Handling Patients in the Casualty (Emergency Department) - India

1. Pre-Hospital Phase Preparation

• Pre-alert the team (doctor, nurse, paramedic) for serious incoming cases via ambulance (108 system)
• Ensure resuscitation equipment is functional: oxygen, suction, defibrillator, crash cart, IV fluids, intubation tray
• Arrange resuscitation bay/red area for critical patients
• Notify blood bank, OT, and relevant specialties if needed

2. Triage - The Cornerstone of Casualty Management

AIIMS Triage Protocol (ATP) - RED Criteria (Trauma)

• Gunshot wounds
• Penetrating injury to thorax, abdomen, or neck
• Major crush injuries / vascular injuries
• Open long bone fractures, fracture pelvis
• Flail chest, open chest wound (sucking wound), pneumothorax
• Traumatic amputation above knee or elbow
• Worsening vitals: SpO2 <90%, SBP <90 mmHg, HR >100/min, RR >24/min, GCS falling

RED Criteria (Medical Emergencies)

• Acute chest pain (<24 hours)
• Suspected stroke within 24 hours of onset
• Acute-onset shortness of breath within 12 hours
• Anaphylaxis
• Severe pain (VAS >7)
• Sudden-onset severe headache
• Suspected acute coronary syndrome, aortic dissection, sepsis

3. Primary Survey - ABCDE Approach (With Simultaneous Resuscitation)

A - Airway (with Cervical Spine Protection)

• Ask the patient "Are you OK?" - a verbal response confirms open airway
• If no response: look for foreign body, secretions, blood
• Interventions: jaw thrust (NOT chin-lift if c-spine injury suspected), suction, oropharyngeal/nasopharyngeal airway, intubation
• Apply cervical collar to all trauma patients until c-spine cleared

B - Breathing and Ventilation

• Expose chest, look for: tracheal deviation, symmetric chest rise, flail chest, sucking wounds
• Count respiratory rate (normal: 12-20/min)
• SpO2 monitoring - target >95%
• Treat: tension pneumothorax (needle decompression 2nd ICS MCL), open chest wound (3-sided occlusive dressing), flail chest (intubate + ventilate)

C - Circulation and Hemorrhage Control

• Apply direct pressure to external wounds immediately
• IV access - two large-bore cannulas (16G or 14G)
• Draw blood for investigations
• Fluid resuscitation: start IV fluids (Normal Saline / Ringer's Lactate)
• Check pulse quality, capillary refill, BP
• In hemorrhagic shock: permissive hypotension (SBP 80-90 mmHg) until bleeding controlled
• Alert blood bank for cross-match; give O-negative blood if needed emergently

D - Disability (Neurological Status)

• GCS (Glasgow Coma Scale) assessment - record E, V, M scores
• AVPU scale as rapid bedside tool: Alert / Voice / Pain / Unresponsive
• Check pupils: size, equality, reaction to light
• Blood glucose (finger prick RBS) - treat hypoglycemia immediately (25 ml of 50% Dextrose IV)
• Seizures: IV lorazepam or diazepam

E - Exposure and Environmental Control

• Completely undress the patient - look for hidden injuries, rashes, petechiae
• Log roll to examine the back
• Prevent hypothermia: warm blankets, warm IV fluids
• Note: "Exposure" is not just undressing - look everywhere

4. Adjuncts to Primary Survey

• 12-lead ECG
• Chest X-ray (AP view, portable)
• Pelvic X-ray (AP view)
• E-FAST (Extended Focused Assessment with Sonography for Trauma) - bedside ultrasound for blood in abdomen/chest/pericardium
• NCCT Head if head injury
• Blood investigations: CBC, ABG, RFT, LFT, serum electrolytes, blood glucose, coagulation profile (PT/INR, aPTT), blood grouping and cross-matching

5. Secondary Survey

• Head-to-toe examination - systematic evaluation from head to toe
• Detailed history: SAMPLE (Signs & Symptoms, Allergies, Medications, Past history, Last meal, Events)
• Re-examine for occult injuries
• Reassess vitals continuously

6. Medico-Legal Obligations (MLC) - Critical in India

Who is a Medico-Legal Case (MLC)?

• Road traffic accidents (RTA)
• Assaults, fights, injuries due to violence
• Burns, poisoning, snake/scorpion bites
• Suspicious circumstances (drowning, hanging, electrocution)
• Sexual assault (POCSO, Section 376 IPC)
• Brought in dead (BID) patients

MLC Procedure:

1. Register the patient as MLC - assign MLC number
2. Inform police immediately (nearest police station) - written intimation, DO NOT wait for police to arrive before treating
3. Take consent from patient (if conscious) or guardian; if unconscious and alone, document and proceed with emergency treatment
4. Prepare injury report - describe each injury precisely: site, size, shape, margins, depth, associated features. Use proper medico-legal terminology (abrasion, contusion, laceration, incised wound, etc.)
5. Preserve evidence: clothes in separate sealed bags labeled and handed to police with acknowledgment
6. Document date and time of all events
7. Brought-in-dead (BID): register as MLC, inform police, send body to mortuary - do NOT hand over to relatives directly

Documentation essentials:

• Casualty card must note exact time of arrival, time of examination, findings, treatment given
• Doctor's full name in BLOCK LETTERS with stamp on every document
• All blood/urine samples in suspected poisoning sent to FSL (Forensic Science Laboratory) via police

7. Disposition from Casualty

• Red area patients: priority admission - dispose within 1 hour (admit to ICU/ward/OT)
• Yellow area patients: dispose within 6 hours from arrival
• If disposal is delayed, routine admissions of that specialty may be blocked
• Transfer out to higher center: only after stabilizing vitals, with proper referral letter, accompanying staff, and equipment

8. Special Scenarios

Unconscious Patient

• Protect airway first (intubate if GCS ≤8)
• Glucose check immediately
• Rule out: hypoglycemia, opioid overdose (give naloxone), benzodiazepine overdose, stroke, meningitis

Poisoning / Overdose

• Identify poison (history from relatives, label)
• Do NOT induce vomiting in corrosive/petroleum ingestion
• Activated charcoal (50g) if within 1 hour and airway protected
• Specific antidotes: Naloxone (opioids), Atropine + Pralidoxime (organophosphate), N-acetylcysteine (paracetamol)
• Preserve gastric lavage sample, blood, urine for FSL

Snake / Scorpion Bite

• Immobilize limb, reassure, do NOT cut/suck wound
• Anti-snake venom (ASV) - 10 vials IV initially in confirmed snake bite
• Watch for anaphylaxis during ASV administration

Burns

• Fluid resuscitation: Parkland formula (4 ml/kg/% TBSA, half in first 8 hours)
• Analgesia (IV morphine), wound cover with clean dressing
• Foley catheter for urine output monitoring (target 0.5-1 ml/kg/hr)

Mass Casualty Incident (MCI)

• Activate hospital disaster plan
• Medical Superintendent is notified
• START triage used at field level
• Color-coded areas in casualty activated
• Call additional staff, blood bank put on alert, OTs cleared

9. Key Indian Legal Points

• You cannot refuse emergency treatment - Supreme Court ruling in Parmanand Katara case (1989) mandates immediate treatment regardless of MLC formalities
• Police intimation is the duty of the doctor, NOT a prerequisite for treatment
• Private hospitals too must provide first-aid stabilization before transfer
• Sexual assault victims: examination by female doctor preferred; preserve evidence per POCSO/IPC guidelines

Quick Reference Summary

Patient arrives in Casualty
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    TRIAGE (RED / YELLOW / GREEN / BLACK)
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Primary Survey: A - B - C - D - E (with simultaneous resuscitation)
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Investigations (bloods, X-ray, ECG, E-FAST, NCCT)
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Is it Medico-Legal? → YES → Register MLC, Inform Police, Document
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Secondary Survey (head-to-toe, SAMPLE history)
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Definitive Care: ICU / OT / Ward / Discharge / Transfer

• Casualty / Emergency - practical steps, what to do on your first posting
• Clinical skills - history taking, examination, procedures (IV line, catheter, suturing, etc.)
• Specific postings - Medicine, Surgery, OBG, Paediatrics, Ortho guidance
• MLC documentation - how to write injury reports, register MLC cases
• Prescriptions & drug doses - common drugs, calculations
• Study during internship - PG entrance prep (INICET/NEET-PG) tips
• Any specific clinical scenario you've encountered and need help with