Contains Algorithms on All important emergency medical conditions

2. CARDIAC ARREST EM 01 Assessment Cardiac arrest means No pulse No BP Unresponsive or deeply comatose Respiration gasping; But pupils still reacting Begin immediately Advanced Cardiac Life Support Start external chest compressions Basic Life Support till defibrillation is available Call colleagues for help Call nurse to start medications Call nursing assistants to assist Attach monitor and defibrillator if available Start oxygen by mask Endotracheal intubation Precordial thumb in Unmonitored Cardiac arrest C2b Monitored Cardiac arrest C1 Call attenders to start oxygen Give loud and clear instructions Be the leader of the team Check for shockable rhythm Open the patients airway Clear mouth, Remove dentures Give throat suction Extent neck and intubate Connect oxygen by tube Start artificial ventilation Use ambu bag or machine Delivered to the middle of chest when onset of VT VF is seen It may convert VT VF to NSR Do not delay defibrillation If unmonitored, can be harmful Even precipitate a VT or VF Do not repeat the procedure Shockable VF, PulselessVT Not Shockable Asystole PEA Give one shock and immediately resume CPR Manual biphasic device –specific give 120-200j Monophasic device give 360 joules Immediately resume CPR for 5 cycles Give adrenaline 1mg mg IV repeat 3 doses Or Vasopressin 40 U IV instead of adrenaline Consider Atropine 1 mg IV if asystole or PEA Repeat 3 doses or till recovery Give 5 cycles of CPR and check for shockable rhythm Give 5 cycles of CPR and check for Shockable rhythm Continue CPR while defibrillator is charging Give one shock and resume CPR If indicated try shock Give adrenaline 1mg mg IV repeat 3 doses

3. EXTERNAL CHEST CARDIAC MASSAGE EM 02 Life saver (prolonger) technique Start immediately Continue unremittingly Position the patient on a hard cot, trolley or other surface Remove pillows and put the patient flat supine Higher levelLower head end if previously elevated Open the mouth of the taker Give two breaths If only 1 giver switch to compressions Giver stands at a higher level Elbows kept at 1800 Pressure shall come from shoulders Place the left hand over the lower sternum Place the right hand over the left hand Keep the arms straight and give firm steady compressions Consider endotracheal intubation And assisted ventilation Compressions of 4 cm depth Less will not be sufficient More may be harmful One cycle is 30 chest compressions and two breaths Complications of CPR: # ribs Pneumothorax Hemopneumothorax Hemopericardium An effective CPR should be able to Restore the circulation to the brain And to the vital organs like the lungs and kidneys Never break the cycle of CPR Except for giving DC shocks CPR - not a substitute for defibrillation Should not stand in the way CPR may be continued Indefinitely if indicated Give 5 cycles of CPR or CPR for minimum of 2 minutes Consider discontinuing CPR only after 30 minutes Give adrenaline 1mg mg IV repeat 3 doses

4. VENTRICULAR FIBRILLATION / PULSELESS VT EM 03 Arrive here from Cardiac arrest overview Monitor showing Ventricular Fibrillation/ Tachycardia Adrenaline 1 mg IV 10 ml of 1:10,000 /2 mg 20 ml 1:10,000 ET Fine Ventricular Fibrillation (lesser chance or correction) Coarse Ventricular Fibrillation Defibrillate at 200 joules biphasic 300 joules monophasic Resume attempts to defibrillate Give 2 min CPR between defibrillations LIDOCAINE 1 mg per kg IV Then 0.5mg per kg q 10 minif required to a maximum total dose of 3mg per kg Pulseless Ventricular Tachycardia 5 cycles of Cardiopulmonary Resuscitation Confirm A/W placement Effective oxygenation and ventilation Resume attempts to defibrillate Assess rhythm only after 5 cycles/2m CPR Establish IV Assess rhythm If Torsae des pointes MAGNESIUM IV ASYSTOLE or Pulseless Electrical Activity ASYSTOLE or PEA so shock protocol Resume attempts to defibrillate Sinus Rhythm – OK Fine

5. DEFIBRILLATION EM 04 Rhythm VF or Pulseless VT Maintain airway, Oxygenate Defibrillation is a technique used to counter the onset of VF, the common cause of cardiac arrest, and pulseless VT, which sometimes precedes VF but can be just as dangerous on its own. In simple terms, the process uses an electric shock to stop the heart, in the hope that heart will restart with rhythmic contractions. Sedate Patient is conscious and anxious Press both buttons together One electrode is placed on the right side of the front of the chest just below clavicle and the other electrode is placed on the left side of the chest just below the pectoral muscle or breast. Ensure no one touches the cot Ensure your body does not touch the cot Charge the defibrillator to chosen energy Place both paddles in appropriate position Check monitor for rhythm VF or Pulseless VT It is not effective for asystole (complete cessation of cardiac activity, ) and pulseless electrical activity (PEA). No Improvement? Cardiac arrest protocol

6. CARDIAC ASYSTOLE AND PEA [No shock advised] EM 05 Arrive here from Cardiac arrest protocol Establish IV line, Give 5 cycles of CPR Confirm airway placement, effective oxygenation and ventilation Search forand treat possible causes, hypovolemia, hypoxia, hyperkalemia, hyokalemia, hypothermia, hydrogen ion acidosis Tableta(Drug overdose) tamponade, tension pneumothorax, thrombosis (cardiac and pulmonary) Adrenaline 1 mg IV Endocratheal tube Atropine 1 mg IV if PEA with rate <60 Assess rhythm Cardiac Asystole Ventricular Fibrillation See VF protocol Consider Sodium bicarbonate Only if hyperkalemia

7. STABLE PATIENT WITH NARROW COMPLEX TACHYCARDIA EM 06 Assessment Patient stable/unstable Look for serious signs of instability SERIOUS SIGNS Chest pain Shortness of breath Loss of conciousness Low Blood pressure Cardiogenic shock Pulmonary edema Congestive cardiac failure ATRIAL FIBRILLATION /FLUTTER SINUS TACHYCARDIA SUPRAVENTRICULAR TACHYCARDIA VAGAL COMPRESSION See procedure Look for and treat underlying Causes: Pain, Hypoxia, Dehydration Deteriorating serious signs or symptoms Not successful Try Digoxin + Verapamil SYNCHRONIZED CARDIOVERSION Start at 100 joules Increase to 200, 300, 360 Adenosine 6 mg IV push Repeat the dose and Double the dose

8. STABLE WIDE COMPLEX TACHYCARDIA EM 07 Arrive here from protocol Tachycardia Overview MONOMORPHIC VT POLYMORPHIC VT UNKNOWN SUPPORTIVE CARE TRANSPORT Supportive Care Transport SUPPORTIVE CARE TRANSPORT MAGNESIUM 1 gm IV LIDOCAINE 1 mg per kg IV Then 0.5mg per kg q 10 minif required to a maximum total dose of 3mg per kg LIDOCAINE 1 mg per kg IV Then 0.5mg per kg q 10 minif required to a maximum total dose of 3mg per kg Deteriorating symptoms or signs SYNCHRONIZED CARDIOVERSION Start at 100 joules Increase to 200, 300, 360 TRANSPORT

9. BRADYCARDIA EM 08 Assessment Heart Rate less than 40 per minute BP/Perfusion adequate Sinus Bradycardia or I0 AV block Observe NO Type II second degree A V Block Or III degree Complete A V Block NO Atropine 0.5 mg q 5 min Transcutaneous Pacing if Symptoms develop Temporary Transcutaneouspacing No response or easy reversions to CHB Not Successful NO Permanent Pacemaker Dopamine 5-20 ug/kg/min IV

10. CARDIOGENIC SHOCK EM 09 Assessment of ABCs Oxygen 100% by mask Call for ALS team intercept Endotracheal intubation See airway management protocol Pump versus rate problem IV access X 2 Bradycardia with hypoperfusion SVT or VT with hypoperfusion MI with hypoperfusion Atropine 0.5mg IV push Repeat to maximum 3 mg Normal saline 500 cc bolus SVT Narrow complex VT Wide complex Synchronized cardioversion Normal saline 500 cc bolus STABLE STABLE Dopamine IV Start at 5ug/kg/minute And titrate EXTERNAL PACEMEAKER Vagal manouere Lidocaine Dopamine IV Start at 5ug/kg/minute And titrate Adenosine Adenosine TRANSPORT

12. CARDIAC FAILURE EM 10 Assessment History: MI, HTN, AS Raised JVP,Gallop, Crackles SEVERE Respiratory distress Crackles throughout Oxygen saturation<92 NEAR DEATH Insufficient Respiratory drive Cyanosis Dropping saturation Decreased LOC MILD/ MODERATE Able to speak sentences Crackles base only Oxygen saturation>92 Oxygen to maintain sat >92 High flow qxygen 100% Oxygen Nitroglycerine SL repeat q5m Nitroglycerine SL repeat q5m Nitroglycerine SL repeat q5m IV saline lock Salbutamol [only if wheeze] Salbutamol [only if wheeze] IV Morphine 2.5-5 mg IV Morphine 2.5-5mg Deteriorating IV Frusemide Only if on diuretics IV Frusemide Only if on diuretics Deteriorating

13. BRONCHIAL ASTHMA EM 11 Assessment Less than 50 years History of Asthma Environmental exposure Severe Decreased a/e throughout With expiratory wheeze Expiratory wheeze Oxygen saturation <92% Mild to moderate Decreased a/e throughout Expiratory wheeze Speaking in sentences Oxygen saturation >92% Near Death Decreased level of conciousnes Ineffective respiratory effect Unable to speak Cyanosis Oxygen saturation <92% Oxygen to maintain sat >92% Oxygen 100% BVM prn Oxygen to maintain sat >92% Salbutamol 5mg nebulization Salbutamol 5mg nebulization Epinephrine 0.3mg SC IV Aminophylline 250 mg in 100ml See suspected cardiac origin protocol Ipratropium bromide 0.3mg aerosol IV saline Lock IV Aminophylline 250 mg in 100ml See suspected cardiac origin protocol Adenosine 6 mg IV push Repeat the dose and Double the dose

14. DIABETIC KETOACIDOSIS EM 12 ASSESSMENT: History and PE, RBS, Urea, S Cr, SE, Urine , CBC, ECG Blood gases, CXR Diagnostic criteria for DKARBS >250mg%, Arterial pH < 7.3m, S Bicarbonate < 15mg%, Moderate ketouria Start IV fluid 0.9% Saline 1L per hour initally(15-20 ml/kg/hour Insulin Potassium IV Fluids Determine hydration status IV Route SC / IM route If Serum K+ level is <3.3 meq/L Hold insulin and give K+40meq/hr 2/3rd as Pot Chloride and 1/3rd as Pot phosphate Hypovolemic shock: Administer 0.9% Sodiunm chloride 1L / hour and or plasma expander Administer Regular Insulin 0.5 U /kg as IV bolus Administer 0.3 U /kg as IV bolus And ½ given SC or IM Cardiogenic shock: Hemodynamic monitoring Administer Regular Insulin 0.1 U /kg as IV infusion Administer 0.1 U /kg per hour And ½ given SC or IM If Serum K= level is . 5.5meq/L do not give K+ but check level every 2 h Mild hypotension: Evaluate corrected serum Na level High or Normal: Administer 0.45% Na cl If RBS dose not fall by 50-70mg in the 1st hour If Serum K+ level is >3.3 meq/L but < 5.5meq/L give 20-30 meq in each liter of IV fluid 2/3rd as Pot Chloride and 1/3rd as Pot phosphate Double insulin infusion Hourly until RBS Falls by 50-70mg/h Give hourly IV insulin Bolus until RBS Falls by 50-70mg/h Serum Na low: Administer 0.9% Na Cl Depending on hydration status When Serum Glucose reaches 250mg/Dl[13.3mmol/L Change to 5% Dextrose0.45% Saline administered at 100-200ml per hour, with adequate insulin 0.05-0.1 U/kg/has IV infusion or 10 U SC 2 hours given to keep glucose level between 150 and 200mg% Check chemistry every 4 hours until patient is stable Look again for precipitating causes After resolution of diabetic ketosis obtain blood glucose Every 4 hours and give sliding scale regular insulin

15. ACUTE ISCHEMIC STROKE EM 13 Assessment New onset of Neurological Deficit Stroke or Transient Ischemic Attack Non contrast Head CT scan Acute cerebral edema cause obtundation herniation Peaks on 2nd day but mass effect till 10th day Larger the infarct more the cerebral edema Can directly compress the brainstem Blood pressure to be lowered if Malignant Hypertension Concomitant Myocardial Ischemia Blood Pressure >180/110 mmHg Care of comatose patients Ryles tube feeding Adequate calorie & fluid intake Intravenous Mannitol 100 ml 8 hourly for 3 days Oral Glycerine 30 ml TID orally or via Ryles tube Water restriction but avoiding hypovolemia Start Amlodipine 2.5mg BID or Tablet Nifedipine 10mg BID Titrate to keep BP At 150/90 Consider catheterization Ensure good urine output Frequent change of position Intravenous rtPA 0.9mg/kg to a90mg maximum In selected patients within 3 hours of the onset Attention directed towards Common complications of bedridden patients Respiratory tract infections Urinary tract infections Pressure sores DVT and Pulmonary Embolism Monitor Blood Sugar regularly Keep RBS value below 200mg% Fever detrimental Use antipyretics as indicated If unmonitored, can be harmful Even precipitate a VT or VF Do not repeat the procedure Aspirin 300mg daily The role of Anticoagulation is uncertain Search for evidence of cardioembolic stroke Investigate with ECG, Chest X Ray and Echo Consider anticoagulation with PTT INR control Consider Neuroprotective agents Give adrenaline 1mg mg IV repeat 3 doses Or Vasopressin 40 U IV instead of adrenaline Rehabilitation of stroke patients Physical, speech, and occupational therapy Education of the patient and family Prevention of complications of immobility Search for risk factors for stroke Hypertension, Diabetes, Smoking, Dyslipidemia Asymptomatic or symptomatic carotid stenosis Relative risk reduction with treatment Balloon Angioplasty with Stenting is the alternative Surgical treatment restricted to Carotid Endartectomy

16. ACUTE EMBOLIC STROKE EM 14 Assessment New onset of Neurological Deficit Stroke or Transient Ischemic Attack Non contrast Head CT scan Anticoagulation to keep INR ranging from 2 to 3 Warfarin reduces the risk by 67% 1% risk per year of a major bleeding complication Can directly compress the brainstem Non rheumatic Atrial Fibrillation Chronic Obstructive Lung Disease Essential Hypertension Mitral Valve Prolapse Artery to artery embolic stroke Thrombus formation on Atherosclerotic plaque in carotid Anticoagulation also reduces risk of embolism after acute Anterior wal Q wave MI A three month course is recommended Recent Myocardial Infarction Post Infarction Mural thrombosis Transmural Anteroapical MI Prophylactic anticoagulation Intracranial atherosclerosis In situ thrombosis or embolization Warfarin sodium and aspirin Intravenous Mannitol 100 ml 8 hourly for 3 days Oral Glycerin 30 ml TID orally or via Ryles tube Paradoxical embolization: Venous thromboses migrate to Arterial circulation via Cardiac Right to left shunt Atrial Septal Defect Patent Foramen Ovale Urinary tract infections Valvular Endocarditis Valvular Vegetations Multifocal symptoms and signs Small microscopic infarcts or Large septic infarcts brain abscess Hemorrhagic Infarcts A greater degree of anticoagulation is indicated for Prosthetic valve Thrombosis Combination of antiplatelets advantageous Search for evidence of cardio embolic stroke Investigate with ECG, Chest X Ray and Echo Consider anticoagulation with PTT INR control Confirmation by Trans esophageal Echocardiography Presence of a venous source of embolus of right to left cardiac shunting Rehabilitation of stroke patients Physical, speech, and occupational therapy Education of the patient and family Prevention of complications of immobility Search for risk factors for stroke Hypertension, Diabetes, Smoking, Dyslipidemia Asymptomatic or symptomatic carotid stenosis Relative risk reduction with treatment Balloon Angioplasty with Stenting is the alternative Surgical treatment restricted to Carotid Endartectomy

17. ACUTE HEMORRHAGICIC STROKE EM 15 Assessment New onset of Neurological Deficit Headache, projectile vomiting Non contrast Head CT scan Hypertensive Intra-parenchymal hemorrhage Spontaneous rupture of a small penetrating artery Common sites are basal ganglia, putamen, thalamus Sometimes the pons and the cerebellum Blood pressure to be lowered if Malignant Hypertension Concomitant Myocardial Ischemia Blood Pressure >180/110 mmHg Care of comatose patients Ryles tube feeding Adequate calorie & fluid intake Intravenous Mannitol 100 ml 8 hourly for 3 days Oral Glycerine 30 ml TID orally or via Ryles tube Water restriction but avoiding hypovolemia Start Amlodipine 2.5mg BID or Tablet Nifedipine 10mg BID Titrate to keep BP At 150/90 Consider catheterization Ensure good urine output Frequent change of position 50% of patients die <30ml Good, 30-60ml intermediate, >30ml poor Attention directed towards Common complications of bedridden patients Respiratory tract infections Urinary tract infections Pressure sores DVT and Pulmonary Embolism Monitor Blood Sugar regularly Keep RBS value below 200mg% Fever detrimental Use antipyretics as indicated If unmonitored, can be harmful Even precipitate a VT or VF Do not repeat the procedure Evacuation of hematoma helpful only in cerebellar Sub Arachnoid Hemorrhage Neurosurgical intervention is necessary by craniotomy and external clipping of the bleeding vessel or aneurysm During this waiting period medical treatments to control blood pressure, bed rest, and a quiet environment reduce the risk of rebleed. Nimodipine is an oral calcium channel blocker, that has been shown to reduce the chance of a bad outcome, even if it does not significantly reduce the amount of angiographic vasospasm. Or by interventional radiology (neuroradiology), which employs transfemoral angiography and inserting of metal coils to stem the bleeding (which is especially useful in aneurysmatic hemorrhage). Balloon Angioplasty with Stenting is the alternative Surgical treatment restricted to Carotid Endartectomy

18. ACUTE SUBARACHNOID HEMORRHAGE EM 16 Assessment Sudden onset of severe headache Lethargy, coma, low back pain No focal neurological deficit in the beginning Nuchal rigidity, positive Kerning sign Retinal hemorrhages ( sub-hyaloid) Rebleeding 20% at two weeks Vasospasm and neurological deficits (days 4-14) Blood pressure to be lowered if Malignant Hypertension Concomitant Myocardial Ischemia Blood Pressure >180/110 mmHg Care of comatose patients Ryles tube feeding Adequate calorie & fluid intake Non contrast CT scan head Lumbar puncture: Uniformly blood stained Xanthochromia on immediate centrifugation Start Amlodipine 2.5mg BID or Tablet Nifedipine 10mg BID Titrate to keep BP At 150/90 Consider catheterization Ensure good urine output Frequent change of position Intravenous Mannitol 100 ml 8 hourly for 3 days Oral Glycerine 30 ml TID orally or via Ryles tube Water restriction but avoiding hypovolemia Attention directed towards Common complications of bedridden patients Respiratory tract infections Urinary tract infections Pressure sores DVT and Pulmonary Embolism Ruptured berry aneurysm Fusiform aneurysms secondary to atherosclerosis Mycotic aneurysm Resulting from septic embolism Hypertensive hemorrhage Arteiovenous malformations Contrast CT or MRI useful in demonstrating Cerebral angiography (DSA) needed pre-surgically Neurosurgical intervention is necessary for Berry aneurysm Timing of surgery after SAH is controversial Depends on clinical condition During this waiting period medical treatments to control blood pressure, bed rest, laxatives and a quiet environment reduce the risk of rebleed. Nimodipine is an oral calcium channel blocker, that has been shown to reduce the chance of a bad outcome, even if it does not significantly reduce the amount of angiographic vasospasm. Or by interventional radiology (neuroradiology), which employs transfemoral angiography and inserting of metal coils to stem the bleeding (which is especially useful in aneurysmatic hemorrhage). Nimodipine Dose is 60 mg PO QID Surgical treatment restricted to Carotid Endartectomy

19. SEIZURES EM 17 Assessment ABCs / Vital signs/ Oximetry Continuos ECG monitoring Place a soft plastic airway Administer oxygen by mask Insert a large bore IV line Ideally two one being dextrose free Glucometer <60mg% Administer Thiamine 100mg IV folloewed by 50ml 50% dextrose Laboratory analysis: Blood sugar, Urea, Creatinine Serum Electrolytes Urine analysis, and drug screen Antiepileptic drug levels RBS Parenteral anticonvulsants indicated if status epilepticus Patient pregnant High BP See pre-eclamsia protocol High BP Lorazepam 0.1mg/kg at 2mg Per minute up to 4mg Diazepam 0.2mg/kg at 5mg per minute up to 10 mg OR Short duration of action of These drugs necessitate maintenance anticonvulsants Phenytoin Sodium Preferred maintenance drug Loading dose 20mg/kg Watch for arrhythmias and hypotension Benzodiazepine infusion A preferable option in some maintenance anticonvulsants See shock protocols The maximum rate of infusion is 50mg per minute and a large bore IV line with dextrose free fluid used to prevent precipitation Respiratory depression may require intubation And assisted ventilation Phenobarbitone 20mg/kg at the rate of 50mg/minute

20. Thank You for the patient listening