The Blue Book

The Blue Book: A
Comprehensive
Guide to Handling
Medical
Emergencies
First Edition
Sami A. Lawgaly
The Blue Book: A
Comprehensive Guide to
Handling Medical
Emergencies
First Edition
Sami A. Lawgaly
THE BLUE BOOK SAMI A. LAWGALY
Preface
This book is intended as a quick reminder to help our junior colleagues during
their on calls in the casualty, medical wards and intensive care units.
The idea of this project started by Dr. Salem Ishtaiwi who is a senior consultant
gastroenterologist at Benghazi medical center, Libya.
We started writing this book in 2020 but unfortunately, we could not finish it at
that time. However, thanks to Dr. Suhaib Ali Issa, Dr. Alhassan Kashbour and Dr.
Alhussen Kashbour we were able to resume this work and make it a realilty!
The first edition of the BLUE BOOK was finished with the help and guidance of our
senior colleagues and consultants.
We strongly recommend continuous readings, as well as consulting your seniors
during your journey in the medical field.
By doing the BLUE BOOK, we strongly encourage our junior colleagues to enjoy
their on call duties and to do the best they can to help and take care of their
patients.
Sami A. Lawgaly, MBChB, MSc, MD

Gastroenterology and Hepatology, Department of Internal Medicine,
Benghazi Medical Center, Faculty of Medicine, University of Benghazi
I
Dedication
To the soul of my beloved father ....
II
Abbreviations
ABG Arterial Blood Gas D5W Dextrose Water 5% INR International Normalized
ACE Angiotensin Converting DBP Diastolic Blood Pressure Ratio
Enzyme Inhibitors DC Direct Current IOP Intra-Orbital Pressure
ACTH Adrenocorticotropic Cardioversion IV Intra-Venous
Hormone DIC Disseminated Intravascular KDIGO Kidney Disease
AD Autosomal Dominant Coagulation Improving Global
AF Atrial Fibrillation DM Diabetes Mellitus Outcome
AKI Acute Kidney Injury DOACs Direct Oral KUB Kidney, Ureter, &
APL Acute Promyelocytic Anticoagulants Bladder radiograph
leukemia DSA Digital Subtraction LBBB Left Bundle Branch
APTT Activated Partial Angiography Block
Thromboplastin Time DVT Deep Vein Thrombosis LDH Lactate Dehydrogenase
ARBs Angiotensin Receptor ECG Electrocardiomyography LFT Liver Function Test
Blockers ER Emergency Room LMWH Low Molecular
ASAP As Soon As Possible ESR Erythrocyte Weight Heparin
ATRA All Trans-Retinoic Acid Sedimentation Rate LP Lumbar Puncture
BD,BID Bis in Die “Twice Daily” FDPs Fibrin Degradation MAP Mean Arterial Pressure
BNP Brain Natriuretic Peptide Products MI Myocardial infarction
CAD Coronary Artery Disease FFP Fresh Frozen Plasma MM Multiple Myeloma
CBC Complete Blood Count G Gauge MRI Magnetic Resonance
CKD Chronic Kidney Disease GBS Guillain Barre Syndrome Imaging
CNS Central Nervous System GERD Gastro-Esophageal Reflux MRA Magnetic Resonance
COPD Chronic Obstructive Disease Angiography
Pulmonary Disease GFR Glomerular Filtration Rate MRSA Methicillin-Resistant
CPAP Continuous Positive GIT Gastro-Intestinal Tract Staphylococcus Aureus
Airway Pressure GN Glomerulonephritis MR Magnetic Resonance
CPK Creatine Phosphokinase GTN Glyceryl Trinitrate MSU Mid-Stream Urine
CPR Cardio-Pulmonary GVHD Graft Versus Host NGT Naso-Gastric Tube
Resuscitation Disease NIV Non-Invasive Ventilation
CRP C-Reactive Protein HAS Human Albumin Solution NPO Nil Per Os “Nothing by
CSF Cerebrospinal Fluid HIV Human Immunodeficiency Mouth"
CT Computed Tomography Virus NS Normal Saline
CTA Computed Tomography HR Heart Rate NSAIDS Non-Steroidal Anti-
Angiography HRT Hormonal Replacement Inflammatory Drugs
CTPA Computed Tomography Therapy OCP Oral Contraceptive Pills
Pulmonary Angiography ICH Intra-Cranial Hemorrhage OD Omne in Die “Once Daily”
CV line Central Venous line ICP Intra-Cranial Pressure OSA Obstructive Sleep Apnea
CXR Chest X-Ray ICU Intensive Care Unit
IHD Ischemic Heart Disease
IM Intramuscular
III
Abbreviations
PaCO2 Partial Pressure of SAH Subarachnoidal Hemorrhage
Carbon Dioxide SBP Systolic Blood Pressure
PBF Peripheral Blood Film SC Subcutaneous
PCC Prothrombin Complex SE Serum Electrolytes
Concentrate SpO2 Saturation of Peripheral Oxygen
PCI Percutaneous Intervention Stat Statim “Immediately”
PE Pulmonary Embolism SVT Supra-Ventricular Tachycardia
PEA Pulseless Electrical Activity TACO Transfusion-Associated Circulatory Overload
PEF Peak Expiratory Flow TBV Total Blood Volume
PLT Platelet TDS Ter Die Sumendum “Three Times a Day”
PMN Polymorph Neutrophils TFT Thyroid Function Test
PND Paroxysmal Nocturnal TLS Tumor Lysis Syndrome
Dyspnea TR Tricuspid Regurgitation
PO Per-Oral TRALI Transfusion Related Acute Lung Injury
PR Pulse Rate UA Uric Acid
PR Per-Rectum UFH Unfractionated Heparin
PRBCs Packed Red Blood Cells USS Ultrasound Sonography
PT Prothrombin Time U&E Urea & Electrolytes
PTH Parathyroid Hormone VBG Venous Blood Gas
PTHrp Parathyroid Hormone VT Ventricular Tachycardia
Related Protein VTE Venous Thrombo- Embolism
PUD Peptic Ulcer Disease V/Q scan Pulmonary Ventilation and Perfusion Scan
q6hr Every 6hrs WBC White Blood Cells
q8hr Every 8hrs WCC White Cell Count
q12hr Every 12hrs
q24hr Every 24hr
QDS, QID Quater Die Quater Die
Sumendum “Four
Times a Day”
RBBB Right Bundle Branch Block
RBC Red Blood Cells
RFT Renal Function Test
RR Respiratory Rate
RRT Renal Replacement Therapy
IV
Table of
Contents
Preface ............................................................................................................ I
Dedication ..................................................................................................... II
Abbreviations .................................................................................................. III
Cardiology:
01. Acute coronary syndrome .................................................................. 01
02. Acute pulmonary edema .................................................................... 02
03. Adult bradycardia .............................................................................. 03
04. Adult tachycardia .............................................................................. 04
05. Adult advanced life support ............................................................... 05
Pulmonology:
06. Acute exacerbation of asthma ......................................................... 06
07. Infective exacerbation of COPD ......................................................... 07
08. Community acquired pneumonia ....................................................... 08
09. Pulmonary embolism ......................................................................... 09
10. Oxygen therapy ................................................................................. 11
11. Spontaneous pneumothorax ............................................................. 12
Gastroenterology:
12. Upper GI bleed ................................................................................. 13
13. Decompensated liver failure ............................................................. 14
14. Bloody diarrhea ................................................................................ 15
Neurology:
15. Acute ischemic stroke ....................................................................... 16
16. Raised intracranial pressure ............................................................. 17
17. Acute severe headache ................................................................... 18
18. Subarachnoid hemorrhage ............................................................. 19
19. Suspected meningitis/encephalitis ................................................... 20
20. Convulsive status epileptics .............................................................. 21
21. Delirium ........................................................................................... 22
Nephrology:
22. Acute kidney injury ........................................................................... 23
23. Acute oliguria ................................................................................... 24
Electrolytes:
24. Hyperkalemia ................................................................................... 25
25. Hypokalemia ................................................................................... 26
26. Hypocalcemia ................................................................................... 27
27. Hypercalcemia ................................................................................... 28
Hematology & Oncology:
28. Acute DVT ........................................................................................ 29
29. Raised INR on warfarin .................................................................... 31
30. Neutropenic sepsis .......................................................................... 32
31. Acute DIC ......................................................................................... 33
32. Massive blood transfusion ................................................................ 34
33. Neoplastic spinal cord compression ................................................... 35
34. Superior vena cava syndrome ........................................................... 36
35. Tumor lysis syndrome ....................................................................... 37
Endocrinology:
36. Diabetic ketoacidosis ........................................................................ 38
37. Hyperosmolar hyperglycemic state ................................................... 40
38. Hypoglycemia ................................................................................... 41
39. Adrenal crisis ..................................................................................... 42
ACUTE CORONARY SYNDROME

Unstable angina, ST elevation MI, Non-ST elevation MI
Signs & Symptoms Initial assessment in ER Risk factors:

Chest discomfort – 12-leads ECG, then repeat every Increased age
tightness, heaviness, 4 to 6 hours Male gender
restriction – last more Bloods: troponin, glucose, U&E, Family history of CAD
than 20 minutes CBC, LFT, Lipids, coagulation Hypertension
Radiate to jaw, throat, CXR Diabetes mellitus
left arm and epigastrium Smoking
Nausea & vomiting Dyslipidemia
Sweating Physical inactivity
Dyspnea Management Obesity
Oxygen (target > 94%, if COPD 88-92%)

IV Morphine 5 mg + Metoclopramide 10mg
Sublingual GTN 500mcg (consider infusion if
pain persists)
Continuous monitoring to BP, pulse and ECG
STEMI NSTEMI
Criteria: ST elevation > 2 mm in V1-V6 Chest pain + raised troponin

ST elevation > 1mm in 2 contiguous leads +/- ECG changes: ST depression, T wave
(for all other leads) inversion or flattening (not in aVR or V1)
New LBBB
Aspirin 300 mg PO stat

If available contact cath lab for primary PCI, Clopidogrel 300 mg PO stat
if not available go to thrombolytic therapy LMWH (therapeutic dose)
Aspirin 300 mg PO stat

Clopidogrel 300 mg PO stat
Thrombolytic therapy (Alteplase
or Tenectoplase
LMWH (therapeutic dose)
Doses of thrombolytic therapy:

IV Alteplase: 15 mg over 5 minutes
50 mg over 30 minutes
35 mg over 1 hour
IV Tenectoplase bolus (over 5 seconds) Secondary prevention:
Dose is according to body weight Aspirin 75 mg PO, Clopidogrel 75 mg PO,
Available dose of 10.000 U Atorvastatin 40-80 mg PO,
Give 100U/kg ACEIs and B-blockers
e.g. for 70 kg person give 7000 U
References:
Acute coronary syndromes. NICE guideline 2021.
1 ESC Clinical practice guidelines, 2020 Acute coronary syndrome in patient presented without persistent ST-segment elevation guideline.
ACUTE PULMONARY EDEMA
Signs and symptoms Initial assessment in ER Differential diagnosis
Dyspnea, orthopnea Set the patient upright COPD

and PND Vital signs monitoring Bronchial asthma
Frothy pink sputum IV access and monitor ECG Pneumonia
Respiratory distress 12-leads ECG If you are not sure
Tachycardia, tachypnea Bloods: Troponin, BNP, ABG, treat for all
Sweating Glucose, U&E, CBC, LFT, Lipids,
Pulsus alternans Coagulation
Fine lung crackles CXR
Triple/gallop rhythm
Management
High flow oxygen if low SpO2

IV morphine 2.5-5mg (caution in liver failure
& COPD) + IV Metoclopramide
IV furosemide 40-80mg (larger doses are
needed in renal failure)
GTN 0.5mg SL (2 tablets) or spray 2 puffs
(don't give if SBP <90mmHg)
If SBP >100mmHg, start nitrate IV infusion
2-10mg/h, keep SBP >100mmHg
If SBP <100mmHg treat as cardiogenic shock
Treat any underlying cause of acute
decompensation
Causes of decompensation
If the patient is worsening
Acute coronary syndrome Give another furosemide 40-80mg IV
Hypertensive emergency Consider CPAP
Arrhythmias Increase the nitrate infusion rate if possible
Pulmonary embolism Consider other diagnoses, e.g. hypertensive heart failure, pulmonary
Infections embolism, aortic dissection, pneumonia, COPD or asthma
Tamponade
References:
ESC Clinical practice guidelines, 2021 Guideline for the diagnosis and treatment of acute and chronic heart failure. 2
ADULT BRADYCARDIA
Always start with ABCDE approach, heart rate typically < 50/min
Treatable causes
Myocardial ischemia
Hyperkalemia Initial assessment in ER
Hypocalcemia
Hypermagnesemia Give oxygen if hypoxic
Hypothyroidism Obtain IV access
Adrenal insufficiency 12-leads ECG
Hypothermia Continuous ECG and BP monitoring
Cholestasis Identify and treat reversible causes
Drugs e.g. B-blockers ,
verapamil, digoxin or
amiodarone
Any adverse feature?
High ICP
Shock
Syncope
Altered mental status
Myocardial ischemia
Heart failure
Yes No
Atropine 1 mg IV bolus Risk of asystole?
Recent asystole?
Respond Yes Mobits II AV block
Complete heart block with broad QRS
Ventricular pause > 2 seconds
No
Repeat every 3 to 5 minutes atropine until

maximum 3 mg
Or Yes No
Transcutaneous pacing
Or
Adrenaline 2-10 mcg/min IV infusion
Consider alternative drugs
Cardiology opinion for possible
transvenous pacing
Continuous observation
Alternative drugs:
• Aminophylline
• Dopamine infusion 5-20 mcg/kg per minute
• Glucagon (if b-blockers or calcium channel blockers overdose)
References:
Adult bradycardia – American heart association 2020.
3 Adult bradycardia – Resuscitation council UK 2021.
ADULT TACHYCARDIA
Assess using the ABCDE approach
Monitor SpO2 and give oxygen if hypoxic

Monitor ECG, BP and do 12-leads ECG
Obtain IV access
Identify and treat reversible causes such as
electrolyte abnormalities
Synchronized DC Adverse features?

shock (up to 3 YES Shock, Myocardial ischemia,
"Unstable"
attempts) syncope or heart failure
Amiodarone 300
mg IV over 10-20 NO "Stable"
min
Repeat shock
Is QRS narrow (< 0.12 s)?
Give amiodarone
900 mg over 24 h
Broad QRS Narrow QRS

Is QRS regular? Is QRS regular?
Irregular Regular Regular Irregular
Vegal manoeuvers
Probable AF:
Seek expert help If IV (or uncertain rhythm): Adenosine 6 mg rapid
Control rate with beta-
Amiodarone 300 mg IV IV bolus
over 20-60 min then blocker or diltiazem
If no effect give 12 mg
Possibilities include: 900mg over 24 h If in heart failure
If no effect give further
AF with bundle If known to be SVT with consider digoxin or
branch block treat bundle branch block: 12 mg
amiodarone
as or narrow Treat as for regular Monitor/record ECG
Assess thromboembolic
complex narrow-complex continuously
risk and consider
tachycardia
Pre-excited AF anticoagulation
consider
amiodarone Sinus rhythm achieved?
YES NO
Probable re-entry Seek expert help

paroxysmal SVT
Record 12-lead ECG in
sinus rhythm If SVT Possible atrial
recurs treat again and flutter:
consider anti- Control rate
arrhythmic prophylaxis (e.g. with beta-
blocker)
Resuscitation Counsel UK - guidelines 4
ADULT ADVANCED LIFE SUPPORT
Unresponsive and not

breathing normally
CPR 30:2
Attach defibrillator/monitor
Minimize interruption
Assess rhythm
Shockable rhythm Return to spontaneous

circulation Non-Shockable rhythm
(VT/Pulseless VT) (PEA/Asystole)
1 Shock Immediate post cardiac arrest

treatment
Minimize interruption
• Use ABCDE approach
• Aim for SpO2 94-98% Immediately resume
• Aim for normal PaCO2 CPR for 2 min
Immediately resume • 12-leads ECG Minimize interruption
CPR for 2 min • Treat precipitating cause
Minimize interruption • Temperature managment
Treat reversible causes (Hs & Ts)

During CPR Hypoxia
Ensure high quality chest compression and minimize interruption Hypovolemia
Give oxygen Hypo and hyperkalemia
Use waveform capnography Hypothermia
Continues compressions when advanced airway in place Thrombosis (coronary or pulmonary)
Vascular access (IV or IO) Tension pneumothorax
Give adrenaline every 3-5 minutes Temponade – cardiac
Give amiodarone after 3 shocks Toxins
5 Resuscitation Counsel UK - guidelines

ACUTE EXACERBATIONS OF ASTHMA
Assessment of severity (may or may not be present)
Impending respiratory failure: Severe exacerbation: Mild to moderate exacerbation:

Cyanosis, inability to maintain Speaks in single words Talks in phrases or sentences
respiratory effort, depressed Sits hunched forward Prefers sitting to lying
mental status, SpO2 <90% Agitated, diaphoretic Not agitated
PaCO2 >40 mmHg RR >30 /minute RR 16 to 30 /minute
PR >120 /minute PR 100 -120 /minute
SpO2 (on air) <90% SpO2 >90%
PEF ≤50% predicted or personal best PEF >50% but <80% predicted or
personal best
Investigations
Bloods: CBC, RFTs & electrolytes

ABG (if O2 sat < 93%)
PEF
Chest X ray
Management
Supplemental oxygen (maintain sat 94-98%)

Standard nebulization – salbutamol 2.5 to 5 mg every 20 min for 3 doses, then 2.5- 5 mg every 4- 6 hours
as needed
If moderate to severe attack add ipratropium 0.5 mg neb ulization every 20 minutes for three doses then
as needed for up to three hours
Oral prednisone 40 to 60 mg for 5 days or more
Single dose of IV magnesium sulfate (1.2- 2 g over 20 min) for patient who is not responding to initial therapy
(contraindicated in renal insufficiency, and hypermagnesemia)
If impending or actual respiratory arrest, in addition to the above therapies, options for ventilatory support
(mechanical ventilation) must be assessed, for anesthesia use IV ketamine
References:
Peter Cameron, Mark Little, Biswadev Mitra, Conor Deasy. Textbook of Adult Emergency Medicine 5th Edition 2020.
The 2019 edition of the BTS/SIGN Asthma Guideline. 6
INFECTIVE EXACERBATIONS OF COPD

Exacerbations of COPD can be precipitated by several factors. The most common
causes are respiratory tract infections
Common symptoms Assessment
Cough Complete history and examination

Breathlessness Bloods: CBC, ESR, RFTs & electrolytes
Increased sputum ABG
production Chest X ray
Change in sputum color ECG
Sputum culture
Management
Supplemental oxygen (maintain O2 sat 88-92%)

Nebulization: salbutamol 2.5- 5 mg QDS and ipratropium bromide 0.5
mg QDS
Prednisolone 30 mg PO OD for 5 - 7 days
Doxycycline 200 mg PO stat, then 100 mg OD for 5 days, or
Azithromycin 500 mg OD PO for 5 days
If no response to the above measures
Consider ICU transfer

Consider aminophylline IV infusion: loading dose 5 mg/kg over 20 min (unless on
maintenance oral therapy), then maintenance dose 0.5-0.7 mg/kg/hr infusion
Noninvasive mechanical ventilation or invasive ventilation if needed
Notes:
Venturi masks (high-flow devices) offer more accurate and
controlled delivery of oxygen than do nasal prongs
Cardiovascular diseases are common and important
comorbidities in COPD
GERD is associated with an increased risk of exacerbations
and poorer health status
References:
7 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019.
COMMUNITY ACQUIRED PNEUMONIA
Initial assessment
Signs & Symptoms CURB-65
Complete history and examination
Fever Bloods: CBC, ESR, CRP, RFTs , LFTs &
Cough, purulent/ rusty Confusion
electrolytes Urea > 7mmol/L
colored sputum ABG (if O2 < 94% on air, or known
Dyspnea Respiratory rate ≥ 30
COPD) Blood pressure (SBP ≤
Pleuritic pain
Chest X ray 90 or DBP ≤ 60 mmhg)
Tachypnea
ECG Age ≥ 65
Lung crepitations
Sputum gram stain and culture
Bronchial breathing
Blood culture if severe
Consider atypical screen
Apply CURB-65 score and proceed
IV hydration if needed
Prescribe oxygen with target sats
Management
MILD MODERATE SEVERE

CURB-65 = 0-1 CURB-65 = 2 CURB-65 = 3-5
Treat as out patient Admit to hospital Admit to ICU

Augmentin 1g PO TDS for 5- IV augmentin 1.2g TDS for IV Ceftriaxone 1g q24h, or
7 days + azithromycin 5-7 days + azithromycin IV Cefotaxime 1 g q8h +
500mg PO, OD for 3-5 days azithromycin 500mg PO/IV
500mg PO, OD for 3-5 days
OR OD or levofloxacin 750 mg
OR PO/IV OD or moxifloxacin
If Penicillin allergy use
If Penicillin allergy use 400 mg PO/IV OD
Doxycycline PO 200 mg stat
doxycycline PO 200 mg stat
then 100 mg for 5 days OR
then 100 mg for 5 days OR
Respiratory fluoroquinolone If Pseudomonas is suspected (e.g.
Respiratory fluoroquinolone
as monotherapy e.g. structural lung disease, steroid
e.g. levofloxacin 750 mg
levofloxacin 750 mg PO OD, use, malnutrition, leucopenia,
PO/IV OD, moxifloxacin 400 immunosuppression, previous
moxifloxacin 400 mg PO OD
mg PO/IV OD hospital admission, malignancy)
give piperacillin-tazobactam 4.5 g
q6h, or ceftazidime 2 g q8h,
If with or post influenza, add:
Meropenem 1 g q8h, duration 10-
Vancomycin 15mg/kg IV q12h 14 days
References:
The Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) issued clinical practice guidelines for
community-acquired pneumonia (CAP) in adults in October 2019.
American college of physicians , MKSAP 18 in infectous diseases , 2018-2021. 8
Beer, stephani L, community acquired pneumonia , medescape.com 2019.
PULMONARY EMBOLISM
Initial assessment
Signs & Symptoms Bloods: CBC, RFT, LFT, SE, Risk factors:
Abrupt onset chest pain coagulation profile and D-dimer
Raised troponin T and I Bed ridden
Dyspnea
DVT
Hypoxia ECG: sinus tachycardia, new RBBB,
Previous DVT or PE
Sudden hemodynamic new atrial arrhythmias, S1Q3T3 Active cancer
collapse pattern Pregnancy and 6 weeks
Tachypnea postpartum
Echocardiography: right ventricular
Rales OCP and HRT
loud p2 dilatation and hypokinesia, TR, and
Trauma to pelvis or lower
Tachycardia interventricular septal flattening with
limbs
S3 or S4 gallop paradoxical leftward septal motion Recent surgery
Evidence of CTPA is the gold standard for Smoking
thrombophlebitis or DVT diagnosis of PE Central venous
V/Q scan instruments
COPD
Management
* Hemodynamic support:
- O2 supplementation.
- IV fluid – is the first-line therapy for patients with hypotension.
- Vasopressors e.g. Norepinephrine, Dobutamine.
* Empiric anticoagulation:
1. Parenteral anticoagulant: LMWHs are more effective and preferred than unfractionated heparin (UFH).
Doses:
- IV UFH 80 units/kg bolus, then continuous infusion of 18 units/kg/hr.
- SC Enoxaparin 1mg/kg every 12 hours or 1.5mg/kg once daily.
2. Oral anticoagulant:
- Warfarin PO (most patient required 5 mg – dose adjusted according to the INR)
- DOACs (Dabigatran, rivaroxaban, apixaban, and edoxaban) are approved for treatment of acute PE.
• Rivaroxaban and apixaban can be used as monotherapy with no need for parenteral heparin.
• Dose: Rivaroxaban 15mg PO twice daily for 21 days, then 20mg PO daily.
* Thrombolytic therapy:
- Used for high-risk, massive PE, defined as with persistent hemodynamic instability and absent of contraindications.
- Dose: IV Alteplase infusion 100mg over 2 hours, followed by IV infusion of unfractionated heparin.
9
Well’s criteria for pulmonary embolism:

Clinical signs and symptoms of DVT No 0 Yes +3
PE is #1 diagnosis or equally likely No 0 Yes +3
Heart rate > 100 No 0 Yes +1.5
Immobilization at least 3 days
or Surgery in the previous 4 weeks No 0 Yes +1.5
Previous, objectively
diagnosed PE or DVT No 0 Yes +1.5
Hemoptysis No 0 Yes +1
Malignancy without treatment within
6 months or palliative therapy No 0 Yes +1
Score interpretation: 0-1 (low risk), 2-6 (moderate risk), >6 high risk.
Access clinical probability of PE
Low or intermediate High
D- dimer
CTPA
Negative Positive
No more tests CTPA
NB: consider high sensitivity d-dimer ± CTPA for intermediate probability .
References:
Konstantinides, s.v ,Meyer , G. , Becattini,C. et. al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonaryembolism
developed in collaboration with the European Respiratory Society (ERS) , European Heart Journal (2020) 41, 543_603.
Aggrwal, V. ,Nicolas, C. D. , Lee, A. , et. al. Acute Management of Pulmonary Embolism, American college of cardiology , 2017.
Burnett AE et al. Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis.
2016 Jan;41(1):206–32. [PMID: 26780747].
Konstantinides SV et al. 2019 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2019 Nov
1;40(42):3453–5. [PMID: 31697840]. 10
OXYGEN THERAPY
Respiratory failure type 1 ABG (normal values) Respiratory failure type 2
Bronchial asthma pH = 7.35 – 7.45 Pulmonary diseases:

Pneumonia PaO2 = COPD, Asthma, OSA,
Emphysema PaCO2 = Pneumonia
Pulmonary embolism HCO3 = 22 – 26 mmol/l Reduced respiratory drive
Pulmonary edema e.g. drugs, CNS tumors or
trauma
Pulmonary fibrosis
Neuromuscular disorders
e.g. myasthenia gravis or
GBS
Thoracic wall problems
e.g. kyphoscoliosis, flail
chest
Management
Aim at O2 saturation (94-96%) High flow O2 via non-

Any critical illness rebreather mask (15L/min)
ABG result
Critical illness with

If COPD or other
Hypoxemia conditions requiring low
dose O2 therapy
NB: If O2 requirement are increased Aim at O2 sat (94-98%)
and treatment is altered as a result, If COPD aim at (88-92%)
ensure ABG taken after 1 hour
Initially by nasal cannula at Initially Ventori mask
2-6L/min if not responding 28% mask at 4L/min
Indications for NIV: use Ventori
COPD with respiratory acidosis
despite maximum medical therapy 24% = 2L/min
If O2 saturation < 85% use
28% = 4L/min
on controlled O2 therapy non-rebreather mask (10 31% = 6L/min
Hypercapnic respiratory failure 15L/min) 35% = 8L/min
secondary to neuromuscular or 40% = 10L/min
chest wall disorders 60% = 15L/min
Cardiogenic pulmonary edema
unresponsive to CPAP
Weaning from tracheal intubation
References:
Oxygen Prescribing Guidelines – Medway NHS Foundation Trust 2015.
11 British Thoracic Society – Emergency Oxygen Guidelines 2008.
SPONTANEOUS PNEUMOTHORAX
If bilateral or unstable patient proceed to chest drain
Definition of Stability
RR < 24 per minute

HR < 120 an >60 per minute
Normal blood pressure
O2 sat >90% on room air
Ability to speak in whole sentences
Age > 50 and significant smoking

Primary history, evidence of underlying lung Secondary
pneumothorax disease on examination or CXR? pneumothorax
Aspirate 14-16G Size > 2 cm and/or

Size > 2 cm and/or
cannula and dyspnic
dyspnic
aspirate < 2.5L
Aspirate 14-16G
cannula and Size 1-2 cm
aspirate < 2.5L
Success (<2cm and

dyspnea improved)
Consider early Success (<1cm)

discharge and
review in 2 weeks
Admit
High flow oxygen
Admit + Observe for 24 hours
Chest drain
References:
MacDuff A. et al., Thorax 2010; 65(2):ii18eii31.
BTS guidelines, Management of spontaneous pneumothorax: British Thoracic Society plural disease guidelines 2010. 12
UPPER GI BLEED
Common causes: Major risk factors: Investigations:

Peptic ulcer Old age Initial bloods: CBC, Urea,
Esophagitis Comorbidities creatinine, serum
Gastritis/Erosion Liver disease electrolytes and LFTs.
Erosive duodenitis Inpatients Clotting screen (INR &
Varices Initial shock
APTT), blood grouping
Portal hypertension Continued bleeding
and
gastropathy Hematemesis
Hematochezia cross matching (4 to 6
Malignancy
High urea level units of PRBCs)
Mallory Weiss tear
Septic screen accordingly
Vascular malformation
(urine, ascites, sputum
and blood) cultures,
CXR
Management
ABCDE
IV access with 2 large bore cannulae (16 G or bigger) or CV line

NPO (nothing orally allowed), provide oxygen by nasal cannula
Fluids resuscitation (IV normal saline according to the volume
status)
Packed RBCs transfusion (variable Hb threshold 7-9 g/dl) sometimes
higher if severe bleeding or cardiovascular compromise
Consider platelets if active bleeding and PLT count < 50 x 109
Consider FFP if actively bleeding and PT or APTT time > x 1.5 normal
Consider prothrombin complex concentrate (if not available give
FFP)
if actively bleeding and taking Warfarin
Review medications chart and stop any relevant medications
Non-variceal bleeding (mostly PUD)

Time for endoscopy Variceal bleeding
Urgent endoscopy for upper GIT
High risk: bleeding should be performed Terlipressin 2mg IV bolus, then
Omeprazole 80mg IV bolus after fluid resuscitation and
within 12 hours of hospital Terlipressin 4-6 hourly IV
followed by 40 mg BD (twice daily)
If low risk: admission < 50 kg = 1 mg
Omeprazole 40 mg PO BD 50-70 kg = 1.5 mg
> 70 kg = 2mg
Treat electrolytes disturbance IV antibiotics prophylaxis ( e.g.

Ceftiaxone 1g daily)
References:
13 • Adrian J Stanley, Loren Laine. Management of acute upper gastrointestinal bleeding. BMJ 2019; 364:1536
DECOMPENSATED LIVER FAILURE
Common causes: Signs and symptoms: Investigations:

GI bleeds
Infections/sepsis Jaundice Bloods: CBC, ESR,
Constipation Worsening ascites glucose, urea, creatinine,
Electrolytes imbalance Confusion serum electrolytes and
Dehydration Sleep pattern disturbance LFTs.
Ischemic liver injury (sepsis Melena/hematemesis/ Clotting screen (INR &
or hypovolemia) hematochazia APTT), blood grouping
Drugs: alcohol, opioids and and cross matching (If
NSIADs bleeding)
Development of hepatoma Septic screen: urine
Acute portal vein dipstick/MSU, blood
thrombosis culture if needed
CXR
USS Abdomen
If Ascites: ascetic tap for
PMN/WCC, culture and
Management albumin
ABCDE
Treat the infections according to the source

If current excess alcohol consumption give IV thiamine
(100 mg TDS) first and then treat hypoglycemia if present
VTE prophylaxis if no contraindication
Hepatorenal Syndrome GI Bleed Encephalopathy
Manage the underlying cause Follow GI bleed algorithm Manage the underlying cause
HAS 25% (1g/kg 100g maximum) for Lactulose 10-30ml TDS
2 days then 25-50 g per day Consider CT brain to exclude
Stop nephrotoxic drugs Spontaneous bacterial peritonitis subdural hematoma or other
Terlipressin 1 to 2 mg IV QDS
intracranial bleeds
Cefotaxime 2 g every 8 hours

Acute kidney injury (alternatives Ceftriaxone 2 g Ascites
per day) if allergic to
cephalosporins give Spironolactone 100mg/day with
Stop diuretics and nephrotoxic Ciprofloxacin 400mg twice or without furosemide 40mg
medications daily Aim for 0.5 to 1 kg of weight
Fluid resuscitation with normal Human albumin solution loss per day
saline 0.9% and HAS 25% (HAS) 25% (1.5g/kg) Consider paracenthesis with
Fluids balance chart
HAS 25% (6 to 8 g/L of fluids
Daily body weight
removal)
Treat Electrolytes Disturbance Avoid angiotensin inhibitors and
NSIADs
Dietary sodium restriction
References:
• British Society of Gastroenterologist. British Association for the study of the liver. Decompensated Cirrhosis Care Bundle – First 24 hours.
• Dina Mansour. Management of decompensated cirrhosis. Clin Med (Lond). 2018 Apr 1; 18 (Suppl 2): s60-s65. 14
ACUTE BLOODY DIARRHOEA
Causes: Initial Assessment:

Infectious diarrhea
Ulcerative colitis including PR examination
Crohn's disease Bloods: CBC, ESR, CRP , serum
Pseudomembranous colitis electrolytes, LFTs, glucose, urea and
Colorectal cancer creatinine
Stool for routine examination and culture,
Diverticular disease including Clostridioides Difficile toxins
Erect abdominal X ray exclude toxic
megacolon or perforation
Management
Treat electrolytes disturbance
ABCDE
Manage the underlying cause if known before

Review medications and stop laxatives or antibiotics if
C. difficile infection is suspected
Isolate with barrier nursing if infectious diarrhea is suspected
IV fluids with potassium, sodium and chloride replacement
Stool chart if possible
Inflammatory bowel disease Infectious diarrhea Other causes
Hydrocortisone 100mg IV QDS Review antibiotics Consider gastroenterology

Low molecular weight heparin Avoid antidiarrheal drugs
prophylaxis or surgical consultations
Topical Mesalamine suppositories, Consider starting C. Difficile
foams or liquids enema 1 gram one infection protocol
to two times daily for proctitis or
left side colitis, also consider
topical steroids if mesalasine is not
tolerated
Non severe Severe

WBC > 15X109 /L or creatinine > 1.5mg/dl Fulminant colitis
3-5 stools per day, WBC <
or temp > 38.5oC, or evidence of severe Hypotension, ileus or megacolon
15X109/L, creatinine < 1.5mg/dl colitis
Metronidazole 400mg PO TDS for Vancomycin 125-500mg PO/NGT QDS Same as severe infection but with
10 to 14 days or Metronidazole 500mg IV TDS for earlier surgical consideration if no
If no improvement after 3-5 days; 10-14 days response within the first 24hrs
Fidaxomicin 200mg PO twice daily
start Vancomycin 125mg PO QDS "not available yet" Rectal Vancomycin may be
for 10-14 days Gastroenterology and surgery considered if ileus is present
Fidaxomicin 200mg PO twice daily consultations
References:
Robert Orenstein, Roberto L. Patron. Clostridioides difficile therapeutics: guidelines and beyond. Ther Adv Infect Dis. 2019.
15 British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults.
ACUTE ISCHEMIC STROKE

Sudden onset focal CNS signs and symptoms
Investigations
Complete history and physical examination

BP, PR, RR & O2 sat
Urgent blood glucose
Non-contrast brain CT or brain MRI (within 1 hour)
CBC, LFTs, RFTs, troponin & coagulation screen,
ECG (this should not delay the non-contrast brain
CT), and later 24hr ECG
Chest X-ray
Echocardiography, carotids, and vertebrobasilar
circulation ultrasound doppler
Consider vasculitis and/or thrombophilia screen
Management
ABCDE
Assess swallowing and keep NPO until swallowing is normal (use NGT if needed)
IV Fluids (Normal saline is of choice) volume depletion worsen cerebral blood flow
Treat hypo- and hyperglycemias (use insulin injections)
Head position: keep the head in neutral alignment with the body, or elevate it to
30 degrees in case of ICP, aspiration, cardiopulmonary decompensation or oxygen
desaturation
Treat infections and give acetaminophen for fever
Monitor BP, treat only if there is hypertension emergency (encephalopathy or
dissection)
Aspirin 300mg PO for 2 weeks, then aspirin 75mg OD or clopidogrel 75mg OD
Anticoagulation with warfarin (or direct oral anticoagulant if non-valvular AF) for
cardiac causes of stroke, can be started 2 weeks after the stroke
High intensity statins (eg, Atorvastatin 40mg BT)
Behavioral and lifestyle changes including smoking cessation
Physiotherapy (starts early)
Note:
IV thrombolytic therapy is first-line therapy if initiated within the time window
Mechanical thrombectomy in case of acute ischemia due to large artery occlusion in the anterior circulation
References:
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update
to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American
Heart Association/American Stroke Association. Stroke 2019; 50:e344. 16
RAISED INTRACRANIAL PRESSURE
Signs & symptoms: Causes:

Headache and vomiting Intracranial mass lesions (eg, tumor, hematoma)
Cerebral edema (such as in acute hypoxic-ischemic
Depressed consciousness encephalopathy, large cerebral infarction, severe
Sixth cranial nerve palsy & papilledema traumatic brain injury)
Bradycardia, respiratory depression, and Increased CSF production (eg, choroid plexus
papilloma)
hypertension Decreased CSF absorption (eg, arachnoid granulation
Focal symptoms related to the cause or due adhesions after bacterial meningitis)
to brain herniation Obstructive hydrocephalus
Obstruction of venous outflow (eg, venous sinus
thrombosis, jugular vein compression, neck surgery)
Idiopathic ICH (pseudotumor cerebri)
General management
ABCDE
Admit patient to the ICU
Support the oxygenation and intubation if needed
BP control (avoid hypotension)
Head elevation
Hyperventilation to a PCO2 of 26 to 30 mmHg
IV mannitol 20%/200ml (1 to 1.5 g/kg) over 20-30 minutes with IV furosemide 20mg twice
(In some centers hypertonic saline is used instead of the mannitol)
IV dexamethasone 4 mg/6hr in the setting of brain tumors
Keep the patient euvolemic (use IV normal saline)
Sedation — can decrease ICP, (propofol has a good effect in this setting, midazolam can be
used also)
Acetaminophen for fever and treat infections if any
Antiseizure therapy for seizures
Urgent neurosurgical consultation
Mannitol side effects:

AKI
Hypotension with rapid infusions
Rebound increase in ICP
Volume overload
Electrolyte imbalances (hypo/ hypernatremia)
Decrease of serum bicarbonate (early and transient)
Hyperkalemia (early and transient)
References:
Dennis LJ, Mayer SA. Diagnosis and management of increased intracranial pressure. Neurol India 2001; 49 Suppl 1:S37.
Swagata Tripathy, Suma Rabab Ahmad. Raised Intracranial Pressure Syndrome: A Stepwise Approach. Indian J Crit Care Med. 2019
17 Jun; 23(Suppl 2): S129–S135.
ACUTE SEVERE HEADACHE

High-risk features
Older than 30 years

Investigations
First or worst headache
Sudden onset or worsening pattern
Patient with a headache and high-risk features,
Triggered by cough or exertion
imaging is needed (CT or MRI with or without
Change in personality, mental status,
consciousness or seizure contrast – depending on the indication or the
Focal neurologic signs patients' contraindication).
Neck stiffness or meningismus CBC, ESR, CRP, RFTs, LFTs, electrolytes,
Papilledema or visual disturbance coagulation profile (if needed).
Systemic illness (eg, fever, rash) Ophthalmological and ENT checkup including
Tenderness over temporal artery fundal and IOP examination.
History of cancer or HIV Check BP
New onset in pregnancy or postpartum
History of trauma
Management
Relief of symptoms (regardless of the headache's underlying cause)

Start with Paracetamol IV 1gram, or NSAID injection if not contraindicated (e.g.
Ketorolac 15 to 30 mg IV or Diclofenac sodium 75 mg IM)
For nausea and vomiting use Metoclopramide or ondansetron
B-Blockers, sumatriptan and oxygen maybe used for both migraine and cluster headache
Anticonvulsants are used for trigeminal neuralgia
If SAH (early referral to neurosurgery)
Note:
Botox injections are used for refractory migraine
Avoid opiates and ergotamine
Steroid maybe used and caffeine instead of opiates
Do not use triptans if family history or patient has IHD
If headache is focal requires imaging
Refer to neurologist all the unusual cases or if new onset, change in character or
refractory to treatment
Newer drugs exist e.g diltans, calcitonin gene-related peptide and its receptor
antagonists and are used for migraine and cluster headache
References:
Torelli P, Campana V, Cervellin G, Manzoni GC. Management of primary headaches in adult Emergency Departments: a literature
review, the Parma ED experience and a therapy flow chart proposal. Neurol Sci 2010; 31:545.
Edlow JA. Managing Patients With Nontraumatic, Severe, Rapid-Onset Headache. Ann Emerg Med 2018; 71:400. 18
SUBARACHNOID HEMORRHAGE
Risk factors:
Symptoms:
Hypertension
Thunderclap headache: Smoking
acute sudden worst Alcohol intake
ever headache may
Female
vomit or lose
consciousness, Age > 50 years
constant pain and Non-white ethnicity
usually occipital Positive family history
Neck stiffness General approach AD polycystic kidney
Photophobia disease
Seizures Connective tissue
Focal signs
disease
ABCDE
Bloods (CBC, RFTs, LFTs, Clotting screen
and troponin)
ECG (50% will have ECG changes on
admission)
Regular observation and follow up
Give analgesia
Insert urine catheter
Monitor fluids with input/output chart
Non contrast - CT Head
SAH Confirmed SAH Not Confirmed
Admit to ICU MRI or LP after 3-10 days maybe

Cardiac monitoring and repeated CNS examination diagnostic
Monitor and control BP – start Nimodipine 60 mg PO LP (if no suspicion of ↑ICP),
every 4 hour for 21 days (Keep SBP < 180 but measure opening pressure and send
maintain MAP > 90) for xanthochromia
Analgesia - opiates (eg, morphine, codeine, CTA, DSA or MRA in specialized
tramadol) are used. Acetaminophen 500 mg every neurosurgical center
three to four hours can be used
Control blood glucose Complication of SAH
Correct electrolytes imbalance or coagulopathy
Consider laxatives, antiemetics and treat coughs to Re-bleeding
reduce risk of ↑ pressure and re-bleed
Ischemia
Urgent neurosurgical referral - it is a neurosurgical
Hydrocephalus
condition and should be taken over by
neurosurgeons Hyponatremia
References:
Lawton MT, Vates GE. Subarachnoid Hemorrhage. N Engl J Med 2017; 377:257.
19 Subarachnoid hemorrhage. BMJ Best Practice. 2019
SUSPECTED MENINGITIS/ENCEPHALITIS
Symptoms & Signs
Investigations
Fever
Nausea and vomiting Bloods: CBC, RFTs, LTFs, electrolytes, CRP, coagulation profile,
Headache glucose, HIV test
Photophobia/Phonophobia Blood culture, throat swap, urine routine culture and
Neck stiffness Chest X-ray
Arthralgia CT head with contrast (before LP if: focal neurological deficit,
Confusion/Drowsiness/Irritability seizures, papilledema, disturbed conscious level or immune
Rash (can be blanching or non- compromised), DW MRI
blanching in early stages) LP (if no contraindications) for CSF pressure, microbiological
examination, glucose, protein, PCR, cell count and differential
(with parallel blood sample)
General measures
ABCD
Fluids and electrolytes management (avoid under- or over hydration)
Immediately starts the antibiotics and steroid therapy
If the patient is in shock 'follow the septic shock algorithm'
Take detailed history including vaccination and travel history
Specific therapy
Ceftriaxone 2 gram IV every 12 hours

Vancomycin 1 gram IV (dilute in 200ml NS or D5W over 60 minutes) every 12 hours
Dexamethasone IV 10 mg every 6 hours (for 2-4 days) given 15 minutes before the first
dose of the antibiotics
Add Ampicillin 2 gram IV every 4 hours (if > 50 years, immunocompromised or brain
stem signs and symptoms to cover listeria)
Add Acyclovir 500 mg IV infusion (over 30 minutes) every 8 hours (if herpes encephalitis
is suspected)
Consider Doxycycline during tick season to treat tick-borne bacterial infections
References:
Nicholas Young, Mark Thomas. Meningitis in adults: diagnosis and management. InternalMedicine Journal 48 (2018) 1294–1307
Van de Beek D, Brouwer M, Hasbun R, et al. Community-acquired bacterial meningitis. Nat Rev Dis Primers 2016; 2:16074.
Noska A, Kyrillos R, Hansen G, et al. The role of antiviral therapy in immunocompromised patients with herpes simplex virus
meningitis. Clin Infect Dis 2015; 60:237.
20
CONVULSIVE STATUS EPILEPTICUS

Defined as ≥5 minutes of continuous seizure activity, or more than one seizure without
recovery in between
General measures
ABCDE
Position the patient in left lateral ''coma'' position to remove any secretions,
dentures or obstruction, and secure the airway
Oxygen 100% and suction as needed
Rapid neurological evaluation
Urgent bedside blood glucose
IV access and draw bloods for (CBC, glucose, calcium, magnesium, sodium,
phosphorus, LFTs, RFTs, toxicology, and anti-seizure drug levels as appropriate)
Cardiac monitoring, BP and pulse oximetry
Correct any metabolic derangement if present
Correct hypotension with fluids
Specific therapy
Diazepam 0.15 mg/kg IV, up to 10 mg per dose (alternative midazolam IV 0.2 mg/kg,
maximum 10 mg can be given by IM route). If available lorazepam is preferred (better body
distribution)
If continued add loading dose phenytoin IV infusion (20 mg/kg, roughly 1g if 60kg, and 1.5g
if 80kg; max 2g – diluted in normal saline over 30 minutes), beware of ↓BP and do not use
if bradycardia or heart block, phosphenytoin is preferred if available
Continue phenytoin 100mg/6–8h as a maintenance dose (check levels)
If phenytoin is contraindicated use midazolam infusion
General anesthesia with intubation: if seizures continue after 60 minutes of above
therapies get expert help with paralysis (eg add propofol infusion 1-2 mg/kg loading dose
over 5 minutes) then maintain on continuous infusion not more than 48 hours
Once the seizures controlled restart the or al antiepileptic medications
Give IV dexamethasone if the cause was vasculitis or cerebral edema (eg, tumour)
Immune epilepsy requires IV methylprednisolone, IV human immunoglobulin (check IgA
first) or plasmapharesis
Get neurologist consultation
References:
Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3.
Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status
Epilepticus. Epilepsia 2015; 56:1515.
Villamar MF, Cook AM, Ke C, et al. Status epilepticus alert reduces time to administration of second-line antiseizure medications. Neurol Clin Pract
2018; 8:486.
21 Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the
Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016; 16:48.
DELIRIUM
Defined as clinical syndrome characterized by disturbed consciousness, cognition or perception, has an
acute onset with fluctuating course. Patients may be hyperactive, hypoactive or have mixed symptoms.
Clinical factors: Assessment Risk factors:
Collateral history Old age ≥ 60 years

Cognitive impairment
Address the clinical History of dementia
or disorientation
and risk factors or cognitive problems
Dehydration
Bloods: CBC, glucose, Severe illness
Constipation
RFTs, LFTs, serum Surgery
Urinary retention
electrolytes including Visual impairment
Hypoxia
calcium level, ESR & Polypharmacy
Infection
CRP Alcohol excess
Limited mobility
Urine routine and
Pain
Multiple medications culture
Poor nutrition ECG and Chest X-ray
Poor sleep pattern Consider: ABG,
Troponin, TFT, B12
and folate levels,
blood culture and
brain imaging
Management
Environment Avoid
Verbal and non-verbal de-
escalation techniques •
Adequate lighting, use of Restrains
Modify the environment •
sensory aids (glasses or Confrontation
where possible •
hearing aids) Ward moves
Treat the clinical factors if any • Catheters, unnecessary
Staff continuity
Orientation aids (clocks and interventions or investigations
calendars) If the above measures failed or risk to
themselves or others
If haloperidol is
• Haloperidol 0.5-1mg PO/IM as
contraindicated give
needed (can be given every 2
Lorazepam 0.5 to 1 mg
hours for the first 24 hour and
PO/IM/IV as needed
BD thereafter- maximum
(Diazepam 5mg PO/IV/IM/PR
5mg/24hr)
can be used as needed)
Haloperidol is contraindicated in
Parkinson's disease, Lewy body
dementia or prolonged QT interval
References:
Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA
Intern Med 2015; 175:512.
Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet 2014; 383:911. 22
ACUTE KIDNEY INJURY
KDIGO guidelines definition: Risk factors:

• Assessment: Older age
Increase in serum creatinine by Chronic comorbidities including CKD,
•≥0.3 mg/dL within 48 hours, or
• History and examination DM, Heart/Liver failure
Increase in serum creatinine to • Assess the volume status Urological obstruction
≥1.5 times baseline, which is • Review drug history Sepsis
known or presumed to have Hypovolemia
• Consider causes; pre-
occurred within the prior seven Nephrotoxic drug use – NSIADs,
• renal,renal or post-renal
days, or Urine volume <0.5 ACEIs, ARBs, Diuretics, Metformin
mL/kg/hour for six hours and others
Investigations
Monitoring
Urine dipstick – if proteinuria then for
protein:creatinine ratio Fluid balance
Bloods: CBC, urea, creatinine, electrolytes, Frequent observations (minimum
LFTs, creatinine kinase, bone profile, CRP
4hrly) Twice daily bloods (RFTs and
Arterial blood gases and lactate if needed
Consider further tests later e.g. electrolytes) Daily body weight
autoimmune, myloma or microangiopathy
screens
USS (exclude obstruction or pyonephrosis)
Consider further images e.g. KUB, or CT Bicarbonate Serious side effects
KUB
Volume overload
Hypokalemia
Indications of RRT Hypocalcemia
Hypernatremia
Uncontrollable volume overload Increase ICP
Uncontrolled hyperkalemia or Management
acidosis Uremic encephalopathy
Uremic pericarditis
Bleeding diathesis ABCDE
Certain alcohol or drug intoxications
Treat the underlying cause including sepsis if present (sepsis algorithm)

Adjust the drugs doses according to the current renal function
Stop the nephrotoxic medications
The treat according to the volume status and BP
Hypovolemic Overloaded Volume status not clear
IV crystalloid fluids 1 to 3 liters with Sit the patient up and give oxygen (60 – Administer smaller fluids volume (up
frequent monitoring and follow up 100% unless contraindicated) to 1 liter) with frequent monitoring
If severe metabolic acidosis (PH <7.1) and IV Furosemide 80-200mg and monitor for for signs and symptoms of fluids
no volume overload and no other indications
increase in the urine output overload
for RRT, sodium bicarbonate can be used; 3
If not responding to diuretics prepare for
ampules (150 mEq) in 1 L dextrose 5% at a
RRT
rate determined by the patients situation
If the patient is euvolaemic give
Treat hyperkalemia with IV regular insulin,
maintenance fluids (estimated output plus IV dextrose, IV calcium and GI potassium
500 mL) and follow up frequently binder (follow the hyperkalemia algorithm)
References:
Alistair Connell, Chris Laing. Acute kidney injury. Clinical Medicine 2015 Vol 15, No 6: 581–4. Sean M. Bagshaw.
23 Acute Kidney Injury Care Bundles. Nephron 2015;131:247–251
ACUTE OLIGURIA
Urine output < 0.5 ml/kg/hr
Causes:
Pre-renal: hypotension, hypovolemia/dehydration, renal artery stenosis
Renal: acute tubular necrosis, pyelonephritis, glomerulonephritis,
vasculitis
Post-renal: obstruction (mechanical or functional)
Initial assessment and investigations
Brief history and examination including prostate

examination if male Assess the volume status
Observation –BP, PR, RR
Urine dipstick – if proteinuria then for Protein:Creatinine
ratio
Bloods: CBC, urea, creatinine, electrolytes (± LFTs,
creatinine kinase, bone profile, CRP)
Arterial blood gases if breathless or acutely ill
Bladder scan and catheter if urinary retention
Imaging if renal or post-renal causes are suspected
Management
Pre-renal Renal Post- renal
IV fluids Stop nephrotoxic drugs Urological consultation for:

Inotropic agents if shocked and not Urethral catheterization
Specific treatment (e.g.
responding to fluids resuscitation Suprapubic catheter if
immunosuppression in GN) If
urethral failed or not possible
there is AKI (follow AKI algorithm)
Laparotomy and
decompression if caused by
↑ intra-abdominal pressure
References:
Adults Medical Emergencies Handbook. NHS Lothian – University Hospital Division. Dr Graham R. Nimmo. 2009/2011 24
HYPERKALEMIA
K > 6.5 mEq/L or if less with ECG changes
First attend the patient – do they look unwell? If not, could it be an artifact results?
Concerning signs and symptoms Some important causes
Renal failure Administration of calcium

Fast irregular pulse, Drugs: K-sparing diuretics, can be repeated every 30 to
chest pain, dyspnea, ACEIs, Heparin and 60 minutes if the
weakness, paralysis and suxamethonium .. etc. hyperkalemic emergency
light-headedness Rhabdomyolysis, TLS persists and the serum
Metabolic acidosis calcium does not become
Excess K therapy elevated
Addison's disease The effect of insulin begins
Massive blood transfusion
in 10 to 20 minutes, peaks at
Malignant hypothermia
30 to 60 minutes, and lasts
Hyperkalemic periodic paralysis
for four to six hours
Initial assessment
Bloods; RFTs, glucose, consider; ABG, CPK, UA, phosphorus, cortisol
Continuous cardiac monitoring and serial ECGs
Monitoring K every 1-2 hours after the initiation of treatment
Measuring glucose every 1 hour for patients receiving insulin therapy
Stop any offending drug
Management
IV calcium gluconate 10 mL of 10% solution over 2-3 minutes or IV calcium chloride

5mL of 10% solution over 2-3 minutes. Doses of Calcium can be repeated after 5
minutes if ECG changes persist or recur
10 units of IV regular insulin in 50 mL of 50% dextrose over 30 minutes (unless
hyperglycemic), or use 10- 20 units of IV regular insulin in 500 mL of 10 % dextrose
over 60 minutes
If hypervolemic and normal RFT, give IV furosemide 40 mg q12 hrs, If eu- or
hypovolemic with normal RFT, give isotonic saline to replete hypovolemia and
maintain euvolemia, then give IV furosemide q 12 hrs.
Salbutamol 2.5mg nebulizer also make K enter into the cells
If acidotic consider IV sodium bicarbonate 150 mEq in 1 L of 5% dextrose over 2-4
hours
Hemodialysis in patients with severe renal dysfunction or persistent hyperkalemia
References:
25 François Dépret, W. Frank Peacock, Kathleen D. Liu. Et al. Management of hyperkalemia in the acutely ill patient. Annals of Intensive
Care volume 9, Article number: 32 (2019).
HYPOKALEMIA
In most cases, the cause of hypokalemia is apparent from the history and physical
examination K less than 3.5 mmol/l (considered severe if less than 2.5)
Important causes
Gastrointestinal Drugs
o Vomiting, nasogastric aspiration e.g. Diuretics, Corticosteroids, Gentamicin,
o Diarrhea, fistula loss amphotericin B, Cisplatin
o Villous adenoma of the colon
o Laxative abuse
Compartmental shift
Renal o Alkalosis, insulin
✓
o Mineralocorticoid excess o Sympathomimetic agents with β2 effect
✓
Conn’s syndrome o Methylxanthines
✓
Bartter syndrome
o Barium poisoning
Ectopic ACTH syndrome e.g. Small cell carcinoma
of the lung o Hypothermia
o Renal tubular acidosis o Toluene intoxication
o Magnesium deficiency o Hypokalaemic periodic paralysis
Initial assessment
Complete history and physical examination

Bloods: CBC, serum K, Na, Mg, Calcium levels , urea, creatinine and ABG
Consider: serum renin, aldosterone, cortisol, thyroid function and
evaluation for renal artery stenosis
Urine for urinary K (to determine if there is a renal or extra-renal loss)
ECG
Abdominal X ray if there is suspension of ileus
Management
Stop any offending drug (use K sparing diuretics if the patient needs diuresis)
Treat the hyperglycemia, vomiting and diarrhea if present
If severe give IV potassium chloride 10 mEq/h in large peripheral line
In emergency as much as 40 mEq/h can be given in a central line (with cardiac supervision)
In severe hypomagnesemia, give 1 to 4 g of magnesium sulfate IV over 30 to 60 minutes
If mild hypokalemia use the oral potassium 10-20 mEq PO BID/QID (20-80 mEq/day)
NB:
• For every 1 mEq/L decrease in K, the
deficit is around 200-400 mEq
• Slow K tab 600 mg 'equivalent to 8 mEq'
References:
Mount DB. Disorders of Potassium Balance. In: Brenner and Rector's The Kidney, 10, Elsevier, 2016.
Castro D, Sharma S. Hypokalemia. StatPearls. 2018 Jan. 26
HYPOCALCEMIA
Are any of the following acute
signs or symptoms present?
Carpopedal spasm
Tetany
Seizures
Yes Prolonged QT intervals No
Asymptomatic or mild symptoms (eg.

paresthesias) acute hypocalcemia?
Asymptomatic or mild symptoms (eg.

What is the corrected serum calcium?
paresthesias) chronic hypocalcemia?
≤ 7.5 mg/dl > 7.5 mg/dl
Able to take and absorb oral calcium?
No Yes
Oral calcium ± vitamin D

Add 11 ampules of 10 % calcium gluconate IV (1000 mg
elemental calcium) to normal saline or 5% dextrose to
volume of 1000 mL and infused over 20 hours
Oral calcium (1 to 4 g of elemental calcium carbonate daily
in divided doses) should be initiated ASAP
If the serum Mg is low, 2 g (16 mEq) IV magnesium sulfate Note:
infused over 10 to 20 minutes, followed by 1 gram (8 mEq) Measure serum magnesium and
in 100 mL of fluid per hour potassium and replace any depletion
For patients with hypoparathyroidism give calcitriol (0.25 to Initially measure calcium every 4 to 6
0.5 mcg twice daily) hours if IV calcium was given
Calcium gluconate 10% = (90 mg of
elemental calcium per 10 mL)
References:
Tohme JF, Bilezikian JP. Diagnosis and treatment of hypocalcemic emergencies. The Endocrinologist 1996; 6:10.
27 Cooper MS, Gittoes NJ. Diagnosis and management of hypocalcaemia. BMJ 2008; 336:1298.
HYPERCALCEMIA
Clinical manifestations are ranging from few or no symptoms to severe obtundation
and coma Normal range (8.5 to 10.3 mg/dL)
Signs & Symptoms Workup
Lethargy, weakness
Confusion, coma Bloods: CBC, ESR, PBF
Polyuria, noctouria, renal stones and Others: serum albumin, RFTs, PTH, Vit D,
renal failure TFT, Phosphate
Nausea, constipation, pancreatitis and ECG
gastric ulcer Serum and urine electrophoresis
Syncope from arrhythmias Urinary calcium excretion
Look for malignancy (eg, breast, lung,
Hypotonia, hyporeflexia
kidney, MM, lymphoma or leukemia) if
Signs of renal failure, malignancy or
know to have malignancy before
pancreatitis
Management
MILD (corrected Ca <12 mg/dL) MODERATE (calcium 12 and 14 mg/dl) SEVERE (Ca > 14 mg/dl)
Asymptomatic or mild symptoms Asymptomatic or mild Isotonic saline initial rate of 200
do not require immediate symptoms with chronic to 300 mL/hour then adjusted to
treatment
moderate hypercalcemia may
maintain the urine output at 100
not require immediate therapy
Avoid factors that aggravate to 150 mL/hour
and they should follow the
hypercalcemia i.e. thiazide and same precautions for mild If no renal failure or heart failure,
lithium therapy, volume hypercalcemia loop diuretics are not
depletion, prolonged bed rest or Acute rise to these recommended
inactivity, and high calcium diet concentrations can cause Zoledronic acid 4 mg IV over 15
Adequate hydration (at least 6-8 changes in sensorium, which minutes
glasses of water per day) to requires more aggressive
Consider hemodialysis if Ca > 18
therapy with IV saline hydration
minimize the risk of and severe symptoms or with
and bisphosphonates, as for
nephrolithiasis severe hypercalcemia renal failure
Note: other drugs can be used in severe hypercalcemia

• Salmon calcitonin (4 international units/kg) IM or SC
• For patients whom bisphosphonates are contraindicated (eg, due to severe
renal impairment), IV denosumab can be used with calcitonin
• Glucocorticoids (eg, prednisone 20 to 40 mg/day) used if the cause is
sarcoidosis, lymphoma, multiple myeloma or PTHrp producing tumors
References:
Stewart AF. Clinical practice. Hypercalcemia associated with cancer. N Engl J Med 2005; 352:373.
Bilezikian JP. Clinical review 51: Management of hypercalcemia. J Clin Endocrinol Metab 1993; 77:1445. 28
ACUTE DVT (Page 1)
Risk Factors: Signs and symptoms:

Previous DVT Limb swelling
Family history of DVT Tenderness
Major medical illness Erythema
Recent immobility Pitting edema
Recent surgery or trauma Collateral superficial vein
Long distance travel > 4 hours
Pregnancy and hormonal Assessment and investigation
therapy including OCP or HRT History and examination
Malignancy Observation –BP, PR, RR
Bloods: CBC, urea, creatinine,
electrolytes, LFTs, coagulation screen,
CRP, D-dimer
Apply Wells Criteria for DVT
Venous duplex ultrasound
Provoked DVT Management Unprovoked DVT
Consider investigations
No need for further for cancer and
investigations thrombophilia screen
Anticoagulation with ONE of the following agents
LMWH Warfarin Rivaroxaban
Therapeutic LMWH as
Warfarin PO with LMWH SC Rivaroxaban 15mg PO with
monotherapy (recommended
(therapeutic dose) bridging; food BD for 21 days, then
therapy for patients with active
requires initial and periodic INR 20mg OD thereafter
cancer and for use in pregnant It is a direct Factor Xa
patients) monitoring to maintain
inhibitors: does not
therapeutic range of 2.0-3.0
require LMWH bridging or
NB Do Warfarin/INR chart and
lab test
Duration of therapy is 3 months adjust the dose accordingly
Have no reversal agent so
for acute uncomplicated DVT with use with caution and
a clear precipitating cause patient education
Recurrent or other types of DVT Do not use if GFR < 30
may require long-term
ml/min, or
anticoagulation
concomitant use of
Refer to coagulation clinic on
discharge enzymes inhibitors
References:
Jason Wilbur, Brian Shian. Deep Venous Thrombosis and Pulmonary Embolism: Current Therapy. Am Fam Physician. 2017 Mar 1;95(5):295-302.
Michigan Quality Improvement Consortium Guideline. Outpatient Management of Acute Uncomplicated Deep Venous Thrombosis
29 Shrey Modi et al. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World J Emerg
Surg. 2016; 11: 24.
ACUTE DVT (Page 2)
Suggested protocol for starting warfarin therapy

Days of warfarin treatment INR<1.5 INR 1.5 to 1.9 INR 2.0 to 3.0 INR>3.0
Initial dose for days 1 and 2
Normal adult 5 mg - - -
Frail adult, malnourished, elderly,
2.5 mg - - -
liver disease
Dosing for day 3 and thereafter

Day 3 5 to 10 mg 2.5 to 5mg 0 to 2.5 no dose
Day 4 10 mg 5 to 7.5 mg 0 to 5 mg no dose
Day 5 10 mg 7.5 to 10 mg 0 to 5 mg no dose
Day 6 7.5 to 1.2 mg 5 to 10 mg 0 to 7.5 mg no dose
The clinician must judge the rapidity and magnitude of INR changes for the individual patient
and make dosage adjustments accordingly. Start LMWH on (day 1) and discontinue when the
INR is within the therapeutic range (2 to 3; target 2.5) for two consecutive days
* This table assumes that the patient has started with an INR in the normal range
Wells' Criteria for DVT:

Active cancer +1
Paralysis, paresis, or recent cast immobilization of the lower limbs +1
Recently bedridden for ≥ 3 days, or major surgery within the last 12 weeks +1
Localized tenderness +1
Entire leg swelling +1
Calf swelling at least 3 cm larger than that on the asymptomatic side
(measured 10 cm below tibial tuberosity) +1
Pitting edema +1
Collateral superficial veins (non-varicose) +1
Previously documented deep vein thrombosis +1
Alternative diagnosis at least as likely as deep vein thrombosis -2
Wells scoring system for DVT: -2 to 0: low probability, 1 to 2 points: Moderate probability, 3
to 8 points: high probability
References:
Jason Wilbur, Brian Shian. Deep Venous Thrombosis and Pulmonary Embolism: Current Therapy. Am Fam Physician. 2017 Mar
1;95(5):295-302.
Michigan Quality Improvement Consortium Guideline. Outpatient Management of Acute Uncomplicated Deep Venous Thrombosis
Shrey Modi et al. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients.
World J Emerg Surg. 2016; 11: 24. 30
RAISED INR ON WARFARIN

Management
YES Major bleeding?
NO High risk patients:

Age > 65 years
Hold the Warfarin Uncontrolled hypertension
Vitamin K 5-10mg IV infusion over Diabetes mellitus
20-30 min (may be repeated at 12- Kidney or liver failure
hour intervals if INR still elevated) Previous GI or cerebral bleeds
Give 4- factor prothrombin Use of antiplatelet drugs
complex concentrate (50 units/kg)
or fresh frozen plasma (15 to 30
mL/kg)
INR < 4.5 INR 4.5 - 10 Any INR with minor bleeding INR > 10
Hold the next Warfarin dose Hold Warfarin (one or two doses) Stop Warfarin (restart when
Repeat INR within 24 hours Repeat INR within 24 hours the INR falls into the
Resume warfarin at reduced dose Resume warfarin at reduced dose therapeutic rang)
(eg, 2/3 the initial one) when INR when INR reaches therapeutic Repeat INR within 12 hours
reaches therapeutic range range Vitamin K (3 to 5 mg) PO/IV
Oral vitamin K (1 to 2.5 mg) if
high risk of bleeding
Notes:
Nonbleeding patients should not be
Major bleedings:
given PCC or FFP as these products
Bleeding in a critical area or organ
have associated risks (eg,
such as intracranial, intraspinal,
thrombosis, transfusion reactions)
intra- ocular, bleeding due to major
Higher doses of vitamin K will
trauma, bleeding leading to
prolong the period in which the INR
haemodynamic instability, or
cannot be raised, and intravenous
bleeding that is life or limb
administration is associated with a
threatening
small risk of anaphylaxis, especially
when given rapidly
References:
Witt DM, Nieuwlaat R, Clark NP, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Optimal
management of anticoagulation therapy. Blood Adv 2018; 2:3257.
31 Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e152S.
NEUTROPENIC SEPSIS
Identification Causes:
Suspect in patients receiving Bone marrow failure due to
anticancer therapy with infiltration by hematological or
Neutrophil counts ≤ 0.5X109/L other malignancies
and either: Bone marrow failure post
Temperature > 38.5 ºC single cytotoxic chemotherapy
reading or 38.0 ºC sustained Immune neutropenia,
over 1 hour hypersplenia, myelodysplasia
Or
Other signs and symptoms
consistent with significant sepsis
Investigations
History, examination and frequent observation

Bloods: CBC, LFTs, RFTs, CRP, lactate, albumin
Blood cultures (peripheral and from existing line)
before commencing antibiotics
Urine, throat, stool, sputum routine and culture
Chest Xray
Management
IV piperacillin-tazobactam (Tazocin 4.5g) every 6 hours

or IV ceftazidime (Fortum 2 g) every eight hours add
Gentamycin 3-5mg/kg OD if patient in septic shock
OR
IV meropenem 1g every eight hours (if penicillin allergy)
If central line site infection or MRSA suspected

Add IV vancomycin 1g BD
Prophylaxis algorithm
Neutropenia (counts ≤
0.5X109/L), clinically well and
neutropenia expected to If patient is in shock follow the sepsis algorithm
continue for > 5 days AND For further management get hematology/oncology consultation
Previous history of gram negative
bacteremia
Ciprofloxacin 500mg BD orally

until neutropenia resolves
References:
Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology and Infectious Diseases
Society of America Clinical Practice Guideline Update.
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Prevention and treatment of cancer-related infections.
Version 1.2018.
Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical
Practice Guideline Update. J Clin Oncol 2018; 36:3043. 32
ACUTE DIC
Main clinical manifestations Common causes
Bleeding Sepsis
Renal dysfunction Hematological and solid
Hepatic dysfunction malignancies
Respiratory dysfunction Trauma
Adrenal dysfunction Obstetric complication
Shock Intravascular hemolysis
Thromboembolism
Central nervous system involvement
Investigations
History, examination and frequent observation

Bloods: CBC, APTT & INR, fibrinogen, FDPs, D-dimer, PBF
LFTs, RFTs, CRP, lactate, albumin and septic screen if needed
Asses and document the extent of hemorrhage and thrombosis
Notes:
Consider the diagnosis of acute DIC if
thrombocytopenia, prolonged PT,
aPTT; low fibrinogen, and fibrinolysis
(eg, increased D-dimer)
Bleeding or thrombosis are
supportive of the diagnosis if present
but are not required for the diagnosis
Management
Check patient's stability and insert large bore cannulae

Treat the underlying cause
Hemodynamic and/or ventilatory support
Supportive measures and correct hypovolemia
Red blood cell transfusion for severe bleeds
Platelet transfusion if bleeding and PLT count <50,000/microL
(Also give platelets if no bleeding and PLT < 20 × 109/l)
If bleeding and prolonged PT or aPTT, or fibrinogen level <100
mg/dL, give either FFP (starting dose 15 mg/kg - be aware of
volume overload) or cryoprecipitate (1 to 2 bags equivalent to
5 to 10 units)repeat if needed, monitor with fibrinogen level
Start ATRA (all-trans retinoic acid) PO in case of APL (M3)
Tranexamic acid and PCC are contraindicated in DIC
References:
Squizzato A, Hunt BJ, Kinasewitz GT, et al. Supportive management strategies for disseminated intravascular coagulation. An
international consensus. Thromb Haemost 2016; 115:896
Wada H, Thachil J, Di Nisio M, et al. Guidance for diagnosis and treatment of DIC from harmonization of the recommendations from
three guidelines. J Thromb Haemost 2013
33 Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British
Committee for Standards in Haematology. Br J Haematol 2009; 145:24
MASSIVE BLOOD TRANSFUSION
Definitions
Monitor (every 30-60 mins)
(i) Transfusion of ≥10 RBC units within 24 h
Full blood count
(ii) Transfusion of 4 RBC units in 1 h with
Coagulation screen
anticipation of continued need for blood
Ionized calcium
product support
Arterial blood gases
(iii) Replacement of 50% of the TBV by blood
products within 3 h
PROBLEMS WITH MASSIVE TRANSFUSION
Risks and complications of large volume resuscitation

with blood products
Volume overload (careful monitoring for volume
status, treat with IV diuretics)
Over-transfusion (monitor Hb regularly, titrate
Aim for: according to needs)
Hypothermia (monitor temp, use fluid warmers to
Temp > 35 C reduce heat loss).
PH > 7.2 Dilutional coagulopathy of clotting factors and
Base excess < -6 platelets (regular and early monitoring of
Lactate < 4 mmol/L coagulation, involvement of hematology if needed).
Ca > 1.1 mmol/L Transfusion related acute lung injury (consider use
PLT > 50 x 109/L of filters, leukodepletion).
PT/APTT < 1.5 Excessive citrate causing metabolic alkalosis and
normal hypocalcaemia (monitor pH and ionized calcium,
INR ≤ 1.5 replace calcium as necessary).
Fibrinogen > 1.0 g/L Hyperkalemia (use of younger blood, monitor
regularly, may require specific therapy).
Disease transmission (use of products only on a
needed basis only)
If uncross-matched / O neg blood
Hemolytic disease of newborn if RhD mismatch.
Difficulty with cross-matching future blood product.
Difficulty with matching solid organs.
Usual transfusion reactions and problems
TRALI / TACO.
Acute / delayed hemolytic transfusion reaction.
Non-febrile hemolytic transfusion reaction.
Bacterial / viral infection.
Anaphylaxis if IgA deficient.
GVHD.
Storage lesion effects.
References:
Raymer JM, Flynn LM, Martin RF. Massive transfusion of blood in the surgical patient. Surg Clin North Am 2012; 92: 221 –34, vii.
H. P. Pham and B. H. Shaz. Update on massive transfusion. British Journal of Anaesthesia 111 (S1): i71–i82 (2013). 34
NEOPLASTIC SPINAL CORD COMPRESSION

Early recognition, diagnosis, and treatment are critically important in the
preservation of neurologic function in patients with spinal cord compression
Signs & symptoms

Causes:
Back pain
Weakness The most common
Sensory loss (with sensory level) malignancies are prostate
Bladder and bowel dysfunction (late) cancer, breast cancer, lung
Ataxia cancer, and multiple myeloma
Cauda equina syndrome
Investigations
Complete history and clinical examination (don’t forget sensory

level & anal tone)
Urgent MRI spine (spinal X rays are useful)
Screening blood tests: CBC, ESR, RFTs, LFTs, malignancy screen
(if not known before)
Management
Dexamethasone 10 mg IV stat, then 4mg/6hr PO (the dose

can be tapered once the definitive treatment is underway)
Pain management (eg, opioid analgesics)
Venous thromboembolism prophylaxis
Bowel and bladder care (i.e. foley catheterization is indicated
in patients with urinary retention)
Urgent neurosurgical (for possible decompression) and
oncology consultations (for possible radiotherapy if
radiosensitive tumors)
References:
·National Institute for Health and Care Excellence (NICE): Quality standard on metastatic spinal cord compression in adults (2014)
35 ·NICE: Clinical guideline on metastatic spinal cord compression in adults – Risk assessment, diagnosis and management (2008)
SUPERIOR VENA CAVA SYNDROME
Signs & symptoms

Causes:
Facial swelling or head fullness
Dyspnea, stridor, cough, hoarseness, and Non-small cell lung cancer (50%)
dysphagia Small cell lung cancer (25-35%)
Respiratory distress Non-Hodgkin lymphoma (10 to 15%)
Headaches, confusion, or visual/auditory Others — include thymic tumors,
disturbances primary mediastinal germ cell
Cerebral edema can lead to brainstem tumors, mesothelioma, and
herniation, and death mediastinal lymph node metastases
(eg, from breast cancer)
Investigations
Complete history and clinical examination

CBC, Coagulation profile, serum calcium, uric acid, LDH
Chest X ray (most common findings were mediastinal widening and pleural effusion)
Other images (eg, Duplex ultrasound, CT venography , MR venography, Superior vena
cavogram)
Management
Urgency of diagnosis and treatment

Elevation of the head, and oxy gen (may help to provide
symptomatic relief)
Corticosteroids and diuretics (although evidence for their
efficacy is lacking), overhydration should be avoided
Radiotherapy
Chemotherapy may be indicat ed in chemo-sensitive tumors
(eg, small-cell lung cancer)
Anticoagulation may be required in cases where
venography has demonstrated central vein thrombosis, to
prevent pulmonary embolism, also in central venous
stenosis to prevent thrombosis
Endovascular interventions eg, stenting and/or angioplasty
References:
·Friedman T, Quencer KB, Kishore SA, et al. Malignant Venous Obstruction: Superior Vena Cava Syndrome and Beyond. Semin Intervent
Radiol 2017; 34:398
·Kalra M, Sen I, Gloviczki P. Endovenous and Operative Treatment of Superior Vena Cava Syndrome. Surg Clin North Am 2018; 98:321 36
TUMOR LYSIS SYNDROME

Oncologic emergency that is caused by massive tumor cell lysis with the release of large
amounts of potassium, phosphate, and nucleic acids into the systemic circulation
Causes:
Clinical manifestations
Hematologic malignancies (mostly)
Hyperkalemia
Other solid malignancies (rarer)
Hyperphosphatemia
Hypocalcemia
Hyperuricemia NB: Tumor lysis syndrome can occur spontaneously, but it is
Acute kidney injury most often seen 48-72 hours after initiation of cancer treatment
Investigations
Identify high-risk patients (and start preventive measures before starting cancer therapy)
Bloods e.g. CBC, Urea, Creatinine, Uric acid, Potassium, Calcium, Phosphate, LDH at least
three times daily
Urine PH and output
USS abdomen, pelvis to exclude post-renal obstructions
Chest X ray
Management
Prevention (with hydration and allopurinol) is the role
Hyperurecemia Hyperkalemia Hypocalcemia and Hyperphosphatemia
• Allopurinol PO 600 mg daily for Serum K every 4- 6 hr Hyperphosphatemia

prophylaxis, 600-900 mg daily (up to a Cardiac monitoring Aggressive hydration
maximum of 500 mg/m2 daily) for Oral phosphate binders
IV regular insulin (10-20 units) in Hyperphosphatemia may lead to
treatment 500 mL of 10% dextrose hypocalcemia, which usually resolves
• Rasburicase IV/IM (not available yet) as phosphate levels are corrected
IV calcium gluconate10% (10ml)
• IV hydration high infusion rate 4-5 L Hypocalcemia
over 2-3 minutes, repeat every IV calcium gluconate (1-2 g
daily (or 3 L/m2 daily), yielding urine
30 to 60 min if ↑K persist equivalent to 90-180 mg elemental
volumes of at least 3 L daily (beaware calcium, in 50 mL of 5% dextrose or
Oral potassium-exchange resins
of volume overload) normal saline) infused over 10-20
• Furosemide or mannitol for diuresis For more details see minutes
(not proven to be beneficial as front- hyperkalemia or hypocalcemia It should not be treated with calcium
algorithms until hyperphosphatemia is
line therapy) corrected
• IV sodium bicarbonate may promote
alkaline diuresis
If the previous measures failed patients should receive dialysis, hemodialysis is preferred
over other modalities because of better phosphate and uric acid clearance rates
References:
The National Comprehensive Cancer Network
37 Howard SC, Trifilio S, Gregory TK, et al. Tumor lysis syndrome in the era of novel and targeted agents in patients with hematologic
malignancies: a systematic review. Ann Hematol 2016; 95:563
DIABETIC KETOACIDOSIS (Page 1)

Definition:
Acidemia venous pH less than 7.3 or HCO3 less than 15.0mmol/L
Hyperglycemia (blood glucose >250mg/dl) or known DM
Ketonemia or significant ketonuria (more that 2+ on dipstick)
Consider euglycemic DKA among patient on flexible regimen and correction dose
Symptoms & signs:
Abdominal pain
Initial investigations:
Nausea, vomiting
Confusion
Venous blood gases Coma
Capillary & venous glucose
Dehydration
Blood ketones
Hyperventilation
Urea and electrolytes (including
phosphate if necessary)
Complete blood count, CRP Precipitating factors:
Blood cultures
Non compliance
ECG + cardiac enzymes (f indicated)
Ineffective insulin
Chest radiograph if clinically indicated
Infections
Urine dipstick, urinalysis and culture
Cardiovascular disease, MI or
stroke
Pregnancy
Trauma and surgery
Management
• Insert two large bore cannula

• Continuous cardiac monitoring and pulse oximetry
• Consider precipitating causes and treat appropriately
• Print and follow DKA chart
Fluids therapy:
A slower infusion rate should be considered in young adults, elderly or patient with renal or heart
failure. If SBP < 90mmHg then give 500mL bolus over 15min and reassess if still low seek senior
review. Avoid hypogycaema when glucose < 250 mg/dl start 10% glucose infusion.
References:
Joint British Diabetes Society - DKA guidelines 2023
38
DIABETIC KETOACIDOSIS (Page 2)
Potassium (K+) therapy:

K+ level in first 24 hours (mmol/L) KCL replacement in mmol/L of infusion solution
Over 5.5 No potassium required
3.5-5.5 40 (maximum 20 mmol/L/hour)
Less than 3.5 Senior Review as additional potassium needs to be given
Insulin therapy (IV infusion):

Add 50 IU regular insulin to 50 ml 0.9% normal saline
Infuse at a fixed rate of 0.1 unit/kg/hr (i.e. 7 ml/hr if weight is 70 kg)
Only give a bolus (stat) dose of intramuscular insulin (0.1 unit/kg) if there is a delay in
setting up the infusion
If the individual normally takes long acting basal insulin (e.g. glargine, degludec,
detemir, or human isophane insulin) continue this at the usual dose and usual time
Delay insulin therapy until you correct the hypokalemia
Follow up:
Measure VBG for pH, bicarbonate and potassium at 60 minutes, 2 hours and 2 hourly
thereafter
During this time, individuals should be reviewed hourly initially to ensure that adequate
progress is being made in reducing the ketone and/or glucose concentrations
Consider urinary catheterization if the person is incontinent or anuric (i.e. not passed urine
by 60 minutes)
Consider naso-gastric tube insertion if the person is obtunded or persistently vomiting
Give prophylactic low molecular weight heparin
Continue fixed rate insulin until ketones < 0.6 mmol/L, venous pH > 7.3 and venous
bicarbonate > 15 mmol/l
Overlap with meal short acting insulin if patient can eat, don't stop infusion tell 30-60
minutes of the subcutaneous short acting insulin (usual patient dose)
If not previously on insulin: total daily dose 0.5x body weight (consider higher up to 0.75
unit/kg in insulin resistance), half total dose given as long acting insulin and other half
divided on the three meals
If patient on basal insulin add meal insulin as usual
Rate of drop in blood glucose not more than 50 mg/dl per hour
Sodium bicarbonate infusion (100-150 mL of 1.4%) only is infused if decompensated
acidosis starts to threaten the patient's life, especially when associated with either sepsis
or lactic acidosis
References:
Joint British Diabetes Society - DKA guidelines 2023
39
HYPEROSMOLAR HYPERGLYCAEMIC STATE (Page 1)

Measured or calculated serum osmolality = [(2xNa+) + glucose + urea]
Until the urea is available, calculate using (2xNa + glucose)
Recalculate osmolality once urea is available, and then use (2xNa+ + glucose + urea)
Characteristic feature:
Initial investigations: Marked hypovolemia

Serum osmolality ≥320 mOsm/kg
Capillary & venous glucose Marked hyperglycemia (≥30mmol/L),
Venous blood gases without significant hyperketonemia
Blood ketones or significant acidosis (pH ≥7.3 and
Urea and electrolytes (including blood or serum bicarbonate ≥15.0
phosphate if necessary) mmol/L)
Complete blood count, CRP
Blood cultures (if indicated) Goal of therapy:
ECG + cardiac enzymes (f indicated) Normalize the osmolality
Chest radiograph if clinically indicated Replace fluid and electrolyte
Urine dipstick, urinalysis and culture losses
Normalize blood glucose
Prevention of arterial or venous
thrombosis, cerebral edema/
central pontine myelinolysis /
osmotic demyelination syndrome
and foot ulceration
Management
0 – 60 minutes
IV 0.9% normal saline (1 liter over 1 hour), more rapid replacement if SBP < 90 mmHg
Caution in the elderly where too rapid rehydration may precipitate heart failure but insufficient may fail to
reverse acute kidney injury
ONLY commence insulin infusion quickly in the following:
Ketonemia (blood ketones >1.0 - ≤3.0 mmol/L or urine ketones < 2+) and not acidotic (venous pH >7.3 and
bicarbonate >15.0 mmol/L) then use 0.05 units/kg/hr.
Significant Ketonemia (ketones >3.0 mmol/L) or ketonuria (≥ 2+) with a pH < 7.3 and bicarbonate < 15.0
mmol/L, (i.e. mixed DKA and HHS) – use the DKA guidelines 0.1 units/kg/hr
References:
Joint British Diabetes Society – hyperosmolar hyperglycemic state guidelines 2023
40
HYPEROSMOLAR HYPERGLYCAEMIC STATE (Page 2)
60 minutes - 6 hours
Treat the underlying cause if known (e.g. chest or urinary tract infections)
IV 0.9% NS (0.5-1 liter/hr depending on clinical assessment of dehydration vs. risk of precipitating heart
failure). The target is to achieve positive fluid balance of 2-3 liters by 6 hours
If sodium and osmolality increasing or decline in osmolality < 3, if positive balance is inadequate increase
rate of normal saline infusion, if balance is adequate switch to half normal saline (0.45%) at same rate of
infusion
Fluid replacement should be adjusted for those who are <50 kg in body weight or with pre-existing heart
and renal disease. More cautious fluid replacement is necessary e.g. 0.25 ml/kg/hr
ONLY start IV insulin once fluid replacement is adequate and glucose level have plateaued. Starting an IV
insulin infusion too early could result in circulatory collapse
Maintain potassium in the normal range (follow DKA algorithm)
When BG < 250 mg/dl start iv dextrose 5 or 10% (125ml/h) and continue normal saline
6 hours – 12 hours
Ensure that clinical and biochemical parameters are improving
Continue IV fluid replacement to achieve positive balance of 3-6 liters by 12 hours
Maintain an accurate fluid balance chart
Assess for complications of treatment e.g. fluid overload, cerebral edema, cerebral pontine
myelinolysis (e.g. deteriorating conscious level)
12 hours – 24 hours
Ensure continuing improvement of clinical and biochemical parameters
o Do not expect biochemistry to have normalized by 24 hrs
Check ketones hourly until HHS resolution
Continue IV fluid replacement to achieve remaining replacement of estimated fluid losses
within next 12 hrs
Continue IV insulin with or without 5 or 10% glucose solution to maintain BG 180-250 mg/dl
Adjust insulin infusion rate hourly by 1 unit/hr increments or decrements to achieve desired
blood glucose
Assess for complications of treatment e.g. fluid overload, cerebral edema, central/ extra
pontine myelinolysis/osmotic demyelination syndrome (e.g. deteriorating conscious level)
Continue treatment of any underlying precipitant(s)
If the person is not improving seek senior advice
Once NKHHS resolved switch to sc insulin (stop insulin infusion after 30-60 minutes of sc
insulin), if patient can eat or variable rate insulin infusion if he can not eat
References:
• Joint British Diabetes Society – hyperosmolar hyperglycemic state guidelines 2023
41
HYPOGLYCEMIA
Hypoglycemia is defined as a blood glucose less than 70 mg/dL.
Some patients have symptoms at higher glucose levels.
Presentation Risk factors

Malaise, nausea, headache, odd Strict glycaemic control
behavior Long duration of type 1 diabetes
Sweating, facial pallor Lipohypertrophy at injection sites
Shakiness/tremors
Severe hepatic dysfunction
Dizziness or light-headedness
Increased appetite, weakness Impaired renal function
Rapid heart rate Sepsis
Tingling around the mouth and Terminal illness
tongue, speech difficulty, Cognitive dysfunction/dementia
incoordination, change in level of Increased exercise
consciousness (ranging from Increasing age
confusion to coma) & seizures
Alcohol
Early pregnancy, breast feeding
Malabsorption syndromes
Bariatric surgery
Addison’s disease
Growth hormone deficiency
Hypothyroidism, Hypopituitarism
If the patient is conscious, oriented and able to swallow
Give 15-20g of quick acting carbohydrate snack (e.g. 200ml orange juice or 3-4 heaped tea
spoons of sugar dissolved in water)
Recheck glucose after 10-15 min (repeat up to 3 times if needed)
If still hypoglycemic after 3 snacks, give IV dextrose or IM glucagon 1mg
Once the patient has recovered and the glucose corrected, give a long acting carbohydrate
based food (e.g. a slice of toast/bread, two biscuits, or a cup of milk) do not omit the insulin
dose, but you may reduce it.
If the patient Unconscious or Uncooperative or NPO
ABCDE, stop IV insulin (if running)

If IV access: give 100ml 20% dextrose or 200ml 10% dextrose IV infusion over 15 minutes
If no IV access AND glucose < 60 mg/dl: Give 1 mg Glucagon SC x1 and start IV access STAT
Recheck glucose after 10 minutes and if less than 70 mg/dL, repeat the above measures
Patient must be turned on their side to prevent aspiration
Once patient has recovered and the glucose corrected, give long acting carbohydrate (e.g. slice
of toast/bread or two biscuits)
If on enteral treatment give extra bolus feed containing 20 gm CHO. IV dextrose 10% 100
ml/hour may be needed
Do not omit insulin dose you may reduce it and the meal should contain CHO.
If on IV insulin infusion, restart the insulin infusion according to charts of variable rate insulin
infusion or reduce the dose to half if on fixed rate insulin infusion
References:
Joint British Diabetes Society Guidelines 2023
42
ADRENAL CRISIS
Presentation Risk Factors:
Nausea, vomiting Known adrenal insufficiency

Fatigue, weakness Patients on steroids (especially high dose or
Headache prolonged use)
Drowsiness Acute illness or infection (most common
Mental agitation, confusion or precipitants)
coma Recent major surgery
Abdominal pain and tenderness Trauma
Hypotension, dizziness
Shock
Hypoglycemia
Initial assessment
If suspected treat before biochemical results

CBC, CRP, glucose, renal function and electrolytes
Cortisol and ACTH (extract the blood before giving the hydrocortisone)
ABG or VBG
Septic workup: CXR, urine, sputum routine and culture, blood culture
ECG
Management
Hydrocortisone 100mg IV stat

Fluid resuscitation with IV 500ml normal saline (0.9% sodium chloride) bolus, give IV
dextrose if hypoglycemic, subsequent fluid administration depends on clinical assessment
After hydrocortisone stat dose, put on 50mg/6hr IV (or IM), then after 72 hours if the
patient's condition improved and accepting orally shift him to oral steroids
Treat any precipitating factors (e.g. antibiotics for infection)
Endocrinologist consultation for review and assessment
References:
BMJ best practice.
43 Adrenal crisis guidelines, Leeds teaching hospital NHS trust 2019.
Acknowledgement
We would like to thank all of our contrubuting senior colleagues who kindly
invested their valuable time in reviewing this humbled project
Prof. Heba Elzawawi

Consultant Neurologist, Benghazi Medical Center, University of Benghazi
Dr. Abdelhakem Elbarsha

Consultant Gastroenterologist, Benghazi Medical Center, University of Benghazi
Dr. Najat Buzaid

Consultant Endocrinologist, 7th October Hospital, University of Benghazi
Dr. Muftah Elsahati

Consultant Hematologist, Benghazi Medical Center, University of Benghazi
Dr. Ashraf Mahmoud Rajab

Gastroenterology Specialist, Benghazi Medical Center, University of Benghazi
Dr. Jamal Elshareef

Hematology Specialist, Benghazi Medical Center, University of Benghazi
Dr. Mahmoud Elswaihli

Internal Medicine Registrar, Department of Medicine, Benghazi Medical Center
The blue book team:

Sami A. Lawgaly
Suhaib Ali Issa
Alhassan Kashbour
Alhussen Kashbour

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The Blue Book: A

Sami A. Lawgaly, MBChB, MSc, MD

To the soul of my beloved father ....

ACUTE CORONARY SYNDROME

Signs & Symptoms Initial assessment in ER Risk factors:

Oxygen (target > 94%, if COPD 88-92%)

Criteria: ST elevation > 2 mm in V1-V6 Chest pain + raised troponin

Aspirin 300 mg PO stat

Aspirin 300 mg PO stat

Doses of thrombolytic therapy:

ACUTE PULMONARY EDEMA

Signs and symptoms Initial assessment in ER Differential diagnosis

Dyspnea, orthopnea Set the patient upright COPD

High flow oxygen if low SpO2

Atropine 1 mg IV bolus Risk of asystole?

Repeat every 3 to 5 minutes atropine until

Assess using the ABCDE approach

Monitor SpO2 and give oxygen if hypoxic

Synchronized DC Adverse features?

Broad QRS Narrow QRS

Irregular Regular Regular Irregular

Probable re-entry Seek expert help

ADULT ADVANCED LIFE SUPPORT

Unresponsive and not

Shockable rhythm Return to spontaneous

1 Shock Immediate post cardiac arrest

Treat reversible causes (Hs & Ts)

5 Resuscitation Counsel UK - guidelines

ACUTE EXACERBATIONS OF ASTHMA

Assessment of severity (may or may not be present)

Impending respiratory failure: Severe exacerbation: Mild to moderate exacerbation:

Bloods: CBC, RFTs & electrolytes

Supplemental oxygen (maintain sat 94-98%)

INFECTIVE EXACERBATIONS OF COPD

Common symptoms Assessment

Cough Complete history and examination

Supplemental oxygen (maintain O2 sat 88-92%)

If no response to the above measures

Consider ICU transfer

COMMUNITY ACQUIRED PNEUMONIA

MILD MODERATE SEVERE

Treat as out patient Admit to hospital Admit to ICU

Well’s criteria for pulmonary embolism:

Access clinical probability of PE

Low or intermediate High

No more tests CTPA

NB: consider high sensitivity d-dimer ± CTPA for intermediate probability .

Respiratory failure type 1 ABG (normal values) Respiratory failure type 2

Bronchial asthma pH = 7.35 – 7.45 Pulmonary diseases:

Aim at O2 saturation (94-96%) High flow O2 via non-

Critical illness with

If bilateral or unstable patient proceed to chest drain

RR < 24 per minute

Age > 50 and significant smoking

Aspirate 14-16G Size > 2 cm and/or

Success (<2cm and

Consider early Success (<1cm)

Common causes: Major risk factors: Investigations:

IV access with 2 large bore cannulae (16 G or bigger) or CV line

Non-variceal bleeding (mostly PUD)

Treat electrolytes disturbance IV antibiotics prophylaxis ( e.g.

DECOMPENSATED LIVER FAILURE

Common causes: Signs and symptoms: Investigations:

Treat the infections according to the source