PEDIATRIC RIGHTS AND RESPONSIBILITIES OF PARENTS/GUARDIAN POLICY: Children from age 1 to 12 visiting in Emergency Department shall have the

following rights: Respect for: Each child and adolescent as a unique individual The care-taking role and individual response of the parent Provision for normal physical and physiological needs of a growing child to include nutrition, rest, sleep, warmth, activity and freedom to move and explore. Consistent, supportive and nurturing care which: Meets the emotional and psychosocial needs of the child Fosters open communication Provision Minimization of emergency department stay duration by recognizing discharge planning needs. i. ii. iii. appropriate treatment in the least restrictive setting available; not receive unnecessary or excessive medication; An individualized treatment plan, and to participate in the development of the plan; To be treated considerately and respectfully regardless of race, religion, sex, sexual orientation, cultural background, economic status, education or illness iv. v. To provide as much information to parents as they need in order to give or refuse consent for any proposed treatment. An environment that provides reasonable protection from harm and appropriate privacy for personal needs; separation from adult patients; and regular communication with family, subject only to restriction as provided by medical necessity or applicable hospital rules. vi. Parents/family shall have the responsibility for: Continuing their parenting role to the extent of their ability Being available to participate

in decision-making and providing staff with knowledge of parents/family where abouts. To receive a clear explanation of the outcome of any treatments or procedures where the outcomes differ significantly from the anticipated outcomes.

PATINETS BELONGINGS AND PROPERTY POLICY:

i.

All patients admitted to the hospital from the Emergency Department will have their property and belongings documented on a Property Sheet./register. kept under the supervision of Charge nurse in resuscitation room.

ii.

All valuables are to be documented on the Property Sheet either as sent home with a family member or placed in the hospital safe in the custody of administrator or social welfare department /patient service department.

iii. iv.

A property form will be signed by attendant /guardian/social worker before shifting the patient in ward. Money is to be counted in front of the patient/Red Crescent crew with a Social worker as a witnessed.

PATIENT ELOPMENT FROM THE EMERGENCY DEPARTMENT DEFINITION:

Any patient, who has been seen by the Triage Nurse but left prior to an evaluation by the Emergency Department physician, or who has been seen by the Emergency Department physician but left before treatment or disposition, is deemed as an elopement. POLICY: i. The patient's primary care provider nurse will also immediately contact the patient's family/friends/support group to determine if the patient was removed from the hospital by these individuals without notifying staff. ii. If it is determined that a true elopement has occurred, and the patient is found at his/her home or with friend , should be contacted to the competent patient and explain any and all risks and consequences associated with leaving the Emergency Department to the patient through the patient Service. iii. If the competent patient wishes to remain in elopement status, this should be documented in the medical record. This should be witnessed by social worker and administrator and two physician and senior nurse. If the patient is not competent, the conservator or guardian should be contacted immediately and informed of the elopement.

PATIENT LEAVING AGAINST MEDICAL ADVISE POLICY:

i. All patients indicating the desire to leave against medical advice shall sign an LAMA form. The senior nurse and/or physician shall discuss, with the patient

and/or family, the potential complications that may occur if the patient leaves prior to the physician discharging the patient. ii. The LAMA form shall state the possible consequences. If after explanation of potential consequences the patient still wishes to leave LAMA, request that patient to sign the LAMA form and give a copy to the nurse, shall instruct the patient to follow-up with his/her PHC or return to the Emergency Department if his/her condition worsens. iii. Document the patient's desire to leave LAMA, conversations on potential complications and patient's condition prior to leaving the Emergency Department. iv. In the event the patient leaves prior to an evaluation by the physician and does not notify any staff member of leaving, the registered nurse shall document in the nursing notes and will inform to social worker /administrator and on duty supervisor. v. LAMA papers will be signed by duty administrator or social worker who will also try to convince the patient and the patient who is critically ill and wants to leave the ED, Social worker must be witnessed and sign the paper.

PATIENT RIGHTS AND RESPONSIBILITIES

POLICY: Patient Rights: Hospital and medical staff have adopted the following statement of patient rights. This list shall include, but not be limited to, the patient's right to:

i.

Become informed of his or her rights as a patient in advance of, or when discontinuing, the provision of care.

ii.

The patient may appoint a representative to receive this information should he or she so desire. Exercise these rights without regard to sex or cultural, economic, educational or religious background or the source of payment for care.

iii.

Considerate and respectful care, provided in a safe environment for his or her plan of care and actively participate in decisions regarding his/her medical care.

iv. v.

To the extent permitted by law, this includes the right to request and/or refuse treatment. Formulate advance directives regarding his or her healthcare, and to have hospital staff and practitioners who provide care in the hospital comply with these directives to the extent provided by MOH rules and regulations.

vi. vii.

The patient in regard to hurt of his desirable right can proceed to the administration through social welfare department Any hurt right will be investigated by the litigation department and the patient or his/her designee can attend the proceedings.

PHOTOGRAPHING/VIDEOTAPING PATIENTS : i.

POLICY

To take photographs and/or film or video tape in an effort to assist educational, treatment, research, scientific,; and to document certain physical conditions when it may be of benefit to the patient's plan of care and treatment.

ii.

Photographs, films and/or videotape made for the purposes of identification, diagnosis or treatment of the patient require patients consent.

iii. iv. v.

But in kingdom of Saudi Arab it is necessary to take the consent and for female it is absolutely prohibited to ask for consent without face cover. The consent will contain a description of the circumstances of the use of the photography, film or videotape. The patient or his/her authorized legal representative has the right to request cessation of photography, filming or videotaping at any time.

PROCEDURES AND TREATMENTS NOT TO BE PERFORMED IN THE ED

POLICY: The following procedures and treatments shall not be performed in the Emergency Department: i. ii. iii. iv. Dilatation and curettage Chemotherapy/antineoplastic drug administration Any procedure requiring general or spinal anesthetic i.e., endoscopy, colonoscopy, Bronchoscopy Repair of: Open fracture, Flexor tendons, Nerves and blood vessels.

REFUSAL OF BLOOD/BLOOD COMPONANT TRANSFUSION

POLICY: It is the policy of Hospital to verify, by means of the Refusal To Permit Blood/Blood Component Transfusion Form, that the patient's informed refusal has been obtained by the treating physician after the patient has been informed of the possible risks and complications that may occur as

a result of the patient's refusal to receive recommended transfusion of whole blood and/or frozen plasma, packed cells, platelets or cryoprecipitates.

PURPOSE OF THE FORM: i. To ensure that the treating physician has obtained an informed refusal from the patient To provide the patient with the representative. ii. Witness: The patient's signature should be witnessed by a responsible employee of Hospital. If the patient refuses to sign, the notation Patient Refuses to Sign, should be made in place of the patient's signature and the witness i.e., the person/guardian/social worker/administrator who received the patient's refusal to sign should sign the form in the designated place. iii. Copies: The form should be completed in duplicate. The original should be placed in the patient's permanent medical record.

RELEASE OF INFORMATION-PATIENT PRIVACY POLICY: i. ii. All patients are guaranteed the right to privacy. Patient will be given the opportunity to express whether the area provided meets his/her privacy expectations, and if not, will be provided with a secluded area. Information on patient care is limited to only those healthcare professionals directly responsible for the patient's care. iii. Any outside agency requesting information on a patient's condition shall be routed to the Supervisor General office .

iv.

Information on patient status or condition will NOT be given out over the telephone.

RESOLUTION OF POTENTIAL CONFLICTS WITH STAFF MEMBERS CULTURAL/ETHICAL/RELIGIOUS BELIEF POLICY: It is the policy of Emergency Department to respect its staff member's cultural values, ethical and religious beliefs and the impact these may have on patient care. Conflicting cultural values, ethical or religious beliefs may be sufficient grounds for granting requests for revisions in daily assignments and/or requests not to participate in the provision of care. PROCEDURE: i. Members of any culture may hold varying degrees of commitment to the predominant values of the culture, but in the emergency department all staff must follow the rules and regulation of kingdom of Saudi Arab and there will be no politico religious discussion among staff members, and there will be no criticism on any sectarian issue at all. ii. iii. The staff member experiencing any such issue will direct supervisor/Head of Department, a Request for Revised/Excused Duty. Fill up incident Form immediately upon identification of the real or potential conflict.

iv.

A conviction of any sort or an unfavorable credit history that may be inconsistent with the duties of the position is subject to forwarding to hospital legislator department.

SUSPECTED CHILD,ADULT,DISABLED PERSON OR ELDERLY ABUSE/NEGLECT/EXPLOITATION

POLICY: i. ii. Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation. It is the policy of this hospital and ED to protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members. iii. This ED mandates that, under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency , Chief of ED,BLEEP#293 and Sr. Specialist on bleep#167, or call at 2309. iv. Any person who is responsible for the care of the above Nature and extent of the patient's condition basis of the reporter's knowledge any other relevant information ,the hospital may not suspend or terminate the employment of or discipline or otherwise discriminate against an employee for reporting the a. employee's supervisor, an administrator of the hospital, a regional b. Directorate regulatory agency or a law enforcement agency for a violation of

c. the law. v. The hospital may not retaliate against a person.

DO NOT RESUSCITATE(DNR)

GUIDELINES FOR DO NOT RESUSCITATE (DNR) ORDERS I. Rationale and Objectives The utilization of cardiopulmonary resuscitation (CPR) has become routine in almost all hospitals in the United States but still not in practiced in this hospital routinely except in ICU , however MOH GUIDELINES determine that dont resuscitate if there is surety of death of a person In fact, it is one of the few medical interventions which can not be undertaken without a physician's order. Yet, when effectiveness of CPR is measured in terms of the patient's surviving to the point of discharge from the hospital, studies of CPR of hospitalized patients demonstrate only a 5% to 20% success rate. This rate is even lower in selected patient populations such as those with metastases cancer, chronic debilitating illness or multiple organ failure. These guidelines recommend the procedures to be followed in making and implementing a decision to withhold utilization of these emergency resuscitation techniques. If a patient has included directives regarding such treatment as part of an "advance directive" such as a Living Will, the provisions of that declaration and related legislation will apply. II. Definitions "Competent Adult Patient" - patient of at least eighteen years of age who is determined to have the capacity to make his/her own treatment decisions, i.e. the capacity to understand relevant information, reflect

on it in accordance with his/her values, and communicate with caregivers. "Incompetent Adult Patient" - patient who has been legally declared incompetent or a patient who is determined to have an irreversible lack of decision making capacity. "Pediatric Patient" - patient of less that eighteen years who is not otherwise legally emancipated. "Cardiopulmonary Resuscitation" emergency treatment of acute failure of cardiac or respiratory systems (cardiac and/or respiratory "arrest") usually including at least one of the following procedures: chest compressions ("closed chest" cardiac massage)intubations/ventilation, and cardiac defibrillation. III. Procedures for Implementation A. Guidelines for Decision making Evaluation and Discussion - A DNR order should be considered in any clinical situation in which resuscitation would likely be futile or in which the utilization of such treatment would be inappropriate in view of the patient's diagnosis and/or prognosis. The patient's attending physician has the primary responsibility to evaluate the patient and to facilitate discussion with patient and/or family in situations in which such an order is judged to be appropriate. Nursing staff can also play an important role in this evaluation process and in supporting discussion with patient and/or family. Identification of Decision-maker - If the patient is a competent adult, discussion and decision- making regarding a DNR order need only involve the patient. A DNR order for such a patient should be written only with his/her informed consent. If the patient has been adjudged to be mentally incompetent by a court, the primary decision-maker is the patient's guardian. If the patient is determined to lack the capacity to participate in the decisionmaking process, the physician should determine if the patient had previously indicated a choice of the appropriate individual to act as decision-maker or

seek to identify a member of the patient's family who will act as a surrogate decision-maker. Making the Decision - The decision about the DNR order should be made in accordance with the expressed wishes of the patient or in accordance with the explicit directives of the patient, i.e. "advance directives" or in accordance with the known preferences and values of the patient. Lacking any of the above, the decision should be based on a careful and reasoned consideration of the patient's interests. Pediatric Patient - Decision-making regarding utilization of CPR for pediatric patients should be made according to the previously approved guidelines. Conflict/Disagreement - Since decision-making regarding DNR orders will frequently involve shared responsibility, there may be situations in which there is disagreement among health care providers or between providers and surrogate decision makers regarding the appropriateness of a DNR order. Such disagreements should be discussed and examined thoroughly and efforts made to achieve agreement. If they cannot be resolved, additional consultation and/or referral to the Ethics Committee should be considered. B. DNR Orders All orders not to resuscitate must be written or signed by the patient's attending physician on the Physician's Order Sheet. It is imperative that caregivers and patients/families realize that resuscitative measures (calling a "Code Blue" and initiation of CPR) will be performed routinely on all patients for whom there is not a written DNR order. In addition to the order "Do Not Resuscitate (DNR)", the physician may wish to modify the order by including instructions regarding specific resuscitative interventions. Verbal DNR orders can be received only by a licensed physician and must be witnessed. Verbal or telephone orders must be countersigned within 12 hours by the attending physician who gave the order.

C. Documentation In addition to the order itself, physicians must make certain that the patient' medical record provides adequate documentation of the evaluation, discussion

SECTION II

PROVISION OF CARE, TREATMENT AND SERVICES

:ADMISSION OF PATIENTS TO EMERGENCY DEPARTMENT

POLICY: i. ii. iii. All patients will take emergency sheet by an Emergency Department Registration Clerk All patients will have the appropriate demographic information obtained by an Emergency Department Registration Clerk. If the Saudi patient has no ID, administrator will sign after getting confirmation, mean time treatment will be given if the patient is critical. iv. For non Saudi patients who are eligible as per Govts rule, ED sheet will be stamped blue and for non eligible there will be red stamp and information will be passed on to business centre, v. If critical patient is brought in the ED by Red crescent or any other agency directly in the resuscitation room, registration clerk will come and will take demographic information from the patient/relative or from ID. vi. vii. viii. All the dead bodies brought in the ED , clerk will make deceaseds ED sheet For Unknown unconscious/severely injured patients, the clerk will write himself if he or she is known later on. Registration clerk will provide the hospital file number on the ED sheet by telephone number or ID.

: AGE-RELATED DOCUMENTATION-PEDIATRIC PATIENT POLICY: i. ii. iii. iv. v. vi. Pediatric patients include infants, children and adolescents. The pediatric patient is up to the age of 12 years. Only registration clerk is responsible to change the DOB if there is confusion about age, from the family card. Documentation of care given to pediatric patients depends on the assessment by ED Physician. ED Physicians documentation shall include: Chief complaint Objective information: Emotional status LOC Communication appropriate for age Activity appropriate for age Vital signs Interaction with parent or guardian Information for patients aged one 1 year and under includes: Head circumference,

ASSESMENT OF THE EMERGENCY DEPARTMENT PATIENT

POLICY: All patients presenting to the Emergency Department will be triaged and categorized as either Resuscitative, Emergency, Urgent, Semi-Urgent or Routine.. All patients admitted to the Emergency Department will have the following documentation: Chief complaint: Subjective data Objective data Assessment of psychological status Initial vital signs: Additional vital signs

shall be obtained depending on patient's condition Critical patients every five 5 to 15 minutes, as needed Intermediate every one. I-Definition Triage is the process used to sort patients in order of acuity or the severity of their illness. Triage is designed to get the right patient to the right place at the right time with the right care provider. Rapid access to health care provider assessment increase patient satisfaction, reduce client anxiety and enhance public relation.

Triage in Saudi Arabia

The Ministry of Health (MOH) in Saudi Arabia has compiled a manual for organizing nursing services in the country with nursing triage guidelines that are to be used across all MOH EDs [unpublished document, General Administration for Nursing, 2003].This document specifies nursing functions and duties together with comprehensive policies and procedures. With regard to specialized emergency nursing care, the manual defines triage, highlights its objectives and policies, defines 3 levels of triage activity and specifies the required manpower, materials, equipment and procedures. Psychiatric triage is not specifically mentioned in the manual but these guidelines are applicable to psychiatric EDs. The document does not mention adaptation of any international triage scale to be used in Saudi health settings apart from the 3-level system outlined above. However, some tertiary MOH hospitals such as Riyadh Medical Complex and King Fahad Medical City already use the CTAS system. Likewise some non-MOH hospitals such as King Faisal Specialist Hospital and Research Center, National Guard Hospital and Armed Forces Hospital and private hospitals use CTAS in their EDs

II Objectives To rapidly identify patients with urgent or life threatening conditions

To determine the most appropriate treatment area for patients presenting to the ED. To decrease congestion in emergency treatment areas. To provide a logical mechanism for ongoing patient assessment. To provide information to patients and families regarding expected care and waiting time To provide reliable information defining department acuity.

III General Triage Principles 1. Triage nurse duties: i. ii. iii. iv. v. vi. vii. viii. Should have rapid access to or be in view of the registration and waiting area at all times. Greeting patients and families in warm, empathetic manner Performing brief visual assessment Documenting the assessment Triaging patients into priority group using appropriate guidelines. Transporting patients to treatment areas when necessary Giving reports to the treatment nurse or ED doctor Measuring the relevant vital signs for appropriate determination of triage level and for reassessment of patients directed to the waiting room. ix. x. xi. Notifying patients and families of delays. Reassessing waiting patients as necessary. Instructing patients and families to notify triage staff of any change in their condition. 2. Triage nurse qualification: i. ii. Communication skills are crucial. Provider must interact with patients, families, police, EMS personnel & visitors. Must have tact, patience and understanding.

iii. iv. v. i. ii. iii. iv.

Organizational skills to deal with patient line-ups, inquiries and unexpected problems. Must have the experience, skill expert clinical judgement to recognize patients who are sick. Must be able to work under stressful conditions. Practical knowledge gained through experience and training Correct identification of signs symptoms Key information from the presenting complaint and relevant history Use of guidelines and triage protocol

3. Accurate assignment of triage level is based on:

4. Triage is a dynamic process: i. A patients condition may improve or deteriorate during the wait for entry to the treatment area. 5. Triage guidelines: i. ii. iii. All patients should be assessed (at least visually) within 10 minutes of arrival Full patient assessment should not be routinely completed in the triage area when other patients are waiting to be triaged. The triage assessment should generally take no more than 2-5 minutes, obtaining sufficient information to determine the urgency and identify any immediate care needs. iv. v. vi. vii. All information obtained should be recorded. Rapid assessment should be performed when there are 2 or more patients waiting to be triaged. The priority for care may change following a more complete assessment or a patients signs and symptoms evolve. Level I and II patients should be placed in a resuscitation area and have a complete assessment immediately.

viii. ix.

Level III patients need full vital sign assessment to document that it is safe for them to wait for treatment. Level IV and V patients may have their vital signs delayed until reevaluation in the waiting area or treatment area.

6. Triage Assessment: NB: (The purpose of the triage assessment is to determine priority of care, not to establish a final medical diagnosis) 1) First impression: quick look initial impression of triage personnel. 2) Chief complaint 3) Assessment of chief complaint A. Subjective evaluation: When did the symptom start? a) What are you doing when it started? b) How long did it last? c) Does it come and go? d) Is it still If painful use a pain scale. e) For mild it is 0 to 3 for moderate 4 to 7 and fore severe 8 to 10. Is there chance of fall? f) Use Morse scale B.Objective evaluation (This part of the triage assessment may be deferred to the treatment area if the patient requires rapid access to the care and intervention e.g. levels I or II patients). Physical appearance: colour, skin, activity. Degree of distress: severe distress, moderate distress, no acute distress.

Emotional response: Anxious, indifferent Complete vital signs if time allows or necessary for assignment of triage level (Levels III, IV, V)

7. Re- triage: To ensure the patient status is not deteriorating after initial triages, re-triage should occur at the time intervals recommended for medical care assessment Level Time interval I Continuou s Care II 15 Minute s III 30 minutes IV 60 minutes V 120 minute s

8. Documentation standards The documentation of the triage assessment Sheet are printed and need to tick accordingly Date & time of assessment Vital Signs Chief presenting problem(s) Allergy History Mode of arrival Pain scale Falls scale Initial triage category allocated Name of the triage Nurse Re-triage category with time and reason Assessment and treatment area allocated Any diagnostic, first aid or treatment measures initiated

9. Effective triage requires the use of sight, hearing, smell and touch. There are many non-verbal clues, including facial expressions, cyanosis and fear. Listen to what the patient is saying and pay attention to questions they are reluctant or unable to answer. Listen for a cough, hoarseness and labored respiration. Touch the patient to assess heart rate, skin temperature and moisture. Notice odours such as smell of ketone, alcohol or infection. Often the most timeconsuming task of triage is to allay patient and family anxiety. Attitude and empathy are therefore important. Difficult patients and families such as those who are combative require special care. Do not prejudge patients based on their appearance or attitude.

10.

Factors which influence triage design and operation: Number of visits. Number of patients requiring rapid intervention Availability of health care providers in the ED treatment area. Availability of specialty services. Environmental, legal and administrative issues.

Level I

Resuscitation

Conditions that are threats to life or limb (or imminent risk of deterioration) requiring immediate aggressive interventions. Time to physician immediate Usual presentations: 1. Code/arrest: patients with cardiac and /or pulmonary arrest (or appears to be imminent) 2. Major trauma: Severe injury of any single body system or multiple system injury(ISS>16) Head injury with GCS<10; severe burns (>25% TBS or airway problems), chest/abdominal injury with any or all of: altered mental state, hypotension, tachycardia, severe pain, respiratory signs or symptoms.

3. Shock states: Conditions where there is an imbalance between Oxygen supply (cardiogenic, pulmonary, blood loss, disorders of oxygen affinity) and demand (hyperdynamic states) or utilization (sepsis syndrome). Hypotension and or tachycardia and possibly bradycardia in advanced/pre arrest situations. 4. Unconscious: Intoxications/overdoses, CNS events, metabolic disturbances can all have an alteration of mental function from disorientation/confusion to completely unresponsive or actively seizuring. Airway protection and supportive care with prompt assessment to determine the cause/treatment are of critical importance. Hypoglycemia is a rapidly reversible problem, which should be ascertained with bedside screening tests. 5. Severe Respiratory Distress: There are many causes for respiratory distress but benign reasons can only be diagnosed by exclusion. Serious intracranial events, pneumothorax, near death asthma (unable to speak, cyanosis, lethargic/confused, tachycardia/bradycardia, O2 sat <90%) COPD exacerbations, CHF, anaphylaxis and severe metabolic disturbances (renal failure, Diabetic Keto acidosis). These patients require rapid assessment of the ABCs and physician intervention. Medications and equipment for management of respiratory and ventilatory failure (Endotracheal intubation-RSI, BIPAP) bronchodilators, inotropes, vasodilators need to be made available. Typical patients: Severe dehydration Non responsive Severe respiratory distress Vital Signs Absent/Unstable

Level II

Emergent

Conditions that are a potential threat to life limb or function, requiring rapid medical intervention or delegated acts. Time to physician assessment/interview 15 min. 1. Altered mental state: Infectious, inflammatory, ischemic, traumatic, poisoning, drug effects, metabolic disorders, dehydration can all affect sensorium from simple cognitive deficits to agitation, lethargy, confusion, seizures, paralysis, coma. Even subtle changes can be associated with serious life threatening and treatable problems. All patients with altered mental state should have a rapid blood sugar screening test. Young children with irritability and poor feeding are examples of altered mental state that could represent serious bacterial infection or dehydration. 2. Head injury: This problem appears in several triage levels. The more severe or high risk patients require a rapid MD assessment, to determine the requirements for airway protection/CT scanning or neurosurgical

3.

4.

5.

6.

intervention. These patients usually have an altered mental state (GCS 13). Severe headache, loss of consciousness, confusion, neck symptoms and nausea or vomiting can be expected. Details regarding the time of impact, mechanism of injury onset and severity of symptoms and changes over time are very important. Severe trauma: These patients may have high-risk mechanisms and severe single system symptoms or multiple system involvement with less severe signs and symptoms in each (ISS 9). Generally the physical assessment of these patients should reveal normal or nearly normal vital signs (Abnormal VS, level I). These patients may have moderate to severe pain and normal mental status (or meet the criteria outlined for level II head injuries). Neonates: Children 7 days are at risk for hyperbilirubinemia, undiagnosed congenital heart abnormalities and sepsis. The signs of serious problems may be very subtle. Parental anxiety is often very high and these patients should brought into the ED treatment area and have prompt physician assessment or verbal review. Eye pain: Pain scale 8-10/10. Chemical exposures (acid or alkali) cause severe pain and blurred vision is usually due to photophobia and runny eyes (blephorrhea). These patients should receive topical analgesics and have eye rinsing according to local guidelines (15 minutes for acid and 30 minutes for alkali). Physician assessment with a slit lamp is suggested after rinsing. Time to physician assessment may be delayed if the treatment protocol can be implemented without a physician order. Other painful conditions such as glaucoma and iritis may have associated visual deficits and require prompt physician assessment. Corneal foreign bodies arc weld, or solar keratitis, would benefit from topical analgesics and physician time to assessment could be delayed if the pain is controlled. If pain is not controlled the diagnosis should be reconsidered. Chest pain: This is one of the most difficult presenting symptoms for triage nurses and Emergency physicians. There are so many ways in which cardiac ischemia presents that we are frequently faced with long and detailed assessments that dont always lead to a definite conclusion. Patients with non-traumatic, visceral pain are most likely to have significant coronary syndromes (AMI, Unstable angina). Careful documentation of the activity at the onset, the duration of each episode, the character, the site, the radiation, associated symptoms aggravating and alleviating factors and risk profile, all influence the ability to predict the presence or absence of significant coronary disease. Visceral pain is continuous (more than a few seconds and almost always more than 2-5 minutes) and is described as pressure, ache, squeezing, heaviness, burning, or just a discomfort. If there are associated symptoms (such as sweat, nausea, and shortness of breath) and/or radiation to neck, jaw, shoulder(s), back or arm(s) then the likelihood of a serious etiology increases dramatically.

Sudden sharp pains: can be associated with chest wall problems, but can also be due to pulmonary embolus, aortic dissection, pneumothorax, pneumonia, or other serious problems associated with vascular or viscous rupture. These patients usually have sharp pains that are severe, sudden, persistent or are associated with other symptoms(Short of breath, syncope/pre syncope) or significant risk factors are present. Sharp pains which are not severe or are easily reproduced by palpation or aggravated by cough, deep breathing, or movement, with normal vital signs can have a delay in physician assessment (Level III or IV). Previous MI, Angina or Pulmonary embolus: Patients with a prior history of these conditions should be level II no matter what the character of the pain. 7. Overdose: Intentional overdoses are particularly unreliable when trying to determine which agents have been ingested and the actual quantity. These patients require early physician assessment, or advice, with regard to the need for toxic screening, monitoring or methods of preventing absorption, enhancing elimination or administration of antidotes. Patients with any signs of toxicity (altered mental state, abnormal vital signs) should be seen very quickly ( 5 minutes). 8. Abdominal pain: Pain severity alone, cannot predict whether serious surgical or medical conditions are present. Visceral pains (constant, ache, pressure, burning, squeezing) with associated symptoms(nausea, vomiting, sweat, radiation, bump or reverberating pain) with vital sign abnormalities(hypertension, hypotension, tachycardia, fever) are much more likely to be serious problems which require prompt investigation, treatment, or pain relief. Crampy, intermittent or sharp brief pains without vital sign abnormality usually may be may be delayed. There is significant overlap between benign conditions and catastrophes such as ruptured AAA (age >50), ectopic pregnancy (females 12-50), perforated viscous, appendicitis, bowel obstruction, ascending cholangitis. This means that all severe abdominal pain (8-10/10) should cause providers to be particularly wary of visceral pains or very sudden pains, particularly with other associated symptoms. 9. GI Bleed: Upper GI causes are more likely to cause instability. Vomiting gross blood, coffee ground emesis and melena are typical of UGI sources. Maroon stool, dark blood or right red blood can also be from UGI sources but are more likely to be lower GI. The source is not as important as how to deal with the patient with hemodynamic instability. One set of normal vital signs carries no guarantee of hemodynamic stability. 10. CVA: Patients with major neurological deficits may require airway protection or emergent CT scanning to determine criteria for thrombolysis, anticoagulation, neurosurgical intervention or prognostication. If the time of

onset of symptoms is <4 hours then time to CT scanning is critical element in treatment strategies. 11. Asthma: Severe asthma is best defined with a combination of objectives measures (FEV1; PEFR, O2 saturation) and clinical factors which relate to the severity of symptoms, vital signs and history of previous severe episodes. The best measure of severity and guide to therapy is some form of spirometric testing. If the FEV1 and /or PEFR are<40% predicted or previous best, the patient is considered severe and requires prompt treatment and close observation until signs of improvement. In children who cannot do Spirometry or PEFR, particularly under age 6, clinical features and O2 saturation are used to estimate severity. 12. Dyspnea: This is subjective and may correlate poorly with lung function or deficits in Oxygen uptake and delivery. Depending on the age, previous history and physical assessment one may not be able to distinguish between asthma COPD, CHF,PE, pneumothorax, pneumonia, croup, epiglottitis, anaphylaxis or a combination of problems. Onset and duration of 13. symptoms, vital signs and auscultation of the chest will frequently allow for early intervention for most of the serious causes of shortness of breath. 14. Anaphylaxis: Severe allergic reactions can deteriorate rapidly. Patients with a history of asthma are at particularly high risk of death. Suspicion of problems should be present if there are any respiratory symptoms or complaints of tightness in the throat. These patients may receive Epinephrine by protocol, and have slightly longer delays to physician assessment , particularly if there is a prior history of this problem, with an uncomplicated course. True anaphylaxis involves multiple body systems: CNS (altered mental state to seizure/coma) CVS (hypotension/tachycardia, vascular collapse/shock) Respiratory (wheeze, cyanosis, cough) Skin (urticaria, itch with any type of non purpuric rash) GI (vomiting, abdominal pain, diarrhea) RenalThe history of time of exposure and type of agent relative to the time of onset of symptoms are important to determine the cause and for future follow or discharge advice. 15. Vaginal Bleeding/acute pelvic lower abdominal pain: Patients with vaginal bleeding and or acute lower abdominal, should be assessed for the possibility of ectopic or other serious problems associated with pregnancy. Patients with abnormal vital signs (hypotension) should have IV access established and prompt physician assessment. Even if the pain is only moderate (4-7/10) ectopic or abruption/fetal distress are still possible. Patients 20 weeks should be assessed promptly and consideration of immediate transfer to the case room with or without physician assessment, depending on local protocols or guidelines. 16. Serious Infections: Patients with bacterial infections or sepsis syndrome usually appear unwell and will have an abnormality in one or more physical signs such as mental state, vital signs, O2 saturation. A history of fever or chills with rigors should be elicited. (rigor is a shaking episode which the

patient cant control: teeth chattering, bed rocking). Purpuric skin rashes (non blanching spots, eg petechiae) may be associated with meningitis. 17. Fever (young children): Temperatures 38.0 in children under 3 months. 18. Fever: With signs of lethargy (any age) should result in a prompt assessment by the physician to consider serious bacterial illnesses such as meningitis. 19. Children: with lethargy, poor feeding, vomiting with or without a fever should have very prompt physician assessment or contact for advice on interventions. 20. Vomiting and diarrhea: with suspicion or signs of dehydration. The signs of dehydration are not always reliable, particularly in younger patients. 21. Acute psychosis/extreme agitation: These patients may be suffering from metabolic disturbances, poisoning or other organic problems. If the acute psychosis/agitation is part of a known ongoing psychiatric illness, the patient and department will benefit from early intervention with antipsychotics, sedatives (chemical restraint) or if necessary physical restraints. History from other health providers (community MD, RN, EMT) witnesses, caregivers, family, friends, Vital signs and physical assessment will usually allow for identification of those at risk from a medical perspective (overdose, CNS events, hypoglycemia). 22. Diabetes: Medic alert bracelets, history from others, physical assessment, vital signs bedside glucose testing will all be useful in identification of diabetics with hyper or hypoglycemia. Diaphoresis and or altered mental state are typical of hypoglycemia. Altered mental state, blurred vision, fever, vomiting, abnormal pulse and respirations (rapid and deep) are more typical of elevated blood sugar with or without diabetic keto acidosis. 23. CVA/Abdominal/groin pain: Renal colic (lithiasis-stones) typically has very severe pain (8-10/10) with CVA, Abdominal, groin, testicular pain. Nausea and sweat are common but it is usually the severity of pain, (with or without a prior history) which alerts care providers to the diagnosis. AAAs have sometimes been missed or have a delay in diagnosis because of some overlapping features in the history and physical. Hematuria is frequently present but is not necessary for the diagnosis of renal colic. Prompt physician assessment or protocols that allow for the administration of IV or rectal analgesics are suggested. Vital sign abnormalities 24. (Hypertension or hypotension) or concern that the diagnosis is not renal in origin should prompt immediate physician notification or assessment. 25. Headache: This presenting complaint appears in multiple triage levels. There are significant concerns about delays in diagnosing CNS catastrophes(Subarachnoid, epidural, subdural, meningitis/encephalitis) which may have several overlapping features with migraine. It is also thought to be important to institute abortive therapy, with non-opiate agents, in a timely fashion to relieve unnecessary pain and suffering and

shorten ED length of stay, for patients with migraine. The key to diagnosis/risk stratification is primarily based on an accurate history of onset, course, duration, associated symptoms and prior history of similar episodes. Activity at the time of onset, how sudden the pain was, neck symptoms, nausea/vomiting, mental status are key questions. It is important to establish what a patient means by a sudden pain. All pains are actually sudden how long it takes to attain maximum intensity is what is critical in medical diagnostics. Pains that are at their worst at the moment they start (like someone hit me with a two by four, or like a thunderclap) or within a few seconds, are almost always serious. Pains that come on rapidly (5-30 minutes are typical of migraine. More gradual pains are not always benign but in headaches they rarely are associated with the catastrophes on the differential list (intra cranial blood). 26. Severe pain (Pain Scales): When a patient claims to have a pain of 810/10 and does not appear to be in distress, or appear to have anything you expect to have intense pain, it is helpful to ask what their most painful experience had been before. The first pain anyone has is by definition a 10/10! If they have had a child, a broken bone, renal colic, migraine or other conditions expected to cause severe pain and their current pain is being compared with one of these entities, this may help you to decide which triage level is appropriate. You my also want to obtain a verbal order from the physician for analgesics. Children or elderly thought to have severe pain (but are unable to score or rate their pain) should be treated as though they have 8-10/10. 27. Abuse/neglect/assault: These patients may not have life threatening problems but have very special needs that relate to their mental well being and specific requirements for the collection of samples for evidence, or the activation of local protocols for the use of assault teams and community services. Victims of acute sexual assault (within 4 hours) should all be level II and others could be level III or less depending on the nature of the injuries or medical condition. These patients require a safe and caring environment with emotional support.

28. Drug withdrawal- severe- (Delirium tremens or other): These patients may be sometimes mistaken for acute psychiatric problems. Occasionally patients who are known substance abusers are assumed to be in the ED for non-medical problems and the danger they are in can be underestimated. Seizures, coma, Hallucinations, confusion, agitation (shakes, tremors), signs of catecholamine excess (tachycardia, hypertension, hyperpyrexia), chest/abdominal pain, vomiting, diarrhea are all part of a spectrum of signs and symptoms associated with drug/alcohol withdrawal.

29. Chemotherapy: Patients on chemotherapy or immunocompromised patients (HIV, known immune deficiency, malignancy) with or without a fever are at higher risk of serious problems These patients can deteriorate quickly, may require isolation and early assessment of absolute white cell counts.

Level III

Urgent

Conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living. Time to physician 30 min 1. Head injury: these patients may have had a high-risk mechanism. They should be alert (GCS 15) moderate pain(<8/10) and nausea or vomiting. Should be changed to level 2 if deteriorating or just appears unwell. 2. Moderate trauma: Patients with fractures or dislocations or sprains with severe pain (8-10/10). Nursing intervention with splinting/analgesics making it reasonable to have some delay in time to physician assessment/intervention. Dislocations should be reduced promptly, so physician assessment should occur in 30 minutes. Patients are stable(normal or near normal vital signs). 3. Asthma, mild/moderate: Patients with mild moderate shortness of breath with exertion, frequent cough or night awakening (unable to lie down flat without symptoms) and FEV1 or PEFR 40-60% predicted or previous best and O2 saturation 92-94%. Mild asthma is FEV1 or PEFR >60% and O2 saturation >95%. Mild asthmatics can have severe attacks and severe asthmatics can have mild attacks. Some documentation of meds and previous attack patterns(Intubated, ICU, frequent admits) can help to identify high risk individuals. It is unwise to assign a low triage level to an asthmatic that has come in because of increased respiratory symptoms. These patients should be placed in areas of the department where they can be observed, there is a means of reevaluation or the patient or companion knows to report any worsening to the Emergency staff. Spirometric measurements (FEV1, PEFR) should be performed on patients (over age 5) with asthma who have come to the ED because of a change in respiratory status. 4. Dyspnea, Moderate: Patients with pneumonia, COPD, URIs, croup may complain of, or appear to be short of breath. As a symptom it is not always

clear how to quantitate it and it may come down to an assessment of vital signs and other accompanying symptoms to decide its likelihood of needing urgent investigation or treatment. Objective measures such as FEV1/PEFR or O2 saturation are helpful, particularly if wheezing is present or they are known to have COPD. 5. Chest pain: Sharp localized pains, worse with deep breathing, cough, movement or palpation not associated with shortness breath or other signs that might suggest significant heart or lung disease. These are usually due to chest wall problems or irritation on one of the linings inside (pleurisy or even pericarditis). If a patient is elderly or has had an AMI or angina, and have this type of pain they should still probably be triaged as level II. No visceral features should be present (see level II chest pain). 6. GI Bleed: Upper or lower GI bleed, not actively bleeding, with normal vital signs. There is always potential for deterioration, so a repeat set of vital signs should be done within 30 minutes or if there is any change in status/symptoms. 7. Vaginal Bleeding and pregnancy: Mild or no pain ( 4/10) and bleeding is not severe, first trimester (LMP 4 weeks and /or previously positive HCG) and normal vital signs. Should be reassessed within 30 minutes. 8. Seizure: Known seizure disorder or new onset but brief (<5 minutes). Alert, breathing normally, protecting airway (normal gag), normal vital signs. 9. Acute psychosis and/or suicidal: Psychiatric problems, not really agitated but some uncertainty as to whether they are threat to themselves or others. Normal vital signs. May be very emotional but not violent and reasonably cooperative. Some bipolars(manic-depressive). Require safe caring environment and some assessment of risk for overdose. 10. Acute pain severe (8-10/10): patients with minor problems but self reported intense pain (8-10/10) should have either nursing intervention (ice, splints..) or a protocol to institute analgesics or early access to verbal physician assessment. Patients with discogenic back pain usually have a very sudden pain while lifting or bending. Radiation of pain to the legs is common. If there is muscle weakness, loss of sensation or unable to urinate/incontinent then more serious neurological problems may be present and urgent physician assessment is necessary. Mechanical back strains/ pains are usually slower in onset or even delayed (hours to 1-2 days). High pain scales (8-10/10) are common and separating acute from chronic back pain often makes these patients challenging with regard to triage assignment. Frequently patients are frustrated and providers often dont know whether potent analgesics are of help. Being judgmental about someones pain can run the risk of missing other important problems and high levels of patient dissatisfaction with their Emergency visit. It is very difficult to assess back pain patients without a stretcher and exposure from

the waist down, the patient should be taken to an area where this can be done. 11. Acute pain moderate (4-7/10): Patients with migraine or renal colic can present with moderate pain but deteriorate rapidly. These patients would probably benefit from earlier intervention. Some moderate non traumatic back discomforts can have potentially serious causes and should have normal vital signs and nursing reassessment if there are delays in physician assessment. Vomiting and or diarrhea: Age 2 years. Dehydration and serious infections can sometimes be subtle in very young children and vital signs may be normal. Dialysis (or transplant patients): Electrolyte and fluid balance problems are common in these patients. This increases the risk for arrhythmias and rapid deterioration.

12.

13.

Level IV

Less Urgent (Semi urgent)

Conditions that related to patient age, distress, or potential for deterioration or complications would benefit from intervention or reassurance within 1-2 hours). Time to physician 1 hour 1. Head Injury: Minor head injury, alert (GCS 15), no vomiting, neck symptoms and normal vital signs. May require brief period of observation, depending on time of injury in relation to ED visit. If time interval from accident >4-6 hours and has remained free of symptoms, a neuro check and head routine sheet may be all that is necessary. The age of the patient and characteristics of the care provider/support at home may also influence the disposition decision or observation period. 2. Minor trauma: Minor fractures, sprains, contusions, abrasions, lacerations, requiring investigation or intervention. Normal vital signs, moderate pain (4-7/10).

3. Abdominal pain: Acute pain of moderate intensity (4-7/10) or in a child in no acute distress. The severity of pain for appendicitis or cholecystitis or other potentially serious problems is not a reliable means of excluding these problems. Vital signs should be normal and the patient should not appear to be in acute distress. Constipation can cause very severe pain or on occasion be confused with other more serious problems. Start by assuming the worst possible, and ensure that there is sufficient clinical or investigative data that allows exclusion of potentially severe but treatable problems. 4. Headache: Not sudden, not severe, not migraine, no associated high-risk features (see level II and III headache). Infectious problems like sinusitis, URI, or Flu like illnesses may cause these. Pain should be no more than moderate (4-7/10) and normal vital signs. 5. Ear ache: Otitis media and externa can cause moderate (4-7/10) to severe (8-10/10) pain and these patients should receive analgesics either as part of nursing protocol/intervention or with a verbal order from the physician. If the patient either has severe pain or is in acute distress (child), the triage level should be III or have orders for analgesics. The provider should use their judgment as to how soon the physician assessment should occur. Determining the cause of ear pain and implementing appropriate treatment or follow up is important. 6. Chest pain: These patients should have no acute distress, pain (4-7/10), no shortness of breath, no visceral features, no previous heart problems, normal vital signs. The pain is usually pleuritic (sharp, worse with deep breath, cough, movement, palpation). These patients may have had a chest wall injury or some strain of the muscles from cough or physical activity. 7. Suicidal/Depressed: Patients complaining of suicidal thoughts or have made gestures but do not seem agitated. Normal vital signs. Because suicidal risk and the possibility of overdose is frequently difficult to accurately define, these patients should have a responsible person staying with them and periodic reassessment should occur. Patients with depression should also be evaluated for their potential for suicide. All providers should show empathy and try to have the patients placed in a quiet and secure area. 8. Corneal Foreign body: If pain is mild or moderate (4-7/10) and no change in visual acuity. 9. Back pain, chronic: These patients may be very challenging and should always be assessed as though their problem has never been seen before. It is usually easy to confirm that the pattern is identical to before and that neurological abnormalities are not present. Occasionally patients may have substance abuse problems and the sole purpose of the visit is to seek a narcotic prescription. It is unwise to label people or be judgmental unless there is clear evidence that you are dealing with substance abuse as opposed to drug addiction and chronic pain syndromes. The triage area is not suited to making this determination and physician assessment is necessary.

URI symptoms: Patients with upper airway congestion, cough, aches, fever, sore throat are frequent visitors to EDs. Unfortunately patients with strep throat, mono, peritonsillar abscess, epiglottitis, pneumonia, or other serious illnesses can not always be identified in routine or quick look assessments. Flu like illnesses with generalized symptoms can be serious for patients who are elderly, have significant health problems, or very young. Because some serious bacterial infections can also have some similarities with what appears to be the flu, these patients may require level III care in some instances. If there are significant respiratory signs or symptoms, perform an O2 saturation and if <95% upgrade triage level. 11. Vomiting and or diarrhea no signs of dehydration (Age >2): The risk of dehydration increases with vomiting and diarrhea together. Most times, simple viral gastroenteritis does not cause any serious problems in healthy adults and most children. Signs of dehydration vary by age. Young children may have behaviour / mental status changes that range from simple fussiness, to being very lethargic or unconscious. Other clues will be found in the vital signs, dry mucous membranes, decreased tears, decreased urine output and skin turgor. The questions in triage should attempt to clearly define the onset and course of the illness with quantification of the episodes of diarrhea and vomiting. Knowing how many times someone had vomited, whether it occurred only when eating or drinking and when the last episode was (exact times are best (not earlier today1000 am). The same is true for diarrhea. If there are less than 5 loose bowel movements per day then dehydration or electrolyte imbalances are unlikely. In older children and adults with >10 bowel movements per day (with or without blood) more serious causes including inflammatory bowel diseases should be considered. Patients with 10 episodes of vomiting in the previous 24 hours and /or > 5 b.m.s per day for 2 or more days should cause consideration of up triage to level II or III depending on the assessment of hydration. It is also important to appreciate that vomiting can be a sign of other problems such as CNS abnormalities, cardiac disease, drug effect, renal failure, hepatic disturbances, diabetes, disorders of pregnancyThese may be identified if they are at least considered. 12. Acute pain-moderate (scale 4-7/10): Moderate pain with minor injuries or MSK problems. 10.

Level V

Non Urgent

Conditions that may be acute but non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration. The investigation or interventions for some of these illnesses or injuries could be delayed or even referred to other areas of the hospital or health care system.

Time to physician 2 hours. 1. Minor trauma: contusions, abrasions, minor lacerations (not requiring closure by any means), overuse syndromes (tendonitis), and sprains. Nursing interventions, splinting, cleansing, immunization status, minor analgesics are all expectations of patients in this category. 2. Sore throat, URI: Patients with minor complaints, not severe and no respiratory symptoms/compromise. Typical viral illnesses, with normal vital signs or low grade fever (<39C). 3. Vaginal bleeding: Can be normal menses or painless bleeding in postmenopausal patients. If pregnancy is excluded and pain is not severe (<4/10), vital signs are normalthese patients can safely have a delay in assessment. 4. Abdominal pain: Mild pain (<4) which is chronic or recurring, with normal vital signs. Some individuals may complain of more severe pain, particularly younger people and be difficult to justify higher triage assignment. It is important to consider the context in which these patients present and take efforts not to be judgmental. Their symptoms may be very challenging and frustrating for the care provider, or patient, neither of whom really want to be in the ED. Extended waiting periods should lead to some reassessment and/or up triaging. 5. Vomiting alone, Diarrhea alone: no signs dehydration and age>2. These patients should have normal mental status and vital signs. 6. Psychiatric: These patients may seem to have minor or insignificant problems from the providers point of view but be frustrated by a lack of availability of other health care options that are community specific. They may also be simply unaware of what other options are available. Having an open mind and being sensitive to socioeconomic and cultural issues will allow the provider the opportunity to evaluate the level care needed and the risk of harm to self or others. Chronic or recurring depression, trouble coping, impulse control normal mental state, without somatic/vegetative findings (appetite, weight, sleep pattern disruption, unexplained crying episodes) and normal vital signs. Some chronic but more serious psychiatric disturbances or behaviour disorders for which there is no evidence of deterioration or changeThis can not usually be fully evaluated in triage. Patients who are hard to group: If a patient seems difficult to assign a triage level because they dont seem to fit any of the categories, the provider needs to either discuss the case with a colleague or make a judgment based on their experience or instinct

Pearl of wisdom: If patients look sick and you are not sure, triage them as Level I or II.

Pediatric Triage assignment

The following descriptions are not all-inclusive but are meant as guides to supplement information contained in the information contained in section 4. Pain scales may not be possible and if pain is believed to be severe the triage decisions should be made as if the rating was 8-10/10 Level I Child/infant in respiratory failure, shock, coma or cardiopulmonary arrest. Any child or infant who requires continuous assessment and intervention to maintain physiological stability. E.g. - coma-seizures, moderate to severe respiratory distress, unconscious, major burns, trauma, significant bleeding and cardio pulmonary arrest. Level II Any physiologically unstable child with moderate to severe respiratory distress, altered level of consciousness, dehydration. Dehydration is difficult to accurately assess. Any suspicion (or evidence) should cause concern. Any child/infant who requires comprehensive assessment and multiple interventions to prevent further deterioration. Fever - age < 3 months > 38.0 C. Temperature is not always a reliable indicator of the severity of illness. The younger patients can have serious problems even though the signs and symptoms may be subtle. E.g. - sepsis, altered level of consciousness, toxic ingestion, asthma, seizure (postictal), DKA, child abuse, purpuric rash (a rash that does not blanch with pressure, like petechiae), fever, open fractures, ingestion/overdose, violent patients, testicular pain, lacerations or orthopedic injuries with neuro vascular compromise, dental injury with avulsed permanent tooth. Level III

Child/infant who is alert, oriented, well hydrated, minor alterations in vital signs. Interventions include assessment and simple procedures. Febrile child > 3 months with a T > 38.5C Mild respiratory distress Infant < 1 month E.g. - Simple burns, fractures, dental injuries, pneumonia without distress, history of seizure, suicide ideation, ingestion requiring observation only, head trauma - alert/vomiting. Level IV Patient with vomiting/diarrhea and no dehydration age>2. Simple lacerations/sprain/strains. Alert child with fever and simple complaints such as ear pain, sore throat or nasal congestion. Head trauma-no symptoms. Level V Child/infant who is afebrile, alert oriented, well hydrated with normal vital signs. Interventions not usually required other than assessment/discharge instruction. Vomiting alone or diarrhea alone with no suspicion or signs of dehydration.

ASSESMENT OF TRAUMA PATIENT BY NURSES

POLICY: i. The trauma patient shall be attended by Emergency Nurses

ii.

As criteria will be used by Emergency Department nurses to perform the EMERGENCY DEPARTMENT PATIENT initial REGISTRATION assessment of a trauma patient:

iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii. xiv. xv. xvi.

Establish and maintain airway Immobilize c-spine Place splint Control bleeding, by pressure Evaluate neurological status Undress patient and assess for other injuries Maintain patient body temperature Take initial vital signs; frequently assess and monitor vital signs. Use warmed solutions if possible for cleaning. Obtain venous blood for lab and type; Band the patient Monitor cardiac rhythm Monitor pulse oximeter Place on oxygen via mask at high flow, unless otherwise indicated Antitetnus injection. xvii. Inform the doctor

POLICY: This hospital is providing emergency medical screening and stabilizing treatment, as necessary, to all individuals coming to the Emergency Department, without delaying, care to inquire about the patient's ability to pay. All critically ill/injured/patients will be evaluated in resuscitation room and be informed to administrator. PROCEDURE:

i.

The receptionist will inform the Triage Nurse if any individual presents with: Chest pain Shortness of breath Severe bleeding Severe trauma Severe pain Penetrating eye injuries Chemical eye injuries Psychiatric

ii. iii.

When a patient arrives at the Emergency registration area and is not eligible and have an emergency condition as stated above, Business center Department Clerk will obtain the following information: Patient name Address Phone number Social security number Date of birth, Chief complaint . The business centre Department Clerk will have the patient/family sign and the iqama copy , Nurse will fill up non Saudi form and business centre person will sign.

iv. Registration area: Computer and printer Direct telephone line (hot line) Wireless telephone line Emergency format Work bench/chair Photocopier Fax and telephone FUNDAMENTAL STANDARDS OF CARE POLICY: Fundamental Emergency Department nursing interventions include, but are not limited to the following: i. Vital signs every 30 minutes on Level I, II, III patients, unless ordered more frequently.

ii. iii. iv.

Vital signs every one to two 1-2 hours on Level IV patients, unless ordered more frequently Vital signs on admission and PRN on Level V patients, unless ordered more frequently Vital signs will be repeated if not within normal limits, as follows: Adult ranges: Temp: 96 to 101 degrees F BP: 100/60 - 140/90 mm/Hg Pulse: 60-100 beats per minute Respirations: 12-24 respirations per/minute.

v. vi.

Postural vital signs will be performed on all patients with potential hypovolemia or dehydration Vital signs will be repeated after administration of medications with potential side effects IV hydration or IV access, if needed Shock prevention.

vii.

Resuscitation Stabilization Basic comfort measures Timely administration of medications Respiratory therapy as needed Pain management Close evaluation Prevention or stabilization of hemorrhage Infection control.

viii.

Fall scale

PATIENT REQUIRING PSYCHIATRIC EVALUATION

POLICY: i. ii. Hospital is a non-psychiatric receiving hospital. Any patient accessing care at this facility who requires psychiatric treatment will be managed through referral and transfer to a psychiatric receiving facility and/or management through consultative psychiatric services on a temporary basis, until the patient's clinical condition has stabilized to allow for psychiatric facility transfer.

iii.

For Patients Accessing the Hospital Through the Emergency Department: The Emergency Department physician will evaluate the patient and determine the need for a psychiatric evaluation.

iv. v. vi. vii. viii. ix. x. xi.

All medical complaints shall be stabilized: Patient must be medically cleared prior to transfer to appropriate psychiatric facility. If the patient is a danger to self, staff or others, security officer will be requested to continually observe the patient. Call Emergency Psychiatric Evaluation Team. Maintain patient safety. Utilize restraints only if patient is a danger to self, staff or others refer to restraint policy. Call local law enforcement agency through Administrator, if there is potential danger If the patient is brought by Police, the patient will be referred immediately to Psychiatric Hospital Buraidah with the consent of on call Psychiatrist or as per his advice or he will come to make referral paper.

ALLEGED ABUSED PEDIATRIC PATIENT

i. ii. iii.

Upon arrival to the Emergency Department, is triaged by the registered nurse level I. If the registered triage nurse suspects or observes signs and symptoms of any injury ,a call shall also be placed to the hospital social worker. Appropriate documentation using elder or child abuse forms will be completed according to state law.

iv.

Documentation in the Nurses' Notes shall include, but is not limited to: a) History of injury if any. b) Any marks, bruises, lacerations or abrasions noted on the assessment c) Description of marks or bruises d) Weight of pediatric patient and patients vital sign. e) A medicolegal report will be written on the request of police docket f) Foot print of child. g) Inform to Pediatric consultant on call. h) Shift the child to NICU.

ROLE OF TRAUMA TEAM

Members of trauma team

1. 2. 3. 4. 5. 6. 7. 8. 9. General/Neuro surgeon Surgical/ortho residents Emergency Medicine physician Emergency Room nurses ICU Physician/ charge nurse Anesthesia consultant/ technician Radiology technologist Respiratory Therapy personnel Emergency room clerical and technical personnel

PURPOSE: To define the number, type, positions and responsibilities of the trauma resuscitation team members in order to facilitate an orderly, complete and cooperative response to the injured patients arrival. POLICY:

ROLES OF TRAUMA TEAM MEMBERS The responsible parties are to know and carry out their duties as defined below. Cooperation, support, and communication among team members is essential to an effective resuscitative effort. PERSON POSITION Emergency Medicine Physician Patients head

RESPONSIBILITIE i. Defining trauma team level; possible need to upgrade level of resuscitation; need for trauma surgeon consultation or announce code yellow. ii. iii. iv. v. vi. vii. viii. Coordination of care (Team Leader) until the attending trauma surgeon arrives Medical staff responsibility for the patient transfers to the attending trauma surgeon after he/she receives report and accepts the patient Gives report to the trauma surgeon or defers report to surgical resident Assesses airway; secures if needed; identifies need for anesthesiology consultation Assesses head, face, neck for injuries Advise X-Rays according to ATLS protocol or as per injuries. Complete the medicolegal requirement as per hospital policy. ED Resuscitation nurses Left side of the patient

PERSON LOCATION

RESPONSIBILITIES i. To help secure airway

ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii.

To check vital signs Take venous blood for Lab(CBC.BIO,Blood grouping and cross matching) Place 18#cannula in both hands Start Ringer Lactate infusion Place pulse oximeter/cardiac monitor Cut the clothes Help ED Physician in pressure bandage or ASD Assist in procedure done by General surgeon Accompany patient during transport to Radiology/inpatient department Complete the nursing notes and get sign for consent from family members. Informs the business centre for non eligible trauma patient.

PERSON LOCATION

Attending General/trauma surgeon Left side of patient

RESPONSIBILITIES i. ii. iii. iv. v. Arrive at the bedside within the time limits set by the trauma team activation policy; Receives report from the EM physician and/or the surgical resident, and assumes responsibility for patient care (Team Leader) Directs and coordinates care among the resuscitation team Identifies consultants as needed and informs the scribe nurse to initiate contact with them Direct or assist surgical residents with procedures;

vi. vii.

Approve release of trauma team members Communicates status of patient to family a. Dictates history and physical examination and any operative or procedure notes

PERSON

General surgical/ ortho resident

LOCATION Right side of patient RESPONSIBILITIES Informs charge nurse /ED Physician on arrival i. ii. iii. iv. v. vi. vii. viii. Obtain EMS report, assess breathing, circulation and carry out interventions as needed; Report findings to scribe and trauma team leader Reassess the General condition of the patient, or direct other personnel to do so; Carry out the general survey of pelvis , prenium, lower extremities, rectum and report findings to Team leader. Employ femoral vein puncture for lab (if no vein in upper extremities) Insert urinary bladder catheter under sterile techniques Ortho resident will do cost or place back slab or splints.

PERSON LOCATION

ICU Nurse Left side of the patient

RESPONSIBILITIES i. ii. Obtain blood pressure , wrist pulse and capillary refill Insert peripheral cannula if could not be placed before

iii. iv.

Administer Narcotics, Paralytics and sedations Cooperate with ED Nurse to prepare medication for continuous infusion

PERSON LOCATION

Respiratory therapist Right side of patients head

RESPONSIBILITIES i. ii. iii. iv. v. vi. vii. viii. ix. x. Confirms administration of oxygen Attaches pulse oximeter probe to left hand Obtains arterial blood gas specimen if not obtained by surgical intern or resident, or if directed by team leader Assists with airway management Secures airway with tape in standard fashion Assists with intubation at direction of emergency medicine physician or anesthesia service; maintains in-line cervical traction; confirms airway placement by auscultation and by use of a CO2 monitor Supplies mechanical ventilator and set up as directed Stay with stable intubated patient until shifted to ordered ward. Radiology Technologist until called in (ask to enter if team seems (distracted) RESPONSIBILITIES Brings a portable x-ray machine to the resuscitation bay with (at a minimum) sufficient film cassettes for three views of the cervical spine, an AP supine CXR and AP supine pelvis. :STANDARD OF CARE-MANAGEMENT OF PATIENT UNDER THE

PERSON LOCATION

INFLUENCE OF DRUGS

POLICY: The patient arriving at the Emergency Department under the influence of drugs will receive the following care: i. ii. Obtain IV access Obtain urine specimen and draw blood to screen for Toxicology and other drugs and call internal medicine team , whose consultant will call poison centre Buraidah , either to send sample urgent or in routine. iii. iv. v. vi. vii. viii. ix. x. xi. Monitor airway and give respiratory support, as necessary Administer intravenous Narcan either as bolus, intramuscular or continuous intravenous infusion drip, Assume other mixed drug intoxications Monitor heart rate on cardiac monitor Monitor respiratory status; administer oxygen, as appropriate Use a cuffed endotracheal tube if the patient is compromised and announce code blue. Lavage with a large-bore Ewald tube or Levin tube with the patient in the left lateral decubitus Trendelenburg position, with the patient's head lowered approximately 15 degrees. Use a tidal wash volume of 150-200 mL in adults and 10 mL per kg in children. Activated charcoal per physician order: Adults: 50 to 100 g Infants younger than one 1 years: 1 g per kg Children one 1 to 12 years old: 1-2 g per kg .

EMERGENCY DRUG LIST

Emergency Drugs List

1. List of narcotics/controlled drugs in locked cabinet. Fentanyl amp 100Mg Morphine amp 10mg Pethidine amp 50, 100mg Valium amp 10mg Dormicum amp 15mg Haldol amp 5mg Phenobarbitone amp 40, 200mg 2. Drugs for crash cart - Atropine amp 1mg - Amiodarone amp 150mg Magnesium sulphate Potassium chloride - Doputamine Adrenaline injection - Adrenaline amp 1 mg Xylocard 1% Calcium chloride amp Dopamine vial Sodium bicarbonate - Atropine inj

4.ED Pharmacy drugs:

GENERIC NAME

UNIT TABLET

TRADE NAME

Paracetamol 500 mg Ibuprofen 400 mg Acetylsalicylic Acid 500 mg Hyoscine N Butyl Bromide 500 mg Chlorpheniramine maleate 4mg Antacid Metoclorpramide 10 mg Isosorbide clinirate sublingual 5 mg Prednisolone 5 mg Prednisolone 20 mg Amoxicillin Trihydrate 250 mg Amoxicillin Trihydrate 500 mg Trimesthoprin + Sulphammethaxazole Erythromycin Stearate 250 mg Nitrofurantion 100 mg Metronidazole 500 mg

Tab

Adol - Fevador Brufen Sapofen Gusprin Aspirin Buscopan Scorpinal Histop Anallerg 4 Moxal Metosil - Primperan Isordil 5 mg Gupison 5 mg Gupison 20 mg Gulphamox 250 mg Gulphamox 500 mg Bactrim Trimole Eromycin 250 mg Colifuran 100 mg Flagyl Flazole

Standrized Seena Pseudo-Ephedrine + Antihistamine Cloxacillin or Fluxacillin 250 mg Nystaatin Vaginal tablet 100,000 Ul

Vag. Tab. SYRUPS

Laxative Laxal Actifed Sedofen Fluxapen Nilstat Mycostation

Amoxicillin as Hydrate 250 mg/5 ml Amoxicillin as Hydrate 15 ml 100/mg/ml Pediatric Erythromycin Ethylsuccinate 200 mg/5ml Trimethoprin + Sulphasmethoxazole Nystatin 100,000 Ul Metronidazole 125 mg/5 ml Acetaminophen 125 mg/5 ml Acetaminophen drops Alluminium Hcl + Magnesium Metoclopramide 5 mg/5 ml Sachets O.R.S. Chlorpheniramine 2 mg/5ml

Susp.

Amoxil susp. Amoxil Ped. drops Erythrocin

Syrup Drops Syrup Sachet Syrup

Bactrim Mycostation Amiorazole Fevadol Paracetamol drops Antacid - Moxal Primperan Histaloc O.R.S. Histop

Dexamethorphan HBR Pseudo-Ephedrin Hcl + Antihistamine Expectorant

Kafosed Actifed Sedofen Exylin Amydarine

3.Drugs available in Fridge - Tetanus toxoid injection - Antirabies vaccine injection - Anti-scorpion serum injection - Adol suppository (paedia & adult) - Glycerine supposotiry - Tetanus antitoxin injection - Anti snake serum injection

PATIENT CARE PROCEDURE

Life-threatening emergencies

I) a. b. c. d. Primary assessment and resuscitation Secondary assessment and emergency treatment Reassessment Definitive care

The aim of the primary assessment is to identify and treat any immediately life-threatening conditions with minimum delay and in a prioritized fashion. Key components of the primary assessment (ABCDE) are assessment and management of: A Airway B Breathing C Circulation D Disability E Exposure
A Airway

Aims = assess patency and identify any imminent threat, e.g. mucosal oedema in anaphylaxis. If necessary, clear and secure the airway = administer high concentrations of inspired oxygen = appreciate the potential for cervical spine injury
B Breathing

Aim

= detect and treat: life-threatening bronchospasm pulmonary oedema tension pneumothorax the presence of critical oxygen desaturation
C Circulation

Aim

= detect and treat shock

D Disability (neurological examination)

Aim = to detect and treat any immediately life-threatening neurological condition (e.g. prolonged fit, hypoglycaemia, opioid overdose, infection or suspected cerebral ischaemia).

The Glasgow Coma Scale Eye Opening Best Verbal Response Best Motor Response

Spontaneous 4

Orientated 5

Obeys commands 6

To speech 3

Confused 4

Localises pain 5

To painful stimuli 2

Inappropriate words 3

Withdraws from pain 4

Nil 1

Incomprehensible sounds 2

Abnormal flexion 3

Nil 1

Abnormal extension 2

Nil 1

E Exposure

Aim

= examine the entire patient and prevent hypothermia

II- Minimum patient monitoring in an acutely unwell patient

a. b. c. d. e. f. g. h. i. j. Pulse oximetry Respiratory rate Blood pressure Continuous ECG monitoring, augmented by a 12-lead ECG Chest X-ray when appropriate Arterial blood gases when appropriate Core temperature Central venous pressure when appropriate Glasgow Coma Score, lateralising signs and pupillary response Urinary output

III.SECONDARY ASSESSMENT A well-phrased history P Problem H History of presenting problem R Relevant medical history A Allergies S Systems review E Essential family and social history D Drugs IV. General A clinical overview of the patients overall appearance from the end of the bed can give clues to underlying pathology Clinical overview a. Posture b. Pigmentation c. Pallor d. Pattern of respiration e. Pronunciation f. Pulsations

V. REASSESSMENT The patients condition should be monitored to detect any changes and assess the effect of treatment. If there is any evidence of deterioration, re-evaluate by returning to A in the primary assessment. Remember to examine the back of the patient either during the primary or secondary assessment VI.DOCUMENTATION Document the findings of the primary and secondary assessments in the ED sheet and fill up all the columns appropriately .The patients records must also contain a management plan, a list of investigations requested and the related results, as well as details of any treatment and its effect. VII.DEFINITIVE CARE Plan This should comprise a list of further investigations and treatment required for the particular patient. This is a dynamic plan that may change according to the clinical condition and test results. It needs to be reviewed regularly and updated. Investigations Tests are not without risks; they should only be done if they directly benefit patient care, it includes CBS BIO CXR (portable) Transport All patients will be transferred sometime during their ED stay either in the ward , or higher centre Transport policy that is central hospital policy is to be followed up.

The patient with breathing difficulties

Acute breathlessness is a common emergency condition Potentially life-threatening causes of breathlessness Respiratory i. _ Asthma ii. _ Acute on chronic respiratory failure

iii. _ Pulmonary edema iv. Simple pneumothorax v. _ Pneumonia vi. _ Pleural effusion vii. _ Pulmonary embolus Non-respiratory i. _ Metabolic acidosis e.g. diabetic ketoacidosis, salicylate overdose ii. _ Pontine haemorrhage Immediately life-threatening causes and signs of breathlessness Airway i. _ Obstruction (see full list in box 1 in Chapter 4) Breathing i. _ Acute severe asthma ii. _ Acute exacerbation of chronic obstructive pulmonary disease (COPD) iii. _ Pulmonary oedema iv. _ Tension pneumothorax v. _ Critical oxygen desaturation Circulation i. _ Acute severe left ventricular failure ii. _ Dysrhythmia iii. _ Hypovolaemia iv. _ Pulmonary embolus (PE) v. _ Cardiac tamponade It is important to remember that the breathless patient does not always have pathology arising primarily from the respiratory or cardiovascular systems
Resuscitation

All patients should receive high concentrations of inspired oxygen, be treated in a seated position (if level of consciousness permits) and have their oxygen saturation, pulse, blood pressure and cardiac rhythm monitored. Intravenous access is necessary and at least one large cannula (1214 gauge) is required. The management of the shocked patient will depend on the underlying cause

Treatment of shock Cause Acute, severe, left ventricular failure Dysrhythmia Tachycardia/ Bradycardia Hypovolaemia Pulmonary embolus

Treatment Inotropes/diuretics Cardioversion, Atropine Inotropes Pacing(in CCU) Fluids Anticoagulation,Thrombolysis,Fluids

Sepsis Anaphylaxis

Fluids,Antibiotics,Inotropes Adrenaline,Fluids,Chlorpheniramine,Hydro cortisone

In the breathless patient, the immediately life-threatening problems are: Airway Obstruction Breathing a. Acute severe asthma b. Acute exacerbation of COPD c. Pulmonary oedema d. Tension pneumothorax e. Critical oxygen desaturation Circulation a. Dysrhythmia b. Hypovolaemia c. Pulmonary embolus d. Cardiac tamponade e. Acute severe left ventricular failure

ASTHMA Follow the Saudi thoracic society guidelines1 to assess and manage adults presenting with asthma. Patients with severe asthma and one or more adverse psychosocial factors (psychiatric illness, alcohol or drug abuse, denial, unemployment) have mortality. Measure the peak expiratory flow rate and compare it against that expected .The peak flow acts as an immediate triage tool: remember that some patients with life-threatening airways obstruction may be too dyspnoeic to register a peak flow. Make an initial assessment of the severity of acute asthma based upon a combination of clinical features, peak flow measurement and pulse oximetry as outlined below.

Acute Status Asthma - Standard of Care

POLICY: 1-The patient arriving at the Emergency Department with acute status asthma will receive the following care: Assure a patent airway. Assist with ventilation, as needed. Recognize the need for potential intubation. Administer oxygen high-flow and medications Establish IV access. Place on pulse oximetry and cardiac monitor. Prepare patient for respiratory breathing treatments, ABGs and medication. Monitor respiratory status continuously. o Documentation shall include, but is not limited to: Initial lung sounds Initial vital signs Skin color; use of accessory muscles Oxygen saturation PROCEDURE o o o o o o o 2 Lab

Arterial blood gas: o Not helpful during the initial evaluation o The decision to intubate should be based on clinical criteria. o Mild-moderate asthma: respiratory alkalosis o Severe airflow obstruction and fatigue: respiratory acidosis Pulse oximetry: o Less than 90% is indicative of severe respiratory distress o Patients with impending respiratory compromise may still maintain saturation above 90% until sudden collapse. WBC: o Leukocytosis is nonspecific o Pneumonia o Chronic steroid use o Stress of an asthma exacerbation o Demargination occurs after administration of epinephrine and steroids

3- Imaging

Chest radiograph: o Indications:

Fever Suspicion of pneumonia Suspicion of pneumothorax or pneumomediastinum Foreign body aspiration First episode of asthma Comorbid illness Diabetes Renal failure AIDS

4.Peak expiratory flow rate: Estimates the degree of airflow obstruction: Normal peak flow in an adult is 400to600 Between 100 and 300 indicates moderate airway obstruction. <100 is indicative of severe airway obstruction. Use serially as an objective measure of the response to therapy Forced expiratory volume (FEV): o More reliable measure of lung function than PEFR o Often unavailable in the ED ECG: o Indicated in patients at risk for cardiac disease: Dysrhythmias Myocardial ischemia
o

5- Corticosteroids:
o o o o o

Administered early Administer intravenously or orally IV Solu-Medrol in the treatment of severe asthma exacerbation Mild-moderate exacerbations may be treated with oral prednisone. Inhaled corticosteroids are currently not recommended as initial therapy.

6.Oxygen:
o

Maintain an oxygen saturation above 90%

5- Agonist

Albuterol: 2.5 mg in 2.5 mL normal saline q20min inhaled (peds: 0.1to mg/kg/dose q20min [minimum dose 1.25 mg]) o Epinephrine: adult: 0.3 mg (1:1,000) SC q0.5hq4.0h three doses (peds: 0.01 mg/kg up to 0.3 mg SC) o Terbutaline: 0.25 mg SC q0.5h two doses (peds: 0.01 mg/kg up to 0.3 mg Anticholinergic agents: o If minimal response to initial -agonist treatment o Severe airflow obstruction o Inhaled anticholinergic agents should be used in conjunction with -agonists. Magnesium sulfate: o No benefit in mild-moderate asthma o Benefit of magnesium remains unclear in severe asthma but can be tried o 2 g IV over 20 minutes
o

5-intubation:
o

o o o

Rapid sequence intubation: Lidocaine to attenuate airway reflexes Etomidate orketamine as an induction agent Succinylcholine should be administered to achieve paralysis. Etomidate: 0.3 mg/kg, or ketamine: 1to5 mg/kg Lidocaine: 1to5 mg/kg Succinylcholine: 1.5 mg/kg A large endotracheal tube >7 mm should be used to facilitate ventilation. May need to mechanically exhale for the patient Permissive hypercapnia

6- Refer the patient to on call medical team for admission or medical tea decscion

ANIMAL BITES-STANDARD OF CARE POLICY: Patients arriving at the Emergency Department with animal bites will receive the following care:

Wound irrigation: o Copious volumes of normal saline irrigation with an 18-gauge plastic catheter tip aimed in the direction of the puncture o Avoid injection of saline through tissue planes due to force of irrigation Debridement: o Remove foreign material, necrotic skin tags, or devitalized tissues o Do not debride puncture wounds o Remove any Escher present so underlying pus may be expressed and irrigated Wound closure: o Closing wounds increases risk of infection and must be balanced with scar formation and effect of leaving wound open to heal secondarily. o Do not suture infected wounds or wounds >24 hours after injury. o Repair of wounds >8 hours: controversial o Close facial wounds (warn patient of high risk of infection). o Infected wounds, those presenting >24 hours after the event, and deep hand wounds should be left open o May approximate the wound edges with Steri-Strips and perform a delayed primary closure Antibiotic indications: o Infected wounds o Cat bites o Hand injuries o Severe wounds with crush injury o Puncture wounds o Full-thickness puncture of hand, face, or lower extremity o Wounds requiring surgical Debridement o Wounds involving joints, tendons, ligaments, or fractures o Immunocompromised patients o Wounds presenting >8 hours after the event Elevate injured extremity.

Tetanus prophylaxis Rabies Immunoprophylaxis

Not required if rabies not known or suspected Rodents (squirrels, hamsters, rats, mice) and rabbits rarely transmit the disease. Skunks, raccoons, bats, and foxes represent the major reservoir for rabies. Recommended in following situations: o Dog or cat in rabies-known area unable to be quarantined for 10 days o Previously healthy dog or cat becomes ill while being quarantined (and awaiting results of rabies fluorescent antibody test) o An ill dog or cat while awaiting rabies test results (to be continued or halted based on results of rabies test) Active immunization: o Human diploid cell vaccine (HDCV): 1 mL IM on days 1, 3, 7, 14, and 28 after exposure Passive immunization: o Human rabies immune globulin (HRIG): 20 IU/kg o Up to one half in area around wound with the rest IM

Cat-Scratch Disease

Analgesics Apply local heat to affected nodes. Avoid lymph node trauma. Disease usually self-limiting Antibiotics controversial, consider if severe disease is present or Immunocompromised victim

Medication (Drugs)

Amoxicillin/clavulanic acid (Augmentin): 500875 mg (peds: 40 mg/kg/24 hr) PO b.i.d. (first line for all three animals) Ampicillin/sulbactam (Unasyn): 1.53.0 g IV q6h Cefoxitin (Mefoxin): 2.0 g IV q8h Cefuroxime axetil (Ceftin): 500 mg PO b.i.d. Clindamycin (Cleocin): 300 mg PO q6h; 900 mg IV q8h Ciprofloxacin (Cipro): 500 mg PO b.i.d.; 400 mg IV q12h Doxycycline (Vibramycin): 100 mg PO b.i.d. Imipenem/cilastatin (Primaxin): 0.51.0 g (peds: 50 mg/kg/24h) IV q6h Piperacillin/tazobactam (Zosyn): 3.375 g IV q6h Ticarcillin/clavulanic acid (Timentin): 3.1 g IV q6h

ANXIET Y
PURPOSE To treat the anxious patient according to guidelines.

PROCEDURE 1- Anxiety disorders are a) b) c) d) e) f) common chronic the cause of considerable distress and disability often unrecognized and untreated If left untreated they are costly to both the individual and society. A range of effective interventions is available to treat anxiety disorders, including g) Medication, psychological therapies and self-help. h) Individuals do get better and remain better. i) Involving individuals in an effective partnership with on call Psychologist, with all decision-making being shared, improves outcomes. 2--Both panic disorder and generalized anxiety disorder, are one subtype of several anxiety disorders, including: generalized anxiety disorder (GAD) Panic disorder (with or without agoraphobia) post traumatic stress disorder

 Obsessive compulsive disorder Specific phobia (e.g. of spiders) Social phobia (social anxiety disorder) Acute stress disorder The anxiety and worry must be accompanied by restlessness being easily fatigued difficulty concentrating irritability muscle tension disturbed sleep 4- Individuals with generalized anxiety disorder may experience the following: muscle tension trembling twitching feeling shaky muscle aches soreness In generalized anxiety disorder, according to somatic symptoms, such as: sweating nausea diarrhea

5-For people who

Present with chest pain at ED services, there appears to be a greater likelihood of the cause being panic disorder if coronary artery disease is not present or the patient is female or relatively young. they should:

 be asked if they are already receiving treatment for panic disorder undergo the minimum investigations necessary to exclude acute physical problems not usually be admitted to a medical or psychiatric bed be referred to primary care for subsequent care, even if assessment has been undertaken in ED. be given appropriate written information about panic attacks and why they are being referred to primary health care unit. be offered appropriate written information about sources .like religious people or social worker .Psychologist. When talking to patients and careers, ED Physician should use everyday, jargon free language and preferably Arabic. If technical terms are used they should be explained to the patient. Where appropriate, all services should provide written material in the language of the patient, and appropriate interpreters should be sought for people whose preferred language is not Arabic. 6-Treatment The following must be taken into account when deciding which medication to offer: the age of the patient previous treatment response risks the likelihood of accidental overdose by the person being treated and by other family members if appropriate the likelihood of deliberate self-harm, by overdose or otherwise tolerability the preference of the person being treated Sedating antihistamines or antipsychotics should not be given for the treatment of panic disorder. Inj Valium 5mg slowly can be given if it is very necessary The Psychiatrist must be called upon

ARTERIALPUNCTU RE

POLICY:

Emergency Department RNs may perform arterial puncture to obtain a blood sample for ABGs. The radial artery shall be used for arterial punctures.

PROCEDURE: The nurse will: Obtain supplies: a) ABG glass syringe Container with ice, b) Patient label Clinical Laboratory requisition (multipurpose form) c) Wash hands, put on gloves. Identify the patient using two 2 patient identifiers. d) Explain the procedure to the patient. Palpate radial pulse. e) Perform Allen test to check for collateral circulation. Prep puncture site the alcohol swab. f) Set syringe plunger to 0.5 mL for ABGs. Insert needle into the artery for a minimum of five 5 minutes. g) Apply pressure dressing. Do not constrict blood flow to the wrist. h) Remove needle. i) Apply syringe cap. j) Roll the syringe between your hands to mix the blood and heparin in the syringe. Ensure there are no air bubbles in the syringe. k) Label syringe with patient information. Place the syringe in a container of ice. Immediately send the blood sample to the Clinical Laboratory. l) Assess puncture site for hematoma. Assess the distal pulse and capillary refill BLOOD TRANSFUSION PRECAUTIONS FOR TRAUMA PATIENTS

PURPOSE To have blood transfusion during code yellow or disaster. POLICY: a) It is the policy of ED to have a uniform method of transfusing blood products. b) The blood transfusion information pamphlet shall be signed by the Attendant. c) A consent form shall be signed prior to blood transfusion. d) Exception: RNs may administer blood transfusions, per physician's order. e) Type and cross match must be performed prior to the administration of blood. RN must be IV therapy certified.

f) Transfusion Reactions policy If reaction occurs, stop the transfusion immediately! Remove the unit of blood. g) Change the IV tubing down to the peripheral IV site. h) Start Normal Saline and call physician immediately. i) Report recent vital signs and symptoms observed. j) Obtain urine specimen. k) Send the blood bag and all tubing to the Blood Bank. l) Record all events in the patient's medical record m) All transfusion reactions must be treated as serious in nature until proven otherwise. The proper procedure must be followed and a transfusion reaction form completed when indicated. Notification of the physician must take place for the following types of transfusion reactions: Type Cause Signs and Symptoms Hemolytic.

BURN
PURPOSE That a burn patient is properly managed according to international guidelines 1. Guidelines for burn and scalds

Take care to avoid personal injury by checking the area is safe and that Assess airway, breathing, circulation, and coexisting injuries; deal with problems which require more urgent treatment than the burn. Offer immediate first aid. Assess the type, depth, and extent of the burn.

Assess the person for coexisting medical conditions, predisposing factors, the possibility of non-accidental injury, and social circumstances. Identify whether referral is required, or whether the person can be safely managed in Emergency treatment room otherwise shift to resuscitation room. A thorough assessment of a person with a burn should then take into account:
o o o o

The type of burn (e.g. flame, scald, electrical, or chemical). The depth and extent of the burn, and therefore the severity. The risk of inhalation injury (singed nasal hair, black carbon in the sputum, or carbon in the oropharynx). Any coexisting medical conditions (e.g. cardiac, respiratory, or hepatic disease; diabetes; pregnancy; or immunocompromised state). Any predisposing factors which may require further investigation or treatment (e.g. a burn resulting from a fit or faint). The possibility of non-accidental injury. The person's social circumstances (e.g. ability to self-care or need for admission). The need for referral.

o o o o

Using the Rule of Nines, the extent of the burn, in terms of total body surface area in adults, can be calculated from the area affected [Herndon, 1996]:
o o o o o o

Arm 9% Head 9% Neck 1% Leg 18% Anterior trunk 18% Posterior trunk 18%

2- Managing superficial dermal burns o Clean the burn.

o Where possible, leave blisters intact. Consider aspirating blisters that are large or in an awkward position. o Cover the wound with a dressing (do not apply creams or ointments to the burn). o Offer pain relief. o Assess the need for tetanus prophylaxis. o Do not prescribe systemic or topical prophylactic antibiotics. o Refer to on call surgery team o Clean the wound with sodium chloride 0.9% or lukewarm tap water. o Gently remove any remaining loose/dead tissue using forceps. o Leave blisters intact wherever possible, to reduce the risk of infection. o Consider aspirating large blisters and blisters that are likely to burst or compromise function due to their location. Use an aseptic technique. o Seek specialist advice regarding the management of any blister that lasts longer than 2 weeks o Cover the burn with a non-adherent dressing. Apply a non-fibrous secondary absorbent dressing such as a dressing pad, and secure well with a light-weight conforming (cotton kling-type) bandage or a tubular gauze bandage.

3.Pain relief
o Ensure the wound is appropriately dressed. o Pain relief with paracetamol or ibuprofen is usually adequate. o Consider adding inj.Pethedine 75mg I/V for more severe pain

CARDIOPULMONARY RESUSCITATION

PURPOSE To perform CPR according to AHA guidelines updated in 2010. CAB (Compression, airway and breathing) PROCEDURE 1 Ensure personal safety. 2 Check the patient for a response. When a Emergency Physician receives a collapse patient, or finds a patient apparently unconscious in a clinical area, he should first shout for code blue, then assess if the patient is responsive by gently shaking his shoulders and asking loudly, Are you all right? If other members of staff are nearby it will be possible to undertake actions simultaneously. and try to shift the patient in resuscitation room if crash cart is not available nearby. If the patient responds: Urgent medical assessment is required. (e.g. medical emergency team (MET)). That includes 1-ED Supervisor 2-Resuscitation nurses 3-consultant medicine on call 4-specialist medicine on call 5-Resident on call 6-ICU team 7-Anesthetist 8-x-rays Technician 9-ECG Technician

10-Social worker/Administrator Start compression and other staff nurse will . Give the patient oxygen. Attach monitoring leads. Obtain venous access. Team must reach with in 3 minutes of announcement of code blue(3) times by central telephone exchange Those experienced in clinical assessment may wish to assess the carotid pulse for not more than 10 sec. This may be performed simultaneously with checking for breathing or after the breathing. The exact sequence will depend on the training of staff and their experience in assessment of breathing and circulation. Agonal breathing (occasional gasps, slow, laboured, or noisy breathing) is common in the early stages of cardiac arrest - it is a sign of cardiac arrest and should not be mistaken for a sign of life If there is no pulse or other signs of life: ED Physician should start CPR as others call the resuscitation team and collect the resuscitation equipment and a defibrillator. If only one member of staff is present, this will mean leaving the patient. ED Physican will maintain definite airway provided he is skilled and certified for ACLS. Apply the electrodes to the patient and for defibrillation that is present on the crash cart or separately available in resuscitation room. Analyze the rhythm. The use of adhesive electrode pads or the quicklook paddles technique will enable rapid assessment of heart rhythm compared with attaching ECG electrodes. Do not pause compression to assess the pulse or heart rhythm. Minimise interruptions to chest compression. Continue resuscitation until the resuscitation team arrives or the patient shows signs of life

 Once resuscitation is underway, and if there are sufficient people available, prepare intravenous cannulae and drugs likely to be used by the resuscitation team (e.g. adrenaline). Identify one person to be responsible for handover to the resuscitation team leader. Locate the patients records. Change the person providing chest compression about every 2 min to prevent fatigue. If the patient is not breathing but has a pulse (respiratory arrest): Ventilate the patients lungs (as described above) and check for a pulse every 10 breaths (about every minute). Only those confident in assessing breathing and a pulse will be able to make this diagnosis. If there are any doubts about the presence of a pulse, start chest compression and continue until more experienced help arrivives Paediatric Advanced Life Support Introduction There is concern that resuscitation from cardiac arrest is not performed as well as it might because the variations in guidelines for different age groups cause confusion to providers, and therefore poor performance. Most of the changes in paediatric guidelines for 2005 have been made for simplification and to minimize differences between adult and paediatric protocols. It is hoped that this will assist teaching and retention. The guidelines have not, however, been simplified in the face of contradictory evidence or against an understanding of pathophysiology. There remains a paucity of good quality evidence on which to base the resuscitation of infants and children. Most conclusions have had to be drawn from extrapolated adult studies and from experimental work. Guideline Changes Where possible, give drugs intravascularly (intravenous or intraosseous), rather than by the tracheal route. Either uncuffed or cuffed tracheal tubes may be used in infants and children in the hospital setting.

 One defibrillating shock, rather than three stacked shocks, is recommended for ventricular fibrillation/pulseless ventricular tachycardia (VF/VT). When using a manual defibrillator, the shock energy for children is 4 J kg-1 for all shocks. A standard AED can be used in children over 8 years. Purpose-made paediatric pads, or programs which attenuate the energy output of an AED, are recommended for children between 1 and 8 years. If no such system or manually adjustable machine is available, an unmodified adult AED may be used for children older than 1 year. There is insufficient evidence to support a recommendation for or against the use of AEDs in children less than 1 year. The dose of adrenaline (epinephrine) during cardiac arrest is 10 microgram kg-1 on each occasion Sequence of Actions 1 Establish basic life support. 2 start chest compression Oxygenate, ventilate, and Provide positive-pressure ventilation with high-concentration inspired oxygen. Provide ventilation initially by bag and mask. Ensure a patent airway by using an airway manoeuvre as described in the paediatric basic life support section. As soon as is feasible, an experienced operator should intubate the child. This will both control the airway and enable chest compression to be given continuously, thus improving coronary perfusion pressure. Take care to ensure that ventilation remains effective when continuous chest compressions are started. Use a compression rate of 100 min-1. Once the child has been intubated and compressions are uninterrupted, use a ventilation rate of approximately 10 min-1. 3 Attach a defibrillator or monitor:

 Assess and monitor the cardiac rhythm. If using a defibrillator, place one defibrillator pad or paddle on the chest wall just below the right clavicle, and one in the left anterior axillary line. Pads or paddles for children should be 8 - 12 cm in size, and 4.5 cm for infants. In infants and small children it may be best to apply the pads or paddles to the front and back of the chest. Place monitoring electrodes in the conventional chest positions. 4 Assess rhythm and check for signs of a circulation (signs of life): Look for signs of a circulation, which include responsiveness, coughing, and normal breathing. Check the pulse if trained to do so: o Child feel for the carotid pulse in the neck. o Infant feel for the brachial pulse on the inner aspect of the upper arm. Take no more than 10 sec for the pulse check. Assess the rhythm on the monitor: o Non-shockable (asystole or pulseless electrical activity) OR o Shockable (VF/VT). A Non-shockable (asystole or pulseless electrical activity): This is the more common finding in children. Perform continuous CPR: o Continue to ventilate with high-concentration oxygen. o If ventilating with bag-mask give 15 chest compressions to 2 ventilations for all ages. o If the patient is intubated, chest compressions can be continuous as long as this does not interfere with satisfactory ventilation.

o Use a compression rate of 100 min-1. o Once the child has been intubated and compressions are uninterrupted use a ventilation rate of approximately 10 min-1. Note: Once there is return of spontaneous circulation (ROSC) the ventilation rate should be 12 - 20 min-1. Measure exhaled CO2 to ensure correct tracheal tube placement. Give adrenaline: o If venous or intraosseous (IO) access has been established, give adrenaline 10 microgram kg-1 (0.1 ml kg-1 of 1 in 10,000 solution). o If there is no circulatory access, attempt to obtain IO access. o If circulatory access is not present, and cannot be quickly obtained, but the patient has a tracheal tube in place, consider giving adrenaline 100 microgram kg-1 via the tracheal tube (1 ml kg-1 of 1 in 10,000 or 0.1 ml kg-1 of 1 in 1,000 solution). This is the least satisfactory route (see routes of drug administration).

Continue CPR. Repeat the cycle: o Give adrenaline 10 microgram kg-1 every 3 to 5 min, (i.e. every other loop), while continuing to maintain effective chest compression and ventilation without interruption. Unless there are exceptional circumstances, the dose should be 10 microgram kg-1 again for this and subsequent doses. o Once the airway is protected by tracheal intubation, continue chest compression without pausing for ventilation. Provide ventilation at a rate of 10 min-1 and compression at 100 min-1. o When circulation is restored, ventilate the child at a rate of 12 - 20 breaths min-1 to achieve a normal pCO2, and monitor exhaled CO2. Consider and correct reversible causes: o Hypoxia

o Hypovolaemia o Hyper/hypokalaemia (electrolyte disturbances) o Hypothermia o Tension pneumothorax o Tamponade o Toxic/therapeutic disturbance o Thromboembolism Consider the use of other medications such as alkalising agents. 5 B Shockable (VF/VT) This is less common in paediatric practice but likely when there has been a witnessed and sudden collapse. It is commoner in the intensive care unit and cardiac ward. Defibrillate the heart: o Give 1 shock of 4 J kg-1 if using a manual defibrillator. o If using an AED for a child of 1-8 years, deliver a paediatric attenuated adult shock energy. o If using an AED for a child over 8 years, use the adult shock energy. Resume CPR: o Without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression. Continue CPR for 2 min. Pause briefly to check the monitor: o If still VF/VT, give a second shock at 4 J kg-1 if using a manual defibrillator, OR the adult shock energy for a child over 8 years using an AED, OR a paediatric-attenuated adult shock energy for a child between 1 year and 8 years. Resume CPR immediately after the second shock.

 Pause briefly to check the monitor: o If still VF/VT: Give adrenaline 10 microgram kg-1 followed immediately by a (3rd) shock. Resume CPR immediately and continue for 2 min. Pause briefly to check the monitor. o If still VF/VT: Give an intravenous bolus of amiodarone 5 mg kg-1 and an immediate further (4th) shock. Continue giving shocks every 2 min, minimising the breaks in chest compression as much as possible. Give adrenaline immediately before every other shock (i.e. every 3-5 min) until return of spontaneous circulation (ROSC). Note: After each 2 min of uninterrupted CPR, pause briefly to assess the rhythm. o If still VF/VT: Continue CPR with the shockable (VF/VT) sequence. o If asystole: Continue CPR and switch to the non-shockable (asystole or pulseless electrical activity) sequence as above. o If organised electrical activity is seen, check for a pulse: If there is ROSC, continue post-resuscitation care. If there is no pulse, and there are no other signs of a circulation, give adrenaline 10 microgram kg-1 and continue CPR as for the non-shockable sequence as above. Important note

Uninterrupted, good-quality CPR is vital. Chest compression and ventilation should be interrupted only for defibrillation. Chest compression is tiring for providers. The team leader should continuously assess and feed back on the quality of the compressions, and change the providers every 2 min. Explanatory notes Routes of drug administration Studies in children and adults have shown that atropine, adrenaline, naloxone, lidocaine, and vasopressin are absorbed via the trachea, albeit resulting in lower blood concentrations than the same dose given intravascularly. However, experimental studies suggest that the lower adrenaline concentrations achieved in this way may produce transient beta-adrenergic effects. These effects can be detrimental, causing hypotension and lower coronary artery perfusion pressure, thereby reducing the likelihood of return of spontaneous circulation.1 On the other hand, prospective, randomised trials in adults and children show that intraosseous access is safe and effective; practice indicates that this route is increasingly being used successfully. Tracheal tubes Several studies2, 3 have shown no greater risk of complications for children less than 8 years when cuffed tracheal tubes rather than uncuffed tubes are used in the operating room and intensive care unit. Cuffed tracheal tubes are as safe as uncuffed tubes for infants (except newborns) and children if rescuers use the correct tube size and cuff inflation pressure, and verify tube position. Under certain circumstances (e.g. poor lung compliance, high airway resistance, and large glottic air leak) cuffed tracheal tubes may be preferable. Therefore, either uncuffed or cuffed tracheal tubes may be used in infants and children, but only in the hospital setting. For defibrillating infants. Dose of adrenaline In paediatric studies9,10, no improvement in survival rates, and a trend towards worse neurological outcomes, have been shown after the administration of highdose adrenaline during cardiac arrest. Children in

cardiac arrest should, therefore, be given adrenaline 10 microgram kg-1 for the first and subsequent IV doses. Routine use of high-dose IV adrenaline (100 microgram kg-1) is not recommended and may be harmful, particularly in asphyxial arrests. High-dose adrenaline should be considered only in exceptional circumstances, for example after beta-blocker overdose.

DRUGS USED IN CPR Amiodarone Amoiodarone is a membrane-stabilising anti-arrhythmic drug that increases the duration of the action potential and refractory period in atrial and ventricular myocardium. An initial IV dose of amiodarone 5 mg kg-1, diluted in 5% dextrose, should be considered if VF or pulseless VT persists after a third shock. Amiodarone can cause thrombophlebitis when injected into a peripheral vein: use a central vein if a central venous catheter is in situ; if not, use a large peripheral vein and a generous flush of dextrose or saline. Lidocaine Until the publication of Guidelines 2000, lidocaine was the anti-arrhythmic drug of choice. Comparative studies with amiodarone have displaced it from this position and lidocaine is now recommended only for use when amiodarone is unavailable. Atropine When bradycardia is unresponsive to improved ventilation and circulatory support, atropine may be used. The dose of atropine is 20 microgram kg-1, with a maximum dose of 600 microgram, and a minimum dose of 100 microgram to avoid a paradoxical effect at low doses. Magnesium This is a major intracellular cation and serves as a cofactor in a number of enzymatic reactions. Magnesium treatment is indicated in children with documented hypomagnesemia or with polymorphic VT (torsade de pointes), regardless of cause.

Give magnesium sulphate by intravascular infusion over several minutes, at a dose of 25 - 50 mg kg-1 (to a maximum of 2 g). Calcium Calcium plays a vital role in the cellular mechanisms underlying myocardial contraction, but there are very few data supporting any beneficial action of therapeutic calcium following most cases of cardiac arrest. The dose of calcium chloride is 0.2 ml kg-1 of the 10% solution.. Sodium bicarbonate Cardiac arrest results in combined respiratory and metabolic acidosis, caused by cessation of pulmonary gas exchange, and the development of anaerobic cellular metabolism respectively. The best treatment for acidaemia in cardiac arrest is a combination of chest compression and ventilation. Furthermore, giving bicarbonate causes generation of carbon dioxide which diffuses rapidly into the cells. This has the following effects: It exacerbates intracellular acidosis. It produces a negative inotropic effect on ischaemic myocardium. It presents a large, osmotically active, sodium load to an already compromised circulation and brain. It produces a shift to the left in the oxygen dissociation curve further inhibiting release of oxygen to the tissues. The routine use of sodium bicarbonate in cardiac arrest is not recommended. It may be considered in prolonged arrest, and it has a specific role in hyperkalaemia and the arrhythmias associated with tricyclic antidepressant overdose. The dose is 1-2 ml kg-1 of the 8.4% solution given by the IV or IO routes. Therapeutic hypothermia Mild hypothermia is thought to suppress many of the chemical reactions associated with reperfusion injury. Two randomised clinical trials showed improved outcome in adults remaining comatose after initial resuscitation from out-of-hospital VF cardiac arrest. There are insufficient data for a firm Recommendation for children.

Current guidance is that post-arrest infants and children with core temperatures less than 37.5C should not be actively rewarmed, unless the core temperature is less than 33C when they should be rewarmed to 34C. Parental Presence Many parents would like to be present during a resuscitation attempt; they can see that everything possible is being done for their child. Reports show that being at the side of the child is comforting to the parents or carers, and helps them to gain a realistic view of attempted resuscitation and death. Families who have been present in the resuscitation room show less anxiety and depression several months after the death.

C-SPINE IMMOBILIZATION

POLICY: Standard application of manual in-line cervical traction/c-spine immobilization is used on a potential c-spine injury arriving to the Emergency Department by private transportation. Indication for Manual Cervical Traction: Suspected or known c-spine injury: Traffic collision Falls Assault to head or neck Change in LOC with unknown mechanism of injury action Steps for Manual Traction: Apply cervical neck collar. Rescuer moves to the top of the patient's head. Reassures patient verbally. Axial stabilization is maintained by staff member placing his/her hands on either side C-spine Immobilization: Logroll patient, utilizing three 3 or more staff members, onto long back board to maintain manual traction and alignment. Cervical Collars: Hold cervical collar Aspen or Newport collar, following directions on collar: Select size: adult or pediatric Apply front panel first, then

center back panel with the occipital support strap at the top, apply side closure straps evenly on both sides, then squeeze the back panel and tighten the occipital support strap.,

CHEST PAIN (MI)

POLICY:

A patient who arrives at the Emergency Department with chest pain or myocardial infarction will receive the following care: Initial Stabilization

IV access Oxygen Cardiac monitoring Oxygen saturation Continuous BP monitoring and pulse oximetry

MANAGEMENT STEMI King Saud Hospital have adopted a international standard policy for the management of ST elevation myocardial infarction Objective Number of eligible (STEMI) patients with heart attacks who need percutaneous intervention (PCI) within 90 minutes of hospital arrival Guidelines

King Saud Emergency Department follows the guidelines in the American College of Cardiology/American Heart Association Guidelines for the Management of Patients with (STElevation) Myocardial Infarction. The time-to-treatment recommendations in these Guidelines start with when the patient presents to the medical system. The Guidelines recommend 90 minutes (from medical system contact) to treatment with PCI Medical system All patients who reach in the emergency department either by ambulance/transferred from PHC/private clinic or themselves having acute myocardial Infarction with associated ECG changes should be identified immediately and sent to PSCC Buraidah. On Call cardiologist is responsible to include or exclude STEMI patient for transfer
Hospital Personnel

1. On call Cardiologist 2. ED Supervisor 3. Triage Nurse 4. Resusitation room nurse 5. Charge nurse 6. Nursing Supervisor 7. Duty administrator or Social worker 8. Tranportaion department

5. Performance Improvement Program for PCI referral cases. i. ii. Meetings to be held on a quarterly basis initially Memebrs of committee will be Chief of Emergency Department Head of CCU

ED quality improve team

6. Data Collection, Submission and Analysis

Head nurse will collect data for a. Number of patients referred b. Time of arrival and transfer to PSCC. c. Time of arrival ofcardilogist and response from PSCC d. Complications during management and transfer. 7. Triage Patient with chest pain that is Retrosternal, radiating to arm with sweating or shortness of breath (age over 30 years) will be shifted to resuscitation room by triage nurse

CARDIOGENIC SHOCK

PURPOSE To have guidelines to treat patients with cardiogenic shock in ED PUROCEDURE

Inadequate tissue perfusion due to cardiac dysfunction Underlying mechanisms in acute myocardial infarction (AMI): o Pump failure: A 40% left ventricle (LV) infarct Infarct in pre-existing LV dysfunction Reinfarction o Mechanical complications: Acute mitral regurgitation

Ventricular septal defect LV rupture Pericardial tamponade o Right ventricular (RV) infarction 6-7% of patients with AMI develop cardiogenic shock Cutting-edge: o Role of a systemic inflammatory response in the pathophysiology of cardiogenic shock o Recent evidence suggests that nitric oxide synthase inhibition may reduce mortality.

Signs and Symptoms

ABCs and vital signs: o Patent airway (early) o Labored breathing and tachypnea (early); respiratory failure (late) o Diffuse crackles or wheezing o Hypoxia o Hypotension: Systolic blood pressure <90 mm Hg Decline by at least 30 mm Hg below baseline level o Tachycardia o Weak pulses General: o Cyanosis o Pallor o Diaphoresis o Dulled sensorium o Decrease in body temperature o Urine flow of less than 20 mL/h Neck: o Jugular venous distention Cardiac: o Ischemic chest pain o Systolic apical blowing murmur o Gallop rhythm: S3 reflects severe myocardial dysfunction S4 is present in 80% patients in sinus rhythm with AMI o Systolic click: Suggests rupture of the chordae tendinae Abdominal: o Epigastric pain o Nausea and vomiting Neurologic: o Obtundation

Tests Electrocardiogram

Normal ECG does not rule out AMI. Findings of AMI (ST-elevations in two or more contiguous leads) May occur in non-ST-elevation acute coronary syndrome Dysrhythmias LV hypertrophy

Chest Radiography Lab B-type natriuretic peptide (BNP Diagnostic and prognostic value Creatine kinase (CK), CK-Mb, troponin Electrolytes and renal function Acute renal failure is a strong predictor of mortality CBC: Identify anemia or elevated WBC

Initial Stabilization

ABCs Two large bore peripheral IV lines Cardiac monitor Endotracheal intubation If airway is compromise(announce code blue) Consider etomidate for induction (minimal effect on blood pressure) Fluid challenge (100-250 mL normal saline) in absence of pulmonary congestion Foley catheter to monitor urine output

Medication (Drugs)

Dobutamine: 3-5g/kg/min, titrate to 20-50 g/kg/min as needed IV Dopamine: 3-5g/kg/min, titrate to 20-50 g/kg/min as needed IV Furosemide: 40-80 mg/d (peds: 1 mg/kg IV or IM, not to exceed 6 mg/kg) IV or IM Milrinone: 50 g/kg loading dose, 0.37-0.75 g/kg/min continuous infusion IV Nitroglycerin: 10-20 g/min (pedis: 0.1-1 g/kg/min) IV Norepinephrine: 2 g/min, titrate up as needed IV

Nitroprusside: 0.3 g/kg/min, titrate to a max. of 10 g/kg/min IV

Admission Criteria All patients in carcinogenic shock require admission to a critical care unit

CHRONIC HEART FAILURE

Guideline
This guideline offers best practice advice to ED Physician on the care of adult patients (aged 18 years or older) who have symptoms or a diagnosis of chronic heart failure. It aims to define the most effective combination of symptoms, signs and investigations required to establish a diagnosis of heart failure, DIAGNOSTIC RECOMMENDATIONS 1. Take a careful and detailed history, and perform a clinical examination. These should combined with tests to confirm the presence of heart failure and make a complete diagnosis. 2. ED Physician should seek to exclude a diagnosis of heart failure through the 3. following investigations: 12 lead ECG Attached cardiac monitor Pulse oximeter 4. If one or both are abnormal a diagnosis of heart failure cannot be excluded and 5. Efforts should be made to exclude other disorders that may present in a similar manner. 6. To evaluate possible aggravating factors and/or alternative diagnoses the following tests are recommended: chest X-ray

blood tests: biochemical profile including electrolytes, urea and creatinine full blood count thyroid function tests must be sent by internal medicine team liver function tests lipids profile

Random glucose and/or Natriuretic peptides if available. urinalysis peak flow or spirometry.

7. Doppler 2D echocardiographic examination It should be performed by internal medicine team in ED to exclude important valve disease, assess the systolic (and diastolic) function of the(left) ventricle, and detect intracardiac shunts Pharmacological treatment i. ii. iii. Oxygen Diuretic is first line therapy when a patient presents with acute pulmonary oedema Inj.Furosemide (or its equivalent) administered as an IV bolus, to a maximum of 180 mg. If target urine outputs are not met, the diuretic dose is doubled and repeated at 2 hours.Adequate output should exceed 500 cc within 2 hours, unless the creatinine is _2.5 mg/Dl Aggressive fluid management monitoring, Oral or IV potassium supplementation is given to maintain a K of 4.0 to 5.0 mEq/dL. If K is 3.9 mEq/dL, give 20 mEq potassium PO 1 dose. If K is 3.2 mEq/dL, give 20 mEq potassium IV and 40 mEq PO 1 dose. Give magnesium if the creatinine is less than 1.5 mg/dL; Magnesium may be given 140 mg magnesium oxide PO 1 dose or I/V in normal saline in 35 minutes in micro burette. Add Digoxin If a patient in sinus rhythm remains symptomatic despite therapy with a diuretic, All patients with symptomatic heart failure and evidence of impaired left ventricular function should be treated with an ACE inhibitor. Patients with recent myocardial infarction and evidence of left ventricular dysfunction should be treated with an ACE inhibitor. Beta blockers prolong life in heart failure patients, but are only indicated if the patient is hemodynamically stable They should not be started in decompensated or congested heart failure. If inotropes are required, the Beta blocker may be withheld.

iv.

v. vi. vii.

viii.

Drugs to be avoided or used with caution in heart failure i. Patients with heart failure may have significant renal (and hepatic) impairment. Drugs cleared predominantly by the kidney (and liver) can accumulate in these patients causing drug-related toxicity these include drugs used to treat heart failure itself, such as ACE inhibitors and digoxin. Calcium channel blockers (CCBs) are not routinely recommended in heart failure. Short term use may result in pulmonary edema and cardiogenic shock; long term, they may increase the risk of worsening heart failure and death. Non steroidal anti inflammatory drugs (NSAIDs) may exacerbate oedema and renal impairment in patients with HF and should be used with caution this applies to both nonselective agents as well as the newer COX-2 selective agents. Oral and intravenous steroids may also exacerbate oedema. Non-prescription drugs (such as herbal remedies) can have important interactions with the prescription drugs taken by patients with heart failure, can affect the blood levels of both warfarin and digoxin Drugs with a negative inotropic effect should also be avoided such as verapamil, diltiazem, and Class I anti-arrhythmic drugs

ii.

iii. iv. v.

Criteria to discharge Patient from ED If normally ambulatory, able to do so without significant orthostasis. a. Resting HR is or more than100 beats/min systolic BP 80 mm Hg. b. Total urine output 1 L, and urine output _30 cc/hr c. Room air oxygen saturation 90% (unless on home oxygen). d. No ischemic-type chest pain. e. No ECG or cardiac marker evidence of myocardial ischemia/infarction. f. No new clinically significant arrhythmia. g. Normal electrolyte profile without increasing azotemia.

CHEMICAL SUBSTANCE INGESTION PURPOSE To manage the alkali and acid ingestion incidentally or intentionally Chemical substance Alkalis

Dissociate in the presence of H2O to produce hydroxy (OH-) ions, which leads to liquefaction necrosis Post-ingestion mainly damages the esophagus: o Gastric damage can occur (see acids). Esophageal damage (in the order of increasing damage) consists of: o Superficial hyperemia o Mucosal edema o Superficial blisters o Exudative ulcerations o Full-thickness necrosis o Perforation o Fibrosis with resulting esophageal strictures Do not directly produce systemic complications

Acids

Dissociate in the presence of H2O to produce hydrogen (H+) ions, which leads to a coagulation necrosis with Escher formation Post-ingestion damages the stomach because of rapid transit time through esophagus: o Esophageal damage can occur (see alkalis). Gastric damage (in the order of increasing damage) consists of: o Edema o Inflammation

Immediate or delayed hemorrhage Full-thickness necrosis Perforation Fibrosis with resulting gastric outlet obstruction Well-absorbed and can cause hemolysis of RBCs and a systemic metabolic acidosis
o o o o

Etiology

Direct chemical injuries Injuries occur secondary to acid and alkali exposures. Many caustic agents (acids and alkalis) are found in common household and industrial products. Caustic substances: o Ammonia hydroxide: Glass cleaners o Formaldehyde: Embalming agent o Hydrochloric acid: Toilet bowel cleaners o Hydrofluoric acid: Glass etching industry Microchip industry Rust removers o Iodine: Antiseptics o Phenol: Antiseptics o Sodium hydroxide: Drain cleaners Drain openers Oven cleaners o Sodium borates, carbonates, phosphates, and silicates: Detergents Dishwasher preparations Sodium hypochlorite Bleaches o Sulfuric acid:

Tests
Lab

CBC Electrolytes, BUN, creatinine, glucose Arterial blood gas

Blood cultures: o If mediastinitis or peritonitis suspected Type and cross-match. Imaging

Chest and abdominal radiographs for:

Esophageal or gastric perforation Initial Stabilization

ED Treatment

Airway, breathing, circulation (ABCs): o Prophylactic intubation if there is any evidence of respiratory compromise o Blind nasotracheal intubation contraindicated Treat hypotension with 0.9% normal saline (NS) IV fluid resuscitation. Decontamination: o Dermal or ocular exposure: Immediate and thorough irrigation with water or 0.9% NS until physiologic pH attained Alkalis typically require more irrigation than acids. o Ipecac, activated charcoal, gastroesophageal lavage, and a neutralizing acid or base are all contraindicated with caustic ingestions. Dilution: o Water or milk in the first 30 minutes of ingestion: Especially useful for solid caustic alkali ingestions Excessive intake may induce vomiting and worsen esophageal damage. o If respiratory distress, intubate before dilution.(announce code blue) o Contraindicated if esophageal or gastric perforation suspected Keep patient NPO (nothing by mouth) if oral exposure. Broad-spectrum antibiotics if mediastinitis or peritonitis suspected Antiemetics for nausea and vomiting Treat dermal exposures according to standard burn recommendations. Detailed examination for ocular exposures Intravenous H2 blockers for symptomatic relief Gastroenterology and surgical consultation Benefit of corticosteroids following esophageal damage is controversial: o May prevent the formation of esophageal stricture o May promote bacterial invasion, immune suppression, and tissue softening o The decision to initiate corticosteroids requires input from entire team caring for patient.

o o o

Initiate broad-spectrum antibiotics if corticosteroids are given. Intradermal injection of 5% calcium gluconate (0.5 mL/cm2 of skin with 30-gauge needle) Intra-arterial infusion of 10 mL of 10% calcium gluconate in 40 mL D5W over 4 hours

Medication (Drugs)
Methylprednisolone: 40 mg q8h IV (peds: 2 mg/kg/d IV); Prochlorperazine (Compazine): 510 mg IV (peds: 0.13 mg/kg per dose IM) Ranitidine (Zantac): 50 mg IV q6-q8h Follow-Up

Admission Criteria

All symptomatic patients and unstable patients ,will be referred to internal medicine Inform administrator /social worker for non accidental or accidental cases Write police report

CHEST PAIN
PURPOSE All patients with chest pain need to be evaluated carefully and follow the guidelines PROCEDURE

One of the most frequent chief complaints in the ED There is a wide differential diagnosis of life-threatening etiologies as well as benign conditions often with minimal physical findings. Chest wall pain: o Inflammation of skin and subcutaneous structures of the chest wall o Pain is reproduced by: Palpation Horizontal flexion of the arms Extension of the neck Vertical pressure on the head Pleuritic pain:

Diagnosi

Inflammation or trauma to the ribs, cartilage, muscles, nerves, pleural or pericardial surface o Pain increased by breathing, laughing, coughing, sneezing o Tenderness to palpation may be present o Diaphragmatic pleurisy: Sharp shooting pains in the epigastrium, lower restrosternal area, or shoulder intensified by thoracic movement Deep visceral pain: o Upper thoracic visceral pain: Pain caused by visceral structures served by sensory fibers originating from T1-T4 May involve the myocardium, pericardium, the ascending aorta, pulmonary artery, mediastinum, and esophagus Pain is generally precordial. Pain is deep, visceral, and poorly localized. Characteristics vary from severe and crushing to mild, burning, or indigestion o Lower thoracic visceral pain: Pain caused by visceral structures served by sensory fibers originating from T5T6 May involve the descending aorta, diaphragmatic muscles, the gallbladder, the pancreas, the duodenum, and the stomach Pain is generally located to the xiphoid region and in the back.
o

Signs and Symptoms Coronary Artery Disease Shortness of breath Pressure Squeezing pain Radiation to arm, jaw Tachycardia or bradycardia Diaphoresis Nausea Vomiting Signs of congestive heart failure (CHF) Anxiety Pulmonary Embolism

Pleuritic pain Shortness of breath Anxiety

Diaphoresis Tachypnea Tachycardia Low-grade fever Localized rales Wheezing Acute Pericarditis

Substernal pain Varies with respiration Increased with recumbency Relieved by leaning forward Anxiety Anorexia Fever Pericardial friction rub History

The history is the most important tool to distinguish between the various etiologies. Have the patient define the key features: o Duration o Location: Retrosternal Subxiphoid Diffus

Frequency: Constant Intermittent Sudden versus delayed onset Precipitating factors: Exertion Stress Food Respiration Movement Timing: Context of onset of pain (i.e., at rest, exertional) Duration of pain Quality: Burning Squeezing Dull

Sharp Tearing Heavy Associated symptoms: Shortness of breath Diaphoresis Nausea Vomiting Jaw pain Back pain Radiation Palpitations Change to focal or generalized weakness Fatigue

Tests
Lab Creatine kinase, with muscle and brain subunits (CK-MB) and troponin T or I: o They have a high positive predictive value. o If negative initially, they cannot be used to rule out myocardial infarction (MI). o Serial troponin studies rule out MI and significantly decrease the probability of significant ischemia. D-Dimer: o Sensitive but poor specificity for physical examination o Increased sensitivity with enzyme-linked immunosorbent assay methods o Indicated for low risk patient Serum lipase: o If an atypical presentation of pancreatitis is suspected Imaging

Ultrasound: o Test of choice for pericardial and valvular disease o May be helpful in acute ischemic coronary artery disease by showing wall motion abnormalities if there is no prior infarction o Right ventricular dilation and hypokinesia may suggest pulmonary embolus.

ECG Obtain and interpret within 10 minutes of arrival Chest radiograph

Pneumothorax

Pneumonia A complication of ischemic heart disease such as CHF Acute pericarditis: o Usually normal unless massive effusion enlarges cardiac silhouette IV access Cardiac monitoring Oxygen Baby aspirin Pain control: o Nitrates o Morphine All chest pain should be treated and referred to internal medicine until proved otherwise after Initial Stabilization ABCs IV Oxygen Cardiac monitoring

ED Treatment

IV, oxygen, and monitoring Treatment varies based on suspected etiologies: Medication (Drugs) Aluminum and magnesium hydroxide: 15 to 30 ml PO q2-q4h Aspirin: 160-325 mg PO Plavax 75mg Cimetidine: 300 mg IV or PO q6h Donnatal: 510 mL PO q6h Esmolol: 50 g/kg bolus, then 50200 g/min drip Labetalol: 20 mg IV every 10 minutes up to 300 mg Metoprolol: 5 mg IV every two hours up to 15 mg Morphine sulfate: 24 mg every five minutes Nitroglycerin: 0.4 mg sublingual, or 12 inches of nitro paste, or drip at 510 g/min and titrate to effect Nitroprusside: 0.310 g/kg/min drip Propranolol: 12 mg IV every 2 minutes

Admission Criteria Dependent on the risk for life-threatening cardiopulmonary etiologies Discharge Criteria Very low risk for untoward event if discharge is planned

CHEST PAIN (TRAUMATIC

PURPOSE To deal chest trauma patient either due to RTA or assault PROCEDURE Significant source of morbidity and mortality in the Kingdom Directly responsible for 20-25% of all deaths attributed to trauma Contributing cause of death in 25% of patients who die from other traumatic injuries Etiology

Common mechanisms of injury include: o Motor vehicle collisions (70-80%) o Motorcycle collisions o Pedestrians struck by a motor vehicle o Falls from great heights o Assaults o Blast injuries Injuries can result from direct blunt force to the chest or from forces related to rapid deceleration. Diagnosis

Signs and Symptoms Obvious contusion, wound, or other defect of the chest wall: o Paradoxical chest wall movement suggests flail chest segment. Usually occurs in combination with other injuries Hypotension Some patients with severe intrathoracic injuries, such as traumatic aortic disruption, may have no visible external signs of trauma. History

Time of injury Mechanism of injury Estimates of motor vehicle accident (MVA) velocity and deceleration Loss of consciousness Chest pain Pain with deep inspiration or cough Dyspnea

Physical Exam Unilaterally absent breath sounds Crepitus or subcutaneous air in the chest wall Decreased or absent breath sounds Tenderness to palpation on the chest wall Jugular venous distention Hyperresonance to percussion on involved side Essential Workup

Check airway, breathing, and circulation (ABCs) to determine the patient's stability. Focused examination of the chest: o Respiratory effort and rate o Chest wall excursion o Crepitus o Subcutaneous air o Breath sounds and heart sounds o Presence of jugular venous distention Obtain a supine chest radiograph immediately: o Avoid an upright chest radiograph because of the potential for other injuries (especially spinal injuries). Electrocardiogram and monitor to detect myocardial ischemia TESTS Lab

Baseline hemoglobin Pulse oximetry Arterial blood gas Serum lactate Type and cross-match Coagulation profile Cardiac enzymes if concerned for cardiac contusion Periodic chemistry panel for patients receiving significant fluid resuscitation Imaging

Chest radiograph is the initial radiologic study of choice: o If chest radiograph reveals widened mediastinum and patient hemodynamically stable, repeat film in upright position. Chest CT is more specific for pneumothoraces and pulmonary contusions/occult injuries.. Electrocardiogram if sternal tenderness is present or abnormalities on cardiac monitor. Pregnancy Considerations

In pregnant patients, remember to use the least amount of radiation available and to shield the uterus during imaging when possible. See Pregnancy, Trauma in, for details. Differential Diagnosis

Simple pneumothorax Tension pneumothorax Open pneumothorax Hemothorax Rib fractures Flail chest Pulmonary contusion Myocardial contusion Myocardial rupture Pericardial tamponade Traumatic aortic disruption Esophageal injury Large vascular injury (subclavian, pulmonary artery) Tracheobronchial injury Diaphragmatic injury Pediatric Considerations

Rib cage is highly elastic in children and can withstand significant forces without overt signs of external trauma, but such patients may have major internal injuries. Treatment Full spinal precautions Needle decompression for tension pneumothorax: o Unilaterally absent breath sounds o Hypotension o Jugular venous distention o Hyperresonance to percussion If large open pneumothorax exists, tape occlusive dressing on three sides; a totally occlusive dressing may produce a tension pneumothorax Initial Stabilization

ABCs management; intubate patient early if signs of respiratory insufficiency, shock, or altered mental status exist.(ANNOUNCE CODE YELLOW) Resuscitation attempts should be initiated only in patients who arrive in the ED with vital signs. Any patient who presents in blunt traumatic arrest is not likely to survive a thoracotomy in the ED, and is therefore not indicated in this group.

If the patient's condition is unstable and clinically shows signs of a tension pneumothorax, perform needle thoracostomy and place a chest tube immediately after: o Do not wait to obtain a chest radiograph. o Place chest tube on the affected side or bilaterally if injury site is unclear. Oxygen by nonrebreather face mask for stable patients Obtain vascular access, preferably two large intravenous lines (>18 gauge). Maintain spinal immobilization. Tube thoracostomy if pneumothorax or hemothorax is identified: o 36-French chest tube in an adult o In children use the largest tube that the intercostals space will accommodate. Provide resuscitation with isotonic fluids and blood products as necessary: o Aggressive fluid resuscitation may be harmful if severe pulmonary contusions exist. Workup for associated intra-abdominal injuries (e.g., with diagnostic peritoneal lavage, abdominal ultrasound, abdominal CT scan): o Patients with chest trauma frequently have concomitant intraabdominal injuries. Medication (Drugs)

Tetanus booster if indicated Methylprednisolone (for signs of spinal cord injury): 30 mg/kg intravenously over 1 hour, followed by a continuous drip of 5.4 mg/kg/h for next 23 hours Judicious doses of short-acting analgesics (fentanyl 12 g/kg IV, morphine 0.1 mg/kg IV) as needed for pain control Follow-Up

Refer all blunt chest trauma patients to surgical team.

CORNEAL ABBRASION

PURPOSE To deal ophthalmologic emergencies in emergency setup PROCEDURE

Instill topical anesthetic (proparacaine/tetracaine). Consider Cycloplegic for intense pain owing to ciliary spasm (homatropine 5%). History: o Past ocular trauma o Ocular/periocular surgery o Pre-existing visual impairment o Glasses o Contact lens use (extended wear has increased risk of corneal ulcer) o Time of onset o Associated symptoms o Treatment before visit o Use of safety glasses (pounding, drilling, grinding metal) o Systemic disease (diabetes, autoimmune disorders) Complete eye exam: o Visual acuity o Evert upper lids to check for retained foreign body o Bright white light for visual inspection of cornea to rule out infiltrate/edema/loss of corneal luster o Slit-lamp to evaluate anterior segment and depth of abrasion o Fluorescein to identify area of damaged corneal epithelium: Damaged area appears bright green using blue Wood lamp. o Funduscopic examination of retina and macula

Examination includes

Removal of superficial foreign body Pain control (topical/oral): o Diclofenac (topical) o Ketorolac (topical) o Oral narcotics o Cool compresses

Cycloplegic (optional): o Cyclopentolate (mydriasis ) o Tropicamide (mydriasis 6 hours) o Homatropine 5% Antibiotic ointment/drop options: o Ciprofloxacin o Erythromycin o Gentamicin o Sulfacetamide o Tobramycin o Contact lens wearers must be covered for Pseudomonas: Use amino glycoside or quinolone. Eye patch: o Controversial regarding efficacy o No patch required for small abrasions o Never patch contact lens-related injury. o Never patch infection-prone injury: Fingernail Vegetable matter Removal of wood particles o Patch non related abrasions >10 mm2 only or recurrent corneal erosions o Collagen shields/soft bandage contact lenses (currently under investigation)

CERBROVASCULA ACCIDENT( STROKE)

PURPOSE To recognize the patient with stroke and adopt proper line of managemen DEFINITION Stroke is defined by the World Health Organization7 as a clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading

to death with no apparent cause other than a vascular origin. A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours. There are limitations to these definitions. The symptoms of a TIA usually resolve within minutes or a few hours at most and anyone with continuing neurological signs when first assessed should be assumed to have had a stroke.

PROCEDURE

Neurologic damage is more likely to occur the longer a stroke goes untreated Rapid response and intervention is crucial to the treatment of stroke Rapid response begins with the early recognition of signs and symptoms and rapid transport to a stroke-capable facility, and it continues in the emergency room with proper assessment and coordination3

A patient who arrives at the Emergency Department with CVA or stroke will receive the following care: Assist to gurney.

Obtain history of onset of complaint. Obtain medical history. Place on cardiac monitor; obtain initial rhythm strip. Place on pulse oximetry. Maintain airway. Administer oxygen via nasal cannula at two to six 2-6 liters per minute, or via mask at eight 8 to 10 liters per minute. Obtain ABGs as ordered.

Maintain patient safety; side rails up. Document neurological deficit. Monitor LOC. Monitor for seizure activity. Establish IV access. Obtain bloods with pressure less than 185 Diastolic blood pressure less than or equal to 110 The patient is not experiencing a minor stroke or rapidly resolving stroke The patient did not have a seizure at onset of stroke The patient is not taking coumadin Prothrombin time is less than or equal to 15 seconds or INR is less than or equal to 1.7 The patient has not received heparin during the past 48 hours with elevated partial thromboplastin time Platelet count greater than or equal to 100,000

AHA/ASA 2007 guidelines: immediate diagnostic tests for all patients with suspected ischemic stroke

Noncontrast brain CT or brain MRI Blood glucose Serum electrolytes/renal function tests Electrocardiogram (ECG) Markers of cardiac ischemia Complete blood count (CBC), including platelet count. Prothrombin time (PT)/international normalized ratio (INR) Activated partial thromboplastin time (aPTT) Oxygen saturation Although it is desirable to know the results of these tests before giving tPA, thrombolytic therapy should not be delayed while awaiting results unless: (1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia; (2) the patient has received heparin or warfarin; or (3) use of anticoagulants is unknown.

AHA/ASA 2007 guidelines: immediate diagnostic tests for selected patients with suspected ischemic stroke

Liver function tests (LFTs) Toxicology screen Blood alcohol level Pregnancy test Arterial blood gas tests (if hypoxia suspected) Chest X-ray (if lung disease suspected) Lumbar puncture (if subarachnoid hemorrhage suspected and CT scan negative for blood) Electroencephalogram (if seizures suspected

DECREASING MEDICATION ERROR

POLICY: It is the policy of ED and Hospital to institute a Medication Safety Awareness program and to take a proactive approach by focusing performance improvement activities on medication use. Be aware that errors can occur at any step of the process: prescribing, ordering, dispensing, administering or monitoring the effects of the medication. The Institute for Safe Medication Practices has identified some common sources of errors: Unavailable patient information prior to dispensing or administering a drug lab values, allergies, etc. Unavailable drug information written resources

PROCEDURE i. The individual discovering the error immediately reports the issue to a supervisor and the attending physician and makes sure the patient is safe; ii. The individual discovering the error completes an unusual occurrence report within 24 hours for review by a supervisor;

iii. iv. v. vi. vii. viii. ix.

Medication error form will be filled up that is available in resuscitation form cupboard. The supervisor reviews the report and forwards it to the Chief of Emergency Department. An interdisciplinary committee meets weekly to review medication errors. Investigation is completed in the department where the error occurred and recommended operational changes are implemented; A Root Cause Analysis may be performed on significant errors; Findings are reported through the Patient Safety Committee. A focused commitment by staff, leadership and medical staff toward quality and safety in delivering patient care.

DEFIBRILLATION

PURPOSE: To outline the proper method for defibrillation of a patient. Defibrillation is the KING SAUD HOSPITAL UNAIZAH EMERGENCY DEPARTMENT TITLE: DEFIBRILLATION INSTITUTIONAL POLICY AND PROCEDURE SECTION:III IPP NUMBER: PAGE 1 OF 1
PREPARED BY EFFECTIVE DATE

REVISED DATE

REVIEWED & CHECKED

DR ABDUALAAZIZ ABULELA

DR SHAHID BASHIR SPECIALIST ED

AUG../../ 2009

AUG/ .2011

FRCS.MS (NEUROSURGEON) CHIEF OF EMERGENCY DEPTT. SIGN.

SIGN

use of an electrical discharge of direct current to a patient's chest wall for the purpose of terminating ventricular fibrillation and ventricular tachycardia. PROCEDURE: The following equipment will be obtained and readied: 1. Defibrillator Paddles Lubricant or defibrillator pads Prepare the defibrillator's paddles. 2. Use adequate lubricant or place prepared pads under the paddles, to prevent electrical burns of the skin. 3. One 1 paddle shall be placed at the upper sternal area just below the right needs. The physician will specify the wattage. 4. The initial setting for adults is usually 200 joules.(BIPASIC) 5. For the pediatric patient, defibrillation attempts begin at 2 joules per kg of body weight, followed by 4 joules per kg of body weight. 6. Deliver wattage to the patient only after everyone is standing clear of the bed. 7. The person defibrillating the patient should state, loudly and clearly, All clear. 8. Look to see if all personnel are away from the bed

DEMENTIA POLICY That demnetail patient is treated with sympathetic way and adopts guidelines for these patients PROCEDURE ED staff need to know about dementia and need to improve the experience of people with dementia in undergoing investigations at Emergency Departments. Older patients are far more likely to spend longer in ED and then to be admitted to hospital because of a lack of support at home. This results in functional decline, loss of independence and increased rates of institutional care. Patients with dementia are many times more likely to be admitted to hospital compared with older people who do not have dementia. 1 People with dementia should not be excluded from any services because of their diagnosis, age (whether designated too young or too old) or coexisting learning disabilities. 2 3 ED Physician and social care staff should treat people with dementia and their careers with respect at all times. An urgent, physical and psychological assessment for all older people with apparent confusion in ED to be undertaken in order to assist with diagnosis and where possible identify whether the person may have dementia. All staff in ED should be trained in how to care for people with dementia once identifies and call internal medicine, if the patient has co morbidity. ED Physician and social services to work together to prevent admission in the first place e.g. implementation of measures for fall prevention, and to manage care in the community which should include rapid access to diagnostic testing and consultant services if necessary by convincing the attendants.

ED Physician and nurse who is dementia trained will be attached to the patient otherwise All staff in A&E to have a training in how to care people with dementia once identified.

ED Physician and social care staff should identify the specific needs of people with dementia and their careers arising from diversity, including gender, ethnicity, age (younger or older), religion and personal care.

If language or acquired language impairment is a barrier to accessing or understanding services, treatment and care, health and social care professionals should provide the person with dementia and/or their career

TREATMENT i. If IM preparations are needed for behavioral control, lorazepam, haloperidol or olanzapine should be used. Wherever possible, a single agent should be used in preference to a combination. If rapid tranquillizations are needed, a combination of IM haloperidol and I/M lorazepam should be considered. If using IM haloperidol (or any other IM conventional antipsychotic) for behavioral control, ED Physician should monitor closely for dystonia and other extra pyramidal side effects. If side effects become distressing, especially in acute dystonia reactions, the use of anticholinergic (inj congentin2mg) agents should be considered.

ii. iii.

EPISTAXIS

POLICY Establish criteria for the emergency delivery of the pregnant woman in active labor on arrival in the Emergency Department.

1. On arrival to the Emergency Department, any patient who is in active labor and is 16 to 18 weeks or more pregnant, shall be escorted directly to Labor and Delivery for evaluation: 2. Notify Labor and Delivery of patient arrival and estimated date of delivery. Transport patient either by wheelchair or gurney. Any patient who is in active labor on arrival to the Emergency Department, and time does not allow safe transportation to Labor and Delivery in the Emergency Department physician: 3. If birth is imminent, prepare for delivery. 4. Contact Labor and Delivery and the Nursery of imminent delivery in the Emergency Department. 5. Request infant warmer be brought to the Emergency Department. 6. Contact the patient's obstetrician or, if patient has no obstetrician, contact the obstetrician on-call. Prepare for possible resuscitation. 7. Trauma patients who are pregnant will be evaluated in the Emergency Department before being sent to Labor and Delivery Department 8. The patient presenting to the Emergency Department with epistaxis nose bleed will receive the following care: a) Escort to treatment Room or resuscitation room. b) Apply nasal clamp Maintain patent airway Utilize standard precautions c) Obtain medical history d) Set up nasal tray e) Documentation shall include, but not be limited to: i. Vital signs ii. Response to treatment iii. Approximate amount of blood loss iv. Local anesthetic Sedation, if used Nasal packing; which nares v. Any vomiting of blood 9. Call for ENT Specialist

HEAD INJURY Definition Any trauma to the head, other than superficial injuries to the face Using the Glasgow Coma Scale

Describe the three individual components (eye-opening, verbal response and motor response) in all communications and in every note so this information always accompanies the total score. Base total scores on a sum of 15, and specify this (for example, 13/15). Include a grimace alternative to the verbal score in the paediatric version to allow scoring in pre-verbal children. Initial assessment and management Follow Advanced Trauma Life Support (ATLS) course or/ Advanced Pediatric Life Support (APLS) 1 2 3 4 5 6 7 Stabilize airway, breathing and circulation (ABC) before attending to other injuries If the GCS is 15/15 then the patient is needed to be examined with in 15 minutes of arrival in the ED Emergency department clinician should re-examine within an hour and assessment should establish need for CT imaging of head and/or cervical spine If the GCS is 9-14/15 then examine immediately as he/she is high risk. If the GCS is 8/15 then announce code yellow or involve anesthetist and ICU Physician and exclude significant brain injury before ascribing depressed conscious level due to intoxication. Manage pain effectively and reassure the patient. Treat significant pain with low dose opioids titrated against clinical response by certified ACLS and conscious sedation Physician otherwise I/V Paracetamol 1gram can be given.

Selection of adults for CT scanning of head i. ii. iii. iv. v. vi. vii. GCS < 13 when first assessed in emergency department GCS < 15 when assessed in emergency department 2 hours after the injury Suspected open or depressed skull fracture Sign of fracture at skull base (haemotympanum, panda eyes, cerebrospinal fluid leakage from ears or nose,Battles sign) Post-traumatic seizure Focal neurological deficit or 1 episode of vomiting Amnesia of events 30 minutes before impact.

Selection of children (under 16) for CT scanning of head i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii. xiv. Witnessed loss of consciousness lasting > 5 minutes Amnesia (ante grade or retrograde) lasting > 5 minutes Abnormal drowsiness i. or more discrete episodes of vomiting Clinical suspicion of non-accidental injury Post-traumatic seizure but no history of epilepsy Age > 1 year: GCS < 14 on assessment in the emergency department Age < 1 year: GCS (pediatric) < 15 on assessment in the emergency department Suspicion of open or depressed skull injury or tense fontanelle Any sign of basal skull fracture (haemotympanum, panda eyes, cerebrospinal fluid leakage from ears or nose, Battles sign) Focal neurological deficit Age < 1 year: presence of bruise, swelling or laceration > 5 cm on the head Dangerous mechanism of injury (high-speed road traffic accident either as a. pedestrian, cyclist or vehicle occupant, fall from > 3 m, highspeed injury b. from a projectile or an object)

Investigation for injuries to the cervical spine 1) In most circumstances, plain radiographs are the initial investigation of choice to detect cervical spine injuries three views of sufficient quality for reliable interpretation (two views for children under 10 years of age). 2) CT imaging is recommended in some circumstances as i. Patient cannot actively rotate neck to 45 degrees to left and right (if safe to assess the range of movement in the neck) ii. Not safe to assess range of movement in the neck. iii. Neck pain or midline tenderness plus: iv. age 65 years, or v. dangerous mechanism of injury vi. Definitive diagnosis of cervical spine vii. injury required urgently (for example, prior to surgery) 3) Children under 10 have increased risk from irradiation, so restrict CT imaging of cervical spine to children with indicators of more serious injury, in circumstances such as: 4) severe head injury (GCS 8).

5) strong suspicion of injury despite normal plain films 6) plain films are inadequate Reassess immediately if 1) Agitation or abnormal behavior developed 2) GCS dropped by 1 point and lasted for at least 30 minutes (give greater weight to a drop of 1 point in the motor response score) 3) Any drop of 3 or more points in the eye-opening or verbal response scores, or 2 or more points in the motor response score 4) Severe or increasing headache developed or persistent vomiting 5) New or evolving neurological symptoms or signs, such as pupil inequality or asymmetry of limb or facial movement Criteria for intubation 1) Coma GCS 8 (use paediatric scale for (children) 2) Loss of protective laryngeal reflexes 3) Ventilatory insufficiency: a. hypoxaemia (PaO2 < 13 kPa on oxygen) b. hypercarbia (PaCO2 > 6 kPa) 4) Spontaneous hyperventilation causing PaCO2 < 4 kPa 5) Irregular respirations 6) Significantly deteriorating conscious level (1 or more points on motor score), even if not coma 7) Unstable fractures of the facial skeleton 8) Copious bleeding into mouth 9) Seizures 10) Ventilate an intubated patient with muscle relaxation and appropriate short-acting sedation and analgesia i. Aim for: b. PaO2 > 13 kPa c. PaCO2 4.55.0 kPa i. If clinical or radiological evidence of raised intracranial pressure, more aggressive hyperventilation is justified ii. Increase the inspired oxygen concentration if hyperventilation is used iii. Adult: maintain mean arterial pressure at 80 mmHg by infusing fluid and vasopressors as indicated

iv. Child: maintain blood pressure at level appropriate for age Admission i. ii. iii. An intubated patient is to be shifted in the ICU and follow the ICU shifting protocol Patient who is not intubated but is of high risk is to be shifted to step down or as per consultation of Neurosurgery team. All head injury patient irrespective to GCS score is to be referred to neurosurgery team who will decide for admission, discharge or refer to other hospital otherwise involve social service department to convince/LAMA the patient.

Transfer of the Patient 1) The patient should be accompanied by a doctor with appropriate training and experience and adequately trained assistant. 2) In all circumstances: complete initial resuscitation and stabilization of the patient and establish comprehensive monitoring before transfer to avoid complications 3) Do not transfer the patient if the patient is persistently hypotensive even after resuscitation until the cause is ruled out. Discharge A. Do not discharge any patient who presents with a head injury until GCS = 15. B. For infants and young children, normal consciousness as assessed by the pediatric Glasgow Coma Scale should be achieved before discharge. C. Specific group a. No career at home: discharge only if suitable supervision arrangements have been organized, or b. when the risk of late complications is deemed negligible (in general, only discharge when certain c. There is somebody suitable at home to supervise the patient). d. Low risk, CT not done, GCS = 15: clinician may conclude risk is low enough to allow discharge if CT not indicated from history and examination, no other factors warrant admission and there are i. appropriate support structures for safe transfer and subsequent care. e. Normal imaging of the head: clinician may conclude risk is low enough to allow discharge if patient has returned to GCS 15, no other factors warrant admission and there are appropriate support structures for safe transfer and subsequent care. f. Normal imaging of the cervical spine: clinician may conclude risk is low enough to allow discharge if patient has returned to GCS 15,

no other factors warrant admission and there are appropriate support structures for safe transfer and subsequent care. g. Admitted for observation: discharge after resolution of all significant symptoms and signs providing suitable home supervision arrangements exist unless patient was admitted out of hours h. and requires a CT scan the following morning . i. At risk of non-accidental injury: do not discharge an infant or child with a head injury that required imaging of the head or cervical spine until a clinician experienced in the detection of nonaccidental injury has assessed him or her. Discharge advice

All patients should receive verbal advice and a written head injury advice card before discharge from emergency department. 1. Discuss details of the advice card before discharge this should include instructions on contacting community services in the event of delayed complications. 2. Alert patients and carers to the possibility that some patients may make a quick recovery, but go on to experience delayed complications. 3. Make all patients and carers aware of the possibility of long-term symptoms and disabilities and of the existence of services that they could contact should they experience long-term problems (details of support services should be included on patient discharge advice cards). 4. If necessary, use other formats to communicate discharge advice (for example, tapes). 5. If there is a need, facilitate communication in languages other than English. 6. Give information and advice on narcotics or drug misuse to patients who presented to the emergency department with drug or alcohol intoxication if they are now fit for discharge. Outpatient appointment 1) Every patient who has undergone imaging of their head: refer to OPD for follow-up within 1 week after discharge. 2) If problems persist: there should be an opportunity for referral from primary care to an outpatient appointment with a professional trained in assessment and management of brain injury sequelae. INFUSION PUMP

POLICY: 1. Infusion pumps for patient use are electrical with battery operation backup support. 2. The infusion pumps are computerized which allows the delivery of specific doses of medications as ordered by the patient's licensed independent practitioner. 3. All infusion pumps utilized in the facility will have free-flow alarm systems and dose-registration locking devices. 4. These protocols are to be followed when cleaning and checking the unit: Activities to be performed found in . 5. Return pump to appropriate shelf and complete inventory documentation. Nursing Staff Responsibilities: 6. Obtain infusion pump from Central Services. Assure proper training on operation of pump prior to use: Patient care staff must be approved as properly trained and deemed competent prior to use of infusion pumps. Training will include all aspects and features of the pump, including dose information/registration keypad operation and any associated locking device.

LACERATION AND/ABRASION CARE

POLICY: 1. The patient arriving at the Emergency Department with lacerations and/or abrasions will receive the following care: 2. Assess airway status. 3. Assess bleeding. 4. Assess neurological and sensory status distal to the injury.

5. 6. 7. 8.

Control bleeding. Clean wound with hospital accepted solutions. Set-up suture equipment. If applicable, give tetanus booster. Documentation shall include, but not be limited to: i. Mechanism of injury ii. Initial vital signs iii. Description and location of injury iv. Any obvious deformity v. Approximate blood loss vi. Type of suture used vii. Medical history viii. Tetanus status ix. Medication/allergy Dressing used x. Police report if indicated MEDICATION ADMINISTARTION

POLICY 1. Medications will be administered only upon the order of physicians, who is on regular or locum contract, observers or internees will not prescribe the medications. 2. Registered nurses may administer all parenteral, oral, rectal and topical medication including blood 3. Saudi internees nurses will not administer medication. 4. the amount ordered and amount prepared must be checked by two 2 nurses if the parental medication is ordered especially nitroglycerine , adrenaline , insulin, streptokinase. 5. Mixed solutions will be observed to assure that the medication is stable and that there are no signs of precipitation, discoloration or particulate matter prior to patient administration 6. Incompatible injectable IM, subcutaneous medications will be administered at different injection sites. Medications will be prepared immediately prior to administration 7. Individual who is administrating medication must ensure that i. The medication is stable (based on visual examination for particulates and discoloration), ii. The medication has not expired, iii. There is no contraindication to administration of the medication (e.g., drug allergy), iv. The medication is being administered at the proper time in the prescribed dosage by the correct route. v. These verifications must occur at the time of administration in the location where the drug is being administered, as much as possible.

vi. The patient or, if appropriate, the patient's family should be advised about any potential significant adverse reactions

ORTHOPEADIC EMERGENCIES

POLICY:

The patient arriving at the Emergency Department with an orthopedic emergency to an extremity will receive the following care:

1) Assess and maintain a patent airway. 2) Immobilize the extremity. 3) Elevate the extremity. 4) Apply ice to area of injury. 5) Assess circulation to area distal to injury. 6) Assess sensation to area distal to injury. 7) Cover open wounds with Normal Saline dressing. 8) Initiate intravenous line with Normal Saline, if obvious deformity or open fracture. 9) Documentation shall include, but not be limited to: 10) 11) 12) 13) 14) 15) 16) Mechanism of injury, if trauma Initial vital signs Position of open fracture. Obvious deformity Any circulatory or sensory abnormality Frequent circulatory and sensory exams Any associated injuries

17) 18) 19) 20)

Any diagnostic test What time orthopedist was notified and arrival time Type of splinting or casting Referrals

PATIENT IDENTIFICATION

POLICY: It is the policy of Hospital to ensure that all patients are properly identified prior to any care, treatment or services provided. Exception:

PRINCIPLES OF IDENTIFICATION:

1. A system for positive identification of all hospital patients fulfills four 4 basic functions: 2. Provides positive identification of patients from the time of admittance or acceptance for treatment. This identification system shall apply to patients in all areas of the hospital. 3. Provides a positive method of linking patients to their medical records and treatment. 4. On admission of patient in the observation room , put ID band in his left hand 5. The patient who is admitted from the clinic must have ID band in his/her left hand 6. Minimizes the possibility that identifying be wearing the band when he/she is discharged. In the event of death, the band shall remain on the patient's body 7. Write four parts of the name of the Saudi patients

RESPIRATORY TRACT INFECTION

DEFINITION Any infectious disease of the upper or lower respiratory tract. Upper respiratory tract infections (URTIs) include the common cold, laryngitis, pharyngitis/tonsillitis, acute rhinitis, acute rhinosinusitis and acute otitis media. Lower respiratory tract infections (LRTIs) include acute bronchitis, bronchiolitis, pneumonia and tracheitis PROCEDURE 1. At first face-to-face contact in emergency departments, adults and children (3 months and older) presenting with a history suggestive of the following conditions should be offered a clinical assessment:

Acute otitis media

Acute sore throat/acute pharyngitis/acute tonsillitis

Common cold

 Acute rhinosinusitis

Acute cough/acute bronchitis.

2. The clinical assessment should include a history (presenting symptoms, use of over-thecounter or self medication, previous medical history, relevant risk factors, relevant comorbidities) and, if indicated, an examination to identify relevant clinical signs. 3. Patients or parents/carers concerns and expectations should be determined and addressed when agreeing the use of the two antibiotic prescribing strategies (no prescribing and immediate prescribing).

A no antibiotic prescribing strategy should be agreed for patients with the following conditions:

Acute otitis media Acute sore throat/acute pharyngitis/acute tonsillitis Common cold Acute rhinosinusitis Acute cough/acute bronchitis

4. Depending on clinical assessment of severity, patients in the following subgroups can also be considered for an immediate antibiotic prescribing strategy (in addition to a no antibiotic): bilateral acute otitis media in children younger than 2 years acute otitis media in children with otorrhoea Acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria1are present. 5. Centor criteria are: presence of tonsillar exudate, tender anterior cervical lymphadenopathy

For all antibiotic prescribing strategies, patients should be given: 6. Advice about the usual natural history of the illness, including the average total length of the illness (before and after seeing the doctor): acute otitis media: 4 days acute sore throat/acute pharyngitis/acute tonsillitis: 1 week common cold: 1 weeks acute rhinosinusitis: 2 weeks acute cough/acute bronchitis: 3 weeks 7. Advice about managing symptoms, including fever (particularly analgesics and antipyretics). For information about fever in children younger than 5 years, refer to pedia specialist.

When the no antibiotic prescribing strategy is adopted, patients should be offered:

Reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash

A clinical review if the condition worsens or becomes prolonged. Identifying those patients with RTIs who are likely to be at risk of developing complications, no antibiotic prescribing strategy should not be considered.

8. An immediate antibiotic prescription and/or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations: If the patient is systemically very unwell If the patient has symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) If the patient is at high risk of serious complications because of pre- existing comorbidity. This includes patients with significant heart, lung, renal, liver or

neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely if the patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria: Hospitalization in previous year Type 1 or type 2 diabetes History of congestive heart failure --current use of oral glucocorticoids.

TREAMENT 9. Advise antipyretics, analgesics, antihistamine and treat according to symptoms and clinical assessment.

Referral to PHC and in Patient team

1. Patients who are having co morbidity but clinically stable. 2. Antibiotics are prescribed in ED for one day and need to continue. 3. Patient is in need to be followed up in OPD at KSH to get referral. 4. Patient who is having co morbidity and breathless. 5. Vital signs are deteriorating. 6. Patient is suspected case of HINI Influenza with positive CXR. 7. Patient full fills the H1N1 criteria as per MOH notices.

SEIZURES

POLICY: A patient who arrives at the Emergency Department with seizures will receive the following care: 1. Establish and maintain a patent airway. 2. Prepare to assist with ventilation, if necessary. 3. Maintain patient safety. 4. Suction airway, as needed. 5. Apply oxygen, high flow. 6. Monitor cardiac status. 7. Establish IV access with 1000 mL Normal Saline. 8. Obtain venous bloods for Clinical Laboratory from IV access. 9. Obtain history of seizure activity. 10. Keep side rails up for patient protection. Pad side rails for patient protection.. 11. Have medication available to stop seizure, per physician's order. 12. Documentation shall include, but is not limited to: i. Initial vital signs ii. Time and length of seizure iii. Time and length of any seizure activity in the Emergency Department iv. History of seizure activity or activity prior to seizure i.e., trauma v. Documentation of LOC vi. Documentation of incontinence vii. Documentation of post ictal state

STAB WOUND POLICY:

A patient who arrives at the Emergency Department with stab wounds will receive the following care: 1. Assess airway. 2. Administer oxygen via nasal cannulas or mask as needed. 3. Control bleeding. 4. Assess for shock. 5. Assess area of wound entrance. 6. Obtain information on length and type of instrument used. 7. Administer IV 1000 mL Normal Saline with large-bore catheter; two 2 IVs if signs and symptoms of shock are present. 8. Obtain venous bloods with IV start. 9. Notify local law enforcement agency of incident. If threat to Emergency Department, have Security and law enforcement available 10. 11. Obtain venous bloods with IV start. Documentation shall include, but is not limited to: i. Initial vital signs ii. Description of area of wound iii. Description of item used in assault iv. Description of mechanism of injury v. Amount of bleeding vi. Notification of appropriate law enforcement agency on arrival Any changes in patient's condition

TELEPHONE,VERBAL AND WRITTEN ORDERS FOR MEDICATION

POLICY

On a continual basis to make all attempts to minimize the use of verbal and telephone orders. It is the policy of this institution never to allow verbal or telephone orders for the purposes of medical staff practitioners convenience only. Whenever possible and practicable, all members of the medical staff with privileges and approval to prescribe medication will do so by physically entering an order in the sheet PROCEDURE 1. All verbal and/or telephone orders for medications shall include the following criteria: 2. Date and time the order is prescribed verbally or via telephone 3. The name of the individual prescribing the drug 4. The generic and brand name of the drug 5. Drug dosage strength or concentration Quantity and/or duration 6. Route drug is to be administered 7. Frequency of administration 8. Verbal orders will only be accepted in emergency situations 9. To ensure safety, verbal orders require a repeat-back verification of the complete order by the person receiving the order. The receiving person will repeat the verbal order back to the ordering clinician, who will verbally confirm that the repeated order is correct. 10. Verbal orders must be signed within 24hours. Verbal orders may be signed by the ED Physician who gave the order, or by another equivalent practitioner. Signatures and stamped must be dated and timed.

VAGINAL BLEEDING

POLICY: A patient who arrives at the Emergency Department with vaginal bleeding will receive the following care: 1. Escort to OB/GYN gurney. 2. Evaluate bleeding, extent, clots, tissue. 3. Save all tissue and send to Pathology. 4. Date of LMP. 5. Obtain initial vital signs. 6. Obtain orthostatic vital signs. Establish IV access with 1000 mL Normal Saline. Obtain venous blood for Clinical Laboratory with IV access. 7. Perform HCG or BHCG. 8. Documentation shall include, but is not limited to: i. Initial vital signs and orthostatic vital signs ii. Amount of bleeding, tissue, clots while in Emergency Department orthostatic vital signs. iii. Amount of bleeding, tissue, clots while in Emergency Department iv. LMP/Gravida and Para status Onset of bleeding

DOS AND DONTS IN ED

ABSCESS:

WHAT TO DO:

i. Simply snip open the cutaneous roof with fine scissor or an inverted #11 blade. ii. When the location of an abscess cavity is uncertain, attempt to aspirate it with a #18 gauge needle after preparing the area with Povidine iodine. iii. Anesthetize the area with regional field block and give additional anesthesia like I/V paracetamol 1 gm. iv. Make the incision at the most dependent area. v. In large abscesses insert a hemostat in to the cavity to break up any loculated collection of pus and irrigate with normal saline, put packing and do dressing, vi. The patient should be instructed to use intermittent warm water soaks. vii. Ask for dressing after two days. viii. Discharge the patient with antibiotic cover. WHAT NOT TO DO: a. Do not incise an abscess that lies close to major vessel, such as in axilla, groin or anticubital space. b. Do not treat deep infections of the hands as simple cutaneous abscesses. c. Routine culture is not indicated.

ANAL FISSURE

Patient complains of painful rectal bleeding and sometimes constipation, the pain occurs with and immediately after defecation, the patient is relatively comfortable between bowel movements. bleeding with defecation is usually slight, only staining the toilet tissue. Mucus discharge may increase perineal moisture and cause itching. Examination of anus reveals a radial tear or ulceration of the posterior midline 95%of the time.
WHAT TO DO:

i. Provide topical anesthesia with lidocain. ii. Advise the patient to take soft diet and use a glycerin suppository twice daily to maintain lubrication of the anal canal. iii. Instruct the patient to use warm, soothing sitz baths after each painful bowel movement. iv. Prescribe analgesia if needed. v. Inform the patient that an acute superficial fissure will take about one month to heal vi. He /she should follow up in OPD. WHAT NOT TO DO: a. Do not assume that a lesion located outside the anterior-posterior midline saggital plane of anus is an anal fissure b. Do not confuse a sentinel pile with a heamorrhoidal vein.

ANKLE SPRAIN:

The patient inverted the foot and either came immediately or a day later with pain, swelling and inability to walk, there is tenderness to palpation of the anterior talofibularr ligament. WHAT TO DO: i. Elevate the foot and apply ice for 15 minutes/hr to treat the reactive inflammation ii. Palpate the prominence on the lateral foot to check the avulsion of peroneus brevious iii. Palpate the fibula on the lateral leg up to the knee, where spiral fracture can propagate iv. If there is tenderness and patient cannot take four steps in the ED, obtain x-rays to rule out a fracture. v. Immobilize the ankle in a stirrup. vi. Anti-inflammatory analgesics. vii. Follow up to ortho OPD/ED. WHAT NOT TO DO: a. b. Dont rule a fracture based on a negative x-rays. Dont overlook fractures of the tarsal navicular, talus or os trigonum, all

visible on the ankle view.

BLACK EYE

The patient has received blunt trauma to the eye, most often from a fist, a fall, or a car accident Family and friends are more concerned than the patient about the appearance of the eye. There may be associated subconjuctival hemorrhage, but the remainder of the eye examination should be negative. WHAT TO DO: i. Clarify as well as possible the specific mechanism of injury. ii. Perform a complete eye exam to rule out a retinal detachment or dislocated lens. iii. Fluorescein stain to rule out corneal abrasion. iv. Test extra ocular eye movements; look especially for diplopia on upward gaze. v. Check sensations over the infra orbital nerve distribution. vi. Symmetrically palpate the supra and infra orbital rims as well as zygoma. vii. If there is any suspicion of any underlying fracture, obtain xrays of the orbit. viii. If significant injury is discovered, then consult with an ophthalmologist.

ix. CT scan is more sensitive and can visualize subtle fractures of the orbit and small amount of air. x. When there is significant injury , reassure the patient that the swelling will subside with in 12-24 hrs xi. Give inj. paracetamol 1gm i/v. or oral paracetamol 1 gm. xii. Instruct the patient to follow up in ophthalmology clinic WHAT NOT TO DO: a. b. Dont get unnecessary radiograph. Minor injuries with normal eye exams and no palpable deformities do not

require X-rays. c. Do not brush off bilateral deep peri orbital ecchymosis (raccoon eye),

especially if caused by head trauma remote to the eye. BITES

A single bite may contain various types of injury, including underlying fractures and tendon and nerve injuries, not all of which are immediately WHAT TO DO: i. Obtain a complete history including, the type of animal that bit, whether or not the attack was provoked, what time the injury occurred, the current health status and vaccination record of the animal has been captured and is being held for observation, report the bite to police or appropriate local authorizes.

ii. Assess the wound for any damage to deep structures, any need for surgical consultation and risk of infection. iii. Look for bone and joint involvement and if present. iv. Obtain appropriate imaging studies (dog bites have caused open depressed fractures in small children). v. Examine for nerve and tendon injury and be aware that crush and puncture wounds as well as bites on the hands, wrist, and feet, are at higher risk for development of infection and significant complications such as tenosynovitis, septic joints, osteomylitis and sepsis. vi. If tissue damage is higher then take opinion of surgery and orthopedic. vii. For crush wounds and contusions, elevate above the heart and apply cold packs. viii. If the wound requires debridement, or will be painful to clean or irrigate, then anesthetize the area. ix. If there is already sign of infection, obtain aerobic and anaerobic cultures of pus. x. Irrigate the wound with antiseptic (10%povidine-iodine solution, dilated 1:10 in normal saline) and sharply debride any debris and non viable tissue. xi. Irrigate the wound, using a 20ml syringe, a 19 gauge needle or an irrigation shield, and at least 200ml of sterile saline. xii. For animal bite wounds that are clean, uninfected lacerations located anywhere other than the hand or foot. You may suture.

xiii. If the wound is infected when first seen .plan either a delayed repair after three to five days of saline dressings or secondary wound healing with out closure. xiv. Prescribe antibiotics for seven days. xv. Severe infection requires hospitalization. xvi. With human bites, animal bites that are punctured or located on he hand, wrist or foot, or bite more than 12 hours old ,in most cases, you should leave the wounds open and apply a light dressing . xvii. Wounds should also be left open on debilitated and patients with diabetes, alcoholism, chronic steroid use, organ transplants, vascular insufficiency, spleenectomy, HIV or other immnunocompromised conditions, xviii. Start prophylactic antibiotics in the ED on these wounds and in patients with artificial or damaged heart valves and implanted prosthetic devices, xix. If the patient has had no tetanus toxoid in the past 5-10 years, provide prophylaxis. xx. Start rapid rabies vaccination:

c. first day (0) d. third day(3) e. seventh day(7) f. Fourteenth (14) g. Twenty-eighth (28)

xxi. .Provide hepatitis prophylaxis for patients who have been bitten by known carriers of hepatitis B. Administer hepatitis B immunoglobulin 0.06ML/kg i/m at the time of injury and schedule a second dose in 30 days. xxii. 22. Follow standard guidelines applicable to contaminated

needle sticks. xxiii. 23. Minimize edema of hand wound by splitting and

elevation. xxiv. 24. Have patient returns for a wound check in two days or

sooner if there is any sign of infections. xxv. 25. Explain the potential for serious complication such as

septic arthritis, swollen immobile, tender along the flexor surface painful on passive extension that will require specially consultation. WHAT NOT TO DO: a. b. Do not overlook a puncture wound. Do not suture debris, non viable tissue or a bacteria inoculation into a

wound. c. Do not use buried absorbable suture, which act as foreign body and

cause a reactive inflammation for about a month and increase the risk of infection. d. Do not routinely suture human bites.

BLEEDING AFTER SURGERY

The patient had an extraction or other dental surgery performed earlier in the day, now ha excessive bleeding at the site and can not reach his/her dentist. WHAT TO DO: i. Ask what procedure was done ii. Inquire about antiplatelet drugs, like aspirin. iii. H/O previous experience of bleeding iv. Use suction and saline irrigation, clear any packing and clot from the bleeding site. v. Roll a 2x2 gauze pad, insert it over the bleeding site. vi. If the site is still bleeding after 20 minutes of gauze pressure ,inject local anesthetic, vii. If this does not stop the bleeding. Pack the bleeding site with Gel foam. viii. An arterial bleeding requires ligation with figure eight stitch. ix. When the bleeding stops, remove the overlying gauze. x. Arrange the follow up for dentist

WHAT DO NOT DO: a. b. Dont do routine lab tests. Dont use tea bags as a gauze BLUNT SCROTAL TRAUMA

Blunt injuries to the scrotum usually occur in patients less than 50 yrs. Of age as a result of an athletic injury, a straddle injury, an automobile or industrial accident, or as an assault. Patient presents with various degrees of pain, ecchymosis and swelling. WHAT TO DO: i. Get a clear history of the exact mechanism of the trauma and the point of maximum impact. ii. Determine if there was any bloody penile discharge or hematuria.b iii. Gently examine the external genitalia and give analgesia according to pain scale. iv. If scrotal swelling is not too severe, try to palpate and assess the intrascrotal anatomy. v. Obtain urinalysis vi. Do digital examination of the prostate and obtain urologic consultation. vii. When urologic intervention is not required, provide analgesia, bed rest, scrotal support, a cold pack and urologic follow up. WHAT NOT TO DO: a. b. Dont miss testicular torsion which can be associated with blunt trauma. Dont miss the rare traumatic testicular dislocation that results in an

empty scrotum.

BROKEN TOE

The patient has stubbed, hyper flexed, hyper extended, hyper abducted or dropped a weight upon a toe. Patients present with a pain, ecchymosis, and decreased range of motion and point tenderness and there may or may not be any deformity. WHAT TO DO: i. Examine the toe, particularly for lacerations. ii. Relieve the pain by anti-inflammatory analgesics. iii. Take x-rays to look fracture entering the joint space. iv. Displaced or angulated phalangeal fracture must be reduced with linear traction after digital block. v. Splint the broken toe by tapping it to an adjacent non effected toe , padding between toes with gauze and using half inch sticking plaster. vi. Advise the patient to be immobilized by using clutches or wearing hard sole shoe and elevate the toe at sleeping time and put ice bar on the pad. vii. Inform the patient that he/she must keep the padding dry between toe while they are tapped together otherwise skin will mace and break down. viii. If the fracture is not of phalanx, but of the metatarsal, construct a pad for the sole with space cut to the foot. ix. Arrange a follow up for the orthopedic OPD with in one week WHAT NOT TO DO:

a.

Do not tape together with out keeping pad between toes wetness and

Friction will maceration will b. Do not let the patient overdo the ice, which should not be applied

directly. c. Dont overlook the possibility of acute gouty arthritis, which sometimes

follow minor trauma. RIB FRACTURE

It is due falling down on the side of the chest, initial chest pain may subside but over the few hours or days pain increases and patient visits the ED for chest pain, there is point tenderness at the site of injury and occasionally bony crepitance can be felt. WHAT TO DO: i. Examine the patient for possible associated injuries ii. Relieve the pain and compress the rib medially if anterior or posterior fracture is suspected, iii. Compress the rib anterior /posterior if the fracture is suspected laterally. iv. When the pain occurs at the suspected fracture site with indirect stress, this is clinical evidence of fracture and document. v. Obtain a history of chronic pulmonary problems or heavy smoking. vi. Send the patient for PA/LAT view of x-rays chest to rule out pneumothorax, hemothorax or evidence of pulmonary contusion.

vii. If there is no evidence of underlying injury and there is clinical and radiological evidence of rib fracture, call surgical team or arrange appointment for Surgical OPD with in 48 hours and discharge the patient by advising potent oral analgesics. viii. Instruct the patient on the intermittent use of an elastic rib belt if it reduces pain. ix. Ask the patient about the importance of deep breathing and coughing to help prevent pneumonia. x. Advise the patient rest for one week according the organization policy. xi. If the patient is compromised and have cardiac or associated respiratory disease and the patient is old then hospitalization is required. WHAT NOT TO DO: a. chest. b. c. Do not tape ribs or use continuous strapping. Do not assume that there is no fracture because the x-rays are negative, Dont confuse simple rib fracture with massive blunt trauma to the

Rib fractures is often not apparent on x-rays, especially when they occur on cartilaginous portion of the rib. BRUISES

The patient has fallen on or thrown against the object has been struck at a site with the point of tenderness and swelling. Pain, ecchymosis and hematoma. On Physical examination there is no loss of function of muscles and tendons,

no instability of bones and ligaments and no crepitus or tenderness produced by remote stress. WHAT TO DO: i. Take a thorough history to ascertain the mechanism of injury and perform a complete examination to document structural integrity and bony injury ii. Do x-rays if you suspect possibility of bony injury or foreign body, fractures are uncommon after a direct blow. iii. Explain the patient that swelling will be at peak in one day and then resolve gradually. iv. Giving anti-inflammatory drugs and prescribing rest of effected part, immobilization, elevation and ice padding reduce the swelling. v. Explain the patient late migration and color changes of ecchymosis. vi. Arrange for follow up in surgical OPD, if the patient returns ED with increased discomfort.. vii. A large hematoma requires drainage by orthopedic team.

WHAT NOT TO DO: a. Do not apply a elastic bandage to the middle of limb where it may act as

a tourniquet. b. Do not confuse patient with instructions for application of heat and

exercise to prevent stiffness and atrophy, concentrate on the here and now therapy.

CELLULITIS

The cardinal sign of infection (pain, redness, warmth, and swelling) are present. Erysipelas is very superficial and bright red with indurate, sharply demarcated borders. Cellulites is deeper, involves the subcutaneous connective tissue and has indistinctive advancing borders. These infections are preceded by minor trauma of the presence of foreign body and are most common in those patients who have predisposing factor like diabetes mellitus, DVT and lymphatic drainage obstruction, they may be associated with an abscess or they may have no clear cut origin. The patient may have tender lymphadenopathy proximal to the site of infection and may or may not have signs of systemic toxicity (fever, rigor and listlessness). WHAT TO DO: i. Look for possible source of infection and remove it. ii. Deride and cleans any wound, remove any foreign body or drain any abscess. iii. When the patient is very sick and there is discoloration of the limb, get medical consultation and take all basic investigation (CBC, BIO. Culture), and X-rays chest and limb. iv. Hospitalize the patient through surgical team, v. If there is low grade fever or none at all then prescribe third generation antibiotics and anti-inflammatory analgesics. vi. Instruct the patient to keep the infected part at rest and elevated and to use intermittent warm moist compression. vii. Advise the patient to follow up in ED with in 24-48 hour

WHAT NOT TO DO: a. Do not send the patient home if there is suspicion of deep facial

cellulites or the patient has deep infection of the handed even the patient is a febrile

COLLER BONE FRACTURE(CLAVICLE)

The patient has fallen into his shoulder or out stretched arm or more commonly has received a direct blow to the clavicle and now present with the pain to direct palpation over the clavicle or with movement of arm or neck, there may be deformity of the bone with the swelling and ecchymosis. An infant or small child might present after a fall, not moving arm with above findings. WHAT TO DO: i. After completing the musculoskeletal examination, evaluate the neurovascular status of the arm. ii. Fit a sling or clavicle strap that comfortably immobilizes the arm. iii. Prescribe analgesics like ibuprofen or naproxen. iv. Obtain x-rays to rule out other injuries and document the fracture. v. Arrange for orthopedic follow up in a week to evaluate heeling and begin pendulum exercise of the shoulder by physiotherapy or advise patient by you. WHAT NOT TO DO:

b.

Do not apply figure of eight dressing or clavicle strap if this form of

splitting increases patients discomfort. c. Do not leave arm immobilized in a sling for more than week , this can

result in loss of range of motion or frozen shoulder, therefore instruct patient before sending home. CARPAL TUNNEL

Patient complains of pain or pins and needle sensation in the hand. Onset may have been abrupt or gradual but the problem is most noticeable upon awaking or after extended use of the hand. The sensations may be bilateral, may include pain in the wrist or forearm and is usually ascribed to the entire hand until specific physical examination localized it to the median nerve distribution. More established cases might include weakness of the thumb and atrophy of the thenaar eminence. Physical examination localizes paresthesia and decreased sensation to the median distribution and motor weakness. WHAT TO DO: i. Perform and document complete examination, sketching the area of decreased sensation and grading the strength of the hand. ii. Hold the wrist flexed at 90-degree angle for 60 seconds, to see if it reproduces symptoms, this is known as PAHALENS TEST and is more sensitive and more specific. iii. Explain the nerve compression etiology to the patient iv. Call surgical team or arrange evaluation and follow up referral.

v. Borderline diagnosis is established with electromyography(EMG) vi. Early surgical intervention is indicated when there is pain and weakness. vii. Anti-inflammatory medication, elevation of the affected hand, ice, immobilization with a volar splint and rest may all help to reduce symptoms. WHAT NOT TO DO: a. Do not rule out thumb weakness just because the thumb can touch the

little finger. b. Do not diagnose carpel tunnel syndrome solely on the basis of a positive

Tinleys sign. CYSTITIS

The patient complains of urinary frequency and urgency, internal dysuria and supra pubic pain, they may sometime have antecedent trauma in females (sexual intercourse) to inoculate the bladder and there may be blood in the urine. WHAT TO DO: i. Take urine for white cells and if possible for Gram stain. ii. If the clinical picture is clearly that of an uncomplicated lower UTI, give Ciprofloxacin and analgesics. For 7days. iii. Instruct the patient to drink plenty of water iv. If there is external dysuria, vaginal discharge, odor, itching and no frequency or urgency then evaluate for vaginitis.

v. If the dysuria is severe then prescribe Phenazopyradine (Pyridium) 200mg tid for two days only to act as surface anesthetic in the bladder. warn the patient that urine will stain orange. vi. Arrange follow up in urology department. WHAT NOT TO DO: a. Do not undertake urine culture for every lower UTI or recent onset in

non pregnant , b. c. Do not follow the single dose or 3 day regimen for possible upper UTI. Do not rely upon gross inspection of urine sample; crystals and odor

usually cause cloudiness usually from diet or medication. d. Do not require follow up visit or culture therapy unless symptoms persist

or reoccur. DIGITAL BLOCK

It is necessary to provide complete anesthesia when treating most fingertip injuries, many techniques for performing nerve block have been described, as the following is the one that is both effective and rapid in onset. This type of digital block will only provide anesthesia distal to the inter phalangeal joint, but this is most often the site that demands a nerve block. WHAT TO DO: i. Cleans the finger and paint the area with Povidine- iodine (Betadine) solution. ii. Using a 27-gauge needle, slowly inject 1%lidocain midway between the dorsal and palmer surface of the finger at the mid point of the middle phalanx.

iii. Inject straight in along the side of the periosteum, then pull with out removing the needle from the skin and fan the needle dorsally. iv. Advance the needle dorsally and inject again v. Advance the needle and inject the lidocain in the vicinity of the digital neurovascular bundle. vi. With each injection, instill enough lidocain to produce visible soft tissue swelling. vii. Repeat this procedure on the opposite side of the finger viii. With painful crush injury or when the pain will be prolonged, substitute bupivicain for lidocain WHAT NOT TO DO: a. Do not use lidocain with epinephrine, The digital arteries that can spasm

and provide prolonged anesthesia, ischemia of the fingertip and potentially necrosis.

EPIDIYMITIS

An adult male complains of dull to severe scrotal pain developing over a period of hours to day and radiating to the ipsilateral lower abdomen or flank, there may be history of recent urethritis, prostitis or prostectomy, straining with lifting heavy object or sexual activity with full bladder. There may be fever, nausea or urinary urgency or frequency .The epididymitis, is tender swollen, warm and difficult to separate from the firm, non tender testicles.

Increasing inflammation can extend up to the spermatic cord and fill the entire scrotum, making examination more difficult as well as produces frank prostatitis or cystitis. The rectal exam therefore may reveal a very tender, boggy prostitis. WHAT TO DO: i. Ascertain that testicles are normal in position and perfusion. ii. Doppler ultrasound may help pick up a drop off in arterial flow from splenic cord to testicle. iii. Palpate and auscultate the scrotum to rule out hernia. iv. Prescribe antibiotics and call surgical tem if the patient is having sever pain v. Give strong analgesics vi. Advise 2-3 days strict bed rest, with the scrotum elevated and urologic follow up. WHAT NOT TO DO: a) b) Do not miss testicular torsion Dont wait more than 4 hours other wise chance of developing ischemia

is present,

FINGER DISLOCATION

The patient has jammed his finger, causing hyperextension injury that forces the middle phalanx dorsally and proximally out of articulation with the distal end of the proximal phalanx.

An obvious deformity will be seen; there should be no sensory or vascular compromise. WHAT TO DO: i. X-Rays shaft of finger. ii. If the patient is having considerable delay and the orthopedic team is busy then give digital block. iii. To reduce the joint, do not pull on the fingertip, instead, push the base of the middle phalanx distally, using your thumb until it slides smoothly into its natural anatomical position. iv. Test the finger by extending his finger at the proximal inter phalangeal joint. v. Post reduction x-rays should be taken chip fracture may represent tendon or ligament avulsions. vi. Splint in extension for 3-4 days. vii. Inform the patient that joint swelling and stiffness may be present for months after the initial injury. viii. Remind the patient to keep the injured finger elevated. ix. Recommend the ice application for next 24 hours, and analgesics FINGER DRESSING

To provide a complete non-adherent compression dressing for an injured finger tip, a first cut out an L shaped segment from a tip of polyurethane or

oil-emulsion (Adaptec) gauze. Cover the gauze with antibiotic ointment to provide occlusion and prevent adhesion. WHAT TO DO: i. Place the tip of the finger over the short leg of the gauze and then fold it over the top of the finger ii. Take the long leg of the gauze and wrap it around the tip of the finger. iii. For absorption and compression, a fluff cotton gauze pad and apply it over the end of the finger. iv. Cover with roller or tube gauze and secure with adhesive tape. WHAT NOT TO DO: a. Do not place tight circumferential wraps of the tape around the finger,

FINGER TIP AVULSION

Mechanism of injury can be knife, a meat slicer, closing door or spinning fan blades or turning gears. Depending upon the angle of amputation, varying degree of tissue loss will occur from the volar pad, or finger tip. WHAT TO DO: i. X-ray of the crush injury caused by high speed mechanical instrument. ii. Consider tetanus prophylaxis. iii. Perform a digital block to obtain complete anesthesia.

iv. Thoroughly debride and irrigate the wound. v. When active bleeding is present , provide a bloodless field by wrapping the finger from the tip proximally. vi. On a less than one square centimeter full thickness tissue loss , apply a simple non adherent dressing with gentle compression. vii. Where there is greater than one square centimeter of full thickness skin loss there are three options that may be followed. b. Simply apply the same non adherent dressing used for smaller wound 1. Call the surgical team, if the avulsed piece of tissue is available to convert it into modified full thickness graft and suture it in place. 2. With the large area of tissue loss that has thoughrly cleaned, debrided and where the avulsed portion has been lost or destroyed, consider a thin split thickness skin graft on the site. i. In infants and young children, finger tip amputation can be sutured back on in their place as a composite graft, ii. When the loss of soft tissue has been sufficient to expose bone, simple grafting will be unsuccessful; therefore plastic surgery consultation is required. iii. Apply a protective four-prong splint for comfort. iv. Advise a course of antibiotics for 3-5 days and analgesics.

WHAT NOT TO DO:

a)

Do not apply a graft directly over the bone or over a devitalized or

contaminated bed. b) Do not attempt to stop wound bleeding by cautery or ligature. FISH HOOK REMOVAL

The patient has been snagged with a fishhook and arrives with it embedded in his skin. WHAT TO DO: i. Cleanse the hook and puncture wound ii. Provide tetanus prophylaxis iii. Give 1% local anesthesia. iv. For hooks lodged superficially, first try the simple retrograde technique. Push the back along the entrance pathway while applying gentle downward pressure in the shank. if the hook does not come out , an 18 gauge needle may be inserted in to puncture hole and use miniature scalpel blade .Manipulate the hook in to position so you can cut bands of connective tissue barb and release it v. For more deep imbedded hooks .call the surgical team WHAT NOT TO DO: a) b) Do not try to remove multiple hooks or fishing lur . Do not attempt to use the :string technique if the hook is near the

patients eye.

FOREIGN BODY BENEATH NAIL

The patient complains of paint chip or silver under the nail. Often he has unsuccessfully attempted to remove the foreign body, which will be visible beneath the nail. WHAT TO DO :(Paint Chip) i. With out anesthesia, remove the overlying nail by shaving it off with a #15 scalpel blade. ii. Cleanse remaining debris with normal saline and trim the nail edges smooth with scissors. iii. Provide tetanus prophylaxis if necessary and then dress the area with antibiotics ointment. iv. Do the bandage. WHAT TO DO (SILVER) i. If the patient is cooperative and can tolerate some discomfort, crave through the nail down to the perimeter of silver with #11 blade until the overlying nails falls away. ii. For a more extensive excision of nail wedge, you will need to perform a digital block. iii. Slide small Mayo or iris scissors between the nail and nail bed on both sides of the silver and cut out the overlying wedge of nail. iv. Cleans any remaining debris with normal saline and trim the fingernail until the corners are smooth.

v. Give inj Tetanus toxoid. vi. Dress with antibiotic ointment and bandage vii. Advise to redress after 2 3 days. WHAT NOT TO DO: a) Do not run tip of the scissors into the nail bed while sliding it under the

fingernail. GANGLION CYST

The patient is concerned about the rubbery, rounded swelling emerging from the general are of a tendon sheath or the wrist and hand .It may have appeared abruptly, been present for years, or fluctuated, suddenly resolving and gradually and returning in pretty much the same place, There is usually little tenderness, inflammation or interference with function. WHAT TO DO: i. Under take a thorough history and physical exam of the hand to ascertain that everything else is normal. ii. X-rays are of no value unless there is some question of bony pathology. iii. Explain the patient that this is a fluid filled cyst. Spontaneously arising from bursa or tendon sheath and posing no particular danger. iv. Treatment option include v. Draining the contents of the cyst with an 18gauge needle to reduce its size vi. Injecting corticosteroid i/m

vii. Follow the wishes of the patient. viii. Recurrence chances are present even with surgical excision

MINOR IMPLEMENT INJURY

A sharp metal object such as a needle, heavy wire, nail or fork is driven into or through a patient s extremity. In some instances, the patient may arrive with a large object attached. WHAT TO DO: i. If implant is acting like a lever and causing pain with movement , either immediately pull the extremity off the sharp object or quickly cut through it to release the patient, it can be cut with orthopedic cutter. ii. Obtain x-rays when pain and further damage from a leveraged object is not a problem. iii. Examine the extremity for possible neurovascular or tendon injury. iv. If surgical debridement is anticipated after removal of the object , then infiltration of an anesthetic should be provided prior to removal. v. Objects with small barbs such as crochet needle and fish spines , can be removed by first anesthetizing the area and

the applying firm traction until the barb is revealed through puncture wound. vi. After removal of the impaled object ,te wound should be appropriately debrided and irrigated vii. Tetanus toxoid is given WHAT NOT TO DO: b) Do not send a patient to x-rays with a leveraged impaled. This creates

further pain and possible injury with movement. c) Do not try to hand saw off a board to an impaled object.

IMPETIGO

Streptococcal lesion consists of irregular or somewhat circular red, oozing, erosions, often covered with a yellow =brown crust. Smaller erythmatous macular or vesicopustular areas may surround these. Streptococcal lesion present as bullae that are quickly replaced by a thin shiny crust over a erythmatous base. WHAT TO DO: i. Prescribe mupiricin 2%ointment (Bactoban) to rash TID .for three days. ii. Tell parents of small children to clean crust with warm soapy compresses before applying the antibiotic ointment.

iii. For repeatedly visiting cases to ED add a 10 days coarse of Erythromycin or penicillin VK (250mg qid) or intramuscular injection of benzathine penicillin (600,000 units i/m for children and younger, 1.2 million units for children over 7 years). iv. For suspected staphylococcus infection use dicloxacillin 250mg qid in place of penicillin or prescribe erythromycin or cefadroxil. WHAT NOT TO DO: a) Do not routinely culture these lesions. JAW DISLOCATION

The patients jaw is out and will not close, usually following a yawn , or perhaps after laughing , a dental extraction , jaw trauma or a dystonic drug reaction . The patient has difficulty speaking and may have severe pain anterior to the ear. A depression can be seen or felt in the particular area and the jaw may appear prominent. WHAT TO DO: i. If there was a no trauma (and especially if the patient is chronic dislocator) proceed directly to attempt reduction. ii. If there is any possibility of associated fracture then take xrays. iii. Have the patient sit on a low stool, his back and head braced against something firm either against the wall, facing you, or with the back of his head braced against your body, facing away from you.

iv. With gloved hands, wrap your thumbs in gauze, seat them upon the lower molars, grasp both sides of the mandible, lock your elbows, and bending from the waist. Exert slow steady pressure down and posterior. The mandible should be at or below the level of your forearm. v. In bilateral dislocation, attempt to reduce one side at a time. vi. Reassess with x-rays. vii. After reducing apply soft collar. viii. Prescribe analgesics ix. If reduction cannot be obtained using above technique, then consider admission for reduction under GA. WHAT NOT TO DO: b) c) d) Try not to get your thumb bitten when the jaw snaps back in to position. Do not put pressure on oral prosthesis that could cause them to break. Do not try to force the patients jaw.

LOW BACK PAIN

Suddenly or gradually after lifting, bending, or other movement the patient develops a steady pain in one r both sides of the lower back. At times this pain can be severe and incapacitating. It usually better on lying down , worse with

movement, and perhaps radiates around the abdomen or down the thigh , but no farther. WHAT TO DO: i. Perform a complete history and physical examination of the abdomen, back, and legs. looking for alternative causes for the back pain, ii. Consider plain x-rays of the lumbosacral spine of those who have suffered from severe pain and difficulty in bending. iii. Order and ESR on patients with history of cancer or I/V drug abuse or sign and symptoms of underlying disease. iv. For point tenderness over a sacroiliac joint with no neurologic findings to suggest nerve root compression, refer to neurosurgery team. v. Advise injection Voltran50 mg +Injection Dexamethasone 8 mg both together IM. vi. If there is acute trauma with in one hour, advise inj. Methylprednisolon, Prescribe ice to the acutely injured area, 20 minutes /hour for first day. vii. Arrange appointment for neurosurgery OPD. viii. Teach them to avoid twisting and bending when lifting and show them how to lift with back vertical, using thigh muscles and holding heavy objects close to the chest to avoid re- injury. WHAT NOT TO DO: a) Dont be eager to use narcotics pain medications.

b)

Do not apply lumber traction.

MINOR HEAD TRAUMA

A patient is brought in the emergency department after suffering a blow to the head, there may or may nor be laceration, scalp hematoma, headache, transient sleeplessness and or nausea but there was no loss of consciousness or amnesia for the injury or preceding events, seizure. Neurological changes or disorientation. WHAT TO DO: i. Take the history and ascertain why the patient was injured. ii. Perform and record physical examination of the head, looking for signs of skull fracture. iii. Perform and record a neurological examination with special attention to mental status, cranial nerves and deep tendon reflex to all four limbs. iv. If the history or physical examination suggests there is clinical evidence of intracranial injury , then call surgical/neuro team. v. Criteria for obtaining CT Scan includes 1. 2. 3. 4. Documented loss of consciousness Amnesia CSF leakage from nose or ear Blood behind the tympanic membrane or over the

mastoid (Battles sign)

5. 6. 7.

Stupor Coma Any focal neurological sign.

vi. If there is no clinical indication for CT Scan or skull x-rays, explain to the patient and concerned family and friends. Many patients expect x-rays, but gladly forego them once you explain they are of little value. vii. Make sure that family understood and are given written instructions that 1) 2) 3) 4) 5) 6) 7) 8) 9) WHAT NOT TO DO: a) b) Do not skip on the neurological examination or its documentation. Do not be reassured by negative skull films, which do not rule out Any abnormal behavior Increasing drowsiness Difficulty in arousing the patient Headache Neck stiffness. Vomiting visual problem Weakness Seizures are signals to return to the ED.

intracranial bleeding or edema.

MUSCLE STARINS AND TEARS

Strains occur during or after a vigorous over stretching of a muscle bundle that leads to an insidious development of pain and tightness that is worse with use and better with rest. Tear of the muscle belly tend to be partial, with sudden onset pain and partial loss of function. Often a tear occurs with considerable bleeding that can lead to remarkable hematomas causing swelling at the site and dissecting along tissue planes to create e ecchymosis at a distant. Complete tears are more likely in the tendinous part of the muscle, WHAT TO DO: i. Obtain a history of mechanism of injury. ii. A complete tear of a muscle merits orthopedic consultation. iii. For muscle strain, provide soft splint, analgesics and instruct the patient to apply warm moist compresses for comfort. iv. For muscle tear, construct a loose splint to immobilize the injured part and instruct the patient in rest, elevation and ice.

NAIL ROOT DISLOCATION

The patient has caught his/her finger in the car door, or dropped a heavy object, like a cane of vegetable on a bare toe, with the edge of the cane striking the base of the toenail and causing a painful deformity. The base of the nail will be found resting above the eponychium instead of its normal anatomical position beneath. WHAT TO DO: i. Take an x-rays to rule out an underlying fracture ii. Anesthetize the area using digital block. iii. Lift the base of the nail off the eponychium and thoroughly cleanse and inspect the nail bed. iv. Minimally debride loose cuticular tissue and test for a possible avulsion of the extensor tendon. v. If bleeding is the problem, then establish a bloodless field using a tourniquet vi. Repair any nailed laceration with a fine absorbable suture like a 7-0 or 6-0 Vicryl. vii. Reinsert the root of the nail under the eponychium. viii. Reduce any underlying fracture. ix. If the nail tends to drift out from under the eponychium. it can be sutured in place with two 4-0 nylon. x. Any non absorbable sutures should be removed after one week. xi. Provide Tetanus Prophylaxis xii. Follow up should be provided in 3-5 days either in surgical OPD or ED.

xiii. Advise analgesics and antibiotics WHAT NOT TO DO: a) Do not ignore the nail root dislocation and simply provide a fingertip

dressing. b) Do not debride any position of the nail bed, sterile matrix or germinal

matrix.

NAIL BED LACERATION

The patient has either cut into his nail bed with a sharp edge or crushed his finger. With shearing forces, the nail may be avulsed from the nail bed to varying degrees and there may be an underlying bony deformity. WHAT TO DO: i. Provide appropriate tetanus prophylaxis. ii. Obtain x-rays of any crush injury or any injury caused machinery. iii. Perform digital block. iv. Remove the nail surrounding the laceration to allow for suturing the laceration closed v. Use straight hemostat to separate the nail from the nail bed.

vi. Use the scissors to cut away the surrounding nail or remove the entire nail intact for re-insertion. After the nail bed is repaired. vii. Cleanse the wound with saline and suture accurately with a fine absorbable sutuer6-0 or 7-0. viii. Apply a non-adherent dressing and antibiotics antiseptic ointment and plan to change the dressing after the 24 hours. ix. When a crush injury results in open hemorrhage from under the fingernail; , the nail must be completely elevated to allow proper inspection of the damage to the nail bed. x. Apply a fingertip dressing. WHAT NOT TO DO: a) b) nail. c) Do not do any more than minimal debridement of the nail bed and its Do not use non absorbable suture Neither does nor attempts to suture a nail bed laceration through the

surrounding structures. NECK STRAIN(CERVICAL)

The patient may arrive directly from a car accident, arrives the following day or long after. The injury occurs when the neck is subjected to sudden extension and flexion, possibly injuring inter vertebral joints and ligaments, cervical muscles, or even nerve roots, as with other strain and sprains, the stiffness and pain may tend to peak on the day following the injury. WHAT TO DO:

i. Obtain a detailed history to determine the mechanism and severity of the injury. ii. Examine the patient for involuntary splinting, point tenderness over the spinous processes of the cervical vertebrae, cervical muscle spasm or tenderness and for strength, sensation and reflexes in the arm. iii. Take the x-rays lateral view of cervical spine. If necessary then AP view and open mouth view of odontoid can also be obtained. iv. To evaluate the head trauma ask the history of loss of consciousness. v. If there is no evidence e of injury then explain the Patient that stiffness and pain will relieve with in 24 hours to 3-4 days. vi. Treat with one or two days of immobilization (a soft collar), topical ice for the first day, then heat for the later spasm vii. Anti inflammatory analgesics (aspirin, ibuprofen. naproxen) viii. Arrange follow up.

WHAT NOT TO DO: a) D o not forgot to tell the patient his symptoms may well be worse a day

after the injury. b) c) D o not skip recording the history and physical exam. D o not x-rays every sore neck.

NEEDLE IN THE FOOT

Although a needle could be embedded under any skin surface, most commonly a patient will have stepped on one while running or sliding bare foot on carpeted floor. WHAT TO DO: i. Tape a partially opened clip as a skin marker to the planter surface of the foot, with the tip of the opened paper clip over the entrance wound. ii. Send the patient for x-rays AP/LAT view of the foot. iii. If the needle appears very deep in x-rays then refer the case to surgical team iv. If the needle is superficial then tourniquet the foot, elevate the, apply BP cuff at thigh and inflate approximately 200 mm HG. v. Remove the tourniquet and paint the area with Povidine. vi. The x-rays should give you an idea of the location of the needle relative to the paper clip skin marker. vii. With the patient lying prone and planter surface of his foot facing upward. viii. Make an incision that crosses perpendicular to the needles apparent position at its midpoint, use iris scissors with the blade open to advance a few millimeters at time before closing the scissor blade.

ix. Continue repeating this process until needle prevents closure of the scissors, if you are using the scalpel blade then there will be audible clicking sound. x. Visualize the needle and grasp it with Kelly clamp. xi. Now push the needle out in the direction from which it entered. xii. Let the thigh cuff down and suture over the skin and apply appropriate dressings, xiii. Provide inj Tetanus Toxoid. WHAT NOT TO DO: a) Do not ignore the patient who thinks he stepped on a needle but in

whom you cannot find a puncture wound, Get an x-rays anyway. b) c) Do not give impression to the patient that removal is easy and quick. Do not make incision near the tip of the needle or directly over and

parallel to the needle. d) e) Do not extend the incision if you dont find the needle. If you dont find the needle with 10 minutes, discontinue the attempt

and call ortho/surgical team. f) Do not attempt to remove the buried needle by pulling on the attached

thread.

PARONYCHIA

The patient will come with finger and toe pain that is either chronic or recurrent in nature or has developed rapidly over the past several hours, accompanied by redness and swelling of the nail fold, there are three distinct varieties. WHAT TO DO: a. Perform uni or bilateral digital block, and establish a blood less field, b. Consider conservative treatment and put a cotton wedge under the corner of in growing nail, and place the patient on antibiotics. c. Try to excise the entire wedge of the affected nail; nail bed and lateral skin fold down to the periosteum of distal phalanx. d. Instruct the patient to soak the toe in warm water for 20 minutes daily two to three times and arrange an ED visit if required. e. In case of acute paronychia there is minimal swelling and there appears to be only cellulitis, gently use an 18 gauge needle to separate the cuticle of the lateral nail fold to rule out or drain any pus. f. A more aggressive approach for the more extensive infection is to excise a portion of the nail. After establishing a digital block and a bloodless field, simple insert a fine straight hemostat between the nail and the nail bed along the edge adjacent to the paronychia. g. In case of subungual abscess consider a conservative treatment not requiring a digital block. h. When there is a distal collection of pus, simple excision of an overlying wedge of nail using iris scissors should provide a complete drainage.

WHAT NOT TO DO: Do not order culture or X-Rays on uncomplicated cases. Do not make an actual skin incision Do not remove an entire fingernail or toenail to drain a simple

paronychia. Do not confuse a felon (tense tender finger pad) with a paronychia;

Felons will require more extensive surgical treatment.

PENCIL POINT PUNCTURE

A small puncture wound lined with graphite tattooing will be present; pencil tip may or may not be present, visible, or palpable. If the puncture wound is palpable, an underlying pencil point may give the patient a foreign body sensation. WHAT TO DO: 1. Reassure the patient or parents 2. Palpate and inspect for foreign body, I uncertain get an x-rays or ultrasound to rule out the presence of foreign body. In order to reduce the amount of tattooing, the wound may be anesthetized and scraped (derma braded) with the tip of a scalpel blade. It is unwise to excise the entire wound because

the resultant scar might be more unsightly that the tattoo. ii. Scrab wound. iii. Administer tetanus prophylaxis, if necessary. iv. Warn the patient or family about signs of infection, and inform them that there will be a permanent black tattoo that can be removed later if the resulting mark is cosmetically unacceptable. WHAT NOT TO DO: Do not excise the entire wound on the initial visit.

PERIORBITAL AND CONJUCTIVAL EDEMA

An allergen or chemical irritant on the hand may cause periorbital edema long before reaction, there may be minimal to marked generalized conjuctival swelling, tenderness and pain should be mild or absent and no erthyma of the skin. Visual acuity should be normal and there should be uptake of Fluorescein over the cornea. WHAT TO DO:

i. After completing the full eye examination, reassure the patient that this is not as serious as it looks. ii. Instruct the patient to use cool compression to reduce swelling and discomfort iii. Inquire about the cause, including allergies and chemical irritants iv. Warn the patient about the potential signs of infection v. Prescribe Hydroxizine 6 hourly for mild to moderate cases and add steroids for severe cases. WHAT NOT TO DO: Do not apply heat, swelling and pruritis will increase. Do not confuse this with periorbital cellulitis

PELVIC INFLAMMATORY DISEASE

A woman aged 15-30, may complains of lower abdominal pain and there could be associated vaginal discharge, foul odor, dysuria, and dysparenuria. Menorrhagia or intermenstrual bleeding. Patient with more severe infection may develop fever, malaise, nausea and vomiting. Woman with severe pelvic

pain tend to walk slightly bent over holding their lower abdomen and shuffling their feet. WHAT TO DO: i. Perform a pelvis examination ii. Obtain end cervical culture iii. Obtain blood for syphilis serology. iv. Do urinalysis for pregnancy test. v. Perform pelvic ultra sound if there is suspected mass, severe pain or positive pregnancy test. vi. Remove any intrauterine device. vii. Treat suspected cases while awaiting diagnostic confirmation viii. Hospitalize such cases with salphingitis. ix. Treat mild to moderate cases as outpatients with one dose of Ceftroxoe1gm stat x. Provide for follow up in 14 days. xi. Advise analgesics. xii. Instruct the patient to avoid intercourse for at least two weeks. xiii. Counsel the patient for the sexually transmitted disease.

WHAT NOT TO DO:

 age.

Dont use Ofloxacine in pregnant woman or patient under 18 years of

Do not miss the more unilateral disorder like ectopic pregnancy,

appendicitis ovarian cyst or torsion. Do not diagnose PID in pregnant with out ruling out ectopic pregnancy. Do not ignore pelvic symptoms if the patient has prehepatic

inflammation.

PINWORM OR THREAD WORM

The patient complains of perineal itching, which is worse at night and may complain to insomnia or super infection of the excoriated peri anal skin, Often a entire family is involved. WHAT TO DO: i. Examine the anus to rule out other causes of itching. ii. Look for the pinworm directly and by pressing the sticky side of cellophane tape wrapped around tongue blade to the perineal skin. Examine the tape under the low power of microscope for female worms. iii. If you suspect or still see pinworm, administer a single oral dose of pyrantel pamoate 11mg/75 kg. Alternate drug is mebandazole (vermox) 100mg in a single dose PO.(not for infants and pregnant woman) iv. Explain to all that it is not a dangerous infection and that it should be eradicated from all family.

PLANTARIS TENDON RUPTURE

The patient will come in limping, having suffered a whip like sting in his calf while stepping off hard on his foot. The deep calf pain persists and may accompanied by mild swelling and ecchymosis, Neurovascular function will be intact. WHAT TO DO: i. Rule out an Achilles tendon rupture (Squeeze the Achilles tendon and palpate for tender deformity that represent a torn segment. ii. When Achilles tendon rupture is ruled out, provide the patient with elastic support from foot to tibial tuberosity. iii. Provide the patient with crutches for several days. iv. Permit weight bearing only as comfort allows. v. Ask the patient to keep legs elevated and rest for next 2448 hours with heat after every few hour. vi. Have an analgesic such as NSAID or Codeine may be helpful initially. WHAT NOT TO DO: Do not take X-Rays unless there is suspected associated injury. This is a

soft injury that is not having fracture.

POLYMYALGIA REHUMATICA

An elderly patient (females commonly) complains of week or two of morning stiffness, which may interfere her ability to raise up from bed but improves during the day. She may ascribe her problem as muscle weakness or joint pain. Physical examination discloses that symmetrical pain and tenderness of neck, shoulder and hip muscles are the actual source of any weakness, there may be mild arthritis of several peripheral joints but the rest of the physical examination is normal. WHAT TO DO: i. Confirm the diagnosis by obtaining an ESR that should be in the 30-100mm/hr. ii. Mild to borderline cases may respond with NSAID (Ibuprofen/Naproxen) more severe cases will respond to Prednisolone 20-60 mg QID with a week or two after that dose should be tapered. iii. Failure to respond to corticosteroid therapy suggests some other diagnosis.

iv. Explain the syndrome to patient. WHAT NOT TO DO: Do not miss temporal artritis. Do not postpone diagnosis or treatment of temporal artritis pending

result of a temporal artery biopsy showing giant cell artritis.

RHUS CONTACT DERMATITIS (POISON IVY OAK )

The patient is troubled with pruritis rash made up of tense vesico-papular lesions on a mildly erythmatous base. Typically these are found in groups of linear streaks and may be weeping, crusted or confluent. If involvement is severe there may be marked edema. Particularly on the face and periorbital and genital area. WHAT TO DO: 1. Have the patient apply cool compresses of Burrows solution for 20 -30 minutes every 3- 4 hours. 2. Small areas can be treated 2-3 times per day, enhanced at night with a occlusive plastic wrap dressing Diphenhydramine or Hydroxizine (Atarax) 25 mg PO TDS will help itching. 3. Taped tub bath with baking powder (1 cup of each in tub) will provide soothing effect

4. When there is involvement of face in severe reactions or in situations where the patients livelihood is threatened, early and aggressive treatment with Inj Adrenaline 3mg I/M and systemic corticosteroids should be initiated. 5. Prednisolone (60-80mg)/day tapered over 2 weeks will be necessary to prevent a late flare up.

WHAT NOT TO DO: Do not institute systemic steroids in the face of secondary infection such

as impetigo, cellulitis or erysipelas, Do not start steroids if there is history of tuberculosis, diabetes, herpes

or severe hypertension. PROSTITIS

A man complains of fever. Chills, perineal or low back pain and may have urinary urgency and frequency as well as sign of obstruction to urinary flow ranging from a weak stream to urinary retention. WHAT TO DO: i. Perform a rectal examination only once, gently palpate the prostate to see if its tender, swollen or edematous. ii. Culture the urine to help identify the organism responsible. iii. For patients 35 years old and younger, treat with Ceftrioxone 125 i/m -1000mg i/v and Azithromycin 1gm PO

iv. For men over 35 years old begin empirical treatment with ciprofloxacin 400mg i/v, then 500 mg PO bid. v. Arrange for Urologic follow up.

WHAT NOT TO DO: Do not message or repeatedly palpate the prostate

PULPITIS

The patient develops a sharp and throbbing pain, it is due to the fluid and gaseous pressure with in closed cavity. Heat increases the volume and hence the pain, while cold reduces it. WHAT TO DO: 1. Administer a strong analgesic such as oxycodone in combination with acetaminophen and prescribe additional medication for home use including NSAID. 2. Severe pain may require nerve block.

3. If small cavity is present, insert a small cotton pledge soaked in xylocain or oil of cloves. Cotton should fill up the cavity with out rising above the opening. 4. Refer the patient to dental OPD. WHAT NOT TO DO: Do not prescribe antibiotics with out signs of cellulitis or abscess

formation. PUNCTURED WOUND

Most commonly, the patient will have stepped or jumped on to a nail, there may be pain and swelling but often the patient is only asking for tetanus and shot and can be found in the emergency department with his foot soaking in a basin of iodine solution. Small, clean, superficial puncture wounds uniformly do well. The pathophysiology and management of wound is dependent upon the material and punctured the foot, the location, depth, and time to presentation.

WHAT TO DO: i. Obtain the detailed history to ascertain the force involved in creating the puncture and the relative cleanliness of penetrating object. ii. Clean the surrounding skin and carefully inspect the wound with the patient lying prone, with good light and adequate time.

iii.

Most puncture wounds only require simple debridement and irrigation, but with deep, highly contaminated wounds, seek orthopedic consultation.

iv.

Suture the puncture wound using a 10# scalpel blade to remove the epithelium.

v.

If debris is found, gently slide a large gauge blunt needle catheter down the wound track and slowly irrigate with physiologic saline solution until debris no longer flows from the wound.

vi. vii.

Provide tetanus toxoid prophylaxis. Cover the wound with bandage, instructs the patient on warning signs of infection.

viii. ix.

Arrange the follow up in surgical OPD. Patients presenting after a day will often have established wound infection.

WHAT NOT TO DO: Do not reassure falsely the patient soaked its wound in Povidine. Do not attempt a jet lavage with in puncture wound. Do not get X-RAYS for simple nail punctures except for the unusual case

where large particulate debris is suspected to be deeply imbedded with in the wound. Do not prescribe antibiotics until there is suspicious of infection. Do not allow beginning soak at home. PYELONEPHRITIS ( UPPER URINARY TRACT INFECTION)

The patient has some combination of urinary frequency, dysuria, flank pain, nausea, fever and chills. There is tenderness elicited by percussing the Costovertebral angle over the kidneys. Urinalysis may help establish the diagnosis with tubular casts of white cells. Studies have shown that 14 days oral treatment is beneficial for the woman with clinical evidence of pyelonephritis. WHAT TO DO: 1. Examine urine for presence of gram positive cocci and send urine for culture. 2. Admission is arranged if the patient is having nausea. Vomiting, feverish or pregnant and WBC are increased. 3. For stable, otherwise healthy patients start with first dose of intravenous antibiotics in ED (Ceftrioxone 1000-2000mg), then discharge home on oral hydration and two weeks of oral antibiotics (Septran 800mg BID, Ciprofloxacin 500mg BID, Norfloxacin 400mg BID or Ofloxacine 400mg BID X 14 Days) 4. Instruct the patient to return to the ED for re evaluation in 24 -48 hours and sooner if the symptoms worsen. Most patients improve on this regimen, but others require hospital admission. WHAT NOT TO DO: Do not miss follow up in ED Do not miss an infection above the urethral stone by doing USG. Dont advise blood culture if the patient is discharged from ED.

RABIES PROPHYLAXIS

When a contagious animal bites the patient, saliva, brain tissue or CSF contaminated an abrasion or mucous membrane. Patients with immunosuppressive illness or those taking corticosteroids or antimalarial drugs may an inadequate immune response to vaccination. Pregnancy is not a contraindication to vaccination. Incubation period of Rabies varies from weeks to months roughly in proportion to the length of the axons up which the virus must propagate to the brain , which is why prophylaxis is essentially urgent in facial bites. WHAT TO DO: i. Cleaning of all bite and scratch wounds with soap and water, 2% benzalkonium chloride, and/or a veridical agent (Povidine-iodine solution) ii. iii. When appropriate, wound closure should be avoided. Rabies vaccines 20 IU /kg, the human diploid cell vaccine (HDCV, Imovax) and the purified chick embryo cell vaccine (PCECV, RabAvert) is given I/M in deltoid muscle. iv. Make arrangement for repeat doses of HDCV at 3, 7, 14 and 28 days post exposure. v. Tetanus prophylaxis is usually indicated, to prevent bacterial infection. vi. vii. Inform the Public Health department. Notify the case.

WHAT NOT TO DO: Do not change the vaccine once a vaccination series is initiated, it is

usually completed with the same vaccine product. Do not treat the bites of Rodents and Lagomorphs (hamsters , rabbits,

squirrels , rats etc) unless rabies is endemic in area, because they dont cause human rabies. Do not use the gluteal region, because this could result in a decreased

immunologic response. HRIG should not be administered. RECTAL FOREIGN BODY

The treatment of rectal foreign bodies has been discussed in the medical literature for many years. Controlled studies of patients with rectal foreign bodies have not been conducted. These patients usually present to the ED because the object is inserted by him/herself with of pain, acute urinary retention often after multiple attempts to remove the object. Presentation is almost always delayed because of embarrassment. Sometimes the patient will not volunteer that any object has been inserted or give outlandish explanations such as having sat or fallen on to object. When interviewed privately. WHAT TO DO: 1. Respect for their privacy, evaluation of the type and location of the foreign body, if removal can be performed in the ED or if surgical

referral is needed, and use appropriate techniques for removal 2. Perform an abdominal and rectal exam, check for rebound tenderness. 3. Start bilateral intravenous lines and take blood for CBC, BIO and do XRAYS Plain abdomen to look for free air under diaphragm. 4. Sedate the patient with benzodiazepines and narcotics to help to remove the object. 5. If the patient feels pain then use local 1% Lidocain Jelly. 6. When the examining finger can reach the object and it is of a nature that will allow it to be grasped, lax anal sphincter may allow you slowly to insert as much as gloves grab the object and gradually take it out. 7. If you are unable to to pull out then ii. Slide a large Foleys catheter with 30 cc balloon

past the object, inflate the balloon and apply traction to the catheter, two catheters may occasionally be needed and air can be instilled through the lumen of catheter.

iii.

Under direct visualization with a endoscope or

vaginal speculum, grasp the object with tenaculum, sponge forceps, Kellys clamp or Tonsil snare. iv. An open object, like a jar or bottle, can be filled

with wet plaster, into which a tongue blade can be inserted like a pop stick . When the plaster hardens, retraction can be used to remove. v. Forceps or soupspoons can be used to deliver a

round object. 1. With an object that is too high to reach, the patient can be admitted and sedated for removal. 2. When blood is present in the rectum or the object is capable of doing harm to the bowel, then sigmoidoscopy should be performed after removal the object. 3. Keep the patient for observation until the bleeding and pain s relieved. WHAT NOT TO DO: it. Do not blindly grasp the object with tenaculum or other such device, this Dont pressurize the patient to give you the exact story. Do not push the object higher into the colon while attempting to remove

can itself cause perforation.

Do not attempt to remove sharp, jagged objects such as broken glass

via the rectum; these should only be removed under anesthesia in OP. Do not send the patient home who is having pain home, admit and

observe for peritoneal signs, increased pain, fever and rising white count. REMOVAL OF DISLOCATED CONTACT LENS

The patient may know the lens has dislocated into one of the recesses of the conjuctiva and complains of only refractory correction. There have been rare cases of lens perforation of the conjuctival sac and migrating posterior to the globe. Pain and blepharospasm suggests a corneal abrasion.

WHAT TO DO: 1. If pain and blepharospasm are a problem, topically anesthetize the eye. 2. Pull back lids as when looking for conjuctival foreign bodies, invert the upper lid and if necessary instill Fluorescein dye. 3. If the lens is loose, slide it over the cornea and let the patient remove it in the usual manner. 4. Irrigate the eye as it looses the stuck lens. 5. For a more adherent lens use commercially available lens suction cup. 6. After removing, put the lens in a proper container (sterile saline)

7. Complete the eye examination, bright light and Fluorescein examination. 8. Patch the eye if there is corneal abrasion. 9. Instruct the patient not to wear the lens until all symptoms have abated for 24 hours 10. Arrange the appointment for ophthalmologist.

WHAT NOT TO DO: Do not give up so easily. Lost lens have been excavated already. Do not omit the Fluorescein test for fear of spoiling a soft contact lens

RING REMOVAL

A Ring has become tight on the patients finger after an injury or after some other cause of swelling, tight fitting rings obstruct lymphatic drainage causing swelling and further constriction, sometime person has very personal attachment with ring therefore he/she does not that ring is cut off. WHAT TO DO: i. Limit further swelling by applying ice and elevating the extremity above the level of the heart. ii. When there is suspicion of fracture, order for x-rays. iii. Apply a digital block for comfortable removal.

iv. Lubricate with soap and water. v. When the ring is too tight to twist off this way, exsanguinate the finger by applying a tightly wrapped spiral of Pensore drain or felt rubber phlebotomy tourniquet tape around the exposed portion of the finger, elevate the hand above the head, wait five minutes and then apply a BP cuff inflated to200-300 mmHg, wrap the cuff with cotton cast, remove the tight rubber wrapping from the finger and, leaving the tourniquet in place, again attempt to twist the ring off using soap and water lubrication. vi. If the ring is still too tight or there is too much pain to allow the above technique, a ring cutter /bone cutter can be used through a narrow ring band. vii. Another technique which tends to be effective is the coiled string technique, slip the end of string under the ring and wind a single layer coil down the finger, compressing the swelling as you go. Pull up on the end of string under the ring, then slide and wiggle the ring down over the coil. viii. Another ring removal method is to pull a length of string under the ring and tie it into large loop that you can place around your own wrist, This will allow you to apply traction and slide the string around the circumference of the ring while you pull the ring off using lubricant as above. WHAT NOT TO DO: If the patient request, not to cut the ring, dont cut until there is vascular

compromise (pallor, cyanosis or pain). He should then be understood that he is to return for further care if the circulation becomes compromised.

RUPTURED EAR DRUM

The patient will present with ear pain after barotraumas, such as a blow to the ear or deep water diving or after direct trauma with a stick or other sharp object, Hemorrhage will often be noticed with in the external canal and the patient will experience some hearing loss. Tinnitis or vertigo may also be present. Otoscopic examination will reveal a defect in the tympanic membrane that may or may not be accompanied by disruption of the ossicles. WHAT TO DO: i. Clear out any debris from the canal, using gentle suction. ii. Test for nystagmus and gross hearing loss. iii. Place a protective cotton plug inside of the ear canal and instruct the patient to keep the canal dry. iv. Prescribe an appropriate analgesics. v. Ensure that the patient gets early follow up by an ENT team. WHAT NOT TO DO: Dont instill any fluid into the external canal or allow the patient to get

water into his ear.

SATURDAY NIGHT PALSY (RADIAL NEUROPATHY)

The patient has injured his upper arm, usually by sleeping with his arm over the back of a chair and now presents holding the affected hand and wrist with

his good hand, complaining of decreased or absent sensation on the radial and dorsal side of his hand and wrist, and inability to extend his wrist, thumb and finger joints, With the hand supinated (palm up) and the extensor aided by gravity, hand function may appear normal, but when the hand is pronated (palm down) the wrist and hand will drop, WHAT TO DO: i. Look for associated injury ii. Document in detail all motor and sensory impairment iii. Draw a diagram of the area of decreased sensation and grade the muscle strength. iv. Put a splint, extending extending from proximal forearm to just beyond metacarpophalyngeal joint (leaving the thumb free). v. Explain to the patient, nature of the nerve injury, slow rate of regeneration and importance of splinting and physical therapy. WHAT NOT TO DO: Dont be misled by the patient s ability to extend the interphalangeal

joints of the fingers that may be accomplished by the ulner innervated interosseous muscles.

SCABIES

Patient develops itching and unable to sleep, Papules and vesicles along thread like tracks are chiefly found in the longitudinal web spaces as well as on the volar aspects of the wrists, antecubital fossa, olecranon area, nipples umbilicus, lower abdomen, genitalia and gluteal cleft, secondary bacterial infection is often present. WHAT TO DO: i. Attempt identification of the mite by placing mineral oil over the papules or vesicles at the proximal end of a track and scraping it with scalpel blade. ii. If the clinical picture is convincing, treatment must be started immediately. iii. Treat with Linden lotion; apply a very thin layer of lotion once over entire body from the neck down to the bottoms of feet. Tell the patient that itching will not go soon as dead mites and eggs continue to itch as the body absorbs them. iv. Alternatively, treat the patient with similar application of crotamiton (Eurax) lotion or cream at the body after taking bath, advise to repeat after 24 hours, v. Advise the patient that clothing, bedding, and towel should be washed with hot water or dry cleaned to prevent reinfection. WHAT NOT TO DO: Do not use Linden lotion on infants, young children or pregnant women, Do not leave it on the skin more than 12 hours.

SEIZURE

A seizure is a general term for a sudden attack. The term seizure is used in neurology to refer to the sudden onset of abnormal electrical discharge within the brain that can lead to convulsions. Convulsions are uncontrolled violent spasms (jerking) of muscles of the body. Epilepsy is the medical term for the condition of having chronic seizure disorder. There are two kinds of seizures, focal and generalized. There are many causes of epilepsy. Treatment of epilepsy (seizures) depends upon the cause and type of seizures experienced. Patient with grand mal seizures can injure themselves and generalized seizures can be prolonged for more than a couple or minutes and can lead to hypoxia, acidosis and even brain damage. WHAT TO DO: i. If the patient is having grandmal seizure, do suctioning and turn the position on his side, but the breathing will be uncoordinated until the phase is over. ii. Watch the pattern of the seizure for clues to the etiology. iii. If the seizure has last more than two minutes and recurs before the patient regains consciousness, this is defines as status epileptics and is best treated with inj. Diazepam (valium) 5-10 mg i.v. Followed by gradual loading of i.v Phenytoin sodium.

iv. Check finger stick blood sugar and administer intravenous 50% glucose in case of adult and 5%in case of children. v. If the patient arrives postictal, examine him/her thoroughly for external injuries. vi. Repeat neurological examine after recovering from the postictal phase. vii. If the patient arrives awake and oriented following an alleged seizure, corroborate the history through witnesses or the presence of injuries like a scalp laceration or bitten tongue. viii. Check old record, if the record is not available regarding the anticonvulsant medications, then take drug history ix. If the drug history is not clear and the patient is known case of epilepsy, draw blood for drug level. x. If the seizures are clearly related to alcohol withdrawal. Ascertain the reason, and giving Benzodiazepines should medically treat his withdrawal. xi. If the seizure is of new onset, and present with postictal state, never discharge the patient and make necessary arrangement for the EEG or CT scan brain either by admission or OPD appointment and draw blood for Serum electrolytes, glucose and calcium, magnesium and albumin, xii. If the patient is being discharged from emergency department, prescribe tab Tegretal 200mg TDS until the date of appointment in OPD WHAT NOT TO DO:

Do not stick anything in the mouth of seizing patient. The ubiquitous

padded throat sticks may be nice for a patient to hold and bite on the first sign of a seizure, but do nothing to protect his airway and is ineffective when the jaw is clenched. Do not rush to give intravenous diazepam to a seizing patient. Most

seizures stop in a few minutes, it is diagnostically useful to see how the seizure resolves on its own, the patient will awake soon, if he has not been medicated and dont give diazepam in postictal, reserve for genuine status epileptics. Do not treat alcohol withdrawal seizures with Phenobarbital or

Phenytoin. Both lack efficacy. Do not rule out Alcohol withdrawal symptoms on the basis of a toxic

serum ethanol level Dont confuse seizure with pseudo seizures and give pinching or

irritating solutions or the patient comes in postictal state. Do not release a patient with persistent neurological abnormalities with

out a CT Brain or specially consultation. Do not let seizure victim drive at home. SEROUS OTITIS MEDIA

Following an upper respiratory tract infection or an airplane flight, an adult may complain of feeling of fullness in the ears, inability to equalize middle ear pressure decreased hearing and clicking, popping or crackling sounds especially when the head is moved. There is a little pain or tenderness. Through Otoscope, tympanic membrane appears retracted with dull to normal light reflex and air fluid level or bubbles could be seen through ear drum,

hearing would be decreased and Rinne test will show decreased air conduction. WHAT TO DO: i. Tell the patient to lay down supine with head tilted back and towards the effective side and then instill vasoconstrictive nose drops like Phenylephirine or Oxymetazoline 0.05% wait two minutes for nasal mucosa to shrink, reinstill nose drops and wait an additional 2 minutes for the medication to seep down to the posterior Pharyngeal wall, around the opening of the Eustachian tube, Advise the patient to repeat the same after every 4 hours for 3 days. ii. After each treatment with nose drops, instruct the patient to insufflate his middle ear via his Eustachian tube by closing his mouth, pinching his nose shut and blowing until his ear POP iii. Unless contraindicated by hypertension or other medical conditions add a systemic vasoconstrictor (Pseudoephedrine60mg qid). iv. Ask the patient to follow up in ENT clinic if there is no improvement.

WHAT NOT TO DO: Do not allow the patient to become habitual of vasoconstrictor drops. Do not prescribe anti histamines (which dry out secretion) unless clearly

indicated by an allergy. SHINGLES (HERPES ZOSTER)

Patient complains of pain, paresthesia or an itch that covers a specific dermatome and then develops into a characteristics rash. Prior to the onset of rash, Zoster can be confused with pleuritic or cardiac pain, cholecystitis or urethral colic. After 3-5 days from the onset of symptoms an eruption of erythmatous macules and papules will appear, first posteriorly then spreading anteriorly along the course of the involved nerve segment. In most instances grouped vesicles will appear with in next 24 hours. Herpes zoster most often occurs in the thoracic and cervical segment. WHAT TO DO: i. Prescribe Acyclovir (Zovirax) 800 mg five times a day. Skip a dose at night or Famiclovir 500mg TDS x 7d. ii. Prescribe analgesics appropriate for the level of pain the patient is experiencing, antinflamtory may help but narcotics are required. iii. Dressing the lesions with gauze and splinting them with elastic wrap may also help bring relief. iv. Secondary infection should be treated with Povidine iodine (Betadine) ointment or systemic antibiotics. v. An ophthalmologist should evaluate ocular lesions.

WHAT NOT TO DO:

Dont prescribe systemic steroids to prevent post herpetic neuralgia,

especially for patient at risk i.e. with latent tuberculosis, peptic ulcer, diabetes mellitus, hypertension and congestive heart failure. SHOULDER DISLOCATION

Patient was holding his shoulder abducted horizontally to the side when a blow knocked the humeral head anteriorly .he arrives holding the shoulder abducted ten degree from his side, unable to move it without increasing the pain, the deltopectoral groove is now a bulge and acromian is prominent laterally with a depression below. i. WHAT TO DO: i. Provide analgesia, and intravenous narcotics are preferable. ii. A qualified Physician can give conscious sedation that may be mild to moderate. iii. Intra-articular Lidocain 2cm inferiorly and directly lateral to the acromian in the lateral sulcus left by the absent humeral head iv. Take pre-reduction x-rays to rule out fracture or unreduceable injuries. v. Test and record the sensations over the deltoid to establish if there is an injury of the axillary nerve and confirm the circulation, sensation and movement in the elbow, wrist and hand. vi. Gain the confidence by holding his arm securely, asking him to relax telling that you will not do anything suddenly and that if any pain occurs you stop. Then in very calm and

gentle manner ask him to let his muscle go loose so his shoulder can stretch out. vii. With the elbow flexed at 90 degrees, apply steady traction at the dorsal humerus, pull inferiorly by applying sheet under the arm pit and one stabilizes the shoulder and other holds the sheet. If the patient complains of pain, stop rotation and increase the dose of analgesia. viii. If you do not feel or see the reduction of shoulder joint, then, while maintaining traction and external rotation, slowly and gently adduct the humerus until it is against the chest wall and softly rotate internally the forearm against the anterior chest. ix. An alternative technique when you can palpate the lateral border of the scapula is reduced by scapular manipulation. With the patient sitting up, place the uninjured shoulder firmly against an immoveable support such as wall or the raised head of the stretcher. Have an assistant face the patient and gently lift the outstretched wrist of the affected arm until it is horizontal. Assistant then gently put firmly pulls the patient s arm towards him .At the same time manipulate the scapula by adducting the inferior tip using thumb pressure, while stabilizing the superior aspect with your upper hand. x. When the patient is comfortable and range of motion has restored, secure the reduction in a sling and swath around the arm and chest. Obtain post reduction X-Rays and discharge the patient once he is alert with a prescription of analgesics as needed and an appointment for Orthopedic follow up in a week or sooner.

WHAT NOT TO DO: Dont use forearm as a lever to fracture the neck of the humerus. Dont redislocate the shoulder by repeating the motions of the

mechanism of injury

SHOULDER SEPARATION (ACROMIOCLAVICULAR JOINT)

The patient fell on the point of the shoulder. He my come in right away because it hurts even with out movement, or he may come in days later with out pain, having noted the injured shoulder hangs lower or the clavicle rides higher WHAT TO DO: i. Examine the shoulder; the diagnosis is supported by tenderness at the lateral end of the clavicle where it joins the acromian process coming up from the scapula and by pain on pulling the humerus down towards the feet, distracting the acromioclavicular joint. Strength may be decreased because of pain, but other bones, joints; range of motion, sensation and circulation should be documented as intact. ii. X-Rays of the shoulder to be sure that there is no associated fracture of the lateral clavicle or fracture or dislocation of the humerus.

iii. Support the injured joint with a sling. iv. Provide additional analgesia. Ibuprofen or Naproxen 500mg. v. Arrange for re-evaluation by an orthopedic surgeon and physical therapy to begin shoulder range of motion exercise with in a week. WHAT NOT TO DO: Dont bother with weight bearing x-rays view to differentiate first,

second and third degree separations based on the widening of the distance between the clavicle and scapula. These are painful and do not change the initial treatment. Dont allow the patient to wear a sling and immobilize the shoulder for

more than a week with out at least beginning pendulum exercise .The shoulder capsule will contract and restrict the range of motion.

SINUSITIS

Follow a viral infection, the patient will usually complain of a dull pain in the face, gradually increasing over a couple of days, exacerbated by sudden motion of the head, or holding the head dependent, between the knees and perhaps radiating to the upper molar teeth or with eye movement. WHAT TO DO: i. Rule out other causes of facial pain or headache through taking proper history taking and physical examination (palpate scalp muscles, temporal arteries tempromandibular joint, eyes and teeth).

ii. Shrink swollen nasal mucosa with 1% Phenylephirine or 0.05%oxymetazolin nose drops. Drip 2 drops in each nostril, have the patient lie supine 2 minutes and then repeat the process. iii. Examine the nose for purulent drainage before and after shrinking the nasal mucosa with topical vasoconstrictor. iv. Add a systemic sympathomimetic decongestant (Sudafed) 60mg 6 hourly or Phenylepropanolamine 75mg OD. v. If there is fever, pus, heat or any other sign of bacterial super infection, add antibiotics (Erythromycin+Septrin or sefuroxime) vi. Provide pain relief, when necessary (Ibuprofen, Naproxen, Acetaminophen) vii. Recommend symptomatic relief with hot water vapour inhalation using a simple teakettle or hot shower or if available, steam vaporizer. viii. Sinusitis can sometimes be demonstrated on x-rays and can usually get adequate visualization of maxillary, frontal and ethmoid sinuses. With one upright Waters view. Chronic sinusitis appears as thickened mucosa: acute as an emergency basis. ix. If symptoms and physical findings of sinusitis are classic. Plain sinus radiographs need to be obtained before treatment. x. Arrange for follow up with in 1-7 days in ENT OPD. WHAT NOT TO DO:

Dont ignore signs of an orbital cellulitis with swelling erthyma,

decreased extra ocular movements and possible proptosis. These patients require consultation and admission for intravascular antibiotics. Dont ignore the toxic patient with marked swelling. High fever, severe

pain, profuse drainage, or other signs and symptoms of a serious infection. Dont prescribe antihistamines, which can make mucous secretions dry

and thick and interfere with necessary drainage. Antihistamines only cure sinusitis when it is due to allergic rhinitis. Dont allow patient to use decongestant nose drops more than 3 days,

thereby allowing their nasal mucosa to become habituated to sympathomimetic. When they will stop the drops they will suffer a rebound nasal congestion that requires time, topical steroids and re-education to resolve. Dont prescribe topical or systemic sympathomimetic decongestant to a

patient who suffers from hypertension, tachycardia or difficulty initiating urination.

SORE THROAT (PHARYNGITIS)

The patient with a bacterial phyarngitis complains of a rapid onset of throat pain worsened by swallowing. There is usually a fever, pharyngeal erthyma and a purulent, patchy, yellow, gray or white exudate, tender cervical

adenopathy, headache and absence of cough. Conjunctivitis, nasal congestion, hoarseness, coughs; aphthous ulcers on the soft palate and myalgias typically accompany viral infections. It is helpful to differentiate pain on swallowing from difficulty swallowing, the later being more likely caused by obstruction or abnormal muscular movement. WHAT TO DO: i. First examine the ears, nose and mouth that are after all, connected to the pharynx and often contain clues to the diagnosis. ii. Depress the tongue with a blade, have the patient raise his soft palate by saying AH, Inspect the posterior pharynx, and swab both tonsiller pillars for a culture (depends upon the clinical decision and ENT verbal consultation, provided that rapid strep test is available). iii. If the patient is visiting ER when there is epidemic of group A streptococcal phyarngitis: and the patient is in between 3 to 25 years old has history of rheumatic fever and recurrent strep throat and has been exposed and if the patient has a red throat fever, tender anterior cervical nodes and no viral URI symptoms give antibiotics .The recommended treatment is oral penicillin VK250mg 8 hourly for 10 days. Inj penicillin is preferred for patients unlikely to finish ten days of pills and those with a personal or family history of rheumatic fever. iv. Patients under 60, or 30 kg weight get an intramuscular injection of benzathine penicillin G6000000 units and those over 30 kg get 1200000u i/m.

v. Those who are allergic to penicillin give Erythromycin 250 mg tid; Amoxicillin has no role in-group A strep. vi. For resistant or recurrent infections with possible betalactamse producing co pathogens, consider instead 10 days of cephalaxin, cefadroxil, cefaclor or cefuroxime. vii. If you suspect mononucleosis, draw blood for atypical lymphocytes and a hetrophile or monospot to confirm the diagnosis. viii. Relieve pain with acetaminophen ibuprofen, aspirin, warm saline gargles or gargles or lozenges containing phenol as a mucosal anesthetic. Viscous Xylocain gargles anesthetize the throat but patient may still have difficulty swallowing because of lack of sensation. For severe pain in-patient with out contraindication, Dexamethasone 10mg i/m once has been used along with antibiotics. WHAT NOT TO DO: Dont miss an acute epiglottitis. In. In. In a child, this presents as a

sudden, severe phyarngitis, with gluteal, rather than hoarse voice, drooling and respiratory distress. Adults usually have a more gradual onset over several days and are not a prone to a sudden airway occlusion, unless they present later in the progression of the swelling, already with some respiratory distress. Dont give Ampicillin to a patient with mononucleosis, the resulting rash

helps make the diagnosis and does not imply ampicillin allergy, but can be uncomfortable. Dont miss abscesses that usually require hospitalization and

intravenous penicillin, if not drained. Peri tonsiller abscesses or cellulitis make

the tonsiller pillar bulge towards the midline. Retropharyngeal abscesses may require soft tissue lateral neck film to visualize. Do not miss gonocccal phyarngitis that can produce a mild clinical

syndrome and require special culture (if the patient is admitted). Dont miss the rare but deadly causes of sore throat, a patient with

paresthesia at the site of an old, healed bite and painful spasm when he even thinks of swallowing may have rabies. A patient with facial palsy , myocarditis and a tough , white , membrane adherent to the posterior pharynx may have diphtheria , you can not diagnose them unless you think of them. SPLIT EAR LOBES

A patient will present with an earlobe split by a sudden pull on earrings WHAT TO DO: i. Excise the skin edges on both sides of the wound, leaving the apical epithelium intact. Suture these freshened wound edges together using a fine monofilament material. ii. If the patient wants to maintain a pierced ear lobe, tie a loop of sterile suture material through the hole to maintain a tract while the rest of the lobe heals, iii. WHAT NOT TO DO: Dont suture the wound primarily. The edges may epitheliaze, resulting Provide tetanus prophylaxis if needed.

in the split redeveloping after the suture are removed STREAKHOUSE SYNDROME (Esopageal Food Bolus Obstruction)

The patient develops symptoms immediately after swallowing a large mouthful, usually of inadequately chewed meat. Resulting of intoxication, wearing dentures .The patient often develops substernal chest pain that mimic the pain of myocardial infarction. Discomfort increases the swallowing, is followed by retained salivary secretions that unlike infarction leads to drooling. At times these secretions will cause coughing, gagging or choking. WHAT TO DO: i. Take complete history and do physical examination. ii. Take PA and lateral x-rays view. iii. Insert a small NG tube to the point of obstruction and attach it to low intermittent suction. iv. If there is question of esophageal obstruction, with the help of invasive radiologist, give 5 ml of dilute barium orally and x-rays the chest to locate the foreign body. v. When the history and physical findings are classic for meat impaction, there is no need to perform barium swallow. vi. Give 1 unit of glucagon i/v to decrease lower esophageal sphincter pressure (infuse slowly). This will allow passage of food. vii. If 6 hours are passed of meat impaction then after glucagon is to have patient sit up and drink 100 ml of a carbonated beverage or EZ Gas (sodium bicarbonate, citric acid, simithicone) followed by 240 ml of water. viii. If the food does not pass spontaneously, and there is no access to gastroenterologist with an endoscope, prepare the

patient for manual extraction. Start an i/v line for drug administration and anesthetize the pharynx with Cetacaine spray or viscous lidocain 2%. Place the patient on his side and slowly administer diazepam intravenously until the patient is drowsy (moderate conscious sedation). Take gastric EDWALD Lavage tube, cut off the end until there are no side ports and round off the new tip with scissors. Push the Ewald lavage tube through the patients mouth until the obstruction is reached. Take a large aspiration syringe, have an assistant apply suction to the free end of the Ewald tube and slowly withdraw it. If suction is maintained, the bolus will come up with tubing. ix. If the patient is unable to tolerate this procedure or you are unsuccessful, need to admit in the hospital.

WHAT NOT TO DO: Dont ignore a patient s claims of foreign body stuck in the esophagus,

they are usually right. Do not try to force the food bolus down with the Ewald tube or an other

catheter or dilator. This may cause an esophageal tear or perforation. Dont use oral enzymes such as papain, trypsin or chymotrypsin, this

treatment is slow, ineffective and may carry a risk of enzyme induced esophageal perforation. Do not attempt to remove a hard, sharp, esophageal foreign body using

any of the above techniques.

Dont give glucagon to patients with pheochromocytoma or insulinoma. Do not use barium impregnated cotton balls to detect esophageal FB

SUBCONJUCTIVAL HEMORRHAGE

This condition may be spontaneous or follow a minor trauma, coughing episode, vomiting, or drinking binge. There is no pain or visual loss, but the patient may be frightened by appearance of his eye. Often it is friend or family member that insists the patient should be seen in the ED. This hemorrhage usually appears a bright red area covering part of the sclera. WHAT TO DO: i. Look for associated trauma, or other signs of a potential bleeding disorder. ii. Perform a complete eye exam. iii. Reassure the patient that there is no serious eye damage: explain that the blood may continue to spread, but all the redness should resolve in two to three weeks. WHAT NOT TO DO: Dont forgot to tell the patient that the redness may spread over the

next two days. Dont ignore any significant finding discovered on the complete eye

exam. SUBCUTANEOUS FOREIGN BODY

Small, moderate velocity metal fragments can be released when a hammer strikes a second piece of metal, such as a chisel. Patient has stinging sensation and is worried that there is something inside. WHAT TO DO: i. Be suspicious of a retained body in all wounds produced by a high velocity missile or sharp fragile object. The most common error in the management of soft tissue foreign bodies is failure to detect their presence. ii. X-rays the wound. iii. Remove the foreign body if it is easy to remove. iv. If the foreign body is in extremity then it is possible, preferable to establish a bloodless field. v. Anesthetize the area with a small infiltration of 1% Xylocain with epinephrine. vi. Take a blunt stiff metal probe (not a needle) and gently slide it down the apparent track of the puncture wound. Move the probe back and forth , fanning it in all direction ,until a clicking contact between the probe and foreign body can be felt and heard . vii. After contact is made, fix the probe in place by resting the hand, cut down along the probe with #15 scalpel blade until you reach the foreign body. Do not remove the probe. viii. Reach into the incision with a pair of forceps and remove the foreign body. ix. Close the wound with suture.

1. If the track is relatively long and foreign body is very superficial and easily and easily palpable beneath the skin, then it may be advantageous to eliminate the probe and just cut down directly over the foreign body. 2. Provide Tetanus prophylaxis. 3. Warn the patient about signs of developing infection. 4. If you are unable to locate foreign body in 15-30 minutes, refer the case to on call surgical team. 5. Schedule a wound check with in 48 hours in ED. WHAT NOT TO DO: Dont cut down on the metal probe if there is any possibility of cutting

across a neurovascular bundle, tendon or other important structure. Dont attempt to cut down to the foreign body, unless it is very

superficial with out a probe in place and in contact with the foreign body SUBUNGEAL ECCYMOSIS

The patient will have had a crushing injury over the fingernail: getting caught between two heavy objects for example or striking it with hammer. The pain is initially intense but rapidly subsides over the first half hour, and by the time he is examined only mild pain and sensitivity may remain. There is light brown or light blue brown discoloration beneath the nail. WHAT TO DO: i. Get an x-rays to rule out a possible fracture of the distal phalangeal tuft.

ii. Apply a protective fingerprint splint, if necessary for comfort. iii. Explain that you are drilling a hole in the patients nail, because there is not a subungual hematoma to evacuate. Inform the patient that, in time, he may lose the fingernail, but that a new nail will replace it. WHAT NOT TO DO: Dont perform a trephination of the nail SUBUNGEAL HEMATOMA

After a blow or crushing injury to a the finger nail , the patient experiences severe and sometimes excruciating pain that persists for hours and may even be associated with a vasovagal response . The finger nail has an underlying deep blue black discoloration that may be localized to the proximal portion of the nail or external beneath its entire surface. WHAT TO DO: i. X-Rays of the finger to rule out an underlying fracture of the distal phalanx and test for a possible avulsion of the extensor tendon. ii. Paint the nail with Povidine (Betadine) solution. iii. Adhere to universal blood and bodily fluid precautions. iv. Perform trephination at the base of the nail, using the free end of a hot paper clip, electric cauterization lance or drill. When performed quickly, patient does not feel the heat, just relief from pain. Tap rapidly with cautery or drill a few times

in the same spot at the base of hematoma until the resistance is finished. v. Pressing with 4x4 gauze can control persistent bleeding from this spot. vi. Apply an antibacterial ointment such as a Betadine and cover the trephination with a bandage. vii. To prevent infection, instruct the patient to keep his finger dry for 2 days and not to soak. viii. Inform the patient that he will eventually lose hid fingernail, until a new nail grows out after two to six months. WHAT NOT TO DO: Dont perform a trephination on a subungual ecchymosis. Dont apply digital block. Dont remove nail even with a large subungual hematoma. SUNBURN

Patient generally seeks help only if there is severe sunburn. There will be history of extensive exposure to sunlight or to artificial source of ultraviolet radiations; Sunburn also results from too much sun or sun-equivalent exposure. Almost everyone has been sunburned or will become sunburned at some time. Anyone who visits a beach, goes fishing, works in the yard, or simply is out in the sun can get sunburned. Improper tanning bed use is also a source of sunburn. Although seldom fatal. Chills Fever Nausea or vomiting, or both Flulike symptoms. Blistering may range from a very fine blister that is only found when you begin to "peel" to very large water-filled blisters with red, tender, raw skin underneath.

WHAT TO DO: i. Inquire as to whether or not the patient is using a photosensitizing drugs (tetracycline, thiazide, sulphonamide, phenothiazine s) and have the patient discontinue its use. ii. Have the patient apply cool compresses of water, as often as desired to relieve pain, this is the most comfortable therapy. iii. Applying topical steroids sprays such as Dexamethasone may help the patient. iv. With a more sever burn; prescribe a short course of systemic steroids (40-60 mg Prednisolone). This will reduce the inflammation, swelling. Pain and itching. WHAT NOT TO DO: Dont allow the patient to use OTC Sunburn medications that contain

local anesthetic (benzocain, dibucaine or lidocain). They are usually ineffective or only provide very transient relief. In addition there is the potential hazard of sensitizing the patient to these ingredients. Dont trouble the patient with unnecessary burn dressings. These

wounds have low probability to be infected. Treatment is directed at making the patient comfortable as much as possible. SWALLOWED FOREIGN BODY

Parents bring in young child shortly after he/she she has swallowed a coin, safety pain , toy, etc. The child may be asymptomatic or have recurrent or transient symptoms of vomiting, drooling, dyspahgia, pain or foreign body sensations.

WHAT TO DO: i. Ask about symptoms and examine the patient, looking for signs of airway obstruction (coughing, wheezing) or bowel obstruction r perforation. ii. Obtain two plain x-rays views of throat to at least the mid abdomen to determine the FB. iii. A foreign body with sharp edges or blunt FB lodged in the esophagus for more than one day must be called upon to Gastroentrogist for endoscopy, iv. When a coin or smooth object is obstructed in the upper esophagus for less than 24 hours, it can be usually removed using simple Foleys catheter technique. Inflate the balloon behind the coin and slowly take out until it reaches the base of the tongue and encourage the patient to cough. v. When a FB has passed into the stomach and there are no symptoms the patient is discharged with instruction to return for reevaluation in seven days. WHAT NOT T DO: Dont push the Foleys catheter if you are not experienced or

fluoroscope is not available.

TAIL BONE FRACTURE (Coccyx Fracture)

The patient fell on his tailbone and now complains of pain that is worse with sitting and perhaps with defecation, there should be little or no pain with standing but walking may be uncomfortable. On Physical examination, there is

point tenderness and perhaps deformity of the coccyx that is best palpated by a finger in the rectum. WHAT TO DO: i. Verify the history and examine thoroughly, including the lumber spine, pelvis and the legs. Palpate the coccyx from inside and out feeling primarily for point tenderness and /or pain on motion. ii. X-rays are optional. iii. Instruct the patient how to sit forward, resting his weight upon ischeal tuberosity and thighs, instead of coccyx. iv. If necessary prescribe anti inflammatory drugs or stool softener. v. Inform the patient that the pain will gradually improve over a week as bony callus forms and motion decreases and arrange for follow up as needed.

TEAR GAS EXPOSURE

The patient may have been in a riot dispersed by the police or accidently sprayed by his own can of Mace, He complains of burring of the eyes nose, mouth and skin: tearing and inability to open eyes because of the severe stinging: sneezing, coughing, a runny nose and perhaps a metallic taste with a burning sensation of the tongue, nausea vomiting and abdominal pains. These signs and symptoms last for 15-30 minutes after exposure. Redness and

edema may be noted from one to two days following exposure to these agents. WHAT TO DO: i. Segregate victims lest they contaminate others. Medical personnel should wears gown, gloves and masks and help victims remove contaminated clothes and shower with soap and water to remove tear gas from the skin ii. Exposed eyes should be irrigated with copious amount of tepid water for at least fifteen minutes. If eye pain lasts longer than 15-20 minutes. Examine with Fluorescein for corneal erosions. iii. Look for signs of and warn patient about allergic reaction to tear gas including bronchospasm and contact dermatitis. iv. Dont rush to help or allow others to rush in heedlessly and themselves become incapacitated.

TENSION HEADACHE

Patient complains of dull steady pain described as an ache, pressure, throb, or constricting band, located anywhere from eye to occipit perhaps including the

neck or shoulders. Most commonly, the headache develops near the end of the day or after some particular stress. WHAT TO DO: i. Perform a complete physical exam (including environmental factors and food which precede the headache) and physical examination (CNS) ii. If the patient complains of sudden onset of the worst headache of my life accompanied by any change in mental status, weakness, vomiting, seizure, stiff neck or persistent neurological abnormalities, suspect a cerebrovascular cause especially SAH. Refer the patient to neurologist or arrange urgent follow up. iii. If the headache is accompanied by fever and stiff neck or change in mental status, you need to rule out bacterial meningitis as soon as possible. iv. If the headache is preceded by ophthalmic or neurologic symptoms, now resolving, suggestive of a migraine headache, you may want to try sumatriptan or ergotamine therapy .If a vasospastic symptoms persists into the headache phase, the etiology mat still be a migraine, but it becomes more important to rule out other CNS causes. v. If the headache follows the prolonged reading, driving or television/internet sitting and there is decreased visual acuity, but improved through pinhole, the headache may be due to optical refraction and is curable by eyeglass lenses. vi. If the temples are tender, check for visual defects and myalgias that accompany temporal artritis.

vii. If there is a history of recent dental work or grinding of teeth, tenderness anterior to the tragus or crepitus on motion of jaw, suspect arthritis of the tempromandibular joint. viii. If there is fever, tenderness to percussion over the frontal or maxillary sinus, purulent drainage visible in the nose, or facial pain exacerbated by lowering the head, consider sinusitis. ix. If pain radiates to the ear, be sure to inspect and palpate the teeth, which are a common site of referred pain. x. Finally, after checking for all these other causes of headache, palpate the temporalis, occiptalis and other muscles of the calvarium and neck, looking for areas of tenderness and spasm. xi. Prescribe NSAID, recommend rest, and have the patient try cool compresses and message of any trigger point. xii. Arrange for follow up, instruct the patients to return the ED or the contact his own Physician. WHAT NOT TO DO: Dont discharge with out follow up instructions. Many serious illnesses

begin with minor cephalgia and patient may postpone urgent: care in the belief that they have been definitely diagnosed on the first visit. Dont miss subarachnoid and meningitis.

TETANUS PROPHYLAXIS

The patient may have stepped on a nail or sustained any sort of laceration, abrasion or puncture wound. WHAT TO DO: i. If the patient has not had tetanus immunization in the past 5 years, give adult tetanus and diphtheria toxoid (TD) 0.5 ml i.m. Give Tetanus toxoid (DT) to children under seven (7) years old. ii. If there any doubt the patient has had his original series of three tetanus immunizations, add tetanus globulin 250mg i.m and make arrangement for him to complete the full series with additional immunization at 4-6 weeks and 6-12 months. iii. With history of true tetanus immune globulin. Instruct the patient that he does not have protection from Tetanus from future injuries. WHAT NOT TO DO: Dont assume adequate immunization .The groups most at risk are

immigrants, elderly women and rural population Dont believe every story of allergy to tetanus toxoid (that is actually

very rare).

THRUSH

An infant will have white patches in his mouth or an older patient (usually with poor oral hygiene diabetes a hematologic malignancy or on steroid therapy). These white patches wipe off easily with a swab, leaving an erythmatous base that may bleed. There may intense dark red inflammation throughout the oral cavity.

WHAT TO DO: i. If there is any doubt about the etiology, confirm the diagnosis by smearing the exudate. ii. For the topical treatment, prescribe an oral suspension of nystatin 200,000 units for infants and 400,000-600,000 u for children and adults, gargled and swished in the mouth a long as possible before swallowing, four times a day for at least two days beyond resolution of symptoms. iii. For adults Fluconazole 200mg once, then 100 mg qid for 7 days may be better regimen. Sometime single oral dose is effective. iv. Look elsewhere for Candida, esophagitis, vaginitis , dipper rash

TINEA (Athletes Foot , Ring worm)

Patient usually seek emergency care for athletes foot ,or ringworm when pruritis is severe or when secondary infection causes pain and swelling .Tinea Pedis is usually seen as interdigital scaling , maceration and fissuring between

toes. At times tense vesicular lesions will be present instead. Tinea cruris is usually a moist, mildly erythmatous eruption symmetrically affecting both groin and upper inner thigh. Tinea Corporis appears most often on the hairless skin of children as dry erythmatous lesions with sharp annular and arciform borders that are scaling or vesicular. WHAT TO DO: i. When microscopic examination of skin scrapping is readily available, definite identification of hypae or spores. ii. Clotrimazole, miconazole, haloprogin and tolnefate solution or cream applied to rash BID will cause involution of most superficial lesions with in 1-2 weeks. iii. With signs of secondary infection, begin treatment first with wet compresses of Burrows solution, with signs of deep infection (cellulitis, Lymphangitis) begin systemic antibiotics in addition, like cefadroxil 1 gm qid x5-7 days or cephalaxin 250-500mg tid x 5-7 days. iv. With inflammation and weeping lesions, a topical antifungal and steroids cream such as (Vioform-Hydrocortisone) in addition to the compresses will be most effective. WHAT NOT TO DO: Dont attempt to treat deep, painful infections of the scalp with local

therapy. Dont treat with corticosteroids alone. They will reduce s and symptoms,

but allow increased fungal growth.

TEMPROMANDIBULAR JOINT (TMJ)

The pain is usually dull and unilateral, centered in the temple, above and behind the ear; the pain may be associated with instability of TMJ, crepitus or crackling with movement of the Jaw. WHAT TO DO: i. Examine the head thoroughly for other causes of the pain, including visual acuity, cranial nerves and palpation of the scalp muscles and temporal arteries. ii. If pain is severe, you may call Dental surgeon, if he/she is not available then refer to pain management centre, In case if you are expert in giving block then you can inject 10 mg of Depo-Medrol anterior to the tragus. iii. Prescribe anti-inflammatory analgesics, a soft diet, heat and muscle relaxants (Diazepam). iv. Refer the patient for follow up to a Dentist or ENT OPD. Long-term treatment includes Orthodontic correction. WHAT NOT TO DO: Dont rule out TMJ arthritis simply because the joint is not tender on your

examination. Dont omit the TMJ in your workup of any headache. Dont give narcotics unless there is going to be early following up. TOOTH TRAUMA (Sublaxation and Displacement)

After a direct blow to the mouth the patient may have a portion of a tooth broken off, or a tooth may be loosened to variable degree. Ellis class 1 dental

fracture involves only enemal, Class II fractures expose yellow dentin, Ellis class III expose pulp that bleeds and hurts. WHAT TO DO: i. Assess the patient for any associated injuries such as facial or mandibular. ii. Consider where any tooth fragments are located. iii. For sensitive Ellis II fracture of dentin, cover the exposed surface with calcium hydroxide composition (Dycal), tooth varnish. Provide analgesics. iv. A dentist should see Ellis III fractures into pulp right away. v. Minimally subluxed (loosened) teeth may require no emergency treatments. vi. Intruded primary teeth and permanent teeth of young patient can be left alone and allowed to re-erupt WHAT NOT DO: neck. Dont miss associated injuries of alveolar ridge, mandible, facial bone or

UPPER RESPIRATORY TRACT INFECTION

Occlusion of the Ostia of paranasal sinuses buildup of permits mucous and pressure, leading to pain and predisposing bacterial super infection. WHAT TO DO:

1.

Perform complete history and physical examination to

document which of the above signs and symptoms are present: to rule out some other, underlying ailment: and to find any sign of bacterial super infection of ears. Sinuses, pharynx tonsils epiglottis, bronchi or lungs that might require antibiotics or other therapy. 2. Explain the course of the viral illness and the

inadvisability of indiscriminate antibiotics. Tailor drug treatment to the patients specific complaint as follows. i. For fever, headache and myalgias prescribe acetaminophen 650mg qid or ibuprofen 600mg 6hourly. ii. To decongest the nose, Ostia of sinuses and Eustachian tubes start with topical sympathomimetic (0.5% Phenylephirine nose drops 4 hourly but only for 3 days) and add systemic sympathomimetic (Pseudoephedrine 60mg 6 hourly) iii. To dry out nose, or if the symptoms are probably caused by an allergy, try antihistamine. iv. To suppress coughing, prescribe dextromethorphan or codeine 10-20 mg 6 hourly. v. To avoid sedation and narcotics, prescribe benzonate (Tessalon) 100200 mg 8 hourly. vi. With bronchitis or suspected bronchospasm, treat the cough with inhaled bronchodilators like albuterol two puffs and inhaled steroids like beclomethasone four puffs 12 hourly. vii. Arrange for follow up if symptoms persist or worsen or if new problems develop.

WHAT TO DO: Dont get bullied into inappropriate prescribing of antibiotics. Most colds

are self-limiting illness and many treatments may appear to work by coincidence alone, Dont prescribe inappropriate antibiotics simply because you suspect the

insistent patient will obtain them elsewhere. Dont undertake expensive diagnostic testing on uncomplicated cases. URINARY TRACT INFECTION

The patient may complain of increasing dull low abdominal discomfort and the urge to urinate, with out having been able to urinate for many hours. A firm distended bladder can be palpated between the symphysis pubis and umbilicus. Rectal exam may reveal an enlarged and tender prostate or suspected. WHAT TO DO: i. Pass a Foley catheter and collect the urine in bag, Reassuring the patient and having him breath through his mouth, this maneuver will help the patient to relax the external sphincter of the bladder and facilitate the passage of the catheter. ii. If the passage remains difficult in a male patient, distend the urethra with lubricant (diluted lidocain jelly) in a catheter tip and try a 16, 18, 0r 20 French Foley.

iii.

If you fail then take the consultation of urologist for stylet, sounds, filiforms, and followers.

iv.

Check renal profile and ascertain the cause of obstruction.

v. vi. vii.

If there is infection of bladder start I/V antibiotics. To relieve pain give Perfalgan (Paracetamol) If the volume drained is modest (1-2 liters) and the patient is stable, ambulatory then attach the Foleys catheter to large leg bag and discharge him for follow up and catheter removal next day.

viii.

If the volume drained is small (100-200ml) remove the catheter and search for alternate etiologies of the abdominal mass and urinary urgency.

WHAT NOT TO DO: Dont use stylets or sound s unless you have experience of instrument

the urethra as these devices can cause iatrogenic trauma. Dont remove the catheter in emergency department if the bladder was

significantly distended. Dont clamp the catheter to slow decompression of the bladder , even if

the volume drained is greater than 2 liters. Dont take sample for bacterial culture from distended bladder; it may

represent colonization that will resolve with drainage. VAGINAL BLEEDING

A menstruating woman complains of greater than usual bleeding, that is either off her usual schedule lasts longer than a typical period or is heavier than usual (menorrhagia) perhaps with crampy pains and passage of clots. WHAT TO DO: i. Obtain orthostatic pulse and blood pressure measurements, a hematocrit and pregnancy test (urine or serum beta hCG). ii. Try to quantify the amount of bleeding by number of saturated pads used. iii. A pulse increase more than 20 /min on standing or hematocrit below 30%, start an intravenous line of lactated Ringers solution and have blood ready to transfuse on short notice. iv. Obtain a sexual, menstrual and reproductive history that her periods usually irregular, occasionally heavy, Does she take OCP and has missed enough to produce estrogen withdrawal bleeding. v. Is IUD in place and contributing to cramps, bleeding and infection, was her last period missed or late, suggesting an anovulatory cycle or an ectopic? Might she be pregnant? vi. Perform a speculum and manual vaginal examination. Look particularly for signs of pregnancy, such as soft, blue cervix, enlarged uterus or passage of fetal parts with the blood.

vii.

Ascertain that blood is coming from the cervical os and not from a laceration, polyp or other vaginal or uterine pathology.

viii.

Confirm suspicion of ectopic pregnancy either with sonogram showing the ectopic gestational sac.

ix.

Discharge the stable patent home on oral contraceptive pills (Ortho-Novum 1/50 or Norinyl 1+50) one qid followed by low dose oral contraceptives for the next two to three months.

x.

If the cause of the uterine bleeding was missed OCP, patient may resume the pills but should use additional contraception for the first cycle.

xi.

If the cause is new IUD, the patient may try to have it removed and use other contraceptives.

xii.

Patient should be referred for follow up to a gynecologist and may be evaluated via endometrial biopsy.

WHAT NOT TO DO: Dont leap to a diagnosis of dysfunctional uterine bleeding with out

ruling out pregnancy tests. VAGINAL FOREIGN BODY Dont rule out pregnancy or venereal infections on the basis of a

negative sexual history--- confirm with physical examination and laboratory

This commonly is a problem of children who may insert foreign body and not tell their parents. The patient is finally brought to the emergency department with a foul smelling purulent discharge with or with out vaginal bleeding. Vaginal foreign bodies in the adult may be result of psychiatrist disorder or unusual sexual practice. Occasionally a tampon or pessary is forgotten or lost and causes discomfort and vaginal discharge. WHAT TO DO: 1. Visualize the foreign body using a nasal speculum in the pediatric patient or vaginal speculum in the adult. 2. Pediatric patients may be placed in a knee-chest position, while performing a rectal examination; you may be able to expel the foreign body from the vagina by pushing with examining finger in the rectum. 3. Friable foreign bodies such as wads of toilet paper may be flushed out using warm water, an infant feeding tube. 4. Lost or forgotten tampons can be removed with vaginal forceps; the vagina should then be swabbed with a Betadine solution.

5. In difficult cases or when large or sharp objects are involved, young and adult patients may require general anesthesia or conscious sedation to allow removal under direct vision. 6. The patient should empty her bladder and lie in stirrups in the lithotomy position, Insert Foley catheter to break any suction between the foreign body and the vaginal mucosa; Most Objects can then be grasped with ring forceps. 7. Reserve x-rays for radio-opaque bodies concealed in the bladder or urethra. Objects in the vagina are usually apparent on examination. WHAT NOT TO DO: Dont ignore a vaginal discharge in a pediatric patient or assume it is the

result of a benign vaginitis. Perform a bimanual or recto abdominal examination to palpate a hard object. Dont forget to ask about possible sexual abuse and consult with a

protective services if it cannot be ruled out. VAGINITIS

A woman complains of itching and irritation of the labia and vagina, Speculum examination may disclose a disclose a diffusely red, inflamed vaginal mucosa with vaginal discharge.

WHAT TO DO: 1. Take a brief sexual history. 2. Perform speculum and bimanual pelvic exam 3. Collect urine for culture 4. Most common organism is either Trichomonous Vaginitis or Candida albican then advise the patient, Tab. Metronidazole 500mg bidx7days, Miconazole or clotrimazole200mg vaginal suppositories. 5. If the diagnosis is bacterial vaginitis which is an overgrowth of gardnerella vaginitis or other anerobes the strongest treatment is metronidazole 500mg bid or clindamycin 300mg bid x7days, Metronidazole vaginal gel 0.75% 5 gram bid x 7 days 6. Arrange for follow up WHAT NOT TO DO: Dont prescribe underlying pelvic inflammatory disease, pregnancy, or

diabetes. All of which can potentiate vaginitis. Dont miss underlying pelvic inflammatory disease, pregnancy or

diabetes Dont miss candidiasis because the vaginal secretions appear essentially

normal in consistency, color, volume and odour .Non pregnant patient may not develop thrush patches curds or caseous discharge.

VASOVAGAL SYNDROME

The patient experience a brief loss of consciousness, preceded by sense of anticipation. Transient bradycardia and few clonic limb jerks may accompany vasovagal syncope, but there is no sustained palpitations arrhythmias or seizures, incontinence, tongue bite. WHAT TO DO: 1. Arrange for patients, family and friends anticipating unpleasant experiences in the ED to sit or lie down and be constantly attended. 2. If someone faints in the ED, catch him so he is not injured in the fall , lie him/her supine on the floor for 5-10 minutes protect his airway , record several sets of vital signs and be ready to proceed. 3. If a patient is brought to the ED following a faint elsewhere, ask about setting, precipitations of several eyewitnesses and sequence of recovery. Be alert for evidence of seizures, hysteria and hyperventilation, record several sets vital signs, including orthostatic changes and examine carefully for signs of trauma. 4. After full recovery, explain to the patient that this is a common physiological reaction and how, in future recurrences. He can recognize the early lightheadedness and prevent a full swoon by lying down or putting his head between his knees. WHAT NOT TO DO: Dont let families stand for bad news, let not parents or relatives to

stand near by while suturing or venipunctures.

Dont traumatize the faint victim with ammonia, slapping or dousing

with cold water.

VERTIGO

A nonspecific complaint, which may be refined further into either, an altered somatic sensation (giddiness) orthostatic blood pressure changes or the sensation of the environment spinning. In the inner ear disease, vertigo is virtually always accompanied by nystagmus, which is the ocular compensation for the unreal sensation of spinning. Nausea and vomiting are common symptoms.

WHAT TO DO: 1) Have the patient tell you in his own words what it feels like . ask about

any sensation of spinning , factors which make it better or worse and associated symptoms , ask about drugs or toxins which could be responsible. 2) Determine whether the patient is describing vertigo (feeling of

movement of ones body or surroundings) or sensation of an impending faint or vague unsteady feeling. 3) If the problem is near syncope or orthostatic lightheadedness, then

consider potentially serious etiologies such as heart disease, cardiac dysarrythmia or blood loss. 4) An elderly patient feeling that he is going to fall, look for peripheral

neuropathy, cervical spondylosis, stiff legs and vasodilator medications.

5)

Instruct the patient to hyperventilate by breathing deeply in and out

fifteen times. 6) If the patient has true vertigo, examine for nystagmus, which can be

horizontal, vertical or rotatory. 7) 8) Examine ears for cerumen, foreign bodies, otitis media and hearing loss. Examine the cranial nerve, test cerebellar function, and Check the

corneal blink reflexes. 9) In the ED treat moderate to severe symptoms of vertigo with

intravenous Valium 10mg or Diphenhydramine 50mg .Add promethazine (Phenergan) 25mg I/V for nausea Nifidipine had been used to alleviate motion sickness but is no longer better than Scopolamine patch. 10) Treat vertigo symptoms in outpatient with diazepam (Valium) 5-10mg-

qid meclizine (Antivert) 12.5-25 mg qid, Diphenhydramine (Dramamine, Benadryl) 25-50mg qid, and bed rest as needed until symptoms improve. 11) Arrange for follow up if there is no clear improvement in 2 days or if

there is any suggestion of a central etiology.

WHAT NOT TO DO Dont attempt provocative maneuvers if the patient is symptomatic with

nystagmus. Dont give anti vertigo drugs to elderly patients with disequilibrium.

Theses medications have sedative properties that can make them worse.

Dont make the diagnosis of Menieres disease with out triad of

paroxysmal vertigo, sensorial deafness and tinnitus, along with a feeling of pressure or fullness in the affected ear. WEAKNESS

An older patient comes to the emergency department or is brought by family complaining of weakness or an inability to carry on his usual activities or care for himself. WHAT TO DO: 1) 2) habit. 3) Check the strength of all muscle groups (graded on a scale of 1-5), deep Obtain as much history as possible. Ask about headache, weight loss, cold intolerance appetite, and bowel

tendon reflexes and neurological status 4) Do CT scan brain that there is an unexplained change in mental status o

if there are abnormal neurological findings. 5) Obtain a spectrum of laboratory tests i.e., Renal profile, electrolyte CBC

as well as attach pulse oximeter, ask for x-rays chest, ECG, to rule out Hypoxia, anemia, infection, diabetes, uremia polymyalgia rheumatica, hyponatremia and hypokalemia, all of which are common causes of weakness. 6) If no etiology for weakness can be found, probe the patient, family and

friends once again for any hidden agenda and if non is found, reassure them about all the serious illnesses which have been ruled out .At this time, discharge the patient and make arrangements for definite follow up.

WHAT NOT TO DO: Dont order any lab test the results of which you will not see. Your best

strategy is to stick to tests that will return while the patient is in the emergency department and defer any long investigations to the follow up physician. Dont insist upon making the diagnosis in the Emergency department in

every case, in this clinical situation, your role in the ED is to rule out acutely life threatening conditions and then make arrangements for further evaluations elsewhere. WEY NECK (TORTICOLIS)

The patient complains of neck pain and is unable to turn his head, usually holding it twisted to one side, with some spasm of the neck muscle with the chin pointing to the other side. These symptoms may have developed gradually, after minor turning of the head, after vigorous movement or injury or during sleep. WHAT TO DO: 1) Ask the patient precipitating factors and perform a thorough physical

examination, looking for muscle spasm, point tenderness and sign of injury, nerve root compression, masses or infection, include a careful nasopharyngeal examination as well as basic neurologic examination. 2) When forceful trauma is involved and subluxation is possible, then

obtain lateral, anteroposterior and odontoid X-Rays view of cervical spine. 3) If there is neurological deficit then do CT or MRI to visualize nerve

involvement.

4)

When there is no suspicion of serious illness or injury, apply heat, give

NSAID and oral cyclobenzaprine (Flexeril) or diazepam, Alternating heat with ice massages may also be helpful as well as gentle range of motion exercises. 5) If there is point tenderness posterior to the sternocleidomastoid muscle

and the head cannot turn towards the side of point tenderness suspect a facet syndrome, obtain x-rays and gently test neck motion again after a few mintes of manual traction along a longitudinal axis. 6) If there is any arm weakness or paresthesia corresponding to a cervical

dermatome, suspect nerve root compression as the underlying cause and arrange for neurosurgical or orthopedic consultation. 7) With signs and symptoms of infection e.g. , fever , toxic appearance ,

lymphadenopathy. Tonsiller swelling, trismus, phyarngitis or dyspahgia, take soft tissue lateral neck film s and CBC, ESR to help rule out early abscess formation. Arrange for specialty consultation. WHAT NOT TO DO: Dont overlook infectious etiologies presenting as Torticollis, especially

the pharyngiotonsillitis of young children that can soften the atlantoaxial ligaments and allow subluxation. Dont undertake violent spinal manipulations in the ED that can make an

acute torticollis worse. Dont confuse torticollis with a dystonic drug reaction from

phenothiazine or butyrophenes.

ZIPPER CAUGHT ON PENIS OR CHIN

Usually a child has gotten dressed too quickly and not wearing underpants, accidently pulled up penile skin in to zipper, The skin becomes entrapped and crushed between the teeth and side of the zipper, thereby painful attaching the article of clothing to the body part involved. WHAT TO DO: 1) Paint the area with small amount of Povidine-iodine and infiltrate the

skin with 1% lidocain, this will allow the comfortable manipulation of the zipper and article of clothing. 2) Cover the area with mineral oil, this lubricates the moving parts and

often frees the skin with out having to cut the zipper. 3) If the mineral oil does not work, then cut the zipper away from the

article of clothing. 4) Cut the slide of zipper in half with pair of metal snips or an orthopedic

pin cutter or use two surgical towel clamps and place their tongs into side grooves at both ends of the slide. Then grip one clamp firmly in each hand and then twist your wrist s in opposite directions. This often will pop the two halves of the zipper slide part, releasing the entrapped skin. 5) Pull the exposed zipper teeth apart, cleanse the crushed skin and apply

an ointment such as Povidine- iodine. 6) Tetanus prophylaxis should be administered as needed.

WHAT NOT TO DO: Dont clothing if mineral oil releases the zipper. Dont destroy the entire article of clothing by cutting into it, you only

need to cut the zipper away allowing repair of the clothing. Dont excise and area of skin or perform a circumcision.

SECTION IV

SURVILLANCE,PREVNTION AND CONTROL

EMERGENCY DEPARTMENT SAFETY

POLICY:

The main purpose of engineered sharps safety is to increase protection from sharps injuries, which can transmit HIV, hepatitis B, hepatitis C and other blood borne pathogens. This is accomplished by stronger requirements for employers to use needles and other sharps which are engineered to reduce

the chances of inadvertent needle sticks or other sharps injuries. Also required is for employers to keep a sharps injury log, which records the date and time of each sharps injury as well as the type and brand of device involved in the exposure incident, the task being done Recapping, bending or removing needles is permissible only if there is no feasible alternative or if required for a specific medical procedure such as blood gas analysis. If recapping, bending or removal is necessary, a mechanical device or one-handed technique must be utilized. If recapping is essential, i.e., between multiple injections for the same patient, employees may never use both hands to recap. Employees may recap with a one-handed scoop technique, using the needle itself. Types of Devices and Engineering Controls, commonly used in emeregency department Hypodermic needles and syringes- sliding sheath/sleeve, needle guards Needleless jet injection Retractable needles Medication Vial Adaptors (used to access ports of medication vials) IV Medication Delivery Systems Needle guards for pre-filled medication cartridges Needleless IV access-blunted cannulas Needleless valve/access ports and connectors Prefilled medication cartridge with safety needles Recessed/protected needle Needle guards for pre-filled medication cartridges IV Insertion Devices Shielded or retracting peripheral IV catheters IV Catheter Securement Devices Blood Collection Devices Arterial blood gas syringes Phlebotomy needles Safety-engineered blood collection needles Blood tube holders Closed venous sampling systems Plastic blood collection tubes Butterfly blood collection needles Blood Donor Plebotomy Devices

Other Catheter Equipment Guidewire Introducers-for venous and arterial access Central Venous Catheters Peripheral Inserted Central Catheters Radial Artery Catheters Blunted Suture Needles (for internal suturing- fascia/muscles Dental Safety Devices

This is multidisciplinary policy and further guidelines will be followed up from manual of infection control.

EMERGENCY DEPARTMENT INFECTION CONTROL

POLICY The personnel in ER shall understand the activities which may influence the risk of infection to personnel and patients. This will prevent personnel and patient from acquisition of hospital infection.

1. Interventions should be made in order to minimize the risk of infections to patients and personnel due to extensive activities in ER. a) Recognizing signs and symptoms of communicable diseases so that designated examination rooms should be used for suspected cases in order to prevent multiple exposures of the infectious agents to patients and personnel. b) Instituting of Universal (standard) precaution by wearing protective equipment such as gloves. Gowns and/or mask as warranted. c) Practicing good hand washing techniques. d) Discharging patient from the department either to home or admit to patient care unit where appropriate isolation techniques can be instituted, as soon as possible. e) When transporting patients with infectious diseases to other areas within the vicinity, e.g. Radiology or patients care areas; i. Wear gloves, masks and gowns as necessary ii. Have patient wear mask for agents spread by droplets iii. Cover draining/open wounds. f) Establishing a system for detecting post discharge infections and report all related infections to infection control team. g) Utilizing surgical asepsis in performing all procedures. h) Using correct colour coded bags: i. Ordinary waste into blue/black plastic bags ii. Clinical/infected waste into orange plastic bags iii. Soiled equipments into special transparent CSSD bag iv. Soiled linen into laundry bag. Infectious linen from infectious patient and any linen saturated with blood + body fluids into a yellow linen bag lined with water soluble bag. i) Disposing sharps/needles into puncture resistant containers.

j) Instructing patients who are returning to home environment with active diseases on infection prevention and control measures:

Practice Settings

1. Hand washing before and after touching wound dressing a) Keeping the home environment clean b) Scheduling and taking of anti-microbials prescribed. c) Upkeeping of follow-up appointment e.g. wound care, if indicated. 2. Ensuring of all invasive equipment to be reprocessed by CSSD 3. Notifying all communicable diseases to all infection control team. Increased frequency of environment cleaning is indicated due to high number of patients using the area.

A. Clean the environment daily and as warranted utilizing hospital approve chlorine base disinfectant. Mop floors in high traffic areas as warranted. B. Wipe up blood spills, body fluids or secretion promptly using chlorine base disinfectant. C. Clean examination tables between patients and removes disposable sheets and place clean sheets on examination tables between patients

SECTION V

IMPROVING ORGANIZATION PERFORMANCE

PLAN FOR PATIENT CARE ABD PERFORMANCE IMPROVEMENT

POLICY: 1) The purpose of the Emergency Department Performance Improvement Plan is to ensure that the medical and professional service staff demonstrate a consistent endeavor to deliver optimal care in an environment of minimal risk. 2) In keeping with the hospitals mission, the Performance Improvement Plan allows for a systematic, coordinated and continuous approach to improving performance focusing upon the processes and mechanisms that address these values.

PROCEDURE

i. ii. iii.

iv. v. vi.

vii.

That the Emergency Department is a service within an integrated multidisciplinary model. The Emergency Department Nurse Manager, in collaboration with the Emergency Department chief, coordinates plans and implements a multidisciplinary plan for a variety of patients. Professional and ancillary nursing staff members deliver nursing care according to established Emergency Department standards structure, process and outcome and participate in all aspects of healthcare delivery. The Emergency Department Nurse Manager directs and evaluates and will review, Patient outcome and length of stay in ED. Follow up of readmissions can be trended and evaluated as a utilization management activity with patient outcome reviewed. The Emergency Department Log shall be maintained and shall contain, but not be limited to the following information relating to the patient: Name Date Time and means of arrival Age Sex Medical record number Nature of complaint Disposition Time of departure. Assure that patient care is provided and maintained at an optimal level, consistent with the professional standards held in the medical community.

viii.

ix.

Focus of quality improvement data at a central point for examination, analysis and documentation of ongoing activities. Data is to include use of statistically valid performance measures and quality control techniques, the emergency department have a statistics secretary who separates the ED sheets and maintains data on daily, weekly and monthly basis. A nursing evaluation regarding the admission criteria a plan is written for each admitted patient.

SENTINEIL EVENTS POLICY Unexpected events or occurrences involving death or serious physical or psychological injury, or the risk thereof i.e., sentinel events, are to be reported to the Quality management Department immediately upon identification. Any sentinel event requires immediate action to examine, in-depth, the event to determine why the incident occurred and how to reduce the likelihood of recurrence. DEFINITIONS: Adverse Event: An event or occurrence which results in significant patient injury or impairment.

Following are the sentineil events. 1- Delay in treatment is the most common type of sentinel event 2- Delay in attending the patient by in patient team leading to death or critically ill patient went in coma and code announced. 3- Less staffing caused in delaying the patient 4- Staff safety at risk due to overcrowding leading to verbal or physical violence 5- Crowding may also involve an inability to appropriately triage patients, with large numbers of patients in the ED waiting area of any triage assessment category. 6- Dirty bed sheets are not changed having spots of blood. 7- Significant drug reaction 8- Medication error and type 9- Unexplained /unexpected death

TASK FORCE Task Force is the subcommittee appointed by the Committee to: Investigate an occurrence or process variation. Determine whether such occurrence or process variation meets the definition of a Sentinel Event, and Complete a thorough and credible Root Cause Analysis and resulting Action Plan describing the hospitals risk reduction strategies when a Sentinel Event occurs in the hospital or is associated with service that the hospital provides, or provides for. PROCEDURE FOR IDENTIFYING AND RESPONDING APPROPRIATELY TO SENTINEL EVENTS Application of Policy Any Sentinel Event occurring within the emergency departmentl or associated with services that the Center provides, or provides for, shall be handled as described in this policy. Identification of Sentinel event If any individual in the EDl (including, but not limited to, any individual employed by the hospital, any individual who independently contracts with the hospital to provide health care services to patients at the hospital, any member of the hospitals Medical Staff, and any allied health care professional) discovers, witnesses, has knowledge of or otherwise becomes aware of any unexpected occurrence that is a possible Sentinel event must be verbally reported Immediately report to the supervisor or designee as well as the Administrator or designee If any of the above are unavailable, verbally report to the Administrator or designee After the verbal report, a completed patient care variance report should be submitted.

Appointment of Task Force As soon as practicable after the ED Committee Chairman is notified of an occurrence or process or process variation that could constitute a Sentinel Event, but not later than fortyeight (48) hours after the occurrence or process variation is reported to the Committee Chairman, the Committee Chairman shall call a meeting

of the Sentinel Event Committee to investigate the occurrence or process variation and to determine whether such occurrence or process variation meets the definition of a Sentinel Event. If the Committee determines that a reasonable possibility of a Sentinel Event has occurred, the committee shall appoint a Task Force composed of hospital personnel at all levels including, but not limited to, personnel closest to the issue(s) involved and personnel with decision-making authority.

SECTION V

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LEADERSHIP

IN THE ABSENCE OF CHIEF AND HEAD NURSE OF EMERGENCY DEPARTMNET POLICY

1. In the event the Emergency Department, the Head of Department / Nurse Manager will be unavailable, a memo shall be addressed by the Medical director and Nursing Director to the department as to which consultant and nursing administrator will be accepting responsibility for the Emergency Department until the return of the Emergency Department Chief and Nurse Manager.

2. Senior supervisor/specialist will be responsible for the smooth working of their shift and if there is any problem that will be brought in the notice of the acting chief of ED a. Senior charge nurse will hold the responsibilities of the Head nurse until there is any change from nursing Director and further she/he will take charge of all inventories.

SCOPE OF SEREVICE

Objectives of ED:

1) To provide unrestricted access to appropriate emergency medical care. 2) To provide appropriate evaluation, management and treatment of patients. 3) To ensure availability of resources in ED to accommodate each patient from the time of arrival, through evaluation, decision making, treatment and disposition.

4) The forge a smooth continuum among pre-hospital providers, emergency medical care providers and providers of definitive follow-up care. 5) To reduce the waiting times within the department 6) To be alert and responsive to the individual needs of patients and their associates. 7) To achieve economies in the use of equipment, stores, drugs, without detriment to patient care.To promote & encourage in service training, staff development & research 8) To conduct active training programs for doctors and nursing staff in primary health care centers and other hospitals. POLICY: The Emergency Department of this hospital is a Level III Emergency Medical Service Department. This hospital has a bed Emergency Department with 24-hour per day care. PATIENT POPULATION: The patient population served by the Emergency Department consists of newborn, pediatric, adolescent, adult and geriatric patients requiring or seeking medical care. SCOPE AND COMPLEXITY OF PATIENT CARE NEEDS: All patients that present to Hospital's premises for a non-scheduled visit and are seeking care shall receive a medical screening exam by an Emergency Department physician. An on-call list of specialty physicians is maintained to assist in stabilizing patients. All necessary definitive treatment will be given to the patient within the hospital's capabilities. Emergency Department patients are then evaluated for response to treatment and are admitted, transferred for further treatment not provided by the hospital or discharged, with follow-up instructions as appropriate.

ED Facilities and Equipments Registration area:

Computer and printer Direct telephone line (hot line) Wireless telephone line Emergency format Work bench/chair Photocopier

Fax Telephone

2. Triage Area:
BP apparatus (Digital as well manual) Thermometers (Digital and manual) Stethoscope Chairs and desk Telephone Mobile examination trolley Examination light

3. Resuscitation Room:

I. The resuscitation room must has the following requirements : Area to fit a specialized resuscitation bed. Space to ensure 360 access to all parts of the patient for uninterrupted procedures. Circulation space to allow movement of staff and equipment around the work area. Space for equipment, monitors, storage, wash up and disposal facilities. Appropriate light. Maximum possible visual & auditory privacy for the occupants of the room and other patients. Minimum size for a single bed resuscitation room is 35 m2 or 25 m2 for each bed space if in a multi bedded room. II. Each resuscitation bed space should be equipped with : Service panel (oxygenation/suction, medical air outlets). Physiological monitor with ECG, printer, NIBP, SPO2, temperature probe, C02 monitor. An operating theatre light. Wall mounted diagnostic set (opthalmoscope/otoscope). Radiolucent resuscitation trolley with cassette trays. Overhead IV track. III.The resuscitation area should also have : Crash cart Airway management equipment Portable monitor/defibrillator Transcutaneous pacemaker Infusion pumps Blood warmer(s)

 Portble ventilator Glucometer Cabinet for narcotics. Cabinet foor IV fluids, emergency drugs . Chairs and desk Registration book Telephone Waste basket & sharp container X-ray viewing boxes White boards IV The following should be immediately accessible : IV access trolleys Peritoneal lavage tray Intercostal tray Urinary catheterization tray Airway management tray (including surgical airway equipment Suture and dressing tray Cut down tray Paediatric resuscitation equipment

4. Examination room (adult) Weighing scale Examination table Examination light BP apparatus Stethoscope Chairs & desk Ophthalmoscope/otoscope Cabinet Registration book for nurses Computer with LCD monitor

5. Examination room (paedia)

Weighing scale for infants Weighing scale for older children Examination table Examination light Stethoscope

6. Observation room (male & female)

BP apparatus Stethoscope Examination light Suction outlet Oxygen outlet Beds Wheelchairs Cabinet for fluids, emergency drugs, . Weighing scale Telephone Glucometer/ophthalmoscopes/otoscope Registration book Desk/chairs IV stand X-ray viewing boxes Waste basket & sharp container Computer with LCD monitor.

Chairs & desk ENT set Cabinet Steam inhaler Registration book Ophthalmoscope/otoscope Two computers with LCD monitors.

7. Plaster room

Oxygen suction outlet Storage for plaster and bandages Plaster trolley Sink drainer with a plaster trap Work bench Chair/desk X-ray box 8. OB/GYNAE room Examination/delivery bed Delivery set Pelvic examination set Baby incubator Doppler IV stand

 BP apparatus & stethoscope Chairs and desk Oxygen/suction outlet Dressing trolley Cabinet Wheel chair Telephone Registration book Waste basket and sharps container 9. Dressing room Examination bed Dressing trolley Big trolley Suture and dressing sets Chairs Oxygen/suction outlet Waste basket & sharps container. Telephone 10. Secretary room 11. ED Computer with printer Cabinet Desk Chairs Files Telephone Chief office

Desk Chairs Cabinet Telephone 12. Record room Shelves Cabinet

13. Clean utility room :

This should be of sufficient size for the storage of clean and sterile supplies and should possess adequate bench top area for the preparation of procedure trays and equipment.

14. Dirty utility/Disposal room : 15. Temporary Mortuary: To keep dead body for 2 hours.

16. Storage facilities : For storage of equipments, linens ..

17. Teaching facilities : A teaching/seminar/conference room needs to be provided. All standard presentational aids should be available. Training mannequins simulators should be available

18. Major disaster equipment storage: For storage of equipments, triage cards that would be required if a major disaster was declared. 19. Pharmacy : Used for the storage of medications used by the department.

20. Waiting room chairs TV health literature toilet

21. Security Station In the waiting area