Emergency Medicine Clinical Guidelines

310 Pages·2016·1.97 MB·English

Emergency Medicine Clinical
Guidelines
Preface

Medical emergencies will always exist, regardless of the established prevention measures that
societies institute. In Rwanda, however, as in much of sub-Saharan Africa, the discipline of
emergency medicine is in its infancy and emergency care training and infrastructure is limited.
Delayed medical response to acute conditions such as injuries from road traffic accidents, severe
malaria, obstetric complications and diarrhea contributes significantly to mortality. In addition,
currently in Rwanda, the vast majority of healthcare providers lack the basic training necessary to
triage and provide patients with adequate care in medical emergencies.
The need for emergency care training in Rwanda is particularly significant as the country is
undergoing an epidemiologic transition where, communicable diseases and emergency obstetric
conditions, injuries resulting from road traffic accidents and industrial accidents, and non
communicable disease constitute an increasingly large proportion of the national burden of disease.
Both of these broad condition domains require specific emergency care training and expertise in
order to secure adequate patient management and favorable outcomes.
The clinical guidelines and protocols for the practice of emergency medicine presented in this
document are designed to be a useful resource not only for those wishing to become emergency
medicine specialists, but also for general practitioners and other healthcare providers tasked with
caring for patients in hospital emergency departments. Healthcare providers using this Emergency
Medicine Clinical Guideline (EMCG) are provided with fundamental concepts and principles
essential to emergency medicine and the management of patients with undifferentiated emergency
conditions.
The EMCG was developed specifically for the Rwandan context using intermediate input
surrounding the emergency medicine protocols, for specialty topics within emergency medicine.
The guidelines are intended to standardize care at both district and referral hospitals. I hope that by
using the EMCG, health care professional will be able to identify acute medical conditions and the
appropriate emergency interventions, in a refined manner.
The Ministry of Health is grateful for the effort of all those who contributed to develop, review,
edit, and validate the EMCG. We would like to thank the many nurses and physicians from district
hospitals, physician specialists and nurses from Kigali University Teaching Hospital, and the
Emergency and Critical Care Medicine physician residents at the College of Medicine and Health
Sciences, and (sidHARTe) program for their technical support.

Dr. Agnes BINAGWAHO Minister of Health
Table of Contents

Chapter 1: General Approach To Emergencies & Critical Care
ABCs & Beyond: Initial Approach To The Patient In Emergency Medicine
Acute Respiratory Failure
Shock
Volume Resuscitation In Children
Chapter 2: Trauma
General Approach To Trauma Patients
Head Trauma
Maxillofacial Trauma
Eye Trauma
Chest Trauma
Abdominal Trauma
Pelvic Trauma
Spinal Injuries
Penetrating Trauma
Trauma In Pregnancy
Trauma In Pediatrics
Chapter 3: Orthopedics
General Approach To Fractures
Management Of Open Fractures
Fall On Outstretched Hand (FOOSH)
Shoulder Dislocation
Elbow Injuries In Adults And Children
Hand Exam And Fractures
Hip Fractures And Dislocations
Long Bone Fractures Of Leg
Knee Injuries
Ankle Injuries
Chapter 4: Respiratory
General Approach To The Dyspneic Patient
Pneumonia
Pneumothorax
Pulmonary Edema
Asthma/COPD
Hemoptysis
Pleural Effusion
Pulmonary Embolus
Chapter 5:Cardiology
General Approach To The Patient With Chest Pain
Cardiogenic Shock
Heart Failure
Bradycardia With A Pulse
Tachycardia
Pericardial Effusion/Tamponade
Hypertensive Emergency
Endocarditis
Syncope
Chapter 6: Gastroenterology
General Approach To The Patient With Abdominal Pain
Gastrointestinal Bleeding
Liver Disorders
Biliary Disease
Appendicitis
Gas And Stool Arrest
Hernias
Diarrhea
Peptic Ulcer Disease/Esophageal Perforation
Abdominal Mass
Chapter 7: Renal And Genitourinary
Acute Scrotal Pain
Hematuria
Urinary Retention
Renal Failure- Acute And Chronic
Penile Disorders
Priaprism
Urolithiasis
Urinary Tract Infection And Pyelonephritis
Chapter 8: Eye, Ear, Nose, & Throat
Pharyngitis And Complications
Epistaxis
ENT Masses
ENT Foreign Bodies
Chapter 9: Neurology
Altered Mental Status/ General Approach To Coma
Acute Stroke
Headache- Non-Traumatic
Seizures
Subarachnoid Hemorrhage
Chapter 10: Hematology
Anemia
Transfusion Reactions And Complications
Chapter 11: Infectious Diseases
Sepsis And Septic Shock
Skin And Soft Tissue Infections
Chapter 12: Endocrine And Metabolic
Hyperglycemia Disorders (DKA, HHS)
Hyperkalemia
Hypokalemia
Hypernatremia
Hyponatremia
Chapter 13: Environmental
Burns
Mammalian Bites
Snake Bites
Drowning
Chapter 14: Toxicology
General Approach To Toxidromes
Alcohol Withdrawal
Chapter 15: Gynecology
Vaginal Bleeding
Emergency Treatment Of Sexual Assault Patient
Chapter 16: Musculoskeletal
Low Back Pain
Chapter 17: Vascular
Unilateral Leg Swelling- DVT, Arterial Clot
Appendix
Procedural Sedation
Fluid Management
Assessment Of Mental Status
Vasopressors
Pain Medications
Log-Roil Procedure
Retrograde Urethrogram
Tube Thoracostomy (Chest Tube)
Pericardiocentesis
Manual Detorsion Of The Testes
Foley Catheter
Suprapubic Catheter
References
Contributors
ACRONYMS

ABG: arterial blood gas
AED: automated external defibrillator
ALT: alanine aminotransferase
ARDS: acute respiratory distress syndrome
AST: aspartate aminotransferase
AV: arterovenous
AVPU: alert, verbal, pain, unresponsive
BID: bis in die (twice daily)
BP: blood pressure
BPM: beats per minute
BVM: Bag-valve mask
Ca: calcium
CHF: congestive heart failure
CO: cardiac output or carbon monoxide
CO2: carbon dioxide
CNS: central nervous system
COPD: chronic obstructive pulmonary disease
CPR: cardiopulmonary resuscitation
Cr: creatinine
CT: computer tomography
CVA: costovertebral angle or cerebrovascular accident
CXR: chest x-ray
DIC: disseminated intravascular coagulation
DKA: diabetic ketoacidosis
DVT: deep venous thrombosis
EBV: Epstein-Barr virus
ECG: electrocardiogram
EM: emergency medicine
ENT: ear, nose and throat
FAST: focused assessment with ultrasound in trauma
FBC: full blood count
FFP: fresh frozen plasma
FNA: fine needle aspiration
GABHS: Group A beta-hemolytic Streptococcus
GCS: Glasgow coma score
GI: gastrointestinal
GU: genitourinary
HELLP: Hemolysis, Elevated Liver enzymes, Low Platelets
Hg: hemoglobin
HIV: human immunodeficiency virus
HSP: Henoch-Schonlein Purpura
HR: heart rate
HSV: herpes simplex virus
HUS: hemolytic uremic syndrome
Hx: history
IM: intramuscular
INH: Isoniazid
INR: international normalized ratio
10: intra-osseous
ITP: idiopathic thrombocytopenia purpura
IV: intravenous
IVC: inferior vena cava
JVD: jugular venous distention
LDH: lactate dehydrogenase
LMWH: low molecular weight heparin
LR: Lactate Ringer's
MAP: mean arterial pressure
MDI: metered dose inhaler
mEq: milliequivalents
ml: milliliters
MI: myocardial infarction
NAC: N-Acetylcysteine
NG: nasogastric
NIPPV: non-invasive positive pressure ventilation
NS: normal saline
OPD: outpatient department
PA: posterior-anterior
PE: pulmonary embolism
PEA: pulseless electrical activity
PEEP: positive end expiratory pressure
PO: per os (oral administration)
PPV: positive pressure ventilation
PT: prothrombin time
PTT: partial thromboplastin time
PTX: pneumothorax
PUD: peptic ulcer disease
RBC: red blood cells
RR: respiratory rate
RTA: road traffic accident
RUG: retrograde urethrogram
RV: right ventricle
SAH: subarachnoid hemorrhage
SBP: systolic blood pressure
SJS: Stevens Johnson Syndrome
SL: sublingual
SSTI: Skin and soft tissue infections
STI: sexually-transmitted infection
SVT: supraventricular tachycardia
TBSA: total body surface area
TMP-SMZ: Trimethoprim/sulfamethoxazole
TEN: Toxic Epidermal Necrolysis
TIA: transient ischemic attack
TB: tuberculosis
TRALI: transfusion-related lung injury
TTP: thrombotic thrombocytopenic purpura
US: ultrasound
UTI: urinary tract infection
VT: ventricular tachycardia
XR: x-ray
Chapter 1

General Approach to Emergencies