Pahs emergency protocol

315 Pages·2016·5.072 MB·English

by  Asish shrestha

Emergency

Patan Academy of Health Sciences
Department of General Practice and Emergency Medicine

November, 2015
Content

Title Page Number

Communicaiton skills 1-4

Clinical examinations 5-25

Emergency structure and operation 26-32

Resuscitation 33-67

Cardiac emergencies 68-79

Respiratory emergencies 80-97

Abdominal emergencies 98-119

Neurological emergencies 120-131

Metaboic emergencies 132-147

Toxicology 148-167

Common problems 168-180

Environmental injuries 181-184

Orthopedic injuries 185-192

Obstetrics and Gynecology emergencies 193-197

Psychiatry emergencies 198-199

Police cases 200-202

Procedures 203-221

Paediatric emergencies 222-284

If there are any corrections or updates in the protocol please send mail at [email protected]
Communication Skills
Contents
Communication in crisis ..................................................................................................................................... 2
Crisis Resource management (CRM).............................................................................................................. 2
Three big CRM skills are ................................................................................................................................. 2
Close loop communication ........................................................................................................................ 2
Sharing information (SBAR) ....................................................................................................................... 2
Reassess ..................................................................................................................................................... 2
Delivering death notification ............................................................................................................................. 3
Griev_ing method .......................................................................................................................................... 3
What reaction to expect? .............................................................................................................................. 3
Medical Ethics .................................................................................................................................................... 4
PATAN ACADEMY OF HEALTH SCIENCES

Communication in crisis
“Communiation errors kill patients.”

Crisis Resource management (CRM)
Crisis Resource Management is the skill of managing the human and physical resources in a stressful, high-
stakes environment.

Three big CRM skills are
1. Uses closed-loop communication
2. Shares information
3. Reassesses

Close loop communication
“What is thought is not said, what is said is not heard, what is heard is not understood, what is understood
is not done, what is done is not confirmed.”

So close the loop by speaking up and confirming that the person you want to communicate has
understood.

Sharing information (SBAR)
• Situation
• Background
• Assessment
• Recommendation

Reassess
Ferquent reassessment is the key to success.

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PATAN ACADEMY OF HEALTH SCIENCES

Delivering death notification
Griev_ing method
Gather Collect family in quiet, respectful place
Resources Call for any additional support to assist the family with their grief
Identiry Identiry yourself, identify deceased patient by name, identify state of
knowledge of the family pertraining to the evens of the day. Are they aware
of possible death or will this be a completely unexpected event for them?
Educate Educate about event occurred in ED
Suggest to them that you are bringing a very bad news
Verify Verify that a family member had died
Space Give family member personal space and time for emotional moment
Inquire Ask them if they have any question
Nuts and bolts Allow relatives to see deceased
Take care of personal belongings
Give Give documents, express condolence

What reaction to expect?
Families may go into denial, anger or guilt. Family anger is not uncommon so prepare to react supportively.
Do not be defensive or judgemental if faced with statement of negligency or what should have been done.
Allow survivors to express their feelings. Remain clam and silent.

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PATAN ACADEMY OF HEALTH SCIENCES

Medical Ethics
Medical ethics for practice:
Ethics is set of principles, values with the help of which we can arrive in right decision. Nothing in right or
wrong in ethics but it all depends on the situation. Something may be right for a person may not be right for
the other. There are few principles in ethics which we can utilize to get right decisions.
1. Autonomy: We should respect patients’ decision in every step. If the patient is incompetent or minor
(less than 16 years to give consent), we can seek help from surrogate decision makers.
2. Beneficence: Do good to the patient. Our every activity should be guided with this principle.
3. Non Maleficence: Do no harm to patient.
4. Justice: We should be guided with equitable distribution of resources.

Besides these principles, we can use some other theories like
• Consequentialism: If the result of the action is beneficial to the patient, we can do it.
• Utilitarian: The action should be guided with positive effect to everyone not only to the person.
• Deontology: every action should be guided by duty and if you are doing an action, you should think
that this action can be done to you or not.
• Confidentiality: we should maintain the confidentiality of the patients’ information as far as possible.
In case of written order from court of law, we can give information to the court only. Sometimes, to
protect society and other people, this principle is waived but we should inform patient before
breaching it.
• Medical Professionalism is a desire to help people and to help society as a whole with quality
healthcare. We should be guided by professionalism to provide good care to the patient.
• Informed Consent: There are three important component of informed consent.
Information- we should provide adequate comprehensible information to the patient. We
o
should provide pros and cons of the procedure and consequences of not giving consent to
patient.
Voluntariness – the consent should be given voluntarily without coercion.
o
Competency: the person giving consent should be competent to give consent. They should
o
have good higher mental function without use of drugs that influence his competency.

In case of life saving and emergency procedure, we can take consent from the surrogate decision makers if
the patient is not competent.

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Clinical Examination
Contents
General Examination .......................................................................................................................................... 5
Respiratory System ............................................................................................................................................ 8
Cardiovascular System ..................................................................................................................................... 13
Abdomen .......................................................................................................................................................... 18
Approach to Coma ........................................................................................................................................... 22
Neurological Examination ................................................................................................................................ 25
PATAN ACADEMY OF HEALTH SCIENCES

General Examination
Skin
• Generalized absence of skin pigmentation occurs in albinism. Syndrom with features of albinism are
– Chediak Higashi syndrome – Phagocytic deficiency disease, Phenylketonuria (Inborn error of
amino acid metabolism)
• Patchy absence of skin pigmentation may be due to vitiligo
• Circumscribed hypopigmentation of lesion of skin occurs in – Hansen’s disease, Tenia vesicolor
• Generalized hyperpigmentation – Hemochromatosis, Addison’s, Cushing’s
• Patchy hyperpigmentation – Pellagra, Scleroderma
• Yellow pigmentation of skin: Jaundice, Carotenemia, Long standing severe anemia
• Bluish discolourisation: Cyanosis; Ruddy complexion: Polycythemia; Pallor: Decrease in Hb
• Diabetes Mellitus
Necrobiosis lipodica diabetocorum – Papulo nodular lesion enlarging to form brownish
o
yellow plaque with waxy surface over front of leg.
Diabetic dermopathy – Dull, red, oval, flat topped
o
Diabetic bulla – over legs, hands, feets bilaterally healing with atrophic scars
o
Diabetic rubeosis – flushed skin of face
o
Carotenoderma – yellowish tint of skin due to deposition of carotene
o
Granuloma annulare – popular lesion over central area of body and flexures of neck, arm
o
and thing
Sclerederma diabeticorum – diffuse waxy, non pitting, induration of skin particularly over
o
back of neck and upper trunk
Infection like furuncle, carbuncle
o
• Chronic renal failure
Uraemic frost
o
Erythema papulatum uraemicum – erythematous nodules over palm, soles and forarm
o
Generalised puritis
o
Metastatic calcification
o
Kyrle’s disease – multiple discrete or confluent hyeperleratotic follicular papules over lower
o
extrimities
Nail change – proximal white and distal half pink
o
Oral manifestations – coating of tongue, xerostomia, ulcerative stomatitis
o
• Internal malignancy
Acanthosis nigricans – adenocarcinoma of GIT
o
Plamo planter keratoderma – Ca bronchus and oesophagus
o
Nectolytic migratory erythema – glucagonoma
o
Pityriasis rotunda – hepatocellular Ca
o
Sign of Leser Trelat – sudden eruption of intensely pruritic multiple seborrhoeic keratosis in
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Ca stomach

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Migratory thrombophlebitis in Ca panceas
o
Cutaneous hamartoma – Ca breast, thyroid, GI polyposis = cowdens disease
o
Face
Forehead
• Prominent forehead: Acromegaly, Chronic Hyerocephalus, Rickets, Thalassemia
• Wrinkling of forehead:
Bilateral: Anxiety, Bilateral ptosis as in Myasthenia Gravis, Bilateral III nerve palsy, Bilateral
o
Horner’s syndrome
Unilateral: Unilateral ptosis as in unilateral III nerve palsy, Horner’s syndrome
o
• Absence of wrinkling of forehead
Unilateral: Bell’s palsy
o
Bilateral: Myotonic dystrophy, hyperthyroidism (Joffroy’s sign)
o
Eyes
• Ptosis, Pallor, Icterus, Bitot’s spot (Vitamin A deficiency), Arcus senilis
Tongue
• Macroglossia: Acromegaly, Down’s syndrome. Tumors
• Microglossia: Pseudobulbar palsy, Facial hemiatrophy
• Fissured tongue: Down’s, Vitamin B deficiency, Acromegaly, Congenital malformation
• Hairy leukoplakia: EB virus, typically seen in lateral margin of tongue
Stature
• Stature is total height measured from vertex of head to sole of feet. Upper segment is vertex of
head to symphysis pubis. Lower segment is from symphasis pubis to sole of foot.
• Stature > Arm span: Adrenal cortex tumor, precocious puberty
• Arm span > stature: Hypogonadism, Marfan’s syndrome, Klinefelter’s syndrome
• Upper segment > lower segment: Adrenal cortex tumor, precocious puberty
• Lower segment > Upper segment: Hypogonadism, Marfan’s syndrome, Klinefelter’s syndrome
• Gigantism: Height more than six feet six inch. Dwarfism is height less than four feet.
Obesity
• Generalised obesity: Uniform distribution of fat throughout the body.
• Android obesity: Obesity characterized by excess deposition of fat over region of waist.
• Gynoid obesity: Characterised by excess deposition of fat over region of hip and thigh.
• Superior or central obesity: Excess fat deposition over face, neck and upper part of trunk –
cushing’s syndrome
Posture
• Parkinsonian posture: Universally flexed posture
• Cerebellar posture: Stands with feed wide apart and is unable to maintain a steady posture while
standing. Patient is ataxic on sittine (trunkal ataxia) when vermis of cerebellum is affected.

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• Decrebrate posture: Extension of elbows and wrist with pronation of arm. Lesion is at brainstem
disconnecting the cerebral hemispheres from the brainstem.
• Decorticate posture: Flexion of elbows and wrist with supination of the arms. It suggest severe
bilateral hemispherical damage above the midbrain.
Nail
• Koilonychia – spoon shaped: Iron deficiency, IHD, Syphillis, Hemochromatosis
• Beau’s line – Transverse ridge in the nail plate due to temporary alteration of nail growth rate:
Acute febrile illness, Pneumonia, MI
• Plummer nail – Onycholysis of nail: Hypothyroidism, Raynaud’s disease
• Lindsay nail – Proximal dull white portion and a distal pink or brown with a well demarcated
transvere line: Uraemia
• White nail (Terry Nail) – White color in the nail bed than nailplate: Anaemia, CCR, DM, Malignancy
• Red nail: CCF, Blue nail: Wilson’s disease
• Black nail: Peutz Jeghers syndrome, Cushing’s syndrome, Addison’s disease
Fever
• Maximum normal oral temperature: 6 am – 98.6, at 6 pm – 99.6
• Normal diurnal variation is 1 degree F, rectal temperature is 1 degree F more than oral. Oral
temperature is 1 degree F more than axillary
Fever with relative bradycardia
• Typhoid Fever, Meningitis, Viral fever (Influenza), Brucellosis, Leptospirosis, Drug induced fever
Fever with exanthema
• Rash appearing on first day of fever – Chicken pox
• Rash appearing on fourth day of fever – Measles
• Rash appearing on seventh day of fever – Typhoid
Patterns of fever
• Continuous: The temperature remains elevated above normal without touching the baseline and
the fluctuation does not exceed 1 degree F. E.g. Lobar pneumonia, infective endocarditis, enteric
fever
• Remittent: Temperature fluctuation exceeds 1 degree F but without touching baseline: abscess
• Intermittent: Temperature touches the baseline in between. E.g. sepsis. Quotidian fever is a hectic
fever occurring daily
• Relapsing: Febrile episodes are separated by normal temperature for more than one day.
Tertian fever: Occuring alternate days, Pl vivax, Pl falciparum, Pl ovale
o
Quartan fever: Occuring every two ays, Pl malariae
o
Pel Ebstein fever: Lasting 3-10 days followed by afebrile period of 3-10 days. Hodgkins
o
Saddle back fever: Initially fever lasts 2-3 days followed by a remission lasting for 2 days and
o
then fever reappears and continues for 2-3 days. Dengue fever
Cyclic neutropenia: Fever occurs every 21 days.
o

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