Algoritma Emergency Di UGD

Emergency Medicine
Algorithms
2014
This is a freely available educational resource in support of the development of
Emergency Medicine in Kenya and the activities of:
www.afem.info
Table of Contents
1. Adult Cardiac Arrest Algorithm ................................................................................................................................................ 3
2. Adult Bradycardia (< 50/min)/Tachycardia (> 150/min) .......................................................................................................... 4
3. Post-Cardiac Arrest Care Algorithm ......................................................................................................................................... 5
4. ACS Algorithm ......................................................................................................................................................................... 6
5. STEMI Algorithm ..................................................................................................................................................................... 7
6. NSTEMI/UA Algorithm............................................................................................................................................................ 8
7. Pulmonary Embolism Algorithm .............................................................................................................................................. 9
8. Rapid Sequence Intubation Algorithm .................................................................................................................................... 10
9. Difficult Airway Algorithm ..................................................................................................................................................... 11
10. Anaphylaxis Algorithm ........................................................................................................................................................... 12
11. Acute Asthma Exacerbation Algorithm .................................................................................................................................. 13
12. Peak Expiratory Flow Chart .................................................................................................................................................... 14
13. Hypertension Algorithm .......................................................................................................................................................... 15
14. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8)
Guidelines................................................................................................................................................................................ 16
15. Hypertensive Emergencies Algorithm..................................................................................................................................... 19
16. Hypertensive Emergencies Drug Infusions ............................................................................................................................. 20
17. SEPSIS Definitions ................................................................................................................................................................. 21
18. Severe Sepsis/Septic Shock Algorithm ................................................................................................................................... 22
19. Hyperglycaemia Algorithm ..................................................................................................................................................... 23
20. Uncomplicated Hyperglycaemia Algorithm ............................................................................................................................ 24
21. Hypoglycaemia Algorithm ...................................................................................................................................................... 25
22. Electrolyte Abnormalities Algorithm ...................................................................................................................................... 26
23. Syncope Algorithm.................................................................................................................................................................. 27
24. Seizures Algorithm .................................................................................................................................................................. 28
25. Transient Ischemic Attack (TIA) Algorithm ........................................................................................................................... 29
26. Stroke Algorithm ..................................................................................................................................................................... 30
27. Stroke Reperfusion Algorithm ................................................................................................................................................ 31
28. Trauma Management Pathway ................................................................................................................................................ 32
29. C-Spine Clearance Algorithm ................................................................................................................................................. 33
30. Mild Traumatic Brain Injury Algorithm .................................................................................................................................. 34
31. Epistaxis Algorithm................................................................................................................................................................. 35
32. Low Back Pain Algorithm ....................................................................................................................................................... 36
33. Epigastric Pain Algorithm ....................................................................................................................................................... 37
34. Upper Gastrointestinal Bleeding Algorithm ............................................................................................................................ 38
35. Management of Pain in Sickle Cell Disease (SCD) Algorithm ............................................................................................... 39
36. Pain Management Algorithm .................................................................................................................................................. 40
37. Analgesia Chart ....................................................................................................................................................................... 41
38. Procedural Sedation and Analgesia (PSA) .............................................................................................................................. 42
39. Antimicrobial Guide ................................................................................................................................................................ 43
40. Poisoning ................................................................................................................................................................................. 49
Algorithm References ..................................................................................................................................................................... 50
1. Adult Cardiac Arrest Algorithm
This clinical pathway is intended to
Unresponsive
supplement, rather than substitute No Breathing or no normal breathing
for, professional judgment and may (i.e. only gasping)
be changed depending upon a
patients individual needs. Failure
to comply with this pathway does Activate Resuscitation Team
Get AED/Defibrillator
not represent a breach of the
standard of care.
Open and maintain patent airway
CHECK PULSE Definite Pulse Give 1 breath every 6 seconds
DEFINITE pulse palpated Recheck pulse every 2 mins
within 10 secs?
Go to 3. Post Cardiac Arrest Care Algorithm
No Pulse
Begin CPR - cycles of 30 COMPRESSIONS then 2 BREATHS High-Quality CPR

Perform continuous compressions until BVM is available Compression rate of at least 100/min
Use BVM when available to give breaths even without O2. Compression depth at least 5 cm
Attach O2 at 15L/min when available Allow complete chest recoil after each
compression
Minimize interruptions in chest
AED/Defibrillator ARRIVES compressions to < 10 seconds
Attach AED pads or use Quick look defibrillator paddles to check rhythm Avoid excessive ventilation Give
enough volume just to produce visible
chest rise. Give 2 breaths after every 30
Rhythm compressions or if intubated, give 1
Shockable? breath every 6 seconds
Yes No
VF/Pulseless VT Asystole/PEA
Shock
Biphasic 200J
Monophasic 360J
Change compressors - CPR 2min

IV/IO access Take bloods for VBG & RBS
IV/IO access Take bloods for VBG & RBS
Attach monitor leads; adjust monitor to lead II
Attach monitor leads; adjust monitor to lead II
Rhythm
Shockable?
Yes No
Shock
Biphasic 200J
Monophasic 360J

Adrenaline 1mg IV/IO with 20ml NS flush
(Repeat dose after 2 CPR cycles)
Identify and treat reversible causes below
Adrenaline 1mg IV/IO with 20ml NS flush
(Repeat dose after 2 CPR cycles)
Rhythm No
Identify and treat reversible causes below
Shockable?
Consider advanced airway, capnography
Yes If return of spontaneous circulation, go to
Shock 3. Post Cardiac Arrest Care Algorithm
Biphasic 200J
Monophasic 360J
Reversible causes
Change compressors - CPR 2min - Hypoglycaemia - Tension Pneumothorax
- Hypovolemia - Tamponade, cardiac
Amiodarone 300mg IV/IO bolus with 20ml NS flush
- Hypoxia - Toxins
(Second dose after 2 CPR cycles) 150mg with 20 ml NS flush)
- Hydrogen ion (acidosis) - Thrombosis, pulmonary
Identify and treat reversible causes below - Hypo-/hyperkalaemia - Thrombosis, coronary
Consider advanced airway, capnography - Hypothermia
2. Adult Bradycardia (< 50/min)/Tachycardia (> 150/min)
(with Pulse) This clinical pathway is intended to
supplement, rather than substitute for,
professional judgment and may be
Airway changed depending upon a patients
Open and maintain patent airway; protect as necessary individual needs. Failure to comply with
this pathway does not represent a
Breathing breach of the standard of care.
Administer Oxygen (if SPO2 < 94%); Assist breathing as necessary
Circulation
Cardiac monitor to identify rhythm; monitor blood pressure, pulse oximetry, To C, RBS
Establish IV access and take bloods for FBC, UEC, VBG
Print rhythm strip or 12-lead ECG if available; dont delay therapy
Identify and treat underlying cause

- Hypoglycaemia - Tension Pneumothorax
- Hypoxia - Toxins
- Hypo-/hyperkalaemia - Thrombosis, coronary
- Hypothermia
Signs of instability
Hypotension?
Acutely altered mental status?
Signs of Shock?
Ischaemic chest discomfort?
Bradycardia (HR < 50/min) Acute heart failure?
With signs of instability
Tachycardia (> 150/min)
Consult a Cardiologist and continue
with the algorithm
Wide QRS?
0.12 seconds
No Yes
Narrow Complex Tachycardia Wide Complex Tachycardia

(Supraventricular Tachycardia) (Ventricular Tachycardia)
HR > 150/min + QRS complexes < 0.12sec HR > 150/min + QRS complexes 0.12sec
Stable Signs of instability Stable
IV Atropine
Exclude: head injury, hypoxia, Vagal Stimulation
hypothermia, heart block, (at least 2 different manoeuvres) Synchronised cardioversion
hyperkalaemia, heart transplant (NOT if varying R-R intervals/Atrial fibrillation) Consider procedural sedation
Valsalva (Abdominal pressure/Breath holding) Start with 100J initially with
First Dose: 0.5mg bolus Facial application of ice water escalation as needed
Repeat every 3-5 minutes Carotid sinus massage (C/I if bruits, CVS Consult a Cardiologist
Maximum: 3 mg disease, elderly)
Adenosine Adenosine
If atropine ineffective: (NOT if varying R-R intervals/Atrial fibrillation) (NOT if varying R-R intervals/Polymorphic)
1. Transcutaneous Pacing 6 mg rapid IV push; follow with 20mls NS flush; 6 mg rapid IV push; follow with 20mls NS flush;
(See pacing protocol) then 12 mg IV after 1-2 mins if required then 12 mg IV after 1-2 mins if required
OR Consult a Cardiologist
2. Dopamine IV infusion
Amiodarone
2 -10g/kg/min
150mg IV over 10 mins then 1mg/min
Amiodarone
OR infusion for first 6 hours
150mg IV over 10 mins then 1mg/min
3. Adrenaline IV Infusion infusion for first 6 hours
2-10 g/min
Alternatives (under expert advice) Consider (if Torsades de Pointes):
Consult a Cardiologist blockers Defibrillation (asynchronous)
Alternative: Glucagon if -blocker or Ca Channel Blockers or Magnesium 2gm IV over 10 mins
CCB overdose Digoxin Overdrive pacing
3. Post-Cardiac Arrest Care Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending
upon a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Return of Spontaneous Circulation (ROSC)
Activate Resuscitation Team (if not already present) AND a Physician/Cardiologist

Monitor, support ABCs. Be prepared to provide CPR and defibrillation
Check vital signs (BP, PR, RR, SPO2, ToC, RBS)
12-lead ECG immediately
If patient is stable, consider immediate transfer to ICU attached to a defibrillator
Optimize ventilation and oxygenation

Avoid excessive ventilation.
- Start at 10 12 breaths/min (1 breath every 6 seconds)
- Titrate FiO2 to minimum necessary to maintain SPO2 94%
- Titrate to target PETCO2 of 35 45 mmHg
Consider advanced airway and waveform capnography
Treat hypotension (SBP < 90mmHg)

IV/IO Bolus: 1-2 L Normal Saline or Ringers Lactate
Vasopressor infusion if NO response to fluid bolus:
- Adrenaline IV Infusion: 0.1 0.5g/kg/min (7-35g/min in 70-kg adult)
- Norepinephrine IV Infusion: 0.1 0.5g/kg/min (7-35g/min in 70-kg adult)
Identify and treat reversible causes
- Hypoglycaemia - Tension Pneumothorax
- Hypoxia - Toxins
- Hypo-/hyperkalaemia - Thrombosis, coronary
- Hypothermia
Keep the patients temperature

< 36oC for 36 hours using ice-
cold fluids, ice packs, and No Patient is able to follow commands?
intravascular or surface
temperature-management
Yes
STEMI or Suspicion of ACS Consult a Cardiologist

Transfer to Critical Care Unit (ICU/CCU) attached to a defibrillator
4. ACS Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Chest discomfort suggestive of ischemia
(includes anginal equivalents (atypical symptoms) like exertional pain in the ear, jaw, neck, shoulder,
arm, back, or epigastric area; exertional dyspnoea; nausea and vomiting; diaphoresis; and fatigue.
Monitor, support ABCs in the Resuscitation Room (ER). Be prepared to provide CPR and defibrillation
Obtain/review 12-lead ECG within 10 minutes of arrival to ER
- Do a V4R if ST elevation in lead V1 with simultaneous ST depression in V2 - ? Right sided STEMI
- Do V7 - V9 if ST depressions 1 mm with upright T-waves in 2 contiguous anterior precordial leads (V1 to V3) - ? Posterior STEMI
- If there is ST elevation in aVR 1mm and aVR V1 with widespread horizontal ST depression, most prominent in leads I, II and V4-6
consult an Interventional Cardiologist immediately for PCI (Left main coronary artery occlusion/Proximal LAD lesion)
- Sinus Tachycardia, T wave inversion in III & V1, V3 or (S1, Q3, T3) pattern - ? See 7. Pulmonary Embolism Algorithm
Start Oxygen IF SPO2 < 90% or if patient is dyspnoeic. Maintain SPO2 90%
Establish IV access in left forearm or antecubital vein and send blood samples for UEC, Coagulation screen & hsTroponin T if 4 hours since
onset of symptoms
Perform brief, targeted history, physical exam Indicate time of symptoms onset
Aspirin 300mg to chew (if not given by EMS, Not Allergic, No active Upper GI Bleeding or Retinal bleeding, not a haemophiliac, No severe untreated BPs)
Nitroglycerin sublingual spray 0.4mg SL for pain relief every 5mins up to relief of discomfort or MAX 3 doses reached. DO NOT give nitroglycerine if:
SBP < 90mmHg (or 30 mm Hg below the patients known baseline),
Heart rate > 100 bpm, or < 50 bpm.
Right ventricular infarction (right ventricular infarction causes a preload dependent state)
Use of sildenafil or vardenafil within the previous 24 hours or tadalafil within the previous 48 hours.
Fentanyl 50g IV if pain is NOT relieved by the 3 doses of SL nitroglycerin. Repeat once if still in pain after 5 mins. For persistent pain, consult a
Cardiologist/Physician. Consider IVI nitroglycerin (see C/I above)
Obtain portable CXR to r/o other causes of chest pain (pulmonary embolus, cardiac tamponade, aortic dissection, tension pneumothorax)
Review initial 12-lead ECG
ST elevation or LBBB meeting ST depression > 0.5mm or dynamic T-wave Normal or Non-diagnostic changes
Sgarbossa criteria (see below) inversion 2mm; strongly suspicious for ischemia in ST segment or T wave
ST-Elevation MI (STEMI) High-Risk Unstable Angina/Non-ST-Elevation MI Intermediate/Low Risk UA
(UA/NSTEMI)
See See
5. STEMI Algorithm 6. UA/NSTEMI Algorithm
Sequence of changes seen during evolution Left Bundle Branch Block (LBBB) Sgarbossa criteria for LBBB (either)
of myocardial infarction 1. Concordant ST elevation 1mm in at least 1 lead
2. Concordant ST depression 1mm in V1 - 3

5. STEMI Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients
individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
ST elevation or LBBB meeting Sgarbossa criteria (see 4. ACS Algorithm)
ST-Elevation MI (STEMI)
No Primary PCI
Consult an
Time from onset of symptoms 12 hours? Obtain informed consent
Interventional Cardiologist
Yes Give:
1. Clopidogrel (600mg) OR
Consult an Interventional Cardiologist Prasugrel (60mg) OR
to determine if the patient is for Ticagrelor (180mg)
Thrombolysis/Fibrinolysis OR Primary PCI 2. Atorvastatin 80mg
Transfer to Cathlab within 90
minutes of arrival to the ER
Thrombolysis/Fibrinolysis
Give:
1. Clopidogrel 600mg
2. Enoxaparin:
If age <75 y: 30-mg IV bolus, followed in 15 min by 1 mg/kg SC (max.100 mg for the first 2 doses)
If age 75 y: no bolus, 0.75 mg/kg SC (max. 75 mg for the first 2 doses)
Regardless of age, if CrCl < 30 mL/min: 1 mg/kg SC
3. Atorvastatin 80mg
Review/Complete Fibrinolysis Checklist

Absolute Contraindications Relative Contraindications
Any prior intracranial haemorrhage History of chronic, severe, poorly controlled hypertension
Known structural cerebral vascular lesson (e.g., AVM) Severe uncontrolled hypertension on presentation (SBP > 180 mmHg or
Known malignant intracranial neoplasm (primary or metastatic) DBP > 110 mmHg)
Ischaemic stroke within 3 months EXCEPT acute ischaemic stroke History of prior ischaemic stroke > 3 months, dementia, or known
within 3 hours intracranial pathology not covered in contraindications
Suspected aortic dissection Traumatic or prolonged (>10 minutes) CPR or major surgery (< 3 weeks)
Active bleeding or bleeding diathesis (excluding menses) Recent (within 2 to 4 weeks) internal bleeding
Significant closed head trauma or facial trauma within 3 months Non-compressible vascular punctures
For streptokinase/anistreplase: prior exposure (> 5 days ago) or prior
allergic reaction to these agents
Pregnancy
Active peptic ulcer
Current use of anticoagulants: the higher the INR, the higher the risk of
bleeding
No Contraindications for Fibrinolysis/Thrombolysis

Obtain informed consent for fibrinolysis/thrombolysis
Ensure patient is connected to a defibrillator (ECG, SPO2, BP) and repeat baseline vitals. Administer fibrinolysis within 30 mins of arrival to ER
TENECTEPLASE
To reconstitute tenecteplase, mix the 50-mg vial in 10 mL sterile water (5 mg/mL). Tenecteplase is administered in a 30-50 mg IV bolus over
5 seconds. The dosage is calculated on the basis of the patients weight, as follows:
- < 60 kg - 30 mg (6 mL)
- 60 to 69 kg - 35 mg (7 mL)
- 70 to 79 kg - 40 mg (8 mL)
- 80 to 89 kg - 45 mg (9 mL)
- 90 kg - 50 mg (10 mL)
OR
STREPTOKINASE
Set up second IV line for the Streptokinase. Run Normal Saline/Ringers Lactate TKVO in other line
The adult dose of streptokinase for STEMI is 1.5 million U in 50 mL of 5% dextrose in water (D5W) given IV over 60 minutes. Allergic
reactions force the termination of many infusions before a therapeutic dose can be administered.
Monitor vital signs (BP, PR, RR, SPO2) every 15 minutes during the infusions
Continue monitoring patient for 30mins after the end of the infusions
Transfer patient to CCU/ICU connected to the defibrillator
6. NSTEMI/UA Algorithm
ST depression > 0.5mm or dynamic T-wave inversion 2mm; strongly Normal or Non-diagnostic changes in ST segment or T wave
suspicious for ischemia Intermediate/Low Risk UA
High-Risk Unstable Angina/Non-ST-Elevation MI (UA/NSTEMI)
TIMI Risk factors TIMI Risk Score Probability of Death, Myocardial

Note: Each of the listed risk factors is worth 1 point Infarction and Revascularization
(range 0-7 points). Within 30 Days, %
Age greater than 65 years 0 2.1
At least 3 risk factors for coronary artery disease (including family 1 5
history of the disease, hypertension, hypercholesterolemia, diabetes
mellitus, and current tobacco use) 2 10.1
Significant coronary stenosis (prior known coronary stenosis 50%) 3 19.5
ST-Segment deviation 4 22.1
Severe anginal symptoms ( 2 anginal events in the previous 24 hours) 5 39.2
Use of aspirin in the previous 7 days 6 45
Elevated serum cardiac marker levels (hsTrop T) 7 100
Repeat 12 lead ECG in 30 mins/Continuous ST-segment monitoring STEMI

See 5. STEMI Algorithm
hsTroponin T > 14ng/L OR TIMI score 3 points OR ST depression OR Dynamic ECG changes
Yes No
hsTroponin T 14ng/L If Troponin done < 4 hours from symptom onset then repeat
Consult a Cardiologist/Physician
Troponin at 3 hours from admission to ER
hsTroponin T < 14ng/L
If no evidence of ischaemia or infarction by testing, can

discharge cardiology follow-up
Criteria for Discharge (must meet ALL the criteria)
Two ECGs which are Normal and No ST Depression and No
Dynamic changes
hsTroponin T < 14ng/L at 4 hours from onset of symptoms OR 3
hours from admission to ER
7. Pulmonary Embolism Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients individual needs.
Failure to comply with this pathway does not represent a breach of the standard of care.
Clinical features suggestive of Pulmonary Embolus
Monitor, support ABCs in Resuscitation room (ER). Be prepared to provide CPR and defibrillation
Obtain/review 12-lead ECG Consider ACS See 5. STEMI Algorithm.
Features of PE on ECG; Sinus Tachycardia, T wave inversion in III & V1, V3 or S1, Q3, T3 pattern. A normal ECG can be seen in 30% of patients
Check vital signs (BP, PR, RR, SPO2, T C, RBS)
o
Start Oxygen IF SPO2 < 94% or if patient is dyspnoeic. Maintain SPO2 94%
Establish IV Access and send blood samples for FBC, UEC, Coagulation screen & hsTroponin T (See 6. UA/NSTEMI Algorithm for interpretation)
Perform brief, targeted history, physical exam
Chest x-ray If alternative cause for symptoms found, treat underlying cause. If not, continue with algorithm
Clinical gestalt or validated clinical decision support tool

Wells score
Criteria Points
Suspected DVT 3.0
An alternative diagnosis is less 3.0
likely than PE
Hear Rate >100bpm 1.5
Immobilisation or surgery in the 1.5
previous 4 weeks
Previous DVT/PE 1.5
Haemoptysis 1.0
Malignancy (on treatment, treated 1.0
in the last 6 months, or palliative)
Score Range Probability of Interpretation of Risk
(Points) PE (%)
0-4 7.8 (5.9 10.1) Low Probability
>4 40.7 (34.9 46.5) Moderate to High
Probability
Hemodynamically stable, low probability for PE (< 15%) Moderate to high probability for PE ( 15%)
Haemodynamically stable?
Any Pulmonary Embolism Rule-Out Criteria met?
1. Is the patient > 49 years of age? No Yes PE safely
2. Is the pulse rate > 99 beats per minute? excluded
3. Is the pulse oximetry reading < 95% while the Negative
Bedside echocardiogram CTPA* consider
patient breathes room air? Presence of RV dilatation, septal other
4. Is there a present history of haemoptysis? shift, or right heart thrombus?
5. Is the patient receiving exogenous oestrogen? Positive diagnosis
6. Does the patient have a prior diagnosis of venous Yes No
thromboembolism?
7. Has the patient had recent surgery or trauma Administer IV fluids Begin anticoagulation therapy
Admit to ICU
requiring endotracheal intubation or hospitalization If contraindication to
Begin anticoagulation No & resuscitate
in the previous 4 weeks? Is patient stable anticoagulation, consider IVC
Consider thrombolysis
8. Does the patient have unilateral leg swelling (visual filter and/or if massive PE,
If contraindication to following initial
observation of asymmetry of the calves)? embolectomy
anticoagulation, resuscitation?
Risk stratification with troponin
continue resuscitation,
Yes No and echocardiogram
consider embolectomy
Admit to ICU or floor as indicated
Quantitative D-dimer assay > 0.5 g/L* PE safely excluded

(ELISA or turbidimetric) consider other diagnosis * Compression ultrasound of lower extremities can be performed as the initial
diagnostic imaging modality in any of the following situations;
< 0.5 g/L* patients with obvious signs of deep vein thrombosis (DVT) for whom venous
Negative PE safely excluded ultrasound is readily available
CTPA*
consider other diagnosis patients with relative contraindications for CT scan (e.g., borderline renal
Positive insufficiency, CT contrast agent allergy)
in pregnant patients with an elevated D-dimer
patients with a moderate to high clinical risk of PE with a negative or
Begin anticoagulation
inconclusive CTPA or an inconclusive V/Q scan.
therapy with unfractionated
or fractionated heparin
A positive finding in a patient with symptoms consistent with PE can be
Consult a Physician considered evidence for diagnosis of VTE disease and potentially eliminate the
need to expose the patient to the radiation from either a CTPA or V/Q scan.
*for patients > 50 yrs, cut off is 10 x patients age in g/L
8. Rapid Sequence Intubation Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon
a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Preparation
LEMON MALE MESS
Look for external markers of difficulty of BVM and Intubation Mask
Airways (oral and nasal)
Evaluate the 3-3-2 rule Laryngoscopes, Laryngeal Mask Airway (LMA)
Endotracheal tubes Males 8F; Females 7.5F
Mallampati Monitoring (pulse oximetry, ECG, capnography), Magill Forceps
Emergency drugs
Obstruction/Obesity Self-inflating bag valve resuscitator;
Suction, Stylet, Bougie
Neck Mobility Plentiful oxygen supply
Position the patient

If patient is breathing spontaneously, prop up patient to allow patient to take deep breaths until you are ready to intubate
BVM ventilation and Intubation Position patients head at the level of your waistline and in the sniffing position as below -
Head extended(A); Neck flexed (B); Do NOT use this position in patients with suspected cervical spine injury.
Pre-oxygenation
Spontaneously breathing patient Allow 5 mins of spontaneous breathing with a tight-fitting non-rebreather facemask at 15L/min
Unconscious/Semi-conscious patient - Self inflating bag valve resuscitator with reservoir and O2 at 15L/min ventilation - Give 8 vital capacity
breaths (synchronized to patients breaths); Avoid positive pressure ventilation if possible
Paralysis with Induction
C
DO NOT use Succinylcholine in any patient suspected of having hyperkalaemia e.g. Renal Failure
Pass the tube

Limit attempt to < 30 seconds. Proceed down the algorithm after 30 seconds
Proof of Intubation
Successful Not Successful
5 Point Auscultation Epigastrium, Bilateral Axillae, Bilateral Bases
Confirm wave form capnography tracing; maintain CO2 level at 35- 45mmHg
Self-inflating bag valve resuscitator ventilation 1 breath every 5s

Secure tube Resume BVM ventilation - 1 breath every 3 seconds
Check vital signs (BP, PR, RR, SPO2, To C, RBS)
Connect patient to ventilator See 9. Difficult Airway Algorithm
Obtain portable CXR
9. Difficult Airway Algorithm
Successful
Direct Laryngoscopy and Intubation (D.L.)
Failed
Resume BVM ventilation - 1 breath every 3 seconds

CALL Anaesthetist immediately
No
Able to ventilate with BVM?
Yes
Reposition patient to align the airway (sniffing position)

One more D.L. attempt. Limit attempt to < 30seconds
Proof of Intubation
5 Point Auscultation
Epigastrium, Bilateral Axillae,
Successful Failed
Bilateral Bases Insert Laryngeal Mask Airway
Confirm wave form
capnography tracing; maintain
CO2 level at 35- 45mmHg
Able to ventilate with BVM?
No
Surgical
Yes
Cricothyrotomy
Maintain ventilation
Wake up patient
or
Advanced airway techniques e.g.
Consult an Anaesthetist for fibre optic intubation
10. Anaphylaxis Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a
A patient meets the definition of anaphylaxis when any 1 of the following 3 criteria are fulfilled:
1. Acute onset of mucocutaneous signs AND 1 of the following:
respiratory compromise (wheezing-bronchospasm, dyspnoea, stridor, hypoxemia),
hypotension (syncope), or
hypotonia.
2. Rapid onset of 2 of the following after exposure to likely allergen:
mucocutaneous signs,
respiratory compromise,
hypotension, or
persistent gastrointestinal symptoms.
3. Hypotension after exposure to a known allergen.
Patients with suspected anaphylaxis should be observed for at least 6 hours. Patients who are not high-risk should be discharged in the care of
others. Before discharge from the hospital, all patients with anaphylactic reactions must be;
Given clear indications for immediate return to the emergency department (ED).
Considered for treatment with antihistamines and oral steroids for 3 days to decrease the chance of further reaction
11. Acute Asthma Exacerbation Algorithm
Acute Asthmatic Attack
Monitor, support ABCs

Start Oxygen IF SPO2 < 92%. Maintain SPO2 92%; Oxygen should be provided to all patients with severe asthma, even those with normal oxygenation.
Perform brief, targeted history, physical exam (auscultation, use of accessory muscles, PR, RR)
Initiate treatment of underlying cause of exacerbation
Check Peak Expiratory Flow (PEF) as per 12. PEF Chart and record best PEF (%) in patients clinical notes. DO NOT measure PEF in patients
with impending/actual respiratory arrest. Start treatment immediately.
Peak Expiratory Flow < 70 % Impending or Actual Respiratory Arrest

Start nebulisation with Salbutamol + Ipratropium bromide (doses Intubation (RSI with Ketamine if no C/I) and Mechanical Ventilation with
below) every 20 mins or 3 doses for 1 hour. A combination of 4 mL 100% oxygen; CXR
volume fill with NS and 6 to 8L/min oxygen flow rate is recommended. Start nebulisation with Salbutamol + Ipratropium bromide (doses below)
Give Oral (if patient can swallow) or IV systemic corticosteroids (dose every 20 mins or 3 doses for 1 hour. A combination of 4 mL volume fill
below) immediately with NS and 6 to 8L/min oxygen flow rate is recommended.
Give IV Hydrocortisone 2mg/kg (maximum 200mg) immediately
Give high-dose IV Magnesium, 2gm in 5% Dextrose over a 20-min
Repeat assessment after 1 hour (3 doses)
Symptoms, physical exam + BP, PR, RR, SpO2, PEF Call ICU/Physician
PEF 40 69% - Incomplete Response PEF < 40% - Poor Response

Continue nebulisation with Salbutamol + Symptoms severe, drowsiness, confusion
Ipratropium bromide (doses below) every 20 Call ICU/Med; continue treatment below
PEF >70% - Good Response
mins or 3 doses for 1 hour ABG + CXR
Repeat assessment after 1 hour (3 doses) Give high-dose IV Magnesium, 2gm in
No Distress
5% Dextrose over a 20-min
Physical Exam Normal
Continue nebulisation with Salbutamol +
Repeat assessment after 1 hour PEF 40 69% - Incomplete Response
Ipratropium bromide (doses below) every
Continue nebulisation with Salbutamol + 20 mins or 3 doses for 1 hour
Ipratropium bromide (doses below) every 20 mins
Consider Intubation and Mechanical
or 3 doses per hour
PEF >70% - Good Response ventilation
Give high-dose IV Magnesium, 2gm in 5%
No Distress Dextrose over 20-min
Physical Exam Normal ABG + CXR
Response sustained 60minutes Call ICU/Physician
after last treatment
Medication Dose Comments
Inhaled SABA
Salbutamol
Discharge Home Nebulizer solution 5 mg every 20 min for 3 doses, Only selective -agonists are recommended. For optimal delivery, dilute
Continue treatment with inhaled SABA (0.63 mg/3 mL, 1.25mg/3mL, then 2.510 mg every 14 h as aerosols to minimum of 3 mL at gas flow of 68 L/min. Use large-volume
2.5 mg/3 mL, 5.0 mg/mL) needed, or 1015 mg/h nebulizers for continuous administration. May mix with ipratropium nebulizer
2 puffs QID for 3-5 days continuously solution.
Continue course of oral systemic MDI (90g/puff) 48 puffs every 20 min up to 4h, In mild to moderate exacerbations, MDI plus valved holding chamber is as
corticosteroids (See dose in table) then every 14 h as needed effective as nebulized therapy with appropriate administration technique
and coaching by trained personnel.
Review medication including inhaler
Systemic (Injected) 2-Agonists
technique Adrenaline 0.30.5 mg every 20 min for 3 No proven advantage of systemic therapy over aerosol
Consider therapy for underlying cause of 1:1,000 (1 mg/mL) doses SC
exacerbation Anticholinergics
Refer to chest clinic for follow-up Ipratropium bromide
Nebulizer solution 0.5 mg every 20 min for 3 doses, May mix in same nebulizer with salbutamol. Should not be used as first-line
(0.25mg/mL) then as needed therapy; should be added to SABA therapy for severe exacerbations. The
addition of Ipratropium has not been shown to provide further benefit once the
patient is hospitalized.
MDI (18 g/puff) 8 puffs every 20 min as needed Should use with valved holding chamber. Studies have examined Ipratropium
up to 3 h bromide MDI for up to 3 h.
Ipratropium with salbutamol
Nebulizer solution (Each 3-mL 3 mL every 20 min for 3 doses, May be used for up to 3 h in the initial management of severe exacerbations.
vial contains 0.5mg ipratropium then as needed The addition of ipratropium to salbutamol has not been shown to provide further
bromide and 2.5 mg benefit once the patient is hospitalized.
salbutamol.)
MDI (Each puff contains 18g 8 puffs every 20 min as needed Should use with valved holding chamber.
Ipratropium bromide and 90g up to 3 h
salbutamol.)
Systemic Corticosteroids
Prednisone 4080 mg/d in 1 or 2 divided For outpatient burst, use 4060 mg in single or 2 divided doses for a total of
doses until PEF reaches 70% of 510 d.
predicted or personal best
Hydrocortisone 200mg IV then 1mg/kg/dose IV Only if patient cannot tolerate PO corticosteroids
QID
ED = emergency department; ICS = inhaled corticosteroid; MDI = metered-dose inhaler; PEF = peak expiratory flow; SABA = short-acting 2-
adrenergic agonist
Notes: There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous
administration over oral therapy provided gastrointestinal transit time or absorption is not impaired. The total course of systemic corticosteroids for an
asthma exacerbation requiring an ED visit or hospitalization may last from 3 to 10 days. For corticosteroid courses of <1 week, there is no need to taper the
dose. For slightly longer courses (e.g., up to 10 d), there probably is no need to taper, especially if patients are concurrently taking ICSs. ICSs can be
started at any point in the treatment of an asthma exacerbation.
12. Peak Expiratory Flow Chart
How to Measure Peak Expiratory Flows (PEF)

c
DO NOT measure PEF in patients with impending/actual respiratory arrest. Start treatment immediately.
1. Put the pointer on the gauge of the peak flow meter to 0 or

the lowest number on the meter.
2. Attach the mouthpiece to the peak flow meter.
3. While standing, take a deep breath.
4. Put the peak flow meter mouthpiece in your mouth, and close
your lips tightly around the outside of the mouthpiece. Don't
put your tongue inside the mouthpiece.
5. Breathe out as hard and as fast as you can for 1 or 2 seconds.
A hard and fast breath usually produces a "huff" sound.
6. Check the number on the gauge, and write it down.
7. Repeat the above 3 times and take the patients best PEF
8. Plot the best PEF on the normal values chart and calculate
the percentage as below
Measured PEF X 100%

Normal PEF
9. Record the PEF in the patients clinical notes

13. Hypertension Algorithm
BP > 140/90mmHg

Start Oxygen IF SPO2 < 94%. Maintain SPO2 94%
Obtain/review 12-lead ECG
Send blood samples for FBC, UEC, TSH
Urinalysis for proteinuria
Perform brief, targeted history and physical exam
Allow patient to rest awaiting results. Repeat BP checks hourly.
DO NOT administer antihypertensives e.g. nifedipine to lower the blood pressure in the ED unless there are
features of progressive or impending end organ damage below. See 15. Hypertensive Emergencies Algorithm
Are there any features of progressive or impending end

organ damage (especially if BP > 180/110 mmHg)?
a) Neurological
Cerebral vascular accident/cerebral infarction (24.5%)
Hypertensive encephalopathy (16.3%)
Subarachnoid haemorrhage Headache is NOT a hypertensive
Intracranial haemorrhage emergency, no matter how high
b) Cardiovascular the blood pressure. It is likely
Acute pulmonary oedema (22.5%) the headache is causing the
Congestive heart failure (12%) hypertension, not the other way
Myocardial ischemia/infarction around. Treat the headache and
Acute left ventricular dysfunction the pressure will come down.
Aortic dissection
c) Other The same is true of epistaxis.
Acute renal failure/insufficiency
Retinopathy
Pre-eclampsia/Eclampsia
Microangiopathic haemolytic anaemia
No Yes
Known Hypertensive Resume regular treatment; if Consult a Physician (Obstetrician in Eclampsia)

unknown, low dose thiazide type diuretic for most; may See 15. Hypertensive Emergencies Algorithm
consider ACE inhibitor, ARB, -blocker, CCB. Follow-up as
below (See 14. JNC VIII Guidelines)
New Onset Hypertension - Final BP prior to discharge
BP > 160/100 low dose thiazide type diuretic for most;
may consider ACE inhibitor, ARB, -blocker, CCB. (See
14. JNC VIII Guidelines). Follow-up as below
BP < 160/100 Follow-up as below
Daily BP checks at nearest clinic and follow-up

in a Medical Clinic in 1 week with BP chart
14. Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 8) Guidelines
BLOOD PRESSURE MEASUREMENT TECHNIQUES
The electronic device, if available, is preferred because it provides more reproducible results.
At the initial evaluation, BP should be measured in both arms; if the readings are different, the arm with the higher
reading should be used for measurements thereafter.
The BP should be taken after patients have emptied their bladders. Patients should be seated with their backs supported
and with their legs resting on the ground and in the uncrossed position for 5 minutes. The patients arm being used for
the measurement should be at the same level as the heart, with the arm resting comfortably on a table.
It is preferable to take 2 readings, 1 to 2 minutes apart, and use the average of these measurements.
It is useful to also obtain standing blood pressures (usually after 1 minute and again after 3 minutes) to check for
postural effects, particularly in older people.
In general, the diagnosis of hypertension should be confirmed at an additional patient visit, usually 1 to 4 weeks after the
first measurement. On both occasions, the SBP should be 140 mm Hg or the DBP 90 mmHg, or both, in order to
make a diagnosis of hypertension.
It can be helpful to measure BP at home. If available, the electronic device is simpler to use and is probably more
reliable than the sphygmomanometer. The average of BPs measured over 5 to 7 days, if possible in duplicate at each
measurement, can be a useful guide for diagnostic and treatment decisions.
If the BP is very high (for instance, a SBP 180 mm Hg), or if available resources are not adequate to permit a
convenient second visit, the diagnosis and, if appropriate, treatment can be started after the first set of readings that
demonstrate hypertension.
CLASSIFICATION OF BLOOD PRESSURE (BP)

CATEGORY SBP mmHg DPB mmHg
Normal < 120 and < 80
Prehypertension 120-139 or 80-89
Hypertension, Stage 1 140-159 or 90-99
Hypertension, Stage 2 160 or 100
DIAGNOSTIC WORKUP OF HYPERTENSION

Assess risk factors and comorbidities
Reveal identifiable causes of hypertension
Assess presence of target organ damage
Conduct history and physical examination
Obtain/review 12-lead ECG, RBS, FBC, UEC, TSH, Urinalysis for proteinuria, Lipid panel
Calculate the 10-year risk for first atherosclerotic cardiovascular disease events (ASCVD; nonfatal myocardial
infarction, coronary heart diseaserelated death, or fatal or nonfatal stroke) with the 2013 AHA/ACC 2013 Prevention
Guidelines ASCVD Risk Estimator - http://www.cardiosource.org/science-and-quality/practice-guidelines-and-
quality-standards/2013-prevention-guideline-tools.aspx
PRINCIPLES OF LIFESTYLE MODIFICATION

MODIFICATION RECOMMENDATION AVG. SBP REDUCTION RANGE1
2
Weight reduction Maintain normal body weight (BMI 18.5-24.9 kg/m ). 5-20 mmHg/10 kg
Adopt a diet rich in fruits, vegetables, and lowfat dairy
DASH eating plan 8-14 mmHg
products with reduced content of saturated and total fat.
Dietary sodium No added salt. Use a limited amount of salt in cooking.
2-8 mmHg
reduction Dont add salt to your food at the table.
Aerobic physical Regular aerobic physical activity (e.g. brisk walking) at
4-9 mmHg
activity least 30 minutes per day, most days of the week.
Men: limit to 2 drinks* per day.
Moderation of
Women and lighter weight persons: limit to 1 drink* 2-4 mmHg
alcohol consumption
per day
1
Effects are dose and time dependent
* 1 drink = 15 mL ethanol (e.g. 355 mL beer, 148 mL wine, 44 mL 80-proof whiskey).
EVIDENCE-BASED DOSING FOR ANTIHYPERTENSIVE DRUGS
15. Hypertensive Emergencies Algorithm
BP > 160/100mmHg
+
Features of progressive or impending end organ damage
(especially if BP > 180/110 mmHg)?

Establish IV Access and send blood samples for FBC, UEC
Urinalysis for proteinuria
Consult a Physician/ (Obstetrician for Eclampsia) and consider treatments as below in consultation with a Physician/Obstetrician
See 16. Hypertensive Emergencies Drug Infusions for Dosages and Precautions
Neurological emergencies
Preferred medications Medications to avoid

Labetalol Nitroprusside
Nicardipine Hydralazine
Esmolol
Hypertensive encephalopathy - Reduce mean arterial pressure (MAP) 25% over 8 hours.
Acute ischemic stroke - Evidence exists that patients who have acute strokes have better outcomes with higher BPs. Antihypertensive therapy is not
routinely recommended for patients with acute stroke and HTN.
Patient otherwise eligible for acute reperfusion therapy except that BP is >185/110 mm Hg:
- Labetalol 1020 mg IV over 12 minutes, may repeat 1 time
- Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate
If BP is not maintained at or below 185/110 mm Hg, do not administer rtPA
Management of BP during and after rtPA or other acute reperfusion therapy to maintain BP at or below 180/105 mm Hg:
- Monitor BP every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours
- If systolic BP >180230 mm Hg or diastolic BP >105120 mm Hg:
Labetalol 10 mg IV followed by continuous IV infusion 28 mg/min;
If BP not controlled or diastolic BP >140 mm Hg, consider IV sodium nitroprusside
After treatment with fibrinolysis, the SBP should be maintained < 180mmHg and DBP < 105mmHg for 24 hours.
In patients with markedly elevated blood pressure (SBP > 220 mm Hg or DBP > 120 mm Hg) who do not receive fibrinolysis, a reasonable goal
is to lower blood pressure by 15% during the first 24 hours after onset of stroke.
Acute intracerebral haemorrhage - No evidence exists to suggest that HTN provokes further bleeding in patients with ICH. A precipitous fall in SBP
may compromise cerebral perfusion and increase mortality. The controlled lowering of BP with IV labetalol (in the absence of bradycardia) is currently
recommended only when the SBP is >200mmHg or the DBP is >110mmHg. Treatment based on clinical/radiographic evidence of increased intracranial
pressure (ICP).
If signs of increased ICP, maintain MAP just below 130mmHg (or SBP < 180mmHg) for first 24 hours after onset.
Patients without increased ICP, maintain MAP < 110mmHg (or SBP < 160mmHg) for first 24 hours after symptom onset.
Subarachnoid haemorrhage - Maintain SBP < 160mmHg until the aneurysm is treated or cerebral vasospasm occurs. Oral nimodipine is used to
prevent delayed ischemic neurological deficits, but it is NOT indicated for treating acute hypertension.
Cardiovascular emergencies
Aortic dissection Immediately reduce the SBP < 110mmHg and maintain it at this level unless signs of end-organ hypoperfusion are present. Preferred
treatment includes a combination of;
a) narcotic analgesics (morphine sulphate),
b) -blockers (labetalol, esmolol) or calcium channel blockers (verapamil, diltiazem); Avoid -blockers if there is;
aortic valvular regurgitation or
suspected cardiac tamponade.
c) vasodilators (nicardipine, nitroprusside).
Acute coronary syndrome - Treat if SBP >160 mmHg and/or DBP >100 mmHg. Reduce BP by 20-30% of baseline. Thrombolytics are
contraindicated if BP is >185/100 mmHg. Preferred medications include -blockers & Nitroglycerin
Acute heart failure - Treatment with vasodilators (in addition to diuretics) for SBP 140 mmHg. IV or sublingual nitroglycerin is the preferred agent.
Other disorders
Cocaine toxicity/pheochromocytoma - Hypertension and tachycardia from cocaine toxicity rarely require specific treatment.
Benzodiazepines are the preferred agents for cocaine-associated acute coronary syndromes.
Pheochromocytoma treatment guidelines are similar to that of cocaine toxicity. -blockers can be added for BP control only after -blockade.
Preferred medications - Diazepam, Phentolamine, Nitroglycerin/nitroprusside
Medications to avoid - -adrenergic antagonists prior to phentolamine administration
Preeclampsia/eclampsia - In women with eclampsia or preeclampsia, SBP should be < 160 mmHg and DBP <110 mm Hg in the prepartum and
intrapartum periods. If the platelet count is < 100,000 cells/mm3 BP should be maintained below 150/100mmHg. Patients with eclampsia or preeclampsia
should also be treated with IV magnesium sulphate to avoid seizures.
Preferred medications - Hydralazine, Labetalol, Nifedipine
Medications to avoid - Nitroprusside, Angiotensin-converting enzyme inhibitors, Esmolol
16. Hypertensive Emergencies Drug Infusions
AGENT MOA DOSE ONSET/DURATION OF PRECAUTIONS

ACTION (AFTER
DISCONTINUATION)
Parenteral Vasodilators
Nitroglycerin Decreases coronary 5-20 g/min as IV 2-5 min/5-10 min Headache, tachycardia, vomiting,
vasospasm, which infusion flushing, methaemoglobinemia;
increases coronary requires special delivery system
blood flow. Also due to drug binding to plastic
induces vessel tubing
dilatation, decreasing
cardiac workload.
Hydralazine Decreases systemic 5-10 mg as IV bolus 10 min/> 1 hr Tachycardia, headache,

resistance through repeat every 4-6 hr vomiting, aggravation of angina
direct vasodilation of pectoris
arterioles.
Parenteral Adrenergic Inhibitors

Labetalol ,1, 2 Blocker 20 mg IV bolus over 10 5-10 min/15-30 min Bronchoconstriction, heart block,
mins then 1-2mg/min IV orthostatic hypotension
infusion
Esmolol Ultra-short-acting - 500 g/kg bolus 1-5 min/15-30 min First-degree heart block,
adrenergic blocker injection IV or 25-1 00 congestive heart failure, asthma
g/kg/min by infusion.
May repeat bolus after 5
min or increase infusion
rate to 300 g/kg/min
17. SEPSIS Definitions
Diagnostic criteria for sepsis
Infection, documented or suspected, and some of the following:
a) General variables
Fever (> 38.3C)
Hypothermia (core temperature < 36C)
Heart rate > 90/min or more than two SD above the normal value for age
Tachypnoea
Altered mental status
Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
Hyperglycaemia (plasma glucose > 7.7 mmol/L or 140 mg/dL) in the absence of diabetes
b) Inflammatory variables
Leucocytosis (WBC count > 12,000/L)
Leukopenia (WBC count < 4000/L)
Normal WBC count with greater than 10% immature forms
Plasma C-reactive protein more than two SD above the normal value
Plasma procalcitonin more than two SD above the normal value
c) Haemodynamic variables
Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or less than
two SD below normal for age)
d) Organ dysfunction variables
Arterial hypoxemia (PaO2/FiO2 < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
Creatinine increase > 44.2 mol/L or 0.5 mg/dL
Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < 100,000/L)
Hyperbilirubinemia (plasma total bilirubin > 70 mol/L or 4 mg/dL)
e) Tissue perfusion variables
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling
Severe Sepsis
a) Sepsis-induced tissue hypoperfusion (infection-induced hypotension, elevated lactate ( 4 mmol/L), or oliguria)
or
b) Organ dysfunction (any of the following thought to be due to the infection)
Sepsis-induced hypotension (is defined as a SBP < 90 mm Hg or MAP < 70 mm Hg or a SBP decrease > 40 mm Hg
or < 2 SD below normal for age in the absence of other causes of hypotension.
Lactate above upper limits laboratory normal
Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
Acute lung injury with PaO2/FiO2 < 250 in the absence of pneumonia as infection source
Acute lung injury with PaO2/FiO2 < 200 in the presence of pneumonia as infection source
Creatinine > 176.8 mol/L (2.0 mg/dL)
Bilirubin > 34.2 mol/L (2 mg/dL)
Platelet count < 100,000 L
Coagulopathy (international normalized ratio > 1.5)
Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation.
18. Severe Sepsis/Septic Shock Algorithm
Severe Sepsis/Septic Shock

Establish IV Access and send blood samples for FBC, MPS, UEC, ABG, Serum lactate
Start IV Fluids using a pressure infusion bag to achieve a minimum of 30mL/kg NS or RL within 3 hours of identification. More
rapid administration and greater amounts of fluid may be needed in some patients
Obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay (> 45 minutes) in the
start of antimicrobial(s). Draw 2 sets of blood cultures 10mL each (both aerobic and anaerobic bottles) from different sites.
Give antibiotics as an EMERGENCY (within the first hour of recognition of septic shock and severe sepsis without septic shock )
- Ceftriaxone 2gm IV stat
- For probable Neutropenic patients or if patient has been admitted in hospital in the last 3 months (Hospital Acquired Infection)
Imipenem 500 mg IV infusion over 3 hrs then QID for general sepsis
OR
Meropenem 1gm IV infusion over 3 hrs then TDS for possible CNS infections
Give antipyretic if indicated (Paracetamol 1gm IV)
CXR; Urinalysis + MCS
Insert urinary catheter and monitor urine output

Repeat vital signs (BP, MAP, PR, RR, SPO2, To C, Serum lactate)
Features of shock despite adequate fluid resuscitation (> 30ml/kg)?

MAP < 65mmHg
Signs of Shock (tachypnoea, cool clammy skin, cool peripheries, hypotensive, tachycardia)
Urine output < 0.5mL/kg/hour
Yes No
Consult a Physician If;

No current indication for admission
Start peripheral vasopressors if MAP < 65mmHg in the face of life-threatening
Clinically stable with NO SIGNS OF SEVERE
hypotension, even when hypovolemia has not yet been resolved - Norepinephrine SEPSIS OR SEPTIC SHOCK AS ABOVE
(0.11.3 g/kg/min) and/or Adrenaline (0.05-0.3g/kg/min). Titrate vasopressors to Identify source of infection and if amenable to oral
a MAP 65 mmHg to preserve tissue perfusion. All patients requiring vasopressors antibiotic therapy, initiate therapy and consider
discharge with MOPC follow-up
must have an arterial catheter placed as soon as practical resources are available
Hemodynamic stability achieved with adequate fluid resuscitation (> 30ml/kg)

and vasopressor therapy?
MAP < 65mmHg Yes Admit HDU/ICU
Signs of shock as above
Urine output < 0.5mL/kg/hour
No
Give Hydrocortisone 200mg IV bolus
Give dobutamine infusion up to 20 g/kg/min

(+ vasopressor if in use) in the presence of;
Evidence of tissue hypoperfusion persists despite adequate a) myocardial dysfunction as suggested by elevated
intravascular volume and adequate MAP? Yes cardiac filling pressures and low cardiac output, or
Hyperlactatemia (> 1 mmol/L) b) ongoing signs of hypoperfusion, despite achieving
Decreased capillary refill or mottling adequate intravascular volume and adequate MAP
Admit HDU/ICU
No
Admit HDU/ICU
19. Hyperglycaemia Algorithm
Hyperglycaemia (RBS > 14mmol/L)

Check vital signs (BP, PR, RR, SPO2, To C)
Establish IV Access and send blood samples for UEC and a
Venous Blood Gas (VBG)
Immediate Urinalysis for ketones
Ketones in Urine + (pH < 7.3 OR HCO3- < 18mmol/L) RBS > 33.3mmol/L + Serum Osmolality > 320mOsm/kg + pH > 7.3 Normal VBG +
Diabetes Ketoacidosis Hyperosmolar Hyperglycaemic State (HHS) No Ketones in urine +
Serum Osmolality < 320mOsm/kg
Uncomplicated Hyperglycaemia
See 20. Uncomplicated

Hyperglycaemia Algorithm
Identify and Treat precipitating illness; consider ACS, Sepsis
Consult a Physician and continue with the Algorithm
1. Fluid Protocol 2. Potassium Protocol 3. Insulin Protocol

(RL or 0.9% NaCl) No potassium should be given if patient is anuric or DO NOT give insulin until you
serum K+ > 5.3mmol/L have K+ levels
If BP unstable, give fluid boluses
IV Insulin Infusion
at 15 to 20mL/kg; Repeat until BP Serum K+
(mmol/L) Action (Start at 0.14u/kg/hr)
stable. Consider Inotropes if no
response to fluid resuscitation. > 5.3 DO NOT give K+, but check potassium levels - Hourly RBS monitoring
hourly and start replacement when K+ < 5.3 - Target RBS drop 3-4mmol/L/hr
If BP stable; 4.0 to 5.3 Add 10mmol K+/1L fluid/hour to IV fluids - If the RBS does not fall by 3-4
1L stat 3.5 to 4.0 Add 20mmol K+/1L fluid/hour to IV fluids
Hold insulin. Add 40mmol K+/1L fluid/hour.
mmol/L/hr, give a bolus of
1L over 30 mins (2000mls/hr) < 3.5
Continuous cardiac monitoring until K+ > 0.14u/kg per hour IV and
1L over 1 hours (1000mls/hr)
3.3mmol/L continue with the infusion
If CORRECTED serum sodium is
140 mmol/L, use 0.45% NaCl
instead of 0.9% NaCl or RL
DO NOT give > 50 mL/kg of
isotonic solution in the first
4 hours of treatment of diabetic Change IV fluid infusion to 5 % Dextrose
ketoacidosis because of the risk of with 0.45% NaCl at 150-250mL/hr
cerebral oedema. Venous Glucose reaches Decrease insulin to 0.02-0.05uits/kg/hour
Success in fluid therapy is
< 11.1 mmol/L (DKA) Maintain glucose between 8.3 11.1mmol/L
< 16.7 (HHS) (DKA)/ 11.1- 16.7mmol/L (HHS) and
reflected by an improvement in
hemodynamic and hydration status continue insulin infusion and fluid hydration
and pH values, a satisfactory urine until ketosis or hyperosmolality resolves
output of 1 to 2 mL/kg/hour, and
clinical progress. Useful formulas in DKA
Anion gap = Na+ - [(Cl- + HCO3-)]
Serum sodium correction = Na+measured + {(Glucose - 5.5) / 3} (all values in mmol/l).
Serum potassium correction during acidemia = [K+] - (0.6 mmol/L X (7.4 - measured pH) X 10)
Serum osmolality (mOsm/L) = 2 [Na+ + K+](mmol/L) + Glucose (mmol/L) + BUN (mmol/L)
Total body water deficit (L) = 0.6men/children or 0.5women x body weight (kg) X [serum Na+ /140 - 1]
20. Uncomplicated Hyperglycaemia Algorithm
Hyperglycaemia (RBS > 14mmol/L)

Establish IV Access and send blood samples for UEC, and a
Venous Blood Gas (VBG)
Immediate Urinalysis
Perform brief, targeted, history and physical exam
Normal VBG +
No Ketones in urine +
Serum Osmolality < 320mOsm/kg
Uncomplicated Hyperglycaemia
Identify and Treat precipitating illness; consider ACS, Sepsis
Known Diabetic Newly Diagnosed Diabetic
Confirm compliance with medication Lifestyle modification advice

- If not compliant, resume previous regimen Start on Metformin as below
- If compliant, optimize dosages - Begin with low-dose metformin - 500 mg BD with meals
Advice on lifestyle Modification (breakfast and/or dinner).
Review RBS daily at nearest facility and keep record - Review RBS daily at nearest facility and keep record
Review in out-patient medical clinic after 5 days - Review in FMC Clinic after 5 days
Refer to Diabetic clinic if poorly controlled - After 57 days, if GI side effects have not occurred, advance
dose to 850mg or 1gm before breakfast and dinner.
- If GI side effects appear as doses advanced, can decrease to
previous lower dose and try to advance dose at a later time.
- The maximum effective dose is usually 850 mg BD, with
modestly greater effectiveness with doses up to 3 g per day. GI
side effects may limit the dose that can be used.
Refer to Diabetic clinic
21. Hypoglycaemia Algorithm
Hypoglycaemia (RBS < 3.3 mmol/L)

Check vital signs (BP, PR, RR, SPO2, T C)
o
Able to tolerate PO
Yes No
Give 15gm of simple carbohydrate PO

AND/OR
A full complex starchy carbohydrate IV Access No IV Access
meal e.g. rice, ugali, wholemeal)
50mls 50% Dextrose IV Glucagon 1mg SC or IM

As soon as IV access is available,
give 50mls 50% Dextrose IV
Symptoms resolved and RBS > 3.3mmol/L
Yes No
Repeat Algorithm
After 2 rounds of the algorithm, begin continuous infusion
of 5% Dextrose saline at 110mls/hr
Treat underlying cause

Provide patient with a full complex starchy carbohydrate meal
e.g. rice, ugali, wholemeal)
Consider thiamine 100mg IVI for malnourished and alcoholic patients
followed by 100mg PO BD for 6 weeks
Consult a Physician for ALL patients
22. Electrolyte Abnormalities Algorithm

Establish IV Access and send blood samples for FBC, UEC
Hyponatraemia Hypernatraemia Hypokalaemia Hyperkalaemia

(< 130 mmol/L) (> 150 mmol/L) ( < 3 mmol/L) (> 5.5 mmol/l.)
For hypotensive patients, give NS For hypotensive patients, give For hypotensive patients, give For hypotensive patients, give
20 mL/kg bolus and repeat until RL 20 mL/kg bolus and repeat RL 20 mL/kg bolus and repeat NS 20 mL/kg bolus and repeat
vital signs are stable until vital signs are stable until vital signs are stable until vital signs are stable
Consult a Physician for ALL Consult a Physician for ALL Mild-Moderate hypokalaemia Give calcium to protect the heart
Patients Patients (2 -3 mmol/L) (not bind K+) ONLY to patients
Patients who have mild or with;
For patients with neurologic signs, After the patient is stabilized, moderate hypokalaemia may need a widening QRS including a sine
including coma, seizures, and focal change fluids to D5 NS to only oral potassium replacement wave,
neurologic deficits (usually in the provide for maintenance therapy if nausea or vomiting is a cardiac arrest that is believed
100 to 110 mmol/L range), requirements and on-going not the cause of the hypokalaemia. to be due to hyperkalaemia, or
administer 3% saline (513 mmol/L losses. signs of rapidly progressing
of sodium chloride [NaCl]) in order to Giving 40 to 60 mmol of hyperkalaemia in the face of
achieve a minimum serum sodium elemental potassium orally every tumour lysis syndrome, massive
level of 120 mmol/L. Hypertonic 2 to 4 hours for 3 days. haemolysis, or rhabdomyolysis
saline is typically reserved for where a normal ECG has rapidly
patients with an acute disease process Severe hypokalaemia progressed through tall peaked T
rather than chronic hyponatremia. (< 2mmol/l) waves and loss of the P wave.
Hypertonic saline can rapidly increase
serum sodium by 2 to 3 mmol/hr or Give 40 mmol K+ in 1L RL over Give 10mls 10% CaCl2
more depending on the amount 1 hour with continuous ECG (6.8mmol) over 10mins
infused. monitoring. OR
30mls 10% Calcium Gluconate
When rapid correction of the serum Additionally, restoration of (6.6mmol) over 10mins
sodium concentration is needed (those normokalaemia relies on the
seizing, with focal findings, or with establishment of Check baseline RBS.
coma) give 150 mL of 3% normomagnesemia as both K+ and If RBS < 14mmol/L, give 50mls
hypertonic saline over 20 minutes. Mg2+ co-transport in the kidney. 50% dextrose IV bolus
If a second bolus is required, give a Give at least 0.5 grams/hr of Give 10units soluble insulin IV
second 150 mL of the 3% solution magnesium sulphate along with bolus AFTER the dextrose above
over the next 20 minutes. potassium replacement to a or if RBS 14mmol/L
maximum of 2gm
Repeat the above twice or until a The Dextrose-Insulin combination
target of 5 mmol/L increase in serum Consult a Physician for ALL may be repeated if repeat K+ is >
sodium concentration is achieved. Patients 5.5 mmol/L
Do not expect patients with severe Re-check RBS after an hour

symptoms to completely recover
immediately, as it may take some time Nebulise Salbutamol 10 to 20 mg
for the brain to fully recover. in 4 ml of NS over 10 minutes -
25-40% of patients do not respond
secondary to tachyphylaxis.
Serum potassium will be lowered

approximately 10 to 30 minutes
after the above measures are
performed, and the effect will last
for 2 to 6 hours.
Consult a Physician for ALL

Patients
23. Syncope Algorithm
History of Syncope
Consider seizure - tongue biting, head turning during

loss of consciousness, no recollection of abnormal Yes See
behaviour, prolonged limb jerking (lasting minutes), 24. Seizures Algorithm
post-event confusion, and prodromal dj vu.
No
Check RBS If RBS < 3.3 mmol/L See 21. Hypoglycaemia algorithm
12 lead ECG - Look for evidence of ischemia/infarction, dysrhythmias, atrioventricular blocks, Brugada
syndrome (RBBB with J-wave elevation of 2 mm), prolonged QT interval, ventricular pre-excitation,
hypertrophic cardiomyopathy
Check Hb/Hct
Post-menarcheal girls should receive urine pregnancy test.
Laboratory studies should be reserved ONLY for those patients in whom electrolyte abnormalities e.g.
Hypokalaemia, or ingestions are suspected e.g. sedatives
An echocardiogram should be pursued in patients with concerning murmurs on examination or if
syncope occurred during exercise or in conjunction with chest pain.
The San Francisco Syncope Rule (SFSR).

The SFSR uses five factors (CHESS predictors) to predict serious adverse outcomes at 7 or 30 days in
patients presenting to the ED.
1. History of Congestive Heart Failure
2. Hematocrit < 30% (Hb < 10g/dL)
3. ECG abnormality (see above)
4. Shortness of breath history
5. SBP < 90 mm Hg after arrival in the ED
SFSR is associated with a pooled negative predictive value of 97%, sensitivity of 87%, and negative LR
of 0.28. Patients with negative SFSR scores had < 3% risk for serious outcomes.
Does the patient have ANY of the 5 SFSR predictors?

Yes No
Consult a Physician Discharge

24. Seizures Algorithm
History of Seizure
Active seizure OR Post ictal OR Status epilepticus
(> 5 minutes of a continuous seizure, or 2 discrete seizures
Maintain and support ABCs between which there is incomplete recovery of consciousness.
Monitor vital signs (BP, PR, RR, SPO2, To C)
Check RBS Position patient on soft mattress/pillows on trolley in
left lateral position and open the airway with head-tilt
manoeuvre; maintain this position until patient is
awake Do not restrain a seizing patient
Known Epileptic or >1 seizure Maintain and support ABCs
First-time Seizure
Send blood samples for CBC, Send blood samples for CBC, (MPS), Post ictal Still Seizing
(MPS), UEC, HIV, Urine PDT UEC, (Phenytoin/Valproate levels) Or
Recurrent Seizure
If epileptic and non-compliant on
medication load PO with;
phenytoin at 20 mg/kg Set up IV access, Check RBS and give Midazolam 0.1mg/Kg
OR IV/IM.
Na Valproate 20mg/kg if on ARVs Provide O2 by Non-Rebreather mask at 15L/min
Send blood samples for CBC, (MPS), UEC, HIV,
If unable to take orally, give same doses Phenytoin/Valproate levels if known epileptic.
IV as below.
Post ictal Still Seizing

An MRI (or CT scan) should be performed immediately when Or
a provider suspects a serious structural lesion or; Recurrent Seizure
new focal deficits,
persistent altered mental status (with or without intoxication),
fever, Repeat Midazolam 0.1mg/Kg IV after 10 minutes from last dose
recent trauma, Load with phenytoin at 20 mg/kg IV in NS strictly at 50 mg/min
persistent headache, by infusion pump with ECG monitoring.
history of cancer, OR
history of anticoagulation Na Valproate 20mg/kg IV push if on ARVs
suspicion of AIDS.
patients who have completely recovered from their seizure
and for whom no clear-cut cause has been identified (e.g., Post ictal Still Seizing
hypoglycaemia, hyponatremia, tricyclic overdose) Or
Recurrent Seizure
Additionally, for patients with first-time seizure, emergent
MRI/CT should be considered if any of the following is present:
Age > 40 years Consult a Physician and continue with algorithm
Partial-onset seizure Repeat Midazolam 0.1mg/Kg after 10 minutes from last
dose
Additionally, for patients with recurrent seizure (prior history Consider hypoglycaemia, hyponatremia, tricyclic overdose
of seizures) emergent MRI/CT should be considered if any of If still in seizing, additional phenytoin at 5 mg/kg IV in
the following is present: NS strictly at 50 mg/min by infusion pump with ECG
New seizure pattern or new seizure type monitoring until cessation. Repeat again once if
Prolonged postictal confusion or worsening mental status necessary. Obtain phenytoin level 30-60 minutes after
completion of infusion. (Aim for 10mg/L)
Patients with typical recurrent seizures related to previously
treated epilepsy are unlikely to have life-threatening structural
lesions. These patients DO NOT require MRI/CT.
Post ictal Still Seizing
Or
Review with ALL results Recurrent Seizure
Criteria for discharge;
First onset single seizure in a patient < 40 years who has Obtain CT Head and
completely recovered from their seizure and for whom no clear-cut review all the results. Intubate and ventilate
cause has been identified (e.g., hypoglycaemia, hyponatraemia, Consult a Physician patient; keep To C 37oC
tricyclic overdose) and with normal investigations. No follow-up is - Propofol 1mg/kg IV +
necessary unless seizure recurs Rocuronium 1mg/kg
Known epileptic who has completely recovered from their seizure Start infusion of midazolam
and for whom a clear-cut cause has been identified (e.g. non- 0.1mg/kg/hour IV
compliance, sub-therapeutic drug levels) and with normal Obtain CT Head and review
investigations. Patient should be loaded with anticonvulsants if non- all the results.
therapeutic prior to discharge and adequate follow-up arranged. Admit ICU
Consult a Physician on ALL other patients
25. Transient Ischemic Attack (TIA) Algorithm
The AHA/ASA has endorsed the current definition of TIA as a transient episode of neurological dysfunction caused by focal
brain, spinal cord, or retinal ischemia, without acute infarction. The new definition of TIA completely eliminates the element of
time and emphasizes neuroimaging instead.
Mimics
Stroke Delirium
Hypoglycaemia / hyperglycemia Recrudescence of old stroke
Seizure with Todd paralysis Syncope (of any aetiology)
Complicated migraine Metabolic disarray (hyponatremia,
Structural brain lesion (tumour, hypokalaemia, etc.)
haemorrhage, aneurysm) Peripheral nervous system lesion
Demyelinating disease (multiple sclerosis) (radiculopathy, neuropathy, plexopathy)
Central nervous system infection Psychogenic (conversion disorder,
(encephalitis, cerebritis, abscess) somatization)
Acute vestibular syndrome (labyrinthine
disorders
Is ABCD3 < 4
See
26. Stroke Algorithm
Consult a
Physician
See Consult a
The ABCD3 Score 26. Stroke Algorithm Physician
Predictor Points
Age > 60 y 1
Blood pressure > 140/90 mm Hg 1
Clinical features (maximum 2) 2
Unilateral weakness (2)
Speech difficulty without weakness (1)
Duration (maximum 2) 2
> 60 min (2)
10-59 min (1)
< 10 min (0) Abbreviations: CT, computed tomography; DWI, diffusion-weighted imaging; ECG, electrocardiogram; ED,
Diabetes 1 emergency department; IV, intravenous; MRI, magnetic resonance imaging; TIA, transient ischemic attack.
Dual TIA (TIA prompting medical
attention plus at least one other TIA in the 2
preceding 7 days.)
Maximum total score 9
26. Stroke Algorithm
Identify signs of possible acute stroke

Patient to be seen by the doctor within 10 minutes of arrival
Monitor, support ABCs in the Resuscitation Room (ER)

Check vital signs (BP, PR, RR, SPO2, To C).
Start Oxygen IF SPO2 94%. Maintain SPO2 > 94%
Check Glucose and treat if < 3.3mmol/L with 50mL 50% Dextrose bolus. Maintain blood
glucose between 7.7- 10mmol/L
Establish 14-16G IV Access and send blood samples for FBC, UEC, coagulation screen
Perform brief, targeted history, physical exam; perform neurologic screening assessment
Indicate time when patient last known normal
National Institutes of Health Stroke Scale (NIHSS)

1a. Level of consciousness 0 = Alert; keenly responsive 6. Motor leg 0 = No drift
1 = Not alert, but arousable by minor stimulation 6a. Left leg 1 = Drift
2 = Not alert; requires repeated stimulation 6b. Right leg 2 = Some effort against gravity
3 = Unresponsive or responds only with reflex 3 = No effort against gravity; limb falls
4 = No movement
1b. Level of consciousness questions: 0 = Both answers correct 7. Limb ataxia 0 = Absent
What is the month? 1 = Answers one question correctly 1 = Present in one limb
What is your age? 2 = Answers both questions incorrectly 2 = Present in two limbs
1c. Level of consciousness commands: 0 = Performs both tasks correctly 8. Sensory 0 = Normal; no sensory loss
1 = Performs one task correctly 1 = Mild-to-moderate sensory loss
2 = Performs neither task correctly 2 = Severe to total sensory loss
2. Best gaze 0 = Normal 9. Best language 0 = No aphasia; normal
1 = Partial gaze palsy 1 = Mild to moderate aphasia
2 = Forced deviation 2 = Severe aphasia
3 = Mute, global aphasia
3. Visual 0 = No visual loss 10. Dysarthria 0 = Normal
1 = Partial hemianopia 1 = Mild to moderate dysarthria
2 = Complete hemianopia 2 = Severe dysarthria
3 = Bilateral hemianopia
4. Facial palsy 0 = Normal symmetric movements 11. Extinction and 0 = No abnormality
1 = Minor paralysis inattention 1 = Visual, tactile, auditory, spatial, or
2 = Partial paralysis personal inattention
3 = Complete paralysis of one or both sides 2 = Profound hemi-inattention or extinction
5. Motor arm 0 = No drift
5a. Left arm 1 = Drift
5b. Right arm 2 = Some effort against gravity Total Score = 0 - 42
3 = No effort against gravity; limb falls
4 = No movement
Obtain brain MRI/CT scan

Haemorrhage
Time from onset of symptoms < 4.5 hours? No Consult a Neurosurgeon
No Haemorrhage
Give 300mg Aspirin
Yes Admit Stroke Unit
Obtain immediate non-contrast enhanced brain CT scan within 25 minutes of patient arrival.
The ER doctor MUST accompany the patient to CT to get the CT report immediately
Does CT scan show any haemorrhage?

CT should be interpreted within 45 minutes of patient arrival
No Haemorrhage Haemorrhage
Consult a Neurologist Consult a Neurosurgeon

See 27. Stroke Reperfusion Algorithm
27. Stroke Reperfusion Algorithm
Probable acute ischaemic stroke
Begin stroke pathway
Review/Complete Fibrinolysis Checklist

Inclusion and Exclusion Characteristics of Patients With Ischemic Stroke Who Additional Inclusion and Exclusion Characteristics of Patients
Could Be Treated With IV rtPA Within 3 Hours From Symptom Onset with Acute Ischemic Stroke Who Could Be Treated With IV
rTPA within 3 to 4.5 Hours From Symptom Onset
Inclusion criteria
Diagnosis of ischemic stroke causing measurable neurological deficit Main inclusion criteria
Onset of symptoms < 3 hours before beginning treatment Diagnosis of ischemic stroke causing measureable neurologic deficit
Aged 18 years Onset of symptoms within 3 to 4.5 hours before beginning treatment
Exclusion criteria
Exclusion criteria Age > 80 years
Significant head trauma or prior stroke in previous 3 months Baseline NIHSS score >25
Symptoms suggest subarachnoid haemorrhage Taking oral anticoagulant regardless of INR
Arterial puncture at non-compressible site in previous 7 days History of both diabetes and prior ischemic stroke
History of previous intracranial haemorrhage Those with imaging evidence of ischemic injury involving more than one
Intracranial neoplasm, arteriovenous malformation, or aneurysm third of the middle cerebral artery territory,
Recent intracranial or intraspinal surgery
Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
NOTES
Active internal bleeding
A physician with expertise in acute stroke care may modify this list.
Acute bleeding diathesis, including but not limited to
- Platelet count <100 000/mm3 Onset time is defined as either the witnessed onset of symptoms or
- Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than
the time last known normal if symptom onset was not witnessed.
the upper limit of normal
- Current use of anticoagulant with INR >1.7 or PT >15 seconds In patients without recent use of oral anticoagulants or heparin,
Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated
treatment with IV rtPA can be initiated before availability of
sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate
factor Xa activity assays) coagulation test results but should be discontinued if INR is >1.7 or
Blood glucose concentration < 50 mg/dL (2.7 mmol/L) PT is abnormally elevated by local laboratory standards.
CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
In patients without history of thrombocytopenia, treatment with IV
Relative exclusion criteria
Recent experience suggests that under some circumstanceswith careful consideration and rtPA can be initiated before availability of platelet count but should
weighting of risk to benefitpatients may receive fibrinolytic therapy despite 1 or more be discontinued if platelet count is <100 000/mm3.
relative contraindications. Consider risk to benefit of IV rtPA administration carefully if any
of these relative contraindications are present:
Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Pregnancy
Seizure at onset with postictal residual neurological impairments - Intravenous rtPA is
reasonable in patients with a seizure at the time of onset of stroke if evidence suggests that
residual impairments are secondary to stroke and not a postictal phenomenon
Major surgery or serious trauma within previous 14 days
Recent gastrointestinal or urinary tract haemorrhage (within previous 21 days)
Recent acute myocardial infarction (within previous 3 months)
Repeat neurologic exam: are deficits rapidly improving to normal?

Patient remains candidate for fibrinolytic therapy?
Candidate Not a Candidate
Review risks/benefits with patient and family. If acceptable, Administer aspirin 325mg PO/PR
obtain consent for fibrinolysis In patients already taking statins,
Ensure patient is attached to monitor (ECG, SPO2, BP) and repeat continue treatment
baseline vitals. Treat BP if indicated
(See 15. Hypertensive Emergencies Algorithm)
Set up second IV line for the fibrinolysis. Run NS/RL TKVO in Admit to stroke unit
other line
Monitor blood glucose and temperature and treat if
ALTEPLASE (give within 60 minutes of patient arrival) indicated. Maintain blood glucose between 7.7mmol/L
The recommended dose of alteplase is 0.9 mg/kg (maximum, and 10mmol/L
90 mg) infused over 60 minutes, with 10% of the total dose
Initiate supportive therapy; treat co morbidities
administered as an initial IV bolus over 1 minute.
Measure blood pressure and perform neurological assessments
every 15 minutes during and after IV rtPA infusion for 2 hours,
then every 30 minutes for 6 hours, then hourly until 24 hours
after IV rtPA treatment.
28. Trauma Management Pathway
SAMPLE HISTORY
Signs and Symptoms
Allergies
Medication
Past Medical History/Pregnancy
Last meal
Events preceding presentation
Primary Survey (ABCDE)

C-Spine Cleared Clinically (See 29. C-Spine Clearance Algorithm)? In-line stabilization then C-Collar applied with Head Blocks
Airway Open? Maintainable? Intubate?
Breathing Rate? SPO2? Air Entry Bilaterally? Pneumothorax? Haemothorax? Flail Chest? Open sucking chest wound?
Circulation Active Bleeding Control? BP? Pulse? CPR? Signs of Shock?
Disability GCS? Pupils? RBS?
Expose patient
Resuscitation (ABCDE)
CONSULT A SURGEON IMMEDIATELY AS YOU BEGIN RESUSCITATION OF ANY POLYTRAUMA PATIENT WITH:
- Hypotension
- GCS < 15
C - C-Collar with Head Blocks?
A - Rapid Sequence Intubation?
B
- Supplementary Oxygenation? Non-Rebreather mask
- Needle Decompression for Tension Pneumothorax with subsequent Intercostal Chest Drain Insertion?
- Emergency Intercostal Chest Drain for Massive Haemothorax
- Seal three sides of an open sucking chest wound with impermeable material?
C
- Control Active Bleeding including;
- Apply a Pelvic wrap to an open book pelvic fracture
- Apply a traction splint for Femur fractures
- Insert 2 large bore IV lines and give appropriate fluid resuscitation (NS/RL/whole blood). Adult trauma patients with, or at risk of,
significant bleeding should be given Tranexamic acid loading dose 1 g over 10 min then infusion of 1 g over 8 h.
- GXM and request adequate supplementary blood
D
- Correct Hypoglycaemia 50mls 50% Dextrose IV
- Give appropriate analgesia e.g. Fentanyl 50 - 100g IV (See 37. Analgesia Chart)
E Check temperature and provide warmth to the patient
Secondary Survey (Head-to-Toe Survey)

CNS Lacerations? Fractures? Signs of Base of Skull Fractures Racoon Eyes, Battle Sign, Otorrhoea, Rhinorrhoea? Focal Neurology?
Chest Lacerations? Rib Fractures?
Abdomen Lacerations? Distension? Tenderness? FAST?
Limbs Lacerations? Fractures? Distal Pulses and Neurology?
Log roll patient Lacerations? Spine tenderness?
Do not forget to give Tetanus Toxoid if there are any open wounds.
Radiological Investigations
EFAST ONLY for;
- Penetrating chest trauma Pneumothorax? Haemothorax? Pericardial Effusion?
- Unstable blunt chest and abdominal trauma Haemothorax? Haemoperitoneum?
- Unexplained hypotension - ? Free fluid in pleural, pericardial or peritoneal cavity
CT-Abdomen For the hemodynamically stable patient with suspected blunt abdominal trauma
CT Head ONLY for;
- GCS < 14
- GCS 14 See 30. Mild Traumatic Brain Injury Algorithm
- Skull fractures including Base of Skull Fractures (NO SKULL X-Rays)
C-Spine X-rays (AP, Lateral AND Open Mouth) See 29. C-Spine Clearance Algorithm. If doing a CT head, do CT Spine instead of
C-spine X-rays if indicated. C-spine is NOT cleared on X-rays/CT but on resolution of patient symptoms
CXR ONLY for patients with symptomatic chest trauma - Pneumothorax? Haemothorax? Lung Contusion? Widened Mediastinum?
Rib fractures? Follow-up with CT-Chest plus angiogram for Lung Contusion? Widened Mediastinum?
Pelvic X-ray ONLY for patients with;
- lower abdominal pain,
- lower back pain,
- Femur fractures
- Clinically tender pelvis
- Patients unable to mobilize
Where a reliable clinical assessment is not possible ALL the investigations should be done.
29. C-Spine Clearance Algorithm
For Alert (Glasgow Coma Scale Score = 15) and Stable Trauma Patients
Where Cervical Spine (C-Spine) Injury is a Concern
Perform in-line immobilization of the C-Spine

Maintain and support ABCs
Age 65 Years
Glasgow Coma Scale score of 14 or less
Decreased alertness secondary to intoxication
Disorientation to person, place, time, or events Yes

Inability to remember 3 objects at 5 minutes
Delayed or inappropriate response to external Perform complete C-spine immobilization with the patient
stimuli flat on a trolley with a cervical collar and head blocks
Keep patient immobilized as above UNTIL patient is
Any focal deficit on motor or sensory examination reviewed and C-spine is cleared by the ED doctor /
or paraesthesia in extremities Orthopaedic surgeon
Order ALL 3 views C-spine x-rays;
No
- a cross-table lateral view - must be of good quality and
adequately visualize the base of the occiput to the upper
Midline Neck Pain part of T1.
Midline C-spine Tenderness (C1 T1) Yes
- an anteroposterior view - must reveal the spinous
Provide immediate adequate analgesia processes of C2 to C7.
- an open-mouth view to visualize the odontoid process of
No
C1. Must visualize the entire dens and the lateral masses
of C1.
Able to Actively Rotate Neck Obtain CT C-spine IF;
45o Left and Right Without Pain? - patient is to receive an immediate CT head. No c-spine x-
The doctor should allow the patient to Unable rays are required initially
perform the above movement while - x-rays are inadequate
maintaining in-line immobilization - patient has persistent symptoms despite analgesia and
without moving the patients neck negative x-rays
Able - pathology is noted on c-spine x-rays
No Radiography necessary
Document clearly in patients clinical notes
successful completion of all the above steps
Review x-rays and/or CT C-spine images and the patient

Symptoms Yes (DO NOT comment on inadequate images)
persist?
C-Spine Cleared on Radiology?
No
Consult an Orthopaedic Surgeon

Remove No Yes
Maintain immobilization with the patient flat on a
Immobilization devices
trolley with a cervical collar and head blocks
30. Mild Traumatic Brain Injury Algorithm
See 28. Trauma Management Pathway
Adult in ED with GCS 14 or 15
Yes No
Loss of consciousness or post traumatic amnesia
Assess for; Assess for;

GCS < 15 Severe Headache
Focal neurological deficit Age 65 years
Coagulopathy, bleeding disorder, or on anticoagulant or Physical signs of basilar skull fractures
anti-platelet agent (haemotympanum, panda eyes, cerebrospinal fluid
Age > 60 years leakage from the ear or nose, Battles sign).
Vomiting (any) Dangerous mechanism of injury:
Headache - Ejection from a motor vehicle
Drug or alcohol intoxication - Pedestrian struck
Seizure - Fall from a height of > 0.9m or 5 steps
Anterograde amnesia/short-term memory deficits Coagulopathy, bleeding disorder, or on anticoagulant
Physical evidence of trauma above clavicles (abrasions, or anti-platelet agent except aspirin
contusions, ecchymosis)
Consider 6 hour observation if the only

criterion present for CT is intoxication
Discharge as below No Assessment positive Yes Consider 6 hour observation if only criterion
is history of GCS score of 14 that returned to
normal within 2 hours of trauma
Worsening or
No Resolution of Symptoms Resolution of Symptoms
Obtain non-contrast head CT scan
Yes CT Positive No
Is patient on Consult a Is patient on

anticoagulant or No Neurosurgeon and anticoagulant or No Discharge
anti-platelet agent assess for admission anti-platelet agent as below
Yes Yes
If symptomatic or INR > 3, admit for

Patient on anti-platelet agent: 24 h observation
Patient on anticoagulant:
If asymptomatic after 6 h ED
Administer FFP or Prothrombin Consult a Neurosurgeon
observation and INR < 3, discharge
Complex Concentrate Consider desmopressin
with reliable adult
Consult a Neurosurgeon
Close follow-up in out-patient clinic
Administer 10mg vitamin K IV
Return for repeat CT if new or
worsening symptoms
Discharge
A CT interpreted as normal by the Radiologist in a neurologically intact person with a normal mental status allows for safe
discharge with appropriate instructions and avoids prolonged ER observation or hospital admission. Written and verbal discharge
instructions must be provided and should include symptoms to expect after a mild TBI, the time course, the overall positive
prognosis, activity limitations, and the point at which a patient return to the ED for further testing.
31. Epistaxis Algorithm
Have the patient squeeze the distal alae while sitting up, bent forward at the waist over a vomit bucket, and expectorating blood for 15mins. USE A
WATCH!! Ask the patient NOT to swallow any blood. A clamping device constructed of four tongue blades secured together by 1-inch tape over the
distal alae can be used to clamp the nose closed.
Nasal trauma from nose picking/blowing is the most common cause of epistaxis.
Hypertension DOES NOT cause epistaxis but may prolong it. Therapy should focus on control of the haemorrhage rather than reduction of the blood
pressure. DO NOT prescribe anti-hypertensive therapy for epistaxis.
DO NOT order lab investigations routinely; in selected patients such as those taking warfarin or with hepatic or renal dysfunction, FBC, UEC &/or
LFTs and coagulation studies are warranted. For patients with severe or recurrent haemorrhage with a lot of clots, throwing up blood, or with unstable
vital signs or underlying medical conditions, a FBC should be performed, as well as a type and screen.
Bleeding controlled
Yes No
Repeat vital signs (BP, PR, RR, SPO2, T C)

o
Insert a 15-cm piece of cotton pledget soaked in injectable
Remove any cotton pledgets and observe the patient for form of tranexamic acid (500 mg in 5 mL) in the nostril
bleeding for at least an hour after control. Encourage the of the bleeding side for 10 mins. USE A WATCH!!
patient to walk or perform other activities that he or she will
need to resume when returning home.
Patients with underlying medication use (aspirin, NSAIDS, Yes Bleeding controlled
warfarin) or renal or hepatic dysfunction- consult an ENT
Surgeon/Physician No
If cause identified to be from nasal picking/blowing with no Insert a 15-cm piece of cotton pledget soaked in
underlying medication use (aspirin, NSAIDS, warfarin) or adrenaline (1 mg in 5 mL) in the nostril of the
renal or hepatic dysfunction, discharge patient (with ENT
bleeding side for 10 mins. USE A WATCH!!
follow-up if recurrent).
Follow-up instructions - Vaseline or a similar moisturizing
agent should be applied liberally in the nose TID for 7-10 Yes
Bleeding controlled
days to promote healing of friable mucosa and superficial
vessels. No
Pack the nostril of the bleeding side using a nasal tampon
or a bacitracin ointment soaked gauze.
* The tampon should be coated with bacitracin ointment or
KY-Jelly to facilitate placement.
Yes
Bleeding controlled
No
Repeat vital signs (BP, PR, RR, SPO2, T C)
o
Pack the contralateral naris using a nasal tampon or a bacitracin
Monitor, support ABCs ointment soaked gauze to provide a counterforce to promote tamponade.
Establish IV access and order FBC, UEC &/or
LFTs, coagulation studies and a type and screen if
warranted Yes
Bleeding controlled
If cause identified to be from nasal picking/blowing
with no underlying medication use (aspirin, No
NSAIDS, warfarin) or renal or hepatic dysfunction, Do NOT remove the contralateral nasal pack.
consult an ENT Surgeon. Insert a lubricated foley catheter (size 12 or 14 F) until the tip and balloons are
Patients with underlying medication use (aspirin, entirely in the nasopharynx. Fill the balloon with sterile saline (usually 5-10cc)
NSAIDS, warfarin) or renal or hepatic dysfunction to allow it to be pulled snugly against the posterior nasal choana with anterior
- consult a Physician & an ENT Surgeon traction. The Foley is secured by placing an umbilical or c-clamp on the catheter
at the level of the nasal ala with padding in between to prevent pressure injury.
Yes
Bleeding controlled
No
While the foley is still in-situ, pack the nostril of the bleeding side using a
nasal tampon or a bacitracin ointment soaked gauze.
* The tampon should be coated with bacitracin ointment or KY-Jelly to
facilitate placement.
32. Low Back Pain Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional
judgment and may be changed depending upon a patients individual needs. Failure to
comply with this pathway does not represent a breach of the standard of care.
Adult with low back pain (LBP)

Monitor and support ABCs
Provide immediate analgesia
Perform a focused history and physical examination, evaluating;

Duration of symptoms
Risk factors for potentially serious conditions (tumour, infection, cauda equina
syndrome, ankylosing spondylitis or vertebral compression fracture).
Symptoms suggesting radiculopathy or spinal stenosis
Presence and level of neurologic involvement - All patients should be evaluated for
the presence of rapidly progressive or severe neurologic deficits, including motor
deficits at more than 1 level, faecal incontinence, and bladder dysfunction.
Psychosocial risk factors
Any potentially serious conditions strongly suspected? (see table)

The possibility of low back pain due to problems outside the back,
such as Ectopic pregnancy, Pancreatitis, Nephrolithiasis, or
Aortic Aneurysm, or Systemic illnesses, such as endocarditis or
viral syndromes, should be considered.
No Yes
Perform diagnostic studies to identify cause (see table)

DO NOT routinely obtain imaging or other diagnostic tests in
patients with nonspecific low back pain. Early, routine imaging
and other tests usually cannot identify a precise cause, do not
improve patient outcomes, and incur additional expenses.
Yes Consult an Orthopaedic Surgeon

Specific cause identified
No
Advice about self-care;
Back pain is mild with no substantial functional impairment - Advice to remain active
Inform all patients of the generally favourable prognosis of acute Yes - Application of superficial heat
low back pain with or without sciatica, including a high likelihood Review indications for reassessment
- Risk factors for potentially serious conditions as above
for substantial improvement in the first month
Discharge with Analgesia and for Physiotherapy.
No Reassess in 4 weeks in Orthopaedic Clinic if necessary
Advice about self-care;

- Advice to remain active
- Application of superficial heat
Discuss non-invasive treatment options;
- Pharmacologic;
* 1st line - Paracetamol and/or NSAIDs
* 2nd line Tramadol for severe, disabling pain that is not controlled
(or is unlikely to be controlled) with acetaminophen and NSAIDs.
- Non-pharmacologic Physiotherapy
Arrive at shared decision regarding therapy trial

Educate patient
No Refer to Orthopaedic Clinic

Patient accepts risks and benefits of therapy
Yes
Continue self-care and non-invasive options (analgesia and physiotherapy)

Discharge and reassess in 4 weeks in Orthopaedic Clinic if necessary
33. Epigastric Pain Algorithm
Adult with Epigastric Pain

Monitor and support ABCs
Provide immediate analgesia See 37. Analgesia Chart

Obtain/review 12-lead ECG if elderly, diabetic or hypertensive
Perform a focused history and physical examination, evaluating;

Duration of symptoms
Risk factors for potentially serious conditions ACS, Pancreatitis, DKA,
Cholecystitis, Perforate Ulcer, Pre-eclampsia/Eclampsia, HELLP
Indications for Stool H. pylori Antigen testing

Send blood samples for FBC, UEC, Lipase.
Active peptic ulcer disease (gastric or
Additional testing as indicated; duodenal ulcer)
- hsTroponin T - ? ACS (elderly, diabetics, hypertensives) Confirmed history of peptic ulcer disease (not
- LFTs - ? Cholecystitis, Pre-eclampsia/Eclampsia, HELLP previously treated for H. pylori)
- CXR - ? Perforated ulcer, Pancreatitis, Pneumonia Gastric MALT lymphoma (low grade)
- VBG Hyperglycaemic patients, Pancreatitis After endoscopic resection of early gastric
- PDT - ? Ectopic pregnancy cancer
Uninvestigated dyspepsia < 55 yr and with no
alarm features (bleeding, anemia, early
satiety, unexplained weight loss, progressive
Probable Dyspepsia
dysphagia, odynophagia, recurrent vomiting,
Other Causes of Epigastric Pain Stool H. Pylori Antigen Test family history of GI cancer, previous
Treat accordingly (see indications) oesophagogastric malignancy).
PPI IV stat
H. Pylori Positive H. Pylori Negative

Symptomatic Treatment Symptomatic Treatment
- Antacid Gel 20-60mins after meals and at bedtime or PRN (for symptom control) - Antacid Gel 20-60mins after meals and at
- Paracetamol (stop ALL NSAID use) bedtime or PRN (for symptom control)
- Dietary advice - Paracetamol (stop ALL NSAID use)
- Dietary advice
PLUS
PLUS
Eradication Therapy
Acid Suppression Therapy
Drug Dosing Duration (d) Eradication Rates - PPI standard dose x 4 weeks
PPI, Standard dose BID, 10-14 70-85%
Consider OGD (see indications below)
Clarithromycin, 500 mg BID,
Amoxicillin 1000 mg BID
PPI, Standard dose BID, 10-14 70-85%
Clarithromycin, 500 mg BID,
Metronidazole 500 mg BID
Consider OGD (see indications below)
Indications for Oesophagogastroduodenoscopy (OGD)

age > 55 yr persistent vomiting,
bleeding, a family history of gastrointestinal cancer,
anaemia, previous oesophagogastric malignancy,
early satiety, previous documented peptic ulcer,
unexplained weight loss (>10% body weight), lymphadenopathy,
progressive dysphagia, an abdominal mass
odynophagia,
34. Upper Gastrointestinal Bleeding Algorithm
Upper Gastrointestinal Bleeding can vary in presentation, but most cases present in one or more of four ways as follows:
a) Melena (69%): the passage of dark and pitchy stools stained with blood pigments or with altered blood. Melena is caused by the passage of at
least 50 mL of blood in the upper GI tract. Bacteria degrade the blood into haematin or other haemachromes. Melena should not be confused
with the dark stools that result from ingestion of iron or bismuth.
b) Haematemesis (30%): the vomiting of bright red blood and indicates an upper GI site of bleeding, usually above the ligament of Treitz.
c) Coffee-ground emesis (28%): emesis consisting of dark, altered blood mixed with stomach contents
d) Haematochezia (15%): the passage of bloody faeces
SHOCKED (HYPOTENSIVE) NOT SHOCKED

Monitor, support ABCs in ER Monitor, support ABCs in ER
Check vital signs (BP, PR, RR, SPO2, To C, RBS) Check vital signs (BP, PR, RR, SPO2, To C, RBS)
Start Oxygen IF SPO2 < 94%. Maintain SPO2 94%; Intubate patient if Start Oxygen IF SPO2 < 94%. Maintain SPO2 94%; Intubate patient
airway is at risk from massive haematemesis or depressed level of if airway is at risk from massive haematemesis
consciousness Establish a large bore IV access (14-16G).
Establish 2 large bore IV accesses (14-16G). Start IV Fluids TKVO Ringers Lactate (RL)/Hartmanns soln. Start
Give rapid fluid boluses at 20mL/Kg Ringers Lactate (RL)/Hartmanns blood transfusions ONLY if Hb < 7 g/dL
soln; repeat if necessary. Start blood transfusions ONLY if Hb < 7 g/dL Obtain a 12-lead ECG
Obtain a 12-lead ECG Send blood samples for FBC, UEC, LFTs, ABG, Coagulation screen,
Send blood samples for FBC, UEC, LFTs, ABG, Coagulation screen. Blood type & screen.
Cross-match 6 units of packed cells. Perform brief, targeted history, physical exam including a rectal exam
Perform brief, targeted history, physical exam including a rectal exam
Insert NGT ONLY if intubated or has recurrent vomiting uncontrolled by
anti-emetics
Monitor vital signs every 15 min until stable, then hourly.

Correct hypotension with repeat fluid boluses/blood transfusion
Monitor urine output - Aim for > 0.5mL/Kg/h
Consult Gastroenterologist Yes

History of Varices or Decompensated Cirrhosis
Admit HDU/ICU
No
Give IV omeprazole/pantoprazole 80-mg bolus followed by 8 mg/hr for 72 hrs

Consult Gastroenterologist
Admit HDU/ICU
35. Management of Pain in Sickle Cell Disease
(SCD) Algorithm
This clinical pathway is intended to
Patient presents with acute pain supplement, rather than substitute for,
professional judgment and may be
changed depending upon a patients
Monitor and support ABCs individual needs. Failure to comply
Check vital signs (BP, PR, RR, SPO2, ToC, RBS). with this pathway does not represent a
Start Oxygen IF SPO2 < 92% or if patient is dyspnoeic. Maintain SPO2 92% breach of the standard of care.
Determine probable cause and precipitating factors for pain e.g. infection
Establish IV Access and send blood samples as below.
No
Related to SCD Perform appropriate work-up
Yes
Start D5 normal saline (NS)* at a maintenance rate unless the patient is

overtly hypovolemic (sepsis, diarrheal illness, vomiting) in which case resuscitate
appropriately.
*In vitro and in vivo studies have shown that lowering of serum osmolality with
hypotonic fluid can reduce erythrocyte sickling. Over-hydration especially
with isotonic crystalloid does not cure crisis and may have detrimental effects.
Administer IV dose of opiate

No
Currently on chronic opiate therapy? Tramadol IV/SC - 50-100mg over 3-5mins. Max 400mg/d
Fentanyl IV - 0.5 3 g/kg over 3-5mins
Yes
Assess degree of relief every 15-30 mins
Administer IV equivalent of home oral opiate dose

No
Administer IV paracetamol 15mg/kg and antihistamine Drop in pain score of 2
(diphenhydramine, hydroxyzine)
Assess degree of relief every 15-30
Repeat IV opiate at the initial dose No Yes

Drop in pain score of 2
DO NOT exceed the maximum dose
Yes
Assess degree of relief every 15-30 mins
Yes
Drop in pain score of 2 Moderate pain
No
Manage cause/precipitating factor
Consult a Physician/Haematologist Disposition with short opiate
prescription with haematology follow-up
Investigations:
Full Blood Count (FBC);
Most patients with HbSS disease have a baseline haemoglobin level of 6 to 9 g/dL and tolerate this level of anaemia well because of physiologic
adaptations.
WBC is NOT a particularly sensitive nor specific indicator for infection
Reticulocyte count - normally elevated (>5%). Levels < 5% are a serious cause for concern as it signifies bone marrow hypoactivity.
In patients with worsened scleral icterus, back pain, fever, or signs that suggest haemolysis, additional tests would include; LFTs and LDH
Renal function tests
Blood typing and screening is necessary if haemoglobin has dropped > 1 mg/dL below baseline or if there is concern that the patient may need a
transfusion. Indications for blood transfusion; Severe anaemia - Hb > 2g/dL below steady state or < 6g/dL; Acute chest syndrome; Priapism; CVA in
children; Before surgery
36. Pain Management Algorithm
ADULT WITH ACUTE SOMATIC PAIN
EVALUATE: Focused history, detailed pain assessment

Assign SEVERITY SCORE (1-10)
MILD PAIN (1-3/10) MODERATE PAIN (4-6/10) SEVERE PAIN (7-10/10)
PO Paracetamol or NSAID As for mild Pain As for mild Pain

+ + +
Adjuvant interventions Weak opioids Strong opioids
(Non-Pharmacologic) e.g. PO tramadol, codeine, hydrocodeine e.g. morphine, fentanyl

non-opioid analgesics
Investigate and treat the cause of pain.
Reassess pain within 60 minutes to ensure relief, and monitor patient appropriately, and document.
Repeat analgesic, titrate to a higher dose, initiate a more potent analgesic or combine analgesics with
different mechanisms of action as is appropriate to relieve pain
Treat the cause of pain as OP/IP, and consult/refer appropriately
Beware of contraindications, allergies, toxicity, interactions with other meds etc. Pethidine
(meperidine) has an active metabolite (nor-meperidine) that causes neuro excitation (apprehension,
tremors, delirium, and seizures) and may interact with antidepressants (contraindicated with MOI and
best avoided with SSRIs), so it is NOT RECOMMENDED for repetitive use. It is also highly
addictive.
Use the PO, SC or IV route, except when that is not possible
Adjuvant interventions include IMMOBILIZATION, SPLINTAGE, POSITIONING, ELEVATION,
ICE etc.
REGIONAL ANAESTHESIA
Indications
Acute pain management for wounds, fractures and dislocations
Alternative to procedural sedation
Alternative to narcotics in certain patient populations (e.g. head injured patient, patients with concomitant mental status change, patients given
buprenorphine)
Contraindications
Allergy to local anaesthetic agents
Active infection at the site of injection
Injuries at risk of compartment syndrome
Uncooperative patient
Pre-existent neurologic deficit
Anticoagulation (relative)
Technique www.nysora.com
Types
Wrist (Ulnar, Median and Radial nerve) block for the hand
Digital nerve blocks for fingers and toes
Femoral nerve block for the anterior thigh, femur, knee and skin anaesthesia over the medial aspect of the leg below the knee
Facial and dental nerve blocks
Ankle blocks for the foot
Haematoma blocks
Anaesthetic - Lidocaine
Dose 3mg/kg
Onset of action - < 2 mins
Duration 60 mins
37. Analgesia
Analgesia Chart
Chart
Drug Dosage Equianalgesic dose Onset/Peak Effect Duration of Action Adverse Effects Comments/Caveats
Morphine IV - 0.1mg/kg; 10mg IV - Onset 3-5 mins; IV - 3 4 hrs Respiratory depression Acute severe pain (trauma) or persistent pain. Morphine is better
max. 0.3mg/kg Peak effect 15-30 mins Hypotension partly due preferred for obstetric pain.
SC 4 hrs to histamine release
SC - 0.1-0.2mg/kg SC Onset 15-30 mins
Fentanyl IV - 0.5 3 g/kg 100g IV - Immediate onset, IV 30 - 45mis Chest wall rigidity and Acute severe pain.
over 3-5mins Peak effect 2-3mins SC 1 2 hrs respiratory depression Fentanyl is preferred for a rapid onset of analgesia in acutely distressed
SC Onset 7 -15mins may occur with rapid patients. Fentanyl is preferred for patients with hemodynamic instability
IV administration or renal insufficiency
Pethidine IV - 0.5-1mg/kg 75 mg IV - 1-3 mins IV 2 - 4 hrs High doses may cause Moderate-to-severe pain (migraine, trauma, acute abdominal pain)
SC - 1-2mg/kg SC - 30-90 mins SC 3 4 hrs respiratory depression,
It may be used in obstetric practice to relieve labour pain.
agitation, muscle
fasciculations, seizures Pethidine has an analgesic potency approximately equal to one-fifth that
or histamine induced of morphine.
hypotension
Pethidine has an active metabolite (nor-meperidine) that causes neuro
excitation (apprehension, tremors, delirium, and seizures) and may interact
with antidepressants (contraindicated with MOI and best avoided with
SSRIs), so it is NOT RECOMMENDED for repetitive use. It is also
highly addictive.
Tramadol IV/SC - 50-100mg 80mg IV/SC 45 mins IV/SC - 9 10 hrs > 400 mg/d are Moderate-to-severe pain.
over 3-5mins associated with an Tramadol is 5 to 10 times less potent than morphine. There is
Max 400mg/d increased risk of consequently an absence of respiratory depression, a low sedative effect,
seizures. and less potential for dependence. There is a high incidence of nausea
and vomiting. Slow administration over 3 - 5 minutes decreases the
incidence of nausea and vomiting. Tramadol does not promote the release
of histamine.
Paracetamol IV 15mg/kg - IV 15mins IV 4hrs Mild-to-moderate pain
(at end of infusion) Can be used to supplement opioid analgesics
Diclofenac IV 75mg - IV 5-10 mins IV 6-8hrs Gastrointestinal Mild-to-moderate pain
IM 75mg IM 15mins IM 6-8hrs bleeding Can be used to supplement opioid analgesics e.g. renal colic
Bleeding secondary
All NSAIDs elevate SBP (median 5 mmHg). This effect predisposes to
to platelet
the development of congestive heart failure and also may contribute to the
inhibition, and
risk of accelerated atherothrombotic disease.
Development of
renal insufficiency Patients with hypovolemia or hypoperfusion, the elderly, and those with
pre-existing renal impairment may be more susceptible to NSAID-
induced renal injury.
IM administration is not generally recommended due to its multiple disadvantages:
Painful administration
Unpredictable absorption
Complications involving tissue fibrosis and abscesses, and
Rapid declines in analgesic effect.
Subcutaneous (SC) administration provides similar pharmacokinetics with greater patient comfort. The SC route should replace the IM route for opioids.
38. Procedural Sedation and Analgesia (PSA)
Procedural sedation is the technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while
maintaining cardiorespiratory function.
Potential indications for procedural in the ED: fracture reduction, joint reduction, incision and drainage, chest tube placement, electrocardioversion, upper endoscopy (with a gastroenterotogist), foreign body removal, burn
or wound debridement
Patient selection: A pre-procedural history and physical exam, as documented in the ED record, should reflect a focused evaluation of the airway, cardiovascular status, pulmonary status, allergies, and history of prior adverse
reactions to sedatives or anaesthetics. PSA may not be ideal for patients with significant chronic morbidities e.g. sleep apnoea, COPD, low baseline oxygen saturations or blood pressure, or anatomic features that would make
bag valve mask (BVM) ventilation or maintaining an airway difficult.
Preparation: Monitoring equipment (continuous telemetry, pulse oximeter, BP; consider continuous end tidal CO2 monitoring), peripheral IV, normal saline, medications for PSA, naloxone (if opiates are given), equipment
for procedure (e.g. scalpel), team ( minimum one practitioner for sedation, one for procedure one of them must be proficient in airway management), airway equipment (oxygen source, nasal cannula/face mask, BVM,
suction), rescue airway equipment (endotracheal tube, laryngoscope, LMA, nasal trumpet)
Obtain consent
Medication for PSA (give both an Analgesic AND a Sedative)
Drug Dosage Analgesic/Sedative Onset/Peak Effect Duration of Action Adverse Effects Comments/Caveats
Fentanyl IV - 0.5 3 g/kg Analgesic IV - Immediate onset, IV 30 - 45mis Chest wall rigidity and Fentanyl is preferred for a rapid onset of analgesia in acutely distressed
over 3-5mins Peak effect 2-3mins respiratory depression patients. Fentanyl is preferred for patients with hemodynamic instability
may occur with rapid or renal insufficiency
IV administration
Midazolam IV - 0.05 Sedative IV - Onset 3-5 mins; IV 20 - 60mis Respiratory depression, Midazolam has a rapid onset and short duration and is classed as an ultra-
0.15mg/kg Peak effect 15-30 mins hypotension short acting benzodiazepine, and is 2 to 3 times more potent than
diazepam, so can produce significant respiratory depression. Blood
pressure decreases and heart rate increases as compensation for a
decreased SVR, although CO remains unchanged.
Ketamine IV 1 mg/kg over Analgesic and IV - Onset 1min; IV 5 - 10mis Laryngospasm (0.3%), Ketamine use should be avoided in patients with psychosis or
30-60 seconds Sedative Peak effect 1 min hypersalivation, schizophrenia.
vomiting, emergence Can be combined in a single-syringe 1:1 mixture of 10 mgmL ketamine
reaction and 10 mgmL propofol (10cc syringe + 100mg Ketamine + 100mg
Propofol to 10mL = 10mg/mL). The median dose is 0.7 mg/kg each of
ketamine and propofol (range = 0.2 to 3.0 mg/kg)
Propofol IV - 0.5mg/kg; Sedative IV - Onset 45 seconds IV Patients Hypotension Propofol can quickly take a patient from deep sedation to general
max. 1 mg/kg generally wake up anesthesia with a lack of spontaneous respirations if too high a dose is
3-5 minutes after administered. Propofol frequently causes hypotension, but this can usually
the last dose. be treated successfully with a fluid bolus.
Contraindicated in patients with an egg or soybean oil allergy.
Propofol can cause burning when it is administered thus can be mixed with
a small quantity of lidocaine.
Consider starting with half of this dose in the geriatric population.
Subsequent doses are administered every 2 to 3 minutes in smaller aliquots
(0.5 mg/kg IV) and titrated to the desired effect.
39. Antimicrobial Guide
For detailed guidelines and other conditions not listed below, please refer to the hospitals guidelines for antimicrobial use
Condition Comments/Caveats Recommended Therapy

URTI/Sinusitis The most common cause of URTIs is viral and Amoxicillin 500mg TDS x 5 days is the first line therapy
thus no antibiotics are necessary for most adults who fail the watchful waiting approach
Watchful waiting - The observation option for In Penicillin-Allergic Patients:

Acute Bacterial Rhinosinusitis (ABRS) refers to Azithromycin 500mg PO OD x 3 days
deferring antibiotic treatment for selected adults Supportive therapy;
with uncomplicated ABRS who have mild Decongestants (-adrenergic) - xylometazoline
illness (mild pain and temperature < 38.3C) for hydrochloride for 3 days.
up to 7 days after diagnosis and limiting Saline irrigation - Nasal saline irrigation, alone or in
management to symptomatic relief and conjunction with other adjunctive measures, may improve
assurance of follow-up. quality of life, decrease symptoms, and decrease
medication use for ABRS, particularly in patients with
frequent sinusitis.
Mucolytics
Antihistamines have no role in the symptomatic relief of
ABRS in non-atopic patients.
Pharyngitis/ The most predictable clinical parameter for Adult patients with acute exudative adult pharyngitis who
GABHS pharyngitis is reported to be the report 3 or 4 Centor criteria ONLY.
Tonsillitis Centor criteria.
a) history of fever > 38oC, Benzathine penicillin G 1.2MU IM stat
b) absence of cough, OR
c) Swollen and tender anterior cervical lymph Amoxicillin 1gm PO OD x 10 days
nodes, and
d) Tonsilar exudates or swelling Consider - Single-dose Prednisone 60 mg PO or
Both the sensitivity and specificity of this Dexamethasone 8 mg IM therapy added to the standard
prediction rule are 75%, compared with throat treatment has a more rapid improvement of pain in adult
cultures. patients with acute exudative adult pharyngitis who report 3
or 4 Centor criteria.
Patients who are allergic to Penicillin
Azithromycin: 500 mg PO on day 1 followed by 250 mg PO
OD on days 2-5
Laryngitis Mostly viral No Antibiotics necessary
Acute Any diarrhoeal illness lasting > 1 day, Food-borne toxigenic diarrhoea usually requires only
especially if accompanied by the following supportive treatment, not antibiotics.
Gastroenteritis features should prompt microscopic evaluation
of a faecal specimen; Treatment of salmonellosis with antibiotics (including
fever, quinolones) can prolong the carrier state and lead to a higher
bloody stools, clinical relapse rate.
systemic illness, Treat ONLY patients with;
recent use of antibiotics, fever,
day-care centre attendance, bloody stools,
hospitalization, or systemic illness,
dehydration (defined as dry mucous dehydration
membranes, decreased urination, tachycardia, diarrhoea > 7days
symptoms or signs of postural hypotension, or immunocompromised patients e.g. HIV, Malignancy
lethargy or obtundation)
Ciprofloxacin 500 mg PO BD x 3 days. The duration of
A stool culture is not necessary or cost- treatment may be extended by 2-3 days for moderate-to-
effective in most cases of diarrhoea without severe cases.
systemic disease or dysentery unless an unusual
bacterial cause is suspected Diarrhoea should NOT be treated with anti-motility agents.
Typhoid - Bone marrow culture is the most
sensitive routinely available diagnostic tool.
Stool culture is positive only in up to 30-40% of
cases, but is often negative by the time that
systemic symptoms bring patients to
hospital. Blood cultures are positive in 40-80%
of patients. Serologic tests e.g. the Widal test
are of limited clinical utility because positive
results may represent previous infection.
Urinary Tract When used together, nitrite and leukocyte Uncomplicated Cystitis
esterase testing have sensitivities between 68 Ciprofloxacin 500 mg PO BD x 3 days
Infection (UTI) and 88%. A review of the literature that OR
included 70 publications concluded that in Nitrofurantoin 100mg TDS x 3 days
adults, the urine dipstick test alone was reliable
in excluding the presence of infection, if both Uncomplicated Pyelonephritis, Outpatient Therapy
the nitrites and leukocyte-esterase were Ceftriaxone 1 g IV stat
negative; however, alone the test was not found PLUS
to be useful for ruling in infection. Ciprofloxacin 500 mg PO BD x 7 days
Pyuria in a urine specimen, in the absence of UTI during Pregnancy, Outpatient Therapy
symptoms, is not an indication for antimicrobial Cefuroxime 500 mg PO BD for 7 days
therapy. (A-II) OR
Nitrofurantoin 100mg TDS x 3 days
Urine cultures are not recommended in most
cases of uncomplicated UTIs in adult women.
Urine Cultures ONLY for;

In patients suspected of having
pyelonephritis, a urine culture and
susceptibility test should always be
performed, and initial empiric therapy should
be tailored appropriately on the basis of the
likely infecting uropathogen. (B-III)
A urine specimen should be obtained for
culture and susceptibility testing before initial
antimicrobial therapy for complicated UTIs.
(A-III)
Complicated UTI
Male gender
Structural or functional anatomic
abnormalities
Renal stones
Indwelling catheters Complicated UTI
Renal transplant
Neurogenic bladder Ciprofloxacin 500 mg PO BD x 14 days
Recent urologic procedure
Inpatient therapy
Sepsis
Pregnancy
Urinary tract obstruction
Persistent vomiting
Poor outpatient follow-up Uncomplicated Pyelonephritis, Inpatient Therapy
Ceftriaxone 1g IV OD 10-14 days
OR
Ciprofloxacin 400 mg IV BD x 10-14 days
UTI during Pregnancy, Inpatient Therapy

Ceftriaxone 1-2 g IV OD
Sepsis See 18. Severe Sepsis/Septic Shock Algorithm Give Antibiotics as an EMERGENCY
Ceftriaxone 2gm IV stat
For probable Neutropaenic patients or if patient has been

admitted in hospital in the last 3 months (Hospital
Acquired Infection)
Imipenem 500 mg IV infusion over 3 hrs then QID for
General sepsis
OR
Meropenem 1 gm IV infusion over 3 hrs then TDS for
possible CNS infections
Community In addition to a constellation of suggestive Outpatient Treatment
clinical features, a demonstrable infiltrate Amoxicillin-clavulanate 2gm PO OD x 7 days
Acquired
by chest radiograph or other imaging
Pneumonia technique, with or without supporting
In Penicillin-Allergic Patients:
microbiological data, is required for the Azithromycin 1gm PO OD x 3 days
diagnosis of pneumonia. (B-III)
The strongest indications for blood

cultures are severe CAP and in
immunocompromised patients or those
with significant co morbidities, as these
patients are more likely to be infected with
pathogens other than S pneumoniae.
Co morbidities:
Chronic heart, lung or renal disease
Diabetes mellitus
Alcoholism
Malignancy
Asplenia
Immunosuppressant condition or drugs
Inpatient Therapy Inpatient Treatment

CURB 65 2 Amoxicillin-clavulanate 1.2gm IV TDS
PSI 4 PLUS
Azithromycin 1gm IV OD
Patient factors requiring hospitalization
Healthcare Associated Pneumonia (HCAP)
HCAP risk factors?
Hospitalization for 2 or more days of the past
Antipseudomonal beta-lactam
90 days
Imipenem 500mg IV infusion over 3 hours QID
Resides in nursing home or long-term care
facility
Received chemotherapy, IV antibiotics, or
wound care within the prior 30 days
Attended a hospital or haemodialysis clinic in
the last 30 days
Malaria Severe manifestations and complications of Uncomplicated Malaria

Falciparum Malaria Artemether + Lumefantrine - Coartem - WHO approved
Coma (cerebral malaria) adult dose is 4 tablets at 0, 8, 24, 36, 48 and 60 hours (six
Convulsions doses).
Hyperpyrexia
Hypoglycaemia Complicated Malaria
Severe anaemia (Hct < 15%) IV artesunate 2.4mg/kg at 0, 12 and 24 hours and daily
Acute pulmonary oedema until patient can take oral
Acute renal failure
Spontaneous bleeding and coagulopathy
Metabolic acidosis
Shock (algid malaria)
Aspiration pneumonia
Hyperparasitaemia (e.g. > 10% of circulating
erythrocytes parasitized in non-immune
patient with severe disease)
Hyper-reactive Malarial Splenomegaly
Community- Empiric coverage of Enterococcus is recom- Piperacillin-Tazobactam 4.5gm IV QID

mended
Acquired Severe
Intra-Abdominal
Infection, Biliary,
and Extra-Biliary
Infections
Minimum criteria for clinical diagnosis of PID STI Urethritis, Epididymitis, Orchitis, Proctitis,
STI Urethritis, Cervicitis
(all 3 should be present):
Epididymitis, a) Bilateral lower abdominal (uterine) Ceftriaxone 250mg IM stat
Orchitis, tenderness (sometimes radiating to the legs) PLUS
Proctitis, b) Cervical motion tenderness - Positive
cervical motion tenderness is defined as Azithromycin 1gm PO stat
Cervicitis increased discomfort from a normal pelvic
examination, as stated by the patient. Of PID
note, cervical motion tenderness is neither Mild-Moderate disease
sensitive nor specific for gynaecologic Ceftriaxone 250mg IM stat
pathology, is a sign of nonspecific
PLUS
peritoneal inflammation,
c) Bilateral adnexal tenderness (with or without Doxycycline 100mg PO BD x 14 days
a palpable mass) WITH or WITHOUT
One or more of the following additional criteria Metronidazole 500mg PO BD x 14 days
can be used to enhance the specificity of the Severe disease/In-patient therapy - Suggested criteria:
minimum criteria and support a diagnosis of surgical emergencies (e.g., appendicitis) cannot be
PID: excluded;
oral temperature >38.3 C; the patient is pregnant;
abnormal cervical or vaginal mucopurulent the patient does not respond clinically to oral
discharge; antimicrobial therapy;
presence of abundant numbers of WBC on the patient is unable to follow or tolerate an outpatient
saline microscopy of vaginal fluid; and
oral regimen;
laboratory documentation of cervical the patient has severe illness, nausea and vomiting, or
infection with N. gonorrhoea or C.
high fever; or
trachomatis.
the patient has a tubo-ovarian abscess.
Amoxicillin-clavulanate 1.2g IV TDS
PLUS
Doxycycline 100mg IV/PO BD x 14days
Cellulitis/ Most abscesses are Staph aureus. Most cellulitis Oral Therapy
is Group A beta-haemolytic streptococcus
Beta-haemolytic Streptococcus coverage:
Abscesses/ (although some is Staph aureus)
Amoxicillin-clavulanate 1gm PO BD x 7 days
Empiric therapy for Streptococcus pyogenes
Folliculitis/ (beta-haemolytic streptococcus) is OR
recommended
Carbuncle/ Clindamycin 450 mg PO QID x 7-10 days
Azithromycin or clindamycin for severe
Furuncle penicillin allergy
Parenteral Therapy (Inpatient)
Clindamycin is bacteriostatic, potential for
cross-resistance and emergence of resistance in Beta-haemolytic Streptococcus and MSSA Coverage
erythromycin-resistant strains; inducible
Cefuroxime 1.5gm IV q8 hours for 7-10 days
resistance in MRSA
OR
Effective treatment of abscesses entails incision,
thorough evacuation of the pus, and probing the Clindamycin 600 mg IV q8 hours for 7-10 days
cavity to break up ovulations (A-I). Gram
stain, culture, and systemic antibiotics are
rarely indicated unless there is extensive
surrounding cellulitis, fever, multiple lesions,
severely impaired host defences, or cutaneous
gangrene. (E-III)
Necrotizing skin Surgical intervention is the major therapeutic Consult a Physician

modality in cases of necrotizing fasciitis.(A-III)
& soft tissue
infections Necrotizing fasciitis falls into two groups;
The spontaneous extremity cellulitis is usually
Group A Streptococcus and sometime Staph
aureus.
The second group includes head and neck,
abdominal/groin and is frequently
polymicrobial.
Bites Prophylaxis: Amoxicillin-clavulanate 1gm BD x 7 days
The use of antibiotics in patients with animal
bites is controversial, and some studies have In Penicillin Allergic Patients:
shown little benefit. However, bites at higher Ciprofloxacin 400mg PO/IV BD OR Azithromycin 500mg
risk for infection, should be treated with PO OD for 3 days
antibiotics for 35 days; Prophylaxis should be PLUS
given for ONLY wounds that are; Tetanus Toxoid 0.5mg IM
moderate to severe
have associated crush injury
have associated oedema (either pre-existing Previous doses
Clean and minor
or subsequent) of adsorbed All other wounds
wounds
that are on the hands or in proximity to a tetanus toxoid
bone or a joint
in compromised hosts Tetanus TIG Tetanus TIG
toxoid toxoid
ALL Human bites should receive; < 3 doses or Yes No Yes Yes
prophylactic antibiotics unknown
consider post-exposure prophylaxis for HIV
3 doses Only if last No Only if last No
within 72hrs. The risk associated with bite
dose given dose given
injuries has not been quantified. The victim
10 yrs ago 5 yrs ago
is usually at low risk unless the biters
saliva is contaminated with blood. The risk
is greater to the biter if blood is drawn from Rabies Prophylaxis
the victims wound because of exposure to
Rabies Prophylaxis Pre-EP No Pre-EP
mucous membranes.
Hepatitis B vaccine preferably 24 hours if Immunoglobulin None Human Ig - 20U/Kg
not previously immunized (Wound Site) OR
Equine Ig - 40U/Kg
Treatment:
ALL infected bites should be treated. Vaccine Day 0, 3 Day 0 , 3 , 7 , 14
(Deltoid or AL thigh)
SNAKE BITES (http://www.bio-ken.com/)

Syndrome Painful progressive swelling Progressive weakness Bleeding
Important African puff adder, Eastern Gaboon Eastern Green Mamba, Coastal Boomslang
snakes viper, Rhinoceros Horned Viper, Eastern Jameson's
Red Carpet Viper, Black-necked Mamba, Black Mamba,
Spitting Cobra, Red Spitting Cobra Egyptian Cobra, Forest
Cobra
Clinical Mild: slow progressive painful Ptosis, diplopia, dilated Bleeding from puncture
Picture swelling pupils, difficulties in sites, Minor lacerations,
Severe: rapidly progressive swallowing, salivation, development of
swelling and severe pain , progressive difficulty disseminated
ecchymosis, blisters, severe tissue breathing, hypoxia intravascular
necrosis, abscess formation, coagulopathy over time
pseudo- and true compartment
syndrome, nausea and vomiting,
hypotension, bleeding tendency,
shock, rhabdomyolysis, renal
failure
Management Establish IV access Establish IV access Establish IV access

Give analgesia Monitor oxygenation Give blood/blood
Position the limb at the level of and ventilation closely component therapy if
the heart (HDU) indicated
Give IV fluid for shock and renal Intubation and Heparin,
failure mechanical ventilation antifibrinolytics,
Treat local complication may be necessary thrombolytics are of no
appropriately value and may be
dangerous
Indications Polyvalent antivenom Polyvalent antivenom Monovalent antivenom
for Swelling progressive at 15cm/hr Triad of (either) Active bleeding
Antivenom Swelling to a knee or elbow from 1. paraesthesia, Non-clotting blood in a

a foot or hand bite within 4 hours 2. excessive clean test tube after 20
Swelling of a whole limb by salivation/metallic minutes
8 hours taste and sweating Laboratory evidence of
Swelling threatening the airway 3. dyspnoea coagulopathy
An associated coagulopathy in the absence of
Unexplained dyspnoea
painful progressive
Consider antivenom if snake is
swelling (mambas)
Paresis in the presence
unknown but envenomation is
severe. of significant swelling
(non-spitting cobras)
Faeces, nasal secretions, saliva, sputum, sweat, PEP is indicated for those with at least a 0.1% risk of
HIV Post tears, urine, and vomitus are not considered to transmission from a high-risk or known HIV-positive source
Exposure be infectious unless they are visibly bloody. patient.
Prophylaxis Perform ELISA for HIV antibodies at baseline, 4-6weeks,
(PEP) 12 weeks and 24 weeks
(Data from CDC. Estimated per-unprotected act risk for Consult local guidelines for the recommended regimens
MMRW January 21, acquisition of HIV by exposure route
2005;54(RR02):120)
Exposure route % Risk Regimen Dose Comments
Blood transfusion 90% High Risk ( 0.1% risk)
Needle-sharing injection-drug use 0.67% Raltegravir 400mg 1 tablet BD Less side-
effects but
Receptive anal intercourse 0.5% expensive
Percutaneous needle stick 0.3%
Receptive penile-vaginal 0.1% PLUS PLUS
intercourse
Insertive anal intercourse 0.06% (Truvada) 1 tablet OD Truvada is not
Tenofovir (300mg) recommended
Insertive penile-vaginal intercourse 0.1% Emtricitabine (200mg) in renal failure
Receptive oral intercourse 0.01% (Combivir) 1 tablet OD Replace
Zidovudine (300mg) Zidovudine
Insertive oral intercourse 0.005% with Abacavir
lamivudine (150mg)
in anaemic
The overall rate of HIV transmission through patients
percutaneous inoculation is reported to be 0.3%
(95% confidence interval [CI] 0.20.5); the risk PLUS PLUS
of acquiring an HIV infection is greater for (Kaletra/Aluvia) 2 tablets BD or
percutaneous injuries that involve; Ritonavir (50mg) 4 tablets OD
hollow-bore needles that have been in Lopinavir (200mg)
contact with an artery or vein,
when blood is visible on the device, Low Risk (< 0.1% risk)
a deep needlestick, and
(Combivir) 1 tablet OD Replace
when the source patient has advanced HIV
Zidovudine (300mg) Zidovudine
disease.
Lamivudine (150mg) with Abacavir
Splashes or infectious material to mucous in anaemic
membranes or broken skin may also transmit patients
HIV infection (estimated risk per exposure,
0.09%; 95% CI 0.0060.5). Exposure of intact PEP should be continued for 28 days
skin to contaminated blood has not been
identified as a risk for HIV transmission. Patients who receive zidovudine plus lamivudine-based
regimens should have a complete blood count and
measurement of liver enzyme levels at 2 weeks of treatment,
irrespective of the presence or absence of clinical symptoms.
40. Poisoning
Decontamination
Activated Charcoal
Indications Contraindications Dosing
Use within ONE HOUR of ingestion of Decreased level of consciousness The optimal dose of charcoal is unknown.
a potentially toxic amount of medication. Ingestion of medication with a low affinity for However, the adult dose ranges from 50 to 100
It is not effective beyond this period. binding with activated charcoal (e.g. iron, g per dose. Lower doses of 0.5-1gm/kg are
lithium) used in children. When drug-induced vomiting
Multiple-dose (30gm in 400mls 4-6hrly) There are insufficient data to support or is anticipated (for example, with a theophylline
activated charcoal should only be exclude the use of activated charcoal for the overdose), an IV antiemetic is recommended.
considered if a patient has ingested a life- elimination of amitriptyline, digoxin, Cathartics such as sorbitol are sometimes added
threatening amount of; carbamazepine, phenytoin, and sodium valproatel. to activated charcoal preparations, but there is
dapsone, phenobarbital, quinine, or Increased risk of gastrointestinal bleeding or no evidence of any additional clinical benefit.
theophylline. perforation
Gastric Lavage SHOULD NOT BE PERFORMED
Clinical studies have failed to show that gastric lavage improves the severity of illness, recovery times, or the ultimate medical outcomes and may
be associated with life-threatening complications (aspiration pneumonitis, oesophageal or gastric perforation, fluid and electrolyte imbalances,
arrhythmia).
Antidotes
Antidote Indications Dose Comments
N-acetylcysteine If it is likely that the patient has 150 mg/Kg IV over 1 hr then 50mg/Kg Anaphylactoid reaction if given too fast
(NAC) ingested > 150 mg/kg (or >10 g) of over the next 4 hrs then 100mg/Kg
paracetamol over the next 16hrs
In contrast, NAC is not IV NAC should be infused as a 3%
recommended for patients with; solution (30 g of NAC in D5W to a total
an unknown ingestion time volume of 1 L
a paracetamol concentration below
detectable limits along with normal
AST levels.
Atropine Organophosphate/Carbamate 2mg IV repeated every 5 minutes until Excessive doses of atropine can result in
poisoning causing rhinorrhoea, the therapeutic endpoint is reached i.e. delirium, agitation, and tachycardia and
lacrimation, dyspnoea, vomiting, until pulmonary secretions are dried hypertension. Tachycardia is not a
fasciculations, weakness, inability to [reflected by improved oxygenation] contraindication to atropine
ambulate, convulsions, respiratory and ease of breathing [or ease of administration.
insufficiency, coma. ventilation].
Miosis alone is not an indication for

atropine administration.
Ethanol Ethylene Glycol or Methanol PO:
poisoning Loading dose: 0.8g/kg in a 20%
ethanol solution diluted in juice.
Maintenance dose: 80mg/kg/h;
increase to maintain a serum ethanol
concentration of 100- 150mg/dL.
IV:
Loading dose: 0.6 - 0.8 g/kg in a 10%
ethanol solution in D5W
(volume/volume).
Maintenance dose: 80 to 130 mg/kg/h
Higher maintenance doses are used in

patients with chronic alcoholism or
during hemodialysis.
Flumazenil Excessive sedation known to be due 10/kg IV over 15 seconds. Repeat The administration of flumazenil to
to the use of benzodiazepines in a every 2-3mins to a maximum of 1mg patients with undifferentiated coma can
patient without known (usual range 0.3 to 0.6mg). precipitate seizures in benzodiazepine-
contraindications (e.g., procedural dependent patients and has been
sedation). associated with seizures, arrhythmia, and
hypotension in patients with co-ingestion
of certain medications, such as tricyclic
antidepressants.
Naloxone Respiratory depression secondary to Dilute one ampoule (0.4mg/ml) into Rapid injection may result in an acute
an opioid overdose 10ml (0.04mg/ml), and give 1 ml every withdrawal syndrome, with severe
1 to 2 minutes. A therapeutic effect is sympathetic effects such as hypertension,
usually seen after 3 to 4 ml tachycardia and pulmonary oedema - can
precipitate a myocardial infarction in
patients at risk of IHD.
Algorithm References
1-4. American Heart Association. 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science. Circulation 2010;122(18 Suppl 3):S639-
S933.
5. OGara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA guideline for the management of ST-
elevation myocardial infarction: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation
2013;127(4):e362-425.
6. 2012 Writing Committee Members, Jneid H, Anderson JL et al. 2012 ACCF/AHA focused update of
the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial
infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the
American College of Cardiology Foundation/American Heart Association Task Force on practice
guidelines. Circulation 2012;126(7):875-910.
10. Soar J, Pumphrey R, Cant A, et al. Emergency treatment of anaphylactic reactions-guidelines for
healthcare providers. Resuscitation 2008;77:157-169.
11. Cydulka RK. Managing Acute Exacerbations and Influencing Future Outcomes in the Emergency
Department: Update on the 2007 National Asthma Education and Prevention Program Guidelines.
<http://www.esng-meded.com/ACEPnews/MEL_20080101.pdf > [last accessed 27 March 2013]
14. James PA, Oparil S, Carter BL et al. 2014 evidence-based guideline for the management of high
blood pressure in adults: report from the panel members appointed to the Eighth Joint National
Committee (JNC 8). JAMA 2014;311(5):507-20.
17-18. Dellinger RP, Levy MM, Rhodes A et al. Surviving sepsis campaign: international guidelines for
management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41(2):580-637.
23. Saccilotto RT et al. San Francisco Syncope Rule to predict short-term serious outcomes: A systematic
review. CMAJ 2011; 183:E1116.
25. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a
scientific statement for healthcare professionals from the American Heart Association/American
Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on
Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the
Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology
affirms the value of this statement as an educational tool for neurologists. Stroke 2009;40(6):2276-
2293.
26-27. Jauch EC, Saver JL, Adams HP Jr et al. Guidelines for the early management of patients with acute
ischemic stroke: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke 2013;44(3):870-947.
32. Chou R, Qaseem A, Snow V et al. Diagnosis and treatment of low back pain: a joint clinical practice
guideline from the American College of Physicians and the American Pain Society. Ann Intern Med
2007;147(7):478-91.
33. Chey WD, Wong BC; Practice Parameters Committee of the American College of Gastroenterology.
American College of Gastroenterology guideline on the management of Helicobacter pylori infection.
Am J Gastroenterol 2007;102(8):1808-25.
Notes:
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Emergency Medicine

Begin CPR - cycles of 30 COMPRESSIONS then 2 BREATHS High-Quality CPR

Change compressors - CPR 2min

Change compressors - CPR 2min

Identify and treat underlying cause

Narrow Complex Tachycardia Wide Complex Tachycardia

Return of Spontaneous Circulation (ROSC)

Activate Resuscitation Team (if not already present) AND a Physician/Cardiologist

Optimize ventilation and oxygenation

Treat hypotension (SBP < 90mmHg)

Keep the patients temperature

STEMI or Suspicion of ACS Consult a Cardiologist

2. Concordant ST depression 1mm in V1 - 3

Review/Complete Fibrinolysis Checklist

No Contraindications for Fibrinolysis/Thrombolysis

TIMI Risk factors TIMI Risk Score Probability of Death, Myocardial

Repeat 12 lead ECG in 30 mins/Continuous ST-segment monitoring STEMI

If no evidence of ischaemia or infarction by testing, can

Clinical features suggestive of Pulmonary Embolus

Clinical gestalt or validated clinical decision support tool

Quantitative D-dimer assay > 0.5 g/L* PE safely excluded

Position the patient

Paralysis with Induction

Pass the tube

Self-inflating bag valve resuscitator ventilation 1 breath every 5s

Resume BVM ventilation - 1 breath every 3 seconds

Reposition patient to align the airway (sniffing position)

3. Hypotension after exposure to a known allergen.

Acute Asthmatic Attack

Monitor, support ABCs

Peak Expiratory Flow < 70 % Impending or Actual Respiratory Arrest

PEF 40 69% - Incomplete Response PEF < 40% - Poor Response

How to Measure Peak Expiratory Flows (PEF)

1. Put the pointer on the gauge of the peak flow meter to 0 or

Measured PEF X 100%

9. Record the PEF in the patients clinical notes

Monitor, support ABCs

Are there any features of progressive or impending end

Known Hypertensive Resume regular treatment; if Consult a Physician (Obstetrician in Eclampsia)

Daily BP checks at nearest clinic and follow-up

CLASSIFICATION OF BLOOD PRESSURE (BP)

DIAGNOSTIC WORKUP OF HYPERTENSION

PRINCIPLES OF LIFESTYLE MODIFICATION

Monitor, support ABCs

Preferred medications Medications to avoid

AGENT MOA DOSE ONSET/DURATION OF PRECAUTIONS

Hydralazine Decreases systemic 5-10 mg as IV bolus 10 min/> 1 hr Tachycardia, headache,

Parenteral Adrenergic Inhibitors

Severe Sepsis/Septic Shock

Monitor, support ABCs

Insert urinary catheter and monitor urine output

Features of shock despite adequate fluid resuscitation (> 30ml/kg)?

Consult a Physician If;

Hemodynamic stability achieved with adequate fluid resuscitation (> 30ml/kg)

Give Hydrocortisone 200mg IV bolus

Give dobutamine infusion up to 20 g/kg/min

Hyperglycaemia (RBS > 14mmol/L)

Monitor, support ABCs

See 20. Uncomplicated

1. Fluid Protocol 2. Potassium Protocol 3. Insulin Protocol

Hyperglycaemia (RBS > 14mmol/L)

Monitor, support ABCs

Identify and Treat precipitating illness; consider ACS, Sepsis