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LIMBE REGIONAL
ffserpeffN HOSPITAL
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Adult medical
emergencies
[Tapez le sous-titre du document]
Dr Frank D. Zouna MD

2016

LIMBE REGIONAL HOSPITAL

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SUMMARY

Table des matières

SUMMARY ............................................................................................................................................... 2
ABREVIATIONS ......................................................................................................................................... 5
MEDICAL CONTACT NUMBERS ................................................................................................................ 7
TRIAGE ..................................................................................................................................................... 9
EVALUATION OF THE ACUTELY ILL PATIENT & FIRST INTERVENTIONS ................................................. 13
ALERT/ CALL FOR HELP .......................................................................................................................... 15
MANAGEMENT OF PAIN IN ADULTS...................................................................................................... 16
SHOCK .................................................................................................................................................... 18
ANAPHYLAXIS ........................................................................................................................................ 20
ACUTE CHEST PAIN ................................................................................................................................ 22
SYNCOPE ................................................................................................................................................ 25
HYPERTENSIVE EMERGENCIES .............................................................................................................. 27
HYPERTENSIVE URGENCIES ................................................................................................................... 29
ACUTE CARDIOGENIC PULMONARY EDEMA ......................................................................................... 30
HEMOPTYSIS .......................................................................................................................................... 32
ACUTE DYSPNOEA ................................................................................................................................. 33
UPPER AIRWAY OBSTRUCTION ............................................................................................................. 35
SEVERE ACUTE ASTHMA ........................................................................................................................ 37
EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE .................................................... 40
ACUTE ABDOMINAL PAIN ...................................................................................................................... 42
PEPTIC ULCER DISEASE .......................................................................................................................... 44
ACUTE DIARRHEA .................................................................................................................................. 46
FOOD POISONING.................................................................................................................................. 49
DIARRHEA IN PLHA ................................................................................................................................ 51
VOMITING.............................................................................................................................................. 52
CAUSTIC POISONING ............................................................................................................................. 54
BLEACH POISONING .............................................................................................................................. 57
FOREIGN BODY INGESTION ................................................................................................................... 58
UPPER GASTROINTESTINAL BLEEDING .................................................................................................. 60
ACUTE HICCUPS ..................................................................................................................................... 64
ACUTE FEVER ......................................................................................................................................... 65

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MALARIA................................................................................................................................................ 69
ENTERIC (TYPHOID) FEVER .................................................................................................................... 72
PEOPLE LIVING WITH HIV/AIDS (PLHA) ................................................................................................. 73
TETANUS ................................................................................................................................................ 76
SKIN AND SOFT TISSUE INFECTIONS...................................................................................................... 78
SCABIES.................................................................................................................................................. 81
HYPERGLYCEMIC CRISIS ......................................................................................................................... 83
HYPOGLYCEMIA ..................................................................................................................................... 86
ACUTE KIDNEY INJURY ........................................................................................................................... 88
ACUTE HYPOCALCEMIA ......................................................................................................................... 91
RENAL COLIC .......................................................................................................................................... 93
DIZZINESS AND VERTIGO ....................................................................................................................... 95
ACUTE STROKE ...................................................................................................................................... 97
ACUTE HEADACHE ................................................................................................................................. 99
SEIZURES .............................................................................................................................................. 101
STATUS EPILEPTICUS ........................................................................................................................... 103
UNCONSCIOUS PATIENT ...................................................................................................................... 104
BELL PALSY ........................................................................................................................................... 105
MENINGITIS ......................................................................................................................................... 106
BRAIN ABSCESS .................................................................................................................................... 108
DELIRIUM or ACUTE CONFUSIONAL STATE ......................................................................................... 109
AGITATION........................................................................................................................................... 113
CONVERSION ....................................................................................................................................... 115
ACUTE LOW BACK PAIN ....................................................................................................................... 116
SCIATICA .............................................................................................................................................. 118
ACUTE GOUTY ARTHRITIS .................................................................................................................... 119
PARACETAMOL POISONING ................................................................................................................ 121
HYDROCARBONS POISONING .............................................................................................................. 122
ACUTE ORGANOPHOSPHORUS PESTICIDE POISONING....................................................................... 123
QUININE POSIONING ........................................................................................................................... 125
ACUTE ALCOHOL INTOXICATION/ETHANOL TOXICITY ........................................................................ 126
DROWNING ......................................................................................................................................... 127
SNAKE BITES ........................................................................................................................................ 128
URTICARIA ........................................................................................................................................... 131

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ANEMIA ............................................................................................................................................... 133

EPISTAXIS ............................................................................................................................................. 135
VASO-OCCLUSIVE CRISIS/SICKLE CELL CRISIS ...................................................................................... 137
RED BLOOD CELLS TRANSFUSIONS STEPS ........................................................................................... 139
TRANSFUSIONS REACTIONS ................................................................................................................ 140
SEXUAL ASSAULT ................................................................................................................................. 146
INTIMATE PARTNER VIOLENCE AND ABUSE........................................................................................ 148

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ABREVIATIONS

ACTs: artemisin based combination therapies

AFB: acid fast bacilli

Amp: ampoule

ART: antiretroviral therapy

ATB: antibiotic

AVPU: alert, voice responsive, pain responsive, unresponsive

AXR: abdomen x ray, plain abdominal radiograph (PAR)

Bid: Bis in die, twice daily

BP: blood pressure

Bpm: beat per min

CRP: c reactive protein

CVAT: costovertebral angle tenderness

CTM: cotrimoxazole

CXR: chest x ray

DBP: diastolic blood pressure

dl: deciliter

DRE: digital rectal examination

ECG: electrocardiogram

FBC: full blood count

ICU: intensive care unit

IV: intravenous

IM: intramuscular

Hb: hemoglobin

HIV: human immunodeficiency virus

HR: heart rate

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LRH: Limbe regional hospital

Lumbar puncture

g: gram

kg: kilogram

max: maximum

min: minute

ml: millimeter

mg: milligram

MP: malaria parasite

NRS: numerical rating scale

Ob/gyn: obstetric and gynecoly

OD: once daily

PLHA: people living with HIV and AIDS

PO: per oral

Qd: Quaque die (qd), once daily

Qid: Quarter in die (qid), four times daily

Q2h: Quaque secunda hora, every two hours

RR: respiratory rate

SC: subcutaneous

Sec: seconde

SL: sublingual

Suppo: suppository

TB: tuberculosis

TBSA: total body surface area

Tid: Ter die (tid), three times a day

WBCT: whole blood clotting time

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MEDICAL CONTACT NUMBERS

Dr André SIMO, obstetrician & gynecologist 674 560 106

Dr Barbara HUNTEN KIRSCH, internist 651 260 826

Dr Josiane NOUWE, GP 677 823 598

Dr Diane NOAH MVONGO, GP 675 719 095

Dr Hilary FOINSO, GP 677 962 489

Dr Nathalie KAMGNIA, GP 677 271 650

Dr Audrey ESSE, GP 677 360 572

Dr Diane NGOUANE, GP 674 395 785

Dr ULRICH HACHMEISTER, GP 651 260 827

Dr Divine EYONGETA, urologist 679 270 421

Dr Frank ZOUNA, internist 675 470 254

Dr René MOULIOM, diabetologist 696 619 445

Dr Marie BALIMBA NJABON, pediatrician 674 199 018

Dr Ernest KENNA, otolaryngologist 699 298 497

Dr Sylvain NLEND, GP, HIV consultant 655 250 194

Dr Pius FOKAM, orthopedist, Buea Regional Hospital 674 877 572

Consultation on thursday

Dr Henry NDASI, orthopedist, Mutengene 677 507 485

Dr ENOW KONGHO, neurosurgeon, Buea Regional 679 733 778

Hospital.
Dr Cyrille NKOUONLACK, neurologist, Buea Regional 677 985 121
Hospital. Consultation all day except Tuesday
Dr KALAMBACK, nephrologist, Buea Regional 651 918 075
Hospital. Consultation monday, wednesday, thursday
Dr Martin MOKAKE, general surgeon, Buea Regional 676 413 408
Hospital. Consultation every day

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Dr John ANDETUNJI, Mutengene 653 829 429

Monday, tuesday, wednesday, thursday, Saturday 653 851 487

Dr MBAH AGWE, psychiatrist, Limbe 679 831 366

Monday, tuesday consultation

Other useful contact

Mr FOSSI Emmanuel, infirmier anesthésiste 677 604 487

Mr KAMGA Jean, infirmier anesthésiste 675 644 055

Mr NDIVE Oscar, radiology technician 674 740 248

Mr AYUK Roland, radiology technician 675 219 039

Mr AGBORTAH, veterinarian, ZTVC 675 076 591/694 733 817

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TRIAGE

Definition

Triage is the sorting of patients into priority groups according to their need and the
resources available

Priority groups

 Emergency (E): require immediate management

 Priority (P): priority in queue
 Non urgent cases: wait their turn in the queue

Procedure

Step 1: registration (name, date of birth, telephone number, residence)

Step 2: identify reason of seeking care, ask last menses period if appropriate

Step 3: take vital signs, assess level of consciousness (AVPU) and report on paper

Step 4: calculate the modified early warning signs (MEWS) score and report on the
same paper

Step 5: orientation

If MEWS score > 3 accompany patient into the observation room and call a
medical doctor

If MEWS score ≤ 3 direct patient to administrative staff and doctor

consultation. Tell him or her that he/she will wait his turn in queue

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Score MEWS

Modify early warning signs

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EMERGENCY: need life saving interventions

o AIRWAY& BREATHING
o Cardiac arrest
o Respiratory distress

o CIRCULATION
o Cardiac arrest
o Severe bradycardia or tachycardia with signs of hypoperfusion
o Hypotension with signs of hypoperfusion
o Anaphylactic shock

o DISABILITY
o Unresponsive patient
o Hypoglycemia with a change in mental status

URGENT: should not wait in queue

o Neurological
o Severe headache
o Seizures
o Agitation
o Confused, lethargic, disoriented

o Ocular
o Chemical splash, significant eye trauma

o Nose & throat

o Stridor, drooling
o Foreign body
o Epiglottitis

o Cardiovascular
o Chest pain
o Hypertensive crisis
o Acute arterial occlusion

o Abdominal
o Severe Pain
o GI bleeding
o Frequent diarrhea more than 6 times per day

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o Genitourinary
o Testicular torsion

o Obstetrical and gynecological

o Abdominal pain
o Vaginal bleeding
o Sexual assault

o Trauma & Orthopedic

o Compartment syndrome
o Amputation
o Arterial bleeding

NONURGENT: should wait in the queue other cases

i.e.,

Emergency Nurses Association (2007). Emergency Nursing Core Curriculum (6th

ed.), Jordan KS, editor. DesPlaines, IL.

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EVALUATION OF THE ACUTELY ILL PATIENT & FIRST INTERVENTIONS

Step 1: primary survey

Assessment Interventions

Airways Added sound: snoring, gurgling, Open

wheeze, stridor  Head tilt, chin lift
Use of accessory muscles  Jaw thrust
See-saw respiratory pattern  Suction

Maintain patency
 Oral airways (Guedel®)

Breathing Respiratory rate & rhythm, effort, Give oxygen if available

pattern, chest movement, pulse Ventilation with a self inflating bag
oximeter and mask (AMBU® bag)
Position up right

Circulation BP, pulse rate & rythm, skin Position supine with leg raised
temperature, skin coloration, urine IV access 16G or 18G
output Fluid challenge: give normal saline
500 ml bolus if SBP < 90 mmHg

Disability Level of consciousness (AVPU or Finger stick glucose

Glasgow coma scale), pain
assessment

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Step 2: secondary survey or focus examination

 Head
 Chest
 Heart
 Abdomen
 CNS: pupils, neck stiffness, focal signs
 Skin

Step 4: alert

15:00 to 8:00

 call the medical doctor on call, if not available within 30 minutes call the
backup doctor,
 if not available within 30 minutes, call the administrative on call.

8:00 to 15:00

 call doctor in duty in Emergency Room, if not available within 30 minutes call
any general practitioner
 if not available within 30 minutes, call the internist

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ALERT/ CALL FOR HELP

Patient requiring urgent

evaluation by a doctor

Doctor on call

233 791 254

Not available within 30 minutes

Back up doctor

233 791 251 ?

Not available within 30 minutes

Administrative on call

233 791 257

233 129 235

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MANAGEMENT OF PAIN IN ADULTS

All cases

 Assessment of vital signs and pain (numerical rating scale)

 Admit in observation room all patients with severe pain (NRS ≥ 6/10)
 Start analgesia
 Check for any emergencies (ectopic pregnancy, appendicitis, peritonitis,
intestinal obstruction)
 Call the doctor

If NRS ≤ 3

o Paracetamol 500 mg 2 tablets every 6 hours

o Assess pain severity at 30 to 45 min; if regression continue every 6 hours

If NRS = 4 or 5 or no change

o Paracetamol 1 g orally every 6 hours AND tramadol 100 mg orally then 50

mg every 6 hours
o With or without KETONAL® 100 mg in 100 mL normal saline or 5%
glucose over 20 minutes every 8 hours

If NRS ≥ 6: observation room

 Insert IV line normal saline 500 ml

 Paracetamol 1 g IV + nefopam 20 mg + ketoprofen 100 mg in same ready
solution over 20 minutes

OR

 Tramadol 100 mg IM every 6 hours AND paracetamol 1 g IV over 15 min every 4

hours (i.e., 6h, 10h, 14h, 18h)
 Report in medical file
 Monitor vital signs and numerical rating scale

FOR PREGNANT WOMEN

Paracetamol is the first choice

NSAIDS: ibuprofen, diclofenac only first and second trimesters

Opioids: tramadol, codeine

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Vital signs

Numerical rating scale

Step 1: mild pain (NRS Step 2: moderate pain Step 3: severe pain
≤ 3) (NRS = 4 or 5) (NRS ≥ 6)

Paracetamol 1 g orally x Paracetamol PO + Paracetamol IV x 4+

4 or NSAIDS (e.g. , tramadol PO 100 mg then tramadol 100 IM x 4 +
naproxen 500 mg x 2, 50 mg x 4 or nefopam 20 naproxen 500 mg x 2
ibuprofen 400 mg x 3, mg SL or IM x 4 or
diclofenac 50 mg x3) ketoprofen IV 100 mg x 3

Nefopam (ACUPAN®) 20 mg/2mL: 1 amp in 100 mL normal saline

over 20 minutes every 6 hours or 1 amp IM every 6 hours

Tramadol 100 mg/2 mL: 100 mg in 100 mL normal saline or 5%

glucose over 20 minutes

Ketoprofen (KETONAL®) 100 mg/2 mL: 100 mg in 100 mL of normal

saline or 5% glucose solution

Paracetamol 1g/100 mL + ketoprofen 100 mg/2 mL+ nefopam 20

mg/2mL in same ready solution

Paracetamol 1g/100 mL + nefopam 20 mg or ketoprofen 100 mg in

same ready solution

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SHOCK

Step 1: recognize shock

 Systolic blood pressure < 90 mmHg or reduced MAP by greater than 30% for
at least 30 minutes
 PLUS
o HR** > 120 bpm,
o RR** > 30, oliguria** (urine output < 20 mL/hour or < 0.3 mL/Kg/h for
two consecutive hours)
o psychomotor agitation**,
o poor peripheral perfusion (cold clammy skin, weak or absent radial
pulse, cyanosis, sweating)

Step 2: identify type of shock if possible

 Cardiogenic: history of heart disease, jugular venous distension, orthopnea,

peripheral edema
 Hypovolemic: history of bleeding; vomiting; diarrhea; dehydration
 Distributive: fever, extremities warm, bounding pulses, increased pulse
pressure. Look for causes: septic shock (signs of urinary, respiratory,
gastrointestinal tract infections); anaphylaxis (respiratory distress, wheezing,
urticaria, angioedema)
 Obstructive: cardiac tamponade, tension pneumothorax, pulmonary embolus

Step 3: treatment

 Oxygenation 5 litres/minutes
 Insert 2 IV line with large 16G or 18G if possible
 Insert urinary catheter
 Give lactate ringer solution or normal saline 20 mL/kg over 20 minutes. Use a
manual pressure
o Repeat as needed until improvement occurs (palpable radial pulse,
systolic BP > 90 mmHg, urine output > 30 mL/hour, ± HR < 100 bpm)
 Monitor vital signs and urine output

Step 4: work up

 According to clinical setting: bedside glucose

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Step 5: disposition

 Admission in adult medical ward if stable

References

Shock: a review of pathophysiology and management. Part 1. Critical Care and Resuscitation 2000; 2:
55-65

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ANAPHYLAXIS

Recognize

Anaphylaxis is likely when any one of the three criteria is fulfilled:

 acute onset of illness (minutes to hours), with involvement of: skin and/or
mucosa (pruritus, flushing, hives, angioedema) and either respiratory
compromise (dyspnea, wheeze-bronchospasm, ↓ Peak expiratory flow, stridor,
hypoxemia), or falling blood pressure or end-organ dysfunction (collapse,
syncope, incontinence);

 2 or more of the following that occur rapidly after exposure to likely allergen for
that patient: skin and/or mucosa; signs of respiratory compromise; falling blood
pressure or end-organ dysfunction; persistent gastrointestinal symptoms (
vomiting, crampy abdominal pain, diarrhea)

 falling blood pressure within minutes to several hours after exposure to a

known allergen.

Look for triggers

In one third of persons with anaphylaxis, a cause can be found:

 Drugs: aspirin, NSAIDS, penicillins

 Food: fish, cow milk, eggs, shell fish, crabs, tree nuts,
 Insect stings: fire ant, bee, wasps
 Physical factors: cold temperatures, exercise
 Others: additives, blood product,

Work up

 Should not delay urgent management

Management

 Place the patient in a supine position.

 Place pregnant women on their left side
 Stop the triggering allergen if possible (medication, blood transfusion…)
 Give oxygen 4 L/min if respiratory distress

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 Adrenaline (amp 1mg/mL) 0.5 mg IM into the mid-anterolateral thigh or 0.01

mg/kg in children less than 6 years if stridor or hoarse voice. Repeat every 5
min according to the response
 Start IV 1000 mL bolus of normal saline or Ringer’s lactate or
GELOPLASMA® (10 mL/kg) bolus if SBP < 100 mmHg or HR> 100 bpm
 Reassess the patient status (BP, HR) after 5 minutes
 Adjunctive measures
o Corticosteroid: betamethasone (CELESTENE ® 4 mg/mL) 4 mg IM or
dexamethasone 4 mg IM or methylprednisolone (SOLUMEDROL®
120 mg/mL) slow IV or IM
o H1 blockers: hydroxyzine (ATARAX®) 100mg/2 mL IM or cetirizine 5
mg orally, loratadine 10 mg orally daily
o H2 blockers: ranitidine 1mg/kg IV
 Observation for 6 hours after mild episodes, 24 hours after severe episodes

Disposition

 Discharge home if with:

o prednisone (CORTANCYL®) 20 mg, 2 tab morning for 7 days;
o loratadine (ALLERCEPT® )10 mg daily for 7 days; record allergy trigger
in file; counsel the patient about avoiding the triggers
o follow up in outpatient department (internist, GP)

References

Tang AW. A practical guide to anaphylaxis. Am Fam physician 2003; 68:1325-32

Campbell RL et al. Emergency department diagnosis and treatment of anaphylaxis: a practice

parameter. Ann Allergy Asthma Immunol 2014;113:599-608

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ACUTE CHEST PAIN

Recognize life threatening and common benign cause

 Pericarditis at least two of the following: typical chest pain, pericardial friction
rub, typical ECG changes, and pericardial effusion
o Typical chest pain: pleuritic pain, relieved by sitting forward, radiates to
the trapezius ridge
 Cardiac pain:
o Typical angina (definite) meets three of the following: substernal chest
discomfort of characteristic quality and duration; provoked by exertion
or emotional stress; relieved by rest and/or glyceryl trinitrate spray.
o Atypical angina (possible) meets two of these characteristics
o Non cardiac pain meets one or none of these characteristics
o Acute myocardial infarction, same as angina, more severe, more
prolonged ( ≥ 30 min)
 Pulmonary embolism: pleuritic chest pain, dyspnea, syncope, haemoptysis
 Aortic dissection: excrutiating , ripping pain of sudden onset in anterior chest
pain, often radiating to back
 GERD: painful retrosternal burning sensation of fairly short duration,
particularly postprandially, or during sleep

Warning symptoms/signs

 Syncope
 Profuse sweating
 Nausea and vomiting
 Dyspnea
 Altered mental status
 FR ˃ 25/min
 HR ˃ 100 bpm
 SBP ˂ 90 mmHg
 BP asymmetry (arms) ˃ 15 mmHg
 Absent foot pulses

Work up

 ECG if suspicion of angina

 Chest radiograph if suspicion of heart failure, pulmonary disease

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Treatment

 Cardiac pain
o IV line: 250 mL of D5W
o Oxygen 5 L/min if SpO2 < 90 %
o TNT(NATISPRAY®) 0.4 mg every 5 minutes for up to 3 doses
o Atenolol 100 mg orally if no contraindication
o Atorvastatin 40 mg daily for life
o Aspirin 165 mg loading dose to chew, then 81 mg daily next day for life
o Clopidogrel 600 mg = 8 tabs (ARTERIOPINE®, PLAVIX®) loading
dose, then 75 mg orally next day up to 12 months
o Lisinopril 5 mg daily in all patients with HTN, stable CKD, DM, anterior
infarct and those with LVEF< 0.40
o Enoxaparine 1 mg/kg SC every 12 hours
o Tramadol 100 mg IM

 GERD
o Antacids: MAALOX® 1 sachet 3 times (2 hours after meals) and 1
sachet bedtime
o Omeprazole 20 mg orally before breakfast for 1 month
OR
o Esomeprazole 40 mg orally before breakfast for 1 month

 Acute pericarditis
o Ibuprofene 400 mg orally 3 times per day

 Pulmonary embolism
o Oxygen 4 L/min if SpO2 < 90%
o Tramadol 100 mg IV
o Enoxaparin 1 mg/kg SC every 12 hours

 Acute aortic dissection

o Tramadol 100 mg IM
o Nicardipine IV + labetalol 200 mg twice orally

Disposition

 Admit for observation all cases

 Refer to cardiologic ICU for reperfusion if cardiac pain, massive pulmonary
embolism, acute aortic dissection
 Admit cardiac pain if symptoms of more than 12 hours
 Discharge home if non cardiac pain, normal ECG and CXR,

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References

Allam Settee S, Seepana S, Griffith KE. 10 steps before you refer for: chest pain. Br J
Cardiol 2009; 16 (2):80-84

O’Gara PT 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 tasks force on practice guidelines. J Am Coll Cardiol
2013; 61(4):78-140

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SYNCOPE

Recognize

 Near-syncope: blurred vision, dizziness, lightheadedness, pallor, nausea,

diaphoresis,
 Syncope: (1) loss of consciousness is transient and abrupt; (2) recovery is
spontaneous, prompt and complete
 Find causes, ask:
o Activity and posture before incident
o Precipitating factors: exertion, positional, stressors (sight of blood, pain,
emotional distress, fatigue, prolonged standing, warm environment,
cough/micturition/defecation, swallowing, head turning or shaving, arm
exercise
o Prodrome: diaphoresis, nausea, blurred vision, dizziness, pallor
o After the incident: nausea/vomiting, bowel or bladder incontinence

Clinical severity

 High risk of cardiac etiology:

o history of congestive heart failure,
o age > 45 years,
o history of ventricular arrhythmia,
o abnormal ECG
 Life-threatening:
o chest pain (acute myocardial infarction, pulmonary embolism, aortic
stenosis);
o headache (subarachnoid hemorrhage);
o abdominal or back pain (leaking aortic abdominal aneurysm, ruptured
ectopic pregnancy)

Work up

 BP in supine and standing position

 FBC
 ECG

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Treatment

 If vasovagal syncope: explain and demonstrate the counter pressure

maneuvers that patient should do when he/she experienced symptoms of near
syncope:
o Hand grip for maximum tolerated time or till to complete disappearance
of symptoms;
o Leg crossing consists of leg-crossing combined with maximum tensing
of leg, abdominal and buttock muscles;
o Arm-tensing consists of the maximum tolerated isometric contraction of
the two arms achieved by gripping one hand with the other and
contemporarily abducting (pushing away) the arms.

Disposition

 Discharge if no high risk of cardiac etiology

 Admit if high risk of cardiac etiology or if the patient has any of these:
o SBP < 90 mmHg
o Shortness of breath
o history of congestive heart failure
o hematocrit < 30%
o abnormal EKG

Reference

GAUER RL. Evaluation of syncope. Am Fam Physician.2011; 84(6):640-650

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HYPERTENSIVE EMERGENCIES

Step1: recognize hypertensive emergencies

Abrupt elevation of blood pressure (SBP ≥ 180 mmHg or ≥ DBP 110 mmHg) AND
target organ damage

End organ damage symptoms/signs include one of the following findings:

 blurred vision
 Seizure
 altered level of consciousness (confusion, somnolence, coma),
 severe headache
 chest pain
 dyspnea
 asymmetric pulses
 oligo-anuria (< 400 ml in 24 hours)
 > 20 wk pregnancy

Step 2: work up

 Urea, creatinine, urinalysis, FBS, ECG

Step 3: treatment

 Insert IV line
 Reduce MAP by 25% over 2 hours, or DBP < 110 mmHg within 2 hours
o MAP = PAS + 1/3(PAS - PAD)
 Nicardipine IV infusion (LOXEN®): 5 amp in SG% 250 mL over 30 minutes
at 10 drips/min

Infusion rate
5 mg/h 10 drops/min
7.5 mg/h 15 drops/min
10 mg/h 20 drops/min
12.5 mg/h 25 drops/min
15 mg/h 30 drops/min

o Monitor BP at 10 min interval, increase at 2.5 mg/h (5 drops/min)

every 5 min to a maximum of 15 mg/h until target BP is achieved

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OR

 Nicardipine IV bolus (LOXEN®): 2.5 mg IV over 2 minutes every 10 min

(max 10 mg or 4 times). Do not dilute!

o Monitor at 10 min interval until target BP is reached

 When a goal is attained, administer nicardipine 20 mg 1 tab 3 times daily.

(maximum 2 tab 3 times) alone or in combination with labetalol 200 mg 2 times
daily

Step 4: disposition

 Refer to in intensive care unit (Douala): if coma, aortic dissection

 Admission in adult medical ward other cases

Reference

Marik PE, Varon J. Hypertensive crises: challenges and management. Chest 2007;
131; 1949-1962

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HYPERTENSIVE URGENCIES

Step 1: recognize hypertensive urgencies

 Abrupt elevation of blood pressure (SBP ≥ 180 mmHg or ≥ DBP 110 mmHg)
with no symptoms and/or signs of end organ damage
 Epistaxis, moderate headache, tinnitus, dizziness may be present
 Look for precipitating factors: acute urinary retention, pain, panic attack,
sympathomimetic drug (nasal drop), interruption /cessation of antihypertensive
drug, drug that can elevate BP: NSAIDS, corticosteroids

Step 2: work up

 No laboratory investigation

Step 3: treatment

 Observation for 60 minutes

 Rest in the bed and reassurance
 BP assessment after 30 minutes
 If BP still ≥ 180/110 mm Hg and no history of hypertension
o Nicardipine 20 mg tab, 1 tab three times a day OR
o Captopril 25 mg, 1 tab, may be repeated after 2 hours OR
o Clonidine 0.1 mg stat, followed by 0.1 mg hourly (max = 0.7 mg)

 If BP still ≥ 180/110 mm Hg and history of hypertension

o If patient has missed his medication, restart
o If patient is compliant with his medication, add nicardipine

 If BP < 180/110 mm Hg
o If no history of hypertension: no treatment
o If history of hypertension:
 Restart antihypertensive medication or
 increase the dose of existing antihypertensive medications or
 add another antihypertensive medications

Step 4: disposition

 Discharge home with internal medicine consultation within 1 week

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ACUTE CARDIOGENIC PULMONARY EDEMA

Step 1: recognize

 Think FACES: Fatigue, Activities limited, Chest congestion, Edema or ankle

swelling, Shortness of breath
 Orthopnea (difficulty lying flat/breathing at night), frothy sputum, ankles
edema, bibasilar crackles, gallop rhythm

Step 2: clinical severity

 SBP < 90 mmHg; other signs of hemodynamic instability(cold extremities,

narrow pulse pressure, delayed capillary refill)
 Respiratory distress (tachypnea, intolerance to supine position, effort of
breathing, degree of hypoxia)
 High BNP

Step 3: work up

 FBC, HIV test, glucose, urea, creatinine, urinalysis, serum electrolytes,

calcium, magnesium,

Step 4: treatment

 Upright sitting position

 Administer oxygen 5 L/min to maintain SaO2 > 92 %
 Insert IV line with 5 % glucose solution 500 mL/24 hours + 2 amp Cl-K/24 h
 Trinitrine 0.4 mg sublingually, every 5 min over 15 minutes
 Sublingual captopril:
o 12.5 mg if SBP < 110 mmHg
o 25 mg if SBP > 110 mmHg
 Furosemide 40 mg IV bolus
o Patient must urinate after 30 minutes if not repeat 80 mg IV furosemide
o If patient urinate within 30 minutes, continue furosemide 40 mg IV every
12 hours.
 Enoxaparine 40 mg SC daily
 Dietary sodium restriction
 Monitoring: BP, HR, RR, SpO2, urine output hourly

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o adequate reduction of dyspnea and adequate diuresis (urine output >

100 mL/h for first 2 hours, with increased SpO2, reduction of HR & RR
within 1 to 2 hours

Step 5: disposition

 Admission in adult medical ward

 Refer to ICU for inotropic and vasopressor agents administration if clinical
severity

References

Mattu A, Martinez, Kelly RS. Modern management of cardiogenic pulmonary edema.

Emerg Med Clin N Am 2005.1105-1125

Bosomworth J. Rural treatment of acute cardiogenic pulmonary edema: applying the

evidence to achieve success with failure. Can J Rural Med 2008;13

Yancy CW et al. 2013 ACCF/AHA guideline for the management of heart failure.

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HEMOPTYSIS

Step1: recognize

 Coughing up blood

Step 2: clinical severity

Attempt to classify the severity

 Scant or blood streaked sputum

 Frank hemoptysis
 Massive hemoptysis interfering with respiration

Step 3: work up

 CXR, FBC, sputum smear AFB if appropriate

Step 4: treatment

If massive hemoptysis/unstable vital signs/airway compromise

 Oxygenation if available
 Insert IV line
 Airway control
 Position bleeding lung down
 Blood type

Step 5: disposition

 Refer to pulmonologist for bronchoscopy if cause is not obvious or massive

hemoptysis
 Discharge home if acute mild hemoptysis and normal chest radiograph. In
most cases, bronchitis is the cause. Close monitoring to confirm cessation of
bleeding. If not refer to pulmonologist.

References

Bidwell JL, Pachner RW. Hemoptysis: diagnosis and management. Am Fam

Physician 2005; 72 (7):1255-1260

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ACUTE DYSPNOEA

Recognize

Patient usually describes a sensation of difficult or uncomfortable breathing

Step 1: clinical severity

 Altered mental status

 Respiratory rate > 40 breaths per minute, retractions, cyanosis, low oxygen
saturation
 Hypoxia
 Abnormal vital signs: HR > 120 bpm, SBP < 90 mmHg
 Unstable arrhythmia
 Stridor and breathing effort without air movement (suggestive of upper airway
obstruction)
 Unilateral tracheal deviation, hypotension, and unilateral breath sounds
(suggestive of tension pneumothorax)

Step 2: work up

 CXR, FBC, ECG

Step 3: treatment

 Sit patient upright

 First, administer oxygen 4 L/min to maintain SaO2 > 92 %
 Next, establish IV line
 Give 5% dextrose 250 mL
 Start specific treatment
o IV furosemide if pulmonary edema
o Inhaled beta agonist (e.g., salbutamol spray) if asthma or COPD

Step 4: disposition

 Transfer to intensive care unit (ICU) of Douala:

o if no easily reversible cause was found (e.g., anemia, pleural effusion,
pulmonary edema, pneumonia) or if respiratory distress not responding
to initial therapy

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 Admission in adult medical ward other cases

 Discharge home if stable

References

Zoorob RJ, Campbell JS. Acute dyspnea in the office. Am Fam Physician 2003;
68:1803-10

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UPPER AIRWAY OBSTRUCTION

Step 1: recognize

 Penetration syndrome may be present with sudden onset of choking and

intractable cough after aspirating a foreign body, with or without vomiting
 Laryngeal dyspnea: stridor (audible inspiratory noise breathing), dysphonia,
dysphagia
 Trachea: stridor, wheezing
 Bronchi: wheezing

Step 2: clinical severity

 Use of accessory muscles respirations

o Indrawing or recession (supraclavicular, intercostal)
o Paradoxical chest and abdomen movement
o Tracheal tug?
 Tachypnea
 Tachycardia
 Cyanosis
 Signs of hypoxemia and hypercarbia (depressed consciousness, irritability,
agitation)


Workup

 Posteroanterior and lateral CXR

Step 3: treatment

 Oxygenation
 Patient position
 specific
 Laryngeal obstruction
 Oxygen 5 L/min
 SOLUMEDROL® 80 mg IV over 3 minutes

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 Specific treatment
o Croup: ceftriaxone 1 g IV
o Anaphylaxis: adrenaline 0.5 mg IM in thigh or 0.01 mg/kg in children
(max 0.5 mg)
o Foreign body: if spontaneous breathing encourage patient to cough;
if not breathing start Heimlich maneuver; if failure of Heimlich
maneuver consider intubation
 Refer to ICU of Buea or Douala

Tracheal obstruction: bronchoscopy

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SEVERE ACUTE ASTHMA

Step 1: recognize asthma

 Two of the following: dyspnea, wheeze, cough

Step 2: clinical severity

 Difficulty to talk or cough

 Breathlessness at rest
 Sit up-right
 RR > 40/min, HR > 120 bpm, bradycardia, SBP < 90 mmHg
 Arythmia
 Use of accessory muscle
 diaphoresis
 Silent lungs
 Paradoxical thoraco-abdominal movement
 Altered mental status or agitation

Step 4: work up

According to clinical findings: chest radiograph is not systematic

Step 5: treatment

If no red sign: use protocol 1 or 2

Protocole 1: use of metered dose inhaler

 Salbutamol (VENTOLINE ® 100 µg); 4 puffs (up to 12) one at time every 20
min for one hour.
o Ask patient to breath in and out 4 times after each puff
 prednisone 1 mg/kg orally once daily for 5 days (prednisone 40-50 mg daily)
 monitor every 15 min after each salbutamol inhalation: HR,RR, ability to talk in
sentences
 evaluation after 4 hours: HR,RR
o If complete improvement
 discharge at home: salbutamol 4 puffs every 6 hours for 24 h
and prednisone 40 mg once daily for 7 days
o If incomplete improvement
 salbutamol 2-4 puffs/4-6 hours until resolution

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Protocole 2: use of bottle spacer/homemade spacer

If patient cannot use metered dose inhaler use a bottle spacers

How to make spacer?

Bottle spacers (500 ml plastic bottle)

How to use?

 Primed newly constructed spacers with 15 puffs before use

 Shake MDI, give 4 (up to 12) puffs and repeat at 20 min intervals for one hour.
One puff at a time, with five slow breaths after each puff.

If one or more red signs: severe acute asthma

 call immediately the doctor, start the protocol if doctor not available within 20
minutes
 place patient in semi recumbent position
 give oxygen 4 l/min to maintain SpO2 ≥ 94%
 Salbutamol 6 puffs (up to 20) every 15 to 20 minutes for one hour.
o Monitor pulse rate, respiratory rate 15 minutes after every salbutamol
puff
o If improvement, then 4 puffs every 4 hours
 Methylprednisolone (SOLUMEDROL®) IV 1 mg/kg once daily
 Consider IV magnesium sulfate 2 g in 100 mL DW over 20 minutes
 IV fluid: 5% glucose 2000 mL/ 24h + NaCl, KCl

Step 4: disposition

 Discharge home: prednisone 40 mg orally for 5 days and salbutamol as

needed
 Refer to ICU: patient not responding to the treatment

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Always watch the patient use the inhaler and give explanation and demonstrate the
appropriate use if incorrect technique

References

Zar HJ, Brown G, Donson H, Brathwaite N, Mann MD, Weinberg EG. Home-made spacers
for bronchodilator therapy in children with acute asthma: a randomized trial. Lancet 1999;
354: 979-82

Gordon S, Tompkins T, Dayan PS. Randomized trial of single-dose intramuscular

dexamethasone compared with prednisolone for children with acute asthma. Pediatr Emerg
Care. 2007 Aug; 23(8):521-7.

Keeney GE et al. Dexamethasone for acute asthma exacerbations in children: a met-

analysis. 2014, 133:493-499

Pollart SN, Compton RM, Elward KS. Management of acute asthma exacerbations. Am Fam
Physician 2011; 84(1):40-47

Hodder R et al.Management of acute asthma in adults in the emergency department:

nonventilatory management. CMAJ 2010; 182(2)

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EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Recognition

Acute change in patient’s baseline symptoms (dyspnea, cough, sputum) that is

sufficient to warrant a change in therapy:

 Increased sputum production

 increased cough
 Increased shortness of breath

Signs (rapid and shallow breathing, use of accessory respiratory muscles,

paradoxical chest wall motion, wheezing, attenuated or absent breath sounds,
hyperresonance on percussion, purse lip breathing)

Triggers

 Infections of tracheobronchial tree

 Exposure to allergens
 Exposure to pollutants
 Exposure to inhaled irritants: tobacco smoke

Severity

 SaO2 < 90%

 Older age
 Respiratory distress
 Increasing confusion

Work up

 FBC, FBS, CXR, ECG

Treatment

 Oxygen therapy by nasal cannula/prongs if SaO2 ≤ 88% to reach target SaO2

≥ 90%

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 Salbutamol 4 to 8 puffs every 20 min for one hour. If improvement, then every
4 hours
o If improvement, then 2-4 puffs every 4 hours
o If no improvement then?
 Prednisone orally 40 mg once daily for 7 days

 Antibiotherapy if all three majors are present; if increased sputum purulence

and one of more (dyspnea, increased sputum volume):

o amoxicillin/clavulanate one 875/125 mg tablet twice daily for 5 days OR

o levofloxacin 500 mg daily for 5 days OR
o clarithromycin 500 mg twice daily for 5 days OR
o azithromycin 500 mg once daily for 5 days

Disposition

 Discharge home if:

o inhaled beta2 agonist no more than every 4 hours;
o patient able to walk across room;
o no frequent awakening due to dyspnea;
o patient clinically stable for 12-24 hours;
o correct use of medication understood
 Discharge with fixed combination salmeterol and fluticasone
 Admit in adult medical ward others cases

References

Evensen AE. Management of COPD exacerbations. Am Fam Physicians 2010; 81 (5):607-613

Marks A. Managing acute exacerbations of CODP. US Pharmacist 2009; 34(7):11-15

Rodriguez-Rosin R. COPD exacerbations : management. Thorax 2006; 61: 535-544

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ACUTE ABDOMINAL PAIN

Clinical severity

 Severity of pain: facial expression, diaphoresis, pallor, agitation

 Pregnancy
 Elderly or young
 Syncope or presyncope
 Genitourinary/gastrointestinal bleeding,
 repeated vomiting
 Abnormal vital signs: BP < 90 mmHg, P > 120 bpm, RR > 25, T< 35°or > 38°C
 Altered mental status

Work up

 Beta-hCG in women of reproductive age, glucose, lipase if suspicion of acute

pancreatitis
 Bedside abdominal ultrasound
 Erect CXR if suspicion of perforation
 AXR if suspicion of bowel obstruction (any two of these: distended abdomen,
increased bowel sounds, constipation, previous abdominal surgery, age over
50 years, vomiting)
 Noncontrast abdomen CT (>> sonography) for suspicion of pancreatitis, renal
colic, small bowel obstruction and appendicitis if available

Treatment

 Admit all severe case

 Insert IV line and start normal saline 500 ml
 If pain Numeric Rating Scale (NRS) ≤ 3
o Paracetamol 500 mg, 2 tab or 1 g IV over 15 min

 If pain Numeric Rating Scale (NRS) 4-6

o Paracetamol 1g IV over 15 minutes + tramadol (TRABAR®)100 mg IM
every 6 hours ± phloroglucinol (SPASFON® lyoc) 2 tab
OR
o Paracetamol-codeine 500mg, 2 tab (EFFERALGAN codeine®,
CODOLIPRANE® ± phloroglucinol (SPASFON® lyoc) 2 tab

 If pain Numeric Rating scale 7-10

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If menstrual cramps

o KETONAL® 100 mg IV over 20 minutes in 100 mL of NS or D5W

Disposition

 Admission in:
o surgical ward if bowel obstruction, peritonitis, appendicitis;
o ob/gy ward if vaginal bleeding or pregnancy,
o medical ward: patient appearing ill, elderly/immunocompromised with
unclear diagnosis, young apparently healthy with unclear diagnosis,
intractable pain or vomiting, altered mental status,
 Discharge home other cases with instruction to return if increased pain,
vomiting or fever

References

Bohner H et al. Simple data from history and physical examination help to exclude bowel
obstruction and to avoid radiographic studies in patients with acute abdominal pain. Eur J
Surg 1998; 164:777-84
Oguztruk H et al. Tramadol or paracetamol do not affect diagnosic accuracy of acute
abdominal pain with significant relief –a prospective, randomized, placebo controlled double
bind stuy. European Review for Medical and Pharmacological Sciences 2012;16: 1983-1988

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PEPTIC ULCER DISEASE

Step 1: recognize

 Burning or gnawing epigastric pain occurring 2 to 5 hours after meal or

awakening at night; relieved by food, milk or antacid.
 Ask for use NSAIDS (e.g., diclofenac, ibuprofen…)

Step 2: clinical severity

 Hematemesis, melena, hematochezia

 Severe, spreading upper abdominal pain
 Abdominal distension or rigidity; generalized abdominal tenderness

Step 3: work up

 Esophagogastroduodenoscopy if bleeding, weight loss, anemia, anorexia, age

above 50 years
 Helicobacter pylori serology
 Abdominal X ray if abdominal rigidity

Step 4: treatment

If not clinically severe

 Antacids:
o oxyde d’aluminium (MAALOX®) sachet dose; 1 sachet three times (1
and 3 hours after meal) and bedtime (maximum 12 sachets daily); 1
spoon three times (1 and 3 hours after meal) and bedtime. MAALOX®
without sugar for diabetic patient
or
o SUPRALOX® syrup; 1 tea spoon 1 and 3 hours after meal, and
bedtime

 AND antisecretory if no Helicobacter pylori infection

o Omeprazole caps 20 mg; 1 caps morning before breakfast for 4 weeks
to heal ulcer
or
o Cimetidine tab 400 mg twice daily for 4 weeks

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 H. pylori eradication if H pylori serology positive

o 10 days concomitant quadruple therapy:
 omeprazole 20 mg bid or alternative (esomeprazole 40 mg bid or
lansoprazole 30 mg bid or pantoprazole 40 mg bid)
 + clarithromycine 500 mg bid, amoxicillin 1 g bid,
metronidazole/tinidazole 500 mg bid
o Hybrid therapy
 7 days dual therapy: omeprazole 20 mg bid + amoxicillin 1 g bid
followed by
 7 days concomitant quadruple therapy: omeprazole 20 mg bid,
amoxicillin 1 g bid, clarithromycin 500 mg bid,
metronidazole/tinidazole 500 mg bid.

If clinically severe

 Bleeding: see upper GI bleeding protocol

 Perforation (sudden, severe spreading upper abdominal pain, abdominal
distension/rigidity,)
o IV with large volume of normal saline or Ringer lactate
o Nasogastric tube
o Metronidazole 500 mg IV every 8 hours + ceftriaxone 1 g IV every 24 h
o Call the surgeon!

Step 5: disposition

 Discharge home with advice to do Helicobacter serology and consult GP or

internist within 7 days
 Admission in
o surgical ward if abdominal distension or rigidity and call surgeon
o adult medical ward if bleeding

References

Federico A et al. Eradication of Helicobacter pylori infection: which regimen first? World J
Gastroenterol 2014; 20(3):665-672

Malfertheiner P et al. Peptic ulcer disease. Lancet 2009 ; 374 :1449-61

Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician 2007;76 :1005-12

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ACUTE DIARRHEA

Step 1: recognize

 Three or more unformed stools less than 2 weeks

Step 2: assess clinical severity

 Suspicion of cholera: profuse “water rice” diarrhea

 Severe dehydration: sunken eyeballs, poor skin turgor, orthostatic
hypotension, tachycardia, oliguria
 Bloody or mucoid diarrhea
 High fever ( T° ≥ 38.5° C)
 ≥ 6 stools/day
 Diarrhea lasting > 72 hours
 Shock
 Host: elderly, infant, heart failure, immunocompromised states

Step 3: work up

 Stool sample if any one of the following: ≥ 6 stools/day; temp ≥ 38.5° C;

persistent diarrhea (≥ 14 days duration); profuse cholera-like watery diarrhea;
dehydration; dysentery; elderly; immunocompromised patients; colitis (small
volume stool with visible blood, with or without mucus, fecal urgency and
tenesmus).
 HIV serology if status unknown; serum sodium and potassium, urea and
creatinine if dehydration

Step 4: treatment

Mild to moderate dehydration: oral rehydration therapy (ORT)

 Replacement fluids: 50-100 mg/kg over the first 4 hours with normal saline or
lactate ringer. Administer 25% of the value of ORT to be replaced each hour
for the first 4 hours.

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 Or give fluids as bellow:

5-14 years 1000-2000 ml

> 15 years 2200-4000 ml

 Replacement ongoing losses from stool (each stool = 200 ml).

Severe dehydration

First phase: restoration of intravascular volume

 Administer RL or normal saline 20 mL/kg over 30 min and assess SBP, radial
pulse, urine output. If no improvement repeat 20 mL/kg until improvement.

Second phase: maintenance fluid + fluid deficit (> 100 mL/kg) + ongoing losses. Give
one half of this volume over 8 hours and administer the remainder over the following
16 hours.

Maintenance fluids can be estimated as below:

Body weight Maintenance fluid

less than 10 kg 100 mL/kg

10-20 kg 1000 mL + 50mL/kg for each kg over 10

Greater than 20 kg 1500 mL + 20 mL/kg for each kg over 20 kg

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Antibiotic

If more than 3 days duration or fever or severe diarrhea or dysentery (bloody or

mucoid diarrhea) and stool examination not feasible

 Ciprofloxacine 500 mg orally twice daily for 7 days OR ceftriaxone 1 g IV for 7

days
 Add [tinidazole tab 500 mg, 4 tab single dose for 3 days + INTETRIX® 2 caps
twice daily for 10 days] OR ENTAMIZOLE® DS 1 tab thrice daily for 10 days

Anti-diarrhea drug

 Loperamide 2 mg caps (IMODIUM®) only if no fever, no dysentery and no

abdominal pain. Give 2 caps at stat, then 1 caps after each unformed stool.
(max= 8 mg/day) OR
 Racecadotril (TIORFAN®) caps 100 mg thrice daily

Disposition

 Admission in medical ward if clinical severity (e.g., severe dehydration; ≥ 6

unformed stools in 24 hours, intolerance of oral fluids)
 Discharge home non severe cases

Reference

Prado D. A multinational comparison of racecadotril and loperamide in the treatment

of acute watery diarrhea in adults. Scand J Gastroenterol 2002; 37(6):656-61

Dupont HL. Acute infectious diarrhea in immunocompetent adults. N engl J Med

2014; 370:1532-40

Government of Western Australia. Department of Health. Remote Area Nursing

Emergencies guidelines. Fourth Edition 2005.

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FOOD POISONING

Recognize

 Occurrence of two or more cases of similar illness resulting from the ingestion
of a common food.

Severity

 Dehydration

Work up

 Stool cultures have little value. Should be asked only if fever, bloody diarrhea,
severe abdominal pain,

Treatment

 Loperamide: initial dose is 4 mg, followed by 2 mg after each unformed stool,

with a total maximum dose of 8 mg per day for 48 hours OR racecadotril
(TIORFAN®) caps 100 mg thrice daily
 Oral hydration for mild dehydration 40 mg/kg over the next 4 hours, moderate
dehydration 100 mg/kg over the next 4 hours
 Antiemetics, analgesics and etc

Disposition

 Observation for 6 hours in all cases

 Admit in adult medical ward if severe
 Discharge with advice on hand hygiene

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Preformed toxins Incubation & illness Food symptoms

duration

Staphylococcus 1-6 hours after eating Eggs ( even hard Cramping and
Heat-stable toxin contaminated food boiled), potato abdominal pain
salad, custard- Vomiting
filled pastries,
D: 10h mayo Diarrhea is
variable, rarely
profuse

Bacilus cereus 2-4 hr Fried rice Profound vomiting

emetic toxin and abdominal
D:10 h cramps

Bacillus cereus 6-14 hr Vegetables, Diarrhea +

diarrheal toxin gravies abdominal cramps
D:24-36h
After colonization

Clostridium 6-24h Meat or poultry Abdominal cramps

perfringrens and diarrhea
D:24 h Vomiting rare

Escherichia coli 24-72h Unsanitary

enterotoxin drinking water
D:72 days

References

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DIARRHEA IN PLHA

Step1: clinical severity

 Signs of severe dehydration: altered level of consciousness, sunken eyes, skin

pinch (> 2 sec), SBP < 90 mmHg, radial pulse weak or absent, HR >110 bpm

Step 2: work up

 Stool ova and parasite;

 Stool acid-fast assay for oocysts;
 Stool culture

Step 3: treatment

Replacement fluids as in acute diarrhea

Anti-infectious drug

 If fever and dysentery (bloody or mucoid stool): ciprofloxacine 500 mg BD for 5

days
 If dysentery without fever: tinidazole (TINAZOL®) tab 500 mg, 4 tab OD for 3
days AND INTETRIX® 2 caps BD for 10 days
 If watery diarrhea: tinidazole (TINAZOL®) tab, 500 mg 4 tablets single dose
AND cotrimoxazole tab 480 mg, 2 tablets BD for 10 days (if not previous on
prophylactic dose)

Anti-diarrheal drug:

 Loperamide (IMODIUM®) caps 2 mg, 2 caps then 1 caps after each unformed
stool (max 6 mg/day) if no dysentery nor fever, nor abdominal pain

OR

 Racecadotril (TIORFAN®) caps 100 mg, 1 caps thrice daily

Step 4: disposition

 Admission in medical ward if clinical severity (e.g., severe dehydration; ≥ 6

unformed stools in 24 hours, intolerance of oral fluids, …)
 Discharge home non severe cases

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VOMITING

Step 1: recognize

 Duration: acute if less than 1 week

 Define: bloody, bilious, posttussive, feculent
 Ask for associate symptoms: fever, abdominal pain, back pain, headache, and
chest pain
 Ask for history of abdominal surgery, diabetes mellitus, recent prescribed
medication, food ingestions,

Step 2: clinical severity

 Chest pain
 Severe abdominal pain
 Central nervous symptoms: headache, cranial nerves dysfunction, long tract
signs; stiff neck, vertigo, focal neurologic deficits
 Dehydration, hypotension or shock
 Vomiting blood
 Fever
 Older age

Step 3: work up

 Serum electrolytes if hypovolemia or vomiting lasting more than 3 days

 Supine and upright abdomen radiograph (AXR) if suspected bowel obstruction
 Pregnancy test in any woman of childbearing age
 Urinalysis if abdominal pain
 Malaria parasite if fever

Step 4: treatment

 Insert IV line
 Commence 1000 ml of normal saline or lactate ringer solution over 1 hour
 If shock see corresponding protocol
o Metopimazine (VOGALENE®) 10 mg IM every 12 hours
o Alternative: metopimazine suppo, OR ondansetron tab (orodisp), 8 mg
every 8 hours

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Step 5: disposition

 Admission if:
o significant underlying disease;
o unclear diagnosis and responds poorly to fluid and antiemetic therapy;
o uncontrolled emesis refractory to medication;
o patient of extremes age with poor response to treatment

 Discharge home: no serious underlying illness; good response to fluid and

antiemetic therapy; patient able to take clear liquids before discharge

References

Scorza K, Williams A, Daniel Phillips J, Shaw J. Evaluation of nausea and vomiting.

Am Fam Physician 2007; 78: 76-84

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CAUSTIC POISONING

Household caustics

Acids Alkali

Battery fluids : sulfuric acid Bleaches: sodium hypochlorite (La

Croix®,…), hydrogen peroxide

Toilet bowl cleaners: hydrochloric or Drain cleaners: sodium hydroxide(caustic

phosphoric or sulfuric acid soda?), sodium hypochlorite

Button batteries:
sodium hydroxide, potassium hydroxide

Recognize

 Patient can be asymptomatic

 Symptoms/signs:
o mouth injury: oropharyngeal burns
o larynx injury: hoarseness, stridor; aphonia,dyspnea
o esophagus injury: dysphagia, odynophagia, refusal of food, drooling
o stomach injury: vomiting, epigastric pain, hematemesis
 Identify amount, type, concentration, time of contact, circumstances
(intentional/accidental)
 encourage family or witness to bring the product container

Step 1: clinical severity

 Shock
 Respiratory distress
 Neck subcutaneous emphysema
 Signs of peritonitis

Step 2: work up

 Esophagogastroduodenoscopy within 24 hours in symptomatic patient [oral

pharyngeal burns, symptoms of serious injury (vomiting, drooling, dyspnea,
stridor )] or after intentional ingestion

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o Normal mouth and throat does not exclude esophagus or stomach

injury
 CXR in all patients
 FBC, electrolytes, hepatic profile, coag profile

Step 3: treatment

 Do not do: give water, milk, antacids, insert nasogastric tube

 Nothing per mouth if oropharyngeal injury or symptomatic
 Place patient in semi-prone position
 Insert IV line with dextrose 5% 500 ml
 Early (within 12 hours) endoscopy
 Start antiemetic if vomiting
 If eye/cutaneous projection: wash with copious water for 20 minutes
 Call the surgeon if esophageal or gastric perforation

Acute Caustic ingestions

ABCD & resuscitation

CXR & AXR

Endoscopy

Grade II Grade III

Grade I
Hemorrhage,
Edema and erythema
erosions, blisters,
ulcers with exudates
Grade IV
Multiple deep ulcers
Perforation
with brown, black, or
gray discoloration

No therapy Observation
Surgery
Liquid diet, then Semifluid diet for 72 hours
Pump proton inhibitor
regular diet in 24 h
NGT if food not tolerated
Dexamethasone 1 mg/kg/day
Pump proton inhibitor 0.7-3.5 mg/kg/day
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Step 4: disposition

 Discharge home if accidental ingestion of small volume of weak or diluted

caustics; and no symptoms/oropharyngeal injury
 Admit all symptomatic patient into surgical ward

References

NUNEZ MJ, LOEB PM. Caustic injury to the upper gastrointestinal tract. In
Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed

Betalli P et al. Update on management of caustic and foreign body ingestion in

children. Diagnostic and therapeutic endoscopy 2009

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BLEACH POISONING

Step 1: clinical severity

 Mild < 100 mL (1 cup ~ 250 mL)

Step 2: work up

 Esophagogastroduodenoscopy

Step 3: treatment

 Eyes decontamination
o Immediate irrigation of affected eye for 10-15 min
o Refer to ophthalmologist

 Skin decontamination
o Remove all clothing
o Wash hair and all contaminated skin with copious amount of water and
soap for 10-15 min

 Mild ingestion (< 100 mL): no treatment

 Observation for 6 hours all asymptomatic patients

Step 4: disposition

 Esophagogastroduodenoscopy

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FOREIGN BODY INGESTION

Recognize

Young children, mentally impaired adults

o Choking, refusal to eat, vomiting, drooling, wheezing, blood stained-saliva,

respiratory distress

Oropharyngeal/ proximal esophageal perforation

o Neck swelling, erythema, tenderness, crepitus

Step 1: clinical severity

 Respiratory distress
 Signs esophageal perforation: crepitus on neck, chest pain? hematemesis?
 Signs of gastric perforation: peritonitis

Step 2: work up

 CXR and AXR initially and at 4 hours interval to monitor the progression
 Endoscopy urgently if: sharp-pointed FB, long FB (> 6 cm), battery, airway
compromise,
 Oral baryt /barium with water soluble if perforation suspected

Step 3: treatment

 Removal of FB
o Food impaction
 Endoscopic removal if food has not passed within 12 hours or
inability to swallow fluid
 10 mg nifedipine SL to relax lower esophageal sphincter if distal
esophageal food impaction followed by CXR

o Coin
 Endoscopic removal within 24 hours if lodged in the esophagus

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o Button battery
 Endoscopic removal if in esophagus or still in stomach after 48
hours observation
 If into the stomach: daily radiograph (AXR)
 if they have passed the duodenal: radiograph every three days

o short-blunt objects
 endoscopic removal if wider than 2.5 cm
 fail to progress beyond the stomach after 3-4 weeks

o Sharp-pointed object
 Endoscopic removal in lodged in esophagus
 If patient symptomatic or are swallowed a sewing needle:
surgical consultation
 If asymptomatic and have swallowed other sharp objects: daily
radiographs (AXR). Surgical removal if fail to progress after 3
days

o Cocaine ingestion
 surgical consultation

Step 4: disposition

 Admission in surgical wards: nothing per mouth

 Discharge home if coin ingestion, button battery into the stomach,

References

ASGE. Management of ingested foreign bodies and food impactions. Date?

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UPPER GASTROINTESTINAL BLEEDING

Recognize

 Hematemesis (vomiting of blood), “coffee grounds” emesis, melena, and/or

hematochezia

Step 1: clinical severity (hemodynamically unstability)

 Frequent melena
 Hematemesis or melena associated with hemodynamically instability:
o HR > 100 bpm,
o supine systolic BP < 100 mmHg,
o postural hypotension,
o RR > 20/min,
o syncope,
o reduced level of consciousness,
o Clammy cold extremities.
 Blatchford score ≥ 6 predicts the need of intervention ( endoscopy, surgery,
blood transfusion)

Step 2: work up

 FBC, blood type, PT/INR, aPPT

 urea, creatinine,
 ± Helicobacter pylori serology if suspected peptic ulcer bleeding

Step 3: treatment

 Insert two IV line with large bore cannulae (16G grey or 18G green if possible)
 Restoration of volume loss: 2 liters bolus of normal saline or ringer lactate until
the patient’s vital signs stabilization.
 Give 1000 mL of normal saline over 1 hour if patient stable: HR < 100 bpm
and SBP > 100 mmHg
 Transfusion of red blood cells: if ongoing blood loss, symptomatic anaemia,
Hb < 7 g/dL or failure to improve vital signs after the infusion of 2 liters of
crystalloid (normal saline or lactated ringer solution)
 Omeprazole PO 40 mg twice daily for five days if suspicion of peptic ulcer
disease.
 Norfloxacine 400 mg twice daily for 7 days if suspicion of variceal bleeding

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 Monitor: vital signs hourly

 Stop all NSAIDS

Step 4: disposition

 Admission of all cases in adult medical ward

 Discharge home without upper endoscopy if patient meet all these criteria:
urea < 18.2 mg/dL, hemoglobin > 13 g/dL (men), > 12 g/dL (women), systolic
blood pressure ≥ 110 mmHg, pulse > 100 bpm, absence of melena, syncope,
cardiac failure, liver diseases

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References

Khuro MS et al. A comparison of omeprazole and palcebo for bleeding peptic ulcer. N Engl J
Med 1997;336(15):1054-8

Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;
107:345-360

Albeldawi M, Qadeer MA, Vargo JJ. Managing acute upper GI bleeding, preventing
recurrences. Clevel Clinic Journal of Med 2010?

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Hematemesis and/ or melena

Hemodynamic status

Resuscitation as needed

Risk assessment of further bleeding

Rockall score

Upper endoscopy

Active bleeding OR Adherent clot Flat spot or

Non-bleeding visible vessels Clean-based ulcer

Endoscopic therapy ± Endoscopic therapy PPI orally

High dose omeprazole oral

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ACUTE HICCUPS

Recognize hiccups

 involuntary respiratory reflex with spastic contraction of the inspiratory muscles

against a closed glottis, producing the characteristic sound
 Persistent: > 48 hours

Work up

 CXR, ECG

Symptomatic treatment

 Chlorpromazine 25 mg (LARGACTIL®) in 125 mL of 5% glucose solution over

20 minutes

OR

 Baclofen 10 mg (LIORESAL® ), ½ tab 3 times

OR

 Chlorpromazine 25 mg (LARGACTIL®) IM single dose

Disposition

 Discharge with follow up by primary care provider

References

Woelk CJ. Managing hiccups. Can Fam Physician 2011;57:672-675

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JAUNDICE

Recognize

 Yellow eyes

Severity

 altered level of consciousness

 hypotension
 fever with abdominal pain
 active bleeding

Work up

 Total & conjugated bilirubin , alkaline phosphatase, ASAT & ALAT,

prothrombin time, urinalysis
o if conjugated hyperbilirubinemia: abdominal ultrasonography
o if unconjugated hyperbilirubinemia: Coombs test, hemoglobin
electrophoresis

Treatment

 acute viral hepatitis: supportive

 cholangitis: ABx IV + surgeon consultation

Orientation

 Hospitalization if ALT > 1000 IU/L, uncomplicated cholecystitis or any criteria

of severity
 referral to internist if no severity

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ACUTE FEVER

Recognize

 Temperature > 38° C for less than 7 days

Clinical severity

 Purpura fulminans
 Patient unable to walk
 Altered mental status
 Abnormal vital signs: SBP < 90 mmHg, HR > 120 bpm, RR ≥ 30 min, T > 40°
or < 35 °C

Work up

 Malaria parasite, urine dipstick.

 Blood sugar if diabetes mellitus
 CXR if cough or dyspnea
 Blood culture if SIRS or Shapiro criteria

Treatment

 Insert IV line and give normal saline 500 mL if one or more criteria of clinical
severity
 Give antipyretic if temperature > 40° or ≥ 38.5°C in young children or elderly
patient: paracetamol 500 mg 2 tablets every 6 hours
 Urgent antibiotherapy if meningitis, endocarditis, severe sepsis, purpura
fulminans, abdominal pain, necrotizing fasciitis, septic arthritis
 If localizing symptoms/ signs: e.g., neck stiffness, cough & purulent sputum,
diarrhea, urgency/dysuria, costovertebral angle tenderness (CVAT), phlebitis
at IV site, … treat as indicated in antibiotic guide
 If purpura fulminans: ceftriaxone 50 mg/kg IV before any bacterial sample

Disposition

 Admit in medical ward if:

o no clear infection is identified in older or immunocompromised patients;
o chronic illness(diabetes, CKD, etc)
 Discharge home if clear diagnosis (e.g., uncomplicated pyelonephritis)

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ANTIBIOTIC GUIDE FOR ADULTS

Infection ATB

Bacterial meningitis Ceftriaxone 2 g IV q24 h for 10 days

Acute bacterial Amoxicillin-clavulanate 875 mg/125 mg bid per os for 7 days

rhinosinusitis OR
Levofloxacin 500 mg once per os for 7 days if betalactam allergy

Pharyngitis Amoxicillin 1 g bid per os for 6 days OR

Cefpodoxime (ORELOX®) 100 mg bid for 5 days OR
Azithromycine (e.g., AZITHRINE®) 500 mg daily for 3 days
Community Amoxicillin 1 g bid per os for 7 days if CURB-65 = 0-1
acquired Amoxicillin/clavuanate 875/125 mg bid daily for 7 days
pneumonia
Amox-clavulanate 1 g TD IV plus [azithromycin 500 mg day1 , then
250 mg daily day2 through day5
OR clarithromycin 500 mg bid] if CURB-65 = 2-5

Enterocolitis Ciprofloxacine 500 mg PO bid for 5 days OR

azithromycin 500 mg once a day for 3 days

Pyelonephritis Ciprofloxacine 500 mg orally bid for 7 days OR

Ceftriaxone 1 g IV/IM q24 h

Cystitis Fosfomycine-trometamol (MONURIL®) sachet 3 g single dose OR

Norfloxacine tab 400 mg bid for 3 days

Pelvic inflammatory Ceftriaxone 250 mg IM single dose plus

disease Doxycycline 100 mg bid for 14 days

Erysipelas Penicillin V (ORAPEN®) 250 mg 4 times a day for 5 days if no SIRS

Ceftriaxone 1 g IV if SIRS
CURB-65 (Confusion, blood urea nitrogen ≥ 20 mg/dl, respiratory rate ≥ 30 breaths/min, systolic blood
pressure < 90 mmHg or diastolic blood pressure ≤ 60 mmHg, and age ≥ 65 years). A score ≥ 2
indicating the need for hospitalization

SIRS: two or more of the following: T > 38°C or < 36°C, HR> 90 bpm, RR > 24 c/mn, WBC >
12 000/mm3 or < 4000/mm3

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Reference

Coburn B and al. Does This Adult Patient With Suspected Bacteremia Require Blood Cultures? JAMA.
2012; 308 (5):502-511

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MALARIA

Step 1: recognize malaria

Fever or a history of fever plus parasitological confirmation by microscopy or rapid

diagnostic tests

Step 2: assess clinical severity

Any one of the following:

 More than two convulsions in 24 h

 Prostration: generalized weakness so that the patient is unable to sit, stand or
walk without assistance;
 Impaired consciousness or coma
 Circulatory collapse: systolic blood pressure < 70 mm Hg in adults plus poor
perfusion signs (limb coolness, weak or absent peripheral pulses)
 Respiratory distress (RR > 32/min, sustained nasal flaring, intercostals
indrawing) or acidotic breathing: increased inspiratory and expiratory excursion of the
chest
 Renal failure: urine output less than 400 mL in 24 h and a serum creatinine > 3
mg/dL
 Haemoglobinuria
 Jaundice
 Spontaneous bleeding
 Cessation of eating and drinking

Step 3: work up
 Hemoglobin level, blood glucose level. Lumbar puncture if coma
 Lab features of severe malaria
 Severe normocytic anemia: hemoglogin < 5 g/dl or Ht < 15%
 Hyperparasitemia : > 20% or > 250 000/mm3
 Hypoglycemia : blood glucose < 40 mg/dL
 Hyperlactatemia : lactate > 5 mmol/L
 Metabolic acidosis : plasma bicarbonate < 15 mmol/L
 Pulmonary edema on chest radiograph

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Step 4: treatment
Severe malaria

Specific treatment

 Artesunate (ARTESUN®, amp 60 mg) 2.4 mg/kg BW IV or IM given on

admission (0, 12 h, 24 h, then once daily). Switch to oral treatment as soon
as he/she is able to take food reliably

 alternatives if artesunate not available

 Quinine base (i.e., QUINIMAX®)16.6 mg/kg infusion over 4 hours in
500 ml 5% dextrose, followed by 8.3 mg/kg infusion over 4 h in 500 mL
5% dextrose, every 8 hours

 Quinine base 8.3 mg/kg infusion over 4 h in 500 mL 5% dextrose, every

8 hours (e.g. QUINIMAX®)

 Quinine salt 10 mg/kg (i.e., quinine dihydrochloride) infusion over 4 h in

500 mL 5% dextrose, every 8 hours. Quinine dihydrochloride is
available in hospital pharmacy

 Artemether IM 3.2 mg/kg loading dose, then 1.6 mg/kg once a day in
the anterior thigh

 Artemether 160 mg IM single dose day 1, then 80 mg IM daily in the

anterior thigh

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Symptomatic treatment

 Analgesics: as per protocol

 Anticonvulsants: diazepam 0.2 mg/kg intravenously if ongoing seizure
 Bolus of normal saline or Ringer’s lactate 500 mL IV if SBP < 90 mmHg

Uncomplicated malaria
 Artemether + lumefantrine (e.g., COARTEM®, ARTEFAN® or BIMALARIL® 1
tab BD for 3 days)

Step 5: disposition

 Admission adult medical ward: if severe malaria and > 15 years of age;
Ob/Gyn ward: if severe malaria in pregnant women; children ward: if severe
malaria and patient < 15 years of age
 Discharge home: if uncomplicated malaria

References:

WHO. Severe falciparum malaria. Trans R Soc Trop med Hyg. 2000; 94 (Supp1):S1-
90

WHO. Guide for the treatment of malaria. 2nd edition 2010

Guide prise en charge du paludisme au Cameroun à l’usage du personnel de santé.

PNLP 2013

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ENTERIC (TYPHOID) FEVER

Recognize

 Fever of more than one week duration without evident causes

 Patient may present with unspecific symptoms such as:
o Influenza-like symptoms: chills, dull frontal headache, malaise,
anorexia, nausea, poorly localized abdominal discomfort, dry cough,
myalgia
o Constipation: usually following brief episode of diarrhea (“pea soup”).
o Tender/distended abdomen
o Severe lethargy/fatigue

Clinical severity

 Obtundation, coma
 Shock

Work up

 Culture of blood & stool

 Felix-Widal test not clinically useful

Treatment

 Antibiotics:
o ciprofloxacine 500 mg orally twice daily for 5 to 7 days or
o Cefixime orally 100-200 mg orally twice daily for 7 to 14 days or
o Azithromycine 500 mg (10 mg/kg) orally once daily for 7 days or
o ceftriaxone 1 g IV or IM daily for 10 days
 Dexamethasone 3 mg/kg slow IV infusion over 30 minutes followed by 1
mg/kg/6 hours for 48 hours in clinical severity: coma, shock, obtundation

References

WHO. The diagnosis, treatment and prevention of typhoid fever.2003

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PEOPLE LIVING WITH HIV/AIDS (PLHA)

Enquire about past medical history, specially:

 ART
o Detail regimen & starting date
o Primary physician
o Compliance
 Cotrimoxazole prophylaxis : CTM 480 mg 2 tablets daily
 CD4 latest value

CLINICAL SITUATIONS

Pulmonary

Symptoms Work up Diagnosis Treatment

TMP-SMX 2 double
Dyspnea, CXR (normal or Pneumocystis strength tab every 8
non productive perihilar infiltrate) jiroveci hours for 21 days
Cough PCR of induced pneumonia
sputum

Fever/chills CXR (lobar Community See corresponding

Acute cough with consolidation) acquired protocol
or without purulent pneumonia
sputum
Unilateral pleuritic
pain

Fever, night sweat CXR (pleural TB

Cough > 3 weeks effusion, infiltrate,
Productive sputum cavitation, hilar
adenopathy node)

Sputum smear for

AFB

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Gastrointestinal

Symptoms Work up Diagnosis Treatment

Acute diarrhea: Salmonella, Ciprofloxacine 500 mg twice

dysentery Shigellosis, daily orally for 5 days
(bloody or Yersinia
mucoid Campylobacter
diarrhea) plus
fever

Acute diarrhea: Stool ova & Entamoeba Metronidazole 30-50 mg/kg in

dysentery parasites histolytica 3 divided doses for 7 days or
(bloody or Tinidazole 4 tablets (50
mucoid ± Stool antigen Non pathogenic mg/kg) OD for 3 days
diarrhea) amebae: E.coli, PLUS
without fever E. hartmani, Tiliquinol +
Endolimax nana, tilbroquinol (INTETRIX®) 2
E. dispar caps twice daily for 10 days

Alternative: metronidazole
400 mg/diloxanide furoate
500 mg (ENTAMIZOLE DS) 1
tab 3 times daily for 10 days

Watery stool Stool ova & Entamoeba Tinidazole 4 tablets OD

(chronic or parasites; histolytica, single dose for 3 days
acute) Giardiasis PLUS
Cotrimoxazole 960 mg 4
Stool MAF Cytoisosporiasis, times twice daily for 10 days
Cyclosporosis
CTM 960 mg twice daily for
10 days may be used

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Neurological

Symptoms Work up Diagnosis Treatment

Headache Brain CT scan Toxoplasma Cotrimoxazole 480 mg 4

Focal gondii tab 3 times for 6 weeks or
neurologic encephalitis 960 mg 2 tab 3 times for
deficit (e.g. 6 weeks
hemiparesis,
aphasia, ataxia) Altern: pyrimethamine
and/or seizures orally 100 mg day1, then
50 mg daily +
sulfadiazine 1 g 4 times +
folinic acid 10 mg daily
for 6 weeks

Replace sulfadiazine by
clindamycine 600 mg 4
times if sulfamide allergy

Headache CSF analysis Cryptococcal Fluconazole 600 mg

Delirium with India ink meningitis twice daily for 2 weeks
test or rapid then 400 mg twice daily
CSF CrAg for 8 weeks
assay

Alternative:
rapid serum
CrAg
CrAg: cryptococcal antigen

References

WHO. Diagnosis, prevention and management of cryptococcal disease in HIV-

infected adults, adolescents and children. 2011

Pereira-Chioccola VL et al. Toxoplasma gondii infection and cerebral toxoplasmosis

in HIV-infected patients. Future Microbiology 2009; 4(10):1363*1379

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TETANUS

Recognize

 Generalized:
o Early signs: neck stiffness, sore throat, poor mouth opening
o trismus (lockjaw), generalized muscle rigidity, generalized spasm
spontaneous or induced by external stimuli (noise, light, touch).
o ± Dysautonomia: tachycardia, hypertension, fever, arrythmias,
diaphoresis
 Localized: persistent muscles spasms close to the site of injury.
 Cephalic: trismus + VII palsy or other cranial nerves palsies ipsilateral to
location of infection site.
 Neonatal: irritability, poor feeding (sucking or swallowing)

Route of entry

 burns, ulcers, gangrene, snakebites, septic abortion, childbirth, IV/IM

injections, surgery

Severity

Ablett classification of severity

Grade Clinical features

I (mild) Mild trismus, general spasticity, no respiratory involvement,

no spasms, little or no dysphagia

II Moderate trismus, rigidity, short spasm, mild dysphagia,

(moderate) moderate resp, RR >30 cycles/min

III (severe) Severe trismus, generalized spasticity, reflex prolonged

spasm, RR > 40 c/min, severe dysphagia, apnoeic spells,
pulse rate >120 bpm

IV (very Grade III + severe autonomic disturbances involving

severe) cardiovascular system.

Severe hypertension and tachycardia alternating with

relative hypotension and bradycardia, either of which may
be persistent

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Treatment

 Surgical debridement
 Prevent further toxin release: metronidazole 500 mg every 6 hours IV, then
oral relay for 7 days
 Neutralize toxin outside the CNS: equine tetanus antitoxin (TAT) 500 IU/kg IM
single dose
 Minimize the effects of the toxin already in the CNS: diazepam 0.1 mg/kg IV
every 4 hours
 Start vaccination first dose on a different site, followed by two doses at month
interval

Disposition

 Refer to ICU if grade III or IV

 Admit in adult medical ward other cases
o Isolation: single room, no light , no noise, one visitor at time
o IV fluid and alimentation:
o NG tube + urinary Foley catheter after sedation

References

Quasim S. Management of tetanus. www.AnaesthesiaUK.com/WorldAnaesthesia

Farrar JJ et al. Tetanus. J Neurol Nuerosurg Psychiatry 2000; 69; 292-301

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SKIN AND SOFT TISSUE INFECTIONS

Recognize:

 Cutaneous abscess: painful fluctuant soft tissue mass

 Furuncles: inflammatory nodules with overlying pustules through which hair
emerges
 Erysipelas: fiery red, tender, painful plaque with well-demarcated edges. pain,
swelling of involved areas, local warmth
 Necrotizing fasciitis: purple bullae, sloughing of skin, marked edema, skin
necrosis or ecchymoses, systemic toxicity, wooden-hard* induration of the
subcutaneous tissue, crepitus

Severity/warning signs

 Systemic toxicity: fever or hypothermia; tachycardia; hypotension

 Pain disproportionate to the physical findings
 Violaceous bullae
 Cutaneous hemorrhage
 Skin loughing
 Skin anesthesia
 Rapid progression
 Gas in the tissue

Work up

 Fasting blood sugar

 if systemic toxicity: FBC, creatinine, CRP

Treatment

Cutaneous abscess:

 Incision and drainage.

 Antibiotics ( e.g., clindamycin) for patients with SIRS or markedly impaired
host defenses: temp >38°C or < 36°C, RR> 24 bm , HR> 90 bpm, WBC count
> 12 000 cells/mm3 or < 4000/mm3

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Furuncle

 Moist heat therapy

 ATB only for large furuncle/carbuncles (coalescence of furuncles) or if SIRS
o Cloxacillin 500 mg 4 times daily for 5 days or FLOXAPEN® 500 mg, 1
caps times a day for 5 days

Erysipelas

 Outpatient therapy if no SIRS, altered mental status, or hemodynamic

instability:
o cloxacillin 500 mg 4 times per day orally for 5 days, to be extended (10-
day course) if infection has not improved within this time period OR
o clarithromycin 500 mg twice daily per day orally OR
o penicillin V (ORAPEN®) 250 mg 4 times a day for 5 days OR
o clindamycin 300 mg 3 times per day orally for 5 days for suspected
MRSA if penetrating trauma, purulent discharge:
o elevation of the affected area
o ibuprofene 400 mg 4 times a day for 5 days to accelerate clinical
improvement.
 Admit in adult medical ward if SIRS, altered mental status, hemodynamic
instability, severe immunocompromised patients, head & neck location.
o Vancomycin for cellulitis associated with purulent discharge, SIRS,
injection drug use, penetrating trauma, evidence of MRSA elsewhere

Necrotizing fasciitis

 Clindamycin 600 mg every 8 h IV+ ciprofloxacine 400 mg every 12 h IV

OR

 Vancomycin + [Ceftriaxone 1 g every 24 h IV + metronidazole 500 mg every 8

h IV] or [imipenem] or [ciprofloxacine + metronidazole]
 Urgent surgical debridement

Disposition

 Admit in adult medical ward if severe erysipelas

 Admit in surgical ward all patients with necrotizing fasciitis
 Discharge home other cases

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References

Stevens et al. Practice guidelines for the diagnosis and management of skin and soft-
tissue infections. Clin Infec Dis 2014

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SCABIES

Recognize

 Itching at night
 Another member of the family affected
 Blisters, papules/nodules: nipples, axillae, buttocks, elbows, web spaces,
wrists, ankles,

Work up

 None

Treatment

Benzil benzoate (ASCABIOL®) 25% lotion

 Take a bath at 7 pm
 Shake the bottle before application
 Apply to the whole body ( scalp, postauricular areas, palms, soles).Do not apply
to the face and mucous membranes
 Second application after 10 minutes, when the first as dried
 Day after take a bath to remove the products :
o at 7 pm for adult
o at 7 am for child less than 2 years
 Always treat the patient and all the family

A-PAR spray for disinfection

 put clothes, drapes into a plastic bag,

 spray A-PAR at 30 cm distance
 seal plastic bag for 48 hours then wash them
 Spray it on “canapé “, chairs, matelas, pillows, fauteuil, shoes

Mequitazine (PRIMALAN®)

 1 cuillère mesure pour 5 kg

 1 tablet daily for 2 weeks

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Alternative to benzyl benzoate lotion = ivermectine

Ivermectine (MECTIZAN®) 3 mg tab

 4 tablets with small water

 Do not eat 2 hours before and after administration
 Repeat 10 or 15 days after

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HYPERGLYCEMIC CRISIS

Step 1: recognize hyperglycemic crisis

 Suspect hyperglycemic crisis if history of polyuria, polydipsia, weight loss,

vomiting, dehydration, weakness, mental status changes.
 Precise the type:
o Hyperosmolar hyperglycemic syndrome: plasma glucose > 600 mg/dL +
profound lethargy/coma. dehydration(poor skin turgor, dry mucous
membranes, sunken eyeballs, tachycardia, hypotension), ± hemiparesis
and hemianopia
o Diabetic ketoacidosis: pH < 7.3 + plasma glucose > 250 mg/dL +
cetonuria + serum bicarbonate < 15 mEq/L. Nausea/vomiting,
abdominal pain, Kussmaul respiration

Step 2: clinical severity

 Coma
 Hypotension
 Severe hypothermia
 Severe comorbidities

Step 3: work up

 Urea, creatinine, serum sodium and potassium, plasma blood sugar, urinalysis
 Check the causes: “Five I’s”: infection, infarction, infant (pregnancy),
indiscretion (including cocaine ingestion), and insulin lack (non adherence or
inappropriate dosing).

Step 4: treatment

Fluid therapy

 Administer 1000 mL normal saline solution first hour, then 0.9% NaCl at 500
mL/ hour for 4 hours, 250 mL/hour for the next 4 hours, 1000 mL every 4
hours
 Add 5% dextrose solution when blood sugar < 250 mg/dL
 oral hydration if patient is conscious (2000-3000 mL/24 h)

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Potassium

 2 g ClK per liter starting with the second liter of normal saline
o 2 amp ClK 10% in each 1000 mL of normal saline

Insulin therapy

 Start IM regular insulin (ACTRAPID®) as below

If blood glucose > 400 mg/dL 16 UI IM stat

then 10 UI IM/h
If blood glucose > 250 mg/dL and < 400 mg/dL 5 UI IM/h

If blood glucose < 250 mg/dL 5 UI IM last dose and

Start one hour after SC insulin
protocol
as before crisis or if insulin-naïve
patients 0,5-0,8 U/ kg/ day

Transition to SC insulin

If resolution of DKA or HHS overlap of 1 or 2 hours between discontinuation of IM

insulin and administration of SC insulin

 Resolution of DKA = plasma glucose < 200mg/dL

 Resolution of HHS = regain normal mental status, normal hydration status

If known diabetic patient, restart the same dose than dose before the onset of DKA if
it was controlling glucose

If insulin naïve patient, 0.5-0.8 unit/kg/day

Monitoring

 Glasgow coma scale, blood glucose every 2 hours, urine output

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Treatment of precipitating factors

 Stroke
 Non compliance; under-dosing of insulin
 Infections (urinary tract infection, pneumonia, etc)
 Myocardial infarction
 Corticosteroids, antipsychotics, thiazides

Step 5: disposition

 Refer to emergency department of Douala if still unconscious

 Admission in adult medical ward if conscious, blood sugar < 250 mg/dL

References

Emergency medicine: a comprehensive study guide. 6th ed. Graeffe CS.

Hyperosmolar hyperglycemic state. 1307-1311

Kitabchi AE et al.Hyperglycemic crises in adult patients with diabetes. Diabetes Care

2009; 32:1335-1343

Alberti KG, Hockaday TD, Turner RC. Small doses of intramuscular insulin in the
treatment of diabetic “coma. Lancet. 1973; 2(7828):515–22.

Sobngwi E et al. Evaluation of a simple management protocol for hyperglycemic

crises using intramuscular insulin in a resource-limited setting. Diabetes &
Metabolism 2009; 35:404-409

McNaughton CD, Self WH, Slovis C. Diabetes in the emergency department: acute
care of diabetes patients

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HYPOGLYCEMIA

Step 1: recognize

 Adrenergic symptoms: sweating, trembling, pounding heart, anxiety, irritability,

dizziness, headache, pallor, hunger, nausea
 Neuroglycopenic symptoms:
o weakness, visual disturbance, difficulty speaking, tingling, dizziness,
impaired concentration, tiredness, drowsiness, disorientation, slurred
speech, irrational or uncontrolled behavior
o focal seizures, hemiplegia, paroxysmal choreoathetosis
o deep coma, papillary dilation, shallow breathing, bradycardia, hypotonia

Step 2: work up

 Finger stick glucose < 55 mg/dl

 Search the causes in diabetic patient
o Medication: dose error, drug interactions
o Dietary: miss a meal
o Unusual physical activity
o Predisposing factors: renal failure, hepatic failure, adrenal insufficiency

Step 3: treatment

Conscious patient

 Oral glucose: 15 g of carbohydrate (e.g., 3 glucose tablets dissolved in water;

4 oz (175 mL or 3/4 cup) regular-sweetened cola or orange juice
 Control finger stick glucose after 15 min, if no improvements retreat with
another 15 g of carbohydrate
 Allow oral feeding immediately: give fruit or meal

Unconscious patient

 Insert IV line and give 250 mL of 10% dextrose solution over 5 min or 500 mL
of 5% dextrose solution
 When consciousness returns, allow oral feeding immediately: give fruit or meal

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Step 4: disposition

 Discharge home if obvious cause and treated; if hypoglycemic episode

reverse rapidly. Advice medical doctor consultation within 3 days
 Admission in adult medical ward:
o if diabetic patient on sulfonylurea (glibenclamide or
glyburide/DAONIL®, glimepiride/AMAREL®, gliclazide/DIAMICRON®),
o no obvious cause is found;
o patient on long acting insulin (MIXTARD®, INSULATARD®);
o persistent neurologic deficit.

Reference

Tomky D. Detection, prevention, and treatment of hypoglycemia in the hospital.

Diabetes Spectrum 2005, 18

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ACUTE KIDNEY INJURY

Recognize

AKI is defined as any of the following criteria:

 Increase in serum creatinine by ≥ 0.3 mg/dL (≥ 26.5 µmol/L) within 48 hours;

 Increase in serum creatinine to 1.5 times baseline (≥ 50%), which is known or
presumed to have occurred within the past 7 days;
 Urine volume < 0.5 mL/kg/hour for more than 6 hours in adults

Severity

Stage Serum creatinine Urine output

1 1.5 to1.9 times baseline < 0.5mL/kg/h for 6-12

Or hours
0.3mg/dL (≥ 26.5 µmol/L) increase

2 2 to 2.9 times baseline < 0.5 mL/kg/h for ≥ 12

hours

3 3 times baseline 0.3 mL/kg/h for ≥ 24 hours

Or Anuria for ≥ 12hours
Increase in serum creatinine to ≥ 4 mg/dL (≥ 353.6
µmol/l)
Or
Initiation of renal replacement therapy
Or
In patients 18 years , decrease in eGFR to < 35
ml/min per 1.73m

Complications

 Uremia
 Hyperkalemia
 Volume overload
 Severe metabolic acidosis

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Causes

 Prerenal suspect if diarrhea, vomiting, polyuria, profuse sweating, bleeding

 Intrarenal suspect if use of nephrotoxic agents ( i.e., NSAIDS,)
 Postrenal: suspect if lumbar pain,

Work up

 Urinalysis
 Sodium, potassium
 Calcium, phosphorus
 Abdominal ultrasound
 FBC

Management

Treatment of life threatening complications

 Pulmonary edema
o furosemide 250 mg in 50 mL of normal saline over one hour. To be
repeated if effective
 Hyperkalemia (K > 6.5 mEq/L)
o 10 ml of 10 % calcium gluconate IV over 5 minutes
o Salbutamol 0.5 mg IV bolus
o KAYEXALATE® 15 g 4 times a day. Dilute in eau sucrée
 Metabolic acidosis:
o bicarbonate
 Uremic complications (i.e., bleeding, etc)

Indications for emergently dialysis

 Any of the following: volume overload, hyperkalemia, metabolic acidosis

Treatment of underlying causes

 In hypovolaemic patient administer 250 mL of normal saline rapidly and

repeatedly until urine output 0.5mL/kg/h?
 Oliguria: use forced diuresis does not change mortality

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Disposition

Referral to nephrologist within 24 hours if any of the following criteria:

 a possible diagnosis that may need specialized treatment (vasculitis, interstitial

nephritis, myeloma);
 AKI with no clear cause;
 inadequate response to treatment;
 complications associated with AKI;
 stage 3 AKI;
 a renal transplant;
 CKD stage 4 or 5

Admit in adult medical ward other case

References

Akute kidney injury. Prevention, detection and management of acute kidney injury up to the point of
renal replacement therapy. 2013. Guidance .nice.org.uk/cg169

Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical
Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl.2012; 2: 1–138.

Fry AC, Farrington K. Management of acute renal failure. Postgrad Med J 2008:82:106-116

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ACUTE HYPOCALCEMIA

Symptoms and/or calcium < 1.9 mmol/L

Step1: recognize

 peri-oral and digital paraesthesiae

 muscle twitching, spasms, tingling, numbness
 positive Trousseau’s and Chvostek’s sign
 Carpopedal spasm
 Tetany
 Laryngospasm

Step 2: clinical severity

 Long QT and Arrhythmia,

 Hypotension,
 Seizures

Step3: work up

 Calcium, phosphorus, albumin,

 magnesium, potassium,
 PTH, vitamin D

Step 4: treatment

 Insert IV line
 IV 10% calcium gluconate
o 10 mL in 100 mL of 5% dextrose/normal saline over 15 minutes. Repeat
until patient asymptomatic
o Then followed by 50 ml of 10 % calcium gluconate (5 vials) in 500 mL of
5% dextrose/normal saline and infuse at 50-100 mL/hour or
….drops/min
 Treat the underlying cause
o magnesium if hypomagnesemia: 6 g of MgSO4, 30 mL of 20% MgSO4
in 500 mL in NS/5 % dextrose over 24 hours
o vitamin D if vitamin D deficiency

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Step 5: disposition

 Admission if severe hypocalcemia: adult medical or pediatric ward

 Discharge home if mild hypocalcemia; oral calcium 500 mg twice daily for 1
month
 Advice internist consultation within one week

References

Cooper MS, Gittoes NJL. Diagnosis and management of hypocalcaemia. BMJ 2008;
336:1298-302

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RENAL COLIC

Step 1: recognize

 Excruciating unilateral flank pain, abrupt, colicky, with or without radiation into
the groin, ± testicles or labia major

Step 2: assess the severity and/or complications

 Temperature > 38°C or chills

 Oligoanuria
 macroscopic hematuria
 Single kidney,
 bilateral obstruction
 Uncontrolled pain
 Repeated vomitting
 Pregnancy

Step 3: work up

Dipstick urinalysis in all patients, creatinine, uric acid, calcium

If complicated renal colic (one or more condition above in step 2):

 FBC, urine culture

 Abdominal ultrasound
 Call the urologist

Step 4: treatment

Ketoprofen 100 mg (KETONAL®) in 100 mL of normal saline or 5% glucose solution

over 20 minutes

OR

Diclofenac 75 mg IM once daily

If NRS ≤ 3: diclofenac 50 mg orally three times a day

If NRS > 6 add tramadol 100 mg IM every 6 hours

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Step 5: disposition

Surgical ward if complicated renal colic

Home if no intractable pain or vomiting and no fever

 Diclofenac 50 mg orally 3 times daily

 Strain all the urine (use of strainers) or void into a glass jar
 Save stone and submit to analysis
 Advice urologic consultation within 7 days
 Advice to return if one of this occurs: vomiting, fever, chills, uncontrolled pain

Reference

Turk C et al. Guidelines on urolithiasis 2014. European Association of Urology

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DIZZINESS AND VERTIGO

Step 1: Recognize
 Dizziness

Step 2: Red flags

 Down-beating or bidirectional gaze evoked nystagmus
 Pure torsional nystagmus
 Inability to walk

Step3: Work up
 Brain CT scan if suspicion of stroke

Step 4: Management
 IV line if repeated vomiting
 Vestibular depressant for 5 days only if vertigo
o Meclizine (AGYRAX® 25 mg, tab) 25 mg PO q6-12 h
OR
o Hydroxyzine (ATARAX® 25 mg, tab) 25 mg-50 mg PO q6
OR
o Dimenhydrinate (DRAMAMINE; NAUSILCAM® 50 mg, caps) 50-100
mg IM, IV, PO q4h
OR
o Acetyl-leucine (TANGANIL® 500mg, amp) 500 mg IV three times daily
 Antiemetic: metopimazine (VOGALENE®)

Step 5: disposition
 Discharge home with advice to see ENT
 Admit in adult medical ward if central vertigo

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References
Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin
North Am 2009:27(1):39
Goldman B. Vertigo and dizziness in Tintinalli, 6th edition,

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ACUTE STROKE

Step1: recognize stroke (FAST test)

 Facial weakness: ask the patient to smile. Is there mouth or eye droop?
 Arm weakness: ask the patient to close both eyes and extend both arms
straight out, with palms up for 10 seconds?
 Speech difficulty: ask the patient to repeat a simple phrase, such as “you can’t
teach and old dog tricks”. Is their speech slurred or strange?
 Time -can the patient tell the time of symptom onset?
o the time of onset is defined as when the patient was last awake and
symptom-free or known to be “normal”.

Step 2: severity

 *Reduced level of consciousness

 Asymmetric pupil

Step 3: workup

 Blood glucose, FBC, electrolytes (Na, K), urea, creatinine, ECG

Step 4: treatment

 Position head up 30°

 Oxygen at 3 l/min if O2 saturation < 92%
 IV line with normal saline 1000 mL over 24 hours or (30 mL /kg of body
weight)
 If temperature > 37.5° C give paracetamol 1 g IV every 6 hours or 500 mg
orally every 6 hours
 Respect the blood pressure
 If BP greater than > 220/120 mmHg or mean arterial pressure (MAP) > 130
mmHg give antihypertensive drug to reduce MAP or systolic blood pressure by
15% of pretreatment levels during first 24 hours
 Maintain blood glucose between 140 to 180 mg/dL
 Perform a water swallow test: give 50 ml of water to drink. If any abnormal
swallowing insert a nasogastric tube to fed
 If urinary incontinence: insert condom catheter in man, urinary catheter in
woman

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Step 5: disposition

 Refer to ICU if Glasgow Coma Scale < 8, clinical evidence of transtentorial

herniation in General Hospital of Douala or Hôpital Laquintinie
 Admission of all other patient in adult medical ward

References

Adams et al. Early management of adults with ischemic stroke. Circulation 2007; 115;
478-534

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ACUTE HEADACHE

Step 1: clinical severity

 Sudden onset of the worst headache in the patient’s life

 Onset after 50 years of age
 Increased frequency or severity of headache
 Focal neurologic signs (limb weakness, seizure)
 Neck stiffness
 Nausea, vomiting
 History of cancer
 HIV positive patient with new type headache
 Recent head trauma

Step 2: work up

 HIV serology
 Funduscopy
 Brain CT scan if clinical severity
 CSF analysis if fever and no focal neurologic signs or symptoms

Step 3: treatment

 Insert IV line
 Analgesic for:
o Acute migraine headache (POUND, Pulsatile quality, One-day duration
(four to 72 hours), Unilateral location, Nausea or vomiting, Disabling
intensity: paracetamol/aspirin/caffeine, or ibuprofene orally 400 mg 3
times daily
o Tension type-headache (bilateral, non pulsatile, not worsened by
exertion) : ibuprofen orally 400 mg 3 times daily
o Others cases: paracetamol 1 g IV every 4 hours (max 4 g/day) and
tramadol 100 mg IM then 50 mg IM every 6 hours

Step 4: disposition

 Admission in adult medical ward and order brain CT scan if clinical severity
 Discharge home if no clinical severity

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References

Hainer BL, Matheson. Approach to acute headache in adults 2013; 87: 82-7

Gilmore B, Michael M. Treatment of acute migraine headache. Am Fam Physician

2011; 83 (3):271-280

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SEIZURES

Step 1: recognize seizures

 Generalized tonic-clonic seizures (grand mal):

o Begin with loss of consciousness, stiffness, ± tongue bite, ± urinary
incontinence;
o then symmetrical rhythmic jerking of the trunk and extremities;
o at the end comatose state with flaccidity, and deep rapid breathing
 Partial seizures:
o Tonic deviation of the head and eyes in awake patient or
o Unilateral tonic or clonic movements limited to one extremity in awake
patient
 Seizure triggers (e.g., sleep deprivation, alcohol use/withdrawal, illness, non
compliance) in epileptic patients

Step 2: assess risk factors for intracranial pathology and clinical severity

 Age older than 40 years

 Repeated convulsion,
 New focal neurologic deficit or new focal onset seizure,
 Persistent altered mental status,
 Fever or persistent headache,
 Recent head trauma,
 AIDS, history of cancer, history of anticoagulation
 Alcoholism,
 Pregnant woman

Step 3: work up

 Sodium, blood glucose level

 Lumbar puncture and malaria parasite if fever
 CT of the brain should be performed to evaluate for any structural or space-
occupying lesions in all patients with new-onset seizures, persistent alteration
in consciousness, or suspected trauma.
 Lumbar puncture should be considered if the patient does not return to
baseline mental status and a clear etiology is not discovered.

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Step 4: treatment

 If not convulsing
o Place the patient in lateral position to maintain airway open
o Keep siderails up to protect patient from fall

 If ongoing seizures
o Stay calm
o As soon as possible turn the patient on the side (left lateral position)
o Ensure adequate ventilation: loosen any tight clothes (tie, collar),
o Keep siderails up
o Diazepam 10 mg IV over 3 minutes not diluted or 0.2 mg /kg IV at 2
mg/min (max 20 mg)

Step 5: disposition

If known epileptic patient and no red flags

 Restart antiepileptic drug

 Advice internist or neurologist consultation within 3 days

If first episode and no red flags

 Advice internist or neurologist consultations within 3 days

 Advice patient to: sleep, rest, avoid swimming or driving, stop drinking, stop
working, avoid work at heights

If first episode and suspected secondary seizure or if patient is a driver

 Start carbamazepine XR 200 mg (TEGRETOL® LP) BD with or without

clobazam 20 mg tab (URBANYL®) 3 tabs OD day1, 2 tabs OD day 2, 1 tab
OD day3
or
 Phenobarbital (GARDENAL®, 100 mg) 100 mg at bedtime

If red signs

 Admit in adult medical ward

References

Adams SM, Knowles PD. Evaluation of a first seizure. Am Fam Physician 2007;
75:1342-47

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STATUS EPILEPTICUS

Step1: recognize

 any seizure activity lasting longer than 5 minutes or at least two successive
seizures without a return to baseline mental status

Step 2: work up

 Finger-stick blood glucose, FBC, CRP, urea, sodium, and calcium

Step 3: treatment

 Protection of patient: siderails up

 Keep open airways: oropharyngeal (Guedel®) airway
 Insert IV line with SG 5% 250 mL
 First step: (0 to 30 minutes )
o Stop seizure
o Diazepam 2 mg/minute until cessation of seizure (maximum 20 mg)

 Then, maintenance treatment

o Phenobarbital 10 mg/kg (max 1 g) in 100 mL of normal saline or 5 %
glucose solution over 20 minutes (max 1 mg/kg/min). If necessary
repeat 10 mg/kg 30 minutes after first dose

Step: disposition

 Admission all cases

References

MSF. Convulsions. Guide Clinique et thérapeutique 2013, page 23-25

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UNCONSCIOUS PATIENT

ABCDE

 Lie the patient supine or in left lateral position

 Insert IV line: if SBP less than 90 mmHg IV normal saline 500 mL bolus, if
SBP > 90 mmHg start normal saline 1000 mL at 125 mL/hour
 Take blood for: blood glucose, blood electrolytes, FBC

Targeted clinical examination

 Obtain history from relatives, friends, witness,

 Look pupils, eye movement, neck stiffness, unilateral weakness by applying a
painful stimulus to each limb
 Examine the rest of the patient: rash,
 Start appropriate treatment if suspicion of:
o Acute bacterial meningitis
o Severe malaria
o Hypoglycemia
 If the cause of coma is not evident refer the patient to ICU

Disposition

 Admission in adult medical ward if easy reversible causes is suspected (e.g.

malaria, hypoglycemia)
 Refer to ICU if the cause of coma is not obvious

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BELL PALSY

Recognize

 Pain behind the ear a day or two before weakness

 Sudden hemifacial weakness: mouth droop to the affected side, inability to
close the eye
 Impairment of taste
 Hyperacusis in ipsilateral ear

Work up

 None

Treatment

 Prednisone 60 mg daily orally for 7 days. To start within 72 hours of symptom

onset
 Acyclovir 400 mg 5 times daily orally for 10 days (6-10-14-18-22)
 Eye patch to cover eyes at night or paper tape to depress upper eyelid during
sleep
 Eyes drop every 2 hours

Disposition

 Discharge home with advice to do physical therapy

References

Hilden DH. Bell’s palsy. N Engl J Med 2004; 351:1323-31

Gronseth GS, Paduga R. Evidence-based guideline update: steroids and antivirals

for bell palsy. Neurology 2012; 79:1-5

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MENINGITIS

Recognize

At least two of the following four symptoms:

 headache
 fever
 altered consciousness (GCS < 14)
 neck stiffness

Neck stiffness alone is present in less than 44 % of cases

Severity

 Impaired consciousness
 Infection with Streptococcus pneumoniae
 Low WBC in CSF

Work up

 HIV serology, blood glucose

 CSF analysis with or without CSF India ink test or cryptococcal antigen if
available
o LP is contraindicated if signs of space occupying lesion (e.g., new onset
seizure, papilledema, focal neurological deficit, evolving signs of brain-
tissue shift)
 Blood culture

Treatment

Bacterial meningitis

 Ceftriaxone 2 g* IV or IM every 24 hours

 Dexamethasone before or with the first dose of antibiotic: 10 mg IV every 6
hours for four days to reduce hearing loss and neurological sequelae
 Antipyretic if temperature above 40°C

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Cryptococcal meningitis

 Fluconazole 1200 mg daily (600 mg twice) for 2 weeks, then 800 mg daily for
8 weeks
 Repeated lumbar puncture with large bore-needles (i.e.,G18) to remove 20 mL
twice weekly if CSF opening pressure 250 mm of water or signs of increased
cranial pressure (confusion, somnolence, severe headache, emesis, cranial
nerves palsies, fading vision)
 Deferred ART initiation until there is evidence of sustained clinical response to
antifungal therapy (after 4 weeks)

Disposition

Admit in adult medical ward

References

Van de Beek D et al. Community-acquired bacterial meningitis in adults. N Engl J Med 2006;
354:44-53

Scarborough M, Thwaites GE. The diagnosis and management of acute bacterial meningitis
in resource-poor settings. Lancet Neurol 2008; 7:637-48

WHO. Rapid advice: diagnosis, prevention and management of cryptococcal disease in HIV-
infected adults, adolescents and children. 2011

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BRAIN ABSCESS

Recognize

 Headache with or without :

o fever
o Altered level of consciousness
o Behavioral changes
o Seizures

Severity

 Brain herniation

Work up

 Brain computed tomographic scanning with contrast enhancing

 HIV serology, blood culture, culture of pus from ear if appropriate

Treatment

 For HIV negative patients

o Ceftriaxone 2 g IV every 12 hours + metronidazole 500 mg IV every 6 -
8 hours
o Sodium valproate (DEPAKINE® 200 mg, DEPAKINE CHRONO® 500
mg) 250 mg 2 times a day if seizure
o corticosteroids if profound edema that is likely to lead to cerebral
herniation
o Stereotactic aspiration of purulent center unless contraindicated
 For HIV positive patients
o Cotrimoxazole 960 mg, 2 tab 3 times daily for 6 weeks

Disposition

 Referral to neurosurgeon bacterial brain abscess

 Admit in adult medical ward brain abscess due to Toxoplasma gondii

References

Brouwer MC et al. Brain abscess. N Engl J Med 2014; 371:447-56

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DELIRIUM or ACUTE CONFUSIONAL STATE

Step 1: recognize

 Altered consciousness (fluctuating drowsiness, inattention) and psychotic

features (hallucinations, delusion) and cognitive dysfunction (disorientation,
memory defects)
 Ask: new medication, alcohol or substance abuse, prior episodes, history of
falls, brain trauma
 Anticholinergics (H1 blockers, antiparkinson, phenothiazine); antidepressants
tricyclics, SSRIs; corticosteroids; antihypertensives; ABx (quinolones,
macrolides)

Step 2: work up

 Blood glucose, calcium, serum electrolytes, FBC, CRP, urinalysis, HIV

serology if status unknown.
 If fever: lumbar puncture, malaria parasite and urinalysis

Step 3: treatment

 Insert IV line with normal saline 500 mL

 Allow one member of the family to be near the patient
 Treatment of any precipitant factors: ATBx, rehydration, stop delirumogenic
drugs: anticholinergics (amitryptiline, etc), corticosteroid, benzodiazepines
 If agitation:
o haloperidol 5 mg IM
o chlorpromazine (LARGACTIL® 25 mg/5mL) 50 mg IM

Step 4: disposition

 Admission in adult medical ward all patient above 40 years or if organic

dysfunction
 Psychiatrist consultation

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Gower et al. Emergency department management of delirium in the elderly. West J

Emerg Med 2012;13(2):19…

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AGITATION

Recognize

 Excessive verbal and/or motor behavior

 Ask to the patient how you can help him or her
 Ask to the family or friend or coworkers
o any history of fever, headache, disorientation, head trauma
o previous psychiatric illness
o prior episodes
o ingestion of medication and illegal substances

 Safely measures
o Approach the patient with nonthreatening voice and posture, avoid
excessive eye contact
o Never turn your back to the patient
o Remove all objects that can be used as weapons
o Make adequate force (several staff members) nearby visible
o Room’s exit should be accessible to patient and medical staff

Clinical severity (potentially violent patient):

 Restlessness
 Pacing in the examining room
 Clenched fists
 Acts of violence directed toward inanimate objects in the room
 Hypervigilance

Work up

 Bedside blood glucose, SpO2. MP and urinalysis if fever

 Consider if appropriate FBC, sodium, calcium, creatinine, CSF analysis, Brain
computed tomography, …

Treatment

 If violent behavior toward him/herself or others:

o Haloperidol (HALDOL®), amp 5 mg/mL IM; 5 mg IM
 onset action 30 minutes, T/2 19 hours
 may be repeated after 30 minutes

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o chlorpromazine (LARGACTIL®) amp; 50 mg IM

 If cooperative: oral treatment

o Haloperidol (HALDOL®), oral susp 2 mg/mL, 10 drops daily
o Risperidone, 1 mg tab; 1 mg daily
o ARTANE should be associated with risperidone

Disposition

 Admission in adult medical ward if a medical etiology has been found

 Psychiatric consultation after exclusion of a medical cause

References

Moritz F et al. Conduite aux urgences à tenir devant une agitation aux urgences.
Reanimation 2004;13;500-506

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CONVERSION

Recognize

The following criteria must be met:

 Change or loss of physical function suggesting a physical disorder

 The patient has experienced a recent psychological stress or conflict
 The patient unconsciously produces the symptoms
 The symptoms cannot be explained by a known organic etiology or culturally
sanctioned response pattern
 The symptoms is not limited to pain or sexual dysfunction

Work up

 none

Treatment

 Legitimate: treat patient with the same care as every patient, do not write
hysteria in consultation booklet
 Reassurance: explained to the patient that no serious disease has been
found, that further testing and additional medications are not indicated at this
time
 Suggest that the symptoms will resolve
 Diazepam 5 mg IV in last resort

Disposition

 Follow up within one week with primary care physician (GP or internist)

References

Shojaee M et al. Comparison of the intravenous haloperidol and diazepam on

recovery from conversion disorders in Emergency ward patients: double blind,
randomized clinical trial of efficacy and safety

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ACUTE LOW BACK PAIN

Recognize

 Pain between the costal angles and gluteal folds that may radiate down one or
both legs of 6 weeks duration.

Step 1: clinical severity/red flags

 Significant trauma related to age

 Cancer metastatic to bone
 Bladder or bowel incontinence or urinary retention,
 Progressive motor or sensory loss
 Major motor weakness < 3 MRC
 Loss of anal sphincter tone
 Saddle anesthesia
 Associated fever and chills
 Signs of urinary tract infection

Step 2: work up

 Order ancillary test if red flags: FBC, CRP, lumbar spine X ray

Step 3: treatment

 Analgesic
o Paracetamol doesn’t work!
o Ketoprofene 100 mg IV + nefopam 20 mg IV.
o Alternative is diclofenac 75 mg IM q24 hour for 2 days
 Myorelaxants
o Tetrazepam 50 mg (MYOLASTAN®) ½ tablet TD for 10 days
 Strict bed rest is not recommended: brief rest only for 24-48 hours, patient
should stay active

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Step 4: disposition

 Discharge home:
o diclofenac (e.g.,VOLTFAST® sachet ) 50 mg 3 times orally or
ketoprofene 100 mg BD orally or naproxene 500 mg orally BD
o patient education: avoid twisting and bending when lifting, stay active,
spontaneous resolution
 Refer in neurosurgical unit: cauda equina syndrome
 Admission in adult medical ward

Reference

Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician
2012:85(4):343-350

Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back
pain: a double-blind, randomised controlled trial. Lancet 2014

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SCIATICA

Clinical diagnosis

 Unilateral radiating pain in the leg that follows a dermatomal pattern with one
of:
o Numbness and paresthesia in the same distribution
o Straight leg raising test or Lasègue’s sign or crossed straight leg raising
test induce more leg pain
o Neurologic deficit in one nerve root distribution

Work up

 Lumbar spine CT scan

o if red flags: malignancies, osteoporotic fractures, radiculitis, cauda
equine syndrome or
o no response to medical treatment after 6-8 weeks
 X rays not useful: cannot visualized disc herniation

Treatment

 Immediate referral is indicated in cases with a cauda equina syndrome, acute

severe paresis or progressive paresis

 Advice to stay active and continuing daily activities

o Paracetamol does not work!

o Ketoprofene 100 mg IV+ nefopam 20 mg IV.
o Alternative: diclofenac 75 mg IM q24 hour for 2 days

Disposition

 Refer to neurosurgeon if symptoms do not improve after conservative

treatment for at least 6-8 weeks

References

Koes BW et al. Diagnosis and treatment of sciatica. BMJ 2007; 334:1313-7

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ACUTE GOUTY ARTHRITIS

Clinical diagnosis

 Patient’s profile: HTN, T2DM, obese, excessive alcohol consumption, CKD

 Monoarthritis of one lower leg joint or oligoarthritis involving lower leg joints

Work up

 Joint arthrocentesis for bacteriology and research of urate crystals

 Uric acid
 Other: fasting blood sugar, total cholesterol, HDL cholesterol, triglycerides,
urea, creatinine

Treatment

Continue urate-lowering therapy

Symptomatic treatment

 if acute gouty arthritis started < 36 hours duration, give colchicine

(COLCHIMAX®, 1 mg)
o 1 mg followed by 0.5 mg 1 hour after, then 12 hours later after 0.5 twice
daily until symptoms resolve

OR

 Naproxen 500 mg twice daily for 10 days

OR

 Etoricoxib (ARCOXIA®) 120 orally daily for 7-10 days or celecoxib 400 mg on
the first day, then 200 mg bid for 6-10 days

Monitor response to therapy evaluation: ≥ 50% improvement in pain score within 24

hours

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Prophylaxis

 If one of following criteria: recurrent crisis (≥ 3 attack per yr), tophi,

arthropathy, nephrolithiasis
 Allopurinol 100 mg orally daily. Increased by 100 mg every 2 weeks until uric
acid < 6 mg/dl. This treatment must be started at distance of acute crisis and
associated with prophylaxis of attacks: colchicine 0.5 mg once daily or
naproxen 250 twice daily until serum urate level is < 6mg/dl

Khanna et al. Guidelines for management of gout. Part 2: therapy and anti-inflammatory prophylaxis
of acute gout arthritis. Arthritis Care & Research 2012:1447-1461

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PARACETAMOL POISONING

Step 1: recognize

 More than 140 mg/kg ingested in a single dose or more than 7.5 g ingested
within a 24 h period

Step 2: clinical severity

 Admit all patients with more than 140 mg/kg ingested in a single dose or more
than 7.5 g ingested within 24 h period

Step 4: work up

 Transaminases 24 hours after ingestion

Step 4: treatment

 Gastrointestinal decontamination
o only within 2 hours after ingestion
o Activated charcoal (CARBOMIX ® 50 g gel) orally or through
nasogastric tube

 Antidote administration
o 72 h oral N-acetylcysteine (MUCOMYST® sachet 200 mg)
o 140 mg/kg stat then 70 mg/kg every 4 hours for 17 additional doses
o Diluted in fruit juice

Step 5: disposition

 Discharge home of ingestion of less than toxic dose

 Transfer to hepatogastroenterologyy department of general hospital of Douala
if hepatic fulminant failure (coagulopathy, renal failure, encephalopathy,
gastrointestinal symptoms, metabolic acidosis)
 Admit in medical ward if other cases

References

Heard KJ. Acetylcysteine for acetaminophen poisoning. N Engl J Med 2008;359:285-92

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HYDROCARBONS POISONING
(e.g., kerosene)

Step 1: clinical severity

 Respiratory signs: cough, cyanosis, noisy respiration, difficult breathing, RR >

20
 Hypotension, HR > 100 bpm
 Vomiting
 Ask about time; suicidal attempt, quantity; quality: petroleum, kerosene,
essence, mineral oil (solvents); self measure taken
 Ask family or friend to bring the offending agent

Step 2: work up

 Chest X ray in all patients if red signs, and after 6 hours observation period if
still asymptomatic

Step 3: treatment

 Admit all patients for at least 6 hours observation period

 Decontamination
o Skin decontamination: remove all contaminated clothes; wash skin with
soap and copious water
o Eye decontamination: irrigate with normal saline
o GI decontamination: do not give milk or oil, induce emesis, gastric
lavage
 Start antiemetic if vomiting
 Encourage family or witness to bring the offending agent
 Avoid steroid (e.g., dexamethasone) and diuretic

Step 4: disposition

 Discharge home if asymptomatic and normal CXR after 6 hours observation

period
 Admit for 24 hours minimum if patient is symptomatic
 Refer to intensive care unit (Douala): if respiratory signs

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ACUTE ORGANOPHOSPHORUS PESTICIDE POISONING

Step 1: recognize

 Bronchospasm (wheezing), bronchorrhea, miosis, lachrymation, urination,

diarrhea, hypotension, bradycardia, vomiting, salivation
 Tachycardia, mydriasis, hypertension, sweating
 Confusion, agitation, coma, respiratory failure

Step 2: clinical severity

 Paralysis, pulmonary edema, respiratory distress, hypotension, coma,

convulsions

Step 2: work up

 None

Step 3: treatment

Decontamination:

 If cutaneous exposure:
o wear protective clothing (gown, gloves, mask) in case of dermal
exposure if available
o remove all patient’s clothes and accessories completely and put them in
a plastic bag then seal
o wash skin with copious water and soap
o irrigate eyes with normal saline for 20 minutes, if contamination of eyes
 If ingestion:
o gastric lavage is indicated within 1 hour following ingestion and after
fully resuscitation and stabilization of patient

Specific treatment: atropine

 Adult: 2 mg IV bolus. After 5 minutes check pulse, BP, pupil size, sweat and
chest sounds. If no improvement double initial dose of atropine. Stop if
bronchorrhea arrests, HR > 80 bpm and SBP > 80 mm Hg
 Child: 0.01-0.04 mg/kg every 10 minutes until bronchorrhea arrest

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 Then every 4 hours for 24 hours depending of the reappearance of signs or

give per hour 20% of total dose required for cessation of bronchorrhea
Example: if 4 mg of atropine was used to dry mucous, then 0.2 mg must be
given IV per hour

Symptomatic treatment

 Left lateral position

 High flow oxygen
 Insert IV line and commence normal saline 500 ml
o If SBP < 100 mmHg administer normal saline 500 ml every 20 minutes
 Diazepam if agitation or convulsion

Step 4: disposition

 Discharge home: if asymptomatic 12 hours after exposure to

organophosphorus
 Refer to in intensive care unit (Douala): coma, respiratory failure, severe
bronchospasm

References

Eddleston M et al. Management of acute organophosphorus pesticide poisoning.

Lancet 2008; 371:597-607

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QUININE POSIONING

Recognize

 ingestion of more than 1.5 g /24h

Clinical severity

 Neurologic toxicity: obtundation, seizure, headache

 Cardiovascular toxicity: hypotension, cardiovascular collapse, arrhythmia
 Ocular toxicity: blindness
 hypoglycemia

Work up

 Blood glucose
 ECG

Treatment

 Supportive measures

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ACUTE ALCOHOL INTOXICATION/ETHANOL TOXICITY

Recognize

 Alcohol ingestion and: reduced level of consciousness, slurred speech, odor of

alcohol on breath, ataxic gait, hypothermia, convulsion, hallucinations,
delusions
 Always a diagnosis of exclusion. Search hypoglycemia, mixed alcohol-drug
overdose, traumatic brain injury,

Clinical severity

 Hypoglycemia
 Respiratory depression

Work up

 Bedside blood sugar

Treatment

 Gastric lavage and activated charcoal are of little value

 Obtain IV access
 10% glucose solution if bedside glucose below 80 mg/dL
 Thiamine 100 mg IM or IV to prevent or treat Gayet Wernicke encephalopathy

Disposition

Admit all patients for 24 hours minimum

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DROWNING

Recognize

 Fatal drowning: respiratory impairment form submersion/immersion in liquid

that result in death at any time.
 Nonfatal drowning: survival after a submersion/immersion in liquid.
 Water rescue: any  submersion  or  immersion  incident  without
evidence of respiratory  impairment s  

Work up

 Chest radiography, arterial blood gases if available

 If GCS < 13 : CXR, sodium, ECG, FBC

Treatment

 ABCs
o Oxygen if GCS <13 oxygen as necessary to keep their SaO2 > 95%
 Warmed isotonic IV fluids
 Cover the patient with blanket
 Submersion victims who are asymptomatic or mildly symptomatic can be
observed for 4 to 6 h.
o If they continue to have a normal pulmonary examination and normal
room air oxygen saturation, they can be safely discharged home.
 If the submersion victim does not require cardiopulmonary resuscitation at the
scene or in the ED, complete recovery within 48 h is expected.
 Victims requiring bystander CPR at the scene have a guarded prognosis.

During CPR, if ventilation and chest  compression do not result in cardiac  activity, a
series of  intravenous doses of norepinephrine or epinephrine, at an individual dose of 
1 mg (or  0.01 mg per kilogram  of body  weight) can be  considered.

References

Szpilman D et al. Drowning. N Engl J Med 2012; 366:2102-10

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SNAKE BITES

Step 1: recognize

 Examine the site of the bite for fang or tooth marks, surrounding erythema,
local swelling, and local bleeding. Puncture marks are not always visible
 Ask time of bite
 Ask self measure taken by patient
 Ask date of last tetanus immunization
 What did the snake look like: snake’s size, color, behavior (e.g, rear up,
hissing?)

Step 2: clinical severity

 Local swelling
 Regional lymph node: enlarged & painful
 Bleeding: fang marks, gums, nose, vomit, stool, urine
 Drooping eyelids
 Identification of syndrome
o Cobraic envenomation:
 profuse sweating, salivation, diarrhea, nausea/vomiting,
abdominal pain, myosis, bronchospasm, tremulations, headache
 early sign (perioral paresthesia extending from the site of the bite
to trunk and head, tingling of fingertips and toes, droopy eyelids,
double vision, difficulty swallowing, and drooling of saliva),
 sign of impending respiratory arrest (dysphonia, dyspnea,
bradypnea)
o Viperin envenomation: local pain, extensive swelling involving the bitten
limb, local erythema/ecchymosis/bleeding, necrosis over the site of the
bite; shock; bleeding & clotting disorders

Step 3: work up

FBC, blood grouping, urea, creatinine, 20 minutes whole- blood- clotting test
(20WBCT)

 WBCT: take 2-5 ml of blood in a clean, dry glass tube without anticoagulant,
wait for 20 min, then tilt the tube at 45 ° and examine it.
o If complete coagulation: there is no hemorrhagic syndrome
o If incomplete or absent coagulation: there is a hemorrhagic syndrome.

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Step 4: treatment

 All patient under observation for 12 hours after the bite

 Reassure the victim: most snakebites has no complications/no envenoming
 Place patient at rest on bed
 Immobilize the whole patient, especially the bitten limb in a functional position
 Remove constricting clothing, rings, bracelets, bands, shoes etc from the
bitten limb
 Baseline circumferential measurement above and below the site of the bite
 Symptomatic treatment
o Insert IV line and administer normal saline 1 liter over 12 hours
o Analgesics if pain: paracetamol and/or tramadol. No NSAIDS
(diclofenac, ibuprofen, etc) because of increased bleeding risk
o Wound care
 Do not wash, rub, massage or tamper with the bite wound in any
way?
 Tetanus prophylaxis
 Antibiotherapy only if sign of infection (hot reddened fluctuant
local swelling like abscess or if necrotic wound)

 Immunotherapy/antivenom if clear clinical signs of envenomation or abnormal

20WBCT
o FAV®-Afrique over 1 hour (2 amp in 500 mL of normal saline) if edema,
abnormal coagulation test and no bleeding
o FAV®-Afrique over 5 minutes (2 amp) if trismus, ptosis, dyspnea,
persistent local bleeding, spontaneous bleeding
o In both cases: repeat 20WBCT at 6 hours, if remains uncoagulable, repeat
ASV and do 20WBCT every 6 hours

Source: WHO 2010

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 Monitoring
o Every hour all patient:
 Level of consciousness, BP, HR, RR
 Ptosis: ask the patient to look upwards
 Extent of local swelling & tenderness
 New symptoms & signs
o In the case of antivenom therapy administration
 vital signs
 Measure circumference of the affected limb below and 12 cm above
bite site every 20 min until edema subsides
 mark the advancing edge
 20WBCT 2 hours after the end of infusion then every 4 hours
 Repeated if blood remains uncoagulable after 6 hours; bleeding
after 1-2 hour; after 1-2 hours if deteriorating neurotoxic or
cardiovascular sign

Step 5: disposition

In the case of snake envenomation:

 when swelling decrease, bleeding stop, patient ambulatory

In the case of dry bites (clinical examination and coagulation test normal at admission
and after 12 hour follow-up)

 advice to return if pain, swelling, bleeding occurs

Reference

BELLEFLEUR JP, LE DANTEC P. Prise en charge hospitalière des morsures de

serpent en Afrique. Bull Soc Pathol Exot 2005; 9: 4: 273-276.
Bellefleur.jp@sentoo.sn

Guidelines for the prevention and clinical the management of snake bites in Africa.
WHO, 2010

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URTICARIA

Step 1: recognize

 Intracutaneous edema surrounded by redness area. Circumscribed, raised,

erythematous, usually pruritic, evanescent areas of edema that involve the
superficial portion of the dermis
 Triggers: drugs (penicillin, aspirin, NSAID, radiocontrast dye, opiates); insect
venom (bee); infections; foods (eggs, tomatoes, fish, groundnut, banana)

Step 2: clinical severity

Signs of anaphylaxis when all of the following 3 criteria are met:

 sudden onset and rapid progression of symptoms

 life threatening airway and /or breathing and/or circulation problems
 skin and/or mucosal changes (flushing, urticaria, angioedema)

Airways problems:

 stridor
 hoarse voice
 airway swelling

Breathing problems:

 Shortness of breath
 Wheeze
 Cyanosis

Circulation problems:

 Systolic BP < 90 mmHg

 HR > 100 bpm

If signs of anaphylaxis, call the MD

Step 3: treatment

 Histamine H1 blockers
o Hydroxyzine (ATARAX®) amp 100 mg/2mL, 100 mg in 100 mL normal
saline over 5 minutes will act in 2 to 4 minutes.

OR

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o Hydroxyzine 100 mg IM will act in 10 to 20 minutes

OR
o Loratadine (CLARITEC®, ALLERCEPT®/ALLERGINE® 10 mg tab) 10
mg daily for 14 days
 Avoidance of known triggers
 Adjunctive treatment (histamine H2 blockers, corticosteroids, first line
histamine H1 blockers) only if severe symptoms

Disposition

 Discharge home with oral antihistamine (e.g., loratadine 10 mg daily) for 5

days. Advice to never take again the responsible drug or food

References

Schaeffer P. Urticaria: evaluation and treatment. Am Fam Physician 2011;

83(9):1078-1084

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ANEMIA

Step 1: recognize

 Palmar pallor

Step 2: clinical severity

 Systolic BP < 90 mmHg, HR > 100 bpm, RR > 20/min

 Active bleeding
 Symptoms of tissue hypoxia (fatigue, headache, dyspnea, lightheadedness,
angina)

Step 3: work up

 Full blood count, blood grouping

o If microcytic anemia: order CRP and/or ferritin
o If normocytic/macrocytic anemia: order the reticulocyte count,
peripheral blood smear

Step 4: treatment

 Insert IV line if clinical severity and start normal saline 500 mL

 Give iron if suspicion of iron-deficiency anemia (microcytic anemia associated
with normal CRP) or confirmed iron-deficiency anemia (low ferritin)
o Ferrous sulphate 325 mg once daily (65 mg of elemental iron) with meal
containing meat for 3 months. Advice patient to take vitamin C 500 units
with the iron pill. Advice patient to avoid tea and coffee.
o Example of ferrous sulphate: TARDYFERON® 80 mg, 1 tab daily for 3
months
 Criteria for red blood cells transfusion:
o Symptomatic anemia:
 Systolic BP < 90 mmHg, HR > 100 bpm, RR > 20/min
 Palpitations, diaphoresis, exertional dyspnea, severe weakness
o Hb < 7 g/dL

Step 5: disposition

 Admission in adult medical ward if clinical severity

 Discharge home if well tolerated with advice to consult internist within 3 days

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References

Deloughery TG. Microcytic anemia. N Engl J Med 2014:371:1324-31

Hebert PC. Transfusion threshold of 7 g per deciliter – the new normal. N Engl J Med
2014

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EPISTAXIS

Recognize

 Nasal bleeding
 Locate the source after asking patient to blow out their nose to clear clot

Work up

 FBC, blood typing if diffuse oozing, multiple bleeding site, recurrent bleeding

Initial management

Compression of the nostrils

 Patient in sitting position with head forward

 Have the patient gently blow out their nose to remove all clots
 Ask patient to open mouth, then pinch both nostrils tightly between your
fingers and thumb
 Hold continuous pressure at least 5 minutes, for up to 20 minutes

If failure placed in the affected nasal cavity cotton pledgets soaked in vasoconstrictor
[phenylephrine solution or oxymetazoline solution(OTRIVINE®)], or 5% lidocaine
topical solution with 0.5% phenylephrine, or 2% lidocaine injection with adrenaline
and pinch nostrils for at least 5 minutes.

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Pack the anterior nares

 Pack the side that appears to be the main source of bleeding. With petroleum
ribbon gauze (or soak gauze 1 mg of epinephrine diluted in 200 ml saline)

Disposition

 Admission if elderly patient, posterior bleeding, coagulation disorder

References

KUCIK CJ, CLENNET T. Management of epistaxis. Am Fam Physician 2005;

71(2):305-311

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VASO-OCCLUSIVE CRISIS/SICKLE CELL CRISIS

Pain in two or more sites: back, legs, knees, arms, chest and abdomen

Step 1: recognize severity

 Fever > 39° C

 Shock
 Limb weakness or alteration of consciousness
 Acute abdominal pain
 Respiratory signs: chest pain, dyspnea, cough,
 Symptomatic anemia

Precipitating factors

 Infections
 Low oxygen tension
 Concomitant medical conditions (e.g., diabetes mellitus, herpes)
 Dehydration
 Acidosis
 Extreme phsyical exercise
 Physical or psychologic tsress
 Alcohol
 Pregnancy
 Cold weather

Step 2: work up

 Full blood count, CRP, MP, urinalysis

Step 3: treatment

 Analgesic
o Paracetamol 1g IV 4 times and tramadol 100 mg IM 4 times or ACUPAN®
20 mg IV 4 times
o NSAIDS:
 Ibuprofen 7.5 mg/kg every 6-8 hours
 Ketoprofen (KETONAL®) 100 mg IV infusion q8 hours (if no
abdominal pain, if no infection or dehydration)

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 Anxiety
o Hydroxyzine (ATARAX®) 25 mg 1 tab twice a day
 Hydration
o lactate ringer® 2 liters per day
 Folic acid 10 mg orally per day 10 days (during crises)
 Red blood cells transfusion if Hb < 5 g/dL or fall > 2 g/dL under patient’s baseline
level

Step 4: disposition

 Admission in adult medical ward; Ob/gyn ward; Ped ward

 Discharge home with EFFERALGAN® codeine with or without ibuprofen

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RED BLOOD CELLS TRANSFUSIONS STEPS

Blood reception

 Check and report identity of blood unit blood group (expiry date, registration
number)
 Check integrity of blood unit (no blood clots, no abnormal color of plasma, no
trapped air bubbles)
 Transfuse within 30 minutes of leaving the fridge of blood bank

Bedside checking

 Ask the patient name and date of birth

 Check the patient blood group
 Do the crossmatch test

Assess and report baseline vital signs

Establish IV line with large cannula if possible (18 gauges)

Connect IV cannula to blood group giving set, and blood giving set to blood unit

Calculate the rate of perfusion; start with 15 drops/min for the first 15 min and
increase after to 60 drops/min if no reaction (1 mL of blood= 15 drops). Total duration
should be less than 4 hours. 15 x Volume (ml)/ time (min) = number of drops/min

Volume as prescribed by medical doctor: 1000 mL can be given in 2-3 hours in

absence of cardiovascular disease. In the case of renal failure or heart failure slow
the rate and administration no more than 1 unit a day

Monitoring

 Every 5 minutes for the first 15 minutes: vital signs, symptoms ( back pain,
rash, shortness of breath, black urine)
 Every hour
 At the end
 1 hour post transfusion

Patient may be allow to eat or drink if he/she wants

Do not give furosemide or dexamethasone

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TRANSFUSIONS REACTIONS

Nurse’s role

 Stop blood transfusion if one or more of the following:

o temperature increase more than 1° C over baseline;
o significative blood pressure change;
o heart rate increase;
o any sign of infection
 Check the blood bag identity
 Check the patient identity
 Call the doctor on call

Doctor’s role

 Identification of transfusion reaction category (table 1)

 Start appropriate treatment (table 2)
 Start appropriate investigations (table3)

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Adult medical emergencies handbook. NHS Lothian 2009/2011

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Adult medical emergencies handbook. NHS Lothian 2009/2011

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Adult medical emergencies handbook. NHS Lothian 2009/2011

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Drugs in the management of acute transfusion reactions

Name Route & dosage

Adrenaline 0.5 mg IM in mid anterolateral thigh
Antihistaminic Hydroxyzine 100 mg in 100 ml of normal saline over 5 minutes
(ATARAX®)
Loratadine 10 mg orally
Antipyretic Paracetamol 10 mg/kg oral

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Adult medical emergencies handbook. NHS Lothian 2009/2011

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SEXUAL ASSAULT

Recognize

 Alleged sexual assault

Clinical evaluation in a consultation room

 AMPLE
o Be neutral: no judgement, do not blame the patient about his/her
responsibility (dress, walking in the night, etc)
o Date, time, place of the alleged assault
o Circumstances of the assault
o Number of perpetrators, perpetrator characteristics (stranger, partner,
ex-partner, acquaintance)
o Details of sexual contact: oral/vaginal/anal penetration, ejaculation,
condom use
o “Penetrant object”: penis, fingers, bottle, etc
o Physical violence; type of physical restraints used: weapons, drugs,
alcohol
o Activities of the victim after the assault: change of clothing, bathing,
douching, urination, defecation
 Head to toe physical examination: bruises, laceration, marks
 Documentation: do not write “she/he was raped”

Work up

 Pregnancy test
 HIV serology
 HBs Ag, anti-HBc, anti-HBs
 TPHA + VDRL

Management

 Pregnancy prophylaxis: contraception if pregnancy test negative: start within

72 hours
o Levonorgestrel (NORLEVO®) 2 tab, then 2 more tab 12 hours later
 Sexual transmitted diseases prophylaxis:
o Ceftriaxone 125 mg IM single dose + metronidazole 2 g single dose +
azithromycine 1 g single dose

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 Post exposure prophylaxis :

o HAART within 72 hours from exposure if high risk (unprotected
receptive anal intercourse with known HIV+ assailant; unprotected
receptive anal intercourse with an assailant of unknown HIV status from
a high–risk population).
o Consider HAART if moderate risk (unprotected vaginal intercourse with
a known HIV+ assailant; unprotected receptive anal intercourse with an
assailant of unknown HIV status from an intermediate-risk population.
 Ob/gyn consultation

Disposition

 HIV serology after 3 months

 VRDL after 3 months
 Refer to hospital social worker

References

Petter LM, Whitehill DL. Management of female sexual assault. Am Fam Physician
1998; 15:58:920-926

Feldhaus KM. Female and male sexual assault. In Tintinalli JE, Kelen GD,
Stapczynski JS. Emergency medicine. McGraw-Hill, 2004,1851-1854

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INTIMATE PARTNER VIOLENCE AND ABUSE

Definition

IPV is a pattern of assaultive, coercive behaviors that may include inflicted physical
injury, psychological abuse, sexual assault, progressive social isolation, stalking,
deprivation, intimidation, and threats.

Recognize

 Patient statements
 Following elements suggest IPVA:
o Characteristic injuries: fingernail scratches bite marks, cigarette burns,
bruises suggesting strangulation, and rope burns.
o Injuries Suggesting a Defensive Posture: Forearm bruises or fractures
o Central Pattern of Injury : injuries to the head, neck, face, and thorax
and abdominal injuries in pregnant
o An Extent or Type of Injury Inconsistent with the Patient's Explanation
Such injuries include multiple abrasions and contusions to different
anatomic sites inconsistent with the mechanism of injury.
o Multiple Injuries in Various Stages of Healing These may be reported as
"accidents" or "clumsiness."
o Substantial Delay between the Time of Injury and the Presentation for
Treatment: Victims may wait several days before seeking medical care
for injuries.
o Suicide Attempts
o Visits for Vague or Minor Complaints without Evidence of Physiologic
Abnormality: chronic pelvic pain and other chronic pain syndromes.
o Partner's Behavior: Partners exhibiting controlling or abusive behavior.
The victim may appear frightened of her partner or refuse to answer
questions and instead defer all responses to the partner.
o Obstetric and Gynecologic Presentations: unwanted pregnancies and
sexually transmitted diseases. Complications related to pregnancy,
including complications of abdominal trauma, smoking or alcohol and
drug use, low maternal weight gain, and neglect of prenatal care,

Work up

 If appropriate

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Management

 Validation (empathy)
o Patients must be told that violence, abuse, and intimidation are not a
part of normal, healthy relationships.
o The victim's reports and experiences should be acknowledged and
believed. Let victims know that you take the situation seriously and that
you are concerned about the health and safety of her and her children.
o Victims also should be told explicitly that they have done nothing that
warrants the violence and abuse.
 Analgesics as per protocol
 Sedatives ( e.g., lorazepam (TEMESTA® 1 mg twice daily for 2 weeks)
 Tetanus prophylaxis if appropriate
 Informs about medicolegal certificate; women empowerment, police

Disposition

 Admission if lethality risk is high ( )

 Refer to hospital social worker

Documentation

 Write the victim’s own words (e.g, “the patient states her husband, DIKWA
struck her in eye with his closed fist”
 Use a body map

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