ATLS AF / atrial flutter Acute Asthma

VF / VT New onset (<48h) • Sit up + O2

• 1mg adrenaline IV (3-5 mins) Compromised (chest pain, HR>150, heart failure, systolic • 5mg salbutamol nebulised
• 300mg amiodorone IV BP<90) • 0.5mg ipratropium nebulised
Unshockable • DC cardiovert, if fails metoprolol up to 5mg IV over 4-5 • 100mg IV hydrocortisone / 40-50mg prednisolone PO
• 1mg adrenaline IV (3-5 mins) minutes • CXR (exclude pneumothorax)
Uncompromised Life-threatening
Narrow complex tachycardia • 1.2-2g IV magnesium sulphate
• Bisoprolol 5-10mg PO, flecainide 2mg/kg IV over 30
• Sinus massage / Valsalva
minutes (discuss SpR+, better for <65y, no cardiac
• If fails, 6mg IV adenosine + saline flush
history, not in flutter)
• If fails, 12mg IV adenosine + saline flush Pulmonary oedema
Pre-existing (>48h)
• Sit up
Bradycardia Compromised
• Oxygen
Compromised (BP <90mmHg, HR <40, ventricular • 1st line IV metoprolol 5mg, 2nd line 500 micrograms
• 2.5-5mg diamorphine slow IV
arrhythmia, heart failure) digoxin IV
• 40-80mg furosemide slow IV
OR Uncompromised
• GTN spray 2x puffs (not if sBP <90mmHg)
Recent asystole, mobitz type 2, complete heart block, • Oral bisoprolol, oral digoxin
• GTN 2-10mg/h IV infusion (keep sBP >110mmHg)
ventricular pause >3 seconds
• 500 micrograms atropine IV STEMI
If no satisfactory response: • 300mg aspirin PO Hypoglycaemia
• Atropine 500 micrograms IV to maximum of 3mg • 5-10mg IV morphine + 10mg IV metoclopramide Emergency treatment (unconscious,
• If fails, adrenaline 2-10 micrograms / minute • GTN spray fitting, NBM, unable to swallow)
• If fails, SpR+ advice / transcutaneous pacing • Phone Hartbury suite (BRI out of hours) • 1mg glucagon IM
• Wait 10 minutes and recheck blood glucose
NSTEMI <4mmol/L
Anaphylaxis • 160ml 10% glucose IV over 15 minutes
• 300mg aspirin + 300mg clopidogrel PO
• 0.5mg IM adrenaline (repeat every 5 minutes as • Repeat blood glucose after 10 minutes
• 2.5mg fondaparinux SC od (if creatinine clearance
required) • If still <4, repeat infusion
<20ml/min use enoxaparin 1mg/kg od)
• 10mg chlorphenamine IV >4mmol/L and conscious
• Atorvastatin 40mg ON
• 200mg hydrocortisone IV • Carbohydrate snack – 2 biscuits / 1 slice bread / 200-
• Bisoprolol PO (HR>70, BP >110)
300ml milk
J. Hutton Updated 22/06/2017
Diabetic ketoacidosis Hyperosmolar hyperglycaemic state Status epilepticus
Discuss with ITU if: Tests • Lorazepam 2-4mg slow IV
• pH <7, age <17 or >75, cardiac or renal failure, • ∆: lab blood glucose (not capillary) >30mmol/L, OR
pregnant, Na<120, K>6, septic, low BP, acute cardiac osmolality (2Na + glucose + urea) >320mOsm • Buccal midazolam: 10mg (10+ years), 5mg (1-4 years),
event • If venous pH <7.3, venous HCO3 <15, capillary ketones 2.5mg (6-12 months)
OR
Tests >3mmol/L or urine ketones 2+  DKA
• U+E, FBC, trop T, ECG, CXR, MSU, cultures • Rectal diazepam 10mg
• ∆: lab blood glucose (not capillary), venous pH <7.3,
Initial treatment Repeat dose after 10 minutes
venous HCO3 <15, capillary ketones >3mmol/L or
urine ketones 2+ • IV fluids according to regimen Hyperkalaemia
• U+E, FBC, trop T, ECG, CXR, MSU, cultures • Reduce osmolality by 5mOsm / kg / hour Severe (>6.5 mmol/L or symptomatic)
Fluids and potassium supplementation • Once glucose no longer falling, start fixed rate IV • Cardiac monitor
insulin at 0.05 units / kg / hour • IV calcium gluconate 10% 10ml over 2 minutes (30
IL 0.9% NaCl 1 hour Plasma K+ Add KCl
• Continue long-acting insulin but discontinue other minutes if on digoxin. Repeat after 5 minutes if
IL 0.9% NaCl 2 hours <3.5 mmol/L 40 mmol diabetes medication required)
IL 0.9% NaCl 2-4 hours Na and Osmolality • IV 10 units actrapid in 50ml of 50% glucose over 15
3.5-5.0 20 mmol
mmol/L
• Reduce osm 3-8mOsm / kg / hour minutes. Repeat as necessary
IL 0.9% NaCl 4 hours • Reduce Na by 10mmol / 24hours
>5.0 mmol/L Nil
• 20mg nebulised salbutamol if no IV access or resistant
IL 0.9% NaCl 4-6 hours • For every 5.5 mmol/L reduction blood glucose, Na+ hyperkalaemia
may rise 2.4mmol/L • If venous HCO3 <20, sodium bicarbonate 0.5-1g QDS
10% dextrose 10 hours
• Only use 0.45% NaCl if osmolality fails to drop despite PO or 250ml 1.26% IV over 2 hours (if not overloaded
Insulin adequate fluid resus or anuric)
• Continue long-acting and discontinue rapid / mixed IV fluid regimen Other
insulins Hypokalaemia
• Fixed rate insulin 0.1 units/kg/h until pH >7.3, HCO3 Severe (<2.5 mmol/L or symptomatic)
>18mmol/L, capillary ketones <3 mmol/L • 40mmol KCl in 1L N. Saline BD or TDS
1L 0.9% NaCl 1-2 hours Urinary catheter + 1hourly
• Check trust DKA protocol for more details • Standard infusion rate 10mmol/h
fluid balance
Bicarbonate supplementation (pH <7, SpR+) 1L 0.9% NaCl 2-4 hours • Maximum infusion rate 20mmol/h
Treat precipitating cause
• 250-500ml 1.26% bicarbonate over 4 hour 1L 0.9% NaCl 4-6 hours Ward round checklist
Prophylactic LMWH • Observations (including blood glucose)
1L 0.9% NaCl 6-8 hours • Fluid balance
Assess pressure area
J. Hutton 1L 0.9% NaCl 8-10 hours • Drug chart (VTE, antibiotics)
• Results and scans