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Chest X-Ray (PA View)

Impression: Normal chest radiograph. No acute cardiopulmonary abnormality.

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ECG (12-Lead) - Settings: 25 mm/s, 7.5 mm/mV, Heart Rate: 74 bpm

Impression: Normal 12-lead ECG. Normal sinus rhythm at 74 bpm. No ischaemic, conduction, or structural abnormality.

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Chest X-Ray (PA View) — Abhijit Majhi, 28M | 24/7/26

Technical Adequacy

• Well-centered, no rotation (clavicle heads equidistant from spine)
• Adequate inspiration (~10 posterior ribs visible)
• Appropriate penetration; full coverage of apices and costophrenic angles
• Scapulae rotated out of lung fields

Lung Fields

• Both lung fields are clear and symmetrically aerated
• No consolidation, collapse, nodule, mass, or opacity
• No interstitial/reticular pattern
• Normal bronchovascular markings tapering to periphery

Cardiac Silhouette

• Normal size - cardiothoracic ratio well < 50%
• Normal cardiac contours; no chamber enlargement

Mediastinum & Trachea

• Trachea midline and patent
• Normal mediastinal width and contours
• Aortic knob normal in size and position

Hila

• Bilateral hila normal in size, shape, and density
• Left hilum appropriately slightly higher than right
• No hilar lymphadenopathy or masses

Pleura & Diaphragm

• Both costophrenic and cardiophrenic angles sharp and clear
• No pleural effusion, thickening, or pneumothorax
• Smooth diaphragmatic domes, normal position
• Normal gastric air bubble under left hemidiaphragm

Bones & Soft Tissues

• Ribs, clavicles, and thoracic vertebrae intact
• No fractures, lytic or blastic lesions
• Soft tissues normal

Impression: Normal chest radiograph. No acute cardiopulmonary abnormality.

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12-Lead ECG — Settings: 25 mm/s | 7.5 mm/mV | HR: 74 bpm

Rate & Rhythm

• Rate: 74 bpm - normal
• Rhythm: Normal sinus rhythm - P wave precedes every QRS; upright in I, II, III, aVF; inverted in aVR; constant PR interval

Axis

• Normal axis - Lead I positive, aVF positive (~0° to +90°)

Intervals

• PR interval: Normal (120-200 ms)
• QRS duration: Narrow (< 120 ms) - no bundle branch block
• QT/QTc: Appears normal for rate

Waveform Analysis

No evidence of:

• Ischaemia or infarction
• Bundle branch block
• Pre-excitation (no delta waves, PR not short)
• Ventricular hypertrophy
• Long QT syndrome
• Conduction abnormality

Impression: Normal 12-lead ECG. Normal sinus rhythm at 74 bpm. No ischaemic, conduction, or structural abnormality identified.

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🏥 Classroom Demonstration Script

First Aid for Sports Injuries, Wound Dressing & Bleeding Management

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MATERIALS NEEDED (Props to bring)

• Sterile gauze pads
• Bandage rolls (crepe/elastic)
• Adhesive plaster / Band-Aid
• Disposable gloves (2 pairs)
• Clean water bottle
• Triangular bandage / sling
• Ice pack (or demonstration cold pack)
• Marker pen (to draw "wound" on volunteer's arm)

---

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PART 1: INTRODUCTION (1-2 minutes)

"Good morning everyone! I'm [Name], an intern doctor from [Hospital]. Today we're going to learn something that every one of you might need someday - maybe on a football field, on a trek, or right here in school. We're going to talk about first aid for sports injuries."

"Quick question - raise your hand if you or your friend has ever been injured playing sports. [Pause] Almost everyone. That's exactly why this matters."

"सुप्रभात! म [नाम] हुँ, [अस्पताल] बाट आएको इन्टर्न डाक्टर। आज हामी त्यो कुरा सिक्ने छौं जुन तपाईंहरूमध्ये कसैलाई पनि एक दिन काम लाग्न सक्छ - फुटबल मैदानमा, ट्रेकिङ गर्दा, वा यही स्कूलमा। हामी खेलकुद चोटपटकको प्राथमिक उपचारबारे कुरा गर्नेछौं।"

"एउटा छिटो प्रश्न - हात उठाउनुस् यदि तपाईं वा तपाईंको साथी खेल खेल्दा कहिल्यै चोटिनुभएको छ। [रोक्नुस्] लगभग सबैजना। त्यही भएर यो कुरा महत्त्वपूर्ण छ।"

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PART 2: THE DR. ABC APPROACH — THE GOLDEN RULE (2 minutes)

"Before touching ANY injured person, we always follow a simple sequence. Remember: D-R-A-B-C"

"If at any point the person is unconscious or not breathing - STOP and call for help immediately. Dial 102 (Nepal ambulance) or shout for a teacher."

"कुनै पनि चोटिएको मान्छेलाई छुनु अघि, हामी सधैं एउटा सरल क्रम पछ्याउँछौं: D-R-A-B-C"

"यदि व्यक्ति बेहोश छ वा सास फेर्दैन भने - रोक्नुस् र तुरुन्त मद्दत माग्नुस्। 102 मा फोन गर्नुस् वा शिक्षकलाई बोलाउनुस्।"

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PART 3: SPORTS INJURIES — THE MOST COMMON ONES (2 minutes)

"In sports, the most common injuries we see are:"

1. Cuts and wounds (lacerations)
2. Sprains (twisted ankle, knee)
3. Bruises / Contusions
4. Nosebleeds
5. Fractures (broken bones)

"Today we'll focus on the top two: wounds with bleeding, and sprains."

"खेलकुदमा सबैभन्दा बढी देखिने चोटहरू:"

1. घाउ (कटेको)
2. मोच (खुट्टा वा घुँडा मुरिएको)
3. नील धब्बा
4. नाकबाट रगत आउनु
5. हड्डी भाँचिनु

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PART 4: LIVE DEMO — WOUND DRESSING (3-4 minutes)

"I need a brave volunteer. [Student comes.] Thank you! Now, imagine this mark is a cut from a fall during football. Let me show you exactly what to do."

"First - gloves on. Always. Blood can carry infections. This is not optional." (Put on gloves visibly for the class)

"पहिले - पन्जा लगाउनुस्। सधैं। रगतले संक्रमण सार्न सक्छ।"

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"Take a clean gauze pad - or a clean cloth if nothing else is available - and press firmly and directly on the wound. Do NOT lift it to check. Keep pressing for at least 10 minutes."

"The latest Red Cross and ANZCOR 2024-25 guidelines say: direct, continuous pressure is the single most effective way to stop most bleeding. Do NOT remove the dressing - if it soaks through, add more on top."

"सफा गज वा कपडा लिनुस् र घाउमाथि सिधा र दृढ रूपमा थिच्नुस्। हेर्न नउठाउनुस्। कम्तीमा १० मिनेट थिचिराख्नुस्।"

"२०२४-२५ को अन्तर्राष्ट्रिय दिशानिर्देश भन्छ: सिधा दबाब नै रगत रोक्ने सबभन्दा प्रभावकारी तरिका हो। ड्रेसिङ नहटाउनुस् - भिजे थप थप्नुस्।"

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"While pressing, raise the injured limb above the level of the heart. Gravity helps reduce blood flow to the wound."

"थिच्दै गर्दा, चोटिएको अंगलाई मुटुभन्दा माथि उठाउनुस्। गुरुत्वाकर्षणले घाउमा रगत बग्न कम गर्छ।"

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"Once bleeding stops - clean gently with clean running water or saline. Do NOT use alcohol, iodine, or hydrogen peroxide directly on the wound - these damage tissue and slow healing."

"रगत रोकिएपछि - सफा पानी वा सलाइनले बिस्तारै सफा गर्नुस्। एल्कोहल, आयोडिन, वा H₂O₂ सिधै घाउमा नहाल्नुस् - यिनले ऊतकलाई नोक्सान पुर्‍याउँछ।"

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"Apply a fresh sterile gauze pad over the wound. Then secure it with a bandage, wrapping from distal to proximal - that means from fingers upward toward the body. Not too tight - you should be able to slip one finger underneath."

"ताजा स्टेराइल गज राख्नुस् र ब्यान्डेजले टाढाबाट शरीरतर्फ बाँध्नुस् - मतलब औँलाबाट माथितर्फ। धेरै कस्सिलो नबाँध्नुस् - एउटा औँला छिर्न सक्नुपर्छ।"

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"Refer to a doctor if:"

• Bleeding does NOT stop after 10-15 minutes of pressure
• Wound is deep, gaping, or over a joint
• Signs of infection appear later: redness spreading, warmth, pus, fever

"डाक्टरकहाँ जानुस् यदि:"

• १०-१५ मिनेट थिचेपछि पनि रगत नरोकिए
• घाउ गहिरो, चौडा छ, वा जोर्नीमाथि छ
• पछि संक्रमणका संकेत देखिए: रातोपन फैलिनु, तातोपन, पीप, ज्वरो

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PART 5: LIVE DEMO — SPRAIN & RICE METHOD (2 minutes)

"Now, the most common sports injury on a football field - a twisted ankle. The international standard treatment is the RICE method:"

"Do NOT apply ice directly to skin - it can cause frostbite. Always wrap in a cloth." "Do NOT massage a fresh sprain - it increases swelling."

"अब, फुटबल मैदानमा सबैभन्दा बढी हुने चोट - खुट्टा मुरिनु। अन्तर्राष्ट्रिय मानक उपचार RICE विधि हो:"

"बरफ सिधै छालामाथि नराख्नुस् - फ्रस्टबाइट हुन्छ।" "ताजा मोचलाई म्यासेज नगर्नुस् - सुन्निन बढ्छ।"

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PART 6: NOSEBLEED — QUICK TIP (1 minute)

"One more common sports injury - nosebleed. What most people do wrong:" ❌ DO NOT tilt the head backward - blood flows down the throat, can cause vomiting ✅ DO lean slightly forward, pinch the soft part of the nose (not the hard bridge), breathe through the mouth, hold for 10-15 minutes continuously. Seek help if it doesn't stop.

"अर्को सामान्य चोट - नाकबाट रगत। अधिकांशले गलत गर्छन्:" ❌ नगर्नुस् - टाउको पछाडि नझुकाउनुस् - रगत घाँटीमा जान्छ ✅ गर्नुस् - अगाडि झुक्नुस्, नाकको नरम भाग (माथिको हड्डी होइन) थिच्नुस्, मुखबाट सास फेर्नुस्, १०-१५ मिनेट थिचिराख्नुस्

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PART 7: KEY MESSAGES — INTERACTIVE RECAP (1 minute)

"Let me hear from you - who can tell me the steps for wound dressing?" (Call on students) "What does RICE stand for?" (Quick-fire answers) "What do you NOT put directly on a wound?" (Alcohol, iodine)

1. Gloves first, always
2. Direct pressure stops most bleeding
3. RICE for sprains

"मलाई सुनाउनुस् - घाउ ड्रेसिङका चरणहरू को भन्न सक्छ?" (विद्यार्थीलाई सोध्नुस्) "RICE को अर्थ के हो?" (छिटो जवाफ)

१. पहिले पन्जा, सधैं २. सिधा दबाबले अधिकांश रगत रोकिन्छ ३. मोचको लागि RICE

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PART 8: CLOSING — CALL TO ACTION (30 seconds)

"You are Grade 11-12 students - you are old enough and smart enough to save a life. The next time someone is hurt around you, don't freeze - act. D-R-A-B-C. Gloves, pressure, elevation, RICE. You've got this." "Thank you. Any questions?"

"तपाईंहरू कक्षा ११-१२ का विद्यार्थी हुनुहुन्छ - तपाईंहरू कसैको जीवन बचाउन सक्षम र बुद्धिमान हुनुहुन्छ। अर्को पटक कोही वरिपरि घाइते हुँदा, नडराउनुस् - कदम चाल्नुस्। D-R-A-B-C। पन्जा, दबाब, उचाइ, RICE।" "धन्यवाद। कुनै प्रश्न छ?"

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QUICK REFERENCE CARD (Print & Give to Students)

SPORTS FIRST AID — QUICK GUIDE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
DRАBC → Danger, Response, Airway, Breathing, Circulation

WOUND / BLEEDING:
1. Gloves on
2. Press firmly with clean cloth/gauze (10 min)
3. Elevate limb above heart
4. Clean with water only
5. Dress with bandage (distal → proximal)

SPRAIN → RICE
Rest | Ice (cloth-wrapped, 20 min) | Compression | Elevation

NOSEBLEED → Lean FORWARD, pinch soft nose, 10-15 min

EMERGENCY → Call 102
━━━━━━━━━━━━━━━━━━━━━━━━━━━━

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Tourniquet in First Aid — What the Latest Guidelines Say

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The Short Answer: YES, but only when direct pressure fails for life-threatening limb bleeding

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1. The Hierarchy of Bleeding Control (2024-25 Guidelines)

STEP 1 ──► Direct Manual Pressure          ← ALWAYS try first
STEP 2 ──► Hemostatic dressing + Pressure  ← If deep/severe wound
STEP 3 ──► Tourniquet                      ← ONLY if Steps 1 & 2 fail
                                              AND bleeding is life-threatening
                                              AND wound is on a limb

⚠️ Important 2025 update: Limb elevation and pressure points are no longer recommended - removed from ILCOR 2025 guidelines. Direct pressure is the only first-line intervention.

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2. AHA / Red Cross 2024 Formal Recommendations

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3. When TO Use a Tourniquet ✅

• Bleeding from an arm or leg that does NOT stop with 10 minutes of firm direct pressure
• Amputation or partial amputation of a limb
• Spurting / pulsatile arterial bleeding
• Mass casualty situation where sustained pressure is not possible
• You are alone and cannot maintain pressure while calling for help

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4. When NOT to Use a Tourniquet ❌

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5. How to Apply Correctly (If Needed)

1. Position: Apply 2-3 inches (5-7 cm) above the wound (proximal), never over a joint
2. Tighten: Tighten until bleeding stops completely - a tourniquet applied loosely is dangerous (increases venous congestion without stopping arterial flow)
3. Note the time: Write the time of application on the patient's skin or the tourniquet - this is critical for the receiving medical team
4. Do NOT remove in the field once applied
5. Commercial > improvised: A proper CAT (Combat Application Tourniquet) or SAM-XT tourniquet is far more effective than cloth or rope

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6. The 2025 Controversy — Is There Harm?

• Studies from civilian and military settings (including Ukraine conflict data, 2024) suggest misuse and overuse of tourniquets may be causing preventable limb loss
• Harm was specifically linked to prolonged application > 2 hours and application without true indication
• ILCOR has commissioned a full systematic review in 2025 - results are pending
• Until that review is published, the recommendation to use tourniquets for true life-threatening limb bleeding remains unchanged

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7. Summary Table — Quick Reference

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Bottom Line for Your Classroom Script

"Tourniquets save lives - but only when used correctly and only when truly needed. Direct pressure first, always. If you apply a tourniquet, write down the time, tighten it until the bleeding fully stops, and do not remove it - let the emergency team handle the rest. Call 102."

Management of Chronic Retention of Urine

Definition & Classification

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Step 1: Immediate Assessment

• Bladder palpation/percussion - distended bladder, loss of suprapubic skin crease
• Renal function - serum creatinine, electrolytes, eGFR
• Upper tract imaging (ultrasound) - to detect hydronephrosis/hydroureter (mandatory before treatment per AUA guidelines - Berek & Novak's Gynecology)
• Post-void residual volume via bladder ultrasound/bladder scan
• Assess for infection - urine culture (chronic retention predisposes to UTI, calculi)
• IPSS symptom score and frequency-volume diary if BPH suspected

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Step 2: Decompression - Catheterisation

• Chronic retention with renal impairment/uraemia - urgent catheterisation is mandatory
• Men with low residual volume, no infection, good renal function do not necessarily need pre-operative catheterisation and can proceed directly to prostatectomy

• Urethral catheterisation is standard first-line
• Suprapubic catheter preferred over urethral for anticipated long-term drainage (lower bacteriuria and discomfort - Pfenninger & Fowler's; Campbell-Walsh)
• Clean intermittent self-catheterization (CISC) is preferred over indwelling catheter where feasible (e.g., neurogenic bladder, detrusor underactivity) - reduces infection risk and preserves bladder cycling

Critical complication after decompression: Postobstructive diuresis

• Defined as urine output >200 mL/hour for 3 consecutive hours
• Occurs due to chronic tubular dysfunction (loss of salt/water reabsorption capacity) from back-pressure
• Management:
  • Strict fluid balance monitoring, daily weight
  • Postural blood pressure checks (detect postural hypotension)
  • Daily serum electrolyte and creatinine monitoring
  • IV fluid replacement if patient cannot keep pace with losses
  • Correct anaemia (transfuse if Hb <9 g/dL, once fluid-stable)

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Step 3: Treat the Underlying Cause

If due to Bladder Outflow Obstruction (BPH is the most common cause in men)

• α-adrenergic blockers (tamsulosin, alfuzosin)
• 5α-reductase inhibitors (finasteride, dutasteride) - especially for larger prostates (>35g); combination therapy superior in glands >35g
• Watchful waiting with fluid/caffeine/alcohol modification for mild cases

1. Chronic retention with renal impairment (residual ≥200 mL + hydronephrosis/hydroureter + abnormal renal function) - ~15% of prostatectomies
2. Complications of BOO: stones, infection, diverticula
3. Recurrent haematuria from a vascular prostate
4. Severe symptoms unresponsive to medical therapy + low max flow rate (<10 mL/s) + residual 100-250 mL

• TURP (transurethral resection of prostate) - remains gold standard
• HoLEP (holmium laser enucleation) or Greenlight laser vaporization - equivalent long-term outcomes to TURP with less bleeding/shorter stay; safe in large glands (>100 mL) and on anticoagulation
• Open/robotic simple prostatectomy for very large glands
• Minimally invasive options: UroLift (prostatic urethral lift), Rezūm (water vapor), Aquablation (waterjet), prostate artery embolisation (PAE)

• Very high PVR (>1 L) - detrusor is often too weak to benefit from surgery; best managed long-term with CISC or permanent catheter (urethral or suprapubic)

If due to other causes

• Neurogenic bladder - CISC is first-line; sacral neuromodulation (SNM) is FDA-approved for chronic non-obstructive retention
• Pelvic malignancy causing extrinsic obstruction - percutaneous nephrostomy may be needed if upper tracts compromised
• Detrusor underactivity/acontractile bladder - CISC or indwelling catheter; SNM in selected non-obstructive cases

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Step 4: Long-term Follow-up

• Regular monitoring of renal function in patients managed conservatively or with long-term catheters
• Men with mild symptoms, good flow rate (>15 mL/s), and low residual (<100 mL) can be safely managed with reassurance and periodic review - low risk of progression to serious complications
• Patients on long-term catheterisation need surveillance for catheter-associated UTI, bladder stones, and (rarely) squamous metaplasia/malignancy risk with prolonged indwelling catheters

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Summary Algorithm

Chronic Urinary Retention Diagnosed
        │
        ▼
Assess: Renal function + Upper tract imaging (USG)
        │
   ┌────┴─────┐
   ▼          ▼
Low-pressure   High-pressure (hydronephrosis/renal impairment)
   │                    │
   ▼                    ▼
Trial medical Rx    URGENT catheterisation
(α-blocker ± 5-ARI)  (mandatory - do not delay)
   │                    │
   ▼                    ▼
Fails / BOO         Monitor for post-obstructive
confirmed →          diuresis (fluid/electrolyte charting)
Surgery (TURP/           │
HoLEP/others)             ▼
                    Treat underlying cause
                    (surgery once stable/fit)
   │
   ▼
PVR >1L or poor detrusor function → CISC or permanent catheter

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• Bailey and Love's Short Practice of Surgery, 28th Ed. - "Urinary Retention," "Catheterisation," "Management of Men with BPH/BOO," p. 1528-1548
• Campbell-Walsh-Wein Urology, 3-Vol Set - "Urinary Retention," "Pharmacotherapy," p. 1708-1713
• Comprehensive Clinical Nephrology, 7th Ed. - "Bladder Outflow Obstruction," p. 881-882
• Sabiston Textbook of Surgery - "Urinary Retention," p. 1959-1974
• Pfenninger and Fowler's Procedures for Primary Care, 3rd Ed. - "Long-Term Catheterization"
• Berek & Novak's Gynecology - "Etiology" and "Treatment" of chronic retention

Foley Catheter Insertion for Retention: Rapid vs. Slow Drainage?

The Historical View vs. Current Evidence

• Hypotension
• Post-obstructive diuresis
• Hematuria ("decompression hematuria" from mucosal shearing/collapse)

What the Evidence Actually Shows

"Placement of a catheter has been reported to cause post-obstructive diuresis, hypotension, and hematuria. Such problems are believed to be related to rapid bladder decompression so, historically, gradual decompression has been recommended to prevent these complications. Neither has been proven to have any clinical significance. We recommend that all patients with AUR undergo rapid and complete decompression of the bladder."

Practical Recommendation

Caveat - Chronic High-Pressure Retention

• Strict fluid balance charting
• Daily weight
• Postural BP checks
• Daily electrolytes/creatinine
• IV fluid replacement if losses outpace intake

Bottom Line

• Rosen's Emergency Medicine: Concepts and Clinical Practice - "Management" of Acute Urinary Retention, p. 1900-1902
• Morgan and Mikhail's Clinical Anesthesiology, 7th Ed. - "Techniques & Complications" of bladder catheterization, p. 246

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Chest X-Ray (PA View)

Impression: Normal chest radiograph. No acute cardiopulmonary abnormality.

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ECG (12-Lead) - Settings: 25 mm/s, 7.5 mm/mV, Heart Rate: 74 bpm

Impression: Normal 12-lead ECG. Normal sinus rhythm at 74 bpm. No ischaemic, conduction, or structural abnormality.

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Chest X-Ray (PA View) — Abhijit Majhi, 28M | 24/7/26

Technical Adequacy

• Well-centered, no rotation (clavicle heads equidistant from spine)
• Adequate inspiration (~10 posterior ribs visible)
• Appropriate penetration; full coverage of apices and costophrenic angles
• Scapulae rotated out of lung fields

Lung Fields

• Both lung fields are clear and symmetrically aerated
• No consolidation, collapse, nodule, mass, or opacity
• No interstitial/reticular pattern
• Normal bronchovascular markings tapering to periphery

Cardiac Silhouette

• Normal size - cardiothoracic ratio well < 50%
• Normal cardiac contours; no chamber enlargement

Mediastinum & Trachea

• Trachea midline and patent
• Normal mediastinal width and contours
• Aortic knob normal in size and position

Hila

• Bilateral hila normal in size, shape, and density
• Left hilum appropriately slightly higher than right
• No hilar lymphadenopathy or masses

Pleura & Diaphragm

• Both costophrenic and cardiophrenic angles sharp and clear
• No pleural effusion, thickening, or pneumothorax
• Smooth diaphragmatic domes, normal position
• Normal gastric air bubble under left hemidiaphragm

Bones & Soft Tissues

• Ribs, clavicles, and thoracic vertebrae intact
• No fractures, lytic or blastic lesions
• Soft tissues normal

Impression: Normal chest radiograph. No acute cardiopulmonary abnormality.

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12-Lead ECG — Settings: 25 mm/s | 7.5 mm/mV | HR: 74 bpm

Rate & Rhythm

• Rate: 74 bpm - normal
• Rhythm: Normal sinus rhythm - P wave precedes every QRS; upright in I, II, III, aVF; inverted in aVR; constant PR interval

Axis

• Normal axis - Lead I positive, aVF positive (~0° to +90°)

Intervals

• PR interval: Normal (120-200 ms)
• QRS duration: Narrow (< 120 ms) - no bundle branch block
• QT/QTc: Appears normal for rate

Waveform Analysis

No evidence of:

• Ischaemia or infarction
• Bundle branch block
• Pre-excitation (no delta waves, PR not short)
• Ventricular hypertrophy
• Long QT syndrome
• Conduction abnormality

Impression: Normal 12-lead ECG. Normal sinus rhythm at 74 bpm. No ischaemic, conduction, or structural abnormality identified.

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🏥 Classroom Demonstration Script

First Aid for Sports Injuries, Wound Dressing & Bleeding Management

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MATERIALS NEEDED (Props to bring)

• Sterile gauze pads
• Bandage rolls (crepe/elastic)
• Adhesive plaster / Band-Aid
• Disposable gloves (2 pairs)
• Clean water bottle
• Triangular bandage / sling
• Ice pack (or demonstration cold pack)
• Marker pen (to draw "wound" on volunteer's arm)

---

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PART 1: INTRODUCTION (1-2 minutes)

"Good morning everyone! I'm [Name], an intern doctor from [Hospital]. Today we're going to learn something that every one of you might need someday - maybe on a football field, on a trek, or right here in school. We're going to talk about first aid for sports injuries."

"Quick question - raise your hand if you or your friend has ever been injured playing sports. [Pause] Almost everyone. That's exactly why this matters."

"सुप्रभात! म [नाम] हुँ, [अस्पताल] बाट आएको इन्टर्न डाक्टर। आज हामी त्यो कुरा सिक्ने छौं जुन तपाईंहरूमध्ये कसैलाई पनि एक दिन काम लाग्न सक्छ - फुटबल मैदानमा, ट्रेकिङ गर्दा, वा यही स्कूलमा। हामी खेलकुद चोटपटकको प्राथमिक उपचारबारे कुरा गर्नेछौं।"

"एउटा छिटो प्रश्न - हात उठाउनुस् यदि तपाईं वा तपाईंको साथी खेल खेल्दा कहिल्यै चोटिनुभएको छ। [रोक्नुस्] लगभग सबैजना। त्यही भएर यो कुरा महत्त्वपूर्ण छ।"

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PART 2: THE DR. ABC APPROACH — THE GOLDEN RULE (2 minutes)

"Before touching ANY injured person, we always follow a simple sequence. Remember: D-R-A-B-C"

"If at any point the person is unconscious or not breathing - STOP and call for help immediately. Dial 102 (Nepal ambulance) or shout for a teacher."

"कुनै पनि चोटिएको मान्छेलाई छुनु अघि, हामी सधैं एउटा सरल क्रम पछ्याउँछौं: D-R-A-B-C"

"यदि व्यक्ति बेहोश छ वा सास फेर्दैन भने - रोक्नुस् र तुरुन्त मद्दत माग्नुस्। 102 मा फोन गर्नुस् वा शिक्षकलाई बोलाउनुस्।"

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PART 3: SPORTS INJURIES — THE MOST COMMON ONES (2 minutes)

"In sports, the most common injuries we see are:"

1. Cuts and wounds (lacerations)
2. Sprains (twisted ankle, knee)
3. Bruises / Contusions
4. Nosebleeds
5. Fractures (broken bones)

"Today we'll focus on the top two: wounds with bleeding, and sprains."

"खेलकुदमा सबैभन्दा बढी देखिने चोटहरू:"

1. घाउ (कटेको)
2. मोच (खुट्टा वा घुँडा मुरिएको)
3. नील धब्बा
4. नाकबाट रगत आउनु
5. हड्डी भाँचिनु

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PART 4: LIVE DEMO — WOUND DRESSING (3-4 minutes)

"I need a brave volunteer. [Student comes.] Thank you! Now, imagine this mark is a cut from a fall during football. Let me show you exactly what to do."

"First - gloves on. Always. Blood can carry infections. This is not optional." (Put on gloves visibly for the class)

"पहिले - पन्जा लगाउनुस्। सधैं। रगतले संक्रमण सार्न सक्छ।"

---

"Take a clean gauze pad - or a clean cloth if nothing else is available - and press firmly and directly on the wound. Do NOT lift it to check. Keep pressing for at least 10 minutes."

"The latest Red Cross and ANZCOR 2024-25 guidelines say: direct, continuous pressure is the single most effective way to stop most bleeding. Do NOT remove the dressing - if it soaks through, add more on top."

"सफा गज वा कपडा लिनुस् र घाउमाथि सिधा र दृढ रूपमा थिच्नुस्। हेर्न नउठाउनुस्। कम्तीमा १० मिनेट थिचिराख्नुस्।"

"२०२४-२५ को अन्तर्राष्ट्रिय दिशानिर्देश भन्छ: सिधा दबाब नै रगत रोक्ने सबभन्दा प्रभावकारी तरिका हो। ड्रेसिङ नहटाउनुस् - भिजे थप थप्नुस्।"

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"While pressing, raise the injured limb above the level of the heart. Gravity helps reduce blood flow to the wound."

"थिच्दै गर्दा, चोटिएको अंगलाई मुटुभन्दा माथि उठाउनुस्। गुरुत्वाकर्षणले घाउमा रगत बग्न कम गर्छ।"

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"Once bleeding stops - clean gently with clean running water or saline. Do NOT use alcohol, iodine, or hydrogen peroxide directly on the wound - these damage tissue and slow healing."

"रगत रोकिएपछि - सफा पानी वा सलाइनले बिस्तारै सफा गर्नुस्। एल्कोहल, आयोडिन, वा H₂O₂ सिधै घाउमा नहाल्नुस् - यिनले ऊतकलाई नोक्सान पुर्‍याउँछ।"

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"Apply a fresh sterile gauze pad over the wound. Then secure it with a bandage, wrapping from distal to proximal - that means from fingers upward toward the body. Not too tight - you should be able to slip one finger underneath."

"ताजा स्टेराइल गज राख्नुस् र ब्यान्डेजले टाढाबाट शरीरतर्फ बाँध्नुस् - मतलब औँलाबाट माथितर्फ। धेरै कस्सिलो नबाँध्नुस् - एउटा औँला छिर्न सक्नुपर्छ।"

---

"Refer to a doctor if:"

• Bleeding does NOT stop after 10-15 minutes of pressure
• Wound is deep, gaping, or over a joint
• Signs of infection appear later: redness spreading, warmth, pus, fever

"डाक्टरकहाँ जानुस् यदि:"

• १०-१५ मिनेट थिचेपछि पनि रगत नरोकिए
• घाउ गहिरो, चौडा छ, वा जोर्नीमाथि छ
• पछि संक्रमणका संकेत देखिए: रातोपन फैलिनु, तातोपन, पीप, ज्वरो

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PART 5: LIVE DEMO — SPRAIN & RICE METHOD (2 minutes)

"Now, the most common sports injury on a football field - a twisted ankle. The international standard treatment is the RICE method:"

"Do NOT apply ice directly to skin - it can cause frostbite. Always wrap in a cloth." "Do NOT massage a fresh sprain - it increases swelling."

"अब, फुटबल मैदानमा सबैभन्दा बढी हुने चोट - खुट्टा मुरिनु। अन्तर्राष्ट्रिय मानक उपचार RICE विधि हो:"

"बरफ सिधै छालामाथि नराख्नुस् - फ्रस्टबाइट हुन्छ।" "ताजा मोचलाई म्यासेज नगर्नुस् - सुन्निन बढ्छ।"

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PART 6: NOSEBLEED — QUICK TIP (1 minute)

"One more common sports injury - nosebleed. What most people do wrong:" ❌ DO NOT tilt the head backward - blood flows down the throat, can cause vomiting ✅ DO lean slightly forward, pinch the soft part of the nose (not the hard bridge), breathe through the mouth, hold for 10-15 minutes continuously. Seek help if it doesn't stop.

"अर्को सामान्य चोट - नाकबाट रगत। अधिकांशले गलत गर्छन्:" ❌ नगर्नुस् - टाउको पछाडि नझुकाउनुस् - रगत घाँटीमा जान्छ ✅ गर्नुस् - अगाडि झुक्नुस्, नाकको नरम भाग (माथिको हड्डी होइन) थिच्नुस्, मुखबाट सास फेर्नुस्, १०-१५ मिनेट थिचिराख्नुस्

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PART 7: KEY MESSAGES — INTERACTIVE RECAP (1 minute)

"Let me hear from you - who can tell me the steps for wound dressing?" (Call on students) "What does RICE stand for?" (Quick-fire answers) "What do you NOT put directly on a wound?" (Alcohol, iodine)

1. Gloves first, always
2. Direct pressure stops most bleeding
3. RICE for sprains

"मलाई सुनाउनुस् - घाउ ड्रेसिङका चरणहरू को भन्न सक्छ?" (विद्यार्थीलाई सोध्नुस्) "RICE को अर्थ के हो?" (छिटो जवाफ)

१. पहिले पन्जा, सधैं २. सिधा दबाबले अधिकांश रगत रोकिन्छ ३. मोचको लागि RICE

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PART 8: CLOSING — CALL TO ACTION (30 seconds)

"You are Grade 11-12 students - you are old enough and smart enough to save a life. The next time someone is hurt around you, don't freeze - act. D-R-A-B-C. Gloves, pressure, elevation, RICE. You've got this." "Thank you. Any questions?"

"तपाईंहरू कक्षा ११-१२ का विद्यार्थी हुनुहुन्छ - तपाईंहरू कसैको जीवन बचाउन सक्षम र बुद्धिमान हुनुहुन्छ। अर्को पटक कोही वरिपरि घाइते हुँदा, नडराउनुस् - कदम चाल्नुस्। D-R-A-B-C। पन्जा, दबाब, उचाइ, RICE।" "धन्यवाद। कुनै प्रश्न छ?"

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QUICK REFERENCE CARD (Print & Give to Students)

SPORTS FIRST AID — QUICK GUIDE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
DRАBC → Danger, Response, Airway, Breathing, Circulation

WOUND / BLEEDING:
1. Gloves on
2. Press firmly with clean cloth/gauze (10 min)
3. Elevate limb above heart
4. Clean with water only
5. Dress with bandage (distal → proximal)

SPRAIN → RICE
Rest | Ice (cloth-wrapped, 20 min) | Compression | Elevation

NOSEBLEED → Lean FORWARD, pinch soft nose, 10-15 min

EMERGENCY → Call 102
━━━━━━━━━━━━━━━━━━━━━━━━━━━━

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The Short Answer: YES, but only when direct pressure fails for life-threatening limb bleeding

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1. The Hierarchy of Bleeding Control (2024-25 Guidelines)

STEP 1 ──► Direct Manual Pressure          ← ALWAYS try first
STEP 2 ──► Hemostatic dressing + Pressure  ← If deep/severe wound
STEP 3 ──► Tourniquet                      ← ONLY if Steps 1 & 2 fail
                                              AND bleeding is life-threatening
                                              AND wound is on a limb

⚠️ Important 2025 update: Limb elevation and pressure points are no longer recommended - removed from ILCOR 2025 guidelines. Direct pressure is the only first-line intervention.

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2. AHA / Red Cross 2024 Formal Recommendations

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3. When TO Use a Tourniquet ✅

• Bleeding from an arm or leg that does NOT stop with 10 minutes of firm direct pressure
• Amputation or partial amputation of a limb
• Spurting / pulsatile arterial bleeding
• Mass casualty situation where sustained pressure is not possible
• You are alone and cannot maintain pressure while calling for help

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4. When NOT to Use a Tourniquet ❌

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5. How to Apply Correctly (If Needed)

1. Position: Apply 2-3 inches (5-7 cm) above the wound (proximal), never over a joint
2. Tighten: Tighten until bleeding stops completely - a tourniquet applied loosely is dangerous (increases venous congestion without stopping arterial flow)
3. Note the time: Write the time of application on the patient's skin or the tourniquet - this is critical for the receiving medical team
4. Do NOT remove in the field once applied
5. Commercial > improvised: A proper CAT (Combat Application Tourniquet) or SAM-XT tourniquet is far more effective than cloth or rope

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6. The 2025 Controversy — Is There Harm?

• Studies from civilian and military settings (including Ukraine conflict data, 2024) suggest misuse and overuse of tourniquets may be causing preventable limb loss
• Harm was specifically linked to prolonged application > 2 hours and application without true indication
• ILCOR has commissioned a full systematic review in 2025 - results are pending
• Until that review is published, the recommendation to use tourniquets for true life-threatening limb bleeding remains unchanged

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7. Summary Table — Quick Reference

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Bottom Line for Your Classroom Script

"Tourniquets save lives - but only when used correctly and only when truly needed. Direct pressure first, always. If you apply a tourniquet, write down the time, tighten it until the bleeding fully stops, and do not remove it - let the emergency team handle the rest. Call 102."# Management of Chronic Retention of Urine

Definition & Classification

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Step 1: Immediate Assessment

• Bladder palpation/percussion - distended bladder, loss of suprapubic skin crease
• Renal function - serum creatinine, electrolytes, eGFR
• Upper tract imaging (ultrasound) - to detect hydronephrosis/hydroureter (mandatory before treatment per AUA guidelines - Berek & Novak's Gynecology)
• Post-void residual volume via bladder ultrasound/bladder scan
• Assess for infection - urine culture (chronic retention predisposes to UTI, calculi)
• IPSS symptom score and frequency-volume diary if BPH suspected

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Step 2: Decompression - Catheterisation

• Chronic retention with renal impairment/uraemia - urgent catheterisation is mandatory
• Men with low residual volume, no infection, good renal function do not necessarily need pre-operative catheterisation and can proceed directly to prostatectomy

• Urethral catheterisation is standard first-line
• Suprapubic catheter preferred over urethral for anticipated long-term drainage (lower bacteriuria and discomfort - Pfenninger & Fowler's; Campbell-Walsh)
• Clean intermittent self-catheterization (CISC) is preferred over indwelling catheter where feasible (e.g., neurogenic bladder, detrusor underactivity) - reduces infection risk and preserves bladder cycling

Critical complication after decompression: Postobstructive diuresis

• Defined as urine output >200 mL/hour for 3 consecutive hours
• Occurs due to chronic tubular dysfunction (loss of salt/water reabsorption capacity) from back-pressure
• Management:
  • Strict fluid balance monitoring, daily weight
  • Postural blood pressure checks (detect postural hypotension)
  • Daily serum electrolyte and creatinine monitoring
  • IV fluid replacement if patient cannot keep pace with losses
  • Correct anaemia (transfuse if Hb <9 g/dL, once fluid-stable)

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Step 3: Treat the Underlying Cause

If due to Bladder Outflow Obstruction (BPH is the most common cause in men)

• α-adrenergic blockers (tamsulosin, alfuzosin)
• 5α-reductase inhibitors (finasteride, dutasteride) - especially for larger prostates (>35g); combination therapy superior in glands >35g
• Watchful waiting with fluid/caffeine/alcohol modification for mild cases

1. Chronic retention with renal impairment (residual ≥200 mL + hydronephrosis/hydroureter + abnormal renal function) - ~15% of prostatectomies
2. Complications of BOO: stones, infection, diverticula
3. Recurrent haematuria from a vascular prostate
4. Severe symptoms unresponsive to medical therapy + low max flow rate (<10 mL/s) + residual 100-250 mL

• TURP (transurethral resection of prostate) - remains gold standard
• HoLEP (holmium laser enucleation) or Greenlight laser vaporization - equivalent long-term outcomes to TURP with less bleeding/shorter stay; safe in large glands (>100 mL) and on anticoagulation
• Open/robotic simple prostatectomy for very large glands
• Minimally invasive options: UroLift (prostatic urethral lift), Rezūm (water vapor), Aquablation (waterjet), prostate artery embolisation (PAE)

• Very high PVR (>1 L) - detrusor is often too weak to benefit from surgery; best managed long-term with CISC or permanent catheter (urethral or suprapubic)

If due to other causes

• Neurogenic bladder - CISC is first-line; sacral neuromodulation (SNM) is FDA-approved for chronic non-obstructive retention
• Pelvic malignancy causing extrinsic obstruction - percutaneous nephrostomy may be needed if upper tracts compromised
• Detrusor underactivity/acontractile bladder - CISC or indwelling catheter; SNM in selected non-obstructive cases

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Step 4: Long-term Follow-up

• Regular monitoring of renal function in patients managed conservatively or with long-term catheters
• Men with mild symptoms, good flow rate (>15 mL/s), and low residual (<100 mL) can be safely managed with reassurance and periodic review - low risk of progression to serious complications
• Patients on long-term catheterisation need surveillance for catheter-associated UTI, bladder stones, and (rarely) squamous metaplasia/malignancy risk with prolonged indwelling catheters

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Summary Algorithm

Chronic Urinary Retention Diagnosed
        │
        ▼
Assess: Renal function + Upper tract imaging (USG)
        │
   ┌────┴─────┐
   ▼          ▼
Low-pressure   High-pressure (hydronephrosis/renal impairment)
   │                    │
   ▼                    ▼
Trial medical Rx    URGENT catheterisation
(α-blocker ± 5-ARI)  (mandatory - do not delay)
   │                    │
   ▼                    ▼
Fails / BOO         Monitor for post-obstructive
confirmed →          diuresis (fluid/electrolyte charting)
Surgery (TURP/           │
HoLEP/others)             ▼
                    Treat underlying cause
                    (surgery once stable/fit)
   │
   ▼
PVR >1L or poor detrusor function → CISC or permanent catheter

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• Bailey and Love's Short Practice of Surgery, 28th Ed. - "Urinary Retention," "Catheterisation," "Management of Men with BPH/BOO," p. 1528-1548
• Campbell-Walsh-Wein Urology, 3-Vol Set - "Urinary Retention," "Pharmacotherapy," p. 1708-1713
• Comprehensive Clinical Nephrology, 7th Ed. - "Bladder Outflow Obstruction," p. 881-882
• Sabiston Textbook of Surgery - "Urinary Retention," p. 1959-1974
• Pfenninger and Fowler's Procedures for Primary Care, 3rd Ed. - "Long-Term Catheterization"
• Berek & Novak's Gynecology - "Etiology" and "Treatment" of chronic retention

The Historical View vs. Current Evidence

• Hypotension
• Post-obstructive diuresis
• Hematuria ("decompression hematuria" from mucosal shearing/collapse)

What the Evidence Actually Shows

"Placement of a catheter has been reported to cause post-obstructive diuresis, hypotension, and hematuria. Such problems are believed to be related to rapid bladder decompression so, historically, gradual decompression has been recommended to prevent these complications. Neither has been proven to have any clinical significance. We recommend that all patients with AUR undergo rapid and complete decompression of the bladder."

Practical Recommendation

Caveat - Chronic High-Pressure Retention

• Strict fluid balance charting
• Daily weight
• Postural BP checks
• Daily electrolytes/creatinine
• IV fluid replacement if losses outpace intake

Bottom Line

• Rosen's Emergency Medicine: Concepts and Clinical Practice - "Management" of Acute Urinary Retention, p. 1900-1902
• Morgan and Mikhail's Clinical Anesthesiology, 7th Ed. - "Techniques & Complications" of bladder catheterization, p. 246This is a broad, high-stakes topic because management differs by age, dehydration severity, dysentery/cholera risk, nutrition, and antibiotic indications. I can tailor it for either clinical rounds or exam revision.Please choose the format you want:

1. Complete adult and child management algorithm
2. Adult acute gastroenteritis approach
3. Pediatric acute gastroenteritis approach
4. Drugs and age/weight-based doses
5. Exam-oriented detailed notes

Acute Gastroenteritis / Acute Infectious Diarrhoea

Complete Adult and Pediatric Management Algorithm

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1. First Contact: Triage and Stabilize

Acute diarrhoea ± vomiting
        │
        ├─► Is there shock, severe dehydration, altered consciousness,
        │    sepsis, peritonitis, or inability to drink?
        │
        │        YES → Resuscitate, IV/IO fluid, investigate, admit
        │
        └─► NO → Assess dehydration and red flags
                    │
                    ├─► No dehydration → Home/ambulatory Plan A
                    ├─► Some mild-moderate dehydration → ORS Plan B
                    └─► Severe dehydration / ORS failure → IV fluid Plan C

Emergency referral or admission criteria

In adults

• Shock, systolic hypotension, syncope, severe orthostatic symptoms
• Confusion, marked weakness, oliguria/anuria
• Severe dehydration or inability to retain oral fluids
• Fever with toxic appearance or sepsis
• Bloody diarrhoea with significant systemic illness
• Severe, focal, worsening, or peritoneal abdominal pain
• Suspected cholera with profuse “rice-water” stool
• Pregnancy, age >65 years with frailty, severe comorbidity
• Significant renal disease, heart failure, diabetes, inflammatory bowel disease
• Immunocompromised state
• Recent antibiotic exposure or healthcare contact with possible Clostridioides difficile
• Persistent diarrhoea ≥14 days

In children

• Lethargy, reduced consciousness, seizures, inability to drink/breastfeed
• Persistent vomiting or vomiting everything
• Severe dehydration, shock, cyanosis, hypoxaemia
• Infant <2 months with diarrhoea, especially with fever or poor feeding
• Blood in stool with toxicity or abdominal distension
• Bilious vomiting, suspected intussusception, appendicitis, or surgical abdomen
• Severe acute malnutrition, immunocompromise, serious chronic illness
• Very young infant, especially <6 months, with poor feeding or reduced urine
• No urine for many hours, sunken eyes, weak pulses, cold extremities
• Failure of oral rehydration or unsafe home circumstances

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2. Assess Dehydration

A. Adult assessment

B. Child assessment

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3. Investigations: Who Needs Testing?

Do not routinely test

Order targeted tests if red flags are present

Blood tests

• CBC
• Electrolytes, urea/creatinine, glucose, bicarbonate
• Blood culture if septic/systemically unwell

• Severe dehydration or IV rehydration needed
• Sepsis/toxic appearance
• Significant fever or bloody stool
• Oliguria, renal disease, severe comorbidity
• Diabetes, suspected electrolyte disturbance
• Elderly/frail adult or high-risk child

Stool testing

• Blood or mucus in stool, dysentery, tenesmus
• Fever ≥38.5°C, toxic appearance, sepsis
• Severe abdominal pain/tenderness
• Persistent diarrhoea, usually ≥7-14 days
• Immunocompromise
• Recent high-risk travel, outbreak, food-handler/childcare cluster
• Suspected cholera
• Before antibiotics when feasible

Specifically test for C. difficile

• Antibiotics in the preceding weeks
• Recent hospitalization or long-term care exposure
• Chemotherapy, immunosuppression, or advanced age

Imaging

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4. Rehydration: The Main Treatment

Use low-osmolarity ORS

• Sodium about 75 mmol/L
• Total osmolarity about 245 mOsm/L

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A. PLAN A: No Dehydration

Adults

• ORS or safe fluids frequently.
• Take small, frequent sips if nauseated.
• Give approximately 200-250 mL after each loose stool, more as desired.
• Continue normal light food as tolerated.

Children

• Continue breastfeeding frequently and on demand.
• Give ORS after each loose stool:
  • <2 years: 50-100 mL
  • 2-10 years: 100-200 mL
  • Older child: as much as wanted
• Give small frequent sips by spoon/cup, especially if vomiting.
• If the child vomits, wait about 5-10 minutes and restart more slowly.

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B. PLAN B: Mild to Moderate Dehydration

Children

• 10 kg child: 750 mL ORS over 4 hours.
• Give small amounts frequently: spoon, syringe, cup, or nasogastric tube if needed.

• <10 kg: 60-120 mL ORS after each stool/vomit
• ≥10 kg: 120-240 mL ORS after each stool/vomit

Adults

• Use ORS, often 2-4 L over 3-4 hours, individualized to losses, comorbidity, and clinical response.
• Frequent small volumes are preferable in vomiting.
• Reassess pulse, BP, urine output, oral tolerance, and mental state.

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C. PLAN C: Severe Dehydration, Shock, or ORS Failure

Adults

1. ABCDE assessment, oxygen if hypoxaemic, monitor vitals and urine output.
2. Two IV lines if possible.
3. Give isotonic crystalloid:
   • Ringer’s lactate preferred when available
   • Normal saline acceptable
4. In shock, give an initial bolus, commonly 20 mL/kg, then reassess perfusion, BP, lungs, and urine output.
5. Continue fluid replacement guided by ongoing losses and clinical reassessment.
6. Start ORS as soon as the patient can safely drink.

Children

1. Immediate emergency assessment and IV/IO access.
2. Use Ringer’s lactate where available; normal saline if not.
3. WHO-style severe dehydration regimen commonly totals 100 mL/kg, with timing based on age and local protocol:
   • Infants <12 months: 30 mL/kg first, then 70 mL/kg more slowly
   • Children ≥12 months: 30 mL/kg rapidly, then 70 mL/kg over the next few hours
4. Reassess frequently: pulse, perfusion, breathing, consciousness, urine, hydration signs.
5. Give ORS by mouth/NG as soon as able, usually about 5 mL/kg/hour while IV fluids are being given if the child can drink.
6. If IV access cannot be obtained promptly and the child can be managed safely, use NG ORS and urgent transfer.

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5. Nutrition

Adults

• Resume normal food early as tolerated.
• Small frequent meals are reasonable.
• Avoid excess alcohol and very sugary drinks.
• Temporary avoidance of lactose can be tried if it clearly worsens symptoms, but routine fasting is unnecessary.

Children

• Continue breastfeeding. Do not stop it.
• Resume age-appropriate normal feeds immediately after initial rehydration.
• Do not routinely dilute formula.
• Do not routinely use lactose-free formula for ordinary acute diarrhoea.
• Avoid fasting, restrictive “BRAT-only” diets, sugary drinks, and fruit juices.

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6. Medicines

A. Zinc in children

Important current WHO update

• <6 months: 10 mg daily
• ≥6 months: 20 mg daily
• for 10-14 days

B. Antiemetics

Children

• Single-dose ondansetron can facilitate ORS in a child with significant vomiting.
• A commonly used dose is 0.15 mg/kg orally, maximum 8 mg.
• Check for QT-prolongation risk, significant electrolyte abnormality, arrhythmia, or interacting drugs.
• Do not use antiemetics as a substitute for assessing dehydration or surgical pathology.
• Avoid routine multi-dose use.

Adults

• Ondansetron can be used short-term if vomiting prevents oral rehydration.
• Consider ECG/QT risk, electrolyte disturbance, and concomitant QT-prolonging drugs.

C. Antidiarrhoeal agents

Adults

• Adult patient
• Watery, non-bloody diarrhoea
• No high fever or systemic toxicity
• No concern for inflammatory/invasive diarrhoea, toxic megacolon, C. difficile, or bowel obstruction

• 4 mg initially, then 2 mg after each loose stool
• Do not exceed the product or local maximum daily dose
• Stop when stools normalize or constipation/abdominal distension develops

Children

• Do not give loperamide routinely.
• Avoid nonspecific antidiarrhoeal drugs.
• Serious adverse effects, including ileus, abdominal distension, lethargy, and deaths in young children, have been reported. IDSA guidance

D. Probiotics

• Do not make probiotics routine treatment in children. Benefits are strain-specific, inconsistent, often modest, and product quality varies.
• Avoid in immunocompromised, critically ill, or central-line patients because of rare invasive infection risk.
• WHO’s recent paediatric direction does not recommend routine probiotics because evidence is low certainty. A 2025 review/meta-analysis exists, but this does not replace guideline-directed rehydration and nutrition (PMID 40739406).

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7. Antibiotics: Use Selectively, Not Routinely

Antibiotics are NOT indicated for

• Most acute watery diarrhoea
• Typical viral gastroenteritis
• Most uncomplicated non-typhoidal Salmonella gastroenteritis
• Mild traveller’s diarrhoea
• Diarrhoea without fever, dysentery, sepsis, or high-risk features

Never give empiric antibiotics if STEC is possible

• Bloody diarrhoea with severe cramps
• Little/no fever
• Exposure to undercooked beef, unpasteurized products, outbreak exposure

Consider empiric antibiotics only if high-risk or severe disease

Pediatric bloody diarrhoea

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8. Infection Prevention and Public Health

• Hand washing with soap and water after toilet/diaper changes and before food preparation.
• In suspected norovirus or C. difficile, soap and water is preferable to relying on alcohol hand rub alone.
• Clean high-touch bathroom surfaces using an appropriate disinfectant.
• Avoid preparing food for others while symptomatic and for at least 48 hours after diarrhoea/vomiting stops, especially food handlers, childcare workers, and healthcare workers.
• Avoid swimming pools while diarrhoea continues and follow local exclusion rules.
• Notify public health authorities if there is a suspected outbreak, cholera, foodborne cluster, or notifiable pathogen.

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9. Disposition

Safe discharge if all are present

• No red flags
• No or corrected mild dehydration
• Drinking adequately and vomiting controlled
• Normal/reassuring mental state and perfusion
• Caregiver/patient understands ORS plan and return precautions
• Reliable follow-up

Review within 24 hours, or sooner, if

• Symptoms are not improving
• Ongoing vomiting limits fluids
• Urine output falls
• Fever persists or rises
• Blood/mucus appears in stool
• Abdominal pain becomes localized or severe
• Diarrhoea persists beyond 7 days, or lasts ≥14 days

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One-Page Practical Summary

ACUTE GASTROENTERITIS

1. First assess severity:
   Shock, severe dehydration, altered consciousness, sepsis,
   peritonitis, bilious vomiting, infant <2 months?
      → Emergency referral/admission and IV/IO isotonic fluid.

2. No red flags:
   Assess dehydration.

   NO DEHYDRATION:
      → ORS after each stool/vomit
      → Continue breastfeeding and normal food
      → Home advice and red flags

   MILD-MODERATE DEHYDRATION:
      → ORS 75 mL/kg over 4 hours in children
      → Adults: ORS frequent small volumes, usually 2-4 L over 3-4 h
      → Reassess

   SEVERE DEHYDRATION / ORS FAILURE:
      → IV Ringer's lactate or normal saline
      → Start ORS as soon as safe
      → Monitor glucose, electrolytes, urine output

3. Tests only for severe/high-risk cases:
   Blood/mucus, high fever, sepsis, severe dehydration,
   persistent illness, immunocompromise, travel/outbreak,
   recent antibiotics/hospitalization.

4. Medicines:
   → Zinc: current WHO conditional child recommendation is
     5 mg once daily up to 14 days, follow local protocol.
   → Ondansetron may enable ORS when vomiting is significant.
   → No loperamide in children.
   → Adult loperamide only for afebrile, non-bloody watery diarrhoea.
   → No routine probiotics.

5. Antibiotics:
   → Never routine.
   → Consider only severe dysentery, suspected cholera,
     enteric fever, sepsis, selected severe traveller's diarrhoea,
     or high-risk/immunocompromised patient.
   → Avoid antibiotics if STEC is suspected.