Surgical and Medical Emergencies Up

SURGICAL AND MEDICAL EMERGENCIES
Course outline
Chapter one: Generalities in theatre nursing
Chapter two: Surgical emergencies
 Traumatic surgical emergencies

 Non traumatic surgical emergencies
Chapter three: Medical emergencies
Dr. BATY/ Dr. CHI Page 1

CHAPTER 1: GENERALITIES IN THEATRE NURSING.
1. Common terms used in an OR
Operating room: a room that provides a sterile environment within a hospital where
surgical operations are carried out.
Operating/surgical team: A team of highly trained professionals with a
wide range of specialties who is present to offer comprehensive patient care.
Scrub: (verb) to wash hands and forearms very thoroughly as before engaging in a
surgery. Also to thoroughly wash a surgical sight, (Noun) a member of the surgical team
who scrubs
Asepsis: A condition in which living pathogenic organisms are absent (a state of sterility)
Antisepsis: Prevention of infection by inhibiting or arresting the growth and
multiplication of germs (free of all living microorganisms)
Anaesthesia: Loss of feeling or awareness, as when an anaesthetic is administered before
surgery
Sterile field: refers to the areas that surround and include the surgical room in which
aseptic technique must be maintained. The sterile area in the operating room includes: OR
bed with sterile drapes, Surgical team, Mayo stand, draped radiological equipements.
Sterilization: the elimination of all forms of microbial life so that there is a < 1
/1000,000 chance of an infectious organism surviving
-ectomy: suffix referring to ablation or excision of the word root. Ex appendectomy=
removal of the appendix
-otomy: opening of a structure, especially a hollow structure. Ex craniotomy= opening of
the skull
-stomy: linking of two or more tubular structures. Ex gastrostomy
-rraphy: repair or closure of a zone of weakness. Herniorraphy = repair of a hernia
2. Layout of an operating room
Operating room must not be used for other purposes. Every operating room must have
following characteristics:

 Proper lightening
 Good ventilation
 Proper equipment for procedures
 Equipment to monitor patients as needed for the procedure
 Drugs and other consumables required for routine and emergency use
It typically contains a monitor that displays vital signs, an instrument table, and an
operating lamp. Anesthetic gases are piped into the anesthetic machine. A catheter attached
to a suction machine removes excess blood and other fluids, which can prevent surgeons
from seeing the tissues clearly. Intravenous fluids, started before the person enters the
operating room, are continued.
Three areas of operating room

For staff and visitors the operating room is classified into 3 areas
a. Unrestricted area-This area has following characteristics:
• Here the traffic is not limited. Street clothes are allowed in this area.
• This area is separated by doors from the main hospital corridor.
• It allows access for communication with department and hospital personnel.
Examples of this area include: operating room supervisor‘s office, locker rooms, surgical
scheduling office.
b. Semi-restricted area- This area has following characteristics:
• Traffic is not allowed to everyone.
• You must wear scrub attire and caps to enter in this area.
• This area includes the support areas of the surgical suite.
Examples of this area include: Clean stores and sub-sterile rooms as designated by the
facility, corridors outside the operating room, and Storage areas for clean and sterile
supplies
c. Restricted area- this area has following characteristics:
 You have to wear scrub attire, caps and masks in this area.
 Areas where unwrapped sterile supplies are provided to carry out
procedures are carried out are included in this section.

Examples of this area include: procedure room, operating room, scrub area, clean cores and
sub-sterile rooms as designated by the facility.
3. The surgical team
The surgical services team consists of following components
Sterile Team includes;
 Surgeon
 First assistant
 Surgical technologist
Non sterile team includes:
 Anesthesia provider
 Circulator
 Environmental service
 Sterile processing

a) Surgeon. Quality: Medical doctor
 Roles
• Requests the surgery

• Provides consent and history and physical
• Communicates exact procedure, operative side and any special needs prior to
surgical case.
• Assists in positioning patient
• Performs surgical procedure
b) First assistant:
Quality: Surgeon, Physician‘s Assistant, Nurse Practitioner
 Role:
• Assist the surgeon in manipulating tissue
• Wound closure.
c) Surgical technologist (scrub): Quality: Usually a nurse
• Roles
• Is scrubbed in at the field
• Set up sterile supplies and instrumentation
• Assist the surgeon as needed during the operative procedure
• Performs all needed counts with the circulating nurse
• Knowledge of aseptic technique
d) Anaesthesia Provider : Quality; MD/Nurse
• Roles
• Assesses patient‘s risk for receiving
anesthesia
• Assesses need for appropriate anesthetic during the surgical procedure
• Communicates equipment needs to the Anaesthesia tech
or circulating nurse
e) Anaesthesia technician (inconstant, usually a nurse)
• Knowledge of equipment used by the Anaesthesiologist

• Assists with the setup of equipment, medications and supplies and cleanup in
assigned operating room
• May assist Anesthesia Provider during induction of anesthesia

f) Circulator : Quality: Must be an RN
• Roles
• Plans patient care
• Communicates patient‘s needs to the health care team
• Manager of the Operating Room Suite, the ―Watch dog‖
g) Environmental Services
• Cleans the theatre and large equipment prior to and after a surgical procedure
• Properly disposes of waste
h) Sterile Processing
• Treats and sterilizes surgical equipment and resets them in boxes
• Treats and sterilizes gowns and other attires (in case of reusable)
4. Practical surgical techniques

a) Suture material
Sutures are made of variety of materials with variety of properties

• Non-absorbable
– Use when possible
– Braided suture not ideal for contaminated wounds
– May sterilize polyester thread or nylon line when commercial suture unavailable
• Absorbable
– Degrades, loses tensile strength within 60 days
– Option when it is not possible for patient to return or for children for whom suture
removal may be difficult
b) Suture techniques
• Interrupted sutures: this is the most commonly used to repair lacerations. It permits
good eversion of wound edges. It is used only when we have minimal skin tension, it
ensures that bites are of equal volume. If wound edge is unequal, bring thicker side to
meet thinner side to avoid putting extra tension on thinner side. Use non-absorbable
suture, if possible.
• Continuous/running sutures: this type is less time-consuming than interrupted
sutures; fewer knots tied, less suture material used, less precise in approximating
wound edges, poorer cosmetic result than other options. Epidermal skin cells growing
into wound (inclusion cyst) or along suture track are potential complications

• Continuous subcurticular sutures: Excellent cosmetic result. Use fine, absorbable
braided or monofilament suture. It does not require removal if absorbable sutures
used. Useful in wounds with strong skin tension, especially patients prone to keloid
formation.
Anchor suture in wound; from apex, take bites below dermal-epidermal border.
Start next stitch directly opposite preceding one
• Mattress sutures: This type provides relief of wound tension, provides precise
wound edge apposition. It more complex, therefore more time-consuming
• Purse string suture: this is done in a circular pattern that draws together tissue in
path of suture. It is used particularly around drain sites. Generally use non-absorbable
sutures.
FOREIGN BODY REMOVAL

Timing
- Urgent: airway compromise
- Less urgent: some deep metal fragments
• May be difficult or time-consuming; patient should be anaesthetized
• X-ray or fluoroscopy is recommended for removal of radio-opaque objects: pins,
needles, glass.
• Foreign bodies in cranium, chest, abdomen, close proximity to vital structures
must be removed in operating theatre with team prepared to manage possible
complications
Ear: Try irrigation unless contraindicated, gentle suction, gentle hook extraction,
inject the lobe with a small amount of lidocaine.
• Grab the visible earring/butterﬂy with forceps, and remove.
• A small ‗nick‘ in the posterior surface of the lobe may be required to ease removal
in embedded earring/butterﬂies.
• Despite the lobe being red and swollen, antibiotics are rarely needed.
Eye: Sterile saline wash, refer if imbedded in eye
Nose: Nasal FBs are commonest in children aged 1–5y where anything that can be
inserted into the nostril may be there! Common FBs are stones, tissue, and beads. Some
may have been in situ for a long period of time. if a child presents with a foul-smelling
nasal discharge, always suspect an FB. if the FB is visible, suction can be applied with a
rigid suction catheter and can be successful. Depending on the shape, size, and texture of
the FB, different equipment is needed. Soft FBs (tissue/peas): use crocodile forceps to
gently grasp the FB.
• Round, hard FBs (beads/stones): a blunt-ended probe, which is slightly bent into a
hook shape, needs to be inserted behind the FB to ‗hook it‘ out. Once removed,
the nostril should be checked for any further FB or signs of trauma. Always check
the other nostril for the presence of a FB.
• Failure to remove requires referral to ENT
Airway: Heimlich maneuver, bronchoscopy
GI tract: Most pass if smooth, refer if sharp or obstruction

SPECIFIC LACERATIONS
Lacerations may be associated with neurovascular or other serious injury; a complete

examination is required to identify injuries that are not immediately obvious.
• Minor problems are important because mismanagement can lead to major
detrimentalconsequences
HandLaceration
• Treat lacerations promptly with careful evaluation, debridement and lavage
• Close wounds only when clean, using suture, spontaneous healing or skin grafts
• After injury, elevate the hand.

• Nail bed injuries require special treatment (keep the nail bed
clean and dry, cover it with petroleum jelly and an adhesive
bandage until the nail bed is firm or grown back. Use a new
bandage each time the old one gets wet). Watch out for any sign of
infection.
Evaluation
 Treat open injuries of the hand promptly. Perform a local examination to check
circulation, sensation and motor function.
 Gently examine the wound using aseptic technique to determine if it is clean or
contaminated. A contaminated wound contains foreign material and crushed or
dead tissue.
Treatment
1. Debride and lavage all wounds in the operating room or emergency area. If a
local anaesthetic is needed, use 1% lidocaine without epinephrine.
2. Administer tetanus toxoid and antibiotics. Obtain X-rays to check underlying
bones and joints.
3. Stop bleeding by compression with sterile gauze. If necessary, extend the wound,
being careful not to cross skin creases in the palm or digits. Remove all foreign
material and devitalized tissue, but do not excise any skin unless it is dead.
4. If the wound is clean, repair extensor tendons but not flexor tendons or nerves.
5. Close a clean wound over a drain using interrupted sutures if there is no tension
on the skin. If the wound is contaminated, delay closure until after a second
debridement. Wounds less than 1 cm square will granulate spontaneously. Use
skin grafts for larger wounds, which will not close without skin tension.
6. Cover the hand with sterile gauze and a compression dressing. (Figure)
7. Apply a plaster splint to hold the wrist in 20 degrees of extension, with the
metacarpophalangeal joints in 90 degrees of flexion and the interphalangeal joints
in full extension. Keep the fingertips exposed unless they are injured.

8. To control oedema, elevate the limb for the first week, either by attachment to an
overhead frame or by the use of a triangular sling.
9. Begin active exercises as soon as possible and inspect the wound in 2– 3 days to
remove drains.
Nail bed injuries
 Sub-ungual haematoma causes severe pain resulting from a collection of blood

deep under the nail. This can be seen as a dark red to black collection beneath
the nail.
 To relieve pain, make one or two small holes in the nail with a hot safety pin or
the tip of sterile number 11 scalpel blade.
 If not repaired, lacerations of the nail bed may result in lasting nail deformity.
 Remove the nail and, after debridement and lavage, repair the laceration using
fine suture.
 If possible, replace the nail over the sutured laceration until it heals and anew
nail has begun to grow.
Blood vessels, nerves and tendons
 Assess the function of tendons, nerves and blood vessels distal to the laceration.
 Ligate lacerated vessels whether or not they are bleeding, as the vessels which are
not bleeding may do so at a later time.
 Large damaged vessels may need to be divided between ligatures. Before dividing
these larger vessels or an end artery, test the effect on the distal circulation by
temporary occlusion of the vessels.
 Loosely oppose the ends of divided nerves by inserting one or two sutures through
the nerve sheath. Similarly fix tendon ends to prevent retraction. These sutures
should be long enough to assist in tendon or nerve identification at a subsequent
procedure.
 Formal repair of nerves and flexor tendons is not urgent and is best undertaken
later by a qualified surgeon.

Facial Lacerations
• It is appropriate to manage most facial wounds in the outpatient department.
• Clean the skin with soap and water, while protecting the patient‘s eyes.
• Irrigate the wound with saline and preserve tissue, especially skin, but remove all
foreign material and all obviously devitalized tissue.
• Close with simple monofilament non-absorbable sutures of 4/0 or 5/0. Reinforce
the skin closure with skin tapes. To avoid skin marking, remove sutures at 3 to 5
days.
• If the wound is contaminated, give prophylactic antibiotics to prevent cellulitis.
• Large facial wounds or wounds associated with tissue loss require referral for
specialized care after primary management.
• Arrest obvious bleeding, clean wounds and remove all foreign material.
• Tack the wound edges in place with a few monofilament sutures after the wound
is packed with a sterile saline dressing.
Lip Lacerations
• Small lacerations of the buccal mucosa do not require suturing.
• Advise the patient to rinse the mouth frequently, particularly after meals.
• Local anaesthesia is adequate for lacerations that do require suturing.
• For good cosmesis, proper anatomical alignment of the vermillion border is essential.
To achieve this alignment, place the first stitch at the border (Figure). This region may be
distorted by the swelling caused by local anaesthetic or blanched by adrenaline, so to
assure accuracy, pre-mark the vermillion border with a pen. After the initial suture is
inserted, repair the rest of the wound in layers, starting with the mucosa and progressing
to the muscles and finally the skin (Figure). Use interrupted 4/0 or 3/0 absorbable suture
for the inner layers and 4/0 or 5/0 monofilament nonabsorbable suture in the skin.

Wounds of the Tongue
• Most wounds of the tongue heal rapidly without suturing.
• Lacerations with a raised flap on the lateral border or the dorsum of the tongue
need to be sutured.
• Suture the flap to its bed with 4/0 or 3/0 buried absorbable stitches (Figure).
• Local anaesthesia is sufficient.
• Instruct the patient to rinse the mouth regularly until healing is complete.
Ear and Nose Lacerations

• The three-dimensional curves of the pinna and nares and the presence of
cartilage present difficulties when injured.
• Wounds are commonly irregular, with cartilage exposed by loss of skin.
• Use the folds of the ear or nose as landmarks to help restore anatomical alignment.
• Close the wound in layers with fine sutures, using absorbable sutures for the
cartilage.
• The dressings are important. Support the pinna on both sides with moist cotton
pads and firmly bandage to reduce haematoma formation.
• Cover exposed cartilage either by wound closure or split thickness skin grafts.
• Wounds of the ear and nose may result in deformities or necrosis of the cartilage.

Nose bleed (epistaxis)
• Epistaxis often occurs from the plexus of
veins in the anterior part of the nasal septum.
• In children it is often due to nose picking;
other causes include trauma, a foreign body,
Burkitt‘s lymphoma and nasopharyngeal
carcinoma.
• Manage epistaxis with the patient in a sitting
position
• Remove blood clots from the nose and throat
to visualize the site of bleeding and confirm the diagnosis.
• Pinch the nose between your fingers and thumb while applying icepacks to the nose
and forehead. Continue to apply pressure. Bleeding will usually stop within 10
minutes.
• If bleeding continues, pack the anterior nares with petroleum impregnated ribbon
gauze.
• If bleeding continues after packing, the
posterior nasopharynx may be the source of
bleeding. Apply pressure using the balloon of
a Foley catheter. Lubricate the catheter, and
pass it through the nose until the tip reaches
the oropharynx. Withdraw it a short distance
to bring the balloon into the nasopharynx.
Inflate the balloon with water, enough to exert
pressure but not to cause discomfort (5–10 ml

of water is usually adequate for an adult, but use no more than 5 ml for a child).
• Gently pull the catheter forward until the balloon is held in the posterior choana.
• Tape the catheter to the forehead or cheek in the same manner as a nasogastric tube.
With the catheter in place, pack the anterior nares with petroleum gauze. Deflate the
Foley catheter after 48 hours and, if bleeding does not recur, remove it.
Ocular Trauma
- Eye injuries are common and are an important cause of blindness.
- Early diagnosis and proper treatment are imperative to prevent blindness. The first
objective in the management of eye injuries is to save sight and to prevent the
progression of conditions that could produce further damage.
a) Superficial injuries
• Superficial lacerations of the conjunctiva or cornea do not require surgical
intervention. If a foreign body is not present, copiously irrigate the eyelid and eye
with sterile saline, apply tetracycline 1% eye ointment and apply an eye pad with
the eyelids closed. Leave the dressing in place for 24 hours, and then re-examine
the eye and eyelids. If the injury has resolved or is improving, continue applying
antibiotic eye ointment 3 times daily for 3 days.
b) Eyelid lacerations
• Carry out wound toilet and minimal debridement,
preserving as much tissue as possible. Never shave
the brow or invert hair-bearing skin into the wound.
• If the laceration involves the lid margin, place an
inter-marginal suture behind the eyelashes to assure
precise alignment of the wound.
• Carry out the repair in layers: the conjunctiva and
tarsus with 6/0absorbable suture, the skin with 6/0 non-absorbable suture and
muscle(orbicularis oculi) with 6/0 absorbable suture (Figure 5.19). Tie suture
knots away from the orbit.
• Lacerations involving the inferior lacrimal canaliculus require canalicular repair.
• Refer the patient for specialized surgical management of the duct but, prior to
referral, repair the lid laceration.
c) Blunt trauma

• Hyphaema (blood in the anterior chamber) is caused by blunt trauma.
• Check for raised intraocular pressure. If intraocular pressure is elevatedor
indicated by a total hyphaema or pain, administer acetazolamide 250mg orally
every 6 hours.
• If a patient has hyphaema, admit to hospital, put on complete bed rest, sedate,
and patch botheyes.
• Examine and dress the eye daily.
• If the hyphaema is not resolving in 5 days, refer the patient.
d) Lacerations and penetrating trauma
• Manage perforations of the cornea without iris prolapse and with a deep intact
anterior chamber with local atropine (1% drops or ointment) and local
antibiotics 1% eye drops).
• Dress the in jured eye with a sterile pad and examine it daily. After 24 hours,
if the anterior chamber remains formed, apply atropine 1% and antibiotic eye
ointment daily for another week. If the anterior chamber is flat, apply a
bandage for 24 hours. If the anterior chamber does not reform, refer the
patient.
• Refer patients with perforation of the cornea complicated with iris
incarceration or posterior rupture of the globe. Suspect a posterior rupture of
the globe if there is low intraocular pressure and poor vision. Instill atropine
1%, protect the injured eye with a sterile pad and shield and refer the patient to
an ophthalmologist.
e) Tendon Lacerations
• Perform immediate repair of tendon lacerations by primary suture for flexor
tendons in the forearm; extensor tendons of the forearm, wrist, fingers; extensor
tendons on the dorsum of the ankle and foot and the Achilles tendon.
• Delay the repair of divided finger flexor tendons within the synovial sheath until
the wound is clean and closed and a qualified surgeon is available.
• To accomplish the repair, use a general or regional anesthetic. After debriding the
wound, pass a loop suture (3/0 non-absorbable or 3/0 polyglycolic acid) on a
straight needle into the tendon through the cut surface close to the edge so that it
emerges 0.5 cm beyond. Construct a figure-of-8 suture, finally bringing the needle
out again through the cut surface (Figures). Pull the two ends of the suture to take

up the slack, but do not bunch the tendon. Deal similarly with the other end of the
tendon and then tie the corresponding suture ends to each other, closely
approximating the cut ends of the tendon and burying the knots deep between
them (Figure). Cut the sutures short.
• Hold the repaired tendons in a relaxed position with a splint for 3weeks.

CHAPTER 2: SURGICAL EMERGENCIES
Learning objectives
• Assess, resuscitate and stabilize a surgical emergency patient‘s condition rapidly and
accurately.
• Understand the basic pathophysiology of Traumatic brain injury.
• Evaluate patients with head injuries.
• Perform a focused neurologic examination.
• Explain the importance of adequate resuscitation in limiting secondary brain injury.
• Determine the need for patient transfer, admission, consultation, or discharge.
• Arrange appropriately for a patient‘s inter-hospital or intra-hospital transfer (what,

who, when, how).

A) TRAUMATIC SURGICAL EMERGENCIES
Trauma is a leading cause of death and disability in the world. Motor vehicle crashes
caused the maximum deaths in last couple of years followed by fall injuries either in the
farm work setting or at the construction sites leading to significant morbidity and
mortality.
On the other hand, surgical emergencies pose a significant anxiety and dilemma to the
local health staff as well as to the patient where there is no surgical set up. It is important
to at least alleviate the anxiety of the patient and also to know which cases require urgent
surgical consultation or immediate transfer to the surgical centers.
Surgical emergencies focus on general trauma, head injury, burns, wound care, pediatric
trauma, and trauma in pregnancy and non-traumatic surgical emergencies.
APPROACH TO TRAUMA
Definition: Trauma is defined as any physical injury severe enough to pose a threat to
limb or life.
Patient assessment
a) Pre-hospital phase: responsibility of first responder and basic life support provider
(Home Health Care).
b) Hospital phase: hospital emergency response.
Triage: system of making a rapid assessment of each patient and assigning a priority
rating on the basis of clinical need and urgency with the goal to do the greatest good
for the greatest number. Triage should be applied in:
a) Multiple casualties
b) Mass casualties
Primary survey
a) Airway maintenance with cervical spine protection
b) Breathing and ventilation
c) Circulation with hemorrhage control
d) Disability (neurologic evaluation)
e) Exposure/ environmental control
Resuscitation
a) Airway

b) Breathing/ventilation/oxygenation
c) Circulation and bleeding control
Adjuncts to primary survey and resuscitation
a) Electrocardiographic monitoring
b) Urinary and gastric catheters
c) Other monitoring as relevant
d) X-rays and diagnostic studies Consider need for patient transfer.
Secondary survey
a) History
b) Physical examination Adjuncts to secondary survey.
Reevaluation.
Definitive care.
In an emergency, stay calm and speak clearly!
REGIONAL TRAUMA
A. Maxillofacial Trauma
• Trauma to the face demands aggressive airway management

• Usually seen in unbelted automobile passenger who is thrown into the windshield and
dashboard
• Trauma to the mid-face can produce fractures and dislocations that compromise the
nasopharynx and oropharynx
• Facial fractures can be associated with hemorrhage, increased secretions, and
dislodged teeth, which cause additional difficulties in maintaining a patent airway
• Fractures of mandible, especially bilateral body fractures, can cause loss of normal
airway support.
• Airway obstruction can result if the patient is in a supine position.
B. Neck Trauma
Neck injuries can be blunt or penetrating

• Blunt or penetrating injury can cause disruption of the larynx or trachea, resulting in
airway obstruction and /or severe bleeding into the trachea-bronchial tree

• Definitive airway and operative control will be urgently required in this situation.
• Cervical spine injury can occur as well commonly at C5-C6 and C6-C7 levels
• Maintain immobilization in suspect C-spine injury until definitely ruled out by a
reliable method.
Figure 1 Cervical collar.
Indications for Cervical collar

• Trauma
• Focal cervical spine tenderness
• Distracting injury
• Intoxication/altered mental status
• New neurological deficit
C. Thoracic Trauma
• Identify and initiate treatment of the following life-threatening injuries during the
primary survey:
a) Airway obstruction
b) Tension pneumothorax
c) Open pneumothorax
d) Rib fractures with Flail chest and pulmonary contusion
e) Massive hemothorax
f) Cardiac tamponade
• Identify and initiate treatment of potentially life-threatening injuries during secondary
survey:
a) Simple pneumothorax
b) Hemothorax

c) Pulmonary contusion
d) Trachea-bronchial tree injury
e) Blunt cardiac injury
f) Traumatic aortic disruption
g) Traumatic diaphragmatic injury
h) Blunt esophageal rupture
• Describe the significance and treatment of:
a) Subcutaneous emphysema
b) Thoracic crush injuries
c) Sternal injury
d) Rib fractures
e) Clavicular fractures
• Describe lifesaving chest procedures like:
a) Needle decompression
b) Chest tube insertion
c) Needle pericardiocentesis
Rib Fractures, Flail chest
• Most common injury after blunt chest trauma, accounts for more than half of thoracic
injuries
• Clinical diagnosis: localized pain, tenderness
• May not be seen on X-ray
• Rule out: pneumothorax, hemothorax, pulmonary contusion, vascular injury.
• More than 2 rib fractures: increased risk of internal injuries
• Flail chest: segmental fractures of 3 or more ribs
 Paradoxical chest wall movement
 May cause hypoxemia via pulmonary contusion
 Treatment: direct pressure, intubation, consider chest
tube

Figure 11.2 Flail chest (paradoxical chest expansion during respiratory movements).
Pulmonary Contusion
• Contusion causes direct capillary damage
• Leads to internal edema, hypoxia, hemorrhage
• Commonly associated with flail chest
• Hemoptysis common, may be cyanotic
• Chest X-ray: patchy alveolar infiltrates, consolidation, can be delayed up to 6 hours
Treatment:
 oxygenation, may need intubation
 aggressive fluid resuscitation can be harmful so keep relatively dry
Figure 11.3 Showing right-sided pulmonary contusion.
Hemothorax
Primary cause is lung laceration or laceration of an intercostals vessel or internal
mammary artery due to either penetrating or blunt trauma. It can be simple or
massive.
Simple:
 Amount of blood <1500ml
 Self-limiting and does not require operative intervention ✓If not drained may get
infected and develop into empyema
Massive:
 Rapid accumulation of blood >1500ml, or one third or more of the patient‘s blood
volume in the chest cavity
 Presents with shock and respiratory distress
Treatment is by correcting the shock and by draining the blood with chest tube
insertion.
As a Guideline, if > 1500 ml of blood is drained immediately through the chest tube,
if drainage of more than 200ml/hr. for 2-4hr occurs, or if blood transfusion is
required, operative exploration should be considered.

Pneumothorax (PTX)
Simple
➢Chest pain, dyspnea, decreased breath sounds, subcutaneous emphysema ➢Seen on
chest X-ray, may be delayed; consider repeating in 4-6hours
Figure 11.4 Showing left-sided

pneumothorax (left) and three-sided occlusive
dressing (right).
Treatment:
Oxygen, chest tube, occlusive dressing (close the wound defect with sterile occlusive
dressing that is large enough to overlap the wound‘s edges; tape it securely on three
sides to provide a flutter-type valve effect)
• Tension
 Severe dyspnea
 Decreased breath sounds
 Distended neck veins
 Tracheal deviation away from PTX
 Do not wait for X-ray before placing chest tube
 Needle in chest 2nd intercostal space before chest tube
Needle decompression in
2nd intercostal space
Figure 11.5: Patient with tension

pneumothorax with bilateral
intercostal needle decompression.
Chest Tube Placement

• Place patient in supine or 450, arm over head
• Topical skin cleaner
• Local anesthesia with 5cc lignocaine 2%, IV analgesia

• 4cm skin incision at midaxillary line in 4th or 5th intercostal space, along the direction
of the rib
• Blunt dissection with instrument through pleura, over the top of the rib (avoid
neurovascular bundle)
• Pass tube through hole, direct towards apex of lung
• Attach to drainage device
• Secure tube on skin with 1-0 silk sutures
• Apply occlusive dressing over tube •Chest x-
ray for confirmation
Figure 11.6:Showing placement of left chest tube drainage on the left-side for
tension PTX.
Cardiac Tamponade
• Fluid (blood) filling pericardial sac, compressing heart and decreasing cardiac output
•More common in penetrating trauma
• Findings:
- Triad: hypotension, JVD, muffled heart sounds
- Pulses paradoxus: weaker pulse & lower systolic pressure with inspiration
- Electrical alternans: alternating QRS direction on ECG
• Diagnosis by ultrasound
• Treatment: pericardiocentesis, thoracotomy

Figure 11.7: Showing cardiac tamponade (left)
schematic and (right) Chest X-ray.
Myocardial Contusion
• Seen in blunt trauma with deceleration forces
• May be caused by sternal or rib fractures
• Symptoms: chest pain, dyspnea
• Diagnosis: echocardiogram. ECG –slowed conduction, ectopy, ST-T wave changes,
tachycardia
• Complications: effusion, aneurysm, thrombosis, dysrhythmia
• Most heal with no specific treatment
D. Abdominal and Pelvic Trauma
Abdominal Trauma
Can be blunt or penetrating injuries
 Most blunt trauma from MVCs and falls
 Can cause compression and crushing injuries to solid organs, hollow organs, vessels
causing rupture with secondary hemorrhage, contamination by visceral contents, and
peritonitis.
 Shearing forces cause crushing injuries
 Deceleration forces cause lacerations of liver and spleen
 Penetrating trauma has high risk of intra-peritoneal, bowel, or solid organ injury
 Often need immediate laparotomy and exploration
 Establish immediate IV access, resuscitate with fluid or blood as appropriately

Figure 11.8 Schematic diagram of Abdomen.
In patients who sustain blunt trauma, the organs most frequently injured are the spleen
(40% to 55%), liver (35% to 45%), and small bowel (5% to 10%). Additionally, there
is 15% incidence of retroperitoneal hematoma in patients who undergo laparotomy for
blunt trauma.
Blunt Abdominal Trauma
Perform Trauma Primary Survey
Unstable VS, • Call Surgeon

Upright CXR: free air or Stable VS Peritonitis • Consider DPL
diaphragm injury? • Prepare for Surgery if:
• Peritoneal signs
• Refractory hypotension
Intra -abdominal free air
• Positive DPL
No free air • X-ray evidence of Intra -
abdominal Free Air or
Diaphragm injury
Mild Tenderness Moderate / Severe Tenderness

• Admit for observation, serial • Obtain CT Abdomen
H&H, serial abdominal exams • If negative, admit if tenderness persists
• If positive, consult surgery.
• Surgery unlikely for Grade I -II liver or spleen
lacerations, likely for Grade IV -V
Figure 11.9 Algorithm of assessment of abdominal trauma.
Blunt Abdominal Trauma Ultrasound Available

Unstable VS,
• Call Surgeon
Upright CXR: free air or Stable VS Peritonitis • FAST ultrasound exam
diaphragm injury? • Prepare for Surgery if:
• Peritoneal signs
• Refractory hypotension
Intra -abdominal free air • Positive FAST
• X -ray evidence of free air
No free air or diaphragm injury
FAST to evaluate for free FAST positive • Call Surgeon

intra -abdominal fluid • CT Abdomen if stable VS
• Admit for obs, H&H, exams
Mild Tenderness Moderate / Severe Tenderness

• Admit for observation, serial • Obtain CT Abdomen
H&H, serial abdominal exams • If negative, admit if tenderness persists
• If positive, consult surgery
Figure 11.10 Algorithm of assessment of abdominal trauma with ultra-sound.
Figure 11.11 Mannequin showing Open chest

wound and open abdominal injury (Intestinal
loops from penetrating abdominal injuries should
be covered with a clean wet cloth or dressing, and
open chest wound should be closed with three -
sided occlusive dressing).

Penetrating Abdominal Trauma
Stable Vital Signs? Unstable VS, peritoneal

signs, or bowel evisceration?
• Consult Surgery Free Air on CXR? • Consult Surgery for

Positive DPL*? immediate evaluation
• Upright CXR for free air
• Surgeon may explore locally, • Resuscitate patient
admit for obs, serial H&H, • Prepare for OR
serial abdominal exams
• Consider DPL, FAST
*Positive DPL: aspiration of frank blood or gastric contents

>100K RBC/mm3 or >500WBC/mm3
Gram stain + for bacteria
Figure 11.12Algorithm of assessment of penetrating abdominal trauma.
Pelvic Trauma
 Pelvic injury commonly involves pelvic fractures and pelvic organ injuries
 Major hemorrhage may occur from pelvic fracture in patients who sustain blunt
truncal trauma
 Early pelvic stability assessment begins with manual compression of the
anterosuperior iliac spines or iliac crests
 Abnormal movement or bony pain suggests fracture and the exam may stop with this
maneuver as further movements can aggravate bleeding.
 Presence of blood at the urethral meatus strongly suggest a urethral tear (high riding
prostate in per-rectal exam suggests urethral disruption) and per-urethral
catheterization should be avoided
 Perineal and rectal injuries may be present as well
 Pelvis should be temporarily stabilized by using an available compression device or
sheet to decrease bleeding.
Figure 11.13Pelvic
stabilization either by
commercial binder or bed
sheet or belt to prevent
further internal

bleeding (Adapted from ACS, 2008. ATLS
8th Edition).
BURNS
• ABCs and initial assessment as discussed in chapter 2.
• Assess burn
 Depth
 % body surface area
 Circumferential burns may require early escharotomy
• Fluid resuscitation
 Warm environment to stop fluid losses
• Wound care, Tetanus •Pain control
Table 11.1 Burn categories
Degree Depth Appearanc Sensatio Healing

s e n
1st Superficial Dry, dry, Painful 3-6days

, epidermis blanching;
degree
no blisters
2nd Superficial Moist More 7-21days

degree , partial blisters, painful
thickness weeping,
red,
blanching
3rd Deep, Blisters, wet Pressure >21days

or dry, red and
degree partial
to white, no
thickness painful
blanching
4th Full Waxy white No pain None:

thickness to gray, (may feel requires
degree
charred, deep
surgical
dry, ache)
inelastic, no debridemen
blanching t and
grafting

Fluid Resuscitation
In contrast to resuscitation for other types of trauma in which fluid deficit is typically
due to hemorrhagic losses, burn resuscitation is required to replace the ongoing losses
from capillary leak due to inflammation.
• Admit if partial thickness burns >10%TBSA for fluid resuscitation
• Ringer‘s lactate is fluid of choice
• The current consensus guidelines state that fluid resuscitation should begin at 2 ml of
Lactated Ringer × patients body weight in kg × TBSA for second- and third- degree
burns
 2ml/kg/%TBSA
 1st half given over 8hours
 2nd half given over next 16 hours
Wound care
• Tetanus booster if indicated (if >5yr give booster)
• Irrigate contaminated wounds before dressing
• Do not apply ice or butter, cool wet dressings best
• Antibiotic ointment or silver sulfadiazine (unless sulfa allergic)
• Superficial burns: apply dressing •Partial thickness
 Do not debride intact blisters
 Debride ruptured blisters, devitalized tissue
 Wound check 48hrs, if no infection, can continue at home
•Full thickness
➢Consult surgery for operative debridement, skin grafting
Burn complications
•Infection
 Pseudomonas
 Gram negative infections
•ARDS
 From shock state
 From direct pulmonary injury
• DIC from diffuse tissue injury
• Toxicity from smoke itself (CO, CN)

• Stress ulcers, GI bleeding
Fasciotomy
•Indicated in full thickness circumferential limb burns and chest wall burns
 Vascular insufficiency, poor pulses and cap refill
 Inadequate ventilatory motion
• Cut along long axis sides (avoid vasculature)
• Painless ―pop‖ as subcutaneous
tissues expand
Figure 11.15 Fasciotomy incision

wound.
Other Burns
•Chemical burns
➢Irrigate copiously with water or saline oAcids: extensive superficial burns oBases:
extensive deep tissue involvement
•Electrical burns
 High voltage may cause limited superficial injury, extensive deep injury
 Exit wound often more severe than entrance wound
 Immediate cause of death: arrhythmias oECG, Monitor, CBC, coagulation profile, IV
• Wound debridement after demarcation of devitalized tissues
• Admit for observation, IVF, monitoring
Assess % Body Surface Area

Figure 11.14 Schematic diagram showing how to assess burn percentage from body
surface area.
WOUND CARE
A wound is defined as a disruption of the integrity and function of tissues in the body.
Wound Evaluation
• Simple or complex
• Clean or contaminated
• Bite or puncture
 Human or animal
 Copious irrigation with normal saline
 Loose approximation if necessary
 High risk of infection treats with prophylactic antibiotics available
 Delayed presentation: can be closed up to 12hrs
 After that must heal by secondary intention
Wound closure
 Sterile environment

 Lignocaine (2%) for analgesia
 Max dose 4.5mg/kg, 7mg/kg if with epinephrine
 No epinephrine in fingers, toes, nose, penis
• Normal saline for irrigation
• Betadine prep for outside wound
• Debride necrotic tissue, remove foreign bodies
• Suture
Suture options
•Absorbable: vascular ligation, muscle/fascia repair, intraoral, dermal approximation
 Plain catgut: strength 7-10
 Chromic catgut: 21-30
 Vicryl:21d
•Non-absorbable: skin closure, eyelid laceration
 Nylon
 Dafilon
 Prolene
 Silk
Wound Repair
Simple
 Face: Nylon or Prolene 6-0
 Extremities: Nylon or Prolene 3-0 or 4-0
 Scalp: Nylon, Prolene, or silk 3-0 or 4-0
Complex
 Scalp: if lacerated galea, place subcutaneous sutures
 Lip: repair vermillion border first if involved
 Face: ENT/Maxillofacial consult if facial nerve or nasolacrimal duct involved
 Eye: Ophthalmological consult if canthus involved
Suture care
 48hr post repair for wound check, dressing change
o Keep wounds clean and dry

o Watch for signs of infection- if present either suture release and /or antibiotics with
more frequent dressing
➢Suture removal oFace: 5 days oNeck :5-6 days oHands & feet: 7 days oScalp, chest,
abdomen & extremities: 7-10 days oBack, upper and lower extremity joints: 10 days
Consider Antibiotic Prophylaxis
• High risk sites (hands, face, feet)
• Puncture wounds, foreign bodies
• Contaminated wounds, bites
• Extensive soft tissue injury
• Through and through mouth lacerations
• Open fractures, exposed joints & tendons
• Prosthetic valves
• Immuno-compromised
Indication for Transfer
• Indication for advanced airway
• Hemodynamic instability
• Identified need for consultant service
 Presumed head bleed
 Cervical spine injury
 Chest tube placement
 Free air under diaphragm
 Positive diagnostic tap or ultrasound of abdomen
 Unstable pelvic fracture
 Open bony fractures
 Any evidence of neurovascular compromise
 Need for surgery (any kind)
Key Messages
• Always start with ABCs
• Quickly identify hemodynamic emergencies
• Immobilize broken bones
• Provide resuscitation as necessary

• Immobilize prior to transfer
• Communicate with receiving physician
SHOCK IN TRAUMA PATIENT

Shock is defined as the inadequate delivery of oxygen to tissues leading to cellular
dysfunction and injury.
Hemorrhagic: Most commonly caused by blood loss.
 Lacerations
 Intra-abdominal injury
 Thoracic injury
 Pelvic injury
 Long bone fractures
 Arterial/aortic injury
Signs of Hemorrhagic Shock:
• Pulse
 Tachycardia
 Thread, weak peripheral pulses
• Blood Pressure
 Narrow pulse pressure (systolic BP- diastolic BP)
 Hypotension
• Peripheral perfusion
 Pale skin & conjunctiva
 Delayed capillary refill
• Mental status
 Anxiety, distress, lethargy, coma Non-hemorrhagic Shock in
Trauma:
• Cardiogenic: blunt chest trauma
 IVF, ventilator support, pressor if needed
 Obtain ECG, admit for cardiac monitoring
•Obstructive: tension pneumothorax, cardiac tamponade
➢Chest tube or pericardiocentesis

•Neurogenic: Spinal cord injury
 Loss of sympathetic peripheral vascular tone leads to vasodilation
 Hypotension with warm & perfused extremities
 Treat with IV fluids
Table 11.2 Classification of Hemorrhagic

Shock
Volume Signs Treatment

loss
Class 0-15% Slight Resuscitate with at least 2L

I tachycardia crystalloid (Ringer‘s lactate).
<500ml
Use warm fluids to prevent
hypothermia
Class 15-30% Tachycardia, Same as above

II narrowed pulse
500-
pressure
1000ml
Class 30-40% Tachycardia, Start with crystalloid, Packed

hypotension, red blood cells (PRBC) if no
III 1-2L
altered improvement (O -ve), surgery
consult
mental status
Class > 40% Unstable, Both crystalloid &PRBC,

IV critical immediate surgery consult,
>2L
hypotension prepare for operation
PEDIATRIC TRAUMA
Injury continues to be the most common cause of death and disability in childhood.
Pediatric trauma presents a big challenge to many surgeons. Hence, there is a need to
deal them separately with application of ATLS principles which can have a significant
impact on ultimate survival.
Initial Assessment and Resuscitation
• Guided by same approach as in adults
• Early involvement of a surgeon is imperative in management of injuries in a child
Unique Characteristics of Pediatric Patients
• Most serious pediatric trauma is blunt trauma that involves the brain
• Apnea, hypoventilation, and hypoxia occur five times more often than hypovolemia
with hypotension in seriously injured children

• Therefore, treatment protocols for pediatric trauma patients emphasize aggressive
management of the airway and breathing
What physiologic differences will have an impact on treatment of pediatric
trauma patients?
• Injuries in children may result in significant blood loss
• A child‘s increased physiologic reserve allows for maintenance of systolic blood
pressure in the normal range, even in the presence of shock
• Tachycardia and poor skin perfusion often are the only keys to early recognition of
hypovolemia and the early initiation of appropriate crystalloid fluid resuscitation
Table 11.3 Common mechanisms of injury and associated patterns of in injury in

pediatric patients
Mechanism of Common patterns of injury injury
Pedestrian Low speed: lower extremity fractures

struck High speed: multiple trauma, head and neck injuries, lower extremity
fractures
Automobile Unrestrained: multiple trauma, head and neck injuries, scalp and facial
occupant lacerations
Restrained: chest and abdomen injuries, lower spine fractures
Fall from height Low: upper extremity fractures

Medium: head and neck injuries, upper and lower extremity fractures High: multiple
trauma, head and neck injuries, upper and lower extremity fractures
Fall from bi-cycle Without helmet: head and neck lacerations, scalp and facial lacerations, upper
extremity fractures
With helmet: upper extremity fractures
Striking handlebar: internal abdominal injuries

Early Resuscitation
Refer to the neonate and pediatric
resuscitation in chapter 3.
Recognition of
circulatory compromise.
TRAUMATIC BRAIN INJURY

(TBI) Figure 11.16 Physiological impact of
Hemodynamic Changes on Pediatric
Patients.
Pathophysiology
The pathophysiology of TBI-related brain injury is divided into two separate but
related categories:primary brain injury and secondary brain injury.Current clinical
approaches to the management of TBI center on these concepts of primary and
secondary brain injury. Surgical treatment of primary brain injury lesions is central to
the initial management of severe head injury.
Likewise, the identification, prevention, and treatment
of secondary brain injury is the principle focus of
neurointensive care management for patients with
severe TBI.
Figure 11.17 Head injury with scalp

laceration (prevent shock from bleeding vessels).
Key messages:
• In chest trauma-mobility of mediastinal structures makes the child more susceptible to
tension pneumothorax.
• In abdominal injury-the chief indication for surgical (operative) management in
children who continue to have no hemodynamic abnormalities is a transfusion
requirement that exceeds one-half the child’s blood volume, or 40ml/kg, during the
first 24hrs after injury.
• In head injury- an infant who is not in a coma but who has bulging fontanelles or
sutures diastases should be treated as having a more severe injury.
• Adequate and rapid restoration of an appropriate circulating blood volume and
avoidance of hypoxia are mandatory.
Primary Brain Injury
Primary brain injury occurs at the time of trauma. Common mechanisms include
direct impact, rapid acceleration/deceleration, penetrating injury, and blast waves.
Although these mechanisms are heterogeneous, they all result from external
mechanical forces transferred to intracranial contents. The damage that results

includes a combination of focal contusions and hematomas, as well as shearing of
white matter tracts (diffuse axonal injury [DAI]) along with cerebral edema and
swelling.
1. Shearing mechanisms lead to DAI, which is visualized pathologically and on
neuroimaging studies as multiple small lesions seen within white matter tracts.
Patients with severe DAI typically present with profound coma without elevated
intracranial pressure (ICP), and often have poor outcome. This typically involves the
gray-white junction in the hemispheres, with more severe injuries affecting the corpus
callosum and/or midbrain. Magnetic resonance imaging (MRI; in particular diffusion
tensor imaging) is more sensitive than computed tomography (CT) for detecting DAI,
and the sensitivity of the test declines if delayed from the time of injury.
2. Focal cerebral contusions are the most frequently encountered lesions. Contusions are
commonly seen in the basal frontal and temporal areas, which are particularly
susceptible due to direct impact on basal skull surfaces in the setting of
acceleration/deceleration injuries. Coalescence of cerebral contusions or a more
severe head injury disrupting intraparenchymal blood vessels may result in an
intraparenchymal hematoma.
3. Extra-axial (defined as outside the substance of the brain) hematomas are generally
encountered when forces are distributed to the cranial vault and the most superficial
cerebral layers. These include epidural, subdural, and subarachnoid hemorrhage.
In adults, epidural hematomas (EDHs)are typically associated with torn dural
vessels such as the middle meningeal artery, and are almost always associated with a
skull fracture. EDHs are lenticular shaped and tend not to be associated with
underlying brain damage. For this reason, patients who are found to have EDHs only
on CT scan may have a better prognosis
than individuals with other
1. Accumulation of blood between traumatic hemorrhage
dura and arachnoid membrane types.
2. Bleeding originates from bridging
veins between venous sinuses and
cortex
3. Most common type of intracranial
mass lesion
Figure 11.18CT scan demonstrating a right EDH. Note the lenticular shape.
Subdural hematomas (SDHs) result from damage to bridging veins, which drain the
cerebral cortical surfaces to dural venous sinuses, or from the blossoming of
superficial cortical contusions. They tend to be crescent shaped and are often
associated with underlying cerebral injury.

1. Accumulation of blood between
skull and dural membrane Figure 11.19 CT scan
2. Bleeding originates from vessels showing a right acute
in close proximity to skull SDH. SDHs are typically
3. Typically, underlying brain is crescent shaped. In this
minimally injured case the SDH is causing
4. Good prognosis if treated as soon significant mass effect and
possible shift of midline structures
to the left.
Subarachnoid hemorrhage (SAH)

Non-aneurysmal SAH can occur with disruption of small pial vessels and commonly
occurs in the sylvian fissures and interpeduncular cisterns. Intraventricular
hemorrhage or superficial
intracerebral hemorrhage
1. Accumulation of blood between
arachnoid membrane and pia may also extend into the
mater subarachnoid space.
2. High mortality rate (18 -26%)
3. Survivors have high rate of
memory, mood, and Figure 11.20 CT scan showing
neurocognitive impairment subarachnoid hemorrhage.
Secondary Brain Injury

Secondary brain injury in TBI is usually considered as a cascade of molecular injury
mechanisms that are initiated at the time of initial trauma and continue for hours or
days.
These mechanisms include:
1. Neurotransmitter-mediated excitotoxicity causing glutamate, free-radical injury to cell
membranes
2. Electrolyte imbalances
3. Mitochondrial dysfunction
4. Inflammatory responses
5. Apoptosis
6. Secondary ischemia from vasospasm, focal microvascular occlusion, vascular injury
These leads, in turn, to neuronal cell death as well as to cerebral edema and increased
ICP that can further exacerbate the brain injury. This injury cascade shares many
features of the ischemic cascade in acute stroke. These various pathways of cellular
injury have been the focus of extensive preclinical work into the development of

neuro-protective treatments to prevent secondary brain injury in TBI. No clinical trials
of these strategies have demonstrated clear benefit in patients.
However, a critical aspect of ameliorating secondary brain injury after TBI is the
avoidance of secondary brain insults, which would otherwise be well tolerated but can
exacerbate neuronal injury in cells made vulnerable by the initial TBI. Examples
include hypotension and hypoxia (which decrease substrate delivery of oxygen and
glucose to injured brain), fever and seizures (which may further increase metabolic
demand), and hyperglycemia (which may exacerbate ongoing injury mechanisms).
Definition of TBI
1. Alteration in mental or physical function due to sudden brain trauma
2. Does not require loss of consciousness
Management Guideline
Primary focus should be to prevent secondary brain injury by providing adequate
oxygenation and maintaining a blood pressure that is sufficient to perfuse the brain
thereby improve the outcome
Initial Assessment
Primary survey: initial assessment as mentioned UP.
Mini-neurologic examination (APVU)
1. Level of consciousness
2. Pupil reactivity
3. Limb motor activity
4. GCS score

Assess level of consciousness
Unconscious Conscious
Rule out:  Assign GCS
 hypoxia- pulse oximetry/ABG-give O2
 hypoglycemia- RBS<70mg/dl- give 25 or 50%
Dextrose
 hyper/hypothermia-temp control
 Alcohol/drug intoxication-confirm GCS < 8 (severe head injury)
1. Resuscitate
2. Order CT scan
3. Consult Neurosurgeon
4. CBC, ABO Rh, S.E, RFT
GCS 9-12(moderate head injury) GCS 13-15 (Minor head injury )

1. Observe for 2hrs
1. Resuscitate 2. Admit if drowsiness
2. Order CT scan 1. Alcohol/drug suspect
3. Admit for observation 2. Extreme age
3. Pregnant woman
4. Skull fractures
Figure 11.21Algorithm of assessment and management of head injury.

Table 11.4 Glasgow coma scale
Best Eye Opening 4 Spontaneous
3 To verbal command
2 To pain
1 No response
Best Motor 6 Obeys

Response
5 Localizes pain
4 Flexion-withdrawal
3 Flexion- abnormal (decorticate rigidity)
2 Extension (decerebrate rigidity)
1 No response
Best Verbal 5 Oriented and converses

Response 4 Disoriented and converses
3 Inappropriate words
2 Incomprehensible sounds
1 No response
The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is
composed of three parameters: best eye response (E), best verbal response (V), and
best motor response (M). The components of the GCS should be recorded
individually; for example, E2V3M4 results in a GCS score of 9. A score of 13 or
higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate
injury, and a score of 8 or less represents severe brain injury.
Secondary survey: examination of rest of the head as in Chapter 2.
Physical examination signs suggesting intracranial mass lesion
1. Coma & unilateral dilated, fixed pupil
2. Lateralized extremity weakness
3. Posturing (esp. if asymmetric)
– Decorticate – arms adducted and flexed, with the wrists and fingers flexed on the
chest, legs are stiffly extended and internally rotated with planter flexion of the feet.

– Decerebrate– arms are adducted and extended and, with wrists pronated and fingers
flexed, legs are stiffly extended, with planter flexion of feet.
Indications for CT scan Head:
1. Altered mental status
2. Lateralizing signs
3. Progressive headache
4. Persistent vomiting
5. Any neurologic deterioration
6. Open brain injury
7. Signs of basilar skull fracture (Battle‘s sign, Racoon‘s sign)
Primary Treatments
1. Initial resuscitation
2. Cervical spine control
3. Prevent secondary injury
Secondary Treatments
1. Antibiotics – anti-staphylococcal (first generation cephalosporins) if penetrating skull

injury, major contamination, or CSF leak
2. Tetanus toxoid if last immunization > 5years ago
3. Diazepam (0.2-0.3mg/kg IV) or lorazepam (0.1-0.2mg/kg IV) followed by phenytoin
sodium (18mg/kg at rate < 50mg/kg/min) for seizures
4. Consider pain medications if severe
5. Catheterization before mannitol
6. Nasogastric tube to decompress stomach
7. NS or RL remains the standard resuscitation fluid
Treatment of Increased ICP/Cerebral edema
1. Hyperventilation to PCO2 of 30 to 35 mmHg (excessive hyperventilation can reduce
blood flow to damaged brain areas
2. Fluid restriction (if not in shock and ongoing fluid losses)
3. Mannitol 5ml/kg IV over 15minutes loading dose, then 2.5-3ml/kg (.25-1g/Kg bw)
and +/- Furosemide 1mg/kg IV bolus and repeat
4. Consider use of barbiturates (Phenobarbital 10-20mg/g IV loading or pentobarbital
36mg/kg IV)

5. Steroids not indicated unless spinal cord injury also present(debatable)
SCALP lacerations
1. Usually can repair in one layer
2. Need to repair galea as separate layer (with absorbable suture) if also lacerated
3. Usually do not require antibiotics
4. Suture removal in 7 days
Skull fractures
1. Most do not require specific treatment (underlying brain injury may need separate
treatment)
2. Need surgery if:
3. open fracture (save any bone fragments identified)
4. depressed >3-5mm
5. skull x-rays only indicated if head CT not otherwise needed and patient has
6. suspected depressed or open skull fracture by physical exam
7. large scalp hematoma thru which skull cannot be felt well enough to rule out
depressed fracture
Concussion
1. Symptoms
2. Brief loss of consciousness (<5min)
3. Headache
4. Dizziness
5. Nausea/vomiting
6. Normal neurologic exam within 6hrs
7. May need to be admitted if severe dizziness or persistent vomiting
8. Usually do not need CT Scan but need observation in hospital for 2-24hours
Penetrating Brain Injury

1. Patients with obvious fatal penetrating brain injuries may still warrant resuscitation to
become organ donors
2. CT indicated even for tangential gunshot wounds to rule out blast effect to brain

3. Post-traumatic seizures can occur in up to 50% of cases, so usually seizure
prophylaxis (with phenytoin or Phenobarbital) is indicated 4.All should receive
antibiotics.
Figure 11.22 Pictures showing penetrating head injury ―Khuru‖ injury (left) and
arrow (right).
Key Messages for Impaled Objects
1. Do not remove impaled object
2. Stabilize object in place
3. Pad around object
4. Use hacksaw to shorten object if needed
5. Consult neurosurgeon
Other Key Messages
1. The best initial treatment for the fetus is the provision of optimal resuscitation of the
mother and early assessment of the fetus
2. A qualified surgeon and an obstetrician should be consulted early in the evaluation of
pregnant trauma patients
3. The abdominal wall, uterine myometrium, and amniotic fluid act as buffers to direct
fetal injury from blunt trauma.
4. As the gravid uterus increases in size, the remainder of the abdominal viscera are
relatively protected from penetrating injury, whereas the likelihood of uterine injury
increases
5. Vigorous fluid and blood replacement should be given to correct and prevent maternal
and fetal hypovolemic shock.
6. Assess and resuscitate the mother first, and then assess the fetus before conducting a
secondary survey of the mother
7. All pregnant Rh-negative trauma patients should receive Rh immunoglobulin therapy
unless the injury is remote from the uterus as even a minor degree of fetomaternal
hemorrhage can cause sensitization of Rh-negative mother
8. Trauma can cause abruptio placentae, amniotic fluid embolism, and premature rupture
of membranes

9. Presence of indicators that suggest domestic violence should serve to initiate further
investigation and protection of the victim
B) NON- TRAUMATIC SURGICAL EMERGENCIES (Acute Abdomen) Definition
of acute abdomen
1. Acute abdomen is defined as sudden or recent onset of unexpected abdominal pain
(usually within 24-72 hours of presentation).
2. Frequently associated with gastrointestinal signs and symptoms indicative of intra-
and extra-peritoneal processes.
3. It is important to detect acute abdominal conditions early and initiate treatment to
prevent morbidity and mortality. However, it does not invariably signify the need for
surgical intervention.
The types of acute abdominal conditions mostly depend on the origin of organs in the
different locations of abdomen as shown below:
Figure
11.23Schematic diagram
showing different
visceral organs in the
abdomen.
Acute Appendicitis
• Classical presentation with colicky pain originating from peri-umbilical region and
later settling down in right iliac fossa associated with fever, nausea or vomiting, and
anorexia
• McBurney‘s point tenderness if localized
• Lower abdominal or diffuse peritonitis in cases of ruptured appendix
• Blood counts will show raised counts with predominant neutrophils
• Treatment – available triple antibiotics therapy with ampicillin, gentamicin and
metronidazole

• Referral for surgery if either signs of peritonitis or not responding to conservative
treatment suspecting abscess, gangrene, perforation and general peritonitis
• Consider other differential diagnoses: gastroenteritis, mesenteric lymphadenitis,
Meckel‘s diverticulitis, perforated peptic ulcer disease, Typhlitis, pyelonephritis,
ureteric colic and gynecologic conditions.
Acute Cholecystitis
• Acute pain in right hypochondrium or epigastrium typically after consumption of a
fatty meal, associated with fever, tachycardia, and tenderness often with guarding and
rebound tenderness (Murphy‘s sign) most commonly due to cystic duct obstructed by
gallstone.
• Blood counts may show leukocytosis
• Ultrasound may show presence of gall stones, thickened gallbladder wall, peri-
cholecysticfluid and sonographic Murphy‘s sign.
• Initial treatment includes bowel rest, intravenous hydration, analgesia, and
intravenous antibiotics

Referral should be urgent if there is no response to conservative treatment or there is a
sign of empyema, perforation or associated pancreatitis
Acute Pancreatitis
• Commonly presents with severe pain in the epigastric region usually after alcohol
consumption or heavy meal associated with nausea and vomiting
• Pain typically radiates to back and better when bending forwards
• Severe cases may have fever, tachycardia, and hypotension if severe
• Treatment initially is to control pain, bowel rest, IV fluids, and broad-spectrum
antibiotics •Blood counts may show increased counts, increased amylase
• Ultrasound may give evidence of pancreatic enlargement but CT scan is required in
severe conditions.
• Refer for further management if suspected.
Intestinal Obstruction
• It usually presents as sharp, crampyperiumbilical pain with intervening pain-free
periods, and associated with:
• Nausea and vomiting
• Constipation or Obstipation (absence of bowel movements and flatus)
• Abdominal distension
• Examination would show marked abdominal distension; high-pitched or tinkling
bowel sounds and variable degree of abdominal tenderness. •Causes can be
mechanical or non-mechanical
• Mechanical:
• Adhesion bands due to previous abdominal surgeries or congenital
• Hernias
• Volvulus (particularly sigmoid volvulus)
• Neoplasms
• Intussusception (especially in children)
• Bowel ischemia
• Non-mechanical
• Post-operative paralytic ileus
• Peritonitis
• Spinal injury
• Drugs, hypokalemia

• Diagnosis:
• Bowel obstruction is a clinical diagnosis
• Plain erect and supine abdominal X-rays will show air in distended bowel loops with
air fluid levels usually in distal obstructions
• Treatment:
• Non-operative with IV fluids, antibiotics, nasogastric aspiration, and analgesics
• Operative for cases not responding to conservative treatment like persistent pain,
rigid, tender and silent abdomen, increasing abdominal distension and visible
peristaltic waves.
Peptic Ulcer Perforation
• Typically presents as sudden onset of severe epigastric pain that eventually involves
the patient‘s entire abdomen.
Associated with chronic use of non-steroidal anti-inflammatory medications
• Most patients provide a history compatible with peptic ulcer disease
• Physical examination would be remarkable for diffuse abdominal tenderness, rigidity
and peritoneal signs
• Plain films usually but not always, reveal free intra-peritoneal air under diaphragm
• Treatment consists of fluid resuscitation, intravenous antibiotics and emergent
surgical exploration.
Peritonitis
• It is an acute life-threatening condition caused by bacterial or chemical contamination
of peritoneal cavity
• Treatment is aimed at treatment of the underlying cause
• Major Causes:
• Appendicitis
• Perforated peptic ulcer
• Strangulated bowel
• Pancreatitis
• Cholecystitis
• Intra-abdominal abscess
• Typhoid perforation
• Anastomotic leak following surgery
• Tuberculosis of abdomen

• Ascending infection from salpingitis and postpartum infections •Clinical Diagnosis:
• Sharp pain, which is worse on movement or coughing
• Fever
• Abdominal distension, tenderness and guarding
• Diminished or absent bowel sounds
• Shoulder pain (referred from diaphragm)
• Tenderness on rectal or vaginal examination (suggests pelvic peritonitis)
• Management: NPO, IV fluids, triple antibiotic therapy, nasogastric aspiration and
surgical consultation
Mesenteric Ischemia
• It presents as sudden onset of severe, constant abdominal pain with associated
vomiting and diarrhea.
• It may result from superior mesenteric artery thrombosis from severe vascular disease
or from superior mesenteric artery occlusion by embolus(e.g. atrial fibrillation)
• Examination may reveal pain out of proportion to physical findings.
• Blood counts may show marked leukocytosis
• Rule out other common causes of pain abdomen
• High suspicion of mesenteric ischemia needs angiography to confirm the diagnosis
Ruptured Abdominal Aortic Aneurysm
• Most lethal cause of abdominal pain
• Patients with free intra-abdominal rupture rarely, if ever, survive until hospital arrival;
those with contained rupture or leak may present in shock
Commonly presents with lumbar or lower abdominal pain with tearing sensation
radiating to back, flank or both
• Associated with nausea and vomiting
• Examination is marked by presence of the following:
• Presence of marked tenderness a pulsatile abdominal mass
• Mottled or spotty abdominal skin
• Decreased or absent femoral or distal pulses
• Urgent referral for definitive management Acute Urologic conditions:
• Paraphimosis

• Testicular torsion
• Urolithiasis
• Massive hematuria
• Acute urinary retention
Paraphimosis
• Inability to pull retracted foreskin back over glans
• It is a surgical emergency•Vascular compromise
• Treatment:
 Continuous firm pressure to glans for 5-10min
 Dorsal slit
 Circumcision
Testicular Torsion
• It develops most often in peripubertal (12-18years old) age group, although it can
occur at any age
• Presents with acute onset of unilateral testicular pain and swelling, commonly
associated with nausea and vomiting.
• Typical history of Strenuous physical activity and blunt trauma
• Some patients give a history of a prior episode that spontaneously resolved
• Absent urinary symptoms
• Examination reveals extreme tenderness, swollen firm testicle high in the scrotum
with transverse lie
• Absent cremasteric reflex
• Elevation of scrotum does not relief pain
• Difficult to differentiate rom epididymitis
• Investigation: Color Doppler ultrasound
• Treatment: manual detorsion (―open book‖ technique), Surgery (orchidopexy) which
can salvage rate 80-100% up to 6hrs of ischemia, 20% after 10hours and 0% after
24hours
Acute urinary retention
Acute urinary retention is a very painful and discomforting condition and it is an
indication for emergency drainage of bladder ✓Predisposing factors
- Pre-existing history of LUTS

- Bladder outlet obstruction (i.e. BPH, urethral stricture)
- Infection (i.e. prostatitis, urethral herpes)
- Bladder neck/prostate/urethral malignancies
- Constipation
- Neurogenic disorders (i.e. spinal cord injury, MS, Parkinson‘s)- Urethral trauma
✓Acute Causes:
- Urethral stricture and benign prostatic hypertrophy, prostatic cancer in males
- Urethral trauma
- If the bladder cannot be drained through the urethra, it requires suprapubic drainage
- Avoid per-urethral catheterization if retention is due to urethral trauma
Chronic retention
Treatment of chronic retention is not urgent but requires referral to surgeon for further
management.
ACUTE GYNECOLOGIC ABDOMINAL PAIN Ruptured ectopic pregnancy
• Always suspect in child bearing woman with reliable or doubtful missed period ✓
Presents with:
• Acute abdominal and pelvic pain
• Collapse and weakness
• Fast and weak pulse
• Hypotension
• Hypovolemia
• Abdominal distension
• Rebound tenderness
• Pallor
• Diagnosis: Serum pregnancy test combined with ultrasonography ✓
Treatment:
- Treat hypotension with fluids and blood
- Immediate laparotomy for definitive management
Ruptured Ovarian cyst
• Rupture of hemorrhagic cyst can occur in both pregnant or non-pregnant woman
• Can be confused with ectopic pregnancy
• Sudden severe lower abdominal pain

• Signs of peritoneal irritation
• CBC and hCG should always be done
• Ultrasound can aid in visualizing cyst or free fluid in pelvis indicating rupture
• Severe bleed can cause hemodynamic instability
• Surgical treatment will be required
Adnexal torsion
• Occurs in a reproductive age group when the ovary, tube, or both, twist on the
infundibulopelvic ligament usually on the right side with large ovaries or ovarian
masses
• Complete torsion is a surgical emergency as it causes necrosis of adnexa
• Presents with acute and severe, sharp, intermittent unilateral lower pelvic pain
• Temperature, tachycardia or bradycardia (from vagal stimulation)
• Diagnosis is clinical and ultrasonography
• Immediate surgical removal for complete necrosis

CHAPTER 3: MEDICAL EMERGENCIES
1. ACUTE PAIN
Acute pain, whether due to a medical or surgical condition, should be relieved as soon as
possible. Simultaneously investigate and treat the underlying cause – it is rare for
analgesia to mask a diagnosis. Pain may be classified as mild, moderate, severe or very
severe and treated accordingly. In general it is more realistic to strive for comfort rather
than complete abolition of pain.
Note that for some conditions, such as acute coronary syndromes, acute painful joints,
and sickle cell crises, analgesic approaches differ.
Treatment details
 SimpleAnalgesic
Paracetamol: 1g PO/6 hourly (maximum 4g/day).
Note: For adult patients <50kg especially those who are malnourished, we advise dosing at
15mg/kg PO/NG/IV 6 hourly.
 Non-Steroidal Anti Inflammatory Drugs (NSAIDs)
Ibuprofen: 200-400mg PO 6 hourly (maximum 2.4g /day).
Naproxen: 250-500mg PO 8 hourly (maximum 1.25g/day) Diclofenac : 75mg IV twice a day
or 75-100mg per day (maximum 150mg/day).
Contraindications: Bleeding diathesis, peptic ulceration, renal dysfunction, allergy to NSAIDs
(care in asthma), severe heart disease (especially with diclofenac).
The “analgesic ladder”
• Mild pain: Paracetamol or an NSAID
• Mild-to-moderate: combination analgesic + an NSAID
• Moderate: oral opioid or combination analgesic + an NSAID
• Moderate-to-severe: oral opioid + Paracetamol + an NSAID
• Severe: parenteral opioid (IM, SC or IV) + Paracetamol + an NSAID
2. ACUTE ALLERGIC REACTION/ANAPHYLAXIS

Anaphylaxis is an acute, severe, life-threatening systemic reaction which can occur in a
person who has a hypersensitivity to a specific antigen (although not all anaphylaxis reactions
are immunologic). The most common anaphylactic reactions are to food, medication
(including vaccine components) and insect bites. Anaphylaxis occurs when the immune

system releases a flood of mast cell and basophil-derived inflammatory mediators into the
circulation leading to-life threatening respiratory distress, usually followed by vascular
collapse and shock. Anaphylaxis requires immediate medical treatment, including a prompt
injection of epinephrine and activation of emergency response system. If not treated properly,
anaphylaxis can be fatal. While reactions can occur days after an exposure, most reactions
occur within 30 minutes of the exposure to the specific antigen. Certain individuals are more
likely to have an anaphylactic reaction including those with allergies, asthma, or a family
history of anaphylaxis. Those individuals with a history of anaphylaxis are also more likely to
have another anaphylactic reaction. Anyone at high risk of anaphylaxis should carry
emergency epinephrine injection (e.g. EpiPen) with them at all times. Patients receiving
vaccines should be assessed for possible allergic reactions/anaphylaxis prior to receiving the
vaccine.
A. Signs and Symptoms of Anaphylactic Reaction
1) A client experiencing an anaphylactic reaction may report:
a) Tingling or numbness of lips.
b) Generalized tingling/itching/burning skin
c) A feeling of restlessness or confusion
d) Difficulty breathing
2) The staff member or provider may note the following in a client who is having a
vasovagal response:
a) Flush or pallor
b) Hives/rash
c) Apprehension, confusion, agitation
d) Acute onset coughing/sneezing
e) Wheezing/difficulty breathing/respiratory distress
f) Cold, clammy skin
g) Involuntary voiding
h) Vomiting and diarrhea
i) Edema of lips and periorbital area
j) Rapidpulse
k) Fall in blood pressure
l) Loss of consciousness

B. Management of a Client with Anaphylactic Reaction
If a client reports the above symptoms or exhibits these or a syncopal episode is
suspected:
1) Remain with the victim and call for assistance and emergency supplies including
epinephrine.
2) Place client in supine position (or Trendelenburg if able); elevate legs, loosen clothing.
3) Do not offer food or fluids or oral medications – give nothing via mouth.
5) Administer Aqueous Adrenaline (Epinephrine): 0.2-0.5ml of 1:1000 concentration
Epinephrine IM into mid outer aspect of thigh.
6) Check pulse, blood pressure, mental status, skin color and breathe sounds.
Repeat examination every 1-3 minutes until they improve or until client is transported.
7) Administer O2 via simple oxygen mask at 5-10 liters/min. or via nasal cannula at 2-6
liters/min.
8) If victim is found or becomes unconscious, assess circulation, airway and breathing
and progress as needed into full CPR.
9) Counsel client/family regarding importance of reporting drug or other allergies
and avoidance of allergy-inducing agents in future.
10) Suggest carrying identification card or bracelet identifying serious allergies.
3. CARDIAC ARREST
Cardiac arrest is the abrupt cessation of heart function that occurs when the heart‘s
electrical system malfunctions. This results in the absence of blood circulation. Cardiac arrest
stops blood from flowing to vital organs, depriving them of oxygen, and, if left untreated,
results in death. Cardiac arrest may be reversed if cardiopulmonary resuscitation (CPR) is
performed and a defibrillator is used to shock the heart and restore a normal heart rhythm
within a few minutes.
While a ―heart attack‖ or myocardial infarction can lead to cardiac arrest, cardiac arrest
is not the same thing and can occur in a person who may or may not have diagnosed heart
disease.
Respiratory arrest (resulting from decreased respiratory effort or airway obstruction such
as results from choking or drowning) is different than cardiac arrest – but, if unrelieved,
one will inevitably lead to the other.

Causes of cardiac arrest:
• Cardiac disease
• Respiratory failure/arrest - Inadequate ventilation leading to hypoxia
• Anaphylaxis
• Pulmonary embolus
• Shock
In critically or terminally ill patients, cardiac arrest is often preceded by a period of
clinical deterioration with rapid, shallow breathing, arterial hypotension, and a
progressive decrease in mental alertness. In sudden cardiac arrest, collapse occurs
without warning, occasionally accompanied by a brief seizure.
A. Signs and Symptoms of Cardiac Arrest
a) Absent pulse
b) Breathing absent or abnormal
B. Management of a Client with Cardiac Arrest
1. Stay with client and call for help, ask for emergency kit, oxygen and automated
external defibrillator (AED).
2. Protect client from falls – place in a supine position.
3. Initiate CPR
4. If severe anaphylactic reaction causes respiratory arrest, continue protocol per
Anaphylaxis above.
5. If vomiting occurs and oxygen mask in use, remove mask, turn patient onto side, clear
mouth, and resume ventilation.
6. Continue resuscitation efforts, per algorithm, until paramedics arrive.
7. Never defibrillate while moving the patient.
8. All clients who have received CPR should be transported via ambulance for follow up
emergency care even if they have improved by the time response team arrives.
4. SHOCK
Shock is a state of widespread tissue/organ hypoperfusion or hypoxemia that leads to
cellular dysfunction and cellular death. This can result in organ failure, cardiopulmonary
arrest and death. Shock can be a result of many conditions such as hemorrhage, infection,
dehydration, electrolyte imbalance, anaphylaxis, cardiac or respiratory arrest. Early

recognition and management of these conditions can reduce the risk of shock. Shock can be
classified by cause:
• Hypovolemic: Loss of blood or fluid
• Cardiogenic: Cardiac arrest
• Pulmonary: Inadequate oxygen intake
• Obstructive: Mechanical interference with ventricular filling or emptying
• Neurogenic: Vasomotor instability (loss of tone in blood vessels)
• Septic: Infectious process or toxins from pathogens
A client in shock needs immediate transportation to a hospital able to manage shock
victims.
A. Signs and Symptoms of Shock.
a) Tachycardia–heart rate 100+
b) Skin cool, clammy.
c) Pallor around mouth or cyanosis
d) Hypotension Blood pressure less than 80 systolic, 50 diastolic.
e) Altered consciousness or awareness
B. Management of Client with Shock.
i. Stay with the client and call for help. If not already at patient side, ask
for emergency kit, oxygen.
ii. Place client in modified Trendelenburg position. Raise feet above heart
level but keep torso flat. Rest legs on pillow(s) so they are slightly
higher than heart. Regular Trendelenburg position is not recommended
for a client in shock.
iii. Provide oxygen via non-rebreather face mask at 100% (10-15
liters/min).
iv. Continuously monitor client including vital signs at least every 3-5
minutes.
v. If site has the ability/equipment start a large bore IV and infuse IV
fluids.
vi. If shock due to hemorrhage, attempt to stop bleeding.
vii. If anaphylaxis – treat per Anaphylaxis guideline above.
viii. Keep warm – turn heat on/up; cover with blankets.
ix. Nothing by mouth/monitor for vomiting and protect airway.

x. If shock is severe, observe client closely for cardiopulmonary arrest
and manage per Cardiac Arrest guideline.
xi. If victim is found or becomes unconscious, assess circulation, airway
and breathing and progress as needed into full CPR
5. RESPIRATORY DIFFICULTIES/RESPIRATORY DEPRESSION
There are various conditions that can cause respiratory difficulties including acute
causes such as an allergic reaction, drug overdose, injury, blood clot, or choking or from
chronic conditions such as asthma or COPD. While the body can often compensate for
brief interruptions of oxygen, the interruption of pulmonary gas exchange for > 5 min
may irreversibly damage vital organs, especially the brain. The time needed for
permanent damage to develop may be shorter in the very young, the very old or those
who have underlying illness.
A. Signs and Symptoms of Respiratory Distress
a) Feeling short of breath/unable to get a full breath
b) Tingling or numbness of lips
c) Dizziness
d) A feeling of restlessness or confusion
e) Chest pain
f) Nause
The staff member or provider may note the following in a client who is having
respiratory difficulties:
a) Apprehension,confusion,agitation
b) Difficultyspeaking
c) Tachypnea–breathing rapidly
d) Depressed respiratory rate (<8 breaths/minute)
e) Client making universal choking sign (hands around neck)
f) Inability to breathe while lying down
g) Cyanosis – bluish tinge to lips, nails
h) Acute onset coughing
i) Coughing blood
j) Rapid or irregular heart rate

k) Gurgling/wheezing/whistling sounds
l) Chest moving in unusual way
B. Management of Client with Respiratory Difficulties/Respiratory Depression
1. Stay with client and summon help including CPR/AED certified provider and
emergency kit, oxygen and AED.
2. Loosen any tight clothing.
3. Assess for cause of respiratory difficulty and assist patient in taking prescribed
medication if appropriate (e.g. asthma inhaler).
4. If airway obstruction with foreign object is suspected or respiratory difficulty
continues or if client becomes unconscious call 911.
5. If airway obstruction suspected or confirmed:
a) If client is moving air or coughing, stay with client, keep them calm and await to
see if spontaneous coughing effort clears airway.
b) If client is unable to exchange air, is unable to cough or is unable to speak or if
they are making the choking sign:
i) Give 5 back blows: bend the person forward at the waist and give 5 back blows
between the shoulder blades with the heel of one hand.
ii) If back blows do not relieve obstruction, give 5 abdominal thrusts (Heimlich
maneuver):
 Wrap arms around patient from behind and place a fist with the thumb side
against the middle of the person‘s abdomen, just above the navel.
 Cover your fist with your other hand.
 Give 5 quick, upward abdominal thrusts.
 Repeat until object dislodged or client becomes unconscious.
c) If client loses consciousness:
i. Lower to floor.
ii. Check for object in mouth:
iii. if visible try to grasp or sweep out of mouth taking care not to lode further
(this should only be done if client has lost consciousness).
iv. If no object visible, open the client‘s airway using the head-tilt/chin-lift or
jaw-thrust.
- attempt two provide two rescue breaths.

- If breaths work (visible chest rise), assess for spontaneous
breathing and for pulse if no spontaneous breathing, continue with
rescue breathing or initiate CPR if appropriate.
- If breaths do not work, attempt modified abdominal thrusts
-Straddle the casualty's thighs.
- Place the heel of one hand against the casualty's abdomen on the midline slightly above
his navel and well below his xiphoid process. (This is the same location as for the
standingabdominal thrust.)
- Place your other hand on top of the hand on the casualty's abdomen. Fingers can be
interlaced or extended away from your body.
- Press down with an inward and upward thrust. Keep your arms straight and do not push
to either side. Use your body weight to help you perform the thrust. After the thrust,
release thepressure on the abdominal area by leaning back.
- If the thrust causes the casualty to vomit, turn his head to one side and clear the vomitus
from his mouth. Then check the casualty for breathing.
(d) Continue doing 5 abdominal thrusts, check mouth, then two rescue
breaths). Continue sequence until you can get air into the lungs or
until the ambulance comes.
(e) Once successful, administer oxygen via non-rebreather mask at
100% (10-15 liter/ min) and assess for cardiopulmonary arrest.
d) If client goes into cardiac arrest, progress as needed into full CPR
5) If opiate overdose suspected or confirmed:
a) Administer naloxone (Narcan) IM, SC, Nasal spray. For a patient with known or
suspected opioid overdose who has a definite pulse but no normal breathing or only
gasping, in addition to providing standard BLS care, it is reasonable forappropriately
trained BLS healthcare providers to administer intramuscular or intranasal naloxone.
Naloxone is a lifesaving drug that can reverse an opioid overdose by restoring
breathing. It has no effect on someone who hasn‘t taken opioids. It is safe for children
and pregnant women.
c) Document administration route time, dose, vital signs and response to medication
(changes in signs and symptoms) and provide this information to paramedics.
d) Once client is breathing at >8 breaths/minute on own, administer oxygen via non-

rebreather mask at 100% (10-15 liter/ min) and assess for cardiopulmonary arrest.
Monitor for vomiting if client vomits, tilt head to side, clear vomitus and reposition
mask once.
e) If client goes into cardiac arrest, progress as needed into full CPR
f) For patients in cardiac arrest, medication administration is ineffective without
concomitant chest compressions for drug delivery to the tissues, so naloxone
administration may be considered after initiation of CPR if there is highnsuspicion for
opiate overdose.
During any of these emergencies: Someone should stay with the client at all times
and provide care until fully recovered or until emergency medical services team arrives.
If an unforeseen and unavoidable situation requires that the client be left unattended, even
briefly— s/he should be placed into the recovery position. Studies show some
respiratory improvement in this position compared to a supine position. If the person is
unresponsive and breathing normally, without any suspected spine, hip or pelvis injury,
turn the victim to a lateral side-lying position. Extend one of the person‘s arms above the
head and roll the body to the side so that the person‘s head rests on the extended arm.
Once the person is on his or her side, bend both legs to stabilize the body.
6. ASTHMA
Patients presenting with any of the following features should be considered unstable
and may warrant admission:
 nocturnal symptoms interrupting sleep (usually cough and dyspnoea)
worseningcough
 increased use of ß2-agonists (less effective and relief shorter lasting)
 decreased efficacy of rescue medication (such as corticosteroids)
Remember that a previous admission to hospital, particularly if it required treatment in
ITU, should be taken to indicate that the patient is prone to life-threatening episodes.
The features of severe asthma include:
 peak flow <50% predicted or best achievable by patient
 tachypnoea (>25 breaths/min)
 tachycardia (>110 beats/min)
 unable to complete full sentences.

The features of potentially fatal asthma include:
o peak flow <33% predicted or best achieved by patient
o cyanosis/hypoxia.
o silent chest on auscultation
o bradycardia/hypotension
Management – Treatment
Oxygen. Patients with acute severe asthma are hypoxaemic and this should be corrected
urgently with a high concentration of oxygen (usually 40-60%) and a high flow mask keeping
oxygen saturations >92%.
Bronchodilators. A bronchodilator, such as salbutamol (2.5-5mg) should be started as
soon as possible via an oxygen-driven nebuliser (drive at a flow rate of at least 6L/min).
This dose should be continued if no improvement is seen.. The administration of
bronchodilators IV is only indicated in patients who fail to respond or deteriorate, despite
repeated treatment given by nebuliser, and in whom intubation is imminent.
Corticosteroids. Patients should be given hydrocortisone 100 mg IV 6-hourly or prednisolone
30-60 mg od by mouth as soon as the initial assessment is made. No material benefit can be
expected for several hours but it is essential not to delay administration. Whichever steroid is
given initially, after 2 days all patients should be taking 30 mg of prednisolone daily by
mouth and this should be continued for a minimum of 5 days. The prednisolone dose does not
need to be tapered off, unless the patient is on a maintenance dose or steroids are required for
more than 3 weeks. Inhaled steroids should be started as soon as possible.
Hydration. Patients tend to become dehydrated because of decreased fluid intake and
extra loss through hyperventilation. This may increase the tenaciousness of the bronchial
secretions. Give IV fluids in amounts to maintain hydration. Monitor electrolytes,
particularly potassium, as hypokalaemia may develop.
Magnesium. In patients with severe asthma who respond poorly to initial treatment, or
with life-threatening asthma, after discussion with senior medical staff, consider giving a
single dose of intravenous magnesium at a dose of 2g (8mmol) in 250mL of NaCl 0.9%
over 20 minutes.
Aminophylline. This should only rarely be given in acute asthma because it is difficult to
use and has limited efficacy. Its administration should be limited to patients in whom all

other treatments have failed, the patient continues to deteriorate and intubation is
imminent. Therapeutic monitoring is essential.
Inpatient Management. A progressive improvement in morning peak flow should be
seen before discharge. Patients should normally be transferred from nebulised to inhaler
therapy when peak flow approaches normal limits. Prior to discharge, it is essential to
check that the patient has a good inhaler technique, that if the technique is poor the
patient is re-taught, and that the correct device is prescribed for their needs.
Discharge. Patients should be discharged on inhaled and/or oral steroids (as appropriate
to their previous history and current severity) and an asthma action plan. They should be
reviewed by their GP in 2 days and by an asthma specialist within 4 weeks. Peak flow
monitoring should be undertaken by patients who have difficulty telling if their asthma is
deteriorating. The Respiratory Nurses can provide advice on asthma management (patient
‗self-management plan‘) and on follow-up arrangements.
7. SEVERE HYPERTENSION
Patients require admission and urgent treatment when blood pressure is known to have
risen rapidly or is severely raised, such that the systolic pressure is equal to or above
220mmHg and/or diastolic pressure equal to or above 120mmHg. Urgent treatment is also
needed for lower blood pressure levels if there is evidence of severe or life-threatening end-
organdamage.
When there is acute, life-threatening organ damage.
The situation is a true hypertension emergency when there is acute and life-threatening
organ damage, such as hypertensive encephalopathy (headache, lethargy, seizures, coma),
intracranial haemorrhage, aortic dissection, acute coronary syndromes (unstable angina/acute
myocardial infarction), acute left ventricular failure with pulmonary oedema, or
preeclampsia/eclampsia. The initial aim of treatment is to lower blood pressure in a rapid
(within 2-6 hours), controlled but not overzealous way, to safe (not normal) levels –
about 160mmHg systolic and 100mmHg diastolic, with the maximum initial fall in blood
pressure not exceeding 25% of the presenting value. Too rapid a fall in pressure may
precipitate cerebral or myocardial infarction, or acute renal failure. Always seek advice
from the Blood Pressure Unit.
Intravenous agents. Hypotensive agents should be administered intravenously
when organ damage is potentially life-threatening. All patients should be admitted to a
high dependency or intensive care bed, for continuous BP monitoring. The choice of drug

will frequently depend on the underlying cause or the organ most compromised. In many
instances, patients will be salt and water deplete and will require fluid replacement with
normal saline in addition to antihypertensive agents.
Sodium nitroprusside is the parenteral drug of choice for most hypertensive
emergencies. It is an arteriolar and a venous dilator and has an immediate onset and short
duration of action, t 1/2 2-3 min. It is administered by intravenous infusion starting at
0.3microgram/kg/min, increasing by 0.5microgram/kg/min every 5 minutes, to a
maximum of 8micrograms/kg/min.
Labetalol, a combined - and -blocker, is a logical option for patients with ischaemic
heart disease, aortic dissection or dysphagic stroke patients; it is also safe in pregnancy. It is
given either by slow intravenous injection: 20mg over 1 minute initially, followed by 20-
80mg every 10 minutes to a total dose of 200mg; or by infusion at a rate of 0.5 to 2mg/min.
Labetalol can cause severe postural hypotension.
Hydralazine, an arteriolar dilator, is used particularly in hypertensive emergencies in
pregnancy but labetalol is preferable. A bolus dose of 5mg can be given by slow
intravenous injection, followed by 5 to 10 mg boluses as necessary every 30 minutes.
Alternatively it can be given as an infusion starting at 200-300micrograms/min; this
usually requires a maintenance dose of 50-150micrograms/min.
Malignant Hypertension Malignant (accelerated) hypertension is a syndrome characterised
by severely elevated blood pressure accompanied by retinopathy (retinal haemorrhages,
exudates or papilloedema), nephropathy (malignant nephrosclerosis) with or without
encephalopathy and microangiopathic haemolytic anaemia. It is usually a consequence of
untreated essential or secondary hypertension. Most patients who present with malignant
hypertension have volume depletion secondary to pressure naturesis. Therefore further
diuresis may exacerbate the hypertension and may cause further deterioration in kidney
function.
Aortic Dissection Aortic dissection must be excluded in any patient presenting with severe
hypertension and chest, back, or abdominal pain. It is life-threatening with very poor
prognosis if not treated. The initial treatment is a combination of IV -blocker (e.g. labetalol)
and a vasodilator (e.g. sodium nitoprusside or dihydropyridine CCB) to decrease systolic
blood pressure below 120 mmHg if tolerated.

8. ACUTE HEART FAILURE
Acute decompensated heart failure is a life-threatening condition with 30-day
mortality of 15% in those with NTproBNP>5000ng/L and 5% in those with
NTproBNP<5000ng/L1 Patients with heart failure should generally be discharged
from hospital only when their clinical condition is stable and the management plan
is optimised (NICE 2010). Community heart failure nurse follow-up reduces the 3-month risk
of re-admission by 35%.
Diagnosis
Heart failure is one of the commonest medical admissions (up to 5%) and one in seven
people >85y has heart failure, therefore it should be in the differential of all elderly patients
presenting with breathlessness. If heart failure is suspected, request serum NTproBNP with
the U+E sample.
Heart failure echo requests
1) NTproBNP level must be documented on the request form.
2) If significant LV impairment is known a repeat echo is not necessary unless a new
lesion (such as new murmur) is being investigated.
Management - Initial treatment
Acute pulmonary oedema:
 O2 to maintain SaO2 (95-98%)
 IV GTN infusion (10-200micrograms/min) - titrate to highest tolerable dose
(systolic BP90-100mmHg)
 IV furosemide 40-100mg bolus followed by an infusion at 5-20mg/h if required
 CPAP (with intubation if respiratory failure develops and appropriate for the
patient)
 IV morphine as a 2.5mg bolus can be given if patient is acutely distressed/in pain
often requires additional antiemetic such as 10mg iv metoclopramide)
9. ACUTE UPPER GASTROINTESTINAL BLEEDING

Immediate Assessment: Once the diagnosis of a bleed has been made, take blood for
haemoglobin, blood grouping/cross match, and coagulation studies. Enquire about drug usage

(especially NSAIDs) and alcohol, retching (Mallory Weiss tear) and previous dysphagia.
Examine for signs of chronic liver disease and portal hypertension (palpable spleen,
abdominal veins), and check for melaena by rectal examination. If endoscopy is to be
undertaken, adequate resuscitation should be ensured prior to the procedure.
Immediate Management: This should be based on the severity of the bleed and the
predicted risk to the patient. It is convenient to divide patients into two main groups - ‗low
risk‘ and 'high risk‘.
Initial Management
 Patients at ‗low risk’ include those with no sign of haemodynamic compromise; Hb >
10g/dl; aged < 60 years, and previously fit. In low-risk patients allow oral fluids,
observe for signs of continued or re-bleeding and arrange an OGD for the next routine
list.
Referral for endoscopy should be made on an endoscopy request form. It is important
to complete all sections of the form to allow appropriate prioritisation of the patient.
Inform the Endoscopy Unit of the need for endoscopy by 9am. Start patient on oral
Omeprazole 40mg BD.
 Patients at ‗high risk’ include those with haematemesis or fresh melaena; systolic
hypotension (<100mmHg); tachycardia (pulse >100 beats per min); postural drop in
diastolic BP; Hb<10g/dL;severe concomitant disease (liver/cardiovascular/repiratory)
age >60 years.
In high-risk patients restore blood volume with blood/blood substitutes, admit to high
dependency ward, monitor closely (pulse rate, blood pressure, CVP), inform GI bleed
registrar and discuss/arrange emergency endoscopy.
High risk patients or those with haematemesis who are vomiting, where endoscopy is
planned but not imminent, can be given IV Omeprazole 40mg BD until ready for an
OGD. The endoscopist should enter the OGD findings in the Endoscopy Unit computer.
If the endoscopist sees a bleeding ulcer, the patient should be given omeprazole (80mg)
as a stat injection IV, followed by an infusion at 8mg/h for 72 hours.
Surgery: Surgery should be considered if bleeding continues or recurs after hospital
admission, despite endoscopic therapy, since this is associated with a tenfoldincrease in
mortality.

10. HYPOGLYCAEMIA

11. STATUS EPILEPTICUS
Generalised status epilepticus is defined as either a run of discreet generalized
tonic/clonic seizures without full recovery in between fits (ie without gaining consciousness),
or continuous generalised tonic/clonic seizure activity lasting for 30 mins. As most seizures
terminate spontaneously within 3 minutes, the following measures should only be instituted
for seizures lasting longer than 7-10 minutes, unless the patient is known to have longer
seizures with self-termination (this information may be obtained from relatives, friends, or
the patient‘s epilepsy card or diary). The mortality and morbidity of generalised status
epilepticus is high, and it is important to control fits as soon as possible.
General management
1. Protect the patient from damage during the seizures - make the environment safe by
using padded bed rails. Do not restrain the patient. Once the flurry of seizures has
ceased, place the patient in a semi-prone position with the head down to prevent
aspiration and to help maintain the airway. The patient should be kept in this position
until full consciousness is restored. Note the time.
2. Initially concentrate on respiratory support. During an inter-ictal period insert an
airway and then administer oxygen. Do not attempt to insert anything in the patient‘s
mouth during a seizure, even if the tongue is injured.
3. Set up an IV line as soon as possible to gain access to the circulation.
4. If there is any suggestion of alcohol abuse or impaired nutrition, give thiamine as high
potency intravenous BEFORE GLUCOSE.
5. Estimate blood glucose rapidly using a blood test. If the patient is hypoglycaemic,
give100ml of 10% glucose rapidly, and if still fitting or unconscious, repeat and then
start10% glucose at 100ml/hr.
6. Draw venous blood for full blood count, clotting, glucose, urea, sodium, potassium,
calcium, liver function and anticonvulsant drug levels (irrespective of known history
at this stage). Save a sample of blood and urine for toxicology.
7. Measure body temperature, take an ECG, monitor respiration and BP.
8. Gain information – is there evidence of previous epilepsy, any anticonvulsant drugs,
diary or wallet card or bracelet.

Drugs
1) The drug of first choice is lorazepam given as an IV bolus injected at 2mg/min,
ideally in a dose of 4mg for adults or 0.1mg per kg for children. See flow chart for
alternatives if Lorazepam is unavailable or no IV access.
2) If seizures persist or recur, repeat lorazepam at 5-10 minutes. Lorazepam, however,
should not be used more than twice in any 24 hour period.
Other drugs: phenytoin a total dose of 18-20mg/kg given at a rate of 50mg per minute, with
cardiac monitoring. If phenytoin is contraindicated phenobarbitone may be given by IV
infusion (dissolved 1:10 in water for injection, max rate 100mg/min) in boluses of 200mg
every 5 mins, to a maximum total dose of 10- 15mg/kg, taking care to monitor respiratory
function. Diazepam 0. 5mg/kg
12. VASOVAGAL REACTIONS/SYNCOPE (FAINTING)
Vasovagal reaction is a reflex parasympathetic response to a variety of stimuli including

pain that leads to a sudden drop in heart rate and blood pressure leading to reduced blood
flow to the brain. A vasovagal reaction can progress to a transient loss of
consciousness (syncope) and may provoke seizure-like activity secondary to inadequate
oxygen perfusion of the brain. Common causes of a vasovagal reaction include pain,
fear, anxiety, breath-holding or prolonged Valsalva maneuver, prolonged standing, or
abrupt positional changes. These episodes are usually transient and self-resolving.
However, there is a risk of harm from falling, so management of a client should focus not
only on optimizing blood flow to the brain, but also on helping to prevent or minimize the
risk of injury. Both of these are best achieved through early recognition and management
of signs of a vasovagal response. Medical conditions other than vasovagal syncope can
also cause syncope. These include cardiac arrhythmia, hyperventilation, hypoglycemia,
local anesthetic toxicity or allergy (such as can happen if cervical block given for IUD
insertion), stroke, or hypovolemia due to a large blood loss or dehydration. Most of these
are not self-resolving and can lead to life-threatening loss of oxygenation to the brain and
heart. It is important, therefore, that providers assess for the presence or these conditions
when managing a client that is experiencing a syncopal episode.
A. Signs and Symptoms of Vasovagal Response

a) The client experiencing a vasovagal response may report the following:
A feeling of lightheadedness, dizziness, or feeling faint or like he/she is going to
―pass out‖
b) Nausea
c) Ringing in the ears/sense that sounds are far away
d) Blurred or reduced vision (spots, dark, grey tone, or tunnel-vision)
e) A feeling of restlessness or of sudden fatigue
f) Sudden sensation of feeling hot/flushed or cold
The staff member or provider may note the following in a client who is having a
vasovagal response:
a) Slow and/or weak pulse (heart rate of 60 or less)
b) Low blood pressure (although pressure may be normal)
c) Cool and clammy skin, sweating
d) Facial pallor
e) Dilated pupils
f) Vomiting
g) Yawning
h) Seizure-like activity, with tonic-clonic muscle movements
B. Management of a Client with Vasovagal Response

1. If a client reports the above symptoms or exhibits these or a syncopal episode is
suspected, remain with the client, reassure and calm the client, and protect from
injury.
2. Do not attempt to ambulate with the client.
3. Assist to a supine position.
a) If client standing or sitting: immediately assist to a supine position on the floor
and elevate legs 8-10 inches.
b) If client on exam table: immediately assist into supine or Trendelenburg position
on table.
4. Summon help and emergency supplies to the scene if needed.
5. Monitor and record blood pressure and pulse and repeat at least every 5 minutes.
If the patient loses consciousness, note the time.

6. If victim is found or becomes unconscious, assess circulation, airway and
breathing and progress as needed into full CPR.
7. If cause of fainting episode is unknown, check for medic alert, allergies, existing
medical conditions, and current medications and address appropriately (e.g. for
client with diabetes, assess glucose status and manage hypoglycemia if present).
8. If victim is conscious, encourage slow deep breathing. Consider activating
ammonia capsule/wipe and quickly move the capsule/wipe back and forth under
patient nostrils. DO NOT use ammonia capsule/wipe if the client‘s face is flushed
or if victim is having respiratory failure or has a history of respiratory disease.
9. If unconscious or no improvement within one minute, apply O2 via simple face
mask at 5-10 liters/minute or via nasal cannula at 2-6 liters/min.
10. Activate emergency response system is worsening status or status not improving.
11. Post syncopal episode, continue to monitor until vitals stabilize and client reports
feeling better and is able to respond appropriately to environments/questions.
a) If the client is fully conscious, there are no signs of respiratory distress and
client is alert and talking juice or water can be offered.
b) Assure pulse and blood pressure have returned to normal range and client is
asymptomatic when standing before discharging client.
c) Advise client to have a friend or family member accompany him/her home.
d) Advise client to see his/her primary care provider or refer for further
evaluation if the vasovagal reaction was severe, led to convulsions, recurs
frequently, or was not associated with a procedure or event.
13. DRUG OVERDOSAGE/ACUTE POISONING
This section describes the general measures that should be taken to support patients in
the first 24 hours after poisoning. It also offers advice on the treatment of some of the
more common causes of poisoning.
Primary assessment:
− ABC
− Conscious level and pupil size
− Body temperature
− Blood glucose level
− Physical state: age, pregnancy

− Identify poison: history from patient, relatives or entourage
Prevent absorption of drug/poison

Removal of drug from the GI tract is controversial. The potential benefits of reducing drug
absorption may be outweighed by the hazards of the methods used, eg aspiration of stomach
contents, paradoxical increase in drug absorption. Syrup of ipecac should not be used to
induce vomiting. Gastric lavage and activated charcoal have a place but they should only be
used according to strict criteria:
A. Gastric lavage
Indications: Lavage should be undertaken if presentation is within 1 hour of ingestion, if
the patient has taken a potentially life threatening drug overdose, and if the procedure is
agreed by a senior member of Accident & Emergency staff.
Contraindications to lavage:
 The patient has a depressed conscious level, unless airway is protected by cuffed
ET tube.
 The substance ingested is a hydrocarbon or corrosive.
 The patient is at risk of GI haemorrhage or perforation
B. Activated charcoal (50-100g) as a single dose to reduce drug absorption
Indications: Presentation within 1 hour of ingestion of a potentially toxic amount of a
drug known to be adsorbed to charcoal (check with NPIS or Toxbase if drug is not on the
list).
Adsorbable drugs include;
 Antiepileptics (phenytoin, phenobarbital, carbamazepine, valproate)
 Analgesics (paracetamol, salicylates, dextropropoxyphene, piroxicam)
 Cardiac drugs (disopyramide, amiodarone, digoxin, Ca channel blockers)
 Antidepressants (SSRIs, tricyclics)
 Miscellaneous(theophylline, quinine, dapsone
Presentation 1-2 hours after ingestion of a potentially toxic amount of drug adsorbed to
charcoal and known to delay gastric emptying. Such drugs include: salicylates, opioids,
tricyclic antidepressants, sympathomimetics, theophylline
Contraindications
• Drugs not adsorbed by activated charcoal (metals, alcohols, acids, alkalis)

• Depressed conscious level, unless airway is protected by cuffed ET tube
ANTIDO PRESENTATI INDICATION

TE ON POSOLOGIE
Alcool Sol à 5 % 0,5 à 1g/kg en 15 - Méthanol
Ethylique min puis même - Ethylène
dose pendant 4h Glycol
Atropine Amp 0,25; 0,50 2 à 8 mg par 24 h en « Faux antidote »
et 1mg 4 inj. selon gravité des
(surveillance organophosphorés
cardiaque
obligatoire)
Bedelix® Sachet de 3g 3 sachets dans un Paraquat, Diquat
(terre de verre d‘eau à
Foulon) renouveler
Bleu de Amp 10 ml à 1-2 mg dilués dans Méyhémoglobiné
Méthylèn 1% du glucose mie
e (risque de
surdosage)
Gluconat Amp 10 ml à 5-10 amp en Hypocalcémiants
e de 10 % perfusion (citrates, oxalates)
calcium (selon
calcémie)
Cyanokit 1 fl Vit B12= Perfusion rapide de Cyanures
4g 80 ml
1fl thiosulf = (à
4g renouveler)
Neostigm Amp 1 à 10 mg 5 à 10 mg IV lente Curarisants
ine + atropine 0,25 mg
Flumazén Amp à 1mg Injection très lente, Benzodiazépines
il ne pas dépasser 2

(Anexate mg
®)
Diazépam Amp à 10 mg 0,5mg/kg puis 2- Chloroquine
(Valium® 4mg/kg
) /24h(intubation et
ventilation assistée
obligatoires)
Glucagon Amp à 1 mg 1 amp+ 500 ml Hypoglycémiants
glucose + 2g de
KCl
Glucosé Glucose 10 à 30 à 60 g sous Hypoglycémie
hypertoni 50 % surveillance stricte
que
4-méthyl- Amp à 100 mg 10mg/kg Méthanol et

pyrazole Ethylène-glycol
N-acétyl- Amp 2 g – 5 g 150mg/kg en 20- Paracétamol

cystéine 30mn, puis
Flumicil 300mg/kg en 24 h
®
Naloxone Amp 1ml à 0,4 0,4 mg renouvelés 4 Morphiniques
mg fois par IV
Pralidoxi Flacon de 200 400mg en 1h puis Vrai antidote des

me mg 200mg/4h en 24 h Organophosphorés
Vitamine Amp 250 50 à 500 mg en 24 h Isoniazide

B6 mg/5ml en perfusion IV
(Beciclan Comp 250mg
)
Vitamine Amp IV 100 mg/kg en 1 h à Méthémoglobiném
C renouveler ie

Vitamine Amp à 50 mg 2 à 4 amp/24 h Anti-vitaminiques
K1 K
Chlorure Amp 10ml à 4g 1 à plusieurs amp en Bromures

de IV lente
sodium
Déferoxa 45 mg/kg/h sans Fer

mine dépasser 6g/h
Protamin Sol 5 – 10 ml à 5 ml en IV très Héparine

e 10 % lente
Penicilla Comp à 300 mg 20 – 40mg/kg/j per As, Pb, Au, Cu

mine os
Dimercap 3 à 5 mg/kg en IM As, Au, Hg

rol (BAL) toutes les 4 h
EDTA 50 à 75 mg/kg/j en Plomb

calcique 3 à 6 injections IM
ou IV pendant 3 à 5
jours
Bleu de Gelule à 500 10 g/100 ml de Thallium

Prusse mg mannitol 15 % à
renouveler
Physostig 0,5 mg/ml et 2 2 mg IV à répéter Tricycliques

mine mg/ml
Talozalin 10 mg/ml 10 mg en IV Clonidine

e
EDTA 500 mg/10 ml 1 amp dans 250 ml Digitaliques

disodique de glucose à 5% en
Diphenyl perfusion lente
hydantoin

e
Ethylbenz Amp de 2 ml ½ à 1 amp en IV Dogmatil,

atropine lente à renouveler Primpéran
en IM

Bibliography
1. Operating room orientation manual [Internet]. [Cited 2014 Jan 5). Available
from:https://www.utmb.edu/surgery/clerks/ormanual.htm.
2. Best practice protocols for clinical procedures safety [Internet]. [Cited 2014 Jan).
Availablefrom: www.who.int/surgery/publications/BestPracticeProtocols.
3. Osman C. Asepsis and aseptic practices in the operating room. [Internet]. [Last updated
2000Jul 1; Cited 2014 Jan 6]. Available
from:http://www.infectioncontroltoday.com/articles/2000/07/asepsis-and-aseptic-practices-
inthe-operating-ro.aspx.
4. Logan CA, Cressey BD, Wu RY, et al. Monitoring universal protocol compliance through
realtime clandestine observation by medical students results in performance improvement. J
SurgEduc 2012;69(1):41-6.
5. Sumner CF, McKee PC. Operating room protocol. Bull Contra Dent Soc 1967;12(4):19-
24.
6. Bykowski T, Stevenson B. Aseptic technique. Curr Protoc Microbiol 2008;Appendix 4:
7. Hart S. Using an aseptic technique to reduce the risk of infection. Nurs Stand
2007;21(47):43-8.
8. Al-Damouk M, Pudney E, BleetmanA. Hand hygiene and aseptic technique in the
emergencydepartment. J Hosp Infect 2004;56(2):137-41.
9. WHO/EHT/CPRBest practice guidelines in disaster situations, 2007
10. R. Crouch, A. Charters, M. Dawood, P. Benett. Oxford Handbook of Emergency Nursing
11. Maryland State Family Planning. Clinical Guidelines Management Of Medical
Emergencies –February 2018
12. St Georges Hospital. Guidelines For The Management Of Common Medical Emergencies
And For The Use Of Antimicrobial Drugs. August 2013
13. Advanced Trauma Life Support: student course manual 10th edition
14. Trauma: Ernest E. Moore 8th edition

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SURGICAL AND MEDICAL EMERGENCIES

Chapter one: Generalities in theatre nursing

Chapter two: Surgical emergencies

 Traumatic surgical emergencies

Chapter three: Medical emergencies

Dr. BATY/ Dr. CHI Page 1

1. Common terms used in an OR

2. Layout of an operating room

Dr. BATY/ Dr. CHI Page 2

Three areas of operating room

Dr. BATY/ Dr. CHI Page 3

3. The surgical team

The surgical services team consists of following components

Sterile Team includes;

Non sterile team includes:

Dr. BATY/ Dr. CHI Page 4

• Requests the surgery

• Knowledge of equipment used by the Anaesthesiologist

Dr. BATY/ Dr. CHI Page 5

4. Practical surgical techniques

Sutures are made of variety of materials with variety of properties

Dr. BATY/ Dr. CHI Page 6

FOREIGN BODY REMOVAL

Dr. BATY/ Dr. CHI Page 7

Dr. BATY/ Dr. CHI Page 8

Lacerations may be associated with neurovascular or other serious injury; a complete

Dr. BATY/ Dr. CHI Page 9

Dr. BATY/ Dr. CHI Page 10

Nail bed injuries

 Sub-ungual haematoma causes severe pain resulting from a collection of blood

Blood vessels, nerves and tendons

Dr. BATY/ Dr. CHI Page 11

Dr. BATY/ Dr. CHI Page 12

Ear and Nose Lacerations

Dr. BATY/ Dr. CHI Page 13

Dr. BATY/ Dr. CHI Page 14

Dr. BATY/ Dr. CHI Page 15

Dr. BATY/ Dr. CHI Page 16

Dr. BATY/ Dr. CHI Page 17

• Understand the basic pathophysiology of Traumatic brain injury.

• Evaluate patients with head injuries.

• Perform a focused neurologic examination.

• Explain the importance of adequate resuscitation in limiting secondary brain injury.

• Determine the need for patient transfer, admission, consultation, or discharge.

• Arrange appropriately for a patient‘s inter-hospital or intra-hospital transfer (what,

Dr. BATY/ Dr. CHI Page 18

Dr. BATY/ Dr. CHI Page 19

• Trauma to the face demands aggressive airway management

Neck injuries can be blunt or penetrating

Dr. BATY/ Dr. CHI Page 20

Figure 1 Cervical collar.

Indications for Cervical collar

Dr. BATY/ Dr. CHI Page 21

Dr. BATY/ Dr. CHI Page 22

Figure 11.3 Showing right-sided pulmonary contusion.

Dr. BATY/ Dr. CHI Page 23

Figure 11.4 Showing left-sided

Figure 11.5: Patient with tension