Emergency Medicine Protocols

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Contains Algorithms on All important emergency medical conditions

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Emergency Medicine Protocols

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

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