Professional Documents
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MEDICAL MASTERCLASS
EDITOR-IN-CHIEF
ACUTE MEDICINE
EDITOR
Second Edition
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Disclaimer
Although every effort has been made to ensure that drug doses
and other information are presented accurately in this publication, the
ultimate responsibility rests with the prescribing physician. Neither the
publishers nor the authors can be held responsible for any consequences
arising from the use of information contained herein. Any product
mentioned in this publication should be used in accordance with the
prescribing information prepared by the manufacturers.
LIST OF CONTRIBUTORS
Dr J Dulay FRCP
Consultant Physician
Southampton University Hospital NHS Trust
Southampton
Dr CA Eynon FRCP
Director of Neurosciences Intensive Care
Wessex Neurological Centre
Southampton General Hospital
Southampton
Dr SE Fairbain MRCP(UK)
Specialist Respiratory Registrar
Llandough Hospital
South Wales
Published by:
Royal College of Physicians of London
11 St. Andrews Place
Regent’s Park
London NW1 4LE
United Kingdom
Distribution Information:
Jerwood Medical Education Resource Centre
Royal College of Physicians of London
11 St. Andrews Place
Regent’s Park
London NW1 4LE
United Kingdom
Tel: +44 (0)207 935 1174 ext 422/490
Fax: +44 (0)207 486 6653
Email: merc@rcplondon.ac.uk
Web: http://www.rcplondon.ac.uk/
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CONTENTS
v
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FOREWORD
Since its initial publication in 2001, Medical Masterclass has been regarded
as a key learning and teaching resource for physicians around the world.
The resource was produced in part to meet the vision of the Royal College of
Physicians: ‘Doctors of the highest quality, serving patients well’. This vision
continues and, along with advances in clinical practice and changes in
the format of the MRCP(UK) exam, has justified the publication of this
second edition.
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PREFACE
The 12 textbooks are divided as follows: two cover the scientific background
to medicine, one is devoted to general clinical skills [including specific
guidance on exam technique for PACES, the practical assessment of clinical
examination skills that is the final part of the MRCP(UK) exam], one deals
with acute medicine and the other eight cover the range of medical
specialties.
The core material of each of the medical specialties is dealt with in seven
sections:
• Communication and ethical scenarios – what are the difficult issues that
commonly arise in each specialty? What do you actually say to the
‘frequently asked (but still very difficult) questions?’
• Acute presentations – what are the priorities if you are the doctor seeing
the patient in the Emergency Department or the Medical Admissions
Unit?
• Self assessment questions – in the form used in the MRCP(UK) Part 1 and
Part 2 exams.
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PREFACE
I hope that you enjoy using Medical Masterclass to learn more about
medicine, which – whatever is happening politically to primary care,
hospitals and medical career structures – remains a wonderful occupation.
It is sometimes intellectually and/or emotionally very challenging, and also
sometimes extremely rewarding, particularly when reduced to the essential
of a doctor trying to provide best care for a patient.
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CONTENTS
ACKNOWLEDGEMENTS
Medical Masterclass has been produced by a team. The names of those who
have written or edited material are clearly indicated elsewhere, but without
the support of many other people it would not exist. Naming names is risky,
but those worthy of particular note include: Sir Richard Thompson (College
Treasurer) and Mrs Winnie Wade (Director of Education), who steered the
project through committees that are traditionally described as labyrinthine,
and which certainly seem so to me; and also Arthur Wadsworth (Project
Co-ordinator) and Don Liu in the College Education Department office. Don
is a veteran of the first edition of Medical Masterclass, and it would be fair to
say that without his great efforts a second edition might not have seen the
light of day.
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CONTENTS
KEY FEATURES
We have created a range of icon boxes that sit among the text of the
various Medical Masterclass modules. They are there to help you identify key
information and to make learning easier and more enjoyable. Here is a brief
explanation:
x
AM_C01 12/15/10 10:16 Page 1
ACUTE MEDICINE
Authors:
J Dulay, CA Eynon, SE Fairbain and L Keating
Editor:
CA Eynon
Editor-in-Chief:
JD Firth
AM_C01 12/15/10 10:16 Page 3
death or within the 14 days not only the person completing scrutinise the scenario very
before death. part 1 but also one of the carefully for details; in routine
nursing staff or another medical clinical practice look through
• Death was violent, unnatural or
practitioner involved in the case to the notes and speak to any staff
suspicious.
ensure there were no suspicious present who may be able to give
• Death may be due to an accident circumstances. you useful information. This is
(whenever that occurred). essential, not only to inform
1.1.2 Stroke appropriate decision-making, but
• Death may be due to self-neglect
also in discussing the issue with
or neglect by others.
Scenario the family. They are much more
• Death may be due to an industrial likely to accept advice from a
disease or related to the person’s Role: you are a junior medical doctor who clearly knows the
employment. doctor on-call for the wards. patient, Mr Patel, rather than
one who seems to regard him as
• Death may be due to an abortion. ‘just another old man who’s had
An 80-year-old man, Mr Anand
• Death occurred during an Patel, has been admitted to a big stroke’.
operation or before recovery hospital with a dense left
• The scenario states that ICU care
from the effects of anaesthetic. hemispheric stroke resulting in
is not appropriate, but if that is
aphasia and a right hemiparesis.
• Suicide. so then what care is to be given?
He has a background history
If the patient were to develop a
• Death occurred during or shortly of prostatic carcinoma, left
chest infection, are you are going
after detention in police or prison ventricular failure, atrial
to try a course of antibiotics or
custody. fibrillation and chronic
is only comfort care indicated?
obstructive pulmonary disease.
These issues may be spelled out
Who should be notified following a His Glasgow Coma Scale score
in a PACES scenario, but in
cardiac arrest? has fallen to 7 (E2, M4, V1),
routine clinical practice it is very
which is presumed to be due
• The coroner may be required to be important to establish and agree
to an extension of his stroke.
notified (see above). amongst the medical and nursing
The consultant has reviewed
team exactly what treatments
• The patient’s GP. the patient and feels that
will and will not be given before
intensive care unit (ICU)
• The consultant responsible for the embarking on discussions with a
care is inappropriate and
management of the patient should patient’s relatives.
that the patient should not be
be notified as soon as possible. resuscitated in the event of • What do the family know already
cardiopulmonary arrest. and what are their expectations?
Who fills in the death certificate? They may have expected Mr Patel
• Part 1 should be completed by Your task: you are asked to to make a full recovery with
one of the medical team caring for explain to the family what supportive care.
the patient. It should include the has happened and why it would
date of death and details as to the be inappropriate to attempt Key points to establish
presumed cause. It has sections resuscitation in the event of
cardiopulmonary arrest. • Get the setting right: ideally you
detailing whether information
need a quiet room adjacent to the
is available (or may become
ward where you are not going to
available later) from a post-
be interrupted. Ensure that you
mortem and whether the Key issues to explore
have left your bleep (and mobile
coroner has been informed. What preparations should you make
phone) with a colleague. Take
before speaking to the family?
• Part 2 is completed by a medical one of the senior ward nurses
practitioner with at least 5 years • Obtain as much information as support (both for the family
of experience. Following the as possible about the patient’s and yourself). The room should
Shipman enquiry, the person comorbidities and functional ideally have a supply of tissues
completing part 2 will contact level before his stroke: in PACES and a telephone.
this. Futile treatments (such as Doctor: yes, I can arrange that. The Key points to explore
resuscitation or transfer to ICU) consultant saw your father earlier What is the patient’s main worry? Why
will not be given. today on the ward round. She is does he want further investigation?
aware of your father’s condition, and
• Explain the management plan:
the plan that I have outlined to you Key points to establish
her father will be given treatments
is the one that she made. However,
to alleviate his symptoms and to • The history and examination have
she is not in the hospital at the
ensure that he is comfortable and given reassuring results: the pain
moment. If you would like to speak
dignified (some people may be is not sinister; he does not have
to someone right away, then I can
worried that a ‘Do not resuscitate’ cancer of the spine (or any similar
find out if the on-call registrar is
order means that no treatment problem).
available to answer any questions
will be given).
you may have that I cannot answer, • Further tests are not indicated at
or if one of the doctors on the ICU this stage.
Appropriate responses to likely
could speak to you, but I’m sure that
questions • There are simple strategies for
they will tell you what I’ve already
coping with the pain.
Daughter: why isn’t he on the said. I’m very sorry. I’d like to be
intensive care unit? able to say something different, but • What to do if the pain fails to settle.
your father is dying and we must
Doctor: I’m sorry to have to tell you
make sure he’s comfortable. Appropriate responses to likely
that your father is dying. He has
questions
been given treatment for his heart
1.1.4 Lumbar back pain
with oxygen, diuretics – drugs to Patient: can you guarantee this pain
get fluid out of the body – and other won’t come back?
Scenario
drugs to help the heart beat more
Doctor: no, I’m afraid that
strongly, but despite all of these
Role: you are a junior doctor on unfortunately I can’t guarantee that.
the situation is deteriorating. Your
the medical assessment unit. The prognosis for mechanical back
father’s heart, lungs, kidneys and
pain is good, with 90% of sufferers
brain are all failing. There is no
You have taken a history and recovering by 6 weeks, but
treatment that will reverse this, on
examined a 40-year-old man, recurrence is common.
the ICU or anywhere else; nothing
Mr Chris Pitman, who called
that will alter the final outcome. Patient: how do you know I don’t
999 with severe lumbar back
have anything seriously wrong with
Daughter: is there nothing more you pain. He is usually fit and well,
me without an X-ray?
can do for him? but has a 2-day history of pain
radiating down his left leg. There Doctor: I’m afraid that an X-ray
Doctor: we can try to make his
are no red flags in the history or will not be helpful here. As I’ve said,
breathing easier for him, we can
on examination. Examination I don’t think that there is a sinister
make sure that he is comfortable
confirms a diagnosis of mechanical problem: I don’t think that you have
and dignified, and we will ensure
back pain. You have prescribed cancer of the spine or anything like
that he is not in any pain.
appropriate analgesia. On review, that. But even if you did, then it’s
Daughter: you are only saying this his pain has settled and you want extremely unlikely that a simple
because that’s what my brother thinks. to discharge him to the care of X-ray would show anything.
his GP. He is insistent that he You’d need other special scans.
Doctor: no, that’s not true. We
needs X-rays prior to discharge.
have spoken about things with your Patient: so shouldn’t I have the
brother, and he does agree with our special scans then?
Your task: to explain to
plan for treatment. But decisions
the patient that no further Doctor: no, I don’t think so. The
about treatment are made us, by
investigation is needed at chances of them showing anything
the medical team, and not by your
this stage and that he can would be extremely small and they
brother or anyone else. We have
be discharged back to his GP are not without risks: some of these
made what we think is the right plan.
for follow-up with referral to scans would expose you to radiation.
Daughter: can I speak to someone physiotherapy if required. However, if the pain continues
more senior about this? beyond 6 weeks then the matter
should be reconsidered. It is Key issues to explore Doctor: yes, I am, at least partly.
important that you arrange to see What are the patient’s concerns People who don’t smoke can get
your GP when you get home, so that regarding discharge? Are there any pneumonia, but smoking damages
he or she can review your symptoms problems with regards to discharge some of the mechanisms that clear
and see if anything further needs to and recuperation at home? Is there infection from the lungs, so as a
be done at that time. a support network available if he is smoker you are more prone to
discharged? respiratory illnesses. Smoking
Patient: is there nothing you can do
will also delay your recovery from
for me?
Key points to establish such an illness, so it is important
Doctor: yes, there is. I can give you to consider stopping seriously. If
some strong painkillers, some anti- • Explain the diagnosis and
you want to try to do this, I would
inflammatories and some tablets to that the treatment plan is
suggest that you discuss matters
help muscle spasm. All of these can in line with current national
with your GP or contact one of the
help and it is advisable for you to recommendations.
relevant support groups.
stay as active as possible. Even
• Explore issue of smoking Patient: what if my symptoms
simple exercises can help. Your
cessation in light of the patient’s deteriorate and I don’t get better?
family doctor could organise a
current illness.
referral to a physiotherapist if Doctor: as I said, I don’t expect your
things don’t settle down quickly. • Give details of who he should symptoms to deteriorate. However,
contact if he has any concerns, if things do not improve or if there
1.1.5 Community-acquired and suggest reattendance if any are any problems then you should
pneumonia there are problems. contact your GP for advice. And if
• Explain follow-up plans after things got really bad, which I am not
Scenario
discharge. expecting, then you could come back
Role: you are a junior doctor on
up to the Emergency Department,
call in the acute medical Appropriate responses to likely although I think it very unlikely
assessment unit. questions that this will be necessary.
Who should be resuscitated? Fig. 1 European Resuscitation Council (ERC) guidelines for single-rescuer BLS.
• If an organised rhythm is
present during a period of CPR,
do not suspend the CPR unless
the patient starts to show signs
of life. If a perfusing rhythm
has been restored, giving chest
compressions does not increase
the chances of VF recurring.
Treatment of non-VF/VT
• Recommence CPR.
• Check electrode/paddle positions
and contact.
• Obtain and secure the patient’s
airway and administer high-flow
oxygen.
• Obtain intravenous access.
• Administer 1 mg epinephrine
(adrenaline) intravenously every
3–5 minutes.
• Assess for potentially reversible
causes.
• Reassess rhythm and defibrillate as
necessary.
saline; palpate for an abdominal What role do buffers have in the form if it is standard hospital
aortic aneurysm; and check for management of cardiac arrest? practice).
rectal bleeding. Adequate ventilation and tissue
• Routine investigations: ECG,
perfusion is the best way to treat the
• Hypokalaemia/hyperkalaemia electrolytes, renal function,
combined metabolic and respiratory
and metabolic disorders: check CXR and arterial blood gases.
acidosis seen in cardiac arrest. In
the patient’s clinical history
specific cases of arrest associated • Other investigations: pursue
(if available) for clues. If the
with tricyclic antidepressant reversible factors as dictated by
patient has a known renal disease,
overdose, hyperkalaemia and clinical suspicion.
presume hyperkalaemia is present
pre-existing metabolic acidosis,
and give 10 mL of 10% calcium If the patient remains unconscious,
giving sodium bicarbonate
chloride or calcium gluconate transfer to the intensive care unit or
intravenously may be of benefit.
intravenously. neuro critical care unit (NCCU) is
• Hypothermia: the patient is never What role does pacing have in the required if active management is to
dead until warm and dead. management of cardiac arrest? be pursued. Cerebral cooling may
External pacing of asystole has be considered: two randomised
• Tension pneumothorax: consider trials have shown improved outcome
shown no clinical benefit. Pacing
especially in patients with in unconscious adult patients
may be of occasional use for the
pre-existing lung disease or in with spontaneous circulation after
treatment of ventricular standstill.
those on a ventilator. Look for out-of-hospital VF arrest who were
asymmetrical chest, deviated cooled to 32–34°C. This is thought
Outcome following cardiac arrest
trachea and unilateral absence of to suppress reperfusion injury.
Return of spontaneous circulation
breath sounds. Immediate needle It is unclear whether cooling is
(ROSC) occurs in about 30% of
decompression of the affected side beneficial for patients who remain
in-hospital cardiac arrests, but only
is mandatory. unconscious after resuscitation
around 15% of patients survive to
• Tamponade: diagnosis is difficult. hospital discharge. Only 2% of from other rhythms.
There is nothing to lose by out-of-hospital arrests survive to
attempting pericardiocentesis. hospital discharge. The survival When should an unsuccessful
rate for VF/VT is 10 –15 times higher attempt at CPR be stopped?
• Toxins including drug overdose:
than for non-VF/VT. Survival from If ROSC does not occur promptly,
check clinical history for clues.
VF/VT correlates with the time taken consideration must be given to
• Pulmonary embolism: always before the first shock is applied, with termination of the attempt. Delays of
consider as a potential primary an approximately 10% reduction more than 5 minutes before the start
diagnosis. in patient survival for each minute of BLS or more than 30 minutes to
taken. Over 80% of patients defibrillation are associated with a
Further comments resuscitated from VF/VT are done very poor prognosis. The presence of
so with one of the first three shocks. systemic sepsis, disseminated cancer
Antiarrhythmics in the and major organ failure are also
management of cardiac arrest If you are successful in predictors of very poor outcome. Age
There is no clear evidence for the resuscitating the patient, what itself is not an independent predictor
use of antiarrhythmics in cardiac should be done? for the success of resuscitation, but
arrest. Although atropine is of use comorbidities are more common
• Transfer to an appropriate area for
for haemodynamically significant and result in lower survival rates
monitoring and treatment.
bradycardia, its use in asystole is in the elderly. Hypothermia and
based on limited data. In cases • Monitoring: ECG, SaO2 and non- the ingestion of some cerebral
of VF, amiodarone administered invasive BP. depressants (sedatives, hypnotics
following three initial shocks and narcotics) provide some
• Treatment: high-flow oxygen.
has been shown to improve the measure of cerebral protection, but
short-term survival of patients • Debrief of the medical team in the absence of reversible factors,
until hospital admission compared and nursing staff involved attempts to resuscitate a patient
with placebo or lidocaine (a nominated person should from non-VF/VT arrest should be
(lignocaine). complete a cardiac arrest audit terminated after 20 minutes.
Priorities
• Resuscitation: airway, breathing Hypoxia kills, hypercapnia
Relatives should only
and circulation (ABC). merely intoxicates
be allowed to observe
resuscitation if there is a trained • Try to establish a diagnosis Even patients with known chronic
member of staff present whose sole obstructive pulmonary disease should
(Table 1).
responsibility is to support them. To receive high-flow oxygen if they are
have relatives watching with no one to in extremis. The oxygen may buy
explain what is going on and attend to Resuscitation you enough time to institute other
their needs is asking for trouble. Regardless of the specific diagnosis, treatments and the patient can then
your priorities must be to correct be slowly weaned from it according to
any problem with airway, breathing blood gas analysis.
or circulation.
1.2.2 Chest pain and
hypotension Circulation Two large (grey)
venflons should be inserted into
Scenario Get help early for any patient
the antecubital fossae. If you
who is extremely unwell. Don’t are confident that a patient is
A 48-year-old male taxi driver has worry about establishing a diagnosis: hypovolaemic (exceedingly unlikely
been brought into the Emergency ask for senior assistance. If necessary, in this case), then give intravenous
Department. He is complaining of put out a cardiac arrest call: it is much fluids quickly to the hypotensive
better to get the arrest team there to
chest pain and breathlessness. patient until the circulation is
help than to wait until the patient’s
He has a pulse rate of 130 bpm heart has stopped. restored. In most cases 0.9%
and his BP is 80/40 mmHg. You (normal) saline will be appropriate
are asked to see him urgently by initially. If there is evidence of acute
the nurse in charge. Airway/breathing Ensure blood loss, then blood should be
the patient’s airway is patent: transfused: an emergency cross-
consider the placement of a match should be available within
Introduction nasopharyngeal or oropharyngeal 20 –30 minutes, but if fluid
airway if conscious level is replacement is more urgent than
depressed. Apply an oxygen this then colloid solutions can be
saturation monitor. Give high- given (or O negative blood).
In dealing with a patient who
is very ill, resuscitation should flow oxygen. If the patient does
begin immediately and history-taking, not respond promptly to this
examination and investigation should or is ventilating inadequately, then
be concurrent. To start by trying to Resuscitation should be
intubation and ventilation may
take a detailed history from someone swift! There is no merit in
be required. Call for anaesthetic
who is dying is likely to end in death resuscitating more slowly than is
and is not good medicine! assistance sooner rather than possible.
later.
Chest pain
• Dull, crushing, central chest pain
radiating to the neck or arms in
association with nausea, vomiting,
pallor and sweating would suggest
a primary cardiac cause.
Breathlessness
• Did the breathlessness come on
Fig. 3 Left subclavian line and iatrogenic left pneumothorax. suddenly or gradually? Sudden
onset (in an instant) suggests starting from the shoulder, and Cardiovascular
pneumothorax, large airway observe where the change occurs. In addition to assessing the overall
obstruction or PE. Is there any Patients who are septic have a adequacy of the cardiovascular
suggestion that the patient has high cardiac output with low system, check carefully for the
had multiple small PEs? systemic resistance, such that following when performing the
they are peripherally vasodilated cardiovascular examination.
• Has the patient suffered from
with warm sweaty skin.
orthopnoea or paroxysmal • Can you feel the left radial pulse
nocturnal dyspnoea? These would • Check the capillary return by as well as the right? If it seems
suggest pulmonary oedema, but pressing on the nail-bed to blanch to be diminished, measure BP in
be aware that a patient with any it and then measuring the time both arms and consider aortic
cause of breathlessness will not taken for the colour to return on dissection.
want to lie down. releasing the pressure: normally
it should be less than 2 seconds; • Can you hear any murmurs?
Any other features? more than 5 seconds is clearly Acute mitral valve regurgitation
abnormal. or a ventricular septal defect can
• Has the patient been feverish or complicate an acute myocardial
systemically unwell? Could he • Heart rate and rhythm, BP when infarction and cause catastrophic
have a severe pneumonia? lying and standing (or sitting, if heart failure (see Cardiology,
the patient is too unwell to stand), Section 1.4.4). Always consider
• Has the patient had leg pain or
and height of the JVP should the possibility of bacterial
swelling, or had haemoptysis?
always be measured. Measure the endocarditis when a murmur
These would clearly point towards
JVP in centimetres from the angle is discovered (see Cardiology,
PE in this context.
of Louis, angling the patient up Sections 1.4.7 and 2.8.1).
or down until venous pulsation
Other relevant history • Consider PE: look for leg swelling,
is seen: it is not good enough to
It will clearly be important to find elevated JVP, right ventricular
settle for ‘venous pressure not
out if the patient has previously had heave, right ventricular gallop
elevated’.
problems with angina or myocardial and loud P2.
infarction, or (much less likely) • Simple measures of organ perfusion
any of the other diagnoses listed in include the ability of the patient • Consider pericardial effusion: it
Table 1. If he says ‘the pain is just to respond to questioning and the is easy to overlook this possibility
like when I had a heart attack last amount of urine produced per hour. (Fig. 4), but the signs of pulsus
year’, then the diagnosis is almost
made.
Examination
Fig. 5 ECG of acute anterior myocardial infarction with early Q-wave formation.
Fig. 6 ECG of acute pericarditis: the ST-segment changes are obvious but note also the depressed PR interval shown especially in leads II and aVF.
Pericarditis
A therapeutic trial of aspirin or
other NSAIDs can sometimes help
in diagnosing pericarditis; relief of
pericarditic pain commonly occurs
within 20 minutes (see Cardiology,
Sections 1.4.8 and 2.6.1).
Oesophageal pain
Inevitably, there will be some
situations in which it is impossible
to decide between an oesophageal
and a cardiac aetiology. In these
situations, your fall-back position
must be to consider it cardiac until
proved otherwise.
Fig. 7 Mediastinal CT scan showing the classical appearances of aortic dissection: note the ‘tennis-ball’
appearance of the ascending and descending aorta.
Diagnostic uncertainty
Two-dimensional echocardiography
can identify regional wall
abnormalities in patients with
cardiac ischaemia and may also detect
important prognostic information
such as systolic dysfunction. Fig. 8 Transoesophageal echocardiogram showing the flap of dissection in the aorta.
1.2.4 Hypotension in acute History of the presenting problem • JVP: if this is markedly raised,
coronary syndrome This man is unlikely to respond well consider right ventricular
to attempts to take a lengthy history infarction, ventricular septal
Scenario from him, but important things defect (VSD), tamponade or
to find out, from him and from pulmonary embolism. A low JVP
A 72-year-old man is admitted to scrutiny of the observation charts, would be a surprise in this clinical
the coronary care unit with chest include the following. context, but if found consider
pain. He has known ischaemic the possibility of gastrointestinal
• Is he in pain? Ongoing or new
heart disease and has had bleeding, especially if
pain in an acute coronary
previous coronary artery bypass thrombolysis has been given.
syndrome may indicate
grafts. On presentation he was
development of ST-elevation • Auscultation of the heart:
sweaty, with BP 120/70 mmHg
myocardial infarction (in other a new pansystolic murmur
and a clear chest. His ECG on
words, an acute myocardial would suggest a VSD or mitral
arrival in the Emergency
infarction, AMI), or cardiac regurgitation as a result of chordal
Department showed ST-segment
rupture. or papillary muscle rupture; a
depression and T-wave changes
gallop rhythm would be expected.
inferiorly. He was commenced • Has his BP fallen suddenly or
on maximal medical therapy, gradually? A sudden onset of low • Crackles in the chest, indicating
including aspirin, intravenous BP in association with new chest pulmonary oedema.
nitrates, intravenous beta- pain is again suggestive of cardiac
• Pulse oximetry.
blockers, low-molecular-weight rupture. Low BP in association
heparin and clopidogrel. It is now with breathlessness resulting from Quantitate the patient’s ‘drowsiness’
6 hours since his admission: he left ventricular pump failure tends by checking his score on the
has become drowsy and his BP to be more gradual in onset. Glasgow Coma Scale. Depression
has fallen to 70/50 mmHg. You
• What drugs has he been given? of consciousness may be due to
are bleeped to review him
Look closely for a temporal hypotension, opioids (how much
urgently.
relationship between his morphine has he had? Are pupils
hypotension and the pinpoint? If so, give naloxone) or,
administration of drugs. particularly if thrombolysis has been
Introduction Although not applicable in this given, stroke (look for deviation of
The cause of profound hypotension gaze, facial asymmetry and
case, hypotension during infusion
in a patient with an acute coronary hemiparesis).
of streptokinase is common and
syndrome can usually be established
usually occurs during the first
by examining the patient, obtaining Investigation
20 minutes.
an ECG and CXR, and review of the See Sections 1.2.2 and 1.2.3 for
drug chart. fuller discussion, but the following
Examination
Key features to concentrate on are clearly vital in this case.
include the following. • ECG: repeat to assess cardiac
Check airway, breathing and • Peripheral perfusion: it is a poor rhythm and look for evidence of
circulation, and begin ongoing ischaemia. In particular,
prognostic sign if the patient is
management immediately.
shut down. How far up the arms has an inferior infarct pattern
• Administer high-flow oxygen and and legs is he cold? developed and are there signs of
monitor pulse oximetry. right ventricular infarction?
• Check heart rate and rhythm, and • Heart rate and rhythm: could a
the BP in both arms. secondary tachycardia or • CXR: will give some information
• Obtain intravenous access (if not about pre-existing chest and
bradycardia be the cause of
already established).
hypotension? cardiac conditions (cardiac shape
• Give 250 mL fluid bolus if the chest
is clear. and size) as well as an assessment
• BP in both arms: could the patient
• Stop any drugs that may be of pulmonary congestion.
have had an aortic dissection in
contributing to hypotension.
• Call for help early. association with an inferior • Echocardiogram: likely to be the
myocardial infarction? most useful investigation in this
• Look at his fluid balance chart: is causes for fever in a postoperative Respiratory
he in a significant positive balance patient, and also that MI and PE Dullness to percussion may
that would explain pulmonary typically cause low-grade fever. indicate lung consolidation or
oedema, perhaps because of the Pleuritic chest pain could be due to pleural effusion. Wheezes may
development of perioperative pneumonia (and also PE, as stated be due to pulmonary oedema
acute renal failure? above). Wheezing supports the (‘cardiac asthma’) or COPD in this
diagnosis of COPD, but can also man. Pulmonary crepitations/
• Look carefully at his drug chart
be caused by pulmonary oedema. crackles, particularly if bibasal,
and compare this with the
suggest pulmonary oedema. A
medications he was taking
Examination pleural rub would be consistent
on admission: have any drugs,
An immediate assessment of the with PE or pneumonia.
for instance diuretics or
severity of the illness is required:
bronchodilators, been stopped
is the patient ill, very ill or nearly Other systems
(probably inadvertently) on
dead? Look for the features Establish a baseline for higher
admission that might explain
described in Section 1.2.2, noting cerebral function (Abbreviated
his deterioration?
in particular the following. Mental Test Score) and neurological
• Review laboratory records: state (Glasgow Coma Scale).
has his serum creatinine risen Cardiovascular Examine the patient’s abdomen.
postoperatively to indicate Is there acute urinary obstruction
• Heart rate and rhythm: sinus
that he has acute renal failure? with a large tender bladder? Has he
tachycardia is likely to be present,
had an intra-abdominal catastrophe
but check for the presence of
manifest with distension and/or
an arrhythmia (of which atrial
peritonism?
When assessing any patient fibrillation would be the most
who has deteriorated in hospital, likely).
always look carefully through the Investigation
medical, nursing and laboratory records. • BP and peripheral perfusion: The following are required urgently.
significant cardiac compromise
• ECG: to exclude an acute or
will result in a low-output state
previous MI, look for evidence
Symptoms suggesting pulmonary with hypotension and poor
of myocardial ischaemia and
oedema peripheral perfusion (capillary
assess the heart rhythm. These
Has the man had any ischaemic refill >5 seconds). Pulsus alternans
may occasionally show features
cardiac chest pain or been aware (alternation between large- and
(manifestations of right
of any palpitations? Angina, MI or low-volume pulse) may also be
ventricular strain) to support
transient tachyarrhythmia could all a sign in severe left ventricular
a diagnosis of PE, but these are
compromise left ventricular function failure.
not reliable for confirming or
and precipitate pulmonary oedema.
• JVP: an elevated venous pressure refuting this diagnosis.
could be due to heart failure or PE
Symptoms suggesting PE • CXR: left ventricular failure
in this context, but it can be very
Ask specifically about leg pain or will classically produce bilateral
difficult to identify the JVP in
swelling, pleuritic chest pain or alveolar/interstitial shadowing,
someone who is hyperventilating
haemoptysis. ‘batwing’ perihilar shadowing,
and frightened.
fluid within the horizontal
Symptoms suggesting chest • Added heart sounds and murmurs: fissure, bilateral pleural effusions
infection/pneumonia/exacerbation these may suggest a primary and cardiomegaly (Fig. 9).
of COPD cardiac pathology, although by Pneumonia will typically show
These diagnoses would be supported themselves they do not secure the consolidation.
by a history of nausea or vomiting, diagnosis. In pulmonary oedema a
Other tests in all patients with
or the presence of a nasogastric ‘gallop rhythm’ with the addition
this presentation include the
tube, all of which increase risk of of a third heart sound may be
following.
aspiration. High fever (>38.5°C) heard. Features of PE can include
would support the diagnosis, but a third heart sound over the right • FBC to rule out significant
remember there may be many ventricle and a loud P2. anaemia.
Fig. 10 Echocardiogram of a ventricular septal defect following MI (a) and the flow across the defect (b). LA, left atrium; LV, left ventricle; RA, right atrium; RV, right
ventricle.
• Very wide QRS complexes: the • AV nodal re-entry tachycardia: the • Echocardiogram: left ventricular
wider the complexes, the more commonest type of SVT. function and other anatomical
likely that the origin of the abnormality.
• AV re-entrant tachycardia:
arrhythmia is ventricular (Fig. 11).
pre-excitation including WPW
QRS complexes >0.14 seconds Management
syndrome.
wide are almost 100% certain to
be due to VT. • Atrial flutter with regular AV Tachycardia causing haemodynamic
conduction (usually 2:1) compromise in an unstable patient
• Capture beats and fusion beats. Synchronised DC cardioversion is
(Fig. 12).
• Concordance: the phenomenon required: the energy levels will
where QRS complexes have the Irregular narrow-complex depend on the underlying rhythm,
same morphology across all the tachycardias the type of defibrillator (biphasic
chest leads. or monophasic) and whether the
• Atrial fibrillation with an patient is on digoxin.
• Extreme left-axis deviation or a uncontrolled ventricular
change in axis from an old ECG. response (Fig. 13). • Atrial flutter/SVT: 25 J
(monophasic).
An irregular broad-complex • Atrial flutter with irregular AV
tachycardia could be atrial conduction (variable block and • Atrial fibrillation: 100 J.
fibrillation with bundle branch hence irregular). • Ventricular tachycardia: 100 J.
block or, less commonly, atrial
If cardioversion is unsuccessful, try
fibrillation with ventricular pre- Other investigations
excitation. Polymorphic VT (torsade moving the paddles to the anterior/
• Electrolytes: hypokalaemia, posterior position with one paddle
de pointes) is another possibility,
hypomagnesaemia and acidosis over the heart apex and the other
but remember that this is unusual
can precipitate arrhythmias. below the right scapula to the right
without any adverse features.
of the spine.
• FBC: anaemia will exacerbate
Regular narrow-complex myocardial ischaemia.
Tachycardia not causing
tachycardias
• CXR: heart size and pulmonary haemodynamic compromise
• Sinus tachycardia. oedema. Management will depend on the cause.
Sinus tachycardia Management manoeuvres (Valsalva and carotid highly effective at terminating
should be directed at the underlying sinus massage, etc.) should be used paroxysmal SVT with re-entrant
cause: attempts to slow the with caution and only by those with circuits that include the AV node
arrhythmia by any other means experience. (AV re-entrant tachycardia and
will almost certainly do more AV nodal re-entrant tachycardia).
harm than good. Adenosine is a naturally occurring In other narrow-complex
purine nucleoside that is highly tachycardias (eg atrial flutter)
Supraventricular tachycardia Vagal efficient at blocking the AV node. Its it will reveal the underlying atrial
manoeuvres or adenosine are the action lasts for seconds only, and it rhythm by slowing the ventricular
treatments of choice. Vagal is not negatively inotropic. It is response.
Fig. 15 Complete heart block with a ventricular rate of 41/minute: whether immediate pacing is required will depend on the clinical context.
• Respiratory: are there signs to decision on management should for red cells. A positive dipstick with
suggest aspiration/hypostatic not be taken on the basis of the no red cells is caused by urinary
pneumonia? ECG alone. Alternatively, there myoglobin in rhabdomyolysis.
may be atrial fibrillation with a
• Neurological: assess using the
slow ventricular response or even Other tests
Glasgow Coma Scale; also look for
profound sinus bradycardia. Is there
focal signs that might indicate she • CXR.
any indication of recent myocardial
has had a stroke (most commonly
infarction (MI) that might demand • CT scan of the brain.
dysphasia, hemianopia, facial
specific treatment?
asymmetry and hemiparesis). • Blood (and other) cultures
depending on clinical suspicion.
• Signs to suggest hypothyroidism: Routine blood tests
general appearance and slow- Electrolytes, renal/liver/bone • Arterial blood gases if patient very
relaxing tendon jerks. profile, glucose, creatine kinase unwell.
(CK), troponin I/T and thyroid
function tests. A very high CK Management
(>10,000 IU/L) with hypocalcaemia Any clear cause of bradycardia or
Do not forget hypothermia
and hyperphosphataemia is typically complication of the collapse should
as a cause of profound
bradycardia, especially in the elderly. seen with rhabdomyolysis. A grossly be treated on its merits. However, if
elevated troponin would indicate MI, the diagnosis is simply ‘heart block’
but a lesser elevation would be non- with no obvious precipitant that
Investigation specific. Similarly a grossly elevated can be removed, then management
thyroid-stimulating hormone should depend on the state of the
ECG level (>20 IU/L) would indicate patient:
Is there heart block (Fig. 15) and, if hypothyroidism, but a more modest
so, is it first-, second- or third-degree increase would not be interpretable. If the patient is well
in type? Generally speaking, the Some patients can tolerate complete
higher the degree of heart block, the Urine heart block at a pulse rate of 30 bpm
less stable the situation. But this is Dipstick for blood and protein. If if their left ventricular function is
by no means always the case and the positive for blood, check microscopy good. They may be fully conscious
Fig. 16 (a) ECG from a patient with a core temperature of 25°C, showing profound sinus bradycardia, first-degree heart block and prominent ‘J’ waves. (b) ECG from
the same patient after warming to 31°C, showing heart rate 75 bpm, persistent first-degree heart block and no ‘J’ waves.
Introduction because (i) the patient is often History of the presenting problem
‘Collapse of unknown cause’ is one unable to give a clear account, Consider the conditions listed in
of the commonest and yet one of the (ii) there is a wide differential Table 2 as you take the history,
most difficult differential diagnoses diagnosis of syncope (Table 2) and looking in particular for the
in acute medicine. The case (iii) the ‘collapse’ may not have a following clues.
described here is typical: an elderly single cause – the blame may be
person has fallen to the floor, attributable to the combination of a Neurally mediated syncope
perhaps injuring themselves in the loose carpet, poor vision, an arthritic Patients with vasovagal syncope
process, and sorting out what has knee and recent introduction of will typically give a long history of
happened and why is problematic antihypertensive therapy. syncope, which occurs after sudden,
unexpected and unpleasant sights, Cardiac syncope It will clearly also be important to
sounds, smells or pain, or after Syncope associated with effort, get a more detailed history of the
prolonged standing or sitting in chest pain, shortness of breath or patient’s other medical conditions
crowded hot places. The syncope palpitations is more likely to have and of the wider social picture:
may occur during a meal or in the a cardiac cause (see Cardiology, organising appropriate discharge
absorptive state after a meal. Typical Section 1.4.1). These can occur and placement for a man with mild
prodromal symptoms include light- when supine. A witness account of dementia and Parkinson’s disease
headedness, ringing in the ears, pallor followed by flushing would be who has fallen at home may not be
visual disturbances, sweating and/or very suggestive of a Stokes–Adams straightforward.
nausea/vomiting. Vasovagal syncope attack (due to the intermittent
is uncommon after early adulthood development of complete heart Examination
(so be very reluctant to make this block) but does not occur in all Aside from establishing that
diagnosis in this case). In the much patients with this condition (see there are no injuries from the fall
rarer condition of carotid sinus Cardiology, Sections 1.4.1 and 2.2.1). following the collapse, particularly
syncope, head rotation puts pressure Cardiac syncope is more likely in the look for a short externally rotated
on the carotid sinus and leads to presence of definite structural heart leg from a fractured neck of femur
syncope. disease, and be aware of those with or for injury to the neck. Then look
a family history of sudden death. for the following.
Orthostatic hypotension
Excluding cardiac syncope as • Heart rate, rhythm and character.
This typically occurs soon after
standing up, but also on prolonged the cause of collapse is important • Postural BP: orthostatic BP
standing, especially in crowded as these patients have a higher measurements are recommended
hot places. Look for a temporal mortality than those with non- after 5 minutes of lying supine,
relationship between presentation cardiac causes. followed by measurements each
and the start or change in dosage minute, or more often, while
of any antihypertensives and Epilepsy standing for 3 minutes. If the
Parkinson’s disease treatments If the patient was awake during an patient does not tolerate standing
(levodopa and dopamine agonists) in attack, ask specifically about any for this period, the lowest systolic
particular. Orthostatic hypotension warnings that he or any witness may BP during the upright posture
frequently occurs in patients have noticed. Features such as lip should be recorded. A decrease
with autonomic neuropathy or smacking, fiddling with clothes or in systolic BP ≥20 mmHg or a
parkinsonism. stereotyped movements would be decrease in the level of systolic
BP to <90 mmHg is defined as antiepileptics, but these should helped? Most asthmatics are used
orthostatic hypotension regardless not be given as a therapeutic trial to their disease and will try to
of whether or not symptoms when the clinical picture is not avoid coming to hospital. To avoid
occur. compelling. admission they often self-medicate
with increasing amounts up to the
• Does the patient have a
pacemaker? 1.2.9 Asthma point at which it is not helping.
treatment, oximetry and arterial rate, heart rate and BP; obtain occurred over a period of time.
blood gas measurements. intravenous access; and give Has she had recent breathlessness
fluid bolus if hypotensive. or had to slow down?
Further comments Cardiovascular collapse indicates
• Haemoptysis: the commonest
Patients with asthma still die. It is massive PE and is an indication
differential diagnosis of pleurisy
important to remember that early for thrombolysis: call for senior
is musculoskeletal pain, and this
review by the ICU is important. If help earlier rather than later.
does not cause haemoptysis.
the patient is admitted in extremis
• Low-molecular-weight heparin:
or does not improve with treatment, • Calf/leg swelling or pain: these
this should be administered
get help. The move to the ICU would suggest deep venous
without delay to protect against
should be a cool elective decision, thrombosis (DVT) and strongly
further embolisation in all
not a panic when the patient is close support the diagnosis of PE in
patients with a high probablity
to respiratory arrest. Important this clinical context.
of PE. Doctors often delay giving
pointers to a deterioration may
heparin until they have completed • Has the patient had a DVT or PE
include:
taking the history, examined the before?
• previous admission to an patient and obtained the result
• Is there a major risk factor? Ask
ICU/HDU; of initial investigations.
about recent immobility/major
• exhaustion, feeble respirations, • Analgesia: pleurisy is painful! surgery/lower limb trauma or
confusion or drowsiness; Relieve the pain as soon as surgery, pregnancy/postpartum,
possible. NSAIDs are excellent for any major medical illness, taking
• deteriorating PEFR;
relieving the pain of pleurisy, but oral contraceptives (as in this
• worsening or persisting hypoxia or opiates may be required as well. case) and a family history of
hypercapnia. such illnesses.
1.2.10 Pleurisy
If it is clear that PE is the Pitfalls in the diagnosis of PE
Scenario number one diagnosis, start
treatment immediately unless there Pleuritic pain is not always a
are obvious pressing contraindications. feature of PE: large central emboli
A 22-year-old woman is referred
typically cause cardiovascular collapse
to the Emergency Department and breathlessness; smaller, more
because of the sudden onset of peripheral emboli tend to cause pain.
right-sided pleuritic chest pain. History of the presenting problem
She has no previous medical or Look specifically for features in
surgical history. She has taken the history that would point to a
oral contraception for the past diagnosis of PE.
Differential diagnosis of
12 months. Her GP writes ‘I pleurisy
• Pain: did it start suddenly or
would be grateful if you could
gradually? The former is typical • Spontaneous pneumothorax:
exclude a pulmonary embolus as
of PE, but a gradual onset of heparin can convert this into a
the cause of her symptoms’. haemothorax.
symptoms does not exclude the
• Pneumonia: fever is often a
diagnosis. Sudden onset of pain
prominent symptom, and chest
(and/or breathlessness) after signs and radiography will usually
Introduction
defecation is highly suggestive show consolidation. However, fever
This is a pulmonary embolism (PE)
of PE, and there is commonly a and radiographic consolidation can
until proved otherwise. Priorities are be a feature of pulmonary
story of becoming suddenly very
as follows. infarction.
frightened (a sense of impending
• Musculoskeletal pain: this can be
• Airway, breathing and circulation doom). difficult to differentiate. If the
(ABC). diagnosis is unclear, anticoagulate
• Breathlessness: post-mortem
until PE is excluded.
• Is the patient ill? If so, administer studies show that patients who
• Less common and rare conditions:
high-flow oxygen and monitor die of PE virtually always have pain indistinguishable from pleurisy
pulse oximetry; check respiratory evidence that embolisms have
more specifically a pleural rub may afterload (Fig. 17); right atrial
can be due to shingles (herpes be present. Always believe other hypertrophy with a ‘P pulmonale’;
zoster) and pleurisy can be the
medical staff if they describe a rub right bundle branch block (can be
presenting symptom of systemic
that is no longer present when you a normal variant, but is significant
lupus erythematosus, in which
case check the relevant serology examine the patient. if new); and evidence of ischaemic
(antinuclear factor and DNA binding) change, which may be left- or
and be particularly suspicious if right-sided.
pleurisy is recurrent.
Chest wall tenderness Other tests that may be appropriate
Patients with PE will tell you include the following.
that it has been uncomfortable lying
on the affected side and they may
• D-dimer: only a negative result
Also remember that the presenting
be locally tender on palpation. This is of any value; hence it should
history (and findings) in PE may be
is an important point because local only be measured where there is
dominated by secondary cardiac
tenderness does not necessarily mean reasonable clinical suspicion of
features, namely ischaemic cardiac pain of musculoskeletal origin: another PE, but not where an alternative
pain and ECG changes. A PE creates classic diagnostic ‘catch’.
diagnosis is highly likely (when
a sudden increase in afterload on the
a ‘positive’ D-dimer will almost
right ventricle, and ‘secondary
inevitably be a false positive) or
cardiac pain’ from the resulting
Other features if the clinical probability of PE is
myocardial ischaemia may be a
Search for a DVT but do not be high (when the patient requires
prominent feature of the history.
surprised if you do not find one. a definitive investigation, whatever
Also, do not let its absence put you the D-dimer result might be).
Examination
off making the diagnosis of PE. In this case it would only be
The first priority will clearly be
A rectal examination (and pelvic appropriate for you to measure
to make an assessment of the
examination in women) will be D-dimer if you thought ‘if this
severity of illness (as described
necessary at some stage, but not test is negative, I will reassure the
in Section 1.2.2). However, with
on admission of a patient who is woman, treat her symptomatically,
regard to the particular diagnosis
breathless and unwell. and send her home’.
of PE, proceed as follows.
Investigation
Cardiovascular
The most common sign is sinus D-dimer is very helpful if used
Routine tests wisely, but it should not be
tachycardia. BP may be elevated due
All patients with this history require used as a routine screening test for PE.
to catecholamine release or may be
the following.
reduced secondary to cardiovascular
collapse. Most importantly, look for • CXR: in PE the findings are • Blood gases: these typically show
signs of pulmonary hypertension: usually normal, but a number of hypocapnia in PE because of
radiographic abnormalities may hyperventilation. Hypoxia may
• elevated venous pressure,
occur, namely line shadows at the or may not be present. If there
particularly with an exaggerated
bases, peripheral wedge-shaped is a base deficit, your concerns
a wave;
shadow(s), areas of relative should be heightened because
• right ventricular heave, which oligaemia in the lung fields it indicates secondary
can develop surprisingly rapidly (rare) and enlarged proximal cardiovascular compromise.
following an acute rise in pulmonary artery (rare). Calculation of the alveolar–
pulmonary artery pressure; arterial gradient may be helpful.
• ECG: in PE the ECG is commonly
• right ventricular gallop rhythm normal but it may show sinus
Definitive investigations
and loud pulmonary second tachycardia; T-wave inversion
CT pulmonary angiography is now
sound. in V1–V3; an ‘S1Q3T3’ pattern,
the imaging modality of choice
commonly described in the
(Fig. 18).
Respiratory medical literature and reflecting
Most patients with a PE have a axis change as a result of sudden Ventilation–perfusion isotope lung
respiratory rate >20/minute, but increase in right ventricular scan may be considered as the initial
Other tests
Routine haematological and
biochemical tests should be
performed: are there any clues to a
systemic disease that might predispose
to PE? A leg ultrasound scan is an
alternative definitive imaging modality
where there is clinical suspicion of a
DVT, because identification of a DVT
precludes the need for further tests.
A patient with a proven DVT and
pleuritic pain should be treated as
if it is PE (because it is virtually
impossible to think that the patient
has not had one). There is a role for
echocardiography in an unstable
patient in whom the clinical
Fig. 18 CT angiogram of the chest showing a clot in the proximal pulmonary artery (arrow). suspicion of PE is high.
Fig. 19 Pulmonary emboli revealed on perfusion isotope lung scanning: (a) large segmental defect in the left lung; (b) virtually complete lack of perfusion in the
right lung. Ventilation scanning was normal in both patients.
• Breathlessness: clearly supports diagnoses? See Sections 1.2.5 and have arterial blood gas (ABG)
the diagnosis of pneumonia, 1.2.10 for discussion. Remember measurements. A rising PaCO2
suggesting that there has been that patients with atypical indicates failing ventilation and is
some ventilation–perfusion pneumonia commonly have a very worrying sign that should
mismatch as may be seen with gastrointestinal symptoms. immediately trigger a request for
pneumonic consolidation. senior support or input from the
Other relevant history intensive care unit or both.
• Cough: is there a cough and is it
A detailed past medical history is
productive, purulent or dry? Does
required, but issues of particular
the woman normally have a cough
relevance include the following.
and/or produce sputum? In the
Measurement of oxygen
patient with normal lungs a dry • Previous respiratory disease: saturation by pulse oximetry
cough is a common presenting does she have known chronic is likely to be inaccurate if there is
feature of pneumonia of any sort; obstructive pulmonary disease, poor peripheral perfusion, an instance
a purulent cough is indicative of bronchiectasis or any other long- when the early assessment of ABG is
essential. Always document the
an underlying bacterial infection; standing lung problems?
inspired oxygen content when the
and brownish-red (rusty coloured) ABG was taken.
• Smoking history.
sputum is most likely due to
pneumococcal infection. • Alcohol history: alcoholism
may predispose the patient
• Chest pain: this may simply be Chest radiograph
to aspiration as well as
due to ‘sore ribs’ from coughing or Pneumococcal pneumonia presents
pneumococcal, Gram-negative
it may be pleuritic, which is more classically as lobar or segmental
and atypical infections. And it is
common in bacterial than non- consolidation (Fig. 20). Multiple,
important to recognise if a patient
bacterial infection. non-contiguous and sometimes
is likely to suffer from alcohol
bilateral segments may be affected,
• When did the illness start? The withdrawal if admitted to hospital.
with multilobar involvement being a
information given here suggests • Pets: is there a parrot or budgie at poor prognostic factor. The absence
it was in the past 48 hours, but home? of an ‘air bronchogram’ within an
it is important to try to pinpoint area of consolidation suggests
the onset of symptoms or the • Is she immunosuppressed?
exudate or pus filling the conducting
prodromal stage of the illness. airways; aside from Streptococcus
Non-bacterial causes of Examination
pneumoniae, organisms commonly
pneumonia (ie Mycoplasma A woman with pneumonia sufficient
responsible for this appearance
pneumoniae) are often to cause confusion is likely to be
include Staphylococcus (Fig. 21)
characterised by a relatively long very ill. Proceed as indicated in
and Gram-negative organisms.
prodromal stage in comparison Section 1.2.2, but noting especially
Early cavitation in an area of
with bacterial pneumonias. if there are signs of consolidation in
consolidation is typical of
the chest. A pleural rub is suggestive
staphylococcal infection, but
• Confusion: indicates that the of bacterial pneumonia.
consider Gram-negative organisms
pneumonia is likely to be severe
such as Klebsiella and do not
(see below), but note that the
forget tuberculosis. Also consider
classic symptoms and signs of
Remember that in non- aspiration pneumonia or proximal
pneumonia are less likely in the
bacterial pneumonia the bronchial obstruction, eg due to
elderly and so confusion may be respiratory signs are commonly
carcinoma or a foreign body. A
the main presenting feature and unimpressive.
variety of radiographic patterns
only diagnostic clue.
are described in Mycoplasma
• Is any other diagnosis more likely? Investigation pneumonia (Fig. 22) and in
Other common causes of acute Legionnaires’ disease. The presence
presentation with breathlessness Pulse oximetry/arterial blood gases of pleural fluid is suggestive of
are pulmonary oedema or Oximetry is mandatory in all bacterial aetiology and a diagnostic
pulmonary embolism: are there patients: those with SaO2 <92% or tap should be performed if this is
features to support either of these features of severe pneumonia should anything more than trivial in size.
Microbiological tests
• Sputum microscopy and culture:
if sputum is obtainable it is
important to send a sample early
Fig. 20 Lingular consolidation due to Streptococcus pneumoniae: the arrow marks an air bronchogram. in the illness; also do this for acid-
fast bacilli if clinically indicated.
• Blood cultures.
Management
General management and
resuscitation (if required) should be
as described in Sections 1.2.2 and
1.2.5, but note the following.
Fig. 21 Dense consolidation with no air bronchogram due to staphylococcal pneumonia following
influenza.
CURB-65 score
1.2.12 Acute-on-chronic
airways obstruction
Scenario
500 µg), repeated as necessary. her urgently as the triage nurse Speed of onset
thinks she has stridor. Aspiration of a foreign body may
• Steroids: start oral (eg present suddenly with a history
prednisolone 30 mg od) or
intravenous (eg hydrocortisone
200 mg qds) steroids.
considered. Surgical referral should Introduction • Has she had liver disease in the
be made at 5 –7 days for those with past or is she at risk of this? After
a persistent air leak, and earlier in explaining why you need to know
those with pre-existing lung disease this information, ask in particular
who have a greater potential for This woman is clearly about alcohol intake: ‘Are you a
complications. extremely unwell: your heavy drinker now or have you
first priority must be to initiate
ever been in the past?’ (See
resuscitation (see Section 1.2.2). Only
Further comments when resuscitation is underway should
Clinical Skills for PACES.)
Patients discharged without your attention move towards trying • Has there been recent weight loss,
intervention should be asked to work out the cause of her
dysphagia or an early feeling of
to reattend for a repeat CXR in haematemesis.
fullness when eating that might
10 –14 days. In all other patients
point to a malignancy?
resolution of the pneumothorax
should be confirmed on a CXR prior History of the presenting problem
to discharge, with further follow-up This woman is most unlikely to be
in 4 – 6 weeks. able to give much of a history at the Are you sure the problem is
moment, but in a patient who was haematemesis? In this case
The BTS Air Travel Working Party there does not seem to be any doubt,
less ill the following information
suggests that patients may travel but patients often report that they
should be sought. have had ‘dark vomit’ and this might
safely by air 6 weeks after the
resolution of a pneumothorax on not be due to haematemesis. Keep an
• Has she vomited blood before and
open mind to alternative diagnoses
CXR. There is still a significant risk if so what was the cause? until haematemesis is proven.
of recurrence up to 1 year after
• Has she had a peptic ulcer in the
resolution depending on whether
past?
the patient has an underlying lung Examination
disease, and because of this some • Is there a history of heartburn, The overall condition of the
patients may decide to avoid dyspepsia, use of medications for patient and the circulation
increasing the risk by not flying indigestion or previous barium should be assessed as described
for a year. meal/endoscopy that might point in Section 1.2.2, but with regard to
to peptic ulcer disease? someone with upper gastrointestinal
Diving should be discouraged
bleeding note the following in
permanently after a pneumothorax • What medications is she on?
addition.
unless a definitive surgical Enquire about both prescribed
intervention has been and over-the-counter medications; • Signs of chronic liver disease or
performed. take note of anticoagulants, portal hypertension (Table 5 and
NSAIDs and steroids in particular. Fig. 24).
1.2.15 Upper gastrointestinal
haemorrhage
A 70-year-old woman is brought Signs of chronic liver Signs of portal Signs of hepatic
to hospital having collapsed in disease hypertension encephalopathy
her home. On arrival of the
Spider naevi Splenomegaly Myoclonic jerks: the ‘liver flap’
ambulance she was hypotensive Palmar erythema Ascites Hepatic fetor
(BP 82/44 mmHg), cold and Leuconychia Caput medusae Impaired conscious level
sweaty. The ambulance crew Clubbing (rarely)
Jaundice
report that there was evidence
Bruising
that she had vomited blood at Scratch marks
home, and that she did so again Gynaecomastia
Loss of secondary
whilst en route. You are asked to
sexual hair
assess her urgently. Testicular atrophy
Investigation
Blood tests
This woman has clearly had a large
bleed: arrange emergency cross-
match of 4 units of her blood; group
and save them in a case without
haemodynamic disturbance. FBC,
clotting screen, electrolytes, and
renal and liver function tests are also
required. Remember that a relatively Fig. 25 Endoscopy showing a peptic ulcer with a spurting artery: an obvious case for intervention.
Management while waiting for blood to arrive; passing red blood per rectum
then repeat the examination with fresh blood in the nasogastric
of pulse rate, BP and JVP. If aspirate are reported to have a
hypotension persists and the mortality rate of 29%; older patients
Gastrointestinal bleeding is a
JVP remains low, give more fluid have a higher mortality; and the
team game: if haemorrhage is
profuse, continuing or recurrent, get a rapidly (blood if available, or 0.9% mortality of all patients who
surgical opinion sooner rather than saline) until the JVP is raised to rebleed in hospital is 40%.
later. the upper limit of normal and
A combination of clinical features
postural hypotension is abolished.
and endoscopic findings has
The immediate priority is to • Insert urinary catheter (‘the poor provided a numerical scoring system
resuscitate (see Section 1.2.2), but man’s central venous pressure’): of risk in upper gastrointestinal
note the following in particular. a good urine output is a much haemorrhage (Table 6), the
better marker of the restoration maximum additive score prior to
• Establish venous access: insert of organ perfusion than diagnosis by endoscopy being 7.
large cannulae into both measurement of central
antecubital fossae. If access is venous pressure. Varices
difficult, insert a line into the
• Proton pump inhibitors: Bleeding oesophageal varices can
femoral vein (which lies medial to
omeprazole 80 mg iv bolus cause a torrential loss of blood. Get
the artery, as remembered by the
followed by infusion of 8 mg/hour specialist help immediately if this
acronym ‘NAVY’: nerve, artery,
for 72 hours has been shown to is likely to be the diagnosis. Urgent
vein and Y-fronts). If you cannot
reduce the early rebleed rate in endoscopy is mandatory: banding
do this, get someone who can.
peptic ulcer with haemorrhage. or sclerotherapy can be attempted
during the procedure. Consider
Further comment giving terlipressin to try to reduce
Never attempt central venous portal BP (2 mg iv, followed by 1 or
cannulation of a neck vein in a Risk scoring in upper 2 mg every 4 – 6 hours until bleeding
collapsed hypovolaemic patient gastrointestinal haemorrhage is controlled, for up to 72 hours).
because the veins are constricted, Haematemesis is a more serious Have a Sengstaken–Blakemore tube
rendering the procedure difficult.
symptom than melaena: mortality available, but this should only be
Insertion of a central line has never
rises from 5% in patients suffering used by those with experience of
made anyone better, but it has killed.
melaena with clear nasogastric the technique. Patients with massive
aspirate to 12% in those with bleeding should be considered for
• Give intravenous fluids: 1 L of melaena and fresh blood in the intubation to reduce the increased
0.9% saline as fast as possible nasogastric aspirate; patients risk of aspiration. Surgical treatment
Score 0 1 2 3
Mortality rate by additive score is as follows: score 0, 0.2%; score 1, 2.4%; score 2, 5.6%; score 3, 11%; score 4, 25%; score 5, 40%; score 6
or 7, 50%.
for acute variceal bleeding is rarely stool frequency can indicate acute Precipitating factors
done because of high mortality, but colonic dilatation and subsequent Consider infectious causes: has
the TIPS (transjugular intrahepatic perforation. the patient eaten any food that she
portosystemic shunt) procedure can thinks may have been contaminated
• What is the nature of the
be considered in some cases. or infected? Has anyone else that
diarrhoea? Frequent passage of
she knows had a similar problem?
small amounts of stool suggests
1.2.16 Bloody diarrhoea Has she been abroad recently? Clues
proctitis or a rectal lesion; large
to specific intestinal infections in the
volumes indicate small-bowel
Scenario patient presenting with diarrhoea
pathology. Bloody diarrhoea
are shown in Table 7. Also ask about
is very suggestive of colonic
A 37-year-old woman is sent to medication: has she taken antibiotics
pathology, whereas copious
the Medical Assessment Unit by recently, which predispose to
foul-smelling bulky stools that
her GP with a 48-hour history of Clostridium difficile? Has she taken
are difficult to flush away are
frequent watery diarrhoea; blood NSAIDs? These are a potent cause
characteristic of malabsorption.
has been mixed with the motions of colonic irritation and bloody
for the past 24 hours, during • Is there diarrhoea at night? This is diarrhoea.
which time she has had her useful in distinguishing irritable
bowels open ten times. You bowel syndrome from organic Other relevant history
are asked to review her. pathology. Has there been a previous history
of bowel problems (could this be a
flare of known inflammatory bowel
History of the presenting problem disease?), bowel surgery or abdominal
irradiation (‘radiation colitis’ can
Physiology of the bowel
Intensity and nature of the present with bloody diarrhoea). Is
diarrhoea The daily dietary intake of food there any other relevant pathology?
and liquid combined with gastric and The sudden onset of pain and bloody
• Has the patient got diarrhoea at intestinal secretions results in a
diarrhoea in an elderly arteriopath
all? The history seems clear-cut volume load of about 7 L entering the
small intestine. By the time intestinal
should alert you to the possibility
in this case, but patients use the
contents have reached the terminal of ischaemic colitis.
term ‘diarrhoea’ to describe
ileum, only about 1.5 L remains, so
different things. How many times The possibility of sexually
small-bowel pathology often causes
has she opened her bowels today? large-volume diarrhoea. transmitted infections and HIV-
Be aware that a sudden fall in related infection must be considered
if the diagnosis does not become Investigation produce a picture alarmingly similar
apparent, in which case it will be to toxic dilatation. Normal rectal
necessary to take a sexual history. Cultures mucosa usually excludes active
As always, this must be done with Faeces should be sent for ulcerative colitis. Inflamed rectal
tact: explain why you need the microbiological investigation mucosa can be a feature of any
information before asking for it (microscopy, culture and specific cause of severe diarrhoea. The
and proceed carefully, as indicated testing for Clostridium difficile mucosal appearance of Clostridium
in Clinical Skills for PACES. toxin); the sample can be obtained difficile infection is also variable,
during sigmoidoscopy if the patient although the adherent yellow-white
Examination has not been able to provide one plaques, or ‘pseudomembrane’,
The overall condition of the before this is performed. Also test is characteristic. A rectal biopsy
patient and the circulation blood cultures. should be taken below the peritoneal
should be assessed as described in reflection, ie within 10 cm of the
Section 1.2.2, but in someone with Radiology anal margin.
bloody diarrhoea take particular An erect CXR should include
note of the following. the hemidiaphragms to look for Blood tests
evidence of perforation (Fig. 26).
• General features: fever, nutritional • FBC may show acute anaemia,
A supine abdominal film should
status and anaemia. but it is more likely to indicate
be taken to exclude toxic dilatation
chronic pathology, eg poorly
and to look for mucosal islands and
• Abdomen: distension, peritonism, controlled inflammatory
a dilated small bowel, which are
masses and character of bowel bowel disease. The blood film
other adverse prognostic radiological
sounds. and haematological indices
signs of inflammatory bowel disease
are important: microcytic
• Digital rectal examination: (Fig. 27).
hypochromic changes are
inspect the perineum first,
likely to indicate blood loss,
looking for skin changes or Sigmoidoscopy
whereas macrocytosis points
fistulae suggestive of Crohn’s Sigmoidoscopy (Fig. 28) should
to malabsorption or alcohol
disease; palpate for a rectal mass; be performed after the abdominal
abuse. A slight elevation in
and examine any faeces for radiograph because introduction
white cell count is of little help
melaena or frank blood. of air during the procedure can
in differential diagnosis, but
if the count is greater than
15 × 109/L consider sepsis.
• Fever >38°C.
• Albumin <30 g/L.
• CRP >45 mg/L.
• Mucosal islands, toxic megacolon
and dilated small bowel on
abdominal radiograph.
Management
Resuscitation, if required, will
as always be the immediate
priority (see Section 1.2.2).
Specific management will depend
on the cause of the problem, but
note the following.
• Pseudomembranous colitis:
associated with antibiotic usage,
particularly third-generation
Fig. 27 Abdominal radiograph in acute ulcerative colitis. The colon is dilated (not quite to 10 cm, but cephalosporins. Treat with
worrying nonetheless). Thumb-printing of colonic mucosa is seen in the left upper abdomen and there are
dilated loops of small bowel. metronidazole (iv or po) or
vancomycin (po) after
sigmoidoscopy (and rectal
biopsy) has been performed
and stool has been sent for
Clostridium difficile toxin.
Further comments
Very rare causes of an acute
abdomen include the following.
• Diabetic ketoacidosis.
• Give a phosphate enema. poor. Cerebral oedema is another 1.2.19 Renal failure, fluid
• Consider giving neomycin or
feared complication: consider giving overload and hyperkalaemia
mannitol 200 mg/kg iv slowly;
metronidazole if the patient is
poorly responsive or comatose.
intracranial pressure monitoring can Scenario
be useful but is not available in all
centres. A 67-year-old man had elective
Coagulopathy
bilateral hip replacement 5 days
• Give vitamin K orally or Acute alcohol withdrawal and ago. Over the last 24 hours
intravenously (preferable). delirium tremens he has become increasingly
breathless and the observation
• Consider giving fresh frozen
charts show that no urine output
plasma or platelets if the patient
has been recorded, which the
is actively bleeding. Acute alcohol withdrawal
nurse in charge of the ward
This is common; it typically
confirms to be true. The
Underlying infection causes tremor and confusion after
8–24 hours and settles after 48 hours. orthopaedic doctor on duty
Start broad-spectrum antibiotics
asks the on-call medical team to
(eg ceftriaxone or cefotaxime 2 g iv
Delirium tremens review this patient urgently.
twice daily) if infection is suspected.
Remember that bacterial peritonitis This is rare, but can be fatal if
occurs in around 25% of patients untreated. Symptoms include tremor,
• absent P waves and very wide does not lower the serum
QRS complexes slurring into potassium level but reduces
Calcium, dextrose/insulin
T waves (Fig. 31); myocardial excitability. Its effect
and salbutamol are holding
is instant, with the ECG becoming measures only, reducing the serum
• cardiac arrest (ventricular
less abnormal in front of your eyes. potassium concentration for 4–6 hours.
fibrillation, ventricular Most patients with severe hyperkalaemia
tachycardia and asystole). • Dextrose (50 mL of 50% solution) require urgent haemodialysis, the
exceptions being the few whose renal
Urgent treatment is required if there plus 10 units short-acting insulin, function improves rapidly, eg after
is any change more severe than eg Actrapid (soluble insulin), relief of acute obstruction.
T-wave peaking; take a specimen for intravenously over 15–30 minutes. After giving emergency treatment
measurement of serum potassium, This shifts potassium into the for hyperkalaemia, do not forget to
intracellular compartment. It contact the intensive care unit (ICU) or
but do not wait for the result. It is local renal unit to arrange transfer for
not a triumph to be told that serum should not cause hypoglycaemia, urgent haemofiltration or dialysis if
potassium was 9.1 mmol/L just after but check fingerprick blood the patient’s urine output does not
glucose if in any doubt. Serum respond immediately and dramatically
the patient has arrested.
to fluid and/or bladder catheterisation.
potassium falls by 1–2 mmol/L
Treatment of significant over 30 – 60 minutes.
hyperkalaemia
• Salbutamol (nebulised) 10 mg:
If the patient’s ECG looks Oral and rectal ion-exchange
this activates the intracellular
like that shown in Fig. 31, give resins increase gut excretion of
adenylate cyclase system and potassium and can be used to take
calcium immediately, followed by
induces a shift of potassium into the ‘edge’ off hyperkalaemia, but they
dextrose/insulin or salbutamol. take 24 hours to have any effect and
the intracellular compartment.
are not an emergency treatment for
• Calcium gluconate 10% solution, Serum potassium falls by hyperkalaemia.
10 mL iv over 1–2 minutes. This 1–2 mmol/L over 30 – 60 minutes.
History of the presenting problem • Heart sounds: listen for gallop • Insert a urinary catheter: this
After considering and (if necessary) rhythm indicating that the left will relieve outflow obstruction
treating hyperkalaemia, consider ventricle is under strain. if present, which may result in a
causes of postoperative prompt diuresis and restoration
• Lungs: are there bilateral crackles
breathlessness as described in of renal function.
suggesting fluid overload or
Section 1.2.5 and find out from
(less likely) localised crackles • Stop nephrotoxins: NSAIDs
the patient, medical records and/or
or a pleural rub to suggest (commonly used for postoperative
observation charts if he has any
infection or PE? analgesia), angiotensin-converting
history of renal/urinary problems
enzyme inhibitors and angiotensin
(any symptoms of prostatism?)
Urinary retention receptor blockers all have adverse
or pre-existing renal impairment
effects on renal blood flow in
(what was the preoperative serum • Is the bladder palpable?
this context and should be
creatinine?). Investigate precisely
(temporarily) stopped, as should
what happened to him during his Investigation
aminoglycoside antibiotics.
operation and afterwards, noting As described in Section 1.2.5, with
vital signs (was he hypotensive at the following of particular note in
Management of fluid overload in
any time, which might explain acute addition to the ECG.
the patient with renal failure
tubular necrosis?), daily fluid
• Electrolytes and renal function
input/output, administration of • Sit the patient up.
tests: to confirm the presence of
drugs and whether he now feels
hyperkalaemia and/or renal • Give high-flow oxygen.
as though he wants to pass urine
failure.
(acute retention). • Restrict fluid input to the
• Serum troponin: has the stress minimum possible.
Examination of the operation precipitated a • Nitrate, eg isosorbide dinitrate
Is this man ill, very ill or nearly myocardial infarction? 2–20 mg/hour iv, titrated to as
dead? As always, begin with an
• Consider sepsis: a common high a dose as the BP will allow.
overall assessment as described in
Section 1.2.2, taking particular care precipitant of postoperative renal • Diuretic, eg furosemide 250 mg iv
to look for evidence of the following. failure; take relevant cultures. over 1 hour, may induce some
• CXR: look at the heart size, and increase in urine output.
Pulmonary oedema for pulmonary oedema or • Dialysis/ultrafiltration: arrange
• Respiratory rate: tachypnoea infection. urgently if the patient remains
would be expected and could overloaded.
• Arterial blood gases: expect a
indicate fluid overload, metabolic
partially compensated metabolic • Non-invasive ventilation/
acidosis or pneumonia. Beware a
acidosis in a sick patient with continuous positive airway
low or normal respiratory rate in
renal failure. A normal PaCO2 pressure: can be very effective
patients who you would expect to
would probably be worrying in in treating breathlessness due
have a high rate, since they may
this case as it would indicate that to pulmonary oedema.
have become exhausted and be
the patient is getting tired and
about to die.
losing respiratory compensation,
• Pulse rate and rhythm: the patient in which case acidosis can worsen
is likely to have tachycardia, but very rapidly with dire
look particularly for fast atrial consequences. When inserting a central line
fibrillation, which is a common for dialysis access in a patient
with pulmonary oedema:
problem postoperatively. Management
If this man looks very ill or about • do not lie the patient down since
• BP: may be elevated in pulmonary cardiac arrest is likely;
to die, then call for help from ICU
oedema. • do not use the subclavian vein
immediately. Otherwise, proceed
because the patient will not tolerate
• Jugular venous pulse: may be as described in Section 1.2.2 and
a pneumothorax;
difficult to see, but expected to take particular care to do the • use the femoral vein.
be high in fluid overload. following.
potential infection in the diabetic required to establish the diagnosis myocardial infarction can be a
presenting with DKA, especially of DKA. precipitant of DKA and electrolyte
chest, feet (remove shoes and disorders can result in arrhythmias.
socks), perianal region and urine Routine blood tests Also perform other imaging tests, eg
(dipstick for nitrites). urinary tract ultrasonography and
• Blood glucose (laboratory): often
bone radiographs, as dictated by
• Abdominal: is there abdominal the fingerprick blood glucose will
clinical suspicion.
tenderness, silent bowel sounds or read high without a precise value.
pain in the renal angles? Has an
• Electrolytes and renal function: Management
intra-abdominal event triggered
serum potassium is likely to
the DKA? In addition to
be high at presentation, but
infection/peritonitis, do not forget
remember that total body
bowel infarction, particularly if Priorities of management
potassium will be significantly
there is a background of diabetic of DKA
depleted. Expect the urea to be
macrovascular disease. Do not • ABC.
elevated out of proportion to the
forget a rectal examination: you • Correction of hypovolaemia.
creatinine because of dehydration;
will not see a perianal abscess • Correction of electrolyte imbalance.
compare the creatinine with
unless you look. • Correction of hyperglycaemia.
any previous measurements to • Empty the stomach.
determine if renal impairment • Treatment of an underlying cause.
is acute, chronic or acute on • Prophylaxis against venous
chronic. thromboembolism.
Remember that DKA can
mimic an acute abdomen: if in
• FBC: a raised white cell count
doubt ask for a surgical opinion.
might suggest sepsis but can Fluid resuscitation and electrolyte
be elevated in the absence of replacement
infection in DKA. Patients with DKA are severely
• Neurological: check score on
dehydrated and very depleted of
Glasgow Coma Scale to assess • C-reactive protein: to confirm
total body sodium and potassium:
this. Also check for the presence suspicion of sepsis.
fluid replacement is the top priority.
of meningeal irritation or focal
• Liver/bone profiles. Proceed as described in Section
signs, which would be unlikely but
1.2.2 if hypovolaemic shock is
of great significance if present.
Sepsis screen present, but most patients are not
There may be signs of chronic Send urine for microscopy and profoundly hypotensive and should
damage caused by diabetes (eg culture, blood cultures and other be given 0.9% (normal) saline with
retinopathy, neuropathy or vascular cultures as appropriate, eg sputum potassium. Typical requirements in
disease) but searching for these is and wound swabs. On the CXR look the first 24 hours are as shown in
not a high priority in the context of for evidence of infection and also for Table 10, but the patient will require
the patient presenting with DKA. air under the diaphragm: perforation frequent clinical reassessment over
of an abdominal viscus can be this time and the fluid regimen may
Investigation remarkably silent in a diabetic. need to be adjusted.
• General: cachexia, FBC (anaemia may be present for enzyme, serum magnesium, urinary
lymphadenopathy and several reasons, most commonly calcium and creatinine excretion,
hepatomegaly. malignant involvement of bone and bone radiographs.
marrow), inflammatory markers,
• Lung cancer: clubbing, Horner’s In any sick patient an ECG should
PTH and serum immunoglobulins/
syndrome and chest signs. also be performed. In severe
serum protein electrophoresis/
hypercalcaemia this can show
urinary Bence Jones proteins.
Clues to other specific causes of slowed conduction, including
Perform a CXR, looking in particular
confusion and drowsiness prolonged PR interval, and a
for evidence of malignancy (Fig. 33)
widened QRS complex and
• Check pupils and respiratory rate: or features of sarcoidosis.
shortened QT interval with ST
small pupils and a low respiratory
segments shortened or absent.
rate probably mean opioid
Bradyarrhythmias, bundle branch
toxicity. If these features are
block and atrioventricular block may
present, give naloxone as When interpreting serum
calcium concentration, develop as the serum calcium rises
described in Section 1.2.31.
remember that free (ionised) plasma to around 4.5 mmol/L.
• Look carefully at the fundi: calcium is dependent on plasma
albumin:
Other tests, eg sepsis screen, arterial
papilloedema suggests raised
blood gases and CT brain scan, may
intracranial pressure. Any clear Corrected calcium = measured calcium
be required depending on clinical
focal neurological signs would + {[40 – serum albumin (g/L)] × 0.02}
suspicion.
suggest cerebral metastasis in this
clinical context.
Management
In most cases the cause of
Investigation hypercalcaemia will be established
Repeat the measurement of serum by the history, examination and
calcium to confirm hypercalcaemia; the investigations listed above, Principles of emergency
also check electrolytes and renal but in selected cases the following management of
hypercalcaemia
function (acute renal failure further tests may be needed: 25-
is commonly seen in severe hydroxyvitamin D3, thyroid function • Increase urinary excretion of calcium
hypercalcaemia), liver/bone profile, tests, serum angiotensin-converting by rehydration with 0.9% saline.
• Inhibit bone resorption with
bisphosphonate therapy.
Rehydration
The first aspect of emergency
management should be rehydration
with intravenous saline as follows.
Volume status Total body water Total extracellular sodium Primary problem Example
Hypovolaemic Low Even lower Renal: urinary Na+ >30 mmol/L Diuretics
Sodium-losing renal disorders
Mineralocorticoid deficiency
Non-renal: urinary Na+ <30 mmol/L Vomiting
Diarrhoea
Burns
Excessive sweating
Euvolaemic Normal/slight excess Reduced/normal SIADH
Glucocorticoid deficiency
Hypothyroidism
‘Sick cells’
Hypervolaemic Great excess Excess Renal: urinary Na+ >30 mmol/L Acute/chronic renal failure
+
Non-renal: urinary Na <30 mmol/L Cardiac failure
Cirrhosis/liver failure
Nephrotic syndrome
CT brain scan approach. This man is a difficult ongoing water losses, which are
It would be appropriate to image case: he is probably symptomatic not predicatable.
the brain even in the absence of as a result of severe acute
• 1.8% saline infused at a rate
focal neurological signs given that hyponatraemia and I would treat
of (1.7 × patient’s weight in kg)
this man is an alcoholic with a him as such, while remaining alert
mL/hour or 3% saline infused at
history of recent head injury and to the fact that there could be other
a rate of (1.0 × patient’s weight in
that subdural haematoma can be reasons for his mental state.
kg) mL/hour is likely to increase
associated with SIADH.
the serum sodium concentration
Asymptomatic hyponatraemia
by 1 mmol/L per hour.
Cause of hyponatraemia Management of the patient with
Urinary sodium concentration asymptomatic hyponatraemia • Aim to increase the serum sodium
(urine ‘spot sodium’) is useful depends on identifying and treating concentration in the early stages
for distinguishing between renal (where possible) the underlying of correction by about 1 mmol/L
and extrarenal hypovolaemic cause (Table 14), coupled with per hour and by no more than
hyponatraemia, as well as restriction of fluid input to 1 L/day 15 –20 mmol/L over 48 hours.
between causes of hypervolaemic to enable the serum sodium
• Monitor the serum sodium
hyponatraemia (see Table 14). Paired concentration to rise. Such fluid
concentration every 2 hours while
urine and plasma osmolalities restriction can be difficult for
infusing hypertonic saline, and
should be sent along with the spot patients to tolerate and for nurses
replace hypertonic saline with
sodium: measurement of these is to enforce: give the allocation in
0.9% saline if the serum sodium is
required to pursue the possibility of aliquots throughout the day; give it
rising more quickly than desired.
SIADH. Remember, however, that as ice cubes to suck; and permit the
this is a diagnosis of exclusion and patient swabs to keep the mouth • Stop the infusion of hypertonic
not proven simply by finding that moist or to suck boiled sweets. saline when serum sodium is
the urine is hypotonic. Further >125 mmol/L and institute water
investigations will depend on the restriction: do not allow rapid
underlying suspected cause. correction into the normal range.
Hyponatraemia alone will
very rarely cause neurological
symptoms when the concentration is
The following criteria for the <120 mmol/L. If the serum sodium Treatment of severe
diagnosis of SIADH must all be concentration is higher than this in a hyponatraemia
satisfied to confirm the dignosis: comatose patient, consider other
Correction of symptomatic
• plasma osmolality <270 mosmol/kg causes of coma.
hyponatraemia with hypertonic saline
with inappropriate urinary requires very close monitoring: check
concentration (>100 mosmol/kg); serum sodium every 2 hours.
• patient is euvolaemic and not taking
a diuretic;
Symptomatic hyponatraemia
• renal sodium excretion >20 mmol/L; Urgent treatment is required if there
• normal renal, thyroid and adrenal are severe neurological effects, eg
function.
1.2.24 Addisonian crisis
fitting. Aside from treating the
underlying cause, use hypertonic
Scenario
saline to elevate the patient’s serum
Management
sodium concentration. However,
The correct strategy for management A 32-year-old woman is brought
remember that central pontine
of hyponatraemia depends on to the Emergency Department by
myelinolysis is reported in
whether the patient is symptomatic her husband. He explains that
association with over-rapid
as a result of it. Harm can be done she collapsed today at work
correction and note the following.
by overzealous correction: in the and was sent home. She has
case of an elderly woman who is • No formula can accurately been unwell for some time with
relatively well but hyponatraemic predict the patient’s response to lethargy and dizziness, and
due to diuretic treatment, she is hypertonic saline. All formulae has lost a significant amount of
much more likely to suffer than to assume a ‘closed system’ and take weight. On arrival she is drowsy,
benefit from an aggressive medical no account of the patient’s
Fig. 34 Hyperpigmentation of the skin (a, b) and buccal tissues (c) in patients with Addison’s disease.
interpret and should be viewed the diagnosis of primary adrenal endocrinological investigations,
with caution. failure. eg pituitary function tests, will be
required in selected cases.
• Short adrenocorticotrophic • Plasma ACTH: a high level
hormone (ACTH; Synacthen) (>80 ng/L) with low or low-normal
stimulation test: in this case it Management
cortisol confirms primary
would be dangerous and wrong Key aspects of resuscitation in this
hypoadrenalism.
to delay treatment, but in less case include the following.
dramatic circumstances this It will be appropriate to check
• Fluids: the patient in addisonian
should be a priority if adrenal thyroid function in all cases of
crisis is significantly depleted of
insufficiency is suspected. adrenal insufficiency. If
both salt and water. Aggressive
Synacthen 0.25 mg im/iv is hydrocortisone is given acutely, as
fluid resuscitation with 0.9%
administered to the patient (time should be done in this case, then
saline is vital.
0); samples for measurement of short (or long) Synacthen testing
plasma cortisol are collected at 0, can be done at a later date after • Glucocorticoid replacement: give
+30 and +60 minutes; a cortisol the omission of hydrocortisone hydrocortisone 100 –200 mg iv
level >550 nmol/L (with rise from for 24 hours or substitution immediately, and then 100 mg iv
baseline >190 nmol/L) excludes with dexamethasone. Further three times daily. Fludrocortisone
consciousness, visual impairment or in this context, indicating damage • ECG shows ST- and T-wave
weakness that follow the headache. to the third cranial nerve either changes in 70 – 80% of cases,
Photophobia is a feature of SAH, but from generalised compression including an infarct pattern in
also of meningitis and migraine. (raised intracranial pressure) or 10 –15%.
localised compression (aneurysm
• CXR shows either neurogenic or
Other relevant history of the posterior communicating
cardiogenic pulmonary oedema
Has the patient had headaches in artery).
developing in 10 –15% of patients.
the past and if so were they like
• Features of SAH: neck stiffness,
this? If patients with a history of • Serum troponin level is often
subconjunctival haemorrhages
headache do have SAH, they almost slightly or moderately elevated.
(also a feature of meningococcal
always identify the pain as being
disease, but subconjunctival
different. Does the patient smoke or CT brain scan
haemorrhages where you cannot
use illicit drugs (amphetamine and About 90% of SAHs are visible
see the lateral limits are indicative
cocaine are associated with SAH, as on a CT scan (Fig. 36), which is
of SAH) and subhyaloid
is smoking)? Ask about any family the investigation of choice. Patients
haemorrhages. Also check for
history of SAH or related conditions who present some days after onset
features (much less likely) of
(adult polycystic kidney disease and of symptoms may be difficult to
connective tissue diseases and for
some connective tissue diseases). diagnose as the degradation of blood
adult polycystic kidney disease,
means that it may have the same
Are there features to support which predispose to SAH.
density as brain tissue.
another diagnosis? Have there been • Features to support another
any recent problems with the eyes, diagnosis: high fever; and Lumbar puncture
ears or sinuses that could indicate infection of ears, nose and throat. All patients suspected of having
sinusitis or otitis media? Has the
an SAH but with a negative
patient travelled abroad recently or
Investigation CT scan should be considered for
had symptoms to suggest infection?
The general approach to lumbar puncture if there are no
Could this be meningitis or malaria
investigation of the patient in coma contraindications (see Section 3.2).
(see Section 1.2.27)?
is discussed in Section 1.2.31. With This should be performed a
regard to general investigations, note minimum of 12 hours after the
Examination that SAH is often associated with onset of symptoms; before this time
Patients with severe headache cardiac dysfunction. breakdown products of red cells in
range from those who walk into
the Emergency Department to
those who are comatose with
cardiorespiratory collapse. The
general approach to the examination
of the patient in coma is discussed
in Section 1.2.31, and for the patient
with cardiovascular collapse in
Section 1.2.2. In dealing with the
patient with suspected SAH, aside
from assessing and alleviating pain
and anxiety, the following are of
particular importance.
the cerebrospinal fluid (CSF) may • Bed-rest, and aperients to avoid • Coiling: the patient requires a
not be apparent. At least three serial excessive straining when opening general anaesthetic. A catheter
CSF specimens should be examined the bowels. is inserted, usually via a femoral
for xanthochromia and red cell artery, and manoeuvred to the site
count. of the aneurysm; thrombogenic
coils are placed within the
All patients with SAH should aneurysm to secure it.
be discussed with the regional
If both techniques are available in a
In suspected SAH wait 12 hours neurosurgical centre unless they are
terminally ill for some other reason. given centre, the decision regarding
from the onset of symptoms
before performing lumbar puncture to
coiling versus clipping depends on
avoid a false-negative result. the site and nature of the aneurysm,
the number of aneurysms present
Further comments
and the comorbidity of the patient.
• Onset of headache: the headache meningitis? Where does he live, nail-beds, resulting from immune
of meningitis is usually a dull, who are his close contacts and complex deposition. Look carefully
progressively worsening one, in have any of these been ill recently? for subconjunctival and sublingual
contrast to that of subarachnoid Contacts will need to be traced and haemorrhages. Look in the fundi for
haemorrhage (see Section 1.2.26). appropriate antibiotic prophylaxis subhyaloid haemorrhages and
given if the case is confirmed as due papilloedema.
• Systemic features: ’flu-like
to meningococcal disease.
symptoms of fever, sweats,
Features of meningeal irritation
muscle aches, joint pains and It will also be important to ask Several physical signs are described,
nausea/vomiting suggest systemic about whether the patient has the most common being the
infection and are common in received any antibiotics recently, following.
meningitis. which may prevent successful
culture of the organism, and if they • Neck stiffness: there is involuntary
• Photophobia: a common
have any allergies especially to resistance to flexion when the
complaint in meningitis but
penicillin. physician attempts to bend the
also seen with migraine and
patient’s neck such that the chin
subarachnoid haemorrhage. Do
touches the chest. The best known
not over-interpret this symptom: Examination
of several signs attributed to
anyone with a severe headache of The general approach to the
Brudzinski is positive when such
any cause will be averse to bright examination of the patient in coma
flexion of the patient’s neck causes
lights. is discussed in Section 1.2.31, and
flexion of both hips and knees.
for the patient with cardiovascular
• Sore throat and earache: these
collapse in Section 1.2.2. In dealing • Kernig’s sign: the patient lies in
may be the primary cause of the
with a case of suspected bed with hip and knee flexed; a
headache or may indicate the
meningococcal meningitis, positive sign is recorded when an
source of meningitis.
note the following. attempt by the physician to extend
• Behaviour: recent changes in the knee is resisted involuntarily
behaviour might point towards Skin, mucous membranes and eyes by the patient (and usually
meningoencephalitis. Any new rash should be treated as causes pain).
highly suspicious. Although the
Other relevant history rash of meningococcal septicaemia Investigation
Given the immediate working is classically purplish and non-
diagnosis of meningococcal blanching (Fig. 37), in its early
meningitis, has the patient been stages it may be erythematous and
in contact with anyone with macular. Look for infarcts in the Suspected meningococcal
septicaemia
Neisseria meningitidis can be antibiotics (eg a single dose History of the presenting problem
cultured from blood, scrapings of of ciprofloxacin 750 mg orally) Important aspects to explore include
skin lesions and cerebrospinal fluid; and to be immunised (if the following.
the diagnosis of meningococcal meningococcaemia is due
• Speed of progression: cord
disease may also be made to serogroup C or A).
compression is usually acute,
immunologically. See Section 3.2
producing non-progressive
for discussion of contraindications, 1.2.28 Acute spastic
and asymmetric weakness.
technique and interpretation of the paraparesis
Guillain–Barré syndrome typically
findings of lumbar puncture.
presents as a distal weakness,
Scenario
usually with tingling or a tight
Management
‘bound’ sensation of the distal
Aside from supportive care, A 38-year-old woman is referred
lower limbs, and progresses
described in Section 1.2.2, the urgently by her GP. For the last
steadily over a few days.
essential requirement is to give 3 days she has had mild bilateral
an appropriate antibiotic without leg weakness with difficulty • Presence or absence of pain:
delay. The choice depends on local climbing stairs. She has not sudden onset of pain in
sensitivities, but is usually a high- passed urine for 18 hours and is association with weakness
dose cephalosporin, eg cefotaxime distressed. You are asked to see suggests a herniated disc,
2 g iv every 4 hours or ceftriaxone and assess her. spinal subarachnoid haemorrhage
2 g iv every 12 hours. or aortic dissection with
involvement of the spinal arteries.
Further comments Introduction
• Sensory symptoms: these (usually
Meningitis is a notifiable disease: The diagnosis in this case is cord
painful) often precede weakness by
refer the case to public health compression until proved otherwise,
some days or even weeks in cord
for contact tracing. Household but consider the possibilities listed
compression; in Guillain–Barré
and other intimate contacts are in Table 16 as you deal with the
syndrome they usually occur
recommended to take prophylactic case.
simultaneously or slightly later.
of malignancy, eg breast cancer, hyporeflexia and unresponsive • Sensory: glove and stocking
or of a multisystem disorder such plantars, although hypertonia, sensory loss, which is often mild.
as SLE? Previous neurological hyperreflexia and upgoing plantars
symptoms might point to a diagnosis develop rapidly and will be found Investigation
of MS. Intravenous drug usage may at presentation in many cases.
lead to osteomyelitis, epidural
• Sensory: examine carefully for a
abscess or (less likely) transverse
sensory level, possibly suspended, Investigation and treatment of
myelitis in association with HIV
that defines the most caudal spinal cord compression is an
infection. emergency. Incomplete lesions with
location of a spinal lesion that
sparing of part of the sensory or
could be responsible for the
Examination: general features motor pathways have a much better
patient’s symptoms and signs. prognosis than complete lesions: rarely
Poor general health may indicate
Do not forget to check sensation can function be restored once lost.
malignancy, anorexia or nutritional
in the saddle area, impairment Discuss lesions immediately with
deficiencies. Breast and thyroid
suggesting a lesion in the cauda radiological colleagues and
examination are important to neurosurgical services.
equina.
exclude two malignancies that
can metastasise to the spine in The finding of neurological signs
this age group. above the level of a cord lesion Imaging of the spine
clearly indicates that more than MRI is the investigation of choice
Cardiovascular abnormalities,
one neurological site is affected, in patients with non-traumatic
eg tachycardia, bradycardia,
eg optic atrophy in a patient with paraplegia or quadriplegia (Fig. 38).
hypertension or hypotension, may
MS, or cerebral and spinal Plain radiography of the spine may
indicate autonomic dysfunction in
metastases in a patient with show an obvious lesion. A CT scan
association with Guillain–Barré
disseminated malignancy. or a myelogram may be indicated in
syndrome.
individual patients, although CT
Respiratory assessment is scanning may not exclude cord
especially important in suspected Urinary retention is not always compression and may not show
Guillain–Barré syndrome. Can the due to mechanical outflow
patient speak in full sentences or obstruction
only words at a time? A simple When performing a rectal examination
method to quantitate respiratory in a patient with urinary retention,
disability is to ask the patient to take always ask ‘Can you feel me touching
a deep breath and then to count out you here?’ before you start. Patients
with cord compression can present
loud as far as possible (1, 2, 3, 4 . . . ).
with urinary retention and little in the
This correlates fairly well with way of leg weakness.
forced vital capacity and can be
easily reproduced to assess if things
are getting better or worse.
evidence of demyelination, and • relieve urinary retention (if • Give high-flow oxygen; apply a
myelography can cause clinical present); pulse oximeter to monitor oxygen
deterioration in patients with cord saturation.
• give adequate analgesia;
compression.
• Obtain intravenous access.
• provide a pressure-relieving
Other tests mattress and turn the patient over • Check fingerprick blood glucose;
Routine haematological and regularly to prevent pressure if <2.5 mmol/L, give 50 mL of
biochemical screening tests will be sores; 50% dextrose intravenously.
required, with particular emphasis Also give high-potency thiamine
• early institution of bowel care.
on looking for evidence of (eg Pabrinex or Parenterovite)
malignancy (anaemia, abnormal to patients with poor nutrition.
Cord compression
liver blood tests, hypercalcaemia,
Disc protrusion requires surgical
raised inflammatory markers and
decompression. Metastatic disease
abnormalities on CXR) and, in an
may be treated with high-dose Insertion of an oral airway is
older patient, myeloma (serum
steroids followed by surgical almost impossible during a
immunoglobulins, serum protein
decompression or radiotherapy, fit and is likely to cause trauma to
electrophoresis and urinary either the teeth or the soft tissues
depending on the context.
Bence Jones proteinuria). Other if performed: wait until the fit has
Spinal/epidural abscess requires
investigations may be appropriate terminated and then insert an oral
surgical drainage and appropriate
depending on the clinical context, or nasal airway as necessary.
antimicrobials.
eg cultures to pursue sepsis/TB and
lymph node biopsy.
Guillain–Barré syndrome
Give intravenous immunoglobulin
If Guillain–Barré syndrome is a 0.4 g/kg daily for 5 days. To terminate status epilepticus
possibility Antiarrhythmic and antihypertensive give either lorazepam or
This is primarily a clinical diagnosis drugs may be required, but use them diazepam.
but can be supported by lumbar with caution and obtain expert help • Lorazepam (4 mg iv at a rate of
puncture (after cord compression in dealing with these problems that 2 mg/min): watch for sedation,
excluded by imaging; typically can arise with autonomic instability. respiratory depression and
reveals elevated protein with normal hypotension. This terminates
fits in 60 – 90% of patients.
cell count), nerve conduction studies 1.2.29 Status epilepticus • Diazepam (10 –20 mg iv at a rate of
(absence or impersistence of F
5 mg/min): can be given rectally at
waves) and anti-GQ1b antibodies Scenario a dose of 10 –20 mg (rectal gel) if
(positive in Miller Fisher variant). intravenous access cannot be
Check stool culture and serology for obtained.
A man who seems to be about
Campylobacter jejuni, serology for 50 years old has been found
Also give fosphenytoin or phenytoin.
atypical pneumonia and collapsed in the street with
cerebrospinal fluid for viral • Fosphenytoin (15–20 mg phenytoin
generalised seizures. He has
infection. equivalents/kg iv at a rate of 150
been fitting continuously mg/min): 50% of patients who
for 20 minutes by the time have not responded to the initial
Because of concern about
he reaches the Emergency benzodiazepine will do so with
respiratory or cardiac involvement,
Department. No past history the addition of fosphenytoin.
check and continue to monitor • Phenytoin (15–20 mg/kg iv at a rate
is available and no family
respiratory function tests (forced of 25–50 mg/min).
members or friends are present.
expiratory volume in 1 second),
arterial blood gases and ECG.
Call for anaesthetic help if there is
Immediate management
Management still no response: the patient may
Specific treatments will depend on • Assess airway, breathing need to be fully anaesthetised using
the diagnosis, but the following are and circulation, and initiate barbiturates or non-barbiturate
important for all patients with acute resuscitation if required (see drugs (eg propofol), intubated and
paraplegia: Sections 1.2.1 and 1.2.2). ventilated.
Routine tests
• Laboratory glucose.
History of the presenting problem Is there an underlying cause for
This man is clearly not in a position the epilepsy that is progressing (eg • Electrolytes/renal/liver/bone
to give an immediate history, but cerebral space-occupying lesion)? profile: hyponatraemia,
consider the possibilities shown in Has he taken large amounts of hypocalcaemia and
Table 17. alcohol or non-prescription drugs hypomagnesaemia can cause fits,
that have precipitated the attack? as can hepatic encephalopathy or
If the patient remains semi-
advanced renal failure.
conscious following termination of
Examination
his fit, then useful information may • FBC.
The general approach to the
be obtained from the following.
examination of the patient in coma • Clotting: impairment increases
• Ambulance crew/notes. is discussed in Section 1.2.31, but risk of intracerebral haemorrhage.
particular points to note in this case
• Medic Alert bracelet or necklace: • Anticonvulsant levels.
would include the following.
look carefully at any jewellery.
• Poor general nutrition or hygiene: • CXR: may show cause of
• Other clues: is he carrying any status, eg malignancy that has
may indicate alcohol or drug
identification, medication or metastasised to the brain, or
abuse, or (less likely) disseminated
prescription cards that might complication, eg aspiration
malignancy.
suggest he is a known epileptic pneumonia.
or diabetic? • Signs of chronic liver disease due
to alcohol abuse, eg spider naevi,
• Emergency Department staff: Imaging
jaundice, Dupuytren’s contractures
many patients with epilepsy are CT and/or MRI are warranted in
and bruising.
regular attenders. Does anyone almost all cases of unexplained
recognise him? • Signs of drug abuse, eg track status epilepticus, but patients
marks. should only be moved from the
When discussion can take place
Emergency Department once they
with the patient or someone who • Glasgow Coma Scale score and
have been stabilised.
knows him, then if he is a known focal neurological signs: pupillary
epileptic it will be important to signs and asymmetry of limb
Other tests
pursue reasons for the development movements may be abnormal
If there is suspicion of an infective
of status epilepticus. Has he following a fit, but persistent
cause, then this should be pursued,
been taking his medication (some asymmetry strongly suggests a
eg blood cultures, lumbar puncture
epileptics are reluctant to accept focal intracranial lesion.
(if there is no contraindication on
their diagnosis)? Has he had an
CT), thick film for malaria and MRI
intercurrent illness that has Investigation
scanning (Fig. 39) as appropriate.
prevented him from taking The first investigation of the patient
his medication or which may presenting with status epilepticus Arterial blood gases can usefully
have altered its absorption (eg should be measurement of document the adequacy of
gastroenteritis)? Have there been fingerprick blood glucose to exclude oxygenation and ventilation,
any other changes in his medication hypoglycaemia. The requirement for and may also reveal unexpected
that might have altered drug levels? further investigation will depend on metabolic acidosis, which gives a
Introduction
The working diagnosis must be
that this woman has had a stroke,
although other conditions must be
considered (Table 18). She has some
difficulty with speech, described
(perhaps loosely) in the scenario as
being ‘slurred’, and so obtaining a
history from her may be difficult.
First consider whether she has
dysphasia.
• Is speech fluent?
Fig. 39 MRI of herpes simplex encephalitis showing classical cortical distribution mainly in the temporal • Do they have any receptive
and parietal lobes: (a–d) T2-weighted images; (e–h) fluid-attenuated inverse response (FLAIR) images. dysphasia: can they obey a one-,
then two-, then three-step
command?
clue to poisoning as an explanation management of epilepsy in • Do they have any expressive
for fits, eg ethylene glycol appropriate cases. dysphasia, eg nominal dysphasia?
(antifreeze).
1.2.30 Stroke
Electroencephalography may be History of the presenting problem
required, particularly in patients
Scenario If a history can be obtained from the
who remain unconscious. The fits patient or her husband, ask about
may become progressively more A 68-year-old woman is found the following.
subtle in prolonged epilepsy: non- on the living room floor by her
convulsive status epilepticus. • Onset of symptoms: strokes come
husband. He phones for an
on suddenly, so a weakness of
ambulance which brings her
Further management gradual onset would suggest a
to the Emergency Department,
Specific treatment, if possible, space-occupying lesion.
where she is immediately
will be determined by the cause observed to have right-sided • Associated symptoms: a sudden
of the fitting. Patients who are weakness and slurred speech. severe headache preceding the
recovering from a seizure should She has a long history of poorly collapse may suggest an SAH
be nursed in the recovery position controlled hypertension. You are or intracerebral haemorrhage.
with appropriate management of asked to assess her. A history of jaw pain and/or
the airway (nasopharyngeal or oral temporal tenderness suggests
airway; suction), continued high-
flow oxygen and close monitoring
(vital signs, neurological TABLE 18 DIFFERENTIAL DIAGNOSIS OF STROKE
Total anterior circulation syndrome (TACS) New higher cerebral dysfunction (eg dysphasia, Large cortical stroke in middle
dyscalculia and visuospatial disorder) and cerebral, or middle and anterior
Homonymous visual field defect and cerebral artery territories
Ipsilateral motor and/or sensory deficit involving at
least two of three areas of the face, arm or leg
Partial anterior circulation syndrome (PACS) Two of the three components of TACS or Cortical stroke in middle or anterior
New higher cerebral dysfunction alone or cerebral artery territory
Motor/sensory deficit more restricted than those
classified as LACS (eg isolated hand involvement)
Lacunar syndrome (LACS) Pure motor stroke or Subcortical stroke due to small-
Pure sensory stroke or vessel disease
Sensorimotor stroke or
Ataxic hemiparesis or
Dysarthria and clumsy hand
Note that evidence of higher cortical involvement or
disturbance of consciousness excludes a lacunar
syndrome
Posterior circulation syndrome (POCS) Ipsilateral cranial nerve palsy with contralateral motor Stroke in posterior circulation,
and/or sensory deficit or brainstem or cortex
Bilateral motor and/or sensory deficit or
Disorder of conjugate eye movement or
Cerebellar dysfunction without ipsilateral pyramidal
tract involvement or
Isolated homonymous visual field defect
Guideline Comment
Indication Consider in all patients with proven ischaemic stroke presenting within 3 hours of onset
Clinical exclusion criteria Use of oral anticoagulants and/or INR >1.7
Use of heparin in the preceding 48 hours or prolonged partial thromboplastin time
Platelet count <100 × 109/L
Stroke or serious head injury in the previous 3 months
Major surgery within the previous 14 days
Pretreatment systolic BP >185 mmHg or diastolic BP >110 mmHg
Rapidly improving neurological condition
Mild isolated neurological deficits
Previous intracranial haemorrhage
Blood glucose >22 mmol/L or <2.8 mmol/L
Seizure at stroke onset
Gastrointestinal or urinary bleeding within the previous 21 days
Recent myocardial infarction
Clinical caution Severe stroke: National Institutes of Health stroke scale score >22
Radiological contraindication CT suggests early changes of major infarction, eg sulcal effacement, mass effect or oedema
Clinical requirement Thrombolytic therapy should only be administered by physicians with expertise in stroke medicine
who have access to a suitable stroke service with facilities for identifying and managing
haemorrhagic complications. It is recommended that treatment and its adverse effects are
discussed with the patient and/or the family before treatment
Regimen Recombinant tissue plasminogen activator 0.9 mg/kg iv, up to a maximum of 90 mg; the first
10% as a bolus, the rest as an infusion over 60 minutes
improves the outcome from acute hypertension, the BP needs to be pursue possible cardiac sources
stroke. lowered slowly: use an intravenous of emboli (echocardiography,
agent such as labetalol and aim to transthoracic and transoesphageal).
• Aspirin: should be given (oral,
reduce BP by 25% over the next Carotid Doppler studies should be
nasogastric tube and rectal
24 hours. performed if the patient would be
preparations are available) when
a suitable candidate for surgery.
haemorrhagic stroke has been The patient should be referred to
excluded. ancillary services sooner rather than 1.2.31 Coma
BP commonly increases following later: speech therapy, physiotherapy,
acute stroke and settles over the occupational therapy and the social Scenario
next 24 – 48 hours. Immediate work department. Secondary
attempts to lower the pressure are prevention (apart from BP control) A man of about 40 years who
much more likely to do harm than should be started soon after lives alone has not been seen
good: cerebral autoregulation is admission, including the need for 2 days. His neighbours go
disturbed and rapid reduction of to stop smoking. to his house to investigate,
BP may reduce cerebral perfusion find him collapsed and call an
below a critical threshold. Most Further comments emergency ambulance. The
would recommend gentle pressure Depending on the outcome from paramedics give oxygen, obtain
reduction only if the systolic is the stroke, further investigation may venous access and bring him
consistently above 220 mmHg or be appropriate for selected cases. In to the Emergency Department
the diastolic above 130 mmHg, young stroke patients make sure that where you are asked to assess
with modified-release nifedipine you obtain an accurate drug/social him. He is unconscious. The
10 mg po stat being a suitable history (amphetamine and cocaine), neighbours have not accompanied
initial treatment. In the rare case of consider detailed thrombophilia him to hospital.
stroke associated with malignant testing (eg lupus anticoagulant) and
• Consider Wernicke’s
encephalopathy, especially
if there are signs of alcohol abuse,
and if this is a possibility give
intravenous thiamine (see
Section 1.2.18). Fig. 40 Glasgow Coma Scale.
1. Frequency is as in UK practice; head injury is usually obvious, but not always. Other routine tests
FBC, clotting, electrolytes,
laboratory glucose and a
Head-to-toe screen suggest severe damage and are renal/liver/bone profile may give an
a very poor prognostic sign (but indication of some of the conditions
• General condition: poor nutrition
ensure the patient is not wearing listed in Table 21. Perform a CXR to
or hygiene may indicate alcohol or
cosmetic contact lenses). A rule out aspiration. About 80% of
drug abuse in this context.
unilateral, fixed and dilated pupil patients who have had an SAH have
• Signs of chronic liver disease: indicates a third nerve lesion, ECG changes, which in around 10%
likely to be due to alcohol abuse. commonly due to uncal herniation suggests an acute myocardial
from a supratentorial mass lesion infarction.
• Signs of drug abuse, eg track
or a posterior communicating
marks.
artery aneurysm. Unilateral Other tests in selected cases
• Signs of trauma: either as a Horner’s syndrome suggests Blood cultures will be appropriate
primary cause of the collapse damage to the hypothalamus is there is clinical suspicion of
(feel the back of the head and or a lateral medullary syndrome. sepsis, and thick films for malaria
neck for bruising/induration) or Bilateral small pupils suggest are necessary in cases with the
as a consequence of it (check for opioid overdose or more rarely possibility of exposure. Lumbar
features of pressure necrosis and pontine damage. puncture may be required, after
compartment syndromes). CT, in selected patients. Aside
• Eye movements: abnormal
from confirming oxygenation and
• Respiratory pattern: conjugate deviation suggests
ventilation, arterial blood gases
Cheyne–Stokes respiration is intracerebral damage.
may show metabolic acidosis, a
associated with bilateral cortical Disconjugate deviation implies
critical clue to the fact that a
damage; hyperventilation may damage to cranial nerves III,
patient’s coma is due to poisoning
occur secondary to metabolic IV or VI.
(see Section 1.2.36).
acidosis, pulmonary pathology or,
• Asymmetry of peripheral tone
rarely, brainstem pathology; and
or reflexes suggests focal Management
bizarre respiratory patterns may
neurological damage. Specific management will clearly
be associated with brainstem
depend on the cause of coma, and
pathology.
Investigation you should have a low threshold
for treating unlikely but plausible
Neurological
Glucose and imaging treatable causes, eg aciclovir if
• Pupillary size and reaction: The first investigation in the herpes simplex encephalitis is
bilateral fixed and dilated pupils unconscious patient should always possible.
Patients who remain in coma after severe, complicated malaria. • exposure to animals;
initial resuscitation measures have Cerebral malaria, a complication of
• sexual history;
been undertaken will require Plasmodium falciparum infection,
transfer to an intensive care unit. may present with coma. There will • vaccinations received prior to
Those who recover to a GCS score probably be an antecedent history travel;
of ≥8 may be managed in a suitable of a short febrile illness with rigors
• antimalarial chemoprophylaxis
high-dependency area; there they and headache. Patients infected with
and compliance.
should be nursed in the recovery Plasmodium vivax, Plasmodium
position with appropriate ovale or Plasmodium malariae tend
management of the airway to have milder symptoms. The
(nasopharyngeal or oral airway, incubation period is at least 7 days, Malaria can cause misleading
suction) and continued high-flow but remember that vivax and ovale localising features such as
oxygen until fully recovered, along malaria can cause symptoms for the abdominal pain, diarrhoea,
breathlessness or jaundice.
with ECG and oxygen saturation first time more than 12 months after
monitoring and regular neurological infection.
and systemic observations. A
suitable pressure-relieving mattress, Other diagnoses
intravenous fluids and a urinary The diagnosis is malaria! However, The fact that a patient has
convene/catheter will be required. be wary: Gram-negative sepsis taken malaria prophylaxis does
commonly coexists with malaria not rule out malaria: it is 70 –90%
effective (if taken).
1.2.32 Fever in a returning and typhoid in particular must be
traveller considered. Meningitis may be the
only manifestation of typhoid, when
Examination
Scenario it may resemble any other pyogenic
The general approaches to
meningitis. Consider a broad
investigation of the patient who is
A 25-year-old man is brought differential including fungal, viral
very ill or in coma are discussed in
to the Emergency Department and other protozoal infections. Also
Sections 1.2.2 and 1.2.31. Malaria
by his friends. He has recently consider encephalitis and cerebral
produces no diagnostic physical
returned from a back-packing abcess, and drug ingestion may be
signs. Anaemia and slight jaundice
trip around Thailand and has not complicating the picture.
are common, with moderate tender
been well since his return. He is
hepatosplenomegaly. There is no
drowsy and has a temperature of History of the presenting problem
rash or lymphadenopathy.
39°C. You are asked to review This man may be too unwell to give
him immediately on his arrival. a lucid account but if he is able to
Investigation
then, aside from routine enquiry
An immediate thick and thin malaria
about how the illness began, how
film is required (Fig. 41). Remember
Introduction it progressed, localising symptoms
that a single negative film does not
and past medical history, the most
exclude malaria: it is very unlikely if
Malaria important issues in this case are
three films are negative, although it
clearly to get a full travel and social
cannot be completely excluded until
history to establish which pathogens
another diagnosis is made or the
the patient may have been exposed to,
• Consider malaria in any illness resolves.
patient presenting to hospital and whether precautions to prevent
with coma and/or fever and a infection have been taken. Ask about: The approach to investigation of
relevant travel history. the patient who is very ill and/or
• There are no diagnostic findings on • countries visited and when;
has suspected sepsis is described
examination.
• areas visited (rural or urban, in Sections 1.2.2 and 1.2.27.
• Missing the diagnosis can be fatal.
rainforest or savannah); Note that anaemia, leucopenia,
thrombocytopenia, abnormal
• accommodation used;
Malaria must be the working clotting, renal failure and deranged
diagnosis in this man. Falciparum • activities whilst there, eg liver function may all be seen with
malaria is usually the cause of freshwater exposure or trekking; malaria.
Further comment
See Infectious Diseases, Sections
Management Drug treatment of malaria 1.3.16 and 2.13.1 for more detailed
Falciparum malaria If the patient discussion of this presentation and
can swallow, first-line treatment is the management of malaria.
now Riamet (each tablet contains
If you are not familiar with the artemether 20 mg with lumefantrine 1.2.33 Anaphylaxis
management of malaria, seek 120 mg), four tablets twice daily for
expert advice sooner rather than later, 3 days. The ‘standard’ alternative, Scenario
particularly if the patient has been to which remains the treatment of
northern Thailand, Laos or Burma as
choice in many countries, is quinine A 40-year-old woman has
there is a high incidence of quinine
resistance in these areas and 600 mg (of salt) three times daily been admitted to the ward for
combination therapy may be required. for 7 days, followed by a single treatment of a community-
dose of three tablets of Fansidar acquired pneumonia. Shortly
(sulfadoxine/pyramethamine) or after taking the first dose of
doxycycline 100 mg daily for 7 days. amoxicillin she complains of
The general approaches to
difficulty breathing and of
management of the patient who is If the patient cannot swallow, give
swollen lips and tongue. The
very ill or in coma are discussed in intravenous quinine (loading dose
nurses have put out a ‘cardiac
Sections 1.2.2 and 1.2.31. With 20 mg/kg of dihydrochloride salt,
arrest’ call. You are the leader of
regard to the patient with malaria, maximum 1400 mg, over 4 hours;
the cardiac arrest team and are
note the following. then 10 mg/kg over 4 hours twice
expected to manage the patient.
daily), intravenous artesunate or
• Hypoglycaemia is common
intramuscular artemether. Omit the
in severe malaria: monitor
loading dose of quinine if the patient
blood glucose hourly and Introduction
has received mefloquine witin the
give intravenous dextrose if
last week or quinine has been given
necessary.
in the last 24 hours.
• Remember that there is a clear Anaphylaxis
While the quinine is being
association between bacterial Anaphylaxis is a severe allergic
administered make sure that the
infection and malaria: in addition reaction to an allergen that the patient
patient is on a cardiac monitor and has previously been exposed to. It is
to treatment for malaria, treat
the fingerprick blood glucose is mediated by antigen-specific cross-
the patient empirically with
measured hourly. linking of IgE molecules on the surface
broad-spectrum antibiotics after
of tissue mast cells and peripheral
taking blood cultures if they are Vivax, ovale and malariae malaria blood basophils.
seriously ill. Give oral chloroquine 600 mg
• Systemic features such as fever, • check motion – synovitis with or Other tests
ulcers (orogenital), rashes and without a synovial effusion may Blood cultures should be taken
eye symptoms. result in a decrease in the range, in all cases and a clotting screen
including a loss of full extension performed if there is haemarthrosis.
• Past history of joint problems:
(flexion deformity) and/or a Other tests rarely provide very useful
this patient is said to have
reduction in flexion; information in patients with a single
probably had RA. What is the
hot joint: the white cell count may
evidence for this? • palpate for crepitus with passive
be raised in infection; elevation of
movement.
• Drug history: anticoagulants inflammatory markers (erythrocyte
predispose to intra-articular sedimentation rate and C-reactive
Investigation
bleeds and corticosteroid use protein) is non-specific; the level of
can result in avascular necrosis. serum uric acid is uninformative
about whether gout is the problem;
In appropriate cases a detailed
The first priority in dealing testing for autoantibodies is rarely
sexual and drug abuse history with an acute hot joint is to rule revealing; and joint radiographs
will be necessary. out septic arthritis.
are usually unhelpful, although
chondrocalcinosis may be seen in
Examination
Joint aspiration pseudogout.
As always begin with an overall
assessment of the patient’s The single most useful and important
test is joint aspiration: send synovial Management
condition: those with a septic
fluid for urgent microscopy (white Specific treatment will depend on
arthritis are usually very ill. On
blood cell count, Gram stain and the diagnosis, but note the following.
general physical examination take
note of the following. polarising microscopy for crystals
of gout or pseudogout) and culture Analgesia
• Temperature. (Table 23). The finding of non- NSAIDs should initially be given
inflammatory joint fluid in an at their maximum recommended
• Rash: reactive arthritis commonly
acutely inflamed joint should dosage until symptoms improve,
occurs with viral illnesses.
prompt consideration of another after which they should be tapered
• Eyes: are there any signs of pathology (eg stress fracture, gradually over several days.
conjunctivitis or uveitis? osteomyelitis or avascular necrosis), Indometacin is very effective,
acute inflammation of periarticular but adverse effects in some patients
• Presence of tophi.
structures (eg gouty inflammation limit its utility; other NSAIDs with
• Consider examination of the of tendon sheaths or bursae, short half-lives (eg ibuprofen and
external genitalia for septic bursitis) or subcutaneous diclofenac) can also be used.
ulceration/discharge. inflammation (eg cellulites). Colchicine has a narrow therapeutic
With regard to the knee: window that limits its effectiveness,
and its use in treating acute gouty
• inspect and palpate for swelling,
Aside from being crucial arthritis (as opposed to being used
erythema, synovial effusion
to obtaining a diagnosis, in low doses to prevent attacks) has
and warmth, comparing the
aspiration of a hot joint often provides been largely supplanted by other
affected joint with the considerable pain relief. therapies.
contralateral one;
Corticosteroids are an effective
alternative to NSAIDs and
TABLE 23 FINDINGS ON ASPIRATION OF SYNOVIAL FLUID colchicine for patients in whom
these drugs may be contraindicated
Condition Macroscopic White cell count Polymorphonuclear
appearance (× 109/L) neutrophils or hazardous (eg patients of
advanced age or with renal
Normal Clear 0–0.2 <10% insufficiency, congestive heart
Non-inflammatory Clear 0.2–2.0 <20%
failure or an inability to take
Inflammatory Slightly turbid 2.0–50 20–70%
Pyo-arthrosis Turbid >50 >70% oral medications). Regimens
include:
neck/compression of the nerve in the diagnosing nerve root compression, protein electrophoresis/urinary
popliteal fossa). This will aggravate discitis and neoplasms (Fig. 42). Bence Jones proteins; CXR and
or elicit pain radiating down the bone scan; and diagnostic biopsy.
raised leg if there is nerve root Other investigations
• Inflammatory: FBC, inflammatory
irritation. The pain should be Patients with simple mechanical
markers, autoimmune rheumatic
relieved by flexion of the knee. The back pain should not be
serology and human leucocyte
PSLT can also be performed in the investigated. If red flags are present,
antigen (HLA)-B27.
sitting position. A discrepancy with then investigation should be
the supine PSLT suggests that the determined by clinical suspicion.
Management
symptoms could be factitious.
• Infection: blood cultures, FBC and
inflammatory markers; also
Neurological examination
diagnostic biopsy. Anyone with symptoms
Look for focal signs as described in
suggestive of cauda equina
Clinical Skills for PACES and shown • Malignancy: FBC, inflammatory
syndrome needs immediate
in Table 24. markers, liver/bone profile,
neurosurgical referral: this is a
prostate-specific antigen and surgical emergency.
serum immunoglobulins/serum
Investigation
Imaging
Plain radiological films are unhelpful
in the acute setting in the absence of
red flags or significant fracture risk;
Fig. 42 MRI scan of a patient presenting with a short history of back pain and perianal anaesthesia. The
MRI is the best procedure for body of L3 and the right psoas muscle are infiltrated. Biopsy revealed high-grade non-Hodgkin’s lymphoma.
For those who do not have simple refuse to stay in hospital or accept overdose it is clearly necessary
mechanical back pain, specific treatment. The capacity to consent to try to establish what has been
management will depend on the to medical treatment or make a taken and when. Always presume
cause. valid refusal is a legal concept not that other tablets or alcohol have
a medical one, and therefore it is been taken.
Patients with simple mechanical
independent of the diagnosis. If
back pain should be given adequate
this woman is assumed to have Other relevant history
analgesia. Follow the analgesic
full capacity to refuse medical Details of previous medical,
ladder from simple non-opioids
treatment, she may well develop psychiatric and social history
(eg paracetamol) to opioids (eg
liver failure and possibly die. If are required, the main aim of
co-codamol, then morphine), give
patients have such a capacity, it is of psychiatric assessement being to
a co-analgesic (eg NSAID), and use
no consequence whether you agree establish the risk of suicide.
muscle relaxants (eg diazepam 2 mg
with their decision, and whatever
three times daily) in the early stages.
their reasons you must respect their Psychiatric and social background
The patient should be discharged
decision unless they are detained Is there a past history of
home as soon as pain has been
under the Mental Health Act. deliberate self-harm? Is the
reduced to tolerable levels, with
patient known to suffer from
instructions to stay active and return It is reasonable to call on psychiatric
affective disorder, schizophrenia,
to work/usual activities as soon as services to make an assessment of a
alcoholism or drug dependence?
possible. The prognosis for simple patient’s capacity, but there is often
Is she socially isolated or recently
mechanical back pain is good: 90% insufficient time to do this and so
separated? Have there been any
recover at 6 weeks, although you must be able to make this
other recent adverse life events?
recurrence is common. The assessment as well. Case law has
Is there a history of aggressive or
prognosis for those with nerve root widely recognised that factors such
impulsive behaviour?
pain (‘sciatica’) is less good, with as drugs, fatigue, panic, pain, shock
only 50% recovering at 6 weeks. and confusion will erode a patient’s
Assessing the risk of suicide
capacity, in which case you will
See Rheumatology and Clinical Did she take the overdose on
be able to proceed with urgent
Immunology, Sections 1.1.12 and impulse or had she planned it for
treatment in good faith, provided
1.1.13 for further discussion. some time? Features that would
you are acting in the patient’s best
suggest planning and a high suicide
interests and in line with the view
1.2.36 Self-harm risk include hoarding of pills, taking
of a responsible body of medical
precautions to make sure that she
opinion. See also Section 1.2.37.
Scenario was alone and undisturbed when she
took the pills, leaving a suicide note,
A 25-year-old woman is giving away treasured possessions
brought to the Emergency before the event, arranging for
Treating a patient who does
Department following an children to be sent away and the
not want to be treated
overdose of 30 500-mg use of more than one means to
If you believe that a patient who has
paracetamol tablets 9 hours try to kill herself.
taken an overdose has a mental illness
prior to her arrival in hospital.
and assess that his or her capacity is in
She refuses to say anything doubt, your duty of care allows you to
other than that she wants to be undertake treatment despite the
left alone to die. She has refused patient’s opposition and ultimately
all medical intervention. You are potentially save the patient’s life. High-risk clinical factors for
asked to see her. suicide
• Severe insomnia.
History of the presenting problem • Self-neglect.
Introduction Getting a reliable history from a • Memory impairment.
• Agitation.
patient who has taken an overdose
• Panic attacks.
Can you treat the patient? can be difficult if not impossible,
• Pessimism, anhedonia, despair and
It is common for patients who have but to be able to judge the likely morbid guilt.
intentionally harmed themselves to medical consequences of an
under common law. The issues can History of the presenting problem hypotension are not features of
become difficult when physical psychiatric illness.
illness may have led to a disability
If possible, check fingerprick blood
of the mind through disordered Dealing with a patient who glucose. Other investigation will be
brain function: this area is not could be dangerous
determined by clinical suspicion
always clear-cut. The senior • Remember that you have a duty to and the willingness (or otherwise)
doctor in the department must yourself and other staff members as
of the patient to cooperate; urine
be involved and a referral made well as the patient: do not take risks.
toxicology may be helpful.
to the psychiatric team as urgently • Be safe: do not see this man on your
as possible whenever there is own; if you meet him in a room
(rather than an open area) make
consideration of the MHA being
sure that he is away from the door
used. Any use of the MHA will and that you are close to the door; if
Write notes that clearly
inevitably take time – for arrival you are wearing a tie, remove it.
describe the situation
of the appropriate personnel
and for their subsequent Your notes in the medical record must
give a clear and precise description of
assessment – so usually the
the situation. Do not use vague terms
detention of the patient will The circumstances mean that it such as ‘patient uncooperative’. What
be under common law. will clearly not be possible to get a did he say? Write it down in quotes:
reliable and useful medical history ‘Patient said “Piss off . . . go away” ’.
Section 136 from the patient. Use any other How did he appear: ‘Bleeding from
head wound and agitated; shouting
Section 136 of the MHA empowers sources of information that may
out loud, sweating, shaking and
a police officer to detain and take be available, as described in tremulous; and holding onto a chair
to a place of safety an individual Section 1.2.31, with points of and threatening to use it as a weapon’.
who may require assessment and/or particular importance being the
treatment. In many areas the speed of onset of symptoms, drug
designated place of safety is a police or alcohol ingestion/withdrawal,
Management
cell, but some hospital emergency recent history of head trauma,
If patients are hypoglycaemic
departments may be so designated, associated symptoms (including
(blood glucose <2.5 mmol/L), try
although most are ill equipped to headache, seizures and vomiting)
to encourage them to drink or eat
deal with disturbed individuals and a history of significant past or
something sweet, but do not give
(and should resist taking on this current medical illness.
them a hot drink which they might
role if they do not have adequate
spill over themselves or throw over
facilities). However, the police Examination and investigation
you. Obtaining intravenous access is
will bring any person to the As with history-taking, it will not
not likely to be straightforward: give
emergency department if they be possible to perform a physical
glucagon 1 mg im if parenteral
consider that the individual examination and pursue
treatment is required.
might be medically unfit. investigation in the usual manner if
the patient is not cooperative. Try If the patient has another specific
and glean as much information as medical or surgical diagnosis,
you can from the following. then this will require appropriate
treatment, but before such treatment
• Inspection: are there any signs
Medical/psychiatric causes of
can be administered it will be
of trauma, particularly to the
violence and aggression necessary to have a practical
head? Are there any localising
strategy for dealing with violence
• Acute confusional state: an acute, neurological signs, eg is the
transient, fluctuating, potentially or aggression.
patient moving both arms in
reversible, organic brain disorder
the same sort of way? Are there
characterised by globally impaired De-escalation techniques
consciousness and inattention.
any other features that suggest
Try to keep calm. Introduce yourself
• Psychiatric conditions: most significant medical illness,
and reassure the patient: speak
commonly personality disorder eg rash?
clearly, do not shout, minimise eye
and substance abuse.
• Other organic brain pathologies. • Vital signs: if the patient will allow contact and always maintain a safe
these to be checked. Fever and/or distance. Ask the patient what the
problem is: acknowledge his Perform sedation as follows. one syringe of benzodiazepine,
or her feelings and empathise as wait 60 seconds and then repeat
• Step 1: begin by encouraging
appropriate; try to establish an as necessary until sedation is
the patient to take oral sedation.
emotional relationship (‘I’m trying achieved.
The oral route is the safest but
to help’); and attempt to address any
with the requirement for patient
immediate problems or explain why
cooperation; the downside is that
you cannot do so.
oral medications take some time Do not take risks!
to be absorbed. Try lorazepam
Sedation If you are confronted with a
1–4 mg stat and haloperidol 2.5 mg violent or aggressive patient and
If the patient needs further
stat (rising to 5–10 mg if needed). genuinely fear for your safety, keep
assessment or treatment and is
yourself and others out of the patient’s
not calmed by discussion, then • Step 2: give intramuscular way until adequate help is available.
sedation may be required. The sedation. However, be careful to Let the patient leave the hospital if
synergistic use of an antipsychotic avoid accidental needle-stick trying to do so, informing duty hospital
and a benzodiazepine is widely injury of individuals other than manager and/or police as appropriate.
recommended, the benzodiazepine the patient and remember that
reducing the dose of antipsychotic the absorption profile of drugs
necessary to produce calm and given intramuscularly is also
therefore limiting the risk of unpredictable. Try lorazepam
Where should the violent or
oversedation and other side effects. 1–4 mg stat and haloperidol aggressive patient be managed?
The most desirable end-point of 2.5 mg stat (rising to 5 –10 mg if
• If an underlying medical problem
using sedatives in the context of needed). requiring admission for treatment
agitation is a calm and cooperative is present, admit the patient to a
• Step 3: if the patient is in extremis
patient not an unresponsive one, medical ward when appropriate
and you think it essential to
which is sometimes a difficult psychiatric input has been organised,
induce sedation immediately, eg one-to-one psychiatrically trained
balance to achieve.
request four people trained in nurse in attendance.
control and restraint (one for each • If the patient has a psychiatric
arm and one for each leg); request disorder but no medical disorder,
it is up to a psychiatrist to decide if
an anaesthetist and ensure that
admission to a psychiatric unit is
Sedation of the violent or resuscitation equipment is required: the patient is not to be
aggressive patient available; and draw up several admitted to a medical ward under
The physician administering sedation syringes, each containing a any circumstances.
must be confident in airway reasonable dose of intravenous • If the patient has no underlying
management, have appropriate back- psychiatric or medical disorder, the
benzodiazepine (eg lorazepam
up from the intensive care unit and person should not remain in hospital;
4 mg). When all are assembled,
must also have the correct doses of the police should deal with any
antagonists available. restrain the patient, insert violent behaviour.
intravenous cannula, inject
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Following paracetamol
overdose specialist advice from
a liver centre should be sought in the
presence of any of the following
indicators of severe hepatotoxicity.
Tricyclic antidepressants
Coma, convulsions and arrhythmias
are the most serious signs of toxicity.
Fig. 43 Paracetamol treatment lines.
Tachycardia and QRS prolongation
(>100 ms) on ECG indicate severe
are likely to be above the treatment The dose of N-acetylcysteine poisoning. Anticholinergic effects
line if more than 150 mg/kg or 12 g, is 150 mg/kg in 200 mL 5% include blurred vision, dry mouth,
whichever is the smaller, has been dextrose intravenously over pupillary dilation and urinary
taken (>75 mg/kg if the patient is at 15 minutes; then 50 mg/kg in retention. Central effects include
high risk of toxicity). 500 mL 5% dextrose over 4 hours; confusion, drowsiness, nystagmus,
and then 100 mg/kg in 1000 mL ataxia, hyperreflexia and
5% dextrose over 16 hours. hyperthermia.
Continued N-acetylcysteine
Patients at high risk of toxicity The most important aspects of
following paracetamol overdose should be given at a rate of
management are cardiac monitoring
150 mg/kg over 24 hours if the
• Patients on enzyme-inducing drugs and efforts to increase urinary
(eg carbamazepine, phenytoin,
patient is symptomatic and/or
excretion of the tricyclic by alkaline
rifampicin or phenobarbital) or there are abnormalities on
diuresis.
who are malnourished (owing to investigation, ie raised
anorexia or HIV). prothrombin time (PT)/INR • Place on cardiac monitor:
• Patients who drink more than 21 and/or elevated plasma dysrhythmias may respond
units of alcohol per week if male,
creatinine and/or acidosis. to correction of hypoxia and
or more than 14 units per week if
female, may also be at greater risk. acidosis, but antiarrhythmic drugs
Adverse reactions to N-acetylcysteine
may be necessary, although some
include nausea, flushing, urticaria,
can exacerbate the toxic effects of
angio-oedema, bronchospasm and
tricyclics (seek expert advice).
hypotension. These usually occur
Chronic or staggered early and often resolve if N- • Urinary alkalinisation with
paracetamol overdose acetylcysteine is stopped and sodium bicarbonate is indicated
In this circumstance the plasma intravenous chlorpheniramine if there is systemic acidosis,
paracetamol concentration cannot given, after which the infusion prolonged QRS, ventricular
be interpreted: if the total dose in may be restarted at the lowest arrhythmias, hypotension or
24 hours exceeds 150 mg/kg or 12 g,
rate. Methionine 2.5 g orally can cardiac arrest. Infuse sodium
whichever is the smaller (>75 mg/kg
be given to those who are intolerant chloride 0.9% 250 mL/hour iv to
in high-risk patients), then N-
acetylcysteine should be given. of N-acetylcysteine and is protective induce diuresis of >150 mL/hour.
if given within 12 hours. When diuresis is established check
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urinary pH and replace saline • Give intravenous benzodiazepine gases: respiratory alkalosis and/or
with sodium bicarbonate 1.26% for convulsions. metabolic acidosis can be expected.
(500 mL over 2 hours) if it is If salicylate levels are >500 mg/L
necessary to obtain urinary Salicylates (3.6 mmol/L), consider alkaline
pH between 7.45 and 7.55. The important clinical features are diuresis with 1.26% sodium
When a satisfactory urinary hyperventilation, tinnitus, deafness, bicarbonate (as described above
pH is attained, replace sodium sweating, vasodilatation, for tricyclic overdose); if salicylate
bicarbonate with saline. Continue convulsions, coma and death. levels are >700 mg/L (5.1 mmol/L),
to monitor urinary pH and give consider haemodialysis.
further bicarbonate if urinary pH Important aspects of management
falls significantly. include checking arterial blood
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Common Arterial puncture (2–8%) Arterial puncture (2–4%) • small scalpel blade, silk suture
Pneumothorax (<1%) Pneumothorax/haemopneumothorax and sterile occlusive dressing.
Bruising/haematoma (1–2.5%)
formation Bruising/haematoma formation
Infection Infection
Less common/rare Nerve damage Nerve damage Technique for central line
Arteriovenous fistula Chylothorax (especially left-sided lines) insertion
Venous thrombosis Arteriovenous fistula The National Institute for Health and
Lost catheters Venous thrombosis
Clinical Excellence (NICE) guidelines
Lost catheters
allow operators experienced in the
1. It is not sensible to inform patients of every possible complication that might arise from landmark technique to continue to use
central line insertion (or any other procedure). However, in the context of explaining the it: junior medical staff should learn to
indications and potential benefits to them of the procedure, it would be expected that they use ultrasound to identify and
would be told of the common problems that can arise. cannulate the vessel.
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3.1.2 Specific techniques for • Attach the introducer needle to needle with your finger to prevent
insertion of central lines the 5-mL syringe and, keeping air embolism.
one finger on the carotid pulse,
• Pass the guidewire into the vein,
Internal jugular vein cannulation insert the needle just lateral to
ensuring that it passes freely.
using the Seldinger technique this at 45° to the skin. Aim for the
Remove the wire if there is any
ipsilateral nipple in men or the
• Ask the the patient to lie down, resistance and check that blood
anterior superior iliac spine in
preferably with a head-down tilt, can still be aspirated easily, then
women. Advance the needle slowly
and turn the head away from the try again.
whilst aspirating for blood. You
side you intend to cannulate.
will only need to insert it a few • Remove the needle, leaving the
• Identify your landmarks (Fig. 44): centimetres as the vein lies wire in the vein.
the internal jugular vein lies superficially. If you do not hit the
vein, withdraw the needle to just • Nick the skin at the base of
superficial, lateral and parallel
below the skin and aim slightly the wire with the small scalpel
to the carotid artery. Identify
more medially and superficially blade to allow easy passage of the
the apex of the triangle formed
before trying again. dilator. If there is resistance do
by the two heads of the
not use force, which can crimp the
sternocleidomastoid muscle at
• Once you are in the vein and can guidewire or the end of the dilator.
the level of the thyroid cartilage.
aspirate blood freely, remove the The usual explanation is that an
This is where you will introduce
syringe and occlude the end of the inadequate nick has been made
the needle, one of the so-called
needle with your finger (to prevent with the scalpel blade.
‘high approaches’ that minimise
air embolism).
the risk of pneumothorax. • Pass the dilator over the wire
• Clean and drape the skin. through the subcutaneous tissue
Seldinger technique
and then remove it, leaving the
• Infiltrate the skin and This technique, which is more
wire in situ.
subcutaneous tissue with 1% reliable than cannula-over-needle
lidocaine (lignocaine). techniques, is widely used for • Pass the central line over the wire
arterial or venous cannulation. into the vein.
• Flush the lumen(s) of the
central line with saline or Hepsal • Once you are in the vein and can • Remove the wire and check that
and ensure you have all your aspirate blood freely, remove the you can aspirate blood freely
equipment within easy reach. syringe and occlude the end of the through the cannula.
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Subclavian vein cannulation using it is lying just under the inferior • Clean and drape the skin.
the Seldinger technique border. Advance the needle,
• Infiltrate the skin and
The axillary vein becomes the aspirating for blood, towards the
subcutaneous tissue with 1%
subclavian vein at the lateral contralateral sternoclavicular
lidocaine (lignocaine).
border of the first rib and extends joint. Try to keep the track of the
for 3 – 4 cm, just deep to the clavicle. needle parallel to the bed in order • Flush the lumen(s) of the
It forms the brachiocephalic vein to avoid puncturing the pleura or central line with saline or
with the internal jugular vein subclavian artery. Hepsal and ensure you have
behind the sternoclavicular joint. all your equipment within
• Once blood is aspirated freely,
The right subclavian vein is easier to easy reach.
rotate the bevel of the needle
cannulate than the left. Cannulation
towards the heart in order to • Feel the femoral pulse and insert
is as follows.
maximise the chance of the wire the introducer needle one finger-
• Identify the landmarks (Fig. 45): passing down the brachiocephalic breadth medial to this, angulating
locate the suprasternal notch, vein rather than up the internal it slightly towards the patient’s
sternoclavicular joint and jugular vein. head, but keeping it in line with
acromioclavicular joint and select the long axis of the leg. Advance
• Insert the central line using the
a point one finger-breadth below slowly, aspirating all the time
Seldinger technique.
the junction of the medial third until there is free flow of blood
and middle third of the clavicle. After the procedure arrange a CXR into the syringe.
to exclude a pneumothorax and to
• Clean and drape the skin. • Insert the central line using the
confirm the correct position of the
Seldinger technique.
• Infiltrate the skin and catheter: ideally the tip should lie in
subcutaneous tissue with 1% the superior vena cava just above the • With the line in place, flush with
lidocaine (lignocaine). right atrium. saline or Hepsal and close the line
off to air. Secure with a suture and
• Flush the lumen(s) of the Femoral vein cannulation using the place a sterile occlusive dressing
central line with saline or Hepsal Seldinger technique over the site.
and ensure you have all your
• Identify your landmarks (Fig. 46):
equipment within easy reach.
the femoral vein lies directly
• Insert the introducer needle medial to the femoral artery in the
attached to the 5-mL syringe femoral triangle (as remembered
until it hits the clavicle and ‘walk’ by the acronym ‘NAVY’: nerve, Do not make a bad situation
the tip down the clavicle until artery, vein and Y-fronts). worse
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Contraindications to performing a
lumbar puncture
These include raised intracranial
Fig. 46 Cannulation of the femoral vein. pressure, posterior fossa or spinal
cord mass lesions, local sepsis,
and a bleeding tendency.
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Fig. 47 Technique for lumbar puncture. (a) The patient should be curled up to increase the space between the vertebrae. (b) The needle should be advanced slowly
until it penetrates the ligamentum flavum: a flashback of CSF when the stylet is removed indicates correct positioning.
Preparation • Anaesthetise the skin and • Remove the needle and dress the
Check platelet count and clotting, subcutaneous tissues with wound.
and obtain informed consent. 5 –10 mL 1% lidocaine
• Ask the patient to remain lying
Prepare equipment as follows: (lignocaine) using a 25G needle;
flat for 2 – 4 hours to reduce the
then switch to an 18G needle and
• dressing pack, gown, drapes and severity of post-lumbar puncture
infiltrate the deeper tissues.
gloves (all sterile); headache.
• Assemble the manometer and
• local anaesthetic, syringe and Always send blood samples for
unscrew the tops of the sterile
needles; glucose and protein estimation
containers.
at the same time as CSF samples:
• antiseptic;
• Insert the lumbar puncture the CSF glucose concentration is
• lumbar puncture needles and needle at 90° to the skin: advance normally 60 – 80% of the blood level.
sterile manometer; slowly, aiming between two In cases of suspected subarachnoid
spinous processes. There is a haemorrhage (SAH), the red cell
• sample tubes (serum glucose
slight loss of resistance as the count in consecutive samples can
bottle and sterile 20-mL
needle enters the dural space help to distinguish SAH from a
containers for differential
(Fig. 47b). bloody tap, and the samples should
counts, bacteriology and
also be examined for xanthochromia
protein estimation). • Remove the stylet and ensure that
(oxyhaemoglobin and bilirubin).
cerebrospinal fluid (CSF) drips
Technique freely from the needle. If no CSF Normal values and values in
is forthcoming, insert the stylet disease for CSF pressure, cell
• Ask the patient to lie on the
and advance the needle a few counts, glucose concentration and
bed (Fig. 47a). Positioning is
millimetres and check again. protein concentration are shown
all-important: the knees should
in Table 28.
be drawn up towards the chest • Attach the manometer and
to open the space between the measure the pressure (normal
spinous processes, and the spine 6 –15 cmH2O).
should be parallel to the bed.
• Collect CSF samples: 2–5 drops
• Gown and glove up. for biochemistry; 5 –10 drops
3.3 Cardiac pacing
for bacteriology (ask for urgent
• Prepare the skin with antiseptic
microscopy and Gram stain, and There are three common types
and cover with sterile drapes.
culture, sensitivities and viral of cardiac pacing: transvenous
• Locate the puncture site (L3/4 or studies); and 5 –10 drops for endocardial (may be temporary
L4/5). cytology. or permanent), epicardial (in
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Pressure (cmH2O) White cells (per µL) Protein (g/L) Glucose (mmol/L)
association with cardiac surgery) ventricular tachycardia) may be • Connect the leads to the patient
and transcutaneous/external. treated by pacing or by premature and slowly increase the current;
electrical stimulation. This may be 50 –100 mA is usually required.
Common indications for pacing done by a temporary transvenous
• Ventricular capture is indicated
pacing wire or, if persistent, by a
when a pacing spike is associated
Bradyarrhythmias permanent system.
with a ventricular complex and a
Temporary pacing The decision to
palpable pulse wave.
pace is based on the presence of Technique for external pacing
haemodynamic compromise or After explaining to the patient what • Make immediate arrangements
potential to do so rather than the you are going to do and ensuring for transvenous pacing: external
specific rhythm. adequate sedation/analgesia, follow pacing is unreliable and should be
the procedure below. continued for as short a period as
• Patients with second- or third-
degree atrioventricular (AV) block • Place one electrode in a position possible.
may need temporary pacing prior equivalent to lead V2–V3 of the
If external pacing is unsuccessful
to general anaesthesia. ECG, with the other either over
ensure there is adequate current,
the apex of the heart or on the
• Patients with second- or third- then try other electrodes or electrode
posterior of the chest below the
degree heart block in association positions, percussion pacing
left scapula (Fig. 48).
with an acute myocardial (forceful rhythmic thumping of
infarction may require pacing • Set the pacing box to demand, the left anterior chest), isoprenaline
(this may be complicated by the with a rate of approximately infusion, or immediate transvenous
need to obtain central venous 60 bpm. pacing.
access in someone who has
received thrombolysis).
Tachyarrhythmias
Some tachyarrhythmias (AV nodal
re-entrant tachycardia, AV re-entry
tachycardia, atrial flutter and Fig. 48 External pacing with a modern monitor/defibrillator/external pacer.
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after initial needle the patient is on warfarin this complete with chest drain (and
thoracocentesis; persistent or should be stopped, aiming for an connectors), guidewire and dilators
recurrent pneumothorax after INR <1.5 prior to the procedure (replaced by Spencer Wells forceps
simple aspiration; large secondary unless he/she has a prosthetic if it is a large-bore drain), scalpel
spontaneous pneumothorax in heart valve, in which case advice and handle, syringe and needle;
patients aged over 50 years. should be sought. scissors; suture 1/0 or 2/0 silk;
dressings; and an underwater seal
• Malignant pleural effusion. • Explain the benefits, risks and
bottle with connections.
technique of the procedure and
• Empyema and complicated
obtain patient consent.
parapneumonic pleural effusion. Technique
• Intravenous access: this should be
• Traumatic haemopneumothorax. • Position the patient, ideally in a
established in all patients. If the
• Postoperative, eg thoracotomy, procedure is being done for a semi-recumbent position with
oesophagectomy and cardiac haemothorax, ensure that you hand resting behind the head.
surgery. have two large-bore intravenous • Identify the landmarks (Fig. 51):
cannulae in place and blood the safest position for chest drain
Small-bore chest drains (10 –14Fr)
available for transfusion before insertion is in the fifth intercostal
are recommended: they are as
starting the procedure. space in the mid-axillary line. In a
effective as large-bore tubes in
most circumstances and are better • Monitoring: the patient should be patient without large breasts this
tolerated by the patient. Large-bore on oxygen during the procedure, will be at the level of the nipple; in
tubes (28 –32Fr) should be used for with monitoring of oxygen someone with large breasts select
haemothoraces and in the event of saturation throughout. the intercostal space a hand’s
failure to drain a pneumothorax via width below the axilla.
• Premedication: this should be
a small-bore tube. They may also
considered and offered to every • Clean and drape the skin: aseptic
still have a role in the treatment
patient who is not in extremis, technique should be observed at
of empyema, although increasing
eg midazolam (1–5 mg iv). all times.
success is being seen with small-
bore drains in conjunction with • Equipment. Make sure you have • Infiltrate the skin with local
thrombolytic therapy. everything you need on the trolley anaesthetic using the orange
before you start: basic sterile pack; needle and then infiltrate down to
local anaesthetic and syringes with the pleura using the green needle;
orange and green needles; chest then go through the pleura to
Tension pneumothorax drain insertion pack (Fig. 50) aspirate air or fluid.
Never wait for a CXR if a tension
pneumothorax has been diagnosed
on clinical grounds: do an immediate
needle thoracocentesis and then insert
a chest drain (see Section 1.2.14).
Preparation
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condition. However, it is not • Pulmonary oedema if the lung and how to use it! Assemble
necessary to repeat the CXR expands rapidly following alcohol swabs and a preheparinised
daily as a routine. drainage of a large pleural ABG syringe or a 2-mL syringe
effusion: drainage of pleural into which you have drawn up
The chest drain can be removed
fluid should be limited to around and then expelled 0.5 mL of
if there is no fluid drainage or
200 mL/hour. heparin solution (5000 units/mL)
bubbling for >24 hours following
through an appropriate needle.
radiographic confirmation of • Surgical emphysema.
25G needles are perfectly adequate
resolution of the effusion or
• Haematoma: check that there for obtaining ABG samples from
pneumothorax. In malignant
are no clotting or platelet a radial artery; 18G or 23G are
effusions pleurodesis may be
abnormalities prior to insertion. needed for a femoral sample.
considered prior to removal. The
CXR should be repeated following • Pain: ensure there is adequate
Technique
removal of the drain. analgesia.
• After gloving up, lay the index
and middle fingers of your non-
dominant hand along the line of
If there is failure of the fluid the artery as a guide (Fig. 52).
level to swing with respiration, 3.6 Arterial blood gases
check the following. • For radial and brachial samples
hold the syringe at 45 – 60° to the
• Is the tube kinked? 3.6.1 Measurement of arterial
• Is the tube blocked? skin and slowly advance in the
blood gases
• Is the tube in the wrong position? line of the artery; for femoral
Indications for arterial blood gases
samples hold the syringe at 90°
(ABGs) include pulse oximetry
to the skin. There is debate over
showing PO2 <92% and any acute
the use of lidocaine (lignocaine):
unexplained severe illness. There
while this is undoubtedly useful
Causes of a persistent are no absolute contraindications,
at easing pain if you are unlucky
pneumothorax although severe bleeding disorder
enough to fail first time, its use is
is a relative contraindication.
• Large primary leak. painful in itself and it often makes
• Leakage at the skin or underwater Explain the procedure to the palpation of the artery more
seal.
patient (those who have had ABGs difficult.
• Bronchopleural fistula.
performed know just how painful
they can be) and then proceed as • A flush of blood indicates
follows. puncture of a vessel: with
Complications of inserting a some ABG syringes the arterial
chest drain pressure will fill the syringe to a
Preparation
• Damage to intrathoracic and/or predetermined volume; in others
• Site: choose the site for arterial you will need to aspirate 1–2 mL.
abdominal organs or vessels: this
puncture carefully (radial,
can be avoided by using the finger • Apply pressure to the puncture
brachial or femoral). The radial
sweep and never using the trocar site for 3 minutes (5 minutes if the
is most commonly used, in which
for large-bore chest drain patient is anticoagulated).
case first perform the Allen test
insertion.
to check the patency of the ulnar • Expel all air from the syringe;
• Damage to the intercostal nerve, artery: ask the patient to clench remove and dispose of the needle
artery or vein: avoid making the the fist firmly, applying pressure to and cap the syringe.
incision below the rib as the the radial artery, and then ask him
intercostal nerves and vessels lie or her to relax the fist, at which • If there is to be a delay in
beneath the lower edge of the rib. point the hand should pink up processing the sample, pack
within 10 seconds. it in ice.
• Sepsis (empyema formation or
cellulitis): ensure complete aseptic • Equipment: before taking the • After the procedure check that
technique, and do not leave chest sample, make sure you know bleeding has stopped, the main
drains in for longer than necessary. where the blood gas machine is complication being haematoma.
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Fig. 52 Taking a sample from the radial artery. The artery should be palpated with two fingers placed
along the line of the artery. The needle should be inserted at 45–60° to the skin and slowly advanced in the
direction of the artery. A flashback of blood indicates successful puncture. Airway compromise results in
rapid hypoxia and secondary
brain injury. Airway management is
3.6.2 Interpretation of component of acid–base the first priority in basic life support
arterial blood gases disturbance: the more negative (airway, breathing and circulation),
Table 29 shows normal arterial the value of the SBE, the greater but be wary of patients who are
blood gas (ABG) values. the degree of metabolic acidosis. spontaneously ventilating but who
cannot protect their airway because
The standard base excess (SBE) is a The types of metabolic and of a reduction in conscious level.
figure calculated by many blood gas respiratory acid–base disturbances
machines as an aid to interpretation and their common causes are shown
of ABG results. The principles of the in Table 30.
calculation are as follows.
Oxygen should be given to
• Predict the pH that would arise in all patients with decreased
normal blood in the presence of conscious levels unless specifically
the PCO2 actually measured. If the 3.7 Airway contraindicated.
PCO2 is high, then the predicted pH
is low; if the PCO2 is low, then the
management
predicted pH is high.
3.7.1 Basic airway management
Stridor, gurgling and snoring all
• Calculate the amount of acid or
suggest an airway at risk. Recognition
base that would have to be added Opening the airway
of airway compromise depends on
to the blood to change the
the following basic and life-saving
calculated pH into the pH as Head tilt/chin lift
techniques: look, listen and feel.
actually measured. Loss of muscle control leads to
• Look for chest movement. occlusion of the airway by the
• This value is the base deficit or
tongue, epiglottis and soft palate.
excess (in mmol/L), which • Listen and feel for air movement
With the patient supine, extend
quantifies the metabolic at the nose and mouth.
the head on the neck by placing
one hand on the forehead and
pushing backwards. Place the fingers
TABLE 29 NORMAL ABG VALUES of the other hand under the tip of
the jaw and lift the chin upwards
Normal range (Fig. 53a).
pH 7.35–7.45
PCO2 4.5–6.0 kPa Jaw thrust
Bicarbonate 22–28 mmol/L Place the fingers of both hands
Standard base excess ±2 mmol/L behind the angles of the mandible.
PO2 10.5–14 kPa (breathing air)
Oxygen saturation 95–100% Use upward pressure to lift the jaw
forward (Fig. 53b).
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Metabolic Low, or normal if Low due to Low: this is the Negative: this is the Lactic acidosis: exercise,
acidosis there is secondary primary abnormality base deficit, which shock and drugs (metformin)
respiratory respiratory in metabolic acidosis quantifies the Ketoacidosis: diabetes
compensation alkalosis metabolic component Hyperchloraemic:
of acid–base bicarbonate wasting, eg
disturbances. The renal losses and
more negative the gastrointestinal fistulae
value, the greater the High anion gap: poisoning,
degree of metabolic eg methanol and antifreeze
acidosis
Respiratory Low, or normal if High: primary Normal in acute Normal Acute: bronchopneumonia
acidosis there has been abnormality is respiratory acidosis; and severe acute asthma
metabolic alveolar high if there has Chronic: chronic obstructive
compensation hypoventilation been time for renal pulmonary disease,
compensation neuromuscular disorders
and restrictive lung diseases
Respiratory Elevated if acute, Low: primary Normal in acute Normal Anxiety
alkalosis normal if there abnormality is respiratory alkalosis; Pain
has been alveolar low if there has been Hypoxia causing stimulation
metabolic hyperventilation time for renal of respiratory centre, eg
compensation compensation pulmonary oedema and
pneumonia
Salicylate overdose: initially
causes direct stimulation of
the respiratory centre (but
also uncouples oxidative
phosphorylation leading to
metabolic acidosis)
Metabolic Elevated: there is Usually normal: Elevated: primary Positive: the more Chronic potassium depletion,
alkalosis rarely significant little, if any, abnormality in positive the value, the eg vomiting and diuretics
respiratory compensatory rise metabolic alkalosis greater the degree of Chloride loss, eg vomiting
compensation metabolic alkalosis
should be removed using a Yankauer angle of the jaw. Open the patient’s
sucker. mouth. Introduce the airway upside
Maintaining an airway in
down and rotate it 180° as it passes
a patient with a suspected
neck injury
Basic adjuncts to airway control into the oropharynx. Reassess the
Oropharyngeal and nasopharyngeal airway.
The jaw thrust method is preferred
airways help to prevent occlusion
because it results in less neck
movement, but remember that
of the pharynx by the tongue and
patients with a neck injury are more soft tissues (Fig. 54). Patients
likely to die from airway obstruction with preserved laryngeal reflexes
than damage due to neck movement. will generally not tolerate an Potential problems with
oropharyngeal airway but may oropharyngeal airways
tolerate a nasopharyngeal one. • Incorrect insertion of the airway can
Removing obstructions from the exacerbate the problem by pushing
oropharynx Insertion of an oropharyngeal the tongue further back.
• In the presence of laryngeal reflexes,
Solid foreign material should be airway
insertion of an oropharyngeal
removed using Magill forceps or Select an airway that corresponds in airway can trigger vomiting and
a finger sweep under direct vision. length to the distance between the laryngospasm.
Semi-solid material or liquid corner of the patient’s mouth and the
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Fig. 53 Opening the airway. (a) Head tilt/chin lift method: place one hand on the patient’s forehead and the other under the point of the patient’s chin, then tilt
the head back to open the airway. (b) Jaw thrust method: with the index and middle fingers behind the angle of the mandible, apply upward and forward pressure
to lift the jaw.
Fig. 54 Basic adjuncts to airway control: (a) oropharyngeal airway in situ; (b) nasopharyngeal airway in situ.
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Fig. 55 Question 1.
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Question 4
Clinical scenario
A 19-year-old diabetic man is
admitted with a 3-day history
of nausea and vomiting. On
examination he is apyrexial (36.5°C)
with respiratory rate 28/minute,
pulse 110 bpm and BP 100/65
mmHg. His abdomen is soft and
non-tender and his chest is clear.
Fig. 56 Question 2.
Investigations reveal a fingerprick
blood glucose of 28 mmol/L. Urine
dipstick records protein + and
ketones ++. Laboratory tests show
C Aspiration and discharge home Question
C-reactive protein 12 mg/dL (normal
after a CXR prior to discharge How would you manage this man’s
<6), white cell count 14.3 × 109/L
to check resolution; follow-up illness?
(normal range 4 –11), potassium
arranged for 4 weeks; and advice
Answers 3.1 mmol/L (normal range 3.5 –5.0),
on smoking cessation
A Discharge with oral amoxicillin urea 14.2 mmol/L (normal range
D Admission and insertion of
and clarithromycin; arrange 3 –7), creatinine 123 µmol/L
28Fr intercostal chest drain
follow-up in 6 – 8 weeks (normal range 60 –115) and glucose
E Admission and insertion of
B Discharge with oral ciprofloxacin; 25.6 mmol/L (normal range 3 – 6.5).
12Fr intercostal chest drain
arrange follow-up in 6 – 8 weeks Arterial blood gases show pH 7.23
Question 3
Clinical scenario
A 72-year-old man is admitted
from a residential home with a
3-day history of progressive
confusion. Examination reveals
he has pyrexia of 38.5°C, respiratory
rate >30/minute, SaO2 90% on air,
pulse 120 bpm, BP 100/75 mmHg
and in the chest there is a dull
percussion note and bronchial
breathing in the right upper zone.
Investigations show C-reactive
protein 253 mg/dL (normal <6),
urea 10.2 mmol/L (normal range
3 –7), creatinine 145 µmol/L (normal
range 60–115) and white cell count
17.2 × 109/L (normal range 4 –11).
Figure 57 shows his CXR. Fig. 57 Question 3.
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and HCO3– 12 mmol/L. The CXR is ‘block and replace’ regimen, upper abdomen. On clinical grounds
unremarkable. becomes generally weak and unwell. it is difficult to decide whether he
She is sent to the Emergency has acute pancreatitis or peritonitis.
Question
Department for assessment.
What is your initial management Question
plan? Question Which of the following statements is
Which of the following would you true?
Answers
not expect to be a feature if she was
A Insulin infusion Answers
presenting in addisonian crisis?
B Fluid replacement with 0.9% A Alcohol abuse causes chronic
saline Answers pancreatitis but not acute
C Fluid replacement with 5% A BP 90/60 mmHg pancreatitis
dextrose B Serum potassium 3.1 mmol/L B Discomfort in the lumbar region
D Fluid replacement with 0.9% C Blood glucose 4.0 mmol/L of the back is more likely in acute
saline (with K+ supplementation), D Vitiligo pancreatitis than in peritonitis
and also insulin infusion E Serum sodium 128 mmol/L C A first presentation with acute
E Fluid replacement with 5% pancreatitis is unlikely at the age
dextrose (with K+ of 67 years
Question 7
supplementation), and also D The diagnosis is unlikely to be
insulin infusion Clinical scenario acute pancreatitis if no pancreatic
A 48-year-old man presents with calcification is seen on an
a 3-week history of worsening abdominal radiograph
Question 5
breathlessness that has become E Serum amylase is a prognostic
Clinical scenario much worse over the last 24 hours. indicator in acute pancreatitis
A 28-year-old woman with He is finding it very difficult to speak
known asthma presents with an or to swallow, is drooling saliva and
Question 9
exacerbation. She cannot speak in has inspiratory stridor. Examination
sentences, has a respiratory rate of of his neck reveals bilateral palpable Clinical scenario
32/minute and a pulse rate of 120 masses probably due to You are asked to review a
bpm. Her peak expiratory flow rate lymphadenopathy. 69-year-old woman in the Medical
(PEFR) is 45% of predicted. Routine Assessment Unit. She is poorly
Question
blood tests are normal, excepting an responsive, with a Glasgow Coma
Which of the following would not
elevated white cell count (WCC) of Scale score of 9. The physician’s
be appropriate in his initial
22 × 109/L (normal range 4 –11). assistant has already performed a
management?
12-lead ECG (Fig. 58).
Question
Answers
Which of these is not a feature of Question
A High-flow oxygen therapy
acute severe asthma? What is the most likely underlying
B CT scan of the thorax/neck
cause of this presentation?
Answers C Intravenous high dose steroids
A PEFR 45% predicted D Intubation and ventilation Answers
B Respiratory rate 32/minute E Intramuscular epinephrine A Hypothyroidism
C WCC 22 × 109/L (1 in 1,000, 0.5 mL) B Myocardial infarction
D Pulse rate 120 bpm C Hypothermia
E Inability to complete a sentence D Beta-blocker overdose
Question 8
E Hypoglycaemia
Clinical scenario
Question 6
A 67-year-old man with a long
Question 10
Clinical scenario history of alcohol abuse presents
A 32-year-old woman with a history with abdominal pain. He has never Clinical scenario
of thyrotoxicosis caused by Graves’ had such a problem before. He looks A dishevelled man of about 30 years
disease, who is taking carbimazole unwell and has cool hands, pulse is brought to the resuscitation room
20 mg three times daily and 110 bpm, BP 110/70 mmHg and of the Emergency Department by
thyroxine 100 µg once daily as a tenderness with guarding across his blue-light ambulance after being
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Fig. 58 Question 9.
found collapsed in the street. He is week’s trip to a game reserve near Question
unable to speak and despite making Johannesburg, South Africa. Which one of the following is true?
substantial respiratory efforts he
Question Answers
looks deeply cyanosed. His pulse
Which one of the following A Appearance at sigmoidoscopy
is difficult to feel and you cannot
statements is true? may not help differentiate
record a BP. His chest looks
between an infective colitis and
asymmetrical, more prominent on Answers an acute episode of inflammatory
the right side. On auscultation you A Plasmodium falciparum is bowel disease
cannot hear breath sounds over the unlikely if the fever started B The surgical team should be
right side of the chest, but you can on day 5 of the trip involved when the colon appears
hear a few in the left axilla. The B Patients with malaria often have dilated >10 cm on a plain
heart sounds are difficult to hear cervical lymphadenopathy abdominal film
and you cannot palpate the apex C Patients with malaria often have a C Outbreaks of amoebiasis are rare
beat. You should: maculopapular rash, particularly in the UK
Answers on the trunk D There is no role for systemic
A Get an urgent ECG D Malaria has been eradicated from steroids when an infective cause
B Get an urgent CXR South Africa is the most likely reason for his
C Get an urgent check of E The presence of neutropenia symptoms
fingerprick blood glucose would help to differentiate E His haemoglobin on admission
D Urgently prepare for between typhoid and malaria is 10.5 g/dL: he should not be
cardioversion prescribed a prophylactic dose
E Insert a needle into the right side of low-molecular-weight heparin
Question 12
of his chest while an inpatient
Clinical scenario
A 50-year-old man with known
Question 11 Question 13
inflammatory bowel disease is
Clinical scenario referred by his GP with a 3-day Clinical scenario
A 22-year-old woman presents history of bloody diarrhoea. A 52-year-old woman presents
with a headache and a temperature. His wife has also been passing with pleuritic chest pain and
Yesterday she flew home from a blood in her stool. breathlessness. She appears anxious,
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a dog bite. On examination there infection and that he had a ‘skin Question
is cellulitis and a small puncture cancer’ removed several years ago, What would be the most
wound exuding pus on the thenar but has no other past history. On appropriate next step in
eminence. He also has some tender examination, his temperature is management?
axillary lymphadenopathy. He has 37.5°C, he is drowsy, and he has
Answers
no drug allergies. a stiff neck and a purulent
A Close observation
discharge from his right ear.
Question B Intramuscular epinephrine
His BP is 200/120 mmHg. He
What is the most appropriate C Subcutaneous epinephrine
has bilateral papilloedema. Both
antibiotic treatment? D Intravenous epinephrine
plantar responses are extensor.
E Discharge home
Answers He undergoes an urgent CT scan of
A Erythromycin the head (non-contrast). This shows
B Benzylpenicillin and flucloxacillin several areas of low attenuation Question 28
C Doxycycline involving both cerebral hemispheres.
Clinical scenario
D Ceftriaxone Evidence of haemorrhage is present
A 40-year-old woman presents
E Co-amoxiclav in several of these areas.
4 hours after an overdose of
Question diazepam and amitriptyline.
Question 25 What is the most likely diagnosis? On examination her Glasgow
Coma Scale (GCS) score is 10,
Clinical scenario Answers she has bilateral dilated pupils
A 28-year-old nursing assistant A Metastatic malignant melanoma and a pulse rate of 140 bpm with
with a history of anxiety and B Hypertensive encephalopathy BP 108/64 mmHg. Pulse oximetry
depression presents to the C Subarachnoid haemorrhage (on air) shows oxygen saturation
Emergency Department with D Primary intracerebral 95%.
acute dyspnoea. She also haemorrhage
complains of parathesiae E Cortical thrombophlebitis Question
affecting both hands. What is the most appropriate
immediate management?
Question Question 27
Which set of blood gas results Answers
(with the patient breathing air) is
Clinical scenario A Administration of activated
A 40-year-old man who has a charcoal
consistent with hyperventilation?
known prawn allergy developed an B Administration of intravenous
Answers urticarial rash 3 hours after eating atenolol
C Administration of intravenous
pH PaO2 (kPa) PaCO2 (kPa) Bicarbonate (mmol/L) flumazenil
D Check ECG
Normal 7.36–7.44 11.3–13.0 4.5–6.0 19–24 E CT scan of head
A 6.90 12.9 3.0 10
B 7.50 7.9 4.0 20
C 7.52 12.5 3.5 19
D 7.28 12.8 2.8 12
Question 29
E 7.32 7.0 8.2 34 Clinical scenario
A 50-year-old schoolteacher
Question 26 presents with a sudden-onset
a meal thought to contain a small
severe headache and vomiting.
Clinical scenario amount of shellfish. He has a history
On examination he has meningism
A 36-year-old man presents in a of asthma. On examination 1 hour
and a left oculomotor nerve palsy.
confused state. He has Down’s after his rash began he was anxious
A CT scan of his head reveals a
syndrome and his care worker with a pulse rate of 100 bpm, BP
subarachnoid haemorrhage.
has witnessed him having two 150/100 mmHg and a respiratory
generalised tonic–clonic seizures. rate of 30/minute. Pulse oximetry Question
She tells you that he had just started (on air) shows oxygen saturation Which artery is the most likely site
a course of antibiotics for an ear 99%. of the aneurysm?
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of recurrence and should be offered Answer to Question 6 (prognostic scoring system) used
to all patients who smoke. Follow-up in acute pancreatitis does not
arranged before discharge, in addition B incorporate the serum amylase.
to general advice, is essential. Acute addisonian crisis is
classically associated with
hypotension and tachycardia, and Answer to Question 9
Answer to Question 3 laboratory investigations showing
C
hyponatraemia, hyperkalaemia and
D The ECG shows sinus bradycardia,
hypoglycaemia. A short Synacthen
The history, examination and first-degree heart block and
test would confirm the diagnosis.
investigation results are compatible prominent ‘J’ waves, which are
Areas of vitiligo are seen as an
with a diagnosis of right upper lobe seen immediately after the QRS
autoimmune association in
pneumonia. According to the CURB- complex in hypothermia. These
Addison’s disease.
65 score he has severe pneumonia disappear with warming of the
(confusion, urea >7 mmol/L, body temperature. The mechanism
respiratory rate >30/minute and Answer to Question 7 is not known.
age >65; score 4/5) that necessitates
hospital admission. Treatment B
Initial management of the patient Answer to Question 10
with intravenous Augmentin
(co-amoxiclav) in addition to a with stridor must be to stabilise the E
macrolide would be appropriate airway, if necessary by intubation. This man has a tension
(British Thoracic Society guidelines High-flow oxygen therapy and pneumothorax: urgent needle
2004). A third-generation high-dose intravenous steroids thoracocentesis should be
cephalosporin may be used as an should be given, and for patients in performed and any of the
alternative in conjunction with a extremis intramuscular epinephrine other courses of action described
macrolide. (adrenaline) may need to be could be fatal.
considered. A CT scan of the
thorax/neck may be required
Answer to Question 4 following initial treatment and Answer to Question 11
D stabilisation of the airway, but A
The diagnosis is diabetic putting this man into a scanner Even if a malaria-infected mosquito
ketoacidosis. The priority for now is likely to be fatal. had bitten her on the first day of her
management is fluid and electrolyte trip, the life cycle demands at least
replacement. Patients are often 7 days before the first symptoms
Answer to Question 8
severely dehydrated and very appear, thus excluding malaria.
depleted of both sodium and B Malaria does not cause rash or
potassium. The serum potassium Acute and chronic pancreatitis lymphadenopathy. Neutropenia
concentration may be high at may be seen in alcohol abuse. may be found in both typhoid and
presentation, but will fall rapidly as Pancreatic pain is typically felt in malaria.
it moves into cells with rehydration the epigastrium, but there is often
and insulin treatment. a lot of associated discomfort in
Answer to Question 12
the lumbar region of the back.
Pancreatitis is a potential cause A
Answer to Question 5
of generalised abdominal pain The sigmoidoscopic appearance
C and can mimic the peritonism of infectious colitis and chronic
The features of acute severe asthma of a ruptured viscus. Pancreatic idiopathic inflammatory bowel
(British Thoracic Society guidelines calcification is present in chronic disease may be indistinguishable.
2003) include a peak expiratory flow pancreatitis, but its absence does The mucosal appearance of
rate of 33 –50% predicted/best, an not exclude the diagnosis of acute Clostridium difficile infection is
inability to complete a sentence pancreatitis. Serum amylase is a also variable, although the
in one breath, a respiratory rate useful biochemical marker of acute adherent yellow-white plaques,
>25/minute and a pulse rate pancreatitis, but is not an indicator or ‘pseudomembrane’, are
>110 bpm. of prognosis: the Ranson score characteristic. The surgical
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team should be involved early, Answer to Question 14 more than 2 hours between doses)
particularly when there is a or where the time of ingestion
suspicion of superadded infection. E is unknown, then the plasma
Amoebiasis can be contracted Activated charcoal is the preferred paracetamol concentration cannot
in the UK. Treatment should method of gut decontamination if be interpreted on the graph and if
include systemic steroids as the dose of toxin taken is significant: the total dose in 24 hours exceeds
well as antibiotics. The patient a single dose of charcoal (50 g for 150 mg/kg or 12 g (whichever is the
is at high risk for systemic adults) can be given up to 2 hours smaller; >75 mg/kg in high-risk
thromboembolism and should after ingestion, and this can be patients), then N-acetylcysteine
be given prophylactic low- extended to 6 hours for drugs that should be given.
molecular-weight heparin. delay gastric emptying (which
includes salicylates). Sodium It is reasonable to call on psychiatric
bicarbonate (1.26%) is given to services to make an assessment of
Answer to Question 13 enhance urinary salicylate excretion capacity, but in this case there is
when the plasma salicylate insufficient time to do this. You
A must be able to assess capacity and
concentration is greater than
A pulmonary embolism (PE) may then proceed with urgent treatment:
500 mg/L (3.6 mmol/L) in adults.
cause a sudden increase in the this can be done in good faith,
Haemodialysis is the treatment of
afterload on the right ventricle provided you are acting in her
choice for severe salicylate poisoning
leading to ischaemia (in addition best interests and in line with a
and should be considered when the
to hypoxia), which may precipitate responsible body of medical opinion.
plasma salicylate concentration
left- or right-sided ischaemic
exceeds 700 mg/L (5.1 mmol/L) or
changes on the ECG when there
in the presence of severe metabolic
is underlying coronary artery Answer to Question 16
acidosis.
disease. There is an increased
C
risk of malignancy being detected
Although back pain is a huge
within 6 –12 months of a first Answer to Question 15 problem, the prognosis is good for
episode of PE, particularly in those
F and G most patients. Red flags from the
with no other risk factors and/or
Administration of activated history and on examination include
recurrent episodes. Occult cancer,
charcoal should be considered if significant injury; past medical
present in 7–12% of those with
paracetamol in excess of 150 mg/kg history of cancer; first presentation
apparently idiopathic PE, can
or 12 g (whichever is the smaller) is <20 or >55 years; systemic upset
usually be detected by a
thought to have been ingested within (fever and weight loss); steroid
combination of careful clinical
the previous hour. The plasma treatment; intravenous drug use;
assessment, routine blood tests
paracetamol concentration should thoracic pain; multilevel neurological
and CXR. This is true according
be checked in all patients suspected signs or symptoms; structural
to current British Thoracic Society
of having taken an overdose: blood deformity; pain that is constant,
guidelines, which also state that
should be taken at 4 hours post progressive and unrelenting; or
D-dimer alone is not a valid routine
ingestion. If the paracetamol level difficulty with bladder or bowels.
screening investigation for PE,
and that it should only be used in is not available within 8 hours of
ingestion, then commence the
conjunction with pretest clinical Answer to Question 17
probability assessment. antidotal therapy without awating
the level. Stop treatment if the level C
If there has been a massive PE, ie is non-toxic. An accurate history A section 136 is the police admission
one so severe as to cause circulatory is essential for the interpretation order that enables a police officer
collapse, the recommended practice of the plasma paracetamol to remove a person apparently
is to use thrombolysis, the earlier concentration; if there is any doubt suffering from a mental disorder
the better, although evidence for a then N-acetylcysteine should be from a public place to a designated
reduction in mortality is sparse. given regardless of the levels. In place of safety (usually the police
Low-molecular-weight heparin has the situation where the patient has station or the local Emergency
equal efficacy and safety, and is taken the tablets over a period of Department) for assessment by a
easier to use. time, in a staggered fashion (eg doctor and a social worker. A section
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135 enables the police officer to to calculate risk in the management there is left ventricular dysfunction.
enter the place of residence of a of patients with unstable If the patient is thought to be at
person they believe to be suffering angina/non-ST-elevation myocardial low risk of recurrence of AF, then
from a mental disorder to take he infarction acute coronary syndrome. antithrombotic treatment should be
or she to a place of safety. It is based on the presence or discontinued. If the patient has
absence of seven independent ventricular pre-excitation (eg Wolff–
The Mental Health Act does not
prognostic risk factors for early Parkinson–White syndrome), then
apply to the detention and treatment
death and myocardial infarction. atrioventricular node-blocking drugs
of patients for physical illness,
Those patients with a score >3 have (including digoxin) should be avoided
for which they must be either
been shown to benefit from early because they cause an increase
consenting or treated under the
intervention. It is based on factors in the pre-excitation and may
common law. Pre-registration
from the history, including the age precipitate ventricular fibrillation.
doctors (Foundation Year 1) are not
of the patient (>65 years), the
able to assess a patient’s capacity. If
presence of at least three recognised
the patient is judged as not having Answer to Question 21
risk factors for coronary artery
the capacity to refuse treatment,
disease, the finding at coronary E
there is a clear duty of care towards
angiography of a stenosis of greater All these diagnoses could cause
the patient to assess and treat any
than 50% and the use of aspirin coma, but the fixed and dilated
possible head injury.
within the last week. It also right pupil makes the most likely
When de-escalation techniques incorporates the current presentation diagnosis subarachnoid haemorrhage
fail and pharmacological methods including severe angina within the caused by a posterior communicating
have to be employed, the current past 24 hours, raised cardiac markers artery aneurysm (affecting the third
recommendation is the use of a and ST-segment change >0.5 mm. nerve).
benzodiazepine for sedation with an
antipsychotic. The newer atypical
Answer to Question 20 Answer to Question 22
antipsychotics can be used in this
situation (po or im). Haloperidol is A B
still widely used, although it should Anticoagulation should be initiated, The ECG shows features of severe
only be given intramuscularly or but this must not delay any hyperkalaemia, with flattened P
orally: intravenous administration emergency intervention. If waves, widened QRS complexes and
may cause life-threatening haemodynamically unstable with AF, tall peaked T waves. The patient has
arrhythmias. then the patient’s life is under threat almost certainly gone into acute or
and he or she should be cardioverted acute-on-chronic renal failure
immediately irrespective of the postoperatively.
Answer to Question 18
duration of the AF. If the AF has
C been present for >48 hours the
Answer to Question 23
Hypotension and breathlessness priority, after antithrombotic
from left ventricular dysfunction treatment, is rate control with B
will be of gradual onset. Right intravenous beta-blockade or The GCS comprises the best verbal
ventricular infarction is preload digoxin. In haemodynamically stable response, the best motor response
dependent and it is important that patients where the AF is of recent and the best eye opening response
these patients receive fluid loading onset, the patient should undergo on a scale of 3–15. Pupillary size
early. Inotropes should be seen electrical cardioversion, and if that and reaction and the presence of
as a holding mechanism pending fails pharmacological cardioversion lateralising signs are not part of the
revascularisation. Pharmacologically should be attempted. Amiodarone GCS but are important parts of the
induced hypotension is common. is both antiarrhythmic and rate assessment of unconscious patients.
limiting. Alternatives include
digoxin, particularly in the presence
Answer to Question 19 Answer to Question 24
of left ventricular dysfunction, and
B intravenous beta-blockade. Verapamil E
The Thrombosis in Myocardial has a significant negatively inotropic Most infected dog-bite wounds yield
Infarction (TIMI) risk score is used effect and must be avoided where polymicrobial organisms. Pasteurella
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specific. However, the definitive diplopia and confusion has (confusion, ataxia and
method for diagnosis remains Wernicke’s encephalopathy ophthalmoplegia) may be absent
isolation of the organism from until proved otherwise. This in many cases, and the diagnosis
respiratory secretions (including is a medical emergency and is easily missed because many
sputum), but culture results typically should be treated with high-dose acutely intoxicated patients
take 3–5 days to become available. intravenous thiamine, usually given are both confused and ataxic.
as a combination of B-group Carbohydrate loading is a
vitamins as an intravenous recognised precipitant; hence
Answer to Question 33
preparation (Pabrinex). The onset the 5% dextrose infusion may
D of Wernicke’s encephalopathy may be of relevance in this case.
A man with a history of chronic be acute, subacute or chronic.
alcohol excess presenting with The classic triad of symptoms
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MOLECULAR
CELL BIOLOGY
MEDICINE ANATOMY
Ion Transport 71
Nucleic Acids and Heart and Major Vessels 135
1.1 Ion channels 72
Chromosomes 3
1.2 Ion carriers 79
Lungs 138
Techniques in Molecular Receptors and Intracellular
Biology 11 Liver and Biliary Tract 140
Signalling 82
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2.12 Benefits 174 1.2.11 Chest infection/ 3.1.2 Specific techniques for
2.13 Legal aspects of elderly care pneumonia 39 insertion of central lines
175 1.2.12 Acute-on-chronic 104
airways obstruction 42 3.1.3 Interpretation of central
1.2.13 Stridor 44 venous pressure
Investigations and Practical 1.2.14 Pneumothorax 46 measurements 106
Procedures 178 1.2.15 Upper gastrointestinal 3.2 Lumbar puncture 106
3.1 Diagnosis vs common sense haemorrhage 48 3.3 Cardiac pacing 107
178 1.2.16 Bloody diarrhoea 51 3.4 Elective DC cardioversion 109
3.2 Assessment of cognition, 1.2.17 Abdominal pain 54 3.5 Intercostal chest drain
1.2.18 Hepatic encephalopathy/
mood and function 178 insertion 109
alcohol withdrawal 56
3.6 Arterial blood gases 112
1.2.19 Renal failure, fluid
3.6.1 Measurement of arterial
Self-assessment 181 overload and
blood gases 112
hyperkalaemia 59
3.6.2 Interpretation of arterial
1.2.20 Diabetic ketoacidosis 62
blood gases 113
1.2.21 Hypoglycaemia 65
Acute Medicine 1.2.22 Hypercalcaemia 67
3.7 Airway management 113
1.2.23 Hyponatraemia 69 3.7.1 Basic airway
1.2.24 Addisonian crisis 71 management 113
1.2.25 Thyrotoxic crisis 74 3.7.2 Tracheostomy 116
ACUTE MEDICINE 1.2.26 Sudden onset of severe 3.8 Ventilatory support 117
headache 75 3.8.1 Controlled oxygen
1.2.27 Severe headache with therapy 117
PACES Stations and Acute
fever 77 3.8.2 Continuous positive
Scenarios 3
1.2.28 Acute spastic paraparesis airway pressure 117
1.1 Communication skills and 79 3.8.3 Non-invasive ventilation
ethics 3 1.2.29 Status epilepticus 81 118
1.1.1 Cardiac arrest 3 1.2.30 Stroke 83 3.8.4 Invasive ventilation 118
1.1.2 Stroke 4 1.2.31 Coma 86
1.1.3 Congestive cardiac 1.2.32 Fever in a returning
traveller 89 Self-assessment 120
failure 5
1.1.4 Lumbar back pain 6 1.2.33 Anaphylaxis 90
1.1.5 Community-acquired 1.2.34 A painful joint 91
1.2.35 Back pain 94
pneumonia 7
1.2.36 Self-harm 96
Infectious Diseases and
1.1.6 Acute pneumothorax 7
1.2 Acute scenarios 8
1.2.37 Violence and aggression Dermatology
97
1.2.1 Cardiac arrest 8
1.2.2 Chest pain and
hypotension 12 Diseases and Treatments 100
1.2.3 Should he be
INFECTIOUS
2.1 Overdoses 100
thrombolysed? 15 2.1.1 Prevention of drug DISEASES
1.2.4 Hypotension in acute absorption from the
coronary syndrome 20 gut 100
2.1.2 Management of overdoses
PACES Stations and Acute
1.2.5 Postoperative
of specific drugs 100
Scenarios 3
breathlessness 21
1.2.6 Two patients with 1.1 History-taking 3
tachyarrhythmia 23 Investigations and Practical 1.1.1 A cavitating lung lesion 3
1.2.7 Bradyarrhythmia 27 Procedures 103 1.1.2 Fever and
1.2.8 Collapse of unknown 3.1 Central venous lines 103 lymphadenopathy 5
cause 30 3.1.1 Indications, 1.1.3 Still feverish after
1.2.9 Asthma 33 contraindications, consent 6 weeks 7
1.2.10 Pleurisy 36 and preparation 103 1.1.4 Chronic fatigue 10
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1.1.5 A spot on the penis 12 1.3.23 Abdominal pain and 2.10.6 Human herpesvirus 8
1.1.6 Penile discharge 15 vaginal discharge 88 131
1.1.7 Woman with a genital 1.3.24 Penicillin allergy 91 2.10.7 Parvovirus 131
sore 17 2.10.8 Hepatitis viruses 132
1.2 Communication skills and 2.10.9 Influenza virus 133
Pathogens and Management 94
ethics 20 2.10.10 Paramyxoviruses 134
1.2.1 Fever, hypotension and 2.1 Antimicrobial prophylaxis 94 2.10.11 Enteroviruses 134
confusion 20 2.2 Immunisation 95 2.10.12 Coronaviruses and
1.2.2 A swollen red foot 21 2.3 Infection control 97 SARS 135
1.2.3 Still feverish after 2.4 Travel advice 99 2.11 Human immunodeficiency
6 weeks 22 2.5 Bacteria 100 virus 135
1.2.4 Chronic fatigue 23 2.5.1 Gram-positive 2.11.1 Prevention following
1.2.5 Malaise, mouth ulcers bacteria 101 sharps injury 140
and fever 24 2.5.2 Gram-negative 2.12 Travel-related viruses 142
1.2.6 Don’t tell my wife 25 bacteria 104 2.12.1 Rabies 142
1.3 Acute scenarios 27 2.6 Mycobacteria 108 2.12.2 Dengue 143
1.3.1 Fever 27 2.6.1 Mycobacterium 2.12.3 Arbovirus infections
1.3.2 Fever, hypotension and tuberculosis 108 143
confusion 30 2.6.2 Mycobacterium leprae 2.13 Protozoan parasites 144
1.3.3 A swollen red foot 33 113 2.13.1 Malaria 144
1.3.4 Fever and cough 34 2.6.3 Opportunistic 2.13.2 Leishmaniasis 145
1.3.5 Fever, back pain and mycobacteria 114 2.13.3 Amoebiasis 146
weak legs 37 2.7 Spirochaetes 115 2.13.4 Toxoplasmosis 147
1.3.6 Drug user with fever and 2.7.1 Syphilis 115 2.14 Metazoan parasites 148
a murmur 40 2.7.2 Lyme disease 117 2.14.1 Schistosomiasis 148
1.3.7 Fever and heart failure 2.7.3 Relapsing fever 118 2.14.2 Strongyloidiasis 149
44 2.7.4 Leptospirosis 118 2.14.3 Cysticercosis 150
1.3.8 Persistent fever in the 2.8 Miscellaneous bacteria 119 2.14.4 Filariasis 151
intensive care unit 47 2.8.1 Mycoplasma and 2.14.5 Trichinosis 151
1.3.9 Pyelonephritis 49 Ureaplasma 119 2.14.6 Toxocariasis 152
1.3.10 A sore throat 52 2.8.2 Rickettsiae 120 2.14.7 Hydatid disease 152
1.3.11 Fever and headache 55 2.8.3 Coxiella burnetii
1.3.12 Fever with reduced (Q fever) 120 Investigations and Practical
conscious level 60 2.8.4 Chlamydiae 121 Procedures 154
1.3.13 Fever in the neutropenic 2.9 Fungi 121
patient 62 2.9.1 Candida spp. 121 3.1 Getting the best from the
1.3.14 Fever after renal 2.9.2 Aspergillus 123 laboratory 154
transplant 65 2.9.3 Cryptococcus 3.2 Specific investigations 154
1.3.15 Varicella in pregnancy neoformans 124
68 2.9.4 Dimorphic fungi 125 Self-assessment 159
1.3.16 Imported fever 70 2.9.5 Miscellaneous fungi
1.3.17 Eosinophilia 74 126
1.3.18 Jaundice and fever after 2.10 Viruses 126
travelling 76 2.10.1 Herpes simplex DERMATOLOGY
1.3.19 A traveller with viruses 127
diarrhoea 78 2.10.2 Varicella-zoster virus
PACES Stations and Acute
1.3.20 Malaise, mouth ulcers 128
Scenarios 175
and fever 81 2.10.3 Cytomegalovirus 130
1.3.21 Breathlessness in a 2.10.4 Epstein–Barr virus 1.1 History taking 175
HIV-positive patient 83 130 1.1.1 Blistering disorders 175
1.3.22 HIV positive and blurred 2.10.5 Human herpesviruses 1.1.2 Chronic red facial rash
vision 86 6 and 7 130 177
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2.11 Disease of systemic arteries 3.6 Chest radiograph in cardiac 1.2 Clinical examination 209
124 disease 161 1.2.1 Coarse crackles:
2.11.1 Aortic dissection 124 3.7 Cardiac biochemical bronchiectasis 209
2.12 Diseases of pulmonary markers 163 1.2.2 Fine crackles: interstitial
arteries 126 3.8 CT and MRI 164 lung disease 210
2.12.1 Primary pulmonary 3.8.1 Multislice spiral CT 164 1.2.3 Stridor 212
hypertension 126 3.8.2 MRI 165 1.2.4 Pleural effusion 213
2.12.2 Secondary pulmonary 3.9 Ventilation–perfusion 1.2.5 Wheeze and crackles:
hypertension 129 imaging 166 chronic obstructive
2.13 Cardiac complications of 3.10 Echocardiography 167 pulmonary disease 215
systemic disease 130 3.11 Nuclear cardiology 170 1.2.6 Cor pulmonale 216
2.13.1 Thyroid disease 130 3.11.1 Myocardial perfusion 1.2.7 Pneumonectomy/
2.13.2 Diabetes 131 imaging 170 lobectomy 217
2.13.3 Autoimmune 3.11.2 Radionuclide 1.2.8 Apical signs: old
rheumatic diseases 131 ventriculography 170 tuberculosis 218
2.13.4 Renal disease 132 3.11.3 Positron emission 1.2.9 Cystic fibrosis 219
2.14 Systemic complications of tomography 171 1.3 Communication skills and
cardiac disease 133 3.12 Cardiac catheterisation 171 ethics 220
2.14.1 Stroke 133 3.12.1 Percutaneous coronary 1.3.1 Lifestyle modification
2.15 Pregnancy and the heart intervention 172 220
134 3.12.2 Percutaneous 1.3.2 Possible cancer 221
2.16 General anaesthesia in heart valvuloplasty 173 1.3.3 Potentially life-
disease 136 threatening illness 222
2.17 Hypertension 136 Self-assessment 176 1.3.4 Sudden unexplained
2.17.1 Hypertensive death 224
emergencies 140 1.3.5 Intubation for
2.18 Venous thromboembolism 141 ventilation 225
2.18.1 Pulmonary embolism RESPIRATORY 1.3.6 Patient refusing
141 ventilation 226
2.19 Driving restrictions in MEDICINE 1.4 Acute scenarios 228
cardiology 145 1.4.1 Pleuritic chest pain 228
PACES Stations and Acute 1.4.2 Unexplained hypoxia
Scenarios 191 232
Investigations and Practical
1.4.3 Haemoptysis and
Procedures 147
1.1 History-taking 191 weight loss 234
3.1 ECG 147 1.1.1 New breathlessness 1.4.4 Pleural effusion and
3.1.1 Exercise ECGs 151 191 fever 237
3.2 Basic electrophysiology 1.1.2 Solitary pulmonary 1.4.5 Lobar collapse in non-
studies 152 nodule 193 smoker 239
3.3 Ambulatory monitoring 154 1.1.3 Exertional dyspnoea 1.4.6 Upper airway
3.4 Radiofrequency ablation and with daily sputum 195 obstruction 241
implantable cardioverter 1.1.4 Dyspnoea and fine
defibrillators 156 inspiratory crackles
Diseases and Treatments 243
3.4.1 Radiofrequency 197
ablation 156 1.1.5 Nocturnal cough 199 2.1 Upper airway 243
3.4.2 Implantable 1.1.6 Daytime sleepiness and 2.1.1 Sleep apnoea 243
cardioverter morning headache 202 2.2 Atopy and asthma 245
defibrillator 157 1.1.7 Lung cancer with 2.2.1 Allergic rhinitis 245
3.4.3 Cardiac asbestos exposure 204 2.2.2 Asthma 246
resynchronisation 1.1.8 Breathlessness with a 2.3 Chronic obstructive
therapy 158 normal chest pulmonary disease 251
3.5 Pacemakers 159 radiograph 206 2.4 Bronchiectasis 253
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1.2 Communication skills and 2.10.2 Postnatal depressive 1.2 Clinical examination 42
ethics 199 disorder 233 1.2.1 Amenorrhoea and low
1.2.1 Panic attack and 2.10.3 Puerperal psychosis blood pressure 42
hyperventilation 199 233 1.2.2 Young man who has
1.2.2 Deliberate self-harm 2.11 Depression 235 ‘not developed’ 43
200 2.12 Bipolar affective disorder 1.2.3 Depression and diabetes
1.2.3 Medically unexplained 237 45
symptoms 201 2.13 Delusional disorder 238 1.2.4 Acromegaly 45
1.3 Acute scenarios 202 2.14 The Mental Health Act 1983 1.2.5 Weight loss and gritty
1.3.1 Acute confusional state 239 eyes 47
202 1.2.6 Tiredness and lethargy
1.3.2 Panic attack and 48
Self-assessment 241
hyperventilation 205 1.2.7 Hypertension and a
1.3.3 Deliberate self-harm 207 lump in the neck 48
1.3.4 The alcoholic in hospital 1.3 Communication skills and
208 ethics 50
1.3.5 Drug abuser in hospital Endocrinology 1.3.1 Explaining an uncertain
210 outcome 50
1.3.6 The frightening patient 1.3.2 The possibility of cancer
212 51
ENDOCRINOLOGY 1.3.3 No medical cause for
hirsutism 52
Diseases and Treatments 215
PACES Stations and Acute 1.3.4 A short girl with no
2.1 Dissociative disorders 215 Scenarios 3 periods 53
2.2 Dementia 215 1.3.5 Simple obesity, not a
2.3 Schizophrenia and 1.1 History-taking 3 problem with ‘the
antipsychotic drugs 217 1.1.1 Hypercalcaemia 3 glands’ 54
2.3.1 Schizophrenia 217 1.1.2 Polyuria 5 1.3.6 I don’t want to take the
2.3.2 Antipsychotics 218 1.1.3 Faints, sweats and tablets 55
2.4 Personality disorder 220 palpitations 8 1.4 Acute scenarios 56
2.5 Psychiatric presentation of 1.1.4 Gynaecomastia 12 1.4.1 Coma with
physical disease 221 1.1.5 Hirsutism 14 hyponatraemia 56
2.6 Psychological reactions to 1.1.6 Post-pill amenorrhoea 1.4.2 Hypercalcaemic and
physical illness (adjustment 16 confused 60
disorders) 222 1.1.7 A short girl with no 1.4.3 Thyrotoxic crisis 61
2.7 Anxiety disorders 223 periods 17 1.4.4 Addisonian crisis 63
2.7.1 Generalised anxiety 1.1.8 Young man who has ‘not 1.4.5 ‘Off legs’ 65
disorder 225 developed’ 20
2.7.2 Panic disorder 226 1.1.9 Depression and diabetes
Diseases and Treatments 68
2.7.3 Phobic anxiety 21
disorders 228 1.1.10 Acromegaly 23 2.1 Hypothalamic and pituitary
2.8 Obsessive–compulsive 1.1.11 Relentless weight gain 24 diseases 68
disorder 229 1.1.12 Weight loss 26 2.1.1 Cushing’s syndrome 68
2.9 Acute stress reactions and 1.1.13 Tiredness and lethargy 29 2.1.2 Acromegaly 71
post-traumatic stress 1.1.14 Flushing and diarrhoea 2.1.3 Hyperprolactinaemia 73
disorder 231 32 2.1.4 Non-functioning pituitary
2.9.1 Acute stress reaction 1.1.15 Avoiding another tumours 76
231 coronary 34 2.1.5 Pituitary apoplexy 77
2.9.2 Post-traumatic stress 1.1.16 High blood pressure and 2.1.6 Craniopharyngioma 78
disorder 231 low serum potassium 37 2.1.7 Diabetes insipidus 80
2.10 Puerperal disorders 233 1.1.17 Tiredness, weight loss 2.1.8 Hypopituitarism and
2.10.1 Maternity blues 233 and amenorrhoea 39 hormone replacement 83
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Diseases and Treatments 49 2.7.10 Hepatorenal syndrome 1.1.5 Flushing and skin rash 12
102 1.1.6 Drug-induced
2.1 Major renal syndromes 49 2.7.11 Pregnancy and the anaphylaxis 14
2.1.1 Acute renal failure 49 kidney 103 1.1.7 Arthralgia, purpuric rash
2.1.2 Chronic renal failure 51 2.8 Genetic renal conditions 104 and renal impairment
2.1.3 End-stage renal failure 2.8.1 Autosomal dominant 16
58 polycystic kidney 1.1.8 Arthralgia and
2.1.4 Nephrotic syndromes 60 disease 104 photosensitive rash 19
2.2 Renal replacement therapy 64 2.8.2 Alport’s syndrome 106 1.1.9 Cold fingers and
2.2.1 Haemodialysis 64 2.8.3 X-linked difficulty swallowing 23
2.2.2 Peritoneal dialysis 66 hypophosphataemic 1.1.10 Dry eyes and fatigue 25
2.2.3 Renal transplantation 69 vitamin-D resistant 1.1.11 Breathlessness and
2.3 Glomerular diseases 72 rickets 106 weakness 27
2.3.1 Primary glomerular 1.1.12 Low back pain 30
disease 72 1.1.13 Chronic back pain 32
Investigations and Practical
2.3.2 Secondary glomerular 1.1.14 Recurrent joint pain and
Procedures 108
disease 79 stiffness 33
2.4 Tubulointerstitial diseases 81 3.1 Examination of the urine 108 1.1.15 Foot drop and weight
2.4.1 Acute tubular necrosis 3.1.1 Urinalysis 108 loss in a patient with
81 3.1.2 Urine microscopy 109 rheumatoid arthritis 35
2.4.2 Acute interstitial 3.2 Estimation of glomerular 1.1.16 Fever, myalgia,
nephritis 82 filtration rate 109 arthralgia and elevated
2.4.3 Chronic interstitial 3.3 Imaging the renal tract 110 acute-phase indices 38
nephritis 82 3.4 Renal biopsy 114 1.1.17 Non-rheumatoid pain
2.4.4 Specific and stiffness 40
tubulointerstitial 1.1.18 Widespread pain 42
disorders 83
Self-assessment 116 1.2 Clinical examination 44
2.5 Diseases of renal vessels 86 1.2.1 Hands (general) 44
2.5.1 Renovascular disease 86 1.2.2 Non-rheumatoid pain and
2.5.2 Cholesterol stiffness: generalised
atheroembolisation 88 osteoarthritis 45
Rheumatology and
2.6 Postrenal problems 89 1.2.3 Rheumatoid arthritis 46
2.6.1 Obstructive uropathy 89 Clinical Immunology 1.2.4 Psoriatic arthritis 47
2.6.2 Stones 90 1.2.5 Systemic sclerosis 49
2.6.3 Retroperitonal fibrosis 1.2.6 Chronic tophaceous gout
or periaortitis 91 49
2.6.4 Urinary tract infection 92 RHEUMATOLOGY 1.2.7 Ankylosing spondylitis 50
2.7 The kidney in systemic AND CLINICAL 1.2.8 Deformity of bone:
disease 92 Paget’s disease 51
2.7.1 Myeloma 92 IMMUNOLOGY 1.2.9 Marfan’s syndrome 51
2.7.2 Amyloidosis 93 1.3 Communication skills and
2.7.3 Thrombotic ethics 52
PACES Stations and Acute
microangiopathy 1.3.1 Collapse during a
Scenarios 3
(haemolytic–uraemic restaurant meal 52
syndrome) 94 1.1 History-taking 3 1.3.2 Cold fingers and
2.7.4 Sickle cell disease 95 1.1.1 Recurrent chest difficulty swallowing 54
2.7.5 Autoimmune rheumatic infections 3 1.3.3 Back pain 55
disorders 95 1.1.2 Recurrent meningitis 5 1.3.4 Widespread pain 56
2.7.6 Systemic vasculitis 97 1.1.3 Recurrent facial swelling 1.3.5 Explain a
2.7.7 Diabetic nephropathy 99 and abdominal pain 7 recommendation to start
2.7.8 Hypertension 101 1.1.4 Recurrent skin abscesses a disease-modifying
2.7.9 Sarcoidosis 102 9 antirheumatic drug 57
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INDEX
Note: page numbers in italics refer to figures, those in bold refer to tables.
A
Abbreviated Mental Test Score 22, 57
status epilepticus 81–3
stridor 44 – 6
management 91
history 91
stroke 83 – 6 immediate management 91
abdominal pain 54 – 6 tachyarrhythmia 23 –7 animal bites 126 –7, 131–2
examination 55 thrombolysis 15 –19 antiarrhythmics 11
history 54 –5 thyrotoxic crisis 74 –5 antibiotics 15, 126 –7, 131–2
investigation 55 – 6, 56 upper gastrointestinal haemorrhage pneumonia 42
management 56 48–51 septic arthritis 94
ACE inhibitors 18 violence and aggression 97–9 anticoagulants, acute cardiac syndrome 18
N-acetylcysteine 101 acute spastic paresis 79 – 81 antiplatelet therapy 18
acid-base disturbance, correction of 64 examination 80 aortic dissection 19, 19, 128, 132
ACTH 73 nervous system 80 artemether 90
activated charcoal 100, 100, 124, 130 Guillain-Barré syndrome 80 arterial blood gases 23, 34, 37, 61
acute coronary syndrome 15 –19 history 79 – 80 diabetic ketoacidosis 63
antiplatelet therapy 18 investigation 80 –1, 80 interpretation 113
diagnosis 16 management 81 measurement 112–13
examination 16 Addisonian crisis 71– 4, 122, 129 preparation 112
history 16 examination 72 technique 112, 113
hypotension in 20 –1 history 72 normal values 113
investigation 16 –18, 17 investigation 72–3, 83 pneumonia 40
resuscitation 16 management 73 – 4 aspirin 18, 86
acute intermittent porphyria 56 adenosine 26 –7 asthma 33 – 6, 122, 129
acute scenarios adrenaline see epinephrine examination 34, 34
abdominal pain 54 – 6 adrenal insufficiency 72 history 33
acute spastic paraparesis 79 – 81 advanced life support 9, 10 investigation 34 – 5
Addisonian crisis 71– 4 airway/breathing 12 management 35 – 6
airways obstruction 42 – 4 airway management 113 –17 atrial fibrillation 25, 26, 75, 125, 126, 131
anaphylaxis 90 –1 basic 113 –16 treatment 27
asthma 33 – 6 adjuncts to airway control 114 atrial flutter 25, 26
back pain 94 – 6 head tilt/chin lift 113, 115 atrioventricular block 120, 120
bloody diarrhoea 51– 4 jaw thrust 113, 115 atropine 30
bradyarrhythmia 27–30 nasopharyngeal airway 115 autoimmune diseases 72
cardiac arrest 8 –12 oropharyngeal airway 114
chest infection /pneumonia 39 – 42
chest pain and hypotension 12–15
collapse of unknown cause 30 –3
removal of obstruction from
oropharynx 114
tracheostomy 116 –17
B
back pain 94 – 6, 124 –5, 130
coma 86– 9 airways obstruction 42– 4 examination 94 –5, 95
diabetic ketoacidosis 62–5 cause of deterioration 43 history 94
fever in returning traveller 89 –90 examination 43 investigation 95
hepatic encephalopathy/alcohol history 42–3 management 95 – 6
withdrawal 56 –9 investigation 43 red flags 94
hypoglycaemia 65–7 management 43 – 4 basic life support 9, 9
hyponatraemia 69 –71 alcohol abuse 56 – 9, 82 Bence Jones proteinuria 68, 81
hypotension in acute coronary alcohol withdrawal 57, 59 beta-blockers 18
syndrome 20 –1 allergy 127, 132 overdose 30
join pain 91– 4 amaurosis fugax 84 binge drinking 57
pleurisy 36 –9 aminophylline 35 bisphosphonates 69
pneumothorax 46 – 8 amoxicillin 44 blood pressure 22
postoperative breathlessness 21–3 amylase 55 bloody diarrhoea 51– 4
renal failure, fluid overload and analgesia 21, 77 examination 52
hyperkalaemia 59 – 62 anaphylactoid reactions 91 history 51–2, 51
self-harm 96 –7 anaphylaxis 90 –1 investigation 52–3, 52, 53
severe headache 75 – 9 examination, investigation and further management 53 – 4
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C
cachexia 68
clomthiazole 59
clopidogrel 18
Clostridium difficile 51, 52, 53, 123, 129–30
delirium tremens 59
dextrose 60
diabetic ketoacidosis 56, 62–5, 121–2,
calcitonin 69 clubbing 45 129
calcium gluconate 60 coagulopathy 59 examination 62–3
Campylobacter jejuni 81 coiling 77 history 62
carbimazole 75 colchicine 93 investigation 63
cardiac arrest 8 –12 collapse of unknown cause 30 –3 management 63 – 4
advanced life support 9, 10 examination 32–3 dialysis 2
antiarrhythmics 11 history 31–2 diarrhoea, bloody 51– 4
basic life support 9, 9 investigation 33 diazepam 81
buffers 11 management 33 digital rectal examination 55
categories of 9 –10 colonic infection 51 diuretics 44, 61
communication 3 – 4 coma 86 –9 do not resuscitate orders 9
confirmation of 8 –9 differential diagnosis 88 Dupuytren’s contractures 82
outcome 11 examination 87– 8 dysphagia 84
pacing 11 Glasgow Coma Scale 4, 5, 20, 22, 76,
post-resuscitation management 11
potentially reversible causes 10 –11
return of spontaneous circulation 11
82, 84, 87
history 87
immediate maximum 87
E
earache 78
stopping resuscitation 11 investigation 88 echocardiography 20 –1
who to resuscitate 9 management 88 –9 transoesophageal 19
who should be notified 4 common law 97 ventricular septal defect 24
cardiac pacing 30, 107–9 communication skills and ethics elective DC cardioversion 109
indications 108 acute pneumothorax 7– 8 electrocardiogram 22
problems 109 cardiac arrest 3 – 4 acute coronary syndrome 16–17, 17
technique 108 –9, 108, 109 community-acquired pneumonia 7 heart block 29
cardiac syncope 32 congestive cardiac failure 5 – 6 hypothermia 31
cardioversion 109 lumbar back pain 6 –7 pleurisy 37, 38
cauda equina syndrome 95 stroke 4–5 tachyarrhythmia 24 –5, 25, 26
central venous lines 13, 103 – 6 community-acquired pneumonia 7 electrolyte replacement 63
central venous pressure 106, 106 computed tomography, subarachnoid endocarditis 84
complications 103 haemorrhage 76 epiglottitis 45
consent for insertation 103 computed tomography angiography 38 epilepsy 32
contraindications 103 concordance 25 epinephrine 10, 91
indications 103 confusion 40 esmolol 75
preparation for insertion 103 alcohol-related 57 exophthalmos 74
Seldinger technique 104 –5, 104 hypercalcaemia 68 external cardiac pacemaker 30
femoral vein 105, 106 congestive cardiac failure 5 – 6
internal jugular vein 104, 104
subclavian vein 105
central venous pressure 13, 106, 106
consent to treatment 96, 97
insertion of central venous line 103
continuous positive airway pressure
F
familial Mediterranean fever 56
abnormal 106 117–18 Fansidar 90
cerebral oedema 64 controlled oxygen therapy 117 femoral vein cannulation 105, 106
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fever 39
in returning traveller 89 –90
recognition of 59 – 60, 60
treatment 60 J
jaundice 58
fluid overload 59 – 62 hyperosmolar non-ketotic diabetic coma
management 61 64 –5 joint pain 91– 4
fluid replacement 63, 64 hyperpyrexia 75 differential diagnosis 92
fluid resuscitation 63 hyperthyroidism 75 examination 93
fluid therapy 21, 77 hypoglycaemia 58, 65 –7, 87 history 92–3
fosphenytoin 81 causes 66 investigation 93
examination 66 management 93 – 4
jugular venous pressure 20, 22
G
gallop rhythm 22, 37
history 65 – 6
investigations 66, 66
in malaria 90
jugular venous pulse 61
H
orthostatic 32
hypotensive collapse 12–15
airway/breathing 12
L
laryngeal oedema 45
haematemesis 48 circulation 12 laryngitis 45
haemoptysis 36 differential diagnosis 12 Legionella pneumophila 128, 132–3
headache examination 14 –15, 14 Legionnaire’s disease 40, 42
with fever 77–9 history 13 –14 liver disease, physical signs 48
examination 78, 78 investigation 15 lorazepam 81
history 77– 8 management 15 low-molecular-weight heparin 36, 39
investigation 78 –9 resuscitation 12 Lugol’s iodine 75
management 79 hypothermia 11, 28, 30, 31, 87, 122, 123, lumbar back pain 6 –7
meningeal irritation 78 129 lumbar puncture 76 –7, 106–7
sudden onset 75 –7 hypothyroidism 30 contraindications 106
examination 76 hypovolaemia 10 –11, 13, 58, 103 CSF findings 108
history 75 – 6 hypoxia 10, 12, 34, 117 indications 106
investigation 76 –7, 76 preparation 107
management 77
heart block 29
heart rate 14, 22
I
infective colitis 53
technique 107, 107
lumefantrine 90
lung cancer 68
heart sounds 1 inflammatory bowel disease 53 Lyme arthritis 92
hepatic encephalopathy 56 –9 inotropes 21 lymphadenopathy 45, 68
examination 57– 8, 58 insulin 64, 64
grades of 57
history 57
investigation 58
intensive care unit 5 – 6, 89
intercostal chest drain insertion 109 –12
complications 112
M
magnesium sulphate 35
management 58 –9 indications 109 –10 magnetic resonance imaging
hepatomegaly 68 post-procedure 111–12 back pain 95
herpes simplex encephalitis 83 preparation 110, 110 herpes simplex encephalitis 83
Horner’s syndrome 68, 88 technique 110 –11, 111 spinal cord compression 80
hydrocephalus 77 large-bore chest drain 111 malaria 89 –90, 123, 129
hydrocortisone 44, 75, 91 small-bore chest drain 111 diagnosis 89
hypercalcaemia 67–9, 72 internal jugular vein cannulation 104, examination 89
causes 67 104 history 89
examination 67– 8 intestinal angina 54 investigation 89, 90
history 67 intra-aortic balloon counterpulsation management 90
investigations 68, 68 21 malignancy, and hypercalcaemia 67–9
management 68 –9 intravenous fluids 35 – 6 Medical Research Council dyspnoea scale
hypercapnia 10, 12, 34, 117 ipratropium 35, 44 42–3
hyperglycaemia, correction of 64 isoprenaline 30 melaena 49, 57
hyperkalaemia 11, 59 – 62, 72 isosorbide dinitrate 61 meningeal irritation 78
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P
pacing 11
pulse rate 61
pulsus alternans 22
pulsus paradoxus 34
serum mast cell tryptase 91
sickle cell crisis 56
sigmoidoscopy 52, 53
pancreatic pain 54 sinus tachycardia 22, 26, 34
pancreatitis 122, 129
paracetamol overdose 100 –1, 101, 128,
132
Q
QRS complex, wide 25
small-bowel infection 51
sore throat 78
spider naevi 49, 82
paraplegia 79 quadriplegia 79 spinal cord compression 79
paroxysmal noctural dyspnoea 43 quinine 90 symptoms 80
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Staphylococcus spp. 40
Staphylococcus aureus 132
syndrome of inappropriate antidiuretic
hormone secretion 70 U
ulcerative colitis 52, 53
statins 18 synovial fluid aspiration 93
status epilepticus 81–3 upper gastrointestinal haemorrhage 48–51
examination 48 –9
causes 82
examination 82
further management 83
T
tachyarrhythmia 23 –7, 108
history 48
investigation 49, 49
history 82 broad-complex 24 management 50 –1
immediate management 81 decision-making algorithm 28 risk scoring system 50
investigation 82–3, 83 treatment 27 uraemia 41
steroids 35, 44 examination 24 urinary retention 61
stiffness 92 history 24
stokes-Adams attack 28, 32
Streptococcus pneumoniae 40, 41
investigation 24 –5, 25, 26
management 25 –7 V
vancomycin 53
stridor 44–6, 122, 129 narrow-complex 24, 25, 26
causes 44 irregular 25 vasospasm 77
exacerbating/triggering factors 45 tachycardia 75 venous pressure 37
history 44 –5 tamponade 11 ventilators 119
investigation 45 tension pneumothorax 11, 15, 110, ventilatory support 117–19
management 45 – 6 122–3, 129 continuous positive airway pressure
stroke 4–5, 83 – 6 thromboembolism, prophylaxis 64 117–18
classification 85 thrombolysis 39, 85 controlled oxygen therapy 117
differential diagnosis 83 Thrombolysis In Myocardial Infarction invasive ventilation 118–19
examination 84 (TIMI) risk score 18 non-invasive ventilation 118
functional/social history 84 thrombophlebitis 127, 132 ventricular fibrillation 10
history 83 – 4 thyrotoxic crisis 74 –5 ventricular septal defect 20
investigation 84 –5 examination 74, 74 echocardiography 24
management 85 – 6 history 74 ventricular tachycardia, pulseless 10
medical history 84 investigation 75 violence and aggression 97–9, 125, 130–1
ST-segment elevation myocardial management 75 common law 97
infarction 16 thyrotoxicosis 45 examination and investigation 98
management 18 tissue plasminogen activator 86 history 98
subarachnoid haemorrhage 75, 126, toxins 11 management 98 – 9
127–8, 131, 132 tracheostomy 116 –17 Mental Health Act (1983) 97–8
complications 77 changing 117 Virchow’s node 49
features 76 complications 116 vitamin B 59
subclavian vein cannulation 105 formal 116 vitamin C 59
suicide risk 96, 97 indication 116 vitiligo 74
sulfadoxine/pyramethamine 90 management 116
supraventricular tachycardia 22,
26
syncope 28
mini-tracheostomy 116
percutaneous 116
transient ischaemic attacks 84
W
Wernicke’s encephalopathy 58, 66, 87,
cardiac 32 tricyclic antidepressant overdose 128, 133
causes 32 101–2 wheezing 34
neurally mediated 31–2 troponin 23, 61, 76 Wolff-Parkinson-White syndrome 27
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