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Upper
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Cardiac

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Stroke -4
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Vital Signs Stroke
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DKA ) Acute Myocardial Infarction ( AMI
Stroke Psychic
Toxicity Cardiac arrest
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** Common cold & headache
** Gastritis & Heart burn History Inferior M.I.
** Vomiting & Abdominal Pain History
Appendicitis
** Diarrhea & colic
** Constipation History Intestinal obstruction
** Dizzines or syncope
** Chest infection & Fever
** Bone ache & Myositis

- 1 Polytrauma
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49

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 -5 Acute Abdomen Appendicitis

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Epistaxis

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51

 .... Direct eye trauma

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(

Arterial Blood Gases ABG :

) RBS ( Random Blood Sugar
DKA or
Hypoglycemic coma

:

Analgesic ampole :
Antispasmodic ampole
20 Lasix ampole 40
Atropine ampole
Adrenaline ampole
Anti allergic ampole ..
Antiemetic ampole .. 6
Dexamethasone ampole
Antihemorrhagic ampole ..

Local Anasthetia ampole )

(
Antitetanic serum Ampole

52


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* Anti HPN
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57

Bronchial Asthma
Presentation
Patient said he is asthmatic
.. Complain of chest allergy
..Dyspnea and chest wheeze
By examination.. Bilateral diffuse sibilant ronchi
Management
250

NB cardiac patient
ventolin

bisolvon, avil

.

nebulizer 6 :
)farcolin (salbutamol
2 saline
anti muscrinic
Atrovent to relive bronchial spasm in vials inhalation solutions

58


(dexamethasone) solucortef

Renal colic
* history Stone
buscopan

visceralgine glucolynamine
spasmofen .
:
loin pain
burning haematuria
Management
250 ) ( stone





Crystals:
* urates urosolvin eff.

Zyloric (200-800) tab Or No-uric (100-300) mg
*oxalate
epimag eff
59



.
* phosphate
vitacid c tab
pus :
* HPF
* 5 30
Uvamine retard cap 12
) Macrofuran(50-100 6
* 30 50 Quinolones UTI
) Ciprofar 250 or ciprofloxacin or bactiflox (250-500 12

)Kiroll or tarivan(ofloxacin200
12 .

*
Coliurinal or proximol Antiseptic eff.
3
Rowatinex cap Analgesic 8
50

vomiting
*You should at first exclude that:
Appendicitis
Acute abdomen
Insecticides
DKA
60

* :

cortigen B6 amp
MOTILIUM tab 3

Hypotention less than 80/60

* 500

10 effortil

urine retention
*

sudden decompression of bladder wall

haematuria

Epistaxis
* hypertension
:
Nasal trauma,dryness of nasal mucosa , bleeding disorders
*bleeding come mainly from kisselbach's plexus at anterior
nasal septum.

First aid
-venous pressure
-Hand compress nostrils for 10 minutes
-Leaning forward

61

-May use cold compresses on nasal septum and not inside nose
-Add amp epinephrine to nasal pack for local use

-Afrin adult spray 0.05%
4

Management
* nasal pack pressure
Vaseline gauze
(full flexed to avoid
)aspiration
* haemostatic haemostop
.Local
(ethmasylate)dicynone 250.
* :
Ruta-C tablets 1X3 ,heamostop tablets 1X3 or dicynone
Antihaemorrhagic and capillary
protective
*
Pt=prothrombin time=10-15 sec
PTT=partial thromboplastin time=35-45 sec
Bleeding time=2-7 min
Platelet count =150,000 - 400,000
*
c
*

recurrent epistaxis

hemorrhagic telangectasia=HHT

62

Hereditary

Wounds



:

fucidin dressing
10 ) ( velosef 500 8 brufen 400 tab

*
.....

) (
* ....

.

* 6 .
*
* .

Hepatic coma
diuretics
Fluid replacement

63

 500 % 5 12 500 24

2ry hyperaldosteronism with salt and water retention

For liver support

250 12Aminoleban
3)Hepamarin or Legalon tab (silymarin
Tri-B
3 Essential forte tab
3)Lactulose syr (Ammoniacal antagonist
comatozed NG TUBE
NEOMYCIN 500 8
250 %25 :
hepa merz amp
: Nootropil amp 1000
oxybral amp
6 ) 5 + 2
( neomycin

)MeasuresAgainst Hge. (If present

IN UPPER GIT BLEEDING : NOTHING IS GIVEN BY
MOUTH
2 2+KONAKION DICYNONE 8
2 CYCLOKAPRON 12

* CEFOTAX 1gm 12
* History

) (coma
def.: loss of consciousness
Causes

64

*intracranial as:
head trauma & inrta cranial. Hge. (cerebrovascular stroke) with
increased B.P
brain abscess, encephalitis ,meningitis, massive infarction
,hypertensive encephalopathy, brain tumor. All intra cranial
causes may &may not come with lateralization signs which
are :
* unequal pupil,*facial asymmetry,*unilateral hyper or
hypotonia
*unilateral Babiniski, asymmetrical deep reflexes
*extra cranial causes:
toxic as co poisoning
-(D.M)may be: 1- hypoglycemic treated with 100 cm glucose
25% 2- DKA
-uraemic (CRF)
-AMI
-hepatic (Encephalopathy)
-resp. failure

Diagnosis:
history + complete physical exam. + Investigations like
*ABG
*renal function tests
*complete urine analysis
*urea & creatinine
*random blood sugar (R.B.S)
* glucose & acetone in urine
* liver functions tests (L.F.T)
*billirubin direct, indirect & total
*SGOT & SGPT
*Prothrombin activity
*ECG
*Abdominal U/S
*Brain CT

TTT:
1- maintain adequate oxygenation
65

Care of patient during coma.

.
2-ttt of shock if present
*By insertion of nasogastric tube and feeding the patient with 2
liters of fluid
. 2 *Insertion of Foley's catheter and estimation of urine in 24h
. 24 12 1 3-hospitalization &recording vital signs at regular intervals.
onset coma *
neurological cases and hypoglycemic coma sudden onset
metabolic coma gradual onset
hyperglycemic coma& DKA

Intracranial Heamorrhage
One of cerebrovascular stroke (C.V.S)
Patient clinically presents with History of hypertension, Right or
lift hemiplegia, hemiparesis, facial deviation, Coma, Slurred
speech.

Investigations needed
*For hypertension
- Na, K
-
-Cholesterol & TG in blood
-Urea &createnine
-Complete urine analysis
*For other causes
-Random blood glucose
66

-ECG
-Urgent CT brain

Treatment:
*Dehydrating measures and antihypertensives
-mannitol 20 % 250 cc IV
12
-lasix 40 mg amp.
70\100 12
-fortacortine amp. IV
24 12

*Cerebral Stimulants :
oxybral ampoule IM improve cerebral and memory
-condition
-Nootropil ampoule IV
8 2
*Measures to prevent stress ulcer
-zantac amp.
150 12
-motilium syp
3
*Intubation
-Ryle catheter ordinary fluid and cannula and give 1.5 liter
-Foley's catheter
24
*Care of comatozed patient

*Specific measures to stop hge.
-dicynone amp IV 8 2
-konakion amp 8 2
-cyclokapron amp 8
*if vomiting give primperan *abimol *flumox 500 mg

Gastritis and hyperacidity

67

 burning pain in epigastrium *

heart burn
nausea

Management
250
tagamet(cimetidine) zantac(ranitidine)




*
zantac 150 or 300 mg tab
3 mucogel susp or epicogel
proton pump inhibitor
or omez or omepack losec
:
anti-inflammatory drugs
as piroxicam
Alternatives:
Zantac (tab&amp) ,Ranitidine(tab&amp) ,Histac(tab&amp) Aciloc
(tab) ,Ranitak(tab)

Fluid therapy
= Fluid assessment
hypovolemia
hypervolemia
B. pressure
Systolic 100 or low
High
Pulse rate & Tachycardia & small Normal & big volume
volume
volume
Central venous
zero
high
pressure

tongue
Skin elasticity

dry
Loss of it

haematocrit

increased
68

wet
Normal or peripheral
edema

decreased

Urine out put

little

normal

*Fluid replacement:
*Glucose 5% given
To replace water loss not associated with electrolyte disturbance
As solvent for many IV drugs
*Dextrose ,Glucose (20,25,40,50%) given in
As nutrient to give calories when GIT feeding isn't accessible as
in deep coma
Strong hypertonic as in case of sever hypoglycemic coma
**25,40,50% are in bottles and amp. Amp=25 ml
*Saline (Nacl 0.9%) used in
Water loss with electrolyte loss
*Sodium bicarbonate
In cases of sever metabolic acidosis
0,5&4,2 % bottles
8,4% in amp.
Ringer solution 500 ml
Contain NaCl , CaCl , KCl

*Plasma expanders
*To maintain normal blood volume as in shock and hemorrhage
*Crystalloids
* As saline & ringer give transient effect
Fate: escape to interstitial space
*Glucose 5% fate is intracellular space
*Colloids
Mannitol, dextran, gelatin, albumin
Fate: intravascular space

Hypertension
More than 150/90 plus headache with or without epistaxis
*

Investigations

69

24

Management
* lasix 3
8 epilat 10mg 12
. cerebral
edema capoten 25 mg
8
Tritac tab 5 mg once daily
aldomet 250
atenolol 50
Combination.
*
:

Drug choice
young adult First line is diuretics & b-blockers
2nd is ACE inhibitors as capoten or Ca channel blockers as
Epilat
In old age 1st line is Ca channel blocker with or without
diuretics
In H. failure Lasix capoten
Nefidipine & B.Blockers
R. failure Lasix-nefidipine(epilat)-aldomet
) thiazide diuretics & capoten (ACE inhibitors
*Alternatives:
*Ca channel blockers
& -Epilat , adalat 10 mg soft capsule (nifedipine) in HPN
)unstable angina(coronary & peripheral V.D
70

-Epilat retad , adalat retard 20 mg

*ACE inhibitors
Captopril 25, 50 mg (capoten- capotril) short acting
ramipril 1,25 -2,5-5 mg (tritace ramipril)long acting
*B.blockers
)Atenolol 50,100 mg (atenolol-ateno-atelol

Appendicitis
Presentation
1- Symptoms
* , fever
* periumblical localized in
R.iliac fossa
* anorexia
* nausea vomiting
2- Signs
*
macburny point
* tenderness and rebound tenderness rigidity
* cross tenderness
* cough tenderness

*
.

Management
* %25
: analgesic not mask the
diagnosis
*
renal colic
* W. Blood cells
71

 11
pelvis*

. history Mid-cyclic pain
*
appendectomy
laparoscopy or laparotomy
peritonitis,
septicemia and septic shock
( typical) *
.
acute abdomen analgesic
mask diagnosis
HCL gastritis

Myositis or back pain or myalgia.

Management
* myolgen cap or norgesic tab or myolax ,myorelax ,myofen
cap. (sk.ms.relaxant&analgesic) or dimra or mark-fast( new)

*cataflam 50 or ketofan 50 or antiflam 50, adwiflam 50,
rheumaren 50, rheumafen 50, voltaren 50(anti inflammatory &
anti rheumatic)

* Felden gel or olfen gel

*Neurovit amp or neuroton or tri B(vitamin B complex)
.

Toxicology Cases

organophosphate poisoning
72

Presentation

pin point pupil, bradycardia, hypotension
salivation, secretion
sweating, diarrhea

nausea, vomiting, dizziness

Management:
*for a case of acute intoxication 4 broad lines should be done.
1-first aid or supportive care
-which is life saving to maintain patent air way and removing
secretions and insertion of oropharyngeal tube.
2-prvention of further absorption of poison here by
- removing contaminated clothes and washing skin Also by
insertion of ryle tube 16 and performing stomach wash
500 :
clear
300 ( 10 charcoal tab)
ryle
3-methods to increase elimination of poison
4- Use antidote
- Atropine 2 ampoule in one injection every 15 min
pupil fully dilated or pulse 15 *
reaches120
secretion
dry tongue

-parlidoxime (protopan chloride)

(choline estrase reactivatore)*
15 2

zantac Home TTT

73

 spasmodigestin tab
gastrofate(sucralfate)mucosal protective

food poisoning

Common cold

+

Management:
flumox cap 500
5
abimol extra tab

bradoral lozeng
3
vitacid -c tab
(antihistaminic 3 Flurest tab
& decongestant)
Alternatives
*Flumox, famox 500, flucamox (cap- vials) ampiclox (cap-vials
5oo-syr),
hi-flucil, miclox(250-500),amoclox(500)
*abimol,cetal,paracetamol,pyral,paramol,temporal,panadol
*flurest,sine-up,flustop,congestal,conta-flu tab,coldex cap,
clarinase tab

Cough
Management
3 coflin syr
mucophyline syr
phenadone syr
3 ( antihistaminic corticosteroid )
74

 Farcolin(salbutamol) tab
Alternatives
* Coflin contain(cough suppressant ,decongestant ,anti
allergic),codilar, tussilar,neo pulmolar, selgon, siloma
* Mucophyline, neominophyline, mucosin, mucovent,
farcosolvin, trisolvin, ambroxol, Koffex, Actifed, solvex
*Phenadone, vendexine, apidone syp
*Farcolin, ventolin, bronchovent, salbovent tab

gastroenteritis
* vomiting, diarrhea, abdominal pain with or without fever

Management
avil + +
adolor
dehydrated
Home TTT
8 antennal cap or diax*
3 spasmocin tab or no-spasm or visceralgine*

) 3 flagyl 500 tab or amrizole*
(
Motilium tab or domperidone or motinorm or gastromotil*

Streptokine tab or entocid*
chronic *
ciprofloxacin500 tab(quinolones)

12
*

uncontrolled DM
Headache ,malaise ,blurring of vision history of DM or patient
on anti DM ttt

75

pin prick the finger tip ,put a blood drop on the tape mark ,put
the tape in the device, wait and read the resulting number ,if
random blood sugar is:
-250 - 200
300 - 250
300 - 350
350- 400
400 25
25 500 20

500
12
3
150
neuritis

hyperglycemic coma and DKA

due to missing insulin dose in patient IDDM.

presentation
random blood glucose more than 400
, low potassium level acetone on urine
polyurea ,acetotic breathing rapid deep breathing, tender
abdomen ,vomiting

Management
500 + kcl
500 +
500 +
500 +

? How to begin

76

 iv fluid replacement
1 1
1 1 8

lowering blood glucose by insulin
25 100
250 250 ) % 5 (

200
200 250
250 300
300 350
350 400
400 25
correction of potassium
potassium chloride two ampoule on 500 cc ringer
correction of acidosis
12 250
prophylactic of DVT
500

Blood glucose level
motilium,zantac,tri-B,prempran

hypoglycemic coma
77

random blood sugar below 50mg/dl,wet tongue,

sweating drowsiness

random blood glucose % 5 % 25 500

intestinal obstruction
abdominal distension and colic ,vomiting ,absolute constipation
x ray show multiple air fluid level

Anaphylactic shock and

Hypersensitivity reaction
clinical picture
sudden and important fall of blood pressure ,tachycardia,
frequent ceutanous manifestation erythema, urticaria ,quincke'
oedema
inconstant respiratory manifestations as dyspnea or even
bronchospasm

Management
12 fortacorten
kenacort vial
Or claritine ) allergex tab avil
(or tavegyl
Topical corticosteroid betaderm

heamatemesis
78



-first or recurrent attack
-amount of blood
-history of liver disease, DM, hypertension,
analgesic abuse

-do general and local examination, comment on neck vein, LL
oedema hepatosplenomegaly, ascitis ,vital sign pulse BP temp,
consciousness

Management
Nothing P.O. (per ...............
)oral

500 %5
cyclokapron
)(tranexamic acid antifibrinolytic
haemostop
antihaemorrhagic and capillary protective
ranitidine

amri-k or konakion or haemokion
) (10-9-7-2

Hyperkalemia
3.5 5
* asystole
*
100 10
* direct iv
.
Acidosis
phHCO3 deficit
79

* 100 %25 5 10
VI Intracelluar shift of K ion
*


* beta agonist
tachycardia cardiac
*

.

-1

-2
-3 & ACEI :
Beta blockers & spironolactone
-4
Acidosis-5

-6
.

Other prescriptions
Impotence

pregnyl 5000 10 /
proctan cap /
Anderiol cap / 12
vasotal tab 400 12 /
......................................... .................................................. .
.
)pregnyl 5000 I.U ( Human chorionic gonadotrophin
5000profasi ) (
: 10
80

 2nd testicular failure

undescended testis 1500
:
proctan ST cap

Impotence
FOR SEXUAL POWER IMPROVMENT
:
:
(Andriol cap ) testosterone undecanthate 250 mg
hypogonadism
: ) 12(
:
(vasotal tab 400 mg ) pentoxifylline
peripheral arterial circulatory disorders
it inhibit platelet aggregation, and decrease blood viscosity
: 400pexal 400trental riboflex
400 400pental : ) 12
(

Premature ejaculation
Prozac disp or anfranil 25 or 75 mg cap
)Antidepressent (delay ejaculation

)Xylocaine jelly (local anesthetic

2 Or lignocaine spray

Common mistakes
* :
:
: 40
: -

81

Rx
Ciprofar 500(-Ciprofloxacin-) tab
)Alternatives:(cipromax- Ciprobay -bactiflox 250,500,750
Diprofos- (betamethasone) amp
Alternatives: (decadron,dexamethason,solu cortef, kenacort
)A
Colostop-( piperment+anise oil) caps

Alternatives: (gastrocare-master gest)digestant

3
Mucogel-( AlOH3+MgOH3- )susp 3

)Alternatives: (epicogel,magsilon,sedo-mag

Answer
* "
""ciprofloxacin
* " " Mucogel " "antacid

*


.
*

interaction ciprofloxacin
.
* interaction ciprofloxacin Ca
Fe ... -
- - -
82

multivitamins
-
- - ciprofloxacin

ciprofloxacin
quinolones (macrolids) azithromycin

Rx
* Zithromax 250 -azithromycin- caps(azalide
cap250,500,susp200)azrolid 500
* Xithrone-zisrocin zithrokan

250 3
500 3
Susp 200 single dose 3

*Mineravit- multivitamins- caps


* betamethsone amp :
...

...

) (.
:
....

:
quinolones
Macrolides
Penicellins rifampicin

83

 -
-
* "
"
Cephalosporons cephalexin

* 12 8
12 .
www.allteb.com
/

84

Listen to me In this Emergencies

bronchial asthma

)(



wheezes
)(
""""""""""""""""""""""""""""""""""""""""""
"""" """"
""""""""""""""""""""""""""""""""""""""""""
"""" "

dysponeic /cyanosed/ sweaty
cardiac
/respiratory/cardiorespiratory failure

-1 : history


85

 -2 chest auscultation
bronchial<<<wheezes
crepitations>>>cardiac
cardiac asthma
wheezy
) (

hypoxia

signs of right side heart failure
lower limb oedema/congested neck
veins/enlarrged tender liver

long standing B.A
PULMONARY HYPERTENSION
right side heart failure


)
(
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::
cardiac asthma
DS3
VASODILATORS AS : ACEI
86

DIURETICS
DIGITALIS
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::

:
FEV

mild to moderate-1

life thereatening-3
)
( ventilator
-2
severe B.A
BOLUS OF +
STEROID
5-4 ) (

200

DRUG
INTER ACTION

87



)(
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::
1
2
3

a case of abdominal pain

:
...
acute
abdominal pain acute abdomen
: acute abdominal pain
)(acute onset pain
: acute abdomen
...
how to exclude or diagnose acute
abdomen
88

: history -1


acute abdomen
absolute constipation , repeated
vomiting
: abdominal examination -2
traid of abdominal : tenderness/rigidity / :
distension
shock -/+
ryle
analgesic/spasmolytic
<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<
<<<<< << <<<<<<<<<<<<<<<<<<
:causes of acute abdomen
surgical causes:
perforated viscuc
intestinal obstruction
mesentric vascular occlusive disease
ectopic pregnancy
peritonitis
pancreatitis
::::::::::::::::::::::::::::::::::::::::::::::::::
:::::::::::::::::::::::::::::::::::

89

 medical causes of acute abdomen

inferior myocardial infarction
DKA
familial mediteranian fever
renal failure
::::::::::::::::::::::::::::::::::::::::::::::::::
:::::::::::::::::::::::::::::::::::::::::::::::

perforated viscuc
cxr
air under diaphragm


""""""""""""""""""
intestinal obstruction
abdominal x
ray erect & supine
erect :for air/ fluid level >>>> more than
3& step ladder appearance
supine : for site of obstruction
""""""""""""""""""""""""""""

90

mesentric vascular occlusive disease

(mvo):2
shocked
MVO AF
ACUTE ,
MVO ABDOMEN
""""""""""""""""""""""""
ectopic pregnancy
FEMALE/ MISSED PERIOD/ PALLOR
""""""""""""""""""""""""
pancreatitis
epigastric pain referred to back
serum amylase/MRI abdomen
"""""""""""""""""""""""""""""""""""""""
MEDICAL CAUSES
inferior MI
epigastric pain /ECG
"""""""""""""""
DKA
bl sugar / acetone /ABG
"""""""""""''
FAMILIAL MEDITERRANIAN FEVER
DIAGNOSED BY EXCLUSION
8

91

 12
24

FMF MAY LEAD TO RENAL

AMYLOIDOSIS & RENAL FAILURE
ACUTE
ABDOMEN FMF
COLCHICINE
"""""""""""""""""""""""""""""
RENAL FAILURE
SERUM CEREATININE & ABG
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::::::::
ACUTE
ABDOMEN




...

92

Loss of conciousness


abc
A:airway secretions
aspiration
B:breathing
arrested
C:circulation shocked
..................................................
.. ..................................................
)
(
shock
shocked 80/120
70/90 shocked

shock
Shock tissue hypoperfusion to vital
organs

93

Hypoperfusion to brain : drowsiness /

confusion/ coma
Hypoperfusion toheart : rapid weak pulse
Hypoperfusion to kidney: oliguria/ anuria
c/p
2 rr >>tachypnea
Hr >>tachycardia
2 ( bp ..>> hypotension (
T >> hypothermia
pale / cold /
oliguric
""""""""""""""""""""""""""""""""""""""""""
""""""""
""""""""""""""""""""""""""""""""""
:
shock
The surest sign of shock is oliguria
oliguria
150-100 retained
urine

::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::::::::
:::::::::::::::::::::::
abc "
94

neurological
examination
Pupil: unequal = brain stem lesion
Mouth :deviated to one side sign of
lateralization
Upper & lower limb weakness : sign of
lateralization
Urine incontinence . sign of
lateralization
Babinisky sign sign of lateralization

:
Meningitis : rigid stiff
neck/fever/photophopia/repeated vomiting
Vertibrobasilar insufficiency : nystagmus
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::
abc

signs of system failure
Heart failure/ respiratory failure/renal
failure/liver cell failure
endocrine causes of
coma
95

 )

systematic (
Or thyroid dysfunction comas
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::
hysterical coma

Blinking & escaping eye ball
::::::::::::::::::::::::::::::::::::::::::::::::::
:::::::::::::::::::::::::::
poisoning

organophosphorus

history
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::
Septic coma

::::::::::::::::::::::::::::::::::::::::::::::::::
:::::::::::::::::::::::::::::::::

96

: Unexplained coma under investigations

-1
-2 stress ulcer
-3
-4 )
(
-5 brain stimulant
oxypral /nootropil

:::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::

Diabetic emergencies
diabetic comas




hypoglycemic coma -1
hyper glycemic comas -2
DKA/ LA/HONK
cerebrovascular stroke -3
97

end stage renal disease -4

4


""""""""""" """""""""""
Hypoglycemic coma
tachycardia /pallor/
sweaty
) 45

(
45
65
comatosed brain
hypoglycemia
tachycardia /pallor/
sweaty
excess catecholamine
secretion brain hypoglycemia
concentrated glucose 25%
hypoglycemic coma
retrograde


98







GLIBENCLAMIDE

GLIBENCLAMIDE 2
PEAKES OF HYPOGLYCEMIA
ATTACK


ATTACKS2


:
irreversible brain damage due to -1
prolonged hypoglycemia
resistant hypoglycemia as insulinoma -2
stroke-3
end stage renal disease -4

99

::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::::::::::::::::::::::::::::::
::::::::::::::::::::::
Hyper glycemic comas
(diabetic keto acidosis (dka -1
lactic acidosis -2
(hyper osmolar non ketotic (honk -3
: c/p
Diabetic patient . with repeated
vomiting/abd pain/
oliguria/dehydrated/precoma/or comatosed
Random blood sugar (rbs) = >300

acidosis

:
Hyper glycemia
20
dehydration

metabolic acidosis

ph<7.1
200 4
100

 hyperkalemia
diastole

systole
antihyperkalemic measures
-1 100
20-2 200 %25
4 -3 200
hyper glycemic comas

Allteb.1aim.net

101

Cases In Emergency Room

Haematemsis & melena.
1st aid measures :1-Vital data : pulse .. ... Bl.pr.
2-Canula & give : ((haematemsis cocktail )) ...............>
Dicynon"hemostatic" , Konakion "vit.k ", Cyclokabron "
antifibrinolytic" ,and Zantac
" H2 blocker"
3-Ryle --------------- Never before canula
*Values : -Ensure no bleeding
-To wash by cold water with or without adrenaline to cause
local VC.
*Continue wash till it become clear to prepare pt. For endoscopy
.
N.B.: Pt. Fit for endoscope means :- Ryle wash becomes clear .
- Pt. is not shocked.
- Pt is not in encephalopathy.
4- 3 blood samples ((obtained from the canula before giving
cocktail ))
- One for CBC ----- baseline Hbe
-----Plat. ((decrease in HCV +ve pt. ))
- One for metabolic profile ----Routine ..
- One for blood preparation.
5- ECG ....to exclude ISHD.
** If bleeding severe or pt not fit for endoscope or not available
endoscope
** We may use Sangstakin ---inflate gastric ballon with 250-300
cc saline
** sangstakin should not be left more than 48 hours to prevent
necrosis .

102

** Also in case of severe bleeding we can give :-Somatostatin:- [Octeriotide = antigrowth hormone] 25-50
ug\h..."one
ampoule contain 100 ug"
+ 4 - 400 saline or Ringer
Value : VC.
- Glypressin "One ampoule contain 1mg "
6 1 2
$$. Take care :
It cause coronary VC, so give nitroderm patches if blood
pr. Allows.
Glypressin is # in IHD, old age..
Blood is given if pt. chocked.
Plasma is given if pt INR >1.5
Plat. Is given if pt plat. >50,000
Till blood --give Colloid which last in intravascular space more
than crystalloids. E.g. : Dextran,haemgel.
If Colloid not available ----- give crystalloids E.g.: Saline,
Ringer.

II- History taking :

History of :- chronic liver dis., Gu or Du, Drug Intake : aspirin,
NSAID, anticoagulant.
III-Examination : HSM , ascites , flapping tremors.
IV:-Upper GIT endoscope should be done when Pt. becomes fit
for it .
Value : 1- Diagnostic for cause of bleeding
2- Therapeutic ( as mentioned before).

TTT of bleeding Oesophageal varices:

I ) 1st aid measures .

II) Injection sclerotherapy.
III) Anticomato avoid encephalopathy..
*Enema \4 h.
103

* protein restriction 20gm\d.

* Lactulose 30 cm\3 times\d stopped if diarrhea
*Eradicate bact. Flora :
- Flagyl 250 mg (1*3*7)esp with renal impairment
- Neomycin 500 mg (2*4*5) #with renal impairment.
Side effect : ototoxicity so not given >5days
IV)Guard against SBP by Noroxin (Norfloxacin ) 1*2 .
V) Give (Dicynon ,konakion, Cyclocapron, Zantac) 2 amp\8h.{
Zantac is # with thrombocytopenia.)
.If bleeding persist we give :Sandostatin, Glypressin
After bleeding stopped :
1- follow up GI for injection
) .(
2Drug to decrease portal hypertensionIndral 10mg 1*4
(If Indral can't be given as in case of DM\BAor PVD or CHF)
Give Effox 40 mg 1*2
3- Vit. K (1*3)
4- Liver support Eg: Legalon 1*3
5- Diuretics depend on pt is compensated or not i.e. pt has
ascites.

TTT OF PU
a)1st aid measures
b)Upper GIT endoscopy for D.D.- if active bleeding injection
with adrenaline
c) Losec ( Omeprazole) vial + 200 cc Ringer over 2 hours.
d) If anteral gastritis or Du Tripple therapy to eradicate h.pylori
It includes :- PPI e.g. : Gastrazole 1*2*15 days
- Clarithromycin 2*2*15 days
- Amoxicilin 2*2*15 days.
Discharge Pt. when :Melena stopped
Hb = 8 or more.
Avoid spicy food , smoking , NSAID
NB: If pt. with PU with severe haematemsis consult Surgery.

104

Indication of admission of pt:

Haematemsis, melena
Tense ascitis
SBP
Hepatic encephalopathy
Recommended pt !!!


Haematemsis & melena
EX
Tense ascitis ( TTT)
Tapping
SBP ( spontinous bacterial peritonitis ):
Hepatic encephalopathy :-

Tense ascitis ( TTT)

1-Rest in bed.2-Salt restriction ( salt free diet )3-Diuretics:
a) Start with Spironolactone (Aldactone) 100 mg
And increase gradually up to 4 tablets \day Value : K sparing diuretic,
Aldosterone antagonist.
b) Lasix 40 mg daily up to 4 tablets ( 160 mg\d)
N.B.: Diuretics esp. Lasix stopped if there is hyopkalemia or precoma
4-Follow up pt. with fluid chart
(body wttarget: decrease B.wt by 1\2 kg \day.)
5-If resistant Tapping or paracentesis should be done if tense ascitis
cause significant discomfort or resp. distress ( Therapeutic purpose of
tapping )

6-Tapping:

105

a-Exclude encephalopathy. b-Palpation of abdomen to avoid injury to

any organ during tapping . c-Sterilization of (Macburny's point) or mid
way bet. Costal margin & ASIS( most dependant area) ***Sterilization
is done in circular manner from in into out by betadine then alcohol. dintroduce canula + IV line.
- Replacement with albumin if tapping > 3L (one bottle contain 10gm)
- Stop if : hypotension , bleeding of tapping ,, disturbed conc. Level.

N.B.:

Diagnostic purpose of tapping : if suspicion of malignant ascitis or SBP or

new onset ascitis.
Fluid obtained from tapping : 3 samples for : culture & sensitivity,
chemistry, pathological exam.
Indication of Albumin in CLD Pt.:

- Tapping > 3 L of ascitis fluid. - Infection - Surgery - SBP Hepatorenal $

SBP ( spontinous bacterial peritonitis ):

Infectious complication of portal HTN related ascitis in absence of
cause for peritonitis . most commen org : E-coli.

C\P : Pt with CLD with [ marked deterioration precipitate

hepaticencephalopathy],, [ fever, abd.pain , tenderness ] ,, [ silent]

D.D : leucocytosis may be present

106

Diagnostic paracentesiscell count [WBC >500\ m3\HPF with out

sympt.,,PNL >250 \m3\HPF with symptoms ]

TTT: - Antipyretic.
- Antibiotic3rd generation cephalosporin E.g. : cefotaxime "claforan"
1 gm \ 8 h for 5 days unless there is renal failure ((dose adjustment)) Anticoma measures ( previousely mentioned ) - Albumin.

Hepatic encephalopathy :It's neuropsychiatric complex in pts with acute or chronic LCF or
portosystemic shunting(i.e.: disorderd conciousness, abnormal
behavior)
Ask about ppt factors in Ch. Liver disease pts :
-Diuretics
- High dietary prot.
- Haematemsis, melena
- Fever (infection)
- SBP
- Severe vomiting or diarrhea, excess tapping of ascitis.
- Hepatotoxicity ( alcohol ,drugs e.g. : sedative, opiod)

Management :
1-Vital data ((fever. Haematemsis ))2-Canula sample for metabolic
profile. ( Na, K, Creat, RBS)3-Ryle &wash to exclude haematemsis.4Chest x ray ( chest infection. . Rt sided P.effustion.5-ECG
107

TTT:
1- To avoid prot. In diet. 2- Eradicate bact. Flora by: - Neomycin 500
mg 2*4*5
Flagyl 250 mg 1*3*7 - Lactulose 30 ml \8 h. (osmotic purgative ) Enema \4h
3- Hepamerz"L-Arnithine L-aspanate (2 amp +200cc glucose 10% \12
h.)
if creat > 3
4-Aminolesan 500ml\12h (AA infusion
5-TTT of the cause :
E.g. : Haematemsis Dicynon ,konakion, cyclokapron ,zantac.
Infection TTT
SBP Antipyretic, Antibiotic, Anticoma, Albumin

Fever
Management:

1-Cold fomentation2-Cold saline enema (# in diarrhea)3-NSAIDs: - Paracetamol

(R/ Cetal or PyralBrufen or Novalgen
) 4Aspegic: - 38
?? thrombocytopenia - ?? Reye $ 5- Search for the cause: sore throat, chest
infection, ear infection, UTI

if u dont find a cause for fever & fever is prolonged > 2 wks >>>>>>
FUO

For FUO) Investigations

1-CBC 2-ESR3-Blood culture , urine culture , sputum analysis + ZN stain4108

Collagen markers5-Malaria & Toxoplasmosis6-Widal & Brucella 7- X- ray chest

UTI:
C/O: dysuria, frequency, urgency, hematuria. Ask for urine analysis: if
pus cells > 100 / hpf (N=0 /hpf) >>>> ask for urine culture ttt: Give the best
antibiotics which is sulfa or Quinolones e.g. -Sutrim tab. 2*2*5-Chemotrim fort
1*2*5-Septrin 1*2*5 ORQuinolones if there is hypersensitivity to sulfa or
resistance to it-Tarivid 200mg (ofloxacin) 1*2*5-Oflicin 200mg (ofloxacin)
1*2*5if pylonephritis: IV AB is required (hospital admission)

Tonsillitis or oropharingitis:
TTT: 1- Antibiotics for 1 wk:
the best is penicillin e.g. Ampiclox 1*4 - 1st generation cephalosporins e.g.
Velosef or Duricef - Sulfa e.g. Sutrim2- Antipyretic 3- mouth wash

Otitis Media:
As above + nasal decongestant e.g. Afrin drops 1*3*7

Bronchitis:
As above + expectorants & mucolytics e.g. Mucosol syrup 1*3
Mucophylline Bronchophene Bisolvon 1*3 Trisolven

if pneumonia >>>>> it is indication of admission for IV AB ( penicillin &

3rd generation Cephalosporins)

Gastroentritis:

SI C/O: Watery diarrhea (no blood, no mucous, no tenesmus)

. >>>> this is viral infection >>>> give antiseptic e.g. streptomycin 1*3
LI C/O: Diarrhea + blood + mucous + tenesmus + fever

Renal Colic: (loin pain radiating to the groin)

Give Glucolynamine IV >>>>> # IM (may cause abscess)
Papaverine IM >>>>>>>> # IV (cause hypotension)
*if no response give {Ca+ atropine + Buscopan + Papaverine + Brufen**
*Ask for urine analysis, pelviabd. U/S

Bronchial asthma
During attacks:

109

1- VD 2- ABG if severly distressed 3- Start by Nebulizer 1 amp.lasix + 2cc

saline +1 amp Atrovent {Ibratropium Bromide** + 1cm Ventoline {B2 agonist
>>> # if tachycardia** 1-if severe ( distressed or not responding) >> give
Cocktail 500 cc saline or Glu + 2 amp. Solucortef + 1 amp. Aminophilline
Mg Sulphate {Smooth ms relaxant** >>> # in hypotension & renal
impairment**

N.B.:
* In case of cocktail if the pt is diabetic give saline & if the pt is
hypertensive gives glucose. *If the pt has HF or CRF give minimal
fluids 100cc or 200cc
Home ttt:
R/- ttt of ppt factor e.g. infection - Spray e.g. Clenil (salbutamol+
Beclomethasone)
6

Coma
(disturbed level of conscious)

Signs of lateralization:
deviation of the angle of the mouth.
Deviation of the tongue.
.Weakness on one side with withdrawal on painful stimulus
Change in the tone on one side.
Eye deviation
Babiniski (extensor planter response)
Causes:
A-With lateralizing signs: ( need CT

1CVS (stroke): cerebral hge or infarction( thrombus or

embolism)
2Hypoglycemia

B-Without lateralizing signs: (mostly metabolic causes

hypertensive encephalopathy
Chronic liver ds (LCF) >>>if he came with lateralizing signs, do CT
Chr. renal failure
Resp. failure
Hypoglycemia
DKA

110

Severe electrolyte disturbance

CNS infection e.g. encephalitis or meningitis

Other causes of DLC:

Drugs & toxins
Hysterical
Space occupying lesion e.g. abscess or brain tumor

N.B.: Hypoglycemic coma & coma due to HTN encephalopathy

are not essentially associated with lateralizing signs.

Management:
Rapid history

of DM ( hemotest, urine for sugar & acetone

Of HTN
Of alcohol intake
Of drug abuse >>>> Antidote
Of any systemic ds
VD
BP >>>>> HTN encephalopathy
Temp. >>>>> fever for e.g. meningitis, encephalitis, chest
infection
Pulse
RR >>>>> resp. distress due to RF e.g. COPD
Examine for signs of lateralization
Metabolic profiles
ABG , ECG , X- ray chest , CT brain

111

Cerebrovascular stroke (CVS)

The hallmark is abrupt onset of symptoms & neurological
deficits
e.g. weakness, deviation of angle of mouth, tongue,
convulsions, incontinence, coma
Risk factors
Ask rapidly about DM, HTN, old age, smoking, heart ds.
(AF>> embolism)
valve replacement, collagen ds >> vasculitis, obesity
1st Aid:
VD: BP, pulse,
History
Examination
if DM >>> hemotest, urine for sugar & acetone.
, CXR, ECG.
PT, PTT if AF or recurrent stroke.
Ryle for feeding if chocking.
Catheterization.
CT scan
.
Value of CT scan
white>>> hge, black>>> infarction)
It demonstrates: - Cerebral hge (from the 1st moment): consult
neurosurgery
- Cerebral infarction: if free follow up CT should be done
after 48hrs
- Space occupying lesion >>> CT with contrast, MRI: consult
neurosurgery
- Brain edema>>> sulci & gyri are not clear
TTT of stroke:

ttt of risk factors:

HTN >>> BP should be reduced gradually (not more than 140/90
to maintain cerebral perfusion), DM, Ht ds, hyperlipidemia...

112

Brain dehydrating measures

To treat brain edema around area of hge or infarction.
Mannitol followed by lasix
If # as in renal failure or ht failure >>> give Decadron or Glycerin
Pt on Mannitol should follow serum creatinine
Nootropil ( neuroprotective) 2amp /6hr
Care of comatosed pt
Frequent change of position in bed.
Ryle for feeding.
Catheter
Regularly check: urine output, DVT, Bed sores, auscultate
chest
Anticoagulants in case of infarction:
Indications
: - Valve replacement
- AF
- Dilated cardiomyopathy
- Stroke in evolution
- Post circulation stroke
- Recurrent stroke
#
: - Recent surgery
- Malignant HTN
- Bl. Tendency
- Inf. endocarditis except if the pt with valve replacement.
Dose:
Heparin 5000IU IV/ 4hr >>>follow up with PT
Antiplatlet (Aspocid) (Trental) in case of infarction
Epanotin is given in case of IC hge to inhibit fits especially in
lesions near cortex.

DM with disturbed level of conscious:

According to urine sugar & acetone

113

Management of DKA:
Hemotest
Urine sugar & acetone
ABG & ECG
MP (glu >250mg/dl, +++ urine sugar &acetone
ABG shows PH < 7.3 or HCO3 low)
We have 4 problems
1Hyperglycemia:
- Give insulin 10 IU IM/hr + urine sugar & acetone & hemotest/ hr
- if the pt is markedly dehydrated start by 10 IU IV
- once Glu is < 250 mg/dl give Glu. 5% to improve cellular
dehydration
2Acidosis:
- HCO3 is not given unless PH < 7.1 or deficit is > -10
3Dehydration:
- 4- 6 L in the 1st 24 hrs
- 500cc/ hr for 2hrs
- 500cc/ 2hr for 4hrs
- 500cc/ 4hrs
with follow up by fluid chart
N.B. diabetic pt with Chr renal failure >>> fluids will lead to
pulmonary
Edema, so central line is fixed & measure CVP & if low
compensate
by oral route
114

4Hypokalemia:
-if K > 6 dont give
- 4.5 -6 give 1 amp.
- 3.4 5 give 2 amp.
- < 3 give 3amp.
5Correction of PPT factors e.g. chest infection >>>>give AB.
N.B.:- In hyperosmolor non ketotic coma, heparin is given for
prophylaxis as
hyperosmolarity >>>> hyperviscosity >>>> infarction.
- AGAIN: if the pt with hyperosmoler coma is not improved, do
CT
exclude infarction.

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Non specific skills:
1- Accurate measuring of blood pressure, pulse and temperature.
2- Withdrew many venous samples and insert many canulae.
3- Withdrew arterial samples and know WRERE to analyze and
learn reading.
4- Inserting male and female urinary catheters.
5- Dealing with central lines (see insertion, how to give through,
withdrew from and how to measure CVP).
6- When, what type, why and how to prepare blood transfusion
and other blood components.
7- How to communicate with residents, staff, nurses and patients
(how to tell bad news, death, cancer, risky operation and strict
follow up?
8- How to write requests for consultation and referral? And stay
beside every consultant and see how they examine and take
decision.
9- Try to read every X ray, C.T., ECG, MRI, ERCP, .. You
meet.
10- Don't go to any request unless you know its value and every
thing about the patient.

Specific skills:
Surgical dressings
1- How to do proper dressing for clean, septic, open and closed
wounds.
2- What is the frequency of dressings?
3- When to use saline, alcohol, betadine, iroxol, EUSOL,
paraffin oil, glycerin, tincture benzoic and others?
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4- How to use instruments, gauze and bandages.

5- How to make wound depridement.
Drains:
1- What is the value?
2- How to read, evacuate, fixate and dress?
3- When and how to remove?
Suters and stiches:
1- What are their types and when to use every type?
2- Take simple interrupted, continuous, mattress and
subcuticular stiches.
3- How to give local anesthesia and ring anesthesia?
4- Know how and when to remove.
5- Know their care (dressing & antibiotics).

Management of specific cases:

1. Polytraumatized patients:
Resuscitation, needed history, proper examination, essential
investigation, initiative and definitive treatment.
2. Post concussion:
Definition, when to admit, when to discharge, investigation and
treatment?
3. Chest trauma:
Watch intercostals tube insertion; know its care, indication and
when to remove?
4. Acute abdomen:
How to differentiate between surgical and medical causes?
How to take history, do examination and ask for investigation
for:
-Acute appendicitis.
-Acute cholicystits and biliary colic.
-Intestinal obstruction.
-Perforated viscus.
-Renal colic and acute retention.
Watching and doing P.R. examination.
Watch and interpret upper GI endoscopy, colonoscopy, ERCP,
mammography, Ba enema and gastrographin meal and follow
through.

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Preoperative preparation:
1. How to write and take surgical consent?
2. How to do colonic lavage, ask for shaving, fasting, resuscitate
and give preoperative analgesics and antibiotic?
Operations:
1. Sterilization and toweling for the patient.
2. Sterilization of you and how to wear gown and gloves?
3. Watch induction and termination of anesthesia try to do
endotracheal intubation.
4. Assist in some operations and do closure of: thyroidectomy,
hernial repair, appendectomy and mastectomy.
5. Watch other major operations to take an idea e.g. Whipple's,
colectomy and others.
6. Interested personal can do appendectomy, abscess drainage
and removal of cysts and swellings.
7. How to use surgical instruments and why every one?
8. How to write operative details?
Postoperative management:
1. What is the treatment given to every case?
2. When to do postoperative dressing?
3. When and how to start oral feeding and what are the fluids
given to nothing per os N.P.O. patients?
4. What Total Parentral Nutrition TPN and when to start?

Conference :
1. Try to learn how senior staff take decision and think of
surgical cases e.g. obstructive jaundice, breast lump, bleeding
per rectum etc.
2. Ask about any thing you don't understand. Don't be ashamed
it's your last chance to learn surgery.

CONCLUSION:
Try to learn and do what junior resident surgeons know and do.
N.B.
5 Days in burn unit:
1. Try to know and see surgical dressings of burns.
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2. Watch some surgical management of burns e.g. grafts, flaps

and escharecromy.
:
)-( -
- - - - .

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