Managing Casualty as an Intern - A Practical Guide

1. The Golden Mindset

• Stabilize first, investigate later. Don't order 10 tests before doing a primary survey.
• Call your senior early. In casualty, calling for help is a sign of wisdom, not weakness.
• Document everything - time of arrival, vitals, your assessment, and every intervention.
• Never leave a critically ill patient alone. Assign a nurse or stay yourself.

2. The PRIMARY SURVEY - Your First Action for Every Sick Patient

• Tintinalli's Emergency Medicine, Table 25A-3

3. TRIAGE - How to Prioritize When Multiple Patients Arrive

4. Common Casualty Presentations & What to Do First

Unconscious Patient / Altered Sensorium

• ABCDE + check BSL immediately (hypoglycemia is the most treatable cause)
• Give Dextrose 50% - 50 mL IV if BSL low or not available
• Posture (lateral/recovery position to prevent aspiration)
• Check pupils - bilateral fixed dilated = bad prognostic sign
• Think: hypoglycemia, drug OD, head injury, stroke, seizure post-ictal state

Chest Pain

• Attach to monitor + ECG within 10 minutes (door-to-ECG rule)
• Check BP in both arms
• Give aspirin 325 mg chewable if ACS suspected
• Look for ST elevation - call senior immediately for STEMI
• IV access + O2 + vitals monitoring

Breathlessness / Dyspnea

• Sit upright, high-flow O2
• Auscultate: wheeze (asthma/COPD) vs crepitations (pulmonary edema/pneumonia) vs absent sounds (pneumothorax/pleural effusion)
• Nebulize salbutamol for wheeze
• Furosemide 40 mg IV for suspected pulmonary edema (after confirming BP is adequate)

Trauma Patient

• C-spine precautions + ABCDE
• Stop bleeding with direct pressure
• 2 large-bore IV lines + fluid resuscitation
• Splint fractures
• FAST exam / X-ray chest + pelvis as needed

Seizures

• Protect airway, lateral position, do NOT put anything in the mouth
• IV access - give Lorazepam 0.1 mg/kg IV (or diazepam 10 mg IV) for active seizure
• Check BSL
• After seizure: phenytoin/valproate loading dose

Poisoning / OD

• ABCDE; identify the poison (history, container, smell)
• Activated charcoal within 1 hour for most oral ingestions (if airway is protected)
• Specific antidotes: naloxone for opioids, atropine for organophosphates, flumazenil for benzo OD
• Call poison control if unsure

Pediatric Emergency

• All doses are weight-based - use a Broselow tape if available
• For febrile seizure: cooling + paracetamol + check BSL
• Dehydration: assess skin turgor, eyes, fontanelle

5. Procedures You Should Know in Casualty

• IV cannulation - every critically ill patient needs IV access
• ECG recording and basic interpretation - ST changes, arrhythmias
• Urinary catheterization
• Nasogastric tube insertion - for poisoning, upper GI bleeds
• Wound suturing - simple lacerations
• Splinting fractures
• Assisting in intubation - know the equipment (laryngoscope, ETT sizes, bag-valve mask)
• Chest compression/BLS - know your ACLS algorithm

6. Routine Documentation (Never Skip This)

1. Time of arrival and mode of arrival
2. Chief complaint
3. Vitals on arrival (BP, PR, RR, SpO2, Temp, BSL)
4. Brief history (SAMPLE: Symptoms, Allergies, Medications, Past history, Last meal, Events)
5. Examination findings
6. Provisional diagnosis
7. Treatment given (drug name, dose, route, time)
8. Investigations ordered
9. Disposition (admitted / discharged / referred / expired)

7. Practical Tips for Survival in Casualty

• Learn vitals interpretation fast - a dropping BP with rising pulse = shock
• BSL (blood sugar level) is your best friend in any altered patient
• "When in doubt, shout" - never hesitate to call your senior resident
• Take quick focused history - you don't have 30 minutes; use AMPLE/SAMPLE
• Keep emergency drugs ready in your mind: adrenaline, atropine, dextrose 50%, lorazepam, salbutamol neb, furosemide, aspirin, nitroglycerin
• For RTA cases: always rule out C-spine injury until proven otherwise
• Don't skip documentation even in a rush - it protects you legally
• Take care of yourself - eat, hydrate, and don't hesitate to hand over properly at shift end

8. Emergency Drug Quick Reference