COLLEGEOFMEDI

CINE&JNM HOSPI
TAL,
WBUHS,
KALYANI

DEPARTMENTOFMEDI
CINE

Basi
ccl
ini
calgui
del
inef
orI
nter
neeandJR

Pat
ientpr
esent
edwi
thUNCONCOIUSNESS/STUPOR/
MENTALOBTUNDATION/NEUROLOGICALDEFI
CITS/
SEI
ZURES

.ASK:
i Diabet
es/Tr
auma/Al
cohol
/AnyDr
ugi
ntoxi
cat
ion/

Pr
evi
oushi
stor
yofsei
zur
e/Fev
er/Gast
roUpset/Thy
roi
d/

Li
verdi
sor
der

.CHECK:Bl
i
i oodSugar(
CBG)
/BP/Pul
se/Hear
tsound

i
i
i.SEND:
CBC,
LFT,
Urea,
Creat
ini
ne,
Na,
K,RBS,
Lipi
dPr
ofi
l
e,TSH,

Fev
erscr
een–MPDA,
Widal
,Dengue,
CRP,
Uri
neRE/
ME/
Ket
one

Body

i
v.I
MAGE:CXR,CTBr
ain–NCCT/CECT,
ECG,
USG

.MAI
v NTAI
NABC:I
VFl
uid(
NSi
n

CVA/
Sepsi
s/Dy
sel
ect
rol
ytemi
a,25%Dor10%Dor5%Di
n

hy
pogl
ycaemi
a/al
cohol
int
oxi
cat
ion,
DNSi
nLi
verdi
sor
der
,No

RLi
nLi
verdi
sor
der
,NOI
VFi
nCHF/
CKD)
;Moi
stOxy
genand/
or

Nebul
i
zat
ion;
Ryl
e’
sTubef
eedi
ng;
HighVol
umeNSi
nDKA–1-
2

n1stHour>2Li
Li nnext2Hour>2Li
nnext4-
6Hour
s
 v
i.TREATaccor
dingl
y

St
andar
dPr
escr
ipt
ion:

b.CVA:

i
.Ry
le’
stubef
eedi
ng

i
i
.Moi
stO2

i
i
i.I
VFNS500ml
8hour
ly

i
v.I
nj.Manni
tol
20%I
VTDS

v
.Inj
cit
icol
i
ne500mgI
VBD

v
i.I
njPi
racet
am 800mgI
VTDS

v
ii
.Inj
Labet
alol
20mgI
V(i
fpat
ienthy
per
tensi
ve,
andunconsci
ous)

v
ii
i.TabAml
odi
pine5mg(
inconsci
oushy
per
tensi
vepat
ient
)

i
x.I
njPan40I
VOD

x.Tabaspi
ri
n75ODHS(
inI
schemi
cCVA)

xi
.Post
ural
car
e,Pr
oppedupat30degr
ee

c.HYPOGLYCEMI
A:
 i
.Sear
chf
orCKD,

i
i
.Gl
ucoset
hroughI
V25%D1-
2ampul
esi
nbol
us,
thenmai
ntai
nIV

gl
ucoseupt
o6-
10hri
fREGULARI
NSULI
Nist
heCause,
24-
36hr

i
nMi
xtar
dINSULI
N,72-
96hri
nOHAbyI
VF5%DorDNS.Check

CBGf
requent
ly.

i
i
i.I
nhy
pogl
ycaemi
ccoma,
wit
hhy
pot
ensi
on-I
VHy
drocor
ti
sone

100mgI
VTDSf
or24-
72hour
s.

d.DKA/
HONK

i
.IVFNS1-
2Li
nFI
RSTHOUR,
anot
her1-
2Li
nnext2hour
s,1-
2L

i
nnext4hour
s,t
henNS4-
6hour
lyt
il
lCBG<250mg

i
i
.Inj
REGULARI
NSULI
NIV0.
1U/
Kguni
tsbol
usandt
hen

0.
1U/
Kg/
Houri
nfusi
ont
il
lCBG250mg.

i
i
i.ChangeI
VFt
o0.
45NSor0.
45%DNSaf
terCBG<250mg,

Mai
ntai
nCBG150-
250mg

i
v.I
VAnt
ibi
oti
cs–PI
P-TAZ/
MEROPENEM,
mai
ntai
nNA/
K

v
.Inj
KCL2ampi
n500ml
NS8hour
lyi
fK<3.
3

e.SEPSI
S:

i
.IVant
ibi
oti
cs–i
njPI
P+TAZ4.
5gm I
VTDS/
QDSorI
nj
 MEROPENEM 1gm I
VBD/
TDSandI
njMETROGYLI
VTDSorI
nj

CLI
NDAMYCI
N300I
VTDS.

f
.ALCOHOLI
NTOXI
CATI
ON:

i
.inj
TRI
NEUROSOLH1ml
IM OD,

i
i
.inj
LORAZEPAM 1mg/
DIAZEPAM I
V/I
M BDandSOS

i
i
i.I
VFDNSor5%DI
VTDS

i
v.I
njPPII
VOD

g.SEI
ZURE:

i
.Moi
stO2,

i
i
.IVFDNSorNS6-
8hour
ly

i
i
i.i
njLORAZEPAM 2mg/
DIAZEPAM 5mgI
Vsl
owl
ybol
us,
maybe

r
epeat
edoncemor
e

i
v.i
njPHENYTOI
N100mg8-
10amp=20mg/
kgBW I
Vov
er4-
6

hour
s,t
hen10mg/
KgI
Vov
er4-
6hour
,then100mgI
VTDS,

v
.inj
LEVETI
RACI
TAM 500mgI
VBDi
n100ml
NS,

v
i.I
VPPI

h.BDZpoi
soni
ng:i
njFLUMAZENI
L(ANNEXATE)0.
5mgI
Vst
at

. OPPo
i i
soni
ng:
 i
.inj
Atr
opi
ne15-
30ampI
Vst
at,
then5-
15ampI
VTDSi
nIVFt
il
l

f
ull
atr
opi
nisat
ion,

i
i
.inj
PAM I
Vst
atandr
epeatoncewi
thi
n12houri
frequi
red,

i
i
i. Or
orphar
yngeal
suct
ion,

i
v.I
njCef
tri
axone+Met
rogy
l

. SDH–i
j mmedi
ater
efert
oNEUROSURGERY,
IVManni
tol

k.LI
VERf
ail
ure:

i
.inj
Cef
otaxi
me1gm I
VTDS,

i
i
.inj
Decadr
on2ccI
VTDS,

i
i
i.i
njManni
tol
IVTDS,

i
v.I
njLOLAI
VTDS,

v
.inj
Met
rogy
lIVTDS,

v
i.P-
ENEMAandLact
ulose30-
120ml
til
ll
oosemot
ion,

v
ii
.Ry
le’
stube–Ri
faxi
min550BD,
UDI
LIV300BD,
I
NDERAL40-
80

mg/
day
,Di
uret
icsi
frequi
redALDACTONELASI
X

v
ii
i.i
njoct
reot
ide50mi
crogr
am/
hri
nfusi
on

i
x.I
VPPI

x.I
njVi
tKI
VOD
2.PATI
ENTPRESENTEDWI
THRESPI
RATORYDI
STRESS/CHEST

PAI
NORDI
SCOMFORT/CARDI
O_NEUROCOMBI
NEDSYMPTOMS:

a.ASK:Angi
nal
Pai
nonsett
ime/anypr
evi
oussi
mil
arepi
sode/Fev
er/

Tuber
cul
osi
s/Sy
ncopei
nLastoney
ear
/Pr
evi
ousCXRandECG

/
Smoki
ngandAl
cohol
hist
ory/Hemopt
ysi
s

b.CHECK:Pal
l
or,
Cyanosi
s,Cl
ubbi
ng,
Oedema,
JVP,
LungandHear
t

Auscul
tat
ion/Ly
mphnode/BP/Pul
se

c.DOURGENTLY:ECG,CBG,TROP-
T,CXRPA

d.SEND:
Rout
ineBl
oodasment
ionedpr
evi
ousl
y,PLEURALFLUI
D

anal
ysi
s–cel
lcount
,cel
lty
pe,
sugar
,pr
otei
n,LDH,
ADA,
M cel
l

e.I
MAGE:ECHO,CECTTHORAX/
HRCTTHORAX

f
.STANDARDPRESCRI
PTI
ONf
orAMI
:

i
.Moi
stO2

i
i
.IVFNS4-
8hour
lydependi
ngonsi
tuat
ion

i
i
i.Ry
le’
stubeorOr
aldr
ugs–

1.TabAspi
ri
n75mg5t
abst
atandt
hen1t
abOD

2.TabCl
opi
dogr
el75mg4t
abst
atandt
hen1t
abOD

3.TabSobi
tr
ate5mgS/
Lst
atandmayber
epeat
ed5-
10mi
n

i
nter
val
(max3t
ab)
 4.TabRami
pri
l1.
25-
10mgperday/Tel
misar
tan20-
80mg

perdayaccor
dingt
oBP

5.TabMet
opr
olol
6.25–50mgperday
/Bi
sopr
olol
1.25-
5

mgperdayaccor
dingt
oBP.DONOTUSEi
nHy
pot
ensi
on,

Hear
tBl
ock,
Brady
car
dia

6.TabAt
orv
ast
ati
n80mgst
att
hen20-
40mgOD/

Rosuv
ast
ati
n40mgst
atand20mgOD

7.Tabcl
onazepam 0.
5ODHS

i
v.I
VPPI

v
.Pl
anf
orThr
ombol
ysi
sinSTEMIof<6-
12Hour
sdur
ati
on,
Check

f
orcont
rai
ndi
cat
ions,
NCCTBr
ain,
theni
njSTREPTOKI
NASE1.
5

mi
l
li
onuni
tIVi
n100ml
NSov
er30-
60mi
ninI
CUwi
thcar
diac

moni
tor
ing,
recheckECG.
..
.ORALTEPLASE15mgI
VBOLUS

ov
er1-
2mi
nut
es,
then50mgi
nfusi
onov
er30mi
n,t
hen35mg

ov
ernextonehour,
ORTENECTAPLASEsi
ngl
eBOLUSdose

ov
er5seconds–30mgi
n<60KG,
35mgi
n60-
70Kg,
40mgi
n

70-
80Kg

v
i.I
fthr
ombol
ysi
snotpossi
bleduet
oLATEARRI
VAL>12hour
,inj

LMWH40-
60mgI
Vst
att
hen40-
60mgS.
CBDf
or5day
s

v
ii
.TabNi
tr
ocont
in2.
6mgBD8AM &3PM orMONOTRATE/
ISMO

30SRODand/
orNI
KORANDI
L5-
10mgOD

v
ii
i.I
nUA/
NSTEMI
,I
njLMWHasdescr
ibedpl
ust
abRANOLAZI
NE
 500BDi
ncont
inuouspai
n

i
x.I
ncar
diogeni
cshock,
SBP<90–i
njDOPAMI
NE2ampi
n500ml

NS@ 40mi
crodr
ops/
min,
SBP<70i
njNor
adr
enal
i
ne2ampi
n

500ml
NS@40mi
crodr
ops/
min

x.I
nar
rhy
thmi
ali
keVT,
DCshockori
njAMI
ODARONE300mgI
V

bol
us,
then300mgi
n500ml
NSov
er5-
6hour
,then300mgi
n

500NS8hour
lyi
nnext18hour
.InPSVT,
VERAPAMI
L5-
10mgI
V

ov
er2mi
nut
es,
orDi
l
tiazem 15-
20mgI
Vov
er2mi
n,or

Ami
odar
oneasabov
e

g.CHF:

i
.NOI
VForcont
rol
l
edDNS

i
i
.Moi
stO2

i
i
i.Pr
oppedupposi
ti
on

i
v.I
njLASI
X1-
2ampI
VOD/
BD

v
.TabAl
dact
one25mgOD

v
i.TabAspi
ri
n75OD,
Clopi
dogr
el75OD,
Rami
pri
lorTel
misar
tan

asabov
e,Met
opr
olol
/Bi
sopr
olol
asabov
e,St
ati
nasabov
e

v
ii
.TabLanoxi
n0.
25ODi
nCHFwi
thAF

h.AECOPD/PLEURALEFFUSI
ON/PNEUMOTHORAX:

i
.Moi
stO22-
4L/
min,
but>6Li
npneumot
hor
ax
 i
i
.Nebul
i
sat
ionwi
thDuol
i
n6hour
lyandBudecor
t12hour
ly

i
i
i.I
njCoamoxy
clav1.
2gm BD/i
njPI
P+TAZ4.
5gm TDSI
V

i
v.Or
alAzi
thr
omy
cin500mgOD,
DONOTUSEFLUOROQUI
NILONE

v
.Inj
Der
iphy
ll
ineI
VTDS

v
i.I
njHy
drocor
ti
sone100I
VTDSi
nCOPD

v
ii
.ChestMedi
ciner
efer
ral
forPneumot
hor
ax

v
ii
i.I
njLasi
xIVBDi
ncorpul
monal
e

3.PATI
ENTPRESENTEDWI
THFUO/
PUO:

a.ASK,
FEELandCHECK:

Pat
ter
noff
ever–i
nter
mit
tent
/cont
inuous,
OnsetandDur
ati
on,

associ
atedf
eat
ures–chi
l
l/r
igor
,

RASH–l
ocat
ion/dayofappear
ance/t
ypeofr
ash,
Bleedi
ng

mani
fest
ati
ons,

CNS–headache/neckpai
nandst
if
fness/nauseaandv
omi
ti
ng/

di
plopi
a/squi
nt/sei
zur
e/LOC/f
oal
neur
ologi
cal
signs–hemi
par
esi
s,

monopar
esi
s,par
a-orquadr
ipar
esi
s,

RS–cough/hemopt
ysi
s/expect
orat
ion/pai
nchest
/SOB,

CVS–pai
nchest
/dy
spnea/si
gnsofCHF,
GIT–j
aundi
ce/pai
n

abdomen/v
omi
ti
ng/di
arr
hoea/dy
sent
ery
/hemat
ochezi
a/

or
ganomegal
y–l
i
ver
,spl
een,
 GENI
TOURI
NARY–l
owerabdomi
nal
pai
n/bur
ningmi
ctur
it
ion/

dy
sur
ia/backpai
n/pusandorbl
oodi
nur
ine/menst
rual
pai
n/whi
te

di
schar
geperv
agi
na/somet
hingcomi
ngoutperv
agi
na,

AUTOI
MMUNE–ar
thr
it
is/
art
hral
gia–numberofswol
l
enandt
ender

j
oint
swi
tht
empor
alpat
ter
nofi
nvol
vement
/phot
osensi
ti
vi
ty/r
ashand

pal
pabl
epur
pur
a/hemat
uri
a/r
aynaud’
sphenomena/ski
nti
ght
eni
ng/

gl
andul
arswel
l
ing/muscl
eweakness/or
alul
cer
s,

I
NFECTI
ON–pasthi
stor
yofTBorcont
actTB,
HIV,
HBV,
HCV,
Blood

t
ransf
usi
onhi
stor
y,occupat
ion,
wor
kingl
onel
ylongdi
stancef
rom

home,
sexual
hist
ory
,tr
avel
toar
easendemi
cforMal
ari
a,kal
a-azar
,

seasonal
disease–dengue,
undert
reat
mentofMDRTy
phoi
d,

BLOOD–st
ernal
tender
ness/l
ymphadenopat
hy/bl
eedi
ng/pur
pur
a,

MALI
GNANCY–Wei
ghtl
oss/speci
fi
csy
stemi
csy
mpt
oms.

b.SEND:

ROUTI
NEBLOOD-CBCwi
thPLATELETSandMPt
hickandt
hinsmear
,

LFT,
RFT-
U/CR,

I
NFECTI
ONSCREEN:Typhi
DOTI
gM,
WIDAL,
MPDA,
DENGUEPROFI
LE,

BLOODCULTURE,
URI
NERE/
ME/
CS,
STOOLRE-
ME/SPUTUM AFB

&CBNAAT

I
MMUNOLOGI
CALSCREEN:ESR,
CRP,
FERRI
TIN,
ANAwi
thENA

PROFI
LE,
RF,
ACPA.

BODYFLUI
DANALYSI
S-CSF/PLEURAL/ASCI
TICFLUI
D–cel
lty
pe,
 cel
lcount
,Pr
otei
n,sugarADA,
LDH,
M cel
l
.

SEROLOGY– HI
V,HBV,
HCV

FNACFROM SOLorLN.

c.I
MAGE:CXRPA/USGABDOMEN/CTBRAI
N,THORAX,
ABDOMEN–

NCCTorCECTorHRCT/ECHOCARDI
GRAPHY/ENDOSCOPY–upper

andl
owerGI

d.TREAT:EMPI
RICALasf
oll
ows

i
.Inj
CETRI
AXONE2gm I
VBDorI
njPI
P+TAZ4.
5gm I
VTDSori
nj

MEROPENEM 1gm I
VTDS

i
i
.Inj
VANCOMYCI
N500mgI
VTDS

i
i
i.TabAZI
THROMYCI
N500BD

i
v.I
njMETROGYLI
VTDS

e.MENI
NGOENCEPHALI
TIS:

i
.Inj
DECADRON2ccI
Vst
atandI
VTDS

i
i
.Inj
CETRI
AXONE2gm I
VBDorI
njMEROPENEM 1gm I
VBD

i
i
i.I
njVANCOMYCI
N500mgI
VTDSi
n100ml
NS(
DONOTusei
n

ARF/CKD)

i
v.I
njE-
MAL150mgI
M ODf
or3day
s
 v
.Inj
ACYCLOVI
R500mgI
VTDSi
n100ml
NS

v
i.I
njPheny
toi
n100mgI
VTDSorI
njLEVETI
RACETAM 500mgI
V

BDi
n100ml
NS

f
.CEREBRALMALARI
AorCOMPLI
CATEDMALARI
A:

i
.Inj
Decadr
on2ccI
VTDS

i
i
.Inj
ARTESUNATE60mgv
ial
2VI
AL=120mgI
VSTATand

seconddoseaf
ter12hourf
rom 1stdosei
nD1,
then120mgi
.e.

2VI
ALI
VODf
or5day
sfr
om D2–D5. Or
,

I
njQUI
NINE20mg/
kgI
Vfi
rstdoset
hen10mg/
kgI
VTDSi
nIVF

i
i
i.I
VF5%Dor10%Di
ncaseofQui
nine,
andDNSor5%Di
n

Ar
tesunat
eIV6-
8hour
ly

i
v.I
njOndanset
ron4I
VTDS

v
.TabLUMERAX80orLUMETHERFORTE1t
abBDf
or3day
s(I
t

i
sini
ti
alt
reat
mentofuncompl
i
cat
edmal
ari
a)

v
i.SendG6PDandi
nnor
mal
casesgi
veMALI
RIDDS15mgODf
or

14day
s(P.Vi
vax)andMALI
RIDDS15mg3t
aboncei
nP.

f
alci
par
um

g.DENGUEandot
herv
iralf
ever
:

i
.IVFNSorRL(DONOTUSE–DNS/
5%D)I
V4-
6hour
ly
 i
i
.ORS2l
i
t/day

i
i
i.TabPARACETAMOL650QDS

i
v.I
VPPI

v
.Inj
ONDEM I
VTDS

v
i.TabAZI
THROMYCI
N500mgBDi
nsel
ect
ivecases

v
ii
.CHECK-PLATELET,
PCV,
SGPT/
SGOTonDAI
LYbasi
s

v
ii
i.Di
schar
geaf
ter36-
72hourofaf
ebr
il
eper
iodandPl
atel
ets

i
ncr
easi
ng>75,
000

i
x.Askt
otakehi
ghpr
otei
nandf
atdi
et

h.MDRTy
phoi
d:

i
.Inj
CEFTRI
AXONE2gm I
VBD

i
i
.TabAZI
THROMYCI
N500mgBD

i
i
i.I
njDECADRON2ccI
VTDSi
nTYPHOI
DSTATEorPsy
chosi
s

i
.GISEPSI
Swi
thDi
arr
hoea(
AGE)

i
.IVFNS6hour
ly

i
i
.Inj
CETRI
AXONE1gm I
VBDorI
njCI
FRANI
VBD

i
i
i.I
njMETROGYLI
VTDS

i
v.CapI
MODI
UM 2mg2capst
atand1capBDt
il
ll
oosemot
ion.

Maxi
mum t
otal
dose16mg.
 v
.CapPREBI
OTI
C-PROBI
OTI
CS(
Ent
eroger
mina/Pr
ovi
dac/Bi
fi
lac

HP/Vi
zyl
acRI
CH/VSL#3)
1capBD/
TDS

v
i.I
VPPI

j
.UTI
:

i
.IVFNS6hour
ly

i
i
.Inj
Cet
ri
axone1gm I
VBDorI
njPi
P+Taz4.
5gI
VTDSorI
nj

Mer
openem 1gm I
VTDS

i
i
i.TabNi
tr
ofur
ant
oin100BD/
TDS

i
v.TabURI
SPAS200TDS

v
.Inj
Dicl
ofenacI
M BDi
fpai
nissi
gni
fi
cant

v
i.Sy
rAl
kasol
2tsfTDS

v
ii
.CapTamsul
osi
n0.
4ODHSi
nMal
e

4.PATI
ENTPRESENTEDWI
THACUTEUPPERGIBLEEDI
NG:

a.ASK:Pr
evi
ousUl
cerhi
stor
y/al
cohol
/smoki
ng/NSAI
DS/Fast
ing/

Chr
oni
cLi
verdi
sease/GIcancer
/Bl
ackst
ool
/Bl
eedi
ngsi
mul
taneous

wi
thv
omi
ti
ngorj
ustast
heendoff
orcef
ulv
omi
ti
ng(
esophageal
tear
)/

Aci
dpoi
soni
ng

b.CHECK:Pal
l
or/Cl
ubbi
ng/Vi
rchow’
sandot
herLN/Asci
tesandLi
ver
-
 spl
een/aci
dinj
urymar
k/pul
se/
BP

c.SEND:
Rout
ineBl
ood/Gr
oupi
ng–cr
ossmat
chi
ngf
orBl
ood

Tr
ansf
usi
on/ser
ology

d.I
MAGE:UGI
E/xr
ayabdomen

e.TREAT:

i
.IVFNS6hour
ly,
mayneedI
VHemaccel

i
i
.Bl
oodt
ransf
usi
on2uni
ts

i
i
i.I
njPan40mg2VI
ALi
nIVF6-
8hour
lyt
il
lact
ivebl
eedi
ng,
then1

v
ial
IVBD

i
v.I
njTr
anexami
caci
d500I
VTDS

v
.Inj
Lor
azepam 2mg/Di
azepam 5mgI
M BD

v
i.I
njOCTREOTI
DE250mi
crogm I
Vbol
ust
hen50mi
crogr
m/hour

i
nfusi
oni
.e100mg2ampi
neachI
VF

v
ii
.Inj
VitKI
VODf
or3day
s

v
ii
i.i
nACI
DPOI
SONI
NG:
NPM/I
VFDNS/i
njCEFTRI
AXONEand

METROGYL/SUCALFATE/
DIAZEPAM

5.PATI
ENTPRESENTEDWI
THCHRONI
CLI
VERDI
SEASEWI
TH

ASCI
TES:

a.ASK:hi
stor
yofALCOHOL/HBVorHCV/anyDr
ug/Sl
eeppat
ter
n
 al
ter
ati
on/Fev
er/upperGIbl
eedi
ng

b.LOOKf
or:
Ast
erexi
s/j
aundi
ce/oedema

c.SEND:
Rout
ineBl
ood/PTI
NR/Ser
ology–HBV,
HCV,
HIV/ASCI
TIC

Fl
uidAnal
ysi
s–cel
lcount
/cel
lty
pe/pr
otei
n/sugar
/LDH/ADA/
M cel
l
/

SAAG

d.I
MAGE:USGabdomen/UGI
E

e.TREAT:

i
.NoI
VForJudi
ciousI
VFDNS12hour
ly.DONOTUSERL

i
i
.Inj
Cef
otaxi
me1gm I
VTDS

i
i
i.I
njLasi
x1ampI
VBD/
TDS

i
v.TabALDACTONE100mgOD/
BD/
TDSdependi
ngonedema

v
.TabI
NDERAL40½t
abBDor1t
abBD

v
i.TabURSODEOXYCHOLI
CACI
D300BD

v
ii
.Sy
rLACTULOSE30-
120ml
perdayi
ndi
vi
deddose

v
ii
i.TabRi
faxi
min550BD

i
x.I
njPPII
VBD

x.I
njVi
tKI
VODf
or3day
s

xi
.Inj
Met
rogy
lIVTDS
 xi
i
.Ther
apeut
icaspi
rat
ion1.
5-3L

xi
i
i.I
njHumanAl
bumi
n20%I
Vov
er4-
6hour
sODf
or3day
s,t
hen

t
wiceweekl
y

6.PATI
ENTPRESENTEDWI
THCKD:

a.ASK:Hi
stor
yofHTN/T2DM/AI
CTD/Dr
ug

b.LOOKFOR:oedema/per
icar
it
is/f
eat
uresofCHF/AVf
ist
ula

c.SEND:Rout
ineBl
ood/RENALFUNCTI
ONTEST/SPOTURI
NEACR/

Ser
ology–HBV,
HCV,
HIV/Ca,
PTH,
HCO3

d.I
MAGE:
USGabdomen,
Echocar
diogr
aphy
,ECG,CXRPA

e.TREAT:

i
.NOI
VF

i
i
.Moi
stO2SOS

i
i
i.I
njLASI
X2ampI
VTDS

i
v.TabZy
tani
x2.
5-5mgOD

v
.TabPHOSTATE667BD

v
i.TabNODOSI
S500BD

v
ii
.Inj
DARGEN40SCONCEweekl
yorERYTHROPOI
ETI
N4000SC

t
wiceweekl
y
 v
ii
i.TabI
RONOD

i
x.TabCALCI
UM OD

x.ANTI
-HTN:
aml
odi
pin5-
10BD

xi
.IfDi
abet
es:
inj
Regul
ari
nsul
i
n/Li
nagl
i
pti
n

xi
i
.BLOODr
equi
sit
ioni
frequi
red,
NEVERTRANSFUSEBLOODi
n

WARD.Bl
oodTr
ansf
usi
ont
obedonedur
ingHEMODI
ALYSI
S.

xi
i
i.Sendt
hePat
ientt
oHDaf
terpr
epar
ati
oni
fneeded.

7.ATTEMPTEDHANGI
NG:

a.ASK:Ti
me,
Place,
andDur
ati
onofi
nci
dence/Ti
met
akent
ocomet
o

medi
cal
faci
l
ity
/anyot
herassoci
atedpoi
soni
ng

b.LOOK:Li
gat
uremar
ks/Pl
ant
arr
efl
ex/Sei
zur
e/Focal
neur
ologi
cal

si
gns

c.CHECK:
Pul
se/
BP

d.TREAT:

i
.Har
dcer
vical
col
l
ar

i
i
.Moi
stO2

i
i
i.I
VFNS8hour
ly

i
v.I
njMet
hyl
Predni
sol
one30mg/
kg(
1.5–2gm)I
Vov
er30mi
n,

t
hen5.
4mg/
kg/
hri
.e2-
3gm i
neachI
VFbot
tl
eov
er23-
47hr
 v
.Inj
PPI

v
i.I
njEPTOI
N100I
Vsos

MANAGEMENTOFSNAKEBI
TE:

 ASK:Ti
meandLocat
ionofBi
te/Hav
eyouseenSNAKE?
/ti
met
o

t
akehospi
tal
faci
l
ity
/anyt
ightbi
ndi
ng/anybl
eedi
ngf
rom

or
if
ices/di
plopi
a/r
espi
rat
orydi
str
essordi
ff
icul
tyi
nbr
eat
hing/

pai
nabdomen

 LOOK:
Local
inj
ury–Bi
temar
ks,
swel
l
ing,
bleedi
ng,
bli
ster
/

Pur
pur
a,ecchy
moses,
bleedi
ngf
rom anysour
ce/Pt
osi
s/Si
gnsof

r
espi
rat
orydi
str
ess/SI
NGLEBREATHCOUNT<28abnor
mal
/

anypr
evi
ousmedi
cat
ion–AVSorphener
gan/chestauscul
tat
ion

–r
honchi
/anyt
ightbi
ndi
ng

 DO:
Opent
ightbi
ndi
ngi
fany
/Immobi
l
izel
i
mbi
nanat
omi
cal

posi
ti
on/mayel
evat
ethel
i
mbathear
tlev
el/Asknott
oWALK/

Resusci
tat
eifr
equi
red

 SEND:
20mi
nut
eWHOLEBLOODCLOTt
est
/Rout
inebl
ood–U,

Cr
/Gr
oupi
ngandCr
ossmat
chi
ng–FFP,
Whol
eBl
ood/CTBr
aini
f

LOCorNeur
ologi
cal
signs/USG–abdi
fpai
nabdomen

 TREAT:
o Moi
stO2SOS

o I
VFNS6-
8hour
ly

o I
njHy
drocor
ti
sone100mgI
VSt
atandsosi
freact
ion

occur
s

o I
njAdr
enal
ine(
1mg/
ml)½ampI
M St
atandSOSi
freact
ion

occur
s

o I
njRant
acI
VSt
atandI
VTDS

o I
njAVS10Vi
ali
n500mlNSov
er60mi
n,St
artsl
owf
or5-

15mi
ntol
ookf
oranyr
eact
ion

o I
njAVS5-
10Vi
ali
n500mlNSov
er30-
60mi
n–MAYBE

REPEATEDi
fsy
mpt
omsper
sist
s–bl
eedi
ng/r
espi
rat
ory

di
str
ess.Tot
al30Vi
alAVScanbei
nfusedi
nav
erage

si
tuat
ion.

o Whol
eBl
oodTr
ansf
usi
onorFFPi
fbl
eedi
ngper
sist
s

o I
njNEOSTI
GMI
NE0.
5mg+I
njATROPI
NE0.
5mgI
VSt
at

andr
epeataf
ter15-
20mi
nint
erv
alI
Mif

Pt
osi
s/Resp.
Dist
ressper
sist
s,oral
ter
nat
ivel
yINJ

NEOSTI
GMI
NE0.
5mg4ampul
esi
n500mlNS,
PLUSi
nj

ATROPI
NE0.
5mgoneampoul
eIVov
er6-
8hour
ly.

o Maybeshi
ft
edt
oICUf
orMechani
cal
Vent
il
ator

o Mayr
equi
reHemodi
aly
sisi
nARF
o I
njPHENERGAN1ampI
M SOSi
nreact
ion.