Emergency Medicine Clinical Protocols - Google Groups

Emergency Medicine Clinical Protocols

Evidence-Based Clinical Practice

2nd Edition

Chief Editors

Dr. Hendry R. Sawe, MD, MMED, MBA Emergency Physician, MUHAS, and MNH

Dr. Brittany Lee Murray, MD Pediatric Emergency Medicine Physician, MNH

MNH | EMAT | MUHAS

Contributors

Contributing Editors Dr. Upendo George, MD, MMED Emergency Physician, MNH

Dr. Jennifer Jamieson, MBBS, BBiomedSc, MPH&TM EMAT Volunteer, MNH

Dr. Irene B. Kulola, MD, MMED Emergency Physician, MNH

Dr. Juma A. Mfinanga, MD, MMED Emergency Physician, MNH and MUHAS

Authors Dr. Bhupinder Singh

Dr. Winfrida Kaihula

Resident Emergency Medicine, MUHAS


Dr. Catherine Reuben Shari

Dr. Ally Akrabi

Dr. Edward Amani

Dr. Francis Sakita

Dr. Meera Nariadhara

Dr. Peter Mabula

Dr. Mundenga Muller

Dr. Prosper Bashaka

Dr. Patrick Shao

Dr. Shahzmah Suleiman

Dr. Amiri Kaduri

Dr. Renatus Tarimo













i

Preface

This is the second edition of the Emergency Medicine clinical protocols (EM Protocols) of the Muhimbili National Hospital Emergency Medicine Department, which were first published in 2011. This is a compilation of the updated protocols for the management of selected common emergency conditions at the emergency department of MNH, and is applicable to acute intake areas (casualty) in Tanzania and across Africa. The protocols focus mainly on up-to-date, evidence based management of acutely ill patients presenting with undifferentiated illnesses, such as acute exacerbation of asthma, seizures, hypertensive emergencies, malaria, burns, sepsis, hypoglycemia, hypokalemia, hyperkalemia, hyperglycemic states (DKA and HHS), upper GI bleeding, rapid sequence intubation and guidelines for administration of inotropes. However, it should be noted that at times, certain recommendations are tailored towards locally available medications and resources, and therefore should be reviewed before use at any institution. The second edition of the clinical protocols was necessitated by the protocol review committee, which provided evidence of changes that needed to be incorporated to improve the first edition. Residents in Emergency Medicine, who went through evidence-based sources to implement changes from the first edition, authored the second edition. A panel of emergency physicians reviewed all the changes, going through the protocols point by point to ensure content is backed by up-to-date literature. The Emergency medicine department (EMD) at Muhimbili National Hospital (MNH) and Muhimbili University of Health and Allied Sciences (MUHAS) has played an active role in the development of the clinical protocols. The Emergency Medicine Association of Tanzania (EMAT) has endorsed the contents of the protocol and advocates for its use across Tanzania. The protocol is an open source material, NOT for sale.

ii

Acknowledgements

The EMD expresses its gratitude to all the members of the protocol development committee who volunteered their own time in order to review and re-review of the contents of the second edition. Original contributors of the first edition EMD thanks the original contributors of the first edition who developed and edited the contents of the first edition: Dr Teri Reynolds, Dr Hendry R. Sawe, Prof Victor Mwafongo, Dr Juma Mfinanga and Dr. Andi Tenner. The Emergency Physicians The EMD thanks the Emergency Physicians who provided their inputs during resident presentation of different drafts of the second edition; Dr. Ghaniya Mbarouk, Dr Said Kilindimo, Dr. Mgalula Sifaeli, Dr Kepha Bernard, Dr Sherin Kassamali, Dr. Hendry R. Sawe, Dr Brittany L. Murray, Dr Irene Kulola, Dr. Geminian Festo, Dr. Philip Michael, Dr. Upendo George, Dr Juma Mfinanga, Dr. Khalid Mbaya and Dr. Jennifer Jamieson. Last, but not least, thank you to all of the EMD-MNH Registrars who provided technical inputs and critiques to improve the content of the protocols. Smart phone App support The EMD thanks Hitesh J. Chohan for generously donating his time to develop Android App to support the accessibility of the contents easily.

iii

Disclaimer

The EMD Clinical protocols are only intended for use by qualified Emergency Medicine healthcare providers. The EM providers using the protocols must also use their own clinical judgments, knowledge and expertise when deciding whether it is appropriate to apply this protocol to any particular patient. Locally available medications and resources must always be considered in the application of the protocols. The EMD, MNH, MUHAS, EMAT, and all the providers who supported the development of the protocols do NOT assume any liability for the information contained herein, be it direct, indirect, consequential, special, exemplary, or other damages.

Contact

Please contact Chief Editor-Dr. Hendry Sawe by sending and e-mail to: [email protected] in case of any noted errors or suggestions for the protocols. The Chief Editor is also happy to discuss and advise medical directors, and other EM health care providers on the local implementation of these protocols with providers in acute intake areas.

iv

Table of content Contributors………………………………………………………….........………………………………………...........

i

Preface………………………………………………………………………..………………………………………..........

ii

Acknowledgment………………………………………………………...………………………………………..........

iii

Disclaimer…………………………………………………………………..………………………………………….......

iv

Contact……………………………………………………………………….………………………………………...........

iv

Hypoglycemia.…………………………………………………………….…………………………………..…….....

1

Rapid Sequence Intubation (RSI)………………………………….……………………………………….....

2

Seizures……………………………………………………………………………………………………………….....

3

Malaria………………………………………………………………………..………………………………………......

4

Hypokalemia……………………………………………………………….………………………………………......

5

Hyperkalemia……………………………………………………………..……………………………………….......

6

Pediatric Sepsis…………………………………………………………..……………………………………….......

7

Adult Sepsis………………………………………………………………..……………………………………….......

8

Asthma……………………………………………………………………….………………………………………........

9

Burn…………………………………………………………………………………………………………………….......

10

DKA and HHS……………………………………………………………….………………………………………......

11

Hypertensive Urgency and Emergencies……………………….…………………………………….........

13

Inotropes and Chronotropes………………………………………...………………………………………........ 14 Nitroglycerine and Sodium Nitroprusside……………………..………………………………………........ 17 Upper GI Bleeding…………………………………………………………………………………………………....... 19 Recommended Further Readings………………………………………………………………………………

20

Hypoglycaemia Protocol For Adult and Paediatric Patients

HYPOGLYCAEMIA

IF NO RBG

CONFIRMED (RBG 6 after first dose and no ECG available)

OR

CALCIUM CHLORIDE- 10mls of 10% Reserve for critical patients with life threatening conditions Give through a central line ADULTS: 1g IV slowly push over 3-5 min PAEDIATRICS: 20mg/kg IV slowly over 5 min *If ECG changes persist, repeat dose every 10min (or if K is still > 6 after first dose and no ECG available)

2. SHIFT K+ INTO CELLS Give glucose immediately followed by insulin. GLUCOSE ADULTS: 50ml of 50% Dextrose IV If unavailable, use 5ml/kg of 10% Dextrose PAEDIATRICS: 5ml/kg of 10% Dextrose INSULIN ADULTS: 10 IU of regular (soluble) insulin IV over 5-10 min. PAEDIATRICS: 0.1 IU/kg of regular (soluble) insulin IV over 5-10 min (maximum 10 IU) Monitor RBG every 15 min for at least 1 hour Β2-AGONISTS- SALBUTAMOL ADULTS: 10mg of nebulized PAEDIATRICS: 5years - 5mg nebulized SODIUM BICARBONATE ADULT: 50 mEq IV stat PAEDIATRICS: 1mEq/kg IV (MAX 50 mEq)

6

3. REMOVE K+ FROM THE BODY LOOP DIURETICS - FRUSEMIDE ADULT: 40 mg IV once PAEDIATRICS: 1mg/kg IV once (maximum 40 mg) HEMODIALYSIS/PERITONEAL DIALYSIS Definitive treatment Consult Nephrology

ECG FINDINGS IN HYPERKALEMIA Slightly peaked T waves Peaked T waves P wave widens and flattens PR segment lengthens P waves disappear Prolonged QRS with bizarre morphology Bradycardia Sine wave appearance Asystole/Vfib

PAEDIATRIC SEPSIS PROTOCOL

RECOGNITION OF SEPSIS

Sepsis: ≥ 2 SIRS criteria PLUS suspected/proven source of infection Severe Sepsis: Sepsis + organ dysfunction + hypo perfusion ± hypotension Septic Shock: Severe Sepsis + hypotension refractory to adequate (6L) of fluid therapy

SIRS CRITERIA: See table 1 for modified SIRS criteria.

INITIAL RESUSCITATION

0 – 20 MIN

20-40 MIN

< 60 MIN

1-3 HRS

Airway: Protect as appropriate

Breathing: Give Oxygen

Circulation: • Establish IV / IO access and draw blood samples for investigations • FLUIDS: Administer 20ml/kg bolus of NS or RL over 5-10mins (FIRST BOLUS). If malnutrition, give 10ml/kg. Disability: Document GCS / AVPU REASSESSMENT Reassess after each bolus: RR, HR, capillary refill, BP, Sp02, temperature, urine output. If necessary, repeat UP TO 3 FLUID BOLUSES unless rales or hepatomegaly develop.

ANTIBIOTICS First Line Treatment: IV Ceftriaxone 100g/kg + IV Metronidazole 10mg/kg PLUS Vancomycin 10mg/kg (if immunocompromised and if available)

Second Line Treatment: IV Meropenem 20mg/kg TDS

Adjust antibiotics based on lab results. Treat any fungal, viral or parasitic infections.

SOURCE CONTROL: CXR, blood cultures, urine dipstick Other labs: RBG, FBP, mRDT, lactate, RFTs & electrolytes, LFTS. If indicated: wound swab, LP IF SHOCK NOT REVERSED (AFTER 2 FLUID BOLUSES) Start dopamine 10mcg/kg/min for cold shock. Cold Shock: cap refill > 3 sec, reduced Start adrenaline 0.05 – 0.3mcg/kg/min if resistant to dopamine or peripheral pulses, cool/mottled for warm shock. extremities If no improvement, give IV hydrocortisone 1mg/kg stat Warm Shock: flash cap refill, bounding peripheral pulses, warm extremities & Consider blood transfusion when Hb age-specific; SpO2 > 95%, urine output > 1mls/kg/hr; source control as early as possible. DISPOSITION: Patients with septic shock should receive consultation in the EMD

Table 1: Modified SIRS Criteria:

Age Group 1 month - 5 – 12 years >12 - 180 or < 90 >140 >130 >110

RR > 34 > 22 > 18 > 14

T >38.5 or 38.5 or 38.5 or 38.5 or 90 RR > 24 Temp < 36 or > 38 WBC < 4 or > 12

INITIAL RESUSCITATION Airway: Protect as appropriate Breathing: Give Oxygen Circulation: 0 – 20 • Establish 2 x large bore IV access MIN • FLUIDS: Administer 2L of NS or RL over 20 mins (FIRST BOLUS) • NB: Small boluses of 250-500ml in CCF Disability: Document GCS REASSESSMENT Reassess HR, BP, Sp02 and volume status (IVC by ultrasound). Repeat fluid bolus as necessary (2L) unless crepitations or hepatomegaly develop (SECOND BOLUS). EMPIRIC ANTIBIOTICS First Line Treatment: 20-40 IV Ceftriaxone 2g + Metronidazole 500mg MIN PLUS Vancomycin 15mg/kg (if immunocompromised or nosocomial and if available) Second Line Treatment: IV Meropenem 1g stat Adjust antibiotics based on lab results. Treat any fungal, viral or parasitic infections. SOURCE CONTROL: CXR, blood cultures, urine dipstick < 60 Other labs: RBG, FBP, mRDT, lactate, RFTs & electrolytes, LFTS. If indicated: wound swab, LP MIN

1-3 HRS

IF SHOCK NOT REVERSED (AFTER 2 FLUID BOLUSES)

If shock persists or dopamine unavailable start adrenaline infusion (refer to inotropes protocol) If no improvement, give IV hydrocortisone 200mg stat Consider blood transfusion when Hb 65mmHg; antibiotics within 60 mins; SpO2 > 94%, urine output > 0.5mls/kg/hr; source control as early as possible. DISPOSITION: Patients with septic shock should receive consultation in the EMD 8

ACUTE EXACERBATION OF ASTHMA FOR ADULT AND PAEDIATRIC ASTHMA PATIENTS

*Signs of severe illness include: Silent Chest, Altered Mental Status, Bradycardia, Hypoxia 30mmol/L

Venous pH 15mmol/L Hyperosmolality (2Na + BUN + RBG) > 320mOsm/L

Anion gap = Na – (Cl- + HCO3 ) > 12 Ketonuria 2+

THESE CRITERIA REFLECT AN UNDERLYNG METABOLIC ACIDOSIS (NOT A HIGH GLUCOSE PROBLEM)

Immediate bedside investigations: RBG, urine dipstick, VBG/ABG, sodium & potassium (repeat hourly).

Further investigations: Electrolytes (re-check Na & K every 2 hours), BUN, Creatinine, Urinalysis, FBP. C/S for blood and urine if fever or localizing signs of infection are present. UPT (for all women of reproductive age). CXR and ECG (in proper clinical context).

MANAGEMENT: The stepwise management of DKA / HHS is essential. 1. CORRECTION OF DEHYDRATION/ HYPOVOLEMIA (OVER 48HRS)

! ! ! !

Initial Bolus: IV NS 2000ml over 1 hour. In children: 20ml/kg over 1hr. THEN for the next 3 hours: give IV NS 1000ml per 1 hour (total of 3000ml). In children: 10ml/kg/hour. THEN for the next 3 hours: give IV NS 500ml per 1 hour (total of 1500ml). In children: 5mls/kg/hour. THEN until resolution: give IV NS 250mls per hour. In children: 2.5mls/kg/hour.

NOTE: 1. During treatment if RBG < 14mmol/L, provide DNS 250mls/hr (in children: 2.5mls/Kg/hr) instead of NS 2. During treatment if RBG > 14mmol/L, switch IV DNS to Normal Saline 3. During treatment if RBG < 3 mmol/L, provide IV 50% Dextrose 50mls bolus or IV D10% 250mls (in children: 5mls/kg of D10%); then re-check RBG.

2. CORRECTION OF POTASSIUM * 4. 250mls (5ml/kg in pediatrics) bolus and then recheck blood glucose

* If results of serum k+ have not returned in 3 hours, then provide IV KCL 10mmol/hr in adults and 0.5 mmol/kg/hr for children (providing they are not anuric) - until you have the investigation results. Otherwise, follow potassium replacement guidelines as below:

11

CORRECTION OF K+ FOR ADULTS

CORRECTION OF K+ FOR PAEDIATRICS

If Potassium level is > 4.5 mmol/L NO potassium replacement is necessary. Check the levels every 2 hours. If Potassium level is 2.5 - 4.5 mmol/L THEN: Give 10 mmol/hour, check the levels every 2 hours until level of potassium is >4.5 mmol/L

"

"

"

"

If Potassium level is 2.5 mmol

"

"

If potassium level is > 5mmol/L, NO potassium replacement is necessary. Check the levels every 2 hours. If Potassium level is 2.5 - 5 mmol/L THEN: Add IV KCL 0.5 mmol/kg/hour in a bolus of NS (maximum 10mmol/hour). Repeat potassium level every 2 hours. If Potassium level is 2.5mmol.

3. CORRECTION OF ACIDOSIS / HYPERGLYCEMIA

Dose: Start an insulin infusion at a rate of 0.1 units/kg/hr IV for both adults and children until resolution of acidosis. In case of insulin sensitivity use lower doses; 0.05units/kg/hr in adults and children. Infusion composition: Dilute 50 units regular (soluble) insulin in 50mL NS Concentration: 1 unit = 1mL DO NOT GIVE IV INSULIN BOLUS INITIALLY (↑ risk of cerebral edema and can exacerbate hypokalemia). Consider SC insulin 0.05U/kg when the venous pH > 7.3, serum HCO3 >16mmol/L or anion gap is normal.

" " "

If RBG = 14mmol/L add 5% Dextrose If RBG 7.3 • HCO3 > 18mmol • Calculated anion gap 180mmHg or DBP 110mmHg WITHOUT signs of end organ damage.

HYPERTENSIVE EMERGENCY: severe hypertension of SBP > 180mmHg or DBP 110mmHg WITH signs of end organ damage. Signs of end organ damage includes: • • • • • • • •

Altered mental status (may indicate hypertensive encephalopathy) Neurological deficit (may indicate cerebrovascular accident) Shortness of breath (may indicate acute pulmonary oedema or myocardial infarction (MI)) Chest pain / Epigastric pain (may indicate acute MI or aortic dissection) Poor left ventricular contractility (may indicate left ventricular dysfunction) Decreased urine output or increased RFTs (may indicate acute renal failure/insufficiency) Pregnancy > 20 weeks (may indicate pre-eclampsia or impending eclampsia) Blurring of vision / abnormal fundoscopy (may indicate hypertensive retinopathy)

TREATMENT

HYPERTENSIVE URGENCY: • Re-check BP to confirm the initial reading • Look for and treat other causes of hypertension (e.g. pain, anxiety, withdrawal, intoxication) • Do baseline investigations (RBG, ECG, creatinine / BUN, urinalysis, FBP) • Consult cardiac (for initiation of oral HTN, disposition & arranging long term follow-up)

HYPERTENSIVE EMERGENCY: ! Re-check BP to confirm the initial reading ! Look for and treat other causes of hypertension (e.g. pain, anxiety, withdrawal, intoxication) ! Use a short-acting, titratable IV drug (see below) ! Lower MAP by 20% over an hour (NB: achieving “normal” BP too quickly is dangerous) ! Do baseline investigations (RBG, ECG, creatinine / BUN, urinalysis, FBP) ! Admit to hospital with cardiac consultation

MEDICATIONS for Hypertensive Emergencies

Choose ONE of these medications based on underlying cause and check BP before / after every dose. 1.

2. 3.

4.

IV LABETOLOL: preferred in aortic dissection. Avoid in CCF, asthma and bradycardia. Dose: Give 15mg over 2 minutes. Repeat every 10 minutes if needed (max total dose = 300mg). If giving infusion, start at 1 mg/min (mix 100mg in 100ml NS, then give 1 drop every 3 seconds). Titrate upward to a maximum of 4 to 5 mg/min if needed. IV NITROGLYCERIN: preferred in MI and CCF. Avoid in Inferior MI. (For dose and administration refer to nitroglycerin protocol) IV SODIUM NITROPRUSSIDE preferred in CCF. Avoid in renal failure and pregnancy. (For dose and administration refer to sodium nitroprusside protocol) IV / IM HYDRALAZINE: preferred in pre-eclampsia / eclampsia. Dose: give 5mg, repeat every 30 minutes if needed (max total dose = 300mg per day).

13

INOTROPES AND CHRONOTROPES PROTOCOL ADULT AND PEDIATRIC PATIENTS

DOPAMINE Indications: Recommended for hypotension (adults < 100SBP) and low cardiac output states due to cardiogenic, septic or neurogenic shock. Contraindications: Pheochromocytoma, tachyarrhythmia, hypersensitivity, idiopathic hypertrophic sub-aortic stenosis Remember: Ensure patient has been adequately fluid resuscitated first • PAEDIATRICS: 3 boluses of normal saline 20ml/kg if not severely anaemic (Hb ≤4) • ADULTS: 2L of normal saline if not severely anaemic (Hb ≤4) • All patients require continuous cardiac monitoring Infusion Composition: Mix 200 mg in 500 ml Normal Saline Final Concentration: 400mcg/ml Start Dose: 5mcg/kg/min Infusion Rate: 1-20 mcg/kg/min • IF NO RESPONSE, INCREASE DOSE AT A RATE OF 2MCG/KG/HR EVERY 5 MINS • Administer via dedicated line (i.e. ideally central venous line) • Once target goal reached, start tapering down at same rate Target SBP: • Adult: ≥ 90mmHg or MAP ≥ 65 • Children: 70 + (2×age) to 90 + (2×age) mcg/min ml/hr drops/min mcg/min ml/hr drops/min

50 7.5 2.5

75 11.25 3.75

100 15 5

125 18.75 6.25

150 22.5 7.5

200 30 10

250 37.5 12.5

300 45 15

350 52.5 17.5

400 60 20

500 75 25

600 90 30

700 105 35

800 120 40

900 135 45

1000 150 50

1250 187.5 62.5

1500 225 75

1750 262.5 87.5

2000 300 100

14

INOTROPES AND CHRONOTROPES PROTOCOL ADULT AND PEDIATRIC PATIENTS

DOBUTAMINE Indications: Recommended for afterload support in hypotension due to cardiogenic shock and severe heart failure. Contraindications: Pheochromocytoma, tachyarrhythmia, hypersentivity, conditions resulting in cardiac outflow obstruction. Tachyphylaxis may occur during prolonged use. Remember: Ensure patient has been adequately fluid resuscitated first • PAEDIATRICS: 3 boluses of normal saline 20ml/kg if not severely anaemic (Hb ≤ 4) • ADULTS: 2L OF normal saline if not severely anaemic (Hb ≤ 4) • All patients require continuous cardiac monitoring Composition: Mix 200 mg in 500 ml NS Final Concentration: 400mcg/ml Start Dose: 5mcg/kg/min Infusion Rate: 1-20 mcg/kg/min • IF NO RESPONSE, INCREASE DOSE AT A RATE OF 2MCG/KG/HR EVERY 5-10 MIN • Administer via dedicated line (i.e. ideally central venous line) • Once target goal reached, start tapering at same rate Target SBP: • Adult: ≥ 90mmHg or MAP ≥ 65 • Children: 70 + (2×age) to 90 + (2×age) mcg/min ml/hr drops/min mcg/min ml/hr drops/min

50 7.5 2.5

75 11.25 3.75

100 15 5

125 18.75 6.25

150 22.5 7.5

200 30 10

250 37.5 12.5

300 45 15

350 52.5 17.5

400 60 20

500 75 25

600 90 30

700 105 35

800 120 40

900 135 45

1000 150 50

1250 187.5 62.5

1500 225 75

1750 262.5 87.5

2000 300 100

15

INOTROPES AND CHRONOTROPES PROTOCOL ADULTS AND PEDIATRIC PATIENTS

ADRENALINE

Indications: Septic shock, anaphylactic shock, post CPR care Contraindications: Pheochromocytoma, tachyarrhythmia, known hypersensitivity to sympathomimetics Remember: Ensure patient has been adequately fluid resuscitated first • PAEDIATRICS: 3 boluses of normal saline 20ml/kg if not severely anaemic (Hb ≤ 4) • ADULTS: 2L OF normal saline if not severely anaemic (Hb ≤ 4) • All patients require continuous cardiac monitoring Composition: Mix 1 mg adrenaline in 500 ml of normal saline Final Concentration: 2mcg/ml Infusion Rate: usual dose range 0.05 - 2mcg/kg/min • Adjustment rate 0.01mcg/kg/min every 15 min • Administer via dedicated line (i.e. ideally central venous line) • Once target SBP reached, start tapering at same rate Target SBP: • Adult ≥ 90mmHg or MAP ≥ 65 • Children 70+ (2×age) to 90+(2×age) mcg/min 1 ml/hr 30 drop/min 10

2 60 20

3 90 30

4 120 40

5 150 50

6 180 60

mcg/min 15 ml/hr 450 drop/min 150

20 600 200

25 750 250

30 900 300

35 40 50 1050 1200 1500 350 400 500 16

7 210 70

8 240 80

9 270 90

10 300 100

60 70 80 1800 2100 2400 600 700 800

IV Nitroglycerin

Indications:

Hypertensive emergency Treatment of myocardial ischaemia Treatment of acute decompensated heart failure CCF Treatment of flash pulmonary oedema

• • • •

Contraindications: ! ! ! !

SBP < 90mmHg Patient has known or suspected right-sided or inferior myocardial infarct Patient has marked bradycardia (HR ≤ 50/min) Patient is using phosphodiesterase inhibitors such as Sildenafil / Tadalafil i.e Viagra®)

Infusion Composition: Mix 5mg of Nitroglycerin in 250ml of NS/DNS Final Concentration: 20mcg/ml Start Dose: 5mcg/min Infusion Rate: 5 – 400mcg/min

mcg/min mL/hr drops/min mcg/min mL/hr drops/min

5 15 5

10 30 10

15 45 15

20 60 20

25 75 25

30 90 30

35 105 35

40 120 40

45 135 45

50 150 50

100 300 100

150 450 150

200 600 200

250 750 250

300 900 300

350 400 450 500 1050 1200 1350 1500 350 400 450 500

*

Sublingual Nitroglycerin

Indications / Contraindications – same as for IV nitroglycerin Caution: absorption may be less predictable via this route than IV nitroglycerin. Spray: a single spray sublingually contains 400mcg nitroglycerin Tablet: a single tablet sublingually contains 300mcg, 400mcg or 600mcg nitroglycerin Administration: give one spray or tablet sublingually every 10 minutes (check BP before giving another spray or tablet).

17

SODIUM NITROPRUSSIDE

Indications:

• •

Hypertensive emergency Acute decompensated heart failure

Contraindications:

• •

Avoid in pregnancy Avoid in renal impairment

Side effects:

• • •

Increased ICP Toxic metabolites (causing cyanide poisoning) Severe necrosis

Remember: Start at a lower dose and titrate to effect Always check blood pressure before giving more medications Infusion Composition: Mix 25mg of sodium nitroprusside in 125ml of NS/DNS. Final Concentration: 200mcg/ml Start Dose: 1mcg/kg/min (titrate to effect up to maximum dose of 10mcg/kg/min) NB: Medication is unstable if exposed to UV light – please cover infusion bag. PATIENT’S Dose in mcg/Kg/min WEIGHT IV DRIP RATE 1 2 3 4 5 6 7 8 40 mL/hr 12 24 36 48 60 72 84 96 KG drops/min 4 8 12 16 20 24 28 32 50 mL/hr 15 30 45 60 75 90 105 120 KG drops/min 5 10 15 20 25 30 35 40 60 mL/hr 18 36 54 72 90 108 126 144 KG drops/min 6 12 18 24 30 36 42 48 70 mL/hr 21 42 63 84 105 126 147 168 KG drops/min 7 14 21 28 35 42 49 56 80 mL/hr 24 48 72 96 120 144 168 189 KG drops/min 8 16 24 32 40 48 56 64 90 mL/hr 27 54 81 108 135 162 189 216 KG drops/min 9 18 27 36 45 54 63 72 100 mL/hr 30 60 90 120 150 180 210 240 KG drops/min 10 20 30 40 50 60 70 80

18

9 108 36 135 45 162 54 189 63 216 72 243 81 270 90

10 120 40 150 50 180 60 210 70 240 80 270 90 300 100

UPPER GASTROINTESTINAL BLEEDING

1.RESUSCITATION (ABCs)

2.MEDICAL THERAPY

1. MAINTAN ABCs

2. IVF: Give normal saline or Ringers lactate Adult 2000mL* Pediatrics 20ml/kg * ****Cautious fluids in anaemia (Hb