Handbook July 2016 - Formatted v3

July
7th
Edition
2016
DEPARTMENT OF EMERGENCY MEDICINE

CLINICAL & ADMINISTRATIVE
GUIDELINES
Table of Contents
INTRODUCTION .................................................................................................................5
HOW TO USE THIS GUIDEBOOK ................................................................................. 6
SURVIVING EMERGENCY MEDICINE .......................................................................... 6
CARDIOLOGY.....................................................................................................................7
ACUTE CORONARY SYNDROME (ACS) ...................................................................... 8
ACUTE PULMONARY OEDEMA (APO)/ DECOMPENSATED CCF ............................ 11
PALPITATIONS............................................................................................................. 11
DIRECT ADMISSION GUIDELINES FOR CVM VS DIM .............................................. 16
POORLY CONTROLLED HYPERTENSION ................................................................. 18
CARDIOTHORACIC EMERGENCIES .............................................................................. 21
ENT EMERGENCIES ........................................................................................................ 23
GASTROINTESTINAL EMERGENCIES ........................................................................... 28
ABDOMINAL PAIN ........................................................................................................ 28
BLEEDING GIT ............................................................................................................. 30
ACUTE GASTRITIS/GERD ........................................................................................... 31
HEPATOBILIARY EMERGENCIES .............................................................................. 31
PANCREATTIS ............................................................................................................. 33
ISCHAEMIC BOWEL .................................................................................................... 33
ABDOMINAL AORTIC ANEURYSM (AAA) ................................................................... 33
PROTOCOL FOR MANAGEMENT OF GS CASES IN DEPARTMENT OF
EMERGENCY MEDICINE ............................................................................................. 34
CT PROTOCOL/ WORKFLOW FOR ABD PAIN ........................................................... 35
HEMATOLOGY AND RHEUMATOLOGY ......................................................................... 37
ANAEMIA ...................................................................................................................... 37
THROMBOCYTOPENIA ............................................................................................... 38
MANAGEMENT OF OVER- ANTICOAGULATION WITH WARFARIN ......................... 39
APPROACH TO SUSPECTED DVT ............................................................................. 40
GOUT ............................................................................................................................ 43
METABOLIC & ENDOCRINE............................................................................................ 44
HYPERKALEMIA .......................................................................................................... 44
HYPOKALEMIA............................................................................................................. 45
HYPONATREMIA.......................................................................................................... 46
HYPOGLYCEMIA.......................................................................................................... 47
DIABETIC KETOACIDOSIS .......................................................................................... 48
HYPEROSMOLAR HYPERGLYCEMIC NON-KETOTIC STATE (HHNK) .................... 49
HYPERTHYROIDISM ................................................................................................... 50
NEUROLOGY .................................................................................................................... 51
CEREBROVASCULAR ACCIDENT .............................................................................. 51
TRANSIENT ISCHAEMIC ATTACK .............................................................................. 52
INTRACRANIAL HEMORRHAGE (ICH) ....................................................................... 53
GIDDINESS................................................................................................................... 54
SEIZURES .................................................................................................................... 55
HEADACHE .................................................................................................................. 56
OBSTETRICS AND GYNAECOLOGY .............................................................................. 57
CONDITIONS TO BE REFERRED TO O&G FROM ED ............................................... 57
EMERGENCY CONTRACEPTION ............................................................................... 58
ONCOLOGY ...................................................................................................................... 59
FEVER IN ONCOLOGY PATIENTS.............................................................................. 59
SPINAL CORD COMPRESSION .................................................................................. 60
PERICARDIAL EFFUSION ........................................................................................... 61
2
HYPERCALCEMIA........................................................................................................ 61
SUPERIOR VENA CAVA SYNDROME ........................................................................ 62
TUMORLYSIS SYNDROME ......................................................................................... 62
ORTHOPAEDICS .............................................................................................................. 63
UPPER LIMB FRACTURE WITH OR WITHOUT DISLOCATION ................................. 65
LOWER LIMB FRACTURE WITH OR WITHOUT DISLOCATION ................................ 71
PODIATRY REFERRALS ............................................................................................. 79
BITE WOUNDS PROTOCOL ........................................................................................ 82
PAEDIATRICS................................................................................................................... 83
RECOGNIZING A SICK CHILD WHO NEEDS TRANSFER TO KKH ........................... 83
WORKFLOW FOR CASES REFERRED FROM SISTER EMERGENCY
DEPARTMENTS TO KKH CHILDREN’S EMERGENCY (CE) ...................................... 86
TREATMENT OF COMMON CONDITIONS IN PAEDIATRIC EMERGENCY MEDICINE
...................................................................................................................................... 87
NEONATAL JAUNDICE (GUIDELINES FOR SGH A&E DEPARTMENT) .................... 90
PALLIATIVE MEDICINE IN THE ED ................................................................................. 94
RENAL .............................................................................................................................. 95
RESPIRATORY ................................................................................................................. 96
APPROACH TO PATIENTS PRESENTING WITH SHORTNESS OF BREATH ........... 96
ASTHMA based on GINA guidelines ........................................................................... 100
PNEUMOTHORAX WORKFLOW (NON TRAUMATIC) .............................................. 101
COPD .......................................................................................................................... 103
PULMONARY EMBOLISM .......................................................................................... 104
CT PROTOCOL/WORKFLOW for PE ......................................................................... 107
SEPSIS PATHWAY AND COMMON INFECTIONS ........................................................ 111
MANAGEMENT OF SEPSIS ....................................................................................... 111
COMMON INFECTIONS ............................................................................................. 112
INFECTIOUS DISEASES ................................................................................................ 115
COMMUNICABLE DISEASES .................................................................................... 118
MANAGEMENT OF GENITAL ULCERS AND DISCHARGES .................................... 119
MANAGEMENT OF EMERGING INFECTIOUS DISEASES ....................................... 120
TOXICOLOGY ................................................................................................................. 121
TOXIDROMES ............................................................................................................ 122
TRAUMA ......................................................................................................................... 123
APPROACH TO TRAUMA .......................................................................................... 123
PAN SCAN CRITERIA / GUIDELINES ........................................................................ 127
MINOR HEAD INJURY ............................................................................................... 135
ABDOMINAL INJURIES .............................................................................................. 136
CHEST INJURIES ....................................................................................................... 136
NECK PAIN ................................................................................................................. 137
BURNS ........................................................................................................................ 139
UROLOGY ....................................................................................................................... 141
ACUTE RETENTION OF URINE ................................................................................ 141
RENAL/URETERIC COLIC ......................................................................................... 142
UROLOGY WORKFLOW IN DEM .............................................................................. 142
EMERGENCY OBSERVATION WARD (EOW)............................................................... 145
RESUSCITATION WORKFLOWS .................................................................................. 146
INTUBATION WORKFLOW ........................................................................................ 146
MANAGEMENT OF SEPSIS ....................................................................................... 148
SEVERE SEPSIS/SEPTIC SHOCK CHECKLIST ....................................................... 149
CARDIAC ARREST AND POST CARDIAC ARREST ................................................. 150
3
GUIDELINE FOR ACTIVATION OF CTS FOR ECMO- CPR IN PATIENTS WITH
CARDIAC ARREST IN ED .......................................................................................... 152
MISCELLANEOUS .......................................................................................................... 154
SYNCOPE ................................................................................................................... 154
SGH DEM to BVH Transfer of ED patients ................................................................. 157
NEEDSTICK INJURIES AND PEP .............................................................................. 160
PATIENTS WITH RADIOACTIVE IMPLANTS............................................................. 160
ADMINISTRATION .......................................................................................................... 161
CULTURE OF SAFETY AND RISK MANAGEMENT IN DEM..................................... 161
SUPERVISION, PATIENT FEEDBACK & COMPLAINTS ........................................... 166
APPROPRIATE ORDERING OF INVESTIGATIONS, RESULT ACKNOWLEDGEMENT
.................................................................................................................................... 167
LEAVE, ROSTER, REPORTING SICK, OFF STANDBY ............................................ 168
MEDICATION ERRORS, CORRECT PATIENT IDENTIFICATION, MEDICAL
REPORTS ................................................................................................................... 171
4
INTRODUCTION
MESSAGE FROM THE HEAD
Welcome to the Department of Emergency Medicine. For the next few months of your
posting, you will be managing a wide range of medical and surgical conditions. To assist
you in your posting, our department has prepared this guidebook to aid you in your daily
interactions and management of patients.
The department is divided into resuscitation, critical care, consultation, fever areas and
the observation ward. Patients are triaged into 4 basic categories; P1, P2, P3 and P4
patients, with P1 being the most critically ill patients, requiring immediate attention, P2
being major emergencies, P3 being minor emergencies and P4 being non-emergencies.
Unlike other disciplines where clinicians spend much time delving into the patient’s
detailed history, physical examination and management, Emergency Medicine is a
specialty where the clinician’s aim is to save or manage as many patients as possible in
a fixed period of time. The practice of emergency medicine is to take focused history,
perform pertinent examination and order investigations relevant to the immediate care
of the patient in order to administer focused treatment and immediate life-saving or limb
saving therapy.
You are expected to fulfill the following during your posting:

At least 12 to 14 P2 cases per shift
At least 22 P3 cases per shift
You will also be assigned to resuscitation shifts with senior doctors to give you an
experience in managing critically ill patients.
Do note that the number of patients you attend to, your clinical skills, test results,
working attitude, attendance at teaching sessions, punctuality and your interaction with
your peers, nursing staff and senior doctors, as well as any medication errors and
patient feedback will be considered during your appraisal.
Each shift has 4 senior doctors for each area in the department except night shifts.
Morning shifts: M1, M2, M2A, M3
Evening shifts: E1, E2 E2A, E3
Night shifts: c, C
If any senior consultation is needed, please contact the specific senior doctor.
You can discharge patients if you deem them suitable for discharge but do consult
seniors when in doubt.
Your roster will be prepared by Dr Tan Tiong Peng and you are to contact him for any
roster issues. Important administration guidelines can be found at the end of the
guidebook.
We trust that you will have an educational and fulfilling posting with us.
Dr Evelyn Wong
Head and Senior Consultant
5
HOW TO USE THIS GUIDEBOOK
This guidebook has been prepared by the senior staff of DEM, with the aim of helping
the junior staff understand the work processes, and as a guide to all things in EM in
general.
We have attempted to cover as much ground as possible, hence this guidebook is NOT
a substitute for your own reading. And while it is updated every 6 months, there is a
need to constantly keep abreast with the latest developments in the medical science.
SURVIVING EMERGENCY MEDICINE
Emergency medicine has traditionally been viewed as a “hardship” posting. Its varied
set of patients and shift work are factors that make it difficult for junior doctors to adapt
to. However it can be one that is enjoyable and where much can be learnt. Bearing
these in mind, here are some ways to make the posting more bearable:
1. Do not over investigate. They cost patients money and results take time to come out.
As a general rule of thumb, any investigation that takes more than 2 hours to be
completed should not be ordered in the ED.
2. Update relatives. They are naturally anxious and have to wait outside the
department not knowing how their loved ones are doing. A simply phone call or bringing
them to the bedside to see the patients and to give a rough plan of management is often
enough to reassure them.
3. Get enough R&R. Watch a movie, exercise and get enough sleep in between shifts
to de-stress. And there’s always post shift supper or breakfast to catch up with each
other!
4. Aim to learn. We all have different backgrounds, and so will take away different
learning points from our postings. But no matter your learning objectives, your posting
will only fulfilling if it helps you grow as a doctor.
6
CARDIOLOGY
(A/P Lim Swee Han / Dr Sohil Pothiawala)
APPROACH TO CHEST PAIN
A. Life threatening Causes B. Other Important Causes
1. Acute Coronary syndrome 1. Cardio-vascular

2. Aortic Dissection - Stable Angina
3. Pulmonary Embolism - Pericarditis/Myocarditis
2. Respiratory
4. Tension Pneumothorax
- Simple pneumothorax
5. Esophageal rupture - Pneumonia
3. Gastrointestinal
- GERD/Gastritis
- Acute mediastinitis
- Esophageal spasm
4. Others
- MSK pain eg. rib fracture
- Costochondritis
Suggested Workflow
Chest pain
Typical Atypical
Normal ECG OR
Risk factors present Risk factors absent
ECG with ST ECG with ST
with normal or with normal or
elevation depression or new
baseline ECG baseline ECG
deep T inversions
NSTEMI / UAP -
CPP and / or rule
STEMI - activate Consult senior
CPP with MIBI out other causes of
cath lab for PCI doctor and refer to
chest pain
CVM
7
ACUTE CORONARY SYNDROME (ACS)
Symptoms and signs Management
STEMI (ST-elevation MI) Uptriage to P1

Monitor, supplemental O2
Chest pain ECG stat and repeat if necessary
Radiation to arm/shoulder/jaw/neck Activate CVL lab after consulting senior
SOB doctor
Lasting > 10 mins Take consent for PCI
Diaphoresis FBC, U/E, Trop T, CK, CKMB, PT/PTT,
Giddiness GXM
CXR
ECG criteria: S/L GTN v/s IV GTN, IV morphine
- >1mm ST elevation in at least 2 (Note: Avoid GTN in RV infarct)
anatomically contiguous limb leads
- >1mm ST elevation in precordial leads
V4 to V6 LOAD:
- >2mm ST elevation in V1 to V3
- New LBBB 1. Aspirin 300mg PO stat
AND
Refer to Sgarbossa Criteria to detect
AMI in presence of LBBB 2. Ticagrelor 180mg PO stat
Or if C/I for Ticagrelor: ventricular

Note: Right-sided chest pain may not pauses > 3 seconds, then
be atypical
3. Clopidogrel (Plavix) 600mg PO instead
Admit CCU
8
PCI Inclusion Criteria in SGH (from March 2016 onwards)
ECG Criteria:
 2mm ST elevation in anterior leads for two or more contiguous leads
  1mm ST elevation in inferior leads for two or more contiguous leads
 ST elevation in II, II, aVF less than 1 mm with ST depression in aVL
 De Winter T waves - Tall symmetrical T waves with up-sloping ST depression seen
in leads V2-V6
 New infarct Q waves in ≥ 2 adjacent leads
 Posterior infarction ST depression ≥ 1 mm over either V1, V2, or V3 and ST
elevation ≥ 1 mm in either V7, V8 or V9
 Wide spread ST depression (≥ 2 areas) and ST elevation ≥ 1 mm over aVR
AND
 Symptom Onset < 12 hours ago or the patient is still in pain at ED
Exclusion Criteria (Refer CVM stat if any present)

 Age  80 years old
 Poor premorbid status (bed bound / wheelchair bound)
 Collapse / comatose / semi-conscious states
 Heparin-Induced Thrombocytopenia (HIT)
 Risk of active bleeding (GI bleeding, traumatic head injury)
 Contrast allergy
What Constitutes Informed Consent by A&E

Summary of information need to convey to and discuss with patient before signing the
informed consent:
1. Explain the cause of AMI
2. Explain the mortality and morbidity risk of AMI
3. Emphasize the need to recannalize the artery as soon as possible
4. Explain two treatment strategies for AMI: thrombolytic therapy vs. primary PCI
5. Explain why primary PCI is better in terms of efficacy and safety
9
NSTEMI (non ST-elevation MI)
Uptriage to P1
Hx similar as above Monitor, supplemental O2
Reduced effort tolerance ECG stat and repeat if necessary
Relieved with rest or use of s/l GTN FBC, U/E, Trop T, CKMB, PT/PTT,
GXM, CXR
ECG shows ST-T changes but no ST S/L GTN v/s IV GTN, IV morphine
elevation Aspirin 300mg PO stat
Plavix 300mg PO stat
Elevated cardiac enzymes s/c Clexane 1mg/kg 12 hrly
Refer CVM to admit HD
Unstable Angina Pectoris (UAP) Supplemental O2

ECG stat and repeat if necessary
Hx similar as above FBC, U/E, Trop T, CKMB, PT/PTT,
GXM
Angina Equivalents: CXR
- Exertional SOB S/L GTN v/s IV GTN v/s GTN patch,
- Exertional pain in KIV IV morphine
jaw/neck/arm/shoulder/epigastrium Aspirin 300mg PO
- diaphoresis Refer CVM to admit HD if needs IV
- fatigue GTN
TIMI Score
Use: Estimates mortality for patients with unstable angina and non-ST elevation MI.
Criteria Value Points
Age ≥ 65 Yes +1 14 day risk of all-cause

mortality, new or recurrent
MI, or severe recurrent
≥ 3 CAD risk factors Yes +1
ischemia requiring urgent
revascularization
Known CAD (Stenosis ≥ 50%) Yes +1
Aspirin use in past 7 days Yes +1 0 to 1 score is 5%

2 score is 8%
Severe angina (≥2 episodes in 24 hours) Yes +1 3 score is 13%
4 score is 20%
ECG ST changes ≥ 0.5mm Yes +1 5 score is 26%
6 to 7 score is 41%
Positive cardiac marker Yes +1
Risk factors for CAD : Family history of CAD, Hypertension, Hypercholesterolemia,

Diabetes, or Current Smoker
10
ACUTE PULMONARY OEDEMA (APO)/ DECOMPENSATED CCF
Moderate to severe SOB Uptriage to P1

Orthopnoea/PND Monitor, supplemental O2
Diaphoresis FBC, U/E, Trop T, CKMB, Pro-BNP,
Chest pain/discomfort PT/PTT, GXM
Palpitations ECG, CXR
IV GTN infusion (up to 300mcg/min)
O/e: tachycardic, IV frusemide
hypertension/hypotension, raised JVP, KIV IV morphine 1-2mg
lung crepitations, wheeze, pedal edema Non Invasive Ventilation (NIV) Consider
+/- Intubation
IV Digoxin/amiodarone to control fast AF
Inotropes if hypotensive
ODD CVM for HD/CCU admission
PALPITATIONS
No CAD risk factors, NSR or occasional FBC, U/E, ECG, FT4, TSH
PVC/PAC, WPW, no prolonged QTc, no
Brugada pattern, no FHx of sudden death Observe in telemetry x 3 hours
or cardiac dysrhythmias
If bloods normal and patient
asymptomatic, discharge with TCU CVM
arrhythmia clinic 1-2/52
+/- chest pain +/- CAD Risk factors +/- FBC, U/E, ECG, Trop T, FT4, TSH
frequent PVC/PAC/bigeminy
Admit EOW under CPP
review telemetry recording
If CPP uneventful, discharge with TCU

CVM arrhythmia clinic 1-2/52
If elevated cardiac enzymes during CPP,

admit CVM
Hx of syncope FBC, U/E, ECG, Trop T, CXR

Family hx of Sudden death
ECG shows Brugada pattern Refer CVM stat
ECG shows non-sustained VT/salvos
11
Narrow Complex Tachycardia – Specific Management
Sinus tachycardia Management
FBC, U/E, ECG

Rule out fever/dehydration/bleeding FT4, TSH (if clinical suspicion of
GIT/PE/thyrotoxicosis/recreational drug thyrotoxicosis)
use/occult bleed
IV hydration
PO paracetamol if fever
Check postural BP
If bloods normal and tachycardia

resolves, discharge
Supraventricular tachycardia Management
ECG
AVNRT – commonest No need to do bloods unless clinically
AVRT – eg WPW indicated (1st presentation in Elderly with
CAD risk factors)
Uptriage to P1
Monitoring, O2
Proximal IV access
Patient stable
Vagal maneuvers:
Valsalva
carotid sinus massage (C/I in
elderly/carotid bruit)
No
response
IV Calcium channel blockers eg.
Diltiazem 50mg or verapamil 20mg
infusion over 20 minutes
No
response
IV adenosine 6mg rapid bolus with 20cc
IV NS flush
If no response, can repeat IV adenosine

12mg x 2 times
Patient unstable
IV adenosine 6mg bolus

If no response, can repeat IV adenosine
12mg x 2 times
12
Synchronized cardioversion 50J
If NSR, observe in telemetry x 3 hours.

Discharge with TCU CVM arrhythmia
clinic 1/52
Advice to avoid caffeinated products
If persistent SVT, ODD CVM for

admission
Atrial Fibrillation Management
Rate controlled Observe in telemetry x 3 hours

No other complaints
Assess CHADS-VASC score and
commence on Aspirin if indicated
Advice to continue aspirin/warfarin if

patient already on it
TCU CVM arrhythmia clinic
FBC, U/E, ECG, CXR

Rapid ventricular rate without CCF FT4, TSH (only if 1st presentation of AF)
(ventricular rate > 130/min) Trop T if patient suspected of associated
ACS
Digoxin level if pt on it
PT/INR if pt on warfarin
Uptriage to P1
Monitoring, O2
Patient stable
IV Calcium channel blockers eg.

Diltiazem 50mg infusion over 1hour AF
protocol
Patient unstable
IV heparin 18 IU/kg pre-shock
Synchronized cardioversion
Atrial Fibrillation 100 – 200 J
Atrial Flutter 50J
Anticoagulation with IV heparin
infusion/LMWH/warfarin after shock
ODD CVM for admission to HD

13
Rapid ventricular rate with CCF IV amiodarone 150mg over 30 minutes.
Can repeat dose if needed
KIV IV digoxin 250 mcg over 30 minutes

after CVM consult
IV frusemide
GTN patch or IV
ODD CVM for admission to HD
Others Management
Narrow complex tachycardia with See “Thyrotoxicosis”

abnormal thyroid function tests
Wide complex tachycardia Follow ACLS protocols

- VT/VF
14
CHA2DS2-VASc Score for stroke risk stratification in AF patients
<65 0
Age 65-74 +1
≥ 75 +2
Male 0
Sex
Female +1
Congestive Heart Failure History Yes +1
Hypertension History Yes +1
Stroke/TIA/Thromboembolism History Yes +2
Vascular Disease History Yes +1
Diabetes Mellitus History Yes +1
0 score is "low" risk and may not require anticoagulation.
1 score is "low-moderate" risk and should consider antiplatelet or anticoagulation*.
2 or greater is "moderate-high" risk and should otherwise be an anticoagulation*

candidate.
*Carefully consider all the risks and benefits prior to initiating anticoagulation in
patients
15
DIRECT ADMISSION GUIDELINES FOR CVM VS DIM
CVM (GW) with telemetry if available DIM CVM review at ED* Chest Pain
Protocol ± MIBI
Heart Failure Heart Failure with Requirement for

- Uncomplicated - obvious pneumonia HD/CCU
- severe anemia Heart Failure with
- chronic renal failure hemodynamic
- Sepsis instability
- Other non- cardiac outstanding
problems
Unstable Angina Atypical chest pain Requirement for Atypical Chest
- Chest pain resolved - with other non-cardiac HD/CCU pain
- Trop T negative outstanding issues/ potential NSTEMI Known IHD with
- No severe ischemic changes on ECG concerns - if straightforward can stable angina
Stable angina Angina/ACS but not suitable admit after phone - with no other
for coronary intervention consult outstanding issues
- eg age >80 years, bed bound, STEMI (activation) requiring DIM
uncommunicative) High risk ACS with management
consideration for
urgent cath
SVT resistant to cardioversion Secondary rhythm disorders Requirement for
AF with rapid ventricular rate - AF from thyrotoxicosis/Sepsis - HD/CCU
- but rate stabilized in ED with no other rate control in ED first Infrahisian 2nd/3rd
significant outstanding issues Bradyarrhythmic conditions degree heart block
Sick sinus with symptomatic where conservative where pacing is
bradycardia management has been considered
decided upon with other
outstanding non cardiac
problems
- patients choice
- Poor premorbid
Symptomatic/complicated valvular Valvular heart disease with
heart disease non- cardiac outstanding
problems
Pericarditis, myocarditis
Adult congenital heart ACHD cases with

disease cases with 1) single medical/surgical issues
ventricle 2)fontan correction with NO single ventricle,
3)Eisenmengers syndrome fontans, Eisenmengers
4)Cyanotic congential heart syndrome, cyanotic
disease congenital heart disease.
- With NON-SURGICAL medical
issues requiring admission (need
not be cardiac)
* When in doubt consult CVM
17
POORLY CONTROLLED HYPERTENSION
(Dr Fua Tzay-Ping)
Definition: BP 140/90 mmHg or higher. No absolute BP defines a hypertensive crises,

but diastolic BP in range of 120-130mmHg may be used as a guide
Hypertensive emergency: elevated BP assoc with acute or on-going end-organ

dysfunction or damage
Hypertensive urgency: elevated BP assoc with imminent end-organ dysfunction or

damage. Severe hypertension in an otherwise relatively asymptomatic patient is usually
described as urgency
Important history
-known hypertensive? (to check HIDS/emrx for f/u and meds records -> MUST!)
->On meds and what meds? Recent adjustments?
->On follow-up with?
->Compliance issues. Defaulted meds for how long and what reasons?
-symptoms to look out for: chest pain/SOB/leg

swelling/headache/giddiness/nausea/vomiting/blurring of vision/altered mental
state/weakness/numbness, possibility of pregnancy in female of reproductive age
-newly diagnosed? Any other reasons for raised BP like pain, anxiety (white coat) or
discomfort?
-family history? other co-morbidities? possible drug or stimulant overdose?
Important physical examination
Repeat BP using a manual sphygmomanometer
To do manual BP bilaterally if not contraindicated i.e. Post mastectomy or dialysis

patients
Check for correct cuff size
To repeat BP later if other causes like pain or discomfort is treated or if patient is

otherwise asymptomatic
Look out for end organ damage: fundoscopy, neurological exam to look out for focal
deficits, altered mental state, cardiovascular exam for LVF, new AR murmur, pedal
edema, pulses for evidence of aortic dissection
*To do postural BP in elderly patients

Relevant Inxs
ECG/CXR/UC9/FBC/UECr
Urine HCG in females who may be pregnant
Cardiac enzymes, CT thorax or CT head only if indicated –> will require senior Dr input
and review
ED management
!! Never treat the patient on a single BP measurement alone. Overzealous correction of

BP may result in CVA or AMI
!! Avoid S/L calcium channel blockers! Absorption is unpredictable and BP may drop too
fast
-If hypertensive emergency is diagnosed, to inform senior Dr stat KIV uptriage to

CC/resus KIV start IV meds and further inxs and mx
-If hypertensive urgency is diagnosed, to inform senior Dr re: EOW hypertensive

protocol (to refer to existing EOW hypertension protocol re: inclusion and exclusion
criteria)
-Initial treatment in known but otherwise asymptomatic hypertensive:
->to serve the patient’s own meds (from existing records) if defaulted and obs 2-4hrs vs.
EOW (to consult senior Dr)
->if meds not known, to serve PO nifedipine 5mg or 10mg if no contraindications and
titrated to patient’s serial hourly BP readings and obs 2-4hrs vs. EOW (to consult senior
Dr). For elderly patients, important to note not to drop BP too drastically or too fast.
-Initial treatment in ?newly diagnosed hypertensive:
->to treat other possible underlying causes of raised BP first like pain or discomfort and
to repeat BP later when feeling better usually 2-4hrs later
->if serial hrly BP readings persistently high despite observation, rest and otherwise
asymptomatic, for PO nifedipine 5mg or 10mg if no contraindications and titrated to
patient’s serial BP readings during obs KIV EOW (to consult senior Dr)
Disposition (if not admitted to EOW or ward)
If BP controlled after short period of observation and patient otherwise asymptomatic

with no abnormal inxs, good social support and no compliance issues:
-in known hypertensive:
->dc with memo to GP/OPD for follow-up within 2-3days and to prescribe patient’s usual
meds if defaulted or increase dose of existing drug or add on another agent if no
contraindications in a compliant pt. Do not prescribe meds for more than 1 week.
19
-in newly diagnosed hypertensive:
->dc with memo to GP/OPD or family med clinic for follow-up within 2-3 days to re-
check BP
->can consider starting any of the 5 main classes of drugs (diuretics, b-blockers,
Calcium channel blockers, ACE-i, ATII blockers) as initial therapy in hypertensive
patients who do not have any compelling indications or contraindications especially if
mod to high risk profile patients with no other causes of raised BP found
**to reinforce importance of compliance and lifestyle modification before dc**
20
CARDIOTHORACIC EMERGENCIES
(Dr Kenneth Tan)
AORTIC DISSECTION
Sudden onset tearing chest pain Uptriage to P1

Pain maximum at onset Monitor, supplemental O2
Radiates to back esp interscapular FBC, U/E, PT/PTT, GXM
Diaphoretic and distressed d-dimer, lactate after discussion with
Restless senior doctor
Abdominal pain ECG, CXR
Occ only back pain Ultrasound – pericardial effusion, aortic
Syncope flap
Stroke/weakness both lower limbs Arrange for CT Aortogram
IV morphine
Normotensive/Hypertensive/ Control BP with IV labetalol 50mg/hr
hypotensive infusion (maintain SBP 110-120mm
Pulse deficits Hg)
Differential BP in both ULs
CTS ODD stat for admission and
definitive repair
Note: CT Aortogram may show Type A
or Type B aortic dissection
For “AORTIC ANEURYSM”, see “ABDOMINAL PAIN”.
21
CT PROTOCOL AND WORKFLOW FOR AORTIC DISSECTION
22
ENT EMERGENCIES
(Dr Oh Jen Jen)
FB throat
Initial Management Refer ENT MO on call when:

 Inspect tonsillar region with light and tongue  Suspected FB throat requiring IDL /
depressor and remove FB if seen. flexiscope evaluation +/- removal (if
 If FB absent, order lateral neck X-ray and DEM doctor unable to do so).
ODD ENT.
 IDL / flexible nasopharyngoscopy to be
attempted only by experienced doctors.
 If all of the above are normal: TCU ENT clinic
x 1-2/7, provided:
1) patient is comfortable,
2) has minimal discomfort and is
able to swallow,
3) has no fever /haemetemesis
 If fit for discharge, prescribe lozenges and
thymol gargle; consider adding Augmentin if
any significant ulcers/abrasions seen
 Give FB advice: to return stat if pain
increases, develops fever/chest pain, or if
haemoptysis occurs.
FB ear
Initial Management Refer ENT MO on call when :

 Insect FB: instill 1% lignocaine /olive oil to  Initial attempt fails to remove FB.
drown insect.  FB is a battery.
 Syringing is not a recommended method for  Refer pediatric FBs to ENT MO stat.
removing FBs of the ear.
 Attempt FB removal once.
If successful :
 Home with antibiotic ear drops if external ear
canal abraded.
 TCU ENT clinic x 1/52
23
FB nose

 Attempt removal of FB once.  Initial attempt fails to remove FB.
 Home with no TCU if nasal mucosa healthy  FB is a battery.
and no evidence of sinusitis.  Refer pediatric FBs to ENT MO stat.
If successful:
 Home with Augmentin x 2 weeks if sinusitis
of mucosal trauma evident, TCU ENT clinic x
1/52.
 TCU x 1/7 if FB is a battery.
Ear Wax

 Impacted ear wax is not a medical  Call ENT MO if there is clinical
emergency. suspicion of malignant otitis externa,
 Prescribe olive oil 2 drops qds x 1/52. i.e. elderly/ diabetic/
 Explain that ear wax must be softened to immunocompromised (or if there is
allow suction removal severe otalgia)
 TCU ENT clinic x 1/52
Epistaxis

 Stabilise patient haemodynamically if  If bleeding persists:
necessary with IV fluids.  Prepare merocel packs 10cm x 4,
 Sit patient up. tetracycline cream for anticipated
 Spray co-phenylcaine generously into both nasal packing.
nostrils.  Stand by Foley’s catheter size
 Pinch nostrils between finger and thumb x 10 Fr12 or 14 for posterior nasal
mins. packing.
 Apply ice packs to nose bridge area.
 Ice-cold gargle (do not swallow) Refer ENT MO regardless if:
intermittently.  epistaxis prolonged
 Inform patient to open mouth and let blood  repeat visit
flow freely from mouth into receptacle  recurrent epistaxis
(discourage swallowing of blood).  sigf drop in Hb
 Check Hb/FBC if significant volume loss;
consider PT/PTT, GXM. Caution in patients with h/o NPC
 Monitor haemodynamic status. who present with epistaxis,
 If bleeding ceases: monitor patient for especially if known to have CA
rebleed x1 hour, discharge if no further recurrence.
bleeding.  may be sentinel bleed
heralding possible
24
carotid artery blowout.
 consider consulting ENT MO
as such cases may require
admission.
Adult Otorrhea
Initial management Call ENT MO on call if :

 Look for likely causes: CSOM, otitis  High fever.
externa.  LMN 7th nerve palsy.
 Treat with topical antibiotics i.e.  Signs of intracranial involvement. .
sofradex 2 drops tds x 2/52.  Signs of mastoiditis present.
 Add oral antibiotics only in serious
infections.
 TCU ENT x 1/52.
 Instruct to keep ear dry.
Traumatic TM perforation
Initial Management
 Symptomatic Rx.
 Do not prescribe ear drops.
 Keep ear dry.
 TCU ENT x 1/7 if labyrinthine injury
suspected (i.e. hearing loss/vertigo).
 Otherwise, can TCU ENT x 1/52.
Sudden unilateral sensorineural hearing loss
Initial Management
 Perform otoscopy and neurological  Refer Neurology if focal neurological
examination. deficit present.
If no obvious cause is found:

 Prescribe prednisolone 1mg/kg
tailing dose over 5 days.
 Acyclovir 800mg 5x/day x 1/52 if
patient presents early, i.e. within 3
days.
 TCU ENT next working day for
audiogram.
25
Bell’s Palsy
Initial Management
 Exclude other causes of facial  Refer neurology for atypical
paralysis. presentation of Bell’s palsy i.e. other
 Document degree of eye neurological sign found/atypical
closure/facial deformity at rest and history
on attempted movement.
 Prednisolone 1mg/kg x 1/52 tailing
dose, Acyclovir 800mg 5x/day x
1/52, if patient presents early, i.e.
within 3 days.
 Eye care: lubricating artificial tears /
eyeshields /night time taping of lids if
needed
 TCU ENT clinic x 3/7.
Vertigo
Initial management Refer ENT MO on call if :

 Ascertain type of dizziness.  Cases of severe vertigo requiring
 Neurological and ear examination. admission should be sent to
 Postural BP neurology for exclusion of central
 Drug history (potentially life-threatening)
 ECG, FBC and U/E/Cr if indicated. pathology.
 IM stemetil and bed rest, observe x  However, if patient is on follow-up
1-2 hours. with ENT for vertigo which has been
 Refer ENT clinic x 1/52 if patient well previously investigated, consider
enough for discharge. consulting ENT MO for admission.
 Consider admission to Giddiness
Co-ordinated Care Pathway.
Nasal trauma /fracture
Initial Management Refer ENT MO on call if :

 Examine for septal haematoma /  Complications such as septal
CSF leak / epistaxis. haematoma/ CSF leak / persistent
 Order nasal view x-rays, especially if epistaxis present.
there are medicolegal issues.
 Order facial views if associated
injuries suspected, KIV refer plastics
accordingly.
 Note any nasal obstruction and
deformities in case notes.
 TCU ENT clinic x 3/7 post injury
26
Lacerations ear/nose
Initial Management Call ENT MO on call if :

 Attempt T&S if simple lacerations.  Complex injuries: avulsions,
 IM ATT exposed cartilage, through-and-
 Oral antibiotics in contaminated through lacerations.
wounds.
 TCU ENT clinic x 5/7 for STO
Tonsillitis

 Prescribe antibiotics, lozenges,  Patient is dehydrated and cannot
analgesics x 10/7 swallow.
 TCU ENT x 10/7  Patient has prolonged fever.
 Patient has severe pain / trismus on
Antibiotic choices: oral examination which is out of
proportion to symptoms (possible
 Augmentin quinsy).
 If allergic to penicillin:
- Erythromycin / EES
- Klacid
- Ciprofloxacin
- Bactrim
Sinusitis

 Prescribe antibiotics ( refer above  Orbital complications (refer eye for
list ) x 14/7 immediate assessment 1st)
 Prescribe decongestants  Facial osteomyelitis
(oxymetazoline x 5/7 )  Intracranial extension present
 TCU ENT x 14/7
Guidelines prepared by Dr Ian Loh (ENT) & Dr Oh Jen Jen (DEM)
Vetted by A/Prof Christopher Goh (HOD, SGH ENT Dept)

& A/Prof Lim Swee Han
27
GASTROINTESTINAL EMERGENCIES
(Dr Annitha / Dr Jeremy Wee / Dr Sohil Pothiwala/ Dr Faraz)
ABDOMINAL PAIN
Minimum documentation for patients presenting with abdominal pain
History
Pain:
Onset
Severity
Position and radiation
Character
Other symptoms:
Nausea or Vomiting
Altered bowel habit
Haematuria / Dysuria
Testicular pain or lump
LMP
Menorrhagia / Dysmenorrhoea
PV bleed, discharge, dyspareunia
Any significant past medical / surgical history
Examination
Vital signs:
Pulse / BP / RR / Glucose / Temp
Positive findings on physical examination
Diagnosis or differential
Investigations
Treatment given
Referral time and arrangement
If discharged
Advice to patient
Instructions for GP
28
RIF pain Consider differential diagnosis:

Male: Acute appendicitis, renal colic,
Associated symptoms: nausea, UTI/pyelonephritis, peritonitis,
vomiting, dysuria, PV bleed/discharge perforated viscus, rupture AAA in
elderly
Female: all of above, ovarian
cyst/torsion, endometritis, Ectopic or
abortion in pregnancy
NBM
FBC, U/E, LFT, Amylase, CXR, ECG
UC9
UPT for all females in reproductive age
group
Ultrasound
IM/IV buscopan, opioids
IV NS
Admit GS unless high likelihood of
Gynae cause in females
ODD urology if pyonephrosis
LIF pain Consider above differentials

Diverticular disease in elderly
Associated symptoms: nausea, NBM
vomiting, dysuria, PV bleed/discharge, FBC, U/E, UC9
PR bleed UPT for all females in reproductive age
group
Blood cultures if diverticulitis
CXR, ECG
Ultrasound
IM/IV buscopan, opioids
IV ceftriaxone 1gm and IV
metronidazole 500mg in diverticulitis
Admit CLR if diverticulitis suspected
Constipation Do PR examination
Impacted stools – Dulcolax suppository
Need to rule out IO x2
Fleet enema x 2
Observe at least 3 hours.
Discharge if well with senna tablets and
syrup lactulose
If persistent constipation, do FBC, U/E,
29
AXR, admit CLR
BLEEDING GIT

If unstable vital signs, uptriage to P1
Upper GIT bleed NBM
FBC, U/E, GXM. PT/PTT, CXR
LFT if patient jaundiced
NG tube (if not variceal)
IV N/S, IV E-blood
IV omeprazole 80 mg
Consider infusion 8mg/hr
Consider early rv by GS Reg
Confirm past hx of variceal bleed/portal

Esophageal Varices hypertension
FBC, U/E, GXM. PT/PTT, LFT, CXR
IV N/S, IV E-blood
IV omeprazole 80 mg
IV somatostatin 250 microgram bolus,
followed by infusion of 250 microgram
per hour
Sengstaken-Blackmore tube if
exsanguinating hemorrhage after
discussion with DEM senior doctor
If unstable vital signs, uptriage to P1.

Lower GIT bleed NBM
FBC, U/E, GXM. PT/PTT, CXR
IV N/S, IV E-blood
Admit colorectal GW (stable)
Call colorectal Reg for HD if unstable
vital signs, profuse bleed
Normal PR exam
? BGIT [c/o Black stools] Normal abdominal examination
Stable vital signs
No postural BP drop
Normal Hb/FBC
Discharge with omeprazole 20mg BD
till TCU
TCU GS SOC (Call reg for early TCU)
Hemorrhoids on proctoscopic
PR bleeding (Hx of small amount of PR examination with no active bleeding
bleed with nil active bleeding) Stable Vitals with no postural drop
Stable Hemoglobin
Discharge with Tab Daflon 2 BD x 1
30
week and TCU Colorectal 1-2/7
ACUTE GASTRITIS/GERD
Mild to moderate symptoms IV or IM Buscopan 40mg

Oral H2 blockers eg. famotidine 20mg
Epigastric pain Magnesium trisilicate 30ml
Burping Consult senior for abdominal pain
Nausea/vomiting protocol if pain persists
Poor appetite Discharge with famotidine or
omeprazole and MMT and abdominal
Exclude life-threatening causes: Eg pain advise
AMI, perforated ulcer, pancreatitis, Memo to OPS for young patients and
aortic dissection, ruptured AAA, acute patient with infrequent symptoms
abdomen TCU Gastro if recurrent symptoms
Severe symptoms FBC, U/E, GXM. PT/PTT, CXR (erect)

ECG
Exclude life-threatening causes: Eg LFT if patient jaundiced
AMI, perforated ulcer, pancreatitis, Ultrasound to look for gall stones, AAA
aortic dissection, ruptured AAA, acute IV omeprazole 40 mg
abdomen Consult senior for EOW versus
gastro/GS admission
HEPATOBILIARY EMERGENCIES
Biliary Colic NBM

FBC, U/E, LFT, Amylase, CXR, ECG
Epigastric or RHC pain Ultrasound
Radiates to back Buscopan 40mg IM/IV
Worse after meals IM pethidine 50-75mg
Associated bloatedness, nausea,
vomiting If pain persistent, for admission to EOW
for abdominal pain protocol
KIV discharge with buscopan,

famotidine and TCU GS if pain free and
normal blood tests.
If blood tests abnormal, KIV consult

senior dr.
31
Acute Cholecystitis
NBM
Epigastric or RHC tendneress FBC, U/E, LFT, Amylase, Blood
Murphy’s sign cultures
CXR, ECG
Ultrasound
Buscopan 40mg IM/IV
IM pethidine 50-75mg
metronidazole 500mg
Consult DEM Snr Dr for GS admission
Cholangitis If unstable vital signs, uptriage to P1.

NBM
Charcot’s Triad: RHC pain + fever + FBC, U/E, LFT, Amylase, GXM.
obstructive jaundice PT/PTT, Blood cultures
CXR, ECG
IV N/S
buscopan 40mg IM/IV
metronidazole 500mg
Inotropes if septic shock
to HD/ICU
Hepatic encephalopathy
Liver disease with altered mental state Triage to P1

Signs of chronic liver disease: spider NBM
naevi, hepatic flap, gynecomastia Blood sugar
FBC, U/E, LFT, amylase, GXM,
PT/PTT, Blood cultures
CXR, ECG
KIV CT Brain
IV N/S
IV dextrose 50% 40mls for
hypoglycemia
IV thiamine 100mg if alcoholic liver
cirrhosis
NGT insertion (if no history of varices)
Lactulose 30ml PO/NG or lactulose
enema
IV omeprazole 40mg
Broad spectrum antibiotics
Admit gastroenterology and call Med
R1 for HD/ICU
32
PANCREATTIS
Epigastric or upper abdominal pain NBM

Radiates to back FBC, U/E, LFT, Amylase, Lipase,
Nausea/vomiting PT/PTT, GXM
fever CXR, ECG
Ultrasound
IV NS
IV omeprazole 40 mg
ISCHAEMIC BOWEL
abdominal pain out of proportion to NBM

physical findings FBC, U/E, LFT, Amylase, lactate,
+/- PR bleed PT/PTT, GXM
Atrial fibrillation on exmn and ECG ABG, CXR, ECG
Diabetics are at higher risk Ultrasound
IV NS
IV ceftriaxone 1gm and metronidazole
500mg
Urinary catheterization
ABDOMINAL AORTIC ANEURYSM (AAA)
Ruptured AAA Uptriage to P1

Monitor, supplemental O2
Abdominal mass, often pulsatile FBC, U/E, PT/PTT, GXM
Back pain ECG, CXR
Syncope Ultrasound – aortic diameter > 3cms
Arrange for CT Aortogram
Normotensive or hypotensive Control BP with IV labetalol 50mg/hr
Pulse deficits infusion
GS/Vascular ODD stat for HD
Risk factors: age, hypertension, admission and surgical v/s
smoking, vasculitis, connective tissue endovascular repair
disorders
Asymptomatic AAA US diameter < 5.5cm, incidental
33
No postural drop in BP, No PR bleed
Discharge with early outpatient
Vascular TCU (call GS Reg)
Abdominal pain is distressing to patients. Treating the pain does not mask, or obscure
the diagnosis. Prompt, sympathetic and proactive administration of analgesia often
helps in further decision making. Combination therapy is synergistic, if you are giving
intravenous morphine, Paracetamol will still be effective.
**Please refer to Protocol for Management of GS cases in DEM **
PROTOCOL FOR MANAGEMENT OF GS CASES IN DEPARTMENT OF

EMERGENCY MEDICINE
1. Straightforward GS admissions
DEM admits directly after DEM Senior Dr’s approval.
Senior doctors MUST personally see all patients with abdominal pain for admission to
GS. Registrars/Senior Residents who are unsure when assessing abdominal pain
(especially elderly, paediatrics, patients with constipation colic), please consult AC/Cs.
2. Indeterminate abdominal pain cases
To consult senior DEM doctor to put on abdominal pain protocol.
Female patients - KIV gynae consult and observe for about 8h for eg constipation colic
to await patient’s bowel opening before reviewing abdomen.
If still painful despite bowel opening -> CT abdo/ pelvis (CTAP). Please refer to CTAP
protocol
If CT AP verbal report abnormal, to admit to respective discipline as per pathology. If

CTAP normal, to trace official CTAP report before discharging patient. The patient may
need an early force-in GS TCU. The CTAP cost is charged under EOW charges which
can be paid by Medisave for Singaporeans/ permanent residents.
- GS registrar may be called for an opinion if despite seeking DEM senior Dr’s opinion,
doubt still exists about patient's disposition.
3. Ill cases
For haemodynamically stable, relatively well patients who need HD/ICA for eg acute
pancreatitis /perforated viscus
-> to admit directly to HD after approval by AC and above. GS registrar to be informed

by phone and SMS and told that patient is to be admitted to HD.
34
For unstable/ unwell patients like possible ischaemic bowel, to call GS registrar to
review at DEM and decide plan of management from DEM. It has been agreed with GS
HOD that the GS registrar has to come to DEM within 30min or even sooner.
4. Force-in GS TCUs – to seek approval from DEM senior before calling GS

Registrar on call.
Be conscientious with management of GS cases which may require catheterisation for

I/O monitoring, prompt IV antibiotics/IV omeprazole, NGT insertion, etc. for cases who
need them.
CT PROTOCOL/ WORKFLOW FOR ABD PAIN

Please tick in the blank boxes as applicable
Presents with abdominal pain

Take appropriate history and PE and perform necessary
investigations and management
NO
Is there a history of AAA
Perform blood
YES tests and
Xrays
Order CT Aortogram
FEMALE: Is UPT positive and suggestive of ectopic pregnancy or

pregnancy related condition?
FEMALE: Is there significant OBGYN hx eg. IUCD insertion, hx of ovarian
cyst or OBGYN hx with no GI cause or UTI symptoms
Does the blood test shows raised WBC and clinical picture indicates acute
appendicitis?
Do the X rays show intestinal obstruction or free air under the diaphragm or
any other radiological features to aid in diagnosis?
Does the bld test, Xrays and physical examination suggest the following
diagnosis:
- Acute pancreatitis
- Cholangitis
- Acute cholecystitis
- Intestinal obstruction
Perforated viscus as evident by free air under diaphragm
Does notonfulfill
Xray any
Fulfills one or
more the of the above
above
To admit to GS or call Does the bld test and physical examination suggest
for urgent GS consult the below:
- ischemic bowel as evident by a high lactate
or refer to OBGYN on - acute abdomen with unstable vital signs
call - acute abdomen with free fluid on US with no hx of
ascites
- acute abdomen despite medical treatment
Has the patient been admitted to EOW (refer to
Annex A) and observed for 8 hours and still have the
Arrange for following:
CT - worsening or persistent RIF pain
Abdo/Pelvis - senior
35 doctor review and now suggestive of
surgical abdomen in addition to having persistent
abdomen pain
Annex A
1. All EOW cases have to be vetted by senior doctors.
2. The EOW cases that are applicable in the above pathway applies mainly to patients with RIF
pain with normal WBC count and are initially indeterminate for appendicitis. Such cases are
to be placed in EOW and reviewed and treated periodically. If they have persistent or
worsening RIF pain despite treatment in EOW, they should have a CT Abd/pelvis
3. Other patients in EOW abdominal pain protocol that still have persistent pain but not a surgical
abdomen as reviewed by the senior on call is to be admitted for further investigation
4. If patients in point 3 however have been deemed as an acute abdomen after review by the
senior doctor on call should also have a CT abd/ pelvis ordered
Approved by DDR and DEM
36
HEMATOLOGY AND RHEUMATOLOGY
(Dr Oh Jen Jen / Dr Sohil Pothiawala)
ANAEMIA
Hb > 8 gm/dL FBC, U/E (high U/Cr ratio implying

acute BGIT, R/O renal impairment as
Rule out: cause) ECG
- Bleeding GIT If hypo/micro – iron tablets (could still
- Menorrhagia be thalassemia)
- Functional decline If Hyper/macro – folate deficiency
(could still be B12)
Asymptomatic
Discharge with Iron tablets
TCU DIM and memo for OPS for f/u
If bleeding GIT (upper), ODD GS

If bleeding GIT (lower), admit colorectal
If menorrhagia, ODD Gyn
Unknown cause but patient
symptomatic, admit DIM
NMB and GXM.
Hb < 8 gm/DL FBC, U/E, PT/PTT, GXM

ECG, CXR
Admit DIM for blood transfusion
If identifiable etiology, admit
accordingly
37
THROMBOCYTOPENIA
- Rule out dengue fever/viral infections FBC, U/E

- Look for bleeding tendencies UC9, CXR, joint x-ray if haemarthrosis
(rash/purpura, gum bleeding, epistaxis,
menorrhagia, haemarthrosis) Asymptomatic and platelet count 80-
139 x 109/L
Discharge with TCU Hematology 1-2/52
and KIV call hematology reg
If platelet count < 80 x 109/L and/or

bleeding tendencies, admit DIM with
inpatient hematology consult
HEMOPHILIA A
Hemarthrosis, bruising, hematuria, Factor VIII replacement:

epistaxis, ICH, muscle hematoma
Contact Hematology registrar for
dosage required
Each U/kg of Factor VIII raises its

levels by 2%
Units of factor VIII required = weight

(kg) x 0.5 x ( % activity desired - %
intrinsic activity)
Discharge v/s admit patient based on

hematology registrar’s advice
38
MANAGEMENT OF OVER- ANTICOAGULATION WITH WARFARIN
No Significant bleeding or low

bleeding risk
INR 4 - 5 Withhold warfarin and check INR after

24 hours
INR 5 - 9 Omit next 1-2 doses and check INR

after 24 hours
Alternatively, give Vitamin K 1-3mg PO
INR > 9 Omit warfarin and give Vitamin K 3-

5mg PO
Recheck INR after 6 hours then daily
for 3 days
Severe bleeding
a. Intravenous 4-factor PCC
INR > 1.5 (Prothromplex) at a starting dose
20-25 iu/kg (needs Haematology
approval)
b. Intravenous Vit K of 5-10 mg
Search for “Warfarin Therapy Guide” on Infonet.
39
APPROACH TO SUSPECTED DVT
Well’s Criteria for DVT
Use: Calculates risk of DVT.
The model should be applied only after a history and physical suggests that venous
thromboembolism is a diagnostic possibility. It should not be applied to all patients with
chest pain or dyspnea or to all patients with leg pain or swelling
No Clinical Characteristics Score

.
Active Cancer (Ongoing treatment or within previous 6/12 or
1 1
palliative)
2 Paralysis, paresis or recent Plaster of the lower limb within 4/52 1
Recently bedridden  3/7

3 1
Major Surgery within 4 /52
4 Localized tenderness along distribution of the deep venous system 1
Swelling of the entire leg

5 1
( not just ankle)
Calf swelling >3cm larger than other limb (at 10cm below tibial
6 1
tuberosity)
7 Pitting edema confined to the symptomatic limb 1
8 Collateral superficial veins (non-varicose) 1
9 Previously documented DVT 1
10 Alternative Dx at least as likely as DVT -2
-2 to 1 score: Low risk group for DVT: ‘Unlikely’ according to Well’s DVT studies.
2 and above: High risk group for DVT: ‘Likely’ according to Well’s DVT studies.
A score of 1 or less is determined as low pretest probability,

A score of 2 or more is determined as high pretest probability.
40
INVESTIGATION
A D dimer should also be done in conjunction with the above. D dimer has high
specificity but low sensitivity. The D dimer is read in conjunction with the Well’s criteria.
It will result in the following combinations:
Well’s D dimer Interpretation/Action Duplex results

criteria
for DVT Negative Positive
Low Negative DVT can be ruled out N.A N.A

Probability and no further action
is needed
Positive Duplex of the leg will Look for Treat for

need to be arranged other DVT
causes
of LL
swelling
High Negative Duplex will need to be Follow- Treat as
Probability arranged, no need to up scan for DVT
Positive await for d dimer is
needed,
DVT
cannot
be rule
out
TREATMENT
If able to obtain scan on the same day, await scan results.

- if scan is positive, consult senior doctor for admission to hematology for
anticoagulation.
- if scan negative in low probability patient, look for other causes of leg swelling
- if scan negative in patients with high probability and d dimer negative, look for other
causes of DVT
- if scan negative in patients with high probability and d dimer positive, to arrange for
early hematology TCU and KIV repeat scan
If unable to perform scan on the same day,

- If D-dimer positive, admit patient to DIM for DVT scan
- If D-dimer negative, look for other causes of LL swelling
41
Special Circumstances
All pregnant patients with DVT should be referred to O&G for further management.
Contraindications to Clexane:
- Contraindications to discharge and /or use of Clexane
 Comorbidities requiring hospital management
 Bleeding risk:
Active bleeding
High risk of bleeding, including

 Recent Haemorrhage within 3/52
 Recent Major Trauma within 3/52
Underlying coagulopathy or cytopenia
 Allergy to heparins
 Renal impairment: Creatinine Clearance < 30 ml/min
Please use Cockroft Gault Formula for Cr Cl:

Cr Cl = (140 - age) X weight (in kilograms)/ 812 X SCr (in mmol/L)
 Extensive DVT with potential for phlegmasia cerulea dolens

 Necessity for parenteral narcotics for pain control
 Inability to have injections administered at home
All above patients should not be discharged and should be considered for admission.
PLEASE CONSULT SENIOR DOCTORS BEFORE STARTING CLEXANE OR THOSE

WITH SPECIAL CIRCUMSTANCES
42
GOUT
- Sudden onset of pain, swelling and FBC, U/E, uric acid

inflammation in joint (esp 1st MTP joint) KIV joint x-ray
- Hx of gout or Gouty tophi
- Polyarticular arthritis in 10% patients Acute attack: NSAIDs, Colchicine
0.5mg
Re NSAIDs: check if baseline creatinine

available, AVOID if patient has h/o
renal impairment or Creatinine done in
ED found to be elevated.
Alternative: Opioids(codeine/tramadol)
If symptoms improve and able to

ambulate, discharge with
NSAIDs/opioids and colchicine and
memo for GP/OPS review 1/52 and KIV
TCU rheumatology next available date
(Note: Do not prescribe allopurinol at

discharge to patients not on that
medication, but it should be continued
at regular dose in those already on it)
Consider suitability for gout protocol

and consult senior doctor eg. 1-2 joint
involvement, no other indication for
inpatient admission
If persistent pain despite protocol or

poor social support, admit
rheumatology
Gout dietary advice: avoid alcohol, soy-

rich foods, etc
43
METABOLIC & ENDOCRINE
(Prof Anantharaman / Dr Sohil Pothiwala)
HYPERKALEMIA
Mild FBC, U/E, ECG, VBG
K: 5 -5.5mmol/L Can be discharged with syrup

ECG: normal to tall tented T waves Resonium PO 15gm TDS x 3 days
TCU OPS/GP 3/7 to re-check K level
Moderate FBC, U/E, ECG, VBG, CXR
K: 5.5 – 6.5mmol/L IV Insulin-Dextrose – 10units actrapid

ECG: tall tented T waves, prolonged insulin + 40mls of 50% Dextrose
PR, absent P
Syrup Resonium 15gm PO
Admit DIM
Admit renal if missed dialysis
Severe FBC, U/E, ECG, VBG, CXR
K: > 6.5mmol/L IV 10% calcium gluconate 10ml, can

ECG: QRS widening, junctional rhythm, repeat if necessary
sine wave, PEA, any other
dysrythmmias IV Insulin-Dextrose – 10units actrapid
insulin and 40mls 50% Dextrose
PO Resonium 15gm stat or PR

resonium enema
IV sodium bicarbonate 1mEq/kg if

severe
Salbutamol nebulization
Hemodialysis
CPR if cardiac arrest
Call R1/ MICU registrar or renal reg:
Admit HD/ICA/MICU
44
HYPOKALEMIA
Mild FBC, U/E, ECG, VBG
Weakness, lethargy, symptoms of Can be discharged with Syrup

precipitating cause (e.g. GE) Potassium Chloride 5ml TDS x 3 days
K: 3 -3.5mmol/L TCU OPS/GP 3/7 to re-check K level
ECG: normal to flattened T waves
Moderate FBC, U/E, ECG, VBG, CXR
Weakness IV KCl 10mEq/hr

K: 2.5 – 3mmol/L
ECG: U wave, non specific ST-T Admit DIM GW early review
changes
Severe FBC, U/E, Mg, PO4

ECG, VBG, CXR
Hypokalemic periodic paralysis
IV KCL 10-20 mEq/hr
K: < 2.5mmol/L
IV Magnesium Sulphate 2gm slow IV
ECG: Prolonged QTc, dysrhythmias infusion if Mg level low or resistant to K
replacement
Admit DIM GW early review, KIV Call

R1/ MICU registrar for HD/ICA
45
HYPONATREMIA
Mild to moderate FBC, U/E, ECG, VBG

Na: 121-135 mEq/L
Hypovolemic: rehydration with IV NS
Weakness, lethargy, symptoms of slowly
precipitating cause (e.g. GE, heart Euvolemic (SIADH): free water
failure, DKA) restriction
Hypervolemic (heart and renal failure):
water restriction, diuretics, dialysis
Pseudohyponatremia: falsely low
reading due to other osmolar particles
(eg hyperglycemia,
hypertriglyceridemia)
Admit DIM GW
Severe FBC, U/E, ECG, VBG, CXR
Na <120 mEq/L IV diazepam 5mg to control seizures
Symptoms as above + Altered Mental state 3% Hypertonic saline 1-2ml/kg (100ml)

including coma, seizures over 10 minutes after discussion with
senior doctor
Admit DIM, Call R1/ MICU registrar for

HD/ICA
Note: Risk of Central Pontine Myelinolysis with Hypertonic Saline
46
HYPOGLYCEMIA
Blood Sugar <3 mmol/L Monitor, supplemental O2

Bedside blood sugar
Behaviour: lethargic, irritable FBC, U/E, ECG, VBG
Decreased conscious level
Focal neurologic deficits Conscious and cooperative patient:
seizures glucose rich drink (milo)
Unconscious: IV 50% dextrose 40mls

followed by 10% dextrose drip over 4
hours
Recheck blood sugar in 15 minutes
Admit hypoglycemia protocol if patient

alert and hypoglycemia due to missed
meal
Admit DIM GW if persistent AMS,

patient on sulphonylureas, underlying
etiology or comorbidities
Admit Endocrine if persistent

hypoglycemia despite treatment,
overdose of sulfonylureas, ingestion of
power walnut
47
DIABETIC KETOACIDOSIS
Uptriage to P1
Diagnostic criteria: Monitor, supplemental O2
- Blood glucose > 14mmol/l Bedside blood sugar
- PH <7.3, HCO3 < 15mmol/l FBC, U/E, ABG,
- Ketonemia (serum ketones > 1) or Serum ketones (if no ketonuria or
ketonuria (urine ketones > 2+) inability to pass urine)
UC9, ECG
Blood cultures if sepsis
IV fluids (see table below)
Insulin infusion
- 5units/hr (0.1unit/kg/hr)
- Hourly blood sugar monitoring
- Slow infusion dose but maintain infusion
till acidosis clears
Electrolyte management
- If K > 5, recheck every 2 hrs
- K 3.3-4.9, IV KCl 10mEq/hr if urine
output
- K <3.3, IV KCl 20 mEq/hr
- Sodium bicarbonate only if PH < 7
(8.4%NaHCO3 50mls over 1 hr)
-
IV Antibiotics if sepsis
Treatment of the underlying cause
Admit Endocrine. Call Med R1/MICU

registrar for ICA/ICU bed
100-200ml/kg Na < 145

Correct over 24- Dextrose - saline
0.9% NS Na < 145
48hrs* Until glucose <= 14
mmol/L
5% Dextrose
0.45% NS
Na > 145 Na > 145

Hyperosmolar Hyperglycemic Non-ketotic state (HHNK)
*Infuse 1-1.5 litres of NS over the first hour. Subsequent rate depends on parameters and clinical state
48
HYPEROSMOLAR HYPERGLYCEMIC NON-KETOTIC STATE (HHNK)
Uptriage to P1
Diagnostic criteria: Monitor, supplemental O2
- Blood glucose > 33mmol/l Bedside blood sugar
- pH > 7.3, HCO3 >15mmol/L FBC, U/E, ABG,
- Absence of ketonemia or ketonuria Serum ketones (if no ketonuria or
- Serum Osmolality >320 mOsm/kg inability to pass urine)
UC9, ECG
Serum osmolality = 2 x Na + glucose + Blood cultures if sepsis
urea (normal 280-290 mOsm)
IV fluids (similar to DKA)
Insulin infusion
- 5units/hr (0.1unit/kg/hr)
- Hourly blood sugar monitoring
- Titrate infusion to keep glucose 14-16
mmol/L until serum osmolality
<315mOsm and patient mentally alert
Electrolyte management
- If K > 5, recheck every 2 hrs
- K 3.3-4.9, IV KCl 10mEq per litre of IV
fluid if urine output
- K <3.3, IV KCl 20 mEq/hr
- Sodium bicarbonate only if PH < 7
(8.4%NaHCO3 50mls over 1 hr)
-
Treatment of the underlying cause
Admit Endocrine. Call Med R1/MICU

reg for ICA bed
49
HYPERTHYROIDISM

FBC, U/E, FT4, TSH
Thyrotoxicosis ECG, CXR
Palpitations, tremors, agitation, B-blocker: Propranolol 20mg PO stat

anxiety, weight loss, heat Antithyroid: Carbimazole 20mg PO stat
intolerance, menstrual irregularity,
goiter, thyroid eye disease (eg. Observe in telemetry if patient in AF/sinus
Proptosis, exophthalmos, lid tachycardia
retraction)
If tachycardia resolves and stable vital signs,
ECG shows sinus tachycardia/AF dc with propranolol 20mg TDS and
carbimazole 30mg OM. Memo for OPS in 1-2
weeks for f/u
If persistent tachycardia/AF or heart failure,

discuss with senior doctor for admission to
endocrinology
Uptriage to P1
Thyroid Storm Monitor, supplemental O2
FBC, U/E, FT4, TSH, cardiac markers and
All of above BNP, LFT,
Altered mental state ECG, ABG, CXR, UC9
Fast AF and CCF Blood cultures if underlying sepsis
Underlying sepsis
B-blocker: Propranolol 20mg TDS (C/I: if
Burch-Wartofsky Score 45 or more patient in CCF or hypotensive)
Antithyroid: Propylthiouracil (PTU) 400mg PO
stat, followed by 200mg 6 hrly
IV hydrocortisone 100mg and q 6hrly

Lugol’s iodine 15ml TDS PO atleast 1-2 hrs after
PTU (alternatively IV sodium iodide 1g 12hrly
diluted in NS can be used if patient not in failure
may be preferred as a more direct administration
of iodine, also given at least an hour after PTU).
Paracetamol 1gm PO stat if fever and q 6hrly

(avoid aspirin)
IV NS judiciously
Intubation if respiratory failure
Consult endocrine reg on-call if needed

Call Med R1/MICU reg for ICA/ICU bed
50
NEUROLOGY
(A/P Fatimah / Dr Kenneth Tan)
CEREBROVASCULAR ACCIDENT
51
Management of Strokes Presenting Outside of RTPA Window
(For Contraindications to RTPA: available from SGH Intranet > Department of

Neurology)
Manage in P2 area.
Bloods: FBC, U/E/Cr, PT/PTT, GXM, capillary blood glucose
Others: ECG, CT Brain
If not bleed on CT or decision not for thrombolysis: PO or S/L Aspirin 300mg if no

contraindications
Admit to Stroke Holding Area.
TRANSIENT ISCHAEMIC ATTACK
ABCD2 Score for TIA
Use: Estimate the risk of stroke after a TIA.

Age ≥ 60 Yes +1
BP ≥ 140/90 Yes +1
Clinical Features Unilateral weakness +2
Speech disturbance without +1
weakness
Other symptoms 0
Duration of symptoms ≥ 60 minutes +2
10-59 minutes +1
<10 minutes 0
Diabetes Mellitus Yes +1
0 to 3: Low – 2-day stroke risk 1.0%, 7-day stroke risk 1.2%, 90-day stroke risk 3.1%
4 to 5: Moderate – 2-day stroke risk 4.1%, 7-day stroke risk 5.9%, 90-day stroke risk
9.8%
6 to 7: High – 2-day stroke risk 8.1%, 7-day stroke risk 11.7%, 90-day stroke risk 17.8%
ED Management
Investigations are the same as for CVA

Load PO Aspirin 300mg if no contraindications
Admit to Stroke Holding Area for further workup.
52
INTRACRANIAL HEMORRHAGE (ICH)
Patient presenting with
- Stroke like symptoms

- Worst headache of their lives with other features like sudden in onset
and thunderclap headache
- Drowsiness, altered mental state
- Head injury that fulfills Canadian CT head rule for scan
All such individuals should have a CT brain. Please consult a senior

doctor.
Proper physical examination and history taking with particular note of

anticoagulation should be taken
CT brain -ve for

bleed
Treatment as for other
causes
CT brain +ve for bleed
Management:
- Manage patient in resus

- Contact NES
- Ensure FBC, renal panel, PT/PTT, GXM done
- If patient on warfarin, to give IV Vitamin K and arrange for 4 Factor PCC
- Control BP. If BP high, KIV start IV labetalol or oral anti HTN
- IV mannitol if there are clinical signs or radiological evidence of raised ICP
- Discuss with NES about starting anti-epileptics
- Catheterize patient
- If GCS< 8, intubate patient for airway protection
- Ensure patient’s bed is raised at a 30 degree head up position
53
GIDDINESS Patient presenting with giddiness
Determine:
- Vertiginous vs non vertiginous
- ? chest pain or palpitations
- Any infective symptoms
- Any PR bleeding or melena
- Whether it is postural in nature
- Any head injury
- Any change in medication
- Past medical hx
VERTIGO NON VERTIGINOUS GIDDINESS
1. ?a/w tinnitus Look for other causes

2. ?worse with head movement
3. ?recent URTI ECG, H/C, FBC renal panel, Trop T
4. ?any unsteady gait
Thorough physical examination. Postural BP.
5. ?any neurological symptoms
6. ?any diplopia DDX:
Giddiness secondary to cardiac cause
Ensure ECG and H/C normal BGIT
Metabolic disturbances, eg. hyponatremia, hypoglycemia
Neuro exam may reveal multidirectional Non- specific symptoms
nystagmus and cerebellar signs
Vertigo of peripheral origin:
BPPV or vestibular neuronitis
Usually has above features 1, 2, 3
Neuro exam normal but can have

unidirectional nystagmus
Treatment:
Vertigo of central origin:
Give IV/IM stemetil
May have all 6 features but have
positive neurological IV hydration
examination
Ensure appropriate bloods done
Ensure routine bloods done and
arrange for CT brain If bloods normal, can observe till better and discharge ENT/OPS.
Supervising senior can also admit patient under EOW giddiness
Administer symptomatic protocol
treatement
If bloods abnormal, eg hyponatremia, admit to appropriate discipline
Admit to neuro if CT brain NAD
If patient still symptomatic after protocol, KIV CT brain with admission
If CT brain +ve ie. mass or ICH to medical or admit to DIM depending on supervising senior’s clinical
refer NES judgement
Fall precautions
54
SEIZURES
Confirm seizures from witness or patient.

Ask for any past hx of seizures
All actively seizing patients are to be treated in
resus, administer up to 10mg of IV diazepam
(can repeat another dose) to abort
Caution: drop in BP or RR
Known hx of
1st episode of seizures
seizures
If known seizures, assess for compliance to meds and triggering factors
Look for other causes of seizures, eg:

Cardiac cause- ECG, hx Toxicology causes Movement disorders
Hypoglycemia- check h/c CNS infections Tremors
Assess suitability for EOW seizures

No further protocol
seizures No further
Those with known seizures check drug seizures
level if applicable, kiv increase drug
dose
If no more seizures, discharge with

early TCU neuro
Still seizing can use up to total of 20mg IV

diazepam
Still If still persistent seizures, consider and treat as for Still

seizing status epilepticus seizing
Start IV phenytoin or IV phenobarbitone, KIV
intubate if needed, arrange for monitored bed or
ICU
55
HEADACHE
Red flags:
- Worst headache of life, different from previous

headaches/ migraines episodes
- Neck stiffness
- Photophobia
- fever
- Thunderclap, acute in onset
- a/w profused vomiting
- a/w drowsiness
- a/w neurological deficits
- trauma with clinical signs of skull fractures or
BOS #
Red flag present

Red flag
absent
CT brain
Treat symptomatically with IM stemetil or CT brain
maxalon. Can add on NSAIDs if needed CT brain positive
negative
Observe patient for 2-3 hrs
If pain has subsided, discharged with stemetil

and NSAIDs/ codeine and OPS apt CT brain Admit to
negative appropriate
Please ensure NSAIDs are not contraindicated Admit to discipline
DIM depending on CT
If pain has not subsided despite analgesia, for IM findings
pethidine and KIV CT scan depending on senior
doctor’s review and clinical impression
If for further observation, observe another 2 hrs
If still symptomatically not better, for CT brain

CT brain positive
Note:
Please also take note of any eye symptoms
Glaucoma can present with headaches as well. If there is

Headache has subsided
decreased vision and unilateral eye redness, please refer to
eye to rule out glaucoma
Temporal arteritis:
Usually presents with eye symptoms as well. However physical
Discharge with stemetil examination might reveal tenderness at the temporal region
/maxalon and appropriate with thickened arteries. It is a sight threatening condition and
analgesia the rheumatology registrar on duty must be informed to start
early treatment if suspected
TCU OPS/ DIM with advice to
return if pain occurs
56
OBSTETRICS AND GYNAECOLOGY
CONDITIONS TO BE REFERRED TO O&G FROM ED
1. Hyperemesis with positive urine ketones

2. Threatened/missed/evitable/incomplete abortion
3. TRO Ectopic pregnancy
4. Pregnancy related issues after 28 weeks e.g. pre-eclampsia
5. Pregnant women with abdominal pain, bleeding or gastrointestinal symptoms
6. Symptomatic anaemia or unstable vital signs sec to menorrhagia or PV bleed (with or
without ongoing PV bleed)
7. Pain sec to ovarian cyst accident
8. RIF pain sec to pelvic inflammatory disease
9. Trauma in Pregnancy
10. Pulmonary embolism in Pregnancy. (Pulmonary embolism in gynaecological
oncology should be admitted to the medical ward).
Stable conditions that should be referred to gynaecological clinic during office hours
or the next morning (no need to call for appointment) with DEM referral letter:
1. Ovarian cyst with minimal or no pain
2. Worried patients with mild PV bleed or other gynaecological complaints.
Stable conditions with referral to gynaecology clinic in 2 weeks

1. Asymptomatic patients with PV bleed – to start NE 5 mg tds x 1 week first (KIV
preceded by IM progesterone 100 mg stat)
2. Other non-urgent gynaecological problems.
Approved by Dr Evelyn Wong (DEM) and Dr Tan Hak Koon (O&G) on 30 Sept 2013
Annex A
1. All unstable O&G patients will be seen by the O&G team in the resuscitation room.
2. Stable patients will be sent to the labour ward for assessment during office hours (8
am to 5 pm), and in DEM Consultation Room A5 after office hours.
3. Pregnant patients above 24 weeks should be directed to the labour ward for
assessment.
4. A designated ultrasound machine from the O&G Centre would be brought to the
DEM for use after office hours
o The O&G Centre is responsible for transferring the machine from O&G Centre to
DEM at 5 pm every weekday (Sister Janet Khoo to arrange).
o The DEM is responsible for transferring the machine from DEM to O&G Centre at 8
am every weekday (Sister Ho Soo Ling to arrange).
o The machine will be left in the DEM over weekends or public holidays as it will not be
needed at the O&G Centre.
o The O&G Centre and DEM are separately responsible for keeping a movement log of
the ultrasound machine (Sisters Janet Khoo and Ho Soo Ling to note).
57
5. Referral of female patients with abdominal pain to OBGYN
 If the DEM clinical impression was that of appendicitis, the patient should be admitted
to General Surgery or reviewed first by the general surgical team. Should the
general surgeon think that it is clinically appropriate for the patient to be
assessed by O&G before admission, it is the responsibility of the surgeon (and
not the DEM doctor) to call the O&G team for review after he has reviewed the
patient.
 When a woman requires admission for management of abdominal pain but the
clinical suspicion of an O&G cause is low (e.g pain in the upper abdomen, significant
gastrointestinal or urinary symptoms), DEM is advised to admit the patient to the most
appropriate specialty with inpatient referral if necessary
 Non- urgent cases (e.g vaginal discharge without abdominal pain, chronic pelvic pain)
that present after office hours should be given an outpatient appointment. TCUs on
the following day can be arranged if clinically indicated.
 It is not encouraged to refer to OBGYN for routine US of female abdominal pain.
As agreed upon by A/P Tan Hak Khoon and Dr Evelyn Wong (13 October 2014)
EMERGENCY CONTRACEPTION
For ALL patients:
• Reinforce contraceptive methods – long term (e.g. IUD, OCP) vs short term (e.g.
condoms)
• Do UPT in ED and advice it to be repeated during the time that the period is due
Less than 72 hours post coitus:
 PO Levonorgestrel 1.5mg ONCE – S$3.74 (before GST)
Between 72 to 120 hours (5 days):
 PO Ulipristal (Ella) 30mg ONCE – S$33.33 (before GST)
Side effects for both include: nausea and vomiting, bloatedness, delayed menses
(sometimes more than 7 days later than expected)
Absolute contraindication: porphyria. Higher doses might be needed in patients on

drugs such as phenytoin, carbamazepine, rifampicin.
Beyond 5 days:
Refer to O&G for IUD insertion
58
ONCOLOGY
(Dr Kenneth Tan / Dr Juliana Poh)
FEVER IN ONCOLOGY PATIENTS
Fever in an oncology patient

Ask history for source of fever,
Date of last chemotherapy (risk of
neutropenic sepsis increases around D7 to
D10)
Physical examination to look for

source of sepsis (skin, chest,
abdomen, urine)
Perform necessary
investigations notably FBC
ANC>0.5 and
patient well (for
discharge with no
source)
ANC<0.5 ANC>0.5 but
needs
admission
NEUTROPENIC SEPSIS TREAT AS FOR CAN BE TREATED

SEPSIS OR SOURCE OUTPATIENT
OF INFECTION
 Ensure blood c/s is done.  Ensure blood c/s  Consider outpatient

Minimise unnecessary done. Start IV treatment if patient and
procedures for pt. cefepime 2g. If allergic family agreeable and
 No PR examination to penicillin to follow patient clinically well
 Start IV cefepime 2g, if as recommended by  If unsure, please
allergic to penicillin to antibiotic guideline consult senior doctor
follow as recommended  Fluid resus if patient is  Discharge with oral
by antibiotics guideline hypotensive, pls refer antibiotics
 Fluid resus if patient is to septic shock  Advice to proceed to
hypotensive, pls refer to guideline walk in oncology clinic
septic shock guideline  Admit to oncology GW next day or to contact
 Arrange for isolation bed early review their respective
or single room for oncologist for early
admission appointment
 Advise to return if
unwell
59
SPINAL CORD COMPRESSION
Patient can present with

- Back pain
- ARU or fecal incontinence
- LL weakness or numbness with sensory level
- Important history of cancer and site of any
metastasis
Physical examination can have findings of

- sensory level
- bilateral LL weakness
- poor or no anal tone
- distended bladder
- spinal tenderness
Investigations:
Spinal X-rays may reveal compressions fractures,
winking owl sign, osteopenic vertebrae
- If suspected spinal cord compression, patient to be

referred to either orthopaedics or neurosurgery.
- Definitive management would include either RT or spinal

surgery. Palliative treatment to improve quality of life
- Start IV dexamethasone 8mg and IV losec to decrease

spinal edema from spinal metastasis
- If not for orthopaedics/ NES admission, admit to med

oncology
60
PERICARDIAL EFFUSION
History Physical examination Investigations
- present with SOB - muffled heart sounds - CXR can show globular
- chest pain - distended neck veins heart +/- pleural
- previous hx of - hypotension effusions
metastasis to lung, *the above 3 makes up - ECG shows low voltages
pericardium Beck’s triad or electrical alternans
- normal lung sounds - Bedside US shows
- can also be associated pericardial effusion +/-
with pleural effusions signs of tamponade
- pulsus paradoxus
Treatment
- Start iv fluids aggressively
- Contact CVM/ CTS for urgent
pericardiocentesis or pericardial
window
- If patient has cardiac arrest,
pericardiocentesis can be performed by
ED physician
HYPERCALCEMIA
Oncology patients can present with complications of hypercalcemia. Hypercalcemia

is usually due to paraneoplastic effects or bony metastasis.
Patients can present with
- altered mental state
- abdominal pain
- severe dehydration secondary to polyuria, polydipsia
- generalized bodyaches
Investigations include routine bloods as well as calcium levels and ECG. ECG may
show shortened QT interval and narrow QRS complex.
Mainstay of treatment is fluid resuscitation. IV bisphosphonates are given in the ward.
Iv Lasix or diuresis is also attempted when the patient has reached euvolemic state.
61
SUPERIOR VENA CAVA SYNDROME
Previously considered as an oncological emergency, it is now considered at most an

oncological urgency. This condition usually presents in patients with invasion of SVC or
compression, commonly in Pancoast tumors.
Patients with SVCO can present with
- shortness of breath
- facial swelling and congestion
- upper limb swelling
Treatment in the ED is supportive in nature with oxygen. Recent papers showed that
dexamethasone does not show significant improvement. Definitive treatment includes
stenting of SVC or radiotherapy.
TUMORLYSIS SYNDROME
This normally occurs after chemotherapy and in patients of lymphoproliferative disease

or high tumor load. This condition can present in a wide spectrum of presentations and
should be considered in the above cases.
To diagnose the above, the following blood tests should be done
- renal panel, hyperkalemia and ARF
- phosphate level, hyperphosphatemia
- calcium level, hypocalcemia
- uric acid, hyperuricemia
Treatment of the above will include

- IV fluids
- Treatment of hyperkalemia
- Allopurinol, usually started in the ward
- KIV dialysis
62
ORTHOPAEDICS
(Dr Jean Lee / Dr Cheah Si Oon)
GENERAL ORTHO INFORMATION

1. Ortho patients managed by DEM doctor who requires Ortho Admission or fast track
Ortho TCU(3 days): such cases must first be approved by the DEM senior doctors.
2. X-rays should include the joint above and below the fracture site.
Recommended workflow when seeing Orthopaedics cases
A. Admissions
All ortho cases for admission MUST go through the approval of the DEM senior Dr. If
DEM senior is unsure of management of the ortho condition, he/she or the DEM MO
may then call the Ortho Registrar for advice as to whether admission is required.
Unstable Medical patients with fractures eg severe pneumonia, septic shock etc should
be admitted to the medical units.
For urgent admission cases of eg open fractures/necrotizing fasciitis, the ortho ward MO
should be called.
Patients with multiple stable medical comorbidities with concomitant fractures should
still be admitted to ortho.
B. One week force- in appointments to SOC Trauma / Fracture Clinic

(As of 2016, the trauma/fracture clinic appointments are all now 3 days)
Only limb fractures and dislocations are to be seen in the FRACTURE/DISLOCATION

ortho CLINICS. Do not put ankle or knee contusions, backaches or lacerations there.
- For Weber B ankle fractures, please call ortho reg on-call to see whether they
want patient to be admitted or to TCU fracture clinic.
- Compression fractures of the spine may be given fracture/dislocation clinic TCU.
- Distal wrist fractures requiring ORIF may now be ODDed to hand surgery for
admission and management.
Only patients with fractures/dislocations are to be given hospitalization leave of 10 days

to cover until fracture clinic TCU.
C. Fast track Clinic
Ortho Dept has initiated a fast track fracture/dislocation SOC clinic (3-4 days) for
traumatic fractures which do not need immediate admission but require very
early TCU. This has been scheduled to be 5 slots a day. DEM MO must again get the
approval of DEM senior before slotting such a case into a fast track clinic.
63
Please ensure you advise patient to elevate the limb as much as possible to prevent
gross swelling of fractured limb.
D. Podiatry clinic
Patients with ingrown toenails and paronychia, leg wounds requiring reviews may be
referred to podiatry clinic during office hours (Mon to Fri 8 am to 5pm, Sat 8 am to 1pm).
Please call Ms Sophie at 81256460 to inform her of such a case. She might come to the
ED to provide free consult and recommendations. After office hours, the patient can be
referred to the podiatry clinic on the next working day.
E. Appointments for non-trauma ortho patients
For non-trauma patients with back pain/OA knee, please give early physio TCU AND
spine/knee ortho TCU respectively as well, following the queue. If the physiotherapist
deems that the patient needs an earlier spine TCU, they will arrange with the spine
surgeon for an early TCU. These cases are NOT to be slotted into fracture/dislocation
clinic TCU just so as to see ortho early.
If the patient has seen multiple GPs/A&Es for the problem and truly needs an earlier
ortho TCU, please speak to appointment clerk and they will see if they can slot into a
general ortho clinic. Continue to give early physio appts to these pts.
If an early doctor review is needed, you may consider referring to the Chinatown
Singhealth Family Clinic.
For cases where knee aspiration has been done and pt discharged, the pt will be given
an early ortho TCU (within 1/52) to the general ortho clinic.
Other remarks
DEM seniors are to vet ortho admissions, force-in appointments and one week fracture
clinic appointments to ensure appropriate admissions and referrals.
Patients with sciatica should be advised that the pain may last for 4-6 weeks and seeing
an orthopaedic surgeon is only with a view for surgical intervention. Meanwhile bed rest
and hospitalization MC (1-2 weeks by putting the patient on the EOW back pain protocol
first) may be warranted. For the elderly with compression fractures and failed Back
Pain protocol after 12h, admission to ortho is advised for KIV vertebroplasty. For other
forms of non-traumatic back pain without any neurological signs/symptoms, admission
to ortho is strongly discouraged and if admission is for social reasons, one may consider
DIM or SKH (AH) instead.
64
UPPER LIMB FRACTURE WITH OR WITHOUT DISLOCATION
Triage Condition Investigations ED Disposition Special

Cat. Management Note
General Principles
Open Xrays AP+ IM ATT Consult
Fractures Lateral Analgesia DEM Snr Dr Try to
or Bloods incl IV Cefazolin to admit align limb
Penetratin GXM 2gm Ortho in long
g injuries IV Inform axis
clindamycin ORTHO stat
600mg ( if
penicillin
allergy)
Haemostasis
and wound
dressing
Extensive Xrays only if IM ATT TCU OPS Deep,

Abrasions bony injury / Analgesia for dressing contamin
Foreign body Wound change/insp ated
suspected dressing ection wounds
may
require
inpatient
care.
Advise
those that
are
discharge
d to look
out for
infection.
Laceration Xray to IM ATT Admit ortho Deep,

s with cut exclude Analgesia or ODD contamin
tendons, foreign bodies IV cefozolin Hand ated
possible Surgery for wounds
joint admission. may
involveme require
nt or inpatient
complicate care.
d deep Advise
wounds(eg those that
breech of are
underlying discharge
fascia) d to look
out for
infection.
65
Clavicle
3 Fracture X ray clavicle Analgesia; TCU Fracture # Clavicle:

Clavicle / AP & Zanca Broad arm Clinic 1/52 For ortho
Acromio- sling admission
clavicular only if
Joint fracture is
(ACJ) comminuted
injury AND
presence of
tenting of
skin
Comminutio
n does not
need
admission
but lung
contusion
does.
Shoulder
Scapular Xrays Analgesia ; Isolated Fracture- High energy

fracture Shoulder AP Broad arm TCU Fracture injury –
with scapular Sling Clinic 1/52 MUST look
lateral view Associated injury- for assoc
consult GS intra-
thoracic/che
st wall
injuries
Shoulder Xrays -M&R under -Collar and cuff Consult
Dislocatio shoulder AP+ conscious - TCU Fracture DEM Senior
n y- scapular sedation in Clinic 2/52 Dr for
view resus room guidance
Fracture AP/Lat view Collar and Fracture- Look for

Proximal/ Humerus Cuff dislocation or 4- other distal
Surgical Analgesia part # - consult injuries and
Neck DEM Snr Dr to check
admit Ortho. neurovascul
Minimal ar status
displacement -
TCU fracture clinic
1/52
66
Humerus
3 Fracture AP/Lat view U Slab with TCU Fracture

Humerus Humerus sling to support Clinic 1/52
forearm Vascular
and check compromise
neurovascular needs to be
status after admitted,
Radial N ortho and
injury( wrist vascular
drop) registrar
-Vascular alerted for e
Compromise( b surgery within
rachial Art) warm
ischaemia
time. New
radial nerve
deficit after
application of
U slab to
admit
Distal X rays Supra- Undisplaced- Document
Humerus Elbow (AP condylar- Long TCU Fast- neurovascular
Fracture and lateral) Arm Backslab track fracture status
(undisplaced) clinic Explain to
patient about
Undisplaced Displaced, NV signs of
Medial compromise – compartment
Epicondylar # - splint in as syndrome
Long Arm near normal
Backslab anatomic Admit Ortho
position as -If bilateral
Lateral possible and humeral #s
Epicondylar #- admit Ortho -Incarceration
higher chance and inform of medial
of malunion - stat condyle
Long Arm fragment
Backslab at 90 within the joint
deg flexion and or
forearm displacement
supination of 1 cm or
more.
Analgesia for
all
67
Elbow
2 Elbow AP /Lat M&R Admit Ortho if Perform
Dislocati Views of under there is NV post
on elbow Conscious compromise/un reduction
Sedation stable # X-rays.
TCU Fracture Document
Gentle Clinic 1/52 NV status
ROM pre and
testing post
post reduction
reduction, Consider
then splint compartm
with ent
forearm in syndrome
slight with
pronation persistent
and elbow pain, esp
flexed at with
90 deg or passive
beyond finger and
wrist
extension
Radius & Ulna

3 Closed AP/Lateral Long arm If Open/ ALWAYS
Fracture Views of above dislocation of look at
Radius / Forearm- elbow proximal or Proximal
Ulna MUST backslab distal joint: and distal
(Undispla include -Admit Ortho joints for
ced) Elbow and after DEM senior dislocation
Wrist joints consult
TCU Fracture
Clinic 1/52
Monteggi AP/Lat Long arm Admit Ortho after To call

a/ view of above DEM senior ortho MO
Galleazi forearm elbow consult if any NV
Fractures backslab deficit.
– fracture +/- prior
with M&R
distal or
proximal
radio
ulnar
dislocatio
68
n
3 Colles AP/Lat M&R If neurovascular Document
Fracture views of under compromise esp. Neurovasc
/ wrist Bier’s Carpal Tunnel ular
Reverse Block / Syndrome/ Open Checks
Colle’s haemato fractures
(Smith’s) ma block -Admit ortho Intra-
/ after DEM senior articular #
consciou consult should be
s referred to
sedation TCU Ortho Hand
in Resus Fracture clinic Surgery
OR Hand stat for
Analgesi Surgery 1/52 KIV ORIF.
a strictly
Below
elbow
back slab
4 Extensiv TCU General Advice to
e Bank 3 weeks look out
abrasion with Referral to for
s GP / OPS for infection
dressing change
Hand/Finger
Dislocati Xrays if Digital TCU Hand Splint side
on open, or block then Surgery 1 week of
fractures M&R. dislocation
suspected Splint if unstable.
Consider
buddy
splint.
Fracture Xrays Open tuft: TCU Hand Tuft #:
Digital Surgery 1 week, Bandage
block, analgesia only, do
irrigate not use
Zimmer’s
Non tuft: Non tuft:
Zimmer splint
extends
Never proximal
immobilis and distal
e entire to fracture
finger! site
69
UPPER LIMB INJURY MANAGEMENT PEARLS
1. Patients with upper limb injuries on wheel chair need to be examined for lower limb
injuries.
2. History must include- Mode of Injury (use interpreter if necessary)
Hand Dominance
Occupation and Hobbies
Time of Injury and Lag time to presentation
3. ALWAYS look for injury to other fingers in the hand, scaphoid tenderness as well as
injury to other limbs and the trunk/head.
4. Analgesia and IM ATT MUST always be provided (unless IM ATT given within last 5
years). Use opioids for amputations.
5. Deformed limbs should be aligned in the long axis as far as possible to preserve
circulation.
6. Patients in severe pain or with a lot of bleeding should be monitored for precipitous
drop in BP
7. Severe pain in a bone-intact limb should make you think about vascular insult,
Brachial Plexus Injury or Compartment Syndrome
8. Pediatric Fractures— minor, undisplaced/non-angulated fractures away from growth
plate may be discharged with back slab and given TCU 3/7 to Paeds Ortho. All others
should be sent to KKH.
70
LOWER LIMB FRACTURE WITH OR WITHOUT DISLOCATION
Triage Condition Investigations ED Disposition Special

Cat. Management Note
General Principles
Any Open X-ray of Analgesia, Admit Ortho

Fracture, involved parts Antibiotics, after DEM
Crush or (AP + lateral) IM ATT senior
Penetrating Bloods Wound consult and
Injuries including GXM irrigation if inform
contaminated Ortho STAT
by calling.
Laceration X-ray of Analgesia, TCU ADMIT
/ Incised involved parts IM ATT OPS/GP Ortho after
wound (AP + lateral) if Antibiotic if 1/52 for DEM senior
high impact contaminated wound consult for
injury; look for For T&S after review; complicated
FB copious STO 2/52 or deep
irrigation if wounds
contaminated (i.e. breach
(100-200mls of
or more underlying
saline via a fascia)
beveled
syringe)
Pelvis
2 Pelvic X-ray pelvis Analgesia Inform Advice to

Fracture AP Pelvic binder Ortho STAT return if
Bloods for open- for unstable difficulty in
including GXM book fracture fracture PU or
TRAUMA haematuria.
SERIES IF Admit Ortho
HIGH after DEM
ENERGY senior
consult for
stable
fractures
who are
unable to
ambulate
Able to walk
– TCU
Fracture
Clinic
2/52.
71
Hip & Thigh
Neck of Femur X-ray Analgesia, Admit Ortho after Treat NOF

Fracture pelvis CXR, ECG DEM senior fracture in
Intertrochanter AP pre-op consult young
ic Fracture X-ray of patients (<
involved 60 yrs) like
hip an open
(lateral) fracture, i.e.
inform Ortho
STAT
Hip X-ray For M&R Admit Ortho after All cases
Dislocation pelvis Abduction DEM senior need
AP pillow post consult admission
X-ray of M&R For
involved prosthetic
hip hip
lateral dislocation,
inform Ortho
early post
M&R
Femoral Shaft X-ray Analgesia Admit Ortho and GXM, large
/ Condyle femur For M&R inform Ortho bore IV
fracture AP + and long STAT. Fat
lateral backslab, embolism needs
Bloods Donway ABG and O2
including splint saturation
GXM monitoring.
and ABG
TRAUM
A
SERIES
IF HIGH
ENERG
Y
Patella
2 Undisplaced X-ray Analgesia, Admit for open Discharge

Patella knee AP Knee fractures from DEM
Fracture with + lateral brace in when patient
intact extensor full TCU Fracture able to walk
mechanism extension Clinic 1/52 with
crutches
NWB
2 Patella X-ray M&R with TCU Sports FWB with

Dislocation knee AP knee in Clinic 2/52 crutches
+ lateral extension
and long
backslab
72
Knee Assess INFORM ORTHO All cases
Dislocation popliteal STAT FOR need
and DP/PT POSSIBLE admission
pulses, NEUROVASCUL after DEM
M&R AR INJURY. senior
STAT and Admit Ortho consult
long Due to worry
backslab, about
X-ray knee vascular
AP + concern
lateral
after M&R
3 Knee Effusion X-ray Analgesia TCU Fracture Admit Ortho
knee if KIV joint Clinic 1-2/52 after DEM
OM / aspiration senior
septic for tense consult if
arthritis effusion, septic
suspecte pressure arthritis
d bandage suspected or
previous
TKR.
NO
ASPIRATIO
N IN ED IF
TKR IN
SITU
3 Soft Tissue X-ray Analgesia, TCU Knee Clinic Admit Ortho
Injuries (e.g. knee AP RICE, 1/52(force-in) to after DEM
ligaments, + lateral Knee see if early repair senior
meniscus) to look brace if is needed. consult if
for unable to tendon
avulsion ambulate rupture
fracture suspected
Chronic Knee X-ray Analgesia TCU Ortho knee Consider
Pain (e.g. OA, knee AP clinic according to admission
RA, CMP) + lateral queue. TCU for
physio early. debilitating
OA/RA flare.
May
consider
admitting to
rheumato/DI
M as
emergency
surgery for
OA RA is
high
infection risk
Leg
2 Tibial Spine & X-ray Analgesia To be admitted Small
73
Tuberosity tibia/fibul for observation undisplaced
Fractures a AP + & KIV avulsion
lateral Angiogram fracture can
be treated
with long
backslab
and TCU
Fracture
Clinic 1-2/52
2 Tibia / Fibula X-ray Analgesia Admit ortho after
Shaft tibia/fibul For M&R if DEM senior
Fractures a AP + vascular consult
lateral compromis
e If isolated fibula
Long #,TCU Fracture
backslab Clinic 1/52.
Educate
Compartment
Syndrome
Ankle
3 Archilles X-ray Analgesia TCU Ortho 1 Simmonds’ test

Tendon ankle Below knee week positive
Rupture AP/lateral front slab
to look for with ankle in Admit Ortho
avulsion full plantar after DEM
fracture flexion, NWB senior consult if
crutches calcaneum
avulsed or
tented skin
3 Soft X-ray Analgesia, TCU OPS/GP TCU Ortho Fast
Tissue ankle RICE, crepe 1-2/52 Track if
Injuries AP+lateral bandage ligamentous
(e.g. ankle injuries
sprain) suspected or
SYNDESMOSI
S WIDENED
3 Ankle X-ray For M&R For Weber B
Fracture / ankle AP STAT before fractures, to
and or + lateral x-rays if consult ortho
Dislocatio overlying reg on-call re
n skin is need for
compromise admission/ORIF
d .
Short
backslab Admit all ankle
Crutches dislocations and
ankle ankle
fractures with
74
disruption of
ankle mortise
after DEM
senior consult.
If for
discharge,TCU
Fracture Clinic
1/52
Foot
3 Talar X-ray Analgesia Admit talar neck

Fracture / ankle AP fractures. For
Dislocatio + lateral others if
n fragments
remain close
together and
joint surfaces
well-aligned->
NWB crutches.
TCU Fast Track
clinic.
If bone
fragments big -
> admit Ortho
3 Calcaneal X-ray Analgesia Admit Ortho if Undisplaced,
Fracture calcaneu Exclude Bohler’s angle extra-articular
m AP + associated disrupted after fracture with
lateral + injuries (e.g. DEM senior intact Boehler’s
axial view long consult or if angle can be
axis/spinal bilateral treated with
injury) calcaneal # jones bandage
NWB and TCU
Fracture Clinic
1-2/52
3 Tarsal X-ray foot Analgesia TCU Fracture Consult if
Fracture AP + Short Clinic 1/52 suspicious of
lateral backslab, Lisfranc
NWB fracture /
crutches dislocation
before
discharge from
DEM
3 Metatarsal Fast track SOC

Analgesia Consider
Fracture for displaced
X-ray foot Short Lisfranc injury if
MT #s
AP + backslab, # of proximal
Admit Ortho if
lateral NWB 1st to 4th MT ->
open # or NV
crutches admit ortho stat
compromise or
75
compartment
syndrome in
multiple #s
3 Phalange X-ray toes Analgesia TCU Ortho
s Fracture AP + For M&R of Trauma 1-2/52
and or lateral displaced
Fracture fracture and
Dislocatio buddy splint
n
Others:
3 Laceration Refer GP / OPS Advice to look
/ Incised for dressing out for infection
Wounds change
4 Foot pain TCU Ortho

(e.g. General 4-6
Plantar wks
fasciitis)
76
Ottawa Knee Rule
Use: To identify low risk patients with knee trauma who do not to warrant knee imaging.
Criteria Value
Age ≥ 55 Yes
Isolated tenderness of the patella (no other boney

Yes
tenderness)
Tenderness at the fibular head Yes
Unable to flex knee to 90o Yes
Unable to bear weight immediately and in ED (4 steps,

Yes
limping is okay)
If any 1 of the above criteria is met, this patient may need knee imaging: the rule is
sensitive to rule-out fractures, but not specific to suggest who may have a fracture.
For significant non-bony injuries, often crutches and a knee immobilizer can be helpful
to assist with ambulation.
Ottawa Ankle and Foot Rules
Use: Shows areas of tenderness to be evaluated in ankle trauma patients to determine

need for imaging.
Patients without criteria for imaging by the Ottawa ankle rule are highly unlikely to have
a clinically significant fracture and do not need plain radiographs.
77
Other conditions for admission to orthopaedics
-All bilateral lower limb fractures that have homecare issues.
-All post prosthesis insertion joint infections (unless very superficial skin infection.
-Extremity abscesses > 4 cm diameter
-Necrotizing Fasciitis of extremities - Start IV Penicillin, clindamycin and Ceftazidime

according to antibiotic guideline.
Management of ingrown toenails
Prior to avulsion of nails please ensure diabetic status of patient before undergoing surgical
therapy. In doubt, please consult senior DEM Doctor.
IGTN in diabetics, without paronychia, should be treated conservatively with elevating the nail
with a wisp of cotton.
78
PODIATRY REFERRALS
(SGH DEM and Podiatry collaboration)
Podiatry will be providing consult in the emergency department with effect from 11 January
2014 for specific foot conditions.
Feel free to call The Podiatry on-call hp within the timeframe listed below if you find that the
patient will benefit from podiatry input and/or follow-up. The on-call Podiatrist will attend the ED
within 15 minutes to triage the patient.
As their service is only during office hours, in the event that you see a patient after office
hours and has no other acute conditions that require admission, you can arrange for the patient
to present to Podiatry the next day or Monday morning with an ED referral letter if the problem is
urgent. For non-urgent problems please book the next available outpatient appointment (see
criteria below).
Please direct them to go to the Podiatry clinic located on Blk 1, level 1 within the Rehab
department.
For initial assessment in the ED, the patient would not be charged any additional fee beyond the
ED charges. However, please let patient know that for subsequent reviews at the podiatry clinic
and or surgical procedures done while in the ED or as outpatient in their clinic, payment is as for
any outpatient care rendered.
Conditions suitable for podiatry referral:
Inclusion criteria:
Urgent (Patient can present to Podiatry as a walk-in)
a) DM foot with ulcers
b) Any foot ulcers (ischemic, venous)
c) Ingrown toe nails (State on referral that referring doctor gives approval for nail avulsion under
local anaesthetic if indicated)
d) Localized paronychia on toes
Non-Urgent (Patient should be booked the next available outpatient appointment)

e) Newly diagnosed DM for DM foot screening
f) Musculoskeletal / overuse injuries
Exclusion criteria:
a) Do not refer any traumatic lacerations or fractures to podiatry.
b) Do not refer anyone with cellulitis with ascending lymphangitis, necrotizing fasciitis and the
likes.
c) Do not refer anyone with an acute ischemic limb please
If in doubt, please consult the senior ED physician on shift for further advice.
Service hours:
Mondays to Fridays 8 to Podiatrist on-call: 81256460
5 pm
Saturdays 8.30 to 1 pm. Podiatry Contact:

Sophie Whitelaw
Principal Podiatrist
Sophie.coral.whitelaw@sgh.com.sg
79
Workflow for DEM to Podiatry referral
DEM Patient requiring

Podiatry input
During OFFICE Hours After Office hours

Week day 8am – 4.30pm After 4.30pm on week days
Week- ends Sat 8am – 12.30pm After 12.30pm on Sat
Sun/Public holidays)
ED Nurse to call the podiatry

re: patient and location of patient
DEM Dr to treat as necessary
Podiatrist On- Call:

8125 6460
IF for discharge, IF for admission, then

then arrange carryout admission
outpatient podiatry as per usual process.
apt Refer to inpatient
Podiatry will assess pt in ED ** if patient fits Podiatry team if
inclusion criteria) necessary
Fax: referral to 6220
2577
DEM doctor to review
podiatry input and decide
disposition and subsequent
care.
80
Technique of Knee aspiration for diagnostic/therapeutic Knee Effusions
- Flex the knee to 90 deg if possible. If patient is in too much pain to flex, then leave the
knee in extension.
- From the lateral aspect of the affected knee, mark the point 1/3 from the superior
aspect of patella. Alternatively mark the point inferior to the femoral condyle and
superior to the tibial plateau at the lateral aspect of the knee.
- Using sterile technique, clean the knee with cetrimide, then chlorhexidine solution
followed by iodine solution. Leave the iodine solution to dry before attempting
aspiration.
-Attach a green needle to a 20ml syringe. Enter from the marked point as described
above and aim the needle towards the suprapatella pouch.
- Aspirate the knee effusion until you can a dry knee tap. Note and document the
appearance of the aspirate, namely purulent, bloody or straw coloured. Send the
aspirate for stains and cultures. You will need 7 bottles, each with 3-5mls of aspirate.
- They are to be sent for knee aspirate :-
1. G stain
2. Culture
3. FEME
4. Crystals
5. AFB smear
6. AFB culture
7. Fungal culture
Additional precautions
- Do not advance the needle after withdrawal so as to minimize any risk of introducing
infection to the knee.
- When removing the 1st syringe, one may like to attach a 2nd new syringe the needle stat
so as to minimize open exposure of interior knee environment.
- Hemophiliacs and over-warfarinised patients with tense knee haemarthrosis should not
have knee aspiration unless the coagulopathy is corrected.
81
BITE WOUNDS PROTOCOL
History
Points to note:
1. Time of bite, location/ country of event.
2. Type of animal & its status. ( Health, vaccination history, behaviour)
3. Location of bites
4. Treatment received so far.
5. Patient’s medical history ( ?immunocompromised, DM, PVD, tetanus vaccination hx)
Physical Examination
Points to note:
1. Distal neurovascular status
2. Tendon or tendon sheath involvement
3. Bone injury
4. Joint space violation
5. Visceral injury
6. FB (e.g. teeth) in wound
Investigations
1. X-ray the affected region, usually an extremity to exclude FB, fracture.
2. Labs usually not indicated unless patient septic, and requiring admission.
Treatment
1. Tetanus prophylaxis ( IM ATT)
2. If complicated bite wound requiring surgical debridement, especially with neurovascular/
tendon involvement, to consult Hand/ Ortho/ Vascular urgently.
3. If simple bite wound, for copious irrigation in the A&E. Recommend running tap water if
possible, otherwise copious saline flush.
4. Generally, to leave wounds open to heal by secondary intention.
5. Exception, for facial wounds, to refer to Plastics or primary closure.
6. To give oral Augmentin 625 mg bd x 1/52
If allergic to penicillin, give Clindamycin 300mg qds & Ciprofloxacin 500mg bd x 1/52.
________________________________________________________________________
Special cases:
1. For human bites, treat as for needle stick injury, with Hep B, C, HIV screening.
KIV prophylaxis. Give ID follow-up appointment.
2. For monkey bites, to consult ID/ IM physician for PEP valacyclovir and follow-up.
_______________________________________________________________________
Follow- up
Close follow-up essential.
Review within 48 hours for low-risk wounds and within 24 hours for high- risk wounds.
82
PAEDIATRICS
RECOGNIZING A SICK CHILD WHO NEEDS TRANSFER TO KKH
The Sick Child would include a child with the following:
1) Hemodynamically Unstable:
a) Pulse rate: <= 60 for all age group if haemodynamically unstable,
>=180 if younger than 5 years old, >=160 if older than 5 years old,
Tachycardia is often the 1st sign of shock, also consider SVT
b) Respiratory rate: >60 or < 16 in newborn to 1 month, >=50 or <=8 over 1 month
Clinical Evidence of severe respiratory distress:
a) Moderate to severe supraclavicular, sternal or intercostal retractions
b) Moderate accessory muscle use
c) Nasal flaring <2 yrs old
d) Grunting respiration
e) Tripod position
f) Recent stridor <12 hrs
g) Cyanosis (or history of cyanotic event, especially in infants)
c) Blood pressure: Neonate: <60 mmHg, Infant (1 month to 1 year): <70mmHg,
Child: SBP less than (70+age x 2)
Clinical Signs of shock:
Pale, sweaty, drowsy, thready pulse, cool peripheries, cap refill > 2 sec
d) Glasgow Coma Scale: <=14
e) Pulse oximetry: <=92%
83
2) High risk markers of serious illness in infants under 6 months:
Feeding <1/2 normal, Weak cry, Decreased activity, Convulsions, Apnoeic episodes,
Cyanotic episodes, Pale and hot, Green vomitus, Bloody stool, < 4 nappies in 24 hrs
3) Major trauma:
a) Mechanism of trauma:
i) Fall from greater than 10 feet or 3 body heights
ii) Motor vehicle crash:
Shattered windscreen
Intrusion into passenger compartment
Bent steering wheel
Vehicle rollover (with unrestrained patient)
Ejection from vehicle
Death of any occupant
Extraction time more than 15 mins
iii) Bicycle injuries (especially handle bar injuries to the abdomen)
iv) Motor vehicle versus pedestrian incident (at >20 mph/ 32 km/h)
v) Burns: > 10 % BSA, facial burns
v) Blast injuries
vi) suspected inhalational injuries
b) Abnormal Physiology: Age dependent variables are HR, RR, BP
AGE HEART RATE RESPIRATORY RATE

Minimum Maximum Minimum Maximum
Birth – 3 months 90 180 30 60
3 months – < 6 months 80 160 30 60
6 months – <1 year 80 140 25 45
1 year – 6 years 75 130 20 30
6 years – < 10 years 70 110 16 24
10 years – < 14 years 60 100 14 20
14 years and above 60 100 12 16
84
Adapted from the Canadian Paediatric ED Triage & Acuity Scale & Melbourne
Metropolitan Ambulance Service guidelines
AGE SYSTOLIC BLOOD PRESSURE

Minimum Maximum
0 – 1 month 61 105
1 month – < 1 year 71 (>70) 105
1 year – < 2 year 81 (>80) 105
2 year – < 3 year 81 109
3 yr – < 4 yr 81 112
4 – < 5 yr 81 114
5-<6 81 115
6 – < 7 yr 82 116
7 – < 8 yr 84 118
8 – < 9 yr 86 119
9 – < 10 91 (>90) 120
10 – < 11 yr 91 122
11 – < 12 91 124
12 – < 13 91 126
13 – < 14 91 129
14 – < 15 101 (>100) 131
15 – < 16 101 134
16 –< 17 101 136
17 and above 101 139
Adapted from: National High Blood Pressure education Program Working Group,
National Heart, Lung and Blood Institute. The 4th report on the diagnosis, evaluation and
treatment of high blood pressure in children and adolescents. Pediatr 2004;114(2);555 –
76.
c) Severe Anatomical disruption
Initial Management Principals follow that of adults, viz Airway, Breathing, Circulation,
using age specific equipment and weight-based dosage. Use a Broselow-Luten tape.
Call the friendly KK CE Senior Shift Dr to discuss all transfers which may be via
CHETS, ambulance or own transport depending on the severity of the child.
Compiled by:
Dr. Jade Kua
Prof Ng Kee Chong
Dr. Arif Tyebally
Childrens’ Emergency, KKH
85
WORKFLOW FOR CASES REFERRED FROM SISTER EMERGENCY
DEPARTMENTS TO KKH CHILDREN’S EMERGENCY (CE)
DIRECT ADMISSION
CALL KK CE SENIOR ABOUT DIRECT ADMISSION (SEE

MONTHLY KK CE SENIOR ROSTER WITH THE SENIORS’
HANDPHONE NUMBERS)
TO BOOK CLASS OF BED, CALL 6394 1188 OR 63941187
NOT FOR DIRECT ADMISSION
ALL CASES SEEN BY THE EDs FROM SGH, CGH, TTSH,

KTPGH, JGH, NUH AND SENT OR THAT PRESENT TO KK CE
WILL BE SEEN BY CE WITHIN 15 MINUTES OF BEING RE-
TRIAGED BY KKH.
NO NEED TO CALL KK CE UNLESS –

NON KKH ED REQUIRES SPECIAL CONSULT ON
SPECIFIC ASPECTS OF THE CASE
Note –
If Case Needs Specialised Transport – Call KKH CHETS (Children’s Hospital

Emergency Transport Service) Team @ 63941778 Not KK CE.
While there is a main telephone line at KK CE, this is not fully manned at all times
and hence this mode of contact is not recommended for emergency calls.
86
TREATMENT OF COMMON CONDITIONS IN PAEDIATRIC EMERGENCY MEDICINE
(Dr Chan Jing Jing)
This section serves as a quick reference for the cases we commonly see in DEM P2/3
area only and is NOT meant to replace the CE guidelines (available from KK Intranet
accessible from SGH Intranet) or clinical judgment, nor does it replace a proper history
and physical examination to rule out emergent conditions. Please refer to a shift senior if
you are not sure.
Remember:
1) Vitals should be appropriate for age, if not please inform a senior.
2) Involve parents in the care of the patient and do not separate child from parent where
possible!
Casemix in DEM
All ill-looking or unstable patients must be seen in resus.
Situations where stable cases may be re-directed to KK:
Investigations not available in DEM eg clean catch urine for UFEME to work up a
preverbal child for fever x 5/7
Treatment/facilities available only in KK eg laceration which clearly requires Ketamine
sedation, post circumcision bleeding
Fever
History Physical Management Special Notes
Examination
Besides eliciting the Perform a thorough If Temp>39 at Always recheck ALL
usual history to physical examination, triage, serve stat vitals before
localize the source of especially in the pre- doses of: discharge!
fever, ask also: verbal child. Look out PO Paracetamol Prolonged or high
Past medical history for:
15mg/kg (above 3 fever does NOT
eg. Ex-prem with Vitals not months) OR increase the risk of
chronic lung appropriate for age PO Ibuprofen febrile fits - do not
disease Hydration status 10mg/kg (if feed fever phobia!
Contact history Include in your
Paracetamol served Advise thin clothing,
Intake and output ie examination:
Otoscopy (for otitis recently, and only if tepid sponging, oral
amount of fluids above 1 year old) hydration
taken, and number media)
Mouth (HFMD, Find the source
of PUs/ diaper (usually viral) and
changes, including tonsillitis)
Genitalia and treat appropriately.
how heavy the Common causes:
diapers are perineum
UTI, pneumonia,
Activity level URTI. Consider
malignancy,
Kawasaki’s.
87
Respiratory
History Physical Management Special notes
Examination
Bronchiolitis Respiratory Nebs: 3mls of 1:1,000 Use Respiratory Index
Presents with conditions are what Adrenaline Score (RIS) to
wheezing following kill in children. No need for CXR if prognosticate (KK
URTI typical – clinical dx! book)
Birth history Look out for signs
Ask for feeding (see of respiratory
distress:
notes on “Fever”)
Tachypneoa
Asthma Nebs: <10kg use 0.5mls Consider discharging
Subcostal/interco with Asthma Action
Atopic triad: of Salbutamol and
stal retractions Plan with tailing
asthma, eczema, Atrovent, >10kg use
“Head-bobbing” ventolin (print from
allergic rhinitis 1mls each
Nasal flaring CE book)
Triggers: URTI, Steroids: PO
Grunting
pets, carpets, Prednisolone 1.5mg/kg
Tripod position Discharge follow up to
stuffed toys stat then for 5/7 on
Drooling be based on criteria
Compliance to discharge OR (see flowchart under
Silent chest
meds IV hydrocortisone 4- Asthma in KK book)
SpO2<95%
5mg/kg
IV MgSO4 50mg/kg over
20min
CXR only if first wheeze
or not responding to
treatment
Blood gas if moderate to
severe attack
Croup Steroids: PO Consider other
Recent URTI, fever Dexamethasone causes of stridor in a
Complaint of “noisy 0.6mg/kg stat (crush child, eg epiglottitis,
breathing” tablets and dissolve) foreign body,
Nebs: (only if in distress) retropharyngeal
abscess
3mls of 1:1,000
Adrenaline Use Wesley Croup
Score for severity (KK
book)
Pneumonia High dose amoxicillin is Admission for children
Fever, tachypnea first line as per under 6 months
and cough international guidelines
History of recent
abx
URTI Oxymetazoline nose drops Do not give
Contact and travel (Iliadin): doses in mucolytics
history RxManager (bromhexine,
PO Promethazine: fluimucil) for more
0.1mg/kg every q6H if 2 than one week as
years and older (prescribe these will cause
only ONE antihistamine at prolonged cough
a time)
PO Chlorpheniramine
0.1mg/kg TDS if between
6 months and 2 year old
88
Gastrointestinal
History Physical Management Special Notes
Examination
Contact history Assess hydration Mild Discharge only if
Rule out other status PO Ondansetron: tolerating orally and
causes of vomiting Look for surgical (1st line anti-emetic, no more abdominal
(including conditions abdomen only in >1yo) 0.1- pain
such as meningitis, 0.2mg/kg once. Clinical findings and
DKA, UTI, testicular Syringe out required abdominal pain
torsion) amount from vial advice must be
and give it orally. documented before
Stocked at DEM discharge.
pharmacy. DO NOT give
PO MgCO3 if buscopan, lomotil or
abdominal pain maxolon
present. DO NOT discharge
Consider short with Ondansetron,
observation with and do not give it
trial of feeds 30min “prophylactically”.
after ondansetron:
<3 years old: 15mls
every 15 min x 4
>3 years old: 30mls
every 15 min x 4
Moderate to Severe
IV hydration, obtain
VBG and correct
electrolytes. Senior
review, then
transfer.
Chan JJ with Pek JH, Dec 2014

Based on KK CE’s June 2014 guidelines
89
NEONATAL JAUNDICE (GUIDELINES FOR SGH A&E DEPARTMENT)
Disclaimer: This guideline is meant for SGH A&E management of NNJ. If in doubt,
please inform Neonatal Registrar on call.
1 Policy
1.1 Well babies with serum bilirubin levels very near to or exceeding phototherapy
criteria require early admission under the SGH “Department of Neonatal and
Developmental Medicine”. All such admissions require approval of the Neonatal
Registrar on-call.
1.2 Babies with jaundice who appear unwell, septic-looking, have abnormal vital signs
or hemodynamic instability are resuscitated before transfer to a tertiary paediatric
hospital for appropriate care.
2 Standards / Guidelines (optional)
Refer to guidelines below
3 Definition
3.1 A “neonate” is defined as an infant aged less than 30 days old.

3.2 “Gestation” refers to the gestation of the baby at birth
3.3 “Neonatal Jaundice” (or NNJ) refers to jaundice (a yellow discoloration of the skin)
occurring soon after birth and commonly resolves by the end of the second week of
life.
3.4 “Prolonged neonatal jaundice” refers to NNJ lasting for ≥15 days.
3.5 “SB” refers to the serum bilirubin.
3.6 “PT” refers to single blue phototherapy.
3.7 “DB” refers to double blue phototherapy.
3.8 “EXΔ” refers to exchange transfusion.
4 Procedure
Refer to guidelines below.
5 Reference Documents
NA
90
GUIDELINES
1. Obtain essential history which includes (but is not limited to) the following:
 Date and time of birth (to calculate the exact age as “hours of life”)
 Preterm or term gestation
 Difference between birth weight and current body weight (which indicates relative
dehydration status)
 Presence of G6PD deficiency (check baby’s health booklet)
 Cord blood TSH level (check baby’s health booklet)
 Perinatal medical history (check baby’s health booklet)
 Feeding history and type of milk (breast milk or formula milk)
 History of fever/ poor feeding/ vomiting/ weight loss
 Maternal / Baby ABO-Rhesus blood groups
2. Babies with jaundice exceeding phototherapy levels will require early admission to
SGH Neonatal Wards. All such admissions require approval of the Neonatal Registrar
on-call. Please refer to the table below (serum bilirubin levels as umol/L)
 Admit babies who require “single blue phototherapy” (PT) to nursery (NEO1) wd 53.
 Admit babies who require “double blue phototherapy” (DB) or “exchange transfusion” (EXΔ)
to the High Dependency nursery (NEO2) at Ward 54.
Babies 35 weeks gestation with Abnormal Jaundice States
DAY (HOUR) LOW RISK (UMOL/L) MEDIUM RISK (UMOL/L)

PT DB EXΔ PT DB EXΔ
D1 (24H) 130 225 255 100 200 230
D2 (25-48H) 170 250 280 130 225 255
D3 (49-72H) 220 295 325 190 260 290
D4 (73-96H) 260 330 360 23 285 315
D5 (97-120H) 290 350 380 245 295 325
D6
ONWARDS 305 370 400 255 295 325
(>120H)
PT = single blue phototherapy level

DB = double blue phototherapy level
Ex = exchange transfusion level
Low Risk: Gestation full term (37 weeks or more) without risk factors
Medium risk: Gestation 35 to 36 weeks 6 days without risk factors OR Gestation full term
with any risk factor:
 ABO/Rh incompatibility, G6PD deficiency, DCT +ve
 Altered blood-brain barrier (BBB): sepsis, asphyxia, acidosis, significant lethargy, temperature
instability, albumin <3g/dl(if available)
3. Babies <35 weeks gestation: Consult Neonatal Registrar or MO for advice.
91
4. Babies with the following symptoms/ signs require immediate transfer to a tertiary
paediatric hospital (KKH or NUH) for admission and management:
 fever, symptoms and signs of infection

 lethargic and quiet, or irritable
 poor feeding, vomiting and dehydration
 respiratory distress, cyanosis or pale
 an otherwise unwell infant requiring inpatient observation, workup or investigation
5. Babies with the following may be discharged from A & E to a general practitioner /
Family doctor/ Polyclinic/ Neonatal Outpatient clinic (located at O&G Centre, block 5 Level
1) for outpatient review:
 SB already shows a downward trend;
 SB remains stable over the past 24-48 hours and baby remains clinically well;
 Baby born at term and aged > 7days with no risk factors (refer to abnormal criteria above)
 Baby born preterm (<36 weeks gestation) and aged > 10days with no risk factors (refer to
abnormal criteria above)
6. Discharge instructions:
 Ensure adequate hydration and normal bowel movement

 Return to A&E immediately if baby is unwell eg poor feeding, vomiting, febrile.
 “Sunning” the baby is strongly discouraged as it is ineffective in lowering SB levels and will
cause sunburn and dehydration.
 Feeding baby with supplementary water in place of milk is not allowed.
 No treatment is required at this point; only careful assessment is required.
 Keep appointment at SOC/ polyclinic/ neonatal clinic
7. Prolonged NNJ (defined as NNJ lasting for ≥ 15 days)
 Phototherapy should not be routinely instituted.
 Most babies with prolonged jaundice require careful evaluation for the cause of prolonged
jaundice, including physical examination and investigations. Consult the Neonatal Registrar
and refer to the Neonatal Outpatient clinic (at Obstetric Gynaecology Centre, Block 5 Level 1)
with an appointment within the next 3 working days.
92
Essential history:
DOB time of birth,
NNJ (≤14 days) prem?
Day of life, weight
G6PD and cord TSH
status
Feeding regime, type of
milk
Fever/poor
Assess vital signs (Temp, feeding/vomiting/
HR, RR, SpO2, BP) weight loss
Maternal/Baby blood
group
Clinically unwell or
Clinically well
abnormal vital signs
Resuscitation as
SB not available
required
Office hours (After office
inform Neonatal
hours/weekends)
Reg/MO
Transfer to other
institution by ambulance
OGC (Neonatal clinic) Do SB at DEM
or CHETS team after
stabilization
Refer to Table 1 for

admission criteria
Call Neonatal Reg/MO
on call if admission or
advice needed
Updated by Dr Poon Woei Bing (Neonates)

November 2015
93
PALLIATIVE MEDICINE IN THE ED
(Dr Puneet Seth)
SGH DEM sees a large number of patients who are on palliation. Most of these patients
are under the care of Medical Oncology, but may come from Respiratory, Cardiology or
Gastroenterology,
The DEM Comfort Care Protocol was created to allow care for such patients to be
expedited. Refer to Infonet for details. Forms are kept in the Resuscitation Room.
94
RENAL
DEM note: Call PD nurse to help with drawing effluent and giving IP antibiotics. PD nurses are on call at home after office hours. DEM doctor to order tests for peritoneal
fluid only if found cloudy by PD nurse.
RESPIRATORY
(Dr Jeremy Wee/Dr Kenneth Tan)
APPROACH TO PATIENTS PRESENTING WITH SHORTNESS OF BREATH
Shortness of breath is one of the more common presentations to the emergency

department. The challenge is that there is a wide variety of differential diagnosis. The
below table is a list of differential diagnosis but not exhaustive.
SYSTEMS DIFFERENTIAL HISTORY / PHYSICAL

DIAGNOSIS EXAMINATION
CARDIOLOGY CCF/APO History of IHD

Chest pain , SOB with exertional
Angina equivalent (no symptoms
CP, but SOB) Fluid indiscretion
Bibasal crepitations
LL swelling
ECG changes
RESPIRATORY Asthma Known history of asthma

Wheezing
COPD Smoker, known COPD

On LTOT
Wheezing with crepitations
Pneumonia, infective Fever, cough

causes eg bronchitis Unilateral crepitations, dullness to
percussion
Septic looking
+/- wheezing
Pulmonary embolism Will be discussed in next chapter
Other chronic lung Known history of CLD

diseases eg pulmonary Bilateral crepes +/- wheezing
fibrosis
RENAL Fluid overload in Known ESRF,

ESRF/CRF patients AVF not working
AOCRF fluid indiscretion
ingestion of nephrotoxic drugs
bibasal crepitations
AVF present with weak or no thrill
GI Symptomatic Ascites Hx of CLD, abdominal distension,
gain in weight
Anasarca from liver Signs of CLD, ascites
disease Decreased air entry bilaterally
NEUROLOGY Neuromuscular Hx of neuromuscular disorders.

disorders eg myasthenia May present with softness of
gravis, Guillian Barre voice and generalized weakness
Clinically can have
abdominal/paradoxical breathing,
ptosis
METABOLIC Severe metabolic Known hx of DM, or evidence of

acidosis eg, DKA, polyuria, polydipsia. Hx of
salicylate, toxic alcohol overdose.
overdose, ARF +/- Clear lung fields, Kussmaul’s
breathing (air hunger)
OTHERS Stridor eg. Epiglottitis Fever with sore throat, hx of

angioedema, Ca larynx allergy
Hx of Ca or RT
Inspiratory and expiratory stridor
+/- clear lung field
Urticarial, periorbital edema
Pericardial effusion Hx of Ca, recent MI or

cardiothoracic surgery
Beck’s triad, +/- clear lung fields
97
Investigations
After history taking and physical examination, appropriate investigation should be done
to reach a diagnosis. It can be divided as below:
Blood tests Miscellaneous Radiological
1. FBC 1. ECG 1. CXR

2. Renal panel 2. Hypocount 2. CT Pulmonary angiogram
3. ProBNP if indicated
4. ABG in selected cases eg, 3. Bedside US to look for
severe asthma, pts in pericardial effusion or
respiratory distress, severe evidence of PE
COPD
5. D dimer- only if there is
suspicion of PE
6. LFT if suspected or known
liver disease
Management
The below subgroups of patients must be managed in the resus area:

1. Stridor
2. Drowsy patients with SOB
3. In severe respiratory distress
The above list is not exhaustive. In summary any patient that is n distress should be
managed in P1 unless ordered by a senior doctor. MOs whose evaluation of their
patient thinks warrants management in P1 are to approach a senior immediately.
Subsequent management is then disease specific.
DIFFERENTIAL
SYSTEMS MANAGEMENT
DIAGNOSIS
CARDIOLOGY CCF/APO IV frusemide

GTN KIV IV GTN
Angina equivalent (no NIV
CP, but SOB)
RESPIRATORY Asthma Nebs, IV

hydrocortisone/
prednisolone
KIV IV magnesium
COPD Nebs, Iv
hydrocortisone
KIV NIV
98
Pneumonia, infective IV abx, high flow O2
causes eg bronchitis
Pulmonary embolism Will be discussed in

next chapter
Other chronic lung High flow 02 kiv

diseases eg steroids
pulmonary fibrosis
RENAL Fluid overload in IV Lasix

ESRF/CRF patients GTN KIV IV
AOCRF Dialysis
GI Symptomatic Ascites Supportive

management
Anasarca from liver Peritoneal tap
disease
NEUROLOGY Neuromuscular High Flow O2

disorders eg IVIG, IV
myasthenia gravis, methylprednisolone
Guillain- Barre NIV
METABOLIC Severe metabolic IV fluids

acidosis eg, DKA, IV NAHCO3 if pH
salicylate, toxic <7.1
alcohol overdose, Treat underlying
ARF cause
OTHERS Stridor eg. Epiglottitis Call ENT immediately

angioedema, Ca IV dexamethasone
larynx IV augmentin
KIV E tracheostomy
Pericardial effusion Pericardiocentesis in

ED if evidence of
tamponade
If patients do not respond to treatment and rapidly deterioating or presented in extremis,

the patient should be intubated.
99
ASTHMA based on GINA guidelines
Take history and physical examination to ascertain

severity of asthma exacerbation
Mild Moderate Severe Life threatening

Spo2 on RA >95% 91-95% <90% <90%
Audible or auscultated wheeze Yes Yes Yes Absence of wheeze
Talk in Sentences Phrases Words
Respiratory rate /min 21-24 25-29 >30
Use of accessory muscles Usually not Usually Usually Paradoxical thoracoabdominal
movement
Pulse/min <100 100-120 >120 Bradycardia
Triage category P1 CC P1 CC P1 resus P1 resus
Mild to Moderate Severe to Life threatening
Managed in resus
Managed in critical care FBC, renal panel, ECG CXR, ABG
Perform peak flow if patient is able to Back to back neb of ventolin (2): N/S (2)
Patient
KIV add on atrovent (1)
CXR, blds are not neccessary deteriorates
Start IV hydrocortisone 100mg
Neb ventolin (2): N/S (2) x3 cycles
Start IV magnesium sulphate 1-2g over 1
Administer prednisolone 30mg stat hr
Observe for a total of 1hr after the 3 If CXR reveals a PTX, to decompression
nebs given immediately followed by chest tube
insertion
If ABG shows worsening respiratory

failure or patient clinically deteriorating,
Still having intubate patient. To only start BIPAP with
Patient has no more respi consult
wheezes, wheezing
SPO2 > 95% Vital signs stable
PEFR >40% predicted
best If patient
Previous ICU improves and with
Can discharge with admissions Admit to
prednisolone 30mg ICU review and
recommendation ICA or ICU
x5/7 and ventolin MDI
Instruct them to use 2
puffs TDS for the next
3 days followed by
Admit to Admit to
PRN
EOW Respi GW
Pt improves No improvement
100
PNEUMOTHORAX WORKFLOW (NON TRAUMATIC) Updated Dec 2014
Confirmed pneumothorax
(non traumatic)
Stable Unstable
-Treat as for tension
pneumothorax
-Needle decompression followed

by chest tube insertion
- Admit to respi once stabilised
Secondary PTX
- Insert Wayne catheter
(Seldinger technique) kiv
chest tube insertion Primary PTX
- Admit to respi
* *
PTX >2cm or symptomatic PTX <2cm
Offer either needle decompression, wayne Can be discharged with early tcu with respi within
catheter insertion or chest tube insertion 3 days with CXR OA, MC till TCU
Consider EOW pneumothorax protocol as
If needle decompression, to admit to EOW PTX needed
protocol. If PTX stable or no further recurrence, They are to be discharged with the following
discharge with TCU respi in 3/7. MC till TCU advice:
CXR OA. If recurrence of PTX or worsening of - no swimming or diving
PTX, for wayne catheter insertion or chest tube - no strenuous physical activities
insertion. Please leave the 3 way valve - no flying
attached to catheter - to come back with worsening of
symptoms
If wayne catheter inserted, to admit to EOW - to inform them that the PTX may become
PTX protocol If no complications, discharge larger and need intervention
with tcu respi in 3/7 CXR OA MC till TCU
However, if patients not confident to care

for catheter or chest tube inserted, to admit If patient has been discharged
to respi and returns to DEM, senior doctor
to reassess. Please look at Annex
A for further action
*
PTX measured from visceral to parietal pleural at level of hilum
For Wayne catheter insertion, there should be at least 2cm margin of PTX for insertion, if not for chest tube
insertion
Please do not let any fluid into hemilich valve and keep note of direction for valve to function
101
ANNEX A
If patient returns, Senior doctor on duty is to assess the patient regarding patient’s
complaint.
Complaint 1: PAIN
Action:
 Ensure that PTX has not expanded by repeating CXR
 Ensure that adequate analgesia has been given to patient
 If PTX re-expanded, please refer to complaint 2
Complaint 2: BREATHLESSNESS
Action:
 Ensure that PTX has not re-expanded by repeating CXR.
 Ensure that dyspnoea is not pain related.
 If PTX has re-expanded, ensure that three way tap is aligned correctly, Heimlich valve is
aligned in the right direction and catheter is in place
 If related to 3 way valve, realign and observe for 2 hours before repeating CXR. If CXR
reveals stable or smaller PTX; and Heimlich valve functioning, discharge with old TCU.
If PTX larger, switch to underwater seal and admit to RCCM.
 If Heimlich valve is aligned incorrectly, readjust and repeat CXR after 2 hrs. If PTX is
stable, discharge with old TCU with RCCM. If Heimlich valve is wet, switch to
underwater seal and admit to RCCM
Complaint 3: FLUID IN THE TUBING

Action:
 If fluid present in tubing, repeat CXR. If PTX still present, switch to underwater seal and
admit to RCCM. If PTX resolved, please look under action for resolved PTX**.
 If blood present in tubing, repeat CXR and ensure no hemothorax. If hemothorax
present or suspected lung or vascular injury, refer to CTS.
 If CXR shows persistent PTX and no hemothorax, switch to underwater seal and admit
to RCCM
 If PTX resolved, please refer to action for resolved PTX**
** IF PTX RESOLVED:
 If CXR at any of the above shows resolved PTX, clamp the catheter via 3 way valve.
 Observe for 2 hrs and repeat CXR.
 If CXR shows no PTX, remove the catheter and stitch or apply steristrip to catheter site
 Discharge with analgesia and MC with initial RCCM TCU on previous discharge
102
COPD
History to note:
SOB with wheezing
Fever, any URTI symptoms
Chest pain
Known hx of COPD, ex-smoker or current heavy smoker
Ascertain whether patient is on LTOT
Physical examination
Ascertain whether patient is in respiratory distress
Respiratory examination can reveal wheezing,
crepitations or silent chest
Stable patients:
Unstable patients, those in respiratory distress Can be managed in P2
Unstable vital signs or drowsiness: ECG, FBC, renal panel, CE+/- bld c/s
CXR to look for pneumothorax and
consolidation
Manage in resus IV hydrocortisone 100mg
ECG, FBC, renal panel, CE +/- bld c/s Neb ventolin (1): N/S (2): atrovent (1) x 3
cycles
CXR to look for PTX or infection Start appropriate IV abx if needed
ABG
IV hydrocortisone 100mg
Back to back neb ventolin (1):N/S (2): atrovent
(1)
IV abx if needed
If CXR shows a PTX, immediate
decompression of PTX is needed followed by
chest tube insertion
If ABG shows worsening respiratory failure,
start BIBAP if no contraindications Patient responsive to
treatment
If unable to start BIBAP, consider intubation
Admit to respi GW
If patient improves and asymptomatic

Maybe discharge for those with good family
support or consider admitting to EOW
asthma protocol
Arrange for admission to

ICA or ICU
103
PULMONARY EMBOLISM
After clinical hx and physical examination, the Well’s criterion for PE is used to assess
the probability of PE.
Well’s Criteria for Pulmonary Embolism
Use: Objectifies risk of pulmonary embolism.
The model should be applied only after a history and physical suggests that venous
thromboembolism is a diagnostic possibility. It should not be applied to all patients with
chest pain or dyspnea or to all patients with leg pain or swelling.

Clinical Signs and Symptoms of DVT Yes +3
PE is number 1 diagnosis, or equally likely Yes +3
Heart rate > 100 Yes +1.5
Immobilisation at least 3 days, or surgery in the previous 4 weeks Yes +1.5
Previous, objectively diagnosed PE or DVT Yes +1.5
Hemoptysis Yes +1
Malignancy with treatment within 6 months, or palliative Yes +1
0 to 1.5 score: Low risk group – 1.3% chance of PE in an ED population.
2 to 6 score: Moderate risk group – 16.2% chance of PE in an ED population.
7 and above score: High risk group – 40.6% chance of PE in an ED population.
*Another study assigned:
Scores ≤ 4 as 'PE Unlikely' and had a 3% incidence of PE.
Scores > 4 as ‘PE Likely’ and had a 28% incidence of PE.
Low : 0-1 points

Intermediate : 2-6 points
High : 7 or more points
104
PERC**
Those with low probability of PE will undergo another clinical decision rule, Pulmonary
Embolism Rule Out Criteria (PERC)
The PERC rule is as follows:
1. Younger than 50 yrs of age
2. HR <100beats/min
3. Spo2 >94%
4. No Hemoptysis
5. No unilateral leg swelling
6. No OCP usage
7. No previous DVT or PE
8. No recent surgery or immbolization within 4weeks
If patient meets all 8 criteria and low probability of PE, PE can be safely rule out without
D dimer.
Investigations
Blood tests Radiological Miscellanous
FBC CXR ECG

Renal Panel CT PA
D dimer Bedside US
ABG
Management
All unstable patients are to be managed in resus. Large PEs are referred to CTS for
urgent embolectomy or catheter directed thrombolysis. Initial dose of IV heparin can be
given. Small PEs can be managed in CTS or respi/ hematology but the medical registrar
will need to be informed for possible ICA bed arrangement if not for CTS admission.
In small PEs, IV heparin or S/C clexane can be administered while anticoagulation is

initiated in the ward.
105
**PERC has high sensitivity and negative predictive value but low specificity. However, if the
above is applied only around 0.5% of PEs are missed.
Patients presenting with SOB

Assess probability of PE using
Well’s criteria
Low probability High Probability

0-1 points 7 points or more
Intermediate
probability
2-6 points
Does not fulfill

PERC
PERC
D dimer D dimer positive
Fulfills all 8
PERC criteria
CT PA (refer to CT
protocol for PE)
Look for other
causes of SOB D dimer negative
Look for other
causes of SOB
106
CT PROTOCOL/WORKFLOW for PE
Ordering of CT Pulmonary Angiogram for Pulmonary embolism
Patients presenting with shortness of breath or chest pain with suggestion of

pulmonary embolism may be considered for scan.
Three factors should be considered:
1. the stability of the patient

2. high pretest probability for PE before going on to no 3.
3. determining the clinical probability of PE. To do so, we will use the Wells Prediction
Rule for Diagnosing Pulmonary Embolism and the pulmonary embolism rule out criteria.
Please refer to the flowchart on the next page.
107
108
PNEUMONIA
Mild OR PSI Risk Class I-II FBC, U/E, CXR

Unilobar Can be discharged with oral antibiotics
Normal or near normal vital signs based on SGH antibiotic guidelines.
Young < 65 years old TCU Resp SOC x 1 week.
Does not fulfill the criteria below. MC till TCU
Moderate OR PSI Risk Class III-V FBC, U/E, CXR, ABG

Does not fulfill the criteria below. Blood c/s
Antibiotics according to SGH antibiotics
guidelines
Admit Respiratory General Ward, early
ward review.
Severe – Scores 2 or more: FBC, U/E, CXR, ABG

Septic shock = 2 Blood c/s
RR > 30/min = 1 Antibiotics according to SGH antibiotics
PaO2 / FiO2 < 250 (FiO2 in decimal guidelines
point) = 1 Call R1/ MICU registrar
CXR : bilateral / multilobar pneumonia = Admit HD/ICA/MICU
1
Systolic BP < 90 mm Hg or Diastolic BP
< 60 mm Hg = 1
Confusional State = 1
PSI = Pneumonia Severity Index
PSI has evolved from a prediction rule for prognosis to a decision aid to guide the
choice of the initial site of treatment for patients with CAP.
109
CURB-65 Severity Score
Use: Estimates mortality of community-acquired pneumonia to help determine inpatient

vs. outpatient treatment.
Value Points
Criteria
Confusion Yes +1
Urea > 7mmol/L Yes +1
Respiratory rate ≥ 30 Yes +1
Systolic BP < 90mmHg or Diastolic BP ≤ 60mmHg Yes +1
Age ≥ 65 Yes +1
0 score: Low risk group: 0.6% 30-day mortality. Consider outpatient treatment.
1 score: Low risk group: 2.7% 30-day mortality. Consider outpatient treatment.
2 score: Moderate risk group: 6.8% 30-day mortality. Consider inpatient treatment or
outpatient with close follow up.
3 score: Severe risk group: 14.0% 30-day mortality. Consider inpatient treatment with
possible intensive care admission.
4 and 5 score: Highest risk group: 27.8% 30-day mortality. Consider inpatient treatment
with possible intensive care admission.
110
SEPSIS PATHWAY AND COMMON INFECTIONS
(A/P Mark Leong / Dr Kenneth Tan)
MANAGEMENT OF SEPSIS
(See also Resuscitation Workflow for Severe Sepsis)
Surviving Sepsis Campaign
SIRS is present if there are 2 or more of the following:
• Temperature >38.3C or <36C
• HR>90/min
• RR>20/min or PaCO2 <32
3 3
• WBC>12,000/mm or <4,000/mm or >10% immature forms
Sepsis is SIRS + source of infection
Severe sepsis is defined as end organ dysfunction from sepsis with:

 Lactate>2mmol/L
 AMS from baseline
 Respiratory failure
 Kidney or hepatic failure
 DIC
 Troponin elevation
 Transient hypotension
 Unexplained acidosis
Septic shock is defined sepsis plus any of the following:

 Hypotension (SBP<90, MAP<65 unresponsive or >40mmHg SBP decrease from baseline) refractory to
IVF
 Lactate greater than 4mmol/L
Multiple Organ Dysfunction Syndrome: Evidence of ≥ 2 organs failing
*based on Surviving Sepsis Campaign. Sepsis 3 was released in 2016 but is not used in SGH MICU.
Severe sepsis/ Septic Shock
EARLY GOAL DIRECTED THERAPY (3 hour bundle)

Sepsis
1. Measure Lactate level
2. Obtain blood c/s before giving antibiotics Initiate appropriate antibiotics
3. Administer broad spectrum antibiotics early
Adequate fluids
4. Administer 30ml/kg crystalloid for hypotension or lactate
≥4mmol/L If BP drops or deteriorates, for IV
fluid boluses** up to 2L
EARLY GOAL DIRECTED THERAPY (6 hour bundle) If BP still unresponsive, this is
1. Apply vasopressors for hypotension that does not respond septic shock, proceed to septic
to initial fluid resuscitation ) to main MAP ≥65mmHg shock pathway
2. In the event of persistent hypotension after initial fluid
If BP stabilizes and patient’s
administration (MAP < 65 mm Hg) or if initial lactate was
general condition improving,
≥4 mmol/L, re-assess volume status and tissue perfusion admit to GW with early review
and document findings as stated below. Patient
3. Remeasure lactate level deteriorates If BP stabilizes but patient’s
general condition not improving,
DOCUMENT REASSESSMENT OF VOLUME STATUS AND to proceed to septic shock
TISSUE PERFUSION WITH: pathway
EITHER • Repeat focused exam (after initial fluid resuscitation) by **Suggested fluids: Hartmann’s
licensed independent practitioner including vital signs,
cardiopulmonary, capillary refill, pulse, and skin findings.
OR TWO OF THE FOLLOWING: • Measure CVP • Measure ScvO2

• Bedside cardiovascular ultrasound • Dynamic assessment of fluid
responsiveness with passive leg raise or fluid challenge 111 Updated June 2016
COMMON INFECTIONS
(Dr Nausheen / Dr Kenneth Tan)
Soft tissue infections

Cellulitis Diabetic or immunocompromised
individuals,:
All such patients are to be admitted.
Perform FBC, U/E, Blood c/s
Start IV augmentin (IV clindamycin for
penicillin allergy)
Admit to DIM
Stable patients with:

Uncomplicated cellulitis with stable vital
signs and no further acute medical issues
Can be considered for EOW Cellulitis
protocol. Please refer to EMERGE for
details
If there is suspicion of concomitant deep

tissue infection, abscess or need for surgical
intervention, please discuss with DEM
senior doctor KIV admit GS or ortho
Necrotising fasciitis Clinical suspicion of NF:

Tenderness out of proportion of clinical
pictures
Hemorrhagic blisters
Subcutaneous emphysema
Gas seen in soft tissues on X-ray
High CK levels
Alternative:
Use LRINEC scoring as below
FBC, U/E, PT/PTT,CRP ( if using LRINEC

scoring), GXM
X-ray of the affected limb
CXR
Start IV Penicillin, clindamycin and
Ceftazidime according to antibiotic guideline
Discuss with DEM senior doctor STAT to
admit ortho
Abscess If abscess is present, and no other acute
medical conditions, eg DKA, discuss with
DEM senior doctor to admit ortho for I&D
(small abscess can be drained in procedure
room)
112
If there are any acute medical conditions
present, inform ortho first and KIV admit to
medical with inpatient ortho input
Diabetic foot/ gangrene GS has requested that all lower limb

gangrene to be admitted under GS
- to discuss with DEM senior doctor
regarding GS admission
However, if there are pulses felt and GS has

reviewed and not for GS admission, to
discuss with DEM senior doctor to admit
Ortho
Bloods and IV antibiotics as per usual
Osteomyelitis If there is radiological evidence of OM and

pulse well felt,
Bloods as per usual
IV antibiotics
Discuss with DEM senior doctor to admit
ortho
If pulses not well felt, or follow-up with GS

Discuss with DEM senior doctor for GS
admission
113
LRINEC SCORING FOR NECROTISING FASCIITIS
Use: To distinguish necrotizing fasciitis from severe cellulitis or abscess. If high

suspicion for necrotizing fasciitis through clinical history and physical exam, do not
calculate a LRINEC score or wait for blood results. Refer to the appropriate surgical
discipline immediately for operative debridement.
A LRINEC score ≥ 6 is a reasonable cut-off to rule in necrotizing fasciitis, but a LRINEC

< 6 does not rule out the diagnosis (low risk but not no risk). Remember:
- Prompt fluid resuscitation and antibiotic administration are crucial in the treatment of
necrotizing fasciitis.
- Any patient with severe cellulitis or worrying signs of deep skin infections which might
not appear to be necrotizing fasciitis must have the LRINEC scoring performed. If the
score is ≥ 6, he must be referred to the appropriate surgical discipline immediately.
Criteria Value Points Criteria Value Points

CRP (mg/L) < 150 0 Sodium ≥ 135 0
≥ 150 +4 < 135 +2
WBC (per mm3 <15 0 Creatinine ≤ 141 0

(mmol/L)
15-25 +1 > 141 +2
> 25 +2 Hemoglobin > 13.5 0

(g/dL)
Glucose (mmol/L) ≤ 10 0 11-13.5 +1
> 10 +1 < 11 +2
114
INFECTIOUS DISEASES
(Dr Nausheen / Dr Kenneth Tan)
DENGUE FEVER
INDICATIONS FOR ADMISSION: Any of the following
Dizziness, lethargy, restlessness and altered mental status
Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation
No urine output for 4 to 6 hours
Signs of bleeding (e.g. mucosal bleeding or internal bleeding such as malaena)
Liver enlargement > 2cm
Increase in haematocrit concurrent with rapid decrease in platelet count
Hct > 50% or > 20% above baseline
Relative hypotension of 20mmHg from baseline or postural hypotension
Significant bleeding (e.g. epistaxis, GI haemorrhage, menorrhagia, haematuria)
Pregnancy
Co-morbid conditions (e.g. DM, hypertension, peptic ulcer, haemolytic anaemia,

congestive cardiac failure, chronic renal failure, chronic obstructive lung disease,
immunocompromised state)
Obesity (BMI > 28)
Infancy
Old age (> or = 65 years old)
Platelet count < or = 80 x 109/L
INDICATIONS FOR REFERRAL TO POLYCLINIC OR GP:
Patients who have platelets > or = 80 x 109/L, AND
Able to drink adequate fluids, AND able to pass urine at least once every 6 hourly.
115
MALARIA
Singapore has been declared malaria free by WHO. However, we still see cases from
time to time as patients who come back from malaria infested countries or from
neighboring countries.
Workflow:
Patient presents with fever with positive travel
history to malaria infested countries
Perform FBC and blood film for malaria
parasite
BFMP negative BFMP positive

Look for other <2% plasmodium falciparum
causes of fever or other plasmodium
species and patient stable
Admit to GW
Start antimalarial meds,
Please refer to SGH

antibiotic guidelines
BFMP positive for plasmodium falciparum with features of severe falciparum malaria
Clinical features
Laboratory
- Impaired sensorium
- Hypoglycemia
- Generalized weakness
- Metabolic acidosis
- Failure to feed
- Severe anemia
- Multiple seizures
- Hemoglobinuria
- Kussmaul breathing
- Hyperparasitemia
- Shock
>2%
- Hemoglobinuria ( black
- High lactate
urine)
- Renal impairment
- Spontaneous bleeding
- Pulmonary edema
- Clinical jaundice or other
end organ damage IV fluids
Start IV antibiotics to cover for superimposed bacterial infection
Arrange for HD/ICU bed
Consult SGH antibiotic guideline for antimalarial meds or contact ID Registrar on treatment options
116
HERPES ZOSTER
Herpes zoster presenting as either chickenpox or shingles can usually be treated as

outpatient. Treatment would include symptomatic treatment with anithistamines and
patient should be isolated. Acyclovir can be prescribed but has to be renal adjusted for
patients with renal failure.
IV acyclovir remains the drug of choice for the following populations of

immunocompromised patients:
1. Patients with evidence of disseminated disease or visceral organ involvement
2. Patients with ophthalmic involvement
3. Patients with advanced HIV/AIDS who harbor active opportunistic infections or exhibit
prominent wasting
4. Transplant recipients who have just undergone transplantation or are being treated for
rejection
These patients should be admitted to isolation wards.
Antiviral therapy has been demonstrated to halt progression and dissemination of acute
herpes zoster in immunocompromised patients, even when initiated more than 72 hours
after rash onset. Accordingly, such therapy is recommended for all
immunocompromised herpes zoster patients who present before the full crusting of all
lesions.
PYREXIA OF UNKNOWN ORIGIN
This is defined as fever for more than 10 days with no source of infection. Such patients
will need to be admitted for more extensive workup.
117
COMMUNICABLE DISEASES
MANAGEMENT OF HIGH RISK PATIENTS WITH INFLUENZA-LIKE ILLNESS
Antiviral treatment can potentially reduce morbidity and mortality. Medical practitioners
are reminded that antiviral treatment is recommended for high-risk patients with ILI
when the prevalence of Influenza A (H1N1-2009) in the community is significant. In the
current mitigation phase, doctors should offer anti-virals to their high-risk patients
with ILI. Patients should be advised to seek medical assistance immediately should
their condition worsen.
Laboratory testing for Influenza A (H1N1-2009) under prevailing prevalence is NOT

necessary before commencement of treatment.
Testing to confirm the diagnosis of Influenza A (H1N1-2009) infection

Is only required in patients who are seriously ill, or in high risk patients e.g. children
less than 1 year old or those who are pregnant, for initiation of treatment or continuation
of treatment and/or in situations where it will be of significant public health importance.
PERSONS AT INCREASED RISK FOR INFLUENZA-RELATED COMPLICATIONS
1. Persons aged 65 years and older

2. Children < 5 years
3. Adults and children who have chronic pulmonary or heart disease
4. Adults and children who have required regular medical follow-up or hospitalisation
during the preceding year because of chronic metabolic diseases (including diabetes
mellitus), renal dysfunction, haemoglobinopathies or immunosuppression
(including immunosuppression caused by medications or by the Human
Immunodeficiency Virus)
5. Children and teenagers aged 6 months to 18 years who are receiving long-term
aspirin therapy and therefore might be at risk for developing Reye syndrome after
influenza infection
6. Pregnant women
Please be reminded of the need to adjust dose of Tamiflu for children and
patients with renal impairment. Please consult the patient's primary specialist/ID
for advice
118
MANAGEMENT OF GENITAL ULCERS AND DISCHARGES
119
MANAGEMENT OF EMERGING INFECTIOUS DISEASES
updated 24 June 2015, based on MOH notification MH 34:24/15 dated 20 June 2015
(Dr Chan Jing Jing)
As front line staff, we need to be aware of emerging infectious diseases both for patient
care and our protection. Examples of such diseases in recent times are Ebola and
MERS-CoV.
It is hence important to stay up to date with the latest advice and protocols from MOH.
These and other SGH specific protocols can be obtained from the Nursing
Officers on duty as well as SGH Infonet.
Important notes:
1. Basic hygiene – surgical masks should be worn at all times on shift. Hand hygiene
should be observed between patients.
2. Personal Protective Equipment – Infectious disease, together with the Infection

Control nurses, will develop institution specific instructions regarding PPE for specific
diseases based on the latest information available. This will be taught to all front line
staff in times of heightened awareness. Please get fitted for an N95 mask.
3. Isolating patients – Be disciplined in taking travel and contact histories for ALL
patients during consultation, and do not delay isolating patients who might fit the criteria.
4. MOH directives – All suspected cases of such infections are immediately notifiable
to MOH via phone call to the Surveillance Duty Officer of the Communicable Diseases
Division and online submission of the MD 131 Form on the Communicable Diseases
Live & Enhanced Surveillance (CDLENS) system (link in EMERGE).
Suspected cases are usually transferred to TTSH or KKCH if stable. If the patient
refuses admission or transfer, call the Surveillance Duty Officer on 9817 1463
(available 24 hours) for assistance and advice. Unstable patients would be managed in
DEM and admitted.
120
TOXICOLOGY
(A/P Palam / Dr Kenneth Tan)
History taking: Physical examination:
- What drug was taken , the amount, time/ - Check vital signs
Is the amount consumed all in one shot - Pupillary size
or over time - General condition of patient:
- Any co ingestion of any other drugs nervous, lethargic diaphoretic,
- Circumstances that lead to overdose, this agitated
is to look for any life threatening - Systemic review
conditions that lead to overdose eg
panadol overdose in patients with SAH Investigations:
- Is the patient experiencing any symptoms ECG, H/C FBC U/E, LFT, PT/INR (if
necessary), paracetamol and salicylate
now level
- Any past medical history or risk factors
that will affect management of overdose
Drug identified?
Drug identified, proceed to Unable to identify drugs. Go on to

treatment algorithim with kiv look for any toxidromes, from hx and
antidote if available physical examination
TREATMENT ALGORITHIM
- Ensure PPE is used especially if high possibility of contamination
- Do a quick ABC assessment and stabilisation of patient before decontamination.

All unstable patients are to be managed in resus
- Decontamination: remove all contaminated clothing and wash patient if there is

any chemical on the body. This acts to protect HCW and prevent further
absorption of agent
- Reassess ABC and stabilize them further after decontamination
- Reduce Absorption of drug: if within 1 hr of ingestion or possibility of decreased

GI absorption, administer activated charcoal. Consider orogastric lavage if within 1
hr and airway is protected (pt intubated) and no contraindications.
- Antidotes: If drug or toxidrome identified, look for any antidote and administer
ASAP. Eg, IV parvolex for Paracetamol overdose, IV pralidoxime for
organophosphate poisoning
- If no antidote is available, continue with supportive management
- Arrange for admission to general ward or monitored bed as needed
121
TOXIDROMES
Cholinergic Toxidrome: Anticholinergic Toxidrome:
D iarrhoea ‘hot as hare’- hyperthermia

U rination ‘red as a beet’- flushed appearance
M iosis ‘dry as a bone’- decreased glandular
B radycardia secretions
B ronchorrea ‘blind as a bat’- mydriasis
E mesis ‘mad as a hatter’- delirium
L acrimation
S alivation
Sympathomimetics Opiates
- Hypertension - Miosis
- Mydriasis - Respiratory depression
- Tachycardia - Hypotension
- Agitation, delirium - Drowsiness
- Hyperpyrexia
Sedation
- Respiratory depression
- Hypotension
- Drowsiness
Common Antidotes:
N-Acetyl Cysteine (Parvolex) Paracetamol overdose

Flumazenil Benzodiazepine
Naloxone Opiates
Digibind Digoxin overdose
2PAM and atropine Organophosphate overdose
122
TRAUMA
(Dr Jean Lee / Dr Jeremy Wee / Dr Kenneth Tan)
APPROACH TO TRAUMA
TRAUMA
PHYSIOLOGICAL ANATOMICAL MECHANISM
- Airway - Penetrating injury to - Prolonged entrapment (>20

compromise head, neck or torso mins)
- RR < 10/min or - Fracture pelvis - Ejection from vehicle/ flung by
>30/min - 2 or more proximal vehicle
- Pulse > 120/min long bone fractures - High velocity/ high transfer of
- SBP < 90mmHg - 2 or more body forces/energies:
- GCS ≤ 13 region injury → Fall from height ≥ 3m
- Spinal cord injury → RTA: speed ≥ 50km/h
- Proximal limb
amputation
- Flail chest
Fulfills above
criteria Does not fulfill
above criteria
Treat as for major trauma Please refer to respective

pathways:
Trauma Activate
- Minor head injury
- Chest injury
- Abdominal injury
- Neck injury
- Minor injuries eg.
Abrasions and
lacerations
123
Trauma Team
1. The Trauma Team (TT) is responsible for the resuscitation and initial management
of a multiply injured patient.
2. The core team comprises of 4 doctors, 2 nurses, a radiographer and a health

attendant. The trauma team leader (TTL) will be a general surgeon. He will work with a
team comprising an A&E Registrar/ MO, a General Surgery MO and an Orthopaedic
MO. Doctors involved in the trauma team should have completed the Advanced Trauma
Life Support Course (ATLS).
3. Each member of the team should have specific duties. This horizontal organization
allows tasks to be performed simultaneously. The trauma team layout and each
member’s role are as outlined (See Picture)
4. Additional disciplines as deemed appropriate or necessary by the Trauma Team

Leader may be activated when the need arises (Anaesthesia, Neurosurgery, Radiology,
Plastics, Cardiothoracic and Obstetrics etc).
5. For Burns patients, all trauma activations and those with TBSA >20% are to be
referred to the registrar. Smaller burns with TBSA<20% can be referred to the MO.
(with effect from January 2015)
6. All Trauma Team members should practice universal precautions. Waterproof

gowns, gloves and masks should be used for all trauma resuscitation.
7. The decision of the Trauma Team Leader is binding. Any disagreements can be
brought to the attention of the Trauma Director the following day or; the Trauma Office:
trauma.service@sgh.com.sg.
8. The TTL is responsible for coordinating the resuscitation and ensuring that the
necessary specialists are contacted. A management plan is formulated by prioritizing
both the investigation and management of the various injuries. The relevant areas
should be alerted – ICU, OT, CT or angiographic room. The TTL is responsible for
ensuring that the Trauma Resuscitation Record is filled up at the completion of the
resuscitation.
124
125
PREHOSPITAL INFORMATION
The following minimum information should be obtained:
M mechanism
I injury
S signs (vital)
T treatment
CONDUCT OF RESUSCITATION
This follows the principles laid out in the ATLS®.
Observe universal precautions.
Documentation of parameters -Every 10 min (HR, RR, BP, GCS)
For severe trauma - Bloods = FBC, UES, ABG, PT/PTT, GXM, LFT,
amylase, lactate, cardiac enzyme
Radiology - Chest, Pelvic, C-spine (in this order)
Selective Tests - ECG, UPT, Extremity X-rays
Specialised Tests - CT head (no IV contrast)

CT chest
CT abdomen
(Oral contrast if used is given 30 min before scan)
Angiographic procedures (may need to activate interventional radiology team – takes
1h)
If patient is not responding to fluid resuscitation or obviously exsanguinating –

GIVE BLOOD EARLY
Involve consultants early in the severely injured patients.

Do not keep patient in the resuscitation room longer than necessary. As a general
guideline, keep ED time to less than 2 hours. Some patients will require a rapid transfer
to OT with minimal investigations (eg. penetrating trauma patient in shock).
Make decision for definitive investigation and treatment within 30 minutes.
Never leave patient unattended in the resuscitation room!
126
PAN SCAN CRITERIA / GUIDELINES
Regardless of whether there is visible evidence of neck, chest or abdominal

injury, as long as the patient is:
Hemodynamically stable, (contra-indication to CT is haemodynamic instability)

AND meet one of the following criteria/ clinical scenarios:
(1) Unable to evaluate examination results secondary to a depressed level of

consciousness or intoxication (GCS 13 or less), i.e regardless of severity of
mechanism
Or
(2) Normal abdominal examination results in neurologically intact patients / clinically no

evidence of significant chest / abdominal injury
AND
Significant mechanisms of injury as any of the following:
(a) Motor vehicle crash at greater than 50 km/hr
(b) Falls of greater than 3m
(c) Ejection from vehicle/ flung by vehicle
Then patient should undergo CT scan of the head, cervical spine, chest, abdomen, and
pelvis (pan scan).
If you think your case should be an exception to the above criteria, please discuss with
consultant on call.
127
Annex
Updated 22 A
April 2016
128
MANAGEMENT OF HYPOTENSION IN TRAUMA
129
MANAGEMENT OF PELVIC TRAUMA
Indication for the use of Pelvic Binder (T-POD, Trauma Pelvic Orthotic device)
1) For initial treatment to stabilize a suspected open pelvic fracture until definitive
treatment is rendered.
2) Create a circumferential compression (tamponade) to the pelvic region.
3) To help minimise blood loss and reduce pain.
* T-POD should be released slowly every 2 hourly to prevent skin damage by medical
personnel for 10 mins - 15 mins. (Write down date and time of the release on the T-
POD).
*To confirm with the principal doctor before the 1st release
Monitor the haemodynamic status when T-POD is released. There is a possibility of

hypotension as the tamponade in the pelvic region is lost. Re-apply the T-POD and
inform the medical team.
130
COMMON RESTRUCTURED HOSPITAL MASSIVE TRANSFUSION PROTOCOL
GENERAL NOTES AND GUIDELINES
A) Blood selection if blood group is unknown:
Red Cells
Blood group O Rhesus Negative pRBC for Caucasian & Indian Female patients of
child-bearing age or younger
Blood group O Rhesus Positive pRBC for all other patients
FFP
Blood group AB Rhesus Positive FFP for all patients
Platelets & Cryoprecipitate
Platelets will usually be Group O, but cryoprecipitate can be of any ABO group. ABO
compatibility is not essential for platelet and cryoprecipitate transfusion
The cryoprecipitate will be either pre-pooled (if available and stored at the hospital
blood bank) or prepared and provided direct from 24-Hour Cross-match Lab, BSG).
Blood group should be determined by each hospital’s blood bank as an urgent

priority so that ABO identical blood products can be issued as soon as possible.
Therefore clinical teams activating the MTP should send a group and cross-match
sample at the earliest opportunity. Patients should be transfused with type specific
and cross matched blood as soon as their blood group has been determined.
Patients who are already known to be RH negative & who have positive
antibodies should be excluded from this MTP protocol:
(a) For MTP patients of known RH Negative Blood Group, the team doctor should
use the 1st two units of Emergency O-ve Blood if necessary, (already available)
but also contact the BSG MO/Team urgently for advice.
(b) For patients with known requirement for rare blood due to clinically significant
red cell allo-antibodies, the team doctor should contact the BSG MO/team
immediately to seek advice.
(PLEASE NOTE: NOT ALL ANTIBODIES ARE CLINICALLY SIGNIFICANT. IF IN

DOUBT-PLEASE CHECK WITH BSG TEAM)
B) Constituents of MTP (Mass Transfusion Protocol) Pack are as follows:
Pack 1: 4 units pRBC, 4 units FFP, 4 units PLC, with Tranexamic Acid 1g Stat Dose
Pack 2: 4 units pRBC, 4 units FFP, 4 units PLC
131
Pack 3: 4 units pRBC, 4 units FFP, 4 units PLC, with cryoprecipitate (10 units);
Consider use of recombinant activated factor VII (dose: 90 mcgm per kg) with Pack 3.
(Recombinant FVIIa has a role in MTP but their use will have to be governed by each
hospital’s oversight policy on the use of this agent
C) Criteria for Activation of the MTP:
Activation of the MTP based on clinical judgment alone or on traditional criteria (such as
> 150ml of blood loss per minute or 1 blood volume transfused in a 12-hour period) can
be challenging. It is also clinician-dependent and subjected to inconsistencies.
We therefore recommend the use of validated scoring systems in risk assessment of

trauma patients for MTP Activation. (eg. ABC Score, TASH Score)
The Assessment of Blood Consumption (ABC) Score.
The ABC Score consists of 4 dichotomous, non-weighted components that are available
at the bedside of the acutely injured patient early in the assessment phase. The
presence of any one component contributes one point to the total score, for a possible
range of scores from zero to four. The parameters include:
 Penetrating mechanism (0 = no, 1 = yes)
 ED SBP of 90 mmHg or less (0 = no, 1 = yes)
 ED HR of 120 bpm or greater (0 = no, 1 = yes)
 Positive FAST (0 = no, 1 = yes)
Assessment of Blood Consumption (ABC) Score > 2 or 3 will trigger activation of the
hospital MTP
D) When to contact the BSG MO:
 The Clinical Team calls their hospital Blood Bank directly for release of MTP Packs 1
& 2. They do not need to call BSG MO for approval or release of Pack 1 & 2 since the
standby inventory of MTP blood products in each hospital would be adequate to meet
the requirements of packs 1 & 2 (including 8 units of platelets and 8 units of FFP)
 Hospital team only needs to call the BSG MO immediately after calling the local
hospital blood bank for delivery of MTP Pack 2. This is to inform BSG of current MTP
activation and potential escalation to MTP Pack 3, as well as confirm the need for
preparation and thawing of cryoprecipitate at BSG Lab (if in-house prepooled
cryoprecipitate is not available in that hospital). (Note : Under current arrangements,
the hemostatic blood products in MTP Pack 3 will still be issued from BSG)
 Please also inform BSG MO when the MTP has ceased or if the MTP needs to be
extended beyond MTP Pack 3, so that arrangements for rapid transfer of additional
blood products can be quickly arranged.
 Patients who are already known to be RH negative & who have positive antibodies will
be exempted from MTP activation. The team doctor should contact the BSG MO &
request for blood products in the usual manner for such patients.
132
E) Typical Locations for MT Delivery:
1. ED resuscitation room
2. OT
3. ED Radiology Department during diagnostic and therapeutic procedures
4. Surgical Intensive Care Unit (SICU)
F) Who can activate the MTP:
To be decided by the individual hospital HTC
As a guide, the authority to activate MTP should be generally restricted to a senior

Doctor (Reg & above) of the following disciplines:
Haematologist for medical cases and the Anaesthetist in the OT, and Trauma Team or
A&E Physician for trauma cases.
Such restriction would be necessary to minimize unnecessary activation and wastage of

blood products.
G) Supportive Measures
1. Avoid Hypothermia (keep T>35C: eg. with IV warming device, Bair Hugger, Ambient
Temperature Control, etc), Acidosis (keep pH> 7.1) and Hypocalcaemia.
2. Constant monitoring of FBC, coagulation profile (PT, aPTT, serum fibrinogen), with a
aim to further correct any coagulation abnormalities on lab result beyond MTP
replacement of hemostatic factors (keep PT/PTT < 1.5x reference value, fibrinogen >
1g/dl, platelets >50x109/L). For example, additional transfusions of cryoprecipitate
should be considered if fibrinogen < 1g/dl.
3. All labs are sent STAT while MTP is in progress. Laboratory values and amount of
products administered should all be tracked
4. Strict compliance with product/recipient identification procedures is mandatory,

regardless of time pressures
5. The MTP leader or designee keeps the BB informed of changing needs or location.
6. Patients are to be transfused with type specific and cross matched blood whenever
possible.
H) Other adjunctive monitoring & treatment options:
 Point of Care thromboelastography Test: TEG analysis may be helpful in identifying

specific issues with hemostasis and guiding its treatment (e.g. whether patient needs
FFP, cryo, platelets, antifibrinolytic drugs, or thrombolytic drugs). However adoption of
TEG point of care testing will be at the discretion of individual hospitals.
133
 Novo-7 (recombinant activated factor VII, initial dose at 90 ugm per kg): Our
recommendation is for Novo-7 be given together with or immediately after transfusion of
cryoprecipitate and platelets of MTP Pack 3, so as to maximize the benefits of Novo-7.
I) Daily Returns of MTP Cases:
Restructured Hospital Blood Banks should give daily returns of MTP activation cases
that include a breakdown of blood products used during the MTP activation period, as
well as basic clinical details such as the name, registration number, main clinical
problems and reason for MTP activation.
134
MINOR HEAD INJURY
Defined as GCS 13-15
To assess need for CT brain, please use the Canadian CT head rule.
Canadian CT head rule:
Use: Clears head injury without imaging.
Note: Only apply to GCS 13-15 Patients with LOC, Amnesia to the Head Injury Event, or
Confusion
Criteria (Major) Criteria (Minor)

GCS < 15 at 2 hours post injury Retrograde amnesia to the event ≥ 30
minutes
Suspected open or depressed skull Dangerous mechanism – pedestrian
fracture struck by motor vehicle, occupant
ejected from motor vehicle, fall from >5
stairs
Any sign of basilar skull fracture 0 score: CT head is unnecessary.
(hemotympanum, racoon eyes, battle’s
sign, CSF otorrhea/rhinorrhea)
≥ 2 episodes of vomiting
Age ≥ 65
Any 1 Major: “high risk” for an injury requiring neurosurgical intervention. (sensitivity
100%).
Any 1 Minor: “medium risk” to rule out an intracranial traumatic finding (sensitivity 83-
100%).
Rule does not apply to age below 16yrs, non trauma, those with bleeding tendencies,
GCS <13 or obvious depressed skull fractures.
Patients on warfarin or aspirin are to be scanned if the supervising senior deems the
injury significant.
Disposition:
If CT brain normal, admit patient to head injury protocol
Please T and S all lacerations before discharge/ handing over
At the end of 8 hrs, if GCS stable and neurological examination normal, the patient can
be discharged with head injury advice.
All alcohol intoxicated patients with no significant head injury (as determined by senior
doctor) are to be admitted to HIP and observed for 4 hours first. If GCS does not
improve by then, a CT brain should be performed.
If CT brain normal, proceed as per disposition.
135
ABDOMINAL INJURIES
If not for trauma activation, consider admitting patient under minor injury protocol for
further observation and treatment.
Inclusion Criteria:
- no acute abdomen
- FAST negative
- No significant abrasions or seatbelt sign
- Patient is not on warfarin
All other patients are to be referred to GS for further evaluation
If the patient fulfills the above criteria, admit him/her to minor injury protocol.
A FBC, Renal Panel, Amylase and LFT should be performed.
Serial abdominal examinations, minimum of 2 inclusive of bedside FAST (this included
initial examination). Blood investigations should also be repeated at the 6hr mark. Treat
with appropriate analgesia.
If there is no change in blood results, no significant changes during serial abdominal

examinations and no more abdominal pain, the patient can be discharged with
abdominal pain advice.
If there is a drop in Hb, rising trend of WBC or amylase, changes in serial abdominal
examination or persistent abdominal pain, a CT abdomen/pelvis is to be arranged.
If CT normal, supervising doctor can choose to observe the patient further in EOW or
discharge patient with analgesia and an appointment with GS trauma clinic.
If CT scan has a positive finding, inform GS ASAP.
CHEST INJURIES
If not for trauma activation, consider admitting patient to minor injury protocol.
Exclusion Criteria:
- more than 3 rib fractures

- fractures of the 1st and 2nd rib or scapula fracture
- flail chest
- obvious pulmonary contusion on CXR
- pneumothorax, hemothorax, widened mediastinum
- ECG changes- suggestive of cardiac contusion
The above patients should be referred to GS as there is a possibility of significant

thoracic injuries.
All other patients can be considered for minor injury protocol. These patients should be
placed under cardiac monitoring.
A FBC, renal panel, trop t should be done and a further 2 sets of ECG and trop t should
be performed.
If there are no ECG changes, maintain good spo2 on room air and stable blood results,
the patient can be discharged with analgesia and chest pain advice.
136
If there are ECG changes, rising trop t and increasing oxygen requirement, an
immediate chest x-ray should be done and bedside US to look for possible pericardial
effusion. These patients must be referred to GS ASAP.
NECK PAIN
All major trauma should have C spine X-ray done. All other neck injuries post trauma
should be cleared using the Canadian C spine rule/NEXUS.
Canadian C spine rule
Use: Clears patients from cervical spine fracture clinically, without imaging.
137
NEXUS
Use: Clears patients from cervical spine fracture clinically, without imaging.
Criteria Value
Focal neurological deficit Yes
Midline spinal tenderness Yes
Altered level of consciousness Yes
138
Intoxication Yes
Distracting injury Yes
If none of the above criteria are present, the C-Spine can be cleared clinically by these
criteria. Imaging is not required.
If any of the above criteria are present, the C-Spine cannot be cleared clinically by these
criteria. Consider Imaging.
If there is midline tenderness and c spine X-ray done which appears normal, administer
analgesia and observe patient for 2 hrs. If still having pain, to refer to ortho for c spine
clearance
If:
1. Fulfill Canadian rule/NEXUS and no x ray done
2. C Spine X-ray normal with resolution or improvement of midline tenderness
Patients can then be discharged with early TCU orthopaedics and analgesia
MULTIPLE ABRASIONS/ LACERATIONS
If the patient does not fulfill trauma activation criteria, patient can be considered for
further observation without protocol or admission to minor injury protocol.
All patients regardless of disposition are to have their tetanus status updated and
wounds to be dressed and all lacerations to be T and S.
After observation, all patients are to be discharged with an OPS TCU for STO or change
of dressing.
BURNS
(Dr Chan Jing Jing)
SGH is the regional burns centre and hence we receive a large number of burns cases.
The burns unit is housed in Ward 43, and has a high dependency, ICU as well as an
operating theatre.
Some important points to note:
History
Time of injury
Location, including whether in enclosed space, and type of material that burnt
Type of burn – inhalational, chemical, flame, scalds, electrical
Duration of exposure
Accidental vs deliberate injury?
Physical Examination
- Total body surface area (TBSA)
o Rule of 9s in adults, patient’s palm (including fingers) estimated as 1%
139
- Look for suggestion of airway burns: singed eyebrows and nasal hair, carbonaceous
sputum, hoarseness of voice, stridor
- Entry/exit wound for electrical burns (not often found)
Management of Major Burns (>20% TBSA)

ABCDE (Burns are to be managed according to the tenets of ATLS.)
Secure airway – edematous airways are airway emergencies
Large bore IVs, preferably in unaffected areas
FBC, U/E, PT/PTT, GXM, CXR, ECG
Special tests: ABG, COHb (can run on COBAS machine in resus), CK (esp in electrical
burns)
Fluids according to Modified Parkland’s formula

Total replacement fluids (N/S or L/R) = 4mls x BW x TBSA, of which 50% in the first 8
hours and the remaining 50% over 16 hours starting from time of burn
Insert IDC – target urine output of 0.5ml//kg/h
Consider nasoscopy to assess airway – by ED or Burns
IV Morphine – do not withhold analgesia from any conscious burns patient; it is not
uncommon to be giving more than 10mg of morphine in total
IM ATT
Call Burns Registrar in ED for early evaluation and admission
(Do not forget that patients can have CO or cyanide toxicity too!)
Management of Minor Burns (<20% TBSA)

(often from scalding injuries)
Irrigate wound with clear water/ saline
Analgesia, before dressing
Update tetanus
TCU Burns 2-3/7 (there is no need to ODD Burns in minor cases, if in doubt, ask a
senior).
Cases that might require ODD to Burns MO would be those that involve the face,
perineum, hands and circumferential burns.
140
UROLOGY
ACUTE RETENTION OF URINE
(Dr Kenneth Tan / Dr Poh Juliana)
History: Important Considerations and Differentials
Male or female patient

Acute onset or acute on chronic
Dribbling, complete ARU, haematuria, hesitancy, frequency
Need to strain to PU
Likely hx of stricture eg hx of STDs
Symptoms of UTI
Ingestion of drugs
Bowel hx: constipation
Injuries eg: low back, spine
Hx of malignancy/ metastatic disease
Recent procedure, instrumentation or surgery
Pregnancy/ gynae hx: e.g. retroverted gravid uterus, impacted fibroid
Examination:
General examination of patient/ systematic review

Ascertain the size of bladder if possible.
Inspect end of urethra for stricture
Prostate bimanual examination
Look also for signs of cord compression: e.g. Enlarged bladder with perianal
anaesthesia and lax anal tone
Investigations: order as appropriate
UC 9 (post catheterisation)
Routine blood investigations such as FBC and U/E are generally not required unless
there are other significant issues.
Management:
Bladder catheterization
Review volume and bladder evacuation
Record volume of urine drained (nurses to do SMU and chart in Emerg)
Note characteristics: colour, sediments and debris, blood etc
If stable and suspect simple case of BPH, can send home with indwelling catheter
Relatives must be instructed to empty urine bag, look out for complications etc
If ARU is secondary to other causes suspected, consider admission for management of

the appropriate problem
Give a follow up with Urology SOC 1-2 weeks

If the appointment is too long to give interim TCU with OPD/GP for change of catheter
as necessary and review
141
RENAL/URETERIC COLIC
(A/Prof Marcus Ong)
Sudden onset of colicky flank pain UC9, KUB

Radiates anteriorly and inferiorly Bedside Ultrasound kidneys
Nausea/vomiting FBC, U/E (only if suspect renal impairment,
Diaphoresis pyelonephritis)
Occult hematuria (microscopic IV NS (if vomiting)
hematuria on UC9) IM diclofenac 75mg (Contraindicated if patient
Normal testicular exam, no hernia has renal impairment secondary to
obstructive uropathy),
And IM/IV buscopan 40mg
Or
(consider alternative medications, oral route
etc)
Discharge if pain free with analgesia,

Tamsulosin (Refer to Worklow) and TCU
Urology 1/52. If TW elevated, KIV cover with
ciprofloxacin 500 mg bd x 7 days.
If hydronephrosis on ultrasound without pain
– call urology for early TCU
Admit EOW renal colic protocol if persistent

pain despite analgesia
ODD urology/for admission if persistent pain

despite protocol, hydronephrosis with renal
impairment, pyelonephritis etc
UROLOGY WORKFLOW IN DEM

(Dr Jean Lee)
Guidelines to Management of Ureteric Colic at DEM

- To prioritise treatment with administration of analgesia -> IM Pethidine 50/75mg
according to patient’s build with IM Maxolon.
- Review the pain 1 hour later. If still in pain, to top up with another analgesia eg IM
diclofenac. Consider enrolling into EOW renal colic protocol.
- If ureteric colic recurs during EOW observation, to top up meds if 2nd round has not
been given. If already administered, to consider admission to urology
Indications for direct admission to Urology

- Recurrence of pain during renal colic EOW protocol after at least 2 administrations of
painkiller.
- 2nd attendance in DEM with prior EOW observation during the 1st DEM visit.
142
- If there was not any EOW admission during the 1st DEM visit for ureteric colic, consider
enrolling in EOW renal colic protocol. Admit urology for failed EOW observation.
- 3rd DEM attendance in 1 week for ureteric colic
- Complications from obstructive calculus
i) Obstructive UTI, pyelo- or pyo-nephrosis , especially on background of diabetes
ii) Acute kidney injury with Cr > 200.
If patient is for discharge after successful pain control, recommended treatment

includes:
- TCU urology 2 weeks. If stone > 8mm, TCU Urology walk-in clinic 1 week. Order CT
KUB for post EOW pts (not CT urogram which uses IV contrast).
- Advise to drink 3-4L of water a day in an attempt to flush out the calculus. Stones <
5mm distal to the sacroiliac joint have a 70% chance of spontaneous per urethral
passage in 4-6 weeks.
- Oral analgesia such as tab Diclofenac (ensure no asthma nor renal impairment) with
famotidine cover and paracetamol prn x 1/52. Alternative will be tramadol.
- One may consider tab Tamsulosin 0.4mg ON x 10 days ($0.70 a tab which causes
smooth muscle relaxation) if the following criteria are fulfilled :-
 stones 5-10 mm diameter and distal to the SI joint (If < 5mm, very likely to be
spontaneously expelled. If > 10mm, DO NOT prescribe as unlikely to have expulsion
despite Tamsulosin.)
 Age of pt <70y
 Strict advice MUST be given that Tamsulosin may cause postural hypotension and
pt has to take it before bedtime. When getting up from a supine/sitting position, pt has to
do it gradually and carefully due to risk of postural dizziness.
- Advice to return to DEM if :-

• persistent severe pain despite the oral analgesics
• fever /flank pain (pyelonephritis)
Guidelines to Management of UTI in a male
- Perform UFEME and urine c/s if underlying urological structural defect/BPH is

suspected to be the cause of the UTI. Prescribe augmentin/ciprobay x 1/52.
TCU Chinatown Family clinic 1/52 (trace UFEME and c/s OA) with urology routine TCU
(which may be 3-4/12 later for further investigations.
- If STD is suspected and there is presence of urethral discharge, perform a urethral

swab and UFEME and c/s. Prescribe doxycycline 100mg bd and ciprobay 500mg bd x
2/52. TCU Kelantan clinic 2/52 for contact tracing. Trace Urethral swab results OA at
Kelantan Clinic.
- Advise pt about additional costs for above urinary tests - ?cost
143
Conditions which warrant urgent Uro consult (to call Uro MO direct) with direct
admission
- ARU with failed urinary catheterisation
- Fournier’s gangrene, testicular rupture etc
- Unwell urological pts requiring HD bed.
- Pyonephrosis – as evidenced by hydronephrosis on U/S, presence of leucocytes on
UC-9 and positive renal punch. Blood culture to be done and pt is to be started on IV
rocephine or IV Ciprobay if allergic to penicillins.
For ALL direct Uro admissions, to CALL Uro MO to inform them of the admission
(not for consult) and to highlight any complications eg pyonephrosis etc.
Exception being gross haematuria which will need further input by uro MO on
call.
Management of Gross Haematuria:
Ensure patient not in clot retention.

1) If in retention, can attempt to insert IDC first to relieve symptoms.
- If drainage is faint haematuria with UC-9 showing UTI and pt is for discharge, to
prescribe oral antibiotics (ciprobay or augmentin) and TCU urology walk-in 2 weeks.
Admit if poorly controlled DM and/or patient unwell.
- If draining gross haematuria with clots or frank blood, ODD uro mo to review -> take
urine culture and start iv antibiotics(Rocephine/Ciprobay)
- Any difficulty with IDC insertion, ODD uro mo
2) If not in retention
- Visualise urine sample, if gross haematuria with clots or frank blood, ODD uro mo to
review
- Otherwise take urine culture, start oral antibiotics and TCU urology walk-in within 2/52
3) Any gross haematuria with recent urological procedures/surgery, ODD uro mo.
Scrotal pain:- for all patients , send UC-9
1) Young patients (<35Y) and acute onset within 24hours, need to exclude testicular
torsion
- ODD uro mo.
2) Older age group, scrotal mass > 3 days history

- treat as for Epididymitis Ochitis with oral ciprofloxacin 500mg bd and doxycycline
100mg bd x 2/52.
- TCU urology walk-in early within 1 week
3) If febrile/septic, suspicious of abscess/Fournier’s gangrene, ODD uro MO.
- do blood and urine cultures, start IV antibiotics
Written with Dr Allen Sim (Urology), Updated October 2015
144
EMERGENCY OBSERVATION WARD (EOW)
(Dr Chan Jing Jing)
The EOW is a unique set up in the Emergency Department where stable patients are
admitted for treatment of specific conditions.
The benefits are that they are considered inpatient (for Medisave and insurance
purposes) and they can receive inpatient care without being admitted to the wards. This
is especially helpful during times of high bed occupation rates.
Senior doctors must be consulted before placing on protocols. Patients need to be

admitted for a minimum of 8 hours, and a maximum of 23 hours. Should the patient’s
symptoms persist or worsen during this period, he will be transferred to an inpatient
ward.
Duties of the EOW MO
1. Take handover from the primary MO

2. Ensure all orders (medications, MSW, physiotherapy etc) are correctly entered into
the system in the EOW inpatient account.
3. Regular reviews of patient’s symptoms and signs (must be documented) and to alert
senior doctor in charge if there is any deterioration or new issues.
4. Prepare discharge documents and medications.
5. Update patient’s family.
List of EOW Protocols
Below are the EOW protocols in our department. Please refer to the Infonet for the
latest protocols.
Medical Conditions Surgical Conditions
Asthma Abdominal pain protocol

Bites and stings (allergy) Giddiness co-ordinated pathway (ENT)
Cellulitis Head injury
Chest pain Back pain
Gastroenteritis (dehydration) Minor injury
Giddiness Renal colic
Heart failure Toxic inhalation
Hyperglycemia
Hypoglycemia
Hypertension
Pneumonia
Pneumothorax
Poisoning
Pyelonephritis
Seizures
145
RESUSCITATION WORKFLOWS
(by Dr Kenneth Tan, Dr Pek Jen Heng)
INTUBATION WORKFLOW
Is NIV contraindicated?
Is intubation necessary?
Please check HIDS or past notes to check for resus status if possible
Preparation:
- Assess patient for possible difficult airway
- Prepare suction and intubation set, size of tube for paeds, age/4 +4, infants size 3.5
- Prepare glidescope or other rescue airway if needed
- ETCO2
- Prepare ventilator settings
- Prepare RSI drugs:
- Etomidate 0.3mg/kg, usual first line drug
- Propofolol 2mg/kg, consider its use in neurosurgical patients
- Ketamine 1-2mg/kg consider for sepsis, asthma or hypotensive
- Succinylcholine 100mcg if no hyperkalemia or neuromuscular disease. If any
present, please use
- Rocuronium 50mg
Preoxygenation:
- Consider delayed sequence intubation ie, proper preoxygenation or using NIV as an
interim
- Please prepare high flow intranasal oxygen in addition to preoxygenation for apnoeic
oxygenation
Premedication:
- lignocaine
- fentanyl
- atropine
Paralysis and induction:
- Rapid sequence induction with selected drugs
Placement/Position of tube:
- Ensure person who intubates sees tube pass through vocal cords
- 5 point auscultation
- ETCO2
- Inflate balloon
Post-intubation care:
- Connect to ventilator, practice permissive hypercapnia maintain SpO2 >94%, ETCO2
32-35, VT 6-8 ml/kg, RR 10-12
- Check CXR
- Sedation and analgesia
- Fentanyl or morphine bolus
- Propofolol infusion1mg/kg/hr
- IV midazolam 1-5mg/hr
146
- Judicious use of paralytic agents
- Look out for post intubation issues
Problems /Issues post intubation
Saturation dropping
- Disconnect from ventilator and bag patient
- Check ventilator: Is oxygen connected, Is machine faulty
- Not ventilator- Is it related to ETT? Reconfirm placement with ETCO2 monitor and
auscultation
- Not ETT issue- is it patient related. Look for pneumothorax and for ‘tight lungs’ in
asthma or COPD patients. Consider autoPEEP as well.
Hypotension
- Observe and start fluid boluses as it could be induction drugs
- If hypotension persist, start inotropes.
- Consider autoPEEP, disconnect ventilator and allow full expiration
- Consider PTX
147
MANAGEMENT OF SEPSIS
To diagnose sepsis:
2 or more of the following SIRS criteria in addition to bacteriaemia or
suspected bacteremia:
•
• HR>90/min
• RR>20/min
• WBC>12,000/mm3 or 4,000/mm3 or >10% immature forms
Sepsis
Initiate appropriate abx within the first hour

Adequate fluids
Severe sepsis If BP stabilizes and patient’s general condition improving,
or Septic Shock admit to GW with early review
Patient deteriorates
Initiate EARLY GOAL DIRECTED THERAPY (modified)
1. BP targets: MAP ≥ 65mmhg (aim higher if chronic hypertension)

IV fluid resus. If still hypotensive despite 2L of fluids or based on US assessement of
IVC, to initiate inotropes. Dopamine vs NA (will need CVP)
CVP line are usually not inserted unless high levels of inotropic support is needed.
2. Urine output ≥ 0.5ml/kg/hr
Catherise patients and fluid resus to achieve objective
3. Initial Lactate levels and followed by rate of lactate clearance
Start appropriate abx (as according to SGH ABX guidelines) within 1hr
All pts in severe sepsis or septic shock must have a lactate level done. High lactate levels correspond
to poorer prognosis
Arrange for ICA or ICU admission
Refer to: ProCESS, ARISE, ProMISE trials, SEPSISPAM
148
SEVERE SEPSIS/SEPTIC SHOCK CHECKLIST
CONFIRM SEVERE SEPSIS OR SEPTIC SHOCK,
Eliminate any other treatable causes
Perform blood cultures, lactate and blood gas
Catherise patient
Initiate IV fluids
Confirm fluid status by US of IVC and by urine output
Start IV antibiotics within the first hour
Use SGH antibiotic guidelines as reference
Consider the use of inotropes, blood transfusion and steroids as needed
149
CARDIAC ARREST AND POST CARDIAC ARREST
RESUSCITATE ACCORDING TO ACLS PROTOCOL
Is patient suitable for ECMO?

Please refer to ECMO protocol.
Yes/No
If for ECMO, please proceed to post cardiac arrest protocol
If ROSC achieved and for active management, proceed below
Proceed to investigate for cause of arrest
Start mechanical ventilation

6ml/kg RR 12, maintain SpO2 >94% and ETCO2 around 35-40
Start Therapeutic hypothermia if patient not responsive after 10mins

Start external cooling with ice pads. Start cold saline based on US
assessment of IVC with max 2L
Maintain MAP ≥ 65mmHg.
Catherise patient. Maintain urine output 0.5ml/kg/hr
Start IV insulin infusion. Maintain hypocount 6-10mmol
Start sedation if patient is waking up

- IV propofolol 1mg/kg/hr
- IV midazolam 1-5mg/kg
Consider paralytics agents as necessary
Arrange for ICU bed
150
ROSC Flowchart
Return of Spontaneous Circulation
post cardiac arrest
Assess if for further No For

active management comfort/palliativ
e care
Yes
Low pressure ventilation if

Identify and treat possible
underlying cause ie Maintain a MAP of 65 and
Start first at 6ml/kg, RR above.
continue with 5H and 10-12
5Ts Administer fluid resuscitation if
Aim SpO2 94-96 %., indicated or guided by bedside
KIV contact CVM for maintain pETCO2 35-40
PCI US
Catheterise patient
Start inotropes early, consider
CVP insertion if high doses of
inotropes needed to prepare
for NA or dual inotropes
Maintain h/c 6-10mmol if possible

giving boluses or start IV insulin
infusion if patient is waiting for
ICU bed Check blood sugar
hourly
Initiate therapeutic hypothermia if patient still unconscious

If unsure, observe patient for 10-15mins,
If GCS still low or unconscious, start cooling patient
- Start cold fluids max 2L- this is dependent on patient
fluid status as assessed by attending clinician.
- Apply ice pads externally
- Prevent patient from shivering. Consider paralysing
patient if needed
- Check temperature every half an hr if patient still in the
ED using rectal temperature
151
GUIDELINE FOR ACTIVATION OF CTS FOR ECMO- CPR IN PATIENTS WITH
CARDIAC ARREST IN ED
Patient still in Cardiac Arrest
ROSC
Continue
No ROSC despite CPR and resuscitation
ACLS for >15mins per ACLS
? Out of hospital
Cardiac Arrest (OHCA)
OHCA IHCA
Does it have any of the below Does it have any of the below
contraindications contraindications
Age > 65 yrs old Age > 65 yrs old
Un-witnessed Cardiac arrest Un-witnessed Cardiac arrest
CPR not initiated within 10mins CPR not initiated within 10mins
Total Arrest time > 30 mins Total Arrest time > 40 mins
Absence of Signs of Life Absence of Signs of Life
Initial rhythm Asystole Initial rhythm Asystole
Severe Chronic/ End organ Severe Chronic/ End organ

failure (kidney, liver or lung) failure (kidney, liver or lung)
Advanced Malignancy Advanced Malignancy
Severe brain Injury/ Preexisting Severe brain Injury/ Preexisting

neurological disease with poor neurological disease with poor
ADL ADL
Shock due to sepsis or Shock due to sepsis or
hemorrhage hemorrhage
Traumatic Cardiac Arrest
Traumatic Cardiac Arrest
Severe AR or suspected Aortic
Dissection Severe AR or suspected Aortic
DNR order Dissection
DNR order
Continue as per ACLS

CONTRAINDICATED
If fulfill the above with no contraindications, to contact CTS R1 after office hour
or ICU reg during office hours for ECMO support
152
APPENDIX
Definitions
ECMO- Extracorporeal Membrane Oxygenation
OHCA- Out of Hospital Cardiac Arrest
IHCA- In hospital cardiac arrest
SOL- Signs of Life, defined as pupillary reflexes present, Spontaneous breathing, VT,VF
or PEA
DNR- Do not resuscitate order- as decided by family or advanced medical directive
ECMO set to prepare
- Sponge Holder
- Gauze Pack x4
- Drape- Sheet x2, towel x6
- Surgical Blade- size 22 x1
- Artery Forceps x2
- Scissors x1
- 10cc syringe x2
- 20cc syringe x1
- Gallipot x1
- Saline
- Heparin
- Heparin saline
- Size 1-0 silk cutting x4
- 16 G single lumen arterial line x2
- Triple Lumen CVP set x1
- Ultrasound with equipment for sterile set
- Oxygen tank and power source
- Arterial pressure monitoring systems x2
Prepared by Dr Kenneth Tan Consultant DEM, Dr Mathew AC CTS,
Approved by
--------------------------------------- -------------------------------------
A/P Kenny Sin HOD CTS A/P Evelyn Wong HOD DEM
153
MISCELLANEOUS
SYNCOPE
(Dr Nausheen)
Important points in the History

Chest pain, SOB, palpitations, sweating,
Giddiness
Abdominal pain, radiation of pain, back pain, black stools
Headache
Fever
LMP and PV bleeding for women of child bearing age
Precipitating event – e.g. standing from lying, crowds
Aura and/ pre-syncopal symptoms- tinnitus, BOV, sweating, nausea
Duration, posturing, post-syncopal period (quickly returns to normal)
History of previous syncopal episodes
Past Medical History –Epilepsy, CHF, WPW, CAD, CMP, valvular heart dis, DM
FHX of Sudden cardiac death- Brugada and Long QT syndromes
Medications/Drug History
Important point in the Examination

Vital signs
Postural BP
General exam (Pallor, Hydration)
Chest (heart and lungs) exam; Cardiac murmurs; Pulses (equality and nature)
Abdominal (tenderness, masses) + Per rectal exam
Full Neurological examination
Differential Diagnoses
Cardiac causes
a) Obstruction to flow - Valvular heart dis-AS, MS, PS, HOCM, tamponade).
b) Dysrhythmias - Tachyarrythmias, WPW, Long QTc & Brugada syndromes,

bradyarrythmias, and pacemaker malfunction).
Vascular
AMI, Pulm Embolism, Aortic Dissection/AAA leak, subclavian steel, Pulm HYPT
CNS/Neurologic causes
TIA/CVA, SAH and other i/cranial bleeds, Seizures, Migraine
Situational
Micturation, defaecation, cough, valsalva, post-tussive
Hypovolaemic
Dehydration, internal bleeding e.g. ectopic pregnancy, BGIT
154
Metabolic
Hypoglycemia, hypoxia
Toxic
CO toxicity, other toxic exposures.
Vasovagal
Psychogenic
Anxiety/ panic disorder, conversion, hyperventilation, breath-holding spells
*May be mistaken for syncope: Seizures (atonic, absence)

Drop attacks (posterior circulation TIA, no LOC)
Presyncope, Vertigo, Atypical migraine.}
Suggested Investigations
Hypocount
ECG
Urine HCG
FBC, U/E/Cr
KIV D-dimer if suspected PE,
CXR
ED Management
If Cardiac syncope : move to resus and put on cardiac monitor, inform senior Dr, send
bloods, add TropT, treat according to ACLS, call CVM for admission KIV to monitored
bed.
If BGIT: iv fluids, iv losec, NBM, kiv NG tube, call GS for admission kiv monitored bed.
If hypovolaemic: IV fluids, supportive and directed treatment.
Disposition
As above, according to cause of the syncope
Admit all with Hx of CHF/ ventricular arrhythmia

Chest pain/ SOB with syncope
Examination suggests CHF/ valvular heart disease
ECG shows ischaemia, arrythmia, prolonged QT, Bundle branch/heart blocks
Hypotension with syncope; Hct<30%
References:
-Emergency medicine practice January 2004
-ACEP Guidelines 2001
-Derivation of San Francisco Syncope Rule to predict patients with short-term serious
outcomes. (Quinn JV, Stiell IG et al. Ann Em Med 2005; 43: 224-232)
155
SOB – shortness of breath
BOV – blurring of vision
CHF- congestive heart failure
CAD- coronary artery disease
CMP- cardiomyopathy
WPW –Wolff-Parkinson White syndrome
TIA- transient ischaemic attack
LOC – loss of consciousness
Hct – haematocrit
156
SGH DEM to BVH Transfer of ED patients
Workflow overview of respective roles
1. Senior ED physician
 Identify suitable patients’ early in the ED ( see inclusion criteria in BVH transfer form)
 Speak to patient/relatives of possible transfer to BVH for inpatient care for pain
control/rehab/respite care
 IF family agreeable then to admit to relevant protocol (MIP/HIP/LBP protocol), basic

bloods as deemed necessary.
 Activate the transfer to BVH
 Inform EOW nurse/Patient navigator nurse (Lay Hong, Seng).
 Call BVH on call to speak to the family physician about the case. Once accepted, this
can be documented in the BVH form which will be faxed to BVH BMU for bed sourcing.
2. Role of medical officer
 Fill up Community Hospital referral form (hardcopy).
 Refer orthopedics if required for f/up plan
 Refer physiotherapy for assessment specifically for patients with fractures/low back pain
, physiotherapist report to follow to BVH for continued rehabilitation
 For elderly >65years, to refer to ACTION team for psychosocial assessment (home
issues, care post discharge.) or inform DEM Patient navigator nurses ( Lay Hong ,
Seng)
 Towards the end of protocol, prepare all documents EOW summary, physiotherapy
summary, orthopedic appts date/time, 2weeks worth of medication
3. Role of EOW nurse
 Once BVH transfer is activated, please fill up the BVH transfer form and fax to BVH
business office.
 Await BVH return fax to confirm if bed available and which bed
 Arrange for ambulance transfer at specific time to pick up patient to transfer to BVH ( by
3pm that day or next day)
 Prepare all the documents and collect med from pharmacy
 Update patients’ relative of transfer time and which bed and family to come to ED to
accompany patient to BVH.
157
158
159
NEEDSTICK INJURIES AND PEP
Please refer to Infonet for the latest NSI and PEP protocols.
PATIENTS WITH RADIOACTIVE IMPLANTS
Please refer to Infonet for the latest protocol.
160
ADMINISTRATION
CULTURE OF SAFETY AND RISK MANAGEMENT IN DEM

(Assoc Prof Fatimah Lateef)
Introduction
The International Federation for Emergency Medicine defines an Emergency

Department as the “area of a medical facility devoted to the provision of an organised
system of emergency medical care that is staffed by appropriately trained personnel
and has the basic resources to resuscitate, diagnose and treat patients with medical
emergencies”
Doctors in the DEM face daily challenges that are unique. These include managing
conditions that are emergent and time-dependent. Despite these challenges the
patients must be treated with utmost care and respect, and be updated on their
condition and what they have to go through. Safe practice and promoting a department
wide Culture of Safety is critical to ensure the delivery of high quality care to our
patients. It is everyone’s responsibility to ensure our patients receive holistic,
appropriate care and are managed according to departmental protocols where
available.
Work in the DEM is also very much team-based and thus, it is important for doctors to
work with other staff such as nursing personnel, radiographers and even clerical staff to
ensure a seamless level of care as much as possible.
Universal Precautions, Personal Safety and Responsibility
It is important to apply all aspects of universal precautions in our day to day work. All
doctors must have gone through Infection Control Briefing and Training before
starting work in the DEM. If you have not, please update your supervisor who will help
to arrange. Wear gloves in all procedures and processes where there is contact with
body fluid, including blood taking. You are to don surgical masks in all areas of the
department. When handling and managing certain high risk cases and especially in the
Fever Area, there may be occasions where you may need to step up and use an N95
mask or don impervious gowns (alert advisory will be provided from time to time as
well).
All procedures involving sharps (venepuncture, IV cannula setting, suturing, delivering

injections, etc) must be managed responsibly. It is your responsibility to discard sharps
appropriately after each use. Do not leave these lying around in the cubicles and
bedside.
If you are involved in a needle stick injury, please clean the affected areas and
administer immediate care. You are to follow the Needle Stick Injury Protocol for
management and reporting as appropriate.
161
AS the DEM is often very crowded with people and trolleys, do be careful when moving
about, pushing trolleys and doing other procedures.
Reporting and Handling Complaints/ Feedback
All cases involving needle stick injuries, personal injuries or trauma, abuse of staff, falls,
medication errors , including near misses which were detected by another staff/
personal ( adverse effect did not reach patient) must be reported on the RMS System.
Please ensure you have access/ password to the RMS System. If you do not, please
contact the Nursing Officer on duty to assist you. Please report truthfully and accurately
what exactly happened in these cases, as each one will be investigated and assessed
in detail to sort out their root causes. If the senior staff request for you to be interviewed
and to make clarifications on the incident, please cooperate with them.
When patients or relatives bring up the issue of long waiting times to you, do
acknowledge (“I understand”) and apologise if you need to (“ I apologise you had to
wait”), without placing any blame on any components of the DEM ( eg “ we do not have
enough staff, we have several doctors on MC today or that staff is slow”)
If you are faced with any complaints and feedback you are unsure how to handle, do
highlight to the senior doctor on duty during clinical hours or consult your supervisor
(senior doctor assigned to mentor you)
Patient Identification and Right Siting and Ordering the Right medication
The patient load in the DEM is high and there are many days when it is very crowded.
Patients are also seen and managed in several different areas of the Department, eg,
Resuscitation, Critical Care Area, Consultation Area, Fever Area, the Chest Pain
Observation Unit or Emergency Observation Ward. It is thus very important that you
identify the patients appropriately and accurately. Patients may also be sent from one
area to another in the course of their stay in the DEM. Therefore, at every point of
contact with the patient do confirm their identity (do use two identifiers as much as
possible which include their names, IC number) to ensure you are managing the correct
patients. This is critical, as often there are patients who look very similar, have almost
similar names (including the spelling) and IC numbers. Wrong identification of patients
can have downstream repercussions and will affect a variety of processes such as
delivery of medication and care. This can be very serious and even harmful in some
cases.
In alignment with the above, do also ensure when taking blood tests and doing other
investigations, correct identification is applied as well . These should be quickly labelled
and ensure that you read and review the label you have printed in order to prevent any
mix-ups. X-Ray, CT scan and all other forms printed must be counter- checked against
the patients to ensure correct identification.
162
Similarly, when you pick up the patients folder or letters and ECGs belonging to them,
please ensure you return them to the appropriate folders for the particular patient.
Always check the names on these documents to ensure you are dealing with the correct
patient. Patients who have DRUG ALLERGY will have their notes placed in a pink or
red folder whilst the rest will have a clear transparent folder. If you are managing a
patient who has any drug allergy, please get the DRUG ALLERGY sticker and stick it
onto all their documents to help alert all providers who come in contact with the patient.
These patients should also have a red alert wrist tag with their names on it.
When ordering drugs on EMERGE, please always review and counter check your
orders to ensure you have made the right order and not ordered a next drug on the list,
due to parallax error. Also please check all allergies everytime you are making orders
Fall Precaution
If you are managing a patient with a predisposition to fall eg elderly, frail patients, those
with weak legs etc, please alert the nurse to put up the identification sign. These
patients will be kept closer to the nurses station as much as possible so that staff can
keep an eye on them. After you have completed managing a patient at their bedside,
please put up the cord side. If you have to leave the patient at any point in time, do also
put up the cord side to prevent patients from rolling over or falling.
Patient Handovers
Continuity of care for our patients is critical. Whilst you work shifts in the DEM, it is
important that you ensure appropriate and adequate hand-over of your patients at the
end of your shift to ensure all the relevant information, history, management plans, etc
get passed on to the doctor you are asking to follow up with the care/ who is coming on
shift. Please ensure these cases and patients are handed over electronically to your
colleague who should accept the transfer. You must also verbally pass these patients
on and include all the following information as relevant. Please document all these
clearly in the follow up notes on EMERGE.
(Refer to Annex 1).
Confidentiality and Privacy
All patients must be accorded the privacy they deserve in their management and care in
the DEM. Please draw the curtains when examining them and doing procedures, Do
explain and ask for permission when doing certain examination and procedures on
them. For male doctors and staff examining or doing procedures on female patients, do
ensure you have a female staff as chaperone at all times.
Our patients share a lot of important, personal and private information with us and it is
our responsibility to make sure we keep these in confidence and maintain confidentiality
163
at all times. When updating relatives, use the Family room or a private area as much as
possible so that medical information and care plans are not overheard by public
members in the waiting areas.
Finally, if you are taking photographs of patients or any part of the patients’ body please
ask for permission and consent must be taken formally on the forms made available.
This is even if the photographs are for teaching purposes.
164
Annex 1
Patient Handover Check List
1. Patient Identifiers
Name
Age
Sex
Location in Department
2. Diagnosis or Problem List
3. Treatment Plans
Test done/ results available or pending
Imaging done/ Results available or pending
Medication given or to be given
Referrals made and ODD referrals to be made
Test to be repeated as needed
4. Allergies
5. Communications
Relatives updated/ state relationship
Name of Doctor handing over

Name of receiving Doctor
Name of Senior Doctor to consult/ Senior Doctor in charge
165
SUPERVISION, PATIENT FEEDBACK & COMPLAINTS
Supervision
All medical officers, clinical associates, and residents are assigned supervisors who will
feedback to you about your performance. In addition, while on shift there are senior doctors
(registrars, senior residents, associate consultants, consultants and senior consultants) who will
supervise your clinical work. It is your responsibility to seek help, supervision or advice in the
following situations:
1. Procedures that you are unfamiliar with or are not credentialed to perform
2. Patients with time sensitive conditions – AMI, acute CVA, sepsis, open fractures
3. Patients with persistent abdominal pain, elderly patients with abdominal pain
4. Patients requiring observation under the listed protocols
5. Patients requiring admission
6. Patients who are unstable and require close monitoring or resuscitation
7. When in doubt with regards to patient’s presentation or physical findings or investigations or
management or disposition
It is your responsibility to be self-directed in your learning and practice. This MO guidebook and
the multiple assessments have been developed to enable you to be more competent and
independent in your management of emergency conditions.
Patient feedback and complaints
Patients often give feedback about the care they received from their doctors. They also often
want clarification about the experience. Upon receiving such feedback and requests from
patients, the HOD or Director of Clinical Service or Manager will forward the feedback for your
explanation of the events that had happened. This is an opportunity for service recovery, if
warranted. It is important for HOD, manager and SQ to understand your version of the story so
that they can craft an acceptable response that will prevent further escalation, and have the
case closed. Some SQ staff are non-clinicians and they do not have access to our patients’
records. Therefore, it is important not to assume that they understand the patient’s conditions or
your clinical decisions. Since they are in direct contact with the patient or relatives, they bear the
brunt of their expressions of unhappiness. We should not make things difficult for them as they
are on our side. Sometimes it is also a learning experience about medical knowledge, patient
care and systems based practice and improvement. If you encounter a difficult patient, do
document the incident in the patient’s confidential notes.
166
APPROPRIATE ORDERING OF INVESTIGATIONS, RESULT
ACKNOWLEDGEMENT
Appropriate ordering of investigations
There is no such thing as a routine test in the ED. Do not take the four blood tubes “just in case”
you need to add on blood tests later. Do not routinely order chest radiographs either.
You will have to discuss with the senior doctors with regard to ordering the following:
CRP, ProBNP, ESR, lactate, therapeutic levels of drugs, toxicology tests, CT scans.
The following tests are not to be ordered in the ED as they do not affect ED management or
disposition:
Pro-calcitonin, HBA1c, lipid profile, tumour markers, immunological markers
Do not order radiographs for every abrasion that you see on physical examination as this will
lead to over exposure of patient to unnecessary radiation and many fractures can be excluded
by clinical examination e.g. axial loading examination, functional testing, examining the gait etc.
The Canadian CT head rule is used for deciding whether to order CT head for head injury.
Results Acknowledgement
Please acknowledge all reported laboratory or radiological tests performed by you. Delayed
acknowledgement might result in delayed reimbursement of locum, night duty, call back,
transport or other claims as this is part of your job responsibility.
167
LEAVE, ROSTER, REPORTING SICK, OFF STANDBY
Leave matters (updated 08th September 2015)
1 MOs who wish to apply leave in the first month of the posting must inform either Ms
Sharon Huin or the Roster Planner before the start of posting.
2 Everyone is otherwise required to give at least 2 months advance notice for any leave
application; priority will be given to those who have forecasted their leave early. ( By the
end of 1st week of the posting, you should have forecasted your 2nd and 3rd months
leave, if there is any, and so on.)
3 At any one time, not more than 5 MOs are allowed to go on leave (this number might
change, subjected to the total number of MOs available).
4 Everyone is required to forecast his/her leave for the whole posting; he/she should
forecast as accurately as possible the dates and the periods of intended leave early in
the beginning of posting.
5 The categories of leave are shown as follow, in descending orders of priority for
approval:
i. maternity leave, in-camp training (should notify at least 3 months in advance, or as soon
as SAF 100 is received)
ii. training leave: for examination (for exam proper, not for studying), conference, or course
iii. marriage or paternity leave
iv. foreigner going back home town
v. all other annual leave
6 Please inform the roster planner about your exam/course leave in advance, even if
the exam dates or acceptance for course is not confirmed; this is because the
planner needs to take all leave commitment into consideration in order to advise other
applicants. It is always easier to cancel than to try and squeeze in a leave later. (Failure
to give prior notice might result in disapproval of leave application, regardless of
whether the examination or course has been fully paid for.)
7 Please limit your total leave period to a maximum of 2 weeks (calendar days) in the
whole 6-month posting. Any leave length longer than 2 weeks would require applicant to
speak to HOD for approval. The department might not be able to sign you up for the
posting if you take excessive leave.
8 You are discouraged to take multiple small blocks of leave consisting of 1 or 2 days that
covers weekends or PH.
9 The onus is in you to inform the roster planner of all leave/course you intend to take.
(Paper/electronic submission of leave or course does not imply that such information
will be passed on to the roster planner.)
168
10 Please remember to apply for your leave electronically once approved verbally by the
roster planner. Failing which your leave might be cancelled and will not be reflected on
the roster, and a competing request might be granted.
For those who have not electronically applied for leave after you have taken it, you have
up to 2 weeks post leave to apply for it, failing which we will apply leave for you and will
also send an email to MOHH informing them that you had taken leave but had not
applied for it. This has implications related to professionalism and integrity.
11 All training/conference/exam leave must be substantiated by proof of

course/conference/exam. Please document this electronically under the
“remarks“ section when you apply for leave.
12 Saturday is counted as 0.5 day in leave application, and Sunday is counted as an Off
day.
Leave over the festive periods
1 Please note that each person is allowed to apply for only 1 block of leave covering any
one of the coming festive periods: i.e. Deepavali, Hari Raya, Christmas, New year, and
Chinese New year.
2 Approval is based strictly on adequacy of working manpower; a ballot might be

necessary if there are too many applications.
3 You must decide and book the slot thru the roster planner by the 1st week of the
new posting if you do intend to take any of this leave.
Your cooperation to adhere to these guidelines would help greatly in the projection of
manpower, in engaging locum in advance, and thus eventually ensuring that everyone
has a fair and successful chance of obtaining leave.
Roster
1 You will need to submit your shift requests to the roster planner before the 15th day of
each preceding month. (You would be reminded thru emails of the deadline for
submission every month)
2 No Off-in-lieu will be given for working on PHs. You are to claim pay-in-lieu for all.
3 Please check your email regularly as communication will be mainly through

emails.
Executive: Ms Sharon Huin

Email: sharon.huin.p.s@sgh.com.sg
Roster Planer: Dr Tan Tiong Peng

Email: morequest@yahoo.com.sg
169
Reporting Sick
1 Please report to work and look for the senior doctor on duty (M2, E2 or c) as early as
possible if you are unable to work before any shift. You will be assessed clinically to
determine the number of medical leave days you require for rest. Medical certificate
from SGH DEM will be issued to you for submission. Medications, if any, will also be
given to you.
2 You need to submit and apply medical leave electronically for the day(s) of absence due
to sickness.
3. If 4 or more MOs report sick on any one day, you will be notified by phone to go to the
SGH staff clinic for further assessment and evaluation. Infection control team will also
be notified of the people taking MC for follow up measures. This is in view of the fact
that you are frontline staff and have direct patient contact who may have been infectious
during the course of your preceding shift(s).
4 For sick leave that falls on Night shift, you need to inform the senior doctor whether you
are applying for:
[a] 02 days of medical leave covering the Night shift and the following day (Night Off); or
[b] 01 day of medical leave covering only the Night shift, and you would be able to work
a shift on your Night Off instead.
5 You are not allowed to go overseas if you are on medical leave.
Off Standby and recall
1 All doctors have to remain contactable at all times as we have to be ready to respond to
any civil emergency.
2 In the event of manpower shortage due to medical leave or emergency leave by

medical officers or clinical associates, the OS1 (off-standby 1) will be activated to return
to work. In the event of multiple doctors being on emergency leave; the OS2 will also be
activated.
3 If the recalled OS works more than 6 hours, another Off day replacement will be given
subsequently by the roster planner; or claim locum pay in the event that a replaced Off
is not possible. (the roster planner will advise according to manpower situation and OS
cannot request which mode of compensation to give).
However, if the recalled OS works anything less than 6 hours, then no Off replacement
will be given, instead, compensation will be in the form of worked hours pay-back.
Please inform the roster planner of your OS recall timely in order to get your
compensation.
170
4 If OS1 is not contactable or is unable to return to cover the shift and resulted in OS2
being activated, then OS1 will have to give up an off day to repay OS2 (Roster planner
will subtract this off day from the roster and replace a shift from OS2 to OS1). In this
case the OS1 will not be able to claim ‘replaced Off’ or “locum” but will only be allowed
to claim the work as “emergency call back”.
MEDICATION ERRORS, CORRECT PATIENT IDENTIFICATION, MEDICAL

REPORTS
Medication Errors
The hospital and the department take medication errors very seriously.
Pay attention to the 5 rights:
1. Right patient – use two identifiers before giving a prescription and administering a drug. Not
uncommonly, the doctor fails to give the patient the right prescription because he/she had
printed the prescription from a wrong patient’s case notes.
2. Right drug – you must check that the drug you are about to give is intended for the patient
that you are attending to. Also be mindful of
- Drug allergies,
- Drug interactions e.g. with warfarin, anti-epileptics, OCPs and immunosuppressants,

macrolides
- Contraindications and adverse effects to certain drugs eg beta-blockers with asthma,

NSAIDs with renal impairment
3. Right dose – be careful when prescribing drugs that you are unfamiliar with. Also be mindful
of renal impairment and dose adjustments
4. Right route – do check if the drug is intended for oral or intravenous, or subcutaneous or
intramuscular or other routes and do be clear when writing the prescription.
5. Right time – be mindful of the dosing intervals
The hospital has installed the Rx Manager which has to be used for all discharge medications.
This has alerts to help you minimise medication errors, those of drug allergies, interactions and
renal dosing, and there is no excuse for not using this when writing prescriptions unless the
computer is experiencing a down time. However, you still have to make sure that the
prescription or medication is given to the right patient. The Rx Manager is there to help you but
nothing replaces safe practices e.g. look and ask for drug allergy before any drug is
administered.
When prescribing stat doses of medications to patients in the ED, be careful when you use the
EMERGE which does not have built in features to detect errors in dosing or interactions or
allergies. You are responsible for the correct dosing, allergies and interactions.
No verbal orders of drugs will be entertained by the nurses unless given in the resuscitation
room for resuscitation purposes.
171
For every commission of a medication error, you will have to write a report in the RMS to
describe why and how the error was committed and what steps you will take to prevent this from
happening again. Recurrent commissions of medication error will affect your performance
appraisal.
Correct patient identification
To prevent wrong laboratory or radiological investigations from being performed or wrong

prescriptions from reaching the patient, it is mandatory that you identify the patient and the
investigation or prescription forms with two identifiers. If an error is made in any of these
actions, it must be reported in RMS. Recurrent commissions of this error will affect your
performance appraisal.
Medical reports
Our department receives the most requests for medical reports. While they are not usually
urgent, the patient and hospital would appreciate our timely completion.
It is part of our job to write the reports. If for some reason you do not wish or cannot complete
medical reports that are assigned to you within the time frame, please ask Ms Wong Lai Peng to
help you reassign the report to someone else. You should however write those for patients
whom you had direct contact with.
Please complete your medical reports within 7 days of receiving them.
Always write down the diagnosis at the end of your report to minimise to and fro
correspondences between the lawyers and you for clarification.
With regard to neck pain after an RTA, do not use the diagnosis of whiplash but rather neck
sprain or neck contusion. The diagnosis of whiplash should be left to the orthopaedic consultant
when he reviews the patient.
Do not bounce the requests back to the MRO as far as possible. Trace the investigation results
online.
Try not to trace the hard copies of the medical records unless absolutely necessary, but use
whatever reports available from EMERGE/SCM. Only trace the records if there is a
contradiction between your diagnosis and the radiographic reports.
Do not answer on behalf of another department. If the patient has been referred to another
department after your encounter, please write, for example, "For further information about his
condition, please refer to the department of Orthopaedic Surgery". Then you can complete your
medical report in a timely fashion.
Do not bring the patient's records home. Leave them in your shelves/pigeon holes as the patient
might have an appointment and require his records. Many medical records have been
misplaced and lost as a result of doctors taking them out of the hospital.
Do not fill up insurance forms asking for percentage of disability unless you are absolutely sure
that there is no disability eg an abrasion. If there is a possibility of disability, the forms should be
redirected to the appropriate department eg hand surgery or orthopaedics. If in doubt, please
ask a senior doctor early so that medical reports are completed on time.
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July

DEPARTMENT OF EMERGENCY MEDICINE

You are expected to fulfill the following during your posting:

SURVIVING EMERGENCY MEDICINE

APPROACH TO CHEST PAIN

A. Life threatening Causes B. Other Important Causes

1. Acute Coronary syndrome 1. Cardio-vascular

Symptoms and signs Management

STEMI (ST-elevation MI) Uptriage to P1

Or if C/I for Ticagrelor: ventricular

Exclusion Criteria (Refer CVM stat if any present)

What Constitutes Informed Consent by A&E

1. Explain the cause of AMI

2. Explain the mortality and morbidity risk of AMI

3. Emphasize the need to recannalize the artery as soon as possible

5. Explain why primary PCI is better in terms of efficacy and safety

Unstable Angina Pectoris (UAP) Supplemental O2

Criteria Value Points

Age ≥ 65 Yes +1 14 day risk of all-cause

Aspirin use in past 7 days Yes +1 0 to 1 score is 5%

Risk factors for CAD : Family history of CAD, Hypertension, Hypercholesterolemia,

Symptoms and signs Management

Moderate to severe SOB Uptriage to P1

Symptoms and signs Management

If CPP uneventful, discharge with TCU

If elevated cardiac enzymes during CPP,

Hx of syncope FBC, U/E, ECG, Trop T, CXR

Sinus tachycardia Management

FBC, U/E, ECG

If bloods normal and tachycardia

Supraventricular tachycardia Management

If no response, can repeat IV adenosine

IV adenosine 6mg bolus

If NSR, observe in telemetry x 3 hours.

If persistent SVT, ODD CVM for

Atrial Fibrillation Management

Rate controlled Observe in telemetry x 3 hours

Advice to continue aspirin/warfarin if

TCU CVM arrhythmia clinic

FBC, U/E, ECG, CXR

IV Calcium channel blockers eg.

IV heparin 18 IU/kg pre-shock

ODD CVM for admission to HD

KIV IV digoxin 250 mcg over 30 minutes

Narrow complex tachycardia with See “Thyrotoxicosis”

Wide complex tachycardia Follow ACLS protocols

Criteria Value Points

Congestive Heart Failure History Yes +1

Hypertension History Yes +1

Stroke/TIA/Thromboembolism History Yes +2

Vascular Disease History Yes +1

Diabetes Mellitus History Yes +1

0 score is "low" risk and may not require anticoagulation.

1 score is "low-moderate" risk and should consider antiplatelet or anticoagulation*.

2 or greater is "moderate-high" risk and should otherwise be an anticoagulation*

Heart Failure Heart Failure with Requirement for

Adult congenital heart ACHD cases with

* When in doubt consult CVM

Definition: BP 140/90 mmHg or higher. No absolute BP defines a hypertensive crises,

Hypertensive emergency: elevated BP assoc with acute or on-going end-organ

Hypertensive urgency: elevated BP assoc with imminent end-organ dysfunction or

->On meds and what meds? Recent adjustments?

->On follow-up with?

to reinforce importance of compliance and lifestyle modification before dc

Please refer to Protocol for Management of GS cases in DEM