3. Aim:
To have clear conception of Medical emergency
To have an idea of the referral system of the
patients
To be rational in the use of drugs
To be rational in sending investigations
To ensure better follow up of the patients
5. Through M.O.P.D Through Emergency
Alive
With
NOD
Without
NOD
Brought dead
Psychiatric/
Functional
Non
psychiatric
Admission
During Office
Hour
Beyond
Office Hour
Transferred/Referred
NOD= No Official Delay
MOPD= Medicine out patient department
6. During Office Hour:
Patients come through MOPD, Outdoor and
sometimes they are transferred from different wards.
Patients coming through emergency may have NOD
note or may have admission ticket
7. In Case of NOD
1. Rush to the patient without any delay
2. Examine the patient, specially, vital signs (Pulse,
Heart sound, Pupil, Planter reflex) to see
whether the patient is alive or Dead
3. If you find the patient dead, show your sincerity
to the attendants during examination though
you are clinically certain that the patient is dead.
4. If found dead clinically, talk to the
attendant/relative (specially with the 1st degree),
start counseling. Tell them that your are almost
sure about the death of the patient, and Now
going to do an ECG just to confirm it!
8. 5. Then do the ECG (This time, the Long Leads only)
6. If straight line is found, then address the EMO and
declare the patient dead as Brought dead
9. If the patient is found gasping on the trolley, don’t
waste time for the bed-head ticket to be available!
Rather, immediately start the treatment with
whatever resources you have.
Never forget to measure CBG of
the Patients!
10. If CBG is found within normal range, you should be
very much cautious regarding examination and
diagnosis.
12. SIMULATED COMA
Psychologically disturbed patients sometimes feign coma. The eyes are
actually closed and the patient is usually lying in a resting position, or supine
with the arms and legs extended.
The eyelids resist attempts to open them
On forced eye opening, the eyes point upwards exposing
the white conjunctiva (Bell's phenomenon) as part of
the patient's attempt to maintain eyelid closure.
The eyelids close rapidly when released. The slow roving
eye movements of organic coma cannot be simulated.
Painful stimuli to the limbs may be ignored, but pinprick to
the nasal mucosa or to the lips usually elicits volitional
grimacing. The pupillary light reflex is normal, as are
plantar responses.
13. Cold caloric testing induces nystagmus with
the fast phase away from the stimulated side,
rather than deviation of the eyes toward the
stimulus as would occur in true coma.
Examination, especially invasive tests as above,
may induce a return of cooperation and
consciousness, or uncover a disturbed mental.
(This is not practised in the ward)
14. Psychogenic
Hyperventilation,
Respiratory distress
Features:
1. May complaints of
Light headedness
2. When excessive,
tingling and numbness
of limbs with
carpopedal spasm may
occur due
hypocalcaemia
resulting from
Respiratory alkalosis
3. X-Ray and ECG is
normal
Features:
1. Typically can locate
exactly with his/her
own hand,
particularly one
finger!
2. On pressing over the
point, shout/cry out
due to pain!
3. X-ray and ECG
(Tachycardia only) is
normal
Severe Chest Pain Acute Mutism/
Unconsciousness
Features:
1. Typical eyeball
movement with
closure of eyelids!
2. Few maneuver
(NG tube insertion
etc) may not be
needed to treat
them!
In case of Functional disorder/Anxiety disorder/Acute stress disorder
coming with NOD, Pseudo emergency may occur, like:
15. Just feel the pulse, hear the Heart sounds and
look for pupillary reflex to make the attendants
think that your are taking the case seriously
Then, address the EMO to admit the patient in the
word
Meanwhile, send one of the attendants to bring
some drugs (Just to make the attendants busy,
other wise, they will make you Busy!)
Start counseling the attendants
Don’t talk/make any comment in front of the
patient regarding your diagnosis (as it may cause
exacerbation of symptoms)!
16. Management of the Patient:
In case of Functional disorder, I.V. drugs are given
(or, sometimes need to be given) to make him/her
think that treatment is started appropriately.
Drug list should include:
I.V. canula 20G
JMS infusion set
1 inch Micropore
Inj. 5% DNS (If non diabetic)
Inj. Omeprazole
Inj. Dormicum/Inj. Haloperidol (suspecting that the
patient may be restless or violent!)
17. Contd……..
Sometimes, only oral medication is enough to treat
the patient specially at night, when Staff nurses are
few in number
Intravenous management is troublesome.
So, there is no reason to engage the sisters in treating
those patient, rather we should think for really
critically ill patients.
In that case, the medication will be:
Tab. Clonazepam (0.5mg ) /Tab. Midazolam 7.5 mg
1 Tab. stat and then 0+0+1
Cap. Omeprazole (20mg)
1+0+1 [½ hr A/C]
Actually, it is the clinical condition and patient’s
surrounding, which will lead you to the treatment.
18. Consciousness is a state of normal cerebral activity in
which the patient is aware of both self and
environment and is able to respond to internal
changes, for example hunger, and to changes in the
external environment.
Altered consciousness resulting from brain disease
may take the form of a confusional state, in which
the patient's alertness is clouded; this is associated with
agitation, fright and confusion, i.e. disorientation.
Such patients usually show evidence of misperception
of their environment, and hallucinations and
delusions may occur.
19. Confusional states must be carefully distinguished
from aphasia, in which a specific disorder of language
is the characteristic feature, and from continuous
temporal lobe epilepsy, a form of focal status
epilepticus in which the behavioural disorder is often
accompanied by aphasia if the epileptic focus is left-
sided. Usually this can be recognized by the
occurrence of frequent but slight myoclonic jerks of
facial and especially perioral muscles, and by
variability in the patient's confusion from moment to
moment during the examination. Always pause and
observe an unconscious or drowsy patient for a few
moments before disturbing them.
20. Abnormal drowsiness is often found in patients with
space-occupying intracranial lesions or metabolic
disorders before stupor or coma supervenes. The
patient appears to be in normal sleep but cannot easily
be wakened and, once awake, tends to fall asleep
despite verbal stimulation or clinical examination.
Further, while awake such patients can usually be
shown to be disorientated. Higher intellectual
function, such as the ability to perform abstract tasks
or to make judgements, is disturbed. Stupor means a
state of disturbed consciousness from which only
vigorous external stimuli can produce arousal. Arousal
from stupor is invariably both brief and incomplete.
21. Pupil:
Pupillary size and responsiveness to a very bright unfocused
light beam (not the light of an ophthalmoscope) should be
noted. If the pupils are unequal, a decision as to which is
abnormal must be made. Usually the larger pupil indicates the
presence of an oculomotor (third) nerve palsy, whether from
damage to the oculomotor nerve by pressure and displacement
or from a lesion in the mesencephalon itself.
Occasionally the smaller pupil may be the abnormal one, as in
Horner's syndrome. If the larger pupil does not react to light it is
likely that there is a partial oculomotor nerve palsy on that side.
If the smaller pupil also fails to react to light this may be the
midposition pupil of complete sympathetic and parasympathetic
lesions, indicating extensive brainstem damage
22. In drug-induced coma and in most patients with
metabolic coma the pupillary responses to light are
normal.
Exceptions to this rule are glutethimide poisoning and
very deep metabolic coma, in which the pupils may
become dilated but only rarely become unreactive to
light. In pontine and in thalamic haemorrhage the
pupils may be very small (pinpoint pupils) and
unreactive to light.
23. Bilateral pinpoint pupils occur with brainstem lesions, opiate and
other drug intoxications, and with pontine infarction
There is ptosis, dilatation of the pupil with absence of the light
reaction, and slight lateral deviation of the eye.
24. There is ptosis and a small reactive pupil
The eyes tend to 'look towards the tip of the nose' and the pupils are
small; later they become large and unreactive as upper brainstem
involvement follows
26. When brainstem death occurs the midbrain disturbance is
manifest by midposition, fixed (unreactive) pupils with eye
closure
27. PATTERN OF BREATHING
Alterations in the rhythm and pattern of breathing are
an important aspect of the assessment of the
unconscious patient.
28. CHEYNE-STOKES (PERIODIC) RESPIRATION
In Cheyne-Stokes respiration, breathing varies in regular
cycles. A phase of gradually deepening respiration is
followed, after a period of very deep rapid breaths, by a
phase of slowly decreasing respiratory excursion and rate.
Respiration gradually becomes quieter and may cease for
several seconds before the cycle is repeated. Depressed
but regular breathing at a normal rate occurs in most
drug-induced comas, but Cheyne-Stokes respiration can
occur in coma of any cause, especially if there is
coincidental chronic pulmonary disease. Cheyne-Stokes
breathing in a comatose patient is a sign of a large
unilateral space-occupying lesion with brainstem distortion,
for example subdural haematoma, or of bilateral
lesions from other causes, for example cerebral
infarction or meningitis.
29. KUSSMAUL RESPIRATION
Deep, rapid sighing breathing at a regular rate should
immediately suggest metabolic acidosis. Metabolic
or uraemia is the commonest cause of this acidotic
(Kussmaul) breathing pattern, but a similar pattern
may occur in some patients with respiratory
failure, and in deep metabolic coma, especially
hepatic coma.
30. CENTRAL PONTINE HYPERVENTILATION
Deep, regular breathing may also occur with rostral
brainstem damage, whether due to reticular pontine
infarction or to central brainstem dysfunction
secondary to transtentorial herniation associated
with an intra- or extracerebral space-occupying
lesion. This breathing pattern is called central
neurogenic (pontine) hyperventilation. Interspersed
deep sighs or yawns may precede the development of
this respiratory pattern.
31. Rapid shallow breathing occurs if central brainstem
dysfunction extends more caudally to the lower pons.
When medullary respiratory neurons are damaged, for
example by progressive transtentorial herniation,
irregular, slow, deep gasping respirations, sometimes
associated with hiccups (ataxic respiration), may
develop. In patients with raised intracranial
pressure, this sequence of abnormal breathing
patterns is often associated with other evidence of
brainstem dysfunction, including a rising blood
pressure, a slow pulse, flaccid limbs, absence of
reflex ocular movements and dilatation of the
pupils.
32. Changing patterns of respiration in an
unconscious patient, particularly the development
of central neurogenic hyperventilation, provide
important and relatively objective evidence of
deterioration. These changes in respiratory pattern
may occur in structural lesions with raised
intracranial pressure, in brainstem infarction, and
less commonly in some varieties of metabolic coma,
especially hepatic coma. They are indicative of
progressive and potentially fatal brainstem
dysfunction, but not of its causation.
33. Now, let us come back to the
patient that has just entered
into the ward!
34. Meanwhile, counseling should be done
simultaneously regarding the prognosis of the
patient.
Try to show pessimistic attitude to the attendant
(Specially when you can understand that the
patient is going to expire very soon)
After initial resuscitation, try to refer the case to
the respective discipline (When indicated), e.g.
CCU/ICU/Nephrology/Neuromedicine etc. (in the
office hour only).
35. Medically unexplained somatic
symptoms
Patients commonly present to doctors with somatic symptoms.
Whilst these are often clearly associated with a medical
condition, in other cases they are not. Symptoms may be
disproportionate to, or occur in the absence of, a medical
condition and are then often referred to as 'medically
unexplained symptoms' (MUS). MUS are very common and
occur in a quarter to a half of patients attending general
medical outpatient clinics. Almost any symptom can be
medically unexplained and common examples include:
pain (including back, chest, abdominal and headache)
fatigue
dizziness
fits, 'funny turns' and feelings of weakness.
36. Patients with MUS may receive a medical diagnosis of
a so-called functional somatic syndrome, such as
irritable bowel syndrome and may also merit a
psychiatric diagnosis on the basis of the same
symptoms. The most frequent psychiatric diagnoses
associated with MUS are anxiety or depressive
disorders. When these are absent, a diagnosis of
somatoform disorder may be applied
37.
38. Cardiac
Emergency
(Non functional)
Gastro
May involve various systems of the body alone, or simultaneously
Respiratory Endocrine
Infection Haematological CNS
Poisoning
Venomous
snake bite
OPC
poisoning
Renal
Others
Through
Outdoor
Transferred
/Referred
39. Cardiac
Respiratory
Gastro
Endocrine
Infection
Haematological
CNS
Shock, LVF, MI, CHB, Hypertensive Crisis
Severe CAP, Acute severe asthma/COPD,
Tension pneumothoraxResp. failure , Ex. of
COPD, Cor-pulmonale
Severe acute Pancreatitis, EV rupture,
Severe hemoptysis, Hypo. Shock,
Perforation, Acute abdomen
DKA, Hypoglycemic attack, HONK,
Addison’s crisis,
Septicaemia, shock, Severe malaria
Septicaemia, shock, anemic heart failure
Encephalopathy, Stroke , Meningitis,
Encehalitis, GBS with resp. distress/failure,
Status Epilepticus etc.
Emergency patients commonly admitted in wards (Except poisoning)
are:
Renal
ARF, Ureamic encephalopathy, LVF,
Metabolic acidosis etc
40. When patient comes through M.O.P.D
Usually these patients are admitted with some
chronic disease, e.g. PUO and sometimes may be
presented with acute exacerbation, e.g. Huge
ascites in case of CLD, Constipation/vomiting in
Ca-stomach etc.
Take proper history and fine out the causes of
their admission this time, i.e. presenting
complaints
Start thorough physical examination.
Share your findings to your colleagues
42. On Bed head Ticket
Fill up the front page with-
(Necessary for disease profile and some Medico-legal condition)
Name of the patient:
Age:
Sex:
Address:
Provisional Diagnosis
Date and Time:
Doctor’s Signature (Preferably name)
43. On next page:
Presenting complaints: (Try to avoid mentioning
more and irrelevant/non specific complaints)
1.
2.
3.
History of present Illness: (Here, the modified
salient feature should be written to save time)
Which should include:
Elaboration of positive findings
Mentioning of Important negative findings
Mentioning risk factors/co-morbid conditions
44. On physical examination:
Try to mention the findings concisely, such as:
Appearance
Build
Anaemia
Jaundice
Cyanosis
Clubbing
Edema
Ascites
Dehydration
Pulse
BP
Temp
Heart
Lungs
GCS
Pupil
Planter reflex:
Deep jerks
Neck rigidity
Kernig’s sign
Engorged vein
Lymphadenopathy
* Sometimes, additional findings
should be noted in some particular
diseases
45. Provisional diagnosis:
Try to be specific
Broad term can be used otherwise, e.g. Anaemia
under evaluation, Acute febrile Illness, Acute
Confusional State etc.
Never write the abbreviated form, like ACS, DVT, RA
etc.
As soon as you are confirmed, try to mention the
latest Diagnosis and omit the previous one.
Try to avoid confusing terms, e.g. Shock, Chest pain,
Respiratory distress, Abdominal pain etc.
46. Before sending Investigations, seek their previous
reports.
Always ask your senior colleague regarding
investigations, because, it will reduce
unnecessary wastage of time and money
Always ask the reason of sending the particular
investigations to your respective senior colleague
Try to learn, in short, the basic pathogenesis of
the disease, and go through the text later on.
Try to know the next plan of investigation
Treat the patient according to the diagnosis
47. Adv:
CBC
Urine R/M/E
CXR P/A view
Blood Urea
Serum Creatinine
Serum Electrolytes
USG of Whole Abdomen
Next Plan:
CT scan of Brain
CT guided FNAC
USG guided FNAC
Endoscopy of UGIT etc.
O/A on Date at Time:(Sample)
Diet: NBM/Liquid/Soft/Normal/Diabetic/Salt and fluid
restricted/Protein restricted etc.
Bed rest in Propped up/Lateral/Semiprone position
O2 Inhalation 2L/min SOS
Inj. N/S 1ooo cc I.V. @ 1o d/min (If I.V. antibiotic to be given)
Inj. 5% DNS I.V. @10 d/min ( If not known to be diabetic and
CBG is normal)
Oral/ Inj. Antibiotic………..
Oral / Inj. Omeprazole (40mg) + 9cc D/W I.V. 12 hourly
Oral Anti pyretic [If febrile]
Oral anxiolytic (less potent)
Suppository antipyretic SOS [If fever > 102˚ For more]
Condom/Foley’s catheter [ In case of bed ridden patients]
Please monitor Daily I/O
Please monitor all vital signs regularly
Name of Doctor
Date: ……..
N
49. If the patient is to be
kept NBM
If Non diabetic
If Parenteral Nutrition
is to be given
Total 2500-3000 ml of
fluid to be given
Inj. 5% DNS 1000
cc+ Inj. Regular
Insulin (U-100)
or Other soluble
Insulin 10 units
I.V @ 25-30
drops/min
If Diabetic
Inj. 5% DNS 1000
cc I.V @ 25-
30drops/min
Fluids
Others
Vitamins and
Electrolytes
1. Inj. Vit B complex
2. Inj. Vit C
3. Extra electrolytes
according to
severity and
deficiency
Special condition deserves special
fluids therapy
If NG tube feeding is
to be given
[150 ml×2 hourly×10
feedings]
Special Milk; Dal;
Soup; F. Juice; Dub
water; etc
The rest of the
fluid should be
replaced by I.V
50. Half Neuralization in Diabetic patients:
InJ. 5% DA/ Inj. 5 % DNS contains 5 gm of Glucose per
100 ml, so 1000 ml of those fluids contain 50 gm of
glucose.
1 U of soluble insulin can neutralize 2.5 gm of glucose
Therefore, full neutralization of 5% DNS 1000 ml
requires (50÷2.5)= 20 U of insulin.
So, half neutralizaton requires 10 U of Insulin
51. If patient is to be kept NBM for prolonged period,
Intracellular fluid requirement should be met with 5%
DA 500 or 1000 cc.
Sometimes, IV amino acids and fatty acid solutions
are given in selected patients along with vitamins.
52. Points to be remembered:
Patients having any kind of respiratory distress = No
normal diet, rather liquid to soft diet should be given
Acute abdomen due to any cause = NBM+ No NG feeding
First few hours in Acute stroke = NBM+ No NG feeding
If aspiration is suspected = NBM+ No NG feeding for at
least 48 hours
Any kind of shock = NBM+ No NG feeding
Unconsciousness patient= No NG in first few hours
Any kind of Poisoning = NBM+ No NG feeding
54. Oxygen should be prescribed to achieve a target
saturation of 94–98% for most acutely ill patients or
88–92% for those at risk of hypercapnic respiratory
failure.
Sometimes, Low dose O2 and High Dose O2 supply is
needed
Low dose means 24-28% O2
Higher dose is required in LVF, Shock, Severe
bronchial asthma etc.
Sometimes 100% O2 is required, prior to intubation
55. O2 % Way of O2 supply
O2 in
L/min
O2 in
L/min
O2 in
L/min
24 Venturi
mask
2-4 Nasal
cannulae
1
28 Venturi
mask
4-6 Nasal
cannulae
2
36 Venturi
mask
8-10 Nasal
cannulae
4
40 Venturi
mask
10-12 Simple
face mask
5-6
60 Venturi
mask
12-15 Simple
face mask
7-10
64. All unconscious patient(Except hypoglycaemia)=
Normal saline
All AWD patients with/Without shock = Cholera saline
until renal failure. If pre-renal ARF is suspected
(clinically), switch over to Normal saline
In any hyperglycameic patients = Normal saline
Vomiting leading to hypovolaemia = Hartsol/
Hartsmann
There is also pre-surgical/post-surgical indication of
various fluid (But, unusual in our ward)
Again, clinical condition and further
investigation will lead us to the selection of
fluids
66. No scope of H2 blocker except allergic reaction
PPI is preferred
Avoid Omeprazole in Pregnancy, Multi organ failure,
renal impairment etc.
Esmoprazole is better in GERD
Pantoprazole is preferred in patients having multiple
drugs chronically
Last, but not the least, we have to consider the socio-
economic condition before choosing the correct drugs
68. Things to be considered:
Irrational use should be avoided
Avoid I.V. route where oral one is sufficient
Choose I.V. in case of septicaemia, shock, aspiration
pneumonia, Acute abdomen (Intestinal obstruction,
along with other suspected GI infection)
Usual site of Colonization of micro-organism should be
taken in consideration, e.g. No Metronidazole in UTI etc.
Proper duration should be maintained
Consider low but effective dose initially
Again , we have to consider the socio-economic
condition before choosing the correct drugs
Always ask your seniors prior to selection
70. Consider in any bed ridden patient
In any patient with shock
Any unconscious patient
Any patient with acute retention
Clinical condition will lead us to the selection of catheter
(Foley’s /Condom)
Patient with restlessness with condom cathether
in situ with oliguria should have Foley’s catheter
In patient with BEP with unconsciousness =
Foley’s catheter
Patients of OPC poisoning = Foley’s catheter etc.
71. Referred or Transferred Patients:
They are usually diagnosed
Due to newly developped complication related with
medicine, they are transferred.
Don’t be fixed on the previous diagnosis written in the
file, rather,
Take proper History and do physical examination to re-
evaluate the case and to find out exactly what happened
during hospital stay
Discuss with the senior colleague and, if needed with the
consultant regarding further management of the
patient.
Advise investigations, depending on the complication
after discussing with the senior
73. Investigation Profile*:
When maximum investigations are available, formulate them into an Investigation
Profile in the following way:
1. CBC:
Hb
ESR
TC
DC
N: %; L: %; E: %; B: %
Atypical cells:
2. Urine RE:
Pus cell:
Epi cell
RBC
RBC Casts
Albumin:
Sugar
3. CXR P/A view:
4. USG of W/A:
5. Endoscopy of UGIT:
6. S. Creatinine:
7. S. Electrolytes:
8. S. Bilirubin
9. Liver function tests:
S. Bilirubon:
SGPT:
SGOT
PT:
Alk. Phosphatase:
S. Albmin
10. Viral Markers:
HBsAg:
Anti HBcAg IgM antibody:
Anti HCV antibody
Anti HEV antibody:
Anti HAV antibody
CT scan of Brain:
MRI of Brain/Cervical spine
X-Ray of DLS (A/P, Lateral view)
X-ray cervical spine all views( Including
Oblique)
* Printed form for Investigation Profile is available
81. Follow up On Date at Time:
S
P
A
O
New drugs to be added
Old drugs be omitted/Altered
New Investigations to be given
Compare the condition with the previous day
Improvement/Static/Deterioration
Pulse
BP
Temp
Heart
Lungs
Complaints on that particular time :
Fever
Abdominal pain
Vomiting
Generalised weakness etc.
GCS (In particular patients)
Bowl
Bladder
Intake
Output
82. Some special conditions demand more detail follow-
up, e.g. Grading of Hepatic Encephalopathy (on that
day), Appearance, Measurement of Body weight and
abdominal girth etc.
83. You should ensure the drugs (by the nurse, or,
sometimes, yourself!) written in the Treatment
sheet on the very beginning!!!!!
84.
85. Everyone should present during round
Gather all the necessary investigation reports before
the round starts
Evacuate the attendants from respective beds prior to
round and allow only the concerned one to stay in case
of Terminal/ unconscoious/Disoriented/Bed ridden
patient
Do not rely completely ( and, thus formulate your plan
of investigations or treatment) on the diagnosis made
earlier, e.g., during night.
Try to listen what the consultant discuss about the
respective beds
Later, discuss with the senior colleague regarding
further plan, Fresh order etc.
