It is also important for the practitioner to know the five stages of adoption: awareness,

interest, trial, decision, and adoption for innovators, early adopters, early majority, and
late majority.

STAGES OF BEHAVIOUR CHANGE IN RELATION TO SMOKING

Smoking counselling efforts should aim to move the smoker progressively through the 4
stages of behaviour change identified by Prochaska and diClemente. These stages have
been adapted for use in smoking cessation as follows:

1. Precontemplation
The smoker is not motivated to stop smoking.
Possible reasons: ignorance of harmful effects, past failed attempts to quit, fatalistic
attitude, etc.
Strategy: Create awareness about the harmful effects of smoking and benefits of
quitting. Assist in analysing reasons for past failed attempts and encourage to try again.

2. Contemplation
The smoker is motivated to stop smoking but has not set a quit date.
Strategy: Emphasise the costs of smoking and the benefits of quitting in more tangible
terms e.g. the amount of money wasted on buying cigarettes, determining the actual
number of cigarettes smoked a day, carbon monoxide testing.

3. Action
The smoker plans to stop smoking within 1 month or has already stopped for less than
a month.
Strategy: Teach specific skills in stopping smoking. Provide positive reinforcement of
efforts and specific coping mechanisms.

4. Maintenance
The smoker has stopped smoking for at least a month.
Strategy: Provide continued reinforcement of their newly acquired no-smoking status and
relapse prevention skills e.g. anticipating situations of possible relapse and planning one's
response beforehand.

5. Termination
This is defined as a stable state in which there is no temptation to smoke across all
problem situations and maximum confidence in one's ability to resist relapse across all
problem situations.
Identifying the Stages in a Smoker
(1) Have you ever thought about stopping smoking? No - Precontemplator stage; Yes - At
least Contemplator stage
(2) Would you like to stop smoking? Yes - At least Contemplator stage
(3) Do you plan to stop smoking in the next month? No - Contemplator stage; Yes Action stage
(4) How long have you stopped smoking? Less than a month - Action stage; More than a
month - Maintenance stage
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B. For the Patient Unwilling to Quit Smoking

Promoting the motivation to quit

All patients entering a health care setting should have their tobacco use status assessed
routinely. Clinicians should advise all tobacco users to quit and then assess a patient's
willingness to make a quit attempt. For patients not ready to make a quit attempt at this
time, clinicians should use a brief intervention designed to promote the motivation to quit.

PATIENT EDUCATION ON EXERCISE

Exercise: How to get Started

Why should I exercise?

Increased physical activity can lead to a longer life and improved health. Exercise helps
prevent heart disease and many other problems. Exercise builds strength, gives you more
energy and can help you reduce stress. It is also a good way to curb your appetite and
burn calories.

Who should exercise?

Increased physical activity can benefit almost everyone. Most people can begin gradual,
moderate exercise on their own. If you think there is a reason you may not be able to
exercise safely, talk with your doctor before beginning a new exercise program. In
particular, your doctor needs to know if you have heart trouble, high blood pressure or
arthritis, or if you often feel dizzy or have chest pains.

What kind of exercise should I do?

Exercises that increase your heart rate and move large muscles (such as the muscles in
your legs and arms) are best. Choose an activity that you enjoy and that you can start
slowly and increase gradually as you become used to it. Walking is very popular and does
not require special equipment. Other good exercises include swimming, biking, jogging
and dancing. Taking the stairs instead of the elevator or walking instead of driving may
also be a good way to start being more active.

How long should I exercise?

Start off exercising 3 or more times a week for 20 minutes or more, and work up to at
least 30 minutes, 4 to 6 times a week. This can include several short bouts of activity in a
day. Exercising during a lunch break or on your way to do errands may help you add
physical activity to a busy schedule. Exercising with a friend or a family member can help
make it fun, and having a partner to encourage you can help you stick to it.

Is there anything I should do before and after I exercise?

You should start an exercise session with a gradual warm-up period. During this time
(about 5 to 10 minutes), you should slowly stretch your muscles first, and then gradually
increase your level of activity. For example, begin walking slowly and then pick up the pace.

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After you are finished exercising, cool down for about 5 to 10 minutes. Again, stretch
your muscles and let your heart rate slow down gradually. You can use the same stretches
as in the warm-up period.
A number of warm-up and cool-down stretching exercises for your legs are shown at the
end of this handout. If you are going to exercise your upper body, be sure to use
stretching exercises for your arms, shoulders, chest and back.

How hard do I have to exercise?

Even small amounts of exercise are better than none at all. Start with an activity you can
do comfortably. As you become more used to exercising, try to keep your heart rate at
about 60 to 85% of your "maximum heart rate." To figure out your target heart rate,
subtract your age in years from 220 (which gives your maximum heart rate), and then
multiply that number by 0.60 or 0.85. For example, if you are 40 years old, you would
subtract 40 from 220, which would give you 180 (220 - 40=180). Then you would
multiply this number by either 0.60 or 0.85, which would give you 108 or 153 (180 x
0.60=108 and 180 x 0.85=153).
When you first start your exercise program, you may want to use the lower number (0.60)
to calculate your target heart rate. Then, as your conditioning gradually increases, you
may want to use the higher number (0.85) to calculate your target heart rate. Check your
pulse by gently resting 2 fingers on the side of your neck and counting the beats for 1
minute. Use a watch with a second hand to time the minute.

How do I avoid injuring myself?

The safest way to keep from injuring yourself during exercise is to avoid trying to do too
much too soon. Start with an activity that is fairly easy for you, such as walking. Do it for
a few minutes a day or several times a day. Then slowly increase the time and level of
activity. For example, increase how fast you walk over several weeks. If you feel tired or
sore, ease up somewhat on the level of exercise, or take a day off to rest. Try not to give
up entirely even if you don't feel great right away! Talk with your doctor if you have
questions or think you have injured yourself seriously.
WHAT ABOUT STRENGTH TRAINING?
Most kinds of exercise will help both your heart and your other muscles. Resistance
training is exercise that develops the strength and endurance of large muscle groups.
Weight lifting is an example of this type of exercise. Exercise machines can also provide
resistance training. Your doctor or a trainer at a gym can give you more information about
exercising safely with weights or machines.

Warm-up and cool-down stretches

Calf stretch
Face a wall, standing about 2 feet away from it. Keeping your heels flat and your back
straight, lean forward slowly and press your hands and forehead to the wall. You should
feel stretching in the area above your heels (this area is shaded in the picture). Hold the
stretch for 20 seconds and then relax. Repeat.
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Quad stretch
Face a wall, standing about 1 foot away from it. Support yourself by placing your right
hand against the wall. Raise your right leg behind you and grab your foot with your left
hand. Gently pull your heel up toward your buttock, stretching the muscles in the front of
your right leg for 20 seconds. Repeat the stretch with your left leg.
Groin Stretch
Squat down and put both hands on the floor in front of you. Stretch your left leg straight
out behind you. Keep your right foot flat on the floor and lean forward with your chest
into your right knee, then gradually shift weight back to your left leg, keeping it as
straight as possible. Hold the stretch for 20 seconds. Repeat the stretch with your right
leg behind you.
Hamstring stretch
Lie down with your back flat on the floor and both knees bent. Your feet should be flat
on the floor, about 6 inches apart. Bend your right knee up to your chest and grab your
right thigh with both hands behind your knee. Gradually straighten your right leg, feeling
gentle stretching in the back of your leg. Hold the stretch for 20 seconds. Repeat the
stretch with your left leg.
Diabetes and Exercise

How can exercise help my diabetes?

Exercise can help control your weight and lower your blood sugar level. It also lowers your
risk of heart disease, a condition which is common in people who have diabetes. Exercise
can also help you feel better about yourself and increase your overall health.

What kind of exercise should I do?

Talk to your doctor about what kind of exercise is right for you. The type of exercise you
can do will depend on whether you have any other health problems. Most doctors
recommend aerobic exercise, which makes you breathe more deeply and makes your
heart work harder. Examples of aerobic exercise include walking, jogging, aerobic dance
or bicycling. If you have problems with the nerves in your feet or legs, your doctor may
want you to do a type of exercise that won't put stress on your feet. These exercises
include swimming, bicycling, rowing or chair exercises.
No matter what kind of exercise you do, you should warm up before you start and cool
down when you're done. To warm up, spend 5 to 10 minutes doing a low-intensity
exercise such as walking. Then gently stretch for another 5 to 10 minutes. Repeat these
steps after exercising to cool down.
When you start an exercise program, go slowly. Then gradually increase the intensity and
length of your sessions. Talk to your doctor for specific advice.

Are there any risks to exercising for people with diabetes?

Yes, although the benefits far outweigh the risks. Exercise changes the way your body
reacts to insulin. Regular exercise makes your body more sensitive to insulin, and your
blood sugar level may get too low (called hypoglycemia) after exercising. You may need
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to check your blood sugar level before and after exercising. Your doctor can tell you what
your blood sugar level should be before and after exercise.
If your blood sugar level is too low or too high right before you plan to exercise, it's better
to wait until the level improves. It is especially important to watch your blood sugar level
if you exercise in really hot or cold conditions, because the temperature changes how
your body absorbs insulin.

How will I know if my blood sugar is too low while I'm exercising?
Hypoglycemia usually occurs gradually, so you need to pay attention to how you're
feeling during exercise. You may feel a change in your heartbeat, suddenly sweat more,
feel shaky or anxious, or feel hungry. When you feel this way, you should stop exercising
and follow your doctor's advice about how to treat hypoglycemia. Your doctor may
suggest you keep candy or juice on hand to treat hypoglycemia.

What else should I do to exercise properly?

Many people with diabetes have problems with the nerves in their feet and legs,
sometimes without even knowing it. So it's important that you wear shoes that fit well
and have plenty of room when you exercise. Otherwise you could develop blisters or
other sores on your feet that can lead to infection and other problems. You should check
your feet before and after you exercise to make sure there are no blisters or other sores.

Should I drink more fluids during exercise?

Yes. When you're exercising, your body uses more fluid to keep you cool. By the time
you feel thirsty, you may already be getting dehydrated. Dehydration (not enough fluid
in your body) can affect your blood sugar level. Drink plenty of fluid before, during and
after exercise.

CHAPTER 5

DISEASE MANAGEMENT SKILLS

Outline
Getting Ready For A New Disease Paradigm
Getting Involved in Disease Management
The Way Ahead

GETTING READY FOR A NEW DISEASE PARADIGM

The new disease paradigm is needed for chronic disease care. The acute care model that we
are all very familiar with does not work well. Table 1 compares the differences between the
acute care model and the chronic care model that necessitate a paradigm shift.

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Table 1. Comparison of The Acute Care Model Versus Chronic Care Model
Characteristics
Main goal of care

Acute care
Cure

Chronic care
Control the progression of the condition;
Increase survival; Enhance quality of life.

Duration
Knowledge

Limited
Concentrated on health
professionals

Long term, Indefinite or Life long.

Health professionals, patients and
families share complementary knowledge

Disease management

Focused on acute & single

medical treatment

Relevant multi-drug & self-management

strategy with appropriate health system,
community and family support..
Comorbidities are usually present

Providers of care

Usually clinicians and clinical

institutions

Broad spectrum of health care

organizations, community services
and family care

Quality of care

Mostly self-contained
approaches within Institutions

Relevance of systemic quality approaches

HELPING PATIENTS TAKE CHARGE OF THEIR ILLNESSES

The doctor-relationship in the acute-care model is the do as I say model of care. The
patient is dominant and patient is passive. For chronic disease, this doctor-centred model
is focused on compliance. The doctor recognizes the patient needs to do something, but
it does not give the patient any more power. The health care professional is still very much
the authority trying to get the patient to do what is needed; the patients job is simply to
be obedient. It is a do as I say model of care.
What has been found, however, is that one cannot get patients to do anything. The
motivation to change ones behavior even to take ones medication is largely
internal. The patient is responsible and must take an active role in his or her own care.

THE PATIENT IS THE SOLUTION

Effective chronic illness care has two requirements. First, it requires a team with the
patient at the centre. Second, it requires active, involved participants especially an
active, involved patient. This model of care can be described using various terms
empowerment, informed choice, patient centered but they all have the same
underlying concept: The patient is at the centre and is actively involved in his or her own
health care.
But why cant we stick with the old models? Why does the patient need to be so
involved? There are at least three reasons.
First, most of the chronic illness care does not even involve physicians and other health
care professionals. On a day-to-day basis, the patient is in charge of his or her own health,
and the daily decisions people make have a huge impact on their own outcomes and
quality of life.
Second, we may know whats best for treating diabetes or asthma or congestive heart
failure, but that does not mean we necessarily know whats best for an individual patient.
Even in close doctor-patient relationships, we cant always know the details of our
patients lives: whats most important to them, what their other priorities are, what
motivates them, or what their financial situation is. Each patient is the expert in his or her
own life.
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 Finally, when patients are encouraged to be more involved and when their physicians
are less prescriptive, they do have better outcomes. We also know that this approach
does not take any more time but, in fact, can be more efficient because the health care
team is addressing the patients agenda first and the patients agenda is, after all, the
real reason for the visit (Nagasawa et al, 1990 in: Funnell MM, 2000).

EMPOWERMENT THROUGH EDUCATION

Its very difficult for patients to do what they dont understand, so the first step in equipping
patients to take on a more active role in their health care is to educate them. Start by
getting the message across to patients that education is as important to their health as
getting their prescriptions filled. They need to know all they can about their disease.
Patients needs should drive the education. For example, diabetes education courses can
be based entirely on questions from the audience. We can have a checklist of topics we
want to cover, but we address those topics in the context of patient questions rather than
through an impersonal lecture. Patients arent interested in their disease from an
intellectual perspective, as doctors are. They want to know about themselves. What does
this mean to me? Hows this different for me? Hows it going to affect my life?
Four important messages patients with chronic diseases need to understand (Funnel,
2000) are:
1. Their illness is serious. There are still patients out there who believe they have the
not-so-serious kind of diabetes. If they dont believe it is a problem, they will never
make changes to improve their health.
2. Their condition is essentially self-managed. Every decision patients make
throughout the day, from what they eat to whether they walk or ride the bus, has an
influence on their health. Communicate to patients that they are the most important
individuals in managing their illnesses.
3. They have options. There is rarely one perfect way to treat a condition. In the case of
diabetes, for example, patients can be treated through diet and exercise, oral medication,
insulin and so on. Patients need to understand the different treatment options available
and should be encouraged to look at the personal costs and benefits of each. Only the
patient can decide if the benefits are greater than the costs.
4. They can change their behaviour. Rarely do patients leave the doctors office and
immediately enact whatever change was recommended. The reality is that it often has to
be spread out into a series of steps. Teach patients that significant behavioral changes can
be made by setting goals, taking that first step and figuring out what you learn about
yourself along the way. This brings us to setting goals.

SETTING GOALS
In the patient-centered model of care, attention should be directed at the patients
agenda or goals related to his or her condition. Ideally, the goal should be clearly
displayed in the patients notes, and each person who handles the notes plays a part in
supporting the patient in that goal, asking, How did it go? What have you done this
week? How can we help you do better?

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Every patient has a goal. Even non-compliant patients have goals. Probably the best
definition of non-compliance is a doctor and patient working toward different goals. The
strategy is to set a goal that is in common.
The process of setting self-management goals with the patient involves essentially
two steps.
1. Start at the problem. Rather than beginning the patient encounter focused on lab
values or weight or blood pressure readings, begin by saying, Tell me what concerns you
most. Tell me what is hardest for you. Tell me what youre most distressed about and
what youd most like to change. Youll get to the lab values and other issues later, but it
will be in the context of the patients personal goal, which will make it more meaningful
for the patient.
2. Develop a collaborative goal. Once you have worked with the patient to identify
the real problem, your instinct may be to try to solve it, but dont. Dont try to fix it. Dont
just say, It will be OK. Instead, validate the patients feelings and his or her capacity to
deal with the problem, and continue asking questions that will lead the patient to his or
her own solution. Ask, What do you think would work? What have you tried in the
past? What would you like to try?

STARTING AT THE PROBLEM

Does the patient have the same goal as the doctor? Will he take the medicines you are
about to prescribe? Or the exercise that you said he should get into?
There is a need to explore the patients ideas, concerns and expectations about the
medicines to be prescribed. Specifically, we need to find out if the patient agrees that they
needed the medication, whether they want to take it at all even though he or she agrees
that it is needed. Is it because he or she thinks it will not work or is it because of worries
on side effects. The issue of affordability arose for only 10.5 percent and 14 percent of
patients in the Upjohn and American Academy of Family Medicine surveys, respectively
on non-adherence. This suggests that non-adherence arises less from financial issues than
from patients beliefs and attitudes.
Table 2. Finding the patients concerns and expectations also applies to nonpharmacological treatment.
Patient says:

Doctor responds:
(Old model)

(New model)

I hate this exercise plan.

Then try walking after

dinner every night with your
husband for 10 minutes.

What do you hate about it?

What would help you do better at it?

I dont think I can quit

smoking.

Smoking is the leading

cause of preventable death ...

Why do you think that? What

has happened in the past when
you tried to quit? What concerns
you most when you think about
trying to quit?

I havent been able to test

my blood sugar four times
a day.

Its hard at first, but just

keep trying. You really need
to keep the track of it.

What is preventing you from

doing that? Do you know what
numbers mean?

Source: Funnell MM, 2000

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FINDING THE COLLABORATIVE GOAL

Its always more meaningful when patients find the ah ha! on their own, so give them
that chance. Encourage them to come up with ideas first, then offer your own
suggestions or additional information that they may need. You can say this works for
some people or have you tried this? or heres why I dont think thats a good idea.
The important thing is to give the patient the opportunity to make the final decision on
what goal to try.
Ultimately, at the end of the conversation, the patient should be able to tell you one step
he or she is going to take. It should be very specific. If the patient says, Im going to
exercise more, ask what that means. Will they exercise four times a week? What activity
will they be doing? How far will they walk? Help them to come up with a specific plan
that they have created for themselves. It may not be the ultimate goal you would have
chosen for the patient, but its one they are more likely to accomplish. At the next visit,
then, you can build on that.
Who actually works with patients to set their goals, whether you or the nurse or the
diabetes educator, is perhaps less important than the fact that patients are encouraged to
be more involved. The emphasis on self-management goals suggests that the visit is for
them. It is their agenda, and they are active participants in the outcome.
Adherence can be promoted by using easily learned communication skills that are part of
patient-centered medicine. They range from phrasing questions in ways that elicit
information efficiently to simply not interrupting patients while theyre talking.
Figure 1. Example of A Written Goal
Blood Pressure Goal
Actual:_________________mm/Hg
Ideal: 130/85 or lower
My goal is: ______________
A blood pressure reading has two numbers. The top number is called systolic blood pressure. This is the
amount of pressure against the blood vessel walls when your heart pumps. The bottom number is called
diastolic blood pressure. This is the amount of pressure against the blood vessel walls when your heart
relaxes, that is, between heart beats.
In general, high blood pressure means that systolic blood pressure, diastolic blood pressure or both may be
too high. For people with diabetes, high blood pressure is 130/85 or higher. High blood pressure increases
your risk for strokes, heart attacks, kidney damage and eye disease.
To lower your blood pressure you can:

Eat less salt,

Take blood pressure medicine,

Exercise,

Stop smoking,

Monitor blood pressure,

Drink less alcohol,

Maintain reasonable weight,

Other: _________________________________

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The Right Communication Processes

Communication processes that promote adherence are not difficult to acquire. There are
several steps in the communication process here:
Agree on the problem. Find out whether you and the patient agree on what the
problem is.
Negotiate reasonable goals. Once you and the patient agree on the diagnosis, set
attainable goals. If a hypertensive patient has a diastolic blood pressure of 120, you may
not want to try to bring it down below 90 immediately. You may suggest 110 as a shortterm objective. Once this has been achieved you can use that success to motivate the
patient to reduce it even more.
Generate options. Reviewing a reasonable range of treatment options, discussing
the benefits and possible side effects of each one in terms the patient can understand will
help in the patients acceptance of the treatment.
Decide on a mutually agreeable and feasible regimen. Doctor and patient can
choose a medical option that makes sense in the patients life. Dosage frequency requires
a similar discussion. Once-a-day drugs can improve adherence because they simplify
dosage. Some may be better off with a less expensive, three-times-a-day version.
Get the significant others involved. In many instances, adherence hinges both on
the patient and on his or her family. Success depended on the wifes understanding the
need and being motivated to meet it. She could undercut the program, either
inadvertently or intentionally, if she was left out of the loop.
Test the patients knowledge. It is useful to have patients repeat what theyve been
told about their illness and treatment plan. It can be, Tell me what you understand
about your illness. Likewise, ask them to explain their treatment plan, just as if they were
talking to their spouse. Its also important for patients to demonstrate any techniques
theyve been taught, such as injecting insulin or using a peak flow meter.
Screen for readiness. Ask two questions at the end of an encounter that allow him
to screen for non-adherence one more time. The first is, On a scale of 1 to 10, how
important do you think it is for you to do the things weve been talking about? The
second question is, On a scale of 1 to 10, how confident are you that you can adhere to
this treatment regiment?
Interventions

Interventions may be grouped into three strategies.

Educational: Information conveyed verbally and in writing.
Behavioural: Telephone reminders, patient contracts, skill building, drug packaging.
Affective: Counselling, home visits, family support.
In general, the more comprehensive the approach, the more adherences will be achieved.
Interventions that combined all three strategies educational, behavioural and affective
were almost twice as effective as education alone.
Keeping Patients on Course
Once a patient embarks on a course of treatment, you need to ensure that he or she stays
on course. The effective physician asks about non-adherence in a nonjudgmental way.
You can say, A lot of people find it difficult to take their pills 100 percent of the time. Tell
me about your experience. Its an open-ended question that elicits far more information
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than just asking, Are you taking your pills? Once the patient admits to non-adherence,
you can talk about ways to get back on course. If cost is the problem, consider lower cost
medications, medical social help, or cognitive redefinition. The understanding that the
result of treatment is worth the cost may help the patient redefine the priority to be given
to medication expenses. If the patient says, I feel fine without the medicine, talk about
the long-term risks of diseases that may have no symptoms.
Offer your congratulations if you find that the patient is following the treatment plan. We
need to praise patients when theyre making any kind of progress. Likewise, doctors
should accept less-than-perfect short-term results for the sake of promoting longterm change.
References for further reading
Funnell MM. Helping Patients Take Charge of Their Chronic Illnesses Family Practice Management, March 2000.
Nagasawa M, Smith MC, Barnes JH, Fincham JE. Meta-analysis of correlates of diabetes patients compliance with
prescribed medications. Diabetes Educ. 1990;16(3):192-200.
Clark LT. Improving compliance and increasing control of hypertension: needs of special hypertensive populations.
Am Heart. 1991; 121(2):664-669.
Roter DL, Stewart M, Putnam SM, Lipkin M, Stiles W, Inui TS. Communication patterns of primary care physicians.
JAMA. 1997; 277(4):350-356

GETTING INVOLVED BY DESIGNING THE CLINIC FOR DISEASE MANAGEMENT

Designing a clinic for disease management needs to pay attention to the care
management processes of needed for chronic diseases. There are barriers to be overcome
and there are also facilitating factors that will allow the clinic to be designed to provide
optimal disease management. This is a growing area where attention to current literature
will be useful. Two papers in the current literature (Rundell at al, 2002 and Cheah, 2001)
are useful in this context and the content of this reading is based on these two papers.
Care Management Processes Needed for Disease Management
The care management processes needed for disease management have been identified by
Rundall and used as a framework to study chronic care management (Rundall et al, 2002):
practice guidelines (descriptions or statements that guide recommended treatment
based on literature and scientific review).
population disease management (a care programme that identifies the population of
patients with chronic diseases served by the medical group and provides these patients
with a symptom management plan, conditioning and drug regimen, education on the
disease, and case management by telephone).
case management (a programme to intensively manage individual patients with
uncontrolled or high cost conditions).
health promotion or disease prevention (an activity occurring outside the clinical
encounter that promotes health such as a newsletter containing advice, a series of classes
addressing a specific health risk, or screening offered in the community).
Clinical information system use of seven selected functions of a clinical information
system that support chronic disease care management namely, (1) electronic medical
record, (2) electronic recording of health history, (3) recording of tests and procedures, (4)
recording of diagnosis and treatment, (5) computerised entry of drug prescriptions, (6)
automated reminders, and (7) electronic exchange of information with patients.
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Framework for Action

Designing the clinic for continuing care requires attention to a framework for action. This
has been described by Cheah (Cheah, 2001) and consists of the following elements:
identify the chronic disease and define the target population for disease management.
organise a multidisciplinary team.
define the core components, treatment protocols, and evaluation methods; and
measure the outcomes and aim for continuous quality improvement.

Identify the chronic disease and define the target population suitable
for disease management These are conditions that have:

High prevalence.
High cost (charges per episode, high drug use, etc).
High variability in practice patterns.
Poor clinical outcomes or a high risk of negative outcomes.
Inefficient delivery systems.
Potential for changes in patients lifestyle to improve outcomes.
Availability of clinical and other expertise to develop the programme.

Organise a multidisciplinary team The importance of a multidisciplinary team in

developing and implementing a disease management programme needs to be noted. The
team should include doctors, nurses, pharmacists, therapists, case managers, and
administrators, and it is important to appoint a clinician champion to lead the team. As
well as defining the goals of the programme and deciding what needs to be done, how it
should be done, who would do it, and how much it would cost, the team must also
anticipate the barriers to change. The same team should also evaluate the success of the
programme on the basis of agreed performance and outcome indicators. Having clinician
leaders and providing them with accountability and resources is crucial to getting their
ownership and support for the programme.

Define the core components, treatment protocols, and evaluation

methods The core components will include patient education, prevention measures,
screening for complications, monitoring of compliance and clinical outcomes, behaviour
modification, and environmental interventions. The Ministry of Health has started to
develop and disseminate evidence based national clinical guidelines to all doctors.
Dissemination alone will not, however, change practice. What is needed is a structured
approach to incorporating these guidelines into everyday use.
One way of achieving the incorporation of clinical practice guidelines into everyday use is
through the use of a protocol driven clinical pathway. The pathways incorporate clinical
documentation and time based interventions and focus the team on coordinating care
across different settings. Pathways in disease management programmes can span the
continuum from acute care to chronic care and provide the necessary linkages to
coordinate clinical management and monitoring of outcomes.

Measure outcomes and aim for continuous quality improvement It is

essential to measure baseline outcomes before beginning disease management
interventions to assess their effectiveness. Measured outcomes should include a mixture
of clinical, humanistic, and financial outcomes.
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References for Further Reading

Rundall et al. As good as it gets? Chronic care management in nine leading US physician organizations. BMJ
2002;325:958-961 ( 26 October )
Cheah J. Chronic disease management: A Singapore perspective. BMJ 2001;323:990-993 ( 27 October )

Keeping Track of Disease Management

We need to be able to keep track of the patient with chronic problems such that at a
glance we are able to make sure they are receiving the care they need. The answer lies in
the use of flow sheets. In order flow sheets work, there is a need to pay attention to
several factors. White describes what one group of doctors have found useful in the case
of flowcharts for diabetes (White, 2000). The tips can be applied in flow sheets for other
chronic conditions like hypertension or hyperlipidemia too.
The Strategies are:
Design a flow sheet that is comprehensive. The flow sheet should list all services
or measures relevant to diabetes, from patients lab values to blood pressure readings to
self-management goals to foot checks. The flow sheet wont be effective if key measures
are missing and overlooked, so dont hesitate to revise it.
Make abnormalities easy to spot. The patient data listed on the flow sheet will be
more useful if you also list the target measures or expectations so that you can
immediately know whether a patient is progressing toward the ideal. By putting the
parameters for normal lab results right on the flow sheet we do not have to wonder
whether a lab result is abnormal. Thus, targets listed on a diabetes flow sheet could
include the following: (a) two or more HbA1c checks per year, (b) with the most current
result at 7 percent or lower; (c) a retinal exam every 12 months; and (d) blood-pressure
readings at 130/85 mm Hg or lower.
Make sure the flow sheet cannot be overlooked in the chart. One way is to print
the flow sheets on coloured, heavy weight paper.
Computerize your flow sheet, if possible. While flow sheets can be easy and
effective tools even in their simplest form (paper), they become infinitely more valuable
when combined with computerized data. Computerized programs offer automatic
reminders when patients need certain services and provide an easy way to track patient
data over time.
Get Everybody to Enter the Flow Sheet. Perhaps the most difficult aspect of any
flow-sheet system is getting people to use it consistently. Filling the flow sheets seem to
work best when several people share the responsibility. For example, the person who files
the lab results in the chart can enter the lab results on the flow sheet. The nurse can be
responsible for inputting clinical data from the visit into the flow sheet. And the physician
can write in elements such as the patients self-management goal.
Set up a Review System. Follow up patients who have missed needed services.
This is where the patient register (list of patients who has a particular chronic problem)
comes in useful. If you have a diabetes patient registry (i.e., a list of your patients who
have diabetes), youll know exactly which patients to look up now that the information is
organized into a single page or two. The reviewing system is now manageable.
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SECTION 05 CONSULTATION SKILLS

Set a Goal. The point of having a goal for flow sheets, or any other aspect of
practice, is simply to spur action and encourage your practice team to work together. For
example, you can set an initial goal to have up-to-date diabetes flow sheets in 80 percent
of patients charts. Once, the goal is reached, that spirit of continuous improvement can
be continued until the ultimate goal of changing diabetes care, can be done in one step,
and for each one patient, one flow sheet that is kept up to date all the time.
Figure 2. Keeping Track of Disease Management With A Good Flow Sheet
DIABETES FLOW SHEET
NAME
DATE OF BIRTH
HbA1c <_ 7% (q 4-6 months)
DATE:
RESULT:
DATE:
RESULT:
Blood pressure < 130/85 mm Hg
DATE:
RESULT:
DATE:
RESULT:
BUN/Creatinine ratio 8-22/0.4-1.1 mg/dL (annual)
DATE:
RESULT:
Urine albumin/Creatinine 0-20 mg/L (annual)
DATE:
RESULT:
Lipids (annual)
DATE:
CHOL:
TRIG:
HDL:
LUL:
Retinal exam (annual)
DATE:

DOCTOR:

Foot screening (annual) HIGH RISK: YES/NO

DATE:
Self-management
DATE:
GOAL:
( ) DIABETES EDUCATION ( ) DIETARY COUNSELLING ( )
HOME BLOOD GLUCOSE MONITORING ( ) DSS MEMVERSHIP
CAD Status: ( ) PAST MI ( ) CABG ( ) PTCA ( ) CURRENT ANGINA ( ) NO HISTORY
Smoking Status: ( ) NONSMOKHR (SINCE _____________) ( ) SMOKER (PPD _______ )
ACE Inhibitor: ( ) YES ( ) NO ( ) MICROALBUMINURIA ( ) HYPERTFNSION
Aspirin Use: ( ) YES ( ) NO
( IF NO,SPECIFY REASON ____________________________________________)

Source: Family Practice Management Jun 2000; 61

154

This chart is copyright @ 2000 American Academy of Family Physicians. Physicians may
photocopy or adapt for use in their own patients charts; all other rights reserved by the
American Academy of Family Physicians. Use of this chart is acknowledged.
Reference and further reading
White B. Using flow sheets to improve diabetes care. Family Practice Management Sep 2000, 7(6):60-64 (Full text
at: http://www.aafp.org/fpm/20000600/60usin.html) Diabetes flow sheet in: Family Practice Management Jun
2000:61

THE WAY AHEAD

Innovative care models for chronic conditions are being formulated and implemented in
selected settings within certain developed countries. Results to date are promising,
showing improved adherence rates and clinical outcomes when the following strategies
are applied comprehensively (WHO, 2001):
Providing care that is respectful of patient preferences, and ensuring that patient
values guide all treatment decision-making.
Educating and supporting patients to self manage their conditions to the
extent possible.
Linking to resources in the broader community.
Developing and supporting health care providers to make and implement evidencebased treatment plans.
Reorganizing health systems to enhance the free flow of knowledge and information.
Coordinating care across patient conditions, health care providers, and settings
over time.
Monitoring the evaluating the quality of services and outcomes.
Reorganizing health care financing so that evidence-based care for chronic conditions
is possible and supported, and coverage of drugs is fully supported.
References and further reading
WH0. Adherence to long term therapies:policy for action, 2001 (http://www.who.int/chronic_conditions/
Adherence%20Meeting%20Report.pdf).
Bodenheimer et al. Improving Primary Care for Patients With Chronic Illness. JAMA. 2002; 288:1775-1779

Use the Plan-do-check-act (PDCA) Process. Continuing improvement is the

engine that keeps the flow sheets alive. Apply the plan-do-check-act (PDCA) process. For
any deficiency discovered that prevent flow sheets from working, get a small group of
people together and work out how it could be improved (plan). Carry out the
improvements (do). Check the results (check). If the improvement works, implement it
(act). Keep improving the flow sheets.
Finally, Be Patient. Changing your system of care isnt easy. It will take time for
physicians and staff members to experiment with the flow sheets and to find what works
best for them. Dont expect your flow sheet to be perfect the first time, but keep at it.
The more you use them and load them with data, the more useful they will become in
ensuring that patients receive the care they need.

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SECTION 05 CONSULTATION SKILLS

CHAPTER 6

EMERGENCY CARE SKILLS

Outline
Initial action
Cardiac emergencies
Respiratory emergencies
Neurological emergencies
Paediatric emergencies

INITIAL ACTION
Keep Cool, Act Swiftly and Confidently
Inform doctors and other staff.
Call ambulance at once.
Resuscitate: Administer O2, with spare cylinder nearby; Air viva taken out and ready;
Emergency trolley ready; Suction pump ready; Drip set ready, with Normal Saline and stand.
ABC
Airway Maintain head tilt, chin lift; Clear foreign body/ vomitus;
Insert oropharyngeal airway.
Breathing Look, feel & listen for breath; Assisted ventilation may be needed.
Circulation Check pulse and BP; Establish IV access.

CARDIAC EMERGENCIES
Cardiac Arrest
Recognise No carotid pulse/ respiration.
Action:
Airway Head tilt / chin lift.
Breathing Initial ventilation with 100% oxygen; 12-15 vent/min.
External Cardiac Massage (ECM) Over lower 1/2 of sternum; Depth 3-5 cm, rate
60 - 80/min; Ventilation compression ratio 1:5; Defibrillation (If available)
Check rhythm If VT/VF, serially defibrillate at 200, 200, 360 J till successful;
Lignocaine maintenance if successful.
Intubation Consider at this stage; Endotracheal tube size usually 7-8 for adults; Not
to interrupt CPR for > 20 secs.
Essential Drugs:
(IV) Adrenaline for asystole 10ml bolus of 1:10,000 (1mg).
Atropine for bradycardia 0.6mg bolus.
Lignocaine for Ventricular Tachycardia /Ventricular Fibrillation 50 mg bolus
over 1 min; Maintenance 1mg/kg/12hr.
NaHC03 if collapse prolonged; 1 ml/kg 8.4%.

156

Shock
Recognise Cold skin, tachycardia, hypotension.
Causes Hypovolaemic, septic, cardiogenic, anaphylactic, neurogenic shock.
Action:
Correct hypovolaemia (if present) Use Normal Saline or Hartmann solution.
Attend to underlying condition.
Transfer to hospital.
Acute Myocardial Infarction
Recognise Classically, anginal pain which is severe, prolonged (>_ hour), at rest, no
relief from GTN, and associated with breathlessness, sweating, vomiting, dizziness or
syncope. N.B. Beware of atypical presentation ECG may be normal in early stage.
Action:
Intranasal oxygen 6-8L/min.
S/L GTN 0.5mg stat, & Nitrodisc 10mg if available (5mg for elderly). Caution: Do not
use if hypotensive.
Slow IV Dextrose 5%.
Oral Aspirin 300mg stat.
IV morphine 2 - 5 mg slowly for pain relief, if necessary (dilute 10mg in 10ml N/
Saline). Caution: Give in 1mg aliquots till pain relief. Watch for respiratory depression
and hypotension. IV Maxolon 10 mg would alleviate nausea and vomiting.
Transfer to hospital.
Acute Pulmonary Oedema
Recognise Orthopnoea, paroxysmal nocturnal dyspnoea, history of heart disease/
hypertension/ similar episodes.
Action:
Prop upright, check BP.
Oxygen 6-8L/min.
S/L GTN 0.5mg stat.
IV Lasix 80mg bolus repeat every 15 mins till diuresis occurs.
Concurrently exclude severe hypertension (give S/L Adalat 5mg); AMI (see
previous page).
If resistant, give IV Morphine 2-5 mg slowly (dilute 10mg in 10ml N/S). Caution: Give
in 1 mg aliquots. Watch for respiratory depression and hypotension.
Consider Salbutamol Nebulisation 2:2 (2ml salbutamol:2ml normal saline) if
bronchospasm is present.
Intubate if indicated.
Transfer to hospital.
Hypertensive Encephalopathy
Recognise Severe hypertension (usually diastolic >120mmHg) associated with
headache, confusion, nausea, vomiting, focal neurological deficit, papilloedema.
Action :
S/L Adalat 5mg stat Caution: Do not give S/L Adalat to elderly patients with only
high BP reading in the absence of encephalopathy or other complications.
Set up Heparinised saline plug.
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SECTION 05 CONSULTATION SKILLS

RESPIRATORY EMERGENCIES
Acute Severe Asthma (Adult)
Recognise Restlessness, confusion, dyspnoea, inability to speak, tachycardia, pulsus
paradoxus. Cyanosis is late. N.B. A silent chest is an indication for immediate intubation.
Severe asthmatic may not complain much and may have minimal auscultatory signs.
Action:
Start Oxygen 4-6 L/min.
Salbutamol Nebulisation 2:2 (2ml salbutamol:2ml normal saline). Repeat if necessary;
Add Ipratropium Bromide (Atrovent) 20 drops (1 ml) if available.
IV Hydrocortisone 200mg stat.
IV Aminophylline 250 mg in 20ml N/S over 15 mins (Do not give loading dose if
already on oral theophylline; infuse 250mg in 500ml N/S over 12 hrs).
Monitor improvement continuously.
Intubate if patient is exhausted or somnolent.
Try S/C Adrenaline 1:1000 in dire situation where intubation cannot be expeditiously
carried out. Use insulin syringe; plaster to the skin. Give 0.3ml up to 0.5ml (0.1 ml at
a time). Caution: in the elderly and patients with IHD, give at slower rate.
Transfer to Hospital.
Breathless Patient
Causes More common: Acute Asthma, Acute exacerbation of COLD, Acute
pulmonary oedema. Less Common: Hyperventilation, Asphyxia/ Choking. Uncommon:
Pneumothorax, Massive pleural effusion / Ca Lung, Severe pneumonia, especially
in debilitated elderly, Acidotic breathing of Diabetic ketoacidosis, Acute
pulmonary embolism.
Action
Quick history (if available), quick examination.
Assess clinically for severity and cause Vital signs - tachycardia, hypotension;
Cyanosis, sweatiness; State of consciousness - restless, confused, drowsy.
Manage underlying cause immediately if it is apparent.
Start oxygen 4-6 L/min (2 L/min if COLD cannot be excluded).
Start Salbutamol Nebulisation 2:2 (2ml salbutamol:2ml normal saline).
Set up Heparinized Saline plug.
Give IV Lasix 40mg stat if unable to exclude acute pulmonary oedema.
Transfer to Hospital.
Choking
Recognise Usually occurs while patient is eating, or in children during play; Patient
often instinctively clutches throat with hands; If airway is completely obstructed, patient
is unable to speak or breathe, becomes pale, then rapidly cyanosed and finally loses
consciousness and collapses.
Action:
Do the Heimlich manoeuvre at once.

158

Adult
Executed for adults and in children older than 12 months.
Deliver 6 to 10 abdominal thrusts until the foreign body is expelled.
How to do it:
Stand behind the patient and encircle the waist with your arms. With one hand,
make a fist and place it, thumb side first, against the patients stomach slightly
above the navel.
Grasp the fist with your hand and press into the patients stomach with a quick
upward thrust.
It has to be of sufficient force and may be necessary to repeat up to 6 times to
clear the airway.

Child
How to do it:
Abdominal thrust with child supine and rescuer kneeling by childs feet.
Place heel of one hand, with the other hand on top of it over midline between
umbilicus and rib cage.
Deliver series of upward and inward thrusts.
If unsuccessful, try to visualize the oropharynx using tongue-jaw lift technique
and remove FB manually if seen. If not, repeat steps 1-4 as necessary.
If the above fails or if no spontaneous respiration occurs, commence artificial
ventilation and intubate.

Below 1 year old

How to do it:
Place child face down 60.
Administer four back blows rapidly with heel of hand high between the
shoulder blades.
If not dislodged, turn to supine position on firm surface, deliver four rapid chest
thrusts over sternum using two fingers.
If unsuccessful, try to visualize oropharynx by tongue-jaw lift technique, and if
foreign body seen, manually remove it. If not, repeat steps 1-4 as necessary.
If the above fails, commence artificial ventilation and intubate.

NEUROLOGICAL EMERGENCIES
Status Epilepticus
Recognise Recurring seizure without recovery of consciousness for 30 mins or more
Action
Protect patient from injury.
IV Diazepam 10 mg bolus over 2 mins; Repeat in 10 mins if necessary, up to maximum
of 30mg.
Maintain airway Position laterally or semiprone; Oropharyngeal airway; Give 100%
oxygen till seizure terminates; Clear pharynx of foreign body.
Transfer to Hospital.

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SECTION 05 CONSULTATION SKILLS

Eclamptic Fit
Recognise Grandmal seizure, history of pre-eclampsia; Premonitory signs: headache,
restlessness and agitation, blurring of vision, epigastric pain, hyperreflexia.
Action:
Treat as for epilepsy Protect patient from injury; Control fit with IV Diazepam.
Control hypertension IV Hydrallazine (100mg in 500ml 5% Dextrose starting with
10 dpm, increasing by 10 dpm every 15 mins till Diastolic BP 90-100 mmHg).
Transfer to hospital.
Comatose Patient
Recognise Causes: stroke, head injury, cardiovascular catastrophe, encephalopathy
(resp/ renal/ hepatic), brain infection/tumour, hyperglycemia, hypoglycemia.
Action:
Assess General state, response to verbal commands or physical stimuli; Check
pulses, BP, Chest, neurological system, and systematically rest of body; History
from relatives.
Resuscitate - Circulatory support - set drip; Respiratory support - suction, remove
dentures, oropharyngeal airway, oxygen, ventilation.
Prevent aspiration Coma position.
Obtain blood for sugar level and give 40 ml Dextrose 50% if appropriate.
Transfer to hospital.

OTHER EMERGENCIES
Anaphylaxis
Recognise Generalized urticaria, laryngeal oedema, bronchospasm, with or
without collapse.
Causes Hornet sting/ parenteral drug injection such as Penicillin/ NSAID.

Anaphylaxis with collapse

Recognise Hypotension, distress and complaint of feeling of impending death if the
patient is still conscious
Action:
IM/SC Adrenaline 1:1000 0.3-0.5ml Use insulin syringe; Repeat every 15-20 mins
as required; AVOID IV bolus (unless patient is collapsed); Caution: elderly and
ischaemic heart disease.
Assess Airway/Breathig/Circulation.
Give oxygen, intubate if necessary.
IM Promethazine 25mg stat.
IV Normal Saline - Volume correction may be needed.
IV Hydrocortisone 200mg bolus.
If bronchospasm is present, give Salbutamol Nebulisation 2:2 (2ml salbutamol:2ml
normal saline).
Continuous monitoring: General condition, BP, pulse & respiration.
Transfer to hospital.

160

Anaphylaxis without collapse

Recognise Generalized urticaria and edema of face/mucous membrane; Patient fully
conscious with no circulatory collapse.
Action:
IM Promethazine 25mg stat.
KIV Salbutamol Nebulisation (2ml salbutamol:2ml normal saline); S/C Adrenaline,
IV hydrocortisone.
Must monitor progress. Refer to A&E for observation.
Diabetic Coma
A diabetic can suffer from hyperglycaemic coma, hypoglycaemic coma and come due to
stroke, fits, infection, head injury or other causes.
Hypoglycaemia Coma
When suspected, do hypocount and collect blood sample first.
Recognise Agitation, altered mentation (may be in deeper coma), tachycardia,
sweating, anxiety; rapid onset. N.B. Unusual presentations include stroke and fits.
Causes DM on long acting sulphonylurea, missed meal, or insulin overdose.
Action:
IV 50% Dextrose 40ml stat Avoid extravasation; expect immediate improvement
(IM Glucagon 1 mg stat if IV access not obtained).
Continue 10% Dextrose drip.
Transfer to hospital.
Hyperglycaemic coma (Ketoacidosis)
Recognise Stertorous or deep breathing, severe dehydration, markedly raised blood
sugar level, urine ketone strongly positive (++); gradual onset over hours or days.
Causes Acute insulin insufficiency; failure to give insulin in known patient due to
misconception, e.g. during intercurrent illness.
Action:
Volume replacement with initially 1L N/S /hr ;If hyperosmotic non-ketotic diabetic
coma suspected, use 0.45% Saline for volume replacement.
IV/IM Soluble Insulin 5 u stat.
Transfer to hospital.
Multiple Injuries
Recognise: Hight index of suspicion in the following situations: (a) more than trivial road
traffic accident, (b) fall from height, (c) more than trivial assaults, (d) explosions.
Action:
Remove patient from area of danger.
If patient is unconscious and extent of injuries cannot be adequately ascertained,
move patient in one piece, ie as a log (may require splints, sandbags and
cervical collar).
Assess vital signs: AIRWAY, BREATHING, CIRCULATION.
(If neck injury suspected, apply cervical collar before assessing airway).
Arrest haemorrhage: direct - pressure dressings; indirect - pressure points compression.
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SECTION 05 CONSULTATION SKILLS

Establish intravenous lines with large bore venula in large veins: more than 1 usually
necessary if bleeding or in circulatory collapse; Use normal saline/ Hartmann.
Assess systematically from head to toe.
Conscious level, pupils.
Pupil size and position; eye movements.
Face/Head intubation may be necessary for severe facial injuries with bleeding
` (to prevent aspiration).
Neck gentle palpation; Do NOT perform passive range of movements of the
neck if the patient is unconscious; Apply cervical collar if in doubt.
Chest Observe respiratory movements carefully for flail chest, pneumo/
haemothorax; Palpate for tenderness, chest compression.
Abdomen Distension, bruising, tenderness.
Spine Palpate for tenderness; use minimal movement while doing so.
Hips Swelling, deformity. Pelvic compression.
Limbs Swelling, deformity; Support with splints if fracture suspected.
Constantly monitor vital signs and consciousness level.
Transfer to Hospital.
Violent Patient
Recognise Have high index of suspicion that the following types of patients may
become violent: (a) the mentally disturbed, (b) the delirious patient, (c) the very angry
patient, (d) the patient under influence of alcohol or drugs.
Action:
Protect yourself, other staff and the patient: Ensure open exit; Do not try to restrain
patient; Summon for help (including police).
Doctor should Allow patient to ventilate feelings; Maintain adequate distance from
the patient; Avoid antagonising the patient by provocative remarks; Avoid direct eye
contact; Be decisive.
If restraint needed (for unarmed patient) Use maximum force available; Act swiftly;
Have one person to direct the restraining process.
Medication IM Haloperidol 5 mg (half dose for elderly) OR IM Largactil 50 mg
(beware of hypotension).
If hypoglycaemia suspected, do hypocount.
Transfer to appropriate custody and care (a) A&E if medical condition present,
including intoxication; beware of unsuspected head injury in such patient, (b) mental
hospital if psyciatric condition present, (c) Police if medical condition unlikely.
Renal Colic
Recognise Loin to groin pain, may be severe enough to cause nausea/ vomiting; Check
BP, femoral pulses (remember dissecting aortic aneurysm).
Action:
IM Pethidine 50-75 mg stat.
IM Buscopan 2cc stat.
IM Stemetil 12.5 mg / Maxolon 10mg if nausea and vomiting is severe.

162

PAEDIATRIC EMERGENCIES
Collapsed Child and CPR
Begin with the ABC of resuscitation before organising a more coordinated team action.
Pay attention to ECM technique.
Initial Steps
Establish absence of breathing: (a) Head tilt/ chin lift, (b) Look for chest movement,
(c) Listen and feel over nose and mouth, (d) Clear pharynx if necessary.
Improve airway patency: (a) head tilt and chin lift (Avoid hyperextension of head),
(b) Bag and mask if necessary.
Palpate for brachial pulse.
Further Action
If foreign body suspected, invert child and apply back blows. Heimlich Manoeuvre
can be applied to children over 1 year old.
Bag and mask to ventilate, 15-30 breaths/min according to size of child.
External Cardiac Massage (ECM) over junction of lower and middle third of
sternum. Compression Ventilation Ratio 5:1.
Intubate, but if repeated attempts unsuccessful, bag and mask and oxygenate. Note:
adequate ECM produces palpable pulse. Adequate ventilation causes the chest to rise.
Establish IV Access (Paed Dext/Saline) - use microdrip set for small children.
Monitor BP, heart and respiration.
ECM Techniques
Baby Use thumbs encircling the babys chest in both hands; Rate 120/min; Depth
1 - 1.5cm.
Toddlers/small children Use tips of 2 fingers; Rate 100/min; Depth 2 - 3cm.
Larger child Use heel of hand; Rate 60 - 100/min; Depth 3 - 5cm.
All doses are expressed as volumes (ml), and to be given intravenously unless
stated otherwise.
Note:
*
May be given by the endotracheal route at the same dose
**
Use microdrip set for small children below 25 kg
Acute Severe Asthma (Child)
Recognise Marked respiratory distress and use of accessory muscles; Prolonged
expiration; Cyanosis (late); Silent chest (very late); Others: PEFR < 50% of predicted value
after nebuliser.
Action:
Give oxygen 4-6L/min by face mask.
Ventolin Solution 0.03 ml/kg/dose diluted to 2 ml with N/Saline, nebulized by O2. Add
Ipratropium -Bromide (Atrovent) if available (10 drops for child below 1 year, 20 drops
for above 1 year).
Review and if necessary, repeat Vent Nebulizer up to a total of 3 doses.
If child is still very dyspnoeic: give IV aminophylline 5mg/kg in Paediatric 0.45% Saline
Infusion over 6 hrs (safer than loading dose over 20 mins).
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SECTION 05 CONSULTATION SKILLS

IV Hydrocortisone 4mg/kg stat.

S/C adrenaline (1:1000) 0.1-0.3 ml (0.01ml/kg) may be used in dire emergency where
intubation cannot be expeditiously carried out. Contraindication: Cardiac failure
or hypertension.
Transfer to hospital.
Stridor
Recognise The typical inspiratory sound: May be both inspiratory and expiratory
Causes The 4 conditions that present as emergency are: (a) Acute Epiglottitis, (b)
Foreign Body inhalation, (c) Acute Angioneurotic Oedema / Anaphylaxis, (d) Severe Acute
Laryngotracheobronchitis (Viral Croup)
Acute Epiglottitis
Recognise Severe respiratory distress, sudden onset, usually 1-5 yrs old, toxic, febrile,
tachycardia, forward sitting posture with drooling of saliva; Sweatiness and cyanosis imminent respiratory arrest.
Action:
DO NOT ATTEMPT TO EXAMINE THE THROAT if acute epiglottitis is suspected.
If child is not cyanosed: Rapid transfer to hospital (with 02 and intubation set standby).
If child is severely ill: (a) Adminster oxygen by mask, (b) Minimal disturbance, (c)
Intubate if respiratory arrest, (d) Immediate transfer to hospital.
Inhaled Foreign Body
Recognise Suspect in all cases of stridor: ask for h/o choking, may only hear wheezing
if foreign body is in bronchus or beyond.
Action
Do Heimlich Manoeuvre. See under choking.
Acute Angioneurotic Oedema / Anaphylaxis
Recognise An acute allergic reaction associated with facial or neck swelling
Action:
Oxygen by mask.
S/C Adrenaline (1:1000) - 0.01 ml/kg up to 0.3-0.5ml (can be repeated every 4 hrs
if necessary).
IV access (Paed Dextrose/Saline).
IV hydrocortisone 5-10 mg/kg stat.
IM Promethazine 0.5 mg/kg stat.
If bronchospasm is present, give Salbutamol Nebulisation 0.03ml/kg/dose diluted to 2
ml N/S. If brochospasm persists, consider IV aminophylline 5mg/kg in IV Paediatric
0.45% Saline infusion over 6 hrs (SAFER than loading dose over 20 mins).
May need to intubate. Do NOT delay if indicated. Restlessness is an indication of
severity and the possible need for intubation.
Acute Laryngotracheobronchitis (Viral croup)
Recognise Usually not as severe as acute epiglottitis; Onset insidious, usual age 3 mths
- 4 yrs; Less toxic, but severe cases may present as emergencies
164

Action:
Give humidified oxygen if available.
IV access (Paed Dextrose/Saline infusion).
Transfer to hospital.
Fits in a Child
Causes Febrile fit; Others - epilepsy, meningitis, metabolic, anoxia, cerebral injury
Action:
Clear airway, suck secretions, loosen clothing around neck; Turn to one side (to
prevent aspiration).
Oxygen during convulsions or if cyanosed.
Protect from injury. (Forcing object into mouth may cause more damage than good;
use padded gag between teeth to prevent biting of tongue only if jaw is relaxed.).
Reduce fever.
Tepid sponging.
Rectal Panadol < 3 yrs old
- 1/4 supp (62.5mg)
3 to 6 yrs
- 1/2 supp (125mg)
7 to 12 yrs
- 1 supp (250mg)
If fits persist or recur:
IV Diazepam 0.3 mg/kg
- rough guide: 1mg/yr of life
- repeat after 20 mins if necessary
- Maximum dose: <5 yrs
- 10 mg
5-12 yrs - 15 mg
Caution: Apnoea/ cardiac depression/ hypotension
Rectal Diazepam if IV access not obtained (5 mg in 2.5 ml)
>3yrs 10mg
<3yrs 5mg
<1yr 0.5 to 0.75mg/kg
After fits controlled, do full neurological examination and check BP.
Transfer to Hospital.
Paediatric Emergency Drugs
Tables 1 and 2 show the dosages of important Paediatric emergency drugs.
Table 1. Modified Reference Chart For Paediatric Resuscitation
Maximum Age (Year
unless indicated)

2
mths

6
mths

3.5

10

13

14

Maximum Length (cm)

55

70

75

90

115

135

155

160

Maximum Weight (kg)

Endotracheal Tube

7.5

10

15

20

30

40

50

Internal diameter (mm)

Length(cm)

3
10

3.5
12

4
13

5
14

5.5
15

6.5
17

7.5
18

8
21

Adrenaline (1:10,000)*

0.5

0.75

1.5

Atropine (600ug/ml)*

0.2

0.25

0.3

0.5

0.7

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SECTION 05 CONSULTATION SKILLS

Table 1. Modified Reference Chart For Paediatric Resuscitation - Contd

Na Bicarbonate (8.4%)

7.5

10

15

20

30

40

50

Calcium Chloride (1mmol/m)

1.5

10

0.4
0.75

0.5
1

0.75
1.5

1
2

1.5
-

2
-

2
50

Diazepam (5mg/ml): Intraveneously 0.25

Per rectum
0.5
Glucose (50%)

15

20

30

40

Glucose (25%)

10

15

20

Lignocaine (1%=10mg/ml)*

0.5

0.75

1.5

Salbutamol (50ug/ml)
Initial Fluid Bp;us (ml)
Colloid
Paed Dext/Saline **

0.5

0.75

1.5

50
100

75
150

100
200

150
300

200
400

300
600

400
800

500
1000

10

15

20

30

40

60

80

100

Initial DC defibrillation (J)

Table 2. Paediatric Emergency Drugs

CONDITION

DRUG/ DOSAGE FORM

DOSAGE

FIT

IV DIAZEPAM
(10MG/2ML)

0.3 mg/kg/dose slowly

Maximum dose:
<5 yrs
10 mg
5-12
15 mg
Caution: apnoea

Supp DIAZEPAM
(5mg/2.5ml)

SEVERE ASTHMA

IV AMINOPHYLLINE
(250mg/10ml)

IV HYDROCORTISONE
(100mg/vial)
SC/IM ADRENALINE
(1:1000)

<3 yrs
5 mg
>3
10 mg
<1 0.5 - 0.75 mg/kg
5mg/kg by infusion
over 6 hrs
Loading dose: 5mg/kg over
20 mins
5mg/kg stat
then 6 hrly
0.01 ml/kg
max 0.5ml
Rpt 4Hr prn

CONGESTIVE
CARDIAC FAILURE

IV LASIX
(20mg/vial)

0.5mg/kg/dose

RESPIRATORY
DEPRESSION

IV NALOXONE
(400 mg/vial)

10 mg/kg
Rpt in 2 mins

Reference
MOH, COFM & CFPS. Emergencies. In:Handbook for Primary Care Doctors. Singapore:MOH, 1996

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