Aaqid Akram MBChB (2013) Clinical Education Fellow
ACC - C Week Aaqid Akram MBChB (2013) Clinical Education Fellow
Objectives Recognise and manage shock IV fluid management
Recognise and manage ACS Recognise and manage acute LVF Recognise
and manage diabetic complications Recognise and manage upper GI
bleeds Be able to interpret ECGs Case 1 40 year old male 2 day
history of diarrhoea and vomiting
Sudden onset haematemesis Now light headed BP 80 systolic Mallory
weiss syndrome acute upper GI bleed - ABCDE Upper GI bleed Peptic
ulcer disease Oesophageal varices
Oesophagitis / gastritis / duodenitis Malignancy Mallory-Weiss tear
Vascular malformations Risk Factors Alcohol Chronic Renal Failure
NSAID use Age
Lower socio-economic class Previous UGIB H Pylori Bleeding
Haematemesis Haematochezia Coffee ground vomit Malaena
Fresh red blood ACTIVE BLEEDING Haematochezia Passage of
fresh/altered blood per rectum Colonic bleeding Profuse upper GI
bleeding Coffee ground vomit Ceased bleeding Relatively modest
bleeding Malaena Black tarry stools Digestion of upper GI bleed If
signs of shock or haemodynamic compromise manage that first.
Management non variceal
Resuscitation Fluid Challenge Blood Transfusion PPI only after
endoscopy If Unstable - Interventional radiology / Surgery
Blatchford Bleeding Score Hb Urea BP Pulse Malaena Syncope Hepatic
disease Cardiac Failure Endoscopy Mechanical (clips) +/- adrenaline
Thermal coagulation + adrenaline Fibrin/Thrombin + adrenaline
Proton Pump Inhibitor If failed first attempt Repeat endoscopy
Interventional radiology Surgery Blatchford bleeding score will
guide to urgency of endoscopy required. >0 is high risk >6 is
50% mortality Rockall score may be used pre and post endoscopy: Pre
- Age / shock / co-morbidity Post Diag / major stigmata of major
haemorrhage Blatchford score Management - variceal Resuscitation
Fluid Challenge Blood Transfusion Terlipressin/octreotide Abx If
Unstable - Interventional radiology / Surgery Blatchford Bleeding
Score Hb Urea BP Pulse Malaena Syncope Hepatic disease Cardiac
Failure Endoscopy Band ligation Stent Insertion Transjugular
intrahepatic portosystemic shunts (TIPS) Gastric:
N-butyl-2-cyanoacrylate injection Balloon tamponade for temporary
salvage treatment of uncontrolled variceal haemorrhage IV fluids
Resuscitation Routine maintenance Replacement Redistribution
Fluid Homeostasis Resuscitation Routine maintenance Replacement
Redistribution Reassessment 5 Rs Fluid status BP Pulse JVP Postural
Hypotension Oedema CRT NEWS
Fluid balance chart Weights FBC U+E Abnormal losses Thirst Initial
Assessment ABCDE Fluid Resuscitation Systolic BP < 100
HR > 90 CRT > 2 seconds RR > 20 NEWS > 4 Passive leg
raise (if positive then likely fluid responsive) Fluid
Resuscitation Fluid Resuscitation Initiate Treatment: Identify
cause of deficit
500 ml crystalloid (15 mins) Reassess (ABCDE) If more fluid needed:
Give up to 2000ml in 500ml boluses Signs of shock Senior Help
Routine maintenance Only use if insufficient oral intake
Initial prescription (24 hours) Water: 30ml/kg/day
Sodium/Potassium/ Chloride: 1mmol/kg/day Glucose: g/day Limit
starvation ketosis Not enough for total nutritional need Further
prescription Reassessment Alter as per electrolytes / renal
function NG/enteral feed preferable if more than 3 days needed
Think about refeeding syndrome Sodium chloride 0.18% in 4% glucose
(Dextrose) + 27 mmol/L Potassium Replacement Existing
fluid/electrolyte deficits or excess
Dehydration Fluid Overload Hyperkalaemia/hypokalaemia Abnormal
Distribution Ongoing losses Ongoing losses Liver / cardiac / renal
failure Hypo / hypernatraemia
Redistribution Gross oedema Severe Sepsis Liver / cardiac / renal
failure Hypo / hypernatraemia Post Operative fluid retention
Malnutrition / refeeding Case 2 50 year old male Sudden onset
central, crushing chest pain
Radiating down left arm SOB + sweating PMH: Hypertension
Hypercholesterolaemia Anteroseptal MI - LAD LBBB (new) STEMI / New
LBBB ABCDE Call PCI centre (Keep YAS there if possible)
If no PCI - Thrombolysis Clopidogrel / Ticagrelor Aspirin (Make
sure YAS not already administered) Nitrates (GTN) Morphine +
antiemetic Oxygen, if required Call PCI centre (Keep YAS there if
possible) ABCDE ABCDE LGI PCI 15L NRB Morphine IV titrate 10mg
Antiemetic IV cyclizine/ondansetron/metoclopramide/levopromazine
GTN 300mcg SL Aspirin 300mg Clopidogrel 300mg / ticagrelor 180mg CI
active bleeding / previous IC bleed / moderate + hepatic impairment
/ CYP3A4 inhibitors (ketoconazole / clarithromycin /
antiretrovirals) Caution major surgery 30 days / gi bleed 6 months
/ severe thrombocytopenia / NSAIDs / fibrinolytics / anticoagulants
/ bradycardia Thrombolysis similar exclusion criteria to ticagrelor
IV Fonda (2.5mg) IV TNK (Tenectoplase) SC Fonda (2.5mg) TNK unless
>75yo female then consider streptokinase Case 3 18 year old
female GCS 8 Collateral Hx: Unwell for 2 days
Vomiting Very tired for 6 months polyuria Variable Value O2 15L NRB
SpO2 98% RR 30 HR 120 Temp 37.5 BP 88/60 DKA Variable Value
Variable Value Range
Na 140 K 5 Creat 100 Urea 16 Cl WCC 15 Neuts 13 Variable Value
Range pH 7.29 pCO2 3.0 pO2 20 11-13 cHCO3 14 22-26 BE -9 -2 / +2
SaO2 60 >95% Lactate 1.8 320 mosmol/kg Glucose + urea + (2 x Na)
Hyperglycaemia >30 mmol/L Hypovolaemia No significant ketones in
urine/blood No significant acidosis There may be a mixed HHS and
DKA picture consult senior Treat underlying precipitant as
required
IV Fluids 0.9% NaCl 1L over 1 hour (Potassium supplementation as
required) IV insulin infusion (Fixed rate) ONLY if ketones present
0.05units/kg/hour Clinical Assessment Sepsis Vascular event Change
in DHx Dehydration Mental State Exam Investigations Blood glucose
U+E Measure osmolality VBG Ketones (Urine/blood) ECG / CXR / Urine
MC+S Urinary catheterisation Measure Urine Output (minimum 0.5
ml/kg/Hr) Calculate fluid balance Alert diabetes specialist team
Give LMWH unless CI Treat underlying precipitant as required IV
Fluids Aim positive balance 6 hours: 2-3L 12 hours: 3-6L
If any complications of Rx: fluid overload / cerebral oedema /
extra pontine myelinolysis seek senior help immediately Osmolality
Measure every 2 hours (1st 12 hours) Glucose + Urea + 2Na
Reduce by 3-8 mosmol/kg/Hr Declining appropriately Continue on 0.9%
NaCl Declining 8 mosmol/kg/Hr Reduce rate of IV fluid +/- Insulin
(if commenced) Glucose Measure at least every 2 hours (1st 12
hours)
Aim for minimum 5 mmol/L/Hr decrease Declining