A Clinician’s Survival Guide to Acute Medical Emergencies

Chapter 1 Introduction: Immediate Assessment of the Critically Ill
ABCDE: Immediate Assessment and Intervention
Early Warning: Track and Trigger – NEWS and NEWS
Soft Signs
Additional Monitoring
NEWS: Oxygen Treatment and Target Oxygen Saturation NEWS: ABCDE and ACVPU
Communication: NEWS and SBAR
Conclusion
Further Reading
Chapter 2 Cardiology
Introduction
Common Clinical Problems
Acute Severe Breathlessness
Chest Pain and Atypical Myocardial Infarction Atrial Fibrillation
Immediate Relevance of Heart Disease to Other Acute Medical Conditions
Core Clinical Skills
Anticipating Problems
Cardiac Failure
Primary Problems in the Heart
Heart Muscle Damage
Valvular Disease
Rhythm Disturbance
Secondary Compensatory Mechanisms in Cardiac Failure
Important Biomarkers of Cardiac Failure: B-Natriuretic Peptide and NT-proBNP
The Specialist Heart Failure Team
Types of Heart Failure
Left-Sided Heart Failure
Right-Sided Heart Failure
Congestive Cardiac Failure
Right Heart Failure and Chronic Obstructive Pulmonary Disease
Diastolic Heart Failure
Clinical Features and Management of Cardiac Failure
Characteristics of Patients Admitted Acutely with Cardiac Failure
Principles of Managing Cardiac Failure
Acute Left Ventricular Failure
Acute on Chronic Congestive Cardiac Failure
Important Clinical Tasks in Congestive Cardiac Failure
Specialist Input
Answering Patients’ and Relatives’ Questions in Cardiac
Failure
Ischaemic Heart Disease
Chest Pain
Approach to the Patient Who Has Chest Pain on the Acute Medical Unit
Acute Coronary Syndromes, ST-Elevation Myocardial Infarctions, Non-ST-Elevation Myocardial Infarctions and Unstable Angina
Troponin T and Troponin I in the Assessment of Chest Pain
Risk Stratification in the Management of Chest Pain
Cocaine and the Heart
What are the Other Causes of Acute Chest Pain? When to Try Glyceryl Trinitrate?
What to Say to the Patient?
Critical Clinical Tasks in the Patient With Chest Pain
Sudden Cardiac Death
Atrial Fibrillation and Arterial Emboli
Causes of Atrial Fibrillation
Importance of Atrial Fibrillation
Uncontrolled Atrial Fibrillation
Complications of Atrial Fibrillation
Diagnosis of Atrial Fibrillation
Management of Atrial Fibrillation
Stroke Prevention Versus Bleeding Risk: CHAD DS-VASc and HAS-BLED
Warfarin and New Direct Acting Oral Anticoagulants (DOACS)— Edoxaban, Dabigatran, Apixaban and Rivaroxaban
Critical Clinical Tasks in Atrial Fibrillation
Important Clinical Tasks in Atrial Fibrillation
Answering Relatives’ Questions in Atrial Fibrillation
Infective Endocarditis
How Infective Endocarditis Presents
Pyrexia of Unknown Origin
Catastrophic Valve Failure
Infected Emboli
Role of the Acute Medical Unit in Suspected Endocarditis
Principles of Management in the First 24 H
Drugs in the Management of Acute Heart Disease
Intravenous Furosemide
Antiplatelet Agents
Intravenous Nitrates
Digoxin
Intravenous Diltiazem
Angiotensin-Converting Enzyme Inhibitors Intravenous Amiodarone
Spironolactone and Eplerenone
Further Reading
Chapter 3 Respiratory Medicine
Introduction
The Breathless Patient: The General Approach
Is this Patient’s Breathlessness due to his Heart or Lungs?
What Tests will be Needed to make the Right Diagnosis?
Principles of Emergency Treatment
Respiratory Failure
Type I and Type II Respiratory Failure
Principles of Treatment
Acute Severe Asthma
Mechanisms
Who Gets Acute Severe Asthma and Why? What Goes Wrong During an Attack?
Assessment of Acute Severe Asthma
Caring for the Patient With Acute Severe Asthma
Critical Clinical Tasks During the Acute Attack
Management of Acute Severe Asthma
Initial Emergency Treatment
Subsequent treatment
Assessing Response
Acute Severe Asthma in Pregnancy
Answering Relatives’ Questions in Severe Asthma
Upper Airway Obstruction: Not to Be Confused With Asthma
Chronic Obstructive Pulmonary Disease
Mechanisms
Caring for the Patient With COPD
Critical Caring Tasks During the Acute Attack
Answering Relatives’ Questions in COPD
Respiratory Infections and Pneumonia
Pneumonia
Signs and Symptoms of Pneumonia
Assessment of Pneumonia
The Severity Score in Pneumonia: CURB-65
Finding the Cause of Pneumonia
Assessing the Effect of Pneumonia on the Patient
Management of Pneumonia
Basic Aims of Treatment
Pleural Effusion and Pleural Empyema
Aspiration Pneumonia
Caring for the Patient With Pneumonia
Five Critical Caring Tasks During the Acute Phase
Watch for Complications
Answering Relatives’ Questions in Pneumonia
Spontaneous Pneumothorax
Safety Issues: Pleural Aspiration and Pleural Drainage
Caring for the Patient With a Chest Drain
Important Clinical Observations
COVID- and the Lungs
Further Reading
Chapter 4 Acute Neurological Problems
Introduction
Role of the Acute Medical Unit in Acute Neurological Problems
Ensuring the Safety of the Patient
Prioritising the Initial Management
Glasgow Coma Score (GCS) and ABCDE: Assessing and Keeping the Patient Alive
Critical Clinical Observations
Managing ‘Medical’ and ‘Neurological’ Coma
The Underlying Mechanism in Coma
Practical Management of Coma
Importance of an Eyewitness in Coma
Responding to Neurological Deterioration
How the Clinical State Can Change in the First Hours of Admission
Reaching Appropriate Outcomes
Making the Correct Diagnosis
Urgent Admission to the Acute Stroke Unit in an Optimum Condition
Avoiding a Major Stroke After a Transient Ischaemic Attack
Surviving Intracranial Sepsis
Reaching the Neurosurgeons Alive and on Time
Full Recovery From Self-Harm
Recovery From Reversible Causes of Neurological Emergencies
Stroke and Stroke-Like Emergencies
Causes
Cerebral Infarction (Approximately 80% of All Strokes)
Transient Ischaemic Attacks and Minor Ischaemic Strokes
Intracerebral Haemorrhage (Approximately 10% of All
Strokes)
Subarachnoid Haemorrhage (Approximately 5% of All Strokes)
Subdural Haemorrhage
Extradural Haemorrhage
Care of the Patient With a Stroke: The First 24 H
Critical Clinical Observations and Immediate Management
Interventions in the First 24 H
Answering Relatives’ Questions on Stroke
Acute Meningitis in Adults
Meningococcal Meningitis
Clinical Picture
Caring for the Patient With Suspected Meningococcal Meningitis
Clinical Care
Critical Clinical Observations in the First 24 H
Clinical Management Apart From the Critical Tasks and
Observations
Answering Relatives’ Questions in Meningitis
Acute Severe Headache
Subarachnoid Haemorrhage
The Computed Tomography and Lumbar Puncture in Subarachnoid Haemorrhage
Caring for the Patient with Subarachnoid Haemorrhage
Answering Relatives’ Questions in Subarachnoid Haemorrhage
Lumbar Puncture
Contraindications to a Lumbar Puncture
Indications on the Acute Medical Unit
Procedure
Xanthochromia: A Practical Guide to Interpreting the CSF Result in Subarachnoid Haemorrhage
Sudden Loss of Consciousness: Faints and Fits
The Basic Mechanisms: Syncope
Cardiac Syncope
Reflex Syncope (Also Termed ‘Neurally Mediated Syncope’)
Situational Syncope
Driving
The Basic Mechanisms: Epileptic Seizures
Partial Seizures
Generalised Convulsions (Tonic–Clonic Fitting)
Caring for the Patient Who Has Sudden Loss of
Consciousness
Clinical Tasks
Drugs Commonly Used in Status Epilepticus
Common Reasons Why Management is Unsuccessful
Sudden Unexplained Death in Epilepsy
Pseudoseizures (Non-Epileptic Seizures)
Management
Acute Paralysis of the Lower Limbs
Spinal Cord Compression
Guillain–Barré Syndrome
Recognising Acute Illness in Patients With Chronic Neurological
Disability
COVID- and the Nervous System
Further Reading
Websites
Chapter 5 Gastroenterology
Introduction
Nausea and Vomiting: Underlying Mechanisms
The Patient Who Is Vomiting: The General Approach
Consider the Underlying Mechanisms and Potential Causes
Establish the History
Is this Gastrointestinal Disease?
Is this Drug Related?
Could this be Raised Intracranial Pressure?
Could this be Metabolic?
Nausea and Vomiting in Acute Medical Conditions
Migraine
Myocardial Infarction
Sepsis
Acute Gastric Dilatation
Acute Upper Gastrointestinal Haemorrhage
Causes of Acute Bleeding
Peptic Ulcer Disease (25%)
Helicobacter pylori Infection and Bleeding Peptic Ulcers
Acute Oesophagitis, Gastritis, Duodenitis and Acute Erosions
(‘Stress Ulcers’) 40%
Mallory–Weiss Tear 3%
Gastro-oesophageal Varices 8%
Gastric and Oesophageal Cancers 3%
Dieulafoy Erosion 2%
Management of Upper Gastrointestinal Haemorrhage
Ensuring the Safety of the Patient: ABCDE
Who Needs Urgent Endoscopy?
Assessing the Degree of Bleeding
Assessing the Risk to the Patient from the Bleed
Risk Assessment With the Glasgow-Blatchford and Full Rockall
Scores
Looking for Evidence of Re-Bleeding
Intravenous Pantoprazole/Omeprazole
Role of the Clinical Team in Facilitating Communication
Answering Relatives’ Questions in Acute Upper Gastrointestinal
Bleeding
Important Questions to Ask the Patient or Relatives
Reassessing the Patient on Return From Endoscopy
Portal Hypertension and the Management of Oesophageal
Varices
Preventative Antibiotics
Fresh Rectal Bleeding
Acute Liver Failure, Jaundice and Hepatic Encephalopathy
Impairment of the Conscious Level
Bleeding Varices and Clotting Abnormalities
Sepsis
Metabolic Abnormalities
Management of Acute Liver Failure in the First 24 H
Hepatic Encephalopathy
Bleeding
Sepsis
Metabolic Problems
Critical Clinical Tasks in Acute Liver Failure
Example Cases in Acute Liver Failure and Hepatic
Encephalopathy
Acute Jaundice
Gallstones, Acute Cholecystitis and Ascending Cholangitis
Acute Abdominal Pain
Critical Clinical Tasks in Acute Abdominal Pain
Important Clinical Tasks in Acute Abdominal Pain
Acute Diarrhoea: Sources and Courses
Infective Diarrhoea
Clostridium difficile Diarrhoea
Enteric Precautions
Infective Diarrhoea Versus Acute Ulcerative Colitis
Medical Conditions Presenting With Gastrointestinal
Symptoms
Cardiovascular Disease
Respiratory Disease
Diaphragmatic Pleurisy
Congestion in Cor Pulmonale
Steroid-Induced Side Effects
Diabetes
COVID- and the Gastrointestinal Tract
Further Reading
Chapter 6 Diabetic Complications
Diabetes in the Acute Medical Unit: The General Approach
Aims of this Chapter
Normal Blood Sugar Control and the Nature of Diabetes
An Overview of Type I and Type II Diabetes
Type I Diabetes
Type II Diabetes
Recent Developments in the Treatment of Diabetes
Type I Diabetes
Type II Diabetes
Acute Medical Conditions Associated With Diabetes
Diabetic Renal Disease
Diabetic Neuropathy
Cardiovascular Disease
Cerebrovascular Disease
Peripheral Vascular Disease
Blood Sugar Control in Adverse Medical Situations
How Good Should Control be During Acute Severe
Illnesses?
Assessing Control
Practical Management of Diabetes in Adverse
Circumstances
Variable Rate Intravenous Insulin Infusion—VRIII (‘Sliding Scale’)
or GKI? Self-Management of Diabetes in Hospital
Glucose Infusion and a Sliding Scale of Insulin (VRIII)
The DIGAMI Regimen: An Example of Controlling the Blood
Sugar in Acute Illness
Glucose, Potassium and Insulin
Could We (or Should We) Assess Obesity in the AMU?
Management of Acute Diabetic Emergencies
Diabetic Ketoacidosis
Information for Diabetics: What to Do on Days When You Are
Sick
Hyperosmolar Non-Ketotic Diabetic Coma
Hypoglycaemia
Symptoms
Causes
Hypoglycaemic Unawareness
Management
Always Seek the Cause for Hypoglycaemia
Infective Complications in Diabetes: The Acute Diabetic Foot
Assessment of the Diabetic Foot
How to Look at the Feet
Management
Further Reading
Chapter 7 Thromboembolic Disease
Introduction
The Nature of the Disease
Thrombosis and Thromboembolisation
Reducing the Risk of Venous Thromboembolism
Tests to Identify Venous Thromboembolic Disease
Diagnostic Approach: The Two-Level Pulmonary Embolism Wells
Score: Likely or Unlikely
Management of Pulmonary Thromboembolism
Critical Clinical Tasks in a Severe Acute Pulmonary
Embolus
Important Clinical Tasks in Acute Pulmonary Embolus
Pulmonary Embolism in Pregnancy
Answering Relatives’ Questions in Pulmonary Embolism
Caring for the Patient With a Suspected Deep Vein
Thrombosis
Clinical Assessment of a Possible Deep Vein Thrombosis
Other Causes of Acute Calf Pain
Other Causes of a Swollen Painful Leg
Management of a Deep Vein Thrombosis
Critical Clinical Tasks in a Suspected DVT
Important Clinical Tasks in a Suspected Deep Vein
Thrombosis
Answering Relatives’ Questions in Deep Vein Thrombosis
Anticoagulation Therapy
Outpatient Management of Venous Thromboembolic Disease
COVID- and Thromboembolic Disease
Further Reading
Chapter 8 Deliberate Self-Harm, Alcohol and Substance Use Disorders
Deliberate Self-Harm
General Principles
Who Commits Suicide?
Who is at a Particularly High Risk of Suicide?
Which Type of Patients Are Admitted With Deliberate Self-Harm?
The Embarrassed and Impulsive
The Serious Attempt
The Recurrent Attender
The High-Risk Self-Harm
Why Do Patients Deliberately Harm Themselves?
Two High-Risk Patients
Caring for the Patient With Self-Harm
Critical Clinical Tasks in Deliberate Self-Harm
Activated Charcoal
Important Clinical Tasks in Deliberate Self-Harm
Relevant Medical History
Psychosocial History
The Patient Who Refuses Treatment
Specific Overdoses
Benzodiazepines
Paracetamol Poisoning
Clinical Picture of Severe Paracetamol Toxicity
Immediate Management
Late Presentation (– H) or Staggered Ingestion Over Several
Hours
Who Gets IV N-acetylcysteine (Parvolex) or Methionine?
Antidepressant Overdose
Management
Immediate Management of Tricyclic and SSRI Overdoses
Carbon Monoxide Poisoning
Basic Mechanisms
Clinical Picture
Assessment and Management
Alcohol Use Disorder
Problems of Alcohol in the Acute Medical Unit
Ethylene Glycol and Methanol: Antifreeze and Windscreen Washer
Solution
Substance Use Disorder
Cocaine
Ecstasy
Management
Liquid Ecstasy
Dystonic Reaction and Psychotropic Drugs
Synthetic Cannabinoid Receptor Agonists – ‘Legal’ Highs
Heroin Use Disorder (Opioid Use Disorder)
Methods of Heroin Ingestion
Heroin Overdose
Methadone Therapy
Clinical Assessment of the Drug User
Infections in Intravenous Drug Users
Special Risks to Members of Staff
Needle Stick Injuries
The Nature of the Risk
Outcome
What Constitutes Significant Exposure?
What Emergency Action Should Be Taken?
Risk Assessment to Identify the Patient’s Infectivity
Hospital-Acquired Methicillin-Resistant Staphylococcus aureus
Infections
Violent Incidents
Prevention
Management
Further Reading
Chapter 9 The ‘Social Admission’
Introduction
Common Errors and Omissions in the Admission of Elderly
Patients
Failure to Obtain an Adequate History
Failure to Establish a Correct Drug History
Failure to Make an Adequate Review of the Patient’s Previous
Hospital Records
Taking the History
Taking a History From the Patient
Taking a History From a Third Party
Frailty and Frailty Syndromes
Falls
The Cause of Falls
Assessment After a Fall
Critical Clinical Tasks in Assessment After a Fall
How to Identify Postural Hypotension
Important Clinical Tasks in Assessment After a Fall
Speak to the Carers and Close Family
Additional Assessment on Examination
Answering Relatives’ Questions in Patients Who Fall
Immobility
Critical Clinical Tasks in Assessing Immobility
Important Clinical Tasks in Assessing Immobility
Delirium
Principles of Management
Hypoxia
Dementia
The Diagnosis of Alzheimer’s Disease
Clinical Observations for a Patient Who Has Required
Sedation
Nursing Home Admissions
Ethical Issues and the Elderly Sick
Who Should Decide?
Withholding Versus Withdrawing Treatment?
COVID-19 in the Older Patients
The Emergency Admission of Patients With a Terminal
Disease
Further Reading
Chapter 10 Multisystem Failure
Shock: The Basic Mechanisms
Cardiogenic Shock
Hypovolaemic Shock
Redistributive (Low-Resistance) Shock
Acute Severe Hypotensive Collapse
Importance of Immediate Resuscitation
Resuscitation of the Patient With Hypotensive Collapse
Critical Clinical Tasks in Assessing Hypotensive Collapse
Important Clinical Tasks in Assessing Hypotensive Collapse
When Do We Use Dopamine, Dobutamine and Noradrenaline
(Norepinephrine) in Patients With Shock?
Ensuring Adequate Oxygen Delivery to Vital Organs: Maintaining
the Oxygen Saturation and the Blood Pressure
Oxygen Therapy
The Blood Pressure
When is a Central Line Used?
Intravenous Fluid Resuscitation and Fluid Challenge
Which Critically Ill Patients May Need Transfer to Intensive Care
Unit/High-Dependency Unit?
Surviving Sepsis
Sepsis Six
NICE Sepsis Guidelines
Anaphylactic Reaction
Management of Anaphylactic Shock
Answering Relatives’ Questions in Shock
Emergency Blood Transfusion in Shock
Transfusion Reactions
Clinical Features and Basic Management
Clinical Assessment to Identify a Severe Transfusion
Reaction
Massive Blood Transfusion
Acute Kidney Injury
Which Patients are at Particular Risk From Acute Kidney
Injury?
Illustrative Case Studies
Management of Acute Kidney Injury
Ensuring the Safety of the Patient
Completing the Clinical Assessment
Establishing a Management Plan
Critical Clinical Tasks in Acute Renal Failure
Important Clinical Tasks in Acute Kidney Injury
Answering Relatives’ Questions in Acute Kidney Injury
Sudden Collapse and Cardiac Arrest
Common Causes of the Sudden Collapse
Assessment of Collapse
Diagnosing Cardiac Arrest
The Chain of Survival
Basic Life Support
Sequence of Actions in Basic Life Support
After Basic Life Support
Treatable Causes of Cardiac Arrest: H and T
Advanced Airway Management
When to Stop the Resuscitation Procedure
Dealing With the Relatives of a Victim of Cardiac Arrest
Answering Relatives’ Questions in Cardiac Arrest
The Aftercare of Patients Who Undergo Successful CPR
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
Communication and Explanation
A DNACPR Protocol
Important Points About DNACPR
Answering Relatives’ Questions About ‘Do Not Resuscitate’
Decisions
Bereavement on the Acute Medical Unit
Critical Tasks When Dealing With the Bereaved
Important Tasks When Dealing With the Bereaved
Further Reading
Chapter 11 Emerging Problems: Outbreaks and Deliberate Releases—SARS
and COVID-19, Toxins and Biologic Agents
Introduction
How Infection Spreads
SARS-CoV-2 and COVID-19
Overcoming Communication Barriers in COVID-19
Surgical Masks Versus Particulate Respirators (Ffp Masks)
Targeted Treatment of COVID-
Other Emerging Infections
HN Influenza (Swine Flu)
Viral Haemorrhagic Fevers: Ebola, Lassa, Marburg and
Crimean-Congo
Unusual Illnesses—Deliberate Release of Infectious and Chemical
Agents
Deliberate Release of Infectious Agents
General Principles
Awareness and Recognition
Communication
Decontamination and Containment
Seek Early Advice
Poisoning With Biological Agents
Examples of Potential Pathogens and Initial Symptoms
Poisoning With Nerve Agents
Antidote Administration
Breathing Support
Coma and Convulsion Care
Key Clinical Skills in Outbreaks and Deliberate Releases
Conclusion
Further Reading

Index