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The Acutely Unwell Patient Jesse Anthony Cthre College 5 YearHow do we approach this?Catastrophic HaemorrhageCoagulation CascadeWarfarin Vitamin K oxidoreductase inhibitor S-enantiomer is x4 more potent than the R-enantiomer, but is not administered alone due to increased risk of adverse effects Broccoli, spinach, kale + many moreHeparin Binds to the enzyme inhibitor antithrombin III (AT) Conformational change that results in its activation through an increase in the flexibility of its reactive site loop Activated AT then inactivates thrombin, factor Xa and other proteases Protamine sulphate Heparin-induced thrombocytopeniaDO ACs/NO ACs Dabigatran (factor IIa) à idarucizumab Apixaban and rivaroxaban (factor Xa) à andexanet alfaClot Lysis CascadeAirway and c -spine It will kill you first Special manoeuvres Airway adjuncts CHECK NO SPINAL INJURYEnd Tidal Carbon DioxideDefinitive AirwayBreathing Check the respiratory rateCirculation Next steps require “no adverse features” otherwise synchronised DC shockSupraventricular TachycardiaAdenosine Adenine attached to a ribose via a β-N9-glycosidic bondG-Protein Coupled Receptors (GPCR)A1R agonistBradycardiaAtropine Tropane alkaloid Same chemical family as cocaine Enantiomeric mixture of d-hyoscyamine and l-hyoscyamine, with most of its physiological effects due to l-hyoscyaminemAchRantagonistVentricular fibrillation3 synchronised DC shocks then adrenaline A phenethylamine Part of a group of monoamines called catecholamines Synthesised in chromaffin cells of adrenal medullaRate limiting stepBeta-blockers Very common class of drug Reduce response of heart to stress Propranolol, carvedilol, atenolol Anxiety, atrial fibrillation, heart failure (interesting one)DigoxinD forDON’T FORGETDiabetes Insulin Therapy 51-amino acid protein consisting of 2 polypeptide chains (A and B) linked by disulphide bonds s/c injection à forms hexamers which dissociate to be absorbed Played around with the pharmacokinetics: ØInsulin lispro à reduces dimer and hexamer formation so faster acting ØInsulin à human sequence so short acting ØNeutral Protamine Hagedorn (NPH) insulin à forms relatively insoluble crystals slowing absorption so intermediate acting ØGlargine à forms a microprecipitate of stable hexamers and higher aggregates which prolong absorption so long acting Addisonian Crisis Steroid demands increased during illness, stress and exercise Acute glucocorticoid deficiency Hypoglycaemia Hyperchloraemic metabolic acidosis à accompanies hyperkalaemia due to impaired exchange of Na+ with H+ and K+ when aldosterone deficient Adrenal gland à ↓aldosterone à ↓Na+ ↓cortisol à ↑ADH à ↑free H2O Hydrocortisone STAT, IV glucose (if needed), IV fluids for shockExposeHaemorrhagic PancreatitisAny questions?