Managing emergencies

Nonischaemic Causes of Chest Pain
Illness/Condition Differentiating Symptoms and Signs
Reflux oesophagitis,  No ECG changes
oesophageal spasm  No ECG changes
 Heartburn
 Worse in recumbent position, and also whilst straining, like angina
pectoris
 The most common cause of chest pain. Be careful to recognize a
risk patient who also has ischaemia.
Pulmonary embolism  Tachypnoea, hypoxaemia, hypocarbia
 No pulmonary congestion on chest x-ray, which is often normal
 Clinical presentation may resemble hyperventilation.
 Arterial oxygen pressure (PaO2
) decreased or normal, partial arterial
pressure of carbon dioxide (PaCO2
) decreased
 Pain is not often marked.
 D-dimer assay positive; negative result excludes pulmonary
embolism.
Hyperventilation Hyperventilation Syndrome
 The main symptom is dyspnoea, as in pulmonary embolism.
 Often a young patient
 Tingling and numbness of the limbs, dizziness
 PaCO2
decreased, PaO2
increased or normal
Secondary Hyperventilation
 Attributable to an organic illness/cause; acidosis, pulmonary
embolism, pneumothorax, asthma
Spontaneous  Dyspnoea is the main symptom in the initial phase, later dyspnoea
pneumothorax on exertion only.
 Auscultation and chest x-ray
9
Aortic dissection  Severe pain with changing localization
 Type A dissection sometimes obstructs the origin of a coronary artery
(usually the right) with signs of impending inferoposterior infarction
 Pulses may be asymmetrical
 Sometimes broad mediastinum on chest x-ray
 New aortic valve regurgitation
Pericarditis  Change of posture and breathing influence the pain.
 A friction sound may be heard.
 ST-elevation but no reciprocal ST depression.
Pleuritis  A stabbing pain when breathing. The most common cause of stabbing
chest pain is, however, prolonged cough.
Costochondral pain  Palpation tenderness, movements of chest influence the pain
 Might also be an insignificant incidental finding.
Early herpes zoster  No ECG changes, rash.
 Rash appears after a couple of days.
 Localized paraesthesia before rash.
Ectopic beats  Transient, in the area of the apex, felt also at rest.
Peptic ulcer,  Clinical examination (inferior wall ischaemia may resemble acute
cholecystitis, abdomen). Be careful to recognize a risk patient who also has
pancreatitis coronary heart disease.
Depression  Continuous feeling of heaviness in the chest, no correlation to
exercise
 ECG normal
Alcohol-related  A young or middle-aged male patient in a casualty department in a
drunken condition H/o Alcohol. Remember the possibility of
ischaemia.
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Uncontrolled Hypertension/Giddiness Severe Headache
1. Pulse, BP, TPR, CNS — Pupils, Plantars, CVS, RS,
2. Relevant History, Fall, Trauma,
3. Fundoscopy, ECG, HGT
4. T. Captopril, ½ SLC Stat
5. Call Med RMO
Guidelines in Respiratory Medicines
HEMOPTYSIS (COUGH WITH BLOOD) CHECK PARAMETERS
Propped up position
Moist nasal Oxygen
Maintain airway
Lateral position
DO NOT SEDATE
I/V line – fluids (check BP)
Send blood for grouping
I/V Ethamsyl 500 mg to be given stat
Once stable
X-ray chest can be asked for
Status Aathmaticus
 Check parameters (vitals & respiratory signs)
 If H/O Bronchial asthma available
 CHECK CYANOSIS ( ATTACH SPO2 if possible)
 Moist nasal oxygen in propped up position
 Nebulisation (asthalin)
 Secure I/V line
 Inj Hydrocort 100mg I/V or IM stat
 I/V Aminophyline 125 mg diluted slow bolus only after oxygen and Hydrocort to avoid
worsening of hypoxemia
 Keep Endotracheal tube ready
If chest pain ask for x ray chest to r/o Pneuno Thorax
Monitor for clinical signs, oxygen saturation till Medical RMO attends
11
Guidelines in Paediatrics
Management of Dehydration
Add potassium chloride 15% solution to the IV fluids at the rate of 1.5 ml per 100 ml after the patient
passes urine.
Monitor every 30 minutes for the first two hours and then hourly for the next 8-10 hours for :
 Pulse and respiratory rate
 Capillary refill time
 Sensorium
 Urine frequency / volume
 Stool and vomit frequency
CAUTION: Avoid over hydration; if signs of over hydration appear, stop fluids and reassess after 1 hr.
(Adapted from the WHO manual on “Management of the child with a serious infection or severe
malnutrition; Guidelines for Care at the First-referral level in Developing Countries”).
Ringer’s lactate 15 ml / kg / hour for the first hour
Continue monitoring during the infusion
Record pulse, breathing rate, capillary refill at the beginning and then every 5-10 minutes
Assess after 1 hour
No improvement Improvement seen
(no change in pulse rate or capillary refill)
or
Worsening
(pulse rate decreases, faster capillary
refill, increase in blood pressure)
Consider severe
dehydration with shock
(increase in pulse rate, slower capillary refill)
Consider septic shock and
treat accordingly
# Repeat Ringers’ lactate 15 ml / kg over 1 hour
Clinically better / no evidence of shock
Give IV fluids 10 ml / kg / hour for next 8 hr
and substitute ORS for IV fluids when
child accepts orally (usually within 4-6 hr)

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Management of Shock (Paediatrics)
Assess baseline hemodynamic status Oxygen
Etiology ABC of resuscitation
Organ dysfunction Rapid vascular access
Fluid refractory dopamine
Resistant shock
Shock persists
Catecholamine resistant shock
SUSPECTED SHOCK
Improvement
No improvement (septic shock)
Exclude
cardiogenic
shock
Repeat 20 ml / kg isotonic saline or
colloid boluses upto 60 ml / kg in
15 min
Hypovolemic/
Hemorrhagic
Shock
Suspected/
early septic
shock
Fluid Responsive Fluid refractory shock
Replace rest
of fluid/blood
Deficit over
3-4 hr
Continue increased rate
of fluid administration
while monitoring above
mentioned parameters and
CVP (consider inotropes) Observe in PICU Insert CVP line
Start dopamine @ 10 g/kg/min
No improvement
Warm shock Cold shock
Reevaluate Reevaluate
Start nor-epinephrine Start epinephrine
If the child is at risk of adrenal
insufficiency, administer steroids
Warm shock
+ low BP
Titrate
Nor-epinephrine
 Infuse 20 ml / kg of crystalloid rapidly over 5 minutes
 Inotropes / afterload reducing agents in cardiogenic shock
 Antibiotics in suspected septic shock
 Catecholamines,steroids, antihistamines in anaphylaxis
 Blood replacement in hemorrhagic shock
Assess heart rate, blood pressure, capillary refill, urine output
Correct hypoglycemia and hypocalcemia
Cold shock
+ low BP
Titrate
epinephrine
Cold shock
+ normal BP
Vasodilators
Inodilators

13
Antidotes in Drug Poisoning
N-acetyl cysteine 140 mg / kg followed by 70 mg / kg every
4 hours for 68 hours (17 doses) as oral solution.
Chlorpromazine 1 mg / kg IM or IV.
Pilocarpine 2-4 mg orally or 0.25-0.5 mg IM. Physostigmine
1-2 mg IM every 30 min.
Physostigmine 0.5-2.0 mg IM every 30 min. Neostigmine is
ineffective because it does not enter the CNS.
Flumazenil IV in incremental doses of 0.1, 0.2, 0.3, 0.5 mg at
1-min intervals until desired effect is achieved.
100% oxygen inhalation or hyperbaric oxygen therapy.
i. Amyl nitrite (vaporal) 0.3 ml inhalation for 15-30 sec after
every min. ii Sodium nitrate 3% solution, 0.33ml / kg
(max 10 ml) slowly IV.
iii. Sodium thiosulphate 1.65 ml / kg 25% solution (max 50 ml)
at a rate of 2.5-5.0 ml per min IV.
Ethanol 10 ml/kg 10% solution IV or 1 ml/kg of 95% by month.
Maintenance dose is 1.5 ml/kg/hr 10% solution IV or 3 ml/kg/hr
10% solution IV during hemodialysis.
i. British anti-lewisite (BAL) 12-24 mg/kg/day in 6 divided
doses IM (BAL or dimercaprol 100 mg/ml; 3 ml amp).
ii. ETDA (calcium disodium ethylene diamine tetra acetic acid)
50-75 mg / kg / day in 4 div doses IM or IV as 0.2-0.4%
solution (200 mg / ml ampoule).
iii. d-Penicillamine 20-40 mg / kg per day orally for 5 days.
iv. Oral thiamine and dimercapto succinic acid (DMSA) is
useful.
2.0 mg protamine sulfate for 100 units heparin as 1% solution
IV (10 mg / ml ampoule).
Deferoxamine 15 mg / kg / hr IV infusion. Therapy needed for
12-36 hours till urine color becomes normal (desferal 500 mg /
vial).
Pyridoxine 1.0mg IV for every 1.0 mg of isoniazid upto a
maximum of 500 mg if amount of isoniazid ingested is
umknown.
Methylene blue 1-2 mg/kg/hr IV 1% solution. May be repeated
after 4 hours (10 mg/ml ampoule) Maximum dose is 7 mg/kg.
Ethyl alcohol (ethanol) 0.75-1.0 ml/kg IV followed by 0.5 ml/kg
every hourly IV as 5% solution in sodium bicarbonate.
Alternatively it can be given as 3-4 ounces of whisky (45%
alcohol) every 4 hourly for 1-3 days in adults (Ing ethanol 2 ml
ampoule).
1. Acetaminophen (paracetamol)
Toxic dose: 150 mg / kg
2. Amphetamines Toxic dose: 50 mg
3. Atropine
4. Belladonna (Dhatura)
5. Benzodiazepines
6. Carbon monoxide
7. CyanideFatal dose: 200-300 mg
8. Ethylene glycol
9. Heavy Metals i.
Mercury i, ii,iii.
Arsenic i,iii.
Lead i, ii, iii, iv.
10. Heparin
11. Iron Toxic dose: 35 mg / kg
12. Isoniazid
13. Methemoglobinemia
14. Methyl alcohol
Poison Antidote
14
Naloxone 0.1 mg / kg IV (max 2 mg) Repeat every 2-3 min till
the reversal of toxic effects or a cumulative dose of 10 mg is
reached (Ing narcan 0.4 mg / ml).
i. Atropine 0.02-0.05 mg / kg / dose IV every 15-30 min till
signs of atropinization develop. For continuous infusion
0.02-0.08 mg / kg / hour after the initial bolus.
ii. PAM or pralidoxime (2-Pyridine aldozime methiodide)
25-50 mg / kg IM or IV as 5% solution over 15-30 minutes.
The dose may be repeated after 1-2 hours and then at 10-12
hours intervals if cholinergic signs recur. For continuous
infusion 9-19 mg/kg/hour after the initial bolus of
25-50 mg / kg.
Diphenhydramine 1-2 mg / kg / IV every 30 min. (benadryl
cap 25 mg; 50 mg ; elixir 12.5 mg / 5 ml; amp 50 mg/ml; vials
10 mg / ml).
Atropine 0.01-0.02 mg / kg per dose SC every 5-10 min to
achieve full atropinisation. Glucagon 0.25-1.0 mg IM or IV
(Glucagon amp 1 mg / ml).
19. Warfarin Vitamin K 5-10 mg IM or IV (Inj kapilin 10 mg / ml).
17. Phenothiazine and metoclopramide (extra-pyramidal
reactions)
18. Propranolol (Beta-blockers)
15. Morphine, other opiates, semi
and synthetic narcotics (heroin),
meperidine, lomotil
(diphenoxylate hydrochloride),
and pentazocin
16. Organo-phosphorous poisoning
(insecticides which are
cholinesterase inhibitors)
15
Management of the dog bite Wound
Do’s
1. Cleansing Wash thoroughly with soap and running water.
2. Chemical treatment Apply alcohol or tincture iodine or aqueous solution of iodine or
quarternary ammonium compound (like cetavalon or savlon).
3. Anti Rabies Serum When ARS is indicated and the bite is less than 24 hours old,
(ARS) most or all of this should be infiltrated around the wounds.
4. Other measures Tetanus toxoid should be given if otherwise indicated. Antibiotics
may be administered if wound appears unhealthy.
Dont’s
1. No cauterization of the wound.
2. No stitching of the wound. If stitching is unavoidable, infiltrate the ARS around the
wound and then apply minimum of stitches.
3. Wounds are best closed by secondary suture after proper cleansing and daily wound care
for a week. Infection is much less of a problem when this is practiced and cosmetic end
result are better.
4. No application of turmeric, chilly powder or oil over the wound.
16
a. Exposure to rodents, rabbits and hares seldom, if ever, require specific anti-rabies treatment.
b. If an apparently healthy dog or cat from a low-risk area is placed under observation, the
situation may warrant delaying initiation of treatment.
c. This observation period applies only to dogs and cats. Except in the case of threatened or
endangered species, other domestic and wild animals suspected as rabid should be killed
humanely and their tissues examined using appropriate laboratory techniques. Treatment
should be started as early as possible after exposure, but in no case should it be denied to
exposed persons whatever time interval might have elapsed.
Category Type of contact with a suspected or
confirmed rabid domestic or wilda
animal or animal unavailable for
observation.
Recommended
treatment
Remarks
None, if reliable case
history is available

Stop treatment if
animal remains healthy
throughout the observation
periodc
of 10 days or if animal
is killed humanely and found
to be negative for rabies by
appropriate laboratory
techniques.
Single or multiple transdermal bites
or scratches with oozing of blood.
Contamination of mucous
membrane with saliva (i.e. licks)
I
II
III
Guidelines for rabies prophylaxix advocated by the WHO
Touching or feeding of animals and
licks on intact skin.
Nibbling of uncovered skin. Minor
scratches or abrasions without
bleeding. Licks over broken skin.
Administer vaccine immediatelyb
Administer the antirabies serum as well
as the vaccine
immediatelyb
Stop treatment if animal
remains healthy throughout the
observation periodc
of 10
days or if animal is killed
humanely and found to be
negative for rabies by
appropriate laboratory
techniques
17
Initial Assessment
(Call Pediatric Resident on call)
Impending respiratory failure/life threatening attack. Moderate to severe attack
a) Oxygen a) Oxygen
b) Nebulized â2 agonist and ipratropium. b) Nebulized â2 agonist
c) IV Corticosteroids c) Corticosteroids IV or Oral
d) Inj.Terbulatilne/Adrenaline sc d) Inj.Terbulatilne/Adrenaline sc
Transfer to PICU Reassess after 1hour
Good response
Poor/ Partial response
i) Increase interval between nebulisations i) Continue above therapy
ii) Observe for 2-4 hrs ii) Add aminophylline
iii) Discharge on bronchodilators. iii) IV fluids, correct acidosis
Intubate and Ventilate
Features of Respiratory Failure
Continue same as above
Trial of IV Ketamine
Transfer to PICU
No response/ Impending respiratory failure
i) Continue above therapy.
ii) Trail of Magnesium sulp/Terbulatine
No response after 2-4 hrs
ACUTE ASTHMA

18
Drug doses:
Adrenaline is available as 1:1000 (1mg/ml) solution to be given as 0.01 mg / kg
(max 0.3 mg) SC every 20 min for three doses.
Terbutaline (SC) is available as 0.05% solution to be given as SC 0.01mg / kg every
20 min for three doses (same as adrenaline)
Salbutamol is available as 0.5% (5 mg / ml) solution to be given as 0.15mg / kg
(0.03 ml / kg) stat followed by 0.01, 0.01-0.03 ml/kg every 20 min till
adequate response. (Minimum single dose 2.5 mg / maximum 5 mg). Later
continue nebulized salbutamol as up to 0.3 mg / kg dose hourly. For adequate
delivery dissolve the aerosols in 2-3 ml NS and to prevent hypoxemia give
oxygen at flow of 6-8 L / min.
OR
MDI (100 microgram / puff) with spacer with/without mask, 8 puffs every 20
min OR 2 puffs every 5 min for 1 hour.
Budecort respules are available as 0.5 mg/ml and are to be given as 1.5 ml added to the nebulizer
solution every 20 min for the first hour and then 4-6 hourly (Act pediatr 1999;
88: 835-40)
OR
MDI (50 / 100 / 200 microgram / puff) with spacer, 400 microgram every
20 min x 3 doses (J Pediatr child health 1999; 35:483-487)
Prednisolone PO 2 mg / kg / day in 2-3 divided doses for 5 days.
Hydrocortisone IV 10 mg / kg / dose stat and then 5 mg / kg 6 hourly till accepting orally
Methyl Prednisolone IV 1-2 mg / kg / dose 6 hourly till orally accepting.
Ipratropium is available as 250 microgram / ml to be given as 1 ml diluted in 3 ml NS every
20 min for three doses and then 4-6 hourly. This may be mixed with salbutamol
nebulization.
Aminophylline is available as 250 mg / 10 ml and 50 mg / ml. To be given as loading dose
5-6 mg / kg in 5% dextrose over 30 min (only if not on aminophylline previously)
and then infusion of 0.9-1.2 mg / kg / hour in 5% dextrose.
Magnesium Sulphate available as 50% solution (500 mg / ml) for injection to be given as
50 mg / kg IV in 30 ml NS over 20 min and may repeat 6 hourly x 4 doses.
(Devi R et al, Indian Pediatrics 1997; 34: 389-397).
Terbutaline (IV) as a bolus of 10 microgram / kg (0.01 mg/kg) over 30 min IV followed by 0.1
microgram / kg / min infusion which can be increased as necessary to a maximum
of 4 microgram / kg / min.
19
Ketamine available as 10 mg / ml injection to be given as 1-2 mg / kg IV at a rate
0.5 mg / kg / min, i.e. over 2-4 min, followed by an infustion of
1.0-2.5 mg / kg / hour in ventilated patients and 0.15 mg / kg / hour in
non-ventilated patients in ICU setup. (Samra VJ, Acta anaesthesiol scand
1992; 36: 106-107).
DROWNING MANAGEMENT (PAEDIATRICS)
DROWNING VICTIM
BREATHING
NO
CAROTID PULSE
YES
NO YES
Subrnerged for > hr Rigor
mortis, putrefaction
YES NO
PULMONARY
EDEMA
SHOCK
FEW CREPTS NORMAL
WITH COUGH
YES NO
Grade VI Grade V Grade IV Grade III Grade II Grade I
DEAD
Do Not
Resuscitate
CPR
Defibrillate
IV Epinephrine
Resuscitate unit
temperature
> 30 C
Artificial
ventilation
151/min O2
Crystallaids/
colloids
Treat as
Grade III
Oxygen 151/
min PICU
care Ventilation (PEEP
5-10 cm
H2O)
Sedation
Normalize
pH Lab
studies
Oxygen 15/min
Admit for 6-48 hr
Chest X-ray
Arterial blood
gases
Warm
and
calm

20
ALGORITHM FOR STATUS EPILEPTICUS
0-5 min Inj. Lorazepam (0.1 mg / kg iv@ 2 mg / min).
or
Inj. Diazepam (0.3 mg / kg iv @ 5 mg / min) 3 doses max.
Seizures persisting after Lorazepam
5-25 min Phenytoin (20 mg / kg iv @ 1 mg / kg / min).
Or
Fosphenytoin (20 mg / kg iv @ 3 mg / kg / min).
Seizures continuing
25-35 min Phenytoin or Fosphenytoin (add 5-10 mg / kg) upto total of 30 mg / kg.
Seizures continuing
35-55 min Phenobaritone (20 mg / kg iv slowly over 20 min).
Seizures persist
55-60 min Phenobarbitone (5-10 mg / kg) slowly over next 20 min.
Seizures persist
>60 minutes Midazolam infusion
Or
Propoful infusion
Or
Barbiturate Coma

21
GUIDELINES IN GENERAL SURGERY
Acute Abdomen
 quick history, examine abdomen – look for tenderness, guarding, rigidity
 Vitals [pulse, BP, spo2, P/A, bowel sounds]
 Wide bore IV access, start IVF [RL]
 If vitals stable, inform surgical RMO
 if BP is low infuse IVF in large doses and inform surgical RMO stat
 Emergency blood investigations (CBC, BUN, Creatinine, Electrolytes, crossmatch)
 ECG, X-RAY chest with both domes of diaphragm and abdomen erect/left lateral [if low BP]
 Ryles tube if persistant vomiting
 Foley’s catheterisation
 Before shifting patient to ward, confirm
1. Vitals
2. Fresh IVF on flow
3. X-rays
TRAUMA
ASSESS A,B,C [TOP PRIORITY]
 A – airway
1. Ask patients name,
2. If answers then airway is clear GO TO B
3. If not clear secretions, jaw thrust, chin lift, airway
 B – breathing –
1. look for respiration
2. If no breathing, start CPR (need a team so call for help from sug. RMO team)
3. If breathing well, chest wall movements good GO TO C
4. chest wall movement not good look for air entry, consider pneumothorax may
need intubation
 C – circulation
1. Palpate peripheral pulses, central pulsations, heart beats
2. If no start CPR
3. Wide bore IV access, infuse large volume of IVF
4. Control external bleeding
5. If circulation good then proceed
 CPR + correct hypoxia – intubate and ventilate, rule out cardiac compression
[pneumothorax, pericardial tamponade], fill heart with fluid – infuse IVF.
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 Vitals [pulse, BP, spo2]
 Oxygen
 Cervical collar (to be put in the ambulance prior to shifting patient to casualty)
 Glasgow Coma Scale scoring
 Pupil size and reaction to light
 RT, foleys, airway if GCS < 12
 If GCS < 8, call anaesthetist for intubation
 Inform surgical RMO
 Emergency blood investigations [CBC, BUN, creatinine, electrolytes, RBS, ABG,
cross match]
 Assess other injuries
 Inform ortho, ENT, ophthal RMO as per other injuries
 X-ray skull and other relevant injured areas
 MLC
 Before shifting to ward
 Confirm vitals
 Fresh IVF on flow
 Patient should be accompanied to ward with emergency tray
 X-rays
HAEMATEMESIS
 On receiving
1. vitals
2. wide bore IV, start IVF[RL]
3. emergency blood investigations[CBC, BUN, Creatinine, ABG, RBS, Electrolytes,
coagulation profile, cross match]
4. RT insertion, washes with NS till clear
5. sos foleys catheterization
6. for intubation call anaesthetist if mental obtundation
 quick history and examination
1. fresh blood/coffee coloured vomitus with or without bleeding p/r or maleena
2. abdominal pain
3. h/o APD, alcoholic, cirrhosis, NSAID ingestion
4. past h/o similar episode
5. p/a, p/r, proctoscopy
 before shifting to ward
1. confirm stable vitals
2. X-RAY chest and abdomen
3. send patient with fresh IV ringers on flow
23
GUIDELINES IN ORTHOPAEDICS
Polytrauma Patient
Management priorities:
1. Assesment and Establishment of Airway and Ventilation
2. Assesment of Circulation and Perfusion
3. Haemorrhage Control
4. Shock Management
5. Fracture Stabilization
6. Patient Transport
Life threatening injuries to be addressed to and to be ruled
out before definitive orthopaedic management of fracture:
1. Head Injuries.
2. Thoracic Injuries
3. Abdominal Injuries
4. Genitourinary Injuries
Radiologic Evaluation of polytrauma patient from orthopaedic point of view
1. Lateral cervical spine X-ray. Must see all cervical vertebrae and top of T1. If cervical spine
injuries cannot be ruled out in absence of proper x-rays, a rigid cervical collar should be
maintained until adequate views or a CT scan is done.
2. AP view of chest
3. AP view of pelvis
4. Possibly lateral thoracolumbar spine X-ray
5. CT scan of head cervical spine thorax abdomen or pelvis with or without contrast as dictated
by injury pattern
6. Other X-rays like Skull X-rays or for abdomen should be taken as the case suggests
Before shifting the patient or before addressing to any limb fracture any life threatening
medical and surgical condition should be addressed to and ruled out.
Open / Compound Fractures
An open fracture refers to osseous disruption in which a break in the skin and underlying soft tissue
communicates directly with fracture and its hematoma.
24
Emergency Room Management
After initial trauma survey and resuscitation for life threatening injuries:
1. Perform careful clinical and radiographic evaluation
2. Wound haemorrhage should be given direct pressure rather than tourniquets or blind clamping
3. Initiate parenteral antibiotics
4. Assess skin and soft tissue damage. Place saline soaked sterile dressing on the wound.
5. Perform provisional reduction and place a splint
Important
1. Do not irrigate debride or probe the wound in emergency room if immediate operative
intervention is planned. If surgical delay is anticipated a thorough but gentle irrigation with
normal saline may be performed. Only obvious foreign bodies that are easily accessible
should be removed
2. Bone fragments should not be removed in the emergency room no matter how seemingly
nonviable they may be.
Be Cautious
Infection
Open fractures may result in cellulitis or osteomyelitis, despite aggressive, serial debridements, copius
lavage, appropriate antibiosis, and meticulous wound care. A gross contamination at the time of injury
is causative, although retained foreign bodies, soft tissue compromise, and multisystem injury are risk
factors for infection.
Compartment syndrome
This results in severe loss of function, especially in tight fascial compartment including the forearm and
leg. It may be avoided by a high index of suspicion with serial neurovascular examinations accompanied
by compartment pressure monitoring, prompt recognition of impending compartment syndrome, and
fascial release at the time of surgery.
Spine Injury in General
Immobilisation
1. A rigid cervical collar indicated until the patient is cleared radiographically and clinically.
A patient with depressed level of consciousness cannot be cleared clinically
2. A special blackboard with a head cutout must be used for children to accommodate their
proportionately larger head size and prominent occiput
3. Patient should be removed from blackboard /hard surface support by log rolling as soon as
possible to minimize pressure sore formation
25
Clearing the spine
1. A cleared spine in a patient implies that diligent spine evaluation is complete and the patient does
not have a spinal injury requiring treatment.
2. Necessary elements for complete spine evaluation are
A) History to assess for high risk events and high risk fracture
B) Physical examination to check for physical signs of spine injury or neurodeficit
C) Imaging studies based on initial evaluation.
Patient with diagnosed cervical spine fracture should have at least one of the following four
characteristics
1. Midline neck tenderness
2. Evidence of intoxication
3. Abnormal level of alertness
4. Severe painful injuries elsewhere
Criteria for clinical clearance are
1. No posterior midline tenderness
2. Full pain free active range of motion
3. No focal neurological deficit
4. Normal level of alertness
5. No evidence of intoxication
6. No distracting injury
Patient with neurological deficit
A patient with non traumatic neurological symptoms or deficit should be approached priority wise with
the following
1. Patient should be evaluated for any medical condition to rule out non compressive myelopathy
2. Past head injury
3. Intracranial compressive lesions
4. Any orthopaedic cause for the symptoms /deficits
Dislocations
Definition
When there is no contact of the surfaces in anatomical alignment, the joint is said to be dislocated.
Dislocation is an orthopaedic emergency.
26
Signs /symptoms of joint dislocation:
1. Severe pain.
2. Swelling.
3. Complete restriction of movements.
4. Tingling / numbness, paresthesias, pallor, cold clammy skin if associated neurovascular
compramise is present.
Major complications:
Distal neurovascular deficit.
Radiological evaluation:
AP and lateral views.
Do not try to manipulate the limb if joint dislocation is diagnosed.
Always check for distal pulsations and active toe/ankle or finger / wrist movements and
sensations to rule out any neurovascular damage.
In case of shoulder or elbow dislocation the upper limb should be given a sling support.
In case of hip or knee dislocation the patient must be moved to the bed gently without
manipulating the affected limb.
POINTS TO REMEMBER
1. A patient should be sent for x -ray after giving an analgesic.
2. A patient with severe back pain or those who limp while walking due to injury/fracture of
lower limb bone and those who are unable to sit on a wheel chair should be transferred only
on a trolley.
3. A patient with upper limb injury / fracture should be given a sling support.
4. Before sending the patient to x-rays the patient and accompanying relatives should be
instructed to remove and take custody of any metal ornament that would obstruct the
radiological view.
5. All bangles and rings from the fingers and toes should be removed at the earliest in view of
increasing swelling due to injury.
6. Portable x-rays should be taken for those patients who cannot be shifted in view of poor
general condition.
7. In case of paediatric patients radiological views of the concerned part should be taken for
both sides for comparison.
27
GUIDELINES IN PHYSIOTHERAPY
Sports Injuries
Physiotherapy management is the primary
conservative treatment for soft tissue injuries. It
is helpful to reduce swelling, pain, further damage
of injured tissue.
Compression therapy
Physiotherapy management
1. RICE: Rest, Ice, Compression, Elevation
2. Cryotherapy
3. Compression bandage
4. Tapping and splinting
5. Ultrasound therapy
6. Positioning
7. Soft tissue release technique
8. Muscle relaxnt spray
9. Stretching exercises
10. Minimize disability
28
Acute Episode of Back and Neck Pain
Acute neck and back pain are very often in day-to-day life. This can happen due to sudden weight
lifting, wrong sleeping posture, sudden jerks, trauma etc.
Physiotherapy management
1. Ice packs or cryotherapy
2. McKenzie positioning
3. Grade –I Maitland mobilization
4. Moist heat packs
5. Tapping
6. Minimize disability
McKenzie positioning and mobilization
Mobilization for acute back pain
Mobilization Exercises
This gentle exercise is a good way to get started.
(1) Lie flat on the floor with knees flexed.
(2) Rotate the pelvis to gently push your back
towards the floor. Release and repeat several
times.
(1) Lie prone on the floor and slowly raise your head.
Repeat.
(2) With improvement, place your forearms on the floor
and raise your upper body on your elbows. Repeat.
(3) With further improvement, your therapist may have
you fully extend your back, raising your upper body
on extended arms.
Standing tall: Stand in a normal, relaxed
posture, then pretend that a string is pulling
you straight up from the top of your head.
Feel the
stretch in
your neck
and spine.
Relax and
repeat 5-10
times.
29
Cervical Headache
Headache is a common and
debilitating symptom. Benign,
recurrent and chronic headache often
present special problems in
differential diagnosis. Diagnosis is
based on nature, characteristic and
temporal pattern of headache.
Pain is more likely to be located in
the frontal, retro orbital, occipital, and
temporal areas. An ache and dull
boring pain and throbbing quality are
reported. It is not excruciating but can be moderate to severe. Associated symptoms are nausea,
blurred vision and other eye symptoms, dizziness or light headedness. When symptoms are unilateral,
they are ipsilateral neurological sign are rare. Sensory deficits are present in distribution of C2-C3.
Sustained neck postures commonly provoke cervical head.
Management
Simple analgesics are ineffective in chronic cervical headache
1. Rest
2. Cervical collar
3. Manual cervical traction
4. NAG and SNAG technique
5. Mainland technique
Acute Shoulder Pain
Acute shoulder pain commonly occurs in fall with outstretched hand or direct fall on the shoulder and
sudden jerk or trauma which causes acute manifestation of pain, swelling and instability.
Management
1. X-ray -To rule out fracture.
2. RICE
3. Cryotherapy with compression cuff.
4. Muscle relaxant spray
5. Sling
6. Ultra sound, IFT
7. Maitland mobilization Gr-I
The correct pillow should keep your spine straight
and your neck in a “neutral” position
Sleeping Position
30
GUIDELINES IN ENT
Epistaxis
 If severe
1. Take pulse / B.P.
2. Send patient’s blood for grouping/cross matching.
3. Pinch patient’s nostrils and make patient lie down with head high position.
4. Call ENT resident.
 If mild
1. Call ENT resident.
2. Can give urgent appointment for next ENT OPD or routine appointment.
Sudden Hearing Loss / Blunt to Ear / Facial Palsy
 Call ENT resident.
 Follow up in next ENT OPD as urgent.
CLW Head and Neck Region
 ENT resident to see in casualty.
Acute Giddiness
 ENT resident to see in casualty.
 Admission under ENT if medically stable, i.e., B.P./ECG etc are normal.
Foreign Body in Ear
 Call ENT resident.
 Do not try to remove.
 If not moving, call in next OPD.
 If moving, put liquid paraffin/sterile oil/spirit in ear.
Foreign Body in Nose
 Call ENT resident
 Do not try to remove.
 If not removable, admit.
31
Foreign Body in Throat
 Call ENT resident.
 Monitor vitals, if patient is in distress.
 If in stridor, manage as below.
Stridor
 Call ENT resident.
 O2 till then.
 Make patient lie down
 See that all other parameters are stable i.e. pulse/B.P.
Neck Infections
 Call ENT resident
 Admit under ENT if in doubt or call in next OPD as urgent.
Ear Pain
 ENT resident to see and decide.
32
How to manage a case of ocular burns in casualty set up?
How to manage a case of red eye in casualty?
GUIDELINES IN OPHTHALMOLOGY
THERMAL BURNS
Common e.g. Fire Cracker
TYPE OF BURNS
Type title here
ACID BURNS
Common e.g. Strong-Car
Battery Fluid MILD Phenol
FIRST THING TO DO
Give through saline/RL wash
for 15-20 mins Inj TT IM
ALKALI BURNS
Common e.g. Cement,
Limestone, Baking Soda.
NEXT? – Check for
Comeo-Seleral Tear
Lid Burns
Comeal Epithelial defect
FIRST THING TO DO
Give through saline/RL wash
for 15-20 mins
FIRST THING TO DO
Give through saline/RL wash
for 15-20 mins
STRONG ACIDS –
Cause Charming
Rx: URGENT OPHTHAL
REF
STRONG & MILD BOTH
are more damaging than
acids
Rx: Oint+Pad
F/U in OPHTHAL OPD CM
MILD ACID –
Comparatively Less
damaging
Rx: Oint+Pad
F/U in OPHTHAL OPD CM
Comeo Scleral TearDiag: Soft Globe on
mild pressure Rx: Pad
the Eye URGENT
OPHTHAL
REF FOR Sx
Lid Burns
Rx-Clean & Dress
wound
Apply ointment
F/U OPHTHAL OPD CM
Comeo Epithelial
Defect- Diag:
Photophobia,
Fluorescein stain +ve
Rx: Oint+Pad
ASK FOR COMPLAINTS
PHOTOPHOBIA -Severe/mild?
DISCHARGE – Purulent/watery?
Any FEVER few days before?
BACTERIAL CONJUNCTIVITIS
Both Eyes.Purulent Discharge with lashes
sticking in morning Mild Photophobia
VIRAL CONJUNCTIVITIS
One eye, Water discharge, Sub conjuntival
Haemorrhage,Marked photophobia,
Marked chemosisFever, Malaise, Pre auncular
Lymphadenopathy
H/o FOREIGN
Try to locate Every
upper Lid & Check
Rx AdviceE/d. Norflox 6/d
Ref to OPHTHAL OPD for
starting topical steroids
Rx AdviceE/d. Norflox 6/d
Wipe eye lashes with clean
wet cloth F/u after 7 days
Gi
Conj & Fomicial FB
Comeal FB ne
33
GUIDELINES IN GYNAECOLOGY
Patient in Haemorrhagic shock – Due to Haemoperitoneum / Bleeding PV
or Patient with Acute Abdomen
 Check vital parameters (pulse rate, volume, rhythm, blood pressure; Oxygen saturation).
 Maintain airway.
 Give 100% oxygen.
 Secure IV access: 14 to 16 gauge cannula.
 Send blood for CBC, grouping cross matching, RBS, s. electrolytes, BUN, s. creatinine.
 Start IV fluid 500 ml Ringer Lactate.
 Insert Foley cather per urethra.
 Inform RMO in labour room if patient is to be shifted to Gynaec. Unit.
34
GUIDELINES IN PSYCHIATRY
A. General Strategy in Handling Patients
1. Self Protection
a. Know as much as possible about the patients before meeting them.
b. Leave physical restraint procedures to those who are trained to handle them.
c. Be alert to risks of impending violence.
d. Attend to the safety of the physical surroundings (e.g. door access, room objects)
e. Have others present during the assessment if needed.
f. Have others in the vicinity.
g. Do not confront or threaten patients.
2. Prevent Harm
a. Prevent self injury & suicide. Use whatever methods are necessary to prevent patients
from hurting themselves during the evaluation.
b. Prevent Violence towards others:
1. Inform the patient that violence is not acceptable.
2. Approach the patient in a non threatening manner.
3. Reassure and calm the patient.
4. Offer medication.
5. Inform the patient that restraint or seclusion will be used if necessary.
6. Have teams ready to restrain the patient.
3. Rule out organic (general medical condition) causes viz
a. Head trauma.
b. Medical illness, including seizure disorders.
c. Substance Abuse like alcohol, cannabis, drugs.
d. Cerebrovascular Diseases.
e. Metabolic abnormalities.
f. Medications induced.
4. Obtain Proper History
35
5. Do a General Medical Exam. Including CNS
6. Sedation of a Violent / Uncooperative Patient
a. Injection Haloperidol 5-10 mg I.M. or slow I.V. over 2 minutes which may be repeated
after every 20 to 30 minutes.
b. Concomittantly Injection Promethazine 25 mg – 50 mg I.M. can be administered alongwith
I.M. Injection Haloperidol for better tranquilization.
c. If the violence is due to general medical conditions then (a) is preferred & it is best to
avoid a hypnotic.
d. If the violence is due to substance/drug intoxication or induced, then (a) is preferred &
avoid hypnotics.
e. If it is due to Drug/Substance withdrawal then in addition to (a) I.V. Diazepam
5-10 mg or I.V. Lorazepam 2-4 mg to be administered slowly over 2 minutes.
f. Extrapyramidal Reactions (EPS) due to psychotropics are best controlled as follows:
i. Marginal – oral T.Trihexiphenydyl 2-6 mg stat.
ii. Minor – Inj. Promethazine 25-50 mg I.M.
iii. Major – Inj. Promethazine 25-50 mg I.V.
B. DSH – Deliberate Self Harm (Minor to Major including suicidal attempt)
1. History from patient as well as accompanying person.
2. Patient must be admitted even if it appears accidental or otherwise.
3. Depending on the clinical status of DSH, medical/surgical intervention should be sought /
attempted.
4. MLC must be made.

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