Low resource setting management

1. Curriculum
1. Stroke Mx in Low Resource Setting
2. Acute Unconsciousness Mx in Low
Resource Setting
3. Status Epilepticus Mx in Low
Resource Setting
4. Acute Paraparesis Mx in Low
Resource Setting
5. Acute Meningo-Encephalitis Mx in
Low Resource Setting
6. Head Injury Mx in Low Resource
Setting
7. MI & UA Mx in Low Resource
Setting
8. Acute Severe Chest Pain Mx in
Low Resource Setting
9. Acute SOB Mx in Low Resource
Setting
10. Hypertensive Emergency Mx in
Low Resource Setting
11. Acute Abdomen Mx in Low
Resource Setting
12. Acute GI Bleeding Mx in Low
Resource Setting
13. Acute Diarrhoea, Vomiting Mx in
Low Resource Setting
14. Acute Anuria/Urinary Retention
Mx in Low Resource Setting
15. Shock Mx in Low Resource Setting
16. Acute Poisoning Mx in Low
Resource Setting
17. Snake bite Mx in Low Resource
Setting
18. Fracture Mx in Low Resource
Setting
19. RTA Mx in Low Resource Setting
20. Na & K Mx in Low Resource Setting
21. Acute Hyper & Hypoglycaemia Mx
in Low Resource Setting
22. Acute Psychosis Mx in Low
Resource Setting
23. Antibiotic Choice in Low Resource
Setting
24. Handling Arrogant Attendant
25. Handling VIP & Politically Powerful
Pt./Attendant

3. mRS Score: CMS Customization
ক োন ধরণের করো করোগী উপণেলোয় ম্যোণনে
রণেন?
• 0 – No Symptoms
• 1 – Can do all ADL
• 2 – Can’t do all ADL
• 3 – Can’t do selfcare
• 4 – Can’t walk
• 5 – Bed bound
• 6 – Dead
• NB: ADL = Activities of Daily Life
• MRS 0 – 3 can be managed @ Low Resource Setting after CT Scan & Cause Evaluation

5. High vs Low Risk NSTE ACS (TIMI Score)
ক োন ধরণের MI করোগী উপণেলোয় ম্যোণনে
রণেন?
Mnemonic: ABC (Score 1 for each point)
• A = Age > 65
• A = Aspirin (Receiving Aspirin – Criteria of Aspirin fulfilled previously)
• A = Angina – two episode in last 24 hr
• B = Biomarker – Raised Trop I (NSTEMI, not UA)
• C = CAD (Known case of CAD)
• C = CAD Risk (3 out of 5 – HTN, DM, Dyslipidaemia, Smoking F/H of CAD)
• E = ECG Changes
• High Risk: 4 or above, should get LMWH, Score < 4 can be managed in Low Resource
Setting as no injectable drugs needed
• Condition: Repeat ECG in every 3-6 hr should be non deteriorating.

6. Acute SOB: Metabolic or Non Metabolic
CMS Differentiation
Metabolic Breathing
• Rate – Low
• Depth – High
• SpO2 – Normal
• Chest – Normal
• Check dehydration, RBS (DKA),
Vision (MP), BP (CKD, DKA), Lactate
• Prepare for HD
Non Metabolic Breathing
• Rate – High
• Depth – Low
• SpO2 – Low
• Chest – Normal/Abnormal
• Auscultate Chest, if normal Check
GCS, Deep Tendon Reflex, Plantar
Reflexes
10/8/2022 6

7. Acute SOB: Metabolic or Non Metabolic
ক োন ধরণের SOB করোগী উপণেলোয় ম্যোণনে
রণেন?
• SOB due to cardio-respiratory cause – Hemodynamic should be
stable, O2 req. < 10 L/min
• SOB due to Neurological Cause (Medulla, Cervical Cord, Phrenic
Nerve, Diaphragm) – All pt. must be referred
• SOB due to metabolic cause – Pt. not needing Haemodialysis (HCO3 >
17

8. Convulsion Mx in Low Resource Setting
নভোলশন করোগী উপণেলোয় ীভোণে ম্যোণনে
রণেন?
• Step 1: PR Diazepam (Easium Suppository), wait 10 min
• Step 2: Repeat PR Diazepam (Easium Suppository), wait 20 min
• Step 3: 9 Phenytoin/6 Phos-phenytoin/6 Barbiturate tablets in NG/PO stat.
Wait 60 min
• Step 4: Midazolam 5 mg IV stat, repeat 2 more doses (5 mg in each dose)
• Step 5: Refer to HIGHER Center with PRIMARY Mx of Underlying Cause

9. Unconsciousness without & with shock
Without Shock
• Brain – Vascular, Infection, Trauma
• Lungs – Type I or II Failure
• Liver – Hepatic Encephalopathy
• Kidney – Uremic Encephalopathy
• Thyroid, Heat Stroke
• Parathyroid
• Environmental
With Shock
• Heart – Cardiac Arrest, Cardiogenic
Shock – Modified MONAS Therapy
2
• Pituitary Apoplexy
• Thyroid – Myxoedema Coma
• Adrenal Crisis
• Blood – Endotoxin (Sepsis)
• Blood – Na Vomiting/Diarrhoea

10. Unconscious Pt stratification
ক োন ধরণের অজ্ঞোন করোগী উপণেলোয়
ম্যোণনণেেল?
Manageable
• Blood – Na, Endotoxin,
• Glands – Pituitary,
• Myxedema Coma, Thyroid Storm
• Parathyroid – Hypercalcemia
• Pancreas, Diabetic Complication – Hyper & Hypo
• Adrenal – Addisonian Crisis
Unmanageable
• Brain – Vascular, Infection, Trauma, Tumor
• Heart – Cardiac Arrest or Cardiogenic Shock
• Lungs – Type II Failure
• Liver – Hepatic Encephalopathy
• Kidney – Uremic Encephalopathy
• Blood – Specific Toxins

11. When to Refer Acute Myelopathy/ATM Pt. from LRS
কখন উপজেলা থেজক থেফাে কেজেন? CMS
Guideline
• Every pt. of Acute Myelopathy need to refer (Except those with normal X ray &
Normal MRI, but MRI is not available at LRS) from Low Resource Setting.
Besides
• Spinal Instability in X ray.
• Suspected Malignancy, Pott’s, Metastasis
• Mx before referral: 3 – 5 g IV Methylprednisolone, 1 g/day for 3 – 5 days.

12. Counselling before referral
Evaluation process is very expensive.
Needs at least 20,000/- tk investigations
• MRI of Dorsal spine with contrast with whole spine screening
• Compressive: TTT – TB, Tumour (Primary – BM, Metastasis), Trauma –
Blunt Trauma/Pathological Fracture – BMD, Vit D)
• Non compressive – MS/ADEM-CSF for OCB, IgG Index, Aquaporin 4,
Anti MAG Ab

13. When to Refer GBS Pt. from LRS
কখন উপজেলা থেজক থেফাে কেজেন? CMS
Guideline
1. RR > 24
2. SpO2 < 94%
3. Counting < 15 digit
4. Breath Holding < 10 sec
5. Unable to Blow from 6” distance
6. Absence of Upper Limb Jerks (Biceps, Triceps, Supinator)
NB: Biceps & Supinator Root C6, Triceps C7, Phrenic nerve root value C 3, 4. So
absence of UL jerks indicates the disease is ascending.

14. When to Refer Meningo-Encephalitis Pt. from LRS
কখন উপজেলা থেজক থেফাে কেজেন? CMS
Guideline
• Non responsive/static to Rx (After 120 hr of Antibiotic, Anti-viral, CS, phenytoin)
• Newly appearance/deterioration of focal signs
• Gradual deterioration of GCS/LOC (> 2 from baseline)
• Newly appearance/deterioration of Raised ICP: Systolic HTN, Brady, Papilloedema
Purpose of Referral
• CSF Study
• Neuro-imaging
• Exclusion of Chr. Meningitis – TBM

15. When to Refer Brain Abscess Pt. from LRS
কখন উপজেলা থেজক থেফাে কেজেন? CMS
Guideline
• Non responsive/static to Rx – 2 weeks
• Gradual deterioration of GCS/LOC
• Newly appearance/deterioration of focal signs
• Newly appearance/deterioration of Raised ICP: Full blown Raised ICP: Systolic
HTN, Brady, Papilloedema
Purpose of Referral
• Neuro-imaging
• Surgical Intervention

16. When to Refer Head Injury Pt. from LRS
কখন উপজেলা থেজক থেফাে কেজেন? CMS
Guideline
• Convulsion
• Vomiting
• Blurring of vision
• Focal Deficit
Examination
• Focal Sign – e.g. plantar extensor
• Systolic HTN, Pulse < 60, Papilloedema
• Mx during referral – 1st Dose Mannitol

17. Acute Diarrhoea Mx Approach in Low Resource
কখন উপজেলা থেজক থেফাে কেজেন? CMS
Guideline
• Assess Dehydration Status – 3%, 6%, 9% or > 10%
• Exclude oedematous state – Face, Chest, Abdomen, Led Oedema
• If no oedema – 2 L fluid in 15 min, If oedema – 1L in 30 min > gradual
increase with cautious evaluation of chest base/lung base
• Maintenance – After bolus, remaining fluid to be given in 24 hr
• Monitoring – Continue Fluid & measure Urine Output
• Diuresis - Add diuretics if fluid overload/5L +ve balance to achieve target
U/O 0.5 ml/kg/hr
• Maintenance Fluid to be added/NOT? Maintenance Fluid given if pt. NPO
• Refer – If Target OUTPUT not fill up in 6 hr, refer the pt. for dialysis.

18. Managing acute vigorous Vomiting Pt.
কখন উপজেলা থেজক থেফাে কেজেন? CMS
Guideline
Acute Projectile Vomiting
• Acute Projectile Vomiting with NORMAL ABDOMEN – must be referred
• ACUTE ABDOMEN – Start Initial Conservative Mx (নোণ নল, শশরোয় েল,
প্রস্রোণের ল), AXR, USG, then refer if immediate surgical intervention needed.
Acute Non Projectile Vomiting
• Check Abdomen, RBS, Urine Strip. If acute abdomen, refer after conservative mx
• If DKA/HONC – Refer if worsening of pt. even after a) 6 L fluid a day, (according
to dehydration), b) 6 U/hr Insulin (Till Sugar > 16.67, If lower, 3 U/hr), c) 60 – 100
mmol K after ECG recording d) LPT
• Weapon you must need for DKA Mx – Glucometer, ECG Machine, Urine Strip

19. CMS AKI Protocol: Summary of six steps
কখন উপজেলা থেজক থেফাে কেজেন?
CMS Guideline
1: Establish the diagnosis (as AKI by AKIN or RIFLE criteria)
2: Exclude post renal cause (obstructive uropathy by abdomen palpation, DRE & USG
of KUB)
3: StartFluid Resuscitation, stop unnecessary medication & send investigation
4: Monitor the Parameters of fluid overload (Pulse, Pulse oximetry, Pressure, CVP,
Bi-basal Creps & U/O)
5: StartIV Frusemide if no output with 5L +ve balance or evidence of fluid overload
6: If stillurineoutputsub optimal, acidosis increased, refer the patient for dialysis
Mx during/before Transfer: K Mx, Acidosis Mx