Your first night on call
(ER style!)
Case 1
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32 year old lady
Acute SOB
Wheeze
Using accessory muscles of respiration
Unable to complete sentences
Case 1 Acute severe asthma
Drug
Dose
Route
Rate/frequency
1
Oxygen
100%
inh
continuous
2
Salbutamol
5mg
neb
15-30mins
3
Hydrocortisone
200mg
iv
iv push/6hourly
4
Ipratropium bromide 0.5mg
neb
6 hourly
5
Aminophylline
250mg
slow iv
100mls
nacl/30mins then
750mg/24hrs
6
Normal saline
1L
iv
6-8 hourly
Case 2
• 62 years
• Crushing central chest pain x 30mins
• Sweating, pale
Case 2 Acute coronary syndrome
Drug
Dose
Route
Rate
1
Oxygen
100%
inh
continuous
2
Morphine
2.5-10mg
iv
Slow iv
3
Cyclizine
50mg
iv
Slow iv
4
Aspirin
300mg
Po chewed
5
Glyceryltrinitrate
400-800mcg
s/l
stat
6
tPA
10mg
iv
Bolus iv
7
Atenolol
5mg
iv
5mins
8
Clopidogrel
300mg
po
stat
Case 3
• 38 yr old male NKDA
• You’ve just given second dose of co-amoxyclav iv
Case 3 Anaphylaxis
Drug
Dose
Route
Rate
1
Oxygen
100%
inh
continuous
2
Adrenaline
1ml 1:1000
IM
stat
3
Chlorphenamine
10mg
Iv
4
Hydrocortisone
100-200mg
iv
5
Salbutamol
5mg
neb
Case 4
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78 yr old man
Known IHD/CCF
Acute SOB
Tachycardia
Gallop rhythm
Wet crackles in bases
Case 4 Acute pulmonary oedema
Drug
Dose
Route
Rate
1
Oxygen
100%
inh
continuous
2
Furosemide
40-120mg
iv
Slow
3
Morphine
2.5-10mg
iv
Slow iv
4
Cyclizine
50mg
iv
Slow iv
5
Glyceryl trinitrate
400-800mcg
s/l
stat
6
Glyceryl trinitrate
2-10mg/hr
iv
infusion
Case 5
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82 yr old Diabetic
Unresponsive
Glucometer 1.3mmol/l
Very poor iv access
Case 5 Hypoglycaemia
Drug
Dose
Route
1
Glucagon
1mg
Im
2
50mls 50% dextrose
50mls 50%
iv
Rate
slow
Case 6
• Collapse
• Bradycardia 36/min
• BP 70/50
Case 6 Bradycardia
1
Drug
Dose
Route
Rate
Atropine
0.5mg
iv
3-6 mins up to
3mg
Case 7
• Conscious
• HR 180
• BP 140/70
Case 7 Stable broad complex tachycardia
Drug
Dose
Route
Rate
1
Oxygen
100%
inh
continuous
2
Amiodarone
150mg in 20 mls
5% dextrose
Iv
Slow 10min
Can repeat if persists
50mg
iv
Slow over 2min &
repeat q 5min up to
300mg
Infusion at 2 - 4 mg per
OR
2
Lidocaine
minute
3
K+ Mg2+
Case 8
• Lab calls
• Potassium 9.0 mmol/l
Case 8 Hyperkalaemia
Drug
Dose
Route
Rate
1
Calcium gluconate
10mls 10%
IV
Push q
10mins
2
Short acting insulin
50mls 50% dextrose
10 units
iv
15-30mins
3
Salbutamol
5mg
neb
stat
4
Calcium resonium
15g qds
30g tds
po
pr
Case 9
• 55 year old man
• Palpitations & SOB
• HR 200 BP 115/70
Case 9 Supraventricular tachycardia
Drug
Dose
Route
Rate
1
Oxygen
100%
inh
continuous
2
Carotid sinus massage
Valsalva
3
Adenosine
3mg
IV
Fast with flush
Can repeat at 6mg &
12mg
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Case 10
23 years
SOB & palpitations
Irregularly irregular pulse 200/min
History of Wolfe Parkinson White syndrome
Case 9 Fast atrial fibrillation with WPW
Drug
Dose
Rout Rate
e
1
Oxygen
100%
inh
continuous
2
Procainamide
17 mg/kg
IV
infusion not to exceed
50 mg/min
3
Enoxaparin
Img/kg
sc
bd (ACS dosing)
Drugs slowing AV conduction may worsen arrhythmia in WPW by
increasing conduction through accessory pathway
Avoid adenosine, beta blockers, digoxin, verapamil
Adverse signs with arrhythmias
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VT/SVT/Fast AF
systolic blood pressure less than 90 mm Hg
pulse rate greater than 150 beats/minute
chest pain
evidence of heart failure
Get anaesthetist (if you have time)
Cardiovert (synchronised)