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Emergency Medicine Protocols
 

Emergency Medicine Protocols

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Contains Algorithms on All important emergency medical conditions

Contains Algorithms on All important emergency medical conditions

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    Emergency Medicine Protocols Emergency Medicine Protocols Presentation Transcript

    • CARDIAC ARREST EM 01
      Assessment
      Cardiac arrest means No pulse No BP
      Unresponsive or deeply comatose
      Respiration gasping; But pupils still reacting
      Begin immediately
      Advanced Cardiac Life Support
      Start external chest compressions
      Basic Life Support
      till
      defibrillation is available
      Call colleagues for help
      Call nurse to start medications
      Call nursing assistants to assist
      Attach monitor and defibrillator if available
      Start oxygen by mask
      Endotracheal intubation
      Precordial thumb in
      Unmonitored Cardiac arrest C2b
      Monitored Cardiac arrest C1
      Call attenders to start oxygen
      Give loud and clear instructions
      Be the leader of the team
      Check for shockable rhythm
      Open the patients airway
      Clear mouth, Remove dentures
      Give throat suction
      Extent neck and intubate
      Connect oxygen by tube
      Start artificial ventilation
      Use ambu bag or machine
      Delivered to the middle of chest
      when onset of VT VF is seen
      It may convert VT VF to NSR
      Do not delay defibrillation
      If unmonitored, can be harmful
      Even precipitate a VT or VF
      Do not repeat the procedure
      Shockable
      VF, PulselessVT
      Not Shockable
      Asystole PEA
      Give one shock and immediately resume CPR
      Manual biphasic device –specific give 120-200j
      Monophasic device give 360 joules
      Immediately resume CPR for 5 cycles
      Give adrenaline 1mg mg IV repeat 3 doses
      Or Vasopressin 40 U IV instead of adrenaline
      Consider Atropine 1 mg IV if asystole or PEA
      Repeat 3 doses or till recovery
      Give 5 cycles of CPR and check for shockable rhythm
      Give 5 cycles of CPR and check for Shockable rhythm
      Continue CPR while defibrillator is charging
      Give one shock and resume CPR
      If indicated try shock
      Give adrenaline 1mg mg IV repeat 3 doses
    • EXTERNAL CHEST CARDIAC MASSAGE EM 02
      Life saver (prolonger) technique
      Start immediately
      Continue unremittingly
      Position the patient on a hard cot, trolley or other surface
      Remove pillows and put the patient flat supine
      Higher levelLower head end if previously elevated
      Open the mouth of the taker
      Give two breaths
      If only 1 giver switch to compressions
      Giver stands at a higher level
      Elbows kept at 1800
      Pressure shall come from shoulders
      Place the left hand over the lower sternum
      Place the right hand over the left hand
      Keep the arms straight and give firm steady compressions
      Consider endotracheal intubation
      And assisted ventilation
      Compressions of 4 cm depth
      Less will not be sufficient
      More may be harmful
      One cycle is 30 chest compressions and two breaths
      Complications of CPR:
      # ribs Pneumothorax
      Hemopneumothorax
      Hemopericardium
      An effective CPR should be able to
      Restore the circulation to the brain
      And to the vital organs
      like the lungs and kidneys
      Never break the cycle of CPR
      Except for giving DC shocks
      CPR - not a substitute for defibrillation
      Should not stand in the way
      CPR may be continued
      Indefinitely if indicated
      Give 5 cycles of CPR
      or CPR for minimum of 2 minutes
      Consider discontinuing CPR only after 30 minutes
      Give adrenaline 1mg mg IV repeat 3 doses
    • VENTRICULAR FIBRILLATION / PULSELESS VT EM 03
      Arrive here from
      Cardiac arrest overview
      Monitor showing
      Ventricular Fibrillation/ Tachycardia
      Adrenaline 1 mg IV 10 ml of 1:10,000
      /2 mg 20 ml 1:10,000 ET
      Fine Ventricular Fibrillation
      (lesser chance or correction)
      Coarse Ventricular Fibrillation
      Defibrillate at
      200 joules biphasic
      300 joules monophasic
      Resume attempts to defibrillate
      Give 2 min CPR between defibrillations
      LIDOCAINE 1 mg per kg IV
      Then 0.5mg per kg q 10 minif required
      to a maximum total dose of 3mg per kg
      Pulseless Ventricular Tachycardia
      5 cycles of Cardiopulmonary
      Resuscitation
      Confirm A/W placement
      Effective oxygenation
      and ventilation
      Resume attempts to defibrillate
      Assess rhythm only after
      5 cycles/2m CPR
      Establish IV
      Assess rhythm
      If Torsae des pointes
      MAGNESIUM IV
      ASYSTOLE or
      Pulseless Electrical Activity
      ASYSTOLE or PEA
      so shock protocol
      Resume attempts to defibrillate
      Sinus Rhythm – OK Fine
    • DEFIBRILLATION EM 04
      Rhythm VF or Pulseless VT
      Maintain airway, Oxygenate
      Defibrillation is a technique
      used to counter the onset of VF,
      the common cause of cardiac arrest,
      and pulseless VT,
      which sometimes precedes VF but
      can be just as dangerous on its own.
      In simple terms, the process uses
      an electric shock to stop the heart,
      in the hope that heart will restart
      with rhythmic contractions.
      Sedate
      Patient is conscious and anxious
      Press both buttons together
      One electrode is placed on the right side
      of the front of the chest just below clavicle
      and the other electrode is placed
      on the left side of the chest just below
      the pectoral muscle or breast.
      Ensure no one touches the cot
      Ensure your body does not touch the cot
      Charge the defibrillator to chosen energy
      Place both paddles in appropriate position
      Check monitor for rhythm VF or Pulseless VT
      It is not effective for asystole
      (complete cessation of cardiac
      activity, ) and pulseless electrical
      activity (PEA).
      No Improvement?
      Cardiac arrest protocol
    • CARDIAC ASYSTOLE AND PEA [No shock advised] EM 05
      Arrive here from
      Cardiac arrest protocol
      Establish IV line, Give 5 cycles of CPR
      Confirm airway placement, effective oxygenation and ventilation
      Search forand treat possible causes, hypovolemia, hypoxia, hyperkalemia, hyokalemia, hypothermia, hydrogen ion acidosis
      Tableta(Drug overdose) tamponade, tension pneumothorax, thrombosis (cardiac and pulmonary)
      Adrenaline 1 mg IV
      Endocratheal tube
      Atropine 1 mg IV if
      PEA with rate <60
      Assess rhythm
      Cardiac Asystole
      Ventricular Fibrillation
      See VF protocol
      Consider Sodium bicarbonate
      Only if hyperkalemia
    • STABLE PATIENT WITH NARROW COMPLEX TACHYCARDIA EM 06
      Assessment
      Patient stable/unstable
      Look for serious signs of instability
      SERIOUS SIGNS
      Chest pain Shortness of breath Loss of conciousness
      Low Blood pressure Cardiogenic shock Pulmonary edema
      Congestive cardiac failure
      ATRIAL FIBRILLATION /FLUTTER
      SINUS TACHYCARDIA
      SUPRAVENTRICULAR TACHYCARDIA
      VAGAL COMPRESSION
      See procedure
      Look for and treat underlying
      Causes: Pain, Hypoxia, Dehydration
      Deteriorating serious
      signs or symptoms
      Not successful
      Try Digoxin + Verapamil
      SYNCHRONIZED CARDIOVERSION
      Start at 100 joules
      Increase to
      200, 300, 360
      Adenosine 6 mg IV push
      Repeat the dose and
      Double the dose
    • STABLE WIDE COMPLEX TACHYCARDIA EM 07
      Arrive here
      from protocol
      Tachycardia Overview
      MONOMORPHIC VT
      POLYMORPHIC VT
      UNKNOWN
      SUPPORTIVE CARE
      TRANSPORT
      Supportive Care
      Transport
      SUPPORTIVE CARE
      TRANSPORT
      MAGNESIUM 1 gm IV
      LIDOCAINE 1 mg per kg IV
      Then 0.5mg per kg q 10 minif required
      to a maximum total dose of 3mg per kg
      LIDOCAINE 1 mg per kg IV
      Then 0.5mg per kg q 10 minif required
      to a maximum total dose of 3mg per kg
      Deteriorating symptoms or signs
      SYNCHRONIZED
      CARDIOVERSION
      Start at 100 joules Increase to
      200, 300, 360
      TRANSPORT
    • BRADYCARDIA EM 08
      Assessment
      Heart Rate less than 40 per minute
      BP/Perfusion adequate
      Sinus Bradycardia or I0 AV block
      Observe
      NO
      Type II second degree A V Block
      Or III degree Complete A V Block
      NO
      Atropine
      0.5 mg q 5 min
      Transcutaneous Pacing if
      Symptoms develop
      Temporary
      Transcutaneouspacing
      No response or
      easy reversions to CHB
      Not Successful
      NO
      Permanent Pacemaker
      Dopamine
      5-20 ug/kg/min IV
    • CARDIOGENIC SHOCK EM 09
      Assessment of ABCs
      Oxygen 100% by mask
      Call for ALS
      team intercept
      Endotracheal intubation
      See airway
      management protocol
      Pump versus rate problem
      IV access X 2
      Bradycardia with hypoperfusion
      SVT or VT with hypoperfusion
      MI with hypoperfusion
      Atropine 0.5mg IV push
      Repeat to maximum 3 mg
      Normal saline 500 cc bolus
      SVT
      Narrow
      complex
      VT
      Wide
      complex
      Synchronized
      cardioversion
      Normal saline 500 cc bolus
      STABLE
      STABLE
      Dopamine IV
      Start at 5ug/kg/minute
      And titrate
      EXTERNAL PACEMEAKER
      Vagal
      manouere
      Lidocaine
      Dopamine IV
      Start at 5ug/kg/minute
      And titrate
      Adenosine
      Adenosine
      TRANSPORT
    • CARDIAC FAILURE EM 10
      Assessment
      History: MI, HTN, AS
      Raised JVP,Gallop, Crackles
      SEVERE
      Respiratory distress
      Crackles throughout
      Oxygen saturation<92
      NEAR DEATH
      Insufficient Respiratory drive
      Cyanosis Dropping saturation
      Decreased LOC
      MILD/ MODERATE
      Able to speak sentences
      Crackles base only
      Oxygen saturation>92
      Oxygen to maintain sat >92
      High flow qxygen
      100% Oxygen
      Nitroglycerine SL repeat q5m
      Nitroglycerine SL repeat q5m
      Nitroglycerine SL repeat q5m
      IV saline lock
      Salbutamol [only if wheeze]
      Salbutamol [only if wheeze]
      IV Morphine
      2.5-5 mg
      IV Morphine
      2.5-5mg
      Deteriorating
      IV Frusemide
      Only if on diuretics
      IV Frusemide
      Only if on diuretics
      Deteriorating
    • BRONCHIAL ASTHMA EM 11
      Assessment
      Less than 50 years
      History of Asthma
      Environmental exposure
      Severe
      Decreased a/e throughout
      With expiratory wheeze
      Expiratory wheeze
      Oxygen saturation <92%
      Mild to moderate
      Decreased a/e throughout
      Expiratory wheeze
      Speaking in sentences
      Oxygen saturation >92%
      Near Death
      Decreased level of conciousnes
      Ineffective respiratory effect
      Unable to speak Cyanosis
      Oxygen saturation <92%
      Oxygen to maintain sat >92%
      Oxygen 100% BVM prn
      Oxygen to maintain sat >92%
      Salbutamol 5mg nebulization
      Salbutamol 5mg nebulization
      Epinephrine 0.3mg SC
      IV Aminophylline 250 mg in 100ml
      See suspected cardiac origin protocol
      Ipratropium bromide 0.3mg aerosol
      IV saline Lock
      IV Aminophylline 250 mg in 100ml
      See suspected cardiac origin protocol
      Adenosine 6 mg IV push
      Repeat the dose and
      Double the dose
    • DIABETIC KETOACIDOSIS EM 12
      ASSESSMENT: History and PE, RBS, Urea, S Cr, SE, Urine , CBC, ECG Blood gases, CXR
      Diagnostic criteria for DKARBS >250mg%, Arterial pH < 7.3m, S Bicarbonate < 15mg%, Moderate ketouria
      Start IV fluid 0.9% Saline 1L per hour initally(15-20 ml/kg/hour
      Insulin
      Potassium
      IV Fluids
      Determine hydration status
      IV Route
      SC / IM route
      If Serum K+ level is <3.3 meq/L
      Hold insulin and give K+40meq/hr
      2/3rd as Pot Chloride and
      1/3rd as Pot phosphate
      Hypovolemic shock:
      Administer 0.9% Sodiunm chloride
      1L / hour and or plasma expander
      Administer
      Regular Insulin
      0.5 U /kg as IV bolus
      Administer
      0.3 U /kg as IV bolus
      And ½ given SC or IM
      Cardiogenic shock:
      Hemodynamic monitoring
      Administer
      Regular Insulin
      0.1 U /kg as IV infusion
      Administer
      0.1 U /kg per hour
      And ½ given SC or IM
      If Serum K= level is . 5.5meq/L
      do not give K+
      but check level every 2 h
      Mild hypotension:
      Evaluate corrected serum Na level
      High or Normal:
      Administer 0.45% Na cl
      If RBS dose not fall by 50-70mg in the 1st hour
      If Serum K+ level is >3.3 meq/L
      but < 5.5meq/L give 20-30 meq
      in each liter of IV fluid
      2/3rd as Pot Chloride and
      1/3rd as Pot phosphate
      Double insulin infusion
      Hourly until RBS
      Falls by 50-70mg/h
      Give hourly IV insulin
      Bolus until RBS
      Falls by 50-70mg/h
      Serum Na low:
      Administer 0.9% Na Cl
      Depending on hydration status
      When Serum Glucose reaches 250mg/Dl[13.3mmol/L
      Change to 5% Dextrose0.45% Saline administered
      at 100-200ml per hour, with adequate insulin
      0.05-0.1 U/kg/has IV infusion or 10 U SC 2 hours
      given to keep glucose level between 150 and 200mg%
      Check chemistry every 4 hours until patient is stable
      Look again for precipitating causes
      After resolution of diabetic ketosis obtain blood glucose
      Every 4 hours and give sliding scale regular insulin
    • ACUTE ISCHEMIC STROKE EM 13
      Assessment
      New onset of Neurological Deficit
      Stroke or Transient Ischemic Attack
      Non contrast Head CT scan
      Acute cerebral edema cause obtundation herniation
      Peaks on 2nd day but mass effect till 10th day
      Larger the infarct more the cerebral edema
      Can directly compress the brainstem
      Blood pressure to be lowered if
      Malignant Hypertension
      Concomitant Myocardial Ischemia
      Blood Pressure >180/110 mmHg
      Care of comatose patients
      Ryles tube feeding
      Adequate calorie & fluid intake
      Intravenous Mannitol 100 ml 8 hourly for 3 days
      Oral Glycerine 30 ml TID orally or via Ryles tube
      Water restriction but avoiding hypovolemia
      Start Amlodipine 2.5mg BID or
      Tablet Nifedipine 10mg BID
      Titrate to keep BP At 150/90
      Consider catheterization
      Ensure good urine output
      Frequent change of position
      Intravenous rtPA 0.9mg/kg to a90mg maximum
      In selected patients within 3 hours of the onset
      Attention directed towards
      Common complications of
      bedridden patients
      Respiratory tract infections
      Urinary tract infections
      Pressure sores
      DVT and Pulmonary Embolism
      Monitor Blood Sugar regularly
      Keep RBS value below 200mg%
      Fever detrimental
      Use antipyretics as indicated
      If unmonitored, can be harmful
      Even precipitate a VT or VF
      Do not repeat the procedure
      Aspirin 300mg daily
      The role of Anticoagulation is uncertain
      Search for evidence of cardioembolic stroke
      Investigate with ECG, Chest X Ray and Echo
      Consider anticoagulation with PTT INR control
      Consider Neuroprotective agents
      Give adrenaline 1mg mg IV repeat 3 doses
      Or Vasopressin 40 U IV instead of adrenaline
      Rehabilitation of stroke patients
      Physical, speech, and occupational therapy
      Education of the patient and family
      Prevention of complications of immobility
      Search for risk factors for stroke
      Hypertension, Diabetes, Smoking, Dyslipidemia
      Asymptomatic or symptomatic carotid stenosis
      Relative risk reduction with treatment
      Balloon Angioplasty with Stenting is the alternative
      Surgical treatment restricted to Carotid Endartectomy
    • ACUTE EMBOLIC STROKE EM 14
      Assessment
      New onset of Neurological Deficit
      Stroke or Transient Ischemic Attack
      Non contrast Head CT scan
      Anticoagulation to keep INR ranging from 2 to 3
      Warfarin reduces the risk by 67%
      1% risk per year of a major bleeding complication
      Can directly compress the brainstem
      Non rheumatic Atrial Fibrillation
      Chronic Obstructive Lung Disease
      Essential Hypertension
      Mitral Valve Prolapse
      Artery to artery embolic stroke
      Thrombus formation on
      Atherosclerotic plaque in carotid
      Anticoagulation also reduces risk of embolism
      after acute Anterior wal Q wave MI
      A three month course is recommended
      Recent Myocardial Infarction
      Post Infarction Mural thrombosis
      Transmural Anteroapical MI
      Prophylactic anticoagulation
      Intracranial atherosclerosis
      In situ thrombosis or embolization
      Warfarin sodium and aspirin
      Intravenous Mannitol 100 ml 8 hourly for 3 days
      Oral Glycerin 30 ml TID orally or via Ryles tube
      Paradoxical embolization:
      Venous thromboses migrate to
      Arterial circulation via
      Cardiac Right to left shunt
      Atrial Septal Defect
      Patent Foramen Ovale
      Urinary tract infections
      Valvular Endocarditis
      Valvular Vegetations
      Multifocal symptoms and signs
      Small microscopic infarcts or
      Large septic infarcts brain abscess
      Hemorrhagic Infarcts
      A greater degree of anticoagulation is indicated for
      Prosthetic valve Thrombosis
      Combination of antiplatelets advantageous
      Search for evidence of cardio embolic stroke
      Investigate with ECG, Chest X Ray and Echo
      Consider anticoagulation with PTT INR control
      Confirmation by Trans esophageal Echocardiography
      Presence of a venous source of embolus
      of right to left cardiac shunting
      Rehabilitation of stroke patients
      Physical, speech, and occupational therapy
      Education of the patient and family
      Prevention of complications of immobility
      Search for risk factors for stroke
      Hypertension, Diabetes, Smoking, Dyslipidemia
      Asymptomatic or symptomatic carotid stenosis
      Relative risk reduction with treatment
      Balloon Angioplasty with Stenting is the alternative
      Surgical treatment restricted to Carotid Endartectomy
    • ACUTE HEMORRHAGICIC STROKE EM 15
      Assessment
      New onset of Neurological Deficit
      Headache, projectile vomiting
      Non contrast Head CT scan
      Hypertensive Intra-parenchymal hemorrhage
      Spontaneous rupture of a small penetrating artery
      Common sites are basal ganglia, putamen, thalamus
      Sometimes the pons and the cerebellum
      Blood pressure to be lowered if
      Malignant Hypertension
      Concomitant Myocardial Ischemia
      Blood Pressure >180/110 mmHg
      Care of comatose patients
      Ryles tube feeding
      Adequate calorie & fluid intake
      Intravenous Mannitol 100 ml 8 hourly for 3 days
      Oral Glycerine 30 ml TID orally or via Ryles tube
      Water restriction but avoiding hypovolemia
      Start Amlodipine 2.5mg BID or
      Tablet Nifedipine 10mg BID
      Titrate to keep BP At 150/90
      Consider catheterization
      Ensure good urine output
      Frequent change of position
      50% of patients die
      <30ml Good, 30-60ml intermediate, >30ml poor
      Attention directed towards
      Common complications of
      bedridden patients
      Respiratory tract infections
      Urinary tract infections
      Pressure sores
      DVT and Pulmonary Embolism
      Monitor Blood Sugar regularly
      Keep RBS value below 200mg%
      Fever detrimental
      Use antipyretics as indicated
      If unmonitored, can be harmful
      Even precipitate a VT or VF
      Do not repeat the procedure
      Evacuation of hematoma helpful only in cerebellar
      Sub Arachnoid Hemorrhage
      Neurosurgical intervention is necessary
      by craniotomy and external clipping
      of the bleeding vessel or aneurysm
      During this waiting period medical treatments
      to control blood pressure, bed rest, and
      a quiet environment reduce the risk of rebleed.
      Nimodipine is an oral calcium channel blocker,
      that has been shown to reduce the chance of a bad outcome,
      even if it does not significantly reduce
      the amount of angiographic vasospasm.
      Or by interventional radiology (neuroradiology),
      which employs transfemoral angiography
      and inserting of metal coils to stem the bleeding
      (which is especially useful in aneurysmatic hemorrhage).
      Balloon Angioplasty with Stenting is the alternative
      Surgical treatment restricted to Carotid Endartectomy
    • ACUTE SUBARACHNOID HEMORRHAGE EM 16
      Assessment
      Sudden onset of severe headache
      Lethargy, coma, low back pain
      No focal neurological deficit in the beginning
      Nuchal rigidity, positive Kerning sign
      Retinal hemorrhages ( sub-hyaloid)
      Rebleeding 20% at two weeks
      Vasospasm and neurological deficits (days 4-14)
      Blood pressure to be lowered if
      Malignant Hypertension
      Concomitant Myocardial Ischemia
      Blood Pressure >180/110 mmHg
      Care of comatose patients
      Ryles tube feeding
      Adequate calorie & fluid intake
      Non contrast CT scan head
      Lumbar puncture: Uniformly blood stained
      Xanthochromia on immediate centrifugation
      Start Amlodipine 2.5mg BID or
      Tablet Nifedipine 10mg BID
      Titrate to keep BP At 150/90
      Consider catheterization
      Ensure good urine output
      Frequent change of position
      Intravenous Mannitol 100 ml 8 hourly for 3 days
      Oral Glycerine 30 ml TID orally or via Ryles tube
      Water restriction but avoiding hypovolemia
      Attention directed towards
      Common complications of
      bedridden patients
      Respiratory tract infections
      Urinary tract infections
      Pressure sores
      DVT and Pulmonary Embolism
      Ruptured berry aneurysm
      Fusiform aneurysms
      secondary to atherosclerosis
      Mycotic aneurysm
      Resulting from septic embolism
      Hypertensive hemorrhage
      Arteiovenous malformations
      Contrast CT or MRI useful in demonstrating
      Cerebral angiography (DSA) needed pre-surgically
      Neurosurgical intervention is necessary for Berry aneurysm
      Timing of surgery after SAH is controversial
      Depends on clinical condition
      During this waiting period medical treatments
      to control blood pressure, bed rest, laxatives and
      a quiet environment reduce the risk of rebleed.
      Nimodipine is an oral calcium channel blocker,
      that has been shown to reduce the chance of a bad outcome,
      even if it does not significantly reduce
      the amount of angiographic vasospasm.
      Or by interventional radiology (neuroradiology),
      which employs transfemoral angiography
      and inserting of metal coils to stem the bleeding
      (which is especially useful in aneurysmatic hemorrhage).
      Nimodipine Dose is 60 mg PO QID
      Surgical treatment restricted to Carotid Endartectomy
    • SEIZURES EM 17
      Assessment
      ABCs / Vital signs/ Oximetry
      Continuos ECG monitoring
      Place a soft plastic airway
      Administer oxygen by mask
      Insert a large bore IV line
      Ideally two one being dextrose free
      Glucometer <60mg%
      Administer Thiamine 100mg IV
      folloewed by 50ml 50% dextrose
      Laboratory analysis:
      Blood sugar, Urea, Creatinine
      Serum Electrolytes
      Urine analysis, and drug screen
      Antiepileptic drug levels
      RBS
      Parenteral anticonvulsants
      indicated if status epilepticus
      Patient pregnant High BP
      See pre-eclamsia protocol
      High BP
      Lorazepam 0.1mg/kg at 2mg
      Per minute up to 4mg
      Diazepam 0.2mg/kg at 5mg
      per minute up to 10 mg
      OR
      Short duration of action of
      These drugs necessitate
      maintenance anticonvulsants
      Phenytoin Sodium
      Preferred maintenance drug
      Loading dose 20mg/kg
      Watch for arrhythmias
      and hypotension
      Benzodiazepine infusion
      A preferable option in some
      maintenance anticonvulsants
      See shock protocols
      The maximum rate of infusion
      is 50mg per minute and a large
      bore IV line with dextrose free
      fluid used to prevent precipitation
      Respiratory depression
      may require intubation
      And assisted ventilation
      Phenobarbitone 20mg/kg
      at the rate of 50mg/minute
    • Thank You for the patient listening