Category: Resus

Anaphylaxis 2021

Not all Allergies are Anaphylaxis!

Anaphylaxis is defined as:

  • Severe life-threatening systemic hypersensitivity reaction
  • Where BOTH of the following criteria are met:
    1. Sudden onset & rapid progression
    2. Life-threatening compromise of ONE or MORE of: Airway/Breathing/Circulation

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Tachycardia

Adult ED Management – RCUK 2025

Treat the patient, not the rate

Sinus tachycardia is usually compensatory — identify and treat the cause. Do NOT cardiovert sinus tachycardia.

INITIAL ASSESSMENT

ABCDE

Cardiac monitor
BP and SpO₂
12-lead ECG
IV access
Bloods as clinically indicated: FBC
U&E / Mg²⁺ / Ca²⁺
glucose
troponin where indicated
other investigations directed by likely cause
Give oxygen only if SpO₂ <94%, unless an alternative target is appropriate.

Think WHY the patient is tachycardic?

Sepsis/Hypovolaemia/Haemorrhage
Pain/Anxiety
Hypoxia
Fever
PE
ACS/Heart failure
Thyrotoxicosis
Drugs/Withdrawal
Pregnancy

Do not attempt to normalise an appropriate sinus tachycardia with anti-arrhythmics or electrical cardioversion.

SIMPLE ED RULE

SICK? → SHOCK

WELL? → WIDTH + REGULARITY

  • Narrow + regular: Vagal → Adenosine → Verapamil / beta-blocker → Shock
  • Narrow + irregular: AF pathway / rate control
  • Broad + regular: VT until proven otherwise → Cardioversion / procainamide
  • Broad + irregular: Pre-excited AF / polymorphic VT → expert help

      UNSTABLE?

      LIFE-THREATENING FEATURES

      > SHOCK: Hypotension with evidence of impaired tissue perfusion.
      > SYNCOPE: Especially with severe or ongoing hypotension.
      > MYOCARDIAL ISCHAEMIA: Ongoing chest pain and/or significant ischaemic ECG changes.
      > SEVERE HEART FAILURE: Particularly pulmonary oedema.
      > IMMEDIATELY POST-ROSC

      DC-Cardiversion (SYNC) RCUK 2025

      > AF → Maximum defibrillator output
      > Flutter / SVT → 70–120 J
      > VT with pulse → 120–150 J

      Escalate subsequent shocks where appropriate.

      STABLE

      Regular  – Sinus Tachycardia, AVNRT (SVT), Atrial flutter with regular block, AVRT (WPW)

      • Sinus Tachycardia – Look for the cause ?infection ?pain ?anaemia ?hypovolaemia ?anxiety ?drugs
      • SVT – Stepwise treatment until NSR regained (ensure cardiac monitoring): –
        • Vagal Manoeuvres – Lie flat and head down, Carotid sinus massage (ensure no bruit 1st), Blow into 50ml syringe
        • Adenosine –  6mg, 12mg, 18mg boluses (not in severe Asthma/Allergy/Heart transplant)
        • Not reverted – call for expert help
      • Atrial Flutter with 2:1 block (150bpm) – consider rate controlling drugs
      • AVRT (WPW) – get expert help (DO NOT give Adenosine)

      PDF: Arrhythmia Clinic referral form (Print and Fax OR can email – use fill and sign function to enter details)

      PDF: Patient Info

      Irregular – likely AF (Follow AF Pathway)

      Assume VT until proven otherwise

      Particularly in:

      • older patients
      • previous MI
      • structural heart disease
      • cardiomyopathy

      Stable monomorphic VT

      Electrical cardioversion is an appropriate first-line strategy

      • Especially where structural heart disease is present or cannot be excluded.
      • SYNCHRONISED CARDIOVERSION For VT with a pulse: 120–150 J initially, escalating if required

      If sedation / anaesthesia presents significant risk

      Drug treatment may be considered:

      • Procainamide 10–15 mg/kg IV over 20 minutes Maximum 1 g OR
      • Amiodarone 300 mg IV over 10–60 minutes followed by: 900 mg IV over 24 hours
      • If ineffective: SYNCHRONISED CARDIOVERSION WITH EXPERT ADVICE

      STOP — HIGH-RISK RHYTHM

      Consider:

      • 1. AF WITH BUNDLE BRANCH BLOCK
      • 2. PRE-EXCITED AF / WPW
      • 3. POLYMORPHIC VT

      Seek senior / cardiology support early.

      PRE-EXCITED AF

      Think pre-excitation when there is:

      • very rapid irregular broad-complex tachycardia
      • varying QRS morphology
      • ventricular rates sometimes >200 bpm
      • known WPW / previous delta wave

      DO NOT GIVE AV-NODAL BLOCKING DRUGS

      Avoid the following as these may increase conduction through the accessory pathway and precipitate VF:

      • Adenosine
      • Beta-blockers
      • Verapamil
      • Diltiazem
      • Digoxin

      Treatment

      • Procainamide OR
      • Synchronised cardioversion

      If polymorphic VT occurs with QT prolongation:

      Magnesium: Mg²⁺ 8 mmol IV over 10 minutes

      Also:

      • Correct K⁺ / Mg²⁺ abnormalities.
      • Stop QT-prolonging drugs.
      • Treat reversible causes.
      • Seek expert help.

      For recurrent pause-dependent torsades consider increasing the heart rate with:

      • Isoprenaline OR
      • Temporary pacing

      ❌ AVOID AMIODARONE because it may further prolong the QT interval.

      ⚠️ PITFALLS

      FAST ≠ ARRHYTHMIA

      Do not treat physiological sinus tachycardia as an arrhythmia.

      BROAD + REGULAR = VT UNTIL PROVEN OTHERWISE

      Do not delay appropriate treatment while attempting to prove SVT.

      BROAD + IRREGULAR ≠ ROUTINE AF

      Always consider pre-excited AF.

      ADENOSINE IS NOT FOR IRREGULAR BROAD-COMPLEX TACHYCARDIA

      DO NOT GIVE AMIODARONE FOR TORSADES / LONG-QT POLYMORPHIC VT

      Give magnesium and correct the underlying problem.

      CARDIOVERSION REQUIRES SYNC

      Confirm the machine is marking the R waves before delivering the shock.

      Re-check SYNC after each shock — some defibrillators automatically revert out of synchronised mode.

      DISPOSITION

      Consider admission / cardiology assessment for:

      • VT
      • broad-complex tachycardia of uncertain cause
      • syncope associated with tachyarrhythmia
      • significant structural heart disease
      • ACS / myocardial ischaemia
      • heart failure
      • recurrent arrhythmia despite treatment
      • pre-excitation
      • significant electrolyte disturbance
      • drug-induced arrhythmia
      • prolonged QT / torsades
      • haemodynamic instability
      • arrhythmia requiring electrical cardioversion

      Patients with uncomplicated successfully terminated SVT may be suitable for discharge following senior review, appropriate investigation and follow-up depending on the clinical circumstances.

      GUIDANCE

      Based primarily on:

      • Resuscitation Council UK — Guidelines 2025: Adult Advanced Life Support
      • Resuscitation Council UK — Adult Tachyarrhythmia Algorithm, current version March 2026
      • Current atrial fibrillation guidance

      EMbeds clinical quick guide

      Last evidence review: September 2026
      Suggested next review: September 2027

      This is a clinical support guide and does not replace clinical judgement, current CHFT medicines guidance or specialist advice.

      Major Haemorrhage Protocol

      In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MHP

      Remember:

      • Do the Basics – don’t forget ABCD
      • Inform Transfusion and get someone to run a G&S sample down
      • FFP can take up to 45min and platelets come from Leeds
      • If you no longer need the MTP – inform transfusion and return products ASAP
      Read more

      Cervical Spine Clearance in the trauma patient

      Although in ED we cannot prevent the primary injury, our objective is to recognise and prevent secondary injury. Through the use of the agreed standards

      Standards:

      1. Spinal protection must remain in place if an injury is suspected/identified, or until it is excluded via an established protocol.
        • Unless a senior clinician has clearly documented a decision, immobilisation not in the patients best interest.
      2. Assessment of the whole spine should be performed and documented where injury is suspected.
      3. If abnormal clinical signs are found, complete neurological examination must be performed and documented.
      4. If spinal injury identified OR abnormal neurological signs consistent with spinal cord injury are found, immediate discussion with and referral to a centre capable of emergency spinal surgery must occur.
      5. Significant spinal injury is excluded following either:
        • Normal clinical examination in an awake and orientated patient with no clinically significant distracting injury OR illness is present; the patient can concentrate on and reliably report neck findings. (in line with Canadian C-Spine rules)
        • Completion of spinal imaging protocols (standard 6).
      6. Imaging protocols:
        • Thoracic and lumbar spine scans should be obtained according to major trauma protocols.If a cervical spine injury is suspected, thin slice CT scanning from occiput to T4, including sagittal and coronal reconstructions should be performed without delay.If whole-body CT (WBCT) for trauma is necessary, this should include the cervical spine if injury is suspected.
        • An initial report of spine clearance imaging should be available before the patient leaves the Emergency Department.
      OptionScenarioAction
      1This investigation demonstrates an injury that may affect spinal stability. (see Notes)Continue spinal protection and seek advice from an appropriate clinical team. 
      2This scan is of good quality and there are no comorbidities confounding its interpretation. No features of instability, such as fracture, haematoma or joint disruption are seen.Patients with NO acute neurological symptoms/signs on examination or mobilisation.Spinal protection may be removed.
      Patient who HAS acute neurological symptoms/signs on examination or mobilisation.Continue spinal protection and seek advice from an appropriate clinical team. 
      Unconscious OR unable to Co-Operate with examination (see Notes)Spinal protection can be removed with caution providingConsultant Radiology report & No evidence of acute neurological deficitIt must be recognised there is a <1% chance of unrecognised injury. ANY evidence of neurological deterioration should be re-immobilised pending MRI
      3Whilst there are no obvious features of spinal instability, the CT scan is either not of good quality and/or there are comorbidities confounding its interpretation.Continue spinal protection until MRI is performed and report available.

      Magnetic Resonance Imaging is necessary when the following are present:

      • Suspected cord injury
      • Ambiguous CT scans, as per option 3 of standard 6
      • Inability to assess patient, as per option 2 standard 6 
      • Ankylosed spines with negative or indeterminate CT appearances for fracture
      • Contraindications to ionising radiation, for example in pregnancy

        Notes:

        • Option 1 Standard 6: Certain Spinal injuries may be combatable with removal of protection on agreement of the base speciality consultant:
          • Facet joint fractures of the thoracic and lumbar spine
          • Spinous process fractures
          • Wedge compression fracture with loss of vertebral body height of less than 25%
          • Type 1 odontoid fracture
          • End-plate fracture
          • Transverse process fracture
          • Trabecular bone injury
          • Osteophyte fracture, excluding corner or teardrop fractures
          • Isolated avulsion fractures
        • Option 2 Standard 6: Management of Unconscious or patients unable to fully co-operate with clinical exanimation is recognised as significant challenge. With advances in CT the number of significant injuries missed is very low <1%. However, there are significant risks associated with prolonged immobilisation, especially for frail patients who are more likely to fall into this group. 

        This pragmatic approach is in line with BOA-Standards, however, it must be recognised there is a chance of deterioration. If ANY evidence of neurological deficit the patient should be re-immobilised and reassessed for further imaging. 

        Complications of prolonged use of Immobilisation:

        • Impaired venous drainage and increased intracranial pressure
        • Difficult laryngoscopy and intubation
        • Increased risk of aspiration and ventilator-associated pneumonia
        • Difficult central venous cannula insertion
        • Increased risk of central venous cannula associated blood stream infections
        • Increased risk of pulmonary thromboembolism
        • Pressure necrosis leading to ulceration
        • Inability to provide good oral care
        • Failed enteral nutrition, gastrostasis and reflux
        • Restricted physiotherapy

        Reference:

        Hip Dislocation – Flowchart

        Dislocation of a Native Hip

        • Uncommon – High-Energy injury
        • All patients presenting with a suspected native hip dislocation following trauma (including falls from standing) must have a primary survey done to assess for other injuries.
        • Early Senior input (if not trauma team) and Resus
        • Neurovascular status of the affected limb must be assessed and documented. 

        Dislocation of Prosthetic Hip

        • Relatively common and frequently low energy
        • All patients should be assessed with low threshold to treat as trauma
          • Remember the biggest cause of ISS >15 Major Trauma in UK is older patients falling from standing height
        • Neurovascular status of the affected limb must be assessed and documented. 
        • If there is neurovascular compromise then move to Resus and inform ED senior 
        Read more

        Swallowed Foriegn Body

        The ingestion of a foreign body or multiple foreign bodies (FB) is a common presenting complaint in paediatric surgery, with a peak incidence from 12-24 months however, can occur at any age. Ingested foreign bodies rarely cause problems; almost 80% of patients pass the foreign body without intervention – in seven days2 (only 1% require surgical removal). However, occasionally foreign bodies can cause significant morbidity (for example, oesophageal rupture) and 1% require surgical removal.

        The presenting symptoms and outcomes of an ingested foreign body is highly dependent on the swallowed object, and for this reason, the guidance for hazardous and non-hazardous foreign body ingestion has been divided accordingly.

        Using the Metal Detector

        Non-Hazardous Objects

        Button Battery

        Ingestion of Button Battery = POTENTIAL EMERGENCY

        See separate post for more resources and education if desired.

        Magnets

         

        Sharp Objects

        PDF copy – HERE