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Emergency Medicine

Algorithms ©

2014

This is a freely available educational resource in support of the development of Emergency Medicine in Kenya and the activities of:

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Table of Contents

  • 1. Adult

Cardiac Arrest Algorithm

3

  • 2. Adult Bradycardia (< 50/min)/Tachycardia (> 150/min)

4

  • 3. Post-Cardiac Arrest Care Algorithm

5

ACS Algorithm

  • 4. .........................................................................................................................................................................

6

STEMI Algorithm

  • 5. .....................................................................................................................................................................

7

  • 6. NSTEMI/UA Algorithm

............................................................................................................................................................

8

  • 7. Pulmonary Embolism Algorithm

9

  • 8. Rapid Sequence Intubation Algorithm

10

  • 9. Difficult Airway Algorithm .....................................................................................................................................................

11

  • 10. Anaphylaxis Algorithm

...........................................................................................................................................................

12

  • 11. Acute Asthma Exacerbation Algorithm

13

  • 12. Peak Expiratory Flow Chart

14

  • 13. Hypertension Algorithm

15

16

  • 15. Hypertensive Emergencies

19

  • 16. Hypertensive Emergencies Drug Infusions

20

  • 17. SEPSIS Definitions

.................................................................................................................................................................

21

  • 18. Severe Sepsis/Septic Shock Algorithm

22

  • 19. Hyperglycaemia Algorithm

23

  • 20. Uncomplicated Hyperglycaemia Algorithm

24

  • 21. Hypoglycaemia Algorithm

25

  • 22. Electrolyte Abnormalities Algorithm

26

  • 23. Algorithm..................................................................................................................................................................

Syncope

27

  • 24. Algorithm

Seizures

28

  • 25. Transient Ischemic Attack (TIA) Algorithm

29

  • 26. Stroke

Algorithm

30

  • 27. Stroke Reperfusion Algorithm

31

  • 28. Trauma Management Pathway

32

  • 29. C-Spine Clearance Algorithm

33

  • 30. Mild Traumatic Brain Injury Algorithm

34

  • 31. Epistaxis Algorithm .................................................................................................................................................................

35

  • 32. Low Back

Pain

Algorithm

36

  • 33. Epigastric Pain Algorithm

.......................................................................................................................................................

37

  • 34. Upper Gastrointestinal Bleeding Algorithm

38

  • 35. Management of Pain in Sickle Cell Disease (SCD) Algorithm

39

  • 36. Pain Management Algorithm

40

  • 37. Analgesia Chart

41

  • 38. Procedural Sedation and Analgesia (PSA)

42

  • 39. Antimicrobial Guide

43

  • 40. Poisoning

49

  • 1. Adult Cardiac Arrest Algorithm

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be
This clinical pathway is intended to
supplement, rather than substitute
for, professional judgment and may
be changed depending upon a
patient’s individual needs. Failure
to comply with this pathway does
not represent a breach of the
standard of care.
Unresponsive
No Breathing or no normal breathing
(i.e. only gasping)
Activate Resuscitation Team
Get AED/Defibrillator
CHECK PULSE
Definite Pulse
DEFINITE pulse palpated
within 10 secs?
• Open and maintain patent airway
• Give 1 breath every 6 seconds
• Recheck pulse every 2 mins
• Go to 3. Post Cardiac Arrest Care Algorithm
No Pulse
Begin CPR - cycles of 30 COMPRESSIONS then 2 BREATHS
• Perform continuous compressions until BVM is available
• Use BVM when available to give breaths even without O 2 .
Attach O 2 at 15L/min when available
High-Quality CPR
• Compression rate of at least 100/min
• Compression depth at least 5 cm
• Allow complete chest recoil after each
AED/Defibrillator ARRIVES
Attach AED pads or use Quick look defibrillator paddles to check rhythm
compression
• Minimize interruptions in chest
compressions to < 10 seconds
• Avoid excessive ventilation – Give
enough volume just to produce visible
Rhythm
chest rise. Give 2 breaths after every 30
compressions or if intubated, give 1
breath every 6 seconds
Shockable?
Yes
No
VF/Pulseless VT
Asystole/PEA
Shock
• Biphasic 200J
• Monophasic 360J
Change compressors - CPR 2min
• IV/IO access – Take bloods for VBG & RBS
• Attach monitor leads; adjust monitor to lead II
Change compressors - CPR 2min
• IV/IO access – Take bloods for VBG & RBS
• Attach monitor leads; adjust monitor to lead II
Rhythm Shockable? Yes No Shock • Biphasic 200J • Monophasic 360J Change compressors - CPR 2min
Rhythm
Shockable?
Yes
No
Shock
• Biphasic 200J
• Monophasic 360J
Change compressors - CPR 2min
• Adrenaline 1mg IV/IO with 20ml NS flush
(Repeat dose after 2 CPR cycles)
• Identify and treat reversible causes below
Change compressors - CPR 2min
• Adrenaline 1mg IV/IO with 20ml NS flush
(Repeat dose after 2 CPR cycles)
Rhythm
No
Shockable?
Yes
Shock
• Biphasic 200J
• Monophasic 360J
• Identify and treat reversible causes below
• Consider advanced airway, capnography
• If return of spontaneous circulation, go to
3. Post Cardiac Arrest Care Algorithm
Reversible causes
-
Hypoglycaemia
- Tension Pneumothorax
Change compressors - CPR 2min
• Amiodarone 300mg IV/IO bolus with 20ml NS flush
(Second dose after 2 CPR cycles) – 150mg with 20 ml NS flush)
• Identify and treat reversible causes below
• Consider advanced airway, capnography
-
Hypovolemia
- Tamponade,
cardiac
-
Hypoxia
- Toxins
-
Hydrogen ion (acidosis)
- Thrombosis,
pulmonary
-
Hypo-/hyperkalaemia
- Thrombosis,
coronary
-
Hypothermia

2. Adult Bradycardia (< 50/min)/Tachycardia (> 150/min) (with Pulse)

This clinical pathway is intended to

2. Adult Bradycardia (< 50/min)/Tachycardia (> 150/min) (with Pulse) This clinical pathway is intended to supplement,

supplement, rather than substitute for,

professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with

Airway

Open and maintain patent airway; protect as necessary

  • this pathway does not represent a breach of the standard of care.

Breathing Administer Oxygen (if SPO 2 < 94%); Assist breathing as necessary

Breathing Administer Oxygen (if SPO < 94%); Assist breathing as necessary

Circulation Cardiac monitor to identify rhythm; monitor blood pressure, pulse oximetry, T o C, RBS Establish IV access and take bloods for FBC, UEC, VBG Print rhythm strip or 12-lead ECG if available; don’t delay therapy

Circulation • Cardiac monitor to identify rhythm; monitor blood pressure, pulse oximetry, T C, RBS •

Identify and treat underlying cause

  • - - Tension Pneumothorax

Hypoglycaemia

  • - - Tamponade, cardiac

Hypovolemia

  • - - Toxins

Hypoxia

  • - Hydrogen ion (acidosis)

- Thrombosis, pulmonary

  • - - Thrombosis, coronary

Hypo-/hyperkalaemia

  • - Hypothermia

Identify and treat underlying cause - - T ension Pneumothorax H ypoglycaemia - - T amponade,
   

Signs of instability

 

Hypotension?

Signs of Shock?

Acutely altered mental status?

Ischaemic chest discomfort?

Acute heart failure?

Tachycardia (> 150/min)
 
Tachycardia (> 150/min)

Tachycardia (> 150/min)

 
 
Signs of instability • Hypotension? Signs of Shock? • Acutely altered mental status? • • Ischaemic
Wide QRS? ≥ 0.12 seconds No Yes Narrow Complex Tachycardia (Supraventricular Tachycardia) HR > 150/min +
Wide QRS?
≥ 0.12 seconds
No
Yes
Narrow Complex Tachycardia
(Supraventricular Tachycardia)
HR > 150/min + QRS complexes < 0.12sec
Wide Complex Tachycardia
(Ventricular Tachycardia)
HR > 150/min + QRS complexes ≥ 0.12sec
Stable
Signs of instability
Stable
Vagal Stimulation
(at least 2 different manoeuvres)
Synchronised cardioversion
(NOT if varying R-R intervals/Atrial fibrillation)
• Valsalva (Abdominal pressure/Breath holding)
• Facial application of ice water
• Carotid sinus massage (C/I if bruits, CVS
disease, elderly)
Consider procedural sedation
Start with 100J initially with
escalation as needed
Consult a Cardiologist

Adenosine

(NOT if varying R-R intervals/Atrial fibrillation)

6 mg rapid IV push; follow with 20mls NS flush; then 12 mg IV after 1-2 mins if required

Consult a Cardiologist

   
2. Adult Bradycardia (< 50/min)/Tachycardia (> 150/min) (with Pulse) This clinical pathway is intended to supplement,

Amiodarone

150mg IV over 10 mins then 1mg/min

infusion for first 6 hours

Adenosine

(NOT if varying R-R intervals/Polymorphic) 6 mg rapid IV push; follow with 20mls NS flush;

then 12 mg IV after 1-2 mins if required

   
2. Adult Bradycardia (< 50/min)/Tachycardia (> 150/min) (with Pulse) This clinical pathway is intended to supplement,

Amiodarone

150mg IV over 10 mins then 1mg/min

infusion for first 6 hours

Alternatives (under expert advice) β blockers Ca Channel Blockers or Digoxin

Consider (if Torsades de Pointes):

Defibrillation (asynchronous) Magnesium 2gm IV over 10 mins Overdrive pacing

Bradycardia (HR < 50/min)

With signs of instability

Consult a Cardiologist and continue with the algorithm

Bradycardia (HR < 50/min) With signs of instability Consult a Cardiologist and continue with the algorithm

IV Atropine

Exclude: head injury, hypoxia, hypothermia, heart block, hyperkalaemia, heart transplant

First Dose: 0.5mg bolus Repeat every 3-5 minutes Maximum: 3 mg

IV Atropine Exclude: head injury, hypoxia, hypothermia, heart block, hyperkalaemia, heart transplant First Dose: 0.5mg bolus

If atropine ineffective:

  • 1. Transcutaneous Pacing (See pacing protocol)

OR

  • 2. Dopamine IV infusion 2 -10µg/kg/min

OR

  • 3. Adrenaline IV Infusion 2-10 µg/min

Consult a Cardiologist Alternative: Glucagon if β-blocker or CCB overdose

  • 3. Post-Cardiac Arrest Care Algorithm

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

 

Return of Spontaneous Circulation (ROSC)

 
   
 
Return of Spontaneous Circulation (ROSC) • Activate Resuscitation Team (if not already present ) AND a

Activate Resuscitation Team (if not already present) AND a Physician/Cardiologist

Monitor, support ABCs. Be prepared to provide CPR and defibrillation

Check vital signs (BP, PR, RR, SPO 2 , T o C, RBS)

12-lead ECG immediately

If patient is stable, consider immediate transfer to ICU attached to a defibrillator

   
 
Return of Spontaneous Circulation (ROSC) • Activate Resuscitation Team (if not already present ) AND a

Optimize ventilation and oxygenation

Avoid excessive ventilation.

  • - Start at 10 – 12 breaths/min (1 breath every 6 seconds)

  • - Titrate FiO 2 to minimum necessary to maintain SPO 2 94%

  • - Titrate to target PETCO 2 of 35 – 45 mmHg

Consider advanced airway and waveform capnography

Optimize ventilation and oxygenation • Avoid excessive ventilation. - Start at 10 – 12 breaths/min (1

Treat hypotension (SBP < 90mmHg) IV/IO Bolus: 1-2 L Normal Saline or Ringers Lactate Vasopressor infusion if NO response to fluid bolus:

  • - Adrenaline IV Infusion: 0.1 – 0.5µg/kg/min (7-35µg/min in 70-kg adult)

  • - Norepinephrine IV Infusion: 0.1 – 0.5µg/kg/min (7-35µg/min in 70-kg adult) Identify and treat reversible causes

  • - Hypoglycaemia

- Tension Pneumothorax

  • - Hypovolemia

- Tamponade, cardiac

  • - Hypoxia

- Toxins

  • - Hydrogen ion (acidosis)

- Thrombosis, pulmonary

  • - Hypo-/hyperkalaemia

- Thrombosis, coronary

  • - Hypothermia

 
Treat hypotension (SBP < 90mmHg) • IV/IO Bolus: 1-2 L Normal Saline or Ringers Lactate •

Keep the patient’s temperature < 36 o C for 36 hours using ice-

 

cold fluids, ice packs, and

cold fluids, ice packs, and No Patient is able to follow commands?

No

Patient is able to follow commands?

intravascular or surface temperature-management

 
 

Yes

 
Keep the patient’s temperature < 36 C for 36 hours using ice- cold fluids, ice packs,

STEMI or Suspicion of ACS – Consult a Cardiologist Transfer to Critical Care Unit (ICU/CCU) attached to a defibrillator

4. ACS Algorithm

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Chest discomfort suggestive of ischemia (includes anginal equivalents (atypical symptoms) like exertional pain in the ear, jaw, neck, shoulder, arm, back, or epigastric area; exertional dyspnoea; nausea and vomiting; diaphoresis; and fatigue.

   
4. ACS Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

Monitor, support ABCs in the Resuscitation Room (ER). Be prepared to provide CPR and defibrillation

Obtain/review 12-lead ECG within 10 minutes of arrival to ER

  • - Do a V4R if ST elevation in lead V1 with simultaneous ST depression in V2 - ? Right sided STEMI

  • - Do V7 - V9 if ST depressions ≥ 1 mm with upright T-waves in ≥ 2 contiguous anterior precordial leads (V1 to V3) - ? Posterior STEMI

- If there is ST elevation in aVR ≥ 1mm and aVR ≥ V1 with widespread horizontal ST depression, most prominent in leads I, II and V4-6 –

consult an Interventional Cardiologist immediately for PCI (Left main coronary artery occlusion/Proximal LAD lesion) - Sinus Tachycardia, T wave inversion in III & V1, V3 or (S1, Q3, T3) pattern - ? See 7. Pulmonary Embolism Algorithm Check vital signs (BP, PR, RR, SPO 2 , T o C, RBS) Start Oxygen IF SPO 2 < 90% or if patient is dyspnoeic. Maintain SPO 2 90% Establish IV access in left forearm or antecubital vein and send blood samples for UEC, Coagulation screen & hsTroponin T if 4 hours since onset of symptoms Perform brief, targeted history, physical exam – Indicate time of symptoms onset

• Monitor, support ABCs in the Resuscitation Room (ER) . Be prepared to provide CPR and

Aspirin 300mg to chew (if not given by EMS, Not Allergic, No active Upper GI Bleeding or Retinal bleeding, not a haemophiliac, No severe untreated BPs)

Nitroglycerin sublingual spray 0.4mg SL for pain relief every 5mins up to relief of discomfort or MAX 3 doses reached. DO NOT give nitroglycerine if:

  • - SBP < 90mmHg (or 30 mm Hg below the patient’s known baseline),

  • - Heart rate > 100 bpm, or < 50 bpm.

  • - Right ventricular infarction (right ventricular infarction causes a preload dependent state)

  • - Use of sildenafil or vardenafil within the previous 24 hours or tadalafil within the previous 48 hours. Fentanyl 50µg IV if pain is NOT relieved by the 3 doses of SL nitroglycerin. Repeat once if still in pain after 5 mins. For persistent pain, consult a

Cardiologist/Physician. Consider IVI nitroglycerin (see C/I above)

• Aspirin 300mg to chew (if not given by EMS, Not Allergic, No active Upper GI

Obtain portable CXR to r/o other causes of chest pain (pulmonary embolus, cardiac tamponade, aortic dissection, tension pneumothorax ) Review initial 12-lead ECG

 
• Obtain portable CXR to r/o other causes of chest pain ( pulmonary embolus, cardiac tamponade,
• Obtain portable CXR to r/o other causes of chest pain ( pulmonary embolus, cardiac tamponade,
• Obtain portable CXR to r/o other causes of chest pain ( pulmonary embolus, cardiac tamponade,

ST elevation or LBBB meeting Sgarbossa criteria (see below)

ST-Elevation MI (STEMI)

ST elevation or LBBB meeting Sgarbossa criteria (see below) ST-Elevation MI (STEMI)

See

5. STEMI Algorithm

ST depression > 0.5mm or dynamic T-wave inversion 2mm; strongly suspicious for ischemia High-Risk Unstable Angina/Non-ST-Elevation MI (UA/NSTEMI)

   
4. ACS Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

See

6. UA/NSTEMI Algorithm

 

Normal or Non-diagnostic changes in ST segment or T wave

Intermediate/Low Risk UA

   
4. ACS Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

Sequence of changes seen during evolution

Left Bundle Branch Block (LBBB)

Sgarbossa criteria for LBBB (either)

of myocardial infarction

of myocardial infarction Concordant ST elevation ≥ 1mm in at least 1 lead
  • 1. Concordant ST elevation ≥ 1mm in at least 1 lead

Sequence of changes seen during evolution Left Bundle Branch Block (LBBB) Sgarbossa criteria for LBBB (either)
Sequence of changes seen during evolution Left Bundle Branch Block (LBBB) Sgarbossa criteria for LBBB (either)
  • 2. Concordant ST depression ≥ 1mm in V1 - 3

Sequence of changes seen during evolution Left Bundle Branch Block (LBBB) Sgarbossa criteria for LBBB (either)

5. STEMI Algorithm

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

ST elevation or LBBB meeting Sgarbossa criteria (see 4. ACS Algorithm) ST-Elevation MI (STEMI)

ST elevation or LBBB meeting Sgarbossa criteria (see 4. ACS Algorithm ) ST-Elevation MI (STEMI)

Consult an

Interventional Cardiologist

No Time from onset of symptoms ≤ 12 hours? Yes Consult an Interventional Cardiologist to determine
No
Time from onset of symptoms ≤ 12 hours?
Yes
Consult an Interventional Cardiologist
to determine if the patient is for
Thrombolysis/Fibrinolysis OR Primary PCI

Primary PCI

Obtain informed consent

Give:

  • 1. Clopidogrel (600mg) OR Prasugrel (60mg) OR Ticagrelor (180mg)

  • 2. Atorvastatin 80mg

Transfer to Cathlab within 90 minutes of arrival to the ER

   

Thrombolysis/Fibrinolysis

   

Give:

  • 1. Clopidogrel 600mg

  • 2. Enoxaparin:

If age <75 y: 30-mg IV bolus, followed in 15 min by 1 mg/kg SC (max.100 mg for the first 2 doses) If age ≥ 75 y: no bolus, 0.75 mg/kg SC (max. 75 mg for the first 2 doses)

Regardless of age, if CrCl < 30 mL/min: 1 mg/kg SC

 
  • 3. Atorvastatin 80mg

   
 
Thrombolysis/Fibrinolysis Give : Clopidogrel 600mg Enoxaparin: If age <75 y: 30-mg IV bolus, followed in 15
   
 

Absolute Contraindications

Review/Complete Fibrinolysis Checklist

Relative Contraindications

Any prior intracranial haemorrhage

History of chronic, severe, poorly controlled hypertension

Known structural cerebral vascular lesson (e.g., AVM)

Severe uncontrolled hypertension on presentation (SBP > 180 mmHg or

Known malignant intracranial neoplasm (primary or metastatic)

DBP > 110 mmHg)

Ischaemic stroke within 3 months EXCEPT acute ischaemic stroke

History of prior ischaemic stroke > 3 months, dementia, or known

within 3 hours Suspected aortic dissection

intracranial pathology not covered in contraindications Traumatic or prolonged (>10 minutes) CPR or major surgery (< 3 weeks)

Recent (within 2 to 4 weeks) internal bleeding

Active bleeding or bleeding diathesis (excluding menses) Significant closed head trauma or facial trauma within 3 months

Non-compressible vascular punctures For streptokinase/anistreplase: prior exposure (> 5 days ago) or prior allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

 
Thrombolysis/Fibrinolysis Give : Clopidogrel 600mg Enoxaparin: If age <75 y: 30-mg IV bolus, followed in 15

No Contraindications for Fibrinolysis/Thrombolysis Obtain informed consent for fibrinolysis/thrombolysis

Ensure patient is connected to a defibrillator (ECG, SPO 2 , BP) and repeat baseline vitals. Administer fibrinolysis within 30 mins of arrival to ER

  • TENECTEPLASE

    • To reconstitute tenecteplase, mix the 50-mg vial in 10 mL sterile water (5 mg/mL). Tenecteplase is administered in a 30-50 mg IV bolus over 5 seconds. The dosage is calculated on the basis of the patient’s weight, as follows:

      • - < 60 kg - 30 mg (6 mL)

      • - 60 to 69 kg - 35 mg (7 mL)

      • - 70 to 79 kg - 40 mg (8 mL)

      • - 80 to 89 kg - 45 mg (9 mL)

      • - ≥ 90 kg - 50 mg (10 mL)

  • STREPTOKINASE

  • OR

    • Set up second IV line for the Streptokinase. Run Normal Saline/Ringers Lactate TKVO in other line

    • The adult dose of streptokinase for STEMI is 1.5 million U in 50 mL of 5% dextrose in water (D5W) given IV over 60 minutes. Allergic reactions force the termination of many infusions before a therapeutic dose can be administered.

    Monitor vital signs (BP, PR, RR, SPO 2 ) every 15 minutes during the infusions Continue monitoring patient for 30mins after the end of the infusions Transfer patient to CCU/ICU connected to the defibrillator

    6. NSTEMI/UA Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    ST depression > 0.5mm or dynamic T-wave inversion ≥ 2mm; strongly suspicious for ischemia Normal or
    ST depression > 0.5mm or dynamic T-wave inversion ≥ 2mm; strongly
    suspicious for ischemia
    Normal or Non-diagnostic changes in ST segment or T wave
    Intermediate/Low Risk UA
    High-Risk Unstable Angina/Non-ST-Elevation MI (UA/NSTEMI)
     
    TIMI Risk factors TIMI Risk Score Probability of Death, Myocardial Note: Each of the listed risk

    TIMI Risk factors

    TIMI Risk Score

    Probability of Death, Myocardial

    Note: Each of the listed risk factors is worth 1 point

    Infarction and Revascularization

    (range 0-7 points).

    Within 30 Days, %

    Age greater than 65 years

     

    0

    2.1

    At least 3 risk factors for coronary artery disease (including family

     

    1

    5

    history of the disease, hypertension, hypercholesterolemia, diabetes mellitus, and current tobacco use)

     

    2

    10.1

    Significant coronary stenosis (prior known coronary stenosis ≥ 50%)

     

    3

    19.5

    ST-Segment deviation

     

    4

    22.1

    Severe anginal symptoms (≥ 2 anginal events in the previous 24 hours)

     

    5

    39.2

    Use of aspirin in the previous 7 days

     

    6

    45

    Elevated serum cardiac marker levels (hsTrop T)

     

    7

    100

         
       
     
    TIMI Risk factors TIMI Risk Score Probability of Death, Myocardial Note: Each of the listed risk
    Repeat 12 lead ECG in 30 mins/Continuous ST-segment monitoring
    Repeat 12 lead ECG in 30 mins/Continuous ST-segment monitoring

    STEMI

    See 5. STEMI Algorithm

    hsTroponin T > 14ng/L OR TIMI score ≥ 3 points OR ST depression OR Dynamic ECG
    hsTroponin T > 14ng/L OR TIMI score ≥ 3 points OR ST depression OR Dynamic ECG changes
    Yes
    No
    hsTroponin T ≥ 14ng/L
    Consult a Cardiologist/Physician
    If Troponin done < 4 hours from symptom onset then repeat
    Troponin at 3 hours from admission to ER
    hsTroponin T < 14ng/L

    If no evidence of ischaemia or infarction by testing, can discharge ± cardiology follow-up

    Criteria for Discharge (must meet ALL the criteria)

    Two ECGs which are Normal and No ST Depression and No Dynamic changes

    hsTroponin T < 14ng/L at ≥ 4 hours from onset of symptoms OR 3 hours from admission to ER

    • 7. Pulmonary Embolism Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    Clinical features suggestive of Pulmonary Embolus • Monitor, support ABCs in Resuscitation room (ER). Be prepared
    Clinical features suggestive of Pulmonary Embolus
    • Monitor, support ABCs in Resuscitation room (ER). Be prepared to provide CPR and defibrillation
    • Obtain/review 12-lead ECG – Consider ACS – See 5. STEMI Algorithm.
    Features of PE on ECG; Sinus Tachycardia, T wave inversion in III & V1, V3 or S1, Q3, T3 pattern. A normal ECG can be seen in 30% of patients
    • Check vital signs (BP, PR, RR, SPO 2 , T o C, RBS)
    • Start Oxygen IF SPO 2 < 94% or if patient is dyspnoeic. Maintain SPO 2 ≥ 94%
    • Establish IV Access and send blood samples for FBC, UEC, Coagulation screen & hsTroponin T (See 6. UA/NSTEMI Algorithm for interpretation)
    • Perform brief, targeted history, physical exam
    • Chest x-ray – If alternative cause for symptoms found, treat underlying cause. If not, continue with algorithm

    Clinical gestalt or validated clinical decision sup port tool

    Wells score

    Criteria Points Suspected DVT An alternative diagnosis is less likely than PE Hear Rate >100bpm Immobilisation
    Criteria
    Points
    Suspected DVT
    An alternative diagnosis is less
    likely than PE
    Hear Rate >100bpm
    Immobilisation or surgery in the
    previous 4 weeks
    Previous DVT/PE
    Haemoptysis
    Malignancy (on treatment, treated
    in the last 6 months, or palliative)
    3.0
    3.0
    1.5
    1.5
    1.5
    1.0
    1.0
    Score Range
    Probability of
    Interpretation of Risk
    (Points)
    PE (%)
    0-4
    > 4
    7.8 (5.9 – 10.1)
    40.7 (34.9 – 46.5)
    Low Probability
    Moderate to High
    Probability
    Hemodynamically stable, low probability for PE (< 15%)
    Moderate to high probability for PE (≥ 15%)
    Haemodynamically stable?
    Any Pulmonary Embolism Rule-Out Criteria met?
    No
    Yes
    1.
    Is the patient > 49 years of age?
    PE safely
    2.
    Is the pulse rate > 99 beats per minute?
    excluded
    Negative
    3.
    Is the pulse oximetry reading < 95% while the
    Bedside echocardiogram
    Presence of RV dilatation, septal
    shift, or right heart thrombus?
    CTPA*
    consider
    patient breathes room air?
    other
    4.
    Is there a present history of haemoptysis?
    Positive
    diagnosis
    5.
    Is the patient receiving exogenous oestrogen?
    Yes
    No
    6.
    Does the patient have a prior diagnosis of venous
    thromboembolism?
    7.
    Has the patient had recent surgery or trauma
    requiring endotracheal intubation or hospitalization
    in the previous 4 weeks?
    Admit to ICU
    • Begin anticoagulation
    • Consider thrombolysis
    • If contraindication to
    anticoagula tion,
    continue resuscitation,
    consider embolectomy
    Administer IV fluids
    & resuscitate
    • Begin anticoagulation therapy
    • If contraindication to
    No
    8.
    Does the patient have unilateral leg swelling (visual
    observation of asymmetry of the calves)?
    • Is patient stable
    following initial
    resuscitation?
    Yes
    No
    anticoagulation, consider IVC
    filter and/or if massive PE,
    embolectomy
    • Risk stratification with troponin
    and echocardiogram
    • Admit to ICU or floor as indicated
    Quantitative D-dimer assay
    (ELISA or turbidimetric)
    > 0.5 μg/L*
    PE safely excluded
    consider other diagnosis
    < 0.5 μg/L*
    * Compression ultrasound of lower extremities can be performed as the initial
    diagnostic imaging modality in any of the following situations;
    patients with obvious signs of deep vein thrombosis (DVT) for whom venous
    ultrasound is readily available
    Negative
    CTPA*
    PE safely excluded
    consider other diagnosis
    Positive
    • Begin anticoagulation
    therapy with unfrac tionated
    or fractionated heparin
    • Consult a Physician
    patients with relative contraindications for CT scan (e.g., borderline renal
    insufficiency, CT contrast agent allergy)
    in pregnant patients with an elevated D-dimer
    patients with a moderate to high clinical risk of PE with a negative or
    inconclusive CTPA or an inconclusive V/Q scan.
    A positive finding in a patient with symptoms consistent with PE can be
    considered evidence for diagnosis of VTE disease and potentially eliminate the
    need to expose the patient to the radiation from either a CTPA or V/Q scan.

    *for patients > 50 yrs, cut off is 10 x patient’s age in μg/L

    8. Rapid Sequence Intubation Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    Preparation

    LEMON

    MALE MESS

    Look for external markers of difficulty of BVM and Intubation

    Mask

    Airways (oral and nasal)

    Evaluate the 3-3-2 rule

    Laryngoscopes, Laryngeal Mask Airway (LMA)

    Endotracheal tubes – Males 8F; Females 7.5F

    Mallampati

    Monitoring (pulse oximetry, ECG, capnography), Magill Forceps

    Emergency drugs

    Obstruction/Obesity

    Self-inflating bag valve resuscitator;

    Suction, Stylet, Bougie

    Neck Mobility

    Plentiful oxygen supply

     
       
    8. Rapid Sequence Intubation Algorithm This clinical pathway is intended to supplement, rather than substitute for,

    Position the patient

    If patient is breathing spontaneously, prop up patient to allow patient to take deep breaths until you are ready to intubate BVM ventilation and Intubation – Position patients head at the level of your waistline and in the sniffing position as below - Head extended(A); Neck flexed (B); Do NOT use this position in patients with suspected cervical spine injury.

    P osition the patient • If patient is breathing spontaneously , prop up patient to allow

    Pre-oxygenation

    Spontaneously breathing patient – Allow 5 mins of spontaneous breathing with a tight-fitting non- rebreather facemask at 15L/min Unconscious/Semi- conscious patient - Self inflating bag valve resuscitator with reservoir and O 2 at 15L/min ventilation - Give 8 vital capacity breaths (synchronized to patient’s breaths); Avoid positive pressure ventilation if possible

       
    8. Rapid Sequence Intubation Algorithm This clinical pathway is intended to supplement, rather than substitute for,

    Paralysis with Induction

    P aralysis with Induction
     

    Pass the tube

     

    Limit attempt to < 30 seconds. Proceed down the algorithm after 30 seconds

       
     
    P ass the tube Limit attempt to < 30 seconds . Proceed down the algorithm after

    Successful

     

    Proof of Intubation

     

    Not Successful

     

    5 Point Auscultation Epigastrium, Bilateral Axillae, Bilateral Bases Confirm wave form capnography tracing; maintain CO 2 level at 35- 45mmHg

     
    P ass the tube Limit attempt to < 30 seconds . Proceed down the algorithm after
     
    P ass the tube Limit attempt to < 30 seconds . Proceed down the algorithm after

    Self-inflating bag valve resuscitator ventilation – 1 breath every 5s Secure tube Check vital signs (BP, PR, RR, SPO 2 , T o C, RBS) Connect patient to ventilator Obtain portable CXR

    Resume BVM ventilation - 1 breath every 3 seconds

    See 9. Difficult Airway Algorithm

    9. Difficult Airway Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    Successful Direct Laryngoscopy and Intubation (D.L.) Failed • Resume BVM ventilation - 1 breath every 3
    Successful
    Direct Laryngoscopy and Intubation (D.L.)
    Failed
    • Resume BVM ventilation - 1 breath every 3 seconds
    • CALL Anaesthetist immediately
    No
    Able to ventilate with BVM?
    Yes
    • Reposition patient to align the airway (sniffing position)
    • One more D.L. attempt. Limit attempt to < 30seconds
    Successful
    Failed

    Proof of Intubation 5 Point Auscultation Epigastrium, Bilateral Axillae, Bilateral Bases Confirm wave form capnography tracing; maintain CO 2 level at 35- 45mmHg

    Insert Laryngeal Mask Airway

    Insert Laryngeal Mask Airway

    Able to ventilate with BVM?

       

    No

     
    Able to ventilate with BVM? No Yes Surgical Cricothyrotomy

    Yes

    Surgical

    Cricothyrotomy

     
    9. Difficult Airway Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional

    Maintain ventilation Wake up patient or Advanced airway techniques e.g. Consult an Anaesthetist for fibre optic intubation

    • 10. Anaphylaxis Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    A patient meets the definition of anaphylaxis when any 1 of the following 3 criteria are fulfilled:

    • 1. Acute onset of mucocutaneous signs AND 1 of the following:

    respiratory compromise (wheezing-bronchospasm, dyspnoea, stridor, hypoxemia), hypotension (syncope), or hypotonia.

    • 2. Rapid onset of 2 of the following after exposure to likely allergen:

    mucocutaneous signs, respiratory compromise, hypotension, or persistent gastrointestinal symptoms.

    • 3. Hypotension after exposure to a known allergen.

    10. Anaphylaxis Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

    Patients with suspected anaphylaxis should be observed for at least 6 hours. Patients who are not high-risk should be discharged in the care of others. Before discharge from the hospital, all patients with anaphylactic reactions must be; Given clear indications for immediate return to the emergency department (ED). Considered for treatment with antihistamines and oral steroids for 3 days to decrease the chance of further reaction

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    Acute Asthmatic Attack

    Acute Asthmatic Attack

    Monitor, support ABCs Start Oxygen IF SPO 2 < 92%. Maintain SPO 2 92%; Oxygen should be provided to all patients with severe asthma, even those with normal oxygenation. Perform brief, targeted history, physical exam (auscultation, use of accessory muscles, PR, RR) Initiate treatment of underlying cause of exacerbation Check Peak Expiratory Flow (PEF) as per 12. PEF Chart and record best PEF (%) in patient’s clinical notes. DO NOT measure PEF in patients with impending/actual respiratory arrest. Start treatment immediately.

     
    • Monitor, support ABCs • Start Oxygen IF SPO < 92%. Maintain SPO ≥ 92%; Oxygen
    • Monitor, support ABCs • Start Oxygen IF SPO < 92%. Maintain SPO ≥ 92%; Oxygen

    Peak Expiratory Flow < 70 %

    Start nebulisation with Salbutamol + Ipratropium bromide (doses below) every 20 mins or 3 doses for 1 hour. A combination of 4 mL volume fill with NS and 6 to 8L/min oxygen flow rate is recommended. Give Oral (if patient can swallow) or IV systemic corticosteroids (dose below) immediately

       
    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be

    Impending or Actual Respiratory Arrest

    Intubation (RSI with Ketamine if no C/I) and Mechanical Ventilation with 100% oxygen; CXR Start nebulisation with Salbutamol + Ipratropium bromide (doses below) every 20 mins or 3 doses for 1 hour. A combination of 4 mL volume fill with NS and 6 to 8L/min oxygen flow rate is recommended.

    Give IV Hydrocortisone 2mg/kg (maximum 200mg) immediately Give high-dose IV Magnesium, 2gm in 5% Dextrose over a 20-min Call ICU/Physician

    PEF < 40% - Poor Response Symptoms severe, drowsiness, confusion Call ICU/Med; continue treatment below ABG + CXR

    Give high-dose IV Magnesium, 2gm in

    5% Dextrose over a 20-min

    Repeat assessment after 1 hour (3 doses) Symptoms, physical exam + BP, PR, RR, SpO 2 , PEF

     
       
     
    Repeat assessment after 1 hour (3 doses) Symptoms, physical exam + BP, PR, RR, SpO ,
    Repeat assessment after 1 hour (3 doses) Symptoms, physical exam + BP, PR, RR, SpO ,
    PEF 40 – 69% - Incomplete Response • Continue nebulisation with Salbutamol +

    PEF 40 – 69% - Incomplete Response Continue nebulisation with Salbutamol +

    Ipratropium bromide (doses below) every 20 mins or 3 doses for 1 hour • Repeat assessment
    Ipratropium bromide (doses below) every 20
    mins or 3 doses for 1 hour
    • Repeat assessment after 1 hour (3 doses)
    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be

    PEF >70% - Good Response No Distress Physical Exam – Normal Repeat assessment after 1 hour

    PEF >70% - Good Response • No Distress • Physical Exam – Normal • Repeat assessment

    PEF >70% - Good Response No Distress Physical Exam – Normal Response sustained 60minutes after last treatment

       
    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be

    Discharge Home Continue treatment with inhaled SABA – 2 puffs QID for 3-5 days Continue course of oral systemic corticosteroids (See dose in table) Review medication including inhaler technique Consider therapy for underlying cause of exacerbation Refer to chest clinic for follow-up

     

    Continue nebulisation with Salbutamol +

     

    PEF 40 – 69% - Incomplete Response

    Continue nebulisation with Salbutamol +

     

    Ipratropium bromide (doses below) every 20 mins or 3 doses per hour

    Give high-dose IV Magnesium, 2gm in 5% Dextrose over 20-min

    Ipratropium bromide (doses below) every 20 mins or 3 doses for 1 hour

    Consider Intubation and Mechanical ventilation

    ABG + CXR Call ICU/Physician

     
     

    Medication

    Dose

     

    Comments

    Inhaled SABA

     

    Salbutamol

     

    Nebulizer solution

    5

    mg every 20 min for 3 doses,

    Only selective β-agonists are recommended. For optimal delivery, dilute

    (0.63 mg/3 mL, 1.25mg/3mL,

    then 2.5–10 mg every 1–4 h as

    aerosols to minimum of 3 mL at gas flow of 6–8 L/min. Use large- volume

    2.5 mg/3 mL, 5.0 mg/mL)

    needed, or 10–15 mg/h continuously

    nebulizers for continuous administration. May mix with ipratropium nebulizer solution.

    MDI

    (90µg/puff)

    4–8 puffs every 20 min up to 4h, then every 1–4 h as needed

    In mild to moderate exacerbations, MDI plus valved holding chamber is as effective as nebulized therapy with appropriate administration technique and coaching by trained personnel.

    Systemic (Injected) β2-Agonists

     

    Adrenaline

    0.3–0.5 mg every 20 min for 3 doses SC

    No proven advantage of systemic therapy over aerosol

    1:1,000 (1 mg/mL)

       

    Anticholinergics

     

    Ipratropium bromide

     

    Nebulizer solution

    0.5 mg every 20 min for 3 doses,

    May mix in same nebulizer with salbutamol. Should not be used as first-line

    (0.25mg/mL)

    then as needed

    therapy; should be added to SABA therapy for severe exacerbations. The addition of Ipratropium has not been shown to provide further benefit once the patient is hospitalized.

    MDI

    (18 µg/puff)

    puffs every 20 min as needed up to 3 h

    8

    Should use with valved holding chamber. Studies have examined Ipratropium bromide MDI for up to 3 h.

    Ipratropium with salbutamol

     

    Nebulizer solution (Each 3- mL vial contains 0.5mg ipratropium bromide and 2.5 mg salbutamol.)

    mL every 20 min for 3 doses, then as needed

    3

    May be used for up to 3 h in the initial management of severe exacerbations. The addition of ipratropium to salbutamol has not been shown to provide further benefit once the patient is hospit alized.

    MDI

    (Each puff contains 18µg

    8

    puffs every 20 min as needed

    Should use with valved holding chamber.

    Ipratropium bromide and 90µg

    up to 3 h

    salbutamol.)

    Systemic Corticosteroids

     

    Prednisone

    40–80 mg/d in 1 or 2 divided doses until PEF reaches 70% of predicted or personal best

    For outpatient “burst,” use 40–60 mg in single or 2 divided doses for a total of 5–10 d.

    Hydrocortisone

    200mg IV then 1mg/kg/dose IV QID

    Only if patient cannot tolerate PO corticosteroids

    ED = emergency department; ICS = inhaled corticosteroid; MDI = metered-dose inhaler; PEF = peak expiratory flow; SABA = short-acting β2- adrenergic agonist

    Notes: There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired. The total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit or hospitalization may last from 3 to 10 days. For corticosteroid courses of <1 week, there is no need to taper the dose. For slightly longer courses (e.g., up to 10 d), there probably is no need to taper, especially if patients are concurrently taking ICSs. ICSs can be started at any point in the treatment of an asthma exacerbation.

    12. Peak Expiratory Flow Chart

    How to Measure Peak Expiratory Flows (PEF) DO NOT measure PEF in patients with impending/actual respiratory
    How to Measure Peak Expiratory Flows (PEF)
    DO NOT measure PEF in patients with impending/actual respiratory arrest. Start treatment immediately.
    1.
    Put the pointer on the gauge of the peak flow meter to 0 or
    the lowest number on the meter.
    2.
    Attach the mouthpiece to the peak flow meter.
    3.
    While standing, take a deep breath.
    4.
    Put the peak flow meter mouthpiece in your mouth, and close
    your lips tightly around the outside of the mouthpiece. Don't
    put your tongue inside the mouthpiece.
    5.
    Breathe out as hard and as fast as you can for 1 or 2 seconds.
    A hard and fast breath usually produces a "huff" sound.
    6.
    Check the number on the gauge, and write it down.
    7.
    Repeat the above 3 times and take the patient’s best PEF
    8.
    Plot the best PEF on the normal values chart and calculate
    the percentage as below
    Measured PEF X 100%
    Normal PEF
    9.
    Record the PEF in the patient’s clinical notes
    • 13. Hypertension Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

     

    BP > 140/90mmHg

     
    BP > 140/90mmHg • Monitor, support ABCs • Check vital signs (BP, PR, RR, SPO ,

    Monitor, support ABCs

    Check vital signs (BP, PR, RR, SPO 2 , T o C, RBS)

    Start Oxygen IF SPO 2 < 94%. Maintain SPO 2 94%

    Obtain/review 12-lead ECG

    Send blood samples for FBC, UEC, TSH

    Urinalysis for proteinuria

    Perform brief, targeted history and physical exam

    Allow patient to rest awaiting results. Repeat BP checks hourly.

    DO NOT administer antihypertensives e.g. nifedipine to lower the blood pressure in the ED unless there are features of progressive or impending end organ damage below. See 15. Hypertensive Emergencies Algorithm

       
     
    BP > 140/90mmHg • Monitor, support ABCs • Check vital signs (BP, PR, RR, SPO ,

    Are there any features of progressive or impending end organ damage (especially if BP > 180/110 mmHg)?

     
    • a) Neurological Cerebral vascular accident/cerebral infarction (24.5%)

     

    Hypertensive encephalopathy (16.3%)

     

    Subarachnoid haemorrhage

    Headache is NOT a hypertensive

     

    Intracranial haemorrhage

    • b) Cardiovascular Acute pulmonary oedema (22.5%) Congestive heart failure (12%) Myocardial ischemia/infarction Acute left ventricular dysfunction

    emergency, no matter how high the blood pressure. It is likely the headache is causing the hypertension, not the other way around. Treat the headache and

    Aortic dissection

    the pressure will

    come down.

    • c) Other

    The same is true

    of epistaxis.

    Acute renal failure/insufficiency Retinopathy Pre-eclampsia/Eclampsia Microangiopathic haemolytic anaemia

       
     

    No

     

    Yes

    Are there any features of progressive or impending end organ damage (especially if BP > 180/110
    Are there any features of progressive or impending end organ damage (especially if BP > 180/110

    Known Hypertensive – Resume regular treatment; if unknown, low dose thiazide type diuretic for most; may consider ACE inhibitor, ARB, β-blocker, CCB. Follow-up as below (See 14. JNC VIII Guidelines)

    New Onset Hypertension - Final BP prior to discharge BP > 160/100 – low dose thiazide type diuretic for most; may consider ACE inhibitor, ARB, β-blocker, CCB. (See 14. JNC VIII Guidelines). Follow-up as below

    BP < 160/100 – Follow-up as below

    Known Hypertensive – Resume regular treatment; if unknown, low dose thiazide type diuretic for most; may

    Daily BP checks at nearest clinic and follow-up in a Medical Clinic in 1 week with BP chart

    Consult a Physician (Obstetrician in Eclampsia) See 15. Hypertensive Emergencies Algorithm

    14. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) Guidelines

    BLOOD PRESSURE MEASUREMENT TECHNIQUES

    The electronic device, if available, is preferred because it provides more reproducible results. At the initial evaluation, BP should be measured in both arms; if the readings are different, the arm with the higher reading should be used for measurements thereafter. The BP should be taken after patients have emptied their bladders. Patients should be seated with their backs supported and with their legs resting on the ground and in the uncrossed position for 5 minutes. The patient’s arm being used for the measurement should be at the same level as the heart, with the arm resting comfortably on a table. It is preferable to take 2 readings, 1 to 2 minutes apart, and use the average of these measurements. It is useful to also obtain standing blood pressures (usually after 1 minute and again after 3 minutes) to check for postural effects, particularly in older people. In general, the diagnosis of hypertension should be confirmed at an additional patient visit, usually 1 to 4 weeks after the first measurement. On both occasions, the SBP should be ≥140 mm Hg or the DBP ≥90 mmHg, or both, in order to make a diagnosis of hypertension. It can be helpful to measure BP at home. If available, the electronic device is simpler to use and is probably more reliable than the sphygmomanometer. The average of BPs measured over 5 to 7 days, if possible in duplicate at each measurement, can be a useful guide for diagnostic and treatment decisions. If the BP is very high (for instance, a SBP ≥180 mm Hg), or if available resources are not adequate to permit a convenient second visit, the diagnosis and, if appropriate, treatment can be started after the first set of readings that demonstrate hypertension.

    CLASSIFICATION OF BLOOD PRESSURE (BP)

    CATEGORY

    SBP mmHg

    DPB mmHg

    Normal

    < 120

    and

    < 80

    Prehypertension

    120-139

    or

    80-89

     

    140-159

    or

    90-99

    Hypertension, Stage 1 Hypertension, Stage 2

    160

    or

    ≥ 100

    DIAGNOSTIC WORKUP OF HYPERTENSION

    Assess risk factors and comorbidities Reveal identifiable causes of hypertension Assess presence of target organ damage Conduct history and physical examination Obtain/review 12-lead ECG, RBS, FBC, UEC, TSH, Urinalysis for proteinuria, Lipid panel Calculate the 10-year risk for first atherosclerotic cardiovascular disease events (ASCVD; nonfatal myocardial infarction, coronary heart disease–related death, or fatal or nonfatal stroke) with the 2013 AHA/ACC 2013 Prevention Guidelines ASCVD Risk Estimator - http://www.cardiosource.org/science-and-quality/practice-guidelines- and-

    PRINCIPLES OF LIFESTYLE MODIFICATION

    MODIFICATION

    RECOMMENDATION

    AVG. SBP REDUCTION RANGE 1

    Weight reduction

    Maintain normal body weight (BMI 18.5-24.9 kg/m 2 ).

    5-20 mmHg/10 kg

    DASH eating plan

    Adopt a diet rich in fruits, vegetables, and lowfat dairy

    8-14 mmHg

    Dietary sodium

    products with reduced content of saturated and total fat. No added salt. Use a limited amount of salt in cooking.

    2-8 mmHg

    reduction

    Aerobic physical

    Don’t add salt to your food at the table. Regular aerobic physical activity (e.g. brisk walking) at

    4-9 mmHg

    activity

    Moderation of

    least 30 minutes per day, most days of the week. Men: limit to 2 drinks* per day.

    per day

     

    alcohol consumption

    Women and lighter weight persons: limit to 1 drink*

    2-4 mmHg

    1 Effects are dose and time dependent * 1 drink = 15 mL ethanol (e.g. 355 mL beer, 148 mL wine, 44 mL 80-proof whiskey).

    EVIDENCE-BASED DOSING FOR ANTIHYPERTENSIVE DRUGS

    EVIDENCE-BASED DOSING FOR ANTIHYPERTENSIVE DRUGS

    15. Hypertensive Emergencies Algorithm

    BP > 160/100mmHg +

    Features of progressive or impending end organ damage

    (especially if BP > 180/110 mmHg)?

       
    15. Hypertensive Emergencies Algorithm BP > 160/100mmHg + Features of progressive or impending end organ damage

    Monitor, support ABCs

    Check vital signs (BP, PR, RR, SPO 2 , T o C, RBS)

    Start Oxygen IF SPO 2 < 94%. Maintain SPO 2 94%

    Establish IV Access and send blood samples for FBC, UEC

    Obtain/review 12-lead ECG

    Urinalysis for proteinuria

    Perform brief, targeted history, physical exam

    Consult a Physician/ (Obstetrician for Eclampsia) and consider treatments as below in consultation with a Physician/Obstetrician

     
    • Monitor, support ABCs • Check vital signs (BP, PR, RR, SPO , T C, RBS

    See 16. Hypertensive Emergencies Drug Infusions for Dosages and Precautions

    Neurological emergencies

    Preferred medications

    Medications to avoid

    Labetalol

    Nitroprusside

    Nicardipine

    Hydralazine

    Esmolol

     

    Hypertensive encephalopathy - Reduce mean arterial pressure (MAP) 25% over 8 hours.

    Acute ischemic stroke - Evidence exists that patients who have acute strokes have better outcomes with higher BPs. Antihypertensive therapy is not routinely recommended for patients with acute stroke and HTN.

    Patient otherwise eligible for acute reperfusion therapy except that BP is >185/110 mm Hg:

    • - Labetalol 10–20 mg IV over 1–2 minutes, may repeat 1 time

    • - Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate

    If BP is not maintained at or below 185/110 mm Hg, do not administer rtPA

    Management of BP during and after rtPA or other acute reperfusion therapy to maintain BP at or below 180/105 mm Hg:

    • - Monitor BP every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours

    • - If systolic BP >180–230 mm Hg or diastolic BP >105–120 mm Hg:

    • Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min;

    • If BP not controlled or diastolic BP >140 mm Hg, consider IV sodium nitroprusside

    After treatment with fibrinolysis, the SBP should be maintained < 180mmHg and DBP < 105 mmHg for 24 hours. In patients with markedly elevated blood pressure (SBP > 220 mm Hg or DBP > 120 mm Hg) who do not receive fibrinolysis, a reasonable goal

    is to lower blood pressure by 15% during the first 24 hours after onset of stroke.

    Acute intracerebral haemorrhage - No evidence exists to suggest that HTN provokes further bleeding in patients with ICH. A precipitous fall in SBP may compromise cerebral perfusion and increase mortality. The controlled lowering of BP with IV labetalol (in the absence of bradycardia) is currently recommended only when the SBP is >200mmHg or the DBP is >110mmHg. Treatment based on clinical/radiographic evidence of increased intracranial pressure (ICP). If signs of increased ICP, maintain MAP just below 130mmHg (or SBP < 180mmHg) for first 24 hours after onset. Patients without increased ICP, maintain MAP < 110mmHg (or SBP < 160mmHg) for first 24 hours after symptom onset.

    Subarachnoid haemorrhage - Maintain SBP < 160mmHg until the aneurysm is treated or cerebral vasospasm occurs. Oral nimodipine is used to prevent delayed ischemic neurological deficits, but it is NOT indicated for treating acute hypertension.

    Cardiovascular emergencies Aortic dissection Immediately reduce the SBP < 110mmHg and maintain it at this level unless signs of end-organ hypoperfusion are present. Preferred treatment includes a combination of;

    • a) narcotic analgesics (morphine sulphate),

    • b) β-blockers (labetalol, esmolol) or calcium channel blockers (verapamil, diltiazem); Avoid β-blockers if there is; aortic valvular regurgitation or suspected cardiac tamponade.

    • c) vasodilators (nicardipine, nitroprusside).

    Acute coronary syndrome - Treat if SBP >160 mmHg and/or DBP >100 mmHg. Reduce BP by 20-30% of baseline. Thrombolytics are contraindicated if BP is >185/100 mmHg. Preferred medications include β-blockers & Nitroglycerin

    Acute heart failure - Treatment with vasodilators (in addition to diuretics) for SBP 140 mmHg. IV or sublingual nitroglycerin is the preferred agent.

    Other disorders Cocaine toxicity/pheochromocytoma - Hypertension and tachycardia from cocaine toxicity rarely require specific treatment. Benzodiazepines are the preferred agents for cocaine-associated acute coronary syndromes.

    Pheochromocytoma treatment guidelines are similar to that of cocaine toxicity. β-blockers can be added for BP control only after α-blockade. Preferred medications - Diazepam, Phentolamine, Nitroglycerin/nitroprusside

    Medications to avoid - β-adrenergic antagonists prior to phentolamine administration

    Preeclampsia/eclampsia - In women with eclampsia or preeclampsia, SBP should be < 160 mmHg and DBP <110 mm Hg in the prepartum and intrapartum periods. If the platelet count is < 100,000 cells/mm 3 BP should be maintained below 150/100mmHg. Patients with eclampsia or preeclampsia should also be treated with IV magnesium sulphate to avoid seizures. Preferred medications - Hydralazine, Labetalol, Nifedipine Medications to avoid - Nitroprusside, Angiotensin-converting enzyme inhibitors, Esmolol

    16.

    Hypertensive Emergencies Drug Infusions

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    AGENT

    MOA

    DOSE

    ONSET/DURATION OF ACTION (AFTER DISCONTINUATION)

    PRECAUTIONS

    Parenteral Vasodilators

     

    Nitroglycerin

    Decreases coronary vasospasm, which increases coronary blood flow. Also induces vessel dilatation, decreasing cardiac workload.

    5-20 µg/min as IV infusion

    2-5 min/5-10 min

    Headache, tachycardia, vomiting, flushing, methaemoglobinemia; requires special delivery system due to drug binding to plastic tubing

    Hydralazine

    Decreases systemic resistance through direct vasodilation of arterioles.

    5-10 mg as IV bolus repeat every 4-6 hr

    10 min/> 1 hr

    Tachycardia, headache, vomiting, aggravation of angina pectoris

    Parenteral Adrenergic Inhibitors

     

    Labetalol

    α,β1, β2 Blocker

    20 mg IV bolus over 10 mins then 1-2mg/min IV infusion

    5-10 min/15-30 min

    Bronchoconstriction, heart block, orthostatic hypotension

    Esmolol

    Ultra-short-acting β-

    500 µg/kg bolus

    1-5 min/15-30 min

     

    adrenergic blocker

    injection IV or 25-1 00 µg/kg/min by infusion. May repeat bolus after 5 min or increase infusion rate to 300 µg/kg/min

    First-degree heart block, congestive heart failure, asthma

    • 17. SEPSIS Definitions

    Diagnostic criteria for sepsis

    Infection, documented or suspected, and some of the following:

    • a) General variables

    Fever (> 38.3°C)

    Hypothermia (core temperature < 36°C)

    Heart rate > 90/min or more than two SD above the normal value for age Tachypnoea

    Altered mental status

    Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)

    Hyperglycaemia (plasma glucose > 7.7 mmol/L or 140 mg/dL) in the absence of diabetes

    • b) Inflammatory variables Leucocytosis (WBC count > 12,000/μL) Leukopenia (WBC count < 4000/μL) Normal WBC count with greater than 10% immature forms Plasma C-reactive protein more than two SD above the normal value Plasma procalcitonin more than two SD above the normal value

    • c) Haemodynamic variables Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm Hg in adults or less than two SD below normal for age)

    • d) Organ dysfunction variables Arterial hypoxemia (PaO 2 /FiO 2 < 300)

    Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid resuscitation)

    Creatinine increase > 44.2 μmol/L or 0.5 mg/dL

    Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)

    Ileus (absent bowel sounds)

    Thrombocytopenia (platelet count < 100,000/μL)

    Hyperbilirubinemia (plasma total bilirubin > 70 μmol/L or 4 mg/dL)

    • e) Tissue perfusion variables

    Hyperlactatemia (> 1 mmol/L)

    Decreased capillary refill or mottling

    Severe Sepsis

    • a) Sepsis-induced tissue hypoperfusion (infection-induced hypotension, elevated lactate (≥ 4 mmol/L), or oliguria) or

    • b) Organ dysfunction (any of the following thought to be due to the infection) Sepsis-induced hypotension (is defined as a SBP < 90 mm Hg or MAP < 70 mm Hg or a SBP decrease > 40 mm Hg or < 2 SD below normal for age in the absence of other causes of hypotension. Lactate above upper limits laboratory normal Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation Acute lung injury with PaO 2 /FiO 2 < 250 in the absence of pneumonia as infection source Acute lung injury with PaO 2 /FiO 2 < 200 in the presence of pneumonia as infection source Creatinine > 176.8 μmol/L (2.0 mg/dL) Bilirubin > 34.2 μmol/L (2 mg/dL) Platelet count < 100,000 μL Coagulopathy (international normalized ratio > 1.5)

    Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid resuscitation.

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    Severe Sepsis/Septic Shock
    Severe Sepsis/Septic Shock

    Monitor, support ABCs Check vital signs (BP, PR, RR, SPO 2 , T o C, RBS) Start Oxygen IF SPO 2 < 94%. Maintain SPO 2 94%

    Establish IV Access and send blood samples for FBC, MPS, UEC, ABG, Serum lactate Start IV Fluids using a pressure infusion bag to achieve a minimum of 30mL/kg NS or RL within 3 hours of identification. More rapid administration and greater amounts of fluid may be needed in some patients Obtaining appropriate cultures before antimicrobial therapy is initiated if such cultures do not cause significant delay (> 45 minutes) in the start of antimicrobial(s). Draw 2 sets of blood cultures 10mL each (both aerobic and anaerobic bottles) from different sites. Perform brief, targeted history, physical exam Give antibiotics as an EMERGENCY (within the first hour of recognition of septic shock and severe sepsis without septic shock )

    • - Ceftriaxone 2gm IV stat

    • - For probable Neutropenic patients or if patient has been admitted in hospital in the last 3 months (Hospital Acquired Infection)

    Imipenem 500 mg IV infusion over 3 hrs then QID for general sepsis OR Meropenem 1gm IV infusion over 3 hrs then TDS for possible CNS infections Give antipyretic if indicated (Paracetamol 1gm IV) CXR; Urinalysis + MCS

    • Monitor, support ABCs • Check vital signs (BP, PR, RR, SPO , T C, RBS
     

    Insert urinary catheter and monitor urine output Repeat vital signs (BP, MAP, PR, RR, SPO 2 , T o C, Serum lactate)

     
       
     
    • Insert urinary catheter and monitor urine output • Repeat vital signs (BP, MAP, PR, RR,

    Features of shock despite adequate fluid resuscitation (> 30ml/kg)?

     

    MAP < 65mmHg Signs of Shock (tachypnoea, cool clammy skin, cool peripheries, hypotensive, tachycardia) Urine output < 0.5mL/kg/hour Hyperlactatemia (> 1 mmol/L)

     

    Yes

    No

     
    • Insert urinary catheter and monitor urine output • Repeat vital signs (BP, MAP, PR, RR,
    • Insert urinary catheter and monitor urine output • Repeat vital signs (BP, MAP, PR, RR,

    Consult a Physician Start peripheral vasopressors if MAP < 65mmHg in the face of life-threatening hypotension, even when hypovolemia has not yet been resolved - Norepinephrine (0.1–1.3 µg/kg/min) and/or Adrenaline (0.05-0.3µg/kg/min). Titrate vasopressors to a MAP 65 mmHg to preserve tissue perfusion. All patients requiring vasopressors must have an arterial catheter placed as soon as practical resources are available

    • Consult a Physician • Start peripheral vasopressors if MAP < 65mmHg in the face of

    If; No current indication for admission Clinically stable with NO SIGNS OF SEVERE SEPSIS OR SEPTIC SHOCK AS ABOVE Identify source of infection and if amenable to oral antibiotic therapy, initiate therapy and consider discharge with MOPC follow -up

    Hemodynamic stability achieved with adequate fluid resuscitation (> 30ml/kg) and vasopressor therapy?

    Yes

    MAP < 65mmHg Signs of shock as above Urine output < 0.5mL/kg/hour Hyperlactatemia (> 1 mmol/L)

     

    No

     
    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be
    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be
    Admit HDU/ICU
    Admit HDU/ICU
     

    Give Hydrocortisone 200mg IV bolus

     
    Give Hydrocortisone 200mg IV bolus Evidence of tissue hypoperfusion persists despite adequate intravascular volume and adequate

    Evidence of tissue hypoperfusion persists despite adequate intravascular volume and adequate MAP?

    Yes

    Evidence of tissue hypoperfusion persists despite adequate intravascular volume and adequate MAP? Yes

    Hyperlactatemia (> 1 mmol/L) Decreased capillary refill or mottling

       
     

    No

    Give Hydrocortisone 200mg IV bolus Evidence of tissue hypoperfusion persists despite adequate intravascular volume and adequate

    Give dobutamine infusion up to 20 µg/kg/min

    (+ vasopressor if in use) in the presence of;

    • a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or

    • b) ongoing signs of hypoperfusion, despite achieving adequate intravascular volume and adequate MAP

    Admit HDU/ICU

    Admit HDU/ICU
    Admit HDU/ICU

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

     

    Hyperglycaemia (RBS > 14 mmol/L)

     
       
     
    Hyperglycaemia ( RBS > 14 mmol/L ) • Monitor, support ABCs • Check vital signs (BP,
     

    Monitor, support ABCs

     

    Check vital signs (BP, PR, RR, SPO 2 , T o C)

    Start Oxygen IF SPO 2 < 94%. Maintain SPO 2 94%

    Establish IV Access and send blood samples for UEC and a

    Venous Blood Gas (VBG) Obtain/review 12-lead ECG

    Immediate Urinalysis for ketones

     

    Perform brief, targeted history, physical exam

     
     
    Hyperglycaemia ( RBS > 14 mmol/L ) • Monitor, support ABCs • Check vital signs (BP,
    Hyperglycaemia ( RBS > 14 mmol/L ) • Monitor, support ABCs • Check vital signs (BP,
    Hyperglycaemia ( RBS > 14 mmol/L ) • Monitor, support ABCs • Check vital signs (BP,

    Ketones in Urine + (pH < 7.3 OR HCO 3 - < 18mmol/L)

    RBS > 33.3mmol/L + Serum Osmolality > 320mOsm/kg + pH > 7.3

    Diabetes Ketoacidosis

     

    Hyperosmolar Hyperglycaemic State (HHS)

       
       
    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be
     

    Identify and Treat precipitating illness; consider ACS, Sepsis

    Consult a Physician and continue with the Algorithm

    • Identify and Treat precipitating illness; consider ACS, Sepsis • Consult a Physician and continue with

    Normal VBG + No Ketones in urine + Serum Osmolality < 320mOsm/kg

    Uncomplicated Hyperglycaemia

    See 20. Uncomplicated Hyperglycaemia Algorithm

    1. Fluid Protocol (RL or 0.9% NaCl) 2. Potassium Protocol No potassium should be given if
    1. Fluid Protocol
    (RL or 0.9% NaCl)
    2. Potassium Protocol
    No potassium should be given if patient is anuric or
    serum K + > 5.3mmol/L
    3. Insulin Protocol
    DO NOT give insulin until you
    If BP unstable, give fluid boluses
    at 15 to 20mL/kg; Repeat until BP
    stable. Consider Inotropes if no
    response to fluid resuscitation.
    +
    Serum K
    Action
    have K + levels
    IV Insulin Infusion
    (Start at 0.14u/kg/hr)
    (mmol/L)
    > 5.3
    DO NOT give K + , but check potassium levels
    hourly and start replacement when K + < 5.3
    -
    Hourly RBS monitoring
    -
    Target RBS drop 3-4mmol/L/hr
    If BP stable;
    • 1L stat
    • 1L over 30 mins (2000mls/hr)
    • 1L over 1 hours (1000mls/hr)
    • 1L over 2 hours (500mls/hr)
    • 1L over 4 hours (250mls/hr)
    4.0
    to 5.3
    Add 10mmol K + /1L fluid/hour to IV fluids
    -
    3.5
    to 4.0
    < 3.5
    Add 20mmol K + /1L fluid/hour to IV fluids
    Hold insulin. Add 40mmol K + /1L fluid/hour.
    Continuous cardiac monitoring until K + >
    3.3mmol/L
    If the RBS does not fall by 3 -4
    mmol/L/hr, give a bolus of
    0.14u/kg per hour IV and
    continue with the infusion
    If CORRECTED serum sodium is
    ≥ 140 mmol/L, use 0.45% NaCl
    instead of 0.9% NaCl or RL
    DO NOT give > 50 mL/kg of
    isotonic solution in the first
    4 hours of treatment of diabetic
    ketoacidosis because of the risk of
    • Change IV fluid infusion to 5 % Dextrose
    cerebral oedema.
    Success in fluid therapy is
    reflected by an improvement in
    hemodynamic and hydration status
    and pH values, a satisfactory urine
    output of 1 to 2 mL/kg/hour, and
    clinical progress.
    Venous Glucose reaches
    < 11.1 mmol/L (DKA)
    < 16.7 (HHS)
    with 0.45% NaCl at 150-250mL/hr
    • Decrease insulin to 0.02-0.05uits/kg/hour
    • Maintain glucose between 8.3 – 11.1 mmol/L
    (DKA)/ 11.1- 16.7mmol/L (HHS) and
    continue insulin infusion and fluid hydration
    until ketosis or hyperosmolality resolves
    Useful formulas in DKA

    Anion gap = Na + - [(Cl - + HCO 3 - )] Serum sodium correction = Na + measured + {(Glucose - 5.5) / 3} (all values in mmol/l). Serum potassium correction during acidemia = [K+] - (0.6 mmol/L X (7.4 - measured pH) X 10) Serum osmolality (mOsm/L) = 2 [Na + + K+](mmol/L) + Glucose (mmol/L) + BUN (mmol/L) Total body water deficit (L) = 0.6 men/children or 0.5 women x body weight (kg) X [serum Na + /140 - 1]

    20. Uncomplicated Hyperglycaemia Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    Hyperglycaemia (RBS > 14 mmol/L) • Monitor, support ABCs • Check vital signs (BP, PR, RR,
    Hyperglycaemia (RBS > 14 mmol/L)
    • Monitor, support ABCs
    • Check vital signs (BP, PR, RR, SPO 2 , T o C)
    • Start Oxygen IF SPO 2 < 94%. Maintain SPO 2 ≥ 94%
    • Establish IV Access and send blood samples for UEC, and a
    Venous Blood Gas (VBG)
    • Obtain/review 12-lead ECG
    • Immediate Urinalysis
    • Perform brief, targeted, history and physical exam
    Normal VBG + No Ketones in urine + Serum Osmolality < 320mOsm/kg Uncomplicated Hyperglycaemia Identify and
    Normal VBG +
    No Ketones in urine +
    Serum Osmolality < 320mOsm/kg
    Uncomplicated Hyperglycaemia
    Identify and Treat precipitating illness; consider ACS, Sepsis
    Known Diabetic
    Newly Diagnosed Diabetic

    Confirm compliance with medication

    • - If not compliant, resume previous regimen

    • - If compliant, optimize dosages

    Advice on lifestyle Modification Review RBS daily at nearest facility and keep record Review in out-patient medical clinic after 5 days Refer to Diabetic clinic if poorly controlled

    Lifestyle modification advice

    Start on Metformin as below

     
    • - Begin with low-dose metformin - 500 mg BD with meals (breakfast and/or dinner).

    • - Review RBS daily at nearest facility and keep record

    • - Review in FMC Clinic after 5 days

     
    • - After 5–7 days, if GI side effects have not occurred, advance dose to 850 mg or 1gm before breakfast and dinner.

     
    • - If GI side effects appear as doses advanced, can decrease to previous lower dose and try to advance dose at a later time.

     
    • - The maximum effective dose is usually 850 mg BD, with modestly greater effectiveness with doses up to 3 g per day. GI side effects may limit the dose that can be used.

    Refer to Diabetic clinic

    • 21. Hypoglycaemia Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    Hypoglycaemia (RBS < 3.3 mmol/L) • Monitor, support ABCs • Check vital signs (BP, PR, RR,
    Hypoglycaemia (RBS < 3.3 mmol/L)
    • Monitor, support ABCs
    • Check vital signs (BP, PR, RR, SPO 2 , T o C)
    • Start Oxygen IF SPO 2 < 94%. Maintain SPO 2 ≥ 94%
    Able to tolerate PO Yes No Give 15gm of simple carbohydrate PO AND/OR A full complex
    Able to tolerate PO
    Yes
    No
    Give 15gm of simple carbohydrate PO
    AND/OR
    A full complex starchy carbohydrate
    meal e.g. rice, ugali, wholemeal)
    IV Access
    No IV Access
    50mls 50% Dextrose IV
    Glucagon 1mg SC or IM
    As soon as IV access is available,
    give 50mls 50% Dextrose IV
    Symptoms resolved and RBS > 3.3mmol/L
    Yes
    No
    Repeat Algorithm
    After 2 rounds of the algorithm, begin continuous infusion
    of 5% Dextrose saline at 110mls/hr
    • Treat underlying cause
    • Provide patient with a full complex starchy carbohydrate meal
    e.g. rice, ugali, wholemeal)

    Consider thiamine 100mg IVI for malnourished and alcoholic patients followed by 100mg PO BD for 6 weeks

    Consult a Physician for ALL patients

    • 22. Electrolyte Abnormalities Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    • Monitor, support ABCs • Check vital signs (BP, PR, RR, SPO 2 , T o
    • Monitor, support ABCs
    • Check vital signs (BP, PR, RR, SPO 2 , T o C, RBS)
    • Start Oxygen IF SPO 2 < 94%. Maintain SPO 2 ≥ 94%
    • Establish IV Access and send blood samples for FBC, UEC
    • Obtain/review 12-lead ECG
    • Perform brief, targeted history, physical exam

    Hyponatraemia (< 130 mmol/L)

    Hypernatraemia (> 150 mmol/L)

    Hypokalaemia ( < 3 mmol/L)

    Hyperkalaemia (> 5.5 mmol/l.)

    For hypotensive patients, give NS 20 mL/kg bolus and repeat until vital signs are stable

    For hypotensive patients, give RL 20 mL/kg bolus and repeat until vital signs are stable

    For hypotensive patients, give RL 20 mL/kg bolus and repeat until vital signs are stable

    For hypotensive patients, give NS 20 mL/kg bolus and repeat until vital signs are stable

    Consult a Physician for ALL Patients

    Consult a Physician for ALL Patients

    Mild-Moderate hypokalaemia (2 -3 mmol/L)

    Give calcium to protect the heart (not bind K + ) ONLY to patients

    For patients with neurologic signs, including coma, seizures, and focal neurologic deficits (usually in the 100 to 110 mmol/L range),

    After the patient is stabilized, change fluids to D5 ½ NS to provide for maintenance requirements and on-going

    Patients who have mild or moderate hypokalaemia may need only oral potassium replacement therapy if nausea or vomiting is not the cause of the hypokalaemia.

    with; a widening QRS including a sine wave, a cardiac arrest that is believed to be due to hyperkalaemia, or

    administer 3% saline (513 mmol/L of sodium chloride [NaCl]) in order to achieve a minimum serum sodium

    Hypertonic saline can rapidly increase

    losses.

    Giving 40 to 60 mmol of elemental potassium orally every

    signs of rapidly progressing hyperkalaemia in the face of tumour lysis syndrome, massive

    level of 120 mmol/L. Hypertonic

    • 2 to 4 hours for 3 days.

    haemolysis, or rhabdomyolysis

    saline is typically reserved for patients with an acute disease process rather than chronic hyponatremia.

    Severe hypokalaemia (< 2mmol/l)

    where a normal ECG has rapidly progressed through tall peaked T waves and loss of the P wave.

    serum sodium by 2 to 3 mmol/hr or

    Give 40 mmol K + in 1L RL over

    Give 10mls 10% CaCl 2

    more depending on the amount infused.

    • 1 hour with continuous ECG monitoring.

    (6.8mmol) over 10mins OR

    Check baseline RBS.

    When rapid correction of the serum sodium concentration is needed (those seizing, with focal findings, or with coma) give 150 mL of 3% hypertonic saline over 20 minutes.

    Additionally, restoration of normokalaemia relies on the establishment of normomagnesemia as both K + and Mg 2+ co-transport in the kidney.

    30mls 10% Calcium Gluconate (6.6mmol) over 10mins

    If RBS < 14mmol/L, give 50mls 50% dextrose IV bolus

    If a second bolus is required, give a

    Give at least 0.5 grams/hr of

    Give 10units soluble insulin IV

    second 150 mL of the 3% solution over the next 20 minutes.

    magnesium sulphate along with potassium replacement to a

    bolus AFTER the dextrose above or if RBS 14mmol/L

    maximum of 2gm

    Repeat the above twice or until a target of 5 mmol/L increase in serum sodium concentration is achieved.

    Consult a Physician for ALL Patients

    The Dextrose-Insulin combination may be repeated if repeat K+ is > 5.5 mmol/L

    Do not expect patients with severe

    Re-check RBS after an hour

    symptoms to completely recover immediately, as it may take some time for the brain to fully recover.

    Nebulise Salbutamol 10 to 20 mg in 4 ml of NS over 10 minutes - 25-40% of patients do not respond secondary to tachyphylaxis.

    Serum potassium will be lowered approximately 10 to 30 minutes after the above measures are performed, and the effect will last for 2 to 6 hours.

    Consult a Physician for ALL Patients

    23. Syncope Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    History of Syncope Consider seizure - tongue biting, head turning during loss of consciousness, no recollection
    History of Syncope
    Consider seizure - tongue biting, head turning during
    loss of consciousness, no recollection of abnormal
    behaviour, prolonged limb jerking (lasting minutes),
    post-event confusion, and prodromal déjà vu.
    Yes
    No

    See

    24. Seizures Algorithm

    Check RBS – If RBS < 3.3 mmol/L – See 21. Hypoglycaemia algorithm 12 lead ECG - Look for evidence of ischemia/infarction, dysrhythmias, atrioventricular blocks, Brugada syndrome (RBBB with J-wave elevation of ≥ 2 mm), prolonged QT interval, ventricular pre-excitation, hypertrophic cardiomyopathy Check Hb/Hct Post-menarcheal girls should receive urine pregnancy test. Laboratory studies should be reserved ONLY for those patients in whom electrolyte abnormalities e.g. Hypokalaemia, or ingestions are suspected e.g. sedatives An echocardiogram should be pursued in patients with concerning murmurs on examination or if syncope occurred during exercise or in conjunction with chest pain.

       
    23. Syncope Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

    The San Francisco Syncope Rule (SFSR). The SFSR uses five factors (CHESS predictors) to predict serious adverse outcomes at 7 or 30 days in patients presenting to the ED.

    • 1. History of Congestive Heart Failure

    • 2. Hematocrit < 30% (Hb < 10g/dL)

    • 3. ECG abnormality (see above)

    • 4. Shortness of breath history

    • 5. SBP < 90 mm Hg after arrival in the ED

    SFSR is associated with a pooled negative predictive value of 97%, sensitivity of 87%, and negative LR

    of 0.28. Patients with negative SFSR scores had < 3% risk for serious outcomes.

       
    23. Syncope Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment
     

    Does the patient have ANY of the 5 SFSR predictors?

     

    Yes

    No

     
    23. Syncope Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment
    23. Syncope Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

    Consult a Physician

    Discharge
    Discharge
    • 24. Seizures Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    History of Seizure
    History of Seizure
    24. Seizures Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

    Active seizure OR Post ictal OR Status epilepticus

    (> 5 minutes of a continuous seizure, or ≥ 2 discrete seizures between which there is incomplete recovery of consciousness.

    Active seizure OR Post ictal OR Status epilepticus ( > of a continuous seizure, or ≥
    • Maintain and support ABCs • Monitor vital signs (BP, PR, RR, SPO 2 , T
    • Maintain and support ABCs
    • Monitor vital signs (BP, PR, RR, SPO 2 , T o C)
    • Start Oxygen IF SPO 2 < 94%. Maintain SPO 2 ≥ 94%
    • Check RBS
    24. Seizures Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment
    • Position patient on soft mattress/pillows on trolley in left lateral position and open the airway
    • Position patient on soft mattress/pillows on trolley in
    left lateral position and open the airway with head-tilt
    manoeuvre; maintain this position until patient is
    awake – Do not restrain a seizing patient
    • Maintain and support ABCs
    Post ictal
    Still Seizing
    Or
    Recurrent Seizure
    • Set up IV access, Check RBS and give Midazolam 0.1 mg/Kg
    IV/IM.
    • Provide O 2 by Non-Rebreather mask at 15L/min
    • Send blood samples for CBC, (MPS), UEC, HIV,
    Phenytoin/Valproate levels if known epileptic.
    Post ictal
    Still Seizing
    Or Recurrent Seizure
    Or
    Recurrent Seizure
    24. Seizures Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment
    • Repeat Midazolam 0.1mg/Kg IV after 10 minutes from last dose • Load with phenytoin at
    • Repeat Midazolam 0.1mg/Kg IV after 10 minutes from last dose
    • Load with phenytoin at 20 mg/kg IV in NS strictly at 50 mg/min
    by infusion pump with ECG monitoring.
    OR
    Na Valproate 20mg/kg IV push if on ARVs
    Post ictal Still Seizing Or Recurrent Seizure • Consult a Physician and continue with algorithm •
    Post ictal
    Still Seizing
    Or
    Recurrent Seizure
    • Consult a Physician and continue with algorithm
    • Repeat Midazolam 0.1mg/Kg after 10 minutes from last
    dose
    • Consider hypoglycaemia, hyponatremia, tricyclic overdose
    • If still in seizing, additional phenytoin at 5 mg/kg IV in
    NS strictly at 50 mg/min by infusion pump with ECG
    monitoring until cessation. Repeat again once if
    necessary. Obtain phenytoin level 30-60 minutes after
    completion of infusion. (Aim for ≥ 10mg/L)
    Post ictal
    Still Seizing
    Or
    Recurrent Seizure
    24. Seizures Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment
    24. Seizures Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

    Intubate and ventilate patient; keep T o C ≤ 37 o C - Propofol 1mg/kg IV + Rocuronium 1mg/kg Start infusion of midazolam 0.1mg/kg/hour IV Obtain CT Head and review all the results. Admit ICU

    Obtain CT Head and review all the results. Consult a Physician

    First-time Seizure
    First-time Seizure
    24. Seizures Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

    Known Epileptic or >1 seizure

       
    24. Seizures Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment
    Send blood samples for CBC, (MPS), UEC, HIV, Urine PDT Send blood samples for CBC, (MPS),
    Send blood samples for CBC,
    (MPS), UEC, HIV, Urine PDT
    Send blood samples for CBC, (MPS),
    UEC, (Phenytoin/Valproate levels)
    If epileptic and non- compliant on
    medication load PO with;
    • phenytoin at 20 mg/kg
    OR
    • Na Valproate 20mg/kg if on ARVs
    If unable to take orally, give same doses
    IV as below.

    An MRI (or CT scan) should be performed immediately when a provider suspects a serious structural lesion or; new focal deficits, persistent altered mental status (with or without intoxication), fever, recent trauma, persistent headache, history of cancer, history of anticoagulation suspicion of AIDS. patients who have completely recovered from their seizure and for whom no clear-cut cause has been identified (e.g., hypoglycaemia, hyponatremia, tricyclic overdose)

    Additionally, for patients with first-time seizure, emergent MRI/CT should be considered if any of the following is present:

    Age > 40 years Partial-onset seizure

    Additionally, for patients with recurrent seizure (prior history of seizures) emergent MRI/CT should be considered if any of the following is present:

    New seizure pattern or new seizure type Prolonged postictal confusion or worsening mental status

    Patients with typical recurrent seizures related to previously treated epilepsy are unlikely to have life-threatening structural lesions. These patients DO NOT require MRI/CT.

       
    24. Seizures Algorithm This clinical pathway is intended to supplement, rather than substitute for, professional judgment

    Review with ALL results

    Criteria for discharge; First onset single seizure in a patient < 40 years who has completely recovered from their seizure and for whom no clear-cut cause has been identified (e.g., hypoglycaemia, hyponatraemia, tricyclic overdose) and with normal investigations. No follow -up is necessary unless seizure recurs Known epileptic who has completely recovered from their seizure and for whom a clear- cut cause has been identified (e.g. non- compliance, sub-therapeutic drug levels) and with normal investigations. Patient should be loaded with anticonvulsants if non- therapeutic prior to discharge and adequate follow-up arranged.

    Consult a Physician on ALL other patients

    25. Transient Ischemic Attack (TIA) Algorithm
    25.
    Transient Ischemic Attack (TIA) Algorithm

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    The AHA/ASA has endorsed the current definition of TIA as “a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.” The new definition of TIA completely eliminates the element of time and emphasizes neuroimaging instead.

    Mimics • Stroke • Hypoglycaemia / hyperglycemia • Seizure with Todd paralysis • Complicated migraine •
    Mimics
    • Stroke
    • Hypoglycaemia / hyperglycemia
    • Seizure with Todd paralysis
    • Complicated migraine
    • Structural brain lesion (tumour,
    haemorrhage, aneurysm)
    • Demyelinating disease (multiple sclerosis)
    • Central nervous system infection
    (encephalitis, cerebritis, abscess)
    • Acute vestibular syndrome (labyrinthine
    disorders
    • Delirium
    • Recrudescence of old stroke
    • Syncope (of any aetiology)
    • Metabolic disarray (hyponatremia,
    hypokalaemia, etc.)
    • Peripheral nervous system lesion
    (radiculopathy, neuropathy, plexopathy)
    • Psychogenic (conversion disorder,
    somatization)
    Is ABCD3 < 4
    See
    26. Stroke Algorithm
    Consult a
    Physician
    See
    Consult a
    26. Stroke Algorithm
    Physician
    The ABCD3 Score
    Predictor
    Age > 60 y
    Blood pressure > 140/90 mm Hg
    Points
    1
    1
    Clinical features (maximum 2)
    Unilateral weakness (2)
    Speech difficulty without weakness (1)
    Duration (maximum 2)
    > 60 min (2)
    10-59 min (1)
    < 10 min (0)
    Diabetes
    Dual TIA (TIA prompting medical
    attention plus at least one other TIA in the
    preceding 7 days.)
    2
    2
    1
    Abbreviations: CT, computed tomography; DWI, diffusion-weighted imaging; ECG, electrocardiogram; ED,
    emergency department; IV, intravenous; MRI, magnetic resonance imaging; TIA, transient ischemic attack.
    2
    Maximum total score
    9

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    Identify signs of possible acute stroke

    Patient to be seen by the doctor within 10 minutes of arrival

    Identify signs of possible acute stroke Patient to be seen by the doctor within 10 minutes

    Monitor, support ABCs in the Resuscitation Room (ER) Check vital signs (BP, PR, RR, SPO 2 , T o C). Start Oxygen IF SPO 2 94%. Maintain SPO 2 > 94% Check Glucose and treat if < 3.3 mmol/L with 50mL 50% Dextrose bolus. Maintain blood glucose between 7.7- 10mmol/L Establish 14-16G IV Access and send blood samples for FBC, UEC, coagulation screen Obtain/review 12-lead ECG Perform brief, targeted history, physical exam; perform neurologic screening assessment – Indicate time when patient last known normal

       
    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be
     

    National Institutes of Health Stroke Scale (NIHSS)

     

    1a. Level of consciousness

    0

    = Alert; keenly responsive

    6.

    Motor leg

    • 0 = No drift

    1

    = Not alert, but arousable by minor stimulation

    6a. Left leg

    • 1 = Drift

    2

    = Not alert; requires repeated stimulation

    6b. Right leg

    • 2 = Some effort against gravity

    3

    = Unresponsive or responds only with reflex

     
    • 3 = No effort against gravity; limb falls

     
    • 4 = No movement

    1b. Level of consciousness questions:

    0

    = Both answers correct

    7.

    Limb ataxia

    • 0 = Absent

    What is the month?

    1

    = Answers one question correctly

     
    • 1 = Present in one limb

    What is your age?

    2

    = Answers both questions incorrectly

    • 2 = Present in two limbs

    1c. Level of consciousness commands:

    0

    = Performs both tasks correctly

    8.

    Sensory

    • 0 = Normal; no sensory loss

    1

    = Performs one task correctly

     
    • 1 = Mild-to-moderate sensory loss

    2

    = Performs neither task correctly

    • 2 = Severe to total sensory loss

    • 2. Best gaze

    0

    = Normal

    9.

    Best language

    • 0 = No aphasia; normal

    1

    = Partial gaze palsy

     
    • 1 = Mild to moderate aphasia

    2

    = Forced deviation

    • 2 = Severe aphasia

     
    • 3 = Mute, global aphasia

    • 3. Visual

    0

    = No visual loss

    10.

    Dysarthria

    • 0 = Normal

    1

    = Partial hemianopia

     
    • 1 = Mild to moderate dysarthria

    2

    = Complete hemianopia

    • 2 = Severe dysarthria

    3

    = Bilateral hemianopia

    • 4. Facial palsy

    0

    = Normal symmetric movements

    11.

    Extinction and

    • 0 = No abnormality

    1

    = Minor paralysis

    inattention

    • 1 = Visual, tactile, auditory, spatial, or

    2

    = Partial paralysis

     

    personal inattention

    3

    = Complete paralysis of one or both sides

    • 2 = Profound hemi-inattention or extinction

    • 5. Motor arm

    0

    = No drift

     

    5a. Left arm

    1

    = Drift

    5b. Right arm

    2

    = Some effort against gravity

     

    Total Score = 0 - 42

    3

    = No effort against gravity; limb falls

     

    4

    = No movement

       

    Obtain brain MRI/CT scan

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be

    Time from onset of symptoms < 4.5 hours?

    No

     

    Yes

    Time from onset of symptoms < 4.5 hours? No Yes
    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be

    Haemorrhage

    Consult a Neurosurgeon No Haemorrhage

    • - Give 300mg Aspirin

    • - Admit Stroke Unit

    Obtain immediate non-contrast enhanced brain CT scan within 25 minutes of patient arrival. T he ER doctor MUST accompany the patient to CT to get the CT report immediately

    • Obtain immediate non-contrast enhanced brain CT scan within 25 minutes of patient arrival. • T
     

    Does CT scan show any haemorrhage? CT should be interpreted within 45 minutes of patient arrival

     

    No Haemorrhage

    Haemorrhage

    Does CT scan show any haemorrhage? CT should be interpreted within 45 minutes of patient arrival
    Does CT scan show any haemorrhage? CT should be interpreted within 45 minutes of patient arrival

    Consult a Neurologist See 27. Stroke Reperfusion Algorithm

    Consult a Neurosurgeon

    This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed dependi ng upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

    Probable acute ischaemic stroke

    Begin stroke pathway

    Probable acute ischaemic stroke Begin stroke pathway
         
     

    Review/Complete Fibrinolysis Checklist

     
     

    Additional Inclusion and Exclusion Characteristics of Patients

    Inclusion and Exclusion Characteristics of Patients With Ischemic Stroke Who Could Be Treated With IV rtPA Within 3 Hours From Symptom Onset