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Shirley ooi emergency medicine pdf

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SHIRLEY OOI EMERGENCY MEDICINE PDF - 5 Jun The first edition of the Guide to the Essentials in Emergency Medicine, co-edited by two. Guide to the Essentials in Emergency Medicine by Shirley Ooi, This second edition preserves several of its predecessor's hallmark features. Guide to the Essentials in Emergency Medicine by Shirley Ooi,, available at Book Depository with free delivery worldwide. The first edition of.

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Guide to essentials in Emergency Medicine 2nd edition Shirley Ooi Emergency Rapid Sequence Intubation: A “How and When To” Guide. Mar 25, eBooks Download Guide to the Essentials in Emergency Medicine (PDF, ePub, Mobi) by Shirley Ooi Online Full Collection. Shirley Ooi is the author of Guide to the Essentials in Emergency Medicine ( avg rating, 37 ratings, 3 reviews, published ), Guide to the Essenti.

Beta blockers is contraindicated in patient with cocaine abuse because of the paradoxical hypertension, when the primary cause of cocaine induced vasoconstriction is untreated and unopposed. Should any features of allergy appear, stop the infusion and institute further treatment with adrenaline. The dosage is IV 0. When you click on a Sponsored Product ad, you will be taken to an Amazon detail page shirley ooi emergency medicine you can learn more about the product and purchase it. Management include crush aspirin mg, heparin, nitrates either given sublingual or intravenous, sedation with benzodiazepines, and morphine for analgesic properties. Are you getting left behind?

Aldosterone antagonists - Aldosterone antagonists spironolactone, epleronone should be given to patients with: If an early conservative strategy is adopted, then the following should be assessed during the hospital stay and follow up: Post discharge therapy Following discharge, patients should be: This should include: New onset ST-segment elevation of: History - Chest pain of STEMI is typically retrosternal, severe, crushing, squeezing or pressing in nature, lasting more than 30 minutes, associated with profuse sweating, nausea, vomiting and shortness of breath.

Common presenting symptoms in these patients are dyspnoea and atypical chest pains.

Emergency medicine ooi pdf shirley

If the clinical index of suspicion of STEMI is high, 12 lead ECG tracings repeated at close intervals of at least 15 minutes might show evolving changes. The latter requires right sided chest leads for diagnosis. One should not, however, wait for the results of these biomarkers before initiating reperfusion therapy. These cardiac biomarkers include: Preferably 2 intravenous lines should be set up. Time from onset of symptoms B. Contraindications to fibrinolytic therapy C. High risk patients These include patients with: Fibrinolytic Therapy a.

Choice of Fibrinolytic Agent Presently the agents available in Malaysia are: Indicators of successful reperfusion Some useful guides are: These patients are more likely to develop complications such as heart failure and arrhythmias. Primary PCI - This is the reperfusion strategy of choice. Facilitated PCI -This is not recommended. Those who may benefit are patients with: As such, patients should be individually evaluated.

Aspirin - The initial dose of mg should be followed by a maintenance dose of 75 to mg daily. Clopidogrel - A loading dose of mg should be given followed by a maintenance dose of 75 mg daily. Synthetic pentasaccharide fondaparinux Synthetic pentasaccharide fondaparinux - fondaparinux is given at a dose of 2. In patients who were given fibrinolytic agents or who were not reperfused, it was shown to be beneficial. No bolus, s. IX Statins - recent data has shown that statins started within 24 hours of admission or continued after admission leads to a reduction in major adverse cardiac events.

Guide to the Essentials in Emergency Medicine

It is given to patients post MI with impaired LV function and with mild heart failure. Flow chart 3: Tachyarrhythmias I Pulseless ventricular tachyarrythmias. V Atrial fibrillation AF. Bradyarrhythmias These are: I Sinus bradycardia.

Atropine may be given in the interim. Differential diagnoses of LV dysfunction and shock Differential diagnoses are: Investigations Investigations that may be helpful in making the diagnosis and in the management includes: Intra-aortic balloon pump may be useful. The decision must be individualized.

However, this ECG finding may be transient, often resolving within hours. This is immunologically mediated. It is treated with aspirin mg times a day. Deep Venous Thrombosis DVT - In high risk patients prolonged bed rest, heart failure, unable to mobilize , prophylactic anti-coagulation therapy subcutaneous heparin units bd, LMWH — e. Risk stratification starts from admission and is a continuing process. This may be done by assessing: The latter patients would benefit from revascularization.

This includes: This programme aims at: The other causes are as listed in Table The most common underlying causes of HF in adults are: Alcohol, adriamycin, cyclophosphamide - Endocrine and metabolic: Aetiology of Heart Failure - The principles of management are: Haemoglobin, serum electrolytes, urea, creatinine, - serum cardiac biomarkers, arterial blood gases - Echocardiography Special Investigations: Investigations in Acute Cardiogenic Pulmonary Oedema 4.

Nitrates are contraindicated in severe valvular stenosis. This would enable the appropriate treatment to be instituted early. Parameters to assess during treatment includes: If the patient fails to respond to the above therapy, further management would depend upon the blood pressure and tissue perfusion. In the presence of an adequate blood pressure: This agent improves symptoms and haemodynamics in AHF.

IABP would be particularly useful in patients with intractable myocardial ischaemia or acute mitral regurgitation. The initial dose of oral diuretics required is generally higher than the intravenous dose. Patient factors - non compliance to medications - dietary indiscretion especially salt and fluid intake - inappropriate medications e.

NSAIDS - alcohol consumption Cardiac causes - superimposed myocardial ischaemia or infarction often asymptomatic - uncontrolled hypertension - arrhythmias - pulmonary embolism - secondary mitral or tricuspid regurgitation Systemic conditions - superimposed infections - anaemia - thyroid disease - electrolyte disturbances - worsening renal disease Table Special situations: Treat accordingly Hypertension: Control BP quickly Valvular heart disease: Management of Acute Cardiogenic Pulmonary Oedema 4.

VAD -? Cardiac transplant Flowchart 5: Oral potassium supplementation is usually necessary. If patients are on large doses of diuretics, the blood pressure and renal function should be monitored.

The dose should be increased gradually to the target dose Table 18 or maximum tolerated dose. The dose should be titrated up to the maintenance level as shown in Table ARB should be considered. Serum potassium should be monitored regularly. Potassium supplements may need to be reduced or stopped.

If hyperkalemia persists, then aldosterone receptor antagonists should be stopped. The usual maintenance dose of digoxin is 0. Lower doses should be used in the elderly and in patients with impaired renal function. The more common ones are: This is most often due to either sustained ventricular tachycardia VT or ventricular fibrillation VF - The following medications have been shown to reduce the incidence of sudden death: These have been found to improve survival both as secondary prevention and as primary prevention in selected patients.

Features include: In the presence of preserved LV systolic function, other causes of shock such as sepsis and intravascular volume depletion should be considered.

This may be due to excessive diuretic or vasodilator therapy, concomitant GI bleed or RV infarction. In the absence of signs of LV failure, fluid challenge with normal saline should be administered usual recommended volume: Invasive haemodynamic monitoring would be useful to guide fluid therapy.

Resistant arrhythmias would require additional anti-arrhythmic drug therapy. If blood pressure is adequate in the setting of near shock, dobutamine may be used.

Cardiogenic shock in this setting could be due to: Often they would require ventilatory support and intra-aortic balloon counterpulsation IABP. Echocardiography will be useful in the diagnosis. Urgent surgery is beneficial but carries a high mortality. Management of Arrhythmias These include: Tachyarrhythmias - Pulseless ventricular tachyarrythmias refer to algorithm 1 [Shockable waves refers to the presence of recognizable organized or disorganized cardiac rhythms on continuous ECG monitoring while non shockable waves refers to the absence of any heart rhythm on ECG monitoring] - Stable Ventricular Tachycardia VT refer to algorithm 2.

Correct underlying ischaemia, hypoxia and electrolyte disturbances. This is especially important in patients with: Bradyarrhythmias - these are: Stable Ventricular Tachycardia A. Algorithm 1: IV — IV Monomorphic VT - Check electrolytes and correct accordingly - Stop all anti-arrhythmics drugs if any - i. Bradycardia 6. Management of Severe Hypertension 6. These include heart failure, stroke, acute coronary syndromes, acute renal failure, dissecting aneursym and hypertensive encephalopathy.

This includes optimizing treatment by using effective combination therapy. This does not necessarily mean that these drugs should be routinely used in all cases of hypertensive urgencies. May repeat sequence 1 — 2 min 3 — 10 minutes Used in peri- operative situations and tachyarrhythmias Table The manifestations and treatment are the same as that for anaphylaxis.

Continue for days to prevent recurrence. May have a role in treating bronchospasm and cutaneous manifestations. Oral steroids are usually continued for 2 to 3 days. Sometimes large volumes may be required. Larger than usual doses or glucagon may be necessary. Severe Asthma 2.

Spontaneous Pneumothorax 3. Haemoptysis 4. Deep Vein Thrombosis 5. Pulmonary Embolism 1. The severity of the attack should be assessed by: Bradycardia or hypotension indicates very severe attack and imminent cardiorespiratory failure. In asthma associated with chronic obstructive pulmonary disease COPD , high O2 flow rates may remove the hypoxic drive and lead to respiratory arrest. A severely distressed patient will find an inhalational aid like a "Volumetric" or a "Nebuhaler" helpful if a nebuliser device is not available.

Once the patient is stable, change therapy to metered dose inhaler. Repeat according to response every half hourly or even more frequently initially to 6 hourly. Be careful of arrhythmias in elderly patients especially if given frequently. It has little side effects and is useful in elderly patients with associated heart disease. May be used in combination with beta 2 agonists.

May be given up to 4 times a day. In patients on oral theophylline, the loading dose is not necessary. Aminophylline has a narrow therapeutic index and may be complicated by seizures, arrhythmias and emesis. IV salbutamol or terbutaline can be used as an alternative to aminophylline. Prednisolone is usually given at dose of 0. In severely ill or unable to tolerate orally, give IV hydrocortisone mg stat and then 6 hourly as an initial therapy. Prednisolone is given for a duration of 1 to 2 weeks in a tailing off dose.

Correction of bronchospasm will spontaneously correct the acidosis. Clinical symptoms and signs of improvement or deterioration should be carefully looked for. Aids to monitoring include: Spontaneous Pneumothorax - Causes: Rupture of subpleural bleb, bulla, lung cyst or abscess. Death can occur from respiratory or cardiac failure.

There may be deviation of the trachea and mediastinum to the contralateral side. To calculate the size of a pneumothorax: British Thoracic Society pleural disease guideline is to measure the distance between the pleural surface and the lung edge taken at the level of the hilum — see Figure 3.

Figure 3: It is only used when differentiating from complex bullous disease, to indicate other pathology such as emphysema and when aberrant tube placement is suspected. Usually takes weeks. If this does not offer improvement, insertion of an intercostal drain should be performed. Aspiration may be performed in those with small pneumothorax and without respiratory compromise. Consider intercostal drain insertion if there is no significant improvement.

The trocar is withdrawn and the drain is left 6 - 8 cm inside the pleural cavity. The drain is kept in position by a suture. The other end of the drain is attached to an underwater seal. Rapid re-expansion of lung is associated with: If this shows full re-expansion, the drain is left clamped for another 24 hours and the CXR is repeated.

Confirmation of no further leakage of air is followed by removal of the drain. Haemoptysis - Common causes: Be careful of oxygen therapy in patients with prolonged hypoxia as this may remove the hypoxic drive.

The patient is often very frightened and reassurance is necessary. Massive haemoptysis is uncommon and haemoptysis is self-limiting in the majority of cases. Careful observation is still mandatory as death may occur from asphyxiation or sudden unexpected massive bleed. The usual dosage is to mg t. Insert a large bore intravenous branula in all cases. Reserve at least 2 units of blood. Deep vein thrombosis - To diagnose this condition, one must be aware and actively looking for it.

The causes and associations are remembered by considering Virchow's triad: Physical signs are highly unreliable and many DVT remain undiagnosed. Homan's sign should NOT be elicited as it may dislodge the clot. Onset of anticoagulation effect takes about 3 days. Warfarin acts by interfering with Vitamin K metabolism. Give IV Vitamin K 10 - 30 mg. The anticoagulant effect is reversed in 24 hours.

For transient reversal of anticoagulation, it is preferable to use FFP because reversal with Vitamin K will cause resistance to warfarin for up to 2 weeks. C low molecular heparin in prophylactic dose in high risk patients. Laboratory monitoring is usually not necessary. This does not cause primary or secondary haemorrhage. The femoro-iliac venous segment is the most common source. Pleuritic chest pain and haemoptysis occur only if infarction has occurred.

Difficult to find the classic wedge shape shadow, elevated diaphragm, pleural effusion and diminished vasculature. With massive embolisation, the patient is in critical condition. Circulatory and cardiac arrest requires resuscitation.

External cardiac massage may break up the embolus. Pulmonary angiography followed by pulmonary embolectomy is the definitive treatment. Thrombolytic agents like streptokinase and plasminogen activators offer alternative treatment. The comatose patient 2. Meningitis 3. Stroke 4. Treatment of Intracranial hypertension 5. Diagnosis of brain death 6. Status epilepticus 7. Tetanus 8.

Gullain Barre Syndrome 9. Myasthenia Gravis 1. The comatose patient - Definition: A patient who fails to respond to call, often stuporose but may have verbal response or movement to pain stimuli. Glasgow Coma Scale is often used to assess the severity of comatose state.

In comatose patients, an oropharyngeal airway is helpful to prevent the tongue from falling back and to assist suction. If negative, initiate CPR. Use a test strip for immediate blood sugar value. A dramatic but short lived response is seen in narcotic overdose.

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Tips on Neurological examination: The pupil contracts for a short while then dilates and does not respond to light.

With further increase in pressure the other pupil is also affected. May be associated with up going plantar on the contralateral side. In subarachnoid haemorrhage, subhyaloid haemorrhage may be noted.

DO NOT use mydriatics. You will lose a very valuable sign. Always check fundi for papilloedema before doing and lumbar puncture. NEVER do an lumbar puncture if a space occupying lesion is present. Main indications for lumbar puncture are: In acute cerebrovascular accident CVA , the side affected is hypotonic and possibly areflexic. In brainstem lesions, they deviate to the contralateral side. Meningitis - Definition: Infection of the meninges of the brain by micro-organisms.

Often there is presence of abnormal cerebrospinal fluids CSF findings. Normal CSF is clear and colorless. Opening pressure is less than 25 cm H The CSF protein level is usually elevated and the sugar level can be either normal or low.

The sugar level is low and the protein level is moderately high. However, in early cases of bacterial meningitis, the CSF findings may be normal. Broad spectrum antibiotics that penetrate the blood brain barrier are used. Stroke - Definition: Cerebral haemorrhage account for the remainder.

The mechanism of cerebral Infarcts may be due to insitu thrombosis or embolism. Embolism may be from a cardiac source or artery to artery emboli. Causes are due to risk factors for artherosclerosis.

Primary Intracerebral Haemorrhage is associated with rupture of Charcot-Bouchard aneurysms in patients who usually have hypertension. It is the only reliable investigation to exclude a cerebral bleed. Intubate patient if necessary. The ischaemic areas around the infracted zone lose auto-regulation of cerebral blood flow and perfusion is dependent on the blood pressure. Rapid lowering of BP may be associated with decreased perfusion to these areas and is thus harmful.

Gentle reduction of the BP is advised. Hypertensive encephalopathy warrants a more rapid reduction of BP. CT scan may show the massive mass effect and herniation of the brain. Dexamethasone is generally ineffective in strokes as cerebral edema is mostly cytopathic rather than vasogenic.

Dehydrating agents e. In a young patient with massive cerebral edema due to an infarct in the non dominant cerebral hemisphere, a radical decompressive surgery may be performed. Hence it is important that a CT scan be performed before anticoagulation is started to avoid secondary haemorrhage. Furthermore, early anticoagulation may precipitate secondary haemorrhage and it is advisable to start anticoagulation only after one to two weeks in large artery territorial infarcts.

Anti-platelet agents such as aspirin or clopidogrel may be given at the onset of acute cerebral infarcts. If the onset of cerebral infarct is less than 4. If symptomatic haemorrhagic transformation occurs, use of cryoprecipitate and neurosurgical referral is needed. Progression to coma and death is rapid due to brainstem compression. Suspect in patients who are rapidly deteriorating. Neurosurgery opinion is required. One third of cases re-bleed in the first one to two weeks.

CT scan brain and angiography is needed to indicate the site of bleeding and other associated aneurysms. Surgical clipping of the aneurysm or intravascular coiling is the preferred definitive treatment. Diazepam may be give per rectum at the same dose if an IV line could not be secured rapidly.

Anticonvulsants should be given as soon as possible. Cheyne — Strokes respiration 4. Treatment of Intracranial Hypertension - Neurosurgical intervention is possible treatment for large intracranial haematomas with mass effect and deterioration of neurological status. However, treatment of underlying cause is the mainstay of treatment. Takes 15 minutes to act and pressure is relieved for 4 — 6 hours. IV dexamethasone 8 mg is given 6 -8 hourly is useful for vasogenic cerebral edema associated with primary or secondary tumours.

Cytopathic cerebral edema due to anoxia or infarction does not usually respond to steroids. This reduces the intracranial volume of blood and decreases intracranial pressure. The Pa CO2 is reduced to 25 — 30mm Hg. Hence, elective ventilation may be needed. Diagnosis of Brain Death - Definition - means irreversible cessation of brain stem function. Need to exclude that this is not due to drugs, primary hypothermia, metabolic or endocrine causes because these cause reversible coma.

If in doubt, re-establish mechanical ventilation. Repeat tests after 24 hours. Status Epilepticus - Definition: The condition where one seizure follows another without recovery of consciousness.

It may be convulsive or non convulsive. Do not force when fitting. Place it in between seizures. The un-coordinated respiratory efforts together with increased metabolism requires oxygen at high flow rates. Use a test strip to determine the blood glucose. Pause at 10 mg and at each subsequent 5 mg to assess the effects.

Maximum bolus dose is 20 mg. The dose may be repeated if necessary after 30 minutes. Risk of hypotension and respiratory depression with high doses. Be prepared for mechanical ventilation. Diazepam may be given per rectum if an IV line is not immediately available. IV diazepam infusion may be given without dilution at 2 to 4 mg per hour.

Watch for respiratory depression. DO NOT give i. IV maintenance at mg every 8 hourly. Monitor the BP closely for hypotension. ECG monitoring is required. Further i. It is important to continue with anticonvulsants as seizure activity may persist despite the paralysis.

EEG monitoring is useful if available to assess the effectiveness of the anticonvulsants in inhibiting the abnormal cerebral discharge. NaHCO3 may be required for correction. Tetanus - Definition - a potentially fatal disease caused by Clostridium tetani. The organism produces tetanospasmin which blocks the function of inhibitory neurons hence increasing reflex excitability of motor nerves. This period varies greatly from one to three months. Generally, it is less than 14 days. The shorter the incubation period, the worse the prognosis.

The shorter the interval, the worse the prognosis. Whole groups of muscles suddenly contract and this will impede respiration. Spasms may be rapidly recurrent and this will seriously embarrass respiration. There is risk of laryngospasm and a tracheostomy is required. Laryngeal spasms may occur suddenly and must be looked for.

Severe cases may be complicated by: Given as early as possible. It is effective only against circulating toxin. Toxin which has already reached the CNS is unaffected.

Medicine emergency shirley pdf ooi

It is however routinely given. These patients should be nursed in a quiet darkened room to minimize external stimuli. The use of tacheostomy circumvents this risk. A tracheostomy is usually required. Patients are paralysed for at least days.

Most patients start to recover by the 3rd week of illness. Parasympathetic over activity is treated with atropine. Active immunisation with 0. Immunity lasts for 5 years and booster doses are then required. If ATT is given during the acute illness, passive immunisation with immunoglobulins must be given at a different site. Post infectious auto immune disease due to the presence of antibodies to myelin and axons.

Myasthenia Gravis - Definition - Autoimmune disease characterized by weakness and fatigability of muscles. Maintain airway and support circulation. Tracheostomy if long term ventilation is needed. Need to maintain good caloric intake.

Both will take a few weeks to work. Diabetes mellitus emergencies A. Hypoglycaemia B. Diabetes ketoacidosis C. Hyperglycaemic hyperosmolar non-ketotic coma D. Lactic acidosis 2. Hypercalcaemia 3. Thyroid emergencies A. Myxoedema coma B. Thyrotoxic crisis 1. Hypoglycaemic Coma - Always rule out this condition first in any comatose patient. May be mistaken as being drunk. They may have focal neurological deficits such as hemiparesis and can be easily mistaken for a stroke.

If prolonged, this may result in permanent brain damage. Further action such as feeding is needed to prevent recurrent episodes. Patient and their relatives should be taught on how to correct impending hypoglycaemia with food or drinks rich in glucose or sugar. Diabetic ketoacidosis DKA - A serious condition characterized by: Type 2 diabetics may also develop DKA if there are precipitating factors causing an increase in insulin requirement.

It is very important to realize that DKA may present as epigastric pain. This is an essential step, which must not be overlooked. Adequate fluid replacement is crucial and patients must be examined frequently to look for signs of overloading or under- hydration.

Suggested regime: The patient must be monitored carefully to avoid overloading and pulmonary oedema especially in the elderly and those with congestive cardiac failure CCF or renal impairment. A central venous line CVP line is helpful. An intravenous loading dose of 10 units of insulin can be given prior to infusion. If no infusion pump is available, insulin is given via a burrette or as hourly intramuscular injections. In patients with serious infections, insulin resistance may occur and will pose a challenge in maintaining good blood sugar control.

Glucose test strip is a convenient and rapid way of monitoring. Put 1gm KCI in each 0. Monitor with blood urea and serum electrolytes twice daily and ECG monitoring in order to determine whether the replacement is adequate or excessive. Please note that the 8. Arterial blood gas monitoring is required. Additional potassium supplement is required whenever alkalis are given.

Indiscriminate use of NaHCO 3 is associated with: Measurement of anionic gap is a more reliable gauge of ketoacidosis. Hyperglycaemic hyperosmolar non-ketotic coma - Occurs predominantly in Type 2 diabetes mellitus, presenting with severe dehydration and hyperglycaemia, without ketoacidosis. This occurs usually in the setting of an elderly diabetic living alone who is ill from some other concurrent illness. Large quantities of fluid are needed for replacement but this must be infused slowly and with careful central venous pressure CVP monitoring.

Overzealous and rapid infusion can result in cerebral oedema, disequilibrium syndrome and pulmonary oedema in these elderly patients.

Quick Management Guide in Emergency Medicine v1.0.25 20111208 (Build13)

Correct deficit over 24 hours. Start at 1 to 3 units per hour. Monitor with glucose test strip 2 to 4 hourly in the first 24 hours. Therefore, appropriate dose of low molecular weight heparin is needed to prevent DVT. Lactic Acidosis - Occurs in elderly diabetics, and often with a background of renal impairment or liver impairment e. Blood sugar may be slightly raised or normal and there is little if any ketonuria. Blood lactic acid levels are raised and HCO 3 reduced.

Laboratory diagnosis of diabetic emergencies 2. Hypercalcaemia - Causes: When patient is rehydrated, i. Potassium supplements are needed. The fluid balance must be carefully monitored. Central venous pressure CVP monitoring is required. It becomes ineffective after a few days for unknown reason.


It can be given by either via intramuscular i. However, it is not useful in primary hyperparathyroidism. The onset is slow and requires several days for therapeutic effect. It may cause shock, fatal hypocalcaemia and renal cortical necrosis. May be given orally or as an enema. Oral phosphate is given at mg of PO 4 2- every 6 hourly.

The use is limited to patients with hypophosphataemia as in primary hyperparathyroidism because of the risk of metastatic calcification. Myxoedema coma - A high index of suspicion is needed to diagnose this condition.

It is important to keep the body temperature within normal with the use of blankets or warmer. Central venous pressure CVP monitoring may be required. Both the oral or intravenous form of T 4 or T 3 can be used. A large dose is necessary in the setting of myxoedema coma because of tissue resistance to T 4.

Clinical response is slow and often takes several days to see the effects. Initial low doses are recommended in the setting of uncomplicated hypothyroidism in the elderly because of the risk of ischaemic heart disease. OR II. T 3 - this is four times as potent as T 4. It has an earlier onset of action, which is 5 hours after dosage. It circumvents the reduced peripheral conversion of T 4 to T 3 in hypothyroidism. Therefore, low dose T 3 must be used in view of the above. T 3 is given at 20 micrograms every 12 hours.

T 4 may be substituted for T 3 when the patient is improving. Thyrotoxic Crisis - It is a state of decompensated thyrotoxicosis, with failure of organs to cope with the additional metabolic demands.

Death is frequently from congestive cardiac failure and bronchopneumonia. May need to continue with infusion and preferably be monitored in intensive care unit. Central venous pressure CVP monitoring is useful for this purpose. Aspirin is contraindicated as it displaces bound thyroxine from its carrier protein. Propylthiouracil - mg given 6 hourly for first 24 hours and then reduce dosage to — mg 8 hourly.

This has the added advantage of inhibitory effect on conversion of T 4 to T 3 , hence this is the drug of choice OR II.

Carbimazole 15 — 30 mg 6 hourly for first 24 hours and then reduce dosage to 10 — 20 mg 8 hourly. This is to ensure that the iodine given is not taken up by the gland for further thyroid hormone synthesis and subsequent release.


Iodine normally only temporarily inhibits the thyroid hormone release the acute Wolff-Chaikoff effect, which lasts only for about weeks. Therefore, the drug should be withdrawn over the subsequent 2 weeks.

This is the drug of choice. Caution in cardiac failure and obstructive airway disease. Thrombocytopaenia 2. Haemophilia I. Haemophilia A II. Haemophilia B 5. Warfarin overdose Introduction - A bleeding disorder is characterized by spontaneous, excessive or delayed bleeding following trauma.

Bleeding can result from diseases of vessels, platelets or coagulation factors. Certain medications can also cause abnormal bleeding. Abnormal when more than 2 seconds longer than control Partial thromboplastin time PTT Measures the intrinsic pathway. Abnormal when more than 10 seconds longer than the control Thrombin time TT Evaluates the last phase of coagulation. Fibrinogen deficiency will results in prolonged TT Table 5. Thrombocytopaenia - Definition: The treatment is directed towards the underlying cause.

In such cases, at least 6 units of platelets or apheresed platelets SDPs are transfused. The bone marrow picture is supportive but not diagnostic. Acute self limited form, usually preceded by infection often viral such as Ebstein-barr virus, cytomegalovirus, hepatitis. Rare in adults II. Chronic recurrent type - associated with obvious initiating illness.

Women aged years are most commonly affected.


Presence of splenomegaly suggests other causes of thrombocytopaenia. The indications are: It should return to normal levels. Steroid side effects may make long-term treatment unacceptable. These steroid responsive but steroid dependent patients respond well to splenectomy. Coli O Fresh frozen plasma FFP transfusions may be given but are less effective. Most common inherited disorder of coagulation, which is X-link recessive. When the patient complains of pain, start treatment as early treatment is more effective, less costly and can be lifesaving.

Efficient replacement therapy requires serial transfusions every hours. This has to be repeated every hourly to maintain the desired level. Haemophilia B - Definition: The diffuse intravascular clotting triggered by the underlying cause consumes clotting factors and platelets. Pathogenesis and clinical presentation — see flowchart 5. Pathogenesis and clinical presentation of DIC Acute Subacute - Obstetric complications - Abruptio placentae - Incomplete or missed abortion - Amniotic fluid embolism - Infections - septicaemia especially Gram negative, meningococcal, staphylococcal and clostridium - Surgery - especially of the heart, lungs and prostate - Snake bite - Vipers - Haemolytic transfusion reaction - Pulmonary embolism - Heat stroke - Fat embolism - Shock - Massive trauma - Neoplasia - Cancer prostate, lung breast, pancreas - Acute leukaemia esp promyelocytic - Systemic lupus erythematosus SLE - Haemangioma Table 5.

Unless serious haemorrhagic or thrombotic features are present, no further therapy is usually needed. Infused platelets may form aggregates and block microcirculation while infused fibrinogen may lead to further deposition and damage. It is usually used in cases with a subacute or chronic cause whereby the triggering factor persists or cannot be immediately removed. Heparin is also used in cases with predominant thrombotic features. Heparin acts by increasing the natural anticoagulant activity of anti thrombin III.

Warfarin overdose - Warfarin overdose may be accidental or due to drug interaction, potentiating the action of warfarin. There is no need to give FFP or vitamin K. The patient can be closely followed up daily as an outpatient unless logistically difficult. Withhold the warfarin and give i.

Give FFP units and i. If INR within therapeutic range and patient is bleeding, look hard for a local cause of the bleeding e. Introduction 2.

Management of blood transfusion reaction 1. Introduction - Blood transfusion is potentially life-saving in appropriate setting but carries a small risk of acute or late adverse effects. Indications should be documented in the clinical notes. Consent need to be taken for blood transfusion. Clinical Presentation subtypes and management of Acute Blood Transfusion Reactions The most common immediate adverse reactions to transfusion are fever, chills and urticaria.

The most potentially significant reactions include acute and delayed haemolytic transfusion reactions and bacterial contamination of blood products. During the early stages of a reaction it may be difficult to ascertain the cause.

Fever and chills due to contaminating white cells in blood products. Fever can be the initial sign in more severe transfusion reactions haemolytic or bacterial sepsis and should be taken seriously. Treatment is symptomatic only, including paracetamol. Use of white cell filter for red cell and platelet transfusion.

In those with urticarial reactions without other signs or symptoms, it is not necessary to submit blood specimens for investigation. Patients with cardiopulmonary disease, elderly and infants are at risk of volume overload especially during rapid transfusion. Avoid unnecessary fluids and use appropriate infusion rates. May need to monitor the transfusion rates with central venous pressure in those at risks. Diuretics may need to be given with blood transfusion. IgA deficiency patients with anti-IgA antibodies can have these reactions.

IgA levels and anti-IgA antibodies. Patient will need washed red blood cells and plasma products prepared from IgA deficient donors. Notify hospital blood bank urgently another patient may also have been given the wrong blood! Usually arises due to clerical errors. Hence, it is of paramount importance to ensure the right blood goes to the right person at the right time for the right indication!

Prevention of non-immune haemolysis requires adherence to proper handling, storage and administration of blood products. Bacteria may be introduced into the pack at the time of blood collection from sources such as donor skin, donor bacteraemia or equipment used during blood collection or processing.

Platelets are more frequently implicated than red cells. Inspect blood products prior to transfusion. Some but not all bacterially contaminated products can be recognized such as presence of clots, clumps, or abnormal colour. Maintain appropriate cold storage of red cells in a monitored blood bank refrigerator. Once removed from blood bank refrigerator, blood is to be immediately transfused and duration of transfusion of packed cells should not be more than 4 hours.

It is characterized by acute respiratory distress and bilaterally symmetrical pulmonary oedema with hypoxaemia developing within 2 to 8 hours after a transfusion. A CXR shows interstitial infiltrates when no cardiogenic or other cause of pulmonary oedema exists. Secondary to cytokines in the transfused product or from interaction between patient white cell antigens and donor antibodies or vice versa. Due to rapid infusion of large volumes of stored blood. Infants are particularly at risk during exchange or massive transfusion.

Appropriately maintained blood warmers should be used during massive or exchange transfusion. Rapid administration of large quantities of stored blood may cause hypocalcaemia and hypomagnesaemia when citrate binds to calcium and magnesium.

This can result in myocardial depression or coagulopathy. Patients most at risk are those with liver dysfunction or neonates with immature liver function having rapid large volume transfusion.

Stored red cells leak potassium proportionately throughout their storage life. Irradiation of red cells increases the rate of potassium leakage.

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Clinically significant hyperkalaemia can occur during rapid, large volume transfusion of older red cell units in small infants and children.

Blood less than 7 days old is generally used for rapid large volume transfusion in small infants in situation such as during cardiac surgery, extra corporeal membrane oxygenation ECMO or exchange transfusion. Management of blood transfusion reaction - Stop the transfusion immediately. Initiate definitive treatment based on the clinical evaluation.

Mild reactions: Big problem! Call for help. Inform blood bank. Chapter 7 Renal Emergencies Table of content 1. Specific Syndromes 2. Acute Renal Insufficiency ARI - Acute renal insufficiency ARI previously known as acute renal failure is defined as rapid decline in glomerular filtration rate GFR from hours to days, leading to metabolic derangement with or without anuria or oliguria. She received the National Outstanding Clinician Educator Award in for her outstanding and immense contribution in meducine and shaping future medical leaders, and the development of the field ioi Emergency Medicine Education in Singapore.

New features of this second edition include: Includes tips for GPs like me. Paperback2nd editionpages. Do you shirley ooi emergency medicine other people are making progress much faster than you?

Rewire your belief system. Are you getting left behind? Shopbop Designer Fashion Brands. She has received multiple research grants and published multiple articles in peer-reviewed journals. Dewa P rated it liked it Dec 30, Goodreads helps you keep track of books you want to read. Thanks for shirley ooi emergency medicine us about the problem. She is also a reviewer with the Annals of the Academy of Medicine of Singapore.

There was a problem filtering reviews right now. The first edition of the Guide to the Essentials in Emergency Medicineco-edited by two prominent emergency physicians, Associate Shirley ooi emergency medicine Shirley Ooi and Peter Manning, with a combined total of 64 years of Emergency Medicine practice between them, was first published in Singapore in Revolutionize your learning capabilities today!

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