Makindo Medical Notes

Related Subjects: |Assessing Chest Pain |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Pulmonary Embolism |Acute Pericarditis |Diffuse Oesophageal Spasm |Gastro oesophageal reflux |Oesophageal Perforation Rupture |Pericardial Effusion Tamponade |Pneumothorax |Tension Pneumothorax |Lactic acidosis

🚨 Profoundly sick patient: Call for help early! Stay calm 😌, focus on ABCs, and work systematically — you can stabilise most situations if you think step by step.

📖 Introduction

• ⏱ Work quickly & logically — always think ABC.
• 🔍 POCUS is invaluable (pneumothorax, tamponade, LVF, AAA).
• 🧃 Start O₂, gain IV access, attach monitoring early.
• ✋ Always check a central pulse & monitor rhythm.
• 💉 Decompress suspected tension pneumothorax immediately.
• 🩸 Major haemorrhage → activate massive transfusion protocol.
• 🧪 High-yield tests (if safe): ECG, CXR, ABG, Lactate, Bedside Echo, CT guided by presentation.
• 💊 Give IV antibiotics early if sepsis suspected (e.g. Co-Amoxiclav 1.2 g IV qds ± Gentamicin, per local policy).
• 🚽 Catheterise shocked patients to monitor urine output.

❓ If patient not improving – always ask

• 🤔 Is the diagnosis correct?
• 🧩 Could there be >1 diagnosis?
• 📊 Do I need more info/tests urgently?
• ☎️ Should I escalate now — registrar/consultant/ICU?

🫁 Airway

• 🚨 Suspected epiglottitis/stridor → do not examine airway. Fast bleep Anaesthetics/ENT. Give high-flow O₂.
• 😮‍💨 Simple obstruction → Head tilt, chin lift, remove debris/foreign body.
• 💊 Opiates → Naloxone 0.4 mg IV (repeat; max 10 mg).
• 🫁 Tension Pneumothorax → Needle decompression 2nd ICS mid-clavicular line.
• 💓 Acute LVF → Crackles, tachypnoea → GTN + IV Furosemide. ECG & CXR. Urgent reperfusion if STEMI.
• 🫀 Acute PE → Chest pain, hypoxia, shock → Bedside Echo/CTPA. Heparin ± thrombolysis if haemodynamically unstable.
• 😤 Acute Severe Asthma → tiring, hypercapnia → urgent ITU review.
• 🌪️ COPD Exacerbation → Controlled O₂ (24–28%), consider NIV if Type 2 RF.
• 🦠 Pneumonia/COVID → Hypoxia + CXR changes.
• 😱 Panic attack → diagnosis of exclusion. Low PaCO₂.

💨 Decompressing Tension Pneumothorax

🩸 Hypotension / Shock

• 💧 No clear cause → Trial 500 ml IV N-Saline (250 ml if breathless/pulmonary oedema).
• 🩸 Haemorrhagic shock → GI bleed, varices → urgent blood + endoscopy/surgical input.
• 🦠 Septic shock → High lactate + infection → start Sepsis 6, IV antibiotics <30 mins.
• 💥 Leaking AAA → Sudden abdo/back pain, pulsatile mass → vascular surgery.
• 👩‍🍼 Ectopic pregnancy → Shock + abdo pain in fertile female → urgent gynae/surgery.
• 🫀 Cardiogenic shock → Post-MI or myocarditis. Echo, ECG. Consider inotropes + PCI.
• 🧩 Tamponade → Raised JVP, muffled HS, hypotension → urgent pericardiocentesis.
• ⚡ Anaphylaxis → IM Adrenaline 500 mcg + IV fluids.
• 🩻 Dissection → Tearing pain, BP asymmetry → CT Aorta, BP control, cardiothoracics.
• ☣️ Meningococcal septicaemia → Purpura, sepsis → IV Ceftriaxone + ITU.
• 🌑 Addisonian crisis → Shock, hyperpigmentation, hyponatraemia → IV Hydrocortisone.

❤️ Chest Pain

• 🫀 ACS → ECG, troponin, O₂, morphine, aspirin, PCI if STEMI.
• 🩻 Dissection → CT Aortogram, avoid anticoagulation until excluded.
• 🫁 PE → CTPA ± Echo if unstable.
• 🪠 Oesophageal rupture/Boerhaave → Severe pain post-vomit → surgical emergency.

🧠 Comatose

• 🍬 Hypoglycaemia → 50 ml 50% dextrose IV.
• 💊 Opiates → Naloxone up to 10 mg.
• 🧠 SOL/Stroke → CT Head ± LP. Consider aciclovir/ceftriaxone empirically if encephalitis/meningitis possible.
• 🍷 Alcohol/Drug intoxication → Supportive, antidotes if available.
• ⚡ Post-ictal or NCSE → EEG, benzodiazepines if seizing.
• 🌍 Cerebral malaria → travel history crucial.

⚡ Arrhythmias

• 📉 Bradycardia (<50 bpm + hypotension) → Atropine → pacing if no response.
• 📈 Tachycardia (>120 bpm + shock) → DC Cardioversion.
• 📊 Always get ECG and follow ALS algorithm.

🤕 Abdominal Pain Emergencies

• 💥 Leaking AAA → Shock + abdo pain → vascular surgery.
• 🔥 Pancreatitis → Severe pain, Grey-Turner’s/Cullen’s signs.
• 🕳️ Perforated viscus → Free air under diaphragm, rigid abdomen → urgent surgery.
• 👩‍🍼 Ectopic pregnancy → Shocked fertile female → Gynae emergency.
• 🩸 GI bleed → Endoscopy, PPI, correct coagulopathy, blood as required.

Cases — Acutely Ill Patient Assessment (ABCDE)

• Case 1 — Sepsis from Pneumonia 🌡️: A 67-year-old man presents with confusion, fever 39.2°C, RR 32, BP 85/50, O₂ sats 86% on air. Exam: crackles over right lung base. Assessment: - A: patent, - B: tachypnoea, hypoxia, - C: hypotension, tachycardia, - D: GCS 13, - E: febrile, no rash. Management: High-flow O₂, IV fluids, IV antibiotics within 1 hr, blood cultures, lactate, escalate to critical care if unstable.
• Case 2 — Acute Severe Asthma 😮‍💨: A 23-year-old woman presents with severe breathlessness, unable to complete sentences. RR 36, O₂ sats 88%, widespread wheeze, PEFR 25% predicted. BP 110/70, HR 128. Assessment: - A: speaking in short phrases, - B: severe bronchospasm, poor air entry, - C: tachycardic but perfusing, - D: alert, - E: no other findings. Management: High-flow O₂, nebulised salbutamol + ipratropium, IV hydrocortisone, IV magnesium, prepare for intubation if tiring.
• Case 3 — Acute Pulmonary Oedema 💔: A 72-year-old woman with known heart failure presents with acute dyspnoea, orthopnoea, frothy pink sputum. O₂ sats 82%, BP 170/100, widespread crackles. Assessment: - A: patent, - B: severe hypoxia, pulmonary oedema, - C: hypertension, tachycardia, - D: anxious but alert, - E: peripheral oedema. Management: Sit upright, high-flow O₂, IV furosemide, IV nitrates if BP allows, morphine if distressed, consider CPAP.
• Case 4 — Anaphylaxis 🐝: A 34-year-old man stung by a wasp develops rapid swelling of lips, wheeze, stridor, BP 70/40, O₂ sats 84%. Assessment: - A: threatened (stridor), - B: bronchospasm + hypoxia, - C: shock, - D: anxious but oriented, - E: urticarial rash. Management: IM adrenaline 0.5 mg, high-flow O₂, IV fluids, IV hydrocortisone + chlorphenamine, prepare for airway management.
• Case 5 — Hypoglycaemia in Diabetic Patient 🍬: A 55-year-old man with type 1 diabetes found drowsy at home. GCS 8, HR 110, BP 110/70. Capillary glucose 1.9 mmol/L. Assessment: - A: patent, - B: normal, - C: tachycardic but perfusing, - D: reduced GCS, - E: pale, sweaty. Management: Immediate IV glucose 10–20% (or IM glucagon if no IV access), monitor response, identify cause (missed meal, insulin overdose, infection).
• Case 6 — Septic Shock from Urosepsis 🌡️: A 75-year-old woman presents with fever, rigors, and confusion. BP 80/40, HR 130, SpO₂ 92% RA. Exam: suprapubic tenderness, oliguria. Assessment: - A: patent, - B: tachypnoea 28/min, SpO₂ 92%, - C: hypotensive, tachycardic, mottled, - D: GCS 12, - E: febrile 39°C. Management: Sepsis 6 (O₂, cultures, IV antibiotics, IV fluids, lactate, urine output); urgent critical care input.
• Case 7 — Upper GI Bleed 🩸: A 58-year-old man with alcohol excess collapses with haematemesis and melaena. BP 85/50, HR 140, pale and clammy. Assessment: - A: patent, - B: tachypnoea, SpO₂ 95%, - C: shocked (tachycardia, hypotension), - D: GCS 14, - E: melaena + haematemesis. Management: Large-bore IV access ×2, bloods (group & save, crossmatch), IV fluids, transfusion as needed, IV PPI, urgent endoscopy once stabilised.
• Case 8 — Tension Pneumothorax ⚡: A 32-year-old man with sudden pleuritic chest pain and dyspnoea after trauma. Exam: tachycardia 150, tracheal deviation, absent breath sounds on right, hyperresonant chest. Assessment: - A: patent, - B: severe distress, absent right breath sounds, - C: hypotension 75/40, JVP raised, - D: anxious, - E: chest trauma. Management: Immediate needle decompression (2nd intercostal space, midclavicular line) → chest drain insertion; O₂; monitor for recurrence.
• Case 9 — Acute Stroke 🧠: A 70-year-old woman presents with sudden left-sided weakness and slurred speech. BP 180/100, HR 88, SpO₂ 95% RA. GCS 14. Assessment: - A: patent, - B: normal, - C: hypertensive, regular, - D: focal neurology (left arm/leg weakness, dysarthria), - E: no trauma, normothermic. Management: FAST + stroke call; urgent CT head; thrombolysis if within 4.5h and no contraindications; aspirin 300 mg once haemorrhage excluded.
• Case 10 — Hyperkalaemia with ECG Changes ⚡: A 66-year-old man on haemodialysis misses 2 sessions, presents with weakness. ECG: tall peaked T waves, widened QRS. BP 100/60, HR 60. Assessment: - A: patent, - B: normal, - C: bradycardic, borderline perfusion, - D: GCS 15, - E: no sepsis, no bleed. Management: IV calcium gluconate, IV insulin + dextrose, nebulised salbutamol, consider calcium resonium or dialysis. Continuous cardiac monitoring.

Teaching Commentary 🧠

Assessing the acutely ill patient requires a structured ABCDE approach. - A: airway patency (threatened? stridor?). - B: respiratory distress, hypoxia, RR. - C: perfusion (pulse, BP, JVP, cap refill). - D: GCS, pupils, glucose. - E: temperature, rashes, exposure. Early recognition and intervention save lives. Always reassess after each step and call for senior/critical care help early in deteriorating patients.