1. 1Confirm PEA or asystole — check gain, leads, contact. Do NOT shock.
2. 2Start CPR. Establish IV/IO access as soon as possible.
3. 3Adrenaline 1 mg IV/IO as soon as access obtained.
4. 4Continue 2-min CPR cycles. Adrenaline every 3–5 min (every alternate loop).
5. 5Actively identify and treat reversible causes (4Hs & 4Ts) — this is the key intervention.
6. 6Consider echo (POCUS) for reversible structural causes (tamponade, PE, massive MI).

1. 112-lead ECG immediately — STEMI or ≥2 contiguous ST changes → activate cardiac cath lab urgently
2. 2Target SpO₂ 94–98% (PaO₂ 10–13 kPa). Avoid hyperoxia — titrate FiO₂ down.
3. 3Target PaCO₂ 4.5–5.0 kPa — avoid hyperventilation (worsens cerebral perfusion)
4. 4Target MAP ≥65 mmHg, SBP ≥100 mmHg. Vasopressors as below.
5. 5Blood glucose: target 6–10 mmol/L. Avoid hypoglycaemia.
6. 6Targeted Temperature Management (TTM): target 36°C × 24h for comatose survivors
7. 7CT head ± CT coronary angiography. Transfer to ICU.
8. 8Neuroprognostication: not before 72h post-ROSC (or 72h after rewarming if TTM used)

Target HR: <110 bpm (RACE II). Tighter <80 bpm if symptomatic or reduced EF.

Men: anticoagulate if ≥1 | Women: anticoagulate if ≥2

• Aspirin 75 mg OD indefinitely
• P2Y12 inhibitor (ticagrelor 90 mg BD or clopidogrel 75 mg OD) × 12 months
• Beta-blocker: Bisoprolol 2.5–10 mg OD (all post-MI)
• ACE inhibitor: Ramipril 2.5 mg OD → titrate to 10 mg OD (especially if EF <40%)
• Statin: Atorvastatin 80 mg OD (high-intensity)
• Eplerenone 25–50 mg OD if EF ≤40% + HF/diabetes (start in hospital)

• Stop ACE inhibitors, ARBs, NSAIDs, K⁺-sparing diuretics, trimethoprim
• Treat AKI: fluid resuscitation, catheter, nephrology review
• Treat DKA: insulin shifts K⁺ into cells (monitor closely)
• Correct acidosis if severe

1. 1High-flow O₂ 15 L/min via NRB mask — target SpO₂ 94–98%
2. 2SABA nebuliser: Salbutamol 5 mg (oxygen-driven). Repeat every 15–20 min. Back-to-back if life-threatening.
3. 3Ipratropium 500 mcg neb (add to salbutamol in severe/life-threatening) q4–6h
4. 4Systemic steroid immediately — oral preferred
5. 5IV access. Bloods: ABG, FBC, U&E, CRP. Cultures if infection suspected.
6. 6If life-threatening & poor response: add Mg sulphate IV. Alert anaesthetics/ITU.

• Blood ketones <0.6 mmol/L AND pH >7.3 AND HCO₃⁻ >18 AND patient eating/drinking
• Give SC insulin 30–60 min BEFORE stopping FRII
• Never stop FRII without starting SC insulin first — risk of rebound ketoacidosis

• Repeat: LFTs, INR/PT, U&E, creatinine, glucose, VBG
• Discharge criteria: LFTs normal or improving, INR <1.3, asymptomatic, no encephalopathy, creatinine normal
• Continue NAC (extend Bag 3 at same rate) if: LFTs rising, INR >1.3 or rising, encephalopathy, renal impairment

• IV glucose (10% dextrose) — monitor closely, hypoglycaemia is life-threatening
• Vitamin K 10 mg IV OD (if coagulopathy)
• FFP only if active bleeding or invasive procedure (do NOT give to normalise INR alone — masks progression)
• Phosphate replacement if hypophosphataemia (refeeding syndrome-like)
• Lactulose 30–50 mL TDS if encephalopathy
• HDU/ICU: ICP monitoring if grade III/IV encephalopathy; avoid sedation
• Contact NPIS (0344 892 0111) and liver transplant centre early

• NO antiplatelets, anticoagulants, or thrombolytics
• Reverse anticoagulation urgently: PCC 25–50 units/kg IV (warfarin); Idarucizumab (dabigatran); Andexanet alfa (apixaban/rivaroxaban)
• BP target: SBP <140 mmHg within 6h (if SBP 150–220 and no contraindication)
• Neurosurgical review: cerebellar haemorrhage >3 cm or obstructive hydrocephalus

1. 1High-flow O₂. IV access ×2. Crash team if arresting.
2. 2Bedside echo: RV dilation, D-sign, McConnell's sign
3. 3CT-PA if patient stable enough — do NOT delay treatment if very unstable
4. 4UFH 80 units/kg IV bolus immediately
5. 5Systemic thrombolysis if no contraindication (see Thrombolysis section)
6. 6If thrombolysis CI / failed → surgical embolectomy or catheter-directed thrombolysis
7. 7Noradrenaline for haemodynamic support

Wells DVT: Score ≥2 → USS | Score <2 → D-dimer; if ↑ → USS. Treat with same anticoagulation as PE. Routine compression stockings NOT recommended for PTS prevention (NICE NG158).

• TIA in preceding 6 months
• Oral anticoagulant use (not within therapeutic range)
• Pregnancy or within 1 week postpartum
• Refractory hypertension (SBP >180 mmHg)
• Advanced liver disease / cirrhosis
• Infective endocarditis
• Active peptic ulcer
• Prolonged or traumatic CPR (>10 min)

1. 1Blood cultures ×2 sets before antibiotics (do not delay abx)
2. 2IV antibiotics within 1 hour of recognition (high-risk); 3 hours for moderate-risk
3. 3Serum lactate: if >2 mmol/L indicates tissue hypoperfusion
4. 4IV fluid resuscitation if hypotensive or lactate >2
5. 5High-flow O₂ — target SpO₂ ≥94% (88–92% in COPD)
6. 6Urine output monitoring — catheterise; target UO >0.5 mL/kg/h

• Vasopressor requirement to maintain MAP ≥65 mmHg
• Lactate ≥4 mmol/L despite resuscitation
• Need for mechanical ventilation (GCS ≤8, RR >35, SpO₂ <88% on 60% O₂)
• AKI requiring RRT
• Multiorgan dysfunction (≥2 systems)

• Severe reaction (respiratory arrest / circulatory collapse)
• Required >1 dose adrenaline
• Co-morbid asthma (especially poorly controlled)
• Evening/night presentation (reduced community support)
• Idiopathic anaphylaxis (no identifiable trigger)

• Discharge with 2 adrenaline auto-injectors — prescribe and demonstrate technique
• Written anaphylaxis action plan
• Prednisolone 50 mg OD × 3 days + Cetirizine 10 mg OD × 3 days
• Referral to allergy specialist clinic within 1–2 months
• Medical alert bracelet advised

1. 1ICU/HDU admission. Continuous arterial line monitoring. IV access.
2. 2Investigations: ECG, FBC, U&E, creatinine, urine dip, LFTs, troponin, CXR, CT head, fundoscopy.
3. 3Target: reduce MAP by no more than 20–25% in first hour, then to ~160/100 over next 2–6h.
4. 4Exception — aortic dissection: target SBP <120 mmHg within 20 min (with labetalol ± SNP).
5. 5Exception — eclampsia/pre-eclampsia: target SBP 130–150 mmHg. Labetalol or hydralazine.
6. 6Haemorrhagic stroke: reduce SBP to <140 mmHg within 1h if SBP >220 mmHg (per NICE).
7. 7Avoid precipitous drops — can cause cerebral/coronary ischaemia.

• Target BG 6–10 mmol/L (acceptable 4–12) during admission
• Variable Rate Insulin Infusion (VRIII/sliding scale) only if patient is NBM >1 meal, vomiting, or perioperative
• Continue usual subcutaneous insulin where possible — review doses
• Stop metformin if eGFR <30, contrast media, or sepsis
• Stop SGLT2i at admission (DKA risk). Restart 48–72h after recovery.
• BG monitoring: 4–6 hourly on insulin; pre-meal and bedtime if diet-controlled
• Diabetes specialist nurse review within 24h if available

• Physiotherapy and occupational therapy from day 1
• Bladder management: catheterisation if retention, ISC if able
• Bowel regimen: laxatives, suppositories
• Thromboprophylaxis (VTE): LMWH — discuss with neurosurgery post-op
• Pressure area care: 2-hourly turns, pressure mattress
• Rehab team referral, palliative care MDT input

1. 1Bed rest. Quiet environment. Continuous monitoring. IV access ×2.
2. 2Analgesia: paracetamol ± opioid (see below). Avoid NSAIDs (platelet inhibition).
3. 3Antiemetics: ondansetron 4 mg IV or metoclopramide 10 mg IV.
4. 4Start Nimodipine immediately for vasospasm prevention.
5. 5BP management: avoid SBP >160 mmHg prior to aneurysm treatment. Labetalol if needed.
6. 6Neurosurgical referral urgently — aim for aneurysm treatment within 24–48h.
7. 7Maintain euvolaemia — isotonic fluids. Avoid hypervolaemia.
8. 8ECG (SAH causes Wellens-like ECG changes, prolonged QT, T-wave inversions).
9. 9U&E, FBC, coagulation, glucose. Correct hyponatraemia (risk of hyponatraemic vasospasm).

• Physiotherapy and graded exercise for radiculopathy and central sensitisation
• TENS (transcutaneous electrical nerve stimulation) — some benefit in localised neuropathy
• Psychological support: CBT for pain management — especially if mood/sleep affected
• Refer to specialist pain service if: diagnosis uncertain, inadequate response to 2+ agents, complex psychosocial factors, or complex conditions (e.g., CRPS)

1. 1Assess pain severity (NRS), baseline opioid regimen, last dose and time.
2. 2Identify cause: bone fracture, visceral obstruction, infection, MSCC, cord compression — treat underlying cause where possible.
3. 3If on regular opioids: give breakthrough dose = 1/6th of TDD SC/IV immediately. Can repeat q20–30 min × 3 if severe.
4. 4If opioid-naïve with severe cancer pain: Morphine 2.5–5 mg IV/SC titrated q5–10 min until NRS ≤4.
5. 5Add adjuvants: IV dexamethasone 8 mg for nerve compression or bone pain crisis.
6. 6Liaise with palliative care team / patient's oncology team. Avoid dose-capping without specialist input.
7. 7On discharge: ensure written plan, escalation plan, and palliative care follow-up arranged.

• GI losses: vomiting, diarrhoea, fistulae, ileostomy
• Diuretics (loop, thiazide) — review dose/type
• Hyperaldosteronism, Cushing's syndrome
• Refeeding syndrome
• Magnesium deficiency (refractory hypokalaemia)
• Drugs: insulin, beta-2 agonists, aminoglycosides, amphotericin

1. 1Calcium gluconate 10% 30 mL IV over 5–10 min (cardiac membrane stabilisation — works within 3 min, lasts 30–60 min). Give first if any ECG changes.
2. 2Insulin 10 units Actrapid + 50 mL 50% glucose IV over 15–30 min (lowers K⁺ by 0.6–1 mmol/L within 15–30 min, lasts 4–6h). Monitor BG 30 min, 1h, 2h post.
3. 3Salbutamol 10–20 mg nebulised (double/triple dose) — lowers K⁺ by 0.5–1 mmol/L; additive with insulin/dextrose.
4. 4Sodium bicarbonate 1.26% 500 mL IV — only if metabolic acidosis (pH <7.2); modest effect alone.
5. 5Lokelma (sodium zirconium cyclosilicate) 10 g PO TDS × 48h — fast-acting K⁺ binder; onset 1–2h. Preferred over Resonium. Avoid if ileus.
6. 6Stop all potassium-raising drugs: ACEi, ARB, K-sparing diuretics, K supplements, NSAIDs, trimethoprim.
7. 7If refractory or AKI/anuria: Emergency haemodialysis — contact renal team urgently.

1. 1Aggressive IV hydration — immediately. Do NOT wait for TLS to develop.
2. 2Rasburicase or allopurinol to lower uric acid (see doses below).
3. 3Treat hyperkalaemia, hyperphosphataemia, hypocalcaemia as per respective protocols.
4. 4Continuous cardiac monitoring — arrhythmia risk from hyperkalaemia/hypocalcaemia.
5. 5Strict urine output monitoring — target UO >100 mL/h (2 mL/kg/h). Catheter.
6. 6Bloods every 4–6h: U&E, Ca²⁺, PO₄, uric acid, LDH, creatinine.
7. 7If AKI develops or electrolytes refractory: emergency haemodialysis. Contact renal team early.

• FBC with differential, CRP, U&E, LFTs, LDH, coagulation
• Blood cultures ×2 sets — peripheral AND central line (if present) before antibiotics if possible, but do not delay antibiotics
• Urine MC&S, CXR
• Throat/nasal swabs, stool if diarrhoea (C.diff, viral)
• CMV/EBV/HSV PCR if prolonged fever
• CT chest/abdomen/pelvis if fever >72–96h — looking for occult source, fungal pneumonia (ground-glass, halo sign)

1. 1Take blood for cortisol and ACTH immediately (before steroids if <2 min delay). DO NOT DELAY treatment.
2. 2Hydrocortisone 100 mg IV bolus immediately.
3. 3IV fluid resuscitation: 0.9% NaCl 1 L over 30–60 min then reassess (avoid hypotonic/dextrose-only fluids).
4. 4Check BM — treat hypoglycaemia with IV dextrose 10% 150–200 mL if BG <4 mmol/L.
5. 5Continue Hydrocortisone 100 mg IV/IM q6–8h (or CSCI 200 mg/24h) for first 24–48h.
6. 6Identify and treat the precipitating cause (e.g., antibiotics for infection).
7. 7Monitor U&E, BG, BP 4-hourly. ICU/HDU if haemodynamically unstable.
8. 8Endocrinology review. Educate patient on sick day rules and steroid emergency card.

1. 112-lead ECG. IV access. Continuous monitoring. Identify and treat reversible causes.
2. 2If no adverse features and low risk of asystole: observe, treat cause, cardiology review.
3. 3If adverse features present: Atropine 500 mcg IV — first-line immediately.
4. 4Repeat atropine 500 mcg IV every 3–5 min up to maximum 3 mg total.
5. 5If atropine ineffective or CHB/Mobitz II: Transcutaneous pacing (TCP) immediately.
6. 6Whilst preparing TCP or as bridge: Isoprenaline infusion or Adrenaline infusion (see doses).
7. 7Arrange urgent transvenous cardiac pacing — cardiology/catheter lab. TCP is a bridge only.
8. 8Identify and treat reversible causes: inferior MI (reperfusion), hyperkalaemia, drug toxicity (digoxin, beta-blocker, CCB, amiodarone), Lyme disease, hypothyroidism.

• CHB (complete heart block) with haemodynamic compromise
• Symptomatic Mobitz II not responding to atropine
• Asystole with P waves (standby pacing)
• Bilateral bundle branch block with PR prolongation (high risk of CHB)
• Post-anterior MI with new RBBB + LAHB/LPHB (high risk)
• As bridge to permanent pacemaker implantation

1. 1ECG (MI, arrhythmia — Type A can occlude coronary ostia).
2. 2CXR: widened mediastinum (>8 cm), loss of aortic knuckle, pleural effusion (left), tracheal deviation.
3. 3CT aorta with contrast (CT angiography) — gold standard. Full aorta from root to iliacs. Identifies extent, branch involvement, true/false lumen.
4. 4Bloods: FBC, U&E, coagulation, G&S, troponin, D-dimer (only if ADD-RS 0), lactate, LFTs.
5. 5Bedside echo (POCUS): pericardial effusion/tamponade, AR, aortic root dilatation — useful while awaiting CT.
6. 6BP in both arms simultaneously. Check all peripheral pulses.

1. 1High-flow O₂, IV access ×2, continuous monitoring. Call cardiology/cardiothoracic urgently.
2. 2Bedside POCUS — confirm effusion and haemodynamic significance.
3. 3IV fluid bolus 250–500 mL 0.9% NaCl — temporising measure to maintain preload (limited benefit, do not over-fluid).
4. 4Avoid vasodilators, diuretics (reduce preload → catastrophic).
5. 5If haemodynamically compromised: USS-guided pericardiocentesis immediately.
6. 6PEA arrest with suspected tamponade: immediate blind pericardiocentesis or thoracotomy.
7. 7Traumatic haemopericardium → emergency thoracotomy (pericardiocentesis insufficient for haemorrhage control).

• Delivery is the definitive treatment — stabilise mother first, then deliver
• Timing: >37 weeks severe pre-eclampsia → deliver. 34–37 weeks → discuss risks/benefits. <34 weeks → consider corticosteroids (foetal lung maturity) then deliver if unable to stabilise
• Corticosteroids (foetal lung maturity): Betamethasone 12 mg IM × 2 doses 24h apart (if <34+6 weeks and delivery likely within 7 days)
• Fluid balance: restrict to 80 mL/h IV unless haemorrhage — risk of pulmonary oedema
• Foetal monitoring: CTG continuously in severe pre-eclampsia
• HELLP: platelet transfusion if PLT <50 before delivery; FFP if coagulopathy
• Postpartum monitoring: continue MgSO₄ for 24h post-delivery; BP may worsen in first 3–5 days
• Postpartum antihypertensives: Enalapril (safe in breastfeeding) or Nifedipine MR

• Small-bore (8–14F Seldinger drain) preferred for spontaneous pneumothorax (BTS 2023)
• Do not clamp drains with ongoing air leak
• Bubbling stops = lung re-expanded. Confirm CXR before removal.
• Persistent air leak >5–7 days → thoracic surgery referral (video-assisted thoracoscopic surgery, VATS)
• Pleurodesis: consider after second ipsilateral PSP or first SSP in high-risk patients
• Recurrence rate: PSP ~30% at 5 years; SSP higher

1. 1Position patient with bleeding lung DEPENDENT (bleeding side down) — prevents blood flooding contralateral lung. If lateralisation unknown, place semi-recumbent.
2. 2High-flow O₂ 15 L/min via NRB mask. Aim SpO₂ ≥94%.
3. 3IV access ×2 large-bore. Bloods: FBC, coagulation, crossmatch, U&E, ABG.
4. 4Correct coagulopathy: FFP, platelets, PCC as needed. Stop anticoagulants.
5. 5Tranexamic acid 1 g IV over 10 min (off-label but widely used — evidence from CRASH-3 extrapolated).
6. 6CT chest with contrast / CT pulmonary angiography — identifies source and guides BAE.
7. 7Urgent respiratory/thoracic surgery/interventional radiology referral.
8. 8If airway compromised: RSI and intubation — consider selective intubation of unaffected bronchus (right main bronchus easier; left using long tube/fibreoptic).

• Failure of NIV or HFNO (PaO₂ <8 kPa on FiO₂ 0.6 / SpO₂ <90% despite maximal support)
• Worsening acidosis: pH <7.25 despite 1h NIV with rising PaCO₂
• Haemodynamic instability (SBP <90 mmHg, shock)
• Reduced GCS/inability to protect airway
• Respiratory arrest or imminent arrest
• Exhaustion — cannot sustain respiratory effort
• NIV failure: pH not improving after 1–2h of optimal BiPAP