MOH Pocket Manual in

Emergency
MOH Pocket Manual in Emergency

COntent
s

cardiac emergency 3
 MOH Pocket Manual in Emergency

Contents

Chapter 1: Cardiac emergency:

Acute ST Elevation Myocardial Infarction1 .

Non ST Elevation Myocardial Infarction.
Atria
Bradydysrhythmias.
Hypertension.
Acute Aortic Syndromes.

Chapter 2: Pulmonary emergency:

Chapter 3 : Neurological emergency:

Headache.
Adult Acute Bacterial Meningitis.
Chapter 4 :Toxicology:

Acetaminophen (Paracetamol, APAP) Overdose.

Chapter 5 : Hematological emergency:

Sickle cell disease in emergency department.

Anticoagulation Emergencies.
Chapter 6 : Endocrinology and electrolyte emergency:

Hypokalemic and Hyperkalemia Emergencies.

4 con tent
 MOH Pocket Manual in Emergency

Chapter 7 : Urological emergency:

Acute Urinary Retention.

Chapter 8 : Trauma and environmental:

Severe Traumatic Brain Injury.

Electrical Injuries.
Heat injury.
Chapter 9 : Medications List

cont en t 5
 MOH Pocket Manual in Emergency

6 cardiac emergency
MOH Pocket Manual in Emergency

Chapter
1

CRADIAC
EMERGENCY

cardiac emergency 7
 MOH Pocket Manual in Emergency

Acute ST Elevation and Non

ST Elevation Myocardial Infarction

Overview

Acute coronary syndrome involves:

1. ST elevation acute myocardial infarction

2. Non–ST-segment elevation acute myocardial infarction

3.

Acute ST elevation myocardial infarction typically occurs when

a clot leads to complete occlusion of a coronary artery with trans
mural , or full thickness myocardial infarction .

The ECG will show ST segment elevation in the involved area

of the heart.

Non–ST-segment elevation acute coronary syndromes (NSTE-

segment elevations on an electrocardiogram (ECG).

8 cardiac emergency
 MOH Pocket Manual in Emergency

Clinical Presentation

o History
Chest pain, when it started, what it feels like

Jaw/shoulder/ neck/arm pain.

Dizziness, nausea.

o
-
ure/left ventricular dysfunction.

-
-

and pulmonary functions.

cardiac emergency 9
 MOH Pocket Manual in Emergency

Differential diagnosis

o Heart
Acute coronary syndrome
Pericarditis
Myocarditis
Endocarditis
Valvular disease
o Lungs

Pneumonia
Empyema

COPD
o Esophagus
Esophagitis
GERD
Spasm

Rupture (Boerhaave’s)
Esophegeal Tear

o Work up
CBC.
Electrolytes.
Coagulation studies.
Cardiac enzymes.
ECG.

10 cardiac emergency
 MOH Pocket Manual in Emergency

Management

o Prehospital Care:
Three goals:

(1) Delivering patients to an appropriate health care facility as

acute cardiac life support (ACLS) protocol when necessary.

(3) Initiating or continuing management of patients during inter-

facility transport.

Checklist to get from the EMS team includes the fol-

lowing information:

1. The person who initiated EMS involvement (patient, family,

2. Complaints at the scene.

4. Therapies given prior to arrival and the patient’s response.

cardiac emergency 11
 MOH Pocket Manual in Emergency

6. The patient’s code status (if known).

7. Family contacts for supplemental information and family mem-

-
ful in completing or verifying the history.

In hospital care for STEMI:

Do ECG.

Treat arrhythmia rapidly according to ACLS protocols.

-
lute contraindication) .

-
sistent chest discomfort, hypertension, or signs of heart
failure and there is no sign of hemodynamic compro-
-

Give morphine sulfate (2 to 4 mg slow IV push every 5

12 cardiac emergency
 MOH Pocket Manual in Emergency

Select reperfusion strategy:

Primary percutaneous coronary intervention (PCI)

strongly preferred, especially for patients with cardio-
genic shock, heart failure, late presentation, or contrain-

minutes, symptoms <12 hours, and no contraindications

Give antiplatelet therapy (in addition to aspirin) to all

patients:

give loading dose of 75 mg.

Give anticoagulant therapy to all patients:

Unfractionated heparin:

-For patients undergoing primary PCI, we suggest an initial in-

cardiac emergency 13
 MOH Pocket Manual in Emergency

to 75 seconds).

Disposition

Admit to ICU

In hospital care for NSTEMI:

o Management

High-risk patient:

:”Early ”invasive-

1. Discuss with cardiology.

3. Prompt PCI.
Not high-risk patient:

-Early ”conservative”:

14 cardiac emergency
 MOH Pocket Manual in Emergency

Disposition

Admit to ICU.

o Alert

Sudden onset of severe pain.

Lasting longer than 15 minutes.

Nausea/vomiting and sweating.

Radiation to left arm or jaw.

In case of inferior myocardial infarction , you must do

Right side and Posterior ECGs to rule out Right ven-
tricular or Posterior MI .

cardiac emergency 15
 MOH Pocket Manual in Emergency

Atrial Fibrillation: Management Strategies

Overview

o Cardiac causes:
Mitral valve disease.
Myocardial disease.
Conduction system disorders.
Wolff-Parkinson-White syndrome.
Pericardial disease.
Conditions associated with AF include:

Hypothermia.
Alcohol use.
Severe infection.

Pneumonia.
Kidney disease.

Intrathoracic surgery, such as cardiac or pulmonary

surgery, or invasive cardiac studies.

16 cardiac emergency
 MOH Pocket Manual in Emergency

Atrial Fibrillation is categorized as follows:

First detected episode.

Recurrent (after two or more episodes).

Clinical Presentation

o History

dizziness, chest pain, or generalized fatigue.

Medications and alcohol and drug use.

Physical Examination

Vital signs.

-
mos and enlarged thyroid).

The cardiac evaluation: rate, rhythm, and the presence

of heart murmurs.

cardiac emergency 17
 MOH Pocket Manual in Emergency

Differential diagnosis

Atrial Ventricular
Rhythm Frequency, Frequency, P-wave

Sinus
Precedes every
tachycar-
dia
Atrial irregu- ,
larly irregular
regu- ,75-15
Atrial lar, sometimes
Sawtooth
alternating

Atrioven-
tricular
nodal
reentrant ((R
tachycar-
dia

Atrial
P-wave differs
tachycar-
from sinus P-
dia
wave
Multifo- or more dif- 3
cal atrial ferent P-wave
< <
tachycar- morphologies at
dia different rates

18 cardiac emergency
 MOH Pocket Manual in Emergency

Atrial
-
tion with with ,
Wolff-
Parkinson- QRS com-
White
syndrome

Work up

Electrocardiogram.

Hepatic function panel.

Coagulation studies.

A thyroid panel.

Chest radiography.

cardiac emergency 19
 MOH Pocket Manual in Emergency

Management

o Prehospital Care:

of hemodynamic compromise or poor coronary artery

perfusion.

o In hospital care:

- Altered mental status.

- Ischemic chest discomfort.

- Acute heart failure.

- Hypotension.

- Signs of shock or hemodynamic compromise.

o Immediate direct current cardioversion:

Anticipate failure.

20 cardiac emergency
 MOH Pocket Manual in Emergency

o If no success repeats direct current cardioversion:

Increase energy level.

Time with patient’s respiratory cycle, shock during full

If Suspicion for accessory pathway?

History of Wolff-Parkinson-White syndrome.

Prior ECG with delta wave.

o Give: Amiodarone.
If No suspicious of accessory pathway:

Or

Amiodarone:

cardiac emergency 21
 MOH Pocket Manual in Emergency

/ kg/ min

o Disposition

Admission of new-onset AF only for patients with de-

compensated heart failure or myocardial ischemia or
for patients who are highly symptomatic and in whom

Follow your hospital policy of admission .

22 cardiac emergency
 MOH Pocket Manual in Emergency

o Alert

Palpitations during exertion or palpitations with

associated syncope or pre-syncope.

ECG abnormalities.

heart condition.

Cardioversion needs procedural sedation and analgesia.

cardiac emergency 23
 MOH Pocket Manual in Emergency

Bradydysrhythmias
Overview

Categories of Bradydysrhythmias

Bradydysrhythmia Bradydysrhythmia Type

Category
Sinus node dysfunc-
tion
Sinus arrest

Chronotropic incompetence

-
itz type I or Wencke-

-
itz type II)

24 cardiac emergency
 MOH Pocket Manual in Emergency

Clinical Presentation

History
Assessing the History of the Patient with Bradydysrhythmia

History

Preceding angina symp- Myocardial ischemia/infarction

toms

Fevers, travel to en- Infectious agent

Cold intolerance, weight Hypothyroidism

gain, increased fatigue

Headache, mental status Intracranial causes, including intra-

change, recent head cranial hemorrhage
trauma, falls

distention

Recent additions or
changes to medications

History of end-stage Hyperkalemia

renal disease, receiving
dialysis

cardiac emergency 25
 MOH Pocket Manual in Emergency

Cancer history, receiving

treatment chemotherapeutic agents

strong emotion preced-

ing the event

Physical Examination

o Differential diagnosis

26 cardiac emergency
 MOH Pocket Manual in Emergency

Category Disease Process

Ischemia and Inferior myocardial infarction, espe-
infarction cially involving the right coronary
artery
Neurocardiogen-
Hypersensitive carotid sinus syn-
drome

Increased intracranial pressure

Hypothyroidism
docrine, and environ- Hyperkalemia
mental
Hypothermia
Infectious and Chagas disease (Trypanosoma cruzi)
postinfectious Lyme disease (Borrelia species)
-
sackievirus B, etc)
Syphilis (Treponema pallidum)

drugs, overdoses of drugs, or

poisoning

cardiac emergency 27
 MOH Pocket Manual in Emergency

Work up

Electrolyte levels, especially potassium.

Thyroid function testing.

CT of the head.

Management

o Prehospital Care:

Cardiac monitor to identify rhythm.

IV access.

28 cardiac emergency
 MOH Pocket Manual in Emergency

including hypotension and altered mentation.

Support (ACLS) algorithm.

In hospital:

assistance.

adrenergic agent (such as dopamine, epinephrine, or

patients who have failed to improve with atropine.

Or

cardiac emergency 29
 MOH Pocket Manual in Emergency

The Stable Patient:

-
mia.

-
logical Causes of BradydysrhythmiasAnti-
dote or Therapy

min, up to 3 doses

-
Calcium chan- -

as needed
-
Digitalis (di- -
(
(

Opioids -
sponse

Organophos-
phates
repeated every 6 h

30 cardiac emergency
 MOH Pocket Manual in Emergency

Disposition

-
ted.

Hypertension

Overview

Hypertensive emergency

Target organ dysfunction

Hypertensive urgency

-
sive

Target organ dysfunction

Hypertensive crisis

A hypertensive emergency or urgency

Mean arterial pressure

cardiac emergency 31
 MOH Pocket Manual in Emergency

calculated

Essential hypertension

Secondary hypertension

Hypertension related to an underlying pathologic process, e.g.,

withdrawal.

Clinical Presentation

History

Key Questions Regarding History of the Present Illness

Question Comments/Concerns

- Do you have any chest pain?

Myocardial infarction, aortic dissection

32 cardiac emergency
 MOH Pocket Manual in Emergency

Myocardial infarction, aortic dissection, pulmonary edema, heart

failure

- Are you on any medications, or are you using any recreational

-
thomimetic.

- Have you recently stopped taking any medications or recreation-

Delirium tremens, clonidine and other drug withdrawal

or clumsiness?

Stroke, transient ischemic attack, intracranial hemorrhage

- Do you snore or wake up during sleep? Do you feel tired

-
sponded to multiple medications?

cardiac emergency 33
 MOH Pocket Manual in Emergency

Physical Examination

for evidence of an aortic aneurysm.

Differential Diagnosis

Stroke.

Aortic dissection.

Drug withdrawal: antihypertensive, alcohol,

sedative hypnotics.

Renal failure.

Pheochromocytoma or other.

34 cardiac emergency
 MOH Pocket Manual in Emergency

Tumor.

Thyroid storm.

Work up

Serum chemistry.

Electrocardiogram.

Chest radiograph.

Urine drug screen.

Urinalysis.

Pregnancy test.

o Management

o Prehospital Care
Evaluated for signs or symptoms of end-
organ damage.

History, including the medications.

cardiac emergency 35
 MOH Pocket Manual in Emergency

In hospital care:

ED

-Instead, these patients should follow up with a primary care

provider within 1 week.

Hypertension on Antihypertensive Medications:

restarted on the drugs.

the patient from taking the medications are addressed.

History of Hypertension:

medication ( no need to aggressive lowering of BP ) , and regu-

lar follow-up in OPD clinic .

36 cardiac emergency
 MOH Pocket Manual in Emergency

Emergencies:

Drug Dose Onset of Dura- Adverse Spe-

Action tion of Effects cial
Indi-
Action ca-
tions
Vasodilators
Sodium Immedi- 1-2 min Nausea, Most
nitro- /kg/ ate vomiting, hyper-
prusside min as muscle ten-
sive
IV in- twitching, emer-
fusion sweating, gen-
thiocynate

and cau-
cyanide tion
- with
tion. May high

increase intra-
intracrani- cra-
al pressure nial
pres-
sure
or

azote-
mia

cardiac emergency 37
 MOH Pocket Manual in Emergency

Nicar- 5-15 Tachy- Most

dipine mg/h min, cardia, hyper-
hydro- IV may headache, ten-
chloride sive
emer-
( not hrs local phle- gen-
in the cies
MOH
formu-
lary ) acute
heart
fail-

cau-
tion
with
coro-
nary

isch-
emia
< 5 min Tachy- Most
/kg/ cardia, hyper-
min IV headache, ten-
nausea, sive
infu- emer-
sion gen-

cau-
tion
with
glau-
coma

38 cardiac emergency
 MOH Pocket Manual in Emergency

Nitro- 2-5 min Headache, Coro-

glycerin /min min vomiting, nary
as IV methemo- isch-
- emia
infu- emia,
sion
tolerance
with

prolonged
use
Enala- 1.25–5 6-12 hrs Precipi- Acute
prilat mg min tous fall in left
every 6 pressure in ven-
( not tricu-
in the hrs IV high-renin lar
MOH fail-
formu-
lary )
response avoid
in
acute
myo-
car-
dial
in-
farc-
tion

cardiac emergency 39
 MOH Pocket Manual in Emergency

Hydral- 1-4 hrs Tachy- Ec-

azine mg IV min IV IV cardia, lamp-
hydro- sia
chloride 4-6 hrs headache,
mg IM min IM IM
vomiting,
aggrava-
tion of
angina

- 3-6 hrs Vomit- Most

alol mg IV ing, scalp hyper-
hydro- tingling, ten-
chloride - sive
every constric- emer-
tion, gen-
cies
dizziness,
mg/min
IV nausea, acute
heart heart
infu- -
sion thostatic failure

hypoten-
sion

40 cardiac emergency
 MOH Pocket Manual in Emergency

Esmolol 1-2 min Hypo- Aortic

hydro- / min tension, dis-
chloride kg/ nausea, sec-
asthma, tion,
min IV peri-
- opera-
then gree heart tive

heart
/kg/
failure

infu-
may
repeat

after 5
min or

in-
crease
infu-
sion to

/
min
Phentol- 5–15 1-2 min Tachy- Cat-
amine mg IV min cardia, echol-
amine
headache

cardiac emergency 41
 MOH Pocket Manual in Emergency

Outpatient Oral Medications for Hypertension Management:

Agent Starting Indication Contraindi-

Dose Useful Dos- cation
age
Thiazide 12.5 mg 25 mg daily Drug of Gout, , hypo-
daily choice for kalemia,
diuretics uncom-
(eg, plicated hypercalce-
hyperten- mia
hydrochlo-
rothiazide)
works well
with other
agents
ACE Patients Bilateral
daily with CHF, renal artery

(eg, fos- previous -

inopril, povolemia
MI with
low ejec-
lisinopril)
tion
fraction

42 cardiac emergency
 MOH Pocket Manual in Emergency

Angioten- Similar Bilateral

sin daily renal artery
ACE
receptor -
used for povolemia
patients
(eg,
who cannot
losartan) toler-
ate these

or in addi-
tion to
them

cardiac emergency 43
 MOH Pocket Manual in Emergency

Patients Not a good

(eg, with coro- monotherapy
nary
metopro- for lone
lol) artery

longterm

manage-
ment sick sinus

hyperthy-
roidism acute decom-
pensated

44 cardiac emergency
 MOH Pocket Manual in Emergency

Calcium Rate Not a good

channel mg daily control or monotherapy
coronary
Daily (formulation for lone
dependent) artery
(eg, diltia- disease in
zem) long-acting
patients agents are
who cannot
safer than
take short-acting

acute

decompen-
sated CHF

sick sinus

syndrome
a-2 Ago- Hyper- Poor adher-
nist (eg, tension ence to medi-
resistant cal
clonidine)
to other regimen
modalities

cardiac emergency 45
 MOH Pocket Manual in Emergency

Hydrala- Hyperten- Coronary ar-

zine qid sion associ- tery disease
ated
(unknown
with preg-
mecha-
nism of
hyperten-
vasodila- sion associ-
tion) ated

with CHF

in African
Americans

resistant to
other

modalities

46 cardiac emergency
 MOH Pocket Manual in Emergency

Disposition

,oral an-

with-

then further consideration for BP treatment or titra-

.

mm Hg, follow-up within

one week is recommended.

Patients with hypertensive emergencies admitted to the

intensive care unit -
pertensive agents.

cardiac emergency 47
 MOH Pocket Manual in Emergency

Acute aortic emergency

Overview

(1) Aortic dissection.

(2) Intramural hematoma.

(3) Penetrating atherosclerotic ulcer.

Acute if it occurs within 2 weeks of the onset of

symptoms.

Chronic if it occurs more than 6 weeks from the

-
sections > 2 weeks as chronic).

48 cardiac emergency
 MOH Pocket Manual in Emergency

into the aortic arch and descending aorta.

Type III originates in the descending thoracic aorta and

type IIIa, which is limited to the descending thoracic

aorta.

.according to whether the ascending aorta is involved or not

Stanford type A dissections involve the ascending

aorta (similar to DeBakey type I and II).

Stanford type B dissections involve the descending

aorta (similar to DeBakey type III).

cardiac emergency 49
 MOH Pocket Manual in Emergency

Clinical Presentation

o History

Time of onset.
Symptoms.

Character of pain.
Radiation of pain.
Alleviating or aggravating factors.
Other associated symptoms.
Past medical history.
History of long-standing hypertension.
Previous cardiac surgery.
Previous aortic pathology.
Medications.

Family history.
Social history.

50 cardiac emergency
 MOH Pocket Manual in Emergency

Physical Examination

jugular venous distension, and tachycardia.

Mesenteric ischemia.

Syncope.

Differential diagnosis

Aortic Regurgitation.

Aortic Stenosis.

Cardiac Tamponade.

Cardiogenic Shock.

Cardiomyopathy.

cardiac emergency 51
 MOH Pocket Manual in Emergency

Gastrointestinal Bleed.

Hemorrhagic Shock.

Hypovolemic Shock.

Hiatal Hernia.

Hypertensive Urgency.

Mediastinitis.

Myocardial Infarction.

Myocarditis.

Pancreatitis.

Pericarditis.

Pleural Effusion.

Pneumonia.

Thoracic Outlet Syndrome.

52 cardiac emergency
 MOH Pocket Manual in Emergency

o Work up

Ultrasound.

CT.

MRI.

Conventional Aortography/Angiography.

CBC.

Electrolytes.

Coagulation studies.

BLLOD GROUPING & CROSS MATCHING.

Cardiac enzymes.

LFT’S.

Pancreatic enzymes.

Urinalysis.

ECG.

cardiac emergency 53
 MOH Pocket Manual in Emergency

Management

o Prehospital Care:
Rapidly transporting them to the appropriate facility.

Transported via advanced life support.

Intravenous access.

Cardiac monitor.

-
sive.

Close monitoring of vital signs.

In hospital care:

prevent progression of dissection.

Intravenous narcotics titrated to pain control.

Options include

54 cardiac emergency
MOH Pocket Manual in Emergency

Esmolol has the advantage of a very short half-

agent.

disease, acute congestive heart failure, or cocaine

-
sodilator ( not used alone ).

cardiac emergency 55
 MOH Pocket Manual in Emergency

Medication Dosage Comments

Esmolol
IV, then infusion to short half-life
Beta 1-receptor and easy titra-
kg/min -
ferred inasthma/
COPD

single agent

mg/min

Metoprolol 5 mg IV q5min up No IV infusion

Beta 1-receptor -
mum
Propranolol 1 mg IV q5 min No IV infusion

56 cardiac emergency
MOH Pocket Manual in Emergency

Diltiazem Second-line
mg/kg IV, then for heart rate
infusion 5-15 mg/ control when
.hr
contraindicated
(e.g., cocaine

Verapamil NA

Nitroglycerin
min infusion. vasodilator

mcg/min

cardiac emergency 57
 MOH Pocket Manual in Emergency

Disposition

Admission to the intensive care unit.

Close monitoring.

Type A aortic dissections will usually require transfer to a

-
diothoracic surgeon or a vascular surgeon, depending on the
institution.

Coordination of care with the treating surgeon will determine

whether or not surgical repair is indicated.

58 cardiac emergency
 MOH Pocket Manual in Emergency

Deep Venous Thrombosis

Overview

through the vein, causing swelling and pain.

veins” in the legs, thighs, or pelvis this is called a deep vein

Clinical Presentation

o History

When did the pain start? The time line of pain onset is

suspicion for other conditions, such as ongoing arterial

trauma or a strain?

Did the pain come on suddenly, or more slowly?

Were there any associated occurrences with the onset

cardiac emergency 59
 MOH Pocket Manual in Emergency

muscle, tendon, or cyst rupture?

Is there any swelling in the leg and, if so, where?

Is there any redness, or does the skin feel hot?

-
jury/surgery, or for other reasons, such as a lengthy au-

Past Medical History:

Malignancy or a history suggestive of ma-

lignancy.

Recent hospitalization, pregnancy (including

current pregnancy, recent pregnancy (within
-
riages) and the puerperium, use of hormonal
agents, or known acquired or inherited throm-

60 cardiac emergency
 MOH Pocket Manual in Emergency

Physical Examination

cast).

Tenderness and its location.

Swelling or pain upon squeezing the calf.

Palpation of a painful area, especially the

Differential diagnosis

Cellulitis.

Baker’s Cyst.

cardiac emergency 61
 MOH Pocket Manual in Emergency

Work up

CBC.

Electrolytes.

PT/PTT and INR.

Venography.

D-Dimer.

Management

o Prehospital Care:

Primarily supportive.

If the patient is asymptomatic, then no need for intra-

venous access.

Start heparin if transportation time is prolonged and pa-

tient was moderate to high risk.

In hospital care:

62 cardiac emergency
 MOH Pocket Manual in Emergency

PTT measurement after 6 hours of infusion, usually

Low molecular weight heparin as:

-
hours.

-
hours.

OR

- Tinzaaparin 175 IU/kg SC every day.

Disposition

Admit most patients with DVT for intravenous unfrac-

tionated heparin.

Patients who are sent home after a nega-

cardiac emergency 63
 MOH Pocket Manual in Emergency

for DVT otherwise increases (e.g., worsening symp-

toms).

64 cardiac emergency
MOH Pocket Manual in Emergency

Chapter
2
PULMONARY
EMERGENCY

cardiac emergency 65
 MOH Pocket Manual in Emergency

Acute Bronchial Asthma in the Emergency

Department
Overview

o Risk Factors for Death from Asthma:

-
mission).

Two or more hospitalizations for asthma in the past

year.

Three or more ED visits for asthma in the past year.

Hospitalization or ED visit for asthma in the past

month.

month.

Social History.

Low socioeconomic status or inner-city residence.

Illicit drug use.

66 Pulmonary Emergency
 MOH Pocket Manual in Emergency

Cardiovascular disease.

Concomitant lung disease.

Chronic psychiatric disease.

unit.

Clinical Presentation

o History

Prior asthma admission to an intensive care unit

Two or more hospitalizations for asthma in the past

year

Three or more emergency department care visits for

asthma in the past year

Pulmonary Emergency 67
 MOH Pocket Manual in Emergency

Hospitalization or an emergency department care visit

for asthma within the past month

canisters per month

Current use of or recent withdrawal from

systemic corticosteroids

Serious psychiatric disease or psychosocial

Illicit drug use, especially inhaled cocaine

and heroin

Physical Examination

Alterations in mentation or consciousness.

Diaphoresis.

Tachypnea and tachycardia

Use of accessory muscles of respiration.

68 Pulmonary Emergency
 MOH Pocket Manual in Emergency

Wheezing.

Identify the complications of asthma such as

-
diastinum.

Differential diagnosis

Adults

Acute coronary syndromes

Congestive heart failure

Pneumonia

Vocal cord dysfunction

Pulmonary Emergency 69
 MOH Pocket Manual in Emergency

Sinus disease

Upper respiratory tract infection.

Children

Croup

Bronchiolitis

Tracheomalacia

Viral upper respiratory tract infection

Work up

admission).

Electrolyte evaluation (if patient has dehy-

dration or for admission)..

-
ing to initial treatment).

Chest radiography (if there is no response to

treatment or pneumonia).

70 Pulmonary Emergency
 MOH Pocket Manual in Emergency

Management

o Prehospital Care:

pressure.

-
tered-dose inhaler with spacer.

In hospital care:

Mild-Moderate Severe
FEV1

Maintain SaO2 Maintain

SaO2
-
tion doses

-
toline)
MDI with spacer:
- to 4 hr. (with supervision)
uterol
(with super-
vision)

Pulmonary Emergency 71
 MOH Pocket Manual in Emergency

Inhaled anticho-
linergic:
solution)
ipratropium solu-
tion
Sys- Oral (preferred):
temic
cortico-
steroids equivalent prednisone
or equiva-
lent

- methylpred-
nisolone (or equivalent) nisolone (or
equivalent)
IV magnesium Not indicated 2–3 g over
sulfate (FEV1

FEV1, forced expiratory volume in 1 second; MDI,

SaO2, oxygen saturation in arterial blood.

72 Pulmonary Emergency
 MOH Pocket Manual in Emergency

Disposition

Good Re- Incomplete Poor Re-

sponse Response sponse
FEV1 or

(predicted/
personal

Disposition site:
Home Yes No, continue No,
therapy continue
therapy
No Yes, if
unit
and appro-
priate
Hospital No - Yes, if ap-
ward vation unit. propriate
Critical care No No Yes, if with
unit respiratory
-
cy/failure
FEV1

Pulmonary Emergency 73
 MOH Pocket Manual in Emergency

Alert

Living alone or socially isolated.

-
sentation (current steroid use).

Presentation at night.

Pregnancy.

Normal PCO2 is a worsening sign.

74 Pulmonary Emergency
MOH Pocket Manual in Emergency

Chapter
3
NEUROLOGICAL
EMERGENCY

cardiac emergency 75
 MOH Pocket Manual in Emergency

Acute Headache
Overview

o Tension-Type Headache

-
utes to 7 days

2. At least two of the following criteria:

• Pressing/tightening (nonpulsatile) quality

activity)

• Bilateral location

activity

3. Both of the following:

are present.

76 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

Migraine without Aura

1.
unsuccessfully treated), which have at least 2 of the 4 following
characteristics:

• Unilateral location.

• Pulsating quality.

-
ties).

-
ity.

1. During headache, at least one of the two following symptoms

occur:

• Nausea and/or vomiting.

Cluster Headache

1.

or more of the following signs occurring on the same side as

the pain:

NEUROLOGICAL EMERGENCY 77
 MOH Pocket Manual in Emergency

• Conjunctival injection

• Lacrimation

• Nasal congestion

• Rhinorrhea

• Forehead and facial sweating

• Miosis

• Ptosis

• Eyelid edema

1.
per day.

Other Primary Headaches

Includes:

• Hypnic headache.

• Primary thunderclap headache.

78 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

Clinical Presentation

o History
Detailed account of the current headache.

may
suggest a dangerous secondary etiology:

-
ache).

• Posterior headache with neck pain or stiffness.

• Change in vision.

• Change in consciousness.

• Syncope.

• History of HIV or immunocompromised.

• History of malignancy.

• Pregnancy or postpartum.

• Headache with seizure.

NEUROLOGICAL EMERGENCY 79
 MOH Pocket Manual in Emergency

The onset.

Location.

Quality of the headache as well as associated symptoms.

headaches.

Important Secondary Causes of Headache:

Secondary Headache Red-Flag Findings

Causes
Thunderclap (sudden, severe
rhage onset) headache
Meningitis Fever, neck stiffness, immunosup-
pression
Temporal arteritis Jaw claudication, vision changes,
polymyalgia rheumatica

poisoning cluster of cases

Acute glaucoma Unilateral vision change, eye pain,
and redness

80 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

Cervical artery dissec- Neck pain, trauma, stroke symp-

tion toms, Horner syndrome
Venous sinus throm- Pregnancy, postpartum, hyperco-

Chronic progressive headaches,

papilledema, history of malig-
nancy
-
ing
Idiopathic intracranial Papilledema, worse when lying

hypertension
Hypotension, hypoglycemia,

history of pituitary tumor

Pre-eclampsia Hypertension, proteinuria, nonde-
pendent edema, pregnancy
Hypertensive encepha- Altered mental status, hyperten-
lopathy sive, neurologic signs in nonana-

Trauma, coagulopathy

rhage arteriovenous malformation

NEUROLOGICAL EMERGENCY 81
 MOH Pocket Manual in Emergency

-
tions.

General History Questions For Evaluation Of Headache

Concerning Responses
Onset: Sudden headache with ex-
• When did the headache or orgasm is concerning

• What were you doing

Pain exacerbated by supine

• What makes the pain position or cough is con-

Occipital headache with

• Describe the pain. dysarthria, dysphagia,
• Where is the pain

82 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

Radiation: Pain with radiation down

meningitis, or carotid or

(maximal pain within min-

headache reached its

sinus thrombosis, or intra-
cranial hemorrhage.

worsening headaches are

etiology.

hemorrhage

NEUROLOGICAL EMERGENCY 83
 MOH Pocket Manual in Emergency

For The Headache Patient

-
tion Finding:

CN II – Optic nerve or its • Unilateral vision loss can

central connections
temporal arteritis, glaucoma,
or optic neuritis.

suggests CNS involvement

posterior to the optic chiasm.
CN III – Oculomotor nerve • May indicate posterior
com¬municating artery aneu-
• Defect in pupillary rysm, uncal herniation, SAH,
constric¬tion, eyelid raise, or mass lesion.

(down and out eye) • Consider cavernous sinus

• Consider increased or
-
• Defect in lateral movement tion.
of eye

84 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

to-shin injur
Altered mental status Concern for mass or vascular
lesion, SAH, hypertensive
encephalopathy, meningitis,

or dissection.

hemorrhage.

Differential diagnosis

Trauma, SAH, CNS tumor/mass.

Meningitis, SAH, idiopathic intracranial hyper-

tension.

Acute glaucoma.

NEUROLOGICAL EMERGENCY 85
 MOH Pocket Manual in Emergency

Temporal arteritis.

o Work up

Noncontrast head computed tomography (CT).

(MRI).
Magnetic resonance venography (MRV) BRAIN.
-
sis.
Visual acuity and intraocular pressure.
ESR.
.

86 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

Secondary Cause

Trauma, SAH, CNS

head
tumor/mass
-

hypertensive encephalopathy
Meningitis, SAH, idiopathic
intracranial hypertension
and OP (opening pressure)
Visual acuity with IOP Acute glaucoma
Erythrocyte sedimentation Temporal arteritis
rate

NEUROLOGICAL EMERGENCY 87
 MOH Pocket Manual in Emergency

Management

o Prehospital Care:
Generalized recommendations include the following:

1.

2. Evaluating mental status.

3.

NB:

medications.

Adjusting temperature.

Minimizing unnecessary light or noise.

-
tion.

88 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

In hospital care:

Primary headache:

For mild pain:

For severe pain:

Diphenhydramine 25 mg IV

Or

Consider

NEUROLOGICAL EMERGENCY 89
 MOH Pocket Manual in Emergency

IV Fluid.

Triptan.

Contraindications for Triptan Use:

Uncontrolled hypertension.

Ischemic heart disease.

Prinzmetal angina.

Cardiac arrhythmias.

Multiple risk factors for atherosclerotic vascular disease.

Primary vasculopathies.

Basilar and hemiplegic migraine.

Use of ergot in past 24 hours.

Use of MAOI or SSRI.

Use of triptan in past 24 hours.

90 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

Management of Cluster Headache

1.

2. And Sumatriptan 6 mg SQ.

NEUROLOGICAL EMERGENCY 91
 MOH Pocket Manual in Emergency

Medications For Primary Headache, Dosing, And American

.Academy Of Neurology Quality Of Evidence
Medication Dose AAN Quality
of Evidence
mg PO A
Aspirin mg PO A
mg PO B
Ketorolac mg IV B
Acetaminophen mg PO B
Aspirin / acetamino- A
phen / caffeine mg PO
Dihydroergotamine mg IV B
IV
Chlorpromazine mg/kg IV B/C
Metoclopramide mg IV B
Prochlorperazine mg IV B
Sumatriptan SQ mg SQ 6 A
Sumatriptan PO mg PO A
Opioids Varies B
mg PO/IV C

92 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

Disposition

To set return precautions.

Alerts of Dangerous Secondary Headaches:

-
ache).

• Posterior headache with neck pain or stiffness.

• Change in vision.

• Change in consciousness.

• Syncope.

• History of HIV or immunocompromised.

• History of malignancy.

• Pregnancy or postpartum.

• Headache with seizure.

Follow-up with a primary doctor.

NEUROLOGICAL EMERGENCY 93
 MOH Pocket Manual in Emergency

Adult Acute Bacterial Meningitis

Overview

Risk Factors for Meningitis:

Upper respiratory tract infection.

Otitis media.

Sinusitis.

Mastoiditis.

Head trauma.

Recent neurosurgery.

Compromised immune system (eg, resulting from hu-

asplenia, alcoholism, cirrhosis/liver disease, malnutri-

tion, malignancy, cirrhosis/liver disease, malnutrition,
malignancy, and immunosuppressive drug therapy).

Crowded living conditions.

94 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

Clinical Presentation

Headache And Nausea

Fever

Altered Mental Status

Neck Stiffness/Nuchal Rigidity

Kernig And Brudzinski Signs

Other Signs/Symptoms

Rash.

Arthritis.

Differential diagnosis

Encephalitis.
Aseptic meningitis.

NEUROLOGICAL EMERGENCY 95
 MOH Pocket Manual in Emergency

Work up

Complete Blood Cell Count, Chemistry Panel, Lactate

Computed Tomography.

Management

o Prehospital Care:
Standard personal protective
equipment such as facial masks.

Vital signs and mental status during trans-

port.

Blood glucose check.

Glasgow Coma Scale (GCS)

score.

saline infused.

Pain medication.

96 NEUROLOGICAL EMERGENCY
 MOH Pocket Manual in Emergency

Predispos- Common Bacterial

ing Factor Pathogen Therapy
Neisseria meningitidis, Vancomycin plus
years Streptococcus pneu- a third-generation
moniae, Haemophilus in- cephalosporin

(patients
Streptococcus pneumoni- Vancomycin plus
years ae, Neisseria meningitidis, a third-generation
Listeria monocytogenes, cephalosporin and
ampicillin

Immu- Listeria monocytogenes, Vancomycin plus

nocom- a third-generation
promised cephalosporin and
System pneumoniae, Neisseria ampicillin
meningitidis
- Vancomycin plus
nal Trauma either a third-gen-
Streptococcus pneu- eration cephalospo-
moniae rin with anti-pseu-
domonal coverage
or meropenem

NEUROLOGICAL EMERGENCY 97
 MOH Pocket Manual in Emergency

Disposition

Admission to hospital.

98 NEUROLOGICAL EMERGENCY
MOH Pocket Manual in Emergency

Chapter
4

cardiac emergency 99
 MOH Pocket Manual in Emergency

Acetaminophen (Paracetamole,APAP) Overdose

Progression of Liver Disease after Acute APAP Ingestion:

- Description Results of Manifesta-

imate Duration tions
Tests
Stage 1 Preclini- Normal Asymptom-
cal injury atic or mild,
phase -
vere poisoning symptoms:
nausea,
vomiting,

malaise
Stage 2 Onset of Nausea, vom-
liver injury iting, RUQ
24-72 hours PT, pain

phosphate,

100 TOXICOLOGY
 MOH Pocket Manual in Emergency

Stage 3 Jaundice,
- coagulation
icity defects, hypo-
ammonia glycemia,
renal failure,
encephalopa-
thy, coma,
MSOF
Stage 4 Recovery Normalization Complete
5-7 days phase resolution of

Clinical Presentation

o History
Dose and time of APAP ingestion.

Formulation of APAP ingested the pattern of use (single

dose or repeated doses).

Duration of ingestion.

Concomitant ingestions.

Intent of use (e.g., suicidal gesture or for analgesia).

History of trauma.

TOXICOLOGY 101
 MOH Pocket Manual in Emergency

History of liver injury or alcoholism.

Physical Examination

ABCs

Tachycardia may suggest congestion of a sympathomi-

metic or anticholinergic agent.

Dehydration.

Blood loss.

Pain.

Agitation.

Mental status which could suggest encephalopathy.

Pupils

102 TOXICOLOGY
 MOH Pocket Manual in Emergency

Skin

Evidence of depression, suicide attempts,

psychiatric illnesses.

Differential diagnosis

Ascending cholangitis.

Biliary disease.

Hepatorenal syndrome.

Hypercalcemia.

Ischemic hepatitis (shock liver).

Fulminant viral hepatitis(hepatitis A, B, B/D, or

Pancreatitis.

Perforated viscus.

Reye’s syndrome.

TOXICOLOGY 103
 MOH Pocket Manual in Emergency

o Work up

-
tion.
-

the Rumack-Matthew Nomogram.

CBC

LFT’S

Serum lipase concentration.

URIN ANALYSIS

Coagulation Studies

Chemistry Panel And Other Blood Work

Pregnancy Test

Electrocardiography

Head Computed Tomography

104 TOXICOLOGY
 MOH Pocket Manual in Emergency

Management

o Prehospital Care
Amount of APAP ingested and any congestion.

Evidence of trauma.

Plasma glucose concentration.

for evaluation and treatment regardless of the amount

ingested.

In hospital care

Activated charcoal (up to one hours after inges-

tion).

Administer antidotal therapy (N-acetylcysteine):

Treat fulminant hepatic failure.

TOXICOLOGY 105
 MOH Pocket Manual in Emergency

Refer patient for urgent liver transplant if criteria

are met.

Provide supportive and appropriate follow-up

care:

l Control nausea and vomiting

l Manage renal dysfunction

Admission

l Monitor and treat hypoglycemia

l Vitamin K and fresh frozen plasma for coagulopathy.

Disposition

instructed to return immediately if symptoms of hepatic

involvement, admission to the intensive care unit (ICU).

106 TOXICOLOGY
 MOH Pocket Manual in Emergency

Carbon Monoxide Poisoning

Overview

At room temperature, CO is a gas that is odorless, taste-

less, and not irritating.

Clinical Presentation

o History

Questions to ask include:

• Where was the patient found, and under what circumstances?

• Was there loss of consciousness?

TOXICOLOGY 107
 MOH Pocket Manual in Emergency

• Was there evidence of trauma?

• Was prehospital ECG performed?

•Was there evidence of attempted self-harm or suicidal intent?

Physical Examination

-
dor.

Cardiac wheezing” or crackles in the lungs, signifying myo-

cardial depression secondary to smoke inhalation.

Differential diagnosis

Acute respiratory distress syndrome.

Altitude illness.
Cluster headache.

108 TOXICOLOGY
MOH Pocket Manual in Emergency

Cyanide poisoning.

Depression.

Encephalitis.

Gastroenteritis.

Hypoglycaemia.

Hypothyroidism.

Lactic acidosis.

Meningitis.

Migraine.

Smoke inhalation.

Tension headache.

TOXICOLOGY 109
 MOH Pocket Manual in Emergency

o Work up

Cardiac Biomarkers.

Lactate.

Pregnancy Testing.

Computed Tomography.

ECG.

Management

o Prehospital Care:

-
tion of the scene for e -
mal odors or fumes.

110 TOXICOLOGY
 MOH Pocket Manual in Emergency

An intravenous (IV) catheter.

recommended.

o In hospital care:

Signs of end-organ dysfunction -

evated:

Disposition

Patients who did not have loss of consciousness.

Complete recovery from any symptoms.

No evidence of end-organ damage (ECG changes, elevated

-
charged to home.

TOXICOLOGY 111
 MOH Pocket Manual in Emergency

hospitalization, with or without HBO therapy.

o Alert

Severe headaches.

Dizziness.

Mental Confusion.

Nausea.

Fainting.

Pregnancy.

112 TOXICOLOGY
MOH Pocket Manual in Emergency

Chapter
5
HEMATOLOGICAL
EMERGENCY

cardiac emergency 113

 MOH Pocket Manual in Emergency

Sickle cell disease in emergency department

Overview

viscosity and cell adhesion produce intermittent vaso-occlu-

sion.

and is associated with a higher risk for developing acute

chest syndrome.

Clinical Presentation

o History
-Pain:

-What complications of SCD have you had?

-Pain - Acute chest syndrome – Stroke - Infections - Avascular

necrosis - Priapism –Cholecystitis - Splenic sequestration - Re-
nal failure - Pulmonary hypertension - Pulmonary disease - Leg
ulcers - Vision loss

114 Hematological Emergency

 MOH Pocket Manual in Emergency

-What surgeries have you had?

Cholecystectomy - Splenectomy - Joint replacement – Tonsillec-

tomy

-How often do you have pain?

-How often do you come to the ED for pain?

-What medicines do you take for pain at home?

Medications-

Eyes.

Auscultate for cardiac murmurs.

Each pain location.

Hematological Emergency 115

 MOH Pocket Manual in Emergency

Signs of infection (tenderness, erythema,

Differential diagnosis

Common Rare
Vaso-occlusive Acute coronary syn- Hepatic seques-
crisis drome tration

Infection Splenic sequestration Renal infarction

Stroke Osteomyelitis Splenic infarc-

tion
Cholelithiasis Transient red cell
aplasia Retinal detach-
Priapism ment

Mesenteric
ischemia

o Work up
CBC.

L.F.T.

Reticulocyte count.

ALT.

116 Hematological Emergency

 MOH Pocket Manual in Emergency

LDH.

Blood typing and screening.

o Management

o Prehospital Care

Administer IV opioids in pain and venous access

o In hospital care

Start D5 ½ normal saline at the maintenance rate.

Hematological Emergency 117

 MOH Pocket Manual in Emergency

Opiate therapy:

Administer IV dose of opiate:

Non opiate Therapy:

• Antihistamines

• Acetaminophen

Assess degree of relief every 15-30 minutes

o Disposition
Admission to hospital if:

Uncontrolled pain.

Blood transfusion needed.

Infections.

Complication of Vasso- Occlusive Crisis.

118 Hematological Emergency

 MOH Pocket Manual in Emergency

Anticoagulation Emergencies
Overview

Target INRs for the anticoagulated Patient:

Indication Target INR (range)

Mechanical heart valve

Mitral valve stenosis
Cardiomyopathy

Hematological Emergency 119

 MOH Pocket Manual in Emergency

Drugs That Potentiate Warfarin:

Drug Effect
Sulfonamides21

Fluoroquino-
lones21,25-27
and decreases vitamin K-producing

Antifungals25
Acetaminophen25 Interferes with vitamin K cycle
Metronidazole -

Amiodarone

Clinical Presentation

o History

Reasons why the patient is anticoagulated.

Last INR levels & last checked.

120 Hematological Emergency

 MOH Pocket Manual in Emergency

Degree of anticoagulation.

History of medications.

Physical Examination

Level of consciousness using the Glasgow Coma Scale

(GCS).

Pupillary response.

Clinical Signs Of Retroperitoneal Hemorrhage

Sign: Location of ecchymosis:
Celluen’s
Tumer’s Flanks
Upper thigh, inferior to inguinal ligament
Bryant’s Scrotum

Hematological Emergency 121

 MOH Pocket Manual in Emergency

Differential diagnosis

Spinal epidural hematoma.

Retroperitoneal hemorrhage.

Rectus sheath hematoma.

Hemopericardium.

Compartment syndrome.

Hematuria.
o Work up

CBC

Chemistry Panel.

Type and Screen/Crossmatch.

Urinalysis.

122 Hematological Emergency

 MOH Pocket Manual in Emergency

o Imaging

Head Computed Tomography.

Magnetic Resonance Imaging.

o Management

o Prehospital Care:

-
ported to a facility with 24-hour diagnostic imaging, and

Universal precautions including gloves, mask, and eye pro-

tection or face shield.

-
taminated items

Hematological Emergency 123

 MOH Pocket Manual in Emergency

o In hospital care:

o Management of Supratherapeutic INR:

If serious or life- threatening administer all of the following:

• FFP.

• PCC or rFVIIa*.

INR = 3 to < 5

2. Recheck INR frequently.

2. Recheck INR

3. Consider oral vitamin K (1- 2.5 mg) if at increased risk of

124 Hematological Emergency

 MOH Pocket Manual in Emergency

2. Administer oral vitamin K (2.5–5 mg)

3.

FFP.

Management of Minor Head Injury in the Anticoagulated Patient:

If INR is not elevated:

Standard head injury management.

If elevated INR and head CT shows intracra-

nial hemorrhage:

If serious or life- threatening administer all of the following:

• FFP.

• PCC or rFVIIa*.

Hematological Emergency 125

 MOH Pocket Manual in Emergency

If elevated INR and head CT shows no intracranial hemor-

rhage:

• Repeat CT scan.

• Correct INR

o Disposition

home unless they have little support or they are a

result in admission.

126 Hematological Emergency

 MOH Pocket Manual in Emergency

Chapter
6
ENDOCRINOLOGY AND
ELECTROLYTE EMERGRNCY

cardiac emergency 127

 MOH Pocket Manual in Emergency

Hypokalemic and Hyperkalemia Emergencies

Overview

mEq/L.

Hypokalemia is divided into the following 3 catego-

ries:

(1) Inadequate potassium intake.

(3) Transcellular shift of potassium.

128 Endocrinology and electrolyte Emergency

MOH Pocket Manual in Emergency

mEq/L.

categories:

Mild: K+ 5.5-6.5 mEq/L

Moderate: K+ > 6.5-7.5 mEq/L

Severe: K+ > 7.5 mEq/L

-
ries:

(2) Transcellular shifting of potassium.

(4) increase K intake

Endocrinology and electrolyte Emergency 129

 MOH Pocket Manual in Emergency

Clinical Presentation

o History
Generalized weakness.

Flaccid paralysis.

Gastrointestinal complaints.

Kidney disease.

Endocrine disease.

New medications started in the last year including di-

medications.

Recent trauma.

Recent gastrointestinal illnesses.

Recent surgery or hospitalizations.

History of familial periodic paralysis.

130 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

Physical Examination

Organ Hypokalemia Hyperkalemia

System
Cardiac Dysrhythmias Dysrhythmias
Conduction Conduction distur-
defects
Increased like-
lihood of dys-
rhythmias due
to digitalis

Skeletal Weakness Weakness

muscle Paralysis Paresthesia
Fasciculations Paralysis
and tetany
Cramping
Gastroin- Ileus Nausea
testinal Nausea Vomiting
Vomiting Diarrhea

distention

Renal Polyuria

Endocrinology and electrolyte Emergency 131

 MOH Pocket Manual in Emergency

Differential Diagnosis

Myocardial infarction.

Stroke.

Viral illnesses.

Myasthenia gravis.

Botulism.

Spinal cord diseases.

Polyneuropathies.

o Work up

ECG.

132 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

Urine studies.

-
ity, and urine electrolytes.

o Electrocardiogram in Hypokalemia

Flattened T-waves.

ST-segment depression.

U-waves.

o Electrocardiogram in Hyperkalemia

Peaked T-wave.

Flattened P-wave.

Prolonged PR interval.

Wide QRS.

Sine-wave pattern.

Endocrinology and electrolyte Emergency 133

 MOH Pocket Manual in Emergency

Management

o Prehospital Care:

In hypokalemia, treating symptoms of the underlying

cause.

In hyperkalemic-induced dysrhythmias and cardiac

guidelines are followed.

In hospital care:

Management of Hypokalemia

Asymptomatic and the treatment of their un-

derlying disorder.

-
vided doses.

Discharge with recommendation to increase

symptomatic or has life-threaten-

134 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

ing ECG changes:

min).

severe renal impairment).

Management of Hyperkalemia

Mild to moderate hyperkalemia (6.5-7.5

mEq/L).

Life-threatening hyperkalemia Any of the

following:

Endocrinology and electrolyte Emergency 135

 MOH Pocket Manual in Emergency

o Peaked T-waves (amplitude > R in

2 leads).

o Broad QRS.

o Sine wave.

o Bradycardia.

o Ventricular tachycardia.

o K level more than 7.

Start:

Cardiac arrest (VT, VF, PEA, asystole):

Consider hemodialysis.

Disposition

136 Endocrinology and electrolyte Emergency

MOH Pocket Manual in Emergency

Hypokalemic patients:

as long as they have close follow-up.

If the patient remains symptomatic or does not tolerate potas-

Hyperkalemic patients:

d-
-

Potassium level of 5.5-6.5 mEq/L, the disposition will

vary depending on the underlying cause.

Endocrinology and electrolyte Emergency 137

 MOH Pocket Manual in Emergency

Overview

- Hyperglycemic Hyperosmolar
toacidosis Syndrome
Ketoaci- Profound Minimal or none
dosis
Glucose
dL
HCO3 < 15 mEq/L > 15 mEq/L
Osmolar-
ity mOsm
Age Young Elderly
Onset
hours to days
Associ- Common Common
ated
diseases
Seizures Very rare Common
Coma Rare Common
Insulin Very low to
levels none

138 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

Mortality

(depends on
underlying
conditions)
Dehydra- Severe Profound
tion

Clinical Presentation

History

Polyuria.

Polydipsia.

Polyphagia.

Weight loss.

Fatigue and weakness.

Nausea and vomiting.

Hyperventilation.

Altered mental status.

Endocrinology and electrolyte Emergency 139

 MOH Pocket Manual in Emergency

Is there an associated infection?

Is there another associated illness?

The mucous membranes dry.

Skin turgor decreased.

Sunken eyes.

Tachycardia and hypotension.

Abdominal pain or tenderness, nausea and

Lack of bowel sounds, and ileus.

Altered mental status.

Febrile.

140 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

Fruity breath in DKA.

Work up

CBC.

Full Chemistry.

VBG’S.

Serum Glucose.

Serum Ketones.

Serum Osmolality.

Urinalysis and Urine Culture.

Management

Prehospital Care:

Primarily supportive.

-
cose measurement devices.

Endocrinology and electrolyte Emergency 141

 MOH Pocket Manual in Emergency

the average-sized adult.

to the ED.

illnesses.

High incidence of infection in HHS patients

has led to a recommendation for early em-

Fluids:

If hypotension persists, then give another

142 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

The patient has renal failure or has a history

of congestive heart failure, and then invasive
monitoring with central venous pressure
(CVP) monitor.

Insulin:

Intravenous insulin administration regimen is

per hour (after you have K level).

for DKA.

Potassium:

-K > 5.5 mEq/L

• Hold K.

• Check K every 2 hours.

-K 3.3-5.5 mEq/L

Endocrinology and electrolyte Emergency 143

 MOH Pocket Manual in Emergency

-K < 3.3 mEq/L

• Hold insulin.

Careful Monitoring:

indicated).

at one and two hours after the onset of treat-

ment, and at two- to four hour intervals until

to monitor clinical status.

every hour.

144 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

Disposition

Admit the patient to the ICU if:

or symptoms suggestive of acute gastric

dilatation are present (surgical consultation

the ward.

Myocardial infarction or trauma.

Endocrinology and electrolyte Emergency 145

 MOH Pocket Manual in Emergency

Thyroid Storm and Myxedema Coma

Overview

.manifestations of hypothyroidism

to the nonpitting puffy appearance of the skin and soft tissues

.related to hypothyroidism

146 Endocrinology and electrolyte Emergency

MOH Pocket Manual in Emergency

Endocrinology and electrolyte Emergency 147

 MOH Pocket Manual in Emergency

Clinical Presentation

o History

Historical Questions In The Evaluation Of Thyroid Storm

• History of thyroid disease?

• Symptoms of hyperthyroidism: tremor, agitation, weight

-
tations, menstrual irregularity?

• Thyroid manipulation?

• Medication changes?

• Recent anesthesia?

• Recent iodinated contrast?

• Infectious syndromes?

148 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

• History of thyroid disease?

• Symptoms of hypothyroidism: weight gain, hair loss, fatigue,

weight gain, dry skin, voice change, depression, constipation,

Menstrual irregularity?

• Medication changes often with menometrorrhagia.

• Physiologic/psychological stressors: infection, trauma, cold

Physical Examination

Tachycardia (widened pulse pressure).

Tremulous.

Endocrinology and electrolyte Emergency 149

 MOH Pocket Manual in Emergency

Weakness.

Weight loss.

Palpitations.

The patient with hypothyroidism classically presents:

Blood pressure low to elevate.

Skin changes.

Hypothermia.

Depressed mental function.

Nonpitting edema.

Weight gain.

Differential Diagnosis in Thyroid Storm

Hypoglycemia.

Sepsis.

150 Endocrinology and electrolyte Emergency

MOH Pocket Manual in Emergency

Encephalitis/meningitis.

Hypertensive encephalopathy.

Alcohol withdrawal.

Opioid withdrawal.

Heat stroke.

Hypoglycemia

Sepsis

Acute myocardial infarction

Intracranial hemorrhage

Panhypopituitarism

Endocrinology and electrolyte Emergency 151

 MOH Pocket Manual in Emergency

Hyponatremia

Conversion disorder

o Work up

TSH, T4 and T3.

Full chemistry.

Cardiac markers.

B-type natriuretic peptide level.

Serum lactate levels.

Random cortisol level.

Urinalysis.

Electrocardiogram.

152 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

Chest Radiography.

Echocardiography.

Computerized Tomography Head.

Management

o Prehospital Care:

Vital Sign’s.

Circulation with emergent transport to the

ED.

Blood glucose levels.

Rewarming for hypothermic patients.

Chemical and physical restraints.

Cardiac monitor and have continuous pulse

Endocrinology and electrolyte Emergency 153

 MOH Pocket Manual in Emergency

In hospital care:

o Management

IV.

Empiric glucocorticoids.

154 Endocrinology and electrolyte Emergency

 MOH Pocket Manual in Emergency

Thyroid Storm:

Three-Step Treatment Of Thyroid Storm

Goal Treatment Effect
Step 1 Block Provide continu- Slows heart
peripheral ous intravenous rate, increases
effect of infusion of
thyroid hor- and decreases
mone tremor.
Step 2 Stop the Provide antithy- Antithyroid
production of roid medication decrease syn-
thyroid hor- (propylthiouracyl thesis of thyroid
mone or methimazole) hormone in the
- thyroid.
sone. Propylthiouracyl
slows conver-
sion of T4 to T3
in periphery.

decreases con-
version of T4 to
T3 in periphery.
Step 3 - Give iodide 1-2 h Decreases re-
mone release after antithyroid lease of thyroid
medication hormone from
thyroid.

Endocrinology and electrolyte Emergency 155

 MOH Pocket Manual in Emergency

Disposition

156 Endocrinology and electrolyte Emergency

MOH Pocket Manual in Emergency

Chapter
7
UROLOGICAL
EMERGECY

cardiac emergency 157

 MOH Pocket Manual in Emergency

Rhabdomyolysis: Advances in Diagnosis and

Treatment
Overview

intracellular contents into the circulatory system.

Clinical Presentation

o History
Localizing myalgia.

Muscle stiffness.

Cramping, swelling.

Tea-colored urine.

Tenderness.

Motor weakness.

Pain with passive range of motion.

158 UROLOGICAL EMERGRNCY

 MOH Pocket Manual in Emergency

Differential diagnosis

Coma (from any cause), prolonged general anesthesia.

-
ercise, tetanus, severe dystonia, acute mania.

Heat stroke, malignant hyperthermia, neuroleptic ma-

lignant syndrome, serotonin syndrome, hypothermia/

Lightning strike, high-voltage injury, electrical cardio-

version.

Hypokalemia (licorice ingestion, diarrhea, diuretics,

primary hypoaldosteronism) hypophosphatemia, hy-
ponatremia, hypernatremia.

Ethanol, methanol, ethylene glycol, heroin, metha-

-
epines, toluene, etc.

Crush syndrome, compartment syndrome

Antihistamines, salicylates, neuroleptics (neurolep-

UROLOGICAL EMERGRNCY 159

 MOH Pocket Manual in Emergency

tic malignant syndrome), cyclic antidepressants and

(especially succinylcholine), quinine, corticosteroids,

theophylline, aminocaproic acid, propofol, colchicine,
antiretrovirals, etc.

Bacteria: Escherichia coli, Shigella, Salmonella,

Streptococcus pneumoniae, Staphylococcus aureus,
Group A Streptococcus, Clostridium, etc.

-
rus, West Nile virus, varicella-zoster virus.

Polymyositis, dermatomyositis, Sjögren syndrome.

Systemic lupus erythematosus.

Hypothyroidism, thyroid storm.

Cardiac arrest, cardiopulmonary resuscitation.

160 UROLOGICAL EMERGRNCY

 MOH Pocket Manual in Emergency

o Work up

Serum creatine phosphokinase (CK) levels.

Urine Dipstick and Urinalysis.

Electrolyte evaluation.

Liver function tests.

Electrocardiogram (ECG).

Management

o Prehospital Care:

Rapid recognition.

Consideration of the diagnosis in the trauma patient

-
ure.

UROLOGICAL EMERGRNCY 161

 MOH Pocket Manual in Emergency

o In hospital care:

Recheck CK periodically

Monitor hourly urine output.

Disposition

.Admission in all cases

162 UROLOGICAL EMERGRNCY

 MOH Pocket Manual in Emergency

Acute Urinary Retention

Overview

Women Men

Cystocele BPH

Tumor Meatal stenosis

Phimosis/ paraphimosis

• Infectious Causes Tumor

• Operative Causes • Infectious Causes

• Operative causes

Clinical Presentation

History

The location, movement, and radiation of the pain.

Medications.

UROLOGICAL EMERGRNCY 163

 MOH Pocket Manual in Emergency

History of psychiatric illness.

Suicidal intent or ideation.

initiating a urinary stream, decreased force of stream, in-

and genital itching.

Physical Examination

or uterine prolapse.

Enlarged prostate.

Phimosis or paraphimosis, lesions, and tumors.

Uterine prolapse, cystocele, enlarged uterus, or enlarged

ovaries.

164 UROLOGICAL EMERGRNCY

 MOH Pocket Manual in Emergency

Differential diagnosis

Benign prostatic hypertrophy.

Bladder calculi.

Bladder clots.

Meatal stenosis.

Neurogenic etiologies.

Paraphimosis.

Penile trauma.

Phimosis.

Prostate cancer.

Prostatic trauma/ avulsion.

Prostatitis.

Urethral strictures.

UROLOGICAL EMERGRNCY 165

 MOH Pocket Manual in Emergency

o Work up

CBC.

-
nine levels.

Urinalysis and culture.

Renal ultrasound.

Magnetic resonance imaging (MRI).

Management

o Prehospital Care

Alleviating pain.

Correcting hypovolemia.

Foley catheter placement.

166 UROLOGICAL EMERGRNCY

 MOH Pocket Manual in Emergency

In hospital care

The current American Urological Association guidelines

-

Treatment of underlying cause.

Disposition

of catheterization require emergent urological consultation

and admission.

from the ED and Follow up with a urologist within 3 days.

UROLOGICAL EMERGRNCY 167

 MOH Pocket Manual in Emergency

168 UROLOGICAL EMERGRNCY

MOH Pocket Manual in Emergency

Chapter
8
TRAUMA AND
ENVIRONMENTAL

cardiac emergency 169

 MOH Pocket Manual in Emergency

Severe Traumatic Brain Injury

Overview

skull) and acceleration-deceleration.

delayed from the moment of impact, and it may super-

-
cal injury.

Mild head Moder- Severe head

injury ate head injury
injury
Initial GCS 14-15

<1
Good functional

170 Trauma and Environmental

 MOH Pocket Manual in Emergency

injury is the Glasgow Coma Score (GCS).

Glasgow Coma Score

Eye Opening Motor Response

(E) (M)
4=opens 5=normal conversation 6=normal

spontaneously 4=disoriented 5=localizes pain

3=opens to conversation 4=withdraws from

voice pain
3=words, incoherent
2=opens to 3=decorticate pos-
pain turing

1=none sounds

1=none posturing

1=none

Clinical Presentation

o History

AMPLE history:

Trauma and Environmental 171

 MOH Pocket Manual in Emergency

A- Allergies.

M- Medications.

P- past medical history.

L- Last meal.

E- events/environment related to the injury.

Mechanism of injury.

Speed involved and potential severity of trauma.

Loss of consciousness - how long it lasted?

Nausea.

Vomiting.

172 Trauma and Environmental

 MOH Pocket Manual in Emergency

Physical Examination

skull fracture (characteristic ecchymosis, or CSF otorrhea or

rhinorrhea).

GCS.

Differential diagnosis

Acute Stroke.

Epileptic and Epileptiform Encephalopathies.

Hydrocephalus.

Metastatic Disease to the Brain.

Prion-Related Diseases.

Psychiatric Disorders Associated With Epilepsy.

Trauma and Environmental 173

 MOH Pocket Manual in Emergency

Tonic-Clonic Seizures.

o Work up

Blood Glucose Level.

CBC.

ABG.

Blood typing in case future transfusions.

Electrocardiogram (ECG).

Non-contrast CT scan.

174 Trauma and Environmental

 MOH Pocket Manual in Emergency

Management

o Prehospital Care

Bystander and emergency medical system (EMS) activation.

A-B-C-D assessment.

GCS.

Assessment and treatment of other traumatic injuries

Blood glucose.

Airways secured with an airway adjunct.

Trauma and Environmental 175

 MOH Pocket Manual in Emergency

In hospital care:

Airway.
Breathing.
Fluid Resuscitation.
Intracranial Pressure Monitoring.
Medical Therapy for Increased ICP:
mg/kg.

phenytoin equivalents/kg respectively.

Disposition

-
rosciences ICU.

Early consultation with neurosurgery and trauma surgery

176 Trauma and Environmental

 MOH Pocket Manual in Emergency

Alert

Loss of consciousness at any time.

GCS <15 on initial assessment.

Retrograde or anterograde amnesia.

Persistent headache.

Vomiting or seizures post injury.

Trauma and Environmental 177

 MOH Pocket Manual in Emergency

Electrical Injuries
Overview

Comparison of High-Voltage and Low-Voltage Electrical Injuries:

Characteristic Low-Voltage High-Voltage

Injury
Injury
Voltage, V
Type of Current Alter- Alternating current
nating current
or direct current
Duration of Prolonged Brief (if direct cur-
Contact rent)
Cause of Cardiac - Asystole
lation
Arrest
Cause of Respira- Thoracic muscle Thoracic muscle
tory tetany tetany or indirect
trauma
Arrest
Muscle contrac- Tetanic Tetanic (if alternating
tion

(if direct current)

178 Trauma and Environmental

 MOH Pocket Manual in Emergency

Burns Deep
Less common More common
Blunt injury Does not usually
violent muscle con-
Occur tractions

Clinical Presentation

o History

Bystanders and Prehospital providers are a good re-

source regarding the electrical source, the voltage, the
duration of contact, environmental factors at the scene,
and resuscitative measures already provided.

injury that initially appears to have resulted from a low-

to a high-voltage source

-
tions, allergies, and tetanus immunization status should

Trauma and Environmental 179

 MOH Pocket Manual in Emergency

Physical Examination

seen with low-voltage electrical injuries

Assessment of vision and hearing should include fundo-

assess for fractures and dislocations

necessary

180 Trauma and Environmental

 MOH Pocket Manual in Emergency

Practice Guidelines For Cardiac

Monitoring After Electrical Injuries

Characteristic Cardiac monitoring Cardiac monitoring

NOT required if is required if ANY
ALL IS the following are true
the following are true of the
Electrocardio- Normal Documented
gram arrhythmia or

evidence of ischemia
History of No Yes
loss of con-
sciousness
Type of injury
(volts (volts

Trauma and Environmental 181

 MOH Pocket Manual in Emergency

Differential Diagnosis

Intracranial hemorrhage.

Lightning Injuries.

Respiratory arrest.

Seizures.

Status Epilepticus.

Syncope.

182 Trauma and Environmental

 MOH Pocket Manual in Emergency

o Work up

Electrocardiogram.

CBC.

FULL CHEMISTRY.

CK levels.

Creatine kinase myocardial isoenzyme (CK-MB).

Head computed tomography (CT).

Trauma and Environmental 183

 MOH Pocket Manual in Emergency

For Patients With Electrical Injuries

Test Rationale/Indication

CBC

Electrolytes

BUN and creatinine

Urinalysis

If urinalysis is positive for myo-

Liver function tests/ I

amylase/lipase suspected

suspected or if surgical course is

projected

Blood type and screen/ If surgical course is projected

Crossmatch

184 Trauma and Environmental

 MOH Pocket Manual in Emergency

Management

o Prehospital Care

Secure the scene.

Turn off the power source.

Involve the local electric company.

Use (ACLS) protocols.

-
sion.

Transport to the closest appropriate facility

Trauma and Environmental 185

 MOH Pocket Manual in Emergency

Cutaneous Injuries

Cleaned and then covered with sterile dressings.

Mafenide acetate is preferred for localized full-thick-

Tetanus immunization.

Management of Injury to the Extremities

and distal interphalangeal joints (Z position) to mini-

of the heart to reduce edema.

Treatment of compartment syndrome.

186 Trauma and Environmental

 MOH Pocket Manual in Emergency

Myoglobinuria

consequences.

Disposition

ICU admition.

All patients with a history of loss of consciousness, doc-

ED (including cardiac arrest), ECG evidence of isch-

emia, or who have a sustained a high-voltage electrical

Trauma and Environmental 187

 MOH Pocket Manual in Emergency

Heat Injuries
Overview

The most serious type of heat related illness is heat stroke.

(2) Central nervous system dysfunction.

-
lignant syndrome or malignant hyperthermia secondary to an-
esthetic agents.

188 Trauma and Environmental

 MOH Pocket Manual in Emergency

Classic Both
• Elderly • Drugs • Protective cloth-
ing
• Children
• Recent alcohol
• Social isolation
illness consumption
• Prior dehydrat- • Lack of sleep,
ing illness food or water
• Skin diseases
• Lack of air condi- • Lack of physical
(i.e. anhydro-
tioning
sis, psoriasis)
• Lighter skin
conditions pigmentation
• Heat Wave increasing • Motivation to
heat production push
• Chronic mental
-
illness oneself/warrior
cosis)
mentality
• Cardiopulmonary • Lack of accli-
disease matization • Reluctance to
report
• Chronic illness • Prior heat
stroke
• Previous days • Lack of coach or
athlete education
• Elevated Heat regarding heat
illness.

Trauma and Environmental 189

 MOH Pocket Manual in Emergency

Clinical Presentation

o History

Medications.

Preceding events in order to understand the circum-

stances of the heat injury, e.g., medical illness or

Physical Examination

ABC’s and reviewing the initial vital signs.

Tachycardia.

Hypotension.

Tachypnea and tachycardia.

Mental status.

Hydration status.

190 Trauma and Environmental

 MOH Pocket Manual in Emergency

Differential Diagnosis

Delirium Tremens.

Encephalopathy, Hepatic.

Encephalopathy, Uremic.

Hyperthyroidism.

Meningitis.

Neuroleptic Malignant Syndrome.

Tetanus.

o Work up

CBC

Serum Chemistries

Trauma and Environmental 191

 MOH Pocket Manual in Emergency

Chest radiograph

Computed tomography (CT) of the Head

Electrocardiogram (ECG).

Echocardiography.

o Diagnosis of Heat Stroke:

• Central nervous system dysfunction.

•
malignant syndrome or malignant hyperthermia secondary
to anesthetic agents.

• Some sources include a marked elevation of hepatic trans-

aminases, however this is not universal.

192 Trauma and Environmental

 MOH Pocket Manual in Emergency

Management

o Prehospital Care

initiate the evaporation process

Manual fanning.

Gradual rehydration

air-conditioning, and continuous monitoring are all ap-

Trauma and Environmental 193

 MOH Pocket Manual in Emergency

In hospital care:

o Heat stroke:

Rapidly removing clothing.

Directing a fan on the patient.

194 Trauma and Environmental

 MOH Pocket Manual in Emergency

min:

if goal is reached:

Start diagnostic studies.

If goal is not reached:

Consider invasive cooling methods:

Intravascular cooling device.

Disposition

Admit all heat stroke victims to ICU.

Trauma and Environmental 195

 MOH Pocket Manual in Emergency

196 cardiac emergency

 MOH Pocket Manual in Emergency

Chapter
9
MEDICATIONS LIST

cardiac emergency 197

 MOH Pocket Manual in Emergency

Antiplatelet drugs:

Code Item Dosage Stength

form
Acetyl Salicylic Acid 75 mg –

Coated)
75 mg

Nitrates, Calcium-Channel blacker and Peripheral

vasodilators:

Code Item Dosage form Stength

Nitroglyc-
erin
Nitroglyc- Ampule- vial
erin

Opioid Analgesic:

Code Item Dosage form Stength

Morphine Ampule
Sulfate

Fibrinolytic drugs:

198 MEDICATIONS LIST

 MOH Pocket Manual in Emergency

Code Item Dosage form Stength

Alteplase Vial
Reteplase Set
Streptokinase Vial

Anticoagulants:

Code Item Dosage form Stength

Heparin Ampoule
Calcium
Heparin Vial
Sodium

syringe
Dalteparin
syringe

MEDICATIONS LIST 199

 MOH Pocket Manual in Emergency

Atrial Fibrillation: Management Strategies

Antiarrhythmic drugs:

Supraventricular and Ventricular arrhythmias:

Code Item Dosage Stength

form
Amiodarone HCL
Amiodarone HCL Ampoule
- Diltiazem Vial 25mg/5ml
Diltiazem HCL
Diltiazem HCL
SR

Bradydysrhythmias

Code Item Dosage form Stength

Atropine Ampule
Sulfate mg/1ml
Atropine
Sulfate
Dopamine Ampoule or Vial
HCL
Dopamine
HCL

200 MEDICATIONS LIST

MOH Pocket Manual in Emergency

Adrenaline
(Epineph-
rine)
Isoprenaline Ampoule
HCL (Iso- (5 ml)
proterenol
HCL)

Bradydysrhythmias

Code Item Dosage form Stength

Glucagon Vial 1 mg
Glucagon 1 mg
syringe
Calcium Gluco- Ampoule
nate
Vial
Insulin (Regular)
Ampoule

Ampoule
Ampoule
ml
Atropine Sulfate Ampule
mg/1ml

MEDICATIONS LIST 201

 MOH Pocket Manual in Emergency

Atropine Sulfate
syringe
- Vial 1gm
ride

Hypertension

Code Item Dosage Strength

form
Sodium nitro- Ampoule or
prusside Vial
- Nicardipine Vial
hydrochloride
- Fenoldopam Vial
mesylate
Nitroglycerin Ampoule or
Vial
- Enalaprilat Vail 1.25 mg / ml
Hydralazine Ampoule
hydrochloride
Sodium nitro- Ampoule or
prusside Vial
- Nicardipine Vial
hydrochloride

202 MEDICATIONS LIST

MOH Pocket Manual in Emergency

- Fenoldopam Vial
mesylate
- Ampole or 5mg/ml –
drochloride Vial
Esmolol hy- Ampoule or
drochloride Vial
Phentolamine Ampoule or
Vial
Hydrochloro- 25 mg
thiazide
Lisinopril
Enalapril
Captopril 25 mg
Perindopril 4-5 mg
Fosinopril

Losartan
Valsartan

Telmisartan

MEDICATIONS LIST 203

 MOH Pocket Manual in Emergency

Metoprolol
Propranolol
Propranolol
Atenolol
Atenolol

Carvidolol 6.25 mg
Bisoprolol 2.5 mg
Carvidolol 25 mg
Bisoprolol 5 mg
Metoprolol
Satolol HCL

Diltiazem
Diltiazem
((SR
Nimodipine
Verapamil
Verapamil
Verapamil
Clonidine
Hydralazine 25 mg

204 MEDICATIONS LIST

MOH Pocket Manual in Emergency

Acute aortic emergency

Code Item Dosage form Strength

Esmolol Ampoule or
Vial
Metoprolol Ampoule 5 mg
Ampoule or 5 mg/ml
Vial
Propranolol Ampoule or
Vial
- Diltiazem Vail 1.25 mg / ml
Verapamil Ampoule 5 mg
Nitroglyc- Ampoule or
erin Vial

Deep Venous Thrombosis

Code Item Dosage form Strength

Heparin Calcium Ampoule
Heparin Sodium Vial
5 ml
Tinzaparin Vial
Tinzaparin
syringe
Tinzaparin
syringe

MEDICATIONS LIST 205

 MOH Pocket Manual in Emergency

Tinzaparin
syringe

syringe
Deltaparin IU
syringe
Tinzaparin
syringe

syringe
Deltaparin
syringe

syringe
Tinzaparin
syringe
Deltaparin
syringe

206 MEDICATIONS LIST

 MOH Pocket Manual in Emergency

Acute Bronchial Asthma in the Emergency Department

Code Item Dosage form Strength

- -
uterol tion
- Metered Inhaler
uterol dose inhalations 5 ml
Ipratro- -
pium tion (Unite dose
ampoule )
Prednis- 5 mg
olone

Methyl- Ampoule Or vial

predniso-
lone
IV mag- Ampoule or vial
nesium
sulfate

MEDICATIONS LIST 207

 MOH Pocket Manual in Emergency

Acute Headache

Code Item Dosage form Strength

Sumatriptan

6 mg
Diphenhydramine Vial 25 mg
HCL
Metoclopramide Ampoule
Ampoule
mg/2ml
Aspirin
mg

Ketorolac
Acetaminophen
- Aspirin / -
acetamino¬phen /
caffeine
Ergotamine 1 mg

- Dihydroergotamine Ampoule -
Chlorpromazine Ampoule 25 mg
- Prochlorperazine - -

208 MEDICATIONS LIST

MOH Pocket Manual in Emergency

Adult Acute Bacterial Meningitis

Code Item Dosage form Strength

Ampoule
Vancomycin Vial
HCL
Vial 1 gm
Sodium
Vial 1 gm
Cefepim Vial 1 gm

2 gm
Susspension
5 ml
Ampicillin Vial
Sodium
1 gm

MEDICATIONS LIST 209

 MOH Pocket Manual in Emergency

Acetaminophen (Paracetamol, APAP) Overdose

Code Item Dosage form Strength

Activated Powder or
Charcoal suspension Container
Acetylcys- Ampoule
teine ml
Vitamin K
(Phytomena-
dione)
Vitamin K Ampoule 2 mg
(Phytomena-
dione)
Vitamin K Ampoule
(Phytomena-
dione)
Protamine Ampoule
sulfate

210 MEDICATIONS LIST

MOH Pocket Manual in Emergency

Sickle cell disease in emergency department

Code Item Dosage form Strength

Morphine sulfate Ampoule
- Hydromorphone Ampoule -
Diphenhydr- Vial
amine
Promethazine Ampoule
Paracetamol Vial 1 gm

Anticoagulation Emergencies

Code Item Dosage Strength

form
Vitamin K (Phytom- Ampoule
enadione)
- Fresh Frozen Plasma - -
Vial 1 mg
VIIa
Vial 2 mg
VIIa
Vial 5 mg
VIIa
- - - -

MEDICATIONS LIST 211

 MOH Pocket Manual in Emergency

Hypokalemic and Hyperkalemia Emergencies

Code Item Dosage form Strength

Potassium
chloride mmol)
Potassium Ampoule
chlorid
Magnesium Ampoule
Sulfate
Human Sol- Vial

(Regular)
-
Solution tole
Ampoule or
vial

Diabetic Emergencies

Code Item Dosage Strength

form
Sodium Chloride (Nor- Bottle or
mal Saline) ml
Sodium Chloride (Nor-
mal Saline) ml
Sodium Chloride (Nor-
mal Saline) ml

212 MEDICATIONS LIST

MOH Pocket Manual in Emergency

Vial
(Regular) ml

Potassium chloride Ampoule

2mmol/
ml

Bottle Or
Bag ml

syringe 1mEq/ml

syringe 1mEq/ml

- Sodium Phosphate - -
Calcium Gluconate Ampoule

Magnesium Sulfate Ampoule

MEDICATIONS LIST 213

 MOH Pocket Manual in Emergency

Thyroid Storm and Myxedema Coma

Code Item Dosage Strength

form
Ampoule
sodium
Hydrocorti- Ampoule or
sone Vial
Propranolol
Propranolol
Propranolol Ampoule 1 mg
- Ampoule 5 mg
sone
Propylthio-
uracil
5 mg
131 l-Iodine Vial
therapy dose

214 MEDICATIONS LIST

 MOH Pocket Manual in Emergency

Rhabdomyolysis: Advances in Diagnosis and Treatment

Code Item Dosage form Strength

Sodium Chlo-
ride (Normal
Saline)
Sodium Chlo-
ride (Normal
Saline)
Sodium Chlo-
ride (Normal
Saline)

Acute Urinary Retention

Code Item Dosage form Strength

Finasteride 5 mg

MEDICATIONS LIST 215

 MOH Pocket Manual in Emergency

Severe Traumatic Brain Injury

Code Item Dosage form Strength

Mannitol

Phenytoin Capsule
Sodium
Phenytoin Capsule
Sodium
Phenytoin Vial
Sodium

216 MEDICATIONS LIST

 MOH Pocket Manual in Emergency

Refrences

Tintinalli’s Emergency Medicine (Emergency Medicine (Tintinal-

li)) Cydulka and Garth Meckler.

-
-
MT.

Rosen’s Emergency Medicine - Concepts and Clinical

G. Rothrock.

MEDICATIONS LIST 217

 MOH Pocket Manual in Emergency

Authors

Hattan Muhammad Bojan

Consultant Emergency Medicine

Director of Emergency Medical Services Makkah Region
General Directorate of Health Affairs Makkah Region

Abdul-Aziz Al-Shotairy

Consultant Emergency Medicine

Director of King Saud Hospital
Ministry of Health

Ayman Yousif Altirmizi

Specialist Mass Gathering Medicine

Primary Health Care
Ministry of Health

Suhail Abdullah Khabeer

Clinical Pharmacist
King Saud Hospital
Ministry of Health

218
 MOH Pocket Manual in Emergency

Illustrations

Reviewed by:

Dr. Sattam AlEnezi, MD, SBEM, ArEM, JBEM, IEM

Consultant Emergency Medicine
Director of Emergency Medicine Departments, MOH

appreciation to Dr Mohammed Okashah for his generous support

and help on this work.

219
 M.O.H
DRUG LIST

ALPHAPITICAL
DRUG INDEX
 MOH Pocket Manual in General Surgery

(A)
-
atropine sulphate
ovudine
acetazolam ide azathioprine
acetylcholine chloride azelaic acid
(acetyl salicylic acid (asprine azithromycin
acitren (B)
acyclovir
adalimumab

adenosine
-
adrenaline hcl
(in
(adrenaline (epinephrine

alendronate sodium
alfacalcidol
allopurinol
alprazolam
alprostadil (prostaglandin e1) pediatric
dose
alteplase

222 ALPHAPITICAL DRUG INDEX

MOH Pocket Manual in General Surgery

amantadine hcl
amethocain
amikacin sulfate

aminoacids for adult

aminocaproic acid
aminoglutethimide
aminophyline
amiodarone hcl

ammonium chlorhde

potassium

mpicilline sodium
anagrelide
anastrozole
antihemorroidal / without steroids
( (C)

( calcipotriol
-
apracloidine hcl
onate
aripiprazole (calcitonin (salmon)-(salcatonin

ALPHAPITICAL DRUG INDEX 223

 MOH Pocket Manual in General Surgery

calcitriol
artemisinin
artesunate calcium chloride
-
calcium gluconate
hamine
calcium lactate
(
(sparaginase (crisantaspase capreomycine
atazanavir captopril
atenolol

atorvastatin

cyclophosphamide
cycloserine
cyclosporine
carmustine
carteolol hcl
carvedilol (D)
caspofungin acetate
cafaclor
cefepime hydrochloride dactinomycin
dalteparin
danazol
ceftazidime pentahydrate dantrolene sodium
dapsone

224 ALPHAPITICAL DRUG INDEX

MOH Pocket Manual in General Surgery

darunavir

cephradine desmopressin acetate

chloral hydrate

chloramphenicol
diazepam

chloroquine diclofenac
chlorpheniramine maleate didanosine
chlorpromazine hcl
chlorthalidone
dihydralazine mesilate or hydralazine
hcl
(cholecalciferol (vitamine d3
cholestyramine (diltiazem hcl (sustainad release
cincalcet hydrochloride dimenhydrinate
cinnararizine dinoprostone
diphenhydramine hcl
cispltin (diphetheria,tetanus,pertussis (dpt
diphetheria,tetanus vaccine for adult
diphetheria,tetanus vaccine for
clarithromycin
children
clindamycin

ALPHAPITICAL DRUG INDEX 225

 MOH Pocket Manual in General Surgery

clindamycin or erythromycin for acne dipyridamol

clindamycin phosphate disodium pamidronate
clofazimin disopyramide phosphate
clomiphene citrate
clomipramine hcl dodutamine hcl
clonazepam
clonidine hcl docusate sodium
clopidogral domperidone
clotrimazole dopamine hcl
dorzolamide&1
clozapine
codeine phosphate
colchicine dydrogesterone
colistin sulphomethate sodium (E)
econazole
corticorelin (corticotrophin-releasing
edrophonium chloride
(factor,crf
cromoglycate sodium efavirenz
( (electrolyte oral rehydration salt (ors
cyclopentolate hcl

cyclophosphamide
cycloserine
cyclosporine
carmustine
carteolol hcl

226 ALPHAPITICAL DRUG INDEX

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(D) carvedilol
caspofungin acetate
cafaclor
dactinomycin cefepime hydrochloride
dalteparin
danazol
dantrolene sodium ceftazidime pentahydrate
dapsone
darunavir

desmopressin acetate cephradine

-
chloral hydrate
rid

chloramphenicol
diazepam

diclofenac chloroquine
didanosine chlorpheniramine maleate
chlorpromazine hcl
chlorthalidone
dihydralazine mesilate or hydralazine
hcl

ALPHAPITICAL DRUG INDEX 227

 MOH Pocket Manual in General Surgery

cholecalciferol (vitamine d3)

diltiazem hcl (sustainad release) cholestyramine
dimenhydrinate cincalcet hydrochloride
dinoprostone cinnararizine
diphenhydramine hcl
diphetheria,tetanus,pertussis (dpt) cispltin
diphetheria,tetanus vaccine for adult
diphetheria,tetanus vaccine for chil-
clarithromycin
dren
clindamycin
dipyridamol clindamycin or erythromycin for acne
disodium pamidronate clindamycin phosphate
disopyramide phosphate clofazimin
clomiphene citrate
dodutamine hcl clomipramine hcl
clonazepam
docusate sodium clonidine hcl
domperidone clopidogral
dopamine hcl clotrimazole
dorzolamide&1
clozapine
codeine phosphate
dydrogesterone colchicine
(E) colistin sulphomethate sodium
econazole

228 ALPHAPITICAL DRUG INDEX

MOH Pocket Manual in General Surgery

corticorelin (corticotrophin-releasing
edrophonium chloride
factor,crf)
efavirenz cromoglycate sodium
electrolyte oral rehydration salt (ors)
cyclopentolate hcl

enalapril malate
enfuvirtide gentamicine

entecvir gliclazide
ephedrine hydrochloride glipizide
glucagon
-
glycrine
(ropoietins
ergotamine tartarate
gonadorelin (gonadotrophine-releas-
(ing hormone, lhrh
erythromycin goserlin acetate
escitalopram granisetron
esmolol hcl griseofulvin micronized
esomeprazole magnesium trihydrate (H)
estradiol valerate
etanercept haloperidol

injection
ethanolamine oleate (
ethinyl estradiol (
ethionamide homatropine
ALPHAPITICAL DRUG INDEX 229
 MOH Pocket Manual in General Surgery

human chorionic gonadotrophin

etomidate
etoposide (human isophane insulin (nph
human menopausal gonadotrophins,-
etravirine
follicle

(F)
hormone

is sterile and free of hepatitis, hivand

i.m injection
any other infectious disease agent
-
(
(centrate
fat emulsion hyaluronidase
( hydralazine hcimesilate
fentanyl citrate hydrochlorothiazide
ferrous salt hydrocortisone

acid

(I)

ifosfamide
iloprost

230 ALPHAPITICAL DRUG INDEX

MOH Pocket Manual in General Surgery

imidazole derivative

imipramine hcl
(indapamide (sustaind release
indinavir
indomethacin
follitropin

foscarnet
(vaccine
fosinopril insulin aspart
furosemide nsulin detmir
fusidic acid insulin glargine
(G) insulin lispro
interferon alpha
ganciclovir

mefenemic acid irintecan hydrochloride

iron saccharate
megestrol acetate isoniazid
isoprenaline hcl (isoproterenol hcl)
melphalan
memantine hcl

ALPHAPITICAL DRUG INDEX 231

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meningococcal polysaccharide sero

isotretinoin
group (a,c,y,w-135)
mercaptopurine itraconazole
meropenem
mesalazine ivermectin
mesna (K)
metformin hcl kanamycin
methadone hcl
ketamine hcl
ketoconazole

ketotifen

methyldopa (L)
methylerrgonovine maleate
methylphenidate lactulose
methylperdnisolone lamivudine
metoclopramide hcl lamotrigine
metolazone tartrate lansoprazole
metolazone latanoprost
metolazone tartrate l-carnitine
etronidazole
lenalidomide
micafungin sodium letrozole
miconazole Leucovorin calcium
midazolam leuprolid depo acetate
miltefosine levamizole

232 ALPHAPITICAL DRUG INDEX

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minocycline hcl levetiracetam

mirtazapine
misoprostol
mitomycin
Lidocaine hcl
linezolid
moclopemide
mometasone furoate lisinopril
montelukast sodium
orphine sulphate lomustine
Loperamide hcl
ultienzyme (pancreatic enzymes:pro-

multivitamins lorazepam
mupirocin losartan potassium

mycophenolate mofetil (M)

(N)
nafarelin mannitol
maprotilline hcl
measles vaccine
naphazoline

mechlorethamine hcl
natamycin

ALPHAPITICAL DRUG INDEX 233

 MOH Pocket Manual in General Surgery

phenylephrine hcl nateglinide

phenytoin sodium
phosphate enema neomycin sulphate
phosphate salt neostigmine methylsulpfate
phytomenadione niclosamide
pilocarpine nicotine(24-hour effect dose)
pioglitazone

plasma protein solution nimodipine

pneumococcal polyvalent (23 valent)
nitrazepam
vaccine

nitrofurantoin
strain)
polyacrylic acid nitroglycerin

potassium chloride 46.6mg/sachet

(cetirizine or noratadine)
polystyrene sulphate resins (calcium)| noradenalin acid tartrate
potassium salt norethisterone

pravastatin nystatin
praziquantel (O)
prazosin hcl octreotide
prednisolone

234 ALPHAPITICAL DRUG INDEX

MOH Pocket Manual in General Surgery

oily phenol injection

olanzapine
Primaquine phosphate olopatadine hcl
Primidone omeprazole sodium
Procainamide hcl ondansetron
orienograstim (g-csf)
Procyclidine hydrochloride
Progesterone
Proguanil hcl
Promethazine hcl
proparacaine
propfol (P)
propylthiouracil
Propranolol hcl paliperidone
Protamine sulfate
prothionmide
Protirelin (thyrotrpphin-releasing
pantoprazoole sodium sesquihydrate
hormone,trh)
-
papaverin
histamine
Pumactant phospholipid para-amino salicylate sodium
paracetamol
Pyrazinamide pegaspargase
Pyrethrins pegylated interferon alpha 2a
Pyridostigmine
penicillamine

ALPHAPITICAL DRUG INDEX 235

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Pyrimethamine
pentamidine isethionate
primaquine phosphate
(Q)
quetiapine perindopril
quinidine sulfate permethrin
quinine dihydrochloride pethidine hcl
quinie sulphate

(R)
v potassium)

phentolamine mesylate
injection

pentavalent antimony)
streptokinase racemic epinphrine
streptomycin sulfate raltegravir
strontium ranelate ranitidine
succinylcholine choloride
sucralfate
sulfacetamide repaglinide
sulfadiazine reteplase
-
retinoin (vitamine a)
mine25mg

sulindac
sulpiride rifampicin
sumatriptan succinate riluzole

236 ALPHAPITICAL DRUG INDEX

MOH Pocket Manual in General Surgery

(T) ringer’s lactate solution

tacrolimus risperidone
ritonavir

telmisartan
temazepam
ropivacaine hcl

teriparatide rosuvastatin
terlipressin acetate (S)

injection
tetanus vaccine scorpion anti – venin
tetracosactrin (corticotrophin) selegiline hcl
tetracycline hcl senna
thalidomide sevelamer
theophylline
thiacetazone
silver sulfadiazine (steril)
thioguanine simethicone
thiopental sodium simvastatin
tigecycline sirolimus
timolol sitagliptin phosphate
tinzaparin sodium snake anti-venin

ALPHAPITICAL DRUG INDEX 237

 MOH Pocket Manual in General Surgery

tiotropium sodium acetate

sodium aurothiomalate

sodium chloride
tolterodine tartrate sodium cormoglycate
topiramate sodium hyaluronate
trace elements additive (pediatric sodium hyaluronate intra-articular
dose) (mw over 3 sillion)
tramadol hcl sodium nitropruprusside
sodium phosphate
sodium valpproate
trazodone somatropin (human growth hormone)
tretinoin
triamcinoloneacetonide sotalol hydrochloride
spectinomycin hcl
spiramycin
spironolactone
trimetazidine dihydrochloride (modi-

sterile water for injection

triple virus vaccine (mea-
verapamil hcl

triptorelin acetate verapamil hcl (sustaind release)

tropicamide

238 ALPHAPITICAL DRUG INDEX

MOH Pocket Manual in General Surgery

typhoid vaccine (W)

(U) warfarin sodium

urea water for injection (sterile)

urofollitrophine f.s.h

(V)

valaciclovir hcl (Y)

valganciclover hcl yellow fever vaccine

valsartan (Z)

vancomycin hcl zidovudine (azidothymidine,AZT)

vaccine)
vasopressine zinc sulfate

zolledronic acid

zolpedem tartrate

vincristine sulfate

vitamine B1 & B6& B12

vitamine E

voriconazole

ALPHAPITICAL DRUG INDEX 239

 MOH Pocket Manual in General Surgery

Authors

Khalid O. Dhafar, MD, MBA, FRCS, FACS

Consultant General Surgery
Health Affair, Ministry of Health

Hassan Adnan Bukhari, MD, FRCSC

Assistant Professor, General Surgery, Umm Al-Qura University
Consultant General Surgery, Trauma Surgery and Critical Care, King

Head of Accident and Emergency Department, Al-Noor Specialist

Hospital

Abdullah Mosleh Alkhuzaie, MD, SBGS

Consultant General Surgery

Ministry of Health

Saad A. Al Awwad, MD, SBGS, JBGS

Consultant General Surgery
King Fahad General Hospital, Ministry of Health

240 ALPHAPITICAL DRUG INDEX

 MOH Pocket Manual in General Surgery

Ali Abdullah S. Al-Zahrani, MD, SBGS

Consultant General Surgery
King Faisal Hospital, Ministry of Health

Mohammed Abdulwahab Felimban, MD, ABFM, FFCM (KFU)

Director of healthcare quality and patient safety
Health affair, Ministry of Health

Faisal Ahmed Al-Wdani, BPharma (KFH)

Clinical Pharmacist
King Faisal Hospital, Ministry of Health

Illustration

Flowchart by Hassan Adnan Bukhari

Medication Table by Faisal Ahmed Al-Wdani

ALPHAPITICAL DRUG INDEX 241

 Acknowledgement

Great appreciation for Dr. Ghiath Al Sayed , Consultant General

Surgery,King Fahad medical city, for reviewing and editing this