Emergency Medicine

MEDICATIONS Mechanism of Action Uses and dosages Adverse Effects

@ RED ZONE
Sodium Bicarbonate reacts with H+ ions o Cardiac Arrest Aggravated CHF
bicarbonate to form water & carbon dioxide. (IV sodium bicarbonate 100mg) Cerebral hemorrhage
8.4% 10 ml It acts as a buffer against o Hyperkalemia Edema
acidosis by raising blood pH o Metabolic Acidosis (Non-Life- Hypernatremia
(Alkalinizing Threatening) Hypocalcemia
Agents) Hypokalemia
Tetany
Metabolic alkalosis
Atropine Competitively inhibits action of o Sinus Bradycardia (ACLS) Anticholinergic
sulphate ACh on autonomic effectors - First line drug symptoms (mydriasis,
1.0mg/ml innervated by postganglionic - 0.5mg IV every 3-5 min, hyperthermia,
nerves total max dose is 3mg tachycardia, cardiac
(Antimuscarinic) o Asystole/Pulseless Electrical arrhythmia, delayed
Increases firing of the SA Node Activity (ACLS) gastric emptying)
by blocking the action of the - 1mg IV every 3-5min
vagal nerve on the heart
resulting in an increased heart # Atropine should be avoided in
rate hypothermic bradycardia and it will
not be effective for Mobitz type
II/Second Degree Block Type 2.
Adrenaline - Strong alpha-adrenergic o Symptomatic brady (ACLS) Angina
injection effects, which cause an - Second-line drug Anxiety
1mg/ml increase in cardio output - 2-10 mcg /min Apprehensiveness
and HR, a decrease in renal o Cardiac arrest (ACLS) Cardiac arrhythmias
(Alpha/Beta perfusion and PVR, and a - 1mg IV every 3-5min Dizziness
Adrenergic variable effect on BP, Dyspnea
Agonists) resulting in systemic Flushing
vasoconstriction and Headache
increased vascular Hypertension
permeability Nausea
- Strong beta1- and Nervousness
moderate beta2-adrenergic Pallor
effects, resulting in Palpitations
bronchial smooth muscle Respiratory difficulties
relaxation Restlessness
Sweating
Tachycardia
Tremor
Vasoconstriction
Vomiting
Weakness

50% Glucose Parenteral dextrose is oxidized Hypoglycemia Hyperosmolarity

injection to carbon dioxide and water, IV: 10-25 g (ie, 20-50 mL 50% Hypervolemia
10ml and provides 3.4 cal/gram of d- solution) Phlebitis
glucose Pulmonary edema

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Cerebral hemorrhage
Cerebral ischemia
Hyperglycemia
Injection site
extravasation

Combivent Salbutamol: COPD Bronchitis

(Ipratropium Beta2-adrenergic bronchodilator In patients on regular Upper respiratory tract
bromide bronchodilator who continue to infection
anhydrous Ipratropium: have bronchospasm and require Lung disease
0.5mg, Anticholinergic second bronchodilator Headache
Salbutamol (parasympatholytic) agent; Dyspnea
sulphate 3mg) inhibits vagally mediated Nebulizer solution: 3 mL inhaled Nasopharyngitis
reflexes by antagonizing every 6hr; not to exceed 3 mL Cough
acetylcholine action; prevents every 4hr Pharyngitis
increase in intracellular calcium Pain
concentration caused by Chest pain
interaction of acetylcholine with Sinusitis
muscarinic receptors on Nausea
bronchial smooth muscle Diarrhea
Urinary tract infection
Influenza
Leg cramps
Nausea
Pneumonia
Rhinitis

Ref: ACLS guideline,

medscape

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Trauma mx USES Measure Size

Oropharyngeal airway Only in unconscious patient to prevent the From angle of mouth to angle of
tongue from mandible
falling back

# Nasopharyngeal airway is used for pt with

presence of gag reflex

Nasopharyngeal airway From tip of nose to tragus

Cervical collar Indication Measure the distance from the base

- Primary purpose - to provide NEXUS criteria ( criteria used to det whether of the patient's neck/ shoulder to
a high degree of the need of cervical-spine imaging) the angle of the mandible with your
immobilisation for a patients - Altered level of consciousness fingers
cervical spine, while - Intoxication (under drug)
maintaining the cervical - Tenderness @ cervical region
spine in neutral alignment. - Focal neurologic deficit
- Should be used with a spine - Distracting injury
board, head immobilisation
devices, and strapping
appropriate for securing the
patients body to the board
Types 3) Semi-rigid neck collar
1) Soft collar
2) Rigid collar

In-line immobilization The aim of Manual In-Line stabilisation is - Without the support of other
- For a pt with the detection or twofold: immobilisation devices,it has
suspicion of SCI as 1st - To provide immediate temporary - never been proven to be safe.
stabilisation of the cervical spine. Further splinting will be

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procedure in spinal mx.
o From behind the patient, the
immobiliser places their
hands over the patients ears
o Then places the thumbs of
each hand against the
posterior aspect of the
patients skull
and at the same time the
immobiliser places both of
their little fingers just above
the patients angle of the
mandible.
o The immobiliser now places
their index and ring fingers of
each hand on either side of
the appropriate cheek bone
of the patient
Pelvic immobilization
Indication
Pelvic ring # / open book #
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- To join the head to the chest to stabilise required before transport or
the neck. movement.
- A semi-rigid Cervical Collar will
at best provide only 50%
immobilization
MANUAL IN-LINE STABILISATION: SIDE
o The immobiliser stands at the side of the
patient, then passes one hand cups the
back of the patients head
o Place the thumb and first finger of their
other hand on the patients cheeks so
that it grasps the patient
# If the patients head is not in the neutral
in-line position, slowly realign it, unless
contraindicated
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1. A sheet wrap
- Applied around the center of
the trochanter to reduce and
maintain a pelvic fracture

Fx
For stabilization of pelvic #
To reduce the bleeding
To strap the pelvis
2. Pelvic binder
The correct application should
ensure that the flat square
portion of the Pelvic binder is
under the patients buttocks and
that the middle strap is
overlapping the patients greater
trochanteric and pubic region

3. Pelvic C-clamp
- Allows rapid reduction and
stabilization of these
unstable pelvic ring fractures
- Consists of two pins applied
to the posterior ilium in the
region of the sacroiliac joints

Spring test Chest spring Pelvic spring

Spring the chest from front to back,
or from side to side, between your
hands.
If this causes severe pain he has
probably broken some ribs
Patient is positioned prone.
The examiner then applies a
downward pressure, creating a
shear of the sacrum on the ilium and
then an upward pressure to the iliac
Positive test: Pain in the SI joint
/crepitus

Chin lift Maneuver --- when performing chin-lift maneuver in trauma pt, the head is not tilted and
cervical spine is maintained in a neutral position

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Jaw thrust Maneuver

The jaw-thrust maneuver
allows for the lifting of the
epiglottis and enlargement
of the laryngeal inlet and
the pharynx, indicated by
an increased glottic
opening and resulting in
improved ventilation

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ADVANCED LIFE SUPPORT

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Use of Defibrillators
1. Defibrillation
2. Synchronous cardioversion
3. Cardiac monitoring
4. Transcutaneous pacing
Synchronous cardioversion Defibrillation
Use for pulse tachycardia Use for pulseless tachy
- In unstable tachy - Unstable tachy
- Stable tachy - resistance to pharmacological
cardioversion (adenosine/verapamil)
Narrow regular: 50-100 J Biphasic 200 J
Narrow irregular: 120-200 J biphasic / 200 J Monophasic 360 J
monophasic
Wide (QRS >0.12s) regular : 100J

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FAST (Focused Sonography Assessment for Trauma) The FAST scan is a 4 view scan reliant on
detecting the presence of fluid within the
pericardium and most dependent zones of the
peritoneum in the horizontal patient

THE VIEWS
Subcostal view Demonstrate both the liver and heart, in a 4 chamber view.
The heart is easily recognizable, due to its characteristic motion.
The heart will be surrounded by a rim of echogenic
pericardium.
Any discrete blackness between this rim and the heart wall
represents fluid in the pericardial sac.
Right Upper Quadrant View demonstrate the liver, kidney and diaphragm.
(Morisons Pouch) Morrison's pouch represents the potential space between the
capsule of the liver and the fascia around the kidney.
A black rim between the 2 organs represents free intraperitoneal
fluid.
Left Upper Quadrant View demonstrates the spleen, kidney and diaphragm
Any evidence of a black rim between the 2 organs represents free
intraperitoneal fluid.
Suprapubic View demonstrates the bladder
A blackness at POD fluid in POD

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Criteria for intubation Before intubation

Respiratory distress L Look (syndromic face, obese, pointed chin, beard)

o Tachypneic (PaO2 < 60,
PaCO2 > 60)
o SpO2 < 85%
o High lactate
Failure ventilation/ oxygenation
GCS < 8 (for trauma pt)
E Evaluate 3.3.2
3 finger mouth opening-interincisor distance (Patils test)
3 finger btw mentum to the hyoid bone
2 finger thyromental distance
M Mallampati scoring
O Obstruction
N Neck stiffness

Rapid sequence Induction (RSI) ---7P

Def: administration, after preoxygenation, of a potent induction agent followed immediately by a

rapid acting neuromuscular blocking agent (NMBA) to induce unconsciousness and motor paralyses
for tracheal intubation.

1. Preparation
o Pt explain to pt
o Equipment (MALESSSS)
Mask Stylete
Airway Suction
Laryngoscope Stethoscope
ET tube (male: 7.5 8.5, female: 6.5-7.5) Syringe
o Medication (analgesic + sedation + ms relaxant)
2. Pre-oxygenation (3-5min/ until SpO2 > 95%) to wash out nitrogen at functional residual
capacity
3. Pre-medication + cardiac monitorin
o Analgesic IV fentanyl 100mcg
o Sedation IV midazolam 5mg/ propofol
o Muscle relaxant IV scoline 100mcg (suxamethonium)
4. Cricoid pressure to facilitate intubation
5. Placement of ET tube
6. Confirmation of placement
o Direct visualization
o Equal chest rise
o 5 pt auscultation (apex rt n lt, midaxial rt n lt, epigastric)
o Misting demisting/ vapour
o CXR
7. Post-intubation care
o Insert ryles tube to decompress the stomach
o Sedation eg: IVI midazolam 2ml/hr
o Post intubation ABG

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