THE GP NOTE

Edited by Dr Firdause. A . H , GMC TVM

Contents Page no

Fever & other common OP cases 2

Pediatrics 19
ENT 25
Orthopedics 36
Medicine 42
Oral Medicine 104
Surgery 106
Ophthalmology 118
Dermatology 122
Psychiatry 134
O&G 137
Emergency cases 148
Procedures 181
ABG 192
Fluid balance & iv fluid therapy 216
Infusion charts 217
Transfusion medicine 220
Pre op & Post op Patients 222
ECG 227
X-ray 249
Lab 269
Injections & strength 274
Antibiotics 275
Drugs- s/e & c/I 283
Vaccination 287
BLS & ACLS algorithm 289
Referral letter 301
Breaking Bad 302
Organ/Tissue Donation 306
 2
THE GP NOTE
Edited by Dr Firdause. A . H , GMC TVM

Don’t try to do anything beyond your level of competence.

FEVER

Fever, if oral T >98.90F (at AM) or T>99.90F (at PM)

Note: 0C*1.8 +32=0F
Note: In case of fever with chills, suspect UTI, malaria, pneumonia, cellulitis, abscess,influenza,
leptospirosis, dengue, gastroenteritis, meningitis, tonsillitis, IMN, TB etc
P’mol C/I in severe liver diseases, renal impairment, infants < 2 kg.
Rx
1.inj P mol 2cc (150 /1 ml) im st (if t>1000 F). 100 ml(1000mg) infusion available(T.N
Paracip)
[for children 10-15 mg/kg/dose,1.5cc/1cc im st] (for infants and small children give
suppositories (T N:-Anamol), normally available as 80,125,170,250 mg; for <5 kg not
recommended); Inj Dolonex (piroxicam) 2cc IM st ATD if allergic to P/L
2.Tepid sponging with luke warm water st & SOS;give IV fluids for very high
fever(>1020 F).
3.Do BRE,ESR/CRP,URE , if infection is suspected & give Antibiotics for infection
4.T or Syp Meftal may be given Stat for high fever.
5.Rest till symptom free; avoid physical exertion; warm soft well cooked home available
food in small quantities frequently.
6.Antiulcerants(especially if certain antibiotics like macrolides, NSAIDs, steroids are
provided).
7.Multivitamin tablets with Vit B complex, vit C.
8.Steam inhalation for relieving ENT congestion.
Note- for recording correct temperature, it is recommended to keep the thermometer for
atleast 3 min in armpit and 2 min in mouth (regardless of the beep sound in digital
thermomometer).

Fever protocol
General approach to short febrile illness(SFI) including Influenza like illness(ILI)
Day 1: history taking and supportive care
More than 3 days: investigations based approach
Partially treated fever: investigation based approach
Note: ILI- a/c respiratory infection with fever≥ 38oC , cough. & onset within last 10 days.
SARI(severe a/c respiratory infection)- ILI +hospitalization.

In a Fever pt suspect and rule out

a)sepsis(infants and children: sick looking, poor activity, toxic appearance, inconsolable cry;
ask about feeding and urine output)
b)myocarditis: tachycardia out of proportion (>10 beats/0 F or >18 beats/ 0C)
c)pneumonia: tachypnoea out of proportion (RR>30/’)
d)meningitis/encephalitis: altered sensorium
e)impending shock: always check BP in sick patients
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Symptom based approach
a)with infective focus: do investigations and manage
common foci of infection: meningitis- neck stiffness, altered sensorium, tense bulging anterior
fontanalle in infants
pneumonia: tachypnea, xray to be taken on day 3
UTI: dysuria, chills and rigor
Cellulitis and sepsis: do a local examination
b)without infective focus
1)upper respiratory symptoms- sore throat, rhinorhea, sneezing: suspect ILI, ARI, SARI(severe
a/c respiratory illness); management as per ABC guidelines. In a child also consider pertusis
and diphtheria
2)without respiratory symptoms: consider dengue, malaria, leptospirosis, chikunguniya
3) with rash: consider dengue, IMN, Rubella
Hints with public health perspective
1.First consultation with fever, conjunctival congestion, severe myalgia, muscle tenderness, risk
of occupational exposure: leptospirosis is likely(consider starting doxycycline)
2.Fever, severe myalgia, conjunctival congestion and rashes- suspect dengue
3.Fever ,chills and rigor especially on alternate days, splenomegaly, migrant pt- suspect Malaria
4.Fever with rash, toxic febrile look, no response to usual antibiotics- look for eschar. Suspect
scrub typhus. Do appropriate investigations and start doxycycline
5.Fever,dry cough,throat pain,fatigue,rhinorrhea,sob, chills,headache,diarrhea,loss of smell or
taste- suspect covid-19
Investigations
Upto 3 days duration: none needed, unless specifically indicated.
Uncomplicated SFI/ILI: no need for investigations
Sick or has unusual symptoms: appropriate investigations- BRE, Plt ct, URE, LFT/RFT, CXR,
peripheral smear for malaria, IgM Elisa for lepto/dengue/scrub typhus etc
Check whether the Area has any specific/endemic disease.
Rx
1.tepid sponging
2.P/L( max 4g/day in adults). Inj P/L IM is not recommended. Iv infusion may be given in
refractory cases.
3.Review if: a)not improving in expected time frame
b)getting worse
c) danger signs: rash/fits/bleeding from any site/jaundice/oliguria/breathing
difficulty/altered behavior
d)not able to take food

Antibiotics
Note:In general, for mild infections use milder antibiotics
1.C Mox or Novamox 500mg 1-1-1 x 5 days (amoxicillin)
Indications:for RTI including bronchitis,sinusitis,otitis media, UTI
2.C Roscillin 500mg 1-1-1-1 x 5 days (ampicillin)
Indications:for RTI including bronchitis,sinusitis,otitis media, UTI
3.C or T Augmentin/Augpen/Mox CV 625/375 1-0-1 x 5 days (amox +clavulanic acid)
T.N:-T Moxiforce-CV or Mega-CV 625,Novaclav 625 , kid tab-228.Dose: 20 mg/kg/dose
BD; TDS may be given in severe infections.
Indications:for RTI , UTI, dental, skin and soft tissue infections, intra abdominal and
gynaecological sepsis, cat scratches,infected animal/human bites).
4.C Novaclox 1-1-1 x 5 days (amoxicillin +dicloxacillin)(dramaclox)(ped tab available)
5.C Megapen 1-1-1-1 x 5 days (ampicillin +cloxacillin)(kid tab available)
6.C Aldinir or Zefdinir 300mg 1-0-1 x 5 days (cefdinir)(very expensive)
Indications:pneumonia,a/c exacerbations of c/c bronchitis, Ent ,skin)
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7.C Phexin/ sporidex 500mg 1-1-1-1 x 5 days (cephalexin)
Indications:For bone and joint infections, pharyngitis, skin and soft tissue,tonsillitis, UTI
8.T Azithral or Azee 500mg 1-0-0 x 3 days 1hr before food(azithromycin).
May also be given as 500 mg once, then 250 mg OD for 4 days.
(specific for respiratory infections)(also for skin,STD’s, PID, urethritis, cervicitis)
9 T Roxid 150mg 1-0-1 x 5 days 30 min before food (roxithomycin)
(for RTI, ENT, skin & soft tissue, genital tract infections)
10.T Droxyl 500mg 1-0-1 x 5 days (cefadroxil);Syp (125 /5 or 250/5) available
(30 mg/kg/day in 2 div doses)(strep throat infections, UTI,skin)
11.T Taxim-O/ topcef 50/100/200mg(DT tab available) 1-0-1 x 5 days (cefixime)
(resp, urinary, biliary infections)
12.T Ciplox 500mg(100/250/750) 1-0-1 x 5 days (ciprofloxacin)(for UTI,bone,soft tissue,
gynaecological,wound infection, Bact gastroenteritis, Respiratory)(all other FQ’s C/I in
children)
13.T Norflox 400mg 1-0-1 x 5 days (norfloxacin)( for UTI & GIT problems) (advise to drink more
water).Best , if taken empty stomach with water, don’t take with diary products
14.T Oflox /Zenflox 200mg 1-0-1 x 5 days (ofloxacin)(c/c bronchitis, other respiratory, ENT)
15.T Levobact or Levoday or Loxof 500mg 1-0-0 x 5 days (levofloxacin) (advise to drink more
water)
16.T Septran/Bactrim d.s. 1-0-1 x 5 days (sulfamethoxazole 800 +trimethoprim 160)
(advise to drink more water) Syp available( 200 + 40)/5 ml
17.T Proflox 400mg 1-0-1 x 5 days (pefloxacin) ( for UTI & GIT problems)
18.T Cepodem/Monocef-o/podocef/macpod 100/200mg 1-0-1x 5 days(cefpodoxime)
(for RTI, UTI, skin and soft tissue).
19.T Klox (cloxacillin) 250/500 mg tds/Qid(furuncle, abscess, carbuncle, impetigo, osteomyelitis,
bites), syp (125 /5) (100-200mg/kg/day in 4 divided doses)
20.T clarithro/claribid/synclar (clarithromycin) 250/500 mg 1-0-1(resp, skin & soft tissue)
21.T Altacef 250/500 1-0-1(cefuroxime)(URI, LRI, UTI).

For children and infants most pediatric medicines are available in syrup/Drops.
0.1 ml= 2 drops
1-3 yrs =1/2 teaspoon(tsp) tds; 3-6 yrs =1 tsp tds; 6-10 yrs =2 tsp tds or 1/2 adult tabs.
One teaspoon= 5 ml; one tablespoon=15 ml
This can be used as a rough guideline to prescribe common pediatric medicines. The
dose should be adjusted according to the built and weight.

Commonly used antibiotics in children

1.Syp Amoxicillin (125 /5 or 250/5) [T N:- mox,Novamox](DT 125, 250 mg available)
Dose: 30-50 mg/kg daily in divided doses Q8H or Q12H. In Practice 15 mg/kg/dose Q8H
Novamox Dps (100 /1) available
2.Syp Augmentin/Mox CV 228 /5, 156 /5, 312 /5 available,(Amox + clavulanic acid) Novamox CV/ Mox
CV/Advent dps,each 1 ml contain amox=80 mg,clavulanic acid=11.4 mg. Augmentin/ Mox
CV Syp 457 (400 + 57)/5ml, 156(125 + 31)/5ml, 228(200+28)/5ml, 312(250 +62) available.
Dose: 20 mg/kg/dose BD
3.Syp Ampicillin(125 /5 or 250/5) Dose is 50-100 mg/kg/daily in divided doses Q6H
4.Syp Azithromycin(100 /5 or 200/5) {T N:- azee, ATM}(Dose for children above 6 months-10
mg/kg/day for 5 days)
5.Syp Cefixime (50 /5 or 100 /5 ) {T N:- taxim-o,topcef}(8 mg/kg/day in divided doses Q12H),
Dps 25/1 available
6.Syp Septran (sulfamethoxazole 200+ trimethoprim 40)(6-10 mg/kg/24 hr(TMP) div into 2
PO)(dose calculated in terms of mg of TMP).Paed tablets: (100+20)
7.Syp Ampoxin Or Syp Roscilox(ampicillin +cloxacillin)
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8.Syp Synclar/Maclar(125 /5)(clarithromycin)(15 mg/kg/day in 2 divided doses)
(URTI,LRTI,sinusitis,otitis media etc)(125 DT available)
9.Syp Kefpod/Macpod(50 /5 or 100/5)( cefpodoxime)(10 mg/kg/day div into 2 doses PO)
(LRTI,URTI)
10Syp Phexin(cephalexin)(125 /5 or 250/5) (50-100 mg/kg day in 3 or 4 doses PO)(DT 125, 250 mg
available). Phexin Dps 100 /1 available.
11.Syp Altacef (cefuroxime)(125 /5)(30 mg/kg/day div into 2-3)

For pregnant ladies

Amoxicillin,cephalosporins, ampicillin & cloxacillin combination,amoxicillin & clavulanate
combination,Penicillin G, Azithromycin(class B)

Antipyretics
Note:- In Children, if fever is accompanied by rashes,esp vesicular or maculo papular suspect
Chickenpox or Measles respectively. In measles, the child is usually sick looking with, rashes
starting from face. In newborns dehydration fever can occur, so encourage feeding the baby.
1.T Calpol/Panadol/Dolo 500mg/650mg/1000mg 1-1-1-1 x 3 days( p’mol or acetaminophen)
2.T Ibugesic or brufen 200/400/600mg 1-0-1 x 3 days(ibuprofen)
3.T Meftal or ponstan 250mg/500 1-1-1x3 days(mefenamic acid)(ideal for dental pain)
4.T Pirox /Dolonex 20mg 1-0-0 x 3 days(piroxicam)
5.T Ibugesic Plus 1-0-1 (ibuprofen+ P’mol)
6.T Meftal forte/ meftagesic(Meftal 500 + P/L 450)
For children
1.Syp P’mol(125 /5 or 250/5)(10-15 mg/kg/dose x 4 times)(C/I in less than 2 kg)
T N:- Calpol,crocin,dolo,febrinil,febrex etc.(Calpol, Dolo,Babygesic,Crocin,Febrinil dps available)
Nopain dps(15 ml) (100 /1) available, Tab 125 available
2.Syp Ibuprofen(100 /5)(8-10 mg/kg/dose x 3 times)(may precipitate aspirin induced asthma, so
don’t give to asthmatic or dyspnoeic pts).Syp ibugesic plus(ibuprofen 100 + P/L 162.5 /5 ml)
Another formula: dose in ml= wt / 2
3.Syp Meftal(50/5 or 100/5) (generally not used < 6 months)(8 mg/kg/dose x 3 times a day)
(DT-Tab 100 available); ( wt x 4/10 = dose in ml, applicable only for 100/5 formulation)
Syp Meftagesic(P/L 125 mg, mefenamic acid 50mg/5 ml)
For pregnant ladies
P ‘mol only
Vitamins
Usual dose: 1 tab od or bd
1.T Becosules/Beplex forte/Polybion(syp available)(vit B complex, vit C, )
2.T Zevit / Becozinc(syp available)(vit B complex , vit C, Zn sulphate)
3.C Nutrolin B plus(syp available) (vit B complex, lactobacillus)
4.T Neurobion forte (syp available)(vit B complex)
5.T BC (β- carotene, vit E, vit C -antioxidants)
6.T Celin 500mg OD(vit C)
7.T MVT OD(multivitamins)
8.T Health Ok ( multiviamins, multiminerals, aminoacids with taurine & ginseng)
For children
1.Syp/Dps A to Z(vit A,vit B complex, vit C,vit D,Fe,Se,iodine)
2.Syp Zincovit(vit A,vit B complex, vit D,vit E,Cu,Se,Zn,iodine),
3.Syp osto-polybion D(Vit B12,Vit D3, Ca2+)
4.OH-D3 /Ultra D3 /Bon D light dps(400 IU/ml)(Vitamin D3 or cholecalciferol) 1 ml OD for infants.
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Iron preparations (can be given in pregnancy)
1.T Autrin(fe fumarate + folic acid +b12 +c) od
2.T Macalvit / Shelcal(ca carbonate+vit D3) od (syp Shelcal & Shelcal kid tab available)
3.T Fefol-Z(fe sulph+ folic acid +b12 +c+Zn) od
4.Syp Vitcofol(fe fumarate+ folic acid +b12)
5.T orofer –XT( 0-1-0)(elemental Fe + folic acid)Dps /Syp available
Note: fat soluble vitamins like A,D,E, K are not excreted in urine. So may be toxic in excessive
quantities.

Anti ulcerants
Rx
1.T Rantac/zinetac/aciloc 150 mg 1-0-1(ranitidine)(30 min before food), T Rantac OD 300 also
available; (Ped dose 2 mg/kg/dose x 2 PO,1-2 mg/kg/dose IV ), syp rantac 75/5,
2.T Pantocid 40 mg 1-0-0(pantoprazole)(30 min before food)(ped dose: 1 mg/kg/dose PO OD)
T Pantop-IT(with itopride), Pantop-L(with levosulpiride). Inj Pantop 40 mg iv od/bd
3.T Rabicip/happi/Razo 20 mg 1-0-0(rabeprazole-fast acid suppression). Inj rabicip 20 mg iv od
4.C Omez 20 mg 1-0-0 empty stomach(omeprazole)(1 hr before meal)
5.C Rabicip D/Roles-D (with domperidone) , Pantop- D( with domperidone)
6.T Lanzole 30 mg 1-0-0 (lansoprazole)
7.T Lesuride 25 / 75mg 1-0-0; Inj Lesuride 2ml (25 mg) iv od
8.T Sompraz 20 mg or 40 mg OD(esomeprazole)
9.T ilapro 10 mg OD(ilaprazole)
Antacids (to be taken after meals and at bedtime)
10.Digene 2tsp tds(Simethicone+Mg(OH)2+Al(OH)2+ Na carboxymethylcellulose)
11.Gelusil MPS 2tsp tds(Simethicone+Mg(OH)2+Al(OH)2+Mg Al silicate)
12.Rantac MPS(Magaldrate+Simethicone)
13.Mucaine(Mg(OH)2+ Al(OH)2+ oxethazaine)
14.Tricaine MPS(Simethicone+Mg(OH)2+Al(OH)2 +oxethazaine)
Antacids: 1-2 ml/kg/dose in infants;5-15 ml/dose every 4-6 hr in children
Note: Take antacids 2 hr before or after ingestion of other drugs to prevent drug interaction
Ulcer protective
15.Syp sucralfate . Max dose- 1g six times a day. Usually comes at a conc of 1g/10 ml.
Note- Antacids should not be given 30 min before and 30 min after sucralfate.
For children
Syp or Tab rantac, T Pantop, T Junior Lanzole 15 mg OD(1mg/kg/day)
For pregnant women
1. Digene 2tsp tds
2. Gelusil MPS 2tsp tds and other antacids
3.T Ranitidine. Inj Rantac can also be given
Steam inhalation may be with
1.Vicks/amrutanjan/tulsi leaves/2-3 dps of essential oils like eucalyptus oil,camphor etc
2.Tincture Benzoin
3.Karvol Plus / Sinarest / Nosikind inhalant capsule (camphor, chlorthymol, eucalyptol, menthol,
terpineol)
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COUGH
Cough is a commonly encountered symptom of various conditions; both pertaining to the
respiratory tract or even of extra respiratory origin( such as GERD).
Etiology-RTI(bacterail & viral), TB, a/c exacerbation of c/c respiratory diseases like asthma/
copd/ILD/bronchiectasis, smoking, GERD, drugs like ACE inhibitors, exposure to organic or
inorganic fumes or irritants, upper airway cough syndrome, inhaled FB/toxic fumes etc
A/c cough < 3 weeks; sub a/c - 3-8 weeks; c/c cough > 8 weeks. Increased Cough particularly at
night should raise suspicion of asthma; seasonal variation of cough may be due to asthma or
bronchitis; while changes in cough with postural variation may be due to lung abscess or
bronchiectasis. Ask for cough+fever+night sweats+ wt loss(cardinal symptoms of TB)
Pharyngeal demulcents provide symptomatic relief in dry cough arising from throat.
Note:give antibiotics if infection is suspected.
Inv-Advise an X-ray chest, sputum-AFB,culture & sensitivity,Gram stain, for otherwise
unexplained Cough>2-3 weeks not responding to antibiotics or cough with haemoptysis/chest
pain/PUO/weight loss/severe breathlessness/fever>48 hrs on antibiotics. Advise adequate
hydration to help expectoration.
Rx
For bronchodilation and expectoration:
1.Syp Ascoril / Bro-Zedex 2tsp tds x 3-5 days (terbutaline sulphate +bromhexine+
guaiphenesin)(Tab available)
3.Syp Asthalin expectorant 2tsp tds (salbutamol+ guaiphenesin)
Dosage: <6 yr= 5-10 ml tid, 6-12 yr= 10 ml tid
4.Syp Ambrolite-S 2tsp tds x 3 days ( salbutamol +ambroxol hcl+ guaiphenesin)
5.Syp Ambrodil-S 2tsp tds x 3 days (salbutamol +ambroxol hcl)
6.Ascoril- LS Syp or Dps(levo salbutamol +ambroxol+Guaiph)
7.Syp Dilosyn Expectorant(Methdilazine HCl+ ammon Cl+Na citrate)
8.Syp Piriton Expectorant (Chlorpheniramine maleate+ammon Cl+Na citrate)
9.Syp Grilinctus BM (terbutaline sulphate +bromhexine)(Tab and Paed syp available) (for
Bronchial asthma, a/c & c/c bronchitis,bronchiolitis, other bronchospastic disorders)
11.Syp Ambrodil/mucolite/ambrolite (Ambroxol)(15/5 or 30/5) 2tsp tds <2y=7.5 mg bd, 2-5y=7.5
mg bd/tid, 6-12 y= 15 mg bid
Ambrodil/AX/xputum paed Dps (7.5 /1 ) <6 month- 0.5 ml bd,6-12 month- 1ml tds,12-24 month-
2ml tds
Tablets
12.T Mucolite/ambrodil (ambroxol) 30 mg tds
13.T Bromex (BH) 8 mg bd/tds
14.T Mucinac 200/600 mg bd/tds (acetylcysteine)
15.T pulmoclear(acebrophylline 100 mg+ acetylcysteine 600 mg) BD
For children: Syp Asthalin ( 2 /5 )(0.1-0.2 mg/kg/dose Q6H) after food or
Zerotuss XP Dps (Levosalbu 0.25 mg/1ml +ambroxol 7.5 mg/1ml+ Guaiphenesin 12.5 mg/1ml)
For cough suppression:
1.Syp Viscodyne D 2tsp tds x 3 days(tripolidine hcl+ pseudoephedrine +dextromethorphan hbr)
3.Syp Piriton/ Dilo-Dx / solvin cough/ Cheston CS 2tsp tds x 3 days(CPM + DM hbr)
5.Syp Ascoril-C/Linctus codeine/codistar /corex 2tsp tds x 3 days(Codeine Phosphate + CPM)
6.Syp Alex cough formula 2tsp tds x 3 days(CPM+Phenylephrine+ DM Hbr)
Dosage:1-5 y=1.25 ml, 6-12y=2.5 ml,>12 y=5 ml tid/qid
7.Syp Ascoril-D 2tsp tds x 3 days(tripolidine hcl+ phenylephrine+DM hbr)
Dosage:2-5 y=2.5ml tds, 6-12 y= 5 ml tds,>12y=10 ml tds
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8.Syp T-minic cough 2tsp tds x 3 days(Phenylephrine hcl +DM hbr)
9.Syp coscopin Plus (Chlorpheniramine maleate+ammon Cl+Na citrate + noscapine)
10.Syp Ambrolite-D 2tsp tds (pseudoephedrine hcl +DM hbr+cetrizine)
11.Syp Zedex 2tsp tds(bromhexine hcl+DM hbr)Dosage: 2-6 y=2.5 ml, 6-12 y= 5 ml
12.Alex Paed Dps /Solvin Cold Dps (CPM+Phenylephrine)
13.Flucold Dps(phenyl propanolamine+ CPM)
14.Syp Zedex-P(DM+bromhexine +phenylephrine); 2-6= ½ tsp, 6-12= ½-1 tsp,(for paediatric
cold, cough)
15.Syp Zerotuss (levocloperastine fendizoate)(cloperastine- cough suppressant acting on CNS)
16.Syp Benadryl (diphenhydramine)
17.T Cheston-DT(CPM+phenyl propanolamine+ BH),T Codifos(codeine) 10 mg, T Sedosolvin
(DM+CPM+BH), T Deletus (DM + tripolidine + phenylephrine)
Note:codeine c/I in asthmatics; codeine as a cough suppressant is not recommended for < 2yrs.

For pregnant ladies give Syp Ascoril, Syp Grilinctus (DM hbr + guaiphenesin + CPM),
Syp Benylin expectorant(Guaifenesin +DM Hbr) or Syp Robitussin DM

For diabetics: Productive cough-Ascoril SF, Macbery-XT;

Dry cough-Robitussin CF(DM hbr + guaiphenesin+ psuedoephedrine)
Tusq-Dx(DM hbr + CPM +phenylephrine hydrochloride ),
Benylin Adult , Alex sugar free , zerotuss- SF can also be given

Lozenges: Alex/Chericof (Dextromethorphan 5 mg), Tusq-D (DM + Amylmetacresol),

strepsils(benzyl alcohol, metacresol)

Analgesics
NSAIDS
1.T Diclofenac sodium 50/75 mg bd(TN:Voveran/Diclonac/Dicloran)
(Diclofenac suppository 12.5mg, 100mg available.TN:Jonac)
2.T Ibuprofen 400-600 mg tds(Ibuprofen) (T N:-ibugesic, brufen, Ibuflammar)(100 mg/5
ml susp available)
3.T Mefenamic acid 250-500 mg tds (T N:-Meftal, Ponstan, Medol)(100 mg/5 ml susp
available)
4.T Aceclofenac 100mg bd (T N:- Aceclo, Dolokind,Zerodol)
5.T Ketorolac 10 mg Qid( TN:Ketanov )(for Post operative, dental, a/c musculoskeletal,
renal colic, migraine, pain due to bony metastasis)
6.T Piroxicam 20 mg OD (TN:Pirox/Dolonex)(for osteo/rheumatoid/ acute gouty arthritis)
7.T Indomethacin 25-50 mg BD-QID (TN:indocid/ articid)(musculoskeletal & joint
disorders)
8.T Etoricoxib 60-120 mg OD(TN:Etoshine/etody)(for osteo/rheumatoid/ acute gouty
arthritis)
Note: Avoid NSAIDs in Dengue,severe liver/kidney d/s,active cerebral hemorrhage,GI
bleeding etc. NSAIDs may also increase the risk of having a stroke or MI in pt’s with existing
cardiovascular disease. In such cases give T Naproxen 250/500 mg bd(T.N Artagen)
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Opioid Analgesics
1.T Tramadol (Trambax or Tramazac) 50 mg tds
2.T Pentazocin 25 mg Qid (Fortwin)
Combinations
1.T Ultracet or Palitex or Dolzero or acuvin(Tramadol+ P’mol) BD/TDS
2.T Dynapar (Diclofenac + p’mol) (Inj available)
3.T Zerodol-P or aceclo plus or Hifenac-P or Dolokind-Plus (Aceclofenac+ P’mol)
4.T Durapain (Diclofenac sodium SR +Tramadol IR) BD
5.T Ibugesic Plus/combiflam (ibuprofen + P’mol) BD/TDS
Note:- for pregnant ladies give P’mol only
Injections: P/L, Diclofenac, Tramadol, Ketorolac, Piroxicam, Pentazocin etc
Tramadol may cause nausea( give emeset),dizziness,sleepiness,sweating, lowering of
seizure threshold.

Abdominal Pain
Common causes: Renal calculi,appendicitis, pancreatitis, intestinal obstruction, peptic
ulcer, Gastroenteritis, cholecystitis, GERD,UTI, medications,mesenteric ischemia etc
Note:In case of renal colic there will be colicky pain radiating from the loin to groin and
h/o similar episodes in the past. All abd pain above the level of umbilicus, rule out
I.W.M.I. Also rule out DKA.
Examination of genitourinary system in men should be performed in all cases of a/c abd
pain to r/o testicular torsion.
Inv: URE,BRE, X-ray abdomen erect view(>3 air fluid levels s/o bowel obstruction)
& supine view(for site),ECG,RBS, USG/CECT abdomen,LFT, RFT, S.amylase &
lipase etc. R/o pregnancy in female pt’s before subjecting to x-rays.
Rx
The immediate treatment of renal pain/colic is bed rest & application of warmth to site.
1.Inj Voveran 1 amp IM st ATD or
Inj Tramadol 1amp IM or slow IV st(+ inj emeset)
2.Inj Buscopan 1 amp IM or IV st ATD(hyoscine butyl bromide, anti spasmodic) or
Inj cyclopam 2cc IM st (Dicyclomine HCl, anti spasmodic) or Inj Drotin 2cc IM st ATD
(drotaverine, antispasmodic)
3.Inj Pantop 40 mg iv st or Rantac 50 mg iv st
If pain is very very severe: Inj Fortwin 1amp IV/IM + Inj Phenergan 1amp IM /IV st
Note: don’t give opioids in undiagnosed abdominal pain, as it is C/I in biliary colic;
fortwin is relatively safer in biliary colic compared to other agents
4.T voveran 50 mg 1-0-1 or T Buscopan or hyocimax(hyoscine/scopolamine)10 mg tds
or T Hyocimax-S (hyoscyamine 0.125 mg) 1-1-1-1 or T Drotin (drotaverine) 40 mg 1-1-1
Or T Cyclopam (Dicyclomine HCl 20 mg + P/L 500 mg) 1-1-1(SOS in pregnancy) or,
T Zerodol spas/aceclo spas(aceclo+ drotaverine) 1-0-1;
For children: Inj Buscopan 0.5 mg/kg slow iv/IM
Syp Cyclopam(Dicyclomine 10 mg+ simethicone)(10/5) (generally not used <6
months)(0.5 mg/kg/dose x 3 times)(> 6 months:up to 5 mg/dose,children 10 mg/dose)
 10
5.T Pantop 40 mg OD; for children:- T Junior Lanzole OD; Plenty of oral fluids
Loin pain, etiology:renal colic, UTI,pyelonephritis,PUJ obstruction,muscular pain,
herpes zoster, PCKD, cholecystitis, glomerulonephritis, BPH, AAA, renal infarction,
kidney tumours, LPH syndrome(Loin Pain Hematuria), lumbar hernia.
Note: NSAIDs are generally not preferred for abdominal pain except for ureteric colic,
since it can aggravate peptic ulcer disease. Always rule out acid peptic disease and
asthma before prescribing NSAIDs. Avoid NSAIDs if renal dysfunction is present.

Vomiting
Common Causes:gastroenteritis, migraine,drugs,pregnancy, food poisoning,alcoholic
gastritis, renal colic, peptic ulcer,viral hepatitis,cholecystitis, labyrinthine disorders,
uremia,dengue,appendicitis, pyelonephritis hypokalemia etc
R/o MI,CVA,raised ICT,meningitis, encephalitis, hypertensive encephalopathy, DKA,
poisoning(like odollum-hypotension, bradycardia, weak pulse, diarrhoea)
Inv:FBC, RFT,LFT, RBS, S. Amylase,ABG,ECG, AXR, CT head etc

Rx
1 Inj Emeset(2mg /1ml) (0.1 mg/kg/dose) (Ondanestron) 4mg/8mg iv / Inj Perinorm(5mg /1ml)
1 amp iv / Inj Stemetil(prochlorperazine) 12.5mg im ST/ Inj Phenergan(25mg /1ml) 25mg
iv(0.5-1 mg/kg/dose IM/IV in children). For severe vomiting, Inj Perinorm + Emeset can
be given.
If vomiting is due to chemotherapy, give Inj Emeset 4mg iv Q3H+ Dexa 4 mg iv st
2.Inj Rantac 50 mg iv ST or Inj Pantop 40 mg iv st
3. Corticosteroids have adjuvant action. Inj Dexamethasone 4 mg iv st
4. Check BP, If low give IVF RL/ Isolyte P +DNS
5.T Domstal(Domperidone)10mg(5mg, 10 mg DT Tab available) 1-0-1 x 2 days(15-30 min
before meals) & SOS or T Emeset 4/8 mg bd Or T Perinorm(metoclopramide)10mg tds(30
min before meals) or T phenergan (promethazine) 25mg bd
6.T Zofer MD 1 SOS(mouth dispersible preparation of ondanestron)
7.T Rantac 150 mg 1-0-1 x 3 days
For children:-
Syp Domstal(1mg /1ml) (0.2 mg/kg/dose x 3 times)(Domperidon) or Syp
Grandem(Granisetron) (1mg /5ml) (20 microgram/kg/dose PO) or Syp
Phenergan(5mg/5ml)(1mg/kg/dose),Syp emeset or Vomikind(2mg /5ml)(children above 5
yrs:4mg/dose PO tds, for smaller children:0.1 mg/kg/dose bd/tds), Syp Perinorm(5/5)(0.1
mg/kg/dose; may ppt seizure)Vomistop Dps(Domperidon) 1mg /1ml ,10mg /1ml available
For Pregnant ladies:-
T Doxinate 2 tab HS(Doxylamine + Pyridoxine) Or perinorm Or T Avomin(Phenergan) SOS
& tds or T Pregnidoxin(Meclizine HCl) SOS & tds or T Emeset.
Inj Perinorm(IV or IM) or Emeset (IV) or Phenergan(IM) can be given
Note:-In adults we may give perinorm, but it is better avoided in children as it may produce
extrapyramidal symptoms. Phenergan has the advantage that it may be used for the
treatment of extrapyramidal symptoms. It also produces some sedation.
 11
If Drug induced extrapyramidal reaction occurs
(Drugs: antipsychotics like haloperidol,chlorpromazine, antiemetics like stemetil,cinnarizine)
1.Stop offending drug
2.T Diazepam 1 st
3.Inj diazepam 2cc IM or IV or Inj Phenergan 2cc IM or IV

Loose stools
Find out whether it is diarrhoea, pseudodiarrhoea, fecal incontinence from history
Aetiology:infection,drugs(certain antibiotics/PPI), a/c IBD, toxin, food intolerance,
diverticulosis
Ask for associated fever(r/o leptospirosis), blood/pus in stools, abdominal
pain,consistency of stools etc.
Rx
1.C Zedott or Redotil 100mg (racecadotril, 1.5 mg/kg/dose in children) or Redotil 10 or 15 or 30
mg sachet x tds can also be given or
T Lomotil(atropine sulphate 0.025 mg, diphenoxylate HCl 2.5 g) (C/I for children <6 yr,
pregnancy, obstructive jaundice)1-1-1-1 x 3 d. Note: Lomotil not used nowadays.
2.T Nutrolin B/ C Vizylac/C Darolac(lactobacillus combinations) 1-1-1(darolac sachet available)
Note: probiotics ideally given for antibiotic induced diarrhea
3.T Cyclopam/ Buscopan 1 SOS, for abdominal pain.
4.Check BP, If low give IVF RL/ Isolyte P +DNS
5.ORS in small sips( unit dose 4.3 g packet to be mixed with 200 ml & multidose 21.5 g packet
to be mixed with 1 L or 5 glasses of boiled & cooled water).Flavoured ORS available in tetra-
pak -Electrokind,electral, electrosip,elect
Dosage after each purge: <6months :50 ml or 1/4 glass, 6months-2years: 50-100ml(1/4-1/2
glass), 2years-5 years:100-200 ml(1/2-1 glass), >5years:as much as able to drink.If child vomits,
wait for 10 min & then resume feeding. Also give Plenty of oral fluids (home available)
6.Report blood or pus in stools
For children, also give Zn,(0.5 mg/kg/day or 10 mg daily for age 2-6 months & 20 mg for >6
months). T.N: Z & D syp/dps(Zn sulphate) or Mintonia syp(Zn acetate) x 2 weeks (syp 10 or 20
mg/5 ml or Dps 20mg/1ml). Below 2 months not indicated.
Note:- if very severe, for adults give Imodium / Lopamide 2mg ( loperamide) 2 tabs stat, then
1 tab after each episode (C/I in <4 yrs and in acute infective diarrhoea and pregnancy)
For Pregnant ladies:-
Give ORS, Darolac sachet, oral fluids
Child-hood diarrhea/ADD
No dehydration→well alert, eyes normal, tears present, mouth & tongue moist, normal thirst,
skin pinch goes back quickly:50-100 ml ORS (if <2 yr) & 100-200 ml ORS (if 2-10 yr) per purge
For >10 yrs as much as wanted. Generally,give one teaspoon every 1-2 minutes.
For some dehydration→restless, irritable, eyes sunken, tears absent, mouth & tongue dry,
thirsty & drink eagerly, skin pinch goes slowly→75 ml/kg ORS in 4 hr and if dehydration
subsides 10-20ml/kg after each stool. If not repeat 75 ml/kg ORS in 4 hr.
For severe dehydration→lethargic or unconscious, eyes very sunken & dry, tears absent,
mouth & tongue very dry, drinks poorly or unable to drink, skin pinch goes back very
slowly→IVF Ringer Lactate 30 ml/kg in ½ hr followed by 70 ml/kg in next 2 ½ hr .In infants <12
months 1 hr & 5 hr respectively
 12
If macroscopic blood,fever,pus,mucus, foul smell , treat as DYSENTRY( a/c diarrhea with
visible blood loss in the stools).Do Stool microscopy & culture.Caused mostly by shigella,
entamoeba.
Traveller’s Diarrhoea prevention-Hand washing with soap, drink with straw, avoid ice, salads,
shellfish. Boil water.
Rx
1.In a febrile pt, antibiotics are used empirically.
T Ciplox TZ 1-0-1 x 5 days(ciplox + tinidazole)// Zenflox-OZ (ofloxacin 200 mg+ ornidazole 500
mg) (others:norflox,cefixime,doxycyclin,cotrimoxazole) (If giardia infection is suspected,
metronidazole 400 mg tds x 7 days or tinidazole 2 g OD single dose is also added).Dose of
tinidazole in amoebic dysentry- 2g OD x 3 days. T Azithromycin 500 mg OD x 3 days
For Traveller’s diarrhoea, ciprofloxacin 750 mg single dose or Azithromycin 1g single dose or
ofloxacin 400 mg or levofloxacin 500 mg single dose can be used. But if s/s are not resolved
after 24 hours, complete a 3 day course of antibiotics.
2.C Zedott or Redotil 100mg (racecadotril) 1-1-1 x 3 days
3.T Nutrolin B(Ped tab available)/ C Vizylac/C Darolac/yogut 1-1-1 , T VSL 3(probiotic) (0-1-0),
Syp or C Enterogermina (bacillus clausii, probiotic)Enterogermina dose: adults: 1 Capsule bd or
tds; children:1 capsule od or bd or Syp 5ml bd, breast feeding infants 5 ml od or bd for 2-5 days
4.T Cyclopam/ Buscopan 1 SOS if abdominal pain
5.Check BP, If low or if dehydrated, give IVF RL/ Isolyte P +DNS
6.T Rantac 150 mg 1-0-1(Proton Pump Inhibitors may cause drug induced diarrhea)
7.Fluid managment same as above;Plenty of oral fluids
In PEDIATRIC cases , old regime: SEPTRAN(cotrimoxazole) or GRAMONEG 300/5 (Nalidixic
acid)(55 mg/kg/day in 3-4 div doses; not to be used below 3 months) .
New regime: ciprofloxacin15mg/kg bd. Cefixime can also be given
In pregnant women- Azithromycin can be used.
Note:- 5 % /10% dextrose not given

Anaphylactic shock
Rx
1.Inj Adrenaline 0.5mg IM or SC(in children: 0.01 ml/kg; don’t exceed 0.5 ml per dose)
(Repeat every 5-10 min in case patient doesn’t improve);1 ml amp of 1:1000 solution, 1mg/ml
2.IV glucocorticoids. Inj efcorlin(hydrocortisone sod.succinate 100-200 mg;10 mg/kg in children
& max 100 mg) iv st,in severe/recurrent cases.
3.Antihistaminics (chlorpheniramine 10-20 mg or Avil) IM /slow IV st.
4.IV fluids NS 1-2 L bolus.
5.Salbutamol nebulization (in bronchospasm)
6..Put the pt in reclining position, administer O2 at high flow rate and perform cardiopulmonary
resuscitation if required.

Patient with wheeze

Monitor SpO2 , work of breathing, Respiratory rate etc. ABG if SpO2 <94 %.
Other inv: blood counts , electrolytes,cxr
Note:In all cases of first episode of wheeze, r/o FB , irrespective of age(take CXR)
Acute severe exacerbation of BA-HR >120/min,RR often>30/min,PCO2 ≥42, PaO2<60,
SpO2<90%, pulsus paradoxus, pt leans forwards and speaks in words
Rx
 13
1.Nebulise with Salbutamol(albuterol) 1cc in 3- 4cc NS + O2 x 3 times at 20 min intervals in
moderate and severe cases(or lesser if there is clinical improvement). Dose in children is
0.03ml/kg with 3 ml NS. 150 mcg/kg/dose, but min dose is 0.5 ml or 2.5mg salbutamol.
Asthalin neb: 0.5 ml for <10 kg, I ml for > 10 kg
For mild cases, one nebulization may be enough.In usual practise give, 0.5 ml for <5yrs, 1ml for
>5 yrs.
In severe cases, Nebulisation can be done by combining Salbu(2.5-5mg) & Ipratropium
bromide(0.5mg) or Duolin(levosalbu + ipratropium). Ipravent dosage: <5 yr :-125 mcg(0.5ml)&
> 5 yr:- 250 mcg(1ml)(12.5 mcg/kg/dose).Budesonide :Children 12 months to 8 years of age:-
0.5 to 1mg OD, or divided and given twice a day, <1yr:0.5 mg. commonly given in croup.
Note: Inhaled salbutamol & terbutaline should not be used on any regular basis; inhaled
Salbutamol,salmetrol, ipratropium bromide,Beclomethasone,Budesonide are safe in
pregnancy. Do not sedate the patient. Prop up the patient if not contraindicated.
For A/c Bronchiolitis, neb with 3% saline 3ml Q1-2H or alternate with salbutamol.
For difficulty in expectoration, mucomix nebulization can be given st and q8H.
Giving salbutamol nebulization without oxygen can aggravate hypoxemia
2.Inj Deriphyllin 1 amp iv st (5mg/kg/dose IM in children)(given in pregnancy)
3.Oral or iv corticosteroids
Inj Efcorlin(hydrocortisone) 100mg (or 200 mg if pt is already on steroid therapy) //Inj Methyl
prednisolone 120 mg// Inj Betnesol 4 mg iv st. Oral prednisolone can be given in acute
asthmatic attack.
For children with severe dyspnoea, administer steroids after 1st nebulization
Dose: Inj Efcorlin (10 mg/kg st & 4mg/kg Q6H), Inj Methyl pred(2mg/kg st & 1mg/kg Q6H) iv st
4.Correction of dehydration & acidosis
Discharge with-
5.T Deriphyllin retard 150 mg 1-0-1 x 5 days after food/T Theoasthalin 1-1-1(>12 yrs) or
½-½-½(if <12yrs) Or T Asthalin 4mg tds or T Bricanyl or Bricarex(Terbutaline) 5mg tds or
T Deriphyllin (Theophylline Hydrate+etophylline) tds .Deriphyllin C/I in seizure
Syp Deriphyllin( 50 /5 etophylline 46.5 and theophylline 12.75)(5mg/kg/dose PO tds)
For children: Syp asthalin( 2 /5 )(0.1-0.2 mg/kg/dose Q6H or Q8H or dose in ml= wt /4) after food
6. If response to bronchodilators not satisfactory, early use of steroids advised.T Prednisolone
10 mg tds X 3-5 days; for children: 1mg/kg/day in 2-3 divided doses x 3-5 days.
7.Antibiotics if a/w infection(fever,purulent sputum) or ineffective cough & retention of secretions.
8.Cough syrup containing Bronchodilator & Mucolytics
9.Advise inhalational medications for BA- Asthalin SOS , Add inhaled corticosteroids(ICS)
Budecort or Pulmicort (Budesonide)- start with 400 or 200 mcg BD & step down with response.
Add LABA to ICS-Seroflo / Esiflo / combitide (salmeterol + fluticasone), aerocort(levosalbu+
beclomethasone), foracort (formoterol+ budesonide), maxiflo(fluticasone + formoterol).
Rotahaler or metered dose inhaler(MDI) may also be used.
Alternatives to the order 5 would be –T Theoasthalin(Salbutamol+Theophylline)(syp available),
T Unicontin 400 or 600mg(Theophylline); T Levolin(levosalbu) 1mg or 2mg(Syp 1/5)(0.05
mg/kg/dose qid); T AB Phylline(acebrophylline) 100 mg BD or Syp 50mg/5ml, 2-5 yrs 2.5 ml
bd/tds, >5 yr 5ml bd; T Doxophyllin 200 mg 1-0-1 may be used instead of deriphylline, as it has
better cardiac & CNS safety profile (D phylline,Doxiflo, Doxobid)
9.Oral stroids & oral bronchodilators are also prescribed in the mainteneace therapy of very
severe prsistent asthma.
S/E of salbutamol & Deriphyllin : tremors, palpitation, nervousness
 14
Common causes of shortness of breath: Asthma, pneumonia,bronchitis,hyperventilation,
pleuritis, COPD, CCF, MI, pulmonary edema,bronchiolitis, pneumothorax,FB,ILD, anxiety,
pulmonary embolism, cardiac tamponade,10 P HTN,pleural effusion,metabolic acidosis, severe
anaemia, obesity, ARDS
Signs of CO2 retention: Confusion, flapping tremor, bounding pulse. Look for associated
cardiovascular(chestpain,palpitation,sweating,nausea) or respiratory (cough, wheeze,
haemoptysis) symptoms.
Note: levolin has better cardiac safety profile than asthalin, hence preferred in cardiac patients.

Dog Bite
( also cat,bandicoot,monkey,cattles,bats,wild animals etc)
Rx
1. Immediate flushing and washing the wounds, scratches and the adjoining areas with
plenty of soap and water for at least 10 minutes is very important.Dont squeeze/cover the
wound
2. Wash with betadine/spirit
3. Inj Rabipur/verorab (rabies vaccine) 0.1ml ID on both shoulders on day 0,3,7,28.
If given IM, then Rabipur 1ml or verorab 0.5 ml on day 0,3,7,14,28(IM is given in
immunocompromised pts). Rabies vaccine should never be given in gluteal region.
4. Inj TT 0.5ml IM st if indicated
5. Advise to observe the cat /dog for 10 days & to r/w if the animal dies/behaves
abnormally
6.For class 3 wound, also give
a) ERIG:Inj equirab 40 IU(immunizing unit)/kg [maximum dose infiltrated around the bite
wound and any remaining volume is given IM(usually gluteal region) away from the site
of rabies vaccine] or 0.133ml/kg. RIG is not to be administered beyond 7 days after the
first dose of vaccine.
Note: a test dose of ERIG must be given first 0.1 ml over forearm. Check after 30 min.
If allergic reaction is present, one may conside HRIG or give inj avil and inj
hydrocortisone 100 mg before administering ERIG
Infiltrate maximum locally; remaining deep IM buttocks(can dilute upto 3x times in case
of large wound.
Observe pt for atleast 1 hr before discharging them or
b) If Human Ig : 20 IU/kg or 0.133ml/kg
For 75 kg or more: 10 ml(3000 IU equirab or 1500 IU HRIG) Or
c) Rabies Human Monoclonal Antibody(rDNA)(T N: Rabishield)(Dose: 3.33 IU/kg). If
anatomically feasible, the full dose should be thoroughly infiltrated in the area around
and into the wounds. In case of multiple wounds, the dose may be diluted in a solution
of 0.9% normal saline in order to provide the full amount required for good infiltration of
all the wounds. Never to be administered in the same syringe or into the same site as
rabies vaccine. Do not inject IV.
Rabishield Available as 2 preparations:
100 IU/2.5 ml(40 IU/ml) vial or 250 IU/2.5 ml(100 IU/ml) vial (250 IU vial cost around Rs
1970)
7. Antibiotics like augmentin
Class 3
 All bites or scratches with oozing of blood on neck, head, face, palms and fingers
 Lacerated wound on any part of the body
 15
 Multiple wounds 5 or more in number
 Bites from wild animals
Note:Bite wounds shouldn’t be immediately sutured; if necessary put minimum no of loose
sutures. Ideally it should be done 24-48 hrs later under the cover of anti-rabies serum locally.
If previously fully vaccinated with rabies cell culture vaccines, then only IDRV day 0,3 dose
(single site) is required. But only adequate wound washing would be required in case of re-
exposure, if there is documented proof of complete PEP or PrEP within the last 3 months.
Pre-exposure Prophylaxis (PrEP): IDRV 0,7, 28, 0.1 ml single site
 Rabies vaccine & RIG are not contraindicated in pregnancy.

Injury
Record MLC:Time of arrival, time & place of occurence of injury, cause of injury, 2 id marks,
brought by whom(address also) should be noted.
Rx
1.C & D (wound toilet). Ideally with NS. Betadine, H202 , cetrimide,
savlon(cetrimide+chlorhexidine) etc may be used for contaminated wounds only.Look
for any foreign body in the wound.
2.Inj TT 0.5 ml im st(Samedose for all age), if indicated.
3.Inj tetglob (Immunoglobulin, tetanus) 250 IU deep IM St ATD(for deep & large wounds,
contaminated wounds)(Same dose for all age) at a site different than that of TT.
4. Excise all devitalised tissues. Remove any foreign body in the wound. If needed,
suture.
Suture the wound without any dead space inside the wound.
Materials needed:- needle holder, forceps (artery , thumb), needle(cutting/ reverse
cutting-skin, round body/tapering- fascia, soft tissue,muscle & tissues that are easy to
penetrate,delicate tissues) , suture material-usually silk, nylon,prolene (non-absorbable)
or catgut,vicryl,monocryl(absorbable). Usually skin is sutured with 3-0 nylon or 4-0
(smaller). For conspicuous places like face, to minimize scarring,use sutures of fine size
like 5.0 or 6.0 and place the sutures close to the wound margins and sutures may be
removed early by 3-5 days. Subcuticular suturing avoids suture marks. Suture should n’t
be too tight. Care must be taken with cutting needles, because they can cut through
tissue lateral to the track of the needle if not used correctly.
Don’t suture if a) underlying tendon is cut,
b) underlying bone is fractured.
c) caused by dog bite (especially stray dogs) or human bite
Give adequate support/immmobilization of the region.
Note: Primary suturing (done within 6 hrs) shouldn’t be done if there is edema/infection/
devitalised tissues/hematoma. Here delayed primary suturing (48 hrs-10 days)can be done.
This time is allowed for the oedema/hematoma to subside.Secondary suturing (10-14 days) is
done in infected wounds.
5.Antibiotics :- C Megapen (Ampiclox)(1-1-1-1) or Ampiclox+ Metrogyl; Children:
augmentin,cefixime
Metrogyl dose: 200 mg 1-0-1, syp 200/5 30-50mg/kg/24 hr div into 3 PO.
Give strong antibiotics in DM
 16
For infected wounds,ulcers give mupirocin oint(Bactroban,mupin,T-bact), futop oint
(Fusidic acid) Megaheal(colloidal silver), Neosporin
powder(neosporin,polymyxinB,bacitracin Zn).
For buccal mucosal injury-Metrogyl DG(metrogyl +chlorhexidine) gel or Dentogel.
Mupirocin also given for folliculitis, furunculosis etc.
6.Analgesics +Serratiopeptidase(anti inflammatory):- C Lyser D/Lizole- D(Diclofenac+
serrapeptase) 1-0-1 x 3 days after food; T Zymoflam-D/ Alanz-D(diclofenac, trypsin,
bromelain, rutoside).
For children give syp ibugesic
For severe contusion: T chymoral forte 1-1-1-1 (trypsin, chymotrypsin) or T Zymoflam/
Rutoheal / Enzomac ( trypsin, bromelain, rutoside)
7.Vitamins (deficiency of vit A & C, Zn,Cu -poor wound healing). T BC OD
8.T.Rantac 1-0-1
9.Fluid & electrolyte balance
10. Change the dressing once in 2 days.Inspect the sutured wound in 48 hrs.

Tetanus prophylaxis in wound management

Clean, minor wounds
 If uncertain h/o previous vaccination or fewer than 3 doses: give vaccine complete
course.
 If has had a complete course(3 or more previous doses):
a)if < 10 years since last dose: no vaccine required.
b) if ≥10 years since last dose:give vaccine one dose.
All other wounds
 If uncertain h/o previous vaccination or fewer than 3 doses : give vaccine complete
course & tetanus Immunoglobulin (TIG).
 If has had a complete course(3 or more previous doses):
a)if < 5 years since last dose: no vaccine required.
b)if ≥5 years since last dose:give vaccine one booster dose with in 48 hrs of injury.
Note: The practise of giving Inj TT every 6 months is wrong, as frequent TT may decrease
immune response.
TT active immunization for previously unimmunized or incomplete immunization.
Complete course:
Inj TT 0.5 ml IM at 0, 1 month. A booster dose is given at 6month(or 1year) after initial 2
doses. An additional booster dose may be given 5 years after the third dose(total 4 doses).

Note:
Simple suture: - Superficial wounds, face ,neck; Mattress suture:- Deep wound, upper &
lower limb.
For injuries associated with severe bleeding, do Hb, PCV.

For phlebitis, thrombophlebitis, swelled up injection sites,haematoma:

Thrombophob Oint (heparin sodium), T Serrapeptase,warm compresses, rest to the part
etc.
 17
Haematoma: If minimal may resolve spontaneously;If massive, may require drainage or
aspiration
For periorbital ecchymosis(black eye) & SCH due to trauma, :
Moxiflox/gatiflox/ciplox eye drops, cold compress, T Serratiopeptidase & ophthal
consultation

For muscle injuries: ice, compression, elevation

Crush injuries:Look for degloving, compartment syndromes;Extensive removal of
devitalised tissue & fasciotomy may be required;Monitoring of Renal function & urine
output is needed. Give IV fluids generously(6 -12 L over 24 hr)

In trauma involving ear auricle(Lacerated wound pinna): only skin is approximated &
sutured with 5.0 or 4.0 prolene or silk (cartilage is spared).
Suturing should be done under the cover of antibiotics . Always better to refer to an ENT
specialist
Explain risk of perichondritis, Give inj TT if indicated.
S/R on 6th day.
Lacerated wound nose
Suturing to be done. Refer to an ENT specialist
1. Inj amox 1g QID x 5 days
2. Inj TT
3. Lyser D
4. S/R after 6 days

Lacerations of the mouth: small lacerations with minimal gaping don’t require suturing.
Needles commonly used are three-eights-circle or half circle cutting needles. Most
commonly used diameter is 3.0; black silk or chromic gut are commonly used. For small
children better use absorbable sutures, as we can avoid one episode of unpleasant struggle
during suture removal. When the exterior surface of the lip is lacerated, precise skin
approximation is very important to avoid an unsightly scar when the lip heals; the
vermilion border must be first approximated;any separation of the underlying musculature
must be buried with absorbable sutures.

Soft tissues of the neck:

Open wounds are frequently associated with vascular involvement. A patent airway may be
compromised by progressive soft tissue swelling. Perform pressure tamponade.
Tracheostomy may be needed.
Injury of larynx/trachea are a/w subcutaneous emphysema, airway obstruction, dysphonia,
lack of thyroid cartilage prominence.

Note on Specific Lacerations

Scalp: shaving of the hair has shown to increase the rate of infection and should n’t be
performed. Hair may be trimmed, if needed.
Lacerations of the eye lid margin or those involving the medial fifth of the lid should be
referred to a surgeon or ophthalmologist as improper repair may produce disastrous and
disabling consequences.
Eyebrows must never be shaved because in a small percentage of patients, regrowth may
n’t occur.
 18
Abrasion
Rx
1.Inj TT 0.5 ml IM stat if indicated.
2.C & D.Preferably dressing is not necessary.
Large abrasions or skin loss lesions may be dressed with cuticell(non medicated), cuticell-c
or bactigras (chlorhexidine), jelonet(non medicated paraffin gauze dressing), cuticell plus
(polymyxin B, bacitracin, neomycin)
3.T-bact oint,Metrogyl-P Gel, Megaheal(colloidal siver), Sepgard ointment(feracrylum),
Neosporin powder/oint (zinc bacitracin, neomycin sulphate, polymyxin B sulphate),
healex spray(Benzocaine +poly vinyl polymer), cetrimide, Savlon(cetrimide+
chlorhexidine), Neosporin-H for L/A
4.Oral antibiotics , if Diabetic / multiple abrasions
5.T Lyser-D BD
6.T Vit C OD
7.T Rantac 150 mg BD before food

I&D
Diagnosed based on Fluctuation.
Rx
I & D by Hilton’s method
Ask patient to lie down to avoid shock induced by pain. Start an IV fluid. Incision put
parallel to neurovascular structures.Press at root with cotton, till frank blood comes. Clean
well with betadine.Dress with GM(glycerine Mag sulf) to reduce edema at the site.
Send pus for C&S
Check RBS, Urine sugar, prescribe antibiotics & ask to review with the report.

Suture Removal
Rx
1.Clean with Betadine
2.Cut close to skin using Blade no. 11 or 10
3.Avoid thread from outside entering inside
4.Remove intermittent sutures to prevent Gaping.

Days of suture removal:-

Thyroid : 4-5 days(if stapler- removed on 3rd day)
Scalp: 5-8 days
Chest,abdomen: 8-10 days
Back:12-14 days
Inguinal : 8-9 days
Wound over a joint(knee,Ankle,foot): 14 days
Face,lip,nose,eyelid : 3-5 days
Upper limb & lower limb : 10-14 days
Ear:10-14 days
 19
Pediatrics

Febrile seizures
Age gp →6 months to 6 yrs.
C/f: May present with frank fits or more commonly uprolling of eyes ,loss of
consciousness, they may also vomit or have increased secretions (foam at the mouth).
The body may go stiff, then generally twitch or shake (convulse).
The seizure normally lasts for less than five minutes.The child's temperature is usually
greater than 38 °C (100.4 °F)
Rx
1. Inj Lora 0.1 mg/kg iv st Or
Inj Diazepam 0.2mg/kg iv to be given very slowly to avoid respiratory depression (per
rectum can be given). May be repeated after 3-5 minutes if needed Or Inj
Midaz(midazolam) 0.1 mg/kg iv st Or
Diazepam suppository 0.5 mg/kg PR(per rectum)(additional 0.25 mg/kg after 10 min if
needed).
Note:- in case of respiratory depression give painful stimulus or ambu bag for few
minutes
2.Tepid sponging + P’mol. Check GRBS.
3.Oxygen inhalation.Clothing around the neck should be loosened.
4.Semiprone position and throat suctioning
5. Protect the child from injury.Keep under observation for some time.Monitor Vitals.
Prescription on discharge as prophylaxis:-
1.Syp P’mol)( 125 /5 ) Qid
2.Syp Calmpose(Diazepam)(2/5) for first 2 days of fever(0.2-0.3mg/kg/dose x 3 times)
(T.Valium/calmpose 2/ 5 /10 mg); T Frisium (clobazam) 5/10/20 mg(0.5-1 mg/kg/day in
2 div doses) if diazepam fails. Above 3 yr start with 5 mg OD.
Midaz Nasal Spray may also be given at home for status. Each spray delivers 0.5
mg/puff
3.Tepid sponging SOS
Note:- the above three instructions to be followed for first 2 days whenever there
is a fever.
4.Syp Mox( 125 /5 ) tds x 5 days if any associated infection
5.Syp Nutrolin B bd x 5 days.

All children below 1yr-11/2 yr presenting with first episode of febrile seizures should be
referred to higher centre after initial treatment as LP is indicated.

Incessant crying of infants/children

Note:-mostly due to nasal block, intestinal colic due to hunger, worms, constipation, over feeding,
aerophagy, food intolerance,sepsis/infection like meningitis, AOM,medications, discomfort from wet
diaper, feeling cold, baby needs to be held, ear ache ,r/o ear wax, loose stools,insect bite ,GERD , a/c
abdomen- intestinal obstruction, intususception etc.
Examine all limbs, trunk, back, orifices. If baby feeding well as usual, mostly Normal.
Advise regarding proper feeding of the baby.Feeding, Burping & carrying the baby
upright in shoulder may bring relief. Breast milk protects against evening colic.
 20
Adequate breast feeding:8-12 times a day or on demand, 15-20 min sucking, then max
2-3 hrs of sleep or rest after feed. Frequent urination 5-7 times a day.1-6 liquid
stools(golden coloured) per day & gaining weight.
Rx
1.Syp Carmicide or syp Cyclopam (10/5)(0.5 mg/kg/dose) or Syp P’mol st
2.Saline nasal dps for nasal block; 20 Q4H
3.Syp Phenergan (5mg/5ml)(1mg/kg/dose) or
Syp Pedicloryl (500/5) 0.5 ml/kg st (in practise 1/4-1/2 tsp for infants, 1 tsp for 1-5 yrs, 1-2tsp
for>5 yrs)
Note: don’t sedate children unnecessarily.

For infants:
1.Carmicide /colicaid/cyclopam-DF Dps( simethicone,Dill oil,fennel oil) or colimex/cyclopam
(dicyclomine 10 /1, dimethicon 40 /1). Colicaid dose: Infant <6 mths: 5-10 drops; infant 6-12 mths:
10-20 dps;over 1 yr: 20 dps qid before food or SOS.
Indications:Infantile colic, flatulent dyspepsia, regurgitation.
Note: Syp carmicide adult (Na citrate, citric acid, tincture cardamom,tinc cinnamon,
alcohol, ginger oil)

Unconscious child
1.Position head to side, oral suction, check pulse. If no pulse follow pediatric BLS/ACLS
2.O2 inhalation, check air entry
3.Check capillary filling time & BP
4.GRBS
5.Collect blood for investigations
6.Control seizures if any.
7.Refer immediately to higher centre

A/c bronchiolitis
Rx
1.humidified O2 inhalation if saturation <95%
2.Neb with 3% saline 3ml Q1-2hrly
3.Neb with adrenaline 0.2 ml/kg(1:1000 solution)(max 5 ml)
4.Alternate 3% saline(mucolytic) nebulization with salbutamol neb sos
5.No improvement:CPAP

ADD
Plan A: child may be sent home, continue feeding, Z&D drops
Darolac sachet BD (probiotics for antibiotic induced diarrhea)
Plan B: replace ongoing loss, continue feeding
Plan C:admit, parenteral fluids RL or NS, vit A
Refer pg no 11

Dyspepsia & For weight gain in children

Rx
1.Syp Carmicide 2.5–5ml tds in children & 5–10ml tds in adults [sodium citrate + citric
acid + alcohol]
2.C Aristozyme 1 tds [diastase, pepsin]. Diastase is a digestive enzyme; also has
antiflatulent action. Aristozyme Syp & Dps available.
 21
Nocturnal enuresis
Recurrent involuntary passage of urine during sleep by a child aged 5 years or older, who has
never achieved consistent night-time dryness.
All children with bedwetting should be evaluated for DM or renal concentrating defect.
Recent Bedwetting in children; r/o UTI and worm infestation(like enterobius).

A/c invasive diarrhea

Rx
Oral cefixime 10 mg/kg/day in 2 div doses
Refer to section on loose stools on pg no 11

UTI
Newborn may p/w non specific signs like failure to gain wt, jaundice, irritability etc
Burning pain on micturition indicates urethritis. Suprapubic pain, frequency and dysuria indicate
cystitis; high fever,toxicity, flank pain and tender renal angles indicate pyelonephritis
Ix- BRE,URE, CRP, ESR
Rx
<1yr and febrile :admit
Pyelonephritis-iv antibiotics(taxim or ampi- genta) for 3-5 days f/b oral antibiotics. Total
duration atleast 10 days.
Advise the child to take plenty of oral fluids and to void every 2-3 hours to prevent bacterial
growth in stagnant urine. 1 week after completion of the antibiotics do a repeat culture to
document the cure.
If afebrile- urine culture & sensitivity before starting antibiotics:oral cefixime(8 mg/kg/day in
divided doses Q12H), plenty of oral fluids
Evaluation following initial UTI: <1yr:USG,MCU,DMSA
1-5 yrs:DMSA & USG
>5 yrs:USG
Refer pg no 50

Vomiting
R/o meningitis/encephalitis, gastroenteritis, migraine, dengue
In infants r/o intestinal obstruction, CDH, dudenal atresia, intususception(red currant jelly stool)
Antiemetics last choice, try to find out cause and treat.
Mx of vomiting given in detail on page no 10

Asthma
Rx
Mild(wheeze only, SpO2>95%)
If risk factors for severe asthma present, keep in observation for 4 hours. After initial
nebulization, if the child is not improving adequately, shift to the management protocol of
moderate exacerbation.
Moderate(work of breathing increased,retractions, SpO2 90-95 %):-
1. neb with asthalin at 20 min interval x 3 times
2.Reassess a) marked improvement: continue as in mild exacerbation b)moderate improvement:
start systemic steroid, then admit the pt. Oral steroid (prednisolone 1mg/kg/day) for 3 to 5 days.
Space out nebulizations 1 to 4 hourly. No significant improvement- reclassify as severe.
 22
3.Severe (silent chest/hypotension/air entry decreased grossly;SpO2<90%):a)O2 inhalation b)
transfer to PICU c)parenteral steroids + neb with salbutamol & ipratropium bromide.
Ipravent respules(2ml): 1/2 respules for 10 kg, 1 respules for >10 kg.
Note: while nebulising children, always give oxygen with salbutamol(asthalin), as hypoxia +
asthalin may have epileptogenic potential.
Refer to section on pg no 12-14

Status Epilepticus
Check temperature, RBS, S Ca
Rx
Inj lora( 0.1 mg/kg) slow push. May be repeated once after 15 min.
If persisting: administer 2nd anticonvulsant phosphenytoin 30 mg/kg at 3mg/kg/min
Or phenytoin 20 mg/kg at 1mg/kg/min.
Note: Phenytoin not preferred in children
Major causes of neonatal seizures-HIE, hypocalcemia,hypoglycaemia,meningitis,
Refer to section on pg no 19 & 52

Acute respiratory infection/Influenza like illness(ILI)

A/c onset of fever>380C and cough or sorethroat in the absence of other diagnosis.Other s/s-
Bodyache, headache(in most cases), tiredness, runny or stuffy nose, loss of appetite, nausea.
Ix-BRE, URE, CRP
Rx
Paracetamol, cough syp, antiviral medicine(started within 2 days of symptoms).
Flu can lead to pneumonia.Refer pg no 93.

Measles
Any person with fever, maculopapular rash lasting more than 3 days, cough, coryza and
conjunctivitis
C/f: prodromal symptoms are like that of flu,dry cough, watering & redness of eyes, fever,
koplik’s spots(appear as tiny table salt crystals on inner cheek),rashes on face(after 3-4 days),
LN enlargement(posterior cervical & angle of jaw)
Rx
1. Supportive treatment: bed rest, cough suppressant, saline nasal drops
2. Isolation(communicability more in pre-eruptive stage till rashes remains)
3. Look for complications like pneumonia; if chest signs + give antibiotics.

Pertusis
A person with a cough lasting atleast 2 weeks with atleast one of the following: paroxysms of
coughing(each paroxysm consists of 15-20 short coughs f/b deep inspiration), inspiratory
whooping, post tussive vomiting( vomiting immediately after coughing) without other apparent
cause, periorbital edema, scattered rhonchi, episodes of choking & apnoea.
Rx
O2, Antibiotics(azithromycin),Syp Deryphillin, other supportive measures

Diphtheria
An illness of the upper respiratory tract characterized by: laryngitis or pharyngitis or tonsillitis;
and adherent membrane of tonsils, pharynx and/or nose.
 23
Rx
Treatment should be initiated even before confirmatory tests are completed due to high mortality
rate. Isolate all cases promptly and use universal and droplet precautions to limit no of possible
contacts
Complete bed rest, liquid diet, Oxygen, cardiac monitoring
Antibiotics- procaine penicillin G IM for 14 days
Antitoxin as a single dose(20,000-80,000 IU) IV/IM depending on severity of disease.
Obtain throat and nasal swabs from persons in close contact with the suspected case and
administer age appropriate diphtheria booster. Initiate anitibiotic therapy with erythroycin or
penicillin for prophylaxis. Rpt throat cultures after 2 weeks.

Misc
Sinus bradycardia- <90/min in neonates & <60/min in older children.
Normal Resting heart rate varies with age:
Newborn: 110 – 150 bpm
2 years: 85 – 125 bpm
4 years: 75 – 115 bpm
6 years+: 60 – 100 bpm
By 5 yrs, HR over 100/min in a resting child is abnormal.
Common causes of bradycardia in neonates are hypoxia,hypothermia, head injury etc.
Normal neonatal phenomena- milia, erythema toxicum, stork bite, epstein pearl, Natal teeth,
withdawal vaginal bleeding on 5th - 7th day, glycosuria, WBC in urine, peeling of skin,
constricted pupils, physiological phimosis, breast engorgement,SCH, palpable
liver/spleen/kidney.

Weaning
Breast feeeding should be continued as long as possible, even if weaning is started.
4 months
Start with a single cereal; consistency must be that of thick fluid. Cereal based porridge(ragi,suji,
rice etc) enriched with jaggery/sugar/oil/ghee and milk may be suitable. Expressed breast milk
may be used to prepare porridge. Cereal porridge without milk(e.g., with addition of a pinch of
salt or jaggery) may also be given. Start with 1-2 teaspoon and increase gradually to 1/2 cup, 1-2
servings a day. Each new item should be introduced after a gap of 5-7 days to observe for any
intolerance.
6 months: mashed rice with pulse, or dhal and ghee, mashed potatoes, mashed
banana/carrots/beetroots/fruits, egg yolk, vegetable soup etc., enriched with
jaggery/sugar/oil/ghee/milk and salt to taste. Children will need variety and the mother should be
prepared to experiment with new items. Commercially different preparations are available like
rice based ones(e.g: Nestum, Dexrice), wheat based ones( e.g: cerelac, first food etc). Easum and
nestum are weaning foods without milk.
9 months
Give food items from family pot that can be easily chewed(but avoid hot and spicy ones) 4-6
times a day. Cereals, pulses, fruits, vegetables, egg, fish, minced meat etc properly prepared are
acceptable e.g chappatti soaked in milk.
1 yr: egg white is best introduced after 1 yr of age. The diet should contain items from all the
basic four groups: that is milk, cereal/pulse, vegetable/fruit and meat/egg/fish. Vegans can
increase pulses in place of non-veg group. Beyond one year of age, a milk intake of 500-750 ml
may be sufficient if the other items are consumed in adequate quantity. Commercially available
 24
pre-cooked cereals are best reduced or taken off, after one year of age, to accustom the child to
the routine diet of the family. Commercially available cereal vegetable preparations are not a
substitute for fresh vegetables or fruits.

Eruption of teeth
Primary teeth eruption in children starts with central incisors, and is first seen in children at
about 6-7 months of age. Eruption of teeth is often preceded by a bluish colored gingival
swelling. During teeth eruption children often display disturbed sleep, irritability, drooling of
saliva, cheek flushing and sometimes a circumoral rash.

Normal Growth
Height. At birth= 50 cm, I yr -75 cm,2-12 yrs= (agex6)+77
Weight, 1-6 yr= 2x+8, 7-12 yrs= (7x-5)/2, x=age in yrs, 3months-1 yr= (x in months+9)/2
Approximate daily wt gain in infants: 0-3 months 30 g/day; 3-6 months 20 g/day; 6-12 months
12-15 g/day.

Pediatric ecg
Common findings which may be normal for the age
Heart rate >100 beats/min
Rightward QRS axis > +90°.Resolves over the first 6 months of life.
T wave inversions in V1-3 (“juvenile T-wave pattern”).During 1st 7 days of life, T waves are
typically upright in most leads. After 7 days of life, T waves become inverted in anterior
precordial leads.The inverted T waves typically become upright in adolescence, but can persist.
Dominant R wave in V1
RSR’ pattern in V1
Marked sinus arrhythmia
Short PR interval (< 120ms) and QRS duration (<80ms)
Slightly peaked P waves (< 3mm in height is normal if ≤ 6 months)
Slightly long QTc (≤ 490ms in infants ≤ 6 months). QTc becomes similar to adult after 6 months
with it being < 440 msec.
Q waves in the inferior and left precordial leads.Usually less than 5mm deep in left precordial
leads and aVF.May be as deep as 8mm in lead III in children younger than 3 years.
A biphasic QRS in AVF can be normal, but needs to have pediatric cardiology review.
Exaggerated precordial voltages may be normal due to small chest walls.

Pediatric dosage of common medicines

Syp asthalin( 2 /5 )(0.1-0.2 mg/kg/dose Q6H or Q8H or dose in ml= wt /4)
Syp P’mol(125 /5 or 250/5)(10-15 mg/kg/dose x 4 times)(C/I in less than 2 kg)
Syp Cyclopam(10/5) (generally not used <6 months)(0.5 mg/kg/dose x 3 times)(> 6
months:up to 5 mg/dose,children 10 mg/dose)
Syp Meftal(50/5 or 100/5) (generally not used < 6 months)(8 mg/kg/dose x 3 times a day)
( wt x 4/10 = dose in ml, applicable only for 100/5 formulation)
Syp Azithromycin(100 /5 or 200/5) {T N:- azee, ATM}(Dose for children above 6 months-
10 mg/kg/day for 5 days)
Syp emeset or Vomikind(2mg /5ml) (children:0.1 mg/kg/dose bd/tds)
Syp Domstal(1mg /1ml) (0.2 mg/kg/dose x 3 times)
Syp alerid/cetzine(Cetrizine)(5mg/5ml)(0.25 mg/kg/dose HS/BD)
Syp amoxicillin 15 mg/kg/dose Q8H
Syp amoxiclav Dose: 20 mg/kg/dose BD
 25
ENT

Epistaxis
Aetiology:Trauma ,Systemic HTN,URI, F B , DNS, drying of mucosa ,drugs, septal perforation,
liver/kidney disease, a/c general infection, vitamin k deficiency, malignancy,angiofibroma,
atherosclerosis ,spur, bleeding disorders etc
Examine nose and paranasal sinuses, vision and extraoccular movements(ethmoid bone fracture
can cause injury to optic nerve)
Nasal bone fracture can be diagnosed clinically. X-ray usually taken for MLC purposes

Inv: CBC, Plt ct,ESR, aPTT, PT-INR, BT,CT, P smear,RFT,LFT,X-ray PNS (water’s). Check BP
Rx
1.Keep head elevated, avoid exertion,aspirin, blowing of nose for 24 to 48 hrs. Reassure the pt
2.If severe Close nose by pinching and breath via mouth for 5-10 minutes. Ask the pt to spit the
blood reaching oropharynx out.
3.Cold compress to nasal area.Keep icecubes in handkerchief over nose. If bleeding still
present, a cotton gauze impregnated with adrenaline & lignocaine(2%) is inserted & nose
pinched for another 10 minutes. Use Gelfoam (absorbable gelatin compressed sponge) if
discrete bleeding point identified.
4.If not controlled, Give Inj Tranexa (tranexamic acid) 500mg slow iv st or Etamsylate iv st
5.Oral Antibiotics(e.g augmentin or cephalexin) or topical antibiotics to prevent sinusitis
6.keep Check on pulse, systemic hypertension,respiration.
7.Give anti-allergics for mild sedation like avil or cetrizine if required
8. For benign cases, oxymetazoline nasal spray/dps(nasivion) can be given.
9.T Cosklot 250/500 1-1-1(etamsylate)
Note: if not controlled, Pressure packing of the nose.Refer the Pt to ENT.
Note: severe epistaxis in an unconscious pt mandates intubation.
In case of septal abscess, I&D should be done within 48 hours; otherwise perforation may
occur.

Foreign body Nose

A foreign body must always be excluded in a child with unilateral nasal discharge.
C/f: nasal block, pain, blood stained fowl smelling discharge.
Rx
 Keep head at 45/90 degree. Attempt only if FB can be seen. Use
Lignocaine+adrenaline spray(reduce pain & swelling) in the affected nose.
 Take from below upwards. Most of the FB can be removed by using an eustachian
catheter which is passed gently past the FB & dragged along the floor.
 Give Antibiotics if trauma +.
Note: if the FB is a button battery ideally refer to ENT immediately.
For procedural sedation, in children,give Syp Pedicloryl(triclofos Na)(500/5 ) 0.5ml/kg(up
to 50 mg/kg can be given). Pedicloryl can also be used in insomnia, recurrent colic,
restlessness, fretfulness etc
 26
Nasopharyngitis/ cold/ acute coryza/catarrh
Rx
1.T cetrizine(alerid/okacet/cetzine) 5mg 1-0-1 or T Levocetrizine (hatric)5mg(Syp Hatric 2.5/5) OD
or T Avil 25mg 1-1-1 or T Rupanex (Rupatadine)10 mg OD x 3 days or T Piriton 4mg tds
(chlorpheniramine) or T allegra 120/180 mg od/bd(fexofenadine)
For pediatric case:
T cetrizine(6-12 months: 2.5 mg OD,12 months - 6 yrs: Initially 2.5 mg OD, which may be
increased to 2.5 mg BD, or Syp alerid/cetzine(Cetrizine)(5mg/5ml)(0.25 mg/kg/dose HS/BD) or
T-minic /alex Dps(CPM 2mg/1ml, phenylephrine) & T-minic syp(CPM 2mg/5ml, phenylephrine)
Levocetrizine is effective at half the dose of cetrizine or 0.1 mg/kg HS
For pregnant ladies: Cetrizine or chlorpheniramine can be given
2.Saline Nasal Dps or Decongestants like nasivion, otrivin.
If nasal congestion:-
Nasivion (Oxy metazoline) or Nasoclear SND/Otrivin S/otrinoz saline nasal spray(NaCl) or
Otrivin / Xylomist (Xylometazoline) 20-20-20
Note: Nasal decongestants should not be used more than 3 days in a row as it may cause
rebound congestion. Nasal decongestants should be used very cautiously in hypertensive
patients. In children give Saline Nasal drops or Nasivion-P; don’t give Nasivion(only for adults)
Note:- for pregnant ladies otrivin and nasivion can be given
3.Steam inhalation (may be with inhalation capsule like karvol)
4.Azelast(azelastine) Nasal spray may be used for rapid relief
If cold + fever:-
1. T Wikoryl or Sinarest or T-minic Plus or Tusq-P or Alex-P 1-1-1x 3 days(Pmol 500+
Phenylephrine HCl 5mg+ Chlorpheniramine maleate 2 mg)(Syp & Dps available)
(Syp wikoryl: P mol 125 mg+ phenylephrine 5 mg+ cpm 1 mg/5 ml) (Wikoryl Dps 125/1) or
2.T Rinostat or Flucold (Syp and Dps available) 1-1-1x 3 days (P’mol+Phenylpropanolamine
+CPM) or
3.T Nasivion (Pmol+Phenylephrine HCl+Caffeine+Diphenhydramine HCl) or
4.T Hatric 3(Pmol+ pseudoephedrine+CPM)
For cold + fever + cough
1.Syp Alex-P (Pmol+Phenylephrine HCl +CPM+ Dextromethorphan)
2.Syp Nasocare Plus or Pedia-3 (Pmol+Pseudoephedrine HCl +CPM+DM)
3. Syp Sinarest (Pmol+Phenylephrine HCl +CPM+Na citrate +menthol)
Note: T Sinarest AF- with out P mol (Syp or Dps available)
For cold + cough
1. Indominic -P drops(phenylephrine 5/1 +cpm 2/1)

For seasonal allergic rhinitis:

1. T Odimont LC/ Montek LC/ Monticope (montelukast 10+ levocetrizine 5) OD
For children: T.Montelukast LC Ped/ Romilast-L (monte 4+ LC 2.5), Syp Montina-L/ romilast-
L(Monte 4mg + LC 2.5mg per 5 ml)available.Montair 4mg sachet available.
<6 yr: 4 mg tab or sachet OD , >6 yr: 5mg OD, >12 yrs: 10 mg
T Allegra-M(fexofenadine + montelukast)
2.Nasal decongestants e.g nasivion, otrivin
3.Topical steroids and antihistamines. E.g. Rhinocort ,Budenase AQ , budecort nasal spray one
puff BD (budesonide) (effective for both allergic & vasomotor rhinitis, nasal polyposis);
combinase AQ N-spray(azelastine+ fluticasone), azelast(azelastine),
 27
Momeflo nasal spray(mometasone), Fluticone/flomist/flutiflo nasal spray (fluticasone),
Rhinase/Beclate Nasal Spray/Drops (beclomethasone)
Precautions in allergic rhinitis : Avoid carpets, woollen clothing,fur pets like cats & dogs; keep
house dust free
Note: pt must be informed about drowsiness and advised to avoid accident prone work, driving
while taking antihistamines.

Sinusitis
Aetiology: URI, DNS,Trauma, Tooth infection {mainly upper}
Acute- <2 weeks, c/c- >3 months
C/f:major-nasal discharge(hallmark), nasal block,purulent rhinorrhoea, fever,headache/
facial pain,anosmia. Minor-halitosis
In ethmoiditis there may be upper or lower lid edema, lacrimation, dull headache etc
Maxillary sinusitis- look for dental infection,lower eyelid swelling
Frontal sinusitis- early morning headache.
Look for PNS tenderness
Inv: X-ray PNS (water’s view, open mouth)(for sphenoid & frontal sinus- Lateral view
also),NCCT scan(indicated in r/c a/c sinusitis, severe infection)
Rx
1.T. Cetrizine 5mg BD/ T. CPM 4 mg tds
2.Analgesics like paracetamol or ibuprofen
3.Antibiotics: amoxclav 625 mg BD; others-azithro/doxy/cefuroxime axetil
4.Steam inhalation with Amrutanjan/ vicks/ Tincture Benzoin, 15-20 minutes after nasal
decongestion for better penetration.
5.Nasal Decongestants:Nasivion(0.05%)[oxymetazoline], Otrivin(0.1%), OtrivinP(.05%)
[xylometazoline] dps/spray. Oral decongestants may also be given.
6.Hot fomentation.Local heat to the affected sinus.

Parotitis
Commonly due to stone.
Rx
1. Antibiotics e.g.Ampiclox /amoxyclav/ Cephalexin/cefixime. If no response give Taxim
2. Anti-inflammatory drugs like ibuprofen 400 mg tds
3. Adequate hydration, oral hygiene(minimum twice daily brushing,rinse mouth either
with warm salt water- half teaspoon or 3g of salt in 1 cup or 240 ml of water or with
chlorhexidine 0.12% thrice daily), local heat, gland massage,
4. L/A of Ichthammol Glycerine to reduce edema.
5. Lime juice & other Citrus fruits to promote salivary secretion
In cases of Mumps(viral Parotitis),
Rx: hydration,rest, analgesics, hot/cold compresses over the parotid (to relieve pain).
Food which promote salivary flow should be avoided.
Complications:Orchitis,Ophritis,Pancreatitis,aseptic meningitis etc.
Advise scrotal support & cold compresses for orchitis

Nasal bone fractures

C/f: traumatic epistaxis, edema, ecchymoses, crepitation, subcutaneous emphysema,
Inv: Digital x-ray Nasal bone Rt & Lt, lateral view
 28
R/O CSF Rhinorrhoea;look for septal hematoma(requires immediate surgical drainage
otherwise may cause abscess formation and or saddle nose deformity.
If there is # & if nose is swollen, reduction is performed after edema subsides(~ 1 week)
using walshams forceps
Rx : C Mox, T lyser-D, T Pantop, Nasivion ND.

Nasal Polyp
Etiology-allergy(ethmoidal-B/L), infection(AC polyp-U/L)
Ix-FESS
Rx
1.Ethmoidal - Antiallergics(oral or nasal spray can be used), steroids
2.Nasal decongestants
3.Antibiotics if there is evidence of infection;
Ent consultation

Furuncle of the nose

Rx
1.Warm compresses
2.Systemic antibiotics like cephalexin; T-bact oint for LA
3.Analgesics
4.I & D of the abscess
Note: the furuncle should not be squeezed due to the danger of spread of infection to
the cavernous sinus
For Vesibulitis, Rx is the same, give Clox, remove the crusts with cotton dipped in H202.

Sore Throat
Aetiology:infection(a/c pharyngitis - 80% viral, retropharyngeal & parapharyngeal
infections),malignancy, ulcers,trauma,referred pain due to angina, reflux esophagitis etc
Rx
1.Antibiotics if any associated infection. E.g Azithromycin, augmentin
2.Analgesics like ibugesic plus
3.Steam inhalation,bed rest, plenty of fluids
4.Warm saline gargle x 3 times/day or Betadine gargle in 10ml of warm water tds
5.Throat lozenges
Note: refer peritonsillar abscess to ENT, as it requires I & D

Foreign body throat

C/f: cough, stridor, aphonia,dyspnoea, haemoptysis, hoarseness,respiratory arrest,
recurrent pneumonia, asthma
Note: FB aspiration should be suspected in any child with sudden onset of cough and
choking episodes.
Inv: CXR, Digital X-ray soft tissue neck - lateral & AP view, CT chest
In Emergency,Perform Heimlich’s maneuver.
If unsuccessful, Immediately refer to ENT for indirect laryngoscopy
 29
Note-button batteries and sharp objects in the esophagus and FB a/w respiratory
symptoms mandate urgent removaland coins lodjed in the esophagus can be observed
for upto 24 hrs in anticipation of passage into the stomach.
Asymptomatic blunt objects

Laryngitis
C/f: hoarseness, inability to speak, Dry sore burning throat, cough, dysphagia, fever,
cold, hemoptysis,dyspnea, Increased production of saliva, swollen lymph nodes in the
throat, chest, or face, sensation of swelling in the area of the larynx
Rx
1.Voice rest, steam inhalation, cough suppressants, plenty of oral fluids,
2.Antibiotics (e.g Azithromycin) if due to bacterial infection
3.Rantac/pantoprazole if due to GERD
Other causes of hoarseness of voice: vocal cord nodules, thyroid problems, allergies,
inhalation of respiratory tract irritants, smoking,CA, trauma, GERD,postnasal drip etc

Globus sensation/globus pharyngis(feeling of lump in the throat)

Etiology: GERD,inflammation of the throat, postnasal drip, stress/psychogenic,smoking,
inadequate relaxation of swallowing muscles, hypertrophy of the base of tongue, LPR,
zenkers diverticulum
Rx
1.T Pantop 40mg OD for GERD.
ENT consultation if s/s persists.

Tonsillitis
C/f: sorethroat, fever, odynophagia,
Examine throat and look for congestion, enlargement of tonsils, tonsils with purulent
material at the crypts(follicular) & membrane over the tonsils(membranous).
Jugulodigastric Lymph nodes are swollen & tender in a/c tonsillitis
Rx
1.Antibiotics like Amoxycillin, Azithromycin. In pt’s with h/o treated recurrent a/c
tonsillitis give Augmentin(DOC) 625 mg BD.
2.Analgesics like paracetamol/ibuprofen
3.Warm saline gargle, Bed rest, plenty of oral fluids
Note: Tonsillitis or pharyngitis in children are usually due to streptococci. If not treated
properly with antibiotics, rheumatic heart disease or glomerulonephritis may result.

A/c bronchiolitis
Usually in children<2 yrs
C/f: cyanosis,respiratory distress, prolonged expiration,fine creps & rhonchi
CXR: Hyperinflation
Rx
1.Oxygen
2.IV fluids
3.Nebulisation (with adrenaline, 3% Normal Saline, asthalin), Saline Nasal Drops.
4.Antibiotics like cefuroxime may be given
 30
Stridor
High pitched noisy breathing caused by larger airway obstruction, usually the larynx and
trachea associated with dyspnea. Stridor is indicative of a potential medical
emergency and should always command attention. Wherever possible, attempts
should be made to immediately establish the cause of the stridor (e.g., foreign body,
vocal cord edema, tracheal compression by tumor, functional laryngeal dyskinesia,
epiglottitis, acute laryngitis, diphtheria, peritonsillar abscess, IMN, etc)
If due to airway edema:
1. Nebulization with racemic adrenaline/epinephrine (0.5 to 0.75 ml of 2.25% racemic
adrenaline added to 2.5 to 3 ml of normal saline)
2.Dexamethasone 4-8 mg IV q 8 - 12 h
3.Oxygen by face mask; propped up position; inj deriphyllin may also be given.
Immediately refer the pt to ENT/surgery

Quinsy
C/f: sore throat, fever, dysphagia, trismus, muffled speech/hot potato voice, inflammed
oropharynx, swollen tonsil, uvula pushed to opposite side,salivary dribbling from angle
of mouth, I/L earache.
Take swab & sent for pus C & S.
Rx
1.IV fluids
2.IV antibiotics(cephalosporin +/- metronidazole) x 7-10 days
3.Analgesics like paracetamol/ ibuprofen
4.Inj Dexona 8 mg iv st (single dose)
5.Refer to ENT for Drainage of pus

A/c epiglottitis
C/f:fever, sore throat, dyspnoea(mainly inspiratory), rapidly progressive respiratory
obstruction, drooling of saliva, hyperextended neck,
Inv- x-ray lateral view: swollen epiglottis- thumb sign
Note: A toungue blade or indirect laryngoscopic examination should not be done in
children with suspected epiglottitis as it might induce laryngospasm.
Rx
1.Oxygen
2.IV antibiotics( 3rd generation cephalosporin or amoxiclav)
3.Adequate hydration
4.Inj Dexona 8 mg iv st
Note:never treat epiglottitis pt at primary level as ICU is mandatory. In severe cases
endotracheal intubation or tracheostomy may be needed.

Laryngo-tracheo-bronchitis(Viral Croup)
C/f: a/c stridor, barking cough, hoarseness, respiratory distress
Xray: steeple sign
Rx
 31
1.Oxygen inhalation if hypoxemic(SpO2 <92%)
2.Inj dexamethasone 0.6 mg/kg iv st(may be given orally/IM)
3.Nebulise with budesonide 1 mg st & BD
4.For severe cases, Nebulise with racemic adrenaline 1:1000, 2-5 ml
5.i/v antibiotics for bacterial croup(ampicillin or 3rd gen cephalosporins)
6.Adequate hydration.Iv fluids if oral intake is difficult

Hoarseness of voice
Etiology- Vocal polyp, vocal nodule, contact ulcer,
Rx
1. Voice rest, Antacids(pharyngo-laryngeal acid reflux is an aggravating factor for most
of the laryngeal pathologies) , Analgesics(if required), antihistamines(allergy is one of
the most imp predisposing factor for vocal cord pathologies)

Vertigo
May be central or peripheral. Central vertigo may occur as a part of CVA , migraine,
epilepsy, multiple sclerosis, tumours. Peripheral vertigo is usually more severe
Peripheral causes: meniere’s d/s, BPPV, Head trauma, drugs, labyrinthitis, CSOM(to r/o
labyrinthitis) etc
Ask duration, aggravating/relieving factors, h/o ear ache/discharge/hard of hearing,
positional variation
Bppv: short duration, r/c episodes, positional changes
Menieres d/s: fluctuating hearing loss, tinnitus, aural fullness
Labyrinthitis-continous vertigo, severe and pt will be sick, fever, h/o CSOM, a/w hearing
loss with or without tinnitus. Immediately refer
If no ENT pathology, but complaints of dizziness, refer to medicine
Look for nystagmus, facial nerve fn, TM, (normal or not)

Check BP, GRBS

Rx
1. Inj Stemetil(prochlorperazine) 12.5 mg IM st( can be given in pregnancy).
Inj promethazine iv st (to counter extrapyramidal effects of stemetil)
Inj Diazepam,also may be given for severe vertigo.Parenteral Stemetil is the most
effective drug for controlling violent vertigo & vomiting.
2.T stemetil 5 mg 1-0-1 or T Vertin/Betavert(Betahistine) 16/32 mg tds or
T Stugeron(cinnarizine) 25 mg tds/ 75 mg HS. S/e is sedation & is more with vertin.
Betahistine C/I in asthmatics, ulcer pts.
3.T Pantop 40 mg OD
All these can be used in combinations. Never give labyrinthine sedatives for more
than 2 weeks. Withdraw as early as possible. Allow early mobilization.
R/w in ENT OPD for positional test.

Otalgia(Earache)
Aetiology: a/c otitis.media, csom,Furuncle, impacted wax, o.externa, otomycosis,trauma,
herpes zoster, myringitis bullosa, mastoiditis, eustachian tube obstruction, extradural
abscess, referred causes like caries tooth, ulcerative lesions of oral cavity or tongue,
a/c tonsillitis, peritonsillar abscess etc
Rx
 32
1.Analgesics
2.Ear Dps: Otogesic(polyethylene glycol, dibucaine, dihydroxymethylcarbamide,glycerin)
Ear Antiseptic Preparations: Ciplox dps(ciprofloxacin),Zenflox Dps (ofloxacin),
Otobiotic-SF(ofloxacin + clotrimazole+ lignocaine),candid/surfaz(clotrimazole,lidocaine)
Preparations with steroids: otocin-o/otobiotic plus/clotrin-AC(oflox, lidocaine,
beclomethasone, clotrimazole), candibiotic(chloramphenicol, lidocaine, beclo, clotri),
Otobiotic( neomycin + Beclomethasone+ clotrimazole + lignocaine),
3.ENT consultation
C/c otorrhoea causes:
Serous: otitis externa, purulent: otitis media, foul smelling: cholesteatoma, bloody
discharge: trauma,

Wax in the Ear

Impacted wax can cause earache, itchiness, reflex cough, dizziness, vertigo, tinnitus,
some hearing loss
Rx
1.Dewax/Soliwax/clearwax/waxolve/otorex/Waxonil(paradichlorobenzene + terpentine +
benzocaine+ chlorbutol) e/d 30 tds for softening x 5 days.After putting in drops, pt may
stay with the affected ear uppermost for 2-3 minutes to allow the drops to soak into
the earwax.
2.Syringe the ear with lukewarm saline after a few days, if impacted wax+.
The pt is seated with the ear to be syringed facing the examiner. A kidney tray is held
just beneath the ear and water at body temperature is used. The pinna is pulled
upwards and backwards and using the aural syringe, a jet of water is introduced
towards the posterosuperior canal wall of the meatus. The pressure of water built deep
to the wax expels the wax out.The same method is employed for non hygroscopic FB.
C/I for syringing: presence of ear infection, TM perforation, presence of gromet, h/o ear
surgery.
Note: As the wax softens deafness may increase.
Ear buds should n’t be used to remove impacted wax. They are for the pinna only..

Trauma to external auditory canal

Mostly by instrumentation either by pt or physician.If bleeding +, r/o facial Nerve palsy;
take HRCT temporal bone; give inj tranexa 500 mg slow iv st.
Minor lacerations heal, while major lacerations should be treated by packing the
external canal with medicated wicks & anitbiotic steroid drops to prevent canal stenosis.
Advise not to use cotton tipped applicators like ear buds.

Ear bleed
R/o fracture temporal bone. Always look for facial nerve fn and CSF rhinorrhea.
EAC injury(In tempero mandibular jt fracture)- look for mouth opening, mastoid
tenderness. O/e- blood stained EAC,TM not visualized.
Look for facial nerve fn, vision and extraocular movements.
Rx
1. No earpack/drops
2. Neuro onservation
3. Watch for facial nerve palsy
4. Start antimeningitic regimen
5. R/w with CT head
 33
6. If facial nerve palsy present-HRCT temporal bone
7. Inj dexamethasone 8 mg iv Q8H
8. If severe ear blood-inj tranexamic acid 500 mg slow iv st

Foreign body in ear

Living: Insects should be killed first by instilling or spraying lignocaine or normal saline
or oil drops. Later it can be removed using a crocodile forceps or by suction.
If a/w any infection give combiderm ear pack.

Non-living: small, irregular FB’s can be removed with Tilley’s forceps & syringe. Forceps
should not be used to remove smooth objects, as they tend to move inwards. Do
syringing only for nonswelling FB. After FB removal, examine TM. Usually no ear pack
needed.

A/c otitis externa

C/f: tragal tenderness, tenderness on application of traction to the pinna.
Ear discharge + normal tympanic membrane
Rx
1. Antibiotics e.g ampiclox/amoxyclav/ciplox
2. Analgesics like paracetamol/ ibuprofen
3. Local heat
4. Aural toilet if exudates & debris is present with special emphasis on the
anteroinferior meatal recess which forms a blind pocket and acts as reservoir of
infective secretion.
Ear pack of 10% ichthammol glycerine or antibiotic steroid cream.e.g combiderm
(Clotrimazole, beclometasone dipropionate, neomycin).
Remove the pack after 24-48 hours.
5. Ciplox ear drops 20 tds(for associated bacterial infection) after removal of ear pack.

AOM
A/c infection of middle ear cavity usually following an URTI.
Ear discharge + any change in TM suspect OM
Aetiology: URI, FB, Trauma
Usually in children. In adults with U/L serous OM, nasopharyngeal ca should be ruled
out.
C/f:earache,deafness, tinnitus, fever,vomiting, seizure ,Tympanic membrane congested
and retracted, moderate to severe tympanic membrane bulging or new-onset otorrhea
not caused by acute otitis externa.
If discharge present-ASOM
Always watch for facial nerve function
Rx
1. Antibiotics: Amoxclav/ azithro/Cephalexin/Cefixime/ cefuroxime axetil etc.
Syp moxclav228.5/5 (wt/2) ml or 457/5 (wt/4) or 20 mg/kg/dose tds
2. Oral decongestants +antihistamines+ antipyretics (e.g Wikoryl/ Hatric-3/Nasivion)
Syp hatric-3 or wikoryl 125/5 (wt/2) ml or 250/5( wt/4) ml
3. Nasivion ND 20 tds(children <2 yrs: Saline ND, >2yrs:Nasivion -P ND). Avoid ear dps
4.T/Syp Vizylac/Nutrolin-B,Syp BC(syp vimenta)
5. Dry local heat to relieve pain; ear toilet/suction if discharge present.keep ear dry.
Note: All eye drops can be put in the ear, but not the reverse
 34
R/w after 1 week. Chidren with evidence of anatomic damage, hearing loss, laguage
delay should be referred to ENT.
A/c OM is a r/c disease. It may be f/b OM with effusion(no associated signs or
symptoms of infection: fever , otalgia, irritability)

CSOM
H/o recurrent episodes of discharge
O/e discharge+, TM-perforation+, fowl smelling,
CSOM tubotympanic type: medical management; atticoantral type:surgical Mx
Rx
1. T ciplox 500 mg 1-0-1 x 5 days
2. T rantac 150 mg 1-0-1
3. T Vitamin B complex OD
4. T Lyser D 1-0-1
5. Xylometazoline nasal drops 2 drops qid
6. Check RBS
7. R/w after 1 week

Otomycosis(fungal infection of ear canal)

C/f: itching,pain, watery discharge with musty odour, ear blockage, HOH(hard of
hearing)
Rx
1.Ear toilet/suction/mopping; medicated ear pack/wicks (e.g Combiderm or Bestopic-N
or Sigmaderm-N: beclomethasone, clotrimazole, neomycin) for 24-48 hrs.
2.After 24-48 hrs Candid e/d.
3.Analgesics;Oral Antibiotics(if associated bacterial infection) e.g.amoxyclav.
4.Avoid antibiotic e/d.No water in the ear.Ear must be kept dry.

Perforation of tympanic membrane

C/f: pain, bleeding, hearing loss
Uncomplicated perforation usually heals by itself in 6-8 weeks; perforations not healed
by 3 months can be repaired. Treatment is aimed at controlling otorrhoea.
Rx
1.Systemic antibiotics like amoxyclav/ciplox/cephalexin
2.Analgesics
3.Antihistamines like T wikoryl 1-1-1
4.Keep ear dry.Ear drops are avoided unless contaminated;ENT consultation
R/w in ENT OPD for pure tone audiometry and further evaluation

Tinnitus
Aetiology: Wax, fluid in middle ear,otitis media,ototoxic drugs, anemia, HTN,
hypotension, hypoglycemia, migraine,epilepsy, arteriosclerosis, psychogenic
Rx
1.T Bilovas 1 tds(ginkgo biloba)
2.Antidepressants. Treat underlying condition.ENT consultation
 35
Perichondritis of pinna
Secondary to lacerations, hematoma & surgical incisions, ear piercing (especially
piercing of the cartilage).
Inflammation of the pinna is followed by abscess formation between the cartilage & the
perichondrium with necrosis of the cartilage, as the cartilage survives only on blood
supply from the perichondrium.
C/f: fever, painful red ear, fluid draining from the wound, swollen ear,etc
Diagnosed by history of trauma to the ear and the ear is red and very tender.
Rx
1.iv antibiotics as early as possible; inj ciplox, inj metrogyl x 7 days
2.T Lyser-D, Pantop
3.Daily local dressings at early stage with T-bact & once abscess has formed, incision is
made along the natural fold, & the devitalized cartilage is removed.
 36
Orthopedics

X-ray Views
Ankle/elbow/shoulder/ hip/knee,forearm,leg,wrist - AP/lateral
Foot/hand- AP/oblique
C spine/T-L spine/ L-S spine/Skull - AP/lateral
Chest- PA view
Acromioclavicular Jt- AP view
X-ray pelvis with both hips- AP view
TM Joint- OPG(orthopantomogram), Mandibular view

Joint sprain
Commonly involve ankle & wrist joints
C/f: pain, swelling, restriction of movement, contusion
Rx
1.PRICE- Pain alleviation(analgesics), rest, ice application, compression (using
dressing/crepe bandages), elevation
Crepe bandage size(in cm),adult: knee 15, ankle 10, wrist 8;children:knee 10, ankle 8, wrist 6

Pain of muscle spasm / musculoskeletal/osteoarthritic pain

Rx
1.Foment with hot water bag 3 times per day for c/c pain;local ice application for a/c
inflammation
2.Diclonac /volini (diclofenac)/ ketorol/ketanov (ketorolac),Dolonex/pirox (piroxicam) for LA
3.T Ibugesic plus BD /pirox 20 mg OD/ voveran 50 mg BD /ketorol 10 mg Qid/
etoshine(etoricoxib) 60mg / 90mg/120mg OD
4.If contusion +, also give:
T Bidanzen or Flanzen or Lyser forte 10 mg tds (serrapeptase) or T chymoral forte Qid 1/2
hr before food (trypsin, chymotrypsin) or T zymoflam/Rutoheal (trypsin, bromelain, rutoside)
5.Inj Myoril(thiocolchicoside) 4 mg IM st for muscle spasm
Muscle relaxants, NSAID combinations
T Robinax 500mg Qid(methocarbamol), T Myoril 2/4/8 mg (Thiocolchicoside), T Tizan 2/4
mg (tizanidine) tds
Ibugesic-M (Ibuprofen + methocarbamol), Xykaa MR 4/8 mg( P mol + Thiocolchicoside)
Robinaxol(methocarbamol 350 + P mol 250) , Volitra MR,Bruspaz(Diclo+ Thiocol),
Mobiswift –D or Myospas D (metaxalone 400 + Diclo),Orthokind-P 400(etodolac 400+ P/L
500), Aceclo-MR(aceclo+P mol +chlorzoxazone), Thioceclo SR/Thiox OD(aceclo+ Thiocol)
Robinaxol-D(Methocarbamol+ P/L +Diclofenac), Etoshine MR( etoricoxib + Thiocol)

ORTHO Emergency
Always note mode of trauma, site of pain/ swelling/deformity, whether moving all 4 limbs.
Note level of consciousness, vitals, swelling, any deformity, ROM(range of motion) around
the joints, tenderness, any DNVD( distal neurovascular deficit).
Abnormal mobility in a long bone is a pathognomonic sign of fracture.
 37
In fracture of femur, there is increased risk of shock, so close monitoring of vitals should be
done. In long bone fractures, especially of femur, there is a risk of fat embolism syndrome
characterised by cardiopulmonary(tachypnoea, dyspnoea, tachycardia, cyanosis, hypoxia,
hypoxemia), cutaneous(petechial rashes over front and back of chest), and cerebral
(delusions, delirium, confusion, stupour, disorientation) features. Fever & tachycardia are
the early signs. It is prevented by immobilization, rigid splintage, oxygen, iv fluid, LMWH,
and early surgical internal fixation. Treated with oxygen, iv fluids, iv steroids(to avoid
pneumonitis), pulmonary embolectomy.Heparin is C/I as treatment.
Always rule out intra abdominal injuries in case of pelvic fracture

First Aid in Fractures

Rx
1. Analgesic
2. For open fractures, including tendon injuries or If there is a open wound near the
fracture site, clean it thoroughly and cover it with sterile dressing. No attempt should be
made to put the bone lying out inside.
Start on IV antibiotics(cefuroxime+ genta+ metronidazole), TT/Tetglob (if indicated) and
IV fluids before referral or further management
For deep injuries, give a good saline wash after giving local anaesthetic around the
wound
Immobilise the limb with a Splint; Splint should be long enough to fix one joint above &
one joint below the suspested # site.For traumatic head or neck injury, suspect a
cervical fracture unless otherwise proved & apply a cervical collar (preferably a
Philadelphia collar). A backboard/spineboard can be used to stabilize the remainder of
the spinal column; Refer the patient to ortho as soon as possible.
In simple # ribs, most cases require only analgesics, early ambulation & physiotherapy.

Back Pain/Lumbago
Aetioligy:musculoligamentous strain/sprain, osteoarthritis of spine, spinal stenosis,
spondylolisthesis, degenerative osteoporotic vertebral collapse, renal or urethral colic,
ruptured intervertebral disc,pott’s spine, pneumonitis, pleurodynia, rib fracture,
pneumothorax, aortic dissection, aortic aneurysm, P embolism, pyelonephritis,
malignancy(10 or 20), pancreatitis, cholecystitis, herpes zoster , ankylosing spondylitis ,
myeloma, etc.
Factors indicating serious pathology or red flag signs: wt loss,fever, night pain,cancer
history, bowel or bladder dysfunction,disturbed gait, h/o prolonged steroid intake(>4
weeks),age <20 yrs or > 55 yrs, thoracic pain etc
Rx
1.Give analgesics,muscle relaxants,
2. Voveran or pirox gel for LA
3.T Duloxetine 30 mg 0-0-1;
4.Bed rest on a firm bed with cotton mattress for 2-3 weeks.
 38
Advise to sit with back straight and to keep knees and hips at the same level; sit only
for short intervals; while getting up, move ahead in the seat, apply pressure on legs,
straight them and then stand up. Advise to not sit on soft couches

Heel pain
Aetiology: Plantar fascitis(calcaneal spur), achilles tendonitis,heel spurs, stress fractures,
bursitis etc
Inv: X-ray foot/calcaneum(axial/lateral view)
Rx For Plantar fascitis:
1.Use soft heeled footwear or silicon shoe inserts.
2.Gentle massage with analgesic cream like pirox or volini.
3.Dip the foot in hot water twice a day. Passive stretching of ankle(dorsiflexion)
4.Analgesics.

Neck Pain
Aetiology:spinal ,extraspinal, psychogenic. Extraspinal causes include ACS,brachial plexus pain,
shoulder disease, pancoast tumour of lungs, carpal tunnel syndrome, retropharyngeal abscess,
carotid artery dissection, etc. Others include stress, prolonged postures,minor injuries,over use,
whiplash,RA, torticollis, ankylosing spondylitis, head injury,SAH,lymphadenitis etc.
The common neck pain radiating to one arm is cervical spondylosis with radiculopathy. In
cervical spondylosis degenerative changes are seen.
Rx
1.Inj Voveran 2cc IM st ATD if very severe pain.
2.T voveran 50mg bd after food.
3.T Myoril (thiocolchicoside)4 mg BD(for spasticity)
4.T Decadron 1mg tds x 5days after food( if acute pain)(dexamethasone)
While giving steroids, always prescribe calcium + vit D3( Trade name- Shelcal, Shelcal-
CT, Bio-D3 plus, Rockbon-D) also to prevent osteoporosis
5.Gelusil MPS 2 tsp tds
6.Volini/Voveran (diclofenac) or Pirox gel / dolonex gel (piroxicam) or Thiox gel( Diclo +
thiocolchicoside, methylsalicylate, menthol) for LA
7.Well fitting Neck collar for 1-2 weeks if pain and spasm severe or if radicular pain +;
ortho consultation.
Advise correction of postural abnormalities such as inappropriate sitting, sleeping
without adequate neck support, carrying unbalanced heavy weight. Advise to not sit with
a bend neck for long time as while using mobile phones. Advise to turn to one side while
getting up from supine position; use pillow of normal thickness in side lying position.
When the acute event has subsided-physiotherapy.
For acute wry neck(torticollis) use a temporary soft cervical collar.

Repetitive Strain Injury(RSI)

Conditions that maybe a/w RSI:Tendonitis, busitis, carpal tunnel syndrome, raynaud’s
disease, de-quervain syndrome, tennis elbow,focal dystonia, thoracic outlet syndrome etc
Rx
1.NSAIDS like ibuprofen
2.Rest with local support or splinting( elastic support or splint)
 39
3.Icepacks locally help to control pain(& bleeding). A bandage or towel must be
interposed between the icepack and skin to avoid burns.
Compression with elastic bandage 20 cm above and below the injury helps to control
bleeding.
4.Physiotherapy :Includes exercises, manual therapy, and advice on adapting activities
to cope with tasks or reduce the risk of worsening the injury.
5.Taking regular breaks from a repetitive task can help.

Bursitis
Rx
1. Local aspiration & Corticosteroid injection using a thin needle and a Z track to prevent sinus
formation.
2. Analgesics.

Acute prolapsed intervertebral Disc syndrome

Rx
1.If severe muscle spasm and pain: Inj Dicofenac, inj Myoril St, inj neurobion
2.Analgesics + muscle relaxants tds after meals.
3.Antacids
4.T Gabapentin HS x 2 weeks
5.Advise: complete bed rest on firm bed with cotton mattress x 1 month. Hot fomentation to
the back BD; subsequently physiotherapy and exercises.
Avoid sitting for long periods of time(it pits more strain on back than standing).
Avoid bending and twisting from the back and lifting of weights.

Fibromyalgia
Rx
1. T Amitriptyline 10 mg HS
2. Reassure the pt.

Osteoarthritis
C/f- pain at the initiation of movement or exercise, morning stiffness,crepitus on movement, joint
swelling, warmth, effusion(esp in knee)
Ix- BRE, ESR, X-ray
Rx
1.Analgesics like Etoshine 90 mg OD or pirox 20 mg OD or Ibugesic 400 mg tds
2.Chondroprotective agents like Glucosamine sulphate and chondroitin sulphate(TN Rejoint
capsules) BD.
3.Advise wt reduction, physiotherapy etc.
Ortho consultation if a/w joint effusion, deformity, nodules,focal tenderness,pain not relieved
with analgesics, esr>40, anemia.

Osteoporosis
Aetiology- age,post menopausal, drugs(corticosteroids, anticonvulsants like phenytoin,
immunosuppressants, heparin, thyroxine etc), other contributing illness. Other risk factors
include alcohol, smoking,tobacco use, sedentary life style, over weight.
C/f- back ache(earliest), pathological fractures, loss of ht over time, stooped posture
Inv-S ca/P/ALP(all 3 are normal),xray, DEXA scan
Prevention- regular exercise, good nutrition(adequate proteins, ca 1000-1200 mg/day for most
adults, vit D 600-800 IU/day for adults)
 40
Rx
1.vit D 6 lac unit/week for 6 weeks
2.T Ca 1200 mg/day
3.bisphosphonates
Criteria for screening of osteoporosis: woman >65 yrs, men >70 yrs, selected post-menopausal
women who are 50-9 yrs with risk factors for fractures.

Compartment syndrome
Elevation of the intracompartmental pressure which increases the risk of tissue ischemia &
necrosis
Etiology: bone #(mostly supracondylar # humerus, proximal tibia), tight circumferential POP,
cast or dressings, intracompartment vascular beeding, traumatic muscle injury leading to
rhabdomyolysis and crush syndrome.
C/f: pain(1st symptom), pain on passive stretching of fingers(most specific sign), pallor,
paraesthesia, pulselessness(late sign so unreliable), paralysis or weakness in active muscle
contraction.
Immediately refer to Surgery/ortho for fasciotomy and exploration

POP Slab Application

Apply a 6 inch bandage roll or stockinette to the desired length of the limb. Apply a thin
layer of non-absorbable cotton or cast padding (Sof-Rol)over the bandage.
Preparation of POP(T.N: Gypsona) roll: Spread the POP roll( 2 for below elbow, 3 for long
arm, 4 for below knee, 7 for below hip) to the exact length of the limb. Layer the POP roll
over itself 9-10 times for upper limb & 11-13 layers for lower limb.
Immerse the POP roll in water for 5 seconds. Squeeze gently to remove excess water & till
the bubbles stop forming, then stretch out the roll. Place the POP layer over the cotton base
& fold the edges of the base over it.
Place the slab over the posterior aspect of limb with the base in contact with the skin. Mount
the slab over the limb. Apply a firm bandage(2-3 layers) over the slab & wait for setting.
Apply crepe bandage firmly over this to hold the slab in position. After slab application feel
for distal peripheral pulse in that limb. If CMR(closed manual reduction) done, then take x-
ray(after 15-30 min) also for checking the reduction.
Precautions
The bandage should not be too tight to avoid rise in compartment pressure.
Bandaging around any joint should be in a figure of eight style.
Splinting should be followed by elevation.
Advise the pt to return immediately in case of any of the following features:
Excessive pain
Excessive tightness
Swelling of the limb or discolouration.

TMJ Dislocation
Anterior & lateral dislocation are the most common & are due to yawning, seizure,
dental extraction ,trauma etc.
C/f: trismus, malocclusion, unable to speak clearly; in anterior dislocation- prognathism;
in lateral dislocation -deviation of jaw from affected side,condylar head may be felt in the
temporal space.
Inv:OPG is the x-ray of choice. CT-face with 3D reconstruction if there are associated
facial injuries.
Rx
Place the pt supine or semi reclining position.
 41
Administer procedural sedation if required.
Stand behind the head of the pt. Place the thumb of your glowed fingers on the inferior
molars. Note: wrap both thumbs with gauze as there is a risk of injury as a consequence
of rapid jaw closure with reduction. Apply downward & backward pressure - slowly,
gently, progressively & persistently. This helps to disengage the condyle from the
anterior eminence & reposition it back into the mandibular fossa. Confirm relocation with
evaluating the range of motion. Splint the mandibe with a bandage & recommend soft
diet for 48 hrs. Advise against wide jaw opening for 1-2 weeks
OMFS review
 42
Medicine
Anaemia
Can cause exertional dyspnoea,lethargy, easy fatiguability, weakness, pallor,
tachycardia, dizziness, loss of concentration, headache, hypotension, tinnitus,glossitis,
angular cheilosis, koilonychia, irritability.
Most c/c illnesses(e.g infection,Malignancy,renal d/s) are accompanied by a moderate
fall in Hb level. Oral & parenteral iron are of little use; treat underlying cause.
Inv: CBC, red cell indices,reticulocyte count, peripheral smear, S ferritin(a ↓in ferritn is
the earliest & most sensitive test), TIBC, S Iron, S vitamin B12, stool occult blood,
transferrin saturation, Bone marrow biopsy etc
Rx for iron deficiency anemia
Amt of iron required for correction: 4x Body wt x (desired Hb-Patient Hb) +500 mg
1.Dexorange (contains ferric ammonium citrate, cyanocobalamine and folic acid)15-30
ml bid after meals; children 2-5 yrs 5ml; 5-12yrs 10ml bid after meals
Also C Dexorange (1 cap bid after meals)(fe, FA, B12) & Paed Syp available or
 T orofer –XT( 0-1-0)(elemental Fe 100mg + folic acid 1.1 mg)Dps /Syp available or
 C autrin/HB plus/hemfast or
 Tonoferon(Fe, FA, B12) Syp(80/1) or Dps(25/1) Dose: 6 mg/kg/day after food, 2-3
months or
 Hemsi-PD drops(fe, FA, B12)( Fe - 30mg/1ml)
2.T Vitafol 5 mg(Folic acid) OD
Iron supplements need to be taken for several months for iron deficiency. Normalization
occurs around 2 months; stores will be replenished after 6 months.
Iron supplements may cause dark stools, stomach irritation etc.
Iron supplements may also be given for children with wheeze.
Parenteral iron given if a)intolerance to oral iron b)poor compliance c) malabsorption etc
2.Vit C (vit C improves the absorption of iron)
In pregnancy with IDA, if < 30 weeks- oral iron therapy. If intolerant or noncompliance-
IM/IV iron. If > 30 weeks- parenteral iron. If > 36 weeks- blood transfusion.
Prophylactic dose & regimen for iron & FA supplementation
Adolescents-60 mg iron + 500 mcg FA weekly
Women of 20-49 years- 60 mg iron + 500 mcg FA weekly
Pregnancy & lactating mothers 60 mg iron + 500 mcg FA daily

Constipation
Aetiology:physiological, IBS, drugs, lack of fibre and water, anorectal disease, metabolic,
DM, intussusception,neurologic, Ca, motility disorder,hypothyroidism.
Note- bowel obstruction must be excluded. Reduce concurrent opiate dosage.
Rx
1.T Dulcolax/Gerbisa 5mg/10mg/20mg Hs(bisacodyl:stimulant purgative)(5mg HS for
child>6yrs, 0.3 mg/kg/day OD)
 43
(Suppository, 5mg if <2y & 10mg if >2y) (Suppository can be given in pregnancy) or
Syp Cremaffin 5ml-15ml HS(Liquid paraffin-stool softener , MgOH2-osmotic purgative);
or
Syp smuth or cremaffin plus(liq paraffin,Na picosulfate, MgOH2) or
Syp Looz(10/15) (lactulose-osmotic purgative) (infants:2.5-10 ml/day, 0.5
ml/kg/dose)(>2 yr start with 5ml x 2; > 5 yrs 10 ml x 3 ) (agent of choice)(larger doses
are required in hepatic failure)
2.Proctoclysis enema can also be given(after checking bowel sounds)
For pregnant ladies : Dulcolax supp x 2 HS, Dietary fibres(cyber powder 1-2 tsp in 50-
100 ml of water/fruit juice/milk), ispaghula(TN-cardiolax)(bulk forming) 2 tsp in a glass
of water od /bd), lactulose(Duphalac, Looz).

Insomnia
Advise brisk walk in the evening,hot bath before sleep, reading in bed; use drugs as last
resort.
Rx
For sleep onset insomnia- T nitrest or Zolfresh 10 or 5mg HS(zolpidem)
For sleep maintenance insomnia- T zolfresh CR 6.25 mg HS, clonazepam
If associated with anxiety give
T Epizam,Lonazep (clonazepam) 0.5 mg or T lora/ativan 2mg (0-0-1)(lorazepam) or T
Alprax 0.5mg HS(alprazolam) or T diazepam
Conditions mimicking or directly resulting in anxiety: anemia, hypoglycemia, hypoxia,
hyperkalemia, alcohol or drug withdrawal, vertigo, thyrotoxicosis, hyponatremia,
hyper/hypocapnia, poor pain control(e.g IHD), CNS disorders.
Note- Alprazolam is not indicated for long term use due to risk of addiction. Alpraxolam
& clonazepam may cause excessive day time sleep.
Note: early morning awakening or terminal insomnia is seen in depression.

Alcohol Withdrawal
For withdrawal symptoms(m/c & 1st - tremor,others-n,v,sweating,anxiety,
impairment of sleep, altered sensorium,convulsions, hallucinations,etc)
Rx
1.Inj lorazepam or Diazepam or Chlordiazepoxide 1 amp deep im or slow iv st
2.Inj Thiamine 1 amp iv st or thiamine 1 amp in 100 ml NS/DNS over 15-30 min.
3.T Lora 2mg 1-1-2 or 1-1-1-2 or T Calmpose 5mg (1-1-2) or
T Librium(Chlordiazepoxide) 25mg 1-1-1-2 x 5-7 days
4.T thiamine 100 mg od/bd (T Benalgis) x 7-14 days
5.Stop alcohol; advise high calorie high carbohydrate diet
6.Once patient’s symptoms have decreased ie after detoxification, anticraving agents
may be started: T Baclofen 5 mg 1-1-1 (to decrease craving)(C/I :CVA, schizophrenia,
epileptic sz, confused, mental disorder with loss of normal personality)
 44
A/c alcoholic intoxication
Presents with Hypotension,blackouts(amnesia), gastritis, hypoglycemia, collapse,
respiratory depression, seizures. Alcohol encephalopathy due to thiamine deficiency
(wernickes) consists of ataxia, ophthalmoplegia, global confusion. C/c thiamine
deficiency leads to korsokoff psychosis(memory loss,confabulation)
R/o SDH
Rx
1.Gastric lavage only if pt is brought immediately after ingesting alcohol, Maintain patent
airway & prevent aspiration of vomitus. Maintenance of fluid & electrolytic balance
2.Inj Thiamine 100 mg iv st or in 500 glucose infusion x 3 days
3.Correction of hypoglycemia by glucose infusion(only after giving thiamine or else it will
ppt wernickes encephalopathy) till alcohol is metabolized
4.T thiamine 1-0-1 x 1-2 weeks
Note: In a/c intoxication with alcohol, librium is contraindicated.

Oedema
Aetiology: generalised-cardiac failure, Cor pulmonale, liver/renal disease, malnutrition,
angioedema, myxoedema, drugs causing Na retention like steroids.
Localized-infection,trauma,burns, insect bites/stings,DVT, Thrombophlebitis, varicose
vein, venous obstruction, gout, etc.
Inv: Chest Xray, BRE, URE, LFT, RFT,TFT, USS of the local site
Rx
Unilateral edema
 Cellulitis: diffuse swelling of one leg with severe tenderness.
Start antibiotics, analgesics
 DVT- swelling of legs with maximum tenderness on the calf
Admit for heparin therapy
 Filariasis: long standing pitting edema on one leg, which is non tender. Intermittent
fever with rigours
DEC, elastocrepe bandage, elevation of leg, paracetamol
 Gout: tender swelling behind great toe

Generalised edema
 Cardiac oedema: over legs in a pt of known heart disease. Due to heart failure
Refer to physician
 Angioneurotic edema/Drug induced edema: Sudden onset with itching, urticaria,
hoarse voice, dyspnoea. Sudden onset of swelling of face including lips, eyelids &
feet following drug intake
Withdraw the drug, give antihistamines, steroids
 Myxoedema or hypothyroidism: non pitting oedema, puffiness of face, wt gain,
hoarse voice, lethargy Do T3, T4, TSH
Premenstrual edema
Restrict salt, give lasix
 Renal
Generalised oedema more on face & in the morning. Do urine examination
T Dytor 10mg(1-0-0)(torasemide) or T Lasix 40 mg (1-0-0)(Furosemide)
 45
Restrict salt, syp potklor if diuretics are given for a long period. Nephrology consultation.
 Hepatic oedema
Known alcoholic develops ascitis & oedema over legs.
T Aldactone, iv human albumin if S. Albumin low
 Anemia with hypoproteinaemia
 SVC syndrome- edema of the face & neck with breathlessness
Seen in poor patients. Pallor, stomatitis, puffiness of face etc.
Treat anaemia.
 Idiopathic oedema

Palpitation
Aetiology:physiological, psychogenic(31%), organic(cardiac 43%)
Organic conditions include ectopics(premature atrial & ventricular contractions),anemia,
thyrotoxicosis,fever of any cause, hypoglycemia (pounding heart), AF,valvular lesions
like MR,AR, hyperkalemia,drugs causing bradycardia and tachycardia, thyroxine,
atropine, aminophylline, caffeine, tobacco,cocaine etc.
Check for anemia, hyperthyroidism,LVH, supraventricular & ventricular arrhythmias
Rx
1.if psychogenic T ativan 1mg 1-0-1 (lorazepam)
2.occasional benign APC or VPC’s can be managed by beta blockers- T Ciplar 10mg
BD or tds(propranolol);
Palpitation due to alcohol or tobacco or illicit drugs need to be managed by abstention.
Physician consultation.

Heartburn/pyrosis/cardialgia/acid indigestion
Etiology:gastritis,GERD, IHD, zenkers diverticulum etc.
Drugs like CCB’s, nitrates, theophylline, may contribute.
Inv: ECG all leads to r/o ACS, endoscopy
Rx
1.inj Pantop/Ranitidine, f/b Pantop-D 1-0-1 x 2 weeks
2.Antacids after food or sos.
3.C or syp Aristozyme bd/tid after food
Note: 10% of cases of discomfort due to cardiac causes are improved with antacids
Avoid overweight,avoid lying down soon after a meal,avoid late meals,avoid smoking,
avoid tight fitting clothes,elevate the head end of bed, avoid foods that trigger heartburn
like coffee,tea,alcohol, chocolate, high fatty food(fried food, cheese), citrus,tomato, mint,
carbonated beverages. Ensure adequate protein intake.

Epigastic Pain
Aetiology: gastritis, acute coronary syndrome, peptic ulcer disease, gastric volvulus,
Biliary colic, acute pancreatitis, aortic dissection, hepatitis , Oesophagitis,
cholecystitis,oesophageal spasm,duodenitis, cholangitis, etc.
Inv- ECG,

Chest pain
Aetiology: a/c MI,angina,aortic dissection, tension pneumothorax, pulmonary embolism, GERD,
pericarditis, pneumonia, chest wall pain, pleurisy, empyema, bronchitis, cervical spondylosis.
 46
Inv: ECG, CXR, Trop T/ Trop I/ CPK MB
A patient is diagnosed with MI if two (probable) or three (definite) of the following criteria
are satisfied:
1.Clinical history of ischemic type chest pain lasting for more than 20 minutes
2.Changes in serial ECG tracings. If the initial ECG is not diagnostic of STEMI but the pt
remains symptomatic, there is a high possibility of evolving STEMI. So take serial ECGs
at 10-15 min intervals as well as continous 12 lead ST segment monitoring.
3.Rise and fall of serum cardiac biomarkers
Note: Trop T becomes + ve only after 6 hrs, CPK-MB + ve after 4 hrs,
Window period for thrombolysis: 12 hrs
Note: Trop T/I may also be +ve in Myocarditis,sepsis,CCF,kidney d/s,cardiomyopathy.
Chemo prevention for Cardiovascular disease- adults with a ≥10% 10-year CVD risk
and at low risk for bleeding may be given aspirin.

Acute coronary syndrome

Consists of Unstable angina, NSTEMI, STEMI

Stable angina: a) retrosternal pain with a characteristic quality and duration(usually < 5
min and can radiate to either shoulder and to both arms, esp the ulnar surfaces of the
forearm and hand) that is b) provoked by stress or exertion and c)relieved by rest or
nitroglycerin(NTG)
Atypical angina: any 2 out of 3 above criteria
Non cardiac chest pain: meets one or none of these characteristics
NSTEMI: prolonged rest angina(>20 min) or new onset angina or progressive angina
a/w absence of ST elevation and presence of elevation of cardiac enzymes (CK-MB or
troponin).ST depression >0.5 mm or dynamic T ↓ and Trop T +ve
Unstable angina: prolonged rest angina (≥20 min) or new onset angina or progressive
angina with no ST elevation or elevation of cardiac enzymes.ST depression or new T
inversion and Trop T –ve,
STEMI: ST elevation and Trop T +ve
any 2 out of 3 criteria: a)prolonged chest discomfort or angina equivalent(>30 min)
b) diagnostic ECG criteria including ST elevation in 2 consecutive leads, new onset
LBBB or evidence of posterior wall MI(reciprocal upsloping ST depressions, upright tall
R wave, upright T in anterior leads V1-3 and frequently a/w ST elevation in inferior leads
due to shared blood supply c)elevated cardiac enzymes.
Diagnostic ECG criteria for STEMI: ST elevations in 2 or more anatomically contiguous
leads-1) In men > 40 yrs, ST elevation≥2 mm in leads V2 and V3 and >1mm in all other
leads.2) In men < 40 years, ST elevation >2.5 mm in V2, V3, and 1 mm in all other
leads.3) In women, ST elevation >1.5 mm in V2,V3 and 1mm in all other leads.4) In
right sided leads, V3R and V4R- elevation >0.5 mm(age >30 yrs) or >1 mm(age<30
yrs).5) New LBBB-s/o large AWMI.6) In old case of LBBB, St elevation >1mm in
presence of a positive QRS;ST elevation > 5 mm in presence of a negative QRS
complex; ST elevation > 1mm in V1-V3
In IWMI, record a right sided ECG to r/o RVMI(esp if signs of low cardiac output/shock+)
History taking
1. Duration, character, site, radiation and associated symptoms of the chest pain
2. Female sex, diabetes, CHF,CKD and old age may p/w atypical ACS symptoms like
dyspnea
 47
3. Jaw, neck, arm or epigastric pain can be angina equivalents
4. Time of index pain
5. Presence of co-morbidities
6. R/o other causes of chest pain-aortic stenosis, HCM, prinzmetal angina, syndrome X,
pericarditis, aortic dissection, GERD, pleuritic pain, pulmonary embolism, pulmonary
HTN, musculoskeletal pain, anemia, thyrotoxicosis.
7. Identify absolute and relative contra indications for PCI and thrombolysis.
Physical examination
1. presence of pulmonary edema, new or worsening MR, S3 or new or worsening creps,
hypotension, bradycardia, tachycardia puts the pt in high risk category.
2.killip class for risk assessment
Inv:
1.ECG
2.Cardiac enzymes;a) trop T or trop I: ideal cardiac markers highly sensitive, elevates in
4-6 hrs and lasts for upto 2 weeks. If Trop T or Trop I is negative within 6 hrs from index
pain, then a repeat value has to be taken during 8-12 hrs period. Trop I is preferred in
diabetic and CKD patients.
In CKD pts cardiac troponin levels are frequently elevated without evidence of ischemia,
therefore the diagnosis of a/c MI cannot be made and requires serial measurements of
cardiac troponin levels.
b)CK-MB: less sensitive, elevates in 3-6 hours, lasts for 48 hrs-72 hrs. Used for
detecting reinfarction. But for detecting reinfarction serial high sensitivity trop values are
ideal.A ratio of CKMB/Total CK >2.5 suggests myocardial injury.
3.RBS, fasting lipid profile, BRE(non specific reaction to myocardial injury is a/w
elevated WBC/neutrophils),RFT,LFT, serum electrolytes,CXR,ECHO
4. others, LDH(elevated)
Rx
STEMI
Initial casualty management:
1.Immediate intervention, give loading dose: T aspirin 325mg + T clopidogrel (300-600 mg)
or T Ticagrelor 180 mg + T Atorva 80 mg st
Note:don’t give ecospirin for loading dose as it is enteric coated & thus delayed release.
2.O2 inhalation(2-4L/min) for pts(with breathlessness, signs of heart failure, shock, or
O2<94%) for initial 6 hrs & continue if saturation is low.
3.If severe bradycadia is present(<40 bpm): inj atropine 1.2 -2 mg iv st fast
4.If in hypotension: for AWMI, inj dopamine 400 mg in 500 ml NS at 4-24 drops/min(10-20
microgram/kg/min). For IWMI iv fluids preferred for restoring BP
5.In the absence of hypotension: inj metoprolol 5mg iv stat, every 2-5 min for a total of 3
doses if pt tolerates f/b oral beta blockers
For pain management:T sorbitrate 10 mg s/l or PO st. Upto 3 tablets, 15 minutes apart may
be given. If there is still no relief, inj morphine 1-5 mg iv st may be given(c/I; hypotension,
bradycadia).Metoclopramide 10 mg / phenergan 25 mg for nausea/vomiting associated
with Morphine. Note: morphine C/I in RVMI. S/e like bradycardia, hypotension a/w
morphine usually responds to atropine.
NTG infusion can also be started after oral sorbitrate @ 5mcg/min infusion. The rate of
infusion may be increased by 10 mcg/min every 3-5 min until symptoms are relieved or
systolic BP falls to <100 mm Hg. Tolerance may develop if administered for more than 24
hours. Nitrate free interval (10-12 hrs) is recommended to avoid tolerance development.
 48
Pethidine & fortwin can result in tachycardia, so C/I in MI.
6.If pulmonary edema develops: a)propped up position b) O2 inhalation c)inj frusemide 40
mg iv st(if BP>90/60 mm Hg) and tds. Infusion can also be given usually started @ 2 mg/hr.
7.Thrombolysis in ICU: criteria - symptoms<12 hrs, ST ↑(not done in UA, NSTEMI)
Inj streptokinase 1.5 MU in 100 ml NS over 60 min with BP monitoring every 10 min and
continuous ECG monitoring. If allergy occurs a)inj hydrocortisone 100 mg iv st.b) inj
pheniramine maleate 25 mg iv st.
Other complications: ICH, ventricular tachycadia
Other agents used:alteplase, reteplase,tenecteplase(TNK)
8.If BP >180/115 mm Hg, it must be controlled before starting thrombolysis. Inj NTG 50 mg
in 500ml NS . Start at 2 drops per minute(maximum:12-14 drops per minute)(C/I:SBP<90
mmHg;PR<50bpm;PR>120%,RVMI, documented use of sildenafil in last 24 hrs)
Ward management
Rx
1.absolute bed rest
2.Monitoring of vitals; I/o chart
3.T ecospirin 150 mg 0-1-0 x 1 year
4.T clopidogrel 75 mg 1-0-0 or T Brilinta(ticagrelor) 90 mg BD or Prasugrel(prax) 10mg
ODx 1 year
5.T atorva 40 mg 0-0-1 or T Rosuvastatin 20 mg 0-0-1(keep LDL<70mg/dl)
6.T metoprolol(betaloc) 25 or 50 mg 1-0-1(C/I: bronchial asthma,COPD, POVD, prolonged
PR interval, 20 or 30 heart block,hypotension, SBP<90,shock, LVF,CHF). Later can switch to
extended preparations Met XL 25 or 50 mg or Metolar XR
7.T enalapril(envas) 2.5 mg 1-0-1 or T Ramipril (cardace)1.25 mg 1-0-1(given to all for 48
hrs if RFT is normal and no other C/I) or T Telmesartan 20 or 40 mg1-0-1
8.Anticoagulant therapy: inj heparin (UFH) 60U/kg iv bolus, f/b 12-14 U/kg infusion. In
practice, it may be given as inj Heparin 5000 U iv Q6H(APTT to be maintained 1.5-2.5 times
control ) or LMWH may be given, for eg, inj enoxaparin (clexane) 0.6 ml s/c BD(1 mg/kg
s/c BD)(give half dose in patients with S creatinine >2.0)
8. T sorbitrate or isordil(isosorbide dinitrate) 5 or 10 mg 1-1-1 or
T monotrate or Monit (isosorbide mononitrate)10 or 20 mg 1-1-0 or
T Nitrolong or nitrocontin or Angispan TR(nitroglycerin) 2.6 or 6.4 mg BD
9. Other anti anginals used T Nikorandil(nikoran) 5 mg bd/tds,
T ranolazine(ranozex, angiotec,caroza)500 mg BD(used in c/c angina,not in acute attacks)
T Flavedon(trimetazidine) 20 mg BD or Flavedon MR 35 mg BD
Ambulation of post MI patients:1. After 24 hrs, pt may sit up on the bed or slowly stand by
the bed.
2.After 48 hours, 3 minutes exercise in the morning and 5 minutes of exercise in evening
3. after 72 hrs, 5 minutes in the morning, 10 minutes in the evening and so on.
Note : following an attack of MI, the mortality & morbidity of pt is indicated y LVEF.
NSTEMI/Unstable Angina
Rx
1.O2 inhalation
2. Absolute Bedrest. Later graded ambulation 2 min in the morning & 5 min in the
evening.
3.300 mg dispirin(don’t give ecospirin as it is enteric coated & thus delayed release ) st
followed by 75 mg/150 mg ecospirin 0-1-0
4.If normal BP T sorbitrate(isordil) 5mg/10 mg S/L st & 1-1-1
 49
Note: In those patients not tolerating Sorbitrate, we may give T.Monotrate 10mg/20mg
1-1-0
5.T Clopidogrel(clopilet/clopikind/deplatt) 75 mg x 4 tab ST & 1-0-0
6.If severe pain persists,IV morphine 2-3 mg/pethidine 50-100mg(may cause vomiting)
Note:C/I in asthmatics, COPD, already in hypotension.
10. β blockers, e.g T metoprolol 25 / 50 1-0-1(Monitor Pulse Rate) or
T Carvedilol 3.125- 25mg (Cardivas) bid or nebivolol 5-40 mg daily(Nebicard)
Note:If refractory with adequate doses of nitrates and beta blockers or in pts unable to
tolerate adequate doses of one or both of these agents start CCBs(Non DHP)
8.ACE inhibitors, e.g T envas(enalapril) 2.5/5 mg 1-0-1(monitor BP, RFT). Avoid CCBs
in pulmonary edema.
9.T Atorvastatin 80 mg st & 10mg 0-0-1
10.Heparin/LMW Heparin(clexane )i.e. Inj heparin 5000 U s/c Q6H x 5 days Or
Inj clexane (enoxaparin)0.6 ml s/c BD(if RFT normal) or inj Fondaparinux 2.5 mg sc OD
or inj fragmin(dalteparin) 5000 IU (120 IU/kg) s/c BD.
11.Syp cremaffin 15-30 ml HS (as stool softner); semi solid diet.

 Aspirin + Clopidogrel Combinations: T.Complatt, T.Deplatt-A, T.Cidogrel-A

Note: Prinzmetal angina(non atherosclerotic epicardial coronary spasm),c/f: angina

commonly occurring b/w 12 am - 8am, Inv: ST↑ + cardiac enzymes Normal, Rx: for
acute - Nitrates, for c/c - CCB. Avoid aspirin and β blockers.

Congestive Heart failure

Left ventricular failure(LVF)

S/s: dyspnoea at rest that rapidly progresses to a/c respiratory distress, orthopnoea,
PND, pink frothy sputum
Signs: distressed, pale, sweaty, tachypnoea, gallop rhythm, pulmonary edema(basal
crepitations), Pulsus alternans, pitting edema, raised JVP,narrow pulse pressure, end
inspiratory lung crepitations.

Right heart failure: raised JVP, hepatomegaly, ascites, bilateral pitting pedal edema

Inv: CBC, urea, electrolytes,TSH, ECG, NT-Pro BNP,CXR.

Note- Troponin, CRP, uric acid may be elevated in heart failure..
CXR in LVF: features can be remembered as ABCDE ie Alveolar edema,kerley B lines,
Cardiomegaly, Dilated prominent upper lobe vessels, pleural Effusion
Rx
Ideally LVF should be managed in ICU
The management of a/c pulmonary edema can be remembered as L M N O P ie
Lasix, morphine,nitroglycerine, oxygen, & propped up position
1.Sit the pt up;CBD
2.Bed rest, salt and fluid restriction.
3.Oxygen inhalation @10L/min through face mask or nasal cannula; CPAP
4.Inj Lasix 20- 80 mg iv st, repeated every 15 min, followed by 40 mg Q6H or Q8H( if there
is no significant fall in BP)(larger doses required in renal failure).
 50
Note:Pt currently treated with furosemide may receive twice the daily oral dose by
intravenous administration.
5.Inj Morphine 2mg slow iv st ( + inj phenergan 25 mg iv st)( may be repeated as
needed every 5-10 minutes; reduces anxiety and is a venodilator.
6.Inj NTG infusion(only if the pt is in ICU). If infusion pump not available- 1 amp (25 mg)
in 500 ml 5D, start @ 4 drops/min(10µg/mt). BP should not fall below 90 mm Hg.
7.Inj Aminophylline 250 mg in 20 ml NS or 5D iv bolus over 20min Q8H.
8.Positive inotropic agents such as dopamine/dobutamine may be needed in pt’s with
concomitant hypotension or shock. Inj dopamine 400 mg(10ml) in 500 ml NS, start @ 4
drops/min(2.5 µg/kg/min, assuming wt to be 60 kg) or Inj dobutamine 250 mg(5ml) in 500 ml
5D, start @ 6 drops/min(2.5 µg/kg/min, assuming wt to be 60 kg). Dobutamine is useful in
ADHF with hypotension especially with renal dysfunction with diuretics. It improves cardiac
output with out increasing HR and improves hemodynamic abnormalities. Dopamine is
usually not used if dubutamine is available.
9.Manage precipitating causes like MI/ infections/arrhythmias
Medications during discharge
1. Beta blockers.Most important for compensated HF. Not started if HR<60 and SBP<100.
Metoprolol(betaloc) started at 12.5 mg OD and carvedilol (cardivas or carca or carloc)
started at 3.125 mg BD.they are titirated up gradually every 2-3 weeks. In pts with
bronchospasm, metoprolol and nebivolol may be useful.
2. ACE inhibitors like Enalapril 5mg 1-0-1(if BP above 120 mm Hg & creatinine < 1.5 mg/dl)
Dry cough associated with ACEi can be diminished by iron supplementation. Check
creatinine after a couple of days after starting ACEi and if it rises by 0.3 mg/dl or more, stop
the drug and investigate for renal artery stenosis.
2.T Lanoxin(Digoxin) 0.25 mg 1/2 tab OD 5 days in a week (useful especially if a/w atrial
fibrillation and reduced cardiac output)
3.T Dytor 5- 20 mg OD initially, doubled until desired diuretic effect is achieved.
Combination of diuretic plus aldosterone antagonist may be used. For eg T dytor plus
5/10/20 mg(spironolactone 50 mg + torasemide 5 or 10 or 20 mg) OD/BD or
T Lasilactone (furosemide 20 mg+ spironolactone 50 mg) OD.
3.T inapure or coralan (ivabradine) 5 mg BD (if betablockers cant be given or if s/s not
controlled with beta blockers)
4.Thiamine may be supplemented as diuretics wash out thiamine.
Causes of pumonary edema
LVF, ARDS, fluid overload(renal failure, iv fluids),hypertensive crisis, neurogenic
causes( seizures, head injury etc).

UTI
c/f :Fever with chills , Burning sensation during micturition,frequency, abd pain,
Burning pain on micturition indicates urethritis. Suprapubic pain, frequency, dysuria:-
cystitis; High fever, toxicity, flank pain, tender renal angles:- pyelonephritis; palpable
kidney swelling:hydronephrosis.
R/o DM, calculi
Inv: URE ,RFT , C & S etc. Urine culture is must for recurrent infection, children,
pregnancy, DM, Indwelling catheter, older people, failure of initial therapy.
Rx
1. T P/L 500 mg tds X 3 days or T cyclopam(for ureteric/renal colic)
 51
2.T Norflox 400mg 1-0-1 X 5-7 days for uncomplicated UTI ( for men give for more
days) or T Furudantin 50/100 mg (nitrofurantoin) 1-0-1(if resistant or recurrent UTI).
For upper UTI give antibiotics for 7-14 days.
(others:Cefpodoxime,cephalexin,cotrimoxazole,amoxicillin + clavulanic acid etc)
Note-Norflox, ofloxacin,nalidixic acid,ciplox are C/I in pregnancy & lactation
Note:Always collect urine in a sterile bottle before giving antibiotics.
If C & S is done, give antibiotics only till the result comes. Once the result comes,
Antibiotic can be changed according to the report
3.Syp Citralka ( Di Na hydrogen citrate) 2 tsp in one tumbler of water tds( can be given
in pregnancy)
4.T pyridium (phenazo pyridine) 200 mg 1-1-1 x 2 days( it is a urinary analgesic. It
produces reddish discolouration of urine. So warn about it. Not to be used for more than
2 days.C/I in pregnancy)(12 mg/kg/24 hr div into 3 for 2 days)
5.Plenty of oral fluids(~2L or more / day), cranberry juice.
Note: UTI in young men needs evaluation for correctable structure anomalies.
In pediatric cases we may give cefixime, septran or gramoneg.Refer all pediatric UTI to
pediatrician for work up(MCU, USG etc),as child below 5 yrs(especially < 2 yrs) are
vulnerable for permanent renal damage following UTI. In infants UTI more common in
males.
T Urikind/Urispas (Flavoxate) 200 1-1-1 (for dysuria, urgency, nocturia, suprapubic pain,
frequency & incontinence, bladder spasm due to catheterization etc)(given in pregnancy)

Hematuria
Aetiology: UTI,pyelonephritis, trauma, Hemorrhagic cystitis, nephrolithiasis,kidney injury
(from accidents),a/c prostatitis, urethral stricture,drugs(like penicillin, anticoagulants like
aspirin, heparin,warfarin,certain anticancer drugs), food dyes like beet root, neoplasm,
TB, traumatic urethritis due to sexual intercourse or masturbation, allergy, strenuous
exercise, viral illness, glomerulonephritis, excessive coagulation therapy, urethral FB,
renal infarction, myoglobinuria, hemoglobinuria.
Inv: URE, BRE, RFT,coagulation profile, USG abdomen etc.
Negative dipstick, no RBC- pseudohematuria, food, dyes, medication
Positive dipstick, no RBC- myoglobin(rhabdomyolysis)
Positive dipstick, positive RBC(true hematuria)- a)hematological(e.g coagulopathy),
b)urological(nephrolithiasis, trauma, tumour, prostatitis, urethritis), c)renal
(glomerulonephritis, pyelonephritis, CTD)
Significant hematuria-RBC> 3/hpf on >3 occasion or RBC>100/hpf on one occasion
Advise medicine/surgery consultation.

Urinary incontinence
R/o UTI, BPH, dementia, CVA,drugs(sedatives, diuretics), fecal impaction,uterine prolapse
Keep pt dry with condom catheter, portable urinals etc.
Put foley’s catheter if necessary.
Medicine, urology consultation.
 52
Status Epilepticus
Occurrence of Seizures for more than 5 min or fits occurring in succession without regaining
consciousness in between.
Practically, a seizure more than 5 minutes is treated as status epilepticus
Causes: hypoxic brain injury, stroke, head injury, ecclampsia, fever, Infections like Meningitis,
Encephalitis, electrolytic abnormalities(low Na+, low ca2+, low Mg2+, hypoglycemia,
hyperglycemia), hyperthyroidism, congenital brain malformations, genetics(PKU, turners
syndrome etc), toxic metabolites(porphyria, uremia, liver failure), drug withdrawal, drug
interaction,ICSOL,Stoppage of current Anti-epileptic medication etc
Inv: RBS, SpO2, ABG, Ca2+, Mg2+, Na+, K+
R/o hypoglycemia
The aim of treatment is to control seizure first(hit hard hit fast) and then identify any
correctable cause and treat it if possible.
Rx:
1.Maintenance of airway + throat suctioning
2.O2 inhalation
3.Maintain iv line & draw blood for metabolic work up
4.Lateral position
5.Intravenous antiepileptic medications
Inj Lorazepam 4 mg iv st (over 1 min)/ inj diazepam 10 mg iv st over 2 minutes(rpt once
after 15 min if needed)
6.Send RBS
7.Inj 25% dextrose 100 ml iv st
8.Inj thiamine 100 mg iv st
9.Inj phenytoin(eptoin) loading dose 10-20 mg/kg( 20 mg/kg first dose as 50 mg/min in
running NS).Usually it is given as inj eptoin 600/800/1000 mg in 100 ml NS(1 pint NS if
dose >1000 mg) over 20 min or Inj Levipil(levitiracetam) 1g in 100ml NS over 20 min.
Phenytoin should not be injected through the same cannula as lorazepam because of
the possibility of crystallization. IV lines should be flushed prior to and after the
administration of phenytoin. Watch for hypotension & arrhythmia during infusion. Don’t
exceed 50 mg/min infusion rate as this may cause hypotension/cardiovascular collapse.
10.Later inj phenytoin 100 mg or inj Na valproate 250 mg iv q8H or inj Levipil 500mg
BD(50 mg/kg in children).
11.If even after step 6, no improvement, rpt diazepam & ½ dose phenytoin
If still no improvement refer the patient to physician/ neurologist.
AEDs- should only be commenced by a specialist , after confirmed epilepsy diagnosis,
≥2 seizure episode and following discussion of treatment options with the pt.
GTCS, 1st line- Na valproate 2nd line- carbamazepine, clobazam,levitiracetam
Focal(partial) seizures-1st line- carbamazepine 2nd line- levitiracetam,Na valproate
Absence seizures-1st line- Na valproate 2nd line- lamotrigine
Myoclonic seizures-1st line- Na valproate 2nd line-levitiracetam. Avoid carbamazepine. May
worsen seizures.
Tonic or atonic seizures1st line- Na valproate
Na valproate-initially 300mg/12hr, increase by 100 mg/12 hr every 3 days upto a maximum of
30 mg/kg(or 2.5 g)
Levitiracetam-initially 250mg/24 hr, increase by 250mg/12 hr every 2 weeks upto
maximum1.5g/12 hr
 53
Carbamazepine-initially 100 mg/12 hr, increase by 200 mg/day every 2 weeks upto maximum
1000 mg/12hr.
Ideally treat with one drug and with one doctor in charge only.slowly build up doses over 2-3
months until seizures are controlled or maximum dose is reached. If ineffective or not tolerated
switch to the next most appropriate drug. To switch drugs, introduce the new drug slowly and
only withdraw the 1st drug once established on the second drug. Dual(adjunct) therapy is
necessary if all appropriated drugs have been tried singly at the optimum dose.
Stopping AEDs- done under specialist supervision if the pt has been sz free for > 2years and
after assessing risks and benefits for the individual(e.g the need to drive). the dose mmust be
decreased slowly, over atleast 2-3 months, or >6 months for BZD and barbituarates.

Hypertension
(pts with newly discovered asymptomatic hypertension or asymptomatic known
hypertensive patients with elevated BP)
Acute lowering of BP is unnecessary and may be harmful in asymptomatic
patients.
Just advise them to consult their primary physician for therapy change.Asymptomatic
Pt with newly discoverd BP, should be advised to consult physician to start on
antihypertensive therapy. Reduce BP, if greater than 220/110.
Don’t give Nicardia /Lasix to reduce hypertension in an asymptomatic, otherwise normal
patient as it causes sudden decrease in blood perfusion to organs and may lead to end-
organ damage. Attain 25% reduction in systolic BP over 4-6 hrs or 160/100.
Note:a/c reduction of BP is required only in hypertensive emergency(rapid ↑ in BP +
rapidly evolving end organ damage) like MI with HTN, stroke with HTN, hypertensive
encephalopathy,pul edema with HTN,HTN with ARF etc
Secondary causes of HTN:renal artery stenosis, renal cysts, hypo/hyperthyroidism,
coarctation of aorta, OSA, primary aldosteronism, cushings syndrome, PCOD,
pheochromocytoma, prolonged use of OCP, adrenal steroid, nasal decongestant etc.
Drugs used for hypertensive crisis
Inj Lasix 20/40mg iv stat (frusemide)(pumonary edema)
Inj Labetalol 10 to 20 mg iv over 1 to 2 minutes(stroke)
Inj β blockers like esmolol, labetalol (aortic dissection)
T Aceten S/L stat (1/4 th of a tablet)(captopril-ACEI)
C.Nicardia 10/5mg S/L stat [nifedipine(CCB)]
C Beta Nicardia S/L stat [atenolol(beta blocker) + nifedipine(CCB)]
T Arkamine 0.1mg stat (Clonidine=alpha2 bloker)(nt preferred as it cause severe
rebound hypertension)(it is preferred in renal pts)
Nitroglycerine infusion(to be given in icu setting only); start with
5mcg/kg/min(pulmonary edema,MI)
T lonitab(minoxidil) 5-10 mg st
T nimodipine( SAH)
Inj Phentolamine(pheochromocytoma)

Newly Detected Systemic Hypertension

BP should be measured in sitting position and a raised BP should be rechecked in other
arm. An elevated reading should be confirmed at two other visits.
 54
90--95% of HTN is primary without any cause.In the rest, it is 2 HTN.
0

Hypertension per se may not cause any symptoms.

C/f: occipital headache usually during early morning hours. S/s due to complications like
palpitation, dyspnoea, epistaxis etc.
Hypertension: investigation for all patients
 Urinalysis for blood, protein & glucose
 Blood urea, electrolytes & creatinine.
 Blood glucose will be high in 20 causes like cushings syndrome, 10 aldosteronism,
pheochromocytoma
 S. total & HDL cholesterol
 12- lead ECG(LVH, CAD)
 CXR (LVH,coarctation)
 TSH(hypothyroidism - DBP↑, hyperthyroidism - SBP ↑)
 S. Ca, P is a screen for hyperparathyroidism, another 20 cause.
Ideally, before starting drugs, R/O secondary HTN. Clinically look for Renal Bruit. Renal
artery doppler may be done.
Mx
If BP not alarmingly high, advise salt restriction & review for BP check up after ~1 wk.
Management of uncomplicated essential HTN: diet modification, exercise, drugs.
 In obese hypertensive pt’s, weight reduction is the primary goal of therapy.
Drug treatment is recommended in:-
 In patients with sustained SBP≥160 Hg or sustained DBP≥100 mm Hg.
 In patients with sustained systolic BP in the range 140-159 mm/Hg, and/or diastolic
BP in the range 90-99 mm/Hg , the decision depends on the risk of coronary events,
presence of diabetes or end-organ damage(i.e.renal impairment etc )
Treatment goal
<140/90 mmHg(<130/80 in diabetes/CKD). Reduce BP slowly.
Hypertension should not be diagnosed on the basis of one measurement alone, unless
it is >210/120 mm Hg or accompanied by target organ damage.Two or more abnormal
readings should be obtained, preferably over a period of several weeks, before therapy
is considered. Gestational HTN is defines as systolic BP≥140 mm Hg or diastolic BP
≥90 mm Hg on two occasions atleast 4 hours apart. It will return to normal within 12
weeks post partum.
Initially monotherapy, then go for multitherapy, if not controlled.
Monotherapy
If >55 yrs, 1st choice is a Ca2+ channel blocker or a thiazide. If <55 yrs, 1st choice is
ACE-i(or ARB if ACE-i intolerant). T clonidine(arkamine) 0.1 mg preferred in renal pts.
ACEi or ARB prefered in presence of microalbuminuria, renal d/s, cardiovascular
d/s(CVD), or additional CV risk factors.In elderly hypertensive pt’s(>60 yrs), start
diuretics as initial therapy.Ca2+ antagonist/ ACEI/ARB are also effective.
Even though thiazide diuretics are considered as first line , in practice, they are not
started early due to the risk of hyponatremia. Hydrochlorothiazide(12.5-25 mg/day).
Usually given in combination.
Multitherapy
 When SBP≥140 or DBP≥90 mm Hg or >20/10 mm Hg above target, combine any
of the first line agents.
 When a second drug is needed, it should be generally be chosen from among the
other first-line agents.A diuretic should be added first, as doing so may enhance
effectiveness of the first drug. But the combination must include ACEi or ARB.
 Another method is, in combination one out of two groups A (ACEI/ARB) or B (β
blockers) is combined with C (calcium channel blocker) or D (thiazide diuretic) ie.
 55
A/B + C/D. Combination of ACEi +CCB is preferred over or better than a
combination of ACEi +diuretic.β blockers are not a 1st line for HTN.
 In pt’s with stage 2 HTN, therapy may be initiated with a 2 drug combination,
typically a thiazide diuretic + Ca2+ antagonist/ACEI/ARB/β-blockers.
 When eGFR<30 ml/min/1.73 cm2 avoid thiazide/thiazide like diuretic and consider a
loop diuretic instead.
 When multiple agents are used, it is better to start a single pill combination(SPC) of
multiple agents for better pt compliance.
 In refractory pts, when 3 agents are to be used, A+C+D is a good choice.
 In those uncontrolled on SPC of 3 drugs, addition of either a low dose
spironolactone(amiloride or other diuretics if spironolactone is not tolerant) or a β
blocker or an α blocker is recommended to achieve control.

 Antihypertensives in pregnancy:- Alpha Methyl Dopa,Nifedipine, labetalol

ACE inhibitors & thiazides are contraindicated in pregnancy
 Ca2+ antagonist should be used with caution in a/c MI.
 In hyperthyroidism + hypertension give beta blockers, anti thyroid drugs
 In HTN + LVH, ACEI have greatest effect on regression.
 In case of CCF give diuretics + ACE inhibitors or ARB .
 HTN with heart failure and reduced EF - ACEi/ARB + diuretic+ beta blocker
 In HTN + DM, 1st line- ACEI/ARB, 2nd line- CCB, avoid thiazides, non selective β
blockers. In HTN + DM, carvedilol and nebivolol have favourable metabolic effects,
but not for metoprolol.
 HTN alone/ HTN +DM/ HTN+cerebrovascular disease-: ACEi/ARB +CCB/diuretic
 In DIABETIC NEPHROPATHY, give ACE inhibitors(best). Avoid β blockers. Any pt
started with ACE inhibitors requires RFT at 2 wks.
 In HTN with CKD, give ACEi/ARB+ diuretics/CCBs
 In CAD (post MI), give ACEI. Another option is to give
a)ACEi/ARB+betablocker/CCB or b) beta blocker +diuretic or c)
CCB+diuretic/betablocker . Avoid short acting CCB(DHP) as it cause reflex
tachycardia.
 In CAD(stable angina) give β blockers, CCB(non DHP), diuretic. Before starting
beta blockers r/o bronchospasm, POVD etc.
 HTN with BA- use CCBs, ACEI,diuretics. Avoid β blockers.
 HTN with gout- use losartan
 In systemic sclerosis, give ACEI. Avoid β blockers.
 Resistant hypertension: BP≥ 140/90 despite ≥3 drugs, one of which is a diuretic.
 In isolated systolic HTN use CCBs , diuretics
 In HTN with hyperlipidemia, use prazosin(↑HDl, ↓LDL), ACEI/ARB. Avoid thiazides,
non selective β blockers
 In elderly male HTNsive with BPH, use prazosin
 Anti HTNsives with erectile dysfunction- thiazides, β blockers

Hypertensive emergencies- a/c severe elevations in BP often > 180/110 mm Hg

Typically with SBP >200 mm Hg and/or DBP>120 mm Hg.
A/w the presence or impendence of end organ dysfunction.
Includes accelerated HTN & malignant HTN. Hypertensive urgencies are characterized
by a/c elevation in BP but are not a/w target organ dysfunction.
Pts with hypertensive emergency have higher average Heart rate, whereas pts with
hypertensive urgency is a/w normal heart rate.
 56
Accelerated hypertension
SBP>210 & DBP >130, presenting with head ache, blurred vision or focal neurological
symptoms. If papilledema is present, it is said to be malignant HTN
Rx
Target is to reduce BP by 20-25% during first hour to minimize target organ damage
while maintaining DBP≥ 100 mm Hg.
2- 6 hours:SBP 160 mm Hg and/or DBP 100-110 mm Hg. 24-48 hrs:normalize
Caution-Volume depletion is common in pts with malignant HTN, and the administration
of a diuretic together with a hypertensive agent can lead to an extreme drop in BP.
Condition agent Therapeutic goal
A/c MI iv metoprolol , iv NTG ↓ of BP by 20-30% or SBP to <140
Pulmonary edema iv furosemide , iv NTG ↓of BP by 20-30% or SBP to <140
HTN sive encephalopathy iv labatalol Reduction of BP by 20-30%
ICH iv labatalol, iv esmolol
(nitroprusside not used as it raise ICP)
A/c ischemic stroke iv labatalol Treat if BP>220/120. If planning
for thrombolysis treat if >180/110. Lowering BP >15% in first 24 hrs should be avoided.
ARF iv labatalol, iv furosemide Reduction of BP by 20-30%
Aortic dissection iv labatalol SBP 100-120, HR<60
Post OP HTN iv labatalol, iv esmolol <180/110
SAH iv labatalol, iv esmolol SBP<160
Pregnancy with eclapmsia iv labatalol 140-150/90-100
 57

Common antihypertensives & Brands :

Amlodipine [5-10mg OD] (CCB)

Amlodac, Amlopres,Amlokind, Amlosafe, Amlovas, Stamlo

Nifedipine [5-20mg bd] (CCB)

Nicardia(Cap), Nicardia retard(tab), Calcigard(both cap & tab)

Cilnidipine(5/10/20 mg) OD/BD- cilacar, cilaheart

Atenolol [25-100mg OD] (beta blocker)

Aten, Beten, Tenolol, Tensimin.

Bisoprolol 5mg or 10 mg(concor, bisoheart, corbis)

Nebivolol 2.5 or 5 mg (Nebicard, nebi, nebistar)

Metoprolol [50-100mg bd] (beta blocker)

Metolar, Betaloc,Met-XL, Meto-ER, Revolol-XL(last 3 sustained release tabs)

Methyldopa [250mg tds] (alpha 2 stimulator)

Alphadopa, Emdopa

Enalapril [5-20mg OD/BD (CCB)] (ACE inhibitor) (can be taken with food)
Envas, Nuril, Enpril
 58
Perindopril 2/4/8 mg(coversyl,perigard)

Ramipril [2-5mg OD] (ACE inhibitor)(before or after food)

Cardace, Cardiopril, Ramace, Ramihart

Losartan [ 25- 100 mg OD](ARB)

Losar,Losakind, Repace, Zaart, Tozaar

Telmisartan(20-80 mg /day)(ARB)
Telma,Telpres, Telmikind

Olmesartan(20/40 mg)( olmy, oImetime, olmesar)

Chlorthalidone(6.25/12.5 mg)(CTD, Hydrazide)

Hydrochlorthiazide(12.5 mg/ 25mg) (Aquazide)

Indapamide 1.5 mg (Natrilix SR)

Metolazone 2.5 or 5 mg(for HTN in Renal failure) (Zytanix)

Prazosin(1-20 mg/day)- Prazopress

Spironolactone(25-50 mg/day)- aldactone

Eplerenone(25-100 mg/day) (eptus)

Amiloride 5-10 mg/day

Atenolol + amlodipine
Amlong-A, Amcard-AT,Amlokind-AT, Stamlo beta, Aten-AM, Amlopres-AT

Atenolol + Nifedipine- Beta Nicardia, Presolar

Amlodipine + Losartan
Amcard LP, Amlokind-L, Amchek Z, Amlopres- Z, Amlotin HS,

Amlodipine + perindopril - Coversyl AM 4/5 or 8/5 or 8/10 or 4/10

Amlodipine + indapamide- Natrilam 2.5/1.5 or 5/1.5 or 10/1.5 mg
Perindopril + indapamide- coversyl plus 4/1.25
Atenolol + Amiloride + Hydrochlrothiazide
Beta-Bidurst, BP-Loride, Hipres D

Metoprolol + Hydrochlorothiazide- Betaloc-H, Selopres

Losartan + hydrochlorothiazide- Losar-H, Repace-H,

Telmisartan +hydrochlorothiazide- Telma-H,Telmikind-H

 59
Telmisartan+ Amlodipine- Telista-AM, Telmikind-AM

Telmisartan + Metoprolol - Telmikind Beta

Amifru 40 (furosemide 40+ amiloride 5)

Amifru plus(torasemide 10+ amiloride 5)
Biduret(hydrochlorthiazide 50 +amiloride 5)

Nitroglycerin(2.6/6.4 mg) - Nitrolong, nitrocontin CR, Angispan TR, monit GTN

Hyperlipidaemia

Inv: 12-hour fasting lipid profile, TFT,RFT,RBS.

Note: screening for hypercholesterolemia should begin in all adults aged 20 yrs or older.
Causes of 20 hyperlipidaemia: hypothyroidism,Renal failure, nephrotic syndrome,
alcohol,DM, drugs like steroids, oral contraceptives, diuretics.

Note: measurement of fasting lipids is indicated if the total cholesterol is >200 mg/dl, or
HDL cholesterol is < 40 mg/dl. If fasting profile can’t be obtained, total & HDL
cholesterol should be measured.
In Isolated increase in LDL, drug therapy is only recomended if LDL>190(except if a/w
DM, HTN). Aerobic exercises increase the level of HDL cholesterol.

Rx
1st line therapy: Statins are given .
2nd line: fibrates, e.g bezafibrate,fenofibrates or cholesterol absorption inhibitors, e.g
ezetimibe(useful combined with a statin to enhance LDL reduction).
Response to therapy should be assessed after 6 weeks.

For hypertriglyceridaemia fibric acid derivatives are given. E.g bezafibrate, fenofibrate
Note: Statins are associated with myalgia, myositis, abdominal pain, derangement in
LFT , raised CPK. Give T Levocarnitine for associated muscle pain. T.N: carnisure
Drugs containing levocarnitine: C evion- LC, T nurokind-LC

Atorvastatin [10-20mg OD HS]

Atorlip, Atorva, Aztor, Vasolip, Statlip, Storvas, Lipikind, atocor
Rosuvastatin(5/10/20 mg OD)
Rosuvas, Novastat, Lipirose, Razel
Fenofibrate(145 or 160 or 200 mg OD)(taken with food) - Lipicard, Stanlip,
Ezetimibe 10 mg OD (ezedoc,zeticure,ezentia)
Atorvastatin + Fenofibrate
Fibator, Stator-F, Lipikind-F
Atorvastatin + Ezetimibe
Atorlip EZ,Storvas-EZ
Saroglitazar 4 mg HS (Lipaglyn) used for diabetic dyslipidemia. Useful for
hypertriglyceridemia in DM uncontrolled by statins, also got anti-diabetic action.
 60
Hyperuricemia
Etiology:renal d/s, drugs(e.g diuretics, immunosuppressive drugs), alcohol, starvation,
hypothyroidism, obesity,psoriasis, purine rich diet(organ meat, seafood, dried beans,
dried peas, mushrooms), vit B3,genetic, etc.
Rx
T Febuxostat(febutaz/febuget) 40 mg 1-0-0(monitor S.creatinine,LFT) or
T Allopurinol (Zyloric)100 mg OD (C/I in a/c gout)
Advise to drink more water.

Hypoglycemia
C/f: sweating, trembling, pounding heart, hunger, anxiety,aaggressive behaviour,
confusion, drowsiness, speech difficulty, inability to concentrate,seizure, nausea,
tiredness, headache, irritability, anger, incordination, amnesia, depersonalization,
derealisation
Rx
1.Check GRBS; if very low give 25% Dextrose(1-2 ml/kg) 3 or 4 amp(1 amp= 25 ml) or
25D 75 or 100 ml infusion or 50%D 25-50 ml; followed by 5%D infusion because insulin
has prolonged action.
2.GRBS should be repeated every 10 minutes until>100 mg/dL
Note: All cases of unexplained hypoglycemia should have an ECG taken.
For infants: 2ml/kg & children: 4ml/kg 25 % dextrose or D10 if RBS <40.
Pt may be observed for 24 hours.

Hyperglycemia
All individuals above 30 yrs should be screened:
Assess life style: tobacco use, alcohol use, diet & exercise
Calculate BMI;Check BP & RBS
If RBS< 200 mg/dl, reassess every 2 years or when diabetic symptoms develop.
Urine microalbuminuria: one of the earliest manifestation of diabetic nephropathy.
50% of GDM pts develop DM later in life. Check blood sugar 6 weeks postpartum.
20 DM a/w Ca pancreas, thyrotoxicosis, acromegaly, hemochromatosis,
pheochromocytoma
ADA recommends screening of all individuals>45 yrs every 3 years.
The diagnosis of DM can be established using any of the following criteria:
HBA1C≥6.5%
FBS≥ 126 mg/dL. A positive value should be confirmed with a rpt test.
Symptoms of diabetes(polyuria,polydipsia, fatigue, wt loss,non healing wound) & a RBS
≥200 mg/dL
OGTT≥200 mg/dL at 2 hrs after ingestion of 75 g of glucose.
Prediabetes
Impaired fasting glucose: FBS≥100 & ≤125 mg/dL
Impaired Glucose tolerance:2-hr glucose 140-199 mg/dL after ingesting 75 g glucose.
A1C in the range 5.7% to 6.4%
Note: Lifestyle modification, including a balanced hypocaloric diet to achieve 7% wt loss
in overwt pt’s & regular exercise of ≥150 min per week, is recommended for persons
with prediabetes to prevent progression to T2DM.
 61
Diabetic pt review- 1. Fasting urinalysis for glucose, ketone, albumin, 2.At least once a
year, spot urine protein to creatinine ratio(ideally albumin creatinine ratio) and eGFR
3.FBS/PPBS,HbA1c 4.LFT,RFT,TFT 5.BP monitoring(target in DM is <140/90) 6.
Enquire about Hypoglycaemic episode
7. Eye(fundus) examination(yearly) 8. Lower limb & feet examination
The blood pressure target for pt’s with diabetes is <130/80. ACEI/ARB is recommended
as first line therapy. For those pt’s not at goal, a diuretic should be added.
The lipid target are as follows: LDL <100 mg/dL, Total Cholesterol<150 mg/dL, HDL>40
mg/dL in men & >50 mg/dL in women. In pt’s with known cardiovascular d/s or two risk
factors in addition to DM, the LDL should be <70 mg/dL, preferably using high-dose
statin therapy.
Aspirin should be advised in pt’s with diabetes & older than 40 yrs or who have other
risk factors. Low dose (75-150 mg) is appropriate for primary prevention.
Hyperglycemia>300 mg/dL on more than one consecutive test should prompt testing for
DKA
Risk factors for DM- HDL<35 mg/dL, TG >250 mg/dL, BP≥140/90, BMI≥25 kg/m2, family
history, physical inactivity, PCOS, acanthosis nigricans, h/o GDM, h/o CVD
Note- the earliest manifestation of D nephropathy is increased GFR.
Rx
Life style modification
Restrict sugar, sweets, fatty & fried foods
Take low glycemic index foods, fibre rich food, plenty of vegetables
Small frequent meals( about 6 meals a day)
Exercise: brisk walk for 20-30 min for 5 to 6 days a week with 5 min warm up and 5 min
cool down
Avoid tobacco & alcohol use
Check HbA1c. if it is very high(>9-10%), or if FBS>300, consider starting insulin therapy
straight away if the pt is willing. If not start on OHAs.

Monotherapy
First line-T Metformin start as 500 mg OD or BD taken with or after food , may be
increased upto 2g/day
If creatinine is >1.5mg/dl in men & >1.4 mg/dl in women & GFR<60 ml/min, metformin is
C/I, since it can augment lactic acidosis.
Metformin is the preferred 1st line drug in overweight individuals. R/w after 3 weeks. If
FBS/PPBS is still uncontrolled, try increasing dose of metformin or add a 2nd line drug.
Note-Metformin is associated with vitamin B12 deficiency, so periodic testing of vitamin
B12 levels should be considered in metformin-treated patients, especially in those with
anemia or peripheral neuropathy.
Second line-SGLT2 inhibitors/GLP-1 RA/DPP-4 inhibitor
Note-Sulfonyl ureas may be used as second line agents in resource constrained
settings and in the short term as per recent guidelines. Gliclazide is the preferred agent
due to relatively lower hypoglycemia risk. Started as 30 mg OD.
T glimepride start as 1mg OD or BD taken before food, may be increased upto 4mg/day
or T Glibenclamide 5 mg-10 mg OD or BD taken before food.
Sulfonyl ureas maybe used as 1st line drugs in non obese individuals or if metformin is
not tolerated.
 62
R/w after 1 week. If FBS/PPBS is still uncontrolled, try increasing the dose or add
insulin therapy.
In general:
For obese patients: T Metformin 500mg(1-0-1) after meals;
For non-obese patients: sulfonylureas(2ndgen- Gliclazide, glibenclamide, glimepiride)
Combination therapy using sulfonylureas may be needed, if monotherapy is
unsuccessful.
Pioglitazone is prescribed as a second line therapy with metformin or third line therapy
in combination with sulphonylurea & metformin. Thiazolidinediones not used with heart
faillure NYHA lll-IV
Voglibose is used for lowering PPBS. Usually given with meals.
Gliflozins are not used in recurrent UTI.
 63
Insulin Therapy
Indicated if HbA1c is very high or uncontrolled inspite of 1st and 2nd line drugs or if
FBS>300 it is ideal to start with a small dose and increase at interval of 2-3 days
according to blood glucose levels. The initial dose is 0.5 U/kg/day for Type 1 and
0.2U/kg/day for Type 11.
Basal insulin controls FBS. Bolus insulin is for post prandial glucose.
Long-acting basal analogs (U-100 glargine or detemir) can be used instead of NPH to
reduce the risk of symptomatic and nocturnal hypoglycemia
Start with NPH insulin bedtime(10 pm) s/c. Titrate according to response. Then twice
daily NPH if needed. S/c administration is fastest from abdomen.
Sulfonylureas may be continued alongside insulin but stop if hypoglycemia occurs.
If FBS is uncontrolled with NPH alone, then start on pre-meal Regular insulin(thrice
daily) or Biphasic insulin (inj Human Mixtard)(twice daily). Start with a small dose taken
20 min before food and titrate according to response every week. Explain the
complication of hypoglycemia to the pt.

Rapid acting insulin analogue can be given at the start of the meals. It can also be given
after meals.
Short acting insulin- usually given 15-30 minutes before a meal.
Premixed insulin(Human & analog) given 5-15 minutes before meal.

In CLD short acting insulin is used.

In CKD, long acting insulin is not useful, so rapid acting insulin is used.

If basal insulin has been titrated to an acceptable fasting blood glucose level (or if the
dose is >0.5 units/kg/day) and A1C remains above target, consider advancing to
combination injectable therapy. When initiating combination injectable therapy,
metformin therapy should be maintained while other oral agents may be discontinued
on an individual basis to avoid unnecessarily complex or costly regimens (i.e., adding a
fourth antihyperglycemic agent). In general, GLP-1 receptor agonists should not be
discontinued with the initiation of basal insulin. Sulfonylureas, DPP-4 inhibitors, and
GLP-1 receptor agonists are typically stopped once more complex insulin regimens
beyond basal are used. In patients with suboptimal blood glucose control, especially
those requiring large insulin doses, adjunctive use of a thiazolidinedione or SGLT2
inhibitor may help to improve control and reduce the amount of insulin needed, though
potential side effects should be considered.
Other options for treatment intensification include adding a single injection of rapid-
acting insulin analog (lispro, aspart, or glulisine) before the largest meal or stopping the
basal insulin and initiating a premixed (or biphasic) insulin (NPH/Regular 70/30, 70/30
aspart mix, 75/25 or 50/50 lispro mix) twice daily, usually before breakfast and before
dinner.
The recommended starting dose of mealtime insulin is 4 units, 0.1 units/kg, or 10% of
the basal dose. If A1C is <8% when starting mealtime bolus insulin, consideration
should be given to decreasing the basal insulin dose.
 64
 Addition of NPH insulin at bed time to control FBS in addition to OHAs. Then twice
daily NPH or consider adding Regular insulin to NPH. Regular insulin needs to be
taken 30 mins before meals.
 Insulin therapy given for pt’s presenting with DKA or with high glucose levels to
prevent glucose toxicity. In advanced renal disease insulin requirement may
decrease.

For hospitalized pts

Initiate insulin therapy for blood glucose (BG) levels ≥180 mg/dL in most hospitalized
patients, with target BG range of 140–180 mg/dL.
Recommended insulin regimens for hospitalized patients with diabetes or
hyperglycemia:
1.Inpatients with adequate nutritional intake: basal + prandial + correction insulin.
2.Inpatients with poor nutritional intake or taking nothing by mouth: basal + correction
insulin.
3.Sliding-scale insulin alone is strongly discouraged.

Dosage of insulin
It is ideal to start with a small dose & gradually increase at intervals of 2-3 days till the
optimum dose is achieved as judged by the blood glucose level. The initial dose
required can be calculated at the rate of 0.5 U/kg/day for Type 1 and 0.2 U/kg/day for
Type 2 DM. If the pt is not symptomatic 50% of the calculated dose can be given initially
& the dose can be gradually increased by 4 units every 3rd/4th day. If the pt is
symptomatic, the calculated dose can be given in full at the start and adjusted
subsequently. Illness often increases insulin requirements despite reduced food intake.
For pt’s naive to insulin, a starting dose of basal insulin should equal 0.2 U/kg. If the
presenting B sugar level is >200 mg/dL, adding premeal insulin is appropriate.The dose
should be 0.2 U/kg divided by three meals. A correction dose of 1 to 2 U per 50 mg/dL
of B sugar, beginning at 150 mg/dL, can be added to the premeal doses.

Other OHAs that may be considered as third line OHA

a)Alpha glucosidase inhibitors: T Voglibose 0.2 mg tid before food; may be considered
when PPBS is not controlled or when other drugs are not tolerated
b)DPP-4 inhibitors: T Sitagliptin , start as 25 mg OD & increase to 100 mg/day over
weeks. Reduce dose in CKD
c)thiozolidinediones: T Pioglitazone, start as 15-30 mg OD and increase to 45 mg OD.
C/I when there is high risk for cardiac failure or occurrence of fractures
other supportive measures
Adequate control of BP and lipid status
Anti thrombotic therapy: low dose aspirin 75 mg in age > 50 yrs if BP <145/90 mm Hg
and in < 50 yrs with high risk for CAD.

Consider initiating dual therapy in patients with newly diagnosed type 2 diabetes who
have A1C ≥9% (75 mmol/mol).
 65
Consider initiating insulin therapy (with or without additional agents) in patients with
newly diagnosed type 2 diabetes who are symptomatic and/or have A1C ≥10% (86
mmol/mol) and/or blood glucose levels ≥300 mg/dL
In patients without atherosclerotic cardiovascular disease, if monotherapy or dual
therapy does not achieve or maintain the A1C goal over 3 months, add an additional
antihyperglycemic agent based on drug-specific and patient factors.

Initiating long-acting basal insulin at a total daily dose (TDD) of 0.1–0.2 units/kg for
patients with an A1C <8% or 0.2–0.3 units/kg for patients with an A1C >8%, with insulin
titration every 2–3 days to reach the glycemic target. For those on fixed regimens, the
TDD may be increased by 2 units, whereas for those on adjustable regimens, the dose
should be adjusted by 1 unit or 10–20% of the TDD according to FPG values.
FBS>180: Add 20% of TDD or add 4 units
FBS 140-180: Add 10% of TDD or add 2 units
FBS 110-139 : Add 1 unit

For patients taking a sulfonylurea, the dose may have to be reduced or discontinued
during titration due to increased risk of hypoglycemia .
If the A1C target(<7% with FBS and premeal BS <110 mg/dl & absence of
hypoglycemia) is unmet, a GLP-1 receptor agonist, sodium–glucose cotransporter 2
inhibitor, dipeptidyl peptidase-4 inhibitor, or prandial insulin may be added to the
treatment regimen. Two approaches to initiating prandial insulin may be used as follows.

Regimen 1: Begin prandial insulin at 10% of basal dose or 5 units before the largest
meal (basal + 1). If A1C target is unmet, progress to injections before meals 2 or 3
(basal + 2 or basal + 3).

Regimen 2: Begin prandial insulin before each meal with a 50% basal/50% prandial
ratio to achieve a TDD of 0.3–0.5 units/kg, starting at 50% of the TDD in three divided
doses before meals.
 66
For both regimens, insulin should be titrated every 2–3 days until glycemic targets are
met. Increase prandial dose by 10 % or 1-2 units if 2 hr postprandial or next premeal
glucose consistently >140 mg/dl. If hypoglycemia, reduce TDD basal and/or prandial
insulin by a)10-20% if BG consistently <70 mg/dl b) 20-40% if BG <40 mg/dl or severe
hypogycemia requiring assistance.

2-hr PPG or next premeal glucose>180 mg/dl-Increase prandial dose for the next meal
by 10%

Insulin can be admministered in areas such as abdomen( exccept 2 inches around

umbilicus), thighs, dorsum of upper arm, flanks, buttocks

Monitor for hypoglycemia

Night time hypoglycemia- reduce basal insulin or reduce short/rapid acting insulin taken
before dinner.
Between meal hypoglycemia- reduce previous premeal short or rapid acting insulin.

Type 1 Diabetes
Recommendation
Most people with type 1 diabetes should be treated with multiple daily injections of
prandial insulin and basal insulin or continuous subcutaneous insulin infusion.
 67
Most individuals with type 1 diabetes should use rapid-acting insulin analogs to reduce
hypoglycemia risk.
Consider educating individuals with type 1 diabetes on matching prandial insulin doses
to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity.
Individuals with type 1 diabetes who have been successfully using continuous
subcutaneous insulin infusion should have continued access to this therapy after they
turn 65 years of age.
Insulin Therapy
Insulin is the mainstay of therapy for individuals with type 1 diabetes. Generally, the
starting insulin dose is based on weight, with doses ranging from 0.4 to 1.0 units/kg/day
of total insulin with higher amounts required during puberty. 0.5 units/kg/day as a typical
starting dose in patients with type 1 diabetes who are metabolically stable, with higher
weight-based dosing required immediately following presentation with ketoacidosis ,
and provides detailed information on intensification of therapy to meet individualized
needs.

Common preparations:
Soluble/regular H.Insulin:- H.Actrapid, Huminsulin-R
Human isophane insulin(NPH):- Huminsulin-N / Human insulatard
H regular insulin+ isophane(NPH) insulin, 30/70 or 40/60 or 50/50:- Huminsulin / H actraphane /
H Mixtard (40 IU/ml, 10 ml)
Ultra short acting-Insulin Lispro(Humalog),Insulin Aspart(novorapid)
Long acting -Insulin glargine (Lantus, toujeo),insulin degludec(Tresiba ), detemir(Levemir)
Aspart + protamine (novomix 30/70, 50/50)
Lispro +protamine(Humalog mix 25/75 , 50/50)
Metformin 500 mg/1g (Glyciphage,glycomet,walaphage,cetapin-XR) OD/BD
Glimepiride 1 or 2 mg (Glimy,Amaryl,Diapride,azulix ) OD/BD
Glibenclamide 2.5/5 mg (Daonil,glinil,glucosafe) OD/BD
Gliclazide 30/40/60/80 mg (diamicron,glicron,glyred,reclide)
Pioglitazone 15/30 mg (pioglit,diavista,P-glitz,piozone) OD
Canagliflozin 100 mg(invokana) OD
Dapagliflozin 5mg or 10 mg OD(forxiga) during morning time
Empagliflozin 10 or 25 mg(gibtulio, jardiance) OD
Teneligliptin 20 mg( ziten, Actiglipt)
Linagliptin 2.5/5mg(trajenta) OD- safe in renal failure
Galvus 50 mg(Vildagliptin) BD
Saxagliptin 2.5 or 5 mg(onglyza) OD
Sitagliptin 25 or 50 or 100 mg(Januvia, istavel, zita) OD
Voglibose 0.2/0.3 mg (Volix, vocarb, volibo,PPG)
Acarbose 25 or 50 mg (recarb,glucar,diabose) TDS
Glimepiride+ metformin (Amaryl-M1 or M2,Diapride Forte,Gluformin G1 or G2, Glimy-M1 or M2,
glyciphage-G1 or G2, Glycomet GP1 or GP2, Gemer 1 or 2) BD
Glibenclamide + metformin(Daonil-M, glinil-M)
Gliclazide + metformin (glycard-M, glyred-M,glychek-M, Diamicron XR Mex)
Metformin + Voglibose( Gluconorm-V)
Vidagliptin + metformin (galvusmet 50/500 , 50/1000) BD
Sitagliptin + metformin (Janumet 50/500, 50/1000) BD
 68
Saxagliptin+ metformin (kombiglyze XR 5/500, 5/1000)
Teneligliptin + metformin(Ziten-M 20/500, 20/1000)
Pioglitazone + metformin(cetapin-P, diavista-M, gluconorm-P, glyciphage-P,walaphage- PZ)
Pioglitazone + glimepiride( glimy-P,pioglit-G, pioglar-G)
Glimepiride+ metformin + Pioglitazone(Amaryl-MP 1 or 2, Glyciphage PG1/PG2, tribet 1 or 2)
Glimepiride+ metformin +Voglibose (Volix trio 1,Volix trio forte 1, Gluconorm-VG)

Diabetic neuropathy
DSPN(distal symmetric sensory & sensorymotor polyneuropathy) is the most common c/c
complication. DSPN is the presenting manifestation of DM in approximately one-third of
patients.
Ist sensation lost is vibration
Rx
1.Improve glycemic control
2.T Pregabalin(for painful neuropathy) 150 mg HS(T.N- Pregaba, Neugaba,Maxgalin) or
Gabapentin or duloxetine can also be used.
3.T Amitryptilline 25 mg HS
Note: in autonomic neuropathy, there may be hypoglycemic unawareness.In such cases
intensive diabetic control, beta blockers are avoided.

Diabetic Ketoacidosis
Risk factors include interruption of insulin therapy, sepsis, trauma, MI, pregnancy,
stroke, Type 1 diabetes, surgery.
c/f
 Anorexia, nausea, vomiting, polyuria, polydypsia,feeling thirsty
 Abdominal pain, flushed hot, dry skin, tiredness, wt loss
 Altered sensorium/coma,confusion, drowsiness, blurred vision
 Rapid deep and labored breathing,Kussmaul’s breathing- fruity odour in breath due
to acetone
 Features of volume depletion(tachycardia, decreased capillary filling), dehydration
or co-existent infection may be present. Rarely respiratory distress(↑ RR), shock
and coma.
Suspect DKA whenever a diabetic pt with h/o trauma, fever or interruption of insulin
therapy p/w non specific symptoms like vomiting, abdominal pain, breathing difficulty.

Diagnosis requires acidosis(pH<7.3), hyperglycemia(>250 mg/dl), bicarbonate< 15

mmol/l(best initial investigation), moderate ketonemia or ketonuria(+++). Azotemia,
uremia may be present, arterial pCO2 20-30 mmHg.
Inv:- RBS, Urine sugar & acetone, BRE, URE, S. Na(hyponatremia), K(hyperkalemia),
urea,creatinine,ABG( high anion gap metabolic acidosis), Serum amylase(↑). Features
of a pre-renal type of renal failure due to volume depletion may also be seen, ECG to
look out for electrolyte imbalance & for unsuspected myocardial ischemia.

Rx
Ideally done in an ICU set up or under close monitoring.priorities in treatment include:
fluid replacement, adequate insulin administration, pottasium repletion(as insulin
administration cause rapid shift of K+ into intracellular compartment).
 69
1.IVF(~5-6 L) NS 1L over 30 min(if cardiac function normal), 1L over 1 hr, 1L over 2hr,
1L over next 2-4 hrs. Those >65 yrs or with CCF need less saline more cautiously.Once
blood glucose decreases to 200-250 mg/dl, start IVF DNS @ 50 to 100 ml/hr over a
parallel line.
2.Inj Regular Insulin 10 to 15 U iv st (0.15 U/kg)
Another option is to give RI 0.3 U/kg, half iv & half sc or im st f/b inj 0.1 u/kg/hr sc or im.
Note: Subcutaneous absorption of insulin is reduced in DKA because of dehydration;
therefore, using intravenous routes is preferable
3. Continuous Regular Insulin infusion. 40U(1ml) in 39 ml NS @ 5-6 ml/hr. If infusion
pump is not available, start in 1 pint NS @ 5 to 10 U/hr(or 0.1 U/kg/hr)
(100 U in 500 ml of 0.9% NS infused @ 50 ml/hr or 14 drops/min delivers a 10 U/hr
infusion or 50 U in 500 ml of 0.9% NS infused @ 100 ml/hr or 25 drops/min delivers a
10 U/hr infusion ).For 60 kg, 50U in 1 pint NS at 150/min; 70 kg-170/min;80kg- 200/min;
90kg-220/min;100 kg-250/min delivers 0.1 U/kg/hr.Check BG hourly initially.
 A decrease in BG levels of 50 to 75 mg/dl/hr is an appropriate response.
 If no reduction in 1st hour,rate of infusion should be increased by 50-100 % until an
appropriate response is observed or repeat the iv loading dose. Excessively rapid
correction @ >100 mg/dl/hr should be avoided to reduce the risk of osmotic
encephalopathy.
 Once BG level decreases to 250 mg/dl, the insulin infusion rate should be
decreased to 0.05 U/kg/hr to prevent dangerous hypoglycemia. Maintenance
insulin infusion rates of 1 to 2 U/hr can be continued (indefinitely) until the pt is
clinically improved. Once oral intake resumes, insulin can be administered s/c & the
parenteral route can be discontinued. Restoration of the usual insulin regimen by s/c
injection should not be instituted, until the pt is able to eat and drink normally.
Note:If pt’s general condition improves and oral intake resumes, insulin infusion may be
stopped once blood glucose level is below 200 mg/dL
Note: Give a s/c dose (~10 U) of insulin 1/2 hr-1 hr prior to discontinuing insulin infusion.
A rough estimate of the amount of insulin required for s/c administration can be
calculated from the total amount of insulin given in the infusion till the time RBS became
<200-250 mg/dl. This amount of insulin is given in three divided doses.
4.RBS every 1-2 hrs/urine sugar acetone chart/ electrolytes every 4 hrs.
5.iv Antibiotics if underlying infection suspected.
6.Inj sodabicarb 7.5% 100 ml over 30 min , if arterial pH <7.0
7.Catheterisation if pt unconscious or if no urine passed after 3-4 hrs of starting fluid
replacement.
8. Ryle’s tube aspiration to keep stomach empty in unconscious or semiconscious pts
9. K+ replacement.
K+ levels can fluctuate severely during the treatment of DKA, because insulin decreases
K+ levels in the blood by redistributing it into cells. K+ should be added routinely to the IV
fluids from second or third liter of fluid replacement(1 ampoule of KCl(20 mEq) in 500 ml
NS along with 2nd or 3rd litre of IV fluids) except in pts with hyperkalemia(>6 mmol/L & or
ECG evidence), renal failure, or oliguria.
If baseline serum K+ levels are <3.3 mmol/L (<3.3 mEq/L), insulin therapy should not be
commenced until the K+ level reaches 3.3 mmol/L. Likewise, if K+ levels reach <3.3
mmol/L at any point of treatment, insulin should be stopped and K+ replaced
intravenously. In all patients with a K+ level <5.3 mmol/L and an adequate urine output
of >50 mL/hour, 10 to 20 mmol (10 to 20 units [mEq]) of K+ per hour should be given
routinely to prevent hypokalaemia caused by insulin. If the K+ level is >5.3 mmol/L
replacement is not needed but K+ level should be checked every 2 hours
 70
Complications of DKA
Cerebral edema due to excessive rapid correction of DKA and overhydration
Rebound ketoacidosis due to premature cessation of IV insulin infusion or inadequate
doses of s/c insulin after the insulin infusion has been discontinued.
Lactic acidosis due to prolonged dehydration, shock, infection,tissue hypoxia etc
Arterial thrombosis( manifested as stroke, MI), Shock, aspiration pneumonia,ARDS etc

Hyperglycemic hyperosmolar Nonketotic coma(HONK) or HHS(hyperosmolar

hyperglycemic state)
It is characterised by severe hyperglycemia (>600 mg/dl), ph>7.3, normal arterial
pCO2,altered sensorium & polyuria, decreased oral intake, dehydration without
ketoacidosis(bicarbonate>15meq/L). Treatment is similar to DKA with two exceptions:
1.Fluid requirements are often higher(~6-10 L) (with 0.45% saline) &
2.Total insulin requirements are less(~half the dose of insulin recommended for DKA)

Hypothyroidism
C/f: fatigue(m/c),cold intolerance, alopecia,poor memory, constipation, menorrhagia,
myalgias, hoarseness, somnolence, ↓ HR, mild diastolic HTN, delayed relaxation of
ankle jerk, weight gain,dyspnoea, paraesthesia,depression, hypomania, delusion
Rare manifestations: carpal tunnel syndrome, deafness, hypoventilation, pericardial or
pleural effusions.
Diagnosis
 TSH is the best initial test. A normal value excludes primary hypothyroidism, and a
markedly elevated value(>20 µU/mL) confirms the diagnosis. Mild elevation(<20
µU/mL) may be due to nonthyroidal illness, but usually indicates mild(or subclinical)
primary hypothyroidism, in which thyroid function is impaired but increased
secretion of TSH maintains free T4 levels. These pt’s may have nonspecific
symptoms that are compatible with hypothyroidism & a mild increase in
S.cholesterol & LDL. Plasma free T4 should be measured if TSH is moderately
elevated, or if secondary hypothyroidism is suspected, and pt’s should be treated for
hypothyroidism if free T4 is low
 Hypothyroidism: TSH ↑, FT3↓, FT4↓; subclinical hypothyroidism: TSH ↑, FT3 N, FT4 N
20 Hypothyroidism: TSH ↓, FT3↓, FT4↓, 30 Hypothyroidism: TRH ↓,TSH ↓, FT3↓, FT4↓
 Anti TPO Ab & Anti Tg Ab(present in Hashimotos thyroiditis,
 ECG

Rx
Thyroxine is the drug of choice. The average replacement dose is 1.6µg/kg PO daily,
and most patients require doses between 75 and 150 µg/d. In elderly patients, the
average replacement dose is lower. The need for lifelong therapy should be
emphasized. Thyroxine should be taken 30 minutes before a meal, preferably morning.

Initiation of a therapy.
 Young & middle-aged adults should be started on 100µg/d. This regimen gradually
corrects hypothyroidism, as several weeks are required to reach steady-state
plasma levels of T4. Symptoms begin to improve within a few weeks.
 In otherwise healthy elderly patients, the initial dose should be 50 µg/d.
 Patients with cardiac disease should be started on 25 to 50 µg/d and monitored
carefully for exacerbation of cardiac symptoms.
 71
Follow-up
 In primary hypothyroidism, the goal of therapy is to maintain plasma TSH within the
normal range. TSH should be measured 6 to 8 weeks after initiation of therapy. The
dose of thyroxine should then be adjusted in 12- to 25- µg increments at intervals of
6 to 8 weeks until TSH is normal. Thereafter , annual TSH measurement is
adequate to monitor therapy.
 In secondary hypothyroidism, TSH cannot be used to adjust therapy. The goal of
therapy is to maintain the free T4 near the middle of the reference range. The dose
of thyroxine should then be adjusted at 6 to 8 weeks intervals until this goal is
achieved.Thereafter , annual T4 measurement is adequate to monitor therapy.
 CAD may be exacerbated by the treatment of hypothyroidism. The dose of thyroxine
should be increased slowly in pt’s with CAD, with careful attention to worsening
angina, heart failure, or arrhythmia.

 Hypothyroidism may impair survival in critical illness by contributing to

hypoventilation, hypotension, hypothermia, bradycardia, or hyponatremia.
 In pregnancy thyroxine dose increased by an average of 50% in the first half of
pregnancy.
 Subclinical hypothyroidism should be treated with thyroxine if any of the following
are present: a) symptoms compatible with hypothyroidism, b) a goitre, c)
hypercholesterolemia that warrants treatment, or d) the plasma TSH is >10µU/mL.
Untreated pt’s should be monitored annually, and thyroxine should be started if s/s
develop or S.TSH increases to >10µU/mL.
 TFT must be evaluated with TSH every 4 weeks in the first trimester and less
frequently after 20 weeks. The levothyroxine dose may be increased by 50% during
pregnancy. Following delivery, doses of thyroxine are usually restored to that of pre-
pregnancy levels. The target TSH level to be maintained in the first trimester of
pregnancy is <2.5 µU/mL. For second and third trimester the target is <3 µU/mL.

T.N: Thyronorm, eltroxin

Hyperthyroidism
C/f: anxiety,wt loss in spite of good appetite, heat intolerance, diarrhoea, amenorrhea, ↑ HR,
HTN(systolic & diastolic), fine tremor, irritability, muscle weakness,mood d/o, panic d/o,GAD.
 Inv: Hyperthyroidism: TSH ↓, FT3↑, FT4↑; subclinical hyperthyroidism: TSH ↓, FT3 N, FT4 N
Rx
1. Start with T carbimazole (TN- neomercazole) 5 mg OD. In pregnancy propylthiouracil(PTU)
is given, especially in first trimester.
PTU is a/w hepatic toxicity.
2. T Inderal 10 mg BD for tachycardia

Thyroiditis
May be subacute thyroiditis or Hashimoto’s thyroiditis
A/w transient hyperthyroidism f/b euthyroid state.
C/f: diffuse swelling, pain, tachycardia
Rx
1. T inderal 10 mg BD or TDS
2. NSAIDS T Dologesic 20 mg OD
3.For acute pain start steroids like prednisolone 10-20 mg daily x 7 days and slowly tapered off.
 72
Sensory Disturbances
Pins & needles, pricking, band like, lightning pain, knife like, twisting, pulling, tightening,
burning, aching, numbness, other raw sensations
Aetiology: neurological or non neurological. Neurological: PNS or CNS lesions, Non
neurological: hyper ventilation, hypocalcemia, hysterical/non organic
Peripheral neuropathy causes: direct trauma, compression, entrapment, DM, leprosy,
HIV, alcohol, vitamin deficiency(B12,E), hypothyroidism, drugs (like FQ, metronidazole,
phenytoin, linezolid), paraneoplastic, liver failure, renal failure etc.
For peripheral neuropathy/ Neuropathic Pain/ fibromyalgia
Rx
1.T Carbamazepine 200 mg 1-1-1(Tegrital,Epilep, Zen, Mazetol etc) or
T Amitryptilline 10 mg HS(Tryptomer) or T Duloxetine 30mg (Dulane,dutin) 0-0-1 or
C Maxgalin(pregabalin) 75/150 mg od or C Gabantin(gabapentin) 300 mg od
C Maxgalin-M/Pregastar M(pregabalin + methylcobalamin), Gabamax Gold/ Pregastar
Plus (B complex, pregabalin), T Nurokind-G(Mecobalamin + Gabapentin)
2. Analgesics - Tramadol.
3.T BC or Neurobione forte or other multi vitamins with Vit B12 & vit E;T Benalgis
(Benfotiamine)100 mg 1-1-1; T Benalgis can be given for sciatica, diabetic neuropathy /
nephropathy/ retinopathy, & other painful nerve conditions.

Facial Nerve Palsy

Aetiology- Idiopathic[bell’s](m/c), ASOM, Inflammatory,
In Bells palsy onset is fairly abrupt. Pin behind the ear may precede the paralysis for a
day or two. Maximal weakness is attained by 48 hours(rule). u/L loss of sensation,
hyperacusis may be present.
Rx
1.Antibiotics.
2.Analgesics
3.Steroids—wysolone 40mg 1-0-0 X 5-7 days, tailing by 10 mg/day
4.In cases of Bell’s Palsy give Acyclovir 800mg 5 times daily x 7-10 days(no proven
benefits in early recovery)
5.Lubrex/refresh (carboxymethylcellulose) Eye dps;
6.Pad & bandage eye; use dark glasses; massage of the weakened muscles

Trigeminal Neuralgia
Attacks commonly occurs during day,affects women (>50 yrs)more, more common on
right side. Pain is repetitive, severe and very brief, triggered by touch, a cold wind or
eating.
DoC is Carbamazepine 200mg tds (T.N Tegrital, Mazetol,Zeptol)
Baclofen may be given
Rx same as above

Giddiness/syncope
Etiology:
1.Hypoglycemia-> h/o DM + Cold extremities, Sweating-> give 25% or 50% dextrose.
2.Vasovagal attack-> Can occur due to prolonged standing, excessive heat or
large meal. Keep the pt in lying down position & feet elevated
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3.Bradycardia- drugs(beta blockers, verapamil, diltiazem, digoxin), AV block, SA
node disease
4.Tachycardia-AF, SVT
5.Postural Hypotension- hypovolemia, sympathetic degeneration(DM, Parkinson’s
disease, old age), drugs(anti anginals, antidepressants, neuroleptics) can cause or
aggravate the condition. Advise to avoid prolonged standing and to get up slowly from
sitting or lying down position.
6.Carotid sinus hypersensitivity- when pressure is applied to neck e.g. wearing a
tight collar
7.Myocardial ischemia; LV outflow tract obstruction- AS, HOCM
8.Drop attacks- sudden spontaneous falls while standing or walking, with complete
recovery in seconds or minutes. Causes-TIA, vertibrobasilar insufficiency, third
ventricular & posterior fossa tumours, neuromuscular disorders(myopathy, neuropathy)
PD, PSP, cataplexy, vestibular disorder like vestibular neuritis,
Note: Whenever a pt is brought with c/o unconsciousness, r/o head injury
Fall/impaired consciousness
Aetiology: Orthostatic hypotension, carotid sinus syndrome, neuro cardiogenic
syncope,cardiac arrythmias, structural heart diseases,stroke , Parkinsonism, arthritic
changes, neuropathy, neuromuscular disease or vestibular disease, visual impairment,
dementia, post prandial hypotension, urinary incontinence, low blood pressure,
hypoglycemia, emotional distress, and lack of sleep, hyper ventilation, head trauma,
ICH, seizure disorder,DKA, alcohol or drug intoxication, dehydration, CO inhalation,
hyponatremia, hypo/hypercalcemia, high g-force, uremic/hepatic/hypertensive
encephalopathy, Medications (Polypharmacy ,Sedatives, Cardiovascular medications
etc), hyper/hypothermia,
There may be a loss of consciousness at the onset of SAH
Orthostatic hypotension- fall in SBP>20 mmHg or in DBP>10 mmHg in response to
assumption of upright posture from a supine position within 3 minutes.

Motion Sickness
Rx
1.T. Avomine 25mg about 1-2 hrs before journey[Promethazine theoclate] or
T Dramamine(dimenhydrinate) 50 mg 1/2-1 hr before journey
2.Avoid alcohol,dietary excess, reading. Position themselves where there is least
motion,a supine/recumbent position with the head braced is best. Keeping the axis of
vision at an angle of 450 above horizon may reduce susceptibility.

Memory defects & Forgetfulness

R/o treatable causes like Vit B12 deficiency, hypothyroidism, SDH,depression
Sudden memory loss Etiology: stroke, head trauma, infections, drugs(antidepressants,
antipsychotics, sleeping pills, analgesics),severe psychological stress, oxygen
deprivation, intense exercise, psychiatric disorders(dissociative fugue, dissociative
identity disorder), binge drinking, hypothyroidism etc
Rx
1.T Citicholine (strocit) 500 mg 1-0-1 Or
2.T piracetam 400 mg 1-1-1; T strocit plus(citicholine+ piracetam) or
3.T Donamem 0-0-1 (donepezil 5 or 10 mg + memantine 5 mg)
Medicine/Neurology consultation.
 74
Dystonia
Increased muscle tone that results in abnormal posturing
May occur as A/E of antipsychotics
Rx
Drug induced dystonia: Diphenhydramine 50 mg IM or IV or inj promethazine iv st.
Other oral drugs used- Baclofen 5 mg, pacitane 2 mg(trihexyphenidyl), Atarax 25 mg
In Akathisia- propranolol (DOC). other drugs used- phenergan, diazepam, pacitane

Headache
Primary headache syndromes : migraine with (classic) or without (common) aura,
tension headaches(most common), cluster headaches, rebound headache, trigeminal
neuralgia, temporal arteritis
Secondary headache: have specific etiologies & symptoms vary depending on
underlying pathology, i.e., SAH, HTN,sinusitis, tumour, glaucoma, SDH, meningitis,
encephalitis, vasculitis, obstructive hydrocephalus, intracerebral hematoma, cerebral
ischemia or infarction, dental problems, pseudotumour cerebri,optic neuritis.
Systemic causes include fever, viremia, hypoxia, CO poisoning, hypercapnia, allergy,
anemia, caffeine withdrawal etc.
Clinical presentation: the sudden onset of severe generalized headache(worst ever
headache) or a severe persistent headache that reaches maximum intensity within a
few seconds or minutes warrants immediate investigation for possible SAH. There may
be a loss of consciousness at the onset of SAH.May be a/w nuchal rigidity.
Tension headache: dull aching pain, band like sensation.
Sinus headache: generally located around or behind the eyes.
Cluster headache: severe u/l peri or retroorbital pain,pptd by alcohol,a/w lacrimation,
rhinorrhoea, conjunctival congestion,may awakens from sleep. May present with
horners syndrome
Glaucoma-eye pain+ redness of eye, N,V
Encephalitis-fever, odd behaviour,fits, reduced consciousnes, papilledema
Pseudotumour cerebri/idiopathic intracranial HTN(IIH)- mostly in obese women during
child bearing years.s/s- headache, diplopia, transient visual obscurations
Temporal arteritis-throbbing/stabbing pain with scalp tenderness, pain increases on
lying down, jaw claudication(difficulty in chewing food), raised ESR(usually>50 mm/hr)
Headache due to raised ICP- diffuse non-pulsating headache with at least one of the
following- a)nausea/vomiting,b)worsened by physical activity and/or manoeuvres known
to increase ICP(such as valsalva, coughing/sneezing),c) occuring in attack like episodes
Acute cerebellar hemorrhage may presents with sudden onset occipital headache,
ataxia, vomiting, drowsiness, down beating nystagmus, gaze paresis, dysarthria,
dysphagia
Physical examination
Check BP, pulse. Look for possible bruits. Check temporal arteries.
If neck stiffness & meningismus(resistance to passive neck flexion,headache etc)
present, then consider meningitis.Check sinus tenderness over maxillary & frontal sinuses.
If papilledema observed, consider an intracranial mass, meningitis or idiopathic
intracranial HTN.
Inv: CT Brain to exclude secondary etiologies.
Rx
Treat the cause
Analgesics(not very useful in raised ICP).
 75
In cluster headache give high flow O2 inhalation @ 12L/min, sumatriptan
Note: Naproxen is the preferred NSAID in people with high risk of cardiovascular
complications like stroke, MI
In pt’s( especially elderly female > 50 yrs) presenting with new onset
headache,fever,polymyalgia rheumatica , tenderness & sensitivity on the scalp, raised
ESR , jaw claudication, suspect Giant-cell(temporal) arteritis.Start treatment
immediately with prednisolone (30-40 mg/day, tapered off in 4-6 weeks)to prevent
blindness.
Tension headache; if < 15 days/month- analgesics; if >15 days/month-
TCA(amitryptilline)

Migraine
In case of any headache R/o refractive errors. Ask for throbbing/pulsating nature,
chronicity, whether U/L or B/L, Duration, presence/absence of nausea/vomiting,
photophobia, phonophobia
Also ask for any aura->visual blackouts, diplasia, nasal block, giddiness, fortification
spectra.
Also ask for any precipitation factors-> like chocolate,TV, food, caffeine, ocp, alcohol,
mental stress, sleep deprivation, travel, exercise etc.
Diagnostic criteria- atleast 2 of the following-u/L pain, pulsatile or throbbing
nature,moderate-severe intensity, aggravated by movement(like walking/climbing) plus
atleast 1 of the following- nausea/vomiting, photophobia, phonophobia. Usually of 4-72
hrs duration.
Basilar migraine may be a/w ataxia, blindness, throbbing occipital headache, LOC
Classical migraine is a/w aura- visual(zigzag lines, transient visual loss, scotoma etc),
sensory(tingling sensation of hand which spreads proximally)
Rx:
1. Inj Migranil [dihydroergotamine]1mg iv over 2-3 min/im stat [C/I in pregnancy, POVD
lactation, HTN,CAD] Or T.Migranil 2 tabs st, rpt after 30 min if necessary.
Note: ergotamine preparations should be best avoided since they easily lead to
dependence.
2.Inj P’mol 2cc im stat[if 1 not available]
3. Inj phenergan 25mg or perinorm or stemetil st -> for nausea. Anti-emetics may help
even in the absence of nausea & vomiting.
4. T Alprax 0.5mg stat
5. T metoclop-P ( metoclopramide + P mol) or T Domstal-P(domperidone + P/L) 1-1-1
6. T Headset SOS (sumatriptan succinate, Naproxen)(Only for A/c migraine
& cluster headache attack)(in elderly, avoid sumatriptan due to risk of CVA, MI) Or
T Clotan 200 mg (tolfenamic acid) or T Rizact 10 MD(rizatriptan) SOS (for a/c migraine)
Note- triptans and ergotamine should not be administered within 24 hours of each other.
For pts with h/o CAD, triptans and ergotamine are contraindicated, because they can
cause coronary vasospasm.Sumatriptan is C/I in basilar migraine.
7. Headache calender
8. Advise to avoid triggering factors.
Note- in pregnancy pmol, ibuprofen or naproxen may be given. But both ibuprofen &
naproxen are category D in 3rd trimester.
Prophylaxis is considered if a pt has at least 3 disabling migraines per month. Usually
given for 3-6 months
1. T.Flunarizine 10 mg HS x 2 weeks-1mnth[T.sibelium/Fine/Flugraine] Or
2. T.Inderal 20mg 1-0-1[propranolol] (C/I in BA, CCF, POVD, Severe bradycardia) or
 76
3. T sodium valproate(encorate) 200 mg 0-0-1 x 1 week f/b 1-0-1 or Dicorate ER 250
mg HS x 1 week f/b 500 mg HS(prevalproate tests (SGOT/PT & C/I if >3 times raised,
UPT) or
4. T amitriptylline 25 mg HS.

Meningitis
Meningitis can be caused by bacterial or viral infections, or by non infectious causes
such as medications.
Meningitis should be considered in any pt with fever and stiff neck or neurological
symptoms, especially if another concurrent infection or head trauma is present
Bacterial meningitis is a medical emergency. Treatment should not be delayed for
diagnostic measures because prognosis hinges on rapid initiation of antimicrobial
treatment.
Aseptic meningitis is usually milder than bacterial meningitis and may be preceded by
upper respiratory symptoms or pharyngitis. Viruses are common causes, as is drug
induced inflammation(e.g, NSAIDs, Tmp-Smx).
c/f->Fever + vomiting + headache,Seizures, Altered sensorium, Cranial nerve deficits,
neck stiffness,+ kernig’s/ brudzinski’s sign. Altered sensorium more common in
encephalitis.
Inv->BRE, URE, RFT, LFT, LP, CT Brain(prior to LP if signs of raised ict or FND), Blood
c/s, Urine c/s(if suspected UTI), Sputum AFB.
CSF study- send for CSF protein, glucose, cell count, gram stain, AFB and culture.
Typical CSF findings in bacterial meningitis include a neutrophilic pleocytosis, markedly
elevated CSF protein, and decreased glucose level. In aseptic meningitis, a lymphocytic
CSF pleocytosis is common(although neutrophils may predominate very early in the
disease course).
CSF PCR can detect enteroviruses, HSV and HIV.
Depending on the clinical scenario, other potentially useful CSf studies include rapid
plasma antigen(RPR), acid fast stain, latex agglutination antigen detection, cryptococcal
antigen, and arbovirus antibodies.
Until the etiology of the meningitis is known, an empiric regimen should be started
immediately based on pt risk factors and gram stain of the CSF:
Rx
1. 4th hourly Temp chart , I/O chart
2. Inj CP 40 LU iv Q4H ATD Or Inj Monocef(ceftriaxone) 2g iv bd ATD
3. Inj Vancomycin 1g iv Q8-12H
4.Inj Ampicillin 2 g iv Q4H should be added in immunocompromised and older patients
(>50 yrs) to cover listeria monocytogenes
5.Inj Dexamathasone 10 mg iv Q6H
Start just prior to or with initial antibiotics;continue for 4 days to reduce the risk of poor
neurologic outcome in meningitis due to streptococcus pneumonia. May be stopped
when culture report shows otherwise.Emperic regimens should be altered once culture
and senstivity data is known
6. Inj Mannitol 20 % 100ml iv Q8H
7. Inj thiamine 100mg iv bd
8. If not taking orally, IVF DNS or NS, as dehydration is common.
9. Inj Pantocid 40mg iv od
10. Inj P’mol 2cc im sos// Tepid sponging sos
11. Inj Phenytoin 100 mg iv q6h( for Px & control of seizures).
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12. RTF, Bladder catheterization sos, frequent change of position q2h, intermittent
throat suction if unconscious.

 If Encephalitis is suspected add Inj Acyclovir 500mg iv Q8H x 14/21 days

 If H influenza infection is suspected or established(usually in children), prophylaxis
is needed for contacts if child < 5yrs is at home.T Rifampicin 600 mg (20 mg/kg)
single dose x 4 days(warn about orange discolouration of urine & other body
secretions).
 If meningococcal infection is suspected or established, chemoprophylaxis with T
Rifampicin(10 mg/kg/dose) 600mg bd x 2 days or T Ciplox 500mg single dose is to
be taken.
 In pediatric cases treat with Inj Ceftriaxone 100mg/kg/day in 2 divided doses.
Another regime is taxim + Amikacin. Treat according to culture and sensitivity.
Note: 1st dose empirical antibiotic should be given on clinical suspicion, prior to all inv.

Tremor
Aetiology: alcohol withdrawal tremors, drug induced(salbutamol, deriphylline,
metoclopramide), hyperthyroidism, parkinsonism, senile tremors, hypoglycemia, stress
induced, vitamin deficiency(thiamine, B12), CKD, liver failure, Stroke,traumatic brain
injury, Hypocalcemia, hyponatremia, caffeine or alcohol induced.
Flapping tremors a/w hepatic encephalopathy, uremia, CO2 narcosis,
Fine tremors are a/w thyrotoxicosis. Intentional tremor a/w cerebellar pathology.
Inv: TFT, RFT, LFT, S.electrolytes,ABG
Rx
1. For benign essential tremor give :T ciplar(propranolol) 40 mg 1-0-1. Dose has to be
tapered gradually over several days. C/I in RAD, bradycardia, AV block, shock, severe
hypotension, etc
2. T Alprax 0.25 mg 1-0-1 for stress induced tremor.
3. For tremors due to parkinsonism give T Syndopa(levodopa + carbidopa) bd,
T pacitane or parkin 2mg (trihexyphenidyl) bd
Note: Vit B complex should not be given along with levodopa, as it reduces the
efficacy of levodopa
4. C Gabapentin OD

SIRS
Systemic inflammatory response syndrome
Two or more of the following
Temp>38oC or <35oC, HR>90/min, RR>20/min or PaCO2<32 mm Hg, TC>12000 or
<4000
Sepsis
SIRS + documented inection
Severe sepsis syndrome- sepsis + one or more organ dysfunction or hypoperfusion(e.g
lactic acidosis, oliguria, altered mental status)
Septic shock- sepsis + organ dysfunction +hypotension (SBP <90 mm Hg or SBP >90
mm Hg with vasopressors)
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Thrombocytopenia
Causes-sepsis, drugs(aspirin,digoxin, chlorproazine, prochlorperazine), ITP,DIC,TTP,
HUS, HIT, chemotherapy agents causing bone marrow suppression, following massive
bleeding and multiple blood transfusions, bone marrow failure(tumour infiltration, drugs),
splenomegaly, collagen vascular disease(e.g SLE), splenomegaly, measles, nutritional
deficiency etc.
C/f- rarely symptomatic until the count<50K, spontaneous bleeding ca occur when plt
count<20k. Although bleeding is often minor, e.g skin petechiae, oozing at iv catheter
sites, it may be massive or life threatening e.g hemoptysis, ICH.
Rx
1. Treat the cause. E.g antibiotics for sepsis, stopping offending drugs, corticosteroids
for ITP, splenectomy
2. Platelet transfusion. In otherwise well pt with no significant bleeding, transfusion can
be withheld until the count falls <10000. give 1-2 units if count<50000 and either
bleeding, sepsis or for undergoing surgery/invasive procedure. For CNS/eye surgery
aim for counts >1 lakh. Transfusion is C/I in TTP,HUS,HIT.

Covid -19/SARS CoV 2

C/f- fever, dry cough, tiredness,sore throat, diarrhea, myalgia,loss of taste or smell,
breathing difficulty
Ix-BRE(leucopenia),SGOT/PT,↑ESR,↑CRP,↑procalcitonin, CXR, ABG(unexplained
metabolic acidosis),serology, RT-PCR on oropharyngeal/nasopharyngeal swab,
Old age, neutrophila, increased LDH & D-dimer levels has been recognised as risk
factors for the development of ARDS and death.
Rx
No specific antiviral treatment recommended. Supportive care to help relieve symptoms.
Bed rest, sufficient calorie and water intake
Oxygen for pt with hypoxia.
Antibiotics for children with bacterial coinfection.
Note:A person who comes in contact with a corona virus(covid-19) case needs to be
followed up for appearance of symptoms for the maximum incubation period of 14 days.
 79
Leptospirosis
A/c febrile illness with headache, myalgia and prostration a/w any of the following:
conjunctival suffusion, meningeal irritation, anuria, oliguria and / or proteinuria, jaundice,
hemorrhage(from intestine or lungs), cardiac arrhythmia or failure, skin rash, and a h/o
exposure to infected animals or an environment contaminated with animal urine. Other
common symptoms may include nausea, vomiting, abdominal pain, diarrhea &
arthralgia
Weils: Leptospirosis with jaundice, renal impairment & haemorrhages.
c/f: fever, bodyache, muscle tenderness & headache, dry cough, sore throat, diarrhea &
dysuria occasionally, calf tenderness. Later jaundice, oliguria, bleeding tendency,HSM,
respiratory distress, cardiac failure, convulsions & coma, conjunctival Congestion , later
may have sub-conjunctival hemorrhage.
Red flag signs: a) no response to antibiotics in 8 hrs
b)RR > 30/min
c)urine output< 20/hr
d)BP<90 mm systolic
e)tachycardia out of proportion to fever
f)flapping tremor
g)altered sensorium
Complications can occur by the end of 1st week:thrombocytopenia, bleeding tendency, liver
failure, renal failure, a/c respiratory distress, hypotension, myocarditis, pancreatitis, convulsion,
coma
Inv:
Early(first 3 days): BRE: neutrophilic leukocytosis, URE
IgM elisa may be positive after 2 days
After 3 days: mild to moderate tcp, increased serum bilirubin with disproportionately low
elevation of SGOT & SGPT ,increased blood urea & serum creatinine, increased CPK, and
serum amylase
CXR: non homogenous patchy opacities if ARDS develops
ECG: tachycardia disproportionate to fever with non specific ST-T changes
LFT,Regular monitoring of RFT
Repeat CXR
Classical picture: ESR ↑, TC ↑ , polymorphs ↑, moderate elevation of SGOT/PT, abnormal &
serially increasing levels of urea & creatinine, elevated S.Bilirubin.
Investigate for DD’s like Dengue (NS1 antigen,IgM, IgG), malaria(peripheral smear, rapid
malarial test), typhoid, scrub typhus.
Rx
First 3 days: may be treated as OP if vital signs are stable and if pt is available for follow up
1)C Doxy 100 mg BD(after food; take plenty of water, otherwise sticks to esophagus; avoid
direct sunlight exposure) x 7 days or C Amoxycillin 500 mg Q8H x 1 week
2)For children over 8 yrs: C doxy 5mg/kg/day divided 12 hrly x 7 days
3)for children < 8 yrs: T Amoxycillin 50 mg/kg/day divided 8th hrly x 7 days or T
Azithromycin 10 mg/kg/day OD x 3 days

Toxic pts with red flag signs, late consultations & organ dysfunction: need IP admission &
parenteral antibiotics as follows:
1) Inj CP 20L IU iv Q6H ATD x 7 days or inj ceftriaxone 1-2 g Q12H ATD or Inj Taxim 1 g BD
ATD x 7 days
 80
2)For children: a) inj CP 2-3 L/kg/day divided Q6H x 7 days or b)inj ceftriaxone 50 mg/kg
divided Q12H x 7 days
3)Monitor fluid intake-output chart for adequate hydration,Temp chart, Daily platelet
count chart, RFT.
4)Inj Pantop
5)Inj P’mol 2 cc im sos;Tepid sponging sos
6) If not taking orally, IVF like DNS with polybion
7) Monitor for red flag signs
8)Avoid NSAIDs
9)Syp Looz 1 oz (30 ml) tds

Chemoprophylaxis
C doxy 200 mg once a week (after food; take plenty of water, otherwise sticks to
esophagus; avoid direct sunlight exposure) to those who are engaged in high risk jobs
like working in contact with stagnant water, canal cleaning etc upto 8 weeks.
Personal protection: gloves, boots, water proof dressings for injuries, local applications
like neem oil and turmeric before engaging in high risk jobs
Animal housing to be kept away from human dwellings

Dengue Fever
An a/c febrile illness of 2-7 days duration with 2 or more of the following: headache, retro orbital
pain, myalgia, arthralgia, rash, hemorrhagic manifestations, leucopenia and with one or more of
the following a)supportive serological tests:PCR(early phase) or IgG(late phase)
b)epidemiological linkage with a confirmed case
Other c/f-> gastroenteritis, change in taste sensations in mouth,Conjunctival
congestion. There may be altered level of consciousness or syncope.

Inv->BRE, PCV,LFT,NS1 antigen, IgM, IgG Dengue,Serial Platelet count is of significance.

NS1 antigen +ve by 1st week, IgM +ve by 2nd week, IgG +ve by 3rd week
Classical picture:PCV ↑, TC ↓ , lymphocytic dominance, ESR normal, plt ↓ when fever
subsides, OT & PT ↑.
Pt monitoring- plt ct, pcv

Presumptive disease
Fever with any two of the following signs
1)anorexia and nausea
2)rashes
3)aches and body pain
4)warning signs: a)abdominal pain, tenderness
b)persistent vomiting c)clinical signs of fluid accumulation(ascites, edema and pleural
effusion) d)mucosal bleeding e) lethargy or restlessness f)liver enlargement > 2cm g)
rapid decrease in plt ct and corresponding increase in pcv
5)leucopenia
6)positive tourniquet test: apply BP cuff to upper arm. Raise BP to a level between
systolic and diastolic. Keep for 5 minutes. Mark an area of 1 inch square over the
anterior aspect of forearm and count for number of petechiae. More than 20 is
diagnostic. More than 10 may be taken as positive
Mx
Pts may be categorised into group A,B or C
 81
Group A: no warning signs. May be sent home.
Criteria; no warning signs, taking oral fluids, passing urine once in 6 hours
Inv: total count on day 3 of fever
Platelet count on day 3 and every 3rd day: should be > 1 lakh
Pcv
Dengue NS1 is positive upto 3 days
IgM dengue is more sensitive from 4-5 days onwards
Rx
1)Adequate bed rest
2)Plenty of oral fluids
3)Continue normal feeding. In fever, the body, infact requires more food.
4)Pmol upto 4 g/day(adult), not more frequent than Q6H
5)Tepid sponging
6)Avoid NSAIDs
7)Avoid fluids containing sugar in diabetics
Monitoring: daily review if possible; to return to hospital if warning signs develop
Reassess if: a)no clinical improvement b)any warning signs
If any of the above, refer to secondary care centre.

Group B: pts who have warning signs or risk factors. To be admitted in a secondary
centre
Criteria: presence of warning signs or any of the following conditions: pregnancy,
infancy, old age, diabetes, c/c hemolytic disease and RF, living alone or away
Ix:TLC, PLC,PCV
Evidence of plasma leakage: a)increase in pcv by 20% or more than 20% drop in pcv
following volume replacement
b)presence of clinical signs of plasma leak(eg: ascitis, pleural effusion)

Rx
1.encourage oral fluids
2.If not tolerating, start iv fluids(0.9 % NS or RL)
a) 5-7 ml/kg/hr x 1-2hrs
b) 3-5 ml/kg/hr x 2-4 hrs
c) 2-3 ml/kg/hr as per clinical response
d) Run at maintenance slow rate only
3.Repeat pcv and reassess clinically and review fluid infusion rate
4.Q4H temp chart, I/O chart,Platelet count chart, RFT
5.T P’mol 500mg 1-1-1 & Inj P’mol 2cc im sos// Tepid sponging sos
6.Inj Pantocid 40 mg iv od
7. Adequte bed rest.
8.Watch for warning signs
9.RBS,LFT,RFT,CXR, coagulation parameters if indicated
10.Discharge if visible clinical improvement, return of appettite and plt ct more than 50,000.
Refer to tertiary care centre if no improvement

Group C:
Severe cases of dengue. To be admitted in a tertiary centre.
Criteria: 1.severe bleed such as upper GI bleed/clinical/USG evidence of internal bleed
 82
2.severe plasma leak; dengue shock syndrome
3.severe organ dysfunction
Ix: TLC/PLC/PCV
Other tests for organ dysfunction: LFT/RFT/PT-INR
Rx
In dengue hemorrhagic fever:
1) give platelet transfusion if a)PLC <10,000 without bleeding manifestations
b)PLC<50,000 with bleeding manifestations
2)3-5 U PRP(platelet rich plasma) per day or PC(platelet concentrate) in patients with high
cardiovascular risk
In compensated shock: 1)IV fluids- NS/RL at 5-10ml/kg/hr x 1st hr(infants and children 10-
20 ml/kg in 1st hr)
2)if improving, decrease dose to 5-7 ml/kg/hr x 2 hrs and then to 3-5 ml/kg/hr
3)IVF maintained for not more than 24-48 hrs
4)check PCV after initial bolus: if pcv higher, IVF NS 10-20 ml/kg/hr plus colloids(IV
Dextran)
If pcv lower and pt is unstable give transfusion with fresh blood or PRC

In hypotensive shock:
1)more vigorous IV fluids: NS 20 ml/kg administered as bolus in 15 min
2)gradually decrease as in compensated shock.

Dengue haemorrhagic fever(DHF): a probable or confirmed case of dengue with the

following signs; haemorrhagic tendencies evidenced by one or more of the following:
heamorrhagic tendencies evidenced by one or more of the following: posistive
tourniquet test, petechiae, ecchymoses or purpura, bleeding from mucosa, GI tract,
injection sites or other, haemetemesis or malaena,TCP(plt ct, 100000 or less). Evidence
of plasma leakage due to increased vascular permeability, manifested by one or more
of the following: ~20% rise in average hematocrit for age and sex. ~20% drop in
average hematocrit following volume replacement treatment compared to baseline,
signs of plasma leakage(pleural effusion, ascites and hypoproteinaemia)

Dengue shock syndrome: all the above criteria plus evidence of circulatory failure
manifested by rapid & weak pulse, narrow pulse pressure(<20 mm of Hg) or
hypotension for age, cold, clammy skin & altered mental status

Chikungunya
Chikungunya: a/c onset of fever with any of the symptoms like headache, backache,
photophobia, severe arthralgia, rash & positive serology
C/f:sudden onset of fever, crippling joint pain & swelling (esp of wrist,elbow, shoulder,knee,
ankle, metatarsal joints), headache, lymphadenopathy, conjunctivitis, maculopapular rash,
fatigue etc.
Rx: Rest, fluids, NSAIDs like Naproxen or P’mol.
Note: In c/c arthritisT Chloroquine 250 mg/day may help . A short course of steroids may
also be useful.
Acute encephalitis syndrome(AES): a person of any age with a/c onset of fever & any of the
following: change in mental status/altered sensorium(confusion, coma, inability to talk), new
onset of seizures(excluding febrile seizures). Other early clinical findings like an increase in
irritability, somnolence or abnormal behaviour greater than that seen with usual febrile illnes.
 83
Japanese encephalitis: an AES case with lab confirmation with IgM elisa for JE. Or a suspect
case that occurs in close geographic and temporal relationship to a lab confirmed case.

Scrub typhus
C/f: high grade continous fever with HSM & lymphadenopathy. Eschar in a hidden wet area of the body.
high grade fever with chills and rigour, severe myalgia, body ache, throat pain, dry cough, chest pain and
breathlessness, Upper respiratory symptoms NOT a feature of scrub.
A sudden onset of high fever >400C with relative bradycadia, severe headache, generalized
lymphadenopathy, photophobia and dry cough with h/o exposure to chigger
Physical examination: conjunctival congestion, maculopapular rash, regional lymphadenopathy,
splenomegaly, presence of eschar: diagnostic finding(painless lesion with a central necrotic
black scab surrounded by a raised ring and erythema not more than 1 cm seen in the concealed
and moist areas like axilla, inguinal region, under breast.
Inv: BRE:leucopenia, relative lymphocytosis, thrombocytopenia may be seen.
LFT: S bilirubin may mildy elevate, SGOT/PT may moderately elevate, ALP may also
elevate
RFT- normal, unless pre renal or renal failure occurs
Special diagnostic tests:
1)scrub antibody test: IgM elisa specific test: single high titre + classical clinical features
indicate a probable case of scrub; a 4 fold increase is confirmatory.
IgM, IgG Scrub

For detecting complications: a) ECG to r/o myocarditis(diffuse ST/T wave changes b)

CXR(non homogenous patchy opacity without air bronchogram(to r/o pneumonitis)
c)EEG/MRI: to r/o encephalitis
Rx
1)P mol
2)Avoid NSAIDs( to prevent renal injury)
3)Tepid sponging and plenty of oral fluids
4)C Doxy 100 mg bd x 5-7 days(C/I: children < 8 yrs and pregnancy) or T Azithromycin
500 mg OD x 5-7 days
Chemoprophylaxis: C Doxy 100 mg once weekly after food x 6 weeks.
In any case of high grade fever with chills in an endemic area, start Doxy. If not
responding to doxy, investigate fopr other causes
C Rifampicin 450 mg BD x 5-7 days may be given in resistant cases in endemic areas
Complications: common: pneumonitis, myocarditis, encephalitis; uncommon: shock,
ARF, DIC

Malaria
C/f: A case of sudden high fever (pt feels burning hot)which may be accompanied with
any of the following headache, back ache, cycles of chills, rigors, and then sweating(pt
feels better after lot of sweating), myalgia, nausea, vomiting, splenomegaly, anemia,
thrombocytopenia, joint pain, generalised convulsions, coma, shock, hypoglycemia,
hypothermia, marked agitation, metabolic acidosis, hyper ventilation,spontaneous
bleeding, renal failure and death(untreated falciparum infection). Pt feels like covering
his body with clothes.Any case of fever in an endemic area may be considered as
malaria. Fever may occur after definite interval on third or fourth day.
Inv:Do RMT,peripheral smear for malarial parasite, RFT, LFT etc. Findings include leucocytosis,
pcv<15%, coagulopathy( tcp< 50,000, prolonged PT,aPTT),hyperlactatemia, elevated creatine,
bilirubin,liver & muscle enzymes, uric acid etc.
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Rx
1.4th hrly temp chart, adequate fluid intake,
2.For uncomplicated malaria: chloroquine 250 mg 4 tabs st, 2 tabs after 6 hrs, 24 hrs
& 48 hrs.For P ovale & P.vivax same as above + T Primaquine 15mg 1-0-0 x 14 days(0.25
mg/kg)
Note:G6PD deficiency must be ruled out before starting primaquine.Primaquine also C/I in
infants & pregnancy.
For uncomplicated P.falciparum- T artisunate(4mg/kg)(available as 50 mg tablets) 4 tab
daily x 3 days+ SP (sulpho -methoxazole 25mg/kg pyremethamine 1.25 mg/kg)(available
as 500 +25 mg tablet) 3 tablets on day 1. For severe cases -artesunate 2.4 mg/kg iv/im
given on admission, then at 12 hrs & 24 hrs & then OD.
3. Inj 25% Dextrose 100ml iv Q8H
4. Inj Pantoprazole 40mg iv od;If not taking orally, IVF 2 pint DNS; P’mol for fever.
General recommendations:
a) Avoid starting treatment on empty stomach. First dose should always be given under
supervision. If the first dose is vomited, then wait for 15 min and then repeat again. If it is
again vomited, it is considered to be a severe case of malaria & should be referred to a
higher centre.
b) Ask the pt to return immediately if the fever does not subside in 24 hours or worsens
during this period.
c) Advise the use of mosquito nets
Chemoprophylaxis(<6 weeks): Doxycycline 100 mg OD in adults(1.5 mg/kg for children>
8 yrs) 2 days before travel & continued for 4 weeks after leaving the malarious area.

Filariasis
Acute lymphangitis & lymphadenitis, Tropical eosinophilia:
Rx :T DEC 100 mg 1-1-1 x 3 weeks(Hetrazan, Banocide)(children-6mg/kg/day div into 3)
Prophylaxis
T DEC 300 mg + albandazole 400mg one dose + ivermectin 200 microgram yearly for 4 -6
yrs
Post-lymphangitic edema:
Elevation of limbs at night, crepe bandage during day time; wash the affected parts with
soap & water BD; regularly working the foot up and down to promote lymph flow; keep
nails clean; proper treatment of small wounds and abrasions.
Tropical pulmonary eosinophilia(TPE)
c/f- cough aggravating at night, asthmatic attacks, weakness,wt loss, low fever,
enlarged spleen, prominent LN in the neck etc,
H/o lymphatic filariasis,AEC>250, peripheral blood negative for microfilariae,peripheral
eosinophilia>3x109/L, clinical response to DEC.
For persistent eosinophilia & c/c dry cough, T prednisolone 5mg tds x 5 days f/b 5 mg 1-
1-0x 5 days f/b 5mg 1-0-0 x 5 days may be given.

Eosinophilia
AEC>500 cells/µL
Aetiology: infections(esp helminthic parasites-most common), allergies(food, medicine),
asthma, eczema,neoplasms, adrenal disorders,auto immune disorders
Inv:CBC, AEC,peripheral smear,RFT,LFT,URE, stool microscopy, CXR
Rx
1. T DEC 100 1-1-1 x 2-3 weeks
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2.T Albendazole 400 0-0-1 single dose
3.T Levocetrizine 10 mg 0-0-1 x 1 week
Advise to avoid the allergent.

Suspected Enteric Fever(Typhoid fever)

In Any pt with fever for more than one week and with any two of the following: toxic look,
coated tongue, relative bradycadia,splenomegaly, exposure to confirmed case, clinical
presentation with complications e.g: G I bleed, perforation etc, suspect Typhoid.
c/f: Fever with Splenomegaly, headache, lethargy,abdominal pain, dry cough,poor appetite,
generalized aches,constipation followed by diarrhoea,epistaxis,malena.
Inv: Routine investigations(leucopenia with relative lymphocytosis) , Widal test , 2 samples
7-10 days apart; O titre>1/160 & H titre >1/320 is significant(a single absolute value of O
titre >200 or an increasing titre of O over one week especially a four-fold rise is considered
positive), blood c/s, Clot culture, typhidot
Rx
1.Temp chart, I/O chart
2.Inj Ciplox 200mg iv bd x ~ 10-14 days(DOC)/Inj Monocef 1-2 g iv bd ATD
T ciplox 500-750 mg bd for 10-14 days can also be given.
Other drugs used: cefixime 200/400 mg BD,Ceftriaxone, cefotaxim,Azithromycin
3.Inj or Tab P’mol sos + Tepid sponging
4.If not taking orally, IVF as required
5.w/f signs of perforation, other complications like arthritis etc & get expert
opinion & management.

Upper GI Bleed
Etiology: esophageal varices, mallory-weiss tear, peptic ulcer, esophagitis, gastritis,
esophageal cancer,vascular ectasias, dieulafoy’s lesions,neoplasm,hemorrhagic and
erosive gastropathy(drug induced, stress related, erosive esophagitis) etc
c/f: hematemesis, coffee ground emesis or aspiration of blood or coffee ground material
from NG tube,melena-black sticky stool with a characterisitic odour
anaemia- fatigue, weaknesss, abdominal pain, pallor
coagulation abnormalities
Inv:Hb, PCV,CBC, Blood grouping & crossmatching ,RFT, LFT,PT INR, aPTT, HBsAg,
Anti HCV, USG Abdomen, OGD scopy.
Rx:
1.Nil per orally(NPO);monitor vitals , watch for tachycardia or hypotension
2.Ryles tube aspiration;oxygen inhalation if hypoxic
3.Inj Octreotide 50 microgm iv st, followed by 25 microgm/hr infusion till 4 hrs after
bleeding stops or till pt is taken to endoscopy Or inj terlipressin 2mg st
f/b Inj terlipressin 1 mg(1mg/10ml) iv q8H(it is very costly~ Rs 1500 per 10 ml)
4.Inj Pantop 40mg iv od Or Inj omez(omeprazole) 80mg iv st f/b 8mg/hr
infusion
5. volume resuscitation: IVF 2 DNS, 2NS, 2% 5D in 24 hrs.
6. Blood Transfusion/FFP sos(if INR> 1.5 then transfuse 2 to 4 units of FFP)
Note: packed cell transfusion (target Hb= atleast 8 mg/dl, and PCV = 25-30%)
7. Inj vit K 1 amp (10 mg) iv/sc OD x 3 days
8. inj thiamine 100 mg iv q8h(if alcoholic)
9. Bowel wash with lactulose BD
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lactulose enema: 300 ml lactulose to 700 ml distilled water with retention for 30 minutes
10. Syp lactulose 30 ml tds( if not NPO)
11.Inj taxim 1 g iv Q8H
12.T Misoprostol 200mg 1-0-1(If thought to be associated with irritant drugs like
NSAID’s. Also stop the offending drugs)

Hepatic Encephalopathy
Ideally Refer to a higher centre
Upper GI Bleed may be associated. Hence orders and investigations may be similar.
Inv:BRE, Platelet count, PCV, Peripheral smear, Blood grouping, URE, LFT, RFT, ECG,
PT-INR, APTT, Blood Ammonia levels, HBsAg, AFP (alpha feto protein), Serum Ferritin(to
r/o secondary haemochromatosis)USS abd, OGD Scopy, RBS.
Rx:
1.Ryle’s tube aspiration(for upper GI bleed), NPO, I/O chart
2.Packed cell transfusion sos
Treat precipitating causes
3.Inj Octreotide 50 microgm st, followed by 25 microgm/hour infusions, ideally till
OGD scopy is done and endoscopic sclerotherapy is done. It is to be given in 5%
Dextrose, Never in NS.
4.Inj Vit K 1 amp s/c or iv od x 3 days for coagulopathy. Fresh blood/FFP transfusion if
needed.
6. Inj Pantop 40mg iv od or Inj omez(omeprazole)80mg iv st f/b 8mg/hr infusion
7. Inj thiamine 100 mg(Trineurosol H)iv bd x 7 days if alcohol related liver disease.
8. Inj Ampicillin 500mg iv Q6H ATD/ Inj taxim for SBP
9. T Rifagut (rifaximine) 400 1-1-1 0r 550 mg 1-0-1(gut sterilizer)(thru Ryle’s tube, or
orally if there is no hemetemesis & sensorium is normal).
10. Bowel wash with lactulose enema bd
11. Syp Looz 30ml tds(if not NPO)(r/o ileus/bowel obstruction before oral lactulose)
with a target loose stools of 2-3/ day.
12.Inj Hepamerz/analiv(L-ornithine L-aspartate) 5g(10 ml) iv bd if RFT is normal
13.If Vomiting present, Inj Emeset 4 mg iv Q8H
14.Inj Mannitol 20% 100ml iv Q8H, if RFT is normal.
15.If hypovolemic, IVF NS 2 pint , 5%D 2 pint in 24 hrs. Once BP is rectifies, NS is not to
be given.
16.Correct dyselectrolytemia like hypokalemia with iv KCl @ 100-20 mmol/hr (pg no
163) , hyponatremia(pg no 163)
17.If stable after OGD scopy, propranolol (to decrease portal HTN) may be started
at a dose of 20mg 1-0-1. Dose may be adjusted so as to cause 25% decrease
in pulse rate. It is not given in acute bleeding.
18.T Monotrate 20mg 1-0-1(isosorbide mononitrate)(Px for variceal bleedeing)
19.If Ascites is present give T Aldactone 25 (1-0-1)(spironolactone)(to decrease fluid
overload) or T Lasilactone(furosemide + spironolactone) 1-0-0.
Refractory ascites means no response to max dose of Aldactone & lasix after ≥ days.
20.If Viral Hepatitis was the cause of CLD anti viral drugs may be required to be given
for long term.
21.Clinical worsening of the patient may due to the development of Spontaneous
Bacterial Peritonitis. The patient may present with suddenly developing abdominal
pain, with rebound tenderness, absent bowel sounds and fever. In such cases, do a
diagnostic tap and send for cytology study. Diagnosed if PMN >250cells/µL or if >50%
 87
polymorphs, cloudy nature of fluid and positivity on culture-> mostly E coli. A culture of
mixed organisms may indicate a hollow viscus perforation. Give Inj Taxim 2g iv Q8H till
clinical improvement(for a minimum of at least 5 days). Other options include
AmoxClav or other 3rd generation Cepholosporins or Genta.
22.If Ascites is present do therapeutic tap, ideally only after giving Human Albumin
intravenous infusion or FFP.
23.Any CLD patient with ascites, give long term prophylaxis with T Norflox 400mg
Once daily or ciprofloxacin 750 mg weekly to prevent SBP.
Diet in Hepatic Encephalopathy
1.Restrict Proteins
2.Fluid intake should be such that the daily weight loss is not more than 1 kg.
3.Carbohydrate rich diet.

Factors Which Preceipitate hepatic encephalopathy

1.Uraemia-spontaneous or diuretic induced.
2.Drugs like Sedatives, Hypnotics or Antidepressants
3.GI Bleeding
4.Excessive protein intake
5.Large volume paracentesis
6.Hypokalemia/hyponatremia/hypoxia/alkalosis
7.Infections
8.Constipation
9.Trauma,Development of portosystemic shunts

Hepatorenal syndrome
State of functional renal failure in pts with severe liver disease.
Major criteria include the following (All major criteria are required to diagnose HRS.):
Low GFR, indicated by a serum creatinine level higher than 1.5 mg/dL or 24-hour
creatinine clearance lower than 40 mL/min
Absence of shock, ongoing bacterial infection and fluid losses, and current treatment
with nephrotoxic medications
No sustained improvement in renal function (decrease in serum creatinine to < 1.5
mg/dL or increase in creatinine clearance to >40 mL/min) after diuretic withdrawal and
expansion of plasma volume with 1.5 L of plasma expander
Proteinuria less than 500 mg/d and no ultrasonographic evidence of obstructive
uropathy or intrinsic parenchymal disease
Additional criteria include the following (Additional criteria are not necessary for the
diagnosis but provide supportive evidence.):
Urine volume less than 500 mL/d
Urine sodium level less than 10 mEq/L
Urine osmolality greater than plasma osmolality
Urine red blood cell count of less than 50 per high-power field
Serum sodium concentration less than 130 mEq/L
Rx
1. Terlipressin or octreotide
2. Iv albumin
3. Renal dose dopamine(2 mcg/kg/min)
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Viral Hepatitis
An a/c illness with dark urine, anorexia, malaise, extreme fatigue, and right upper
quadrant tenderness. Biological signs include increased urine urobilinogen and >2.5 times
the upper limit of serum ALT.
C/F: fever, malaise,fatigue, anorexia, nausea, arthralgia, jaundice,pruritus, headache,
abdominal pain, tender hepatomegaly
Inv: Hep A: Anti-HAV;AST & ALT rise 22-40 d after exposure, & usually return to normal
over 5-20 weeks.IgM rises from day 25 & signifies recent infection.IgG remains detectable
for life.Hep B: HBsAg(surface antigen) is present from1 to 6 months after exposure. HBeAg
is present for 11/2 - 3 months after the a/c illness & implies high infectivity.The persistence of
HBsAg for >6months defines carrier status.Antibodies to HBcAg(anti-HBc) imply past
infection. Antibodies to HBsAg(anti HBs) alone imply vaccination.
HCV: anti-HCV antibodies, SGOT:SGPT <1:1 until cirrhosis develops.
AST & ALT are increased 2-7 times with AST/ALT ratio >1 in alcoholic hepatitis

Admit if :
>15 Bilirubin, prolongation of PT
Enzymes grossly elevated, Coagulopathies
Significant Vomiting, abdominal pain, malaise
Ascites and Encephalopathy, Hypoglycemia,Co-morbid conditions

Among investigation, the prolongation of PT is the earliest marker. If the test value
exceeds the control value by >4sec, it is considered abnormal.
Rx: Mainly supportive
1.Absolute bed rest, avoid alcohol
2.Protein and fat restricted, carbohydrate rich diet.
3.T Silybon (silymarin, herb derivative used as hepatoprotective)140mg 1-0-1
4.T Udihep/Udiliv/Ursochol (ursodeoxycholic acid/ursodiol) 300mg 1-0-1.
Note: ursodiol used in cholestasis, cirrhosis, other hepatic disorders)
5.Inj Vit K 1 amp s/c od x 3 days if coagulopathy is suspected.
6.Avoid P’mol. Do tepid sponging for fever
7.Hepatic drip(Usually in children if oral feeds are not well tolerated. (100ml NS
400ml 10% glucose + 5ml 15% KCL + 2ml Polybion)
Note:Fulminant hepatitis, C/c Hep B, a/c or c/c Hep C may require specific antivirals.
For c/c Hep B, T entecavir 0.5 mg OD or T Tenofovir 300mg OD may be started.
For c/c Hep C, T daclatasvir 60 mg+ sofosbuvir 400 mg OD or T ledipasvir 90 mg +
sofosbuvir 400 mg OD is started after HCV genotyping & RNA quantitative PCR.

ADD/Gastroenteritis
Acute diarrhoeal disease: passage of 3 or more loose stools or watery stools in the past 24 hours
with or without dehydration
C/f: Diarrhoea, vomiting, abdominal discomfort,fever etc.
Inv: BRE, RFT, electrolytes,stool RE, C & S etc.
1.4th hrly Temp chart , I/O chart
2.Inj Ciplox 200mg iv BD [Ciprofloxacin] or T Ciplox 500 mg bd
3.Inj Metrogyl 500mg iv Q8H[Metronidazole] or T Metrogyl 400 mg tds
4.Inj Rantac 50mg iv tds [Ranitidine]
5.Inj P’mol 2cc im sos
6.Inj Cyclopam / Buscopan 1 amp im sos[dicyclomine / hyoscine butylbromide]
7.Plenty Of Oral Fluids/ORS.If not taking orally IVF RL/DNS/NS
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8.C.Hydral or Redotil 1-1-1[Racecadotril]
Note: C Doxy 100mg bd x 3-5 days can also be given.

Cholera
Definition
In an area where the disease is not known to be present: severe dehydration or death
from a/c watery diarrhoea in a pt aged 5 years or more.
In an area where cholera is endemic: a/c watery diarrhea with or without vomiting in apt
aged 5 years or more.
In an area where there is cholera epidemic: a/c watery diarrhea with or without vomiting
in any pt.
C/f: Diarrhoea, nausea, vomiting, dehydration,irritability, lethargy, sunken eyes, a dry mouth,
extreme thirst, dry and shrivelled skin that's slow to bounce back when pinched into a fold,
little or no urine output, low blood pressure, an irregular heartbeat, muscle cramps due to
loss of electrolytes
Rx
1.Plenty of Oral fluids/ORS. If can’t drink give iv fluids.
Standard home solutions such as salted rice water, salted yogurt drinks, vegetable and
chicken soups with salt can be given. Home solutions such as water in which cereal has
been cooked, unsalted soup, green coconut water, weak tea (unsweetened), and
unsweetened fresh fruit juices can also be given.
2. Antibiotics. While antibiotics are not a necessary part of cholera treatment, some of
these drugs may reduce both the amount and duration of cholera-related
diarrhea.Antibiotic treatment is indicated for severely dehydrated patients who are older
than 2 years. A single dose of doxycycline 300 mg or azithromycin 1 g(20 mg/kg) may
be effective.Begin antibiotic therapy after the patient has been rehydrated (usually in 4-6
h) and vomiting has stopped. No advantage exists to using injectable antibiotics.
3.Zn, vitamin A supplements for children.

IBS(Irritable Bowel syndrome)

C/f: recurrent abdominal pain & tenderness, abdominal bloating, n,v,alternating
episodes of diarrhoea & constipation, mucus in stools, feeling of incomplete defecation.
Diagnosis is mostly clinical. Age of onset is usually <45 years. Essential criteria-
abdominal pain/discomfort ≥ 3 days/month for the last 3 months . ≥ 2 of 3 associated
criteria- pain(↓ by defecation), onset a/w stool frequency change, onset a/w change in
stool consistency
Diet: avoid excess tea, coffee, fried food etc.
Increase leafy vegetables & fruits (if constipation predominant).
Note: fibre rich diet can cause bloating & occasional impaction if ingestion is not
accompanied by adequate volume of liquid.
Also explain the nature of the illness to stressful situations.
Rx
1.T Colospa / Morease (mebeverine - antispasmodic) 100 1-1-1
2.T Librax / Spasril (chlordiazepoxide + clidinium bromide) 1-1-1
Note: T Normaxin (chlordiazepoxide + clidinium bromide+dicyclomine) tds can also be
given
3.C Econorm (saccharomyces Boulardii) 250 1-0-1
4.T Amitriptylline 10-25 mg HS.
5.T Rifaximin 550mg tds (in IBS-D)
6.T Loperamide (in IBS-D)
 90

Liver abscess
C/f: fever, chills,jaundice,wt loss, tender hepatomegaly,intercostal tenderness, dry
cough, pain in the right shoulder etc.
Inv:CBC, LFT, Blood C&S,coagulation profile,Stool RE, CXR,USG abdomen, CCT.
Rx
For pyogenic liver abscess: iv antibiotics e.g cephalosporin (3rd gen) ± gentamycin
For amoebic liver abscess/Amoebiasis:
1. Inj Metrogyl 500 iv Q8H x 7-10 days or T metrogyl 400/800 mg tds or T Tinidazole /
ornidazole 2g daily x 3-5 days(After 10 days give T Diloxanide 500 mg tds x 10 days ) +
Inj CP 10 LU iv q6H ATD x 5 days
2.T Chloroquine 250 2-0-2 x 2 days followed by 1-0-1 x 10-14 days
Needle aspiration for large abscess or if the response to chemotherapy is not prompt.
Prevention is by avoiding fresh uncooked vegetables or drinking unclean water.

Deworming/Drenching
Symptoms of worm infestation: abdominal pain/ itching, blood in stools, wt loss, gagging,
rashes, anal itching, etc
 In a normal child deworming usually done > 1yr.In a child with pica, 9 month.
 Repeat every 6 months upto 6 yrs, every 1yr up to 12yr.
Note:recent anemia mukt bharat programme advices biannual deworming for
adolescents & women of 20-49 years also.
 For pregnany, one 400 mg tablet of albendazole in 2nd trimester
 May be in every 2 yrs in adults, every 3 months in case of pica.
After deworming, give vitamins/Iron/Appetizer.In pica, give Fe
 2nd dose on 15th day for extra intestinal coverage
 Not given in case of Fever
 Ideally do stool RE for ova/parasites, then decide the best deworming therapy.
 Advise to cut nails regularly.
Albendazole
 400mg HS, Rpt on 15th day
 Syp 200mg/5ml available;Below 2 yrs - 200mg HS, ≥2 yrs- 400 mg HS
 frequency
 For hookworm,round worm,strongyloides,trichuriasis,
 TN: Zentel, Bendex 400, Albend
Mebendazole
 T Mebex 100mg bd X 3 dys
 Syp Mebex 100mg/5ml
 For hookworm,round worm,trichuriasis,enterobiasis(pin/thread worm)
 TN: Mebex

Pyrantel pamoate
Syp 250mg/5ml; Rpt after 15 days.
11mg/kg/day single dose
<2yrs: safety & efficacy not established,
 Upto 3yrs half bottle HS
 >3yrs, one bottle HS
 For hookworm,round worm,enterobiasis(pin/thread worm)
 TN: Expent/Nemocid/Shalminth
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Piperazine citrate (DoC in worm vomiting)
 Safe in pregnancy
 75-100 mg/kg OD x 2 days; adult 4 g OD x 2 days
 1-2 yrs:5ml, 2-5 yrs:10 ml, >5 yrs: 15 ml
 Worm allergy , Rx-> Nil orally, IVF, Piperazine Citrate [Antepar]120mg/kg HS x 2dys,
(750mg/5ml)
Repeat on 15th day adult : 4mg [30ml] one bottle. Up to 12 yrs, 2gm, give in small doses over
few hours.

Hiccups/Singultus
Aetiology: benign, IWMI, DKA,aortic aneurysm, mediastinitis,CVA,renal/hepatic,respiratory
failure, liver abscess, hepatitis,cholecystitis,alcohol ingestion,pericarditis,pneumonia,
empyema, esophageal obstruction etc
Rx
1. Mucaine gel 2tsp Q2-4H(oxethazaine,Mg hydrox,Aluminium hydrox)
Note: Mucaine can also be used for gastroesophagitis, heart burn)
2.T Perinorm /Cyclopam/ Buscopan or T Baclofen (most effective)(T.N- Liofen) 5 or 10 mg
tds
3.T Largactil(chlorpromazine) 50mg st & tds(preferred for intractable hiccough)
4.C pantop 40 OD
5. Breathing in & out in a plastic/paper bag.Breath holding as long as possible. Drink Ice
cold water
Other drugs that may be tried arelorazepam, gabapentin, etc
If severe
1.Inj Metoclopramide 2cc iv or Haloperidol, 2 -10 mg IM or Largactil(chlorpromazine) 2cc IM/IV
2.Xylocain viscous (Lignocaine) 30ml to drink.

Continous belching/flatulence
R/o I.W.M.I.
Ask pt to eat slowly; avoid aerated drinks/talking during meals, chewing gums etc. Advise to
close the mouth while belching.Avoid gas forming foods such as cabbage, cauliflower, beans,
peas, onions, nuts, apple, cucumber etc
Rx
1.T perinorm tds
2.Antacid preparations with methylpolysiloxane or dimethicone like Gelusil MPS
3. Aristozyme Cap or syp or Dps bd/tid after meals

Anal itching/pruritus ani

Aetiology:infection,dietary irritants, anxiety, dermatitis, diarrhea, poor hygiene etc
Rx
1.T mebex 100mg bd x 3days(Syp mebex 100/5 , dose same as adult) or T albendazole
400 mg st & rpt after 2 weeks (as booster). For child <2 yrs - 200 mg.
Note: Albendazole C/I in pregnancy & lactation
2. T avil 25 mg HS & SOS
3. Mid steroids- hydrocorisone acetate 1% (TN- cutisoft) for LA
4. Avoid soap
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Anorexia
Aetiology:gastritis,carcinoma,TB,CCF,renal/respiratory failure, drugs, alcohol,infective fevers,
hyperparathyroidism, physiological, psychogenic,
Rx
1. Syp Practin (2/5) 1tsp tds x ½ hr before meals (Cyproheptidine,anti histamine) ( For Ped
0.25 -0.5 mg/kg/24 hr div into 3. 2-6 yrs:2mg/dose) or Bayers tonic(liver fraction, alcohol)15 ml
Bid preferably before meals or Elixir neogadine 1tsp OD(iodised peptone, manganese chloride)
or T Apetone/T Practin / T Ciplactin 2mg/4mg ½ hr before meals (Cyproheptidine).
2. T Megasty or megeetron (megestrol acetate) 160 mg OD(in CA, CKD, AIDS pts)

Rectal Bleeding/hematochezia/melena
Aetiology:Hemorrhoids,fissure,fistula,rectal trauma, rectal FB,proctitis, carcinoma, IBD,polyp,
diverticulosis, infectious diarrhea, any cause of brisk upper GI bleeding,meckel’s diverticulum,
angiodysplasia, intussusception,drugs, coagulation disorder, uremia etc
Inv: FBC, U & E, LFT, Coagulation profile, USG Abdomen
Medicine/Surgery consultation.

Acute Bronchitis
Short term inflammation of the bronchi, mostly viral
C/f: productive cough(mucoid to mucopurulent), fever, rhonchi, creps, absence of CXR
findings.
Rx
1.Bed rest, avoid smoking, steam inhalation, plenty of hot oral fluids to help expectoration.
2.Antipyretics
3.Asthalin expectorant
4.Antibiotics if severe or complicated cases to prevent secondary infection and in children.

Haemoptysis
Etiology: TB, a/c LVF, MS, bronchiectasis, pulmonary embolism, AVM, a/c bronchitis,
lung abscess, suppurative pneumonia, bronchial CA, trauma, SLE, FB, parasites,
mycetoma, hemophilia, aortic aneurysm, pulmonary infarction, leukemia ,
drugs(anticoagulants , aspirin, cocaine), vasculitis
Inv: CBC, coagulation studies, URE, AFB, ANA,ECG, CXR(1st inv), Chest CT, rigid
bronchoscopy
Rx
1. Reassure the pt;Q4H temp chart, I/O chart, pulse/BP chart(watch for hypotension)
2.Prevent aspiration; raise foot end, turn head to one side/ lateral decubitus position
3.Absolute bed rest; supplemental oxygen
4.Broad spectrum antibiotics
5.Blood transfusion if systolic BP less than 90 mmHg or massive hemoptysis.
6.Antitussives like codeine 5 ml tds
7.Bronchodilators
8.Sedation e.g: diazepam
9.Inj ethamsylate 500 mg iv Q8H.
If large volume bleeding continues or the airway is compromised, the pt should be
intubated and undergo emergency bronchoscopy.Medicine/chest consultation
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Influenza / H1N1
C/f:fever,cold, sore throat, muscle pain, head ache, cough, tiredness etc
1.Antipyretics, analgesics, cough medications, antibiotics for 20 infection
2.Antiviral agents: T. Oseltamivir 75 mg bd x 5 days(tamiflu). Syp Oseltamivir (12mg/ml)
Prophylaxis: T. Oseltamivir 75 mg OD x 10 days
Influenza like illness(ILI)
a)fever >1000 F
b) Upper respiratory symptoms: cough, sore throat
c) Head ache, body ache, fatigue, diarrhea and vomiting
Categorization
Category A
Mild fever plus cough/sore throat with or without body ache, head ache, diarrhea and
vomiting
Category B
i) B 1- category A + high grade fever and severe sore throat
ii) B 11- any mild ILI in people with comorbidities: a)pregnancy, any ILI in
pregnancy(antenatal & postnatal), suspect H1N1, start oseltamivir
b)lung/head/liver/kidney/neurological disease/ blood disorders/ diabetes/cancer/HIV c)
on long term steroids d) children -mild illness but with predisposing risk factors e) age>65
yrs
Category C
Breathlessness, chest pain, drowsiness, fall in BP, hemoptysis, cyanosis
Children with ILI with red flag signs- somnolence, high/persistent fever, inability to feed
well, convulsions, dyspnoea/ respiratory distress etc)
Worsening of underlying c/c conditions
Investigations
a) Cat A- no testing needed
b) Cat B- no testing needed
c) Cat C - test may be needed, but do not wait for test results
If testing is indicated: contact nodal MO of district hospital
Specimen: 1 throat swab and 1 nasal swab immersed in VTM(viral transport medium) tube
put in cold chain/refrigerated till dispatch at 2-8 degree celsius
Specimen should be dispatched through the DMO/DSO of the district
Rx
ILI- Cat A
1.no oseltamivir required
2Symptomatic treatment
3Complete rest
4.Report in case of deterioration or failure to improve
Cat-B
1.B1- home isolation, oseltamivir to be started as per clinical assessment
2.B11-start oseltamivir immediately
Cat-C
1.hospitalization stat
2.Start oseltamivir immediately, without waiting for test results
Oseltamivir dosage schedule
Wt<15 kg: 30 mg BD x 5days
15-23 kg: 45 mg BD x 5 days
24-40 kg:60 mg BD x 5 days
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>40 kg:75 mg BD x 5 days
Available as syrup oseltamivir (12 mg/ml) and Tab oseltamivir 75 mg
For infants <3 months:12 mg BD x 5 days, 3-5 months:20 mg BD x 5 days, 6-11 months: 25
mg BD x 5 days

Pneumonia
C/f:
Frequent symptoms- fever(high grade a/w chills and rigor), cough(1.productive-
mucoid,purulent or blood tinged; 2.nonproductive), pleuritic chest pain, dyspnea, brochial
breath sounds
Less frequent & non specific symptoms: hemoptysis, chills,rigors, nausea, vomiting,
diarrhea(more common with viral pneumonia),
fatigue,malaise,headache,myalgia,arthralgia, abdominal pain,anorexia,wt loss, altered
sensorium
Typical pneumonia: a/c onset,high grade fever, chills,cough with sputum expectoration,CBC
shows leucocytosis,CXR: consolidation.
Atypical pneumonia:sub a/c onset,low grade fever,cough with minimal sputum,marked
systemic features, (headache, sweating, myalgia)CBC: may not have leucocytosis,
CXR:patchy infiltrates.
Physical examination
Febrile, ill looking, tachypnea, tactile/vocal fremitus-a)increased(consolidation)
b)decreased(pleural effusion) c)dull on percussion(consolidation/pleural effusion),
crepitations, bronchial breathing, pleural rub.
Legionella- relative bradycardia, diarrhoea, hyponatremia, sputum gram stain will show
plenty of neutrophils with no bacteria.
Inv: CXR, CBC, ABG,pulse oximetry, LFT , U & E, blood culture, CRP, procalcitonin
Hospitalised pt’s should have regular monitoring of pulse, RR,BP, O2 saturation. Assess
severity using CURB-65(≥2 admit; ≥3may require icu care)
Sputum AFB & gram stain, sputum culture. If atypical organism is suspected: urine
legionella antigen. Respiratory secretions may be sent for enzyme immunoassay,
immunofluorescence, PCR,

Rx
In pt’s with mild community acquired pneumonia, amoxicillin may be used.
Out Pt- macrolides(Azithromycin 500 mg PO od single dose followed by 250mg PO
daily x 4 more days) or doxycycline(100 mg PO x 5 days),
In pt’s with exposure to antibiotics within the last 90 days or those with cardiopulmonary
comorbidities, use a respiratory FQ monotherapy(eg. Levo) or β-lactam(like amox high
dose 1g tds or amoxyclav or cefpodoxime or cefuroxime) + a macrolide/doxy x 5 days.
CURB 65 0 point- treat as outpatient:Azithromycin 500 mg OD or clarithromycin 500 mg
BD or Doxy 100 mg BD
Score 1- Azithromycin 500 mg OD + ceftriaxone 2 gm OD
Score 2- Azithromycin 500 mg OD + ceftriaxone 2gm iv OD
IP, non ICU pt’s, choose one option from below:-
 β-lactam im /iv(ceftriaxone/cefotaxim) + macrolide iv/oral(Azithromycin)
 β-lactam im /iv + doxycycline iv/oral
 FQ(antipneumococcal) iv/im(levoflox)
 If the pt is younger than 65 yrs with no risk factors for drug-resistant organisms,
administer macrolide iv/oral
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For ICU pt’s, choose one from below:-
 β-lactam iv + macrolide iv
 β-lactam iv + FQ(antipneumococcal) iv
 If the pt has a documented β-lactam allergy, administer iv FQ(antipneumococcal) +
aztreonam iv
For pt’s with increased risk of infection with Pseudomonas, choose one from below:-
 Antipseudomonal β-lactam iv (piptaz,cefepime,meropenem,imipenem)+
antipseudomonal FQ(ciprofloxacin,levofloxacin)
 Antipseudomonal β-lactam iv + aminoglycoside iv + macrolide iv//
FQ(antipneumococcal)// if the pt has β-lactam allergy, give aztreonam iv +
aminoglycoside iv + FQ(antipneumococcal) iv
For CA MRSA
Iv vancomycin/linezolid + beta lactam +fq/azithromycin
For anaerobes clindamycin is added.
 4th hourly temp chart, PR/RR/BP monitoring. SpO2 monitoring for severe cases.
 Supportive: rest, adequate hydration, symptomatic treatment for fever,bodyache,
pleuritic chest pain,O2 inhalation,Nebulisation with salbutamol for 20 min Q6H,inj
deriphylline Q8H, syp Ambroxol 2tsp tds, chest physiotherapy, rpt x-ray on day 7.
Atypical pneumonia: azithromycin
Aspiration pneumonia: cephalosporin + metronidazole+ respiratory FQ
Hospital acquired(dvps 48 hrs after hospitalization): aminoglycoside iv +
antipseudomonal penicillin iv or 3rd gen cephalosporin.

Viral pneumonia: m/c cause of pneumonia in children; mostly by influenza A,B, RSV
C/f: constitutional symptoms more prominent( viz fever, dyspnea, malaise,
headache,myalgia etc), dry cough (may be a/w mucoid with scanty sputum),failure of
resolution with antibiotic, depressed wbc count, inconsistent cxr findings,
Rx
Antipyretics
Broad spectrum antibiotics to avoid bacterial super infection.
Oxygen if cyanosis or dyspnea +
In severe cases give antiviral agents like Oseltamivir
Note-all pts should be reviewed after 6 weeks. A follow-up xray should be arranged.
For lung abscess : clindamycin is given or pencillin + metronidazole

Severe Acute Respiratory syndrome

It is a fulminant febrile influenza like respiratory illness that progress to pneumonia and
ARDS, caused by SARS- associated corona virus(SARS CoV). SARS should be
considered in clusters of cases of undiagnosed febrile illness, particularly in the setting
of travel to mainland china, Hong Kong, Taiwan within 10 days of symptom onset.
Inv- acute or convalescent SARS-CoV antibodies or RT-PCR.
Rx
Primarily supportive.

Pleural Effusion
Etiology- transudative- CHF, IVC obstruction, myxedema, cirrhosis, nephrotic syndrome,
PEM
Exudative- infection(para-pneumonic,TB),malignancy, a/c pancreatitis,PTE, esophageal
rupture, hypersensitivity reaction (to drugs like nitrofurantoin,amiodarone, parasite), post
CABG, meigs syndrome, auto immune causes(RA, SLE etc)
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Inv- CXR, pleural fluid analysis
Rx - treat the cause
Indication for chest tube in parapneumonic effusion- empyema, impending empyema
(pH<7.2, sugar<60, bacteria in fluid as evidenced by + gram stain/culture)

Bronchiectasis
Etiology- post infection- TB, pneumonia, HIV, measles, bronchiolitis. Congenital- cystic
fibrosis, others-bronchial obstruction(tumour,FB),ABPA, RA,ulcerative colitis, idiopathic
C/f- persistent cough, copious purulent sputum, intermittent hemoptysis, coarse
inspiratory creps, clubbing, wheeze
Inv-cxr, sputum c & s, HRCT chest, spirometry, brochoscopy, CF sweat test.
Rx
1. Mucolytics like mucinac or mucomix
2. Antibiotics according to bacterial sensitivity x 10-14 days
3. Bronchodilators like asthalin
4. Corticisteroids for ABPA

Obstructive sleep apnoea(OSA)

C/f- nocturnal s/s-snoring, apneas, gasping & choking sensations that arouse the pt
from sleep, nocturia, insomnia
Day time s/s-morning headache, sore throat, excessive day time sleepiness, day time
fatigue,cognitive defects, sexual dysfunction, GERD, hypertension
Risk factors- obesity, male, hypothyroidism, smoking,
Inv-polysomnography(EEG,EMG,EOG,ECG, O2 saturation,ventilation, breathing pattern)
Rx
1.Avoid supine position,smoking, alcohol, BZD,
2.Nasal CPAP

Hyperventilation
Aetiology: stress or anxiety, stroke, head injury, DKA, metabolic acidosis, bleeding,
infection, heart/lung disease, drugs, pregnancy,severe pain
C/f- fatigue, chest pain, dizziness, headache, palpitations, sweating, tetany,
paraesthesia, loss of consciousness, alkalosis
Typical h/o stress f/b symptoms; pt frequently sighs during interview
Rx
1. Breath into a paper/plastic bag- pt is told to breath in and out of a bag, so that
they rebreathe the expired air and thus increase the levels of arterial CO2. This
quickly reverts the symptoms.
2. O2 inhalation
3. Propped up position
4. Diazepam if necessary

Nocturnal leg cramps

Etiology: peripheral artery disease, spinal stenosis, drugs( like statins, diuretics, BP drugs),
DM, dehydration, diarrhoea,fatigue, OA, pregnancy, hyper/hypothyroidism,CKD, cirrhosis,
electrolyte abnormalities, B complex deficiency, dialysis, idiopathic etc
Rx
1.Analgesics
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2.Vit B12(Cap Meganeuron OD Plus 0-0-1)/T Shelcal OD/ C evion 400 mg OD,
3.T gabapentin(Gabantin) 300 mg od.
4.Plenty of oral fluids, stretching leg muscles before going to sleep, massage etc

Feeling tired or fatigue/weakness

Aetiology:physiological, psychogenic, organic
Organic conditions include anemia, infection/fever, dehydration,electrolyte disturbance
like hyponatremia, hypokalemia;DM,occult malignancy, hypoglycemia, depression,
hypothyroidism,hyperthyroidism, C/c fatigue syndrome(CFS), c/c renal/liver disease,
CCF, MI, AS,MR,myocarditis, P HTN, COPD, drugs, hypotension, IE, IMN, CVA, TB,
HIV,hepatitis, MG etc
Inv- CBC, RFT,LFT,S electrolytes, RBS,ecg, TFT
Rx
1. IV fluids after checking BP , GRBS
2.C Becadexamin 1 bd(multivitamin) or T neurobion forte or fe/folic acid;Physician
consultation
3.Inj Renerve Plus or neurobion 1 amp in 100 ml NS over 30 min.

Shivering
Aetiology:hypothermia, post operative
1.Cover with blankets.Drink warm non-alcoholic beverages to prevent dehydration.
2. Inj Dexona /efcorlin 1 amp iv st, & or Inj Avil for shivering;
3.Inj Tramadol 1 amp IM(for post-operative shivering)
Note: Antihistamines have prophylactic value in blood/saline infusion induced rigor.

Rheumatoid arthritis
C/c inflammatory d/s characterised by recurrent inflammation of connective tissue
primarily of joints and related structures.
C/f: pain, early morning stiffness(>60 min), joint swelling, tenderness, polymyositis,
anorexia, wt loss,malaise,LN enlargement, rheumatoid nodules( commonly over
olecranon), peripheral neuropathy, pericarditis, pleural effusion, generalized
osteoporosis of vertebra.
Suspect the diagnosis if there is symmetric arthritis in 3 or more joints (especially
involving small joints, hands>foot) with classical distal interphalangeal joint sparing.
Inv:BRE(Hb↓,WBC↑)ESR,CRP,RF, anti-CCP antibody, x-ray, ultrasound,MRI
1.General measures:Education,avoid cold and damp climate, Exercise, Diet(lipid
lowering diet, fibre rich), Physiotherapy.
2.NSAIDs e.g Indomethacin 25/50 mg 1-1-1, Lornoxicam 4-8mg 1-0-1, Etoricoxib 90-
120 mg OD or Naproxen 250/500 mg BD etc
3.DMARDs: for mild RA- T HCQ (hydroxychloroquine) 200-400 mg OD/BD after meals
( s/e retinal toxicity) or T sulphasalazine(TN-saaz) 500 mg OD increased to BD/TID. For
moderate to severe - methotrexate (TN-folitrax) 7.5-10 mg once a week increased to
20-25 mg a week.
If methotrexate is given, also prescribe, T folvite 5 mg(folic acid) twice weekly
4.T Wysolone 5 -20 mg(low dose in early stages for disease modifying effects & high
dose for severe disease)
5.T shelcal 500 mg OD
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6.Calcitriol sachet 60,000 IU once/week.
Note:before commencing DMARD therapy, check CBC, LFT,RFT, CXR, visual acuity(if
HCQ is given).
Note- the classic presentation of a triad of fever, joint pain, and raash in a woman of
childbearing age should prompt investigation into the diagnosis of SLE.

Myocarditis
C/f- usually presents with symptoms of heart failure. Others include chest pain(in
concurrent pericarditis), fever, chills, sweats,sob. In viral myocarditis, patients may
present with a history of recent (within 1-2 wk) flulike syndrome of fevers, arthralgias,
and malaise or pharyngitis, tonsillitis, or upper respiratory tract infection.Palpitation,
syncope, tachycardia, arrhythmia, edema
Inv
Complete blood count (CBC) - Leukocytosis (may demonstrate eosinophilia)
Esr,crp, Rheumatologic screening - To rule out systemic inflammatory diseases
Elevated cardiac enzymes - Creatine kinase or cardiac troponins
Serum viral antibody titers like HIV, HBsAg, anti HCV, - For viral myocarditis
Echo-to exclude other causes of heart failure (eg, amyloidosis or valvular or congenital
causes) and to evaluate the degree of cardiac dysfunction (usually diffuse hypokinesis
and diastolic dysfunction)
Ecg- often nonspecific (eg, sinus tachycardia, nonspecific ST- or T-wave changes).
Occasionally, heart block (atrioventricular block or intraventricular conduction delay),
ventricular arrhythmia, or injury patterns, with ST- or T-wave changes mimicking
myocardial ischemia or pericarditis (pseudoinfarction pattern).
Rx
Detection of dysrhythmia with cardiac monitoring, the administration of supplemental
oxygen, and the management of fluid status as in management of CHF.
It includes supportive therapy for symptoms of acute heart failure with use of diuretics,
nitroglycerin/nitroprusside, and ACE inhibitors. Inotropic drugs (eg, dobutamine) may be
necessary for severe decompensation, although they are highly arrhythmogenic. Long-
term treatment follows the same medical regimen, including ACE inhibitors, beta
blockers, and aldosterone receptor antagonists.
Withdrawal of the offending agent is called for, if applicable (eg, cardiotoxic drugs,
alcohol). Treat underlying infectious or systemic inflammatory etiology. Nonsteroidal
anti-inflammatory agents should be avoided in the acute phase, as their use may
impede myocardial healing and actually exacerbate the inflammatory process and
increase the risk of mortality.
Patients who present with Mobitz II or complete heart block require temporary
pacemaker.

Infective endocarditis
C/f- fever&chills (m/c symptoms),heart failure symptoms,heart murmurs, anorexia,
weight loss, malaise, headache, myalgias, night sweats, shortness of breath, cough, or
joint pains, back pain, Splenomegaly,Stiff neck,Delirium,Paralysis, hemiparesis,
aphasia,Conjunctival hemorrhage, Pallor, Gallops, Rales, Cardiac
arrhythmia,Pericardial rub,Pleural friction rub, Petechiae, Subungual (splinter)
hemorrhages,Osler nodes,Janeway lesions,Roth spots. FND due to embolic stroke can
also occur.
Complications- heart failure, embolic events, acute renal failure, uncontrolled infection
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Inv- BRE,URE, Blood C & S(either two samples taken 12 hr apart or 4 samples, each
taken 20 minutes apart with 1st and last samples taken minimum 1 hr apart and from
different sites), esr, crp, echo. Diagnosed using Dukes criteria
Rx
General measures include treatment of heart failure, oxygen supplementation etc.
HACEK- Ceftriaxone 2 g iv q12H or ciprofloxacin 500 mg BD x 4-6 weeks
Enterococci- ampicillin(4-6 weeks)/vancomycin + gentamycin(4-6 weeks)
Staphylococci/MRSA- vancomycin 30 mg/kg/24 hr in 2 doses iv x 4-6 weeks. Linezolid
can also be used.
Streptococci- ceftriaxone 1 g iv BD + gentamycin 3mg/kg/24 hr divided into 3,iv or im,x
2-4 weeks.
Resisitant streptococci- vancomycin 30 mg/kg/24 hr in 2 doses iv x 4 weeks.
Culture negative native valve endocarditis(NVE) & prosthetic valve endocarditis(PVE) is
usually treated with vancomycin and gentamycin
PVE caused by MRSA should be treated with vancomycin at 30 mg/kg (not to exceed 2
g/d unless serum levels are monitored) for 6 weeks or longer combined with rifampin
300 mg orally q8H and gentamicin.
Infective Endocarditis Prophylaxis
Px is recommended for following conditions: prosthetic valves, previous endocarditis,
CHD(unrepaired CCHD, 6 months following complete repair, incompletely repaired with
residual defects adjacent to prosthetic material),cardiac transplant recipients with
valvular heart disease.
Px is given only for : Dental or upper respiratory tract procedures or procedures on
infected skin, skin structures , musculoskeletal tissue->
 Standard prophylaxis: Amoxycillin 2g PO 1 hour before the procedure.
 Unable to take PO : Ampicillin 2g IM or IV or cephazolin/ ceftriaxone 1g IM or IV
within 30 min before procedure.
 If allergic to Penicillin: Clindamycin 600mg PO or cephalexin 2g PO or
azithromycin/clarithromycin 500 mg PO 1 hour before the procedure.
 Penicillin allergic & unable to take PO: Clindamycin 600 mg IV, or
cephazolin / ceftriaxone 1 g IV within 30 min before procedure.

Erectile dysfunction
Etiology- vascular(atherosclerosis, pvd, MI, HTN, injury from radiation therapy),
systemic disease(DM, RF, DLP, HTN, scleroderma, liver cirrhosis), neurological(cva,
MS, GBS), endocrine(hypo/hyper thyroidism, hypogonadism), psychiatric(depression,
performance anxiety, PTSD),nutritional(malnutrition, Zn deficiency), drugs( some anti
hypertensives , cholesterol lowering drugs, anti depressants etc), surgical procedures
(e.g TURP), local conditions(e.g peyronie disease)
Ix-S testosterone(free & total, morning level 8am), S prolactin and LH,TSH, PSA, URE,
HbA1c, lipid profile, USG
Rx
Advise to increase physical activity, reduce weight, stop smoking
T penegra 50mg or 100 mg (sildenafil citrate) or tadact 10 mg(tadalafil). taken 30
minutes to 4 hours before sexual activity.
Urology,Psychiatry consultation

Premature ejaculation
Rx
1. Desensitizing agents lignocaine cutaneous spray
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2.T Dapoxetine 30 mg (Brand name: Duralast/Dapox)( for men aged 18-64 yrs)
One tablet to be taken 1 to 3 hrs before sexual activity. The tablet should be swallowed
whole with a full glass of water. Make sure to drink plenty of fluids while taking this
medicine to prevent side effects such as dizziness and fainting.
It is not suitable for everyone and should not be used in:
 adolescents under the age of 18;
 people who are allergic to dapoxetine or any other ingredient in this product;
 people with significant heart problems, such as heart failure and cardiac arrhythmias;
 people with a history of fainting;
 people with a history of severe depression or mania.
Note: If a/w Erectile dysfunction, Give T Powerforce(sildenafil 50mg + dapoxetine 30) or
T Duraplus (tadalafil 10mg + dapoxetine 30). In pts with concomitant PE and ED, the
ED should be treated first.

Tetanus
Diagnosis is clinical : Trismus or lock jaw(1st sign) f/b neck or back stiffness,
descending paralysis,Tonic spasms, Opisthotonus, DTR increased, h/o injury
Rx
1.Keep in a quiet, dark room , with minimal handling
2.O2 inhalation and respiratory support sos
3.Inj Telglob 5000 IU im.(Each vial contains 250 IU. So 20 vials are required.
Sites->Deltoid, Anterolateral aspect of thigh. Give as multiple doses as early as possible)
4. Inj Diazepam 0.2 mg/kg Q4H or more frequently
5. Muscle relaxants
6. IVF->DNS or NS; Ryle’s tube feeding, care of bladder
7. Immunization after recovery
8. Tracheostomy and mechanical ventilation sos.

TB Prophylaxis
Px
In <6 years->T INH 10mg/kg OD X 6months.
In adults, there is no proven benefit for prophylaxis.

Post- exposure Prophylaxis in HIV

PEP in HIV must be started ideally within 2 hours(but certainly within 72 hrs) after a
recent possible exposure to HIV.
Do baseline BRE, URE, LFT, RFT, HIV,HBsAg, anti HCV, ELISA. Repeat HIV test after
3 months.
Rx
1.T Tenofovir(TDF) 300 mg+ lamivudine(3TC) 300 mg FDC OD X 4 weeks
2.T Lopinavir 200 mg + ritonavir 50 mg(LPV/r) FDC 2 Tab BD x 4 weeks
If Lopinavir not available or intolerant start on alternate regime:
T Tenofovir 300 mg + Lamivudine 300 mg +Efavirenz(EFV) 600 mg OD x 4 weeks.
Latest WHO regime: Tenofovir 300 mg + Lamivudine 300 mg + Dolutegravir(DTG) 50
mg OD x 4 weeks.
3.T Domstal 10mg 1 sos
4.Repeat investigations at 4 weeks, 3 months, 6 months
Exposures that may warrant occupational PEP include: parenteral or mucous
membrane exposures(splashes to eye, nose, or oral cavity). body fluids that may pose a
 101
risk of HIV infection: blood, blood stained saliva, breast milk, genital secretions, CSF,
amniotic, rectal, peritoneal, synovial, pericardial or pleural fluids.
Exposure to body fluids that do not pose a significant risk includes tears, non blood-
stained saliva, urine, sweat.

Post-exposure Prophylaxis in Hepatitis B

Rx
1.Hepatitis B immunoglobulin is to be given as early as possible(within 24 hours).
Dose-> 0.06ml/kg
2.Active immunization with Inj Engerix B or Inj Shanvac B 1ml (for ≥ 20 yrs) & 0.5
ml(for ≤19 yrs) IM X 3 doses (0, 1month,6 month) then check titre. For persons on
hemodialysis or immunocompromised persons 2 ml IM 0,1,2,6 months.
Refer pg no 168 for needle stick injuries.

ART
First line regimen- Tenofovir 300 mg + lamivudine 150 mg +Efavirenz 600 mg/
nevirapine200 mg
If Hb> 9 g/dl- Zidovudine +Lamivudine+Efavirenz/ nevirapine
CD4 monitoring- if pt is on ART or If previous CD4>500 & not on ART- rpt CD4 every 6
months.
CD4 between 350-500 & not on ART- rpt every 3 months

Steroid tapering
 If steroids are tapered too quickly, withdrawal symptoms can occur, such as joint
pain, fatigue, dizziness, muscle pain, vomiting, shortness of breath, fainting,
headaches, low blood sugar, fever, nausea etc
 One view is that tapering is not necessary in short term therapy (14 days or less)
 Gradual withdrawal of systemic corticosteroids is advisable in patients who have
received more than 2 weeks treatment or have history of adrenal suppression or
have had repeated courses of steroids or received doses at night or have received
Prednisolone >40mg daily or equivalent (e.g. dexamethasone 6mg) for any length of
time

Prednisolone tapering
A decrease in dose is usually made every 2-3 days
Reduce dose by 2.5- to 5.0-mg decrements every 3–7 days until physiologic dose (5 to
7.5 mg of prednisolone per day) is reached.
For eg 5mg 1-1-1 x 5 days f/b 5 mg 1-1-0 x 5 days f/b 5mg 1-0-0 x 5 days.
Other recommendations state that decrements usually should not exceed 2.5 mg every
1–2 weeks

Dexamethasone tapering
In patients who have received less than 14 days of dexamethasone therapy, treatment
may be abruptly discontinued without adverse events, because the HPA axis is not
suppressed. Dexamethasone tapering schedules are often prescribed for short-term
therapy, and usually consists of a reduction in dose of 2-4 mg every 1-3 days, by either
reducing the dose and/or the interval.
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Drugs predisposing to renal dysfunction

NSAIDs, ACE inhibitors,Lithium, radiographic contrast media, Aminoglycosides,PPI ,

penicillins,chemotherapy.
Drugs avoided in renal failure- Metformin,glimepride,aminoglycoside, tetracyclin,
sulfonamides, quinolones, NSAIDS, ACEi, ARB, digoxin, LMWH, gabapentin ,
pregabalin,levitiracetam, antacids, acyclovir, gadolinium contrast etc

Albumin/creatinine ratio(mg/g)
Normal- <30, microalbuminuria- 30-300, proteinuria- >300
Microalbuminura- consider- early diabetes, essential HTN, early stages of
glomerulonephritis (esp with RBC, RBC casts)
Dipstick proteinuria
Microalbuminuria -/trace/1+
Proteinuria trace-3+

Urinary casts
RBC cast(or Hb cast, dysmorphic RBC)- GN
Isomorphic or eumorphic RBC- non glomerular hematuria like hypercalciuria, renal
stone
WBC cast- pyelonephritis, interstitial nephritis
Granular cast- ATN, pyelonephritis, c/c lead poisoning
Hyaline cast-physiological, concentrate urine, dehydration(fever, exercise),
Waxy cast- DM, malignant HTN,
Broad cast- CKD
Epithelial cast- heavy metal poisoning, amyloidosis, eclampsia, ethylene glycol
intoxication.
Fatty cast- heavy proteinuria
 103
Vitamin D deficiency
Causes- inadequate exposure to sunlight, malabsorption syndrome, nephritic syndroe,
c/c granulomatous disorders(TB, sarcoidosis etc), primary hyperparathyroidism,
drugs(anticonvulsants, HIV medicines) etc
The ideal dose of vit D is determined by testing 25(OH)D level and increasing the vit D
dose, if the level is not within normal limits.
Rx
If 25(OH)D is less than 10 ng/ml (25 nmol/L), normal treatment includes 60,000 IU of
vit D3 orally once per week for 6-8 weeks (T N- D3 Must 60K,Uprise D3 60K, Gen D3
60K), and 800-1000(or more) IU of vit D3 daily thereafter(TN-.Uprise D3 1K)
If 25(OH)D is between 10-20 ng/ml (25-50 nmol/L)- 800-1000(or more) IU of vit D3 daily
orally usually for 3 months. Some pts may require higher doses .Once normal limit is
achieved, continue therapy with 800 IU of vit D per day.
If 25(OH) is 20-30 ng/ml (50-75 nmol/L)- 600-800 IU of vit D3 daily orally
In infants and children, if 25(OH)D is less than 20 ng/ml (50 nmol/L)- 1000-5000 IU of vit
D2 orally per day(depending on the age of the children) for 2 to 3 months.
In people who have disease that prevent normal vit D absorption, the recommended
dose of vit D will be determined on an individula basis. If vit D level is normla(>3o ng/ml
or ≥ 75 nmol/L) 800 IU of vit D per day.
Obese children and adults on anticonvulsants, glucocrticoids, antifungals such as
ketoconazole, HAART, should be given at least 2 to 3 times more vit D for their age
group to satisfy their requirement.
Calcitriol supplementation is required in CKD and hypoparathyroidism.
Vit D toxicity
S/s of acute intoxication are due to hypercalcemia and include- confusion, anorexia,
vomiting, muscle weakness,wt loss, polyuria, polydypsia,arrhythmias
Ix-hypercalcemia, elevated 25- levels, hypercalciuria, suppressed PTH.
Hypercalcemia Mx is given on pg no 160.
Serum 25(OH)D levels above 125-150 nmol/L (50-60 ng/ml) should be avoided as even
serum levels as low as 75-120 nmol/L or 30-48 ng/l are associated with increased risk
of cancer, CV events and more falls and fractures in elderly.

Vit B12 deficiency

Causes- dietary deficiency(esp in vegans),pernicious anemia, gastrectomy, small bowel
disease, c/c pancreatitis, long term PPI, metformin etc
C/f- fatigue or irritability, anaemia,leucopenia, thrombocytopenia,macrocytosis without
anaemia, hemolytic anaemia, numbness of handness preceding paresthesia in legs,
ataxia, hyperreflexia etc
Deficiency: S vit B12<148 pmol/L, border line deficiency:148-221 pmol/L
Rx
Oral B12- 1000 µg/day (TN Nurokind-500)
For symptomatic anemia, neuropathy, after bariatric surgery give Injectable B12- 1000
µg IM on alternate day for 2 weeks to start with. Later on once in a month or even
alternate month may be adequate.TN- Meganeuron, Nurokind, Renerve, Neurobion RF
forte.Prophylactic B12 may be given after bariatric surgery, in vegetarians, small
intestinal disease e.g crohn’s, TB etc
Nurokind D3 contains B12 1500 mcg, D3 1000 IU, pyridoxine, FA
Administration of FA to a pt with B12 deficiency can potentially mask untreated B12
deficiency, or even worsen the neurological complications. Hence testing for and/ or
treatment of B12 deficiency is required in all pts treated with folic acid.
 104
Oral Medicine

Caries Tooth
Rx
1.Analgesics->Brufen 200/400 mg TDS
2.Antibiotics; Amoxicillin, Metronidazole
Dental consultation

Gum Abscess
Rx:
1.Antibiotics; Amoxicillin, Metronidazole
2.Analgesics ; Vit C
3.Warm saline gargle, Apply Pressure
4.Refer to dentist for I & D

Gingivitis
Rx:
1.Clohex Plus oral rinse(chlorhexidine)
2.Vit C
3.Antibiotics
4.Analgesics

Cheilosis/angular stomatitis
Etiology: Iron/Vit B 12 deficiency, infection
Rx
1. C. Becosules Z/ Berocin CZ [vit B-complex, C & Zinc] 1-0-1x 5dys, then 0-0-1.
Other drugs with Vit B12: Matilda forte, ME-12, trinerve
2. Antibiotics like septran / Erythromycin may be given
3. Inj Trineurosol H/ neurobion forte(Vit B1 100mg,B6 50mg,B12 1000mcg) im od

Halitosis
Aetiology->Gingivitis, poor oral Hygiene,smoking,dry mouth, Caries Tooth , hepatic
failure, uremia,DKA, bronchiectasis, lung abscess, atrophic rhinitis,alcohol, zenkers
diverticulum etc.
Rx:
1.Metrogyl DG gel[chlorhexidine gluconate, metronidazole] or
Hexidine mouth wash or Betadine Mouth Gargle
T Metrogyl may be given for severe cases.
2.Maintain proper oral hygiene
3.Tongue cleaning twice daily
4.Chewing gum help in production of saliva, preventing dry-mouth.
5.Holding 2 curry leaves in the mouth for 5-7 minutes decreases bad breath

Aphthous Ulcers(canker sores)

C/f-painful shallow ulcers involving soft oral mucosal surfaces, often covered with
white/yellow exudates surrounded by erythematous margins.Frequently reccur.
Aetiology-> Vit/Fe/folate Deficiency, Antibiotic Induced,stress,allergies, c/c trauma d/t ill
fitting dentures, immunological abnormalities like celiac disease, genetic predisposition
etc.
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Rx:
1. Vit B 12 +Vit C+ Antioxidants; adequate hydration
2. Dologel for pain or Dologesic gel(has Lignocaine), Dentogel(lignocaine+
choline salicylate), Lexanox QID (Amlexanox,anti-inflammatory) or
3. Chlorhexidine mouth wash/ betadine mouth wash, or
4. Kenacort /oraways/Tess oral paste for LA(triamcinolone) or
5. Antibiotics like tetracyclin 250 mg dissolved in 50 ml of water administered as
a mouth rinse for 3 min(to coat ulcers) & then to be swallowed, Qid or
6. Syp Sucralfate (sparacid)5-10 mL PO swish and spit/swallow Qid.
Biopsy of the ulcer may be needed, if it does n’t heal.
In cases of herpetic gingivostomatitis, ulcers involve hard mucosal surfaces like hard
palate, gingiva and are vesicular: Rx-> given as above + T. Acyclovir 400mg bd x7 days
[Acivir, Zovirax, Herperex]

Oral Candidiasis(Oral Thrush)

Aetiology: stress, drugs, immunocompromise, dry mouth, Cancer, smokers, oral
dentures,etc
Rx
1.Candid mouth paint[clotrimazole]
2.Chlorhexidine oral rinse
3.Vit C
4. in moderate to severe cases give,T fluconazole 100 mg OD for 1-2 weeks.

Dry Mouth(xerostomia)
R/o drugs- antihistamines,atropine group, clonidine,methyl dopa, tricyclic
antidepressants, anti-parkinsonian drugs, bronchodilators, DM with polyuria, ill fitting
dentures, fungal infection of mouth, dehydration, radiotherapy, HIV infection
Rx:
1.Diabetes control, treatment of candidiasis, sugar free chewing gum, adequate
hydration, avoid alcohol containing oral rinses,avoid salty/dry foods/alcohol/caffeine etc
2.E-saliva oral spray 3 to 4 times(Na carboxymethylcellulose,sorbitol, kcl,Nacl,Mgcl2,
CaCl2,K dihydrogen PO4)

Bitter taste in mouth

Rx
1.Stop the drug if any, causing it and use enteric coated tablets
2.Antacids like Digene 2 tsp Q4H
3.Chew cardamom, chocolate etc; plenty of oral fluids.
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Surgery

Burns
Attend only if burns <10-15 %. Refer large Burns to surgery/burns unit.
Do BRE, LFT, RFT.
Burns>10% in children and >15% in adults enough to cause circulatory shock.
Put iv line before edema develops. R/o inhalational injury(burns in closed space, fire work
accidents, high velocity explosion).Rapid primary survey is performed to assess the ABCs.
Any constricting clothing and jewelry should be removed to prevent these items from
exerting a tourniquet like effect after the development of burn edema.Don’t apply ice or ice
cold water to burns
Rx
1.Inj fortwin 1cc IM / IV st or Tramadol (& emeset). For severe burns morphine 5 mg iv
Q8H
2.Clean gently with copius volume of cold(~15oC) water for 10- 20 minutes,(it will
minimize degree of burns, provide analgesia and delay the microvascular damage) and
is effective upto 1 hour after the burn injury ;then clean with betadine
3.Smear antiseptic ointment like soframycin(framycetin) for face, silverex(silver
sulfadiazine) for trunk & limbs; Fusidic acid oint(fucidin-L, fucibact, fusiderm), Betadine
etc.
Second degree wounds are treated with daily dressing changes.
4. Inj TT 0.5 cc IM st if indicated.
5. Inj tetglob 250 IU IM st ATD
6.Oral Antibiotics(iv antibiotics like taxim, metrogyl for severe burns)
7.IV fluids(Ringer Lactate is preferred) using ATLS 2018 Modification of parkland’s
formula (for flame/scalds-2 ml/% burn/ kg body wt/24hrs for adults & 4 ml/kg/% burn for
children. For electrical burns 4 ml/% burn/ kg body wt/24hrs for all age groups) with
half given during first 8 hours & remaining half given during next 16 hours. Target urine
output is adults-0.5 ml/kg/hr, children< 14 yrs-1ml/kg/hr for scalds & flame; 1-1.5
ml/kg/hr - all age groups for electrical burns
Note: colloids are better avoided in first 24 hours of burns
8.Inj Dexona 2cc IV/IM Q12H x 2 days(dexamethasone) or hydrocortisone(efcorlin)
9.Inj Pantop/Rantac to prevent curling’s ulcer.
10.For severe burns requiring admission ,give O2 ,RT,CBD & measure urine output.
Watch for metabolic derangements like hyperglycemia.
Note:Give cold water compress,large blisters may be deroofed with a sterile needle or
aspirated; leave blisters on the palms or soles intact. No need of bandage to head and
neck.Superficial burns without blisters- no need of dressing. Immobilisation is suggested
for upper limb burns.
For chemical and eye burns: irrigate the ocular surface with copious volume of
water/NS. Identify the agent which caused the burns. Remove any particles or crystals
from the surface. Give cyclopegics (Homide eyedrops),Antibiotic + steroid eyedrops(eg
ciplox-D).
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Dangerous signs s/o airway burns(indications to intubate)- burns in a closed room,
head/face/neck burns, carbonaceous deposits in sputum, signs of airway obstruction
like hoarseness of voice, singed/burnt nasal hair.

Testicular/scrotal Pain or Swelling

Aetiology: a/c epididymoorchitis, testicular torsion, inguinal hernia, hydrocele, varicocele,
spermatocele
Inv: USG doppler scrotum
The sudden onset of testicular pain in a young man or child suggests testicular torsion ,
a true urologic emergency. Immediate surgery/urologic consultation is required.
Swelling, retraction, and severe discomfort are important signs of testicular torsion.
Testicular torsion occurs unilaterally & may follow or be precipitated by exercise or may
occur spontaneously. This leads to the abrupt cessation of blood flow & testicular
ischemia & infarction, which is likely to be irreversible after 12 hrs.

A/c Cholecystitis
C/f: upper abdominal pain, nausea, vomiting, fever,jaundice
Inv: FBC, URE,RFT, LFT,USG abdomen, CT abdomen
1.Bed rest,NPO,IV fluids, continous nasogastric aspiration, antiemetics
2.Analgesics
3.Antibiotics such as ceftriaxone/ciplox/ taxim+metrogyl //cefaperazone + sulbactum,
piperacillin+ tazobactum etc.
4.Surgery consultation

Gall stones/cholelithiasis
Pre requisite for medical treatment- cholesterol/radiolucent stones, stones <10 mm
diameter, functioning gall bladder, no a/c symptoms,
Rx
T udiliv 300 mg BD

A/c Appendicitis
C/f: Rt lower quadrant pain, periumbilical pain shifting to right iliac fossa(shifting pain),
nausea, vomiting, anorexia, diarrhoea, constipation, Rebound tenderness, pain on
percussion, rigidity, and guarding,tenderness at McBurney’s point,fever.
Note: rt lower quadrant pain secondary to perforation of peptic ulcer may mimic appendicitis.
Inv: FBC, URE,RFT, LFT,CRP,USG abdomen(for children & pregnant women), CECT
abdomen
Rx
1.Bed rest,NPO
2.IV fluids
3.Nasogastric suction
4.Analgesics,antiemetics
5.Antibiotics if perforated /gangrenous appendicitis or peritonitis, e.g taxim + metrogyl
6.Surgery consultation
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Head injury
 Ask for h/o LOC, vomiting, seizure, bleeding from ear, nose & mouth.
 Assess pupillary reaction. A difference in pupil diameter of >1 mm is abnormal
 Assess level of consciousness using GCS, 1/2 hourly for first 2 hours hourly for next
4 hours, and 2 hourly thereafter. Earliest manifestation of raised ICP following head
injury is altered mental status.
 Examine the scalp for wound, deformity(eg.depressed, tenderness).
 Observe for bleeding or CSF leak from ear or nose. Other evidence of # of base of
skull includes Raccoon eyes, Battle’s sign.
 If BP is low, search for other causes of hypotension like intraabdominal bleeding,
lower cervical spine injury, since hypotension is very unlikely in a pure head injury.
 Ask for lucid interval s/o extradural hemorrhage. SDH common in old age &
alcoholics.
 Suspect associated cervical spine injury in an unconscious head injury pt.So
manipulation of the neck should be minimised & with special care. A Hard or
Philadelphia cervical collar may be applied till a cervical injury is ruled out.
Irrespective of the GCS, a pt is considered to have serious head injury if any of the
following are present: unequal pupils, unequal motor response, an open head injury with
leaking CSF or brain tissue, neurological deterioration, depressed skull fracture.
Any insult to the brain is manifested as signs of raised ICT like bradycardia,
deterioration in the level of consciousness(earliest), hypertension. Cushing’s triad(HTN
with widened pulse pressure, bradycardia, irregular respirations/cheyne-stokes
breathing) signals impending danger of brain herniation and requires reduction of ICP. It
is usually a late sign.In case of tachycardia, look for other injuries like blunt trauma
abdomen, chest injury, # pelvis.
In case of altered level of consciousness r/o other causes like alcoholism, meningitis,
hyper/hypoglycemia, epilepsy, metabolic abnormality, drug intoxication, poisoning etc.
Indications for CT in pts with head injury- GCS 13 at admission or <15 within 2 hrs of
admission, base of skull ＃, seizure, FND, >1 episode of vomiting.
Rx
Immediate care: ABCD is the order of examination & resuscitation.
Suture the scalp wounds at the earliest as it can result in significant blood loss.
1.NPO,Monitor vitals/GCS. If GCS<8 & SpO2 <90%, intubate & ventilate immediately.
2.Anti meningitic regime (if skull # or pneumocephalus etc)
Inj Ceftriaxone 1g iv Q12H x 21 days, Inj Amikacin 500 mg iv Q12H x 21 days
Inj Metrogyl 500 mg iv Q8H x 21 days
3.Inj Mannitol 20% 100 ml iv Q8H (not given in EDH, pneumocephalus)
4.For large head injuries give prophylaxis with Inj Eptoin 100 mg iv Q8H (monitor pulse
while giving eptoin).
5.Inj Thiamine 100 mg iv bd x 5 days
6.Put Ryle’s tube, Catheterize the pt.
7.Start IV fluids if the pt is in shock, but avoid fluid overload.
8.Daily RBS(brain injury aggravated by hyperglycemia), Na+, K+
9.Repeat CT if GCS falls. Never sedate a pt with head injury
Note: Inj Aravon(edaravone) 30 mg(20 ml) iv bd (neurotrophic drug, reduces cerebral
edema & infarction) is also given.
Avoid dextrose containing IV fluids especially 5%D, as it can raise ICT. Mx of raised
ICT- nurse pt in 30 head up position, iv mannitol, adequate ventilation, maintain BPwith
IVF.
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A/c Pancreatitis
Etiology-gall stones,alcohol, trauma, steroids, hyperlipidemia, hypercalcemia,
drugs(thiazides, furosemide, azathioprine), infections(ascaris, cmv, cox-sackie),
autoimmune, ercp, emboli etc
C/f: abdominal pain/tenderness/guarding/distension, pain refractory to usual doses of
analgesics,pain relieved in sitting forward position,nausea, vomiting, retching, hiccups,
diarrhoea,fever, jaundice, hematemesis or melena, dyspnea, tachypnea, diminished
bowel sounds, left side basal lung creps, tachycardia, hypotension, pleural
effusion(L>R), hyperglycaemia, azotemia due to dehydration etc
Inv:FBC, RFT, LFT,S.electrolytes with S.calcium, CRP,BUN,Lipid profile, S.Amylase,
S.lipase(more specific), LDH, USG abdomen, CECT abdomen(optimal time for CECT is >
72 hrs after onset of symptoms)
Rx
1.Bed rest,NPO
2.Aggressive iv fluid therapy, continous nasogastric aspiration, antiemetics
3.Analgesics like tramadol
4.Antibiotics only if associated infection is suspected
5.Inj Ranitidine or Pantoprazole
6.Inj octreotide 100 µg iv or s/c bd/tds x 3 days
Note: also treat metabolic complications like hyperglycemia, hypocalcemia etc
For c/c pancreatitis: T Creon 10,000U 1-1-1 x 2 weeks(lipase, amylase, protease)

A/c intestinal obstruction

Etiology: adhesion, hernia, carcinoma, intussusception, volvulus
C/f: abdominal pain, distension, vomiting, absolute constipation, visible peristalsis
Examine hernial orifice to r/o hernial obstruction/strangulation. Do PR examination to r/o
rectal pathology.
Inv:BRE, URE, LFT, RFT, S.electrolytes, X-Ray Abdomen(distended bowel loops,
multiple air fluid levels in established cases of obstruction), USG abdomen, CECT
Rx
1.Nasogastric aspiration
2.IV fluids & electrolytes correction, blood transfusion if needed.
3.Antibiotics e.g taxim + metrogyl
Refer to surgery for early surgical intervention.

A/c Peritonitis
Etiology: Localized or generalized; localized due to inflammation of underlying viscera.
Generalized due to perforation / hemorrhage.
C/f: guarding, severe tenderness, rigidity, silent abdomen, rebound tenderness
Inv:CBC, URE, RBS, S amylase, S electrolytes, urea, creatinine, plain x-ray abdomen
erect view,USG abdomen, CT scan
Rx
1.NPO, IV fluids
2.Nasogastric aspiration
3.Analgesics & Antibiotics( e.g taxim/ciplox + metrogyl)
4.Emergency surgical intervention.

Liver Abscess
Pyogenic/amoebic
C/f: fever with chills(most common in pyogenic abscess), RUQ pain(m/c symptom in
 110
amoebic abscess), jaundice, cough & dyspnoea(diaphragm involvement), elevated
ALP( most common abnormal LFT), CXR(elevated right hemidiaphragm, right pleural
effusion, atelectasis)
Ix: CBC, LFT,CXR, PT-INR, Blood culture,USG
Rx
For amoebic abscess- T metronidazole 750 mg tds x 10 days
Refer pg no 90

A/c retention of urine

Rx
Initial treatment: to drain the bladder
If the pt is in bed, make him sit up or stand up to pass urine. Warm waterbag to the
lower abdomen or warm sitz bath helps.
Inj Buscopan 1 amp iv st.
If not relieved catheterise with strict aseptic precautions. Use 12 or 14 F foleys for
females and 14 or 16 F for males. Inject 10 ml lignocaine jelly into the urethra and wait
for 2-3 minutes.this will reduce incidence of sphincter spasm during catheterisation. A
single simple catheterisation may be adequate in cases of acute post op retention in
young patients.
If catheterisation couldn’t be done, refer to urology.

BPH(benign prostatic hyperplasia)

C/f- urinary frequency,urgency, nocturia,hematuria, sensation of incomplete emptying
and terminal dribbling, narrow stream of urine.
Ix- DRE,PSA, URE,USG-KUB,
Rx
1. T Urimax 0.4mg(Tamsulosin) HS or Urimax-D(tamsulosin 0.4 mg+ dutasteride 0.5
mg)

Acute bacterial prostatitis

C/f: fever, chills, dysuria
inv: BRE,URE, Urine C & S, S PSA(>4 ng/ml in prostatitis)
Rx
T ciplox 500 mg BD x 2-4 weeks

Renal calculi
Etiology: laxative abuse, drugs(lasix, guaifenesin, etc)
C/f: pain,hematuria, hydronephrosis
Ix:RFT, USG Abdomen,NCCT
Px for Ca stone
1. Ensure daily urine output of atleast 2 litres.
2. Avoid vit C, calcium supplements, Ca containing antacids.
3. Avoid excessive intake of meat, food rich in Ca(milk products, seafood like shellfish),
oxalate(chocolate, cocoa, tea, coffee, tomato, citrus fruits, nuts, spinach etc). But
ensure normal dietary Ca intake because low Ca diets increase oxalate excretion.
4. R/o and treat hyperparathyroidism,
5. Syp Potrate-M( K citrate+ Mg citrate) 30 min after food or Syp citralka 2 tsp tds or
T Ston 1 B6 (K citrate+ Mg citrate+ Vit B6)
6. Initial treatment- Stones <5 mm in lower ureter, 90-95% pass spontaneously.
Increase fluid intake. Stones>5mm/pain not resolving, start T Tamsulosin 0.4 mg HS. It
 111
promotes expulsion & reduce analgesia requirements.Most pass within 48 hrs. If not,
Urology consultation.

Piles
Rx
1. Proctosedyl oint(Butyl amine Benzoate+Framycetin +Hydrocortisone acetate)or
Faktu (policresulen, cinchocaine) or Shield(Hydrocortisone,lidocaine,Zn oxide, allantoin)
or
2. Anovate (beclomethasone +phenylephrine+lidocaine) or Smuth cream (calcium
dobesilate, lignocaine, hydrocortisone, Zn)for LA.
2.Syp Cremaffin 3tsp HS(HS means at bed time from latin word ‘ hora somni’)
3.T Daflon 500mg(diosmin + hesperidin) bd/tds or Venusmin/Venex(Diosmin) 300mg
tds
4.T Caldob(Calcium dobesilate) od/bd
5.Antibiotics if required; NSAID’s for acute attack.
6.Sitz bath for 20 minutes twice daily.
7.Fibre rich diet ;plenty of oral fluids; surgery consultation

Anal fissures
C/f: anal itching or bleeding, rectal pain, small lump or skin tag near the anal fissure
Rx
Diltiazem 2% gel for LA(TN Crema gel, Diltigesic) TDS
Syp cremaffin HS
Sitz bath; fibre rich diet, plenty of water

Perforated peptic ulcer

C/f: general peritonitis, shock
Inv: plain X-ray abdomen- free gas under diaphragm, S. Amylase to r/o pancreatitis
Rx
1.NPO,IV fluids, IV pantop
2.Analgesics & Antibiotics
Refer to surgery for early surgical intervention.

Felon(whitlow or terminal pulp space infection)

C/f:Throbbing pain, red swollen warm tender pulp or finger tip

Rx
1.Warm water or saline soaks
2.I & D if pus +
Procedure:using a midline/midlateral incision that adequately divides the fibrous
septa.Do not divide vertical fascial strands (septa).The incision should not cross the
distal interphalangeal (DIP) joint to prevent formation of a flexion contracture at the DIP
flexion crease. Probing is not carried out proximally to avoid extension of infection into
the flexor tendon sheath.Pack gauze loosely into the wound to prevent skin closure.
Apply a loose dressing, splint the finger, and elevate the hand above the heart.
Update tetanus immunization.
3.C Megapen 1-1-1-1
4.T Lyser-D 1-0-1
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If Rx delayed, complications : skin necrosis, septic arthritis, osteomyelitis, tenosynovitis.
Infectious flexor tenosynovitis & deep space infections require emergency care.Infection
involving little finger should be treated aggressively as the infection can spread to the
palm of hand.

Skin Ulcers
Causes: venous stasis, arterial insufficiency, DM,lymphoedema,vasculitis, malignancy,
infection(TB, syphilis), trauma(pressure),Drugs, pyoderma
Diabetic ulcers most often occur on the pt’s heel or on the plantar surface of the
metatarsal heads. Venous stasis ulcers most often occur on the medial aspect of the
pt’s lower leg or ankle & are associated with c/c edema.Arterial insufficiency ulcers tend
to occur distally on the tips of the toes or at or near the lateral malleolus
Inv : FBC,RBS,LFT, RFT, skin & ulcer biopsy, C & S of discharge, x-ray of the limb/part
to look for periostitis/osteomyelitis or gas in the soft tissues. Chest x-ray , Mantaux test
in suspected case of tuberculous ulcer, FNAC of the limb node, arterial/venous doppler.
Rx
Optimize nutrition, stop smoking, correct anaemia, protein & vitamin deficiency.
Analgesics, give rest to the part.
Clean wounds are treated with minimal debridement,& damp gauze or hydrogel based
dressings.
Ulcer cleaning is done using Normal Saline(better & ideal), or diluted povidone Iodine.
Antiseptic solutions such as hydrogen peroxide, Povidone-iodine etc should not be
routinely used as they are toxic to tissues & impede healing.
Oxum Spray(super-oxidised solution), megaheal ointment can also be used.
Pt’s with suspected infected diabetic foot ulcer should be admitted for impatient wound
care & broad spectrum antibiotic therapy directed at both gram +ve and gram -ve
organisms.
Infected wounds require a thorough exploration with drainage of all abscess cavities &
debridement of infected, necrotic, or divitalized tissues.
Wound cultures should be obtained prior to initiation of antibiotics.
In the acute phase parenteral treatment is indicated. For mild infections limited to soft
tissues, 1 to 2 weeks of therapy is enough; moderate or severe infections require 2 to 4
weeks of antibiotics. For osteomyelitis involving viable bone, 4 to 6 weeks of IV therapy
may be indicated.
Topical antibiotics may be given for infected ulcers.
Antibiotics are not required once healthy granulation tissues are formed. Once
granulates, defect is closed with Secondary suturing, skin graft, flaps.
Pressure ulcers
Prevention
Skin care: skin should be kept well moisturized, but protected from excessive contact
with extraneous fluids. Take care during transfers to avoid friction & shear stress.
Frequent repositioning at a minimum of every 2 hours.Bowel & bladder care.
Appropriate support surfaces: air/ water mattresses.
Need for special support surfaces-pts with severely restricted mobility due to external
traction or cardiorespiratory instability, pts with decreased skin integrity like burns,
pressure sores, chronic corticosteroid use,diabetes mellitus.
Treatment
Debridement, wound cleansing, dressings(e.g.sofra tulle) ensuring wound base remains
moist- change once in 24-48 hours, systemic antibiotic therapy, nutrition(high protein
diet, vitamins especially vit C), bowel and bladder care, regular turning, avoid steroids
 113
and heavy sedation if possible. Wound packing if there is crater formation. Packing
should occlude the ulcer but should be loose to avoid adding to the pressure damage.
Stress ulcer prophylaxis in sick/ICU pts
Give gastroprotective agents like sucralfate/Rantac/Pantop
Note- PPI(pantop) increases gastric pH leading to increased gastric colonization thus
increasing chances of VAP(ventilator associated pneumona).

Venous insufficiency leg ulcer

Irregular ulceration often on medial aspects of lower leg above medial malleolus
Rx
Compression stockings reduce edema. Compression should achieve a pressure of 50
mm Hg below knee and 40 mmHg at the ankle.
Metronidazole gel to reduce bacterial growth and odour
Red dermatitis skin is treated with corticosteroid ointment.
Ulcer covered with an exclusive hydroactive dressing.
T Ciplox 500 mg BD if infected
T Daflon 500mg BD
Zinc supplementation is beneficial

Wound Management
Wound cleansing
Wound should be cleaned by irrigation with isotonic saline(NS). Soaps irritate the
wound but may be useful on the surrounding skin. Both iodine and peroxide irritate the
wound, are unnecessary, and best avoided.
Wound infection- features consists of pain,redness, increased warmth, tenderness,
oedema/boggy swelling, purulent discharge, foul odour.
Rx
It is important to keep wound warm and moist. For local infection, local treatments may
be sufficient viz topical antibiotics (e.g silver sulfadiazine, mupirocin), iodine based
preparations(e.g povidone iodine ointment), silver preparations. Local treatment should
only be used for short term treatment of mild cases. Systemic or spreading signs of
infection(e.g cellulitis) if present may mandate systemic antibiotic therapy. The wound
should be swabbed prior to treatment.
Surgical debridement may be needed in some cases.
Wound dressing
Dressing should be non adherent, sterile, and cover the wound completely. Adherent
dressings delay wound healing. While dressing the wounds an aseptic technique must
be used

Lumps
Examine the lump/swelling as well as the regional lymph nodes. If the lump is a node,
examine its area of drainage. Also examine the circulation & nerve supply distal to any
lump.
Etiology: Lipomas,cysts, Lymph nodes, sebaceous cysts, fibromas, cutaneous
abscesses, rheumatoid nodules,dermoid cysts, ganglia,malignant tumours of
connective tissue, neurofibromas, keloids, granuloma, bursa, warts, papilloma etc
Inv: BRE, Microbiolgcal inv for appropriate suspected infections, for cyst- aspiration
followed by microscopy culture & cytology, FNAC, excision biopsy, USG,doppler,
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CT/MRI. Surgery consultation.
Lumps in the neck
85% of neck swellings are lymph nodes.
If < 3 weeks- self limiting infection may be the most probable cause.
Etiology-dermoid cyst, thyroglossal cyst, thyroid isthmus mass, salivary stone,
sialadenitis,parotid tumour, TB, IMN,cervical ribs, chondroma, lymphoma, goiters, mets,
lipoma
Hodgkins lymphoma p/w intermittent high grade fever, wt loss & night sweats.
Inv-CXR,USG neck,FNAC, Mantaux
Note- don’t biopsy lumps until tumours within head & neck have been excluded. Culture
all biopsied lymph nodes for TB

Chronic Lower limb ischemia

Advice:
1.care of the foot
 Inspect the foot daily for accidental injury
 Ensure cleanliness of foot, socks, foot wear
 Look for any ulceration or inflammation, avoid tight shoes
 Avoid over heating/cooling of foot
 Don’t walk barefooted
2. Stop smoking & start walking
3. Lose weight, if overweight/obese.
4. Look for hyperlipidemia, anemia,DM
5. T Trental 400mg 1-1-1(Pentoxifylline)
6. T Pletoz 50-100mg 1-0-1(Cilastazol) (C/I in CCF)
7. T Nialip 375mg 1-1-1(Nicotinic acid)
Surgery consultation if evidence of advanced ischemia(rest pain, gangrene), presence
of DM, rapid progress of the disease, if leg pain during exertion interferes with patient’s
occupation.The leg pain of peripheral arterial disease must be distinguished from other
causes of leg pain, such as arthritis,muscle pain, radicular pain,spinal cord compression,
thrombophlebitis, anemia & myxedema.

Acute Limb Ischemia

Etiology-embolic(80% cardiac- valve, mural thrombus, 20% non cardiac-thrombosed
aneurysm, ulcerated atherosclerotic plaque), RHD, thrombotic(hypercoagulable states),
vasculitis(e.g buerger’s disease), vasospasm(e.g Raynaud’s disease- usually b/l),
thoracic outlet syndrome,aortic or vascular dissection
C/f-a/c arterial occlusion-Pain, pallor, paresis, pulselessness, parasthesia,
poikilothermia
Ix:CBC,RFT. S electrolytes, B glucose, PT/apTT,CKMB, Colour doppler, Peripheral
angiography, CT/MR angiogram.
Rx
1. T Aspirin st (reduces the chance of suffering a vascular event by 25%).
2. Inj Heparin 5000 U iv st f/b 18 U/kg/hr to reduce the propagation of thrombus and
peri-catheter thrombosis during angiography. Target aPTT of 1.5-2.5 times normal
assuming no contraindications like aortic dissection, compartment syndrome, vascular
trauma.
3. Pain control. Inj Tramadol may be given
4. Positioning extremity in dependent position to have gravity improve limb perfusion
pressure and avoid extremes of temperature to affected extremity.
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Crush synrome
systemic manifestation of muscle necrosis. Commonly caused due to prolonged
external compression of an extremity.
C/f- affected limb is pulseless, red, swollen and blistered. Sensation & muscle power
may be lost. There may be signs of impaired renal function, metabolic acidosis,
hyperkalemia, and hypocalcemia.
Mx
Encourage high urine output, alkalization of the urine with sodium bicarbonate,
hemofiltration, radical excision of the dead muscle, fasciotomy if there is compartment
syndrome.
Rhabdomyolysis
Triad- muscle weakness, myalgia, dark urine

Phimosis
It is a clinical condition in which the foreskin of the penis is unable to be fully retracted
over the glans. Non-retractability can be considered pathological only in adult for males,
since the prepuce may remain non-retractile until late puberty. Significant proportion of
men with non-retractile foreskins have no difficulties & do not seek correction. Phimosis
is usually an incidental finding, when preparation of urinary catheterisation is underway.
Rx
If there is no urgency, phimosis can be managed by conservative therapy- application of
dexamethasone cream locally thrice daily x 1 week, manual dilatation & urology
consultation
If there is urgency, dorsal slit is the procedure of choice.

Paraphimosis
It is an emergency occurring in uncircumcised males, in which the foreskin becomes
trapped behind the corona & forms a tight constricting band of tissue. This can impair
the blood & lymphatic flow to & from the glans & prepuce, resulting in penile ischemia &
vascular engorgement. The glans & prepuce become swollen & edematous. If left
untreated, penile gangrene & auto-amputation may follow.
Rx
Administer penile ring block similar to mid-dorsal digital block. Encircle your gloved
hands around the distal end of the penis & on the prepuce. Apply gentle & persistent
pressure over 5 min to disperse the oedema fluid from the glans & the prepuce. Reduce
the glans back into the preputial fold. Crushed ice wrapped in cloth would be an additive
measure, especially prior to digital pressure. If manual reduction is unsuccessful,an
emergency dorsal slit is required.

Abscesses
Cutaneous abscesses with true fluctuance ( the perception that true pus is contained
within the tissues) are best treated with routine incision and drainage. Local cutaneous
infection without fluctuance will not benefit from I & D.These patients should be
instructed to apply heat to the area 4-6 times per day, receive an appropriate
antistaphylococcal antibiotic such as cloxacillin or cephalexin, and be reevaluated in 24
to 48 hrs; patients should be told that at that time the abscess may be ready for I & D
Note: Refer Deep and large abscesses to a surgeon. Patients who appear systemically
ill with high fever or rigors, those with extensive abscesses, or those with diabetes or
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other immunocompromising conditions should be considered candidates for hospital
admission and surgical consultation.
The method employed is Hilton’s method
Ask the Pt to lie down to avoid shock induced by pain.
The area overlying and surrounding the abscess is prepared with povidone-iodine.
Local anaesthesia is provided depending on the size and depth of the abscess. Large
abscesses are given circumferential field anaesthesia which require 5 to 10 min for the
area to become anaesthetized.

Cellulitis
Non suppurative invasive infection of tissues. Usually follows a beach in skin such as a
fissure, cut, laceration, insect bite or punctue wound. Pts with lymphatic obstruction,
venous insufficiency, pessure ulcers, obesity etc are particularly vulnerable to recurrent
episodes of cellulitis.
c/f-erythema, pain, swelling, warmth, fever, chills, toxicity,regional lymphadenopathy.
Leg is the most common site. Crepitus hemodynamic instability, lymphangitic
spread,circumferential cellulitis, are indications of severe infections requiring more
aggressive management. Signs requiring emergent surgical evaluation- violaceous
bullae, cutaneous hemorrhage, skin sloughing, skin anesthesia, rapid progression, gas
in the tissue.
Ix- CBC, CRP,ESR,KFT, CPK, wound swab,blood cultures in severe infection, xray. R/o
deep infection by imaging studies.
Rx
1. Antibiotics. An initial dose of parenteral antibiotic with a long half life(e.g ceftriaxone)
followed by an oral agent- fro mild cases give amoxiclav, cephalexin. For severe cases
parenteral therapy is required like ceftriaxone. For cases a/w diabetic ulcers give broad
spectrum gram positive, gram negative and anerobic coverage. Clindamycin or
vancomycin for penicillin allergic pts. In hospitalized pts administer agents effective
against MRSA like, vancomycin, linezolid etc.
2. Elevation of limbs,
3. Dressing with glyceryl magnesium sulphate
Note- strong clinical suspicion of necrotizing fascitis should prompt surgical consultation
without delay for imaging.

Hematoma
Ix-Hb, PCV, USG
Rx
Manual compression in case of hematoma over puncture site , limb immobilization,
volume resuscitation.
Small to moderate sized abscesses are adequately anaesthetized simply by directly
instilling the anaesthetic agent along the tract to be incised. Lignocaine is infiltrated
superficially in the overlying skin till blanching is seen. Actual incision should proceed
along normal skin lines to minimize subsequent scar formation.
Always remember to make an adequate incision for complete initial or continued
drainage.The incision should be of adequate length to allow exploration and
subsequent drainage of the abscess over the next several days.Clean well with
betadine.
An incision is made into the skin (on the point of maximum tenderness) & deep facia.
After incision, as much purulent material should be removed as possible by pressing at
the root with cotton or exploration with artery forceps, till frank blood comes. A sinus
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forceps is passed through the opening in the deep fascia towards the site of the
suspected abscess. Once the pus is seen coming out, the blunt sinus forceps is opened
to enlarge the opening, & to break the locules. Once the pus is removed, the bleeding
from the granulation tissue is stopped by a tight pack of roller gauze soaked in betadine
ointment or GM(glycerine Mag Sulfate) or H2O2 to reduce edema at the site. The two
ends of the roller gauze are kept out of the cavity before dressing so that the whole
pack is subsequently taken out & nothing is left inside.The pack is removed after 48 hrs
and repeat packing may be done with the roller gauze soaked in Xylocaine jelly to
minimise pain.No further tight packing is necessary.
Stress the need for 24-48 hr follow-up in patients with significant abscess as pus can
recollect.
Institute antibiotic treatment for 3 to 5 days or recommend hospital admission in
patients with significant cellulitis, systemic evidence of infection, or compromise of the
immune system (including DM)
An appropriate analgesic should be provided to patients for 24 to 36 hrs if needed.
Note: Never incise a cellulitis as there is risk of bactaraemia

Excision of nail
Complete Excision of nail may be required in many conditions like trauma, infection etc
The procedure is quite mutilating and is better if referred to a surgeon.
Anaesthesia of the digit is achieved through digital block with lignocaine. If required
incisions are put, oriented proximally as a continuation of LNF. The nail is grasped &
rotated outwards both from medial and lateral side.

Digital Nerve Block

Digital blocks are extremely useful for anesthetizing the digit, there by facilitating the
repair of lacerations, paronychia drainage, nail removal and so on. Each digit is supplied
by two dorsal and palmar nerve branches. To obtain adequate anesthesia, all 4
branches must be anesthetized with local instillation. Clean the area with Betadine &
drape as for a sterile procedure.A small gauge needle(usually 25G 1 1/2 ) is inserted
dorsally, into the web space or at the mid point of the dorsal aspect of the finger and
should touch the periosteum at the base of the proximal phalanx; after withdrawing the
needle slightly(by 2mm to ensure that the needle is not inside the periosteum), aspirate
to ensure that a vessel is not entered, 1.0 to 1.5 ml of anesthetic agent, usually 1%
lignocaine without epinephrine/adrenaline, is then injected. Without withdrawing the
needle, it may then be redirected toward the plantar corner until it is palpable on the
palmar surface and a similar volume of anesthetic agent injected.
The finger would appear to swell & by gentle massage circumferential spread of the
local anaesthetic can be achieved.This procedure may be
repeated on the opposite side of the digit and will produce total anesthesia within 5-10
minutes. Ideally limit the injection volume to < 5 ml.
For nail removal, wing block may also be given.
Site where lignocaine with adrenaline should not be used
Digits, tip of nose, pinna of ear, shaft of penis
Because it causes local vasoconstriction, if it is used around end arteries, it may cause
gangrene.
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Opthalmology
Whatever be the opthalmic solution, not more than a drop needs to be instilled
into the conjunctival sac at a time because the conjunctival sac holds only 10-15
microliters of fluid at a time & the average volume of one drop is 60 microliter.
Only the frequency of instillation needs to be adjusted depending on the clinical
condition.
If an eye drop & an eye ointment has to be instilled at the same time, instill the
drop first followed by ointment 10-15 minutes later.
Conjunctivitis
C/f: Bacterial:conjunctival congestion with matting of lashes, mucopurulent discharge,
gritty sensation, normal pupil, viral: conjunctival congestion, edema,watery discharge,
gritty sensation; allergic: watery discharge
Rx
1.Moxiflox /Gatilox / Ciplox(not preferred) eye drops 10 Q1H-Q4H as per severity.
2.Frequent Washing. Dark glasses, if photophobia. Never pad & bandage.
3.Tocin(tobramycin) eye oint at night to prevent glueing of the eyelashes in the morning
4.Eye lubricantslike refresh e/d
5.If severe -> Antihistamines, Anagesics, Antibiotics[Oral] e.g Ciplox
Note: no role for prophylactic topical antibiotics in unaffected eye.
Pure viral conjunctivitis may require topical steroids, acyclovir/gancyclovir (Virson 0.15
% )ointment etc.
In children give tobramycin e/d
Eye pain causes: ocular pain- conjunctivitis, corneal abrasions/ulcerations, burns,
blepharitis, chalazion,stye;
orbital pain-glaucoma,iritis,optic neuritis, sinusitis, migraine, trauma
A/c red eye: conjunctivitis, glaucoma, injury, iritis,keratitis, scleritis, blepharitis,SCH etc

Simple Allergic conjunctivitis

Rx
1.Antihistamines, NSAIDs, cold compress.
2.Neolap/Winolap/Optihist pat(olopatadine) e/d 0.1 % or 0.2 % , 1 or 2 dps bid at an
interval of 6-8 hrs.
3.Dexamethasone e/d 0.05% qid.(solodex-J, Low-Dex)
Note: Steroid e/d should be used only in severe & non-responsive cases & for short
duration.

Foreign body eye

Commonly seen on the cornea.
If pt has FB sensation & FB can’t be localised, evert the upper eyelid to r/o UTC(upper
tarsal conjunctival) FB.
Rx
Copius irrigation should be done with 1pint normal saline in case of multiple FB in the
cul de sac.
Removal done under aseptic precautions
Anaesthetize the conjunctival sac with 0.5 % proparacaine(Paracain) (preferred) or 4%
Xylocaine twice at 5 minutes interval.Wait for a minute to numb the cornea.
Eyelids are separated with speculum or using thumb & index finger. Remove the
corneal FB with a 23G/ 25G/26G needle. While removing the FB, the needle should be
held parallel to the corneal surface to prevent accidental penetration. If the FB is
embedded in superficial cornea, gently scrape around it with the needle and remove it.
 119
After removal , instill a drop of homatropine, apply antibiotic eye drops/ointment, pad &
bandage the eye overnight.
Duration of action of paracain is 10-20 minutes

Injury to eyeball
Rx
For mild injuries like corneal abrasions: topical cyclopegics eg. Homatropine e/d bd &
topical steroids qid would suffice.
If IOP is raised, T Acetazolamide 250 mg tds is also given.
The eye is patched to protect the eye from further trauma.
Note: In penetrating injuries, the foreign body should not be removed manually, as it
may cause further injury. A CT scan is performed to rule out intraorbital, intraocular or
intracranial FBs or penetration.Gently pad the eye without instilling any e/d or ointment.
Broad spectrum parenteral antibiotics should be started eg. Ciplox, genta. Once the
extent of the injury is ascertained,wound has to be repaired under LA/GA.
For conjunctival tear: wash the eye with betadine. If the tear is around 2-3 mm, leave it
alone and give antibiotic drops/ointment. If the tear is large, it requires suturing under
LA. Refer to ophthalmologist.

Corneal abrasion
C/f: pain, watering of eyes, photophobia
Rx
1.Wash with NS if FB’s are present
2.Instill Homatropine eye drops( T.N Homide) followed by antibiotic eye ointment
3.Pad & Bandage
4.Advice to instill antibiotic eye drops eg.Moxiflox Q4H at home
5.R/w next day.

Hordeolum Internum, Externum, Chalazion

Disorder of the eyelid. It is an acute focal infection (usually staphylococcal) involving
either the glands of Zeis (external hordeolum, or styes) or, less frequently, the
meibomian glands (internal hordeola).Most hordeola eventually point & drain by
themselves.
Rx
1.Antibiotic eye Oint/drops[moxiflox/tobra] to be applied to affected lid margin
2.P’mol / brufen
3.Hot sponging
4.Oral antibiotics if severe; Amoxyclav/Ciplox
If the stye is pointing at particular eyelash, epilate it.

Photo-ophthalmitis(welders flash)
C/f: corneal epithelial erosion
Rx
Cold compression;Lubricant eye drops;Bandage with antibiotic ointment
R/w in opthal OPD next day.

A/c Dacrocystitis
Rx
1.Broad spectrum antibiotics like ciplox
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2.Analgesics
3.Local hot compress 3-4 times a day; I & D if abscess points

Corneal Ulcer
C/f: redness, pain, watering, photophobia, redness, foreign body sensation etc
R/o DM
Rx
1. Pad & bandage;hot fomentation; dark goggles
2. Moxiflox /Ciplox/ Tobra eye drops; if the corneal ulcer is not responding to above
treatment in two days time or the ulcer is more than one mm size at the time of
presentation fortified antibiotic eye drops(cefazolin & gentamycin) should be given.
Fortified 5% Cefazoline(Reflin) e/d 10 Q1H-Q2H;it is prepared by adding 5-10 cc distilled
water into a vial of injection cefazoline 500 mg to get a strength of 50-100 mg/ml. The
solution should be kept in refrigerator & every 3rd day fresh e/d should be prepared as
cefazoline is not stable in aqueous solution.
Fortified gentamicin (13.6 mg/ml) e/d Q1H-Q2H;prepared by reconstituting
gentamicin (0.3%) e/ d with gentamicin (40 mg/ml) injection. inject 2 mL of gentamycin,
40 mg/mL, directly into a 5-mL bottle of gentamycin 0.3%, ophthalmic solution
3. Vit C; Analgesics & antiinflammatory drugs.
4. 1% atropine or 2 % homatropine e/d tds to relieve ciliary spasm.
Refer to Ophthalmology.
Never prescribe steroid eye drops if corneal ulcer is suspected, as it will lead to
rapid corneal perforation.

Fungal Corneal Ulcer

C/f: pain, watering, photophobia, blurred vision, redness of eye, FB sensation
Rx
1.Natamycin (5%) e/d (Natamet) hourly during day time & Q2H during night or
Ketoconazole eye drops(Phytoral) or Voriconazole e/d x 6-8 weeks
2.Atropine e/d or 2 % homatropine e/d tds to relieve ciliary spasm
3.T.Flucan / Syscan 150mg OD [Fluconazole] x 2-3 weeks
4.Analgesics, Vitamins, hot fomentation, dark goggles(for photophobia) etc.

A/c congestive glaucoma

It is an ophthalmic emergency
C/f: pain in the affected eye, headache, vomiting, congested eye, hazy cornea, tender
stony hard eye on palpation, shallow AC, middilated vertically oval non-reacting pupil.
IOP must be lowered immediately.
Rx
1. IV Mannitol 20% , 200 ml in 20 minutes
2. T Diamox(acetazolamide) 250 mg tds
3. Dexamethasone e/d Q4H to tackle uveitis
4. Timolol e/d 0.5 % bd
Refer to ophthalmology.

Blepharitis
Inflammatory d/s of eyelid usually chronic & involves the part where the eyelashes grow.
Etiology- dandruff, staph
Rx
 121
1.Steroid + antibiotic eye oint application at lid margin
Eg.ciplox+ dexamethasone (ciplox-D),tobramycin+ dexa (tobaren-D) bd x 2 weeks
2. Antibiotic e/d
3.If ulcerative:Oral antibiotics like Doxycycline x 2 weeks.
4.Treat scalp dandruff.

Scleritis
Systemic therapy is always required.
Rx
1. Oral NSAIDs like indomethacin (100 mg od)
2.Steroid + Antibiotics e/d e.g:
Betnesol-N[betamethasone sodium phosphate, neomycin sulphate] e/d or
Toba-DM [dexamethasone, tobramycin] e/d or
Microflox-DX [ciprofloxacin hydrochloride, dexamethasone] e/d

A/c iridocyclitis(anterior uveitis)

C/f: acute red eye, moderate to severe pain, watering, photophobia, defective vision;
circum corneal congestion, small sluggishly acting irregular pupil, ciliary tenderness etc
Rx
1. Atropine e/d tds
2. Prednisolone acetate e/d Q2H-Q4H depending on severity to be tapered over a
period of 4-6 weeks.
Note: never stop topical steroids abruptly as it will precipitate uveitis.
3. Dark goggle

Superficial punctuate Keratitis

Mainly due to viral infections, So give Acyclovir.
C/f: pain, photophobia, lacrimation,
Rx
1.Acivir or Zovirax or Herperex eye drops 1 drop Q4H
2.Topical steroids
3.Tobramycin [eyebrex,toba,tocin] or moxiflox (milflox)e/d to prevent 20 infection.
4.Artificial tears like Refresh eye drops.
 122
Dermatology & Venereology
In dermatology nature of treatment depends on the stage of disease. More acute the
condition, less strong the local applications, e.g. Lotions for a/c conditions, creams for
sub a/c conditions, creams/ointments for c/c conditions.
Areas near the eyes & genitals should be treated with mild strength preparations.
Hydration of the skin before topical application enhances absorption
Calamine Lotion can cause dryness of skin & thereby may lead to itching. So it’s use is
now limited to urticaria.
Associated conditions like DM, HTN, peptic ulcer or pulmonary TB should be excluded
before prescribing certain drugs like corticosteroids.
In contagious skin disease, not only the pt, but all the family members and contacts
should be examined and if found infected, should be treated simultaneously e.g scabies.
Flat nonpapabe circumscribed :Macule <1 cm, patch >1cm; papulosquamous:
papule<0.5 cm, plaque>0.5 cm; vesiculobullous: vesicle≤0.5 cm, bullae>0.5 cm.
Antifungals:
1.Sebifin cream [terbinafine, benzy alcohol]
2.Candid, Surfaz, Canesten, Canazole [Clotrimazole]
3.Candid B, Clocip-B [Clotrimazole + Beclomethasone]
4.Ketovate cream, nizral cream [Ketoconazole]
5.Nizral shampoo, Phytoral shampoo, Dandoff solution[Ketoconazole]
6.Fungitop gel, Candistat Cream [Miconazole]
7.Olamin, Batrafan,onylac[ Cyclopirox olamine]
Antifungals + Antibacterials + Steroid:
1.Clobenate GM cream[clobetasol, gentamicin, miconazole]
2.Clocip NB cream[beclomethasone, clotrimazole, neomycin, chlorocresol]
3.Sigmaderm, candiderma[beclometasone, clotrimazole, gentamycin]
4.Betnovate GM [betamethasone, gentamycin, miconazole]
5. Surfaz-SN(clotrimazole+ betamethasone+neomycin)
6.Totalderm +(oflox, ornidazole, terbinafine, clobetasol)
Steroid + antibacterial/antifungal
1. Dipgenta, Gentopic [ betamethasone, gentamycin]
2. Eumosone G [clobetasone + gentamycin]
3. Tenovate G [clobetasol + gentamycin]
4. Eumosone M [clobetasone + miconazole]
Antibacterials:
1. T-bact/ Bactroban( mupirocin 2%)
2. Futop/fucidin(fusidic acid)
3. Sisomicin cream
4. Neosporin oint

Allergy/pruritus(itch)/urticaria(hives)
Look for offending food or drugs(cutaneous drug eruption),insect bite, parasites, etc.
Conditions associated with generalized pruritus without a rash: obstructive jaundice, Fe
deficiency, lymphoma, carcinoma(especially bronchial) ,CKD,DM,gout, HIV, senile
pruritus, hyper or hypothyroidism.Look for any breathing difficulty like stridor.
Inv: FBC, ESR, urea, electrolytes, TFT,LFT, P Smear. Allergy testing can be
suggested.
Rx
1. Inj avil 1amp IM st (if severe) or Inj Atarax(hydroxyzine) 1 amp IM st
 123
2. Inj Efcorlin/betnesol/Dexona 1 amp iv st
3. T Piriton(CPM) 2/4/8 mg tds/ bd (0.1 mg/kg/dose x 3; 2-6 yr: 1mg Q6H, 6-12 yr:2 mg
Q6H) or
T Cetrizine 10 mg 0-0-1(poor antipruritic action) or T Atarax 10-25 mg 1-1-1 (Syp atarax
5 ,dps 1 2mg/kg/day in 3-4 divid doses) or T Levocet 10mg(0-0-1)(levocetrizine) or T
10/ 6/

Avil 25/50 mg
4.T Rantac 150(1-0-1)[ H2 blockers have adjuvant beneficial action in certain causes of
urticaria,who don’t adequately respond to H1 antagonist alone]
5.T wysolone(prednisolone) 0.5 mg/kg bd/tds x 3 days for severe cases.
T Wysolone(prednisolone) 5/10/20/40 mg bd/tds (Syp omnacortil 5mg/5ml Dps 5mg/1ml
available, 2mg/kg/24 hr div into 2-4 PO, asthma:0.5-2 mg/kg/24 hr); Betnesol 0.5mg/1ml
Dps available
(0.2 mg/kg/24 hr div into 2 to 3 PO), Dexona Dps 0.5mg/1ml (0.2 mg/kg/day).T betnesol
0.5/ 1 mg ; T dexona 0.5/ 2 /4 mg ;T Deflazacort (cortimax)1/6/30 mg, Syp Dezacor
6mg
/5ml available.
6.Calamine Lotion(calamine + Zn oxide)(T N: Calacreme, Calaminol, calamyl); calosoft
(calamine+ aloevera+ liquid paraffin), Calskin (calamine + diphenhydramine + camphor
+ alcohol)
Lactocalamine(Zn oxide, Zn carbonate, light kaolin, glycerin, castor oil,aqua, aloe vera)
Caladryl Lotion(calamine+ Diphenhydramine )
For children
Syp Atarax 10/5 or Dps 6mg/5ml(2mg/kg/day in 3-4 divided doses ) or
Syp Avil(15/5) (0.5 mg/kg/dose x3) or cetrizine or chlorpheniramine maleate(CPM)
For pregnant ladies: chlorpheniramine maleate,cetrizine, diphenhydramine
Note: look for anaphylactic like reactions, if present give Inj Adrenaline.

Insect Bite Reaction

Treatment same as above
Note: for infected insect bite Mupirocin Oint can be given.

Dandruff
Rx
1.Warm oil Massage; after 10 min, apply Nizral 2 % shampoo on to scalp for a period of
ten minutes; then wash away all the oil. Rpt twice or thrice weekly x 2 months
Other options include Danclear shampoo, KTC medicated shampoo,Scalpe/Dandrop
shampoo [Ketoconazole + Zn pyrithione]
2.Ionax-T[Coal tar + Salicylic acid] :relieves itching & flaking in dandruff,
seborrheic dermatitis & psoriasis of the scalp.

Seborrhoeic dermatitis
Rx
1.Nizral shampoo for scalp & body wash twice weekly.
2.Keto-B cream for LA (ketoconazole+ betamethasone) x 5 days
After 5 days Ketoconazole oint 2%(nizral) for LA BD x 2 weeks
3. Systemic antifungals may be needed.
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Acne Vulgaris
Rx
 Wash the face with soap & hot water 2-3 times a day.
 Avoid excessive exposure to sun. High glycemic index food may increase acne.
For mild cases:Persol-AC Gel or Benzac - AC gel 2.5% or 5%, apply; wait for 2 min &
then wash off (benzoyl peroxide)(start as once daily, during day time) (for black heads)
or Retino-A/eudyna cream, to be applied 2-3 times a week HS(for black heads)
For inflammatory & pustular lesion:
 C Doxycycline 100mg 1-0-1 x 10 days or T Azithromycin 500 mg od x 5 days
 Clindac A gel [clindamycin],Clinmiskin cream( Clindamycin, Niacinamide).
Note: Clindamycin usually not given alone;give with benzoyl peroxide or adapelene
 Topical retinoids-Azelaic acid 2% or Adapelene 0.1 % gel(adaferin, deriva)
Deriva-CMS gel(adapelene + clindamycin).
For nodulocystic:T isotretinoin 10 or 20 mg(isotret)(0.5mg/kg/day) at night (teratogenic)
 With all anti-acne creams look for irritation, dryness, redness, itching, burning every
10-15 days.
Note: with oral retinoids therapy, LFT must be monitored.

Alopecia
Aetiology: Poor nutrition,tinea capitis, hyper/hypothyroidism,pregnancy, SLE,Diabetes,
Drugs(eg. Steroids), excessive dandruff, severe illness/stress, chemotherapy
Check for iron deficiency. Do FBC, LFT, RFT,TFT, S.Fe, Ferritin
Rx
1.Multivitamins (with biotin)e.g.T Xtraglo OD x 1 month(biotin,L-methionine, L-cysteine)
or Keraglo-Men or Keraglo eva(gamma lenolenic acid, multivitamin, natural extracts).
2.ProAnagen Shampoo
For Alopecia areata: topical steroids.Diprovate scalp lotion(betamethasone) or Flucort
lotion (fluocinolone). Apply OD
For androgenetic alopecia: Minoxidil topical solution BD. 2% for women, 5 % for men
(T N: hair 4 U, morr, morr-F).

Eczema
The term eczema is almost synonymous with dermatitis. They refer to distinctive
reaction patterns of the skin, which may be due to a variety of a/c or c/c causes. Skin
reaction pattern characterised by erythema, edema, oozing, crusting, vesiculation in
acute stage; papules and scales in sub acute stage; lichenification in c/c stage.The
basic pathological features are Spongiosis(edema of epidermis with the formation of
intraepidermal vesicles) & Acanthosis(thickening of epidermis in the c/c stage)
May be of two types:
1.Dry Eczema:without oozing
2.Wet Eczema:with oozing,it may be infected, in such cases R/o DM.
Several types:Atopic, Seborrhoeic, Irritant, Allergic etc.
Rx
The aim of treatment is to control the inflammatory process & also to control the
infection, if present.
1.Antihistamines( T CPM or T cetrizine )
2.Saline soaks/ wet compresses(soak cotton cloth in salt water,just squeeze it. Fold it
for 3-4 times. Apply it for 2-3 minutes. Repeat it for 30 minutes)
3.Emolients : white soft paraffin for dry, scaling lichenified lesions
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4.Steroids, Topical applications of Betamethasone or Beclomethasone
5.Antibiotics like T Ampiclox( 500 mg qid x 5 days) in case of secondary infection.
6.In cases of fungal infections, as evidenced by severe pruritus, give antifungals.
7.T. Calcium Dobesilate 500 mg BD as adjuvant therapy in pt’s with venous ulcers &
stasis dermatitis; C Nutrolin B.

Contact Dermatitis
Definitive treatment of allergic contact dermatitis is the identification and removal of any
potential causal agents; otherwise, the patient is at increased risk for chronic or
recurrent dermatitis
Rx
1.Wet compresses/ saline soaks
2.Emollients Emoderm/novasoft or calamine may be beneficial in chronic cases.
3.Oral antihistamines like T CPM 4mg 1-0-1
4.Topical corticosteroids like clobetasol are the mainstay of treatment.
Note:When choosing a topical glucocorticosteroid, match the potency to the location of
the dermatitis and the vehicle to the morphology (ointment for dry scaling lesions; lotion
or cream for weeping areas of dermatitis).
5.For severe acute allergic contact dermatitis or widespread and severe chronic
dermatitis, systemic glucocorticosteroids may be required( administered for 2 weeks).

Stasis Dermatitis
Due to venous stasis on the lower portions of legs.
Rx
1.Wet compresses/saline soaks for 5 minutes(10 teaspoon salt in 20 glass of water)
2.Emollients like Emoderm/Novasoft(white soft paraffin, liquid paraffin)
3.T Caldob 500 mg OD (ca2+ Dobesilate)
4.Topical corticosteroids like triamcinolone 0.1 %(T.N: Ledercort oint)
5.Daily use of elastic stockings.Raise leg end of bed at night by 15 cm( 2 brick).

Ringworm infection of skin(Tinea/Dermatophytosis)

Erythematous plaque with peripheral activity. It can be tinea corporis(body), tinea
pedis(feet), tinea cruris(groin) or onychomycosis(nail).
Note: consider a fungal infection in any pt where isolated, itching, dry, and scaling
lesions occur without any apparent reason. Lesions due to fungal infections are often
asymmetrical.
Inv :skin scrapping, nail clipping.
Rx
1.Most of the cases are managed with topical preparations.Topical therapy is indicated
for limited infection of the body, groin, superficial involvement of the beard region, palms,
& soles
Nizral(ketoconazole 2%) or exifine(terbinafine 1%) or fungitop(miconazole 2%) or
candid(clotrimazole 1%) or whitfield ointment(benzoic acid 6%, salicylic acid 3%).
Duration of the therapy is 4 to 6 weeks or 2 weeks more after clearance of lesions.
2.Before starting systemic therapy confirm the diagnosis. T Fluconazole 150 mg once
weekly for 4 weeks. Give 400 mg st for severe disease

Tinea Versicolor(Pityriasis versicolor)

Hypo or hyperpigmented macules predominantly on upper torso due to hypersensitivity
to a common skin commensal, Malassezia furfur.
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Rx
1. Ketoconazole(Nizral) crm/soln/Clotrimazole(Candid)ointment BD for 4 weeks.
Each application is allowed to remain on the skin for at least 10 minutes prior to being
washed off.
In resistant cases, overnight application can be helpful.
Ketoconazole cream/soln/Miconazole/Clotrimazole ointment every night for 2 weeks.
In cases of extensive Tinea versicolor, Ketoconazole solution(Nizral) to be applied 15
min before taking bath, twice weekly. After bath any of the above preparations may be
applied locally.
Another option is preparation containing Selenium sulphide 2.5%(Selsun shampoo) for
5 to 10 minutes application daily for 3-4 weeks. But take care to avoid contact with gold
as it is corrosive.
Topical Terbinafine ,Ciclopirox olamine are also used.
2.Second line-Systemic therapy: T Fluconazole 400 mg st. Rpt after 2 weeks if required.
Note- it may take several months for the skin colour to become normal, even after anti-
fungals removes the fungus.

Scabies
Rx
1.Initially scrub bath is advised to open up the burrows. Pt should have a bath with soap
and hot water with rubbing and scrubbing to open all burrows, and dry the skin before
applying the medicine.
Permethrin 5%(TN Permite) lotion is the DOC.It is applied from the neck down, usually
before bedtime, and left on for about 8 to 14 hours, then washed off in the morning.
One application is normally sufficient for mild infections. For moderate to severe cases,
another dose is typically applied 7 to 14 days later OR
Apply Gamma Benzene Hexachloride(lindane or Scaboma) 1% Lotion for a period of
atleast 10-12 hours and Rpt scrub bath OR
Apply 25 % benzyl benzoate for 3 days over whole body except head.
Another option is T.Ivermectin. If > 50kg give two 6mg tabs at early morning on empty
stomach. If <50 kg give 3mg tabs. Rpt after 2 weeks.
Ivermectin should be avoided in children<15 kg, old age, during pregnancy,lactation.
Crotorax/Eurax(crotamiton) 2-3 times a day , can also be given.
Note:All clothes,towels & bed sheets etc should be washed well(ideally in hot water) &
dried in sun or if possible ironed well.It may be repeated after 1 week.
Ideally, treat all family members at a time, otherwise reinfection will amost always occur.
Apply over entire body, below the neck to toes
2.Antihistamines for pruritus.
3.Scabies may also get infected, so in such cases, give antibiotics eg. Ampiclox.

Pediculosis
C/f: LNE: Sub occipital & post auricular
C/o may be itching & constant ulceration.
Rx
1. Antibiotics like Ampiclox
2. Permethrin 1%(Medicare, Zeromite) lotion
Massage into scalp, Bath after 10 min & then comb. Rpt after 7-10 days to kill nits. Hair
should be dry(oil free). Apply from root to tip of hair
3. T ivermectin 12 mg single dose to be taken on empty stomach(0.2 mg/kg)
4. Anti inflamatory:brufen
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5. Rantac / Omeprazole
6. T.Celin 500mg OD / BD
In case of lice ulcer in Axilla, Permethrin Cream for L/A. Petrolatum ointment, is the
preferred treatment for infestations of the eyelashes and eyebrows.

Chickenpox/varicella
Chickenpox: a febrile illness with acute onset of diffuse maculopapular rash without
other apparent cause.
Infection is by exposure to respiratory droplets, or direct contact with lesions, within a
period lasting from three days prior to the onset of the rash, to four days after the onset
of the rash. Centripetally distributed vesicles. Pre eruptive stage: fever, back pain,
shivering etc
Rx
1.Keep the skin clean by frequent showers. Avoid vigorous rubbing.
2.T Acyclovir 800 mg(Zovirax 200,400,800 mg available) (1-1-1-1-1) x 7 days
3.T CPM; T Rantac
4.Calamine Lotion for LA after bath; or Mupirocin Oint for LA onto the vesicles.
If 20 infection: Amoxiclav / azithromycin
Note: Acyclovir for Paed 20 mg/kg QID or 80 mg/kg/day div into 5 doses,Zovirax(400/5).

Herpes zoster
Rx
1.T Acyclovir 800 1-1-1-1-1 x 7-10 days( efffective only if started within 48 hours)
Other antivirals used are Famciclovir 500 mg tds or Valacyclovir 1gm tds
2.Analgesics like Ibuprofen or P’mol
3.For sever cases: Oral steroids like prednisolone 40-60 mg/day x 1 week tapered
over 1-2 weeks.
4.Calamine for LA;T-bact for LA;Acyclovir cream for LA
5.Oral Antibiotics like Mox, if secondary infection
6.Advise Rest, plenty of oral fluids.
7.For postherpetic neuralgia: T gabapentin 300 mg OD x 3 weeks
Note: advise to drink more water as acyclovir may rarely cause nephrotoxicity

Itching due to prickly heat in summer(miliaria rubra)

Rx
1.Bath 2 times per day, avoid tight/excessive clothing
2.Sprinkle Nycil powder or Candid dusting powder bd
3.T Cetrizine 10mg HS x 5 days
4.T vit C 500 mg BD
5.Emoderm/Calamine lotion/oint.
2nd line: Topical antibiotics if secondary infection;Mild topical steroids

Excessive Sweating/hyperhydrosis
Seen in Hypoglycemia, MI, Defervescence in fevers, Hyperthyroidism, Vasovagal
attacks, Rheumatic fever, gout, nervous excitement,alcohol/drug withdrawal, anxiety etc.
Rx
1.Palmoplantar/ axillary sweating: Aldry lotion for LA HS(aluminium chlorohydrate) or
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2.Losweat powder for LA(miconazole, chlorhexidine )

Hand-Foot-mouth Disease
A/c onset of fever in young children with sores in mouth, tongue and oral cavity.
Papulovesicular rash in palms, soles and diaper area. Confirmation is by throat/faecal
swabs tested for EV 71 or coxsackie A-16 in accredited virology lab.
C/f:fever, feeling tired, generalized discomfort, loss of appetite, and irritability.Skin
lesions/rash followed by vesicular sores with blisters on palms of the hands, soles of the
feet, buttocks, around the nose,mouth and lips.HFMD usually resolves on its own after
7–10 days.
Rx
1.Antihistamines
2.Antipyretics
3.Adequate fluid intake, preferably Cold fluids. Avoid spicy foods.
4.Soothing lotions like calamine lotion for rashes.

Dyschromias in children
Most commonly hypopigmentation of face
Aetiology:Pityriasis alba, tinea versicolor, etc
Rx
1.Deworm
2.Multivitamins,Calcium supplements,Leafy vegetables & milk in diet,
3.Advise to use Dermadew baby soap(glycerin,aloe vera, coconut oil etc) or Dove/Pears
soap for bathing.
4.Moisturizers like elovera/cetaphil lotion for LA to be applied just after bathing.
5.If no improvement, Eumosone cream (clobetasone) for LA x 1 week.
If tinea versicolor, give topical antifungals also.

Diaper dermatitis
Rx
Frequent diaper changes
Skin in diaper area should be kept clean and free from irritation.
In irritant diaper dermattis: use emolients
If candidal superinfection: antifungals like clotrimazole and 1% hydrocortisone
If secodary infection: T bact with 1% hydrocortisone.

Paronychia
Most common hand infection. Another infection is felon(commonly bacterial,viral also)
A/C paronychia is commonly bacterial(Staph).
Rx
If soft tissue swelling is present without fluctuance, the infection may resolve with warm soaks
3-4 times daily.If abscess, do I & D.
Drain the pus by making an incision over the eponychium. If there is a floating nail,
removal of nail is required.
1.C.Ampiclox 1-1-1-1 x 5 days or amoxiclav or cephalexin or doxycycline(100 mg OD).
2.T.Lyser D 1-0-1 X 5 days
3.Fucidin or T-bact oint for LA
C/c paronychia is commonly due to fungal infection
1.T. Flucos 150mg once weekly X 6 months[fluconazole] for c/c paronychia.
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2.Topical antifungals like Daktarin(miconazole) or Onylac nail lacqer(ciclopirox) to be
applied over the affected nails at bed time. Should be applied starting from the skin
adjacent to the nail bed.Use the brush provided to apply into crevasses & ridges.Cut
nails weekly & rub over the nails using accessory provided once every week.

Intertrigo
Inflammation of the body folds. Bacterial/fungal/viral
Commonly Candidial infection, usually involves the lateral two interdigital spaces, inner
thighs,genitalia, under the breasts, underside of the belly, behind the ears. Sometimes
there may be superimposed bacterial infection
Rx
1.T. Flucos 150mg once weekly x 1 month
2.Aciderm G for L/A x 10 days[betamethasone, gentamycin, clotrimazole]
3.C Carofit 1-0-0 x 1 month[vit C, vit E, zinc sulphate, beta carotene, carrot].

Pyodema
(impetigo, folliculitis,furuncle,sycosis barbae, carbuncle,tropical ulcer etc)
Rx
1.Antibiotics:Ampiclox/ciplox/amoxclav/doxycycline/ cephalosporins
2.Analgesics, antihistamines
3.T-bact /Futop/Neosporin Oint for LA bd
4.Saline washing – One tsp salt in 2 glasses of water
5.Good hygiene.
Impetigo:Highly contagious bacterial skin infection,primarily caused by Staphylococcus.

Psoriasis
C/f-Scaly lesions over extensor aspect[mainly], nail pitting,scaly papules & plaques,
arthropathy.
Exacerbation of psoriasis caused by smoking, alcohol, stress, infections(strep sore
throat, HIV etc),drugs like NSAIDs, beta blockers, anti malarials, Li, corticosteroid
withdrawal.
Rx s
1. Dipsalic/betnovate-S/betasalic/Saltopic lotion/ointment [betamethasone, salicylic acid]
or Diprovate MF cream [betamethasone, lactic acid, salicyclic acid, urea, sodium
lactate] bd for L/A .
2. Antihistamines to prevent scratching.
3. T Calcium OD/BD, liquid paraffin for LA;
4. Oral antibiotics like Doxycycline bd for a/c psoriasis
5. Cetrilak mild shampoo for scalp (cetrimide)
Note: Dry scaly conditions like Psoriasis, Atopic dermatitis, Ichthyosis requires
moisturizing cream e.g Elovera cream to be applied after bathing [vit E, aloe vera]
Strecth marks, striae, cracked nipples, dark circles :
1.Alovit-AF cream for L/A. [lactic acid, vitamin E, sunflower oil, aloe]
Antioxidants:
It is a usual practice to give antioxidants- C Evion 400mg /T Carofit / T antoxid OD
x 1month
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Fissuring of soles(athlet’s foot/tenia Pedis)
Rx
Keep the foot dry.Avoid using strong chemical soaps. Foment in hot water for 10 mins,
2 times daily, followed by drying and application of antibiotic & keratolytic ointments.
1.Moisturex cream (urea, lactic acid,propylene glycol, liquid paraffin) for LA Or
Salytar-ws/Salicylix-SF(salicylic acid) to be applied on the hard skin only or vaseline.
2.If secondary infection : Surfaz –SN or Sigmaderm for LA
Note: if inflamed or swollen, give antibiotics, anti inflammatory drugs, steroids

Premature Graying of Hair

Aetiology: vit B12 deficiency, thyroid d/s like thyroditis, FA deficiency, chemotherapy,
using electric dryers/ concentrated hair dyes, alopecia areata etc
Rx
1.T Curlzvit 1-0-0(contains PABA)
2.Altris Gel for LA(Melitane).

Icthyosis
Rx
Avoid using strong soaps/excess sun exposure
After a bath , apply emollients or moisturizers to prevent scaling & dryness.
Moisturex cream for LA
Other topical preparations: Retino-A cream(tretinoin) for LA OD or Daivonex oint for
LA(calcipotriol) or Keralin oint for LA(salicylic acid, benzoic acid,hydrocortisone) or
Copriderm(Betamethasone, urea, lactic acid, propylene glycol, salicylic acid) for LA

Hyper pigmentation of skin

Also blemishes, dry scaly surface, mottling, wrinkles, rough & leathery texture,
sagging of loose skin, melasma(due to pregnancy, OCP use)
Avoid perfumes, hair dyes etc. Treat anemia if present.
Rx
1. Reduce sun exposure;Apply Sun screen agents eg: sper lotion for LA 30 min before
going outside(octinoxate , avobenzone , oxybenzone , zinc oxide).
2. Skinlite cream(Hydroquinone, Tretinoin, Mometasone Furoate) HS
Note: Apply at night only. Should be applied in limited quantity only
Or Retino-A, Eudyna(tretinoin)
Or Brite-Lite cream for LA at night(glycolic acid, kojic dipalmitate)
For lips: also give a moisturizer, emoderm Oint for LA( white soft paraffin);quit smoking.

Keloids & hypertrophic Scars

Rx
Opexa Gel (Dimethicone, ascorbyl tetraisopalmitate) or contractubex gel
(heparin,allantoin) or Retino-A(Tretinoin) LA OD at night.

Warts
Caused by HPV
Rx
1.Salicylix-SF 12% cream(salicylic acid) for LA or
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2.Imiquad/Nilwart cream(imiquimod) for LA on alternate days ; wash after 8 hours.

Molluscum contagiosum
C/f: distinct central umbilication of the dome shaped lesion
Rx
1.Apply KOH over the lesion(5% for children & 10% for adults)
2.Protect surrounding area with plain vaseline

Dry skin/Xeroderma
Etiology:Zn & essential fatty acid deficiency,end-stage renal disease, hypothyroidism,
HIV, malignancies,sjogren’s syndrome, neurologic disorders, drugs, topical preparations
containing alcohol, detergents, harsh bathing soaps, vitamin A/D deficiency, winter etc
Rx
1.Emolients/moisturizers e.g Emoderm/Elovera/Novasoft for LA
2.Adequate hydration.

Corns & callosities

Find prime cause for callosities/corns-improper gait due to back/spine problem, arthritis,
improper footwear etc.
Usually they go by themselves, once the irritating factor is avoided. Use proper fitting
footwear or MCR footwears.
Rx
1. Keratolytic agents like Salicylic acid 40% pads and plaster or solution. Apply & leave
for 4-5 days. Also used- 40% urea cream, and 12% lactic acid cream.
Note:patients with peripheral neuropathies should avoid or use topical salicylic acid with
caution.
TN:- cleanoderm/duofilm(salicylic acid+ lactic acid) lotion/solution daily x 3 weeks
2.Carnation Decorn corn caps(salicylic acid), To be kept in position with the corn for few
days. To be reapplied again till the corn drops out.

Herpes simplex
Rx
1.For initial infection:Acyclovir 5% cream(Zovirax) for LA 3-5 times daily Q4H x 5 days.
2.T Acyclovir 200 mg 1-1-1-1-1 or 400 1-1-1 x 7- 10 days (5-20 mg/kg Q8H)
Dermatology consultation.

Photodermatitis
Rx
1. Avoid Sun exposure
2. Apply sunban lotion 20 minutes before going out.
3. Betamethasone for LA at night for 1-2 weeks.
4. T Cetrizine 10 mg HS

Moniliais/candidiasis (of skin, mucous membrane and nail)

R/o diabetes and HIV infection

Rx
Candid 1% cream/nizral cream bd
If severe, T Nizral 200 mg OD x 10 days or T Fluconazole 150 mg once a week for 3-4
weeks
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Bromhidrosis
Etiology:metabolic cause, infectious, drugs, food(garlic,onion, asafoetida etc)
Bathe twice daily.
Remove hair from under arms and genital regions
Wear clean washed clothes
Use deodorants as required
If too much sweating, use antiperspirants on alternate days.

Phrynoderma
Rx
1.Deworm the pt
2.C Vit A bd
3.B complex
4.Retino-A cream locally

Balanitis(balanoposthitis)
C/f: Pain, discharge, redness
Rx
1.Gentle retraction of the foreskin daily and soak in lukewarm water to clean penis and
foreskin. Avoid soaps when inflammation is present. Use a moisturising cream/ointment
(emollient) to clean, instead of soap.
2. Clotrimazole LA for candidial balanitis.
3.Mild Steroids like Betamethasone 0.05% for inflammation in addition to antibiotic
creams
Note: steroid creams shouldn’t be used alone, as it may worsen the infection
4.Antibiotic ointments like neosporin, if bacterial infection suspected.

Skin peeling
Aetiology -dry climate,hyperhidrosis, ringworm, sunburn, chemicals like
soaps,solvents,detergents, eczema, psoriasis,allergic contact dermatitis,kawasaki
disease, medication side effects, staph infections, SJS, TSS, frequent hand washing
with soap, hand eczema,
Rx
Moisturizers or emolients, for hand eczema topical steroids may be used.
Treat underlying conditions, avoid irritants, use non soap cleanser for hand washing.

STD(Sexually Transmitted Diseases)

In all venereal cases, check for HIV and VDRL. If possible get the partner also checked.
Urethritis in Men/cervicitis or vulvovaginitis in women
C/f- dysuria, genital discharge, anorectal discharge, dyspareunia,urinary frequency,
itching, painful scrotal swelling
Inv-CBC, URE, blood culture, males-urethral discharge gram staining. Females-
endocervical swab culture,
Rx
For chlamydia
1.T Azithromycin, 1gm, single oral dose or
2.T Doxycycline 100 mg bd x 7-14 days or
3.T Levoflox 500 mg Od x 7 days or C oflox 300 mg BD x 7 days
Sexual partner should be treated with the same regime.
For trichomonal vaginitis
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4.T Tinidazole/metronidazole 2g single dose for both husband and wife
For Bacterial vaginalis(gardenella)
5. T secnidazole 2 g single dose.Treat partner only if symptomatic
For candida
6.Locally Candid (clotriamzole) vaginal cream or vaginal tablet
7.Systemic - T Fluconazole 150 mg after food single dose for uncomplicated cases.
For complicated cases- 150 mg q72hr for 3 doses.Treat partner only if symptomatic
For Herpetic
8.T Acyclovir 400 mg tds x 7 days.Treat partner only if symptomatic
For gonococcal urethritis,
Rx -single dose regimen of inj ceftriaxone 250 mg IM. Regimen should include Tab
Azithromycin 1g single dose for chlamydia as upto 30-70% may have coinfection. If
ceftriaxone is unavailable, give a single oral dose of cefixime 400 mg plus azithroycin 1g
single dose.
Treat both partners. Pt should be reviewed in 1week for test of cure.
Note-Husband should use condom irrespective of contraceptive practice, until wife is cured.
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Common Psychiatric Disorders

Note: Ideally Always Refer the pt to a Psychiatrist.

Aggressive Psychiatric Patient

R/o hypogylcemia
Rx
1.Inj Lorazepam 2/4 mg IM st or Inj Serenace(haloperidol)2cc IM st or Inj Calmpose
(diazepam)2cc iv st or Inj Olanzapine 10 mg IM st.
Inj Serenace 5 mg + phenergan 12.5, serenace + lorazepam can be given for severe
cases
2.T Diazepam 5 mg tds or T largactil 25mg tds;Psychiatry consultation
For pregnant ladies: Haloperidol

Bipolar Disorder
Manic episode
Rx
In aggressive pt’s: Inj haloperidol 5mg IM, or Inj Lora 2 mg IM or Inj Olan 10 mg im st.
Rx with antimaniacs +.mood stabilizers. If the pt is on antidepressants, stop
antidepressants.
1.T Valproate 500 1-0-1 [Lithium is the DOC]
2. Consider an antipsychotic if symptoms are severe and behaviour is disturbed.T
Olanzapine 5 mg 0-0-1 or Risperidone 1 or 2 mg 1-0-1 or T Haloperidol 5mg 1-0-1 or T
Quetiapine 100 mg 0-0-1(Antipsychotics)
3. Add short acting BZD like T Lora 1mg 0-0-1
Depression episode
Depression may be a/w many medical illnesses like hypothyroidism,
hyperparathyroidism, addison’s disease

Rx with antidepressants
1.T Escitalopram 5 mg 0-0-1 x 2 weeks; after 2 weeks 10 mg HS x 2 weeks(T.N-Nexito,
stalfopam, szetalo, cilentra, citel, citofast)
2.T Clonazepam 0.5 mg 0-0-1 x 2 weeks; after 2 weeks 0.25 mg HS x 2 weeks(T.N-
clonotril, clonafit, epizam, lonazep,rivotril)
Depression: cardinal symptoms-lethargy,easy fatiguability,energy lack.
R/o hypothyroidism, hyperparathyroidism,hypo pituitarism, adrenal disorders like
cushings or addisons disease.
Identifying depression : specific symptoms, atleast 5 of the following 9, & atleast one out
of the first two symptoms should be present nearly every day for atleast 2 weeks
1. depressed mood or irritable most of the day, nearly every day, as indicated by either
subjective report(e.g., feels sad or empty) or observation made by others(e.g., appears
tearful)
2. Decreased interest or pleasure in most activities, most of each day
3. Significant weight change(5%) or change in appetite
4. Change in sleep; insomnia or hypersomnia, early morning awakening
5. Change in activity: psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Excessive Guilt/worthlessness
8. Diminished concentration
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9. Suicidality

Bipolar in normal mood- give mood stabilizers

Obsessive Compulsive Disorder

Rx
1.T Fluoxetine 20 0-0-1 or sertraline 50 mg 0-0-1 or escitalopram (SSRIs)
2.T Quetiapine 100 mg 0-0-1 or risperidone or olanzapine (for augmenting SSRIs)
3.Antianxiety agents like nitrazepam 10 0-0-1 (for augmentation)

Panic attack
A/c paroxysmal anxiety & Intense fear with s/s related to various systems like sweating,
palpitation, feeling of choking, trembling,sweating, chest discomfort,dizziness, feeling of
impending doom.
Take ECG to r/o angina/MI. Rule out other medical conditions like hyperthyroidism,
pheochromocytoma, epilepsy, asthma, withdrawal s/s,mvp, pulmonary embolus,
amphetamine & anticholinergic drugs.
Rx
For aggressive pt’s ,Inj Lora 2mg IM or slow iv st or Inj Diazepam 10 mg slow iv or IM or
Inj Serenace 5mg IM St.
1.Antidepressants like SSRI eg Escitalopram 5mg 0-0-1 or
2.BZD eg T clonazepam 0.5 mg 1-0-1 x 4 weeks, then tapered off.

Generalized anxiety disorders(GAD)

C/f-Characterized by excessive, uncontrollable and often irrational worry, that is,
apprehensive expectation about events or activities >6 months and 3 or more of the
following s/s-restlessness, being easily fatigued, insomnia, irritability, poor concentration,
muscle tension.
R/o hyperthyroidism
Rx
 Cognitive behavior therapy
 Pharmacotherapy
1.SSRIs: E.g. escitalopram 10 mg 1-0-0 or sertraline 50 mg 1-0-0;
SNRIs:T duloxetine 20 1-0-0 or T desvenlafaxine 50 1-0-0 ;
Tricyclic antidepressants like T amitriptyline 10 1-0-1 x 2 weeks
2.Benzodiazepines. They should n’t be used for long time because they are associated
with the development of tolerance, psychomotor impairment, cognitive and memory
impairments, physical dependence and a withdrawal syndrome
3.T Pregabalin or Gabapentin OD
Note- due to the risk of insomnia, SSRI should be given only in the morning.

Schizophrenia
R/o hypothyroidism(myxedema madness)
Rx
If pt is aggressive: Inj lora 2mg IM or slow iv, or inj haloperidol 5 mg IM + phenergan
25mg IM st or Inj olan 10 mg IM.
1.Antipsychotics E.g: T risperidone 1mg 1-0-1 or T olan 15 mg 0-0-1 or T clozapine 25
0-0-1(for refractory pt’s) or T ziprasidone 20 1-0-1 or T quetiapine 25 1-0-1 or T
aripiprazole 15 1-0-0
2.Depot injections eg fluanxol(flupentixol) given for c/c schizophrenics every 2-4 weeks.
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3.T Parkin 2mg bd(trihexyphenidyl) to prevent dystonic movements/extrapyramidal
symptoms/akathisia associated with antipsychotics; BZD or β-blockers are also used.
Note- SSRI’s are the DOC for most of the neurotic diseases

Post partum blues - onset within 2-3 days of delivery. Last less than 2 weeks.
Associated with low mood,fearfulness. Rx is supportive.
Post partum depression. Lasts more than 2 weeks. Rx CBT, antidepressants SSRI
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Obs & Gyn
UPT should be done in all gynecology cases in reproductive age gp irrespective of h/o
sterilization, contraceptive use or marital status, to r/o pregnancy

Basic gynecological conditions

Menorrhagia (hyper discharge of menses)

In all cases : check Hb, r/o other medical cases like bleeding/coagulation disorders,
TSH imbalance
In emergency, if severe bleeding: Inj Tranexamic acid 1g or 500 mg in 100 ml NS IV
In 20-40 age group, give Tranexa MF(tranexamic acid + mefenamic acid) 1-1-1 x 5 days
If > 40yrs, it is better to refer to gynaecologist, as D&C is a must.
In younger girls always R/O haematological causes.
Rx
1.T Regestrone or T Primolut-N 5mg bd(Non ethisterone acetate) or
T Tranexa-MF(1-1-1)
2.T Sylate 500mg (1-1-1-1) till bleeding stops(Ethamsylate)
3.If mildly anemic(Hb>8) give a) Iron tablets (T autrin, C conviron, C dexorange, C
fesovit spansule, C fefol spansule) 1-2 daily b) T folic acid 5 mg OD c) T Vit B complex
OD d) Reassure the pt
4.Advise to keep a menstrual cycle diary.
Post menopausal bleed- causes- atrophic vaginitis,senile endometritis, endometrial
CA/polyps/hyperplasia, exogenous estogen, cervical CA,etc. Inv- pap smear, TVS,
endometrial biopsy

Amenorrhea(absence /abnormal stoppage of menses)

May be due to pregnancy,lactation, menopause
Amenorrhea + menstrual pattern of pain may be due to hematometra
In case of a missed periods at any age gp
1.Do UPT(to R/o Pregnancy)
2.Can wait for 10 days from the date. Repeat UPT.
3.If features of PCOD: check TSH, S prolactin
R/o hypothyroidism, hypoprolactinemia
If hypothyroid, start thyroxine
Estimate serum Prolactin & if low, give Bromocriptine 2.5mg HS
Also do CT scan for microadenoma
If thyroid & pituitary status normal, & If suspecting a delayed cycle ie UPT negative,
and no features of PCOD:
induce withdrawal bleeding with T Meprate or Provera or Modus 10mg OD/BD X 5-
10 days [Medroxyprogesterone Acetate]. Usually withdrawal bleeding may occur within
7-10 days of medoxy progesterone .Even then if no bleeding needs evaluation for
secondary amenorrhea.Do FSH level estimation, which if low indicates a pituitary lesion
& if high indicates an ovarian lesion
 It is obvious that Pt should be referred after R/o pregnancy, in a GP setup.
In PCOD: if symptomatic PCOD- it is better to be referred as it needs further evaluation.
Metabolic syndrome may be associated with it.
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AUB
Etiology: PALM-COEIN
Polyps,adenomyosis,leiomyoma, malignany & hyperplasia, coagulopathy, ovulatory
dysfunction, endometrial,iatrogenic and not yet classified.
inv: first inv in reproductive age gp- urine/serum beta HCG. Others- pap smear, TVS,
endometrial sampling

Discharge PV
Do a per speculum examination to know type of discharge
Foul smelling or not
 Inv: per speculum to know type of discharge(foul smelling or not), to r/o pregnany
products, to r/o blood stained discharge
Rx
 Cases with whitish discharge may be due to Vulvovaginal Candidiasis – give candid
V6 cream or Cansoft CL vaginal tab(clindamycin+clotrimazole) 1 pv HS x 1 week or
T Fluconazole 150 mg single dose or
AF kit(fluconazole x1 morning+azithromycin x1 afternoon+ ornidazole x2 night)
single day dose for both partners. All 4 tablets can be taken at night also.
 Greenish yellow Purulent discharge may be due to Trichomonas infection.Treat both
partners.Give metronidazole 500mg TDS x 7dys/Tinidazole 2g single dose
For bacterial vaginosis, give T Metronidazole 500 mg bd orally x 7 days or
clindamycin 300 mg bd x 7 days

If PID: mild case, 1.T ciplox TZ 1-0-1 x 5 days 2.Clotrimazole CL vaginal tablets 1 HS x
3 days
Otherwise syndromic approach: 1.clotrimazole CL vaginal tablets 1 HS x 3 days2.
antifungal kit(azithromycin, fluconazole, ornidazole) for both partners 3. Ask to go for a
cervical smear and per speculum examination

Pelvic Inflammatory Disease

Risk factors include multiple sexual partners, IUD insertion,intercourse during
menstruation, young age, bacterial vaginosis, cervicitis etc
C/f: May present with bilateral lower abdominal pain, abnormal vaginal discharge,
menometrorrhagia,postcoital bleeding, fever, nausea
Inv: BRE, ESR, CRP, USG
Rx
1. Rest, iv fluids if dehydration/vomiting.
2. Inj Ceftriaxone 250 mg IM single dose +
3. T Oflox 400 1-01 + T.Metrogyl 500mg 1-0-1 x 14 days or
T Doxy 100 1-0-1 + T.Metrogyl 500mg 1-0-1 x 14 days or
T Ciplox TZ 1-0-1 may also be given.
Note- There is no need to remove IUCD if the woman responds to antibiotics. Failed
response for 48-72 hours calls for its removal. Partners should be investigated and
treated.

Postponement of Periods
Rx
 T. Primolut-N 5mg 1-0-1[Norethisterone] ;start 3-5 days before expected date of
periods, and to be continued till needed. Another brand is Regestron or
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 T Meprate 10 mg 1-0-1(medoxy progesterone acetate) to be given from 5 days
before anticipated periods & to be continued till required or
 T Ovral-G (Norgestrel I.P. 500 µg, Ethinyl estradiol I.P. 50 µg);For postponement of
menses, one tablet should be taken daily starting with the 20th day i.e. eight days
prior to expected date of menstruation. With this dosage, the menstrual period can
be postponed to the 40th day i.e. about two weeks beyond the expected date
 To postpone next period & the pt comes to you one cycle before: start combined
OCP(Mala-D) from day 3/5 of the period till how many days you want to postpone
continuously
 Note: before any hormonal treatment, counsel the lady about menstrual
irregularities following treatment. Break through bleeding can occur with medoxy
progestrone if taken after 20 days.

Dysmenorrhea(painful menstruation)
1 Dysmenorrhea: Pain in lower abdomen & may radiate to the back & legs; may be
0

accompanied by nausea, vomiting, diarrhoea, headache, malaise.

20 Dysmenorrhea: dull pain , deep seated in pelvis with no radiation.
Rx
1. Inj cyclopam/ voveran 1 amp IM st ATD
2.T cyclopam or Baralgan tds x 3-5 days days or T mefenamic acid 500 mg tds or T
Meftal-Spas(Mefenamic acid+ dicyclomine) or T Drotin-M(drotaverine + mefenamic
acid).
Note:If pt doesn’t respond to the treatment, suspect endometriosis

Menopause
Clinical features: hot flushes(m/c), vaginal dryness,loss of libido
Problems a/w menopause- osteoporosis, atrophic vaginitis, depression, urge and
stress incontinence, irritability, poor concentration, insomnia, IHD, stroke,
Alzheimers disease, hypothyroidism
Inv: S FSH>40 IU
Rx
 Nutritious diet with proteins, wt bearing exercises, elevation of head may reduce
frequency and severity of hot flushes.
 Calcium + Vitamin D, vit E
 T Gabapentin may improve vasomotor symptoms. SSRIs like fluoxetine may be
given.
 Premarin cream(conjugated estrogen) for vaginal dryness, burning, irritation,painful
intercourse. Administered as daily regimen starting at 0.5 g for 21 days, then off for
7 days.
 Pap smear / regular Breast examination
 Gynaec consultation for HRT

Fibroadenosis, Cyclic Mastalgia

Rx:
1. Vit E 200-600mg OD( Evion)
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2. NSAIDs(oral & topical)
3. Alprax
4. Proper Breast Support
5. Life style change (wt loss, avoid caffeine, chocolate,smoking)
Surgery consultation if needed.

Breast Abscess/Mastitis
Seen in lactational age group. Mostly caused by staph aureus from oropharynx of child
C/f- pain, swelling, fever, cracked nipples
Ix - USG may be required
Rx
1.Suppress lactation. But it is not a c/I for breast feeding.
2.Antibiotics(cloxacillin/ampicillin/cephalexin)
3.Analgesics
4.I & D if abscess points

Cracked Nipples
Most often a/w breast feeding,it probably means that the baby is not latching on well to
the breast. A postpartum lady p/w h/o breast pain, fever, warm, swollen, red nipples with
no induration/fluctuance/pus s/o mastitis.
Avoid soaps and harsh washing or drying of the breasts and nipples. This can cause
dryness and cracking.
Rub a little breast milk on the nipple after feeding to protect it.
Keeping the nipples dry to prevent cracking and infection.
Apply White paraffin jelly on your nipples.
Continue efficient breast feeding of baby from both the breasts..

Vulvitis/vaginitis
Aetiology: bacterial vaginosis, trichomoniasis, yeast/candida infection, non-
infectious(vaginal sprays, perfumed soaps, spermicidal products,tissue papers,
forgotten tampons)
C/f: severe itching,discharge, burning sensation, redness, blisters on vulva
Rx
1. Clotrimazole-beclomethasone cream for LA
2. Lactacid liquid solution: wash 2-3 times a day
3. If recurrent episodes - to r/o Diabetes and other STDs
Note: in treating UTI- avoid imidazole group of drugs in reproductive age gp eg:
ketoconazole, clotrimazole

Acute salpingo-oophoritis
Rx
1. T ofloxacin 400 mg 1-0-1 x 14 days
2. T Metronidazole 500 mg 1-0-1 x 14 days
3. Analgesics

Abdominal mass
It needs detailed evaluation and management accordingly. Ovarian tumours may
present as acute abdomen.
Gynaec/surgery consultation.
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Family planning
Ideal contraceptive for a newly married couple is OCP. Barrier method has high failure
rate. Copper T is C/I in newly married couples
Copper T: can be placed 45 days after normal delivery or 45 days after
LSCS(sometimes after 3 months of CS)/ postpartum/intraoperatively. It is put on 5th-
10th day of periods. Copper T check up-after 1 month/ after first period, then yearly. If
missing thread, do USG abdomen.
Note: menorrhagia and dysmenorrhea are the most common side effects of copper T. It
may be present for the next 2-3 cycles. So counsel the pt in advance. It may even
persist upto 6 months. In severe cases, can give mefenamic acid or tranexamic acid.

Missed contraceptive pills

Advice regarding missed pills depends on the preparation the woman is taking.
It varies depending on whether she is taking the combined or progestogen-
only pill. She will need to know what to do with the rest of her packet, whether
she needs to use additional contraceptive precautions and for how long, and
whether she needs emergency contraception. Patient information leaflets
within the packet should give this information.
The Pill typically comes in a 28 day pack and depending on the type of pill, it will have
between two and seven pills that have no hormones (inactive pills). Pt usually have
vaginal bleeding during the days when she takes the inactive pills.
How to take pill: Combined Oral Contraceptive Pill. This pill has 21 hormone pills and 7
inactive pills (28 pills).
There are different ways of taking the pill:
a) take all 28 pills and have a bleed each month
b)take just the hormone pills and have no bleeds at all
c)take just the hormone pills some months and have a bleed every few months. Taking
hormone pills all the time is better contraception. Take one pill at the same time every
day.
If pt wants to avoid bleeding: Miss out the inactive pills and start the hormone pills in
the next packet. Continue like this, taking all the hormone pills without a break.
If pt wants to have a bleed each month: Take the inactive pills ,pt will get a bleed during
this time. If pt wants to have a bleed every few months: Miss out the inactive pills most
months and just take the inactive pills when pt wants to have a bleed.
Missed pill from combined OCP

1)No of missed pill-one( more than 24 hours and upto 48 hours late)
Action- take the missed pill as soon as remembered then take the next one at the usual
time (which means two pills to be taken in one day).
Backup contraceptive method (ie condom)- not needed
Emergency contraceptive- not needed usually. However, it should be considered if other
pills have been missed recently, either earlier in the current packet, or at the end of the
previous packet.
7 day break- taken as normal

2)No of active pills missed in a row- two or more active pills in a row(more than 48 hours
late)
Action- take the last pill missed straight away(which means two pills to be taken in one
day). Do not take any earlier missed pills. Continue with the rest of the pack as usual.
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The next step then depends on where in the packet the pills are missed:
If the pills are missed in the first week of a pack (pills 1-7): emergency
contraception should be considered if the patient had unprotected sex in the pill-free
interval or the first week of the pill packet. She should finish the packet and have the
usual pill-free interval.
If the pills are missed in the second week of a pack (pills 8-14): there is no need for
emergency contraception as long as the pills in the preceding seven days have been
taken correctly. The packet should be finished and the usual pill-free interval taken.
If 2 or more pills are missed in the third week (pills 15-21) omit the pill-free interval by
finishing the pills in the current pack and starting a new pack the next day (discard
placebo pills).
Back up contraceptive method-Yes; or abstain from sex until one pill has been taken
every day in a row for 7 days.
If more than seven pills are missed, the woman should start again as if starting for the
first time. (Exclude pregnancy, and start a new pack on the first day of the next
menstrual period.)
Emergency contraceptive- Consider emergency contraception if the women have had
unprotected sex in the previous 5 days and have missed 2 or more pills in the first week
of the pill pack.

When you come to the end of your pill pack, after missing 2 or more pills:
if there are 7 or more pills left in the pack after the last missed pill – finish the pack, take
7-day pill-free break as normal, or take inactive pills before starting the next pack
if there are less than 7 pills left in the pack after the missed pill – finish the pack and
start a new pack the next day; this means missing out the pill-free break or not taking
the inactive pills
Pt may also need emergency contraception if you have missed 2 or more pills in the first
week of a pack and had unprotected sex in the previous 7 days.

If more than one pill is missed in the first seven days of a new pack of pills, or starting a
new pack more than 24 hours late and pt have had sex in the hormone pill break, or
have had sex in the seven days after the pills are missed, pt should consider using the
Emergency Contraceptive Pill (ECP). Pt needs to use other contraception such as
condoms for the next seven days, as well as continuing with the Pill.

3)No of missed pills-One or more reminder (dummy or inactive) pills

Action-Throw away the missed reminder pills
Take the next reminder pill at the usual time
Backup contraceptive- not needed
Emergency contraceptive-not needed.

Missed pill for progestin only pills(mini pill)

Progestin-only pills are often recommended for women who are breastfeeding and
women who cannot use the combined oral contraceptive pill for medical reasons. You
might find the progestin-only pills a little trickier to use than combined hormonal birth
control pills because the progestin-only pill MUST be taken at the same time each day
(no more than 3 hours late)((12 hours for desogestrel pills such as Cerazette®).
Number of missed pills (by more than 3 hours)- one
When in cycle pills were missed- anytime
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Action required- Take a pill as soon as remembered
Take the next pill at the usual time (which means the women may take two pills in one
day)
If had sex in the last 3 to 5 days, consider emergency contraception.
Consider emergency contraception if there was unprotected sexual intercourse 2-3 days
prior to the missed pills, or there has been intercourse since the missed pill(s).
48-hour back-up contraceptive method (i.e., condom/spermicides)- needed or
absistenence for next 48 hrs

Emergency Post-coital contraception

Rx
 Within 72hrs , Tab levonorgestrol(I-pill, unwanted 72) 1 tab st & 1 tab 12 hr later Or
single 1.5 mg dose.Most effective within 24 hours or
 IUCD insertion within 5 days or
 Mifepristone 600mg [200mg x 3] as a single dose (with in 72 hrs) followed 2 days
later by 4mg of misoprostol [T.Misoprost] as single dose.
Mifepristone, T N: T. Mtpill,T.unwanted, T.Mifegest Cost~1000rs.

Injectable Contraceptives
Rx
 Inj Depot Provera (Medroxyprogesterone Acetate)150mg deep IM (or 104 mg sc)
every 90 days during first 5 days of menstrual cycle
 Inj Noristerat (norethisterone enanthate) 200 mg deep IM during first 5 days of
menstrual cycle at 2 months interval

Delayed menarche
Ask family history
Ask for secondary sexual characters development: 1)if secondary sexual characters
present-can wait till 16 years. 2)If secondary sexual characters absent- investigate by
14 yrs of age.

Irregular cycles
1.if unmarried or if married & wants contraception: can give combined OCPs(Mala-D)
for 3 months
2.If married, and consider child bearing: so better not to start OCPs. Persistent irregular
cycles or if it affects fertility, then it may need further evaluation.

Premenstrual Syndrome
C/f:abdominal bloating,abdominal pain,sore breasts,acne,food cravings especially for
sweets,constipation,diarrhea,headaches,sensitivity to light or sound,fatigue,irritability,
changes in sleep patterns,anxiety,depression,sadness,emotional outbursts.
Rx
1. Reassure the pt.
2. Exercise,adequate sleep,plenty of fluids,salt restriction, avoid caffeine & alcohol.
3. Vitamin supplementation.
4. T Lasix 20 mg daily can be given starting 2-3 days before the periods to stop bloating
and water weight gain(When exercise and limiting salt intake aren't enough to reduce
the weight gain)
5. T Lorazepam 1mg 1-0-1(TN:Ativan or Lora)
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6. NSAID’s for cramping and breast discomfort.
7. C Primosa(evening prim rose oil) OD x 10 days

Basic obstetric conditions

Early Pregnancy
 Pt may present with pain, which may be due to Abortion, Ectopic gestation,
Vesicular mole, pregnancy with torsion of ovarian cyst.
 Other 1st trimester complications-UTI,a/c urinary retention, hyperemesis gravidarum
 Always confirm live Intra Uterine Gestation with USG
 GCT ideally at 20-24 wks
 GTT with 100g glucose over 3 hrs in abnormal GCT cases
 Do ICT in Rh negative cases
 Prophylactic IFA tablets OD X 100 days
Physiological changes
Physiological pedal edema(unassociated with proteinuria ,preeclampsia,no
cardiac,renal pathologies present), usually confined to one leg, usually right. Treated
with bed rest

Hyperemesis gravidarum
C/f: nausea followed by excessive vomiting, severe dehydration, confusion, low BP,
DD:vesicular mole, multiple pregnancy, hepatitis, Appendicitis,Biliary
Disease,DKA,Esophagitis,Fatty Liver, Gastroenteritis, GERD, Hyperparathyroidism,
Hyperthyroidism, Irritable Bowel Syndrome, Nephrolithiasis, Pancreatitis, Acute
Intermittent Preeclampsia, peptic ulcer disease, Acute Paralytic Ileus/Bowel Obstruction
Inv: PCV,S.electrolytes, β-hCG, TFT, LFT, URE,urine acetone, USG abdoomen to r/o
multiple pregnancy, vesicular mole
Look for dehydration
Rx
1.Inj emest 4mg iv st or inj phenergan 25 mg or inj perinorm 10 mg iv slowly
2.If dehydration is present or urine acetone + :IV fluids 2-3L, initially 5D f/b NS & RL.
Check urine acetone after iv fluids.
3.Antacids or pantop or rantac
4.Send home with T pyridoxine 20 mg OD or 10 mg 1-1-1
5.Diet-avoid fatty foods
6.Vit B1(thiamine) / B6 in drip
7.T Doxinate (doxylamine + pyridoxine) 2 Tab HS

Other Common conditions

Respiratory infection in pregnancy
Rx
1.T azithromycin 500 mg OD x 3 days
2.T pmol 500 mg tds/qid
Other antibiotics that can be used- ampicillin, mox, cephadroxyl.
Better avoid moxclav
Any influenza like illness in pregnancy- suspect H1N1
Advise T oseltamivir 75 mg BD x 5 days
Refer to higher centre. Note- oseltamivir better avoided in first trimester

Diarrhoea in pregnancy
Look for dehydration and treat accordingly:
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Rx
1.consider iv fluids, ORS
2.T metronidazole 400 mg 1-1-1 x 5 days(if infectious)

UTI in pregnancy
Send urine for C & S before starting antibiotics
Rx
1.C mox 500 mg 1-1-1-1 or T cefixime 20 mg 1-0-1 x 3- 5 days
2.Plenty of oral fluids

High BP in pregnancy
Antihypertensives are started if BP ≥ 160/110 or DBP ≥ 100 persisently.
Rx
1. Antihypertensives given in pregnancy: methyl dopa 250-500 md tds/qid, nifedipine
10-20 mg bd, labetalol 100 mg tds/qid, hydralazine 10-25 mg bd
2. A/c HTN in pregnancy:iv labetalol 20 mg iv every 20 minutes(max dose 300 mg in 24
hrs). T nifedipine 10 mg st may be given
2. Refer the pt to higher centre

Seizure in pregnancy
Rx
1.stabilize the pt
2.Inj lora 2 mg iv st or inj phenytoincan be given(phenytoin is teratogenic only on long
term use).
3.Refer immediately
Note: if any antenatal pt is detected to have high BP or high blood sugar value, refer to
a higher centre a s they need strict control. Any antepartum hemorrhage, abdominal
pain, leaking pv should also be referred.

Varicosities
Varicosities(lower leg,vulva,rectum) may appear for the first time or aggravate during
pregnancy usually in the later months. Usually disappear following delivery. Specific
treatment is avoided.

Eclampsia
C/f: seizures, high BP, proteinuria, associated with pregnancy.
Inv: Hb, Plt ct, S.electrolytes, urea, creatinine, LFT, coagulation profile
Rx
1. Left lateral position, protect airway, administer Oxygen.
2. Ensure wide bore iv access
3. Administer loading dose of Inj Magnesium sulphate 20 % solution, 4 g slow iv over 5 -
10 minutes irrespective of renal status. Follow promptly with inj MgSO4 50 %, 2-5 g in
each buttock as deep IM. Maintenance therapy is given as inj MgSO4 1g/hr infusion for
24 hrs. After each 4 hr, Check urine output, RR & examine Knee jerk & monitor for
adverse effects of MgSO4 like urinary retention, muscle weakness, respiratory
distress,chest pain,heart block. Repeated/maintenance dose IM injections are continued
only if the patellar reflex is present, no respiratory depression, u/o in the previous 4
hours exceeds 100 ml.
Note: In eclampsic pt’s with low BP or decreased urine output, MgSO4 should be
withheld, iv fluids administered & seizures controlled with Diazepam or lorazepam.
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Warn the pt of the warm feeling that will be felt when MgSO4 is administered. Pregnant
mother with sudden onset of LOC or severe headache should be suspected as
eclampsia. Postpartum eclampsia should be suspected in pt’s with worsening oedema
& BP within 2 weeks of delivery.
Mx of Mg toxicity- stop Mg therapy, estimate S Mg & Cr levels(measurement of SMg
levels is indicated to monitor Mg toxicity if serum creatinine >1/0 mg/dL, inj ca gluconate
10 ml 10 % iv.

Ectopic Pregnancy
C/f: Pain, amenorrhoea, bleeding PV(triad), tachycardia, hypotension, shoulder pain.
h/o acute abdominal catastrophe with fainting attack and collapse ie shock following a
short period of amenorrhoea in a women of child bearing age always points towards
ruptured ectopic pregnancy.
Inv: h/s/o ectopic: do UPT(negative UPT do not rule out ectopic). If UPT +ve do TVS or
TAS, serial β-HCG.
HCG≧1500 s/o ectopic
Mx
Unruptured ectopic- <3 cm- methotrexate, >3 cm- laparoscopy/laparotomy
Ruptured ectopic- has a/c and sub a/c presentations, and pt may be hemodynamically
stable or unstable
Simultaneous resuscitation and emergency laparotomy may be required.

Bleeding pv in pregnancy
During first trimester,Mnemonic :AGE IS Low
Abortion,Gestational trophoblastic disease( e.g vesicular mole), ectopic pregnancy,
implantation bleeding,spotting, lower GU tract causes like cervical or vaginal bleed.
During second or third trimester :Pacenta praevia , placental abruption,preterm labour
Inv: CBC,coagulation profile, β-hCG,URE, USG
Refer to O & G.

Enhancement of Lactation
Rx
1.C.Lactare 2-2-2 x 5 days(asparagus racemosus 200 mg,withania somnifera100mg etc)
2.T perinorm 10 mg(1-1-1) x 5 days

Suppression of lactation
Rx
T. B-long (pyridoxine) 100 mg 2-2-2 .
Pt should be advised to wear a tight bra and not to express milk.

Puerperium
General physiological changes
Pulse increases for few hours after delivery and then settles down. Temperature may
increase on day 3 due to breast engorgement.in the first 24 hours, temperature shouldnt
be > 990F. R/o UTI in rise of temperature.
Urinary retention, constipation, loss of wt upto 2 kg due to diuresis, ↑ ESR & fibrinogen.
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For 2 hrs after delivery, BP & pulse should be taken every 15 minutes. Temperature is
assessed every 4 hrs for first 8 hrs and then atleast evry 8 hrs subsequently.
PPH
Inj tranexamic acid 1 g in 10 ml(100 mg/ml) iv at 1 ml per minute, with a second dose of
1 g iv if bleeding continues after 30 minutes.

Fetal Monitoring
FHR- 110-160 bpm, Normal beat to beat variability- 5-25 bpm, acceleration FHR
increases by 15 bpm above baseline lasting for 15 sec.
NST started at 32 weeks.

Drugs C/I in pregnancy

Alcohol, warfarin, phenytoin, sodium valproate, diethylstilbestrol, isotretinoin, androgens
and danazol, antineoplastic drugs, cocaine, ACEI, tetracyclines

Drugs C/I in lactation

Ciplofloxacin,fluconazole,iodine,iodides,ketoconazole,metformin,tetracycline,amiloride,
amphetamine, ethosuccimide, indomethacin,anti cancer drugs, chloramphenicol,
ergotamine, bromocriptine,amiodarone,phenytoin,lithium, etc

Drugs to be used with special precaution in lactation:

Note-Advise the mothers to take medicines just after lactation.

If the lactating mother should take medicines an are deemed safe, the dosing
optimally should be 30-60 minutes after nursing and atleast 3-4 hours before the
next feeding.
ACEI, losartan,beta blockers,acyclovir,aminoglycosides,amlodipine,nifedipine, pencillins
like ampicillin, amoxicillin,azithromycin, norfloxacin, cotrimoxazole,naldixic acid,
metronidazole, anticonvulsants like carbamazepine, phenobarbital,anti psychotics,
antihistamines, atorvastatin, corticosteroids, ephedrine, furosemide, metoclopramide,
montelukast, morphine, omeprazole, ranitidine,warfarin, theophylline, isoniazid etc.
Avoid tramadol, diazepam, ketorolac etc
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EMERGENCIES
Poly Trauma Patient
Rigorous evaluation is important for pts with multiple injuries.Begin the initial
assessment using the mnemonic ABCD
A Upper Airway is established & maintained with cervical spine control.
B Breathing (or the adequacy of air exchange) is evaluated & established.
C Circulation- blood pressure is evaluated & corrected, & bleeding is arrested.
D Deficits of neurologic function are identified & treatment is initiated.
Airway
All patients presenting with head, neck, or facial trauma, or neurologic symptoms such
as weakness or abnormalities of mental status after trauma, however subtle, must be
assumed to have injuries to the cervical spine, unless otherwise proved, and strict
attention must be given to immobilization of the neck
If the patient can speak normally, a reasonable airway probably exists. Patients without
inspiratory effort & those with a GCS score of 8 or less require intubation to establish &
secure a functional airway. Pharynx must be assessed to exclude local obstruction
related to posterior movement of the tongue or the presence of swelling, bleeding,
secretions, or gastric contents. Rigid suction & manual extraction should be used to
clear the pharynx of any foreign body.Obstruction of airway caused by posterior
movement of the tongue may be quickly corrected by the insertion of an oral airway & or
the head-tilt chin-lift technique(if no neck injury) or jaw-thrust maneuver(if neck injury is
suspected).
Breathing
After an airway is secured & ventilation with O2 initiated, the adequacy of air
exchange must be assessed. Look for RR > 30/min, unequal chest movements,
gross tracheal deviation , flapping chest wounds. Bilateral & symmetric breath
sounds (best heard in axilla) should be present immediately after intubation or
other airway establishment. When problems associated with endotracheal
intubation are excluded & ventilation /oxygenation remains inadequate,
hemothorax, simple/tension pneumothorax, flail chest, aspiration etc must be
considered & corrected if present.
Circulation
Blood pressure is evaluated & bleeding arrested. Evaluating the patient’s pulse,
skin colour, & level of consciousness can be performed very quickly & it can
provide a rapid bedside assessment of the adequacy of circulation. Tachycardia
may be an early indication of concealed acute bleeding.External bleeding should
be controlled by direct pressure. IV access should be established using 16 G
cannula. IV fluids & blood replacement should be done.
Deficit of neurologic function are identified & treatment initiated.
Initially the patient’s overall neurologic status may be simply classified as alert,
responsive to verbal stimuli, responsive to painful stimuli, or unresponsive to all
stimuli.Use GCS. Rapidly reversible causes of CNS depression, including
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hypoglycemia, wernicke encephalopathy, opiate overdose must be considered &
prophylactically treated.
Exposure
Patients may be undressed(maintain privacy) for complete evaluation.
Secondary assessment
The posterior neck, back, chest & abdomen are inspected & palpated for local skin
disruption or tenderness. Injury to the larynx/trachea can occur from either blunt or
penetrating trauma; subcutaneous emphysema, airway obstruction, dysphonia, lack of
thyroid cartilage prominence are seen in such trauma.Tracheostomy is needed in the
presence of unstable airway. Pt with blunt trauma & hypovolemia should be examined
first for intraabdominal bleeding, even if there is no overt existence of abdominal
trauma.Patient with intra-abdominal bleeding or injury require urgent laparotomy.
Assessment of vision may be undertaken in conscious patients. Bilateral equal breath
sounds & heart sounds should again be evaluated.The genitalia are examined. The
extremities are examined for evidence of hematoma, crepitus, deformity, & peripheral
pulses. Perform CCT (chest compression test), PCT(pelvic compression test),
SLR(straight leg raise test; if normal then Slr negative). Look for tenderness
/crepitations of rib. Look for spine tenderness/ long bone injuries, palpate for peripheral
pulses. Look for intra-oral injuries. Look for Battle’s sign & Racoon eye. Catheterise if pt
is intubated or GCS is deteriorating.
Give Inj TT(if indicated), IV fluids(avoid dextrose, give NS/RL), Analgesics
(avoid tramadol as it may cause drowsiness & thus may interfere with clinical
assessment of pt). Fractures are aligned & splinted.
Radiological studies are done after the patient is stabilised.
 Chest x-ray PA view, X-ray C spine AP/lateral view, USS abdomen, CT Brain,
X-ray pelvis with both hips
 CT Brain with C-Spine screening may be done in patients with head injury &
suspected cervical spine injury.

Chest Trauma
Rapidly fatal conditions: tension pneumothorax,flail chest, open pneumothorax,
massive hemothorax(shock without elevated jvp) ,cardiac tamponade(engorged
neck veins,hypotension,muffled heart sounds)
Potentially fatal conditions evolving less acutely:simple pneumothorax,Rib
fracture and contusion,blunt cardiac injury, traumatic asphyxia, thoracolumbar
vertebral injury, scapular/sternal fracture,esophageal perforation,subcutaneous
emphysema, diaphragmatic rupture, pulmonary contusion,
Diagnosis: history, physical examination, X-ray, CT etc
Raised JVP, hypotension, breathlessness; seen both in cardiac tamponade, tension
pneumothorax, but in tension pneumothorax there is also absent breath sounds,
hyperresonant percussion note.
Emergency management of tension pneumothorax- needle thoracotomy , 5th
intercostal space , just anterior to mid axillary line. In children-2nd ICS
midclavicular line.
Immediately refer the patient to higher centre without any delay for ICD insertion.
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Other Medical Emergencies

Anaphylaxis
Diagnostic criteria
Anaphylaxis is likely when one of the 3 criteria occurs
1.Acute skin & mucosal s/s, Eg hives, pruritus, flushing, lip/toungue/uvula
swelling) and one of the following a) respiratory s/s(wheezing, stridor, shortness of
bearth, hypoxia) b) hypotension/associated end organ damage(eg, hypotonia,
syncope, incontinence)
2.exposure to probable allergen for the pt and 2 or more of the following:
a) skin/mucosal involvement
b)respiratory symptoms
hypotension/end organ dysfunction
d)persistent GI symptoms(emesis, abdominal pain)
3.decreased bP after exposure to known allergen for the pt:
a)adults- systolic bp <90 or > 30% decrease b)infants and children – hypotension
for age or > 30% decrease
Mild anaphylactic reactions (urticaria, generalized edema, pruritus):
Inj avil 25 to 50 mg slow iv or im
Inj efcorlin 100 mg(upto 1g) iv
Keep the pt under observation. If no bronchospasm or further complaints, pt can be
sent home
Severe anaphylactic reaction(if bronchospasm present):-
Give nebulization with asthalin. Pt should be admitted
Monitor BP. If systolic BP> 90 mm Hg, manage with iv fluids, inj avil, efcorlin,
s/c adrenaline may also be given
If systolic BP falls below 90 mmHg, give IM adrenaline 0.3-0.5 mg(0.3 -0.5 ml of
1:1000 solution). . Repeat at 15 minutes interval if necessary
If laryngeal edema: pt should be intubated immediately. If intubation fails
tracheostomy must be done.

Choking
Obstructed Airway Airway obstructions can lead to respiratory and even cardiac arrest if
not addressed quickly and effectively. A conscious person who is clutching the throat is
showing what is commonly called the universal sign for choking. However, in many
cases a patient will just panic. Other behaviors that might be seen include running about,
flailing arms or trying to get another’s attention.

Caring for an Adult and Child

For an adult or child, if the patient can cough forcefully, encourage him or her to
continue coughing until he or she is able to breathe normally.
If the patient can’t breathe or has a weak or ineffective cough, you will need to perform
abdominal thrusts to clear the obstruction. To perform abdominal thrusts, stand behind
the patient and while maintaining your balance, make a fist with one hand and place it
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thumb-side against the patient’s abdomen—just above the navel. Cover the fist with
your other hand, and give quick, upward thrusts.
Continue delivering abdominal thrusts until the object is forced out; the person can
cough, speak or breathe; or the patient becomes unconscious.
If you cannot reach far enough around the patient to give effective abdominal thrusts or
if the patient is obviously pregnant or known to be pregnant, give chest thrusts. To
perform chest thrusts: from behind the patient place the thumb side of the fist against
the lower half of the sternum and the second hand over the fist. Then give quick, inward
thrusts.
If a patient who is choking becomes unresponsive, carefully lower the patient to a firm,
flat surface, send someone to get an AED, and summon additional resources if
appropriate and you have not already done so. Immediately begin CPR with chest
compressions.
As you open the airway to give ventilations, look in the person’s mouth for any visible
object. If you can see it, use a finger sweep motion to remove it. If you don’t see the
object, do not perform a blind finger sweep, but continue CPR. Remember to never try
more than 2 ventilations during one cycle of CPR, even if the chest doesn’t rise.
Continuing cycles of 30 compressions and 2 ventilations is the most effective way to
provide care. Even if ventilations fail to make the chest rise, compressions may help
clear the airway by moving the blockage into the upper airway where it can be seen and
removed.
Evidence suggests that it may take more than one technique to relieve an airway
obstruction in the conscious patient and that abdominal thrusts, back blows and chest
thrusts are all effective.
Note: Based upon local protocols or practice, it is permissible to provide a series of back
blows and abdominal thrusts to an adult or child who is choking. Always follow local
protocols, practice or medical direction instructions.

Caring for an Infant

When an infant is choking and awake but unable to cough, cry or breathe, you’ll need to
perform a series of 5 back blows and 5 chest thrusts. Start with back blows. Hold the
infant face-down on one arm using your thigh for support. Make sure the infant’s head is
lower than his or her body and that you are supporting the infant’s head and neck. With
your other arm, give firm back blows with the heel of your hand between the infant’s
scapulae.
After 5 back blows, start chest thrusts. Turn the infant over onto your other arm using
your thigh for support. Make sure to support the head and neck as you move the infant.
Place two fingers in the center of the infant’s chest, about 1 finger-width below the
nipple line. Give 5 quick thrusts. Continue this cycle of 5 back blows and 5 chest thrusts
until the object is forced out; the infant can cough, cry or breathe; or the infant becomes
unresponsive.
If an infant does become unresponsive while choking, carefully lower the infant onto a
firm, flat surface, send someone to get an AED, and summon additional resources if
appropriate and you have not already done so. Immediately begin CPR starting with
compressions.
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Cardiac arrest

Check carotid pulse, confirm pupillary reaction, start basic life support.
Consider advanced life support if defibrillator available. In unstable Vt, Cardiac thump
may be tried, if rhythm can be monitored and defibrillator is not immediately available.
Don’t repeat cardiac thump.
Start external chest cardiac massage(ECCM) or CPR
Place the pt on a flat & hard surface. Extend the jaw & keep neck extended. Stand at a
height higher than the pt. Keep the hands straight & elbows extended at 1800. Place
both hands over the sternum, one above the other. Give firm steady compression to the
chest wall squeezing the heart between the sternum & vertebra. Ideal movement of the
provider is at the level of hip.Give compressions approximately 4cm in depth at a rate of
30 cardiac compression & 2 assisted respirations.
Continue cardiac compressions unremittingly till pt is revived or decision to discontinue
ECCM is made. Interrupt cardiac compressions only for giving assisted respirations or
DC shock.
Check cardiac rhythm to see for any ventricular fibrillation; if so connect defibrillator &
charge to 200 joules non synchronized shock. Make sure no one touches the cot or the
pt & the provider does not touch the cot. Apply conductive jelly to the pads of the
fibrillator & place it at the right & left axilla respectively. Press both buttons of the pads
simultaneously to deliver the shock. Check the monitor to see whether the rhythm has
reverted to normal sinus rhythm. If yes discontinue ECCM & make sure the pt is stable
with normal BP. Otherwise continue ECCM till decided on giving a second or if
necessary third shock.
Assisted ventilation should be given at the rate of 2 mouth to mouth breathing(or
preferably use an ambu bag) for every 30 cardiac compressions. If mouth to mouth
respiration is applied insert a gauze in between the mouths.ECCM should be
discontinued only after such a decision has been made taking into all considerations.

CARDIOPULMONARY RESUSCITATION (CPR)

First confirm cardiac arrest; absence of repiratory efforts, absence of major pulse like
carotid is diagnostic of cardiopulmonary arrest.If pulse +, open the airway & give
ventilation.
Healthcare providers, should perform all 3 components of CPR (chest compressions,
airway, and breathing).For an unconscious adult, CPR is initiated using 30 chest
compressions. Perform the head-tilt chin-lift maneuver to open the airway and
determine if the patient is breathing. Before beginning ventilations, rule out airway
obstruction by looking in the patient’s mouth for a foreign body blocking the patient’s
airway. CPR in the presence of an airway obstruction results in ineffective
ventilation/oxygenation and may lead to worsening hypoxemia.
Positioning
CPR is most easily and effectively performed by laying the patient supine on a relatively
hard surface, which allows effective compression of the sternum.
The health care provider giving compressions should be positioned high enough above
the patient to achieve sufficient leverage, so that he or she can use body weight to
adequately compress the chest.
Chest compression
The heel of one hand is placed on the patient’s sternum, and the other hand is placed
on top of the first, fingers interlaced. The elbows are extended and the provider leans
directly over the patient. The provider presses down, compressing the chest at least 2
 153
inches. The chest is released and allowed to recoil completely.Chest compressions are
to be delivered at a rate of at least 100 compressions per minute.
With the hands kept in place, the compressions are repeated 30 times at a rate of
100/min. The key thing to keep in mind when doing chest compressions during CPR is
to push fast and hard. Care should be taken to not lean on the patient between
compressions, as this prevents chest recoil and worsens blood flow.
After 30 compressions, 2 breaths are given (see Ventilation). Of note, an intubated
patient should receive continuous compressions while ventilations are given 8-10 times
per minute or 1 breath/6-8 seconds. This entire process is repeated until a pulse returns
or the patient is transferred to definitive care.
When done properly, CPR can be quite fatiguing for the provider. If possible, in order to
give consistent, high-quality CPR and prevent provider fatigue or injury, new providers
should intervene every 2-3 minutes (ie, providers should swap out, giving the chest
compressor a rest while another rescuer continues CPR).
Ventilation
If the patient is not breathing, 2 ventilations are given via the provider’s mouth or a bag-
valve-mask (BVM).
The mouth-to-mouth technique is performed as follows :
The nostrils of the patient are pinched closed to assist with an airtight seal.The provider puts
his mouth completely over the patient’s mouth.The provider gives a breath for approximately
1 second with enough force to make the patient’s chest rise. Effective mouth-to-mouth
ventilation is determined by observation of chest rise during each exhalation. Failure to
observe chest rise indicates an inadequate mouth seal or airway occlusion. As noted , 2
such exhalations should be given in sequence after 30 compressions (the 30:2 cycle of
CPR). When breaths are completed, compressions are restarted. If available, a barrier
device (pocket mask or face shield) should be used.More commonly, a BVM can be used,
which forces air into the lungs when the bag is
squeezed. Several adjunct devices may be used with a BVM, including oropharyngeal and
nasopharyngeal airways.The BVM or invasive airway technique is performed as follows: The
provider ensures a tight seal between the mask and the patient’s face.The bag is squeezed
with one hand for approximately 1 second, forcing at least 500 mL of air into the patient’s
lungs. Next, the provider checks for a carotid or femoral pulse. If the patient has no pulse,
chest compressions are begun.

Cardiac Arrhythmias
Bradycardia
Any rhythm disorder with a HR<50/min
Causes-hypovolemia,hypoxia,hydrogen ion(acidosis), hypo/hyperkalemia,
hypoglycemia,hypothermia; toxins(beta blockers, CCBs, digoxin,othullum),
tamponade(cardiac), tension pneumothorax, thrombosis(coronary),
thrombosis(pulmonary), trauma(shock, raised ICP), uremia, hepatic coma, obstructive
jaundice, sick sinus syndrome
if the pulse rate is low (<50/min), it is a clue that the pt may be having a bradyarrhythmia
like complete heart block.Mild degrees of bradycardia don’t require any intervention in
the casualty. Symptomatic bradycardia exists when the following 3 criteria are present
1)the heart rate is <50/min 2)the pt has symptoms 3)the symptoms are due to the slow
heart rate. Symptoms are hypotension, altered mental status, ongoing ischemic chest
pain/discomfort/dyspnoea, evidence of a/c pulmonary edema, signs of shock.
Management :- identify and treat underlying cause, maintain airway, if hypoxemic start
 154
oxygen, connect to cardiac monitor(HR,rhythm,BP),iv line with 2 wide bore needles, 12
lead ECG if available.Severe symptomatic Bradycardia may be treated with Inj Atropine
0.6 mg rapid IV stat after definite ECG diagnosis. Repeat Q3-5 minutes upto maximum
total dose of 3 mg or .04 mg/kg.The vagolytic dose of atropine is 2 mg, so give 2-3
ampoules of atropine with a relatively fast push. Do not give atropine if there is evidence
of a high degree (second degree mobitz type II or third degree) AV block. Atropine use
may be harmful in the setting of cardiac ischemia. If atropine is not effective then start
dopamine infusion or adrenaline infusion.Adr dose- 1 mg in 500 ml NS/5D @ 2-10
µg/min titrated to effect(start with 1 ml/min). Pacing may be required if refractory to
inotropes. Transcutaneous pacing(TCP) may be tried. Search for 6 Hs and 6 Ts.
T Alupent (orciprenaline or metaproterenol)10 mg may be given for mild cases of
bradycardia.

Sinus Tachycardia
Causes- fever, anxiety, thyrotoxicosis,anemia, HF,drugs( e.g salbutamol),pregnancy
excessive use of tea, coffee, tobacco.
Rx
Usually needs no treatment. Management depends on the underlying condition.
Emotional factors are controlled by anti anxiety medications like alprazolam. In some
cases, beta blockers may be useful. T clonafit beta(clonazepam 0.25 mg + propranalol
20 mg) OD/BD may be used if a/w emotional disturbance. T ivabradine 2.5/5 mg BD
may also be used if sinus rhythm is present.

Tachyarrhythmia
Irregular narrow complex tachycardia may be caused by AF, atrial flutter with variable
AV nodal conduction, MAT(multifocal atrial tachycardia), sinus tachycardia with frequent
premature atrial beats.
Regular narrow complex- PSVT
In all arrhthymias, connect to monitor to identify rhythm; give O2(if hypoxemic),
Atrial Fibrillation
Aetiology:heart d/s(valvular,ischemic,hypertensive), thyrotoxicosis, pulmonary embolism,
COPD, hypoxia, alcohol, s/p cardiac surgery
C/f: palpitation,syncope, angina, fatigue, stroke, cardiac failure
Inv: ECG, TFT, cardiac biomarkers,CBC, S electrolytes,D-dimer, CXR,ABG,BNP, Echo
Ecg-P waves not seen, RR interval irregularly irregular, narrow QRS
Rx
Unstable Pt(SBP<90, CHF,chest discomfort,cyanosis,Syncope)
Synchronised DC shock (150-200 J)
Stable pt
1. If AF with FVR(> 100), control HR using β blockers(DOC), inj metoprolol 5mg iv over
2 minutes or inj Diltiazem 10 mg st over 2 minutes or verapamil 5-10 mg iv over 3-5
minutes. Amiodarone 150 mg iv over 10 minutes then 1 mg/min for 6 hours f/b 0.5
mg/min for 18 hours(useful in resistant AF, AF with evidence of accessory pathway and
in AF with cardiac failure)
After controlling HR, convert AF into sinus rhythm using either DC shock or drugs (Inj
Amiadarone may be used). Before cardioversion r/o RA thrombus if AF>48 hrs.
To maintain AF in sinus rhythm Amiodarone is used.
Note - CCB, beta blockers, digoxin should not be used to treat AF in pts with WPW.
For AF a/w hypotension amiodarone may be used.
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2.Inj lasix 20-40 mg iv st
3.Pts with newly diagnosed AF and those awaiting electrical cardioversion can be
started on IV heparin or LMWH 1mg/kg BD or Anticoagulation with warfarin to prevent
embolic episodes ( keep INR of 2-3) or T aspirin 150 mg/day(in low risk pts) or newer
anticoagulants like Apixaban 5 mg BD.In the absence of contraindications it is usually
appropriate to initiate systemic anticoagulation with heparin(2500 IU iv BD) immediately
or with an oral anticoagulant that has rapid onset of action, while evaluation and other
therapies are implemented. When AF has been present for >48 hrs and in pt at high risk
for thromboembolism, such as those with mitral stenosis or HCM, conversion to sinus
rhythm is a/w an increased risk of thromboembolism. Thromboembolism can occur soon,
or several days after restoration of sinus rhythm if appropriate anticoagulation measures
are not taken. Pts without MS are often referred to as having nonvalvular AF.CHA2DS2-
VASc score can be used to estimate stroke risk in these patients.
5.Digoxin is indicated in pts in cardiac failure with AF-0.5 mg in 20 ml NS over 20 min.
On discharge, T Dilzem 90/60/30 mg tds or T cordarone(amiodarone) 200 mg bd/tds for
2 weeks, then 200 mg BD for 2 weeks f/b maintenance dose of 200/100 mg OD.

Atrial flutter
Treatment same as that of AF

MAT(multifocal atrial tachycardia)

Treatment includes correction of possible precipitants such as hypokalemia,
hypomagnesemia, and hypoxia.
Rx - CCB(verapamil) or low dose amiodarone

PSVT
P waves not seen, RR interval regular, narrow QRS
Rx
Unstable :Synchronised DC shock(50 J)
Stable Pt: Non pharmacological measures may be tried like carotid massage.
Carotid massage- make pt upright for 5 minutes prior to massage; start cardiac
monitoring; identify carotid sinus location at midpoint b/w angle of mandible and
superior border of thyroid cartilage; auscultate carotid for bruit(if present avoid
massaging, because it may produce embolism);make the neck fully extended and the
head turned away from the side being massaged;start with carotid sinus on right
side;gently touch the carotid sinus observing the ecg rhythm in a monitor;if there is no
change in heart rate, firm pressure is applied with a gentle rotating motion;massage
carotid firmly but gently;donot apply so much pressure to occlude carotid;continue
massaging for 5 seconds;observe pt in supine position for 10 minutes. If not successful,
Control the rate using short acting drugs, like Adenosine(DOC) 6mg iv f/b 12 mg after 1-
2 min if needed.Each iv bolus of adenosine should be followed with 20 ml NS flush and
elevation of the limb to ensure drug enters the central circulation before it is metabolized.
Use half of the dose(3mg) if administered via central line, or if the pt is taking
carbamazepine. Larger doses may be required (eg. 18 mg) may be needed in pts taking
theophylline or who consume large amount of caffeine.Adenosine to be used with
caution in pts with asthma/COPD because it can promote bronchospasm.
If adenosine C/I use CCB(non-DHP) viz Diltiazem 12.5 mg(0.25 mg/kg) iv st over 2
minutes, if no response may repeat 0.35mg/kg in next 15 minutes and if effective f/b
infusion @ 5 mg/hr(only for first 24 hours).
Inj Metoprolol 5mg iv bolus over 2 minutes may also be used;then PO 25 mg BD.
 156
Amiodarone 150 mg in 100 5%D over 10 minutes f/b continuous infusion 1 mg/min for 6
hours, then 0.5 mg/min for 18 hours may also be used;then PO 100/200 mg BD.
If rhythm not converted, it may be atrial flutter, ectopic atrial tachycardia, junctional
tacycardia; control rate with diltiazem, beta blockers.
Maintenance therapy may be given with T verapamil 40 mg bd/tds
Do not give adenosine to pts who are unstable or manifest wide complex tachycardia
with an irregular rhythm or a polymorphic QRS complex. Adenosine may be used in
cases of regular wide complex tachycardia with monomorphic QRS complex.
SVT with aberrancy may present as wide complex tachycardia; because differentiation
with VT and SVT with aberrency can be difficult, assume VT is present.
SVT with aberrancy , if definitely identified(e.g old ECG shows bundle branch block),
may be treated in the same manner as narrow complex SVT as given above.
In SVT with hypotension, amiodarone may be used.
Irregular wide complex tachycardia- may be AF with preexcitation(e.g WPW), AF with
aberrancy(bundle branch block)or polymorphic VT/torsades de pointes. Use of AV nodal
blockers like beta blockers ,CCBs, digoxin, adenosine) may precipitate VF and is
therefore contraindicated. If AF with aberrancy manage as irregular narrow complex
tachycardia.Preexcited AF with FVR, may be treated with immediate electric
cardioversion or antiarrhythmic therapy with amiodarone 150 mg iv over 10 minutes.In
polymorphic VT Magnesium sulfate 2g iv over 5-60 minutes f/b infusion may be given.

VT
ECG with ≥ 3 consecutive ventricular ectopics with rate > 100 /min
Non sustained(<30 sec) oral amiodarone + treat underlying cause
Sustained(> 30 sec) asynchronised DC shock, 120-200 J(biphasic), 300 J(monophasic)
If stable wide regular complex tachycardia and uncertain rhythm, start amiodarone 150 mg iv
bolus over 10 minutes.
If unstable synchronized cardioversion/shock: 50-100 J after premedication with midaz 0.1
mg/kg iv

VF/ Pulseless VT
Asynchronised DC shock with maximum joules. Amiodarone 300 mg iv with a repeat
dose of 150 mg iv may be given if unresponsive to 2nd defibrillation,CPR and Adr.

Synchronised cardioversion
Steps
1) Take consent
2) Sedate the pt, usually with midaz 0.1 mg/kg iv st. Usually given as a starting dose of
2 mg iv and repeated if required.
3) Prepare Crash cart
4) Give shock after selecting appropriate charge and pressing SYNC button. Two pads
are placed on the chest of the pt(one at the apex and other at the upper sternum).Apply
firm pressure for contact. For PSVT start with 50 J, VT 100 J, AF 150 J.Repeat shock
with double the joules, if not successful.
5) Wait for 2 to 3 seconds with defib in place to give synchronized shock

Pulmonary embolism
Aetiology:Thrombosis in peripheral veins, Major surgeries, major trauma, indwelling
venous catheter, pregnancy, puerpeurium, woman on oral contraceptives or HRT,
severe burns, malignancy(especially lung CA), immobilization, venous stasis(due to
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polycythemia, dehydration, CCF etc). Risk factors include varicose vein, smoking,
obesity, travel of 4 hours or more in the past month, IBD.
C/f: unexplained hypotension, haemoptysis,unexplained dyspnoea, chest pain,
tachycardia,cough,rales, hiccoughs, pleuritic or chest pain aggravated by deep breaths,
new adult onset asthma, S4, . Other atypical s/s include new onset AF,decreased level
of consciousness, sz,fever, delirium(in elderly),
Inv: ECG(tachycardia, S1 Q3 T3),D-dimer, ABG, WBC, Coagulation study, CXR, Ct pulmonary
angiography
Rx
1.Administer Oxygen
2.Propped-up position
3.Avoid fluid overload.
4.Inj Heparin 5000 IU as iv bolus & Q6H or continous infusion 1300 U/hr or 80 U/kg iv
bolus f/b continous infusion of 18 u/kg/hr
Note:Investigate aPTT(to achieve 2-3 times upper limit of normal,INR to maintain an
INR of 3.
Or Inj clexane 1mg/kg BD or fondaparinux OD or apixaban 10 mg BD for 1 week f/b 5
mg BD or fragmin 200U/kg OD 100U/kg BD/ warfarin.
Warfarin requires 5-10 days of administration to achieve effectiveness as monotherapy.
UFH, LMWH, fondaparinux are the usual bridging agents used when initiating warfarin.
Usual starting dose is 5 mg. Titrate to target INR 2-3. Continue parenteral
anticoagulation for a minimum of 5 days and until two sequential INR values, at least 1
day apart achieve the target INR range for atleast 24 hours.
Note:Suspect PE in unexplained dyspnoea;no baseline investigation is diagnostic.
Start heparin on suspicion of diagnosis.
5.Thrombolysis- considered for pts who are hemodynamically unstable, pts having right
sided heart strain, and high risk pts with underlying poor cardiopulmonary reserve.

Prevention
After major orthopedic sx- inj fondaparinux 2.5 mg s/c OD/ clexane 40 mg(0.4ml) s/c
OD or 30 mg BD/fragmin 2500 or 5000U OD or
T apixaban 2.5 mg BD beginning 12-24 hr postoperatively/ warfarin(INR2-3)/ aspirin 150
mg OD and intermittent pneumatic compression.
High risk non orthopedic sx- UFH 5000U s/c BD/TDS or clexane 40 mg OD or fragmin
2500 or 5000U OD
Medically ill pts(e.g CCF, severe lung disease,CA) during hospitalization- UFH 5000U
s/c BD/TDS or clexane 40 mg OD or fondaparinux 2.5 mg s/c OD or fragmin 2500 or
5000U OD.
Cancer surgery- clexane 40 mg OD, consider 1 month of prophylaxis.
If anticoagulation contraindicated-intermittent pneumatic compression devices.

Hypotension
May be due to dehydration, arrhythmia, some medicines like beta blockers, diuretics,
anti depressants etc
C/f: fainting, light headedness, dizziness, blurred vision, increased thirst,nausea, cold
clammy skin,
Rx
1.Start intravenous drip of NS or RL or DNS, fast infusion.
2.Address the underlying problem
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Shock
C/f: Hypotension, systolic BP < 100 mg Hg, tachycardia > 100 beats/min, cold clammy
peripheries(cardiogenic),warm peripheries(non cardiogenic) tachypnoea(> 20
breaths/min), rapid shallow breathing,drowsiness, confusion, irritability, oliguria,
reduced/elevated JVP, poor or altered cerebral function, hypoxemia, hypothermia, etc
It may be compensated(normal BP with inadequate perfusion) or uncompensated
(hypotension & inability to maintain normal perfusion).
Inv: CBC,URE, LFT,RFT, S electrolytes,RBS, ECG, CXR, ABG, S lactate level,
Blood/urine C /S, coagulation profile, peripheral smear,USG abdomen.
Address the underlying problem(eg sepsis, MI,blood loss, adrenal insufficiency etc)
which may lead to shock.
Chest pain, palpitation, risk factors of MI: Assess ischemia,infarction, arrhythmia, :
cardiogenic shock
Fever, look for focus of infection: septic shock
Drug intake/trigger food/insect bite- look for stridor, wheezing, hives: Anaphylactic shock
History of trauma, assess blood loss, absent breath sounds, elevated JVP:
Hemorrrhagic shock, pneumothorax, cardiac tamponade
Evidence of GI bleed or gastroenteritis,acidosis, severe burns, vomiting,
diarrhoea,assess volume status: Hypovolaemic shock
Brain & spinal cord injury: Neurogenic shock
Pleuritic chest pain, shortness of breath & leg swelling, look for unexplained tachycardia,
hypotension, hypoxia: pulmonary embolism
Drug ingestion, steroid withdrawal, look for unexplained bradycardia, hypotension:
adrenal crisis
Severe back pain, look for pulsatile abdominal mass: look for aortic aneurysm.
Rx
First priority is to maintain vital functions, Take care of ABC
Airway-Keep O2 saturation above 94%. if the pt cannot protect the airway, has a GCS
score<8 in shock, has extremes of respiratory rate or is hypoxic despite supplemental
oxygen, ET is indicated.
Circulation-Establish multiple (atleast two) large bore peripheral IV access and place on
a cardiac monitor
1.volume resuscitation to correct hypovolemia. Aggressive volume resuscitation is
important in septic shock. Position the patient-give head low position & lift up of legs
2.Central venous catheter and arterial catheter placement should be considered.
3.Blood support with a vasopressor
4.Ensure adequate tissue perfusion and keep the pt warm.
5.Address the underlying problem
Sympathomimetics in shock (refer pg no 198-200 for infusion chart )
Dopamine is given if there is associated cardiac failure/cardiogenic/septic shock.
5-20 mcg/kg/min infusion. Start with Dopamine 400mg(10ml) in 500 ml 5D @ 8 dps/mt
for 60 Kg (5 mcg/kg/min) or 5ml(1amp) +100 ml NS @ 3 drops/min(5 mcg/kg/min).
check BP half hourly & inc or dec no of dps. Dopamine c/I in hypovolaemic shock.
Noradrenaline:it is more potent vasoconstrictor than dopamine & it is the most useful
vasoconstrictor in septic shock. 0.05-5 mcg/kg/min infusion. 4ml Norad +500 ml NS @ 6
dps/min(5 mcg/min) or 1 ml(1 amp) + 100 ml NS @ 10 dps/min(5 mcg/min).
Dobutamine: it is the most useful inotropic agent in cardiac failure.5-20 mcg/kg/min
infusion. 5ml(1amp) Dobutamine + 500 ml NS @6 drops/min(2.5 mcg/kg/min) or 5 ml +
100 ml NS @ 3 drops/min(5 mcg/kg/min).
 159
Management of sepsis- start antibiotics
Bicarbonates in shock. If pH <7 and HCO3 <10 a partial correction of acidosis is
acceptable. Calculate bicarbonate deficit, (normal HCO3 -patients HCO3) x 0.5 x body
wt in kg. Slowly infuse half of calculated deficit. Infuse the remainder in next 6-8 hours.
Stop infusion when arterial pH=7.25

ACS-STEMI
Described in detail in medicine section pg no 44
Rx
Give loading dose of aspirin 325mg , clopilet 300 mg/ Brilinta 180 mg, atorva 80mg/
rosuvastatin 40 mg,sorbitrate 10mg s/l st
Admit the pt in ICU
1.Absolute Bed rest
2.Hourly BP, PR; Q4H temp chart
3.If pt is in severe pain give Inj Morphine 2-4 mg iv st + Inj phenergan 25 mg iv st
4. Thrombolysis if not contraindicated. Inj SK 1.5 MU in 100 ml NS over 1 hr with
continous BP monitoring or Inj TNK(tenecteplase) iv bolus st.
In case of allergy to SK, administer efcorlin, avil.
Note: thrombolysis is indicated if given within 12 hours of onset of symptoms & it is most
effective when given in the first 3 hours of symptom onset.
Thrombolysis is C/I in pt’s with ST depression(unless posterior MI suspected)
5.Inj NTG 50 mg in 1 pint NS starting at 2 drops/min(for relief of chest pain & or control
of BP)(titrate upwards to a max of 12-14 drops).
6.T Ecospirin 150 0-1-0
7.T Clopidogrel 75 1-0-0
8.T Atorva 20-40 mg 0-0-1
9.T Metolar 25-100 1-0-1(β-blockers are not given if HR,60/1’ or systolic BP< 90 mm Hg)
10.T Envas 2.5-5 mg 1-0-1, if BP stable.
11.T Sorbitrate 10 mg s/l tds(after checking BP) & 5mg s/l sos
12.T Rantac 150 1-0-1
13.Syp Lactulose 30 ml HS(as stool softner)
14.T Alprax 0.25 mg HS

Contraindications for thrombolysis

Prior intracranial hemorrhage (ICH)
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Severe uncontrolled hypertension(unresponsive to emergency therapy)
Intracranial or intraspinal surgery within 2 months.
Significant closed head trauma or facial trauma within 3 months.
Relative contraindications
Active peptic ulcer, pregnancy,dementia, h/o prior ischemic stroke not within the last 3
months, concurrent use ofan anticoagulant that has produced an elevated INR higher
than 1.7 or a PT> 15 seconds, recent (within 2-4 weeks) internal bleeding, traumatic or
prolonges CPR(>10 minutes) or major surgery less than 3 weeks previously, significant
BP on presentation(SBP>180, DBP>110),noncompressible vascular punctures.
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COPD a/c Exacerbation
C/f: seen more in males than females, more than 50 yrs of age, breathlessness(dyspnoea on
exertion)> 2 yrs duration,cough with expectoration, seen in smokers, presents as exacerbation
of breathlessness, increase in RR, use of accessory muscles of respiration. Look for cyanosis &
features of respiratory failure(flapping tremor, bounding pulse, cyanosis & drowsiness). look for
elevated JVP, edema(to r/o cor-pulmonale). chest- barrel shaped, air entry reduced bilaterally,
expiratory wheeze can be heard. Crepitations indicate infection.
Inv: SPO2, CXR, CBC, ECG(to r/o cardiac cause), ABG(to look for respiratory acidosis), CXR:
required only if there is suspicion of pneumothorax or malignancy or pneumonia. Spirometry is
needed for definitive diagnosis & long term management is based on post-bronchodilator
FEV1(in COPD FEV1<80%).
Rx of a/c exacerbation:
1.Oxygen inhalation at 2L/min if SpO2 < 90%, propped up position, Q4H Temp chart.
NIV may be used in presence of respiratory acidosis and pH b/w 7.25-7.35.
2. Nebulisation with Duolin (ipratropium bromide+ levosalbutamol) + Budecort sos &
Q6H/Q8H
3. Inj Hydrocortisone 100mg iv st, then Q8H
If orally tolerable, give oral prednisolone 1-2 mg/kg (usually 30 mg OD for 5 days)
If very severe we can give Inj Methyl Prenisolone 120mg iv stat, followed by 60 mg iv Q8H
4.Inj terbutaline 0.5ml S/c Q8H
5. Inj deriphyllin I amp iv st. Inj aminophyllin 250/500 mg in 250/500 ml NS/ 5D Q8H over
4 hr (treatment of asthma & COPD exacerbations with aminophylline is not
recommended by current guidelines).
Note: deriphyllin may cause tachycardia, whereas aminophyllin has better cardiac profile.
6. If crepitations present add antibiotics: Tab Azithromycin 500 mg OD x 5 days or
Moxclav 625 1-1-1 x 5 days
7.Inj Monocef 1g iv BD ATD + Inj levofloxacin/ Azithromycin 500mg iv OD.
Indications for antibiotics in the presence of 3 cardinal symptoms: increased dyspnoea,
sputum volume and sputum purulence or any two out of the three cardinal symptoms if
one of the symptoms is sputum purulence & pt with a need for mechanical ventilation.
8.Inj Pantoprazole 40 mg iv OD
9.T prednisolone 10 mg tds (after a/c phase).
Note: In COPD pts not responding to treatment, suspect pneumothorax
At discharge also prescribe Levolin 50mcg MDI 2 puff SOS(GOLD≥1), T Deriphylline,
asthalin, ambroxol etc.
If persistent symptoms(GOLD≥2) start Duova (formoterol-LABA ,6mcg+ tiotropium-LAMA,
9mcg) MDI 2 puff OD or RC(12 + 18 mcg) 1 OD
If still persistent symptoms or further exacerbations(GOLD≥3) add inhaled steroid. start
Seroflo (salmeterol + fluticasone) 125 or 250 MDI 2 puff BD or Rotacap(RC) 1 BD; or
foracort (formoterol + budesonide) 200 or 400 MDI 2 puff BD or RC 1 BD +
Tiova(tiotropium-LAMA) 9 mcg MDI 2 puff OD or 18 mcg RotaCap(RC) 1 OD, + levolin MDI
sos.
If 2 puffs are to be taken, wait for 1 minute , shake well before taking 2nd puff.
For Smoking cessation- T champix(vareniciline) 0.5 mg OD x 3 days, f/b 0.5 mg BD x 4
days f/b 1 mg BD till end of treatment. May be given for 12 weeks. Dose adjustment may be
necessary with drugs such as theophyllin, warfarin, insulin or Nicotex chewing gums 2 mg
starting from 12 gum per day tapered to 1 gum per day over a period of 12 weeks or
T Zyban(bupropion) 150 mg ODx 3 days f/b 150 mg bd x 4 days f/b 150 mg bd x 7 days
(stop smoking by day 8) and continue bd till end of treatment.
 161
Acute renal failure
Rise of S creatine by atleast 0.3 mg/dl or more within 48 hrs or 50% higher than
baseline with in last 7 days or urine output decreases to <0.5 ml/kg/hr for > 6 hours
Etiology- prerenal(m/c)- hypovolemia, cardiogenic shock
Renal/intrinsic- ATN,GN, vascular, interstitial
ATN may be due to ischemic, septic,toxic(contrast, drugs like aminoglycosides,
amphotericin B, myoglobin etc)
Post renal-retention, obstruction due to stone/ stenosis/ tumour etc
C/f- preoliguric stage- lethargy, headache, N,V
Oliguric- uremia(earliest)-↑BUN & S creat,N,V, hiccough
Electrolye imbalance(↑ K+, Mg2+, P, ↓ Ca2+),vit D deficiency, metabolic acidosis, anemia
Hyperkalemia may cause parasthesias, general weakness, flaccid paralysis, depressed
reflexes
diuretic stage-u/o increased to around 1000 ml in 24 hours
Inv- CBC, RFT including BUN,LFT,S electrolytes,RBS, S iPTH, Vit D 25(OH), ABG,
URE, urine albumin/creatine ratio,S LDH, peripheral smear,ECG, CXR, X-ray/USG KUB
etc
Rx
1.Correct fluid imbalance if any. Restore BP.
Maintain strict I/O chart, daily wt, daily RFT/electrolytes,
Restrict protein intake. For volume overload- salt & water restriction, diuretics. In
euvolemic pts, without edema aim for a positive balance of 500 ml/day(hourly
input=previous hours output plus 25 ml)(plus 200 ml may be added per degree of fever
if any). In pts with edema fluid intake in 24 hours should be less than the volume of
urine produced per day.
Sufficient protein and calorie intake(20-30 kcal/kg per day) to avoid negative nitrogen
balance
2. Treat the cause/infection/anemia
3. Avoid Nephrotoxic drugs like NSAIDs
4. Diuretics for fluid overload & hyperkalemia. In severe cases of volume overload lasix
may be given as a bolus 200 mg f/b iv infusion (10-40 mg/hour) with or without a
thiazide diuretic.
5. If metabolic acidosis, give soda bicarb iv or oral(if pH<7.2 to keep serum bicarbonate
>15 mmol/L). Overcorrection should be avoided because of the possibility of met
alkalosis, hypocalcemia, hypokalemia, volume overload.
6. Treat electrolyte abnormalities like hyperkalemia(refer pg no 160),
hyponatremia(restrict fluids, minimization of hypotonic iv fluids including those
containing dextrose, don’t use hypertonic saline, refer pg no 134),
hyperphosphatemia[restriction of dietary phosphate intake, phosphate binding agents
like sevelamer(800 mg tds with meals), aluminium hydroxide, calcium acetate],
hypocalcemia( calcium carbonate or ca gluconate if symptomatic)(monitor ionized
calcium rather than total calcium when hypoalbuminemia is present),
hypermagnesemia(stop Mg containing antacids) and hyperuricemia(a/c treatment
usually not required except in the setting of tumour lysis syndrome)
7. Fundus examination to r/o retinopathy in diabetic pts
8.Indications for RRT-hyperkalemia not responding to medication, severe metabolic
acidosis, fluid overload, pulmonary edema, progressive azotemia, uremic
encephalopathy/pericarditis
 162
A/c on CKD
As the GFR progresses to decline and reach stages 3 & 4, clinical and lab
complications of CKD become more prominent. The most evident complication is
anemia a/w easy fatiguability.
C/f- fatiguability, anemia, gastritis,sz(due to water intoxication), myopathy, peripheral
neuropathy, restless leg, encephalopathy, nocturia, impotence
Inv: BRE, URE, RFT, LFT, ECG,RBS, Urine C & S, USG abdomen, CXR, S.Ca/P, iPTH
Rx
1.Q4H temp chart
2.Daily I/O chart, weight chart,RFT, RBS, ABG,hemogram
3.Restrict Na+, K+
4.Input= output + 500 ml
5.Inj lasix 40 mg iv Q8H(use diuretics if oedema, oligura,weight gain, hyponatremia,
uncontrolled HTN) or T Lasix 40 1-1-0
6.Treat hyperkalemia
7.If acidosis : T sodabicarb 500 1-1-1 one hour Before food(T.N Acidose/Nodosis)
Note: for rapid correction give Inj soadbicarb 7.5 % 100 ml over 20-30 minutes. IV
correction is usually given only if pH<7.2.
8.T shelcal 500 mg OD/BD
9.T Alfa D 0.25mcg OD(alfacalcidol)
10.Treat underlying factors like anaemia,infection, DM, HTN, hyperlipidemia, obstruction.
For mild anemia: iron & folic acid supplements; if severe: Recombinant Human
Erythropoietin(EPO) Alfa (TN- Espogen) 50-100 units/kg slow iv/sc 2-3 times weekly.
Usually Initiated when Hb level <10g/dL.Increase by 25 U/kg monthly till Hb adequate.
Then maintain with 50 U/kg/week in 2-3 divided doses. If Hb level approaches or >11
g/dL in CKD pts on dialysis or Hb level >10 g/dL in CKD pts not on dialysis reduce or
interrrupt dose.Inj EPO beta (TN- mircera )(usual adult dose 100 mcg s/c once in 2
weeks) may also be used.
Note-Correct iron deficiency before starting EPO. For dialysis dependent pts- Inj Enofer
(iron sucrose) 5 ml(100mg) iv per dialysis session not to exceed total cumulative dose
of 1000mg divided in 3 doses/week. For non-dialysis dependent CKD pts 200 mg iv inj x
5 doses in over 14 days.(cumulative 1000 mg in 14 days)
11.T sevelamer 800 mg1-1-1(T N- revlamer, sevagel)(phosphate binding drug; used in
pts with CKD and on dialysis)
12.Inj carnitor (levo carnitine) iv bolus over 2-3 min; administer into venous return line
after dialysis session. Indicated for ESRD pts on hemodialysis. Initial Dose - 10-20
mg/kg bolus. Downward dose titration may begin as within 3-4 weeks after initiating.
Later may be given as 5ml(500 mg) per dialysis session.
13.Dialysis if indicated(hyperkalemia not responding to medications, severe
acidosis(pH<7.2 and refractory to HCO3 or unable to give HCO3 due to volume
overload; fluid overload, pulmonary edema, progressive azotemia, uremic
encephalopathy, sz,pericarditis, deteriorating clinical status etc).
In CKD dialysis should be instituted whenever the GFR is <15 mL/min and there is one
or more of the following: symptoms or signs of uremia, inability to control hydration
status or BP or a progressive deterioration in nutritional status.
Nephrology consultation

Hyperkalemia
(S. K >5.4 mEq/L), mild(5.5-6), moderate(6.1-7), severe(≥7)
+

C/f: muscle weakness/cramps,palpitations,chest pain, nausea or vomiting,dyspnea,

 163
paraesthesia, hypotonia, focal deficits,
Inv-ECG, S K+,CBC, ABG(if acidosis is suspected),RFT, S uric acid & Phosphorus(for
tumor lysis syndrome), CPK & Ca(for rhabdomyolysis)
ECG: tall peaked T waves,prolonged PR & QRS, loss of P waves,sine wave pattern.
Rx
1.Nebulisation with salbutamol Q8H
2.Inj Ca gluconate 10% 10 ml over 10 min iv Q8H(only if ECG changes are present).
3.Inj RI(actrapid) 8U or 10U in 25% D 100 ml iv Q8H.
4.K-bind 1/3 rd sachet(5mg)(calcium polystyrene sulfonate) in 10 ml sorbiline (tricholine
citrate, sorbitol) TDS.
5.Inj Lasix 20 or 40 mg iv st(to increase K+ excretion)
6.Correct severe metabolic acidosis with sodium bicarbonate. IV correction is required
only if pH<7.2.
7.Restriction of dietary K intake, stop K sparing diuretics, ACEI,ARBs, NSAIDs
8.Emergency dialysis - for pts with lethal hyperkalemia unresponsive to conservative
measures.

Hypokalemia
(K+ <3.5 mEq/L)
If S. K+ >2.5 give Syp Potklor (Pottasium chloride) 1-2 meq/kg/day in 1 glass
water(15ml=20 meq =1.5g )if normal urine output. Oral doses of 40 mEq are generally
well tolerated & can be given as often as every 4 hours. Traditionally, 10 meq of
pottasium are given for each 0.10 mEq/L decrement in S. K+. Monitor S. K+ every 4
hr.Monitor ECG, urine output.If S. K+ <2.5 , give iv pottasium. Administer 4 g of Inj KCl
in 100 ml of NS over 4 hrs. Replace at 10 -20 mEq/hr if urine output is normal.

Hyponatremia
S. Sodium < 135 mEq/L
Note: Pt’s with acute hyponatremia( developing over 48 hours or less) are subject to
cerebral edema, which is the primary cause of morbidity & death.
C/f:Headache, confusion, lethargy, agitation, obtundation, coma or status epilepticus,
anorexia, muscle cramps
Rx
In acute hyponatremia, the therapeutic goal is to increase the S. sodium level rapidly by
4-6 mEq/L over the first 1-2 hours, especially in pts with seizures, severe confusion,
coma or signs of brainstem herniation.
Administer hypertonic saline(3%) to rapidly correct sodium level towards normal, but
only enough to arrest the symptoms. However it should be reserved for life threatening
cases, since there is the risk of pontine myelinosis.

Asymptomatic: Oral NaCl supplementation like salt capsules

Symptomatic: IV correction
Oxygen inhalation to pts with lethargy or obtundation
Manage seizures, if present
Rate of correction is over 48 hours. Correct half the deficit in 24 hours.Correcte at a rate
not to exceed 10-12 mEq/L in the first 24 hours and not to exceed 18 mEq/L in the first
48 hours.
Exception to the rule would be pts with Na+<105mEq/L with symptoms such as status
epilepticus.
Usually given as 3% NS 100ml over 4-6 hours.
 164
In euvolemic & hypervolemic hyponatremia, restrict fluid & give T Natrise (tolvaptan)15
mg OD.
In hypovolemic hyponatremia give iv Normal saline, care being taken to avoid rapid
raise in S. Na+ level.
Note: One litre of NS contains 154 mEq of Na+. One litre of 3% NS contains 513 mEq
of Na+.

Hypocalcemia
<8.5 mg/dl. In true hypocalcemia, ionized S ca, is also low(<4.6 mg/dl)
Correction formula, add 0.8 mg/dl to S ca level with every 1 g/dl fall in S albumin level
below 4 g/dl.
Etiology-ARF, a/c pancreatitis, drugs(diuretics, heparin etc), sepsis, burns,
hypomagnesemia, hypoparathyroidism,parathyroid surgery, malignancy, vit D deficiency,
rhabdomyolysis, hypoalbuminemia, malabsorption,medullary ca thyroid
C/f- tetany, paraesthesia(perioral, limbs), irritability, depression, psychosis, arrhythmia,
prolonged QTc, precipitation of HF, sz etc
Inv- S electrolytes, including ionized S ca & S Mg, ABG, ECG
Rx
1. mild to moderate hypocalcemia- oral supplementation of Ca & vit D.
2. Severe symptomatic hypocalcemia- iv Ca gluconate 10 ml 10% over 10 minutes f/b
infusion 60 ml in 500 ml glucose at a rate of 0.5-2 mg/kg/hr. Monitor S ca every 4-6 hrs
and infusion rate adjusted to keep S ca between 8-9 mg/dl.
3. Correct hypomagnesemia if present. If tetany is not relieved by giving ca, Mg may be
tried. Hypocalcemia due to hyperventilation(alkalosis) may be overcome by rebreathing
expired air in a paper bag.

Hypercalcemia
Acute hypercalcemic crisis can lead to development of systolic arrest of the heart.
Rx
IV Normal saline & subsequent lasix drip. 200-500 ml/hr of NS should be aministered to
maintain a urine output of > 100 ml/hr
NS will cause hydration and once the rehydration is complete then initiate lasix drip(for
hypercalcemic crisis a/w heart failure/renal failure). This will lead to urinary loss of
calcium.
Steroids(dexamethasone) are effective in the treatment of hypercalcemia when a/w
malignancy, sarcoidosis, vit D intoxication.

Delirium
Sudden transient, usually reversible confusional state occuring with physical / mental
illness. Can occur in ICU pts as ICU psychosis, assessed by CAM-ICU scoring.
C/f:disorientation to time/place/person(hallmark), decreased attention, fluctuating
confusion, disorganized thinking, decreased mobility, incontinence & obtundation.
Aetiology: infections, metabolic & electrolyte abnormalities, hypoglycemia, alcohol or
sedative withdrawal,hypoparathyroidism etc.
Inv: pulse oximetry, ECG, RBS, CBC, electrolytes, URE, LFT, RFT, CT head, LP.

Delirium tremens
Most severe manifestation of alcohol withdrawal and occurs 3–10 days following the last
drink being worst on the fourth or fifth day.
 165
Rapid onset of confusion usually caused by abrupt withdrawal following high intake of
alcohol for long period.Commonly affects those with a history of habitual alcohol use >
10 years.
It may also be triggered by head injury, infection, or illness in people with a history of
heavy use of alcohol,abrupt stopping of tranquilizer drugs of the barbiturate or
benzodiazepine classes in a person with a relatively strong addiction to them.
C/f:shaking, shivering,nightmares, agitation, global confusion, disorientation,
visual,auditory,tactile hallucinations, fever,seizures, heavy sweating, and other signs of
autonomic hyperactivity (pupillary dialatation,fast heart rate and high blood pressure).
Occasionally, a very high body temperature.feelings of impending doom, severe
anxiety,uncontrollable tremors of the extremities, panic attacks and paranoia.
Symptoms are characteristically worse at night.
DT should be distinguished from alcoholic hallucinosis.
Rule out other associated problems such as electrolyte abnormalities, pancreatitis, and
alcoholic hepatitis.
Prevention is by treating withdrawal symptoms. If delirium tremens occurs, aggressive
treatment improves outcomes.
Rx
Treatment in a quiet intensive care unit with sufficient light is often recommended.
1.Benzodiazepines are the DOC.High doses may be necessary to prevent
death.Amounts given are based on the symptoms.The pt is kept sedated with diazepam,
lorazepam, chlordiazepoxide(50-100 mg q4H)
In cases not related to alcohol, antipsychotics, such as haloperidol may also be used.
Antipsychotics may reduce the seizure threshold in pts with alcohol withdrawal delirium
and should be avoided.
2.Inj thiamine 100 mg iv or IM for 3 days
3.Acamprosate is occasionally used in addition to other treatments, and is then carried
on into long-term use to reduce the risk of relapse.

ARDS
Etiology, pulmonary- pneumonia,gastric aspiration, inhalation, injury, vasculitis, contusion.
Others- shock, septicemia,hemorrhage, multiple transfusions, DIC, pancreatitis, a/c liver failure,
trauma, head injury, malaria, fat embolism, burns, drugs/toxins, eclampsia, amniotic fluid
embolism
C/f-cyanosis, tachypnoea, tachycardia, b/l fine inspiratory crackles
Inv-CBC,RFT, LFT,CXR,ABG, blood c & s, S amylase,crp,
Diagnostic criteria-1. a/c onset 2.cxr-b/l infiltrates 3. absence of CHF 4.refractory hypoxemia
with PaO2:FiO2<200
Rx
Admit in ICU. Give supportive treatment. Treat the cause.
Respiratory support. In early ARDS, CPAP with 40-60% O2 may be adequate to
maintain oxygenation. But most pts need mechanical ventilation with FiO2≤0.6, I:E>1
A low tidal volume, pressure limited approach, low to moderate high PEEP (12-15 mm
Hg) improves outcome.
 166
Circulatory support-A conservative fluid managment approach improves outcome.
Maintain cardiac output & O2 delivery with inotropes, vaso dilators and blood
transfusion.
Manage Sepsis- identify organism & treat.
Nutritional support

CVA
C/f: in addition to usual history taking the following points should be asked: a)time of
onset, this is very important if thrombolytic therapy is to be considered. If the pt is
presenting within 4-5 hrs(golden period) of stroke onset then thrombolysis with
recombinant tissue plasminogen activator may be done. b)h/o systemic
HTN/DM/dyslipidemia. H/o arrhythmias, valvular heart disease, prosthetic valves.
Look for rhythm abnormalities(AF), bradycardia(cushing’s reflex),
Relevant neurological examination: assess sensorium, check pupillary reflexes, neck
stiffness. DTR, plantar reflex. If sensorium is normal assess the tone and power

Other S/s: Change in alertness,consciousness, sense of

hearing/taste.Clumsiness/Confusion/ loss of memory, balance,
coordination.Seizure/weakness in the face,arm,or leg (usually unilateral). Difficulty in
swallowing/ writing / reading/ walking/ speaking/ understanding others;Lack of control
over the bladder or bowels.Dizziness, vertigo,headache, decreased vision, double
vision, or total loss of vision.Numbness or tingling on one side of the body; Personality,
mood, or emotional changes. Changes that affect touch and the ability to feel pain,
pressure, or different temperatures.
Young male with spontaneous sudden onset headache with seizure should raise
suspicion of aneurysmal SAH.
SDH’s are common in old age, alcoholics & a/w anticoagulants.
Inv: Plain CT Brain, ECG, FBC, RBS,S electrolytes, BRE,LFT,RFT, S cholesterol,PT-INR and APTT if
planning for thrombolysis, carotid doppler, echo
CT scans obtained in <6 hrs(may be upto 24-48)hrs of an ischemic infarction generally show no
abnormality.
Rx
If CT report pending
1.RTF(for pts with dysphagia, dysarthria or facial deviation)/CBD
2.Inj Mannitol 20% 100ml over 20 min iv Q8H(if sensorium is altered)
3.Inj Ranitidine 50 mg iv Q8H
4.C Diamox(acetazolamide) 250 1-1-1
5.T Atorva 10 mg 0-0-1

If CT shows IC Bleed
1.RTF/CBD, Q4H temp chart.
2.Inj Mannitol 20% 100ml over 20 min iv Q8H
3.Inj Ranitidine 50 mg iv Q8H
4.Inj eptoin 100 mg iv Q8H
Note: antiepileptics are required only in case of a lobar hemorrhage. Prophylactic anti
epileptics are not advised. Also, phenytoin is not the ideal antiepileptic in stroke due to
its drug interactions. So levitiracetam is advisable(inj levipil 500 mg iv Q8H)
5.T Atorvastatin 10 mg 0-0-1
6.Syp Cremaffin/lactulose 30 ml tds
7.C Diamox 250 1-1-1
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8.IVF as /if necessary
9.T Amlo 2.5-5 mg bd to maintain a target BP of 150/90
10.Oral glycerine 30 ml tds for 3-5 days
11.Frequent change of position, intermittent throat suction if unconscious(to prevent
aspiration). Keep the back dry. Use water or air bed.
12.Neurosurgery consultation

If CT shows SAH also give T Nimodipine 30 mg 2-2-2-2-2-2, to prevent vasospasm of

surrounding vessels. May cause symptomatic hypotension. Hence judicious use of drug
+ volume expansion + vasopressors(norad) is used.Combination of induced
hemodilution, hypertension, hypervolemia, (triple H therapy) is used to prevent and
treat cerebral vasospasm in aneurysmal SAH.

If CT shows Infarct
In a case of a/c ishemic stroke, if the pt reaches within 4.5 hrs of onset of stroke then
thrombolysis with rTPA may be considered. If the pt is seen out of this window period
then management is as follows
1.RTF/CBD, BP chart,Daily RBS monitoring, Q4H temp chart. Fever is detrimental.
2.Inj Mannitol 20% 100ml over 20 min iv Q8H
3.Inj Ranitidine 50 mg iv Q8H
4.T Ecospirin 325 mg st & 150 0-1-0(if no C/I and not within 24 hrs of t-PA)
5.T Atorvastatin 10 mg 0-0-1
6.Syp Cremaffin 30 ml tds
7.C Diamox 250 1-1-1
8.Inj Strocit(citicholine) 500 mg tds or T Strocit 500 mg 1-1-1 for 3-5 days
9.T Amlo 2.5-5 mg bd to maintain a target BP of 150/90
10.Oral glycerine 30 ml tds for 3-5 days
11.IVF as /if necessary
12.Neurosurgery consultation
13.Frequent change of position, intermittent throat suction if unconscious.
14.Spasticity may be treated with baclofen or tizanidine.
15.In cardiogenic embolism(AF, artificial valve), heparin & warfarin.
16.DVT prophylaxis if pt unable to walk- limn physiotherapy, pneumatic compression
stockings, s/c heparin etc
Kep the head in neutral alignment with the body and elevating the head of the bed to
300 for all pts in a/c phase of stroke who are at risk of raised ICP, aspiration or
worsening cardiopulmonary status.

Mx of HTN in a/c stroke:

Ischemic stroke: perfusion pressure in areas of brain distal to the arterial occlusion may
be low.cerebral perfusion depends on mean systemic arterial pressure. Thus a degree
of HTN may be necessary to maintain adequate perfusion pressure. Therefore
aggressive lowering of BP is not advised in acute ischemic stroke. Reduce BP only if >
220/130.Target BP should be <185/110 mmHg if pt eligible for thrombolysis. Anti-
Hypertensives are withheld for atleast 5 days after thromboembolic stroke. But in case
of hypertensive crisis with end organ involvement or congestive heart failure or systolic
BP >220 or diastolic BP>120, antihypertensives should be added.
Hemorrhagic stroke:hematoma expansion may occur with acutely elevated BP.
Reduction of BP is advised in hemorrhagic stroke to a mean arterial pressure of 130
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mm Hg.Keep SBP<160.Aggressive Reduction of BP if > 220/130. check BP every 5
minutes.
If SBP>180 & no evidence of raised ICP then consider modest reduction of BP with a
target of 160/90 and peform clinical examination of the pt every 15 minutes.
If SBP>180 & ICP may be elevated, reduce BP using intermittent or continuous Iv
medications.
In pts p/w SBP of 150 to 220 , acute lowering of SBP to 140 is probably safe.
In pts with aneurysmal SAH, lower SBP<160 acutely to reduce rebleeding.

Physiotherapy in post stroke pts

Must be started as soon as pts condition is stable. For pts with grade 0 power, passive
movement exercises in full range of movement is advised. For hemiparesis, both active
and passive movements must be encouraged. Position change atleast 2 hourly to
prevent bed sores

Indications for thrombolysis in stroke- clinical diagnosis of stroke, onset of s/s to time of
drug administration <4.5 hrs, age >18 yrs, CT scan showing no haemorrhage or edema
>1/3rd of the MCA territory.
Contra-Indications of thrombolysis- sustained BP >185/110 despite treatment, bleeding
diathesis, major surgery in last 2 weeks, GIT bleeding in last 3 weeks,recent MI, coma
or stupor, recent history of stroke(within previous 3 months), use of heparin within 48
hrs and prolonged PTT or PT, platelet count <1 lakh, haemocrit <25% and blood
glucose <50 or >400 mg%, rapidly improving symptoms

Needlestick injuries
Immediate care
For needlestick injuries & for skin exposure: wash with soap & water.Do not scrub.Do
not use antiseptics or skin washes.
For mucous membrane splash e.g eyes: make the pt lie down, open the concerned eye
& allow 1 pint of NS (connected to an iv set) to run freely into the conjunctival sac.
Treatment
 Exposure to Hepatitis B positive pt. If not vaccinated administer HBIG x one dose &
Initiate vaccination.
If previously vaccinated, Test for anti-HBs antibody levels.
If anti-HBs antibody > 10 mlU/ml- reassurance & no specific treatment is needed;
if anti-HBs antibody < 10 mlU/ml- administer HBIG x one dose & Initiate revaccination.

 If exposure to HCV source: check for HCV antibody & LFT at 0, 3 & 6 months, &
follow-up.
 Exposure to HIV source:first check HIV status, immediate chemoprophylaxis( Pg
No.100) & test for HIV antibodies after 6 weeks, 3 months & 6 months following the
exposure.

Adrenal crisis
It is a medical emergency. It is caused usually due to rapid withdrawal of longterm
steroid therapy, drugs such as ketoconazole, phenytoin, rifampin & frequently due to
septic shock.
C/f: unexplained shock, usually refractory to resuscitation. H/o nausea, vomiting,
abdominal pain, hyperthermia or hypothermia.
Inv: RBS, S.cortisol, electrolytes, creatinine, WBC count.
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Rx
1. Inj hydrocortisone 100 mg iv bolus (after collecting sample for S.cortisol level) Q6H,
until pt is stable.
2. Replenish volume deficit.

Hanging
Inv: CXR, x-ray c-spine, ABG, electrolytes,creatinine, CT- brain with C-spine screening.
Early aggressive oxygenation is life saving; majority of pt’s recover with ventilator
management.
Rx
1.Oxygen by face mask at 8L/min. Intubate & ventilate if SpO2 <90 % or GCS <9
2.Protect C-spine with hard cervical collar until x-rays have ruled out fracture.
3.Inj Mannitol 20% 100 ml iv st over 20 minutes
4.Inj Dexona 8 mg iv st & tds or Inj Methyl pred 1g iv st (to prevent tracheal edema).
5.Inj eptoin 100 mg iv q8h for prevention & control of seizure.
6.Inj Rantac or Pantop
Note: aggressive behaviour is due to hypoxia & should prompt ventilatory management.
Associated methods of DSH such as poisoning or drug overdose should be kept in mind.
ARDS or aspiration pneumonia is a frequent event.
All DSH pt’s need psychological evaluation & support, prior to discharge.

Drowning(Submersion injury)
C/f: altered consciousness,cardiopulmonary arrest, tachypnoea, dyspnoea, hypoxia,
metabolic acidosis,
Inv: ECG, ABG, RBS, electrolytes, CXR,X-ray c-spine(to r/o neck involvement in diving
accident), CT Head(in pt’s with altered mental status or unclear history), bronchoscopy may
be necessary for removal of inhaled sediments. Examine oral cavity.
Rx
1.100% O2 by mask. Airway suction,OPA. If pt still dyspnoeic use CPAP or intubate.
Decompress the stomach using a nasogastric tube to lessen any risk of aspiration.
2.Monitor blood sugar, BP (for hypotension),SpO2, ECG( for dysrhythmias)
3.Inj methyl pred 1g iv st or Dexona 8 mg iv st & tds
4.Immobilise the neck with hard cervical collar.
5.Aggressive warming is mandatory in the presence of hypothermia. Remove the wet
clothing before the victim is wrapped in warming blankets.
6.Inj taxim 1g iv Q8H; Inj Metrogyl 500 mg iv bd.
7.Treat complications; cerebral edema: IV mannitol; Bronchospasm: bronchodilators (neb
with salbutamol, inj deriphyllin); metabolic acidosis: sodium bicarbonate & mechanical
ventilation; seizures: eptoin; pulmonary edema: lasix.

Electrical injuries
May be due to lightning, low voltage or high voltage electricity.
C/f: burns occur frequently and can result in massive tissue destruction.Entry & exit
burns may be present, but in AC current injury it may not be apparent. Haemorrhage
behind the intact tympanum is an occasional feature in lightning injury; perforation of
the tympanic membrane is common. High energy electrical injury causes massive
muscle damage with myoglobinuria. Tetanic muscle contraction may occur.Current
passing through the brain results in loss of consciousness. Myocardial injury includes
heat injury, coronary artery spasm, myocardial spasm, arrhythmias like VT and VF.
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Ventricular fibrillation may occur if the current passes through the chest, arm to arm,
arm to leg or head to arm. Asystole more likely with high current(>10A). In males burns
may occur on the undersurface of the scrotum.Even low voltage injuries may be fatal if
the skin resistance is decreased by sweat or bath water. Respiratory arrest can also occur.
Lightening strike differs from contact electrocution is that high intensity, ultra short
duration current may produce cardiac arrest with little tissue destruction.
Irregularities of pulse, ECG changes, myoglobinuria or CNS abnormalities require
hospitalisation.
Inv: CBC, ECG,LFT,URE for myoglobin, RFT, CPK,ABG, cardiac enzymes for degree of
myocardial injury.
Rx
1. Administer Oxygen. Plan early intubation for pts with burns above the neck because of
high probabilityof airway and lung damage.
2. Monitor ECG for arrhythmia, especially in high voltage injury.
3. CBD, spine immobilization, removal of smouldering clothes.
4. Hydrate all pts with RL 10 ml/kg/hr during initial resuscitation. Hydration is the key to
reduce the morbidity of electrical injury.
Note- standard burn formulae cannot be used for fluid resuscitation in pts with electrical
burns. Fluid requirements are greater for electrical injury pts.
5. Provide pain relief.
6. Mannitol when there is elevated CPK level & or myoglobinuria. This provides diuresis for
prevention of a/c tubular necrosis & renal failure, secondary to myoglobinuria.
7. Surgical debridement of necrotic tissue and fixation of bony injury if present.Fasciotomy
may be needed to improve circulation in circumferential burns or when compartment
syndrome is suspected.
8. Look for acidosis, if present give bicarbonate. Treat heart failure if present.
Note- electrocution is one of the most common cause of suspended animation. So don’t
hurry in death declaration. Take ecg for confirmation.

Bites and Stings

C/f- pain, edema, warmth, tenderness over sting site, nausea, vomiting, urticarial rash,
tachypnoea, wheezing, respiratory arrest, hypotension, shock, airway obstruction due to
laryngeal edema
Usually encountered are cases involving snake, honeybees,wasps,spiders,scorpion, etc.
Patients with no history of angioedema, bronchospasm, urticaria or anaphylaxis should
be observed for 1 to 2 hrs and carefully monitored for evidence of evolving
anaphylaxis.The wound must be examined for a stinger, which should be removed by
gentle scraping with blade to prevent further envenomation. Do not grasp with forceps
or fingers in order to avoid expressing more venom from the poison sac into the
skin.The wound should be thoroughly cleaned, tetanus prophylaxis administered if
appropriate, and ice applied. Patient who remain asymptomatic 2 hrs after the injury
may be discharged with instructions to return immediately if shortness of breath,
wheezing, generalized pruritus, oropharyngeal swelling, or rash occurs. In scorpion
stings, advise elevation for 24 to 48 hrs
Rx:Check airway, Inj avil, Inj efcorlin, Inj adrenaline(if bronchospasm), remove stings, apply ice ,
elevate extremity to limit edema
Scorpion stings are very painful, so infiltrate the area with lignocaine 2% through the
puncture wound. Look for systemic symptoms. If present refer.
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Centipede bite: Usually requires only conservative management. Local heat application
or immersion in warm water. Severe pain may be managed with locally injected
lignocaine
Observe 4 hours for systemic toxicity.
Update tetanus status, NSAIDs, antihistamines. Prophylactic antibiotics not necessary.
If systemic envenomation is suspected do, URE, RFT, ECG, S electrolytes, CPK, etc. In
a severe case the affected limb can be elevated and administered diuretic medications.

Snake bite-first aid

If an extremity is involved, it should be placed in neutral position below the heart;
intravenous access should n’t be established in the bitten extremity. Wounds should n’t
be incised and oral suction is not recommended. Splint the affected limb.The placement
of an arterial interrupting tourniquet is not advised; alternatively compression or
constriction bands which are placed proximally around the bitten extremity and interrupt
venous and lymphatic flow may be helpful. The band is placed so that a finger slips
under the band and distal arterial pulsations are easily palpated. Bands may be made
from clothing, rope, rubber gloves etc. O2 should be administered and the patient
transported as soon as possible.

Snake bite
Best Initial first aid : Immobilize with splint in the same way as a fractured limb. Use
bandages or cloth to hold the splint, special attention taken not to block the blood
supply or apply pressure. Do not allow the victim to walk even for a short distance; just
carry the pt in any form, specially when the bite is at leg.
Look for signs of envenomation: clotting time>20 min
Bleeding manifestations including hematuria, bleeding from bite site, hypotension
Ptosis, circumoral paraesthesia, vomiting, aphonia/dysarthria, diplopia, pain numbness,
edema spreading from site of bite, respiratory arrest
Cosely monitor the following:PR/BP/urine output, capillary refill time, bleeding
time/clotting time- every 30 minutes for 3 hours, every 3 hours for next 9 hours and 6th
hourly for 24-48 hours, level of consciousness, look for bulbar muscle weakness-
aphonia/dysarthria/diplopia. 20 MIN Whole Blood Clotting test(20WBCT)- a few ml of
fresh venous blood is placed in a clean small glass test tube, and left undisturbed at
ambient temperature for 20 minutes. Then gently tilt the tube(not shaken). if the blood is
still liquid, then the pt has incoagulable blood. If incoagulable blood is detected, then 6
hourly cycle is then adopted to test for the requirement for repeat doses of ASV.
Inv: CBC, electrolytes, RBS, creatinine, coagulation profile, Hb, PCV, plt ct,blood
grouping and cross matching, BT, CT(complete 20 min clotting time is preferred),
peripheral smear- to look for hemolysis, prothrombin time,APTT, URE=to look for
hematuria/hemoglobinuria, urea,ECG
Monitor BT, CT, aPTT every 4 hours & WBC count every day. Monitor RFT every day
(urine output, urea, S creatinine, S electrolytes).
Observe for e/o envenomation : local bleeding, swelling, ptosis, respiratory depression,
diplopia, dysphagia, severe pain. Examine extra ocular movement.
Single breath count(>20 - normal) to be tested every 15 minutes in suspected cobra or
krait bites.
If an extremity is bitten, it should be kept slightly dependant. IV access should be
established in an unbitten extremity.Observe for ascending cellulitis.
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Apply tourniquet proximal to site of bite(loose enough to allow a finger in between).
Release tourniquet 1 hr after ASV or every 30 min advance proximally if swelling
advances.
Rx
1.Hourly pulse/BP chart; 4th hourly temp chart;I/O chart
2.Inj TT 0.5 ml IM st.
3.ASV(Anti snake venom) is given if there is local reaction or signs of systemic
envenomation.
Inj ASV 5 vials (in case of local reaction only) or 10 vials (for moderate systemic
envenomation) & 15 vials(for severe systemic envenomation) diluted in NS as iv
infusion 16-20 drops per minute over 1-2 hrs.
ASV is best effective if used within 4 hours, but can be administrated upto 24 hours.
However, it is also said to be effective even upto 6-7 days.

Indications for ASV:a)hemostatic abnormalities: clotting time > 20 min, spontaneous

bleeding, prolonged PT-INR, TCP(<1,00000/mm3)
b)Neurotoxic signs:ptosis, ophthalmoplegia, paralysis
c)Cardiovascular abnormalities:hypotension, shock, arrhythmia, abnormal ECG
d)Signs of AKI:oliguria,anuria, elevated blood urea/creatinine
e)Significant local reaction:local swelling involving more than half of bitten limb within 48
hours, Rapid extension of swelling within few hours, development of enlarged tender
lymph nodes draining the bitten limb.
Prerequisites
A) Inj Hydrocortisone 200 mg iv st
B)Inj avil 2 cc iv st
No test dose for ASV required. Keep loaded adrenaline ready before starting ASV.
The usual dose of polyvalent ASV is 10 vials irrespective of age and body wt,pregnant
or not, given as infusion in 200 ml NS over 30 minutes. A second dose of 10 vials may
be given if overt bleeding is present even after 1-2 hours of ASV or repeat 20 min CTs
>20 min.
When local reaction only present-
3-5 vials of ASV used. Start as infusion of 1 vial in 100 ml normal saline slowly over 20
minutes. Rest of vials as infusion over 1 hour.
When systemic envenomation present-
10 vials ASV given as infusion in 20-30 minutes. Simultaneously start-6 vials ASV in 5
% Dextrose to be run in 4-6 hrs. Rpt 10 vials ASV if blood coagulability not restored in 6
hrs.

In neurotoxic bites, repeat dose of 10 vials can be given after 1 hour if there is no
clinical improvement. Start as infusion of 1 vial in 100 ml normal saline. After 10-15 min
of infusion , add remaining 9 vials in the same fluid and infuse over 1 hour. If there is an
increased risk of allergic reaction, inj adrenaline (1:1000) 0.01 ml/kg s/c and inj
hydrocortisone 200 mg iv st(2mg/kg iv) should be given 5 minutes before starting ASV.

Usually massive dosses of ASV like 50 + vials are required only for snakes that inject
massive amounts of venom such as King cobra.
If allergic reaction occurs(urticaria, fever, itching, chills, nausea, vomiting, diarrhea,
abdominal cramps, tachycardia, hypotension, bronchospasm, angioedema) discontinue
ASV. Then give inj adrenaline (1:1000) 0.5 mg (0.01 ml/kg) im st, inj chlorpheniramine
maleate 10 mg(0.2 mg/kg) iv st, inj hydrocortisone 2 mg/kg iv st. If there is no
 173
improvement after 15 min, repeat adrenaline (maximum of 4 doses can be given). Once
pt recovers ASV should be started slowly for 10-15 min and kept under close
observation, then normal drip rate may be resumed.
Respone to ASV : normalization of BP, bleeding stops in 1-30 minutes, normalization of
coagulation parameters(may take upto 6 hours), resolution of neurological signs in 30
minutes - 48 hrs
Complications; cardiogenic shock, hypovolemic shock, anaphylaxis
4.Premedicate with Inj efcorlin or methyl pred, inj Avil 20 min prior to ASV
5.Inj Metrogyl 500 mg iv Q6H ATD
6.Inj Ampicillin 500 mg iv Q6H ATD
7.Inj clox 500 mg iv Q6H or T Klox 500 1-1-1-1
Or inj CP 20 L U iv q6H ATD + Inj Metrogyl 500 mg iv Q8H
9. Inj Rantac 50 mg iv Q8H
10. Inj Tramadol 50-100 mg iv/im sos
11.Glyceryl Mag sulph for LA; surgical management of local reaction with excision of
areas of necrosis.Local anti edma measures- do not apply tourniquet, simply immobilize
the limb. If tourniquet was present check vascularity of limb after removing it.
12.In case of neurotoxic snake bite coming with ptosis, give all the above plus the
following:
Inj Neostigmine 0.5 mg q30 min, 1 hr, 2 hr & then 4 hr intervals + inj atropine 0.6 mg iv
before every injection of neostigmine. In children 0.05mg/kg atropine f/b neostigmine
0.04mg/kg iv st.
13.Nephrology consultation for appropriate renal failure management.
14.IV FFP or whole blood transfusion (if clotting abnormalities persists).
Note: Non-poisonous bites can be observed for 24 hrs, coagulation parameters
repeated & discharged.
Note- Sudden removal of tourniquets may cause gush of venom leading to fatality.
Check distal pulse before removal of tourniquet. If tourniquet has occluded distal pulse,
a BP pressure cuff can be used to release the pressure slowly.

Heat stroke(heat hyper pyrexia/Sun stroke)

Hyperthermia with a body temp > 40.6oC(105.1oF)
C/f: skin dry(no sweating) & hot, confusion, disorientation, coma
Rx
1.Immediate cooling of body :spraying the pt with water at 150C,Cold sponging, Ice
compresses to forehead,spraying water on the body,covering the patient with ice water–
soaked sheets,placing ice packs in the axillae and groin; gastric lavage with ice
water(put ryle’s tube and give ice cold water. Remove after half hour)
Shift pt to air-conditioned room if possible. Remove restrictive clothing.
2.Oxygen, ensure Patent airway, IV lines
3.Inj Voveran 1 amp IM st ATD
4.T P’mol 500 mg qid
5.Treat Hypoglycemia(common occurence in heat stroke pts)
6.Chlorpromazine 50-100 mg IM q4-6H to produce hypothermia and to control shivering
during cooling(better avoided due to seizure threshold lowering property)
Immediate administration of benzodiazepines is indicated in patients with agitation and
shivering, to stop excessive production of heat.
Note:Any individual with a history of heat stroke is at increased risk for future episodes.
Excess sun exposure and heavy physical exertion should always be avoided in the hot
weather and especially during the hours before and after noon.
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Heat exhaustion: thirst is a characteristic feature; Untreated heat exhaustion can
progress to heat stoke if sweating stops.Rx:transfer to a cool room.IV NS f/b increased
intake of salt and fluids. Patients should be advised to avoid heat and exertion for at
least 24 hours after an episode of heat exhaustion.
Heat cramps:deep and painful spasms in the most actively used muscles and are a
direct result of salt depletion. The affected muscles harden and become tender. Rx:IV
NS, increased intake of salt and fluids.
Heat fever: shift pt to AC room,maintain fluid and electrolyte balance.
Sun burns are usually first degree burns, which are painful, appears red and heals
spontaneously in 3-5 days with out scarring.

Toxicology

Note: For all doubts and enquiries regarding management of common and uncommon
poisonings, contact National Poisons Information Centre(NPIC), AIIMS, New Delhi, working
24 x 365.
Toll free:1800 116 117, Tel: 011 26589391, 011 26593677
General principles of management
Hypoglycemia must be excluded in all comatose patients. Early identification of the toxic
substance saves time & decreases toxicity.If possible, retrieve the container of the
offending substance for identification.
Primary care
 Airway
Assess airway for obstruction; remove oral secretions. If the pt is comatose, insert
oropharyngeal airway(OPA). Nurse the pt in left semiprone position.
 Breathing
Most poisons that depress consciousness also impair respiration. If breathing is
inadequate, intubate & ventilate.
 Circulation
Establish venous access, connect pt to an ECG monitor. Correct hypotension with IV
fluids.
Decontamination
Terminate topical exposure to poison by removing contaminated clothing & washing
skin with soap & water. Terminate ingested exposure to poison by performing gastric
lavage with a wide bore orogastric tube (32- 40 F in adults, 16-28 F in children)(Ryle’s
Tube is inadequate).
Unprotected airway in a comatose pt : first perform intubation & then perform lavage.
Sent sample for toxicological study. Take CXR
Note: gastric lavage is C/I in :- ingestion of corrosives (acids, alkalis, oxidants) or volatile
hydrocarbons(kerosene, petrol).
Detect & correct hypoglycemia, seizures (BZD preferred over phenytoin) &
hyperthermia
Continous RT aspiration, maintain NPO for 48 hrs; resume feeding on day 3.
 Emergency antidote administration
 Others
1.IVF 5%D 2 pints & DNS 3 pints
2.Inj taxim 1g iv Q8H
3.Inj Metronidazole 500 mg iv Q8H
Care of comatose pt: care of bladder, bowel, eyes, skin, joints & buccal mucosa.
 175
Prevention of aspiration into lungs: frequent change in position, clearing of airways,
throat suction.
Treatment of complications- pulmonary edema, cerebral edema, a/c renal failure &
hepatic failure. Continous O2 inhalation & assisted ventilation if needed.
 Psychiatry consultation on Day 5.

Relative contraindications of gastric lavage:

 Hemodynamically unstable: Resuscitate first
 GCS<8: Intubate , prior to the procedure
 Absence of gag reflex: Intubate prior to procedure
 Associated head injury: causes increase in the ICP
 Period of ingestion is > 3 hours

OP poisoning
C/f:muscarinic effects: SLUDGE syndrome: salivation, lacrimation, urination, diarrhea, G I
crampingand emesis
Nicotinic efffects: ganglionic: tachycardia, HTN, mydriasis, diaphoresis
Neuromuscular: fasciculations, motor weakness, paralysis
Central: confusion, lethargy, agitation, coma
Inv: S. Pseudocholinesterase, stomach wash sample for toxiclology analysis.
Rx
1.Decontaminate skin - change clothing; wash with soap & water.Irrigate eyes if exposed.
Induce emesis, if the pt is conscious stomach wash is done with salt water; if unconscious
pt, RT wash is given.
3. Assess ABC, IV fluids as bolus of 20 ml/Kg
3.Inj atropine 30-40 mg iv st(for moderate poisoning) & 100 mg iv st (for life threatening) ;
or alternatively 1-3 g iv bolus, then titrate according to persistence of bronchorrhoea by
giving the double of the previously used dose every 5 minutes till atropinisation is achieved.
Atropinisation is defined as drying of bronchial secretions with normal O2 saturation,
HR>80 bpm, systolic BP>80.
Check for signs of atropinisation- dry skin, mucous membrane, fever, tachycardia, dilated
pupils. Followed by infusion, atropine started with 10-20% of initial atropinisation dose till
anticholinergic effects occur(absent bowel sounds, urinary retention, agitation)
Maintain atropinisation for 5-7 days, till the effect of poison weans off.
Inj atropine 50 mg in 500 ml 5D 16 drops per minute(over 8 hrs) q8h, without producing
psychotic behaviour.
4.Inj Pralidoxime(Aldopam) 25-50 mg/kg iv bolus( 1-2 g in 100 ml NS iv over 20
min,followed by infusion of 500 mg q12H) (not indicated in furudan poisoning)
5.4th hourly temp/BP chart,Hourly pulse, atropine, pupil chart
6.Continous RT aspiration for 48 hrs, CBD, NPO for 48 hrs,
7.Care of comatose pt: care of bowel, bladder, eyes, skin, joints & buccal mucosa.
Prevention of aspiration into lungs: frequent change in position, clearing of airways, throat
suction.
8.Restrain the pt if needed; give intermittent throat suction; start refeeding by 72 hrs if
conscious & bowel sounds +.
9.T Distenil 10 1-1-1(activated charcoal)
10.Inj taxim 1g iv q8h ATD as Px.
11.Inj Metrogyl 500 mg iv q8H.
12.Inj pantocid 40 mg iv od
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13.IVF 5D 2 pints, NS 3 pints.
14.BZD can be given if seizures occur
15.Inj haloperidol 5 mg iv st & sos if violent behaviour.
16.Syp cremaffin 30 ml tds/HS.
Complications
1.intermediate syndrome-post acute paralysis from persistent Ach excess
2.OP induced delayed neurotoxicity

Odollum poisoning
Explain prognosis
Inv:ECG(tall peaked T waves, PR prolongation, heart block, VF), toxicological analysis of
gastric aspirate,Serum pottassium(hyperkalemia),ABG
Rx
1.If the pt has bradycardia, give inj atropine 1 or 2 amp iv st &
Inj Atropine 1.2 mg iv sos if the HR < 50/min
2.Stomach wash if the pt is conscious.
3.RTA/CBD
4.Syp cremaffin half bottle f/b 30 ml tds
5.T Distenil 10 1-1-1
6.Inj Rantac/Pantop
7.IVF as necessary.
8.ECG monitoring twice daily
Also address two associated complications: hyperkalemia & heart blocks.
1.If bradyarrhythmia occurs: inj atropine 1.2 mg iv; cardiology consultation in case of
complete heart block(will need temporary pacemaker insertion)
2.If hyperkalemia occurs:
a)to increase K+ secretion- iv frusemide 40-80mg iv, K-bind
b)To shift K+ intracellularly- insulin-dextrose infusion:
i)8-10 U insulin in 100 ml 25% D over 15-30 minutes
ii)Neb with salbutamol
iii)Sodium bicarbonate 50 mEq over 5 minutes(only if there is metabolic acidosis)
c) to stabilize myocardium: inj calcium gluconate 10% 10 ml iv over 2-5 minutes
For mild hyperkalemia(5-6 mEq/L) follow only (a); for moderate hyperkalemia(6-7 mEq/L)
follow both (a) and (b);For severe hyperkalemia(>7 mEq/L) follow (a), (b) , and (c )

Paracetamol poisoning
Toxic dose: >150mg/kg
C/f: first 24 hours: nausea, vomiting, anorexia, pallor, lethargy
24-48 hours:hepatotoxic stage- right upper quadrant tenderness, bilirubinemia,
transaminitis, elevated prothrombin time and INR, persistent vomiting.
2-4 days: fulminant hepatic failure stage- increased hepatic enzymes, jaundice,
coagulopathy, hypoglycemia, anuria, even coma can occur.
4-14 days; stage of recovery or fatality
History & examination
Obtain the time of ingestion, dose, form(combination/extended release form), co
ingestions(alcohol/other medications)
Assess vitals and mental status
H/o prior liver disease
Ix
Serum concentration of P/L after 4 hrs of ingestion
 177
LFT: AST is relatively a sensitive non prognostic marker
PT-INR(PT>100), S bicarbonate, blood pH(> 7.3 two dasy post ingestion indicates liver
damage), serum lactate(>3 mmol/L indicates liver damage), RFT, S.phosphate(>1.2
mmol/L)
Daily GRBS monitoring
Rx
1) activated charcoal- in pts presenting < 4 hrs. Dose is 1 g/kg per oral
2) N-acetyl cysteine- specific antidote to prevent P/L related hepatic injury. Given within
8 hrs of exposure for best results. Can be given beyond this time, may provide some
protection.oral dose: loading dose 140 mg/kg followed by 70 mg/kg every 4hrs for a
total of 17 doses.
IV dosing:150 mg/kg IV over 1 hour followed by 14 mg/kg/hr for 20 hrs.
3)stop NAC when INR<5; AST becomes normal or < half of peak level; Serum
paracetamol concentrate returns to 0.
Indications of NAC
1)Any poisoning with toxic P/L level
2)Pt p/w > 24 hrs of ingestion with increased AST/detectable serum levels of P/L.
Signs of fulminant hepatic failure: NAC started immediately and referred for liver
transplantation.
Complications: pt with progressive liver failure needs ICU care. In case of fulminant
hepatic failure, transplantation may be required.

NSAID posioning
Over dose can cause ulceration of GI mucosa and renal dysfunction.
GI distress, massive overdose can result in coma and seizures
Ix
RFT - to assess renal function and hydration status
P/L serum concentrations in case of combination preparations
Rx
Mainly supportive measures
1)Maintain ABC (airway, breathing, circulation)
2)RTA
3)Vitals monitoring and urine output monitoring
4)IVF to maintain hydration
5)Antiemetics and antacids in pts with significant distress
6)BZDs if seizures occur

Rat poison
Contains Zn aluminium phosphide or warfarin like compounds
C/f: epigastric pain, vomiting, intense thirst, arrhythmia, hypotension, respiratory
distress, bleeding manifestations such as epistaxis, hematemesis, hematuria. Even IC
bleed can occur, if it contains warfarin like compounds.
Ix:Monitor RFT,LFT and PT-INR
Rx
1.gastric lavage with saline f/b 1:10000 pottasium permanganate solution f/b sodium
bicarbonate solution
2.If bleeding manifestation occurs: inj Ranitidine 50 mg iv st, inj vit K 10 mg iv st, FFP
transfusion if PT-INR deranged
3.All symptomatic patients to be observed for atleast 72 hours
Complications: fulminant hepatic failure
 178
Formic acid poisoning
Commonly used in rubber plantations
C/f: intense pain, edema over the exposed site, bleeding from oral mucosa, charring of
oral mucosa, acid marks over face, edema of larynx/glottis may result in asphyxia and
can even cause death; shock, renal failure
Ix: ABG
Rx
1.NPO
2.Gastric lavage, RTA, emesis and activated charcoal are contraindicated
3.O2 inhalation if there is hypoxia
4.Inj Dexamethasone/methyl pred at 2 mg/kg/dose. Steroids should be started within 48
hrs of ingestion
5.Inj Omeprazole 80 mg st + infusion at a dose of 8mg/hr
6.Inj frusemide 40 mg iv Q8H
7.IV fluids 2-4 L/day
8.Inj soda biacarb 7.5% 30-50 ml IV Q8H
9.IV antibiotics
10.Medical gastro consultation and OGD scopy once the pt is stable.

TCA poisoning
C/f- dilated pupils, dry mouth, urine retention,tachycardia, arrhythmia(a/w QT
prolongation, PR prolongation and wide qrs complex), hypotension, hyper-reflexia,
metabolic acidosis,convulsion,coma,
Rx
No specific treatment. Stabilization of the ABC’s. Gastric decontamination with lavage
1. Continuous Ecg monitoring for first 24 hr and until Ecg changes have disappeared for
12 hr.
2. cardiac arrhythmias are more common if there is an acidosis. Give bicarbonate to
achieve a pH of 7.5. If arrhythmias occur with no acidosis and fail to respond to
treatment with amiodarone or lignocaine, bicarbonate(25-50 ml, 8.4%) may still be
useful. Sodium bicarbonate has been demonstrated to narrow the QRS, decrease the
incidence of ventricular arrhythmias, and improve hypotension. QRS >100msec may be
considered as the threshold for the initiation of sodium bicarbonate. Bicarbonate is the
single most effective intervention for the management of TCA cardiovascular toxicity.
3. Seizures managed with benzodiazepines(diazepam). Phenytoin better avoided.
4. Noradrenaline in hypotensive pts.

Sedative poisoning
C/f altered consciousness, respiratory failure, CV disturbances
Note- consider the possibility of rhabdomyolysis after prolonged immobility.
Benzodiazepine poisoning
Treatment is mainly supportive.Flumazenil is the specific antidote. 0.2-1 mg iv given in
0.1 mg increments. But is dangerous in benzodiazepine dependence and mixed
poisoning with TCA.

Opoioid poisoning
Treatment is mainly supportive with attention particularly to respiratory depression and
cardiovascular disturbances.
Naloxone may be used as an antidote(0.2-0.4 mg iv)
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Beta blockers/CCB overdose
1. atropine 1 mg iv may be tried and given upto 3 mg for syptomatic bradycardia
2. iv fluid bolus of 20 ml/kg. Monitor for fluid overload.
3. Rule out hypoglycemia in beta blocker overdose.
4. calcium gluconate 3 to 9 g iv through peripheral line in pts with hypotension.
Alternatively give calcium chloride 1 to 3 g through a central line slow iv push over 10
minutes.
5. Any pt with hypotension is a candidate for high dose insulin euglycemia therapy. This
involves giving a bolus of 1U/kg of regular insulin, f/b an infusion of 0.5 to 1.0 U/kg/hr
of regular insulin. This should be accompanied by a dose of 50 ml of 25D and a
dextrose drip at 1g/kg/hr of dextrose(start 1 pint of 5D) . RBS should be obtained every
30 minutes, and potasium levels should be followed every 2 hours with repletion as
profound hypokalemia can occur.
 180
Adult Glasgow coma Scale
Spontaneous--open with blinking 4
Opens to verbal command, speech, or shout 3
Eye Opening
Opens to pain, not applied to face(a peripheral pain stimulus, such as squeezing
Response the lunula area of the patient's fingernail is more effective than a central stimulus such as 2
a trapezius squeeze, due to a grimacing effect).

None 1
Oriented(Patient responds coherently and appropriately to questions such as the
patient’s name and age, where they are and why, the year, month, etc.)
5

1. Confused conversation, but able to answer questions(The patient responds to

questions coherently but there is some disorientation and confusion.)
4
Verbal
Response
2. Inappropriate responses, words discernible(Random or exclamatory articulated
speech, but no conversational exchange. Speaks words but no sentences.)
3

Incomprehensible speech(Moaning but no words.) 2

None 1
Obeys commands for movement 6
Purposeful movement to painful stimulus( e.g., brings hand up beyond chin when
supra-orbital pressure applied.)
5

Withdraws from pain(Absence of abnormal posturing; unable to lift hand past chin with
supra-orbital pain but does pull away when nailbed is pinched)
4
Motor
Response Abnormal (spastic) flexion, decorticate posture accentuated by pain (flexor
response: internal rotation of shoulder, flexion of forearm and wrist with clenched fist, leg 3
extension, plantarflexion of foot)

Extensor (rigid) response, decerebrate posture accentuated by pain (extensor

response: adduction of arm, internal rotation of shoulder, pronation of forearm and 2
extension at elbow, flexion of wrist and fingers, leg extension, plantarflexion of foot)

None 1
Individual elements as well as the sum of the score are important. Hence, the score is expressed
in the form eg ."GCS 9 = E2 V4 M3 at 07:35".
In intubated pt’s no score is given for V and is written as NT(non testable) as per
ATLS 10th edition.
Generally, brain injury is classified as:
 Severe, with GCS < 8-9
 Moderate, GCS 8 or 9–12 (controversial)
 Minor, GCS ≥ 13.
A new parameter, pupil reactivity score has been added to GCS and it is referred to as GCS-P. P
stands for pupils unreactive to light.
Both pupil unreactive to light- score is 2. one pupil-1, neither -0.
The pupillary score is substracted f rom the GCS to give the final value. Therefore the range of
GCS-P is 1-15.
 181
Procedures
NIV
Delivered through either nasal mask, face mask, or nasal plugs.
BIPAP delivers both IPAP and EPAP.
Initial inspiratory pressure of 8-10 cm H2O.Initial expiratory pressure of 2-4 cm H2O.
increase in increments of 2-4 cm H2O.Maximum inspiratory pressure is 24 cmH2O and
expiratory pressure is 20 cm H2O. IPAP and EPAP should have a minimum 4 mm of Hg
difference. Increasing the IPAP will help in increasing oxygenation. Increasing
EPAP/IPAP difference will help in CO2 elimination.
CPAP(continous positive airway pressure)
Start with 5 cm H2O. Increase in increments of 2cm H2O, as tolerated and indicated.
Noninvasive pressure support ventilation
Pressure support of 8-10 cm H2O and PEEP of 2-4 cm H2O. Adjust as per BiPAP

Indications for NIV

Dyspnoea(moderate to severe)
Tachypnoea(>25 breaths/min)
Increased work of breathing(accessory muscle use, pursed lips breathing)
Hypoxemia(PaO2/FIO2 <200 mm Hg)
Moderate hypercarbia(PaCO2 >45 mm Hg, <92 mm Hg)
Hypercapnic encephalopathy(if not improved in 1-2 hours,intubate)
Moderate acidemia(pH <7.35)
Contraindications of NIV
Depressed sensorium, lethargy, respiratory arrest, cardiac instability, shock, impaired
cough or swallowing,pneumothorax, potential for upper airway obstruction( like GI
bleeding, uncontrollable vomiting),inability to tolerate the mask, seizures, esophageal
lesions, recent gastroesophageal surgery. Relative c/I include, agitation, inability of the
pt to cooperate, drowsiness(pt must improve neurologically within 1 hr of applying NIV).

Indications for mechanical ventilation

Severe respiratory failure
RR> 35/minute
Hypercarbia(PaCO2 >60 mm Hg)
Acidosis(pH<7.25)
Respiratory arrest, altered mental status, hypotension, cardiac failure, shock, NIV failure.

Endotracheal intubation
Indications
Respiratory insufficiency-apnoea,hypoxia,hypoventilation,airway obstruction, FB,
traumatic deformity
Continued bleeding,secretions or emesis
Inability to protect airway- altered mental status, loss of normal airway reflexes
Need for hyperventilation(raised ICP), head injury
Metabolic acidosis in critically ill or injured pt
Anticipated or impending airway compromise, shock,multiple trauma, need for sedation
or paralysis.
Preparation: includes assessing the patient’s airway, developing an airway
management plan & assembling necessary equipment & medication; check suction,
laryngoscope, ET tube of appropriate size. If a stylet is placed inside the ET tube,
 182
ensure that it does not protrude beyond the tube or through the Murphy’s eye. Use
cuffed ET tube for all children over 3 kg and adults.
Pre procedure vitals checked & recorded.
Position the patient in sniffing position i.e neck flexed & head extended.
Preoxygenate with 100 % oxygen using bag-valve-mask for 3 minutes.
Premedicate with an inducing agent e.g midazolam (0.1-0.3 mg/kg) or fentanyl (1-5
mg/kg) & a paralytic agent e.g: succinyl choline( 1-2 mg/kg). if succinyl choline is
contraindicated consider vecuronium (0.1-0.25 mg/kg), rocuronium(0.6 mg/kg)
Note: both midazolam & fentanyl may produce hypotension, so deliver as slow iv.

Contraindications of succinyl choline- hyperkalemia,crush injury,renal failure,extensive

burns,elevated intracranial or intraocular pressure, malignant hyperthermia,myopathies
with elevated CK.
Continue pre-oxygenation while observing for fasciculations to appear.
Observe for fasciculations followed by apnoea.
Immediately intubate upon onset of apnoea.
Patients mouth should be fully opened with index finger & thumb of right hand in a
scissor action.
Keep the laryngoscope in your left hand; stand far enough, so that you maintain
binocular vision of the larynx. Do not shift your gaze from the cords, until the procedure
is over. Hold the ET tube in such a manner that visibility of the tip entering between the
vocal cords is not hampered. Intubate- Displace the tongue horizontally to the left ,
hyoid bone and attached tissues are moved anteriorly & epiglottis is elevated directly or
indirectly to reveal the larynx. Force applied to the laryngoscopic blade should lift the
toungue, posterior pharynges, hyoid bone & attached tissues parallel to the line of sight,
bringing the glottis into view. The laryngoscope should never be hinged on teeth.
Adequate lifting force is a key factor in successful laryngoscopy. When the vocal cords
or the arytenoid cartilages are clearly seen, advance the tube down the right side of the
mouth, keeping the vocal cords in view until the last possible moment, then advance the
tube through the vocal cords.
Begin ventilation by attaching ambu bag to tube & confirm tube position.
Clinically tube position is confirmed by
1)use of 5 point auscultation-one breath each at b/l upper chest, b/l axilla &
epigastrium. Look for equal air entry. If air entry is not equal, retract the ET tube to a
point that air entry is equal.
2) Fogging in the ET tube

Inflate endotracheal tube cuff adequately, usually require 5-10 ml of air & release
cricoid pressure.
Cuff is adequately inflated so that there is no air leak. This is confirmed by auscultating
the neck for adventitious sounds, during expiration.
Secure tube at 23 cm(at incisors) in men & 21 cm in women with adhesive tape.
Take CXR to confirm position
Ensure proper attachment to mechanical ventilator & review ventilator settings
Check post procedure vitals & record
Provide additional sedation & paralysis as indicated.
Note: monitor for bradycardia, since this is an adverse effect of succinylcholine.
However , it is transient & can be treated with Inj atropine 0.6 mg iv.
Endotracheal Tube size
Common size(mm)- adults: 6, 6.5, 7, 7.5, 8, 8.5; children: 3, 3.5, 4, 4.5, 5
 183
Ventilatory support & management- basics

Modern ventilators deliver a gas flow with a cycling mechanism to cut airflow during
expiration.The ventilator breath may be volume controlled (a predetermined tidal volume
is delivered), pressure controlled(gas flow is at a pre-determined pressure), or volume
controlled with a limited pressure( the ventilator delivers a preset VT within a pressure
limit unless the lungs are non-compliant or airway resistance is high. Various mixed
modes are also available.

Modes of ventilation: Controlled mechanical ventilation (CMV), assist control

mechanical ventilation(ACMV), intermittent mandatory ventilation(IMV), pressure
support ventilation(PSV), Volume support ventilation(VSV).
CMV- a preset no of breaths are delivered to supply all the pt’s ventilatory requirements.
Breaths may be at a preset VT(volume controlled) or at a preset inspiratory
pressure(pressure controlled).
ACMV- the ventilator delivers preset breaths in coordination with the respiratory effort of
the pt. Pts can breath, triggering the ventilator to determine the respiratory rate.
However a preset no of breaths are delivered if the spontaneous RR falls below the
preset level.spontaneous breathing independent of the ventilator b/w assist control
breaths is not allowed.
IMV- a no of breaths are preset, but pts are free to to breath spontaneously in between.
Mandatory breaths may be synchronised with spontaneous efforts(synchronised IMV) to
avoid mandatory breaths occuring on top of spontaneous breaths(stacking). this may
lead to excessive VT, high airway pressure, incomplete exhalation, and air trapping.
Positive pressure support may be added to spontaneous breaths to reduce the work of
breathing.
PSV- a preset positive inspiratory pressure is added to the ventilator circuit during
inspiration in spontaneously breathing pts. Preset pressures should be adjusted to an
adequate VT( but not excessive).
VSV- a target VT is set and pressure support is adjusted to achieve the target volume.

Choosing the appropriate mode.

The initial mode of ventlation is institution and practitioner dependent.
ACMV like CMV is a full support mode in that the ventilator performs most if not all, of
the work of breathing. These modes are beneficial for pts requiring high minute
ventilation. Full support reduces O2 consumption and CO2 production.
Pressure controlled ventilation avoids the dangers a/w high airway pressure, although it
may result in marked changes in VT if respiratory compliance alters. Allowing the pt to
make some spontaneous respiratory effort may reduce sedation requirement, retrain
respiratory muscles, and reduce mean airway pressure.
For the spontaneously breathing pts, Pressure support ventilation(PSV) has been advoc
ated to limit barotrauma and to decrease the work of breathing. PSV differs from ACMV
and IMV in that a level of support pressure is set to assist every spontaneous effort. Air
way pressure support is maintained unti the pt’s inspiratory flow falls below a certain cut
off(e.g 25% of peak flow). the pt determines the tidal volume, RR and flow rate. PSV is f
requently the mode of choice in pt’s whose respiratory failure is not severe and who
have an adequate respiratory drive. It can result in improved pt comfort, reduced cardio
vascular effects, reeduced risk of barotrauma, and improved distribution of gas.
 184
Apnoeic pts- use of IMV or ACMV in totally apnoeic pts provides total minute volume
requirement if the preset rate is high enough(effectively CMV), but allows spontaneous
respiratory effort on recovery.
Pts taking limited spontaneous breaths- a minimum minute volume is assured with both
ACMV and IMV, depending on the preset rate. The work of spontaneous breathing is
reduced by supplying the preset VT for spontaneously triggered breaths with ACMV or
by adding pressure support to spontaneous breaths with IMV. With ACMV, the
spontaneous tidal volume is guaranteed, whereas with IMV and pressure support,
spontaneous tidal volume depends on lung compliance and may be less than preset
tidal volume. The advantage of IMV and pressure support is that gradual reduction of
preset rate, as spontaneous effort increases, allows a smooth transition to pressure
support ventilation. Subsequent weaning is by reduction of pressure support level. A
potential drawback of ACMV in pts with OAD(obstructive airway disease is worsening of
air trapping and breath stacking.

Initial ventilator set-up

Check for leaks
Check O2 is flowing
FiO2 : 0.6-1
VT :5-10 mL/kg
Rate: 10-15/min
I:E ratio : 1:2
Peak pressure ≤35 cm H2O
PEEP : 3-5 cm H2O

Setting up the ventilator

Tidal volume:values of 6-7 mL/kg ideal body weight relaed better outcome in severe a/c
respiratory failure. Smaller VT & minute volume may be needed in severe airflow
limitation (e.g. Asthma, a/c bronchitis) to allow prolonged expiration
Respiratory Rate: usually set in accordance with VT to provide minute ventilation of 85-
100mL/kg/min.
Inspiratory flow: usually set between 40-80 L/min. Higher flow rates are more
comfortable for alert patients. This allows for longer expiration in pt’s with severe airflow
limitation, but may result in higher peak airway pressures.
I:E ratio: A function of RR, VT, inspiratory flow, & inspiratory time. Prolonged expiration
is useful in severe airflow limitation while a prolonged inspiratory time is useful in ARDS
to allow slow-reacting alveoli time to fill. Alert pt’s are more comfortable with shorter
inspiratory times & high inspiratory flow rates.
FIO2: set according to arterial blood gases, usual to start at FIO2 = 0.6 -1, then adjust as
per ABG & pulse oximetry.
PEEP: routinely set between 3-5 cm H2O. However in severe respiratory failure, it will
often need to exceed 10 cm H2O especially in severe ARDS. It rarely needs to exceed
20 cm H2O to avoid cardiorespiratory complications and alveolar over-distension.Ideal
PEEP is the lowest level of PEEP that achieves SpO2>90% allowing lowering of
FiO2(ideally ≤ 60%), though not at the expense of peak airway pressure >35-40 cmH2O
or significant reductions in DO2(delivered oxygen).
Airway pressure: In pressure-controlled or - limited modes, a peak airway pressure can
be set(ideally ≤30 cm H2O). PEEP is often increased to maintain FRC when compliance
is low.
 185
Adjusting the ventilator
Adjustments are usually made in response to ABG, pulse oximetry, pt agitation or discomfort,
or during weaning. Migration of the ET, either distally to the carina or beyond, or proximally
such that the cuff is at vocal cord level, may result in agitation, excess coughing, & a
deterioration in ABG. Tube migration or obstruction should be considered & rectified before
changing ventilator settings or sedative dosing.
The choice of ventilator mode depends upon conscious level, the no of spontaneous
breaths being taken, & ABG. Many spontaneously breathing pt’s can cope adequately
with pressure support ventilation alone. However a few intermittent mandatory
breaths(SIMV) may be needed to assist gas exchange or slow an excessive
spontaneous rate. The paralysed/heavily sedated pt will require either volume- or
pressure-controlled ventilation. Earlier use of increased PEEP is advocated to recruit
collapsed alveoli & thus improve oxygenation in sever respiratory failure.

Low PaO2 : increase FIO2/PEEP/I:E ratio. Consider increasing pressure

support/pressure control or VT. In CMV consider increasing sedation ± muscle relaxants.

High PaO2: decrease FIO2 or I:E ratio or PEEP or level of pressure control/pressure
support if VT adequate.

High PaCO2: increase VT (if low) or RR. Reduce rate if too high( to reduce intrinsic
PEEP), reduce dead space. In CMV, increase sedation ± muscle relaxants

Low PaCO2: decrease RR, VT.

Adjusting PEEP
Measure ABG, monitor hemodynamic variables. If indicated, alter level of PEEP by3-5
cmH2O increments. Remeasure ABG and hemodynamic variables after 15-20 min. The
following may help in approximation and starting point for further titration of therapy.
FiO2 30 % 40% 50% 60% 70% 80% 90% 100%
PEEP 5 5-8 8-10 10 10-14 14 14-18 ≥18
(cm H2O)
Complications of PEEP-
A)Reduced cardiac output. May need additional fluid overloading or even inotropes.
Caution should be exercised in pts with myocardial ischaemia.
B)Increased airway pressure(and potential risk of ventilator trauma).
C)Higher levels will decrease venous return, raise ICP, and increase hepatic congestion.
D)Overinflation leading to air trapping and raised PaCO2. use with caution in pts with
c/c asthma. In pressure controlled ventilation, over distension is suggested when an
increase in PEEP produces a significant fall in tidal volume.

Peak pressure determines airway resistance while plateau pressure is the determinant
of lung compliance.
Raised peak pressure:brochospasm, mucus plug,retained secretion,
Raised plateau pressure: pneumothorax, ARDS,pneumonia,pulmonary edema.

Failure to tolerate ventilation

Agitation or fighting the ventilator may occur at any time. If paralysed or heavily sedated,
poor ventilator tolerance may be indicated by hypoxemia, hypercapnia, ventilator alarms,
or cardiovascular instability. The first priority is to assess the pt. Check whether the pt is
 186
cyanosed or not, chest movements, breath sounds(whether present and equal and any
abnormal sounds), SpO2.
Basic clinical assessment is necessary to judje how serious the problem is and whether
immediate resuscitative steps are required. If the problem is serious, the first step must
be to disconnect the ventilator and manually ventilate. Manual ventilation with 100% O2
and a non-breathing bag allows assessment of how difficult it is to inflate the lungs, how
long exhalation takes, and whether the problem with ventilation relates to patient
(problem persists) or ventilator(problem resolved) factors.
Poor initial tolerance- increase FiO2 to 100% and start manual ventilation. Check ET is
correctly positioned and both lungs are being inflated. Consider tube replacement, intra-
tracheal obstruction, pneumothorax, or bronchospasm. Check ventilator circuit is both
intact and patent, and ventilator is functioning correctly. Check ventilator settings,
including FiO2, PEEP, I:E ratio, set tidal volume,RR, and/or pressure control. Check
‘pressure limit’ settings as these may be set too low causing ventilator to cycle to
expiration prematurely.
Poor tolerance after previous good tolerance
If agitation occurs in a pt who has previously tolerated ventilator, either the pt’s condition
has deteriorated, or there is a problem in the ventilator circuit(including artificial airway)
or the ventilator circuit.
The pt should be removed from the ventilator and placed on manual ventilation with
100% O2 while the problem is resolved. Resorting to increased sedation and muscle
relaxation in this situation is dangerous until the cause is understood. Check patency of
the ET(e.g with a suction catheter) and reintubate if in doubt. Consider CXR to identify
ET malposition(e.g cuff above vocal cords, tip at carina, tube in main bronchus). seek
and treat changes in the pt’s condition, e.g bronchospasm, tension pneumothorax,
sputum plug, pain, raised intra-abdominal pressure, pulmonary edema. If pts are
making spontaneous respiratory effort, consider increasing pressure support or adding
mandatory breaths. If pts fail to synchronise with IMV by stacking spontaneous and
mandatory breaths, increasing pressure support and reducing mandatory rate may help.
Use of pressure support ventilation may also be adequate.
Failure to deliver ventilation
Failure to ventilate despite apparently appropriate ventilator settings and exclusion of pt
factors requires assessment of which ventilator settings are not being delivered.
Low VT or low pressure alarm
In situations where expired VT is suddenly significantly lower than inspired VT or
maintenance of circuit pressure is not possible, there is a leak in the ventilator circuit.
The pt should be manually ventilated while the leak is identified and corrected. If the
leak persists with manual ventilation, repositioning or replacement of the ET is required.
High pressure alarm
A sudden increase in airway pressure indicates a change in resistance to gas flow. After
pt factors have been excluded- check patency of the ET(e.g with a suction catheter),
reintubate in doubt. Check patency of ventilator circuit and catheter mount. Look for
excessive trapped water partially occluding the catheter mount. Check for sputum
obstructing the HME. Consider a CXR to identify ET malposition.
Poor gas exchange
Increase FiO2 to 100% and start manual ventilation. Exclude pt factors. Check ET is
correctly positioned, patent, and both lungs are being inflated. Consider ET replacement.
Check ventilator circuit is both intact and patent, and ventilator is functioning correctly.
Check ventilator settings, including FiO2, PEEP, I:E ratio, set VT, RR and/or pressure
control.
 187
Weaning
Prior to weaning , it is important that the cause of respiratory failure and any
complication arising have been corrected.
Sepsis should be eradicated as should factors that increase O2 demand. Attention is
required to nutrition, fluid, and electrolyte balance. Sedatives are often withdrawn, but
may be still needed in specific situations likr residual agitation, raised intracranial
pressure. Adquate analgesia must be provided.
Spontaneous(pressure supported) breathing should generally start as soon as possible
to allow a reduction in sedation levels and to maintain respiratory muscle function.
Weaning with the intention of removing mechanical support is unlikely to be successful
while FiO2>40%. continous SpO2 monitoring and regular clinical review are essential
during weaning. ABG should be takenafter 20-30 min of spontaneous breathing. After
short term ventilation, extubate if ABG and respiratory pattern remain satisfactory, the
cough reflex is adequate and the pt can clear sputum. Pts being weaned from longer
term ventilation(>1 week) should generally be allowed to breath spontaneously for
atleast 24 hrs before extubation.
In pts ventilated for short periods(no more than a few days), it is common to allow 20-30
min breathing on a ‘T piece before removing the ET. For pts who have received longer
periods of ventilation usually cannot be withdrawn suddenly. Several methods are used.
A) Intermittent ‘T’ piece or CPAP
Spontaneous breathing is allowed for increasingly prolonged periods with a rest on
mechanical ventilation in between. The use of a ‘T’ piece for longer than 30 min may
lead to basal atelectasis. Therefore it is common to use 5cm H2O CPAP as
spontaneous breathing periods get longer. In the eary stages of weaning, mechanical
ventilation is often continued at night to encourage sleep, avoid fatigue, and rest
respiratory muscles.
B) Pressure support ventilation
All respiratory efforts are spontaneous but positive pressure is added to each breath,
the level being chosen to maintain an appropriate tidal volume. Weaning is performed
by a gradual reduction of the pressure support level while the respiratory rate is <30/min.
The pt is extubated or allowed to breath with 5 cm H2O CPAP when pressure support is
minimal(<10-15 cm H2O).

Factors predicting weaning success

Minute volume<12 L/min, vital capacity>10 ml/kg, maximum inspiratory force (Pl max)
>20 cm H2O, respiratory rate/tidal volume<100, Qs/Qt<15%, dead space/tidal volume
<60%, haemodynamic stability,a ratio of respiratory rate to tidal volume(f/Vt, shallow
breathing index)≤105, PaO2/FiO2>27.5 kPa

Factors a/w weaning failure

Muscle fatigue(malnutrition, peripheral neuropathy or myopathy, electrolyte
abnormalities(low Mg,K, phosphate), drugs like muscle relaxants and aminoglycosides
Inadequate respiratory drive(alkalosis, opiates, sedatives, malnutrition, CVA, coma)
Inadequate cardiac reserve and heart failure.
Increased O2 cost of breathing.

Indications for re-ventilation

If spontaneous ventilation is discordinate or the pt is exhausted, agitated, or clammy,
the ventilator should be reconnected. Successful weaning is more easily accomplished
if excessive fatigue is not allowed to set in. Tachypnea(>30/min), tachycardia(>110/min),
 188
respiratory acidosis(pH<7.2), rising PaCO2, and hypoxemia(SpO2<90%) should all
prompt reconnection to the ventilator.
Unplanned extubation
It may be self-extubation or accidental extubation
Risk factors- delirium, inadequate sedation, inadequately secured ETT, h/o previous self
extubation.
Attend to potential life-threats using an ABC approach
Many pts(>50%) do not require reintubation if oxygenation & ventilation remains
adequate. Consider oxygen via nasal prongs or mask or NIV.
If stridor present, may need a smaller ETT than previously used due to laryngeal
trauma/edema
Ensure the incident is documented.Address the cause of self-extubation
Complications- respiratory failure, aspiration,airway obstruction,laryngeal injury or
edema,hemodynamic effects(hypotension,arrhthmia, a/c pulmonary edema due to loss
of CPAP/PEEP in a pt with LVF etc.
Sedation for ventilated pt
Start with Fentanyl 5 vial(1 vial of 2ml and 50 µg/ml)+ midazolam 5 vial (1 vial of 5 ml
and 1mg/ml) + 15 ml NS @ 4 ml/hr. This delivers fentanyl 10 µg/ml and midaz 0.5
mg/ml.

Ventilator associated pneuonia(VAP)

Pneumonia occuring in pts after 48 hrs of endotracheal intubation. Early onset VAP-
within 4 days, mostly due to sensitive organisms. Late onset- on day 5 or after, mostly
due to MDR pathogen. Most common organisms remain gram negative bacilli like
pseudomonas, klebsiella, acinetobacter, E coli. Others include S aureus, S pneumonia.
Definition- For any pt atleast one of the following-a)fever (>380 C or 100.40 F) with no
other recognized cause, b) leucopenia(<4000) or leucocytosis(>12000) c) for adults>75
years,altered mental status with no other recognized cause
Radiological- 2 or more serial cxrs with atleast one of the following a) new or
progressive and persistent infiltration b)consolidation c) cavitation
And atleast two of the following- a)new onset purulent sputum or change in character of
sputum or increased respiratory secretions b) new onset or worsening of cough or
dyspnoea or tachypnoea c)rales or bronchial breath sounds d) worsening gas
exchange(oxygen desaturation e.g PaO2/FiO2 ≤240, increased oxygen requirement or
increased ventilator demand)
Inv- cbc, blood c & s,cxr, S procalcitonin, microbiological sampling of lower airways
using mini- BAL or BAL or protected specimen brush(PSB)
Rx
May be started with Meropenem/Piptaz + Levoflox/amikacin + linezolid/vancomycin.
Use narrower spectrum antibiotics once the etiological agent is identified. Consider
switching over to monnotherapy on day 3-5.
Antibiotics usually given for 7-8 days. Long duration (14-21 days) is required in
multilobar consolidation, malnutrition, cavitation,gram negative necrotizing pneumonia,
MDR pseudomonas & acinetobacter
Prevention
Established well designed ICU practices,eduaction and monitoring of infection control
policy, routine Handwash/Handrub of ICU health care providers, semi recumbent
positioning(30-450) of the pt whenever possible, intermittent aspiration of subglottic
secretions, reducing ventilator circuit changes etc. Oropharyngeal and skin
decontamination with chlorhexidine leads to reduced VAP.
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Peripheral venous access

Hypodermic Needle used

Brown 26 G, Purple 24 G,Blue 23 G, Grey 22 G, Green 21 G, Yellow 20 G, Pink 18 G

Making the Vein More Visible

1)Make sure your tourniquet has been applied properly. Applying a tourniquet
increases the amount of blood in the vein to make them stand out more. The tourniquet
should not be so tight that it cuts off the circulation.
The tourniquet should be put on the arm about four inches above the vein.
A blood pressure cuff that is inflated to 40–60 mm Hg also works well.
2)Put a warm pack or water bottle over the area. Warmth will make the patient's
veins dilate and expand, making them easier to see.
3)Use proper palpation techniques. Contrary to popular culture, you should palpate
the arm, rather than slapping it. Slapping the skin is poor technique that may result in a
hematoma. Use your index finger to look for a vein, which feels soft and spongy. Don't
use your thumb, as it contains its own pulse.
The warm pack or water bottle should be put on the area before it is disinfected.
Nothing more should touch the area after it is disinfected.
Do not apply the warm pack or water bottle directly to the skin. Wrap it in a thin
towel to prevent burns. If it hurts, it is too hot.

4)Tell the patient to relax. Many people have needle phobias and nervousness and
apprehension is a normal response. Stress not only makes the veins hard to hit, but it
could also negatively affect the test results (particularly for biochemistry panels).
Reassure your patient and explain that the pain is very brief and minor.
Tell your patient to try visualization and deep breathing.
Observe your patient and have them lie down on their back if you think they might
faint. This will improve the blood flow to their head. It also reduces their chances
of falling and injuring themselves if they do pass out.

Taking blood from the forearm

1)Verify patient information. Verify the patient name, date of birth and reason for
blood draw and check the labeling to ensure no mistakes are made. Mislabeling could
lead to difficulty processing or even safety issues down the line.
2)Locate the vein. The inside of the elbow is generally the preferred location because
the median cubital vein is usually easily visible.
The median cubital vein runs between the muscles and may be clearly visible as a
blue bulge in the inside of your elbow. If it cannot be seen it can usually be felt. It
is also relatively easy to access because the tissue around it prevents it from
rolling away from the needle.
Avoid drawing blood from a place where your veins divide or join together. Doing
so increases risk of bleeding under the skin.
3)Disinfect the area. A common disinfectant is 70 percent alcohol. Wipe an area that is
at least two centimeters by two centimeters for at least a half a minute. After a minute or
two it will have dried.
Alcohol is better than iodine because if the iodine gets into the blood it can alter
values that the lab may be looking for. If you do use iodine, follow it with a 70%
alcohol swab.
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Allow the disinfectant to dry before inserting the needle. Do not blow on or fan it
with your hand as this will contaminate the area.
4)Perform the venipuncture.
Anchor the vein by pulling the skin below the vein taut. This will prevent the vein
from rolling.
Insert the needle in at a 15 to 30 degree angle and then hold it still while collecting
blood.
Fill the collection tube with blood, following the order of draw as specified by your
laboratory.
Release the tourniquet after 1 minute and before removing the needle. Leaving
the tourniquet on for longer than a minute will affect the concentration of red blood
cells, possibly altering the test. Withdrawing the needle while the tourniquet is still
on will result in pain.
5)Apply pressure to the puncture area for 5 minutes after the needle is out to stop
the bleeding
6)Dispose of the needle in a hard sided, biohazard container.
7)Double check the labeling on the tube to make sure it is accurate.
Trouble shooting
1) Look for another vein if the median cubital vein is not visible. If you cannot find
the vein in the inside of the elbow in either arm, look for another one.
Move down the forearm looking for the basilic vein or cephalic vein. These veins
may also be visible through the skin. Have the patient lower their arm and make a
fist to make the veins more obvious.
The cephalic vein runs along the radial side of the forearm. The basilic vein runs
along the ulnar side. The basilic vein is less frequently used than the cephalic. It is
more likely to roll away from the needle than the cephalic vein because it is not
held as tightly in place by the tissues around it.
If no veins can be accessed, find the metacarpal veins on the back of the hands.
They are usually very visible and can be palpated. They should not be used for
elderly patients because the skin is not as supple and does not support the veins
as well. In addition, the veins themselves become more fragile.
2)Notice sites to avoid. Do not draw blood from areas that:
Are near an infection
Have scarring
Have a healed burn
Are on an arm that is on the same side as where the patient had a mastectomy or
fistula placed
Are bruised
Are above an IV line
Are on an arm where the patient has a cannula, fistula, or vascular graft
3)Correct improper needle placement. Occasionally, you may encounter problems
with the needle, such as going too far into the tissues or inserting it at too low of an
angle (so the bevel is against the wall of the vein and impedes blood flow).
Pull the needle back a little bit without removing it from the skin.
Change the angle of the needle while it is still under the skin so that it can be
inserted into the vein.
4)Give up and have a colleague do the procedure if your second attempt
fails.Protocol in many laboratories dictates that phlebotomists must attempt a
venipuncture two times, and to have another person do it if both attempts are
unsuccessful.
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Sampling for ABG analysis
Gather equipment
Arterial blood gas syringe.Take a little amount of heparin in a 2ml syringe to lubricate
the inner wall of the syringe and then flush out the heparin completely.
Needle (23G). 20 or 25 G may also be used.smaller gauges are more likely to lyse the
specimen
Alcohol wipe – 70% isopropyl ,Gauze,
Lidocaine – with small needle/syringe for administration
Gloves
A container with crushed ice for transportation of the sample to the laboratory (if the
analysis is not done at the point of care);
Preparation
1. Position the patient’s arm preferably on a pillow for comfort with the wrist
extended (20-30°)
2. Prepare all the equipment in the equipment tray using an aseptic non touch technique
3. Palpate the radial artery on the patient’s non-dominant hand (most pulsatile over the
lateral anterior aspect of the wrist).Locate the radial artery by performing an Allen test
for collateral circulation. If the initial test fails to locate the radial artery, repeat the test
on the other hand. Once a site is identified, note anatomic landmarks to be able to find
the site again. If it will be necessary to palpate the site again, put on sterile gloves.
4. Clean the site with an alcohol wipe for 30 seconds and allow to dry before
proceeding
5. Wash hands again
6. Don gloves
7. Local anesthetic is not generally considered necessary for single punctures.Prepare
and administer lidocaine subcutaneously over the planned puncture site (aspirate to
ensure you are not in a blood vessel before injecting the local anaesthetic).
8. Allow at least 60 seconds for the local anesthetic to work
9. Attach the needle to the ABG syringe, expel the heparin and pull the syringe plunger
to the required fill level (check with your local laboratory).
If the pt is on oxygen therapy but is able to breathe without it, take the abg sample after
the oxygen has been turned off for 20 minutes.
Taking the sample
The first choice is the radial artery.Alternative sites for access are brachial or femoral
arteries
1. Palpate the radial artery with your non-dominant hand’s index finger around 1cm
proximal to the planned puncture site (avoiding directly touching the planned puncture
site that you have just cleaned)
2. Warn the patient you are going to insert the needle
3. Holding the ABG syringe like a dart insert the ABG needle through the skin at an
angle of 45° over the point of maximal radial artery pulsation (which you identified
during palpation)
4. Advance the needle into the radial artery until you observe blood flashback into
the ABG syringe
5. The syringe should then begin to self-fill in a pulsatile manner (ideally do not pull back
the syringe plunger)
6. Once the required amount of blood(minimum 0.5 ml, preferably 1-2 ml) has been
collected remove the needle and apply immediate firm pressure over the puncture site
with some gauze
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7. Engage the needle safety guard .Activate the mechanisms of a safety needle to cover
the needle before placing it in the ice cup. In the absence of a safety-engineered device,
use a one-hand scoop technique to recap the needle after removal.
8. Remove the ABG needle from the syringe and discard safely into a sharps bin
9. Place a cap onto the ABG syringe and label the sample.Expel air bubbles, cap the
syringe and roll the specimen between the hands to gently mix it. Cap the syringe to
prevent contact between the arterial blood sample and the air, and to prevent leaking
during transport to the laboratory.
10. Yourself or an assistant/bystander/patient should continue to apply firm pressure for
3-5 minutes to reduce the risk of haematoma formation.Five minutes or more may be
needed for patients who have high blood pressure or a bleeding disorder, or are taking
anticoagulants
Take the ABG sample to be analysed as soon as possible after being taken as delays
longer than 10-15 minutes(for specimens held at room temperature) can affect the
accuracy of results. Iced samples should be analyzed within 1 hour.
Observe the extremity for 15-20 minutes after the procedure for arterial spasm.
Sampling errors
Inappropriate collection and handling of arterial blood specimens can produce incorrect
results.
Reasons for an inaccurate blood result include:
presence of air in the sample,collection of venous rather than arterial blood,
an improper quantity of heparin in the syringe, or improper mixing after blood is drawn,a
delay in specimen transportation.
One-hand scoop technique
1.Leave the needle cap on the surface and guide the tip of the used needle tip into it
using only one hand. Clean the surface with disinfectant afterward to avoid leaving
blood.
2.Place the needle cap against a firm upright surface with its opening towards the
phlebotomist, and place the used needle tip into it.
3.Lift the needle and syringe vertically and, once the tip is covered, use the other hand
to fix the cap into place.

ABG
Normal values
pH: 7.4(7.35-7.45)
pCO2: 40 mm Hg(35-45). To convert mmHg to kPa, multiply mmHg value by 0.133
HCO3: 24mEq/L(22-26)
Note- aHCO3 is the actual measurement of bicarbonate in the actual blood sample. It is
markedly affected by PaCO2. If the PaCO2 is high, the aHCO3 is dragged higher and
viceversa. sHCO3(standard) is the value of the HCO3 that would have been had the
PaCO2 been normal.
SpO2: 99%(acceptable normal range is over 95 %)
PaO2: 97 mmHg(acceptable normal range is over 80 mmHg)
Hypoxemia: mild-PaO2<80 mmHg in room air
Moderate- PaO2<60 mmHg in room air
Severe-PaO2<40 mm Hg in room air
Note: low PaO2 and a normal PCO2 indicates ventilation-perfusion mismatch
(interference with exchange). Seen in asthma, pneumonia.
Base excess-measures all bases.since bicarbonate forms the greatest part of the base
buffer, for practical purposes, BE provides essentially the same information as
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bicarbonate. Normal value is -3 to +3. if the problem is respiratory, then the BE can
denote the duration of the problem.
Basic Analysis
1.Look at the pH. pH <7.35 is an acidosis; pH >7.45 is an alkalosis
2.CO2 concentration (normal conc: 4.7-6.0 kPa, PaCO2: 35-45 mm Hg). CO2 is an
acidic gas. It is raised in acidosis & lowered in alkalosis. Look whether the change (in
CO2 conc )is in keeping with the pH, i.e whether the change in pH & change in
CO2 conc are in the same direction: increase/decrease or not. If it is in keeping with the
change in pH, or both pH & CO2 either simultaneously increase or decrease, then it is
due to a respiratory problem. If there is no change in CO2 conc , or an opposite one to
that of pH, then the change is compensatory.
3.HCO3 concentration (normal conc:22-28 mmol/L). Look whether the change (in
HCO3 conc )is in keeping with the pH. HCO3 is alkaline; it is raised in alkalosis &
lowered with an acidosis. If it is in keeping with the change in pH, it is due to a metabolic
problem.
Note: Arterial PaO2: 80-100 mm Hg, Venous: 28-48 mm Hg
Eg: A patient’s ABG shows pH 7.04, CO2 2.0 kPa, HCO3 8.0 mmol/L.
So here there is an acidosis as the pH is <7.35. The CO2 is low, and thus it is a
compensatory change. The HCO3 is low & is thus the primary change ie a metabolic
acidosis.

Detailed intepretations:
Step 1:clinical history
Step 2: look at the pH. If pH<7.4, it is acidosis. If pH>7.4, it is alkalosis. If pH is normal,
then look at pCO2 and HCO3. if both are normal, then acid base status is normal. If not,
it is a well compensated acid base disorder.
Step3: look at the pCO2, to decide which is the primary disorder, metabolic or
respiratory. Do NOT look at HCO3 to decide which is the primary acid base disturbance.
a) Acidosis with high pCO2: respiratory acidosis
b) Acidosis with low pCO2: metabolic acidosis
c) Alkalosis with low pCO2: respiratory alkalosis
d) Alkalosis with high pCO2: metabolic alkalosis
e)Compensation: if pH is normal, with abnormal pCO2 then acid base imbalance is a
compensated one.
f)Incomplete compensation: compensation has occured, but pH has not reached the
normal value
g)Uncompensated: if pH is abnormal with normal pCO2, then it is said to be
uncompensated one.
Step 4: now, look at HCO3, to diagnose whether the body’s compensatory response is
adequate or not(by comparing with the expected change in HCO3 and pCO2). if the
response of the second variable(HCO3) is as expected by calculation, then it is a simple
acid-base disorder. If the response is not as expected, a mixed disorder exists.
a) if bicarbonate value and pCO2 values are changing in the same direction, it is simple
acid-base disorder.
b)in respiratory acidosis for every 1 mmHg increase of pCO2 from 40, HCO3 increases
by 0.1 from 24( for a/c ) and by 0.4 mEq/L from 24 (for c/c disturbance)
For eg, if in a case of a/c resp acidosis, if PaCO2 is 70 mmHg,increase in PaCO2 above
40 is 30 mmHg, so 30x0.1=3 then expected HCO3- is 24+3=27
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c) in respiratory alkalosis for every 1 mm Hg decrease of pCO2 from 40, HCO3
decrease by 0.2 from 24( for a/c ) and by 0.4 mEq/L from 24 (for c/c disturbance)
If metabolic, calculate expected/compensatory PaCO2; PaCO2 =15 +HCO3-
d) in metabolic acidosis every 1mEq/L decrease in HCO3, pCO2 decrease by 1-1.5
mmHg(lower value for c/c and higher value for a/c disturbance)
e) in metabolic alkalosis every 1 mEq/L increase in HCO3, pCO2 increase by 0.5-1
mmHg (lower value for c/c and higher value for a/c disturbance)
Step5:compare given value with expected value
If given value=expected value or within ±2, then there is only single disorder ie step 3
diagnosis, if not then step 3 diagnosis + additional disorder ie mixed disorder.
If unequal values,
a)if step 3 diagnosis is metabolic then we calculate expected pCO2 and if given pCO2 is
more than expected, then it is met disorder +respiratory acidosis.
if given pCO2 is less than expected, then it is met disorder +respiratory alkalosis.
b)if step 3 diagnosis is respiratory then we calculate expected HCO3 and if given HCO3
is more than expected, then it is respiratory disorder +metabolic alkalosis.
if given HCO3 is less than expected, then it is respiratory disorder +metabolic acidosis

Correction of acidosis with bicarbonate:

It is needed when pH is too low(<7.1 or 7.2)or when the serum bicarbonate is low
enough( I.e <10 to 12 mEq/L)
Dose of sodium bicarbonate for partial correction= 0.3X(base deficit)x weight (in kg) in
mmol/L
Base deficit= 24-current HCO3 level
Base deficit is corrected to the level of 10-12 mEq/L of HCo3 in c/c metabolic acidosis
and 15 mEq/L in a/c metabolic acidosis after establishing adequate pulmonary gas
exchange.
In practise we give iv correction only if pH<7.2. Replace 50% of bicarbonate deficit over
2 to 3 hours and the remainder over 24 hours or give 50-100 mEq of sodabicarb over
30-45 minutes. The aim is to increase bicarbonate to 10 mEq/L and the pH to 7.2. Once
the pH is 7.2 -7.25, the serum HCO3 should not be increased by more than 4 to 8
mEq/L over 6 to12 hours to avoid the risk of over alkalinization. Bicarbonate should be
avoided in respiratory acidosis since it may paradoxically worsen the condition. A/c
respiratory acidosis requires O2 supplementation but in c/c hypercapnia, hypoxia is the
primary stimulus to respiration and therefore should not be abruptly corrected.
Anion gap:
Normal anion gap is 12 mEq/L(if K is not included in calculation). if K is included, then
the normal anion gap is 16 mEq/L
Causes of metabolic acidosis with increased anion gap: lactic acidosis, a/c renal failure,
ketoacidosis(diabetic starvation), toxins(like methanol, salicylates).
Causes of metabolic acidosis with normal anion gap: RTA, diarrhea, acetazolamide
Causes of metabolic alkalosis: vomiting, continous NG suction, diuretic therapy, cystic
fibrosis, adenoma, pottasium deficiency, post hypercapnia.
Excessively corrected hypoxemia- PaO2>100 mm Hg
Venous blood
PO2= 40 mmHg
SpO2= 75%
PCO2= 45 mmHg
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 196
Catheters
The size of Foley catheter is measured commonly using french scale. It is abbreviated
as F or Ch(charriere, it’s inventor). The diameter of a french catheter can be determined
by Dividing the French size by 3, i.e
D (mm)= Fr / 3. An increase in French size corresponds to a larger external diameter.
The commonly available catheters in our wards are F 12(white), 14(green), 16(orange),
18(red). The colour corresponds to the colour of the balloon port. The volume of the
fluid recommended to inflate the balloon is marked in the drainage port.
Catheterization
During catheterization, insert to the hilt;wait until urine emerges before inflating the
balloon.
In men , stretch the penis perpendicular to the body & then insert the catheter.
Remember to reposition the foreskin in uncircumcised men after the catheter is inserted
to prevent massive edema of the glans & paraphimosis.
Position of women: knees flexed, hips abducted with heels together.
After catheterization provide a ‘mesentry’ fold of adhesive tape, so that it prevents
kinking of the tube as well as reduce discomfort to the pt on movement.
Urine output should be >400 ml in 24 hr or >0.5ml/kg/hr
C/I:blood at urethral meatus, perineal bruising, blood in scrotum, pelvic # etc.

Routine urethral catheter removal

Timing of catheter removal
Catheters are routinely removed early in the morning. This means that any
problems, such as urinary retention, will normally present during the day and can
be dealt with by appropriate health professionals.
Equipment
Dressing pack containing paper towel, swabs and gallipot;
Kidney dish to receive the catheter;
Syringe for deflating the balloon (usually a 10ml syringe);
Disposable gloves and apron;
Cleansing solution, for example 0.9% sodium chloride.
The procedure
Ensure the patient understands the procedure and gain consent to remove the catheter.
Explain any symptoms that may occur after removal, such as urgency, frequency and
discomfort, and what action to take if these occur.
Check the patient’s records to see how much water was used to inflate the catheter
balloon. The same volume should be removed to completely deflate the balloon, before
attempting to remove the catheter.
Assemble the relevant equipment. Screen the patient to maintain privacy and protect
bed linen using protective covering.
Ask the patient to lie in a supine position so the catheter is easily accessible and the
patient can relax.
Release any catheter fixation devices to allow easy removal.
Empty the patient’s catheter bag or drain the bladder via a catheter valve to prevent any
spillage of urine during removal.
Wash your hands and put on non-sterile gloves to reduce the risk of cross infection.
 197
Place the paper towel under the patient and a kidney dish between the patient’s legs to
receive the used catheter and to catch any urine spillage.
If necessary, clean around the meatus and catheter using an appropriate solution
(usually 0.9% NS ). Always swab away from the urethral opening to reduce the risk of
introducing infection into the urethra. In women, never clean from the perineum or
vagina towards the urethra as this can transfer bacteria and potentially cause urinary
tract infection.
Following the manufacturer’s instructions, attach the syringe to the inflation/deflation
valve to deflate balloon.Put the syringe into the balloon port on the catheter. The syringe
fits tightly into the port with a firm push and twist motion. Do not pull on the syringe but
allow the solution to flow back naturally as the balloon deflates.
Check that the volume of fluid in the syringe is equal to the volume inserted; this
indicates that the balloon is completely deflated (although silicon catheters may not give
back the same volume as fluid can be lost from the balloon by osmosis).
Ask the patient to relax, and to breathe in and out as this relaxes the pelvic floor
muscles
Ask the patient to exhale and gently remove the catheter using continuous traction. In
male patients, extend the penis as this straightens the urethra. Men should be warned
about potential discomfort as the deflated balloon passes through the prostatic urethra.
Women can experience a stinging sensation and discomfort.
Clean and dry the meatus if necessary and make the patient comfortable.
Inspect the removed catheter for any signs of encrustation, especially if a new catheter
is to be inserted. This can affect how often the catheter is replaced.
Dispose of equipment according to local policy.
Remove gloves, and wash and dry hands. Ensure the patient is able to walk to the toilet
or has a call bell to ask for help.
Patients often experience symptoms of urgency and frequency so calls for assistance
should be responded to promptly.
Document the date and time of the catheter removal.
Record urine output until the frequency and voided volumes are satisfactory.
Encourage the patient to drink 2-3L of fluid a day. This helps to flush out any bacteria
that may be present in the urinary tract and prevent infections, which in turn will prevent
burning/pain on passing urine. Concentrated urine can also irritate the bladder and
cause unwanted contractions and spasms.
Ask the patient to observe for any signs of voiding difficulties and report these
immediately.
Troubleshooting
All Foley catheters have balloons that must be deflated before the catheter is removed.
If the balloon will not deflate, some simple techniques can be tried before referral to a
urologist.
These include:
Trying a different syringe;
Leaving the syringe attached to the inflation valve, with the plunger removed, for
20 minutes;
‘Milking’ the catheter along its length to help unblock any debris or obstruction;
Inserting a few millilitres (ml) of sterile water – this may help clear a blockage;
Attaching a 25-gauge (orange) needle into the inflation chamber just above the cuff and
drawing back – this will bypass a faulty valve.
 198
Do not:
1)Attempt to burst the balloon by overinflation – this could break it into fragments within
the bladder;
2)Cut the inflation arm or catheter, as the balloon may not deflate and, if there is any
traction on the catheter, it could retract into the bladder.
Note
Difficulty in voiding after removal of the catheter, especially in aging patients with poor
bladder contractile function can be prevented by Clamping the indwelling urinary
catheter before removal. The clamping process is supposed to strengthen the bladder
detrusor muscle, improve muscle tone and sensation of the bladder, and stimulate
normal filling and emptying of the bladder .Indwelling urinary catheter is clamped before
removal and unclamped when the patient expresses his desire to urinate. bladder
training by clamping prior to removal of urinary catheters is not necessary in short-term
catheter patients. In addition, clamping carries the risk of complications such as
prolonging urinary catheter retention and urinary tract injury.
Ryle’s Tube
Place lubricated tube in nostril with it’s natural curve promoting passage down, rather
than up. Advance directly backwards(not upwards). When the tip is estimated to be
entering the throat, rotate the tube by ~180 to discourage passage into the mouth.
Advance the tube into the esophagus during a swallow. It may be easier to swallow with
a sip of water.Advance >60 cm.Also provide a ‘mesentry’ fold of adhesive tape.
Common size FG12(white), FG14(green), FG16(orange) FG18(red)
C/I:Possible basal skull #

Cannula
In contrary to a catheter , in needle- gauge size, an increase in gauge corresponds to a
smaller diameter needle.
Purple/violet 26 G 13 ml/min
Yellow 24 G 23ml/min( commonly used in pediatrics)
Blue 22 G 36 ml/min
Pink 20 G 65ml/min
Green 18 G 96 ml/min
White 17 G 125ml/min
Grey 16 G 180 ml/min
Orange 14G 270 ml/min
How to insert cannula
Preparing to insert cannula
1)Gather materials. Cannulation requires some basic preparation and precaution.
You will need to protect yourself from contact with a patient's body fluids and you
need to protect the patient from injury or infection. In order to do this you will need:
Non-sterile gloves,Tourniquet
Antiseptic solution or alcohol wipes
Local anesthetic solution (optional)
Syringe with needle of appropriate gauge
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Venous access device
Transparent dressing
Paper tape
Sharps container

2)Choose the size of the cannula you will use. In general, the larger gauge needle
you use, the higher the maximum flow rate of the fluid entering into the vein. Larger
sized needles actually have a smaller number, so a 14 gauge is large, while a 22 gauge
is small. Choose a size that can easily fulfill the purpose of the procedure but is not
oversized.
The smallest needles are used in children. The largest are used for rapid blood
transfusion.
3)Have a discussion with your patient. Get informed consent from the patient before
you begin the procedure. This is usually done verbally. This builds up a rapport with the
patient and allows for a less traumatic experience.
Introduce yourself to your patient.
Verify your patient’s identity before starting any procedures.
Explain the procedure to the patient and answer any questions they may have.
Also take a quick history, primarily to exclude any allergy or sensitivity that the
patient may have. This is particularly true for latex allergy. Should an allergy to
latex be confirmed, then the tourniquet, gloves, and the cannula must be latex-free
4)Wash your hands and put on gloves. All medical professionals should follow
thorough and proper hygiene practices before coming into contact with a patient. It is
important to keep the risk of the patient getting infection to a minimum while inserting a
cannula by washing your hands thoroughly and putting on gloves.
5)Use proper personal protective equipment. Using gloves will not only protect your
patient, but will also protect you from exposure to bodily fluids and potentially infectious
material. A single pair of non-sterile gloves will probably be sufficient for this task.
Depending on your facility’s requirements, you may also wish to wear protective
eyewear when inserting or removing an IV catheter.
6) Apply the tourniquet around the patient's arm. In most cases, the patient’s non-
dominant arm is preferable. The tourniquet should be placed on the arm just above the
cannulation site. Tighten it appropriately, so that the patient's veins are highlighted.
Other methods for locating a good vein include:
Tapping on the vein to make it dilate.
Asking the patient to open and close their fist.
Using gravity to highlight the vein by holding the patient’s arm down.
Applying mild heat to the site of the vein.
If you have a difficult time finding a good vein on the arm you have selected,
inspect the opposite arm. In some cases (e.g. if the patient has diabetes or a
history of IV drug abuse), you may need to use an ultrasound to help you locate a
good vein.
7)Clean the skin. Using an alcohol wipe or antiseptic solution, clear away pathogens
on the skin around the vein used for cannulation. Apply the antiseptic to the site with
friction for 30-60 seconds, and then allow the site to air dry for up to one minute. This
will help prevent the risk of infection and reduce stinging.
If the area is really covered in hair, you may need to shave it. This will help you to
identify the vein, get a clear aim at it, and it will help when cleaning the area
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Inserting the needle
1)Insert the cannula needle at an appropriate angle. The correct angle will depend on
the size of the device and the depth of the vein.
If you are trying to access a small, superficial vein, you should use a small catheter (with a
gauge of 22-24) and insert at an angle of 10°-25°.
For a deeper vein, use a larger catheter and insert at an angle of 30°-45°.
Make sure you insert the needle bevel up (with its eye is facing upwards). This
means that the point of the needle is down against the skin.
2)Advance the cannula until you achieve flashback. Hold the cannula in the front of
its wings with your pointer and middle finger and in the back with your thumb. Advance
it slowly into the skin until blood enters the base of the cannula. This is called a
flashback, and it signals that you have entered a vein.
Once flashback occurs, reduce the angle of the needle to avoid puncturing the posterior
wall of the vein.
3)Advance the plastic piece of the cannula. The needle should now be held
stationary while the plastic component of the cannula is advanced another 2-3 mm into
the vein. The goal is to get the plastic sheath into the vein, and keep it there, while the
needle is removed.
Keep advancing the plastic component of the cannula until the plastic tube is fully
inserted. The "hub" of the plastic component will hit the skin when it is all the way in.
4)Allow blood to flow into an attachment. Remove the tourniquet from the patient's
arm. Remove the needle from the base of the cannula, leaving the plastic component in
sight. Allow blood to flow into the base of the cannula, so there is less risk of air going
into the vein if something is injected through the cannula, called an air embolism.
Then cap the cannula or attach test tubes or other supplies.
5)Find another vein, if your catheterization is unsuccessful. If you are unable to
catheterize a vein successfully, never attempt to reinsert the needle. This could result in
fragmentation of the catheter and embolism in the patient.
Finishing the procedure
1) Secure the cannula with an appropriate dressing. If the cannula needs to stay in
the vein, you will need to secure it. Using transparent dressing and tape, or a
specialized dressing that comes with the cannula, secure the venous access device to
the skin. Attach the cannula to the skin so that it is comfortable for the patient but stays
in place in the vein. You may need to tape attachments to the skin as well, for example
a tube leading to another attachment point.
Place a label over the transparent dressing with the date, time, and any other
information required by your facility.
If you are simply using the cannula to get several samples of blood, for example,
extensive securing is not required. However, you do need to be sure that it stays
in place long enough to get your sample, so you may want to tape it down a bit.
2)Inspect and clean the cannula. First, pull back on the syringe to withdraw a little
blood. This will confirm that the cannula is still in place inside the vein.Then flush the
cannula with a flushing solution, usually normal saline or heparin. This will assure that
the site is clean and will check for adequate positioning within the vein.
To flush the cannula you will need 5-10ml of saline in a syringe. This may come in
a pre-filled syringe or you may need to fill it yourself. Flush the cannula by
attaching the syringe of saline onto the cannula port, inject the saline into the port,
detach the syringe, and then close the port.
If you are returning to put an injection into a cannula, flush the it with saline
solution again. This will assure that the cannula is still in place.
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3)Recatheterize, if necessary. If you do not observe blood in the flashback
chamber when you inspect the cannula, you will need to recatheterize the vein. If
there is no flashback, this may mean that the catheter has punctured the posterior
wall of the vein. It can also occur in patients with severe hypotension (low blood
pressure).
Withdraw the device until it is just below skin level, and attempt to recatheterize.
If swelling develops at the site, remove the device and release the tourniquet.
Apply direct pressure to the site for 5 minutes.
4)Clean up after the procedure. Dispose of the needle in a sharps container to
reduce the risk of a needle stick. Dispose of any other waste appropriately.
Document the procedure in the appropriate set of notes.
If removing the cannula, place a piece of gauze on the injection site and keep it in
place with medical tape or a bandage. This will assure that the patient is not
bleeding after the procedure.

Hypodermic Needle
Brown 26 G, Purple 24 G,Blue 23 G, Grey 22 G, Green 21 G, Yellow 20 G, Pink 18 G

Central venous catheter

Uses
Invasive hemodynamic monitoring.
Infusion of drugs that can cause peripheral phlebitis or tissue necrosis if tissue
extravasation occurs(e.g TPN, epinephrine, amiodarone),Rapid volume infusion,For
pacing wire insertion,Eergency access when peripheral veins are inaccessible.
Renal replacement therapy, pasmapheresis, exchange transfusion.
Contraindications/cautions
Coagulopathy, agitated restless pt, undrained pneuomothorax on contralateral side.
Insertion
Ultrasound guided insertion should be considered if available, especially for difficult
insertion.
Anatomical Landmarks
Internal jugular vein- halfway between mastoid process and sternal notch, lateral to
carotid pulsation, and inside medial border of sternocleidomastoid.Aim toward
ipsilateral nipple, advancing under body of sternocleidomastoid until vein entered.
Subclavian-3 cm below junction of lateral third and medial two-thirds of clavicle. Turn
head to contralateral side. Aim for point between jaw and contralateral shoulder tip.
Advance needle to hit clavicle. Scrape needle around clavicle and advance further until
vein entered.
Femoral-locate femoral artery in groin. Insert needle 3 cm medially and angled rostrally.
Advance until vein is entered.
Technique
The seldinger technique is generally used.
Use aseptic technique throughout. Clean area with antiseptic(2% chlorhexidine) and
surround with sterile drapes. Anaesthetize locally with 1% lignocaine. Flush lumen of
catheter with saline.
If available, use ultrasound to distinguish the vein from an adacent artery by its
compressibility, thinner wall and ovoid shape. The internal jugular and femoral veins are
the easiest to locate by ultrasound.
Use needle to locate central vein. Confirm by aspiration of non-pulsatile blood into
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attached syringe or direct ultrasound visulaisation of the needle entering the vein.
Pass wire (with or floppy end leading) through needle into vein. Only minimal
resistance should be felt. If not, remove wire and confirm needle tipis still within vein
lumen. If arrhythmias occur, the wire may be at thetricuspid valve and should be
withdrawn a few cm.
Remove needle leavving wire extruding from skin puncture site.
Depending on size/type of catheter, a rigid dilator (+/- a prior scalpel nick to enlarge
puncture site) may be passed over the wire to form a track through the subcutaneous
tissues to the vein. Remove dilator. Thread catheter over wire. Ensure end of wire
extrudes from catheter to prevent accidental loss of wire in vein. Insert catheter intovein
to depth of 15-20 cm. Remove wire.
Aspirate and check respiratory swing, then flush with saline. Attach catheter to skin
using appropriate fixation device or by suturing. Suturing is not generally recommended
in view of increased risk of infection. Clean and dry the area. A chlorhexidine-
impregnated cuff may help avoid contamination. Use a sterile transparent semi-
permiable dressing.
A chest xray should be done to verify correct tip position(junction of svc and right atrium)
and excludes pneumothorax. A satisfactory position should generally be confirmed
before use of the catheter.
Complications
Infection- incidence of infection(usually S. aureus) usually arises after 5 days. The
catheter site should be kept clean with an occlusive dressing which should be changed
within 7 days using 2% chlorhexidine in alcohol to clean the site. Strict asepsis should
be used for dressing changes. The need for maintaining the catheter in situ should be
reviewed daily. Unless the risk of new catheter insertion is very high(e.g marked
coagulopathy, anatomical issues), changing the catheter over a wire is not
recommended. Catheter related blood stream infection )CRBSI should be considered if
the pt develops an unexplained pyrexia, or neutrophilia. Antibiotics may not be needed if
mild localised infection is present.
Removal of the catheter is necessary if the site is cellulitic or blood cultures taken
through the catheter are positive. If the catheter is removed, the tip should be sent to
the laboratory for culture.
Arterial puncture- apply firm pressure directly over puncture site for 10-15 minutes(or
longer). if continues consider correcting any coagulopathy. Rarely vascular surgical
assistance may be needed.
Haemorrhage- this may occur from around puncture site or from a previously failed
attempt at insertion.
Arrhythmias- usually related to catheter tip irritating tricuspid valve and normally
resolves by withdrawing catheter by a few cm.
Pneumothorax- if significant (e.g >one third of hemithorax), compromising
cardiorespiratory status, chest drain may be required.
Air embolism-avoid by ensuring all luer lock connections are not loosely attached. If air
ebolism does occur, roll pt to left hand side, and place head down(trendelenberg
position) to prevent air entering pulmonary artery. Give FiO2 100 % O2 to speed up
resorption of air. Try aspirating air through central line or consider angiography guided
aspiration if large.
Venous thrombosis. Suggested by unilateral swelling of distal limb. This can be
confirmed by ultrasound. Remove catheter and anticoagulate(unless contraindicated)
Hemothorax-drain if necessary and monitor blood loss. Usually self resolving. If
bleeding persists, ensure coagulopathy is corrected. Take cardiothoracic surgery
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opinion if blood loss is substantial(>1L)
Chylothorax- loss can exceed 1L/d. Often resolves spontaneously within 5-7 days. If it
persists, surgical ligation of the lymphatic duct may be necessary. The volume of loss
may be reduced with TPN or a low fat enteral diet.

Arterial cannulation
Indication-Continous monitoring of BP and frequent sampling of blood.
It is indicated in any pt with unstable or potentially unstable hemodynamic or respiratory
status.
Radial artery cannulation
Radial artery is most frequently chosen because it is accessible and has good collateral
blood flow. Allens test used to confirm ulnar blood supply is not reliable.
Technique
Use aseptic technique. Hyper extend the wrist and abduct the thumb. After skin
cleansing, local anaesthetic (1% lignocaine) is injected into the skin and subcutaneous
tissue over the most prominent pulsation. The course of the artery is noted and cannula
is inserted along the line of the vessel. The vessel is usually entered in similar fashion to
an iv cannula. There is usually some resisitance to skin puncture. To avoid accidentally
puncturing the posterior wall of the artery, the skin and artery should be punctured as
two distinct manoeuvres. Alternatively a small skin nick may be made to facilitate skin
entry. Seldinger type kits are available. A guide wire is first inserted through a rigid steel
needle. The indwelling plastic cannula is then placed over the guidewire.
The cannula should be connected to a continous flushing device after successful
puncture. Flushing with a syringe should be avoided since the high pressures generated
may lead to a retrograde cerebral embolus.
Complications
Digital ischemia due to arterial spam, thrombosis or embolus.
Bleeding, infection, false aneurysm
Alternative sites-ulnar artery- should be avoided if the radial artery is occluded.
Brachial artery- supply large volume of tissue, hence thrombosis has severe
consequences
Femoral artery- difficult to keep clean.
Dorsalis pedis artery-BP will be ≥10-20 m Hg higher than in central vessels.

Injections
Note: ideally give injections only after test dose(ATD).In case of any reactions,
don’t give the injection. In case of minimal/doubtful reactions on test dose, you
may give the drug along with a dose of dexamethasone.

IM injection
Wash your hands prior to starting the procedure
Reassure the patient and explain how the procedure will unfold
Sanitize the area with an alcohol swab starting in the center and working outward.
Allow the alcohol to air dry for 30 seconds. Do not touch the area until you give the
injection; if you do, you'll just have to clean the area again
Encourage the patient to relax
Insert the needle into the specific location. Start by removing the cap, and then
insert it smoothly at an angle of 90 degrees to the skin.
It can be helpful to pull up the skin around the injection site with your non-dominant
hand (as your dominant hand will be doing the injection) prior to injecting. Pulling up the
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skin can help you mark your target and make it less painful for the patient when the
needle goes in.
Pull back the plunger before injecting. After injecting the needle but before injecting
the medication, pull the plunger back a little. Although this may seem counter-intuitive, it
is important because if any blood comes into the syringe when you pull back, it means
your needle is located in a blood vessel and not in the muscle.[6] You will need to begin
again with a new needle and syringe if this happens.
The medication is designed to be injected into a muscle and not into the
bloodstream, so if you see any red color when you pull back you will need to
remove the needle and dispose of it. Prepare a new needle and choose a different
injection site — don't try to give the shot in the same place
Inject the medication slowly. While it is best to insert the needle quickly to
minimize pain, the opposite is true for the actual injection. This is because the
medication takes up space in the muscle, and the surrounding tissue will need to
stretch to accommodate the added fluid in the space. Injecting slowly gives more
time for this to happen and causes the patient less pain.
Pull the needle out at the same angle as you injected it
Press gently on the injection site with the 2 x 2 gauze. The recipient may feel a slight
discomfort; this is normal. Have the recipient hold the gauze in place while you dispose
of the needle.
Dispose of the needle properly

Gluteal region
You'll be giving this medication in the muscle in the buttock, so have the person getting
the medication lower their pants slightly and lie down on their stomach.
Divide one buttock into quadrants. You will always want to give the injection in the outer,
upper quadrant, almost toward the hip.
Select the site: It should be free of scars or bumps.
Clean the site with an alcohol pad and allow to dry. Do not blow on it or fan the site to
quicken the drying process. That just pushes the bacteria back onto the site.
Spread the skin with your fingers and inject the needle straight down in a dart-like
motion all the way.
Apply ice on the site to numb the area just prior to cleaning it.
Have the patient relax their buttock. Tension in the muscle makes the injection more
painful.
Massage the area after ward to enhance absorption of the medication.
After drawing up the medication, change the needle. The sharper the needle is, the less
painful the injection will be.
Hold the syringe by the barrel and not the plunger. Keeping a finger on the plunger may
cause you to inadvertently push the plunger before the needle is entirely in the tissue.
This can help prevent you from wasting medication.
Deltoid
Ask the patient what arm they prefer for the injection to be administered in because it
can sometimes be sore the next day,try to use the non-dominant arm, if not
contraindicated.Find the injection site by first locating the acromion process. This forms
the highest part of the outer shoulder and is a bony area.Once you find this area, go
about 2 fingers widths below this area, which will be the injection site for the deltoid
muscle.
Use the z-track technique to administer the medication. Don’t pinch or bunch up the skin.
The z-track technique is recommended for IM injections. This technique decreases pain
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to the patient, BUT most importantly it prevents the instilled solution from seeping into
the subcutaneous tissue.
To do this technique, take your non-dominant to the side of the injection site and pull the
skin to the side (opposite of the injection site).
1.Steady the needle by using the thumb and forefinger of the non-dominant hand. This
prevents potential damage to the muscle or surrounding tissues along with accidental
displacement of medication.
2.Use the dominant hand to inject the solution at a rate of 10 seconds per mL (don’t
inject too fast because this can cause damage). Example: if you’re administering 0.5 mL,
instill this solution over 5 seconds.
3.Once the solution is injected completely, wait 10 seconds before removing the needle.
Remove the needle at the same angle it was inserted (90’ degrees).
4.Don’t massage the injection site (this could force some of the solution into the
subcutaneous tissue). Light pressure can be applied to the site if bleeding occurs. You
may place a Band-Aid over the site if needed.

S/c injection
Needle insertion Pinch up on subcutaneous tissue to prevent injection into muscle.
Insert needle at 45° angle to the skin.
ID injections
Place the needle almost flat against the patient’s skin, bevel side up.
Insert the needle so that the point of the needle can be seen through the skin-only about
1/8 of an inch.
Slowly inject agent while watching for a small weal or blister to appear. If none appears,
withdraw the needle slightly
Withdraw the needle at the same angle it was inserted.
Do not massage the area after removing the needle.
Do not recap the used needle. Discard the needle and syringe in the appropriate
receptacle.
Assist the patient into a position of comfort.
Remove your gloves and dispose of them properly. Perform hand hygiene.
Chart the administration of medication, as well as the site of the administration.
(Charting may be documented on MAR, including location. Some agencies recommend
circling the injection site with ink.)
Observe the area for signs of reaction at ordered intervals, usually 24 to 72 hour periods.

Suction procedure

Suction Catheter
6(green), 8(blue),10(black),12(white)
Tracheostomy suction
Wash hands, put on gloves and protective eyewear
Explain the procedure to the pt & position the pt upright.Ensure a non-fenestrated inner
cannula is in place if the pt has a double cannula tube. Turn on suction, use minimum
pressure required to clear secretions to reduce risk of mucosal damage.Adults-100-150
mm Hg(13.5-20 kPa), adolescents 80-120 mm Hg, children 80-100 mm Hg, neonates
60-80 mm Hg.
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Select a suction catheter of no more than half the diameter of the tracheostomy tube.
Consider preoxygenating the pt with 100% oxygen for atleast a minute prior to
suctioning if the pt is critically unwell with high oxygen requirements or the suction
procedure has caused them respiratory compromise previously. Using an inert
technique, introduce the catheter into the tracheostomy tube. In adults it is
recommended that the catheter is inserted to the level of carina and then withdraw 1-2
cm before suction is applied. Measuring the tube and only introducing the catheter 1.5
cm or less beyond the top of tube may minimize trauma to carina. Slowly and smoothly
withdraw the catheter.
Tracheal secretions should be suctioned limiting the time to less than 10-15 seconds on
each attempt.

Ascitic Fluid Tapping

Indications:
1. To determine the cause of ascites. 2. To determine if intra-abdominal bleeding is
present or if a viscous has ruptured. 3. For therapeutic removal of fluid when distension
is pronounced or there is associated respiratory distress.
Contraindications:
1. Marked bowel distention (correct distension first, using NG suction or rectal tube
decompression).
2. Previous abdominal surgery (scar near proposed insertion site).
3. Severe thrombocytopenia (platelet count < 20,000).
4. Clotting abnormalities: Prothrombin time or partial thromboplastin time prolongation of
>1.5 times control (relative contraindication; correct these abnormalities first)
Materials
Betadine/Chlorexidine solution, 1% lidocaine, 3ml syringe with 25-27 gauge needle and
21 gauge 1 1/2” needle 18-20 gauge 1 1/2 needle, 20-60 ml syringe, drainage bag or
vacuum containers if available, stopcock, vials, Sterile drape
Procedure
1. Explain the purpose, risks, benefits and steps of the procedure. a. Risks include
perforation or laceration of abdominal/pelvic viscera, bleeding, infection, leak of ascitic
fluid b. Benefit includes relief of pain and yielding information, which may be useful in
diagnosis and /or signifying of altering treatment
2. Obtain informed consent from the patient or appropriate legal designee.
3. Check platelet count and/or presence of coagulopathy. Consult with attending
physician if platelet count is <50,000, or there is a known coagulopathy as to whether
platelet transfusion or other intervention is needed prior to the procedure.
4. The patient does not need to restrict food or fluids.
5. Explain that he/she will receive a local anesthetic to alleviate pain during the
procedure.
6. Check patient history for hypersensitivity to the local anesthetic.
7. Assemble materials and prepare sterile field
8. Have patient empty the bladder (insertion of a Foley catheter is not recommended but
may be necessary in some patients).
9. Place the patient supine at the edge of the bed (right side of the bed if you are right
handed), with the trunk elevated 45 degrees. Perform a time out with all appropriate
steps.
10. Access to the peritoneal space is usually midline 3 to 4 cm below the umbilicus,
halfway between the symphysis pubis and the umbilicus. Alternatively, the entry site can
be in the left or right lower quadrant between the umbilicus and the anterior superior
 207
11. iliac spine or the patient’s flank, depending on the location of the fluid as determined
by percussion of fluid wave. Be sure to avoid old surgical scars since the bowel may be
adherent to the abdominal wall.
12. Arrange equipment on a sterile field on a bedside stand.
13. Prep and drape the patient appropriately. Observe sterile technique.
14. Select the paracentesis site in the midline or lower quadrant.
15. Anesthetize the skin over the insertion site with 1% lidocaine using a 3 ml syringe
and a 25 or 27 gauge needle. Change to a 22 gauge needle, then anesthetize down to
and including the peritoneum.
16. Attach a 18-20 gauge 1½ inch needle to a 20-60 ml syringe. (In markedly obese
patients a 3½ inch 20 or 22 gauge spinal needle may be needed).
With the catheter mounted to the syringe, puncture the anesthetized skin. Insert the
catheter/introducer through the skin. The nondominant hand then stretches the skin to
one side of the puncture site, and the needle is further inserted to create a Z tract.
Keeping the needle perpendicular to the abdominal wall, advance the needle slowly
until fluid flows freely into the syringe. You will meet some resistance as you enter the
fascia. While advancing the syringe, maintain constant, gentle suction. When you get
return of fluid, leave the catheter in place, remove the needle, and begin to aspirate,
using a vacuum bottle. If no fluid returns, rotate, slightly withdraw, or advance the
catheter until fluid is obtained. If still no fluid returns, abort the procedure, and try an
alternative site or method. Sometimes it is necessary to reposition the catheter because
of abutting bowel.
17. For diagnostic paracentesis, collect 50 ml of ascitic fluid.
18. For a therapeutic tap, do not remove more than 500 ml in ten minutes. One liter is
the maximum that should be removed at one time; this volume permits the fluids and
electrolytes to equilibrate.
19. When enough fluid has been withdrawn, quickly withdraw the catheter. Cover the
insertion site with a sterile pressure dressing. If leakage of ascitic fluid occurs, close the
paracentesis with a mattress stitch.
20. Specimen handling: Fill the tubes completely with fluid. Dispose of the needles, then
gloves.
21. Check that each tube is properly labeled.
22. Depending on the clinical picture, send samples for a)cell count and differential,
b)total protein, specific gravity, albumin, LDH, glucose and amylase,c) AFB stain,
Gram’s stain, fungal stain, and bacterial and fungal cultures. If neoplasm is suspected,
consider sending carcino-embryonic antigen (CEA) level and cytogical evaluation
(requires up to 1 L in cytology bottle)
Post Procedure
1. Observe patient for 30 minutes for signs/symptoms of hypotension, bleeding, or
abdominal distress.
2. Provide post-procedural analgesics as needed.
Interpretation
A polymorphonuclear cell count of >500 cells/mm3 is highly suggestive of bacterial
peritonitis. An elevated peritoneal fluid amylase level or a level greater than the serum
amylase level is found in pancreatitis. Grossly bloody fluid in the abdomen (>100,000
red blood cells/mm3) indicates more severe trauma or perforation of an abdominal
organ. The classic positive test for hemoperitoneum is the inability to read newspaper
type through the paracentesis lavage fluid.
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Pleural aspiration
Drainage of pleural fluid using needle/cannula/flexible small bore drain. Increasingly
being performed under USG guidance.
Blood/pus often requires large bore needle/drain.
Indications
Improvement of blood gases
Symptomatic improvement of dyspnoea
Diagnostic tap
Contraindications/caution
Coagulopathy
Procedure
Confirm presence of effusion by cxr or usg
Select drainge area either my maximum area of stony dullness under percussion or by
usg.
Use aseptic technique. Clean area with antiseptic and infiltrate local skin and
subcutaneous tissue with 1% lidocaine. Advance into deeper tissues, aspirating to
confirm absence of blood, then infiltrate with local anesthetic until pleura is pierced and
fluid can be aspirated. Advance drainage needle/cannula/drain slowly through chest
wall and intercostal space(above upper border of rib to avoid neurovascular bundle).
Apply gentle suction until fluid is aspirated. Withdraw 10-20 ml for microbiological(M, C
& S etc), biochemical(protein, glucose etc), cytological analysis, as indicated. Either
drain insitu connected to a drainage bag or connect needle/cannula by a three-way tap
to a drainage. Continue aspiration or drainage until no further fluid can be withdrawn or
if pt becomes symptomatic(pain/dyspnea). Dyspnoea or hemodynamic changes may
occur due to removal of large volumes of fluid(>1-2L) and subsequent fluid shifts. If this
is considered to be a possibility, remove no more than 1L at a time, either by clamping
or declamping drain or repeating needle aspiration after an interval.
Remove needle/drain. Cover puncture site with firmly applied gauze dressing.
Complications
Puncture of lung or subdiaphragmatic viscera, bleeding.
Fluid protein level
Protein>30 g/L is an exudate, caused by inflammatory events (e.g pneumonia,
pulmonary embolism, neoplasm, collagen vascular disease.
Protein<30 g/L is a transudate caused by raised venous pressure(heart failure, fluid
overload), decreased colloid osmotic pressure(critical illness leading to reduced plasma
protein from capillary leak and hepatic dysfunction, hepatic failure, nephrotic syndrome).

Lumbar Puncture
Contraindications
Presences of increased intracranial pressure (ICP), regardless of cause, can increase
risk of cerebral or cerebellar brainstem herniation at the level of the foramen magnum.
Use of anticoagulants (e.g., warfarin, enoxaparin, etc) due to increased risk of
developing an epidural hematoma.
Evidence of cellulitis or abscess over the area where LP would be performed due to risk
of introducing infection into the subarachnoid space.
Significant degenerative joint disease or prior back surgeries where hardware maybe in
place (Note: many of these patients may require an LP under fluoroscopy)
Complications
Herniation of the brainstem
 209
Accidental puncture of the aorta or vena cava leading to retroperitoneal hematoma
Accidental puncture of the spinal cord from being in wrong location
Infection being introduced into the subarachnoid space
Pain over the LP site
Headache from CSF leak-Can worsen with sitting up or standing, and if lasting longer
than 1-2 days may require a blood patch in the area of the LP puncture site
Before the Procedure
Verify that no contraindications exist.This may include doing a CT head to rule out
active bleeding, midline shift, space-occupying lesions or signs of brain swelling.
Neuroimaging should be done prioe to to LP in following pts-altered level of
consciousness, FND, new onset seizure, papilledema, immunocompromised state.
Explain the procedure to the patient and answer all questions
Obtain informed consent with appropriate documentation
Do a baseline neurologic exam with special notation on the strength, sensation and
ability to move extremities
Place the necessary orders so that the CSF tubes can be labeled after the procedure is
completed
Wash hands, open the lumbar puncture tray without compromising sterility and consider
any extra supplies (i.e., spinal needles or extra tubes)
During the Procedure
Position the patient either in lateral decubitus / fetal position, or sitting upright leaning
forward over a small table.Opening pressures cannot be obtained accurately if the
patient is upright.If opening pressures are indicated, the patient will need to straighten
out after insertion of the needle to accurately measure the opening and closing pressure,
because they can be falsely increased with the pressure applied to the abdomen in a
fetal position
Locate the L3/L4 space by locating the superior iliac crests and placing your thumbs
midline to the spine. Palpate above and below to determine the widest space and
attempt to mark location with the nail of your thumb or create a small indentation with an
object like pen or needle cap
Aseptically clean the skin using chlorhexidine skin prep.
This can also be done using the skin prep provided in the LP tray once they have their
sterile gloves on.Put on sterile gloves, facemask, and protective gear as per institutional
policy.
Finish setting the LP tray including opening the CSF tubes in preparation to be easily
accessed, and apply the sterile drapes to the patient
Draw up and inject 10 mL of 1% or 2% lidocaine (preservative free; without epinephrine)
to the area.Consider injecting some anesthetic a level above or below this area in case
an adjustment is needed.
Insert the spinal needle directed at a slight cephalad angle (imagine aiming towards the
umbilicus) and with the bevel of the needle oriented to the longitudinal fibers in attempt
to separate the fibers instead of cutting them
If the patient is lying in lateral decubitus position the bevel should be oriented up.If the
patient is sitting upright and leaning forward the bevel should be oriented to the left or
right.
The entry into the subarachnoid space is commonly described as feeling a "pop"
sensation, the needle insert (obturator) is then removed and CSF should begin to drip
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out.Have the patient slowly stretch out legs (if lying in lateral decubitus).Attach the
sterile manometer to the end of the spinal needle to measure the opening pressure
Normal opening pressures: < 20 cm H2O
Measuring opening pressure is very important for evaluation for cryptococcal meningitis
or pseudotumor cerebri.
Empty the manometer into one of the CSF tube and about 10 drops each of CSF into
another 2-4 tubes.
Measure the closing pressure (if indicated).
Reinsert the needle insert (obturator) and withdraw the spinal needle and immediately
apply pressure and an adhesive bandage over the insertion site
After the Procedure
The patient may be advised to remain lying flat after the procedure, there is no evidence
that it has any effect on the development of post-LP headache. At the same time, there
is no harm in having the patient lie flat if they desire to do so.
Some clinicians will have the patient lay prone with a pillow under the abdomen to
increase the pressure on the tissues around the area of the LP in the thought that it
might prevent CSF leaking.
The patient may be advised to drink extra fluids to help replace the CSF drained off and
prevent a headache (or give the patient IV fluids if warranted)
Immediately label the CSF tubes. Have the tubes hand carried/delivered to the lab for
analysis
If meningitis is suspected, initiate empiric antibiotics with or without steroids based on
the clinical scenario.
Repeat neurologic assessment to evaluate for any changes post-LP.
Document the procedure, number of attempts, opening and closing pressure (if
applicable), total amount of CSF drained
Note
Before the procedure, no fasting needed
During the procedure, encourage the patient to not move and try to remain calm.
After the procedure, encourage fluid intake to prevent headache and consider resting
and lying flat for first 12 hours to help prevent possible headaches while things heal.

Bonemarrow Aspiration & Biopsy

Bone marrow examination is useful in the diagnosis and staging of hematologic disease,
as well as in the assessment of overall bone marrow cellularity.
Aspiration of the marrow done for cytologic assessment, with analysis directed toward
assessing the morphology and obtaining a differential cell count. Further sampling
allows material to be directed toward other ancillary tests, such as cytogenetics,
molecular studies, microbiologic cultures, immunohistochemistry, and flow cytometry.
Biopsies done for evaluation of the marrow’s overall cellularity, detection of focal lesions,
and determination of the extent of infiltration by various pathologic entities.
Indications
Diagnosis, staging, and therapeutic monitoring for lymphoproliferative disorders such as
chronic lymphocytic leukemia CLL), HL & NHL, hairy cell leukemia, myeloproliferative
disorders, myelodysplastic syndrome and MM.
Evaluation of cytopenia,thrombocytosis, leukocytosis, anemia, and iron status.
To rule out inflitrative infectious diseases such as fungal infections, tuberculosis, and
other granulomatoses.
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Nonhematologic conditions-workup for fever of unknown origin (FUO).
Diagnosis of storage diseases, assessment for metastatic carcinoma and
granulomatous diseases (eg, sarcoidosis),nutritional deficiencies (eg, deficiencies of
copper/zinc or vitamin B12/folate).
Preprocedural
Perform a thorough physical examination to assess the patient for signs of malignancy,
infections, lesions associated with hemorrhagic injury, as well as disorders of
hemostasis and coagulation.
Laboratory tests should initially include the following:
CBC,Reticulocyte count,Peripheral blood smears,PT,INR,aPTT,Serum iron, Serum
ferritin,Vitamin B12 and folate levels, x ray.
Take consent
Patient Preparation
Bone marrow biopsies can be done regardless of the platelet count and while the
patient is on anticoagulation, provided that the INR is not severely abnormal (eg, INR
≥5). Care should be taken to maintain hemostatic pressure longer in patients with
bleeding diatheses.
Materials required
bone marrow needle,10ml/20 ml syringes,25-gauge needles,22-gauge needles,4 x 4
and 2 x 2 gauze pads,Povidone-iodine swabs,Sterile drapes, Lidocaine 1% multidose
vial,Alcohol swabs, Elastoplast adhesive, or other pressure dressing,Sterile gloves
Anesthesia
Local anesthesia is employed. General anesthesia is required for pediatric cases, some
sternal bone marrow sampling cases, and in those patients who are highly anxious
Positioning
The patient is placed in the lateral decubitus position, with the top leg flexed and the
lower leg straight. Alternatively, the patient may be placed in the prone position.A towel
roll or small pillow placed under the hips may allow easier location of the iliac crest.
Sampling for Aspiration and biopsy
The posterior superior iliac crest is the most commonly employed site for reasons of
safety, decreased risk of pain, and accessibility. The posterior superior iliac crest site is
localized to the central crest area.
The anterior superior iliac crest is an alternative site when the posterior iliac crest is
unapproachable or unavailable as a result of infection, injury, or morbid obesity.
For aspiration
The sternum is sampled only as a last resort in those older than 12 years and in those
who are morbidly obese, but sternal sampling should be avoided in highly agitated
patients. To decrease the risk of penetrating the underlying soft-tissue organs, the
sternal site is limited to a region that spans between the second and third intercostal
spaces.
The tibia is sampled only for infants and under GA. This site is localized to the proximal
anteromedial surface, below the tibial tubercle. The tibial location is not utilized in older
patients, because the marrow cellularity is not consistent.
Sternal bone marrow aspiration has a higher risk of complications than other sites
because of the delicate bone structure in this area (~1 cm thick in adults). Penetration of
the underlying mediastinal organs can result in mediastinitis, pulmonary embolism,
pneumothorax, cardiac tamponade, and cardiac tissue injury, so biopsies are not to be
performed from the sternum.
Aspiration sampling is generally performed before marrow biopsy of the posterior or
anterior iliac crest. The reason is that the biopsy technique induces elevated
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thromboplastic substances, and this leads to a reduction in the effectiveness of an
aspiration sampling.
With the patient positioned as previously described the iliac crest is palpated and the
preferred sampling site marked with a pen. If the patient is obese, it is helpful to ask him
or her to place a hand on the hip so as to facilitate identification of the pelvic rim. It is
not uncommon for the lateral sacral crest to be mistaken for the posterior superior iliac
crest, an error that will lead to a painful procedure and a dry tap.
Aseptic technique is employed, including sterile gloves and gown. The site is prepared
with an antiseptic (eg, povidone-iodine or chlorhexidine), scrubbed, and draped so that
only the area immediately surrounding the site to be sampled is exposed.
The skin and the underlying tissue to the periosteum are infiltrated with a local
anesthetic (eg, ~10 mL of 1% lidocaine). A 10-mL syringe with a 25-gauge needle is
used to inject an initial 0.5 mL directly under the skin, raising a wheal. Perpendicularly
inject lidocaine subcutaneously and into periosteum. Avoid
injecting too much and obscuring landmarks.A 22-gauge needle is used to penetrate
deeper into the subcutaneous tissue and the underlying periosteum, an area roughly 1
cm in diameter.Allow 2-3 minutes for lidocaine to take effect.
The adequacy of the anesthesia is tested by gently prodding the periosteum with the tip
of the needle and asking the patient for any painful sensation. It is important to be
aware of changes in the patient's comfort level throughout the procedure, not only to
decrease the patient's anxiety level but also to minimize movements that may affect the
efficacy of the procedure.
Having a family member present may help alleviate the patient's anxiety. To ensure that
pain control is sufficient and being managed well, the person performing the procedure
should talk to the patient, discuss the steps taken throughout the process, and listen to
the manner as well as the content of the patient's response. The pt may be advised to
concentrate on their breathing, inspiring slowly through the nose and expiring slowly
through an open mouth; this helps ease any anxiety and pain.
Stretch skin taunt over puncture site, keeping crest between thumb and index
finger of one hand.Holding bone marrow needle with stylet locked in place, puncture
skin and advance through subcutaneous tissue, periosteum and into marrow cavity
using a steady, controlled pressure with a twisting motion.
Once the needle contacts the bone, it is advanced by slowly rotating clockwise and
counterclockwise until the cortical bone is penetrated and the marrow cavity is entered.
Contact with the marrow cavity is usually signaled by a sudden reduction in pressure.
The depth of the penetration should not extend beyond an initial 1 cm.Once within the
marrow cavity, the stylet is removed. A 20-mL syringe is used, and approximately 0.3-
0.5 mL of bone marrow is aspirated applying strong & quick suction.Aspirating more
than 0.3-0.5 mL risks diluting the sample with peripheral blood and thus is not
recommended.
The material collected for bone marrow slides is generally not mixed with an
anticoagulant, and it is processed immediately by a technologist; this avoids any cellular
morphologic artifacts. If there is to be a delay in slide preparation, place the sample in
an EDTA anticoagulant-containing tube, preferably a pediatric-sized tube to avoid
exposure to excess anticoagulant.
If additional marrow is needed for ancillary studies, subsequent specimens are obtained
by attaching a separate syringe and collecting 5 mL at a time. Usually, a 20-mL syringe
with 1 mL of 1:1000 heparin is prepared before the aspiration procedure is started so
that the samples do not clot easily. The samples are then transferred into an
anticoagulant-containing tube that is appropriate to the requested study, as follows:
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10-mL heparinized aspirate into heparin for cytogenetic analysis and
immunophenotyping/flow cytometry
3-mL nonheparinized aspirate into EDTA for molecular studies involving PCR
Formalin for a Cytoblock preparation (clot)
Glutaraldehyde for ultrastructural examination
If the biopsy is for workup of fever of unknown origin, sterile nonheparinized aspirates, 5
mL each, are also drawn for blood cultures for aerobes, anaerobes, acid-fast bacilli, and
fungi.
The marrow needle is removed, and pressure is applied to the aspiration site with gauze
until any bleeding has stopped.
Biopsy
The Jamshidi needle is commonly used. This disposable needle is tapered at the distal
end to help retain the specimen for improved extraction.
Some kits allow aspiration and biopsy to be done with the same needle, which is
convenient for the patient. However, if the latter is used, it is important to change the
needle position slightly to a different area of bone after aspiration is obtained. Otherwise,
an aspiration artifact is created where the marrow has been aspirated out of the core.
The needle, with stylet locked in place, is held within the palm and index finger and
repositioned so that a new insertion site is created for biopsy sampling. Once the needle
touches the bone surface, the stylet is removed.
With firm pressure applied, the needle is slowly rotated in an alternating clockwise-
counterclockwise motion and advanced into the bone marrow cavity to obtain an
adequate bone marrow specimen measuring approximately 1.6-3 cm in length.The
needle is rotated along its axis to help loosen the sample, pulled back approximately 2-3
mm, and then advanced again slightly, at a different angle, to help secure the specimen.
After this procedure, the needle is slowly pulled out while being rotated in an alternating
clockwise and counterclockwise motion.
The specimen is removed from the needle, and a probe is introduced through the distal
cutting end. If the aspirate was unsuccessful (ie, a dry tap), the core biopsy may be
used to make touch preparations . This must be performed before the specimen is
placed in formalin. Finally, the specimen is placed in formalin solution for histologic
processing.
Postprocedural Care
After the procedure, apply firm pressure for 2-5 minutes with sterile gauze placed over
the wound site until any bleeding has stopped.
Remove residual antiseptic to avoid further skin irritation by the solution.
If hemorrhage from the wound persists, then place the patient in the supine position,
with gauze over the wound site, so that consistent pressure can be applied for a
minimum of 30 minutes. If bleeding persists,consider placing a pressure dressing,with
the patient in a supine position, for an additional 1 hour.
Discharge the patient with the wound dressing which is to be maintained in a dry state
for 48 hours. The wound site is to be checked frequently, and if persistent bleeding or
worsening pain occurs, the patient must report.
Slide Preparation
This stage in bone marrow preparation should be performed by trained personnel (eg, a
hematopathology technician). Thin-spread preparations of aspiration-collected samples,
placed onto glass slides, can be prepared by numerous methods, all of which are aimed
at retaining and evaluating marrow particles. These spicules of fat droplets (not
prominently seen in pediatric cases) and fragmented bone are likely to have adherent
cellular material and thus to be a target for morphologic evaluation.
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An aspirate smear (or wedge) is the simplest of the methods, similar in presentation to a
peripheral blood smear. A drop of the acquired specimen is placed 1 cm from the edge
that opposes the frosted "labeled" end, and with a second glass slide placed at a 30º
angle, the sample is pushed toward the opposing side in one rapid smooth stroke.
Excess sample can be removed by tilting the glass slide onto gauze or pipetting the
extraneous fluid.
Squash (or crush) preparations are prepared on glass slides by placing marrow
particles on a slide and pressing the particles with another slide. These preparations
allow better observation of cellular interactions, in that they preserve the architecture of
the marrow unit.The crush technique is better for evaluating the percentage composition
of bone marrow cells, whereas the wedge technique may be better for identifying
cellularity.
The cover slip method produces more highly concentrated samples than the squash
preparation does. The aspirate particles are selected from a petri dish and directly
placed onto a glass cover slip. In a manner similar to the squash method, a second
cover slip is gently applied to crush the sample. Each cover slip is then stained
individually. Thus, enhanced removal of contaminating peripheral blood is performed,
again with retention of the marrow unit architecture.
At times, biopsy touch prints are useful, especially if the aspirate is dry and the only
sample available is the bone marrow biopsy. In touch preparations, the
hematopathology technician gently touches the tissue fragment onto a glass slide; this
can provide morphologic details similar to those that can be obtained with an
aspirate.Marrow particles can be collected in aggregate as a clot and processed in a
similar manner to that of tissue. The solid component is concentrated by placing the
specimen in a finely meshed bag that retains the tissue fragments but allows excess
fluid to escape.
Complications
Hemorrhage,Needle breakage,Infection
Risk factors for hemorrhage included concurrent anticoagulation therapy or underlying
myeloproliferative/myelodysplastic syndrome.

Oxygen therapy

Nasal prongs concentration achieved 25-30%, quantity 2-3L/min

Simple face mask 30-50%, 6-12 L/min

Venturi mask
24%- blue 2L/min, 28% white 4L/min,31% orange 6L/min, 35% yellow 8L/min, 40% red
12L/min, 60% green 15L/min

General considerations
Oxygen should be given to achieve a target saturation of 94-98% for most acutely
unwell patients. In CO poisoning the target saturation is 100%.
Baseline ABG is recommended for pts with saturation<94%.
Humidification is recommended if therapy extends beyond 4 hours, to prevent drying of
the respiratory tract.
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Avoid over oxygenation in COPD, severe c/c asthma, kyphoscoliosis, neuromuscular
disease, obesity hypoventilation,
Caution- oxygen supports combustion, therefore there should be no sources of ignition
near oxygen ports.

Trans cutaneous pacing(TCP)

Temporary means of pacing a pt’s heart during an emergency and stabilizing the pt until
a more permanent means of pacing is achieved. It stimulates the heart to contract.
Indications- symptomatic bradycardia, resulting from complete heart block, sinus node
dysfunction, acute MI. Hemodynamically significant(hypotension, chest pain, pulmonary
edema, altered mental status) bradydysrhythmias unresponsive to atropine, asystolic
cardiac arrest(more likely to be successful when initiated early after a witnessed cardiac
arrest). R/o and treat if present, alternative causes for a/c dysrhythmia like trauma,
hypoxia, drug overdose, hypothermia, electrolyte imbalance.
Technique
Electrical pads are placed on the pt’s chest either in anterolateral position or antero-
posterior position. AP position is more preferred because it minimizes transthoracic
electrical impedance. Electrical pads are connected to defibrillator, heart rate is selected
and pacing is initiated. Begin at 10 milliamps and increase by increments of 10 until
capture is noted. Target rate is generally 60-80 bpm. Current is applied until electrical
capture (characterized by a wide QRS complex since the SA node-AV node conducting
pathway is bypassed, with tall, broad T-waves on the Ecg) with a corresponding carotid
pulse occurs. Strongly consider sedation, as external pacing can be quite uncomfortable.
Most pt’s cannot tolerate currents of 50 milliamps and higher without sedation. Often 50-
100 mA are required. Ideal current is 1.25x what was required for capture.
Mechanical capture of the ventricles is evidenced by signs of improved cardiac output,
including a palpable pulse, rise in BP, improved level of consciousness, improved skin
colour and temperature. Both electrical and mechanical capture must occur to benefit
the pt. Pulses are difficult to palpate due to excessive muscular response. It is safe to
touch pt’s (e.g to perform CPR during pacing).
In addition to synchronised TCP, there is an option for asynchronous TCP in cases of
VF,VT, complete heart block. Over drive pacing is used to stop symptomatic
tachyadysrhythmias.
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Fluid Balance and IV fluid therapy

Fluid requirement
In a normal person fluid requirement over 24 hr is roughly 2500 ml. Normal daily losses
are through urine(1500 ml), stool(200 ml), & insensible losses(800 ml). This requirement
is normally met through food(1000 ml) & drink (1500 ml).

Intravenous fluids are given if sufficient fluids can’t be given orally. About 2500 ml fluid
containing roughly 100 mmol Na+ & 70 mmol K+ per 24 hr are required. Thus a good
regimen is 2L of 5% Dextrose and 1 L of 0.9% saline every 30 hr with 20 mmol of K+
per litre of fluid.

Remember that all cannulae carry a risk of MRSA infection, so always resume oral fluid
intake as soon as possible.
In sick pt’s, don’t forget to include additional sources of fluid loss when calculating daily
fluid requirements, such as drains, fever, or diarrhoea

Assessing fluid balance

Underfilled
Tachycardia, postural drop in BP, ↓ capillary refill time, ↓ urine output, cool peripheries,
dry mucous membrane, ↓ skin turgor, sunken eyes
Over filled
Pitting edema of the sacrum, ankles, or even legs & abdomen, tachypnoea, bibasal
crepitations, pulmonary edema on CXR, ↑ JVP

Pottasium in IV fluids
Pottasium can be given with 5% dextrose, or 0.9% saline, usually 20 mmol/L or
40mmol/L.
K+ may be retained in renal failure, so beware giving too much IV. GI fluids are rich in
K+, so increased fluid loss from the gut(eg diarrhoea, vomiting, high-output stoma,
intestinal fistula) will need increased K+ replacement.
The maximum concentration of K+ that is safe to infuse via a peripheral line is 40
mmol/L, at a maximum rate of 20 mmol/h.
Note
Elderly pt’s are more prone to fluid overload, so give iv fluids with care
Pancreatitis: aggressive fluid resuscitation is required in a/c pancreatitis
Fever, burns: large amounts of fluid can be lost unseen through transpiration.
Liver failure: these pt’s often have a raised total Na+, so restrict 0.9 % saline
Heart failure: use IV fluids with care to avoid fluid overload.
Shock: resuscitate with colloid or 0.9% saline via large bore cannulae.
Hypertonic dextrose(10% or 50%): irritant to veins, so infusion sites inspected & flushed
with 0.9% saline after use.

In children- Maintenance requirement

Upto 10 kg: 100 ml/kg/24 hr; 10-20 kg: 1000 ml + 50 ml/kg/24 hr for the weight above 10
kg; more than 20 kg: 1500 ml + 20 ml/kg/24 hr for the weight above 20 kg.
Add approx. 1ml 15% KCl(=2mEq) per 100 ml fluids like NS. Isolyte-P already contains
K+, & hence K+ need not be added to isolyte-P.
In case of significant dehydration, poor pulse etc., give NS 20-30 ml/kg & reassess.
 217
Maintenance fluid in adults: DNS(5% dextrose in normal saline), which, in addition,
contains normal saline (0.90% w/v of NaCl).

Calculation of rate of fluid infusion

Routine IV set, 1ml=15 drops

Drop rate per minute from fluid volume to be infused in one hour:
Volume in ml/hour ÷ 4 = Drop rate/minute
For more than one hour: Volume to be infused ( in ml) = Drop rate / minute
Duration of infusion in hours x 4
Drop rate per minute from fluid volume to be infused in 24 hours:
Fluid in litre/24 hours x 10 = Drop rate/minute
Perfect method to calculate fluid volume from drop rate in 24 hrs:
Drop rate x 96 = volume in ml per 24 hr
Microdrip set, 1ml = 60 drops
Number of microdrops per minute = volume in ml/hour
Adrenaline infusion
Preparation- 4 ampoule of Adr (4ml) + 46 ml Normal saline: 4 mg in 50 ml
Initial dose- 1 to 4 mcg/min, max dose- 20 mcg/min. Start @ 1.4 ml/hr (2 mcg/min)
Noradrenaline infusion chart
Composition- each ml contains 2 mg(4 mg in 2 ml)
Preparation- 1)1 ampoule of Norad(2ml) + 48 ml Normal saline: 4 mg in 50 ml
2)2 ampoule of Norad(4ml) + 46 ml Normal saline: 8 mg in 50 ml
Initial dose: 1-2 mcg/min, Max dose-30 mcg/min

Dosage Range 4 mg in 50 ml 8 mg in 50 ml
(double strength)

1 mcg/min 0.8 ml/hr 0.4 ml/hr

2 mcg/min 1.6 ml/hr 0.8 ml/hr

5 mcg/min 2.8 ml/hr 1.9 ml/hr

10 mcg/min 7.5 ml/hr 3.8 ml/hr

15 mcg/min 11.2 ml/hr 5.6 ml/hr

20 mcg/min 15 ml/hr 7.5 ml/hr

25 mcg/min 18.8 ml/hr 9.4 ml/hr

30 mcg/min 22.5 ml/hr 11.2 ml/hr

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Nitroglycerine infusion chart
1 ampoule has 5 ml
Composition : Each ampoule contains 25 mg(25 mg in 5 ml)
Preparation : 1 ampoule (5ml) + 45 ml NS: 25 mg in 50 ml.
2 ampoule (10ml) + 40 ml NS: 50 mg in 50 ml
Dosage: 5 mcg/min to 100 mcg/min. Increase by 5 mcg/min every 3-5 min upto 20
mcg/min, then increase by 10 mcg/min

Dose (mcg/min) 25 mg in 50 ml 50 mg in 50 ml

5 0.6 ml/hr 0.3 ml/hr

10 1.2 ml/hr 0.6 ml/hr
15 1.8 ml/hr 0.9 ml/hr
20 2.4 ml/hr 1.2 ml/hr
30 3.6 ml/hr 1.8 ml/hr
40 4.8 ml/hr 2.4 ml/hr
60 7.2 ml/hr 3.6 ml/hr
80 9.6 ml/hr 4.8 ml/hr
100 12 ml/hr 6 ml/hr

Dopamine infusion chart

Ampoule-5 ml ampoule
Composition - each ml contains 40 mg(200 mg in 5 ml)
Preparation- 1 ampoule of dopamine (5ml) +45 ml NS: 200 mg in 50 ml
Max dose- 20 mcg/kg/min
Dosage Range Patient’s weight (in Kg)

50 55 60 65 70 75 80 85 90

2.5 mcg/kg/min ml/h 1.9 2.1 2.3 2.4 2.6 2.8 3 3.1 3.4

5 mcg/kg/min ml/h 3.8 4.1 4.5 4.8 5.3 5.6 6 6.4 6.8

10 mcg/kg/min ml/h 7.5 8.3 9 9.8 10.5 11.3 12 12.8 13.5

15 mcg/kg/min
ml/h 11.3 12.4 13.5 14.6 15.8 16.9 18 19.1 20.2

20 mcg/kg/min ml/h 15 16.5 18 19.5 21 22.5 24 25 27

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Dobutamine infusion chart
Dosage in adults: 2.5-10 mcg/kg/min
Dose in pediatric pts:initial dose of 5 mcg/kg/min, adjusted according to clinical
response to 2-20 mcg/kg/min is recommended. Occasionally a dose as low as 0.5-1
mcg/kg/min will produce a response.
Composition: each ml contains 50 mg(250 mg in 5 ml)
Preparation: 1 ampoule (5ml) + 45 ml NS: 250 mg in 50 ml

Dosage Range Patient’s weight (in Kg)

50 55 60 65 70 75 80 85 90

2.5 mcg/kg/min ml/h 1.5 1.7 1.8 2 2.1 2.3 2.4 2.6 2.7

5 mcg/kg/min ml/h 3.0 3.3 3.6 3.9 4.2 4.5 4.8 5.1 5.4

10 mcg/kg/min ml/h 6 6.6 7.2 7.8 8.4 9 9.6 10.2 10.8

Amiodarone
1 ampoule has 3 ml
Composition : each ml contains 50 mg(150 mg in 3 ml)
Preparation: 4 ampoules(12ml) +38 ml NS: 600 mg in 50 ml
Dosage: 150 mg in NS slow iv over 10 min. 1 mg/min for 6 hrs(5ml/h), then 0.5 mg/min for 18
hrs(2.5ml/h). If infusion pump is not available, add 18 ml (900 mg) + 500 ml 5D, give 11-12
dps/min for first 6 hrs and 5-6 drops/min for next 18hrs
Labatalol
1 ampoule has 4 ml
Composition: each ml contains 5 mg(20 mg in 4 ml)
Preparation :2.5 ampoules (10ml) +40 ml NS( 50 mg in 50 ml)
Dosage- initial dose of 10-20 mg slow iv over 2 minutes. The max effect usually occurs within 5
minutes of each injection. Additional injections nof 40-80 mg can be given at10 minutes intervals
until a desired supine bP is achieved or a total of 300 mg has been injected. Infusion at a rate of
2mg/min(120 ml/h).
Lasix(Furosemide)
1 ampoule has 2 ml. Each ml has 10 mg(20 mg in 2 ml)
Preparation - 4 ampoules(8 ml) + 32 ml NS(80 mg in 40 ml). It will deliver @ 2mg/ml. Start @ 4
ml/hr in CHF.
Sodium nitroprusside(SNP)
Hypertensive crisis/Acute heart failure : initial dose - 0.3 mcg/kg/min. Evaluate BP for at least 5
min before titrating to a higher or lower dose. Not to exceed 10 mcg/kg/min
50 mg/5 ml vial available. Preparation-50 mg in 500 ml 5D. initial dose- 3 drops/min(0.3
mcg/kg/min) or 11 ml/hour. Note-infusion @ maximum dose rate should never last more than 10
minutes. If BP has not been adequately controlled after 10 minutes of infusion @ the maximum
rate, administration of SNP should be terminated immediately. Ordinary iv apparatus should not
be used. BP should be continously monitored using a continually reinflated sphygmanometer or
preferably an intra arterial pressure sensor(especially when used for treatment of CHF). Discard
solution 24 hours after dilution. The diluted solution should be protected from light using the
supplied opaque sleeve, aluminium foil, or other opaque material. It is not necessary to cover
the infusion drip chamber or the tubing.
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Transfusion Medicine

Fresh whole blood

It is the ideal component for pt’s who have sustained a/c haemorrhage of>25% total
blood volume loss. Normal transfusion rate: 10 drops/minute(1 unit in < 4 hrs)
Ideally transfusion should be started within 30-60 minutes after issuing the blood from
the blood bank. Do not keep blood in a domestic refrigerator. If blood is not used return
back in < 30 minutes

Packed red cells

They are most commonly used to raise the haematocrit. Each unit has a volume of
about 300 ml of which 200 ml consists of RBC
One unit of PRC will usually raise the haematocrit by approximately 4% and Hb by
1gm%.
Start transfusion within 30 minutes & should be transfused within 4 hours after
crossmatching and getting from blood bank. PRBS stored in 2-6 degrees.
ABO, Rh & cross matching done
Indications: Hb 7-8 g/dL with no cardiac risk.
Hb < 10 g/dL with a h/o CAD or risk of ischemia.
Blood or blood substitutes should be given early in hemorrhageic shock pt’s not readily
responding to crystalloid infusion.
If the cause of anaemia is easily correctable ( e.g Fe or FA deficiency) & no
cerebrovascular or cardiopulmonary compromise is present, it is better to avoid blood
transfusion
In severe anaemia with heart failure, transfusion must be done with care. Give it slowly
with 10-40 mg lasix iv with alternate units. Check for signs of worsening overload-rising
JVP and basal creps which may require stopping of transfusion.

FFP
It is available in units of approximately 200 ml. Blood grouping done. Rh &cross
matching not done.
It contains stable coagulation factors & plasma proteins: fibrinogen, antithrombin,
albumin as well as protein C & S
Indications: correction of coagulopathies, including the rapid correction of warfarin
toxicity, bleeding in CLD, snake bite, sepsis , treatment of TTP, supplying deficient
plasma proteins.
FFP after thawing should be transfused within 24 hours. Start transfusion immediately,
completion time <30 min. If transfusion is delayed,store in refrigerator(2-60 C) and to be
used in 24 hours.
200-250 ml of FFP can increase coagulation factors by about 2%.
The accepted dose of FFP for transfusion is 15ml/kg of body weight.

Cryoprecipitate
One unit has a volume of approximately 20 ml
Start infusion immediately , completion time <30 min
One unit of cryoprecipitate usually raises the fibrinogen level by 6-8 mg/dl.
It is a source of fibrinogen, factor V111, vWF
ABO, Rh & cross matching not done

Platelet transfusion
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Indication: active bleeding irrespective of plt count,TCP
ABO, Rh & cross matching not done
Start infusion immediately & Each unit transfused in <30 minutes. Platelet stored in
room temperature(20-24 oC)
If the transfusion is delayed shake the bag constantly to avoid platelet aggregation.
Ideally 1 unt will raise the platelet count by 5000-7000/ mm3. Check the platelet count in
6 hrs for knowing the increment.
C/I for plt transfusion-ITP, HIT

Before Transfusion
Check ABO gp & Rh compatibility on the label on the blood bag.
Inspect the blood for clots, abnormal colour, haemolysis & gas bubbles. Remain at the
bed side & observe for adverse effects at least for 10 min. Document the time of start of
procedure, blood/component(amount,gp, Rh type) with bag no.

Blood admministration set

Change the set at least 12 hourly during blood transfusion. In a very warm climate,
change the set more frequently and usually after every 4 units of blood, if given within a
12-hour period.
Minor adverse effects are rigour, fever, light headedness, urticaria, itching & flank
pain.Monitor vital signs every 15 min for the fist hour, if stable the frequency of
monitoring can be reduced after first hour. Continue monitoring till the end of the
transfusion.
Other hazards includes transfusion associated circulatory overload(TACO), pottasium
load( especially if blood is stored at room temperature), jaundice(hemolysis or
incompatible or old blood), TRALI(pulmonary edema in the absence of circulatory
overload, transient leukopenia), pyrexia (immunological transfusion reactions to
incompatible blood products), DIC(partial activation of clotting factors and destruction of
stored cells, either in old blood or when transfusion is incompatible).
A/c blood transfusion reaction presents immediately during or within 24 hrs of the transfusion.
TRALI- breathlessness and drop in SpO2 within 6 hrs of transfusion. Occurs mainly if plasma
is transfused. Pt is febrile, with low BP and transient decrease in WBC, b/l radiographic
infiltrates. Delayed TRALI occurs 6-72 hrs after transfusion. Supportive management with NIV
or CPAP.
TACO- breathlessness,temperature normal, WBC unchanged, BP raised. Administer diuretics.
In case of adverse reaction:-chills, fever, nausea, chest & flank pain
1.Immediately stop the transfusion
2.Inj Avil 1 amp iv, Inj efcorlin 100 mg iv st,
For anaphylactic reaction, if the pt is hypotensive, administer 0.5 mg of adrenaline IM.
Check information on the blood bag label & the pt’s details. Ensure that right blood was
administered to the right pt. Keep the IV line open with NS
Disconnect the tubing & the blood bag. Send all the material to the blood bank for
investigation along with a freshly collected sample from the pt for cross matching,
coagulation studies & platelet count. Investigate for acute hemolytic reaction. Insert
urinary catheter,collect the pt’s urine sample & look for hemoglobinuria. In hemolytic
reactions, Osmotic diuresis may be initiated with mannitol and iv fluids.
In the presence of rapid blood loss, platelets and FFP are indicated.

Complications of blood donation

Vasovagal syncope, hypovolemic shock,hematoma & bruise at sit of venepuncture
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Pre op patient
Npo period- Adults- 6 hrs for solid, 4 hrs for clear liquids
Oral anti coagulants/warfarin -stop 3-5 days before surgery & switch to heparin. Monitor
INR. Heparin/LMWH(0.4ml s/c BD) may be started 2 days before stopping Oral
anticoagulants. After surgery, both oral anticoagulant + heparin/LMWH restarted on
Post OP day 1, and heparin/LMWH continued till INR>2 is achieved.
LMWH can be given till 12-48 hrs before surgery.
Oral hypoglycemics/insulin- morning dose omitted. But SGLT2 inhibitors like
canagliflozin should be discontinued 3 days before surgery due to higher risk of DKA.
Antihypertensives- all anti-HTN to continue except ACEI and ARBs(morning dose)
Combined OCP- should be stopped 4 weeks before surgery as there is increased
chance of DVT
Thyroid drugs- continued
Antiplatelets: aspirin, if low dose-75 mg can be continued except for closed space
surgery(brain,spinal cord,eye), >75 mg stop 3-5 days before surgery. Clopidogrel- stop
7 days before surgery. Can be restarted after 12 hours
ATT - to be continued. Do LFT
Anti anginals including Nitrates, CCB- continued
Lithium-stop 2-3 days before surgery
Smoking- stop 12-24 hrs before surgery. Ideally 6-8 weeks before surgery.
Herbal medicines- stop 8 weeks before surgery.
Levodopa, anticonvulsants- to continue
MAO inhibitors-3 weeks before surgery.
TCAs- continued till the day of surgery.
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Postoperative Patient
Routine Care in all post-op patients
IVF
DVT prophylaxis,
Pulmonary toilet: early mobilization, incentive spirometry
Medications: antiemetics, peptic ulcer prophylaxis, Pain ctrl, antibiotics,
Lab tests

General complications

Pyrexia
May be due to atelectasis, tissue damage, blood transfusions. Look for signs of wound
infection,UTI, chest infection, cannula site erythema, peritonism, endocarditis,DVT.
Send FBC, CRP, RFT, LFT

Confusion/agitation/disorientation
Look for hypoxia, urinary retention, MI, stroke,infection,alcohol withdrawal, drugs,
liver/renal failure

Dyspnoea/hypoxia
Sit up, give O2, monitor peripheral O2 by pulse oximetry. Look for pneumonia, aspiration,
LVF, pulmonary embolism,pneumothorax,MI, RAD exacerbation.
Send FBC,ABG,CXR,ECG ,D-dimer

Decreased urine output

Look for blocked catheter, little replacement of lost fluid, ARF (following shock, drugs,
transfusion, trauma). Aim for urine output >30 ml/h in adults

Nausea/vomiting: look for emetic drugs(opiates,digoxin, anaesthetics), mechanical

obstruction, ileus. Send AXR

A/c retention of urine

If pt is in bed, make him sit up or stand to pass urine. Warm water bag to the lower
abdomen or pouring water to the leg/foot may help
If not relieved give inj buscopan
If still not relieved, catheterise.

Hypotension
Inadequate fluid input(monitor urine output),hemorrhage(r/w wounds & abdomen).Also
consider sepsis, cardiogenic/neurogenic causes, anaphylaxis.Look for evidence of MI,
Pulmonary Embolism.
Check pulse,BP. If severe, tilt bed head down (unless cardiogenic)& give O2, IVF(unless
cardiogenic)

BP ↑: may be from pain, urinary retention, missed medication, inotropic drugs

↓ Na+ :look pre-op level. SIADH can be precipitated by perioperative pain, nausea,
opioids, chest infection. Over administration of iv fluids may exacerbate the situation.
Correct slowly.
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Specific complications

Thyroid surgery
Haemorrhage
Dyspnoea: laryngeal edema,tracheal obstruction due to hematoma in the wound.Relieve
by immediate removal of stitches or clips. Other causes-hypoparathyroidism(late),
tracheomalacia,
Voice muffled/different due to intubation & local edema, injury to rec Laryngeal nerve.
Hypocalcemia/hypoparathyroidism(2-5 days of procedure)- initial symptom is perioral
numbness f/b paresthesia & tetany and finally respiratory distress.

Mastectomy
Seroma formation, hemorrhage, nerve injury,Arm lymphoedema, skin/flap necrosis

Colonic surgery
Sepsis, ileus, fistula, anastomotic leak, hemorrhage, obstruction from adhesions, trauma
to ureters, spleen.

Laparotomy
Wound dehiscence leading to burst abdomen with evisceration of bowel. Put the gut
back into the abdomen, place a sterile dressing over the wound, give iv analgesics, IVF.
Call Ur seniors. Serous wound discharge is an early clinical sign of impending burst
abdomen.

Small bowel surgery

Diarrhoea,malabsorption

Biliary surgery
Biliary colic,jaundice,hemetemesis, pancreatitis,post-op hemorrhage, biliary peritonitis

Tracheostomy
Stenosis,mediastinitis,surgical emphysema

Splenectomy
A/c gastric dilatation, thrombocytosis, sepsis

Genitourinary surgery
Septicemia

Hemorrhoidectomy
Constipation,infection, bleeding, stricture

Bariatric surgery
Dumping syndrome,wound infection,hernias,diarrhoea,malabsorption

Hernioplasty
Infection, mesh extrusion,FB reaction, Mesh inguinodynia causing Hyperaesthesia &
pain along the distribution of ilioinguinal or iliohypogastric nerves.
 225
How to Put On (Don) PPE Gear
More than one donning method may be acceptable. Training and practice using
your healthcare facility’s procedure is critical. Below is one example of donning.
1. Identify and gather the proper PPE to don. Ensure choice of gown size is
correct (based on training).
2. Perform hand hygiene using hand sanitizer.
3. Put on isolation gown. Tie all of the ties on the gown. Assistance may be
needed by other healthcare personnel.
4. Put on N95 filtering facepiece respirator or higher (use a facemask if a
respirator is not available). If the respirator has a nosepiece, it should be
fitted to the nose with both hands, not bent or tented. Do not pinch the
nosepiece with one hand. Respirator/facemask should be extended under chin.
Both your mouth and nose should be protected. Do not wear
respirator/facemask under your chin or store in scrubs pocket between
patients.
1. Respirator/mask: Respirator straps should be placed on crown of head
(top strap) and base of neck (bottom strap). Perform a user seal check
each time you put on the respirator.
2. Facemask: Mask ties should be secured on crown of head (top tie) and
base of neck (bottom tie). If mask has loops, hook them appropriately
around your ears.
5. Put on face shield or goggles. When wearing an N95 respirator or half
facepiece elastomeric respirator, select the proper eye protection to ensure
that the respirator does not interfere with the correct positioning of the eye
protection, and the eye protection does not affect the fit or seal of the
respirator. Face shields provide full face coverage. Goggles also provide
excellent protection for eyes, but fogging is common.
6. Put on gloves. Gloves should cover the cuff (wrist) of gown.
7. Healthcare personnel may now enter patient room.

How to Take Off (Doff) PPE Gear

More than one doffing method may be acceptable. Training and practice using your
healthcare facility’s procedure is critical. Below is one example of doffing.
1. Remove gloves. Ensure glove removal does not cause additional
contamination of hands. Gloves can be removed using more than one
technique (e.g., glove-in-glove or bird beak).
2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be
broken rather than untied. Do so in gentle manner, avoiding a forceful
movement. Reach up to the shoulders and carefully pull gown down and away
from the body. Rolling the gown down is an acceptable approach. Dispose in
trash receptacle.
 226

3. Healthcare personnel may now exit patient room.

4. Perform hand hygiene.
5. Remove face shield or goggles. Carefully remove face shield or goggles by
grabbing the strap and pulling upwards and away from head. Do not touch
the front of face shield or goggles.
6. Remove and discard respirator (or facemask if used instead of
respirator). Do not touch the front of the respirator or facemask.
1. Respirator: Remove the bottom strap by touching only the strap and
bring it carefully over the head. Grasp the top strap and bring it
carefully over the head, and then pull the respirator away from the face
without touching the front of the respirator.
2. Facemask: Carefully untie (or unhook from the ears) and pull away
from face without touching the front.
7. Perform hand hygiene after removing the respirator/facemask and
before putting it on again if your workplace is practicing reuse.
 227
ECG Basics
Six Limb leads – L1, L2, L3, aVR, aVL, aVF
Six Chest(precordial) Leads – V1 V2 V3 V4 V5 and V6
L1, L2 and L3 are called bipolar leads
aVR, aVL, aVF are called unipolar leads
Inferior wall:11, 111, aVF
Lateral wall:1, aVL, V4, V5, V6(V5 and V6 record events of left lateral wall

To record right side events V2R to V6R are needed – In dextrocardia, in RV infarction)
Anterior wall:V1 to V4(V1 and V2 record events of septum)
(V3 and V4 record events of the anterior wall)

RR Interval – One Cardiac cycle, 0.80 sec

X-Axis represents time - Scale X-Axis – 1 mm = 0.04 sec
Y-Axis represents voltage - Scale Y-Axis – 1 mm = 0.1 mV
One big square on X-Axis = 0.2 sec (big box)
Two big squares on Y-Axis = 1 milli volt (mV)
Each small square is 0.04 sec (1 mm in size)
Each big square on the ECG represents 5 small squares
=> 0.04 x 5 = 0.2 seconds
5 such big squares => 0.2 x 5 = 1sec = 25 mm
One second is 25 mm or 5 big squares
One minute is 5 x 60 = 300 big squares
Low voltages in obese women and men

Systematic approach in ECG interpretation

The following 15 points should be analysed carefully in every ECG.
1. standardisation(caliberation)
2. aVR(lead placement)
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3. Rhythm
4. Rate
5. P wave
6. PR interval
7. QRS voltage(also any LVH/RVH, LBBB/RBBB)
8. QRS interval
9. Pathological Q wave
10.Mean QRS electrical axis
11.Precordial wave progression
12.ST segment changes
13.T wave
14.QT/QTc interval
15.U wave

Note
Before you start reading an ECG, check the name of the pt, paper speed, voltage scale and
lead aVR
Standardization
Standardization – 10 mm (2 boxes) = 1 mV
ECG paper speed- 25 mm/sec, voltage- 10 mV.

Rhythm
Normal rhythm is sinus rhythm ie., every P wave is f/b a QRS complex, R-R constant
Abnormal rhythm include: atrial rhythm, nodal/junctional rhythm, idioventricular rhythm
If in, ECG the R-R intervals are not constant-sinus arrythmia
Atrial and nodal rhythms are called supraventricular rhythms. Supraventricular rhythms
have narrow QRS complexes while ventricular rhythms have wide QRS complex. But if
there is supraventricular rhythm with RBBB/LBBB or WPW syndrome QRS complex will
be wide.

Cardiac arrhythmia or cardiac dysrhythmia or irregular heartbeat: 4 main types - 1.

extra beats(ectopics/extra systole)- premature atrial contraction and premature
ventricular contraction.
2. Supraventricular tachycardias- PSVT, multifocal atrial tachycardia(MAT), atrial flutter,
atrial fibrillation.
AF, HR in AF= no of R waves in 30 big square(6 seconds) x 10
3. Ventricular arrhythmia- ventricular tachycardia(VT), ventricular fibrillation(VF)
4. Brady arrhythmias- sick sinus syndrome, AV nodal bradycardia/junctional rhythm,
ventricular escape rhythm/idioventricular rhythm.

Rate
HR=1500 div by no of small squares between two R waves or HR=300/no of big
squares between two R waves
If rate is irregular, count no of R waves in a 6 second rhythm strip or 30 boxes, then
multiply by 10

P wave
P Wave is Atrial contraction – Normal 0.12 sec or 120 ms
 229
P waves – always examine for in L2, V1, L1. Look whether all p waves look alike,
whether p waves occur at a regular rate, is there one p wave before each QRS. If you
are not sure , whether there is p wave or not, take it as no P wave.
Wide p wave >2.5 mm indicates left atrial hypertrophy
Tall p wave> 2.5 mm indicate right atrial hypertrophy
P wave can normally be biphasic in V1
P wave >2.5 small segment ht- P pulmonale( Rt atrial enlargement), P wave >2.5 small
segment breadth and notch- P mitrale( Lt atrial enlargement)

PR interval
PR interval is from the beginning of P wave to the beginning of QRS- Normal up to 0.2s
Shortened: WPW syndrome, LGL syndrome
Prolonged: in AV block

QRS complex
QRS is Ventricular contraction –Normal 0.08 sec or 80 ms
QRS positive in L1, L2, L3, aVF and aVL; Neg in aVR

Q waves
First negative deflection of QRS complex
Normal Q waves:The normal Q wave in lead I is due to septal depolarization
It is small in amplitude – less than 25% of the succeeding R wave, or less than 3 mm
Its duration is < 0.04 sec or one small box
It is seen in L1,111 and sometimes in V5, V6
Pathological Q wave:
The pathological Q wave of infarction in the respective leads is due to dead muscle
It is deep in amplitude–more than 25% of the succeeding R wave,or more than 4 mm
Its duration is > 0.04 sec or > 1 small box
It is seen in Leads facing the infarcted muscle mass.
Regarding abnormal q wave(pathological q wave) and interpretation of prior MI
Isolated pathological Q wave(> 1mm in width and depth) in lead V1 and lead III are
normal. In V2,V3 Q wave >0.02 sec or a qs complex is normal. In leads other than
V1,V2,V3 presence of a Q wave > 1mm in width and depth or a qs complex in any two
contiguous leads suggest prior MI.
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J point

The point at which the S wave touches the base line and the ST segment begins.
Normally it is distinct seen

Mean QRS electrical axis or ECG axis

LEAD 1 LEAD AXIS

AVF
Positive Positive Normal
Positive Negative Possible LAD
Is lead 11 positive?
Yes-> Normal
No-> LAD(left axis
deviation)
Negative Positive RAD(right axis deviation)
Negative Negative Extreme Axis deviation

Left axis deviation can occur as a normal variant but is more commonly a/w LVH,LAHB
and IWMI.
Right axis deviation can also occur as a normal variant in children and young adults.
Other conditions include RVH, LWMI, LPHB, dextrocardia and left pneumothorax

Precordial wave progression

Normally R wave progress from V1 to V4 and then decreases

ST segment changes
ST segment – Normal Isoelectric (electric silence)
 231

ST segment elevation DDs

A/c MI, a/c pericarditis, post MI infarction, LVH, a/c pulmonary embolism, brugada
pattern, hypercalcemia, hyperkalemia, hypothermia, DC cardioversion, class 1
antiarrhythmics

ST segment depression:Angina, hypokalemia, digoxin, ventricular hypertrophy with

strain
Q wave
Physiologic, positional variation, ventricular conduction disease, hypertrophic
cardiomyopathy, ventricular hypertrophy, non coronary myocardial injury
 232
T wave
Normal T↓ in aVR,V1, V2
T inversions in V2, V3 and V4 – Juvenile T ↓
Similarly in women also T↓
T inversion:ventricular hypertrophy with strain, cardiomyopathy, myocarditis, pulmonary
embolism, cerebrovascular injury, c/c pericarditis

T Wave Inversion
Deep symmetric inverted T waves in more than 2 precordial(chest) leads
85% of the patients with such T wave ↓ had > 75% stenosis of the coronary artery
T wave ↓ are significantly associated with MI or death during follow up

QT Interval
QT Interval – From the beginning of QRS to the end of T wave , Normal:- 0.40 sec
QT prolongation:Hypokalemia, hypocalcemia, hypothermia, amiodarone, drugs like TCA,
SAH,CVA, mvp,myocarditis

Long QT Syndrome (QT> 440 ms)

C/f: syncope, Seizures, sudden death,
Etiology: inherited, drugs like certain antibiotics, antidepressants, antihistamines,
diuretics, heart medications etc, QT prolongation in the course of other diseases, e.g MI,
cerebral hemorrhage
Inv: S.K, Mg, Na, TFT, ECG(of the pt & family members), genetic study. Rx: beta
blockers
QT shortening: hypercalcemia,hyperthermia,digitalis

Ischemia produces ST segment depression >0.1mV below baseline(ie the PR

segment) and lasting longer than 0.08s with or without T inversion.
Injury causes ST segment elevation with or without loss of R wave voltage
Infarction causes deep Q waves with loss of R wave voltage.
Upward sloping depression of ST segment is not indicative of IHD
It is called J point depression or sagging ST seg
 233

Downward slopping or Horizontal depression of ST segment leading to T↓ is

significant of IHD

Evolution of Acute MI

Acute Anterior MI
 Significant Q waves, ST elevation and T inversions in Leads V2, V3 and V4
 Q waves and T inversion in L1
 If only V1 and V2 show the changes it is called septal MI
Acute Anterio-Lateral MI
 Significant Q waves, ST elevation and T inversions in Lead 1, aVL, V5 and V6
 This is the most common form of MI
Acute Inferior wall MI
Significant Q waves, ST elevation and T inversions in Lead II, Lead III, aVF
Acute True Posterior MI
 Lead V1 shows unusually tall R wave (it is the mirror image of deep Q),ST ↓,
peaked T
 V1 R/S > 1, Differential Diagnosis - RVH
Right wall MI
V3R, V4R

Reciprocal changes- supports STEMI diagnosis and also indicate high risk pt.
Defined as ST segment depression occuring on an ecg which also has ST segment
elevation in at least 2 leads in a single anatomic segment. The concept cannot be used
in pts with following patterns on ECG- LBBB,RBBB, LVH with strain,RV paced rhythm.
Inferior leads(RCA), reciprocal leads-1,aVL
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Lateral leads(circumflex), reciprocal leads- 11,111,aVF
Anterolateral, reciprocal leads- 11,111,aVF
Posterior leads, reciprocal leads- V1-V4

Hyperkalemia(>5.4 mEq/L)

 Mild increase-Wide, tall and tented T waves(earliest ecg change ie T wave is the
tent house of K (pottasium) normal/shortened QT interval, ST segment
depression
 Moderate increase-Small or absent P waves, PR interval increases,Wide QRS
 Severe increase - high grade AV block with slow junctional and ventricular
escape rhythm, fascicular or bundle branch block,Finally sine wave pattern.
 Other changes-Shortened or absent ST segment ,Atrial fibrillation

Hypokalemia(<3.5 mEq/L)

 Mild decrease-Small or absent T waves or inverted T ,Prominent U waves

 Moderate decrease- increased PR interval,ST sagging
 Severe - prolonged QT interval, cardiac arrest

Hypocalcemia
 QT interval prolonged

Hypercalcemia
 QT interval shortened, ST elevation

Supraventricular Tachycardias
 Narrow QRS, regular, no P wave
It includes sinus tachycardia,AF, Atrial flutter,MAT,Focal atrial tachycardia, junctional
tachycardia, AVNRT,AVRT
 235
Atrial Fibrillation
 The heart rate is irregularly irregular
The R-R intervals are very different from beat to beat
There is narrow QRS tachycardia
There are no regular P waves – instead small fibrillary waves called ‘ f ’ waves
are seen especially in V1.

Atrial Flutter
 The heart rate is regular or variable
 Atrial rate is 300 per minute
 All P waves are not conducted to ventricles. There will be acquired /fixed AV block.
 The R-R intervals very depending on the AV conduction ratio
 The QRS is narrow : < 0.12 sec
 The P waves have a ‘saw toothed’ appearance called ‘F’ waves

Sinus Tachycardia

 P wave is symmetrical & T wave is asymmetrical

 causes:fever, hyperthyroidism,drugs like β agonists
 236
Atrial Tachycardia
 ≥3 consecutive atrial ectopics with a rate of >100/min
 cause:hypoxia(pulmonary disease)
 Multifocal atrial tachycardia(MAT)- irregular narrow complex with atleast 3 different p
morphologies. Usually due to pulmonary problems.

AVNRT
No pwaves, pseudo R’ waves may be seen. HR is 150-250/min

AVRT
P wave always follows QRS. RP interval <PR interval

PSVT
Tachycardias that occur with sudden onset and termination, they are not sustained
arrhythmias. They include AVNRT,AVRT and atrial tachycardia.
Features-narrow complex tachycardia @150 bpm; no visible p waves;pseudo R’ waves in
lead avR due to retrograde atrial activation.

Ventricular Tachycardia

 A wide regular QRS tachycardia is VT until proved otherwise.

Features suggesting VT include:
 Evidence of AV dissociation
 Independent P waves
 Beat to beat variability of the QRS morphology
 Very wide complexes (> 0.14 ms)
 The QRS is similar to that in ventricular ectopics
 Concordance (chest leads all positive or negative)
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Ventricular Fibrillation

 No definitive QRS complexes or wide QRS , irregular, no P wave

 Causes MI, hyperkalemia

Right Atrial Enlargement

 Always examine Lead 2 for RAE

 Tall Peaked P Waves, Arrow head P waves
 Amplitude is 4 mm ( 0.4 mV) - abnormal
Causes:
 Pulmonary Hypertension, Mitral Stenosis
 Tricuspid Stenosis, Regurgitation
 Pulmonary Valvular Stenosis ,Pulmonary Embolism
 Atrial Septal Defect with L to R shunt

Left Atrial Enlargement

 Always examine V 1 and Lead 1 for LAE

 Biphasic P Waves, Prolonged P waves
 P wave 0.16 sec, ↑ Downward component
 238
Causes:
 Systemic Hypertension, MS and or MR
 Aortic Stenosis and Regurgitation
 Left ventricular hypertrophy with dysfunction
Atrial Septal Defect with R to L shunt

Right Ventricular Hypertrophy

 Tall R in V1 with R >> S, or R/S ratio > 1

 Deep S waves in V4, V5 and V6
 The DD’s are RVH, Posterior MI, Anti-clock wise rotation of Heart
 Associated Right Axis Deviation, RAE
 Deep T inversions in V1, V2 and V3, Absence of Inferior MI
 QRS pattern changes from V1-V6
 V1 and V2-prominent R waves
 V5 and V6-prominent S waves
 If R V1> 7mm or S V6>7mm then RVH + OR (R V1) + (S V6)>mm then RVH+

Left Ventricular Hypertrophy

Pressure overloadvolume overload

 High QRS voltages in limb leads

 R in Lead I + S in Lead III > 25 mm; R in aVF > 20 mm;S wave in aVR>14 mm.
 S in V1 + R in V5/V6 > 35 mm or S in V1 or V2> 25 mm or V5/V6 R wave ht > 25 small
squares; largest R wave plus largest S wave in precordial leads >45mm
 R in aVL > 11 mm or S V3 + R aVL > 24 ♂, > 20 ♀
 QRS duration > 0.09 sec, Associated Left Axis Deviation, LAE
 In V1, V2 deep S wave will be seen; V5 and V6 tall R waves will be seen.
 Non voltage criteria- ST segment depression and deep symmetric T wave inversion in left
sided leads( 1,avl,V4-V6) aka left ventricular strain pattern; increased R wave peak time
>50 ms in leads V5 or V6.
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RBBB

 Complete RBBB has a QRS duration > 0.12 sec

 R' wave in lead V1 (usually see RSR' complex)
 S waves in leads I, aVL, V6, R wave in lead aVR
 QRS axis in RBBB is -30 to +90 (Normal)
 Incomplete RBBB has a QRS duration of 0.10 to 0.12 sec with the same QRS features
as above.
 The "normal" ST-T waves in RBBB should be oriented opposite to the direction of QRS

Complete LBBB

 Always pathological; a/w left axis deviation

Diagnostic criteria
 Complete LBBB has a QRS duration > 0.12 sec
 Prominent S waves in lead V1, tall and broad monophasic R in L I, aVL, V5,V6
 Absence of Q waves in lateral leads(1,V5,V6;small Q waves are allowed in aVL)
 The "normal" ST-T waves in LBBB should be oriented opposite to the direction of QRS
Other features
 Usually broad, Bizarre R waves are seen, M pattern
 Poor R progression from V1 to V3 is common.
 Incomplete LBBB looks like LBBB but QRS duration is 0.10 to 0.12 sec, with less ST-T
change.
 This is often a progression of LVH changes. Left Axis deviation may be present.
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Sgarbossa’s criteria
Used to determine whether there is acute ischemia on ECGs with LBBB. It consists of 3
criteria which may be applied to all LBBBs, regardless of time of onset.

A score of 3 points is required to diagnose an acute MI.

ECG Criteria for Left Anterior Fascicular Block (LAFB)

Left axis deviation (usually between -45 and -90 degrees)

Small Q waves with tall R waves (= ‘qR complexes’) in leads I and aVL
Small R waves with deep S waves (= ‘rS complexes’) in leads II, III, aVF
QRS duration usually normal or slightly prolonged (80-110 ms)
Prolonged R wave peak time in aVL > 45 ms
Increased QRS voltage in the limb leads
In LAFB, the QRS voltage in lead aVL may meet voltage criteria for LVH (R wave height > 11
mm), but there will be no LV strain pattern.

ECG Criteria for Left Posterior Fascicular Block (LPFB)

Right axis deviation (RAD) (> +90 degrees)
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Small R waves with deep S waves (= ‘rS complexes‘) in leads I and aVL
Small Q waves with tall R waves (= ‘qR complexes‘) in leads II, III and aVF
QRS duration normal or slightly prolonged (80-110ms)
Prolonged R wave peak time in aVF
Increased QRS voltage in the limb leads
No evidence of right ventricular hypertrophy
No evidence of any other cause for right axis deviation
Bifascicular block is the combination of RBBB with either LAFB or LPFB.

Ectopics
Occasional irregular beats observed in ECG may be due to ectopics or AV blocks.
Ectopics may be PAC,PJC,VPC.
In PAC(atrial premature complexes) there is p wave in the ectopic beat which is premature
and either abnormal or hidden. The abnormality in shape is only of p wave & they are
followed by a compensatory pause.

In PJC (premature junctional complexes)there is either no p wave or inverted p wave in

the ectopic beat.

If ectopic is wide(>0.12 s),notched, p wave absent and if there is a complete compensatory

pause following a QRS, it is usually VPC( ventricular premature complexes).
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Heart blocks
If no of P wave = no of QRS, i)normal ECG(if PR interval≤200ms) ii)10HB(if PR
interval>200ms)
 243

If no of P wave ≠ no of QRS, i)if PR interval constant: 20 Type 2 HB(mobitz type 2)

ii)If PR interval not constant,
a) 30HB (if RR interval constant)
b)20 Type 1 HB(if RR interval not constant)(mobitz 1)

Digitalis toxicity
Rate decreases, PR interval prolonged, ST depression, T inversion-inverted tick sign

Ventricular asystole

A potentially fatal arrhythmia identified by large bizarre waves without P waves preceding the
QRS complexes or p waves unrelated to the QRS complexes but a regular rhythm.

Myocarditis
Tachycardia
Diffuse T wave ↓
Saddle shaped ST elevation

Dextrocardia
 Rt axis deviation; Positive QRS complex(with upright P & T waves) in aVR
 Lead 1- inversion of all complexes(global negativity-inverted P & T,negative QRS)
 Absent R wave progression in the chest leads (dominant S wave through out)
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Pericarditis
 ST↑ in all leads( bulges downwards/concave upward)( In MI ,ST segment elevation
bulges upwards) with reciprocal depression only in aVR & V1.
 PR segment depression

Pulmonary embolism
 Sinus tachycardia,
 anterior T wave inversion,
 S1Q3T3, RBBB, low amplitude deflections
 Rt axis deviation, new onset p pulmonale

COPD
P pulmonale, low voltage qrs in limb leads, RAD.
S1 S2 S3 pattern with large S waves in V5,V6
Spontaneous pneumothorax
Loss of R in chest leads, symmetrical T inversion, reduced QRS voltage

Pacemaker rhythm

It is identified by the presence of abnormally thin and narrow vertical line followed by a bizarre
complex with a T wave in opposite direction as in a ventricular rhythm
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Electrical interference

It is identified by the presence of rapidly occurring irregular spikes in the ECG base line due to
electrical interference or improper earthing of the machine to the ground.

Muscle tremors

Baseline artifacts may also occur following muscle contraction of the patient. These are also
spikes in relation to the base line and may interfere with correct diagnosis

Wandering baseline

Sometimes the base line of ECG can be found to be wandering and shifting upwards and
downwards. This is of no consequence, but may interfere with other diagnosis.

Wolff parkinson white syndrome

It is recognized by the presence of a short PR interval, abnormal wave in the upstroke called
delta wave and prolongation of the QRS complex. Predisposition to supraventricular arrhythmias.
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Pericardial Effusion

Ideo ventricular rhythm

It is said to exist when SA node & AV node have stopped functioning and ventricular
myocardium has taken over with a very slow rate which is inherent to it. Hence no p waves
≥3 consecutive PVCs with HR<50, if HR is 60-100: AIVR, if HR>100:VT

Accelerated ideo ventricular rhythm

ventricular contractions at a higher rate usually between 80 and 100 per minute after sinus and
AV node failed. Even if p waves are present they are unrelated to the QRS complexes
SAH ECG changes
Raised ICP is associated with certain characteristic ECG changes:
Widespread giant T-wave inversions (“cerebral T waves”).
QT prolongation
Bradycardia .Other possible ECG changes that may be seen:
ST segment elevation / depression — this may mimic myocardial ischaemia or pericarditis.
Increased U wave amplitude.
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Other rhythm disturbances: sinus tachycardia, junctional rhythms, premature ventricular
contractions, atrial fibrillation.

Early repolarization

This ECG has all normal features

The ST-T (J) Junction point is elevated. T waves are tall, May be inverted in LIII, The ST
segment initial portion is concave. This does not signify Ischemia

Sinus nodal dysfunction

can result in sinus pauses, followed by the normal sinus beat or sinus arrest followed by an
escape rhythm from Junctional rhythm or sick sinus syndrome with tachycardia & bradycardia

Wandering atrial pacemaker

is caused by the impulses produced in multiple foci(2 or more) in the atrial musculature or AV
nodal tissue. Hence p waves have multiple shapes and forms. Causes- c/c lung disease, valvular
heart disease.
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ECG changes observed during pregnancy

It includes sinus tachycardia, left axis deviation as pregnancy advanced, ectopic beats,
inverted or flattened T waves in lead III, V1-V3, a Q wave in lead II, III, aVF and
augmented voltage unipolar left foot lead
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X-RAY interpretation

Chest X-ray(CXR)

Standard views
PA view

The standard chest examination consists of a PA view. The pt is examined in full inspiration. Pt’s
chest is placed against the cassette. The PA view minimizes cardiac magnification which can
complicate other views.
Expiratory chest X-ray is done in pneumothorax, diaphragmatic palsy,conditions causing air
trapping like FB, partial bronchial obstruction etc.

AP view

It is performed on patients who are unable to stand for the PA view. It is usually performed at the
bedside. This may cause cardiac magnification. AP view also provides better visualization of
posterior chest. It is also sometimes useful to determine whether a questionable opacity on PA
view is genuine by altering the position of overlying ribs. In AP view scapulae are over lung
fields, clavicle mostly above apex of lung fields. Anterior ribs are distinct.
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Lateral view

A lateral view is ordered in conjunction with a PA view. This view may expose lesions that are
retrosternal or hidden by the diaphragm. Conventionally left lateral view(with the left side of chest
held against the film) is taken. The pt is placed with the film against the side of the chest where the
lesion is suspected.
Interpretation
The key to successfully interpreting any x-ray is to be systematic. Examine all parts of the film in
an orderly manner, and do this consistently.
First, make sure that the chest xray belongs to the correct pt, correct date & time, and correct
view/side.
Utilize a systemic approach using the mnemonic RIP-ABCDE-Lungs
Assessing technical quality
R- Rotation
I- Inspiration
P -penetration
Rotation- ideally CXR beam should be transmitted perpendicular to the chest. Abnormal angles
will distort the image by creating an oblique view. Clavicular heads should be equidistant from
thoracic vertebral spinous processes. A pt with a thoracic scoliosis may appear to have a rotated
film. Check whether the spinous processes on the vertebral column are aligned. If they are, it is
more likely that the pt is rotated.
Inspiration- assessment of inspiratory effort and lung volumes. Ideally 7-9 posterior ribs should be
visible. Less than 7 ribs suggests poor effort by the patient and/ or low lung volumes as in
restrictive lung disease, atelectasis, etc. 10 or more ribs typically suggests hyperinflation as in
COPD, asthma, bronchiectasis.
Penetration- exposure quality of the film. On a good PA film, the thoracic spine disk spaces should
be barely visible through the heart but bony details of the spine are not usually visible. Penetration
is sufficient if bronchovascular structures can be seen through the heart. If the vertebral bodies
behind the heart are too clearly seen, the film is over penetrated making the lungs appear
black.Over penetration will make structures more radiolucent which could lessen significance of
opacities. Lung fields are blacker than usual. Absence of peripheral vasculature. Under-penetration
will make structures more radioopaque, which may lead to over calling certain findings. On the
lateral view, you can look for proper penetration and inspiration by
observing that the spine appears to darken as you move caudally. This is due to more air in lung in
the lower lobes and less in chest wall.
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Evaluation of structures
A-Airway
A-Bones (and soft tissues)
B-Cardiac silhouette
C-Diaphragm
D-Everything else
Airway
Trachea- deviation, caliber
Carina- typical angle, splaying
Mainstem and lobar bronchi- right mainstem is more straightly aligned with trachea
Bones(and soft tissues)
scan all bony structures
fractures, thoracic cage deformities
Cardiac silhouette
Evaluate the size and shape of the cardiac silhouette. Two-thirds of the heart lies on the left side of
the chest with one-third on the right. The heart should take up no more than half of the thoracic
cavity. Look for the following
Cardiomegaly-width of the silhouette is greater than 1/2 the thoracic cage width. Can be
exaggerated or over called AP films, supine views
Aortic knob, left atrium, pulmonary arteries, shift of mediastinal structures, cardiac borders,
pericardial effusion
Look at the right heart border and follow it up from the diaphragm. From the diaphragm to the
hilum the heart border is formed by the edge of the right atrium. From the hilum upwards it is
formed by the superior vena cava.
Follow the left heart border up from the diaphragm. From the diaphragm up to the hilum it
consists of the left ventricle. The left border is then concave at the lower level of the left hilum
and here it is made up of the left atrial appendage. This concavity is lost when the left atrium is
enlarged leading to a straightening of the left heart border and sometimes the development of a
convexity at this point. At the level of the hilum the border is made up of the pulmonary artery
and above this the aortic knuckle.
Diaphragm
Diaphragmatic line should be clearly demarcated. Left hemidiaphragm is at a higher level than the
right.
Evaluate costophrenic and cardiophrenic angles
Retrocardiac space
Elevation or flattening of the hemidiaphragms.Also look at structures immediately beneath
diaphragm(liver, gastric bubble,free air in the abdomen)
Things that obscure the diaphragm- pleural effusion,atelectasis,lower lobe infiltrates or mass
Everything else
Endotracheal tube- tube should be 2-4 cm from the carina
Central line- tip of catheter should lie in the cavo-atrial junction
Pacemaker or defibrillator- know how to tell the difference. Leads may be placed in the atria or
ventricles.
Chest tubes- always identify the sentinel hole to make sure it is within the pleural space.
Lungs
Evualuate the lung parenchyma last.
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Look at each side independently and then compare the two sides. Point out features that seem
abnormal. Always describe before diagnosing.
Opacities- something which appears relatively radio-opaque compared to normal lung, alveolar
opacity, interstitial opacity.
Mass/Nodule- discrete appearance with apparent borders. Nodule <3 cm, can be pleural based or
parenchymal
Consolidation- focal confluence of alveolar opacities, air bronchograms, obliteration of vessels.
Atelectasis vs effusion- look for discrete lines or lobar distribution for atelectasis. Effusions are
usually independent which causes gradation from base upwards.
Edema- alveolar vs interstitial patterns
Fibrosis- septal thickening, honey combing
Hilum
Composed of pulmonary artery and its branches, adjacent airway and pulmonary veins. Since
airways donot produce a significant shadow on plain film, the majority of the detectable hilar
structures are vascular. The pulmonary arteries and upper lobe veins significantly contribute to the
hilar shadow on plain CXR. Left hilum is slightly at a higher position than the right hilum. Both
the hila should be of equal size, density with concave lateral borders. Normal lymph nodes are not
seen.
Pulmonary vessels
The arteries and veins branch out from hila, becoming smaller towards the periphery. The large
central vessels are better seen, peripherally the vessels overlap as they run laterally. In the upright
position, the lower lung vessels are larger than the upper vessels due to gravitational effects on
flow. If the pt is supine, there is redistribution of flow to the upper lung vessels, know nas
cephalization of flow. CCF also causes cephalization even when the pt is upright when the CXR is
taken.
Comparison with previous xray is a very important diagnostic maneuver in the xray interpretation.

CXR in pregnancy
straightening of left heart border. Cardiac size may appear larger. Small pericardial effusions are
also physiological.

Supine film
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CXR shows decreased lung volume. Increase venous return to heart- distends azygous and
pulmonary vein. Diaphragm rises and intracardiac pressure increases- heart and mediastinal
structures enlarge. Fluid and air migrate. Pleural effusions disappear. Small pneumothorax
disappears. Air fluid levels (e.g lung abscess) disappear.
Upper lobe diversion is normal on supine film and is not suggestive of heart failure.
Pneumothorax signs on supine film- deep sulcus sign(deep lateral costophrenic angle on a supine
cxr). It is usually helpful in icu pts.

Air bronchogram
It is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or
inflammatory exudates. It is diagnostic of consolidation.
Causes of air bronchogram- consolidation, pulmonary edema, non obstructive pulmonary
atelectasis, severe interstitial disease, neoplasm and normal expiration.

Important CXR pathology

The position of lesion can be described in terms of zones. The upper zone lies above the right
anterior border of the 2nd rib, the middle zone between the right anterior borders of the 2nd and
4th ribs, and the lower zone between the right anterior border of the 4th rib and the diaphragm.
Abnormal hilum
Suspect Hilar enlargment if
a)one hilum is denser and bigger than the other b)there is a loss of the normal concave shape-
the hila are usually concave in shape. This concavity may disappear and be the first sign of hilar
enlargment.
If unilateral hilar enlargment is suspected then a)check the technical quality of the film,a rotated
film will make one hilum appear larger than the other b)check older films to see whether the
enlargment is new or not c) take lateral view xray as enlarged hilum appears denser in lateral
film and is easier to spot.
If hilar enlargment is suspected,a) look for peripheral lung lesions(tumour,TB), lung infiltration
(carcinomatous lymphangitis), bone lesions(mets) b)look at the rest of the mediastinum.
Malignant hilar enlargment may be a/w superior mediastinal lymphadenopathy c) look for
calcification which appears as dense white which suggests lymphadenopathy d) look at the hilar
edges. Vascular margins are smooth,lymphadenopathy gives smooth lobular appearance,
malignancy suggested by irregular spiculated indistinct margins.
Hilar enlargment always warrants further investigation. The commonest causes of b/l hilar
enlargment are pulmonary HTN, sarcoidosis

Abnormal heart shadow

Pericardial effusion
If pericardial effusion is suspected them a) confirm that the heart shadow is enlarged. Check that
it is a PA film and that the largest diameter of the heart shadow is more than half the largest
diameter of thorax b) look at previous films. A sudden increase in heart size is s/o pericardial
effusion c) look at the hilum. In a pericardial effusion the heart shadow may cover both hila. This
will not occur with other forms of cardiac shadow enlargment d) look at the lung fields. If cardiac
enlargment is due to LV failure then the vascular markings should be increased making the lung
fields whiter than usual. In a pericardial effusion, the vascular markings are usually normal e)look
at the heart shadow borders. Enlargment due to an effusion is generalized, producing a globular
shadow f)look at the white line on the edge of the right side of the trachea(the paratracheal
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density). This should be less than 2-3 mm wide on an erect cxr. If it is wider, one cause is
enlargment of svc. This would be consistent with pericardial effusion.

Widened mediastinum
Try to relate to clinical history. Compare with old films to see if mediastinum has got larger. A
normal cxr doesnot exclude a significant aortic event such as a dissection and in the presence of
clinical suspicion an urgent CT may be done. Major causes are enlargment of thyroid/mediastinal
LN, dilatation of aorta/oesophagus, thymic tumours.
Look for xray rotation. A badly rotated film can make the mediastinum appear widened. If the
widening is at the top it is likely to be thyroid,thymus or innominate artery. If in the middle or
bottom of the mediastinum, it could be lymphadenopathy, aortic widening, dilatation of the
esophagus or a hiatus herna. If the shadowing is at the top then look at the position of the
trachea. An enlarged thyroid will displace or narrow the trachea. This will not happen with a
tortous innominate artery which is a common finding in the elderly.
The commonest cause of an abnormal whiteness of the mediastinum in the elderly will be
unfolding of aorta. Some calcification in the wall of aortic knuckle is a common feature. If the
line of the calcium is separated from the edge of the aortic shadow, it strongly suggests a
dissection.
Look at the right side of the trachea. The white edge of the trachea should be less than 2-3 mm
wide on an erect film. An increase in its width suggests either an enlarged svc or a paratracheal
mass. This rule doesnot apply for supine films.
If thyroid enlargment is suspected, then trace the outline of the shadow. Thyroid has a well
defined outline that tends to become less clear as one moves up the neck. If aortic widening is
suspected then trace its outline keeping in mind that the root of aorta is not visible. A continous
edge which widens to form the edge of the enlarged mediastinum is suggestive of aortic
dilatation.
Rib fractures- look along the edges of each rib. A new fracture will be seen as a break in the edge.
A fracture of any of the first 3 ribs is unusual and is s/o tremendous force. Damage to lower 3
ribs may cause hepatic, splenic or renal injury. A line of fractures is s/o traumatic injury whereas
fractures scattered throughout the ribs may suggest repeated injury(as in alcoholic) or
underlying bony weakness(as in malignancy). If rib fractures present, look for complications-
surgical emphysema, pneumothorax and hemothorax. Callus formation following old rib fracture
may cause rib expansion and can stimulate a lung mass.
Small areas of increased whiteness(calcification) under the right diaphragm corresponds to
gallstones and dilated loops of bowel under the left diaphragm.

Air under diaphragm

If it is difficult to differentiate free air under the diaphragm from the normal stomach bubble
look at the following- a) look at the thickness of the diaphragm, that is the line between the
blacker area below and the lungs above. If there is free air immediately below the diaphragm,
then the white line between the air and the chest will appear very thin since it will consist of the
diaphragm only. If the air is in the stomach, then the white line created will consist of both
stomach lining and diaphragm and appear thicker. In genera if the line is less than 5 mm, then
free air is probably present b) look at the length of the air bubble, ie the distance from its medial
to lateral aspect. If it is longer than half the length of the hemidiaphragm it is likely to be free air,
since air within the stomach is restricted by the anatomy of the stomach c)look at both
hemidiaphragm, if air is present below the right and left hemidiaphragms, it is likely to be free air
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in the abdomen d) take a decubitus film which is taken with pt in the left lateral position. Free air
will rise away from the diaphragm and come to lie lateral to the liver in the uppermost aspect of
the abdomen whereas air within the stomach will remain in the same position. It takes over 10
minutes for these changes to occur, so the pt needs to be on the left lateral side for 10 minutes
before the x-ray is taken.
Before deciding an x-ray is normal-a) look carefully at the apices of the lungs(pancoast tumour,
c/c fibrosis),b) look carefully at the heart shadow- lesions behind the heart are often missed
because they are obscured by the whiteness of the heart. Look carefully for any parts of the
heart shadow that look whiter than the rest. Look also for triangular shadow of left lower lobe
collapse and other subtle changes such as consolidation behind the heart c)read the radiologists
report.
Black lung field
B/L Black lung
Check x-ray penetration. If it is ok, the most common cause of b/l black lung is copd. Look at the
shape of the diaphragm. In copd, the diaphragms are flat, or scallop shaped instead of concave
upwards. This is a more reliable sign of hyperexpansion than rib counting. Count the no of
anterior ribs. If the lungs are enlarged, more than 7 ribs can be counted. However more than 7
ribs can be counted in normal pts if they are tall and slim. Look at the shape of the heart. The
enlarged thorax of copd appears on the x-ray to elongate and narrow the heart, elevating the
lower border. Heart also appears small unless there is an element of cardiac failure in which case
it will be normal in size or large. Look for bullae which are densely black areas of lung usually
round surrounded by fine curvilinear shadows. Bullae distort the surrounding vasculature. So
look out for areas of distortion of vascular markings. Look at the distribution of lung markings.
The lung markings are reduced bilaterally and fan out in straight lines from hilum, starting off
chunky but stopping two-thirds of the way out termed as peripheral pruning.
U/L black lung
Check for rotation. A rotated film may make one side less dense than the other. Determine the
side which is abnormal. This is usually the side with the reduced lung markings. Lung markings
are made up of bronchi and blood vessels and it is their absence that makes the lung look black.
Vascular shadows will disappear if the lung is replaced by air, which will occur with a
pneumothorax, or bullous or cystic lung disease or if the vessels are deprived of blood as in a
pulmonary embolism.
Look for a lung edge. In a pneumothorax, the edge of lung will be seen, which is not normally
seen. Look carefully at the upper zone where air will accumulate first.
Look at the mediastinum. Mediastinal shift away from the black lung suggests that a tension
pneumothorax is developing, which is a medical emergency and needs urgent review of the pt.
Look at the rest of the lungs. Bullous disease is more likely if bullae or emphysematous changes
are seen in the rest of the lung.Look carefully for lung markings. If they cross the area of
blackness,or if if they are peripheral to the area of blackness, it is probably a bulla.
Differentiating between pneumothorax and bulla can be difficult. In a pneumothorax the
distribution of blackness will be peripheral and upper zone, or lateral and even undeneath the
lung. Bullae are within the lung and have curvilinear margins. In a pneumothorax the edge of the
blackness will run parallel to the chest wall, which will not be the case with a bulla lying within
the lung.
White lung field
First look at the nature of the whiteness and its border. If it is uniform with a well demarcated
border, it is most likely to be an area of collapse or a pleural effusion. If the shadowing is not
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uniform and the border is not so well demarcated the possibilities are consolidation, fibrosis, or
some other infiltrative condition.
Collapse of lung is an important cause of a white lung.
Compare with previous films. The change may be long standing and benign and may not require
further investigation. Consider the clinical context.
Look at the lung fields. The right lung should be larger than the left lung- if it is not , suspect an
area of right side collapse. Look at the diaphragms. The right diaphragm is usually higher than
the left. Collapse in the left lung may distort this. Look for the horizontal fissure in the right lung.
The horizontal fissure on the right should run from the centre of the right hilum to the level of
the 6th rib at the axillary line. If this is pulled up, it suggests right upper lobe collapse or, if pulled
down, right lower lobe collapse. The heart should lie in the midline with one-third to the right
and two-thirds to the left. The heart shadow will be deviated to the side of collapse. The heart
border should be distinct. If the lung adjacent to the heart is collapsed, then the heart border
will appear blurred. If the right heart border is blurred, this indicates right middle lobe collapse
and if the left is blurred, llingular collapse.
The trachea should be central. Collapse of the right or left upper lobes can pull the trachea
towards the area of collapse. Compare with old xray films.
In pneumonectomy, trachea is shifted to the side of pneumonectomy,heart is often shifted so far
that its border is no longer visible. Contralateral lung is hyperinflated and thus appears darker
than usual. Upper border of diaphragm is not visible on the side of pneumonectomy. Look
carefully at the ribs. If the pt has had a pneumonectomy, ribs would either have been cut or
removed during the operation. Therefore look for any rib deformity or note the absence of any
rib. The most usual rib to be affected is the 5th.
Consolidation-ask the clinical history. In the presence of a temperature and signs of infection,
consolidation is the most likely abnormality. Look at old xrays. Fibrosis is usually a c/c condition
and consollidation is much more transient. The presence of a similar abnormality on a previous
xray indicate fibrosis rather than consolidation. Look carefully at the nature of the shadowing. In
consolidation the alveolar spaces become filled with fluid making them appear white, whereas
the airways retain air making them appear black. At an area of consolidation, often small airways
is visible as black against a white background- the so called air bronchogram. Look at the
distribution of the shadowing. Fluid sinks, so consolidation gets denser as one moves down the
lung. The shadowing in consolidation will often be denser and more clearly demarcated at its
lower border.
If there is an area of whiteness at the base of the lung, then the possible causes are a pleural
effusion, a raised hemidiaphragm and an area of consolidation or collapse. Look closely at the
texture of the whiteness. Consolidation usually causes more heterogenous shadowing, typically
with the presence of an air bronchogram. Presence of air bronchogram points to consolidation
rather than a pleural effusion. Look at the shape of the upper border of the shadowing. Fluid will
have a meniscus, so the upper outer border of an effusion will be concave. To differentiate an
effusion from a raised hemidiaphragm look again at the shape of the upper border. The upper
border of an effusion will peak much more laterally than expected. Look for mediastinal shift. It
can be difficult to differentiate an effusion from lung collapse. Collapse usually causes
mediastinal shift towards the white lung field so the absence of shift suggests the presence of an
effusion. However that collapse can accompany an effusion so that, although the absence of
shift implies an effusion, its presence does not exclude it. If there is an exclusion look on the xray
for possible causes. Check the size of the heart, a large heart points to heart failure. Look at the
hilum for possible enlargement. Look at the visible parts of the lung fields for obvious masses
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and check the bones for signs of metastasis. Look very carefully at the apices of the lungs for
tumours and TB. To confirm the presence of pleural fluid request an ultrasound of the chest. This
is important if aspiration is planned or if a chest drain is to be put.
Lung nodule- discrete area of whiteness within a lung field. It is less than 3 cm in diameter. It
may be a localized area of consolidation, or a carcinoma or a pleural abnormality. Look at the
edge of the lesion. A spiculated, irregular or lobulated edge is suggestive of malignancy. Look for
areas of calcification. These would be dense white(the same density as bone) and be obviously
much denser than the rest of the lesion. Calcification is rare in a malignant lesion and would
point to an alterenate diagnosis. Look at the nature of the whiteness. If the lesion is cavitating
the centre may be darker than the circumference. If looking at an xray film, stand back from the
xray since a cavity is often easier to see from a distance. Look for an air bronchogram. This is a
sign of consolidation and so would be a most unusual finding if the lesion was a tumour. Look for
other coin nodules. The presence of more than one strongly suggests metastatic disease. Look
for abnormalities peripheral to the lesion. A tumour may cause problems distal to it such as
infection causing consolidation or an area of collapse. Look carefully at the rest of the xray.
Malignant tumours may be associated with mediastinal lymphadenopathy or bone metastasis.
Look at old films if available. Tumours grow, and so if the lesion was present on an earlier film
compare its size. Some tumours grow slowly, but it is safe to say that if the lesion has not
changed over a period of 2 yrs or greater it is unlikely to be malignant.
Cavitating lung lesion- look at the centre of the lesion and compare it to the periphery. If the
centre is darker this points to cavitation. Look for a fluid level. Look for a horizontal line within
the lesion. There will be whiteness(fluid) below the line with an area of black(air) above. Fluid
levels are common in cavities and their presence should suggest one. Look at old films. If the
lesion is longstanding, it may be possible to see the cavity developing. If a cavitating lesion is
diagnosed, look at the wall of the cavity. Usually cavity walls are thicker(>5 mm) when the lesion
is a neoplasm as opposed to an abscess. This rule does not always hold, but the thicker the wall
the more likely it is that the lesion is neoplastic. Look carefully at the inside of the cavity. If there
appears to be a white ball within it, this is characteristic of an aspergilloma.
LVF- look at the size of the heart. The presence of LV dilatation is strongly suggestive of heart
failure. In a PA film, the maximum diameter of heart should be less than half that of the
maximum diameter of the thorax(the cardiothoracic ratio). If it exceeds this then there is cardiac
abnormality, such as LV enlargement, and this suggests that the associated shadowing is due to
LVF. In a/c LVF there may not be cardiac enlargement. Look for kerley B lines. They are caused by
oedema of the interlobular septa. They are horizontal, non-branching, white lines best seen at
the periphery of the lung just above the costophrenic angle. Compare the size of the upper lobe
and lower lobe blood vessels. Take an upper lobe and a lower lobe blood vessel at similar
distances from the hilum and compare the widths. The upper should be narrower than the lower.
If they are the same size or the upper is wider then there is upper lobe blood diversion-the first
sign of heart failure. This applies only to an erect film.
Severe pulmonary edema gives a confluent alveolar shadowing which spreads out from the
hilum giving a ‘bat’s wing ‘ apearance. In pulmonary edema, the hilum may appear distended
and the vessels close to the hilum may be blurred. In non-cardiogenic pulmonary edema,the
heart size is likely to be normal and there will not necessarily be sparing of the peripheries.
ARDS- respiratory failure with associated cxr showing confluent alveolar opacification(whitening)
of the lungs that looks like pulmonary edema. If ARDS is suspected, look at the distribution of the
shadowing. In ARDS it should be present in both lungs and is usually fairly ill defined, which
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means it is difficult to see a clear edge. It may also have features of consolidation like air
bronchogram.
To distinguish ARDS from LV failure- look at the heart size. In LV failure, heart may be big, in
ARDS it may be normal size. Look again at the distribution of the shadowing. In LV failure, it
tends to be more central whereas in ARDS it is more peripheral. Look for kerley B lines. Although
these do occur in ARDS, they are far more common in LV failure. Look for the presence of a
pleural effusion. Theses may be small so look carefully at the edge of the diaphragm for loss of
the normal costophrenic angle. Pleural effusions can occur in ARDS but they are much more
common in LV failure. Look at old films. A large heart and pleural effusion may have shown on
earlier films and may point to LV failure as a more likely diagnosis. A pt with ARDS should have
their chest xray repeated daily. Look for signs of disease progression or resolution. Look also for
the development of a pneumothorax or lung cysts due to barotraumas caused by the use of
positive pressure ventilation in the treatment of ARDS.
Fibrosis - rare cause of white lung. Look at old xrays if available. Fibrosis is a c/c process so if
present a while ago it is more likely to be fibrosis than consolidation or oedema. Look at the
distribution of the shadowing. This may help differentiate fibrosis from edema since the latter is
more likely to be bilateral, basal and peripheral. Shadowing that is bilateral and basal could be
either oedema or fibrosis. Shadowing that is mid zone or apical is more likely to be fibrosis. Look
at the size of the lungs. Fibrosis may cause shrinkage of the lungs which will not be caused by
consolidation or edema. The presence of small lungs points strongly to fibrosis. Look at the
shape of the mediastinum. Since fibrosis causes shrinkage of the lungs it will pull the
mediastinum and distort the outline.
Look at the nature of the shadowing. Pulmonary fibrosis gives reticular-nodular shadowing which
simply means a meshwork of lines that combine to form nodules and ring shadows of about 5
mm in diameter. Look at the heart border and diaphragm. Both of these may appear blurred if
fibrosis is present. Look at the vascular markings. These become less distinct in areas of fibrosis.
This is due to the development of numerous small areas of lung collapse.
Findings in ILD- bibasilar reticular pattern, nodular opacities, honeycombing.
 259
Normal X-ray films

Upper limb
 260

Hand

Pelvis and Lower limb

 261

Knee joint
 262

Leg

Ankle joint & foot

 263

Abdomen
 264
Cervical spine
 265
Thoracic spine

Lumbar spine
 266
Paranasal sinus

Lateral View
 267
OPG

X-ray Skull lateral view

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Nasal bones-lateral view

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LABORATORY VALUES

Complete Blood Count

Hb
Males:13.5-17.5 g/dl
Females:12-15.5 g/dl
RBC count
Males:4.5-6.5 x 1012/L
Females: 3.8-5.8 x 1012/L
Differential count
Polymorphs(neutrophils): 40-75%
Lymphocytes: 20-50%
Monocytes: 2-10%
Eosinophils :1-6% Basophils : <1% Band forms: 3-5%
Total count
Adults: 4,000-11,000
Infants(1 yr): 6,000-16,000, at birth (10,000-25,000)
Platelets:1,50000-4,00000
PCV
Male(40-54%) Female(37-47%)
ESR
Male(0-9 mm/hr) Female(0-20 mm/hr) - wintrobes method
Male(0-15 mm/hr) Female(0-20 mm/hr) – westergen method
Others
Normal Reticulocyte count: 0.8 – 1.5 %
Red cell distribution Width(RDW):42.5±3.5 fL or 12.8±1.2%
Absolute eosinophil count(AEC): 50-350/mm3
Absolute neutrophill count(ANC):1,500 to 8,000/mm3
Red cell indices
Mean corpuscular volume, MCV: 80 - 100 femtoliter
Mean corpuscular haemoglobin,MCH: 27 - 32 picograms/cell
Mean corpuscular hemoglobin concentration, MCHC: 32 - 36 grams/deciliter

Coagulation screening tests

Normal bleeding time : 2-7 min
Normal clotting time : 4 -9 min
Prothrombin time:12-15 sec
aPTT(activated partial thromboplastin time):28-31 s
INR: 1
Thrombin time:<20 s(control ± 2 sec)

LFT
SGOT or AST: <40 units/ml(12-38 U/L)
SGPT or ALT : <40 units/ml(7-41 U/L)
S Alkaline Phosphatase: adult 30-120 U/L, children <350 IU/L
S Albumin: 3.5-5.5g/dL or gm%
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S Bilirubin(Total): 0.3-1.3 mg/dL
S Bilirubin(Direct or conjugated): 0.1-0.4 mg/dL
S Total protein:6.7-8.6 g/dL
Gamma glutamyl transpeptidase: 0-40 IU/L

RFT
B Urea:20-40 mg/dL
Urea Nitrogen(BUN):7-20 mg/dl, BUN= urea (in mg/dl)/ 2.14
S Creatinine: 0.6- 1.6 mg%
S Uric acid: 3.1-7mg/dL(males), 2.5-5.6 mg/dl(females)

S.Electrolytes
S Na : 136-145mM/L
S K: 3.5-5.4 mM/L
S Ca,total: 8.5 -10.5 mg%
S P: 2.5 - 4.5 mg/dL
S Mg: 1.5-2 mEq/L
S Cl:102-109 mEq/l

Lipid profile
Total cholesterol:150-200mg%, borderline high: 200-239 mg/dl, high undesirable:≥240 mg/dl
Triglycerides:50-160 mg%(<160 mg/dl)
HDL: 40-60mg%(desirably >60mg%), low:<40 mg/dl
LDL: 80-160mg%(desirably<130mg%,borderline high:130-159 mg%,high undesirable: ≥160 mg%)

Cardiac Biomarkers
LDH:115-221 u/l
C Tn i: 0-0.08 ng/ml
C Tn T:0-0.01 ng/ml
Creatine kinase: males:51-294 U/L, females:39-238 IU/L
CK-MB:0-5.5 ng/ml
D-dimer: <0.5 µg/mL
Other cardiac risk profile
NT Pro BNP <450(age <50 yrs), <900 pg/ml(age 50-75 years)
Homocysteine 5-15 µmol/L

Blood sugar monitoring

Fasting (8hrs of fasting with no calorie intake);Normal:70-100 mg/dl, In DM≥ 126 mg/dl
Post prandial(2hrs after 75 mg glucose intake) :<140 mg/dl, In DM >200 mg/dl
RBS>200 in DM
HbA1c :4-6% ( a rise of 1% corresponds to an approx average increase of 36 mg/dl (2 mmol/L)in
blood glucose.

TFT
T4: 5.4-11.7 µg/dl or 70-151 nmol/L
T3: 77-135 ng/dl or 1.2-2.1nmol/L
TSH:0.4-5 µU/ml or 0.4-5 mU/L
 271
FT3: 1.4-4.2 pg/ml
FT4:0.8-2 ng/dl
Anti TPO: <50 U/ml
Anti Thyroglobulin(Tg) ab: <50 U/ml

Plasma Proteins
Albumin: 3.5-5.5 g/dL
Globulin: 2-3.5 g/dL
Fibrinogen:0.2-0.4 g/dL
A/G:1.5-3:1

Iron profile
S iron 50-75 µg/dL
TIBC adult 250-450 µg/dL
S Ferritin: 30-250 ng/ml or µg/L(males), 10-150 ng/ml(females)
% Transferrin saturation ≥16%
Anemia profile also includes S Vit B12:140-980 ng/L, S folate upto 10 ng/ml

Bone profile
Vitamin D 30-75 ng/ml
S iPTH 10-65 pg/ml

Sepsis markers
C reactive protein:0-10 mg/L
Procalcitonin: <0.1 µg/L
Lactate 0.5-1 mmol/L

Tumour Marker
PSA: 0-4 ng/ml
β –HCG: <3 mIU/L or IU/L
Alfa fetoprotein <9 ng/ml
CEA <5.0ng/ml
CA-125 <35 U/ml
PSA <4.0 mg/ml
Free PSA 0-0.9 ng/ml
CA 19.9 <35 U/ml
CA 15-3 <30 U/ml

Auto-immune /Ab profile

APLA IgG<10 GPL units/L, IgM <10 MPL Units/L
Anti cardiolipin Ab (IgM) <15 U/L
Anti-CCP 7-17 U/ml
Tissue TG(IgA) <7 U/ml

ENA profile(Extractable Nuclear antigen)

Usually ordered as a followup after a positive ANA test in a person who has signs and
symptoms of an autoimmune disease.
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Jo-1 antibody- <20
Scl-70 antibody <20
Sm antibody(IgG) <20
SSA/Ro antibody<20
SSB/La antibody<20
U1RNP antibody<20
Centromere antibody<20

Fertility profile
LH women 0.5-61.2 U/l men 1-10 U/L PMW 20-100 U/L
FSH women 1.0-22 U/l men 1-10 U/L PMW 20-100 U/L
Prolactin: 2-20 ng/ml(µg/L) (males), 2-30 ng/ml(females), 10-209 ng/ml(pregnancy)
Estradiol women 30-370 pg/ml, men 10-50 pg/ml PMW <30 pg/ml

Other hormonal assays

S progesterone women 0.2-25 ng/dl, men 0-20 ng/ml
S Testosterone women 0.2-1.2 ng/ml, men 3-12 ng/ml
S Free Testosterone women 0.3-1.9 ng/dl, men 9-30 ng/dl
S DHEAS men 0.6-2.9 µg/mL women 0.4-2.2 µg/mL
S 17-OH Progesterone children0.2-1 ng/ml women 0.2-4.5 ng/ml men 0.2-2.3 ng/ml
S cortisol 8 am 50-230 ng/ml 4pm 30- 150 ng/ml
S insulin fasting values<25 IU/ml

Others
S. Amylase : 20-96 u/l
S. Lipase:0-160 U/L
Rheumatoid factor: <30 IU/ml
S.Osmolality:275-295 mOsmol/kg

Urine examination
pH:5-9
Colour: pale yellow to deep amber
Specific gravity ,quantitative:1.002-1.028
Protein excretion(24 hr):<150 mg/day
Protein qualitative:negative
Gucose excretion, quantitative(24 hr):50-300 mg/day
Glucose , qualitative:negative
Porphobilinogen:negative
Urobilinogen:1-3.5 mg/day
Microalbuminuria(24 hr): 0-30 mg/24 hr
Red cells:0-2/hpf
WBC:0-5/hpf
Epithelial cells:0-2/hpf
Bilirubin:0.02 mg/dl or negative
Bence-jones protein: negative

Casts
Hyaline cast- dehydration, strenuous exercise
Granular cast- CKD, strenuous exercise
RBC cast(always pathological)- glomerulonephritis, vasculitis
WBC cast- inflammation/infection
 273
Stool examination
Coproporphyrin:400-1000 mg/day
Fecal fat excretion:<6 g/day
Occult blood:negative(<2 ml blood/day)
Urobilinogen:40-280 mg/day

Gases, arterial
Bicarbonate(HCO3-): 22-30 mEq/L
pH: 7.35-7.45
Pco2: 22-45 mmHg
Po2: 72-104 mmHg
Total CO2: 23-30 mmol/L or 100-132 mg/dL
H+: 35–45 nmol/L (nM)

Ascitic Fluid Analysis

Total count- less than 500 WBC/µL
Polymorphs- less than 250 /µL(>250 occurs in SBP)

CSF analysis
Opening pressure: 90-180 mm H2O
Appearance & colour: clear, colourless
Blood cell count,WBC: <5, RBC:<5
Glucose: 50-80 mg/dl or > 60% of blood level; chloride: 118-132 mEq/L
T protein: 15-60 mg/dl or < 0.45 g/L; Gamma globulin: 3-12 % total proteins
Oligoclonal bands: negative

Pleural fluid analysis

pH: 7.60-7.64
Protein: <2%(1-2 g/dL)
Cells: wbc<1000/mm3, (>1000/mm3 s/o exudative effusion)
Glucose- same as serum( low in malignancy, empyema,RA)
Bicarbonate- higher than serum
LDH: <50% plasma level
Amylase: 30-110 U/L
Triglycerides: <2 mmol/L
Cholesterol: 3.5-6.5 mol/L

Pericardial fluid analysis

mild: <10 mm, moderate:10-20 mm, large:>20 mm
WBC count <300 cells/microlitre, RBC
Transudate-clear to pale yellow,Protein <3g/dL,WBC:<100 cells/microlitre, LDH: <200 IU/L, pH
>7.2, glucose: equal to serum, specific gravity: <1.015, cholesterol:<55 mg/dL, fluid
protein/serum protein ratio <0.5, Fluid LDH/Serum LDH ratio <0.6
Exudate-cloudy, bloody, turbid Protein>3 g/dL,WBC:>1000 cells/microlitre,LDH: >200 IU/L, pH
<7.2(7.2-7.4 in TB,CA), glucose: <60 mg/dL, specific gravity: >1.015, cholesterol:>55 mg/dL,
fluid protein/serum protein ratio >0.5,fluid LDH/S LDH ratio >0.6

ADA(adenosine Deaminase)
In Serum plasma ADA<15 U/L
In CSF ADA:<11 U/L
In Pleural, Pericardial & ascitic fluids ADA <40 U/L
 274
Common injections Amp/vial volume - Total strength
Adrenaline 1ml-1mg
Atropine 1ml/2ml- 0.6mg/1.2 mg
Aminophylline 10ml-25mg/ml
Amiodarone 3ml-50 mg/ml
Avil(pheniramine maleate) 2ml-22.75mg/ml
Atarax(hydroxyzine) 2ml-25 mg/ml
Betnesol 1ml-4mg
Buscopan(hyoscine) 1ml-20mg
Chlorpheniramine maleate 1ml-10 mg
Cyclopam(dicyclomine) 2ml- 20mg
Ca gluconate 10ml-100mg/ml
Deriphylline 2ml-220mg(each ml, etofyl 84.7 mg+Theo 25.3mg)
Diazepam 2ml-10mg
Dexona 2ml-8mg
Digoxin 2ml- 40 mg
Dopamine 5ml-200mg
Dobutamine 5ml-250mg
Drotin(drotaverine) 2ml-40mg
Ethamsylate 2ml- 125mg/ml
Eptoin(phenytoin) 2ml-100mg
Emeset(ondansetron) 2ml/4ml- 4mg/8mg
Fortwin(pentazocine) 1ml-30 mg
Gentamycin 2ml-80mg
Granisetron 1ml- 1mg
Ketorolac 1ml-15mg
Kcl(15% w/v) 10ml-150mg/ml or 2meq/ml
Labetalol 4ml-20 mg
Lasix(furosemide) 1ml/2ml-10 mg/20 mg
Metoprolol 5ml-5mg
Midazolam 5ml-5mg
Nitroglycerine 5ml-25mg
Na bicarbonate 10ml-7.5% w/v per ml(8.92 mEq/10 ml),8.4%(10 mEq/10 ml)
Noradrenaline 2ml- each ml contains norad 0.2 % w/v
Pantoprazole 2ml- 40mg
P’mol 2ml-150mg,2ml-150mg/ml, 3ml-150mg/ml
Perinorm 2ml-10mg
Phenergan 2ml-50 mg
Pirox(piroxicam) 2ml-20 mg/ml
Rantac(ranitidine) 2ml-50mg
Serenace(haloperidol) 1ml-5mg
Stemetil(prochlorperazine) 1ml-12.5mg
Terbutaline 1ml-0.5mg
Tramadol 1ml-50 mg
Tranexa 5ml-500mg
Vitamin K 1ml-10mg
Voveran(diclofenac) 3ml-75 mg
Respules
Asthalin 2.5 ml-2.5 mg, respirator solution 15 ml- 5mg/ml
Ipravent 2ml-500mcg, respirator solution 15 ml-250mcg/ml
Levolin 2.5ml-0.31 mg/0.63 mg/1.25 mg
Duolin 2.5 ml-ipra 500mcg+ levosalbu 1.25 mg
Budecort 2ml-0.25mg/0.5 mg/1mg
 275
Organism Antibiotics

Streptococcus pneumoniae/viridans
Staphylococcus, neisseria meningitidis, Penicillin, cephalosporin
treponema pallidum, actinomyces,
bacillus cereus,

Pseudomonas -piptaz,ceftazidime,carbepenem,aminoglycoside, colistin

H influenza- amoxicillin, macrolide, cephalosporin,

Clostridium -clindamycin, penicillin

E coli, klebsiella, proteus, salmonella- ceftriaxone, quinolone, aminoglycoside

H ducreyi, mycoplasma-azithromycin

Enterococcus faecalis,listeria- ampicillin+gentamycin, macrolide, vancomycin,

carbapenem

MRSA, coagulase negative staphylococcus -vancomycin

MRSA,VRSA -vancomycin, teicoplanin, clindamycin, linezolid,

Serratia, enterobacter, acinetobacter - carbapenems

Nocardia cotrimoxazole

Corynebacterium Benzyl penicillin,erythroycin

Moraxella catarrhalis macrolide, cephalosporin

Bordetella pertusis macrolides

Gonococcus,Trichomonas vaginalis - metronidazole

Calymmobacterium donovani Azithromycin, Doxycycline

HACEK Ceftriaxone, ampicillin-sulbactam, ciprofloxacin

 276
Antibiotics
Ampicillin

Aminopenicillin; Mainly effective against Grain +ve & also some gram –ve
1.Drops 100mg/ml
0-1.5 months > 0.5ml qid (8 drops)
1.5-5 months > 1ml qid (16drops)
2.Syrup:125mg/5ml or 250mg/5ml
3.Cap:250mg or 500mg
Indications: UTI, RTI, meningitis, cholecystitis,
May be combined with gentamycin or third gen cephalosporins
Always give test dose.
Complication > May produce rashes, especially in cases of IMN. It may be combined
with sulbactum (given parenterally only)
Dosage is 50-100 mg/kg/day in 4 divided doses, oral.
Usual pediatric inj dose: 50 mg/kg Q6H if > 7 days of age, Q8H if <7 days of age.
T.N: Roscillin, Campicillin, Presmox

Amoxicillin
Preferred over ampicillin for bronchitis,UTI,
Dose: 0.25- 1 g tds oral/im, children: 30-50 mg/kg/24 hr div into 2 or 3 PO
T.N: Mox, Novamox
Note: better bioavailability if taken with food.

Cloxacillin
More active than methicillin against pencillinase producing staph.
Dose: 500 mg Q6H oral/iv, children: 100 mg/kg/day
C 250 mg, 500 mg, syp 125/5 available
T.N: klox

Coamoxiclav
Addition of clavulanic acid (β- lactamase inhibitor) re-establishes the activity of
amoxicillin against β-lactamase producing resisitant staph aureus
Indications: skin/soft tissue infections, intra abdominal & gynaecological sepsis, urinary,
biliary, respiratory infections
Dose: 1.2 g iv bd/tds
T.N: Mega-CV, Augmentin. T 375, 625, 1g available.

Cephalexin
1st generation cephalosporin.
Indications
Severe LRI
Infections during pregnancy
Bone & joint infections, skin & soft tissue infections
Pharyngitis, tonsillitis, UTI
CSOM, ASOM
Usually combined with Metrogyl in cases of mild diarrhea + URI or LRI
Dose> 50-100mg/kg/day in 4 divided doses > similar to Ampicillin
T.N: Phexin, Sporidex, Blucef, Citacef, Lexin
 277
Cefadroxil
1st generation cephalosporin
Indications
 Pharyngitis
 Skin & soft tissue infections
 UTI
May produce gastritis, nausea, epigastric distress
Available as Tab 125, 250, 500 & Syp 125/5ml, 250/5ml & drops 100mg/ml
Dose 30mg/kg/day in 2 divided doses orally
T.N: cefadur, droxyl,cefastar
Cefazolin
1st generation cephalosporin
Available as 125mg, 250mg, 500mg, and 1g vials
Indications
Surgical prophylaxis
Bone and joint infections
Skin and soft tissue infections
Speticemia
Pneumonia, UTI
Doses > 50-100mg/kg/day in 4 divided doses im or iv(similar to Ampicillin)
For im use either distilled water or normal saline may be used as the diluent. For iv use
10ml distilled water is to be used. It may be administered over a period of 3-5 min
For newborn, 20mg/kg/dose 12th hourly if <7 days and 8th hourly if > 7 days
T.N: Maxicef-O,Reflin
Cefaclor
2nd generation cephalosporin
Available as 250mg cap, dry syp or readymade suspension 125 or 187 mg/5ml and
drops 50mg/5ml.
Dose 40mg/kg/day in 2 or 3 divided doses
Indications
PUO in children
LRI
Intra abdominal infections like Cholecystitis Appendicitis, Pancreatitis
T.N: Distaclor, Keflor.
Cefuroxime Axetil
2nd generation. Preventing bacterial infections before, during, or after certain surgeries.
Other indications: Respiratory infections, uncomplicated skin & soft tissue,UTI
Dose: 250-500 mg BD, children:30 mg/kg/day div into 2-3, IM/IV:100-150 mg/kg/24 hr
div into 3. Adult iv dose: 1.5 g Q8H
T.N: Ceftum,Spizef, altacef
Cefixime
Oral 3rd generation cephalosporin
Available as susp 50 or 100mg/5ml and T or Cap 100mg or 200mg
Strong antibiotic useful especially in diabetic patients and in other serious infections,
Useful for continuation therapy after initial parenteral therapy.Highly active against
enterobacteriaceae, H influenzae. Not active against Staphylococci and Pseudomonas.
Other indications: RTI, uncomplicated UTI, STD, typhoid fever
Doses -> 8mg/kg/day, od or bd.
T.N: Taxim-o,Milixim,Fixx, Extracef, Cefspan, topcef, Ceftiwin,Omnix
 278
Cefotaxime
3rd generation. Indications > Meningitis, Specticemia, serious bone and soft tissue
infections
Dose > 100-200mg/kg/day in 4 divided doses im or iv. In newborn, 50mg/kg/dose 12th
hourly, if < 7 days old & 8th hourly if > 7 days old. Available as 250mg, 500mg & 1g
vials.Usual Adult dose: 1g iv tds
May be reconstituted with D5, D10 or NS.
T.N: Taxim, Omnatax,
Ceftazidime
Parenteral 3 generation cephalosporin
rd

Highly Active against Pseudomonas aeruginosa. Also, Gram –ve coverage, synergistic
action with Aminoglycosides
Available as Inj 250mg, 500mg, & 1g.
Dose > 100-150mg/kg/day in 3 divided doses im or iv. Max of 6g/day
T.N: Fortum , Psedocef.
Ceftriaxone
3rd generation cephalosporin. Effective against Gram+, gram- & some anaerobes
Indications
Enteric fever (DOC is Ciprofloxacin 500mg bd x 2 wks)
Bacterial Meningitis
Abdominal sepsis, Septicemias
Compicated UTI
Dose > 50-100mg/kg/day in 2 doses im or iv. May be reconstituted with D5, D10 & NS
Do not mix other antimicrobials.Available as Inj 250mg & 1g.usual adult dose 1g iv bd
T.N: Monocef, Monotax, Ciplacef.

Cefdinir
Oral 3 generation cephalosporin
rd

Wide spectrum with gram + & gram – coverage, Good activity against Beta-lactamase
producing strains. Effective in RTI – both upper and lower and skin & soft tissue
infections.
Dose > Adults 300mg bd x 10 days or 600mg od x 10 days; children 14mg/kg in 2
divided doses or even as a single dose.
T.N: Aldinir, Cefdins, available as syp 125/5ml and 300mg cap; Expensive

Cefpodoxime Proxetil
3 generation. Useful mainly in respiratory tract infection , skin & soft tissue infections
rd

and also in cases of uncomplicated UTI. Highly active against enterobacteriaceae &
streptococci. Not against pseudomonas
Available as a T 100mg, 200mg or as dry syrup 50 or 100mg/5ml.
Dose> 10mg/kg/day in 2 divided doses, to be taken with food.
T.N: monocef-o, cepodem, podocef
Cefoperazone + sulbactum
3rd generation cephalosporin + β- lactamase inhibitor.
Useful for empirical therapy.Wide spectrum, including pseudomonas.Achieves high
biliary concentration & hence useful in case of cholecystitis
Indications: Severe urinary, biliary, respiratory, skin-soft tissue infections, meningitis,
septicaemia
 279
Dose: 1 or 2 g iv in adults in two divided doses.Usual adult dose: 1.5 g iv bd.
In children, 50-200mg/kg in 2 divided doses.
T.N: cefactum,cefpar SB(very costly)

Doxycycline
Tetracycline
Indications
 Leptospirosis treatment & prophylaxis
 Scrub typhus, malaria prophylaxis, brucellosis, cholera
 Prophylaxis for COPD exacerbation
 Acne, UTI, RTI like a/c bacterial rhinosinusitis,
 Chlamydia, gonorrhoea, prevention of STD’s following sexual assault
 Inflammation of the gums
Dose: 100 mg/ 200mg bd, children: 5mg/kg/day div into 2 PO or OD
T.N: Doxy-1
Gentamicin
Aminoglycoside. Wide spectrum, mostly gram negative including pseudomonas
Remember oto and nephrotoxicity
Dose>5-7.5 mg/kg/24 hr div into 2 or 3 doses im or iv. In case of neonates give 2.5
mg/kg Q12H.Usual adult dose: 80 mg iv od/bd
Available as vials of 100mg, 250 mg and 500 mg/ml.
T.N: garamycin
Amikacin
Widest spectrum of activity than other aminoglycosides
Usual adult dose : 500 mg iv od/bd
Dose:15mg/kg/day
T.N: mikacin

Vancomycin
Glycopeptide; Useful mainly against staphylococcus , MRSA
Indicated in septicemia, bone & joint infections. LRTI and skin & soft tissue infections.
Dose->500mg 6th hourly or 1g iv 12th hourly in adults. In children 40-60 mg/kg/day in 4
divided doses. Administrated slow iv only. Monitor auditory & renal functions
T.N: Vanlid, vanmax
Teicoplanin
Semisynthetic Glycopeptide; Has lesser nephrotoxicity when compared with
vancomycin
Mainly active against staphylococci
Dose->400 mg (10mg/kg) once daily im or iv; Available as 200 mg & 400 mg vials.
T.N: targocid
Aztreonam
Monobactam; Novel Betalactam antibiotic, active against pseudomonas and
enterobacter. Poor activity against gram +ve cocci and anaerobes
Indications: hospital acquired infections originating from urinary, biliary, GI & female
genital tracts.
Dose->100mg/kg/day in 3 or 4 divided doses im or iv. Smaller dose for neonates
May be reconstituted with D5, D10 or NS for iv infusions
T.N: Azenam, Trezam 250 mg /500mg /1g Inj
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Ciprofloxacin
FQ; wide spectrum, Active mainly against gram-negative.
Indications
UTI,Bacterial gastroenteritis,Typhoid,Respiratory infections,bone,soft tissue,
gynaecological & wound infections, gram - ve septicemia, conjunctivitis,
Dose: 250 - 750 mg BD oral, 100-200 mg BD iv,
For children: 20-30 mg/kg/24 hr div into 2 PO/IV
T.N: cifran, ciplox
CAUTION: Don’t prescribe NSAIDs & FQ together at a time, because of it’s
seizurogenic potential. Ciplox should not be given to an asthmatic using theophylline
as ciplox inhibits theophylline metabolism & may lead to its toxicity.
Norfloxacin
FQ. Effective against a wide range of gram +ve, gram -ve organisms including
pseudomonas. Not effective against anaerobes
Indications
 A/c UTI - 400 mg bd x 7-10 days
 C/c UTI - 400 mg bd x 4 weeks and then 400 mg od x 12 weeks(especially in cases
of reflux as seen in ultrasound scan)
 Dysentry 200-400 mg bd x 5 days
 Urological procedures in neutropenic patients-> 400 mg bd x 8 weeks
T.N: norflox, uroflox
Ofloxacin
Highly potent FQ. Useful in serious infections like septicemia
Dose->200mg iv infusion over 30 min or oral-200 mg bd
T.N: oflacin, bactof
Levofloxacin
FQ; Very useful in resp infections,skin/soft tissue infections.
May be used in combination with pencillins in pneumonia.
Dose->500 mg od x 5 days oral or inj
T.N:levobact, levoday, glevo

Linezolid
Oxazolidinone, Active against MRSA,VRSA,VRE, penicillin resistant streptococci
Restrict use to serious hospital acquired pneumonia, febrile neutropenia, wound
infections to prevent emergence of resistance.
Available as 300ml infusion; each 100ml contains 200mg. 600 mg tablets available
Usual adult dose 600 mg iv bd, children: 10 mg/kg/dose Q12H PO/IV
T.N: Linox, Lizoforce
Azithromycin
Macrolide with high activity on respiratory pathogens.
Indications:
 RTI, Atypical pneumonia,
 Uncomplicated Skin & skin structure infections,
 STD’s, prevention of STD’s following sexual assault,genital ulcer disease,
 Cat scratch disease,
 a/c PID etc
Dose: 500 mg PO/IV OD x 3 days,children: 10 mg/kg/day on first day, then 5mg/kg/day
on days 2-5.
T.N: Azee, Azithral, Azax
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Piperacillin +Tazobactum
Piperacillin: ureidopenicillin. Tazobactum: β- lactamase inhibitor.
Indications: peritonitis, pelvic/urinary/respiratory infections
Concurrent use of gentamycin is advised.
Dose: 4.5 g iv Q8H, 200-300 mg/kg/24 hr div into 4 doses, im or iv.
Term newborn:<7days, 50 mg/kg/dose Q8H; and >7days, Q6H
T.N: Piptaz

Meropenem
Carbapenem; Active against both gram-positive & gram-negative bacteria, aerobes &
anaerobes
It is the reserve drug for the treatment of septicemia, intra abdominal & pelvic infections
Usual adult dose: 1 g iv bd,children: 60 mg/kg/day div into 3 doses IV
T.N:Meronem
Clindamycin
Mostly reserved for pencillin allergic pts
Acne, PID,intra abdominal infections, serious respiratory, skin & soft tissue
infections,infections of the female pelvis and genital tract etc
Dose 150 mg/ 300 mg tds/qid. Parenteral-Serious infection: 600 to 1,200 mg via IV
infusion or IM injection per day, in 2 to 4 equally divided doses, for eg. 300 mg iv tds
Stay upright for 30 minutes after intake.
T.N:clindasure,clincin, dalacin

Tigecycline
Active against complicated skin infections caused by E coli, staph aureus,
streptococcus pyogenes, bacteroides fragilis;complicated intra-abdominal infections
caused by e-coli, enterococcus, S aureus, klebsiella pneumoniae, clostridium
perfingens
Dose- 50 mg IV BD
T.N-Tiganex

Metronidazole
Activity for anaerobic organisms.
Usual adult dose 500 mg iv Q8H, oral- 400 mg tds, children:30-50 mg/kg/24 hr div into 3
PO. Tab 200, 400 & Syp 200/5 available
T.N: Metrogyl,Flagyl

Tinidazole
Similar to metronidazole, better tolerated,long duration of action, higher cure rate
Usual iv adult dose : 800 mg infusion once daily. Tab 300mg, 500 mg, 1g available
T.N: Tiniba

Colistin
Used for gram neg infections(e.g enterobacter aerogenes, E coli, klebsiella,
pseudomonas) resistant to other antibiotics, multi drug resistant gram neg infection.
Dose- 2.5-5 mg/kg/day divided q6-12 hr IV/IM. Usual adult dose 1-2 MU q8H.
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Polymyxin B
Used in bacterial septicemia due to P aeroginosa, E aerogenes, K pneumoniae,
H influenza meningitis, UTI due to E coli.
Dose- 15,000-25,000 units/kg/day divided q12H iv, 25,000-30,000 units/kg/day divided
q4-6H IM

Combinations
Cefixime 200 + ofloxacin 200: Mahacef Plus,Milixim-O,Cefolac-O, zenflox-plus
Cefixime 200 + Ornidazole 500: Milixim-OZ,Cefolac-OZ
Cefixime + clavulanic acid : Milixim-CV
Cefixime 200 + Azithromycin 500/250 : Azifine-C, Cefolac-AZ
Ornidazole 500 + ofloxacin 200: Ornof, Oflomac-OZ
Azithromycin 250/500+ Levofloxacin 250/500: Azifine-L
Cefuroxime axetil 250/500 + Clavulanic acid 125: Altacef CV, Forcef-CV
Cefpodoxime + clavulanic acid :Kefpod CV, Monocef-O CV
Cefpodoxime + Ofloxacin: Macpod-O
Cefpodoxime + Azithromycin: Macpod-AZ
Cefpodoxime + Levofloxacin: Macpod LX

Antifungals

Fluconazole
Oropharyngeal/esophageal candidiasis 200 mg PO on day 1, then 100 mg OD
Cryptococcal eningitis 400 mg PO on day 1, then 200 mg PO OD
Candida UTI: 50-200 mg PO OD
TN:flucan/ultican

Voriconazole
Esophageal candidiasis: 200 mg PO BD
Invasive aspergillosis/candidemia/serious fungal infections: 6 mg/kg iv q12H for first 24
hours, then 4 mg/kg iv q12H or 200 mg PO q12H
TN: Voritrol/voritek

Itraconazole
Available as 100 mg, 200 mg tablet, 10 mg/ml solution
Esophageal candidiasis: 100 mg (10ml) PO OD for minimum 3 weeks. Continue for 2
weeks following resolution of symptoms
Oropharyngeal candidiasis: 200 mg(20ml) PO OD for 1-2 weeks. Unresponsive to
fluconazole: 100 mg (10ml) PO BD
onychomycosis:200 mg q12H for 1 week
T.N sporanox/syntran

Amphotericin B
Systemic fungal infections: loading: 0.25-0.5 mg/kg iv infused over 2-6 hr. Maintenance:
0.25-1 mg/kg iv OD
TN-ambisome, phosome,
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S/e of common drugs
Acarbose(also voglibose)- abdominal distension, flatulence
Acetazolamide: metallic taste,lactic acidosis, hypothyroidism
ACEI: dry persistent cough, rash, altered taste, hyperkalemia,angioedema, hypotension
Amoxyclav:cholestatic jaundice,
Amiodarone: hypotension,pulmonary fibrosis, pulmonary eosinophilia, peripheral neuropathy,
pseudotumor cerebri, hyperthyroidism, prolonged QTc interval
Aminoglycosides: ototoxicity
Antacids-diarrhoea(Mg based antacids), constipation(Al based antacids), increased risk of
nosocomial pneumonia, metabolic alkalosis if large amounts are taken.
Antihistaminics: sedation
ARBs: hyperkalemia,
Atropine: dry mouth,dry flushed & hot skin, difficulty in swallowing & micturition, hypotension,
hallucination, excitement, photophobia,blurring of vision
Atypical antipsychotics-metabolic syndrome(max with clozapine, olanzapine)
Β-blockers: CCF, hypoglycemia, decreased libido/impotence, hyperkalemia(initially)
BZD: sedation
Calcium channel blockers- hypotension, reflex tachycardia, ankle edema, constipation
Carbamazepine: diplopia,ataxia,hyponatremia, aplastic anemia, pulmonary eosinophilia,
arrhythmia
Chlordiazepoxide: drowsiness, dizziness, nausea
Chloroquine:vestibular ototoxicity,myopathy, peripheral neuropathy
Chlorpromazine- arrhythmia, respiratory depression
Clonidine: rebound HTN, constipation, drynesss of mouth, mental depression,sedation
Clozapine:agranulocytosis,seizure,wt gain,DM,myocarditis
Cefixime:diarrhoea,stool changes
Corticosteroids: glaucoma,myopathy, pancreatitis,CCF, hypertriglyceridemia, hypokalemia
Dihydropyridine(eg.amlodipine): hypotension,reflex tachycardia,ankle edema,constipation.
Dobutamine :tachyarrhythmia, hypertension, vpc,
Domperidone:hyperprolactinemia,
Dopamine: N,V, tachycardia, palpitation, ectopic beats,
DPP-4 inhibitors- pancreatitis
FQs: anorexia,N,V,headache,insomnia,seizures,↑QTc
Gabapentin- tremor
Glucocorticoids: hyperglycemia, osteoporosis, pseudotumor cerebri, hypertension,
Haloperidol:extrapyramidal reactions, arrhythmia, respiratory depression
Heparin: HIT,elevated serum aminotransferase level,hyperkalemia, Reversible alopecia,
osteoporosis. Monitoring done with aPTT.
Insulin:hypokalemia, hypoglycemia
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Isotretinoin- cheilitis/dryness of lips(m/c),Hightriglyceridemia
Ivabradine-bradycardia
Ketoconazole:gynaecomastia,
Levitiracetam-aggression,irritability,mood changes
Levodopa- N,V, tachycardia,palpitation,arrhythmia,angina,mydriasis
Lithium: hyperkalemia,hypothyroidism, altered taste, tremors, cardiomyopathy, nephrogenic
DI,decreased libido,leucocytosis, aggravates psoriasis
Loop diuretics:hypotension, hyperuricemia, hyperglycemia, hyperlipidemia,
hypo(Na,K,Cl,Mg,Ca), vestibular ototoxicity, pancreatitis, metabolic alkalosis
Methotrexate- alopecia, hepatotoxicity, GI mucosal injury, BM suppression,
Metronidazole: metallic taste, peripheral neuropathy
Mannitol: headache, hyponatremia, hypokalemia,
Metformin: GI toxicity, lactic acidosis, megaloblastic anemia
Metoclopramide: extrapyramidal reactions,hyperprolactinemia, arrhythmia
Morphine: hypotension
Nifedipine: exacerbation of angina,
Nicorandil- headache,hypotension,flushing,aphthous ulcer,hyperkalemia,
Noradrenaline : bradycardia, hypertension, arrhythmia, confusion, anxiety, N, V,tremor,
Norethisterone : acne
NSAIDs: hyperkalemia, auditory ototoxicity, interstitial nephritis
Octreotide: Gall stones, vit B12 deficiency,hypoglycemia,
Ondansetron:constipation,headache, dizziness,
Opioids:pancreatitis,
Oral contraceptives:hyperglycemia, myopathy, pancreatitis,cholestatic jaundice, pseudotumor
cerebri, HTN, hypertriglyceridemia, megaloblastic anemia, decreased libido
Orceprenaline-tachycardia,tremor,nervousness, hypokalemia, increased serum glucose
Paroxetine- wt gain, teratogenicity
Penicillins: seizure
Pioglitazone- Ca bladder, hepatotoxicity,CHF, reduce BMD
Propranolol:hyperglycemia,
Prochlorperazine- arrhythmia, postural hypotension, dystonia
Phenytoin:peripheral neuropathy, hyperglycemia, hypocalcemia, maculopapular rash,
arrhythmia, hypothyroidism, megaloblastic anemia, hirsutism, gingival hyperplasia, pulmonary
eosinophilia, lymphadenopathy
Large iv dose- cardiac arrythmia and arrest, large oral dose- vestibulo cerebellar
abnormality(nystagmus,vertigo,diplopia)
PPI- long term use leads to mild to moderate decrease in vit B12, iron, and Ca absorption;
inceased risk of enteric infections including C difficile and bacterial gasroenteritis, pneumonia,
osteoporosis
Ranolazine- QT prolongation,
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Risperidone: postural hypotension, stroke,EPS
Salbutamol: tremors, N,V,dizziness,dyspepsia, hypokalemia, tachycardia,nervousness&
insomnia(in children)
Spironolactone:gynaecomastia,hyperkalemia, lactic acidosis
SSRI- nausea,vomiting, anxiety, diarrhoea, flatulence, dyspepsia, dry mouth, headache,
insomnia, akathisia, extremely vivid dreams,anorgasmia, decreased libido, discontinuation
syndrome
Statins: myopathy
Sucralfate-constipation, reduced bioavailability of some drugs like digoxin, phenytoin. Can be
overcome by giving agents atleast 2 hour apart. Use sucralfate with caution in renal failure pts
due to risk of increased Aluminium absorption.
Sulfonamides: pancreatitis,hypothyroidism, colour vision alteration,aplastic anemia, interstitial
nephritis
Theophylline:seizure, tremors,hypotension,hypokalemia,
Thiazide diuretics: hyperglycemia, hypertriglyceridemia,hypokalemia,hyponatremia,
hypercalcemia, hyperuricemia, hypomagnesemia,colour vision alteration, pancreatitis,interstitial
nephritis, erectile dysfunction

Thyroxine:osteoporosis, exacerbation of angina

Tranexa: nausea, diarrhoea,giddiness,headache

TCAs: tremors,seizure,sedation,peripheral neuropathy,HTN, glaucoma, hyperprolactinemia,

decreased libido, constipation, urinary retention, blurred vision, dry mouth, cardiac(tachycardia,
flattened T, QT prolongation, ST segment depression, arrhythmias etc).
Note-b TCA should be avoided in glaucoma, BPH

Valproic acid:pancreatitis,hepato toxicity, alopecia, N,V, wt gain,rashes

Vancomycin:ototoxicity,tense blisters
Verapamil - bradycardia,AV block, ankle edema, constipation.
Warfarin- alopecia, bleeding, urticaria, teratogenic
Drugs not to be stopped abruptly
Clonidine, Beta blockers in angina, nitrates, psychotropic drug(neuroleptics, Li,
benzodiazepines), oral anticoagulants etc
Drugs whose absorption is reduced/delayed by food
Aspirin, ampicillin, atenolol, azithromycin, doxycycline, captopril, rifampicin, isoniazid, indinavir,
sucralfate,
Drugs whose absorption is increased by food
Metoprolol, diazepam, cefuroxime, carbamazepine, lithium, hydralazine, chlorthiazide, ritonovair,
ganciclovir
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C/I for common drugs

Acetazolamide: liver failure
ACEI, ARB- pregnancy,b/l renal artey stenosis, hyperkalemia, S cr>3.5, single kidney
Atenolol- renal failure
Beta blockers(in general)- bronchial asthma, variant angina, decompensated CHF,WPW
CCB-
Digoxin - WPW,HOCM,
FQs: pregnancy,children<15 yrs
Ipratropium: urinary retention
Ivabrad- sick sinus syndrome, along with drugs like verapamil,diltiazem, macrolide, azole
antifungals
Lithium-pregnancy, lactation,SSS
Levodopa- glaucoma, malignanat melanoma
Mgso4- deranged renal function, myasthenia gravis.
Mannitol: LVF, pulmonary edema, cerebral hemorrhage, end stage renal failure
Nicorandil-cardiogenic shock, a/c MI, a/c pulmonary edema,
NTG: IWMI, severe hypotension,
Orceprenaline- tachycardia secondary to heart condition,
Phenytoin- absence sz, myoclonic sz
Propranolol - DM
Sodium nitroprusside- pregnancy
Triptans- ischemic heart disease, HTN, epilepsy, pregnancy,liver and renal impairment.
Verapamil- WPW
Drug/Food combinations to be avoided
Clarithromycin + CCB= can cause hypotension and a/c renal failure
Trimethoprim/sulfamethoxazole+ ACEI/ARB= hyperkalemia
Levodopa +vit B6(pyridoxine)= reduced efficacy of levodopa
Warfarin+ NSAIDS= GI bleeding
Warfarin + regular use of Paracetamol= increase in INR
NSAIDs(esp indomethacin, piroxicam, naproxen) + Antihypertensives(ACEIs/ARBs/diuretics)-
reduced effectiveness of antihypertensives.
NSAIDs + diuretics- attenuation of action of diuretics
Thyroxine+ PPI= may require increased dose of thyroxine
Grape juice+ Amiodarone/ amlodipine/nifedipine/ atorvastatin= may increase plasma drug
concentration.
Ampicillin+ allopurinol- drug rash in 20% pts.
Clopidogrel + omeprazole/esomeprazole- failure of clopidogrel activation
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Vaccination

Courtesy: National Immunization Program, IAP Recommendation- 2014 Update

Birth :BCG, OPV -0, Hep B0

6 weeks: DTwP 1, OPV-1, Hep -B1, Hib 1(meningitis), Rotavirus 1, PCV 1, IPV1
10 weeks: DTwP 2, OPV-2, Hib 2, Rotavirus 2, Hep B2
14 weeks :DTwP 3, OPV-3, Hib 3, Rotavirus 3, PCV 2, IPV2, Hep B3
6 months:
9 months: MR 1 or Measles, PCV booster, JE 1,Vit A(1st dose)
12 months: Hep A 1
15 months:Varicella 1,
16-18 months: vit A 2 nd dose. Then one dose every 6 months upto the age of 5 years.
16-24 months: DTwP B1, OPV B1, Hib B 1, JE2, MR 2 or measles
18 months: Hep A 2
2 years : Typhoid 1
4-6 years: DTwP B2, , Varicella 2, Typhoid 2
10-12 years : Tdap/ Td/TT, HPV 1, note: HPV 2(1 month after 1st dose), HPV 3(after 6 months),
16 yrs: Td/TT

Note: HPV 2(1 month after 1st dose), HPV 3(after 6 months),Two doses of HPV vaccine for
adolescent/pre-adolescent girls aged 9-14 years
For two-dose schedule, the minimum interval between doses should be 6 months
Three dose schedule for adolescent girls aged 15 years and older to continue
Note: if measles vaccine is given at 9 months, then MMR 1 at 12-18 months & 2nd dose 8
weeks after 1st dose. Varicella 2 can be given anytime 3 months after 1st dose.
Note: for 6, 10 & 14 week vaccination, always give paracetamol Q6H for 1day as most common
s/e of DPT is fever.
Age limits for vaccines
BCG/pentavalent- till 1 year, measles/OPV/vit A prophylaxis- upto 5 years, DPT- upto 7 years
Others
Meningococcal vaccine: recommended over 2 yrs of age, single dose 0.5 ml s/c or IM,
T N : Mencevax A & C
PCV : Pneumococcal conjugate vaccine, T N :Prevenar
Pneumococcal Polysaccaride vaccine : after 2 yrs of age, one booster dose after 5 years of age,
T N :Pneumo 23, Pneumovax 23 (0.5 ml IM) . Also given in >64 years. A single revaccination is
recommended in adults=5 yrs of age if they were vaccinated>5 years previously at a time when
they were <65 yrs, and in immunocompromised pts, five yrs or more after the first dose.
Varicella Vaccine, T N : Varilrix
Rotavirus, T N: Rotarix,
HPV T N: Gardasil(0.5 ml IM 0, 2 ,6 months), Cervarix(0,1,6 months);
Typhoid Vaccine ,T N: Typherix(IM)
Hepatitis B T N: Engerix-B IM. 1 ml 0,1,6 months as preexposure prophylaxis for ≥ 20 yrs.
Hepatitis A T.N: Havrix 0.5 ml IM
MMR T.N: Tresivac 0.5 ml s/c;
Hib Vaccine T N: Hiberix (IM)
Cholera vaccine: given for children above 1 yr, 2 doses 2 weeks apart.
JE Vaccine : 1st above 8 months of age, 2nd dose at 16-18 months, T.N:JEEV
Influenza:1st dose above 6 months, 2nd dose after 1 month , T.N: Fiuarix. Also in adults yearly.

For pregnant women

Td-1 early in pregnancy . Td -2 4weeks after Td -1.
Td booster if previously received 2 doses of Td in a pregnancy Within the last 3 years.
Td-2 or booster doses given before 36 weeks of pregnancy.
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Screening tests

Abdominal aortic aneurysm- USG , men 65-75 yrs who have ever smoked

Breast cancer- mammography, women 50-75yrs, every two years

Cervical cancer- pap smear, HPV testing, women 21-65yrs, every 3 yrs

Colorectal cancer- Fecal occult blood testing,adults 50-75 yrs, every year

CA Prostate-PSA

Depression- screening questions, all adults periodically

Diabetes-FBS, HgbA1c, adult overweight, obese or with HTN, every 3 yrs

HCC in CLD- serial USG + AFP

Hyperlipidemia- Total cholesterol, adult 40-75 yrs

HTN- BP, all adults periodically

Obesity- BMI, all adults

Osteoporosis- DEXA , women >65 or >60 with risk factors

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Basic Life support

Adult Cardiac Arrest Algorithm
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ADVANCED CARDIAC LIFE SUPPORT ALGORITHMS

PULSELESS/CARDIAC ARREST ALGORITHM

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BRADYCARDIA ALGORITHM
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TACHYCARDIA ALGORITHM
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Adult Immediate Post cardiac Arrest Care Algorithm

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Sample Referral letter
Date:
Time:
To whomsoever it may concern

Sir/madam
I’am referring Mr./ Smt ..............., ......yrs, a k/c/o ................. .....................
now presented with c/o .................................................................................................
O/e, he/she has.............................................................................................................
The investigation done show.........................................................................................
My clinical impression is ...............................................................................................
I have given the following treatment..............................................................................
I’am referring him/her to you, for expert evaluation, care & Management. Kindly do the
needful.

Thanking you
Your’s sincerely
Signature

WHAT TO DO WHEN A PATIENT DIES

When a pt dies, write the following format, in the pt’s case sheet irrespective of the
cause of death.
00:00
Pt gasping 1.Inj Atropine 1 amp, inj adrenaline 1 amp iv st
Pulse not palpable , BP unrecordable 2.Inj Dopamine 400 mg in NS @ 14 dps/min
CPR started
Pt intubated;Ambu bag ventilation given
Note: 2010 ACLS guidelines excludes atropine administration for PEA/asystole
00:05
Pulse, BP unrecordable 1.Inj Atropine 1 amp, inj adrenaline 1 amp
CPR & Ambu bag ventilation continued 2.Inj Dopamine
00:10
Pulse, BP unrecordable 1.Inj Atropine 1 amp, inj adrenaline 1 amp
CPR & Ambu bag ventilation continued 2.Inj Dopamine
00:15
Pulse, BP unrecordable
ECG shows asystole or no cardiac activity
No spontaneous respiratory effort
Pupils Dilated & fixed
Irrespective of all resuscitative efforts as per ACLS protocol, pt expired at _ _:_ _ am/pm
on _ _/_ _/_ _(Date)
Pt declared clinically dead.

Signature
Filling death certificate
Part -1 is to be filled with condition leading to death. For e.g if a pt with h/o DM & D
nephropathy died of renal failure, then 1a Renal Failure (immediate cause) 1b D
nephropathy (antecedent/underlying cause) 1c DM (main underlying disease) 1d
Part-11 Associated conditions for e.g HTN
Don’t write the mode of dying like heart failure or respiratory failure in 1a.
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BREAKING BAD NEWS to the patient

SPIKES Protocol

STEP 1: SETTING UP the Interview

1.Physical – position of body (level with patient, lower if the patient is
angry),preferably sitting, eye contact (avoid when situation is "hot")
2.Time: by appointment and not during ward rounds.
3.Listening Skills – use of silence and pauses, use of patient’s own language as a
bridge; appropriate use of touch like touching th pt on arm or holding the hands.
4.Where: preferably a quiet room with privacy. Respect confidentiality. Avoid
external interruption. Better put your mobile on silent mode for the time being.
5.Make sure you have checked all the available information and have test
results(including getting the right pt)
6.Involve significant 1 or 2 close relatives, if the pt has no objection

STEP 2: Assessing the Patient’s PERCEPTION

ie. patient’s perception of the current situation. Finding out how much the pt knows;how
serious the pt thinks the illness is and or how much it will affect the future.It is important
to know the pt’s level of understanding so that the doctor can later begin providing
information at the same level.Note pt’s vocabulary and comprehension

STEP 3: Obtaining the Patient’s INVITATION

Find out how much the pt wants to know.If patients do not want to know details, offer to
answer any questions they may have in the future or to talk to a relative or friend.

STEP 4: Giving KNOWLEDGE and Information to the Patient

Warning the patient that bad news is coming may lessen the shock that can follow the
disclosure of bad news. Start at a level compatible with the patient’s current
comprehension. Give information in small chunks. Use common nontechnical
words,avoid Medspeak. Acknowledge all patient’s responses and tailor delivery of
information appropriately to patient’s responses.Check reception of information often.
Avoid excessive bluntness especially during bad prognosis.Repeat important points; pt
who are upset or in shock don’t hear or remember well. Listen to pt’s agenda and
concerns

STEP 5: Addressing the Patient’s EMOTIONS with empathic responses. Pt’s responses
can vary from silence to distress, anger or denial.Allow expression of emotion without
criticism.
Respond to pt’s feelings empathically. Observe the pt and give them time.Empathy
allows the pt to express their feelings and concerns. Do not argue.

STEP 6: Strategy and Summary

Planning & followup
Offer a plan or strategy for the future and explain it. Before discussing a treatment plan, it
is important to ask patients if they are ready at that time for such a discussion.
Identify coping strategies of pt and reinforce them. Identify other sources of support for
the pt and incorporate them. Invite questions. Tell them what happens next.Sharing
responsibility for decision-making with the patient may also reduce any sense of failure on
the part of the physician when treatment is not successful.
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Breaking bad news to the bystanders/ bereaved family members

Initial contact with the family

If the family members are in the hospital, summon them to the ICU as emergency.
However, problem comes when nobody is around.
A senior member of the health care team should call the family members. Inform them
that the patient has become ill suddenly and initiation of the prompt treatment. The
family member should be asked to come to the hospital immediately.If the patient is
already dead, care should be taken not to break news on the telephone unless the
family members live a long distance away. However, if the death is expected, simply
break the news to anyone who receives the phone and note down the person's identity
and his/her relation to the deceased
If we are to break the sad news over the phone, make sure that someone is around with
the person who is going to receive it.

Receiving the family members at the ICU

A relatively confident member of the health care team should receive the relatives at the
ICU and confirm their identity and relation to the patient. Prefer to talk to somebody who
is familiar to the health care team already.
A comfortably furnished room should be ideally available near ICU to talk to the
relatives.Try to limit the discussions to only one or two members of the family.

Handling of the family members will differ if the patient is already dead or if the patient is
alive and receiving resuscitation:

 When the patient is alive:

Prepare the relatives for the possibility of death
A relatively senior and confident clinician should introduce himself first and then begin
the talk.
Foreshadow the bad news, “I am sorry, but I have bad news”
Explain the relatives how well the patient was doing earlier and his sudden deterioration.
The clinician should try to explain the possible reasons for the sudden deterioration. He
should be very patient and encourage the family members to ask questions and express
feelings and should be most willing to answer them. This will help to build a sense of
trust and good rapport with the family members
One of the relative who is relatively confident and well-versed with the hospital set up
should be given opportunity if possible, atleast once in a while to witness the ongoing
resuscitation in the ICU. The senior most clinician in the team should explain the
resuscitation procedure and should show the signs of life like spontaneous breathing or
heart beat in the cardiac monitor, limb movements etc. The sincere words of this
witness will simply help the relatives to confirm that everything possible is being done.
Then, the relative should be taken back to the discussion room and the senior clinician
to explain the prognosis and chances of survival.
A priest or any other spiritual counsellor should be allowed to offer final prayer if the
relatives wish so.The staff should keep the family informed with frequent updates on the
progress of the resuscitation.
These steps will give the family ample of time to prepare themselves mentally for the
most inevitable.
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Informing family about death
And finally, if the resuscitation is not successful, the clinician in charge , who is
responsible for the patient, should sit with the relatives and break the bad news
Again, as earlier, try to engage only one or two members of the family. Friends and
others should be asked to wait outside the room. Prefer talking to the same person who
has been briefed about the patient's critical illness earlier. It is always easier to converse
and convince a familiar person than a stranger. Moreover, it will be lot easier to break
the sad news to the person who is quite aware of the ongoing treatment and patient's
problem rather than to a totally new person.
Use simple language like he is dead or died rather than euphemisms like “passed away
or left us, no more etc.” This will help to avoid the risk of misinterpretations.

Facilitating the grief reaction

Having announced the bad news, the doctor's next duty is to help the relatives to go
through the process of grief.

Encourage the relatives to express their feelings like crying loudly or sobbing etc
Encourage them to talk about the patient's illness, and if they open up, try to explain the
efforts taken to save him and the inevitable outcome
Remaining silent with physical touch like placing hand on the sobbing person's hand or
shoulder may be tried depending upon the situation, ethnic background, age & sex.
Appreciating the efforts taken by the relatives to get the patient treated may help them
to come out of a sense of guilt or self-blame. Convince them again that there has been
no shortage of efforts either from the health care team or from the relatives
In certain cases, especially when the diseased has been in deep coma, explain them
how peaceful the death was. This would help to convince them that their beloved one
did not suffer much. Such reassurances also reduce guilt feelings.
Some amounts of religious philosophy like “ultimately everything depends on God's
wish” or “Life-span being over as per God calculation” etc., may help to console the
bereaved relatives, and again, this depends on cause of death, ethnicity and religious
background.
Do not respond or argue with the relatives if they blame or comment on the healthcare
team or the hospital.
They may realize their mistake and surely apologize when the emotions settles down.
Whenever there is a medico-legal implication or other situations where a medical
autopsy may be needed to ascertain the cause of death, relatives should be informed
about the possible autopsy well in advance.

Arrange for viewing the body of the deceased

Before allowing the relatives to view the body, make it more presentable.
Cover the body with proper bed clothes.
Disconnect all the life supports like endotracheal tube, cardiac monitors, ventilators,
urinary catheters, ryles tube etc
Wipe the face neatly to clean blood and other secretions.
Clean the jelly on the chest used for the DC shock.
Avoid emotionally charged or labile relatives viewing body as they themselves may
collapse inside the ICU.
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 When the patient is already dead before the arrival of the relatives
Receive the relatives at the ICU as described earlier and confirm their identity.
Make them seated in the well-furnished room, if available as described before.
Again, the relative who is known to health care team if any should be preferred.
Clinician should introduce himself first and then begin the talk.
Prepare the relatives with foreshadow of the bad news, “I am sorry, but I have bad
news”
Break the sad news in simple language and avoid using euphemisms like “passed away
or left us, no more etc” to avoid misinterpretations.
Facilitate the grief reaction as described earlier.
Help the family members to view the deceased.Help the relatives to go through the
official formalities.
One of the hospital staff should assist the relatives in completing the formalities like
filling the details of deceased so as to get a legal death certificate etc.
If an autopsy is needed, guide the relatives about various procedures.
And finally, ensure smooth and timely handing over the body of deceased along with
valuables and personal belongings.
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Organ/Tissue Donation

Care of the potential organ /tissue donor

Pts with suspected brain stem death should be considered candidates for organ or
tissue donation. Tissue donation is excluded if there is systemic malignancy(other than
for eye donation), HIV/HTLV/Hepatitis B/C positive or behavioural risk, syphilis,
progressive neurological condition of uncertain pathology, previous transplantation,CJD
or family history of CJD.
Absolute C/I for solid organ donation- HIV, CJD or suspected CJD

The transplant coordinator should be contacted early (before the family is approached)
to confirm likely suitability.

Management
1.confirm brain stem death with appropriate testing.
2.Lab tests for blood group, HIV and hepatitis status, and electrolytes
3.maintain optimal cardiorespiratory status with fluid +/- inotropes and vasopressin,
optimal ventilation, low PEEP, and physiotherapy.
4.Maintain Hb >9 mg/dL and correct coagulation disturbance
5.Maintain body temperature with warmed fluids and heated blankets
6.Contact surgical & anaesthetic teams

Organ suitability
Kidneys, Heart, Lungs, Liver
The transplant adviser will advise on other organ & tissue suitability

Non -heart beating Donation

Solid organs suitable for transplantation from non-heart beating donors include kidneys,
livers, lungs. Tissue donation (e.g corneas etc) should also be considered in asystolic
cadaveric donors. Contraindications are similar to those for brain stem dead heart
beating donors. Consideration of non-heart beating donation should be made in all
patients in whom treatment is to be withdrawn.

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