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Emergency Procedures: Clinical Quick Reference

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1. CARDIAC ARREST

Definition

Diagnosis

• Sudden loss of consciousness (occasionally with convulsions)
• Absent femoral or carotid pulse (confirm within 10-15 seconds)
• Apnea or agonal gasping
• Pallor/cyanosis/skin blotching
• Dilated pupils (unless patient is on opiates)

Common Causes

1. Myocardial infarction (VF or PEA)
2. Hypoxia (most common cause in surgical patients - airway obstruction, hypovolemia, acidosis)
3. Electrolyte imbalance (hyperkalaemia - diastolic arrest or VF)
4. Drug toxicity (adrenaline, potassium, calcium, halothane combination)
5. Cardiac tamponade
6. Hypothermia
7. Pulmonary or air embolism
8. Tension pneumothorax
9. Anaphylaxis
10. Drowning / electrocution

Treatment Steps

• Activate the cardiac arrest team (in-hospital: emergency code call)
• Note the time of arrest

• Lay patient supine on a firm surface; remove pillows
• Quickly check and clear the upper airway (dentures, food bolus, vomit)
• Head-tilt / chin-lift to open the airway

• One firm thump with the ulnar border of a clenched fist to the lower sternum (may restart asystole)

• Heel of hand on the lower third of the sternum, other hand on top, arms straight
• Sharp, jerky downward compressions - aim to depress sternum 4-5 cm
• Rate: approximately 100 compressions/minute (once per second)
• If alone: 30 compressions : 2 rescue breaths; if team available, continue compressions uninterrupted while airway is managed separately
• One ventilation per 8 compressions (once intubated, do not pause for ventilation)

• If untrained or alone: mouth-to-nose or mouth-to-mouth resuscitation (12-15 breaths/min)
• Preferred: endotracheal intubation (8-9 mm tube for average adult), inflate cuff, connect reservoir bag with oxygen (100%)
• Confirm ETT position: bilateral chest rise, auscultation, ETCO2 if available
• If intubation not immediately possible: tight-fitting face mask + bag-valve-mask with IPPV

• Large-bore IV x 2; if veins collapsed, cut-down at antecubital fossa or central line (subclavian/internal jugular)
• Give sodium bicarbonate 200 mL of 4.2% IV to counter metabolic acidosis
• Elevate the legs

• Connect ECG monitor (often incorporated in defibrillator)
• Identify rhythm: VF/pulseless VT → immediate defibrillation; Asystole/PEA → drugs + CPR

• Adrenaline (epinephrine): 1 mg IV (1 mL of 1:1000 or 10 mL of 1:10,000) every 3-5 min - universal agent for all rhythms
• Amiodarone: 300 mg IV bolus for refractory VF (after 3rd shock); repeat 150 mg if VF recurs
• Lignocaine (lidocaine): 1 mg/kg IV if amiodarone unavailable
• Bicarbonate: 50 mL of 8.4% solution for severe metabolic acidosis or hyperkalaemia
• Calcium chloride: 10 mL of 10% for hyperkalaemia or hypocalcaemia
• Atropine: no longer routinely recommended for asystole/PEA in 2015 ALS guidelines

• If unconscious after ROSC: targeted temperature management (TTM) - cool to 32-36°C using ice packs/cooling blanket
• Chlorpromazine 12.5 mg IV may assist cooling
• Urinary output: give mannitol 500 mL of 10% IV to reduce cerebral oedema
• Dexamethasone 4-6 mg IM every 4 hours for 24 h (cerebral oedema, controversial)
• ICU admission; identify and treat precipitant

• Indicated in: intrathoracic operation, cardiac tamponade from penetrating wound, air embolism, bilateral pneumothorax
• Fourth or fifth left intercostal space incision; extend from lateral sternal border to posterior axillary line; direct massage of the heart

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2. ANAPHYLAXIS

Definition

Diagnosis Criteria (any one):

• Sudden onset illness with skin/mucosal symptoms PLUS respiratory compromise OR hypotension/end-organ dysfunction
• OR two or more of: skin/mucosal changes, respiratory compromise, hypotension, GI symptoms - after exposure to likely allergen
• Or hypotension alone after known allergen exposure

Common Triggers

Treatment Steps

• Airway-Breathing-Circulation evaluation
• Vital signs, pulse oximetry
• Assess for angioedema (uvular edema, stridor, hoarseness, respiratory distress)
• Call for help; lay patient supine (Trendelenburg if hypotensive)

• Adult: Epinephrine 0.3-0.5 mg IM into the anterolateral thigh (vastus lateralis), using 1 mg/mL (1:1000) solution
• Child (<30 kg): Epinephrine 0.15 mg IM; use EpiPen Jr if available
• Child (dosing): 0.01 mg/kg IM, up to 0.5 mg per dose
• Repeat every 5-10 minutes if no improvement (most patients need only 1 dose)
• IM thigh preferred over deltoid - faster, higher, more consistent peak plasma levels than SC
• If cardiovascular collapse or refractory to 2-3 IM doses: IV epinephrine infusion (0.1-0.5 mcg/kg/min titrated to response); or IV bolus 0.1 mg of 1:10,000 solution slowly
• Auto-injectors: EpiPen (0.3 mg adult), EpiPen Jr (0.15 mg pediatric <30 kg)

• High-flow O2 to maintain SpO2 >90%
• If angioedema is progressing and causing respiratory distress: early intubation (do not delay - complete obstruction can develop rapidly)
• Emergency surgical airway (cricothyroidotomy) if intubation fails

• Large-bore IV access
• 1-2 L isotonic crystalloid (NS or LR) for hypotension; 10-20 mL/kg bolus in children
• Repeat fluid boluses as needed; consider vasopressors (norepinephrine, dopamine) if refractory

• Remove causative agent if identifiable (remove stinger, stop IV drug infusion)
• Do NOT perform gastric lavage for food allergens

• Nebulized salbutamol (albuterol) 2.5-5 mg for wheeze/bronchospasm
• Ipratropium bromide if bronchospasm refractory
• Inhaled beta-2 agonists are adjuncts, NOT replacements for epinephrine

• H1-antihistamine: Diphenhydramine 25-50 mg IV/IM (adults) - for urticaria and pruritus
• H2-antihistamine: Ranitidine 50 mg IV or famotidine 20 mg IV
• Corticosteroids: Methylprednisolone 1-2 mg/kg IV or hydrocortisone 200-300 mg IV (onset 4-6 h; reduce risk of biphasic reaction)
• Glucagon: 1-2 mg IV/IM for patients on beta-blockers who are refractory to epinephrine (beta-blockers block epinephrine's beta-receptor effects)

• Minimum 6 hours of observation after a severe reaction
• Patients with severe anaphylaxis or who received multiple epinephrine doses: observe 12-24 hours (biphasic anaphylaxis occurs in up to 20% of cases)
• Prescribe epinephrine autoinjector at discharge; educate on self-administration; refer to allergist

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3. TYPES OF SHOCK

3A. Hypovolemic / Hemorrhagic Shock

1. Control hemorrhage: direct pressure, tourniquet, surgical intervention as appropriate
2. IV access x 2 large-bore; send type & crossmatch, CBC, coagulation panel, lactate
3. Fluid resuscitation with IV crystalloid (NS or LR) initially
4. Target MAP 60-65 mmHg (permissive hypotension 50 mmHg acceptable in penetrating trauma until hemorrhage controlled)
5. For hemorrhagic shock: packed red blood cells; massive transfusion protocol (pRBC:FFP:platelets in 1:1:1 ratio) for large volume losses
6. Patients without major comorbidities can tolerate Hb ≥7 g/dL; do not over-transfuse
7. Avoid overresuscitation - worsens dilutional coagulopathy, abdominal compartment syndrome
8. Definitive surgical intervention for hemorrhage source control

3B. Distributive Shock (Septic)

1. Recognize early - qSOFA score (AMS, RR ≥22, SBP ≤100 mmHg)
2. Blood cultures x 2 sets BEFORE antibiotics if delay <1 hour
3. Broad-spectrum antibiotics within 1 hour of septic shock recognition (independent risk factor for mortality if delayed)
4. IV crystalloid 30 mL/kg in first 3 hours
5. Target MAP ≥65 mmHg
6. If inadequate response to fluids: norepinephrine (first-line vasopressor) 0.01-0.5 mcg/kg/min IV; titrate to MAP goal
7. Add vasopressin 0.03 units/min IV if norepinephrine requirements are high (reduces norepinephrine dose)
8. Hydrocortisone 200-300 mg/day IV in refractory septic shock (vasopressor-dependent)
9. Source control: drain abscesses, remove infected devices, surgical intervention as warranted
10. Glucose management: target 140-180 mg/dL; avoid hypoglycemia

3C. Cardiogenic Shock

1. Identify and treat the underlying cause (emergent PCI for acute MI)
2. Supplemental oxygen; NPPV (BiPAP) or intubation with mechanical ventilation reduces afterload and improves oxygenation; clears pulmonary edema
3. Careful fluid management (avoid volume overload - worsens pulmonary edema)
4. Inotropes: Dobutamine 2-20 mcg/kg/min IV (first-line inotrope); may add norepinephrine for hypotension
5. Vasopressors: Norepinephrine or dopamine; avoid excess vasoconstriction
6. Diuretics if volume-overloaded (furosemide IV)
7. Intra-aortic balloon pump (IABP) or Impella device for mechanical circulatory support in refractory cases
8. Cardiology consultation; consider emergent LVAD or heart transplant evaluation in refractory cases

3D. Obstructive Shock

1. Clinical diagnosis (do not wait for X-ray): tracheal deviation away from affected side, absent breath sounds, hypotension, distended neck veins
2. Immediate needle thoracocentesis: 14-16G cannula, 2nd intercostal space, midclavicular line
3. Definitive: chest tube (28-32 Fr) in 4th-5th intercostal space, anterior axillary line

1. Beck's triad: hypotension + muffled heart sounds + distended neck veins; pulsus paradoxus >10 mmHg
2. Confirm with bedside echo (pericardial effusion + RV collapse in diastole)
3. Cautious IV fluid bolus to maintain preload
4. Pericardiocentesis: subxiphoid approach, needle angled toward left shoulder, under echo guidance if possible; drain 15-20 mL for immediate hemodynamic improvement
5. Surgical drainage for traumatic tamponade (thoracotomy)

1. Hemodynamic compromise + hypoxia + right heart strain (S1Q3T3, new RBBB, RV dilation on echo)
2. High-flow O2; IV access
3. Systemic thrombolysis: alteplase 100 mg IV over 2 hours (or 0.6 mg/kg over 15 min in cardiac arrest)
4. Heparin anticoagulation: after thrombolysis is completed
5. Surgical embolectomy or catheter-directed thrombolysis if systemic lysis is contraindicated

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4. ACUTE ISCHEMIC STROKE

Time is Brain - Goal: Door-to-needle ≤60 minutes

Diagnosis

• Sudden focal neurological deficits (face drooping, arm weakness, speech difficulty - FAST acronym)
• Assess with NIHSS (0-42 scale; higher = worse deficit)
• Non-contrast CT head STAT to exclude hemorrhagic stroke (mandatory before thrombolysis)

Treatment Steps

• Prenotify stroke team before arrival
• Note time of symptom onset (or last known normal) precisely
• Transport directly to a stroke center with CT capability

• Supplemental O2 only if SpO2 <94%
• Correct hypoglycemia (glucose <60 mg/dL mimics stroke)
• IV access; do NOT give hypotonic fluids

• Non-contrast CT head within 25 minutes of arrival
• CT angiography (CTA) to assess large vessel occlusion (LVO) if thrombectomy candidate
• MRI-DWI more sensitive but takes longer; use if CT equivocal

• Indication: ischemic stroke within 4.5 hours of onset in eligible patients
• Dose: alteplase 0.9 mg/kg IV (maximum 90 mg); give 10% as bolus over 1 minute, remainder over 60 minutes
• Serum half-life: 4-10 minutes
• Contraindications: hemorrhagic stroke on CT, INR >1.7, active bleeding, recent surgery/trauma, platelet count <100,000, BP >185/110 mmHg (treat first)
• Tenecteplase (0.25 mg/kg IV bolus, max 25 mg) - alternative, easier single-bolus administration; non-inferior in some trials
• After tPA: no anticoagulants or antiplatelet agents for 24 hours; monitor in stroke unit

• Indication: large vessel occlusion (MCA, ICA, basilar), NIHSS ≥6, within 6 hours (up to 24 hours with favorable imaging/perfusion mismatch)
• Stent-retriever thrombectomy is the standard technique
• Can be performed even if tPA is given (bridging therapy) or if tPA is contraindicated

• Before thrombolysis: treat if BP >185/110 mmHg (labetalol 10-20 mg IV, nicardipine infusion)
• After thrombolysis: maintain BP <180/105 mmHg for 24 hours
• Without thrombolysis: permissive hypertension (allow up to 220/120 mmHg in first 24 h to maintain collateral flow)

• Aspirin 325 mg orally or via NG tube within 24-48 hours of stroke onset (if no thrombolysis within preceding 24 h)
• For minor stroke/TIA: dual antiplatelet (aspirin + clopidogrel) for 21 days reduces recurrence

• Atrial fibrillation: initiate oral anticoagulation (DOAC or warfarin) for secondary prevention; timing depends on infarct size (usually 4-14 days post-stroke)
• Heparin is NOT routinely indicated for acute ischemic stroke

• Stroke unit admission
• Glucose: target 140-180 mg/dL (hyperglycemia worsens outcomes)
• Temperature: treat fever aggressively (paracetamol ± cooling)
• DVT prophylaxis: compression stockings; LMWH after 24-48 h if no hemorrhagic transformation

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5. ACUTE MYOCARDIAL INFARCTION (STEMI)

Diagnosis

• Chest pain (pressure, radiation to jaw/arm/epigastrium)
• ST elevation ≥1 mm in 2 contiguous leads, or new LBBB
• Troponin elevation (may not be elevated in first hours - clinical + ECG diagnosis)

Treatment Steps

• 12-lead ECG within 10 minutes of arrival
• Aspirin 300 mg chewed immediately (if not already on aspirin)
• Clopidogrel 600 mg loading dose OR ticagrelor 180 mg OR prasugrel 60 mg (P2Y12 inhibitor)
• IV access, O2 only if SpO2 <90%
• Morphine 2-4 mg IV for pain (titrate, but note: may impair antiplatelet absorption)
• Nitrates sublingually (GTN 0.4 mg SL); avoid if systolic BP <90 mmHg or if right ventricular infarction suspected

• Activate cath lab immediately
• Unfractionated heparin (UFH) 60-70 units/kg IV bolus (max 5000 units) OR bivalirudin
• Door-to-balloon goal: ≤90 minutes

• Tenecteplase (TNK-tPA) weight-based single IV bolus: 30 mg (<60 kg), 35 mg (60-70 kg), 40 mg (70-80 kg), 45 mg (80-90 kg), 50 mg (>90 kg)
• Streptokinase 1.5 million units IV over 60 min (older agent, less fibrin-specific)
• Antithrombins must accompany thrombolysis: enoxaparin or UFH

• Beta-blockers (metoprolol succinate): within 24 hours if no contraindications (Killip Class I-II)
• ACE inhibitor (ramipril): within 24 hours, especially if LVEF <40%, anterior STEMI, hypertension, diabetes
• Statin: high-intensity (atorvastatin 80 mg) immediately

• Continuous ECG monitoring (VT/VF risk highest in first 24-48 h)
• Reperfusion arrhythmias (accelerated idioventricular rhythm) are common and self-limiting
• Treat VF with defibrillation; sustained VT with amiodarone 150 mg IV or synchronized cardioversion

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6. STATUS EPILEPTICUS

Definition

Treatment Steps (time-critical - follow the sequence)

1. Lateral position (recovery position if possible); suction airway
2. Supplemental oxygen; check blood glucose immediately (hypoglycemia is a common cause)
3. IV access x 2; send: glucose, electrolytes, Ca/Mg, toxicology screen, AED levels, CBC
4. If glucose <60 mg/dL: thiamine 100 mg IV THEN dextrose 50 mL of 50% IV

• Lorazepam 4 mg IV (preferred; slower redistribution, longer duration) - may repeat once after 5-10 min if seizure continues
• If no IV: Diazepam 10 mg PR (rectal); or Midazolam 10 mg IM or intranasal (buccal)
• In children: Midazolam 0.2 mg/kg IM/IV/buccal; Lorazepam 0.1 mg/kg IV

• Fosphenytoin 20 mg PE/kg IV at 150 mg PE/min (preferred; less hypotension/cardiac toxicity than phenytoin)
• OR Phenytoin 20 mg/kg IV at ≤50 mg/min (monitor ECG for PR prolongation, hypotension)
• OR Valproate 40 mg/kg IV over 10 minutes (preferred in absence epilepsy; avoid in pregnancy, liver disease, mitochondrial disease)
• OR Levetiracetam 60 mg/kg IV (max 4500 mg) - excellent safety profile, increasingly used first

• Intubation and mechanical ventilation required
• Propofol infusion 1-2 mg/kg IV loading, then 2-10 mg/kg/h
• OR Midazolam infusion 0.2 mg/kg IV loading, then 0.05-2 mg/kg/h
• OR Thiopentone (sodium thiopental) 3-5 mg/kg IV loading, then 3-5 mg/kg/h
• Continuous EEG monitoring mandatory; target burst-suppression pattern
• Treat precipitant: CNS infection (LP when safe), metabolic abnormality, AED non-compliance

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7. DIABETIC EMERGENCIES

7A. Diabetic Ketoacidosis (DKA)

1. IV access; send: ABG, BMP, ketones, urine ketones, CBC, cultures if infected
2. Fluid resuscitation (highest priority): 1 L NS over 30-60 minutes; then 250-500 mL/h NS until hemodynamically stable; switch to 0.45% NaCl when glucose <250 mg/dL; add 5% dextrose when glucose <200 mg/dL
3. Insulin: Regular insulin 0.1 units/kg/h IV infusion (do NOT give insulin before K+ is confirmed >3.5 mEq/L); target glucose fall of 50-75 mg/dL/h
4. Potassium replacement (mandatory): DKA patients are total-body K+ depleted; replace if K+ <5.2 mEq/L
5. Bicarbonate: only if pH <6.9 (50 mEq in 200 mL water over 2 h)
6. Phosphate: replace if <1.0 mg/dL
7. Monitor glucose hourly; electrolytes every 2-4 hours
8. Identify and treat precipitant (infection, missed insulin, new diabetes)
9. Transition to subcutaneous insulin when: pH >7.3, HCO3 ≥15, anion gap closed, patient eating

7B. Hyperosmolar Hyperglycemic State (HHS)

7C. Severe Hypoglycemia

1. If conscious and able to swallow: 15-20 g fast-acting oral glucose (glucose tablets, 150 mL fruit juice)
2. If unconscious/unable to swallow:
   • Dextrose 50 mL of 50% IV (D50W) followed by 100 mL D10W infusion
   • Glucagon 1 mg IM or SC (if no IV access); glucagon 0.5 mg in children <25 kg
3. Recheck blood glucose 15 minutes after treatment; repeat if still <70 mg/dL
4. Once awake: carbohydrate-protein snack to prevent recurrence
5. Identify cause: excess insulin, missed meal, renal failure, adrenal insufficiency, insulinoma

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8. ACUTE RESPIRATORY FAILURE

Categories: Hypoxic (Type I) vs. Hypercapnic/Ventilatory (Type II)

Treatment Steps

• ABG: PaO2 <60 mmHg on air = hypoxic failure; PaCO2 >45 mmHg = hypercapnic failure
• Pulse oximetry is not adequate alone - get ABG

• Controlled O2 via Venturi mask 24-28% (COPD/Type II - avoid high-flow O2 blunting hypoxic drive)
• Unrestricted high-flow O2 (non-rebreather mask 15 L/min) for Type I failure without hypercapnia

• CPAP: for pulmonary edema, OSA-related respiratory failure, oxygenation failure
• BiPAP (IPAP/EPAP): for COPD exacerbation (Type II), neuromuscular disease, obesity hypoventilation
• Indications: RR >25, SpO2 <90% on high-flow O2, PaCO2 rising
• Contraindications: obtundation/unconsciousness, inability to protect airway, facial trauma, vomiting

• Indications: GCS ≤8, failure of NIV, impending respiratory arrest, hemodynamic instability
• Rapid Sequence Intubation (RSI): Preoxygenate (5-10 min high-flow O2) → sedation + neuromuscular blockade → intubation
  • Sedative: Ketamine 1-2 mg/kg IV (preferred in bronchospasm, hypotension) or etomidate 0.3 mg/kg IV
  • Paralytic: Succinylcholine 1.5 mg/kg IV (contraindicated in hyperkalaemia, crush injuries >72h, burns); or Rocuronium 1.2 mg/kg IV
• Initial vent settings: FiO2 100% → wean; TV 6-8 mL/kg IBW (lung-protective); rate 12-20/min; PEEP 5-8 cmH2O
• Treat underlying cause: antibiotics (pneumonia), bronchodilators (COPD/asthma), diuretics (pulmonary edema)

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9. HYPERTENSIVE EMERGENCY

Definition

Treatment Steps

1. IV access; monitor BP continuously (arterial line preferred for severe cases)
2. Identify end-organ damage: ECG, head CT, troponin, BMP, urinalysis with microscopy, fundoscopy
3. Goal: reduce MAP by no more than 15-25% in the first hour (rapid reduction causes ischemic stroke, MI)
4. Drug of choice depends on target organ:

1. Admit to ICU/monitored unit for continuous BP titration

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10. TRAUMA EMERGENCIES

Primary Survey: ABCDE Approach (ATLS Protocol)

Massive Hemorrhage Control

1. Direct pressure (do not remove packing - "scoop and run")
2. Tourniquet: apply 2-3 cm above wound for limb hemorrhage; note time of application
3. Pelvic binder for pelvic fracture with hemodynamic instability
4. Permissive hypotension: target SBP 80-90 mmHg in penetrating trauma until OR
5. Massive transfusion protocol: 1:1:1 (pRBC:FFP:platelets) + tranexamic acid 1 g IV within 3 hours of injury (reduces mortality)
6. Damage control surgery: abbreviated surgical intervention to control hemorrhage and contamination; formal repair deferred until patient is resuscitated

Traumatic Brain Injury (TBI)

1. Avoid hypotension (SBP <90 mmHg) and hypoxia (SpO2 <90%) - secondary brain injury drivers
2. Head CT immediately after primary survey
3. ICP monitoring if GCS ≤8 after resuscitation
4. Elevate head of bed 30 degrees
5. Target PaCO2 35-40 mmHg (mild hyperventilation only for acute herniation)
6. Mannitol 0.25-1 g/kg IV or hypertonic saline 3% for elevated ICP
7. Neurosurgical consultation for evacuable lesions (epidural hematoma, large SDH)

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11. ACUTE ABDOMEN / SURGICAL EMERGENCIES

General Principles

• IV access, IV fluids, analgesia (do NOT withhold opioids pending diagnosis - does not mask the diagnosis)
• NPO, NG tube if vomiting
• Bloods: CBC, BMP, LFTs, amylase/lipase, coagulation, group & screen
• Imaging: plain X-ray (erect CXR for perforation), CT abdomen/pelvis with contrast

Key Surgical Emergencies

1. Erect CXR: free subdiaphragmatic air (present in 70%)
2. Broad-spectrum antibiotics: ceftriaxone + metronidazole IV
3. IV fluids resuscitation; insert urinary catheter
4. Emergency laparotomy: peritoneal lavage + primary repair (omental patch for duodenal perforation)

1. NG tube (decompression)
2. IV fluids + electrolyte correction
3. Serial abdominal X-rays: step-ladder pattern (small bowel); haustra absent, grossly dilated colon
4. CT with contrast: identifies level and etiology
5. Strangulated obstruction: emergency surgery without delay
6. Simple SBO (adhesions): initial non-operative management; surgery if no improvement in 24-48 h

1. Clinical diagnosis (McBurney's point tenderness, Rovsing's, Psoas/obturator signs)
2. USS or CT for confirmation (reduce CT dose in children - USS first)
3. IV antibiotics (cefuroxime + metronidazole) - can resolve uncomplicated appendicitis
4. Appendicectomy (laparoscopic preferred) within 24 hours; emergency if perforated/abscess

1. IV fluids + analgesia
2. Antibiotics: piperacillin-tazobactam or ceftriaxone + metronidazole
3. Laparoscopic cholecystectomy within 72 h (acute cholecystitis) OR ERCP + sphincterotomy (choledocholithiasis/cholangitis)
4. ERCP within 24 h for ascending cholangitis (Charcot's triad: fever + jaundice + RUQ pain); urgent if Reynold's pentad (add confusion + shock)

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12. DENTAL EMERGENCIES

12A. Dental Abscess / Dentoalveolar Infection

1. Examine for fluctuant swelling (intra- or extraoral)
2. Incision and drainage (I&D): local anaesthesia, stab incision at most fluctuant point, blunt dissection, irrigate with saline, place corrugated drain 24-48 h
3. Antibiotics: amoxicillin 500 mg TID for 5 days; amoxicillin-clavulanate if severe/mixed flora; clindamycin if penicillin-allergic
4. URGENT referral to ENT/surgery if Ludwig's angina (bilateral submandibular space infection) - life-threatening airway emergency requiring early intubation/tracheostomy + IV antibiotics + surgical drainage

12B. Tooth Avulsion (complete dental displacement)

1. Handle tooth by crown only (never touch root)
2. Rinse gently with saline or milk (do NOT scrub)
3. Storage: replant immediately or keep in cold milk, saline, or patient's buccal vestibule (saliva) if transport needed
4. Replant and stabilize with flexible splint for 7-14 days
5. Root canal treatment within 7-10 days (unless tooth is immature/open apex)
6. Refer to dentist/oral surgeon immediately

12C. Dental Fractures (Ellis Classification)

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13. OBSTETRIC EMERGENCIES

Eclampsia

1. Left lateral position; supplemental O2
2. Protect airway; call obstetric + anaesthesia teams
3. Magnesium sulfate: 4 g IV loading dose over 5-10 minutes; then 1-2 g/h IV maintenance (prevents and terminates eclamptic seizures)
4. If seizure ongoing with Mg: lorazepam 4 mg IV
5. Monitor: urine output (>25 mL/h), patellar reflexes (absent reflexes = Mg toxicity), respiratory rate
6. Mg toxicity: calcium gluconate 1 g IV (antidote)
7. Anti-hypertensives: labetalol IV or hydralazine IV to keep SBP <160 mmHg
8. Definitive treatment: delivery of the fetus (consult obstetrics)

Postpartum Hemorrhage (PPH)

1. Bimanual uterine massage
2. Oxytocin 10 IU IM or 5 IU slow IV; then oxytocin infusion 20 IU in 500 mL NS at 125 mL/h
3. Ergometrine 0.25 mg IM (avoid in hypertension)
4. Carboprost (15-methyl PGF2α) 0.25 mg IM every 15-90 min (max 8 doses); avoid in asthma
5. Misoprostol 800-1000 mcg rectal/sublingual
6. IV fluids + blood transfusion; massive transfusion protocol if massive hemorrhage
7. Balloon tamponade (Bakri balloon or Sengstaken-Blakemore tube)
8. Surgical options: B-Lynch suture, uterine artery ligation, emergency hysterectomy

Emergency Childbirth (Precipitate Delivery)

1. Assist crowning with gentle pressure to control head delivery
2. Check for nuchal cord (loop over head or clamp and cut)
3. Allow natural restitution and external rotation
4. Deliver anterior shoulder with gentle downward traction, then posterior shoulder upward
5. Support and deliver the body; clamp and cut cord after pulsations cease
6. Dry and stimulate the newborn; assess breathing and tone
7. Await placenta (up to 30 min); never forcibly tug the cord

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14. POISONING / OVERDOSE

General Approach (ABCDE + toxidrome recognition)

• Airway management (risk of vomiting and aspiration); intubate if GCS ≤8
• IV access; ECG (QRS and QTc prolongation are ominous)
• Blood: glucose, BMP, LFTs, ABG, CBC, toxicology screen, specific drug levels

• Activated charcoal 50 g orally (adults): only if airway protected, within 1-2 h of ingestion, substance adsorbs to charcoal; NOT for hydrocarbons, metals, acids/alkalis
• Gastric lavage: rarely indicated; reserved for life-threatening ingestion within 1 hour; protect airway first
• Whole bowel irrigation (polyethylene glycol): for body packers, iron, lithium, sustained-release preparations

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Summary Quick-Reference Table

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