Marshall & Reudy’s ON CALL Principles & Protocols SECOND EDITION This page intentionally left blank Marshall & Reudy’s ON CALL Principles & Protocols SECOND EDITION Australian adaptation by Mike D Cadogan MA (Oxon), MB ChB, FACEM Staff Specialist in Emergency Medicine, Department of Emergency Medicine, Sir Charles Gairdner Hospital, Perth. Team Doctor, Emirates Western Force. Anthony F T Brown MB ChB, FRCP, FRCS (Ed), FACEM, FCEM Professor, Discipline of Anaesthesiology and Critical Care, School of Medicine, University of Queensland, Brisbane. Senior Staff Specialist, Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane. Tony Celenza MB BS, MClinEd, FACEM, FCEM Winthrop Professor of Emergency Medicine and Medical Education, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth. Staff Specialist, Department of Emergency Medicine, Sir Charles Gairdner Hospital, Perth. Original edition by Shane A Marshall MD, FRCPC; Director of Cardiac Care, Chief of Medicine, King Edward the VIIth Memorial Hospital, Paget, Bermuda John Ruedy MDCM, FRCPC, LLD(Hons); Professor (Emeritus) of Pharmacology Faculty of Medicine, Dalhousie University, Halifax, Canada Sydney  Edinburgh  London  New York  Philadelphia  St Louis  Toronto Marshall & Reudy’s ON CALL Principles & Protocols SECOND EDITION Saunders is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 © 2011 Elsevier Australia This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation. This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication. National Library of Australia Cataloguing-in-Publication Data Cadogan, Mike Marshall & Ruedy’s on call principles & protocols / Mike Cadogan … [et al.]. 2nd ed. ISBN: 9780729539616 (pbk.) Previous ed.: Marrickville, N.S.W.: c2007. Includes index. 1. Emergency medicine—Australia—Handbooks, manuals, etc. 2. Medical emergencies—Australia—Handbooks, manuals, etc. 3. Emergency nursing—Australia—Handbooks, manuals, etc. 4. Communication in emergency medicine—Australia—Handbooks, manuals, etc. 616.0250994 Publisher: Sophie Kaliniecki Developmental Editor: Neli Bryant Publishing Services Manager: Helena Klijn Project Coordinator: Geraldine Minto Edited by Rivqa Berger Proofread by Kerry Brown Illustrations by Greg Gaul, Rod McClean and Tor Ercleve; Associate Professor of Emergency Medicine, University of Western Australia Cover and internal design by Darben Design Index by Robert Swanson Typeset by Toppan Best-set Premedia Limited Printed by China Translating & Printing Services Ltd. Contents Foreword  vii Preface  ix About the authors  xi Acknowledgements  xiii Reviewers  xiv Abbreviations  xv Section A – General principles  1  Approach to the diagnosis and management of on-call  problems  2  2  Documentation and communication of on-call problems  5  3  Professional issues  9  4  Ethical and legal considerations  16  5  Death, dying and breaking bad news  21  6  Preparation of patients for transport  30 Section B – Emergency calls  7  The critically ill patient  36  8  Cardiac arrest  41  9  Acute airway failure  49 10  Acute respiratory failure  58 11  Acute circulatory failure  64 12  Disability: acute neurological failure  79 13  Environment, exposure and examination  82 14  Hospital-based emergency response codes  84 Section C – Common calls 15  Shortness of breath, cough and haemoptysis  88 16  Chest pain  116 17  Heart rate and rhythm disorders  134 18  Hypertension  157 19  Hypotension  168 20  Altered mental status  183 21  Collapse, syncope and mechanical falls  197 22  Headache  208 23  Seizures  220 24  Weakness, dizziness and fatigue  230 25  Abdominal pain  243 26  Altered bowel habit  264 27  Gastrointestinal bleeding  276 v vi  ON CALL ■ Principles and Protocols 28  Haematuria  288 29  Urine output: decreased  293 30  Urine output: increased  301 31  Leg pain  308 32  The febrile patient  321 33  Skin rashes and urticaria  334 34  Transfusion reactions  346 Section D – Investigations 35  Electrocardiogram  353 36  Chest X-ray  361 37  Abdominal X-ray  367 38  CT head scan  372 39  Urinalysis  377 40  Acid–base disorders  385 41  Glucose disorders  395 42  Sodium disorders  406 43  Potassium disorders  414 44  Calcium disorders  421 45  Anaemia  429 46  Coagulation disorders  435 Section E – Practical procedures 47  General preparations for a practical procedure  450 48  Infection control and standard precautions  454 49  Venepuncture  458 50  Blood cultures  461 51  Peripheral venous cannulation  464 52  Arterial puncture  470 53  Administering injections  474 54  Local anaesthetic infiltration  481 55  Nasogastric tube insertion  484 56  Urinary catheterisation  487 57  Paracentesis  492 58  Pleural tap  496 59  Chest drain insertion and removal  500 60  Lumbar puncture  505 61  Joint aspiration  511 62  Cardiac monitoring and the electrocardiograph  514 63  Defibrillation  519 64  Electrocardioversion (DC reversion)  523 65  Transthoracic cardiac pacing  525 66  Central venous cannulation  527 Section F – Formulary 67  The on-call formulary  537 Foreword This book is a treasure trove of useful, up-to-date, practical informa- tion for newly qualified doctors responding to hospital ward calls. Indeed, such is the scope of its content, many senior doctors in various fields within acute medicine will find it an invaluable resource to have on hand for everyday practice. The practicality of its con- tents and its coherence reflect the authors’ clear currency in clinical emergency medicine and their very strong educational backgrounds. All three are among the finest teachers of emergency medicine in Australasia, with complementary and widely recognised experience in translating knowledge into the clinical performance of students and junior doctors. The book is remarkably well organised, with a clear and easy-to-follow structure that belies the great depth of information provided. One could be forgiven for anticipating a dry read when looking at so much information set out with so many dot points, but the book is so relevant to the concerns of junior doctors, and so full of concise clinical wisdom, that it is frankly a joy to read. The book is a source of excitement for those of us who have spent our careers in acute hospital medicine and watched junior staff come and go in the sometimes chaotic and confusing hospital environment, and wished for some more structure and consistency in their teaching. The authors provide clear guidelines on how to respond to a range of acute emergencies, illuminating the decision-making process in what can be very difficult and challenging situations. Few text- books discuss what might go through one’s mind on the way to an emergency; this one does. Similarly, there is often little attention given in textbooks to what does not need to be done in such emer- gencies and what is frankly wasting valuable time; this book teaches students and young doctors how to prioritise clinical assessments so that the important issues are addressed in a logical and timely sequence, with the unimportant ones left to wait for a more appro- priate time. The table of contents gives a welcome indication of the relative importance and priority the authors assign in on-call sce- narios, highlighting professional, ethical and end-of-life issues before any discussion of managing the critically ill patient. Junior doctors would do very well to follow this lead in the development of their careers. The authors have done a great service to acutely ill hospital patients and their attending medical staff by producing this wonder- ful book. It should make the hospital experience a whole lot better vii viii  ON CALL ■ Principles and Protocols for all concerned! If only a book like this could have been around when I was a junior doctor. Professor George A Jelinek, MD, DipDHM, FACEM Director Emergency Practice Innovation Centre St Vincent’s Hospital, Victoria Professorial Fellow Department of Medicine The University of Melbourne, Victoria