Emergency Medicine

Critical Care Emergencies 25

UNCONSCIOUS PATIENT

(ii) Remove all the clothing, but keep the patient covered and avoid

heat loss.

5 Insert an i.v. cannula and take blood for FBC, coagulation profile, blood
sugar, ELFTs, blood culture and drug screen for salicylate and paracetamol if
not already done.
(i) Perform ABGs, recording the amount of oxygen being delivered
(FiO 2 ).
(ii) Give 50% dextrose 50 mL i.v. if the blood glucose test strip is low
(a) remember dextrose i.v. can precipitate Wernicke’s
encephalopathy in alcoholic or malnourished patients, who
require thiamine 100 mg i.v. immediately.

6 Record the temperature (if 35°C, repeat with a low-reading thermometer to
exclude hypothermia), pulse, blood pressure, and the pupil size and reaction.
(i) Consider naloxone 0.4–2 mg i.v. slowly if there are pinpoint
pupils with hypoventilation to reverse narcotic poisoning, but
beware of precipitating an acute withdrawal reaction.

7 Consider other critical conditions requiring immediate action:
(i) Tension pneumothorax
(a) this usually follows trauma, especially if positive-pressure
ventilation is being given
(b) insert a large-bore cannula or intercostal drain without
waiting for an X-ray (see p. 471).
(ii) Cardiac arrhythmia
(a) treat as necessary after recording a formal 12-lead ECG (see
p. 60).
(iii) Exsanguination
(a) bleeding may be external and obvious, or internal and
concealed from the gastrointestinal tract, a ruptured AAA or
ectopic pregnancy
(b) cross-match blood, give i.v. fluids, arrange an ultrasound and
refer the patient for an urgent surgical opinion.
(iv) Anaphylaxis
(a) this may follow drug therapy, food ingestion, or an insect sting
(b) give 1 in 1000 adrenaline (epinephrine) 0.3–0.5 mg
(0.3–0.5 mL) i.m. repeated as necessary every 5–10 min
(c) give 1 in 10 000 or 1 in 100 000 adrenaline (epinephrine)
0.75–1.5 μg/kg i.v. if there is circulatory collapse, i.e.
50–100 μg or 0.5–1.0 mL of 1 in 10 000, 5–10 mL of 1 in
100 000 adrenaline (epinephrine), slowly i.v. for a 70 kg
patient (see p. 27).
(v) Extradural haemorrhage
(a) this may follow even trivial trauma; look for a local bruise on
the scalp, for instance in the temporoparietal area over the
middle meningeal artery territory