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Medical Log Book - Complete Writing Plan

B.Sc Accident & Emergency Care Technology | TN Dr. MGR University

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SECTION 1: COVER PAGE

• Name of Student
• Register Number
• College Name & Address
• Year & Semester
• Academic Year (e.g., 2024-2025)
• Guide / Clinical Supervisor Name
• Hospital / Clinical Posting Venue

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SECTION 2: CERTIFICATE PAGE

• Clinical Supervisor / Faculty Guide
• Head of Department
• College Principal

"This is to certify that this log book is the bonafide record of clinical work done by [Student Name], Register No. [XXXXX], during the academic year [YYYY-YYYY]."

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SECTION 3: DAILY DUTY LOG

• Fill every clinical posting day
• Departments include: Emergency, Casualty, ICU, OT, Ambulance Duty, OPD, Trauma Unit

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SECTION 4: CLINICAL CASE LOG (Most Important Section)

Case Format:

1. Case No & Date
2. Patient Details - Age, Sex, IP/OP Number
3. Chief Complaint - What brought them to Emergency
4. History of Present Illness
5. Vitals on Arrival
   • BP, Pulse, RR, SpO2, Temperature, GCS Score
6. Triage Category (Red / Yellow / Green / Black)
7. Assessment / Diagnosis
8. Emergency Interventions Done
   • IV Access, O2 therapy, CPR, Airway management, Wound dressing, Splinting, etc.
9. Outcome - Admitted / Discharged / Referred / Expired
10. Supervisor Signature

Target: Minimum 50-100 cases across 3 years

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SECTION 5: SKILLS & PROCEDURES LOG

• Airway Management - Oral airway, Bag-Valve-Mask, Intubation assist
• BLS / CPR - Basic Life Support
• ACLS - Advanced Cardiac Life Support
• IV Cannulation - Peripheral IV access
• Wound Management - Dressing, suture assist
• Splinting & Immobilization
• 12-Lead ECG recording
• Oxygen therapy - Nasal cannula, Face mask, Non-rebreather mask
• Vital Signs Monitoring
• Triage Assessment
• Trauma Assessment - ABCDE approach
• Spinal Precautions / Cervical collar application
• Nebulization
• NG Tube / Urinary Catheter assist
• Ambulance / Pre-hospital care
• Patient Transfer / MICU transport

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SECTION 6: EMERGENCY CATEGORIES LOG

1. Trauma Emergencies - RTA, Fall, Assault
2. Cardiovascular Emergencies - Chest pain, MI, Cardiac Arrest
3. Respiratory Emergencies - Asthma, COPD, Pneumothorax
4. Neurological Emergencies - Stroke, Seizure, Altered Sensorium
5. Gastro-Intestinal Emergencies - GI Bleed, Acute Abdomen
6. Nephro/Urology Emergencies - Renal failure, Poisoning
7. Obstetric Emergencies - PPH, Eclampsia
8. Paediatric Emergencies
9. Environmental Emergencies - Snake bite, Burns, Drowning, Heat stroke
10. Mental Health Emergencies
11. Mass Casualty / Disaster Management

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SECTION 7: RESUSCITATION LOG

• CPR performed
• Defibrillation assisted
• Emergency drug administration assisted (Adrenaline, Atropine, etc.)

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SECTION 8: AMBULANCE / PRE-HOSPITAL LOG

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SECTION 9: DISASTER MANAGEMENT / MOCK DRILL LOG

• Mass Casualty Incident (MCI) drills
• Hospital disaster drills
• NDRF / Civil exercises observed

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SECTION 10: SPECIAL POSTINGS LOG

• ICU / MICU
• Operation Theatre
• Trauma Bay / Resuscitation Room
• Cardiac Cath Lab (observation)
• Radiology (Emergency X-ray, FAST scan)

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SECTION 11: ACADEMIC ACTIVITIES LOG

• Case presentations
• Journal clubs
• Seminars attended
• CME / workshops attended (BLS, ACLS, PALS certification)
• Skill lab sessions

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SECTION 12: INTERNSHIP POSTING SCHEDULE (Final Year)

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SECTION 13: SELF-ASSESSMENT / REFLECTION

• What you learned
• Challenging cases
• Skills improved
• Areas to improve

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SECTION 14: GUIDE / SUPERVISOR REMARKS

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WRITING TIPS

1. Write neatly in blue or black ink only
2. Get supervisor signature on every page or table
3. No patient names - use IP/OP numbers only (patient privacy)
4. Use standard medical abbreviations (BP, HR, RR, GCS, SpO2)
5. Submit log book for internal marks - it carries 10 marks as per MGR University
6. Keep log book updated weekly - do not leave it for last minute
7. Take a photocopy before submitting to college

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Internal Assessment Marks: Log Book / Project = 10 marks (MGR University regulation - must score minimum 50% in IA to appear for university exam)

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Blood and Blood Products in Emergency Medicine

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1. INTRODUCTION

• Restore oxygen-carrying capacity (in hemorrhage/anemia)
• Correct coagulation defects (in bleeding disorders)
• Replace volume (in shock)
• Treat thrombocytopenia (in massive bleeding)

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2. COMPONENTS OF BLOOD

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3. BLOOD PRODUCTS AND THEIR DETAILS

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A. WHOLE BLOOD

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B. PACKED RED BLOOD CELLS (PRBC)

• Hb < 7 g/dL - stable ICU patients
• Hb < 8 g/dL - cardiovascular disease or active bleeding
• Hb 7-9 g/dL - severe trauma patients

• Use Group O Negative (O-) - universal donor RBCs
• O- is preferred for females of childbearing age and pregnant women
• O+ can be used for adult males in life-threatening emergencies

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C. PLATELETS

• Active haemorrhage with thrombocytopenia
• Massive transfusion protocol (MTP)
• Post-cardiopulmonary bypass bleeding
• Dengue haemorrhagic fever with severe thrombocytopenia

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D. FRESH FROZEN PLASMA (FFP)

• Massive transfusion (give with PRBCs and platelets in 1:1:1 ratio)
• DIC (Disseminated Intravascular Coagulation)
• Liver failure with bleeding
• Reversal of warfarin when Prothrombin Complex Concentrate (PCC) is not available
• Factor deficiencies (V, XI) where concentrates are unavailable
• Coagulopathy: PT/INR > 1.5 times control

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E. CRYOPRECIPITATE

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F. FIBRINOGEN CONCENTRATE

• More concentrated than cryoprecipitate
• Used in severe hypofibrinogenaemia (fibrinogen <1.5 g/L)
• Faster to prepare than cryoprecipitate in emergency
• Dose: 2-4 grams IV

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G. PROTHROMBIN COMPLEX CONCENTRATE (PCC)

• Contains Factors II, VII, IX, X (and Proteins C & S)
• Emergency use: Rapid reversal of warfarin/Vitamin K antagonists, life-threatening bleeding
• Acts faster than FFP
• Dose: Based on INR and body weight
• Does NOT require thawing - ready to use immediately

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H. ALBUMIN

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I. ANTI-D IMMUNOGLOBULIN

• Given to Rh-negative mothers or patients who receive Rh-positive blood products
• Prevents anti-D alloimmunization
• Important in emergency transfusion of Rh- females

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4. COMPATIBILITY TESTING IN EMERGENCY

• O Negative RBCs = Universal donor RBCs (emergency use)
• AB Positive Plasma = Universal donor plasma (no anti-A or anti-B antibodies)

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5. MASSIVE TRANSFUSION PROTOCOL (MTP)

Trigger Criteria for MTP:

• Systolic BP < 90 mmHg
• Heart Rate > 120 bpm
• Mechanism suggesting major haemorrhage (RTA, stab, gunshot, ruptured AAA)
• Haemoglobin < 7 g/dL with ongoing bleeding

MTP Ratio - PROPPR Trial Evidence:

• Prevents dilutional coagulopathy
• Reduces crystalloid use
• Reduces acidosis
• Improves 24-hour and 30-day survival

MTP Steps in Emergency:

1. Activate MTP - inform blood bank immediately
2. Start with 6 units PRBCs + 6 units FFP + 1 apheresis platelet
3. Check labs every 30-60 minutes (Hb, PT, aPTT, platelet count, fibrinogen)
4. Add cryoprecipitate if fibrinogen < 1.5 g/L
5. Consider Tranexamic Acid (TXA)
6. Aim for: Hb > 7, Platelets > 50,000, Fibrinogen > 1.5 g/L, INR < 1.5

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6. TRANEXAMIC ACID (TXA) - Emergency Adjunct

• Drug class: Antifibrinolytic
• Mechanism: Inhibits plasminogen activation, prevents clot breakdown
• Dose: 1 gram IV over 10 minutes, then 1 gram IV over 8 hours
• Time limit: Must be given within 3 hours of injury (CRASH-2 trial)
• Indications: Trauma with haemorrhage, post-partum haemorrhage, TBI with haemorrhage
• Contraindication: Do NOT give after 3 hours - may increase mortality

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7. DAMAGE CONTROL RESUSCITATION (DCR) - Emergency Principle

1. Direct pressure / tourniquet to control external bleeding
2. Permissive hypotension - target SBP 70-90 mmHg until surgical haemorrhage control (avoids "popping the clot")
3. Minimal crystalloid - avoid normal saline (causes hyperchloraemic acidosis)
4. Early blood product transfusion in 1:1:1 ratio
5. Early operative control - transfer to OT or angiography for definitive haemostasis
6. TXA within 3 hours
7. Warm blood products - prevent hypothermia (use blood warmers)
8. Correct the Lethal Triad:
   • Hypothermia (<35°C)
   • Acidosis (pH <7.35)
   • Coagulopathy

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8. TRANSFUSION REACTIONS

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9. SPECIAL SITUATIONS IN EMERGENCY

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10. BLOOD GROUPS - QUICK REFERENCE

• O Negative = Universal RBC Donor
• AB Positive = Universal Plasma Donor

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11. SUMMARY TABLE - BLOOD PRODUCTS AT A GLANCE

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ARTERIAL BLOOD GAS (ABG) - Complete Details

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WHAT IS ABG?

• How well the lungs are working (oxygenation and ventilation)
• Acid-base balance of the body

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NORMAL ABG VALUES (Must Memorize)

Quick Memory Trick:

• pH = Lungs + Kidneys balance
• PaCO2 = Lungs control this (respiratory indicator)
• HCO3- = Kidneys control this (metabolic indicator)

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HOW TO INTERPRET ABG - STEP BY STEP

• pH < 7.35 = Acidosis
• pH > 7.45 = Alkalosis

• PaCO2 > 45 = Respiratory cause
• HCO3 < 22 = Metabolic cause

• Anion Gap = Na+ - (Cl- + HCO3-)
• Normal = 8-12 mEq/L

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ABG INTERPRETATION FLOWCHART

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THE 4 RESULTS OF ABG - ONE BY ONE

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RESULT 1: RESPIRATORY ACIDOSIS

Definition

ABG Values:

Simple Rule:

pH ↓ + PaCO2 ↑ = Respiratory Acidosis

Mechanism:

• Hypoventilation → CO2 builds up in blood
• CO2 + H2O → H2CO3 (Carbonic acid) → pH falls
• Lungs are the problem

Causes (Emergency Medicine):

Compensation:

• Kidneys compensate (slow - takes 3-5 days)
• Kidneys retain HCO3- → HCO3 rises to correct pH
• Acute: HCO3 rises 1 mEq/L per 10 mmHg rise in PaCO2
• Chronic: HCO3 rises 3.5 mEq/L per 10 mmHg rise in PaCO2

Clinical Features:

• Dyspnoea, confusion
• CO2 narcosis - drowsiness, headache
• Flushed, warm skin (vasodilation due to CO2)
• Cyanosis (in severe cases)
• Papilloedema (raised ICP from CO2-induced cerebral vasodilation)

Emergency Management:

1. Open airway - head tilt, chin lift, jaw thrust
2. Bag-Valve-Mask (BVM) ventilation
3. Intubation if not breathing
4. Treat cause (naloxone for opioid OD, bronchodilators for asthma)
5. Non-invasive ventilation (NIV/BiPAP) for COPD
6. Do NOT give NaHCO3 (controversial, not effective in respiratory acidosis)

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RESULT 2: RESPIRATORY ALKALOSIS

Definition

ABG Values:

Simple Rule:

pH ↑ + PaCO2 ↓ = Respiratory Alkalosis

Mechanism:

• Hyperventilation → too much CO2 blown out
• Less carbonic acid → pH rises
• Lungs are over-working

Causes (Emergency Medicine):

Compensation:

• Kidneys compensate (slow - 2-3 days)
• Kidneys excrete HCO3- → HCO3 falls
• Acute: HCO3 falls 2 mEq/L per 10 mmHg fall in PaCO2
• Chronic: HCO3 falls 5 mEq/L per 10 mmHg fall in PaCO2

Clinical Features:

• Tingling / numbness of hands, feet, lips (perioral)
• Carpopedal spasm (Chvostek's / Trousseau's sign in severe cases)
• Light-headedness, dizziness
• Palpitations
• Chest tightness
• Syncope (fainting)

Emergency Management:

1. Reassure the patient (if anxiety-related)
2. Rebreathing into a paper bag (for hyperventilation syndrome - controversial now)
3. Treat the underlying cause (PE: anticoagulation; fever: antipyretics)
4. For mechanically ventilated patients: reduce respiratory rate or tidal volume
5. Pain management if pain is the cause

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RESULT 3: METABOLIC ACIDOSIS

Definition

ABG Values:

Simple Rule:

pH ↓ + HCO3 ↓ = Metabolic Acidosis

Mechanism:

• Acid accumulates in body OR bicarbonate is lost
• pH falls
• Kidneys or metabolism is the problem
• Lungs try to compensate by blowing off CO2 (deep fast breathing)

ANION GAP - Important Classification:

High Anion Gap Metabolic Acidosis (HAGMA):

Normal Anion Gap Metabolic Acidosis (NAGMA):

• Diarrhoea (loss of HCO3)
• Renal Tubular Acidosis (RTA)
• Fistulas (pancreatic, small bowel)
• Addison's disease
• Dilutional (excess IV normal saline)

Compensation:

• Lungs compensate (fast - minutes to hours)
• Hyperventilation to blow off CO2
• Winter's Formula: Expected PaCO2 = (1.5 × HCO3) + 8 ± 2
• Classic: Kussmaul breathing - deep, rapid, laboured breathing (seen in DKA)

Clinical Features:

• Deep rapid breathing (Kussmaul)
• Fruity breath (DKA)
• Confusion, drowsiness
• Hypotension, shock
• Weakness, fatigue
• Nausea, vomiting
• Cardiac arrhythmias (severe)

Emergency Management:

1. Treat the underlying cause
   • DKA: Insulin + IV fluids + K+ replacement
   • Sepsis/Lactic acidosis: Antibiotics + fluid resuscitation
   • Renal failure: Dialysis
   • Poisoning: Specific antidote
2. NaHCO3 (Sodium Bicarbonate):
   • Give ONLY when pH < 7.1 or severe symptomatic acidosis
   • Dose: 1-2 mEq/kg IV slow infusion
   • NOT routinely given for DKA
3. IV fluids (correct hypovolaemia)
4. Oxygen therapy
5. Monitor ECG for arrhythmias

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RESULT 4: METABOLIC ALKALOSIS

Definition

ABG Values:

Simple Rule:

pH ↑ + HCO3 ↑ = Metabolic Alkalosis

Mechanism:

• Acid is lost from the body OR bicarbonate accumulates
• pH rises
• Kidneys/GI tract is the problem
• Lungs try to compensate by retaining CO2 (slow, shallow breathing)

Causes (Emergency Medicine):

Compensation:

• Lungs compensate (limited)
• Hypoventilation to retain CO2
• Expected PaCO2 = 0.7 × HCO3 + 21 ± 2
• Limited compensation - body won't let PaO2 drop too much

Classification by Urine Chloride (Cl-):

Clinical Features:

• Nausea, vomiting
• Muscle weakness, cramps
• Tetany (in severe cases - low ionised calcium due to high pH)
• Confusion, seizures
• Cardiac arrhythmias (especially with hypokalemia)
• Slow, shallow breathing (hypoventilation compensation)

Emergency Management:

1. IV Normal Saline (0.9% NaCl) - first line if volume depleted
2. Potassium replacement (KCl IV) - essential, correct hypokalaemia
3. Stop the cause - stop diuretics, stop NG suction if possible
4. Acetazolamide - used in critically ill, makes kidneys excrete HCO3-
5. Spironolactone - for hyperaldosteronism
6. HCl via central line - for severe refractory cases
7. Dialysis - if in renal failure

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QUICK COMPARISON TABLE - ALL 4 ABG RESULTS

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SAMPLE ABG QUESTIONS (Exam Practice)

• pH low → Acidosis
• PaCO2 high → Respiratory Acidosis (uncompensated)

• pH high → Alkalosis
• PaCO2 low → Respiratory Alkalosis

• pH low → Acidosis
• HCO3 low → Metabolic Acidosis (with respiratory compensation)

• pH high → Alkalosis
• HCO3 high → Metabolic Alkalosis (with respiratory compensation)

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EMTC HANDOVER AND REFERRAL SHEET

Emergency Medicine and Trauma Care

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PART A: WHAT IS A HANDOVER?

Why is Handover Important?

• Prevents errors in patient care
• Ensures continuity of treatment
• Reduces risk of missed information
• Legally required documentation
• Protects both patient and staff

When is Handover Done?

• Shift change (duty handover)
• Department to department (ED to ICU, ED to OT)
• Inter-hospital transfer (referral)
• Pre-hospital to ED (ambulance to emergency team)
• ED to ward (admission handover)

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PART B: HANDOVER PROTOCOLS

PROTOCOL 1: SBAR (Most commonly used in India)

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PROTOCOL 2: MIST (Used in Trauma / Pre-hospital handover)

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PROTOCOL 3: IMIST-AMBO (Paramedic to ED Handover)

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PART C: EMTC DUTY HANDOVER SHEET

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╔══════════════════════════════════════════════════════════╗
║         EMTC DUTY HANDOVER SHEET                         ║
║         Emergency Medicine & Trauma Care                  ║
╚══════════════════════════════════════════════════════════╝

HOSPITAL: ___________________________  DATE: ____________

DEPARTMENT: Emergency / Casualty / Trauma Bay / ICU

HANDOVER FROM: _______________________ DESIGNATION: ________
               (Outgoing Staff)

HANDOVER TO:   _______________________ DESIGNATION: ________
               (Incoming Staff)

SHIFT TIMING:  ___:___ to ___:___ hrs

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SECTION 1: ACTIVE PATIENT LIST

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SECTION 2: CRITICAL / HIGH PRIORITY PATIENTS

Patient 1:
Name: _________________ Age/Sex: _____ Bed: ____
Diagnosis: ___________________________________________
Current Vitals: BP: ___ HR: ___ RR: ___ SpO2: ___ Temp: ___
GCS: ___/15
IV Access: _______ Drips running: ______________________
Investigations pending: _______________________________
Action required: _____________________________________

Patient 2:
Name: _________________ Age/Sex: _____ Bed: ____
Diagnosis: ___________________________________________
Current Vitals: BP: ___ HR: ___ RR: ___ SpO2: ___ Temp: ___
GCS: ___/15
Investigations pending: _______________________________
Action required: _____________________________________

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SECTION 3: MEDICATIONS / DRIPS TO WATCH

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SECTION 4: PENDING INVESTIGATIONS

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SECTION 5: EVENTS DURING SHIFT

□ Any cardiac arrest / resuscitation: YES / NO
  Details: ___________________________________________

□ Any deaths during shift: YES / NO
  Details: ___________________________________________

□ Any referrals made: YES / NO
  Details: ___________________________________________

□ Any complaints / incidents: YES / NO
  Details: ___________________________________________

□ Equipment issues: YES / NO
  Details: ___________________________________________

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SECTION 6: EQUIPMENT STATUS CHECK

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SECTION 7: SIGNATURES

Outgoing Staff Signature: ____________  Time: ________
Name: ________________________________

Incoming Staff Signature: ____________  Time: ________
Name: ________________________________

Supervisor / Sr. Nurse / MO Signature: ______________

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PART D: EMTC REFERRAL SHEET

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╔══════════════════════════════════════════════════════════╗
║              EMTC PATIENT REFERRAL SHEET                 ║
║         Emergency Medicine & Trauma Care                  ║
╚══════════════════════════════════════════════════════════╝

HOSPITAL NAME: _________________________________
DATE: _______________    TIME: _________________
REFERRAL NO.: __________

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SECTION A: PATIENT DETAILS

Patient Name:    ________________________________________
Age:  _____ years    Sex: M / F / Others
IP / OP Number:  _______________
Address:         ________________________________________
Mobile No.:      _______________
Attender Name:   _______________  Relation: ____________

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SECTION B: REFERRAL INFORMATION

Referred FROM: Department: ______________
               Hospital:   ______________
               Doctor Name: _____________  Designation: _________
               Contact No.: _____________

Referred TO:   Department: ______________
               Hospital:   ______________
               Doctor Name: _____________  Designation: _________

Reason for Referral:
□ Higher level of care required
□ Specialist consultation needed - Specialty: _______________
□ Facility/equipment not available
□ Patient request
□ ICU bed not available
□ Surgical intervention required
□ Other: _____________________________

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SECTION C: CLINICAL SUMMARY (SBAR FORMAT)

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
S - SITUATION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Chief Complaint: ___________________________________
Duration of Illness: _______________________________
Mechanism (if trauma): ______________________________

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
B - BACKGROUND
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Past Medical History:
□ Diabetes  □ Hypertension  □ CAD  □ Asthma  □ CKD  □ Nil
Others: ____________________________________________

Past Surgical History: _____________________________
Current Medications: _______________________________
Allergies: __________________ (Drug / Food / Others)
Immunisation Status: _______________________________

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
A - ASSESSMENT (Vitals & Clinical Findings)
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Triage Category:  □ Red (Immediate)  □ Yellow (Urgent)
                  □ Green (Minor)    □ Black (Expectant)

VITAL SIGNS AT TIME OF REFERRAL:
Blood Pressure:     ______ / ______ mmHg
Heart Rate:         ______ /min    Rhythm: Regular / Irregular
Respiratory Rate:   ______ /min
SpO2:              ______ %  (on Room Air / O2 ___ L/min)
Temperature:        ______ °C
Blood Sugar (RBS):  ______ mg/dL
GCS:               E___ V___ M___  Total: ___ /15
Pain Score (VAS):  ______ /10
Weight (if known): ______ kg

PUPILS:  Right: ____mm  Reactive: Y/N
         Left:  ____mm  Reactive: Y/N

Airway Status:
□ Patent and self-maintained
□ Maintained with airway adjunct (OPA/NPA)
□ Intubated  ETT size: _____  Depth: _____ cm
□ Surgical airway (Cricothyrotomy / Tracheostomy)

Breathing: □ Spontaneous  □ Assisted  □ Ventilated
           Mode: _________  FiO2: _____  PEEP: _____

Circulation:
IV Access: □ Peripheral  □ Central  □ Intraosseous
           Site: _____________  Size: _____G

Skin: □ Warm  □ Cold  □ Clammy  □ Mottled
Capillary refill: ______ seconds

Working Diagnosis:
___________________________________________________
___________________________________________________

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
R - RECOMMENDATION / TREATMENT GIVEN
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Treatment Given Before Referral:
□ O2 therapy - Type: _________ Flow rate: _____ L/min
□ IV Fluids - Type: _________  Volume: _____ mL  Rate: _____
□ IV/IM Medications Given:
  1. _____________________ Dose: _____ Route: _____ Time: _____
  2. _____________________ Dose: _____ Route: _____ Time: _____
  3. _____________________ Dose: _____ Route: _____ Time: _____

□ CPR performed: YES / NO  Duration: _______
□ Defibrillation: YES / NO  Joules: _______
□ Wound dressing: YES / NO
□ Splinting/immobilisation: YES / NO  Part: _________
□ NG Tube inserted: YES / NO  Size: _____
□ Urinary Catheter: YES / NO  Size: _____
□ Blood transfusion started: YES / NO
  Type: _______  Units: _____ Group: _____

Reason for Continuing Management at Receiving Centre:
___________________________________________________

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SECTION D: INVESTIGATIONS DONE

Lab Results Sent with Patient: YES / NO

CBC: Hb: ___ WBC: ___ Platelets: ___ PCV: ___
RFT: Urea: ___ Creatinine: ___ Na: ___ K: ___
LFT: Total Bili: ___ ALT: ___ AST: ___
Coagulation: PT: ___ INR: ___ aPTT: ___
Blood Sugar: _____ mg/dL
ABG: pH: ___ PaCO2: ___ PaO2: ___ HCO3: ___ SpO2: ___
Cardiac Markers: Trop I/T: ___  CK-MB: ___  BNP: ___
Lactate: ___ mmol/L

Imaging:
□ X-ray: _________________ Findings: ___________________
□ ECG: __________________ Findings: ___________________
□ USG/FAST: _____________ Findings: ___________________
□ CT Scan: ______________ Findings: ___________________

Other investigations: ________________________________

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SECTION E: TRANSPORT DETAILS

Mode of Transport:
□ Ambulance (BLS)    □ Ambulance (ALS/ACLS)
□ Patient's own vehicle  □ Air ambulance

Oxygen during transport:  YES / NO
Monitoring during transport:
□ Pulse Oximetry   □ ECG   □ BP   □ ETCO2   □ Ventilator

Staff accompanying:
Name: ________________________ Designation: _____________
Contact during transport: _____________________________

Documents sent with patient:
□ This Referral Sheet
□ Discharge Summary / Case Sheet copy
□ All Lab Reports
□ Imaging (X-ray, CD)
□ ECG copy
□ Consent form for transfer
□ Medico-legal documents (if applicable)

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SECTION F: CONSENT AND SIGNATURES

Patient / Attender Consent for Transfer: YES / NO

Attender Name: _________________ Signature: ___________
Relationship: __________________

Referring Doctor:
Name: __________________________ Sign: ________________
Designation: ____________________
Registration No.: ________________
Date & Time: ____________________

Receiving Hospital Contact:
Hospital Name: __________________
Doctor Informed: ________________ Time: _______________
Bed confirmed: YES / NO   Ward/ICU: __________________

Senior Doctor Approval for Transfer:
Name: __________________________ Sign: ________________

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PART E: INTER-HOSPITAL REFERRAL - KEY POINTS

WHEN TO REFER (Indications):

1. Facility or specialist not available at current centre
2. Patient requires higher level of care (ICU, Neurosurgery, Cardiac Cath Lab)
3. Bed not available in current hospital
4. Patient or family request transfer
5. MLC (Medico-Legal Cases) - as directed by police/court

BEFORE TRANSFERRING - CHECKLIST:

• Patient stabilised as much as possible
• Receiving hospital informed and confirmed bed
• All documents prepared and handed over
• Patient/attender consent obtained
• Appropriate transport arranged
• Trained staff accompanying patient
• Equipment and drugs loaded in ambulance
• IV access secured, fluids running
• Airway secured if needed before transfer
• Time-sensitive conditions (stroke, STEMI) - notify receiving team early

GOLDEN RULE:

"Stabilise before you mobilise" Never transfer an unstable patient without securing airway, breathing, and circulation first.

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PART F: COMMON REFERRAL ACRONYM - ACCEPT

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PART G: SAMPLE FILLED REFERRAL (Practice)

Patient: Mr. Rajan, 55yrs Male, IP No. 1234
Date: 20/07/2026  Time: 01:30 hrs

SITUATION:
Patient brought to ED after Road Traffic Accident.
H/O unrestrained driver, frontal collision at high speed.
GCS on arrival: 10/15 (E3V3M4)

BACKGROUND:
Known hypertensive on Amlodipine 5mg OD.
No known drug allergy.

ASSESSMENT:
BP: 90/60  HR: 124  RR: 28  SpO2: 91% on 10L NRM
GCS: 10/15  Pupils: R - 4mm sluggish, L - 2mm reactive
Suspected traumatic brain injury + haemothorax

RECOMMENDATION:
Patient requires emergency CT brain + chest,
Neurosurgical and Cardiothoracic consult.
Facility not available at this centre.
Referring to Government General Hospital Trauma Centre.

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• Copy PART C as your duty handover template
• Copy PART D as your referral sheet template
• Write one sample filled case using PART G format

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PAGE 1: SCORPION STING 🦂

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DEFINITION

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VENOM MECHANISM

• Scorpion venom contains neurotoxins that keep sodium channels open
• This causes massive release of catecholamines (adrenaline, noradrenaline)
• Results in autonomic storm - both sympathetic and parasympathetic overactivation

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GRADES OF SCORPION STING (Clinical Grading)

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CLINICAL FEATURES

Local:

• Severe burning pain at sting site
• Swelling, redness, ecchymosis
• Paresthesia (tingling/numbness)
• Tap test positive - tapping on sting site increases pain

Systemic (Autonomic Storm):

Neuromuscular:

• Muscle twitching, jerking (can look like seizure)
• Blurred vision, abnormal eye movements
• Slurred speech
• Difficulty swallowing secretions

Cardiovascular (Severe):

• Acute pulmonary oedema (most common cause of death)
• Myocarditis
• Cardiogenic shock

Other:

• Hyperthermia
• Rhabdomyolysis
• Acidosis
• Acute kidney injury (Hemiscorpius species - cytotoxic)

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INVESTIGATIONS

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EMERGENCY MANAGEMENT

Step 1 - Stabilise (ABC)

• Airway: Maintain; intubate if GCS falls
• Breathing: O2 therapy; mechanical ventilation if pulmonary oedema
• Circulation: IV access, ECG monitoring, fluid management

Step 2 - Local Care

• Do NOT incise or suck the sting site
• Apply cold pack / ice pack to slow venom absorption
• Pressure dressing around site
• Keep patient calm and still

Step 3 - Drug Treatment

Step 4 - Antivenom

• Scorpion Antivenom (Polyvalent, India - Bharat Serums)
• Given IV diluted in 100 mL NS over 30 min
• Effective against Mesobuthus tamulus (Indian Red Scorpion)
• Indicated for Grade II and Grade III envenomation
• Keep adrenaline ready for anaphylaxis

Step 5 - Tetanus Prophylaxis

• TT injection if not vaccinated in last 5 years

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DISPOSITION

• Grade I: Observe 4-6 hours, discharge with advice
• Grade II/III: ICU admission, monitor ECG, BP, SpO2 continuously
• Symptoms peak at ~5 hours; resolve in 24-48 hours
• Pain and paresthesia may last weeks

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KEY POINT FOR INDIA 🇮🇳

Prazosin is the specific treatment for Indian Red Scorpion (Mesobuthus tamulus) sting. It is NOT available in some countries but is the drug of choice in India. Give early before pulmonary oedema develops.

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PAGE 2: DOG BITE WITH RABIES (RIG/Vaccine)

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DEFINITION

1. Wound management (infection, tetanus)
2. Rabies Post-Exposure Prophylaxis (PEP) - the most critical step

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RABIES - KEY FACTS

• Caused by Rabies Lyssavirus - a Rhabdovirus
• Transmitted via saliva of infected animal through bite, scratch, or mucous membrane contact
• 100% fatal once clinical symptoms develop
• Incubation period: 1-3 months (range: 1 week to 1 year)
• Virus travels via peripheral nerves to the brain (retrograde axonal transport)
• India accounts for 36% of global rabies deaths (approximately 20,000/year)

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WHO CLASSIFICATION OF BITE (Category System)

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WOUND MANAGEMENT (First and Most Important Step)

"Immediate wound washing is the single most important first aid measure"

Steps:

1. Wash wound immediately with soap and water for minimum 15 minutes
2. Apply 70% alcohol / povidone iodine - viricidal
3. Do NOT suture the wound immediately (allows virus to escape)
   • If suturing needed (cosmetic/large wound), give RIG first, then suture after 2-4 hours
4. Do NOT cover tightly - leave slightly open
5. Debride devitalised tissue if present
6. Assess wound depth and nerve/tendon involvement

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RABIES POST-EXPOSURE PROPHYLAXIS (PEP)

TWO COMPONENTS:

1. RIG - Rabies Immunoglobulin (Passive Immunity - Immediate Protection)

Key Rules for RIG:

• Give on Day 0 only (same day as first vaccine)
• Maximum dose of infiltration INTO wound first; remaining IM
• If anatomically impossible to inject all into wound, give remainder IM at a site away from vaccine
• Do NOT give RIG and vaccine in the same syringe or same site
• RIG gives immediate antibodies for 7-10 days until vaccine kicks in
• If RIG not given on Day 0, give up to Day 7 (after that, not needed)

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2. RABIES VACCINE (Active Immunity - Long-term Protection)

Schedule - ESSEN Protocol (5 Dose - IM):

Alternative - Zagreb Protocol (4 Dose - 2-1-1):

Note: In India, WHO recommends the Essen 5-dose IM protocol or the Updated 4-dose protocol (Days 0,3,7,14)

Vaccine Types Available in India:

• PCECV - Purified Chick Embryo Cell Vaccine (Rabipur)
• PVRV - Purified Vero Cell Vaccine (Verorab, Abhayrab)
• Give in deltoid muscle (adults) or anterolateral thigh (children)
• Never give in gluteal region (poor immune response)

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TETANUS PROPHYLAXIS (Mandatory for all Dog Bites)

• TT dose: 0.5 mL IM (deltoid)
• TIG dose: 250 IU IM (if unvaccinated)

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ANTIBIOTIC PROPHYLAXIS

• Bacteria in dog mouth: Pasteurella multocida, Staphylococcus, Capnocytophaga canimorsus

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ANIMAL OBSERVATION RULE

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COMPLETE EMERGENCY MANAGEMENT SUMMARY

Dog Bite Patient Arrives
         ↓
1. WOUND WASH - Soap + water 15 min + Povidone iodine
         ↓
2. ASSESS - WHO Category (I / II / III)?
         ↓
Category III → RIG Day 0 + Vaccine Day 0,3,7,14,28
Category II  → Vaccine Day 0,3,7,14,28 (No RIG)
         ↓
3. Tetanus Prophylaxis (TT ± TIG)
         ↓
4. Antibiotics (Amoxicillin-Clavulanate 5-7 days)
         ↓
5. Analgesics (Paracetamol / Ibuprofen)
         ↓
6. Document MLC if required (unprovoked bite)
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7. Advise patient on vaccine return dates
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8. Animal observation / report to health authorities

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WHEN IS PEP NOT NEEDED?

• Category I exposure only
• Bite by rodent (rat, squirrel, rabbit) - almost never rabid
• Previously fully vaccinated individuals with documented titre (may need 2 booster doses only, no RIG)

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QUICK MEMORY TABLE

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