Emergency Medicine Clinical Protocols Evidence-Based Clinical Practice 2nd Edition Chief Editors Dr

Emergency Medicine Clinical Protocols Evidence-Based Clinical Practice 2nd Edition Chief Editors Dr. Hendry R. Sawe, MD, MMED, MBA Emergency Physician, MUHAS, and MNH Dr. Brittany Lee Murray, MD Pediatric Emergency Medicine Physician, MNH MNH | EMAT | MUHAS

Contributing Editors Dr. Upendo George, MD, MMED Emergency Physician, MNH Dr. Jennifer Jamieson, MBBS, BBiomedSc, MPH&TM EMAT Volunteer, MNH Dr. Irene B. Kulola, MD, MMED Emergency Physician, MNH Dr. Juma A. Mfinanga, MD, MMED Emergency Physician, MNH and MUHAS Authors Dr. Bhupinder Singh Resident Emergency Medicine, MUHAS Dr. Catherine Reuben Shari Resident Emergency Medicine, MUHAS Dr. Edward Amani Resident Emergency Medicine, MUHAS Dr. Meera Nariadhara Resident Emergency Medicine, MUHAS Dr. Mundenga Muller Resident Emergency Medicine, MUHAS Dr. Patrick Shao Resident Emergency Medicine, MUHAS Dr. Amiri Kaduri Resident Emergency Medicine, MUHAS Dr. Winfrida Kaihula Resident Emergency Medicine, MUHAS Dr. Ally Akrabi Resident Emergency Medicine, MUHAS Dr. Francis Sakita Resident Emergency Medicine, MUHAS Dr. Peter Mabula Resident Emergency Medicine, MUHAS Dr. Prosper Bashaka Resident Emergency Medicine, MUHAS Dr. Shahzmah Suleiman Resident Emergency Medicine, MUHAS Dr. Renatus Tarimo Resident Emergency Medicine, MUHAS Contributors i

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Preface This is the second edition of the Emergency Medicine clinical protocols (EM Protocols) of the Muhimbili National Hospital Emergency Medicine Department, which were first published in 2011. This is a compilation of the updated protocols for the management of selected common emergency conditions at the emergency department of MNH, and is applicable to acute intake areas (casualty) in Tanzania and across Africa. The protocols focus mainly on up-to-date, evidence based management of acutely ill patients presenting with undifferentiated illnesses, such as acute exacerbation of asthma, seizures, hypertensive emergencies, malaria, burns, sepsis, hypoglycemia, hypokalemia, hyperkalemia, hyperglycemic states (DKA and HHS), upper GI bleeding, rapid sequence intubation and guidelines for administration of inotropes. However, it should be noted that at times, certain recommendations are tailored towards locally available medications and resources, and therefore should be reviewed before use at any institution. The second edition of the clinical protocols was necessitated by the protocol review committee, which provided evidence of changes that needed to be incorporated to improve the first edition. Residents in Emergency Medicine, who went through evidence-based sources to implement changes from the first edition, authored the second edition. A panel of emergency physicians reviewed all the changes, going through the protocols point by point to ensure content is backed by up-to-date literature. The Emergency medicine department (EMD) at Muhimbili National Hospital (MNH) and Muhimbili University of Health and Allied Sciences (MUHAS) has played an active role in the development of the clinical protocols. The Emergency Medicine Association of Tanzania (EMAT) has endorsed the contents of the protocol and advocates for its use across Tanzania. The protocol is an open source material, NOT for sale. ii

Acknowledgements The EMD expresses its gratitude to all the members of the protocol development committee who volunteered their own time in order to review and re-review of the contents of the second edition. Original contributors of the first edition EMD thanks the original contributors of the first edition who developed and edited the contents of the first edition: Dr Teri Reynolds, Dr Hendry R. Sawe, Prof Victor Mwafongo, Dr Juma Mfinanga and Dr. Andi Tenner. The Emergency Physicians The EMD thanks the Emergency Physicians who provided their inputs during resident presentation of different drafts of the second edition; Dr. Ghaniya Mbarouk, Dr Said Kilindimo, Dr. Mgalula Sifaeli, Dr Kepha Bernard, Dr Sherin Kassamali, Dr. Hendry R. Sawe, Dr Brittany L. Murray, Dr Irene Kulola, Dr. Geminian Festo, Dr. Philip Michael, Dr. Upendo George, Dr Juma Mfinanga, Dr. Khalid Mbaya and Dr. Jennifer Jamieson. Last, but not least, thank you to all of the EMD-MNH Registrars who provided technical inputs and critiques to improve the content of the protocols. Smart phone App support The EMD thanks Hitesh J. Chohan for generously donating his time to develop Android App to support the accessibility of the contents easily. iii

Disclaimer The EMD Clinical protocols are only intended for use by qualified Emergency Medicine healthcare providers. The EM providers using the protocols must also use their own clinical judgments, knowledge and expertise when deciding whether it is appropriate to apply this protocol to any particular patient. Locally available medications and resources must always be considered in the application of the protocols. The EMD, MNH, MUHAS, EMAT, and all the providers who supported the development of the protocols do NOT assume any liability for the information contained herein, be it direct, indirect, consequential, special, exemplary, or other damages. Contact Please contact Chief Editor-Dr. Hendry Sawe by sending and e-mail to: [email protected] in case of any noted errors or suggestions for the protocols. The Chief Editor is also happy to discuss and advise medical directors, and other EM health care providers on the local implementation of these protocols with providers in acute intake areas. iv

Table of content Contributors………………………………………………………………………………………………………………….. i Preface………………………………………………………………………..………………………………………………. ii Acknowledgment…………………………………………………………………………………………………………. iii Disclaimer…………………………………………………………………..………………………………………………. iv Contact……………………………………………………………………….……………………………………………….. iv Hypoglycemia.…………………………………………………………….…………………………………..……….. 1 Rapid Sequence Intubation (RSI)………………………………….………………………………………….. 2 Seizures………………………………………………………………………………………………………………….. 3 Malaria………………………………………………………………………..…………………………………………… 4 Hypokalemia……………………………………………………………….…………………………………………… 5 Hyperkalemia……………………………………………………………..……………………………………………. 6 Pediatric Sepsis…………………………………………………………..……………………………………………. 7 Adult Sepsis………………………………………………………………..……………………………………………. 8 Asthma……………………………………………………………………….…………………………………………….. 9 Burn…………………………………………………………………………………………………………………………. 10 DKA and HHS……………………………………………………………….…………………………………………… 11 Hypertensive Urgency and Emergencies……………………….…………………………………………… 13 Inotropes and Chronotropes……………………………………………………………………………………….. 14 Nitroglycerine and Sodium Nitroprusside……………………..…………………………………………….. 17 Upper GI Bleeding………………………………………………………………………………………………………. 19 Recommended Further Readings……………………………………………………………………………… 20

1 HYPOGLYCAEMIA CONFIRMED (RBG 6 after first dose and no ECG available) OR CALCIUM CHLORIDE- 10mls of 10% Reserve for critical patients with life threatening conditions Give through a central line ADULTS: 1g IV slowly push over 3-5 min PAEDIATRICS: 20mg/kg IV slowly over 5 min *If ECG changes persist, repeat dose every 10min (or if K is still > 6 after first dose and no ECG available) 2. SHIFT K+ INTO CELLS Give glucose immediately followed by insulin. GLUCOSE ADULTS: 50ml of 50% Dextrose IV If unavailable, use 5ml/kg of 10% Dextrose PAEDIATRICS: 5ml/kg of 10% Dextrose INSULIN ADULTS: 10 IU of regular (soluble) insulin IV over 5-10 min. PAEDIATRICS: 0.1 IU/kg of regular (soluble) insulin IV over 5-10 min (maximum 10 IU) Monitor RBG every 15 min for at least 1 hour ?2-AGONISTS- SALBUTAMOL ADULTS: 10mg of nebulized PAEDIATRICS: 5years – 5mg nebulized SODIUM BICARBONATE ADULT: 50 mEq IV stat PAEDIATRICS: 1mEq/kg IV (MAX 50 mEq) 3. REMOVE K+ FROM THE BODY LOOP DIURETICS – FRUSEMIDE ADULT: 40 mg IV once PAEDIATRICS: 1mg/kg IV once (maximum 40 mg) HEMODIALYSIS/PERITONEAL DIALYSIS Definitive treatment Consult Nephrology ECG FINDINGS IN HYPERKALEMIA Slightly peaked T waves Peaked T waves P wave widens and flattens PR segment lengthens P waves disappear Prolonged QRS with bizarre morphology Bradycardia Sine wave appearance Asystole/Vfib

PAEDIATRIC SEPSIS PROTOCOL 7 Start dopamine 10mcg/kg/min for cold shock. Start adrenaline 0.05 – 0.3mcg/kg/min if resistant to dopamine or for warm shock. If no improvement, give IV hydrocortisone 1mg/kg stat Consider blood transfusion when Hb age-specific; SpO2 > 95%, urine output > 1mls/kg/hr; source control as early as possible. DISPOSITION: Patients with septic shock should receive consultation in the EMD Age Group HR RR T SBP WBC 1 month – 180 or 34 >38.5 or 22 >38.5 or 15.5 or 5 – 12 years >130 > 18 >38.5 or 13.5 or 12 – 110 > 14 >38.5 or 11 or < 4.5 RECOGNITION OF SEPSIS Sepsis: ? 2 SIRS criteria PLUS suspected/proven source of infection Severe Sepsis: Sepsis + organ dysfunction + hypo perfusion ± hypotension Septic Shock: Severe Sepsis + hypotension refractory to adequate (6L) of fluid therapy SIRS CRITERIA: See table 1 for modified SIRS criteria. INITIAL RESUSCITATION Airway: Protect as appropriate Breathing: Give Oxygen Circulation: • Establish IV / IO access and draw blood samples for investigations • FLUIDS: Administer 20ml/kg bolus of NS or RL over 5-10mins (FIRST BOLUS). If malnutrition, give 10ml/kg. Disability: Document GCS / AVPU 0 – 20 MIN 20-40 MIN REASSESSMENT Reassess after each bolus: RR, HR, capillary refill, BP, Sp02, temperature, urine output. If necessary, repeat UP TO 3 FLUID BOLUSES unless rales or hepatomegaly develop. ANTIBIOTICS First Line Treatment: IV Ceftriaxone 100g/kg + IV Metronidazole 10mg/kg PLUS Vancomycin 10mg/kg (if immunocompromised and if available) Second Line Treatment: IV Meropenem 20mg/kg TDS Adjust antibiotics based on lab results. Treat any fungal, viral or parasitic infections. IF SHOCK NOT REVERSED (AFTER 2 FLUID BOLUSES) 1-3 HRS 3 sec, reduced peripheral pulses, cool/mottled extremities Warm Shock: flash cap refill, bounding peripheral pulses, warm extremities & wide pulse pressure Modified SIRS Criteria Table 1: Modified SIRS Criteria:

ADULT SEPSIS PROTOCOL 8 If shock persists or dopamine unavailable start adrenaline infusion (refer to inotropes protocol) If no improvement, give IV hydrocortisone 200mg stat Consider blood transfusion when Hb 65mmHg; antibiotics within 60 mins; SpO2 > 94%, urine output > 0.5mls/kg/hr; source control as early as possible. DISPOSITION: Patients with septic shock should receive consultation in the EMD RECOGNITION OF SEPSIS Sepsis: ? 2 SIRS criteria PLUS suspected/proven source of infection Severe Sepsis: Sepsis + organ dysfunction + hypo perfusion ± hypotension Septic Shock: Severe Sepsis + hypotension refractory to adequate (6L) of fluid therapy SIRS CRITERIA: HR > 90 RR > 24 Temp 38 WBC 12 INITIAL RESUSCITATION Airway: Protect as appropriate Breathing: Give Oxygen Circulation: • Establish 2 x large bore IV access • FLUIDS: Administer 2L of NS or RL over 20 mins (FIRST BOLUS) • NB: Small boluses of 250-500ml in CCF Disability: Document GCS 0 – 20 MIN 20-40 MIN REASSESSMENT Reassess HR, BP, Sp02 and volume status (IVC by ultrasound). Repeat fluid bolus as necessary (2L) unless crepitations or hepatomegaly develop (SECOND BOLUS). EMPIRIC ANTIBIOTICS First Line Treatment: IV Ceftriaxone 2g + Metronidazole 500mg PLUS Vancomycin 15mg/kg (if immunocompromised or nosocomial and if available) Second Line Treatment: IV Meropenem 1g stat Adjust antibiotics based on lab results. Treat any fungal, viral or parasitic infections. IF SHOCK NOT REVERSED (AFTER 2 FLUID BOLUSES) 1-3 HRS 12 Hyperosmolality (2Na + BUN + RBG) > 320mOsm/L Ketonuria 2+ THESE CRITERIA REFLECT AN UNDERLYNG METABOLIC ACIDOSIS (NOT A HIGH GLUCOSE PROBLEM) Immediate bedside investigations: RBG, urine dipstick, VBG/ABG, sodium & potassium (repeat hourly). Further investigations: Electrolytes (re-check Na & K every 2 hours), BUN, Creatinine, Urinalysis, FBP. C/S for blood and urine if fever or localizing signs of infection are present. UPT (for all women of reproductive age). CXR and ECG (in proper clinical context). MANAGEMENT: The stepwise management of DKA / HHS is essential. 1. CORRECTION OF DEHYDRATION/ HYPOVOLEMIA (OVER 48HRS) ! Initial Bolus: IV NS 2000ml over 1 hour. In children: 20ml/kg over 1hr. ! THEN for the next 3 hours: give IV NS 1000ml per 1 hour (total of 3000ml). In children: 10ml/kg/hour. ! THEN for the next 3 hours: give IV NS 500ml per 1 hour (total of 1500ml). In children: 5mls/kg/hour. ! THEN until resolution: give IV NS 250mls per hour. In children: 2.5mls/kg/hour. NOTE: 1. During treatment if RBG 14mmol/L, switch IV DNS to Normal Saline 3. During treatment if RBG 4.5 mmol/L NO potassium replacement is necessary. Check the levels every 2 hours. ” If Potassium level is 2.5 – 4.5 mmol/L THEN: Give 10 mmol/hour, check the levels every 2 hours until level of potassium is >4.5 mmol/L ” If Potassium level is 2.5 mmol CORRECTION OF K+ FOR PAEDIATRICS ” If potassium level is > 5mmol/L, NO potassium replacement is necessary. Check the levels every 2 hours. ” If Potassium level is 2.5 – 5 mmol/L THEN: Add IV KCL 0.5 mmol/kg/hour in a bolus of NS (maximum 10mmol/hour). Repeat potassium level every 2 hours. ” If Potassium level is 2.5mmol. 3. CORRECTION OF ACIDOSIS / HYPERGLYCEMIA Dose: Start an insulin infusion at a rate of 0.1 units/kg/hr IV for both adults and children until resolution of acidosis. In case of insulin sensitivity use lower doses; 0.05units/kg/hr in adults and children. Infusion composition: Dilute 50 units regular (soluble) insulin in 50mL NS Concentration: 1 unit = 1mL DO NOT GIVE IV INSULIN BOLUS INITIALLY (? risk of cerebral edema and can exacerbate hypokalemia). Consider SC insulin 0.05U/kg when the venous pH > 7.3, serum HCO3 >16mmol/L or anion gap is normal. ” If RBG = 14mmol/L add 5% Dextrose ” If RBG