CARDIOLOGY

INTERVENTION ORDERS GUIDE LIST FOR EMERGENCY DEPARTMENT DOCTORS
possible to increase the contractility of the heart. The
Asytole: 1mg adrenaline (“1 adrenaline”) every 3 minutes
underlying causes of the APO also need to be treated eg:
+ 1 mg atropine x 3
Acute Myocardial Infarction
Hypertensive Emergency.
VT/VF: defib on pads, align apex. Clear. 360J, check
Ix: ECG, FBC, BUSE + Creat, PT/APTT, CE, GSH,
Prop up pt, calm the pt, give 100% O2 through HFM,
rhythm, 360, check, 360 then adrenaline 1mg,
Bedside TropT (to d/w senior Dr), ABG, CXR
titrate morphine (up to 0.1mg/kg) + Maxolon/phenergan,
Amiodarone 300 mg IV push
ECG: ST elevation +/- Q waves. R sided leads if consider
IV Lasix titrate according to BP, max dose 120 mg. KIV IV PEA/EMD: Tx as for K+ ↑. Give Excl pneumothorax,
Inferior AMI (changes II, III, aVf)
Lasix infusion 0.1 mg/kg.hr. Start IV GTN or Isoket
cardiac tamponade esp trauma / post-op. 6H/6T. Rapid
Rx: O2, CRIB, Aspirin 300mg chewed stat, then 100mg
accordingly. Starts inotropes preferably Dobutamine if
USS. If still no response & no help: Check premorbid
om [CI: Bleeding GIT, anemia ?cause], else Ticlopidine
patient in cardiogenic shock.
status, case sheet or ask family.
250mg (d/w Cardio), GTN S/L, Clopidogrel 4 tabs stat.
Call in Cardio MO
Intubate: Preoxy. Wear mask. ETT: Males: Size 7.5 to 20 -
CARDIOLOGY
22cm. Fem: Size 7.0 to 20 cm. Visualize, intubate, check
Major MI: add Morphine 5mg i/v + maxolon. S/C Clexane
0.1 mg/kg or IV Heparin 5000 u. Discuss with Cardio.
Chest pain
both lungs, SaO2, anchor (if difficult, use device).
IF AMI confirmed and no C/I to start IV Stretokinase, to
Causes: cardiac / pleuritic / musculoskeletal / lung
IV HCO3 50mls after 5 mins of resuscitation.
give IV Streptokinase 1.5 MUnits in 100 ml NS over 1
PMHx, recent ECG / CE.
hour. Close monitoring of Streptokinase complications
Ix: ECG (ST elevation, Q waves, then T inversion), CXR
and sequelae of AMI. (Hypotension / Vent Arrhythmias)
Rx: Analgesia depending on the pain score. Rx according
Refer to Cardio MO.
to cause of chest pain. Observe and repeat ECGs in Obs
Ward if necessary.
Time taken to first ECG+interpret must be < 10 minutes.
Decompensated CCF
Inx: FBC (infection), BUSE + Creat (renal failure), CE
(ACS), ABG (severity of gaseous exchange) , ECG
GENERAL MEDICINE
Alcohol intoxication
Ix: FBC, BUSE, alcohol toxicology level on police request
(document no alcohol swab used). Look for signs of
trauma. If suspected head trauma to consider CT scan if
RESUSCITATION
GCS low or presence of neurological deficit.
(ACS), CXR (infections and condition of heart / lungs);
Rx: Fluid maintenance , Valium 2mg, 2mg, 5mg for
Rx: Prop up patient, O2 to achieve SpO2 > 95%.
Collapse / CPR
Delirium tremors.
IV Lasix 40-80mg x 1. CBD and I/O chart. For admission.
A/B : 100% O2 BVM, Dentures, Oral airway. Synchronize
Folate 10mg, Vit B Co, Thiamine 30mg
with breaths if breathing.
If violent / dangerous, police assistance required.
Acute Heart Failure (Ac Pulm Oedema)
C: No pulse = pump 30:2. IV access + Blood Inx. Monitor
Ix: FBC, BUSE+Creat, CE, PT/APTT, ABG, CXR, ECG
continuous rhythm monitoring. BP on Auto 3 minutes. IV
Rx : Aim is to redistribute the fluids peripherally as well as N/S 1Θ fast. Blood for ABG baseline stat.
reducing load to the heart by reducing the fluid volume. If
EMERGENCY DEPARTMENT RESOURCE BOOK Valid until next review Jan 2011
INTERVENTION ORDERS GUIDE LIST FOR EMERGENCY DEPARTMENT DOCTORS
Allergic reaction (acute)
Hypotension
Potassium - High
Stop offending medication / substance / food (if known),
Ix : FBC, BUSE+Creat, PT/APTT, CE, ECG, ABG, GXM
Ix: ECG(Tall T,wide QRS, small P), BUSE+Creat, VBG
secure airway if pending obstruction, Neb Ventolin 1:3 if
Treat the hypotension according to perceived cause
More leeway(add ≈0.5) in: ESRF, recent AMI, “lysed”
wheezing. If Anaphylactic shock, IV Adrenaline 1 mg
Fluid resuscitation:
Rx: > 5.0: Find reversible causes and treat
diluted to 10 ml; give 3 mls watch for response. Repeat.
Order 1Θ N/S(no K+) fast (1L in 15 minutes). You can
> 5.5: Dext 10% 500 mls with 10 U Insulin over 30 mins
Oral Rx: Piriton 1st dose stat, predisolone 10-30mg
choose to mix crystalloid and colloid.
> 6.0: Neb Salbutamol 5 mg; NaHCO3 50 mls if [H+] ↑
IV Rx: Promethazine 25-50mg or Piriton 10 mg and
Only start inotropes when fluid is optimally resuscitated
> 6.5 or ECG changes: CaCloride 10ml 10% slow IV over
Hydrocortisone 100-200mg stat. Observe patient until
(around 2 L for adult pt without CCF)
5 min first; followed by Dext / Insulin, Neb Salbutamol
stable and discharge with advice Piriton 4mg tds and
Bedside Ultrasound (Abd, Aorta, Heart, IVC, Lungs)
Repeat ECG, continuous Cardiac monitoring. Refer Med.
Neutropenic sepsis
Sodium - Low (<125):
Anemia
Ix: FBC, BUSE+Creat, ECG, CXR, UFEME
Ix: BUSE, Reflomet,
Hx: Diet, Gastritis, NSAIDs, Menorrhagia
Admit patient to the ward for antibiotics
True Na+ = Na + gluc/4 (esp in DKA)
Prednisolone 0.5 mg dly X 3/7 to prevent relapse.
PE: PR, Postural BP, identify possible area of blood loss
Dry: 0.9% N/S [(125-Na+)*0.6*wt÷154] litres/24h
Ix: FBC, BUSE+Creat, ECG if hx of IHD
Poisoning, ingested
Repeat BUSE Aim Na = 125 slow increase
Rx: RIB, O2.
Ix: BUSE, LFT, toxicology screen, urine for drugs, ABG,
Stop Diuretics
Admit if Hb < 8.0 for KIV transfusion
(Salicylates), levels(PCM/salicylate/etc)
Euvolemic: Hx and P/Ex to look for cause eg :SIADH
Prescribed haematinics if Hb > 8 with minimal symptoms
Rx: Lavage [<1h], NG aspirate [< 2h], Act charcoal. 50g
(malig, CNS, chest, metab, drugs), iatrogenic
and no risk of IHD.
stat [<4h], protect airway, give O2 [unless paraquat], IV
- Ix: According to suspected cause
fluids. Admission required unless accidental, confirmed
- Fluid restrict 1L/d +/- Saline +/- Lasix . Stop D5% drip.
non-toxic dose, single poison. Discuss with EP.
Overloaded: CCF, CRF, hypoalb. Diuretics.
Rx: < 38.0: sponge, paracetamol
Potassium - Low:
Sodium - High (>160):
38+, already on antibiotics: Paracetamol
Ix: +/- ECG(Inverted T,U wave, PR ↑, ST ↓)
Encourage plain water intake else D5% drip 3-5L/24h.
38+, no source, no antibiotics: Hx, P/Ex,
Rx: <2.5 or < 3.0 with digoxin tox/AMI/IHD for op:
Large amt urine: ?DI. Low K+, high bicarb: ?
KIV septic workup in ward & IV antibiotics.
Infection Sites: lungs, urine, gut, plug site, op site, DVT,
Potassium Chloride 10% 10 mls in 100ml N/S inf over 1hr Aldosteronism.
Do NOT double dose or exceed rate; do NOT flush line
bedsores, cellulitis, viral fevers, URTI / sinuses
Stop diuretics or add Mist KCl. Treat cause (eg vomiting)
Fever
Ix: FBC, BUSE, UFEME, CXR, VBG
Continuous monitoring, repeat K+ 1h post
EMERGENCY DEPARTMENT RESOURCE BOOK Valid until next review Jan 2011
INTERVENTION ORDERS GUIDE LIST FOR EMERGENCY DEPARTMENT DOCTORS
ENDOCRINE
GASTROENTEROLOGY
INFECTIOUS DISEASES
Newly Dx DM
Abdominal pain
Dengue
Ix: FBC, BUSE+Creat, RBS, ECG, CXR, Urine or blood
Causes: GI, KUB. Cardio, Lung / Pleua, AAA, DKA, GB,
PE: Bleeding, Postural BP, DSS presentation
ketone if reflomet > 16 mmol
Ca+, Dengue, Psych reasons
Ix: FBC, BUSE+Creat, PT/APTT, Dengue Sero, CRIB,
Rx: SC/IV. Short acting insulin accordingly
PE: +/- PR. Exclude acute abdomen. KIV Bedside USS
Notify. No i/m injection (if platelet low)
D/W senior MO if there is a need for admission in regards Ix: FBC, BUSE, amylase, Ca+ (ABG), AXR supine / erect
Rx: Paracetamol and fluids. Admit if WBC < 3,000, PLT <
to blood sugar control and patient’s education.
50,000, HCT > 55%, worried, poor care at home
CXR, +/- CE & ECG, +/- Urine Dipstick, UPT.
Rx: According to cause.
DKA/HHNK (Sugar “HI”, Acidotic, patient sick/drowsy)
NBM. MMT/Ranitidine/ analgesia eg tramadol.
Malaria
Ix: To confirm the diagnosis and to look for precipitating
Ix: FBC(Hb < 8), PT/APTT, Reflomet
factors and disease complications
Bleeding GIT
Admit medical ward for treatment. Notify.
FBC, BUSE+Creat, ABG/vBG, CXR, RBS, Urine ketones
On iron tabs? PR
(stat dipstick) or blood, ECG, CXR, UFEME.
Ix: FBC, BUSE+Creat, LFT, CE, GXM, KIV Bedside USS,
Sepsis unknown source
Rx: NBM, I/O +/- catheterize. +/- head chart if drowsy.
+/- ECG in IHD prone patients. AXR if ?perforated viscus
Ix: FBC, BUSE+Creat, CXR. Urine dipstick
Fluids resuscitation and replacement by NS 1L stat.
organ, signs of CA, KIV emerg OGDS or proctoscope.
Rx: Paracetamol stat. KIV IV antibiotics after Blood C/S
Caution in elderly and heart failure or renal failure.
Rx: NBM, IV drip, Off NSAIDS. IV Omeprazole 40 mg
Guidelines on antibiotics (d/w EP)
IV Actrapid(SI) 10U stat then infusion: 50U SI in 50 ml NS
Cellulitis: Cloxacillin 0.5-1g 6h
6mls/hr then change NS infusion above to D5% at 3mls/
Gastroenteritis
GE, severe: >6x, fever, toxic: Ciproflox 500mg bd po
hr once BSL<12. Continue IV N/S 2L/2h + add K+ 0.5 gm
Ix: FBC, BUSE, AXR
Pneumonia, mild: Amoyxcillin/Augmentin po + EES.
each 500 mls if urinate or K levels < 4. CVP. Admit.
NBM->Clear feeds->Non-milk diet.
Pneumonia, CAP: ceftriaxone 1g om + EES 800mg bd po
Reflomet / ABG or VBG every 30 minutes.
Rx: IV Dext Saline 1 L in 2 - 3 hrs. IV Maxalon 10mg
Pneumonia, CAP, severe: Admit Resp ward
Ciprofloxacin if septic (EP approval required)
Pneumonia, nosocomial: Admit Resp ward
Hypoglycemia
Pneumonia, aspiration: Admit Resp ward
FBC, BUSE+Creat, reflomet 1-2 hourly
Acute Hepatitis / Hepatic Encephalopathy
Septic arthritis: Admit Ortho ward
Reflomet: <2.5: IV D50% 20-40mls (dilute with N/S). add
Ix: FBC, BUSE+Creat, LFT, PT/APTT, ABG
Septic shock: Admit ward
IV thiamine 100mg if alcoholic.
Requires admission if jaundiced, feverish, ill
Thrombophlebitis: cloxacilln 500mg 6h x 2/7, dressing
Reflomet <3.0: Glucose drink. Recheck reflomet 2h later.
UTI: IV Ceftriaxone or Augmentin 375 MG TDS (d/w EP)
Then: IV D5 drip esp if NBM. Off OHAs & insulin.
or Oral Bactrim 2 tab BD
EMERGENCY DEPARTMENT RESOURCE BOOK Valid until next review Jan 2011
INTERVENTION ORDERS GUIDE LIST FOR EMERGENCY DEPARTMENT DOCTORS
Giddiness, postural hypotension
Hemoptysis
Causes: CNS, Vestibular, Cardiac, Metab/drugs
Ix: FBC, BUSE+Creat, CXR (Bronchiectasis) GXM
Bell’s palsy (not admitted unless to exclude stroke)
PE: Nystagmus, cerebellar s/s, postural BP, gait
KIV Emergency-bronchoscopy (refer Chest)
Ix: KIV CT scan if cannot exclude stroke
Ix: FBC, BUSE+Creat, PT/APTT, reflomet, ECG,
Rx:. If massive(die from asphyxia, not blood loss): Lie on
Rx: Prednisolone 40mg om x 2/7 -> 20mg om x 5/7.
Rx: Stugeron ‘/’ tds/prn, Stemetil 10mg tds/prn, IVD 1O
affected side (see CXR). 100% O2. Suction. Intubate (KIV
Eyedrop /shield.
NS if severely hypotensive.
double lumen ETT - refer Anaes).
CVA
NEPHROLOGY
PE
NEUROLOGY
NBM / NG tube / check gag reflex
Ix: FBC, BUSE+Creat, PT/APTT, CE, ABG [A-a gradient]
FBC, BUSE+Creat, PT/APTT. ECG, CXR, CT brain (plain) Renal Failure
Rx: 100% O2, Refer Medical Team
Rx: Aspirin 150mg stat + IV ranitidine after exclude bleed
Ix: FBC, BUSE+Creat, ABG, Urine Dipstick
BP up to 160/100 normal post-CVA: don’t treat.
Rx: watch infusion fluid amount. Admit for dialysis if
Pneumonia
acidotic, [K+] raised or fluid overloaded.
Ix :FBC, BUSE, ABG
Rx: Nasal Prongs O2 2L/min.
Drowsy/Confusion
Causes: Structural, infective, metabolic, drugs, any organ
Pyelonephritis
In ward: EES 800mg bd/tds, paracetamol
failure, hypoxia / hypercarbia, overdose
Ix: FBC, BUSE+Creat, UFEME/ dipstick
Hosp Acquired / High Risk : Admit
Ix: reflomet stat. Off sedatives.
Admit ward for IV antibiotics
Aspiration: Metronidazole
Allergy to penicillins: EES / Doxycyclin / Clarithromycin
Struc: CT head + CVA workup. Infective: septic workup
Metab/drugs: FBC, BUSE+Creat, PT/APTT, SpO2, ABG,
RESPIRATORY MEDICINE
Pneumothorax
toxicology screening.
Ix: FBC, BUSE, SpO2/ABG, CXR (in full inspiration), ECG
Asthma (Reversibility) / COPD
Epilepsy/Fits
Ix: FBC, BUSE+Creat, ABG(on x l/min), CXR, PEFR
Ix: reflomet stat. 100% O2 FBC, BUSE+Creat, PT/APTT,
Rx: Oxygen supplements. Off β-blockers.
ECG, ABG, CT head if new onset of fit or fit of different
pattern from usual or fit associated post trauma.
Rx(Pt fitting): Diazepam 5mg slow bolus max 15mg. 2nd
line: phenytoin loading 20mg/kg in 500 mls NS with BP
Rx: 100% O2(even if not SOB) -> Chest tap -> Chest
tube (consent, repeat CXR post tube); 22 - 28 Fr Spont
Neb Vent:NS 1:3(asthma) or vent:atrov:NS 1:1:2(COPD)
2-6 hourly, i/v hydrocort 100mg 6h or pred 10-30mg x 3/7.
Rx any pneumonia.
Pn; 32 Fr Traumatic
Shortness of breath No clear cause
Ix: FBC, BUSE+Creat, PT/APTT, SaO2/ABG A-a
gradient, +/- CE & ECG, +/- CXR. +/- PE Ix, D dimer
and cardiac monitor in Resus area
Rx: O2 (keep Sp02 > 95%), Treat cause
EMERGENCY DEPARTMENT RESOURCE BOOK Valid until next review Jan 2011
INTERVENTION ORDERS GUIDE LIST FOR EMERGENCY DEPARTMENT DOCTORS
GENERAL SURGERY
Intestinal Obstruction (IO)
Septic arthritis
Acute abdomen
Ix: FBC, BUSE+Creat, reflomet. ECG, AXR, CXR(sitting/
Admit orthopaedic ward
Ix: PR. FBC. BUSE+Creat, amylase/lipase, CE. UPT,
erect/L lat decub AXR). Hourly V/S, NBM. I/O chart. KIV
Ix: FBC, X ray of the knee
Urine Dipstick, ECG, AXR, CXR(erect or lat decub AXR),
CT abdo. PFO esp if large bowel(haustra incomplt cross)
Rx: Analgesia
Bedside USS. Vital Signs Monitoring, NBM. KIV CT abdo- >8cm , RIF tender, BS ++.
Rx: IV fluids. NG tube intermittent suction. Admit ward
pelvis. NBM.
Cellulitis
Rx: i/v fluids. Pain relief. Refer Surgery
Ix: FBC, X ray at the affected area
EYE EMERGENCIES
Refer Ortho for abscess, osteomyelitis, necrotizing
Acute retention of urine
Redness + Pain + decreased visual acuity = glaucoma /
fasciitis, wet gangrene.
Ix: UFEME Dipstick, FBC, BUSE+Creat, Bedside U/S
keratitis / iritis [Eye review required]
Rx: Admit ward if condition is severe or if pt has
KUB TRO hydronephrosis.
Blindness(sudden) + RAPD + white fundus & pale disc =
premorbid condition such as poorly controlled DM.
Rx: Catheterize if pain/UTI/ARU. 12 small, 16 big.
CRAO [Eye Emergency !]
Mild cellulitis can be discharged with Cloxacillin 500 mg
Replace foreskin. C/I: Pelvic #, prostatitis.
Peripheral vision loss +/- “curtain” +/- floaters = retinal
QID X 10/7 and analgesia. Give a review appointment.
“In-out cath”: Cath, measure, if < 300mls, remove cath
detachment [Eye Emergency !]
Suprapubic cath falls out: Use normal foleys, insert
through track as per normal ASAP before track distorted.
TRAUMA / ORTHOPAEDICS
Call Urology ASAP if can’t cath.
Head injury(Stable)/”Patient fell down”
Cholecystitis / biliary colic / cholangitis.
Hx, PE: VS, Scalp, pearl, GCS, joint ROM, bony pain.
Ix: FBC, BUSE+Creat, amylase, LFT, CE, AXR(10%
Ix: Xrays / CT head Hourly VSM & Head Chart. Need
gallstones). Bedside USS.
incident report? Need police case?
Rx: IV fluids. Pain relief. Admit ward if confirm stone,
Fractures
feverish and jaundice for IV antibiotics.
Xrays. ABG for long bone # to excl fat embolism.
Testicular torsion
D/dx: Epididymitis(>30yrs old usu), UTI, tumour, trauma.
Dislocations
Ix: FBC, BUSE+ Creat, PT/APTT +/- urgent U/S testes.
Splint then Xrays. Reduce after procedural sedation.
Surgical Emergency! Rx: Pain relief.
Repeat X-rays post reduction.
EMERGENCY DEPARTMENT RESOURCE BOOK Valid until next review Jan 2011
`