Medical emergency

Chest pain, breathlessness, fits, poisoning and fever in the medical ER.

• Chest painECG within 10 minutes, then think of the six killers: heart attack, aortic dissection, PE, tension pneumothorax, tamponade and oesophageal rupture. "Gas" is a diagnosis of exclusion.
• Acute breathlessnessOxygen to target, sit them up, then work out which of the common causes you are dealing with. A quiet, tired patient who was breathless is about to arrest.
• Acute asthmaGrade the attack with peak flow and SpO₂, give back-to-back nebulisers and steroids, add magnesium if it is not working, and fear the patient who goes quiet.
• COPD flare (acute exacerbation)Controlled oxygen to 88–92%, nebulisers, steroids, antibiotics when the sputum is purulent, and NIV early for those who meet the criteria.
• Community-acquired pneumoniaScore the severity with CURB-65 and oxygen levels, give the right antibiotic within 4 hours (1 hour if septic), and think of TB when it does not settle.
• Pulmonary embolismThink of it in anyone with unexplained breathlessness, low oxygen or a fast pulse. Use the Wells score to choose D-dimer or CTPA, start anticoagulation early, and thrombolyse a PE that drops the BP.
• PneumothoraxTension means decompress now, X-ray later. Otherwise, decide on the X-ray and the symptoms: primary or secondary, breathless or not, and treat with observation, aspiration or a drain.
• AnaphylaxisLie the patient flat, give IM adrenaline into the thigh straight away, repeat after 5 minutes if needed, and give fluids for low BP. Antihistamines and steroids come later, not first.
• The shocked patientShock is not just low BP: it is organs not getting enough blood. Recognise it early, give a fluid challenge, find the type (bleeding, sepsis, heart, blockage, allergy), and treat the cause.
• SepsisRecognise it early, give the Sepsis Six within one hour, then find and control the source. A normal temperature does not rule sepsis out.
• Fever in adultsWho is the patient and where is the source? In a Pakistani ER, dengue, malaria and typhoid are on the list for every fever.
• Dengue feverKnow the day of illness, watch for warning signs as the fever settles, give fluids by protocol only when needed, and do not chase the platelet count.
• Collapse and syncopeMost faints are harmless. Your job is to find the few that are not: the heart, bleeding, PE, and the bleeding brain. A good story from a witness and an ECG find most of them.
• StrokeCheck the sugar, pin down the time last known well, get a CT head immediately, and decide with your senior who needs thrombolysis, thrombectomy, aspirin only, or supportive care.
• TIA (transient ischaemic attack)Stroke symptoms that have fully resolved are still an emergency. Aspirin 300 mg now, specialist review within 24 hours, carotid imaging, and secondary prevention before the stroke happens.
• Headache in the emergency departmentMost headaches are benign, but a few kill. Ask how fast it peaked, look for red flags, examine the fundi, and treat meningitis before you scan.
• Status epilepticusProtect the airway, check the sugar, give a benzodiazepine at 5 minutes and once more if needed, then a second-line drug by 20 minutes and anaesthesia by 40.
• Reduced consciousness (the unconscious patient)Protect the airway, check the sugar, look at the pupils, and give the obvious antidote. Then work through the causes systematically: the brain, the metabolism, poisons and infections.
• DKA and HHSFluids first, check the potassium, then fixed-rate IV insulin by weight. Keep the insulin running and always find out why it happened.
• Upper GI bleedTwo big cannulas, bloods and cross-match, resuscitate, and decide early whether this could be a variceal bleed. Terlipressin and antibiotics for varices, endoscopy within 24 hours (12 for varices).
• Overdose and poisoningTreat the patient first: airway, breathing, sugar and ECG. Then find out what, how much and when, check paracetamol levels in everyone, and give the specific antidote if there is one.
• Organophosphate poisoningProtect the airway, decontaminate, and give IV atropine fast, doubling the dose every 5 minutes until the chest is clear. Then watch the neck muscles for days.
• Wheat pill (aluminium phosphide) poisoningThere is no antidote. Call ICU early, support the heart with careful fluids and early noradrenaline, correct acid, potassium, magnesium and sugar, and protect staff from the gas.
• Snake biteKeep the patient still, do a 20-minute whole blood clotting test, give anti-snake venom only if there are signs of envenoming, and have adrenaline ready.
• Heat strokeTemperature above 40 °C with confusion is heat stroke until proven otherwise. Cool first, fast, then look for complications. Paracetamol does not work.
• Meningitis and encephalitisAntibiotics within an hour, before the CT and before the LP if either will cause delay. Add dexamethasone, and aciclovir if the brain itself may be infected.