ED Emergency Tool — Part 2
32 conditions · Eye · ENT · Procedures · Vascular · GI · Neurology · NICE / RCEM / RCOphth guidelines
NICE UK 2024–25 · RCEM · RCOphth · BSACI · ReviseMRCEM⚠ Clinical Disclaimer: For qualified clinicians only. Always verify doses against current BNF and local formulary. Apply clinical judgement. Not a substitute for senior advice or formal training. Doses are for adults unless stated. Last reviewed: Feb 2025
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Part 1
Cardiac · Respiratory · Neuro · Metabolic · Trauma · Obs · 60+ topics
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Part 2 — You are here
Eye · ENT · Procedures · Vascular · GI · Neurology · 32 topics
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Paediatrics
55 topics · Live weight calculator · APLS 2023 · NICE · RCPCH
Chemical Eye Burns
Immediate irrigation · pH testing · Alkali worse · Ophthalmology
Acute Angle-Closure Glaucoma
IOP >21 · Pilocarpine · Acetazolamide · Timolol
Corneal Abrasion & FB
Fluorescein · Topical anaesthetic · Chloramphenicol · FB removal
Retrobulbar Haematoma
Sight-threatening · Lateral canthotomy · IOP · CT orbit
Orbital / Pre-septal Cellulitis
Chandler classification · CT · IV ceftriaxone · ENT/ophth
Endophthalmitis
Post-op / endogenous · Intravitreal vancomycin · Vitrectomy
Acute Uveitis & Iritis
Slit lamp · Flare/cells · Topical steroids · Cyclopentolate
Peritonsillar Abscess
Quinsy · Needle aspiration · Co-amoxiclav · ENT
Malignant Otitis Externa
Pseudomonas · Diabetic · IV ciprofloxacin · CT skull base
Otitis Media & Externa
AOM · Topical acetic acid · Amoxicillin · Mastoiditis risk
Excited Delirium / ExDS
High mortality · Ketamine · Cooling · Restraint risks
Umbilical Cord Prolapse
RCOG · Manual elevation · Knee-chest · Emergency CS
Choking — Adult & Child
RCUK · Back blows · Heimlich · Laryngoscopy · Magill
Drowning
RCSUK · C-spine · Warm water · Modified ALS · Rewarming
Devastating Brain Injury
RCEM 2022 · DNACPR · Organ donation · Brainstem testing
Failed Intubation
DAS 2015 · CICO · Plan A–D · Surgical airway
Cricothyroidotomy
Scalpel-finger-bougie · Needle crico · FONA
Tracheostomy Emergencies
Tube displacement · Obstruction · NTSP algorithm
Chest Drain Insertion
Seldinger vs blunt · BTS 2023 · Landmarks · Complications
Needle Thoracocentesis
Tension PTX · 2nd ICS MCL · 4th/5th ICS AAL · IO needle
Procedural Sedation
RCEM · Ketamine · Propofol · Midazolam · Monitoring
Fascia Iliaca Block
NOF fracture · Inguinal ligament · 40 mL 0.25% bupivacaine
Haematoma Block
Colles' fracture · Lidocaine into haematoma · Technique
Lateral Canthotomy & Cantholysis
Orbital compartment syndrome · Sight-saving · Technique
Acute Limb Ischaemia
6 Ps · Rutherford · Heparin · Embolectomy · Thrombolysis
Warfarin Reversal
INR · Vitamin K · PCC (Beriplex) · FFP · Bleeding risk
DOAC Reversal
Idarucizumab · Andexanet alfa · PCC · Timing
Neurogenic Shock
SCI · Bradycardia + hypotension · Noradrenaline · Atropine
ROSIER Score
Stroke recognition · Score ≥1 · Validated tool · CT pathway
Diverticulitis
Hinchey classification · CT · Co-amoxiclav · Surgery
Diverticular Bleed
Lower GI bleed · Colonoscopy · CTA · Embolisation
Ischaemic Colitis
Watershed areas · CT colonography · Supportive · Surgery
Chemical Eye Burns
RCOphth · Immediate copious irrigation · pH testing · Alkali worse than acid
RCOphth 2021 · RCEM🚨
Irrigate IMMEDIATELY — do not wait for consent, history, or ophthalmic review. Every second of delay worsens prognosis. Alkali burns are sight-threatening emergencies; alkalis penetrate deep and continue reacting.
💧 Immediate Irrigation Protocol▾
- 1Instil topical anaesthetic (proxymetacaine 0.5% or oxybuprocaine 0.4%) to allow adequate irrigation and examination.
- 2Irrigate with 1–2 litres of 0.9% sodium chloride (or Hartmann's). Use a giving set directly — hold open eyelids with speculum or fingers. Morgan lens ideal for prolonged irrigation.
- 3Evert upper eyelid — remove any solid/particulate matter with cotton bud or moist swab. Fornix irrigation essential.
- 4Check pH with litmus paper in inferior fornix. Target pH 7.0–7.4. Repeat if pH not normalised. Wait 5 min after stopping irrigation before rechecking.
- 5Document time of exposure, agent type (alkali/acid/unknown), concentration, and volume.
- 6Emergency ophthalmology referral — same day for any significant chemical burn.
Alkali vs Acid Burns
Alkali (cement, lime, bleach, ammonia, oven cleaner): liquefactive necrosis — penetrates deep, continues reacting. WORSE prognosis.
Acid (battery acid, pool chemicals): coagulative necrosis — self-limiting. Still serious but less deep penetration.
Hydrofluoric acid: special case — fluoride ions penetrate tissue. Calcium gluconate gel/drops required in addition.
🔬 Grading & Subsequent Management▾
Roper-Hall Classification (after irrigation)
Grade I: corneal epithelial erosion, no limbal ischaemia — excellent prognosis
Grade II: hazy cornea (iris visible), <1/3 limbal ischaemia — good prognosis
Grade III: total epithelial loss, 1/3–1/2 limbal ischaemia — guarded prognosis
Grade IV: opaque cornea (iris not visible), >1/2 limbal ischaemia — poor prognosis
Medications (Ophthalmology-initiated)
Vitamin C (ascorbic acid) drops hourly + systemic 2g QDS — promotes collagen synthesis, reduces perforation risk
Topical steroids (dexamethasone 0.1% QDS) — reduce inflammation
Cyclopentolate 1% TDS — cycloplegia for ciliary spasm, prevents posterior synechiae
Chloramphenicol 0.5% QDS — prophylactic antibiosis
Sodium citrate 10% drops — inhibits neutrophil collagenase, reduces corneal melting
Acute Angle-Closure Glaucoma
RCOphth · IOP reduction · Pilocarpine · Acetazolamide · Laser iridotomy
RCOphth 2022 · NICE🚨
Ophthalmic emergency. Untreated, permanent visual loss within hours. IOP typically 40–70 mmHg (normal <21 mmHg). Treat immediately — do NOT wait for ophthalmology review before starting drops.
🔬 Diagnosis & Clinical Features▾
Classic Presentation
Severe unilateral eye pain + headache + nausea/vomiting (may mimic migraine or acute abdomen)
Blurred vision with coloured halos around lights (corneal oedema)
Fixed mid-dilated pupil (4–6 mm), unreactive to light. Injected/red eye. Cloudy cornea
Rock-hard eyeball on gentle palpation (cf. soft in other causes of red eye)
Precipitants: dim lighting, mydriatic eye drops, anticholinergic drugs, stress, crowded space
Investigations
IOP measurement (tonometry) — target <21 mmHg, usually 40–70 mmHg in AACG
Slit lamp: shallow anterior chamber, corneal oedema, flare/cells
Gonioscopy (ophthalmology): confirms closed angle. Fellow eye examination — often similar anatomy
💊 Medical Treatment Protocol▾
Immediate Topical Treatment (Apply All)
Pilocarpine 2% eye drops — 1 drop q15 min for 1h then QDS. Constricts pupil, opens trabecular meshwork. Only effective once IOP <50 mmHg (ischaemic iris sphincter unresponsive at higher pressures)
Timolol 0.5% eye drops (beta-blocker) — 1 drop. Reduces aqueous production. Avoid in asthma/COPD/2nd–3rd degree heart block
Brimonidine 0.2% (alpha-2 agonist) — 1 drop. Reduces aqueous production + increases uveoscleral outflow
Latanoprost 0.005% (prostaglandin analogue) — 1 drop. Increases uveoscleral outflow
Systemic Treatment
Acetazolamide 500 mg IV (or 500 mg oral if not vomiting) — carbonic anhydrase inhibitor, reduces aqueous production. Avoid in sulfonamide allergy, severe renal failure, sickling disorders
Glycerol 50% oral 1–1.5 g/kg (osmotic agent) — reduces vitreous volume if IOP remains high. Use mannitol 20% 1–2 g/kg IV if unable to take oral
Analgesia: paracetamol ± antiemetic (metoclopramide 10 mg IV). Supine positioning may help open angle
Definitive Treatment (Ophthalmology)
Laser peripheral iridotomy (LPI) — creates bypass drainage. Performed on both eyes (prophylactic on fellow eye)
Surgical iridectomy if laser fails. IOP recheck at 1–2h after treatment
Corneal Abrasion & Foreign Body
Fluorescein staining · Slit lamp · Removal technique · Antibiotic cover
RCOphth · RCEM🔬 Assessment & Diagnosis▾
Examination
VA testing before any examination or drops. Topical anaesthetic (proxymetacaine 0.5%) before FB removal
Fluorescein stain: bright yellow-green under blue light confirms abrasion. Seidel test: streaming fluorescein = full-thickness wound (refer urgently)
Evert upper eyelid: subtarsal FB often missed — swipe with moistened cotton bud
Exclude penetrating injury: irregular pupil, peaked pupil, uveal prolapse, hyphema, reduced VA → URGENT ophthalmology referral. Do NOT instil drops or apply pressure
Rust ring around metallic FB: present after >6–12h. Remove at slit lamp or refer ophthalmology in 24h
💊 Treatment▾
Corneal Abrasion
Chloramphenicol 0.5% drops QDS for 5 days — antibiotic prophylaxis
Systemic analgesia: paracetamol + ibuprofen (regular, not PRN). NSAIDs reduce inflammation and pain
Cyclopentolate 1% — for large abrasions (>3 mm) to relieve ciliary spasm
Eye padding: NOT recommended routinely (delays healing, increases infection risk). Exception: contact lens wearers — use Pseudomonas cover (ciprofloxacin drops QDS)
Most abrasions heal within 24–48h. Review in 48h if >3 mm or significant pain
Superficial Foreign Body Removal
Irrigate first with saline. If unsuccessful: damp cotton bud or 21G needle (bevel up, tangential approach under slit lamp or loupe)
Refer to ophthalmology if: deep, multiple, penetrating, rust ring not removable, contact lens wearer
Post-removal: treat as corneal abrasion (chloramphenicol + analgesia + review)
Retrobulbar Haematoma
Orbital compartment syndrome · Sight-saving emergency · Lateral canthotomy and cantholysis
RCOphth · RCEM 2023🚨
Sight-threatening emergency — vision loss within 90–120 minutes of arterial occlusion. Do NOT wait for CT or ophthalmology if diagnosis is clinical. Perform lateral canthotomy immediately to decompress.
🔬 Diagnosis & Clinical Features▾
Clinical Features (Orbital Compartment Syndrome)
Proptosis (exophthalmos). Periorbital ecchymosis/oedema (usually post-trauma or post-op)
Raised IOP (>40 mmHg). Restricted extraocular movements. Tense orbit
Afferent pupillary defect (RAPD) — indicates optic nerve compression. Vision loss
Cause: facial trauma, retrobulbar block, orbital surgery, anticoagulants, bleeding diathesis
CT orbit confirms if time permits — but do NOT delay canthotomy if clinical diagnosis is clear
🔪 Lateral Canthotomy & Cantholysis Technique▾
Procedure (also covered separately under procedures)
Consent (implied in emergency). Local anaesthetic: lidocaine 1–2% with adrenaline to lateral canthus
Clamp lateral canthus with haemostat for 60 seconds (reduces bleeding)
Cut lateral canthus horizontally with scissors — full 1–1.5 cm to bony orbital rim
Inferior cantholysis: with scissors, cut inferior crus of lateral canthal tendon (feel the "pop" — relief immediate)
Recheck IOP and RAPD. Superior cantholysis if insufficient decompression
Wound: leave open, cover with moist dressing. Ophthalmology repair when stable
Adjunctive Measures
Acetazolamide 500 mg IV — reduces IOP. Mannitol 20% 1 g/kg IV over 20 min — osmotic IOP reduction
Timolol 0.5% drops + brimonidine 0.2% drops — topical IOP reduction
Head of bed 30° elevation. Avoid valsalva. Remove contact lenses
Orbital & Pre-septal Cellulitis
Chandler classification · CT orbit · IV antibiotics · ENT/ophthalmology
RCOphth · NICE · ENT UK⚠
Orbital cellulitis (post-septal) is a sight and life-threatening emergency. Distinguish from pre-septal (peri-orbital) cellulitis — orbital cellulitis has proptosis, restricted/painful EOM, and reduced VA.
🔬 Classification & Diagnosis▾
Pre-septal (Peri-orbital)
Anterior to orbital septum. Lid oedema/erythema. Normal EOM, VA, IOP. No proptosis. Treat with oral antibiotics as outpatient if mild.
Orbital (Post-septal)
Behind orbital septum. Proptosis, restricted/painful EOM, ↓VA, RAPD, chemosis. Intracranial spread possible (cavernous sinus thrombosis, meningitis). ADMIT — IV antibiotics.
Chandler Classification (Orbital Cellulitis)
Group I: inflammatory oedema (pre-septal) | Group II: orbital cellulitis (post-septal, no abscess)
Group III: subperiosteal abscess | Group IV: orbital abscess | Group V: cavernous sinus thrombosis
Investigations
CT orbits with contrast (with brain if CNS signs) — mandatory for suspected orbital cellulitis. Identifies abscess
FBC, CRP, blood cultures x2. Nasal/conjunctival swabs. Ophthalmology assessment (VA, IOP, EOM, pupils)
Source: sinusitis (most common — ethmoid), dental, skin trauma, insect bite, dacryocystitis
💊 Antibiotic Treatment▾
Pre-septal Cellulitis — Mild (Oral, Outpatient)
Co-amoxiclav 625 mg TDS for 7 days (oral, if completing over 5 years, not infant)
Review in 24–48h. Worsening → CT + IV antibiotics
Orbital Cellulitis — IV (Admit, ENT + Ophth review)
Ceftriaxone 2 g IV OD + metronidazole 500 mg IV TDS (covers sinus-derived anaerobes)
MRSA risk: add vancomycin or teicoplanin
Cavernous sinus thrombosis: anticoagulation controversial — discuss with neurology/haematology
Surgical drainage: for subperiosteal/orbital abscess not responding to 24h IV antibiotics, or VA deterioration
Step-down to oral when CRP falling, apyrexial 24h, tolerating oral: co-amoxiclav 625 mg TDS for 14 days total
Endophthalmitis
Post-operative / endogenous · Intravitreal antibiotics · Vitrectomy · Urgent referral
RCOphth · EVS Trial🚨
Ophthalmic emergency. Intraocular infection causing rapid irreversible vision loss. Intravitreal antibiotics must be given within hours. Immediate same-day ophthalmology referral — do NOT delay.
🔬 Types, Features & Management▾
Post-operative
Most common. 1–7 days post-cataract/intraocular surgery. Coagulase-negative Staph. Presenting VA often LP/HM. Intravitreal vancomycin + ceftazidime.
Endogenous
Haematogenous spread. IV drug users, immunocompromised, long-term IV lines, candidaemia. Often bilateral. Systemic treatment required.
Post-traumatic
Penetrating injury. Bacillus cereus (soil), Staph. Often severe — bacillus causes devastatingly rapid destruction.Clinical Features
Severe pain, photophobia, markedly decreased VA. Hypopyon (pus in anterior chamber)
Vitreous haze/cells on slit lamp. Lid oedema, conjunctival injection
Post-op: onset 1–7 days. Delayed (>6 weeks) = less virulent organism (Propionibacterium acnes)
Emergency Management (Ophthalmology-led)
Intravitreal vancomycin 1 mg/0.1 mL + ceftazidime 2.25 mg/0.1 mL — standard EVS regimen
Vitreous/aqueous tap for culture before injection. Vitrectomy if VA = light perception only (EVS trial)
Endogenous: systemic antifungals (voriconazole) for candida; systemic antibiotics for bacterial
Topical: intensive fortified antibiotics (vancomycin 50 mg/mL, ceftazidime 50 mg/mL). Cyclopentolate 1% TDS
Acute Uveitis & Iritis
Anterior uveitis · Slit lamp · Topical steroids · Cycloplegia · HLA-B27 associations
RCOphth · NICE🔬 Diagnosis & Causes▾
Clinical Features
Painful, photophobic, red eye. Decreased VA. Small/irregular pupil (posterior synechiae). Ciliary flush (limbal injection)
Slit lamp: anterior chamber cells and flare (hallmark). Keratic precipitates (KPs) on corneal endothelium
Fibrin/hypopyon in severe cases. IOP may be raised or low
Associations
HLA-B27 related (most common): ankylosing spondylitis, reactive arthritis, psoriatic arthropathy, IBD
Infectious: HSV, VZV, toxoplasmosis, syphilis, TB, Lyme, CMV
Sarcoidosis, Behçet's, JIA (juvenile idiopathic arthritis — often asymptomatic)
First episode: FBC, ESR, CRP, HLA-B27, syphilis serology, CXR (sarcoid). ANA, RF in children
💊 Treatment▾
Topical Treatment
Prednisolone acetate 1% drops — q1h initially, then taper based on response. Cornerstone of treatment
Cyclopentolate 1% TDS (cycloplegic/mydriatic) — prevents posterior synechiae, reduces ciliary spasm and pain
Atropine 1% OD-BD if severe (longer-acting cycloplegia for severe uveitis)
IOP elevated: timolol 0.5% BD (avoid if asthma). Do NOT use pilocarpine (worsens inflammation)
Systemic Treatment (Specialist Decision)
Oral prednisolone: severe, bilateral, or posterior uveitis. Periocular steroid injection for selected cases
Treat underlying cause: NSAIDs for HLA-B27, antivirals for HSV/VZV, anti-TB for TB uveitis
Immunosuppression (methotrexate, mycophenolate): for recurrent/chronic uveitis requiring steroid-sparing
Peritonsillar Abscess (Quinsy)
RCEM · Needle aspiration / I&D · Antibiotics · ENT referral · Airway monitoring
RCEM · ENT UK 2022⚠
Monitor airway — large abscess or bilateral involvement can compromise airway. Trismus (difficulty opening mouth) is characteristic. Unilateral uvular deviation away from abscess side.
🔬 Diagnosis & Management▾
Clinical Features
Severe unilateral sore throat. Trismus (limited mouth opening). Muffled "hot potato" voice. Drooling
Uvular deviation to opposite side. Unilateral peritonsillar bulge. Fever, halitosis
Distinguish from peritonsillar cellulitis (no pus, no fluctuance) — management differs
CT neck: if diagnosis uncertain, suspected deep space infection, or inadequate drainage
Drainage — Needle Aspiration (RCEM Recommended First-Line)
Position: upright. Topical anaesthetic spray (co-phenylcaine). Good lighting and suction available
16–18G needle on 10 mL syringe. Insert at point of maximum bulge (superior pole of tonsil, lateral to midline) to max depth 1 cm — medial = risk of carotid artery
Aspirate pus (brownish fluid). Repeat if aspirate dry (may be cellulitis). Send pus for MC&S
Incision and drainage (I&D): if aspiration fails or insufficient drainage. ENT preferred setting
Antibiotics
Co-amoxiclav 1.2 g IV q8h (polymicrobial — Group A Strep + anaerobes)
Alternative: Benzylpenicillin 1.2 g IV QDS + metronidazole 500 mg IV TDS
Penicillin allergy: clindamycin 900 mg IV q8h
Step-down to oral when tolerating: co-amoxiclav 625 mg TDS for 7–10 days
Dexamethasone 10 mg IV (single dose) — reduces oedema, improves pain and trismus, speeds resolution
Malignant (Necrotising) Otitis Externa
Pseudomonas aeruginosa · Diabetic/immunocompromised · Skull base osteomyelitis · CT/MRI
ENT UK · BSACI 2023🚨
Not a malignancy — a life-threatening invasive infection. Almost exclusively in diabetics and immunocompromised. Facial nerve palsy (CN VII) is the most common complication and indicates skull base involvement. Mortality up to 20%.
🔬 Diagnosis & Management▾
Clinical Features
Severe, unrelenting otalgia (disproportionate to appearance). Temporal/mastoid pain. Otorrhoea (purulent)
Granulation tissue at bony-cartilaginous junction of EAC (pathognomonic). Facial nerve palsy (late, poor sign)
CN IX, X, XI, XII palsies if jugular foramen involved. High fever, toxicity
Organism: Pseudomonas aeruginosa in 90%. Aspergillus in immunocompromised
Investigations
Blood glucose + HbA1c. FBC, CRP, ESR. Blood cultures. EAC swab (MC&S + fungal)
CT temporal bones: extent of bony destruction (skull base osteomyelitis). MRI: soft tissue extent, dural/venous involvement
Tc-99m bone scan: most sensitive for osteomyelitis (diagnosis). Gallium scan: treatment monitoring
Tissue biopsy: exclude malignancy (squamous cell carcinoma of EAC can mimic)
Treatment
Ciprofloxacin 400 mg IV BD — first-line (anti-pseudomonal quinolone). Duration: minimum 6 weeks
Step-down to oral ciprofloxacin 750 mg BD once improving (equivalent bioavailability)
Antifungal if Aspergillus suspected/confirmed: voriconazole 6 mg/kg IV BD loading × 2, then 4 mg/kg BD
Diabetes control: HbA1c optimisation critical — hyperglycaemia impairs neutrophil function
Surgical debridement: limited role, for removal of sequestrum. ENT + ID joint management
Otitis Media & Otitis Externa
NICE NG91 · Amoxicillin · Topical acetic acid · Mastoiditis · Complications
NICE NG91 2018 · SIGN🔬 Acute Otitis Media (AOM)▾
Diagnosis
Otalgia, fever, bulging/erythematous tympanic membrane, conductive hearing loss. Discharge if TM perforated
Bilateral in children <2 years. Otoscopy: loss of light reflex, air-fluid level, TM bulging
Organisms: Strep pneumoniae, H. influenzae, Moraxella catarrhalis, viral (RSV, rhinovirus)
Treatment (NICE NG91)
Analgesia: paracetamol ± ibuprofen regularly (most important). Antipyretics
Delayed prescribing strategy: give prescription for antibiotics but advise to use only if not improving after 3 days
Immediate antibiotics if: bilateral AOM in <2 years, AOM with otorrhoea (perforated TM), systemically unwell, immunocompromised, high complication risk
Amoxicillin 500 mg TDS for 5–7 days (adults). Children: 40–90 mg/kg/day in 3 doses. Penicillin allergy: erythromycin or clarithromycin
Amoxicillin-clavulanate if treatment failure after 48–72h on amoxicillin
Complications — URGENT Referral
Mastoiditis: postauricular swelling/tenderness, pinna displaced forward. CT mastoid. IV antibiotics + ENT (cortical mastoidectomy if abscess)
Intracranial: meningitis, brain abscess, lateral sinus thrombosis, subdural empyema — immediate CT + LP + IV antibiotics
Facial nerve palsy, labyrinthitis — ENT urgent review
👂 Otitis Externa▾
Diagnosis
Otalgia (worsened by tragus pressure/jaw movement), otorrhoea, EAC erythema/oedema, pruritus
Organisms: Pseudomonas (most common), Staphylococcus, mixed. Fungal (Aspergillus) especially post-antibiotic
Risk factors: swimming, hearing aids, cotton buds, eczema, psoriasis, diabetes
Treatment (NICE NG91)
Aural toilet: gentle syringing or microsuction (preferred). Remove debris before topical treatment
Acetic acid 2% spray (EarCalm) — first-line, OTC. Lowers pH, bacteriostatic/fungistatic
Gentamicin + hydrocortisone drops (Gentisone HC) TDS — if no TM perforation
Ciprofloxacin + dexamethasone drops (Cetraxal) — if TM perforated (safe — not ototoxic unlike aminoglycosides)
Wick insertion if EAC oedematous: Bishop Harman wick expands on insertion, improves drop penetration
Oral antibiotics NOT indicated for uncomplicated OE. Reserve for spreading cellulitis or failed topical treatment
Excited Delirium / ExDS
RCEM 2021 · High mortality · Restraint risks · Ketamine · Rapid medical care
RCEM 2021 · ACEP🚨
High mortality (up to 10%). Death can occur suddenly, often during or after restraint (positional asphyxia). Medical emergency — requires immediate clinical intervention, not just security management. Hyperthermia is the key driver of mortality.
🔬 Diagnosis & Features▾
Clinical Triad (Must Have All Three)
1. Delirium — agitation, confusion, disorientation, combativeness
2. Hyperthermia — core temp >39°C. Sweating profusely or paradoxically dry (severe)
3. Extraordinary strength — superhuman strength resistant to multiple officers
Additional: tachycardia, hypertension, diaphoresis, clothing removal, attraction to glass/light, pain insensitivity
Precipitants: stimulant drugs (cocaine, methamphetamine, MDMA, PCP, bath salts, cathinones), psychiatric illness, alcohol withdrawal, metabolic emergencies
Immediate Investigations
BM (hypoglycaemia), VBG (lactate, pH), temperature (rectal/core). ECG (QTc, arrhythmias)
FBC, U&E, LFT, CK (rhabdomyolysis), troponin, coagulation, urine toxicology, blood cultures
CT head when stable (intracerebral pathology)
💊 Treatment▾
Chemical Restraint / Sedation (RCEM 2021)
Ketamine 4–5 mg/kg IM — first-line in prehospital/difficult IV access. Onset 3–5 min IM. Maintains airway reflexes. Do NOT mix with other agents initially
Ketamine 1–2 mg/kg IV — if IV access available. Onset 60 seconds
Alternative: Droperidol 10 mg IM or midazolam 10 mg IM — may be less effective in ExDS
Avoid haloperidol alone (inadequate sedation depth, QTc risk). Avoid succinylcholine (rhabdomyolysis hyperkalaemia)
Supportive Care Priorities
Cooling is priority #1: remove clothing, fans, cold IV fluids, ice packs to axillae/groin. Target temp <39°C
Position: lateral/supine once sedated. NEVER prone (positional asphyxia risk — do NOT allow prone restraint)
Continuous SpO₂, ETCO₂ if intubated, ECG monitoring. Prepare for RSI if airway lost post-ketamine
IV fluids: 1–2 L crystalloid — rhabdomyolysis prevention. Treat hyperkalaemia if CK markedly raised
Document: restraint type, duration, who applied, clinical observations throughout
Umbilical Cord Prolapse
RCOG GTG50 · Manual elevation · Knee-chest position · Emergency CS
RCOG GTG50 2023🚨
Obstetric emergency. Cord compression → fetal hypoxia → fetal death. Call crash team. Category 1 caesarean section target delivery within 30 minutes of diagnosis. Do NOT remove the cord from the vagina.
🏥 Immediate Management▾
- 1Call for help immediately — obstetric team, anaesthetics, neonatology, theatres. Activate cord prolapse protocol.
- 2Do NOT handle the cord unnecessarily — manipulation causes vasospasm. Keep cord warm and moist (warm saline-soaked swabs).
- 3Manual elevation of presenting part: insert gloved hand vaginally, elevate fetal head off the cord manually — maintain this until delivery.
- 4Positioning: knee-chest (all-fours) position OR Trendelenburg (head-down tilt 30°) OR exaggerated Sims position — gravity reduces cord compression.
- 5Bladder filling: instil 500–750 mL 0.9% NaCl via urinary catheter to elevate presenting part and relieve cord compression — useful during transfer to theatre.
- 6Tocolysis: terbutaline 0.25 mg SC or salbutamol to reduce uterine contractions and cord compression.
- 7Continuous CTG monitoring. IV access. Bloods (FBC, G&S). Consent for emergency CS.
- 8Category 1 CS: target delivery within 30 min. If fully dilated and safe: instrumental delivery (forceps/ventouse).
Choking — Adult & Child
Resuscitation Council UK 2021 · Back blows · Heimlich · Laryngoscopy · Magill forceps
RCUK 2021🏥 Adult Choking Algorithm (RCUK 2021)▾
Mild Obstruction (can cough effectively)
Encourage continuous coughing. Do NOT intervene. Monitor closely
Mild: can speak, cough forcefully, breathe — stand by, reassure, monitor
Severe Obstruction (cannot cough, speak, or breathe adequately)
5 back blows: lean forward, heel of hand between shoulder blades, firm blows. Check mouth after each
5 abdominal thrusts (Heimlich): stand behind, fist above umbilicus below xiphisternum, pull sharply inward and upward. Check mouth after each
Alternate 5 back blows + 5 abdominal thrusts. Call 999/emergency team
If unconscious: lower to floor, start CPR (chest compressions may dislodge object). Look in mouth before each rescue breath
In ED — Advanced Techniques
Direct laryngoscopy + Magill forceps under direct vision — remove visible FB
Video laryngoscopy: improved visualisation. Suction for soft/liquid material
RSI + fibreoptic bronchoscopy if laryngoscopy fails or FB beyond cords. Rigid bronchoscopy (thoracic surgery)
Emergency surgical airway (cricothyroidotomy) if complete upper airway obstruction cannot be relieved
👶 Infant & Child Choking (RCUK 2021)▾
Infant (<1 year)
Face-down on forearm, head lower than chest. 5 back blows — heel of hand between shoulder blades
Turn face-up, support head. 5 chest thrusts — 2 fingers, centre of chest, 1 finger-breadth below nipple line, sharp downward
Do NOT use abdominal thrusts in infants (liver injury risk)
If unconscious: start infant CPR. Do NOT do blind finger sweeps
Child (>1 year)
5 back blows (lean forward). Then 5 abdominal thrusts — as in adult but gentler, use proportionate force
Alternate until object dislodged or child becomes unconscious → CPR
Look in mouth only if object visible — do NOT perform blind finger sweeps (may push FB deeper)
Drowning
RCUK 2021 · ILCOR · Modified ALS · Rewarming · Cervical spine
RCUK 2021 · ILCOR⚠
No patient is dead until warm and dead. Prolonged resuscitation is warranted in cold-water drowning (neuroprotective hypothermia). Core temp must be >32°C before ceasing resuscitation. C-spine immobilisation only if mechanism suggests injury.
🏥 Resuscitation & Management▾
Prehospital / Immediate
Remove from water safely. Horizontal position — do not stand upright (cardiovascular collapse risk)
C-spine immobilisation ONLY if: diving, high-speed watercraft, signs of injury, alcohol involved
Rescue breathing starts on extraction if apnoeic — even in water if safe
Remove wet clothing. Active rewarming. Warm blankets. Warm IV fluids 39°C
Modified ALS Algorithm for Drowning (RCUK 2021)
5 rescue breaths first (prioritise ventilation — hypoxic arrest), then standard CPR 30:2
Early intubation — aspiration, laryngospasm, pulmonary oedema common. Suction immediately
Defibrillation: if VF/VT — attempt but hypothermic heart may be refractory until temp >30°C
Drugs: withhold if temp <30°C. Double intervals 30–35°C. Normal intervals >35°C
Continue resuscitation until: core temp >32°C, serum K⁺ <12 mmol/L (high K⁺ indicates non-survivable cell death)
Post-Resuscitation / Admission
All significant submersion patients: admit for minimum 6–8h monitoring (delayed pulmonary oedema)
CXR, ABG, ECG, FBC, U&E, glucose, coagulation. Bronchoscopy if aspiration of solids
Lung-protective ventilation: PEEP 5–10, TV 6 mL/kg. Neurological monitoring. Blood glucose control
Rewarming methods — passive (warm environment), active external (warming blankets), internal (warm humidified O₂, warm IV fluids, bladder/gastric lavage). ECMO for severe hypothermia
Devastating Brain Injury (DBI)
RCEM 2022 · DNACPR · Ceiling of treatment · Organ donation · Brainstem death
RCEM 2022 · NHSBT · GMCℹ
DBI refers to brain injuries from which meaningful neurological recovery is not expected. Early, sensitive communication with families is essential. Always consider organ donation — NHSBT specialist nurses (SNODs) should be contacted early.
📋 Recognition & Decision-Making▾
Clinical Features Suggesting DBI
GCS 3 post-resuscitation (with no reversible cause). Absent brainstem reflexes. Fixed dilated pupils bilaterally
CT: massive intracerebral haemorrhage, diffuse axonal injury, cerebral oedema with herniation, massive stroke
Causes: traumatic brain injury, subarachnoid haemorrhage, intracerebral haemorrhage, cardiac arrest anoxic injury, stroke
RCEM DBI Framework — 4 Key Questions
1. Is the diagnosis correct? Exclude reversible causes: hypoglycaemia, hypothermia, drugs, locked-in syndrome
2. What is the prognosis? Neurosurgical/neurological opinion. Imaging severity scoring
3. What would the patient want? Advance decisions, ADRT, ReSPECT form, DNACPR. Next of kin discussion
4. Is organ donation possible? Early SNOD referral (even before death). DCD (donation after circulatory death) or DBD (brainstem death)
🏥 Brainstem Death Testing & Organ Donation▾
Brainstem Death (DBD) — Prerequisites
Apnoeic coma requiring ventilatory support. Irremediable structural brain damage. Known cause
Exclude: hypothermia (<34°C), drugs (sedatives, neuromuscular blocking agents), metabolic/endocrine (Na, glucose)
Two sets of tests by two senior doctors (one must be a consultant), at least 6 hours apart. Neither can be on transplant team
Brainstem Reflexes Tested
Pupillary response (no response to bright light). Corneal reflex (absent). Oculovestibular reflex (cold caloric)
Motor response to supraorbital pressure (absent). Gag/cough reflex (absent). Apnoea test (PaCO₂ rises ≥0.5 kPa above resting without respiratory effort)
Organ Donation Pathway
SNOD referral early (even pre-death) — improves donation rates and family experience
DCD (donation after circulatory death): planned withdrawal, WLST, circulatory arrest → retrieval within 2–5 min
Family approach: SNODs ideally lead conversation. Decoupled conversation (treatment withdrawal decision separate from donation)
Never deny treatment to a patient to facilitate organ donation. Organ donation must not compromise end-of-life care
Failed Intubation Algorithm
DAS 2015 guidelines · Plan A–D · CICO · Surgical airway · Wakeup vs proceed
DAS 2015 · AAGBI🚨
Declare "failed intubation" after 2 failed attempts (or 3 including aide). Call for help immediately. Prioritise oxygenation over intubation — NEVER persist with intubation at the expense of oxygenation. CICO = cannot intubate, cannot oxygenate = surgical airway NOW.
📋 DAS 2015 Failed Intubation Algorithm — Plans A–D▾
Plan A — Tracheal Intubation
RSI: pre-oxygenate to SpO₂ >94%, position (ramping for obese), 2 attempts maximum at direct laryngoscopy
Optimisation: BURP/ELM, video laryngoscopy, bougie, change blade/operator, jaw thrust
After 2 failed attempts → declare failed intubation, call for help, move to Plan B
Plan B — Maintain Oxygenation & Awaken Patient (if possible)
Face mask oxygenation (2-person technique) ± oropharyngeal airway. SpO₂ priority
Insert supraglottic airway device (SAD) — second-generation SGA (i-gel, LMA Supreme, Proseal)
Decision: Wake patient up (if non-emergency — safer, plan next airway approach) OR proceed with SGA (if cannot wake, urgent surgery, or oxygenation maintained via SGA)
Plan C — Attempt Intubation via SGA
Intubation via SGA with fibreoptic bronchoscope if oxygenation maintained via SGA
Or intubating LMA (ILMA/Fastrach). Single attempt
Plan D — CICO: Emergency Front-of-Neck Access (FONA)
Cannot Intubate, Cannot Oxygenate (CICO): SpO₂ falling despite all above — immediate surgical airway
Scalpel-finger-bougie technique (DAS recommended): horizontal stab incision through cricothyroid membrane, finger to confirm trachea, bougie through, tube over bougie
Alternative: commercial kit (Melker), cannula crico (high failure rate — only as bridge)
Do NOT attempt needle cricothyroidotomy as sole plan — high failure, CO₂ retention
Cricothyroidotomy
DAS / FONA · Scalpel-finger-bougie technique · Cannula approach · Anatomy
DAS 2015 · RCEM🚨
Last-resort airway in CICO. Speed and decisiveness save lives. The scalpel-finger-bougie technique is DAS-recommended for emergency cricothyroidotomy. Have the kit at bedside before every RSI.
📋 Anatomy & Scalpel-Finger-Bougie Technique▾
Anatomy
Cricothyroid membrane (CTM): between thyroid cartilage (superior) and cricoid cartilage (inferior)
Located in midline. Width ~30 mm, height ~9–10 mm. Avascular superior portion — safest incision zone
Palpate: thyroid notch → thyroid cartilage → soft CTM depression → cricoid ring. Laryngeal handshake technique
Difficult identification: obese, oedema, haematoma, abnormal anatomy → use USS or stab midline inferiorly
Scalpel-Finger-Bougie (DAS 2015 — Standard)
Step 1: Laryngeal handshake — stabilise larynx with non-dominant hand, palpate CTM
Step 2: Horizontal stab incision through CTM with scalpel (10-blade) — bold, confident incision through skin AND membrane
Step 3: Hook — insert hooked finger caudally to identify and dilate the opening, maintaining position
Step 4: Bougie — insert bougie through incision into trachea, feel tracheal rings
Step 5: Tube — railroad size 6.0 cuffed ETT over bougie. Remove bougie. Inflate cuff. Confirm ventilation (ETCO₂)
Cannula Cricothyroidotomy (Bridge Only — Limited Utility)
14G IV cannula through CTM, aspirate air, remove needle, attach high-pressure O₂ (15 L/min jet ventilation)
High failure rate (kinking), CO₂ retention, max 30–45 minutes — bridge only to surgical airway
Commercial kits (Portex Minitrach): Seldinger technique — may be faster in trained hands
Tracheostomy Emergencies
NTSP algorithm · Tube displacement · Obstruction · Bleeding · Stoma care
NTSP 2022 · RCEM · ICS🚨
Call for help: anaesthetics, ENT, ICU. Always call for expert help early. Primary emergency: is the patient breathing? Can you ventilate? Displaced tracheostomy tube = remove it, oxygenate from above (face mask) + attempt reintubation orally/nasally first.
📋 NTSP Emergency Algorithm▾
Step 1 — Call for Help & Assess
Call anaesthetics, ENT, ICU urgently. Note: Is patient breathing? SpO₂? Is stoma new (<7 days) or mature (>7 days)?
Look at stoma: is tube in correct position? Suction inner tube (if present) — remove and clean/replace
Step 2 — Assess Tube Patency (Obstruction)
Pass suction catheter: if passes easily, tube patent. If resistance → obstruction. Remove inner tube (if present) and retry
Remove outer tube if suction fails: attempt reintubation through stoma with same or smaller tube
Deflate cuff first before attempting to remove or replace tube. Use blunt-ended dilator if available
Step 3 — Tube Displacement
Remove displaced tube. Apply 15L/min O₂ via face mask over mouth AND stoma simultaneously
New stoma (<7 days): do NOT blindly attempt reinsertion (tract not established — risk of paratracheal placement). Attempt oral/nasal intubation. ENT urgently
Mature stoma (>7 days): attempt reinsertion with introducer or smaller tube. Confirm with capnography
Laryngoscopy: oral intubation easier — cover/block stoma when ventilating from above
Tracheostomy Bleeding
Minor: suction, silver nitrate, topical adrenaline-soaked gauze. Haematology/coagulation review
Major (tracheo-innominate artery fistula): rare but rapidly fatal. Hyper-inflate cuff to tamponade. Compress artery through stoma with finger. Immediate surgical emergency
Chest Drain Insertion
BTS 2023 · Seldinger vs surgical blunt dissection · Landmarks · USS guidance
BTS 2023 · RCEM📋 Indications & Approach Selection▾
Seldinger (Small-Bore 8–14Fr)
Pleural effusion, haemothorax (small-moderate), empyema, pneumothorax (simple). Safer for effusions.
Surgical Blunt Dissection (Large-Bore 24–36Fr)
Massive haemothorax (>1.5L), trauma, viscous fluid. Rapidly drains large volumes. Standard in trauma.
Indications
Pneumothorax: tension (immediate), large (>2 cm rim) or symptomatic, failed aspiration, haemopneumothorax, ventilated patient
Haemothorax: significant (drainage needed). Pleural effusion: large/symptomatic, exudate needing sampling
Empyema: requires drainage (pH <7.2, glucose <3.3, LDH >3× upper limit). Chylothorax, malignant effusion
🔧 Technique — Surgical Blunt Dissection (Trauma)▾
Position & Landmarks
Patient: supine or 45° head-up. Arm abducted. "Safe triangle": anterior border of latissimus dorsi, lateral border of pectoralis major, above nipple level (5th ICS AAL)
Site: 4th/5th intercostal space, anterior axillary line. Never below 5th ICS (diaphragm level)
USS guidance mandatory for non-emergency pleural effusion drainage (BTS 2023)
Blunt Dissection Steps
Infiltrate 10–20 mL lidocaine 1% (skin → rib → pleura). Horizontal skin incision 2 cm, over upper border of lower rib (avoids NVB inferiorly)
Blunt dissection with curved clamp down to pleura. Controlled entry through pleura — "pop" felt. Digital exploration of pleural space
Insert drain (clamped) with finger guidance. Direct posteriorly and superiorly for pneumothorax; posteriorly and inferiorly for effusion/haemothorax
Connect to underwater seal drain. Unclamp. Confirm: swinging + misting. Secure with purse-string and mattress suture. CXR post-insertion
Monitoring Post-Insertion
Drainage >1.5L immediately or >200 mL/h → consider clamping and surgical thoracotomy (haemothorax)
Drain removal: when <200 mL/24h (effusion) or lung fully re-expanded. Remove at end-expiration/Valsalva
Complications: malposition, lung injury, haemorrhage, infection (empyema risk <2%), surgical emphysema
Needle Thoracocentesis / Decompression
Tension pneumothorax · 2nd ICS MCL · 4th/5th ICS AAL · Finger thoracostomy
ATLS 10th Ed · RCEM · TCCC🚨
Tension pneumothorax is a clinical diagnosis — do NOT wait for CXR. Treat immediately. Failure to decompress is rapidly fatal. If needle decompression fails (no air release), immediately proceed to finger thoracostomy.
📋 Tension Pneumothorax — Diagnosis & Decompression▾
Clinical Features (Tension PTX)
Respiratory distress, tachycardia, hypotension. Tracheal deviation (LATE — unreliable)
Absent breath sounds on affected side. Hyperresonance on percussion. JVD (may be absent if hypovolaemic)
In cardiac arrest: PEA with above signs → immediate needle decompression
Needle Decompression — 2nd ICS Midclavicular Line (Classic)
Site: 2nd intercostal space, midclavicular line, affected side. Upper border of 3rd rib
14–16G cannula (minimum 4.5 cm length — may fail in obese patients with thick chest wall)
Insert perpendicular to chest wall. "Hiss" of air = successful decompression. Remove needle, leave cannula
High failure rate (~50% with 14G, especially obese/muscular) — proceed to finger thoracostomy if no response
Finger Thoracostomy — 4th/5th ICS Anterior Axillary Line (Preferred in Trauma)
Site: 4th–5th ICS, anterior axillary line (same as chest drain site). More reliable than MCL approach
2 cm horizontal incision over rib. Blunt dissection with curved clamp. Digital entry into pleural space
Sweep finger to confirm pleural space (no adhesions). Air rush = decompression. Convert to chest drain
Preferred in major trauma (ATLS 10th Ed): more reliable, can be performed with gloved finger in arrest
Procedural Sedation & Analgesia
RCEM guidelines · Ketamine · Propofol · Midazolam · Monitoring · Fasting
RCEM 2020 · RCOA📋 Preparation & Risk Assessment▾
Pre-Procedure Assessment
ASA classification (I–II routine; III–IV senior anaesthetic review). Airway assessment (Mallampati, neck mobility, mouth opening)
Fasting: ideally 2h liquid, 6h food — however RCEM states starvation not mandatory for urgent procedures when risks/benefits considered. Document decision
Consent: risks of sedation (respiratory depression, aspiration, allergy, failure of sedation)
Equipment: monitoring (SpO₂, ETCO₂, ECG, NIBP), supplemental O₂, BVM, airway adjuncts, reversal agents, suction, crash trolley available
Two-person minimum: one dedicated to sedation/monitoring, one for procedure
💊 Drug Options▾
Ketamine (Dissociative — Preferred in ED)
IV: 1–2 mg/kg slowly over 60 seconds. Onset 60 seconds, duration 10–20 min
IM: 4–5 mg/kg. Onset 5 min, duration 20–40 min. Useful when IV access difficult
Advantages: maintains airway reflexes, bronchodilator, analgesic, preserves BP
Disadvantages: emergence phenomena (hallucinations) — pre-treat with midazolam 0.05 mg/kg IV. Hypersalivation — glycopyrrolate 200 mcg IV. Laryngospasm rare but prepare for
Contraindications: age <3 months, psychosis, elevated ICP, ischaemic heart disease, hypertensive emergency, known laryngospasm history
Propofol (Sedation/Anaesthesia)
0.5–1 mg/kg IV slow titration. Onset 30–60 seconds. Duration 5–10 min. Repeat 0.25 mg/kg boluses
Advantages: rapid onset/offset, antiemetic, smooth sedation
Disadvantages: dose-dependent respiratory depression, hypotension, no analgesia. Requires anaesthetic presence in UK (RCOA guidance). Pain on injection (use antecubital vein, pre-lidocaine)
Midazolam + Fentanyl (Anxiolysis/Light Sedation)
Midazolam 1–2.5 mg IV titrated. Onset 2–5 min. Elderly: 0.5–1 mg
Fentanyl 1–2 mcg/kg IV (or 50–100 mcg) for analgesia
Reversals: flumazenil 0.2 mg IV (repeat to 1 mg) for benzodiazepines; naloxone 0.4 mg IV for opioids
Post-Sedation Monitoring
Continuous monitoring until: GCS 15, SpO₂ on room air, able to walk (if applicable). Minimum 30 min
Discharge criteria: escort home, no driving for 24h, written instructions, contact number provided
Fascia Iliaca Compartment Block
Neck of femur fracture · Inguinal landmark technique · USS guidance · Bupivacaine
RCEM 2020 · NICE NG111💊 Indications, Anatomy & Technique▾
Indications
Neck of femur fracture (NICE NG111 recommends within 1 hour of ED arrival). Femoral shaft fracture. Knee surgery analgesia
Reduces opioid requirements, delirium, complications. Effective analgesia for 8–18h
Contraindications: anticoagulation (relative), skin infection at site, allergy to LA, coagulopathy
Landmark Technique (Injection Point)
Palpate inguinal ligament (ASIS to pubic tubercle). Mark point 1/3 lateral from pubic tubercle (medial 2/3 junction with lateral 1/3)
1–2 cm below inguinal ligament. Palpate femoral artery — needle lateral to artery
Technique: short-bevel needle. Two distinct "pops" felt (fascia lata, then fascia iliaca). Aspiration: no blood/air
Inject 40 mL of 0.25% bupivacaine (max 2 mg/kg = do NOT exceed 150 mg in 70 kg adult). Apply digital pressure distally and inject superiorly. Fan technique to spread LA
USS-Guided Technique (Preferred)
High-frequency linear probe. Identify femoral artery, nerve, fascia iliaca layer
In-plane needle approach. Watch local anaesthetic spread under fascia iliaca (real-time confirmation)
Onset: 15–30 min. Assess by ice/cold sensation over anterior thigh. Document block, dose, time, consent
Haematoma Block
Colles' / distal radius fracture · Lidocaine into haematoma · Technique · Monitoring
RCEM · BES💊 Technique & Management▾
Indications & Contraindications
Displaced distal radius fracture requiring manipulation (Colles', Smith's). Simple alternative to sedation/Bier's block
Contraindications: open fracture, skin infection at site, coagulopathy, allergy to lidocaine
Advantages: simple, no sedation required, rapid onset, no fasting needed, safe in elderly/comorbid
Procedure
Clean skin with antiseptic. Position wrist in neutral. Identify fracture site on X-ray
Insert 21G needle dorsally at fracture site (aspirate: dark blood = haematoma confirmed)
Inject 10 mL of 2% lidocaine (plain, no adrenaline) directly into haematoma. Wait 10 minutes
For both fracture sites (if comminuted): repeat on ulnar side with additional 5 mL lidocaine 2%
Maximum dose: lidocaine 3 mg/kg (i.e. 15 mL of 2% in 70 kg patient). Do NOT exceed
Manipulation after 10–15 min. Apply plaster of Paris backslab. Post-manipulation X-ray
Monitoring
SpO₂, HR, BP. Observe for systemic LA toxicity: tinnitus, perioral tingling, metallic taste, confusion, seizures, cardiac arrhythmias
Intralipid 20% immediately available if LA toxicity suspected. Intralipid 1.5 mL/kg IV bolus, then 0.25 mL/kg/min infusion
Lateral Canthotomy & Cantholysis
Orbital compartment syndrome · Sight-saving · Step-by-step technique · IOP monitoring
RCOphth · RCEM · AAO🚨
Sight-saving emergency for orbital compartment syndrome. Permanent vision loss can occur within 90–120 minutes. Perform in ED without delay if ophthalmology unavailable. Do NOT wait for CT if clinical diagnosis is clear.
🔪 Indications & Step-by-Step Technique▾
Indications
Retrobulbar haematoma with: raised IOP (>40 mmHg), proptosis, RAPD, restricted EOM, reduced VA
Post-traumatic orbital compartment syndrome. Do not delay for CT if clinical diagnosis clear
Equipment
Straight haemostat (artery forceps), iris scissors or sharp-pointed scissors, lidocaine 2% with adrenaline, 25G needle/syringe
Technique — Step by Step
Step 1: Infiltrate lateral canthus with 1–2 mL lidocaine 2% with adrenaline (1:80,000) — reduces bleeding
Step 2: Clamp lateral canthus horizontally with straight haemostat for 60 seconds to achieve haemostasis
Step 3: Canthotomy — cut along the clamped area with scissors: full-thickness horizontal cut from lateral canthus to bony orbital rim (~1–1.5 cm). Blunt dissection to bone
Step 4: Inferior cantholysis — identify inferior crus of lateral canthal tendon (like a taut violin string running from lateral orbital rim to lower eyelid). Cut completely with scissors. Feel tissue "pop" — orbital pressure released
Step 5: Recheck IOP and RAPD. If IOP still high → perform superior cantholysis (cut superior crus)
Step 6: Wound management — leave open, moist dressing. Ophthalmology repair under GA when stable
Adjunctive Measures
Acetazolamide 500 mg IV. Mannitol 20% 1 g/kg IV. Timolol + brimonidine drops. Head 30° elevation
Reverse anticoagulation if applicable. Ophthalmology urgent review for definitive repair
Acute Limb Ischaemia
NICE NG145 · 6 Ps · Rutherford classification · Heparin · Embolectomy · Thrombolysis
NICE NG145 2019 · ESVS🚨
Limb viability threatened after 6 hours without revascularisation. "Time is muscle." Immediate vascular surgery referral. Anticoagulate immediately once diagnosis confirmed. Embolic causes have better outcomes than thrombotic.
🔬 Diagnosis — 6 Ps & Rutherford Classification▾
6 Ps of Acute Limb Ischaemia
Pain — severe, sudden onset, worsened by elevation. Pallor — white/mottled limb
Pulselessness — absent distal pulses (Doppler may still detect). Paraesthesia — tingling/numbness (nerve ischaemia)
Paralysis — weakness/loss of movement (LATE, near-irreversible). Perishing cold — cold to touch above usual level
Rutherford Classification (SVS)
Class I — Viable: no neurological deficit, Doppler audible (venous + arterial). No immediate threat. Anticoagulate, urgent workup
Class IIa — Marginally Threatened: minimal sensory loss, no motor deficit. Doppler venous audible, arterial not. Urgent revascularisation (<6h)
Class IIb — Immediately Threatened: sensory + motor deficit, rest pain. Doppler venous only. Emergency revascularisation (<1–2h)
Class III — Irreversible: anaesthesia, paralysis, rigor. No Doppler. Primary amputation
Embolic vs Thrombotic
Embolic: sudden onset, source (AF, MI, valvular), no prior claudication, contralateral pulses normal. Better prognosis with embolectomy
Thrombotic: history of PVD, claudication, contralateral disease, atherosclerosis. Requires angioplasty/bypass
💊 Emergency Treatment▾
Immediate Management
Heparin 5000 units IV bolus immediately (unfractionated) — prevents clot propagation. Then heparin infusion 1000 units/h (APTT-guided)
Analgesia: IV morphine/opioids. Lower limb: neutral position (not elevated — worsens ischaemia)
Bloods: FBC, coagulation, G&S/crossmatch, U&E, LFT, troponin (cardiac source), group & save
ECG: AF? (embolic source). Duplex USS: confirms occlusion level. CT angiography: maps anatomy for intervention
Definitive Treatment (Vascular Surgery)
Embolectomy: Fogarty catheter balloon embolectomy — for embolic ALI. Excellent results if within 6h
Catheter-directed thrombolysis (CDT): tPA (alteplase) infused directly. For thrombotic/sub-acute (<14 days). Takes hours, not suitable for Class IIb
Percutaneous mechanical thrombectomy: rapid clot removal with device. Increasingly used
Post-reperfusion: monitor for reperfusion injury, compartment syndrome (fasciotomy if needed), hyperkalaemia, myoglobinaemia
Warfarin Reversal
BCSH guidelines · INR · Vitamin K · Prothrombin complex concentrate (PCC) · FFP
BCSH 2022 · NICE📋 Reversal Strategy by Clinical Context▾
Life-Threatening Bleeding (Intracranial, Massive GI, Haemodynamically Unstable)
Prothrombin complex concentrate (PCC) — Beriplex/Octaplex: dose based on INR and weight
INR 2–3.9: 25 units/kg | INR 4–6: 35 units/kg | INR >6: 50 units/kg (max 3000 units)
+ Phytomenadione (Vitamin K₁) 5–10 mg IV slowly (anaphylaxis risk — give over 20–30 min). Sustains reversal
FFP 15 mL/kg: only if PCC unavailable. Slower, large volume, risk of TACO/TRALI
Recheck INR 30 min after PCC. Target INR <1.5 for haemostasis
Non-Life-Threatening Major Bleeding (e.g. haematuria, haemarthrosis, epistaxis)
Withhold warfarin. Vitamin K₁ 1–3 mg IV or 5 mg oral. INR check in 6–12h
PCC if INR very high (>8) or bleeding significant
Supratherapeutic INR Without Bleeding
INR 4.5–8, no bleeding: withhold 1–2 doses. Vitamin K₁ 1–2.5 mg oral
INR >8, no/minor bleeding: Vitamin K₁ 2.5–5 mg oral. Repeat INR in 24h
Do NOT over-reverse — thromboembolism risk especially in AF/mechanical valves
Restarting Warfarin
After haemostasis achieved: restart at lower dose or same dose depending on INR trajectory
Intracranial haemorrhage: discuss with haematology/neurology — typically 7–14 day hold minimum
DOAC Reversal
Idarucizumab · Andexanet alfa · PCC · Timing considerations · NICE guidance
NICE TA905 · BCSH 2022💊 Specific Reversal Agents by DOAC▾
Dabigatran (Pradaxa) — Direct Thrombin Inhibitor
Idarucizumab (Praxbind) 5 g IV (two 2.5 g vials) — specific antidote. NICE approved. Reversal within minutes. Renally cleared
Indications: life-threatening/uncontrolled bleeding, emergency surgery within 8h, overdose
Dialysis: dabigatran is dialysable (70% removal in 4h) — option if idarucizumab unavailable
Monitor: dilute thrombin time (dTT) or ecarin clotting time (ECT). aPTT if unavailable
Factor Xa Inhibitors — Apixaban (Eliquis) / Rivaroxaban (Xarelto) / Edoxaban (Lixiana)
Andexanet alfa (Ondexxya) — specific antidote. NICE TA905 (2023): restricted to life-threatening intracranial haemorrhage
Low dose (apixaban ≤5 mg or rivaroxaban ≤10 mg, or last dose >8h): 400 mg IV bolus over 15 min + 480 mg over 2h
High dose (apixaban >5 mg or rivaroxaban >10 mg, or dose unknown, or <8h): 800 mg IV bolus + 960 mg over 2h
Thromboembolic events reported (10–18%): give VTE prophylaxis post-reversal when safe
When Specific Antidotes Unavailable / Non-Intracranial Bleeding
4-Factor PCC (Beriplex/Octaplex) 25–50 units/kg — non-specific but widely used for Xa inhibitors. Less evidence than andexanet
Tranexamic acid 1 g IV — adjunct to reduce fibrinolysis. Useful in all DOAC-related major bleeding
Activated charcoal (50 g) if ingestion <2–4h and patient alert — reduces absorption
Last dose timing critical: Xa inhibitors: peak 1–4h, half-life 8–15h. Most DOAC bleeds manageable without reversal if time elapsed
General Principles
Time from last dose matters — >24h since last dose: minimal anticoagulant effect remaining in normal renal function
Avoid pressure on non-compressible sites. Local haemostatic measures first. Transfuse pRBC/platelets as needed
Renal function critical: dabigatran — CrCl <30: significantly prolonged effect. Monitor carefully
Neurogenic Shock
Spinal cord injury · Sympathetic disruption · Bradycardia + hypotension · Vasopressors
RCSUK · NICE NG41⚠
Neurogenic shock ≠ spinal shock. Neurogenic shock = haemodynamic instability from loss of sympathetic tone (injury ≥T6). Spinal shock = temporary loss of all neurological function below injury (resolves in days-weeks). Distinguish from hypovolaemic shock — fluids alone insufficient.
🔬 Diagnosis & Management▾
Clinical Features
Hypotension + bradycardia (classic triad with warm peripheries due to vasodilation) — in setting of SCI ≥T6
Warm, dry, flushed below level of injury (loss of sympathetic vasoconstriction)
Paradoxically normal or low heart rate despite hypotension (loss of cardiac sympathetic innervation — T1–T4)
Priapism in males — pathognomonic of spinal cord injury. Poikilothermia
Haemodynamic Targets
MAP target ≥85–90 mmHg for first 7 days — prevents secondary spinal cord ischaemia (RCSUK)
Do NOT fluid-resuscitate excessively — pulmonary oedema risk in denervated chest. Max 1–2 L crystalloid, then vasopressors
Vasopressor Management
Noradrenaline (norepinephrine): first-line vasopressor. Start 0.05–0.1 mcg/kg/min, titrate to MAP target. Alpha > beta — predominantly vasoconstrictive
Phenylephrine: pure alpha agonist — useful if tachycardia not desired. Avoid if bradycardia present
Dopamine: alternative if bradycardia + hypotension — positive chronotropic and inotropic effects
Atropine 0.5–1 mg IV for symptomatic bradycardia (HR <50 or haemodynamically significant). Repeat to max 3 mg
Temporary pacing: if atropine-refractory bradycardia (especially complete heart block from high cervical injury)
ROSIER Score — Stroke Recognition
Recognition of Stroke in the Emergency Room · Validated tool · CT pathway
NICE NG128 2019 · RCEM📋 ROSIER Score Calculation▾
Step 1 — Exclude Hypoglycaemia First (BM <3.5 = treat, then reassess)
If BM <3.5: give glucose and reassess. Do not apply ROSIER until normoglycaemic
ROSIER Scoring Items
Loss of consciousness or syncope: Yes = –1, No = 0
Seizure activity: Yes = –1, No = 0
Asymmetric facial weakness: Yes = +1, No = 0
Asymmetric arm weakness: Yes = +1, No = 0
Asymmetric leg weakness: Yes = +1, No = 0
Speech disturbance (dysphasia/dysarthria): Yes = +1, No = 0
Visual field defect: Yes = +1, No = 0
Total range: –2 to +5. Score ≥1 = stroke likely → activate stroke pathway
Interpretation & Action
Score ≥1: probable stroke. Immediate CT head + CT angiography (CTA). Stroke team activation. Thrombolysis if eligible within 4.5h of onset
Score ≤0: stroke unlikely — consider stroke mimics (hypoglycaemia, Todd's paresis, functional, migraine, sepsis)
Sensitivity 92%, specificity 86% for ischaemic stroke. Validated in multiple ED populations
NIHSS: quantify deficit severity. FAST-ED: pre-hospital large vessel occlusion screen
Acute Diverticulitis
NICE NG147 · Hinchey classification · CT · Antibiotics · Hartmann's procedure
NICE NG147 2019 · ACPGBI🔬 Diagnosis & Classification▾
Clinical Features
Left iliac fossa pain (right-sided in sigmoid redundancy or right-sided diverticula). Fever, nausea, altered bowel habit
Local peritonism (guarding/tenderness LIF). Leucocytosis, elevated CRP. PR examination: tenderness, exclude rectal pathology
Complications: abscess, perforation (purulent/faecal peritonitis), fistula, obstruction
Hinchey Classification (CT-Defined)
Stage I: pericolic abscess — IV antibiotics ± percutaneous drainage if >3 cm
Stage II: distant/pelvic abscess — antibiotics + percutaneous drainage. Surgery if fails
Stage III: purulent peritonitis — emergency surgery (Hartmann's or primary anastomosis with defunctioning stoma)
Stage IV: faecal peritonitis — emergency surgery (Hartmann's). High mortality 30–40%
Investigations
FBC, CRP, U&E, LFT, amylase (exclude pancreatitis), lactate, blood cultures. Urine dip (colovesical fistula)
CT abdomen/pelvis with IV contrast — gold standard. Do NOT scope acutely (perforation risk). Colonoscopy 4–6 weeks post-resolution (exclude malignancy)
💊 Antibiotic Treatment & Disposition▾
Uncomplicated (Hinchey I without significant abscess) — Outpatient or Admit
NICE NG147: antibiotics NOT routinely recommended for uncomplicated acute diverticulitis (evidence limited — resolves without in many cases)
If antibiotics given: Co-amoxiclav 625 mg TDS oral × 5–7 days (covers gram-negatives + anaerobes)
Alternative (penicillin allergy): ciprofloxacin 500 mg BD + metronidazole 400 mg TDS
Liquid diet initially, analgesia (avoid NSAIDs — renal vasoconstriction and may worsen inflammation), laxatives
Complicated or Hospitalised
Co-amoxiclav 1.2 g IV q8h + fluid resuscitation. Nil by mouth if surgical candidate
Septic: add gentamicin 5–7 mg/kg OD IV (single-daily dosing, renal-adjusted). Broad-spectrum: meropenem 1 g IV q8h
Surgical consult for Hinchey II–IV. Percutaneous drainage for abscesses >3 cm (radiology-guided). ITU if septic shock
Diverticular Bleed
Most common cause of massive lower GI bleed · Colonoscopy · CTA · Embolisation
BSG 2019 · NICE NG141⚠
Diverticular bleeding is the most common cause of major lower GI haemorrhage in adults >50 years. Usually right-sided diverticula. 80% stop spontaneously. Haemodynamic instability requires urgent resuscitation and intervention.
🏥 Assessment & Management▾
Initial Assessment
PR examination. Proctoscopy/rigid sigmoidoscopy to exclude ano-rectal source (haemorrhoids, anal fissure)
Oakland score: risk stratification for safe discharge vs admission. Score <8 = low risk, consider outpatient colonoscopy
Bloods: FBC, U&E, LFT, clotting, crossmatch (4 units), group & save. Lactate
Reverse anticoagulation if applicable (see warfarin/DOAC reversal sections)
Resuscitation
Two large-bore IVs. IV crystalloid. Transfuse pRBC if Hb <80 g/L (haemodynamically unstable: transfuse at higher threshold)
Platelet transfusion if count <50 × 10⁹/L with active bleeding. FFP/PCC if coagulopathic
Urinary catheter, strict fluid balance. HDU/ICU if haemodynamically unstable
Definitive Haemostasis
CT angiography (CTA): if haemodynamically unstable or active bleeding — identifies bleeding site (>0.3 mL/min). Guides intervention
Colonoscopy: within 24h of resuscitation — allows direct haemostasis (clips, adrenaline injection, bipolar diathermy). Requires bowel preparation
Interventional radiology embolisation: super-selective embolisation of bleeding mesenteric vessel — high success rate (85–95%), ischaemia risk 5–10%
Surgery (Hartmann's or right hemicolectomy): last resort for refractory bleeding or haemodynamic instability
Ischaemic Colitis
Watershed areas · Splenic flexure · CT colonography · Supportive care · Surgery
BSG 2016 · ACG Guidelines🔬 Diagnosis & Management▾
Clinical Features
Sudden onset crampy left-sided abdominal pain + rectal bleeding (fresh blood PR) + diarrhoea
Usually mild and self-limiting (85%). Watershed areas most vulnerable: splenic flexure (Griffiths point), sigmoid-descending junction (Sudeck's point)
Risk factors: atherosclerosis, AF/embolic disease, post-aortic surgery, hypotension, constipation, IBS, vasculitis, cocaine
Severe: peritonism, fever, significant bloody diarrhoea → transmural infarction (surgical emergency)
Investigations
FBC (leukocytosis), CRP (elevated), LFT, lactate (>2 = bowel ischaemia more likely), clotting
AXR: thumb-printing (submucosal oedema/haemorrhage) — classic finding. Pneumatosis coli = transmural ischaemia
CT abdomen/pelvis with contrast: bowel wall thickening, pneumatosis, portal venous gas (severe). Doppler for SMA/IMA if mesenteric ischaemia suspected
Colonoscopy (within 48h): pale, oedematous mucosa with superficial ulceration. Single stripe sign (SS) = mild
Treatment
Mild-moderate (no peritonism, haemodynamically stable): bowel rest, IV fluids, optimise cardiovascular status
Antibiotics if fever/systemic features: co-amoxiclav 1.2 g IV q8h + metronidazole 500 mg IV q8h
Avoid vasopressors if possible (worsen ischaemia). Treat precipitant (AF, hypotension, constipation)
Anticoagulation: if embolic cause (AF) — requires specialist decision (bleeding vs re-occlusion risk)
Surgery: for peritonitis, transmural infarction, uncontrolled haemorrhage, or failure to improve in 24–48h
Chronic: up to 20% develop stricture requiring resection. Follow-up colonoscopy at 6–8 weeks