Ed Algorithms 2014

Emergency Medicine
Algorithms
2014
This is a freely available educational resource in support of the development of
Emergency Medicine in Kenya and the activities of:
www.afem.info
Table of Contents
1.
Adult Cardiac Arrest Algorithm ................................................................................................................................................ 3
2.
Adult Bradycardia (< 50/min)/Tachycardia (> 150/min) .......................................................................................................... 4
3.
Post-Cardiac Arrest Care Algorithm ......................................................................................................................................... 5
4.
ACS Algorithm ......................................................................................................................................................................... 6
5.
STEMI Algorithm ..................................................................................................................................................................... 7
6.
NSTEMI/UA Algorithm............................................................................................................................................................ 8
7.
Pulmonary Embolism Algorithm .............................................................................................................................................. 9
8.
Rapid Sequence Intubation Algorithm .................................................................................................................................... 10
9.
Difficult Airway Algorithm ..................................................................................................................................................... 11
10. Anaphylaxis Algorithm ........................................................................................................................................................... 12

11. Acute Asthma Exacerbation Algorithm .................................................................................................................................. 13
12. Peak Expiratory Flow Chart .................................................................................................................................................... 14
13. Hypertension Algorithm .......................................................................................................................................................... 15
14. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8)
Guidelines................................................................................................................................................................................ 16
15. Hypertensive Emergencies Algorithm..................................................................................................................................... 19
16. Hypertensive Emergencies Drug Infusions ............................................................................................................................. 20
17. SEPSIS Definitions ................................................................................................................................................................. 21
18. Severe Sepsis/Septic Shock Algorithm ................................................................................................................................... 22
19. Hyperglycaemia Algorithm ..................................................................................................................................................... 23
20. Uncomplicated Hyperglycaemia Algorithm ............................................................................................................................ 24
21. Hypoglycaemia Algorithm ...................................................................................................................................................... 25
22. Electrolyte Abnormalities Algorithm ...................................................................................................................................... 26
23. Syncope Algorithm.................................................................................................................................................................. 27
24. Seizures Algorithm .................................................................................................................................................................. 28
25. Transient Ischemic Attack (TIA) Algorithm ........................................................................................................................... 29
26. Stroke Algorithm ..................................................................................................................................................................... 30
27. Stroke Reperfusion Algorithm ................................................................................................................................................ 31
28. Trauma Management Pathway ................................................................................................................................................ 32
29. C-Spine Clearance Algorithm ................................................................................................................................................. 33
30. Mild Traumatic Brain Injury Algorithm .................................................................................................................................. 34
31. Epistaxis Algorithm................................................................................................................................................................. 35
32. Low Back Pain Algorithm ....................................................................................................................................................... 36
33. Epigastric Pain Algorithm ....................................................................................................................................................... 37
34. Upper Gastrointestinal Bleeding Algorithm ............................................................................................................................ 38
35. Management of Pain in Sickle Cell Disease (SCD) Algorithm ............................................................................................... 39
36. Pain Management Algorithm .................................................................................................................................................. 40
37. Analgesia Chart ....................................................................................................................................................................... 41
38. Procedural Sedation and Analgesia (PSA) .............................................................................................................................. 42
39. Antimicrobial Guide ................................................................................................................................................................ 43
40. Poisoning ................................................................................................................................................................................. 49
Algorithm References ..................................................................................................................................................................... 50
1. Adult Cardiac Arrest Algorithm
This clinical pathway is intended to

supplement, rather than substitute
for, professional judgment and may
be changed depending upon a
patients individual needs. Failure
to comply with this pathway does
not represent a breach of the
standard of care.
Unresponsive
No Breathing or no normal breathing
(i.e. only gasping)
Activate Resuscitation Team

Get AED/Defibrillator
CHECK PULSE
DEFINITE pulse palpated
within 10 secs?
No Pulse
Definite Pulse
Open and maintain patent airway

Give 1 breath every 6 seconds
Recheck pulse every 2 mins
Go to 3. Post Cardiac Arrest Care Algorithm
Begin CPR - cycles of 30 COMPRESSIONS then 2 BREATHS

Perform continuous compressions until BVM is available
Use BVM when available to give breaths even without O2.
Attach O2 at 15L/min when available
AED/Defibrillator ARRIVES
Attach AED pads or use Quick look defibrillator paddles to check rhythm
Rhythm
Shockable?
Yes
High-Quality CPR
Compression rate of at least 100/min
Compression depth at least 5 cm
Allow complete chest recoil after each
compression
Minimize interruptions in chest
compressions to < 10 seconds
Avoid excessive ventilation Give
enough volume just to produce visible
chest rise. Give 2 breaths after every 30
compressions or if intubated, give 1
breath every 6 seconds
No
VF/Pulseless VT
Asystole/PEA
Shock
Biphasic 200J
Monophasic 360J
Change compressors - CPR 2min

IV/IO access Take bloods for VBG & RBS
Attach monitor leads; adjust monitor to lead II

IV/IO access Take bloods for VBG & RBS
Attach monitor leads; adjust monitor to lead II
Rhythm
Shockable?
Yes
No
Shock
Biphasic 200J
Monophasic 360J

Adrenaline 1mg IV/IO with 20ml NS flush
(Repeat dose after 2 CPR cycles)
Identify and treat reversible causes below
Rhythm
Shockable?
No
Yes
Shock
Biphasic 200J
Monophasic 360J

Adrenaline 1mg IV/IO with 20ml NS flush
(Repeat dose after 2 CPR cycles)
Consider advanced airway, capnography
If return of spontaneous circulation, go to
3. Post Cardiac Arrest Care Algorithm
Reversible causes
Amiodarone 300mg IV/IO bolus with 20ml NS flush
(Second dose after 2 CPR cycles) 150mg with 20 ml NS flush)
Consider advanced airway, capnography
- Hypoglycaemia
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypo-/hyperkalaemia
- Hypothermia
- Tension Pneumothorax
- Tamponade, cardiac
- Toxins
- Thrombosis, pulmonary
- Thrombosis, coronary
2. Adult Bradycardia (< 50/min)/Tachycardia (> 150/min)

(with Pulse)
Airway
Open and maintain patent airway; protect as necessary
Breathing
Administer Oxygen (if SPO2 < 94%); Assist breathing as necessary
supplement, rather than substitute for,

professional judgment and may be
changed depending upon a patients
individual needs. Failure to comply with
this pathway does not represent a
breach of the standard of care.
Circulation
Cardiac monitor to identify rhythm; monitor blood pressure, pulse oximetry, To C, RBS
Establish IV access and take bloods for FBC, UEC, VBG
Print rhythm strip or 12-lead ECG if available; dont delay therapy
Identify and treat underlying cause

-
Bradycardia (HR < 50/min)

With signs of instability
Hypoglycaemia
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/hyperkalaemia
Hypothermia
Tension Pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary
Signs of instability
Hypotension?
Acutely altered mental status?
Signs of Shock?
Ischaemic chest discomfort?
Acute heart failure?
Tachycardia (> 150/min)
Consult a Cardiologist and continue

with the algorithm
Wide QRS?
0.12 seconds
No
Yes
Wide Complex Tachycardia
(Ventricular Tachycardia)
HR > 150/min + QRS complexes 0.12sec
Narrow Complex Tachycardia

(Supraventricular Tachycardia)
HR > 150/min + QRS complexes < 0.12sec
Stable
IV Atropine
Exclude: head injury, hypoxia,
hypothermia, heart block,
hyperkalaemia, heart transplant
First Dose: 0.5mg bolus
Repeat every 3-5 minutes
Maximum: 3 mg
If atropine ineffective:
1. Transcutaneous Pacing
(See pacing protocol)
OR
2.
3.
Vagal Stimulation
(at least 2 different manoeuvres)
(NOT if varying R-R intervals/Atrial fibrillation)
Valsalva (Abdominal pressure/Breath holding)
Facial application of ice water
Carotid sinus massage (C/I if bruits, CVS
disease, elderly)
Adenosine
(NOT if varying R-R intervals/Atrial fibrillation)
6 mg rapid IV push; follow with 20mls NS flush;
then 12 mg IV after 1-2 mins if required
Adrenaline IV Infusion
2-10 g/min
Consult a Cardiologist
Alternative: Glucagon if -blocker or
CCB overdose
Stable
Synchronised cardioversion
Consider procedural sedation
Start with 100J initially with
escalation as needed
Adenosine
(NOT if varying R-R intervals/Polymorphic)
6 mg rapid IV push; follow with 20mls NS flush;
then 12 mg IV after 1-2 mins if required
Dopamine IV infusion
2 -10g/kg/min
OR
Signs of instability
Amiodarone
150mg IV over 10 mins then 1mg/min
infusion for first 6 hours
Alternatives (under expert advice)
blockers
Ca Channel Blockers or
Digoxin
Amiodarone
150mg IV over 10 mins then 1mg/min
infusion for first 6 hours
Consider (if Torsades de Pointes):

Defibrillation (asynchronous)
Magnesium 2gm IV over 10 mins
Overdrive pacing
3. Post-Cardiac Arrest Care Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending
upon a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Return of Spontaneous Circulation (ROSC)
Activate Resuscitation Team (if not already present) AND a Physician/Cardiologist

Monitor, support ABCs. Be prepared to provide CPR and defibrillation
Check vital signs (BP, PR, RR, SPO2, ToC, RBS)
12-lead ECG immediately
If patient is stable, consider immediate transfer to ICU attached to a defibrillator
Optimize ventilation and oxygenation

Avoid excessive ventilation.
- Start at 10 12 breaths/min (1 breath every 6 seconds)
- Titrate FiO2 to minimum necessary to maintain SPO2 94%
- Titrate to target PETCO2 of 35 45 mmHg
Consider advanced airway and waveform capnography
Treat hypotension (SBP < 90mmHg)
IV/IO Bolus: 1-2 L Normal Saline or Ringers Lactate
Vasopressor infusion if NO response to fluid bolus:
- Adrenaline IV Infusion: 0.1 0.5g/kg/min (7-35g/min in 70-kg adult)
- Norepinephrine IV Infusion: 0.1 0.5g/kg/min (7-35g/min in 70-kg adult)
Identify and treat reversible causes
- Hypoglycaemia
- Tension Pneumothorax
- Hypovolemia
- Tamponade, cardiac
- Hypoxia
- Toxins
- Hydrogen ion (acidosis)
- Thrombosis, pulmonary
- Hypo-/hyperkalaemia
- Thrombosis, coronary
- Hypothermia
Keep the patients temperature

< 36oC for 36 hours using icecold fluids, ice packs, and
intravascular or surface
temperature-management
No Patient is able to follow commands?

Yes
STEMI or Suspicion of ACS Consult a Cardiologist

Transfer to Critical Care Unit (ICU/CCU) attached to a defibrillator
4. ACS Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Chest discomfort suggestive of ischemia
(includes anginal equivalents (atypical symptoms) like exertional pain in the ear, jaw, neck, shoulder,
arm, back, or epigastric area; exertional dyspnoea; nausea and vomiting; diaphoresis; and fatigue.
Monitor, support ABCs in the Resuscitation Room (ER). Be prepared to provide CPR and defibrillation
Obtain/review 12-lead ECG within 10 minutes of arrival to ER
- Do a V4R if ST elevation in lead V1 with simultaneous ST depression in V2 - ? Right sided STEMI
- Do V7 - V9 if ST depressions 1 mm with upright T-waves in 2 contiguous anterior precordial leads (V1 to V3) - ? Posterior STEMI
- If there is ST elevation in aVR 1mm and aVR V1 with widespread horizontal ST depression, most prominent in leads I, II and V4-6
consult an Interventional Cardiologist immediately for PCI (Left main coronary artery occlusion/Proximal LAD lesion)
- Sinus Tachycardia, T wave inversion in III & V1, V3 or (S1, Q3, T3) pattern - ? See 7. Pulmonary Embolism Algorithm
Start Oxygen IF SPO2 < 90% or if patient is dyspnoeic. Maintain SPO2 90%
Establish IV access in left forearm or antecubital vein and send blood samples for UEC, Coagulation screen & hsTroponin T if 4 hours since
onset of symptoms
Perform brief, targeted history, physical exam Indicate time of symptoms onset
Aspirin 300mg to chew (if not given by EMS, Not Allergic, No active Upper GI Bleeding or Retinal bleeding, not a haemophiliac, No severe untreated BPs)
Nitroglycerin sublingual spray 0.4mg SL for pain relief every 5mins up to relief of discomfort or MAX 3 doses reached. DO NOT give nitroglycerine if:
SBP < 90mmHg (or 30 mm Hg below the patients known baseline),
Heart rate > 100 bpm, or < 50 bpm.
Right ventricular infarction (right ventricular infarction causes a preload dependent state)
Use of sildenafil or vardenafil within the previous 24 hours or tadalafil within the previous 48 hours.
Fentanyl 50g IV if pain is NOT relieved by the 3 doses of SL nitroglycerin. Repeat once if still in pain after 5 mins. For persistent pain, consult a
Cardiologist/Physician. Consider IVI nitroglycerin (see C/I above)
Obtain portable CXR to r/o other causes of chest pain (pulmonary embolus, cardiac tamponade, aortic dissection, tension pneumothorax)
Review initial 12-lead ECG
ST elevation or LBBB meeting

Sgarbossa criteria (see below)
ST-Elevation MI (STEMI)
ST depression > 0.5mm or dynamic T-wave

inversion 2mm; strongly suspicious for ischemia
High-Risk Unstable Angina/Non-ST-Elevation MI
(UA/NSTEMI)
See
5. STEMI Algorithm
See
6. UA/NSTEMI Algorithm
Sequence of changes seen during evolution

of myocardial infarction
Left Bundle Branch Block (LBBB)
Normal or Non-diagnostic changes

in ST segment or T wave
Intermediate/Low Risk UA
Sgarbossa criteria for LBBB (either)

1. Concordant ST elevation 1mm in at least 1 lead
2. Concordant ST depression 1mm in V1 - 3
5. STEMI Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients
individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
ST elevation or LBBB meeting Sgarbossa criteria (see 4. ACS Algorithm)
ST-Elevation MI (STEMI)
Consult an
Interventional Cardiologist
No
Time from onset of symptoms 12 hours?

Yes
Consult an Interventional Cardiologist

to determine if the patient is for
Thrombolysis/Fibrinolysis OR Primary PCI
Primary PCI
Obtain informed consent
Give:
1. Clopidogrel (600mg) OR
Prasugrel (60mg) OR
Ticagrelor (180mg)
2. Atorvastatin 80mg
Transfer to Cathlab within 90
minutes of arrival to the ER
Thrombolysis/Fibrinolysis
Give:
1. Clopidogrel 600mg
2. Enoxaparin:
If age <75 y: 30-mg IV bolus, followed in 15 min by 1 mg/kg SC (max.100 mg for the first 2 doses)
If age 75 y: no bolus, 0.75 mg/kg SC (max. 75 mg for the first 2 doses)
Regardless of age, if CrCl < 30 mL/min: 1 mg/kg SC
3. Atorvastatin 80mg
Review/Complete Fibrinolysis Checklist

Absolute Contraindications
Relative Contraindications
Any prior intracranial haemorrhage
History of chronic, severe, poorly controlled hypertension
Known structural cerebral vascular lesson (e.g., AVM)
Severe uncontrolled hypertension on presentation (SBP > 180 mmHg or
DBP > 110 mmHg)
Known malignant intracranial neoplasm (primary or metastatic)
History of prior ischaemic stroke > 3 months, dementia, or known
Ischaemic stroke within 3 months EXCEPT acute ischaemic stroke
intracranial pathology not covered in contraindications
within 3 hours
Traumatic or prolonged (>10 minutes) CPR or major surgery (< 3 weeks)
Suspected aortic dissection
Recent (within 2 to 4 weeks) internal bleeding
Active bleeding or bleeding diathesis (excluding menses)
Non-compressible vascular punctures
Significant closed head trauma or facial trauma within 3 months
For streptokinase/anistreplase: prior exposure (> 5 days ago) or prior
allergic reaction to these agents
Pregnancy
Active peptic ulcer
Current use of anticoagulants: the higher the INR, the higher the risk of
bleeding
No Contraindications for Fibrinolysis/Thrombolysis

Obtain informed consent for fibrinolysis/thrombolysis
Ensure patient is connected to a defibrillator (ECG, SPO2, BP) and repeat baseline vitals. Administer fibrinolysis within 30 mins of arrival to ER
TENECTEPLASE
To reconstitute tenecteplase, mix the 50-mg vial in 10 mL sterile water (5 mg/mL). Tenecteplase is administered in a 30-50 mg IV bolus over
5 seconds. The dosage is calculated on the basis of the patients weight, as follows:
- < 60 kg - 30 mg (6 mL)
- 60 to 69 kg - 35 mg (7 mL)
- 70 to 79 kg - 40 mg (8 mL)
- 80 to 89 kg - 45 mg (9 mL)
- 90 kg - 50 mg (10 mL)
OR
STREPTOKINASE
Set up second IV line for the Streptokinase. Run Normal Saline/Ringers Lactate TKVO in other line
The adult dose of streptokinase for STEMI is 1.5 million U in 50 mL of 5% dextrose in water (D5W) given IV over 60 minutes. Allergic
reactions force the termination of many infusions before a therapeutic dose can be administered.
Monitor vital signs (BP, PR, RR, SPO2) every 15 minutes during the infusions
Continue monitoring patient for 30mins after the end of the infusions
Transfer patient to CCU/ICU connected to the defibrillator
6. NSTEMI/UA Algorithm
ST depression > 0.5mm or dynamic T-wave inversion 2mm; strongly
suspicious for ischemia
High-Risk Unstable Angina/Non-ST-Elevation MI (UA/NSTEMI)
TIMI Risk factors

Note: Each of the listed risk factors is worth 1 point
(range 0-7 points).
Age greater than 65 years
At least 3 risk factors for coronary artery disease (including family
history of the disease, hypertension, hypercholesterolemia, diabetes
mellitus, and current tobacco use)
Significant coronary stenosis (prior known coronary stenosis 50%)
ST-Segment deviation
Severe anginal symptoms ( 2 anginal events in the previous 24 hours)
Use of aspirin in the previous 7 days
Elevated serum cardiac marker levels (hsTrop T)
Normal or Non-diagnostic changes in ST segment or T wave

Intermediate/Low Risk UA
TIMI Risk Score
Probability of Death, Myocardial

Infarction and Revascularization
Within 30 Days, %
2.1
2
3
10.1
19.5
22.1
5
6
39.2
45
100
STEMI
See 5. STEMI Algorithm
Repeat 12 lead ECG in 30 mins/Continuous ST-segment monitoring
hsTroponin T > 14ng/L OR TIMI score 3 points OR ST depression OR Dynamic ECG changes
No
Yes
Consult a Cardiologist/Physician
hsTroponin T 14ng/L
If Troponin done < 4 hours from symptom onset then repeat

Troponin at 3 hours from admission to ER
hsTroponin T < 14ng/L
If no evidence of ischaemia or infarction by testing, can

discharge cardiology follow-up
Criteria for Discharge (must meet ALL the criteria)
Two ECGs which are Normal and No ST Depression and No

Dynamic changes
hsTroponin T < 14ng/L at 4 hours from onset of symptoms OR 3
hours from admission to ER
7. Pulmonary Embolism Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients individual needs.
Failure to comply with this pathway does not represent a breach of the standard of care.
Clinical features suggestive of Pulmonary Embolus
Monitor, support ABCs in Resuscitation room (ER). Be prepared to provide CPR and defibrillation
Obtain/review 12-lead ECG Consider ACS See 5. STEMI Algorithm.
Features of PE on ECG; Sinus Tachycardia, T wave inversion in III & V1, V3 or S1, Q3, T3 pattern. A normal ECG can be seen in 30% of patients
Check vital signs (BP, PR, RR, SPO2, T C, RBS)
Establish IV Access and send blood samples for FBC, UEC, Coagulation screen & hsTroponin T (See 6. UA/NSTEMI Algorithm for interpretation)
Perform brief, targeted history, physical exam
Chest x-ray If alternative cause for symptoms found, treat underlying cause. If not, continue with algorithm
o
Clinical gestalt or validated clinical decision support tool

Wells score
Criteria
Points
Suspected DVT
3.0
An alternative diagnosis is less
3.0
likely than PE
Hear Rate >100bpm
1.5
Immobilisation or surgery in the
1.5
previous 4 weeks
Previous DVT/PE
1.5
Haemoptysis
1.0
Malignancy (on treatment, treated
1.0
in the last 6 months, or palliative)
Score Range
Probability of
Interpretation of Risk
(Points)
PE (%)
0-4
7.8 (5.9 10.1)
Low Probability
>4
40.7 (34.9 46.5)
Moderate to High
Probability
Moderate to high probability for PE ( 15%)
Hemodynamically stable, low probability for PE (< 15%)
Haemodynamically stable?
Any Pulmonary Embolism Rule-Out Criteria met?
1. Is the patient > 49 years of age?
2. Is the pulse rate > 99 beats per minute?
3. Is the pulse oximetry reading < 95% while the
patient breathes room air?
4. Is there a present history of haemoptysis?
5. Is the patient receiving exogenous oestrogen?
6. Does the patient have a prior diagnosis of venous
thromboembolism?
7. Has the patient had recent surgery or trauma
requiring endotracheal intubation or hospitalization
in the previous 4 weeks?
8. Does the patient have unilateral leg swelling (visual
observation of asymmetry of the calves)?
Yes
Quantitative D-dimer assay

(ELISA or turbidimetric)
No
> 0.5 g/L*
No
Bedside echocardiogram
Presence of RV dilatation, septal
shift, or right heart thrombus?
Yes
Admit to ICU
Begin anticoagulation
Consider thrombolysis
If contraindication to
anticoagulation,
continue resuscitation,
consider embolectomy
PE safely excluded
consider other diagnosis
< 0.5 g/L*

CTPA*
Negative
PE safely excluded
consider other diagnosis
Positive
Begin anticoagulation
therapy with unfractionated
or fractionated heparin
Consult a Physician
*for patients > 50 yrs, cut off is 10 x patients age in g/L
Yes
CTPA*
Positive
Negative
PE safely
excluded
consider
other
diagnosis
No
No
Administer IV fluids
& resuscitate
Is patient stable
following initial
resuscitation?
Begin anticoagulation therapy

If contraindication to
anticoagulation, consider IVC
filter and/or if massive PE,
embolectomy
Risk stratification with troponin
and echocardiogram
Admit to ICU or floor as indicated
* Compression ultrasound of lower extremities can be performed as the initial

diagnostic imaging modality in any of the following situations;
patients with obvious signs of deep vein thrombosis (DVT) for whom venous
ultrasound is readily available
patients with relative contraindications for CT scan (e.g., borderline renal
insufficiency, CT contrast agent allergy)
in pregnant patients with an elevated D-dimer
patients with a moderate to high clinical risk of PE with a negative or
inconclusive CTPA or an inconclusive V/Q scan.
A positive finding in a patient with symptoms consistent with PE can be
considered evidence for diagnosis of VTE disease and potentially eliminate the
need to expose the patient to the radiation from either a CTPA or V/Q scan.
8. Rapid Sequence Intubation Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon
a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Preparation
LEMON
Look for external markers of difficulty of BVM and Intubation
Evaluate the 3-3-2 rule
Mallampati
Obstruction/Obesity
Neck Mobility
MALE MESS
Mask
Airways (oral and nasal)
Laryngoscopes, Laryngeal Mask Airway (LMA)
Endotracheal tubes Males 8F; Females 7.5F
Monitoring (pulse oximetry, ECG, capnography), Magill Forceps
Emergency drugs
Self-inflating bag valve resuscitator;
Suction, Stylet, Bougie
Plentiful oxygen supply
Position the patient
If patient is breathing spontaneously, prop up patient to allow patient to take deep breaths until you are ready to intubate
BVM ventilation and Intubation Position patients head at the level of your waistline and in the sniffing position as below Head extended(A); Neck flexed (B); Do NOT use this position in patients with suspected cervical spine injury.
Pre-oxygenation
Spontaneously breathing patient Allow 5 mins of spontaneous breathing with a tight-fitting non-rebreather facemask at 15L/min
Unconscious/Semi-conscious patient - Self inflating bag valve resuscitator with reservoir and O2 at 15L/min ventilation - Give 8 vital capacity
breaths (synchronized to patients breaths); Avoid positive pressure ventilation if possible
Paralysis with Induction
DO NOT use Succinylcholine in any patient suspected of having hyperkalaemia e.g. Renal Failure
Pass the tube

Limit attempt to < 30 seconds. Proceed down the algorithm after 30 seconds
Successful
Proof of Intubation
5 Point Auscultation Epigastrium, Bilateral Axillae, Bilateral Bases

Confirm wave form capnography tracing; maintain CO2 level at 35- 45mmHg
Self-inflating bag valve resuscitator ventilation 1 breath every 5s

Secure tube
Check vital signs (BP, PR, RR, SPO2, To C, RBS)
Connect patient to ventilator
Obtain portable CXR
Not Successful
Resume BVM ventilation - 1 breath every 3 seconds
See 9. Difficult Airway Algorithm
9. Difficult Airway Algorithm
Successful
Direct Laryngoscopy and Intubation (D.L.)

Failed
Resume BVM ventilation - 1 breath every 3 seconds

CALL Anaesthetist immediately
Able to ventilate with BVM?
No
Yes
Reposition patient to align the airway (sniffing position)
One more D.L. attempt. Limit attempt to < 30seconds
Proof of Intubation
5 Point Auscultation
Epigastrium, Bilateral Axillae,
Bilateral Bases
Confirm wave form
capnography tracing; maintain
CO2 level at 35- 45mmHg
Successful
Failed
Insert Laryngeal Mask Airway
Able to ventilate with BVM?

No
Yes
Surgical
Cricothyrotomy
Maintain ventilation
Wake up patient
or
Advanced airway techniques e.g.
Consult an Anaesthetist for fibre optic intubation
10. Anaphylaxis Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a
A patient meets the definition of anaphylaxis when any 1 of the following 3 criteria are fulfilled:
1.
Acute onset of mucocutaneous signs AND 1 of the following:

respiratory compromise (wheezing-bronchospasm, dyspnoea, stridor, hypoxemia),
hypotension (syncope), or
hypotonia.
2.
Rapid onset of 2 of the following after exposure to likely allergen:

mucocutaneous signs,
respiratory compromise,
hypotension, or
persistent gastrointestinal symptoms.
3.
Hypotension after exposure to a known allergen.
Patients with suspected anaphylaxis should be observed for at least 6 hours. Patients who are not high-risk should be discharged in the care of
others. Before discharge from the hospital, all patients with anaphylactic reactions must be;
Given clear indications for immediate return to the emergency department (ED).
Considered for treatment with antihistamines and oral steroids for 3 days to decrease the chance of further reaction
11. Acute Asthma Exacerbation Algorithm
Acute Asthmatic Attack
Monitor, support ABCs

Start Oxygen IF SPO2 < 92%. Maintain SPO2 92%; Oxygen should be provided to all patients with severe asthma, even those with normal oxygenation.
Perform brief, targeted history, physical exam (auscultation, use of accessory muscles, PR, RR)
Initiate treatment of underlying cause of exacerbation
Check Peak Expiratory Flow (PEF) as per 12. PEF Chart and record best PEF (%) in patients clinical notes. DO NOT measure PEF in patients
with impending/actual respiratory arrest. Start treatment immediately.
Peak Expiratory Flow < 70 %
Start nebulisation with Salbutamol + Ipratropium bromide (doses

below) every 20 mins or 3 doses for 1 hour. A combination of 4 mL
volume fill with NS and 6 to 8L/min oxygen flow rate is recommended.
Give Oral (if patient can swallow) or IV systemic corticosteroids (dose
below) immediately
Repeat assessment after 1 hour (3 doses)

Symptoms, physical exam + BP, PR, RR, SpO2, PEF
PEF >70% - Good Response

No Distress
Physical Exam Normal
Repeat assessment after 1 hour
PEF >70% - Good Response

No Distress
Physical Exam Normal
Response sustained 60minutes
after last treatment
Impending or Actual Respiratory Arrest
Intubation (RSI with Ketamine if no C/I) and Mechanical Ventilation with

100% oxygen; CXR
Start nebulisation with Salbutamol + Ipratropium bromide (doses below)
every 20 mins or 3 doses for 1 hour. A combination of 4 mL volume fill
with NS and 6 to 8L/min oxygen flow rate is recommended.
Give IV Hydrocortisone 2mg/kg (maximum 200mg) immediately
Give high-dose IV Magnesium, 2gm in 5% Dextrose over a 20-min
Call ICU/Physician
PEF 40 69% - Incomplete Response

Continue nebulisation with Salbutamol +
Ipratropium bromide (doses below) every 20
mins or 3 doses for 1 hour
Repeat assessment after 1 hour (3 doses)
PEF 40 69% - Incomplete Response
Ipratropium bromide (doses below) every 20 mins
or 3 doses per hour
Give high-dose IV Magnesium, 2gm in 5%
Dextrose over 20-min
ABG + CXR
Call ICU/Physician
Medication
Dose
PEF < 40% - Poor Response

Symptoms severe, drowsiness, confusion
Call ICU/Med; continue treatment below
ABG + CXR
Give high-dose IV Magnesium, 2gm in
5% Dextrose over a 20-min
Ipratropium bromide (doses below) every
20 mins or 3 doses for 1 hour
Consider Intubation and Mechanical
ventilation
Comments
Inhaled SABA
Salbutamol
Discharge Home
Continue treatment with inhaled SABA
2 puffs QID for 3-5 days
Continue course of oral systemic
corticosteroids (See dose in table)
Review medication including inhaler
technique
Consider therapy for underlying cause of
exacerbation
Refer to chest clinic for follow-up
Nebulizer solution
(0.63 mg/3 mL, 1.25mg/3mL,
2.5 mg/3 mL, 5.0 mg/mL)
5 mg every 20 min for 3 doses,

then 2.510 mg every 14 h as
needed, or 1015 mg/h
continuously
Only selective -agonists are recommended. For optimal delivery, dilute

aerosols to minimum of 3 mL at gas flow of 68 L/min. Use large-volume
nebulizers for continuous administration. May mix with ipratropium nebulizer
solution.
MDI (90g/puff)
48 puffs every 20 min up to 4h,

then every 14 h as needed
In mild to moderate exacerbations, MDI plus valved holding chamber is as

effective as nebulized therapy with appropriate administration technique
and coaching by trained personnel.
0.30.5 mg every 20 min for 3

doses SC
No proven advantage of systemic therapy over aerosol
Nebulizer solution
(0.25mg/mL)
0.5 mg every 20 min for 3 doses,

then as needed
May mix in same nebulizer with salbutamol. Should not be used as first-line
therapy; should be added to SABA therapy for severe exacerbations. The
addition of Ipratropium has not been shown to provide further benefit once the
patient is hospitalized.
MDI (18 g/puff)
8 puffs every 20 min as needed

up to 3 h
Should use with valved holding chamber. Studies have examined Ipratropium
bromide MDI for up to 3 h.
Nebulizer solution (Each 3-mL

vial contains 0.5mg ipratropium
bromide and 2.5 mg
salbutamol.)
3 mL every 20 min for 3 doses,

then as needed
May be used for up to 3 h in the initial management of severe exacerbations.

The addition of ipratropium to salbutamol has not been shown to provide further
benefit once the patient is hospitalized.
MDI (Each puff contains 18g

Ipratropium bromide and 90g
salbutamol.)
8 puffs every 20 min as needed

up to 3 h
Should use with valved holding chamber.
Prednisone
4080 mg/d in 1 or 2 divided

doses until PEF reaches 70% of
predicted or personal best
For outpatient burst, use 4060 mg in single or 2 divided doses for a total of
510 d.
Hydrocortisone
200mg IV then 1mg/kg/dose IV

QID
Only if patient cannot tolerate PO corticosteroids
Systemic (Injected) 2-Agonists

Adrenaline
1:1,000 (1 mg/mL)
Anticholinergics
Ipratropium bromide
Ipratropium with salbutamol
Systemic Corticosteroids
ED = emergency department; ICS = inhaled corticosteroid; MDI = metered-dose inhaler; PEF = peak expiratory flow; SABA = short-acting 2adrenergic agonist
Notes: There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous
administration over oral therapy provided gastrointestinal transit time or absorption is not impaired. The total course of systemic corticosteroids for an
asthma exacerbation requiring an ED visit or hospitalization may last from 3 to 10 days. For corticosteroid courses of <1 week, there is no need to taper the
dose. For slightly longer courses (e.g., up to 10 d), there probably is no need to taper, especially if patients are concurrently taking ICSs. ICSs can be
started at any point in the treatment of an asthma exacerbation.
12. Peak Expiratory Flow Chart

How to Measure Peak Expiratory Flows (PEF)
c
DO NOT measure PEF in patients with impending/actual
respiratory arrest. Start treatment immediately.
1. Put the pointer on the gauge of the peak flow meter to 0 or

the lowest number on the meter.
2. Attach the mouthpiece to the peak flow meter.
3. While standing, take a deep breath.
4. Put the peak flow meter mouthpiece in your mouth, and close
your lips tightly around the outside of the mouthpiece. Don't
put your tongue inside the mouthpiece.
5. Breathe out as hard and as fast as you can for 1 or 2 seconds.
A hard and fast breath usually produces a "huff" sound.
6. Check the number on the gauge, and write it down.
7. Repeat the above 3 times and take the patients best PEF
8.
Plot the best PEF on the normal values chart and calculate
the percentage as below
Measured PEF X 100%

Normal PEF
9. Record the PEF in the patients clinical notes
13. Hypertension Algorithm
BP > 140/90mmHg

Start Oxygen IF SPO2 < 94%. Maintain SPO2 94%
Obtain/review 12-lead ECG
Send blood samples for FBC, UEC, TSH
Urinalysis for proteinuria
Perform brief, targeted history and physical exam
Allow patient to rest awaiting results. Repeat BP checks hourly.
DO NOT administer antihypertensives e.g. nifedipine to lower the blood pressure in the ED unless there are
features of progressive or impending end organ damage below. See 15. Hypertensive Emergencies Algorithm
Are there any features of progressive or impending end

organ damage (especially if BP > 180/110 mmHg)?
a) Neurological
Cerebral vascular accident/cerebral infarction (24.5%)
Hypertensive encephalopathy (16.3%)
Subarachnoid haemorrhage
Headache is NOT a hypertensive
Intracranial haemorrhage
emergency, no matter how high
b) Cardiovascular
the blood pressure. It is likely
Acute pulmonary oedema (22.5%)
the headache is causing the
Congestive heart failure (12%)
hypertension, not the other way
Myocardial ischemia/infarction
around. Treat the headache and
Acute left ventricular dysfunction
the pressure will come down.
Aortic dissection
c) Other
The same is true of epistaxis.
Acute renal failure/insufficiency
Retinopathy
Pre-eclampsia/Eclampsia
Microangiopathic haemolytic anaemia
No
Known Hypertensive Resume regular treatment; if
unknown, low dose thiazide type diuretic for most; may
consider ACE inhibitor, ARB, -blocker, CCB. Follow-up as
below (See 14. JNC VIII Guidelines)
New Onset Hypertension - Final BP prior to discharge
BP > 160/100 low dose thiazide type diuretic for most;
may consider ACE inhibitor, ARB, -blocker, CCB. (See
14. JNC VIII Guidelines). Follow-up as below
BP < 160/100 Follow-up as below

Daily BP checks at nearest clinic and follow-up
in a Medical Clinic in 1 week with BP chart
Yes
Consult a
Physician (Obstetrician in Eclampsia)

See 15. Hypertensive Emergencies Algorithm
14. Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 8) Guidelines
BLOOD PRESSURE MEASUREMENT TECHNIQUES
The electronic device, if available, is preferred because it provides more reproducible results.
At the initial evaluation, BP should be measured in both arms; if the readings are different, the arm with the higher
reading should be used for measurements thereafter.
The BP should be taken after patients have emptied their bladders. Patients should be seated with their backs supported
and with their legs resting on the ground and in the uncrossed position for 5 minutes. The patients arm being used for
the measurement should be at the same level as the heart, with the arm resting comfortably on a table.
It is preferable to take 2 readings, 1 to 2 minutes apart, and use the average of these measurements.
It is useful to also obtain standing blood pressures (usually after 1 minute and again after 3 minutes) to check for
postural effects, particularly in older people.
In general, the diagnosis of hypertension should be confirmed at an additional patient visit, usually 1 to 4 weeks after the
first measurement. On both occasions, the SBP should be 140 mm Hg or the DBP 90 mmHg, or both, in order to
make a diagnosis of hypertension.
It can be helpful to measure BP at home. If available, the electronic device is simpler to use and is probably more
reliable than the sphygmomanometer. The average of BPs measured over 5 to 7 days, if possible in duplicate at each
measurement, can be a useful guide for diagnostic and treatment decisions.
If the BP is very high (for instance, a SBP 180 mm Hg), or if available resources are not adequate to permit a
convenient second visit, the diagnosis and, if appropriate, treatment can be started after the first set of readings that
demonstrate hypertension.
CLASSIFICATION OF BLOOD PRESSURE (BP)

CATEGORY
Normal
Prehypertension
Hypertension, Stage 1
Hypertension, Stage 2
SBP mmHg
< 120
120-139
140-159
160
and
or
or
or
DPB mmHg
< 80
80-89
90-99
100
DIAGNOSTIC WORKUP OF HYPERTENSION
Assess risk factors and comorbidities

Reveal identifiable causes of hypertension
Assess presence of target organ damage
Conduct history and physical examination
Obtain/review 12-lead ECG, RBS, FBC, UEC, TSH, Urinalysis for proteinuria, Lipid panel
Calculate the 10-year risk for first atherosclerotic cardiovascular disease events (ASCVD; nonfatal myocardial
infarction, coronary heart diseaserelated death, or fatal or nonfatal stroke) with the 2013 AHA/ACC 2013 Prevention
Guidelines ASCVD Risk Estimator - http://www.cardiosource.org/science-and-quality/practice-guidelines-andquality-standards/2013-prevention-guideline-tools.aspx
PRINCIPLES OF LIFESTYLE MODIFICATION

RECOMMENDATION
AVG. SBP REDUCTION RANGE1
2
Maintain normal body weight (BMI 18.5-24.9 kg/m ).
5-20 mmHg/10 kg
Adopt a diet rich in fruits, vegetables, and lowfat dairy
DASH eating plan
8-14 mmHg
products with reduced content of saturated and total fat.
Dietary sodium
No added salt. Use a limited amount of salt in cooking.
2-8 mmHg
reduction
Dont add salt to your food at the table.
Aerobic physical
Regular aerobic physical activity (e.g. brisk walking) at
4-9 mmHg
activity
least 30 minutes per day, most days of the week.
Men: limit to 2 drinks* per day.
Moderation of
Women and lighter weight persons: limit to 1 drink*
2-4 mmHg
alcohol consumption
per day
1
Effects are dose and time dependent
* 1 drink = 15 mL ethanol (e.g. 355 mL beer, 148 mL wine, 44 mL 80-proof whiskey).
MODIFICATION
Weight reduction
EVIDENCE-BASED DOSING FOR ANTIHYPERTENSIVE DRUGS
15. Hypertensive Emergencies Algorithm

BP > 160/100mmHg
+
Features of progressive or impending end organ damage
(especially if BP > 180/110 mmHg)?

Establish IV Access and send blood samples for FBC, UEC
Urinalysis for proteinuria
Consult a Physician/ (Obstetrician for Eclampsia) and consider treatments as below in consultation with a Physician/Obstetrician
See 16. Hypertensive Emergencies Drug Infusions for Dosages and Precautions
Neurological emergencies
Preferred medications
Labetalol
Nicardipine
Esmolol
Medications to avoid
Nitroprusside
Hydralazine
Hypertensive encephalopathy - Reduce mean arterial pressure (MAP) 25% over 8 hours.
Acute ischemic stroke - Evidence exists that patients who have acute strokes have better outcomes with higher BPs. Antihypertensive therapy is not
routinely recommended for patients with acute stroke and HTN.
Patient otherwise eligible for acute reperfusion therapy except that BP is >185/110 mm Hg:
- Labetalol 1020 mg IV over 12 minutes, may repeat 1 time
- Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate
If BP is not maintained at or below 185/110 mm Hg, do not administer rtPA
Management of BP during and after rtPA or other acute reperfusion therapy to maintain BP at or below 180/105 mm Hg:
- Monitor BP every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours
- If systolic BP >180230 mm Hg or diastolic BP >105120 mm Hg:
Labetalol 10 mg IV followed by continuous IV infusion 28 mg/min;
If BP not controlled or diastolic BP >140 mm Hg, consider IV sodium nitroprusside
After treatment with fibrinolysis, the SBP should be maintained < 180mmHg and DBP < 105mmHg for 24 hours.
In patients with markedly elevated blood pressure (SBP > 220 mm Hg or DBP > 120 mm Hg) who do not receive fibrinolysis, a reasonable goal
is to lower blood pressure by 15% during the first 24 hours after onset of stroke.
Acute intracerebral haemorrhage - No evidence exists to suggest that HTN provokes further bleeding in patients with ICH. A precipitous fall in SBP
may compromise cerebral perfusion and increase mortality. The controlled lowering of BP with IV labetalol (in the absence of bradycardia) is currently
recommended only when the SBP is >200mmHg or the DBP is >110mmHg. Treatment based on clinical/radiographic evidence of increased intracranial
pressure (ICP).
If signs of increased ICP, maintain MAP just below 130mmHg (or SBP < 180mmHg) for first 24 hours after onset.
Patients without increased ICP, maintain MAP < 110mmHg (or SBP < 160mmHg) for first 24 hours after symptom onset.
Subarachnoid haemorrhage - Maintain SBP < 160mmHg until the aneurysm is treated or cerebral vasospasm occurs. Oral nimodipine is used to
prevent delayed ischemic neurological deficits, but it is NOT indicated for treating acute hypertension.
Cardiovascular emergencies
Aortic dissection Immediately reduce the SBP < 110mmHg and maintain it at this level unless signs of end-organ hypoperfusion are present. Preferred
treatment includes a combination of;
a) narcotic analgesics (morphine sulphate),
b) -blockers (labetalol, esmolol) or calcium channel blockers (verapamil, diltiazem); Avoid -blockers if there is;
aortic valvular regurgitation or
suspected cardiac tamponade.
c) vasodilators (nicardipine, nitroprusside).
Acute coronary syndrome - Treat if SBP >160 mmHg and/or DBP >100 mmHg. Reduce BP by 20-30% of baseline. Thrombolytics are
contraindicated if BP is >185/100 mmHg. Preferred medications include -blockers & Nitroglycerin
Acute heart failure - Treatment with vasodilators (in addition to diuretics) for SBP 140 mmHg. IV or sublingual nitroglycerin is the preferred agent.
Other disorders
Cocaine toxicity/pheochromocytoma - Hypertension and tachycardia from cocaine toxicity rarely require specific treatment.
Benzodiazepines are the preferred agents for cocaine-associated acute coronary syndromes.
Pheochromocytoma treatment guidelines are similar to that of cocaine toxicity. -blockers can be added for BP control only after -blockade.
Preferred medications - Diazepam, Phentolamine, Nitroglycerin/nitroprusside
Medications to avoid - -adrenergic antagonists prior to phentolamine administration
Preeclampsia/eclampsia - In women with eclampsia or preeclampsia, SBP should be < 160 mmHg and DBP <110 mm Hg in the prepartum and
intrapartum periods. If the platelet count is < 100,000 cells/mm3 BP should be maintained below 150/100mmHg. Patients with eclampsia or preeclampsia
should also be treated with IV magnesium sulphate to avoid seizures.
Preferred medications - Hydralazine, Labetalol, Nifedipine
Medications to avoid - Nitroprusside, Angiotensin-converting enzyme inhibitors, Esmolol
16. Hypertensive Emergencies Drug Infusions
AGENT
MOA
DOSE
ONSET/DURATION OF
ACTION (AFTER
DISCONTINUATION)
PRECAUTIONS
Parenteral Vasodilators
Nitroglycerin
Decreases coronary
vasospasm, which
increases coronary
blood flow. Also
induces vessel
dilatation, decreasing
cardiac workload.
5-20 g/min as IV
infusion
2-5 min/5-10 min
Headache, tachycardia, vomiting,

flushing, methaemoglobinemia;
requires special delivery system
due to drug binding to plastic
tubing
Hydralazine
Decreases systemic
resistance through
direct vasodilation of
arterioles.
5-10 mg as IV bolus
repeat every 4-6 hr
10 min/> 1 hr
Tachycardia, headache,
vomiting, aggravation of angina
pectoris
Parenteral Adrenergic Inhibitors

Labetalol
,1, 2 Blocker
20 mg IV bolus over 10
mins then 1-2mg/min IV
infusion
5-10 min/15-30 min
Bronchoconstriction, heart block,

orthostatic hypotension
Esmolol
Ultra-short-acting adrenergic blocker
500 g/kg bolus

injection IV or 25-1 00
g/kg/min by infusion.
May repeat bolus after 5
min or increase infusion
rate to 300 g/kg/min
1-5 min/15-30 min
First-degree heart block,

congestive heart failure, asthma
17. SEPSIS Definitions
Diagnostic criteria for sepsis
Infection, documented or suspected, and some of the following:

a) General variables
Fever (> 38.3C)
Hypothermia (core temperature < 36C)
Heart rate > 90/min or more than two SD above the normal value for age
Tachypnoea
Altered mental status
Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
Hyperglycaemia (plasma glucose > 7.7 mmol/L or 140 mg/dL) in the absence of diabetes
b) Inflammatory variables
Leucocytosis (WBC count > 12,000/L)
Leukopenia (WBC count < 4000/L)
Normal WBC count with greater than 10% immature forms
Plasma C-reactive protein more than two SD above the normal value
Plasma procalcitonin more than two SD above the normal value
c) Haemodynamic variables
Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or less than
two SD below normal for age)
d) Organ dysfunction variables
Arterial hypoxemia (PaO2/FiO2 < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)
Creatinine increase > 44.2 mol/L or 0.5 mg/dL
Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < 100,000/L)
Hyperbilirubinemia (plasma total bilirubin > 70 mol/L or 4 mg/dL)
e) Tissue perfusion variables
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling
Severe Sepsis
a) Sepsis-induced tissue hypoperfusion (infection-induced hypotension, elevated lactate ( 4 mmol/L), or oliguria)
or
b) Organ dysfunction (any of the following thought to be due to the infection)
Sepsis-induced hypotension (is defined as a SBP < 90 mm Hg or MAP < 70 mm Hg or a SBP decrease > 40 mm Hg
or < 2 SD below normal for age in the absence of other causes of hypotension.
Lactate above upper limits laboratory normal
Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
Acute lung injury with PaO2/FiO2 < 250 in the absence of pneumonia as infection source
Acute lung injury with PaO2/FiO2 < 200 in the presence of pneumonia as infection source
Creatinine > 176.8 mol/L (2.0 mg/dL)
Bilirubin > 34.2 mol/L (2 mg/dL)
Platelet count < 100,000 L
Coagulopathy (international normalized ratio > 1.5)
Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation.
18. Severe Sepsis/Septic Shock Algorithm
Severe Sepsis/Septic Shock

Establish IV Access and send blood samples for FBC, MPS, UEC, ABG, Serum lactate
Start IV Fluids using a pressure infusion bag to achieve a minimum of 30mL/kg NS or RL within 3 hours of identification. More
rapid administration and greater amounts of fluid may be needed in some patients
Obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay (> 45 minutes) in the
start of antimicrobial(s). Draw 2 sets of blood cultures 10mL each (both aerobic and anaerobic bottles) from different sites.
Give antibiotics as an EMERGENCY (within the first hour of recognition of septic shock and severe sepsis without septic shock )
- Ceftriaxone 2gm IV stat
- For probable Neutropenic patients or if patient has been admitted in hospital in the last 3 months (Hospital Acquired Infection)
Imipenem 500 mg IV infusion over 3 hrs then QID for general sepsis
OR
Meropenem 1gm IV infusion over 3 hrs then TDS for possible CNS infections
Give antipyretic if indicated (Paracetamol 1gm IV)
CXR; Urinalysis + MCS
Insert urinary catheter and monitor urine output

Repeat vital signs (BP, MAP, PR, RR, SPO2, To C, Serum lactate)
Features of shock despite adequate fluid resuscitation (> 30ml/kg)?
MAP < 65mmHg

Signs of Shock (tachypnoea, cool clammy skin, cool peripheries, hypotensive, tachycardia)
Urine output < 0.5mL/kg/hour
Yes
No
Consult a Physician
If;
No current indication for admission
Clinically stable with NO SIGNS OF SEVERE
SEPSIS OR SEPTIC SHOCK AS ABOVE
Identify source of infection and if amenable to oral
antibiotic therapy, initiate therapy and consider
discharge with MOPC follow-up
Start peripheral vasopressors if MAP < 65mmHg in the face of life-threatening

hypotension, even when hypovolemia has not yet been resolved - Norepinephrine
(0.11.3 g/kg/min) and/or Adrenaline (0.05-0.3g/kg/min). Titrate vasopressors to
a MAP 65 mmHg to preserve tissue perfusion. All patients requiring vasopressors
must have an arterial catheter placed as soon as practical resources are available
Hemodynamic stability achieved with adequate fluid resuscitation (> 30ml/kg)

and vasopressor therapy?
MAP < 65mmHg
Yes
Signs of shock as above
Admit HDU/ICU
Urine output < 0.5mL/kg/hour

No
Give Hydrocortisone 200mg IV bolus
Evidence of tissue hypoperfusion persists despite adequate

intravascular volume and adequate MAP?

Decreased capillary refill or mottling
No
Admit HDU/ICU
Yes
Give dobutamine infusion up to 20 g/kg/min

(+ vasopressor if in use) in the presence of;
a) myocardial dysfunction as suggested by elevated
cardiac filling pressures and low cardiac output, or
b) ongoing signs of hypoperfusion, despite achieving
adequate intravascular volume and adequate MAP
Admit HDU/ICU
19. Hyperglycaemia Algorithm
Hyperglycaemia (RBS > 14mmol/L)

Check vital signs (BP, PR, RR, SPO2, To C)
Establish IV Access and send blood samples for UEC and a
Venous Blood Gas (VBG)
Immediate Urinalysis for ketones
Ketones in Urine + (pH < 7.3 OR HCO3- < 18mmol/L)
RBS > 33.3mmol/L + Serum Osmolality > 320mOsm/kg + pH > 7.3
Diabetes Ketoacidosis
Hyperosmolar Hyperglycaemic State (HHS)
Normal VBG +
No Ketones in urine +
Serum Osmolality < 320mOsm/kg
Uncomplicated Hyperglycaemia
Identify and Treat precipitating illness; consider ACS, Sepsis

Consult a Physician and continue with the Algorithm
1. Fluid Protocol
(RL or 0.9% NaCl)
If BP unstable, give fluid boluses
at 15 to 20mL/kg; Repeat until BP
stable. Consider Inotropes if no
response to fluid resuscitation.
If BP stable;
1L stat
1L over 30 mins (2000mls/hr)
1L over 1 hours (1000mls/hr)
2. Potassium Protocol
No potassium should be given if patient is anuric or
serum K+ > 5.3mmol/L
Serum K+
(mmol/L)
> 5.3
4.0 to 5.3
3.5 to 4.0
< 3.5
Action
DO NOT give K+, but check potassium levels
hourly and start replacement when K+ < 5.3
Add 10mmol K+/1L fluid/hour to IV fluids
Add 20mmol K+/1L fluid/hour to IV fluids
Hold insulin. Add 40mmol K+/1L fluid/hour.
Continuous cardiac monitoring until K+ >
3.3mmol/L
See 20. Uncomplicated

Hyperglycaemia Algorithm
3. Insulin Protocol
DO NOT give insulin until you
have K+ levels
IV Insulin Infusion
(Start at 0.14u/kg/hr)
- Hourly RBS monitoring
- Target RBS drop 3-4mmol/L/hr
- If the RBS does not fall by 3-4
mmol/L/hr, give a bolus of
0.14u/kg per hour IV and
continue with the infusion
If CORRECTED serum sodium is

140 mmol/L, use 0.45% NaCl
instead of 0.9% NaCl or RL
DO NOT give > 50 mL/kg of
isotonic solution in the first
4 hours of treatment of diabetic
ketoacidosis because of the risk of
cerebral oedema.
Success in fluid therapy is
reflected by an improvement in
hemodynamic and hydration status
and pH values, a satisfactory urine
output of 1 to 2 mL/kg/hour, and
clinical progress.
Venous Glucose reaches

< 11.1 mmol/L (DKA)
< 16.7 (HHS)
Change IV fluid infusion to 5 % Dextrose

with 0.45% NaCl at 150-250mL/hr
Decrease insulin to 0.02-0.05uits/kg/hour
Maintain glucose between 8.3 11.1mmol/L
(DKA)/ 11.1- 16.7mmol/L (HHS) and
continue insulin infusion and fluid hydration
until ketosis or hyperosmolality resolves
Useful formulas in DKA

Anion gap = Na+ - [(Cl- + HCO3-)]
Serum sodium correction = Na+measured + {(Glucose - 5.5) / 3} (all values in mmol/l).
Serum potassium correction during acidemia = [K+] - (0.6 mmol/L X (7.4 - measured pH) X 10)
Serum osmolality (mOsm/L) = 2 [Na+ + K+](mmol/L) + Glucose (mmol/L) + BUN (mmol/L)
Total body water deficit (L) = 0.6men/children or 0.5women x body weight (kg) X [serum Na+ /140 - 1]
20. Uncomplicated Hyperglycaemia Algorithm
Hyperglycaemia (RBS > 14mmol/L)

Establish IV Access and send blood samples for UEC, and a
Venous Blood Gas (VBG)
Immediate Urinalysis
Perform brief, targeted, history and physical exam
Normal VBG +
No Ketones in urine +
Serum Osmolality < 320mOsm/kg
Uncomplicated Hyperglycaemia
Identify and Treat precipitating illness; consider ACS, Sepsis
Newly Diagnosed Diabetic
Known Diabetic
Confirm compliance with medication

- If not compliant, resume previous regimen
- If compliant, optimize dosages
Advice on lifestyle Modification
Review RBS daily at nearest facility and keep record
Review in out-patient medical clinic after 5 days
Refer to Diabetic clinic if poorly controlled
Lifestyle modification advice

Start on Metformin as below
- Begin with low-dose metformin - 500 mg BD with meals
(breakfast and/or dinner).
- Review RBS daily at nearest facility and keep record
- Review in FMC Clinic after 5 days
- After 57 days, if GI side effects have not occurred, advance
dose to 850mg or 1gm before breakfast and dinner.
- If GI side effects appear as doses advanced, can decrease to
previous lower dose and try to advance dose at a later time.
- The maximum effective dose is usually 850 mg BD, with

modestly greater effectiveness with doses up to 3 g per day. GI
side effects may limit the dose that can be used.
Refer to Diabetic clinic
21. Hypoglycaemia Algorithm
Hypoglycaemia (RBS < 3.3 mmol/L)

o
Check vital signs (BP, PR, RR, SPO2, T C)
Able to tolerate PO
Yes
No
Give 15gm of simple carbohydrate PO

AND/OR
A full complex starchy carbohydrate
meal e.g. rice, ugali, wholemeal)
IV Access
50mls 50% Dextrose IV
No IV Access
Glucagon 1mg SC or IM
As soon as IV access is available,
give 50mls 50% Dextrose IV
Symptoms resolved and RBS > 3.3mmol/L
Yes
No
Repeat Algorithm
After 2 rounds of the algorithm, begin continuous infusion
of 5% Dextrose saline at 110mls/hr
Treat underlying cause

Provide patient with a full complex starchy carbohydrate meal
e.g. rice, ugali, wholemeal)
Consider thiamine 100mg IVI for malnourished and alcoholic patients
followed by 100mg PO BD for 6 weeks
Consult a Physician for ALL patients
22. Electrolyte Abnormalities Algorithm
Establish IV Access and send blood samples for FBC, UEC
Hyponatraemia
(< 130 mmol/L)
Hypernatraemia
(> 150 mmol/L)
Hypokalaemia
( < 3 mmol/L)
Hyperkalaemia
(> 5.5 mmol/l.)
For hypotensive patients, give NS

20 mL/kg bolus and repeat until
vital signs are stable
For hypotensive patients, give

RL 20 mL/kg bolus and repeat
until vital signs are stable

RL 20 mL/kg bolus and repeat

NS 20 mL/kg bolus and repeat
Consult a Physician for ALL

Patients

Patients
For patients with neurologic signs,

including coma, seizures, and focal
neurologic deficits (usually in the
100 to 110 mmol/L range),
administer 3% saline (513 mmol/L
of sodium chloride [NaCl]) in order to
achieve a minimum serum sodium
level of 120 mmol/L. Hypertonic
saline is typically reserved for
patients with an acute disease process
rather than chronic hyponatremia.
Hypertonic saline can rapidly increase
serum sodium by 2 to 3 mmol/hr or
more depending on the amount
infused.
After the patient is stabilized,

change fluids to D5 NS to
provide for maintenance
requirements and on-going
losses.
Mild-Moderate hypokalaemia
(2 -3 mmol/L)
Patients who have mild or
moderate hypokalaemia may need
only oral potassium replacement
therapy if nausea or vomiting is
not the cause of the hypokalaemia.
Give calcium to protect the heart

(not bind K+) ONLY to patients
with;
a widening QRS including a sine
wave,
a cardiac arrest that is believed
to be due to hyperkalaemia, or
signs of rapidly progressing
hyperkalaemia in the face of
tumour lysis syndrome, massive
haemolysis, or rhabdomyolysis
where a normal ECG has rapidly
progressed through tall peaked T
waves and loss of the P wave.
Giving 40 to 60 mmol of
elemental potassium orally every
2 to 4 hours for 3 days.
Severe hypokalaemia
(< 2mmol/l)
Give 40 mmol K+ in 1L RL over
1 hour with continuous ECG
monitoring.
When rapid correction of the serum

sodium concentration is needed (those
seizing, with focal findings, or with
coma) give 150 mL of 3%
hypertonic saline over 20 minutes.
Additionally, restoration of
normokalaemia relies on the
establishment of
normomagnesemia as both K+ and
Mg2+ co-transport in the kidney.
If a second bolus is required, give a

second 150 mL of the 3% solution
over the next 20 minutes.
Give at least 0.5 grams/hr of

magnesium sulphate along with
potassium replacement to a
maximum of 2gm
Repeat the above twice or until a

target of 5 mmol/L increase in serum
sodium concentration is achieved.
Do not expect patients with severe
symptoms to completely recover
immediately, as it may take some time
for the brain to fully recover.

Patients
Give 10mls 10% CaCl2

(6.8mmol) over 10mins
OR
30mls 10% Calcium Gluconate
(6.6mmol) over 10mins
Check baseline RBS.
If RBS < 14mmol/L, give 50mls
50% dextrose IV bolus
Give 10units soluble insulin IV
bolus AFTER the dextrose above
or if RBS 14mmol/L
The Dextrose-Insulin combination
may be repeated if repeat K+ is >
5.5 mmol/L
Re-check RBS after an hour
Nebulise Salbutamol 10 to 20 mg
in 4 ml of NS over 10 minutes 25-40% of patients do not respond
secondary to tachyphylaxis.
Serum potassium will be lowered
approximately 10 to 30 minutes
after the above measures are
performed, and the effect will last
for 2 to 6 hours.
Patients
23. Syncope Algorithm
History of Syncope
Consider seizure - tongue biting, head turning during

loss of consciousness, no recollection of abnormal
behaviour, prolonged limb jerking (lasting minutes),
post-event confusion, and prodromal dj vu.
Yes
See
24. Seizures Algorithm
No
Check RBS If RBS < 3.3 mmol/L See 21. Hypoglycaemia algorithm
12 lead ECG - Look for evidence of ischemia/infarction, dysrhythmias, atrioventricular blocks, Brugada
syndrome (RBBB with J-wave elevation of 2 mm), prolonged QT interval, ventricular pre-excitation,
hypertrophic cardiomyopathy
Check Hb/Hct
Post-menarcheal girls should receive urine pregnancy test.
Laboratory studies should be reserved ONLY for those patients in whom electrolyte abnormalities e.g.
Hypokalaemia, or ingestions are suspected e.g. sedatives
An echocardiogram should be pursued in patients with concerning murmurs on examination or if
syncope occurred during exercise or in conjunction with chest pain.
The San Francisco Syncope Rule (SFSR).

The SFSR uses five factors (CHESS predictors) to predict serious adverse outcomes at 7 or 30 days in
patients presenting to the ED.
1. History of Congestive Heart Failure
2. Hematocrit < 30% (Hb < 10g/dL)
3. ECG abnormality (see above)
4. Shortness of breath history
5. SBP < 90 mm Hg after arrival in the ED
SFSR is associated with a pooled negative predictive value of 97%, sensitivity of 87%, and negative LR
of 0.28. Patients with negative SFSR scores had < 3% risk for serious outcomes.
Does the patient have ANY of the 5 SFSR predictors?

Yes
Consult a Physician
No
Discharge
24. Seizures Algorithm
History of Seizure
Active seizure OR Post ictal OR Status epilepticus
(> 5 minutes of a continuous seizure, or 2 discrete seizures

between which there is incomplete recovery of consciousness.
Maintain and support ABCs

Monitor vital signs (BP, PR, RR, SPO2, To C)
Check RBS
First-time Seizure
Send blood samples for CBC,

(MPS), UEC, HIV, Urine PDT
Position patient on soft mattress/pillows on trolley in

left lateral position and open the airway with head-tilt
manoeuvre; maintain this position until patient is
awake Do not restrain a seizing patient
Known Epileptic or >1 seizure
Send blood samples for CBC, (MPS),

UEC, (Phenytoin/Valproate levels)
Post ictal
If epileptic and non-compliant on

medication load PO with;
phenytoin at 20 mg/kg
OR
Na Valproate 20mg/kg if on ARVs
If unable to take orally, give same doses
IV as below.
Set up IV access, Check RBS and give Midazolam 0.1mg/Kg

IV/IM.
Provide O2 by Non-Rebreather mask at 15L/min
Send blood samples for CBC, (MPS), UEC, HIV,
Phenytoin/Valproate levels if known epileptic.
Post ictal
An MRI (or CT scan) should be performed immediately when
a provider suspects a serious structural lesion or;
new focal deficits,
persistent altered mental status (with or without intoxication),
fever,
recent trauma,
persistent headache,
history of cancer,
history of anticoagulation
suspicion of AIDS.
patients who have completely recovered from their seizure
and for whom no clear-cut cause has been identified (e.g.,
hypoglycaemia, hyponatremia, tricyclic overdose)
Additionally, for patients with first-time seizure, emergent
MRI/CT should be considered if any of the following is present:
Age > 40 years
Partial-onset seizure
Additionally, for patients with recurrent seizure (prior history
of seizures) emergent MRI/CT should be considered if any of
the following is present:
New seizure pattern or new seizure type
Prolonged postictal confusion or worsening mental status
Patients with typical recurrent seizures related to previously
treated epilepsy are unlikely to have life-threatening structural
lesions. These patients DO NOT require MRI/CT.
Post ictal
Still Seizing
Or
Recurrent Seizure
Consult a Physician and continue with algorithm

Repeat Midazolam 0.1mg/Kg after 10 minutes from last
dose
Consider hypoglycaemia, hyponatremia, tricyclic overdose
If still in seizing, additional phenytoin at 5 mg/kg IV in
NS strictly at 50 mg/min by infusion pump with ECG
monitoring until cessation. Repeat again once if
necessary. Obtain phenytoin level 30-60 minutes after
completion of infusion. (Aim for 10mg/L)
Review with ALL results
Consult a Physician on ALL other patients
Still Seizing
Or
Recurrent Seizure
Repeat Midazolam 0.1mg/Kg IV after 10 minutes from last dose

Load with phenytoin at 20 mg/kg IV in NS strictly at 50 mg/min
by infusion pump with ECG monitoring.
OR
Na Valproate 20mg/kg IV push if on ARVs
Post ictal
Criteria for discharge;

First onset single seizure in a patient < 40 years who has
completely recovered from their seizure and for whom no clear-cut
cause has been identified (e.g., hypoglycaemia, hyponatraemia,
tricyclic overdose) and with normal investigations. No follow-up is
necessary unless seizure recurs
Known epileptic who has completely recovered from their seizure
and for whom a clear-cut cause has been identified (e.g. noncompliance, sub-therapeutic drug levels) and with normal
investigations. Patient should be loaded with anticonvulsants if nontherapeutic prior to discharge and adequate follow-up arranged.
Still Seizing
Or
Recurrent Seizure
Obtain CT Head and

review all the results.
Consult a Physician
Still Seizing
Or
Recurrent Seizure
Intubate and ventilate

patient; keep To C 37oC
- Propofol 1mg/kg IV +
Rocuronium 1mg/kg
Start infusion of midazolam
0.1mg/kg/hour IV
Obtain CT Head and review
all the results.
Admit ICU
25. Transient Ischemic Attack (TIA) Algorithm
The AHA/ASA has endorsed the current definition of TIA as a transient episode of neurological dysfunction caused by focal
brain, spinal cord, or retinal ischemia, without acute infarction. The new definition of TIA completely eliminates the element of
time and emphasizes neuroimaging instead.
Mimics
Stroke
Hypoglycaemia / hyperglycemia
Seizure with Todd paralysis
Complicated migraine
Structural brain lesion (tumour,
haemorrhage, aneurysm)
Demyelinating disease (multiple sclerosis)
Central nervous system infection
(encephalitis, cerebritis, abscess)
Acute vestibular syndrome (labyrinthine
disorders
Delirium
Recrudescence of old stroke
Syncope (of any aetiology)
Metabolic disarray (hyponatremia,
hypokalaemia, etc.)
Peripheral nervous system lesion
(radiculopathy, neuropathy, plexopathy)
Psychogenic (conversion disorder,
somatization)
Is ABCD3 < 4
See
26. Stroke Algorithm
Consult a
Physician
The ABCD3 Score
Predictor
Age > 60 y
Blood pressure > 140/90 mm Hg
Clinical features (maximum 2)
Unilateral weakness (2)
Speech difficulty without weakness (1)
Duration (maximum 2)
> 60 min (2)
10-59 min (1)
< 10 min (0)
Diabetes
Dual TIA (TIA prompting medical
attention plus at least one other TIA in the
preceding 7 days.)
Maximum total score
See
Consult a
Physician
Points
1
1
2
1
2
9
Abbreviations: CT, computed tomography; DWI, diffusion-weighted imaging; ECG, electrocardiogram; ED,
emergency department; IV, intravenous; MRI, magnetic resonance imaging; TIA, transient ischemic attack.
Identify signs of possible acute stroke
Patient to be seen by the doctor within 10 minutes of arrival
Monitor, support ABCs in the Resuscitation Room (ER)

Check vital signs (BP, PR, RR, SPO2, To C).
Start Oxygen IF SPO2 94%. Maintain SPO2 > 94%
Check Glucose and treat if < 3.3mmol/L with 50mL 50% Dextrose bolus. Maintain blood
glucose between 7.7- 10mmol/L
Establish 14-16G IV Access and send blood samples for FBC, UEC, coagulation screen
Perform brief, targeted history, physical exam; perform neurologic screening assessment
Indicate time when patient last known normal
National Institutes of Health Stroke Scale (NIHSS)

1a. Level of consciousness
0 = Alert; keenly responsive

1 = Not alert, but arousable by minor stimulation
2 = Not alert; requires repeated stimulation
3 = Unresponsive or responds only with reflex
6. Motor leg
6a. Left leg
6b. Right leg
1b. Level of consciousness questions:

What is the month?
What is your age?
1c. Level of consciousness commands:
0 = Both answers correct

1 = Answers one question correctly
2 = Answers both questions incorrectly
7. Limb ataxia
0 = Performs both tasks correctly

1 = Performs one task correctly
2 = Performs neither task correctly
0 = Normal
1 = Partial gaze palsy
2 = Forced deviation
8. Sensory
0 = No visual loss
1 = Partial hemianopia
2 = Complete hemianopia
3 = Bilateral hemianopia
0 = Normal symmetric movements
1 = Minor paralysis
2 = Partial paralysis
3 = Complete paralysis of one or both sides
0 = No drift
1 = Drift
2 = Some effort against gravity
3 = No effort against gravity; limb falls
4 = No movement
10. Dysarthria
2. Best gaze
3. Visual
4. Facial palsy
5. Motor arm
5a. Left arm
5b. Right arm
0 = No drift
1 = Drift
2 = Some effort against gravity
3 = No effort against gravity; limb falls
4 = No movement
0 = Absent
1 = Present in one limb
2 = Present in two limbs
0 = Normal; no sensory loss
1 = Mild-to-moderate sensory loss
2 = Severe to total sensory loss
0 = No aphasia; normal
1 = Mild to moderate aphasia
2 = Severe aphasia
3 = Mute, global aphasia
0 = Normal
1 = Mild to moderate dysarthria
2 = Severe dysarthria
9. Best language
0 = No abnormality
1 = Visual, tactile, auditory, spatial, or
personal inattention
2 = Profound hemi-inattention or extinction
11. Extinction and

inattention
Total Score = 0 - 42
Time from onset of symptoms < 4.5 hours?
No
Yes
Obtain brain MRI/CT scan

Haemorrhage
Consult a Neurosurgeon
No Haemorrhage
Give 300mg Aspirin
Admit Stroke Unit
Obtain immediate non-contrast enhanced brain CT scan within 25 minutes of patient arrival.
The ER doctor MUST accompany the patient to CT to get the CT report immediately
Does CT scan show any haemorrhage?

CT should be interpreted within 45 minutes of patient arrival
No Haemorrhage
Consult a Neurologist
See 27. Stroke Reperfusion Algorithm
Haemorrhage
27. Stroke Reperfusion Algorithm
Probable acute ischaemic stroke

Begin stroke pathway
Review/Complete Fibrinolysis Checklist

Inclusion and Exclusion Characteristics of Patients With Ischemic Stroke Who
Could Be Treated With IV rtPA Within 3 Hours From Symptom Onset
Inclusion criteria
Diagnosis of ischemic stroke causing measurable neurological deficit
Onset of symptoms < 3 hours before beginning treatment
Aged 18 years
Exclusion criteria
Significant head trauma or prior stroke in previous 3 months
Symptoms suggest subarachnoid haemorrhage
Arterial puncture at non-compressible site in previous 7 days
History of previous intracranial haemorrhage
Intracranial neoplasm, arteriovenous malformation, or aneurysm
Recent intracranial or intraspinal surgery
Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
Active internal bleeding
Acute bleeding diathesis, including but not limited to
- Platelet count <100 000/mm3
- Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than
the upper limit of normal
- Current use of anticoagulant with INR >1.7 or PT >15 seconds
Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated
sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate
factor Xa activity assays)
Blood glucose concentration < 50 mg/dL (2.7 mmol/L)
CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
Relative exclusion criteria
Recent experience suggests that under some circumstanceswith careful consideration and
weighting of risk to benefitpatients may receive fibrinolytic therapy despite 1 or more
relative contraindications. Consider risk to benefit of IV rtPA administration carefully if any
of these relative contraindications are present:
Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Pregnancy
Seizure at onset with postictal residual neurological impairments - Intravenous rtPA is
reasonable in patients with a seizure at the time of onset of stroke if evidence suggests that
residual impairments are secondary to stroke and not a postictal phenomenon
Major surgery or serious trauma within previous 14 days
Recent gastrointestinal or urinary tract haemorrhage (within previous 21 days)
Recent acute myocardial infarction (within previous 3 months)
Additional Inclusion and Exclusion Characteristics of Patients

with Acute Ischemic Stroke Who Could Be Treated With IV
rTPA within 3 to 4.5 Hours From Symptom Onset
Main inclusion criteria
Diagnosis of ischemic stroke causing measureable neurologic deficit
Onset of symptoms within 3 to 4.5 hours before beginning treatment
Exclusion criteria
Age > 80 years
Baseline NIHSS score >25
Taking oral anticoagulant regardless of INR
History of both diabetes and prior ischemic stroke
Those with imaging evidence of ischemic injury involving more than one
third of the middle cerebral artery territory,
NOTES
A physician with expertise in acute stroke care may modify this list.
Onset time is defined as either the witnessed onset of symptoms or
the time last known normal if symptom onset was not witnessed.
In patients without recent use of oral anticoagulants or heparin,
treatment with IV rtPA can be initiated before availability of
coagulation test results but should be discontinued if INR is >1.7 or
PT is abnormally elevated by local laboratory standards.
In patients without history of thrombocytopenia, treatment with IV
rtPA can be initiated before availability of platelet count but should
be discontinued if platelet count is <100 000/mm3.
Repeat neurologic exam: are deficits rapidly improving to normal?

Patient remains candidate for fibrinolytic therapy?
Candidate
Review risks/benefits with patient and family. If acceptable,
obtain consent for fibrinolysis
Ensure patient is attached to monitor (ECG, SPO2, BP) and repeat
baseline vitals. Treat BP if indicated
(See 15. Hypertensive Emergencies Algorithm)
Set up second IV line for the fibrinolysis. Run NS/RL TKVO in
other line
ALTEPLASE (give within 60 minutes of patient arrival)
The recommended dose of alteplase is 0.9 mg/kg (maximum,
90 mg) infused over 60 minutes, with 10% of the total dose
administered as an initial IV bolus over 1 minute.
Measure blood pressure and perform neurological assessments
every 15 minutes during and after IV rtPA infusion for 2 hours,
then every 30 minutes for 6 hours, then hourly until 24 hours
after IV rtPA treatment.
Not a Candidate
Administer aspirin 325mg PO/PR
In patients already taking statins,
continue treatment
Admit to stroke unit
Monitor blood glucose and temperature and treat if
indicated. Maintain blood glucose between 7.7mmol/L
and 10mmol/L
Initiate supportive therapy; treat co morbidities
28. Trauma Management Pathway
SAMPLE HISTORY
Signs and Symptoms

Allergies
Medication
Past Medical History/Pregnancy
Last meal
Events preceding presentation
Primary Survey (ABCDE)
C-Spine Cleared Clinically (See 29. C-Spine Clearance Algorithm)? In-line stabilization then C-Collar applied with Head Blocks
Airway Open? Maintainable? Intubate?
Breathing Rate? SPO2? Air Entry Bilaterally? Pneumothorax? Haemothorax? Flail Chest? Open sucking chest wound?
Circulation Active Bleeding Control? BP? Pulse? CPR? Signs of Shock?
Disability GCS? Pupils? RBS?
Expose patient
Resuscitation (ABCDE)
CONSULT A SURGEON IMMEDIATELY AS YOU BEGIN RESUSCITATION OF ANY POLYTRAUMA PATIENT WITH:
- Hypotension
- GCS < 15
C - C-Collar with Head Blocks?
A - Rapid Sequence Intubation?
B
- Supplementary Oxygenation? Non-Rebreather mask
- Needle Decompression for Tension Pneumothorax with subsequent Intercostal Chest Drain Insertion?
- Emergency Intercostal Chest Drain for Massive Haemothorax
- Seal three sides of an open sucking chest wound with impermeable material?
C
- Control Active Bleeding including;
- Apply a Pelvic wrap to an open book pelvic fracture
- Apply a traction splint for Femur fractures
- Insert 2 large bore IV lines and give appropriate fluid resuscitation (NS/RL/whole blood). Adult trauma patients with, or at risk of,
significant bleeding should be given Tranexamic acid loading dose 1 g over 10 min then infusion of 1 g over 8 h.
- GXM and request adequate supplementary blood
D
- Correct Hypoglycaemia 50mls 50% Dextrose IV
- Give appropriate analgesia e.g. Fentanyl 50 - 100g IV (See 37. Analgesia Chart)
E Check temperature and provide warmth to the patient
Secondary Survey (Head-to-Toe Survey)
CNS Lacerations? Fractures? Signs of Base of Skull Fractures Racoon Eyes, Battle Sign, Otorrhoea, Rhinorrhoea? Focal Neurology?
Chest Lacerations? Rib Fractures?
Abdomen Lacerations? Distension? Tenderness? FAST?
Limbs Lacerations? Fractures? Distal Pulses and Neurology?
Log roll patient Lacerations? Spine tenderness?
Do not forget to give Tetanus Toxoid if there are any open wounds.
Radiological Investigations
EFAST ONLY for;

- Penetrating chest trauma Pneumothorax? Haemothorax? Pericardial Effusion?
- Unstable blunt chest and abdominal trauma Haemothorax? Haemoperitoneum?
- Unexplained hypotension - ? Free fluid in pleural, pericardial or peritoneal cavity
CT-Abdomen For the hemodynamically stable patient with suspected blunt abdominal trauma
CT Head ONLY for;
- GCS < 14
- GCS 14 See 30. Mild Traumatic Brain Injury Algorithm
- Skull fractures including Base of Skull Fractures (NO SKULL X-Rays)
C-Spine X-rays (AP, Lateral AND Open Mouth) See 29. C-Spine Clearance Algorithm. If doing a CT head, do CT Spine instead of
C-spine X-rays if indicated. C-spine is NOT cleared on X-rays/CT but on resolution of patient symptoms
CXR ONLY for patients with symptomatic chest trauma - Pneumothorax? Haemothorax? Lung Contusion? Widened Mediastinum?
Rib fractures? Follow-up with CT-Chest plus angiogram for Lung Contusion? Widened Mediastinum?
Pelvic X-ray ONLY for patients with;
- lower abdominal pain,
- lower back pain,
- Femur fractures
- Clinically tender pelvis
- Patients unable to mobilize
Where a reliable clinical assessment is not possible ALL the investigations should be done.
29. C-Spine Clearance Algorithm
For Alert (Glasgow Coma Scale Score = 15) and Stable Trauma Patients
Where Cervical Spine (C-Spine) Injury is a Concern
Perform in-line immobilization of the C-Spine

Age 65 Years
Glasgow Coma Scale score of 14 or less
Decreased alertness secondary to intoxication
Disorientation to person, place, time, or events
Yes
Inability to remember 3 objects at 5 minutes

Delayed or inappropriate response to external
stimuli
Any focal deficit on motor or sensory examination
or paraesthesia in extremities
No
Midline Neck Pain
Midline C-spine Tenderness (C1 T1)
Provide immediate adequate analgesia
Yes
No
Able to Actively Rotate Neck
45o Left and Right Without Pain?
The doctor should allow the patient to
perform the above movement while
maintaining in-line immobilization
without moving the patients neck
Unable
Able
Perform complete C-spine immobilization with the patient

flat on a trolley with a cervical collar and head blocks
Keep patient immobilized as above UNTIL patient is
reviewed and C-spine is cleared by the ED doctor /
Orthopaedic surgeon
Order ALL 3 views C-spine x-rays;
a cross-table lateral view - must be of good quality and
adequately visualize the base of the occiput to the upper
part of T1.
an anteroposterior view - must reveal the spinous
processes of C2 to C7.
an open-mouth view to visualize the odontoid process of
C1. Must visualize the entire dens and the lateral masses
of C1.
Obtain CT C-spine IF;
- patient is to receive an immediate CT head. No c-spine xrays are required initially
- x-rays are inadequate
- patient has persistent symptoms despite analgesia and
negative x-rays
- pathology is noted on c-spine x-rays
No Radiography necessary
Document clearly in patients clinical notes
successful completion of all the above steps
Symptoms
persist?
Review x-rays and/or CT C-spine images and the patient

(DO NOT comment on inadequate images)
Yes
C-Spine Cleared on Radiology?

No
Remove
Immobilization devices
No
Yes
Consult an Orthopaedic Surgeon

Maintain immobilization with the patient flat on a
trolley with a cervical collar and head blocks
30. Mild Traumatic Brain Injury Algorithm
See 28. Trauma Management Pathway
Adult in ED with GCS 14 or 15

Yes
Loss of consciousness or post traumatic amnesia
Assess for;
GCS < 15
Focal neurological deficit
Coagulopathy, bleeding disorder, or on anticoagulant or
anti-platelet agent
Age > 60 years
Vomiting (any)
Headache
Drug or alcohol intoxication
Seizure
Anterograde amnesia/short-term memory deficits
Physical evidence of trauma above clavicles (abrasions,
contusions, ecchymosis)
No
Discharge as below
No
Assess for;
Severe Headache
Age 65 years
Physical signs of basilar skull fractures
(haemotympanum, panda eyes, cerebrospinal fluid
leakage from the ear or nose, Battles sign).
Dangerous mechanism of injury:
- Ejection from a motor vehicle
- Pedestrian struck
- Fall from a height of > 0.9m or 5 steps
Coagulopathy, bleeding disorder, or on anticoagulant
or anti-platelet agent except aspirin
Assessment positive Yes
Consider 6 hour observation if the only

criterion present for CT is intoxication
Consider 6 hour observation if only criterion
is history of GCS score of 14 that returned to
normal within 2 hours of trauma
Worsening or
No Resolution of Symptoms
Resolution of Symptoms
Obtain non-contrast head CT scan

Yes
Is patient on
anticoagulant or
anti-platelet agent
No
CT Positive
Consult a
Neurosurgeon and
assess for admission
Yes
Patient on anticoagulant:
Administer FFP or Prothrombin
Complex Concentrate
Administer 10mg vitamin K IV
Patient on anti-platelet agent:

Consider desmopressin
No
Is patient on
anticoagulant or
anti-platelet agent
No
Discharge
as below
Yes
If symptomatic or INR > 3, admit for
24 h observation
If asymptomatic after 6 h ED
observation and INR < 3, discharge
with reliable adult
Close follow-up in out-patient clinic
Return for repeat CT if new or
worsening symptoms
Discharge
A CT interpreted as normal by the Radiologist in a neurologically intact person with a normal mental status allows for safe
discharge with appropriate instructions and avoids prolonged ER observation or hospital admission. Written and verbal discharge
instructions must be provided and should include symptoms to expect after a mild TBI, the time course, the overall positive
prognosis, activity limitations, and the point at which a patient return to the ED for further testing.
31. Epistaxis Algorithm
Have the patient squeeze the distal alae while sitting up, bent forward at the waist over a vomit bucket, and expectorating blood for 15mins. USE A
WATCH!! Ask the patient NOT to swallow any blood. A clamping device constructed of four tongue blades secured together by 1-inch tape over the
distal alae can be used to clamp the nose closed.
Nasal trauma from nose picking/blowing is the most common cause of epistaxis.
Hypertension DOES NOT cause epistaxis but may prolong it. Therapy should focus on control of the haemorrhage rather than reduction of the blood
pressure. DO NOT prescribe anti-hypertensive therapy for epistaxis.
DO NOT order lab investigations routinely; in selected patients such as those taking warfarin or with hepatic or renal dysfunction, FBC, UEC &/or
LFTs and coagulation studies are warranted. For patients with severe or recurrent haemorrhage with a lot of clots, throwing up blood, or with unstable
vital signs or underlying medical conditions, a FBC should be performed, as well as a type and screen.
Bleeding controlled
No
Yes
o
Repeat vital signs (BP, PR, RR, SPO2, T C)
Remove any cotton pledgets and observe the patient for
bleeding for at least an hour after control. Encourage the
patient to walk or perform other activities that he or she will
need to resume when returning home.
Patients with underlying medication use (aspirin, NSAIDS,
warfarin) or renal or hepatic dysfunction- consult an ENT
Surgeon/Physician
If cause identified to be from nasal picking/blowing with no
underlying medication use (aspirin, NSAIDS, warfarin) or
renal or hepatic dysfunction, discharge patient (with ENT
follow-up if recurrent).
Follow-up instructions - Vaseline or a similar moisturizing
agent should be applied liberally in the nose TID for 7-10
days to promote healing of friable mucosa and superficial
vessels.
Insert a 15-cm piece of cotton pledget soaked in injectable

form of tranexamic acid (500 mg in 5 mL) in the nostril
of the bleeding side for 10 mins. USE A WATCH!!
Yes
Bleeding controlled
No
Insert a 15-cm piece of cotton pledget soaked in
adrenaline (1 mg in 5 mL) in the nostril of the
bleeding side for 10 mins. USE A WATCH!!
Yes
Bleeding controlled
No
Pack the nostril of the bleeding side using a nasal tampon

or a bacitracin ointment soaked gauze.
* The tampon should be coated with bacitracin ointment or
KY-Jelly to facilitate placement.
Yes
Bleeding controlled
No
Repeat vital signs (BP, PR, RR, SPO2, T C)

Establish IV access and order FBC, UEC &/or
LFTs, coagulation studies and a type and screen if
warranted
If cause identified to be from nasal picking/blowing
with no underlying medication use (aspirin,
NSAIDS, warfarin) or renal or hepatic dysfunction,
consult an ENT Surgeon.
Patients with underlying medication use (aspirin,
NSAIDS, warfarin) or renal or hepatic dysfunction
- consult a Physician & an ENT Surgeon
o
Pack the contralateral naris using a nasal tampon or a bacitracin

ointment soaked gauze to provide a counterforce to promote tamponade.
Yes
Bleeding controlled
No
Do NOT remove the contralateral nasal pack.

Insert a lubricated foley catheter (size 12 or 14 F) until the tip and balloons are
entirely in the nasopharynx. Fill the balloon with sterile saline (usually 5-10cc)
to allow it to be pulled snugly against the posterior nasal choana with anterior
traction. The Foley is secured by placing an umbilical or c-clamp on the catheter
at the level of the nasal ala with padding in between to prevent pressure injury.
Yes
Bleeding controlled
No
While the foley is still in-situ, pack the nostril of the bleeding side using a
nasal tampon or a bacitracin ointment soaked gauze.
* The tampon should be coated with bacitracin ointment or KY-Jelly to
facilitate placement.
32. Low Back Pain Algorithm
This clinical pathway is intended to supplement, rather than substitute for, professional
judgment and may be changed depending upon a patients individual needs. Failure to
comply with this pathway does not represent a breach of the standard of care.
Adult with low back pain (LBP)

Monitor and support ABCs
Provide immediate analgesia
Perform a focused history and physical examination, evaluating;

Duration of symptoms
Risk factors for potentially serious conditions (tumour, infection, cauda equina
syndrome, ankylosing spondylitis or vertebral compression fracture).
Symptoms suggesting radiculopathy or spinal stenosis
Presence and level of neurologic involvement - All patients should be evaluated for
the presence of rapidly progressive or severe neurologic deficits, including motor
deficits at more than 1 level, faecal incontinence, and bladder dysfunction.
Psychosocial risk factors
Any potentially serious conditions strongly suspected? (see table)

The possibility of low back pain due to problems outside the back,
such as Ectopic pregnancy, Pancreatitis, Nephrolithiasis, or
Aortic Aneurysm, or Systemic illnesses, such as endocarditis or
viral syndromes, should be considered.
No
Yes
Perform diagnostic studies to identify cause (see table)

DO NOT routinely obtain imaging or other diagnostic tests in
patients with nonspecific low back pain. Early, routine imaging
and other tests usually cannot identify a precise cause, do not
improve patient outcomes, and incur additional expenses.
Yes
Specific cause identified

No
Back pain is mild with no substantial functional impairment
Inform all patients of the generally favourable prognosis of acute
low back pain with or without sciatica, including a high likelihood
for substantial improvement in the first month
Yes
No
Consult an Orthopaedic Surgeon

Advice about self-care;
- Advice to remain active
- Application of superficial heat
Review indications for reassessment
- Risk factors for potentially serious conditions as above
Discharge with Analgesia and for Physiotherapy.
Reassess in 4 weeks in Orthopaedic Clinic if necessary
Advice about self-care;

- Advice to remain active
- Application of superficial heat
Discuss non-invasive treatment options;
- Pharmacologic;
* 1st line - Paracetamol and/or NSAIDs
* 2nd line Tramadol for severe, disabling pain that is not controlled
(or is unlikely to be controlled) with acetaminophen and NSAIDs.
- Non-pharmacologic Physiotherapy
Arrive at shared decision regarding therapy trial

Educate patient
Patient accepts risks and benefits of therapy
No
Yes
Continue self-care and non-invasive options (analgesia and physiotherapy)
Discharge and reassess in 4 weeks in Orthopaedic Clinic if necessary
Refer to Orthopaedic Clinic
33. Epigastric Pain Algorithm
Adult with Epigastric Pain

Provide immediate analgesia See 37. Analgesia Chart

Obtain/review 12-lead ECG if elderly, diabetic or hypertensive
Perform a focused history and physical examination, evaluating;

Duration of symptoms
Risk factors for potentially serious conditions ACS, Pancreatitis, DKA,
Cholecystitis, Perforate Ulcer, Pre-eclampsia/Eclampsia, HELLP
Send blood samples for FBC, UEC, Lipase.

Additional testing as indicated;
- hsTroponin T - ? ACS (elderly, diabetics, hypertensives)
- LFTs - ? Cholecystitis, Pre-eclampsia/Eclampsia, HELLP
- CXR - ? Perforated ulcer, Pancreatitis, Pneumonia
- VBG Hyperglycaemic patients, Pancreatitis
- PDT - ? Ectopic pregnancy
Other Causes of Epigastric Pain

Treat accordingly
Probable Dyspepsia
Stool H. Pylori Antigen Test
(see indications)
PPI IV stat
H. Pylori Positive
Symptomatic Treatment
- Antacid Gel 20-60mins after meals and at bedtime or PRN (for symptom control)
- Paracetamol (stop ALL NSAID use)
- Dietary advice
PLUS
H. Pylori Negative
Symptomatic Treatment
- Antacid Gel 20-60mins after meals and at
bedtime or PRN (for symptom control)
- Paracetamol (stop ALL NSAID use)
- Dietary advice
PLUS
Eradication Therapy
Drug
PPI,
Clarithromycin,
Amoxicillin
PPI,
Clarithromycin,
Metronidazole
Indications for Stool H. pylori Antigen testing

Active peptic ulcer disease (gastric or
duodenal ulcer)
Confirmed history of peptic ulcer disease (not
previously treated for H. pylori)
Gastric MALT lymphoma (low grade)
After endoscopic resection of early gastric
cancer
Uninvestigated dyspepsia < 55 yr and with no
alarm features (bleeding, anemia, early
satiety, unexplained weight loss, progressive
dysphagia, odynophagia, recurrent vomiting,
family history of GI cancer, previous
oesophagogastric malignancy).
Dosing
Standard dose BID,
500 mg BID,
1000 mg BID
Standard dose BID,
500 mg BID,
500 mg BID
Duration (d)
10-14
Eradication Rates
70-85%
10-14
70-85%
Acid Suppression Therapy

- PPI standard dose x 4 weeks
Consider OGD (see indications below)
Consider OGD (see indications below)
Indications for Oesophagogastroduodenoscopy (OGD)

age > 55 yr
bleeding,
anaemia,
early satiety,
unexplained weight loss (>10% body weight),
progressive dysphagia,
odynophagia,
persistent vomiting,
a family history of gastrointestinal cancer,
previous oesophagogastric malignancy,
previous documented peptic ulcer,
lymphadenopathy,
an abdominal mass
34. Upper Gastrointestinal Bleeding Algorithm
Upper Gastrointestinal Bleeding can vary in presentation, but most cases present in one or more of four ways as follows:
a) Melena (69%): the passage of dark and pitchy stools stained with blood pigments or with altered blood. Melena is caused by the passage of at
least 50 mL of blood in the upper GI tract. Bacteria degrade the blood into haematin or other haemachromes. Melena should not be confused
with the dark stools that result from ingestion of iron or bismuth.
b) Haematemesis (30%): the vomiting of bright red blood and indicates an upper GI site of bleeding, usually above the ligament of Treitz.
c) Coffee-ground emesis (28%): emesis consisting of dark, altered blood mixed with stomach contents
d) Haematochezia (15%): the passage of bloody faeces
SHOCKED (HYPOTENSIVE)
Monitor, support ABCs in ER
Start Oxygen IF SPO2 < 94%. Maintain SPO2 94%; Intubate patient if
airway is at risk from massive haematemesis or depressed level of
consciousness
Establish 2 large bore IV accesses (14-16G).
Give rapid fluid boluses at 20mL/Kg Ringers Lactate (RL)/Hartmanns
soln; repeat if necessary. Start blood transfusions ONLY if Hb < 7 g/dL
Obtain a 12-lead ECG
Send blood samples for FBC, UEC, LFTs, ABG, Coagulation screen.
Cross-match 6 units of packed cells.
Perform brief, targeted history, physical exam including a rectal exam
Insert NGT ONLY if intubated or has recurrent vomiting uncontrolled by
anti-emetics
NOT SHOCKED
Monitor, support ABCs in ER
Start Oxygen IF SPO2 < 94%. Maintain SPO2 94%; Intubate patient
if airway is at risk from massive haematemesis
Establish a large bore IV access (14-16G).
Start IV Fluids TKVO Ringers Lactate (RL)/Hartmanns soln. Start
blood transfusions ONLY if Hb < 7 g/dL
Obtain a 12-lead ECG
Send blood samples for FBC, UEC, LFTs, ABG, Coagulation screen,
Blood type & screen.
Perform brief, targeted history, physical exam including a rectal exam
Monitor vital signs every 15 min until stable, then hourly.

Correct hypotension with repeat fluid boluses/blood transfusion
Monitor urine output - Aim for > 0.5mL/Kg/h
Consult Gastroenterologist
Admit HDU/ICU
Yes
History of Varices or Decompensated Cirrhosis

No
Give IV omeprazole/pantoprazole 80-mg bolus followed by 8 mg/hr for 72 hrs

Consult Gastroenterologist
Admit HDU/ICU
35. Management of Pain in Sickle Cell Disease

(SCD) Algorithm
Patient presents with acute pain

Check vital signs (BP, PR, RR, SPO2, ToC, RBS).
Determine probable cause and precipitating factors for pain e.g. infection
Establish IV Access and send blood samples as below.
Related to SCD
No

supplement, rather than substitute for,
professional judgment and may be
changed depending upon a patients
individual needs. Failure to comply
with this pathway does not represent a
breach of the standard of care.
Perform appropriate work-up
Yes
Start D5 normal saline (NS)* at a maintenance rate unless the patient is
overtly hypovolemic (sepsis, diarrheal illness, vomiting) in which case resuscitate
appropriately.
*In vitro and in vivo studies have shown that lowering of serum osmolality with
hypotonic fluid can reduce erythrocyte sickling. Over-hydration especially
with isotonic crystalloid does not cure crisis and may have detrimental effects.
Currently on chronic opiate therapy?
No
Administer IV dose of opiate

Tramadol IV/SC - 50-100mg over 3-5mins. Max 400mg/d
Fentanyl IV - 0.5 3 g/kg over 3-5mins
Yes
Assess degree of relief every 15-30 mins
Administer IV equivalent of home oral opiate dose
Administer IV paracetamol 15mg/kg and antihistamine
(diphenhydramine, hydroxyzine)
No
Drop in pain score of 2
Assess degree of relief every 15-30

No
Repeat IV opiate at the initial dose

DO NOT exceed the maximum dose
Yes
Yes
Assess degree of relief every 15-30 mins
Yes
Moderate pain
No
Consult a Physician/Haematologist
Manage cause/precipitating factor

Disposition with short opiate
prescription with haematology follow-up
Investigations:
Full Blood Count (FBC);
Most patients with HbSS disease have a baseline haemoglobin level of 6 to 9 g/dL and tolerate this level of anaemia well because of physiologic
adaptations.
WBC is NOT a particularly sensitive nor specific indicator for infection
Reticulocyte count - normally elevated (>5%). Levels < 5% are a serious cause for concern as it signifies bone marrow hypoactivity.
In patients with worsened scleral icterus, back pain, fever, or signs that suggest haemolysis, additional tests would include; LFTs and LDH
Renal function tests
Blood typing and screening is necessary if haemoglobin has dropped > 1 mg/dL below baseline or if there is concern that the patient may need a
transfusion. Indications for blood transfusion; Severe anaemia - Hb > 2g/dL below steady state or < 6g/dL; Acute chest syndrome; Priapism; CVA in
children; Before surgery
36. Pain Management Algorithm
ADULT WITH ACUTE SOMATIC PAIN
EVALUATE: Focused history, detailed pain assessment

Assign SEVERITY SCORE (1-10)
MILD PAIN (1-3/10)
MODERATE PAIN (4-6/10)
SEVERE PAIN (7-10/10)
PO Paracetamol or NSAID
+
Adjuvant interventions
(Non-Pharmacologic)
As for mild Pain

+
Weak opioids
e.g. PO tramadol, codeine, hydrocodeine
As for mild Pain

+
Strong opioids
e.g. morphine, fentanyl
non-opioid analgesics
Investigate and treat the cause of pain.

Reassess pain within 60 minutes to ensure relief, and monitor patient appropriately, and document.
Repeat analgesic, titrate to a higher dose, initiate a more potent analgesic or combine analgesics with
different mechanisms of action as is appropriate to relieve pain
Treat the cause of pain as OP/IP, and consult/refer appropriately
Beware of contraindications, allergies, toxicity, interactions with other meds etc. Pethidine
(meperidine) has an active metabolite (nor-meperidine) that causes neuro excitation (apprehension,
tremors, delirium, and seizures) and may interact with antidepressants (contraindicated with MOI and
best avoided with SSRIs), so it is NOT RECOMMENDED for repetitive use. It is also highly
addictive.
Use the PO, SC or IV route, except when that is not possible
Adjuvant interventions include IMMOBILIZATION, SPLINTAGE, POSITIONING, ELEVATION,
ICE etc.
REGIONAL ANAESTHESIA
Indications
Acute pain management for wounds, fractures and dislocations
Alternative to procedural sedation
Alternative to narcotics in certain patient populations (e.g. head injured patient, patients with concomitant mental status change, patients given
buprenorphine)
Contraindications
Allergy to local anaesthetic agents

Active infection at the site of injection
Injuries at risk of compartment syndrome
Uncooperative patient
Pre-existent neurologic deficit
Anticoagulation (relative)
Technique www.nysora.com
Types
Wrist (Ulnar, Median and Radial nerve) block for the hand
Digital nerve blocks for fingers and toes
Femoral nerve block for the anterior thigh, femur, knee and skin anaesthesia over the medial aspect of the leg below the knee
Facial and dental nerve blocks
Ankle blocks for the foot
Haematoma blocks
Anaesthetic - Lidocaine
Dose 3mg/kg
Onset of action - < 2 mins
Duration 60 mins
Drug
Dosage
Morphine
IV - 0.1mg/kg;
max. 0.3mg/kg
Equianalgesic dose
10mg
37.
Analgesia
Chart
Analgesia
Chart
Onset/Peak Effect
Duration of Action
Adverse Effects
Comments/Caveats
IV - Onset 3-5 mins;

Peak effect 15-30 mins
IV - 3 4 hrs
Respiratory depression
Hypotension partly due
to histamine release
Acute severe pain (trauma) or persistent pain. Morphine is better

preferred for obstetric pain.
Acute severe pain.

Fentanyl is preferred for a rapid onset of analgesia in acutely distressed
patients. Fentanyl is preferred for patients with hemodynamic instability
or renal insufficiency
SC 4 hrs
SC - 0.1-0.2mg/kg
SC Onset 15-30 mins
Fentanyl
IV - 0.5 3 g/kg
over 3-5mins
100g
IV - Immediate onset,
Peak effect 2-3mins
SC Onset 7 -15mins
IV 30 - 45mis
SC 1 2 hrs
Chest wall rigidity and

respiratory depression
may occur with rapid
IV administration
Pethidine
IV - 0.5-1mg/kg
SC - 1-2mg/kg
75 mg
IV - 1-3 mins
SC - 30-90 mins
IV 2 - 4 hrs
SC 3 4 hrs
High doses may cause

respiratory depression,
agitation, muscle
fasciculations, seizures
or histamine induced
hypotension
Tramadol
IV/SC - 50-100mg
over 3-5mins
Max 400mg/d
Paracetamol
IV 15mg/kg
Diclofenac
IV 75mg
IM 75mg
80mg
IV/SC 45 mins
IV/SC - 9 10 hrs
IV 15mins
(at end of infusion)
IV 4hrs
IV 5-10 mins
IM 15mins
IV 6-8hrs
IM 6-8hrs
> 400 mg/d are

associated with an
increased risk of
seizures.
Moderate-to-severe pain (migraine, trauma, acute abdominal pain)

It may be used in obstetric practice to relieve labour pain.
Pethidine has an analgesic potency approximately equal to one-fifth that
of morphine.
Pethidine has an active metabolite (nor-meperidine) that causes neuro
excitation (apprehension, tremors, delirium, and seizures) and may interact
with antidepressants (contraindicated with MOI and best avoided with
SSRIs), so it is NOT RECOMMENDED for repetitive use. It is also
highly addictive.
Moderate-to-severe pain.
Tramadol is 5 to 10 times less potent than morphine. There is
consequently an absence of respiratory depression, a low sedative effect,
and less potential for dependence. There is a high incidence of nausea
and vomiting. Slow administration over 3 - 5 minutes decreases the
incidence of nausea and vomiting. Tramadol does not promote the release
of histamine.
Mild-to-moderate pain
Can be used to supplement opioid analgesics
Gastrointestinal
bleeding
Bleeding secondary
to platelet
inhibition, and
Development of
renal insufficiency
IM administration is not generally recommended due to its multiple disadvantages:

Painful administration
Unpredictable absorption
Complications involving tissue fibrosis and abscesses, and
Rapid declines in analgesic effect.
Subcutaneous (SC) administration provides similar pharmacokinetics with greater patient comfort. The SC route should replace the IM route for opioids.
Mild-to-moderate pain
Can be used to supplement opioid analgesics e.g. renal colic
All NSAIDs elevate SBP (median 5 mmHg). This effect predisposes to
the development of congestive heart failure and also may contribute to the
risk of accelerated atherothrombotic disease.
Patients with hypovolemia or hypoperfusion, the elderly, and those with
pre-existing renal impairment may be more susceptible to NSAIDinduced renal injury.
38. Procedural Sedation and Analgesia (PSA)
Procedural sedation is the technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while
maintaining cardiorespiratory function.
Potential indications for procedural in the ED: fracture reduction, joint reduction, incision and drainage, chest tube placement, electrocardioversion, upper endoscopy (with a gastroenterotogist), foreign body removal, burn
or wound debridement
Patient selection: A pre-procedural history and physical exam, as documented in the ED record, should reflect a focused evaluation of the airway, cardiovascular status, pulmonary status, allergies, and history of prior adverse
reactions to sedatives or anaesthetics. PSA may not be ideal for patients with significant chronic morbidities e.g. sleep apnoea, COPD, low baseline oxygen saturations or blood pressure, or anatomic features that would make
bag valve mask (BVM) ventilation or maintaining an airway difficult.
Preparation: Monitoring equipment (continuous telemetry, pulse oximeter, BP; consider continuous end tidal CO2 monitoring), peripheral IV, normal saline, medications for PSA, naloxone (if opiates are given), equipment
for procedure (e.g. scalpel), team ( minimum one practitioner for sedation, one for procedure one of them must be proficient in airway management), airway equipment (oxygen source, nasal cannula/face mask, BVM,
suction), rescue airway equipment (endotracheal tube, laryngoscope, LMA, nasal trumpet)
Obtain consent
Medication for PSA (give both an Analgesic AND a Sedative)
Drug
Dosage
Fentanyl
IV - 0.5 3 g/kg
over 3-5mins
Midazolam
IV - 0.05
0.15mg/kg
Ketamine
IV 1 mg/kg over
30-60 seconds
Propofol
IV - 0.5mg/kg;
max. 1 mg/kg
Analgesic/Sedative
Onset/Peak Effect
Duration of Action
Adverse Effects
Comments/Caveats
Analgesic
IV - Immediate onset,
Peak effect 2-3mins
IV 30 - 45mis
Chest wall rigidity and

respiratory depression
may occur with rapid
IV administration
Fentanyl is preferred for a rapid onset of analgesia in acutely distressed

patients. Fentanyl is preferred for patients with hemodynamic instability
or renal insufficiency
Sedative
IV - Onset 3-5 mins;

Peak effect 15-30 mins
IV 20 - 60mis
Respiratory depression,
hypotension
Midazolam has a rapid onset and short duration and is classed as an ultrashort acting benzodiazepine, and is 2 to 3 times more potent than
diazepam, so can produce significant respiratory depression. Blood
pressure decreases and heart rate increases as compensation for a
decreased SVR, although CO remains unchanged.
IV - Onset 1min;
Peak effect 1 min
IV 5 - 10mis
Laryngospasm (0.3%),
hypersalivation,
vomiting, emergence
reaction
Ketamine use should be avoided in patients with psychosis or

schizophrenia.
Can be combined in a single-syringe 1:1 mixture of 10 mgmL ketamine
and 10 mgmL propofol (10cc syringe + 100mg Ketamine + 100mg
Propofol to 10mL = 10mg/mL). The median dose is 0.7 mg/kg each of
ketamine and propofol (range = 0.2 to 3.0 mg/kg)
IV - Onset 45 seconds
IV Patients
generally wake up
3-5 minutes after
the last dose.
Hypotension
Propofol can quickly take a patient from deep sedation to general

anesthesia with a lack of spontaneous respirations if too high a dose is
administered. Propofol frequently causes hypotension, but this can usually
be treated successfully with a fluid bolus.
Contraindicated in patients with an egg or soybean oil allergy.
Propofol can cause burning when it is administered thus can be mixed with
a small quantity of lidocaine.
Consider starting with half of this dose in the geriatric population.
Subsequent doses are administered every 2 to 3 minutes in smaller aliquots
(0.5 mg/kg IV) and titrated to the desired effect.
Analgesic and
Sedative
Sedative
39. Antimicrobial Guide
For detailed guidelines and other conditions not listed below, please refer to the hospitals guidelines for antimicrobial use
Condition
Comments/Caveats
Recommended Therapy
URTI/Sinusitis
The most common cause of URTIs is viral and

thus no antibiotics are necessary
Amoxicillin 500mg TDS x 5 days is the first line therapy

for most adults who fail the watchful waiting approach
Watchful waiting - The observation option for

Acute Bacterial Rhinosinusitis (ABRS) refers to
deferring antibiotic treatment for selected adults
with uncomplicated ABRS who have mild
illness (mild pain and temperature < 38.3C) for
up to 7 days after diagnosis and limiting
management to symptomatic relief and
assurance of follow-up.
In Penicillin-Allergic Patients:
Azithromycin 500mg PO OD x 3 days
The most predictable clinical parameter for

GABHS pharyngitis is reported to be the
Centor criteria.
a) history of fever > 38oC,
b) absence of cough,
c) Swollen and tender anterior cervical lymph
nodes, and
d) Tonsilar exudates or swelling
Both the sensitivity and specificity of this
prediction rule are 75%, compared with throat
cultures.
Adult patients with acute exudative adult pharyngitis who

report 3 or 4 Centor criteria ONLY.
Pharyngitis/
Tonsillitis
Supportive therapy;
Decongestants (-adrenergic) - xylometazoline
hydrochloride for 3 days.
Saline irrigation - Nasal saline irrigation, alone or in
conjunction with other adjunctive measures, may improve
quality of life, decrease symptoms, and decrease
medication use for ABRS, particularly in patients with
frequent sinusitis.
Mucolytics
Antihistamines have no role in the symptomatic relief of
ABRS in non-atopic patients.
Benzathine penicillin G 1.2MU IM stat

OR
Amoxicillin 1gm PO OD x 10 days
Consider - Single-dose Prednisone 60 mg PO or
Dexamethasone 8 mg IM therapy added to the standard
treatment has a more rapid improvement of pain in adult
patients with acute exudative adult pharyngitis who report 3
or 4 Centor criteria.
Patients who are allergic to Penicillin
Azithromycin: 500 mg PO on day 1 followed by 250 mg PO
OD on days 2-5
Laryngitis
Mostly viral
Acute
Gastroenteritis
Any diarrhoeal illness lasting > 1 day,

Food-borne toxigenic diarrhoea usually requires only
especially if accompanied by the following
supportive treatment, not antibiotics.
features should prompt microscopic evaluation
Treatment of salmonellosis with antibiotics (including
of a faecal specimen;
quinolones) can prolong the carrier state and lead to a higher
fever,
clinical relapse rate.
bloody stools,
systemic illness,
Treat ONLY patients with;
recent use of antibiotics,
fever,
day-care centre attendance,
bloody stools,
hospitalization, or
systemic illness,
dehydration (defined as dry mucous
dehydration
membranes, decreased urination, tachycardia,
diarrhoea > 7days
symptoms or signs of postural hypotension, or immunocompromised patients e.g. HIV, Malignancy
lethargy or obtundation)
Ciprofloxacin 500 mg PO BD x 3 days. The duration of
A stool culture is not necessary or costtreatment may be extended by 2-3 days for moderate-toeffective in most cases of diarrhoea without
severe cases.
systemic disease or dysentery unless an unusual
bacterial cause is suspected
Diarrhoea should NOT be treated with anti-motility agents.
Typhoid - Bone marrow culture is the most
sensitive routinely available diagnostic tool.
Stool culture is positive only in up to 30-40% of
cases, but is often negative by the time that
systemic symptoms bring patients to
hospital. Blood cultures are positive in 40-80%
of patients. Serologic tests e.g. the Widal test
are of limited clinical utility because positive
results may represent previous infection.
No Antibiotics necessary
Urinary Tract
Infection (UTI)
When used together, nitrite and leukocyte

esterase testing have sensitivities between 68
and 88%. A review of the literature that
included 70 publications concluded that in
adults, the urine dipstick test alone was reliable
in excluding the presence of infection, if both
the nitrites and leukocyte-esterase were
negative; however, alone the test was not found
to be useful for ruling in infection.
Uncomplicated Cystitis
Ciprofloxacin 500 mg PO BD x 3 days
OR
Nitrofurantoin 100mg TDS x 3 days
Uncomplicated Pyelonephritis, Outpatient Therapy
Ceftriaxone 1 g IV stat
PLUS
Pyuria in a urine specimen, in the absence of

UTI during Pregnancy, Outpatient Therapy
symptoms, is not an indication for antimicrobial Cefuroxime 500 mg PO BD for 7 days
therapy. (A-II)
OR
Urine cultures are not recommended in most
cases of uncomplicated UTIs in adult women.
Nitrofurantoin 100mg TDS x 3 days
Urine Cultures ONLY for;

In patients suspected of having
pyelonephritis, a urine culture and
susceptibility test should always be
performed, and initial empiric therapy should
be tailored appropriately on the basis of the
likely infecting uropathogen. (B-III)
A urine specimen should be obtained for
culture and susceptibility testing before initial
antimicrobial therapy for complicated UTIs.
(A-III)
Complicated UTI
Male gender
Structural or functional anatomic
abnormalities
Renal stones
Indwelling catheters
Renal transplant
Neurogenic bladder
Recent urologic procedure
Inpatient therapy
Sepsis
Pregnancy
Urinary tract obstruction
Persistent vomiting
Poor outpatient follow-up
Complicated UTI
Uncomplicated Pyelonephritis, Inpatient Therapy

Ceftriaxone 1g IV OD 10-14 days
OR
Ciprofloxacin 400 mg IV BD x 10-14 days
UTI during Pregnancy, Inpatient Therapy
Ceftriaxone 1-2 g IV OD
Sepsis
See 18. Severe Sepsis/Septic Shock Algorithm
Give Antibiotics as an EMERGENCY

Ceftriaxone 2gm IV stat
For probable Neutropaenic patients or if patient has been
admitted in hospital in the last 3 months (Hospital
Acquired Infection)
Imipenem 500 mg IV infusion over 3 hrs then QID for
General sepsis
OR
Meropenem 1 gm IV infusion over 3 hrs then TDS for
possible CNS infections
Community
Acquired
Pneumonia
In addition to a constellation of suggestive

clinical features, a demonstrable infiltrate
by chest radiograph or other imaging
technique, with or without supporting
microbiological data, is required for the
diagnosis of pneumonia. (B-III)
Outpatient Treatment
Amoxicillin-clavulanate 2gm PO OD x 7 days
In Penicillin-Allergic Patients:
Azithromycin 1gm PO OD x 3 days
The strongest indications for blood

cultures are severe CAP and in
immunocompromised patients or those
with significant co morbidities, as these
patients are more likely to be infected with
pathogens other than S pneumoniae.
Co morbidities:
Chronic heart, lung or renal disease
Diabetes mellitus
Alcoholism
Malignancy
Asplenia
Immunosuppressant condition or drugs
Inpatient Therapy
CURB 65 2
PSI 4
Patient factors requiring hospitalization
HCAP risk factors?
Hospitalization for 2 or more days of the past
90 days
Resides in nursing home or long-term care
facility
Received chemotherapy, IV antibiotics, or
wound care within the prior 30 days
Attended a hospital or haemodialysis clinic in
the last 30 days
Malaria
CommunityAcquired Severe
Intra-Abdominal
Infection, Biliary,
and Extra-Biliary
Infections
Inpatient Treatment
Amoxicillin-clavulanate 1.2gm IV TDS
PLUS
Azithromycin 1gm IV OD
Healthcare Associated Pneumonia (HCAP)
Antipseudomonal beta-lactam
Imipenem 500mg IV infusion over 3 hours QID
Severe manifestations and complications of

Falciparum Malaria
Coma (cerebral malaria)
Convulsions
Hyperpyrexia
Hypoglycaemia
Severe anaemia (Hct < 15%)
Acute pulmonary oedema
Acute renal failure
Spontaneous bleeding and coagulopathy
Metabolic acidosis
Shock (algid malaria)
Aspiration pneumonia
Hyperparasitaemia (e.g. > 10% of circulating
erythrocytes parasitized in non-immune
patient with severe disease)
Hyper-reactive Malarial Splenomegaly
Uncomplicated Malaria
Artemether + Lumefantrine - Coartem - WHO approved
adult dose is 4 tablets at 0, 8, 24, 36, 48 and 60 hours (six
doses).
Empiric coverage of Enterococcus is recommended
Piperacillin-Tazobactam 4.5gm IV QID
Complicated Malaria
IV artesunate 2.4mg/kg at 0, 12 and 24 hours and daily
until patient can take oral
STI Urethritis,
Epididymitis,
Orchitis,
Proctitis,
Cervicitis
Minimum criteria for clinical diagnosis of PID

(all 3 should be present):
a) Bilateral lower abdominal (uterine)
tenderness (sometimes radiating to the legs)
b) Cervical motion tenderness - Positive
cervical motion tenderness is defined as
increased discomfort from a normal pelvic
examination, as stated by the patient. Of
note, cervical motion tenderness is neither
sensitive nor specific for gynaecologic
pathology, is a sign of nonspecific
peritoneal inflammation,
c) Bilateral adnexal tenderness (with or without
a palpable mass)
One or more of the following additional criteria
can be used to enhance the specificity of the
minimum criteria and support a diagnosis of
PID:
oral temperature >38.3 C;
abnormal cervical or vaginal mucopurulent
discharge;
presence of abundant numbers of WBC on
saline microscopy of vaginal fluid; and
laboratory documentation of cervical
infection with N. gonorrhoea or C.
trachomatis.
STI Urethritis, Epididymitis, Orchitis, Proctitis,

Cervicitis
Ceftriaxone 250mg IM stat
PLUS
Azithromycin 1gm PO stat
PID
Mild-Moderate disease
Ceftriaxone 250mg IM stat
PLUS
Doxycycline 100mg PO BD x 14 days
WITH or WITHOUT
Metronidazole 500mg PO BD x 14 days
Severe disease/In-patient therapy - Suggested criteria:
surgical emergencies (e.g., appendicitis) cannot be
excluded;
the patient is pregnant;
the patient does not respond clinically to oral
antimicrobial therapy;
the patient is unable to follow or tolerate an outpatient
oral regimen;
the patient has severe illness, nausea and vomiting, or
high fever; or
the patient has a tubo-ovarian abscess.
Amoxicillin-clavulanate 1.2g IV TDS
PLUS
Doxycycline 100mg IV/PO BD x 14days
Carbuncle/
Most abscesses are Staph aureus. Most cellulitis Oral Therapy

is Group A beta-haemolytic streptococcus
Beta-haemolytic Streptococcus coverage:
(although some is Staph aureus)
Amoxicillin-clavulanate 1gm PO BD x 7 days
Empiric therapy for Streptococcus pyogenes
OR
(beta-haemolytic streptococcus) is
recommended
Clindamycin 450 mg PO QID x 7-10 days
Furuncle
Azithromycin or clindamycin for severe

penicillin allergy
Cellulitis/
Abscesses/
Folliculitis/
Clindamycin is bacteriostatic, potential for

cross-resistance and emergence of resistance in
erythromycin-resistant strains; inducible
resistance in MRSA
Effective treatment of abscesses entails incision,
thorough evacuation of the pus, and probing the
cavity to break up ovulations (A-I). Gram
stain, culture, and systemic antibiotics are
rarely indicated unless there is extensive
surrounding cellulitis, fever, multiple lesions,
severely impaired host defences, or cutaneous
gangrene. (E-III)
Necrotizing skin
& soft tissue
infections
Surgical intervention is the major therapeutic

modality in cases of necrotizing fasciitis.(A-III)
Necrotizing fasciitis falls into two groups;
The spontaneous extremity cellulitis is usually
Group A Streptococcus and sometime Staph
aureus.
The second group includes head and neck,
abdominal/groin and is frequently
polymicrobial.
Parenteral Therapy (Inpatient)

Beta-haemolytic Streptococcus and MSSA Coverage
Cefuroxime 1.5gm IV q8 hours for 7-10 days
OR
Clindamycin 600 mg IV q8 hours for 7-10 days
Consult a Physician
Bites
Amoxicillin-clavulanate 1gm BD x 7 days

Prophylaxis:
The use of antibiotics in patients with animal
In Penicillin Allergic Patients:
bites is controversial, and some studies have
Ciprofloxacin 400mg PO/IV BD OR Azithromycin 500mg
shown little benefit. However, bites at higher
PO OD for 3 days
risk for infection, should be treated with
PLUS
antibiotics for 35 days; Prophylaxis should be
given for ONLY wounds that are;
Tetanus Toxoid 0.5mg IM
moderate to severe
have associated crush injury
Previous doses
have associated oedema (either pre-existing
Clean and minor
All other wounds
of adsorbed
or subsequent)
wounds
tetanus toxoid
that are on the hands or in proximity to a
bone or a joint
Tetanus
TIG
Tetanus
TIG
in compromised hosts
toxoid
toxoid
ALL Human bites should receive;
< 3 doses or
Yes
No
Yes
Yes
prophylactic antibiotics
unknown
consider post-exposure prophylaxis for HIV
3 doses
Only if last
No
Only if last
No
within 72hrs. The risk associated with bite
dose given
dose given
injuries has not been quantified. The victim
5 yrs ago
10 yrs ago
is usually at low risk unless the biters
saliva is contaminated with blood. The risk
is greater to the biter if blood is drawn from
Rabies Prophylaxis
the victims wound because of exposure to
Rabies Prophylaxis
Pre-EP
No Pre-EP
mucous membranes.
Immunoglobulin
None
Human Ig - 20U/Kg
Hepatitis B vaccine preferably 24 hours if
not previously immunized
(Wound Site)
OR
Equine Ig - 40U/Kg
Treatment:
Vaccine
Day 0, 3
Day 0 , 3 , 7 , 14
ALL infected bites should be treated.
(Deltoid or AL thigh)
SNAKE BITES (http://www.bio-ken.com/)
Syndrome
Painful progressive swelling
Progressive weakness
Bleeding
Important
snakes
African puff adder, Eastern Gaboon

viper, Rhinoceros Horned Viper,
Red Carpet Viper, Black-necked
Spitting Cobra, Red Spitting Cobra
Eastern Green Mamba,

Eastern Jameson's
Mamba, Black Mamba,
Egyptian Cobra, Forest
Cobra
Coastal Boomslang
Clinical
Picture
Mild: slow progressive painful

swelling
Severe: rapidly progressive
swelling and severe pain ,
ecchymosis, blisters, severe tissue
necrosis, abscess formation,
pseudo- and true compartment
syndrome, nausea and vomiting,
hypotension, bleeding tendency,
shock, rhabdomyolysis, renal
failure
Ptosis, diplopia, dilated

pupils, difficulties in
swallowing, salivation,
progressive difficulty
breathing, hypoxia
Bleeding from puncture

sites, Minor lacerations,
development of
disseminated
intravascular
coagulopathy over time
Management
Indications
for
Antivenom
Establish IV access
Give analgesia
Position the limb at the level of
the heart
Give IV fluid for shock and renal
failure
Treat local complication
appropriately
Polyvalent antivenom
Swelling progressive at 15cm/hr
Swelling to a knee or elbow from
a foot or hand bite within 4 hours
Swelling of a whole limb by
8 hours
Swelling threatening the airway
An associated coagulopathy
Unexplained dyspnoea
Consider antivenom if snake is
unknown but envenomation is
severe.
Establish IV access
Monitor oxygenation
and ventilation closely
(HDU)
Intubation and
mechanical ventilation
may be necessary
Polyvalent antivenom
Triad of (either)
1. paraesthesia,
2. excessive
salivation/metallic
taste and sweating
3. dyspnoea
in the absence of
painful progressive
swelling (mambas)
Paresis in the presence
of significant swelling
(non-spitting cobras)
Establish IV access
Give blood/blood
component therapy if
indicated
Heparin,
antifibrinolytics,
thrombolytics are of no
value and may be
dangerous
Monovalent antivenom
Active bleeding
Non-clotting blood in a
clean test tube after 20
minutes
Laboratory evidence of
coagulopathy
HIV Post
Exposure
Prophylaxis
(PEP)
Faeces, nasal secretions, saliva, sputum, sweat,

tears, urine, and vomitus are not considered to
be infectious unless they are visibly bloody.
(Data from CDC.

MMRW January 21,
2005;54(RR02):120)
Estimated per-unprotected act risk for

acquisition of HIV by exposure route
Consult local guidelines for the recommended regimens
Exposure route
% Risk
Regimen
Blood transfusion
90%
High Risk ( 0.1% risk)
Needle-sharing injection-drug use
0.67%
Receptive anal intercourse
0.5%
Percutaneous needle stick
0.3%
Receptive penile-vaginal
intercourse
0.1%
PLUS
Insertive anal intercourse
0.06%
1 tablet OD
Insertive penile-vaginal intercourse
0.1%
(Truvada)
Tenofovir (300mg)
Emtricitabine (200mg)
Truvada is not
recommended
in renal failure
Receptive oral intercourse
0.01%
1 tablet OD
Insertive oral intercourse
0.005%
(Combivir)
Zidovudine (300mg)
lamivudine (150mg)
Replace
Zidovudine
with Abacavir
in anaemic
patients
PEP is indicated for those with at least a 0.1% risk of

transmission from a high-risk or known HIV-positive source
patient.
Perform ELISA for HIV antibodies at baseline, 4-6weeks,
12 weeks and 24 weeks
The overall rate of HIV transmission through

percutaneous inoculation is reported to be 0.3%
(95% confidence interval [CI] 0.20.5); the risk
of acquiring an HIV infection is greater for
percutaneous injuries that involve;
hollow-bore needles that have been in
contact with an artery or vein,
when blood is visible on the device,
a deep needlestick, and
when the source patient has advanced HIV
disease.
Splashes or infectious material to mucous
membranes or broken skin may also transmit
HIV infection (estimated risk per exposure,
0.09%; 95% CI 0.0060.5). Exposure of intact
skin to contaminated blood has not been
identified as a risk for HIV transmission.
Raltegravir 400mg
PLUS
(Kaletra/Aluvia)
Ritonavir (50mg)
Lopinavir (200mg)
Dose
Comments
1 tablet BD
Less sideeffects but

expensive
PLUS
PLUS
2 tablets BD or
4 tablets OD
Low Risk (< 0.1% risk)

(Combivir)
Zidovudine (300mg)
Lamivudine (150mg)
1 tablet OD
Replace
Zidovudine
with Abacavir
in anaemic
patients
PEP should be continued for 28 days

Patients who receive zidovudine plus lamivudine-based
regimens should have a complete blood count and
measurement of liver enzyme levels at 2 weeks of treatment,
irrespective of the presence or absence of clinical symptoms.
Decontamination
Activated Charcoal
40. Poisoning
Indications
Contraindications
Dosing
Use within ONE HOUR of ingestion of

a potentially toxic amount of medication.
It is not effective beyond this period.
Decreased level of consciousness

Ingestion of medication with a low affinity for
binding with activated charcoal (e.g. iron,
lithium)
There are insufficient data to support or
exclude the use of activated charcoal for the
elimination of amitriptyline, digoxin,
phenytoin, and sodium valproatel.
Increased risk of gastrointestinal bleeding or
perforation
The optimal dose of charcoal is unknown.

However, the adult dose ranges from 50 to 100
g per dose. Lower doses of 0.5-1gm/kg are
used in children. When drug-induced vomiting
is anticipated (for example, with a theophylline
overdose), an IV antiemetic is recommended.
Cathartics such as sorbitol are sometimes added
to activated charcoal preparations, but there is
no evidence of any additional clinical benefit.
Multiple-dose (30gm in 400mls 4-6hrly)

activated charcoal should only be
considered if a patient has ingested a lifethreatening amount of; carbamazepine,
dapsone, phenobarbital, quinine, or
theophylline.
Gastric Lavage SHOULD NOT BE PERFORMED

Clinical studies have failed to show that gastric lavage improves the severity of illness, recovery times, or the ultimate medical outcomes and may
be associated with life-threatening complications (aspiration pneumonitis, oesophageal or gastric perforation, fluid and electrolyte imbalances,
arrhythmia).
Antidotes
Antidote
Indications
Dose
Comments
N-acetylcysteine
(NAC)
If it is likely that the patient has

ingested > 150 mg/kg (or >10 g) of
paracetamol
150 mg/Kg IV over 1 hr then 50mg/Kg

over the next 4 hrs then 100mg/Kg
over the next 16hrs
Anaphylactoid reaction if given too fast
In contrast, NAC is not

recommended for patients with;
an unknown ingestion time
a paracetamol concentration below
detectable limits along with normal
AST levels.
IV NAC should be infused as a 3%

solution (30 g of NAC in D5W to a total
volume of 1 L
Atropine
Organophosphate/Carbamate
poisoning causing rhinorrhoea,
lacrimation, dyspnoea, vomiting,
fasciculations, weakness, inability to
ambulate, convulsions, respiratory
insufficiency, coma.
2mg IV repeated every 5 minutes until

the therapeutic endpoint is reached i.e.
until pulmonary secretions are dried
[reflected by improved oxygenation]
and ease of breathing [or ease of
ventilation].
Excessive doses of atropine can result in

delirium, agitation, and tachycardia and
hypertension. Tachycardia is not a
contraindication to atropine
administration.
Miosis alone is not an indication for

atropine administration.
Ethanol
Ethylene Glycol or Methanol

poisoning
PO:
Loading dose: 0.8g/kg in a 20%
ethanol solution diluted in juice.
Maintenance dose: 80mg/kg/h;
increase to maintain a serum ethanol
concentration of 100- 150mg/dL.
IV:
Loading dose: 0.6 - 0.8 g/kg in a 10%
ethanol solution in D5W
(volume/volume).
Maintenance dose: 80 to 130 mg/kg/h
Higher maintenance doses are used in
patients with chronic alcoholism or
during hemodialysis.
Flumazenil
Excessive sedation known to be due

to the use of benzodiazepines in a
patient without known
contraindications (e.g., procedural
sedation).
10/kg IV over 15 seconds. Repeat

every 2-3mins to a maximum of 1mg
(usual range 0.3 to 0.6mg).
The administration of flumazenil to

patients with undifferentiated coma can
precipitate seizures in benzodiazepinedependent patients and has been
associated with seizures, arrhythmia, and
hypotension in patients with co-ingestion
of certain medications, such as tricyclic
antidepressants.
Naloxone
Respiratory depression secondary to

an opioid overdose
Dilute one ampoule (0.4mg/ml) into

10ml (0.04mg/ml), and give 1 ml every
1 to 2 minutes. A therapeutic effect is
usually seen after 3 to 4 ml
Rapid injection may result in an acute

withdrawal syndrome, with severe
sympathetic effects such as hypertension,
tachycardia and pulmonary oedema - can
precipitate a myocardial infarction in
patients at risk of IHD.
Algorithm References
1-4.
American Heart Association. 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science. Circulation 2010;122(18 Suppl 3):S639S933.
5.
OGara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA guideline for the management of STelevation myocardial infarction: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation
2013;127(4):e362-425.
6.
2012 Writing Committee Members, Jneid H, Anderson JL et al. 2012 ACCF/AHA focused update of
the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial
infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the
American College of Cardiology Foundation/American Heart Association Task Force on practice
guidelines. Circulation 2012;126(7):875-910.
10.
Soar J, Pumphrey R, Cant A, et al. Emergency treatment of anaphylactic reactions-guidelines for

healthcare providers. Resuscitation 2008;77:157-169.
11.
Cydulka RK. Managing Acute Exacerbations and Influencing Future Outcomes in the Emergency
Department: Update on the 2007 National Asthma Education and Prevention Program Guidelines.
<http://www.esng-meded.com/ACEPnews/MEL_20080101.pdf > [last accessed 27 March 2013]
14.
James PA, Oparil S, Carter BL et al. 2014 evidence-based guideline for the management of high
blood pressure in adults: report from the panel members appointed to the Eighth Joint National
Committee (JNC 8). JAMA 2014;311(5):507-20.
17-18.
Dellinger RP, Levy MM, Rhodes A et al. Surviving sepsis campaign: international guidelines for
management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41(2):580-637.
23.
Saccilotto RT et al. San Francisco Syncope Rule to predict short-term serious outcomes: A systematic
review. CMAJ 2011; 183:E1116.
25.
Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a
scientific statement for healthcare professionals from the American Heart Association/American
Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on
Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the
Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology
affirms the value of this statement as an educational tool for neurologists. Stroke 2009;40(6):22762293.
26-27.
Jauch EC, Saver JL, Adams HP Jr et al. Guidelines for the early management of patients with acute
ischemic stroke: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke 2013;44(3):870-947.
32.
Chou R, Qaseem A, Snow V et al. Diagnosis and treatment of low back pain: a joint clinical practice
guideline from the American College of Physicians and the American Pain Society. Ann Intern Med
2007;147(7):478-91.
33.
Chey WD, Wong BC; Practice Parameters Committee of the American College of Gastroenterology.
American College of Gastroenterology guideline on the management of Helicobacter pylori infection.
Am J Gastroenterol 2007;102(8):1808-25.
Notes:
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Emergency Medicine

Adult Cardiac Arrest Algorithm ................................................................................................................................................ 3

Adult Bradycardia (< 50/min)/Tachycardia (> 150/min) .......................................................................................................... 4

Post-Cardiac Arrest Care Algorithm ......................................................................................................................................... 5

ACS Algorithm ......................................................................................................................................................................... 6

STEMI Algorithm ..................................................................................................................................................................... 7

Pulmonary Embolism Algorithm .............................................................................................................................................. 9

Rapid Sequence Intubation Algorithm .................................................................................................................................... 10

Difficult Airway Algorithm ..................................................................................................................................................... 11

10. Anaphylaxis Algorithm ........................................................................................................................................................... 12

1. Adult Cardiac Arrest Algorithm

This clinical pathway is intended to

Activate Resuscitation Team

Open and maintain patent airway

Begin CPR - cycles of 30 COMPRESSIONS then 2 BREATHS

Change compressors - CPR 2min

Change compressors - CPR 2min

Change compressors - CPR 2min

Change compressors - CPR 2min

2. Adult Bradycardia (< 50/min)/Tachycardia (> 150/min)

supplement, rather than substitute for,

Identify and treat underlying cause

Bradycardia (HR < 50/min)

Consult a Cardiologist and continue

Narrow Complex Tachycardia

Consider (if Torsades de Pointes):

3. Post-Cardiac Arrest Care Algorithm

Return of Spontaneous Circulation (ROSC)

Activate Resuscitation Team (if not already present) AND a Physician/Cardiologist

Optimize ventilation and oxygenation

Keep the patients temperature

No Patient is able to follow commands?

STEMI or Suspicion of ACS Consult a Cardiologist

ST elevation or LBBB meeting

ST depression > 0.5mm or dynamic T-wave

Sequence of changes seen during evolution

Left Bundle Branch Block (LBBB)

Normal or Non-diagnostic changes

Sgarbossa criteria for LBBB (either)

2. Concordant ST depression 1mm in V1 - 3

Time from onset of symptoms 12 hours?

Consult an Interventional Cardiologist

Review/Complete Fibrinolysis Checklist

No Contraindications for Fibrinolysis/Thrombolysis

TIMI Risk factors

Normal or Non-diagnostic changes in ST segment or T wave

TIMI Risk Score

Probability of Death, Myocardial

Repeat 12 lead ECG in 30 mins/Continuous ST-segment monitoring

If Troponin done < 4 hours from symptom onset then repeat

If no evidence of ischaemia or infarction by testing, can

Two ECGs which are Normal and No ST Depression and No

7. Pulmonary Embolism Algorithm

Clinical features suggestive of Pulmonary Embolus

Clinical gestalt or validated clinical decision support tool

Moderate to high probability for PE ( 15%)

Hemodynamically stable, low probability for PE (< 15%)

Quantitative D-dimer assay

> 0.5 g/L*

< 0.5 g/L*

Begin anticoagulation therapy

* Compression ultrasound of lower extremities can be performed as the initial

8. Rapid Sequence Intubation Algorithm