Six True Emergencies

One day, in a town not too far from here, an ICU registrar (you!) is doing her morning round. Suddenly, the overhead page goes off…

Medical Emergency Team to Ward 9, Medical Emergency Team to Ward 9.

The Consultant and Fellow are arguing over the relative benefits of suxamethonium over rocuronium, whilst the Senior Registrar is struggling at the top end, trying to remember the algorithm to the “Can’t Intubate, Can’t Ventilate” scenario. The Medical Student is in the background, jumping and waving her hands, saying something about sugammadex, although her cries go ignored.

It looks like YOU are it!

You decide to take the lead. You grab the resident and intern and head for the lifts, throwing in your 2 cents as you go. “Roc rocks!” you yell, prompting puzzled looks from the doctors and knowing nods from the charge nurse.

On your way up, to the 9th floor, you say to the resident “OK, why don’t you run this one?”

The resident looks startled and beads of sweat form on his brow… You glance at the intern, but she is cowering in the corner, pretending not to be there. Your resident stammers –“b-b-but I don’t know what to do…”

You try to reassure them…

“Look, whenever I turn up to a MET call, all I do is rule out six things.”

“Six things?” says the resident, trying to remember the 15 causes of hyperkalaemia.

“Yes! Only six things!” you say, trying to remember the treatment for hyperkalaemia, and wondering about the etymology of potassium.

“Surely, there are more than six diagnoses that matter?” says the medical student cockily.

“Ah yes, you are correct!”, you respond, pleasing the medical student. “EVERYTHING matters! BUT, not everything makes a difference. Do you understand the nuance?”

You stare in the distance remembering your student days and a poem by Linda Goodman. The medical student looks confused. “Google it!”, you say, whilst lamenting the lack of proper education in the younger generation.

“Anyway, as I was saying, there are just six things that need immediate diagnosis and treatment. EVERYTHING else can wait… There is never any hurry, once you have ruled out these six things…”

Your intern says “What, like an MI?”

“No, THAT can wait!”

Your resident says “Rapid AF?”

“NO…atrial fibrillation with rapid ventricular response…that too can wait”

An ED physician with itchy ears, who happens to be in the lift says, “What about a rapid sequence induction?”.

You reply, shaking your head, “No, there should be nothing rapid about a Rapid Sequence Induction…”


Do you think you can work them out from the meagre prompts given below?

AIRWAY

TRUE EMERGENCY (1)

Obstructed airway

  • Prevalence: Not uncommon
  • Problem: Lack of oxygenation and ventilation (usually due to opiates!)
  • Solution: Own the airway! (and I don’t necessarily mean intubate!) Simple manoeuvres – chin lift, jaw thrust, airway adjuncts, BVM, supraglottic devices! Naloxone, naloxone and naloxone…
  • Time taken: 10-60 seconds!
  • Difficulty: Easy

BREATHING

TRUE EMERGENCY (2)
Tension Pneumothorax
  • Prevalence: Rare
  • Problem: Increased intrathoracic pressure, resulting in haemodynamic collapse
  • Solution: Own the thorax! Needle decompression, a chest tube can wait!
  • Time taken: 60 seconds
  • Difficulty: Easy

CIRCULATION

TRUE EMERGENCY (3)
Ventricular Dysrhythmias: VT, VF, WCT, Torsades de pointes, asystole
  • Prevalence: Uncommon
  • Problem: No or low cardiac output
  • Solution: Own the Heart! DC Shock, CPR, adrenaline, amiodarone, Mg
  • Time taken: 60-180 seconds!
  • Difficulty: Moderate

CIRCULATION

TRUE EMERGENCY (4)
Exsanguination
  • Prevalence: Uncommon
  • Problem: Loss of circulating blood volume
  • Solution: Own the blood vessels! STOP the bleeding!
  • Time taken: 10-60 seconds (direct pressure… resuscitation may take longer)
  • Difficulty: Easy (most of the time…)

CIRCULATION

TRUE EMERGENCY (5)
Pericardial Tamponade
  • Prevalence: Extremely rare
  • Problem: Low or no Cardiac Output
  • Solution: Own the pericardium! Pericardiocentesis…
  • Difficulty: Hard
  • Time taken:  3-5 minutes

METABOLIC

TRUE EMERGENCY (6)
Hypoglycaemia
  • Prevalence: Not uncommon
  • Problem: Loss of metabolic fuel, resulting in reduced conscious state.
  • Solution: Own the BSL! IV glucose, IM glucagon
  • Time taken:  60 seconds
  • Difficulty: Easy

There you have it! When you review MET calls and pre-arrest patients, once you diagnose and treat (or otherwise rule out) the above 6 things, everything else can wait.

It should take under 2 minutes from arrival to diagnosis for each of the above conditions, and treatment shouldn’t take much longer. Assess the airway and breathing. Get a pulse and an ECG strip. Get a glucose, stop the bleeding. Finally, learn the ECG and clinical signs for pericardial tamponade…

And just remember, it’s as simple as…

  • ABC – Airway Breathing Circulation
  • DEFG – Don’t Ever Forget Glucose
  • HIJK – Heroin IV Just Kills
  • LMN – Lots More Naloxone!

CCC 700 6

Critical Care

Compendium

Specialist Intensive Care Physician working at the Austin Hospital, Melbourne. Interests: Shoulder Dislocations, Pain Management, End-of-life care, Organ Donation and ECGs | Linkedin |

One comment

  1. love he references , Gerard, to etymology of potassium (amazing) and Linda Goodman (amazinger).
    thank you

    tom f.

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