St George’s University Hospitals NHS Foundation Trust GUIDELINES FOR THE MANAGEMENT OF COMMON MEDICAL EMERGENCIES AND FOR THE USE OF ANTIMICROBIAL DRUGS St George's Hospital August 2021 73rd edition Cardio-vascular emergencies Page Cardiac arrest 3 Hypertension 11 Acute coronary syndromes 16 Management of STEMI 18 Management of NSTE-ACS 20 Acute heart failure 22 Disorders of cardiac rhythm 24 Acute deep vein thrombosis (DVT) 27 Acute pulmonary embolism 30 Respiratory emergencies Respiratory arrest 34 Oxygen therapy in acute illness 36 Asthma 37 Spontaneous pneumothorax 39 Gastro-intestinal emergencies Acute gastro-intestinal bleeding 42 Bleeding oesophageal varices 44 Acute bloody diarrhoea 46 Diabetic & endocrine emergencies Diabetic ketoacidosis (DKA) 48 Hyperosmolar hyperglycaemic state (HHS) 51 Hypoglycaemia 54 Addisonian crisis 55 Neurology emergencies Acute stroke 57 Status epilepticus (convulsive SE) 61 Acute management of Parkinson’s Disease 64 Anaphylaxis 65 Acute pain 66 Suggestions for the use of antimicrobial drugs in adults 70 Sepsis 73 Infective endocarditis 75 Diabetic foot infection 77 Infectious diarrhoea 77 Surgical wound infection 77 Malaria 77 Drug overdosage/acute poisoning 78 Decompensated liver disease 90 Acute painful joints 93 Suspected giant cell arteritis (GCA) 95 Renal emergencies & Electrolyte disturbancies Acute kidney injury (AKI) 98 Electrolyte disturbances: Hypokalaemia, Hyperkalaemia 100 Hypocalcaemia, Hypercalcaemia 102 Hyponatraemia 104 Hypernatraemia 105 Sickle cell crises 107 Acute psychiatric emergencies Managing acutely agitated patients 110 Management and prevention of delirium 115 Management of alcohol withdrawal 118 Appendix 1 Cardiac markers in acute coronary syndromes 124 Appendix 2 Cardio-pulmonary resuscitation 125 Appendix 3 Perioperative management of diabetes mellitus 126 Appendix 4a Enteral/parenteral feeding 128 Appendix 4b Severely ill patients with Eating Disorders 130 Appendix 4c Prevention and management of refeeding in adults 132 Appendix 5 Assessing the anion gap 138 Appendix 6 Indications for lumbar puncture 140 Appendix 7 Protecting anticoagulated patients from bleeding 142 Appendix 8 HIV post-exposure prophylaxis and 146 Working with AIDS patients Appendix 9 First steps in a major incident 150 Appendix 10 Monitoring selected therapeutic drug levels 151 Antifungal monitoring 152 Amikacin, Vancomycin guidelines 152 Appendix 11 Urgent removal of tunnelled lines 152 GENERAL POINTS In editing the Grey Book every attempt is made to ensure that statements are fully compatible with the advice given by the British National Formulary, the Drug and Therapeutics Bulletin, the various professional bodies (such as the British Thoracic Society), the Royal Colleges (particularly the Royal College of Physicians; RCP), National Service Frameworks and NICE. The Intranet version can be found at the St George’s NHS Trust Intranet website: https://stginet.unily.com/sites/grey-book/SitePageModern/48789/grey-book-home If you have any comments or questions please send them to the Link Consultant named at the beginning of the section concerned. Editor takes no responsibility for the content of Intranet links referenced in the Grey Book. The doses given are for adults unless otherwise stated. If the patient is pregnant, discuss management with the duty obstetric registrar as soon as possible. When medical problems arise seek advice as follows. During the working day, or when on in-take, refer upwards through your own medical firm. If on “cover” at night and you need advice about a patient on another firm and there is no policy written in the notes, first turn to the in-taking registrar and then to the patient’s own consultant. If the patient’s consultant cannot be contacted, refer next to the registrar/senior registrar and finally to the in-taking consultant. Editorial: Teck Khong (editor: [email protected]), Vivien Perkins Pharmacy liaison: Wendy Pullinger 2 ADULT CARDIAC ARREST – Extracted from RCUK Guidelines (2015)*available as free download: https://www.resus.org.uk/resuscitation-guidelines/adult-advanced-life-support/ (Link: Jeannie Walls – Lead Resuscitation Officer – Ext 2489) 3 Heart rhythms associated with cardiac arrest are divided into two groups: Shockable Rhythms: Ventricular Fibrillation/pulseless Ventricular Tachycardia (VF/pVT) Non-shockable Rhythms: Asystole and pulseless electrical activity (PEA). The main difference in the treatment of these two groups is the need for attempted defibrillation in patients with VF/pVT. Other actions, including chest compression, airway management and ventilation, vascular access, administration of adrenaline, and the identification and correction of reversible factors, are common to both groups. The ALS algorithm provides a standardised approach to the management of adult patients in cardiac arrest. Drugs and advanced airways are still included among ALS interventions, but are of secondary importance to early defibrillation and high quality, uninterrupted chest compressions. Treatment of shockable rhythms (VF/VT) 1. Confirm cardiac arrest – Check for signs of life and normal breathing, and if trained to do so check for breathing and a pulse simultaneously. 2. Call resuscitation team. 3. Perform uninterrupted chest compressions while applying self-adhesive defibrillation/monitoring pads – one below the right clavicle and the other in the V6 position in the midaxillary line. 4. Plan actions before pausing CPR for rhythm analysis and communicate these to the team. 5. Stop chest compressions; confirm VF/pVT from the ECG. This pause in chest compressions should be brief and no longer than 5 seconds. 6. Resume chest compressions immediately; warn all rescuers other than the individual performing the chest compressions to “stand clear” and remove any oxygen delivery device as appropriate. 7. The designated person selects the appropriate energy on the defibrillator and presses the charge button. Choose an energy setting of 150 Joules for the first shock (Manufacturer’s guidance is non-escalating for subsequent shocks.) 8. Ensure that the rescuer giving the compressions is the only person touching the patient. 9. Once the defibrillator is charged and the safety check is complete, tell the rescuer doing the chest compressions to “stand clear”; when clear, deliver the shock. 10. After shock delivery immediately restart CPR using a ratio of 30:2, starting with chest compressions. Do not pause to reassess the rhythm or feel for a pulse. The total pause in chest compressions should be brief and no longer than 5 seconds. If the patient has a definitive airway i.e. ETT or LMA/iGel (if no leak present) Compressions should be continuous with a ventilation rate of 10 breaths per minute. 11. Continue CPR for 2 min; the team leader prepares the team for the next pause in CPR. 12. Pause briefly to check the monitor. 13. If VF/pVT, repeat steps 6–12 above and deliver a second shock. 14. If VF/pVT persists, repeat steps 6–8 above and deliver a third shock. Resume chest compressions immediately. Give adrenaline 1 mg IV and amiodarone 300 mg IV while performing a further 2 min CPR. Withhold adrenaline if there are signs of return of spontaneous circulation (ROSC) during CPR. 15. Repeat this 2 min CPR – rhythm/pulse check – defibrillation sequence if VF/pVT Give further adrenaline 1 mg IV after alternate shocks (i.e. approximately every 3–5 min). 4 16. Give further adrenaline 1 mg IV after alternate shocks (i.e. approximately every 3–5 min). 17. If organised electrical activity compatible with a cardiac output is seen during a rhythm check, seek evidence of ROSC (check for signs of life, a central pulse and end-tidal CO2 if available). If there is ROSC, start post-resuscitation care. If there are no signs of ROSC, continue CPR and switch to the non-shockable algorithm. 18. If asystole is seen, continue CPR and switch to the non-shockable algorithm. The interval between stopping compressions and delivering a shock must be minimised. Longer interruptions to chest compressions reduce the chance of a shock restoring a spontaneous circulation. Chest compressions are resumed immediately after delivering a shock (without checking the rhythm or a pulse) because even if the defibrillation attempt is successful in restoring a perfusing rhythm, it is very rare for a pulse to be palpable immediately after defibrillation. The use of waveform capnography can enable ROSC to be detected without pausing chest compressions and may be used as a way of avoiding a bolus injection of adrenaline after ROSC has been achieved. Regardless of the arrest rhythm, after the initial adrenaline dose has been given, give further doses of adrenaline 1 mg every 3–5 min until ROSC is achieved; in practice, this will be about once every two cycles of the algorithm. If signs of life return during CPR (e.g. purposeful movement, normal breathing or coughing), or there is an increase in end- tidal CO2, check the monitor; if an organised rhythm is present, check for a pulse. If a pulse is palpable, start post-resuscitation care. If no pulse is present, continue CPR. Give amiodarone 300 mg IV after three defibrillation attempts irrespective of whether they are consecutive shocks, or interrupted by CPR, or for recurrent VF/pVT during cardiac arrest. Consider a further dose of amiodarone 150 mg IV after a total of five defibrillation attempts. Lidocaine 1 mg kg-1 may be used as an alternative if amiodarone is not available but do not give lidocaine if amiodarone has been given already. Witnessed, monitored