2

Department of Emergency Medicine, AIIMS New Delhi

Manual for Junior Residents

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CONTENTS
Initial assessment of patients at the counter: Page no. Common drugs used in Emergency: Page no.

1. General instructions for patient assessment & triage in ED 3 1. Drugs for Hyperkalaemia 32

2. Guide to succinct clinical documentation in ED 5 2. Loading dose for Acute Coronary Syndrome 32

3. Initial assessment of a patient with chest pain 6 3. Drugs for a patient with UGI Bleed 33

4. Initial assessment of a patient with suspected stroke 8 4. Doses of common Analgesics used in ED & contra-indication 33

5. Initial assessment of a patient with breathing difficulty 10 5. Common antibiotics used in ED dose & Indication 34

6. Initial assessment of a patient with altered mental status 14

7. Initial assessment of a patient with pain abdomen 16

8. Initial assessment of a patient with UGI bleed 18

9. Initial assessment of a patient with Haemoptysis 19

10. Initial assessment of a patient with gastro-intestinal symptoms 21

11. Initial assessment of patients with Fever 22

12. Initial assessment of a patient with toxin ingestion 24

13. Assessment of an unresponsive patient 26

14. Initial assessment of a patient of Chronic liver Disease 27

15. Initial assessment of a patient of Chronic Kidney disease
16. Initial assessment of a patient of Haematological disorders
Compiled under guidance of: Dr Praveen Aggarwal, Professor & Head
Final compilation & editing by: Dr Rachana, Senior Resident
28
Content contribution by: Dr Roshan Mathew, Dr Ankit Sahu, Dr Brunda RL, Dr Sakshi Yadav,
Dr Akshaya R, Dr Bharath G, Dr Prawal, Senior Residents,
30 Department of Emergency Medicine, AIIMS, New Delhi
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General instructions for patient assessment & triage in ED

This manual aims to orient the junior residents (JRs) working in department of emergency medicine, AIIMS, New Delhi, about the common emergencies
encountered during their shift. The goal is to give evidence based standard of care to patients in a high volume and high acuity setup. Although every attempt is
made to make it as current and complete as possible, situations will undoubtedly arise which are not included in the manual. All residents are requested to read
this manual before starting their residency.

General Instruction
1. The Department of Emergency Medicine is divided into four zones;
a. Screening Emergency (Initial assessment and Triage)
b. Main Emergency (Surgical patients)
c. New Emergency (Medical patients)
d. Paediatric Emergency

2. Senior Residents (SRs) are the team leaders on the shift and are responsible for allotting the JRs in different areas.
3. The New Emergency is further divided in to Red areas, yellow areas and counter.
4. Red Areas have critically ill patients and are usually manned by the Academic Junior Residents.
5. The 1st assessment after triage is done by the counter JR, who after history examination and relevant investigations shifts the patient to appropriate areas
in consultation with the SR.
6. Red patients are priority; if a resident is evaluating a yellow/green patient and is allotted a red patient, he/she has to attend the red patient 1st.
7. In the yellow areas, the junior resident has to the write progress notes with vitals and ensure further work up and consultations as per SRs instruction. A
written handover has to be given to the next team in the given format.
8. Whenever CODE BLUE is announced, all JRs who are not attending critical patients should report to the concerned area.
9. Residents should report on time for their shifts. Remember the dictum ‘If you are five minutes early you are on time, if you are on time you are late’.
10. Mature interactions are expected with patients as well as with office and hospital personnel at all times.
11. Ensure clear & legible documentation in the case sheet of the patient. Document your name, time and date while writing the notes.
12. Start antibiotics only after consultation with your Senior Resident

TRIAGE
Triage is the process of determining the priority of patients' treatments by the severity of their condition or likelihood of recovery with and without treatment.
In the Emergency department, sequence of treatment of patients is determined by patient’s triage category and not first cum first serve basis.
In case of large number of patients and longer waiting times, periodic reassessment & re-triaging of patients is important.
Triage categories: RED, YELLOW & GREEN
RED
 First priority
 Require immediate assessment & care
Compromised primary survey
A - Noisy breathing/ Stridor/ Pooling of secretions
Angioedema involving face
B - RR < 10 or > 24/minute, SpO2 < 94%
Increased work of breathing , audible wheeze
C - HR < 50 or >120 (without fever)
SBP < 90 or >200 , DBP >110
Shock index (pulse rate/SBP >1)
Presence of active bleeding
D – GCS < 13 ; Responding only to Pain or Unresponsive
Patient with ongoing seizure
Time sensitive Emergencies
 Acute Chest Pain < 24hr duration (?ACS)
 Suspected Stroke < 24 hr (in window period)
 Drowning/hanging/electrocution/ trauma with
dangerous mechanism of injury
4
 Acute limb ischemia <48 hr duration YELLOW
 Acute scrotal/inguinal pain in Young male  Second Priority
 Sudden onset abdominal pain or pain with  Require emergent care, however can withstand
vaginal bleeding some delay in comparison to Red triaged patients
Stable primary survey
 Toxin ingestion / Bites & stings
 Patent Airway
 Any evaluation suggestive of Sepsis
 RR 10 to 24/min ; SpO2 > 95%
 Pregnancy in third trimester with pain abdomen
 SBP >90 without tachycardia or bradycardia
or bleeding per vagina
 GCS >13
 Severe pain anywhere in body (Pain score >7)
 H/o syncope
Vulnerable population / Risk for early deterioration
 Sudden onset severe headache (?SAH) Patients with stable primary survey with
 Agitated/ violent patient  Chronic Liver disease
 Acute urinary retention  Chronic Kidney disease
 Fever Temperature > 39oC with any one of  Uncontrolled Diabetes Mellitus
- Aplastic Anaemia  h/o Fever with Immune suppression
- Acute Leukaemia  Post ictal patient
- H/o Chemotherapy in last 14 days  Elderly or paediatric or pregnant patient
 Outside reports of S.Potassium > 5.5mEq/L  Persistent vomiting/ decreased urine output
Priority Red even without above criteria GREEN
 Require minimum or OPD based care
AIIMS EHS patient
 Patients with stable primary survey & No risk
factors for deterioration
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Sample Format for initial documentation in the Emergency Medicine case sheet

Date & Time at Case Seen by Dr ABC (Write your Name & Designation)
which patient is
examined
 Previous known co-morbid illness of the patient
POC Investigation  Chief complaint of the patient (with duration)
 Write the Primary Survey (with steps for stabilisation)
investigation sent
with Time at A-Airway: Patent/ Threatened/Obstructed  intervention
which sent B-Breathing RR:
SpO2
 Mention salient
investigation Bilateral Air Entry
findings such as
C- Circulation Pulse rate: /min (Regular. Irregular)
ECG, Blood gas
findings BP:
Capillary refill time/ peripheral perfusion
 RBS
D- Disability GCS E V M

Consultations if If any Focal neurologic deficit present

informed any with Pupil examination/ meningeal signs/plantar reflexes

time at which E- Exposure Temperature
informed Salient Head to examination findings

Other specific
documentation  Brief history as per the presenting complaint
 Relevant Negative history
Ex: Blood product
arrangement,  Relevant focussed systemic examination finding
important
investigation to be
reviewed etc Documentation of Emergency Treatment advised/given

1) Inj. Paracetamol 1g i.v. stat

Instructions regarding  Number the drugs

shifting the patient
to specific area as
per triage category
Yellow/ Red &
handover note
 Mention the name of the medication, formulation, dose and
route of administration clearly
Mention if any other intervention done such NG lavage, Foleys
catheterisation etc

*If Patient has any known allergies to any specific drug mention on the front sheet in Capital letters

Salient history to be taken
 Site of pain – Localised or not
 Onset & duration of pain
 Radiation of pain: Jaw, arm, epigastrium,
neck, back, Inter-scapular region
 Aggravating factors: Exertion, post
prandial
 Relieving factors: Rest, Medication
 Associated- Nausea, vomiting, sweating,
palpitation, syncope, any limb weakness
 H/o Recent surgery/ immobilisation /any
limb swelling/ prolonged travel/ trauma
 H/o Fever/ cough/ expectoration,
breathing difficulty/ Hemoptysis
 Co-morbid illness: Diabetes,
Hypertension, Coronary artery disease,
Chronic Kidney disease, Malignancy
 Medication history: Patient previously
continuing & medications if any given at
the referring healthcare facility
The second page of each symptom approach has a brief guide to critical and emergent differentials in ED ; which is only for knowledge purpose
No critical treatment or intervention to be initiated independently by the JR without informing the SR Emergency Medicine on shift
Assessment of a patient with Chest Pain in ED
Salient clinical examination
 Compete primary assessment
 Measure Blood pressure in
both upper limbs
 JVP, Pedal oedema
 Chest auscultation to look for
air entry, wheeze, crepitation
 Cardiac auscultation for any
systolic murmur
 Quick Neurologic assessment
to look for limb weakness,
slurring of speech
RED FLAG SIGNS
 Patient has associated profuse sweating/ persistent vomiting
 Unstable primary assessment
 ECG Showing ST elevation or depression in any leads
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Point of care Investigation Basic initial management
Investigations to be done based *Always discuss with the Senior
on probable clinical diagnosis. Resident on shift before proceeding
with any of the following management
“*” marked investigations to be
discussed with Senior Resident
Shift to Red area if Red flags present
before proceeding.
Loading dose of medications:
 Expedite ECG (within 10
Tab Aspirin 325mg
minutes of patient
Tab Clopidogrel 300mg
presentation to ED)
Tab Atorvastatin 80mg
 Point of care USG – Lung &
cardiac & vascular USG Tab Sorbitrate 5mg sublingual stat
 Baseline CBC & Renal
function Test Refer “medications in ED” section at
 Blood gas (when indicated page no. 31 for contraindications and
clinically) other details
 Troponin I*
 D- dimer*
 Chest X-ray

Quick guide to important ED Differentials of Chest Pain
Acute Coronary Syndrome
 Patient with central chest wall heaviness/
dyspnoea/ giddiness/ ghabrahat/syncope
 Associated sweating, nausea, vomiting
 Exertional symptoms
 Radiation anywhere from jaw to epigastrium or
either arms
ECG: New ST/T changes OR conduction blocks
STEMI: ST elevation of minimum 1mm in contiguous
leads except in v2,v3 > 1.5 mm (F) ; > 2mm (M)
ST elevation II,III, aVF: Inferior wall STEMI
STE V1-V4 : Anterior wall STEMI
STE I, aVL, V5, V6 : Lateral wall STEMI
NSTEMI
New onset ST elevation, depression or T inversion
(not fitting into above criteria) Or elevated Troponin I
Unstable angina
Typical angina symptoms lasting for > 20 minutes,
crescendo pattern with no new ECG changes and NO
troponin elevation
Troponin elevation > 99 percentile (see reference
value as per the test)
ECHO: RWMA (regional wall motion abnormality)
Expedite initial treatment : ECG within 10 mins
Window period : 6-12 hours
Aortic Dissection
 Sudden onset chest pain radiating to back
(inter scapular region)
 Chest pain plus syndrome ( chest pain with limb
weakness, chest pain with stroke, limb ischemia)
 BP/Pulse deficit in two limbs
 h/o Hypertension/ previous aortic disorders
 Diagnosis : CT Aortogram
Management of the below diagnoses have been explained briefly in the section on Dyspnoea Page 11-13
Massive Pulmonary Embolism
 Patient with recent surgery, limb immobilisation, Deep
vein thrombosis, limb swelling or Malignancy
 Sudden onset breathlessness/ chest pain/syncope
 Hypoxia with clear chest on auscultation/POCUS
ECG: Sinus tachycardia, T inversion in V1,V2,V3 or
inferior chest leads, S1Q3T3 sign
ECHO: RA/RV dilatation or RV dysfunction
Tension Pneumothorax
 h/o Trauma, COPD, Bullous lung disease, TB
 Sudden onset SOB
 Tracheal deviation, unilateral absence of breath sounds,
hypotension, raised JVP, distended neck veins
POCUS : Absent lung sliding (Barcode sign on M mode)
Emergency treatment: Needle thoracentesis
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Boerhaave Syndrome
 Spontaneous oesophageal rupture
 Sudden onset sharp substernal pain
 h/o severe retching, vomiting or manoeuvres with
sudden negative intrathoracic pressure
 Tachycardia, dyspnoea, sweating, Fever
 Hamman’s crunch (audible crepitus with heart
beat) – rare finding on examination
 Pneumothorax, Pneumomediastinum, Pleural
effusion, subcutaneous emphysema
 Diagnosis: CECT thorax with oral contrast
Cardiac Tamponade
 H/O trauma, mediastinal or lung malignancy, CKD,
TB/ recent MI
 Raised JVP/ distended neck veins/ hypotension
POCUS: circumferential fluid collection around the
heart with RA/RV diastolic collapse
 Get wide bore i.v. access & i.v. crystalloid bolus
 Prepare for pericardiocentesis
Lobar Pneumonia
 H/O fever + chills, productive cough, pleuritic chest
pain, haemoptysis
 Fever, tachycardia, tachypnea, crepitation, decreased
breath sounds
POCUS: Focal B lines, Pleural shredding,
hepatisation, syn-pneumonic effusion
CXR: e/o lobar radio-opacity with air bronchogram,
syn-pneumonic effusion

Salient history to be taken
 Typical symptoms: FAST
Facial deviation
(asymmetrical face while smiling/ clenching)
Arm drift/limb weakness
Speech abnormality (Slurring / aphasia)
(Time to call SR neurology)
 Atypical symptoms: numbness, dizziness/
vertigo, confusion/altered sensorium, visual
disturbance, severe headache
 Baseline neurological status, time last seen
at normal/ at baseline
 Onset & duration of symptoms
 Progression or resolution of symptoms
 Associated: headache, vomiting, seizure,
incontinence
 H/o trauma, intracranial haemorrhage
 Co-morbid illness: Diabetes,
Hypertension, Coronary artery disease,
Valvular heart disease, Chronic Kidney
disease, Malignancy
 Medication history: anticoagulants, any
other medicines/ medicines given at
referring facility
Assessment of a patient with Suspected Stroke
Salient clinical examination
 Check random blood sugar
 Complete primary
assessment
 Document GCS and 3 Ps
Pupil: size & reaction
Power: B/L upper & lower
limbs
Plantar response
 In case of ongoing vertigo
/cerebellar symptoms,
perform HINTS plus
examination
RED FLAG SIGNS
 Unstable primary assessment: ex. BP > 185/110, SpO2 < 94%
 Patient is unresponsive/difficult to arouse/ ongoing seizure
 Anisocoria, extensor posturing
Point of care Investigation
 RBS
 Inform SR Neurology ASAP in
suspected stroke after ruling out
hypoglycaemia
 CBC & Renal function Test
 Coagulation profile
 NCCT head  Stroke imaging
 ECG & Chest X-ray - can be
deferred till after CT
 POC ECHO: If cardio-embolic
stroke/ dissection is suspected
 Blood gas ( if indicated in an
unstable patient)
 Rapid Antigen Test for COVID
-19 (expedite for CT purpose)
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Basic initial management
*Always discuss with the Senior
Resident on shift before
proceeding with any of the
following management
 IV cannula: preferably in right
arm (20G or larger)
 If RBS < 70mg/dL  Inj.
50% dextrose 50 ml IV &
reassess
 Inform SR EM & SR
Neurology ASAP & shift
patient for CT
TARGETS TO ACHIEVE:
 SR neurology review &
NCCT head by 25 minutes of
arrival (Always NCCT first to
r/o haemorrhagic stroke)
 Glucose = 140 - 180
 BP < 185/110
 Fibrinolytic therapy started by
60 minutes of arrival if
eligible
 Endovascular therapy by 6
hours of arrival if eligible
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Quick guide to important interventions in stroke
BP control HINTS plus examination UMN vs LMN facial palsy
UMN = stroke & LMN ex. Bell’s
Labetalol 10-20 mg IV over 1-2 min (repeat once) Head Impulse test - corrective saccade absent
OR Nystagmus - multidirectional Features of UMN palsy:
Test of Skew - vertical skew
Forehead wrinkling on upward gaze - present
Nicardipine IV infusion at 5 mg/h Plus - new onset hearing loss (check by rubbing
titrate up by 2.5 mg/h every 5-15 min fingers next to each ear) Ability to completely close the eye - present
(max of 15 mg/h)
If above truecentral cause of vertigo (R/o stroke)

Fibrinolytic therapy Inclusion criteria (within 3 hrs of symptom onset): Contraindications for fibrinolysis:
 Age >= 18  Not meeting inclusion criteria
 Measurable diagnosis of ischemic stroke  Acute or prior IC bleed
Alteplase 0.9 mg/kg IV (max 90 mg)
10% over 1 min, remaining over 60 min  Severe head trauma/ischemic stroke in past
Inclusion criteria (within 4.5 hrs of symptom onset):
OR  Above criteria AND 3 months
 Age <=80  Intracranial /intra spinal surgery in past 3
Tenecteplase 0.5 mg/kg IV (max 50 mg)  NIHSS <= 25
As bolus over 5-10 sec months
 No h/o uncontrolled DM, prior stroke,
anticoagulant use  GI bleed/malignancy in past 3 weeks
 Imaging shows <=1/3rd MCA territory involved  BP > 185/110 despite therapy
 Platelet < 1 lakh or INR > 1.7
Endovascular therapy Inclusion criteria (must meet ALL criteria):
 Age >= 18
 NIHSS >= 6
Stent retriever or  ASPECTS >= 6
Mechanical thrombectomy
 Pre-stroke modified Rankin Scale score 0-1
 Stroke due to ICA/proximal MCA occlusion
 Fibrinolysis received within 4.5 hrs of onset
 Groin puncture for endovascular therapy initiated within 6 hrs of onset

Salient history to be taken
 Onset: sudden (think pulmonary embolism,
AMI, pneumothorax) vs progressive (other)
 Duration: acute or chronic
 Severity assessment: SOB on exertion /
limitation of daily activities / at rest
 Positional change like orthopnoea, PND
 Associated symptoms – Fever, chest pain
(central or lateral), diaphoresis, musical sound
on breathing, cough, haemoptysis, pedal
oedema, unilateral limb swelling, recurrent
vomiting, abdominal pain
 Previous H/O – similar episode, any seasonal
variation, any recent surgery, immobilisation,
prolonged travel
 Co-morbid illness: Diabetes, Hypertension,
Coronary artery disease, Chronic Kidney
disease, Malignancy, Tuberculosis
 Medication history: Patient previously
continuing & medications if any given at the
referring healthcare facility (particularly about
inhalers, cardiac medications, pain killers,
diuretics)
 Personal history – smoking, working near
chulha or furnaces, working in mines
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Assessment of a patient with Shortness of Breath (SOB)
Salient clinical examination Point of care Investigation Basic initial management
 Compete primary assessment Investigations to be done based on *Always discuss with the Senior Resident
probable clinical diagnosis on shift before proceeding with any of the
 Signs of airway obstruction, use of following management
 ECG
accessory muscles
 Arterial blood gas (always note Shift to Red area immediately if Red
 Raised JVP, Pedal oedema, Calf
the supplemental oxygen rate if flags present
tenderness
given)
 Chest auscultation: to look for air
 Point of care lung & cardiac &  Shift all patients of Acute SOB to
entry (any unilateral decrease),
vascular USG monitored areas and connect to the
wheeze, crepitation
 Baseline CBC, RFT cardiac monitor and SpO2 probe
 Cardiac auscultation for any
 Chest X-ray (if patient is  Provide supplemental oxygen to target
systolic murmur
unstable – never send the a goal SpO2 > 94% (for COPD patients
 Subcutaneous emphysema in neck
patient out of ED) target SpO2 88 – 92%)
and/or chest, Tracheal deviation
 Testing for COVID -19  Get an intravenous access (preferably
 Evidence of chest or neck trauma
 Troponin I* wide bore) and send all the samples
 INR, D- dimer*  Manage as per the following table of
 NTproBNP* differentials
 Blood culture
 RBS and urine ketones*
RED FLAG SIGNS
 Signs of airway obstruction – stridor, pooling of oral secretion, gross
lips/tongue swelling, neck mass or injury
 Severe tachypnea (RR > 30/min), hypoxia (SpO2 < 94%)
 Associated with – chest pain, profuse sweating, altered sensorium
 Unilateral air entry absent, use of accessory respiratory muscles
 Silent chest on auscultation

Quick pictorial differentials for Shortness of breath in ED
Differential Diagnosis of SOB
Airway obstruction
Pulmonary causes of SOB
Pneumothorax (PTX)
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Suggestive Symptoms and Signs Relevant Diagnostic tests findings Initial Treatment
 H/O sudden choking, neck/face  No diagnostic test needed  Head tilt – chin lift / Jaw thrust
trauma, depressed consciousness  Oral suction if secretions
 Stridor, pooling of oral secretions, low  Connect to supplemental oxygen
GCS (< 8)  Prepare for definitive airway
 H/O trauma, COPD, lung malignancy,  If patient is hemodynamic unstable,  Supplemental oxygen
TB, connective tissue D DO NOT send the patient for CXR  Tension PTX (unstable): Needle (use 16”
 Sudden onset SOB  POCUS – lung scan IV cannula) decompression in 5th intercostal
 Signs – Tracheal deviation, unilateral space in the anterior axillary line
absence of breath sounds, hypotension,  Plan for – ICD placement
raised JVP

Acute exacerbation of Asthma  Asthma – h/o similar episode in past,
and COPD seasonal variation, allergy , MDI use,
family dry cough
 COPD – known smoker, similar
episode in past, MDI use, dry cough
 Signs – audible wheeze, bilateral
wheeze, tripod positioning, pursing of
lips, air hunger, use of accessory
muscles
 Features of precipitants like LRTI,
Cardiac ischemia
Pneumonia  H/O fever + chills, productive cough,
pleuritic chest pain, haemoptysis
 H/O travel
 Exposure to COVID patient
 Signs – fever, tachycardia, tachypnea,
crepitation, decreased breath sounds
Pleural effusion  H/O TB, malignancy, CKD, CLD,
CHF, pneumonia (see pneumonia
section)
 Unilateral decrease breath sounds
Anaphylaxis  Sudden onset SOB, with exposure to
likely/known allergen; any recent drug
or new diet change
 Lips/tongue swelling, skin rash (like
urticaria), wheezing, pain abdomen,
vomiting , giddiness
 POCUS/ CXR – to r/o LRTI,
Pneumothorax, pleural effusion,
pulmonary oedema
 Blood gas – acute or acute on chronic
respiratory acidosis (pH < 7.35,
pCO2 > 40mmHg, HCO3 normal or
slight increased)
 ABG – if patient is hypoxic (always
note the FiO2 or rate of O2 supplied,
to find out P/F ratio)
 CBC – change in TLC
 POCUS/ CXR – consolidation
 SEND COVID CBNAAT/RTPCR
 Send blood cultures prior to start of
antibiotics
 CRB65 score: 1 point for each of
confusion, RR>30, BP<90/60 and
age>65yrs
 POCUS – lung scan
 CXR – pleural effusion
 No diagnostic test needed
12
 SpO2 target : 88 – 92%
 Salbutamol: start MDI (2-4puffs) or
Nebulisation (1 respoule), q20mins X thrice
 Ipratropium: MDI (2puffs) or neb (2 resp),
q20mins X 3 times
 Adequate hydration
 If precipitant is LRTI: give antibiotics as
per SR advise (see the Pneumonia section)
 *Oral/IV steroid (Inj. prednisolone 1mg/kg)
 Plan for NIV vs intubation – SR decision
 Red triaged - Shift to ‘Isolation’ Red area
 Supplemental O2 Target SpO2 > 94%
 Start antibiotics:
o CURB65 < 1: oral
o Tab Amoxi-clav 625mg, PO, TDS + Tab
Azithromycin 500mg, PO, OD X 5 days
o CURB65 > 2: IV: Inj. Ceftriaxone – 1g
IV BD (SR decision to escalate) +
Tab/Inj. Azithromycin500mg, OD
 Adequate IV fluids / oral hydration
 SR discretion for starting dexamethasone
 If patient is in respiratory distress, shift the
patient to Red area and plan for
thoracentesis
 Adequate O2 and IVF
 Inj. Epinephrine – 0.3mg, IM, anterolateral
thigh X repeat if necessary
 Neb SABA + ipratropium (as described in
asthma section)
 Inj. Ranitidine – 50mg, IV
 Inj. Hydrocortisone – 250-500 mg, IV

Acute heart failure and
Pulmonary edema (non-cardiac
causes of fluid overload)
Cardiac causes
Pulmonary embolism (PE)
Cardiac tamponade
Metabolic acidosis
Metabolic and Others
 H/O SOB on exertion, any heart  ECG – for ACS, arrhythmias
disease, previous similar history, PND  Lung POCUS – B/L B-profile
 Raised JVP, bilateral crepitation,  Echo – EF measurement, valve
cardiac murmurs, pedal edema motion, cardiac tamponade
 If associated with chest pain – follow  Blood gas: oxygenation, acidosis, K+
the Chest pain section  CXR – bilateral hilar prominence (bat
 Check non-adherence to medications wing pattern)
 H/O RHD and valve replacement  BNP/ NTproBNP – raised
 H/O CKD, haemodialysis schedule,  Send INR (in RHD patients)
CLD  RFT, LFT
 USG KUB (AKI vs CKD)
 H/O chest pain, SOB, syncope, prolong  ECG – sinus tachycardia, ST/T
immobilisation, malignancy, unilateral changes, RBBB/RAD
leg swelling, previous H/O PE  POCUS – RA, RV dilatation, RV
 One important differential of SOB dysfunction; CXR – usually normal
WITH CLEAR CHEST  Send – CBC, coagulation, RFT
 Tachypnea, tachycardia, hypoxia, DVT  USG Doppler of lower limb: to r/o
suspected DVT
 CTPA and D-dimer *
 H/O trauma, mediastinal or lung  ECG – low voltage QRS, electrical
malignancy, CKD, TB alter nans
 Signs – raised JVP, hypotension  Echocardiography
 H/O diabetes, oral anti-  Metabolic acidosis: pH < 7.35,
diabetics/insulin non-adherence HCO3 < 22, pCO2 decreased
 Polyuria, polydipsia, polyphagia,  DKA:
abdominal pain, recurrent vomiting, o RBS > 250 mg/dL
 Any signs and symptoms of infection o VBG: pH < 7.3, HCO3 < 18
 H/O CKD + haemodialysis o Urine ketones +
 Send electrolytes (K+), RFT,
 USG KUB ( AKI vs CKD,
Pyelonephritis)
13
 Head end elevation and O2 as needed
 Decide according to BP:
 If > 140/90mmHg:
 Inj. Furosemide – 40mg, IV
 NIV and NTG infusion as per SR
o Normal BP:
 Inj. Furosemide – 40mg, IV
 NIV – as per SR advice
o < 90/60 mmHg: follow SR advice
 If suspected LRTI: start antibiotics
 Management of uraemia – as per SR advice
 O2 as per requirement
 Follow SR instructions
 If planned to start anticoagulation:
o Inj. Enoxaparin – 0.6mL s.c BD OR
o Inj. UFH – 80U/kg IV stat, f/b infusion
@ 18U/kg/hr
 Shift the patient to Red area
 Follow SR instructions
 Primary survey and stabilisation
 For DKA:
o 2 wide bore IV lines, IVF (1L/hr RL)
o Check serum K+ (VBG) and follow SR
advice to start insulin + KCl infusion
o Connect to ECG & put Foley’s (UO)
 Follow SR instruction for managing
metabolic acidosis: like starting NaHCO3
infusion

Salient history to be taken
Onset: sudden (think vascular cause)
Duration, progression
Fluctuating symptoms? delirium
Associated symptoms
- Fever, headache, vomiting, photophobia
- Focal limb weakness, speech disturbance
- H/o seizure
- h/o toxin/ drug overdose/bite/sting
- h/o trauma
- h/o Cough/ dyspnoea/dysuria/loose
stools
Co-morbid illness: Diabetes, Hypertension,
Coronary artery disease, CKD, CLD, COPD,
Malignancy, Tuberculosis, Psychiatric
illness, previous stroke, Thyroid disorder,
other
Medication history:
- Anticholinergics, sedatives,
anticoagulant
- Psychiatric/ Thyroid medication
- any change in dosage, drug overdose
- any history of illicit drug use, alcohol
use, use of herbal medications
- Oral contraceptive pills/ Other
Assessment of a patient with Altered Mental Status
Salient clinical examination
 Complete primary assessment
including temperature
 Focal neurologic deficit
 Pupillary examination
 Plantar reflex
 Meningeal signs
 Head to toe & focussed systemic
examination
- To assess if features match any
toxidrome (refer toxicology section
; page )
- For features of chronic liver
disease, CKD or thyroid disorder,
i.v. drug abuse
- If any other focus of infection
 Focussed neurological
examination including reflexes
(DTR)
RED FLAG SIGNS
Compromised Primary Survey
Extensor posturing/ anisocoria on pupillary examination
H/o toxin ingestion
Blood gas s/o severe acidosis/ high lactate value
Ongoing seizure
Point of care Investigation
Investigations to be done based on
probable clinical diagnosis
If suspected acute stroke – expedite as
per stroke protocol (refer page 8)
 RBS
 CBC - infection? Low platelet?
 RFT, Serum electrolytes, Bilirubin
 Blood gas – acidosis, initial
electrolytes, lactate, anion gap
 PT/aPTT/INR – in suspected
coagulopathy
 ECG – toxins & electrolyte changes
 Urine toxin screen
 Blood culture if sepsis is suspected
 POC Malaria Ag test (if suspected)
 Imaging
NCCT head- intracranial bleed?
CECT brain: Meningoencephalitis?
SOL? Brain abscess?
MRI brain – stroke/TIA
 Lumbar puncture - in Meningitis
(after r/o raised ICP, coagulopathy)
14
Basic initial management
*Always discuss with the Senior Resident
on shift before proceeding with any of the
following management
Shift to Red area if Red flags present
 IV crystalloid bolus RL( if SBP < 90)
 Supplemental oxygen if SpO2 < 94%
If RBS < 70mg%
- Inj. Dextrose 50% 50ml i.v. stat
- Inj. Thiamine 100mg i.v.
(if h/o regular ethanol use/ has poor
nutrition status)
Treat as per the probable diagnosis
Consult SR if diagnosis is unclear
*Antibiotics in Meningitis dose (if
Meningitis suspected) Refer page 34
Anti- hepatic encephalopathy measures

Quick differentials for Altered Mental Status in ED
T Trauma
Toxin/Drugs – Anticholinergic, Sympathomimetic,
Sedative hypnotic, Opioids, psychiatric medications,
overdose of prescription medications
I Intra cranial event – stroke/ bleed/CVT
Infection – Meningitis, Encephalitis
(bacterial/viral/parasitic)
Cerebral malaria
Septic encephalopathy
ICSOL – Tumour, Abscess, Metastasis
M Metabolic Hypoglycaemia
Hepatic
Uremic
Wernicke’s
CO2 retention
Malignancy related
E Electrolyte related – Sodium, Calcium
Endocrine - Thyroid related
Hyperglycaemic emergencies
Environmental Hypothermia/ heat stroke
Bites/ stings
High altitude/ marine/dive
Epilepsy disorder
Brief Initial approach to Seizure in ED
Salient History
 Onset of seizure, Number of episodes,
interval between episodes
 Semiology : Description of the seizure
- Presence of any aura
- Focal onset? Loss of consciousness?
GTCS?
- H/o tongue bite, secondary trauma
- Bladder/ bowel incontinence
- Any post ictal confusion
 H/o Previous seizure disorder, anti-
seizure medications and compliance to
medication, recent change is medication
or dosage of medication
 Any precipitating event?
- Sleep deprivation/stress
- Dehydration
- Fever/ focus of infection
- Any new medication intake with
drug interaction
 Ask history pertaining to other
precipitating events as given by TIME
mnemonic in the previous column
 H/o chest pain, palpitation (? Syncope)
Salient examination & POC Investigations
& Red Flags as in above AMS section
 Neuroimaging is indicated in all cases of
1st episode of unprovoked seizure
presenting to ED
15
Basic Initial management of patient with seizure
 Rule out Hypoglycaemia in all patients with seizure
 If RBS < 70mg/dl, Inj. Dextrose 50% 50ml IV
 If patient has an ongoing seizure
- Protect patient from falls/ trauma
- Inj. Lorazepam (0.1mg/kg) 4mg IV /IM (if
no iv access)
- Inj. Midazolam 0.05-0.1mg/kg IV
- Midazolam Nasal spray 2puffs in each
nostril (if available)
 Common anti-epileptic drugs in ED & dose
- To be prescribed only after discussing with SR
- All anti-seizure medication except Fosphenytoin to
be diluted in 100ml NS and administered slow IV
over 20- 30 minutes
- Inj. Levetiracetam 20-30mg/kg BW
- Inj. Phenytoin 10-20mg/kg BW (max 1g)
- Inj. Fosphenytoin 10-20mg PE/kg IV
- Inj. Sodium Valproate 20-40mg/kg IV
- Tab. Levetiracetam 500mg/750mg/ 1g BD
- Tab. Phenytoin 100mg TDS/ 300mg HS
- Tab. Clobazam 10mg OD/BD
- Tab. Clonazepam 0.5mg/ 1mg OD/BD
- Tab. Carbamazepine 100mg OD/BD
For patients with previous diagnosed Seizure disorder, non-
compliant to medications; not all patients require NCCT
brain. Discuss with SR for indication

Salient history to be taken
2
(LMN-OP QRST ) 2
 Last menstrual period/menstrual history
 Medical history: Diabetes, Hypertension,
Coronary artery disease, Chronic Kidney
disease, Malignancy, other co-morbid illness
 Natal & ante-natal history (when indicated)
 Onset of pain
 Provocative/ Palliative(relieving) factors
 Quality of pain – colicky? Dull aching?
 Radiation of pain
 Symptoms associated : Fever, rash/
Nausea, vomiting, sweating, palpitation,
syncope / Constipation, loose stools
Abdominal distension, jaundice/ hematemesis,
haematochezia/ dysuria, haematuria, decreased
urine output/
bleeding pv, discharge per vagina/ altered
mental status, seizures/ Cough, expectoration
 Timing of pain
 Treatment history : medications patient is
previously continuing & medications if any
given at the referring healthcare facility
 H/o Recent or past surgery
Assessment of a patient with Pain Abdomen in ED
Salient clinical examination
 Complete primary assessment
 Head to toe examination for any
stigmata of chronic disease
 Chest auscultation to look for air
entry, wheeze, crepitation
 Abdomen: for swelling, scars,
sinuses, ecchymosis, dilated
veins/ Tenderness, guarding,
rigidity, rebound tenderness,
organomegaly/ bowel sounds
 Hernial orifices
 Scrotum/ testicular examination
 Per rectal examination (when
indicated)
 Cardiac auscultation for any
murmur
 CNS – Patient sensorium and
focused neurological exam (when
indicated)
Point of care Investigation
Investigations to be done based on
probable clinical diagnosis.
 ECG (if suspecting ACS)*
 RBS (random blood sugar)
 Urine pregnancy test/ b-hCG
(women in reproductive age
group)
 Blood gas & lactate
 Baseline CBC & Renal
function Test, electrolytes
 Blood grouping & cross
matching
 Bilirubin, liver enzymes
 Amylase/lipase
 Clotting function (PT/ INR)
 Blood culture (if indicated)
 POCUS : Patient’s fluid status,
presence of free fluid in
abdomen, Abdominal Aorta
Imaging:
 Abdomen X-ray erect/ lateral
decubitus – if suspecting
obstruction/ perforation
 USG abdomen –Appendicitis.
Gall bladder, Hepatic, Renal,
OBG pathology, pancreas
 *CT abdomen (NCCT/
CECT/CT-angiography) –
Vascular pathology, complex
pathology not picked on above
imaging
16
Basic initial management
*Always discuss with the Senior Resident
on shift before proceeding with any of the
following management
* Resuscitation: If patient has
compromised A, B,C
 Shift to Red area/ monitored bed
 Oxygen supplementation – hypoxia
 Wide bore i.v. access with – shock
 i.v. crystalloids
 Arrange blood products
Antiemetic: (any one)
Inj. Ondansetron (emeset) 4mg/8mg i.v.
Inj. Metoclopramide (perinorm) 10mg i.v.
Inj Pantoprazole 40mg i.v. (Antacid)
Analgesic: (any one)
Inj. Paracetamol 1g i.v.
Inj. Tramadol 50mcg in 100ml NS i.v.
Inj. Buscopan 10mg i.v. or i.m.
Inj. Drotaverine 20mg i.v
Inj. Diclofenac 75mg i.v. or i.m.
NG tube insertion – If GI bleed or
suspected obstruction for bowel
decompression
Foleys catheterisation: urinary obstruction
or patient in shock (monitor urine output)
*i.v. / oral antibiotics – suspected
infection/ sepsis
 17

Quick differentials for Pain abdomen in ED

RED FLAG SIGNS

 Unstable primary survey
 Female patient in a reproductive age group with pain abdomen with or without bleeding per vagina
 Elderly hypertensive patient with pain abdomen
 High blood sugars or metabolic acidosis on blood gas
 18

Initial assessment of a patient with UGI Bleed

Salient history to be taken Salient examination POC Investigation Basic initial management
 Quantity – Duration, No of episodes per day, Amount  Complete primary survey  Blood grouping and Cross Shift to Red area in case of Red Flag signs
of bleed per episode  Per Abdomen: Ascites, match *Inform SR about the case
 Colour – Coffee /Dark/Fresh tenderness  CBC – Hb, PLT, TLC  Get wide bore i.v. access (18 or 16 G)
 Blood gas - Lactate, Base
 Differentiate between hematemesis and haemoptysis*  CNS: GCS, Focal deficit  IVF RL 1L bolus. (IF patient in shock)
deficit
Additional fluid based on patient
 Malaena - Black, foul smelling, sticky, associated  RS: Decreased breath  LFT, RFT profile.
with loose stools sounds, localised  PT/INR
Variceal bleed (CLD):
 Associated: Haematochezia without clots, Altered crepitation  ECG if age > 50y,
 Inj. Somatostatin 500 µg stat f/b 250
sensorium, Abdominal pain, Fever, Decreased urine h/o CAD
µg/hr infusion OR
output, other bleeding manifestations  Signs of CLD if aetiology  Inj. Terlipressin 1-2mg IV q 4th hrly
 USG abdomen – IF  Inj. Pantoprazole 40mg IV
 Previous history of hematemesis and treatment if any of bleed is unknown**
previous CLD is
 Chest pain, epigastric pain undiagnosed Non variceal bleed (others):
Never send an unstable  Inj. Pantoprazole 80mg stat f/b 8mg/hr
History for aetiology
infusion
 H/o Jaundice, abdominal pain, fever, vomiting, patient for USG abdomen
 NG lavage (Do not perform without
history of CLD, alcohol intake, blood transfusion: supervision if patient has compromised
CBNAAT – COVID 19
CLD airway or in altered sensorium)
testing for UGI scopy
 Antibiotics: Inj. Cefotaxim 2g IV ATD
 H/o medication use – NSAID abuse, Anti platelet
(Aspirin, Clopidogrel), anticoagulant, Steroids: Blood products
 Activate Massive Transfusion Protocol
Peptic ulcer disease
if patient has ongoing GI bleed with
 H/o vomiting and retching, Binge drinking, DKA: haemorrhagic shock (Discuss with SR)
Mallory Weiss tear RED FLAG SIGNS  Transfuse PRBC if
 o Active bleed
 H/o loss of weight, loss of appetite, abdominal Unstable primary assessment
o Hb < 7
distention, anorexia: Gastric malignancy  Massive/ ongoing UGI Bleed  RDP if PLT < 50,000/massive bleed
Co-morbid illness: Diabetes, Hypertension, Chronic  FFP if INR > 1.5/massive bleed
liver disease, Coronary artery disease, GI Malignancy
Inform SR Gastro for UGI Scopy
 19

Initial assessment of a patient with Haemoptysis

Salient history to be taken Salient clinical POC Investigation Basic initial management
examination
 Quantity – Duration, No of episodes per day, Amount  Complete Primary survey  Blood grouping and Cross *Always discuss with the Senior Resident
match on shift before proceeding with any of
of bleeding per episode  Respiratory system for the following management
 Colour – Bright red blood/Frothy/ mixed with sputum  CBC – Hb, PLT, TLC
features of COPD, lung
 Blood gas – PO2, PCO2,
 Differentiate between hematemesis and haemoptysis* Malignancy, wheeze , Shift to Red area if Red Flag signs
Lactate
 Associated: Cough, expectoration, Fever, loss of
crepitation  RFT  Supplemental O2 if SpO2< 94%
weight & appetite, Decreased urine output, other
 Cardiac auscultation for  PT/INR  Get wide bore i.v. access
bleeding manifestations murmurs  Troponin/ D-dimer*  IVF RL 500mL bolus. (IF patient in
 Chest pain, epigastric pain, syncope  Head to toe for any e/o  POCUS e/o LRTI, Lung
shock); Additional fluid based on
 Dyspnoea/ orthopnoea mass/abscess/ Valvular
autoimmune diseases, patient profile.
heart diseases, Pulmonary
 Previous history of haemoptysis and treatment if any systemic bleeding embolism - Inj. Tranexamic acid 1g i.v. stat
 H/o trauma/invasive procedures manifestation  ECG
- Treat co-existing LRTI if present
 H/o epistaxis  CXR
 Oro-nasal examination with antibiotics #refer Page 34
Never send an unstable
for any local causes of patient for CXR
Co-morbid illness: Diabetes, Hypertension, Tuberculosis, - Transfuse PRBC if Hb <7g/dl
bleeding - CT Bronchial angiogram
COPD, Coronary artery disease, Valvular heart disease - Correct deranged coagulation if any
(CTBA)
Malignancy, Autoimmune diseases - For patients with massive
Medication History: Anticoagulant medication, haemoptysis For TB/ Bronchiectasis/ Fungal
antiplatelet, Treatment given at referring hospital (if any),
infection/ Lung malignancy related
illicit drug abuse CBNAAT – COVID 19
testing for massive Haemoptysis – SR pulmonary medicine
RED FLAG SIGNS haemoptysis cases with consult for admission/ intervention
planned procedure
 Unstable primary assessment
 Patient has massive/ ongoing haemoptysis *If clinically indicated
 Patient with cardiac ailments or on anticoagulant medications
 20

Quick guide on Haemoptysis, Hematemesis, Oro-nasal Bleed in ED

Hematemesis vs Haemoptysis Oro- Nasal bleed  Shift to red area if compromised primary survey
 CLD/Peptic ulcer  TB/CA lung - Wide bore i.v. access; arrange blood, CBC, Coagulation studies
 Dark brown/coffee colour  Fresh blood If patient has epistaxis,
- Anterior epistaxis: external pressure by pinching the nose x15-20 mins
 Vomiting precedes blood  Cough precedes blood
- Topical phenylephrine/ Oxymetazoline
 Not frothy  Frothy due to air - Posterior epistaxis: Check BP, treat hypertension if BP > 160/90
 Melena – Present  Melena – Absent - If persistent bleeding – anterior/ posterior nasal packing/ cauterization
 Food particles – Present  Food particles – Absent If oral bleed : check source – trauma, tumour, tooth
- Topical vasoconstrictor/ pressure/ haemostat – Inform SR on shift
 Acidic pH  Alkaline pH
Management of UGI bleed case Post Endoscopy Haemoptysis
 Repeat CBC if patient has hemodynamic instability, ongoing GI bleed,  Massive Haemoptysis: Blood loss of 100-600ml in 24 hours
If not @ 12 hours post endoscopy
Variceal Bleed  Practical definition of Massive Haemoptysis in ED : Any amount of
haemoptysis that causes airway , breathing or hemodynamic
 High grade varices: Somatostatin infusion for 72 hours
compromise
 Low grade varices: Somatostatin infusion for 24-48 hours
 Requires imaging MDCT/ CT bronchial angiogram  aetiology
Non Variceal Bleed evaluation  intervention (radiology/CTVS)
 High grade ulcers: NPO for 24 hours, Pantoprazole infusion/boluses for 3-5 days
 Low grade ulcers: Discharge with oral Pantoprazole 40mg BD  Minor Haemoptysis with recurrent episodes, deranged coagulation or

Re-bleed/Failure endoscopy: anticoagulant medications require ED evaluation & observation

 >100ml bleed in 2 hours  Other cases of minor haemoptysis may be reassured and referred to
 Unstable Vitals OPD after explaining warning signs
 Haemoglobin drop by > 3gm/dl
 Haematocrit drop >9%
 Monitor vitals every 2 hourly


Salient history to be taken
 Onset, duration, progression
 Number of episodes
 If oral intake present
 Associated Fever/ cough/ URI symptoms
 Last urine output/ decreased urine output
 Loose stools: If associated with blood,
mucus, colour, consistency
 Vomiting: If associated nausea present,
Colour – red, brown/black (hematemesis),
Bilious/ non bilious/feculent
 If associated pain abdomen, distension,
constipation/obstipation
 Previous history of similar complaints/
any abdominal surgeries
 Allergy to any specific food substance
 H/o headache/ chest pain
Co-morbid Illness: Diabetes, Malignancy,
Thyroid disorders, Inflammatory bowel
disease, HIV
Drugs & toxin: Chemotherapeutic drugs,
Immunosuppressive drugs, Digoxin, Other
Toxin/ Organophosphate compounds
21
Initial assessment of a patient with Gastro-intestinal symptoms
Salient clinical examination Point of care Investigation Treatment / Disposition plan
 Complete primary survey Investigations to be done based *Always discuss with the Senior
on probable clinical diagnosis Resident on shift before proceeding with
 Head to toe: signs of any of the following management
 RBS
dehydration, stigmata of
 Hb, TLC, Platelet
Shift to monitored area/ Red area if Red
hyperthyroidism, other co-
flag signs present
If indicated clinically,
morbid illness, odour, features
 Blood gas: Lactate, Base deficit
of toxidrome If in Shock , wide bore IV access
 RFT + Serum electrolytes IV crystalloid bolus (RL 1L) reassess
 P/A : Distension, guarding/
 ECG (ACS, Hyper/Hypo K+)
rigidity, scar, Bowel sounds Common Antiemetic drugs
 POCUS: fluid status, Echo
 CNS: Any focal Neurologic Inj. Ondansetron (Emeset) 4mg/8mg IV
 Abdomen X-ray erect/ Inj.Metoclopramide (Perinorm)10mg IV
deficit, pupils, cranial nerve
lateral decubitus - ? Tab. Ondansetron 4mg/8mg
involvement, meningeal signs
obstruction/ volvulus
 CVS & RS : Tachycardia, Drugs for Non-infective diarrhoea
 USG abdomen/ NCCT without warning signs
irregular heart rate, systolic
abdomen – intra-abdominal  ORS ad lib
murmur, crepitation
 Tab. Racecadotril 100mg TDS
pathology
(anti-secretory agent)
# Refer page 34 for other
RED FLAG SIGNS
? Intestinal obstruction:
 Compromised primary survey
 Keep Patient NPO
 Severe dehydration, decreased urine output
 NG tube  continuous drainage
 Metabolic acidosis, high lactate on blood gas
 IV hydration
Presence of vomiting does NOT localise the pathology to abdomen.
Treat hypokalaemia if any
Rule out life threatening emergencies like acute coronary syndrome,
IVF NS + Inj. KCl 20/40meq @
raised ICP, endocrine & toxicological emergencies, obstruction
100ml/hr
thorough history & clinical examination

Salient history to be taken
 Onset
 Duration
 >100.4 F- Fever, >105.8F Hyperpyrexia
 Timing & Pattern- Continued, Remittent,
Intermittent
 Associated symptoms- Chills & rigor,
Productive cough, Shortness of breath, URI
Symptoms, Chest pain, Dysuria, Increased
frequency of urination, Flank pain,
Abdominal pain, Loose stools, Decreased
urine output, Nausea & Vomiting, Rash,
Headache, Altered sensorium, Yellowish
discoloration of skin
 Co- morbidities- DM, Malignancy,
HIV/AIDS, Liver Disease, CKD, Post-
transplant, Previous surgeries, Thyroid
disorder
 Recent hospitalization or use of antibiotics
 Recent history of travel
 Current medication- Chemotherapy,
Glucocorticoids, Psychiatric medications
 Any Drug/ Medication intake
Assessment of a patient with Fever in ED
Salient physical examination
 Complete primary assessment
 Temperature
 General physical examination
from head to toe including oral
cavity & ENT, skin and
extremity examination
 Chest examination for wheeze,
crepitation, pleural rubs or
dullness on percussion
 Cardiac auscultation for
pericardial rub or new onset
murmur
 Abdominal examination to look
for guarding and rigidity
 CNS examination to look for
mental state, nuchal rigidity,
Kerning’s & Brudzenski sign,
any cranial nerve involvement,
limb rigidity & reflexes
22
Point of care investigation Basic initial management
Investigations to be done based Shift to Red area if Red flags present
on probable clinical diagnosis  Oxygen by face mask if hypoxic
 Complete blood count  Initiate IV NS/RL bolus of in shock
 Blood gas & lactate  Paracetamol 650 mg oral OR 1g i.v.
 Liver & Kidney function  *Antibiotics as per suspected or
tests
source of infection
 Blood Culture
 *Broad spectrum antibiotics if
 Optimal & peripheral
unknown source of infection
smear for malarial parasite
 RAT & CBNAAT for * Always discuss with the Senior
COVID-19 Resident on shift before proceeding
 POCUS – for shock
with these
evaluation, source of
infection (chest
/abdomen/extremity)
 Chest X ray
 CECT & CSF analysis if
meningitis/encephalitis is
suspected
 23

Common Differential diagnoses of Fever in ED

Respiratory  Otitis media Non Infectious Causes (Hyperthermia)
 Bacterial/ Viral pneumonia  Sinusitis/ Pharyngitis  Thyroid storm
 Intracranial haemorrhage
 Peri-tonsillar abscess  Bronchitis
 Neuroleptic-malignant syndrome
 Retropharyngeal abscess  Influenza  Serotonin Syndrome
 Epiglottitis  Tuberculosis  Anticholinergic or sympathomimetic toxicity
 Malignancy/ Autoimmune disorders
Neurologic Skin & soft tissue infection
 Gout/ Sarcoidosis
 Meningitis, Encephalitis  Cellulitis  Transfusion reaction
 Brain abscess  Infected decubitus ulcer  Transplant rejection
 Cavernous sinus thrombosis  Soft tissue abscess  Drug fever
 Pancreatitis
Cardiovascular Systemic
 Deep vein thrombosis
 Endocarditis  Meningococcemia  Recent seizure
 Pericarditis  Sepsis or septic shock
Gastrointestinal Other Acute Febrile illness Warning signs in case of Fever

 Peritonitis/ Intra-abdominal abscess  Dengue  Unstable primary assessment

 Appendicitis  Malaria  Persisting vomiting/ No oral intake

 Cholecystitis  Scrub Typhus  Pain abdomen with guarding/tenderness

 Cholangitis  Leptospirosis  Decreased urine output

 Diverticulitis  Typhoid  Thrombocytopenia <20,000

 Colitis or enteritis  Other seasonal viral illness  Bleeding manifestation/ positive tourniquet test

Uro-genital  Vulnerable population : Pregnancy, infancy, old

 Urinary tract infection/ Pyelonephritis age, Immunocompromised, Diabetic, renal

 Pelvic Inflammatory disease failure, poor social support


Salient history to be taken
 Time of ingestion
 Substance ingested and amount
 Suicidal/Accidental/Homicidal
 Symptoms: nonspecific (nausea vomiting
abdominal pain) & specific toxidromes*
 Previous psychiatric/ Co-morbid illness
 Medication history: Patient previously
continuing & medications if any given at the
referring healthcare facility
Common Agents encountered in AIIMS ER
 Corrosives
 Drugs(Benzodiazepines/PCM/antipsychotics)
 Rodenticides (Superwarfarin/Aluminium
phosphide)
 Cypermethrin(All out)
 Organophosphates
Assessment of a patient with Toxin Ingestion
Salient clinical examination
 Compete primary assessment
 Check consciousness and
pupils
 Particular odors associated
with certain intoxicants
 Examine skin and mucous
membranes  discoloration
and hydration
 Examine CNS focusing on
muscle tone, clonus,
hyperpyrexia
 Evidence of drug abuse
RED FLAG
 Unstable primary assessment
 Patient with persistent vomiting
Point of care Investigation
Investigations to be done based
on probable clinical diagnosis.
 ECG
 RBS
 Baseline CBC & Renal
function Test
 Blood gas
 Urine Toxicology
 Chest X-ray & Abdominal
X-ray (in corrosive
ingestions)
 Osmolar gap (urine/serum)
24
Treatment / Disposition plan
*Always discuss with the Senior
Resident on shift before proceeding
with any of the following
management
 Oxygen if SpO2< 94%
 IV crystalloid bolus – if SBP <90

Inj. Dextrose 50% 50ml i.v. if
RBS< 70mg/dl with
 Inj. Thiamine 100mg i.v.
Treat as per the toxin*
refer next page
 Do not do lavage for patients with
corrosive ingestion
 For patients with persistent
vomiting, altered sensorium,
unstable airway do an NG lavage
only under SR supervision
 Every patient coming with history
of toxin ingestion is a Medico
legal case (MLC). The same has
to be made and countersigned by
the Senior Resident.
 25
Quick guide to important Toxidrome
Cholinergic (organophosphates and carbamates) Anticholinergic Sympathomimetic
• Salivation • Altered mental status • Agitation
• Lacrimation • Mydriasis • Tachycardia
• Diaphoresis • Dry flushed skin • Hypertension
• Vomiting, Urination • Urinary retention • Hyperpyrexia
• Defecation • Decreased bowel sounds • Diaphoresis
• Bronchorrhea, bronchospasm, bradycardia • Hyperthermia • Seizures
• Fasciculation • Dry mucous membranes • Mydriasis
• Miosis • Seizures & Arrhythmias • Acute coronary syndrome
• Seizures
Antidote: Atropine (Initial dose 0.6- 2mg i.v.)
Snake Bite Corrosive injury Opioid
 Neurotoxic  Look for Airway compromise • Hypoventilation
- Look for signs of limb weakness /diplopia/ptosis) (hoarseness of • CNS depression
- Do a Single Breath Count (<10) voice/stridor/difficulty breathing) • Hypothermia
 Hemotoxic  Signs of Perforation • Bradycardia
- Whole Blood clotting time (>20 mins) (Guarding/rigidity/hematemesis) • Miosis
- Signs of obvious bleeding Antidote: Naloxone
Antidote: Anti-snake Venom (only if signs of envenomation) (Initial dose: 2 mg i.v.
(Dose: 10 vials ASV in 500ml 5% dextrose over 1 hour ) OR 0.4 mg i.v. in chronic drug user)
Other common antidotes N-acetyl Cysteine dose
 N-acetyl cysteine: Paracetamol Intravenous: (for an average 60kg person)
 Sodium bicarbonate: Sodium channel blockers toxicity 150mg/kg in 200 ml 5% dextrose i.v. over 1 hour (9g in 200ml 5%D)
 Glucagon: Calcium channel blockers/ β-Blockers toxicity 50mg/kg in 500mL 5% D over 4 hours (3g in 500ml 5%D @ 125ml/hr)

 IV lipid emulsion 20%: Local anesthetic toxicity 100mg.kg in 1L 5% D over 16 hrs (3g in 500ml 5%D @ 60ml/hr)

 Methylene blue: Oxidizing toxins (e.g nitrites, benzocaine, sulphonamides) Oral dose :

 Hydroxycobalamin: Cyanide Loading dose: 140mg/kg PO stat.

Maintenance: Start after 4 hrs 70mg/kg PO q4th hourly X 17 doses
 Flumazenil: Benzodiazepines toxicity
 26
Approach to an Unresponsive patient

Salient history to be taken
 Duration of Chronic Liver Disease
 Aetiology (if already known)
- Ethanol, Viral, autoimmune,
- Non-alcoholic Fatty Liver disease
(NASH/ NAFLD)
- Hepatocellular Ca (HCC)
- Budd Chiari syndrome/HVOTO
 Current symptoms
- UGI bleed, Melena, Constipation
- Fever, Abdomen pain/distension
- Worsening jaundice/ other bleeding
- Cough/ shortness of breath/syncope
- Altered sleep /sensorium/ Seizure
- Loose stools/decreased urine output
 Past & treatment history
- Medications patient is taking
- Previous UGI scopy/colonoscopy
- Previous episodes of similar illness
- H/o Portal venous thrombosis/
anticoagulant medication
Co-morbid illness
Diabetes, Hypertension, CAD
Hepatitis B (HBV) , HCV
Assessment of a patient with Chronic Liver Disease (CLD) in ED
Salient clinical examination
Complete primary survey
Head to toe examination: Pallor, oedema
Stigmata of CLD
- Frontal alopecia, Icterus
- Parotid enlargement (raised ear lobule)
- Spider angioma (telangiectasia)
- Loss of axillary hair, Gynaecomastia
- Palmar erythema, Asterixis
- Duputryn’s contracture
- Ascites, caput medusa
- Testicular atrophy
Other: Ecchymosis/ bleeding manifestation
P/A: Ascites – shifting dullness/ fluid thrill
Organomegaly, Bowel sounds, scrotal
oedema, hernia orifices
Chest: Decreased breath sounds/ crackles
CVS: Any systolic murmur?
CNS: Focal neurologic deficit, pupils,
Meningeal signs
Per rectal examination – For melena
(if there is diagnostic dilemma)
Point of care investigation
 Blood grouping & Cross
match
 CBC – Hb, PLT, TLC
 Blood gas – Lactate; RBS
 LFT, RFT + S. electrolytes
 PT/INR/apTT
 POCUS: Fluid status of
patient, Ascites, pleural
effusion/ any e/o LRTI
 ECG if age > 50y, h/o CAD
 Ascitic fluid (SBP): TC/DC/
protein/ albumin & culture
Imaging:
 USG abdomen – If previous
CLD is undiagnosed, portal
venous thrombosis
 X-ray abdomen erect/lateral
decubitus: If perforation/
obstruction suspected
 NCCT brain – to r/o
coagulopathy related bleed if
anisocoria or focal deficit +
Never send an unstable patient
for imaging or USG abdomen
 CBNAAT – COVID 19
testing for UGI scopy
27
Brief initial management
 Get wide bore i.v. access
(18 or 16 G)
 IVF RL 1L bolus. (IF patient
in shock); Additional fluid
based on patient profile.
 Inj Dextrose 50% 50ml i.v. if
RBS <70mg/dl
 Inj Thiamine 100mg IV
 NG lavage ( To check for UGI
bleed/ active GI bleed)
For detailed management of UGI
bleed refer page 18
For management of other CLD
complications refer Page 29
RED FLAG SIGNS
 Unstable primary survey
 Active GI bleed
 Hb < 4g/dL
 Metabolic acidosis or high
lactate on blood gas

Salient history to be taken
 Duration & stage of CKD
 Present symptoms :
- Shortness of breath
- Chest pain, Palpitation, syncope
- Headache, seizure, limb weakness
- Fever, cough, expectoration
- Dysuria, pain abdomen, decreased
urine output
- Worsening limb/body swelling
- Vomiting, loose stools
 Symptom onset, progression &
associated features
 If patient has undergone renal transplant;
If yes, when? Immunosuppressive
medications & any complications
 Haemodialysis related history
- If Dialysis initiated, If yes, when?
- Number of Dialysis per week
- Last dialysis & if any events
- Access for dialysis – Fistula/catheter
 Medication history & baseline creatinine
 Blood transfusions if any
 Co-morbid illness : Diabetes, HTN, old
CVA, CAD, any autoimmune illness,
Malignancy, Retro-viral illness
Assessment of a patient with Chronic Kidney Disease (CKD) in ED
Salient clinical examination
 Complete primary assessment
 Head to toe examination: Pallor,
oedema, JVP, Oral cavity & skin
for any lesion/infective foci
including Dialysis access site,
Asterixis
 Chest auscultation - crepitation,
wheeze, dullness on percussion
 Cardiac auscultation for S3,
pericardial friction rub, muffled
heart sounds
 Quick neurological examination
– altered sensorium, focal deficit,
meningeal signs
 P/A for ascites, organomegaly,
renal angle tenderness
RED FLAG SIGNS
 Unstable primary assessment
 Tall tented T waves on ECG
 Severe metabolic acidosis or
Potassium > 5.9 on blood gas
Point of care investigation
 CBC – Hb, platelet, TLC
 RBS
 Blood gas – acidosis, K+ levels,
 RFT + Serum electrolyte
 ECG – Hyperkalaemia or ACS
 POCUS – Lung for fluid
overload, Pleural effusion, LRTI,
Pericardial effusion, LV function,
 *Blood group + Cross match
 *Urine microscopy – UTI
 *Blood/ Urine culture – Sepsis
*if indicated
Imaging
 USG abdomen: If dilemma
between AKI & CKD ; e/o
Pyelonephritis, Obstructive
uropathy
 CXR : LRTI/ Pleural effusion
Avoid sampling/ cannulation / BP
cuff attachment on the limb with
functional AV fistula
28
Basic Initial Management
 Obtain IV access (preferably
right upper limb)
Shift to monitored area/ red
area if red flags present
 Supplemental oxygen if
SPO2< 94 % ; Initiate NIV if
severely hypoxic with high
work of breathing
 POCUS guided IV fluids
Do not give IV fluid boluses
without consulting SR
 Anti-hypertensive medication
& IV Diuretics (Consult SR)
 If K+ > 5.5 – anti hyper-
kalaemia measures (Page 31)
 Other management - next page
Note:
1. Blood transfusion in CKD
patients to be done under strict
monitoring, preferably in red
areas
2. Post renal transplant patients,
being immunocompromised,
may be relatively asymptomatic
and hence require careful
examination before final
disposition

Diagnosis & management of common CLD, CKD related complications in ED
Hepatic Encephalopathy (HE)
West Haven classification of HE grades
1: Shortened attention span, reversal of sleep cycle,
euphoria/anxiety
2: Lethargy/apathy, minimal disorientation for time or
place, asterixis
3: Somnolence/ semi stupor, gross disorientation,
responsive to verbal stimuli
4: Comatose, unresponsive to verbal/ noxious stimuli
Management of Hepatic encephalopathy
- Syp. lactulose 30ml Q 4-8th hrly PO or via NG tube
- Tab Rifaximin 550mg PO TDS
- Correct electrolyte imbalance if any
(Hypokalaemia or Hyponatremia)
- Lactulose enema PR (if constipation not resolved)
- Treat precipitating cause/ infection
Pulmonary oedema/ SCAPE
Fluid overload
Insidious onset gradually progressive symptoms
Diuretics main stay of treatment
IV Furosemide 40-60mg IV
SCAPE (Sympathetic crashing acute pulmonary edema)
 Sudden onset dyspnoea
 Tachycardia, tachypnea, hypertension with
bilateral crepitation on chest auscultation
Management: Initiate NIV
 NTG IV bolus of 400-1000 mcg followed by IV
infusion at 100 mcg/min and rapid titration with
continuous BP monitoring Q 10-15minutes
Spontaneous bacterial Peritonitis (SBP)
- Fever, Abdomen pain, chronic ascites
- Worsening jaundice, Altered mental status,
decreased urine output
Diagnosis: Diagnostic ascitic tap
- >250 neutrophils/ul or TLC > 1000/uL
- Ascitic fluid culture positive
*R/o secondary bacterial peritonitis due to
perforation if patient has severe symptoms
Management of SBP
- Inj. Cefotaxime 2g IV ATD TDS OR
- Inj. Piperacillin – Tazobactam 4.5g IV ATD
f/b TDS ; 2.25g TDS (if AKI/CKD)
- Inj. Albumin 20% 1.5g/kg IV on day 1
Accelerated Hypertension : BP >180/110
Examine for end organ damage: Acute
coronary syndrome, Pulmonary oedema, Stroke,
AKI on CKD
If present – treat with IV medications
Else , oral antihypertensive may be given
 Tab Amlodipine 5mg, 10mg PO
 Tab Clonidine (Arkamine) 0.1mg/0.2 mg PO
 Tab Telmisartan 40mg PO
 Inj. Furosemide (Lasix) – 20mg-80mg IV
 Inj. Labetalol 10mg, 20mg IV
 Inj. Nitro glycerine infusion 25mg in 25ml NS @
0.6ml/hr (titrated as per BP)
*Always consult SR before prescribing any of above
29
Massive ascites
- Tense ascites with fluid thrill
- Associated dyspnoea/orthopnoea
Management :
- Therapeutic paracentesis (up to 5L) if
hemodynamically stable ;
- Send diagnostic samples to r/o SBP
- Inj. Albumin 20% if > 5L paracentesis 
give 8g/L tapped
- Expect worsening of HE
Hepato-renal Syndrome
- Inj. Terlipressin 2mg Q 4th – 12th hrly IV
- Inj. Norad 0.5-3mg/kg per hr
- Inj. Albumin 20% 1g/kg IV
Treat hypovolemia, infection precipitating AKI
Indications for Emergency dialysis
A: Acidosis (severe, refractory)
E : Electrolyte (refractory hyperkalaemia)
I : Ingestions (Dialyzable toxins)
O : Overload (Fluid overload/pulmonary edema)
U : Uremic symptoms( encephalopathy etc)

Salient history to be taken
 Malaise, generalized weakness, fatigue,
dyspnoea on exertion, headache,
orthostatic light-headedness, angina,
decreased exercise tolerance (Anaemia)
 Fever(recurrent infections) (Leukopenia)
 Petechiae, purpura, mucosal bleeding
(Thrombocytopenia)
 Other bleeding manifestation (UGI
bleed, Haemoptysis, Melena etc.)
 Fever, weight loss, night sweats
 History to localise any focus of infection
( Cough, expectoration, pain abdomen,
dysuria, vomiting, diarrhoea, headache/
seizures/ skin lesions, limb
redness/swelling, indwelling catheters )
 H/o prior/recent Blood transfusion
 H/o Recent Chemotherapeutic /
Immunosuppressive medications
 H/o previous similar illness/ family
history of illness
Co-morbid illness
Tuberculosis, Aplastic anaemia,
Malignancy( Haematological/other)
Assessment of a patient with Haematological disorder in ED
Salient clinical examination
 Complete primary assessment
 Temperature
 Skin & mucosa: rash, petechiae,
ecchymosis, folliculitis/ vesicular
lesion
 Lymphadenopathy
 Fever or focal sign of infection –
Lung/ Urinary tract/ per abdomen/
joints & soft tissue abscess, cellulitis / 
Indwelling catheter/ lines
 Active bleeding, including oral,
nasopharyngeal, haemoptysis vaginal,
and gastrointestinal
 Hepatosplenomegaly
 Stigmata of underlying cause of
pancytopenia
RED FLAG SIGNS
 Compromised primary survey
 shock index > 1 with neutropenia
 Severe anaemia/thrombocytopenia
 High lactate on initial blood gas
30
Point of care investigation Basic initial management
Investigations to be done based - IV access (widest bore possible)
on probable clinical diagnosis.
- Supplemental oxygen if SpO2
 Baseline CBC
< 94% or patient in shock
 RFT + Serum electrolytes - Shift to monitored area/ red
 Blood culture in all patients area in case of red flags
of Febrile neutropenia
Transfusion goals
when indicated,
 Blood gas, lactate  Asymptomatic patients: Hb ≤ 6
LFT/ PT INR  Known CAD: Hb ≤ 8 g/dL
 Blood group + cross match
 Symptoms of ACS  Hb10
 Chest X-ray (? LRTI)
 Abdomen X-ray and USG if  Thrombocytopenia
suspecting any intra- - Non-bleeding: <10,000
abdominal infection OR
- Clinically significant bleeding
neutropenic enterocolitis
≤ 50,000
 POCUS – focus of infection,
pleuro-pericardial effusion, Refer next page for other
fluid status of patient management
 Peripheral smear – to
evaluate for abnormal cells Do not give IV fluid boluses without
indicative of leukaemia, SR supervision for a severely
anaemic patient
lymphoma
 NCCT brain? IC bleed
 CECT brain - ? Infection
? CNS metastasis

Quick guide to common emergencies in Hematological disorders
Febrile Neutropenia
 A single oral temperature measurement of
≥38.3°C OR temperature of ≥38.0°C sustained
over a 1-hour period.
 Neutropenia: defined as an ANC of <500
cells/mm3, OR an ANC expected to decrease
to <500 cells/mm3 during the next 48 hours
 Look for signs of mucositis, abscesses, skin
breakdown, and line infections
 Take blood cultures & Start antibiotics ASAP
MASCC Score
Burden of illness: no or mild symptoms -- 5
Burden of illness: moderate symptoms --3
Burden of illness: severe symptoms --0
No hypotension (systolic BP >90 mmHg) -- 5
No chronic obstructive pulmonary disease --4
Solid tumour with no previous fungal infection -- 4
No dehydration –3 ; Age <60 years -- 2
Outpatient status (at onset of fever) -- 3
Scores ≥21 are at low risk of complications.
Score < 21 defines high-risk patients
Score >21 : Oral antibiotics & close follow up
Score < 21: Broad spectrum IV antibiotics
# Refer page 35
Treat source of infection – Abscess drainage /
removal of indwelling lines which are probable
source
31
Hyperleucocytosis Tumor Lysis syndrome
• Elevated WBCs > 50,000  H/o recent chemotherapy
• Typically > 1,00,000/ cc  Anorexia, lethargy, nausea, vomiting, diarrhoea,
• Typically seen in AML or CML with blast haematuria, seizures
crisis - Hyperuricemia (>7)
• Features of Leucostasis: Lung (hypoxia);
- Hyperkalaemia (>6)
CNS ( Vision changes, headache, dizziness,
- Hyperphosphatemia (>4.5)
Altered sensorium, IC bleed), Myocardial
- Hypocalcaemia (<8)
ischemia, Renal failure DIC
- Acute kidney injury
• Classic Triad is mucosal bleeding (epistaxis,
- Cardiac arrhythmia/sudden death
vaginal/rectal bleeding, hematuria), visual
- Seizures
disturbances, and altered consciousness
 High volume IV crystalloid to maintain urine
Management
output & prevent AKI
 Maintain Hydration
 T. Allopurinol 100mg BD (up to 800mg/day)
 Prophylaxis with Allopurinol (Tab 100mg BD)
 Anti- hyperkalaemia measures
 Treat hyperkalaemia
 Rasburicase(Inj. 6 mg over 30mins; single dose)
 Tab Hydroxyurea 50-100mg/kg/day OR
induction chemotherapy ( as per SR  Treat symptomatic hypocalcaemia
Haematology advice)  Renal replacement (Haemodialysis) if not
Transfusion goals: responding to above
Hb : 5-6 g/dl; Platelet : 10,000
Excessive transfusion precipitates hyper viscosity
symptoms

Guide to common medications used in ED
Medications for treating Hyperkalaemia (S. K+ > 5.5 mEq/L)
1. Get an IV access, send VBG, RBS and get an ECG for diagnosis of
Hyperkalaemia
2. Connect to continuous ECG monitor
3. Inj. CALCIUM GLUCONATE (10%) 10mL IV over 10 minutes
4. Inj. DEXTROSE (50%) 50 mL over 30 minutes
(give only if RBS < 250 mg/dL)
5. Inj. INSULIN (Regular) 10 units IV (give only if RBS > 70mg/dL)
(usually added to dextrose infusion)
6. Nebulisation SALBUTAMOL (1 respoule = 2.5mg) 4 to 8 respoules
over 10 minutes; (COVID transmission prevention: use MDI salbutamol
8 puffs q20minutes for 3 times)
7. *Inj, SODIUM BICARBONATE 100 mEq, infused over 30 minutes
8. *Inj. FUROSEMIDE 40 to 80 mg IV stat (avoid in anuric patients and
in hypotension)
9. If the patient is in cardiac arrest, all the above drugs (step 3 to 7 ) will be
given as IV bolus
*Discuss with SR on shift
32
Initial loading dose for suspected ACS patient
Expedite ECG within 10 minutes of patient’s arrival
Inform SR emergency medicine and show the ECG
1. Tab TRINITROGLYCERIN (0.4mg)/ ISOSORBIDE DINITRATE (5 mg)
– sublingual stat. May be repeated every 5 minutes X 3 times
2. Tab ASPIRIN (non-enteric coated, e.g. DISPIRIN) 300mg
(4 tablets of 75 mg) PO stat
3. Tab CLOPIDOGREL 300 mg (4 tablets of 75 mg) PO stat
4. Tab ATORVASTATIN 80 mg (2 tablets of 40 mg) PO stat
Important Precautions:
 Avoid Nitrates: ECG showing inferior wall or RV AMI (ask SR), SBP <
90mmHg or > 30 mmHg drop from baseline, marked tachycardia or
bradycardia, known case of HCM or severe AS, recent use of
SILDENAFIL (24hrs) or TADALAFIL (48hrs)
 Avoid ASPIRIN + CLOPIDOGREL: massive Upper GI bleed, suspected
stroke, known aspirin allergy
 Patient who is unable to take orally, all the above medications (2 to 6) can
be given through NG tube
 In patients who are being taken up for primary PCI , total dose of
Tab CLOPIDOGREL 600mg PO dose is given (additional 300mg PO)

Drugs for initial management of Upper GI Bleed
 Place 2-wide bore IV access (Green or Grey cannula)
 Send Blood samples – CBC, blood for cross match, VBG, INR, LFT/RFT
 If active and massive UGI bleed shift the patient to Red Area for airway
management
1. IVF 1L RINGER’S LACTATE bolus
2. Inj. PANTOPRAZOLE 80 mg IV stat followed by Infusion @ 8mg/hr
OR 40 mg IV BD (if suspecting PUD or NSAIDs related UGI bleed;
whereas in CLD, follow 40 mg IV OD only)
3. Inj. SOMATOSTATIN 500 mcg IV bolus followed by 250 to 500
mcg/hr IV infusion { if patient is a K/C/O CLD or variceal bleed is
suspected}
OR Inj. TERLIPRESSIN 1 mg IV every 4 to 6 hours
4. Inj. ONDANSETRON – 8 mg IV TDS
OR Inj. METOCLOPRAMIDE (Perinorm) 10 mg IV
5. Inj. CEFTRIAXONE 1g IV OD
6. Call blood bank for urgent PRBC transfusion, to keep Hb > 7 g/dL
7. Nasogastric tube lavage (14, 16 or 18”) with 10mL/kg NS, to see for
active bleed (bright red color) * To be done only when airway is stable
and hemodynamic resuscitation is initiated
 Inform SR Gastroenterology for UGI endoscopy planning
33
Common analgesics in ED
NSAIDs
1. PARACETAMOL (PCM) -
a. Oral: Tab PCM 325 to 650 mg q 6 hourly (max 3 g)
b. IV: Inj PCM 1 gram IV q6 hourly
2. DICLOFENAC: 75mg IM / IV / PO BD
Can cause severe thrombophlebitis and give diluted preparation when
administering i.v.; Avoid IM injection in patients with coagulopathy
3. IBUPROFEN: IV or PO IBU 400 to 800 mg q 6 hourly
4. INDOMETHACIN, PO tablet 25 - 50 mg q 8 hourlies
OPIODS
Have risk of respiratory depression and constipation/ obstruction
1. TRAMADOL: 50 – 100 mg, IM / IV / PO
Causes severe nausea and emesis ; Hence to be administered slowly i.v. or
diluted with 10 ml NS and preferably with antiemetic premedication
2. *FENTANYL: 1 mcg/kg, IV
(always connect to ECG/SpO2 monitor and elevate the head end)
3. *MORPHINE: 2 to 3 mg IV (max 0.1 mg/kg IV single dose) or
10 mg IM/SC can be administered also (follow same fentanyl precautions)
4. *PENTAZOCINE (Inj FORTWIN) 30 mg IV / IM / SC q 6 hrly
ANTISPASMODICS
1. DROTAVERINE: 40 to 80 mg, IM / slow IV q 6 hourly
FOR NEUROPATHIC PAIN
1. Tab NORTRYPTILLINE 10mg PO OD
2. Tab PREGABALIN 50mg PO OD to TDS
ADJUCTS TO ANALGESIA
1. Inj. PROMETHAZINE (Phenergan) 25 to 50 mg, IV / IM
2. Inj. PANTOPRAZOLE 40 mg + Inj. METOCLOPRAMIDE 10 mg
 34

Common Antibiotics in ED and their doses (Syndromic approach) – A quick guide

To be prescribed after consulting SR on shift
PNEUMONIA / LRTI: DIARRHEA:
1. CRB-65 (<1): Outpatient: 1. Non-bloody: No antibiotics recommended
Tab AMOXICILLIN-CLAVULINIC ACID (625mg) PO TDS + DO NOT prescribe Ciprofloxacin of Metronidazole for every case of diarrhea
Tab AZITHROMYCIN 500mg PO OD X 5 days 2. Bloody diarrhoea or fever:
2. CRB-65 (>2): Inpatient: a. Orally tolerating: Tab CIPROFLOXACIN 500mg PO BD OR
Inj AMOXICLAV (1.2g) IV ATD TDS OR Tab CEFIXIME 200mg PO BD for 3 to 5 days
Inj CEFTRIAXONE 1g IV ATD BD + b. Not tolerating orally: Inj CIPROFLOXACIN 200 mg IV BD
Inj AZITHROMYCIN 500mg IV OD plus/minus Inj. METRONIDAZOLE 500mg IV TDS

LIVER ABSCESS SUSPECTED PERITONITIS

1. Inpatient management (Left lobe, size > 5cm, percutaneous drainage
possible, ruptured, subcapsular location, hemodynamically unstable):
Inj CEFTRIAXONE 1g IV ATD BD
Inj. METRONIDAZOLE 500mg IV TDS
2. Outpatient management (no indication of inpatient admission):
Tab CEFIXIME 200 mg PO BD AND
Tab METRONIDAZOLE 800mg PO TDS X 7 – 10 days
CELLULITIS
1. Inpatient management (hemodynamic instability, systemic toxicity, rapid
progression):
Inj. PIPTAZ 4.5g IV ATD TDS (in AKI/CKD, Give 2.25g IV TDS)
Inj. VANCOMYCIN (15mg/kg) 1g IV in 100ml NS over 1 hour BD
OR Inj. CLINDAMYCIN 900mg IV TDS (If Staph/ streptococcal infection
is suspected)
2. Out patient management (no indication of admission, tolerating
orally): Tab AMOXICLAV 625 mg PO TDS X 5 days
1. Spontaneous bacterial peritonitis (as in CLD: frank pus, >250
neutrophils/ul or TLC > 1000/uL in ascitic tap):
Inj. Cefotaxime 2g IV ATD TDS
2. Secondary bacterial peritonitis (e.g. Perforation, post-op etc.):
Inj PIPERACILLIN – TAZOBACTAM (PIPTAZ) 4.5g IV ATD TDS
(in AKI/CKD Give 2.25g IV TDS)
MENINGITIS
1. Inj. CEFTRIAXONE 2g IV ATD
2. Inj. VANCOMYCIN (15-20mg/kg) 1g IV in 100ml NS over 1 hour BD
3. Inj. AMPICILLIN 2g IV q4hrly (add if old age, malignancy, pregnant)
4. Inj. DEXAMETHASONE 10mg IV QID (1st dose just before with 1st
dose of antibiotics)
5. Inj. ACYCLOVIR (10mg/kg) 600mg IV TDS (In suspected Viral
encephalitis, commonly HSV)
 35

Common Antibiotics in ED and their doses (Syndromic approach) – A quick guide

MALARIA: SUSPECTED SEPSIS, FEVER WITH MULTIORGAN INVOLVEMENT
1. Severe (hemodynamic instability, ANY organ involvement): Ask SR in charge for appropriate antibiotics
th th th
Inj. ARTESUNATE 2.4mg/kg (120mg) IV 0 / 12 / 24 / q24hrly 1. Common empirical regimens:
2. Non- severe P. vivax: a. Inj. PIPTAZ 4.5g IV ATD TDS OR
Tab CHLOROQUINE 300mg base PO: 2 tabs on Day 1, 2 & 1 tab on Day3 Inj. MEROPENEM 1g IV ATD TDS OR
Tab PRIMAQUINE (0.25mg/kg) 15 mg PO OD for 14 days Inj. CEFOPERAZONE-SULBACTAM (Magnex) 2g IV ATD TDS
(r/o G6PD deficiency before PQ initiation) ‘Plus’
3. Non- severe P. falciparum: b. Inj. VANCOMYCIN 15mg/kg (1g) IV in 100ml NS over 1 hr OR
Oral ACT (Ex ARTEMETHER – 80mg and LUMEFANTRINE – 480mg), Inj. TEICOPLANIN (Targocid) 400mg IV in 100ml NS over 1 hr
One FDC(Fixed Dose Combination) tablet BD for 3 days AND at 0th / 12th/ 24th hour and then OD
Tab PRIMAQUINE (0.75mg/kg) 45 mg (3 tablets of 15 mg) PO on Day 2 c. Inj. DOXYCYCLINE 100mg IV BD (same dose orally acceptable)
ENTERIC FEVER: FEBRILE NEUTROPENIA (Fever plus neutropenia < 1000 /mcL)
1. Inpatient management (not tolerating orally, organ involvement): 1. Inpatient (MASCC score < 21):
Inj. CEFTRIAXONE 1g IV ATD BD Inj. CEFOPERAZONE-SULBACTAM (Magnex) 2g IV ATD TDS and
2. Outpatient management: Inj. AMIKACIN (15mg/kg) 750mg IV OD
Tab CEFIXIME 400mg (2 tabs of 200mg) PO BD for 10 – 14 days AND 2. Outpatient (MASCC score > 21):
Tab AZITHROMYCIN 1g (2 tabs of 500mg) for 5 days Tab AMOXICILLIN-CLAVULINIC ACID (625mg) PO TDS AND
Tab LEVOFLOXACIN 750mg PO OD for 3 days  OPD follow up
URINARY TRACT INFECTION (UTI) RENAL MODIFICATION OF SPECIFIC ANTIBIOTICS: (Ask SR)
1. Uncomplicated UTI (no structural or functional abnormality in urinary  Inj. VANCOMYCIN
tract): Tab NITROFURANTOIN – 100mg PO BD OR  Inj. PIPERACILLIN – TAZOBACTAM
Tab CEFIXIME 400mg PO BD OR  Inj. AMIKACIN
Tab CIPROFLOXACIN 500mg PO BD for 5days  Inj. MEROPENEM
2. Pyelonephritis or catheter related or patient is sick:
Inj. PIPTAZ (Piperacillin Tazobactum) 4.5g, IV ATD TDS
Inj. MEROPENEM 1g IV ATD TDS