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.
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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.
Popular Features. New in Guide to the Essentials in Emergency Medicine. Description The first edition of the Guide to the Essentials in Emergency Medicine, co-edited by two prominent emergency physicians, Associate Professors Shirley Ooi and Peter Manning, with a combined total of 64 years of Emergency Medicine practice between them, was first published in Singapore in This book focuses on the practical management of the most life-threatening and common conditions encountered by emergency physicians.
It is designed to offer a balanced viewpoint advocating the tenets of evidence-based medicine. This second edition preserves several of its predecessor's hallmark features.
Easy-to-read format: 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.
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. 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. 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.
Brown granular casts, cellular debris. Table 7. A normal size and normal echogenicity will indicate non chronicity.
Small shrunken kidneys on ultrasound indicate chronicity. If the renal hypoperfusion is left uncorrected it will lead to established acute tubular necrosis. There may be cases where one is not sure if there is a volume deficit.
In these cases, a fluid challenge test may be conducted. For fluid challenge test: Normal CVP from mid-axillary line is about 5 to 10 cm of water. Strict monitoring of the input and output of fluids is required as there is a risk of fluid overload. As the diuretic phase comes, large volumes of fluids may be needed to maintain balance.
In established oliguric ARI, reduce fluids to avoid overloading Normal Increase by 5 cm Decrease to normal Normal Increase by 5 cm Remain high Fluid overload Restrict fluids High No need fluid challenge Fluid overload or heart failure Decrease fluids or treat heart failure with inotropes.
Urgent ultrasound and other imaging investigation may be needed. Hyperkalaemia associated with ECG changes must be treated urgently.
The effect lasts only about 1 — 2 hours. The onset of effect is in 15 minutes and lasts 1 - 2 hours only. Response in 30 minutes and lasts about 4 to 6 hours. Commonly available formulation is calcium polystyrene sulfonate Kalimate , given orally at a dose of 15 — 30 gm daily in 2 or 3 divided doses. A high CHO diet is given to provide calories, with 0. No fruit or fruit juices are allowed as they contain significant amounts of potassium.
Referral to a dietician for advice and patient counseling should be done.
For infections, use of third generation cephalosporins as the initial antibiotic of choice. Acute upper gastrointestinal bleeding UGIB 2. Treatment of Hepatic Encephalopathy 1. Resuscitation must be commenced immediately. Fresh frozen plasma may be given if the prothrombin time is at least 1.
Initial hemoglobin or haematocrit level obtained in a patient with acute bleeding may not be reflective the degree of blood loss.
This is due to haemoconcentration. Passage of "fresh" malaena, which is maroon coloured or passage of bright red visible clots suggest active bleeding. Early endoscopy has 3 major roles, which is for diagnosis, treatment and risk stratification. Alternatively, Octreotide is administered as a bolus injection of 50 mcg followed by an infusion at a rate of 50 mcg per hour. Asterixis absent. Shortened attention span.
Impaired addition or subtraction. Hypersomnia, insomnia or inversion of sleep pattern. Euphoria or depression. Asterixis can be detected. Inappropriate behaviour. Slurred speech. Obvious asterixis. Bizarre behaviour. Semistupor to stupor. Asterixis generally absent. Consider inserting a nasogastric tube to deliver lactulose if unable to take orally. Efforts should be directed at correcting or treating the underlying precipitating factors and to maintain or improve the nutritional status.
Chapter 9 Sepsis Table of contents 1. Definition 2. Clinical aspects 3. Initial Resuscitation of Sepsis 4. Other Supportive Therapies 1. Definition - Definition - sepsis is considered present if infection is highly suspected or proven and two or more of the following systemic inflammatory response syndrome SIRS criteria are met: Some patients may progress to all the different stages of sepsis despite receiving appropriate treatment.
Conditions such as cellulitis inflammation of the skin's connective tissue can cause sepsis. International guidelines for management of sepsis and septic shock Intensive Care Med Dopamine or norepinephrine is the initial vasopressor of choice. Doses of dopamine often required are 0. If the respond is inadequate, norepinephrine at dose of 0. Insert an arterial catheter as soon as possible if patient requires vasopressors.
Once the blood pressure and perfusion have been stabilized, always use the lowest dosage that maintains blood pressure in order to minimize the complications of vasoconstriction. Obtain appropriate cultures e.
Begin antibiotic as early as possible within one hour of recognizing sepsis. Antimicrobial therapy is often an empiric choice and generally broad spectrum antibiotics one or more agents are used. A specific anatomic site of infection should be established as rapidly as possible.
Implement source control measures e. Intubation and mechanical ventilation is often needed in almost all patients with ARDS. Renal dysfunction is reflected by decreasing urine output, increasing blood urea and increasing creatinine. The aim is to maintain urine output of greater than 30 ml per hour. Insert urinary catheter to monitor urine output. However, avoid prolonged catheterization if possible. Blood glucose must be monitored. Continuous insulin infusion may be necessary to maintain target blood glucose levels.
A referral to a haematologist may be necessary as both anticoagulants and factors replacement therapy is potentially dangerous and should be used with caution. Chapter 10 Poisoning Table of contents B. Concept C. General Approach to Management D. Specific poisoning 1. Salicylate 2. Paracetamol 3. Narcotics Analgesic 4.
Pesticide a. Organophosphorus Compounds b. Paraquat 6. Methanol 7. Warfarin 8. Carbon Monoxide Sedative Hypnotics Caustics A. Concept - A high index of suspicion for intoxication and poisoning is warranted in the practice of medicine.
The inconsistent manifestations of poisoning are a challenge, particularly if patients present with altered sensorium or when there is no history of intoxications. Recognition of specific toxic syndrome or toxidrome is essential, but often the symptoms are often nonspecific or masked by other condition.
The term poisoning suggests an acute event demanding immediate care and attention. Poisoning may, however, be chronic resulting from environment sources such as food, water supplies etc. The cause for poisoning can be classified as accidental or deliberate.
It is also in the past referred to as parasuicide. Systemic toxicity is usually dose related and may be organ specific or may have multi organ involvement. General Approach to Management I. Prevention of Absorption III. Enhancement of Elimination IV. Antidotes V. Resuscitation — Airway, Breathing and Circulation Good early supportive care is the key to the management of poisoning.
Presence of cough and gag reflexes together with adequate spontaneous ventilation DO NOT warrant endotracheal intubation. However, when there is concern regarding airway protection and clinical deterioration, it is recommended to secure the airway.
Circulation - Patient may present with hypotension or hypertension, bradyarrhythmias or tachyarrhythmias depending on the poison or level of toxicity.
Treatment should be tailored to the most probable cause, however the initial bolus of 1 litre in adult of normal saline is recommended.
Inotropic support may be required for refractory hypotension - Hypertension may occur in the setting of sympathomimetic drugs such as amphetamines, ecstasy, methamphetamines ice, crystals , cocaine, anticholinergic, withdrawal from alcohol, nicotine and sedatives. Treatment of hypertension depends on its chronicity and severity.
Hypertensive emergencies evidence of end organ damage require prompt treatment. Intravenous glyceryl trinitrate GTN can be initiated together with close monitoring of the patient blood pressure.
This cocktail is both therapeutic and diagnostic. However, one should beware of the risk of seizures with flumazenil administration. Prevention of Absorption The route of entry for poisons can be dermal, ocular, gastrointestinal or parenteral.
Medical personnel handling the patient MUST at all times adhere to practices using personal protective equipments PPE or standard universal protection.. It involves prolong period of irrigation with normal saline solution and subsequent referral to the ophthalmologist. Caution should be exercised in patients with medical conditions such as bleeding diasthesis and combative patients. Efficacy which lavage removes gastric contents decreases with time. Insertion of orogastric lavage tube requires special care as known potential complications such as tracheal intubation, esophageal tear, stomach rupture trauma, arrhythmias and aspiration may occur.
Stomach content should be retained for analysis. Whole bowel irrigation is contraindicated in bowel ileus, gastrointestinal bleeding and bowel perforation. 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.
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