8.scoring and Criterias

Contemporary Clinical Guidelines for
Emergency Medicine – 2017
Prepared for SEMICON 2017
Disclaimer:
This compilation of Internet-based guidelines has been done so, exclusively for the purpose of
the PG Refresher Course, being conducted under the aegis of SEMI – Society of Emergency
Medicine, India. It is not to be reproduced for commercial purposes or otherwise.
Page i
Editorial Board
Contributors (In alphabetical Order):
1. Dr Benita Florence
benitaflorence@yahoo.com
2. Dr Jaizal Issac
drjaiizl83@gmail.com
3. Dr Ravi Pratap
ravipratap2@yahoo.co.in
4. Dr Sandeep David
sanada_124@yahoo.com
5. Dr Sandeep Gore
drsandeepbgore@gmail.com
6. Dr Senthil Kumaran
maniansenthil@yahoo.co.in
7. Dr Shweta Tyagi
shwrah@gmail.com
8. Dr Suhas Rao
suhasagastya@gmail.com
Editor:
Prof. Dr. Suresh S. David

suresh.david@pushpagiri.in
Page ii
TABLE OF CONTENTS
Section Chapter and Title of Guidelines Page

Number
I Burns
1. Lund and Browder 1
2. Parkland Fluid calculation 2
3. Wallace Rule of 9 2
II Cardiovascular
4. 4Ts Score for Heparin-Induced Thrombocytopenia 3
5. ATRIA 4
6. Brugada Syndrome 5
7. CHA2DS2 (Stroke risk for patients with AF) 6
8. Grace ACS risk calculator 7
9. HAS BLED Score 8
10. HEART score 9
11. Indications for PCI 10
12. Indications/CI for Thrombolysis – MI 11
13. Killip Classification 12
14. Leriche Fontainne Classification 13
15. San Francisco Syncope Rule 14
16. Sgarbossa Criteria 15
17 Stanford & DeBakey Classification 17
18. TIMI Score 18
19. Vancouver chest pain rule for Early Discharge 19
20. WELL’s DVT 20
21. Wellen Syndrome 21
III Central Nervous System
22. ABCD2 22
23. GCS 23
24. HUNT & HESS – SAH 24
25. ROSIER Score 25
26. Stroke Thrombolysis 26
IV Gastrointestinal System
26. Child Pugh 28
28. Glasgow Blatchford score 29
29. Grades of Hepatic Encephalopathy 30
30. Indications for liver transplant 31
31. Ranson’s criteria 32
32. Rockall Score 34
33. Truelove & Witt – Ulcerative Colitis 35
V Infectious Diseases
34. Centor Criteria 36
35. Components of current “care bundles” (e.g. The Surviving Sepsis 37
Campaign 6 hour bundle)
36. Duke’s Criteria – IE 39
Page iii
37. EGDT 40
38. Indications/C/I LP 41
39. Light’s Criteria – Pleural Effusion 42
40. Lung Protective Ventilation (in Septic shock) 43
41. SIRS 44
42. SOFA score 45
VI Joints
43. Garden classification Hip # 46
44. Kanavell’s 47
45. Kocher’s clinical prediction 48
46. Ottawa Ankle Rule 49
47. Ottawa Knee Rule 51
48. Red Flags – Back pain 52
49. Salter Harris Classification 53
50. Young & Burgess Classification of Pelvic Fractures 54
VII Obstetrics and Gynaecology
51. Amsell’s Criteria 55
52. Anti D Ig indications 56
53. Emergency Contraception 57
54. Gillick Competency & Fraser Guidelines 58
VIII Paediatrics
55. APLS criteria for dehydration 59
56. D/D limping child 61
57. Kawasaki NICE diagnostic criteria 62
58. Length of ET tube 63
59. NICE atypical UTI for admission 64
60. Traffic light system (paediatrics) Risk of serious illness 65
61. Weight of child 66
62. Westley Croup Score 67
IX Psychiatry
63. CAGE questionnaire 69
64. Mental capacity 70
65. Modified SAD Persons 71
X Respiratory System
66. CURB 65 72
67. Geneva PE score 73
68. PERC 75
69. WELL’s PE 76
XI Resuscitation
70. Anaphylaxis guidelines 77
71. Cardiac Arrest Algorithm 78
72. Cormack and Lehane classification 80
73. LEMON 81
74. Mallampatti Classification 81
XII Surgery and Sub Speciality
75. ALVARADO Score 82
76. Charcot’s triad and Reynold’s pentad 83
Page iv
77. Large vs Small bowel Obstruction 84
XIII Toxicology
78. Coma Cocktail 85
79. Repeat dose of activated Charcoal 86
80. Rumack Matthew Normogram 87
81. Substances that do not bind to charcoal 89
XIV Trauma
82. Canadian C Spine Rule 90
83. Criteria for positive DPL 92
84. Beck’s triad 93
85. Cushing’s triad 94
86. Features S/O aortic injury on CXR 95
87. Features S/O base of skull # 96
88. Fluid loss according to patients’s condition ATLS Class I – IV 97
89. Gustillo Classification of open fractures 98
90. Indications for ED thoracotomy/C/I 99
91. Indications for ORIF in distal radius # 101
92. Indications for TT 102
93. Laparotomy in abdominal trauma patients 105
94. Le Forte Classification 106
95. MESS score 107
96. METHANE 108
97. NEXUS C Spine Rule 110
98. NEXUS Chest Rule 111
99. NEXUS CT Brain 112
100. NICE CT Brain – Children 113
101. NICE CT Brain – Adults 114
102. Schatzker classification 115
XV Miscellaneous
103. Analgesic Ladder 116
104. Indications for Rabies vaccine/Ig 117
105. NSI – indication for drugs/Vaccines 118
106. RIFLE 119
107. Raised Anion Gap Metabolic Acidosis 120
108. Whole Bowel Irrigation 121
109. GINA 2017 121
110. JNC HTN 122
111. Prevention & Management of Wound Infection WHO 125
Page v
INTRODUCTION
Dear Trainee
Welcome to the PG Refresher Course of the Society of Emergency Medicine!
SEMICON 2017 has adopted an unprecedented program schedule this year. One of the highlights
is this compilation of nearly 107 General Consensus documents and Clinical Guidelines, which
has been collected painstakingly, by the contributors – a team of active Emergency Physicians,
across the country. We believe this would be invaluable for rapid revision, prior to your
respective exit examinations and also for your day-to-day clinical practice. This document is
restricted to the essentials necessary for the practice of Emergency Medicine and it is imperative
that you focus and adapt the information, according to your needs and resources.
Aristotle, the teacher of Alexander the Great, is one of my favourite role models. His most
impressive trait was that he was keen to learn everything about everything. And it was he who
said, “We are, what we repeatedly do. Excellence, therefore, is not an act but a habit.” I am fond
of this quotation, since it defines us Emergency Physicians. My intention is to kindle the flames
of your curiosity; to challenge you to explore the frontiers of Emergency Medicine. It has indeed
been an enjoyable and thought-provoking process, preparing this Manual. I look forward to your
interaction, your feedback and constructive suggestions, which would then pave the way for
revisions in the future.
Prof. Dr. Suresh S. David MS (Surg) FRCP (Lond) FACEM (Aust) MPhil (HHSM) PhD
Emergency Medicine, Pushpagiri Medical College Hospital
Tiruvalla – 689191, Kerala, India.
suresh.david@pushpagiri.in
Page vi
Section I. Burns
1. Lund and Browder
Purpose: Assessing the area of a burn. It can give an accurate assessment of burns area in
children as It compensates for the variation in body shape with age.
Relative percentages of areas affected by growth (age in years)
0 1 5 10 15 Adult
A Half of head 9 /2 8 /2 6 /2 5 ½ 4 1/2
1 1 1 3 1/2
B Half of thigh 2 3/4 3 1/4 4 4 ½ 4 1/2 4 3/4
C Half of leg 2 /2 2 /2 2 /4 3 ¼ 3 1/4
1 1 3 3 1/2
Second-degree _____and Third-degree ______ = Total percent burned ______
Reference:
 Hettiaratchy S, Papini R. Initial management of a major burn: II—assessment and
resuscitation. BMJ : British Medical Journal. 2004; 329(7457):101-103.
Contemporary Guidelines For Emergency Medicine - SEMICON 2017 1

2. Parkland Fluid calculation
Purpose: It is simplest and most widely used formula to calculate the fluid to be
replaced in first 24 hours of burns.
Adults
4 × weight (kg) × % BSA burned = volume (ml) over initial 24 h
Half over the first 8 h from the time of burn and the second half is given in the
subsequent 16 hours
Children
3 × weight (kg) × % BSA burned = volume (ml) over initial 24 h plus
maintenance
Half over the first 8 h from the time of burn and the second half is given in the
subsequent 16 hours
Indication for Intravenous fluid resuscitation burns over 10% TBSA (Total Body
Surface Area) in children and over 15% TBSA in adults
Reference:
Judith E. Tintinalli, M. M. (2016). Tintinalli’s Emergency Medicine, A
Comprehensive Study Guide (Eighth ed.). McGraw-Hill.
3. Wallace Rule of 9
Purpose: Assessing the area of a burn. Good and quick way of estimating
medium to large burns in adults.
The body is divided into areas of 9%, and the total

burn area can be calculated.
Only second-degree and deeper burns should be
used to calculate the percentage of TBSA (Total Body
Surface Area) affected.
It is not accurate in children.
Reference:
Hettiaratchy S, Papini R. Initial management of a major burn: II—assessment
and resuscitation. BMJ : British Medical Journal. 2004;329(7457):101-103.

Section II. Cardiovascular System
4. 4Ts Score for Heparin-Induced Thrombocytopenia
The 4 Ts for the diagnosis of heparin-induced thrombocytopenia (HIT) is a tool developed

to help clinicians rule out HIT in patients who develop thrombocytopenia in the clinical
setting
Category 2 points 1 point 0 points

Thrombocytopenia Platelet count fall > Platelet count fall 30%– Platelet count
50% 50% fall < 30%
and platelet nadir ≥ 20 or platelet nadir 10–19 or platelet
× 109 L−1 × 109 L−1 nadir < 10 ×
109 L−1
Timing of platelet Clear onset between Consistent with days 5– Platelet count
count fall days 5 10 fall, fall < 4 days
and 10 or platelet fall ≤ but not clear (e.g. without recent
1 day missing platelet heparin
(prior heparin counts) exposure
exposure within 30 or onset after day 10 or
days) fall ≤ 1 day
(prior heparin
exposure 30–100 days
ago)
Thrombosis or New thrombosis Progressive or None
other sequelae (confirmed) or skin recurrent thrombosis
necrosis at heparin or nonnecrotizing
injection sites or (erythematous) skin
acute systemic reaction lesions
after or suspected
intravenous heparin thrombosis (not
bolus proven)
Other causes for None apparent Possible
thrombocytopenia
Score Risk Classification

Less than or Equal to 3 points Low probability for HIT
4-5 points Intermediate probability
6-8 points High probability
Reference
Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A. Evaluation of pretest
clinical score (4 Ts) for the diagnosis of heparin-induced thrombocytopenia in two clinical
settings. J Thromb Haemost 2006; 4: 759–65.

5. ATRIA
Purpose: A validated risk score to predict warfarin-associated haemorrhage.
ATRIA risk factors Score

Anemia (hemoglobin <13 g/dL in men, <12 g/dL in women) 3
Severe renal disease (GFR <30 mL/min; dialysis dependent) 3
Age ≥75 2
Any prior hemorrhagic diagnosis 1
Diagnosed hypertension 1
Risk Score Risk Level Annualized hemorrhage rate

0-3 Low 0.76%
4 Intermediate 2.62%
5-10 High 5.76%
Reference
Fang MC, Go AS, Chang Y, et al. A new risk scheme to predict warfarin-associated
hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) study. J
Am Coll Cardiol. 2011; 58:395-401.

6. Brugada Syndrome
 The type I ECG is characterized by a J elevation ≥2 mm (0.2 mV) a coved type ST

segment followed by a negative T wave. Brugada syndrome is definitively
diagnosed when a type 1 ST-segment is observed in >1 right precordial lead (V1 to
V3).
 The type II ECG is characterized by a saddle-back ST segment elevation in
precordial leads V1 to V2 with a positive or biphasic T wave.
Reference:
Brugada P and Brugada J. Right bundle branch block, persistent ST segment elevation and
sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter
report. J Am Coll Cardiol. 1992 Nov 15;20(6):1391-6.

7. CHA2DS2 (Stroke risk for patients with AF)
Purpose: Calculates stroke risk for patients with atrial fibrillation

Criteria Score
C Congestive Heart Failure 1
H Hypertension 1
A Age 65-74 1
A >75 2
D Diabetes Mellitus 1
S Prior Stroke or TIA 2
VA Vascular disease (previous myocardial infarction, arterial disease, or 1
aortic plaque)
SC Sex category - Female 1
Maximum Score 9
Annual Stroke Risk

CHA2DS2VAsc Stroke Risk %
0 0
1 1.3
2 2.2
3 3.2
4 4
5 6.7
6 9.8
7 10.2
8 12.5
9 15.2
Reference:
European Heart Journal doi:10.1093/eurheartj/ehv431 Sept 10, 2015

8. Grace ACS risk calculator
Acronym Expansion: Global Registry of Acute Coronary Events score.
Purpose: To predict in-patient mortality and post-discharge 6-month mortality for the
entire spectrum of ACS.
Eight parameters are used for calculating GRACE score that include Patient’s age, Heart
rate, Systolic blood pressure, Killip class, Serum creatinine level, Cardiac arrest at hospital
admission, ST-segment deviation in ECG and Elevated cardiac marker.
Variables Range Min Score Max Score
Patient’s age <30 to >90 years 0 100
Heart rate ≤ 50 to ≥ 200 beats/min 0 46
Systolic blood pressure ≤ 80 to ≥ 200mmHg 0 58
Killip class Class I – IV 0 59
Serum creatinine level <0.38 to ≥ 4mg/dl 1 28
Cardiac arrest at hospital admission Yes/ No 0 39
ST-segment deviation in ECG Yes/ No 0 28
Elevated cardiac marker Yes/ No 0 14
Total Score Risk assessment

≤ 100 Low risk patients– In-hospital death rate less than 1%
101-170 Medium risk patients – In-hospital death rate 1-9%
≥ 171 High risk patients – In-hospital death rate more than 9%
Reference:
 Granger CB, Goldberg RJ, Dabbous O, et al. Predictors of hospital mortality in the
global registry of acute coronary events. Arch Intern Med 2003;163:2345–53.
 Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model for all forms of
acute coronary syndrome: estimating the risk of 6- month post discharge death in
an international registry. JAMA 2004; 291:2727–33.
 Newby DE, Grubb NR, Bradbury A. Cardiovascular disease. In: Colledge NR, Walker
BR, Ralston SH, Penman ID eds. Davidson’s Principles & Practice of Medicine. 22st
ed. China: Churchill Livingstone, 2014: 542, 59.

9. HAS BLED Score
Purpose: A tool that can potentially guide the decision to start anticoagulation, in
patients with atrial fibrillation. To assess one year risk of major bleeding in these
patients.
HAS BLED Risk Score

Hypertension 1
Abnormal Renal function 1
Abnormal Liver function 1
Stroke 1
Bleeding 1
Labile INRs 1
Elderly: Age >65 1
Drugs Alcohol 1
Score Bleeding risk classification (% bleeds per 100 patient-years)

0 – 1 Low risk (1.1%)
2 Intermediate risk (1.9%)
>/=3 High risk (4.9%)
 Hypertension: systolic blood pressure >160 mm Hg

 Abnormal renal function: presence of chronic dialysis or renal transplantation or
serum creatinine ≥200 μmol/L
 Abnormal hepatic function: chronic hepatic disease or biochemical evidence of
significant hepatic derangement (e.g., bilirubin >2x upper limit of normal, in
association with aspartate aminotransferase/ alanine aminotransferase/alkaline
phosphatase >3x upper limit of normal, etc.)
 Bleeding refers to previous bleeding history and/or predisposition to bleeding (e.g.,
bleeding diathesis, anemia)
 Labile INRs refers to unstable/ high INRs or poor time in therapeutic range (e.g.,
<60%); Drugs/alcohol use refers to concomitant use of drugs, such as antiplatelet
agents, nonsteroidal anti-inflammatory drugs, alcohol abuse
Reference
Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJGM, Lip GYH. A novel user-friendly
score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial
fibrillation: The Euro Heart Survey. Chest. 2010;138:1093-1100.

10. HEART score
Purpose: Predicts 6-week risk of major adverse cardiac event (MACE)
HEART Score Score

Criteria
History Highly suspicious 2
Moderately suspicious 1
Slightly suspicious 0
ECG Significant ST-depression 2
Non specific repolarisation disturbance 1
Normal
0
Age ≥ 65 years 2
45 – 65 years 1
≤ 45 years 0
Risk Factors ≥ 3 risk factors or history of atherosclerotic disease 2
1 or 2 risk factors
No risk factors known 1
0
Troponin ≥ 3x normal limit 2
1 – 3x normal limit 1
≤ normal limit 0
HEART Score Risk of MACE Proposed Policy

0-3 1.6% Discharge
4-6 13% CXR ECG
7-10 50% CAG
Reference
Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score.
Neth Heart J. 2008 Jun;16(6):191-6. PubMed PMID: 18665203; PubMed Central PMCID:
PMC2442661.

11. Indications for PCI
Reference: PCI Guidelines 2013 AHA

12. Indications/CI for Thrombolysis – MI
Indications for Thrombolytic Therapy
 Evidence of ST-segment elevation MI (STEMI) presenting within 12 hours of the
onset of symptoms.
 STEMI equivalents, such as isolated posterior-wall MI, present with ST
depression in the Early precordial leads.
 New onset of left bundle-branch block (LBBB) presenting within 12 hours of the
onset of symptoms
Absolute Contraindications Against the use of Thrombolytic Therapy

 Any previous history of hemorrhagic stroke
 Head trauma or brain surgery within 6 months
 Known intracranial neoplasm
 Suspected aortic dissection
 Internal bleeding within 6 weeks
 Active bleeding or known bleeding disorder
 Major surgery, trauma, or bleeding within 6 weeks
 Traumatic cardiopulmonary resuscitation within 3 weeks
Relative Contraindications Against the Use of Thrombolytic Therapy

 Oral anticoagulant therapy
 Pregnancy or within 1 week postpartum
 Active peptic ulceration
 Intracardiac thrombi
 Uncontrolled hypertension (systolic blood pressure >180 mm Hg, diastolic blood
pressure >110 mm Hg)
 Puncture of noncompressible blood vessel within 2 weeks
 Previous streptokinase therapy
 Active cavitating pulmonary tuberculosis
 Advanced liver disease
 Transient ischemic attack within 6 months
Reference:
 O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the
Management of ST-Elevation Myocardial Infarction: A Report of the American
College of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines.Circulation. 2013. 127:e362-e452.
 Writing Group Members, Mozaffarian D, Benjamin EJ, Go AS, et al, American Heart
Association Statistics Committee., et al. Heart Disease and Stroke Statistics-2016
Update: A Report From the American Heart Association. Circulation. 2016 Jan 26.
133 (4):e38-360.
 Jain S, Ting HT, Bell M, et al. Utility of left bundle branch block as a diagnostic
criterion for acute myocardial infarction. Am J Cardiol. April 2011. 107(8):1111-6.

13. Killip Classification
Purpose: A system used in individuals with an acute myocardial infarction to
predict and stratify their risk of mortality
Killip Clinical Signs Mortality

Class Rate
I No clinical signs of heart failure. 6%
II Rales or crackles in the lungs, an S3, and elevated jugular 17%
venous pressure.
III Frank acute pulmonary edema. 38%
IV Cardiogenic shock 81%
Reference:
Killip T, Kimball JT (Oct 1967). "Treatment of myocardial infarction in a coronary care
unit. A two year experience with 250 patients".Am J Cardiol.20(4): 457–
64.doi:10.1016/0002-9149(67)90023-9.PMID6059183

14. Leriche Fontaine Classification
Purpose: A method by which peripheral artery disease is clinically classified
Stages Symptoms Pathophysiology

Satge I Asymptomatic Relative Hypoxia
Stage II Effort pain / Pain free walking Relative Hypoxia
A distance >200 m
Stage II Pain free walking distance <200 Relative Hypoxia
B m
Stage III Rest pain Cutaneous hypoxia, tissue acidosis,
ischemic neuritis
Stage IV Trophic lesion, necrosis or Cutaneous hypoxia, tissue acidosis,
gangrene necrosis
Reference
Novo, S, Coppola, G, Milio, G. Critical limb ischemia: definition and natural history.
Curr Drug Targets Cardiovasc Haematol Disord. 2004;4:219-225.

15. San Francisco syncope rule
Purpose: High risk for a serious outcome following a syncopal event if any of the
following is present:
C History of Congestive heart failure
H Haematocrit <30%
E Abnormal ECG
S Shortness of breath
S Systolic Blood Pressure <90 mmHg
Reference
Quinn J, McDermott D, Stiell I, Kohn M, Wells G. Prospective validation of the San
Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med.
2006;47(5):448–454

16. Sgarbossa Criteria for acute MI in the presence of LBBB
Purpose: To diagnose Acute MI in patients with left bundle branch block (LBBB) or
ventricular paced rhythm on basis of ECG.
Three criteria used to diagnose Myocardial infarction in patients with LBBB are:
 Concordant ST elevation > 1mm in leads with a positive QRS complex (score 5)
 Concordant ST depression > 1 mm in V1-V3 (score 3)
 Excessively discordant ST elevation > 5 mm in leads with a negative QRS complex
(score 2).
Inference: These criteria are specific, but not sensitive for myocardial infarction. A total
score of ≥ 3 is reported to have a specificity of 90% for diagnosing myocardial infarction.
Modified Sgarbossa Criteria

Purpose: Modified Sgarbossa criteria have been created to improve diagnostic accuracy.
The important change is the modification of the rule for excessive discordance.
Modified criteria are:
 ≥ 1 lead with ≥1 mm of concordant ST elevation

 ≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
 ≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE,
as defined by ≥ 25% of the depth of the preceding S-wave.

Reference:
 Sgarbossa EB et al. Electrocardiographic diagnosis of evolving acute myocardial
infarction in the presence of left bundle-branch block. GUSTO-1. N Engl J Med 1996
Feb 22; 334(8) 481-7.
 Smith SW et al. Diagnosis of ST Elevation Myocardial Infarction in the Presence of
Left Bundle Branch Block using the ST Elevation to S-Wave Ratio in a Modified
Sgarbossa Rule. Annals of Emergency Medicine 2012;60:766-76.

17. Stanford & DeBakey Classification
Classification of aortic dissection
Percentage 60% 10–15% 25–30%

Type DeBakey I DeBakey II DeBakey III
Stanford A (Proximal) Stanford B
(Distal)
 Type I: involves ascending and descending aorta (= Stanford A)

 Type II: involves ascending aorta only (= Stanford A)
 Type III: involves descending aorta only, commencing after the origin of the left
subclavian artery (= Stanford B)
Reference:
Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part
I: from etiology to diagnostic strategies. Circulation 2003;108:628-35.

18. TIMI Score
Purpose: The Thrombolysis in Myocardial Infarction (TIMI) Score is used to
determine the likelihood of ischemic events or mortality in patients with unstable
angina or non–ST-segment elevation myocardial infarction (NSTEMI)
Criteria Score
Age ≥65 years 1
Three or more risk factors for coronary artery disease (CAD) (family history of
CAD, hypertension, hypercholesterolemia, diabetes mellitus, tobacco use)
1
Known CAD (stenosis >50%) 1
Aspirin use in the past 7 days 1
Severe angina (≥2 episodes in 24 hours) 1
ST deviation ≥0.5 mm 1
Elevated cardiac marker level 1
Score Risk of Death/MI/Urgent

Revascularization by Day 14
0-1 5%
2 8%
3 13%
4 20%
5 26%
6-7 41%
Reference:
Antman EM, Cohen M, et. al. The TIMI risk score for unstable angina/non-ST
elevation MI: A method for prognostication and therapeutic decision making. JAMA.
2000 Aug 16;284(7):835-42.

19. Vancouver chest pain rule for early discharge
Low risk of ACS if

 Completely normal ECG
 Negative Troponin
 No H/O ACS
 No use of nitrates
 Age<50
 No radiation of pain
 Palpation produces pain
Reference
Xavier Scheuermeyer F, Wong H, Yu E, Boychuk B, Innes G, Grafstein E, Gin K,
Christenson J. Development and validation of a prediction rule for early discharge of
low-risk emergency department patients with potential ischemic chest pain. CJEM.
2013;15(0):1-14.

20. WELL’s DVT
Purpose: Clinical probability for DVT
Predictor Score
Active Cancer 1
Paralysis, paresis, or recent plaster immobilisation 1
Recently bedridden (>3 days) or major surgery past 4 weeks 1
Localised tenderness along deep venous system 1
Entire limb swollen 1
Previously documented DVT 1
Pitting oedema - greater in the symptomatic leg 1
Dilated collateral superficial veins (non-varicose) 1
Calf swelling by more than 3cm compared to asymptomatic leg 1
Alternative diagnosis likely or more possible that DVT -2
Possible score -2 to 9
Score Risk Stratification

<2 D Dimer
If Negative – Low risk
>2 Doppler
Reference:
Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell
M, Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected
deep-vein thrombosis. N Engl J Med. 2003; 349:1227–1235. doi:
10.1056/NEJMoa023153.

21. Wellen Syndrome
This is a preinfarction stage of coronary artery disease, also referred to as LAD coronary T-
wave syndrome. The syndrome criteria include the following:
 History of angina + T wave inversion (Type1) or biphasic T waves (Type 2) in V2–V4

 Normal or minimally elevated cardiac enzymes
 No pathologic precordial q waves or loss of precordial R wave progression
There are two types: Type 1 (75% of cases) and Type 2 (25% of cases)
Wellens type ECG signifies a critical high grade proximal LAD stenosis.
Reference:
 De Zwaan C et al. Angiographic and Clinical Characteristics of Patients with Unstable

Angina Showing an ECG Pattern Indicating Critical Narrowing of the Proximal Coronary
Artery. Am Heart J 1989 Mar; 117 (3): 657–65.
 De Zwaan C et al. Characteristic Electrocardiographic Pattern Indicating a Critical
Stenosis High in Left Anterior Descending Coronary Artery in Patients Admitted
Because of Impending Myocardial Infarction. Am Heart J 1982 Apr 102(4): 730–6.

Section III. Central Nervous System
22. ABCD2 score for TIA
Purpose: The ABCD2 score is a risk assessment tool designed to improve the
prediction of short-term stroke risk after a transient ischemic attack (TIA). The
score is optimized to predict the risk of stroke within 2 days after a TIA, but also
predicts stroke risk within 90 days.
Risk Category Score

A Age of patient >/=60 1
<60 0
Blood pressure on SBP>140 DBP>/=90 1
B
assessment
Other 0
Clinical features presented Unilateral weakness 2
C
with
Speech disturbance 1
only
Other 0
D Duration of TIA >/=60 minutes 2
10-59 minutes 1
<10 minutes 0
D Diabetes mellitus 1
ABCD2 2 day Comment

Score Stroke Risk
0–3 1.0% Hospital observation may be unnecessary
without another indication (e.g., new atrial
fibrillation)
4–5 4.1% Hospital observation justified in most
situations
6–7 8.1 Hospital observation worthwhile
Reference :
Johnston SC, Rothwell PM, Huynh-Huynh MN, Giles MF, Elkins JS, Sidney S,
"Validation and refinement of scores to predict very early stroke risk after transient
ischemic attack," Lancet, 369:283-292, 2007.

23. GCS
Acronym expansion: Glasgow Coma Scale
Purpose: To assess level of conscious level after head injury
Elements of the scale Score

Eye Opening Spontaneously 4
To verbal command 3
To pain 2
No response 1
Not assessable (Trauma, edema etc) NA
Verbal Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1
Intubated T
Aphasia A
Motor Obeys commands 6
Localizes pain 5
Withdrawal from pain 4
Flexion to pain 3
Extension to pain 2
No motor response 1
Severity of Injury Score

Severe Head Injury 8 or less
Moderate Head Injury 9 – 12
Mild Head Injury 13 – 15
Reference:
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Lancet 1974; 81-
84.

24. HUNT & HESS Scale
Purpose: Used for categorizing severity of SAH
Grade 1: Asymptomatic or mild headache
Grade 2: Cranial nerve palsy or moderate to severe headache/nuchal rigidity
Grade 3: Mild focal deficit, lethargy, or confusion
Grade 4: Stupor and/or hemiparesis
Grade 5: Deep coma, decerebrate posturing, moribund appearance
Higher grades, which are reflective of progressively higher hemorrhage severity and
neurological dysfunction, are associated with higher overall mortality.
The scale does not apply to SAH due to trauma, arteriovenous malformations,
cavernous angiomas, dural arteriovenous fistulae, cortical or sinus venous
thromboses, mycotic aneurysms, or septic emboli with hemorrhagic transformation
Reference:
Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of
intracranial aneurysms.J Neurosurg. 1968 Jan. 28(1):14-20

25. ROSIER Score
Acronym Expansion: Recognition of stroke in the emergency room
Purpose: To differentiate stroke and "stroke mimics"
Has there been loss of consciousness or syncope Y (-1) N (0)

Has there been seizure activity Y (-1) N (0)
Is there a new onset (or waking from sleep)?

1. Asymmetric facial weakness Y N (0)
(+1)
2. Asymmetric arm weakness Y N (0)
(+1)
3. Asymmetric leg weakness Y N (0)
(+1)
4. Speech disturbance Y N (0)
(+1)
5. Visual field defect Y N (0)
(+1)
Interpretation
Stroke is likely if total score > 0
Scores of < / = 0 have low probability of stroke but not excluded
Reference:
Azlisham Mohd Nor,John Davis,Bas Sen, Dean Shipsey, Stephen J Louw, Alexander G
Dyker,Michelle Davis, Prof Gary A Ford,The Recognition of Stroke in the Emergency Room
(ROSIER) scale: development and validation of a stroke recognition instrument, The lancet
Neurology Volume 4, No. 11, p727–734, November 2005

26. Stroke Thrombolysis
Inclusions
Inclusion Criteria
Diagnosis of ischemic stroke causing measurable neurological deficit
Age greater than 18 years
Time of symptom onset to potential treatment 0-3 hours
Time of symptom onset to potential treatment 3-4.5 hours (additional exclusions
shaded)
Exclusions
1 Significant head trauma or prior stroke in previous 3 months
2 Symptoms suggest subarachnoid haemorrhage
History of arterial puncture at a non-compressible site within the previous 7
3 days
4 History of previous intra cranial haemorrhage
5 History of intracranial neoplasm, arteriovenous malformation or aneurysm
6 Recent intracranial or intraspinal surgery
7 Elevated blood pressure (systolic >185 mm Hg or diastolic >110mmHg)
8 Active internal bleeding
Acute bleeding diathesis, including, but not limiting to : a) Platelet count
<100000/mm b) Use of heparin in the previous 48 hours, resulting in
abnormally elevated aPTT greater than the upper limit of normal c) Current
use of anticoagulant with INR > 1.7 or PT >15tt d) Current use of direct
thrombin (eg., dabigatran) or factor Xa inhibitors (eg., rivaroxaban,
apixaban)with elevated sensitive laboratory tests (such as aPTT,INR, platelet
count, and ECT; TT; dabigatran level; or appropriate factor Xa activity
9 assays)
10 Blood glucose <50 mg/dl
CT demonstrates multilobar infarction (hypodensity >1/3 cerebral
11 hemisphere)

Relative Contraindications
Under some circumstances, patients may receive IV tPA despite one or more
1 relative contraindications. Consider risk to benefit ratio for IV tPA if these relative
contraindications are present:
2 Only minor or rapid improving stroke symptoms (clearing spontaneously)
3 Pregnancy
4 Seizure at onset with postictal residual neurological impairments
5 History of major surgery or serious trauma within the preceding 14 days
6 Recent gastrointestinal or urinary tract haemorrhage (within previous 21 days)
7 History of acute MI in previous 3 months
8 Aged >80 years
9 Severe stroke (NIHSS >25)
10 Taking an oral anticoagulant regardless of INR
11 History of both diabetic and prior ischemic stroke
Reference: AHA 2015 protocol

Section IV. Gastrointestinal System
27. Child Pugh

This score is modified from Child Turcotte Pugh score after removing nutritional status for
Prothrombin time.
Purpose: Assess the Severity and Prognosis of Chronic Liver Disease
Measure 1point 2points 3points
Total Bilirubin (mg/dl) <2 2-3 >3
Serum Albumin (g/dl) >3.5 2.8-3.5 <2.8
Prothrombin Time (sec) <4 4-6 >6
or INR <1.7 1.7-2.3 >2.3
Ascites None Mild( or suppressed with Moderate to Severe (or
Medication) Refractory)
Hepatic Encephalopathy None Grade I-II Grade III-IV
Grading and Prognosis:

Points Class One year Survival (%) Two year Survival (%)
5-6 A 100 85
7-9 B 81 57
10-15 C 45 35
Reference:
 Child CG, Turcotte JG (1964). "Surgery and portal hypertension". In Child CG. The
liver and portal hypertension. Philadelphia: Saunders. pp. 50–64.
 Jump up Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R (1973).
"Transection of the oesophagus for bleeding oesophageal varices". The British
journal of surgery. 60 (8): 646–9.

28. Glasgow Blatchford score
Criteria Score
Blood Urea Nitrogen
BUN 18.2 to 22.4 mg/dl (6.5 to 8 mmol/L) 2
BUN 22.4 to 28 mg/dl (8 to 10 mmol/L) 3
BUN 28 to 70 mg/dl (10 to 25 mmol/L) 4
BUN >70 mg/dl (>25 mmol/L) 6
Haemoglobin
Men
Haemoglobin 12 to 13 g/dl 1
Haemoglobin <10 g/dl 6
Women
Haemoglobin <10 g/dl 6
Systolic Blood Pressure (SBP)
SBP 100 to 109 mmHg: Score 1 1
SBP 90 to 99 mmHg: Score 2 2
SBP <90 mmHg: Score 3 3
Miscellaneous Markers
Pulse >100 per minute: 1 1
Presentation with Melena: 1 1
Presentation with Syncope: 2 2
Hepatic disease: 2 2
Cardiac failure: 2 2
Interpretation
Score Plan of management
0 Low risk for intervention, Outpatient
0–5 Inpatient
>5 High risk for intervention
.
Advantages over Rockall score:
1. Predicts the need for a hospital based intervention.
2. Lack of subjective variables (e.g. severity of systemic diseases) and
3. Lack of a need for OGD to complete the score.
However it is not as good as the Rockall score in predicting overall mortality
.
Reference:
Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for
upper gastrointestinal haemorrhage: Lancet. 2000 Oct 14;356(9238):1318-21

29. Grades of Hepatic Encephalopathy –West Haven Classification
Grade Clinical Feature

0 Minimal Covert HE, asterixis absent
1 Mild Trivial lack of awareness, disturbed sleep pattern, mild
confusion
2 Moderate Lethargy or apathy; disorientation; inappropriate
behavior; slurred speech; obvious asterixis
3 Severe Somnolent but can be aroused, marked confusion
4 Coma Coma with or without response to painful stimuli
Reference:
Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei A (2002). "Hepatic
encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the
working party at the 11th World Congresses of Gastroenterology, Vienna,
1998". Hepatology. 35 (3): 716–21. doi:10.1053/jhep.2002.31250. PMID 11870389

30. Indications for liver transplant
King's College criteria for liver transplantation in Acute Hepatic Failure.
Acetaminophen induced AHF
 Arterial pH < 7.3
OR
 Prothrombin Time > 100sec or INR > 6.5

 serum creatinine >3.4 mg/dl
 Grade III–IV encephalopathy
All other causes of AHF

 Prothrombin Time > 100sec or INR > 6.5
(OR) any three of the following variables:
 Age <10 or >40 years

 Cause is nonA, nonB hepatitis or idiosyncratic drug reaction
 Duration of jaundice before encephalopathy >7 days
 Prothrombin Time >50sec or INR > 3.5
 Serum bilirubin >17.5 mg/dl
Reference:
 O'Grady J, Alexander G, Hayllar K, Williams R (1989). "Early indicators of prognosis
in fulminant hepatic failure.". Gastroenterology. 97 (2): 439–45.
 Clark R, Borirakchanyavat V, Davidson A, Thompson R, Widdop B, Goulding R,
Williams R (1973). "Hepatic damage and death from overdose of
paracetamol.". Lancet. 1 (7794): 66–70.

31. Ranson’s criteria for Acute Pancreatitis
Purpose: To predict the severity of acute pancreatitis. Scoring available for

Non-Gallstone and gallstone pancreatitis
Non-Gallstone pancreatitis:
0 hours
Age >55
White blood cell count >16,000/mm3
Blood glucose >200mg/dl
Lactate dehydrogenase >350 U/L
Aspartate aminotransferase (AST) >250 U/L
48 hours
Hematocrit Fall by >10%
Blood urea nitrogen Increase by ≥5mg/dl
Serum calcium <8 mg/dl
pO2 <60 mmHg
Base deficit >4 Meq/L
Fluid sequestration >6000 ml
Gallstone Pancreatitis:
0 hours
Age >70
White blood cell count >18,000/mm3
Blood glucose >220mg/dl
Lactate dehydrogenase >400 U/L
Aspartate aminotransferase (AST) >250 U/L
48 hours
Hematocrit Fall by >10%
Blood urea nitrogen Increase by ≥2mg/dl
Serum calcium <8 mg/dl
pO2 <60 mmHg
Base deficit >5 mEq/L
Fluid sequestration >4000 ml
Score Mortality (%)

<3 0-3
3-6 11-15
>6 40

Reference: Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC (1974).
"Prognostic signs and the role of operative management in acute
pancreatitis". Surgery, Gynecology & Obstetrics. 139 (1): 69–81.

32. Rockall Score
Purpose: Helps in predicting outcomes of patients with acute upper
gastrointestinal bleeding
Variable Score 0 Score 1 Score 2 Score 3

Age <60 60 - 79 >80
Shock No Shock HR > SBP <100 mm Hg
100
bpm
Co morbidity Nil Major CHF, IHD Renal failure, liver
failure, metastatic
cancer
Diagnosis Mallory All other GI Malignancy
Weis
Evidence of None Blood, adherent
bleeding clot, spurting
vessel
Score Prognosis
<3 Good Prognosis
>8 Poor Prognosis
Reference
Kim BJ, Park MK, Kim SJ, Kim ER, Min BH, Son HJ, Rhee PL, Kim JJ, Rhee JC, Lee
JH. Comparison of scoring systems for the prediction of outcomes in patients
with nonvariceal upper gastrointestinal bleeding: a prospective study. Dig Dis
Sci 2009; 54: 2523-2529 [PMID: 19104934 DOI: 10.1007/ s10620-008-0654-7]

33. Truelove & Witt Severity index for Ulcerative Colitis
Criteria Mild Moderate Severe

Number of bowel Fewer than 4 4-6 6 or more plus at least
movements per day one of the features of
systemic upset (marked
with * below)
Blood in stools No more than Between Visible blood
small amounts mild &
of blood Severe
Pyrexia No No Yes
(temperature
greater than 37.8°C)*
Pulse rate greater No No Yes
than 90 bpm*
Anaemia* No No Yes
Erythrocyte 30 or below 30 or below Above 30
sedimentation rate
(mm/hour) *
Reference:
Truelove S C, Witts L. Cortisone in ulcerative colitis: final report on a therapeutic
trial. BMJ. 1955;2:1041–1048

Section V. Infectious Diseases
34. Centor Criteria modified for streptococcal pharyngitis
Purpose: Likelihood of a sore throat being due to bacterial infection

Criteria Score
Tonsillar exudates 1
Tender anterior cervical adenopathy 1
Fever over 38°C (100.5°F) by history 1
Absence of cough. 1
Age range
Group A streptococcus (GAS) rare under 3
3-14 years +1
15-44 years 0
>45 years -1
If 3 or 4 of Centor criteria are met, the positive predictive value is 40% to 60%. The
absence of 3 or 4 of the Centor criteria has a fairly high negative predictive value of 80%.
Reference:
Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K The diagnosis of strep throat in
adults in the emergency room Med Decis Making. 1981;1(3):239-46.

35. Components of current “care bundles” (e.g. The Surviving Sepsis
Campaign 6 hour bundle)
Purpose: Resuscitative bundle to be done within 1 hour of recognising sepsis
Can reduce mortality by 50% if all 6 are done
1. High Flow O2 – Improve O2 delivery, reduce Anaerobic Metabolism
2. IV bolus (30 ml/kg) – “Fill the tank” before pressing the accelerator, ie,
Improve Preload
3. Blood Cultures/Source Cultures – Can adjust ABX according to strain
4. Broad Spectrum Antibiotics – Full loading dose even in suspected AKI
5. Lactates (Venous Blood Gas) and FBC – Can assess the degree of
septicaemia and degree of Anaerobic Metabolism (Lactate >= 4 is SEPTIC
SHOCK!!)
6. Catheterise and check hourly urine output monitoring – Watch out
for evolving AKI, colour of urine
References
 “Sepsis-Induced Acute Kidney Injury” - Indian J Crit Care Med. 2010 Jan-Mar; 14(1):
14–21. doi: 10.4103/0972-5229.63031
 “Factsheet: Implementation of the ‘Sepsis Six’ care bundle”-
http://www.england.nhs.uk/wp content/uploads/2014/02/rm-fs-10-1.pdf

Components of current “care bundles” (e.g. The Surviving Sepsis Campaign 6 hour
bundle)
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION*:
1. Measure lactate level

2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
* “Time of presentation” is defined as the time of triage in the emergency department or, if
presenting from another care venue, from the earliest chart annotation consistent with all
elements of severe sepsis or septic shock ascertained through chart review.
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation)
to maintain a mean arterial pressure (MAP) ≥65mmHg
6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm
Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and
document findings according to Table 1.
7. Re-measure lactate if initial lactate elevated.
DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH:

EITHER
• Repeat focused exam (after initial fluid resuscitation) by licensed independent
practitioner including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.
OR TWO OF THE FOLLOWING:

• Measure CVP
• Measure ScvO2
• Bedside cardiovascular ultrasound
• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
References:
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International
guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;
41:580–637

36. Duke’s Criteria – IE
Purpose: Diagnostic criteria for Infective Endocarditis.
Major Criteria:
 Positive blood culture for typical Infective Endocarditis organisms (strep viridins or
bovis, HACEK, Staph.aureus without other primary site, enterococcus), from 2
separate blood cultures or 2 positive cultures from samples drawn > 12 hours apart,
or 3 or a majority of 4 separate cultures of blood (first and last sample drawn 1 hour
apart)
 Echocardiogram with oscillating intracardiac mass on valve or supporting structures,
in the path of regurgitant jets, or on implanted material in the absence of an
alternative anatomic explanation, or abscess, or new partial dehiscence of prosthetic
valve or new valvular regurgitation
Minor Criteria:
 Predisposing heart condition or intravenous drug use
 Temp > 38.0° C (100.4° F)
 Vascular phenomena: arterial emboli, pulmonary infarcts, mycotic aneurysms,
intracranial bleed, conjunctival hemorrhages, Janeway lesions
 Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid
factor
 Microbiological evidence: positive blood culture but does not meet a major criterion
as noted above or serological evidence of active infection with organism consistent
with endocarditis (excluding coag neg staph, and other common contaminants)
 Microbiological evidence: positive blood culture but does not meet a major criterion
as noted above or serological evidence of active infection with organism consistent
with endocarditis (excluding coag neg staph, and other common contaminants)
Diagnostic Criteria:
 2 Major Criteria and 0 Minor Criteria
Reference:
 Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis:
utilization of specific echocardiographic findings. Duke Endocarditis
Service. American Journal of Medicine. 96(3):200-9, 1994.
 Lukes AS, Bright DK, Durack DT. Diagnosis of infective endocarditis. Infect Dis Clin
North Am. 1993 Mar;7(1):1-8. Review.

37. Early Goal Directed Therapy (EGDT)
Purpose: EGDT targeted at the use of a combination of physiologic endpoints to guide fluid
management in patients with sepsis and septic shock.
EGDT combine the targets (ScvO2, CVP, MAP, urine output and lactate) for fluid
management with early administration of antibiotics, both within the first six hours of
presentation.
Reference:
 Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of
severe sepsis and septic shock. N Engl J Med 2001; 345:1368.
 Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation
for septic shock. N Engl J Med 2015; 372:1301.

38. Indications/Contraindications for Lumbar Puncture
Indications:
Urgent indications for LP
 Suspected CNS infection (with the exception of brain abscess).
 Suspected subarachnoid hemorrhage (SAH) in a patient with a negative CT scan
Nonurgent indications for LP

 Idiopathic intracranial hypertension (pseudotumor cerebri)
 Carcinomatous meningitis
 Tuberculous meningitis
 Normal pressure hydrocephalus
 CNS syphilis
 CNS vasculitis
 Multiple sclerosis
 Guillain-Barré syndrome
 Paraneoplastic syndromes
Indications of LP for therapeutic manoeuvre

 Spinal anesthesia
 Intrathecal administration of chemotherapy
 Intrathecal administration of antibiotics
 Injection of contrast media for myelography or for cisternography
Contraindications:
Contraindications for lumbar puncture
 Conditions causing unequal pressures between the supratentorial and
infratentorial compartments including CNS lesions.
 Possible raised intracranial pressure.
 Thrombocytopenia or other bleeding diathesis (including ongoing anticoagulant
therapy)
 Suspected spinal epidural abscess.
 Skin infection near the site of the lumbar puncture.
Reference:
 Gorelick PB, Biller J. Lumbar puncture. Technique, indications, and complications.

Postgrad Med 1986; 79:257.

 The diagnostic spinal tap. Health and Public Policy Committee, American College of
Physicians. Ann Intern Med 1986; 104:880.
 Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th.
Philadelphia, PA: Saunders; 2004.
39. Light’s Criteria – Pleural Effusion

Determination of transudate versus exudate source of pleural effusion
Fluid is exudate if one of the following Light’s criteria is present
 Effusion protein/serum protein ratio greater than 0.5
 Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6
 Effusion LDH level greater than two-thirds the upper limit of the laboratory's
reference range of serum LDH
References:
Light RW. Clinical practice. Pleural effusion. N Engl J Med. 2002 Jun 20. 346(25):1971-7

40. Lung Protective Ventilation (in Septic shock)
 Use a target tidal volume of 6 mL/kg predicted body weight
 Use an upper limit goal for plateau pressures of 30 cm H2O over higher plateau
pressures
 Use higher positive end-expiratory pressure (PEEP) over lower PEEP 4.use
recruitment maneuvers in adult patients with sepsis-induced, severe ARDS
 Use prone over supine position in adult patients with sepsis-induced ARDS and a
PaO2/FIO2 ratio <150
 Use neuromuscular blocking agents for 48 hours in adult patients with sepsis-
induced ARDS and a PaO2/FIO2 ratio < 150 mm Hg
 A conservative fluid strategy for patients with established sepsis-induced ARDS

who do not have evidence of tissue hypoperfusion
 Against the use of ß-2 agonists for the treatment of patients with sepsis-induced
ARDS without bronchospasm
 Against the routine use of the pulmonary artery catheter for patients with sepsis-
induced ARDS
 Use lower tidal volumes over higher tidal volumes in adult patients with sepsis-
induced respiratory failure without ARDS
 Mechanically ventilated sepsis patients be maintained with the head of the bed
elevated between 30 and 45 degrees to limit aspiration risk and to prevent the
development of ventilator-associated pneumonia
References:
guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med
2013; 41:580–637

41. SIRS
SIRS is defined as 2 or more of the following variables
 Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)

 Heart rate of more than 90 beats per minute
 Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide
tension (PaCO 2) of less than 32 mm Hg
 Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature
[band] forms)
SIRS is nonspecific and can be caused by ischemia, inflammation, trauma, infection, or

several insults combined. Thus, SIRS is not always related to infection.
References:
guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;
41:580–637

42. SOFA score
The Sequential Organ Failure Assessment (SOFA) score is used to track a person's
status during the stay in an ICU to determine the extent of a person's organ function
or rate of failure.
Both the mean and highest SOFA scores are predictors of outcome. An increase in
SOFA score during the first 24 to 48 hours in the ICU predicts a mortality rate of at
least 50% up to 95%. Scores less than 9 give predictive mortality at 33% while above
11 can be close to or above 95%.
QSOFA
A simplified version of the SOFA Score as an initial way to identify patients at high
risk for poor outcome with an infection. The presence of 2 or more qSOFA points
near the onset of infection was associated with a greater risk of death or prolonged
intensive care unit stay.
References:
 Jones, Alan E., Stephen Trzeciak, and Jeffrey A. Kline. “The Sequential Organ
Failure Assessment Score for Predicting Outcome in Patients with Severe
Sepsis and Evidence of Hypoperfusion at the Time of Emergency Department
Presentation.” Critical care medicine 37.5 (2009): 1649–1654. PMC. Web. 30
Jan. 2017.

Section VI. Joints
43. Garden classification Hip #

Purpose – Intra-capsular hip fracture of femur neck causes disruption of blood supply
to the head. This classification indirectly grades the viability of the head. Grade 3 and 4
have higher risk of avascular necrosis.
Grade Criteria
Incomplete stable fracture with impaction in valgus.
1
Complete fracture but not displaced with two groups of
trabeculae in-line.
2
Completely displaced fracture with varus with all three
trabeculae
disturbed.
3
Completely displaced fracture with no contact between the
fracture fragments.
4
References - BMJ, Vol. 285, 11 Dec. 1982 Page 1751

44. Kanavel’s Sign
Purpose: For diagnosing Flexor tenosynovitis
 The affected finger is held in slight flexion as there is intense pain on attempt to
extend partly flexed finger .
 Uniform, fusiform swelling involving entire finger (Sausage digit)
 Percussion tenderness along the course of the tendon sheath .
 There is pain on passive extension of the affected finger.
Reference:
Kanavel M. Infections of the hand. Philidelphia: Lea and Febigel, 1912

45. Kocher’s clinical prediction
Purpose: A tool useful in the differentiation of septic arthritis from transient

synovitis in the child with a painful hip.
Criteria Score
Non-weight-bearing on affected side 1
Erythrocyte sedimentation rate > 40 mm/hr 1
Fever > 38.5 °C/101.3 F 1
White blood cell count > 12,000 cells/mm3 1
Score Likelihood of septic arthritis

1 3%
2 40 %
3 93 %
4 99 %
Reference:
Kocher MS, Zurakowski D, Kasser JR (1999). "Differentiating between septic
arthritis and transient synovitis of the hip in children: an evidence-based clinical
prediction algorithm.". J Bone Joint Surg Am. 81 (12): 1662–70

46. Ottawa Ankle Rule
The Ottawa ankle rules were developed, tested, and validated in adult patients
presenting to the emergency department with acute ankle injuries.
The Ottawa ankle rules are as follows:
An ankle series is only indicated for patients who have pain in the malleolar zone
AND
●Have bone tenderness at the posterior edge or tip of the lateral or medial malleolus
OR
●Are unable to bear weight both immediately after the injury and for four steps in
the emergency department or doctor's office.
A foot series is only indicated for patients who have pain in the midfoot zone AND
●Have bone tenderness at the base of the fifth metatarsal or at the navicular
OR
●Are unable to bear weight both immediately after the injury and for four steps in
the emergency department or doctor's office.
The following apply to the use of the Ottawa ankle rules:
●If the patient can transfer weight twice to each foot (four steps), he or she is
considered able to bear weight even if he or she limps.
●Palpate the distal 6 cm of the posterior edge of the fibula when assessing for bone
tenderness.

Reference:
Modified from Stiell, IG, McKnight, RD, Greenberg, GH, et al, JAMA 1994; 271:827.

47. Ottawa Knee Rule
The Ottawa Knee Rules are a set of rules used to help physicians determine whether an x-
ray of the knee is needed.
They state that an x-ray is required only in patients who have an acute knee injury with
one or more of the following:
 Age 55 years or older

 Tenderness at head of fibula
 Isolated tenderness of patella
 Inability to flex the knee greater than 90°
 Inability to bear weight both immediately and in the emergency department (4
steps)
Illustration in Diagram:
Reference:
Stiell IG, Greenberg GH, Wells GA, et al. Prospective validation of a decision rule for the use
of radiography in acute knee injuries. JAMA 1996; 275:611–5.

48. Red Flags – Back pain
Purpose - The “Red Flags” are a criteria to suspect organic cause of low backache
and patients must undergo detailed evaluation before disposition.
No. Red Flags Possible Cause

1 Duration >6 weeks Tumour, infection, Rheumatologic disorder.
2 Age <18 years Congenital defect, tumour, infection,
spondylolisthesis
3 Age >50 years Tumour, intra-abdominal processes (such as
abdominal aortic aneurysm) infection.
4 Major trauma in young/minor Fracture
trauma in elderly
5 Cancer Metastasis.
6 Fever, chills, night sweats Infection
7 Weight loss Tumour, Infection.
8 Injection drug use Infection
9 Immunocompromised status Infection
10 Recent Infection
genitourinary/gastrointestinal
procedure
11 Night Pain Tumour, infection
12 Unremitting pain, even when Tumour, Infection, AAA, Nephrolithiasis.
supine
13 Pain worsened while coughing, Herniated disc
sitting or Valsalva Manoeuvre
14 Pain radiating to below knee Herniated disc or nerve root compression
15 Incontinence Cauda equina syndrome, spinal cord
compression.
16 Saddle anaesthesia Cauda equina syndrome, spinal cord
compression.
17 Severe or rapidly progressive Cauda equina syndrome, spinal cord
neurologic deficit compression.
Reference - Consultant360.com/article/acuteclowcbackcpain-volume53, issue6,

June 2013, Page 436-440.

49. Salter Harris Classification
Purpose - To classify epiphyseal plate fractures of long bones in children

(Constituting 15% of childhood long bone fractures). Types IV to VI are indication
for closed reduction.
Type Description Mnemonic

Type Transverse fracture through the growth plate S = SLIP (Separated or
I (physis) straight across
Type Fracture through physis and epiphysis, sparing A= Above (fracture lies above
II the metaphysis the physis
Type Fracture through physis and epiphysis, sparing L = Lower (fracture lies
III the metaphysis, but fracture line goes away below the physis, in the
from the epiphysis epiphysis)
Type Fracture through physis, epiphysis and TE = Through Everything
IV metaphysis
Type Compression fracture of the physis resulting in R = Rammed (Crush or
V decrease in space between epiphysis and compression)
metaphysis
Type Injury to peripheral portion of physis resulting
VI in angular deformity
Reference - Salter RB, Harris WR (1963), "Injuries involving epiphyseal plate" , J

Bone Joint Surg Am. 45(3): 587-622

50. Young & Burgess Classification of Pelvic Fractures
Purpose - It is a classification used in categorizing pelvic fracture based on fracture
pattern. Thus, allowing judgement on the stability of the pelvic ring and hence the
management.
Type Antero-Posterior Compression Lateral Compression Vertical Shear

LC I - Pubic Ramus Fracture
and Ipsilateral Anterior
APC I - Symphysis widening < 2.5 cms.
I Sacral ala compression
fracture
VS-Posterior
and Superior
APC II - Symphysis widening > 2.5 LC II - Rami Fracture and directed force
II
cms. Anterior SI joint diastasis. Ipsilateral Posterior Ilium
Disruption of sacrospinous and fracture dislocation
sacrotuberous ligament.
LC III - Ipsilateral
APC III - SI dislocation with
III Compression and
associated vascular injury
Contralateral APC.
References - Burgess AR, Eastrige BJ, Ellison TS, Ellison PS Jr., Poka A, Bathon GH,
Brumback RJ (1990)."Pelvic Ring Disruption: Effective Classification System and
Treatment Protocols’ Trauma. 30(7):848-56

Section VII. OBSTETRICS AND GYNAECOLOGY
51. Amsell’s Criteria

Purpose: Diagnostic criteria for bacterial vaginosis
 Homogeneous discharge
 Clue cells on microscopy
 pH of vaginal fluid >4.5
 Release of a fishy odour on adding alkali—10% potassium
hydroxide (KOH) solution. (Whiff Test)
Three of the four criteria should be present for a confirmatory diagnosis
Reference:
Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK (1983).
"Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic
associations". Am. J. Med. 74 (1): 14–22.

52. Anti D Ig indications
Purpose: Rh(D) immune globulin is a medication used to prevent Rh isoimmunization in
mothers who are Rh negative and to treat idiopathic thrombocytopenic purpura (ITP) in
people who are Rh positive.
Sr. No. Indications
1 D-negative pregnant mother, where father is D-positive (Where there is a 50%-100%

chance that the fetus will be D-positive) – As prophylaxis
2 D-negative mother who is not alloimmunized, after delivery of a D-positive infant
3 Rosette and Kleihauer-Betke test positive, post delivery
4 Non- splenectomized, Rh(D)-positive children with chronic or acute ITP, adults with
chronic ITP, and children and adults with ITP secondary to HIV infection
Reference:
 "Rho(D) Immune Globulin". The American Society of Health-System

Pharmacists. Retrieved 8 January 2017.
 Hatfield, Nancy T. (2007). Broadribb's Introductory Pediatric Nursing.
Lippincott Williams & Wilkins. p. 251. ISBN 9780781777063.
 "WHO Model List of Essential Medicines (19th List)" (PDF). World Health
Organization. April 2015. Retrieved 8 December 2016.
 British national formulary : BNF 69 (69 ed.). British Medical Association.
2015. p. 871. ISBN 9780857111562.
 Hamilton, Richart (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe
Lab-Coat Edition. Jones & Bartlett Learning. p. 368. ISBN 9781284057560.
 "Pregnancy - routine anti-D prophylaxis for RhD-negative women". National
Institute for Health and Clinical Excellence. May 2002

53. Emergency Contraception – Options, Advantages and Disadvantages
Method of
Levo-Norgestrel (1.5 mg) Copper IUCD
Contraception
 Single dose  More effective
 Can be taken within compared to
72 hrs Levonorgestrel
 Easily available over-  Effective upto 5
Advantages the-counter days
 No limit to number of  Provides long term
times it can be taken contraception
 Unaffected by any
other medications
 High failure rate if taken >  Less readily available
72 hrs  Requires a trained
 Does not provide long term person to insert
contraception  Insertion may cause
 Repeat dose required if abdominal pain
vomiting within 2 hours  May result in
 Double dose required in Polymennorhea
women taking enzyme  Higher chance of ectopic
Disadvantages inducers pregnancy, if fertilisation
 Side effects – Spotting, occurs
menstrual variations  Rarely, unnoticed
 Contraindications – Liver spontaneous expulsion
disease, porphyria, may occur
migraine, pregnancy,  Risk of Uterine
malabsorption syndromes Perforation while
inserting (Rare)
 Risk of PID

54. Gillick Competency & Fraser Guidelines
Gillick Competency - Used to identify patients less than 16 years of age (ie –
“Children” as per the British Judicial System), capable of giving consent to any
treatment.
- Coined in the House of Lords in Gillick v West Norfolk and Wisbech AHA [1986]
where a mother of girls under 16 objected to doctors giving contraceptive advice
and treatment to children without parental consent.
- It states that a child under 16 had the legal competence to consent to medical
examination and treatment provided they had sufficient maturity and intelligence
to understand its nature and implications, including risks and alternative options.
- Where a Gillick competent child refuses consent to a necessary treatment, then

consent may be obtained from a person with parental responsibility instead.
Fraser Criteria – Gives the criteria to be met to allow children to give consent, ie, assesses
Gillick Competence, specifically for
i. Emergency Contraception (Original indication)
ii. Treatment of STDs
Since 2006
iii. Termination of Pregnancy
1. Has sufficient maturity and intelligence to understand the nature and implications
of the proposed treatment.
2. Cannot be persuaded to tell her parents or to allow the doctor to tell them.
3. Very likely to begin or continue having sexual intercourse with or without
contraceptive treatment.
4. Physical or mental health is likely to suffer unless he/she received the advice or
treatment.
5. The advice or treatment is in the young person’s best interests.

Section VIII. Paediatrics
55. APLS criteria for dehydration
Clinical signs of dehydration give only an approximation of the deficit.
Patients with mild (<4%) dehydration have no clinical signs. They may have increased
thirst.
Moderate dehydration(4-6%)
 Delayed CRT
(Central Capillary Refill Time) > 2 secs
 Increased respiratory rate
 Mild decreased tissue turgor
Severe dehydration (>/= 7%)

 Very delayed CRT > 3 secs, mottled skin
 Other signs of shock (tachycardia, irritable or reduced conscious level, hypotension)
 Deep, acidotic breathing
 Decreased tissue turgor
ASSESSMENT OF DEHYDRATION AND FLUID CALCULATION
Give 20 ml/kg of Normal saline (0.9%) upto 3 boluses for Shocked child.
Degree of dehydration (deficit) plus Maintenance fluid requirements plus Ongoing losses
DEFICIT:
Weight loss provides the most reliable way of assessing fluid depletion but requires
accurate pre-illness weight
Calculation based on weight loss and degree of dehydration
5% dehydration = 5g/100g of bdwt= 50ml/kg
10% dehydration = 10g/100g of bdwt =100 ml/kg loss

Maintenance Fluid Calculation:
(100 ml for each of the first 10kg) + (50ml for each kg 11-20) + (20 ml for each additional
kg) / 24hour
Ongoing Fluid losses:
• Insensible fluid loss: 10-30 ml/kg/day

• Losses from stool: 0-10 ml/kg/day
• Losses from urine: 1-2 ml/kg/day
This is often judged by the response of the child to maintenance and replacement fluids.
Reference:
NICE clinical guideline 84. Diarrhoea and vomiting caused by gastroenteritis in under 5s:
diagnosis and management (April 2009). www.nice.org.uk/CG84

56. D/D limping child
VINDICATE (Mnemonic)
Vascular - Legg-Calve-Perthes
Infection - Septic arthritis, psoas abscess, diskitis, osteomyelitis
Neoplasm - tumor, lymphoma, leukemia
Benign Neoplasm – Osteoblastoma, Osteoid osteoma
Malignant – Ewing sarcoma, Osteosarcoma
Developmental or Neuromuscular disorders - Cerebral palsy, Meningitis
Inflammatory - Transient synovitis, RA, SLE
Congenital - DDH
Autoimmune
Trauma - Child abuse, Toddler’s fracture
Endocrine / Metabolic
Reference:
 Matava MJ, Patton CM, Luhmann S, Gordon JE, Schoenecker PL. Knee pain as the
initial symptom of slipped capital femoral epiphysis: an analysis of initial
presentation and treatment. J Pediatr Orthop. 1999;19(4):455–460.
 Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG, Dormans JP. Factors
distinguishing septic arthritis from transient synovitis of the hip in children. A
prospective study. J Bone Joint Surg Am. 2006; 88(6):1251–1257.
 Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an
18-year review. Pediatrics. 2000; 105(6):1299–1304.

57. Kawasaki NICE diagnostic criteria
Fever Duration of 5 days or more
PLUS 4 of 5 of the following:
1. Conjunctivitis - Bilateral, bulbar, non-suppurative
2. Lymphadenopathy Cervical, often >1.5 cm
3. Rash Polymorphous, no vesicles or crusts
4. Changes in lips or oral mucosa Red cracked lips; ‘strawberry’ tongue; or diffuse
erythema of oropharynx
5. Changes of extremities Initial stage: erythema and oedema of palms and soles
Convalescent stage: peeling of skin from fingertips
Reference:
Diagnostic guidelines for Kawasaki disease. 5th edn. Japan Kawasaki Disease
Research Committee Tokyo, 2002.

58. Length of ET tube
Length:
ORAL ETT: (Age/2) + 12
NASAL ETT: (Age/2) + 15
Diameter: (Age/4) + 4

59. NICE atypical UTI for admission
 Seriously ill
 Poor urine flow
 Abdominal & Bladder mass
 Raised creatinine
 Septicaemia
 Failure to respond to treatment with suitable antibiotics within 48 hrs
 Infection with an atypical organisms ( non E-coli)
Reference:
NICE clinical guideline 54. Urinary tract infections in children ( August 2007).
www.nice.org.uk/CG54

Traffic light system for identifying risk of serious illness*
Green – low Amber – intermediate risk Red – high risk
risk
Colour Normal colour Pallor reported by Pale/mottled/ashen/
(of skin, parent/carer blue
lips or
tongue)
Activity Responds Not responding normally to No response to
normally to social cues social cues
social cues No smile Appears ill to a
Content/smiles Wakes only with prolonged healthcare
Stays awake stimulation professional
or awakens Decreased activity Does not wake or if
quickly roused does not
Strong normal stay awake
cry/not crying Weak, high-pitched
or continuous cry
Respiratory Nasal flaring Grunting
Tachypnoea: Tachypnoea:
- RR >50 breaths/ RR >60
minute, age 6–12 months breaths/minute
- RR >40 breaths/ Moderate or severe
minute, age >12 months chest indrawing
Oxygen saturation ≤95% in air
Crackles in the chest
Circulation Normal skin Tachycardia: Reduced skin
and and eyes - >160 beats/minute, turgor
hydration Moist mucous age <12 months
membranes - >150 beats/minute,
age 12–24 months
- >140 beats/minute,
age 2–5 years
CRT ≥3 seconds
Dry mucous membranes
Poor feeding in infants
Reduced urine output
Other None of the Age 3–6 months, Age <3 months,

amber or red temperature ≥39°C temperature ≥38°C
symptoms or Fever for ≥5 days Non-blanching rash
signs Rigors Bulging fontanelle
Swelling of a limb or joint Neck stiffness
Non-weight bearing limb/not Status epilepticus
using an extremity Focal neurological
signs
Focal seizures
CRT, capillary refill time; RR, respiratory rate

* This traffic light table should be used in conjunction with the recommendations in
the guideline on investigations and initial management in children with fever. See
http://guidance.nice.org.uk/CG160 (update of NICE clinical guideline 47).
‘Feverish illness in children’, NICE clinical guideline 160 (May 2013)

© National Institute for Health and Care Excellence 2013. All rights reserved
61. Weight of child
1-12 months = (0.5 * age months) + 4
1-5 years = (2* age years) + 8
6-12 years = (3 * age years) + 7

62. Westley Croup Score
Level of
Score Stridor Retractions Air Entry Cyanosis consciousness
0 None None Normal None Normal
Upon Mild
1 agitation Mild decrease
Marked
2 At rest Moderate decrease
3 Severe
Upon
4 agitation
5 At rest Decreased
Score Severity Description Management

Home treatment: Symptomatic care
including antipyretics, mist, and
Occasional barky cough, oral fluids
0 to 2 Mild no stridor at rest, mild or
no retractions Outpatient treatment: Single dose of
oral dexamethasone 0.6 mg/kg
(maximum 10 mg)*
Single dose of oral dexamethasone
0.6 mg/kg (maximum 10 mg)*
Frequent barky cough,
Nebulized epinephrine**
stridor at rest, and mild-
3 to 7 Moderate to-moderate retractions,
Hospitalization is generally not
but no or little distress or
needed, but may be warranted for
agitation
persistent or worsening symptoms
after treatment with glucocorticoid
and nebulized epinephrine
Single dose of oral/IM/IV
Frequent barky cough,
8 to 11 Severe dexamethasone 0.6 mg/kg
stridor at rest, marked
(maximum 10 mg)*

retractions, significant
distress and agitation Repeated doses of nebulized
epinephrine** may be needed
Inpatient admission is generally

required unless marked
improvement occurs after
treatment with glucocorticoid and
nebulized epinephrine
Single dose of IM/IV
dexamethasone 0.6 mg/kg
(maximum 10 mg)*
Repeated doses of nebulized

Depressed level of
epinephrine** may be needed
Impending consciousness, stridor at
12 to 17 respiratory rest, severe retractions,
Intensive care unit admission is
failure poor air entry, cyanosis
generally required
or pallor
Consultation with anesthesiologist
or ENT surgeon may be warranted
to arrange for intubation in a
controlled setting
Notes
 IV: intravenous; IM: intramuscular; ENT: ear, nose, throat.
 *Theintravenous preparation of dexamethasone (4 mg per mL) can be given orally;

mix with flavored syrup.
 **Nebulized epinephrine has an onset of effect within 10 minutes. Nebulized

racemic epinephrine is administered as 0.05 mL/kg per dose (maximum of 0.5 mL)
of a 2.25% solution diluted to 3 mL total volume with normal saline. Racemic
epinephrine is commercially available in the United States and some other
countries as a nebulizer preparation (ie, single-use preservative-free bullets
[ampules]). Nebulized L-epinephrine is administered as 0.5 mL/kg per dose
(maximum of 5 mL) of a 1 mg/mL (1:1000) preservative-free solution. L-
epinephrine is the same type of epinephrine used in other medical indications (eg,
IM injection for anaphylaxis) and is widely available as a parenteral preparation.
Use of either product by nebulization is acceptable and may be determined by
availability and institutional protocol.
References
Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the
treatment of croup: a double-blind study. Am J Dis Child. 1978 May;132(5):484-7

Section IX. Psychiatry
63. CAGE questionnaire

Acronym expansion: Concern/Cut-down, Anger, Guilt, and Eye-opener
Purpose: An internationally used assessment questionnaire for identifying alcoholics

and potential problem with alcohol abuse
 Have you ever felt you should Cut down on your drinking?
 Have people Annoyed you by criticizing your drinking?
 Have you ever felt bad or Guilty about your drinking?
 Have you ever had a drink first thing in the morning to steady your nerves or to
get rid of a hangover (Eye opener)?
‘Yes’ to 2 or more questions is considered significant.
Reference:
Ewing, John A. “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907,
1984 PMID 6471323

64. Mental capacity
Purpose: Abbreviated Mental Test Score – Helps is rapidly assess elderly patients
for possibility of dementia, confusion or cognitive impairment.
A score of below 8 suggests cognitive impairment at the time of assessment and
warrants further investigation to ascertain the cause.
No. Question Score
1 What is your age? 1
2 What is the time? (to nearest hour) 1
3 Give the patient an address and ask him to repeat it. 1

e.g. 36, Gandhi Road, Delhi
4 What is the year? 1
5 What is the name of the doctor you are seeing today? 1
6 Can the patient recognize 2 known persons? (e.g. relative/attender) 1
7 What is your date of birth? (Day and month is important) 1
8 Is he able to remember the year of a significant event? 1

(When did India get its independence?)
9 Is he able to name a significant public figure? 1

(Prime minister / President)
10 Count backwards from 10 to 1 1
Reference:
Hodkinson, HM (1972). "Evaluation of a mental test score for assessment of mental
impairment in the elderly.". Age and Ageing. 1 (4): 233–8

65. Modified SAD Persons
Purpose: Clinical assessment tool for suicide risk
Acronym Criteria Score

S Sex Male 1
Female 0
A Age <20 or >44 1
D Depression 1
P Previous attempt 1
E Ethanol abuse 1
R Rational thinking loss 1
S Social Supports Lacking 1
O Organized Plan: if plan is made and is 1
lethal
N No Spouse: if divorced, widowed, 1
separated, or single
S Sickness: if chronic, debilitating, and 1
severe
Guidelines for action with the SAD PERSONS scale
Score Plan of action

0 to 2 Send home with follow-up
3 to 4 Close follow-up; consider hospitalization
5 to 6 Strongly consider hospitalization, depending on
confidence in the follow-up arrangement
7 to Hospitalize
10
Reference:
Patterson, WM; Dohn, HH; Patterson, J; Patterson, GA (April 1983). "Evaluation of
suicidal patients: the SAD PERSONS scale." Psychosomatics 24 (4): 343–5, 348–
9. doi:10.1016/S0033-3182(83)73213-5. PMID 6867245

Section X. Respiratory System
66. CURB 65
Criteria Score
Confusion of recent onse 1
Urea > 7 mmol/l 1
Respiratory rate =/> 30 per minute 1
Low systolic blood pressure (< 90mmHg) or low diastolic blood pressure =/< 1
60mmHg)
Age 65 or over 1
CURB-65 score Risk of mortality Recommendation

1 Low risk 0.7 – 3.2 % Consider home treatment
2 13% Short inpatient hospitalization or
closely supervised outpatient
treatment
3 17% Severe pneumonia; hospitalize and
consider admitting to intensive care
4 or 5 41.5 – 57 % Severe pneumonia; hospitalize and
consider admitting to intensive care
Reference:
British Thoracic Society Pneumonia Guidelines Committee. BTS guidelines for the
management of community-acquired pneumonia in adults - 2004 update. Available at
http://www.brit-thoracic.org.uk/c2/uploads/MACAPrevisedApr04.pdf. Accessed March
20, 2006.

67. Geneva PE score
Clinical prediction rule used in determining the pre-test probability
of pulmonary embolism (PE)
Variability Score
Age 60 – 79 years 1
>79 years 2
Previous PE / DVT 2
Recent surgery within 4 weeks 3
Heart Rate >100 beats per minute 1
PaCO2 <35 mmHg 1
Pa CO2 35-39mmHg 2
PaO2 <49mmHg 4
Pa O2 49 – 59 mm Hg 3
Pa O2 60 – 71 mm Hg 2
Pa O2 72 – 82 mm Hg 1
Band atelectasis on CXR 1
Elevation of hemidiaphragm 1
Score Probability of PE
<5 Low
5–8 Moderate
>8 High
Reference:
Klok FA, Mos IC, Nijkeuter M et al. (Oct. 2008). Simplification of the revised Geneva score
for assessing clinical probability of pulmonary embolism. Archives of Internal
Medicine 168 (19): 2131–6.

Revised Geneva PE
Criteria Score
Age > 65 years 1
Previous DVT or PE 3
Surgery or fracture in the last 4 weeks 2
Active malignant condition 2
Unilateral lower limb pain 3
Pain on palpation of lower limb and unilateral edema 4
Hemoptysis 3
Heart rate 75-94 bpm 3
Heart rate >94 bpm 5
Score Probability of PE
0-3 Low
4 – 10 Moderate
>11 High
Reference:
Le Gal G, Righini M, Roy PM et al. (Feb. 2006). Prediction of pulmonary embolism in
the emergency department: the revised Geneva score. Annals of Internal
Medicine 144 (3): 165–71.

68. Pulmonary Embolism Rule out criteria (PERC)
Yes to all – Not suggestive of PE

 Age < 50 years
 Pulse < 100 bpm
 Pulse oxymetry > 94%
 No unilateral leg swelling
 No hemoptysis
 No surgery or trauma within 4 weeks
 No prior deep vein thrombosis or pulmonary embolism
 No oral hormone use
Reference:
Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, Richman PB,
O Neil BJ, Nordenholz K. Prospective multicenter evaluation of the pulmonary
embolism rule-out criteria. J Thromb Haemost 2008; 6: 772–80

69. WELL’s PE
Purpose: Clinical probability for PE
Predictor Score
Clinical signs and symptoms of DVT (minimum of leg swelling and 3
pain with palpation of deep veins)
An alternative diagnosis is less likely than PE 3
Heart rate greater than 100 1.5
Immobilisation at least 3 days or surgery in previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy 1
Total Score
12.5
Risk of PE Associated Score

Low (3% risk of PE) <2
Moderate (28%) 2-6
High (78%) >6
Reference:
Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al.
Derivation of a Simple Clinical Model to Categorize Patients Probability of
Pulmonary Embolism-Increasing the Models Utility with the SimpliRED Ddimer.
Thromb Haemost. 2000; 83(3): 416-20.

Section XI. Resuscitation
70. Anaphylaxis guidelines
Emergency management of anaphylaxis in adults

Diagnosis is made clinically:
The most common signs and symptoms are cutaneous (e.g., sudden onset of generalized
urticaria, angioedema, flushing, and pruritus). However, 10 to 20% of patients have no
skin findings.
Danger signs: Rapid progression of symptoms, respiratory distress (e.g., stridor,
wheezing, dyspnea, increased work of breathing, persistent cough, cyanosis),
vomiting, abdominal pain, hypotension, dysrhythmia, chest pain, collapse.
Acute management:
The first and most important treatment in anaphylaxis is epinephrine. There are NO
absolute contraindications to epinephrine in the setting of anaphylaxis.
Airway: Immediate intubation if evidence of impending airway obstruction from
angioedema. Delay may lead to complete obstruction. Intubation can be difficult and
should be performed by the most experienced clinician available. Cricothyrotomy may
be necessary.
Promptly and simultaneously, give:

IM epinephrine (1 mg/mL preparation): Give epinephrine 0.3 to 0.5 mg
intramuscularly, preferably in the mid-outer thigh. Can repeat every 5 to 15 minutes (or
more frequently), as needed. If epinephrine is injected promptly IM, most patients
respond to one, two, or at most, three doses. If symptoms are not responding to
epinephrine injections, prepare IV epinephrine for infusion (see below).
Place patient in recumbent position, if tolerated, and elevate lower extremities
Oxygen: Give 8 to 10 L/minute via facemask or up to 100% oxygen, as needed.
Normal saline rapid bolus: Treat hypotension with rapid infusion of 1 to 2 liters IV.
Repeat, as needed. Massive fluid shifts with severe loss of intravascular volume can
occur.
Albuterol (salbutamol): For bronchospasm resistant to IM epinephrine, give 2.5 to 5
mg in 3 mL saline via nebulizer. Repeat, as needed.
Adjunctive therapies:
H1 antihistamine*: Consider giving diphenhydramine 25 to 50 mg IV (for relief of
urticaria and itching only).
H2 antihistamine*: Consider giving ranitidine 50 mg IV.
Glucocorticoid*: Consider giving methylprednisolone 125 mg IV.
Monitoring: Continuous non-invasive hemodynamic monitoring and pulse oxymetry

monitoring should be performed. Urine output should be monitored in patients
receiving IV fluid resuscitation for severe hypotension or shock.

Treatment of refractory symptoms:
Epinephrine infusion¶: For patients with inadequate response to IM epinephrine and
IV saline, give epinephrine continuous infusion, beginning at 0.1 mcg/kg/minute by
infusion pump. Titrate the dose continuously according to blood pressure, cardiac rate
and function, and oxygenation.
Vasopressors: Some patients may require a second vasopressor (in addition to
epinephrine). All vasopressors should be given by infusion pump, with the doses titrated
continuously according to blood pressure and cardiac rate/function and oxygenation
monitored by pulse oximetry
Glucagon: Patients on beta-blockers may not respond to epinephrine and can be given
glucagon 1 to 5 mg IV over 5 minutes, followed by infusion of 5 to 15 mcg/minute. Rapid
administration of glucagon can cause vomiting.
IM: intramuscular; IV: intravenous.

* These medications should not be used as initial or sole treatment.
All patients receiving an infusion of epinephrine and another vasopressor require
continuous non-invasive monitoring of blood pressure, heart rate and function, and oxygen
saturation.
Reference:
1. Anaphylaxis a practice parameter update 2015 Ann Allergy Asthma Immunol
115 (2015) 341-384
2. Adapted from: Simons FER. Anaphylaxis. J Allergy Clin Immunol 2010; 125:S161

71. Cardiac Arrest Algorithm
Acronym Expansion: CPR- Cardio Pulmonary Resuscitation, IV – Intravenous, IO -

Intraosseous
Purpose: To manage a patient in cardiac arrest within the “platinum minutes”
Steps Action
1 Assess for response and check for breathing

Assess carotid pulse
(If None present, go to step 2)
Activate arrest code and start CPR

Attach Cardiac monitor
Assess rhythm
Step 2 VF/VT PEA/Asystole Step 9
Step 3 200J DC Shock 2 min CPR

Step 10
Secure IV access
2 min CPR Inj. Adrenaline 1 mg in at 3-5 minutes’ interval
Step 4 Secure IV/IO access Consider advanced airway
v Reassess rhythm Reassess rhythm

Shockable? Shockable?
YES NO
NO YES
Step 12
Step 5
200J DC Shock Go to step 5 or 7

Step 11
Step 6 2 min CPR 2 min CPR
Inj. Adrenaline 1 mg iv Treat reversible cause
at 3-5 minutes’ interval
Consider advanced airway

Reassess rhythm Reassess rhythm
Shockable? Shockable?
YES NO NO YES To Step 5 or 7
Step 7 200J DC Shock

Asystole / PEA -> 10 or 11
Step 12 Organized rhythm – Check Pulse
2 min CPR If Pulse is present – Post ROSC
Inj. Amiodarone care
Step 8 (First dose 300mg, Second To Step 5

dose 150mg)
Treat reversible causes
Reference: American Heart Association – 2015 guidelines
**********
72.Modified Cormak-Lehane Laryngoscopic Grades
- Full view of the Glottis

- Vocal chords fully seen
- Glottis and/or Arytenoids seen

i. 2A – Vocal chords partially seen
ii. 2B – Arytenoids/posterior part of
vocal chords seen
- Only Epiglottis visualised

- Glottis not seen
- Only soft palate seen

- Epiglottis and Glottis not seen
73.LEMON Assessment for Difficult
Intubation
 Look externally – Short neck, small mouth, abnormal dentition, etc

 Evaluate – 3-3-2
 Mallampatti
 Obstruction/Obesity
 Neck Mobility
First 3 Second 3 2
- 3 finger space between - 3 finger space between - 2 finger space between
the upper and lower the Symphysis Mentum Hyoid and thyroid notch
incisors and Hyoid bone
- Assesses the distance
- Ensures adequate mouth - Assesses the space to between the tongue and
opening to accommodate push the tongue during the glottis
blade + ETT displacement
74. Mallampatti Classification
P U S H
Palatine Tonsils Uvula seen (except Soft palate seen Only hard palate
Uvula Fully seen tip) Base of Uvula seen visualised
Assessment
- Seated position, at eye level with the doctor
- Must open mouth as wide as possible
- Must stick out tongue
- Must NOT phonate (i.e., must not say “aaaah”)
Grade 0 – If the Epiglottis is visualised on opening the mouth
Reference: Mallampati, S.R., Gatt, S.P., Gugino, L.D. et al. Can Anaesth Soc J (1985) 32: 429.
doi:10.1007/BF03011357
CONTEMPORARY GUIDELINES FOR EMERGENCY MEDICINE - SEMICON 2017 81

Section XII. Surgery and Subspecialties
75. ALVARADO Score

Purpose : The Alvarado score is the most widely used diagnostic aid for the
diagnosis of appendicitis and has been modified slightly since it was introduced.
However, clinical judgment remains paramount.
The modified Alvarado scale assigns a score to each of the following diagnostic
criteria:
(MANTREL)
●Migratory right iliac fossa pain (1 point)

●Anorexia (1 point)
●Nausea/vomiting (1 point)
●Tenderness in the right iliac fossa (2 points)
●Rebound tenderness in the right iliac fossa (1 point)
●Fever >37.5°C (1 point)
●Leukocytosis (2 points)
A low Alvarado score (<5) has more diagnostic utility to “rule out” appendicitis than
a high score (≥7) does to “rule in” the diagnosis
Reference:
The Alvarado score for predicting acute appendicitis: a systematic review,Ohle R,

O'Reilly F, O'Brien KK, Fahey T, Dimitrov BD , BMC Med. 2011; 9:139. Epub 2011
Dec 28.

76. Charcot’s triad Reynold’s pentad
Purpose: Features suggestive of ascending cholangitis
 Right upper quadrant abdominal pain
 Fever
 Jaundice
Reynold’s Pentad
Charcot’s triad with Hypotension and Altered mental status
Reference:
Reynolds BM, Dargan EL (August 1959). "Acute obstructive cholangitis; a distinct
clinical syndrome". Ann Surg. 150 (2): 299–303. doi:10.1097/00000658-
195908000-00013. PMC 1613362 PMID 13670595

77. Large vs Small bowel Obstruction
Large Bowel Features Small Bowel Features

1. Seen Peripheral with a diameter Centrally seen with a diameter
of maximum 6 cm ofmaximum 3 cm
2. Presence of Haustrations Valvulae coniventae seen
3. Ileum appears featureless
4. No gas in the colon

Section XIII. Toxicology
78. Coma Cocktail

“DONT (Dextrose, Oxygen, Naloxone, Thiamine)”
Purpose: It is given empirically to a comatose patient. However, this strategy is not
well supported by the literature, and empiric administration of coma cocktail has
been questioned.
Reference:
Hoffman RS, Goldfrank LR. The poisoned patient with altered consciousness.
Controversies in the use of a ‘coma cocktail’. JAMA 1995; 274: 562-9.

79. Repeat dose of activated Charcoal
Mechanism:
It can increase the clearance of drugs by interrupting enterohepatic circulation. The other
putative mechanism is by 'gastrointestinal dialysis'. Lipid soluble drugs of relatively low
molecular weight are able to move from the gut capillaries back into the lumen (if there is a
diffusion gradient) and be bound to charcoal (which maintains the gradient).
Drugs:
 Antimalarials, Aminophylline, Aspirin, Amitriptyline

 Barbiturates (phenobarbital) and beta-blockers
 Carbamazepine
 Dapsone, Digoxin
 Salicylate.
Dose: 25-50 g (0.5 g/kg) every 4 hours.
Duration: To continue until there is a sustained improvement in the patient's clinical

condition or until drug concentrations (if available) are below the concentration at which
major complications are likely to occur.
Reference:
American Academy of Clinical Toxicology and European Association of Poison Centres and
Clinical Toxicologists. Position statement and practice guidelines on the use of multi-dose
activated charcoal in the treatment of acute poisoning. J Toxicol Clin Toxicol. 1999; 37: 731–
751

80. Rumack Matthew Normogram
It is an acetaminophen toxicity nomogram plotting serum concentration of acetaminophen
against the time since ingestion in an attempt to prognosticate possible liver toxicity as well
as allowing emergency physician to decide whether to proceed with N-Acetylcysteine
treatment or not.
Indication:
 Single, acute ingestion occurring <24hr prior to presentation.
Not Indicated:
 Not useful for chronic ingestion (patients who take supratherapeutic doses for
several days)
 If time of ingestion is unknown
Interpretations:
 Obtain acetaminophen concentration at 4 hours post-ingestion or as soon as possible

thereafter.

 Plot acetaminophen concentration on Rumack-Matthew nomogram.
 If above “treatment line” (line connecting 150 mg/mL at 4 hours and 4.7 mg/mL at
24 hours), NAC is indicated.
 Dotted line should be used for those at higher-risk of liver toxicity (eg. alcoholics,
those on enzyme-inducing drugs).
 Co-ingestion of drugs (Opiates or anticholinergics (diphenhydramine, etc.) that
reduce GI motility should prompt repeating acetaminophen level at 8 hours.
Reference:
White SJ, Rumack BH. The acetaminophen toxicity equations: "solutions" for
acetaminophentoxicity based on the Rumack-Matthew nomogram. Ann Emerg Med. 2005
May; 45(5):563-4

81. Substances that do not bind to charcoal
Those substances not well adsorbed by charcoal can be recalled by the mnemon
“CHARCOAL”.
C- Caustics & Corrosives
H- Heavy Metals
A- Alcohol
R- Rapidly absorbed substances
C- Cyanide
O- Others (Iron)
A- Aliphatic Hydrocarbon
L- Lithium
Reference:
Senthilkumaran S. Thirumalaikolundusubramanian P. Approach to Acute
Poisoning. Suresh David (Ed). Clinical Pathways in Emergency Medicine, 2016;
pp.467-483:1st edition. Springer India

Section XIV. Trauma
82. Canadian C Spine Rule
Purpose: To assess the need for cervical spine imaging in alert (GCS 15/15) and
stable trauma patients
Inclusion Criteria Exclusion Criteria

Adults (>16 years of age) Trivial injuries and not fulfilling the ‘at risk’
criteria
Acute trauma to the head/neck Penetrating trauma
Stable Acute paralysis
Alert Known Vertebral disease (Ankylosing
spondylitis, rheumatoid arthritis, spinal
stenosis or previous cervical spine injury)
Injury within 48 hours and Either Returned to the ED for assessment of the
 Neck pain (or) same
 No neck pain but meet the Pregnancy
following criteria:
o Visible injury
above the clavicle
AND
o Non ambulatory
o Dangerous
mechanism of
injury

High-risk factors  Age older than 65 years Mandatory
 Mechanism of injury imaging
considered dangerous
 Numbness or tingling
present in the
extremities
Low-risk factors that  Simple rear-end motor None of these

indicate safe assessment vehicle collision low-risk
of range of motion  Patient ambulatory at factors is
any time since injury present, the
 Delayed onset of neck patient is at
pain risk for having
 Patient in sitting a cervical
position in emergency spine injury
department and neck
 Absence of midline radiography
cervical spine should be
tenderness performed
Unable to actively rotate Mandatory Imaging

his or her neck 45° left
and right
Dangerous mechanism:
 Fall from an elevation of 3 feet or higher
 Bicycle collision
 Axial load to the head (eg, resulting from a dive into an empty swimming
pool)
 Motor vehicle collision involving high speed, rollover, or ejection.
Simple rear-end motor vehicle collision (Excludes) :

 Pushed into oncoming traffic
 Hit by bus/large truck
 Roll over
 Hit by high speed vehicle
Reference:
Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The
Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA.
2001; 286(15): 1841-8.

83. Criteria for positive DPL
Clinical criteria
Initial aspiration of >10 ml frank blood (positive predictive value > 90%)
Bile or solid visceral material in lavage fluid (positive predictive value > 80%)
Laboratory criteria
Diagnostic Peritoneal Lavage RBC Criteria (per mm3)
POSITIVE INDETERMINATE
Blunt trauma 100,000* 20,000-100,000
Stab wound
ANTERIOR ABDOMEN 100,000 20,000-100,000
FLANK 100,000 20,000-100,000
BACK 100,000 20,000-100,000
LOW CHEST 5000-10,000 1000-5000
Gunshot wound 5000-10,000 1000-5000
*In a hemodynamically stable patient with a pelvic fracture and a positive or equivocal red
blood cell count, computed tomography should be obtained to corroborate or refute
intraperitoneal injury.
Diagnostic Peritoneal Lavage Non–RBC Criteria
POSITIVE INDETERMINATE
Lavage Amylase (IU/L) >20 10-19
Lavage Alkaline Phosphatase (IU/L) ≥3 not applicable
WBCs (per mm3) >500 250-500
Reference:
Roberts, J. R. (2013). Roberts and Hedges’ Clinical Procedures in Emergency Medicine
(sixth ed.). Elsevier.

84. Beck’s triad
Purpose: Components of Cardiac Tamponade
 Hypotension
 Jugular Venous Distension
 Muffled heart Sounds
Reference:
Sternbach G (1988). "Claude Beck: cardiac compression triads". J Emerg Med. 6
(5):417–9. doi:10.1016/0736-4679(88)90017-0. PMID 3066820

85. Cushing’s triad
Purpose: Late sign of increasing intracranial pressure, indicating that brainstem
herniation is imminent
 Increase in systolic and pulse pressure (Hypertension)

 Bradycardia
 Irregular breathing
Reference:
Molnar C, Nemes C, Szabo S, Fulesdi B. Harvey Cushing, a pioneer of
neuroanesthesia. J Anesth 22(4): 483–6, 2008.

86. Features S/O aortic injury on CXR
1. Abnormal/indistinct aortic knob

2. Obscured aortopulmonary window
3. Widened left paraspinal stripe
4. Deviation of trachea or NGT to right
5. Other signs are: mediastinum/chest ratio >25% or width >8cm, left 1st rib
fracture
6. Widened mediastinum (more than 8 cm when supine, or more than 6 cm when
upright)
7. Indistinct or abnormal aortic contour
8. Depression of left main bronchus
9. Widened paratracheal stripe
10. Left apical pleural cap
11. Large left haemothorax
Reference: Creasy JD, Chiles C, Routh WD et-al. Overview of traumatic injury of

the thoracic aorta. Radiographics. 17 (1): 27-45. Radiographics (abstract) -
Pubmed citation

87. Features S/O base of skull #
1. Periorbital ecchymosis (Raccoon eyes)

2. CSF rhinorrhoea
3. CSF otorrhoea
4. Haematotympanum
5. Mastoid ecchymosis (Battle’s sign)
6. VIIth (facial paralysis) and VIIIth (hearing loss) CN dysfunction
Reference:
https://web.archive.org/web/20080227162001/http://www.orlandoregion
al.org/pdf%20folder/overview%20adult%20brain%20injury.pdf

88. Fluid loss according to patient’s condition ATLS Class I – IV
Class of haemorrhagic shock
1 2 3 4
Blood Loss (ml) Upto 750ml 750-1500 1500-2000 >2000
Blood loss Up to 15 15 -30 30-40 >40
(%blood
volume)
Pulse rate per <100 100-120 120-140 >140
minute
Blood pressure Normal Normal Decreased Decreased
mmHg
Pulse pressure Normal or Decreased Decreased Decreased
mmHg increased
Respiratory 14-20 20-30 30-40 >35
rate per minute
Urine output >30 20-30 5-15 Negligible
ml/hr
Central Slightly anxious Mildly anxious Anxious, Confused ,
Nervous confused lethargic
System /
Mental status
References:
1. American College of Surgeons. Advanced Trauma Life Support (Student Manual).
American College of Surgeons 2016.ATLS Student’s manual 9th Edition
2. Guly HR, Bouamra O, Liitle R, Dark P, Coats T, Driscoll P, Lerkey FE Testing validiy of
the ATLS classification of hypovolemic shock. Resuscitation. 2010 Sep 81(9):1142-7

89. Gustillo Classification of open fractures
Important for prognosis
Based on 5 criteria
1. Size of the wound
2. Degree of contamination
3. Degree of comminution - simple vs. comminuted
4. Soft tissue injury - mild, moderate, severe
5. Level of energy
Type Size of Degree of Degree of Soft tissue injury Level of

the contamination comminution Energy
wound
1 <1cm Clean Simple # Mild Low
2 1-10cm Moderate Simple # Moderate Moderate
3 >10cm Dirty Comminuted Extensive High
#
3a Adequate soft
tissue coverage
3b Extensive soft
tissue lost with
periosteal
stripping and bony
exposure
3c Major arterial
injury requiring
repair for limb
salvage
77.

90. Indications & Contraindications for ED thoracotomy
Accepted Indications
Penetrating thoracic injury

- Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-
hospital)
- Unresponsive hypotension (BP < 70mmHg)
Blunt thoracic injury

- Unresponsive hypotension (BP < 70mmHg)
- Rapid exsanguination from chest tube (>1500ml)
Relative Indications
Penetrating thoracic injury

- Traumatic arrest without previously witnessed cardiac activity
Penetrating non-thoracic injury

hospital)
Blunt thoracic injuries

hospital)
Contraindications
Blunt injuries
- Blunt thoracic injuries with no witnessed cardiac activity
- Multiple blunt trauma
- Severe head injury

91. Indications for ORIF in distal radius #
Purpose: Indications for ORIF in distal radius fracture
 Metaphyseal unstable extra- or minimal articular fractures with Distal fragment >1
cm and Irreducible
 Intra-articular fractures with articular displacement of more than 2 mm
 Partial articular fractures (dorsal and volar Barton fracture, volar comminution)
 High velocity injuries and open fractures
Reference:
Court-Brown, C. M. (2015). Rockwood and Green’s Fractures in Adults. Lippincott
Williams & Wilkins.

92. Indications for TT
For Children Aged 6 Weeks Through 6 Years

Vaccination Clean and Minor Wound TIG? All Other Wounds3 TIG?
History
Incomplete DTaP Give DTaP (if minimum No Give DTaP (if minimum Yes
series1 interval met since last interval met since last
dose) dose)
Complete DTaP No further action No No further action required No
series 1 required
For Children Aged 7 Through 10 Years

Vaccination History Clean and TIG? All Other Wounds3 TIG?
Minor Wound
Incomplete DTaP series1 Give Tdap No Give Tdap Yes2
(preferred) or (preferred) or Td4
Td4
Complete DTaP series with an No further
1 No Aged 7-9 years: Give
interval of 5 years or more action required Td
from last dose Aged 10 years Give
Tdap (Prefered ) or
Td4
Complete DTaP series1 with an No further No No further action is No
interval of less than 5 years action required required
from last dose

For Persons Aged 11 Years and Older
Vaccination History Clean and Minor Wound TIG? All Other TIG?
Wounds3
Incomplete 3-dose Give Tdap (preferred) or No Give Tdap Yes
primary series with any Td4 (preferred) or
tetanus-containing Td4
vaccine4
Complete 3-dose No further action required No Give Tdap
primary series (any for wound care6 Tetanus- (preferred) or
tetanus-containing containing vaccine booster Td4 No
vaccine5) with an is recommended at least
interval of 5 years or every 10 years3
more from last dose
Complete 3-dose primary No No

series (any tetanus- No further action No further
containing vaccine5) with required for wound care6 action
an interval less than 5 required for
years from last dose wound care6
1. Complete DTaP series: 5 doses of DTaP before age 7 years or 4 doses of DTaP with one
dose at/after age 4 years. DTaP is licensed for children aged 6 weeks through 6 years.
2. If at least 3 doses of a tetanus-containing vaccine have been administered, TIG is not
indicated.
3. Including but not limited to: wounds contaminated with dirt, feces, soil or saliva,
animal bites, puncture wounds, avulsions, wounds resulting from missiles (gunshots),
crushing, burns, & frostbite
4. Tdap is recommended for persons aged 10 years & older who have not received a
previous dose. Pregnant women need Tdap vaccine during each pregnancy. For wound
care, administer Td if Tdap is not readily available. Two Tdap brands: Boostrix® (GSK)
for persons aged 10 years & older and Adacel ® (sanofi pastuer) for persons aged 11
through 64 years. Both brands may be used for persons aged 7-10 years when
indicated. Adacel may be used for persons aged 65 years & older when Boostrix is not
readily available.
5. Tetanus-containing vaccines include: DTaP, DT, Tdap, Td, & TT
6. One dose of Tdap is recommended for all adolescents beginning at age 11 years and for
all adults regardless of interval since last Td. If no documentation of a previous dose, do
not miss an opportunity to provide pertussis protection-- administer a Tdap dose even
if wound care is not required.

References:
 DTaP: Recommendations for Vaccine Use and Other Preventative Measures,
Recommendations of ACIP, MMWR 1991:40(10);
 Preventing Tetanus, Diphtheria, and Pertussis Among Adolescents: Use of Tdap,
Recommendations of ACIP, MMWR 2006:55(3);
 Preventing Tetanus, Diphtheria, and Pertussis Among Adults: Use of Tdap,
Recommendations of ACIP, MMWR 2006: 55(17);
 Updated Recommendations on Use of Tdap, ACIP 2010, MMWR 2011:60(01);
 Updated Recommendations for use of Tdap in Pregnant Women & Persons who
Have/Anticipate Having Contact with Infants Aged Less Than 12 Months, ACIP
2011, MMWR 2011:60(42);
 Updated Recommendations for Use of Td/Tdap for Adults aged 65 Years & Older,
MMWR 2012: 61(25)

93. Laparotomy in abdominal trauma patients
Purpose: Indication for abdominal exploration in patients with abdominal
trauma patients
Clinical Indications for Laparotomy after Penetrating Abdominal Injuries
Peritonitis
Evisceration
Impaled object
Hemodynamic instability
Associated bleeding from natural orifice
Documented Pneumoperitoneum
Clinical Indications for Laparotomy after Blunt Abdominal Trauma

Hemodynamic instability
Pneumoperitoneum
Evidence of diaphragmatic injury
Significant gastrointestinal bleeding
Peritonitis
References:
 Zinner, M. J. (2013). Maingot's Abdominal Operations (Twelfth ed.). Mc
Graw Hill Medical.
 Marx, J. A. (2014). Rosen's Emergency MedIcine Concepts and Clinical
Practice (Eighth ed.). Elservier.

94. Le Forte Classification
Le Fort I (floating palate) is a transverse fracture separating the body of the maxilla from
the pterygoid plate and nasal septum. Fracture line passes through the alveolar ridge,
lateral nose, and inferior wall of maxillary sinus
Le Fort II (floating maxilla) is a pyramidal fracture through the central maxilla and hard
palate. Fracture arch passes through posterior alveolar ridge, lateral walls of maxillary
sinuses, inferior orbital rim, and nasal bones
Le Fort III is craniofacial dysjunction when the entire face is separated from the skull from
fractures of the frontozygomatic suture line, across the orbit and through the base of the
nose and ethmoids.
Reference:
Rhea JT, Novelline RA. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J
Roentgenol. 2005;184 (5): 1700-5.

95. MESS score

96. METHANE
Letter Description
M Message can be pre-fixed by 'Major incident activation' or 'standby'
E Exact location of incident
T Type of incident (fire, road traffic, explosion)
H Hazards indentified on scene
A Most suitable route of access and egress
N Estimated number of casualties
E Specific emergency services or specialist teams required

METHANE is used by first on scene to convey information back to ambulance control.

MIST
Letter Description
M Mechanism of injury
I Apparent injuries
S Pre-hospital signs (heart and respiratory rate, blood pressure etc.)
T Pre-hospital treatment administered

On arrival at hospital, the pre-hospital clinician can communicate this information
and hand over rapidly to the ED staff.

97. NEXUS C Spine Rule
Purpose: Clinical decision rule used to guide C-spine imaging in patients with
blunt trauma.
If the answer is "yes" to any of these questions, imaging is recommended for
patients with blunt trauma to clearance of C-Spine.
1.Is a focal neurologic deficit present?
1.Is there midline spinal tenderness?
1.Does the patient have altered mental status?
1.Is the patient intoxicated?
Does the patient have an apparent distracting ainjury?
Reference:
Hoffman JR, M. W. (2000, July 13). Validity of a Set of Clinical Criteria to Rule Out Injury to
the Cervical Spine in Patients with Blunt Trauma. National Emergency X-Radiography
Utilization Study Group. New England Journal of Medicine, 343, 94-99.
86.

98. Nexus Chest Rule
Purpose: Clinical decision rule used to guide CT imaging in adult(>14years) with blunt
chest injuries to identify clinically significant and minor chest injury.
SCORE CRITERIA SCORE

Age > 60 years 1
Rapid deceleration mechanism (fall > 20 ft or MVC > 40 mph) 1
Chest pain 1
Intoxication 1
Abnormal mental status 1
Distracting painful injury 1
Tenderness to chest wall palpation 1
NEXUS Chest score = 0

No thoracic imaging required
NEXUS Chest score ≥ 1
In well-appearing patient with no evidence of multiorgan injury, consider CXR only
without chest CT
In ill-appearing patients and/or those who will receive workup for other serious injury,
consider chest CT as well.
Reference:
Robert M. Rodriguez, et al (2013, October). NEXUS Chest Validation of a Decision
Instrument for Selective Chest Imaging in Blunt Trauma. JAMA SURGERY, 148(10), 940-946.

99. NEXUS CT Brain
Purpose: Clinical decision rule used to guide CT imaging in blunt head injuries
Indication for CT scan head - If any of the following are present, CT Head is required.
Behaviour Abnormal
Persistent Vomiting
Age > 65years
Neurological Deficit
Coagulopathy
Altered Mental Status
Evidence of Significant Skull Fracture
Hematoma of Scalp
Reference:
Mower WR, Hoffman JR, Herbert M, Wolfson AB, Pollack CV, Jr., Zucker MI.
Developing a decision instrument to guide computed tomographic imaging of
blunt head injury patients. J Trauma. 2005; 59(4): 954-9.

100. NICE CT Brain – Children
Purpose: NICE Guideline for CT Brain in children who have sustained a
head injury.
Table 1. Indications for CT head in children with head injury (CT scan within 1
hour of the any risk factor being identified):
Suspicion of non-accidental injury

Post-traumatic seizure but no history of epilepsy.
On initial ED assessment, GCS less than 14, or for children under 1 year GCS
(paediatric) less than 15.
At 2 hours after the injury, GCS less than 15.
Suspected open or depressed skull fracture or tense fontanelle.
Any sign of basal skull fracture (haemotympanum, 'panda' eyes, CSF leakage Battle's
sign)
Focal neurological deficit.
For children under 1 year, presence of bruise, swelling or laceration of more than 5
cm on the head.
Patients having warfarin treatment perform (a CT head scan within 8 hours of the
injury)
Table 2. Indications for CT head in children with head injury and have more than 1 of the
following risk factors (None from above table 1)
Loss of consciousness lasting more than 5 minutes (witnessed).

Abnormal drowsiness.
Three or more discrete episodes of vomiting
Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an
occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre
or 5 stairs).
Amnesia (antegrade or retrograde) lasting more than 5 minutes
Table 3. Child with head injury and have only 1 of the risk factors from table 2, should be
observed for a minimum of 4 hours after the head injury. If during observation any of the
risk factors below are identified, perform a CT head scan within 1 hour:
GCS less than 15

Further vomiting.
A further episode of abnormal drowsiness.
Reference:
National Institute for Health and Care Excellence (January 2014) Head injury: assessment
and early management. NICE guideline [CG176]

101. NICE guideline for CT Brain -- Adults
Purpose: NICE Guideline for CT Brain in Adults who have sustained a head
injury.
Indications for CT head in adults with head injury (within 1 hour of the
risk factor being identified):
GCS less than 13 on initial assessment in the emergency department

GCS less than 15 at 2 hours after the injury on assessment in the emergency department
Suspected open or depressed skull fracture.
Any sign of basal skull fracture (haemotympanum, 'panda' eyes, CSF leakage from the ear
or nose, Battle's sign)
Post-traumatic seizure
Focal neurological deficit
More than 1 episode of vomiting.
Indication for CT Head in Adults with some loss of consciousness or

amnesia since the injury (within 8 hours of the head injury)
Age 65 years or older.
Any history of bleeding or clotting disorders.
Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an
occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre
or 5 stairs).
More than 30 minutes' retrograde amnesia of events immediately before the head
injury.
Patients having warfarin treatment
Reference:
National Institute for Health and Care Excellence (January 2014) Head injury:
assessment and early management. NICE guideline [CG176]

102. Schatzker classification
Type Feature
I Lateral split fracture
II Lateral Split-depressed fracture
III Lateral Pure depression fracture
IV Medial plateau fracture
V Bicondylar fracture
VI Metaphyseal-diaphyseal disassociation
Reference:
Markhardt B, Gross J, Monu J. Schatzker Classification of Tibial Plateau Fractures: Use of
CT and MR Imaging Improves Assessment1. Radiographics. 2009;29 (2): 585-
597. Radiographics (full text) - doi:10.1148/rg.292085078

Section XV. Miscellaneous
103. Analgesic Ladder

Purpose: Providing adequate and equated analgesia to a patient in pain coming
to ED.
Stage Class Drugs
First choice – Paracetamol

I Non-opioid +/- Adjuvants Second choice - NSAIDS
II Mild Opioid +/- Stage I Tramadol
III Strong Opioid +/- Non-opioids Morphine/Fentanyl/Buprenorphine
Reference: Schug SA & Auret K. Clinical pharmacology: Principles of analgesic

drug management. In: Sykes N, Bennett MI & Yuan C-S. Clinical pain management:
Cancer pain. 2nd ed. London: Hodder Arnold; 2008. ISBN 978-0-340-94007-5. p.
104–22

104. Indications for Rabies vaccine/Ig
Bite from following animals is an indication for anti-rabies treatment –
Bats, monkeys, raccoons, foxes, skunks, cattle, wolves, coyotes, dogs, mongooses, cats,
bears, domestic farm animals, groundhogs, weasels, wild carnivorans, hares, rabbits, and
small rodents like squirrels.
Category Type of exposure Management
1. Washing of exposed area with soap

I 1. Touching/ feeding of
&water.
infected animal.
2. Reassure patient.
2. Lick over intact skin
1 Nibbling of intact skin. 1. Wash with soap and water.

2 Minor scratch without 2. Inj. T.T. 0.5ml i/m stat. (After
II
bleeding. checking immunization status)
3. Rabies vaccine 1 dose i/m stat.
4. To take follow up doses on the 3rd,
7th, 14th, and 28th day of exposure.
1. Transdermal bites 1. Follow all four steps of Category II

2. Lick on broken skin. bite management.
3. Exposure to mucous 2. A) Inj. Human Immunoglobulin 20
III membrane. IU/Kg Infiltrate around the wound as
4. Any bite involving much as possible, and give the
hands/neck/face/head. remaining amount intramuscularly.
(No test dose required)
OR
B) Inj. Equine Immunoglobulin 40
IU/Kg to be given as above, but after
a test dose.
Reference: http://www.ncdc.gov.in/Rabies_Guidelines.pdf

105. NSI – indication for drugs/Vaccines
Purpose: To provide a healthcare worker apt treatment following a needle
stick injury
No. Indication Drug / Vaccine
1. Dirty source of injury Tetanus prophylaxis (if not immunized earlier)
2. Previously immunized for Booster dose of Hepatitis B Vaccine

Hepatitis B (Anti Hbs Titre >
10)
3. Unimmunized for Hepatitis First dose of Hepatitis B Vaccine ( followed by 1 dose

B each at 1 and 6 months interval) + Anti Hep B
immunoglobulin within 72 hrs.
(<30kg – 100IU im, >30kg – 400 IU im)
4. Unknown source 2 drug anti-retroviral stat (Zidovudine + Lamivudine).
5. Known HIV positive source Start 2 drug regime and urgent referral to ID
consultant.
Reference:
upsacs.in/pdf/GUIDELINES/PEP
http://www.rch.org.au/clinicalguide/guideline_index/Needle_stick_injury/

106. RIFLE
Purpose: To ascertain kidney function by measuring serum creatinine levels and urine
output, and decide upon treatment plan.
Creatinine Urine Output Score
1.5X increase from baseline <0.5ml/kg/hr for 6 hrs “R”

Risk
2X increase from baseline <0.5ml/kg/hr for 12 hrs “I”

Injury
3X increase from baseline or Sr. <0.3ml/kg/hr for 24 hrs or Anuria “F”

creatinine >4mg% for 12 hrs Failure
Persistent ARF / Loss of renal “L”

function for > 4 weeks Loss of function
“E”
Nonfunctioning kidneys End stage renal
disease

107. Raised Anion Gap Metabolic Acidosis
Mnemonic: “CAT MUDPILES”
Mnemonic Causes
C Carbon Monoxide
Cyanide
Congestive cardiac failure
A Aminoglycosides
T Theophylline
Toluene
M Methanol
U Uremia
D Diabetic Ketoacidosis
P Paracetamol
Paraldehyde
I Iron
Isoniazid
Inborn errors of metabolism
L Lactic acidosis
E Ethanol
Ethylene glycol
S Salicylates
Reference:
 "Anion Gap (Blood)". University of Rochester Medical Center. Retrieved 2014-02-18.
 Sabatini, S; Kurtzman, NA (2009). "Bicarbonate Therapy in Severe Metabolic Acidosis".
Journal of the American Society of Nephrology. 20 (4): 692–695.
doi:10.1681/asn.2007121329.

108.Whole Bowel Irrigation
Purpose: It is a method of decontamination in case of poisoning with substances that are
not adsorbed with activated charcoal or there is increase in drug concentration even after
regular decontamination methods.
Indications Contraindications
Poorly adsorbed by Activated Charcoal: 1. Ileus

1. Iron 2. Significant gastrointestinal
2. Lithium hemorrhage
3. Inorganic salts (K+) 3. Hemodynamic instability
4. Mercury 4. Uncontrollable intractable
5. Arsenic vomiting
6. Fluoride 5. Bowel obstruction
Formation of concretion: 6. Bowel perforation
7. Salicylates
8. Barbiturates
9. Carbamazepine
10. Large overdose of enteric coated
preparations
11. Body packing
12. Meprobamate
Reference:
 http://www.calpoison.org/hcp/2003/callusvol1no4.html
 Tenenbein M (1988). "Whole bowel irrigation as a gastrointestinal decontamination
procedure after acute poisoning". Med Toxicol Adverse Drug Exp. 3 (2): 77–84.
doi:10.1007/bf03259934. PMID 3287090
 Tenenbein M, Cohen S, Sitar D (1987). "Whole bowel irrigation as a
decontamination procedure after acute drug overdose". Arch Intern Med. 147 (5):
905–7. doi:10.1001/archinte.147.5.905. PMID 3579442

JNC 8 Hypertension Guideline Algorithm
Initial Drugs of Choice for Hypertension
Adult aged ≥ 18 years with HTN • ACE inhibitor (ACEI)
Implement lifestyle modifications
• Angiotensin receptor blocker (ARB)
Set BP goal, initiate BP-lowering medication based on algorithm
• Thiazide diuretic
General Population • Calcium channel blocker (CCB)
(no diabetes or CKD) Diabetes or CKD present
Strategy Description
Age ≥ 60 years Age < 60 years All Ages All Ages and Races Start one drug, titrate to maximum
Diabetes present CKD present with or
A
dose, and then add a second drug.
No CKD without diabetes
BP Goal BP Goal B Start one drug, then add a second
< 150/90 < 140/90 drug before achieving max dose of
BP Goal BP Goal first
< 140/90 < 140/90
C Begin 2 drugs at same time, as
separate pills or combination pill.
Initiate ACEI or ARB, Initial combination therapy is
Nonblack Black
alone or combo recommended if BP is greater than
w/another class 20/10mm Hg above goal
Initiate thiazide, ACEI, ARB, Initiate thiazide or CCB,
or CCB, alone or in combo alone or combo
Lifestyle changes:
Yes • Smoking Cessation
At blood pressure goal?
• Control blood glucose and lipids
No
• Diet
Reinforce lifestyle and adherence Eat healthy (i.e., DASH diet)
Titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, Thiazide) Moderate alcohol consumption
Reduce sodium intake to no
Yes more than 2,400 mg/day
At blood pressure goal?
• Physical activity
No
Moderate-to-vigorous activity
Reinforce lifestyle and adherence 3-4 days a week averaging 40
Add a medication class not already selected (i.e. beta blocker, aldosterone antagonist, others) and titrate min per session.
above medications to max (see back of card)
Yes
At blood pressure goal? Continue tx and monitoring
No
Reference: James PA, Ortiz E, et al. 2014 evidence-based guideline for the management
Reinforce lifestyle and adherence of high blood pressure in adults: (JNC8). JAMA. 2014 Feb 5;311(5):507-20
Titrate meds to maximum doses, add another med and/or refer to hypertension specialist
Card developed by Cole Glenn, Pharm.D. & James L Taylor, Pharm.D.
Compelling Indications
Hypertension Treatment
Indication Treatment Choice
Heart Failure ACEI/ARB + BB + diuretic + spironolactone
Post –MI/Clinical CAD ACEI/ARB AND BB
Beta-1 Selective Beta-blockers – possibly safer in patients
CAD ACEI, BB, diuretic, CCB with COPD, asthma, diabetes, and peripheral vascular
Diabetes ACEI/ARB, CCB, diuretic disease:
• metoprolol
CKD ACEI/ARB • bisoprolol
Recurrent stroke prevention ACEI, diuretic • betaxolol
• acebutolol
Pregnancy labetolol (first line), nifedipine, methyldopa
Drug Class Agents of Choice Comments

Diuretics HCTZ 12.5-50mg, chlorthalidone 12.5-25mg, indapamide 1.25-2.5mg Monitor for hypokalemia
triamterene 100mg Most SE are metabolic in nature
K+ sparing – spironolactone 25-50mg, amiloride 5-10mg, triamterene Most effective when combined w/ ACEI
100mg Stronger clinical evidence w/chlorthalidone
Spironolactone - gynecomastia and hyperkalemia
furosemide 20-80mg twice daily, torsemide 10-40mg Loop diuretics may be needed when GFR <40mL/min
ACEI/ARB ACEI: lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril 5- SE: Cough (ACEI only), angioedema (more with ACEI),
10mg, trandolapril 2-8mg hyperkalemia
ARB: candesartan 8-32mg, valsartan 80-320mg, losartan 50-100mg, Losartan lowers uric acid levels; candesartan may
olmesartan 20-40mg, telmisartan 20-80mg prevent migraine headaches
Beta-Blockers metoprolol succinate 50-100mg and tartrate 50-100mg twice daily, Not first line agents – reserve for post-MI/CHF
nebivolol 5-10mg, propranolol 40-120mg twice daily, carvedilol 6.25-25mg Cause fatigue and decreased heart rate
twice daily, bisoprolol 5-10mg, labetalol 100-300mg twice daily, Adversely affect glucose; mask hypoglycemic awareness
Calcium channel Dihydropyridines: amlodipine 5-10mg, nifedipine ER 30-90mg, Cause edema; dihydropyridines may be safely combined
blockers Non-dihydropyridines: diltiazem ER 180-360 mg, verapamil 80-120mg 3 w/ B-blocker
times daily or ER 240-480mg Non-dihydropyridines reduce heart rate and proteinuria
Vasodilators hydralazine 25-100mg twice daily, minoxidil 5-10mg Hydralazine and minoxidil may cause reflex tachycardia
and fluid retention – usually require diuretic + B-blocker
terazosin 1-5mg, doxazosin 1-4mg given at bedtime Alpha-blockers may cause orthostatic hypotension
Centrally-acting clonidine 0.1-0.2mg twice daily, methyldopa 250-500mg twice daily Clonidine available in weekly patch formulation for
Agents resistant hypertension
guanfacine 1-3mg
Department of Violence and Injury Prevention and Disability
World Health Organization
Prevention and management of wound infection

Guidance from WHO’s Department of Violence and Injury Prevention and Disability and
the Department of Essential Health Technologies
Introduction
Open injuries have a potential for serious bacterial wound infections, including gas
gangrene and tetanus, and these in turn may lead to long term disabilities, chronic
wound or bone infection, and death. Wound infection is particularly of concern when
injured patients present late for definitive care, or in disasters where large numbers of
injured survivors exceed available trauma care capacity. Appropriate management of
injuries is important to reduce the likelihood of wound infections. The following core
principles and protocols provide guidance for appropriate prevention and management
of infected wounds.
Core Principles
• Never close infected wounds1. Systematically perform wound toilet and surgical
debridement (described in Protocol 1 given below). Continue the cycle of surgical
debridement and saline irrigation until the wound is completely clean.
• Do not close contaminated wounds2 and clean wounds that are more than six
hours old. Manage these with surgical toilet, leave open and then close 48 hours
later. This is known as delayed primary closure.
• To prevent wound infection:
• Restore breathing and blood circulation as soon as possible after
injury.
• Warm the victim and at the earliest opportunity provide high-energy
nutrition and pain relief.
• Do not use tourniquets.
• Perform wound toilet and debridement as soon as possible (within 8
hours if possible).
• Respect universal precautions to avoid transmission of infection.
• Give antibiotic prophylaxis to victims with deep wounds and other
indications (described in Protocol 3).
• Antibiotics do not reach the source of the wound infection. Antibiotics only
reach the area around the wound; they are necessary but not sufficient and need to
be combined with appropriate debridement and wound toilet as described above.
• Use of topical antibiotics and washing wounds with antibiotic solutions are
not recommended.
1. An infected wound is a wound with pus present.
2. A contaminated wound is a wound containing foreign or infected material.
1
Protocols
Protocol 1: Wound toilet and surgical debridement
Apply one of these two antiseptics to the wound:
o Polyvidone-iodine 10% solution apply undiluted twice daily.
The application to large open wounds may produce systemic adverse effects.
o Cetrimide 15% + chlorhexidine gluconate 1.5%
Note: The freshly prepared aqueous solution (0.05%) of Chlorhexidine gluconate 5% is not
recommended in emergency situations (risk of flakes according to water quality)
1. Wash the wound with large quantities of soap and boiled water for 10 minutes, and then
irrigate the wound with saline.
2. Debridement: mechanically remove dirt particles and other foreign matter from the wound
and use surgical techniques to cut away damaged and dead tissue. Dead tissue does not bleed
when cut. Irrigate the wound again. If a local anaesthetic is needed, use 1% lidocaine without
epinephrine.
3. Leave the wound open. Pack it lightly with damp saline disinfected or clean gauze and cover
the packed wound with dry dressing. Change the packing and dressing at least daily.
Protocol 2: Management of tetanus-prone wounds

1. Wounds are considered to be tetanus-prone if they are sustained either more than 6 hours before
surgical treatment of the wound or at any interval after injury and show one or more of the
following: a puncture-type wound, a significant degree of devitalized tissue, clinical evidence of
sepsis, contamination with soil/manure likely to contain tetanus organisms, burns, frostbite, and
high velocity missile injuries.
2. For patients with tetanus-prone injuries, WHO recommends TT or Td and TIG.
3. When tetanus vaccine and tetanus immunoglobulin are administered at the same time, they
should be administered using separate syringes and separates sites.
Tetanus vaccine
ADULT and CHILDREN over 10 years:
• Active immunization with tetanus toxoid (TT) or with tetanus and diphtheria vaccine (Td)
1 dose (0.5 ml) by intramuscular or deep subcutaneous injection. Follow up: 6weeks, 6 months.
CHILDREN under 10 years:
Diphtheria and tetanus vaccine (DT)
0.5 ml by intramuscular or deep subcutaneous injection. Follow up at least 4 weeks and 8 weeks.
Tetanus immune globulin (TIG)
In addition to wound toilet and absorbed tetanus vaccine. Also consider if antibacterial prophylaxis
(Protocol 3 below) is indicated.
ADULT and CHILD
• Tetanus immunoglobulin (human) 500 units/vial
250 units by intramuscular injection, increased to 500 units if any of the following conditions
apply: wound older than 12 hours; presence, or risk of, heavy contamination; or if patient weights
more than 90 kg.
Note: national recommendations may vary
2
Protocol 3: Antibiotic prophylaxis and treatment
Antibiotic prophylaxis
Antibiotic prophylaxis is indicated in situations or wounds at high risk to become infected such as:
contaminated wounds, penetrating wounds, abdominal trauma, compound fractures, lacerations greater
than 5 cm, wounds with devitalized tissue, high risk anatomical sites such as hand or foot. etc. These
indications apply for injuries which may or may not require surgical intervention. For injuries requiring
surgical intervention, antibiotic prophylaxis is also indicated and should be administered prior to
surgery, within the 2 hour period before the skin is cut.
Recommended prophylaxis consists of penicillin G and metronidazole given once (more than once if
the surgical procedure is > 6 hours).
• Penicillin G ADULT: IV 8-12 million IU once. CHILD: IV 200,000 IU/kg once.

• Metronidazole ADULT: IV 1,500 mg once (infused over 30 min). CHILD: IV 20 mg/kg once.
Antibiotic treatment
If infection is present or likely, administer antibiotics via intravenous and not intramuscular route.
Penicillin G and metronidazole for 5-7 days provide good coverage.
• Penicillin G ADULT: IV 1 - 5 MIU every 6 hours.

After 2 days it is possible to use oral Penicillin: Penicillin V 2 tablets every 6 hours.
CHILD: IV 100mg/kg daily divided doses (with higher doses in severe infections),
In case of known allergy to penicillin use erythromycin.
In case of sudden allergy reaction (seldom):
IM adrenaline 0.5 - 1.0 mg to adults. 0.1 mg/ 10 kg body weight to children.
• Metronidazole ADULT: IV 500 mg every 8 hours (infused over 20 minutes).

CHILD: IV 7.5 mg/kg every 8 hours.

8.scoring and Criterias

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

8.scoring and Criterias

Загружено:

Авторское право:

Доступные форматы

Contemporary Clinical Guidelines for

Emergency Medicine – 2017

Prepared for SEMICON 2017

Prof. Dr. Suresh S. David

Section Chapter and Title of Guidelines Page

Welcome to the PG Refresher Course of the Society of Emergency Medicine!

Relative percentages of areas affected by growth (age in years)

Second-degree _____and Third-degree ______ = Total percent burned ______

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 1

The body is divided into areas of 9%, and the total

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 2

The 4 Ts for the diagnosis of heparin-induced thrombocytopenia (HIT) is a tool developed

Category 2 points 1 point 0 points

Score Risk Classification

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 3

ATRIA risk factors Score

Risk Score Risk Level Annualized hemorrhage rate

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 4

 The type I ECG is characterized by a J elevation ≥2 mm (0.2 mV) a coved type ST

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 5

Purpose: Calculates stroke risk for patients with atrial fibrillation

Annual Stroke Risk

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 6

Total Score Risk assessment

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 7

HAS BLED Risk Score

Score Bleeding risk classification (% bleeds per 100 patient-years)

 Hypertension: systolic blood pressure >160 mm Hg

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 8

HEART Score Score

HEART Score Risk of MACE Proposed Policy

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 9

Reference: PCI Guidelines 2013 AHA

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 10

Absolute Contraindications Against the use of Thrombolytic Therapy

Relative Contraindications Against the Use of Thrombolytic Therapy

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 11

Killip Clinical Signs Mortality

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 12

Stages Symptoms Pathophysiology

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 13

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 14

Modified Sgarbossa Criteria

 ≥ 1 lead with ≥1 mm of concordant ST elevation

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 15

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 16

Classification of aortic dissection

Percentage 60% 10–15% 25–30%

 Type I: involves ascending and descending aorta (= Stanford A)

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 17

Aspirin use in the past 7 days 1

Severe angina (≥2 episodes in 24 hours) 1

Elevated cardiac marker level 1

Score Risk of Death/MI/Urgent

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 18

Low risk of ACS if

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 19

Score Risk Stratification

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 20

 History of angina + T wave inversion (Type1) or biphasic T waves (Type 2) in V2–V4

 De Zwaan C et al. Angiographic and Clinical Characteristics of Patients with Unstable

Contemporary Guidelines For Emergency Medicine - SEMICON 2017 21

22. ABCD2 score for TIA

Second-degree _and Third-degree = Total percent burned ____