Gastrointestinal, Renal, Metabolic and Endocrine Emergencies
Gastrointestinal bleeding
Resuscitate first, then localise. Two large-bore cannulae, cross-match, and restrictive transfusion (haemoglobin below 70 g/L, or below 80 g/L with ischaemic heart disease). For suspected variceal bleeding give a vasoactive agent (terlipressin or octreotide) and prophylactic antibiotics. Endoscopy within 24 hours once stabilised.
Hyperkalaemia: ECG changes (peaked T waves, widened QRS, sine wave) demand intravenous calcium gluconate or chloride immediately for cardiac protection, then insulin with dextrose, nebulised salbutamol, and bicarbonate if acidotic; dialysis for refractory cases. Recheck potassium and glucose, and treat the patient, not just the number.
Diabetic ketoacidosis: fluids first (1 L in the first hour), insulin 0.1 units/kg/h, and potassium replacement - every DKA patient is total-body potassium depleted, and insulin without potassium can be fatal. Add dextrose when glucose falls below 14 mmol/L, and avoid bicarbonate unless pH is below 6.9. Identify the precipitant: infection, infarction or non-adherence.
Hyperosmolar hyperglycaemic state: profound dehydration, very high glucose and osmolality with minimal ketones - fluid resuscitation is the mainstay.
Adrenal crisis: refractory hypotension with hyponatraemia and hyperkalaemia - give hydrocortisone 100 mg IV immediately, before confirmation.
Rule of thumb: in metabolic chaos ask what has changed - sepsis, a new drug, or a missed dialysis session.
Emergency Procedural Skills and Point-of-Care Ultrasound
Focused ultrasound
Point-of-care ultrasound is an extension of the physical examination: ask a specific question, answer it, and stop. Use a low-frequency probe for deep structures (FAST, cardiac, aorta) and a high-frequency linear probe for superficial ones (lung sliding, vessels, nerves).
FAST examines Morison's pouch, the splenorenal recess, the pelvis and the pericardium. A negative scan does not exclude retroperitoneal or hollow-viscus injury. Absent lung sliding with a lung point is diagnostic of pneumothorax; B-lines indicate interstitial oedema. Cardiac views: subxiphoid for effusion and tamponade (right ventricular diastolic collapse), parasternal and apical for global function. Inferior vena cava assessment informs fluid status but must never be used alone. Measure the abdominal aorta in two planes; 5 cm or more, or a symptomatic aorta over 3 cm, is an aneurysm.
Procedural standards: informed consent where possible, the WHO checklist, maximal sterile barriers for central lines, ultrasound guidance for vascular access, and objective confirmation of placement. Rapid sequence intubation: preoxygenate, optimise haemodynamics, induce with ketamine or etomidate, paralyse with rocuronium 1.2 mg/kg, and have a declared plan for failed airway including front-of-neck access.
Traps: single-view diagnoses, letting the machine delay a life-saving intervention, and failing to repeat the scan when the clinical picture changes.
Rule of thumb: treat the patient, not the image - a normal scan never overrides a deteriorating patient.
Emergency Medical Services, Disaster Medicine and Departmental Administration
Prehospital and major incidents
Prehospital priorities are scene safety, triage and time-critical transport, with a structured handover (ATMIST or SBAR). In a major incident the aim of triage is the greatest good for the greatest number, not the greatest effort for each individual.
Primary triage uses the triage sieve: walking wounded are delayed; those not breathing after airway opening are deceased; respiratory rate, capillary refill and consciousness then separate immediate from delayed. JumpSTART applies the same logic to children with different respiratory thresholds. Secondary triage (for example MIMMS) confirms priorities. Treatment must not delay movement out of the hot zone.
Incident command requires one incident commander, a clear chain of command, controlled spans of control and designated sectors; nobody self-deploys. Chemical, biological, radiological and nuclear incidents require personal protective equipment and decontamination before hospital entry, since secondary contamination is a genuine risk.
Departmental administration: crowding is a patient safety issue, not merely an inconvenience - it delays antibiotics and analgesia and increases mortality. Escalate early through bed management, place a senior clinician at triage, and document decisions and capacity assessments.
Medicolegal: valid consent requires capacity, adequate information and voluntariness; treat under necessity when a patient lacks capacity and the treatment is life-saving; respect advance decisions and do-not-attempt-resuscitation orders.
Rule of thumb: the first message from the scene should state exact location, number and severity of casualties, and the resources needed - nothing else.