Oxford Handbook of Clinical Surgery - Book 2

790 INDEX

examination 355 plasmin 180 post-operative management
Peyronie’s disease 370, plaster instructions 465 88–9
plastic surgery 589–618
614 platelets 96 post-transplant
priapism 370–1 pleomorphic adenoma 230 lymphoproliferative
pentalogy of Cantrell pleural effusion 634–5, 634–9 disorder 679–80
Plummer’s syndrome 252
440–55 Plummer–Vinson syndrome Pott’s carcinoma of scrotum
peptic ulcer disease 284–5 773
peptic ulcer perforation 772
pneumatic compression Pott’s disease of spine 773
740–1 Pott’s peculiar tumour 773
percutaneous boots 72 Pott’s puffy tumour 773
pneumatosis cystoides pouch of Douglas 217
nephrolithotomy 359 power (muscle) 492
performance monitoring intestinalis 772 power (statistical) 8–9
pneumaturia 772 pregnancy
20–1 Pneumocystis jiroveci
perianal abscess 414–15 consent 15
perianal haematoma 414–15 (P. carinii) 679 prescribing drugs 49
pericardial effusion 638–9 pneumomediastinum 637 surgery in 48–9
pericardiocentesis 204–5 pneumonectomy, chest pregnancy tests 48
pericolic abscess/mass 404 premature ejaculation 355
perilunate dislocation 509 drains 203 premedication 71
perineal hernia 346 pneumothorax 480, 530–1, prepuce 448–9
peripheral aneurysms 653 presenting complaint 26
peripheral nerve injuries 636–7 pressure control ventilation
chest drains 90
564–5 Poland’s syndrome 772–3 130
peripheral parenteral polycythaemia 184 pressure support 130
polyostotic fibrous dysplasia priapism 370–1
nutrition 67, 137 primary hyperaldosteronism
peripheral vascular disease 758
polyps 398–9 266–7
40–1, 641–74 Ponseti casting 471 primary hyperparathyroidism
peritoneal catheter 215 popliteal aneurysm 653
peritoneal irritation 34 popliteal artery entrapment 260–1
peritonitis 300–1, 404, primary spontaneous
648
420, 421 portal hypertension 322–3 pneumothorax 636–7
Perkins rules 495 Portex bag 202 primary survey 478–9
pes planus 472–3 positioning patients 76–7 probity 2–3
PET scan, abdomen 37 positive end-expiratory procoagulants 96–7
Peutz–Jeghers syndrome proctalgia fugax 773
pressure 130 proctitis 392, 393
398 positron emission proctoscopy 38
Peyronie’s disease 370, 614 professional organizations 20
phaeochromocytoma 268–9 tomography, abdomen progesterone-only
phalangeal injury 504–7, 548 37
Phalen’s test 570, 772 POSSUM 122 contraceptive pills 50
pharyngeal pouch 276–7 post-declamp shock 672 proprioception 493
phenytoin 62 post-embolization syndrome prostate
phimosis 368–9, 369, 448–9 657
phlebothrombosis 154 posterior cord syndrome adenocarcinoma 378–9
phlegmasia alba dolens 556 anatomy 363
post-exposure prophylaxis benign prostatic
154, 772 179
phlegmasia cerulea dolens Postgraduate Medical hyperplasia 362–3
Education and Training screening 165
154, 772 Board (PMETB) 20 prostate-specific antigen
phosphorus burns 607 post-mortems 17
pigtail thoracostomy 200 post-operative (PSA) 171, 356
pilon fracture 545 complications prosthetic valves 54–5, 629
pilonidal sinus disease 408–9 cardiac 106–7 protein C 180
pilonidal sinus excision gastrointestinal 114–15 protein S 180
haematological 118–19 proximal humerus fracture
744–5 neurological 116–17
placental alkaline renal 110–11 525
respiratory 108–9 proximal interphalangeal
phosphatase (PAP) 171 urinary 112–13
plagiocephaly 772 post-operative haemorrhage joint dislocation 505
plain radiographs 102–3 proximal phalanx fracture

abdominal 37 505
chest, post-operative 88 pseudocysts 150
orthopaedics 502–3 pseudomembranous colitis
spine 550–2
396, 397

INDEX 791

pseudomyxoma peritonei Regan and Morrey sacral fracture 534
773 classification 522 Saint’s triad 774
saline, isotonic 64
pseudopolyposis 392 regression analysis 9 salivary gland
psoas abscess 350, 351 regulatory T-cells 677
psychosocial back pain 578 rehabilitation 89 anatomy and physiology
pulmonary artery catheter Reidel’s thyroiditis 773 227
Reinke’s oedema 773
128–9 Reiter’s syndrome 773 calculi 226–7
pulmonary artery pressure rejection 676–80 swellings 454
relative risk 7 tumours 230–1
129, 631 relative risk reduction 7 saphena varix 763
pulmonary artery wedge relatives, communicating scalpels 80, 81
scaphoid fracture 508
pressure 631 with 4 scapholunate ligament
pulmonary contusion 481 renal complications 110–11
pulmonary embolism 121 renal failure 60, 110–11 injury 509
pulmonary vascular renal impairment 60 scapula fracture 524
renal support 134–5 scars 598–9
resistance 631 renal transplantation 682, Scheie’s syndrome 774
pulmonary vascular Scheuermann’s disease 774
692–3 schistosomiasis 712–13
resistance index 631 Rendu–Osler–Weber Schmorl’s node 774
pulseless ventricular scissors 80, 81
syndrome 773 screening 164–6
tachycardia 190 reperfusion syndrome 672
pulse oximetry 109 reporting systems 21 abdominal aortic
push endoscopy 273 respiratory acidosis 95 aneurysm 164
p-value 8–9 respiratory alkalosis 95
pyloric stenosis 430–1, respiratory complications breast 164–5, 244–5
cervical 165
431–55 108–9 colorectal 165–6
respiratory conditions 59 prostate 165
Q respiratory failure 108 scrotum
respiratory support 130–1 oedema 389, 445
Quinke’s sign 628 respiratory tract infection 59 Pott’s carcinoma 773
rest pain 29 swellings 366–7, 444–5
R retention cysts 150 scrubbing up 79
retractors 80, 81 sebaceous cysts 454
radial artery 196 retrobulbar bleed 235 secondary spontaneous
radial head and neck revalidation 21
rhabdomyosarcoma 282, 452 pneumomediastinum
fracture 516 rib fracture 530–1 637
radial head fracture 520 Richter’s hernia 346, 774 secondary spontaneous
radiation colitis 396, 397 right hemicolectomy 748–9 pneumothorax 637
radioactive iodine 251, 253 rigid cytoscopy 357 secondary survey 479
radius and ulnar shaft rigid proctoscopy 38 seminoma 382, 383
rigid sigmoidoscopy 38, Sengstaken tube 330–1
fracture 512–13 sensation 493
randomized controlled trial 216–17 sensitivity 7
Ringer’s lactate solution 64 sentinel node biopsy 242
(RCT) 10 risk management 20 sepsis 138–9
ranula 773 risk ratio 7 septic arthritis 562–3
raspberry tumour 773 risk scoring 13, 122 septic embolism 155
Raynaud’s disease 664 risk stratification 13 septic shock 100–1
Raynaud’s phenomenon 664 river blindness 714 sequestration dermoid
recombinant human TSH Rockall score 295 cyst 150
Rockwood classification 526 Sever’s disease 474, 774
257 Rolando fracture 504 sex hormones 356
recombinant tissue Romberg’s test 492 sexual dysfunction 355,
Roos test 644 372–3, 673
plasminogen activator 670 Rovsing’s sign 298, 774 sharps 80, 81
record keeping 26–7 rule of nines 605 shave excision 618
rectal anatomy 217 shock 100–1
rectal bleeding, acute S shoulder
dislocations 526–9
416–17 sabre tibia 774 fractures around 524–5
rectal prolapse 406–7, sacral curvature 217 shoveller’s fracture 774

414–15
rectus sheath haematoma

347
recurrent laryngeal nerve

injury 258
redcurrant jelly stool 773
referred back pain 578
reflexes 492–3

792 INDEX

sickle cell anaemia 182–3, Staphylococcus aureus 174 systemic vascular resistance
708 statistical significance 8–9 631
status epilepticus 62–3
sigmoidoscopy sterilization 78 systemic vascular resistance
flexible 36, 38–9 sternoclavicular joint index 631
rigid 38, 216–17
dislocation 526 systolic pressure 631
silicone gel 598 sternum fracture 530–1
Sinding–Larsen’s disease 774 steroids 53 T
single incision laparoscopic Stevens–Johnson syndrome
Takayasu’s arteritis 644
surgery (SILS) 403 774 talus fracture 546
sinuses 151 Stewart–Treves syndrome tap test 666
SIRS 138–9 tar burns 608
Sister Joseph’s nodule 774 774 tarsometatarsal fracture
Sjögren’s syndrome 774 Stimson’s technique 527
skeletal radiographs 502–3 stomach, anatomy and dislocation (Lisfranc)
skewed distribution 6 547–8
skin physiology 287 tarsus fracture 546–8
stoma formation 750–1 T-cell receptors 676
cancer 602–3 stomas 84 T-cells 677
evaluation of disease 42–3 streptococci 174 activation 676
excision of simple lesions Streptococcus pyogenes 174 T cytotoxic cells 677
streptokinase 670 tenesmus 29
600–1 stress incontinence 354 tension pneumothorax
grafts 594–5, 595 stretched scars 598, 599 480, 531
wound healing 147 stroke 62, 116–17, 658–9 terminal ileum 289
sleeping sickness 720 stroke volume 630, 631 terminology
sliding hernia (hernia-en- stroke volume index 631 immunology 677
struvite stones 358 ITU 126
glissade) 346 Stulberg classification 469 surgery 24–5
slipped upper femoral subclavian steal syndrome terrible triad 522
testes
epiphysis 460–1 644 acute pain 388–9
small bowel subclavian vein cannulation torsion 350, 351, 388, 389
tumours 382–3
post-operative mechanical 198 undescended 450–5
obstruction 114–15 subcutaneous tissue disease test feed 431–55
testicular appendages,
transplantation 682, 698–9 42–3 torsion 388
tumours 292–3 submandibular gland 226, 227 tetanus 175
small cell lung cancer 632 subungual haematoma 610 thalassaemia 183
small intestine, anatomy 289 suicide 19 theatre
Smith’s fracture 511 sump syndrome 775 in-theatre preparation
smoking 58 supracondylar fracture 514
social history 27 suprapubic catheterization 74–5
SOCRATES 28 positioning patients 76–7
soft tissue infections 176–7 212–13 preparing patients 70–1
specificity 7 supraventricular tachycardia scrubbing up 79
spermatic cord 339 T helper cells 677
spermatocele 367 188 Thiersch grafts 594, 595
sperm granuloma 367 surgical emphysema 201 thoracic injuries 480–1
spigelian hernia 346, 774 surgical flaps 596–7, 597 thoracic outlet syndrome
spinal cord injury 555 surgical instruments 80–1
spinal injuries 550–2, 554–6 surgical performance 13 644, 645, 646
spinal instability 551–2 surgical symptoms 28–9 thoraco-abdominal
spinal radiograph 550–2 surgical terminology 24–5
spinal shock 555 survival curves 9 aneurysm 652
spinal stenosis 648 sutures 86–7, 590–2 thoracolumbar spinal
spleen palpation 35 Symes amputation 663
sports hernia 348 symptoms 28–9 injuries 555
squamous cell carcinoma synchronized intermittent thoracolumbar spinal
bladder 376
lung 632 mandatory ventilation 130 radiographs 551
oesophagus 282 synergistic spreading thoracotomy 82
salivary gland 230–1 threadworms 727
skin 602–3 gangrene 175 thrombocytopenia 181
staghorn calculi 358 syphilitic osteomyelitis 561
standard deviation 6 systematic enquiry 27 heparin-induced (HIT) 118
standard setting 20 systematic review 10 thromboembolic deterrent
staphylococci 174 systemic inflammatory
stockings (TEDS) 72
response syndrome
(SIRS) 138–9

INDEX 793

thromboembolic disease contraindications 682 tuberculosis 722
154–6 deceased donors 19, typhoid 704–5
Trousseau’s sign 775
thrombolysis 670–1 684–99 true aneurysms 652
thrombophlebitis 154 heart–lung 691 trypanosomiasis 720
thrombophlebitis migrans immunology 676–7 tuberculosis 561, 722
immunosuppression tuberculous epididymitis 366
154, 775 tubo-ovarian infection
thromboprophylaxis 72–3 678–80, 680–99
thrombus 154 indications for 682 306, 307
through knee amputation islet cell 695 tubulo-dermoid cysts 150
liver 682, 696–7 tubulo-embryonic cysts 150
662, 663 living donors 687–8 tumour markers 170, 171
thumb injuries 504 lung 682, 691 tumours
thymoma 639 machine perfusion 687
thyroglobulin 171 organ availability 684 benign 160
thyroglossal cyst, sinus and organ preservation 687 bone 574–7
pancreas 682, 694–5 classification 160, 161
fistula 222–3 post-transplant cystic 150
thyroid definitions 160
lymphoproliferative doubling time 162
anatomy 257 disorder 679–80 gastric 286–7
goitre 250–1 rejection 676–7, 678–80 genetic abnormalities 162
Hurtle cell adenoma 759 renal 682, 692–3 grading 168–9
post-surgery emergencies routine investigations 683 growth 162
small bowel 682, 698–9 immunosuppression-link
258–9 trans-scaphoid perilunate
tumours 254–7 dislocation 509 679–80
thyroid storm 252 transverse rectus abdominis invasion 161
thyrotoxic crisis 252, 258–9 myocutaneous (TRAM) malignant 160
thyrotoxicosis 252–3 flap 618 metastasis 161
tibial shaft fracture 540–2 trash foot 673 oesophageal 282–3
Tietze’s disease 248, 775 trauma, facial 235–6; see salivary gland 230–1
timor mortis 124 also major trauma small bowel 292–3
Tinel’s sign 570, 644, 775 traumatic fat necrosis 247 solid tumours in children
tissue valves 629 traumatic infarction 481
TNM staging 168, 169 Treacher Collins syndrome 452–3
tolerance 677 775 staging 168–9
tongue-tie 759 trenchfoot 159 testicular 382–3
total hip replacement 586–7 Trendelenberg test 667 thyroid 254–7
total parenteral nutrition Trethowan’s sign 460, 461 transitional cell 376–7
triangular fibrocartilage vascular 656
67, 137 complex injury 509 see also cancer
toxic dilatation 418 triceps skinfold thickness 66 tumour suppressor genes
tracheobronchial rupture 481 trichlobezoars 760
traction apophysitis 474 triple phosphate stones 358 162
TRAM flap 618 Troisier’s sign 286, 775 type I/II errors 8–9
tranexamic acid 97 tropical diseases 701–28 typhoid 704–5
transabdominal rectopexy 407 amoebiasis/amoebic liver
transanal endoscopic abscess 706–7 U
anaemias 708–9
microsurgery (TEMS) 403 ascariasis 718 ulcerative colitis 392–3, 419
transferrin (serum) 66 filariasis 714 ulcers 43, 148–9
transfusion reactions 98–9 guinea worm infestation 726 ulnar styloid fracture 511
transfusion-related acute hydatid disease 716–17 ultralow anterior section 402
leishmaniasis 719 ultrasound
lung injury 99 leprosy (Hansen’s disease)
transient ischaemic attack 724–5 breast 30
malaria 710–1 developmental dysplasia of
(TIA) 658–9 mycetoma (madura foot)
transitional cell tumours 728 hip 459
schistosomiasis endoanal 39
376–7 (bilharziasis) 712–13 endoscopic 272
transjugular intrahepatic threadworms 727 neck 32
trypanosomiasis 720 peripheral vascular
portosystemic shunt 331
transplantation 675–99 disease 41
transabdominal 36, 39
ABO-incompatible living transrectal 39
donors 688 transvaginal 39

accepting patient on to
transplant list 683

cadaveric organ retrieval
686–7

cardiac 682, 690–1

794 INDEX

urinary tract disease 356 valvular heart disease 54–5, Waterhouse–Friderichsen
varicose veins 667 628–9 syndrome 776
umbilical hernia 342–3, 446
umbolith 775 variceal bleeding 330–1, 331 Whipple’s triad 776
undescended testes 450–5 varicocele 366, 366, 367, whistle-blowing 21
univariate analysis 9 Whitaker test 776
universal donors 97 444–5 whitlow 612
universal precautions 179 varicose veins 666–7 WHO checklist approach
universal recipients 97 vascular developmental
upper gastrointestinal 74–5
abnormalities 656–7 Wilm’s tumour 452
bleeding 294–5 vascular injuries 484–5 Winterbottom’s sign 720
upper gastrointestinal vascular surgery, Wolfe grafts 594, 595
wounds
endoscopy 272–3 complications 672–4
upper gastrointestinal vasopressors 132–3 body cavity incisions 82
vasospastic disorders 664–5 burns 607
perforation 296–7 vena caval filter 669 classification 146
upper gastrointestinal venepuncture 192–3 dehiscence 104–5
venous ulcers 148–9 haematoma 103
surgery 271–309 ventilation 126 healing 146–7
ureteric obstruction 360–1 incision closures 82
ureterocele 775 invasive 130 infection 104, 172–3
ureteroscopy 357 non-invasive 131 stitch marks (tramline
urethral catheterization ventricular assist devices 133
ventricular fibrillation 190 effect) 590
210–1 Venturi mask 131 suturing 86–7, 590–2
urethral stricture 364–5 verbal consent 15 W-plasty 599
urge incontinence 354 Vermooten’s sign 775 W pouch 402
uric acid stones 358 vibration sense 493 wrist injuries 508–9
urinanalysis 356 viral hepatitis 178 written consent 15
urinary complications Virchow’s triad 120, 154,
X
112–13 668
urinary incontinence 354–5 visceral aneurysm 653 xenograft 594, 677
urinary retention, acute 113, visceral leishmaniasis 719
vomiting 426 Y
386–7 von Hippel–Lindau disease
urinary tract disease Young and Burgess
775 classification 532
infection 113 von Recklinghausen’s
investigations 356–7 Youssef’s syndrome 776
stones 358–9 disease 775
urine output 620 von Rosen’s sign 775 Z
urokinase 670
urology 353–89 W Zenker’s diverticulum 776
urostomy 84 Zollinger–Ellison syndrome
Waldenström disease 776
V Waldenström’s sign 468 285, 776
ward rounds 88–9 Z-plasty 599
VACTERL syndrome 775 warfarin 119, 180
vacuum dressings 595 Warthin’s tumour 230

Index to emergency topics

Acute abdominal emergencies: overview 426
Acute abdominal pain 302
Acute anorectal pain 414
Acute appendicitis 298
Acute breast pain 248
Acute groin swelling 350
Acute haematemesis 294
Acute limb ischaemia 570
Acute pancreatitis 332
Acute rectal bleeding 416
Acute severe colitis 418
Acute testicular pain 388
Acute upper GI perforation 296
Acute urinary retention (AUR) 386
Acute variceal haemorrhage 330
Burns: assessment 604
Burns: management 606
Cardiac complications 106
Gynaecological causes of lower abdominal pain 306
Haematuria 384
Intra-abdominal abscess 308
Post-operative anastomotic leakage 420
Post-operative haemorrhage 102
Pulmonary embolism 120
Respiratory complications 108
Ruptured abdominal aortic aneurysm 654
Stroke 62
Wound emergencies 104

Common haematology values If outside this range, consult:

Haemoglobin men: 13–18g/dL
women: 11.5–16g/dL
Mean cell volume, MCV 76–96fL
Platelets 150–400 × 109/L
White cells (total) 4–11 × 109/L
40–75%
Neutrophils 20–45%
Lymphocytes 1–6%
Eosinophils

Blood gases kPa mmHg
pH 7.35–7.45
PaO2 >10.6 75–100
PaCO2 4.7–6 35–45
Base excess ±2 mmol/L

U&E etc If outside this range, consult:

Sodium 135–145mmol/

Potassium 3.5–5mmol/L

Creatinine 70–150μmol/L

Urea 2.5–6.7mmol/L

Calcium 2.12–2.65mmol/L

Albumin 35–50g/L

Proteins 60–80g/L

LFTs 3–17μmol/L
Bilirubin 3–35U/L
Alanine aminotransferase, ALT 3–35U/L
Aspartate transaminase, AST 30–35U/L (adults)
Alkaline phosphatase

‘Cardiac enzymes’ 25–195U/L
Creatine kinase 70–250U/L
Lactate dehydrogenase, LDH

Lipids and other biochemical values <6mmol/L desired
Cholesterol 0.5–1.9mmol/L
Triglycerides 0–180somorgyi U/dL
Amylase <10mg/L
C-reactive protein, CRP 3.5–5.5mmol/L
Glucose, fasting 0–4ng/mL
Prostate specific antigen, PSA 70–140mmol/L
T4 (total thyroxine) 0.5–75mu/L
TSH

Common perioperative care

Bowel prep KleenPrep® 4 sachets over 8h the day preop or CitragMag®
2 sachets over 4h the night preop.

Thromboprophylaxis

Low risk, e.g. day or fully ambulatory cases: TEDS only.
Medium risk, e.g. major surgery without risk factors or past history of

DVT: TEDS + Clexane® 30mg SC od or Fragmin® 2500U SC od.
High risk, e.g. pelvic surgery, malignancy, obesity, past history of DVT:

TEDS + Clexane® 30mg SC bd or Fragmin® 5000U SC od.

Diabetic perioperative regimens

Minor surgery (e.g. day surgery)

Oral controlled: give normal regimen.
Insulin controlled: omit preop insulin on day of surgery; monitor blood

sugar (BS) every 4h; restart normal insulin once oral diet established.

Major surgery

Oral controlled: omit long-acting hypoglycaemics preoperatively; monitor
BS every 4h. If BS > 15mmol/L start IV insulin regimen.

Insulin controlled: commence on IV insulin sliding scale preoperatively once
NBM and continue until normal diet re-established. Check BS 4-hourly.
Restart normal insulin regimen (initially at half dose) once oral diet
established.

Typical IV sliding scale (Actrapid® with 5% dextrose):
BS < 4mmol/L: infusion 0.5U/h;
BS 4–15mmol/L, infusion 2.0U/h;
BS 15–20mmol/L, infusion 4.0U/h;
BS > 20mmol/L, infusion 4.0U/h plus consult diabetology team. Con-
sider treatment as for ketoacidosis.

Fluid balance

Fluid depletion = ((PCV1 – PCV2)/PCV1) x 0.7 x weight in kg
where PCV1 = normal haematocrit and PCV2 = current haematocrit.
Fluid maintenance regimen (correct for age and losses)

Fluid volume Na+ K+

100mL/kg for 1st 10kg of weight + 150mL/kg 2mmol/kg/24h 1mmol/kg/24h
for next 10kg of weight + 20mL/kg for every
kg of weight thereafter

Managing oliguria
Check catheter not blocked.
Check fluid balance status—try bolus crystalloid with frequent reviews.
Check drug chart for possible drug toxicity.

Managing postoperative hypotension
Check fluid balance status first. If in doubt assume it is hypovolaemia.
Check epidural status. Check drug chart for possible drug toxicity.

Cardiac arrest: 2010 Adult Advanced Life-Support Algorithm1
Each step assumes the previous one has been unsuccessful

UNRESPONSIVE? Call
not breathing or resuscitation team
only occasional gasps

CPR 30:2
Attach defibrillator/monitor

Minimise interruptions

Assess
rhythm

Shockable Non-Shockable
(VF/Pulseless VT) (PEA/Asystole)

1 Shock Return of
spontaneous
circulation

Immediately resume Immediately resume
CPR for 2 min CPR for 2 min

Minimise interruptions Minimise interruptions

Immediate post cardiac (S aO2 94 – 98%)
arrest treatment
Primary angioplasty may also be an
appropriate immediate Use ABCDE approach
post-cardiac arrest treatment. Controlled oxygenation and ventilation

12-lead ECG
Treat precipitating cause
Temperature control/
therapeutic hypothermia

Give 1mg adrenaline During CPR Reversible Causes
every 3–5 min, Ensure high-quality CPR: rate, depth, recoil Hypoxia
starting after the Plan actions before interrupting CPR Hypovolaemia
3rd shock, on Give oxygen Hypo-/hyperkalaemia/metabolic
alternate cycles Consider advanced airway and capnography Hypothermia
Continuous chest compressions
when advanced airway in place Thrombosis-coronary or pulmonary
Vascular access (intravenous, intraosseous) Tamponade-cardiac
Toxins
Give adrenaline every 3–5 min Tension pneumothorax
Correct reversible causes

Do not interrupt CPR for >10s, except to defibrillate.

Shockable rhythm:
• Amiodarone 300mg IV should be given with first dose of adrenaline (peripherally

if no central access). A further 150mg may be given, followed by an infusion of
1mg/min for 6h, then 0.5mg/min for 6h.
• Alteratives to amiodarone are:
• Lidocaine 100mg IV; can repeat once; then give 2–4mg/min IVI.
• Procainamide 30mg/min IV to a total dose of 17mg/kg.
• Seek expert advice from a cardiologist.

Asystole/PEA: Give adrenaline 1mg immediately IV access is achieved. Atropine 3mg
IV is no longer recommended. If P waves the patient may respond to pacing.

Treat acidosis with good ventilation. Sodium bicarbonate may worsen intracellular
acidosis and precipitate arrhythmias, so use only in severe acidosis after prolonged
resuscitation (eg 50mL of 8.4% solution by IVI).

1 Algorithm reproduced with the permission of the Resuscitation Council (UK), ©2010. NB: adrena-
line/epinephrine in large doses (eg 5mg) has theoretical haemodynamic advantages, but studies have
failed to show benefit (Ballew K 1997 BMJ i 1462). See Baskett P 1992 Br J Anaesthesia 69 182

2 PEA = Pulseless Electrical Activity = electromechanical dissociation (EMD)