ocul oves t i bul ar res pons es i ni t i al l y reveal onl y t he pal s y, but are ot herwi s e i nt act . Mi d-brai n compres s i on by t he herni at i ng uncus may fol l ow rapi dl y (t he di encephal i c s t age of cent ral herni at i on i s by-pas s ed). The pat i ent becomes progres s i vel y l es s al ert and s l i ps i nt o coma. The ocul ocephal i c and ocul oves t i bul ar res pons es cannot be el i ci t ed. A hemi pl egi a i ps i l at eral t o t he expnadi ng s uprat ent ori al l es i on (due t o t he oppos i t e cerebral peduncl e bei ng compres s ed at t he t ent ori al edge) devel ops and s oon progres s es t o bi l at eral ext ens or pl ant ar res pons es . As compres s i on cont i nues bot h pupi l s become fi xed i n mi d-pos i t i on and cent ral neurogeni c hypervent i l at i on commences . The ros t rocaudal progres s i on of s i gns as s oci at ed wi t h cent ral herni at i on t hen fol l ow wi t h
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decerebrat e/ext ens or ri gi di t y et c. as above. Not e decort i cat e/fl exor res pons e t o pai n i s not us ual l y s een i n uncal herni at i on becaus e t he di encephal i c s t age i s by-pas s ed.
False localizing signs

As t hey expand, s uprat ent ori al l es i ons may di s t ort i nt racrani al s t ruct ures and produce s i gns whi ch appear t o hel p i n l ocal i s i ng t he pri mary l es i on but are i n fact due t o t ract i on at a di s t ance. The mos t common of t hes e i nvol ve crani al nerves VVIII.
Tonsillar herniation
Sub-t ent ori al expandi ng l es i ons caus e herni at i on of t he cerebel l ar t ons i l s t hrough t he foramen magnum and compres s t he pons and mi d-brai n di rect l y. A degree of upward herni at i on t hrough t he t ent ori al hi at us may al s o occur and l ead t o compres s i on of t he upper mi d-brai n and di encephal on. It may be di ffi cul t t o di s t i ngui s h t hes e effect s from t hos e produced by s uprat ent ori al l es i ons . One cl ue i s t hat t here i s us ual l y a l ack of t he ros t rocaudal s equence of cent ral herni at i on.
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> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Oc uloc ephalic and oc ulovest ibular responses
Oculocephalic and
oculovestibular responses
Background
Pas s i ve rot at i on of t he head wi t h res pect t o t he t runk s t i mul at es ves t i bul ar and neck recept ors . In comat os e pat i ent s wi t h i nt act brai ns t ems , t hi s l eads t o refl exi ve s l ow c onjugat e eye movement s i n t he di rect i on oppos i t e t o head rot at i on. The cont ri but i on of neck propri ocept ors (cervi co-ocul ar refl ex) i s mi ni mal ; t he mos t i mport ant refl ex pat hway i n t he brai ns t em ext ends from t he s emi -ci rcul ar canal s t o t he ocul omot or nucl ei (VOR). Ice wat er i rri gat i on of a s emi -ci rcul ar canal s wi t ches off i t s cont ri but i on t o t hi s pat hway and l eads t o unoppos ed funct i on of t he cont ral at eral s emi -ci rcul ar canal . The eyes t hen devi at e t oward t he i rri gat ed s emi -ci rcul ar canal . Bot h t he dol l 's head manoeuvre and cal ori c t es t s check t he i nt egri t y of t he VOR; t he l at t er i s more s ens i t i ve.
Oculocephalic/doll's head response
The dol l 's head manoeuvre s houl d not be at t empt ed i f t here i s any pos s i bi l i t y of cervi cal s pi ne i njury. The pat i ent 's head i s fi rs t rot at ed l at eral l y from one s i de t o t he ot her. Vert i cal movement s may be el i ci t ed by fl exi on and ext ens i on of t he head. Pos i t i ve res pons es are not ed i f t urni ng of t he head el i ci t s s l ow c onjugat e devi at i on of bot h eyes i n t he di rect i on oppos i t e t o head movement (fi gure, oppos i t e). Becaus e t here i s much confus i on about what cons t i t ut es pos i t i ve or negat i ve res pons es , i t i s bes t
Pa g e 9 2 1
s i mpl y t o des cri be what you s ee.
Oculovestibular/caloric response
Cal ori c t es t i ng s houl d be performed when t he ocul ocephal i c res pons e i s abnormal or cannot be performed (e.g. s pi ne fract ure). The head i s t hen rai s ed 30 above s upi ne and 100ml of i ce wat er i s i nject ed i nt o t he ext ernal audi t ory meat us us i ng a t hi n pol yet hyl ene cat het er. A pos i t i ve res pons e occurs when bot h eyes move t oward t he i rri gat ed ear (fi gure, oppos i t e). Thi s may t ake up t o a mi nut e. Fi ve mi nut es s houl d el aps e before t he ot her ear i s t es t ed.
Significance of results
If t he VOR i s i nt act , major brai ns t em pat hol ogy i s unl i kel y. If t he hori zont al VOR i s abs ent but t he vert i cal one i s pres ent , t here may be a l es i on at t he l evel of t he pons . If bot h res pons es are abs ent , t here i s ei t her a major s t ruct ural brai ns t em l es i on (fi gure, oppos i t e) or t here i s a met abol i c di s t urbance depres s i ng brai ns t em funct i on (e.g. opi at es ). Check pupi l s i ze and res pons e t o l i ght ; s ymmet ri cal l y, react i ve pupi l s s ugges t met abol i c coma. Onl y a few drugs s uch as at ropi ne, s copol ami ne, and gl ut et hi mi de depres s brai ns t em funct i on and produce pupi l l ary abnormal i t i es . If dys conjugat e eye movement s are el i ci t ed, a brai ns t em l es i on i s l i kel y. Check t o s ee i f t here i s an i nt ernucl ear opht hal mopl egi a. It may not be pos s i bl e t o el i ci t a VOR us i ng t he dol l 's head manoeuvre becaus e t he pat i ent has fas t , rovi ng s accadi c eye movement s . Thes e s ugges t an i nt act brai ns t em.
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Ocul ocephal i c res pons es
Page 923
> T able of Cont ent s > Chapt er 7 - Neurologic al emergenc ies > Brain deat h
Brain death
Thi s i s i rrevers i bl e l os s of t he capaci t y for cons ci ous nes s combi ned wi t h i rrevers i bl e l os s of t he capaci t y t o breat he. W i t hout t he brai ns t em bot h t hes e funct i ons are l os t . But pat i ent s wi t h s evere, i rrevers i bl e brai n damage who have no brai ns t em funct i on may s urvi ve for weeks or mont hs provi ded t hey have a normal ci rcul at i on and are mechani cal l y vent i l at ed. Cri t eri a for brai n deat h have t herefore been devel oped. It has been s hown t hat pat i ent s who ful fi l t hes e, even i f t hey are vent i l at ed, wi l l event ual l y devel op cardi ovas cul ar col l aps e.
Preconditions
There mus t be no doubt t hat t he pat i ent has i rremedi abl e s t ruct ural brai n damage whi ch has been di agnos ed wi t h cert ai nt y. Us ual l y, t hi s a head i njury or i nt racrani al haemorrhage, but i t may be anoxi a pos t cardi ac arres t when i t i s not al ways pos s i bl e i mmedi at el y t o be cert ai n t hat brai n damage i s i rremedi abl e. The pat i ent mus t be i n apnoei c coma (unres pons i ve t o noxi ous s t i mul i and on a mechani cal vent i l at or) wi t h no s pont aneous res pi rat ory effort . There mus t be no pos s i bi l i t y of drug i nt oxi cat i on and no paral ys i ng or anaes t het i c drugs s houl d have been admi ni s t ered recent l y. Hypot hermi a mus t be excl uded as a caus e of coma and t he core t emperat ure (rect al or ext ernal audi t ory meat us ) s houl d be >35C. There mus t be no s i gni fi cant met abol i c, endocri ne, or el ect rol yt e di s t urbance ei t her caus i ng or cont ri but i ng t o coma.
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Tests for confirming brain death All brainstem reflexes must be absent
Pupi l s fi xed and unres pons i ve t o bri ght l i ght (t hey need not be di l at ed). Paral yt i c eye drops , ocul ar i njury, and l es i ons of t he IInd/IIIrd crani al nerves may pos e probl ems i n t hi s as s es s ment . Abs ent corneal refl exes . Abs ent ves t i bul o-ocul ar refl exes on i rri gat i on of each ear i n t urn wi t h 20ml i ce-col d wat er. No mot or res pons e wi t hi n t he crani al nerve di s t ri but i on (eye, face, head) el i ci t ed by s t i mul at i on of any s omat i c area (nai l bed, s upraorbi t al and Achi l l es t endon pres s ure on each s i de). Purel y s pi nal refl exes , e.g. deep t endon refl exes , may be ret ai ned. No refl ex res pons e t o t ouchi ng t he pharynx (gag refl ex), nor t o a s uct i on cat het er pas s ed i nt o t he t rachea (cough refl ex).
Apnoea
No res pi rat ory movement s when t he vent i l at or i s di s connect ed and P a CO 2 reaches 6.65kPa. (In order t o avoi d anoxi a duri ng t hi s procedure, t he pat i ent s houl d be vent i l at ed wi t h 100% oxygen for 10 mi nut es beforehand; duri ng di s connect i on, 6L/mi n 100% oxygen s houl d be del i vered vi a a t racheal cat het er. If jus t pri or t o di s connect i on P a CO 2 i s <3.5kPa, gi ve 5% CO 2 i n oxygen vi a t he vent i l at or unt i l t hi s l evel i s reached, us ual l y wi t hi n 5 mi nut es .)
The t es t s mus t be performed by t wo experi enced cl i ni ci ans (one mus t be a cons ul t ant and t he ot her a s eni or regi s t rar or above) and al l t he above s houl d be repeat ed aft er an i nt erval whi ch depends upon t he cl i ni cal cont ext . NB: Cons i der t he pat i ent a pot ent i al organ donor. Di s cus s wi t h rel at i ves and cont act t he t rans pl ant co-ordi nat or for your area. Al t ernat i vel y cont act t he dut y offi cer for t he UK Trans pl ant Support
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Servi ce (t el : 01179 757575).
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> T able of Cont ent s > Chapt er 8 - Psyc hiat ric emergenc ies
Chapter 8
Psychiatric emergencies
P.534
Acute confusion: assessment

Ac ut e c onfus i onal s t at es , or del i ri um , are rel at i vel y common: rat es i n exces s of 30% i n general hos pi t al pat i ent s have been report ed, and t hey are part i cul arl y common i n care of t he el derl y, t rauma, and ort hopaedi c wards . Acut e confus i on may occur on a background of chroni c cogni t i ve i mpai rment (dement i a), and may l as t for a prol onged peri od of days or even weeks . The caus e of acut e confus i on i s organi c unt i l proven ot herwi s e.
Common features of acute confusion

Rapi d ons et Fl uct uat i on Cl oudi ng of cons ci ous nes s Impai red recent and i mmedi at e memory Di s ori ent at i on Percept ual di s t urbance, es peci al l y i n vi s ual or t act i l e modal i t i es Ps ychomot or di s t urbance Al t ered s l eepwake cycl e Evi dence of underl yi ng caus e.
Common causes of acute confusion

Pai n or di s comfort (e.g. uri nary ret ent i on, cons t i pat i on) Hypoxi a Met abol i c derangement (renal fai l ure, l i ver fai l ure, aci dos i s , hypercal caemi a, hypogl ycaemi a) or endocri ne
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derangement (t hyrot oxi cos i s , Addi s on's di s eas e, di abet es mel l i t us )

Infect i on (s ys t emi c or l ocal i zed) Cardi ac (MI, CCF, endocardi t i s ) Neurol ogi cal (head i njury, s ubdural haemat oma, CNS i nfect i on, pos t -i ct al s t at es ) Drugs ( pres c ri bed: benzodi azepi nes , opi at es , di goxi n, ci met i di ne, s t eroi ds , ant i -parki ns oni an drugs , ant i -chol i nergi cs , or rec reat i onal : es peci al l y s t i mul ant s ) Al cohol or drug wi t hdrawal .
Detection of acute confusion
The pres ence or abs ence of cogni t i ve i mpai rment can hel p di s t i ngui s h bet ween organi c and funct i onal ment al i mpai rment . The 10-poi nt Abbrevi at ed Ment al Tes t Score or t he 30-poi nt Mi ni Ment al St at e Exami nat i on (s ee t abl e) gi ve a rapi d es t i mat e of key cogni t i ve funct i ons . Hi s t ory from fri ends and rel at i ves hel ps det ermi ne whet her or not t he del i ri um i s s uperi mpos ed upon dement i a.
P.535
Abbreviated Mental Test Score

Question W hat i s your age? W hat i s your dat e of bi rt h? W hat year i s i t ? W hat t i me of day i s i t ? W hat addres s /pl ace are we i n? Regi s t er 3-l i ne addres s and Score 1 for exact age 1 for dat e and mont h correct (not year) 1 for current year onl y 1 for neares t hour 1 for exac t addres s or name of hos pi t al (not jus t i n hos pi t al ) 1 i f correct l y regi s t ered and recal l ed
recal l at end of t es t W ho i s t he Ki ng or Queen? 1 for current monarch W hat year was W orl d W ar 1? 1 for ei t her fi rs t or l as t year
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Count back from 20 t o 1 Ident i fy t wo peopl e (names /jobs )
1 i f no mi s t akes /correct s s el f-s pont aneous l y 1 i f bot h recogni zed
T otal score /10 : l es s t han 7 abnormal
Mini Mental State Examination

Ti Da /5 dat e, mo nt h , s ea s on , yea r Pl a Co /5 ce unt ry, cou nt y , to wn
me y,
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/ci t y, bui l di ng, fl o or Re 3 /3 gi s obj t ra ect tio s n (e. g. cl o ck, t ab l e, um bre l l a) At t Sp /5 ent el l i on w o an rl d d bac con kw cen ard t ra s t i o or n S eri al 7s
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: 1 poi nt for eac h cor rec t l et t er /nu mb er Rec Of /3 al l t he 3 obj ect s list ed ab ove Na Sh /2 mi ow ng 2 obj ect s: 1 poi nt per cor
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rec t na me Re Re /1 pe pe at i at ng N o i fs , an ds , or but s : cor rec t if wor d per fec t 3-s /3 t ag T e k ake s pa per in you r t as t hi
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ri g ht ha nd, fol d it in hal f an d dro p it on t he fl o or : 1 ma rk for eac h par t do ne cor rec tly Re W ri /1 adi t e ng cl
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os e you r eye s : as k pat i en t to ob ey t hi s W ri As k /1 t i n pat g i en t to wri te a s en t en ce: s co re if gra mm at i cal l y cor
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rec t, not for a fra gm ent Co Dra /1 ns t w a ruc pai t i o r of n i nt erl ock i ng pe nt a go ns , as k pat i en t to cop y: s co re if ap pro xi m at e ly
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ri g ht an d fi g ure s i nt erl ock i ng Tot Us al ual s co l y re 23 /30 i s t he ap pro xi m at e cut -of f for sig ni fi can t im pai rm ent in t he
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el d erl y. Pre -m orb id i nt el l i ge nce an d cul t ur e can aff ect t hi s P.536
Acute confusion: management
It i s oft en s uffi ci ent t o t reat t he pat i ent cons ervat i vel y. Nurs e i n a wel l l i t qui et room wi t h fami l i ar nurs i ng s t aff or, bet t er s t i l l , a fami l i ar pers on s uch as a fami l y member. Treat t he caus e. Al ways cons i der al cohol wi t hdrawal (s ee bel ow). Occas i onal l y pat i ent s may refus e i nves t i gat i ons or t reat ment . It may be i mport ant t o go ahead wi t h bas el i ne i nves t i gat i ons i n order t o rul e out
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l i fe-t hreat eni ng caus es for t he confus i on and t hi s may need t o be done under common l aw (s ee bel ow).
If s edat i on i s requi red, s mal l amount s gi ven oral l y are bes t . Offer l i qui d preparat i ons i f t abl et s are refus ed. Parent eral medi cat i on may be i ndi cat ed i f pat i ent s refus e or are part i cul arl y di s t urbed. See bel ow for drugs and dos es . Pat i ent s wi t h on-goi ng di s t urbance may requi re regul ar s edat i on (e.g. ri s peri done 0.250.5mg od/bd). Regul ar us e of benzodi azepi nes may i nduce t ol erance and dependence, s o t hi s i s bes t avoi ded.
Sedation for acutely disturbed patients
St art wi t h at ypi cal ant i -ps ychot i cs s uch as ri s peri done 12mg or ol anzapi ne 510mg (hal f dos es i n t he el derl y): bot h are avai l abl e i n rapi dl y di s pers i ng t abl et s . If at ypi cal ant i -ps ychot i cs are unavai l abl e, hal operi dol 2.510mg or c hl orpromazi ne 2550mg may be us ed. If needed, add l orazepam 12mg (0.51mg i n el derl y) but remember t hat benzodi azepi nes may exacerbat e confus i on. Some pat i ent s , s uch as t hos e wi t h parki ns oni s m or t hos e who are neurol ept i c nave, are ext remel y s ens i t i ve t o neurol ept i cs and may devel op s evere ext ra-pyrami dal s i de-effect s i f t hes e drugs are gi ven. Us e l ow dos es i f you are uns ure and ens ure t hat ant i -chol i nergi c drugs s uch as procycl i di ne are avai l abl e. If parent eral medi cat i ons are requi red, us e l orazepam and/or hal operi dol (dos es as above). i m di azepam i s s omet i mes us ed but i s errat i cal l y abs orbed and hence us ual l y avoi ded. Reas s es s t he pat i ent aft er 1520 mi nut es t o as s es s t he effect s of t he s edat i on. Pat i ent s gi ven l arge amount s of s edat i on requi re vi t al
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s i gns moni t ori ng every 510 mi nut es for t he fi rs t hour t hen hal f-hourl y unt i l t hey are ambul at ory.
Prognosis in acute confusion

Del i ri um and dement i a bot h carry advers e prognos i s . In part i cul ar, del i ri um i ncreas es l engt h of hos pi t al s t ay (by up t o 10 days ) and mort al i t y and may produce res i dual cogni t i ve i mpai rment . It i s i mport ant t o ens ure t hat cogni t i ve as s es s ment i s repeat ed aft er t he epi s ode pri or t o di s charge as res i dual defi ci t s may go undet ect ed ot herwi s e. P.537
Practice point
Pat i ent s wi t h vi s ual hal l uci nat i ons us ual l y have organi c behavi oural di s t urbance.
P.538
Acute alcohol withdrawal

Al s o s ee p500. Unt reat ed, t hi s carri es a ri s k of s ei zures , permanent neurol ogi cal compl i cat i ons , and deat h. It s houl d be t reat ed as a medi cal emergency.
Detection of alcohol withdrawal

Earl y cl i ni cal feat ures i ncl ude anxi et y, res t l es s nes s , t remor, i ns omni a, s weat i ng, t achycardi a, at axi a, and pyrexi a. W i t hdrawal may be compl i cat ed by s ei zures es peci al l y i n t hos e wi t h known epi l eps y. Del i ri um t remens can devel op, and i s charact eri zed by confus i on and di s ori ent at i on, l abi l e mood and i rri t abi l i t y, hal l uci nat i ons (audi t ory and vi s ual ), and fl eet i ng del us i ons , oft en very fri ght eni ng. Unt reat ed, t hi s condi t i on carri es a s i gni fi cant ri s k of deat h. Do not forget t o s creen for W erni ckeKors akoff s yndrome, a
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compl i cat i on of acut e t hi ami ne defi ci ency whi ch may occur i n chroni c al cohol i s m. W erni cke's encephal opat hy pres ent s wi t h acut e confus i on, at axi a, nys t agmus , opht hal mopl egi a, and peri pheral neuropat hy but not al l of t hes e s ympt oms need t o be pres ent . Unt reat ed, a l arge number of t hes e pat i ent s wi l l devel op l ong-t erm memory probl ems from Kors akoff s yndrome.
Treatment of alcohol withdrawal
Al cohol wi t hdrawal pat i ent s can oft en be t reat ed as out -pat i ent s . However, pat i ent s wi t h a hi s t ory of s ei z ures or del i ri um t remens , or t hos e wi t h s i gns s ugges t i ve of del i ri um t remens , s houl d be t reat ed on a medi cal ward. Treat ment of t he wi t hdrawal requi res a l ong-act i ng benzodi azepi ne. The drug of choi ce i s us ual l y chl ordi azepoxi de. Oral chl ormet hi azol e has been us ed i n t he pas t , but i t i s hi ghl y dependence i nduci ng and dangerous i f combi ned wi t h al cohol . If an i v agent i s needed us e di azepam. A s ugges t ed reduci ng regi me i s s ugges t ed bel ow. B-compl ex vi t ami ns are requi red t o prevent W erni ckeKors akoff s yndrome (s ee above). In t he fi rs t i ns t ance, parent eral t herapy as pabri nex (ampoul es 1 and 2, 12 pai rs dai l y for 35 days i v or i m) and t hereaft er oral vi t ami n s uppl ement s s houl d be gi ven. Ot her us eful drugs may i ncl ude
o o o
-bl ockers for hypert ens i on Carbamazepi ne for s ei zures Hal operi dol for hal l uci nat i ons : not us ual l y requi red.
Withdrawal regime
See p500.
Aftercare
Mai nt enance t hi ami ne or mul t i -vi t ami n t herapy i s oft en
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i ndi cat ed, at l eas t i n t he i ni t i al peri od.

Screen for res i dual cogni t i ve i mpai rment . Mobi l i t y and occupat i onal t herapy as s es s ment s before di s charge may hel p i f t here are probl ems wi t h t he home envi ronment . Ident i fy t he pat i ent 's l ocal drug and al cohol s ervi ce and encourage t he pat i ent t o s el f-refer. Some hos pi t al s have al cohol l i ai s on nurs es who may be abl e t o as s i s t wi t h couns el l i ng or fol l ow-up.
P.539
Practice point
Sudden ons et of confus i on, del i ri um wi t h s weat i ng and s haki ng, part i cul arl y i n pat i ent s recent l y hos pi t al i zed, may i ndi cat e al cohol wi t hdrawal . Check t he s erum phos phat e, as i t may be very l ow (<0.4 mmol /l ) i n acut e al cohol wi t hdrawal .
P.540
Dealing with violent patients

Occas i onal l y you may encount er vi ol ent pat i ent s i n medi cal s et t i ngs , and as s aul t s on doct ors and nurs es do happen from t i me t o t i me.

Del i ri um Dement i a Epi l eps y Brai n damage (es peci al l y t emporal or front al l obes ) Al cohol i nt oxi cat i on or wi t hdrawal Drugs (cocai ne, crack, amphet ami ne, opi at e, or s edat i ve wi t hdrawal ) Funct i onal ment al i l l nes s (es peci al l y acut e ps ychos i s or
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acut e mani a)

Pers onal i t y di s order Previ ous vi ol ent behavi our i n pat i ent s wi t h s uch condi t i ons may gi ve an i ndi cat i on of fut ure ri s k.
Management
Ri s ks pos ed by vi ol ent pat i ent s may be mi ni mi zed by fol l owi ng s ome s i mpl e rul es .
Do not s ee pat i ent s who may be vi ol ent i n an i s ol at ed room, and do not s ee t hem on your own: as k a nurs e or ot her profes s i onal t o joi n you. Keep yours el f bet ween t he pat i ent and t he door. If you are uncomfort abl e or afrai d, end t he i nt ervi ew and l eave. It i s us ual l y s uffi ci ent t o cal m t he pat i ent down verbal l y and by avoi di ng confront at i on. On occas i on, i t i s neces s ary t o s edat e vi ol ent pat i ent s . Offer oral medi cat i on fi rs t , but gi ve i m i f neces s ary. Hal operi dol 510mg i s t he drug of choi ce, wi t h l orazepam 12mg i f addi t i onal s edat i on i s requi red. Res t rai nt may be requi red, part i cul arl y i f s edat i on i s t o be gi ven: s ecuri t y and nurs i ng s t aff may do t hi s , or t he pol i ce may be abl e t ohel p i f t hi s i s not pos s i bl e. Li ai s e wi t h t he ps ychi at ri c t eam about current and on-goi ng management . Nurs i ng on a medi cal ward wi t h a ps ychi at ri c nurs e i s al ways an opt i on.
P.541
P.542
Deliberate self-harm
Del i berat e s el f-harm (DSH) i s a common pres ent i ng compl ai nt t o A&E and reas on for admi s s i on. Severi t y of t he s equel ae of DSH vary great l y, from s uperfi ci al cut s t o s eri ous overdos es requi ri ng
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prol onged s pel l s i n hos pi t al . Sui ci de i s uncommon, but DSH i ncreas es t he ri s k of s ubs equent s ui ci de (1% of t hos e who commi t act s of DSH ki l l t hems el ves i n t he next year100x t he general popul at i on ri s k) and 4060% of s ui ci des have a hi s t ory of DSH. As s es s ment of pat i ent s who have harmed t hems el ves i s i mport ant i n order t o

Det ect t hos e at ri s k of s ubs equent DSH or s ui ci de Ident i fy pat i ent s wi t h s i gni fi cant ment al heal t h probl ems requi ri ng t reat ment Pl an aft ercare i n hos pi t al or i n t he communi t y.
Assessment by general medical staff

As s es s ment of DSH i s normal l y done by a profes s i onal experi enced i n t he fi el d: a ps ychi at ri s t , s peci al i s t nurs e, or s oci al worker. However, i t i s i mport ant for al l s t aff t o be abl e t o make a bas i c as s es s ment of t hes e pat i ent s , becaus e pat i ent s may refus e t o s ee a ment al heal t h worker or may at t empt t o l eave t he ward or depart ment before a det ai l ed as s es s ment can be carri ed out .
What if a patient wants to leave before they are assessed by a mental health professional?
Y ou have a dut y of care t o t he pat i ent t hat i ncl udes prot ect i ng t hem as bes t you can from on-goi ng ri s k.
Try t o pers uade t he pat i ent t o s t ay for an as s es s ment . If t hey agree, refer t o t he ps ychi at ri c t eam and as k t he nurs i ng s t aff t o moni t or t he pat i ent . If t he pat i ent refus es , t hen you wi l l need t o as k t hem t o s t ay whi l s t you make your own as s es s ment of ri s k. If t hey wi l l not s t ay, and you are concerned, you wi l l need t o det ai n t hem under common l aw pendi ng a formal ps ychi at ri c as s es s ment . If t hey agree t o s t ay, make your as s es s ment . Do not forget t o enqui re about pas t epi s odes of s el f-harm and on-goi ng ps ychi at ri c probl ems , as wel l as t he ques t i ons
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above.
If, aft er your as s es s ment , you have concerns t hat requi re t he pat i ent t o s ee a ment al heal t h profes s i onal , t ry t o pers uade t hem t o s t ay. If t hey refus e, cons i der det ai ni ng t hem under common l aw pendi ng urgent ps ychi at ri c as s es s ment . If you are s at i s fi ed t hat t he on-goi ng ri s k i s not of a magni t ude t hat requi res t hem t o be det ai ned, t hen al l ow t hem t o be di s charged but ens ure t hat t he GP i s i nformed. Det ai ni ng pat i ent s who wi l l not s t ay i n hos pi t al : s ee p548. Gui del i nes on t reat ment for pat i ent s who are refus i ng t reat ment : s ee p546.
P.543
Points to remember about DSH
Ri s k as s es s ment i n ol der adul t s or chi l dren and adol es cent s requi res s peci al i s t i nput . Al ways obt ai n advi ce i n t hes e cas es . St aff at t i t udes t owards pat i ent s who s el f-harm, es peci al l y i f t hey do s o frequent l y, can be very negat i ve. Pat i ent s us ual l y not i ce t hi s . Try and mai nt ai n an empat hi c at t i t ude and t o unders t and what may mot i vat e t he behavi our, however di ffi cul t t hi s may be. Some pat i ent s pres ent repeat edl y wi t h DSH. Thes e pat i ent s may have pers onal i t y di s orders wi t h or wi t hout s ubs t ance mi s us e, and may be very diffi cul t t o manage. Mos t A&E depart ment s know t hei r frequent at t endees wel l and have s t rat egi es i n pl ace for part i cul ar i ndi vi dual s : al ways as k.
Questions to assess suicide risk after an act of self-harm
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Current mood and mood at t i me of act ? Any forward pl anni ng, fi nal act s , or s ui ci de not es ? Any precaut i ons agai ns t bei ng di s covered? W hat was goi ng t hrough t hei r mi nd at t he t i me of t he act ? Di d t hey mean t o di e? W hat i s t hei r vi ew on havi ng s urvi ved? W hat are t hei r t hought s about t he fut ure now? Have t hey any feel i ngs now t hat t hey wi s h t o harm t hems el ves ? Have t hey made pl ans ?
P.544
The Mental Health Act and common law

There i s frequent confus i on about one's l egal ri ght s around pat i ent s who may be ment al l y i mpai red.
The Mental Health Act 1983

Di fferent rul es appl y i n Sc ot l and al t hough t he pri nc i pl es are t he s ame: s eek l oc al advi c e . Thi s act al l ows for t he compul s ory det ent i on and/or t reat ment of pat i ent s wi t h ment al i l l nes s and/or ment al i mpai rment of a nat ure and/or degree t hat requi res i n-pat i ent t reat ment agai ns t t hei r wi s hes . Thus pat i ent s who need t o be i n hos pi t al becaus e of a ri s k t o t hei r heal t h and s afet y or t hat of ot hers may be det ai ned or brought i nt o hos pi t al i f t he appropri at e peopl e agree t hat t hi s i s neces s ary.
Sec t i on 2 al l ows a peri od of as s es s ment and/or t reat ment for up t o 28 days , and i s us ual l y appl i ed t o pat i ent s pres ent i ng for t he fi rs t t i me or known pat i ent s wi t h a new probl em. Sec t i on 3 (whi ch may al s o fol l ow a Sect i on 2) al l ows det ent i on for t reat ment for up t o 6 mont hs . Pat i ent s have t he ri ght t o appeal agai ns t bot h Sect i ons 2 and 3. Bot h s ect i ons requi re opi ni ons from t wo appropri at el y qual i fi ed doct ors and an approved s oci al
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worker.
Sec t i on 4 al l ows pat i ent s t o be brought i nt o hos pi t al wi t h onl y one medi cal opi ni on and t hat of a s oci al worker, and i s onl y us ed i n emergenci es . Sec t i ons 5(2) and 5(4) appl y t o hos pi t al i n-pat i ent s and are des cri bed bel ow. Sec t i on 136 al l ows pat i ent s t o be brought by t he pol i ce t o A&E (or anot her des i gnat ed pl ace of s afet y) t o be as s es s ed by a doct or and a s oci al worker who may make t hem i nformal or arrange for a Sect i on 2 or 3.
Peopl e may be pl aced under a s ect i on ei t her i n t he communi t y or i n hos pi t al . It i s pos s i bl e t o det ai n a pat i ent on a medi cal ward and nurs e t hem t here i f t hey requi re medi cal t reat ment (s ee bel ow).
Common law
Thi s al l ows medi cal pract i t i oners t o act i n t he pat i ent 's bes t i nt eres t s i n emergency s i t uat i ons where t hey are unabl e t o gi ve cons ent (e.g. i f t hey are uncons ci ous , or cons ci ous but l ack capaci t y). If i n an emergency, i t i s deemed neces s ary t o det ai n a pat i ent pendi ng as s es s ment or t o t reat a pat i ent agai ns t t hei r wi l l t hen i t i s done s o under common l aw. Treat ment under common l aw i s gi ven i n t he bes t i nt eres t s of t he pat i ent i f i t i s carri ed out t o s ave l i fe or t o ens ure i mprovement or prevent det eri orat i on of phys i cal or ment al heal t h.
Al w ays doc ument i n t he not es t hat you are gi vi ng t reat ment i n t he pat i ent 's bes t i nt eres t s under c ommon l aw . P.545
P.546
Treating patients against their will

Pa g e 9 4 6
The i s s ue of how and whet her t o t reat pat i ent s agai ns t t hei r wi l l ari s es s urpri s i ngl y oft en. It i s frequent l y pres umed t hat t hi s i s due t o ment al i l l nes s al t hough oft en t hi s i s not s o.
What to do in this situation

The key t o whet her or not a pat i ent i s abl e t o refus e t reat ment i s whet her or not t hey have c apac i t y t o do s o. Ps ychi at ri s t s are frequent l y as ked t o as s es s capaci t y, but i n an emergency t hi s i s not al ways pos s i bl e. For a pat i ent t o have capaci t y, t hey mus t
Be abl e t o t ake i n and ret ai n t he i nformat i on rel evant t o maki ng t he deci s i on and t he cons equences of refus al Bel i eve t hi s i nformat i on W ei gh up t he i nformat i on and arri ve at a deci s i on. Pat i ent s may have t he capaci t y t o make s ome deci s i ons and not ot hers Capaci t y i n t he s ame pat i ent may fl uct uat e over t i me.
Remember
Ment al i l l nes s or cogni t i ve i mpai rment may i mpai r capaci t y, but need not do s o: t here are l egal precedent s where pat i ent s who are ment al l y unwel l have been wrongful l y t reat ed agai ns t t hei r wi l l . Di s agreei ng wi t h medi cal advi ce does not aut omat i cal l y cons t i t ut e i ncapaci t y. If a pat i ent does not have capaci t y and requi res emergency t reat ment , t hen t hi s may be gi ven agai ns t t hei r wi l l under common l aw (s ee p550).
The law on consent and capacity
There i s no s uch t hi ng as proxy cons ent for adul t s i n t he UK: a t hi rd part y cannot make a deci s i on on a pat i ent 's behal f, t hough i t i s good pract i ce t o t ake t hei r vi ews i nt o cons i derat i on. T he Ment al Heal t h Ac t 1983 does not al l ow doc t ors t o t reat ment al l y i mpai red pat i ent s agai ns t t hei r w i l l for phys i c al probl ems . Ps ychi at ri s t s are occas i onal l y as ked t o s ect i on pat i ent s i n order t hat t hey s houl d be t reat ed for a medi cal condi t i on. Thi s i s i l l egal , even i f
Pa g e 9 4 7
t he phys i cal probl em res ul t s from t he ment al probl em (e.g. del i berat e s el f-poi s oni ng). The onl y except i on woul d be where t he phys i cal condi t i on i s t he c aus e of t he ment al condi t i on, e.g. det ai ni ng and t reat i ng a pat i ent wi t h s evere confus i on s econdary t o organi c i l l nes s .
Di fferent rul es appl y t o c hi l dren and i ndi vi dual s wi t h advanc e di rec t i ves : you mus t al ways obt ai n s peci al i s t advi ce i n s uch cas es . Treat i ng a pat i ent who has capaci t y t o refus e agai ns t t hei r wi l l can cons t i t ut e a cri mi nal offence. However, you are unl i kel y t o be cri t i ci zed for t aki ng a deci s i on t o gi ve l i fe-s avi ng t reat ment agai ns t a pat i ent 's wi l l i f you are uns ure about capaci t y. Mos t peopl e woul d acknowl edge t hat i t bet t er t o t reat t han not t o t reat i n s uch s i t uat i ons . In any s i t uat i on where you are uns ure of what t o do, obt ai n s eni or advi ce at an earl y s t age. Many of t he medi cal defence organi zat i ons offer l egal advi ce on a 24-hour bas i s .
P.547
P.548
Patients who do not wish to stay in hospital

Somet i mes pat i ent s do not wi s h t o s t ay i n hos pi t al . Us ual l y t he probl em can be di s cus s ed and an agreement can be reached bet ween t he pat i ent and t he medi cal t eam. From t i me t o t i me t hi s i s i mpos s i bl e. If a pat i ent i s acut el y confus ed, t hey may not be wi l l i ng t o s t ay and requi re phys i cal res t rai nt i n order t o keep t hem t here. In t he cas e of pat i ent s who have harmed t hems el ves , t eams may be concerned about t he pos s i bl e ri s ks t o t he pat i ent i f t hey
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l eave t he ward.
What to do in this situation
As s es s t he pat i ent . W hat are t he medi cal i s s ues t hat requi re t hem t o s t ay? Is t hei r wi s h t o l eave part of an organi c i l l nes s t hat may be t reat ed? Is i t pos s i bl e t o reas on wi t h t he pat i ent and pers uade t hem t o s t ay? If not , t hey may requi re ps ychi at ri c as s es s ment regardi ng t hei r capaci t y t o deci de t o l eave. If t he pat i ent t ri es t o l eave before ps ychi at ri c as s es s ment , t hey may be det ai ned under common l aw. If t he wai t for a ps ychi at ri c opi ni on i s l i kel y t o t ake a l ong t i me (e.g. no ps ychi at ri c t eam on s i t e), i t may be neces s ary for t hem t o be det ai ned. Hos pi t al i n-pat i ent s may be det ai ned by a nurs e under Sect i on 5(4), or by a s i ngl e doct or under Sect i on 5(2). Pat i ent s i n A&E depart ment s mus t be det ai ned under common l aw.
P.549
P.550
Detaining a patient in an emergency Common law

If you bel i eve i t i s i n t he i nt eres t s of t he pat i ent not t o be al l owed t o l eave, t he s ecuri t y s t aff may be as ked t o prevent t hem from doi ng s o. Document t hat you are doi ng t hi s under common l aw. Thi s s houl d t ake pl ace unt i l a ps ychi at ri c opi ni on may be obt ai ned.
Section 5(2)
Thi s s ect i on al l ows an i n-pat i ent on any ward t o be prevent ed from l eavi ng. It l as t s a maxi mum of 72 hours and i s onl y a hol di ng meas ure pendi ng a ful l Ment al
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Heal t h Act as s es s ment by appropri at e doct or(s ) and a s oci al worker.
Any regi s t ered medi cal pract i t i oner may us e Sect i on 5(2), not onl y a ps ychi at ri s t . It mus t be appl i ed by t he cons ul t ant under w hos e c are t he pat i ent c urrent l y i s or t hei r nomi nat ed deput y, i .e. a member of t hei r t eam or whoever i s coveri ng t hei r pat i ent s out of hours . It i s act i oned by fi l l i ng i n a Form 12 (t hes e s houl d be avai l abl e on t he ward) whi ch s houl d be del i vered t o t he l ocal Ment al Heal t h Act admi ni s t rat i on offi ce as s oon as i t i s pract i cabl e. The Sect i on 5(2) expi res once t he pat i ent has been s een by an appropri at el y qual i fi ed doct or and i t i s convert ed t o a Sect i on 2 or 3, or i s res ci nded. If a pat i ent has been pl aced under Sect i on 5(2), t he dut y ps ychi at ry t eam s houl d be i nformed, as s houl d t he ment al heal t h dut y Soci al worker, t o ens ure t hat t he pat i ent i s reas s es s ed appropri at el y and qui ckl y. Sect i on 5(2) does not al l ow you t o enforce medi cal t reat ment of any ki nd. T hi s w oul d need t o be gi ven under c ommon l aw i f t he pat i ent i s not c ons ent i ng .
Section 5(4)
Thi s s ect i on ent i t l es a s ui t abl y qual i fi ed nurs e t o hol d a pat i ent for up t o 6 hours pendi ng t he arri val of a doct or t o as s es s t he pat i ent for Sect i on 5(2). It i s onl y us ed i n s i t uat i ons where a doct or cannot arri ve qui ckl y, e.g. i f t hey are off s i t e. If t he doct or deci des t hat t he pat i ent needs t o be hel d under Sect i on 5(2), t hen t he 72-hour durat i on of t hi s l at t er s ect i on begi ns at t he t i me t he nurs e i mpos ed t he Sect i on 5(4). It ends once t he pat i ent has been as s es s ed by appropri at e ment al heal t h profes s i onal s regardi ng furt her det ent i on or bei ng made i nformal .
Sec t i ons 5(2) and 5(4) are onl y appl i c abl e t o i n-pat i ent s , not t o pat i ent s A&E or out -pat i ent s . Pat i ent s i n t hes e areas are det ai ned
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under c ommon l aw pendi ng ps yc hi at ri c as s es s ment . P.551
Practice point
It i s bes t t o det ai n peopl e under common l aw i f you don't t hi nk t hat t hey s houl d l eave t he A&E dept . Y ou are unl i kel y t o be cri t i ci zed for t hi s , and you may ens ure t hei r s afet y i n t he s hort t erm.
P.552
Mentally ill patients in hospital

Pat i ent s wi t h ment al i l l nes s es are s ubject t o s t i gma from t hos e worki ng i n t he medi cal profes s i on as wel l as s oci et y at l arge. Pat i ent s wi t h chroni c ment al i l l nes s es , s uch as s chi zophreni a, are at i ncreas ed ri s k of i l l heal t h compared wi t h t he general popul at i on, and may from t i me t o t i me requi re care from medi cal t eams .
Guidelines for looking after patients with mental illness
Hos pi t al i s fri ght eni ng enough for t he ment al l y wel l , l et al one for t he ment al l y i l l . Ment al l y i l l pat i ent s may requi re a l ot of reas s urance and expl anat i on about what i s happeni ng t o t hem. If peopl e are on regul ar ps ychot ropi c medi cat i ons , t hen gi ve t hem . They wi l l us ual l y be abl e t o t el l you what t hey t ake and when. Remember t hat s udden di s cont i nuat i on of cert ai n medi cat i ons , s uch as l i t hi um and SSRIs , can preci pi t at e ment al heal t h cri s es . Some pat i ent s are on depot i nject i ons , rat her t han t abl et s . Fi nd when t hei r next i nject i on i s due and, i f t hi s fal l s duri ng t hei r hos pi t al s t ay, ens ure t hat t hey recei ve i t .
Pa g e 9 5 1
If t here i s a medi cal reas on for s t oppi ng a medi cat i on, or i f you are at al l uns ure, t hen as k for advi c e . Ideal l y, t hi s s houl d be from a ps ychi at ri s t who knows t he pat i ent , but ot herwi s e t he on-cal l or l i ai s on ps ychi at ri s t wi l l be abl e t o hel p. It i s good pract i ce t o communi cat e wi t h t he ment al heal t h t eam who know t he pat i ent , who wi l l probabl y be bas ed i n t he communi t y. They wi l l have a cons ul t ant and may have a s oci al worker, communi t y ps ychi at ri c nurs e, or ot her keyworker who wi l l appreci at e knowi ng t hat t hei r pat i ent i s i n hos pi t al . Communi cat e di s charge pl ans t o t he communi t y t eam: i t may hel p you t o s peed t he di s charge up as communi t y s upport may al ready be i n pl ace.
Remember, i f you are ever uns ure about a pat i ent 's ment al s t at e, i t i s bes t t o t al k t o a ps yc hi at ri s t about i t and as k for t hem t o be revi ew ed i f nec es s ary .
Sectioned patients on medical wards

Occas i onal l y, pat i ent s who are i n hos pi t al under a s ect i on of t he Ment al Heal t h Act 1983 become medi cal l y unwel l . They may need t o be t rans ferred t o and cared for on medi cal rat her t han ps ychi at ri c wards at t hes e t i mes . Pl eas e remember t he fol l owi ng.
Pat i ent s who are det ai ned are l i kel y t o be s eri ous l y ment al l y unwel l and t herefore prone t o becomi ng di s t urbed. It i s accept abl e for pat i ent s t o be det ai ned on a medi cal rat her t han a ps ychi at ri c ward under t hei r s ect i on i f t hat i s where t hey need t o be, but you s houl d expect on-goi ng i nput from t he ps ychi at ri c t eam cari ng for t he pat i ent duri ng t hei r s t ay. Pat i ent s who are under a s ect i on s houl d be nurs ed by a ment al heal t h nurs e at al l t i mes , al ongs i de t he general ward nurs es . If a pat i ent pres ent s part i cul ar ri s ks or i s very di s t urbed, more t han one nurs e may be requi red. Ens ure t hat t he ps ychi at ri c t eam l ooki ng aft er t he
Pa g e 9 5 2
pat i ent are kept i nformed of t he pat i ent 's progres s , s o t hat t hei r t rans fer back t o t he ps ychi at ri c uni t and t hei r on-goi ng medi cal care may be co-ordi nat ed s moot hl y.
Many ps ychi at ri c wards have nei t her t he s t aff nor t he equi pment t o perform even bas i c procedures (e.g. i v dri ps , moni t ori ng). Pat i ent s goi ng back t o t hes e wards need t o be wel l s t abi l i zed medi cal l y before t hey ret urn.
P.553
Practice points
Al ways fi nd out what medi cat i on a ps ychi at ri cal l y di s t urbed pat i ent i s t aki ng. It i s dangerous t o s t op cert ai n ps ychot ropi c medi cat i ons . New ons et of confus i on i s organi c unt i l proved ot herwi s e. Have a l ow t hres hol d for s t art i ng acycl ovi r or ot her ant i -vi ral t herapy unt i l herpes encephal i t i s i s excl uded.
Further reading
Bet hl em and Mauds l ey NHS Trus t (1999) T he Maze : Bet hl em and Mauds l ey NHS Trus t , London. Hughes R (2003) Neurol ogi c al Emergenc i es , 4t h edn; BMJ Books , London. Jones R (2001) T he Ment al Heal t h Ac t Manual , 7t h edn; Sweet & Maxwel l , London. Royal Col l ege of Ps ychi at ri s t s and Royal Col l ege of Phys i ci ans (2003) T he Ps yc hol ogi c al Care of Medi c al Pat i ent s , A Prac t i c al Gui de , 2nd edn; Royal Col l ege of Ps ychi at ri s t s and Royal Col l ege of Phys i ci ans , London. Tayl or, McConnel l , Kerwi n (2001) T he Mauds l ey Pres c ri bi ng gui del i nes , 6t h edn; Mart i n Duni t z, London. W yat t , Il l i ngwort h, Cl ancy, Munro, Robert s on (2001) Oxford Handbook of Ac c i dent and Emergenc y Medi c i ne ; OUP, Oxford.
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Diabet ic ket oac idosis (
Diabetic ketoacidosis (DKA):
assessment
DKA predomi nant l y occurs i n pat i ent s wi t h i ns ul i n-dependent di abet es (t ype I). It does not us ual l y occur i n non-i ns ul i n-dependent di abet es . DKA i s bei ng i ncreas i ngl y recogni z ed i n s ome t ype II di abet i cs , es p. Afro-Cari bbeans . Remember, pat i ent s may be pres cri bed i ns ul i n for poor di abet i c cont rol , and yet have non-i ns ul i n dependent di abet es .
Clinical features
Thes e i ncl ude
Pol yuri a and pol ydi ps i a: pat i ent s become dehydrat ed over a few days W ei ght l os s , weaknes s Hypervent i l at i on or breat hl es s nes s : t he aci dos i s caus es Kus s maul 's res pi rat i on (a deep s i ghi ng res pi rat i on) Abdomi nal pai n: DKA may pres ent as an acut e abdomen Vomi t i ng: exacerbat es dehydrat i on Confus i on, coma occurs i n 10% On exami nat i on as s es s s t at e of hydrat i on, vent i l at i on rat e, and s mel l for ket ones .
Investigations
Bl ood gl ucos e Thi s need not be hi gh. Severe aci daemi a may be pres ent wi t h gl ucos e val ues as l ow as 10mM (e.g. i f t he pat i ent has recent l y t aken i ns ul i n: t hi s , al one, i s i ns uffi ci ent t o correct t he aci daemi a i n t he
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ABG U&Es
pres ence of dehydrat i on) As s es s t he degree of aci daemi a (pH and bi c.) Correct ed
Uri nal ys i s
As s es s s erum K and renal funct i on Ket ones s t rongl y pos i t i ve (ket ones may be pres ent i n normal i ndi vi dual s aft er a peri od of s t arvat i on) NB: capt opri l and ot her s ul phydryl drugs can gi ve a fal s e pos i t i ve t es t for uri nary ket ones W BC may be el evat ed (neut rophi l i a): a l eukaemoi d react i on can occur i n abs ence of i nfect i on Bl ood and uri ne cul t ures (s ee not e bel ow) Look s peci fi cal l y for any i nfect i on May be hi gh wi t h abdomi nal pai n vomi t i ng i n abs ence of pancreat i t i s . Acut e pancreat i t i s may occur i n ~ 10% of pat i ent s wi t h DKA.
FBC Sept i c s creen Pl as ma ket ones CXR Amyl as e
Note

Serum os mol al i t y = 2 (Na + K ) + urea + gl ucos e. Di agnos i s of DKA requi res pos i t i ve uri nary or pl as ma ket ones and art eri al pH 7.30 and/or s erum bi carbonat e 15mmol /L. Many l abs do not meas ure pl as ma ket ones . P.557
The el derl y pat i ent pres ent i ng wi t h a hi gh gl ucos e, rel at i vel y normal aci dbas e bal ance, and ket ones i n t he uri ne does not have di abet i c ket oaci dos i s , and may not be i ns ul i n dependent . Cons i der ot her caus es of hypergl ycaemi a/aci dos i s , e.g. as pi ri n overdos e, and i n t he el derl y cons i der l act i c aci dos i s . Pl as ma ket ones can be es t i mat ed by di l ut i ng pl as ma
Pa g e 9 5 5
1:1 wi t h N s al i ne, and appl yi ng t o a uri ne ket one di ps t i ck. A res ul t of +++ corres ponds t o a pl as ma ket one body concent rat i on of 5mmol /L.
Common precipitants of DKA

30 Inf ect i on s 20 No n-c om pl i anc e wi t h t re at me nt 25 Ne wl y di a gn os e d di a bet % % %
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es
Poor prognostic features in DKA

pH <7.0 Ol i guri a Serum os mol al i t y >320 Newl y di agnos ed di abet es
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Diabet ic ket oac idosis: management
Diabetic ketoacidosis:
1
management
General measures
Rehydrat i on and i ns ul i n t herapy are t he mai ns t ays of t reat ment .
Si t e t he i v cannul a away from a major vei n i n t he wri s t . Thi s may be requi red for an AV fi s t ul a i n pat i ent s s ubs equent l y devel opi ng di abet i c nephropat hy. St art fl ui d repl acement (s ee bel ow). Ins ert a cent ral l i ne i n pat i ent s wi t h a hi s t ory of cardi ac di s eas e/aut onomi c neuropat hy or t he el derl y (s ee P866). Cons i der an art eri al l i ne t o moni t or ABGs and pot as s i um. Ni l by mout h for at l eas t 6 hours (gas t ropares i s i s common). Nas ogas t ri c t ube: i f t here i s i mpai red cons ci ous l evel t o prevent vomi t i ng and as pi rat i on. Uri nary cat het er i f ol i guri a i s pres ent or s erum creat i ni ne i s hi gh. Broad-s pect rum ant i bi ot i cs i f i nfect i on s us pect ed. LMW H (e.g. enoxapari n) s houl d be gi ven as prophyl axi s agai ns t DVTs , but i s not s t andard cl i ni cal pract i ce. The t of i ns ul i n i s s hort and cont i nued repl acement (i v or s c) i s es s ent i al .
Fluid replacement
Us e N s al i ne pot as s i um unt i l bl ood gl ucos e i s <12mmol /L. The average fl ui d l os s i n DKA i s 36 l i t res . Ai m t o res t ore t hi s over
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24 hours . (The fol l owi ng regi me s houl d be modi fi ed for pat i ent s wi t h cardi ac di s eas e.)
If hypot ens i ve and ol i guri c, gi ve i v col l oi ds ( N s al i ne) i ni t i al l y t o res t ore BP; t hen 1 l i t re N s al i ne over t he fi rs t 30 mi nut es t hen 1 l i t re N s al i ne wi t h pot as s i um (s ee t abl e) 2 hourl y for 8 hours t hen 1 l i t re N s al i ne (wi t h K , s ee t abl e) 4 hourl y unt i l rehydrat ed (~24hours ). The us e of bi carbonat e i s cont rovers i al . If t he pH <7.0, i s ot oni c (1.26%) s odi um bi carbonat e gi ven at a maxi mal rat e of 500ml (i .e. 75mmol ) over 1 hour i s s afe. Fas t er i nfus i on rat es caus e a paradoxi cal i nt racel l ul ar aci dos i s . Add 1020mEq K per 500 ml . There i s no evi dence t hat t he us e of bi carbonat e i n DKA i mproves out come. W hen bl ood gl ucos e i s <12mmol /L, commence a 5% dext ros e i nfus i on and cont i nue i ns ul i n i nfus i on. Cont i nued i ns ul i n i s requi red t o i nhi bi t ket oaci d product i on.
+ +
Potassium replacement
See t abl e. Tot al body pot as s i um can be depl et ed by 1000mmol and t he pl as ma K
+
fal l s rapi dl y as pot as s i um s hi ft s i nt o t he cel l s under
t he act i on of i ns ul i n. Us e l es s pot as s i um i n pat i ent s wi t h renal i mpai rment or ol i guri a.
Insulin replacement
See t abl e. Modi fy t hi s regi men dependi ng on t he res pons e t o t herapy.
Ai m for a fal l i n gl ucos e of 5mmol /L per hour (and correct i on of aci dos i s and pl as ma bi carbonat e). If t he gl ucos e or aci dos i s are not i mprovi ng, i ncreas e t he i ns ul i n i nfus i on rat e accordi ngl y. Keep t he bl ood gl ucos e >1014mmol /L for t he fi rs t 24 hours or unt i l t he ket oaci dos i s res ol ves ; mai nt ai n
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t hi s wi t h 5% dext ros e i nfus i on. P.559
Plasma potassium (mmol/L) <3.0 <4.0 <5.0
Amount of K (mmol) to add to each litre 40 30 20
The s l i di ng s cal e bel ow i s a gui de and s houl d be t ai l ored t o t he pat i ent and res pons e t o t herapy.
Add 50 uni t s of act rapi d t o 50ml 0.9% s al i ne and admi ni s t er by i nt ravenous i nfus i on. St art t he i ns ul i n i nfus i on at 0.1U/kg/h i ni t i al l y. That i s 7U/h for a 70kg pers on. If t he bl ood gl ucos e fal l s by >5mmol /L i n 1 hour, t hen decreas e t he rat e of i nfus i on t o 0.05U/kg/h (i .e. reduce t o hal f-dos e). W hen t he bl ood gl ucos e i s <12mmol /L, gl ucos e s houl d be i nfus ed i ns t ead of s al i ne, and bl ood gl ucos e s t abi l i zed accordi ng t o t he s l i di ng s cal e bel ow. Do not s t op i ns ul i n i nfus i on unt i l regul ar s ubc ut aneous i ns ul i n i s res t art ed .
Blo Ins od uli glu n cos inf
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e usi (m on mo (u l/L nit ) s/ (h ho ou ur) rly ) 0.0 St o p 2.0 i ns ul i n c al l doc t or 2.1 Cal l 4.0 doc t or 4.0 0.5 or 7.0 1 7.1 2 11. 0 11. 4 1 2 0.0 >2 7 0 c al l
Pa g e 9 6 1
doc t or
Footnote
1
Lebovi t z HE (1996) Lanc et 345 : 767772.
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Diabet ic ket oac idosis: c omplic at ions
Diabetic ketoacidosis:
complications
Assessment during treatment
Remember rapi d normal i zat i on of bi ochemi s t ry can be det ri ment al i n any pat i ent . It i s wi s er t o be caut i ous and s ub-opt i mal t han ent hus i as t i c and dangerous .

Bl ood gl ucos e hourl y wi t h l ab bl ood gl ucos e 4 hourl y. Pl as ma el ect rol yt es 2 hours aft er s t art of t reat ment and t hen 4 hourl y. The mai n ri s k i s hypokal aemi a. ABGs 4 hourl y, unt i l pers i s t ent i mprovement or normal i zed. Pl as ma os mol al i t y 4 hourl y. Some pat i ent s may requi re moni t ori ng on an ECG for T-wave changes duri ng t reat ment . Phos phat e l evel s s houl d be moni t ored dai l y duri ng t reat ment (s ee bel ow). Magnes i um l evel s s houl d be moni t ored dai l y (s ee bel ow). The i v i ns ul i n i nfus i on s houl d be cont i nued unt i l 4 hours aft er t he pat i ent i s commenced on s ubcut aneous i ns ul i n.
Complications
See t abl e.
Avoi d hypogl yc aemi a from overzeal ous i ns ul i n repl acement . Cerebral oedema occurs mai nl y i n chi l dren. It may be preci pi t at ed by s udden s hi ft s i n pl as ma os mol al i t y duri ng t reat ment . Sympt oms i ncl ude drows i nes s , s evere
Pa g e 9 6 3
headache, confus i on. Treat as on P454. Gi ve i v manni t ol 0.5g/kg body wei ght , repeat ed as neces s ary. Res t ri ct i v fl ui ds and move t o ITU. Mort al i t y i s ~70%; recovery of normal funct i on onl y 714%.
Serum phos phat e fal l s duri ng t reat ment , as i t moves i nt racel l ul arl y wi t h pot as s i um. If t he phos phat e l evel fal l s t o bel ow 0.4mmol /L, gi ve phos phat e i v (monobas i c pot as s i um phos phat e i nfus ed at a maxi mum rat e of 9mmol every 12 hours ). Check preparat i ons wi t h your pharmacy. Serum magnes i um may fal l duri ng i ns ul i n t herapy. If magnes i um l evel s fal l <0.6 mmol /L, gi ve 48mmol (2ml of 50%) magnes i um s ul phat e over 1530 mi nut es i n 50ml N s al i ne. Repeat as neces s ary. Hyperc hl oraemi c ac i dos i s (hi gh ani on gap aci dos i s i n a wel l -hydrat ed pat i ent ) may be s een wi t h exces s i ve admi ni s t rat i on of s al i ne and i ncreas ed cons umpt i on of bi carbonat e. No s peci fi c t reat ment i s requi red. Ti s s ue hypoperfus i on res ul t s from dehydrat i on and may t ri gger t he coagul at i on cas cade and res ul t i n t hromboembol i s m. Cons i der us i ng LW MH (e.g. enoxapari n s c) for prophyl axi s i n t hos e at ri s k.
Complications of DKA

Hypokal aemi a Hypophos phat aemi a Hyperchl oraemi c aci dos i s Hypogl ycaemi a Cerebral oedema i n chi l dren Thromboembol i s m
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hyperosmolar non- ket ot ic c oma (
Hyperosmolar non-ketotic
coma (HONC)
HONC occurs i n el derl y pat i ent s wi t h non-i ns ul i n-dependent di abet es . Thes e pat i ent s are al s o at i ncreas ed ri s k of venous and art eri al t hrombos es . The mort al i t y i s very much hi gher t han for ket oaci dos i s .
Presentation
A hi s t ory of di abet es i s not us ual l y known, and t he pat i ent i s el derl y Ins i di ous ons et of pol yuri a and pol ydi ps i a Severe dehydrat i on Impai red cons ci ous l evel : t he degree correl at es mos t wi t h pl as ma os mol al i t y. Coma i s us ual l y as s oci at ed wi t h an os mol al i t y >440 Res pi rat i on i s us ual l y normal The pat i ent may rarel y pres ent wi t h a CVA, s ei zures , or a MI.
Investigations
Gl ucos e U&Es Us ual l y very hi gh (>50mmol /L) Dehydrat i on caus es a great er ri s e i n urea t han creat i ni ne (normal rat i o of Cr:Ur up t o 20:1 (M:mM). Si gni fi cant hypernat raemi a may be hi dden by t he hi gh gl ucos e. The hypernat raemi a may appear t o wors en as t he gl ucos e fal l s Rel at i vel y normal cf. DKA. A coexi s t ent l act i c aci dos i s cons i derabl y wors ens t he prognos i s
Pa g e 9 6 5
Pl as ma os m. FBC ECG CXR Uri ne
Cal cul at e by [2 (Na + K ) + urea + gl ucos e] needs t o be >350mos m/kg for di agnos i s Pol ycyt haemi a and l eukocyt os i s may i ndi cat e dehydrat i on or i nfect i on res pect i vel y Look for MI or i s chaemi a Look for s i gns of i nfect i on For uri nal ys i s , MC&S. Remember t hat ket ones may occur i n any s t arved pers on, but t he l evel wi l l be bel ow 5mM. Bl ood and prot ei n on uri nal ys i s may i ndi cat e UTI.
Management: general measures
Rehydrat i on and i ns ul i n t herapy are t he mai ns t ays of t reat ment . Fl ui d repl acement s houl d be more caut i ous i n t he el derl y. Gi ve oxygen i f hypoxi c on ai r. Avoi d fl ui d overl oad: moni t or cent ral venous pres s ure i n al l pat i ent s . Ni l by mout h for at l eas t 6 hours and i ns ert an NG t ube i n pat i ent s wi t h i mpai red cons ci ous l evel t o prevent vomi t i ng and as pi rat i on. Uri nary cat het er i f ol i guri a i s pres ent , or s erum creat i ni ne i s hi gh. Ant i -coagul at e wi t h LW MH (e.g. enoxapari n 40mg s c dai l y).
Fluid replacement
The average fl ui d l os t i s 810L. Thi s s houl d be repl aced caut i ous l y.

1 l i t re N s al i ne over t he fi rs t 60 mi nut es t hen 1 l i t re N s al i ne wi t h K (s ee t abl e, P559) every 2 hours for 4 hours t hen P.563
+
Pa g e 9 6 6
1 l i t re N s al i ne wi t h K (s ee t abl e, P559) q6h unt i l rehydrat ed (~48 hours ). If t he pl as ma Na i s >160mM gi ve 0.45% s al i ne (0.5 N s al i ne) for t he fi rs t 3 l i t res . The Na
+
l evel i s art i fi ci al l y
l owered by t he hi gh gl ucos e l evel (s ee bel ow) and appears t o cl i mb as t he bl ood gl ucos e fal l s .
W hen bl ood gl ucos e <12mmol /L, commence a 5% dext ros e i nfus i on, and cons i der s t oppi ng i ns ul i n t herapy and s t art i ng oral hypogl ycaemi c agent s or di et al one.
Insulin regimen
Thi s i s s i mi l ar t o t hat for di abet i c ket oaci dot i c coma (s ee t abl e, P559), except t hat s t oppi ng i ns ul i n compl et el y i s l es s hazardous i n t he s hort t erm.
Practice points: hyperosmolar non-ketotic coma
Severe hypergl ycaemi a can caus e a t echni cal error i n t he meas urement of Na concent rat i ons . The correct ed concent rat i on can be cal cul at ed by*
+
Treat ment of s evere hypergl ycaemi a caus es an apparent i ncreas e i n pl as ma Na whi ch i n real i t y may not act ual l y change Occas i onal l y pat i ent s pres ent wi t h hyponat raemi a whi ch bas ed on t he above i s a form of ps eudohyponat raemi a (s ee P574)
+
Footnote
*Thes e formul ae s houl d be us ed wi t h caut i on. Check wi t h l aborat ory as s ome l abs meas ure i oni c Na .
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Pa g e 9 6 7
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hypoglyc aemic c oma: assessment
Hypoglycaemic coma:
assessment
Al l uncons ci ous pat i ent s s houl d be as s umed t o be hypogl ycaemi c unt i l proved ot herwi s e. Al w ays check a bl ood gl ucos e us i ng a Gl ucos t i x (or BM s t i x) i mmedi at el y, and c onfi rm wi t h a l ab det ermi nat i on. The mos t common caus e of coma i n a pat i ent wi t h di abet es i s hypogl ycaemi a due t o drugs . The l onger act i ng s ul phonyl ureas s uch as gl i bencl ami de are more prone t o do t hi s t han t he s hort er act i ng ones . Pat i ent s who are not known t o have di abet es , but who are hypogl ycaemi c, s houl d have a l aborat ory bl ood gl ucos e, and s erum s aved for i ns ul i n and C-pept i de det ermi nat i on (i ns ul i noma or fact i t i ous drug admi ni s t rat i on) before admi ni s t rat i on of gl ucos e.
Presentation
Sympathetic overactivity (glc <3.6mmol/L)

Tachycardi a Pal pi t at i ons Sweat i ng Anxi et y Pal l or Tremor Col d ext remi t i es Confus i on Sl urred s peech Focal neurol ogi cal defect (s t roke-l i ke s yndromes )
Neuroglycopenia (glc <2.6mmol/L)

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Coma Pat i ent s wi t h wel l -cont rol l ed di abet es have more frequent epi s odes of hypogl ycaemi a, and can become des ens i t i zed t o s ympat het i c act i vat i on. Thes e pat i ent s may devel op neurogl ycopeni a before s ympat het i c act i vat i on and compl ai n of l os s of warni ng. -bl ockers bl unt t he s ympt oms of s ympat het i c act i vat i on and pat i ent s t aki ng t hes e drugs l os e t he earl y warni ng of hypogl ycaemi a. Pat i ent s wi t h poorl y cont rol l ed di abet es devel op s ympat het i c s i gns earl y, and avoi d t hes e by runni ng a hi gh bl ood gl ucos e. They may compl ai n of bei ng hypo when t hei r bl ood s ugar i s normal or hi gh. They do not requi re gl ucos e. Pat i ent s who have di abet es fol l owi ng a t ot al pancreat ect omy have more frequent and s evere epi s odes of hypogl ycaemi a (bri t t l e di abet es ) becaus e t hey l ack gl ucagon produci ng () cel l s as wel l as i s l et cel l s .
Investigations

Bl ood gl ucos e (BM s t i x and confi rmed by l ab gl ucos e). U&Es (hypogl ycaemi a i s more common i n di abet i c nephropat hy) Save s erum, pri or t o gi vi ng gl ucos e, for i ns ul i n and C-pept i de l evel s (s end ~20ml bl ood t o t he l ab for i mmedi at e cent ri fugat i on i f i ndi cat ed).
Note
A l ab gl ucos e of l es s t han 2.2mmol /L i s defi ned as a s evere at t ack. Coma us ual l y occurs wi t h bl ood gl ucos e <1.5mmol /L. Low C-pept i de and hi gh i ns ul i n l evel i ndi cat e exogenous i ns ul i n; hi gh C-pept i de and i ns ul i n l evel i ndi cat e endogenous i ns ul i n [e.g. s urrept i t i ous drug (s ul phonyl urea) i nges t i on or i ns ul i noma].
P.565
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Causes of hypoglycaemia
Drugs

Ins ul i n Sul phonyl ureas Al cohol Sal i cyl at es Pres cri pt i on errors (e.g. chl orpropami de for chl orpromaz i ne) Ot hers Di s opyrami de -bl ockers Pent ami di ne Qui ni ne
Organ failure

Hypopi t ui t ari s m (es p. acut e pi t ui t ary necros i s ) Acut e l i ver fai l ure Adrenal fai l ure Myxoedema Rarel y CCF or CRF Seps i s s yndrome Mal ari a Ins ul i noma Ret roperi t oneal s arcoma
Infections

T umours

Pa g e 9 7 0
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hypoglyc aemic c oma: management
Hypoglycaemic coma:
management
Acute measures
Remember t o t ake bl ood pri or t o gl ucos e admi ni s t rat i on (gl ucos e, i ns ul i n, C-pept i de). See P564. If t here i s a hi s t ory of chroni c al cohol i nt ake or mal nouri s hment , gi ve i v t hi ami ne 12mg/kg t o avoi d preci pi t at i ng W erni cke's encephal opat hy. If pat i ent i s cons ci ous and co-operat i ve, gi ve 50g oral gl uc os e or equi val ent (e.g. Lucozade, or mi l k and s ugar). Gi ve 50ml of 50% dext ros e i v i f pat i ent i s unabl e t o t ake oral fl ui ds . If i v acces s i s i mpos s i bl e, gi ve 1mg of gl uc agon i m. Then gi ve t he pat i ent s ome oral gl ucos e t o prevent recurrent hypogl ycaemi a. Gl ucagon i s l es s effect i ve i n hypogl ycaemi a due t o al cohol . Admi t t he pat i ent i f t he caus e i s a l ong-act i ng s ul phonyl urea or a l ong-act i ng i ns ul i n, and commence a cont i nuous i nfus i on of 10% gl ucos e (e.g. 1 l i t re 8 hourl y) and check gl ucos e hourl y or 2 hourl y.
Further management
Pat i ent s s houl d regai n cons ci ous nes s or become coherent wi t hi n 10 mi nut es al t hough compl et e cogni t i ve recovery may l ag by 3045 mi nut es . Do not gi ve furt her bol us es of i v gl ucos e wi t hout repeat i ng t he bl ood gl ucos e. If t he pat i ent does not wake up aft er ~10 mi nut es , repeat t he bl ood gl ucos e and cons i der
Pa g e 9 7 1
anot her caus e of coma (e.g. head i njury whi l e hypogl ycaemi c, s ee P444).
Prol onged s evere hypogl ycaemi a (>4 hours ) may res ul t i n permanent cerebral dys funct i on. Pat i ent s on s ul phonyl ureas may become hypogl ycaemi c fol l owi ng a CVA or ot her i l l nes s prevent i ng adequat e food i nt ake. Recurrent hypogl ycaemi a may heral d t he ons et of di abet i c nephropat hy, as t hi s decreas es i ns ul i n requi rement s : i ns ul i n i s part l y degraded by t he ki dney. Revi ew pat i ent 's current medi cat i on, and i ns pect al l t abl et s from home. Cons i der ps ychi at ri c revi ew i f s el f-i nfl i ct ed.
Liver dysfunction and recurrent hypoglycaemia
Hypogl ycaemi a i s common i n acut e l i ver fai l ure, when coma may occur (as a res ul t of l i ver fai l ure rat her t han hypogl ycaemi a). Severe hypogl ycaemi a i s rare i n chroni c l i ver di s eas e. In chroni c al cohol i cs i t i s advi s abl e t o admi ni s t er i v t hi ami ne (12mg/kg) before i v dext ros e t o avoi d preci pi t at i ng neurol ogi cal damage. An acut e i nges t i on of al cohol can al s o s uppres s hepat i c gl uconeogenes i s .
Pa g e 9 7 2
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Urgent surgery in pat ient s wit h diabet es
Urgent surgery in patients
with diabetes
Surgery requi res pat i ent s t o fas t for s everal hours . In addi t i on a general anaes t het i c and s urgery produce s i gni fi cant s t res s es on an i ndi vi dual . The hormonal res pons e t o s t res s i nvol ves a s i gni fi cant ri s e i n count er-regul at ory hormones t o i ns ul i n, i n part i cul ar cort i s ol and adrenal i ne. For t hi s reas on, pat i ent s wi t h di abet es undergoi ng s urgery wi l l requi re an i ncreas ed dos e of i ns ul i n des pi t e t hei r fas t i ng s t at e.
Type I DM (insulin dependent)
Try t o put t he pat i ent fi rs t on t he l i s t . Inform t he s urgeon and anaes t het i s t earl y. Di s cont i nue l ong-act i ng i ns ul i n t he ni ght before s urgery i f pos s i bl e. If t he pat i ent has t aken a l ong-act i ng i ns ul i n and requi res emergency s urgery, an i nfus i on of 10% dext ros e (10100ml /h) can be us ed, t oget her wi t h an i ns ul i n s l i di ng s cal e. Ens ure i v acces s i s avai l abl e. W hen ni l by mout h, s t art i v i nfus i on of 5% dext ros e wi t h pot as s i um (20mmol /L) at 100ml /h and cont i nue unt i l oral i nt ake i s adequat e. Remember s al i ne requi rement s (~100150mmol Na/24h but i ncreas es pos t -operat i vel y) but do not s t op dext ros e i nfus i on (ri s k of hypogl ycaemi a). Commence an i v i ns ul i n s l i di ng s cal e (s ee t abl e). Meas ure fi nger-pri ck gl ucos e hourl y and adjus t t he i ns ul i n i nfus i on accordi ngl y. Ai m for 711mmol /L. Cont i nue t he i ns ul i n s l i di ng s cal e unt i l t he s econd meal
Pa g e 9 7 3
and res t art t he normal s c dos e of i ns ul i n. As i v i ns ul i n has a very s hort hal f-l i fe (3.5 mi n), t hi s mus t be cont i nued unt i l t he pat i ent 's s ubcut aneous i ns ul i n i s bei ng abs orbed; an overl ap of 4 hours i s recommended.
Type II DM (non-insulin dependent)
Di s cont i nue gl ucos e-l oweri ng t abl et s or l ong-act i ng i ns ul i n t he ni ght before s urgery i f pos s i bl e. If t he pat i ent has t aken t hei r oral hypogl ycaemi c or i ns ul i n and requi res emergency s urgery, s t art an i nfus i on of 10% dext ros e (10100ml /h) wi t h an i ns ul i n s l i di ng s cal e. Check a fas t i ng gl ucos e: i f >12mmol /L t reat as above. If t he pat i ent 's di abet es i s normal l y managed wi t h oral hypogl ycaemi c agent s , t hes e can be res t art ed once t he pat i ent i s eat i ng normal l y. The s l i di ng s cal e can be t ai l ed off 4 hours l at er. Di et -cont rol l ed di abet i cs oft en do not requi re a s l i di ng s cal e at t he t i me of s urgery but may requi re i v i ns ul i n pos t operat i vel y for a s hort peri od i f bl ood gl ucos e ri s es >12mmol /L. Thi s may be t ai l ed off, when eat i ng normal l y.
P.569
Add 50 uni t s of act rapi d t o 50ml 0.9% s al i ne and admi ni s t er by i nt ravenous i nfus i on. The s l i di ng s cal e bel ow i s a gui de onl y. Blood glucose (mmol/L) (hourly) Insulin infusion (units/hour) 0.02.0 St op i ns ul i ncal l doct or 2.14.0 Cal l doct or 4.17.0 0.5 or 1 7.111.0 2 11.120.0 4 >20.0 Cal l doct or
Pa g e 9 7 4
Adjus t t he s cal e accordi ng t o t he pat i ent 's us ual requi rement of i ns ul i n (e.g. a pat i ent on Mi xt ard 36U/24U requi res 60U/24 h, i .e. 2.5 U/h normal l y). If bl ood gl ucos e i s pers i s t ent l y l ow (<4mmol /L) decreas e al l i ns ul i n i nfus i on val ues by 0.51.0U/h. If bl ood gl ucos e i s pers i s t ent l y hi gh (>13.0mmol /L) i ncreas e al l i ns ul i n i nfus i on val ues by 0.51.0U/h.
Pa g e 9 7 5
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hyponat raemia: assessment
Hyponatraemia: assessment
+
Presentation
Mi l d hyponat raemi a (Na 130135mmol /L) i s common es peci al l y i n pat i ent s t aki ng t hi azi de di uret i cs and i s us ual l y as ympt omat i c. Moderat e hyponat raemi a (Na has devel oped rapi dl y.
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120129mmol /L) i s us ual l y as ympt omat i c unl es s i t Severe hyponat raemi a (Na <120mmol /L) may be as s oci at ed wi t h di s t urbed ment al s t at e, res t l es s nes s , confus i on, and i rri t abi l i t y. Sei zures and coma prevai l as t he s odi um approaches 110mmol /L. Hi s t ory s houl d focus on drugs , fl ui d l os s es (di arrhoea, frequency, s weat i ng), s ympt oms of Addi s on's , s ympt oms or hi s t ory of cardi ac, l ung, l i ver, or renal di s eas e. Exami nat i on s houl d focus on careful as s es s ment of vol ume s t at us , and i n part i cul ar s houl d as s es s whet her t he pat i ent i s hypovol emi c, normovol emi c, and/or oedemat ous . Pat i ent s s houl d t herefore have an as s es s ment of t hei r l yi ng and s t andi ng BP, HR, JVP CVP, s ki n t urgor, and t he pres ence of oedema or as ci t es . Pat i ent s w ho are hyponat raemi c and hypovol emi c are s al t depl et ed .
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Investigations
In addi t i on t o U&Es , ot her t es t s s houl d be ai med at excl udi ng ot her caus es of hyponat raemi a (s ee t abl e, P572). Meas ure s erum os mol ari t y and compare i t t o t he cal cul at ed os mol ari t y [2(Na + K ) + urea + gl ucos e]: an i ncreas e i n os mol ar gap i s wi t h s ubs t ances s uch as et hyl ene gl ycol , s evere hypergl ycaemi a, manni t ol , et c.
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Pa g e 9 7 6
Uri ne Na combi ned wi t h cl i ni cal as s es s ment of fl ui d s t at us may hel p det ermi ne t he underl yi ng caus e:
o
Vol ume depl et i on from an ext ra-renal caus e (s ee t abl e, P572) i s normal l y as s oci at ed wi t h a l ow uri nary Na (<10mmol /L)
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Vol ume depl et i on wi t h a hi gh uri nary Na
(>20mmol /L) s ugges t s i nappropri at e renal s al t -was t i ng (e.g. i nt ri ns i c renal di s eas e, hypot hyroi di s m, adrenal i ns uffi ci ency, di uret i cs )
o
A l ow uri ne Na (<10mmol /L) i s s een i n condi t i ons s uch as CCF, ci rrhos i s , or nephrot i c s yndrome where t here i s s odi um ret ent i on i n res pons e t o poor renal perfus i on Euvol aemi a wi t h hi gh uri ne Na
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i s s een wi t h SIADH
and rarel y wi t h s evere myxoedema.
General principles
As s es s ment of t he pat i ent 's vol ume s t at us (neck vei ns , ort hos t at i c hypot ens i on, cardi ac s i gns of fl ui d overl oad, as ci t es s ki n t urgor) wi l l hel p i n bot h di agnos i s and s ubs equent t reat ment . Mi l d as ympt omat i c hyponat raemi a wi l l us ual l y res pond t o t reat ment of t he underl yi ng caus e and no s peci fi c t herapy i s neces s ary. Correct i on of hyponat raemi a s houl d be gradual t o avoi d vol ume overl oad and/or cent ral pont i ne myel i nol ys i s . Ai m t o res t ore t he s erum Na t o ~125mmol /L act i vel y (i v fl ui ds ) and al l ow t o ri s e gradual l y aft er t hat by t reat i ng t he underl yi ng caus e. Seek expert hel p i f s erum Na <120mmol /L s everel y s ympt omat i c. P.571
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Pat i ent s wi t h ci rrhos i s and as ci t es and s evere hyponat raemi a s houl d have di uret i cs s t opped, and be
Pa g e 9 7 7
t reat ed wi t h vol ume expans i on.
SIADH or ot her condi t i ons as s oci at ed wi t h pl as ma vol ume expans i on can caus e hypouri caemi a (i ncreas ed renal cl earance).
Pa g e 9 7 8
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hyponat raemia: c auses
Hyponatraemia: causes
Decreased serum osmolarity

Hypovolaemia (hyponatraemia + hypovolaemia = salt depletion) Renal l os s es (uNa >20mmol /L) Di uret i cs Addi s on's di s eas e Na-l os i ng nephropat hi es GI l os s es (di arrhoea, vomi t i ng) Burns Fl ui d s eques t rat i on (e.g. peri t oni t i s , pancreat i t i s ) Non-renal l os s es (uNa <20mmol /L)
Normovolaemic (normal or mildly increased ECV) SIADH: uri ne os m. >100, s erum os m. l ow (<260), uri ne Na >40mmol /L CNS di s orders Trauma St roke/SAH Mal i gnancy (1/2) Vas cul i t i s (e.g. SLE) Infect i on (abs ces s or Mal i gnanc y Lung (oat cel l ) Pancreas Lymphoma or l eukaemi a Pros t at e Uri nary t ract Pul monary di s eas e Pneumoni a TB Lung abs ces s Cys t i c fi bros i s Lung vas cul i t i s
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meni ngoencephal i t i s ) Drugs (vi a SIADH renal s ens i t i vi t y t o ADH or Na > H 2 O l os s ) Opi at es Thi oradi zi ne Chl orpropami de Hal operi dol Carbamazepi ne Thi azi des Ami t ri pt yl i ne Cl ofi brat e Cycl ophos phami de
Pa g e 9 7 9
Vas opres s i n Oxyt oci n Vi ncri s t i ne Mi s cel l aneous caus es Severe myxoedema Ps ychogeni c pol ydi ps i a Oedematous states Conges t i ve cardi ac fai l ure Ci rrhos i s wi t h as ci t es Severe renal fai l ure Nephrot i c s yndrome
Normal serum osmolarity
Ps eudo-hyponat reemi a (e.g. l i paemi c erum, paraprot ei n >10g/dl ) Int racel l ul ar s hi ft of Na (e.g. hypergl ycaemi a, et hyl ene gl ycol )
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hyponat raemia: management
Hyponatraemia: management
Exc l ude ps eudohyponat raemi a: l i paemi c s erum wi l l be obvi ous (as k t he bi ochemi s t ). Cal cul at e t he os mol ar gap t o check t here are no hi dden os mol es (P572). Al ways excl ude t he pos s i bi l i t y of art efact ual Na from bl ood t aken proxi mal t o an i v i nfus i on.
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As ympt omat i c hyponat raemi a s houl d be correct ed s l owl y s o t hat s erum s odi um does not i ncreas e by >12mmol /L/day. Sympt omat i c hyponat raemi a (e.g. s ei zures or coma) requi res a more aggres s i ve i ni t i al correct i on t o i ncreas e s erum s odi um concent rat i on by ~6mmol /L over 34 hours . Thereaft er, correct s erum s odi um s l owl y, s o t hat t he overal l i ncreas e i s <12mmol /L per 24 hours . Seek expert hel p earl y. St art i v i nfus i on of normal s al i ne (150mmol /L) at 250500ml /h wat chi ng careful l y for fl ui d overl oad. As a gui de, i f 1 l i t re of N s al i ne i s i nfus ed i ns t ant aneous l y, i t woul d i ncreas e s erum s odi um by 45 mmol /L. Al t ernat i vel y, i nfus e 5% s al i ne at 40700mmol Na /h unt i l s erum s odi um i ncreas es adequat el y. I f vol ume depl et e (dehydrat ed) s t art an i v i nfus i on of normal s al i ne (0.9% = 150mmol /L Na ); i ns ert a cent ral venous l i ne i f i ndi cat ed. Moni t or fl ui d out put : cat het eri ze t he bl adder i f t here i s renal i mpai rment . W at ch out for heart fai l ure. I f not dehydrat ed: for pat i ent s wi t h moderat e SIADH, res t ri ct fl ui d i nt ake t o 500/24h. Seek expert hel p.
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Clinical manifestations of osmotic
Pa g e 9 8 1
demyelination

May be del ayed 25 days Oft en i rrevers i bl e or onl y part i al l y revers i bl e Dys art hri a Dys phas i a Parapares i s or quadri pares i s Let hargy Coma or s ei zures .
Pa g e 9 8 2
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hypernat raemia
Hypernatraemia
Abnormal i t i es i n s erum s odi um are us ual l y as s oci at ed wi t h changes i n s erum os mol al i t y and ECV.
Presentation
Sympt oms oft en rel at e t o s evere vol ume depl et i on: weaknes s , mal ai s e, fat i gue, al t ered ment al s t at us , confus i on, del i ri um, or coma. The way t o det ermi ne t he caus e of abnormal s erum Na i s by
Careful as s es s ment of t he ECV (eval uat i on of neck vei ns , s upi ne and s t andi ng BP, any cardi ac s i gns of fl ui d overl oad (e.g. S3, oedema), and s ki n t urgor), i n as s oci at i on wi t h Meas uri ng t he s erum ( uri ne) os mol al i t y. [Serum os mol al i t y may be es t i mat ed by (2 (Na + K ) + urea + gl ucos e) but t hi s i s i naccurat e when t here are ot her os mol es (e.g. ket ones , et hanol , met hanol , et hyl ene gl ycol , renal fai l ure) t hat cont ri but e.]
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Serum Na >145mmol /L i s al ways as s oci at ed wi t h hyperos mol ari t y.
Causes of hypernatraemia
Normal or extracellular volume (excessive Na and H 2 O loss)
Renal water losses (uri nary os m i nappropri at el y l ow )

o o
Di abet es i ns i pi dus (cent ral or nephrogeni c) Os mot i c di ures i s wi t h wat er repl acement onl y (e.g. DM)
Non-renal water losses (uri nary os m >400mos mol /L)

o o
Hypot oni c GI l os s es (e.g. di arrhoea) Cut aneous l os s es (burns , heat s hock, s weat i ng, and hi gh fever) Ches t i nfect i ons wi t h prol onged hypervent i l at i on
Pa g e 9 8 3
Salt overload (usually iatrogenic)

o o o
Concent rat ed NaHCO 3 Pos t -operat i vel y when huge vol umes of fl ui d us ed In ITU when vol ume l oaded wi t h s al i ne bas ed fl ui ds Concent rat ed i nfant formul a Conn's s yndrome (hypert ens i on, hypokal aemi a, al kal os i s )
o o
Management
Avoi d rapi d and ext reme changes i n s erum s odi um concent rat i on. It i s s afer t o change s erum s odi um caut i ous l y. If t here i s hypovol aemi a, s t art fl ui d repl acement . Normal s al i ne (0.9%) cont ai ns el ement al s odi um at 150mmol /L. Us e t hi s i ni t i al l y t o correct hypovol aemi a i f pres ent , t hen change t o 5% dext ros e t o repl ace wat er and s l owl y correct s odi um concent rat i on. If t he pat i ent i s haemodynami cal l y s t abl e encourage oral fl ui ds . Moni t or el ect rol yt es t wi ce dai l y i ni t i al l y.
Pa g e 9 8 4
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Ac ut e hypoc alc aemia
Acute hypocalcaemia
Presentation
Abnormal neurol ogi cal s ens at i ons and neuromus cul ar exci t abi l i t y Numbnes s around t he mout h and paraes t hes i ae of t he di s t al l i mbs Hyperrefl exi a Carpopedal s pas m Tet ani c cont ract i ons (may i ncl ude l aryngos pas m) Focal or general i zed s ei zures . Rarel y ext ra-pyrami dal s i gns or papi l l oedema Hypot ens i on, bradycardi a, arrhyt hmi as , and CCF Chvos t ek's s i gn i s el i ci t ed by t appi ng t he faci al nerve jus t ant eri or t o t he ear, caus i ng cont ract i on of t he faci al mus cl es (s een i n 10% of normal s ) Trous s eau's s i gn i s el i ci t ed by i nfl at i ng a bl ood pres s ure cuff for 35 mi nut es 1020mmHg above t he l evel of s ys t ol i c bl ood pres s ure. Thi s caus es mi l d i s chaemi a, unmas ks l at ent neuromus cul ar hyperexci t abi l i t y, and carpal s pas m i s obs erved.
NB: Carpopedal s pas m may occur duri ng hypervent i l at i on i nduced res pi rat ory al kal os i s .
Investigations

Pl as ma Ca , PO Pl as ma Mg U&Es
2+
2+
34
, and al bumi n
ECG (Prol onged QT i nt erval ) Pl as ma PTH l evel SXR (i nt racrani al cal ci fi cat i on es p. hypoparat hyroi di s m)
Pa g e 9 8 5
Management
The ai m of acute management i s t o amel i orat e t he acut e mani fes t at i ons of hypocal caemi a, and not neces s ari l y t o ret urn t he cal ci um t o normal . For frank t et any, 10ml of 10% cal ci um gl uconat e (2.25mmol ) can be gi ven by s l ow i v i nject i on over 10 mi nut es . NB: 10ml of 10% c al c i um c hl ori de (9 mmol ) c ont ai ns ~4-fol d more c al c i um t han c al c i um gl uc onat e. Cal ci um gl uconat e i s preferred as i t caus es l es s t i s s ue necros i s i f i t ext ravas at es . i v cal ci um s houl d never be gi ven fas t er t han t hi s becaus e of t he ri s k of arrhyt hmi a. Thereaft er, an i nfus i on of cal ci um (~0.0250.05mmol /kg/h s houl d be s t art ed). For a 70kg adul t , add 50ml of 10% cal ci um gl uconat e or 10ml of 10% cal ci um chl ori de t o 200ml N s al i ne, and i nfus e at 5080ml /h. Pos t parat hyroi dect omy, mi l d hypocal caemi a normal l y ens ues , requi ri ng obs ervat i on onl y. In pat i ent s who have parat hyroi d bone di s eas e however, hungry bones may caus e profound hypocal caemi a s hort l y aft er t he parat hyroi ds are removed. Thi s may caus e a s evere and prol onged hypocal caemi a whi ch requi res prol onged t reat ment . Chroni c hypocal caemi a i s bes t managed wi t h oral cal ci um t oget her wi t h ei t her vi t ami n D, or, i f t he caus e i s hypoparat hyroi di s m or an abnormal i t y i n vi t ami n D met abol i s m, a form of act i vat ed (hydroxyl at ed) vi t ami n D s uch as al facal ci dol or cal ci t ri ol . If magnes i um defi ci ency i s pres ent , add 20ml (~40mmol ) of 50% magnes i um s ul phat e s ol ut i on t o 230ml N s al i ne (10g/250ml ). Infus e 50ml of t hi s (equi val ent t o 2g MgSO 4 , 8 mmol ) over 10 mi nut es , and at 25ml /h t hereaft er.
P.579
Pa g e 9 8 6
Causes of hypocalcemia
Vitamin D deficiency

As i ans Chroni c renal fai l ure

2+
Loss of Ca
from circulation
Extra-vascular deposition
o o o
Hyperphos phat aemi a (renal fai l ure, t umour l ys i s ) Acut e pancreat i t i s Os t eobl as t i c met as t as es (e.g. pros t at i c) Ci t rat e or bl ood product s Fos carnet (ant i -CMV drug) Acut e res pi rat ory al kal os i s
Intra-vascular binding
o o o
Hypoparathyroidism

Pos t parat hyroi d, t hyroi d, or neck s urgery Idi opat hi c Ps eudo-hypoparat hyroi di s m Infi l t rat i on HIV i nfect i on
2+
Disorders of Mg
metabolism
Magnes i um defi ci ency Seps i s , burns Fl uori de i nt oxi cat i on Chemot herapy (e.g. ci s pl at i n)
Other

Practice point
If hypocal caemi a i s di ffi cul t t o correct , check for magnes i um defi ci ency.
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hyperc alc aemia
Hypercalcaemia
The free (i oni c) pl as ma Ca pl as ma al bumi n.
2+
concent rat i on i s dependent
on bot h art eri al pH ( duri ng aci daemi a) and t he Ioni zed Ca

2+
= meas ured Ca
2+
+ [40 - s erum
2+
al bumi n(g/L)] 0.02. (e.g. If meas ured Ca = [(40 - 30) 0.02] = 2.30mM).
=
2+
2.10mM and al bumi n = 30g/L, t he correct ed Ca Mos t ITUs can now meas ure i oni zed cal ci um.
= 2.10
Presentation

Rout i ne bi ochemi cal s creen i n an as ympt omat i c pat i ent General : depres s i on (3040%), weaknes s (30%), t i rednes s , and mal ai s e Gas t roi nt es t i nal : cons t i pat i on, anorexi a; vague abdomi nal s ympt oms (naus eas , vomi t i ng), wei ght l os s Renal : renal cal cul i (i f l ong s t andi ng); nephrogeni c di abet es i ns i pi dus (20%); t ype 1 RTA; pre-renal fai l ure; chroni c hypercal caemi c nephropat hy, pol yuri a, pol ydi ps i a, or dehydrat i on Neurops yc hi at ri c : anxi et y, depres s i on, and cogni t i ve dys funct i on; coma or obt undat i on Cardi ac : hypert ens i on, cardi ac dys rhyt hmi as .
Urgent treatment is required if

Cal ci um >3.5mmol /L Cl oudi ng of cons ci ous nes s or confus i on i s pres ent Hypot ens i on Severe dehydrat i on caus i ng pre-renal fai l ure.
Management
Pa g e 9 8 8
Rehydrat e pat i ent wi t h i v N s al i ne (0.9%). Ai m for about 36L/24h dependi ng on fl ui d s t at us (CVP), uri ne out put and cardi ac funct i on. If pat i ent does not pas s uri ne for 4h, pas s a uri nary cat het er, and a cent ral venous l i ne t o moni t or CVP. Di uret i c s : once pat i ent i s rehydrat ed, cont i nue N s al i ne i nfus i on and add frus emi de 40mg every 24hours . Cont i nue moni t ori ng CVP careful l y t o prevent ei t her fl ui d overl oad or dehydrat i on. Moni t or el ect rol yt es , es peci al l y K and Mg (2040mmol /L of s al i ne) and Mg s al i ne) i nt ravenous l y. If t hi s fai l s t o reduce pl as ma Ca cons i dered:
2+ 2+ + 2+
whi ch may
+
fal l rapi dl y wi t h rehydrat i on and frus emi de. Repl ace K (upt o 2 mmol /L
2+
adequat el y (Ca
still
>2.8mM) t hen t he fol l owi ng meas ures s houl d be Sal mon c al c i t oni n 400IU q8h. Thi s has a rapi d ons et of act i on (wi t hi n hours ) but i t s effect l as t s onl y 23 days (t achyphyl axi s ).
Bi s phos phonat es i nhi bi t os t eocl as t act i vi t y t hereby caus i ng a fal l i n pl as ma Ca . Admi ni s t er pami dronat e at 3060 mg i v over 46 hours . (As a general rul e gi ve 30mg over 4h i f Ca 8h i f Ca
2+ 2+ 2+
i s <3 mmol /L or for al l

2+
pat i ent s wi t h s i gni fi cant renal i mpai rment , 60mg over i s 34 mmol /L. Ca l evel s begi n t o fal l aft er 48 hours and remai n s uppres s ed for up t o 14 days . Zol endronat e has a s hort er i nfus i on t i me (15mi ns ) and i s s ai d t o more effect i ve wi t h a l onger durat i on of act i on.
St eroi ds (predni s ol one 3060mg po od): Mos t effect i ve i n hypercal caemi a due t o s arcoi dos i s , myel oma or vi t ami n D i nt oxi cat i on. Fami l i al beni gn hypoc al c i uri c hyperc al c aemi a: Ca , N 24h uri nary Ca . Thi s caus es few s ympt oms (mi l d fat i gue or l et hargy). The PTH may be rai s ed but t he pat i ent s do not res pond t o parat hyroi dect omy.
2+ 2+
Pa g e 9 8 9
P.581
Causes of hypercalcaemia
Pri mary (or t ert i ary) hyperparat hyroi di s m (85% of cas es ) Mal i gnancy
o o
Humoral hypercal caemi a Local os t eol yt i c hypercal caemi a (e.g. myel oma, met as t as es )
Hypert hyroi di s m (pres ent i n 1520% of pat i ent s ) Granul omat ous di s orders (s arcoi dos i s ) Drug rel at ed
o o o o o
Vi t ami n D i nt oxi cat i on Theophyl l i ne t oxi ci t y Mi l k-al kal i s yndrome Thi azi de di uret i cs Li t hi um (mi l d, pres ent i n 50% pat i ent s on l ong-t erm l i t hi um)
Immobi l i zat i on (Paget 's di s eas e) Beni gn fami l i al hypocal ci uri c hypercal caemi a HTLV-1 i nfect i on may pres ent wi t h s evere hypercal caemi a Phaeochromocyt oma (part of MEA t ype II), acromegal y Adrenal fai l ure Rhabdomyol ys i s (cal ci um may be hi gh or l ow) Congeni t al l act as e defi ci ency
Investigations for hypercalcaemia

Pl as ma Ca , PO U&Es LFTs CXR
2+
34
, and Mg
2+
Pl as ma PTH l evel 24h uri nary Ca

2+
Pa g e 9 9 0
Uri nary cAMP
Pa g e 9 9 1
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hypophosphat aemia
Hypophosphataemia
Pl as ma phos phat e i s normal l y 0.81.4mmol /L. Hypophos phat aemi a i s common, and oft en unrecogni zed by cl i ni ci ans . Mos t i nt racel l ul ar phos phat e i s pres ent as creat i ne phos phat e or adeni ne phos phat es (e.g. ATP), and i n RBC t he predomi nant s peci es i s 2,3-di phops hogl ycerat e. Hypophos phat aemi a does not neces s ari l y i ndi cat e phos phat e defi ci ency; s i mi l arl y phos phat e defi ci ency may be as s oci at ed wi t h normal or hi gh pl as ma phos phat e concent rat i ons .
Causes of hypophosphataemia
Modest (0.40.75mmol/L)

Decreas ed di et ary i nt ake Vi t ami n D defi ci ency Chroni c l i ver di s eas e Hyperparat hyroi di s m Decreas ed abs orpt i on (vi t D defi ci ency, s t eat orrhoea, phos phat e bi ndi ng ant aci ds ) Hungry bones s yndrome (pos t parat hyroi dect omy, acut e l eukaemi a) Lymphoma or t he l eukaemi as s yndrome Hyperal dos t eroni s m Di uret i cs Fanconi s yndrome Res pi rat ory al kal os i s Treat ment of di abet i c ket oaci dos i s Al cohol wi t hdrawal (es p. wi t h ket oaci dos i s ) Acut e l i ver fai l ure Hyperal i ment at i on (i .e. feedi ng aft er s t arvat i on)
Severe (<0.4mmol/L)

Pa g e 9 9 2
Vent i l at i on of chroni c s evere res pi rat ory fai l ure Neurol ept i c mal i gnant
Presentation
Mos t cas es of s evere hypophos phat aemi a occur i n very s i ck pat i ent s (oft en i n an ITU). Oc c as i onal l y s een i n as ympt omat i c pat i ent s . Coi nci dent Mg
2+
defi ci ency exacerbat es PO
34
, depl et i on
and vi ce vers a.
Modes t hypophos phat aemi a has no effect , but warrant s i nves t i gat i on. Severe hypophos phat aemi a (<0.4mmol /L) may caus e s ympt oms and requi res t reat ment .
Manifestations of severe hypophosphataemia

Myopat hy (i nvol vi ng s kel et al mus cl e and di aphragm) Rhabdomyol ys i s Cardi omyopat hy Eryt hrocyt e dys funct i on Leukocyt e dys funct i on Met abol i c aci dos i s CNS dys funct i on (encephal opat hy, i rri t abi l i t y, s ei zures , paraes t hes i ae, coma) Res pi rat ory fai l ure Reduced pl at el et hal f-l i fe Mi neral mobi l i zat i on
P.583
Treatment
Phos phat e repl et i on s houl d general l y be res erved for pat i ent s wi t h s us t ai ned hypophos phat aemi a. Gi ve oral efferves cent Phos phat e Sandoz 2 t abs t ds or pot as s i um phos phat e i v (918mmol /24h). Exces s i ve phos phat e repl acement may caus e
Pa g e 9 9 3
hypocal caemi a and met as t at i c cal ci fi cat i on; moni t or Ca

2+
, PO 4 , K , and ot her el ect rol yt es .
3-
Pa g e 9 9 4
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Addisonian c risis: assessment
Addisonian crisis: assessment
Adrenocort i cal i ns uffi ci ency may be s ub-cl i ni cal for days or mont hs i n ot herwi s e wel l i ndi vi dual s . St res s , s uch as i nfect i on, t rauma, or s urgery, may preci pi t at e an Addi s oni an cri s i s wi t h cardi ovas cul ar col l aps e and deat h i f t he condi t i on i s not s us pect ed. Cri s es may al s o occur i n pat i ent s wi t h known Addi s on's di s eas e on repl acement hydrocort i s one i f t hey fai l t o i ncreas e t hei r s t eroi d dos e wi t h i nfect i ons .
Presentation

Hypot ens i on and cardi ovas cul ar col l aps e (s hock) Fai nt nes s , part i cul arl y on s t andi ng (pos t ural hypot ens i on) Anorexi a, naus ea, vomi t i ng, and abdomi nal pai n Hyponat raemi a Dehydrat i on (t hi rs t may not be apparent becaus e of t he l ow s odi um) Di arrhoea i n 20% of cas es Sympt oms of preci pi t ant [fever, ni ght s weat s (i nfect i on); fl ank pai n (haemorrhagi c adrenal i nfarct i on); et c]. Not e s i gns /s ympt oms of ot her endocri nopat hi es . Non-s peci fi c s ympt oms : wei ght l os s , fat i gue, weaknes s , myal gi a. Hyperpi gment at i on s ugges t s chroni c hypoadrenal i s m. Ps ychi at ri c feat ures are common and i ncl ude as t heni a, depres s i on, apat hy, and confus i on (t reat ment wi t h gl ucocort i coi ds revers es mos t ps ychi at ri c feat ures ).
Malignant secondaries
Pres ent i n t he adrenal s of a hi gh percent age of pat i ent s wi t h l ung
Pa g e 9 9 5
cancer, breas t t umours , and mal i gnant mel anomas . Adrenal fai l ure wi l l onl y occur when over 90% of t he gl and i s repl aced by met as t as es .
Adrenal haemorrhage
Thi s may compl i cat e s eps i s (meni ngococcal s ept i caemi a, t he W at erhous eFri deri chs en s yndrome), t raumat i c s hock, coagul opat hi es , and i s chaemi c di s orders .
Severe s t res s s ubs t ant i al l y i ncreas es t he art eri al bl ood s uppl y t o t he adrenal s . However t he adrenal gl and has onl y one or t wo vei ns , maki ng i t vul nerabl e t o venous t hrombos i s . Bl ood t es t s : a preci pi t ous drop i n haemogl obi n, hyponat raemi a, hyperkal aemi a, aci dos i s , uraemi a, and neut rophi l i a. The Wat erhous eFri deri c hs en s yndrome i s t he as s oci at i on of bi l at eral adrenal haemorrhage wi t h ful mi nant meni ngococcaemi a. Adrenal haemorrhage i s al s o s een wi t h ot her gram-negat i ve endot oxaemi as s uch as Di pl oc oc c us pneumoni ae, Haemophi l us i nfl uenzae B and DF-2 baci l l us i nfect i ons .
Hypopituitarism
As t here i s no mi neral ocort i coi d defi ci ency, t he s al t and wat er l os s and s hock are l es s profound t han i n pri mary Addi s on's di s eas e.
Drugs
Ri fampi ci n, phenyt oi n, and phenobarbi t one accel erat e t he met abol i s m of cort i s ol and may preci pi t at e Addi s oni an cri s i s i n part i al l y compromi s ed i ndi vi dual s , or i n t hos e on a fi xed repl acement dos e. Mos t adrenal cri s es preci pi t at ed by ri fampi ci n occur wi t hi n 2 weeks of i ni t i at i ng t herapy. P.585
Recognized causes of adrenal failure
Pa g e 9 9 6
Aut oi mmune adrenal i t i s (70%) Tubercul os i s of t he adrenal s (1020%) Mal i gnant s econdari es i n t he adrenal gl ands Adrenal haemorrhage i ncl . meni ngococcal s ept i caemi a Di s emi nat ed fungal i nfect i on (hi s t opl as mos i s , paracocci di oi domycos i s ) Hypopi t ui t ari s m Drugs : met yrapone or ami nogl ut et hi mi de can preci pi t at e adrenal fai l ure. Ot her drugs (s ee bel ow) may caus e rel at i ve adrenal i ns uffi ci ency Congeni t al condi t i ons
o o o
Adrenol eukodys t rophy Congeni t al adrenal hyperpl as i a Fami l i al gl ucort i coi d defi ci ency
Causes of relative adrenal insufficiency
Drugs
o o o o o o o
Met yrapone or ami nogl ut et hi mi de Ket oconazol e Et omi dat e Ri fampi ci n, phenyt oi n, and phenobarbi t one Tri l os t ane Meges t rol acet at e Surami n
HIV Severe s eps i s Burns Acut e or chroni c l i ver fai l ure
Practice points
~50% of pat i ent s wi t h aut oi mmune adrenal i t i s have one or more ot her aut oi mmune di s orders s uch as pol ygl andul ar aut oi mmune s yndrome t ype 1 or 2. Never forget Addi s on's di s eas e i n a s i ck pat i ent when t he di agnos i s i s uncl ear.
Pa g e 9 9 7
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Addisonian c risis: management
Addisonian crisis:
management
Investigations
U&Es Hyponat raemi a and hyperkal aemi a (rarel y great er t han 6.0mM). Hi gh ur:cr rat i o i ndi cat i ve of hypovol aemi a FBC Gl ucos e Cal ci um Serum cort i s ol ABG Uri ne CXR AXR Anaemi a (normal MCV); moderat e neut ropeni a rel at i ve eos i nophi l i a/l ymphocyt os i s Hypogl ycaemi a (rarel y s evere) May be hi gh Save for rout i ne as s ay. Bas el i ne <400nmol /L. Shoul d be >1000nmol /L i n s i ck pat i ent s Met abol i c aci dos i s , res pi rat ory fai l ure MC&S for i nfect i on; uri nary Na excret i on oft en hi gh i n s pi t e of hypovol aemi a Previ ous TB, bronchi al carci noma Adrenal cal ci fi cat i on
Management
Treat ment may be requi red before t he di agnos i s i s confi rmed. General meas ures i ncl ude oxygen, cont i nuous ECG moni t ori ng, CVP moni t ori ng, uri nary cat het er (for fl ui d bal ance), and broad s pect rum ant i bi ot i cs (e.g. cefot axi me) for underl yi ng i nfect i on. T reat s hoc k (P260): gi ve i v N s al i ne or col l oi d (Haemaccel ) for hypot ens i on: 1L s t at t hen hourl y
Pa g e 9 9 8
dependi ng on res pons e and cl i ni cal s i gns . Inot ropi c s upport may be neces s ary.

Gi ve i v 50% dext ros e (50ml ) i f hypogl ycaemi c. If adrenal cri s i s i s s us pect ed, t he pat i ent needs gl ucocort i coi ds urgent l y: us e dexamet has one 8mg i v whi ch wi l l not i nt erfere wi t h t he cort i s ol as s ay of a s hort Synact hen t es t . If dexamet has one i s unavai l abl e us e hydrocort i s one (can be s t opped l at er). Thi s s i ngl e ext ra dos e can do l i t t l e harm and may be l i fe s avi ng. Short Synac t hen t es t (omi t i f t he pat i ent i s known t o have Addi s on's di s eas e): t ake bas el i ne bl ood s ampl e (s erum) and admi ni s t er t et racos act ri n (Synact hen) 250g i m or i v. Take furt her s ampl es at 30 and 60 mi nut es for cort i s ol as s ay. Cont i nue s t eroi d t reat ment as i v hydroc ort i s one (200mg s t at ), t hen 100mg t ds . Change t o oral s t eroi ds aft er 72 hours . Fl udroc ort i s one (100g dai l y oral l y) when s t abi l i zed on oral repl acement dos es of hydrocort i s one.
Prevention
Pat i ent s on l ong-t erm s t eroi d t herapy and/or known adrenocort i cal fai l ure s houl d be i ns t ruct ed t o i ncreas e s t eroi d i nt ake for predi ct abl e s t res s es (e.g. el ect i ve s urgery, acut e i l l nes s es wi t h fever >38). For mi l d i l l nes s es , i f not vomi t i ng, doubl e t he oral dos e. Vomi t i ng requi res i v/i m t herapy (hydrocort i s one 50mg t ds ). For mi nor operat i ons or procedures (e.g. cys t os copy) gi ve hydrocort i s one 100mg i v/i m as a s i ngl e dos e before t he procedure. More s eri ous i l l nes s es requi re hydrocort i s one 100mg q68h i v/i m unt i l recovered or for at l eas t 72 hours . Doubl e repl acement dos es when s t abi l i zed i f on enz yme-i nduci ng drugs .
Pa g e 9 9 9
P.587
Equivalent doses of glucocorticoids 1

Dr Eq ug uiv ale nt do se (m g) De 0.7 xa 5 me t ha s on e Me 4 t hy l pr ed ni s ol o ne Tri 4 am ci n ol o ne Pre 5 dni s ol on e
Pa g e 1 0 0 0
Hy 20 dro cor tis on e Cor 25 tis on e ace t at e
Footnote
1
Bri t i s h Nat i onal Formul ary (1995) Pharmaceut i cal Pres s , Royal Pharmaceut i cal Soci et y of Great Bri t ai n, London: Sect i on 6.3.2.
Pa g e 1 0 0 1
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Myxoedema c oma
Myxoedema coma
A common preci pi t ant of coma i s t he us e of s edat i ves , and s ubs equent hypot hermi a, i n el derl y femal e pat i ent s wi t h undi agnos ed hypot hyroi di s m.
Presentation
Al t ered ment al s t at us : di s ori ent at i on, l et hargy, frank ps ychos i s Coma (s ymmet ri cal , s l ow-rel axi ng refl exes ; ~25% have s ei z ures ) Hypot hermi a Bradycardi a, hypot ens i on (rare) Hypovent i l at i on Hypogl ycaemi a.
Investigations
U&Es Gl ucos e FBC Rai s ed CPK Thyroi d funct i on Cort i s ol ABG To excl ude co-exi s t ent Addi s on's di s eas e, i .e. Schmi dt 's s yndrome Hypovent i l at i on wi t h P a CO 2 , P a O 2 and aci dos i s Sept i c s creen Bl ood and uri ne cul t ures ECG CXR Smal l compl exes wi t h prol onged QT i nt erval Peri cardi al effus i on may occur. Hyponat raemi a i s common (50%) Hypogl ycaemi a may occur Normocyt i c or macrocyt i c ( coexi s t ent perni ci ous anaemi a) anaemi a Oft en wi t h a cl i ni cal myopat hy T4 and TSH
Pa g e 1 0 0 2
Poor prognostic indicators
Hypotension . Pat i ent s wi t h hypot hyroi di s m are us ual l y hypert ens i ve. BP i ndi cat es pos s i bl e adrenal fai l ure or cardi ac di s eas e. Res pons e t o i not ropes i s poor as pat i ent s are us ual l y maxi mal l y vas ocons t ri ct ed. Hypoventilation . Thi s i s t he commones t caus e of deat h i n pat i ent s wi t h myxoedema coma. The hypoxi a res ponds poorl y t o oxygen t herapy whi ch t ends t o exacerbat e hypercapnoea.
Management
Trans fer t he pat i ent t o an i nt ens i ve care uni t . Mort al i t y i s up t o 30%. Mechani cal vent i l at i on s houl d be i ns t i t ut ed for res pi rat ory fai l ure. CVP l i ne. Pat i ent s are us ual l y hypert ens i ve and hypovol aemi c as chroni c myxoedema i s compens at ed for by ri s i ng cat echol ami nes . Broad-s pect rum ant i mi crobi al s (e.g. cefot axi me). Bact eri al i nfect i on i s a common preci pi t ant of myxoedema coma. Hypot hermi a s houl d be t reat ed as on P844: a s pace bl anket i s us ual l y s uffi ci ent . Rapi d ext ernal warmi ng can caus e i nappropri at e vas odi l at at i on and cardi ovas cul ar col l aps e. Hydrocort i s one (100mg i v t ds ) unt i l Addi s on's i s excl uded. Ins t i t ut e repl acement t herapy before confi rmi ng t he di agnos i s . P.589
Ideal l y gi ve 520g i v (s l ow bol us ) t ri -i odot hyroni ne (T3) t wi ce dai l y for 3 days . Aft er a few days t reat ment , commence oral t hyroxi ne at 2550g/day or oral t ri odot hyroni ne at 20g bd. Some cl i ni ci ans s t art
Pa g e 1 0 0 3
t hyroxi ne at a much hi gher dos e, but t hi s does carry a ri s k or preci pi t at i ng cardi ac i s chaemi a. T3 i s preferabl e due t o i t s s hort hal f-l i fe and i t s effect di s appears 2448 hours aft er i t i s s t opped.
If T3 i s unavai l abl e us e t hyroxi ne, 2550g po or vi a NG-t ube dai l y. Myxoedema coma has a hi gh mort al i t y i f i nadequat el y t reat ed.
Precipitants of myxoedema coma

Drugs , i ncl udi ng s edat i ves and t ranqui l l i zers Infect i on Cerebrovas cul ar acci dent Trauma
Pa g e 1 0 0 4
> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > T hyrot oxic c risis: assessment
Thyrotoxic crisis: assessment
The t erm t hyrot oxi c cri s i s refers t o a cons t el l at i on of s ympt oms and s i gns whi ch t oget her i mpl y a poor prognos i s . Thyroi d funct i on t es t s provi de no di s cri mi nat i on bet ween s i mpl e t hyrot oxi cos i s and t hyrot oxi c cri s i s . If t he di agnos i s has not been made, l ook for cl ues s uch as a goi t re, or exopht hal mi c Graves ' di s eas e. The pres ent at i on may be confus ed wi t h s eps i s or mal i gnant hypert hermi a.
Presentation
Cardiovascular symptoms

Pal pi t at i ons Tachycardi a/t achyarrhyt hmi as Cardi ac fai l ure/oedema Anxi et y/agi t at i on Vi ol ent out burs t s Ps ychos i s /del i ri um Fi t t i ng/coma Di arrhoea Vomi t i ng Jaundi ce Fever Hypervent i l at i on Sweat i ng Pol yuri a
CNS Symptoms

Gastrointestinal symptoms

General symptoms

Precipitants of thyrotoxic crisis

Thyroi d s urgery/general s urgery W i t hdrawal of ant i -t hyroi d drug t herapy/radi oi odi ne
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t herapy

Thyroi d pal pat i on Iodi nat ed cont ras t dyes Infect i on Cerebrovas cul ar acci dent /pul monary embol i s m Part uri t i on Di abet i c ket oaci dos i s Trauma or emot i onal s t res s .
Investigations
Thyroi d funct i on t es t s (mos t l abs can perform an urgent TSH/free T4 i f needed) U&Es (?dehydrat i on) Cal ci um (may be el evat ed) Gl ucos e (may be l ow) FBC Li ver funct i on t es t s (?jaundi ce) Bl ood and uri ne cul t ures CXR (?pul monary oedema or evi dence of i nfect i on) ECG (rat e, ?at ri al fi bri l l at i on).
The t abl e oppos i t e i s us ed t o as s es s t he s everi t y of a t hyrot oxi c cri s i s . Rarel y, pat i ent s may pres ent wi t h an apat het i c t hyroi d s t orm, and l aps e i nt o coma wi t h few ot her s i gns of t hyrot oxi cos i s .
P.591
Assessment of severity of a thyrotoxic crisis
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T e Pul Ca CN GI mp se rdi S ( C ) Sc or e Ap <9 Ab Nor Nor 0 yre 9 xi a s en ma ma t l l sy ac eff mp fail ect to ur e s ms
l >3 >9 An 5 7.2 9 kl e oe de ma >3 >1 Ba Agi Di a 10 7.8 10 s al t at rrh cre i on oe ps . a, vo mi t i ng >3 >1 Pul 15 8.3 20 mo >3 >1 Del Un 20 nar 8.9 30 i ri u exp y m l ai oe ne de d ma jau ndi >3 >1 9.4 40 ce 25
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>4 0
Co 30 ma , s ei zur e
Add t he s cores for each col umn. Add an ext ra 10 poi nt s i f at ri al fi bri l l at i on i s pres ent . Add 10 poi nt s i f t here i s a defi nabl e preci pi t ant . A t ot al s core of over 45 i ndi cat es t hyroi d cri s i s ; a s core of 2544 i ndi cat es i mpendi ng cri s i s .
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > T hyrot oxic c risis: management
Thyrotoxic crisis: management
Patients with a thyrotoxic crisis or impending crisis

(s core >25, P591)

Admi t t he pat i ent t o i nt ens i ve care. Fl ui d bal anc e : CVP moni t ori ng i s es s ent i al t o avoi d preci pi t at i ng or wors eni ng cardi ac fai l ure. In pat i ent s wi t h arrhyt hmi as , t he CVP wi l l not accurat el y refl ect l eft -s i ded pres s ures and SwanGanz moni t ori ng s houl d be cons i dered. Gas t roi nt es t i nal and i ns ens i bl e (pyrexi a and exces s i ve s weat i ng) fl ui d l os s es may exceed 5L/day and mus t be repl aced. Fever s houl d be t reat ed wi t h parac et amol and aggres s i ve peri pheral c ool i ng t ec hni ques . Dant rol ene has been occas i onal l y us ed t o cont rol hypert hermi a i n t hyrot oxi c cri s i s . Do not us e s al i cyl at es whi ch wi l l di s pl ace T4 from TBG and can hence wors en t he s t orm. - bl oc k t he pat i ent wi t h propranol ol 6080mg q4h po or 1mg i v (repeat ed every 10mi n as neces s ary) wi t h cardi ac moni t ori ng. Propranol ol i nhi bi t s peri pheral T4 T3 convers i on. Fever, t achycardi a, and t remor s houl d res pond i mmedi at el y. An al t ernat i ve i s Es mol ol (1530mg as a bol us fol l owed by 36mg/mi n). If -bl ockade i s cont ra-i ndi cat ed (e.g. as t hma), guanet hi di ne (3040mg po 6 hourl y) can be us ed.
T reat prec i pi t at i ng fac t ors s uch as i nfect i on (e.g. cefuroxi me 750mg i v t ds ). Hi gh-dos e ant i -t hyroi d drugs . Propyl t hi ouraci l (1g
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l oadi ng dos e t hen 200300mg q4h po/ng) is more effect i ve t han carbi mazol e (20mg 4 hourl y), at i t i nhi bi t s peri pheral T4 T3 convers i on.
Hydroc ort i s one 300mg i v s t at , t hen 100mg 6 hourl y. Thi s i nhi bi t s convers i on of T4 t o T3. Enoxapari n (cl exane) 20mg/day s c s houl d be gi ven t o very s i ck pat i ent s at ri s k of t hromboembol i s m. Once organi fi cat i on of i odi ne has been bl ocked by ant i -t hyroi d drugs , i odi ne can be us ed t o i nhi bi t t hyroxi ne rel eas e from t hyroi d gl and. Lugol 's i odi ne cont ai ns 5% i odi ne and 10% pot as s i um i odi de i n wat er. Gi ve 1ml every 6 hours . Do not gi ve Lugol 's i odi ne unt i l at l eas t 1 hour aft er t he ant i -t hyroi d drugs have been gi ven . Any i odi ne gi ven pri or t o ant i -t hyroi d medi cat i on may i ncreas e t hyroi d hormone s t ores . Cont i nue i odi ne-cont ai ni ng preparat i ons for a maxi mum of 2 weeks (l i t hi um i s an al t ernat i ve t o i odi ne i n al l ergi c pat i ent s ). Moni t or gl uc os e l evel s 4 hourl y and admi ni s t er gl ucos e 510% as requi red. Hepat i c gl ycogen s t ores are readi l y depl et ed duri ng t hyroi d s t orm.
Continuing treatment
Res pons e t o t reat ment i s gauged cl i ni cal l y and by s erum T3 l evel s . St op i odi ne/pot as s i um i odi de/l i t hi um and -bl ockers when cont rol l ed. Cons i der defi ni t i ve t reat ment (e.g. s urgery or radi oact i ve i odi ne). Treat at ri al fi bri l l at i on i n t he us ual way (P88). Hi gher dos es of di goxi n may be requi red as i t s met abol i s m i s i ncreas ed. Ami odarone i nhi bi t s peri pheral T4 T3 convers i on.
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Pit uit ary apoplexy
Pituitary apoplexy
Presentation
Pi t ui t ary i nfarct i on may be s i l ent . Apopl exy i mpl i es t he pres ence of s ympt oms . The cl i ni cal mani fes t at i ons may be due t o l eakage of bl ood/necrot i c t i s s ue i nt o t he s ub-arachnoi d s pace or rapi d expans i on of a s upras el l ar mas s and pres s ure on l ocal s t ruct ures . Thi s may be t he pres ent i ng s ympt om of t he pi t ui t ary t umour.
Headache occurs i n 95% of cas es (s udden ons et ; vari abl e i nt ens i t y) Vi s ual di s t urbance occurs i n 70%, (us ual l y bi t emporal hemi anopi a) Ocul ar pal s y (40%) caus i ng di pl opi a. Uni l at eral or bi l at eral Naus ea/vomi t i ng Meni ngi s m (common) Hemi pares i s or rarel y s ei zures Fever, anos mi a, CSF rhi norrhoea, and hypot hal ami c dys funct i on (di s t urbed s ympat het i c aut oregul at i on wi t h abnormal BP cont rol , res pi rat i on, and cardi ac rhyt hm) are al l des cri bed, but are rare Al t ered ment al s t at e, l et hargy, del i ri um, or coma Sympt oms of precedi ng pi t ui t ary t umour Acut e hypopi t ui t ari s m.
Cl i ni cal l y, pi t ui t ary apopl exy may be very di ffi cul t t o di s t i ngui s h from s ub-arachnoi d haemorrhage, bact eri al meni ngi t i s , mi d-brai n i nfarct i on (bas i l ar art ery occl us i on), or cavernous s i nus t hrombos i s . Trans i ent neurol ogi cal s ympt oms are common i n t he precedi ng few days . The cl i ni cal cours e i s vari abl e. Headache and mi l d vi s ual
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di s t urbance may devel op s l owl y and pers i s t for s everal weeks . In i t s mos t ful mi nant form, apopl exy may caus e bl i ndnes s , haemodynami c i ns t abi l i t y, coma, and deat h. Res i dual endocri ne di s t urbance (panhypopi t ui t ari s m) i nvari abl y occurs .
Investigations
U&Es Endocri ne t es t s CT s can Hyper- or hyponat raemi a may occur. Cl ot t ed bl ood for cort i s ol , t hyroi d funct i on, prol act i n, GH, and t he gonadot rophi c hormones . Pi t ui t ary cut s , wi t h admi ni s t rat i on of i v cont ras t , wi l l reveal a t umour mas s (or haemorrhage) wi t hi n 2448 hours . MRI s can May be us eful i n t he s ub-acut e s et t i ng.
Management

St abi l i ze t he pat i ent (Ai rway, Breat hi ng, Ci rcul at i on). Hydrocort i s one 100mg i v s houl d be gi ven i f t he di agnos i s i s s us pect ed aft er t he bl ood s ampl es above have been col l ect ed. Moni t or U&Es and uri ne out put for evi dence of di abet es i ns i pi dus . Neuros urgi c al dec ompres s i on may be i ndi cat ed (s eek neuros urgi cal revi ew). Obt undat i on and vi s ual det eri orat i on are abs ol ut e i ndi cat i ons for neuros urgery. Pat i ent s wi t hout confus i on or vi s ual di s t urbance general l y do wel l wi t hout s urgery. As s es s pi t ui t ary funct i on once t he acut e i l l nes s has res ol ved and t reat as neces s ary. A TSH i n t he normal range may be i nappropri at e i f t he T4 i s l ow i n pi t ui t ary di s eas e, but t hi s may occur i n t he s i ck eut hyroi d s t at e charact eri s t i c of many s eri ous l y i l l pat i ent s .
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P.595
Causes of apoplexy in patients with pituitary adenomas
Spont aneous haemorrhage (no obvi ous preci pi t ant , t he commones t ) Ant i -coagul ant t herapy Head t rauma Radi at i on t herapy Drugs (e.g. bromocri pt i ne or oes t rogen) Fol l owi ng t es t s of pi t ui t ary funct i on.
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Hypopit uit ary c oma
Hypopituitary coma
Hypopi t ui t ari s m does not become evi dent unt i l 75% of t he adenohypophys i s i s des t royed, and at l eas t 90% des t ruct i on i s requi red for t ot al l os s of pi t ui t ary s ecret i on. Compl et e l os s of hormone s ecret i on can rapi dl y become l i fe t hreat eni ng and requi res i mmedi at e t herapy. In a mi l d or i ncompl et e form, hypopi t ui t ari s m can remai n uns us pect ed for years .
Presentation
In t he abs ence of s t res s , pat i ent s wi t h s evere hypopi t ui t ari s m may have few s ympt oms or s i gns . A general anaes t het i c or i nfect i on may preci pi t at e hypogl ycaemi a and coma, due t o t he combi nat i on of a l ack of GH, cort i s ol , and t hyroxi ne, al l of whi ch have a count er-regul at ory effect on i ns ul i n. Cl ues from t he hi s t ory i ncl ude

Known pi t ui t ary adenoma Recent di ffi cul t del i very: pi t ui t ary i nfarct i on fol l owi ng pos t part um haemorrhage and vas cul ar col l aps e i s s t i l l t he commones t caus e of hypopi t ui t ari s m. Feat ures i ncl ude fai l ure of l act at i on (defi ci ency of prol act i n oxyt oci n), fai l ure of mens t ruat i on (l ack of gonadot rophi ns ), non-s peci fi c feat ures , e.g. t i rednes s , weaknes s , l os s of body hai r, and l os s of l i bi do (due t o ACTH defi ci ency, hypot hyroi di s m, and gonadot rophi n defi ci ency) Men may gi ve a hi s t ory of i mpot ence, l et hargy, and l os s of body hai r W omen report l os s of mens t ruat i on.
Examination
Exami nat i on of t he comat os e pat i ent i s di s cus s ed on
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P40615
Exami ne s peci fi cal l y for s econdary s exual charact eri s t i cs and phys i cal s i gns of myxoedema Cons i der ot her caus es for coma (P406).
Investigations
General i nves t i gat i ons for pat i ent s i n coma are di s cus s ed on P408 Take bl ood for bas el i ne cort i s ol , ACTH, t hyroi d funct i on, LH, FSH, prol act i n, and GH Short s ynact hen t es t mus t be performed t o t es t for adrenocort i cal res erve (P586) LHRH and TRH t es t can be performed at t he s ame t i me as t he s hort Synact hen t es t Defer formal pi t ui t ary funct i on t es t i ng unt i l t he pat i ent i s s t abl e CT s can of pi t ui t ary (t umour or empt y s el l a) MRI s can may gi ve addi t i onal i nformat i on.
Management

General meas ures are as for any pat i ent i n coma (P406) Gi ve i v col l oi ds s al i ne t o res t ore BP i f t he pat i ent i s i n s hock Gi ve gl ucos e i f t he pat i ent i s hypogl ycaemi c Hydrocort i s one 100mg i v s houl d be admi ni s t ered i f t he di agnos i s i s s us pect ed and cont i nued (100mg i v t ds , s ee P586) St art t ri -i odot hyroni ne (10g bd) aft er hydrocort i s one i s s t art ed Inves t i gat e and t reat any preci pi t at i ng i nt ercurrent i nfect i on P.597
If t he pat i ent fai l s t o i mprove, cons i der ot her caus es for coma (s ee P406) Long t erm, t he pat i ent s wi l l requi re repl acement wi t h
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hydrocort i s one or predni s ol one, t hyroxi ne, t es t os t erone, oes t rogen/proges t erone GH.
Causes of panhypopituitarism
Pituitary

Mas s l es i ons (adenomat a, cys t s ) Pi t ui t ary s urgery or i rradi at i on Infi l t rat i ve (haemochromat os i s ) Infarct i on (Sheehan's ) Apopl exy (haemorrhage) Empt y s el l a s yndrome Mas s l es i ons (met as t as es , e.g. breas t , l ung; crani opharyngi omas ) Radi ot herapy Infi l t rat i on (s arcoi d, hi s t i ocyt os i s ) Trauma, e.g. fract ured s kul l bas e Infect i ons (TB)
Hypothalamic
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Phaeoc hromoc yt omas: assessment
Phaeochromocytomas:
assessment
Phaeochromocyt omas are cat echol ami ne-produci ng t umours us ual l y i nvol vi ng one or more adrenal gl ands . ~0% are bi l at eral , ~10% are ext ra-adrenal [us ual l y around t he s ympat het i c chai n (paragangl i omas )] and ~10% are mal i gnant . They us ual l y s ecret e AD or NA. A s mal l proport i on s ecret e DA, when hypot ens i on may occur. Mos t are di agnos ed duri ng rout i ne s creeni ng of hypert ens i ve pat i ent s (t hey are found i n onl y 0.1% of hypert ens i ves ). Pure AD-produci ng t umours may mi mi c s ept i c s hock due t o AD-i nduced peri pheral vas odi l at at i on ( 2 -recept ors ).
Presentation
Cl as s i cal l y a t ri ad of epi s odi c headaches , s weat i ng, and t achycardi a Hypert ens i on (mi l d t o s evere s us t ai ned uncont rol l ed paroxys mal , hypert ens i ve epi s odes ) and ort hos t at i c hypot ens i on (l ow pl as ma vol ume). 50% have s us t ai ned BP and 50% have paroxys mal BP Anxi et y at t acks , t remor, pal pi t at i ons , col d ext remi t i es , and pal l or Cardi ac dys rhyt hmi as (i ncl . AF and VF) and di l at ed cardi omyopat hy Hypert ens i ve cri s es may be preci pi t at ed by -bl ockers , t ri cycl i c ant i -depres s ant s , met ocl oprami de, and nal oxone
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Unexpl ai ned l act i c aci dos i s Tri ggers for hypert ens i ve cri s es i ncl ude s urgery, opi at es and cont ras t medi a.
Investigations
There are no t es t s whi ch wi l l di agnos e a phaeochromocyt oma acut el y. Inves t i gat i ons are l i s t ed i n t he t abl e oppos i t e.
Hypert ens i ve pat i ent s wi t h gl c and K may have a phaeochromocyt oma, but t hes e are bot h non-s peci fi c feat ures . Uri nary VMA l evel (a cat echol ami ne met abol i t e) i s us eful i f markedl y el evat ed (510 upper l i mi t of normal ). Mi l d el evat i ons are frequent (15%) i n pat i ent s wi t h es s ent i al hypert ens i on, as VMA can be deri ved from di et ary s ources , i ncl udi ng vani l l a es s ence gi vi ng a fal s e +ve t es t res ul t . Uri nary c at ec hol ami nes (AD, NA, and DA) or met anephri nes are more s peci fi c. Uri ne col l ect i ons mus t be compl et ed before pent ol i ni um or cl oni di ne t es t s as wi t hdrawal of t hes e compounds can gi ve a fal s e +ve res ul t . Pl as ma c at ec hol ami nes s houl d be col l ect ed from an i n-dwel l i ng cannul a pl aced over 30 mi nut es previ ous l y i n a s upi ne pat i ent . Sampl es need t o be t aken di rect l y t o t he l ab (on i ce) for cent ri fugat i on. Pent ol i ni um s uppres s i on t es t . Take t wo bas el i ne s ampl es as above, t hen gi ve 2.5mg pent ol i ni um i v, and t ake bl ood agai n at 10 and 30 mi nut es . Pl as ma cat echol ami nes decreas e i n normal s ubject s fol l owi ng gangl i on bl ockade wi t h pent ol i ni um. If t he res pons e i s borderl i ne and no hypot ens i on occurs , t hen repeat wi t h 5mg pent ol i ni um. Cl oni di ne s uppres s i on t es t . An al t ernat i ve t o t he pent ol i ni um s uppres s i on t es t empl oys cl oni di ne. Fol l owi ng t wo bas el i ne s ampl es , gi ve 0.3mg cl oni di ne oral l y, and t ake bl ood hourl y for 3 hours . Agai n i f rai s ed cat echol ami nes are due t o anxi et y, t hey wi l l
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s uppres s i nt o t he normal range wi t h cl oni di ne. Rai s ed cat echol ami nes from phaeochromocyt oma wi l l not be affect ed by cl oni di ne. P.599
MRI or CT of t he abdomen are us eful t o l ocal i ze t he t umour. Radi ocont ras t can l ead t o cat echol ami ne rel eas e. MI BG s c an . MIBG (
131
I-met ai odobenzyl guani di ne) i s
t aken up s el ect i vel y by adrenal t i s s ue. Us eful t o l ocal i ze t umour or s econdari es .
Sel ec t i ve venous s ampl i ng : t o l ocal i ze ext ra-adrenal t umours .
Investigations for suspected phaeochromocytoma

+
U&Es (K , urea) Gl ucos e () Uri nary VMA Uri nary cat echol ami nes (AD, NA, and DA), met anephri nes Pl as ma cat echol ami nes (AD, NA, and DA) Pent ol i ni um s uppres s i on t es t Cl oni di ne s uppres s i on t es t MRI or CT s can of adrenal s MIBG s can for l ocal i zat i on
Other causes of sympathetic overactivity

Abrupt wi t hdrawal of cl oni di ne or -bl ockers Aut onomi c dys funct i on e.g. Gui l l ai nBarr s yndrome or pos t s pi nal cord i njury St res s res pons e t o s urgery, pai n, or pani c Sympat homi met i c drugs
o o
Phenyl propanol ami ne (deconges t ant ) Cocai ne
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MAOI pl us t yrami ne-cont ai ni ng foods (chees e, beer, wi ne, avocado, bananas , s moked or aged fi s h/meat )
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Phaeoc hromoc yt omas: management
Phaeochromocytomas:
management
Pat i ent s are us ual l y vol ume depl et ed at pres ent at i on, and s houl d be rehydrat ed pri or t o i ni t i at i on of -bl ockade, ot herwi s e s evere hypot ens i on may occur. -bl ockade al one may preci pi t at e a hypert ens i ve cri s i s , and mus t never be gi ven pri or t o adequat e -bl ockade. Labet al ol i s predomi nant l y a -bl ocker and s houl d not be us ed al one. Long act i ng -bl ockers prevent es cape epi s odes .

Adequat e fl ui d repl acement wi t h CVP moni t ori ng. Acut e hypert ens i ve cri s es s houl d be cont rol l ed wi t h phent ol ami ne (25mg i v bol us , repeat ed as neces s ary every 1530 mi nut es ). Al t ernat i vel y s t art an i nfus i on of ni t roprus s i de (0.51.5g/kg/mi n, t ypi cal dos e 100g/mi n, s ee P164). Preparat i on for s urgery
o
Ini t i at e oral -bl ockade: phenoxybenzami ne 10mg dai l y i ncreas i ng gradual l y t o 40mg t ds . Moni t or BP cl os el y. Tumour -s t i mul at i on may produce exces s i ve vas odi l at at i on and hypot ens i on requi ri ng i not ropi c s upport . Recent s t udi es have s hown t hat prazos i n or doxazos i n are equal l y effect i ve and are bei ng us ed i ncreas i ngl y W hen t he bl ood pres s ure i s cont rol l ed wi t h phenoxybenzami ne, add propranol ol 1020mg t ds Invas i ve moni t ori ng [pul monary art ery (SwanGanz) cat het er and art eri al l i ne] i s mandat ory.
Hypot ens i on commonl y occurs i nt ra-operat i vel y when
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t he t umour i s removed, and t hi s s houl d be managed wi t h bl ood, pl as ma expanders , and i not ropes as requi red. Inot ropes s houl d onl y be us ed when t he pat i ent i s appropri at el y fl ui d repl et e. Expans i on of i nt ravas cul ar vol ume 12 hours before s urgery s i gni fi cant l y reduces t he frequency and s everi t y of pos t -operat i ve hypot ens i on. Angi ot ens i n II s houl d be avai l abl e as an al t ernat i ve i not rope for cas es of res i s t ant hypot ens i on. Aut os omal domi nant condi t i ons wi t h a hi gh ri s k of devel opi ng phaeochromocyt oma i ncl ude
Von-Rec kl i nghaus en di s eas e [neurofi bromat a, caf au l ai t s pot s , Li s ch nodul es (i ri s hamart omas ), and axi l l ary freckl i ng]. Von-Hi ppel Li ndau di s eas e (cerebel l ar haemangi obl as t omas , ret i nal haemangi omas , and ot her neopl as ms i ncl udi ng hypernephroma). Mul t i pl e endoc ri ne neopl as i a t ypes 2a (hyperparat hyroi di s m and medul l ary t hyroi d carci noma) and 2b (medul l ary t hyroi d carci noma, bowel gangl i oneuromat os i s , and hypert rophi ed corneal nerves ).
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Polyuria
Polyuria
Defi ni t i on: >3 l i t res uri ne per day.
Presentation

Confus i on (hyponat raemi a or dehydrat i on) Coma Prot ei nuri a on s creeni ng Depres s i on or ot her ps ychi at ri c mani fes t at i ons Renal s t ones .
Causes

Exces s i ve fl ui d i nt ake Endocri ne dys funct i on (DM, di abet es i ns i pi dus , hypercal caemi a) Hypokal aemi a Int ri ns i c renal di s eas e (pol ycys t i c ki dneys , anal ges i c nephropat hy, medul l ary cys t i c di s eas e, amyl oi dos i s ) or renal recovery from ATN. Pos t obs t ruct i ve, e.g. aft er cat het eri zat i on of pat i ent i n chroni c ret ent i on. Pos t renal art ery angi opl as t y Drugs (frus emi de, al cohol , l i t hi um, amphot eri ci n B, vi nbl as t i ne, demecl ocycl i ne, ci s pl at i num).
History
Durat i on and s everi t y (noct uri a, frequency, wat er cons umpt i on at ni ght ) FH of di abet es mel l i t us , pol ycys t i c ki dneys , renal cal cul i Drug hi s t ory (di uret i cs , anal ges i cs , l i t hi um, et c., s ee above) Renal cal cul i (hypercal caemi a)
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W eaknes s (l ow pot as s i um), depres s i on (hypercal caemi a) Ps ychi at ri c hi s t ory Endocri ne hi s t ory (mens es , s exual funct i on, l act at i on, pubi c hai r) Ot her s i gni fi cant pat hol ogy (e.g. caus es of amyl oi d).
Investigations

U&Es (renal di s eas e, hypokal aemi a) Gl ucos e Cal ci um, phos phat e, and al kal i ne phos phat as e Pl as ma and uri ne os mol al i t y [a U:P os mol al i t y of <1.0 i ndi cat es di abet es i ns i pi dus , i nt ri ns i c renal di s eas e (i ncl . K ), or hys t eri cal dri nki ng]
+
AXR (nephrocal ci nos i s ) Li t hi um l evel s i f appropri at e Di ps t i ck prot ei n and quant i t at i on i f i ndi cat ed.
Management
As s es s fl ui d s t at us (JVP, BP, pos t ural drop, wei ght chart s , CVP). St ri ct fl ui d bal ance and dai l y wei ght s . Ins ert cent ral l i ne t o moni t or t he CVP. Meas ure uri nary s odi um and pot as s i um (random s ampl es wi l l gi ve an i ndi cat i on of t he l os s of s odi um or pot as s i um i ni t i al l y, and i f l os s es are great , accurat e t i med s ampl es of <6 hours are pos s i bl e). P.603
Repl ace fl ui d l os s es as appropri at e t o mai nt ai n a normal homeos t as i s , us i ng combi nat i ons of s al i ne and dext ros e. Moni t or pot as s i um, cal ci um, phos phat e, and magnes i um dai l y or t wi ce dai l y i f neces s ary. If l i t hi um t oxi ci t y i s pres ent , s ee P820. Avoi d chas i ng fl ui ds . At s ome poi nt a cl i ni cal
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judgement has t o be made t o s t op repl aci ng uri nary l os s es wi t h i v fl ui ds t o al l ow t he pat i ent t o reach t hei r normal equi l i bri um. Once t he pat i ent i s opt i mal l y hydrat ed t hen avoi d repl aci ng fl ui ds i v t o al l ow phys i ol ogi cal homeos t as i s t o occur.
If di abet es i ns i pi dus s us pect ed, arrange wat er depri vat i on t es t (s ee bel ow).
Water deprivation test
St op al l drugs t he day before t he t es t ; no s moki ng or caffei ne Supervi s e t he pat i ent careful l y t o prevent s urrept i t i ous dri nki ng Empt y t he bl adder aft er a l i ght breakfas t . No furt her fl ui ds po W ei gh t he pat i ent at t i me 0, 4, 5, 6, 7, 8 hours i nt o t he t es t (s t op t he t es t i f >3% of body wei ght i s l os t ) Meas ure s erum os mol al i t y at 30 mi nut es , 4 hours , and hourl y t i l l end of t he t es t (check t hat t he pl as ma os mol al i t y ri s es t o >290mos mol /kg t o confi rm an adequat e s t i mul us for ADH rel eas e) Col l ect uri ne hourl y and meas ure t he vol ume and os mol al i t y (t he vol ume s houl d decreas e and t he os mol al i t y ri s e; s t op t es t i f uri ne os mol al i t y >800mos mol /kg as DI i s excl uded) If pol yuri a cont i nues , gi ve des mopres s i n 20mcg i nt ranas al l y at 8 hours Al l ow fl ui ds po (wat er) aft er 8 hours . Cont i nue t o meas ure uri ne os mol al i t y hourl y for a furt her 4 hours
Interpretation
Normal res pons e: uri ne os mol al i t y ri s es t o >800mos mol /kg wi t h a s mal l ri s e aft er des mopres s i n Crani al DI : uri ne os mol al i t y remai ns l ow (>400mos mol /kg) andi ncreas es by >50% aft er des mopres s i n Nephrogeni c DI : uri ne os mol al i t y remai ns l ow
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(<400mos mol /kg) andonl y ri s es a l i t t l e (<45%) wi t h des mopres s i n
Ps yc hogeni c pol ydi ps i a: uri ne os mol al i t y ri s es (>400mos mol /kg) but i s t ypi cal l y l es s t han t he normal res pons e
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Malignant hypert hermia
Malignant hyperthermia
Mal i gnant hypert hermi a i s a drug- or s t res s -i nduced cat abol i c s yndrome charact eri zed by exces s i ve mus cul ar cont ract i ons , a s udden ri s e i n body t emperat ure, and cardi ovas cul ar col l aps e. The i nci dence i s ~1:15 000, wi t h a 30% mort al i t y. The caus e i s unknown, but may i nvol ve abnormal cal ci um homeos t as i s i n s kel et al mus cl e cel l s . The condi t i on s eems t o be i nheri t ed i n an aut os omal domi nant manner wi t h vari abl e penet rance.
Drugs precipitating malignant hyperthermia

Hal ot hane Succi nyl chol i ne Met hoxyfl urane and enfl urane Ket ami ne Phencycl i di ne Cycl opropane
Hal ot hane and s uc c i nyl c hol i ne ac c ount for 80% of c as es
Drugs considered safe in malignant hyperthermia

Barbi t urat es Ni t rous oxi de Di az epam Tubocurare Pancuroni um Opi at es
Diagnosis
Mal i gnant hypert hermi a mos t commonl y pres ent s i n t he
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earl y 20s . The earl y s i gns are mus cul ar ri gi di t y, s i nus t achcardi a and SVTs , i ncreas ed carbon di oxi de product i on, and hypert ens i on.
Hypert hermi a occurs l at e, and may be rapi dl y fol l owed by hypot ens i on, aci dos i s , and hyperkal aemi a, whi ch gi ves ri s e t o vent ri cul ar t achycardi a. The condi t i on al mos t al ways occurs peri -operat i vel y. The di fferent i al di agnos i s i ncl udes phaeochromocyt oma, t hyrot oxi c cri s i s , narcot i c-i nduced hypert hermi a i n pat i ent s t aki ng MAOIs , and drug-i nduced hypert hermi a (caus ed by cocai ne, phencycl i di ne, amphet ami ne, LSD, t ri cycl i cs , and as pi ri n), and cert ai n i nject i ons s uch as mal ari a. Pl as ma CPK i s hi gh.
Treatment
The ai m of t herapy i s t o decreas e t hermogenes i s , and promot e heat l os s .
Dant rol ene: 12.5mg/kg i nt ravenous l y every 510 mi nut es t o a maxi mum dos e of 10mg/kg. The dant rol ene s houl d t hen be cont i nued at a dos e of 12 mg/kg (i v or oral l y every 6 hours for 2 days ). St op any anaes t het i c agent . Ext ernal cool i ng by s ubmers i on i s hel pful . Al l admi ns i t ered fl ui ds s houl d be chi l l ed. Procai nami de s houl d be gi ven t o al l pat i ent s t o prevent vent ri cul ar dys rht hmi as ( upt ake of cal ci um and may reduce hypert hermi a). Hypot ens i on s houl d be t reat ed wi t h s al i ne/col l oi ds i s oprot enerol . Dopami nergi c and -adrenergi c agoni s t s reduce heat di s s i pat i on and s houl d be avoi ded. Some aut hori t i es advocat e prophyal ct i c ant i -convul s ant s as s ei zures are common.
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> T able of Cont ent s > Chapt er 9 - Endoc rine emergenc ies > Neurolepet ic malignant syndrome
Neurolepetic malignant
syndrome
The neurol pet i c mal i gnant s yndrome res ul t s from an i mbal ance of dopami nergi c neurot rans mi t t ers fol l owi ng neurol ept i c drug us e. The i nci dence i s ~0.5% i n pat i ent s t aki ng neurol ept i c drugs . Thi s s yndrome i s cl i ni cal l y di s t i nct from mal i gnant hypert hermi a (P604); i t i s not an al l ergi c react i on. The mean age of ons et i s 40 years . The mort al i t y i s ~10%.
Drugs associated with the neuroleptic malignant syndrome

Hal operi dol Phenot hi azi nes Loxapi ne Thi oxant henes Dopami ne-depl et i ng drugs
o o o
met ocl oprami de t et rabenazi ne wi t hdrawal of l evadopa or amant adi ne
Clinical features

Mus cul ar ri gi di t y i ncl . dys phagi a, dys art hri a earl y (96%) Ext ra-pyrami dal s i gns (ps eudo-parki ns oni s m), t remor (90%) Cat at oni a: mut enes s (95%) Al t ered cons ci ous nes s coma Increas ed s erum CPK/AST (97%) Pyrexi a (rarel y >40C) fol l ows ons et of ri gi di t y.
The s yndrome can occur wi t hi n hours of i ni t i at i ng drug t herapy, but
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t ypi cal l y t akes ~1 week. It can al s o occur fol l owi ng a dos age i ncreas e of a wel l -es t abl i s hed drug.
Complications

Rhabdomyol ys i s (P392) Renal (15%) and hepat i c fai l ure Fi t t i ng i s rare Cardi ovas cul ar col l aps e DIC Res pi rat ory fai l ure.

Mal i gnant hypert hermi a (P604) Heat s t roke (P842) Ot her caus es of cat at oni a Thyrot oxi c cri s i s (P590) Phaeochromocyt oma (P598) Drug-i nduced hypert hermi a (caus ed by cocai ne, LSD, phencycl i di ne, amphet ami ne, t ri cycl i cs , and as pi ri n).
Management

W i t hdrawal of caus at i ve agent Dant rol ene (12mg/kg every 6 hours up t o a maxi mum 300mg/day) Paral ys i s and vent i l at i on (curare, pancuroni um) Bromocri pt i ne, amant adi ne, l evodopa (i ncreas e dopami nergi c t one and reduce ri gi di t y, t hermogenes i s , and ext ra-pyrami dal s ympt oms ).
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac ut e upper gast roint est inal bleeding 1
Acute upper
gastrointestinal bleeding 1
Presentation

Haemat emes i s (bri ght red, dark cl ot s , coffee grounds ) Mel aena (bl ack, s t i cky, s mel l y). Thi s may ari s e from anywhere proxi mal t o and i ncl udi ng t he caecum. Bl ood i s cat hart i c and t akes 46 hours t o be pas s ed. W i t h mas s i ve bl eedi ng (e.g. vari ceal ) t here may be dark cl ot s i n t he s t ool . Ot her caus es of dark s t ool i ncl ude i ron t herapy, bi s mut h (pres ent i n De-Nol ), l i quori ce, or dri nks s uch as red wi ne or Gui nnes s W eaknes s /s weat i ng and pal pi t at i ons Pos t ural di zzi nes s and fai nt i ng Col l aps e or s hock. Causes Approx % 3550% 815% 515% 510% 15% 1% 5% 5% (e.g. Meckel 's , Crohn's di s eas e)
Pept i c ul cer Gas t roduodenal eros i ons Oes ophagi t i s Vari ces Mal l oryW ei s s t ear Upper GI mal i gnancy Vas cul ar mal format i ons Rare mi s cel l aneous
It i s es s ent i al t o cat egori ze pat i ent s at t he t i me of admi s s i on i nt o
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hi gh or l ow ri s k of deat h [s ee Rockal l 's Score (t abl e) BSG Gui del i nes ]. Mos t deat hs occur i n t he el derl y wi t h co-morbi d di s eas e. In general hi gh ri s k fact ors i ncl ude t he fol l owi ng

Age >60 years (30% ri s k of deat h i f >90years ) Shock (BP <100mmHg s ys t ol i c i n pat i ent s <60 years or <120mmHg i n pat i ent s >60 years . Measure postural change i n BP i n pat i ent s who are not s hocked, and change i n HR Inappropri at e bradycardi a or HR >120 per mi nut e Chroni c l i ver di s eas e Ot her chroni c di s eas e (e.g. cardi ac, res pi rat ory, renal ) Bl eedi ng di at hes i s Decreas ed cons ci ous l evel .
Management
Li ai s e wi t h s peci al i s t s earl y (on-cal l endos copy t eam and s urgeons ). An experi enced anaes t het i s t s houl d be i nformed. Mos t pat i ent s wi l l have s t opped bl eedi ng by t he t i me t hey are s een: however, al l upper GI bl eeds s houl d be t aken s eri ous l y as t hey may re-bl eed i n hos pi t al , and t he mort al i t y fol l owi ng a re-bl eed i s hi gh. Pri ori t i es are
St abi l i ze t he pat i ent : prot ect t he ai rway, res t ore t he ci rcul at i ng vol ume Ident i fy t he s ource of t he bl eedi ng Defi ni t i ve t reat ment of t he caus e t o s t op t he bl eedi ng.
P.609
Rockall's Score
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Cli
Points
nic scored 0 1 2 3 al var iab le Ag < 6 > e 6 0 8 (ye 0 0 ars y y ) e 7 e ar 9 ar s y s e ar s Sh N H H ock o R R s > > h 1 1 oc 0 0 k 0 0 S S B B P P > < 1 1 0 0 Co- Ni mo l rbi di t y 0 0 C Li ar v di er ac R e n
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al M al ig n a nc y Di a M Al G gn al l s I os i l o ot t r ry h ac er t W ei ss m al ig n a nc St i N gm o at a n of e rec or ent d bl e ar ed k s p ot y Bl o o d in u p p er G I tr ac t A
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d h er e nt cl ot ; s p ur te r Score <3 = excel l ent prognos i s Score >8 = hi gh ri s k of deat h
Page 1035
Acute upper
Initial management

Prot ec t t he ai rw ay: pos i t i on t he pat i ent on s i de. i v ac c es s : us e 12 l arge bore (14G16G) cannulae i nt o peri pheral vei n for i ni t i al fl ui d res us ci t at i on. If peri pheral acces s i s di ffi cul t , acces s vi a jugul ar, s ubcl avi an, or femoral vei n may be neces s ary. CVP moni t ori ng (s ee P866) al l ows earl y i dent i fi cat i on of bl eedi ng, and i s us eful t o prevent overfi l l i ng. It i s es s ent i al i n ol der pat i ent s or i n t hos e wi t h mas s i ve haemorrhage. A fal l of 5cm H 2 O over 2 hours i s s ugges t i ve of re-bl eed. Take bl ood for Hb and PCV (does not fal l unt i l t he pl as ma vol ume has been res t ored, but i f l ow at pres ent at i on s ugges t s mas s i ve bl ood l os s or acut e-on-chroni c bl eedi ng). WCC may be el evat ed but us ual l y <15 000/mm . If W CC i s el evat ed l ook for s eps i s (s eps i s predi s pos es t o haemorrhage). Pl at el et c ount : i f l ow s ugges t s hypers pl eni s m and chroni c l i ver di s eas e. U&Es : urea out of proport i on t o t he creat i ni ne i ndi cat es prot ei n abs orpt i on by t he gut . Bl ood gl uc os e : may be l ow i n pat i ent s wi t h chroni c l i ver di s eas e. PT and LFT s i f l i ver di s eas e s us pect ed, Group and X-mat c h 48 uni t s . Moni t or ABG i n s everel y i l l pat i ent s . Res t ore t he c i rc ul at i ng vol ume
o
3
If t here are no s i gns of haemodynami c compromi s e
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us e a s l ow i nfus i on of N s al i ne (0.9%) t o keep t he i v l i ne pat ent and for mai nt enance fl ui ds .

o
Tachycardi a, hypot ens i on, or a pos t ural fal l i n BP or a pos t ural i ncreas e i n HR (by > 30 bp)s ugges t s a l ow i nt ravas cul ar vol ume. Gi ve 500 ml 1L col l oi d over 1 hour (e.g. Haemaccel) and t hen crys t al l oi d and cont i nue unt i l bl ood i s avai l abl e. St abl e BP t akes precedence over body s odi um bal ance. Us e compat i bl e bl ood when i t i s ready (gi ve 1uni t /h) unt i l vol ume i s res t ored or CVP 510cm). If t he rat e of bl eedi ng i s s l ow, packed cel l s are preferred. If t here i s mas s i ve haemorrhage, as k for O-negat i ve bl ood whi ch may be gi ven wi t hout cros s -mat chi ng. Save s erum for ret ros pect i ve cros s -mat ch.
Moni t or uri ne out put and cat het eri ze t he pat i ent i f t here are s i gns of haemodynami c compromi s e. Ai m for >30ml /h. Prompt res cus ci t at i on s houl d res t ore uri ne out put (s ee ol i guri a, P378). Wat c h for t he us ual s i gns of overl oad (rai s ed JVP or CVP, pul monary oedema, peri pheral oedema). Too rapi d t rans fus i on may preci pi t at e pul monary oedema even before t he t ot al l os t vol ume has been repl aced. Commenc e i nt ravenous PPI . Aft er endos copi c t reat ment of bl eedi ng ul cers , re-bl eedi ng recurs i n ~20% of pat i ent s . Int ravenous omepraz ol e (80mg i v, fol l owed by 8mg/h for 72 hours ) decreas es t he ri s k of rebl eedi ng from >20% t o ~7% aft er endos copi c t herapy. Many cent res us e i v pant oprazol e. P.611
Cons i der pas s i ng an NG t ube : t hi s may hel p confi rm coffee-grounds or bl ood i n t he s t omach and i s us eful i n di agnos i ng re-bl eedi ng. However NG t ubes
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bl ock eas i l y, and are uncomfort abl e. They may predi s pos e t o furt her bl eedi ng, gas t ro-oes ophageal refl ux, and pul monary as pi rat i on.
Keep t he pat i ent ni l by mout h for t he endos copy.
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Acute upper
Determine the source
Hi s t ory: as k s peci fi cal l y about dys peps i a, al cohol , drug hi s t ory (e.g. NSAIDs , ant i -coagul ant s ), ri s k fact ors for l i ver di s eas e, normal vomi t pri or t o haemat emes i s (Mal l oryW ei s s t ear, vari ceal bl eed), previ ous GI bl eeds , ul cers , or s urgery. Phys i c al exami nat i on: l ook for s t i gmat a of chroni c l i ver di s eas e (i ncl udi ng hepat omegal y and s pl enomegal y), s cars of previ ous s urgery, t el angi ect as i a (Os l erW eberRendu s yndrome), abdomi nal brui t , brui s es . Rect al exami nat i on may reveal mel aena or s emi -fres h bl ood. Upper GI endos c opy s houl d be done wi t hi n 12 hours of t he bl eed. It may be di ffi cul t t o preci s el y l ocat e t he s i t e of bl eedi ng due t o cl ot s i n t he s t omach but i t i s eas y t o excl ude pos s i bl e areas of bl eedi ng whi ch may hel p deci de furt her management . Remember upper GI bl eedi ng i n pat i ent s wi t h ci rrhos i s has a non-vari ceal ori gi n i n ~30% of cas es . Sel ec t i ve art eri ography of t he coel i ac axi s , s uperi or mes ent eri c or i nferi or mes ent eri c art ery i s of val ue when t he bl eedi ng s i t e cannot be i dent i fi ed, us ual l y aft er 2 or more negat i ve endos copi es and bl eedi ng i s bri s k (0.51ml /mi n). Bari um s t udi es may be us ed t o di agnos e s mal l bowel caus es of mel aena (e.g. Crohn's or t umour). Label l ed
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RBC s c ans may al s o be us eful . Mec kel 's s c an may be us eful i n younger pat i ent s .
Caps ul e endos c opy i s bei ng i ncreas i ngl y us ed i n s ome cent res .
General measures to stop the bleeding
Correc t any c oagul opat hy

o
Pl at el et count bel ow 50 000/mm s houl d be t reat ed wi t h pl at el et s upport (612 uni t s of pl at el et s ). If t he pat i ent i s on ant i -coagul ant s , as s es s t he need for ant i -coagul at i on before revers al . If t he pat i ent may requi re re-ant i -coagul at i on (e.g. pros t het i c mi t ral val ve) correct wi t h fres h frozen pl as ma and/or a very l ow dos e of vi t ami n K (0.51mg, i v). Ot herwi s e gi ve fres h frozen pl as ma (24 uni t s ) and i v vi t ami n K (510mg). Cryopreci pi t at e may be requi red i f t he fi bri nogen l evel s are l ow.
Serum c al c i um may fal l aft er s everal uni t s of ci t rat e-cont ai ni ng bl ood t rans fus i on. Gi ve 10 ml (4.5mEq) of cal ci um gl uconat e for every 34 uni t s t rans fus ed. Suppl ement magnes i um and phos phat e as neces s ary (l ow i n al cohol i cs ). Ul c er heal i ng agent s : gi ve an i v PPI s uch as pant opraz ol e (40mg i v dai l y) or omeprazol e (80mg i v, fol l owed by 8mg/h for 72 hours ). T ranexami c ac i d (0.51.5g i v t ds , or 11.5g t ds po) i ncreas es t he l evel s of fi bri nogen and may be hel pful . Li kewi s e DDAVP may be us eful i n pat i ent s wi t h renal fai l ure.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Pept ic ulc er disease
Peptic ulcer disease
Bl eedi ng pept i c ul cers form t he mai ns t ay of upper GI bl eedi ng, account i ng for 60% of al l cas es , and one-t hi rd of t hes e have been t aki ng a NSAID. Pat i ent s may gi ve a hi s t ory of epi gas t ri c di s t res s rel i eved by food but oft en t here i s no pri or hi s t ory.
Endos c opy al l ows t he bl eedi ng s i t e t o be vi s ual i zed. Ident i fi cat i on of t he bl eedi ng ves s el or adherent cl ot has prognos t i c s i gni fi cance: >80% of t hes e pat i ent s wi l l re-bl eed, cf. <5% wi t hout t hes e s t i gmat a.
o
The bl eedi ng poi nt may be t reat ed endos copi cal l y by el ect ro-coagul at i on, i nject i on of adrenal i ne, al cohol or endocl i ps around t he bl eedi ng poi nt and i nt o t he bas e, heat probe, or l as er phot ocoagul at i on, dependi ng on t he l ocal faci l i t i es Keep t he pat i ent NBM for 68 hours pos t endos copy i n cas e a repeat endos copy or s urgery i s needed.
I ndi c at i ons for s urgery: s ee t abl e. Medi c al management

o o
Treat wi t h PPI for 48 weeks Repeat endos copy at 68 weeks t o check t he l es i on has heal ed A bi ops y s houl d be t aken at t he ori gi nal endos copy for t he ureas e t es t for Hel i c obac t er pyl ori . If pos i t i ve add an H. pyl ori eradi cat i on regi men (s ee BNF ).
Prognos i s : overal l mort al i t y i s <10%. Mort al i t y i s reduced by earl y s urgery i n hi gh-ri s k pat i ent s .
P.615
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Practice point
In one major s t udy, i nt ravenous PPI i nfus i on was al mos t as effect i ve as t herapeut i c endos copy i n bl eedi ng pept i c ul cer di s eas e.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Erosive gast rit is/oesophagit is
Erosive
gastritis/oesophagitis
Thes e general l y pres ent as rel at i vel y mi nor bl eeds but may be s i gni fi cant . Repres ent ~15% of upper GI bl eeds , and are as s oci at ed wi t h pri or us e of as pi ri n or ot her NSAIDs i n previ ous l y fi t pat i ent s , or s t res s i n t he cri t i cal l y i l l pat i ent .
Management : at endos copy t here i s commonl y a general i zed ooze of bl ood from t he i nfl amed mucos a. Ini t i al management i s as before. Gi ve PPI or s ucral fat e 12g q6h po or via NG-t ube. PPIs are bet t er t han H 2 -ant agoni s t s i n heal i ng oes ophagi t i s and oes ophageal ul cers . Correct any cl ot t i ng di s order. If t he l es i ons are t oo di ffus e and t he bl eedi ng cont i nues , part i al gas t ri c res ect i on may be neces s ary. Prognos i s : ~6% of pat i ent s wi t h haemorrhagi c gas t ri t i s requi re s urgery. Overal l mort al i t y i s <10%.
Relative indications for surgery

Exangui nat i ng haemorrhage (t oo fas t t o repl ace) Profus e bl eedi ng

o o o
>6 uni t s bl ood i n i ni t i al res us ci t at i on cont i nued bl eedi ng at >1 uni t per 8 hours pers i s t ent hypot ens i on
Re-bl eed i n hos pi t al Fai l ed endos copy t herapy Rebl eed aft er endos copi c t herapy i n pat i ent s >65 years Les i ons whi ch are at hi gh ri s k of re-bl eedi ng, e.g. pos t eri or DU wi t h vi s i bl e ves s el or gi ant gas t ri c ul cer
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Speci al s i t uat i ons , e.g. pat i ent s wi t h a rare bl ood group or pat i ent s refus i ng bl ood t rans fus i on s houl d be expl ored earl i er
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Varic eal haemorrhage: medic al management
Variceal
haemorrhage: medical management

Oes ophageal and gas t ri c vari ces devel op wi t h port al hypert ens i on of what ever caus e. Bl eedi ng from vari ces i s t ypi cal l y vi gorous and di ffi cul t t o cont rol and oft en occurs i n t he s et t i ng of abnormal cl ot t i ng, t hrombocyt openi a, and s eps i s .
Diagnosis
Hi s t ory and phys i cal exami nat i on may rai s e t he s us pi ci on of a vari ceal s ource of bl eedi ng but ~30% of ci rrhot i cs have a non-vari ceal s ource of bl eedi ng. The mos t rel i abl e met hod i s upper GI endos c opy whi ch s houl d be performed as s oon as i s feas i bl e. Bl eedi ng may occur from ei t her gas t ri c or oes ophageal vari ces , or rarel y port al hypert ens i ve gas t ropat hy.
Medical management

Ini t i al res us ci t at i on i s as des cri bed earl i er (P610). Trans fus e wi t h bl ood, fres h frozen pl as ma, and pl at el et s as neces s ary accordi ng t o haemat ol ogi cal paramet ers t o t ry t o s t op t he bl eedi ng. Gi ve vi t ami n K 10mg i v once onl y t o excl ude vi t ami n K defi ci ency. Avoi d over-t rans fus i on (may port al pres s ure and t he ri s k of rebl eedi ng). Gi ve a bol us dos e of met ocl oprami de 20mg i v. Thi s t rans i ent l y i ncreas es t he l ower oes ophageal pres s ure and decreas es azygous bl ood fl ow. Ant i bi ot i c s : t ake bl ood, uri ne, and as ci t i c cul t ures mi cros copy. St art broad-s pect rum ant i bi ot i cs . Several s t udi es have s hown t hat vari ceal bl eedi ng i s as s oci at ed wi t h s eps i s . Commence a t hi rd-generat i on
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cephal os pori n or ci profl oxaci n and amoxyci l l i n. Treat for 5 days .
T erl i pres s i n (gl ypres s i n) (2mg i ni t i al l y, and t hen 12mg every 46 hours for up t o 72 hours ) i s effect i ve i n cont rol l i ng vari ceal bl eedi ng by caus i ng s pl anchni c vas ocons t ri ct i on (rel at i ve reduct i on i n mort al i t y of ~34%). Seri ous s i de-effect s occur i n 4% and i ncl ude cardi ac i s chaemi a, peri pheral vas ocons t ri ct i on, whi ch may produce s i gni fi cant hypert ens i on, s ki n, and s pl anchni c i s chaemi a. Ni t rat es have been us ed t o reduce t he peri pheral effect s of vas opres s i n, but are not general l y us ed wi t h t erl i pres s i n. Oc t reot i de i s a s ynt het i c anal ogue of s omat os t at i n. It does not have t he cardi ac s i de-effect s of t he ot her agent s and ni t rat es are not requi red. A recent Cochrane revi ew found t hat oct reot i de had no effect on mort al i t y, and had a mi ni mal effect on t rans fus i on requi rement s . Endos c opi c i njec t i on of s cl eros ant i nt o t he vari ces or para-vari ceal can cont rol t he bl eedi ng acut el y. Si de-effect s (s eri ous i n 7%) i ncl ude ret ros t ernal pai n and fever i mmedi at el y pos t i nject i on, mucos al ul cerat i on, l at e oes ophageal s t ri ct ures . Emergency i nject i on s houl d be fol l owed up by repeat i nject i on s cl erot herapy of vari ces unt i l obl i t erat ed. Gas t ri c vari ces are more di ffi cul t t o i nject , and t hrombi n s houl d be us ed. Band-l i gat i on of t he vari ces i s frequent l y us ed but i s t echni cal l y more di ffi cul t i n t he s et t i ng of acut e haemorrhage. P.619
Bal l oon t amponade A Sengs t akenBl akemore or Li nt on t ube may be i ns ert ed (P928). Infl at i on of t he gas t ri c bal l oon only us ual l y s uffi ces . Thi s s houl d not be
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l eft i n pl ace for more t han 12 hours as i s chaemi c ul cerat i on may occur, a ri s k i ncreas ed by t he co-admi ni s t rat i on of t erl i pres s i n.
Li ver fai l ure regi men (P664): gi ve l act ul os e 1015ml q8h po or per NG t ube t o prevent encephal opat hy and s uppl ement wi t h t hi ami ne and mul t i vi t ami ns as neces s ary. Us e magnes i um or phos phat e enemas for pat i ent s wi t h s evere encephal opat hy.
Drugs to control variceal haemorrhage

Terl i pes s i n (gl ypres s i n)

Inject 2mg as an i v bl ous . Inject 12mg every 46 hours St op at 72 hours Add 120 uni t s t o 250ml 5% dext ros e Infus e 50ml (24 uni t s ) over 15 mi nut es t hen 50 ml /h (0.4U/mi n) for 12 hours
Vas opres s i n (us ed rarel y)
An i nfus i on of ni t rat es or a t rans dermal GTN pat ch are s omet i mes us ed t o mi ni mi ze t he cardi ac s i de-effect s of vas opres s i n
Oct reot i de
100g i v bol us fol l owed by a cont i nuous i nfus i on at 2550g/h (500g i n 50ml ; 2.55ml /h). No effect on mort al i t y
Page 1047
> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Varic eal haemorrhage: furt her management
Variceal
haemorrhage: further management

Radiological management
T I PS i s avai l abl e i n s peci al i zed uni t s . Us i ng a jugul ar or femoral approach, t he hepat i c vei ns are cannul at ed and an expandabl e s t ent i s pl aced bet ween t he hepat i c vei ns (l ow pres s ure) and t he port al venous s ys t em (hi gh pres s ure). The port al pres s ure s houl d be decompres s ed t o bel ow 12mmHg.
Surgical management
Thi s has been l argel y s upers eded by TIPS.
Emergenc y port o-c aval s hunt i ng i s effect i ve i n cont rol l i ng t he bl eed (>95%) but has a hi gh operat i ve mort al i t y (>50%) and does not i nfl uence l ong-t erm s urvi val . Few s urgeons can do t hi s now Oes ophageal t rans ec t i on i s us ed very rarel y i n t he UK.
Prognosis
Overal l mort al i t y i s 30%. Thi s i s hi ghes t i n t hos e wi t h s evere l i ver di s eas e (Chi l d's Grade C, s ee t abl e oppos i t e). Succes s rat es for ces s at i on of acut e bl eedi ng vari ces Inject i on s cl erot herapy or bandi ng Bal l oon t amponade Terl i pres s i n Oct reot i de Vas opres s i n + ni t rat es ~7085% ~80% ~70% ~70% ~65%
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I njec t i on s c l erot herapy wi t h 0.51ml s cl eros ant paravari ceal or 15ml i nt ravari ceal at weekl y i nt erval s unt i l t he vari ces are obl i t erat ed (1 mont h); t hen at 36 mont hl y i nt erval s . Bandi ng l i gat i on i nvol ves a s i mi l ar regi men t o i nject i on t herapy but achi eves vari ceal obl i t erat i on more rapi dl y (39 days vers us 72 days ). Propranol ol (80mg t ds : ai m for a 3040% reduct i on i n res t i ng heart rat e, but confi rm reduct i on of port al pres s ure by meas urement of wedged hepat i c venous pres s ure gradi ent ) reduces t he rat e of re-bl eedi ng from vari ces and port al hypert ens i ve gas t ropat hy. It has not been s hown t o decreas e mort al i t y. T I PS or s hunt proc edures provi de a more defi ni t e cure and bl eedi ng t ends t o recur onl y when t he s hunt bl ocks , but t here i s an i ncreas ed i nci dence of chroni c hepat i c encephal opat hy.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > MalloryWeiss t ear
MalloryWeiss tear
Thi s i s a t ear i n t he mucos a at t he gas t ro-oes ophageal junct i on fol l owi ng s evere ret chi ng and i s part i cul arl y common fol l owi ng l arge bout s of al cohol . The vomi t i s normal i ni t i al l y and becomes bri ght red.
Management

Mos t s t op bl eedi ng s pont aneous l y. Tamponade wi t h a Sengs t akenBl akemore t ube may be us ed. Surgi cal over-s ewi ng of bl eedi ng poi nt or s el ect i ve art eri ography and embol i zat i on of t he feedi ng art ery may be neces s ary. Clinical or Points scored 1 None Abs ent <35 >35 14 2 12 Mi l d 3660 2835 46 34 Moderat es evere >60 <28 >6 3
biochemical variable Encephal opat hy grade As ci t es Bi l i rubi n (mol /L) Al bumi n (g/L) PT (s econds prol onged)
The Chi l dPugh s cori ng s ys t em i s a very effect i ve way t o get an i ndex of t he s everi t y of l i ver di s eas e i n pat i ent s wi t h ci rrhos i s . It i s not di rect l y appl i cabl e t o pat i ent s wi t h pri mary bi l i ary ci rrhos i s or s cl eros i ng chol angi t i s .
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Chi l dPugh A Chi l dPugh B Chi l dPugh C
Score 6 Score 79 Score 10
Page 1051
> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac ut e gast roent erit is: assessment
Acute gastroenteritis:
assessment
Food-poi s oni ng i s an acut e at t ack of abdomi nal pai n, di arrhoea vomi t i ng 140 hours aft er i nges t i ng cont ami nat ed foods t uffs and l as t i ng 17 days . W i t h t he except i on of an acut e at t ack of i nfl ammat ory bowel di s eas e and mes ent eri c i s chaemi a (s ee acut e col i t i s ) t he majori t y of acut e ons et di arrhoea has an i nfect i ve aet i ol ogy.
Differential diagnosis of acute diarrhoea Common

Gas t ro-ent eri t i s (bact eri al , vi ral , prot ozoal ) Cl os t ri di um di ffi c i l e di arrhoea (ps eudomembranous col i t i s ) Infl ammat ory bowel di s eas e Food i nt ol erance/al l ergy (e.g. l act as e defi ci ency) Drugs (s ee t abl e P630) Cons t i pat i on wi t h overfl ow
Less common

Coel i ac di s eas e Tumour (beni gn or mal i gnant ) Carci noi d s yndrome Bact eri al overgrowt h Pancreat i c i ns uffi ci ency Bi l e s al t ent eropat hy Hypert hyroi di s m Aut onomi c neuropat hy
Presenting features
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As k s peci fi cal l y about
Recent eat i ng habi t s es p. res t aurant s and food prepared by cat erers . Anyone el s e (fami l y/fri ends ) wi t h s i mi l ar s ympt oms ? Ti me i nt erval bet ween eat i ng any s us pi ci ous s ubs t ance and ons et of s ympt oms . Earl y ons et of vomi t i ng or di arrhoea (612 hours ) s ugges t s i nges t i on of preformed t oxi n (e.g. St aph . exot oxi n). Ent erot oxi n-produci ng organi s ms may t ake 13 days t o produce s ympt oms . Recent t ravel (ent erot oxogeni c E. c ol i , Sal monel l a , Gi ardi a , or amoeba)? Recent medi cat i on? Any ant i bi ot i cs ( Cl . di ffi c i l e )? PMH, e.g. gas t ri c s urgery or i mmunos uppres s i on (drugs or HIV). Anal i nt ercours e i ncreas es t he ri s k of amoebi as i s , gi ardi as i s , s hi gel l os i s , rect al s yphi l i s , rect al gonorrhoea, Chl amydi a t rac homat i s , HSV of rect um and peri anal area (di arrhoea i n HIV-i nfect ed pat i ent s i s di s cus s ed on p358). The gros s appearance of t he di arrhoea may hel p: frankl y bl oody s t ool , Campyl obac t er or Shi gel l a ; wat ery, ri ce-wat er s t ool cl as s i cal l y s ecret ory di arrhoea due t o chol era, ent erot oxogeni c E. c ol i , or neuro-endocri ne t umours . Typhoi d produces greeni s h pea-s oup di arrhoea. Abdomi nal pai n may be pres ent us ual l y cramp-l i ke, or t enes mus . Fever: common wi t h t he s evere bact eri al di arrhoeas and acut e exacerbat i ons of Crohn's or UC.
P.625
Investigations
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FBC U&Es Bl ood cul t ures St ool cul t ures
W BC; haemat ocri t (dehydrat i on) Urea (dehydrat i on); K

+
Sys t emi c i nfect i on may occur Fres h s ampl es , mandat ory for wet mount mi cros copy for ova, cys t s and paras i t es , cul t ure, and ant i bi ot i c s ens i t i vi t i es . W BC i n s t ool i mpl i es i nt es t i nal i nfl ammat i on (mucos al i nvas i on, t oxi n, i nfl ammat ory bowel di s eas e, i s chaemi c col i t i s )
Cl os t ri di um di ffi c i l e t oxi n Si gmoi dos copy and rect al bi ops y
Speci fi cal l y reques t t hi s for al l pat i ent s who have recent l y t aken ant i bi ot i cs Us eful for pers i s t ent bl oody di arrhoea (>45 days ) wi t hout di agnos i s or
General approach to treat acute diarrhoea i mprovement .

Sev Ma eri t na y of mp to ms Ora d l ds Mi l fl ui (1 onl 3 y sto ol s /da y) Ora l ge me
s y nt
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Mo fl ui der ds , at e l op (3 era 5 mi s t o de ol s (Im /da odi y) um ) Fl u i ds Sev ( ere (> i vi ) 6 , s t o ant ol s i -m /da i cr y, obi fev al er) ag ent
When to use antibiotics early

Unl es s s hi ga t oxi n-produci ng E. c ol i i s s us pect ed, i t i s reas onabl e t o gi ve s pecul at i ve ant i bi ot i c t reat ment t o al l pat i ent s who have an i ncreas ed ri s k of fat al or s evere di arrhoea. Thes e i ncl ude frai l el derl y pat i ent s wi t h achl orhydri a (i ncl udi ng pat i ent s on PPIs s uch as omepraz ol e), i nfl ammat ory bowel di s eas e, poor haemodynami c res erve, or t he i mmunocompromi s ed.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Bac t erial gast roent erit is
Bacterial gastroenteritis
Salmonella sp . may produce acut e gas t roent eri t i s (e.g. S. ent eri t i di s , ~7080% of cas es ), ent eri c fever ( S. t yphi and S. t yphi muri um , s ee P318), or as ympt omat i c carri age. Acut e gas t roent eri t i s oft en occurs i n epi demi cs , and i s deri ved from poul t ry, eggs or egg product s , and occas i onal l y pet s (t errapi ns ). Sympt oms : 848 hours aft er i nges t i on wi t h headache, vomi t i ng (wors e t han ei t her Shi gel l a or Campyl obac t er ), fever, and di arrhoea l as t i ng 24 days (rarel y bl oody wi t h mucus ). React i ve art hri t i s may occur (i n HLA-B27 +ve). ent eri c fever, s ee P318. Management : us ual l y s el f-l i mi t i ng aft er 25 days , and t reat ment i s s upport i ve for mos t cas es . Some ant i bi ot i cs can prol ong carri age of t he i l l nes s , and make cl i ni cal rel aps e more l i kel y. Clostridium perfringens (type A). 1525% of cas es of bact eri al food poi s oni ng. Spores are heat res i s t ant and may germi nat e duri ng reheat i ng or s l ow cooki ng of meat s . Ent erot oxi n i s rel eas ed when s porul at i on occurs i n i nt es t i ne. Incubat i on 822 hours Sympt oms : di arrhoea, abdomi nal pai n, naus ea (rare t o get vomi t i ng). No fever. Las t s 1224 hours . Management : Support i ve. Campylobacter i nfect i ons are common (510% of pat i ent s wi t h acut e di arrhoea). The i ncubat i on peri od i s 37 days , s ympt oms l as t for 12 weeks . Pres ent at i on oft en fol l ows eat i ng cont ami nat ed poul t ry. Sympt oms : fl u-l i ke i l l nes s fol l owed by headache, myal gi a, abdomi nal pai n (cont i nuous t hen col i cky), di arrhoea, rect al bl eedi ng occas i onal l y. Rarel y compl i cat ed by react i ve art hri t i s (12%), Gui l l ai nBarr s yndrome, or Rei t er's s yndrome. Management : Us ual l y s el f-l i mi t i ng <5 days . Treat ment compri s es ei t her eryt hromyci n or t et racycl i ne. Ant i -di arrhoeal s are cont rai ndi cat ed. Staph. aureus (25% of cas es ) can mul t i pl y at room t emperat ure
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i n foods ri ch i n carbohydrat es and s al t (dai ry product s , col d meat s , mayonnai s e). A heat -s t abl e exot oxi n produces naus ea, vomi t i ng, and di arrhoea 16 hours aft er i nges t i on. Fever i s uncommon. Treat ment i s s upport i ve. Bacillus cereus as s oci at ed wi t h s l ow-cooki ng foods and reheat ed ri ce (fas t food t akeaways ). It produces an emet i c t oxi n t hat res ul t s i n vomi t i ng i n 15 hours , and di arrhoea 816 hours l at er. Treat ment i s s upport i ve. Vibrio parahaemolyticus produces epi gas t ri c pai n (cf. t hos e above), di arrhoea, vomi t i ng, and fever 1218 hours aft er i nges t i on of raw s eafood (s hel l fi s h). May l as t up t o 5 days . Vibrio cholerae i s uncommon i n t he W es t ern nat i ons . It produces profus e s ecret ory di arrhoea. The di s eas e i s us ual l y s el f-l i mi t i ng (57 days ) but t et racycl i nes may be us ed. Yersinia enterocolitica: i ncubat i on peri od 410 days aft er cont act wi t h i nfect ed ani mal s , wat er, or i ce cream. Sympt oms : di arrhoea (80%), abdomi nal pai n (80%), fever (40%), bl oody s t ool i n 10%, mes ent eri c adeni t i s , l ymphadenopat hy, react i ve art hri t i s . Di agnos ed by s erol ogy rat her t han cul t ure. Management : Support i ve. Shiga toxin-producing E. coli (e.g. O157:H7). Infect i on i s us ual l y from cont ami nat ed meat /burgers . The i ncubat i on peri od i s ~5 days . St ool s rapi dl y become bl oody over 2448 hours , s econdary t o a di ffus e col i t i s . Mos t pat i ent s res ol ve over 57 days wi t hout t reat ment . However, s ome, es p. chi l dren, may go t o devel op HUS wi t h t i rednes s , mi croangi opat hi c anaemi a, t hrombocyt openi a, renal fai l ure encephal opat hy. Mos t recover wi t h s upport i ve care. Ant i bi ot i cs are cont rai ndi cat ed, as cert ai n ant i bi ot i cs caus e s hi ga t oxi n product i on and may exacerbat e or caus e t he devel opment of HUS.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Viral gast roent erit is
Viral gastroenteritis
In addi t i on t o di arrhoea, URTI-l i ke s ympt oms , abdomi nal cramps , headache, and fever may occur. The caus at i ve agent i s us ual l y not found but many vi rus es i mpl i cat ed (e.g. echovi rus , Norwal k vi rus , and adenovi rus es ). Sel f-l i mi t i ng i l l nes s (35 days ). Management : oral fl ui ds and res t ri ct i ng s ol i d foods and dai ry product i nt ake us ual l y s uffi ce.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Pseudomembranous c olit is
Pseudomembranous
colitis
Thi s i s produced by a necrol yt i c t oxi n produced by Cl os t ri di um di ffi c i l e . Infect i on t ypi cal l y fol l ows ant i bi ot i c t herapy. Di arrhoea may occur duri ng or up t o 4 weeks fol l owi ng ces s at i on of t reat ment . Sympt oms : di arrhoea i s us ual l y profus e, wat ery, and wi t hout bl ood (may be bl oody i n ~5%). It i s commonl y as s oci at ed wi t h abdomi nal cramps and t endernes s , fever, and an el evat ed whi t e cel l count . Di agnos i s i s bas ed on det ect i on of Cl os t ri di um di ffi c i l e t oxi n i n s t ool . Cul t ure of t he organi s m i t s el f i s unhel pful ; ~5% of heal t hy adul t s carry t he organi s m. Si gmoi dos copy i s not di agnos t i c, but may s how mucos al i nfl ammat i on t oget her wi t h mul t i pl e yel l ow pl aques . Management : pat i ent s s houl d be i s ol at ed and barri er nurs ed. Rehydrat e and correct el ect rol yt e abnormal i t i es . Mi l d di s eas e res ponds t o oral met roni dazol e (500mg t ds ). Oral vancomyci n 250mg qds for 714 days i s an al t ernat i ve. Severe di s eas e requi res i v t herapy. Compl i cat i ons i ncl ude t oxi c megacol on and col oni c perforat i on.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Giardiasis
Giardiasis
Gi ardi a l ambl i a i s t rans mi t t ed by t he faeco-oral rout e. Ri s k fact ors i ncl ude recent t ravel , i mmunos uppres s i on, homos exual i t y, and achl orhydri a. Sympt oms : more chroni c di arrhoeal i l l nes s wi t h epi gas t ri c di s comfort due t o duodenal i nfes t at i on. Mal ai s e, bl oat i ng, fl at ul ance, and occas i onal l y mal abs orpt i on occur. Di agnos i s i s by s t ool mi cros copy for cys t s or t rophozoi t es or duodenal as pi rat i on. If negat i ve, cons i der bl i nd t herapeut i c t ri al . Management : met roni dazol e i s t he t reat ment of choi ce, 2g dai l y for 3 days or 400mg t ds for 5 days oral l y. Al t ernat i ves i ncl ude t i ni daz ol e (2g s i ngl e dos e) or mepacri ne hydrochl ori de 100mg t ds for 57 days . Lact os e i nt ol erance pos t i nfect i on may pers i s t for up t o 6 weeks .
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > T ravellers' diarrhoea
Travellers' diarrhoea
Travel t hrough devel opi ng count ri es i s commonl y as s oci at ed wi t h s el f-l i mi t i ng acut e di arrhoeal i l l nes s t rans mi t t ed t hrough food and wat er. The mos t frequent pat hogen i s ent erot oxi geni c E. c ol i (40% of cas es ). The i l l nes s l as t s 35 days wi t h naus ea, wat ery di arrhoea, and abdomi nal cramps . Oral rehydrat i on i s us ual l y s uffi ci ent . Ant i mot i l i t y agent s (e.g. l operami de) may be us ed wi t h caut i on. Ant i bi ot i c t reat ment (ci profl oxaci n 500mg bd) may hel p pat i ent s wi t h more prot ract ed i l l nes s . Al t ernat i ves i ncl ude doxycycl i ne or co-t ri moxazol e. Di arrhoea t hat pers i s t s for more t han 7 days requi res furt her i nves t i gat i on i ncl udi ng s t ool mi cros copy and cul t ure, s erol ogy s i gmoi dos copy, and bi ops y (s ee t abl e). A 35-day cours e of a broad-s pect rum ant i bi ot i c s uch as ci profl oxaci n may t ermi nat e t he i l l nes s .
Causes of travellers' diarrhoea

Bacterial

Ent erot oxi geni c E. c ol i (40%) Shi gel l as and ent eroi nvas i ve E. c ol i (10%) Sal monel l a (5%) Campyl obac t er (3%) Aeromas /pl es i omonas (5%) Vi bri oparahaemol yt i cus (1%)
Not-identified (22%) Viruses (10%)

Norwal k Rot avi rus Gi ardi a
Protozoa (4%)
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Ent amoeba Crypt os pori di um Mi c ros pori di um
Causes of persistent diarrhoea in travellers

Protozoa

Gi ardi a Lambl i a Ent amoeba hi s t ol yt i c a Cyc l os pora c ayet anens i s Sal monel l a Campyl obat er St rongyl oi des Col oni c s chi s t os omi as i s (rare)
Bacteria

Helminths

Common drugs that may cause acute diarrhoea

Laxat i ves Ant aci d (Mg , Ca ) Lact ul os e Di uret i cs t herapy Ant i bi ot i cs
2+ 2+
Col chi ci ne Qui ni di ne Di gi t al i s Theophyl l i nes Chol i nergi c agent s
Propranol ol As pi ri n NSAIDs Cyt ot oxi c Capt opri l
There are many drugs ot her t han t hos e l i s t ed above t hat can caus e di arrhoea
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Bloody diarrhoea
Bloody diarrhoea
Causes
Acut e i nfect i ous col i t i s

o o o o
Baci l l ary dys ent ery ( Shi gel l a s pp.) Sal monel l os i s (P318) Campyl obac t er (P626) Haemorrhagi c col i t i s (s hi ga-l i ke t oxi n-produci ng E. c ol i ) Ps eudomembranous col i t i s (P628)
Infl ammat ory bowel di s eas e (IBD, UC or Crohn's ).
Presenting features
As k about durat i on of s ympt oms and recent eat i ng habi t s . Ot hers affect ed? Recent t ravel (ent erot oxogeni c E. c ol i , Sal monel l a , Gi ardi a , or amoeba)? Recent medi cat i on? Any ant i bi ot i cs ( Cl . di ffi c i l e )? The gros s appearance of t he s t ool may hel p. Infl ammat ory bowel di s eas e may res ul t i n rect al bl eedi ng (fres h red bl ood) i n pat i ent s wi t h di s eas e l argel y confi ned t o t he rect um and s i gmoi d col on. Di ffus e di s eas e t ends t o be as s oci at ed wi t h di arrhoea. Infect i ous col i t i s res ul t s i n frankl y bl oody s t ool ( Campyl obac t er or Shi gel l a ). Abdomi nal pai n may be pres ent : us ual l y cramp-l i ke, or t enes mus . Vomi t i ng i s uncommon i n acut e i nfl ammat ory bowel di s eas e. Sys t emi c feat ures s uch as general mal ai s e and l et hargy, dehydrat i on el ect rol yt e i mbal ance, or fever
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are s een wi t h t he s evere bact eri al di arrhoeas and acut e exacerbat i ons of Crohn's or UC. Ski n, joi nt s , and eyes may be i nvol ved i n ei t her IBD or fol l ow acut e i nfect i on.
Previ ous al t ered bowel habi t , wei ght l os s , s moki ng hi s t ory, vas cul ar di s eas e (mes ent eri c i nfarct i on), mes ent eri c angi na may be rel evant .
Examination
Look for
Fever, s i gns of dehydrat i on (t achycardi a, pos t ural hypot ens i on), abdomi nal di s t ens i on. Abdomi nal t endernes s or rebound over affect ed col on (IBD) may i ndi cat e col oni c di l at at i on or perforat i on. An abdomi nal mas s may i ndi cat e t umour or i nfl ammat ory mas s . Mout h ul cers and peri anal di s eas e are common i n act i ve IBD. Eryt hema nodos um and pyoderma gangrenos um occur i n i nfl ammat ory bowel di s eas e; Y ers i ni a may produce eryt hema nodos um. Ros e s pot s i ndi cat e t yphoi d fever. Joi nt i nvol vement (oft en an as ymmet ri cal , non-deformi ng s ynovi t i s , i nvol vi ng l arge joi nt s of t he l ower l i mbs ) may occur i n act i ve IBD, but al s o i n i nfect i ous col i t i s (e.g. Campyl obac t er, Y ers i ni a ). Uvei t i s i s as s oci at ed wi t h bot h IBD and acut e i nfect i ous col i t i s .
Investigations
The pri ori t y i s t o excl ude any i nfect i ous caus e for t he bl oody di arrhoea and t o moni t or for compl i cat i ons . Bl ood t es t s Mi crobi ol ogy Si gmoi dos copy bi ops y FBC, U&Es , LFTs , CRP, ESR, coagul at i on s t udi es St ool MC&S, bl ood cul t ures , Cl os t ri di um di ffi c i l e t oxi n May hel p t o di s t i ngui s h bet ween acut e i nfect i ous col i t i s and i nfl ammat ory bowel di s eas e (i ncreas ed ri s k of perforat i on duri ng
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Imagi ng
col onos copy) Pl ai n AXR may hel p moni t or col oni c di l at at i on. Cont ras t s t udi es are cont rai ndi cat ed acut el y. Nucl ear i magi ng s t udi es (e.g. W BC s cans ) are us ed i n IBD t o demarcat e ext ent of di s eas e.
P.633
Practice point
Al ways t es t for C. di ffi c i l e i n pat i ent s wi t h new ons et bl oody di arrhoea.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Bac t erial dysent ery
Bacterial dysentery
Thi s i s due t o i nfect i on wi t h Shi gel l a (S. dys ent eri ae, S. fl exneri , S. boydi i , S. s onnei ) or s ome s hi gel l a-l i ke E. c ol i (0157:H7). Trans mi t t ed by t he faeco-oral rout e, and cl us t ers of cas es are oft en found.
Symptoms
It caus es mi l d di arrhoea t o a s evere s ys t emi c i l l nes s bet ween 1 and 7 days fol l owi ng expos ure. Fever (us ual l y res ol ves i n 34 days ). Abdomi nal cramps wi t h t enes mus . W at ery di arrhoea naus ea and vomi t i ng (res ol ves by day 7). Bl oody di arrhoea occurs l at er (aft er 2472 hours ) due t o i nvas i on of t he mucos a. Di agnos ed by s t ool cul t ure. E. c ol i i nfect i ons may be compl i cat ed by haemol yt i c uraemi c s yndrome.
Management

Pat i ent s may requi re i v fl ui d repl acement Ant i bi ot i cs s houl d be res erved for t he mos t s evere cas es . Ampi ci l l i n (250mg po qds 510 days ) i s us ual l y effect i ve, but i n res i s t ant cas es co-t ri moxazol e or ci profl oxaci n may be us ed. Ant i -mot i l i t y agent s s uch as l operami de and codei ne are cont rai ndi cat ed as t hey prol ong carri age and wors en s ympt oms .
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Amoebic dysent ery
Amoebic dysentery
Ent amoeba hi s t ol yt i c a can produce i nt ermi t t ent di arrhoea or a more s evere i l l nes s t hat res embl es i nfl ammat ory bowel di s eas e. There i s an i ncreas ed ri s k i n homos exual s , and i n t hos e wi t h recent t ravel t o t hi rd worl d count ri es . It i s t rans mi t t ed by t he faeco-oral rout e.
Symptoms
Di arrhoea or l oos e s t ool ( bl ood), abdomi nal di s comfort , mi l d fever. In s evere cas es , l i ver abs ces s . Ful mi nant at t acks pres ent abrupt l y wi t h hi gh fever, crampi ng abdomi nal pai n, and profus e bl oody di arrhoea. Marked abdomi nal t endernes s i s pres ent . Di agnos i s i s made by i dent i fyi ng amoebi c cys t s on s t ool mi cros copy. May be compl i cat ed by l at e devel opment of amoebi c l i ver abs ces s .
Treatment
Ai med at repl acement of fl ui d, el ect rol yt e, and bl ood l os s , and eradi cat i on of t he organi s m. In acut e-i nvas i ve i nt es t i nal amoebi as i s oral met roni dazol e 800mg t ds , for 510 days i s t he t reat ment of choi ce. Ti ni dazol e (2g dai l y for 23 days ) i s al s o effect i ve. Thi s s houl d be fol l owed wi t h oral di l oxani de furoat e 500mg t ds for 10 days t o des t roy gut cys t s . Met roni dazol e (or t i ni dazol e) and di l oxani de furoat e are al s o effect i ve for l i ver abs ces s es , and USS-gui ded as pi rat i on may hel p i mprove penet rat i on of t he drugs and s hort en i l l nes s . Di l oxani de furoat e i s t he t reat ment of choi ce for
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as ympt omat i c pat i ent s wi t h E. hi s t ol yt i c a cys t s i n t he s t ool as met roni dazol e and t i ni dazol e are rel at i vel y i neffect i ve.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Inflammat ory bowel disease (
Inflammatory bowel
disease (IBD) 1
Infl ammat ory bowel di s eas e i ncl udes Crohn's di s eas e and UC. Crohn's di s eas e i s a chroni c i nfl ammat ory di s eas e of any part of t he GIT, charact eri zed by granul omat ous i nfl ammat i on. UC i s a chroni c i nfl ammat ory di s eas e of t he col on of unknown aet i ol ogy. It al ways affect s t he rect um, and ext ends proxi mal l y t o a vari abl e ext ent of t he col on.
Ulcerative colitis Presentation
Gradual ons et of s ympt oms , whi ch are progres s i vel y more s evere Di arrhoea i s dependent on di s eas e act i vi t y and ext ent . Noct urnal di arrhoea and urgency are common s ympt oms of s evere UC Mucus and frank pus , or bl ood, i s oft en mi xed i n wi t h t he s t ool Occas i onal l y abdomi nal pai n (not a promi nent feat ure, t hough l ower abdomi nal crampi ng pai ns rel i eved by defecat i on i s common; s evere abdomi nal pai n s ugges t s a s evere at t ack wi t h acut e di l at at i on or perforat i on, or i s chaemi c col i t i s ) Urgency and t enes mus In s evere di s eas e t here i s s evere (>6 mot i ons /day) and noct urnal di arrhoea, anorexi a, and wei ght l os s . Bl ood may be al t ered i n col our Apht hous ul cers (al s o pres ent i n Crohn's ) As k about recent ces s at i on of s moki ng (preci pi t ant ).
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Examination
Look for fever , s i gns of dehydrat i on (t achycardi a, pos t ural hypot ens i on), and abdomi nal di s t ens i on. Abdomi nal t endernes s or rebound over affect ed col on may i ndi cat e col oni c di l at at i on or perforat i on. Thi s may be mas ked i f t he pat i ent i s on s t eroi ds . An abdomi nal mas s may i ndi cat e t umour or i nfl ammat ory mas s . Sys t emi c feat ures : exami ne for ext ra-i nt es t i nal mani fes t at i ons .
Crohn's disease Presentation

Di arrhoea 80% Abdomi nal pai n 50% (col i c and vomi t i ng s ugges t i l eal di s eas e) W ei ght l os s 70% Fever 40% Obs t ruct i ve s ympt oms (col i c, vomi t i ng) Rect al bl eedi ng 50% (commoner i n col oni c di s eas e, but i s pres ent i n 50% wi t h i l eal di s eas e; col oni c di s eas e i s as s oci at ed wi t h peri -anal di s eas e i n 30%) Ext ra-i nt es t i nal mani fes t at i ons s uch as eryt hema nodos um (510%), art hropat hy (10%), or eye compl i cat i ons (5%) (s ee t abl e P639) Sympt oms of anaemi a (i ron, B12, or fol at e defi ci ency) or nut ri t i onal defi ci enci es .
Examination
Exami ne nut ri t i onal s t at us and for evi dence of mal abs orpt i on. Exami ne for evi dence of i nt es t i nal obs t ruct i on (s t ri ct ures ). Fi s t ul ae may occur bet ween t he bowel and ot her organs (bl adder, vagi na). Toxi c megacol on (>6cm on AXR) occurs but i s much rarer t han i n UC. Bl oody di arrhoea i s occas i onal l y mas s i ve. P.639
Extra-intestinal manifestations of UC
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Related to disease activity

Apht hous ul cers Fat t y l i ver Eryt hema nodos um Peri pheral art hropat hy Epi s cl eri t i s Pyoderma gangrenos um Ant eri or uvei t i s Sacroi l i i t i s Ank. s pondyl i t i s Pri mary s cl eros i ng chol angi t i s Chol angi ocarci noma (us ual l y wi t h PSC)
Unrelated to disease activity

Extra-intestinal manifestations of Crohn's disease

Related to disease activity

Apht hous ul cerat i on (20%) Eryt hema nodos um (5%) Pyoderma gangrenos um (0.5%) Acut e art hropat hy (8%) Eye compl i cat i ons (5%)
o o o
Conjunct i vi t i s Epi s cl eri t i s Uvei t i s
Unrelated to disease activity

Sacroi l i i t i s (15%) Ank. s pondyl i t i s (4%) Li ver di s eas e (5%)

o o o o
Gal l s t ones common Chroni c act i ve hepat i t i s (2%) Ci rrhos i s (2%) Fat t y change (5%)
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Inflammat ory bowel disease 2
Inflammatory bowel
disease 2
Markers of a severe attack of IBD

>6 bl oody s t ool s /day Sys t emi cal l y unwel l : pyrexi a and t achycardi a Hb <10g/dl Al bumi n <30g/L Toxi c di l at at i on (col on >6cm)
Al t hough t he pres ence of t he above s ympt oms , s i gns , or fi ndi ngs i ndi cat e s evere i nfl ammat ory bowel di s eas e (UC or Crohn's ), i t s houl d be not ed t hat s evere Crohn's di s eas e may be pres ent i n t he abs ence of any of t he above.
Investigations
Blood tests. Anaemi a may be pres ent i f t he col i t i s i s acut e and fl ori d s evere and i ron-defi ci ency pi ct ure may be obs erved. W CC (neut rophi l i a) and pl at el et s . K may fol l ow s evere di arrhoea. There may al s o be an el ement of pre-renal dehydrat i on. In s evere col i t i s al bumi n oft en fal l s t o 2030g/L. ESR and CRP refl ect di s eas e act i vi t y, t hough are oft en not el evat ed i n di s t al (rect al ) di s eas e. They are us eful t o moni t or t herapy. Stool culture and microscopy Supine AXR erect CXR. To l ook for wal l t hi ckeni ng (moderat es evere) and mucos al oedema, wi t h l os s of haus t rat i on and col oni c di l at at i on (more s evere cas es ). Col oni c di amet er >6cm i ndi cat es t oxi c di l at at i on, wi t h ri s k of perforat i on. The ext ent of t he di s eas e can be i ndi rect l y as s es s ed; di s t al col i t i s i s oft en as s oci at ed
+
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wi t h proxi mal faecal l oadi ng. In t he acut e s t ages of a s evere at t ack abdomi nal fi l ms s houl d be performed dai l y, or t wi ce dai l y i f t here i s borderl i ne t oxi c di l at at i on. Free ai r under t he di aphragm on an erect CXR i ndi cat es perforat i on.
White cell scan.
111
Indi um-l abel l ed W BC accumul at e i n
areas of act i ve i nfl ammat i on, and are a us eful adjunct t o pl ai n AXR t o as s es s t he ext ent of act i ve di s eas e. Crohn's t ypi cal l y s hows pat chy upt ake and i nvol vement of t he s mal l bowel whi l e UC i s commonl y l i mi t ed t o col on.
Sigmoidoscopy colonoscopy. Bowel preparat i on i s unneces s ary and may caus e reddeni ng of t he mucos a. Fl exi bl e s i gmoi dos copy has a l ower ri s k of bact eraemi a and i s eas i er t han ri gi d s i gmoi dos copy. Non-s peci fi c fi ndi ngs s uch as hyperaemi a and cont act or s pont aneous bl eedi ng are common. Ul cerat i on s ugges t s acut e di s eas e; ps eudopol yps and at rophy of t he bowel mucos a i ndi cat e chroni c UC. Rect al bi ops y from t he pos t eri or wal l bel ow 10cm s houl d be t aken from al l pat i ent s (l es s ri s k of perforat i on).
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Inflammat ory bowel disease 3
Inflammatory bowel
disease 3
Management
Rehydrat e pat i ent wi t h i v fl ui ds and correct any el ect rol yt e i mbal ance (hypokal emi a i n part i cul ar). Inform and di s cus s t he pat i ent wi t h s urgi cal col l eagues , es peci al l y i f moderat es evere. The di fferent i al di agnos i s i s wi de (s ee above). Excl ude i nfect i ous col i t i s (normal s t ool mi cros copy and cul t ure) and s ys t emi c i nfect i ons as far as pos s i bl e. Avoi d ant i -mot i l i t y opi at e drugs (s uch as l operami de and codei ne) and ant i -s pas modi cs as t hey caus e proxi mal cons t i pat i on and may preci pi t at e paral yt i c i l eus and megacol on. Corticosteroids. Acut e at t acks of UC may res pond t o rect al s t eroi ds (e.g. Predfoam or Preds ol enema, 20mg 12 t i mes dai l y) es peci al l y i f di s eas e i s confi ned t o t he rect um. However s evere at t acks requi re i nt ravenous s t eroi ds (hydrocort i s one 100mg qds i v) unt i l remi s s i on i s achi eved. Crohn's di s eas e i s onl y t reat ed i f i t i s caus i ng s ympt oms . Severe Crohn's di s eas e s houl d be t reat ed wi t h i nt ravenous s t eroi ds (hydrocort i s one 100mg qds i v or predni s ol one 6080mg i v dai l y. Aminosalicylates. In pat i ent s wi t h UC, mes al azi ne s houl d be s t art ed (800mg bd or t ds oral l y) mes al azi ne foam enema (1g od pr) i n addi t i on t o s t eroi ds : t hey hel p i nduce, and mai nt ai n, remi s s i on
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aft er s t eroi ds are t ai l ed off. Us e Pent as a for s mal l bowel Crohn's .
Elemental diets. El ement al di et s are as effect i ve as s t eroi ds for t he t reat ment of Crohn's di s eas e. However, i t i s di ffi cul t t o get pat i ent s t o compl y. Other agents. UC: t here are few dat a t o s upport t he us e of az at hi opri ne, cycl os pori n, or met hot rexat e i n acut e at t acks . Two t ri al s have report ed t hat ni cot i ne pat ches s i gni fi cant l y i mprove s ympt oms and hel p t o i nduce remi s s i on of UC. Crohn's di s eas e: each of t hes e agent s has been t ri ed wi t h vari abl e s ucces s (t hey t ake up t o 16 weeks t o become effect i ve). Az at hi opri ne (2mg/kg dai l y) may be us eful for mai nt enance of remi s s i on. Antibiotics. There i s no evi dence t hat broad-s pect rum ant i bi ot i cs are us eful i n UC. Met roni dazol e i s us eful i n t he t reat ment of peri anal Crohn's fi s t ul ae. Ci profl oxaci n may al s o be us eful i n Crohn's di s eas e. Ot her ant i bi ot i cs s houl d onl y be us ed i f s peci fi cal l y i ndi cat ed and s houl d be cons i dered for pat i ent s devel opi ng t oxi c megacol on. Infl i xi mab i s bei ng i ncreas i ngl y us ed (wi t h s ucces s ) for peri anal and fi s t ul at i ng Crohn's di s eas e. Nutrition. There i s no evi dence for keepi ng t he pat i ent ni l by mout h. However a l ow res i due and earl y i ns t i t ut i on of TPN may be of benefi t , es peci al l y i f t he pat i ent i s l i kel y t o come t o s urgery. W hen t he pat i ent i s recoveri ng, s t ool -bul ki ng agent s (e.g. met hyl cel l ul os e) may be us ed t o adjus t s t ool cons i s t ency. Smoking. Encourage pat i ent s who s moke t o s t op, as t hi s enhances remi s s i on rat es .
P.643
Differential diagnosis of inflammatory
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bowel disease
Bacteria

Shi gel l a Sal monel l a E. c ol i Campl yobac t er Cl . di ffi c i l e TB Gonoc oc c us Chl amydi a Y ers i ni a Amoebi as i s s chi s t os omi as i s Is chaemi c col i t i s Lymphoma Trauma Radi at i on col i t i s
Parasites

Miscellaneous

Indications for surgery
Fai l ure of s ympt oms t o res ol ve aft er 5 days i s an i ndi cat i on for proct ocol ect omy (710 days i n s ome cent res ). Col oni c perforat i on, uncont rol l abl e bl eedi ng, t oxi c megacol on, andful mi nat i ng di s eas e requi res urgent proct ocol ect omy; ~30% of al l pat i ent s wi t h UC wi l l requi re a col ect omy at s ome s t age. Toxi c di l at at i on pri or t o t reat ment i s not an i ndi cat i on for s urgery(fai l ure of t he col oni c di amet er t o decreas e aft er 24 hours ). Thedevel opment of di l at at i on duri ng t reat ment i s an i ndi cat i on for s urgery. Surgery i n Crohn's di s eas e i s not curat i ve and i s onl y i ndi cat ed forperforat i on, obs t ruct i on, abs ces s format i on, and fi s t ul ae (ent erocut aneous or ent eroves i cal ). Recurrence rat e aft er s urgery i s hi gh.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Jaundic e: assessment
Jaundice: assessment
Jaundi ce requi res urgent i nves t i gat i on and di agnos i s . It may heral d t he ons et of a s evere hepat i t i s and acut e l i ver (renal ) fai l ure (s ee P658). It may i ndi cat e an obs t ruct i ve jaundi ce whi ch can be compl i cat ed by chol angi t i s and s ept i caemi a (P654).
History
Non-s peci fi c s ympt oms i ncl ude anorexi a, pruri t us , mal ai s e, l et hargy, drows i nes s , confus i on, or coma. Dark uri ne and pal e s t ool s may be feat ures of ei t her obs t ruct i ve jaundi ce or hepat i t i s . Col i cky RUQ pai n, previ ous bi l i ary col i c, or known gal l s t ones s ugges t s bi l i ary col i c (s ee P654). Fever, ri gors , abdomi nal pai n, and fl uct uat i ng jaundi ce s houl d rai s e t he s us pi ci on of chol angi t i s . Pai nl es s jaundi ce and wei ght l os s s ugges t pancreat i c mal i gnancy. Take a det ai l ed drug hi s t ory i ncl udi ng homeopat hi c or propri et ary preparat i ons . As k s peci fi cal l y about us e of paracet amol and al cohol . Ri s k fact ors for i nfect i ous hepat i t i s : bl ood t rans fus i on, i v drugs , homos exual , t ravel , et hni c ori gi n, i nges t i on of s hel l fi s h.
Examination
Not e t he degree of jaundi ce and l ook for s t i gmat a of chroni c l i ver di s eas e (s pi der naevi or t el angi ect as i a, pal mar eryt hema, Dupuyt ren's cont ract ures , et c.). Lymphadenopat hy may refl ect mal i gnancy. Hepat i c encephal opat hy res ul t s i n fal l i ng cons ci ous l evel , and l i ver fl ap. Not e t he BP and t he di as t ol i c careful l y: i t fal l s wi t h
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l i ver fai l ure. Ol i guri a or s hock may occur wi t h acut e l i ver fai l ure (s ee P658). Exami ne for pl eural effus i ons (may occur wi t h as ci t es ).
Exami ne t he abdomen for as ci t es , hepat omegal y, s pl enomegal y (port al hypert ens i on or i nt ravas cul ar haemol ys i s ), or mas s es .
Urgent investigations for jaundice (on the day of admission)

U&Es , LFTs Gl ucos e Excl ude renal fai l ure (hepat orenal s yndrome P394) DM i s common i n haemochromat os i s or pancreat i c carci noma; hypogl ycaemi a i n acut e l i ver fai l ure PT FBC i n s evere l i ver i njury or DIC pl at el et s (chroni c l i ver di s eas e wi t h hypers pl eni s m, mal ari a, or al cohol i s m, et c.); W BC (s eps i s , al cohol i c hepat i t i s ) Uri nal ys i s and s ept i c s creen Abs ence of bi l i rubi n i n t he uri ne i n a jaundi ced pat i ent (achol uri c) i ndi cat es haemol ys i s or a conjugat i on defect (Gi l bert 's ). Cul t ure uri ne, bl ood, and as ci t i c fl ui d CXR USS s can CT s can Tumour or met as t as es , effus i on as s oc. wi t h as ci t es If pat i ent i s unwel l or s ept i c, excl ude bi l i ary obs t ruct i on whi ch may requi re urgent decompres s i on. Not e s pl een s i ze and any mas s es i n t he l i ver Paracet amol P.645 If overdos e i s s us pect ed or pos s i bl e.
Non-urgent investigations for jaundice
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Vi ral s erol ogy Immunol ogy Ferri t i n, i ron, t rans ferri n
Ant i -HAIgM, HBs Ag and ant i -HBc, ant i -HCV, EBV or CMV s erol ogy. ANA, ant i -SM, AMA and Igs (CAH, PBC) ferri t i n i s s een i n any acut e i l l nes s , but may i ndi cat e haemochromat os i s ( i n al cohol i c l i ver hepat i t i s ).
Causes of jaundice

Vi ral hepat i t i s Al cohol i c hepat i t i s ci rrhos i s Drug-i nduced hepat i t i s (i ncl udi ng paracet amol ) End-s t age ci rrhos i s (al cohol i c, chroni c vi ral hepat i t i s , haemochromat os i s , W i l s on's , crypt ogeni c ci rrhos i s , et c.) Haemol yt i c anaemi a Gi l bert 's s yndrome Bi l i ary obs t ruct i on (s t ones or t urnover) Int rahepat i c chol es t as i s , pos t hepat i t i c (pri mary bi l i ary ci rrhos i s , pri mary s cl eros i ng chol angi t i s , s eps i s , drugs ) Aut oi mmune hepat i t i s Is chaemi c hepat i t i s Seps i s
Not e: EBV and CMV i nduced hepat i t i s /jaundi ce are rare i n adul t s .
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Viral hepat it is
Viral hepatitis
Charact eri zed by prodromal fl u-l i ke i l l nes s and very hi gh t rans ami nas e (up t o ~4000U/L) wi t h l i t t l e i ncreas e i n ALP. If t here i s no coagul opat hy, encephal opat hy, or renal fai l ure, s end t he pat i ent home, and awai t vi rol ogy res ul t s . Advi s e t he pat i ent t o avoi d al cohol . Arrange repeat LFTs and cl ot t i ng aft er 23 days , and s ee t he res ul t s (but not neces s ari l y t he pat i ent ). See t he pat i ent agai n wi t hi n a week. Ins t ruct t he pat i ent t o ret urn i f i ncreas i ngl y unwel l , or drows y. For ant i -HAV IgM pos i t i ve pat i ent s no s peci fi c t reat ment i s requi red but al l hous ehol d and s chool cont act s s houl d be i mmuni zed wi t h HAV vacci ne. Thi s repl aces previ ous gui del i nes t hat s t at e t hat cont act s s houl d recei ve normal human i mmunogl obul i ns . For HBs Ag pos i t i ve pat i ent s , vacci nat e fami l y. Fol l ow up for at l eas t 6 mont hs t o ens ure vi rus i s cl eared (HBs Ag -ve, HBeAb +ve). Prophyl act i c-s peci fi c hepat i t i s B i mmunogl obul i n (HBIG 500 uni t s i m) i s prot ect i ve i f gi ven wi t hi n 10 days of expos ure t o HBV: however onl y us e for pers ons wi t h cl ear expos ure t o HBs Ag-cont ami nat ed mat eri al (needl e-s t i ck or s exual cont act s who are Hbs Ab negat i ve). For ant i -HCV pos i t i ve pat i ent s , t ry and det ermi ne s ource. Check LFTs and HCV RNA for cont i nued vi ral repl i cat i on; s eek s peci al i s t advi ce.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Alc oholic hepat it is
Alcoholic hepatitis
Acut e hepat i t i s may be as ympt omat i c or pres ent wi t h naus ea, vomi t i ng, and anorexi a, rarel y RUQ pai n. Fever may refl ect s evere l i ver damage but i nfect i on needs t o be excl uded. Mos t pat i ent s who pres ent wi t h al cohol i c hepat i t i s have ci rrhos i s at pres ent at i on. The t erm al cohol i c hepat i t i s i s mi s nomer, as t he t rans ami nas es rarel y exceed 200U/L and are al ways <400U/L. The AST i s al ways hi gher t han t he ALT (t hi s i s i n cont ras t t o mos t ot her l i ver di s eas es ). Inves t i gat i ons : bi l i rubi n may be up t o 800M; al bumi n i s oft en reduced; a prol onged PT us ual l y s i gni fi es underl yi ng ci rrhos i s ; W BC wi t h l eft s hi ft may occur (even wi t hout i nfect i on), anaemi a and t hrombocyt openi a s ugges t s ci rrhos i s ; renal fai l ure (hepat orenal s yndrome) may occur i n s evere al cohol i c hepat i t i s . Screen for bact eri al or fungal i nfect i ons (bl ood, uri ne as ci t i c mi cros copy, and cul t ure. If cl i ni cal l y s us pect ed s t art broad-s pect rum ant i bi ot i cs (e.g. ci profl oxaci n 750mg bd po and amoxyci l l i n 1t ds po fl uconazol e (50100mg i v dai l y) as prophyl axi s agai ns t fungal i nfect i ons . Admi t mos t pat i ent s t o hos pi t al , unl es s mi l d (bi l i rubi n <50M, normal PT) or pat i ent i n abs t i nent envi ronment . Gi ve t hi ami ne (100200mg/day), fol i c aci d, and mul t i vi t ami ns . Moni t or and correct K+, Mg , PO 4
32+
and gl ucos e. St art a hi gh-cal ori e, hi gh-prot ei n
di et . Low-prot ei n di et s are cont rai ndi cat ed.
Del i ri um t remens or s evere agi t at i on may be managed
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wi t h di azepam or chl ordi azepoxi de po (P501). Avoi d i v chl ormet hi azol e as t hi s may caus e res pi rat ory depres s i on. Treat s ei zures i n t he s t andard way (P472, 500). P.647
Cal cul at e t he di s cri mi nant i ndex for al cohol i c hepat i t i s :
[e.g. bi l i rubi n = 340M, PT = 17s (cont rol 12s ) woul d s core (340 17) + (17-12) = 43]
A val ue >32 s houl d be t reat ed wi t h predni s ol one 40mg/day for 4 weeks . The onl y pract i cal cont rai ndi cat i on i s unt reat ed s eps i s . If t here i s doubt , t hen gi ve broad-s pect rum ant i bi ot i cs for 2448 hours pri or t o s t eroi ds .
Practice points
The AST l evel i s normal l y > t he ALT and bot h are us ual l y <200 U/L i n al cohol i c hepat i t i s . Never di agnos e al cohol i c hepat i t i s i f t he AST or ALT exceed 400 U/L Mus cl e i njury or exces s i ve exerci s e can i ncreas e bot h AST and ALT A very hi gh AST or ALT (i .e >10,000 U/L) s houl d s ugges t paracet amol (acet ami nophen) overdos e or i s chemi a.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Drug- induc ed hepat it is
Drug-induced hepatitis
Pat i ent s wi t h drug-i nduced jaundi ce s houl d be moni t ored t hree t i mes per week or admi t t ed for obs ervat i on, as many are s eri ous and may not res ol ve. W i t hdraw s us pect ed drug and obs erve. Look for ras h and eos i nophi l i a and excl ude ot her caus es (s ee t abl e). (For paracet amol overdos e, s ee P658). Drugs caus i ng jaundi ce are l i s t ed i n t abl e oppos i t e. Drugs caus i ng a ri s e i n t rans ami nas es , but rarel y caus i ng jaundi ce, are not l i s t ed. Al l drug-i nduced caus es of jaundi ce s houl d be report ed t o t he CSM (yel l ow pages at t he back of t he BNF ).
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Aut oimmune hepat it is
Autoimmune hepatitis
Thi s i s charact eri zed by el evat ed t rans ami nas es , up t o a few t hous and, us ual l y <2000U/L, ant i -s moot h mus cl e ant i body pos i t i ve, ANA pos i t i ve, and rai s ed IgG (pol ycl onal ). The t ot al gl obul i ns (t ot al prot ei n-al bumi n) s houl d be <35g/L i n normal s . Increas ed gl obul i n (>45g/L) s houl d al ways rai s e s us pi ci on of aut oi mmune hepat i t i s . Confi rm wi t h l i ver bi ops y. Treat ment : s t eroi ds (predni s ol one 3040mg od) azat hi opri ne (1mg/kg) as a s t eroi d-s pari ng agent once vi ral hepat i t i s has been excl uded (i .e. HBs Ag negat i ve). If t here i s fai l ure t o res pond i n a young pat i ent (<30 years ), cons i der W i l s on's di s eas e.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac holuric jaundic e
Acholuric jaundice
Thi s i s charact eri zed by t he abs ence of bi l i rubi n i n t he uri ne. Thi s may be caus ed by haemol yt i c anaemi a (previ ous hi s t ory, exces s uri nary urobi l i nogen, s pl enomegal y, ret i cul ocyt os i s , et c.) or a congeni t al di s order of conjugat i on (Gi l bert 's s yndrome, 2% of popul at i on). Fas t i ng (<400 cal ori es ) for 4872 hours (or i v ni cot i ni c aci d 50mg) wi l l i ncreas e s erum unconjugat ed bi l i rubi n i n pat i ent s wi t h Gi l bert 's (bi l i rubi n rarel y >80M).
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Sepsis
Sepsis
Any s evere i nfect i ons may caus e jaundi ce (i ncl . pneumoni a). Mos t s evere wi t h i nt ra-abdomi nal s eps i s . LFTs may be chol es t at i c, or charact eri zed by a predomi nant ri s e of t he bi l i rubi n onl y. Excl ude ot her caus es and t reat i nfect i on wi t h ant i bi ot i cs s urgi cal drai nage.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Isc haemic hepat it is
Ischaemic hepatitis
Presentation
Occurs wi t h s i gni fi cant hypot ens i on or hepat i c art eri al occl us i on. Predi s pos i ng fact ors i ncl ude conges t i ve cardi ac fai l ure hypoxi a. In i t s mi l des t form i t mani fes t s as mi l dl y deranged LFTs (hepat i t i c pi ct ure, PT) i n a pat i ent wi t h CCF and i n i t s mos t s evere form may pres ent as acut e l i ver P.649 fai l ure. Look for hypoxi a, hypot ens i on (may have normal i zed by t he t i me of as s es s ment ), s i gns of art eri opat hy (abdomi nal brui t s from hepat i c art eri al occl us i on), and s i gns of ri ght vent ri cul ar fai l ure. May caus e confus i on encephal opat hy. Excl ude ot her caus es of hepat i t i s (P644).
Management
Mos t wi l l res pond t o correct i on of t he underl yi ng aet i ol ogy. Correct hypot ens i on (s ee P257) and gi ve oxygen t o correct hypoxi a. If hepat i c art ery or coel i ac axi s are occl uded prognos i s i s poor, and depends on t he ext ent of hepat i c necros i s . Us ual l y age and ext ent of di s eas e precl ude s al vage s urgery. Di s cus s wi t h s peci al i s t cent re. If s i gns of s evere (acut e) l i ver fai l ure pres ent , s ee P662 for gui dance. Mos t pat i ent s are not fi t enough for l i ver t rans pl ant at i on.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Obst ruc t ive jaundic e
Obstructive jaundice
See bi l i ary obs t ruct i on, P654.
Common drugs that cause jaundice

Hepatitic Paracet amol Ri fampi ci n Al l opuri nol NSAIDs Hal ot hane Met hyl dopa Hydral azi ne Is oni az i d Phenyt oi n Cholestatic Chl orpromaz i ne Fl ucl oxaci l l i n Azat hi opri ne Capt opri l Co-amoxi cl av Peni ci l l ami ne Eryt hromyci n Anabol i c s t eroi ds Oral cont racept i ve Mixed Sul phonami des Sul phas al azi ne Carbamazepi ne Daps on Rani t i di ne Ami t ri pt yl i ne Ni t rofurant oi n Co-amoxi cl av
Page 1088
> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Gallst one disease
Gallstone disease
Gal l s t one di s eas e affect s 1020% of t he popul at i on. The s t ones may be predomi nant l y chol es t erol (>80%), pi gment s t ones (<25% chol es t erol ; mul t i pl e, i rregul ar, fri abl e), or mi xed (facet ed, cal ci um cont ai ni ng). The majori t y are as ympt omat i c and di agnos ed i nci dent al l y.
Complications of gallstones

Bi l i ary col i c Chol ecys t i t i s empyema and gangrene of gal l bl adder Acut e pancreat i t i s (P479) GB fi s t ul a, gal l s t one i l eus Obs t ruct i ve jaundi ce Chol angi t i s s ept i caemi a or l i ver abs ces s es Perforat i on and peri t oni t i s
Biliary colic Presentation

Abdomi nal pai n (RUQ) radi at i ng t o epi gas t ri um, back, or s houl ders as s oci at ed wi t h naus ea and vomi t i ng. At t acks commonl y fol l ow a heavy meal and pas s s pont aneous l y. Di fferent i al di agnos i s i ncl udes acut e MI, l eaki ng aort i c aneurys m, pept i c ul cer, i nt es t i nal obs t ruct i on or i s chaemi a, pancreat i t i s , renal col i c, and pneumoni a.
Investigations
USS t o det ect t he s t one and gal l bl adder di s t ent i on. Uri ne mi cros copy, CXR, ECG wi l l hel p excl ude ot her condi t i ons .
Management
Pai n rel i ef (pet hi di ne 50100mg i m q4h + prochl orperaz i ne 12.5mg i m q8h); avoi d morphi ne.
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Laparas copi c chol ecys t ect omy i n t he l onger t erm.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac ut e c holec yst it is
Acute cholecystitis
Presentation
Sudden ons et s evere RUQ pai n and s ympt oms s i mi l ar t o bi l i ary col i c wi t h fever and pers i s t i ng s ympt oms . Pers i s t ent vomi t i ng s ugges t s a bi l e duct s t one. Phys i cal s i gns i ncl ude fever, t achycardi a, s weat i ng, RUQ t endernes s , and peri t oni s m, es peci al l y i n i ns pi rat i on (Murphy's s i gn) pal pabl e gal l bl adder. Jaundi ce (~33%) s ugges t s obs t ruct i on of CBD. Ac al c ul ous c hol ec ys t i t i s i s s een i n el derl y or pat i ent s wi t h co-exi s t i ng di s eas e or t rauma, i n t he ITU, and pat i ent s on TPN. Mort al i t y i s hi gh (up t o 50%) i f not di agnos ed earl y.
Investigations
Bl ood t es t s USS AXR HIDA Scan W CC i s us ual . LFTs s how bi l i rubi n, and chol es t at i c l i ver funct i on t es t s ; amyl as e Shoul d demons t rat e gal l s t ones or bi l i ary s l udge t hi ckeni ng of gal l bl adder wal l Gal l s t ones vi s bl e i n ~10% of pat i ent s . Local peri t oni t i s may produce a s ent i nal l oop Us i ng
99
Tc-l abel i s us ual l y di agnos t i c.
Management
NBM and i v fl ui ds ; i ns ert an NG-t ube i f t here i s s evere vomi t i ng. Ant i bi ot i cs s houl d cover ent eri c organi s ms and
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Ent eroc oc c us (e.g. cefuroxi me 750mg i v q8h + met roni dazol e 500mg i v q8h).
Earl y l aparos copi c chol ecys t ect omy i s t he t reat ment of choi ce. Compl i cat i ons i ncl ude perforat i on, gal l s t one i l eus , or fi s t ul a.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Biliary obst ruc t ion
Biliary obstruction
Bi l i ary obs t ruct i on or apparent bi l i ary obs t ruct i on wi l l be as s oci at ed wi t h ei t her a di l at ed or non-di l at ed bi l i ary s ys t em and t he pat i ent may be ei t her s ept i c or as ept i c. Bi l i ary di l at at i on i n pat i ent s wi t h mechani cal bi l i ary obs t ruct i on may not al ways be apparent on USS.
Presentation

Jaundi ce (pai nful or pai nl es s ) fl uct uat i on RUQ pai n t endernes s Fever (i ndi cat es i nfect i on or chol ecys t i t i s ) It chi ng Dark uri ne pal e s t ool s (not very us eful i n pract i ce) Sept i c s hock.
Investigations
Bl ood W CC i ndi cat es s eps i s . U&Es may i ndi cat e renal t es t s fai l ure or pre-renal uraemi a. LFTs s how bi l i rubi n, ALP, and -GT; amyl as e wi t h concomi t ant pancreat i t i s ; t rans i ent ALT, AST wi t h pas s age of a s t one and pers i s t ent i n chol angi t i s (us ual l y 400U/L; hi gher s ugges t s hepat i t i s ). Bl ood cul t ures USS and CRP mandat ory. Thi s i s mandat ory, and s houl d be performed wi t hi n 12 hours i f pos s i bl e, t o demons t rat e t he pres ence of di l at ed duct s gal l s t ones . Pos t chol ecys t ect omy AXR ERCP s l i ght di l at at i on (~0.8cm) of CBD i s normal . Aerobi l i a may i ndi cat e a gas -formi ng organi s m or recent i ns t rument at i on. There may be l ocal i zed i l eus . Shows s t ones i n CBD and al l ows exami nat i on of GI t ract and ampul l a t o excl ude ot her pat hol ogy. Gi ve
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MRCP
broad-s pect rum ant i bi ot i cs i f i nt ervent i on i s pl anned. Magnet i c res onance chol angi o panereat ography i s a very accurat e noni nvas i ve i nves t i gat i on.
Poor prognostic features

(depend on the cause)

El derl y (>65 years ) Shock Renal fai l ure Chol angi t i s wi t h ci rrhos i s , l i ver abs ces s , or hi gh mal i gnant s t ri ct ure Chol angi t i s fol l owi ng t rans hepat i c percut aneous chol angi ography Acut e pancreat i t i s .
Management
See al gori t hm.
Anal ges i a (pet hi di ne 50100mg i mq4h), NBM, i v fl ui ds . Ant i bi ot i cs (e.g. cefot axi me or ci profl oxaci n + amoxyci l l i n) i f s ept i c. Emergency decompres s i on of t he bi l i ary s ys t em by
o o o
ERCP Percut aneous drai nage Surgi cal decompres s i on.
Fol l ow up wi t h LFTs , CRP, and t emperat ure. P.655
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Repeat ERCP when wel l t o excl ude mi s s ed s t ones or furt her anat omi c abnormal i t y. Repeat USS or CT l i ver s can t o l ook for hepat i c abs ces s es .
Causes of biliary obstruction

Mechanical obstruction

Gal l s t ones chol angi t i s Mal i gnancy (pancreat i c carci noma, nodes , s econdary depos i t s , chol angi ocarci noma) Pos t -operat i ve s t ri ct ure Cavernous t rans format i on of port al vei n Paras i t i c i nfect i on (e.g. onchocerci as i s ) Pri mary s cl eros i ng Pri mary bi l i ary ci rrhos i s Chol es t at i c drug react i on
Intra-hepatic Cholestasis

Management al gori t hm for bi l i ary obs t ruct i on NB: In ci rrhos i s t here may be no duct di l at at i on wi t h bi l i ary obs t ruct i on.
Page 1095
> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Asc it es
Ascites
Presentation
The pat i ent may pres ent wi t h s ympt oms due t o t he fl ui d (abdomi nal di s t ens i on, wei ght gai n, abdomi nal pai n), t he underl yi ng caus e (jaundi ce, haemat emes i s , fever, or ni ght s weat s , frot hy uri ne due t o prot ei nuri a), or compl i cat i on of t he as ci t es (dys pnoea, anorexi a, refl ux oes ophagi t i s , herni ae, pl eural effus i ons , s crot al or l eg oedema, peri t oni t i s ). As k s peci fi cal l y about al cohol , ri s k fact ors for chroni c l i ver di s eas e, GI bl eedi ng (port al hypert ens i on), previ ous pancreat i t i s , ri s k fact ors for TB, cardi ac hi s t ory, exerci s e t ol erance, and mens t rual hi s t ory (?ovari an mal i gnancy).

Ovari an cys t Pregnancy Abdomi nal mas s Obes i t y (s i mpl e or met abol i c)
Investigations
Bl ood U&Es , gl c, FBC, PT, LFTs , bl ood cul t ures . Amyl as e
t es t s As ci t i c t ap An as ci t i c t ap s houl d be carri ed out i n al l pat i ent s (s ee P924) unl es s a di agnos i s of mal i gnant as ci t es i s cert ai n. Inocul at e bl ood cul t ure bot t l es and s end fl ui d i n Imagi ng s t eri l e pot for mi cros copy and W BC Pl ai n AXR s hows a gl as s ground pat t ern wi t h l os s of ps oas s hadow. USS can det ect as l i t t l e as 30 ml . Not e t he s i ze and t ext ure of t he l i ver and s pl een, check pat ency of hepat i c vei ns . CT s can may be
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Uri ne
requi red Uri ne s odi um (ci rrhot i c as ci t es ), 24 hour prot ei n.
Management
Admi t al l pat i ent s wi t h s ympt omat i c as ci t es . Treat t he underl yi ng caus e.
Ci rrhot i c as c i t es : do not s t art di uret i cs i f t here i s renal i mpai rment . Sal t res t ri c t t o 90mmol /day. Parac ent es e i f t ens e or moderat e as ci t es : drai n al l as ci t es as qui ckl y as pos s i bl e (maxi mum 25L i n 5 hours ), and t hen gi ve 68g al bumi n per l i t re of as ci t es removed as 20% al bumi n. St art s pi ronol ac t one upt o 100mg/day i ncreas i ng t o 400mg/day. Add Frus eni de 40mg/day i f res pons e i s poor. If t here i s renal i mpai rment (creat i ni ne >140M) gi ve an ext ra c ol l oi d and c rys t al l oi d vol ume c hal l enge (e.g. 500ml gel ofus i ne, over 1 hour fol l owed by 1L N s al i ne over 4 hours ). There i s no hurry t o commence di uret i cs ; s t art once s et t l ed aft er paracent es i s . More harm t han good i s done by di ures i ng pat i ent s who are hypovol aemi c. Mal i gnant as c i t es : t reat ment i s pal l i at i ve, and may i ncl ude t ot al paracent es i s t o make t he pat i ent more comfort abl e. Speci al i s t advi ce s houl d be s ought for fut ure management of t he mal i gnancy. P anc reat i c as c i t es : us ual l y as s oci at ed wi t h a pancreat i c ps eudocys t and s houl d be managed i n cons ul t at i on wi t h
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s urgi cal col l eagues . P.657
Spont aneous bac t eri al peri t oni t i s occurs i n up t o ~15% of pat i ent s admi t t ed wi t h ci rrhot i c as ci t es , and i s frequent l y as ympt omat i c. It rarel y, i f ever, occurs i n non-ci rrhot i c as ci t es . The ri s k i s i ncreas ed wi t h l ow as ci t i c prot ei n. >90% wi l l yi el d +ve as ci t i c cul t ures i f i nocul at ed i nt o bl ood cul t ure bot t l es . Al l as ci t i c fl ui d s houl d be i nocul at ed i nt o BC bot t l es at t he beds i de. Di agnos i s : as ci t i c W CC >250PMN/mm . If cul t ure +ve but acs i t i c W BC l ow, repeat t ap for mi cros copy and t reat i f W BC >250PMN/mm . Treat wi t h broad-s pect rum ant i bi ot i c for ent eri c organi s ms and G +ve cocci (e.g. cefot axi me). Sus pect TB as ci t es i f t here i s a predomi nant l ymphocyt os i s .
3 3
Causes of ascites

Ci rrhos i s and port al hypert ens i on Mal i gnant as ci t es Conges t i ve cardi ac fai l ure Pancreat i c as ci t es Hepat i c venous obs t ruct i on Nephrot i c s yndrome Hypot hyroi di s m Infect i on (e.g. TB)
I t does not oc c ur w i t h port al vei n t hrombos i s , c ongeni t al hepat i c fi bros i s , or ot her c aus es of non-c i rrhot i c port al hypert ens i on
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac ut e liver failure: assessment
Acute liver failure:
assessment
Acut e l i ver fai l ure (ful mi nant hepat i c fai l ure) i s defi ned as a pot ent i al l y revers i bl e s evere l i ver i njury, wi t h an ons et of hepat i c encephal opat hy wi t hi n 8 weeks of t he appearance of t he fi rs t s ympt oms and i n t he abs ence of pre-exi s t i ng l i ver di s eas e. A more recent cl as s i fi cat i on i s Hyper-acut e l i ver fai l ure: encephal opat hy wi t hi n 7 days of jaundi ce Acut e l i ver fai l ure: encephal opat hy wi t hi n 828 days of jaundi ce Sub-acut e l i ver fai l ure: encephal opat hy wi t hi n 2984 days of jaundi ce.
Presentation
The hi s t ory may poi nt t o a caus e (s ee t abl e P660). As k s peci fi cal l y about recent vi ral i l l nes s es , paracet amol , al cohol , and drug hi s t ory. Si gns of chroni c l i ver di s eas e are t ypi cal l y not pres ent (unl es s acut e-on-chroni c). Spl enomegal y does not occur. If pres ent cons i der an acut e pres ent at i on of W i l s on's di s eas e, aut oi mmune chroni c act i ve hepat i t i s , or l ymphoma. Frequent l y t he pres ent i ng feat ure i s a compl i cat i on of l i ver fai l ure. Pat i ent s wi t h paracet amol overdos e may pres ent wi t h s evere abdomi nal pai n and ret chi ng. Encephalopathy. Pres ent i n al l cas es (by defi ni t i on) and convent i onal l y di vi ded i nt o 4 grades (s ee t abl e). Cerebral oedema i s heral ded by s pi kes of hypert ens i on, dys conjugat e eye-movement s , papi l l oedema i s rare. Unl es s t reat ed t hi s progres s es t o decerebrat e pos t uri ng (back, arms and l egs ri gi d, hands i n fl exi on,
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opi s t honus ), and brai ns t em coni ng.
Grades of hepatic encephalopathy

Grade 1 Grade 2 Grade 3 Grade 4 Drows y but coherent ; mood change Drows y, confus ed at t i mes , i nappropri at e behavi or Very drows y and s t uparos e but rous abl e; al t ernat i vel y res t l es s , s creami ng Comat os e, barel y rous abl e
Metabolic disturbances. Hypogl ycaemi a and hyponat raemi a are common. Ot her abnormal i t i es i ncl ude K , res pi rat ory al kal os i s , and s evere hypophos phat aemi a. Lact i c aci dos i s carri es a poor prognos i s . Cardiovascular abnormalities. Spi kes of s ys t ol i c hypert ens i on may refl ect cerebral oedema. The di as t ol i c BP fal l s as di s eas e progres s es wi t h a vas odi l at ed hyperdynami c ci rcul at i on (SVR, cardi ac out put ). Respiratory failure. Hypoxi a i s rel at i vel y common and may be wors ened by l ocal i zed i nfect i on, as pi rat i on, or at el ect as i s . Non-cardi ogeni c pul monary oedema i s s een i n ~10%. Renal failure. Indi cat es a wors e prognos i s wi t h cons ervat i ve t reat ment , and may be due t o hepat orenal s yndrome (s ee P394) or ATN (paracet amol ). Bleeding problems. The PT i s prol onged and refl ect s t he progres s i on of t he di s eas e. Low-grade DIC may occur wi t h bl eedi ng from t he GI t ract from gas t ri t i s or el s ewhere. Sub-conjunct i val haemat oma i s common i n paracet amol -i nduced l i ver fai l ure.
+
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Infections. Bact eri al and fungal i nfect i ons (s ept i caemi a, pneumoni a, peri t oni t i s , UTIs ) are more frequent due t o i mpai red neut rophi l funct i on.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac ut e liver failure: invest igat ions
investigations
Investigations
Bl ood t es t s (dai l y) U&Es , gl ucos e (and 2 hourl y BM s t i x), FBC, PT, LFTs (al bumi n i s us ual l y normal on admi s s i on unl es s acut e-on chroni c), phos phat e, art eri al bl ood gas es . Bl ood group and cros s mat ch on admi s s i on. Bl ood t es t s (for di agnos i s ) Vi ral s erol ogy (A IgM, HBs Ag, HBcore Ab IgM, del t a i n HBs Ag +ve, EBV, CMV, HSV), drug s creen (es p. paracet amol ), pl as ma caerul opl as mi n (i f <50 years 24 hour uri ne copper). Bact eri ol ogy Bl ood cul t ures , uri ne, and s put um MC&S dai l y (i ncl . fungal cul t ures ). Throat and vagi nal s wabs . USS (l i ver) To as s es s hepat i c vei ns , port al vei n pat ency, s i ze (i f pos s i bl e), s pl een s i ze, nodes (l ymphoma). ECG/CXR EEG Li ver bi ops y Repeat CXR dai l y (i nfect i on/ARDS). May be hel pful i n t he as s es s ment of hepat i c encephal opat hy t hough not wi del y us ed. Rarel y neces s ary but wi l l excl ude underl yi ng mal i gnant i nfi l t rat i on or ci rrhos i s where t he di agnos i s i s i n doubt . The t rans -jugul ar approach i s preferred as i t carri es l ower ri s k of haemorrhage (P930).
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Causes of acute liver failure in the UK

Drug-i nduced P649) Paracet amol OD (P828). Les s commonl y phenyt oi n, val proat e, peni ci l l i ns , MAOIs , ecs t as y, s ul phas al azi ne, di s ul phi ram, ket oconazol e Vi ral hepat i t i s (36%) Hepat i t i s A, B, del t a co-i nfect i on i n HBs Ag (s ee P646) Toxi ns +ve carri er, NANB ( not HCV i n UK), E, l es s commonl y CMV, EBV, and HSV Amani t a phal l oi des (t hes e mus hrooms are avai l abl e i n t he UK), herbal remedi es , CCl 4 Mal i gnancy Vas cul ar Lymphoma, mal i gnant i nfi l t rat i on BuddChi ari s yndrome, veno-occul i ve di s eas e, i s chaemi c i njury (s hock and hypot ens i on) Mi s cel l aneous W i l s on's (not s t ri ct l y acut e, as many are ci rrhot i c, but i n al l cl i ni cal res pect s s i mi l ar), aut oi mmune hepat i t i s , mal i gnant hypert hermi a (i ncl . ecs t as y), fat t y l i ver of pregnancy, PET/HELLP s yndrome, Reye's s yndrome
hepat i t i s (58%) (s ee hal ot hane, i s oni azi d, s ul phonami des , NSAIDs ,
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac ut e liver failure: management
management
The mai ns t ay of t reat ment i s s upport unt i l t he acut e i ns ul t res ol ves . If a pat i ent ful fi l s cri t eri a for l i ver t rans pl ant at i on (s ee t abl e) on or duri ng t hei r admi s s i on t hey s houl d be referred t o a cent re where l i ver t rans pl ant at i on i s avai l abl e (t hes e are l i s t ed on P961). I t i s vital t o di s c us s al l c as es of s evere l i ver i njury w i t h one of t he regi onal l i ver t rans pl ant c ent res even t hough pat i ent s may not ful fi l t he cri t eri a above, as i t general l y t akes up t o 48 hours t o obt ai n an emergency graft , and del ay i n referral can res ul t i n fai l ure t o procure an adequat e graft . Al l of t hes e cent res are al s o experi enced i n managi ng t hi s s eri ous i l l nes s . None of t he known caus es of acut e l i ver fai l ure res pond wel l t o medi cal t herapy. St eroi ds may be of benefi t i n pat i ent s wi t h l ymphoma or aut oi mmune hepat i t i s , but by t he t i me mos t pat i ent s pres ent i t i s us ual l y t oo l at e. Al l pat i ent s s houl d be admi t t ed t o a hi gh dependency or i nt ens i ve t herapy uni t .
Paracetamol overdose. Gi ve N-acet yl cys t ei ne (s ee P828). The benefi t of N-acet yl cys t ei ne may be evi dent up t o 48 hours and pos s i bl y l onger. General measures. Nurs e s upi ne (not 45 as oft en s t at ed). Keep i n a peaceful envi ronment . Ins ert an art eri al l i ne and CVP l i ne for moni t ori ng and i f pos s i bl e a pul monary art ery cat het er (SwanGanz ) t o opt i mi ze t he haemodynami c s t at us . Coagulopathy. The PT i s t he bes t i ndi cat or of l i ver funct i on. Avoi d gi vi ng FFP unl es s t here i s bl eedi ng or unl es s undergoi ng s urgi cal procedures or l i ne i ns ert i on. Fact or concent rat es may preci pi t at e DIC. The PT may
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ri s e and fal l preci pi t ous l y and s houl d be meas ured t wi ce dai l y i f det eri orat i ng. Gi ve vi t ami n K 10mg once onl y i v. Gi ve pl at el et s upport i f t hrombocyt openi c and bl eedi ng.
Cerebral oedema. ICP moni t ori ng i s us ed i n s ome cent res . If s i gns of cerebral oedema are pres ent t hen gi ve manni t ol (100ml of 20% manni t ol ); i f i n renal fai l ure, wat ch for fl ui d overl oad. Hypervent i l at i on decreas es ICP at t he expens e of cerebral bl ood fl ow and s houl d be avoi ded. Pros t acycl i n and N-acet yl cys t ei ne may decreas e ICP. Hypert ens i on i s al mos t al ways s econdary t o rai s ed ICP and s houl d be t reat ed wi t h manni t ol as above; ant i hypert ens i ve drugs may preci pi t at e brai ns t em coni ng. There i s no evi dence t hat gi vi ng l act ul os e or neomyci n affect s prognos i s or prevent s grade 34 encephal opat hy. Fl umazeni l i s report ed t o i mprove encephal opat hy but does affect out come. Sei zures s houl d be t reat ed i n t he us ual way (P472). Haemodynamic support. Correct hypovol aemi a wi t h col l oi d or bl ood but avoi d fl ui d overl oad. Pers i s t ent hypot ens i on may res pond t o noradrenal i ne or vas opres s i n i nfus i on. Metabolic changes. Moni t or gl uc os e (BM s t i x) 2 hourl y, and gi ve 10% or 50% gl ucos e t o keep gl c >3.5mM. Moni t or s erum phos phat e (oft en very l ow), repl ace wi t h i v (918mmol /24 hours ) i f l es s t han 0.4mM. Nut ri t i on : an i l eus i s us ual pres ent , s o mos t feedi ng has t o be parent eral . Renal failure. See P394. Moni t or renal funct i on (renal fai l ure occurs i n ~70% cas es ). Treat by haemodi afi l t rat i on rat her t han haemodi al ys i s . P.663
Respiratory support. Moni t or oxygen s at urat i ons
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cont i nuous l y and gi ve oxygen by mas k i f SaO 2 < 90%. Vent i l at e when grade 3 or 4 coma (avoi d ET t ube t i es whi ch compres s t he IJ vei ns ).
Infection. St art prophyl act i c ant i bi ot i cs and ant i -fungal s (e.g. cefot axi me and fl uconazol e). Wilson' s disease. Cons i der peni ci l l ami ne and i v vi t ami n E.
Indications for liver transplantation

Paracetamol OD with arterial pH <7.3 (admission) Grade 3 or 4 encephalopathy and PT >100s or i n t he abs enc e of above ALL 3 of the following or

PT >100s Creat i ni ne >300M Grade 34 encephal opat hy PT >50s Jaundi ce t o encephal opat hy >7 days Age <10 years or >40 years Bi l i rubi n >300M Unfavorabl e aet i ol ogy (i .e. non-paracet amol , not Hep A, not Hep B)
Any 3 of the following

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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac ut e- on- c hronic liver failure
Acute-on-chronic liver failure

Pat i ent s wi t h chroni c l i ver di s eas e from ci rrhos i s may pres ent wi t h acut e decompens at i on due t o a vari et y of caus es (s ee t abl e).
Clinical features
As k s peci fi cal l y for a hi s t ory of previ ous hepat i t i s , jaundi ce, al cohol i nt ake, previ ous drug hi s t ory. W ei ght l os s may poi nt t o a mal i gnancy. Pruri t i s , pi gment at i on, and xant hel as ma i n a young woman may be due t o pri mary bi l i ary ci rrhos i s . Exami ne for evi dence of l ong-s t andi ng l i ver dys funct i on: l euconychi a, pal mar eryt hema, cl ubbi ng, s pi der naevi , gynaecomas t i a, and s mal l t es t es . Spl enomegal y and di s t ended abdomi nal vei ns s i gni fy port al hypert ens i on. Exami ne s peci fi cal l y for feat ures of decompens at i on: encephal opat hy (confus i on, l i ver fl ap), as ci t es , oedema, jaundi ce, or fever.
Causes of acute decompensation of chronic liver disease
Int ercurrent i nfect i on

o o o
s pont aneous bact eri al peri t oni t i s pneumoni a s ki n i nfect i ons
Acut e GI haemorrhage Addi t i onal hepat ot oxi c i ns ul t
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al cohol i c bi nge acut e vi ral hepat i t i s hepat ot oxi c drugs s edat i ves /narcot i cs di uret i cs hypogl ycaemi a el ect rol yt e di s t urbance
Drugs
o o
Met abol i c derrangement

o o
Major s urgery Cons t i pat i on Progres s i on of di s eas e
Investigations
Unl es s t he caus e for t he decompens at i on and t he di agnos i s for t he pre-exi s t i ng l i ver di s eas e are known t he pat i ent warrant s ful l i nves t i gat i on (s ee P644).
Management
As for pat i ent s wi t h acut e l i ver fai l ure, t he mai ns t ay of t reat ment i s s upport i ve. The deci s i on on how aggres s i vel y you manage t he pat i ent (i .e. admi s s i on t o ICU, i nvas i ve moni t ori ng, et c.) depends on t he previ ous di agnos i s , on a revers i bl e el ement t o t he acut e i ns ul t , and whet her t he pat i ent i s a candi dat e for l i ver t rans pl ant at i on. They have l es s capaci t y t o regenerat e t hei r hepat ocyt es and prognos i s of pat i ent s requi ri ng mechani cal vent i l at i on and haemodynami c s upport i s very poor wi t hout a t rans pl ant .
Sepsis
St art bl i nd t reat ment i f t here i s a fever or i ncreas ed W CC (e.g. cefot axi me) and be gui ded by cul t ure res ul t s (e.g. a t hi rd-generat i on cephal os pori n, bact eri al peri t oni t i s , s ee P657). Add i v fl uconazol e as an ant i -fungal agent .
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Hepat ic enc ephalopat hy
Hepatic encephalopathy
Hepat i c encephal opat hy i s a neurops ychi at ri c di s t urbance of cogni t i ve funct i on i n a pat i ent wi t h acut e-on-chroni c l i ver di s eas e (P664). It i s s ai d t hat pat i ent s wi t h ci rrhos i s do not devel op cerebral oedema, al t hough we have s een ext ens or pos t uri ng i n al cohol i c ci rrhot i cs fol l owi ng vari ceal haemorrhage. Cl i ni c al l y t here i s us ual l y al t ered cons ci ous l evel , as t eri xi s (l i ver fl ap), abnormal EEG, i mpai red ps ychomet ri c t es t s , and an el evat ed art eri al ammoni a concent rat i on. Pat i ent s may pres ent wi t h Parki ns oni an feat ures . However i n pat i ent s wi t h chroni c l i ver di s eas e, i t may be s ub-cl i ni cal wi t h s ubt l e changes i n awarenes s or at t ent i on s pan. It i s graded as on P658. T reat ment : t he ai m of t reat ment i s t o i mprove morbi di t y.

Excl ude ot her caus es of confus i on (s ee P496). Di et ary res t ri ct i on i s cont rovers i al , and may be harmful i n mal nouri s hed pat i ent s . Ens ure adequat e cal ori e i nt ake. Gi ve l act ul os e: t hi s s emi -s ynt het i c di s acchari de i s poorl y abs orbed. It i s di ges t ed i n t he l arge bowel and undergoes ferment at i on. Thi s al t ers faecal pH and ni t rogen ut i l i zat i on by bowel fl ora. Lact i t ol has a s i mi l ar act i on t o l act ul os e but has fewer s i de-effect s . Phos phat e enemas hel p t o purge t he l arge bowel . Mos t us eful i n t he cont ext of an acut e food l oad (e.g. GI bl eedi ng).
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Liver absc esses
Liver abscesses
Presentation
Commonl y pres ent wi t h fever and ni ght s weat s , wei ght l os s , or ri ght upper quadrant or i nt ercos t al pai n. The underl yi ng caus e (e.g. appendi ci t i s ) may be s i l ent or barel y not i ced. As k about recent abdomi nal pai n, al t ered bowel habi t , di arrhoea, bi l i ary col i c, bl ood PR, or i nfl ammat ory bowel di s eas e. The t ravel hi s t ory, occupat i on (farmi ng i s a ri s k fact or for amoebi as i s ), or cont act wi t h i nfect ed pers ons (TB) may hel p. Exami ne for jaundi ce, hepat omegal y, pl eural effus i ons (commonl y ri ght -s i ded), i nt ercos t al t endernes s (charact eri s t i c of amoebi c abs ces s es ), abdomi nal mas s es (t umour or i nfl ammat ory mas s ), andl ymphadenopat hy. Perform a rect al exami nat i on for pel vi c t umour. Severe i nfect i on may be as s oci at ed wi t h s ept i c s hock (P270).
Causes
Pyogeni c organi s ms (appendi ci t i s , di vert i cul i t i s , carci noma, bi l i ary) Amoebi c abs ces s ( Ent amoeba hi s t ol yt i c a ) Hydat i d cys t ( Ec hi noc oc c us granul os us ) TB (very rare)
Investigations
U&Es (renal i mpai rment wi t h s eps i s ). LFTs (non-s peci fi c, t end t o be chol es t at i c; may be normal
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wi t h amoebi c abs ces s ).
Prot hrombi n t i me may be prol onged wi t h mul t i pl e abs ces s es . FBC (l eucocyt os i s , eos i nophi l i a, non-s peci fi c anaemi a). Bl ood cul t ures , CRP, ESR. Amoebi c and hydat i d s erol ogy. St ool may cont ai n amoebi c cys t s or veget at i ve forms . CXR (l ooki ng for effus i on, or pul monary TB). USS of l i ver, bi l i ary t ree, and abdomen (i l i ac fos s ae i n part i cul ar) CT s can wi t h cont ras t , l ooki ng for mas s es . Bot h pyogeni c and amoebi c abs ces s es t end t o be t hi ck wal l ed; hydat i d cys t s are t hi n wal l ed and t here may be daught er cys t s . Sol i d t umours are echodens e but may have necrot i c hypodens e cent res . Gal l i um s can (or i ndi um-111 l abel l ed W BC s can) wi l l s how up pyogeni c foci i n t he l i ver and el s ewhere (e.g. t ermi nal i l ei t i s ); amoebi c abs ces s es do not t ake up t he l abel . As pi rat e any l arge abs ces s es and s end for gram s t ai n, and cul t ure. If t here i s a s us pi ci on of hydat i d di s eas e as pi rat i on i s cont rai ndi cat ed.
Management
As pi rat e any l arge abs ces s es under USS. It i s poi nt l es s t o t ry and drai n mul t i pl e abs ces s es . If t here i s a cont i nui ng i nt ra-abdomi nal s ource i t i s vi rt ual l y i mpos s i bl e t o eradi cat e l i ver abs ces s es wi t hout removi ng or deal i ng wi t h t hat s ource (e.g. appendi x). Pyogeni c abs c es s : percut aneous as pi rat i on of any l arge abs ces s es . Broad-s pect rum ant i bi ot i cs (e.g. cefot axi me and met roni dazol e). P.669
Amoebi c abs c es s : s ee P636. Treat wi t h met roni dazol e (or t i ni dazol e) fol l owed by di l oxani de furoat e.
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USS-gui ded as pi rat i on may hel p i mprove penet rat i on of t he drugs and s hort en i l l nes s . Secondary bact eri al i nfect i on occurs i n up t o 20%.
Hydat i d di s eas e: open s urgi cal drai nage i s t he t reat ment of choi ce. Al bendazol e may hel p reduce t he ri s k of recurrence pos t s urgery or be us ed i n i noperabl e cas es . Ant i -t ubercul ous t herapy for t ubercul ous abs ces s es .
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac ut e panc reat it is: assessment
Acute pancreatitis:
assessment
Acut e pancreat i t i s i s occas i onal l y managed by phys i ci ans , part i cul arl y i f i t pres ent s i n an unus ual way (e.g. ches t pai n).
Presentation
Abdomi nal pai n: epi gas t ri c or general i zed, of rapi d ons et , but may occur anywhere (i ncl udi ng ches t ); dul l , cons t ant , and bori ng. Radi at i on t o t he back or bet ween t he s capul ae, oft en rel i eved by l eani ng forward (di fferent i al di agnos i s i s l eaki ng aort i c aneurys m). Naus ea, vomi t i ng, and dehydrat i on jaundi ce. Peri t oni t i s wi t h epi gas t ri c t endernes s , l ocal i zed rebound t endernes s , or general i zed abdomi nal ri gi di t y. An abdomi nal mas s may i ndi cat e a pancreat i c ps eudocys t or abs ces s . Bowel s ounds us ual l y abs ent . Tachycardi a and hypot ens i on; s hock/col l aps e and res pi rat ory fai l ure i n s evere cas es (es peci al l y i n t he el derl y). Very rarel y s i gns of bl eedi ng i n t he pancreat i c bed, GreyTurner's s i gn (ecchymos i s i n t he fl anks ) or Cul l en's s i gn (peri -umbi l i cal brui s i ng), t ender red s ki n nodul es (due t o s ubcut aneous fat necros i s ). Hypocal caemi c t et any.
Investigations
Amyl as e El evat ed, but not s peci fi c (s ee t abl e, P671), es peci al l y i f onl y up t o 4 upper l i mi t of normal .
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A pers i s t ent l y rai s ed amyl as e (s everal days t o weeks ) may i ndi cat e t he devel opment of a FBC U&E's Gl ucos e LFTs ps eudocys t Rai s ed haemat ocri t and l eucocyt os i s Urea may be rai s ed wi t h hypovol aemi a May be rai s ed AST and bi l i rubi n oft en el evat ed es peci al l y i n gal l s t one pancreat i t i s . Di s proport i onat el y el evat ed Cal ci um CRP ABGs AXR -GT may i ndi cat e an al cohol aet i ol ogy 2+ Hypocal caemi a (unl es s preci pi t ant was Ca ) El evat ed: us ed t o moni t or progres s i on of t he at t ack Mandat ory. Hypoxi a met abol i c aci dos i s General i zed i l eus or s ent i nel l oops (di l at ed gas -fi l l ed l oops i n t he regi on of t he pancreas ). Look for evi dence of pancreat i c cal ci fi cat i on or bi l i ary CXR USS CT abdomen s t one May s how a pl eural effus i on, el evat ed di aphragm, or pul monary i nfi l t rat es . May confi rm di agnos i s and det ect gal l s t ones bi l i ary obs t ruct i on, ps eudocys t s , and abs ces s es Dynami c cont ras t -enhanced i s rel i abl e at det ect i on of pancreat i c necros i s and gradi ng s everi t y.
The s everi t y of di s eas e has no correl at i on wi t h t he el evat i on of s erum amyl as e. Several prognos t i c i ndi ces have been publ i s hed, but i t t akes 48 hours t o ful l y appreci at e di s eas e s everi t y. See t abl e. The mort al i t y from acut e pancreat i t i s i s approxi mat el y 10%, and ri s es t o 40% i n t hos e devel opi ng a pancreat i c abs ces s . The mort al i t y i s hi ghes t P.671
i n t hos e wi t h a fi rs t epi s ode of pancreat i t i s . Around 15% of pat i ent s pres ent i ng wi t h acut e pancreat i t i s have recurrent di s eas e.
Causes of abdominal pain and elevated
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serum amylase

Acut e pancreat i t i s St omach or s mal l bowel perforat i on Perforat ed pept i c ul cer Mes ent eri c i nfarct i on Acut e l i ver fai l ure Acut e chol ecys t i t i s or chol angi t i s Renal fai l ure (modes t el evat i on) Di abet i c ket oaci dos i s
Markers of severity in acute pancreatitis 1

At presentation

Age >55 years W BC >16 10 /L Gl ucos e >10mM (non-di abet i c) LDH >350IU AST >250i u/L Haemat ocri t fal l >10% Urea ri s e >10mM Serum Ca
2+ 9
During the first 48 hours

<2.0 mmol /L
Bas e exces s >4 mmol /L P a O 2 <8 kPa Serum al bumi n <32g/L Es t i mat ed fl ui d s eques t rat i on >6L
Mort al i t y: 02 cri t eri a = 2%; 34 = 15%; 56 = 40%; >7 = 100%.
Practice point
Severe acut e abdomi nal pai n i s nearl y al ways due t o a s urgi cal caus e.
Footnote
1
Dat a compi l ed from Imri e CW et al . (1978) Br. J. Surg. 65 : 37 and Rans on JH et al . (1974) Surg. Gynaec ol . Obs t et . 139 :69.
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> T able of Cont ent s > Chapt er 10 - Gast roent erologic al emergenc ies > Ac ut e panc reat it is: management
Acute pancreatitis:
management
The pri nci pl es of management are

Li ai s e wi t h s urgeons Support i ve meas ures : t he majori t y wi l l s ubs i de i n 310 days Careful obs ervat i on for t he devel opment of compl i cat i ons Ident i fy t he caus e (s ee t abl e P673).
Supportive treatment
Es t abl i s h i v acces s . If t here i s s hock, markers of moderat es evere pancreat i t i s , el derl y pat i ent , hypoxi a not readi l y correct i ng wi t h O 2 or ot her co-exi s t ent di s eas e, i ns ert a CVP l i ne t o hel p cont rol fl ui d bal ance. Pat i ent s are us ual l y s everel y vol ume depl et ed: gi ve prompt fl ui d repl acement wi t h col l oi d (e.g. Haemaccel ) or 0.9% s al i ne. Moni t or uri ne out put and i ns ert a uri nary cat het er i f requi red. Oxygen s houl d be gi ven i f t here i s hypoxi a on ai r (us e cont i nuous pul s e oxi met ry i n s evere cas es and 6 hourl y for t he fi rs t 48 hours for res t , t o moni t or for res pi rat ory fai l ure). Keep ni l by mout h. The us e of nas ogas t ri c s uct i on has never been proven. There i s an i ncreas i ng vogue for t he commencement of earl y ent eral nut ri t i on (nas ojejunal ), whi ch i s as effect i ve as TPN i n acut e pancreat i t i s .
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Moni t or bl ood gl ucos e regul arl y and t reat wi t h i ns ul i n i f hi gh. Pet hi di ne caus es t he l eas t s pas m of t he s phi nct er of Oddi . Ant i bi ot i c prophyl axi s wi t h cefuroxi me decreas es s econdary i nfect i ons . Oct reot i de (s omat os t at i n anal ogue): t hi s s uppres s es pancreat i c enzyme s ecret i on but i s of unproven benefi t . Peri t oneal l avage: t here i s no proven benefi t . H 2 -ant agoni s t s have not been s hown t o affect mort al i t y.
Complications (seen in ~20%)

Local

Abs ces s Ps eudocys t i nfect i on Bi l i ary obs t ruct i on As ci t es , pl eural effus i on Fi s t ul a Spl eni c, port al , or mes ent eri c vei n obs t ruct i on El ect rol yt e i mbal ance Ca , Mg Shock Res pi rat ory fai l ure Seps i s
2+ 2+
Systemic

Acut e renal fai l ure
Septic complications
Seps i s i s t he mos t common caus e of deat h. Thi s s houl d be s us pect ed when t here i s a pers i s t ent fever, l eucocyt os i s , pai n/t endernes s , or an overal l cl i ni cal det eri orat i on. Thes e s i gns are an i ndi cat i on for mul t i pl e bl ood cul t ures and an abdomi nal CT. Pancreat i c ps eudocys t s are more common i n al cohol i c pancreat i t i s (15% vers us 3% i n gal l s t one AP), but i nfect i on i s more common i n gal l s t one pancreat i t i s . P.673
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Biliary pancreatitis
Urgent ERCP wi t hi n 72 hours of pres ent at i on reduces compl i cat i ons and mort al i t y i n pat i ent s wi t h s evere gal l s t one pancreat i t i s . The benefi t has not been demons t rat ed i n mi l d cas es . There i s a growi ng vogue for t he us e of MRCP (magnet i c res onance chol angi opancreat ogaphy) t o di agnos e bi l i ary di s eas e pri or t o ERCP.
Indications for surgery

Infect ed pancreat i c necros i s or pancreat i c abs ces s . Radi ol ogi cal l y gui ded percut aneous drai nage i s now preferred t o s urgery for pancreat i c ps eudocys t s .
Causes of acute pancreatitis

Common (80%)
Gal l s t ones (i ncl udi ng bi l i ary mi crol i t hi as i s or s l udge) (60%) Al cohol (20%) Iat rogeni c (ERCP or any form of abdomi nal s urgery) Trauma (even s eemi ngl y mi ni mal t rauma, as pancreas i s i n a very vul nerabl e pos i t i on, e.g. s eat -bel t s i gn or bi cycl e handl e-bar i njury) Infect i ons Vi ral : mumps , rubel l a, coxs acki e B, EBV, CMV, Hep A and B) Bact eri al : mycopl as ma Ot hers : as cari s , fl ukes ( Cl onorc hi s s i nens i s )
Rare (10%)

Sys t emi c vas cul i t i s (SLE, pol yart eri t i s nodos a, et c.) Drugs (e.g. t hi azi des , frus emi de, NSAIDs , s ul phonami des , az at hi opri ne, t et racycl i nes , and val proat e; pos s i bl y s t eroi ds ) Hypert ri gl yceri daemi a (s erum amyl as e fal s el y l ow) Hypercal caemi a or i v cal ci um i nfus i ons
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Hypot hermi a Pancreat i c carci noma (3% pres ent wi t h acut e pancreat i t i s ) Mi s c.: anat omi cal abnormal i t i es (pancreas di vi s um, duodenal orperi -ampul l ary di vert i cul ae), s corpi on bi t es , cys t i c fi bros i s
Unknown (10%)
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Blood t ransfusion reac t ions: assessment
Blood transfusion
reactions: assessment
Presentation Shock (major haemolysis) Lumbar pai n, headache Ches t pai n, SOB Ri gors , pyrexi a Urt i cari a, fl us hi ng Hypot ens i on Ol i guri a Haemogl obi nuri a Jaundi ce DIC Shock (septic) Ri gors , pyrexi a Hypot ens i on Ol i guri a DIC Fever Is ol at ed pyrexi a Ri gors Allergic reactions Urt i cari a Pyrexi a Ri gors Faci al oedema Dys pnoea Circulatory overload Breat hl es s nes s Cough T ransfusion-related acute lung injury (T RALI) Non-cardi ogeni c pul monary oedema Pyrexi a Cough Causes Red cel l ant i bodi es ABO i ncompat i bi l i t y Ot her ant i bodi es T iming Immedi at e (mi nut es /hours )
Bact eri al cont ami nat i on
Immedi at e (mi nut es /hours )
W hi t e cel l ant i bodi es Earl y (3090 Reci pi ent cyt oki nes mi nut es ) Donor pl as ma prot ei ns (more common wi t h pl as ma or pl at el et s ) Rapi d t rans fus i on Donor whi t e cel l ant i bodi es (rare) Earl y (hours ) Earl y (mi nut es /hours ) Earl y (mi nut es /hours )
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Breat hl es s nes s CXR changes Delayed haemolysis Pyrexi a Anaemi a Jaundi ce Delayed thrombocytopenia Purpura Mucos al bl eedi ng Infection
Mi nor red cel l ant i bodi es Pl at el et ant i body (commonl y ant i -Pl )
A1
Lat e (710 days )
Lat e (210 days )
Hep. B, C, nonA/B/C Lat e (days /mont hs ) CMV, EBV, HIV Toxopl as mos i s Mal ari a, s yphi l i s
Page 1121
> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Blood t ransfusion reac t ions: management
Blood transfusion
reactions: management
The mai n probl em encount ered i n pract i ce i s di fferent i at i ng a (common) ri s e i n t emperat ure duri ng a bl ood t rans fus i on from (t he rare but pot ent i al l y l et hal ) major t rans fus i on react i ons . The common pat t erns of react i ons are out l i ned on P676. Poi nt ers t o a s evere react i on i ncl ude

Sympt oms : does t he pat i ent feel unwel l ? Pat t ern of t emperat ure: a rapi d ri s e i n t emperat ure t o >38C i s common i n mi nor react i ons . Hypot ens i on or t achycardi a.
Management
Isolated pyrexia Sl ow t rans fus i on Gi ve paracet amol Fi ni s h t rans fus i on i f no progres s i on of s ympt oms . Sl ow t rans fus i on Gi ve chl orpheni rami ne 10mg i v/po Compl et e t rans fus i on i f no progres s i on of s ympt oms Rarel y, pat i ent s need hydrocort i s one Shock Anaphylaxis 100mg i v. St op t rans fus i on and gi ve oxygen Gi ve adrenal i ne 0.51mg s c and cons i der repeat i ng every 10 mi nut es ABO incompatibility Septic shock unt i l i mprovement Cont act dut y anaes t het i s t and ITU Gi ve chl orpheni rami ne 10mg i v i v col l oi ds (al s o cons i der crys t al l oi d, i not ropes , P257) Moni t or fl ui d bal ance
Urticarial reaction
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Take bl ood: FBC, U&Es ; ful l coagul at i on s creen (for DIC); repeat cros s -mat ch and Coomb's t es t ; ret urn donor bl ood Uri ne: bi l i rubi n, free Hb. Circulatory overload Oxygen, frus emi de i v (40120mg) Ni t rat e i nfus i on (010mg/h). (s ee p108) T RALI Li fe-t hreat eni ng. Treat as ARDS (P230). Delayed haemolysis Report t o bl ood bank Repeat cros s -mat ch and Coomb's t es t Trans fus e wi t h fres hl y cros s -mat ched T hrombocytopenia bl ood. A1 Immune medi at ed: t reat wi t h Pl -negat i ve t rans fus i ons , hi gh-dos e i v IgG, s t eroi ds , and pl as mapheres i s (di l ut i onal pl at el et s s een i f >5 uni t s t rans fus ed). Report any s eri ous or haemol yt i c reac t i on t o haemat ol ogi s t .
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Sic kle c ell c risis: present at ion
Sickle cell crisis:
presentation
A s mal l percent age of s ufferers wi t h s i ckl e cel l di s eas e have recurrent cri s es , and repeat ed hos pi t al admi s s i ons . There i s an unwarrant ed t endency t o at t ri but e t hi s t o a l ow pai n t hres hol d, or t o dependence on opi at es , rat her t han t o s everi t y of di s eas e. Anal ges i a s houl d never be deni ed t o pat i ent s . Thi s group of pat i ent s has t he hi ghes t rat e of s eri ous compl i cat i ons and mort al i t y as a res ul t of t hei r s evere di s eas e.
Painful (vaso-occlusive) crisis
Thi s i s t he mos t common pres ent at i on i n adul t s and chi l dren. Severe/excruci at i ng pai n i s fel t at one or more s i t es , es peci al l y l ong bones (s mal l bones i n chi l dren), back, ri bs , s t ernum. There may be as s oci at ed pyrexi a (us ual l y <38.5 C), t endernes s , l ocal warmt h and s wel l i ng, or t here may be no object i ve feat ures . Haemol ys i s may be i ncreas ed (i ncreas ed bi l i rubi n, fal l i n Hb), but i s not a good correl at e. T here are no rel i abl e c l i ni c al markers for s everi t y of c ri s i s .
Chest crisis

The commones t caus e of mort al i t y. Vas o-occl us i on of pul monary mi crovas cul at ure res ul t s i n reduced perfus i on and l ocal i nfarct i on. May be heral ded by ri b/s t ernal pai n. Oft en preci pi t at ed by a ches t i nfect i on.
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Sympt oms (whi ch may be mi nor i ni t i al l y) i ncl ude pl euri t i c ches t pai n, breat hl es s nes s . Si gns are mi ni mal ; us ual l y reduced ai r ent ry at l ung bas es . CXR s hows uni /bi l at eral cons ol i dat i on, us ual l y bas al . P a O 2 i s oft en markedl y reduced.
Cerebral infarction

Us ual l y i n chi l dren <5 years , rare i n adul t s . Pres ent s as acut e s t roke. Hi gh ri s k of recurrence.
Splenic/hepatic sequestration

Us ual l y i n chi l dren <5 years . RBCs t rapped i n s pl een and/or l i ver, us ual l y caus i ng organomegal y. Caus es s evere anaemi a; ci rcul at ory col l aps e.
Aplastic crisis

Us ual l y i n chi l dren, young adul t s . Mai nl y caus ed by parvovi rus i nfect i on, exacerbat ed by fol at e defi ci ency. Sudden fal l i n Hb, reduced ret i cul ocyt e count .
Haemolytic crisis

Oft en accompani es pai nful cri s es . Fal l i n Hb; i nc reas ed ret i cul ocyt e count .
Cholecystitis/cholangitis/biliary colic

Pi gment s t ones common due t o haemol yt i c anaemi a. Can be mi s i nt erpret ed as vas o-occl us i ve cri s i s .
P.681
Priapism
Prol onged, pai nful erect i ons due t o l ocal vas o-occl us i on.
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May res ul t i n permanent i mpot ence. Thi s i s a urol ogi cal emergency. On-cal l urol ogi s t s s houl d be i nformed on t he pat i ent 's arri val i n cas ual t y.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Sic kle c ell c risis: management
Sickle cell crisis:
management
General measures Control pain
Oral anal ges i a (di hydrocodei ne/NSAIDs ) may be s uffi ci ent for mi nor cri s es . Us ual l y parent eral opi at es are neces s ary, oft en i n hi gh dos es , e.g.
o o
morphi ne 1040mg i m every 2 hours di amorphi ne 1025mg s c every 2 hours .
Fai l ure t o cont rol pai n us i ng t hes e regi mes us ual l y i ndi cat es t he need for a cont i nuous opi at e i nfus i on, or a PCA pump. Some pat i ent s prefer pet hi di ne but t here i s a ri s k of s ei zures as t he drug met abol i t es accumul at e. Suppl ement ary anal ges i cs , s uch as di cl ofenac 50mg t ds po, may have a s mal l addi t i onal benefi t .
Ensure hydration
i v crys t al l oi ds are preferred, but venous acces s may be a probl em. Ai m for an i nput of 34L/day.
Give oxygen
Not of proven benefi t (except i n ches t cri s es ), but oft en provi des s ympt omat i c rel i ef. In a s evere ches t cri s i s , CPAP/ful l vent i l at i on may become neces s ary. Trans fer t o ITU earl y.
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Give folic acid

Gi ve 5mg po od (cont i nue l ong t erm i n al l pat i ent s ).
Give antibiotics
If an i nfect i ve preci pi t ant , or component , of t he cri s i s i s s us pect ed, s t art bl i nd ant i bi ot i cs (e.g. cefuroxi me 750mg i v t ds ) aft er i nfect i on s creen.
Investigations
FBC Hb (?fal l from s t eady s t at e) W CC (neut rophi l i a common) Ret i cul ocyt es Rai s ed i n haemol ys i s , reduced i n apl as t i c cri s i s HbS% Can gui de t rans fus i on requi rement s
Bl ood cul t ures If pyrexi al St ool cul t ures If di arrhoea + bone pai n (?s al monel l a os t eomyel i t i s ) CXR Pul s e oxi met ry Bone X-ray ?os t eomyel i t i s (pers i s t i ng pai n, pyrexi a, or bact eraemi a). ?avas cul ar necros i s (chroni c hi p/s houl der pai n) Vi ral s erol ogy If apl as t i c cri s i s (?parvovi rus ) X-mat ch P.683 If t rans fus i on/exchange i ndi cat ed (s ee bel ow). Regardl es s of s ympt oms Art eri al bl ood gas es i f hypoxi c
Exchange transfusion
Thi s i s performed by venes ect i on of 12 uni t s , wi t h fl ui d repl acement (N s al i ne, 1 l i t re over 24 hours ) fol l owed by t rans fus i on of cros s -mat ched bl ood. If a l arger exchange i s requi red, or fl ui d bal ance i s precari ous , t he exchange can be performed on a cel l s eparat or. Ai m for Hb bet ween 79g/L i n ei t her cas e; a hi gher Hb c an i nc reas e bl ood vi s c os i t y and
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prec i pi t at e furt her s i c kl i ng . In s evere cri s es , red cel l exchange s houl d be repeat ed unt i l t he HbS% i s <40%.
Indications for urgent exchange transfusion

Ches t cri s i s Cerebral i nfarct i on Severe, pers i s t i ng pai nful cri s i s Pri api s m
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Bleeding disorders: general approac h
Bleeding disorders:
general approach
Presentation
Normal haemos t as i s requi res t he i nt eract i on of pl at el et s , fi bri n from t he cl ot t i ng cas cade, and t he mi crovas cul at ure. An abnormal i t y of any of t hes e component s may pres ent as eas y brui s i ng, purpura, or s pont aneous or exces s i ve bl eedi ng. Mus cl e haemat omas or haemart hros es s ugges t s cl ot t i ng fact or defi ci enci es (e.g. haemophi l i a) whereas purpura or brui s i ng s ugges t s abnormal i t i es of pl at el et funct i on. Mucos al haemorrhage (acut e GI bl eed) may occur wi t hout any haemos t at i c abnormal i t i es , e.g. due t o pept i c ul cer di s eas e. If a coagul at i on or pl at el et abnormal i t y i s uncovered on rout i ne t es t i ng, exami ne t he pat i ent for occul t bl eedi ng (e.g. i ron-defi ci ent anaemi a, fundal haemorrhages ).
Causes
Thes e can be di vi ded i nt o

Coagul at i on abnormal i t i es Pl at el et abnormal i t i es (t oo few or dys funct i onal ) Mi crovas cul ar abnormal i t i es .
Investigations
All patients should have

Coagul at i on s creen (PT, APTT, TT) FBC and fi l m
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U&Es LFTs X-mat ch Bl eedi ng t i me Pl at el et funct i on t es t s Bone marrow as pi rat e and t rephi ne Aut oant i body s creen Ant i -pl at el et ant i bodi es Speci fi c coagul at i on fact or l evel s Acqui red fact or i nhi bi t ors
Where appropriate consider

Management General measures

Avoi d non-s t eroi dal medi cat i ons , es peci al l y as pi ri n. Never gi ve i nt ramus cul ar i nject i ons . Avoi d art eri al punct ures . Enl i s t expert hel p wi t h i nvas i ve procedures . Us e i nt ernal jugul ar rat her t han s ubcl avi an rout e for cent ral l i ne i ns ert i on. Avoi d aut omat ed bl ood pres s ure meas urement devi ces as t hey may provoke bl eedi ng i nt o t he upper arm. Exami ne s ki n, oral mucos a, and fundi for evi dence of fres h bl eedi ng. Res t ore ci rcul at ory vol ume wi t h i v col l oi d i f t here i s haemodynami c compromi s e and cons i der bl ood t rans fus i on.
Specific therapy
Look for any l ocal caus e for t he bl eedi ng (e.g. oes ophageal vari ci es , vas cul ar damage caus i ng epi s t axi s , ches t i nfect i on caus i ng haemopt ys i s ) t hat may be amenabl e t o t reat ment . St op any drug t hat may be exacerbat i ng bl eedi ng (t abl e oppos i t e). Correct coagul at i on abnormal i t i es i f appropri at e (P688).
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Correct pl at el et abnormal i t i es i f appropri at e (P692).
P.685
Drugs that may cause bleeding disorders

Coagulation abnormalities Hepari n W afari n As paragi nas e (dVi t ami n K-dependent fact ors ) Hepari n anal ogues (argat roban, hi rudi n) T hrombocytopenia Im No mu n-i ne m mu ne He Cyt par ot o in xi c che mo t he rap y Qui Chl ni n ora e mp he ni c ol Pe Pri ni ci ma l l i n qui H2 ne Al c
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-re oh cep ol t or ant ag oni sts Thi az i de di u ret i cs Abnormal platelet function As pi ri n, NSAIDs Ti cl opi di ne Ant i bi ot i cs (e.g. pi peraci l l i n, cefot axi me) Dext ran Al cohol Abnormal microvasculature Cort i cos t eroi ds
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Abnormal c oagulat ion 1
Abnormal coagulation 1
Common causes

Ant i -coagul ant s Li ver di s eas e Vi t . K defi ci ency

o o
obs t ruct i ve jaundi ce s mal l bowel di s eas e
DIC
Rarer causes

Mas s i ve t rans fus i on Haemophi l i a A, B von W i l l ebrand's di s eas e Acqui red fact or VIII i nhi bi t ors Amyl oi d (acqui red Fact or X defi ci ency) 2 -pl as mi n i nhi bi t or defi ci ency
Diagnosis
Defect PT APTT Interpretation Ext ri ns i c pat hway defect Int ri ns i c pat hway defect Consider W arfari n, l i ver di s eas e, vi t ami n K defi ci ency Hepari n, haemophi l i a, von W i l l ebrand's di s eas e, l upus ant i -coagul ant (ant i -phos phol i pi d PT and APTT TT Mul t i pl e defect s (us ual l y acqui red) Abnormal fi bri n product i on s yndrome) Li ver di s eas e, DIC, warfari n Hepari n effect , fi bri nogen defect , exces s FDPs (whi ch
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PT, APTT, TT
Mul t i pl e (acqui red) defect s
i nt erfere wi t h react i on) Defi ci ent or abnormal fi bri nogen or hepari n. 1 Rept i l as e t i me wi l l be normal i f due t o hepari n Cons umpt i ve coagul opat hy (but not neces s ari l y ful l DIC), s evere l i ver di s eas e The exact i nt erpret at i on depends on t he l ab t es t us ed. Some do not di s t i ngui s h bet ween fi bri n and FDPs . Some are more s peci fi c t o fi bri n degradat i on (e.g. D-Di mers ) and are t herefore s ugges t i ve of wi des pread cl ot format i on and breakdown (i .e. DIC) von W i l l ebrand's di s eas e (APTT), congeni t al or acqui red pl at el et dys funct i on (s ee t abl e P685). Cons i der pl at el et funct i on s t udi es
Fi bri nogen
Exces s cons umpt i on of cl ot t i ng fact ors and fi bri nogen Fi bri n(ogen) degradat i on
FDPs
Bl eedi ng t i me Abnormal pl at el et funct i on
The l upus ant i coagul ant us ual l y confers a pro-t hrombot i c rat her t han a bl eedi ng t endency.
Footnote
1
Rept i l as e i s a s nake venom not i nhi bi t ed by hepari n. It convert s
fi bri nogen t o fi bri n.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Abnormal c oagulat ion 2
Abnormal coagulation 2
Management
Opt i ons are
Fres h frozen pl as ma: i ndi cat ed for rapi d warfari n revers al or t reat ment of acut e DIC. Gi ve approx. 15ml /kg i .e. 45 uni t s (approx. 200 ml /uni t ). W at ch for s i gns of fl ui d overl oad and gi ve i v frus emi de i f neces s ary. Vi t ami n K: Phyt omenadi one 510mg i v s l owl y (dai l y for 3 days ) i f defi ci ency i s s us pect ed. 25mg i v/po wi l l correct over-warfari ni zat i on i n 612 hours . 0.51mg for mi nor adjus t ment . Prot ami ne s ul phat e (1mg i v neut ral i zes 100i u hepari n) i s rarel y us ed i n pract i ce. St oppi ng a hepari n i nfus i on wi l l normal i ze an APTT i n 24 hours . Cryoprec i pi t at e s houl d be cons i dered i f t he fi bri nogen i s bel ow 500g/L. Fac t or c onc ent rat es can be us ed i n t he t reat ment of i s ol at ed fact or defi ci enci es , e.g. haemophi l i a. Concent rat es of Fact ors II, VII, IX, and X are al s o avai l abl e i n s ome cent res for s peci fi c revers al of warfari n effect s (prot hrombi n compl ex concent rat e). Ant i -fi bri nol yt i c s are us ed occas i onal l y for t he t reat ment of l i fe-t hreat eni ng bl eeds fol l owi ng t hrombol yt i c t herapy or pros t at ect omy and i n cert ai n condi t i ons as s oci at ed wi t h hyperpl as mi naemi a (e.g. acut e promyel ocyt i c l eukaemi a, cert ai n mal i gnanci es . Gi ve aprot oni n 50100ml (0.51MU) s l ow i v fol l owed by 20ml (200kU) every hour unt i l bl eedi ng
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s t ops ; al t ernat i vel y, t ranexami c ac i d 0.51g s l ow i v i nject i on t ds .
Mi s c el l aneous DDAVP and oes t rogens are occas i onal l y us ed for haemophi l i a and renal fai l ure.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Circ ulat ing inhibit ors of c oagulat ion
Circulating inhibitors of
coagulation
Lupus anti-coagulant
Caus es prol onged APTT but predi s pos es t o t hrombos i s , not bl eedi ng (ant i -phos phol i pi d s yndrome).
Acquired haemophilia
El derl y pat i ent s pres ent i ng wi t h s evere brui s i ng and prol onged APTT Di s cus s wi t h haemat ol ogi s t s .
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Abnormal plat elet s 1
Abnormal platelets 1
Causes Thrombocytopenia
Increased platelet consumption Immune

Idi opat hi c (ITP) Drug i nduced SLE HIV rel at ed Mas s i ve t rans fus i on Hypers pl eni s m DIC, TTP Myel os uppres s ant drugs , al cohol , vi ral i nfect i ons Marrow i nfi l t rat i on/fai l ure B 1 2 or fol at e defi ci ency Inheri t ed di s orders (rare)
Non-immune

Reduced platelet production

Abnormal platelet function

Drugs (e.g. as pi ri n) Uraemi a Li ver di s eas e Myel oprol i ferat i ve di s orders Myel odys pl as i a Dys prot ei naemi a (e.g. myel oma) Inheri t ed di s orders (rare)
o o o
Gl anzman's di s eas e (GP Ia defi ci ency) BernardSoul i er (GP IIb/IIIa defi ci ency) Chedi akHi gas hi s yndrome (abn. pl at el et
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granul es )
Investigations
Peri pheral bl ood Evi dence of haemol ys i s (?DIC ?TTP), or fi l m Coagul at i on s creen Aut oant i body s creen Bone marrow as pi rat e Increas ed megakaryocyt es general l y i ndi cat es peri pheral cons umpt i on; decreas ed or abnormal megakaryocyt es s ugges t a marrow probl em Ant i -pl at el et ant i bodi es Pl at el et funct i on t es t s
marrow i nfi l t rat i on ?DIC As s oci at ed aut oi mmune di s eas es
Rarel y i ndi cat ed For bl eedi ng i n t he pres ence of adequat e pl at el et numbers on t he bl ood fi l m.
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Low pl at el et s (<20 10 /L) may caus e s pont aneous bl eedi ng and requi re pl at el et t rans fus i on t reat ment for t he underl yi ng caus e. Moderat el y l ow count s (20140 10 /L) wi l l rarel y caus e s pont aneous bl eedi ng, unl es s t here i s an as s oci at ed cl ot t i ng abnormal i t y (e.g. DIC) or a pri mary marrow defect , wi t h product i on of defect i ve pl at el et s (e.g. myel odys pl as i a). Trans fus e onl y i f t here i s cont i nued bl eedi ng or i n preparat i on for major s urgery. Hi gh count s (5001000 10 /L) may al s o i ndi cat e a pri mary product i on probl em, wi t h abnormal pl at el et s (e.g. myel oprol i ferat i ve di s orders ). (NB: moderat el y rai s ed pl at el et count i s a normal res pons e t o bl eedi ng and i s al s o s een i n chroni c i nfl ammat i on.)
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Abnormal plat elet s 2
Abnormal platelets 2
Management
Thi s depends on t he pl at el et count and s everi t y of bl eedi ng.
Immune-mediated thrombocytopenia
Pl at el et t rans fus i ons are us ual l y i neffect i ve as s ol e t herapy and rarel y i ndi cat ed. Predni s ol one (1mg/kg od) i s s t andard fi rs t -l i ne t reat ment for adul t ITP. Immunogl obul i n 0.4g/kg/day i v i nfus i on for 5 days (or 2g/kg/day for 1 day): t hi s us ual l y works qui cker t han s t eroi ds , but t he effect onl y l as t s 24 weeks . St art t he i nfus i on very s l owl y, as anaphyl act i c react i ons (fever, urt i cari a, bronchos pas m, and hypot ens i on) are not uncommon. Pool ed pl as ma product may be combi ned wi t h t he above.
Acute DIC/massive transfusion

Gi ve pl at el et t rans fus i ons t o mai nt ai n pl at el et count >50 10 /L (for chroni c DIC, t rans fus e onl y for act i ve bl eedi ng).
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Surgery

Ai m for pl at el et count >50 10 /L. For CNS s urgery or mul t i pl e t rauma, ai m for count >100 10 /L.
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Reduced platelet production (chronic, stable)

If no bl eedi ng, t rans fus e i f count <10 10 /L.
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TTP/heparin induced thrombocytopenia

Pl at el et t rans fus i ons are cont rai ndi cat ed. Di s cus s al l cas es wi t h t he haemat ol ogi s t s .
Platelet transfusion
A s i ngl e uni t i s ei t her a pool of s everal buffy coat s or pl at el et s from a s i ngl e donor from aphores i s . The number of pl at el et s i n a uni t i s <240 10 whi ch i s s uffi ci ent for mos t i ndi cat i ons unl es s t here i s on-goi ng cons umpt i on (e.g. s evere DIC). If no cons umt pi on, t he pl at el et s s urvi ve 25 days i n ci rcul at i on.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Ant i- c oagulant t herapy
Anti-coagulant therapy
Warfarin
W arfari n overdos e (acci dent al or del i berat e s el f-harm) res ul t s i n a prol onged PT (and t hus INR). Ri s k fact ors for s i gni fi cant bl eedi ng i ncl ude poor cont rol , l ocal l es i on (e.g. pept i c ul cer, angi odys pl as i a of t he col on), hi gh l evel of ant i -coagul at i on (INR >2.5), co-exi s t ent haemat ol ogi cal abnormal i t y (e.g. t hrombocyt openi a, myel odys pl as i a, et c.).
Management
Moderat e warfari n overdos e (INR 58) wi t hout overt bl eedi ng does not us ual l y requi re s peci fi c t reat ment and pat i ent may be managed as an out pat i ent provi ded t hey can at t end for dai l y INR. W i t hhol d warfari n unt i l t he INR fal l s t o t he t herapeut i c range. Try t o i dent i fy t he caus e (i ncorrect t abl et s , al cohol bi nge, et c.). As ympt omat i c pat i ent s wi t h INR >8 s houl d recei ve vi t ami n K as t he ri s k of s evere bl eedi ng i s hi gh. W i t hhol d warfari n and gi ve 2mg of phyt amenadi one (i v preparat i on but abs orbed wel l oral l y al s o) i f INR <12, or 5mg phyt amenadi one i f INR >12. Repeat INR t he next day t o confi rm reduct i on. Rei nt roduce warfari n when INR <5. Bl eedi ng i n pat i ent s on warfari n requi res urgent correct i on of cl ot t i ng. Gi ve FFP 24 uni t s i v and vi t ami n K 24mg i v (t hi s dos e does not us ual l y i nt erfere wi t h re-ant i -coagul at i on, whereas hi gher dos es make s ubs equent ant i -coagul at i on di ffi cul t ). Ident i fy and t reat t he l ocal l es i on from whi ch t he
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pat i ent i s bl eedi ng. Cons i der gi vi ng prot hrombi n compl ex concent rat e (puri fi ed Fact ors II, VII, IX, and X) for l i fe-t hreat eni ng bl eedi ng (e.g. GI or CNS bl eed). Di s cus s wi t h t he haemat ol ogi s t s .
Heparin
Ri s k fact ors for bl eedi ng i ncl ude age, recent s urgery or t rauma, renal or l i ver fai l ure, mal i gnancy, APTT rat i o >3, co-exi s t ent haemat ol ogi cal abnormal i t y.
Management
St op hepari n: t he APTT us ual l y normal i zes i n 34 hours . Prot ami ne s ul phat e (1mg i v neut ral i zes 100U hepari n) may be us ed; hal ve t he dos e i f hepari n has been t urned off 1 hour previ ous l y. Low mol ec ul ar w ei ght hepari ns are t hought t o have fewer bl eedi ng compl i cat i ons . However, t hei r pl as ma hal f-l i fe i s l onger and t hey are l es s eas i l y revers ed wi t h prot ami ne. Treat ment of overdos e i s as above, but wi t h not e t hat t he APTT i s normal on LMW H. Hepari n as s oc i at ed t hromboc yt openi a : s ee P692.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Bleeding wit h fibrinolyt ic t herapy
Bleeding with fibrinolytic
therapy
Ri s k fact ors for bl eedi ng wi t h fi bri nol yt i c t herapy are gi ven on P22. Severe haemorrhage s houl d be managed wi t h

Support i ve meas ures (col l oi d and bl ood t rans fus i on) Cryoprec i pi t at e t rans fus i on as a s ource of fi bri nogen Aprot oni n 50100ml (0.51MU) s l ow i v fol l owed by 20ml (200kU) every hour unt i l bl eedi ng s t ops (al t ernat i vel y, gi ve t ranexami c aci d 0.51g s l ow i v i nject i on t ds ).
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Bleeding in liver disease
Bleeding in liver disease
The l i ver i s i nvol ved i n t he s ynt hes i s of Fact ors II, III, IX, and X (t he vi t ami n K-dependent fact ors ) as wel l as t he cl earance of act i vat ed coagul at i on fact ors , fi bri n mol ecul es , and t PA. The abnormal i t i es mos t commonl y found are Obs t ruct i ve jaundi ce Acut e l i ver fai l ure Ci rrhos i s Prol onged PT and l at er prol onged APTT and TT (DIC) Prol onged PT, APTT, and TT; l ow fi bri nogen and/or dys fi bri nogenaemi a; rai s ed FDPs , decreas ed cl earance of t PA; l ow pl at el et s (hypers pl eni s m, DIC marrow dys funct i on). Prol onged PT (vi t ami n K defi ci ency)
Management
Treat ment i s requi red for act i ve GI bl eedi ng or as prophyl axi s for s urgery or l i ver bi ops y.

Gi ve vi t ami n K 10mg i v s l owl y (s i ngl e dos e). FFP t rans fus i on i s more effect i ve. Cons i der prot hrombi n compl ex concent rat e (puri fi ed Fact ors II, VII, IX, and X) for l i fe-t hreat eni ng bl eedi ng. Cont act t he haemat ol ogi s t s .
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Bleeding in uraemia
Bleeding in uraemia
Uraemi a res ul t s i n bot h pl at el et dys funct i on (i mpai red aggregat i on, adhes i on and act i vat i on) and endot hel i al dys funct i on.
Management

The t reat ment of choi ce i s haemodi al ys i s . Ot her meas ures t hat have been s hown t o be effect i ve i ncl ude
o o o o
cyropreci pi t at e i nfus i on DDAVP (P698) conjugat ed oes t rogens bl ood t rans fus i on or eryt hropoi et i n t o rai s e t he haemat ocri t t o >0.25.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Massive t ransfusion/c ardiopulmonary bypass
Massive
transfusion/cardiopulmonary bypass
Di l ut i onal t hrombocyt openi a and coagul opat hy us ual l y occur once red cel l concent rat es equi val ent t o approxi mat el y t wo bl ood vol umes have been t rans fus ed. W i t h cardi opul monary bypas s , t he ext racorporeal ci rcui t furt her damages t he nat i ve pl at el et s and depl et es coagul at i on fact ors . Abnormal i t i es i ncl ude PT, APTT, FDPs , fi bri nogen. Pos t -t rans fus i on t hrombocyt openi a i s a di s t i nct di s order s een 810 days fol l owi ng t rans fus i on and i s due t o a pl at el et -s peci fi c ant i body (s ee P678).
Management
Treat ment s houl d be di s cus s ed wi t h t he haemat ol ogy t eam and i nvol ves pl at el et t rans fus i on t o keep pl at el et count >50 10 /L (or >100 10 /L for CNS l es i ons /mul t i pl e t rauma), FFP (45 uni t s ) i f PT or APTT >1.5 cont rol , and cryopreci pi t at e (1015 uni t s ) i f fi bri nogen <500g/L.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Haemophilia and relat ed disorders 1
Haemophilia and related
disorders 1
Haemophilia A Haemophilia B X-l i nked reces s i ve defi ci ency of Fact or VIII ( APTT; Fact or VIII act i vi t y) X-l i nked reces s i ve defi ci ency of Fact or IX ( APTT; Fact or IX act i vi t y)
Cl i ni cal pres ent at i on depends upon t he degree of fact or defi ci ency:
Pat i ent s wi t h <2% act i vi t y have a s eri ous bl eedi ng di at hes i s . Mos t are on home t herapy Pat i ent s wi t h 25% act i vi t y are moderat el y affect ed; t hey bl eed rarel y but s houl d be t reat ed as s evere haemophi l i acs when t hey do Pat i ent s wi t h 540% fact or act i vi t y rarel y bl eed s pont aneous l y.
von Willebrand's Disease
Aut os omal domi nant (Types I, IIa, and IIb) or reces s i ve (Type III) wi t h varyi ng expres s i on. Reduced l evel s of vW fact or, whi ch normal l y promot es pl at el et adhes i on and prot ect s fact or VIII from des t ruct i on (hence fact or VIII act i vi t y; bl eedi ng
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t i me; or normal APTT).
Les s s evere t han t he haemophi l i as , wi t h haemart hros es and mus cl e bl eeds bei ng rare. Mucous membrane bl eedi ng (es p. epi s t axi s ) and pos t -t raumat i c bl eedi ng are t he mai n probl ems .
Acute presentations
Ac ut e haemart hros es oft en occur at s i t es of previ ous bl eedi ng, part i cul arl y i f t hi s has l ed t o degenerat i ve joi nt di s eas e. Ankl es , knees , hi ps , el bows are t he mos t common s i t es . Sympt oms i ncl ude l ocal t endernes s , warmt h, and s wel l i ng, and may t ake days or weeks t o res ol ve. I nt ramus c ul ar bl eeds can caus e a compart ment -t ype s yndrome, l eadi ng t o i s chaemi c necros i s and cont ract ure. I l i ops oas bl eed caus es ent rapment of femoral nerve and produces t he t ri ad of groi n pai n, hi p fl exi on, and s ens ory l os s over femoral nerve di s t ri but i on. The pai n may radi at e t o t he abdomen, and mi mi c appendi ci t i s . I nt rac rani al bl eedi ng i s i nfrequent , but i s s t i l l a common caus e of mort al i t y. It oft en fol l ows mi nor head i njury. Prognos i s of i nt racerebral haemorrhage i s general l y poor. Ext ra-dural and s ub-dural haemorrhage have a bet t er prognos i s . Bl eedi ng pos t -t rauma: cl as s i cal l y t here may be i ni t i al peri od of haemos t as i s ; bl eedi ng t hen becomes pers i s t ent or i nt ermi t t ent over days /weeks . Haemat uri a/uret eri c c l ot c ol i c i s rare i n haemophi l i a. Us ual l y t here i s no det ect abl e underl yi ng abnormal i t y of renal t ract s . Probl ems rel at i ng t o c o-exi s t ent HI V or hepat i t i s B/C i nfec t i on are now t he commones t caus e of mort al i t y, due t o i nfect ed Fact or VIII admi ni s t ered duri ng t he 1980s .
Investigations
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General l y, acut e i nves t i gat i ons are not neces s ary for s i mpl e joi nt and mus cl e bl eeds i n a known haemophi l i ac. Cons i der

USS: for mus cl e haemat omas (e.g. i l i ops oas bl eed) CT s can: hi s t ory of head t rauma, headache, abnormal neurol ogy Fact or VIII l evel s : i f bl eed i s s evere and t reat ment i s neces s ary Fact or VIII i nhi bi t or t i t re: i f refract ory bl eeds /hi s t ory of i nhi bi t or devel opment .
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Haemophilia and relat ed disorders 2
Haemophilia and related
disorders 2
Mos t pat i ent s cont act t hei r haemat ol ogi s t di rect l y unl es s t hey bl eed when away from home. Be gui ded by your l ocal haemat ol ogi s t .
General measures
Res t of t he affect ed part and i ce packs may be of benefi t . Anal ges i a: avoi d NSAIDs and i nt ramus cul ar i nject i ons . Oral anal ges i a (e.g. di hydrocodei ne) for mi nor bl eeds ; i v i nject i ons or i nfus i ons of hi gh-dos e opi at es may be neces s ary. No i m i njec t i ons .
Moderate or severe haemophiliac
Treat wi t h i v Fact or VIII concent rat e (mi nor bl eeds , DDAVP).
Mild haemophiliac
Fact or VIII defi ci ency onl y: mi l d or moderat e bl eeds s houl d be t reat ed wi t h DDAVP. Severe bl eeds or t hos e not res pondi ng t o DDAVP: t reat wi t h i v Fact or VIII concent rat e. Fact or IX defi ci ency onl y: t reat wi t h Fact or IX.
von Willebrand's disease
Mi l d and moderat e bl eeds : Type I and IIat reat wi t h DDAVP + t ranexami c aci d. Type IIbnot DDAVP (ri s k of t hrombocyt openi a). Us e Fact or VIII. Severe bl eeds : t reat wi t h Fact or VIII concent rat e and i f bl eedi ng cont i nues , gi ve cryopreci pi t at e and pl at el et
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t rans fus i ons . NB : Al l CNS and peri -s pi nal bl eeds are regarded as s evere.
Factor VIII replacement

See t abl e.
Mi nor bl eeds may res pond t o a s i ngl e, s l ow, i v bol us of fact or VIII. Major bl eeds : 12 hourl y t reat ment s (8 hourl y i n s evere bl eedi ng) wi t h frequent moni t ori ng of Fact or VIII l evel s , pre and pos t t reat ment . Pat i ent s wi t h Fac t or VI I I i nhi bi t ors pres ent a part i cul ar probl em. Thi s can s omet i mes be ci rcumvent ed by t he us e of al t ernat i ve forms of fact or VIII (human or porci ne, dependi ng on t he t ype of i nhi bi t or), or by t he us e of ot her product s (e.g. FEIBA).
Factor IX replacement
See t abl e.
Pl as ma hal f-l i fe i s l onger t han Fact or VIII, and once dai l y admi ni s t rat i on i s s uffi ci ent (t wi ce dai l y i n s evere bl eeds ). Never gi ve >3 dos es (each a maxi mum of 50U/kg) of Fact or IX i n 36 hours as i t i s hi ghl y t hrombogeni c.
DDAVP
I ndi c at i ons : Mi l dmoderat e haemophi l i a A, es peci al l y i n chi l dren, von W i l l ebrand's di s eas e Type 1 and s ome Type II. Dos age: 0.4g/kg i n 100ml N s al i ne i v over 20 mi nut es ; may be repeat ed 812 hours l at er. Peak haemos t at i c effect i n 6090 mi nut es . Moni t or pul s e and BP every 5 mi nut es : s i de-effect s i ncl ude fl us hi ng, hypot ens i on, t achycardi a, headache, and naus ea, rare report s of MI (caut i on i n pat i ent s >40 years or wi t h cardi ac hi s t ory).
P.701
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Tranexamic acid
Gi ve wi t h DDAVP i n von wi l l ebrand's di s eas e or mi l d Haemophi l i a A. Mos t us eful i n mucos al bl eeds . Avoi d i n renal t act bl eedi ng (may caus e cl ot s ). Dos age: 1g po qds (adul t s ). Mout hwas h 4.8% q10 mi n for oral bl eedi ng.
Cryoprecipitate
Gi ve for s evere bl eedi ng i n von W i l l ebrand's di s eas e not res pondi ng t o DDAVP and t ranexami c aci d. Dos age: 1020 uni t s (bags ) for 70kg adul t .
A rough guide for Factor VIII and IX replacement

Co De Do Do ndi sir se se tio ed of of n fac Fa Fa tor cto cto lev r r el VII IX (iu I (iu /dl (iu /k ) /k g) g) Mi l 50 25 65 d/ mo der at e bl e eds = be nef ix 40 = rep l en
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i ne Maj 10 50 13 or/l 0 i fet hr eat eni ng bl e eds 0 = be nef ix 80 = rep l en i ne
e.g. A 70kg man wi t h a mi nor bl eed who i s known t o have haemophi l i a B and us ual l y recei ves benefi x s houl d recei ve 65 70 = 4550 uni t s (round t o t he neares t vi al = 4500 uni t s ).
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Combined t hrombot ic and haemorrhagic disorders
Combined
thrombotic and haemorrhagic disorders

A group of di s orders i n whi ch t he pat hways of haemos t as i s become deregul at ed, l eadi ng t o mi crot hrombus format i on, pl at el et cons umpt i on, and t o a vari abl e ext ent , cl ot t i ng fact or cons umpt i on. The exact pat hogenes i s vari es , but i n each cas e mi crot hrombi caus e organ damage, and t hrombocyt openi a res ul t s i n bl eedi ng. Thi s co-exi s t ence of t hrombos i s and bl eedi ng makes management very di ffi cul t .
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Disseminat ed int ravasc ular c oagulat ion (
Disseminated
intravascular coagulation (DIC)

An i nappropri at e act i vat i on of t he coagul at i on pat hways l eadi ng t o
Depl et i on of cl ot t i ng fact ors , caus i ng prol ongat i on of PT and APT T W i des pread t hrombi n act i vat i on, caus i ng i nc reas ed T T and reduc ed fi bri nogen Format i on of mi crot hrombi , l eadi ng t o end-organ damage Des t ruct i on of RBCs i n fi bri n mes h, caus i ng mi c roangi opat hi c haemol ys i s Cons umpt i on of pl at el et s ; t hromboc yt openi a i ncreas i ng t he bl eedi ng t endency Act i vat i on of t hrombol ys i s (rai s ed FDPs ) and furt her bl eedi ng.
The ful l hous e of abnormal i t i es does not need t o be pres ent i ni t i al l y, as t he proces s i s a progres s i ve one.
Management
T reat t he underl yi ng c aus e (60% have underl yi ng s eps i s ). Support i ve meas ures s uch as correct i on of s hock, aci dos i s , and hypoxi a may l ead t o an i mprovement i n t he coagul opat hy. Trans fus e bl ood t o correct anaemi a. Mas s i ve t rans fus i on may exacerbat e coagul opat hy by di l ut i on of coagul at i on fact ors and pl at el et s .
Product replacement
In acut e DIC cons i der
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FFP (15ml /kg, i .e. 45 uni t s ) i f PT or APTT >1.5 cont rol 1 uni t pl at el et s i f pl at el et count <50 10 /L or <100 10 /L and rapi dl y fal l i ng
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Cryopreci pi t at e (1015 uni t s ) i f fi bri nogen <500 g/L.
Prot ei n C concent rat e has been us ed i n non-randomi zed t ri al s for s evere s eps i s and meni ngococcal s ept i caemi a wi t h s ome s ucces s , but i s not yet wi del y avai l abl e. Pl as ma exchange may al s o be cons i dered.
Prognosis
In s evere acut e DIC overal l mort al i t y i s hi gh. Obs t et ri c compl i cat i ons have t he bes t prognos i s i f managed expedi ent l y. There i s l i t t l e evi dence t hat meas ures t o prevent t hrombos i s (hepari n, ant i t hrombi n III) or prevent t hrombol ys i s i mprove t he general prognos i s . P.703
Causes of DIC
Common

Gram -ve s ept i caemi a St aph. aureus s eps i s Meni ngococcal s ept i caemi a Mal ari a (es p. fal c i parum ) Di s s emi nat ed mal i gnancy
o o
Muci nous adenocarci nomas Pros t at i c carci noma
Li ver fai l ure Incompat i bl e bl ood t rans fus i on Severe t rauma/burns Acut e promyel ocyt i c l eukaemi a
o
Rarer

Obs t et ri c emergenci es
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ABC Ambe r CHM Conve rte r Tria l ve rsion, http://w w w .proce sste x t.com/a bcchm.html o o o o
Abrupt i o pl acent ae Amni ot i c fl ui d embol i s m Ret ai ned dead foet us Severe pre-ecl amps i a
Anaphyl axi s (e.g. s nake bi t es ) Hypoxi a Haemangi oma
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > T hrombot ic t hromboc yt openic purpura (
Thrombotic
thrombocytopenic purpura (TTP) and haemolytic-uraemic syndrome (HUS)

The pri mary event appears t o be endot hel i al damage, caus i ng mi crot hrombus format i on, end-organ damage (es p. brai n, ki dneys ), and pl at el et cons umpt i on. Pat i ent s wi t h cl as s i c TTP have been found t o have an ant i body agai ns t a met al l oprot ei nas e (ADAMTS-13) whi ch cl eaves very l arge mul t i mers of von W i l l ebrand fact or. Thes e t hen accumul at e and caus e mi crot hrombi and t hrombocyt openi a. The cl i ni cal pi ct ure t ends t o vary wi t h age, renal abnormal i t i es bei ng more common i n chi l dren and neurol ogi cal probl ems i n adul t s , but wi t h cons i derabl e overl ap.
Presentation
Mos t commonl y occurs s uddenl y i n a young or mi ddl e-aged woman, or fol l owi ng a vi ral i nfect i on Fever Anaemi a (haemol yt i c pi ct ure: as s oci at ed wi t h jaundi ce and haemogl obi nuri a) Thrombocyt openi a wi t h purpura and bl eedi ng CNS (confus i on, headache, meni ngi t i c s ympt oms , aphas i a, vi s ual di s t urbance, fi t s , coma, paral ys i s , ps ychos es oft en fl uct uat i ng) Renal i nvol vement (ol i guri a, anuri a, haemat uri a) oft en mi l d i ni t i al l y HUS i s oft en preceded by gas t roent eri t i s or URTI.
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Investigations
FBC Bl ood fi l m Cl ot t i ng U&Es Anaemi a wi t h t hrombocyt openi a. Moderat e l eukocyt os i s wi t h l eft -s hi ft Fragment ed RBCs , pol ychromas i a, t hrombocyt openi a Us ual l y normal In adul t s , creat i ni ne s l ow t o ri s e over a few days ; rapi d det eri orat i on more common i n chi l dren LFTs Bi l i . (unconjugat ed). LDH (from haemol ys i s ) Hapt ogl obi ns Decreas ed Uri nal ys i s St ool Prot ei nuri a frequent ; haemat uri a, haemogl obi nuri a Cul t ure, es peci al l y for E. c ol i s t rai ns .
Associations of TTP and HUS

Recognized

HIV i nfect i on SLE Normal pregnancy Drugs (OCP, cycl os pori n) Gas t roent eri t i s (es p. wi t h E. c ol i , t ype 0157 : H7 i n chi l dren)
Controversial

Coxs acki e B i nfect i on Myc opl as ma Mal i gnanci es Bee s t i ngs Radi ot herapy
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Mic roangiopat hic haemolyt ic anaemia
Microangiopathic
haemolytic anaemia
Management of HUS and TTP

Refer t o s peci al i s t uni t (renal and/or haemat ol ogy). Gi ve FFP whi l e arrangi ng urgent pl as ma exchange. Pl as ma exchange: aggres s i ve regi men (65140ml /kg/day) wi t h FFP res ul t s i n i mprovement (and pos s i bl y cure) of TTP i n many pat i ent s . Tai l onl y aft er remi s s i on obt ai ned. St eroi ds us ed wi t h pl as ma exchange may be effect i ve. Di al ys i s (haemodi al ys i s or peri t oneal di al ys i s ) i s us ed for acut e renal fai l ure (us ual l y chi l dren). Broad-s pect rum ant i bi ot i cs : unproven benefi t , but s eem s ens i bl e gi ven i nfect i ous aet i ol ogy i n s ome pat i ent s . Bl ood t rans fus i on t o correct anaemi a. Pl at el et t rans fus i on c ont rai ndi c at ed ; exacerbat es t hrombos i s and may wors en t he s i t uat i on. As pi ri n may be us ed once pl at el et count i s >50 10 /L. Refract ory TTP may res pond t o hi gh-dos e s t eroi ds , vi ncri s t i ne, or cycl os pori n.
9
Prognosis
Chi l dren/predomi nant HUS pi ct ure: 530% mort al i t y. Renal i mpai rment and hypert ens i on i s common i n s urvi vors . Adul t s /predomi nant TTP pi ct ure: 90% mort al i t y i f unt reat ed; mos t di e i n fi rs t few days . W i t h aggres s i ve and earl y pl as ma exchange, mort al i t y i s now 710%, but
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rel aps es are frequent .
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Heparin- assoc iat ed t hromboc yt openia
Heparin-associated
thrombocytopenia
An i di os yncrat i c react i on s een i n 12%. Much l es s common wi t h l ow-mol ecul ar-wei ght hepari ns . It may be mi l d and t rans i ent i n t he fi rs t week, oft en res ol vi ng s pont aneous l y wi t h cont i nued t herapy. Lat e-ons et t hrombocyt openi a i s s een 10 days t o 2 weeks aft er s t art i ng t herapy and i s caus ed by an IgG aut oant i body t hat res ul t s i n pl at el et act i vat i on, haemorrhage and, i n 740%, t hromboembol i c event s . Cons i der t he di agnos i s i f t he probl em demandi ng hepari ni zat i on does not res ol ve or wors ens whi l e t he pat i ent i s on hepari n (e.g. propagat i on of DVT) or a new t hrombot i c event t akes pl ace i n a hepari ni zed pat i ent .
Management
As for hepari n i nduced t hrombocyt openi a and t hrombos i s .
St op hepari n i mmedi at el y. Do not wai t t o s ee what happens t o t he pl at el et count . Cons i der hepari n al t ernat i ves s uch as hi rudi n or danaporoi d (di s cus s wi t h your haemat ol ogi s t s ). Low-mol ecul ar-wei ght hepari ns can have a cros s -over effect , and perpet uat e t he probl em. Swi t ch t o warfari n as s oon as pos s i bl e. Do not gi ve pl at el et s t o t reat t hrombocyt openi a, as t hi s can l ead t o furt her pl at el et act i vat i on and t hrombos i s .
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Ac ut e leukaemias: present at ion
Acute leukaemias:
presentation
Types of acute leukaemia Acute lymphoblastic leukaemia (ALL)

Us ual l y B-cel l , occas i onal l y T-cel l i n ori gi n Mai nl y chi l dren and young adul t s .
Acute myeloid leukaemia (AML)

Cl as s i fi ed i nt o t ypes M1M7 (FAB t ypes ) Mai nl y adul t s , i ncl udi ng el derl y.
Bot h AML and ALL can devel op by t rans format i on of chroni c myel oi d l eukaemi a, or s econdary t o an underl yi ng myel odys pl as t i c s yndrome, as wel l as occurri ng de novo .
Poor prognostic factors

Increas i ng age Hi gh whi t e cel l count at pres ent at i on Underl yi ng myel odys pl as t i c s yndrome Phi l adel phi a chromos ome pos i t i ve acut e l eukaemi a Depends upon s ub-cl as s i fi cat i on of l eukaemi a on bas i s of morphol ogy, chromos omal abnormal i t i es , and cel l s urface markers .
Presentation Red cell problems

Anaemi a : caus ed by s uppres s i on of eryt hropoi es i s by l eukaemi a cel l s ; al s o by bl eedi ng due t o l ow pl at el et s or deranged cl ot t i ng. The MCV i s us ual l y normal or hi gh, unl es s bl ood l os s i s predomi nant .
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White cell problems
Hi gh bl as t c ount : may caus e l eucos t as i s (crudel y, s l udgi ng of whi t e cel l s i n s mal l ves s el s ), caus i ng res pi rat ory i mpai rment , myocardi al i s chaemi a/i nfarct i on, renal i mpai rment , acut e confus i on, s t roke, fi t s , mi grai ne. Leukaemi a-rel at ed phenomena : pyrexi a, mal ai s e, mus cl e and joi nt pai ns . Neut ropeni a : s econdary t o marrow i nfi l t rat i on by l eukaemi c cel l s .
Platelet problems
T hromboc yt openi a due t o myel os uppres s i on by l eukaemi c i nfi l t rat e. Exi s t i ng pl at el et s may have s ub-normal funct i on. Ri s k of bl eedi ng i ncreas es i f pl at el et s are <10 10 /L or <20 10 /L i f t here i s concomi t ant s eps i s or coagul at i on abnormal i t y.
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Coagulation problems
Range from a prol ongat i on of PT t o DI C: may be due t o s eps i s , or t he effect s of l eukaemi a i t s el f, es p. acut e promyel ocyt i c l eukaemi a (M3).
Priorities

St abi l i ze t he pat i ent Treat i mmedi at e probl ems , e.g. bl eedi ng, s eps i s Confi rm di agnos i s Defi ne t reat ment s t rat egy.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Ac ut e leukaemias: management
Acute leukaemias:
management
Airway. St ri dor may be s econdary t o medi as t i nal obs t ruct i on i n cert ai n cas es of l eukaemi a, mai nl y T-ALL. If pres ent , cal l anaes t het i s t i mmedi at el y and arrange t rans fer t o ITU. Breathing. Breat hl es s nes s may be due t o i nfect i on (i ncl udi ng at ypi cal organi s ms ), l eucos t as i s (hi gh W CC), s evere anaemi a, cardi ac fai l ure (l eucos t as i s , s evere s eps i s ), pul monary haemorrhage. Gi ve oxygen: where pos s i bl e, us e pul s e oxi met er t o moni t or oxygen s at urat i on, avoi di ng art eri al punct ure wi t h t hrombocyt openi a. Circulation. Shock i s us ual l y s econdary t o s eps i s , but cons i der t he pos s i bi l i t y of bl ood l os s i f l ow pl at el et s /cl ot t i ng abnormal i t i es , or cardi ac fai l ure from l eucos t as i s .
o o
Res t ore ci rcul at ory vol ume Gi ve broad-s pect rum ant i bi ot i cs i mmedi at el y (aft er bl ood cul t ures ) i f s eps i s s us pect ed (s ee s ect i on on febri l e neut ropeni a P718).
Refer to a haematologist .
Treat immediate problems
Infection. Unt i l t he bl ood fi l m has been revi ewed by a haemat ol ogi s t , as s ume t he pat i ent i s neut ropeni c, and t reat al l i nfect i ons aggres s i vel y. See s ect i on on febri l e neut ropeni a (P718).
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Bleeding
o
Trans fus e cros s -mat ched bl ood (CMV-negat i ve bl ood i f avai l abl e). Caut i on i f hi gh whi t e cel l count s If pl at el et s <20 10 /L, gi ve 1 i ni t of pl at el et s . If t here i s act i ve bl eedi ng and pl at el et count <50 10 /L gi ve pl at el et s
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If prot hrombi n t i me prol onged (>1.5 cont rol ), gi ve 45 uni t s FFP If fi bri nogen <500 g/L, cons i der cryopreci pi t at e i n addi t i on.
T rans fus i on i n t he pres enc e of a hi gh WCC i s dangerous , and c an prec i pi t at e t he c ompl i c at i ons of l eukos t as i s .
High WCC. Di s cus s wi t h haemat ol ogi s t s . May requi re urgent l euko-pheres i s , preferabl y i n an ITU s et t i ng.
Confirmation of diagnosis
Take a ful l hi s t ory, l ooki ng for pos s i bl e aet i ol ogi cal fact ors . Lengt h of i l l nes s (was t here a precedi ng chroni c condi t i on, e.g. myel odys pl as i a?). PMH (?Down's s yndrome, radi at i on/chemot herapy expos ure). Occupat i on (?expos ure t o i rradi at i on, benzenes , ot her mut agens ). Fami l y hi s t ory (rare fami l i al s yndromes , e.g. Fanconi 's anaemi a). Exami ne t he pat i ent , l ooki ng for acces s ory cl ues t o di agnos i s (?l ymphadenopat hy, hepat os pl enomegal y, gum hyperpl as i a) and i dent i fyi ng pot ent i al s i t es for i nfect i on (dent al cari es , s ki n l es i ons , et c.) Fi nal confi rmat i on t hen res t s upon a bone marrow as pi rat e, wi t h s ampl es bei ng s ent for morphol ogy, chromos ome anal ys i s , and cel l s urface markers .
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Ac ut e leukaemias: t reat ment
Acute leukaemias:
treatment
The t reat ment of acut e l eukaemi a depends upon t he t ype of l eukaemi a, and i nvol ves s everal cours es of chemot herapy, t aki ng mont hs or even years t o compl et e. The prognos i s has i mproved i n recent years and depends upon t he exact di agnos i s . 80% of chi l dren wi t h ALL are now cured whereas onl y around 30% of adul t s wi t h AML are cured. The i mpact of t he di agnos i s on oft en young pat i ent s and t hei r fami l i es i s devas t at i ng, and ext ens i ve t i me i s needed i n di s cus s i on. Before embarki ng on chemot herapy, t he fol l owi ng mus t be cons i dered.
Sperm banking
Al mos t al l forms of chemot herapy carry a hi gh i nci dence of s ubs equent i nfert i l i t y. W hen des i red by t he pat i ent , every at t empt mus t be made t o provi de for banki ng of s perm col l ect i on pri or t o s t art i ng chemot herapy. Unfort unat el y i n pract i ce t he pres ence of l eukaemi a i t s el f oft en makes s perm non-vi abl e, and t he need t o s t art t reat ment precl udes repeat ed col l ect i ons .
Discussion about side-effects

Pat i ent s need t o be warned about hai r l os s , s t eri l i t y, emes i s (l es s of a probl em wi t h current ant i -emet i cs , but vari es wi t h i ndi vi dual ), i nfect i ons , bl eedi ng, mucos i t i s , et c. Pat i ent -ori ent at ed l i t erat ure i s avai l abl e on acut e l eukaemi a and chemot herapy, and may be hel pful .
Other considerations
Lumbar punct ure (?CNS i nvol vement ). Indi cat ed i n

o
Acut e l ymphobl as t i c l eukaemi a
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AML i f hi gh W CC at pres ent at i on Any neurol ogi cal s ympt oms /s i gns .
HLA t ypi ng of pat i ent /s i bl i ngs may be cons i dered, wi t h a vi ew t o pos s i bl e bone marrow t rans pl ant i n t he fut ure. Thi s i s us ual l y, however, l eft t o a l at er s t age, once t he pat i ent has achi eved cl i ni cal remi s s i on. CMV s t at us s houl d be det ermi ned, and CMV-negat i ve product s admi ni s t ered t o CMV-negat i ve pat i ent s t hroughout t hei r t reat ment , es peci al l y i f bone marrow t rans pl ant at i on i s an opt i on.
Prior to commencement of chemotherapy
Commence al l opuri nol 24 hours i n advance. Ras buri cas e i s us ed i f t here i s a hi gh ri s k of t umour l ys i s s yndrome (200mcg/kg i v od for 57 days ). Pres cri be regul ar ant i s ept i c mout hwas hes , t o be us ed 45 /day i n conjunct i on wi t h ant i -t hrus h prophyl axi s (nys t at i n s us pens i on, amphot eri ci n l oz enges , or oral fl uconazol e). Ens ure adequat e hydrat i on ai mi ng for 3L/day i nput . Gi ve an ant i emet i c before chemot herapy, and at regul ar i nt erval s duri ng t reat ment wi t h chemot herapy. Appropri at e regi mes i ncl ude
o o
ondans et ron 48mg i v/po bd met ocl oprami de 1020mg i v/po pl us dexamet has one 24mg i v/po 48 hourl y.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Early c omplic at ions of bone marrow t ransplant at ion (
Early
complications of bone marrow transplantation (BMT)

Al w ays c ont ac t and refer t he pat i ent bac k t o t hei r BMT c ent re . The morbi di t y and mort al i t y fol l owi ng BMT (es peci al l y al l ogenei c BMT) i s hi gh, part i cul arl y wi t hi n t he fi rs t 100 days . The pat i ent s are very rel i ant on cl os e medi cal and nurs i ng s urvei l l ance t o ens ure t hat t hey do not peri s h from prevent abl e/t reat abl e caus es . Pat i ent s may occas i onal l y pres ent out s i de on t hei r t rans pl ant uni t overni ght or at weekends . They wi l l be vul nerabl e t o al l ki nds are i nfect i ons : bact eri al , vi ral , fungal , and prot ozoal . Even i n t he neut rophi l count as normal , t reat t he pat i ent s as bei ng neut ropeni c, and t hey wi l l have poorl y funct i oni ng l ymphocyt es and l ow ant i body product i on. The fol l owi ng i s a gui de t o s ome of t he probl ems encount ered.
Acute graft versus host disease

Thi s caus es s ki n ras hes ei t her l ocal i zed (e.g. t o pal ms ) or wi des pread. The ras h i s t ypi cal l y non-i t chy. There may be upper or l ower GI s ympt oms (s evere wat ery di arrhoea) and l i ver dys funct i on (deranged LFTs ). Mi l d GVHD of one s i t e may be accept abl e but cons i der earl y t reat ment (us ual l y hi gh-dos e met hyl -predni s ol one) for wi des pread GVHD or di arrhoea. Di s cus s wi t h t he t rans pl ant cent re.
Fever
See s ect i on on t he neut ropeni c pat i ent , P718.
Upper GI symptoms (mucositis, vomiting)

Sympt omat i c management i ncl udi ng adequat e anal ges i a (e.g.
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opi at es ) and H 2 -ant agoni s t s or PPIs . Search for an i nfect i ous caus e (mout hwas h and s wabs for HSV and Candi da ). Ant i emet i cs us ual l y requi red: l orazepam 12mg q812h, met ocl oprami de 1020mg q68h, or ondans et ron 48mg q12h.
Diarrhoea
Rehydrat e. Moni t or s t ri ct fl ui d bal ance. St ool cul t ure (green wat ery di arrhoea s ugges t s GVHD). May requi re earl y bi ops y and s t eroi ds i f l arge vol ume di arrhoea. Di s cus s wi t h t rans pl ant cent re.
Abnormal LFTs (drugs, GVHD, veno-occlusive disease)

Support i ve meas ures : moni t or fl ui d bal ance, coagul at i on t es t s , renal funct i on; adjus t drug dos es accordi ngl y. Search for an i nfect i ous aet i ol ogy. Veno-occl us i ve di s eas e pres ent s as hepat omegal y, jaundi ce, and wei ght gai n. Li ver ul t ras ound wi t h doppl er of t he hepat i c and port al vei ns (revers ed hepat i c-port al fl ow s een i n veno-occl us i ve di s eas e). Di s cus s wi t h t he t rans pl ant cent re.
Interstitial shadowing on CXR

Thes e may be di ffus e or l ocal i zed and as s oci at ed wi t h varyi ng degrees of fever, breat hl es s nes s , and hypoxi a.
Causes
Pul monary oedema (fl ui d overl oad, cardi ac fai l ure due t o chemo/radi ot herapy, non-cardi ac (ARDS)rel at ed t o s eps i s or drug t oxi ci t y); P.715 i nfect i on [bact eri al , vi ral (es p. CMV), fungal , Pneumoc ys t i s ]; t hromboembol i c; GVHD; pul monary haemorrhage; idi opat hi c.
Management
Support i ve t reat ment : oxygen, di uret i cs (i f pul monary oedema) and vent i l at ory s upport . CXR changes oft en mi nor i f neut ropeni c. Cover for i nfect i ous caus es wi t h broad-s pect rum ant i bi ot i cs , ant i -fungal
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agent s , or occas i onal l y ant i -vi ral agent s (i f vi ral RTI i s s us pect ed). PCP i s unus ual i f t he pat i ent i s on co-t ri moxazol e prophyl axi s . Cons i der bronchos copy.
Early complications of BMT

Ski n ras h GI compl i cat i ons

o o o
Naus ea and vomi t i ng Mucos i t i s Di arrhoea
Abnormal LFTs Haemorrhagi c cys t i t i s Int ers t i t i al s hadowi ng on CXR Cardi ovas cul ar compl i cat i ons
o o o
Cardi ac fai l ure Hypert ens i on Endocardi t i s
Det eri orat i ng renal funct i on CNS compl i cat i ons
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Complic at ions of bone marrow t ransplant at ion
Complications of bone
marrow transplantation
Cardiac failure
Cardi ac t oxi ci t y may be s econdary t o hi gh-dos e cycl ophos phami de, t ot al body i rradi at i on, and/or ant hracycl i ne expos ure. Trans i ent ST- and T-wave abnormali t i es and LV dys funct i on on Echo are s een i n up t o 30% fol l owi ng condi t i oni ng pri or t o BMT. Overt cardi ac fai l ure may be s een wi t h repeat ed hi gh-dos e s t eroi d t herapy t hat i s requi red for epi s odes of GVHD.
Management
St andard t herapy wi t h di uret i cs and ACE-I.
Hypertension
Very common i n t he earl y days pos t BMT and due t o cycl os pori n t herapy 9 renal i mpai rment .
Treatment
Cal ci um ant agoni s t s (e.g. ni fedi pi ne SR, 1020mg po bd).
Deteriorating renal function Causes
Drug t herapy (cycl os pori n A, amphot eri ci n, ami nogl ycos i des , chemot herapy, acycl ovi r, al l opuri nol ) Pre-renal (dehydrat i on, s hock, bl eedi ng) Tumour l ys i s s yndrome (s ee P730).
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Haemorrhagic cystitis
Frequency, dys uri a, and haemat uri a; commonl y rel at ed t o cycl ophos phami de (caus ed by acreol i n, a met abol i t e), but al s o s een wi t h ant hracycl i nes , cyt os i ne arabi nos i de, et opos i de, adenovi rus , and BK vi rus i nfect i on. Prevent wi t h mes na (s ee dat a s heet for dos e).
Management
Support i ve t herapy wi t h bl ood and pl at el et t rans fus i on and hydrat i on i s us ual l y s uffi ci ent .
CNS complications Symptoms

May i ncl ude s ei zures , drows i nes s /confus i on, focal neurol ogi cal s i gns , s t roke.
Causes
Met abol i c (Mg , Ca , hypoxi a, l i ver fai l ure, renal fai l ure) Infect i on [bact eri al , vi ral (e.g. HSV), fungal (es p. As pergi l l us ), T oxopl as ma ] Drug t oxi ci t y. Cycl os pori n can caus e t remor, confus i on, and s ei zures Int racrani al haemorrhage Cerebral i nfarct i on (embol i c) Rel aps e of di s eas e.
2+
2+
P.717
Investigations
CT s can, LP (aft er correct i ng cl ot t i ng and pl at el et s ), bl ood cul t ures , s erol ogy, Mg
2+
and Ca
2+
l evel s , Echo.
Management
Speci fi c t herapy for underl yi ng caus e.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > T he febrile neut ropenic pat ient 1
The febrile neutropenic
patient 1
Neut ropeni a (i n t hi s cont ext ) may be defi ned as a t ot al neut rophi l count of <1 10 /L, regardl es s of t ot al W CC. Si gni fi cant i nfect i ons are us ual l y as s oci at ed wi t h a fever; and a s pi ke t o 38C i s regarded as warrant i ng act i on. Severel y i l l pat i ent s may not , be abl e t o mount a fever. The s i t e of i nfect i on i s not us ual l y obvi ous ; pot ent i al s i t es i ncl ude ches t , Hi ckman, or ot her cent ral l i ne (or i nfl ammat i on around exi t s i t e of l i ne), mout h, peri anal area/peri neum, uri ne, or s ki n.
9
Organisms
Common Gram-pos i t i ve (60%) Coagul as e S -ve s t aphyl ococci S. epi dermi s St rept ococci vi ri dans s t rept ococci Gram-negat i ve (30%) Es c heri c hi a c ol i Kl ebs i el l a s pp. Ps eudomonas aerugi nos a Ot her (10%) St aph. aureus Corynebac t eri um JK Ac i net obac t er s p. Mi xed i nfect i ons Anaerobes Fungal i nfect i ons Candi da s p. As pergi l l us fumi gat us Vi ral i nfect i ons (VZV, CMV) Pneumoc ys t i s c ari ni i

A mi crobi ol ogi cal di agnos i s i s reached i n onl y 740%. Coagul as e -ve s t aphyl ococci : Hi ckman or ot her i v l i nes
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Vi ri dans s t rept ococci : mucos i t i s 9 previ ous expos ure t o qui nol ones Fungal i nfect i ons : occur aft er prol onged and profound neut ropeni a, previ ous ant i bi ot i c t herapy, underl yi ng l ung di s eas e (pul monary as pergi l l os i s ).
Basic microbiological investigations
Bl ood c ul t ures t aken from Hi ckman l i ne and by venepunct ure. Thi s al l ows l i ne i nfect i ons t o be di fferent i at ed from bact eraemi as . Cul t ure of uri ne and faec es i ncl udi ng s t ool for C. di ffi c i l e . Cul t ures from ot her s us pec t ed s i t es , e.g. l i ne exi t s i t es , s put um, s ki n l es i ons , t hroat . Vi ral s erol ogy : l es s us eful , as a ri s i ng t i t re i s oft en neces s ary t o di agnos e i nfect i on. Vi ral ant i gen/part i cl e det ect i on (e.g. CMV DEAFF t es t ), where pos s i bl e, may be more hel pful i n an acut e s i t uat i on. Li ne t i ps : rus h t o l aborat ory. Do not al l ow t o dry out on ward bench or i ns ert i nt o t hroat s wab medi um.
Important points
Ant i bi ot i c t herapy s houl d never be del ayed t o aw ai t furt her as s es s ment of c l i ni c al progres s , or l ab res ul t s . Neut ropeni c pat i ent s may not s how a l ocal i zed res pons e t o i nfect i on. The mos t common pres ent at i on i s t hat of a fever of unknown ori gi n. A pyrexi a l as t i ng >48 hours , des pi t e i v ant i bi ot i cs , us ual l y requi res s ome al t erat i on t o t he ant i -mi crobi al regi me. P.719
Platelet requirements increase with sepsis . Neut ropeni c pat i ent s are commonl y al s o t hrombocyt openi c: keep pl at el et count above 20 10 /L.
9
Pa g e 1 1 7 7
Thrombocyt openi a al s o demands care wi t h i nvas i ve procedures . Cent ral l i nes and uri nary cat het ers s houl d be i ns ert ed wi t h pl at el et cover, and art eri al punc t ure i s bes t avoi ded (us e pul s e oxi met ry).
Pa g e 1 1 7 8
patient 2
Immediate management
Gi ven t he caveat s on t he previ ous page, t he s t abi l i zat i on of a s ept i c neut ropeni c pat i ent i s s i mi l ar t o t hat of any ot her s ept i c pat i ent .
Oxygen, i v col l oi d, crys t al l oi d, and i not ropes s houl d be admi ni s t ered as i s appropri at e t o t he pat i ent 's cl i ni cal condi t i on. CVP readi ngs may be t aken from exi s t i ng cent ral l i nes t o as s es s t he pat i ent 's hydrat i on s t at us , but , wi t h Hi ckman l i nes i n part i cul ar, t he readi ngs are frequent l y not accurat e, and s houl d be i nt erpret ed i n t he cont ext of t he cl i ni cal as s es s ment .
Anti-microbial regime
W hen i n doubt , t ake mi crobi ol ogi cal advi ce; us e hos pi t al pol i cy. Regi mes for empi ri cal t herapy are bas ed on broad-s pect rum, bact eri ci dal ant i bi ot i cs . Monot herapy i s hardl y ever appropri at e, even when an organi s m has been i s ol at ed: t he pat i ent may wel l have more t han one i nfect i on. A t ypi cal pol i cy i s s hown bel ow.
Empirical antibiotic therapy for febrile neutropenia

1s t l i ne T azoc i n 4.5g i v t ds (or Meropenem 500mg i v qds i f peni ci l l i n al l ergi c) pl us Gent ami c i n 7mg/kg i v od (gui ded by l evel s ) 2nd l i ne Vanc omyc i n 1g i v bd (gui ded by l evel s )
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or T ei c opl ani n 400mg i v od (bd for fi rs t 24 hours ) i f l i ne i nfect i on i s s us pect ed 3rd l i ne Cons i der amphot eri c i n i f fever i s not s et t l i ng aft er 72 hours es peci al l y i n pat i ent s wi t h l ong peri ods of neut ropeni a (e.g. AML or BMT pat i ent s ). Di s cus s wi t h l ocal haemat ol ogi s t s and mi crobi ol ogi s t s
Notes
Dos es of vanc omyc i n and gent ami c i n wi l l need t o be adjus t ed accordi ng t o s erum l evel s . Add met roni dazol e 500mg i v q8h t o 1s t - or 2nd-l i ne regi mens i f fever pers i s t s and anaerobi c i nfect i on pos s i bl e (mucos i t i s ). Add amphot eri c i n B 200g/kg/day i v i ncreas i ng s t epwi s e t o 1mg/kg/day for 4 weeks for proven (or pos s i bl e) fungal i nfect i on. The c hange from 1s t - t o 2nd-l i ne t herapy s houl d be cons i dered under t he fol l owi ng ci rcums t ances
o
Pers i s t ent pyrexi a >48 hours (or l es s i f t he pat i ent 's condi t i on markedl y det eri orat es ) A new s pi ke of t emperat ure once t he fever has s et t l ed on 1s t -l i ne ant i bi ot i cs (s ugges t i ng emergence of anot her, res i s t ant organi s m) Ri s i ng CRP i n t he face of apparent l y appropri at e ant i bi ot i cs .
Choi ce of 3rd-l i ne ant i bi ot i c s i s oft en more arbi t rary, and combi nat i ons s houl d agai n be di s cus s ed wi t h t he mi crobi ol ogi s t s . Durat i on of neut ropeni a i s an i mport ant fact or, as fungal i nfect i ons become more l i kel y t he l onger t he peri od of neut ropeni a.
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patient 3
Particular situations
I nfec t i ons of t he mout h, peri anal area, or el s ew here i n t he GI t rac t : cons i der addi ng met roni dazol e . Sus pec t ed l i ne i nfec t i ons : ens ure good gram-pos i t i ve cover ( vanc omyc i n or t ei c opl ani n ). Di arrhoea aft er prol onged ant i bi ot i c t herapy : s us pect Cl os t ri di um di ffi c i l e ; cons i der empi ri cal oral vanc omyc i n or met roni dazol e whi l e awai t i ng s t ool cul t ure res ul t s . Orophyrangeal mucos i t i s due t o reac t i vat i on of herpes s i mpl ex vi rus i s common. It i s effect i vel y t reat ed wi t h ac yc l ovi r; t he mai n compl i cat i on i s bact eri al s uper i nfect i on. Pyrexi as as s oc i at ed w i t h a normal CRP vi rt ual l y excl ude bact eri al or fungal i nfect i on as a caus e of t he fever. Det eri orat i ng renal func t i on : avoi d nephrot oxi c agent s , part i cul arl y i n combi nat i on (e.g. vancomyci n, amphot eri ci n, gent ami ci n). Sys t emi c c andi di as i s may be mani fes t onl y as fever unres pons i ve t o ant i bi ot i cs : bl ood cul t ures are rarel y pos i t i ve; s i gns of l ocal i nvas i on, (e.g. endopht hal mi t i s ) are s een i n a mi nori t y. Have a hi gh i ndex of s us pi ci on and t reat aggres s i vel y wi t h amphot eri ci n or fl uconazol e. I nvas i ve as pergi l l os i s pres ent s as fever, abnormal CXR and dys pnoea, or s i nus i t i s (i nvas i ve di s eas e of s i nus es ). There i s ext ens i ve l ocal t i s s ue des t ruct i on
Pa g e 1 1 8 1
wi t h cavi t at i ng l ung l es i ons or bone des t ruct i on of s i nus es . Treat aggres s i vel y wi t h i v amphot eri ci n.
GCSF may s hort en a peri od of neut ropeni a and may be us ed for cert ai n pat i ent s . Di s cus s wi t h t he haemat ol ogi s t s .
W hen s el ect i ng an ant i -mi crobi al regi me, i t i s wort hwhi l e revi ewi ng al l recent mi crobi ol ogy res ul t s , i ncl udi ng s ki n s wabs (axi l l a, groi n, peri neal ).
Causes of failure to respond to empirical antibiotics
W rong mi crobi ol ogi cal di agnos i s Cons i der i nfect i on wi t h fungi , vi rus es , prot ozoa, mycobact eri a Li ne-as s oci at ed fever Graft vers us hos t di s eas e (al s o pos s i bl e wi t h l i ver t rans pl ant at i on) Drug fever Inadequat e ant i bi ot i c dos es Underl yi ng di s eas e (e.g. rel aps e)
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Infec t ions in t he t ransplant pat ient
Infections in the
transplant patient
Infect i ous di s eas es are a major caus e of mort al i t y and morbi di t y fol l owi ng bot h s ol i d organ and bone marrow t rans pl ant at i on, rel at ed t o t he i mmunos uppres s i on (and i n t he cas e of BMT, t he i nnat e i mmuno-i ncompet ence i n t he neut ropeni c and earl y engraft ment phas es ). Di fferent pat hogens are t ypi cal l y i mpl i cat ed i n i nfect i ons dependi ng on t he degree of i mmunocompet ence of t he pat i ent :

The neut ropeni c pat i ent (s ee P718) The non-neut ropeni c t rans pl ant pat i ent .
Cel l -medi at ed i mmuni t y may be i mpai red for s everal mont hs aft er bone marrow (and s ol i d organ) t rans pl ant at i on. Thi s predi s pos es t o vi ral (CMV, HSV, adenovi rus ) and prot ozoal ( Pneumoc ys t i s c ari ni i , t oxopl as mos i s ) i nfect i ons .

Cyt omegal ovi rus i nfec t i ons : s ee P726. Sus pec t ed Pneumoc ys t i s pneumoni a : t reat wi t h hi gh-dos e s ept ri n ; (0.961.44g q12h i v); cons i der urgent bronchos copy/broncho-al veol ar l avage. T oxopl as mos i s : us ual l y due t o react i vat i on of l at ent i nfect i on. Pres ent s as i nt ra-crani al s pace-occupyi ng l es i on, meni ngoencephal i t i s , or di ffus e encephal opat hy. Sei z ures and focal neurol ogi cal s i gns are common. Treat ment i s wi t h pyri met hami ne and s ul phonami des . Ot her vi ral i nfec t i ons
o
HSV commonl y produces l ocal i zed i nfect i on and di s s emi nat i on i s rare but recogni zed t o produce encephal i t i s and pneumoni a: Treat wi t h hi gh-dos e ac yc l ovi r i v.
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VZV react i vat i on i s frequent l y s een and mos t i nfect i ons are mi l d; encephal i t i s and pneumoni t i s are us ual l y fat al . Treat wi t h hi gh-dos e ac yc l ovi r (10mg/kg i v q8h). Adenovi rus i nfect i on produces an i nt ers t i t i al pneumoni t i s s i mi l ar t o CMV and may di s s emi nat e.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Cyt omegalovirus (
Cytomegalovirus (CMV)
infections in transplant patients

Al s o s ee P351. May be acqui red from t he react i vat i on of previ ous CMV i nfect i on i n reci pi ent , due t o i mmunos uppres s i on. May be acqui red from t he bone marrow from a CMV-pos i t i ve donor or CMV-pos i t i ve bl ood product s . ( Al l BMT rec i pi ent s s houl d rec ei ve CMV-negat i ve bl ood produc t s i f t hey are CMV I gG negat i ve pri or t o BMT . CMV IgG-pos i t i ve reci pi ent s can recei ve uns creened bl ood product ). Do not us ual l y occur unt i l day 21 fol l owi ng BMT. Occur more commonl y i n al l ogeni c and unrel at ed donor t rans pl ant s , due t o t he great er i mmunos uppres s i on.
Presentation of acute CMV infections

Fever of unknown ori gi n. Ant i genaemi a (det ect ed by rout i ne CMV-ant i gen t es t i ng, bl ood and uri ne). Graft fai l ure/myel os uppres s i on (anaemi a, t hrombocyt openi a, l eukopeni a). Int ers t i t i al pneumoni t i s : det eri orat i ng oxygen s at urat i on, wi t h wi des pread bi l at eral i nt ers t i t i al opaci t i es on CXR. Ent eri t i s (oes ophagi t i s , gas t ri t i s , col i t i s ): pyrexi a, di arrhoea. Hepat i t i s .
Immediate management
Ens ure adequat e res pi rat i on; cons ul t anaes t het i s t s and
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cons i der CPAP/vent i l at i on earl y i f oxygen requi rement s are i ncreas i ng, or t he pat i ent i s becomi ng exhaus t ed.

Inform haemat ol ogi s t res pons i bl e for pat i ent 's care. Take bl ood for CMV ant i gen, cul t ure, and ant i body t es t i ng. Send uri ne s ampl e for CMV ant i gen. If CMV i s s t rongl y s us pect ed, commence ganci cl ovi r t reat ment i mmedi at el y. Ot herwi s e, cons i der
o
bronchos copy/bronchoal veol ar l avage i f pul monary i nfi l t rat e (s end was hi ngs for CMV ant i gen) upper GI endos copy and bi ops y.
Treatment

Ganc i c l ovi r s houl d be commenced at 2.5mg/kg i v t ds . Si de-effect s of ganci cl ovi r i ncl ude nephrot oxi ci t y, and myel os uppres s i on/graft fai l ure, whi ch may be di ffi cul t t o di s t i ngui s h from t he effect s of CMV i t s el f.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Hypervisc osit y syndrome
Hyperviscosity syndrome
Causes
Increased cellularity Pol ycyt haemi a (p or s ) Haemat ocri t . 5060% Leukocyt os i s (acut e l eukaemi as ) W CC >50100 10 /L Paraprot ei n l evel >80g/L
9
Raised plasma proteins W al dens t rom's macrogl obul i naemi a IgM paraprot ei n l evel >30g/L Myel oma us ual l y IgA s ubt ype
Presentation
Mos t pat i ent s devel op s ympt oms when s erum vi s cos i t y reached 56 cent i poi s es (normal <1.8).
General features

Mus cl e weaknes s Let hargy, headache Ment al confus i on, proceedi ng t o coma Vi s ual di s t urbance Conges t i ve cardi ac fai l ure Fundos copy
o o o
engorgement and s l udgi ng i n t he vei ns haemorrhage, exudat es papi l l oedema.
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Specific features
The predomi nant s ympt oms vary wi t h t he underl yi ng caus e.
Rai s ed paraprot ei n
o
Bl eedi ng/purpura: pl at el et dys funct i on and fact or defi ci ency Neuropat hi es Renal i mpai rment Cardi ac conduct i on abnormal i t i es . Myocardi al i s chaemi a/i nfarct i on Pul monary i nfi l t rat es . Peri pheral i s chaemi a Trans i ent i s chaemi c at t acks /s t rokes Myocardi al i nfarct i on.
o o o
Leuc os t as i s
o o
Pol yc yt haemi a
o o o
Management
Arrange urgent i nt ervent i on (s ame day) dependi ng on caus e. Pol ycyt haemi a Venes ect 12 uni t s Repl ace wi t h N s al i ne Leukaemi a Hi gh paraprot ei n Leucopheres i s or chemot herapy Pl as mapheres i s
Page 1188
> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > T umour lysis syndrome
Tumour lysis syndrome
A s yndrome of met abol i c abnormal i t i es and renal i mpai rment t hat can occur wi t hi n hours or days of commenci ng chemot herapy, due t o rapi d l ys i s of t umour cel l s . It i s mos t l i kel y t o occur wi t h bul ky, hi ghl y chemos ens i t i ve di s eas e (e.g. l ymphomas , hi gh bl as t -count l eukaemi as , germ-cel l t umours ).
Features
Hyperuri caemi a urat e nephropat hy and ol i guri c renal fai l ure. Hyperkal aemi a (es peci al l y wi t h progres s i ve renal i mpai rment ). Hyperphos phat aemi a. Hypocal caemi a and hypomagnes aemi a (due t o ri s i ng phos phat e). Cardi ac arrhyt hmi as (s econdary t o K , Ca , and Mg ).
2+ + 2+
W eaknes s , t wi t chi ng, t et any (hypocal caemi a). Severe met abol i c aci dos i s (renal fai l ure).
Management

Emergency t reat ment of hyperkal emi a. Excl ude bi l at eral uret eri c obs t ruct i on by ul t ras ound. Al kal i ni ze t he uri ne (P834) i f hyperuri caemi a i s pres ent . St op as s oon as urat e l evel s normal . Avoi d cal ci um s uppl ement s except i f t here i s neuromus cul ar i rri t abi l i t y. Moni t or U&Es , PO 4 , Ca , and urat e at l eas t t wi ce dai l y for t he fi rs t few days of t reat ment . St ri ct fl ui d bal ance meas urement s , wi t h uri nary cat het er i f neces s ary.
32+
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Indi cat i ons for haemodi al ys i s /i nt ens i ve care

o
Ri s i ng K , creat i ni ne, or PO 4 i n s pi t e of meas ures above Met abol i c aci dos i s Fl ui d overl oad or ol i guri a i n s pi t e of di uret i cs .
o o
Prevention
St art al l opuri nol 300mg od (or bd) 48 hours pri or t o chemot herapy. Some uni t s us e ras buri cas e for hi gh-ri s k pat i ent s (200mcg/kg i v od for 57 days ). Hyperhydrat e (i v fl ui ds , 35 l i t res /24 hours ) pri or t o chemot herapy. Uri ne al kal i ni zat i on hel ps promot e urat e excret i on. Leuc opheres e i f hi gh peri pheral bl as t count . Cont i nue i v fl ui ds duri ng t herapy, gi vi ng frus emi de t o mai nt ai n di ures i s .
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Hyperc alc aemia of malignanc y
Hypercalcaemia of malignancy
2+
See P580

Urgent i nt ervent i on requi red i f Ca NB: t rue Ca 0.02].

2+
>3mmol /L
= meas ured Ca
2+
+ [(40 - al bumi n)
Causes

Bony met as t as es : probabl e l ocal cyt oki ne effect Myel oma: s ecret i on of an os t eocl as t -act i vat i ng fact or Secret i on of PTH-rel at ed pept i de (non-s mal l cel l l ung cancer).
Presentation
Naus ea, vomi t i ng, drows i nes s , confus i on, noct uri a, pol yuri a, bone and abdomi nal pai ns , cons t i pat i on.
Management
Hydrat i on: 34L over 24 hours , cont i nui ng for 45 days . Frus emi de t o mai nt ai n di ures i s ; has an addi t i onal Ca -l oweri ng effect . Fol l owi ng overni ght hydrat i on recheck Ca , al bumi n. If s ympt oms pers i s t , and/or Ca is
2+ 2+ 2+
remai ns >3mmol /L,
gi ve pami dronat e di s odi um i v. A t ypi cal dos i ng regi men
Ca <3mmol /L 2+ Ca 34mmol /L 2+ Ca >4mmol /L
2+
30mg over 4 hours 60mg over 8 hours 90mg over 24 hours .
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For myel oma, cons i der predni s ol one 3060mg po dai l y.
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Superior vena c ava obst ruc t ion
Superior vena cava
obstruction
Presentation
Awarenes s of ful l nes s of head and t i ght nes s of col l ar, s ympt oms exacerbat ed by bendi ng down, s yncope, breat hl es s nes s , faci al s uffus i on and oedema, engorgement of vei ns i n neck, arms , and upper t horax.
Causes
Us ual l y bronchogeni c carci noma (9 s econdary t hrombos i s of SVC) Ot her t umours , i ncl udi ng l ymphoma, more rarel y.
Management

FBC and fi l m, U&Es , Ca , al bumi n CXR, Doppl er USS of neck vei ns i f di agnos i s uncert ai n Hepari n, provi di ng pl at el et count and cl ot t i ng funct i on are normal Arrange urgent radi ot herapy (wi t hi n 24 hours ).
2+
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> T able of Cont ent s > Chapt er 11 - Haemat ologic al emergenc ies > Massive mediast inal mass
Massive mediastinal mass
Presentation
Dry cough, s t ri dor and dys pnoea, es peci al l y on l yi ng fl at .
Causes

ALL (es peci al l y T-ALL wi t h hi gh W CC) Hi gh-grade non-Hodgki n's l ymphoma Hodgki n's di s eas e Germ cel l t umour.
Management
Hi s t ol ogi cal di agnos i s (or cyt ol ogi cal from pl eural effus i on i f pres ent ) General anaes t het i c carri es cons i derabl e ri s k Defi ni t i ve t reat ment (radi ot herapy or chemot herapy) Cons i der predni s ol one 1mg/kg/day i f urgent t reat ment i s requi red.
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> T able of Cont ent s > Chapt er 12 - Rheumat ologic al emergenc ies
Chapter
12 Rheumatological emergencies
P.736
Acute monoarthritis: presentation

An acut e monoart hri t i s s houl d al ways be t reat ed as s ept i c art hri t i s unt i l proved ot herwi s e. Fai l ure t o t reat s ept i c art hri t i s i s a medi cal di s as t er. 50% of cart i l age prot eogl ycan i s l os t wi t hi n 48 hours ; bone l os s i s evi dent wi t hi n 7 days ; mort al i t y of St aph. aureus art hri t i s i s 10%.
Presentation

Hot , s wol l en red joi nt Joi nt l i ne t endernes s Res t ri ct ed range of movement Sys t emi c feat ures of fever and mal ai s e.
Assessment
Look for any ri s k fac t ors for i nfec t i on :

Di abet es mel l i t us Immunodefi ci ency s t at e (monoart hri t i s i s rare i n AIDS) Underl yi ng s t ruct ural joi nt di s eas e (e.g. rheumat oi d art hri t i s or ot her deformi ng art hropat hy, pros t hes i s ) Sexual i mpropri et y, i nt ravenous drug abus e (predi s pos es t o s acroi l ei t i s and acromi ocl avi cul ar joi nt i nfect i on) Tubercul os i s needs t o be cons i dered i n at ri s k popul at i ons (e.g. As i ans ).
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As k for ri s k fac t ors for gout :

Al cohol Hi gh-puri ne di et (prot ei n, e.g. meat ) Drugs (e.g. t hi azi des , frus emi de, et hambut ol ) Hi gh cel l t urnover s t at es (e.g. l ymphoma, pol ycyt haemi a, ps ori as i s ).
Exami ne for evi denc e for mul t i -s ys t em di s eas e :

Ras h Ocul ar i nvol vement Oro-geni t al ul cerat i on Gas t roi nt es t i nal s ympt oms Renal i nvol vement Pul monary mani fes t at i ons .
Conditions that mimic monoarthritis

Bone pai n or fract ure cl os e t o a joi nt Tendi ni t i s (es peci al l y at t he wri s t ) Burs i t i s (commonl y ol ecranon or pre-pat el l ar burs ae; no joi nt l i ne t endernes s ) Neuropat hi c pai n Soft t i s s ue pai n.
P.737
Differential diagnosis of a monoarthritis Traumatic

Traumat i c s ynovi t i s Haemart hros es Fract ure Haemophi l i a Rupt ured ant eri or cruci at e l i gament
Non-traumatic
Infective
St aphyl oc oc c us aureus
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Nei s s eri a gonoc oc c us St aphyl oc oc c us al bus St rept ococcal Gram negat i ve rods Uri c aci d (gout ) Cal c i um pyrophos phat e (ps eudogout ) Hydroxyapat i t e [us ual l y a monoart hri t i s (s houl der) i n el derl y pat i ent s ]
Crystals

Monoarticular presentation of

Rheumat oi d art hri t i s Seronegat i ve art hri t i s (e.g. Rei t ers , ps ori as i s ) SLE
Miscellaneous

Pi gment ed vi l l onodul ar s ynovi t i s Secondary depos i t s Os t eos arcoma
Practice point
Al ways as s ume an unexpl ai ned monoart hri t i s i s due t o s eps i s unt i l proved ot herwi s e.
P.738
Acute monoarthritis: investigations

1 Synovi al fl ui d anal ys i s: as pi rat e t he joi nt
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to drynes s (s ee p946) and s end fl ui d for Fl u C id y be pl a ced in ED TA t ub e Fl u id Mi c i nt rob o i ol s t e ogy ri l e con t ai ner an d a sa mp le i nt W B ma
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o bl o od cul t ur e bot tle s an d for AF Bs For cry Pol s t a ari l s ; z ed fl ui mi c d ros i nt cop o y ste ri l e con t ai ner . 2 T ake bl ood for Bl o od
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cul t ur es W B C C h in i nf ect i on an d cry sta l art hri t is El e vat CR ed P/E wi t SR h an i nfl am ma t or y art hri t is El e vat FB hi g
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ed ES R an d nor ma l CR P s ug ges t SLE Ma y U& be Es , i m LFT pai s red wi t h s ep sis ?Di ab Gl u et i cos c e ?G Uri c aci d out
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Bl e edi Cl o ng t t i di a ng t he sis cau sin g ha em art hro sis RF, AN Im A, mu ant nol i -d ogy s D NA, co mp le me nt l ev el s (?R A or SLE ). 3 X-ray
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t he joi nt : Chondr ocal ci n os i s s ugges ts ps eudo gout . But not hel pful i n t he earl y di agno s i s of a s ept i c art hri t i s as t he appear ance may be unchan ged for up t o 2 weeks in i nfect i on. 4 Seps i s
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s c reen : Cervi c al , rect al , and t hroat s wabs . As pi rat e any cut ane ous pus t ul es for gram s t ai n in pat i en t s wi t h s us pec t ed gonoco ccal i nfect i on.
Indications for synovial fluid aspiration in casualty

Sus pect ed s ept i c art hri t i s Sus pect ed crys t al art hri t i s Sus pect ed haemart hros i s Rel i ef of s ympt oms by removal of effus i on i n degenerat i ve art hri t i s
Contraindications to joint aspiration
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Overl yi ng s eps i s Bl eedi ng di at hes i s
P.739
P.740
Septic arthritis
The commones t pat hogen i n t he UK i s St aph. aureus (70%). N. gonorrhoea i s a common caus e i n t he young s exual l y act i ve popul at i on. Ot her i mport ant caus es i ncl ude St rept oc oc c i . H. i nfl uenzae s houl d be cons i dered i n chi l dren.
Management

Admi t and i nform ort hopaedi c t eam. As pi rat e t he joi nt t o drynes s . Li ai s e wi t h t he ort hopaedi c t eam and cons i der earl y art hros copy t o faci l i t at e effect i ve joi nt was hout es peci al l y i f i nfl ammat ory markers are s l ow t o fal l . St ri ct res t for t he joi nt (bed res t ) and no wei ght beari ng on i nfect ed joi nt s . Anal ges i cs (NSAIDs ). Cons i der addi ng H 2 -ant agoni s t i f hi s t ory of dys peps i a.
Antibiotics
Ini t i al l y i nt ravenous for 2 weeks , t hen oral for a furt her 4 weeks . Emperi cal l y s t art wi t h fl uc l oxac i l l i n 1g q6h and benzyl peni c i l l i n 1.2g q4h. For peni ci l l i n al l ergy us e vanc omyc i n and c l i ndamyc i n . In young chi l dren us e cefot axi me t o cover H. I nfl uenzae . (NB: ami nogl ycos i des are not effect i ve i n t he aci d pH of an i nfect ed joi nt ; eryt hromyci n penet rat es t he s ynovi al fl ui d poorl y.) Revi ew ant i bi ot i cs when mi crobi ol ogy avai l abl e.
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For gonococcal art hri t i s , t reat wi t h i .v. benzyl peni c i l l i n 1.2g q4h for 7 days and t hen po amoxyc i l l i n 500mg t ds for 10 days . Remember t o t race and t reat cont act s (l i as e wi t h GU medi ci ne t eam).
Crystal arthropathy Management

May us ual l y be managed as an out -pat i ent . Bed res t . Anal ges i cs . NSAI Ds , e.g. di cl ofenac SR 75 mg bd (us e caut i ous l y i n t he el derl y, pat i ent s wi t h pept i c ul cerat i on, or pat i ent s wi t h cardi ac fai l ure, renal , or l i ver di s eas e). Col c hi c i ne i s a good al t ernat i ve i f NSAIDs are cont rai ndi cat ed. Gi ve 1mg i ni t i al l y fol l owed by 500g every 6 hours for t he fi rs t 48 hours , mai nt enance dos e 500g bd. Gi ve one dos e of cort i cos t eroi d ( predni s ol one EC 30mg po) t o hel p reduce t he i nfl ammat i on acut el y and reduce s ympt oms . Do not gi ve s t eroi ds i f t here i s any pos s i bi l i t y of s ept i c art hri t i s . Rheumat ol ogy cons ul t at i on i f s ympt oms fai l t o s et t l e; i nt ra-art i cul ar cort i cos t eroi d may be gi ven. Bot h al l opuri nol and probeneci d are cont rai ndi cat ed duri ng acut e gout as bot h may prol ong s ympt oms . They may be s t art ed for prophyl axi s when t he acut e at t ack has s et t l ed i f t he pat i ent has had more t han t hree at t acks of acut e gout i n 1 year, i f t ophi are pres ent , or s erum uri c aci d l evel s are hi gh. Ini t i at i on of t hes e drugs s houl d be accompani ed by ei t her a NSAID or col chi ci ne for t he fi rs t 2 weeks .
P.741
P.742
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Polyarthritis Presentation

Pai n St i ffnes s (es p. earl y morni ng) Los s of funct i on Joi nt i nfl ammat i on
Rheumat oi d art hri t i s Seronegat i ve art hri t i s

Ps ori at i c art hropat hy React i ve art hri t i s Ankyl os i ng s pondyl i t i s Ent eropat hi c art hri t i s
Sys t emi c l upus eryt hemat os us Crys t al art hropat hy

Chondrocal ci nos i s Gout Vi ral Bact eri al
I nfec t i ons

Miscellaneous
Sarcoi d: as s oci at ed wi t h eryt hema nodos um (20%), and a t rans i ent RA l i ke pol yart hri t i s or acut e monoart hri t i s . Behet 's s yndrome: pol yart hri t i s (9 eryt hema nodos um) wi t h pai nful orogeni t al ul cerat i on and i ri t i s . Fami l i al medi t erranean fever: occurs i n mi ddl e eas t ern i ndi vi dual s wi t h recurrent at t acks of fever, art hri t i s (us ual l y monoart i cul ar), abdomi nal or ches t pai n (pl euri s y). Trans i ent pol yart hri t i s may be as s oci at ed wi t h SLE, bact eri al endocardi t i s (p120), para-i nfect i ous , Rei t er's , react i ve art hri t i s , and HenochSchnl ei n purpura.
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Investigations
As pi rat e a l arge affect ed joi nt and anal ys e s ynovi al fl ui d (s ee p946) Bl ood cul t ures i f appropri at e FBC wi t h di fferent i al count CRP and/or ESR Bi ochemi cal profi l e (U&Es , LFTs , urat e) and gl ucos e Rheumat oi d fact or, ANA, ant i -ds DNA (RA and SLE) Compl ement l evel s Vi ral s erol ogy X-rays (may s how chondrocal ci nos i s t ypi cal l y knees and wri s t s , or earl y changes of rheumat oi d art hri t i s wi t h peri art i cul ar os t eoporos i s ).
Management
General measures

Bed res t : res t for t he affect ed joi nt s . NSAIDs , e.g. i ndomet haci n 50mg t ds adjus t i ng dos e accordi ng t o s ympt oms and res pons e (caut i on i n el derl y pat i ent s , pat i ent s wi t h dys peps i a, as t hmat i cs , and pat i ent s on ant i -coagul ant s ). Cons i der s peci fi c t reat ment of underl yi ng condi t i on (s ee above). Cons i der t he need for phys i ot herapy and exerci s e regi mens t o reduce l ong-t erm di s abi l i t y.
P.743
An As tib soc od iati y on Rh Rh eu eu
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ma ma toi t oi d d fac art tor hri t infl i s am an ma d tor ma y ny di s ord ers AN SLE A an d ma ny aut oi mm un e di s ord ers An SLE tids DN A EN Ext A rac t ab le
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nuc l ea r ant i ge n con sis ts of RN P Ro (SS A) La (SS B) Ant i -s m Ant i -c ent ro me re SC L-7 0 Jo1 Ant i -c ard i ol i pi n
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RN MC P TD SLE Ro Pri (S ma SA ry ) Sj gr ens , SLE La Pri (S ma SB ry ) Sj gr ens An SLE ti-s , m chr oni c act i ve he pat itis An Li m ti-c i t e ent d ro s ys me t e re mi c s cl ero sis
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SC Sys L-7 t e 0 mi c s cl ero sis (di f fus e) Jo- Pol 1 ym yos itis An SLE ti-c , ar ant dio i -p lipi hos n ph ol i pi d s yn dro me P.744
Rheumatoid arthritis Clinical features

Typi cal l y young women (F : M, 3 : 1). Symmet ri cal pol yart hri t i s i nvol vi ng t he s mal l joi nt s of t he hands and feet . May pres ent as a rel aps i ng or pers i s t ent monoart hri t i s . Al l s ynovi al joi nt s are i nvol ved. Si gns mos t common i n
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hands , feet , knees but remember s ynovi al joi nt s of s pi ne (and at l ant oaxi al joi nt /l i gament s ) and l arynx (aryet enoi d joi nt s ).
Ext ra-art i cul ar mani fes t at i ons : vas cul i t i s , s ubcut aneous nodul es , l ymphadenopat hy, peri pheral neuropat hy, anaemi a (normochromi c normocyt i c, Fe defi ci ency, drug-i nduced apl as i a, haemol yt i c), ocul ar i nvol vement , pl euri s y, peri cardi t i s , pul monary fi bros i s .
Management

General meas ures as before (p742). Earl y s t eroi ds reduce l ong-t erm joi nt des t ruct i on. Sympt omat i c t reat ment wi t h NSAIDs . Long-t erm i mmunos uppres s i ve t herapy wi t h met hot rexat e, gol d, s ul phas al azi ne, peni ci l l ami ne, az at hi opri ne, and hydroxychl oroqui ne are al l us ed.
Seronegative arthritides Psoriatic arthropathy

Clinical features
May pres ent as an as ymmet ri cal l arge or s mal l joi nt ol i goart hri t i s , s ymmet ri cal pol yart hri t i s , or cl i ni cal pi ct ure s i mi l ar t o RA or AS. Joi nt des t ruct i on may be ext ens i ve (art hri t i s mut i l ans ). Look for ras h (s cal p, behi nd ears , umbi l i cus , nat al cl eft ), nai l changes (pi t t i ng, onychol ys i s , ri dgi ng).
Management
Treat ment i s as for rheumat oi d art hri t i s wi t h NSAIDs as t he mai ns t ay. Avoi d chl oroqui ne as t hi s preci pi t at es ps ori as i s .
Reactive arthritis
Clinical features
Typi cal l y young s exual l y act i ve i ndi vi dual wi t h oro-geni t al ul cers (pai nl es s ), conjunct i vi t i s (whi ch may
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progres s t o i ri t i s ), ras h (s ol es kerat oderma bl enorrhagi ca).
May occur fol l owi ng non-s peci fi c uret hri t i s or i nfect i on wi t h Shi gel l a, Sal monel l a, Y ers i ni a , or Campyl obac t er .
Treatment

NSAIDs are t he mai n t herapy. See p746 for Rei t er's s yndrome.
P.745
Practice point
Marked morni ng joi nt pai n or s t i ffnes s i s mos t l i kel y t o be due t o rheumat oi d art hri t i s .
P.746
Reiter's syndrome Clinical features
Compri s es a t ri ad of s eronegat i ve art hri t i s , non-s peci fi c uret hri t i s , and conjunct i vi t i s . Ski n l es i ons are ps ori as i form (kerat oderma bl enorrhagi cum) wi t h brown macul es progres s i ng t o pus t ul es on t he s ol es and pal ms . The art hri t i s begi ns 72 weeks aft er i nfect i on and t he l ower l i mb joi nt s are mos t commonl y affect ed (as ymmet ri cal ) and res ol ves over mont hs ; occas i onal l y t he s ki n l es i ons and art hri t i s progres s t o t ypi cal ps ori at i c art hropat hy. It may be as s oci at ed wi t h a s t eri l e uret hral di s charge and mi l d dys uri a. Eros i ve l es i ons may affect t he peni s (ci rci nat e bal ani t i s ) or mout h. Rarel y progres s es t o gi ve aort i c i ncompet ence, heart bl ock, peri cardi t i s .
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Treatment
NSAIDs , and s omet i mes s t eroi ds are t he mai ns t ay of t herapy.
Ankylosing spondylitis Clinical features
Enqui re about axi al s kel et on i nvol vement (l ower l umbar back pai n wi t h earl y morni ng s t i ffnes s ). Peri pheral joi nt i nvol vement (740%), uvei t i s (p428), anaemi a of chroni c di s eas e, and progres s i ve i mmobi l i t y may be found.
Management

NSAIDs for pai n. Exerci s e t o t ry t o prevent progres s i ve i mmobi l i t y. Sul phas al azi ne may be t ri ed for joi nt di s eas e. Refer t o a rheumat ol ogi s t for l ong-t erm management .
Enteropathic arthritis
Large joi nt art hri t i s oft en coi nci des wi t h act i ve i nfl ammat ory bowel di s eas e. Art hri t i s may predat e t he ons et of i nt es t i nal s ympt oms ; oft en t here are ot her ext ra-i nt es t i nal mani fes t at i ons (e.g. eryt hema nodos um and i ri t i s ). Treat ment of col i t i s i mproves art hri t i c s ympt oms .
Infections
Vi ral : rubel l a, parvovi rus B19 (common, oft en pres ent s wi t h a general i zed ras h), and HIV s eroconvers i on may pres ent wi t h pol yart hri t i s . Bac t eri al : Gonoc oc c us (ras h, t enos ynovi t i s , s exual l y act i ve), St aphyl oc oc c us (i mmunos uppres s ed wi t h s ept i caemi a and s eedi ng t o s everal joi nt s ), i nfect i ve endocardi t i s (vas cul i t i c l es i ons , heart murmur). T reat ment : s ee p295.
P.747
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P.748
Vasculitis
The t erm vas cul i t i s denot es an i nfl ammat ory react i on wi t h des t ruct i ve change of bl ood ves s el wal l s . The vas cul i t i des are cl as s i fi ed i nt o pri mary and s ec ondary t ypes .
Classification Primary systemic vasculitis (simplistic classification)

Pri Se ma co ry nd ary Lar Gi a Aor ge nt t i t i art cel l s eri art 2 es eri t is, to Tak RA aya or s u' s yp s eri t is Me Pol Inf di u yar ect m t eri i on art t i s , eri no e.g hi l i art s
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es dos . a, wa s ak i Sm Ch Va al l urg s cu an l i t i d St r s me aus 2 di u s , m We to HB Ka V
art ge RA, eri ner SLE es 's , , mi c s ys ros t e cop mi c ic s cl pol ero yan s i s gi i t , is dru gs , or HI V Sm He Dru al l noc gs , ves h HC s el S V cho or nl e HB in V
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pur i nf pur ect a, hyp ers ens itiv ity vas cul i tis i on
Causes of secondary vasculitis

Infect i ve endocardi t i s Mal i gnancy Rheumat oi d art hri t i s Sys t emi c l upus eryt hemat os us Cryogl obul i naemi a (s t rongl y as s oci at ed wi t h hepat i t i s C) Drug react i on Organ i nvol vement vari es wi t h t he t ype of vas cul i t i s but commonl yi ncl udes s ki n, joi nt s , ki dneys , l ung, and nervous s ys t em
Presentation

Art hral gi a or art hri t i s , myal gi a PUO General i zed s ys t emi c i l l nes s , e.g. wei ght l os s , mal ai s e Ras hes : s pl i nt er haemorrhages , nai l fol d i nfarct s , purpura, l i vedo, nodul es Renal di s eas e: haemat uri a, prot ei nuri a, hypert ens i on, renal fai l ure Lung di s eas e: haemopt ys i s , cough, breat hl es s nes s , pul monary i nfi l t rat es Neurol ogi cal di s eas e: mononeuri t i s mul t i pl ex,
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s ens ori mot or pol yneuropat hy, confus i on, fi t s , hemi pl egi a, acut e cerebral s yndrome. P.749
Causes of lung haemorrhage and renal failure

Goodpas t ure's s yndrome W egener's granul omat os i s Mi cros copi c pol yart eri t i s Sys t emi c l upus eryt hemat os us Lept os pi ros i s
Causes of renal failure only (no lung haemorrhage)

Ant i -GBM di s eas e Smal l ves s el vas cul i t i s Secondary vas cul i t i s Medi um ves s el vas cul i t i s (rare)
ANCA
c-ANCA (ant i -neut rophi l A-prot ei nas e 3) W egener's granul omat os i s Mi cros copi c pol yart eri t i s p-ANCA (ant i -myel operoxi das e or el as t as e) Mi cros copi c pol yart eri t i s ChurgSt raus s s yndrome Atypical ANCA Ul cerat i ve col i t i s (al s o x-ANCA) Scl eros i ng chol angi t i s ANCA t es t s need t o be i nt erpret ed i n t he cl i ni cal cont ext . ANCA pos i t i ve t es t s are s een i n i nfect i on, mal i gnancy, and a wi de range of connect i ve t i s s ue di s orders . A negat i ve ANCA does not excl ude any of t he above. P.750
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Systemic lupus erythematosus (SLE): Assessment

Thi s i s a chroni c aut oi mmune di s order charact eri zed by t he product i on of a wi de range of aut oant i bodi es agai ns t bot h i nt racel l ul ar and cel l s urface ant i gens , t hough mos t oft en wi t h ANA. It commonl y affect s young women (1 : 3 000 i n t he UK) and i s t en t i mes more common i n W es t Indi an bl acks . Pat i ent s wi t h SLE may pres ent t o A&E i n one of t wo ways :
Known di agnos i s of l upus havi ng become acut el y unwel l . Cl i ni cal l y one has t o det ermi ne whet her t hei r s ympt oms refl ect di s eas e act i vi t y, an underl yi ng i nfect i on whi ch may preci pi t at e a fl are up of t he di s eas e, or an unrel at ed condi t i on. As a pres ent i ng di agnos i s ; t he at t endi ng phys i ci an s houl d be al ert t o t he vari ed pres ent at i ons of l upus .
Clinical features
Co Fev ns t er, i t u ma t i o l ai nal s e, (90 wei %) ght l os s Mu Art s cu hra l os l gi kel a, et a my l al g
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(90 i a, %) my os i tis, def or mi ng art hro pat hy (Ja cco ud' s) 2 to lig am ent an d cap s ul ar l ax i t y, as e pt i c nec ros
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is 2 to ste roi d t he rap y Cut But an t er eo fl y us ras (80 h, ph 90 ot o %) s en siti ve ras h, di s coi d l up us , Ra yna ud' s ph en om en
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on, pur pur a, s ca rri n g al o pec i a, liv ed o ret i cul ari s, urt i car ia Ha Thr em om at o boc l og yt o i cal pe (75 ni a %) , an ae mi a (no rm och ro
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mi c nor mo cyt i c, Co om b's +v e in 15 %) , l eu kop eni a an d l ym ph op eni a Ne De uro pre ps y s s i chi on, at ri ps y c cho (55 s i s %) , fi t s ,
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he mi pl e gi a , cra ni a l ner ve l es i on s, at a xi a , cho rea , as e pt i c me ni n gi t i s /e nce ph al i t is Re Gl o nal me (50 rul %) on ep
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hri t is, ne phr itis or ne phr ot i c s yn dro me , pro t ei nur i a, hyp ert ens i on CV Pl e S uri or s y, RS per (40 i ca %) rdi t Ap is, ht h pl e ous ura ul c l or ers per (40 i ca %) rdi
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al eff us i on, Li b ma n S ack s en doc ard itis , s hr i nk i ng l un g s yn dro me
An C ae a, WC C, an d FB mi
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pl t s (s e e ab ove ) Re nal U& fai l Es , ure cre at i ni n e El e R vat wi t h di s eas e act i vi t y Typ P i cal nor ma l. s ug CR l y ES ed
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ges ts i nf ect i on Pro l on AP ge TT d i f t he re is an a nt i -ca rdi ol i pi n ant i bo dy (Ig G or Ig M) Inf ect Bl o i on od -i n cul duc
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t ur ed es fl ar e-u ps Di p sti Uri ck ne for pro t ei nur ia or ha em at u ri a, mi c ros cop y for cas ts, cul t ur e for i nf ect i on Inf R ect or CX i on
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pl e uri sy Hy G pox wi t h i nf ect i on . P.751 AB i a
Practice point
SLE i n oft en charact eri zed by a hi gh ESR and a normal CRP.
P.752
Systemic lupus erythematosus: management Other investigations

AN A, Im DN mu A, nol EN ogy A, AC
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A, co mp le me nt l ev el s Us s ual nor ma l PC al R cyt om eg al o vi r us 24 ho Uri ur ne col l ect i on for cre at i ni n e cl e Vi r for LFT l y
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ara nce an d pro t ei n exc ret i on.
Points to note
I mmunol ogy
o
>95% are ANA +ve (ds DNA ant i body i s al mos t pat hognomoni c of SLE) Ant i -ds DNA ant i body t i t re may correl at e wi t h di s eas e act i vi t y Low compl ement l evel s correl at e wi t h di s eas e act i vi t y (and renal i nvol vement ) 40% are rheumat oi d fact or pos i t i ve.
Pneumococcal and meni ngococcal i nfect i ons are more common i n pat i ent s wi t h SLE as a cons equence of ei t her heredi t ary or acqui red defi ci enci es of t he component s of t he compl ement pat hway. Immunos uppres s i ve t herapy renders pat i ent s s us cept i bl e t o t he us ual range of opport uni s t i c i nfect i ons i ncl udi ng pneumocys t i s , cyt omegal ovi rus , and mycobact eri a. Ches t and uri ne are t he commones t s ources of i nfect i on i n cl i ni cal pract i ce. Pat i ent s wi t h di s eas e act i vi t y cl as s i cal l y have an el evat ed ESR but a rel at i vel y normal CRP.
An el evat ed CRP s houl d al ert you t o l ook for an underl yi ng i nfec t i on .
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Management

Predni s ol one 3060mg od. Addi t i onal i mmunos uppres s i ve t herapy s uch as pul s ed met hyl predni s ol one, azat hi opri ne, or cycl ophos phami de s houl d be gi ven on cons ul t at i on wi t h a rheumat ol ogi s t . Ant i bi ot i c s i f i nfect i on i s s us pect ed (e.g. cefot axi me) whi ch wi l l t reat mos t ches t or uri nary t ract i nfect i ons . If t he s ource i s known t hen ant i -mi crobi al t herapy can be more rat i onal l y pres cri bed. Hydroxyc hl oroqui ne (200mg/day) may be added i f t here i s cut aneous or joi nt i nvol vement .
P.753
P.754
Wegener's granulomatosis and microscopic polyarteritis nodosa (PAN) 1
Bot h of t hes e s mal l ves s el vas cul i t i des may pres ent t o cas ual t y wi t h acut e renal fai l ure (rapi dl y progres s i ve gl omerul onephri t i s ). W egener's granul omat os i s cl as s i cal l y i nvol ves t he upper and l ower res pi rat ory t ract s and t he ki dneys .
Clinical features
Fev er, Sys ma t e l ai mi c s e, fea wei t ur ght
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es l os s Na s al Up di s per cha res rge pi r , at o nos ry e bl e eds , sin us i tis, col l aps e of t he nas al bri dg e, de afn es s (al l s ug ges t a di a gn
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os i s of We ge ner 's ) Sh ort Lo nes wer s res of pi r bre at o at h ry , ha em opt ys i s, cav ita tin g l un g l es i on s Ne phr Ki d i t i s ney wi t s h der
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an ge d ren al fun ct i on, ha em at u ri a, pro t ei nur i a, an d act i ve uri nar y s ed im ent My al g Mu i a, s cu art l os hra kel l gi et a a l Bot
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Ne per uro i ph l og era i cal l an d cen t ral St r on As k gl y ab as s out oci s m at e oki d ng wi t h l un g ha em orr ha ge.
An C ae a, ne ut r op FB mi
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hi l l eu koc yt o sis , t hr om boc yt o sis Im pai Re red nal ren fun al ct i fun on ct i on or acu te ren al fai l ure Lo s w um in (ne phr ot i c LFT al b
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s yn dro me ). El e vat ed AS T, AL T, an d AL P wi t h he pat itis El e vat CK ed an du d T e my os i tis Pro l on PT ge an d d wi t AP h AS t o
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TT wi d es p rea d vas cul i tis an d DI C El e R an d CR P Se od cul t ur es Hy G pox (ha em orr ha ge or AB i a ps i Bl o s vat ES ed
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i nf ect i on ), me t ab ol i c aci dos is (re nal fai l ure ) Di p sti Uri ck ne for bl o od or pro t ei n, mi c ros cop y an d cul t ur e 24
Pa g e 1 2 4 2
ho ur col l ect i on for cre at i ni n e cl e ara nce an d pro t ei n exc ret i on Cul t ur Sp e ut u (i nf m ect i on oft en pre ci pi t at es l un g
Pa g e 1 2 4 3
ha em orr ha ge) Lo w Cal cor ci u rec m/ t ed ph cal os p ci u hat m e an d hi g h ph os p hat e s ug ges t chr oni ci t y Sh R ad ng s ee n in CX owi
Pa g e 1 2 4 4
l un g ha em orr ha ge or i nf ect i on ; cav ita tin g l es i on s t yp i cal ly occ ur in We ge ner 's gra nul om at o sis
Pa g e 1 2 4 5
If S of in al fai l US ren
t he ure ki d t o ney exc s l ud e obs t ru ct i on. P.755
P.756
Wegener's granulomatosis and microscopic polyarteritis nodosa 2 Immunology

Pos itiv c-A e NC (s e A e bel ow ) To
Pa g e 1 2 4 6
exc
AN l ud A, e ant SLE i -d sD NA RF Co mp le me nt l ev el s A pos Ant i t i v i -G e BM t es ant t i bo s ug dy ges ts pri ma ry ant i -G BM di s
Pa g e 1 2 4 7
eas e s uc h as Go od pas t ur e's s yn dro me , in whi ch t he re is rap id pro gre ssi ve gl o me rul on ep hri t is an d
Pa g e 1 2 4 8
l un g ha em orr ha ge To exc Cry l ud ogl e ob as ul i a ns s ec on dar y cau se of vas cul i tis He pat He i t i s pat B i t i s an s er d ol o C. gy
Miscellaneous investigations
Ba
Pa g e 1 2 4 9
s el cha ng es of hyp erk al a em ia if AR F is pre s en
EC i ne
t Me g as u me Lun re fun nt ct i of on KC t es O ts (i n cre as e d wi t h l un g
Pa g e 1 2 5 0
ha em orr ha ge) To o rul out uns us p ect ed i nd ol e nt i nf ect i ve en doc ard itis (s e con dar y cau se of vas cul i tis) Co mm Ech e
Pa g e 1 2 5 1
X-r onl ay y s i n i nv us e ol v s ed in We ge ner 's Hi s t ol Re ogi nal cal bi o di a ps y gn os i s (l i g ht / im mu nof l uo res cen ce/ EM ).
Management
Invol ve s peci al i s t s earl y, rheumat ol ogy and renal .
Emergency management
Pat i ent s commonl y di e from hypoxi a (pul monary haemorrhage, pul monary oedema), arrhyt hmi as
Pa g e 1 2 5 2
(s econdary t o el ect rol yt e abnormal i t i es ), and concomi t ant i nfect i on.
Ens ure adequat e oxygenat i on and cons i der vent i l at i on i f neces s ary. As s es s fl ui d bal anc e and moni t or uri ne out put careful l y. Cons i der i nvas i ve haemodynami c moni t ori ng (CVP, art eri al l i ne, SwanGanz cat het er). Pat i ent s wi t h nephri t i s may be vol ume overl oaded wi t h pul monary oedema . Treat wi t h i nt ravenous frus emi de (80120mg; hi gh dos es may be requi red), GTN i nfus i on, venes ect i on, or haemodi al ys i s or haemofi l t rat i on. Correc t el ec t rol yt e abnormal i t i es : hyperkal aemi a (s ee p384). Cons i der urgent haemodi al ys i s or haemofi l t rat i on i n pat i ent s wi t h ARF or hyperkal aemi a (cons ul t renal phys i ci ans ). Treat preci pi t at i ng i nfect i ons empi ri cal l y wi t h c efot axi me unt i l a pat hogen i s i dent i fi ed. Treat underl yi ng vas cul i t i s
o o
Hi gh-dos e predni s ol one (60mg/day) Cycl ophos phami de (onl y aft er renal or rheumat ol ogi cal opi ni on) Pl as mapheres i s (renal uni t s ).
P.757
Points to note
The ANCA t es t provi des a rapi d s creeni ng t es t and s hows hi gh s ens i t i vi t y for pat i ent s wi t h s mal l ves s el vas cul i t i s . Pat i ent s wi t h W egener's granul omat os i s are cl as s i cal l y c-ANCA pos i t i ve (cyt opl as mi c pat t ern of i mmunofl uores cence, ant i body agai ns t el as t as e I), whi l s t pat i ent s wi t h mi cros copi c pol yart eri t i s may be
Pa g e 1 2 5 3
ei t her p-ANCA (peri nucl ear pat t ern of i mmunofl uores cence, ant i body agai ns t myel operoxi das e) or c-ANCA pos i t i ve. A negat i ve ANCA does not however precl ude t he di agnos i s of a s mal l ves s el vas cul i t i s .
Underl yi ng i nfect i on es peci al l y i nfect i ve endocardi t i s and chroni c meni ngococcaemi a s houl d al ways ent er t he di fferent i al di agnos i s of a pat i ent wi t h s mal l ves s el vas cul i t i s . An i nfect i ous epi s ode s uch as an upper res pi rat ory t ract i nfect i on oft en wi l l preci pi t at e t he pres ent at i on of a s mal l ves s el vas cul i t i s .
P.758
Cryoglobulinaemia
Cryogl obul i ns are i mmunogl obul i ns t hat preci pi t at e at l ow t emperat ures and di s s ol ve on re-warmi ng. They preci pi t at e i n t he s uperfi ci al capi l l ari es or out s i de ves s el s i n t he col des t part of t he s ki n t o produce mi croi nfarct s or purpura. Cryogl obul i naemi a occurs i n s everal condi t i ons .
Es s ent i al cryogl obul i naemi a i mpl i es t he abs ence of an i dent i fi abl e caus e. Renal di s eas e i s as s oci at ed wi t h al l t hree t ypes , and i s t hought t o i nvol ve i mmune-compl ex pat hways . Mean age, 4259 years . M : F, 2 : 3.
Type 1 monoclonal
Type 1 cryogl obul i naemi a, or s i mpl e cryogl obul i naemi a, i s t he res ul t of a monocl onal i mmunogl obul i n, us ual l y IgM or IgG. As s oci at ed wi t h myel o- or l ymphoprol i ferat i ve di s eas e. Heavy prot ei nuri a, haemat uri a, and renal fai l ure may occur (membranoprol i ferat i ve gl omerul onephri t i s ). Serum C4 and C1q are l ow.
Pa g e 1 2 5 4
Type 2 (mixed monoclonal) and type 3 (mixed polyclonal)
Type 2 and t ype 3 cryogl obul i naemi a (mi xed cryogl obul i naemi a) cont ai n RFs (oft en IgM). Thes e RFs form compl exes wi t h t he fragment , crys t al l i zabl e (Fc) port i on of pol ycl onal IgG. The act ual RF may be monocl onal (i n t ype 2 cryogl obul i naemi a) or pol ycl onal (i n t ype 3 cryogl obul i naemi a) i mmunogl obul i n. Type 2 i s as s oci at ed wi t h i mmune compl ex vas cul i t i s and 50% have evi dence of renal di s eas e. Many cas es are as s oci at ed wi t h HCV i nfect i on. Type 3 Mi xed pol ycl onal i s as s oci at ed wi t h SLE, and s ys t emi c i nfect i ons (pos t -s t rept ococcal nephri t i s , l epros y, and s yphi l i s ). Renal i nvol vement i s al s o s een.
Clinical features
Renal i nvol vement (haemat uri a, prot ei nuri a, renal fai l ure) Raynaud's phenomenon Purpura (es p. l egs ) Art hral gi a and fever Confus i on and weaknes s (2 t o hypervi s cos i t y) Hepat os pl enomegal y (probabl y a mani fes t at i on of underl yi ng aet i ol ogy).
Management

There i s no s peci fi c t reat ment . Pl as mapheres i s and i mmunos uppres s i ve t herapy may be t ri ed.
P.759
P.760
Pa g e 1 2 5 5
Giant cell arteritis (temporal arteritis)
The commones t t ype of pri mary l arge ves s el vas cul i t i s i n cl i ni cal pract i ce wi t h an i nci dence of 1 : 10 000. Thi s i s t ypi cal l y a di s order of t he el derl y (mean age 70 years , wi t h a F : M rat i o of 2 : 1). The di agnos i s i s made cl i ni cal l y (s ee bel ow) and i s s upport ed by an el evat ed acut e phas e res pons e (ESR, CRP, and t hrombocyt os i s ), and t emporal art ery hi s t ol ogy. The cl as s i cal pat hol ogi cal des cri pt i on i s of a s egment al granul omat ous pan-art eri t i s but i n t he earl y s t age changes may be confi ned t o t hi ckeni ng of t he i nt ernal el as t i c l ami na as s oci at ed wi t h a mononucl ear cel l i nfi l t rat e.
Clinical features
90 He ad ach e 85 Te mp ora l art ery t en der nes s 75 % %
Pa g e 1 2 5 6
Sca lp t en der nes
s 70 Ja w cl a udi cat i on 35 Thi cke ne d/n od ul a r te mp ora l art ery 40 Pul s el es s % % %
Pa g e 1 2 5 7
te mp ora l art ery 40 Vi s ual sy mp to ms (i n cl . bl i nd nes s) 40 % Pol (s e ym e yal p7 gi c 62) sy mp to ms 40 Sys te mi c % %
Pa g e 1 2 5 8
fea t ur es rar CV A or MI e
Investigations
Nor C mo om ic an ae mi a, t hr om boc yt o sis El e vat Bi o ed che al k mi s al i t ry ne ph FB chr
Pa g e 1 2 5 9
os p hat as e ES R R 0m m in t he fi rs t ho ur, 95 % of cas es El e vat CR ed P Exc l ud Ch e es t un x-r der ay l yi ng bro nch i al car ci n ES >5
Pa g e 1 2 6 0
om a Exc l ud Uri e nal ha ys i em s at u ri a an Te d mp pro ora t ei l nur art ia ery bi o ps y .
Management
Pat i ent s wi t h s us pect ed gi ant cel l art eri t i s s houl d be s t art ed on hi gh-dos e predni s ol one i mmedi at el y , as del ay may res ul t i n bl i ndnes s . For mos t pat i ent s 40mg od i s s uffi ci ent but hi gher dos ages 6080mg may be us ed i f t he pat i ent has vi s ual s ympt oms . Al l pat i ent s s houl d have a t emporal art ery bi ops y performed wi t hi n 48 hours of commenci ng s t eroi ds t o t ry t o confi rm t he di agnos i s . A normal bi ops y does not excl ude t he di agnos i s becaus e of t he s ki p nat ure of t he di s eas e.
P.761
Practice point
Pa g e 1 2 6 1
Cont i nuous headaches i n pat i ent s .60 years may i ndi cat e crani al art hri t i s , but may be s pondyl i t i c.1
Footnote
1
Hawkes C (2002) Hos p Med 63 : 73242. P.762
Polymyalgia rheumatica (PMR)

PMR i s a cl i ni cal s yndrome charact eri zed by an acut e phas e res pons e (hi gh ESR or hi gh CRP) whi ch predomi nant l y affect s t he el derl y Caucas i an popul at i on, medi an age of ons et 70 years , femal es > mal es , annual i nci dence approxi mat el y 1 : 2500.
Clinical features
Proxi mal mus cl e s t i ffnes s and pai n wi t hout weaknes s or was t i ng. Sys t emi c s ympt oms of mal ai s e, fever, and wei ght l os s .
Causes of proximal upper and lower girdle stiffness or pains

No acu Cer t e vi c ph al as e s po res ndy po l os ns e is , CP ad K hes (N) i ve
Pa g e 1 2 6 2
cap s ul itis Lu mb ar s po ndy l os is Os t eo ma l aci a Fi b ro my al g ia No acu Hy t e pot ph hyr as e oi d res i s m po ns e ,
Pa g e 1 2 6 3
CP K Acu Pol t e ym ph yos as e i t i s res /de po rm ns e at o , my os i CP tis K Acu Infl t e am ph ma as e t or res y hri t is po art ns e
Investigations
(No C rm ro mi c nor mo cyt FB och
Pa g e 1 2 6 4
ic an ae mi a) [El eva U& t ed Es , al k LFT al i s ne ph os p hat as e is co mm on (50 %) ] Nor K ma (i f hi g h con sid er pol ym yos itis CP l
Pa g e 1 2 6 5
or hyp ot h yro i di sm ) Hi g R h 40 mm /h i ni t i al l y) Hi g CR P PM R Rh ma eu y ma be t oi t he d pre fac s en t or t i n g fea t ur e of rhe h ES (>
Pa g e 1 2 6 6
um at o id art hri t is PM R R mp to ms ma y be t he pre s en tin g fea t ur e of a ne opl as m. CX s y
Treatment
St eroi ds : predni s ol one 20mg po od i ni t i al l y reduci ng t o 510mg od over 23 mont hs and very s l ow reduct i on t hereaft er. Some pat i ent s may requi re t reat ment for years . Moni t or res pons e wi t h s ympt oms and ESR.
Pa g e 1 2 6 7
Points to note
Pol ymyal gi a rheumat i ca and gi ant cel l art eri t i s form part of a cl i ni cal s pect rum of di s eas e and up t o 40% of pat i ent s wi t h bi ops y-proven gi ant cel l art eri t i s have pol ymyal gi c s ympt oms . Pol ymyal gi c s ympt oms may be t he pres ent i ng feat ure of an underl yi ng neopl as m or connect i ve t i s s ue di s eas e. Pol ymyal gi c s ympt oms s houl d res pond dramat i cal l y t o predni s ol one. Fai l ure t o res pond s houl d al ert t he cl i ni ci an t o t he pos s i bi l i t y of an underl yi ng neopl as m or connect i ve t i s s ue di s eas e.
P.763
Practice point
Never di agnos e pol ymyal gi a rheumat i ca i n a pat i ent , 50 years ol d.
P.764
Back pain: assessment

Approxi mat el y 5% of al l medi cal cons ul t at i ons i n t he UK are for back or neck pai n. In t he majori t y of pat i ent s no defi ni t e anat omi cal di agnos i s i s made (non-s peci fi c back pai n) but i t i s i mport ant not t o mi s s t he s i ni s t er caus es of back pai n.
Causes of back pain

Mechanical back pain

Spondyl ol i s t hes i s Spondyl os i s Int ervert ebral di s c prol aps e Spi nal s t enos i s (cl audi cat i on t ype pai n) Apophys eal joi nt di s eas e (exacerbat ed by l umbar ext ens i on, cervi cal or t horaci c rot at i on)
Pa g e 1 2 6 8
Non-s peci fi c back pai n Trauma Rheumat oi d art hri t i s Seronegat i ve s pondyl oart hri t i des
o o o o o
Inflammatory back pain

Ps ori at i c Ankyl os i ng Spondyl i t i s Rei t er's Ent eropat hi c Behet 's
Referred pain

Aort i c aneurys m Pyel onephri t i s , renal cal cul us Pancreat i t i s
Causes of sinister back pain

Infect i on (di s ci t i s /epi dural abs ces s ) Mal i gnancy Myel oma Os t eoporot i c crus h fract ure Paget 's di s eas e
History
Is pai n l i kel y t o be mechani cal , i nfl ammat ory, or s i ni s t er i n ori gi n?
Mechani cal back pai n i s exacerbat ed by prol onged s i t t i ng or s t andi ng, rel i eved by movement , and preci pi t at ed by t rauma. Infl ammat ory back pai n i s charact eri zed by prol onged earl y morni ng s t i ffnes s and i s rel i eved by exerci s e. Si ni s t er back pai n (e.g. mal i gnancy and i nfect i on) oft en l ead t o pai n at ni ght , cons t ant pai n, l ocal bony t endernes s , and may be accompanied by ot her s ys t emi c s ympt oms . Are t here any s ens ory or mot or s ympt oms ? As k s peci fi cal l y for any change i n bowel or bl adder funct i on.
Examination
Pa g e 1 2 6 9
General : l ook for evi dence of mal i gnancy. Spi ne (pal pat i on for t endernes s , mus cl e s pas m, cervi cal s pi ne fl exi on, ext ens i on, rot at i on and l at eral fl exi on, t horaci c s pi ne rot at i on, l umbar s pi ne fl exi on, ext ens i on, s i de fl exi on, compres s i on of s acroi l i ac joi nt s . Neurol ogi cal exami nat i on l ooki ng s peci fi cal l y for abs ent ankl e jerks (s l i pped di s c) or l ong-t ract s i gns i n t he l egs . S1 nerve root s i gns and s ympt oms can be produced by a l es i on i n t he regi on of t he upper l umbar cord (cent ral di s c prol aps e compres s i ng t he S1 nerve root ). Al ways do a rect al exami nat i on and t es t peri neal s ens at i on.
P.765
Practice points
Back pai n at ni ght s ugges t s a s i ni s t er caus e s uch as cancer or i nfect i on. Pat i ent s wi t h acut e ons et of back pai n and s i gns s ugges t i ve of a hi gh l es i on (eg L1- L3/4) may have weak t hi ghs and abs ent knee jerks , and are unl i kel y t o have a di s c l es i on and may have a t umour.
P.766
Back pain: management Investigations

Pat i ent s wi t h back pai n occurri ng at ni ght and pat i ent s wi t h neurol ogi cal s i gns warrant i nves t i gat i on.

X-rays of s pi ne 9 CXR (?mal i gnancy) FBC and ESR (el evat ed wi t h s i ni s t er caus es of pai n) Bi ochemi cal profi l e (cal ci um, al kal i ne phos phat as e, and phos phat e)
Pa g e 1 2 7 0
Immunogl obul i ns and prot ei n el ect rophores i s (?myel oma) Aci d phos phat as e PSA Bence-Jones prot ei n and uri ne prot ei n el ect rophores i s .
Further imaging

CT s can MRI s can (s uperi or t o CT for i magi ng t he s pi nal cord and root s ) Technet i um bone s can (hot -s pot s i dent i fy neopl as t i c or i nfl ammat ory l es i ons ) Myel ography Radi cul ography (t o l ook for cord or root compres s i on).
Management

Anal ges i cs Bed res t Phys i ot herapy Appropri at e referral t o a s peci al i s t .
Prolapsed intervertebral disc

Acut e pos t ero-l at eral herni at i on of a l umbar di s c, us ual l y L4L5 or L5S1, i s a common caus e of acut e i ncapaci t at i ng l ower back pai n. There i s oft en a cl ear preci pi t at i ng event (e.g. l i ft i ng) and pai n may radi at e i n t he di s t ri but i on of t he L5 or S1 nerve root . Pat i ent s s houl d be exami ned careful l y for

Paras pi nal mus cl e s pas m i s oft en promi nent St rai ght l eg rai s i ng i s t ypi cal l y reduced on t he affect ed s i de Look for nerve root s i gns and t es t s acral and peri neal s ens at i on. Al ways do a rect al exami nat i on L5 l es i on l eads t o weaknes s of ext ens or hal l us l ongus , ankl e dors i fl exi on, and ankl e evers i on and al t ered s ens at i on i s percei ved i n t he L5 dermat ome S1 l es i on l eads t o weaknes s of ankl e pl ant ar fl exi on, ankl e evers i on, and a di mi ni s hed or l os t ankl e jerk and
Pa g e 1 2 7 1
al t ered s ens at i on i s percei ved i n t he S1 dermat ome.
Treatment
If t he X-rays reveal a fract ure, refer t he pat i ent t o t he ort hopaedi c t eam; s evere pai n from i nfl ammat ory art hri t i des s houl d be referred t o t he rheumat ol ogi s t s . Majori t y of pat i ent s res pond t o cons ervat i ve management . P.767
Bed res t unt i l t he acut e pai n s ubs i des fol l owed by mobi l i zat i on and phys i ot herapy (pat i ent s may oft en be managed at home wi t h i ns t ruct i ons t o ret urn t o t he GP or doct or for revi ew i n 23 weeks ). Non-s t eroi dal ant i -i nfl ammat ory agent s . Phys i ot herapy.
Neurosurgical emergencies presenting as back pain

An acut e di s c prol aps e at t he L2/3 l evel may caus e bi l at eral mul t i pl e root l es i ons and may affect bl adder and bowel funct i on (cauda equi na s yndrome). Thi s requi res i mmedi at e i nves t i gat i on:

Acute cauda equina compression (p508) Acute cord compression (p508)
P.768
C1-esterase inhibitor deficiency (angioneurotic oedema)

Thi s condi t i on may be i nheri t ed or acqui red, occurri ng approxi mat el y i n 1 : 50 000 i n t he UK.
Hereditary
Pa g e 1 2 7 2
Aut os omal domi nant i nheri t ance Us ual l y pres ent s i n t he s econd decade Charact eri zed by l ow s erum concent rat i ons of compl ement component s C2, C4, and C 1 -i nhi bi t or, but normal C1 and C3 l evel s .
Acquired
Paraneopl as t i c s yndrome: aut oant i body agai ns t C 1 -es t eras e i nhi bi t or Charact eri zed by l ow s erum concent rat i ons of compl ement component s C1, C2, and C4.
Clinical features
Laryngeal oedema (48% of at t acks ); may be l i fe t hreat eni ng Subcut aneous oedema (91% of at t acks ) affect i ng face, but t ocks , geni t al s , and l i mbs . Us ual l y non-i t chy Abdomi nal s ympt oms : pai n, vomi t i ng, and di arrhoea.
Precipitating factors include

St res s Infect i on Pre-mens t rual Oes t rogen-cont ai ni ng cont racept i ve pi l l Angi ot ens i n-convert i ng enzyme i nhi bi t ors .
Management
Acute severe attack
C 1 -es t eras e i nhi bi t or pl as ma concent rat e (an i nt ravenous i nfus i on of 1000 t o 1500 uni t s ) us ual l y effect i ve i n 3060 mi nut es . Fres h frozen pl as ma 24 uni t s may be gi ven i f C 1 -es t eras e i nhi bi t or pl as ma concent rat e i s not avai l abl e.
Laryngeal oedema
If a pat i ent i s admi t t ed wi t h l aryngeal oedema 60% oxygen s houl d be gi ven i mmedi at el y, bl ood gas es
Pa g e 1 2 7 3
s houl d be checked, and a s eni or anaes t het i s t or ENT s urgeon cal l ed as i nt ubat i on or t racheos t omy may be requi red (p914).
Int ramus cul ar adrenal i ne 0.51ml , 1 : 1000 (s ee p264). Hydrocort i s one 200mg i v. Chl orpheni rami ne 10mg i v may be admi ni s t ered i ni t i al l y pri or t o t he i nfus i on of C 1 -es t eras e i nhi bi t or.
Prophylaxis
Thos e wi t h great er t han 1 at t ack per mont h:
Tranexami c aci d (11.5g 24 t i mes dai l y). Effect i ve i n 28%. At t enuat ed androgens , e.g. danaz ol (unl i cens ed i ndi cat i on).
Pa g e 1 2 7 4
> T able of Cont ent s > Chapt er 13 - Dermat ologic al emergenc ies
Chapter
13 Dermatological emergencies
P.770
Cutaneous drug reactions: presentation
Mac ul opapul ar eryt hema wi t h vari abl e pruri t us and s cal i ng. Res ol ves over 2 weeks once t he drug i s s t opped. 46% of cut aneous drug react i ons . Urt i c ari a/angi oedema: account s for ~25% of drug react i ons . Sudden ons et of i ndi vi dual pruri t i c eryt hemat ous l es i ons whi ch res ol ve wi t hi n 24 hours . Angi oedema may i nvol ve mucous membranes and can be as s oci at ed wi t h l i fe-t hreat eni ng anaphyl axi s (s ee p264). As pi ri n, morphi ne, codei ne act di rect l y i n mas t cel l s t o l i berat e hi s t ami ne i n s ens i t i ve i ndi vi dual s . Peni ci l l i n (and as pi ri n) can caus e an IgE-medi at ed or IgG compl ement -fi xi ng al l ergi c react i on. Urt i cari al erupt i ons as s oci at ed wi t h s erum s i cknes s may be pers i s t ent and can be as s oci at ed wi t h s ys t emi c s ympt oms . Fi xed drug erupt i on: charact eri zed by a few wel l -demarcat ed pai nful eryt hemat ous l es i ons whi ch frequent l y bl i s t er oft en i nvol vi ng t he face, hands , forearms , and geni t al i a. Local hyperpi gment at i on pers i s t s aft er recovery. Rechal l enge i s as s oci at ed wi t h recurrent l es i ons i n t he s ame l ocat i on. Drugs i mpl i cat ed i ncl ude s ul phonami des , t et racycl i nes , barbi t urat es ,
Pa g e 1 2 7 5
s al i cyl at es , and daps one. Repres ent s 10% of cut aneous drug react i ons .
Phot os ens i t i ve drug erupt i ons : cut aneous react i on l i mi t ed t o expos ed s i t es wi t h charact eri s t i c s pari ng of cert ai n areas . May be due t o ei t her a phot oal l ergi c (i mmune-medi at ed, e.g. chl orpromaz i ne, s ul phani l ami de, ami odarone) or phot ot oxi c (non-i mmune, e.g. t et racycl i nes , s ul phonami des , gri s eoful vi n, naproxen, hi gh-dos e frus emi de) react i on. Some drugs may i nduce phot os ens i t i ve di s orders s uchas porphyri a cut anea t arda or phot o-onychol ys i s . Eryt hema mul t i forme/St even's Johns on s yndrome: as s oci at ed wi t h 10% of drug react i ons . Sudden ons et of eryt hemat ous l es i ons affect i ng t he s ki n and mucous membranes . Acral s i t es are preferent i al l y i nvol ved and i ndi vi dual l es i ons may have necrot i c or t arget oi d appearances . As s oci at ed wi t h fever, mal ai s e, and s ore t hroat due t o mucous membrane i nvol vement (St even's Johns on s yndrome) and rarel y confl uent epi dermal necrol ys i s as s een i n t oxi c epi dermal necrol ys i s (s ee p786). Drugs i mpl i cat ed i ncl ude s al i cyl at es , s ul phonami des , peni ci l l i n, s ul phonyl ureas , and barbi t urat es . St op t he drug; gi ve s t eroi ds (predni s ol one 30mg/day). Exfol i at i ve dermat i t i s : pres ent s as eryt hroderma. 4% of drug react i ons . Caus at i ve drugs i ncl ude barbi t urat es , s al i cyl at es , peni ci l l i n, s ul phonami des , and s ul phonyl ureas . T oxi c epi dermal nec rol ys i s : t here are t wo t ypes . In adul t s i t i s an i mmunol ogi cal di s eas e provoked by drug hypers ens i t i vi t y, but i n babi es i t i s due t o t he di rect necrol yt i c effect of a St aphyl oc oc c al t oxi n. It may be caus ed by many di fferent drugs i ncl udi ng peni ci l l i ns , s ul phonami des and ot her ant i bi ot i cs , bl ood product s , NSAIDs , and ant i -convul s ant s .
P.771
Pa g e 1 2 7 6
P.772
Cutaneous drug reactions: management Points to note
Us ual l y devel op wi t hi n 12 weeks fol l owi ng i ni t i at i on of t herapy but occas i onal l y react i ons pres ent l at er (due t o cumul at i ve t oxi ci t y). Devel opment of ext ens i ve angi oedema i s as s oci at ed wi t h a ri s k of anaphyl axi s and s hock charact eri zed by hypot ens i on, bronchos pas m, oropharyngeal i rri t at i on as s oci at ed wi t h angi oedema, fl us hi ng, or urt i cari a and acral oedema. Pat i ent s who pres ent wi t h ei t her eryt hema mul t i forme or St even's Johns on s yndrome may devel op confl uent areas of epi dermal necrol ys i s as s een i n t oxi c epi dermal necrol ys i s (p786). Peri pheral bl ood eos i nophi l i a i s rare. Int ravenous rout es of drug admi ni s t rat i on are more l i kel y t o be as s oci at ed wi t h anaphyl axi s . Cut aneous drug react i ons are common i n t reat ment of HIV di s eas e.
Management
Severe angi oedema and anaphyl axi s requi re i mmedi at e t reat ment (s ee p264). Seek s peci al i s t advi ce for s evere St even's Johns on s yndrome or t oxi c epi dermal necrol ys i s . St op any res pons i bl e drugs and pres cri be an al t ernat i ve i f neces s ary. Hos pi t al i zed pat i ent s recei vi ng numerous drugs s houl d be as s es s ed careful l y and al l non-es s ent i al t herapy di s cont i nued. Pres cri be oral non-s edat i ng or s edat i ng ant i -hi s t ami nes
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wi t h s i mpl e emol l i ent s and medi um-pot ency t opi cal s t eroi ds . Short cours es of s ys t emi c s t eroi ds may be requi red i n eryt hema mul t i forme or St even's Johns on s yndrome.
Pyrexi a may occur wi t h cut aneous drug react i ons but underl yi ng i nfect i on s houl d al ways be excl uded. There s houl d be cl i ni cal i mprovement wi t hi n a few days : pers i s t ent react i ons s houl d prompt a s earch for ot her caus es . Al t hough rechal l enge wi t h a s us pect ed drug can provi de a defi ni t i ve di agnos i s , react i ons may be more s evere and can l ead t o fat al anaphyl axi s or s evere t oxi c epi dermal necrol ys i s . Speci fi c RAST can be us ed t o meas ure s erum IgE ant i body product i on i n pat i ent s wi t h peni ci l l i n al l ergy. However, a pos i t i ve BPO-s peci fi c RAST for peni ci l l i n i s onl y s een wi t h t he major ant i geni c det ermi nant s and a negat i ve react i on does not excl ude peni ci l l i n al l ergy. Ski n bi ops i es can be us eful for s peci fi c forms of cut aneous drug react i ons s uch as fi xed drug erupt i on and eryt hema mul t i forme.
P.773
P.774
Erythroderma Presentation
Eryt hroderma may be acut e or chroni c. Acut e eryt hroderma i s more l i kel y t o pres ent as an emergency. There i s general i zed eryt hema as s oci at ed wi t h exfol i at i on. Scal i ng can be fi ne (pi t yri as i form) or coars e
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(ps ori as i form).
Pat i ent s may be febri l e or hypot hermi c becaus e of l os s of t emperat ure cont rol mechani s ms . Chroni c eryt hroderma may be as s oci at ed wi t h nai l dys t rophy, di ffus e hai r l os s , and ect ropi on. Pal mo-pl ant ar hyperkerat os i s and peri pheral l ymphadenopat hy may be promi nent .
Causes
Co Ecz mm em on a, cau ps o s es ri a : sis , dru g rea ct i ons Rar Cut e an cau eo s es us : T-c el l l ym ph om a, pi t yri as i s
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rub ra pi l ari s, t ox ic s ho ck s yn dro me , Ka wa s ak i di s eas e, s ar coi dos is
Investigations
Moni t or FBC, U&Es , al bumi n, cal ci um, and LFTs regul arl y. Bl ood cul t ures and s ki n s wabs s houl d be performed and s us t ai ned pyrexi a, hypot ens i on, or cl i ni cal det eri orat i on s houl d prompt a s earch for underl yi ng s eps i s .
Management
General measures
Nurs e i n a warm room wi t h regul ar moni t ori ng of core
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t emperat ure and fl ui d bal ance. Pat i ent s s houl d be nurs ed on a pres s ure-rel i evi ng mat t res s and/or Lyofoam i f neces s ary.
Encourage oral fl ui ds and hi gh cal ori fi c food and prot ei n s uppl ement s . Nas ogas t ri c feedi ng may be requi red. Avoi d i nt ravenous canul ae becaus e t hey can act as a pot ent i al s ource of i nfect i on. Moni t or fl ui d bal ance cl os el y: dai l y wei ght s and cl i ni cal exami nat i on (as al l owed by t he exfol i at i on).
Specific therapy
The s ki n s houl d be t reat ed at l eas t four t i mes dai l y wi t h emol l i ent s s uch as 50% whi t e s oft paraffi n/50% l i qui d paraffi n or Epaderm. A dai l y bat h s houl d be s uppl ement ed wi t h emol l i ent s s uch as oi l at um or bal neum. Oral s edat i ng ant i -hi s t ami nes s uch as hydroxyz i ne (10100mg i n di vi ded dos es ) may be us ed and t he dos e adjus t ed accordi ng t o s everi t y and wei ght . Appl i cat i on of mi l d or pot ent t opi cal s t eroi ds may be appropri at e but l i ai s e wi t h s peci al i s t at earl y opport uni t y. In eczema, s ys t emi c t reat ment wi t h predni s ol one, az at hi opri ne, or cycl os pori n may be appropri at e, and i n ps ori as i s , aci t ret i n, met hot rexat e or cycl os pori n may be requi red. Li ai s e wi t h s peci al i s t pri or t o embarki ng on t hi s approach.
P.775
Complications

Hypot hermi a Infect i on Hypoal bumi naemi a Hi gh out put cardi ac fai l ure.
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Practice point
Non-res pons i ve or rel aps i ng eczemi c ras h s houl d s ugges t cont act dermat i t i s .
P.776
Urticaria: assessment Presentation
Urt i cari a pres ent s as eryt hemat ous pruri t i c evanes cent areas of oedema i nvol vi ng t he s uperfi ci al dermi s whi ch may be s mal l weal s or l arger pl aques . Les i ons pres ent s uddenl y and wi l l res ol ve wi t hi n 24 hours , al t hough new l es i ons may devel op repeat edl y. In s evere urt i cari a s ys t emi c s ympt oms may predomi nat e wi t h t he devel opment of anaphyl axi s charact eri zed by hi s t ami ne s hock and col l aps e (s ee p264). Feat ures i ncl ude hypot ens i on, bronchos pas m, angi oedema, and di ffus e urt i cari a. Pres ence of ext ens i ve urt i cari al l es i ons does not i mpl y anaphyl axi s i n t he abs ence of s ys t emi c feat ures . Drug s ens i t i vi t i es and react i ons t o radi ographi c cont ras t medi a are more l i kel y t o produce anaphyl axi s .
Causes
Bee/was p s t i ngs , drug react i ons (peni ci l l i n common, as pi ri n and non-s t eroi dal ant i -i nfl ammat ory drugs ), radi ographi c cont ras t medi a, bl ood product s , food s ens i t i vi t y s uch as nut s and s hel l fi s h. Phys i cal caus es of urt i cari a s uch as dermographi s m, pres s ure, vi brat i on, col d, aquageni c, s ol ar, and chol i nergi c (heat /exerci s e). Cont act urt i cari a. Heredi t ary angi oedema as s oci at ed wi t h a genet i c defi ci ency of t he enzyme C 1 -es t eras e i nhi bi t or (s ee
Pa g e 1 2 8 2
p768).
Mal i gnancy and aut oi mmune di s orders s uch as l upus as s oci at ed wi t h a funct i onal defi ci ency of C 1 -es t eras e i nhi bi t or. Chroni c i di opat hi c urt i cari a pos s i bl y due t o aut oant i bodi es produced agai ns t t he l ow affi ni t y IgE recept or.
Diagnostic points

A fami l y hi s t ory may s ugges t heredi t ary angi oedema. In pat i ent s wi t h chroni c urt i cari a, as k s peci fi cal l y about pos s i bl e phys i cal caus es (e.g. i nduced by col d, exerci s e, wat er, pres s ure, heat , and rarel y l i ght and vi brat i on. Dermographi s m i s t he mos t common form of phys i cal urt i cari a; bri s kl y s t roki ng t he s ki n wi t h a fi rm object produces l i near weal s . Cont act urt i cari a us ual l y occurs wi t hi n mi nut es aft er di rect cont act wi t h vari ous agent s s uch as pl ant s , aeroal l ergens , foods s uch as chees e, eggs , and fi s h and i n heal t hcare workers aft er cont act wi t h l at ex. Cont act s ens i t i vi t y t o l at ex product s i s al s o as s oci at ed wi t h a hi gh i nci dence of anaphyl axi s . If i ndi vi dual urt i cari al l es i ons pers i s t for more t han 24 hours a di agnos i s of urt i cari al vas cul i t i s i s l i kel y. Such l es i ons are t ender and pai nful rat her t han pruri t i c and may appear brui s ed. Unl i ke ot her forms of urt i cari a t hi s di agnos i s s houl d be es t abl i s hed by hi s t ol ogy. Pat ch t es t s are not i ndi cat ed i n urt i cari a. Pri ck t es t s wi l l i ndi cat e i f i ndi vi dual s are at opi c but rarel y may al s o be us eful i n es t abl i s hi ng a s peci fi c caus e of cont act urt i cari a (s houl d onl y be carri ed out under medi cal s upervi s i on becaus e of a ri s k of anaphyl axi s ). Tot al s erum IgE l evel s may be el evat ed i n at opi c i ndi vi dual s . Speci fi c IgE RAST may be us ed t o i dent i fy pot ent i al s ens i t i vi t i es but can produce fal s e negat i ve/pos i t i ve res ul t s .
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P.777
P.778
Urticaria: management
Anaphyl act i c react i ons requi re i mmedi at e t reat ment (s ee p264).

o o o
Lay t he pat i ent fl at . Secure t he ai rway and gi ve oxygen. Gi ve i nt ramus cul ar adrenal i ne 0.5mg (0.5ml of 1 i n 1000 adrenal i ne i nject i on) and repeat every 5 mi nut es accordi ng t o BP, pul s e, and res pi rat ory funct i on. i v adrenal i ne may be requi red i f t he pat i ent i s s everel y i l l wi t h poor ci rcul at i on (s ee p264). St art i v fl ui ds i f hypot ens i ve. Gi ve i v hydrocort i s one 100300mg and chl orpheni rami ne 1020mg. Cont i nue H 1 -ant agoni s t (e.g. chl orpheni rami ne 4mg q46h) for at l eas t 2448 hours ; l onger i f urt i cari a and pruri t i s pers i s t . If t he pat i ent cont i nues t o det eri orat e, s t art i v ami nophyl l i ne i nfus i on (s ee p213). Pat i ent s on -bl ockers may not res pond t o adrenal i ne i nject i on and requi re i v s al but amol i nfus i on.
o o
Heredi t ary angi oedema may pres ent wi t h ext ens i ve urt i cari a and angi oedema as s oci at ed wi t h s ys t emi c feat ures i ncl udi ng anaphyl axi s . Management i s di s cus s ed on p768. Severe acut e urt i cari a wi t h or wi t hout angi oedema i s us ual l y not l i fe t hreat eni ng unl es s as s oci at ed wi t h s ys t emi c feat ures of anaphyl axi s .
o
Gi ve oral ant i -hi s t ami nes s uch as hydroxyz i ne
Pa g e 1 2 8 4
25mg or chl orpheni rami ne 4mg.

o
A s i ngl e dos e of predni s ol one 50mg oral l y may be pres cri bed but s houl d not be cont i nued i ndefi ni t el y wi t hout s peci al i s t advi ce. W hen t he pat i ent 's condi t i on has s t abi l i zed, t hey can be di s charged on regul ar mai nt enance t reat ment wi t h an oral non-s edat i ng ant i -hi s t ami ne s uch as cet i ri zi ne 10 t o 20mg dai l y, l evocet ri zi ne 5mg dai l y, des l orat i di ne 5mg dai l y, or fexofenadi ne 180mg dai l y (s edat i ve ant i -hi s t ami nes s uch as hydroxyz i ne or chl orpheni rami ne are us ual l y not requi red for mai nt enance t reat ment of chroni c urt i cari a).
Pat i ent s wi t h no s peci fi c i dent i fi abl e caus e of acut e urt i cari a and al l pat i ent s wi t h chroni c or phys i cal forms of urt i cari a s houl d be referred for s peci al i s t advi ce. Pat i ent s wi t h cont act s ens i t i vi t y t o l at ex s houl d us e al t ernat i ves s uch as Al l ergard gl oves , vi nyl gl oves , or non-s t eri l e copol ymer gl oves . Such i ndi vi dual s s houl d be warned t o us e onl y non-l at ex pol yuret hane condoms .
P.779
P.780
Autoimmune bullous disease Presentation

Int act pruri t i c fl ui d-fi l l ed bl i s t ers Very i t chy urt i cat ed eryt hemat ous pl aques (pre-bul l ous erupt i on) Cut aneous and/or mucos al eros i ons .
Causes
Common: bul l ous pemphi goi d, pemphi gus vul gari s
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Rare: pemphi goi d ges t at i ones (s econd/t hi rd t ri mes t er), dermat i t i s herpet i formi s , pemphi gus fol i aceus , epi dermol ys i s bul l os a acqui s i t a, bul l ous l upus eryt hemat os us , l i near IgA di s eas e, paraneopl as t i c pemphi gus .
Pemphi gus (hi gher mort al i t y t han ot her aut oi mmune bul l ous di s eas e) Age >60 years Ext ens i ve i nvol vement .
Diagnosis
Bi ops y of a fres h bl i s t er for hi s t ol ogy and a s mal l fragment of peri l es i onal s ki n s houl d be s ent for di rect i mmunofl uores cence s t udi es . Serum s houl d al s o be s ent for i ndi rect i mmunofl uores cence s t udi es .
Management
Li ai s e wi t h s peci al i s t at an earl y opport uni t y.
General measures
Int act bl i s t ers s houl d be as pi rat ed. Exami ne for new bl i s t ers dai l y. Pat i ent s s houl d be bat hed dai l y wi t h emol l i ent s and i f neces s ary chl orhexi di ne bat h addi t i ve i n order t o prevent s econdary bact eri al i nfect i on. Us e di l ut ed pot as s i um permanganat e s oaks for eroded and weepi ng areas wi t h non-adherent dres s i ngs s uch as Jel onet or Mepi t el under t ubofas t body s ui t /bandages . Avoi d Fegaderm or ot her adhes i ve dres s i ngs . Nurs e t he pat i ent on a Cl i ni t ron bed. Gi ve oral s edat i ng ant i -hi s t ami nes (e.g. hydroxyz i ne) for pruri t i s . Pot ent t opi cal s t eroi ds (e.g. Dermovat e cream) s houl d be appl i ed t o i ndi vi dual l es i ons t wi ce dai l y.
Pa g e 1 2 8 6
Pres cri be prophyl act i c s c hepari n for i mmobi l e el derl y pat i ent s . Moni t or fl ui d bal ance careful l y, FBC, U&Es , and LFTs regul arl y.
Specific systemic therapy

Li ai s e wi t h s peci al i s t s .
Refer s evere conjunct i val di s eas e t o an opht hal mol ogi s t earl y. Pemphi gus requi res hi gh-dos e i mmunos uppres s i on (predni s ol one 80100mg/day) but mi l d di s eas e may be cont rol l ed wi t h l es s . Bul l ous pemphi goi d, when l ocal i zed or mi l d, may res pond t o pot ent t opi cal s t eroi ds al one (e.g. Dermovat e cream) or can occas i onal l y be cont rol l ed wi t h ni cot i nami de 0.52.5g/day and ant i bi ot i cs (eryt hromyci n or t et racycl i nes ) Ext ens i ve di s eas e wi l l requi re i mmunos uppres s i on. Predni s ol one 3060mg/day i s us ual l y requi red and t he dos age gradual l y reduced accordi ng t o res pons e (i .e. once no new bl i s t ers are formed). P.781
St eroi d s pari ng agent s s uch as azat hi opri ne 50100mg/day s houl d al s o be cons i dered for ext ens i ve di s eas e, where res pons e t o s t eroi ds i s i nadequat e. For res i s t ant di s eas e cons i der met hyl predni s ol one, cycl ophos phami de, cycl os pori n, mycophenol at e, IrIgs , chl orambuci l , and pl as mapheres i s . Mucos al di s eas e requi res regul ar Di fl amm and t et racycl i ne mout h was hes wi t h Corl an l ozenges (hydrocort i s one 2.5mg) for pai nful eros i ons . 0.1% t acrol i mus i n orabat e i s current l y experi ment al . If condi t i on det eri orat es cons i der s econdary bact eri al or
Pa g e 1 2 8 7
vi ral i nfect i on of cut aneous or mucos al s i t es . Pemphigus i s charact eri zed by i nt raepi dermal s eparat i on and acant hol ys i s of i ndi vi dual kerat i nocyt es . In pemphi gus vul gari s t he s pl i t i s s uprabas al whi l e i n pemphi gus fol i aceus t he s eparat i on i s much hi gher i n t he epi dermi s . Peni ci l l ami ne, capt opri l , ri fampi ci n, and ot her drugs can rarel y i nduce a pemphi gus -l i ke s yndrome whi ch i s i ndi s t i ngui s habl e from pemphi gus vul gari s . Thi s account s for <10% of al l cas es of pemphi gus . Bullous pemphigoid i s charact eri zed by a s ub-epi dermal s pl i t and an i nfl ammat ory i nfi l t rat e cont ai ni ng eos i nophi l s . Speci al i s t advi ce i s requi red. Excl ude ot her caus es of bul l ous di s eas e s uch as porphyri as , drugs (NSAIDs , barbi t urat es , frus emi de), di abet es mel l i t us , and bul l ous amyl oi d. Al s o cons i der bul l ous i ns ect bi t e react i on and bul l ous i mpet i go i n t he di fferent i al di agnos i s part i cul arl y for l ocal i zed bl i s t ers . Tens e bl i s t ers on t he pal ms and s ol es may be due t o endogenous ecz ema (pomphol yx) or fungal i nfect i on (t i nea). P.782
Eczema herpeticum Presentation
Pat i ent s wi t h at opi c endogenous ecz ema are predi s pos ed t o s econdary herpes s i mpl ex i nfect i on. Thi s may occur as a pri mary i nfect i on fol l owi ng an epi s ode of herpes l abi al i s or aft er cont act wi t h an affect ed i ndi vi dual . Pat i ent s pres ent wi t h a s udden det eri orat i on of t hei r ecz ema charact eri zed by wi des pread ves i cul o-pus t ul ar l es i ons whi ch are t ender and gradual l y become necrot i c. Res ol ut i on of t he condi t i on produces ext ens i ve crus t i ng and exudat i on. Pat i ent s are us ual l y pyrexi al and t oxi c wi t h a t achycardi a. Cardi ores pi rat ory col l aps e i s unus ual .
Pa g e 1 2 8 8
Management
The condi t i on can progres s rapi dl y and t herefore l ocal i zed di s eas e s houl d be t reat ed aggres s i vel y. Pat i ent s s houl d be admi t t ed and earl y s peci al i s t advi ce i s requi red. Refer pat i ent s wi t h ocul ar di s eas e t o an opht hal mol ogi s t urgent l y. Ext ens i ve mucos al di s eas e may make oral nut ri t i on di ffi cul t and pat i ent s may requi re i nt ravenous fl ui ds . Perform bact eri al s wabs dai l y: s econdary bact eri al i nfect i on i s common and i f pres ent requi res t reat ment wi t h s ys t emi c ant i bi ot i cs . Topi cal t herapy
o o o
Do not us e t opi cal s t eroi ds Us e s i mpl e emol l i ent s s uch as aqueous cream Chl orhexi di ne (t opi cal ant i s ept i c) and di l ut ed pot as s i um permanganat e (1/10 000) (s houl d be pal e pi nk i n col our or i t i s t oo s t rong) as a s oak once or t wi ce dai l y for bri ef peri ods t o areas of exces s i ve exudat i on.
Gi ve oral non-s edat i ng ant i -hi s t ami nes . St art hi gh-dos e i nt ravenous acycl ovi r at t he earl i es t opport uni t y (maxi mum 10mg/kg/8 hourl y). If i nt ravenous t herapy i s not pos s i bl e, gi ve val aci cl ovi r 1000mg t ds for 7 days . Pat i ent s wi t h s evere at opi c eczema s houl d be advi s ed about prompt t reat ment of herpes l abi al i s and t o avoi d cont act wi t h herpes s i mpl ex. Adul t s wi t h herpes l abi al i s s houl d be advi s ed t o avoi d cont act wi t h chi l dren wi t h at opi c eczema.
Herpes zoster
See p312. P.783
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P.784
Generalized pustular psoriasis Presentation
Rapi d ons et of s uperfi ci al pus t ul es , us ual l y i n a pat i ent wi t h t ypi cal pl aque ps ori as i s . Pus t ul es may be confl uent or pi n-poi nt and may be s t udded around t he peri phery of t ypi cal ps ori at i c pl aques . Irri t ant t opi cal t herapi es (e.g. pot ent t opi cal s t eroi ds , vi t ami n D anal ogues , coal -t ar, and di t hranol preparat i ons ) may preci pi t at e general i zed pus t ul ar ps ori as i s i n pat i ent s wi t h uns t abl e ps ori as i s (hot t ender eryt hemat ous ps ori at i c pl aques ). Rarel y pat i ent s devel op general i zed pus t ul ar ps ori as i s wi t hout a previ ous hi s t ory, and s i mi l ar pres ent at i ons can occur i n pregnancy. Pyrexi a i s oft en accompani ed by s ys t emi c s ympt oms s uch as mal ai s e, anorexi a, and art hral gi a. Cut aneous i nfect i on wi t h St aphyl oc oc c us aureus i s common and may res ul t i n s ept i caemi a. Di fferent i al di agnos i s i ncl udes bul l ous i mpet i go, t oxi c epi dermal necrol ys i s , s t aphyl ococcal s cal ded s ki n s yndrome, aut oi mmune bul l ous di s orders , and i n part i cul ar s ubcorneal pus t ul ar dermat os i s , pus t ul ar vas cul i t i s part i cul arl y due t o herpes s i mpl ex i nfect i on or drugs , and eczema herpet i cum.
Natural history
There are repeat ed acut e epi s odes of general i zed pus t ul at i on as s oci at ed wi t h pyrexi a and s ys t emi c s ympt oms res ol vi ng i n 57 days t o produce ext ens i ve s uperfi ci al crus t i ng. Epi s odes recur every 710 days . Pat i ent s wi t h l ocal i zed pal mo-pl ant ar pus t ul ar ps ori as i s have a mi l d chroni c di s eas e whi ch i s not as s oci at ed
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wi t h s ys t emi c abnormal i t i es .
Pat i ent s wi t h general i zed di s eas e may devel op ARDS and s hock due t o rel eas e of cyt oki nes or t he pres ence of s ept i caemi a. El derl y pat i ent s wi t h general i zed pus t ul ar ps ori as i s (Von Zumbus ch) have a wors e prognos i s .
Investigations
Moni t or FBC, U&Es , and LFTs regul arl y. A neut rophi l l eukocyt os i s i s i nvari abl e. Abnormal LFTs and Ca may occur.
2+
Pri mary bact eri al or vi ral i nfect i on s houl d be excl uded by appropri at e bact eri al and vi ral s wabs . If febri l e, t ake bl ood cul t ures . Perform ABGs i n hypoxi c pat i ent s or t hos e wi t h an abnormal CXR.
Management
Li ai s e wi t h s peci al i s t s at an earl y opport uni t y.
Enforce bed res t ; moni t or t emperat ure and fl ui d bal ance cl os el y. Oral fl ui ds wi t h hi gh cal ori e and hi gh prot ei n i nput /s uppl ement s .
Topical therapy
The ext ens i ve crus t i ng and exudat i on of t he earl y phas e of pus t ul at i on can be t reat ed wi t h t opi cal pot as s i um permanganat e (1/10 000) s oaks . For ext ens i ve di s eas e, nurs e on a Cl i ni t ron bed i n a warm room. Bat he dai l y wi t h emol l i ent s and ant i s ept i c was hes . Treat s ki n at l eas t four t i mes dai l y wi t h emol l i ent s s uch as 50% W SP, 50% LP, Epaderm, or aqueous cream. Avoi d t opi cal s t eroi ds , vi t ami n D anal ogues , coal t ar, and di t hranol (may caus e s evere i rri t at i on and exacerbat i on of t he di s eas e).
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P.785
Systemic therapy
Gi ve regul ar oral s edat i ve ant i -hi s t ami nes (e.g. hydroxyz i ne). Bact eri al i nfect i on s houl d be t reat ed wi t h appropri at e ant i bi ot i cs . Severe general i zed pus t ul ar ps ori as i s may requi re s ys t emi c t reat ment wi t h ret i noi ds , met hot rexat e, or cycl os pori n: s eek s peci al i s t advi ce.
Practice point
Ps ori as i s rarel y becomes s econdari l y i nfect ed.
P.786
Toxic epidermal necrolysis (TEN) 1 Presentation

Acut e ons et of morbi l l i form or confl uent eryt hema as s oci at ed wi t h wi des pread bl i s t eri ng (necrol ys i s ) and s ki n t endernes s .
Diagnostic points
Necrol ys i s i s us ed t o des cri be confl uent bl i s t eri ng of t he s ki n as s oci at ed wi t h epi dermal s eparat i on rat her l i ke a l arge burn. It s houl d be di s t i ngui s hed from di s cret e i nt act bl i s t ers whi ch are charact eri s t i c of aut oi mmune bul l ous di s eas es . There may be cl i ni cal overl ap bet ween t oxi c epi dermal necrol ys i s and eryt hema mul t i forme as s een i n t he St even's Johns on s yndrome. Mucocut aneous i nvol vement i s common and bot h oral and conjunct i val eros i ons may be pres ent . TEN s houl d be di s t i ngui s hed from t he s t aphyl oc oc c al s c al ded s ki n s yndrome (SSS) . Thi s us ual l y occurs i n
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chi l dren or i mmunos uppres s ed adul t s and i s as s oci at ed wi t h t he product i on of s t aphyl ococcal t oxi ns . A s ki n bi ops y i s di agnos t i c: i n TEN t here i s ful l t hi cknes s epi dermal necros i s , s ub-epi dermal s eparat i on, and a s pars e or abs ent dermal i nfi l t rat e whi l e i n SSS t here i s s uprabas al epi dermal s eparat i on wi t h an i nt act bas ement membrane.
Causes

Idi opat hi c Drug i nduced [s ul phonami des and occas i onal l y ot her ant i bi ot i cs , ant i -convul s ant s (not des cri bed wi t h s odi um val proat e), NSAIDs ].
Adverse prognostic factors

Age great er t han 60 years (25% overal l mort al i t y) Area of cut aneous i nvol vement great er t han 50% Bl ood urea great er t han 17mmol /L Neut ropeni a (neut rophi l count <1 10 /L) Idi opat hi c aet i ol ogy.
9
Management
The pri ori t i es are

Try t o i dent i fy t he caus e and t reat . St op drug Support i ve care: fl ui d bal ance and nut ri t i on Prevent compl i cat i ons Eye care Screeni ng and t reat ment of s eps i s .
P.787
P.788
Toxic epidermal necrolysis 2 1 Identify the cause
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A s peci fi c drug i s unl i kel y t o be res pons i bl e i f t reat ment was s t art ed aft er t he ons et of eryt hema, necrol ys i s , or mucous membrane i nvol vement . A drug aet i ol ogy s houl d be cons i dered i f TEN devel ops 721 days aft er t he fi rs t admi ni s t rat i on of a drug, or wi t hi n 48 hours i f t he drug has caus ed an erupt i on i n t he pas t . If pat i ent s are on s everal di fferent drugs , s t op al l t hat may be a caus e.
2 General supportive care
Pat i ent s s houl d be nurs ed on an ai r fl ui d or Cl i ni t ron bed i n a s i de room. A s i ngl e des i gnat ed nurs e s houl d at t end t he pat i ent cont i nuous l y and t he room s houl d be kept warm i n order t o prevent hypot hermi a. Core t emperat ure s houl d be cont i nuous l y moni t ored vi a a rect al probe and a s pace bl anket may be requi red i f t he pat i ent becomes hypot hermi c becaus e of cut aneous vas odi l at at i on. However, pat i ent s frequent l y al s o devel op hypert hermi a whi ch may neces s i t at e t emporary cool i ng of t he room wi t h fans . Lyofoam dres s i ngs s houl d be us ed bet ween t he pat i ent and beddi ng i n order t o eas e mobi l i t y and s ki n dres s i ngs . Emol l i ent s s houl d be appl i ed every 24 hours t o al l areas or pat i ent s can be wrapped t o i mprove eas e of handl i ng and reduce s heer forces on t he s ki n. Thi s i nvol ves coveri ng t he s ki n wi t h aqueous cream generous l y, t hen appl yi ng Jel onet , fol l owed by Sofban t hen Coban bandages . Oral mucos al s urfaces s houl d be cl eaned every 46 hours and s prayed wi t h chl orhexi di ne and Di fl amm. Mucos al i nvol vement may produce oral eros i ons or cons t ri ct i ons affect i ng t he oral apert ure or pharynx. Nas opharyngeal i nvol vement may res ul t i n ai rway obs t ruct i on and neces s i t at e vent i l at i on. Mucous membrane i nvol vement us ual l y ant edat es s ki n
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necrol ys i s for s everal days before pres ent at i on. Gas t roi nt es t i nal i nvol vement may be charact eri zed by bl eedi ng and/or a prot ei n l os i ng ent eropat hy. The net res ul t i s a profound negat i ve fl ui d and ni t rogen bal ance.
Moni t or fl ui d bal ance cl os el y, preferabl y by dai l y wei ght s . If pos s i bl e, fl ui ds s houl d be admi ni s t ered oral l y or vi a a nas ogas t ri c rout e. Avoi d i v l i nes t o reduce t he ri s k of s eps i s . 57 l i t res are us ual l y requi red duri ng t he fi rs t 24 hours . A prot ei n- and energy-ri ch nas ogas t ri c feed s houl d be admi ni s t ered (11.5 L/day). Dai l y FBC, U&Es , LFTs , amyl as e(), phos phat e(), and gl ucos e (hypergl ycaemi a produces an os mot i c di ures i s aggravat i ng dehydrat i on), CXR s houl d be performed regul arl y. Pul monary oedema and ARDS are frequent compl i cat i ons . ABGs s houl d be moni t ored and i f t here i s det eri orat i on, have a l ow t hres hol d for admi s s i on t o ITU and vent i l at i on. Prophyl act i c ant i -coagul at i on s houl d be us ed (s ubcut aneous cal ci um hepari n 5000 uni t s t ds or enoxapari n 40mg s c od). Pat i ent s are frequent l y t erri fi ed and i n cons i derabl e pai n. Adequat e anal ges i a and t ranqui l l i zers s houl d be admi ni s t ered. Pos t -i nfl ammat ory pi gment ary changes are common and wi l l gradual l y res ol ve.
P.789
P.790
Toxic epidermal necrolysis 3 1 Prevent complications: Infection
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Cent ral venous l i nes s houl d be avoi ded i f pos s i bl e. i v l i nes s houl d be di s cont i nued as s oon as pos s i bl e i n order t o reduce i nfect i on ri s k. Several cut aneous and mucous membrane s i t es s houl d be s wabbed dai l y. Cul t ure s put um and uri ne dai l y. Int ravenous and i n-dwel l i ng cat het ers s houl d be changed frequent l y and t i ps s ent for cul t ure. Perform bl ood cul t ures dai l y i f febri l e. Remember t hat pyrexi a i s a feat ure of TEN and does not al ways i ndi cat e i nfect i on. Prophyl act i c ant i bi ot i cs are onl y i ndi cat ed i f t he ri s k of s eps i s i s ext remel y hi gh s uch as s evere neut ropeni a or a heavy s i ngl e s t rai n bact eri al col oni zat i on of t he s ki n. Ant i bi ot i cs s houl d be s t art ed i f t here i s pos i t i ve bl ood, uri ne, or s put um cul t ure or i ndi rect evi dence of s eps i s s uch as hypot hermi a, hypot ens i on, fever, decreas i ng l evel of cons ci ous nes s , reduced uri nary out put , or fai l ure of gas t ri c empt yi ng. W eepi ng, crus t ed, and exudat i ve areas of t he s ki n s houl d be t reat ed by l ocal appl i cat i on of pot as s i um permanganat e s oaks (1 : 10 000). Necrot i c epi dermi s s houl d be careful l y removed becaus e i t forms a focus for i nfect i on. Affect ed s ki n t hat has not become necrot i c s houl d not be removed. Topi cal Fl amazi ne s houl d be avoi ded as t hi s can caus e neut ropeni a when appl i ed t o l arge s urface areas .
2 Prevent complications: Ocular involvement
Corneal s carri ng and bl i ndnes s are t he commones t s equel ae of TEN. The cornea s houl d be exami ned dai l y by an opht hal mol ogi s t and ant i bi ot i c or ant i s ept i c eye drops s houl d be appl i ed every 12 hours . Synechi ae form us ual l y i n t he s econd week. Thes e can be s eparat ed us i ng a bl unt i ns t rument s everal t i mes a
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day but t hi s i s cont rovers i al and t he advi ce of an opht hal mol ogi s t i s es s ent i al .
Si cca s yndrome and vi s ual i mpai rment due t o corneal neovas cul ari zat i on may produce corneal s carri ng and bl i ndnes s . Sympt oms us ual l y devel op s everal weeks aft er t he ons et of TEN.
3 Specific systemic therapy
There i s no cont rol l ed evi dence t hat any s peci fi c s ys t emi c t herapy i mproves prognos i s . In part i cul ar t here i s no evi dence t hat s ys t emi c s t eroi ds are benefi ci al and advers e effect s are numerous . St eroi ds s houl d not be us ed as a s t andard t herapy for TEN. Earl y t reat ment i n fi rs t 1224 hours wi t h cycl os pori n (34mg/kg/day) or cycl ophos phami de (150300mg per day) are benefi ci al but nei t her drug i s es t abl i s hed as a s t andard t herapy i n TEN and t hes e drugs s houl d not be pres cri bed wi t hout s peci al i s t advi ce. More recent l y good prel i mi nary res ul t s have been obt ai ned wi t h hi gh-dos e i nt ravenous i mmunogl obul i n t herapy us ed i n conjunct i on wi t h pul s ed met hyl predni s ol one. Pl as mapheres i s may be of benefi t i n s ome pat i ent s .
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> T able of Cont ent s > Chapt er 14 - Drug overdoses
Chapter 14
Drug overdoses
P.792
Overdoses: general approach
Overdos es account for 15% of acut e medi cal emergenci es . 65% of drugs i nvol ved bel ong t o t he pat i ent , a rel at i ve, or fri end. 30% of s el f-poi s oni ngs i nvol ve mul t i pl e drugs . 50% of pat i ent s wi l l have t aken al cohol as wel l . The hi s t ory may be unrel i abl e. Ques t i on any wi t nes s es or fami l y about where a pat i ent was found and any pos s i bl e acces s t o drugs . Exami nat i on may reveal cl ues as t o t he l i kel y poi s on (e.g. pi npoi nt pupi l s wi t h opi at es ) and s i gns of s ol vent or et hanol abus e and i v drug us e s houl d be not ed.
Management
Pri ori t i es are

o o o
Res us ci t at e t he pat i ent Reduce abs orpt i on of t he drug i f pos s i bl e Gi ve s peci fi c ant i dot e i f avai l abl e.
Moni t or t hei r ai rway (pl ace i n t he recovery pos i t i on) and breat hi ng, BP, t emperat ure, aci dbas e and el ect rol yt es , and t reat s ei zures or dys rhyt hmi as . Int ubat e i f GCS 8, and not revers i bl e wi t h nal oxone or fl umazeni l . Take account of any act i ve medi cal probl ems t hat t he
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pat i ent may have, e.g. i v drug us ers may have concurrent s ept i caemi a, hepat i t i s , SBE, pul monary hypert ens i on, or HIV-rel at ed di s eas e.
Meas ures t o reduce gut abs orpt i on i ncl ude

o
Gas t ri c l avage i s onl y effect i ve i f us ed up t o 1 hour pos t OD. It i s cont rai ndi cat ed i f corros i ve s ubs t ances or hydrocarbons have been i nges t ed. Prot ect t he ai rway wi t h endot racheal i nt ubat i on i f cons ci ous l evel i s i mpai red. Ac t i vat ed c harc oal (50 g as a s i ngl e dos e) wi l l abs orb many drugs i f gi ven wi t hi n 1 hour of i nges t i on al t hough i t s effect i venes s fal l s off rapi dl y t hereaft er. Drugs not abs orbed by charcoal i ncl ude i ron, l i t hi um, s al t s , al kal i s , aci ds , et hanol , met hanol , et hyl ene gl ycol , and organi c s ol vent s . Repeat ed admi ni s t rat i on of act i vat ed charcoal (50g every 4 hours ) may al s o accel erat e whol e body cl earance of s ome drugs by i nt errupt i ng ent erohepat i c cycl i ng, e.g. phenobarbi t one, phenyt oi n, carbamazepi ne, di goxi n, paraquat , daps one, qui ni ne, and s l ow-rel eas e preparat i ons s uch as t heophyl l i ne. Charcoal i s rat her unpl eas ant t o dri nk repeat edl y and wi l l be more rel i abl y t aken i f gi ven down a nas ogas t ri c t ube. PEG bow el l avage: i n whol e bowel i rri gat i on, a s ol ut i on of pol yet hyl ene gl ycol (not t o be confus ed wi t h et hyl ene gl ycol !!) i s gi ven oral l y or by NG t ube at 2L/h i n adul t s . It i s cont i nued unt i l t he rect al effl uent becomes cl ear. I ndi c at i ons : i nges t i on of s eri ous s ubs t ances s uch as s us t ai ned-rel eas e or ent eri c-coat ed preparat i ons . May be us ed for l i t hi um, i ron, ars eni c, l ead oxi de, or z i nc s ul phat e. Cont rai ndi c at i ons : bowel obs t ruct i on, perforat i on, i l eus , or i n pat i ent s s eri ous l y i l l e.g. haemodynami c i ns t abi l i t y.
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I pec ac -i nduc ed emes i s i s no l onger us ed.
Al w ays s eek advi c e from t he l oc al poi s ons uni t (l i s t ed i ns i de t he front cover of t he BNF and on p961). P.793
Assessment of poisoning in the unconscious patient

Sign Hypovent i l at i on Hypervent i l at i on Consider Opi at es , et hanol , benzodi azepi nes Met abol i c aci dos i s (as pi ri n, paracet amol ), gas t ri c as pi rat i on, carbon monoxi de Pi npoi nt pupi l s Di l at ed pupi l s Bradycardi a Tachyarrhyt hmi as Opi at es , organophos phat es Met hanol , ant i chol i nergi cs , t ri cycl i cs , LSD -bl ockers , di goxi n, opi at es Tri cycl i cs , ant i -chol i nergi cs , caffei ne, t heophyl l i ne, l i t hi um, di goxi n Hypert hermi a Pyrami dal s i gns , at axi a, hypot ni a, hyper-refl exi a and ext ens or pl ant ars Hypert ens i on Cocai ne, amphet ami nes , ecs t as y Ecs t as y, amphet ami nes , ant i -chol i nergi cs Tri cycl i cs or ant i -chol i nergi c agent s
NB: Occas i onal l y pat i ent s pres ent where poi s oni ng i s s us pect ed but not known. Even where t he hi s t ory s ugges t s s el f-poi s oni ng be aware t hat s eri ous underl yi ng di s eas e may be pres ent . For exampl e, pat i ent s who feel very i l l wi l l oft en s el f-medi cat e wi t h as pi ri n and paracet amol . P.794
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Drug overdoses and antidotes

Dr Act An ug ion tid ote /T he ra py Ant Act Di a i -d i va zep epr t ed am es s cha for ant rco con s al vul sio ns , car di a c mo ni t ori As pi ri n ng Al k al i ne di u res is, ha em odi
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al y sis Be Pro Fl u nz o t ec ma di a t zen z ep ai r i l i f i ne wa s ev s y ere - Ch At r bl o eck opi cke BP, ne rs HR, (3 an mg d ), bre gl u at h cag i ng on 7m g i m, con sid er pac i ng Cal Cal Ant ci u ci u i -c m m hol ant gl u i ne ag con rgi oni at e cs sts Car Gi v Tre bo e n at 10 cer
mo 0% ebr
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nox oxy al i de ge oe n de ma wi t h ma nni t ol , con sid er hyp erb ari c oxy ge n Cy Gi v So ani e di u de 10 m 0% t hi oxy os u ge l ph n at e , di c ob al t ed et a te Di g Ch Di g oxi eck i bi
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K d
nd (di i nbi n di n g ant i bo
an EC gox G
dy) Et h Ga Inf yl e s t ri us e ne c et h gl y em an col pt y ol , i ng 4me t hy l pyr azo le He Ga Di avy s t ri me me c s rca t al em pro pt y l , i ng pe ni ci lla mi ne, s od iu
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m cal ci u m ed et a te Iro Ga De n s t ri s fe rri o t ab c s
l et em xa pt y mi i ng ne Li t Ga Di u hi u s t ri res m c is/ em di a pt y l ys i i ng s Mef Co No en nvu ne am l s i ic d ons y occ ur. Tre at wi t h di a z ep am Me Mo Inf t ha ni t us e aci ma
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nol or et h U& an Es , ol , gl u ph cos eny e t oi n for s ei zur es , di a l ys i s if s ev ere Org Ga At r an s t ri opi op c ne, hos em pra ph pt y l i d oru i ng oxi s , me i ns re ect mo i de ve s cl o t he s, an d dec ont am i na
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te Opi Ens Nal at e ure oxo s bre ne at h i ng is ad eq uat e Par Ga N-a ace s t ri cet ta c l yl c mo em ys t pt y ei n i ng e if (or wi t me hi n t hi 4 oni ho ne) urs Par Ga Ful aq s t ri l er' uat c s em Ear pt y t h i ng (or be nt o ni t e or act
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i va t ed cha rco al ), i nt r ave no us vi t am in E ma y be of be nef it Th Ch rep eo eck eat phy pl a dos llin sm e e a of pot act as s i va iu m t ed cha
urg rco ent al ly P.795
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P.796
Amphetamines
Thi s agent (and i t s cogener met hamphet ami ne) i s wi del y abus ed for i t s effect s on CNS arous al . A number of i t s met hyl enedi oxy deri vat i ves (e.g. ecs t as y or MDMA) are al s o avai l abl e on an i l l i ci t bas i s and have addi t i onal hal l uci nogeni c act i ons (LSD l i ke).
Presentation
Sympath Central omimetic effects
effects
Mydr i as i s
Hyp erex ci t a bi l i t y
Hyp ert e ns i o n
Agi t at i o n
Tach ycar di a
Tal k at i v enes s
Ski n pal l or
Para noi a (es p . wi t h chro ni c
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us e)
Complications
Int racrani al (and s ubarachnoi d) haemorrhage: al t hough at t ri but ed t o i t s hypert ens i ve effect t hi s can occur aft er s i ngl e dos e. Vas os pas m may be s een on angi ography (s t ri ng-of-beads s i gn). Ecs t as y i s as s oci at ed wi t h a heat -s t roke-l i ke s yndrome (p604).

Hyperpyrexi a (>42C) Rhabdomyol ys i s Di s s emi nat ed i nt ravas cul ar coagul at i on Acut e renal fai l ure Acut e l i ver fai l ure.
Management
Sedat e agi t at ed pat i ent s wi t h a benz odi azepi ne (e.g. 510mg di azepam i v or 12mg l orazepam i m). Frankl y ps ychot i c pat i ent s may requi re hal operi dol (510mg i m). Hal operi dol may decreas e t he s ei zure t hres hol d. Moni t or core t emperat ure at l eas t hourl y i ni t i al l y. Sei z ures s houl d be cont rol l ed wi t h di azepam (510mg
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i v s t at ). New focal s i gns s houl d prompt urgent CT s canni ng l ooki ng for evi dence of i nt racrani al bl eedi ng.
Si gni fi cant hypert ens i on (di as t ol i c >120mmHg) may res pond t o s edat i on wi t h di azepam. If not i t s houl d be cont rol l ed wi t h l abet al ol , a combi ned - and -bl ocker: gi ve 50 mg s t at i v fol l owed by an i nfus i on of 12mg/mi n whi ch s houl d be s t opped when t he BP i s cont rol l ed (s el ect i ve -bl ockers s uch as at enol ol may act ual l y wors en t he hypert ens i on). Hyperpyrexi a requi res prompt cool i ng wi t h t epi d s pongi ng or even chi l l ed i v fl ui ds as neces s ary t o keep t he rect al t emperat ure <38.5C. Chl orpromaz i ne (2550mg i m) wi l l decreas e t he core t emperat ure but may caus e s edat i on and hypot ens i on. Dant rol ene can decreas e hyperpyrexi a. Aci di fi cat i on of t he uri ne can s ubs t ant i al l y i ncreas e drug el i mi nat i on but can exacerbat e el ect rol yt e and pH di s t urbances . Avoi d i f rhabdomyol ys i s i s pres ent . It s houl d onl y be us ed for s evere overdos e and where t he pat i ent can be cl os el y moni t ored for res pons e and advers e effect s .
P.797
P.798
Benzodiazepines
Del i berat e overdos e wi t h t hi s group of compounds i s very common. Unl es s combi ned wi t h ot her s edat i ves (e.g. al cohol or t ri cycl i cs ) effect s of overdos i ng are general l y mi l d.
Presentation

Drows i nes s Sl urred s peech Nys t agmus
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Hypot ens i on (mi l d) At axi a Coma Res pi rat ory depres s i on Cardi ores pi rat ory arres t (wi t h i v admi ni s t rat i on)
The el derl y are general l y more s us cept i bl e t o cardi ores pi rat ory depres s i on wi t h benz odi azepi ne overdos e.
Management
If pat i ent s pres ent wi t hi n 1 hour, empt y t he s t omach by gas t ri c l avage and gi ve 50g act i vat ed charcoal . Act i vat ed charcoal may be gi ven whi l s t l avage i s bei ng s et up. Ens ure t he pat i ent can prot ect t hei r ai rway. No furt her i nt ervent i on i s us ual l y requi red for mi l d t o moderat e overdos es . Severe overdos e may requi re us e of t he benzodi azepi ne ant agoni s t , fl umazeni l , e.g. comat os e pat i ent s part i cul arl y where t he di agnos i s i s uncert ai n and pat i ent s wi t h s i gni fi cant cardi ores pi rat ory depres s i on. Fl umazeni l i s gi ven as an i v bol us of 0.2mg fol l owed by a furt her bol us dos e of 0.1mg every 23 mi nut es unt i l t he pat i ent i s rous abl e. Mos t benzodi azepi nes have a s ubs t ant i al l y l onger durat i on of act i on t han fl umazeni l and an IVI of 0.10.4mg/h wi l l be needed t o prevent earl y res edat i on. Avoi d gi vi ng exces s fl umazeni l t o compl et el y revers e t he effect of a benz odi azepi ne. In chroni c benzodi azepi ne abus ers t hi s can caus e marked agi t at i on and may preci pi t at e s ei zures i n pat i ent s who have t aken an overdos e of a combi nat i on of benzodi azepi nes and proconvul s ant s (e.g. dext ropropoxyphene, t heophyl l i nes , and t ri cycl i cs ).
P.799
P.800
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-blockers
Thes e agent s compet i t i vel y ant agoni ze t he effect s of endogenous cat echol ami nes . They caus e profound effect s on at ri ovent ri cul ar conduct i on and myocardi al cont ract i l i t y, and t hei r effect s are predi ct abl e bas ed on t hei r known pharmacol ogy.
Presentation

Si nus bradycardi a Hypot ens i on Cardi ac fai l ure Cardi ac arres t (as ys t ol e or VF) Bronchos pas m (rare i n non-as t hmat i cs ) Drows i nes s Hal l uci nat i ons Fi t s (es p. wi t h propranol ol ) Coma Hypogl ycaemi a (rare)
Prognostic features
Subject s wi t h pre-exi s t i ng i mpai red myocardi al cont ract i l i t y are l es s l i kel y t o t ol erat e even moderat e overdos es of -bl ockers . The ECG may provi de s ome i ndi cat i on as t o t he dos e i nges t ed: mi l d overdos e i s s ugges t ed by fi rs t -degree heart bl ock; wi deni ng of t he QRS and prol ongat i on of t he correct ed QT i nt erval (part i cul arl y aft er s ot al ol ) are as s oci at ed wi t h moderat e t o s evere overdos e.
Management

Es t abl i s h i v acces s . Check a 12-l ead ECG and t hen moni t or ECG cont i nuous l y. Record BP regul arl y (at l eas t every 15 mi nut es ). Gas t ri c l avage s houl d be at t empt ed i f s een wi t hi n 1
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hour of i nges t i on. Gi ve at ropi ne (0.61.2 mg i v) before l avage t o prevent vagal -i nduced cardi ovas cul ar col l aps e.
Hypot ens i on: t reat wi t h i v gl ucagon (50150g/kg fol l owed by an i nfus i on of 15mg/h). Thi s pept i de i s abl e t o exert an i not ropi c effect i ndependent of -recept or act i vat i on by rai s i ng myocardi al cAMP l evel s . Bradyc ardi a: may res pond t o at ropi ne al one (0.61.2mg i v 68 hourl y). Is oprenal i ne i nfus i ons (550g/mi n) may be t ri ed but are oft en i neffect i ve. If t he bradycardi a pers i s t s and t he pat i ent i s i n cardi ogeni c s hock a t rans venous paci ng wi re s houl d be i ns ert ed (s ee p878). Convul s i ons : t reat i n t he s t andard way (p472). Gi ve di az epam 510mg i v i ni t i al l y. Bronc hos pas m: t reat i ni t i al l y wi t h hi gh-dos e nebul i zed s al but amol (510mg) (hi gher dos es may be needed). Nebul i zed i prat ropi um bromi de (250500g) may be t ri ed but i t i s unl i kel y t o offer addi t i onal bronchodi l at at i on i n a ful l y at ropi ni zed s ubject . If nebul i zed bronchodi l at ors are i neffect i ve, an ami nophyl l i ne i nfus i on s houl d be us ed (e.g. 0.5mg/kg/mi n). Moni t or bl ood gl uc os e regul arl y (hourl y BMs ). If hypogl ycaemi a devel ops gi ve 50ml of 50% dext ros e fol l owed by an IVI i nfus i on of 10% dext ros e adjus t i ng t he rat e as neces s ary.
P.801
P.802
Carbon monoxide
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See s moke i nhal at i on, p856. The commones t s ources are s moke i nhal at i on, poorl y mai nt ai ned domes t i c gas appl i ances and del i berat e i nhal at i on of car exhaus t fumes . It caus es i nt ens e t i s s ue hypoxi a by t wo mechani s ms . Fi rs t l y, i t i nt errupt s el ect ron t rans port i n mi t ochondri a. Secondl y, i t reduces oxygen del i very bot h by compet i ng wi t h O 2 for bi ndi ng t o Hb (i t s affi ni t y for Hb i s 220-fol d t hat of O 2 ) and al t eri ng t he s hape of t he HbO 2 di s s oci at i on curve (maki ng i t l es s s i gmoi dal ).
Presentation
Pat i ent s pres ent wi t h s i gns of hypoxi a wi t hout cyanos i s . Ski n and mucos al s urfaces may appear cherry-red (mos t obvi ous pos t mort em). Level s of COHb bel ow 30% caus e onl y headache and di z z i nes s . 5060% produces s yncope, t achypnoea, t achycardi a, and fi t s . Level s over 60%, caus e i ncreas i ng ri s k of cardi ores pi rat ory fai l ure and deat h.
Complications
Thes e are t he predi ct abl e res ul t of l ocal hypoxi a. Si t es at part i cul ar ri s k are CNS, affect i ng cerebral , cerebel l ar, or mi d-brai n funct i on, e.g. Parki ns oni s m and aki net i c-mut i s m; t he myocardi um wi t h i s chaemi a and i nfarct i on; s kel et al mus cl e caus i ng rhabdomyol ys i s and myogl obi nuri a; s ki n i nvol vement ranges from eryt hema t o s evere bl i s t eri ng.
Prognostic features
Anaemi a, i ncreas ed met abol i c rat e (e.g. chi l dren), and underl yi ng i s chaemi c heart di s eas e al l i ncreas e s us cept i bi l i t y t o CO. Neurol ogi cal recovery depends on t he durat i on of hypoxi c coma; compl et e recovery has been report ed i n young s ubject s (under 50) aft er up t o 21 hours , vers us 11 hours i n ol der s ubject s .
Management
An art eri al bl ood gas s houl d be t aken. Al t hough P a O 2 may be normal i t i s es s ent i al t o meas ure t he COHb concent rat i on. Mos t ITUs have a carboxyhemogl obi nomet er.
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NB: moni t ori ng O 2 s at urat i on wi t h a pul s e oxi met er i s unhel pful s i nce i t wi l l not di s t i ngui s h HbO 2 and COHb (hence t he apparent oxygen s at urat i on wi l l be fal s el y hi gh).
Appl y a t i ght -fi t t i ng facemas k and gi ve 100% O 2 . Check a 12-l ead ECG and cont i nuous l y moni t or rhyt hm. Take bl ood for FBC, U&E, CPK, and cardi ac enz ymes . If t he pat i ent i s comat os e t hey s houl d be i nt ubat ed and vent i l at ed wi t h 100% Fi O 2 (t hi s reduces t he hal f-l i fe of COHb t o 80 mi nut es cf. 320 mi nut es on room ai r). Thi s s houl d al s o be cons i dered i n pat i ent s who are s everel y aci dot i c or s how evi dence of myocardi al i s chaemi a. Fi t s s houl d be cont rol l ed wi t h i v di azepam (510 mg). The met abol i c aci dos i s does not general l y requi re correct i on wi t h i v NaHCO 3 . Hyperbari c oxygen wi l l s hort en t he was hout of COHb but acces s and t rans fer t i mes t o a hyperbari c chamber can make t hi s di ffi cul t . Cons i der i f (1) t he pat i ent s has been uncons ci ous , (2) i f COHb i s >40%, and (3) i f t here are neurol ogi cal or ps ychi at ri c s i gns .
Ens ure medi cal fol l ow-up as t he neurops ychi at ri c s equel ae may t ake many weeks t o evol ve. P.803
P.804
Cocaine
Int oxi cat i on duri ng i t s t herapeut i c us e as a t opi cal anal ges i c i s ext remel y rare. It i s rapi dl y abs orbed, when appl i ed i nt ranas al l y (s nort i ng) or s moked (free-bas i ng crack). Occas i onal l y i t pres ent s as mas s i ve overdos i ng when t he s wal l owed packet s of i l l i ci t , s muggl ed cocai ne rupt ure. It s s ubject i ve and s ympat homi met i c act i ons are oft en i ndi s t i ngui s habl e from
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amphet ami ne.
Presentation

Hypert ens i on Tachycardi a Ski n pal l or Vent ri cul ar arrhyt hmi as Paranoi d del us i ons (chroni c us e) Sei z ures (common), may occur i n epi l ept i cs even at l ow dos es CNS depres s i on (wi t h hi gh dos es ) es peci al l y t he medul l ary cent res Cardi ores pi rat ory fai l ure
Complications
Vas ocons t ri ct or effect s on t he coronary ci rcul at i on can caus e myocardi al i s chaemi a and i nfarct i on even i n s ubject s wi t h normal ves s el s . In t he cerebral ci rcul at i on t he hypert ens i on may preci pi t at e s t roke. Ps ychot i c react i ons (s i mi l ar t o amphet ami ne ps ychos i s ) may occur.
Prognostic features
The l et hal dos e of cocai ne i s approxi mat el y 1200mg (regul ar us ers oft en t ol erat e dos es cons i derabl y i n exces s of t hi s ). Cocai ne can caus e s ei zures i n epi l ept i cs i n recreat i onal dos es but for non-epi l ept i cs pres ent at i on i n s t at us epi l ept i cus general l y i mpl i es mas s i ve overdos e and carri es a poor prognos i s . Rhabdomyol ys i s , hyperpyrexi a, renal fai l ure, s evere l i ver dys funct i on, and DIC have been report ed and carry a hi gh mort al i t y. Pat i ent s wi t h defi ci ency of s erum ps eudochol i nes t eras e appear t o be at part i cul ar ri s k of l i fe-t hreat eni ng cocai ne t oxi ci t y.
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Management
General meas ures : es t abl i s h i v acces s t aki ng bl ood for U&Es and CPK. Ens ure t he ai rway i s cl ear. If GCS 8, cons i der i nt ubat i on and mechani cal vent i l at i on. Agi t at i on may requi re di azepam (510mg i v). Moni t or ECG cont i nuous l y for arrhyt hmi as . Vent ri c ul ar arrhyt hmi as : t reat wi t h l abet al ol (50mg i v bol us and IVI of 12mg/mi n), provi ded t he pat i ent i s cons ci ous . Us e l i gnocai ne wi t h caut i on as i t may preci pi t at e s ei zures . Phenyt oi n may be t ri ed (250mg s l ow bol us over 5 mi nut es ) part i cul arl y i n pat i ent s wi t h s ei z ures . Moni t or core t emperat ure for evi dence of hyperpyrexi a . If neces s ary, s t art cool i ng meas ures (s ee p604), e.g. t epi d s pongi ng, or chi l l ed i v fl ui ds as neces s ary t o keep t he t emperat ure bel ow 38.5C. Chl orpromaz i ne 2550mg i m may be us eful but s edat i on and hypot ens i on may occur. Si gni fi c ant hypert ens i on (di as t ol i c >120mmHg) s houl d be cont rol l ed i ni t i al l y wi t h di azepam (510mg i v); i f i t remai ns hi gh s t art l abet al ol (50mg s t at i v, t hen an IVI of 12mg/mi n: s t op when BP i s cont rol l ed). Non-s el ect i ve -bl ockers (e.g. propranol ol ) may act ual l y wors en t he hypert ens i on. Sei zures s houl d be cont rol l ed wi t h di azepam (1030mg i v s t at and i f neces s ary an IVI of up t o 200mg/24h). Pres ent at i on wi t h new focal s ei zures aft er cocai ne i nges t i on us ual l y i mpl i es i s chaemi c or haemorrhage s t roke: arrange an urgent brai n CT s can.
P.805
P.806
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Cyanide
Poi s oni ng i s mos t commonl y s een i n vi ct i ms of s moke i nhal at i on (HCN i s a combus t i on product of pol yuret hane foams ). Cyani de deri vat i ves are, however, wi del y empl oyed i n i ndus t ri al proces s es and fert i l i zers . Chi l dren may al s o i nges t amygdal i n, a cyanogeni c gl ycos i de, cont ai ned i n kernel s of al monds and cherri es . Cyani de act s by i rrevers i bl y bl ocki ng mi t ochondri al el ect ron t rans port .
Presentation
HCN gas can l ead t o cardi ores pi rat ory arres t and deat h wi t hi n a few mi nut es . Ons et of effect s aft er i nges t i on or s ki n cont ami nat i on i s general l y much s l ower (up t o s everal hours ). Earl y s i gns are di z z i nes s , ches t t i ght nes s , dys pnoea, confus i on, and paral ys i s . Cardi ovas cul ar col l aps e, apnoea, and s ei zures fol l ow. Cyanos i s i s not a feat ure. The cl as s i cal s mel l of bi t t er al monds i s unhel pful (i t i s genet i cal l y det ermi ned and 50% of obs ervers cannot det ect i t ). Pul monary oedema and l act i c aci dos i s are common i n s evere poi s oni ng.
Prognostic features
Inges t i on of a few hundred mg of a cyani de s al t i s us ual l y fat al i n adul t s . Abs orpt i on i s del ayed by a ful l s t omach and hi gh gas t ri c pH (e.g. ant aci ds ). Pat i ent s s urvi vi ng t o reach hos pi t al aft er i nhal at i on of HCN are unl i kel y t o have s uffered s i gni fi cant poi s oni ng. Aci dos i s i ndi cat es s evere poi s oni ng.
Management
Do not at t empt mout h-t o-mout h res us ci t at i on. Gi ve 100% O 2 by t i ght fi t t i ng face mas k or vent i l at e vi a ET t ube i f neces s ary. Es t abl i s h i v acces s . Check art eri al bl ood gas es . Aci dos i s i ndi cat es s evere poi s oni ng. Provi di ng t here are no s i gns of cyani de t oxi ci t y, i nges t ed cyani de s houl d be removed by gas t ri c l avage
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(i f <1h). Ski n cont ami nat i on requi res t horough was hi ng of t he affect ed area wi t h s oap and wat er.
If s i gns of cyani de t oxi ci t y are pres ent , gi ve 300mg of di cobal t edet at e (Kel ocyanor) IV over 1 mi nut e. If t here i s no res pons e i n 1 mi nut e, repeat up t o a max. of 900mg. Al t ernat i vel y, gi ve s odi um ni t ri t e (10ml of a 3% s ol ut i on) and s odi um t hi os ul phat e (25ml of 50% s ol ut i on).
P.807
P.808
Digoxin
Del i berat e overdos i ng wi t h di goxi n i s unus ual . Si gni fi cant t oxi ci t y i s , however, a common advers e drug react i on i n pat i ent s t aki ng di goxi n t herapeut i cal l y (up t o 25% of pat i ent s i n s ome s eri es ). It i s part i cul arl y common when renal i mpai rment occurs (di goxi n i s al mos t t ot al l y cl eared by t he ki dneys ), and i s exacerbat ed by hypokal aemi a.
Presentation

Naus ea, vomi t i ng, confus i on, and di arrhoea. Vi s ual di s t urbance (bl urri ng, fl as hes , di s t urbed col our vi s i on). Cardi ac dys rhyt hmi as (t achyarrhyt hmi as or bradyarrhyt hmi as ).
Complications

Hyperkal aemi a. Cardi ac dys rhyt hmi as . The i ni t i al effect i s us ual l y a marked s i nus bradycardi a whi ch i s vagal l y medi at ed. Thi s i s fol l owed by at ri al t achyarrhyt hmi as (wi t h/wi t hout heart bl ock), accel erat ed junct i onal rhyt hms , vent ri cul ar ect opy, and fi nal l y VT or VF.
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Prognostic features

Di goxi n l evel >15ng/ml repres ent s a s evere overdos e. Sus cept i bi l i t y t o di goxi n t oxi ci t y i s i ncreas ed by renal i mpai rment , el ect rol yt e di s t urbance (K or Mg ), and hypot hyroi di s m.
+ 2+
Management

Take bl ood for a di goxi n l evel and U&Es . Bas el i ne 12-l ead ECG and cont i nuous ECG moni t ori ng. Gas t ri c l avage s houl d be at t empt ed i f s een wi t hi n 1 hour of overdos e, fol l owed by act i vat ed charcoal (50g s t at ). Act i vat ed charcoal (50g) s houl d be repeat ed every 2 hours . Pat i ent s pres ent i ng >4 hours s houl d be gi ven chol es t yrami ne oral l y (4g qds ). Si nus bradyarrhyt hmi as and AV bl ock us ual l y res pond t o at ropi ne (0.6mg i v repeat ed t o a t ot al of 2.4mg). As ympt omat i c vent ri cul ar ect opi cs do not requi re s peci fi c t reat ment . Vent ri c ul ar t ac hyarrhyt hmi as s houl d be t reat ed wi t h phenyt oi n (250mg over 5 mi nut es ). If t hi s i s not effect i ve, gi ve ami odarone (600mg over 1 hour) or l i gnocai ne (100mg i v l oadi ng dos e; t hen IVI of 14mg/mi n). Pat i ent s wi t h haemodynami c i ns t abi l i t y, res i s t ant vent ri cul ar t achyarrhyt hmi as , or hi gh K requi re t reat ment wi t h di goxi n-bi ndi ng ant i body fragment s (Fab, Di gi bi nd). Dos e: (no. of vi al s ) = 1.67 amount i nges t ed (mg). If l at t er unknown gi ve 20 vi al s (i nfus ed over 30 mi nut es ). Dos e for pat i ent s i nt oxi cat ed duri ng chroni c t herapy: (no. of vi al s ) = di goxi n l evel (ng/ml ) wt (kg) 0.01. Fab t herapy wi l l t ermi nat e VT i n 2040 mi nut es . The K and free s erum di goxi n l evel s s houl d be moni t ored for 24 hour aft er Fab t herapy. A s ubs t ant i al hypokal aemi a can devel op and not i nfrequent l y t here i s a rebound i n di goxi n l evel s whi ch may requi re admi ni s t rat i on of
+ +
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addi t i onal Fab. In pat i ent s wi t h renal i mpai rment t hi s rebound i s del ayed and moni t ori ng s houl d be ext ended t o 72 hours . P.809
Pat i ent s wi t h s evere renal fai l ure are obvi ous l y unabl e t o cl ear t he Fabdi goxi n compl exes . Pl as mapheres i s i s i ndi cat ed t o cl ear t he bound di goxi n. If Di gi bi nd i s not avai l abl e, i ns ert a t rans venous paci ng wi re and t ry t o cont rol arrhyt hmi as wi t h a combi nat i on of overdri ve paci ng, DC s hock, and drugs (s ee p884).
P.810
Ecstasy
Ecs t as y, E, and XTC are s t reet names for MDMA (met hyl enedi oxy-met amphet ami ne). It produces a pos i t i ve mood s t at e wi t h feel i ngs of i ncreas ed s ens ual i t y and euphori a. Si de-effect s wi t h chroni c us e i ncl ude anorexi a, pal pi t at i ons , jaw s t i ffnes s , gri ndi ng, of t eet h, s weat i ng, and i ns omni a. It can caus e dehydrat i on wi t h hypert hermi a, agi t at i on, and fi t s . Ot her feat ures i ncl ude hyponat raemi a, cerebral i nfarct i on, cerebral haemorrhage, and vas cul i t i s . Mos t deat hs from ecs t as y res ul t from di s t urbance of t hermo- and os moregul at i on l eadi ng t o hypert hermi a and i ncreas ed pl as ma os mol al i t y. MDMA al s o caus es l i fe-t hreat eni ng, cardi ac dys rhyt hmi as , abnormal l i ver funct i on t es t s , acut e l i ver fai l ure, and has been as s oci at ed wi t h cerebral i nfarct i on and haemorrhage. The hypert hermi c s yndrome occurs wi t hi n hours of i nges t i on, and oft en fol l ows i nt ens e phys i cal act i vi t y. Feat ures i ncl ude core t emperat ure >40C, s evere met abol i c aci dos i s , mus cl e ri gi di t y, DIC, and rhabdomyol ys i s . Ecs t as y may be combi ned wi t h LSD, ket ami ne, caffei ne, or s i l denafi l (s ext as y). Ket ami ne caus es pai n-free fl oat i ng s ens at i ons
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wi t h vi vi d dreams .
Management
Cons i der ot her caus es of hypert hermi a (p604). Pat i ent s s houl d be t reat ed wi t h dant rol ene 1mg/kg up t o a maxi mum of 5mg/kg. Dant rol ene i nhi bi t s rel eas e of cal ci um from t he SR i n cel l s . Rhabdomyol ys i s s houl d be t reat ed i n t he us ual way (p392). P.811
P.812
Ethanol: acute intoxication

Pat i ent s may pres ent ei t her wi t h acut e i nt oxi cat i on (oft en on a background of chroni c mi s us e), wi t hdrawal s yndromes , nut ri t i onal defi ci ency s yndromes , or chroni c t oxi ci t y (l i ver, CNS, peri pheral neuromyopat hy, et c).
Presentation
Et hanol i ni t i al l y res ul t s i n di s i nhi bi t i on and euphori a, and wi t h i ncreas i ng s erum l evel s , t hi s progres s es t o i ncoordi nat i on, at axi a, s t upor, and coma. Chroni c al cohol i cs t end t o requi re hi gher bl ood et hanol l evel s t han s oci al dri nkers for i nt oxi cat i on. Try t o obt ai n a hi s t ory from fri ends or rel at i ves . Exami ne t he pat i ent for s i gns of chroni c l i ver di s eas e, t rauma, or s i gns of i nfect i on.
Complications
Acut e gas t ri t i s caus es N&V, abdomi nal pl ai n, and GI haemorrhage. Res pi rat ory depres s i on and arres t , i nhal at i on of vomi t (wi t h ARDS Mendel s on's s yndrome), and hypot hermi a may accompany t he profound s edat i on. Hypogl ycaemi a i s common and s houl d be excl uded. Al cohol i c ket oaci dos i s or l act i c aci dos i s . Acci dent al i njury, part i cul arl y head i njury (s ubdural ).
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Rhabdomyol ys i s and acut e renal fai l ure. Infect i on (s ept i caemi a, meni ngi t i s ).
Management
Mi l d t o modern i nt oxi cat i on us ual l y requi res no s peci fi c t reat ment : t he need for admi s s i on for re-hydrat i on and obs ervat i on depends on t he i ndi vi dual pat i ent . Admi t al l pat i ent s wi t h s t upor or coma. Check t he ai rway i s cl ear of vomi t us and t he pat i ent i s abl e t o prot ect i t . Nurs e i n t he recovery pos i t i on. Ipecachuanha, gas t ri c l avage, or charcoal are not i ndi cat ed. Take bl ood for U&E, CPK, gl ucos e, amyl as e, and et hanol (and met hanol ) l evel s , ABG (aci dos i s ), l act at e, ammoni a. Anal ys e, uri ne (myogl obi n, p294). Cons i der t he pos s i bi l i t y of ot her drug overdos e. Moni t or cl os el y for res pi rat ory depres s i on, hypoxi a, cardi o arrhyt hmi as , and hypot ens i on and wi t hdrawal s yndromes (s ee p396). Check BM s t i x. In comat os e pat i ent s , t here i s a good argument for gi vi ng 2550ml of 50% dext ros e i mmedi at el y for pres umed hypogl ycaemi a becaus e t hi s wi l l us ual l y not caus e any harm. Fol l ow wi t h an IVI of 10% gl ucos e i f neces s ary. The onl y concern i s t hat gl ucos e may preci pi t at e W erni cke's encephal opat hy i n mal nouri s hed i ndi vi dual s . Some cl i ni ci ans t herefore favour gi vi ng a bol us of t hi ami ne 12mg/kjg i v beforehand. Rehydrat e wi t h i nt ravenous fl ui ds (avoi d exces s i ve us e of s al i ne i n pat i ent s wi t h s i gns of chroni c l i ver di s eas e); moni t or uri ne out put . Nal oxone reduces t he effect s of al cohol t oxi ci t y but i t s us e i s not s t andard at pres ent . Rarel y, haemodi al ys i s i s us ed i f i nt oxi ci at i on i s very s evere or i n t he pres ence of aci dos i s . W at ch for compl i cat i ons (s ee above) and t reat as
Pa g e 1 3 2 4
neces s ary. P.813
Aft er recovery from t he acut e epi s ode arrange for a ps ychi at ri c or medi cal as s es s ment and fol l ow-up and referral t o an al cohol rehabi l i t at i on programme i f appropri at e.
Alchohol withdrawal and delirium tremens (DT s) see p500 P.814
Ethylene glycol
Inges t i on may be del i berat e but us ual l y i t i s t aken acci dent al l y as an et hanol s ubs t i t ut e; i t i s pres ent i n ant i -freeze. EG t oxi ci t y i s due t o accumul at i on of t oxi c met abol i t es (al dehydes , gl ycol at e, oxal at es , and l act at e). Thi s met abol i c rout e may be bl ocked by compet i t i ve ant agoni s m wi t h et hanol .
Presentation
Impai red cons ci ous nes s (i nebri at i on wi t hout al cohol on t he breat h). Sei z ures and focal neurol ogi cal s i gns (e.g. opht hal mopl egi as ) are s een i n t he fi rs t 24 hours . Loi n pai n, haemat uri a, and ATN occurs over t he next 48 hours .
Prognostic features
As l i t t l e as 30ml of et hyl ene gl ycol can be fat al i n adul t s . It i s oft en t aken wi t h et hanol whi ch i s act ual l y prot ect i ve by bl ocki ng t he met abol i s m of gl ycol t o t oxi c met abol i t es . Renal fai l ure can be avert ed i f s peci fi c t reat ment i s i ns t i t ut ed earl y. Pl as ma l evel s of EG >500mg/L (8mmol /L) i ndi cat e
Pa g e 1 3 2 5
s evere overdos e.
The degree of aci dos i s i s t he bes t i ndi cat or of l i kel y out come.
Complications

Ol i guri c renal fai l ure (crys t al nephropat hy) Non-cardi ogeni c pul monary oedema Cerebral oedema Cardi ovas cul ar col l aps e Myocardi t i s
Management
Perform gas t ri c l avage i f pres ent i ng wi t hi n 1 hour of i nges t i on. Thi s wi l l al s o enabl e confi rmat i on t hat EG has been t aken; commerci al ant i -freeze oft en cont ai ns fl uores cei n whi ch i s eas i l y det ect ed wi t h a UV l i ght s ource (al s o det ect abl e i n uri ne). Es t abl i s h i v acces s and t ake bl ood for U&Es , gl ucos e, bi ochemi cal profi l e i ncl udi ng Ca , pl as ma os mol al i t y, and et hanol and EG l evel s . Check art eri al bl ood gas es t o as s es s degree of aci daemi a. Cal cul at e ani on gap. Mi cros cope a fres h uri ne s ampl e l ooki ng for t he needl e-s haped crys t al s of cal ci um oxal at e monohydrat e whi ch are pat hognomoni c. 4-met hyl pyrazol e (1020mg/kg/day oral l y) i s an i nhi bi t or of al cohol dehydrogenas e and has t he advant age t hat unl i ke et hanol i t does not caus e CNS depres s i on. It i s now t he drug of choi ce. The hal f-l i fe of EG i s s hort (3 hours ). If 4-met hyl pyraz ol e i s unavai l abl e t hen an et hanol i nfus i on s houl d be s t art ed as s oon as pos s i bl e (det ai l ed under met hanol , p824). The i nfus i on s houl d be cont i nued unt i l pl as ma EG i s undet ect abl e. Infus i on of et hanol wi l l caus e i nt oxi cat i on.
2+
Indications for dialysis
Pa g e 1 3 2 6
Severe aci dos i s (decl i ni ng vi t al s i gns or an EG l evel >500mg/L) or ol i guri a requi res haemodi al ys i s or peri t oneal di al ys i s (t he former i s 23 fol d more effect i ve). Normal renal funct i on i s general l y res t ored i n 710 days al t hough permanent i mpai rment has been report ed. P.815
P.816
Flunitrazepam
Fl uni t raz epam (rohypnol ) i s s omet i mes referred t o as t he dat e rape drug. It i s us ed as a s hort -t erm t reat ment for i ns omni a, as a s edat i ve hypnot i c, and a pre-anaes t het i c. It has s i mi l ar effect s t o Val i um (di azepam), but i s ~10 more pot ent . Fl uni t raz epam i nt oxi cat i on l eads t o i mpai red judgment and i mpai red mot or s ki l l s and can make a vi ct i m unabl e t o res i s t a s exual at t ack. The combi nat i on of al cohol and fl uni t razepam has a more marked effect t han fl uni t razepam al one. Effect s begi n wi t hi n 30 mi nut es , peak by 2 hours , and can pers i s t for up t o 8 hours . It i s commonl y report ed t hat pers ons who become i nt oxi cat ed on a combi nat i on of al cohol and fl uni t razepam have bl ackout s l as t i ng 824 hours fol l owi ng i nges t i on. Advers e effect s of fl uni t razepam i ncl ude decreas ed bl ood pres s ure, memory i mpai rment , drows i nes s , vi s ual di s t urbances , confus i on, di z zi nes s , gas t roi nt es t i nal di s t urbances , and uri nary ret ent i on. Manage as for benzodi azepi ne over dos e.
Gamma hydroxybutyric acid (GHB) or liquid ecstasy

Thi s drug i s di s s ol ved i n wat er and cons umed unt i l a hi gh i s reached. GHB i ncreas es i nt ra-cerebral dopami ne l evel s l eadi ng t o drows i nes s , s ei zures , hypovent i l at i on, and uncons ci ous nes s . It act s s ynergi s t i cal l y wi t h et hanol l eadi ng t o CNS and res pi rat ory depres s i on.
Pa g e 1 3 2 7
P.817
P.818
Iron
Acci dent al i nges t i on i s al mos t excl us i vel y a probl em i n chi l dren. In overdos e, i ron bi ndi ng mechani s ms are rapi dl y s at urat ed l eadi ng t o hi gh concent rat i ons of free i ron. The l at t er cat al ys es t he wi des pread generat i on of free radi cal s whi ch i s t he bas i s of t he t oxi c mani fes t at i ons of i ron overdos e.
Presentation
Iron i s ext remel y i rri t ant and caus es promi nent abdomi nal pai n, vomi t i ng and di arrhoea, haemat emes i s , and rect al bl eedi ng. Us ual l y t he i ni t i al GI s ympt oms s ubs i de before s econdary s i gns devel op 1224 hours aft er i nges t i on. Hepat i c fai l ure, jaundi ce, fi t s , and coma are common. Very l arge overdos e can caus e earl y cardi ovas cul ar col l aps e and coma. In chi l dren, 12g of i ron may prove fat al . Pat i ent s al i ve 72 hours aft er i nges t i on us ual l y make a ful l recovery. Lat e s equel ae of gas t ri c fi bros i s and pyl ori c obs t ruct i on have been occas i onal l y report ed.
Management
The s t omach s houl d be empt i ed by gas t ri c l avage (i f <1h). The l avage fl ui d s houl d cont ai n 1% NaHCO 3 . 50100ml of a s ol ut i on of 510g des ferri oxami ne i n 50100 ml wat er s houl d be i ns t i l l ed and l eft i n t he s t omach t o prevent furt her abs orpt i on. A pl ai n AXR may be us eful t o as s es s t he number of t abl et s i nges t ed.
Pa g e 1 3 2 8
Es t abl i s h i v acces s . Take bl ood for U&Es , LFTs , FBC, s erum i ron, % s at urat i on. Parent eral c hel at i on t herapy i s i ndi cat ed i f t he s erum Fe i s >90mol /L.
o
Des ferri oxami ne s houl d be gi ven i m (2g for adul t s and 1g for chi l dren) every 612 hours (NB: 100mg of des ferri oxami ne bi nds 8.5mg of el ement al Fe). If t he pat i ent i s hypot ens i ve gi ve des ferri oxami ne i v at a rat e of 15mg/kg/h (recommended max dai l y dos e i s 80mg/kg; al t hough i f t he pat i ent t ol erat es i t , and i t i s i ndi cat ed by t he s erum Fe, hi gher dos es may be gi ven). The IVI i s cont i nued unt i l t he s erum Fe fal l s bel ow t he TIBC.
Di al ys i s : haemodi al ys i s i s i ndi cat ed for very hi gh s erum i ron l evel s t hat res pond poorl y t o chel at i on t herapy or i f t he uri ne out put i s not mai nt ai ned duri ng chel at i on t herapy as t he i ron-chel at e i s onl y excret ed i n t he uri ne. Exc hange t rans fus i on has al s o been us ed s ucces s ful l y for very s evere i nt oxi cat i on.
P.819
P.820
Lithium
Li t hi um has a l ow t herapeut i c i ndex and acci dent al t oxi ci t y can and does occur much more frequent l y t han del i berat e s el f-admi ni s t rat i on. Toxi ci t y i s commonl y preci pi t at ed by admi ni s t rat i on of di uret i cs or i nt ercurrent dehydrat i on, e.g. fol l owi ng vomi t i ng or a febri l e i l l nes s .
Presentation
Thi rs t , pol yuri a, di arrhoea, vomi t i ng, and coars e t remor
Pa g e 1 3 2 9
are common.
In s evere t oxi ci t y t he effect s on t he CNS general l y predomi nat e, wi t h i mpai rment of cons ci ous nes s , fi ne t remor, hypert oni a, s ei zures , and focal neurol ogi cal s i gns . Cardi ac arrhyt hmi a and hypot ens i on are s een i n very s evere poi s oni ng.
Prognostic features
Feat ures of t oxi ci t y are us ual l y as s oci at ed wi t h Li >1.5mmol /L. However, Li
+ +
l evel s of
ent ers cel l s rel at i vel y s l owl y s o t hat t he
l evel s t aken s hort l y aft er a l arge overdos e may be very hi gh wi t h t he pat i ent s howi ng few i f any s i gns of t oxi ci t y. Level s >4mmol /L wi l l probabl y requi re haemo- or peri t oneal di al ys i s .
Management
Pat i ent s pres ent i ng wi t hi n 1 hour of i nges t i on s houl d undergo gas t ri c l avage. If s l ow-rel eas e preparat i ons are i nvol ved whol e bowel i rri gat i on wi t h PEG i s us eful . Act i vat ed charcoal i s not us eful . Check s erum Li
+
l evel (ens ure t he t ube us ed does not
cont ai n l i t hi umhepari n ant i -coagul ant ).
Check U&Es : i f hypernat raemi a i s pres ent check s erum os mol al i t y. Any di uret i c (es peci al l y t hi azi des ) or ot her drug l i kel y t o al t er renal handl i ng of Li s t opped.
+
(e.g. NSAIDs ) s houl d be
Correct any fl ui d or el ect rol yt e defi ci t s . Forced di ures i s us i ng i v 0.9% s al i ne e.g. 34l i t res /24 hours s houl d be s t art ed i f t here are any s i gns of s evere t oxi ci t y or l evel s >3mmol /L. (wat ch for fl ui d overl oad). The s erum Na
+
and os mol al i t y mus t be moni t ored dai l y as bot h are
l i kel y t o ri s e.
If l evel s are >4mmol /L or ol i guri a precl udes di ures i s t hen t he pat i ent s houl d be haemodi al ys ed. Al t hough Li can be effect i vel y cl eared from t he ext racel l ul ar compart ment wi t h di al ys i s , movement out of cel l s i s
+
Pa g e 1 3 3 0
much s l ower. Di al ys i s s houl d be cont i nued unt i l Li be meas ured dai l y for t he next week i n cas e Li P.821
+
is
not det ect ed i n t he s erum or di al ys at e. Level s s houl d rebounds due t o s l ow rel eas e from i nt racel l ul ar s t ores .
P.822
Lysergic acid diethylamide (LSD)

It i s t he prot ot ypi cal ps ychedel i c drug. Al t hough i t s abus e was a feat ure of t he 1960s and earl y 1970s i t has reappeared i n t he l as t few years i n i ncreas i ng amount s . It i s no l onger manufact ured for medi ci nal us e but i l l i ci t s ources are s urpri s i ngl y pure, i .e. free of adul t erant s . The preferred rout e i s i nges t i on al t hough i t i s occas i onal l y i nject ed and has been report ed t o be act i ve i f s nort ed.
Presentation
A t ypi cal dos e of around 100g caus es

Pupi l l ary di l at at i on Sweat i ng An acut e anxi et y s t at e Tachycardi a Depers onal i zat i on, vi s ual i l l us i ons , and di s t ort i on of t i me
Large dos es can caus e convul s i ons , focal neurol ogi cal defi ci t (due t o vas os pas m), and coma.
Complications
Acut e ps ychos i s wi t h vi s ual hal l uci nat i on, paranoi a, or feat ures of mani a i s wel l des cri bed. Very l arge overdos es have been as s oci at ed wi t h a mi l d bl eedi ng di s order due t o bl ockade of 5-HT-i nduced pl at el et aggregat i on. Rhabdomyol ys i s has been report ed i n t he pas t but
Pa g e 1 3 3 1
appears t o have refl ect ed t he phys i cal res t rai nt s us ed, i .e. s t rai ght -jacket s .
Deat h from even l arge overdos es i s unus ual and us ual l y refl ect s s ui ci de or acci dent al t rauma whi l e under t he ps ychedel i c effect s of LSD.
Management
Abs orpt i on i s l i kel y t o be compl et e by t he t i me s ympt oms are mani fes t . Lavage may act ual l y wors en t he behavi oural di s t urbance. Mos t pat i ent s wi l l need a qui et s i de room and verbal reas s urance onl y (t al ki ng down). The vi s ual i l l us i ons fade i n 48 hours . Very agi t at ed pat i ent s can be s edat ed wi t h di azepam (510mg i v) or i m l orazepam (12mg) and/or i m hal operi dol 510mg. Sei z ures res pond t o di azepam i v (510mg bol us ). The devel opment of focal neurol ogi cal s i gns s houl d prompt a CT s can and probabl y cerebral angi ography. Occas i onal l y i nt ens e vas os pas m i s s een i nvol vi ng even t he i nt racrani al carot i ds . Comat os e pat i ent s requi re ful l s upport i ve care (p406) but general l y recover ful l y i n 24 hours . As pi rat i on appears t o be a defi ni t e ri s k and prot ect i on of t he ai rway i s part i cul arl y i mport ant . There are no s peci fi c ant i dot es or met hods for enhanced drug el i mi nat i on.
P.823
P.824
Methanol
Poi s oni ng us ual l y fol l ows i nges t i on of cont ami nat ed al cohol beverages or met hyl at ed s pi ri t s . Int oxi cat i on i n i ndus t ri al
Pa g e 1 3 3 2
s et t i ngs fol l ows abs orpt i on acros s t he s ki n or l ung. Al cohol dehydrogenas e met abol i zes i t t o formal dehyde whi ch i s oxi di zed t o t he t oxi c formi c aci d.
Presentation
Si gni fi cant i nges t i on caus es naus ea, vomi t i ng, and abdomi nal pai n. It s effect s on t he CNS res embl e t hos e of et hanol al t hough i n l ow dos es i t does not have a euphori c effect . Vi s ual s ympt oms pres ent wi t h fal l i ng vi s ual acui t y, phot ophobi a, and t he s ens at i on of bei ng i n a s now s t orm.
Complications
Up t o 65% of pat i ent s have a rai s ed amyl as e but t hi s does not neces s ari l y repres ent pancreat i t i s (us ual l y s al i vary-gl and amyl as e t ype). If pancreat i t i s i s s us pect ed cl i ni cal l y, meas ure s erum l i pas e (haemorrhagi c pancreat i t i s has been report ed at pos t mort em). Sei z ures are s een i n s evere i nt oxi cat i on. CT s canni ng us ual l y s hows cerebral oedema or even necros i s i n t he bas al gangl i a. Pat i ent s wi t h vi s ual s ympt oms may devel op i rrevers i bl e vi s ual i mpai rment even wi t h aggres s i ve i nt ervent i on. Rhabdomyol ys i s and acut e renal fai l ure. Hypogl ycaemi a.
Prognostic features
10ml of met hanol can caus e bl i ndnes s and 30ml can be fat al . Peak pl as ma met hanol i s us eful ; >0.2g/L (6.25mmol /L) i ndi cat es s i gni fi cant i nges t i on and 0.5g/L (15.6mmol /L) i s s evere. Art eri al pH correl at es wi t h format e l evel s ; pH <7.2 i s s evere i nt oxi cat i on.
Pa g e 1 3 3 3
Management
Take bl ood for U&E, CPK, gl ucos e, amyl as e and et hanol /met hanol l evel s , ABG (aci dos i s ), ani on gap, uri ne (myogl obi n, p392). Sei zures are probabl y bes t t reat ed i ni t i al l y wi t h di az epam (510 mg i v) fol l owed by phenyt oi n (250mg i v over 5 mi nut es ). Excl ude hypogl ycaemi a. 4-met hyl pyrazol e (1020mg/kg/day po) i s an i nhi bi t or of al cohol dehydrogenas e and has t he advant age t hat unl i ke et hanol i t does not caus e CNS depres s i on. It i s now t he drug of choi ce. Gi ve t o al l pat i ent s pendi ng met hanol l evel s , pat i ent s wi t h met hanol l evel s >0.2g/L (6.25mmol /L), aci dot i c pat i ent s , and anyone needi ng haemodi al ys i s . Et hanol i nfus i on s houl d be us ed i f 4-met hyl pyraz ol e i s unavai l abl e. Gi ve i v as a 10% s ol ut i on i n 5% dext ros e or N s al i ne (i .e. t ake 50ml from a 500ml bag and repl ace wi t h 50ml et hanol ). A l oadi ng dos e of 10ml /kg s houl d be gi ven fol l owed by an IVI of 0.15ml /kg/h for non-dri nkers (regul ar dri nkers , 0.3ml /kg/h). Ti t rat e t o a pl as ma et hanol l evel of 11.5g/L (21.732.6mmol /L). Cont i nue et hanol IVI for at l eas t 48 hours . Met abol i c aci dos i s s houl d be correct ed wi t h i v NaHCO 3 . Haemodi al ys i s i s res erved for t hos e pat i ent s wi t h renal fai l ure, any vi s ual i mpai rment , or a pl as ma met hanol l evel of >0.5g/L (15.6mmol/L). The et hanol i nfus i on rat e s houl d be doubl ed duri ng di al ys i s (or et hanol may be added di rect l y t o t he di al ys i s fl ui d).
P.825
P.826
Pa g e 1 3 3 4
Isopropanol
Is opropanol i s pres ent i n car s creen was h. As a caus e of poi s oni ng wi t h al cohol s t hi s i s s econd aft er et hanol . It has t wi ce t he pot ency of et hanol on t he CNS (i t s major met abol i t e, acet one, compounds t hi s ) and i s opropanol -i nduced coma can l as t >24 hours . Effect s are s een wi t hi n 3060 mi nut es of i nges t i on and l arge overdos es caus e coma and hypot ens i on as t he major effect . Haemodi al ys i s i s i ndi cat ed i f t he hypot ens i on fai l s t o res pond t o i v fl ui ds , vi t al s i gns decl i ne, or bl ood l evel s are >4g/L (66.7 mmol /L). Moni t or for hypogl ycaemi a and myogl obi nuri a.
Opiates
Overdos i ng wi t h opi at es us ual l y occurs i n regul ar drug us ers where t he mos t commonl y abus ed agent i s di amorphi ne (heroi n). It may t aken i nt ravenous l y, by s ki n-poppi ng, s moked, or s nort ed. A number of ot her opi at es have been s i mi l arl y abus ed. Opi at es s uch as dext ropropoxyphene and di hydrocodei ne (pres ent i n combi nat i on formul at i ons wi t h paracet amol ) are oft en t aken wi t h al cohol by non-addi ct s wi t h s ui ci dal i nt ent .
Presentation
Pi npoi nt pupi l s , s evere res pi rat ory depres s i on cyanos i s , and coma are t ypi cal . The depres s i ve effect s are exacerbat ed by al cohol . BP may be l ow but i s oft en s urpri s i ngl y wel l mai nt ai ned. Al t hough s ome opi at es , e.g. dext ropropoxyphene and pet hi di ne, i ncreas e mus cl e t one and caus e fi t s i n overdos e i n general opi at es caus e marked hypot oni a.
Prognostic features
Non-cardi ogeni c pul monary oedema carri es a poor prognos i s . Pat i ent s wi t h underl yi ng i s chaemi c heart di s eas e may be more s us cept i bl e t o haemodynami c di s t urbance aft er nal oxone i s gi ven. Renal i mpai rment reduces t he el i mi nat i on of many opi at es and prol ongs t hei r durat i on of act i on.
Pa g e 1 3 3 5
Management
Moni t or res pi rat ory rat e, dept h of res pi rat i on, and pul s e oxi met ry. Gi ve oxygen by mas k. Moni t or ECG cont i nuous l y for arrhyt hmi as Es t abl i s h i v acces s ; t ake bl ood for U&Es and CPK. If paracet amol + opi at e combi nat i ons have been i nges t ed meas ure a paracet amol l evel (s ee p828). Any pat i ent who i s comat os e or has res pi rat ory s i gns requi res a CXR (s i gns of i nfect i on, s ept i c embol i , i nt ers t i t i al s hadowi ng). The s peci fi c ant i dot e i s nal oxone (a pure opi at e ant agoni s t ) whi ch s houl d be gi ven i v i n bol us es of 0.4mg at 23-mi nut e i nt erval s unt i l t he pat i ent i s rous abl e and any evi dence of res pi rat ory depres s i on correct ed. Dos es of up t o 2mg (and above) may be requi red but i f no res pons e i s s een at t hi s l evel t hen t he di agnos i s of opi at e overdos e s houl d be revi s ed. The durat i on of act i on of nal oxone i s s hort er t han many opi at es hence an i nfus i on s houl d be s t art ed t o avoi d res edat i on (s t art i ng wi t h 0.2mg/h P.827
and i ncreas i ng as neces s ary). In t he cas e of overdos e wi t h l ong-act i ng opi at es s uch as met hadone i nfus i on of nal oxone may be neces s ary for 4872 hours .
Avoi d gi vi ng s uffi ci ent nal oxone t o compl et el y revers e t he effect of opi at es i n an opi at e-dependent s ubject . Thi s i s l i kel y t o preci pi t at e an acut e wi t hdrawal react i on. If t hi s occurs and hypert ens i on i s marked (di as t ol i c >120mmHg) t hen gi ve di azepam (510mg i ni t i al l y i v), and i f i t pers i s t s , commence i v l abet al ol (50mg s t at fol l owed by IVI unt i l BP i s cont rol l ed). NB: marked hypert ens i on, acut e pul monary oedema and VT/VF have been obs erved i n non-addi ct s gi ven
Pa g e 1 3 3 6
nal oxone t o revers e t he effect s of hi gh t herapeut i c dos es of opi at es for pai n.
Convul s i ons whi ch are opi at e i nduced (us ual l y pet hi di ne or dext ropropoxyphene) may res pond t o i v nal oxone. Addi t i onal ant i -convul s ant t herapy may be requi red. Pul monary oedema pres ent on admi s s i on requi res oxygen, CPAP, or mechani cal vent i l at i on (p904). It does not res pond t o nal oxone. Rhabdomyol ys i s and acut e renal fai l ure, s ee p392.
Complications
Al l opi at es can caus e non-cardi ogeni c pul monary oedema al t hough i t i s mos t frequent l y s een wi t h i v heroi n. Rhabdomyol ys i s i s common i n opi at e-i nduced coma and s houl d be l ooked for i n al l cas es . The s ubs t ances us ed t o di l ut e (cut ) i l l i ci t opi at es may al s o carry s i gni fi cant t oxi ci t y when i nject ed (e.g. t al c and qui ni ne). i v drug us ers may devel op ri ght -s i ded endocardi t i s and s ept i c pul monary embol i (s everal l ocal i zed i nfi l t rat es on CXR). Inges t i on of paracet amol cont ai ni ng preparat i ons (e.g. co-dydramol ) may devel op renal or hepat i c fai l ure.
Important points
Dext ropropoxyphene i n combi nat i on wi t h al cohol can caus e marked CNS depres s i on. Res pi rat ory arres t can evol ve rapi dl y wi t hi n <30 mi nut es of i nges t i on. Gi ve nal oxone even i f t he pat i ent i s onl y mi l dl y drows y. Dext ropropoxyphene al s o caus es an acut e cardi ot oxi ci t y wi t h arrhyt hmi as due t o a membrane-s t abi l i zi ng effect (nal oxone i neffect i ve). The res pi rat ory depres s ant effect s of buprenorphi ne are not ful l y revers ed by nal oxone. Doxapram has been us ed i n mi l der cas es of buprenorphi ne overdos e as a res pi rat ory s t i mul ant (14mg/mi n) al t hough s evere
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cas es may requi re mechani cal vent i l at i on. P.828
Paracetamol: assessment
In t herapeut i c dos es , onl y a mi nor fract i on i s oxi di zed t o t he react i ve/t oxi c s peci es (NABQI) whi ch i s det oxi fi ed by conjugat i on wi t h gl ut at hi one. In overdos e, normal met abol i c rout es become s at urat ed; t herefore an i ncreas ed fract i on i s met abol i zed vi a t he cyt ochrome p450 s ys t em t o t oxi c met abol i t es , whos e det oxi fi cat i on rapi dl y depl et es hepat i c gl ut at hi one s t ores .
Presentation
Apart from mi l d naus ea, vomi t i ng, and anorexi a, pat i ent s pres ent i ng wi t hi n 24 hours of i nges t i on are general l y as ympt omat i c. Hepat i c necros i s becomes apparent i n 2436 hours wi t h ri ght s ubchondral pai n/t endernes s , jaundi ce (and acut e l i ver fai l ure), vomi t i ng, and s ympt oms of neurogl ycopeni a (confus i on). Encephal opat hy may wors en over t he next 72 hours . Ol i guri a and renal fai l ure. Lact i c aci dos i s : ei t her <12 hours (very rare) or l at e (10% of pat i ent s wi t h ALF).
Complications
Acut e l i ver fai l ure (ALF, s ee p658) wi t h hypogl ycaemi a, cerebral oedema, and GI bl eedi ng. Severe met abol i c (l act i c) aci dos i s . Pancreat i t i s (al one or wi t h l i ver fai l ure). Some 10% of pat i ent s devel op acut e renal fai l ure from acut e t ubul ar necros i s whi ch may be s een i n t he abs ence of l i ver fai l ure. Very rarel y pat i ent s wi t h G6PD defi ci ency devel op met haemogl obi naemi a and haemol ys i s .
Investigations
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Me as u Par re ace l ev t a el s mo at l l ea st 4 ho urs pos t i ng es t i on an d pl o t on t he gra ph in t he fi g ure on p8 31. If t he tim
Pa g e 1 3 3 9
e of ove rdo se is not kno wn, me as u re par ace ta mo l 4 ho urs l at er, but co mm enc e N-a cet yl c ys t ei n e if in do
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ubt . Re nal U& fai l Es ure ge ner al l y occ urs on day 3. Ma y Gl u fal l cos wi t e h pro gre ssi ve liv er fai l ure . Gi v e iv dex t ro se
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(25 50 ml of 50 % dex t ro s e) if nec es s ary . In C pat ts wi t h s ev ere ove rdo s es an d liv er fai l ure , t hr om FB i en
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boc yt o pe ni a is co mm on an d ma y be s ev ere . Tra s ns a nas es ri s e ear l y. Thi s y be nor ma l des pi t PT ma LFT mi
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e hi g h t ra ns a mi nas es . Th e PT is t he bes t i nd i ca t or of t he s ev eri t y of liv er fai l ure . To as s AB es s Gs de gre e
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of aci dos is.
Prognostic features
Fat al overdos e may occur wi t h <10g (us ual l y i n al cohol i cs , epi l ept i cs , or pat i ent s on enz yme-i nduci ng drugs ), but us ual l y i nvol ves >30g. The caus e of deat h i s us ual l y acut e l i ver fai l ure. Chroni c al cohol i cs or pat i ent s on P.829 phenobarbi t one or phenyt oi n are more s us cept i bl e t o devel opi ng hepat ot oxi ci t y and nephrot oxi ci t y.
Refer t o a l i ver uni t al l pat i ent s wi t h aci dos i s (pH <7.32) and coagul opat hy (INR >1.5). If renal fai l ure occurs i n i s ol at i on (no coagul opat hy but t rans ami nas e l evel s hi gh), t hen refer t o a renal uni t .
Indications for liver transplantation in paracetamol overdose
Lat e aci dos i s (>36 hours pos t overdos e) wi t h art eri al pH <7.3 PT >100s Serum creat i ni ne >300M Grade 3 encephal opat hy (confus ed, di s t res s ed, barel y rous abl e)
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Practice point
Pat i ent s wi t h paracet amol OD oft en devel op s ub-conjunct i val haemat oma due t o vomi t i ng, coagol opat hy t hrombocyt openi a.
P.830
Paracetamol: management
Pat i ent s pres ent i ng wi t hi n 1 hour of i nges t i on s houl d undergo gas t ri c l avage . Al l pat i ent s wi t h a l arge overdos e of paracet amol (>10g) s houl d be t reat ed wi t h NAC unt i l l evel s are avai l abl e. Al l ergi c react i ons t o NAC occur i n <5% of pat i ent s . Meas ure paracet amol l evel s at l eas t 4 hours pos t i nges t i on and i deal l y 4 hours l at er, and pl ot on t he graph i n t he fi gure on p831. Al l pat i ent s on or above t he normal t reat ment l i ne (and pres ent i ng up t o 24 hours aft er i nges t i on) s houl d be gi ven NAC (s ee t abl e). Pat i ent s who are al l ergi c t o NAC may be t reat ed wi t h met hi oni ne, but t hi s i s l es s effect i ve unl es s gi ven earl y. Pat i ent s on enz yme-i nduci ng drugs (e.g. phenyt oi n, carbamazepi ne, ri fampi ci n, phenobarbi t one) or wi t h a hi s t ory of hi gh al cohol i nt ake may devel op t oxi ci t y at l ower pl as ma l evel s and s houl d be t reat ed i f t he l evel i s above t he hi gh-ri s k t reat ment l i ne (fi gure, p831). If t he i ni t i al l evel s i ndi cat e no t reat ment i s neces s ary, repeat t he paracet amol l evel s 4 hours l at er. Occas i onal l y t here may be del ayed abs orpt i on and t reat ment i s i nappropri at el y wi t hhel d. Gi ve NAC t o al l s evere overdos es (>10g) t hat pres ent at 2472 hours wi t h s ympt oms or deranged i nves t i gat i ons (LFTs , PT).
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Moni t or U&Es , FBC, PT, LFTs , gl ucos e, and art eri al bl ood gas es dai l y. Moni t or gl ucos e wi t h BM s t i x at l eas t 6 hourl y. Gi ve vi t ami n K i v 10mg (as a s i ngl e dos e, i n cas e body s t ores are defi ci ent ) but avoi d gi vi ng FFP unl es s t here i s act i ve bl eedi ng. The PT i s t he bes t i ndi cat or of t he s everi t y of l i ver fai l ure; FFP may onl y make management deci s i ons (e.g. l i ver t rans pl ant at i on) more di ffi cul t . Al l pat i ent s who are encephal opat hi c or have a rapi dl y ri s i ng PT mus t be referred t o a l i ver uni t . Management of ac ut e l i ver fai l ure i s di s cus s ed on p658.
Specific treatment for paracetamol poisoning
NAC infusion 150mg/kg i n 200ml 5% dext ros e over 15 mi nut es , fol l owed by 50mg/kg i n 500ml 5% dext ros e over 4 hours , and fi nal l y 100mg/kg i n 1L 5% dext ros e over 16 hours . [Up t o 10% of pat i ent s have a ras h, bronchos pas m, or hypot ens i on duri ng t he i nfus i on. St op t he IVI and gi ve chl orpheni rami ne (10mg i v).]
Oral methionine Onl y us e i f pat i ent i s al l ergi c t o NAC. Gi ve 2.5g s t at and 3 furt her dos es of 2.5g every 4 hours
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P.832
Paraquat
Thi s bi pyri di l i um herbi ci de (Grammoxone i s a 20% s ol ut i on cf. W eedol 2.5%) i s not ori ous l y t oxi c i n overdos e. Chi l dren may dri nk i t i nadvert ant l y and hort i cul t uri s t s have occas i onal l y been poi s oned t hrough s ki n s pl as hi ng. Deat h i s us ual l y due t o del ayed pul monary fi bros i s and res pi rat ory fai l ure. The mechani s m i s
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t hought t o be due t o t he generat i on of cyt ot oxi c oxygen radi cal s .
Presentation
Naus ea and vomi t i ng are s een wi t hi n a few hours of i nges t i on. Mout h and oes ophageal ul cerat i on are common. Ol i guri c renal fai l ure devel ops wi t h dos es >2g wi t hi n 12 hours of i nges t i on. Very hi gh dos es (e.g. 50100ml 20% s ol ut i on, i .e. >10g) may caus e acut e dys pnoea wi t h an ARDS-l i ke pi ct ure and rapi d mul t i -organ fai l ure. Ins i di ous pul monary fi bros i s devel ops i n t he s econd week aft er expos ure (oft en as t he ol i guri a i s res ol vi ng). Thi s i s not revers i bl e and occas i onal s urvi vors i nvari abl y have a s evere handi cap. Li ver fai l ure and myocardi t i s are al s o report ed and t hought t o refl ect t he s ame free radi cal -medi at ed cel l damage.
Prognostic features
The dos e i nges t ed i s a good predi ct or of out come: deat h has been report ed aft er onl y 1015ml of t he 20% s ol ut i on (3g) of paraquat and i s uni vers al aft er 50ml (10g). Pl as ma l evel s of paraquat e.g. >2 mg/L at 4 hours or 0.1mg/L at 24 hours are as s oci at ed wi t h a poor prognos i s . A l ow W BC on admi s s i on carri es a poor prognos i s .
Management
Pat i ent s pres ent i ng wi t hi n 6 hours of i nges t i on s houl d rec ei ve gas t ri c l avage wi t h t he i ns t i l l at i on of a 30% s ol ut i on of Ful l er's eart h (250ml ) repeat ed 4 hourl y. If t he l at t er i s not avai l abl e t hen act i vat ed charcoal s houl d be gi ven (50100g). Bl ood s houl d be t aken for FBC, U&E, LFT, and paraquat l evel s .
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Perform a bas el i ne CXR and art eri al bl ood gas es . Moni t or uri ne out put (cat het eri ze i f neces s ary). i v fl ui ds (but not a forced di ures i s ) are i ndi cat ed when oes ophageal ul cerat i on i s s evere enough t o produce dys phagi a. The us e of haemoperfus i on or haemofi l t rat i on s houl d be res erved for s ubject s whos e out come i s borderl i ne. It i s onl y i n t hes e cas es t hat t he very s mal l amount s of paraquat removed by ei t her proces s (perhaps a few t ens of mg) coul d concei vabl y affect out come. Haemodi al ys i s may of cours e be needed i ndependent l y of drug el i mi nat i on i f renal fai l ure devel ops . At t empt s have been made t o prevent or s l ow t he proces s of pul monary fi bros i s and i ncl ude radi ot herapy t o t he l ungs and i mmunos uppres s i on wi t h dexamet has one cycl ophos phami de. Nei t her has proved t o be effect i ve and cannot be recommended. A s i ngl e report exi s t s of acut e l ung t rans pl ant at i on t o s al vage a pat i ent wi t h t ermi nal fi bros i s but t he pat i ent s ubs equent l y di ed of a l at e paraquat -i nduced myopat hy.
P.833
P.834
Salicylates
As pi ri n i s probabl y t he commones t drug t o be i nges t ed del i berat el y i n overdos e. Occas i onal l y poi s oni ng fol l ows t he t opi cal appl i cat i on of s al i cyl i c aci d i n kerat ol yt i cs or i nges t i on of met hyl s al i cyl at e (oi l of wi nt ergreen). It s pri mary t oxi c effect i s t o uncoupl e oxi dat i ve phos phoryl at i on.
Presentation
The t ypi cal feat ures of moderat e s al i cyl at e t oxi ci t y are
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s weat i ng, vomi t i ng, epi gas t ri c pai n, t i nni t us , and bl urri ng of vi s i on.
In adul t s , t here i s al s o an earl y i ncreas e i n res pi rat ory rat e caus i ng an al kal os i s t hat precedes t he l at er devel opment of a met abol i c aci dos i s (chi l dren do not devel op t he earl y res pi rat ory al kal os i s ). In s evere overdos e, t he aci dos i s reduces t he i oni zat i on of s al i cyl i c aci d whi ch enhances t i s s ue penet rat i on. In t he CNS, t hi s pres ent s as agi t at i on, t remor and fi t s , coma, and res pi rat ory depres s i on.
Complications
Di s t urbance of el ect rol yt es (hypokal aemi a and ei t her hyper- or hyponat raemi a) and bl ood gl ucos e ( or ) are common. Pul monary oedema (non-cardi ogeni c, ARDS). Acut e renal fai l ure. Abnormal cl ot t i ng due t o hypoprot hrombi naemi a i s very rare. Si gni fi cant GI bl eeds are s urpri s i ngl y i nfrequent .
Prognostic features
Therapeut i c l evel s of s al i cyl at e are general l y <300mg/L (2.2mmol /L). Level s of 500750mg/L repres ent moderat e OD and >750mg/L (5.4mmol /L) i s s evere. Severe met abol i c aci dos i s i s as s oci at ed wi t h a poor out come.
Management
Gas t ri c l avage s houl d be at t empt ed where pos s i bl e up t o 12 hours aft er i nges t i on (or l onger i f t here i s evi dence of cont i nued abs orpt i on, as t abl et s may adhere t o form l arge mas s es i n t he s t omach). Take bl ood for U&Es , PT, s al i cyl at e, (and paracet amol ) l evel on admi s s i on (i deal l y repeat 4 hours l at er t o acces s cont i nued abs orpt i on). Check art eri al bl ood gas es t o as s es s degree of
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aci dos i s .
Moni t or bl ood gl ucos e regul arl y (l ab and/or BM s t i x every 2 hours ). Mi l d or moderat e s al i cyl at e overdos e requi res onl y oral or i v rehydrat i on wi t h part i cul ar at t ent i on t o K s uppl ement s . Marked s i gns /s ympt oms of s al i cyl i s m or l evel s >750mg/L need s peci fi c el i mi nat i on t herapy (bel ow, i n order of us e).
o
+
Act i vat ed charcoal s houl d be gi ven oral l y (50g 4 hourl y). Forced al kal i ne di ures i s i s no more effect i ve t han s i mpl e al kal i ni zat i on of t he uri ne, e.g. 1 l i t re 1.26% NaHCO 3 over 2 hours and repeat as neces s ary t o keep t he uri nary pH >7.5). Haemodi al ys i s i s i ndi cat ed for l evel s >1000mg/L (7.25mmol /L), pers i s t ent or progres s i ve aci dos i s , det eri orat i ng l evel of cons ci ous nes s .
Pul monary oedema may i ndi cat e ei t her fl ui d overl oad or i ncreas ed vas cul ar permeabi l i t y. Admi t t o ITU and i ns ert a pul monary art ery cat het er for meas uri ng wedge pres s ures . Non-cardi ogeni c pul monary oedema may requi re CPAP or mechani cal vent i l at i on (p906).
P.835
P.836
Theophylline
Int oxi cat i on can be del i berat e or i at rogeni c due t o t he l ow t herapeut i c i ndex of t heophyl l i ne.
Presentation
The feat ures of acut e i nges t i on refl ect t he l ocal i rri t ant
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GI effect s of t heophyl l i ne, i .e. naus ea, vomi t i ng, abdomi nal cramps , and di arrhoea. GI bl eedi ng i s al s o wel l recogni zed.
Feat ures of s ys t emi c t oxi ci t y i ncl ude cardi ac arrhyt hmi as , hypot ens i on, and s ei zures .
Complications
Aci dbas e di s t urbance: an i ni t i al res pi rat ory al kal os i s whi ch gi ves way t o a s econdary met abol i c aci dos i s . Marked hypokal aemi a i s common. Theophyl l i ne-i nduced fi t s carry a hi gh mort al i t y (up t o 30%) and us ual l y refl ect s erum t heophyl l i ne l evel s of >50mg/L (0.28mmol /L).
Management
Gas t ri c l avage s houl d be at t empt ed i f s een wi t hi n 12 hours of i nges t i on. Act i vat ed charcoal s houl d al s o be gi ven bot h t o prevent furt her abs orpt i on and t o enhance s ys t emi c cl earance (50100g s t at t hen 50g 4 hourl y), al t hough t hi s may not be pract i cal i n t he pres ence of s evere naus ea and vomi t i ng. Take bl ood for U&E and t heophyl l i ne l evel . Hypokal aemi a s houl d be correct ed aggres s i vel y wi t h i v s uppl ement s (4060mmol /h may be needed). Record a 12-l ead ECG and t hen moni t or ECG cont i nuous l y for arrhyt hmi as . Verapami l (10mg i v) and propranol ol (25mg i v) are us eful for t reat i ng s upravent ri cul ar and vent ri cul ar t ac hyarrhyt hmi as res pect i vel y. Li gnocai ne appears t o have l i t t l e effect on vent ri cul ar ect opy and s houl d be avoi ded. GI bl eedi ng s houl d be managed i n t he us ual way (p608). Avoi d ci met i di ne whi ch s ubs t ant i al l y i nhi bi t s t heophyl l i ne met abol i s m (rani t i di ne i s s afe, e.g. 50mg i v t ds ). Sei zures s houl d be cont rol l ed wi t h di azepam (10mg i v prn).
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Haemoperfus i on (charcoal or res i n) s houl d be cons i dered i n s evere overdos es part i cul arl y t hos e wi t h recurrent s ei zure act i vi t y or i nt ract abl e vomi t i ng. The l at t er repres ent s di rect s t i mul at i on of t he area pos t rema and general l y res ponds poorl y t o ant i emet i cs , e.g. met ocl oprami de and prochl orperaz i ne.
P.837
P.838
Tricyclic anti-depressants
Fi rs t -generat i on agent s (e.g. ami t ri pt yl i ne, i mi prami ne, and des i prami ne) are t he mos t l i kel y t o caus e l et hal i nt oxi cat i on. The newer s econd-generat i on t ri cyl i cs (e.g. l ofeprami ne) and t et racyl i cs are general l y much s afer i n overdos e.
Presentation
Ant i -chol i nergi c feat ures are promi nent earl y on wi t h dry mout h, di l at ed pupi l s , bl urred vi s i on, s i nus t achycardi a, uri nary ret ent i on, myocl oni c jerki ng, agi t at i on, and even hal l uci nat i ons . Cardi ac arrhyt hmi as from a qui ni di ne-l i ke (t ype Ia) effect on t he heart , profound hypot ens i on, convul s i ons , and coma fol l ow.
Complications
Severe i nt oxi cat i on caus es deep coma wi t h res pi rat ory depres s i on, hypoxi a, and a met abol i c aci dos i s . Neurol ogi cal s i gns i ncl ude a t emporary l os s of ocul ocephal i c and ocul oves t i bul ar refl exes , l ong t ract s i gns , and i nt ernucl ear opht hal mopl egi a. Hypot hermi a, s ki n bl i s t eri ng (cf. barbi t urat es ), and rhabdomyol ys i s are al s o report ed.
Prognostic features
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Deat h may fol l ow i nges t i on of as l i t t l e as 1000mg of a t ri cycl i c. Prol ongat i on of t he QRS >100ms s ugges t s s i gni fi cant i nt oxi cat i on wi t h a hi gh ri s k of convul s i on; a QRS >160ms i s general l y s een before vent ri cul ar arrhyt hmi as devel op. Pat i ent s wi t h i s chaemi c heart di s eas e (es peci al l y pos t MI) and conduct i on defect s are part i cul arl y at ri s k.
Management
Pat i ent s wi t h CNS depres s i on s houl d be moni t ored cl os el y, preferabl y on an ITU or hi gh-dependency area. Gas t ri c l avage s houl d be at t empt ed i f s een wi t hi n 12 hours of i nges t i on. Act i vat ed charcoal s houl d be gi ven oral l y (50100g, s i ngl e dos e). Record a 12-l ead ECG and moni t or cont i nuous l y for up t o 48 hour. Res pi rat ory fai l ure may evol ve rapi dl y, neces s i t at i ng i nt ubat i on and vent i l at i on. Severe hypot ens i on requi res i not ropi c s upport (s ee p262). Severe aci dos i s s houl d be correct ed wi t h i v NaHCO 3 (s ee p294). Cont rol s ei zures wi t h di azepam (510mg i v bol us prn). Si nus t achycardi a and arrhyt hmi as t hat do not compromi s e cardi ac out put do not need t reat ment . If out put i s fai l i ng t hen correct any aci dos i s or hypoxi a before cons i deri ng ant i -arrhyt hmi cs . Mos t cl as s I ant i -arrhyt hmi c agent s are i neffect i ve or wors en t he conduct i on di s t urbance. Phenyt oi n (250mg i v over 5 mi nut es ) or ami odarone (300mg IVI over 30 mi nut es ) are t he mos t us eful for cardi ac dys rhyt hmi as . If al l meas ures fai l t hen an i nduced al kal os i s (by hypervent i l at i on or 50100mmol NaHCO 3 over 15 mi nut es i .e. 50100ml 8.4% NaHCO 3 ) may hel p by
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i ncreas i ng bi ndi ng of t he t ri cycl i c t o pl as ma prot ei ns .
Tri cycl i c coma may l as t 2448 hours . In many pat i ent s recovery i s marked by profound agi t at i on and fl ori d vi s ual and audi t ory hal l uci nat i on (a cent ral ant i chol i nergi c s yndrome). Sedat i on may be neces s ary (e.g. po di azepam or chl ormet hi azol e).
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> T able of Cont ent s > Chapt er 15 - Disorders due t o physic al agent s
Chapter 15 Disorders due to physical agents

P.840
Disorders due to heat
Pat i ent s expos ed t o heat pres ent wi t h a s pect rum of di s orders , from mi l d oedema/s yncope (vas odi l at at i on), t hough mi l d t o moderat e di s orders (cramps and exhaus t i on) but wi t h i nt act t hermoregul at i on, t o heat s t roke where t hermoregul at i on fai l s . Predi s pos i ng fac t ors : obes i t y, s t renuous exerci s e, al cohol , ol d age, ant i chol i nergi c drug i nges t i on, and hot cl i mat e.
Heat cramps
Typi cal l y pai nful s pas m of heavi l y exerci s i ng mus cl es (commonl y i n cal ves or feet ) t hought t o be due t o s al t depl et i on. The di agnos i s i s cl i ni cal and furt her i nves t i gat i on rarel y i ndi cat ed.
Treatment
Res t , mas s age of affect ed mus cl e and fl ui d repl acement , ei t her i nt ravenous l y (N s al i ne 1 l i t re over 2h repeat ed i f neces s ary) or oral l y wi t h 0.1% s al t s ol ut i on. Pl ai n s al t t abl et s may be us edt ake wi t h copi ous amount s of wat er; i n t he s t omach t hey wi l l produce a hypert oni c s ol ut i on and may caus e gas t ri c i rri t at i on.
Pa g e 1 3 5 7
Fres hl y s queezed orange jui ce (part l y di l ut ed wi t h wat er) provi des a s i mpl e way t o repl ace s al t , pot as s i um, and wat er. Admi s s i on t o hos pi t al rarel y i ndi cat ed.
Heat exhaustion
The s ympt oms refl ect t he effect s of s al t and wat er depl et i on, dehydrat i on, and accumul at i on of met abol i t es . Predomi nant s al t l os s pres ent s i ns i di ous l y over days (cramps , naus ea, weaknes s , pos t ural di zzi nes s , mal ai s e), whereas mai nl y wat er l os s pres ent s more acut el y wi t h headache, naus ea, and CNS s ympt oms (confus i on, del i ri um, i ncoordi nat i on). Exami nat i on : Us ual l y t he pat i ent i s fl us hed and s weat i ng wi t h evi dence of dehydrat i on. Body t emperat ure may be normal or mi l dl y el evat ed (~38C). I nves t i gat i ons : U&E may s how hyper- or hypo-nat raemi a and pre-renal fai l ure. FBC may s how haemoconcent rat i on. Mi l d el evat i ons of CK and LFT s are common. Uri ne s houl d be exami ned for myogl obi nuri a i f t he s erum CK i s markedl y el evat ed >2000U/l (rhabdomyol ys i s ).
Treatment

As s es s fl ui d defi ci t and repl ace wi t h i vi i f s evere. Res t and fl ui d repl acement are t he mai ns t ay. Y oung pers ons may jus t requi re aggres s i ve oral rehydrat i on [wat er, s al t , commerci al l y avai l abl e rehydrat i on preparat i ons (e.g. Di oral yt e )] and may requi re 46 l i t res over 68 hours . Int ravenous t herapy s houl d be gui ded by el ect rol yt es (caut i on wi t h or Na ); a s ugges t ed regi men i s N s al i ne 1 l i t re over 30mi n fol l owed by anot her over 1 hour, t hen al t ernat i ng bags of 5% dext ros e and N s al i ne 2 hourl y: be gui ded by t he cl i ni cal s t at e and U&E
+
Pa g e 1 3 5 8
of t he pat i ent . The el derl y wi l l requi re more caut i ous fl ui d repl acement , i f i ndi cat ed, gui ded by CVP.
Recovery i s us ual l y rapi d (1224 hours ).
P.841
P.842
Heat stroke
Exces s i ve expos ure t o heat or s t renuous exerci s e i n a hot envi ronment res ul t s i n event ual fai l ure of t he t hermoregul at ory mechani s ms , wi t h ri s i ng body t emperat ure and ext ens i ve mul t i s ys t em damage. Presentation
Sympt oms i ncl ude headache, naus ea, di zzi nes s , paras t hes i ae i n l i mbs , pi l oerect i on, confus i on, del i ri um, s ei z ures , and coma. Exami nat i on s hows el evat ed body t emperat ure (>40C). There i s profus e s weat i ng unl es s t he pat i ent i s s everel y dehydrat ed. Ini t i al l y t here i s t achycardi a and i ncreas ed cardi ac out put whi ch fal l s as cardi ovas cul ar col l aps e ens ues . Neurol ogi cal fi ndi ngs i ncl ude mus cl e ri gi di t y, dys t oni as , at axi a, s ei zures , and coma.
Investigations
Pa g e 1 3 5 9
E or K , de hyd rat i on, ren al fai l ure fro m AT N or rha bd om yol ys i s, or Na Rai CK, wi t AS h T, d rha om an bd LD yol
+ +
U&
s ed
Pa g e 1 3 6 0
ys i
s Nor ma Gl u l or cos l ow e Al l
2+
us u , y
Ca al l PO 4 l ow
3-
Mg
2+
Evi de Cl o nce t t i of ng DI s cr C ee n Ha C em nce nt r at i on, ne ut r op hi l i a Ini FB oco
Pa g e 1 3 6 1
t i al pi r at o ry al k al o sis , t he n me t ab ol i c (l a ct i c ) aci dos
AB res
is Us ual Uri l y ne s m al l vol um es an d con cen t ra t ed .
Pa g e 1 3 6 2
Tes t for my ogl obi n, t ub ul a r cas ts, pro t ei n Co G mm y s ho ws no n-s pec i fi c ST an d T wa ve cha ng es an d/o EC onl
Pa g e 1 3 6 3
r SV T If T >1 0IU /l i t re in t he fi rs t 24 ho urs , pro gn os i s is po or wi t h s er i ou s bra i n, ki d ney , an AS 00
Pa g e 1 3 6 4
d liv er i nj ury
Management
St abi l i ze t he pat i ent

o
Ens ure adequat e ai rway and vent i l at i on. Gi ve oxygen. St art peri pheral i v fl ui ds (crys t al l oi d) prompt l y; i ns ert CVP l i ne PA (Swan-Ganz) cat het er t o gui de fl ui d repl acement i not ropes . Ins ert a uri nary cat het er and ai m for an out put of >30ml /h. If myogl obi nuri a i s pres ent cons i der al kal i ne di ures i s (p392). Anuri a and hyperkal aemi a are i ndi cat i ons for di al ys i s (p378). Treat s ei zures wi t h i v di azepam (p472); phenyt oi n has been report ed t o be i neffect i ve. Excl ude hypogl ycaemi a. Begi n ext ernal cool i ng wi t h i ce packs (i n axi l l ae, groi n, and neck), t epi d s pongi ng and cool i ng fans ; col d wat er i mmers i on i s i nappropri at e for uns t abl e pat i ent s . Vi ol ent s hi veri ng s houl d be s uppres s ed as i t i nt erferes wi t h cool i ng; gi ve chl orpromaz i ne 1025mg i v s l owl y. St op cool i ng when body t emperat ure reaches
Reduc e body t emperat ure prompt l y

o
Pa g e 1 3 6 5
39C; t he t emperat ure wi l l fal l furt her and hypot hermi a i s t o be avoi ded.
o
Dant rol ene has been effect i ve i n s ome cas es but needs furt her eval uat i on.
P.843
P.844
Hypothermia: assessment
Thi s i s defi ned as a core (rect al ) t emperat ure <35C; i t i s des i gnat ed mi l d (3235C), moderat e (2632C), or s evere (<26C). Risk factors
Increas i ng age (i mpai red t hermoregul at i on, reduced met abol i s m) Abnormal ment al s t at e Immobi l i t y (ort hopaedi c, Parki ns oni s m) Drugs (al cohol , barbi t urat e, major t ranqui l l i zers , ant i depres s ant s ) Endocri ne (hypot hyroi di s m, hypogl ycaemi a, adrenal i ns uffi ci ency, hypopi t ui t ari s m) Aut onomi c neuropat hy (DM, Parki ns oni s m) Mal nut ri t i on Renal fai l ure Seps i s (exces s i ve heat l os s from vas odi l at at i on) Expos ure (i nadequat e cl ot hi ng/heat i ng, near-drowni ng). Mi l d hypot hermi a pres ent s as s hi veri ng whi ch i s maxi mal at 35C and decreas es t hereaft er, bei ng abs ent at t emperat ures bel ow 32C. Ot her s ympt oms i ncl ude mi l d confus i on, weaknes s , fat i gueabi l i t y, l et hargy, at axi a, and dys art hi a. Progres s i ve hypot hermi a i s as s oci at ed wi t h del i ri um,
Presentation
Pa g e 1 3 6 6
coma, bradycardi a and l ow res pi rat ory rat e, cardi ac arrhyt hmi as , di l at ed unres pons i ve pupi l s , and l os s of refl exes . The EEG i s fl at at , <20C. As ys t ol e occurs at <15 C.
Compl i c at i ons : VF at ri al t achy- and brady-arrhyt hmi as , ARDS, as pi rat i on pneumoni a, pancreat i t i s , bowel i s chaemi a, acut e renal fai l ure, rhabdomyol ys i s , DIC.
Investigations
Check t he core t emperat ure wi t h a l ow readi ng rect al t hermomet er.
U& Es , Urg CK ent (de bl o hyd ods rat i on, rha bd om yol ys i s ). Gl u c os e (us ual ly hi g h). Am yl a se (pa
Pa g e 1 3 6 7
ncr eat itis 2 to hyp ot h er mi a). FB C, Ro ph ut i os p ne hat bl o e ods ( ), ma gn es i um ( ) Bl o od cul t ur es Thy roi d fun ct i
Pa g e 1 3 6 8
on Tox ic s cr ee n Ser um cor tis ol .
ABG: The val ues obt ai ned are abnormal an art efact ual l ower pH and hi gher P a O 2 and P a CO 2 as mos t ABG machi nes as s ume t he s ampl e was t aken at 37C. Some machi nes can be programmed wi t h t he pat i ent 's t emperat ure t o al l ow correct i on for t he l ower t emperat ure before t he s ampl e i s anal ys ed. Al t ernat i vel y, t o correct pH add 0.015 for every degree t he pat i ent 's t emperat ure i s bel ow 37C. The P a O 2 and P a CO 2 need t o be decreas ed by 7.2% and 4.4% res pect i vel y for every degree bel ow 37C. ECG: Thi s may s how bradycardi a, t achycardi a, AF and/or prol ongat i on of PR and QTC i nt erval s . J-waves are s een wi t h t emperat ures <30C, as a hump i n t he i nt erval bet ween t he QRS and T waves (bes t s een i n V4V6). Uri ne: MCS, di ps t i ck (bl ood and prot ei n), ?myogl obi nuri a.
P.845
P.846
Pa g e 1 3 6 9
Hypothermia: management

o
Ens ure t he ai rway i s prot ect ed and gi ve oxygen. Avoi d hypervent i l at i on as an acut e fal l i n P a CO 2 may t ri gger VF. If t he pat i ent i s uncons ci ous , and i njury s us pect ed, i mmobi l i ze t he cervi cal s pi ne unt i l fract ure can be excl uded. Es t abl i s h venous acces s ; excl ude hypogl ycaemi a. St art vol ume expans i on wi t h warm, i v crys t al l oi d i nfus i on i f dehydrat ed (e.g. 5% dext ros e 80100ml /h) (fl ui d may be warmed i n a bl ood-warmer devi ce). CVP moni t ori ng and PA wedge pres s ure moni t ori ng may hel p gui de fl ui d repl acement . Ins ert a uri nary cat het er t o moni t or uri ne out put (pot ent i al rhabdomyol ys i s ). Gi ve i v t hi ami ne 250mg i f t here i s an al cohol hi s t ory. Severe met abol i c aci dos i s (pH <7.1) s houl d be t reat ed wi t h s l ow i v bi carbonat e i nfus i on (s ee p716) moni t ori ng ABG. Avoi d rapi d changes i n pH. Mi l der degrees of aci dos i s are wel l t ol erat ed and requi re no s peci fi c t reat ment . Vent ri c ul ar fi bri l l at i on i s common (preci pi t at ed by rapi d changes i n P a CO 2 or pH, i nt ubat i on wi t hout adequat e pre-oxygenat i on, movement ) and s houl d be t reat ed as normal (p6) whi l e act i ve rewarmi ng proceeds (s ee bel ow). Cl as s 1 agent s (l i gnocai ne) may be i neffect i ve at l ow t emperat ures ; bret yl i um t os yl at e i s more s ucces s ful i n cardi overt i ng i nt ract abl e VF. At ri al arrhyt hmi as and vent ri cul ar ect opi cs wi t hout haemodynami c compromi s e do not requi re t reat ment . In t he event of cardi o-res pi rat ory arres t ,
o o
Pa g e 1 3 7 0
res us ci t at i on s houl d be cont i nued unt i l core t emperat ure reaches at l eas t 35 C as t he col d t emperat ure may provi de a degree of neuroprot ect i on.
Rewarming
o
Pat i ent s wi t h mi l d hypot hermi a may be managed wi t h pas s i ve ext ernal rewarmi ng. Cover t he pat i ent , i ncl udi ng s cal p, i n warm, dry bl anket s (s pace bl anket i f avai l abl e). Gi ve warmed i v fl ui ds t o correct dehydrat i on. Ai m for a ri s e i n t emperat ure of 0.51C/h and moni t or cl os el y for compl i cat i ons . Hypot ens i on may be due t o rapi d vas odi l at at i on; s l ow t he rat e of rewarmi ng i v fl ui ds . Moderat e or s evere hypot hermi a may requi re act i ve re-warmi ng, ei t her ext ernal (heat ed bl anket s , wat er-bot t l es , warm bat h) or i nt ernal [heat ed humi di fi ed oxygen, peri t oneal di al ys i s wi t h rapi d exchange of warm fl ui ds (~40C), ext ra-corporeal bl ood warmi ng t echni ques (e.g. haemodi al ys i s , cardi opul monary bypas s ]. Thi s may res ul t i n vas odi l at at i on, hypot ens i on, and arrhyt hmi as and s houl d onl y be us ed i n pat i ent s who are uns t abl e or i n cardi ac arres t . Appl y i ni t i al l y onl y t o t he t runk t o avoi d exces s i ve vas odi l at at i on of ext remi t i es .
Other measures
o
If t he t emperat ure i s s l ow t o correct , cons i der whet her t he pat i ent i s Addi s oni an or hypot hyroi d. If you s us pect myxoedema, gi ve l i ot hyroni ne 2040g i v (T3) and hydrocort i s one (HC) 200mg i v repeat i ng as neces s ary. Al ways gi ve HC wi t h T3 i n cas e t here i s underl yi ng hypoadrenal i s m. P.847
Pa g e 1 3 7 1
Aft er s ept i c s creen, cons i der broad s pect rum ant i bi ot i cs for as pi rat i on pneumoni a or underl yi ng s eps i s as a preci pi t at i ng fact or. Gi ve prophyl act i c ant i bi ot i cs t o pat i ent s wi t h moderat e-s evere hypot hermi a (e.g. cefot axi me 12g q8h).
P.848
Hypothermia: localized injury Chilblains (perniosis)
Pres ent at i on : Pai nful , i t chi ng, dark red s wel l i ngs , t ypi cal l y s een on t he fi ngers or t oes . Rarel y t he cal ves may be affect ed. Hors e-ri di ng i n t he wi nt er mont hs may res ul t i n chi l bl ai ns on t he upper, out er t hi ghs , des pi t e t he ri di ng t rous ers . More common i n women. Di agnos i s i s eas y; al l i nfl ammat i on i s warm except chi l bl ai ns whi ch are cool t o t ouch. T reat ment i s s ympt omat i c and warmer coveri ng. The l es i ons may recur every wi nt er.
Trench foot
Pres ent at i on : Us ual l y occurs 1224 hours aft er expos ure t o col d and damp. Ini t i al l y t he foot i s col d and pal e, wi t h reduced s ens at i on and pul s es . Thi s i s fol l owed by hyperaemi a, pai nful s wel l i ng, s omet i mes wi t h ul cerat i on or gangrene i f s evere. T reat ment : Cons ervat i ve wi t h el evat i on, res t , and s t ri ct at t ent i on t o as eps i s .
Frostbite
Presentation
Thi s res ul t s from freezi ng of t he t i s s ues and i s chaemi c necros i s due t o vas os pas m. Sympt oms i ncl ude numbnes s , s t i ngi ng, or burni ng pai n.
Pa g e 1 3 7 2
Superfi ci al fros t bi t e (s ki n and s ub-cut aneous t i s s ues onl y) appears pal e and has a s omewhat s oft and rubbery feel . Deep fros t bi t e i nvol ves deeper t i s s ues , even bone, res ul t i ng i n a hard, woody feel .
Treatment

Treat any as s oci at ed hypot hermi a (as above). If t here i s any pos s i bi l i t y of refreezi ng, do not t haw (even i f i t means wal ki ng on froz en feet ); refreezi ng i ncreas es t i s s ue damage. Rapi d rewarmi ng i s es s ent i al t o mi ni mi ze t i s s ue necros i s ; i mmers e i n a wat er bat h (4042C i f t ol erat ed) for s everal mi nut es . There i s oft en cons i derabl e pai n t hat may requi re i v/i m anal ges i a. Cl ean t he affect ed part and appl y t opi cal di s i nfect ant s (i odi ne 510%), bed res t , el evat i on. Debri dement s houl d be del ayed unt i l t he l i mb has demarcat ed. Gi ve t et anus prophyl axi s i f neces s ary. There i s s ome evi dence for t he us e prophyl act i c ant i bi ot i cs (aft er appropri at e s wabs ) i n pat i ent s wi t h deep fros t bi t e (hi gh dos e peni ci l l i n). Hepari n has not been s hown t o be us eful .
P.849
P.850
Diving accidents Decompression illness

W at er pres s ure i ncreas es by 1 at mos phere for every 10m (33ft ) bel ow t he s urface. The i ncreas ed pres s ure i ncreas es t he amount of di s s ol ved ni t rogen i n t he pl as ma. Rapi d as cent res ul t s i n t he
Pa g e 1 3 7 3
format i on of bubbl es as t he gas comes out of s ol ut i on. Symptoms
Us ual l y occur wi t hi n t he fi rs t hour of s urfaci ng but may be del ayed by up t o 36 hours . Deep mus cl e aches (t he bends ). Ski n s ympt oms : pai n, paras t hes i ae, i t chi ng, and burni ng. The chokes : ret ros t ernal pai n, cough, breat hl es s nes s . Neurol ogi cal s ympt oms : parapl egi a, uri nary ret ent i on, pat chy s pi nal cord necros i s due t o ret rograde venous t hombos i s . Sus pect al l neurol ogi cal s ymproms are due t o decompres s i on i l l nes s unt i l proven ot herwi s e.
Air embolism
If t he breat h i s hel d on as cent (due t o breat h-hol di ng or l aryngos pas m) t he vol ume of gas i n t he l ungs expands , and l arge pres s ure gradi ent s are generat ed. Event ual l y al veol i rupt ure res ul t i ng i n pneumot horax, pneumomedi as t i num, and s ub-cut aneous emphys ema. Rupt ured pul monary vei ns al l ow art eri al ai r embol i s m (commonl y i nt o t he carot i d ci rcul at i on).
Sympt oms vary from behavi our changes , confus i on, focal neurol ogi cal defect s , s ei zures , coma, and deat h. A vari et y of ot her s ympt oms may occur dependi ng on t he art eri al bed t he embol i t ravel t o and due t o t he free ai r i n t he t horaci c cavi t y.
Treatment
Gi ve oxygen, anal ges i a, and i nt ravenous fl ui ds i f dehydrat ed. Do not gi ve ni t rous oxi de ( Ent onox ). If t here i s a pos s i bi l i t y of ai r embol i s m l i e on t he l eft s i de wi t h head-down t i l t t o col l ect ai r i n t he ri ght at ri um. Occas i onal l y i t may be pos s i bl e t o as pi rat e t he ai r from t he ri ght at ri um wi t h a venous cat het er. Immediate recompression i s t he onl y effect i ve t reat ment . Cont act your l ocal poi s ons uni t (s ee p854 for t el ephone numbers ) who wi l l be abl e t o put you i n
Pa g e 1 3 7 4
cont act wi t h your neares t recompres s i on chamber t o your hos pi t al and arrange urgent t rans fer.
Never at t empt recompres s i on i n wat er.
Pneumothorax
(s ee p236) P.851
P.852
Near-drowning
W hen i mmers ed i n wat er, a peri od of breat h-hol di ng i s fol l owed by i nvol unt ary i ns pi rat i on. As pi rat i on of wat er, bact eri a, and ot her part i cul at e mat eri al fol l ows . The di s t i nct i on bet ween fres h-wat er (hypot oni c) and s al t -wat er (hypert oni c) drowni ng i s onl y us eful i n t hat fres h-wat er i nhal at i on res ul t s i n marked haemol ys i s , el ect rol yt e di s t urbances , i nt ravas cul ar vol ume overl oad, whereas s al t -wat er i nges t i on may res ul t i n hypovol aemi a and haemoconcent rat i on. Thei r management i s i dent i cal . In pract i ce t he vol ume of wat er as pi rat ed i s s mal l ; i n 1015%, l aryngos pas m res ul t s i n dry drowni ng and as phyxi a.
Presentation
Sympt oms may range from none, t o cough and mi l d breat hl es s nes s , t o cardi ores pi rat ory arres t and coma. Ini t i al exami nat i on, bl ood gas es , and CXR may be normal and do not predi ct s ubs equent cl i ni cal cours e. Exami ne s peci fi cal l y for t rauma t o cervi cal or t horaci c s pi ne.
Prognostic features
Pa g e 1 3 7 5
Survi val i s rel at ed t o durat i on of s ubmers i on, ext ent and durat i on of hypoxi a, wat er t emperat ure, ext ent of hypot hermi a, pres ence of as pi rat i on, adequacy of i ni t i al res us ci t at i ve effort s , age, and pres ence of co-exi s t i ng medi cal condi t i ons .
Management
As ympt omat i c pat i ent s s houl d be obs erved for at l eas t 612 hours . If exami nat i on, art eri al gas es , and CXR remai n normal , t hey may be di s charged. At t he s cene, manoeuvres t o drai n t he l ungs are pot ent i al l y dangerous and i neffect i ve; aggres s i ve mout h-t o-mout h res us ci t at i on and cardi ac mas s age s houl d be s t art ed i f neces s ary. Gi ve oxygen as s oon as avai l abl e. Int ubat e and vent i l at e i f t here i s pers i s t ent hypoxi a. 510cm H 2 O PEEP may i mprove oxygenat i on. Pat i ent s wi t h hi s t ory of di vi ng or evi dence of head or s pi ne t rauma s houl d be t reat ed as havi ng head/s pi ne i njury unt i l proven ot herwi s e. Hypot hermi a s houl d be t reat ed i n t he us ual manner (p848). The l ow t emperat ures may provi de a degree of neuro-prot ect i on and res us ci t at i ve effort s s houl d not be s t opped unt i l t he core t emperat ure reaches >35C. Met abol i c aci dos i s i s i nvari abl e; i f pH <7.1, gi ve i v bi carbonat e 50ml 8.4% over 1520 mi nut es (s ee l act i c aci dos i s , p278). If t here i s cl i ni cal or radi ol ogi cal evi dence of ches t i nfect i on begi n t reat ment wi t h broad s pect rum ant i bi ot i cs (e.g. cefot axi me and met roni dazol e or amoxyci l l i n, gent ami ci n and met roni dazol e).
P.853
P.854
Pa g e 1 3 7 6
Electric shock
Damage i s caus ed by a combi nat i on of t hermal t i s s ue i njury and di rect i njury from t he el ect ri c current pas s i ng t hough t he t i s s ue. The t reat ment i s s upport i ve.
Domestic electric shock
Ski n burns at t he s i t e of ent ry and exi t of t he current are common. Thes e s houl d be referred t o a burns cent re for s peci al i s t management . Cardi ac damage may res ul t i n ST and T wave changes on ECG, VF, as ys t ol e, and ot her cardi ac arrhyt hmi as . Moni t or for at l eas t 24 hours , i f t he ECG i s abnormal . Rhabdomyol ys i s wi t h varyi ng degrees of renal fai l ure i s common due t o t et ani c cont ract i on and i s chaemi c necros i s of s kel et al mus cl e (p392). There may be s evere mus cl e burn i njury even when t here i s mi ni mal s ki n damage. If s us pect ed, refer t o a burns or pl as t i c s urgery uni t . Neurol ogi cal damage res ul t s i n al t ered ment al s t at e, confus i on, depers onal i zat i on, and pat chy s pi nal cord demyel i nat i on. Heat may al s o be res pons i bl e for i nt ravas cul ar coagul at i on and i s chaemi c necros i s of ot her t i s s ues . Thi s i s cl as s i cal l y del ayed by s everal hours . Treat ment i s s upport i ve. Excl ude co-exi s t ent fract ures of s pi ne and l ong bones .
Lightning injuries
The vol t age and current are s everal orders of magni t ude great er t han domes t i c el ect ri cal i njuri es (up t o 10 A and 10 V) but expos ure i s ext remel y bri ef. Mos t of t he current pas s es over t he s ki n and deep t i s s ue damage i s l es s common. Ski n ent ry burns have a fern-l i ke pat t ern and are mai nl y s uperfi ci al or part i al t hi cknes s burns .
5 6
Pa g e 1 3 7 7
Mos t pat i ent s s urvi ve wi t hout any s i gni fi cant arrhyt hmi as . Vent ri cul ar fi bri l l at i on or as ys t ol e are occas i onal l y s een. Myocardi al i nfarct i on, ECG abnormal i t i es , and l at e arrhyt hmi as have been report ed. Di l at ed pupi l s may be t he res ul t of t rans i ent aut onomi c s ympat het i c di s charge and s houl d not det er act i ve res us ci t at i on. Di rect i njury t o abdomi nal vi s cera, l ungs , s pi nal cord, and t ympani c membrane may be s een. Lat e compl i cat i ons i ncl ude opt i c at rophyand cat aract s .
P.855
P.856
Smoke inhalation
Thi s caus es a combi nat i on of t hermal and chemi cal i njury t o t he l ungs and varyi ng degrees of s ys t emi c t oxi ci t y. The mai n caus e of deat h i n pat i ent s wi t h s moke i nhal at i on i s cerebral hypoxi a s econdary t o carbon monoxi de expos ure. Combus t i on of hous ehol d mat eri al s can al s o generat e a number of ot her t oxi c s ubs t ances s uch as s ul phur di oxi de, ni t rogen di oxi de, acrol ei n (from wood and pet rol eum), hydrochl ori c aci d (PVC), t ol uene di i s ocyanat e (pol yuret hane), and hydrogen cyani de t hat may res ul t i n di rect l ung, s ki n, and conjunct i val i njury.
Presentation
Common s ympt oms i ncl ude cough, s ore t hoat , breat hl es s nes s , pl euri t i c ret ros t ernal ches t pai n, headache, di zzi nes s , naus ea. Exami nat i on: Not e t he s ki n col our (normal , cyanot i c).
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Look for peri oral and peri nas al burns , s i ngei ng of nas al hai r, burns of oral mucos a (markers of s i gni fi cant , t hermal , res pi rat ory-t ract i njury).
Not e cough and col our of s put um (?bl ack), t achypnoea, wheez e, s t ri dor and/or t achycardi a. As s es s ment al s t at e (?confus ed).
Initial investigations
(Hy G pox CO 2 ret ent i on ) no te t he c al c ul at e d O
2
AB i a,
s at ura tio n fro m t he ma chi nes is
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ove res tim at e d in t he pre s en ce of sig ni fi can t CO Hb. (C OH Car b) box l ev y-H el b fro m cooxi me t er (av ai l abl e in so me
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ITU s or con t ac t dut y bi o che mi s t ). No n-s mo ker s <1 %, sm oke rs 4 6 %, >1 0% sig ni fi can t CO exp os u
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re, >5 0% co ma , >7 0% fat al (s e e p8 02) . Ma R y nor ma l. Pro gre ssi ve i nt ers titi al an d al v eol ar s ha CX be
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do wi n g mi mi c ki n g car di o ge ni c pul mo nar y oe de ma (up per > l ow er l ob es ) No G n-s i fi c STT wa ve cha ng EC pec
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es or sig ns of my oca rdi al isc ha em i a. Ina ccu Pul rat s e e; oxi ma me y t ry onl y be nor ma l in t he pre s en ce of hi g h l ev el s of
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CO Hb.
Indications for admission

Hi s t ory of s i gni fi cant s moke i nhal at i on i njury Cl i ni cal s i gns of s i gni fi cant l ung i njury (above) Confus i on COHb l evel >15%, Hypoxi a ( P a O 2 <10kPa on ai r) Rai s ed P a CO 2 on ai r.
Management
T he initial ABG and CXR may be normal and do not predict subsequent clinical course.
Res us ci t at e t he pat i ent (Ai rway, Breat hi ng, Ci rcul at i on). If t he i ni t i al CXR and ABG are normal , obs erve t he pat i ent for 46 hours and i f t here i s no cl i ni cal det eri orat i on, di s charge wi t h i ns t ruct i ons t o ret urn i f t hey devel op any res pi rat ory s ympt oms . P.857
Gi ve s uppl ement al , humi di fi ed, cool ed oxygen. Treat bronchos pas m wi t h i nhal ed and i v bronchodi l at ors (s ee p213).
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Encourage deep breat hi ng and cough t o cl ear s ecret i ons ; t here may be copi ous s put um product i on. Send a s peci men for cul t ure. St art ant i bi ot i cs i f t here i s evi dence of i nfect i on. Indications for intubation and ventilation i ncl ude fal l i ng P a O 2 des pi t e maxi mal i ns pi red oxygen, fai l ure t o cl ear s ecret i ons , or ri s k of upper ai rways obs t ruct i on (s ee ARDS, p230).
Carbon monoxide poisoning s ee p802. P.858
Acute mountain sickness

Us ual l y s een wi t hi n 2436 hours of as cent . Sympt oms i ncl ude headache (mos t common), l et hargy, i rri t abi l i t y, di ffi cul t y concent rat i ng, naus ea, vomi t i ng, pal pi t at i ons , breat hl es s nes s , di zzi nes s , and di ffi cul t y s l eepi ng. Sympt oms oft en wors en over t he fi rs t 23 days t hen res ol ve compl et el y by day 57. Exami nat i on and i nves t i gat i ons are us ual l y normal except for mi l d dehydrat i on, al kal aemi a, and bi carbonat e di ures i s i f accl i mat i zat i on has begun. The mos t effect i ve t reat ment i s des cent t o l ower al t i t ude and s uppl ement al oxygen. Encourage bed res t and fl ui d i nt ake. Sedat i ves may depres s res pi rat ory dri ve, exacerbat i ng hypoxi a, and mas k s i gns of al t ered ment al s t at us . Dexamet has one i s effect i ve i n reduci ng t he s ympt oms of acut e mount ai n s i cknes s but does not reduce t he object i ve mani fes t at i ons of t he i l l nes s or ret ard progres s i on; i t i s onl y recommended i f des cent t o l ower al t i t ude i s not pos s i bl e or del ayed. Do not us e di uret i cs acut el y.
Acute high-altitude pulmonary oedema
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(HAPO)
Non-cardi ogeni c pul monary oedema occurs wi t hi n 1296 days of as cent . Type 1 HAPO i s s ai d t o occur when an unaccl i mat i zed i ndi vi dual as cends t o hi gh al t i t ude; Type 2 HAPO i s s ai d t o occur when a hi gh-al t i t ude res i dent devel ops pul monary oedema aft er ret urni ng from a vi s i t t o a l ower al t i t ude. The di s t i nct i on i s i mport ant as t reat ment di ffers (s ee bel ow). Sympt oms are as for acut e mount ai n s i cknes s (s ee above), but i n addi t i on t here i s l ow-grade fever, cough, and breat hl es s nes s at res t . Exami nat i on s hows pul monary oedema W ITHOUT t he us ual s i gns of heart fai l ure (el evat ed JVP, S3 gal l op, cardi ac enl argement ). Inves t i gat i ons : ABG s hows res pi rat ory al kal os i s and hypoxaemi a; ECG may s how s i nus t achycardi a wi t h s i gns of ri ght -heart s t rai n. CXR may s how pat chy l ung s hadowi ng.
T reatment
Mi l d t ype 1 and 2 HAPO may be t reat ed wi t h oxygen and bed res t ; s ympt oms us ual l y res ol ve i n 12 days . Treat ment wi t h di uret i cs , di gi t al i s , and s t eroi ds have not been s hown t o be us eful . Moderat e-s evere t ype 1 HAPO may requi re i nt ubat i on and vent i l at i on wi t h PEEP. Type 2 HAPO us ual l y res ponds t o bed res t and s uppl ement al oxygen onl y.
P.859
P.860
High-altitude encephalopathy
Us ual l y occurs wi t hi n 24 hours of as cent over 12 000 feet (~3600m).
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Ini t i al s ympt oms of acut e mount ai n s i cknes s (s ee above) progres s t o papi l l oedema, ret i nal haemorrhages , at axi a, and focal neurol ogi cal defect s , s ei zures , and coma. Treat ment i s wi t h oxygen and i mmedi at e des cent t o l ower al t i t udes . Hi gh dos es of dexamet has one may be benefi ci al but manni t ol and di uret i cs are not rout i nel y gi ven.
Prevention
Gradual as cent , adequat e res t and fl ui ds , and avoi dance of s t renuous exerci s e reduce t he i nci dence of hi gh-al t i t ude i l l nes s . Prophyl act i c acet azol ami de (250mg po q812h) gi ven t he day before and for t he fi rs t few days of as cent reduces t he i nci dence and s everi t y of acut e mount ai n s i cknes s .
Practice points: High altitude illness
Hi gh al t i t ude i l l nes s i s us ual l y s een when an unaccl i mat i zedi ndi vi dual t ravel s t o al t i t udes above ~7000 feet (2300m); t hei nci dence and s everi t y i ncreas es progres s i vel y wi t h hi gher al t i t udes and wi t h rapi d rat es of as cent . Acut e s ympt oms occurs wi t hi n 68 hours of as cent wi t h markedi ndi vi dual vari at i on i n t ol erance t o hypoxaemi a at al t i t ude. Commerci al ai rl i nes crui s i ng at al t i t udes of 29 00037 000 have cabi npres s ures equi val ent t o an al t i t ude of 60008000 feet ; t hus t ravel l ers may be bri efl y expos ed t o condi t i ons t hat may provoke mi l d hi gh-al t i t ude s i cknes s !
P.861
P.862
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Stings and insect bites Acute presentation (within 23 hours)

Hi s t ory As k s peci fi cal l y i f react i ons have occurred i n t he pas t and i f t here i s any pas t hi s t ory of angi oedema, urt i cari a, bronchos pas m, or anaphyl axi s . Mos t pat i ent s devel opi ng anaphyl axi s have no previ ous hi s t ory of s i gni fi cant react i on. Exami ne t he wound for t he s t i nger and remove careful l y. Obs erve t he pat i ent careful l y for 12 hours for any s i gns of evol vi ng anaphyl axi s (general i zed urt i cari a and pruri t us , bronchos pas m, or oropharyngeal oedema). If pres ent t he pat i ent requi res urgent t reat ment (s ee bel ow).
Management
Loc al reac t i ons

o o o o
Cl ean t he wound of any foreign mat eri al . Appl y an i ce compres s . Gi ve t et anus prophyl axi s i f appropri at e. Di s charge wi t h i ns t ruct i ons t o ret urn i f t hey devel op breat hl es s nes s , wheeze, ras h, oropharyngeal s wel l i ng, or general i zed pruri t us . Some woul d advocat e gi vi ng pat i ent s who may be pot ent i al l y i mmunos upres s ed (e.g. di abet es , hi gh-dos e s t eroi d t herapy) prophyl act i c ant i bi ot i cs (e.g. co-amoxi cl av po) but t here i s l i t t l e evi dence t hi s i s of benefi t . Obs erve pat i ent s wi t h pri or hi s t ory of s ys t emi c react i ons cl os el y.
Sys t emi c reac t i on (s ee p264, anaphyl axi s )

o
Secure t he ai rway: If res pi rat ory obs t ruct i on i s i mmi nent , i nt ubat e and vent i l at e or cons i der emergency cri cot hyroi dot omy (s ee p914). A 14 or 16G needl e and i ns uffl at i on wi t h 100% O 2 can t empori ze unt i l t he anaes t het i s t arri ves . Gi ve oxygen; i f t here i s refract ory hypoxi a,
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i nt ubat e and vent i l at e.

o
Give intramuscular adrenaline 0.51mg (0.51ml of 1 i n 1000 adrenal i ne i nject i on) and repeat every 10 mi nut es accordi ng t o bp and pul s e. Admi ni s t er t hi s before s earchi ng for i nt ravenous acces s s o as not t o was t e t i me. Es t abl i s h venous acces s and s t art i v fl ui ds (col l oi d i f hypot ens i ve). Pers i s t ent hypot ens i on requi res i v i not ropes (s ee p262). Intravenous adrenaline may be requi red i f t he pat i ent i s s everel y i l l wi t h poor ci rcul at i on. Gi ve slow i nject i on of 500 mi crograms (5ml of t he di l ut e 1 i n 10 000 adrenal i ne i nject i on) at 1mL/mi nut e stopping when a res pons e i s obt ai ned. If t he pat i ent cont i nues t o det eri orat e, s t art i nt ravenous ami nophyl l i ne i nfus i on. Pat i ent s on bet a-bl ockers may not res pond t o adrenal i ne i nject i on and requi re i v s al but amol i nfus i on. Is ol at ed bronchos pas m may be t reat ed wi t h nebul i zed -agoni s t s (s al but amol ). If t here i s pri or hi s t ory of s ys t emi c react i ons , i m adrenal i ne i s t he t reat ment of choi ce. Gi ve i v hydrocort i s one 100300mg and chl orpheni rami ne 1020mg. Cont i nue H 1 ant agoni s t (e.g. chl orpheni rami ne 4mg q46h) for at l eas t 2448h; l onger i f urt i cari a and pruri t us pers i s t . Do not forget l ocal wound care as above.
P.863
Prevent i on Pat i ent s prone t o s eri ous react i ons from s t i ngs s houl d be provi ded wi t h, and i ns t ruct ed on, t he us e of commerci al l y
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avai l abl e bee-s t i ng ki t s . [Avai l abl e freel y i n t he US and on a named-pat i ent bas i s i n t he UK from t he manufact urers (s ee BNF).] Thes e cont ai n pre-fi l l ed s yri nges of adrenal i ne for i m i nject i on and one al s o cont ai ns chewabl e t abl et s of chl orpheni rami ne.
Delayed presentation
Due t o l ocal t oxi c react i on or i nfect i on, and rarel y wi t h s erum s i cknes s , vas cul i t i s , Henoch-Schnl ei n purpura, and haemol ys i s . Cl ean t he wound and gi ve t et anus prophyl axi s i f i ndi cat ed as above. Pract i cal l y, i t i s di ffi cul t t o di s t i ngui s h a l ocal t oxi c react i on from i nfect i on. Treat wi t h bot h an oral ant i hi s t ami ne and oral ant i bi ot i c (e.g. chl orpheni rami ne 4mg q46h and co-amoxi cl av). El evat e i f t here i s marked s wel l i ng and cons i der s urgi cal drai nage of fl uct uant mas s es .
P.864
Snakebite
The onl y i ndi genous venomous s nake i n t he UK i s t he adder ( Vi pera berus ) and acut e envenomat i on i s rare.
Presentation
Local effect s i ncl ude pai n, s wel l i ng, eryt hema, brui s i ng, t ender regi onal l ymphadenopat hy. Sys t emi c effect s s uch as hypot ens i on and s yncope, angi oedema, abdomi nal col i c, di arrhoea and vomi t i ng, coagul opat hy and s pont aneous haemorrhage, ECG abnormal i t i es , s hock, ARDS, rhabdomyol ys i s , and renal fai l ure are omi nous , but V. berus bi t es are s el dom fat al i n adul t humans .
Management
Ident i fy t he s nake i f at al l pos s i bl e. The i ns t i nct i ve
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res pons e on bei ng bi t t en i s t o gi ve t he s nake a ri t ual beat i ng, but t hi s does not hel p i n t he i dent i fi cat i on.
Non-poi s onous bi t es s houl d be cl eaned, ant i -t et anus prophyl axi s gi ven t o t he pat i ent i f needed, wi t h prophyl act i c ant i bi ot i cs as for ani mal bi t es (s ee p328).
Poisonous snake bites

First aid
Immobi l i ze t he bi t t en part and keep bel ow t he l evel of t he heart i f pos s i bl e. A veno-occl us i ve t ourni quet s houl d be pl aced i mmedi at el y above t he bi t e, t aki ng care not t o obs t ruct t he art eri al s uppl y. Inci s i on and s uct i on of t he wound i s onl y i ndi cat ed i f t he pat i ent i s s een wi t hi n 1520 mi nut es , t he s nake i s l arge and i dent i fi ed as poi s onous , t he vi ct i m i s young or el derl y, and t he neares t s ource of ant i -venom i s more t han 2 hours away. The pat i ent s houl d be kept cal m and qui et t o avoi d t achycardi a and furt her vas odi l at at i on and venom abs orpt i on.
In hospital
Al l pat i ent s wi t h bi t es from poi s onous s nakes s houl d be admi t t ed. Es t abl i s h venous acces s and s end bl ood for FBC, coagul at i on profi l e, U&E, group and X-mat ch. Exami ne uri ne for myogl obi n or haemogl obi n. Treat hypot ens i on and s hock (p257). W at ch for evol vi ng compart ment s yndrome. Al l bi t es s houl d be cul t ured and t reat ed wi t h ant i bi ot i cs (s ee bi t es ). Some aut hori t i es recommend hi gh-dos e hydrocort i s one and ant i hi s t ami ne t o reduce l ocal i nfl ammat i on and s ys t emi c s ympt oms . Indi cat i ons for ant i -venom t reat ment i ncl ude s ys t emi c feat ures (as above), coagul opat hy, neut rophi l
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l eukocyt os i s , and i f s wel l i ng ext ends t o wri s t /ankl e wi t hi n 4 hours of a bi t e on t he hand/foot .
Cont ac t your regi onal c ent res for det ai l s on i dent i fi c at i on, management and s uppl y of ant i -venom for adder and c ert ai n forei gn s nakes (s ee p961). General meas ures : Al l bi t es s houl d be s wabbed for MC&S (s ee bi t es ).
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> T able of Cont ent s > Chapt er 16 - Prac t ic al proc edures
Chapter 16
Practical procedures
P.866
Central line insertion You will need the following:

St eri l e dres s i ng pack and gl oves 10ml and 5ml s yri nge wi t h green (21G) and orange (25G) needl es Local anaes t het i c (e.g. 2% l i gnocai ne) Cent ral l i ne (e.g. 16G l ong Abbocat h or Sel di nger cat het er) Sal i ne fl us h Si l k s ut ure and needl e No. 11 s cal pel bl ade St eri l e occl us i ve dres s i ng (e.g. Tegaderm)
Risks

Art eri al punct ure (remove and appl y l ocal pres s ure) Pneumot horax (i ns ert ches t drai n or as pi rat e i f requi red) Haemot horax Chyl ot horax (mai nl y l eft s ubcl avi an l i nes ) Infect i on (l ocal , s ept i caemi a, bact eri al endocardi t i s ) Brachi al pl exus or cervi cal root damage (over ent hus i as t i c i nfi l t rat i on wi t h l ocal anaes t het i c) Arrhyt hmi as
General procedure
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The bas i c t echni que i s t he s ame what ever vei n i s cannul at ed. Li e t he pat i ent s upi ne ( head-down t i l t ). Turn t he pat i ent 's head away from t he s i de you wi s h t o cannul at e. Cl ean t he s ki n wi t h i odi ne or chl orhexi di ne: from t he angl e of t he jaw t o t he cl avi cl e for i nt ernal jugul ar vei n (IJV) cannul at i on and from t he mi d-l i ne t o axi l l a for t he s ubcl avi an approach. Us e t he drapes t o i s ol at e t he s t eri l e fi el d. Fl us h t he l umen of t he cent ral l i ne wi t h s al i ne. Ident i fy your l andmarks (s ee p869 and p870). Infi l t rat e s ki n and s ub-cut aneous t i s s ue wi t h l ocal anaes t het i c. Have t he i nt roducer needl e and Sel di nger gui de-wi re wi t hi n eas y reach s o t hat you can reach t hem wi t h one hand wi t hout havi ng t o rel eas e your ot her hand. Y our fi ngers may be di s t ort i ng t he anat omy s l i ght l y maki ng acces s t o t he vei n eas i er and i f rel eas ed i t may prove di ffi cul t t o rel ocat e t he vei n. W i t h t he i nt roducer needl e i n t he vei n, check t hat you can as pi rat e bl ood freel y. Us e t he hand t hat was on t he pul s e t o i mmobi l i ze t he needl e rel at i ve t o t he s ki n and mandi bl e or cl avi cl e. Remove t he s yri nge and pas s t he gui de wi re i nt o t he vei n; i t s houl d pas s freel y. If t here i s res i s t ance, remove t he wi re, check t hat t he needl e i s s t i l l wi t hi n t he l umen, and t ry agai n. Remove t he needl e l eavi ng t he wi re wi t hi n t he vei n and us e a s t eri l e s wab t o mai nt ai n gent l e pres s ure over t he s i t e of venepunct ure t o prevent exces s i ve bl eedi ng. W i t h a No. 11 bl ade make a ni ck i n t he s ki n where t he wi re ent ers , t o faci l i t at e di l at at i on of t he s ub-cut aneous t i s s ues . Pas s t he di l at or over t he wi re and remove, l eavi ng t he wi re i n s i t u . P.867
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Pas s t he cent ral l i ne over t he wi re i nt o t he vei n. Remove t he gui de-wi re, fl us h t he l umen wi t h fres h s al i ne, and cl os e off t o ai r. Sut ure t he l i ne i n pl ace and cover t he s ki n penet rat i on s i t e wi t h a s t eri l e occl us i ve dres s i ng.
Measuring the CVPtips and pitfalls
W hen as ked t o s ee a pat i ent at ni ght on t he wards wi t h an abnormal CVP readi ng, i t i s a good habi t t o al ways re-check t he zero and t hereadi ng yours el f. Al ways do meas urement s wi t h t he mi d-axi l l ary poi nt as t he zero reference. Si t t i ng t he pat i ent up wi l l drop t he cent ral fi l l i ng pres s ure (pool i ng i n t he vei ns ). Fi l l t he manomet er l i ne, bei ng careful not t o s oak t he cot t on bal l s t op. If t hi s get s wet i t l i mi t s t he free-fal l of s al i ne or dext ros e i n t he manomet er l i ne. Look at t he rat e and charact er of t he venous pres s ure. It s houl d fal l t o i t s val ue qui ckl y and s wi ng wi t h res pi rat i on. If i t fai l s t o fal l qui ckl y cons i der whet her t he l i ne i s open (i .e. s al i ne runni ng i n), bl ocked wi t h bl ood cl ot , pos i t i onal (up agai ns t ves s el wal l ; as k pat i ent t o t ake s ome deep breat hs ), art eri al bl ood (bl ood t racks back up t he l i ne). Rai s e t he whol e dri ps t and (i f you are s t rong), and make s ure t hat t he l evel fal l s . If i t fal l s when t he whol e s t and i s el evat ed i t may be t hat t he CVP i s very hi gh. It i s eas i er, and s afer, t o cannul at e a cent ral vei n wi t h t he pat i ent s upi ne or head down. There i s an i ncreas ed ri s k of ai r embol us i f t he pat i ent i s s emi -recumbent .
P.868
Internal jugular vein cannulation
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The i nt ernal jugul ar vei n (IJV) runs jus t pos t erol at eral t o t he carot i d art ery wi t hi n t he carot i d s heat h and l i es medi al t o t he SCM i n t he upper part of t he neck, bet ween t he t wo heads of SCM i n i t s medi al port i on and ent ers t he s ubcl avi an vei n near t he medi al border of t he ant eri or s cal ene mus cl e (s ee fi gure). There are t hree bas i c approaches t o IJV cannul at i on: medi al t o s t ernocl ei domas t oi d (SCM), bet ween t he t wo heads of SCM, or l at eral t o SCM. The approach us ed vari es and depends on t he experi ence of t he operat or and t he i ns t i t ut i on.
Locat e t he carot i d art ery bet ween t he s t ernal and cl avi cul ar heads of SCM at t he l evel of t he t hyroi d cart i l age; t he IJV l i es jus t l at eral and paral l el t o i t . Keepi ng t he fi ngers of one hand on t he carot i d pul s at i on, i nfi l t rat e t he s ki n wi t h LA t horoughl y, ai mi ng jus t l at eral t o t hi s and ens uri ng t hat you are not i n a vei n. Ideal l y, fi rs t l ocat e t he vei n wi t h a bl ue or green needl e. Advance t he needl e at 45 t o t he s ki n, wi t h gent l e negat i ve s uct i on on t he s yri nge, ai mi ng for t he i ps i l at eral ni ppl e, l at eral t o t he pul s e. If you fai l t o fi nd t he vei n, wi t hdraw t he needl e s l owl y, mai nt ai ni ng negat i ve s uct i on on t he s yri nge (you may have i nadvert ent l y t rans fi xed t he vei n). Ai m s l i ght l y more medi al l y and t ry agai n. Once you have i dent i fi ed t he pos i t i on of t he vei n, change t o t he s yri nge wi t h t he i nt roducer needl e, cannul at e t he vei n, and pas s t he gui de-wi re i nt o t he vei n (s ee p869).
T ips and pitfalls
Venous bl ood i s dark, and art eri al bl ood i s pul s at i l e and bri ght red! Once you l ocat e t he vei n, change t o t he s yri nge wi t h t he i nt roducer needl e, t aki ng care not t o rel eas e your fi ngers from t he pul s e; t hey may be di s t ort i ng t he anat omy s l i ght l y maki ng acces s t o t he vei n eas i er and i f rel eas ed i t may prove di ffi cul t t o rel ocat e t he vei n.
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The gui de-wi re s houl d pas s freel y down t he needl e and i nt o t he vei n. W i t h t he l eft IJV approach, t here are s everal acut e bends t hat need t o be negot i at ed. If t he gui de-wi re keeps pas s i ng down t he wrong rout e, as k your as s i s t ant t o hol d t he pat i ent 's arms out at 90 t o t he bed, or even above t he pat i ent 's head, t o coax t he gui de-wi re down t he correct pat h. For pat i ent s who are i nt ubat ed or requi ri ng res pi rat ory s upport i t may be di ffi cul t t o acces s t he head of t he bed. The ant eri or approach may be eas i er (s ee fi gure) and may be done from t he s i de of t he bed (t he l eft -s i de of t he bed for ri ght -handed operat ors , us i ng t he l eft hand t o l ocat e t he pul s e and t he ri ght t o cannul at e t he vei n). The IJV may al s o be readi l y cannul at ed wi t h a l ong Abbocat h. No gui de-wi re i s neces s ary, but , as a res ul t , mi s pl acement i s commoner t han wi t h t he Sel di nger t echni que. W hen us i ng an Abbocat h, on cannul at i ng t he vei n, remember t o advance t he s heat h and needl e a few mm t o al l ow t he t i p of t he pl as t i c s heat h (~1mm behi nd t he t i p of t he bevel l ed needl e) t o ent er t he vei n. Hol di ng t he needl e s t at i onary, advance t he s heat h over i t i nt o t he vei n. Arrange for a CXR t o confi rm t he pos i t i on of t he l i ne.
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Int ernal jugul ar vei n cannul at i on P.869
P.870
Subclavian vein cannulation

The axi l l ary vei n becomes t he s ubcl avi an vei n (SCV) at t he l at eral border of t he 1s t ri b and ext ends for 34cm jus t deep t o t he cl avi cl e. It i s joi ned by t he i ps i l at eral IJV t o become t he
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brachi ocephal i c vei n behi nd t he s t ernocl avi cul ar joi nt . The s ubcl avi an art ery and brachi al pl exus l i e pos t eri orl y, s eparat ed from t he vei n by t he s cal enus ant eri or mus cl e. The phreni c nerve and t he i nt ernal mammary art ery l i e behi nd t he medi al port i on of t he SCV and, on t he l eft , l i es t he t horaci c duct .
The s ubcl avi an vei n and s urroundi ng s t ruct ures
Sel ect t he poi nt 1cm bel ow t he junct i on of t he medi al t hi rd and mi ddl e t hi rd of t he cl avi cl e. If pos s i bl e pl ace a bag of s al i ne bet ween t he s capul ae t o ext end t he s pi ne. Cl ean t he s ki n wi t h i odi ne or chl orhexi di ne. Infi l t rat e s ki n and s ub-cut aneous t i s s ue and peri os t eum of t he i nferi or border of t he cl avi cl e wi t h l ocal anaes t het i c up t o t he hi l t of t he green (21G) needl e, ens uri ng t hat i t i s not i n a vei n. Ins ert t he i nt roducer needl e wi t h a 10ml s yri nge, gui di ng gent l y under t he cl avi cl e. It i s s afes t t o i ni t i al l y hi t t he cl avi cl e, and wal k t he needl e under i t unt i l t he i nferi or border i s jus t cl eared. In t hi s way you keep t he needl e as s uperfi ci al t o t he dome of t he pl eura as pos s i bl e. Once i t has jus t s ki mmed underneat h t he cl avi cl e, advance i t s l owl y t owards t he cont ral at eral s t ernocl avi cul ar joi nt , as pi rat i ng as you advance. Us i ng t hi s t echni que t he ri s k of pneumot horax i s s mal l , and s ucces s i s hi gh.
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Once t he venous bl ood i s obt ai ned, rot at e t he bevel of t he needl e t owards t he heart . Thi s encourages t he gui de-wi re t o pas s down t he brachi ocephal i c rat her t han up t he IJV. The wi re s houl d pas s eas i l y i nt o t he vei n. If t here i s di ffi cul t y, t ry advanci ng duri ng t he i ns pi rat ory and expi rat ory phas es of t he res pi rat ory cycl e. Once t he gui de-wi re i s i n pl ace, remove t he i nt roducer needl e, and pas s t he di l at or over t he wi re. W hen removi ng t he di l at or, not e t he di rect i on t hat i t faces ; i t s houl d be s l i ght l y curved downwards . If i t i s s l i ght l y curved upwards , t hen i t i s l i kel y t hat t he wi re has pas s ed up i nt o t he IJV. The wi re may be mani pul at ed i nt o t he brachi ocephal i c vei n under fl uoros copi c cont rol but i f not avai l abl e i t i s s afer t o remove t he wi re and s t art agai n. P.871
Aft er removi ng t he di l at or pas s t he cent ral venous cat het er over t he gui de-wi re, remove t he gui de-wi re, and s ecure as above. A ches t X-ray i s mandat ory aft er s ubcl avi an l i ne i ns ert i on t o excl ude a pneumot horax and t o confi rm s at i s fact ory pl acement of t he l i ne, es peci al l y i f fl uoros copy was not empl oyed.
P.872
Ultrasound guided central venous catheterization

Tradi t i onal cent ral venous cat het eri zat i on met hods rel y on anat omi cal l andmarks t o predi ct vei n pos i t i on. However, t he rel at i ons hi p bet ween s uch l andmarks and vei n pos i t i on vari es s i gni fi cant l y i n normal i ndi vi dual s . Fai l ure and compl i cat i on
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rat es us i ng l andmark met hods are s i gni fi cant and t herefore s eri ous compl i cat i ons may occur. Recent advances i n port abl e ul t ras ound equi pment have now made i t pos s i bl e t o i ns ert cent ral venous cat het ers under 2D ul t ras ound gui dance. Advant ages of t hi s t echni que i ncl ude:

Ident i fi cat i on of act ual and rel at i ve vei n pos i t i on Ident i fi cat i on of anat omi cal vari at i ons Confi rmat i on of t arget vei n pat ency.
Gui del i nes from t he Nat i onal Ins t i t ut e for Cl i ni cal Excel l ence (Sept ember 2002) s t at e: T w o-di mens i onal i magi ng ul t ras ound gui danc e i s rec ommended as t he preferred met hod for i ns ert i on of c ent ral venous c at het ers i nt o t he i nt er-jugul ar vei n (I JV) i n adul t s and c hi l dren i n el ec t i ve s i t uat i ons . However, t rai ni ng and equi pment avai l abi l i t y render s uch recommendat i ons effect i vel y us el es s i n t he UK at pres ent .
Equipment/personnel needed
St andard Sel di nger-t ype ki t or what ever i s l ocal l y avai l abl e An as s i s t ant i s es s ent i al Ul t ras ound equi pment :
o
Screen: di s pl ays 2D ul t ras ound i mage of anat omi cal s t ruct ures Sheat hs : dedi cat ed, s t eri l e s heat hs of PVC or l at ex l ong enough t o cover probe and connect i ng cabl e (a rubber band s ecures t he s heat h t o t he probe) Probe: t rans ducer whi ch emi t s and recei ves ul t ras ound i nformat i on t o be proces s ed for di s pl ay. Marked wi t h arrow or not ch for ori ent at i on Power: bat t ery or mai ns St eri l e gel : t rans mi t s ul t ras ound and provi des good i nt erface bet ween pat i ent and probe.
o o
Preparation
Perform a prel i mi nary non-s t eri l e s can t o acces s each i nt ernal
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jugul ar vei n for pat ency and s i ze.
Patient
St eri l e precaut i ons s houl d be t aken wi t h pat i ent 's head t urned s l i ght l y away from t he cannul at i on s i t e. Head-down t i l t (i f t ol erat ed) or l eg el evat i on t o i ncreas e fi l l i ng and s i ze of t he i nt ernal jugul ar vei n. Ens ure adequat e drapes t o mai nt ai n a s t eri l e fi el d. Exc es s i ve head rot at i on or ext ens i on may dec reas e t he di amet er of t he vei n .
Ultrasound equipment

Ens ure t hat t he di s pl ay can be s een Sheat h i s opened (operat or) and gel s qui rt ed i n (as s i s t ant )
P.873
A generous amount of gel ens ures good c ont ac t and ai r-free c oupl i ng bet w een probe t i p and s heat h. T oo l i t t l e may c ompromi s e i mage qual i t y .
Probe and connect i ng cabl e are l owered i nt o s heat h (as s i s t ant ) whi ch i s t hen unrol l ed al ong t hem (operat or) Rubber band s ecures s heat h t o probe Sheat h over probe t i p i s s moot hed out (wri nkl es wi l l degrade i mage qual i t y) Appl y l i beral amount s of gel t o t he s heat hed probe t i p for good ul t ras ound t rans mi s s i on and i ncreas ed pat i ent comfort duri ng movement .
Scanning
The mos t popul ar s canni ng ori ent at i on for i nt ernal jugul ar vei n cent ral cat het er pl acement i s t he t rans vers e pl ane:
Appl y probe t i p gent l y t o neck l at eral t o t he carot i d pul s e at t he cri coi d l evel or i n t he s t ernomas t oi d-cl avi cul ar t ri angl e
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Keep probe perpendi cul ar at al l t i mes wi t h t he t i p fl at agai ns t t he s ki n Ori ent probe s o t hat movement t o t he l eft ens ures t hat t he di s pl ay l ooks t o t he l eft (and vi ce vers a). Probes are us ual l y marked t o hel p ori ent at i on. By convent i on t he mark s houl d be t o t he pat i ent 's ri ght (t rans vers e pl ane) or t o t he head (l ongi t udi nal s can). The marked s i de appears on t he s creen as a bri ght dot If t he ves s el s are not i mmedi at el y vi s i bl e, keep t he probe perpendi cul ar and gent l y gl i de medi al l y or l at eral l y unt i l found
When movi ng t he probe w at c h t he s c reen not your hands .
After identification of the internal jugular vein (IJV)
Pos i t i on probe s o t hat IJV i s s hown at t he di s pl ay's hori zont al mi dpoi nt Keep probe i mmobi l e Di rect needl e (bevel t owards probe) caudal l y under t he marked mi dpoi nt of t he probe t i p at approxi mat el y 60 t o t he s ki n The needl e bevel faces t he probe t o hel p di rect t he gui de wi re down t he IJV l at er Advance t he needl e t owards IJV
Needl e pas s age caus es a wavefront of t i s s ue compres s i on. Thi s i s us ed t o judge t he progres s of t he needl e and pos i t i on. Abs ence of vi s i bl e t i s s ue react i on i ndi cat es i ncorrect needl e pl acement . Jus t before ves s el ent ry t ent i ng of t he vei n i s us ual l y obs erved. One of t he mos t di ffi c ul t as pec t s i ni t i al l y, w hen l earni ng t hi s t ec hni que, i s t he s t eep needl e angul at i on requi red, but t hi s ens ures t hat t he needl e ent ers t he I JV i n t he US beam and t akes t he s hort es t and mos t di rec t rout e t hrough t he t i s s ues . Needl e pres s ure may oppos e vei n w al l s res ul t i ng i n vei n t rans fi xi on. Sl ow w i t hdraw al of t he needl e w i t h c ont i nuous as pi rat i on c an hel p res ul t i n l umen ac c es s .
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Pas s t he gui dewi re i nt o t he jugul ar vei n i n t he us ual fas hi on. Re-angl i ng t he needl e from 60 t o a more s hal l ow angl e, e.g. 45, may hel p gui dew i re feedi ng. Sc anni ng t he vei n i n t he l ongi t udi nal pl ane may demons t rat e t he c at het er i n t he ves s el but aft er s ec uri ng and dres s i ng t he CVC, an x-ray s houl d s t i l l be obt ai ned t o c onfi rm t he CVC pos i t i on, and exc l ude pneumot horax . Mai nt ai n s t eri l i t y at al l t i mes , and s ecure t he l i ne s o t hat i t i s comfort abl e for t he pat i ent . P.874
The mos t common error i n meas urement of cent ral venous pres s ure, part i cul arl y i n CVP l i nes whi ch have been i n pl ace for s ome t i me, i s due t o part i al or compl et e l i ne bl ockade. W i t h t he manomet er connect ed, ens ure t hat t he l i ne i s free fl owi ng, mi nor bl ockages can be removed by s queezi ng t he rubber bung, wi t h t he l i ne proxi mal bei ng obl i t erat ed by acut e angul at i on (i e, bend t he t ube proxi mal ). Meas ure t he CVP at t he mi d-axi l l ary l i ne wi t h t he pat i ent s upi ne. CVP fal l s wi t h upri ght or s emi up-ri ght recumbency, regardl es s of t he reference poi nt . If t he CVP i s hi gh, l i ft t he s t and t hat hol ds t he manomet er s o t hat t he apparent CVP fal l s by 10cm or s o, and repl ace t he CVP s t and t o ground l evel . If t he s al i ne or manomet er readi ng ri s es t o t he s ame l evel , t hen t he CVP readi ng i s accurat e. In ot her words , one ens ures t hat t he CVP manomet er l evel bot h fal l s t o and ri s es t o t he s ame l evel . P.875
P.876
Pulmonary artery catheterization 1 Indications

PA cat het ers (SwanGanz cat het ers ) al l ow di rect meas urement of a number of haemodynami c paramet ers t hat ai d cl i ni cal
Pa g e 1 4 0 5
deci s i on-maki ng i n cri t i cal l y i l l pat i ent s (eval uat e ri ght and l eft vent ri cul ar funct i on, gui de t reat ment and provi de prognos t i c i nformat i on). The cat het er i t s el f has no t herapeut i c benefi t and t here have been a number of s t udi es s howi ng i ncreas ed mort al i t y (and morbi di t y) wi t h t hei r us e. Cons i der i ns ert i ng a PA cat het er i n any cri t i cal l y i l l pat i ent , aft er di s cus s i on wi t h an experi enced phys i ci an, i f t he meas urement s wi l l i nfl uence deci s i ons on t herapy (and not jus t t o reas s ure yours el f). Careful and frequent cl i ni cal as s es s ment of t he pat i ent s houl d al ways accompany meas urement s and PA cat heri zat i on s houl d not del ay t reat ment of t he pat i ent . General i ndi cat i ons (not a comprehens i ve l i s t ) i ncl ude:

Management of compl i cat ed myocardi al i nfarct i on. As s es s ment and management of s hock. As s es s ment and management of res pi rat ory di s t res s (cardi ogeni c vs non-cardi ogeni c pul monary oedema). Eval uat i ng effect s of t reat ment i n uns t abl e pat i ent s (e.g. i not ropes , vas odi l at ors , mechani cal vent i l at i on, et c.). Del i veri ng t herapy (e.g. t hrombol ys i s for pul monary embol i s m, pros t acycl i n for pul monary hypert ens i on, et c.). As s es s ment of fl ui d requi rement s i n cri t i cal l y i l l pat i ent s .
Equipment required
Ful l res us ci t at i on faci l i t i es s houl d be avai l abl e and t he pat i ent 's ECG s houl d be cont i nuous l y moni t ored. Bag of hepari ni zed s al i ne for fl us hi ng t he cat het er and t rans ducer s et for pres s ure moni t ori ng. (Check t hat your as s i s t ant i s experi enced i n s et t i ng up t he t rans ducer s ys t em BEFORE you s t art .) 8F i nt roducer ki t (pre-packaged ki t s cont ai n t he i nt roducer s heat h and al l t he equi pment requi red for cent ral venous cannul at i on). PA cat het er: Commonl y a t ri pl e l umen cat het er, t hat al l ows s i mul t aneous meas urement of RA pres s ure
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(proxi mal port ) and PA pres s ure (di s t al port ) and i ncorporat es a t hermi s t or for meas urement of cardi ac out put by t hermodi l ut i on. Check your cat het er before you s t art .
Fl uoros copy i s preferabl e, t hough not es s ent i al .
General technique
Do not at t empt t hi s wi t hout s upervi s i on i f you are i nexperi enced. Obs erve s t ri ct as ept i c t echni que us i ng s t eri l e drapes , et c. Ins ert t he i nt roducer s heat h (at l eas t 8F i n s i ze) i nt o ei t her t he i nt ernal jugul ar or s ubcl avi an vei n i n t he s t andard way (pp868p70). Fl us h t he s heat h wi t h s al i ne and s ecure t o t he s ki n wi t h s ut ures . Do not at t ach t he pl as t i c s t eri l e expandabl e s heat h t o t he i nt roducer yet but keep i t s t eri l e for us e l at er once t he cat het er i s i n pos i t i on (t he cat het er i s eas i er t o mani pul at e wi t hout t he pl as t i c coveri ng). P.877
Fl us h al l t he l umens of t he PA cat het er and at t ach t he di s t al l umen t o t he pres s ure t rans ducer. Check t he t rans ducer i s zeroed (convent i onal l y t o t he mi d-axi l l ary poi nt ). Check t he i nt egri t y of t he bal l oon by i nfl at i ng i t wi t h t he s yri nge provi ded (2ml ai r) and t hen defl at e t he bal l oon. The procedure i s det ai l ed on t he fol l owi ng pages .
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Fi gure. No capt i on avai l abl e. Pul monary art ery cat het eri zat i on
The s heat h and di l at or are advanced i nt o t he vei n over t he gui de-wi re. A t wi s t i ng mot i on makes i ns ert i on eas i er. The gui de-wi re and di l at or are t hen removed. The s heat h has a haemos t at i c val ve at t he end prevent i ng l eakage of bl ood. The PA cat het er i s t hen i ns ert ed t hrough t he i nt roducer s heat h i nt o t he vei n (s ee above).
P.878
Pulmonary artery catheterization 2 Insertion technique
Fl us h al l t he l umens of t he PA cat het er and at t ach t he
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di s t al l umen t o t he pres s ure t rans ducer. Check t he t rans ducer i s zeroed (convent i onal l y t o t he mi d-axi l l ary poi nt ). Check t he i nt egri t y of t he bal l oon by i nfl at i ng i t wi t h t he s yri nge provi ded (~2ml ai r) and t hen defl at e t he bal l oon.
Pas s t he t i p of t he PA cat het er t hrough t he pl as t i c s heat h, keepi ng t he s heat h compres s ed. The cat het er i s eas i er t o mani pul at e wi t hout t he s heat h over i t ; once i n pos i t i on, ext end t he s heat h over t he cat het er t o keep i t s t eri l e. W i t h t he bal l oon defl at ed, advance t he t i p of t he cat het er t o approx. 1015cm from t he ri ght IJV or SCV, 1520cm from t he l eft (t he marki ngs on t he s i de of t he cat het er are at 10cm i nt erval s : 2 l i nes = 20cm). Check t hat t he pres s ure t raci ng i s t ypi cal of t he ri ght at ri al pres s ure (s ee fi gure). Infl at e t he bal l oon and advance t he cat het er gent l y. The fl ow of bl ood wi l l carry t he bal l oon (and cat het er) acros s t he t ri cus pi d val ve, t hrough t he ri ght vent ri cl e and i nt o t he pul monary art ery. W at ch t he ECG t raci ng cl os el y whi l s t t he cat het er i s advanced. The cat het er commonl y t ri ggers runs of VT when cros s i ng t he t ri cus pi d val ve and t hrough t he RV. The VT i s us ual l y s el f-l i mi t i ng, but s houl d not be i gnored. Defl at e t he bal l oon, pul l back, and t ry agai n. If more t han 15cm of cat het er i s advanced i nt o t he RV wi t hout t he t i p ent eri ng t he PA, t hi s s ugges t s t he cat het er i s coi l i ng i n t he RV. Defl at e t he bal l oon, wi t hdraw t he cat het er i nt o t he RA, rei nfl at e t he bal l oon and t ry agai n us i ng cl ockwi s e t orque whi l e advanci ng i n t he vent ri cl e, or fl us hi ng t he cat het er wi t h col d s al i ne t o s t i ffen t he pl as t i c. If t hi s fai l s repeat edl y, t ry under fl uoros copi c gui dance. As t he t i p pas s es i nt o a di s t al branch of t he PA, t he bal l oon wi l l i mpact and not pas s furt her, t he wedge pos i t i on, and t he pres s ure t raci ng wi l l change (s ee
Pa g e 1 4 0 9
fi gure).
Defl at e t he bal l oon and check t hat a t ypi cal PA t raci ng i s obt ai ned. If not , t ry fl us hi ng t he cat het er l umen, and, i f t hat fai l s , wi t hdraw t he cat het er unt i l t he t i p i s wi t hi n t he PA and begi n agai n. Rei nfl at e t he bal l oon s l owl y. If t he PCW pres s ure i s s een before t he bal l oon i s ful l y i nfl at ed, i t s ugges t s t he t i p has mi grat ed furt her i nt o t he art ery. Defl at e t he bal l oon and wi t hdraw t he cat het er 12cm and t ry agai n. If t he pres s ure t raci ng fl at t ens and t hen cont i nues t o ri s e, you have overwedged. Defl at e t he bal l oon, pul l back t he cat het er 12cm, and s t art agai n. W hen a s t abl e pos i t i on has been achi eved, ext end t he pl as t i c s heat h over t he cat het er and s ecure i t t o t he i nt roducer s heat h. Cl ean any bl ood from t he s ki n i ns ert i on s i t e wi t h ant i s ept i c and s ecure a coi l of t he PA cat het er t o t he pat i ent 's ches t t o avoi d i nadvert ent removal . Obt ai n a CXR t o check t he pos i t i on of t he cat het er. The t i p of t he cat het er s houl d i deal l y be no more t han 35cm from t he mi d-l i ne.
Pres s ure t raci ngs duri ng pul monary art ery cat het eri zat i on P.879
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Normal values of right heart pressures and flows

Ri g 0 ht 8 at ri mm al pre ssu re Ri g ht ven t ri c le s 15 ys t ol i c 30 mm Hg e 0 nd 8 di a mm s t o Hg lic Pul mo nar y art ery s 15 ys t ol i c 30/ /di 4 Hg
Pa g e 1 4 1 1
as t 1 ol i c 2m mH g 9 me 1 an 6m mH g Pul 2 mo 1 nar 0m y illa ry we dg e pr. Car 2.8 di a c 4.2 i nd L/ ex mi n/ m ) (s ee p280 for haemo dynami c formul ae) P.880
2
mH
cap g
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Pulmonary artery catheterization 3 Tips and pitfalls

Never wi t hdraw t he cat het er wi t h t he bal l oon i nfl at ed. Never advance t he cat het er wi t h t he bal l oon defl at ed. Never i nject l i qui d i nt o t he bal l oon. Never l eave t he cat het er wi t h t he bal l oon i nfl at ed as pul monary i nfarct i on may occur. The pl as t i c of t he cat het er s oft ens wi t h t i me at body t emperat ure and t he t i p of t he cat het er may mi grat e furt her i nt o t he PA branch. If t he pres s ure t raci ng wi t h t he bal l oon defl at ed i s part i al l y wedged (and fl us hi ng t he cat het er does not i mprove t hi s ), wi t hdraw t he cat het er 12cm and repos i t i on. Somet i mes i t i s i mpos s i bl e t o obt ai n a wedged t race. In t hi s s i t uat i on one has t o us e t he PA di as t ol i c pres s ure as a gui de. In heal t h t here i s ~24mmHg di fference bet ween PA di as t ol i c pres s ure and PCW P. Any condi t i on whi ch caus es pul monary hypert ens i on (e.g. s evere l ung di s eas e, ARDS, l ong-s t andi ng val vul ar di s eas e) wi l l al t er t hi s rel at i ons hi p. Val vul ar l es i ons , VSDs , pros t het i c val ves , and pac emakers : If t hes e are pres ent t hen s eek advi ce from a cardi ol ogi s t . The ri s k of SBE may be s uffi ci ent l y great t hat t he pl acement of a PA cat het er may be more det ri ment al t han benefi ci al . PEEP (s ee p910). Meas urement and i nt erpret at i on i f PCW P i n pat i ent s on PEEP depends on t he pos i t i on of t he cat het er. Ens ure t he cat het er i s bel ow t he l evel of t he l eft at ri um on a l at eral CXR. Removi ng PEEP duri ng meas urement caus es marked fl uct uat i ons i n haemodynami cs and oxygenat i on and t he pres s ures do not refl ect t he s t at e once back on t he vent i l at or.
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Complications
Arrhyt hmi as : W at ch t he ECG t raci ng cl os el y whi l s t t he cat het er i s advanced. The cat het er commonl y t ri ggers runs of VT when cros s i ng t he t ri cus pi d val ve and t hrough t he RV. If t hi s happens , defl at e t he bal l oon, pul l back, and t ry agai n. The VT i s us ual l y s el f-l i mi t i ng, but s houl d not be i gnored. Pul monary art ery rupt ure : (~0.2% i n one s eri es ). Damage may occur i f t he bal l oon i s overi nfl at ed i n a s mal l branch. Ri s k fact ors i ncl ude mi t ral val ve di s eas e (l arge v wave confus ed wi t h poor wedgi ng), pul monary hypert ens i on, mul t i pl e i nfl at i ons , or hyperi nfl at i ons of bal l oon. Haemopt ys i s i s an earl y s i gn. It i s s afer t o fol l ow PA di as t ol i c pres s ures i f t hes e correl at e wi t h t he PCW P. Pul monary i nfarct i on. Knot s : Us ual l y occur at t he t i me of i ni t i al pl acement i n pat i ent s where t here has been di ffi cul t y i n t ravers i ng t he RV. Si gns i ncl ude l os s of pres s ure t raci ng, pers i s t ent ect opy, res i s t ance t o cat het er mani pul at i on. If t hi s i s s us pect ed or has occurred, s t op mani pul at i on and s eek expert hel p. I nfec t i on : Ri s ks i ncreas e wi t h l engt h of t i me t he cat het er i s l eft i n s i t u . Pres s ure t rans ducer may occas i onal l y be a s ource of i nfect i on. Remove t he cat het er and i nt roducer and repl ace onl y i f neces s ary. Ot her c ompl i c at i ons : Compl i cat i ons as s oci at ed wi t h cent ral l i ne i ns ert i on, t hrombos i s and embol i s m, bal l oon rupt ure, i nt racardi ac damage.
P.881
P.882
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Indications for temporary pacing 1 Following acute myocardial infarction

As ys t ol e Sympt omat i c compl et e heart bl ock (CHB) (any t erri t ory) Sympt omat i c 2 heart bl ock (any t erri t ory)
o
Tri f as c i cul ar bl o ck
al t er nat i ng LBB B and RBB B
1 hear t bl oc k + RBB B + LAD
new RBB B and l eft pos t eri or hemi
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bl oc k
o
LBB B and l ong PR i nt er val
Aft er ant eri or MI
as y mpt oma tic CHB
as y mpt oma tic 2 (Mob itz II) bl oc k
Sympt omat i c s i nus bradycardi a unres pons i ve t o at ropi ne Recurrent VT for at ri al or vent ri cul ar overdri ve paci ng
2 Unrelated to myocardial infarction
Sympt omat i c s i nus or junct i onal bradycardi a
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unres pons i ve t o at ropi ne (e.g. carot i d s i nus hypers ens i t i vi t y)

Sympt omat i c 2 heart bl ock or s i nus arres t Sympt omat i c compl et e heart bl ock Tors ades de poi nt es t achycardi a Recurrent VT for at ri al or vent ri cul ar overdri ve paci ng Bradycardi a-dependent t achycardi a Drug overdos e (e.g. verapami l , bet a-bl ockers , di goxi n) Permanent pacemaker box change i n a pat i ent who i s paci ng dependent
3 Before general anaesthesia

The s ame pri nci pl es as for acut e MI (s ee above) Si noat ri al di s eas e, 2 (W enckebach) heart bl ock onl y need prophyl act i c paci ng i f t here are s ympt oms of s yncope or pre-s yncope Compl et e heart bl ock
Transvenous temporary pacing
The t echni que of t emporary wi re i ns ert i on i s des cri bed on p884. The mos t commonl y us ed paci ng mode and t he mode of choi ce for l i fe-t hreat eni ng bradyarrhyt hmi as i s vent ri cul ar demand paci ng (VVI) wi t h a s i ngl e bi pol ar wi re pos i t i oned i n t he ri ght vent ri cl e: (s ee p886 for an expl anat i on of common paci ng modes ). In cri t i cal l y i l l pat i ent s wi t h i mpai red cardi ac pump funct i on and s ympt omat i c bradycardi a (es peci al l y wi t h ri ght vent ri cul ar i nfarct i on), cardi ac out put may be i ncreas ed by up t o 20% by mai nt ai ni ng at ri ovent ri cul ar s ynchrony. Thi s requi res t wo paci ng l eads , one at ri al and one vent ri cul ar, and a dual paci ng box.
Epicardial temporary pacing
Fol l owi ng cardi ac s urgery, pat i ent s may have epi c ardi al w i res (at t ached t o t he peri cardi al s urface of t he heart ) l eft i n for up t o 1 week i n cas e of pos t operat i ve heart
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bl ock or bradyarrhyt hmi a. Thes e may be us ed i n t he s ame way as t he more fami l i ar t rans -venous paci ng wi res , but t he t hres hol d may be hi gher. P.883
Atrio-ventricular sequential pacing

In cri t i cal l y i l l pat i ent s wi t h i mpai red cardi ac pump funct i on and s ympt omat i c bradycardi a (es peci al l y wi t h ri ght vent ri cul ar i nfarct i on), cardi ac out put may be i ncreas ed by up t o 20% by mai nt ai ni ng at ri o-vent ri cul ar s ynchrony. Thi s requi res t wo paci ng l eads , one at ri al and one vent ri cul ar, and a dual paci ng box.
Patients most likely to benefit from AV sequential pacing

Acut e MI (es peci al l y RV i nfarct i on) St i ff l eft vent ri cl e: (aort i c s t enos i s , HCM, hypert ens i ve heart di s eas e, amyl oi dos i s ) Low cardi ac out put s t at es (cardi omyopat hy) Recurrent at ri al arrhyt hmi as .
P.884
Temporary cardiac pacing 1 Ventricular pacing
Cannul at e a c ent ral vei n : The wi re i s eas i es t t o mani pul at e vi a t he RIJ approach but i s more comfort abl e for t he pat i ent vi a t he ri ght s ubcl avi an (SC) vei n. The LIJ approach i s bes t avoi ded as t here are many acut e bends t o negot i at e and a s t abl e pos i t i on i s di ffi cul t t o achi eve. Avoi d t he l eft s ubcl avi cul ar area as t hi s i s t he preferred area for permanent pacemaker i ns ert i on and s houl d be kept vi rgi n i f pos s i bl e. The femoral vei n may be us ed
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but t he i nci dence of DVT and i nfect i on i s hi gh.
I ns ert a s heat h (s i mi l ar t o t hat for PA cat het eri zat i on) t hrough whi ch t he paci ng wi re can be fed. Paci ng wi res are commonl y 5F or 6F and a s heat h at l eas t one s i ze l arger i s neces s ary. Mos t commerci al l y avai l abl e paci ng wi res are pre-packed wi t h an i nt roducer needl e and pl as t i c cannul a s i mi l ar t o an Abbocat h whi ch may be us ed t o pos i t i on t he paci ng wi re. However, t he cannul a does not have a haemos t at i c s eal . The pl as t i c cannul a may be removed from t he vei n, l eavi ng t he bare wi re ent eri ng t he s ki n, once a s t abl e pos i t i on has been achi eved. Thi s reduces t he ri s k of wi re di s pl acement but al s o makes repos i t i oni ng of t he wi re more di ffi cul t s houl d t hi s be neces s ary, and t he i nfect i on ri s k i s hi gher. Pas s t he wi re t hrough t he s t eri l e pl as t i c cover t hat accompani es t he i nt roducer s heat h and advance i nt o t he upper ri ght at ri um (s ee fi gure p886) but do not unfurl t he cover yet . The wi re i s much eas i er t o mani pul at e wi t h gl oved hands wi t hout t he addi t i onal hi ndrance of t he pl as t i c cover. Advance t he wi re wi t h t he t i p poi nt i ng t owards t he ri ght vent ri cl e; i t may cros s t he t ri cus pi d val ve eas i l y. If i t fai l s t o cros s , poi nt t he t i p t o t he l at eral wal l of t he at ri um and form a l oop. Rot at e t he wi re and t he l oop s houl d fal l acros s t he t ri cus pi d val ve i nt o t he vent ri cl e. Advance and rot at e t he wi re s o t hat t he t i p poi nt s i nferi orl y as cl os e t o t he t i p of t he ri ght vent ri cl e (l at eral l y) as pos s i bl e. If t he wi re does not rot at e down t o t he apex eas i l y, i t may be becaus e you are i n t he coronary s i nus rat her t han i n t he ri ght vent ri cl e. (The t i p of t he wi re poi nt s t o t he l eft s houl der.) W i t hdraw t he wi re and re-cros s t he t ri cus pi d val ve. Leave s ome s l ack i n t he wi re; t he fi nal appearance
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s houl d be l i ke t he out l i ne of a s ock wi t h t he heel i n t he ri ght at ri um, t he arch over t he t ri cus pi d and t he bi g t oe at t he t i p of t he ri ght vent ri cl e.
Connect t he wi re t o t he paci ng box and check t he t hres hol d. Vent ri cul ar paci ng t hres hol ds s houl d be <1.0 vol t s , but t hres hol d up t o 1.5V i s accept abl e i f anot her s t abl e pos i t i on canot be achi eved. Check for pos i t i onal s t abi l i t y. W i t h t he box paci ng at a rat e hi gher t han t he i nt ri ns i c heart rat e, as k t he pat i ent t o t ake s ome deep breat hs , cough forceful l y, and s ni ff. W at ch for fai l ure of capt ure, and i f s o repos i t i on t he wi re. Set t he out put t o 3 vol t s and t he box on demand. If t he pat i ent i s i n s i nus rhyt hm and has an adequat e bl ood pres s ure s et t he box rat e t o jus t bel ow t he pat i ent 's rat e. If t here i s compl et e heart bl ock or bradycardi a s et t he rat e at 7080/mi n. P.885
Cover t he wi re wi t h t he pl as t i c s heat h and s ut ure s heat h and wi re s ecurel y t o t he s ki n. Loop t he res t of t he wi re and fi x t o t he pat i ent 's s ki n wi t h adhes i ve dres s i ng. W hen t he pat i ent ret urns t o t he ward, obt ai n a CXR t o confi rm s at i s fact ory pos i t i oni ng of t he wi re and t o excl ude a pneumot horax.
Complications of temporary pacing

Compl i cat i ons as s oci at ed wi t h cent ral l i ne i ns ert i on Vent ri cul ar ect opi cs Non-s us t ai ned VT Perforat i on Peri cardi t i s Di aphragmat i c paci ng
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Infect i on Pneumot horax Cardi ac Tamponade
P.886
Temporary cardiac pacing 2 Atrial pacing
The t echni que of i ns ert i ng an at ri al t emporary wi re i s s i mi l ar t o t hat of vent ri cul ar paci ng. Advance t he at ri al wi re unt i l t he J i s re-formed i n t he ri ght at ri um. Rot at e t he wi re and wi t hdraw s l i ght l y t o pos i t i on t he t i p i n t he ri ght at ri al appendage. Ai m for a t hres hol d of <1.5 vol t s . If at ri al wi res are not avai l abl e, a vent ri cul ar paci ng wi re may be mani pul at ed i nt o a s i mi l ar pos i t i on or pas s ed i nt o t he coronary s i nus for l eft at ri al paci ng.
Pos i t i oni ng an art i al wi re for art i al paci ng P.887
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P.888
Temporary cardiac pacing 3 Complications

(s ee t abl e)
1 Ventricular ectopics or VT
Non-s us t ai ned VT i s common as t he wi re cros s es t he t ri cus pi d val ve (es peci al l y i n pat i ent s recei vi ng an i s oprenal i ne i nfus i on) and does not requi re t reat ment . Try t o avoi d l ong runs of VT and i f neces s ary wi t hdraw t he wi re i nt o t he at ri um and wai t unt i l t he rhyt hm has s et t l ed. If ect opi cs pers i s t aft er t he wi re i s pos i t i oned, t ry adjus t i ng t he amount of s l ack i n t he wi re i n t he regi on of t he t ri cus pi d val ve (ei t her more or l es s ). Paci ng t he ri ght vent ri cul ar out fl ow t ract can provoke runs of VT.
2 Failure to pace and/or sense
It i s di ffi cul t t o get l ow paci ng t hres hol ds (<1.0V) i n pat i ent s wi t h ext ens i ve myocardi al i nfarct i on (es peci al l y of t he i nferi or wal l ), cardi omyopat hy, or who have recei ved cl as s I ant i -arrhyt hmi c drugs . Accept a s l i ght l y hi gher val ue i f t he pos i t i on i s ot herwi s e s t abl e and s at i s fact ory. If t he pos i t i on of t he wi re appears s at i s fact ory and yet t he paci ng t hres hol ds are hi gh, t he wi re may be i n a l eft hepat i c vei n. Pul l t he wi re back i nt o t he at ri um and t ry agai n, l ooki ng s peci fi cal l y for t he vent ri cul ar ect opi cs as t he wi re cros s es t he t ri cus pi d val ve. The paci ng t hres hol d commonl y doubl es i n t he fi rs t few days due t o endocardi al oedema.
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If t he pacemaker s uddenl y fai l s , t he mos t common reas on i s us ual l y wi re di s pl acement .

o o
Increas e t he paci ng out put of t he box. Check al l t he connect i ons of t he wi re and t he bat t ery of t he box. Try movi ng t he pat i ent t o t he l eft l at eral pos i t i on unt i l arrangement s can be made t o repos i t i on t he wi re.
3 Perforation
A peri cardi al rub may be pres ent i n t he abs ence of perforat i on (es peci al l y pos t MI). Pres ent at i on : Peri cardi al ches t pai n, i ncreas i ng breat hl es s nes s , fal l i ng bl ood pres s ure, enl arged cardi ac s i l houet t e on CXR, s i gns of cardi ac t amponade, l eft di aphragmat i c paci ng at l ow out put . Management
o
If t here are s i gns of cardi ac t amponade arrange for urgent ECHO and peri cardi al drai nage (p890). Repos i t i on t he wi re. Moni t or t he pat i ent careful l y over t he next few days wi t h repeat ECHOs t o det ect i nci pi ent cardi ac t amponade.
o o
4 Diaphragmatic pacing
Hi gh out put paci ng (10V), even wi t h s at i s fact ory pos i t i on of t he vent ri cul ar l ead may caus e paci ng of t he l eft hemi di aphragm. At l ow vol t ages t hi s s ugges t s perforat i on (s ee above). P.889
Ri ght hemi di aphragm paci ng may be s een wi t h at ri al paci ng and s t i mul at i on of t he ri ght phreni c nerve. Repos i t i on t he wi re i f s ympt omat i c (pai nful t wi t chi ng, dys pnoea).
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Checklist for pacing wire insertion
Check t he s creeni ng equi pment and defi bri l l at or are worki ng. Check t he t ype of paci ng wi re: at ri al wi res have a pre-formed J t hat al l ows eas y pl acement i n t he at ri um or appendage and i s very di ffi cul t t o mani pul at e i nt o a s at i s fact ory pos i t i on i n t he vent ri cl e. Vent ri cul ar paci ng wi res have a more open, gent l e J. Check t he paci ng box (s i ngl e vs dual or s equent i al paci ng box) and l eads t o at t ach t o t he wi re(s ). Fami l i ari ze yours el f wi t h t he cont rol s on t he box: you may need t o connect up i n a hurry i f t he pat i ent 's i nt ri ns i c rhyt hm s l ows furt her. Remember t o don t he l ead apron before weari ng t he s t eri l e gown, mas k, and gl oves .
Ins ert i on of a vent ri cul ar paci ng wi re (s ee t ext for det ai l s )
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P.890
Pericardial aspiration 1 Equipment

Es t abl i s h peri pheral venous acces s and check t hat ful l faci l i t i es for res us ci t at i on are avai l abl e. Pre-prepared peri cardi ocent es i s s et s may be avai l abl e. Y ou wi l l need:
Trol l ey as for cent ral l i ne i ns ert i on, wi t h i odi ne or chl orhexi di ne for s ki n, dres s i ng pack, s t eri l e drapes , l ocal anaes t het i c (l i gnocai ne 2%), s yri nges (i ncl udi ng a 50ml ), needl es (25G and 22G), No. 11 bl ade, and s i l k s ut ures Peri cardi ocent es i s needl e (15cm, 18G) or s i mi l ar W al l ace cannul a J-gui de wi re (80cm, 0.035 di amet er) Di l at ors (up t o 7 French) Pi gt ai l cat het er (60cm wi t h mul t i pl e s i dehol es , a l arge Sel di nger-t ype CVP l i ne can be us ed i f no pi gt ai l i s avai l abl e) Drai nage bag and connect ors Faci l i t i es for fl uoros copy or echocardi ographi c s creeni ng.
Technique
Pos i t i on t he pat i ent at ~30. Thi s al l ows t he effus i on t o pool i nferi orl y wi t hi n t he peri cardi um. Sedat e t he pat i ent l i ght l y wi t h mi dazol am (2.57.5mg i v) and fent anyl (50200g i v) i f neces s ary. Us e wi t h caut i on as t hi s may drop t he bp i n pat i ent s al ready compromi s ed by t he effus i on. W eari ng a s t eri l e gown and gl oves , cl ean t he s ki n from mi d-ches t t o mi d-abdomen and put t he s t eri l e drapes on t he pat i ent . Infi l t rat e t he s ki n and s ub-cut aneous t i s s ues wi t h l ocal
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anaes t het i c s t art i ng 11.5cm bel ow t he xi phi s t ernum and jus t t o t he l eft of mi d-l i ne, ai mi ng for t he l eft s houl der and s t ayi ng as cl os e t o t he i nferi or border of t he ri b cart i l ages as pos s i bl e.
The peri cardi ocent es i s needl e i s i nt roduced i nt o t he angl e bet ween t he xi phi s t ernum and t he l eft cos t al margi n angl ed at ~30. Advance s l owl y as pi rat i ng gent l y and t hen i nject i ng more l i gnocai ne every few mm, ai mi ng for t he l eft s houl der. As t he pari et al peri cardi um i s pi erced, you may feel a gi ve and fl ui d wi l l be as pi rat ed. Remove t he s yri nge and i nt roduce t he gui de-wi re t hrough t he needl e. Check t he pos i t i on of t he gui de-wi re by s creeni ng. It s houl d l oop wi t hi n t he cardi ac s i l houet t e onl y and not advance i nt o t he SVC or pul monary art ery. Remove t he needl e l eavi ng t he wi re i n pl ace. Enl arge t he s ki n i nci s i on s l i ght l y us i ng t he bl ade and di l at e t he t rack. Ins ert t he pi gt ai l over t he wi re i nt o t he peri cardi al s pace and remove t he wi re. Take s peci mens for mi cros copy, cul t ure (and i nocul at e a s ampl e i nt o bl ood cul t ure bot t l es ), cyt ol ogy and haemat ocri t i f bl ood s t ai ned (a FBC t ube; as k t he haemat ol ogi s t s t o run on t he Coul t er count er for rapi d es t i mat i on of Hb). As pi rat e t o drynes s wat chi ng t he pat i ent careful l y. Sympt oms and haemodynami cs (t achycardi a) oft en s t art t o i mprove wi t h removal of as l i t t l e as 100ml of peri cardi al fl ui d. P.891
If t he fl ui d i s heavi l y bl ood s t ai ned, wi t hdraw fl ui d caut i ous l y; i f t he pi gt ai l i s i n t he ri ght vent ri cl e, wi t hdrawal of bl ood may caus e cardi ovas cul ar col l aps e.
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Arrange for urgent Hb/haemat ocri t .
Leave on free drai nage and at t ached t o t he drai nage bag. Sut ure t he pi gt ai l t o t he s ki n s ecurel y and cover wi t h a s t eri l e occl us i ve dres s i ng.
Peri cardi al as pi rat i on P.892
Pericardial aspiration 2 Aftercare
Cl os el y obs erve t he pat i ent for recurrent t amponade (obs t ruct i on of drai n) and repeat ECHO. Di s cont i nue ant i -coagul ant s . Remove t he drai n aft er 24 hours or when t he drai nage s t ops . Cons i der t he need for s urgery (drai nage, bi ops y or peri cardi al wi ndow) or s peci fi c t herapy (chemot herapy i f mal i gnant effus i on, ant i mi crobi al s i f bact eri al , di al ys i s i f renal fai l ure, et c.).
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Tips and pitfalls
If t he needl e t ouc hes t he heart 's epi c ardi al s urfac e , you may feel a t i cki ng s ens at i on t rans mi t t ed down t he needl e: wi t hdraw t he needl e a few mm, angul at e t he needl e more s uperfi ci al l y and t ry caut i ous l y agai n, as pi rat i ng as you advance. I f you do not ent er t he effus i on , and t he heart not encount ered:
o
W i t hdraw t he needl e s l i ght l y and advance agai n, ai mi ng s l i ght l y deeper, but s t i l l t owards t he l eft s houl der. If t hi s fai l s , t ry agai n ai mi ng more medi al l y (mi dcl avi cul ar poi nt or even s upras t ernal not ch). Cons i der t ryi ng t he api cal approach (s t art i ng l at eral l y at cardi ac apex and ai mi ng for ri ght s houl der), i f echo confi rms s uffi ci ent fl ui d at t he cardi ac apex.
If avai l abl e, i nt rat horac i c ECG can be moni t ored by a l ead at t ached t o t he needl e as i t i s advanced. Thi s i s s el dom cl i ni cal l y us eful i n our experi ence. Penet rat i on of t he myocardi um res ul t s i n ST el evat i on, s ugges t i ng t he needl e has been advanced t o far. Di ffi c ul t y i n i ns ert i ng t he pi gt ai l
o
Thi s may be becaus e of i ns uffi ci ent di l at at i on of t he t ract (us e a l arger di l at or). Hol di ng t he wi re t aught (by gent l e t ract i on) whi l e pus hi ng t he cat het er may hel p; t ake care not t o pul l t he wi re out of t he peri cardi um.
Haemorrhagi c effus i on vs bl ood

o
Compare t he Hb of t he peri cardi al fl ui d t o t he venous bl ood Hb. Pl ace s ome of t he fl ui d i n a cl ean cont ai ner; bl ood wi l l cl ot whereas haemorrhagi c effus i on wi l l not as t he whi ppi ng act i on of t he heart t ends t o defi bri nat e i t .
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Confi rm t he pos i t i on of t he needl e by fi rs t wi t hdrawi ng s ome fl ui d and t hen i nject i ng 1020ml of cont ras t ; us i ng fl uoros copy, s ee i f t he cont ras t s t ays wi t hi n t he cardi ac s i l l houet t e. Al t ernat i vel y, i f us i ng ECHO gui dance, i nject 510ml s al i ne i nt o t he needl e l ooki ng for mi crobubbl e cont ras t i n t he cavi t y cont ai ni ng t he needl e t i p. Inject i ng 20ml s al i ne rapi dl y i nt o a peri pheral vei n wi l l produce cont ras t i n t he ri ght at ri um and vent ri cl e and may al l ow t hem t o be di s t i ngui s ed from t he peri cardi al s pace. Connect a pres s ure l i ne t o t he needl e; a charact eri s t i c waveform wi l l confi rm penet rat i on of t he ri ght vent ri cl e (s ee fi gure p879).
P.893
Complications of pericardiocentesis
Penet rat i on of a cardi ac chamber (us ual l y ri ght vent ri cl e) Lacerat i on of an epi cardi al ves s el Arrhyt hmi a (at ri al arrhyt hmi as as t he wi re i s advanced, vent ri cul ar arrhyt hmi as i f t he RV i s penet rat ed) Pneumot horax Perforat i on of abdomi nal vi s cus (l i ver, s t omach, col on) As cendi ng i nfect i on
P.894
DC cardioversion 1 Relative contraindications

Di goxi n t oxi ci t y El ect rol yt e di s t urbance (Na , K , Ca , Mg

+ + 2+ 2+
Pa g e 1 4 2 9
, aci dos i s )
Inadequat e ant i -coagul at i on and chroni c AF
Check list for DC cardioversion

Ch eck Def t hi i bri s l l at i s or fun ct i oni ng wi t h a ful l y eq ui p pe d arr es t t rol l ey to ha nd in cas e of arr es t
Pa g e 1 4 3 0
(Un l es Inf s or l i fe me -t h d rea con t en s en i ng t em erg enc y.) AF, fl ut 12 t er l ea , d G SV VT, sig ns of isc ha em ia or di g oxi n. If ven t ri c ul a r EC T,
Pa g e 1 4 3 1
rat e is slo w hav e an ext ern al (t r ans cut an eo us ) pac i ng s ys te m ne arb y in cas e of as y sto le For at Ni l l ea
Pa g e 1 4 3 2
by s t mo 4 ut h ho urs Do es Ant t he i -c pat oa i en gul t at i req on ui r e ant i -c oa gul ant s? Is t he IN R >2. 0 ? (Ha s it be en so for >3 wk s ?)
Pa g e 1 4 3 3
Pot Ch as s eck iu m t hi s is >3. 5m mo l /L Di g Ch oxi eck n t he re are no fea t ur es of di g oxi n t ox i ci t y (s e e p8 08) . If t ak i ng >2 50
Pa g e 1 4 3 4
g/d ay che ck t ha t ren al fun ct i on an d rec ent di g oxi n l ev el are nor ma l. If t he re are fre qu ent ven t ri c ul a
Pa g e 1 4 3 5
r ect opi cs , gi v e iv Mg
2+
8m mo l Tre at Thy t hy roi rot d oxi fun cos ct i i s on or my xoe de ma fi rs t Per iv i ph era
acc l es s ven ous can nul a
Pa g e 1 4 3 6
Sh ort Se ge dat ner i on al an aes t he sia (pr op ofo l) is pre fer abl e to s ed at i on wi t h be nz o di a z ep i ne an d fen t an yl .
Pa g e 1 4 3 7
Ba g t he pat i en t wi t h 10 0% oxy ge n (Se e Sel t ab ect l e.) en erg y Ch eck Syn t hi chr s oni i s z at s el i on ect ed on t he def i bri l l at or for
Pa g e 1 4 3 8
al l s ho cks (un l es s t he pat i en t is in VF or ha em o-d yna mi c al l y uns t ab l e). Adj us t t he EC G gai n so t ha t t he
Pa g e 1 4 3 9
ma chi ne is onl y s en sin g QR S co mp l ex es an d not P or T wa ves Co nd Pa uct ddl i ve e gel pl a pa ce ds me s ho nt ul d be pl a ced
Pa g e 1 4 4 0
bet we en t he pa ddl es an d t he s ki n. Pos itio n on e jus t to t he ri g ht of t he ste rnu m an d t he ot h er to
Pa g e 1 4 4 1
t he l eft of t he l eft ni p pl e (an t .mi d-a xi l l ary lin e), Al t ern at i vel y, pl a ce on e ant eri orl y jus t l eft of t he ste
Pa g e 1 4 4 2
rnu m, an d on e pos t eri orl y to t he l eft of mi d-l i ne. Th ere is no con vi n ci n g evi de nce for s up eri ori t y of
Pa g e 1 4 4 3
on e pos itio n ove r t he ot h er Ch eck Car no di o on ver e sio is n in con t ac t wi t h t he pat i en t or wi t h t he me t al be d. Ens
Pa g e 1 4 4 4
ure you r ow n l eg s are cl e ar of t he be d! Ap pl y fi r m pre ssu re on t he pa ddl es Do ubl Un e s uc t he ces en s fu erg l y l ev el
Pa g e 1 4 4 5
an d rep eat up to 36 0J. Co ns i der cha ngi ng pa ddl e pos itio n (s e e ab ove ). If pro l on ge d sin us pa us e
Pa g e 1 4 4 6
or ven t ri c ul a r arr hyt hm ia dur i ng an el e ct i ve pro ced ure , sto p Re pe Suc at ces EC s fu G. l Pl a ce in rec ove ry pos itio n
Pa g e 1 4 4 7
unt il aw ake . Mo ni t or for 2 4 h an d ens ure eff ect s of s ed at i on hav e pas s ed . Pat i en ts s ho ul d be
Pa g e 1 4 4 8
acc om pa ni e d ho me by fri e nd or rel at i ve if bei ng di s cha rge d P.895
Complications of DC cardioversion

As ys t ol e/bradycardi as Vent ri cul ar fi bri l l at i on Thromboembol i s m Trans i ent hypot ens i on Ski n burns As pi rat i on pneumoni t i s
Suggested initial energies for DC shock for elective cardioversion
Pa g e 1 4 4 9
2 Sy 0 nc 0J hr S us ta in e d V T 5 Sy 0 nc hr At o ri 1 ni al 0 z e fi 0J d br ill at io n 5 Sy 0J nc At ri al fl ut te r 5 Sy 0J nc hr o ni ze d o ni ze d
Pa g e 1 4 5 0
O th er S V
hr o ni ze d
Ts If t he i ni t i al s hock is uns ucc es s ful , i ncreas e t he energy (50, 100, 200,36 0J) and repeat . If still uns ucc es s ful cons i d er changi ng paddl e pos i t i o n and
Pa g e 1 4 5 1
t ry 360 Joul es agai n. It i s i nappr opri at e to pers i s t furt her wi t h el ect i v e DC cardi ov ers i on P.896
DC cardioversion 2 Notes
1 Anti-coagulation
The ri s k of t hromboembol i s m i n pat i ent s wi t h chroni c AF and di l at ed cardi omyopat hy i s 07% dependi ng on t he underl yi ng ri s k fact ors . Increased risk

Pri or embol i c event Mechani cal heart val ve Mi t ral s t enos i s Di l at ed l eft at ri um Age <60 years No underl yi ng heart di s eas e Recent ons et AF (<3 days )
Low risk

Ant i -coagul at e pat i ent s at ri s k wi t h warfari n for at l eas t 34 weeks . For recent ons et AF (13 days ), ant i -coagul at e wi t h i v
Pa g e 1 4 5 2
hepari n for at l eas t 1224 hours and, i f pos s i bl e, excl ude i nt racardi ac t hrombus wi t h a t rans oes ophageal ECHO pri or t o DC s hock. If t here i s t hrombus , ant i -coagul at e wi t h warfari n as above. For emergency cardi overs i on of AF (<24h), hepari ni ze pri or t o s hock. The ri s k of s ys t emi c embol i s m wi t h cardi overs i on of at ri al fl ut t er and ot her t achyarrhyt hmi as i s very l ow, provi ded t here i s no vent ri cul ar t hrombus , s i nce t he co-ordi nat ed at ri al act i vi t y prevent s format i on of cl ot . Rout i ne ant i -coagul at i on wi t h warfari n i s not neces s ary but we woul d recommend hepari n before DC s hock as t he at ri a are oft en rendered mechani cal l y s t at i onary for s everal hours aft er s hock even t hough t here i s co-ordi nat e el ect ri cal depol ari z at i on. Aft er s ucces s ful cardi overs i on, i f t he pat i ent i s on warfari n, cont i nue ant i -coagul at i on for at l eas t 34 weeks . Cons i der i ndefi ni t e ant i -coagul at i on i f t here i s i nt ri ns i c cardi ac di s eas e (e.g. mi t ral s t enos i s ) or recurrent AF.
2 Special situations
Pregnanc y DC s hock duri ng pregnancy appears t o be s afe. Aus cul t at e t he fet al heart before and aft er cardi overs i on and i f pos s i bl e, fet al ECG s houl d be moni t ored. Pac emakers There i s a danger of damage t o t he pacemaker generat or box or t he junct i on at t he t i p of t he paci ng wi re(s ) and endocardi um. Pos i t i on t he paddl es i n t he ant eropos t eri or pos i t i on as t hi s i s t heoret i cal l y s afer. Faci l i t i es for back-up paci ng (ext ernal or t rans venous ) s houl d be avai l abl e. Check t he pacemaker pos t cardi overs i onbot h earl y and l at e probl ems have been report ed. P.897
P.898
Intra-aortic balloon counterpulsation 1
Pa g e 1 4 5 3
Indications

Cardi ogeni c s hock pos t MI Acut e s evere mi t ral regurgi t at i on Acut e vent ri cul ar s ept al defect Pre-operat i ve (os t i al l eft coronary s t enos i s ) W eani ng from cardi opul monary bypas s Treat ment of vent ri cul ar arrhyt hmi as pos t MI Uns t abl e angi na (as a bri dge t o CABG)
Rarely

Contraindications

Aort i c regurgi t at i on Aort i c di s s ect i on Severe aort o-i l i ac at heroma Bl eedi ng di at hes i s Di l at ed cardi omyopat hy (i f pat i ent not a candi dat e for t rans pl ant at i on)
Complications

Aort i c di s s ect i on Art eri al perforat i on Li mb i s chaemi a Thrombocyt openi a Peri pheral embol i s m Bal l oon rupt ure
Principle
The devi ce cons i s t s of a cat het er wi t h a bal l oon (40ml s i ze) at i t s t i p whi ch i s pos i t i oned i n t he des cendi ng t horaci c aort a. The bal l oon i nfl at i on/defl at i on i s s ynchroni zed t o t he ECG. The bal l oon s houl d i nfl at e jus t aft er t he di crot i c not ch (i n di as t ol e), t hereby i ncreas i ng pres s ure i n t he aort i c root and i ncreas i ng coronary perfus i on. The bal l oon defl at es jus t before vent ri cul ar s ys t ol e, t hereby decreas i ng aft erl oad and i mprovi ng l eft vent ri cul ar performance (s ee bel ow).
Pa g e 1 4 5 4
Count erpul s at i on has a number of benefi ci al effect s on t he ci rcul at i on.

Increas ed i n coronary perfus i on i n di as t ol e. Reduced LV end di as t ol i c pres s ure. Reduced myocardi al oxygen cons umpt i on. Increas ed cerebral and peri pheral bl ood fl ow.
2
The IAB cannot as s i s t t he pat i ent i n as ys t ol e or VF; i t requi res a mi ni mum cardi ac i ndex of 1.21.4L/mi n/m , oft en neces s i t at i ng addi t i onal i not ropes . P.900
Intra-aortic balloon counterpulsation 2 Technique

Balloon insertion
Previ ous experi ence i s es s ent i al . Formerl y, a cut -down t o t he femoral art ery was requi red, but newer bal l oons come equi pped wi t h a s heat h whi ch may be i nt roduced percut aneous l y. Us i ng fl uoros copy, t he bal l oon i s pos i t i oned i n t he des cendi ng t horaci c aort a wi t h t he t i p jus t bel ow t he ori gi n of t he l eft s ubcl avi an
Pa g e 1 4 5 5
art ery. Ful l y ant i -coagul at e t he pat i ent wi t h i v hepari n. Some uni t s rout i nel y gi ve i v ant i bi ot i cs (fl ucl oxaci l l i n) t o cover agai ns t St aph . i nfect i on.
Triggering and timing

The bal l oon pump may be t ri ggered ei t her from t he pat i ent 's ECG (R wave) or from t he art eri al pres s ure waveform. Sl i de s wi t ches on t he pump al l ow preci s e t i mi ng of i nfl at i on and defl at i on duri ng t he cardi ac cycl e. Set t he pump t o 1 : 2 t o al l ow you t o s ee t he effect s of augment at i on on al t ernat e beat s . T rouble-shooting
Seek hel p from an expert ! There i s us ual l y an on-cal l cardi ac perfus i oni s t or t echni ci an, s eni or cardi ac phys i ci an or s urgeon. Count erpul s at i on i s i neffi ci ent wi t h heart rat es over 130/mi n. Cons i der ant i -arrhyt hmi cs or 1 : 2 augment at i on i ns t ead. Tri ggeri ng and t i mi ng: For ECG t ri ggeri ng, s el ect a l ead wi t h mos t pronounced R wave; ens ure t hat t he pump i s s et t o t ri gger from ECG not pres s ure; permanent pacemakers may i nt erfere wi t h t ri ggeri ng-s el ect l ead wi t h negat i ve and s mal l es t paci ng art efact . Al t ernat i vel y, s et t he pump t o be t ri ggered from t he ext ernal paci ng devi ce. A good art eri al waveform i s requi red for pres s ure t ri ggeri ng; t he t i mi ng wi l l vary s l i ght l y dependi ng on t he l ocat i on of t he art eri al l i ne (s l i ght l y earl i er for radi al art ery l i ne, cf. femoral art ery l i ne). Be gui ded by t he haemodynami c effect s of bal l oon i nfl at i on and defl at i on rat her t han t he preci s e val ue of del ay. Li mb i s chaemi a: Exacerbat ed by poor cardi ac out put , adrenal i ne, noradrenal i ne and peri pheral vas cul ar di s eas e. W ean off and remove t he bal l oon (s ee bel ow). Thrombocyt openi a: Commonl y s een; does not requi re t rans fus i on unl es s t here i s overt bl eedi ng and ret urns t o normal once t he bal l oon i s removed. Cons i der
Pa g e 1 4 5 6
pros t acycl i n i nfus i on i f pl at el et count s fal l bel ow 100 10 /L. IABP removal
The pat i ent may be progres s i vel y weaned by gradual l y reduci ng t he count erpul s at i on rat i o (1 : 2, 1 : 4, 1 : 8, et c.) and/or reduci ng t he bal l oon vol ume and checki ng t hat t he pat i ent remai ns haemodynami cal l y s t abl e. St op t he hepari n i nfus i on and wai t for t he ACT (act i vat ed cl ot t i ng t i me) t o fal l <150s (APTT <1.5 normal ). Us i ng a 50ml s yri nge, have an as s i s t ant appl y negat i ve pres s ure t o t he bal l oon. Pul l t he bal l oon down unt i l i t abut s t he s heat h; do not at t empt t o pul l t he bal l oon i nt o t he s heat h. W i t hdraw bot h bal l oon and s heat h and appl y fi rm pres s ure on t he femoral punct ure s i t e for at l eas t 30 mi nut es or unt i l t he bl eedi ng i s cont rol l ed.
P.901
P.902
Principles of respiratory support 1

The ai m of t herapy i s t o rel i eve hypoxi a and mai nt ai n or res t ore a normal P a CO 2 for t he i ndi vi dual . Rel at i ve i ndi cat i ons for mechani cal vent i l at i on are di s cus s ed i n t he appropri at e chapt ers . Thi s s ect i on di s cus s es s ome of t he pri nci pl es i nvol ved.
Oxygen therapy
Oxygen s houl d be admi ni s t ered by a s ys t em t hat del i vers a defi ned percent age, bet ween 28% and 100% accordi ng t o t he pat i ent s requi rement s (e.g. vi a fi xed percent age del i very mas ks s uch as Vent i mas k Mk i v). A Huds on mas k or nas al cannul ae gi ve very vari abl e F i O 2 dependi ng upon bot h fl ow rat e of oxygen and t he
Pa g e 1 4 5 7
pat i ent s breat hi ng pat t ern.
Nas al prongs onl y del i ver at F i O 2 of 30% at fl ows of 2L/mi n, and become l es s effi ci ent at hi gher fl ow rat es (~35% at 3L/mi n wi t h l i t t l e furt her i ncreas e wi t h i ncreas i ng fl ow). Hi gher fl ow rat es requi re humi di fi cat i on. A properl y pos i t i oned, hi gh fl ow oxygen mas k, us i ng oxygen at 6L/mi n, can provi de an F i O 2 of 60%. Combi ni ng nas al prongs and a hi gh fl ow mas k can achi eve an F i O 2 of ~8090%. In pract i ce i t i s rarel y pos s i bl e t o cons i s t ent l y del i ver >60% unl es s us i ng CPAP or vent i l at i on. W here s udden det eri orat i on i n oxygenat i on occurs al ways check t he del i very s ys t em for empt y cyl i nders , di s connect ed t ubi ng, et c.
Indications

Type I res pi rat ory fai l ure Type II res pi rat ory fai l ure (cont rol l ed t herapy) Bronchi al as t hma Acut e myocardi al i nfarct i on Si ckl e cel l cri s i s Carbon monoxi de poi s oni ng Cl us t er headaches
Complications
Tracheobronchi t i s occurs wi t h i nhal at i on of 80% oxygen for over 12 hours and pres ent s as ret ros t ernal pai n, cough, and dys pnoea. Parenchymal l ung damage from oxygen occurs wi t h F i O 2 >60% for more t han 48 hours wi t hout i nt ermi t t ent peri ods of breat hi ng ai r.
Monitoring oxygen therapy
The res ul t s of oxygen t herapy s houl d general l y be meas ured by i nt ermi t t ent or cont i nuous oxi met ry and i nt ermi t t ent art eri al bl ood gas es .
Pa g e 1 4 5 8
Oxi met ry i s an i nval uabl e ai d, but has l i mi t at i ons . In s ome s i t uat i ons (e.g. Gui l l ai nBarr s yndrome) fal l i ng oxi met ry i s a very l at e marker of i mpendi ng res pi rat ory fai l ure, and CO 2 accumul at i on (e.g. i n COAD) i s cl earl y not moni t ored by oxi met ry. A Sa O 2 of 93% correl at es very approxi mat el y wi t h a P a O 2 of 8kPa, and bel ow 92% t he P a O 2 may fal l di s proport i onat el y qui ckl y.
P.903
P.904
Principles of respiratory support 2 Lung expansion techniques
Peri odi c s i ghs are a normal part of breat hi ng and revers e mi croat el ect as i s . Lung expans i on t echni ques are i ndi cat ed for pat i ent s who cannot or wi l l not t ake peri odi c l arge breat hs (e.g. pos t abdomi nal or ches t s urgery, neuromus cul ar ches t wal l weaknes s ). Pos t operat i ve t echni ques us ed commonl y by phys i ot herapi s t s i ncl ude i ncent i ve s pi romet ry, coached maxi mal i ns pi rat i on wi t h cough, combi ned wi t h pos t ural drai nage and ches t percus s i on. Vol ume generat i ng devi ces s uch as the BIRD are t ri ggered by t he pat i ent i ni t i at i ng i ns pi rat i on, and del i ver a pre-s et t i dal vol ume t o augment t he pat i ent 's breat h. Li ai s e wi t h your phys i ot herapi s t . Pres s ure-generat i ng t echni ques (s uch as CPAP, NIPPV, and Bi PAP) have t he advant age t hat even i f a l eak devel ops around t he mas k, t he vent i l at or i s abl e t o compens at e t o provi de t he pat i ent wi t h t he pres cri bed pos i t i ve pres s ure (s ee bel ow). For bot h vol ume and pres s ure generat i ng t echni ques ,
Pa g e 1 4 5 9
t he pat i ent s mus t be abl e t o prot ect t hei r ai rway and generat e enough effort t o t ri gger t he machi ne.
Continuous positive airways pressure (CPAP)
CPAP provi des a cons t ant pos i t i ve pres s ure t hroughout t he res pi rat ory cycl e. It act s t o s pl i nt open col l aps i ng al veol i whi ch may be ful l of fl ui d (or a col l aps i ng upper ai rway i n obs t ruct i ve s l eep apnoea), i ncreas es funct i onal res i dual capaci t y (FRC) and compl i ance, s uch t hat t he work of breat hi ng i s reduced and gas exchange i s i mproved. It al l ows a hi gher F i O 2 (approachi ng 80100%) t o be admi ni s t ered, cf. s t andard oxygen del i very mas ks . CPAP s houl d us ual l y be commenced aft er l i ai s on wi t h anaes t het i s t s ; i n a pat i ent for act i ve management i t s houl d us ual l y be s t art ed on t he ITU. A s t andard s t art i ng pres s ure i s 5cmH 2 O; >10cmH 2 O pres s ure i s rarel y us ed.
Indications

Pul monam oedema Acut e res pi rat ory fai l ure (e.g. s econdary t o i nfect i on), where s i mpl e face mas k oxygen i s i ns uffi ci ent at t reat i ng hypoxami a. Acut e res porat ory fai l ure where vent i l at i on i s ei t her i nappropri at e or t o be avoi ded i f at al l pos s i bl e. W eani ng from t he vent i l at or. Obs t ruct i ve s l eep apnoea (OSA). In t hos e for act i ve management i t i s not a s ubs t i t ut e for vent i l at i on, and us ual l y onl y buys a modes t amount of t i me before i nt ubat i on i s requi red. Pat i ent needs t o:
o o o
be awake and al ert be abl e t o prot ect t he ai rway pos s es s adequat e res pi rat ory mus cl e s t rengt h
Pa g e 1 4 6 0
be haemodynami cal l y s t abl e.
P.905
P.906
Mechanical ventilation Negative pressure ventilation (NPV)
Thi s works by s ucki ng out t he ches t wal l and i s us ed i n chroni c hypovent i l at i on (e.g. pol i o, kyphos col i os i s , or mus cl e di s eas e). Expi rat i on i s pas s i ve. The i ron l ung or t ank vent i l at or i s t he mos t wel l known; al t ernat i ves i ncl ude t horaci c cui ras s es wi t h a s emi -ri gi d cage around t he ches t onl y and ot her devi ces whi ch may be cus t om bui l t . Thes e t echni ques do not requi re t racheal i nt ubat i on. However, acces s t o t he pat i ent for nurs i ng care i s di ffi cul t , and pos i t i ve pres s ure vent i l at i on i s t he modal i t y of choi ce i n t he acut e s et t i ng; t he pat i ent may be ext ubat ed i n a t ank vent i l at or once t he acut e epi s ode i s over. Al t ernat i ve devi ces s uch as rocki ng beds may be cons i dered for s t abl e pat i ent s requi ri ng l ong t erm-vent i l at ory as s i s t ance.
1
Intermittent positive pressure ventilation (IPPV)

Indications
Det eri orat i ng gas exchange due t o a pot ent i al l y revers i bl e caus e of res pi rat ory fai l ure.

Pneumoni a Exaerbat i on of COAD
Pa g e 1 4 6 1
Mas s i ve at el ect as i s Res pi rat ory mus cl e weaknes s Myaes t heni a gravi s Acut e i nfect i ve pol yneuri t i s
Vent i l at i on of t he i l l pat i ent on t he ITU i s vi a ei t her an ET t ube or a t racheos t omy. If vent i l at i on i s ant i ci pat ed t o be needed for >1 week, cons i der a t racheos t omy. Head i njury Cerebral hypoxi a (e.g. pos t cardi ac arres t ) Int racrani al bl eed Rai s ed i nt racrani al pres s ure Major t rauma or burns Pressure cycled ventilators del i ver gas i nt o t he l ungs unt i l a pres cri bed pres s ure i s reached, when i ns pi rat ory fl ow s t ops and, aft er a s hort paus e, expi rat i on occurs by pas s i ve recoi l . Thi s has t he advant age of reduci ng t he peak ai rway pres s ures wi t hout i mpai ri ng cardi ac performance i n s i t uat i ons s uch as ARDS. However, i f t he ai rway pres s ures i ncreas e or compl i ance decreas es t he t i dal vol ume wi l l fal l , s o pat i ent s need t o be moni t ored cl os el y t o avoi d hypovent i l at i on. Volume cycled ventilators del i ver a pres et t i dal vol ume i nt o t he l ungs over a predet ermi ned i ns pi rat ory t i me (us ual l y ~30% of t he breat hi ng cycl e), hol d t he breat h i n t he l ungs (for ~10% of t he cycl e), and t hen al l ow pas s i ve expi rat i on as t he l ungs recoi l .
There are t wo bas i c t ypes of vent i l at or.
Footnote
1
Hi l l s NS (1986) Ches t 90 : 897. P.907
P.908
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Nasal ventilation
Nas al i nt ermi t t ent pos i t i ve pres s ure vent i l at i on (NIPPV) del i vers a pos i t i ve pres s ure for a pres cri bed i ns pi rat ory t i me, when t ri ggered by t he pat i ent i ni t i at i ng a breat h, al l owi ng t he pat i ent t o exhal e t o at mos pheri c pres s ure. The pos i t i ve pres s ure i s s uppl i ed by a s mal l machi ne vi a a t i ght -fi t t i ng nas al mas k. It i s general l y us ed as a met hod of home noct urnal vent i l at i on for pat i ent s wi t h s evere mus cul os kel et al ches t wal l di s eas e (e.g. kyphos col i os i s ) or wi t h obs t ruct i ve s l eep apnoea (OSA). It has al s o been us ed wi t h modes t s ucces s as an al t ernat i ve t o formal vent i l at i on vi a ET t ube i n pat i ent s where pos i t i ve expi rat ory pres s ure i s not des i rabl e, e.g. acut e as t hma, COAD wi t h CO 2 ret ent i on, and as a weani ng ai d i n t hos e i n whom s eparat i on from a vent i l at or i s provi ng di ffi cul t . The s ys t em i s rel at i vel y eas y t o s et up by experi enced pers onnel , but s ome pat i ent s t ake t o i t bet t er t han ot hers . It s houl d not be commenced by i nexperi enced pers onnel .
P.909
P.910
Positive pressure ventilation 1 CMV (continuous mandatory ventilation)
CMV act s on a pres et cycl e t o del i ver a gi ven number of breat hs per mi nut e of a s et vol ume. The durat i on of t he cycl e det ermi nes t he breat h frequency.
The mi nut e vol ume i s cal cul at ed by ( t i dal vol ume frequenc y ).
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The rel at i ve proport i ons of t i me s pent i n i ns pi rat i on and expi rat i on (I : E rat i o) i s normal l y s et at 1 : 2, but may be al t ered, e.g. i n acut e as t hma, where ai r t rappi ng i s a probl em, a l onger expi rat ory t i me i s needed (p214); i n ARDS, where t he l ung compl i ance i s l ow, a l onger i ns pi rat ory t i me i s benefi ci al (i nvers e rat i o vent i l at i on, s ee p232) The pat i ent s s houl d be ful l y s edat ed. Pat i ent s capabl e of s pont aneous breat hs who are vent i l at ed on CMV can get s t acki ng of breat hs , where t he vent i l at or worki ng on i t s pres et cycl e may gi ve a breat h on t op of one whi ch t he pat i ent has jus t t aken, l eadi ng t o over-i nfl at i on of t he l ungs , a hi gh peak i ns pi rat ory pres s ure, and t he ri s k of pneumot horax. Prol onged us e of t hi s mode wi l l res ul t i n at rophy of t he res pi rat ory mus cl es ; t hi s may prove di ffi cul t i n s ubs equent weani ng, es peci al l y i n combi nat i on wi t h a proxi mal myopat hy from s t eroi ds , e.g. i n acut e as t hma. Vent i l at i on may ei t her be t ermi nat ed abrupt l y or by gradual t rans fer of t he vent i l at ory workl oad from t he machi ne t o t he pat i ent (weani ng).
SIMV (synchronized intermittent mandatory ventilation)
SIMV modes al l ow t he pat i ent t o breat h s pont aneous l y and be effect i vel y vent i l at ed and al l ows gradual t rans fer of t he work of breat hi ng on t o t he pat i ent . Thi s may be appropri at e when weani ng t he pat i ent whos e res pi rat ory mus cl es have was t ed. It i s i nappropri at e i n acut el y i l l pat i ent s (e.g. acut e s evere as t hma, ARDS); CMV wi t h deep s edat i on reduces oxygen requi rement and res pi rat ory dri ve and al l ows more effect i ve vent i l at i on. Exact det ai l s of t he met hods of s ynchroni zat i on vary bet ween machi nes , but al l act i n a s i mi l ar manner: t he
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pat i ent breat hes s pont aneous l y t hrough t he vent i l at or ci rcui t . The vent i l at or i s us ual l y pres et t o ens ure t hat t he pat i ent has a mi ni mum number of breat hs per mi nut e, and i f t he number of s pont aneous breat hs fal l s bel ow t he pres et l evel t hen a breat h i s del i vered by t he machi ne.
Mos t SIMV modes of vent i l at i on provi de s ome form of pos i t i ve pres s ure s upport t o t he pat i ent 's s pont aneous breat hs t o reduce t he work of breat hi ng and ens ure effect i ve vent i l at i on (s ee bel ow).
Pressure support
Pos i t i ve pres s ure i s added duri ng i ns pi rat i on t o rel i eve part or al l of t he work of breat hi ng. Thi s may be done i n conjunct i on wi t h an SIMV mode of vent i l at i on, or as a means of s upport i ng ent i rel y s pont aneous pat i ent -t ri ggered vent i l at i on duri ng t he proces s of weani ng. It al l ows t he pat i ent s t o det ermi ne t hei r own res pi rat ory rat e, and s houl d ens ure adequat e i nfl at i on of t he l ungs and oxygenat i on. It i s , however, onl y s ui t abl e for t hos e whos e l ung funct i on i s reas onabl y adequat e and who are not confus ed or exhaus t ed.
P.911
P.912
Positive pressure ventilation 2 PEEP (positive end esxpiratory pressure)
PEEP i s a pres et pres s ure added t o t he end of expi rat i on onl y, t o mai nt ai n t he l ung vol ume, prevent ai rway or al veol ar col l aps e, and open up at el ect i c or fl ui d-fi l l ed l ung (e.g. i n ARDS or cardi ogeni c pul monary
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oedema).
It can s i gni fi cant l y i mprove oxygenat i on by maki ng more of t he l ung avai l abl e for gas exchange. However, t he t rade-off i s an i ncreas e i n i nt rat horaci c pres s ure whi ch can s i gni fi cant l y decreas e venous ret urn and hence cardi ac out put . There i s al s o an i ncreas ed ri s k of pneumot horax. Aut o-PEEP i s s een i f t he pat i ent 's l ungs do not ful l y empt y before t he next i nfl at i on (e.g. as t hma). In general PEEP s houl d be kept at a l evel of 510cm H 2 O where requi red, and t he l evel adjus t ed i n 23 cm H 2 O i nt erval s every 2030 mi nut es accordi ng t o a bal ance bet ween oxygenat i on and cardi ac performance. Meas urement and i nt erpret at i on i f PCW P i n pat i ent s on PEEP depends on t he pos i t i on of t he cat het er. PCW P wi l l al ways refl ect pul monary venous pres s ures i f t hey are great er t han PEEP. If t he cat het er i s i n an api cal ves s el where t he PCW P i s normal l y l ower due t o t he effect s of gravi t y, t he pres s ure meas ured may be t he al veol ar (PEEP) pres s ure rat her t han t he t rue PCW P; i n a dependent area t he pres s ures are more accurat e. Removi ng PEEP duri ng meas urement caus es marked fl uct uat i ons i n haemodynami cs and oxygenat i on and t he pres s ures do not refl ect t he s t at e once back on t he vent i l at or.
P.913
P.914
Cricothyroidotomy Indications
To bypas s upper ai rway obs t ruct i on (e.g. t rauma, i nfect i ons , neopl as ms , pos t operat i ve, burns and
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corros i ves ) when oral or nas ot racheal i nt ubat i on i s cont rai ndi cat ed.
In s i t uat i ons when endot racheal i nt ubat i ons fai l (e.g. mas s i ve nas opharyngeal haemorrhage, s t ruct ural deformi t i es , obs t ruct i on due t o forei gn bodi es , et c.) As an el ect i ve procedure i n s el ect pat i ent s t o provi de a rout e for s uct i on of ai rway s ecret i ons (e.g. pat i ent s i n neuromus cul ar di s eas e). Thi s s houl d be convert ed t o a t racheot omy i f requi red for prol onged peri ods or i f i nfect i on or i nfl ammat i on occurs .
Procedure
Thi s s houl d not be at t empt ed i f you have not been t aught i t by an experi enced phys i ci an/s urgeon. Seek hel p.

Locat e t he t hyroi d and cri coi d cart i l ages . The cri cot hyoi rd s pace i s jus t under 1cm i n i t s vert i cal di mens i on. The cri cot hyroi d art ery runs acros s t he mi d-l i ne i n t he upper port i on. Cl ean t he s ki n wi t h i odi ne and i s ol at e t he area wi t h s t eri l e t owel s . Infi l t rat e t he s ki n and t he area around t he cri cot hyroi d s pace wi t h l ocal anaes t het i c. Make a 3cm vert i cal mi d-l i ne i nci s i on t hrough t he s ki n, t aki ng care not t o cut t he membrane. Pal pat e t he cri cot hyroi d membrane t hrough t he i nci s i on. St abi l i ze t he l arynx by hol di ng bet ween t he i ndex fi nger and t humb. Make a s hort t rans vers e i nci s i on i n t he l ower t hi rd of t he cri cot hyroi d membrane, jus t s crapi ng over t he upper part of t he cri coi d cart i l age (preferabl y us i ng t he t i p of a No. 11 bl ade t o go t hrough t he membrane). Thi s mi ni mi zes t he ri s k of cut t i ng t he cri cot hyroi d art ery. Di l at e t he membrane wi t h forceps , i ns ert t he t racheot omy t ube t hrough t he i nci s i on i nt o t he t rachea, and s ecure.
Percutaneous cricothyrotomy us i ng t he Sel di nger t echni que i s
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qui cker, may be performed by non-s urgeons at t he beds i de, and i s s afer. See fi gure. Aft er anaes t het i zi ng t he area, a needl e i s us ed t o punct ure t he cri cot hyroi d membrane and t hrough t hi s a gui de-wi re i s i nt roduced i nt o t he t rachea. Over t hi s a s eri es of di l at ors and t he t racheos t omy t ube can be s afel y pos i t i oned. P915
Complications of cricothyrotomy
Haemorrhageus ual l y due t o damage t o t he cri cot hyroi d art ery Tube mi s pl acement may occur i n up t o 15% of cas es Subgl ot t i c s t enos i s Hoars enes s Laryngot racheal -cut aneous fi s t ul a
Needl e cri cot hyroi dot omy P.915
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P.916
Endotracheal intubation
Thi s i s t he bes t met hod for provi di ng and mai nt ai ni ng a cl ear ai rway for vent i l at i on, prot ect i on agai ns t as pi rat i on, and s uct i oni ng and cl eari ng l ower res pi rat ory t ract s ecret i ons . The mos t common i ndi cat i on for urgent i nt ubat i on by a phys i ci an i s cardi ac arres t . Thi s i s not a t echni que for t he i nexperi enced: t he des cri pt i on bel ow i s not i nt ended as a s ubs t i t ut e for pract i ce under s upervi s i on of a s ki l l ed anaes t het i s t .
You will need

Laryngos cope, us ual l y wi t h a curved bl ade (Maci nt os h) Endot racheal t ube (89mm i nt ernal di amet er for men and 78mm for women) and appropri at e adapt ors Syri nge for cuff i nfl at i on and cl amp t o prevent ai r es capi ng from t he cuff once i nfl at ed Sci s s ors and t ape or bandage t o s ecure t he t ube Lubri cat i ng jel l y (e.g. KY jel l y) Suct i on apparat us wi t h ri gi d (Y ankauer) and l ong fl exi bl e cat het ers .
Potential problems during intubation
Cert ai n anat omi cal vari at i ons (e.g. recedi ng mandi bl e, s hort neck, promi nent i nci s ors , hi gh arched pal at e) as wel l as s t i ff neck or t ri s mus may make i nt ubat i on compl i cat ed; s ummon experi enced hel p. Vomi t i ng: s uct i on i f neces s ary. Cri coi d pres s ure may be of us e. Cervi cal s pi ne i njury: i mmobi l i ze t he head and neck i n l i ne wi t h t he body and t ry not t o ext end t he head duri ng i nt ubat i on. Faci al burns or t rauma may make orot racheal i nt ubat i on i mpos s i bl e. Cons i der cri cot hyroi dot omy (s ee p915).
Procedure
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Pl ace t he pat i ent wi t h t he neck s l i ght l y fl exed and t he head ext ended. Take care i f cervi cal i njury i s s us pect ed. Cri coi d pres s ure: The oes ophagus can be occl uded by compres s i ng t he cri coi d cart i l age pos t eri orl y agai ns t t he body of C6. Thi s prevent s pas s i ve regurgi t at i on i nt o t he t rachea but not act i ve vomi t i ng. As k your as s i s t ant t o mai nt ai n pres s ure unt i l t he t ube i s i n pl ace and t he cuff i nfl at ed. Pre-oxygenat e t he pat i ent by hypervent i l at i on wi t h 85% oxygen for 1530 s econds . Open t he mout h and s uct i on t o cl ear t he ai rway. W i t h t he l aryngos cope i n your l eft hand, i ns ert t he bl ade on ri ght s i de of mout h. Advance t o bas e of t ongue, i dent i fyi ng t he t ons i l l ar fos s a and t he uvul a. Pus h t he bl ade t o t he l eft movi ng t he t ongue over. Advance t he bl ade unt i l t he epi gl ot t i s comes i nt o vi ew. Ins ert t he bl ade t i p bet ween t he bas e of t he t ongue and t he epi gl ot t i s (i nt o t he val l ecul a) and pul l t he whol e bl ade (and l arynx) upwards al ong t he l i ne of t he handl e of t he l aryngos cope t o expos e t he vocal cords . Bri ef s uct i on may be neces s ary t o cl ear t he vi ew. Ins ert t he ET t ube bet ween t he vocal cords and advance i t unt i l t he cuff i s jus t bel ow t he cords and no furt her. Infl at e t he cuff wi t h ai r. If t he cords cannot be s een, do not poke at t he epi gl ot t i s hopi ng for s ucces s , cal l for more s ki l l ed hel p and revert t o bas i c ai rway management . P.917
Int ubat i on mus t not t ake l onger t han 30 s econds ; i f t here i s any doubt about t he pos i t i on, remove t he t ube, reoxygenat e, and t ry agai n. W i t h t he t ube i n pl ace, l i s t en t o t he ches t duri ng i nfl at i on t o check t hat BOTH s i des of t he ches t are
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vent i l at ed. If t he t ube i s i n t he oes ophagus , ches t expans i on wi l l be mi ni mal t hough t he s t omach may i nfl at e; ai r ent ry i nt o t he ches t wi l l be mi ni mal .
Ti e t he ET t ube i n pl ace and s ecure t o prevent i t from s l i ppi ng up or down t he ai rway. Vent i l at e wi t h hi gh concent rat i on oxygen.
Landmarks for endot racheal i nt ubat i on. P.918
Aspiration of a pneumothorax
If t he pneumot horax i s <75% and t he pat i ent i s haemodynami cal l y s t abl e, i t i s reas onabl e t o at t empt as pi rat i on of t he pneumot horax i n t he fi rs t i ns t ance (p236).
You will need the following:
10ml and 50ml s yri nge wi t h green (18G) and orange (25G) needl es Dres s i ng pack (s wabs , s t eri l e drapes , ant i s ept i c) and s t eri l e gl oves 19G Venfl on or al t ernat i ve cannul a Local anaes t het i c (e.g. 2% l i gnocai ne) Three-way t ap
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Procedure

1 as s i s t ant i s requi red. Si t pat i ent up, propped agai ns t pi l l ows wi t h hand behi nd hi s /her head; ens ure you are comfort abl e and on a s i mi l ar l evel . Sel ect t he s pace t o as pi rat e, t he 2nd i nt ercos t al s pace i n t he mi d-cl avi cul ar l i ne. Confi rm wi t h CXR t hat you are as pi rat i ng t he correct s i de (a s urpri s i ngl y common caus e of di s as t ers i s as pi rat i ng t he normal s i de). Cl ean t he s ki n and us e as ept i c t echni que. Connect a 50ml s yri nge t o a t hree-way t ap i n readi nes s , wi t h t he l i ne whi ch wi l l be connect ed t o t he pat i ent t urned off s o t hat no ai r wi l l ent er t he pl eural cavi t y on connect i ng t he apparat us . Infi l t rat e 510ml of l i gnocai ne from s ki n t o pl eura, jus t above t he upper border of t he ri b i n t he s pace you are us i ng. Confi rm t he pres ence of ai r by as pi rat i ng approxi mat el y 5ml vi a a green needl e. Ins ert a 16G or l arger i nt ravenous cannul a i nt o t he pneumot horax, preferabl y whi l s t as pi rat i ng t he cannul a wi t h a s yri nge, s o t hat ent ry i nt o t he pl eural s pace i s confi rmed. Al l ow t he t i p of t he cannul a t o ent er t he s pace by approxi mat el y 1cm. As k t he pat i ent t o hol d t hei r breat h and remove t he needl e. Swi ft l y connect t he 3-way t ap. As pi rat e 50ml of ai r/fl ui d and voi d i t t hrough t he ot her l umen of t he t ap. Repeat . As pi rat i on s houl d be s t opped when res i s t ance t o s uct i on i s fel t , t he pat i ent coughs exces s i vel y, or 2.5 l i t res of ai r has been as pi rat ed. W i t hdraw t he cannul a and cover t he s i t e wi t h a dres s i ng pl as t er (e.g. El as t opl as t or Band-ai d) Check pos t procedure CXR. If t here i s s i gni fi cant res i dual pneumot horax i ns ert a ches t drai n.
Aspiration of a pleural effusion
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The bas i c procedure i s s i mi l ar t o t hat for a pneumot horaxt he s i t e i s di fferent : one or t wo i nt ercos t al s paces pos t eri orl y bel ow t he l evel at whi ch dul l nes s i s det ect ed. Ideal l y al l cas es s houl d have an USS fi rs t t o confi rm t he l evel of t he effus i on and ens ure t hat t he di aphragm i s not hi gher t han ant i ci pat ed due t o underl yi ng pul monary col l aps e.
Pos i t i on t he pat i ent l eani ng forward over t he back of a chai r or t abl e. Cl ean t he s ki n and i nfi l t rat e wi t h l ocal anaes t het i c as above. Ins ert t he cannul a and as pi rat e t he effus i on wi t h a 50ml s yri nge, voi di ng i t t hrough t he 3-way t ap. Repeat unt i l res i s t ance i s fel t and t he t ap i s dry. Check a pos t procedure CXR.
P.919
P.920
Insertion of a chest drain 1 You will need the following:
Dres s i ng pack (s t eri l e gauze, gl oves , drapes , Bet adi ne) Local anaes t het i c (~20ml 1% l i gnocai ne), 10ml s yri nge, green (18G) and orange (25G) needles Scal pel and No. 11 bl ade for s ki n i nci s i on; 2 packs s i l k s ut ures (10) 2 forceps (Kel l y cl amps ), s ci s s ors , needl e hol der (oft en pre-packaged as a ches t drai n s et ) W here pos s i bl e, us e t he new Sel di nger-t ype ches t t ubes es peci al l y for pneumot horax Ches t t ubes a s el ect i on of 24, 28, 32, and 36Fr Ches t drai nage bot t l es , wi t h s t eri l e wat er for underwat er s eal 1 as s i s t ant .
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Procedure
Pos i t i on t he pat i ent l eani ng forward over t he back of a chai r or t abl e. If pos s i bl e, premedi cat e t he pat i ent wi t h an appropri at e amount of opi at e ~30 mi nut es before. Mark t he s pace t o be drai ned i n t he mi d-axi l l ary l i ne; us ual l y t he 5t h i nt ercos t al s pace for pneumot horax, bel ow t he l evel of t he fl ui d for an effus i on. Cl ean t he s ki n. Sel ect t he ches t t ube: s mal l (24Fr) for ai r al one, medi um (28Fr) for s erous fl ui d, or l arge (3236Fr) for bl ood/pus . Remove t he t rocar. Check t hat t he underwat er s eal bot t l es are ready. Infi l t rat e t he s ki n wi t h 1520ml of l i gnocai ne 1%. Make a s hort s ub-cut aneous t unnel for t he ches t t ube before i t ent ers t he pl eural s pace (s ee fi gure). Anaes t het i ze t he peri os t eum on t he t op of t he ri b. Check t hat you can as pi rat e ai r/fl ui d from t he pl eural s pace. Make a hori zont al 2cm i nci s i on i n t he anaes t het i zed s ki n of t he ri b s pace. Us e t he forceps t o bl unt -di s s ect t hrough t he fat and i nt ercos t al mus cl es t o make a t rack l arge enough for your gl oved fi nger down t o t he pl eural s pace. St ay cl os e t o t he upper border of t he ri b t o avoi d t he neurovas cul ar bundl e. Check t he l engt h of t he t ube agai ns t t he pat i ent 's ches t t o confi rm how much needs t o be i ns ert ed i nt o t he pat i ent 's ches t . Ai m t o get t he t i p t o t he apex for a pneumot horax; keep t he l owermos t hol e as l ow as pos s i bl e (~2cm i nt o t he ches t ) t o drai n pl eural fl ui d. Ins ert t wo s ut ures acros s t he i nci s i on (or a purs e-s t ri ng, s ee fi gure). Thes e wi l l gent l y t i ght en around t he t ube once i ns ert ed t o creat e an ai rt i ght s eal but do not knot t hes e s ut ures wi l l be us ed t o cl os e t he wound aft er drai n removal . Remove t he t rocar. Cl amp t he end of t he t ube wi t h t he
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forceps and gent l y i nt roduce t he t ube i nt o t he pl eural s pace. Rot at i ng t he forceps 180 di rect s t he t ube t o t he apex (s ee fi gure). Condens at i on i n t he t ube (or fl ui d) confi rms t he t ube i s wi t hi n t he pl eural s pace. Check t hat al l t he hol es are wi t hi n t he t horax and connect t o t he underwat er s eal . Tape t hes e t o t he s ki n
Gent l y t i ght en t he s ki n s ut ures (s ee above) but do not knot . The drai n s houl d be s ecured wi t h s everal ot her s t i t ches and copi ous amount s of adhes i ve t ape. They are very vul nerabl e t o acci dent al t ract i on. W rap adhes i ve t ape around t he joi n bet ween t he drai n and t he connect i ng t ubi ng. P.921
Pres cri be adequat e anal ges i a for t he pat i ent for when t he anaes t het i c wears off. Arrange for a CXR t o check t he pos i t i on of t he drai n. Do not drai n off more t han 1 l i t re of pl eural fl ui d/24 hours t o avoi d re-expans i on pul monary oedema.
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Insertion of a chest drain 2 Tips and pitfalls
The ches t drai n s houl d onl y be l eft i n pl ace whi l e ai r or fl ui d cont i nue t o drai n. The ri s k of as cendi ng i nfect i on i ncreas es wi t h t i me. Prophyl act i c ant i bi ot i cs are not us ual l y i ndi cat ed. Malpositioned tube: Obt ai n a CXR pos t procedure (and dai l y) t o check t he pos i t i on of t he drai n and exami ne t he l ung fi el ds .
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If t he drai n i s t oo far out , t here wi l l be an ai r l eak and t he pat i ent may devel op s ub-cut aneous emphys ema. Ideal l y, remove t he drai n and repl ace wi t h a new drai n at a new s i t e; t he ri s k of as cendi ng i nfect i on i s hi gh i f t he non-s t eri l e port i on of t he t ube i s jus t pus hed i nt o t he ches t . If t he drai n i s t oo far i n, i t may be uncomfort abl e for t he pat i ent and i mpi nge on vi t al s t ruct ures (e.g. t horaci c aort a). Pul l t he t ube out t he appropri at e di s t ance and re-s ut ure.
Obstructed tube: Check t he wat er col umn i n t he ches t drai n bot t l e s wi ngs wi t h res pi rat i on. Thi s wi l l s t op i f t he t ube i s obs t ruct ed.
o
Check t he drai ns and t ubi ng are free of bends and ki nks . Bl ood cl ot s or fi bri n may bl ock t he t ube and may be mi l ked caut i ous l y. If t he l ung i s s t i l l col l aps ed on CXR, repl ace t he ches t drai n wi t h a new t ube at a new s i t e.
Lung fails to re-expand: Thi s i s ei t her due t o an obs t ruct ed s ys t em or pers i s t ent ai r l eak (e.g. t racheobronchi al fi s t ul a).
o
If t he ches t drai n cont i nues t o bubbl e, appl y s uct i on t o t he drai n t o hel p expand t he l ung. Cons i der i ns ert i ng furt her drai ns or s urgi cal repai r of l eak. If t he ches t drai n i s obs t ruct ed (s ee above), repl ace t he drai n.
Removing the chest drain

o o
DO NOT cl amp t he ches t drai n. Remove t he dres s i ngs and rel eas e t he s ut ures hol di ng t he drai n i n pl ace. Leave t he s ki n i nci s i on s ut ures (purs e-s t ri ng) i n pos i t i on t o cl os e t he wound once t he drai n i s removed.
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Remove t he drai n i n a gent l e mot i on, ei t her i n i ns pi rat i on or i n expi rat i on wi t h Val s al va. Ti ght en t he s ki n s ut ures . Thes e s houl d be removed aft er 34 days and a fres h dres s i ng appl i ed. Any res i dual pneumot horax s houl d be t reat ed dependi ng on t he pat i ent 's s ympt oms , wi t h a fres h ches t drai n i f neces s ary.
Complications
Bl eedi ng (i nt ercos t al ves s el s , l acerat i on of l ung, s pl een, l i ver) Pul monary oedema (t oo rapi d l ung expans i on) Empyema Sub-cut aneous emphys ema Res i dual pneumot horax or effus i on (mal pos i t i oned or obs t ruct ed ches t drai n)
P.923
P.924
Ascitic tap Indications
Di agnos e or excl ude s pont aneous bact eri al peri t oni t i s (SBP) As ci t i c prot ei n and al bumi n As ci t i c cyt ol ogy may requi re 100ml fl ui d As ci t i c amyl as e (pancreat i c as ci t es ) St ai n and cul t ure for AFBs ; l ymphocyt e count (N <500 cel l s /mm )
3
To drai n ci rrhot i c or mal i gnant as ci t es for pat i ent comfort or fl ui d overl oad.
Pa g e 1 4 7 8
T r Ex an ud su ate dat e T o <3 tal 0g/ pr L ote in citi 5 c pr ote in: ser um pr ote in Se >1 <1 ru 1g/ 1 m- L asc itic alb um in gr adi ent
3 0g/ L 5
As <0. >0.
g/L
Ascitic tap
Li e pat i ent s upi ne, and t i l t ed s l i ght l y t o t he l eft or ri ght .
Pa g e 1 4 7 9
Sel ect t he s i t e (l evel wi t h umbi l i cus , and 34cm l at eral t o a l i ne pas s i ng t o mi d-i ngui nal poi nt ) and cl ean t he area wi t h i odi ne or equi val ent . Ens ure t he bl adder i s empt y and avoi d any s cars . Us e a 20ml s yri nge wi t h a 18G (green) needl e. In obes e pat i ent s us e a l onger needl e (e.g. 18G Abbocat h). If you pl an t o us e a l arger needl e, i nfi l t rat e t he area wi t h l ocal anaes t het i c before proceedi ng. Ins ert t he needl e s l owl y i nt o t he abdomen whi l s t as pi rat i ng unt i l fl ui d i s obt ai ned. Inocul at e 5ml s of t he fl ui d i nt o each bot t l e of a s et of bl ood cul t ure bot t l es (i n ci rrhot i cs for ?bact eri al peri t oni t i s ) and s end s ome i n a s t eri l i n or pl ai n bot t l e for mi cros copy (5ml ) and prot ei n (1ml ). Add 2ml as ci t es t o EDTA t ube s end for bl ood count t o haemat ol ogy. Remove t he needl e and appl y a s t eri l e pl as t er over t he punct ure s i t e.
Causes of transudative and exudative ascites

T ransuda Exudativ tive ascites
e ascites
Ci rrh os i s
Ci rrh os i s (rare l y)
Nep hrot i c s ynd rom e

Panc reat i c Tube rcul o
Pa g e 1 4 8 0
us peri t oni t i s
Bud d Chi a ri s ynd rom e (hep at i c vei n t hro mbo sis)
Mal i gnan cy
Card i ac as ci t es
NB: Mos t caus es of t rans udat es can al s o gi ve ri s e t o exudat es and vi ce vers a. P.925
P.926
Pa g e 1 4 8 1
Total paracentesis
Dai l y s mal l vol ume paracent es i s i s t i me-cons umi ng, unneces s ary, and i ncreas es t he ri s k of i nfect i on and as ci t i c l eakage. It i s dangerous t o l eave a peri t oneal t ap cat het er i n pl ace for more t han a few hours . The ri s k of i nfect i on i n our experi ence i s great . It i s s afer t o drai n t he as ci t es t o drynes s . The rat e of fl ui d drai nage s houl d be as fas t as pos s i bl e. Duri ng t he fi rs t 36 hours of paracent es i s , t here i s a s i gni fi cant i ncreas e i n cardi ac out put , a decreas e i n s ys t emi c vas cul ar res i s t ance, and a modes t fal l i n mean art eri al pres s ure (by 510mmHg). In t he pres ence of t ens e as ci t es t he ri ght at ri al pres s ure (RAP) may be art i fi ci al l y el evat ed by t rans mi t t ed i nt ra-abdomi nal pres s ure, and RAP may fal l acut el y by ~35cm wat er. Thus fl ui d repl acement i s es s ent ai l .
Us e ei t her a Kus s needl e (i f avai l abl e), a l arge 14G l ong Abbocat h (us ed for cent ral l i nes ), a peri t oneal di al ys i s cat het er or a SwanGanz i nt roducer (8.5F and rat her l arge for t he purpos e). To avoi d t he cat het er bl ocki ng due t o oment um pl uggi ng t he end, remove t he met al i nt roducer under s t ri ct as ept i c condi t i ons , and careful l y make s everal perforat i ons i n t he pl as t i c of t he cat het er us i ng a green or bl ue needl e. Avoi d hol es cl os e t oget her and re-i ns ert t he met al i nt roducer needl e very careful l y t o avoi d caus i ng a t ear i n t he cannul a (t hi s woul d i ncreas e t he ri s k of t he cannul a breaki ng off i n t he abdomen). Not et he manufact urers do not recommend t hi s ; s ome compani es produce s peci al cat het ers wi t h pre-formed s i de-hol es . Al ways us e t hes e i f avai l abl e. Take a dri p s et (i v fl ui d gi vi ng s et ) and, wi t h a s t eri l e bl ade, cut off t he res ervoi r, l eavi ng t he t ubi ng, l uer l ocki ng devi ce, and rat e cont rol mechani s m. If a PD cannul a or ot her devi ce i s us ed t hen s ome form
Pa g e 1 4 8 2
of t ubi ng needs t o be at t ached t o faci l i t at e drai nage.
Pos i t i on t he pat i ent s upi ne and s l i ght l y t i l t ed t o one s i de. Sel ect , cl ean, and i nfi l t rat e t he s i t e wi t h 2% l i gnocai ne as for as ci t i c t ap. Ins ert t he cannul a (at t ached t o a 20ml s yri nge), as pi rat i ng as one advances t he cannul a. W hen as ci t i c fl ui d i s obt ai ned, advance t he needl e ~5mm more, t hen advance t he pl as t i c cannul a hol di ng t he met al i nt roducer, ready t o prevent i t goi ng any deeper (as for i ns ert i ng a Venfl on). Remove t he met al i nt roducer and at t ach t he drai nage t ube (modi fi ed gi vi ng s et ). St rap t he i nt roducer t o t he abdomi nal wal l wi t h el as t opl as t . It i s not neces s ary t o s ut ure t he cannul a i n pl ace s i nce i t wi l l be removed wi t hi n 34 hours . Drai n t he as ci t es as rapi dl y as pos s i bl e i nt o an appropri at e recept acl e (have bucket t o hand for empt yi ng t he cont ent s ). W hen t he as ci t es s t ops drai ni ng or s l ows down, move t he pat i ent from s i de t o s i de, and l i e t owards t he drai nage s i t e. W hen drai nage i s compl et e, remove t he cat het er, appl y pl as t er, and l i e t he pat i ent wi t h t he drai nage s i t e uppermos t for at l eas t 4 hours .
P.927
P.928
Insertion of SengstakenBlakemore or Minnesota tube

The Sengs t akenBl akemore or Mi nnes ot a t ube are i ns ert ed t o cont rol vari ceal bl eedi ng when ot her meas ures (i nject i on s cl erot herapy, i nt ravenous vas opres s i n, or oct reot i de) have fai l ed.
Pa g e 1 4 8 3
It s houl d not be us ed as t he pri mary t herapy of bl eedi ng vari ces s i nce i t i s unpl eas ant , and i ncreas es t he ri s k of oes ophageal ul cerat i on. If pl aced i n t he uni nt ubat ed pat i ent t here i s a very real ri s k of as pi rat i on. Seek experi enced or s peci al i s t hel p earl y. Bal l oon t amponade i s not a defi ni t i ve procedure: make arrangement s for vari ceal i nject i on or oes ophageal t rans ect i on once t he pat i ent i s s t abl e. Cont i nue i nfus i ons of vas opres s i n or oct reot i de (pp48890).
You will need the following

Sengs t aken or Mi nnes ot a t ube Bl adder s yri nge (for bal l oons ) Sphygmomanomet er X-ray cont ras t (di l ut ed)
Procedure
It i s as s umed t hat t he pat i ent i s al ready bei ng res us ci t at ed, and i s recei vi ng i nt ravenous gl ypres s i n (p618). The pat i ent s houl d i deal l y be i nt ubat ed and vent i l at ed. If not , t here i s an i ncreas ed ri s k of as pi rat i on. Thi s ri s k may be reduced i n t he uni nt ubat ed pat i ent by i nject i ng 10mg met ocl oprami de i mmedi at el y before i ns ert i on. Thi s can caus e t emporary ces s at i on of haemorrhage and reduce t he as pi rat i on ri s k. Have a l ow t hres hol d for s edat i on, endot racheal i nt ubat i on, and vent i l at i on. The SBT or Mi nnes ot a t ube s houl d be s t ored i n t he fri dge (t o maxi mi ze s t i ffnes s ) and removed jus t before us e. Fami l i ari ze yours el f wi t h t he vari ous part s before i ns ert i on i f neces s ary. Check t he i nt egri t y of t he bal l oons before you i ns ert t he t ube. Pl ace an endos cope prot ect i on mout hguard i n pl ace (t o prevent bi t i ng of t he t ube). Cover t he end of t he t ube wi t h KY jel l y, and, wi t h t he pat i ent i n t he l eft s emi -prone pos i t i on, pus h t he t ube down, as ki ng t he pat i ent t o s wal l ow (i f cons ci ous ). If t he t ube curl s up i n t he mout h, t ry agai n or t ry anot her cool ed t ube.
Pa g e 1 4 8 4
Ins ert at l eas t 50cm, and s t art i nfl at i ng t he gas t ri c bal l oon wi t h 200ml wat er cont ai ni ng gas t rografi n (t hi s enabl es t he bal l oon t o be vi s ual i zed on a CXR or AXR). Cl amp t he bal l oon channel . Then gent l y pul l back on t he t ube unt i l t he gas t ri c bal l oon abut s t he gas t ro-oes ophageal junct i on (res i s t ance fel t ), t hen pul l furt her unt i l t he pat i ent i s begi nni ng t o be t ugged by pul l i ng. Not e t he pos i t i on at t he edge of t he mout h pi ece (mark wi t h pen), and at t ach wi t h el as t opl as t t o t he s i de of t he face. W ei ght cont rapt i ons s houl d not be neces s ary. In general t he oes ophageal bal l oon s houl d never be us ed. Vi rt ual l y al l bl eedi ng vari ces occur at t he oes ophagogas t ri c junct i on and are cont rol l ed us i ng t hi s t echni que. If t he bl eedi ng cont i nues , i nfl at e t he oes ophageal bal l oon. Connect t hi s t o a s phygmomanomet er vi a a 3-way t ap t o moni t or t he bal l oon pres s ure. Infl at e t o 40mmHg and cl os e t he 3-way t ap. Check t he pres s ure i n t hi s bal l oon every 12 hours . Do not defl at e every hour. P.929
Do NOT l eave t he bal l oons i nfl at ed for more t han 12 hours s i nce t hi s i ncreas es t he ri s k of oes ophageal ul cerat i on. Obt ai n a CXR t o check t he pos i t i on of t he t ube. The gas t ri c channel s houl d be as pi rat ed cont i nuous l y. If faci l i t i es for vari ceal i nject i on are avai l abl e, remove t he SBT or MT i mmedi at el y pri or t o endos copy. If not , di s cus s t he pat i ent wi t h your regi onal cent re and t rans fer i f appropri at e.
Pa g e 1 4 8 5
Pos i t i oni ng of Sengs t akenBl akemore t ube for compres s i on of oes ophageal vari ces . P.930
Transjugular liver biopsy Indications

It i s not wi t hout ri s k, and s houl d not be appl i ed merel y t o obt ai n hi s t ol ogy for compl et enes s .
Bl eedi ng di at hes i s cont rai ndi cat i ng convent i onal bi ops y t echni ques
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The bi ops y wi l l as s i s t di agnos i s and s ubs equent management .
Procedure
Thi s i s rel at i vel y s t rai ght -forward, and i s bas ed on t he as s umpt i on t hat by t aki ng t he bi ops y t hrough t he hepat i c vei n any bl eedi ng wi l l occur i nt o ci rcul at i on. A l arge i nt roducer i s pl aced i nt o t he i nt ernal jugul ar vei n or femoral vei n. A cat het er i s i nt roduced t hrough t hi s and mani pul at ed i nt o t he hepat i c vei n. The cat het er i s removed l eavi ng a gui de wi re i n s i t u . A met al t rans jugul ar bi ops y needl e i s pas s ed over t he wi re and advanced i nt o t he hepat i c vei n. One has t o avoi d bei ng t oo peri pheral (ri s k of caps ul ar punct ure). The wi re i s removed, and t he needl e advanced whi l s t s uct i on i s appl i ed. A bi ops y i s obt ai ned by t he Menghi ni t echni que. The bi ops i es obt ai ned are much poorer t han t hos e obt ai ned by convent i onal t echni ques . P.931
P.932
Transjugular intrahepatic porto-systemic shunt (TIPSS) Indications
Uncont rol l ed or recurrent bl eedi ng of oes ophageal or gas t ri c vari ces Di uret i c res i s t ant as ci t es
Principle
To l ower t he port al pres s ure acut el y, a s hunt i s pl aced bet ween a hepat i c vei n and port al vei n t ri but ary. Bl ood t hen fl ows from t he hi gh pres s ure port al s ys t em t o t he l ower pres s ure hepat i c venous s ys t em whi ch drai ns i nt o t he IVC. The l owered port al pres s ure t hen makes bl eedi ng from oes ophageal vari ces l es s l i kel y.
Pa g e 1 4 8 7
It i s carri ed out i n rel at i vel y few s peci al i s t cent res and i s t echni cal l y qui t e di ffi cul t . It s advant age i s t hat i t does not requi re a general anaes t het i c, t he ri s k i s l ower t han for a formal port acaval or mes ocaval s hunt procedure, and i t does not hi nder fut ure l i ver t rans pl ant at i on. The cent res carryi ng out mos t of t hes e procedures i n t he UK are The Royal Free Hos pi t al , London, Newcas t l e RI, Edi nburgh RI, and Addenbrookes , Cambri dge. Cont act your regi onal cent re i f you feel t hi s may be appropri at e.
Method
The i nt ernal jugul ar vei n i s cat het eri zed, and a cannul a pas s ed t hrough t he ri ght at ri um i nt o t he IVC, and i nt o an hepat i c vei n. The port al vei n i s l ocal i zed by USS, and a met al t rans jugul ar bi ops y needl e advanced t hrough t he l i ver s ubs t ance i nt o one of t he port al vei n t ri but ari es (us ual l y ri ght port al vei n). A wi re i s t hen pas s ed i nt o t he port al vei n and t he met al needl e wi t hdrawn, l eavi ng t he wi re joi ni ng t he hepat i c vei n and port al vei n. An expandabl e s t ent i s t hen pas s ed over t he wi re, and expanded by bal l oon i nfl at i on. A t ypi cal s t ent s i ze i s 812mm.
Complications

The mort al i t y i s ~3%, us ual l y from a caps ul ar punct ure. Hepat i c encephal opat hy occurs i n ~20%. Fai l ure t o reduce port al pres s ure may occur i f t here are l arge ext rahepat i c s hunt s . Thes e may need t o be embol i zed.
P.933
P.934
Percutaneous liver biopsy Procedure
Obt ai n pat i ent cons ent , warni ng of ri s k of bl eedi ng,
Pa g e 1 4 8 8
pneumot horax, gal l -bl adder punct ure, and fai l ed bi ops y. W arn about s houl der t i p pai n, whi ch may l as t s everal hours .
Ens ure prot hrombi n t i me i s <3 s econds prol onged cf. cont rol , and t he pl at el et count i s >80 10 /L, and t hat t here i s no ot her bl eedi ng di at hes i s (e.g. s evere renal fai l ure i n whi ch pl at el et funct i on i s i mpai red). Ot her cont rai ndi cat i ons are as ci t es , and pos s i bl y t umour dependi ng on pl anned management (ri s k of t umour s eedi ng). If avai l abl e al ways us e ul t ras ound gui dance, es peci al l y i f t he l i ver i s s mal l and ci rrhot i c. Y ou wi l l need a bi ops y needl e (Tru-cut or Menghi ni ), 1% l i gnocai ne, an orange (25G) and green (18G) needl e, 5ml s yri nge, a No. 11 s cal pel bl ade, i odi ne or equi val ent , s t eri l e t owel s , a pl as t er, s t eri l e gl oves , a dres s i ng pack, and a bot t l e of formal i n. Pre-medi cat e t he pat i ent wi t h an appropri at e amount of anal ges i a (e.g. 3060mg di hydrocodei ne) 1530 mi nut es before t he procedure. Li e t he pat i ent s upi ne wi t h t he ri ght hand behi nd t hei r head. Percus s t he upper border of t he l i ver i n expi rat i on and mark wi t h a pen. Sel ect a s i t e 2 i nt ercos t al s pace bel ow t he upper border, maki ng s ure i t i s not t oo cl os e t o t he cos t al margi n (and t hence gal l -bl adder). Cl ean t he s ki n wi t h ant i s ept i c and i nfi l t rat e wi t h l i gnocai ne as far as t he caps ul e. Al ways go jus t above a ri b, and make an i nci s i on wi t h t he s cal pel t o faci l i t at e t he l arger bi ops y needl e pas s i ng t hrough t he s ki n. The caps ul e i s fel t as a grat i ng feel i ng, and i f t he s yri nge i s al l owed t o fl oat on t he pal m of t he hand wi l l be s een t o move wi t h gent l e res pi rat i on when t he t i p of t he needl e has penet rat ed t he caps ul e. Do not prevent t he needl e from movi ng wi t h res pi rat i on as t hi s wi l l i ncreas e t he ri s k of caps ul ar t ear, and do NOT as k t he pat i ent t o breat he deepl y wi t h t he needl e i n t hi s
9
Pa g e 1 4 8 9
pos i t i on.
Remove t he needl e. Rehears e t he pat i ent as ki ng t hem t o breat he i n, t hen out and s t op (i n expi rat i on). It i s i mperat i ve duri ng t he act ual bi ops y t hat t hey do not t ake a s udden gas p of breat h. Rehears e i t s everal t i mes . W e fi nd i t us eful t o keep s ayi ng s t op, s t op et c. unt i l t he bi ops y i s compl et e. Avoi d s ayi ng hol d s i nce many pat i ent s wi l l t hen breat he i n at t he cruci al moment . Make a s mal l s ki n i nci s i on wi t h t he s cal pel and i ns ert t he bi ops y needl e when t he pat i ent i s at end expi rat i on. Aft er t he bi ops y (do not at t empt more t han 2 pas s es ), pl ace a pl as t er over t he s i t e and as k t he pat i ent t o l i e on t hei r ri ght s i de for 4 hours . Nurs i ng obs ervat i ons are pul s e and bp every 15 mi nut es for 1 hour, every 30 mi nut es for 2 hours , hourl y for 3 hours , 2 hourl y for 8 hours . Avoi d eveni ng or l at e aft ernoon bi ops i es .
Plugged biopsy technique

Thi s t echni que i s us ed i f t here i s a mi l d bl eedi ng di at hes i s , and can be performed when t he prot hrombi n t i me i s up t o 6 s econds prol onged wi t h a pl at el et count of > 40 000mm . The bi ops y i s done t hrough a s heat h and t he t ract embol i zed us i ng Gel foam t o t ry t o prevent bl eedi ng. Seek experi enced hel p. P.935
3
P.936
Acute peritoneal dialysis

Rarel y us ed but does not requi re vas cul ar acces s or ant i -coagul at i on. Provi des i ns uffi ci ent di al ys i s for t he hypercat abol i c pat i ent . (Creat i ni ne cl earance rat e of ~10ml /mi n
Pa g e 1 4 9 0
may be achi eved). Thi s requi res :
Peri t oneal di al ys i s cat het er (may be i ns ert ed under LA on t he ward) Int act peri t oneal cavi t y free of i nfect i on, herni ae, adhes i ons .
Complications of peritoneal dialysis

Peritonitis The commones t compl i cat i on of CAPD: 0.8 epi s ode/pt /yr. Infect i on occurs t hrough t he l umen of t he cat het er, al ong cat het er t ract , t rans mural l y from GIT, or haemat ogenous l y (rare).
Assessment
Common feat ures are cl oudy PD bag (99%), abdominal pai n (95%), and abdomi nal t endernes s (80%). Ot her feat ures i ncl ude fever (33%), naus ea and vomi t i ng (30%), l eucocyt os i s (25%), di arrhoea or cons t i pat i on (15%). Inves t i gat i ons : PD effl uent cel l count (peri t oni t i s i f >100 neut rophi l s /mm ), cul t ure PD fl ui d (i nocul at e a bl ood cul t ure bot t l e), Gram s t ai n PD fl ui d, FBC (for l eukocyt os i s ), bl ood cul t ures .
3
Management
Al l pat i ent s requi re ant i bi ot i cs , but may not requi re admi s s i on. The ant i bi ot i cs us ed depends on Gram s t ai n and cul t ure res ul t s . A t ypi cal prot ocol woul d be ci profl oxaci n or vancomyci n, pl us met roni dazol e. Pat i ent s who have hi gh fever wi t h l eukocyt os i s , and/or who are s ys t emi cal l y unwel l warrant IV ant i bi ot i cs . Gram-negat i ve i nfect i on, i n part i cul ar Ps eudomonas , i s as s oci at ed wi t h more s evere i nfect i on. Severe epi s odes may be accompani ed by i l eus , what ever t he organi s m. If pai n i s promi nent , gi ve anal ges i a (opi at e) and cons i der i nt ermi t t ent peri t oneal di al ys i s (IPD) i ns t ead of PD. Pat i ent s may l os e up t o 25g prot ei n/day i n s evere
Pa g e 1 4 9 1
cas es and s houl d recei ve adequat e nut ri t i onal s upport .
If t he i nfect i on i s res i s t ant t o t reat ment , cons i der removal of Tenckhoff cat het er and at ypi cal organi s ms (e.g. fungi ). Cons i der underl yi ng gas t roi nt es t i nal pat hol ogy es peci al l y i f mul t i bact eri al , Gram-negat i ve organi s ms , or ot her s ympt oms .
Fluid overload
Mi l d cas es may res pond t o hypert oni c exchanges (6.36% or 4.25% dext ros e), fl ui d res t ri ct i on (1 l i t re/day), and l arge dos es of di uret i cs (e.g. frus emi de 500mg bd). W i t h pul monary oedema, fl ui d removal i s bes t achi eved by rapi d cycl e IPD (4.25% dext ros e, 60 mi n cycl e t i me).
Poor exchanges

Cons t i pat i on may caus e mal pos i t i on of cat het er Mal pos i t i oned cat het er: The cat het er s houl d s i t i n pel vi s , but occas i onal l y fl i ps upwards t o l i e agai ns t t he di aphragm, caus i ng s houl der t i p pai n and poor drai nage. If t he pat i ent i s cons t i pat ed t ry l axat i ves , but may requi re s urgi cal repos i t i oni ng. P.937
Oment um wrappi ng around t i p of cat het er can be prevent ed by oment ect omy at t i me of i ns ert i on. Fi bri n debri s bl ocki ng cat het er s een as whi t e depos i t s i n effl uent . Treat by addi t i on of hepari n (1000U/l i t re) t o bags .
Hyperglycaemia
A s i gni fi cant amount of t he dext ros e i n peri t oneal di al ys i s s ol ut i ons i s abs orbed (es peci al l y wi t h heavy 4.26% dext ros e bags ). Renal fai l ure i nduces i ns ul i n res i s t ance, s o an el evat ed bl ood gl ucos e may occur, as wel l as hyperchol es t erol aemi a. Di abet i c pat i ent s requi re s peci al at t ent i on t o i ns ul i n t herapy.
Pa g e 1 4 9 2
P.938
Intermittent haemodialysis
A bl ood fl ow of ~250300ml /mi n i s needed acros s t he di al ys i s membrane. The equi val ent cl earance obt ai ned i s approxi mat el y 20ml /mi n.
Vascular access. Vas cul ar acces s may be obt ai ned by fas hi oni ng an AV s hunt us i ng t he radi al art ery, or more commonl y by us i ng a Vas cat h whi ch us es venous rat her t han art eri al bl ood. Thi s i nvol ves cannul at i on of t he i nt ernal jugul ar, s ubcl avi an, or femoral vei n. Anti-coagulation. Hepari n i s normal l y us ed. If cont rai ndi cat ed, e.g. recent haemorrhage, t hen pros t acycl i n may be us ed, but may caus e hypot ens i on and abdomi nal cramps . Haemodynamic stability. Pat i ent s wi t h mul t i -organ fai l ure commonl y devel op hypot ens i on duri ng haemodi al ys i s . Thi s may be amel i orat ed by hi gh s odi um di al ys at e, and pri mi ng t he ci rcui t wi t h 4.5% human al bumi n s ol ut i on.
Complications of haemodialysis
Hypotension Us ual l y occurs wi t hi n t he fi rs t 15 mi nut es of commenci ng di al ys i s . It probabl y i nvol ves act i vat i on of ci rcul at i ng i nfl ammat ory cel l s by t he membrane, os mot i c s hi ft s , and pos s i bl y l os s of fl ui d. T reat ment : Caut i ous fl ui d repl acement and i not ropes (wat ch for pul monary oedema i f over-t rans fus ed). Ri s k fac t ors or exac erbat i ng fac t ors for hypot ens i on

Mul t i -organ fai l ure Aut onomi c neuropat hy Val vul ar l es i ons (e.g. mi t ral regurgi t at i on, aort i c s t enos i s ) Arrhyt hmi as Peri cardi al t amponade MI or poor LV funct i on
Pa g e 1 4 9 3
Seps i s
Line infection Cent ral l i nes are a common focus of i nfect i on. W hen a di al ys i s pat i ent devel ops a fever of >38C i t s houl d be as s umed t hat t he neck l i ne i s i nfect ed even i f an al t ernat i ve s ept i c focus i s known. Management : Take bl ood cul t ures bot h peri pheral l y and from t he neck l i ne and repl ace t he cent ral l i ne (avoi d rai l roadi ng over t he previ ous l i ne). Treat empi ri cal l y wi t h vancomyci n 750mg1g i v i n 100ml N s al i ne over 1h at end of di al ys i s . Vancomyci n s houl d be gi ven s l owl y or s evere vas odi l at at i on may gi ve ri s e t o t he red man s yndrome. An al t ernat i ve i s t ei copl ani n 400mg i v fol l owed by 200mg i v dai l y. Bot h drugs are poorl y removed by haemodi al ys i s , a s i ngl e dos e wi l l ens ure t herapeut i c l evel s for s everal days . 90% wi l l be due t o St aph. aureus or epi dermi di s . Ri ght -s i ded endocardi t i s may occur (p132). Dialysis disequilibrium Thi s occurs duri ng t he i ni t i al di al ys i s es peci al l y i n pat i ent s wi t h marked uraemi a, and i s more common i n paat i ent s wi t h pre-exi s t i ng neurol ogi cal di s eas e. Cl i ni c al feat ures : Headache, naus ea and vomi t i ng, fi t s , cerebral oedema. T reat ment : Treat cerebral oedema as on p462. Short and s l ow i ni t i al di al ys es may prevent t hi s . Dialyser reaction Thi s i s caus ed by an IgE or compl ement res pons e agai ns t t he et hyl ene oxi de (s t eri l i zi ng agent ) or t he cel l ul os e component . Us e of bi ocompat i bl e membranes [e.g. pol ys ul fone, pol yacryl oni t ri l e (PAN)] or di al ys ers s t eri l i zed by s t eam or -i rradi at i on may prevent furt her react i ons . P.939 The ci rcui t s houl d al s o be ri ns ed wi t h N s al i ne. Cl i ni c al feat ures are of al l ergy: It chi ng, urt i cari a, cough and wheeze. Severe react i ons may caus e anaphyl axi s . Management : St op di al ys i s and t reat anaphyl axi s (s ee p258)ant i hi s t ami nes (chl orpheni rami ne 10mg i v), hydrocort i s one 100mg i v, bronchodi l at ors (s al but amol 5mg by nebul i z er), and, i f s evere, adrenal i ne (1mg i m). Air embolism Rare, pot ent i al l y fat al . Sympt oms may vary dependi ng on pat i ent 's pos i t i on. If s i t t i ng, ai r may pas s di rect l y t o t he
Pa g e 1 4 9 4
cerebral vei ns caus i ng coma, fi t s , deat h. If l yi ng, ai r may pas s t o R vent ri cl e and t hen t o pul monary ves s el s caus i ng SOB, cough, and ches t t i ght nes s . I f s us pec t ed : Cl amp di al ys i s l i nes , l i e pat i ent head-down on l eft s i de, admi ni s t er 100% O 2 by mas k. As pi rat i on of ai r wi t h an i nt racardi ac needl e may be at t empt ed i n ext reme ci rcums t ances .
Complications of haemodialysis

Hypot ens i on Li ne i nfect i on Di al ys i s di s equi l i bri um Di al ys i s react i on (al l ergy) Cramps Ai r embol i s m Haemorrhage
P.940
Haemofiltration and haemodiafiltration

Cont i nuous art eri ovenous haemofi l t rat i on (CAVH) i mpl i es bul k s ol ut e t rans port acros s a membrane and repl acement . Haemodi afi l t rat i on (CAVHD) i nvol ves t he pumpi ng of di al ys at e acros s t he ot her s i de of t he membrane. For bot h, art eri al bl ood (dri ven by art eri al pres s ure) i s cont i nuous l y fi l t ered at a rel at i vel y l ow fl ow rat e (50100ml /mi n). Cont i nuous venovenous haemofi l t rat i on i nvol ves pumpi ng bl ood from a venous acces s t o t he di al ys i s membrane (150200ml /mi n) (CVVH or CVVHD). The equi val ent GFR obt ai ned by t hes e are approxi mat el y 1530ml /mi n. Thes e are us ed mos t commonl y on ITU. Bot h of t hes e met hods caus e l es s haemodynami c i ns t abi l i t y, and are part i cul arl y us eful i n pat i ent s wi t h mul t i -organ fai l ure.
Plasmapheresis
A t herapy di rect ed t owards removal of ci rcul at i ng hi gh mol ecul ar wei ght compounds not removed by di al ys i s . Part i cul arl y us ed i n t he removal of ant i bodi es , or l i poprot ei ns .
Pa g e 1 4 9 5
Indications

Myas t heni a gravi s Gui l l ai nBarr s yndrome Goodpas t ure's s yndrome Thrombot i c t hrombocyt openi c purpura (TTP) Haemol yt i c uraemi c s yndrome (HUS) Severe hyperl i pi daemi a Mul t i -s ys t em vas cul i t i s Hypervi s cos i t y s yndrome (e.g. W al dens t rom's macrogl obul i naemi a) HLA ant i body removal
Method
Requi res cent ral venous acces s wi t h a l arge bore, dual l umen cannul a. Us ual l y fi ve t reat ment s es s i ons are gi ven on cons ecut i ve days . Pl as ma i s removed and repl aced wi t h, t ypi cal l y, 2 uni t s FFP, 3 l i t res 4.5% al bumi n. i v cal ci um (10ml 10% cal ci um gl uconat e) s houl d be gi ven wi t h t he FFP. Febri l e react i ons may occur as wi t h ot her bl ood product s . Pl as mapheres i s has no effect on t he underl yi ng rat e of ant i body product i on, but i s a us eful t reat ment i n acut e s i t uat i ons s uch as Goodpas t ure's and myas t heni a gravi s .
For HUS and TTP one mus t us e fres h frozen pl as ma ONLY (preferabl y cryodepl et ed), us ual l y a mi numum of 3L/day (s ee p704). For hypervi s cos i t y s yndrome, a cent ri fugat i on s ys t em i s requi red rat her t han a pl as ma fi l t er (s ee p728). For l i popheres i s t here may be s evere react i ons i f t he pat i ent i s on an ACE i nhi bi t or. An al t ernat i ve t o pl as mapheres i s i s i mmunoabs orpt i on i n whi ch 2 col umns are us ed i n paral l el . Thi s may be us ed i n t he removal of HLA ant i bodi es , ant i -GBM di s eas e, or mul t i -s ys t em vas cul i t i s .
P.941
P.942
Pa g e 1 4 9 6
Renal biopsy Indications (see table )

Bi ops y i s now performed us i ng real -t i me ul t ras ound gui dance.
Contraindications

Bl eedi ng di at hes i s unl es s correct abl e pri or t o bi ops y Sol i t ary funct i oni ng ki dney Uncont rol l ed hypert ens i on, i .e. di as t ol i c >100mmHg Uri nary t ract obs t ruct i on Smal l ki dneys , s i nce i t i s unl i kel y t o reveal any t reat abl e condi t i on Pat i ent unabl e t o compl y wi t h procedure (? bi ops y under GA)
Prior to biopsy

Check Hb, cl ot t i ng s creen, G&S s erum. Ens ure IVU or ul t ras ound has been carri ed out t o det ermi ne pres ence and s i ze of t wo ki dneys . Cons ent pat i ent quot i ng ~1% ri s k of bl eedi ng requi ri ng t rans fus i on. Do not at t empt t hi s i f you have not been t aught by an expert .
Technique
Y ou wi l l need a Tru-Cut or ot her bi ops y needl e (e.g. Bi opt i gun). Ens ure you are fami l i ar wi t h t he worki ngs of t he needl e. Pos i t i on pat i ent prone on bed wi t h pi l l ows under abdomen. Vi s ual i ze l ower pol e of ei t her ki dney wi t h ul t ras ound (ri ght ki dney l i es more i nferi orl y and may be eas i er t o i mage). St eri l i ze s ki n, drape wi t h t owel s . Infi l t rat e l ocal anaes t het i c (10ml 2% l i gnocai ne) under s ki n and t o
Pa g e 1 4 9 7
dept h of ki dney. Make a s mal l s ki n i nci s i on wi t h a s cal pel t o faci l i t at e ent ry of bi ops y needl e.
Ins ert bi ops y needl e as far as t he renal caps ul e under US gui dance. As k pat i ent t o hol d breat h i n at t he end of i ns pi rat i on (di s pl aces ki dney i nferi orl y) and t ake bi ops y from l ower pol e. Appl y s t eri l e dres s i ng. Bed res t for 24h t o mi ni mi ze ri s k of bl eedi ng. Moni t or bp and pul s e hal f hourl y for 2h, 1 hourl y for 4h, t hen 4 hourl y for 18h. Send renal bi ops y t i s s ue for l i ght mi cros copy, i mmunofl uores cence, and EM. Speci al s t ai ns (e.g. Congo red) i f i ndi cat ed.
Complications
Bl eedi ng: Mi cros copi c haemat uri a i s us ual ; macros copi c haemat uri a i n 510%; bl eedi ng requi ri ng t rans fus i on i n 1%. Format i on of an i nt rarenal AV fi s t ul a may occur, but i s rarel y of s i gni fi cance. If bl eedi ng occurs from t hi s , angi ography and embol i zat i on may be needed. Loi n pai n i f s evere s ugges t s bl eedi ng. Pneumot horax i s now rare. Il eus rarel y. Lacerat i on of l i ver, s pl een, bowel rarel y.
P.943
Renal transplant biopsy

Indications

Decl i ne i n t rans pl ant funct i on Pri mary non-funct i on pos t t rans pl ant
Procedure
In pri nci pl e t he t echni que i s s i mi l ar t o nat i ve renal bi ops y, t hough
Pa g e 1 4 9 8
t he t rans pl ant ed ki dney l i es more s uperfi ci al l y i n t he i l i ac fos s a. Ul t ras ound l ocal i zat i on i s us eful . Bi ops y may be t aken from ei t her upper or l ower pol e. Some cent res fi nd fi ne needl e as pi rat i on bi ops y (FNAB) us eful i n di agnos i s of t rans pl ant reject i on.
Indications for renal biopsy

Caus e i s unknown Heavy prot ei nuri a (>2g/day) Feat ures of s ys t emi c di s eas e Act i ve uri nary s edi ment Immune-medi at ed ARF Prol onged renal fai l ure (>2 weeks ) Sus pect ed i nt ers t i t i al nephri t i s (drug i nduced)
P.944
pH i determination (gastric tonometer)

Pat i ent s i n s hock have reduced s pl anchni c perfus i on and oxygen del i very. The res ul t i ng mucos al i s chaemi a may be di ffi cul t t o di agnos e cl i ni cal l y unt i l i t pres ent s as GI bl eedi ng or t he s eps i s s yndrome. The earl i es t change det ect abl e fol l owi ng an i s chaemi c i ns ul t t o t he gut i s a fal l i n i nt ramucos al pH. Gas t ri c mucos al pH paral l el s t he changes i n pH i n ot her port i ons of t he GI t ract and moni t ori ng t hi s al l ows det ect i on of gut i s chaemi a earl y.
1
A t onomet er i s es s ent i al l y an NG-t ube wi t h a s econd l umen l eadi ng t o a bal l oon whi ch l i es wi t hi n t he mucos al fol ds of t he s t omach. The bal l oon i s i nfl at ed wi t h 0.9% s al i ne for 3090 mi nut es . Thi s al l ows CO 2 from t he mucos a t o di ffus e i nt o t he s al i ne and equi l i brat e. The s al i ne i s t hen removed and anal ys ed for pCO 2 wi t h s i mul t aneous art eri al bl ood [HCO 3 ] meas urement . pH i i s t hen cal cul at ed us i ng a modi fi cat i on of t he Henders on-Has s el bal ch equat i on. The correct i on fact ors and equat i ons are s uppl i ed wi t h t he t onomet er and you are advi s ed t o cons ul t t he l i t erat ure t hat t he t onomet er i s s uppl i ed wi t h.
-
Pa g e 1 4 9 9
Footnote
1
Fi ddi an-Green RG, Baker S (1987) Cri t i c al Care Med 15 : 153156. P.945
P.946
Joint aspiration
Many s ynovi al joi nt s can be s afel y as pi rat ed by an experi enced operat or. Knee effus i ons are common and as ept i c as pi rat i on can be s afel y performed i n cas ual t y. The ri s k of i nduci ng a s ept i c art hri t i s i s l es s t han 1 i n 10 000 as pi rat i ons , but cert ai n rul es s houl d be fol l owed.

Anat omi cal l andmarks are i dent i fi ed The s ki n i s cl eaned wi t h al cohol or i odi ne A no t ouch t echni que i s es s ent i al .
Indications for synovial fluid aspiration in casualty

Sus pect ed s ept i c art hri t i s Sus pect ed crys t al art hri t i s Sus pect ed haemart hros i s Rel i ef of s ympt oms by removal of effus i on i n degenerat i ve art hri t i s .
Contraindications to joint aspiration

Overl yi ng s eps i s Bl eedi ng di at hes i s
Knee joint Pat i ent l i es wi t h knee s l i ght l y fl exed and s upport ed. The joi nt s pace behi nd t he pat el l a ei t her medi al l y or l at eral l y i s pal pat ed, t he s ki n cl eaned, and a needl e (18G, green) i ns ert ed hori z ont al l y bet ween t he pat el l a and femur us i ng a no-t ouch t echni que. There i s a s l i ght res i s t ance as t he needl e goes t hrough
Pa g e 1 5 0 0
t he s ynovi al membrane. As pi rat e on t he s yri nge unt i l fl ui d i s obt ai ned. Elbow joint Fl ex t he el bow t o 90 and pas s t he needl e bet ween t he proxi mal head of t he radi us (l ocat e by rot at i ng pat i ent s hand) and t he l at eral epi condyl e; or t he needl e can be pas s ed pos t eri orl y bet ween t he l at eral epi condyl a and t he ol ecranon. Ankle joint Pl ant arfl ex t he foot s l i ght l y, pal pat e t he joi nt margi n bet ween ext ens or hal l uci s l ongus (l at eral ) and t i bi al i s ant eri or (medi al ) t endons jus t above t i p of medi al mal l eol us . W hen s ynovi al fl ui d i s obt ai ned:

Not e t he col or and as s es s vi s cos i t y Mi cros copy for cel l count and crys t al s Gram s t ai n and cul t ure Synovi al fl ui d gl ucos e (cf. bl ood gl ucos e i n s eps i s ).
Synovial fluid analysis

Co Vis Op Le ndi cos aci uk tio ity ty oc n yte co unt (p er m m
3
) Nor Hi g Cl e <2 ma h ar 00 l Os t Hi g Cl e 10 eo h art hri t is ar 00 (< 50 % PM
Pa g e 1 5 0 1
N) Rh Lo Cl o 1 eu w ma t oi d udy 5 0 00 0 PM N Cry Lo Cl o 5 sta w l udy 5 0 00 0 PM N Se Lo Cl o 10 ps i w s udy 10 0 00 0 PM N
Pa g e 1 5 0 2
Approaches us ed for joi nt as pi rat i on (aft er Crawl ey M (1974) Br Hos p Med 11 : 74755) P.947
P.948
Intracranial pressure monitoring Indications
Cerebral t rauma (GCS 8, compres s i on of bas al ci s t ern on CT, mi d-l i ne s hi ft >0.5mm on CT, rai s ed ICP not requi ri ng s urgery) Acut e l i ver fai l ure (Grade 4 coma wi t h s i gns ICP)
Pa g e 1 5 0 3
Met abol i c di s eas es wi t h ICP (e.g. Reye's s yndrome) Pos t -operat i ve oedema (aft er neuros urgery) Aft er i nt racrani al haemorrhage (SAH or i nt racerebral ).
ICP moni t ori ng i n pat i ent s who are at ri s k of unexpect ed ri s es i n ICP s houl d i deal l y be s t art ed before s econdary brai n i njury has occurred, and where i t woul d i nfl uence management of t he pat i ent . As faci l i t i es i n neuros urgi cal cent res may be l i mi t ed, i t has been s ugges t ed t hat t hes e pat i ent s may be effect i vel y managed i n Di s t ri ct Hos pi t al s .
1
Contraindications

Uncorrect abl e coagul opat hy Local i nfect i on near pl acement s i t e or meni ngi t i s Sept i caemi a.
Method
There are s everal t ypes of devi ces avai l abl e (s ubdural , ext radural , parenchymal , or i nt ravent ri cul ar); parenchymal and i nt ravent ri cul ar moni t ors are more accurat e but carry a hi gher ri s k t han ext radural moni t ors . They s houl d be i mpl ant ed by experi enced pers ons onl y. There are pre-packaged ki t s avai l abl e (e.g. t he Codman s ubdural bol t ). Thi s moni t or i s i ns ert ed i n t he pre-front al regi on and t he ki t cont ai ns t he neces s ary s crews for creat i ng a burr-hol e, s pi nal needl es t o perforat e t he dura, et c. The ICP waveform obt ai ned i s a dynami c recordi ng t hat l ooks s uperfi ci al l y very s i mi l ar t o t he pul s e waveform. It i s due t o pul s at i ons of t he cerebral bl ood ves s el s wi t hi n t he confi ned s pace of t he crani um, wi t h t he effect s of res pi rat i on s uperi mpos ed. Cerebral perfus i on pres s ure = mean art eri al pres s ure-ICP. The normal res t i ng mean ICP meas ured i n a s upi ne pat i ent i s l es s t han 10mmHg (<1.3kPa). The l evel whi ch requi res t reat ment depends t o s ome
Pa g e 1 5 0 4
ext ent on t he di s eas e: i n beni gn i nt racrani al hypert ens i on val ues of ~40mmHg may not be as s oci at ed wi t h neurol ogi cal s ympt oms ; i n pat i ent s wi t h cerebral t rauma t reat ment s houl d be i ni t i at ed wi t h mean ICP >25mmHg, t hough t hi s val ue i s debat ed.
There are s everal t ypes of pres s ure waves des cri bed of whi ch t he mos t s i gni fi cant are A w aves s us t ai ned i ncreas es of t he ICP l as t i ng 1020 mi nut es up t o 50100mmHg (613kPa). Thes e are as s oci at ed wi t h a poor prognos i s . The readi ngs of t he ICP moni t ors s houl d al ways be accompani ed by careful neurol ogi cal exami nat i on. Treat ment of rai s ed ICP i s di s cus s ed on p452.
P.949
Complications

Infect i on (up t o 5%) Bl eedi ng (l ocal , s ubdural , ext radural , or i nt racerebral ) CSF l eak Sei z ures Mi s readi ng of ICP pres s ures .
Footnote
1
Goodwi n J et al . (1993) Cl i n I nt Care 4 : 190192. P.950
Lumbar puncture 1 Contraindications
Rai s ed i nt racrani al pres s ure (fal l i ng l evel of cons ci ous nes s wi t h fal l i ng pul s e, ri s i ng bp, vomi t i ng, focal s i gns , papi l l oedema). In general a CT s can s houl d al w ays be carri ed out pri or t o LP t o excl ude an
Pa g e 1 5 0 5
obs t ruct ed CSF s ys t em or SOL (s ee p452).
Coagul opat hy or pl at el et s (<50 10 /L).
You will need the following:

Spi nal needl es . Dres s i ng pack (s t eri l e gauze, drapes , ant i s ept i c, gl oves , pl as t er). Local anaes t het i c (e.g. 2% l i gnocai ne), 5ml s yri nge, orange (25G) and bl ue (22G) needl es . 3 s t eri l e bot t l es for col l ect i ng CSF and gl ucos e bot t l e. Manomet er and 3-way t ap for meas uri ng t he openi ng CSF pres s ure.
Procedure
For s us pect ed meni ngi t i s , ant i bi ot i cs s houl d be gi ven fi rs t (s ee p432).

Expl ai n t he procedure t o t he pat i ent . Spend t i me pos i t i oni ng t he pat i ent , t hi s i s cruci al t o s ucces s . Li e pat i ent on t hei r l eft s i de (or R s i de i f you are l eft handed), wi t h back on edge of bed, ful l y fl exed (knees t o chi n), wi t h a fol ded pi l l ow bet ween t hei r l egs , keepi ng t he back perpendi cul ar t o t he bed. Fl exi on s eparat es t he i nt ers paces bet ween t he vert ebrae. The s afes t s i t e for LP i s t he L4L5 i nt ers pace (t he s pi nal cord ends at L1L2). An i magi nary l i ne drawn bet ween t he i l i ac cres t s i nt ers ect s t he s pi ne at t he L4 proces s or L4L5 s pace exact l y. Mark t he L4,5 i nt ervert ebral s pace (e.g. wi t h a bal l poi nt pen). Cl ean t he s ki n wi del y and pl ace t he s t eri l e drapes over t he pat i ent . Inject 0.250.5ml 2% l i gnocai ne under s ki n at pen mark wi t h t he 25G needl e. Anaes t het i ze t he deeper s t ruct ures wi t h t he 22G needl e. Us e t he anaes t het i c s pari ngl y: t hi s may di s t ort t he anat omy maki ng t he procedure di ffi cul t and unneces s ari l y l onger. Ins ert t he s pi nal needl e (s t i l et t e i n pl ace) i n t he
Pa g e 1 5 0 6
mi d-l i ne, ai mi ng s l i ght l y crani al l y (t owards umbi l i cus ), hori zont al t o t he bed. Do not advance t he needl e wi t hout t he s t yl et i n pl ace.
W i t h experi ence, you wi l l feel t he res i s t ance of t he s pi nal l i gament s , and t hen t he dura, fol l owed by a gi ve as t he needl e ent ers t he s ubarachnoi d s pace. Al t ernat i vel y, peri odi cal l y remove t he s t yl et and l ook for es cape of CSF. Repl ace t he s t yl et before advanci ng. Meas ure CSF pres s ure wi t h manomet er and 3-way t ap. Normal openi ng pres s ure i s 720cm CSF wi t h t he pat i ent i n t he l at eral pos i t i on. CSF pres s ure i s i ncreas ed wi t h anxi et y, SAH, i nfect i on, s pace occupyi ng l es i on, beni gn i nt racrani al hypert ens i on, CCF. Col l ect 0.51.5ml fl ui d i n 3 s eri al l y numbered bot t l es and remember t o fi l l t he gl ucos e bot t l e. Send s peci mens prompt l y for mi cros copy, cul t ure, prot ei n, gl ucos e (wi t h a s i mul t aneous pl as ma s ampl e for compari s on), and where appropri at e, vi rol ogy, s yphi l i s s erol ogy, cyt ol ogy for mal i gnancy, AFB, P.951
ol i gocl onal bands (mul t i pl e s cl eros i s ), crypt ococcal ant i gen t es t i ng, Indi a i nk s t ai ns , and fungal cul t ure.

Remove needl e and pl ace a pl as t er over t he s i t e. Pat i ent s houl d l i e fl at for at l eas t 6h and have hourl y neurol ogi cal obs ervat i on and bp meas urement . Encourage fl ui d i nt ake.
Pa g e 1 5 0 7
Lumbar puncture 2 Complications of lumbar puncture
Headac he : Common (up t o 25%). Typi cal l y pres ent when t he pat i ent i s upri ght and bet t er when s upi ne. May l as t for days . Thought t o be from i nt racrani al t ract i on due t o CSF depl et i on from a pers i s t ent l eak from t he LP s i t e. May be prevent ed by us i ng fi ner s pi nal needl es , keepi ng t he pat i ent s upi ne for 612 hours pos t LP, and encouragi ng fl ui d i nt ake. Treat wi t h s i mpl e anal ges i a, fl ui ds , and reas s urance.
Pa g e 1 5 0 8
T rauma t o nerve root s : Rarer but s een i f t he needl e does not s t ay i n t he mi d-l i ne. The pat i ent experi ences s harp pai ns or paras t hes i ae down t he l eg. W i t hdraw t he needl e and i f t he s ympt oms pers i s t , s t op t he procedure and s eek expert hel p. Bl eedi ng : Mi nor bl eedi ng may occur wi t h a t raumat i c t ap when a s mal l s pi nal vei n i s ni cked. The CSF appears bl oody (s ee bel ow) but t he bl eedi ng s t ops s pont aneous l y and does not requi re s peci fi c t herapy. Coagul opat hy, s evere l i ver di s eas e, or t hrombocyt openi a carri es t he ri s k of s ubarachnoi d/s ubdural bl eedi ng and paral ys i s . Coni ng : Herni at i on of cerebel l ar t ons i l s wi t h compres s i on of t he medul l a i s very rare unl es s t he pat i ent has rai s ed ICP. Al ways get a CT brai n s can pri or t o LP and revi ew t hi s yours el f i f pos s i bl e. Mort al i t y i s hi gh, but t he pat i ent may res pond t o s t andard meas ures for t reat i ng t hi s (s ee p452). I nfec t i on : Rare i f proper s t eri l e t echni que us ed.
CSF analysis
Ly mp No hoc rm yt e al s val <4 ue /m s: m ; pol ym orp hs 0m m
3 3
Pa g e 1 5 0 9
Pro t ei n <0. 4g/ L Gl u cos e >2. 2m mo l /L (or >7 0% pl a sm a l ev el ) Op eni ng pre ssu re <2 00 mm CS F
Pa g e 1 5 1 0
Ba Vir T B cte al me rial nin giti s Ap Tur Cl e Cl e pe bi d ar ar ar an ce Cel 5 5 5 ls m

3
2 5 1 0 0
(m 00 00 00 ) Ma Ne Ly Ly in ut r mp mp cell op hoc hoc typ hi l yt e yt e e Glu Ver Nor Lo cos y e (m M) Pr Oft 0.5 Oft ote en en in /L ) Ot Gra PC Zi e he m r sta tes i n ts Bac R hl Ni e el s on >1. 0.9 >1. 0 (g 0 ma w l ow l
Pa g e 1 5 1 1
t eri al ant i ge n
Fl u ore s ce nt t es t PC R
Bloody tap: Art efact i s i ndi cat ed by fewer red cel l s i n s ucces s i ve bot t l es , no yel l owi ng of CSF (xant hochromi a). The t rue W BC count may be es t i mat ed by:
True CSF W BC = CSF W BC - Bl ood W BC CSF RBC/bl ood RBC (i .e. i f t he pat i ent 's bl ood count i s normal , s ubt ract approx. one whi t e cel l for every 1000 RBC). To es t i mat e t he t rue prot ei n l evel s ubt ract 10mg/L P.953 for every 1000 RBCs /mm (be s ure t o do t he count and prot ei n es t i mat i on on t he s ame bot t l e).
Subarachnoid haemorrhage: (s ee p466) xant hochromi a (yel l ow CSF). Red cel l s i n equal numbers i n al l bot t l es . The RBCs wi l l exci t e an i nfl ammat ory res pons e (CSF W CC), mos t marked aft er 48h. CSF prot ei n: Acous t i c neuroma and s pi nal t umours ; Gui l l ai nBarr; s yndrome (p512).
Pa g e 1 5 1 2
> Bac k of Book > Resourc es > Appendic es > Referenc e int ervals
Reference intervals
Reference intervals: biochemistry (Always consult your local laboratory)
Substance Aci d phos phat as e (t ot al ) Aci d phos phat as e (pros t at i c) ACTH Al ani ne ami not rans feras e (ALT) Al bumi n 1 Al dos t erone Al kal i ne phos phat as e -fet oprot ei n Amyl as e 1 Angi ot ens i n II Ant i di uret i c hormone (ADH) As part at e t rans ami nas e (AST) Bi carbonat e Bi l i rubi n Cal ci t oni n Cal ci um (i oni zed) Cal ci um (t ot al ) Chl ori de 2 Chol es t erol LDL chol es t erol HDL chol es t erol Cort i s ol am mi dni ght Reference interval 15IU/l i t re 01IU/l i t re <80ng/l i t re 535IU/l i t re 3550g/l i t re 100500pmol /l i t re 30300IU/l i t re (adul t s ) <10kU/l i t re 0180 Somogyi U/dl 535pmol /l i t re 0.94.6pmol /l i t re 535IU/l i t re
2430mmol /l i t re 317mol /l i t re (0.251.5mg/dl ) <0.1g/l i t re 1.01.25mmol /l i t re 2.122.65mmol /l i t re 95105mmol /l i t re 3.95.5mmol /l i t re 1.554.4mmol /l i t re 0.91.93mmol /l i t re 450700nmol /l i t re 80280nmol /l i t re Creat i ne ki nas e (CK) Men 25195IU/l i t re W omen 25170 IU/l i t re Creat i ni ne 70130mol /l i t re C-react i ve prot ei n (CRP) 010 Ferri t i n 12200g/l i t re Fol at e 56.3 nmol /l i t re (2.12.8g/L) -gl ut amyl t rans pept i das e Men 1151IU/l i t re
Pa g e 1 5 1 3
(-GT) Gl ucos e (fas t i ng) Gl ycos yl at ed haemogl obi n (HbA 1 C) Growt h hormone Iron Lact at e dehydrogenas e (LDH) Magnes i um Os mol al i t y Parat hyroi d hormone (PTH) Phos phat e (i norgani c) + Pot as s i um (K ) Prol act i n Pros t at e s peci fi c ant i gen (PSA) Prot ei n (t ot al ) Red cel l fol at e 1 Reni n (erect /recumbent ) + Sodi um (Na ) Thyroi d s t i mul at i ng hormone (TSH) Thyroxi ne (T4) Thyroxi ne (free) Tot al i ron bi ndi ng capaci t y (TIBC) Tri gl yceri de (fas t i ng) Tri -i odot hyroni ne (T3) Urea Urat e
W omen 733IU/l i t re 3.55.5mmol /l i t re 58% <20mU/l i t re Men 1431mol /l i t re W omen 733IU/l i t re 70250IU/l i t re 0.751.05mmol /l i t re 278305mos mol /kg <0.88.5pmol /l i t re 0.81.45mmol /l i t re 3.55.0mmol /l i t re Men <450 U/L; W omen < 600U/L 04ng/ml 6080g/l i t re 0.361.44mol /L (160640g/L) 2.84.5/1.12.7pmol /ml /h 135145mmol /l i t re 0.33.8mU/l i t re 70140nmol /l i t re 10.026.0pmol /l i t re 5475mol /l i t re
0.551.90mmol /l i t re 1.23.0nmol /l i t re 2.56.7mmol /l i t re Men 0.210.48mmol /l i t re W omen 0.150.39mmol /l i t re Vi t ami n B 1 2 0.130.68nmol /l i t re (>150ng/l i t re) 1 The s ampl e requi res s peci al handl i ng: cont act t he l ab. 2 The l evel of chol es t erol s houl d be t aken i n cl i ni cal cont ext . Loweri ng l evel s above 5.5mmol /L reduces morbi di t y and mort al i t y i n pri mary and s econdary prevent i on t ri al s . P.956
Reference intervals: urine

Su Re bst fer
Pa g e 1 5 1 4
an en ce ce int erv al Adr 0.0 en 3 al i 0 ne .10 mo l /2 4h Cor tis ol 2 (fr 80 ee) nm ol / 24 h Do 0.6 pa 5 mi 2 ne .70 mo l /2 4h Hy 16 dro xyi 73 nd ol e mo ace l /2 t i c 4h
Pa g e 1 5 1 5
aci d (HI AA) Hy 16 dro xy 48 me t hy mo l m l /2 an 4h del ic aci d (H MM A, VM A) Me 0.0 t an 3 ep 0 hri .69 nes mo l /m mo l cre at i ni n e Nor 0.1 adr 2
Pa g e 1 5 1 6
en 0 al i .5 ne m ol / 24 h Os 35 mo 0 l al i 1 t y 00 0m os mo l /k g Ph 15 os p hat 50 e mm (i n ol / org 24 ani h c) Pot 14 as s iu m 12 0m mo l /2 4h So 10 di u 0 m 2 50 mm ol /
Pa g e 1 5 1 7
24 h
P.957
Reference intervals: cerebrospinal fluid

s ee p952.
Reference intervals: ascitic fluid

s ee p657.
Reference intervals: haematology

M e a s ur e m e nt R ef er e n c e in te rv W B al 3. 2
Pa g e 1 5 1 8
C ( w hi te bl o o d ce ll
1 1. 0 1 0
9
/L
s) R M 4. B e 5 C n (r e d bl o o d ce 6. 5 1 0
12
/L l l W 3. s) o 9 m e n 5. 6 1 0
12
/L
Pa g e 1 5 1 9
H M 1 a e 3. e n 5 m o gl o bi n (H b) 1 8. 0 g/ dl W1 o 1. m 5 e n 1 6. 0 g/ dl H M 0. a e 4 e n m at oc ri t (H C T) or p ac ke d 0. 5 4 l/ L W 0. o 3 m 7 e n 0.
Pa g e 1 5 2 0
ce ll vo lu m e( P C V) M e a n ce ll vo lu m e ( M C V) M e a n ce ll h a e m o gl
4 7l /L
8 2 9 8f l
2 6. 7 3 3. 0 p g
Pa g e 1 5 2 1
o bi n ( M C H) M e a n ce ll h a e m o gl o bi n co nc e nt ra ti o n ( M C H C) 3 1. 4 3 5. 0 g/ dl
Pa g e 1 5 2 2
Pl at el et co u nt
1 2 0 4 0 0 1 0
9
/L N %4 e ut ro p hi ls 0 7 5 % A 1. bs 9 . n o. 7. 7 1 0
9
/L M % 3. o n oc 0
Pa g e 1 5 2 3
yt es
1 1. 0 % A 0. bs 1 . n o. 0. 9 1 0
9
/L E % 0. os in o p hi ls 0 7. 0 % A 0. bs 0 . n o. 0. 4 1 0
9
/L B % 0. as o 0
Pa g e 1 5 2 4
p hi ls
1. 0 % A 0. bs 2 . n o. 0. 8 1 0
9
/L Ly % 2 m p h oc yt es 0 4 5 % A 1. bs 3 . n o. 3. 5 1 0 R et ic
9
/L 0. 8
Pa g e 1 5 2 5
ul oc yt e co u nt
1
2. 0 % (2 5 1 0 0 1 0 ) d e p e n ds o n a g e (& in a n a
9
/L Er yt hr oc yt e se di m e nt at io n ra te
Pa g e 1 5 2 6
e m ia ) (E M ~ S e (a R) n g e in ye ar s) -2 W~ o (a m g e e n in ye ar s + 1 0) Pr ot hr o m bi n ti 2 1 0 1 4 se co
Pa g e 1 5 2 7
m e (P T) -f ac to rs II , VI I, a n d X Ac ti va te d p ar ti al th ro m b o pl as ti n ti
n ds
3 5 4 5 se co n ds
Pa g e 1 5 2 8
m e (A P T T) -f ac to rs VI II , IX , XI , a n d XI I
1
Onl y
us e percen t ages i f red cel l count is normal ; ot herw ise us e
Pa g e 1 5 2 9
abs ol u te val ue.
P.958
Guidelines on oral anti-coagulation

Int Cli er nic nat al ion co al ndi no tio rm n ali ze d rat io (I NR ) 2.0 Tre at 3.0 me nt
Pa g e 1 5 3 0
of DV T, PE, TIA s; chr oni c AF. 3.0 Rec urr 4.5 ent DV Ts an d PEs ; art eri al gra ft s an d art eri al di s eas e (i n cl u di n g
Pa g e 1 5 3 1
MI) ; pro sth et i c car di a c val ves .
Aci d bas e nomogram i n t he i nt erpret at i on of art eri al bl ood gas es (aft er Fl enl ey DC(1971) Lanc et I: 2703)
Pa g e 1 5 3 2
Nomogram for body s i ze
Page 1533
> Bac k of Book > Resourc es > Appendic es > Useful t elephone numbers
Useful telephone numbers

Useful telephone numbers Liver Units
Royal Free Hos pi t al , London Addenbrookes Hos pi t al , Cambri dge Freemans Hos pi t al , Newcas t l e Queen El i zabet h Hos pi t al , Bi rmi ngham St James Hos pi t al , Leeds Edi nburgh Royal Infi rmary, Edi nburgh Ki ngs Col l ege Hos pi t al , London 0207 794 0500 01223 245 151 0191 284 3111 0121 472 1311 0113 243 3144 0131 536 1000 0207 737 4000
UKTS
Uni t ed Ki ngdom Trans pl ant Servi ce 0117 975 7575
Pa g e 1 5 3 4
Poisons Units
Nat i onal Hel pl i ne 0870 600 6266
National Teratology Unit

Drug & Chemi cal Expos ure i n Pregnancy 0191 232 5131
Tropical and Infectious Diseases

Ho 02 s pi 07 t al 38 for 7 Tro 44
Pa g e 1 5 3 5
pi c 11 al Di s eas es , Lon do n Nor 02 t h 08 wi c 86 k k, 9 31 Par 28 Lon (da do yt i n me ) 02 08 86 4 32 32 (ou t of ho urs , bl e ep i nf ect i ou
Pa g e 1 5 3 6
s di s eas es reg istr ar) Li v 01 erp 51 ool 70 8 93 93 Gl a 01 s go 41 w 21 1 10 00
Anti-venom kits for snakebites

For i nformat i on on i dent i fi cat i on and management cont act : Oxf 01 ord 86 (ad 5 vi c 22 e 0 onl 96 y) 8 Li v 01 erp 51 ool 70 8 93 93
Pa g e 1 5 3 7
Li v 01 erp 51 ool 52 (s u 9 ppl 32 y onl y) Lon 02 do 07 n 77 1 53 94 26
Virus reference laboratory

Col 02 i nd 08 al e 20 , 0 Lon 44 do 00 n
Page 1538
> Bac k of Book > Resourc es > Appendic es > Change in names of c ert ain medic inal subst anc es
Change in names of certain
medicinal substances
Current l y bot h Bri t i s h Approved Names (BANs ) and recommended Int ernat i onal Non-Propri et ary Names (rINNs ) are i n us e i n t he UK and for s ome s ubs t ances t hes e names di ffer, gi vi ng ri s e t o confus i on and t he ri s k of medi cat i on error. Si nce 1 December 2003, where t he names di ffer t he rINN i s t he correct name. Former BAN Acros oxaci n Amet hocai ne Amoxyci l l i n Amyl obarbi t one Amyl obarbi t one Sodi um Becl omet has one Bendrofl uazi de Benoryl at e Benz hexol Benz t ropi ne Bus ul phan But obarbi t one Cart i cai ne Cephal exi n Cephamandol e Nafat e Cephaz ol i n Cephradi ne Chl oral bet ai ne Chl orbut ol Chl ormet hi azol e Chl orpheni rami ne Chl ort hal i done Chol ecal ci ferol Chol es t yrami ne Cl omi phene Col i s t i n Sul phomet hat e Sodi um Cort i cot rophi n Cycl os pori n Cys t eami ne Dant hron New BAN Ros oxaci n Tet racai ne Amoxi ci l l i n Amobarbi t al Amobarbi t al Sodi um Becl omet as one Bendrofl umet hi azi de Benori l at e Tri hexypheni dyl Benzat ropi ne Bus ul fan But obarbi t al Art i cai ne Cefal exi n Cefamandol e Nafat e Cefazol i n Cefradi ne Cl oral bet ai ne Chl orobut anol Cl omet hi azol e Chl orphenami ne Chl ort al i done Col ecal ci ferol Col es t yrami ne Cl omi fene Col i s t i met hat e Sodi um Cort i cot ropi n Ci cl os pori n Mercapt ami ne Dant ron
Pa g e 1 5 3 9
Des oxymet has one Dexamphet ami ne Di bromopropami di ne Di cycl omi ne Di enoes t rol Di met hi cone (s ) Di met hyl Sul phoxi de Dot hi epi n Doxycycl i ne Hydrochl ori de (Hemi hydrat e Hemi et hanol at e) Eformot erol Et hams yl at e Et hi nyl oes t radi ol Et hynodi ol Fl umet has one Fl upent hi xol Fl urandrenol one Frus emi de Ges t ronol Guai phenes i n Hexachl orophane Hexami ne Hi ppurat e Hydroxyurea Indomet haci n Li gnocai ne Lys uri de Met hi mazol e Met hot ri meprazi ne Met hyl Cys t ei ne Met hyl ene Bl ue Mi t oz ant rone Mus t i ne Ni coumal one Oes t radi ol Oes t ri ol Oes t rone Oxpent i fyl l i ne Phenobarbi t one Pi pot hi azi ne Pol yhexani de Pot as s i um Cl orazepat e Pramoxi ne Procai ne Peni ci l l i n Prot hi onami de Qui nal barbi t one Ri bofl avi ne Sal cat oni n Sodi um Cal ci umedet at e Sodi um Cromogl ycat e Sodi um Ironedet at e Sodi um Pi cos ul phat e
Des oxi met as one Dexamfet ami ne Di brompropami di ne Di cycl overi ne Di enes t rol Di met i cone Di met hyl Sul foxi de Dos ul epi n Doxycycl i ne Hycl at e Formot erol Et ams yl at e Et hi nyl es t radi ol Et ynodi ol Fl umet as one Fl upent i xol Fl udroxycort i de Furos emi de Ges t onorone Guai fenes i n Hexachl orophene Met henami ne Hi ppurat e Hydroxycarbami de Indomet aci n Li docai ne Li s uri de Thi amazol e Levomepromaz i ne Mecys t ei ne Met hyl t hi oni ni um Chl ori de Mi t oxant rone Chl ormet hi ne Acenocoumarol Es t radi ol Es t ri ol Es t rone Pent oxi fyl l i ne Phenobarbi t al Pi pot i azi ne Pol i hexani de Di pot as s i um Cl orazepat e Pramocai ne Procai ne Benzyl peni ci l l i n Prot i onami de Secobarbi t al Ri bofl avi n Cal ci t oni n (s al mon) Sodi um Cal ci um Edet at e Sodi um Cromogl i cat e Sodi um Feredet at e Sodi um Pi cos ul fat e
Pa g e 1 5 4 0
Sorbi t an Monos t earat e St i bocapt at e St i l boes t rol Sul phacet ami de Sul phadi azi ne Sul phamet hoxaz ol e Sul phapyri di ne Sul phas al azi ne Sul phat hi azol e Sul phi npyraz one Tet racos act ri n Thi abendazol e Thi oguani ne Thi opent one Thymoxami ne Thyroxi ne Sodi um Tri bavi ri n Tri meprazi ne Urofol l i t rophi n
Sorbi t an St earat e Sodi um St i bocapt at e Di et hyl s t i l bes t rol Sul facet ami de Sul fadi azi ne Sul famet hoxaz ol e Sul fapyri di ne Sul fas al azi ne Sul fat hi azol e Sul fi npyrazone Tet racos act i de Ti abendazol e Ti oguani ne Thi opent al Moxi s yl yt e Levot hyroxi ne Sodi um Ri bavi ri n Al i memazi ne Urofol l i t ropi n
Page 1541
> Bac k of Book > Resourc es > Appendic es > ECG Ruler
ECG Ruler
Pa g e 1 5 4 2
Page 1543
Fi gure. No capt i on avai l abl e.
Page 1544
> Bac k of Book > Resourc es > Appendic es > Color Plat es
Color
Plates
Pl at e 1: Eryt hema nodos um. The l es i ons can be very fai nt , but are i ndurat ed and pai nful on pal pat i on.
Pl at e 2: Bl i s t ers of bul l ous pemphi goi d. Large, t ens e, rai s ed l es i ons are s een on an eryt hemat ous ecz emat i zed bas e.
Pa g e 1 5 4 5
Pl at e 3: Eryt hema mul t i forme on t he l eg, not e t he pres ence of t arget l es i ons .
Pl at e 4: Morbi l l i form erupt i on caus ed by admi ni s t rat i on of ampi ci l l i n t o a pat i ent wi t h i nfect i ous mononucl eos i s .
Pa g e 1 5 4 6
Pl at e 5: Acut e papi l l oedema.
Pl at e 6: The t ypi cal appearance of cyt omegal ovi rus ret i ni t i s i n a pat i ent wi t h AIDS, charact eri zed by ret i nal necros i s wi t h an i rregul ar granul ar border, pat chy ret i nal haemorrhage, and ret i nal i nfl ammat ory s heat hi ng of t he ret i nal ves s el s .
Page 1547
Pl at e 7: Hard exudat es and cot t on-wool s pot s i n t he ri ght eye.
Pl at e 8: Cent ral ret i nal vei n occl us i on wi t h as s oci at ed cl os ure of t he art eri al ci rcul at i on above t he macul a.
Footnote
The dermat ol ogy pl at es are t aken from: Rona M MacKi e (2003) Cl i ni c al dermat ol ogy , fi ft h edi t i on. Oxford Uni vers i t y Pres s , Oxford (wi t h permi s s i on) The opht hal mol ogy pl at es are t aken from: Davi d L Eas t y and John M Sparrow (eds ) (1999) Oxford T ext book of Opht hal mol ogy . Oxford Uni vers i t y Pres s , Oxford (wi t h permi s s i on).
Pa g e 1 5 4 8

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Contributors to the second edition

Advice on chapter revisions was also given by the following

Foreword to the first edition by Professor John Ledingham

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Adult basic life support

Assessment of the patient

As s es s s i gns of ci rcul at i on by feel i ng t he carot i d pul s e for no more t han 10 s econds .

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Adult advanced life support