Clinical Management

of Common
Emergency Cases at
PHC

Directorate General of
Primary Health Care
Ministry of Health
2
Introduction:

Primary Health Care (PHC) institutes at Sultanate of Oman receive different types of
medical and surgical emergency cases that have to be assessed and managed before re-
ferring to hospitals. Developing a Clinical Guideline for Management of Common
Emergencies at PHC will standardize the medical care provided by doctors and nurses
at these institutes resulting in reduction in morbidity and mortality of such cases.

This ”Clinical Guideline for Management of Common Emergencies” developed by 6

Family and Community doctors and 3 General practitioner doctors working at Ministry
of Health at the primary health centers. Twenty one acute emergency cases were cho-
sen, algorithmic diagram on assessment and management of these cases were devel-
oped based on international guidelines, and customized according to the setup
(instruments & medication) available at PHC in Sultanate of Oman. The following doc-
tors took the initiative of developing this guideline:

Dr. Badriya Al-Rashdi (Senior consultant Family & Community Medicine)

Dr. Hanan Al-Mahrooqi (Senior consultant Family & Community Medicine)
Dr. Hanan Al-Khalili (Senior consultant Family & Community Medicine)
Dr.Ahmed Salim Al-Wahabi (Senior specialist Family & Community medicine)
Dr. Balqees Al-Zidjali (Senior consultant Family & Community Medicine)
Dr. Nadia Al-Lawati (Senior specialist Family & Community Medicine)
Dr. Jamshed Khan (Senior specialist Family & Community Medicine)
Dr. Maymona Al-Azri (Senior medical Officer)
Dr. Hanaa Al-Kindi (Senior medical Officer)

This Clinical Guideline for Management of Common Emergencies at PHC were re-
vised by senior consultants working at Accidents & Emergencies and specialized
fields, the following doctors were involved:
Dr Ammar Al-Kashmeri (Senior consultant A&E)
Dr.Said Al –Obaidani (Senior consultant Pediatric)
Dr. Hood Al-Abri (Senior consultant A&E)
Dr.Said Al-Busaidi (Senior consultant plastic surgery)
Dr. Idris Al-Farsi (Senior consultant A&E)
Dr. Mohammed Al-Mukhani (Senior consultant Cardiology)

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 Table of Content
Chapter 1 Acute Decompensate Heart Failure
Chapter 2 Adult Chocking
Chapter 3 Anaphylaxis
Chapter 4 Animal Bite
Chapter 5 Arrhythmias
Chapter 6 Asthma Exacerbation
Chapter 7 Burn
Chapter 8 Coma
Chapter 9 CPR
Chapter 10 Dehydration
Chapter 11 Diabetic Ketoacidosis
Chapter 12 Difficulty in Breathing – Child
Chapter 13 Head Trauma
Chapter 14 Hyperglycemia Hyperosmoler
Chapter 15 Hypoglycemia
Chapter 16 Myocardial Infraction
Chapter 17 Near Drowning
Chapter 18 Chocking Pediatric
Chapter 19 Seizure
Chapter 20 Tension Pnemothorax
Chapter 21 Urgency & Emergency Hypertension

5
 Acute decompensated heart failure
New or markedly worsening signs and symptoms of inadequate
systolic or diastolic heart function.

Symptoms
Shortness of breath , fatigue, cough with or without haemoptysis
Some relief from sitting / standing

Signs
Dyspnea
Tachycardia + gallop rhythm
Coarse crackles at both bases
Ankle/ sacral edema if right heart failure also present
Hypotension

Call Ambulance
- Be reassuring
- Airway assessment to assure adequate oxygenation and
ventilation, including continuous pulse oximetry.
- Vital signs assessment with attention to hypotension or
hypertension.
- ECG & chest x-ray if possible.
- Continuous cardiac monitoring.
- Intravenous access
- Seated posture.
- GTN spray 2 puffs or 300 micro sublingual
- If overload is likely, frusemide 20-40 mg IV.
larger dose is required if patient already on diuretics.
- If distressed or in pain, morphine 3 mg iv (repeat as necessary)
with antiemetics (metoclopromide 10mg iv)

Refer

6
 Adult Choking Treatment

Assess
severity

Sever airway Mild airway

obstruction obstruction
(ineffective (effective
cough) cough)

Unconscious Conscious Encourage cough

Continue to check
Start 5 back blows for deterioration to
CPR 5 abdominal ineffective cough
thrusts or until obstruction
relieved

Refer to emergency Discharge home if

obstruction relived

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 Anaphylactic reaction

Airway, Breathing, Circulation, Disability, Exposure

Diagnosis - look for:

• Acute onset of illness
• Life-threatening Airway and/or Breathing and/or Circulation problems 1
• And usually skin changes

• Call for help

• Lie patient flat
• Raise patient’s legs

Adrenaline 2

When skills and equipment available:

• Establish airway
• High flow oxygen Monitor:
• IV fluid challenge 3 • Pulse oximetry
• Chlorphenamine 4 • ECG
• Hydrocortisone 5 • Blood pressure

1Life-threatening problems:
Airway: swelling, hoarseness, stridor
Breathing: rapid breathing, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion
Circulation: pale, clammy, low blood pressure, faintness, drowsy/coma

2Adrenaline (give IM unless experienced with IV adrenaline) 3IV fluid challenge:

IM doses of 1:1000 adrenaline (repeat after 5 min if no better) Adult - 500 – 1000 mL
• Adult 500 micrograms IM (0.5 mL) Child - crystalloid 20 mL/kg
• Child more than 12 years: 500 micrograms IM (0.5 mL) Normal Salain
• Child 6 -12 years: 300 micrograms IM (0.3 mL) Stop IV colloid
• Child less than 6 years: 150 micrograms IM (0.15 mL) if this might be the cause
Adrenaline IV to be given only by experienced specialists of anaphylaxis
Titrate: Adults 50 micrograms; Children 1 microgram/kg

4Chlorphenamine 5 Hydrocortisone
(IM or slow IV) (IM or slow IV)
Adult or child more than 12 years 10 mg 200 mg
Child 6 - 12 years 5 mg 100 mg
Child 6 months to 6 years 2.5 mg 50 mg
Child less than 6 months 250 micrograms/kg 25 mg

REFER TO A&E

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9
 Asthma exacerbation

Episodes of progressive increase in shortness of breath, coughing, wheezing, chest tight-

ness or a combination of these symptoms.

Levels of Severity of Asthma Exacerbation

Mild Moderate Severe

Breathlessness While walking While Talking While At Rest

Can lie down Prefers Sitting Hunched Forward
Talks in Sentences Phrases Words
Alertness May be agitated Usually agitated Usually agitated
Respiratory Rate Increased Increased Usually > 30
Accessory muscle use Usually not Usually Usually
Wheeze Moderate (often Loud Loud
end respiratory)
Pulse Rate < 100 100 - 120 > 120
S O2 > 95 % 91 – 95 % < 91 %
PEF 00< % 00 – 60% 60> %

Mild Exacerbation

•Put the patient in a comfortable sitting position, so that he/she can bend forward if need-
ed and have support for hands and legs.
•High flow oxygen to maintain saturation above 92%.
•2.5 – 5 mg salbutamol every 20 minutes x 3 doses, via oxygen driven nebulizer.
•Prednisolone 40 mg Po stat.

 Reassess after 1 hour ( physical examination, Sa O2 , PEF).

 Improved : discharge on 5-7 days course of oral prednisolone 40 mg od, and their reg-
ular preventer and controller inhalers.

01
Moderate Exacerbation

•Put the patient in a comfortable sitting position, so that he/she can bend forward if
needed and have support for hands and legs.
•High flow oxygen to maintain saturation above 92%.
•2.5 – 5 mg salbutamol every 20 minutes x 3 doses, via oxygen driven nebulizer.
 Hydrocortisone 100 mg IV stat.
 Reassess ( physical examination, Sa, PO2EF) after 1 hour.

Improved: Not improved:

Discharge on prednisolone Refer to 3ry hospital for
40 mg Od x 5 7 days and admission.
their regular preventer and
controller inhalers .

Severe Exacerbation

•Put the patient in a comfortable sitting position, so that he/she can bend forward if need-
ed and have support for hands and legs.
•High flow oxygen to maintain saturation above 92%.
•2.5 – 5 mg salbutamol and 0.5 mg Ibratrobium Bromide every 20 minutes x 3 doses, via
oxygen driven nebulizer.
•Hydrocortisone 100 mg iv.

Refer to 3ry for admission.

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02
 Burns

Initial assessment and management of burns in Primary Health Care

Child or Adult with new burn

Brief History (Nurse/Dr)

When: (Time Of burn, duration of exposure)
Where: (Open or closed space...High risk of Co poisoning)
How: (Scald, Contact, Flame, Flash, Electrical, Chemical

First AID (Nurse/Dr)

Remove Clothing and Jewelry (Unless Adherent)

Cover the burn with sterile dry sheet
Irrigation with running tap water (8-15°C) for at least 20 minutes (No Ice)
Irrigation of chemical burns should continue for 1 hour or till ambulance arrival
Avoid hypothermia (esp. paediatric pt)
Avoid Topical application till burn assessment

Emergency Examination (Dr)

A, B, C, D & E Primary Survey:

Specific Scenarios:
Inhalational burns:
Suggested by hoarness, wheeze, stridor, dysphagia, facial swelling, singed
Nasal hair soot in nostril, depressed mental status
Spinal injury:
Particularly seen with blast injuries those who have jumped from building to
escape fire
Breathing:
Constricting full thickness circumferential burns of the chest wall may
limit or prevent chest movement
Circulatory Problems:
Hypovolameic shock (feature of severe burn).Circumferential burns around a limb
Examination for other injuries

03
 Treatment (Nurse/Dr)

Secure Airway, If inhalational burn provide O2

Measure Vital signs including temperature
Obtain I.V access with two large peripheral cannula
Start Ringer lactate solution (If burns >10% BSA)
Insert Folley catheter (If burns 10% TBSA)
Pain relief (I.V Morphine or as needed)
Immunization against tetanus (Refer to MOH guideline)

Special Scenarios

Chemical Burns:
Burn Assessment
Copious irrigation should continue for
Extent of burn (Lund & Browder Chart) one hour or till ambulance arrival
Depth of burn See Table 1 Do not attempt to neutralize Chemical
burns in PHC
All chemical burns should be referred
Chemical Eye Burns:
Copious irrigation of water
Removal of lenses
Decide The Level Of Care Needed Refer to eye A & E
Electrical Injuries
ECG should be done
All cases should be referred

Is hospital care Referral Criteria

Burns with greater than 10% of total
indicated?
body surface area
Burns of face, genitalia, perineum and
major joints, hand feet (if needed)
Electrical Burns
Chemical burns
Burns with inhalational injury
Circumferential burns of limbs or chest
Yes No Burns in child <3 years >60 years
Burns in people with pre existing
medical illness
Burns with trauma
Full thickness burns >1cm

Continue managing in
Refer to A&E
Primary Care
Refer to Algorithm 2
(Wound Care)

04
05
 Depth Assessment

N Layers of Skin
Classification Clinical Features Treatment Facility
o affected
Dry red blanches with pres-
sure
No blisters
First Degree Epidermis & May be painful
1 Health Center
(Superficial) dermis Intact Healing time within seven
days
No Scarring involved
E.g. Sun Burn
Moist pink with Blisters
Superfi-
Epidermis & blanches with pressure <10% Heath Center
cial Par-
Upper layers Usually extremely painful
tial
of Dermis Healing 14 days >10% Ref to
Sec- Thick-
involved Low risk of hypertrophic Scars Tertiary Care
2 ond ness
E.g. scald/hot water
De-
Epidermis Moist blotchy red
gree Deep
with Upper No capillary refill
Partial Refer to Tertiary
and Deep Layers No sensation
Thick- Care
of Dermis Healing over 21 days
ness
involved High risk of hypertrophic scar
All the Layers White, waxy & charred
of Skin to No blisters
Subcutaneous No capillary refill
Third Degree >1cm Refer to
3 tissue such as No sensation
(Full thickness) Tertiary Care
fat, fascia, Does not heal spontaneously
muscle and Grafting needed if >1cm
bone Will scar

06
Algorithm 2

Wound Care in Primary Health Center

Day 1: Assessment of Burn (Table)

First Degree/Superficial Second Degree/Partial Thickness Third Degree/Full Thickness

Irrigation
De-roof large blisters
Moisturizing Is the burn
Apply double layer of liquid Paraffin Gauze area >1cm
cream Silver Sulphadiazine dressing wide?
Dry gauze
Change of dressing on A/D
Pain Relief
Yes

Day 3 Reassessment Day 3 Reassessment No Refer to

A&E

Intact Irrigation
Skin Healing Double layer of liquid Paraffin Gauze
Silver Sulphadiazine dressing
Daily dressing
Pain Relief

Yes No Yes No

Day 7 Reassessment
Healing
Change to Double Continue Silver
layer liquid paraf- Sulphadiazine
fin Gauze dressing dressing on A/D
Healed, Review > 72 Hrs
Continue
Moisturizer & Yes No
Sun-block

Reassessment
Is healing on day 10
progressing? No If no healing
Urgent refer- Change to Continue Silver
ral Double layer Sulphadiazine
liquid dressing as
paraffin above
Yes Gauze

Reassessment on
day 14
If no healing
Urgent referral

07
 Coma
Unarousable, irresponsible even by powerful stimuli

IMMEDIATE ASSESSMENT:
A-AIRWAY-clear Airway and intubate ,if gag reflex is absent. Or GSC <8
B-BREATHING-administer 60% oxygen by face mask if patient not intubated.
C-CIRCULATION-check the pulse if absent then appropriate resuscitation should perform .
Establish I/V access.

Quick hx. Should be obtained from any witness and relatives,,

e.g. (speed of onset of coma, D.M drug or alcohol abuse ,past medical hx. And medication)

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CPR
WHAT IS CPR?
IT IS A COMBINATION OF RESCUE BREATHING AND CHEST COMPRESSIONS DE-
LIVERED TO VICTIMS THOUGHT TO BE IN CARDIAC ARREST.
COMPONENT ADULTS CHILDREN INFANTS

RECOGNITION UNRESPONSIVE
NO BRE THING OR ONLY GASPING
NO PULSE PALPATED WITHIN 10 SECONDS FOR ALL AGES

CALL FOR HELP

ACTIVATE EMERGENCY RESPONSE
RETRIVE THE AED
PLACE VICTIM ON HIS BACK
PLACE HIM ON A FIRM FLAT SURFACE

CPR SEQUENCE C-A-B

COMPRESSION AT LEAST 100/MIN
RATE
COMPRESSION AT LEAST 2 INCH- AT LEAST 1/3 AP AT LEAST 1/3 AP
DEPTH ES ( 5CM ) DIAMETER DIAMETER ABOUT
ABOUT 2 INCHES 1 ½ INCHES
(5 CM) ( 4CM)

CHEST WALL ALLOW COMPLETE RECOIL BETWEEN COMPRESSIONS

RECOIL

COMPRESSION ATTEMPT TO LIMIT INTERRRUPTIONS TO < 10 SECONDS

INTERRUP-
TIONS

AIRWAY HEAD TILT-CHIN LIFT ( SUSPECTED TRUMA ; JAW THRUST)

COPRESSION 30:2 30:2 SINGLE RESCUER
TO VENTILA- 1 OR 2 RESCUERS 15:2 2 RESCUERS
TION RATIO

VENTILA- 1BREATH EVERY 6-8 SECONDS ( 8-10 BREATHS /MIN)

TIONS WITH ASYNCHRONOUS WITH CHEST COMPRESSIONS.
ADVANCED
AIRWAY
DEFIBRILLA- ATTACH AND USE AED AS SOON AS AVAIBLE
TION RESUME CPR BEGINNING WITH COMPRESSIONS IMMEDI-
ATELY AFTER EACH SHOCK.

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 During CPR
Unresponsive Airway adjuncts ( LMA/ETT)
No breathing or no normal breathing Oxygen
(ie. Only gasping) IV/IO access
Plan actions before interrupting
compressions
(e.g. charge manual defibrillator)
Drugs
Shockable:
Adrenaline 1mg after 2nd shock
(then every 2nd cycle)
Activate emergency response system Amiodarone 300mg after 3rd shock
Get AED/ Defibrillator Non Shockable
Or send second rescuer ( if available) to do this Adrenaline 1 mg immediately
( then every 2nd cycle)

Give 1 breath
Check pulse: every 5 to 6
Definite pulse seconds
Within 10 seconds? Recheck pulse
every 2 minutes

Start CPR
30 compressions: 2 breaths minimize inter-
ruptions

Attach
Defibrillator/Monitor

Shockable Assess Non

Rhythm shockable

Shock

Return of
spontaneous CPR for 2 minutes
CPR for 2 minutes circulation?

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24
 Acute Breathing Difficulty

Mild Moderate Severe

If O2 saturation is,> If O2 saturation is, <95%- If O2 saturation is, <
95% and non/mild 92%, irritable 92%, lethargic/
chest in-drawing, no Moderate chest in- decrease level of
nasal flaring no grunt- drawing consciousness,
ing no apnoea , nor- May be nasal flaring agitation, severe
mal feeding and be- No grunting no apnoea chest in-drawing or
haviour reduce feeding silent chest, cyanosis,
bradycardia, Nasal
flaring &grunting h/o
apnoea , poor feeding
Upper respiratory tract
infection, Discharge
Look for Stridor
home f/u with GP or cough
Pt education about ill- Check:
ness Airway
Breathing
No Circulation
Yes

Start BLS if needed

Discuss with senior doctor Measure RR, give
Go algorithm Consider alternative oxygen, and insert iv
(Stridor) diagnosis -line
(Cough) Arrange for referral Then refer urgently

25
 Stridor

Agitated/ Laryngitis/ Barking

drooling Pharyngitis cough

Yes Laryngitis/Pharyngitis Toxic + high

fever

Epiglottis No
Yes

Call for senior

doctor
Consider ENT Bacterial Tracheitis Croup
referral and
PICU Secure airway Treat with oral
dexamethasone
Refer 0.6mg/kg, if vom-
iting use nebu-
lised budensonide

Home with f/u with GP

Patient education when to Improve
Yes
come back
No

Consider
adrenaline
nebulizer 1:1000
(5ml)
Close observation
Refer for admis-
sion to PICU

26
 Head Injury

Red Flags

Yes No
Red flags: GCS 15
-Glasgow Coma Scale <15 at any
time since injury.
- LOC
- Focal neurological deficit since
injury e.g. abnormal fundi or pupil
reaction.  Focused History
-Any suspicion of skull injury e.g.  General Examination
CSF from nose or ear.
- Amnesia for event before or after  Local Examination
injury e.g. wound
- Persistent headache.
- Vomiting
- Seizure
- Any previous cranial neurological
interventions.  Rest
-High energy head injury (Hit by
vehicle ,Fall > 1 m or > 5 stairs)
 Analgesia
-Hx. Of bleeding or clotting disorder  Wound management
or on anticoagulant therapy.
- Difficulty in assessing the patient
if indicated
e.g. very old ,very  Written head injury
young ,intoxicated ,or epileptic.
- Suspicion of non-accidental injury
information regard-
ing warning signs to
trigger consultation

 ABC
 Spine Immobilization if needed
 Inform & Refer to A/E

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 Management of Myocardial Infarction

Diagnose MI or Unstable Angina

 Diagnosis sometimes is not obvious, always have a high index
of suspicious.
 Typical presentation: Sustained chest pain not relieved by s/l
GTN. May present with collapse with or without cardiac arrest, breathlessness,
anxiety, nausea, vomiting, sweating, pain in arms, jaw, back or upper abdomen
 ECG: ST elevation ..etc. or R wave and ST depression in leads V1-V3 or new
LBBB

Insert IV Cannula

GIVE
 Oxygen
 Aspirin 300 mg oral unless contraindicated
 Analgesic; Morphine 2.5- 5mg I.V.
(Can be repeated in 15 minutes if necessary)
 Anti-emetic Metoclopramide 10 Mg IV
 GTN S/L if systolic BP>90 & pulse <100

Transfer patient as soon as you can for

thrombolysis

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33
 Pediatric choking treatment Algorithm

Assess severity

Ineffective cough Effective cough

Unconscious Conscious Encourage cough

Open airway 5 back blows Continue to check for
5 breaths 5 thrusts deterioration to ineffective
Start CPR (chest for
infant)
cough or until obstruction
(abdominal for relieved.
child more than
1 year)

Discharge home if
Refer to emergency obstruction relived

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 SEIZURE
Definition

A seizure is an episode of neurologic dysfunction caused by ab-

normal neuronal activity that results in a sudden change in be-
havior, sensory perception, or motor activity.

It can be caused by high grade fever (febrile convulsion), hypo-

glycemia, hypoxia, head trauma, epilepsy, drug withdrawal,….

Seizures Management

Active seizure
 Place in recovery position.
 Don't try to stop the movement

 Support ABC.
 Monitor O2, temperature, RBS.
> 5 mins < 5 mins
 Give O2
duration duration
 Establish 2 IV lines.
 Watch for time <,> 5 mins.

Diazepam 10 mg iv slowly( 5 Stopped

mg/min) Spontaneously
Child : Diazepam IV (0.2 mg/
kg) or Rectal 0.4 mg/kg
Wait 5 mins.
Post ictal care:
 Monitoring and observa-
Seizure controlled tion for recurrence.
If not controlled :  Determine cause by de-
Diazepam 10 mg iv slowly tailed history and exam-
(5mg/min). ination.
Child: (Diazepam IV 0.2 mg/kg  Refer immediately un-
iv) or Rectal 0.4 mg/kg. less known epileptic
Wait 5 mins with issue of non com-
pliance (routine refer-
ral).
 Consult senior doctors
INFORM AND ARRANGE
before discharging fe-
FOR EMERGENCY REFERL
brile convulsion.

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 Tension Pneumothorax

Management of Tension Pneumothorax

Tension Pneumothorax:
Air in pleural cavity with a valvular mechanism develops at the
opening where air is sucked into pleural space during inspiration
but cannot be expelled during expiration.
Caused by Trauma (RTA chest trauma , injections around chest)
and rarely spontaneous.

Critical Features
 Agitated and distressed patient, often with chest trauma
 Tachycardia
 Tachypnea
 Sweating
 Hypotension
 Decrease breath sounds and decreased chest movement at af-
fected side
 Mediastinal shift – Trachea deviated away from affected side

Management

 Sit the patient upright if possible

 Insert a large bore cannula (Size 14 or 16) through the

second intercoastal space of the chest wall in mid-
clavicualr line on the side of pneumothorax to relieve
the pressure in the pleural space

 Transfer as an emergency to hospital

36
Emergency & Urgency Hypertension

SBP ≥180 mmHg and/or DBP ≥120 mmHg

URGENCY : WITHOUT SIGNS OF ACUTE TARGET ORGAN DAMAGE (TOD)
EMERGENCY : WITH SIGNS OF ACUTE TOD
TOD include one or more of these systems :
CVS ( Angina , MI, Heart failure,CABG or Angioplasty)
CNS(Stroke, TIA, Encephalopathy)
RENAL (CKD, new protienurea or hematurea) Retinopathy or Periphral vascular disease.

SBP ≥180 &/or DBP ≥120 mmHg

1- HISTORY :
- BASELINE BP.
- PRESENCE OF PREVIOUS TARGET ORGANE DAMAGE
- Details about HTN therapy, compliance.
Intake of OTC medication (sympathomimitics, NSAIDs, herbal e.g. Licorice root) or illucit drug use
e.g. cocaine, or abrupt stopping of B blockers or sympatholytic drugs.
- Chest pain (MI, Aortic Dissection)
- SOB(Acute Pulmonary Edema)
- Back pain (Aortic Dissection)
Neurological symptoms( headache, blurred vision, nausea, vomiting, altered mental status, seizure).

2- Examination:
Vital signs.
Ophthalmic exam : new retinal hemorrhage, exudates, pappillodema)
CVS: signs of heart failure (raised JVP, peripheral edema, crackles)
Abdomen : bruit ( aortic dissection).
CNS: level of consciousness, visual fields, focal neurological signs.

3- Investigations:
ECG .
Urine routine: new protienurea or hematurea.

37
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References

Adult and Child choking:

*2010 Resuscitation guidelines UK

Animal bites :
*Bites - human and animal - Management
Clinical knowledge Summery –NHS

Asthma :
*Guidelines for the management of asthma. Oman respiratory society & Oman Famco society in
association of MOH. 2nd edition, 2009.
*Pocket guide for asthma management & prevention. Global initiative for asthma. Updated 2005

Burn :
*Management of Burns and scalds in primary case –June 2007.Evidence base practice guideline
summary (Newzealand).
*Emergency case of Moderate to severe thermal burns in adult. Up to Date 2010.
*Dr Said saud mohd AL Busaidi – Seniors Consultant , plastic surgery, khoula hospital.
*Submersion Injuries by Dipak chandy M.D, Gesald L.Weinhouse MD up to Date – May *010.

DKA and Hyperosmolar hyperglycemia

*Cclinical features and Diagnosis of Diabetic ketoacidosis and hyperosmolar hyperglycemia state
in adult. Up to Date –January 2011.
*Treatment of Diabetic ketoacidosis and hyperosmolar hyperglycemia state in adult. Up to Date
May 27,2010.
*Guidelines for Management of Diabetic ketoacidosis in children SOUH –CHD- PROTOCOL -
04.

Drowning :
*Drowning –E- Medicine by Suzane Moore stepheed Jun 28/2010.
*Dr Houd Al-Albri –Senior Consultant , A & E , Royal hospital.

Coma, and head truma

*Clinical medicine saunders, Oxford handbook of clinical surgery, Oxford handbook ofgeneral practice

CPR and Arrhythmia:

*Americam Heart Association Guidline 2019
*BLS provider manual (MOH)

Dehydration:
*The Journal of Emergency Medicine, Vol. 38, No. 5, pp. 686–698, 2010. Clinical Reviews, The
management of children with gastroenteritis and dehydration in the emergency depart-
ment.
*Diarrhoea and vomiting in children Issue date: April 2009 NICE clinical guideline 84
www.emedicine /medscape .com 84
Developed by the National Collaborating Centre for Women’s and Children’s Health
*Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children
younger than 5 years, NICE GUIDELINE 84
Issue date: April 2009

41
Difficulty in breathing in children:
*An evidence-based guideline for children presenting with acute breathing difficulty
M Lakhanpaul, R MacFaul, U Werneke, K Armon, P Hemingway,T Stephenson
Emerg Med J 2009; 26:850-853 doi:10.1136/emj.2008.064279
National Collaborating Centre for Women’s and Children’s Health

Hypoglycemia
*Medescape Overview of hypoglycemia in adults
*Up to date --Physiologic response to hypoglycemia in normal subjects and patients with diabetes
mellitus
* The Hospital management Of Hypoglycemia In adults (NHS). March 2010.
*Resuscitation council UK- Hypoglycemia -- Revised 2008.

Myocardial infraction:
*Oxford handbook of general practice .Third edition

pneumothorax:
*Oxford handbook of general practice .Third edition

Seiziur :
* The Royal Children's Hospital Melbourne. Clinical practice guidelines. Convulsion guidelines.
* Advanced Clinical practice guidelines. Prehospital Emergency care council, Ireland. Dec 2007.
*Diagnosis and management of Epilepsy in adults. A national Clinical guidelines. Scottish
Intercollegiate Guideline network. April 2003

Urgency /Emergency Hypertension:

*Urgency hypertension management. Uptodate.com
*Flanigan JS, Vitberg D. Hypertensive emergency and severe hypertension: what to treat, who to
treat, and how to treat. THE MEDICAL CLINICS OF NORTH AMERICA. MAY 2006;90(3):439-51
(PUBMED SEARCH)
*McCowan C. Hypertensive Emergencies. Emedicine website. Aug.2007
*Vaidya & Ouellette : Hypertensive Urgency & Emergency : pp. 43–50. 44 Hospital Physician March
2007 .www.turner-white.com

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