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Antipyretics
Note:- In Children, if fever is accompanied by rashes,esp vesicular or maculo papular suspect
Chickenpox or Measles respectively. In measles, the child is usually sick looking with, rashes
starting from face.
1.T Calpol/Panadol/Dolo 500mg/650mg 1-1-1-1 x 3 days( p’mol or acetaminophen)
2.T Ibugesic or brufen 200/400/600mg 1-0-1 x 3 days(ibuprofen)
3.T Meftal or ponstan 250mg/500 1-1-1x3 days(mefenamic acid)(ideal for dental pain)
4.T Pirox /Dolonex 20mg 1-0-0 x 3 days(piroxicam)
5.T Ibugesic Plus 1-0-1 ( ibuprofen+ P’mol)
6.T Meftal forte/ meftagesic(Meftal 500 + P/L 450)
For children
1.Syp P’mol(125 /5 or 250/5)(10-15 mg/kg/dose x 4 times)(C/I in less than 2 kg)
T N:- Calpol,crocin,dolo,febrinil,febrex etc.(Calpol, Dolo,Babygesic,Crocin,Febrinil dps available)
Nopain dps(15 ml) (100 /1) available, Tab 125 available
2.Syp Ibuprofen(100 /5)(8-10 mg/kg/dose x 3 times)(may precipitate aspirin induced asthma, so
don’t give to asthmatic or dyspnoeic pts).Syp ibugesic plus(ibuprofen 100 + P/L 162.5 /5 ml)
Another formula: dose in ml= wt / 2
3.Syp Meftal(50/5 or 100/5) (generally not used < 6 months)(8 mg/kg/dose x 3 times a day)
(DT-Tab 100 available); ( wt x 4/10 = dose in ml, applicable only for 100/5 formulation)
Syp Meftagesic(P/L 125 mg, mefenamic acid 50mg/5 ml)
For pregnant ladies
P ‘mol only
Vitamins
Usual dose: 1 tab od or bd
1.T Beplex forte(syp available)(vit B complex with folic acid, vit C, )
2.T Bicozinc(syp available)(vit B complex with Folic acid , vit C, Zn sulphate)
3.C Becosules(syp available)(vit B complex with Folic acid, vit C)
4.C Nutrolin B plus(syp available) (vit B complex with Folic acid, lactobacillus)
5.T Polybion (syp available)(vit B complex with Folic acid, vit C)
6.T Neurobion forte (syp available)(vit B complex)
7.T BC (β- carotene, vit E, vit C -antioxidants)
8.T Celin 500mg OD(vit C)
9.T MVT OD(multivitamins)
10.T Health Ok ( multiviamins, multiminerals, aminoacids with taurine & ginseng)
11.T Becozym C Forte OD (vit B + vit C)
For children
1.Syp/Dps A to Z(vit A,vit B complex, vit C,vit D,Fe,Se,iodine)
2.Syp Zincovit(vit A,vit B complex, vit D,vit E,Cu,Se,Zn,iodine),
3.Syp /Dps Delices(Vit A,B,D,E, aminoacids, antioxidants)
4.Syp osto-polybion D(Vit B12,Vit D3, Ca2+)
5.OH-D3 /Ultra D3 /Bon D light dps(400 IU/ml)(Vitamin D3 or cholecalciferol) 1 ml OD for infants
Iron preparations (can be given in pregnancy)
1.T Autrin(fe fumarate + folic acid +b12 +c) od
2.T Macalvit / Shelcal(ca carbonate+vit D3) od (syp Shelcal & Shelcal kid tab available)
3.T Fefol-Z(fe sulph+ folic acid +b12 +c+Zn) od
4.Syp Vitcofol(fe fumarate+ folic acid +b12)
5.T orofer –XT( 0-1-0)(elemental Fe + folic acid)Dps /Syp available
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Anti ulcerants
1.T Rantac/zinetac/aciloc 150 mg 1-0-1(ranitidine)(30 min before food)
(Ped dose 2 mg/kg/dose x 2 PO,1-2 mg/kg/dose IV ), syp rantac 75/5
2.T Pantocid 40 mg 1-0-0(pantoprazole)(30 min before food)(ped dose: 1 mg/kg/dose PO OD)
T Pantop-IT(with itopride), Pantop-L(with levosulpiride). Inj Pantop 40 mg iv od/bd
3.T Rabicip/happi/Razo 20 mg 1-0-0(rabeprazole-fast acid suppression). Inj rabicip 20 mg iv od
4.C Omez 20 mg 1-0-0 empty stomach(omeprazole)(1 hr before meal)
5.C Rabicip D/Roles-D (with domperidone) , Pantop- D( with domperidone)
6.T Lanzole 30 mg 1-0-0 (lansoprazole)
7.T Lesuride 25 mg 1-0-0; Inj Lesuride 25 mg iv od
8.Digene 2tsp tds(Simethicone+Mg(OH)2+Al(OH)2+ Na carboxymethylcellulose)
9.Gelusil MPS 2tsp tds(Simethicone+Mg(OH)2+Al(OH)2+Mg Al silicate)
10.Rantac MPS(Magaldrate+Simethicone)
11.Mucaine(Mg(OH)2+ Al(OH)2+ oxethazaine)
12.Tricaine MPS(Simethicone+Mg(OH)2+Al(OH)2 +oxethazaine)
13.Syp sucralfate (ulcer protective)
Antacids: 1-2 ml/kg/dose in infants;5-15 ml/dose every 4-6 hr in children
Note: Take antacids 2 hr before or after ingestion of the drug to prevent drug interaction
For children
Syp or Tab rantac, T Pantop, T Junior Lanzole 15 mg OD(1mg/kg/day)
For pregnant women
1. Digene 2tsp tds
2. Gelusil MPS 2tsp tds and other antacids
3.T Ranitidine, famotidine. Inj Rantac can also be given
Steam inhalation may be with
1.Vicks/amrutanjan/tulsi leaves/2-3 dps of essential oils like eucalyptus oil,camphor etc
2.Tincture Benzoin
3.Karvol Plus / Sinarest / Nosikind inhalant capsule (camphor, chlorthymol, eucalyptol, menthol,
terpineol)
COUGH
Pharyngeal demulcents provide symptomatic relief in dry cough arising from throat.
Note:give antibiotics if infection is suspected.Advise an X-ray chest, AFB sputum for otherwise
unexplained Cough>2-3 weeks not responding to antibiotics or cough with haemoptysis/chest
pain/PUO/weight loss. Advise adequate hydration to help expectoration.
For bronchodilation and expectoration:
1.Syp Ascoril / Capex bron / Bro-Zedex 2tsp tds x 3-5 days (terbutaline sulphate +bromhexine+
guaiphenesin)(Tab available)
2.Syp Bricarex A / Cosome A / avocof / Mucosolvin/ instaryl-P 2tsp tds x 3 days (terbutaline
sulphate +ambroxol hcl+ guaiphenesin)
3.Syp Asthalin expectorant 2tsp tds (salbutamol+ guaiphenesin)
Dosage: <6 yr= 5-10 ml tid, 6-12 yr= 10 ml tid
4.Syp Ambrolite-S 2tsp tds x 3 days ( salbutamol +ambroxol hcl+ guaiphenesin)
5.Syp Ambrodil-S 2tsp tds x 3 days (salbutamol +ambroxol hcl)
6.Ascoril- LS Syp or Dps(levo salbutamol +ambroxol+Guaiph)
7.Syp Dilosyn Expectorant(Methdilazine HCl+ ammon Cl+Na citrate)
8.Syp Piriton Expectorant (Chlorpheniramine maleate+ammon Cl+Na citrate)
9.Syp Grilinctus BM or instaryl(terbutaline sulphate +bromhexine)(Tab and Paed syp available)
5
(for Bronchial asthma, a/c & c/c bronchitis,bronchiolitis, other bronchospastic disorders)
10.Syp Mucolite /ambrolite 2tsp tds x 3 days (Ambroxol)
Syp Ambrodil (15/5 or 30/5) 2tsp tds <2y=7.5 mg bd, 2-5y=7.5 mg bd/tid, 6-12 y= 15 mg bid
Ambrodil/AX/xputum paed Dps (7.5 /1 ) <6 month- 0.5 ml bd,6-12 month- 1ml tds,12-24 month-
2ml tds
11.T Mucolite/ambrodil (ambroxol) 30 mg tds
12.T Bromex (BH) 8 mg bd/tds
13.T Mucinac 200/600 mg bd/tds (acetylcysteine)
For children: Syp Asthalin ( 2 /5 )(0.1-0.2 mg/kg/dose Q6H) after food.
For pregnant ladies give Syp Ascoril, Syp Grilinctus (DM hbr + guaiphenesin + CPM),
Syp Benylin expectorant(Guaifenesin +DM Hbr) or Syp Robitussin DM
Febrile seizures
Age gp →6 months to 6 yrs.
C/f: May present with frank fits or more commonly uprolling of eyes ,loss of
consciousness, they may also vomit or have increased secretions (foam at the mouth).
The body may go stiff, then generally twitch or shake (convulse).
The seizure normally lasts for less than five minutes.The child's temperature is usually
greater than 38 °C (100.4 °F)
1.Inj Diazepam 0.2mg/kg iv to be given very slowly to avoid respiratory depression(per
rectum can be given). May be repeated after 3-5 minutes if needed Or
Inj Lora 0.1 mg/kg iv st can also be given Or
Diazepam suppository 0.5 mg/kg PR(per rectum)(additional 0.25 mg/kg after 10 min if
needed)
Note:- in case of respiratory depression give painful stimulus or ambu bag for few
minutes
2.Tepid sponging + P’mol. Check GRBS.
3.Oxygen inhalation.Clothing around the neck should be loosened.
4.Semiprone position and throat suctioning
5. Protect the child from injury.Keep under observation for some time.Monitor Vitals.
Prescription on discharge as prophylaxis:-
1.Syp P’mol)( 125 /5 ) Qid
2.Syp Calmpose(Diazepam)(2/5) for first 2 days of fever(0.2-0.3mg/kg/dose x 3 times)
(T.Valium/calmpose 2/ 5 /10 mg); T Frisium (clobazam) 5/10/20 mg(0.5-1 mg/kg/day in
2 div doses) if diazepam fails. Above 3 yr start with 5 mg OD.
3.Tepid sponging SOS
Note:- the above three instructions to be followed for first 2 days whenever there
is a fever.
4.Syp Mox( 125 /5 ) tds x 5 days if any associated infection
5.Syp Nutrolin B bd x 5 days
All children below 1yr-11/2 yr presenting with first episode of febrile seizures should be
referred to higher centre after initial treatment as LP is indicated.
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Vomiting
Causes:gastroenteritis, migraine,drugs,pregnancy, food poisoning,alcoholic gastritis, renal colic,
peptic ulcer,viral hepatitis,cholecystitis, labyrinthine disorders, uremia,dengue,appendicitis,
pyelonephritis hypokalemia etc
R/o MI,CVA,raised ICT, hypertensive encephalopathy, DKA, poisoning(like
odollum-hypotension, bradycardia, weak pulse, diarrhoea)
Inv:FBC, RFT,LFT, RBS, S. Amylase,ABG,ECG, AXR, CT head etc
1 Inj Emeset(2mg /1ml) (0.1 mg/kg/dose) (Ondanestron) 4mg/8mg iv / Inj Perinorm(5mg /1ml) 1 amp iv /
Inj Stemetil(prochlorperazine) 12.5mg im ST/ Inj Phenergan(25mg /1ml) 25mg iv(0.5-1 mg/kg/dose
IM/IV in children). For severe vomiting, Inj Perinorm + Emeset can be given.
If vomiting is due to chemotherapy, give Inj Emeset 4mg iv Q3H
2.Inj Rantac 50 mg iv ST or Inj Pantop 40 mg iv st
3. Check BP, If low give IVF RL/ Isolyte P +DNS
4.T Domstal(Domperidone)10mg(5mg, 10 mg DT Tab available) 1-0-1 x 2 days(15-30 min before
meals) & SOS or T Emeset 4/8 mg bd Or T Perinorm(metoclopramide)10mg tds(30 min before
meals) or T phenergan (promethazine) 25mg bd
5.T Zofer MD 1 SOS(mouth dispersible preparation of ondanestron)
6.T Rantac 150 mg 1-0-1 x 3 days
For children:-
Syp Domstal(1mg /1ml) (0.2 mg/kg/dose x 3 times)(Domperidon) or Syp Grandem(Granisetron) (1mg /5ml)
(20 microgram/kg/dose PO) or Syp Phenergan(5mg/5ml)(1mg/kg/dose),Syp emeset or
Vomikind(2mg /5ml)(children above 5 yrs:4mg/dose PO tds, for smaller children:0.1 mg/kg/dose bd/tds),
Syp Perinorm(5/5)(0.1 mg/kg/dose; may ppt seizure)Vomistop Dps(Domperidon) 1mg /1ml ,10mg /1ml
available
For Pregnant ladies:-
T Doxinate 2 tab HS(Doxylamine + Pyridoxine) Or perinorm Or T Avomin(Phenergan) SOS & tds or
T Pregnidoxin(Meclizine HCl) SOS & tds or T Emeset.
Inj Perinorm(IV or IM) or Emeset (IV) or Phenergan(IM) can be given
Note:-In adults we may give perinorm, but it is better avoided in children as it may produce extrapyramidal
symptoms. Phenergan has the advantage that it may be used for the treatment of extrapyramidal
symptoms. It also produces some sedation.
If vomiting is due to chemotherapy , Emeset is the best.
If Drug induced extrapyramidal reaction occurs
(Drugs: antipsychotics like haloperidol,chlorpromazine, antiemetics like stemetil,cinnarizine)
1.Stop offending drug
2.T Diazepam 1 st
3.Inj diazepam 2cc IM or IV or Inj Phenergan 2cc IM or IV
Loose stools
Find out whether it is diarrhoea, pseudodiarrhoea, fecal incontinence from history
Aetiology:infection,drugs(certain antibiotics/PPI), a/c IBD, toxin, food intolerance, diverticulosis
Ask for associated fever(r/o leptospirosis), blood/pus in stools, abdominal pain,consistency of
stools etc.
1.C Zedott or Redotil 100mg (racecadotril, 1.5 mg/kg/dose in children) or Redotil 10 or 15 or 30
mg sachet x tds can also be given or
T Lomotil(atropine sulphate, diphenoxylate HCl) (C/I for children <6 yr, pregnancy)1-1-1 x 3 d
Note: Lomotil not used nowadays.
2.T Nutrolin B/ C Vizylac/C Darolac(lactobacillus combinations) 1-1-1(darolac sachet available)
3.T Cyclopam/ Buscopan 1 SOS, for abdominal pain.
4.Check BP, If low give IVF RL/ Isolyte P +DNS
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5.ORS(Electrokind, electrosip,elect) in small sips( unit dose 4.3 g packet to be mixed with 200
ml & multidose 21.5 g packet to be mixed with 1 L or 5 glasses of boiled & cooled water).
Dosage after each purge: <6months :50 ml or 1/4 glass, 6months-2years: 50-100ml(1/4-1/2
glass), 2years-5 years:100-200 ml(1/2-1 glass), >5years:as much as able to drink.If child vomits,
wait for 10 min & then resume feeding. Also give Plenty of oral fluids (home available)
6.Report blood or pus in stools
For children, also give Zn,(0.5 mg/kg/day or 10 mg daily for age 2-6 months & 20 mg for >6
months). T.N: Z & D syp/dps(Zn sulphate) or Mintonia syp(Zn acetate) x 2 weeks (syp 10 or 20
mg/5 ml or Dps 20mg/1ml). Below 2 months not indicated.
Note:- if very severe, for adults give Imodium / Lopamide 2mg ( loperamide) 2 tabs stat, then
1 tab after each episode (C/I in <4 yrs and in acute infective diarrhoea and pregnancy)
For Pregnant ladies:-
Give ORS, Darolac sachet, oral fluids
Child-hood diarrhea/ADD
No dehydration→well alert, eyes normal, tears present, mouth & tongue moist, normal thirst,
skin pinch goes back quickly:50-100 ml ORS (if <2 yr) & 100-200 ml ORS (if 2-10 yr) per purge
For >10 yrs as much as wanted. Generally,give one teaspoon every 1-2 minutes.
For some dehydration→restless, irritable, eyes sunken, tears absent, mouth & tongue dry,
thirsty & drink eagerly, skin pinch goes slowly→75 ml/kg ORS in 4 hr and if dehydration
subsides 10-20ml/kg after each stool. If not repeat 75 ml/kg ORS in 4 hr.
For severe dehydration→lethargic or unconscious, eyes very sunken & dry, tears absent,
mouth & tongue very dry, drinks poorly or unable to drink, skin pinch goes back very
slowly→IVF Ringer Lactate 30 ml/kg in ½ hr followed by 70 ml/kg in next 2 ½ hr .In infants <12
months 1 hr & 5 hr respectively
If macroscopic blood,pus,mucus, foul smell , treat as DYSENTRY. Do Stool culture.
1.T Ciplox TZ 1-0-1 x 5 days(ciplox + tinidazole)// Zenflox-OZ (ofloxacin 200 mg+ ornidazole
500 mg) (others:norflox,ampicillin,doxycyclin,cotrimoxazole)
2.C Zedott or Redotil 100mg (racecadotril) 1-1-1 x 3 days
Or T Lomotil(atropine sulphate, diphenoxylate HCl)
3.T Nutrolin B(Ped tab available)/ C Vizylac/C Darolac 1-1-1 , T VSL 3(probiotic) (0-1-0),
Syp or C Enterogermina (bacillus clausii, probiotic)Enterogermina dose: adults: 1 Capsule bd or
tds; children:1 capsule od or bd or Syp 5ml bd, breast feeding infants 5 ml od or bd for 2-5 days
4.T Cyclopam/ Buscopan 1 SOS if abdominal pain
5.Check BP, If low or if dehydrated, give IVF RL/ Isolyte P +DNS
6.T Rantac 150 mg 1-0-1(Proton Pump Inhibitors may cause drug induced diarrhea)
7.Fluid managment same as above;Plenty of oral fluids
In PEDIATRIC cases , old regime: SEPTRAN(cotrimoxazole) or GRAMONEG 300/5 (Nalidixic
acid)(55 mg/kg/day in 3-4 div doses; not to be used below 3 months) .
New regime: ciprofloxacin15mg/kg bd. Cefixime can also be given
Note:- 5 % /10% dextrose not given
Anaphylactic shock
1.Inj Adrenaline 0.5mg IM or SC(in children: 0.01 ml/kg; don’t exceed 0.5 ml per dose)
(Repeat every 5-10 min in case patient doesn’t improve);1 ml amp of 1:1000 solution, 1mg/ml
2.IV glucocorticoids(hydrocortisone sod.succinate 100-200 mg;10 mg/kg in children & max 100
mg) in severe/recurrent cases.
3.Antihistaminics (chlorpheniramine 10-20 mg) IM /slow IV
4.Put the pt in reclining position, administer O2 at high flow rate and perform cardiopulmonary
resuscitation if required.
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Patient with wheeze
Monitor SpO2 , work of breathing, Respiratory rate etc.
Note:In all cases of first episode of wheeze, r/o FB , irrespective of age(take CXR)
1.Nebulise with Salbutamol(albuterol) 1cc in 3- 4cc NS + O2 x 3 times at 20 min intervals in
moderate and severe cases(or lesser if there is clinical improvement). Dose in children is
0.03ml/kg with 3 ml NS. 150 mcg/kg/dose, but min dose is 0.5 ml or 2.5mg salbutamol.For mild
cases, one nebulization may be enough.In usual practise give, 0.5 ml for <5yrs, 1ml for >5 yrs.
In severe cases, Nebulisation can be done by combining Salbu(2.5-5mg) & Ipratropium
bromide(0.5mg) or Duolin(levosalbu + ipratropium). Ipravent dosage: <5 yr :-125 mcg(0.5ml)&
> 5 yr:- 250 mcg(1ml)(12.5 mcg/kg/dose).Budesonide :Children 12 months to 8 years of age:-
0.5 to 1mg OD, or divided and given twice a day, <1yr:0.5 mg. commonly given in croup.
Note: Inhaled salbutamol & terbutaline should not be used on any regular basis; inhaled
Salbutamol,salmetrol, ipratropium bromide,Beclomethasone,Budesonide are safe in
pregnancy.
2.Inj Deriphyllin 1 amp iv st (5mg/kg/dose IM in children)(given in pregnancy)
3.Inj Efcorlin(hydrocortisone) 100mg //Inj Methyl prednisolone 120 mg// Inj Betnesol 4 mg iv st.
For children with severe dyspnoea, administer steroids after 1st nebulization
Dose: Inj Efcorlin (10 mg/kg st & 4mg/kg Q6H), Inj Methyl pred(2mg/kg st & 1mg/kg Q6H) iv
4.T Deriphyllin retard 150 mg 1-0-1 x 5 days after food/T Theoasthalin 1-1-1(>12 yrs) or
½-½-½(if <12yrs) Or T Asthalin 4mg tds or T Bricanyl or Bricarex(Terbutaline) 5mg tds or
T Deriphyline (Theophylline Hydrate+etophylline) tds .Deriphyllin C/I in seizure
Syp Deriphyllin( 50 /5 etophylline 46.5 and theophylline 12.75)(5mg/kg/dose PO tds),
For children: Syp asthalin( 2 /5 )(0.1-0.2 mg/kg/dose Q6H or dose in ml= wt /4) After food
5. If response to bronchodilators not satisfactory, early use of steroids advised.T Prednisolone
10 mg tds X 3-5 days; for children: 1mg/kg/day in 2-3 divided doses x 3-5 days.
6.Antibiotics if associated infection(fever,purulent sputum) or ineffective cough & retention of
secretions.
7.Cough syrup containing Bronchodilator & Mucolytics
8.Advise inhalational medications if affording- Asthalin,Ventorlin(both Salbu), Budenase AQ or
Budecort or Pulmicort or Rhinocort (Budesonide)- start with 400 or 200 mcg BD & step down
with response.Others: Seroflo / Esiflo / combitide (salmeterol + fluticasone), aerocort(levosalbu+
beclomethasone), foracort (formoterol+ budesonide), maxiflo(fluticasone + formoterol).
Rotahaler or metered dose inhaler(MDI) may also be used.
Alternatives to the order 4 would be –T Theoasthalin(Salbutamol+Theophylline)(syp available),
T Unicontin 400 or 600mg(Theophylline); T Levolin(levosalbu) 1mg or 2mg(Syp 1/5)(0.05
mg/kg/dose qid); T AB Phylline(acebrophylline) 100 mg BD or Syp 50mg/5ml, 2-5 yrs 2.5 ml
bd/tds, >5 yr 5ml bd; T Doxophylline 200 mg 1-0-1 may be used instead of deriphylline, as it has
better cardiac & CNS safety profile (D phylline,Doxiflo, Doxobid, Doxoril)
For A/c Bronchiolitis, neb with 3% saline 3ml Q1-2H or alternate with salbutamol.
S/E of salbutamol & Deriphyllin : tremors, palpitation, nervousness
Common causes of shortness of breath: Asthma, pneumonia,bronchitis,hyperventilation,
pleuritis, COPD, CCF, MI, pulmonary edema,bronchiolitis, pneumothorax,FB,ILD, anxiety,
pulmonary embolism, cardiac tamponade,10 P HTN,pleural effusion,metabolic acidosis, severe
anaemia, obesity, ARDS
Signs of CO2 retention: Confusion, flapping tremor, bounding pulse. Look for associated
cardiovascular(chestpain,palpitation,sweating,nausea) or respiratory (cough, wheeze,
haemoptysis) symptoms.
Note: levolin has better cardiac safety profile than asthalin, hence preferred in cardiac patients.
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Dog Bite
( also cat,bandicoot,monkey,cattles,bats,wild animals etc)
1. Immediate flushing and washing the wounds, scratches and the adjoining areas with plenty of
soap and water for at least 10 minutes is very important.Dont squeeze/cover the wound
2. Wash with betadine/spirit
3. Inj Rabipur/verorab (rabies vaccine) 0.1ml ID on both shoulders on day 0,3,7,28
If given IM, then Rabipur 1ml or verorab 0.5 ml on day 0,3,7,14,28
(IM is given in immunocompromised pts)
4. Inj TT 0.5ml IM st if indicated
5. Advise to observe the cat /dog for 10 days & to r/w if the animal dies/behaves abnormally.
For class 3 wound, also give
6. Inj equirab 40 IU(immunizing unit)/kg [maximum dose infiltrated around the bite wound and any
remaining volume is given IM(usually gluteal region) away from the site of rabies vaccine] or
0.133ml/kg. If Human Ig : 20 IU/kg or 0.133ml/kg
For 75 kg or more: 10 ml(3000 IU equirab or 1500 IU HRIG)
7. Antibiotics like augmentin
Class 3
All bites or scratches with oozing of blood on neck, head, face, palms and fingers
Lacerated wound on any part of the body
Multiple wounds 5 or more in number
Bites from wild animals
Note:Bite wounds shouldn’t be immediately sutured; if necessary put minimum no of loose
sutures. Ideally it should be done 24-48 hrs later under the cover of anti-rabies serum locally.
If previously fully vaccinated with rabies cell culture vaccines, then only IDRV day 0,3 dose
(single site) is required. Pre-exposure Prophylaxis: IDRV 0,7, 28, 0.1 ml single site
Rabies vaccine & RIG are not contraindicated in pregnancy.
Injury
Time of arrival, time & place of occurence of injury, cause of injury, 2 id marks, brought by
whom(address also) should be noted.
1.C & D (wound toilet). Ideally with NS. Betadine, H202 , cetrimide, savlon(cetrimide+chlorhexidine)
etc may be used for contaminated wounds only.Look for any foreign body in the wound.
2.Inj TT 0.5 ml im st(Same for all age), if indicated.
3.Inj tetglob (Immunoglobulin, tetanus) 250 IU deep IM St ATD(for deep & large wounds,
contaminated wounds)(Same dose for all age)
4. Excise all devitalised tissues. Remove any foreign body in the wound. If needed, suture.
Suture the wound without any dead space inside the wound.
Materials needed:- needle holder, forceps (artery , thumb), needle(cutting/ reverse cutting-skin,
round body/tapering- fascia, soft tissue,muscle & tissues that are easy to penetrate) , suture
material-usually silk, nylon,prolene (non-absorbable) or catgut,vicryl,monocryl(absorbable). Usually
skin is sutured with 3-0 nylon or 4-0(smaller). Suture should n’t be too tight.
Don’t suture if a) underlying tendon is cut,
b) underlying bone is fractured.
c) caused by dog bite (especially stray dogs) or human bite
Give adequate support/immmobilization of the region.
Note: Primary suturing (done within 6 hrs) shouldn’t be done if there is edema/infection/
devitalised tissues/hematoma. Here delayed primary suturing (48 hrs-10 days)can be done.
This time is allowed for the oedema/hematoma to subside.Secondary suturing (10-14 days) is
done in infected wounds.
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5. Antibiotics :- C Megapen (Ampiclox)(1-1-1-1) or Ampiclox+ Metrogyl; Children: augmentin,cefixime
Metrogyl dose: 200 mg 1-0-1, syp 200/5 30-50mg/kg/24 hr div into 3 PO.Give strong antibiotics in DM
For infected wounds,ulcers give mupirocin oint(Bactroban,mupin,T-bact), futop oint (Fusidic acid)
Megaheal(colloidal silver), Neosporin powder(neosporin,polymyxinB,bacitracin Zn).
For buccal mucosal injury-Metrogyl DG gel or Dentogel. Mupirocin also given for folliculitis,
furunculosis etc.
6.Analgesics +Serratiopeptidase(anti inflammatory):- C Lyser D/Lizole- D(Diclofenac+ serrapeptase)
1-0-1 x 3 days after food; T Zymoflam-D/ Alanz-D(diclofenac, trypsin, bromelain, rutoside).
For children give syp ibugesic
For severe contusion: T chymoral forte 1-1-1-1 (trypsin, chymotrypsin) or T Zymoflam/ Rutoheal /
Enzomac ( trypsin, bromelain, rutoside)
7.Vitamins (deficiency of vit A & C -poor wound healing).
8.T.Rantac 1-0-1
9.Fluid & electrolyte balance
10. Change the dressing once in 2 days.Inspect the sutured wound in 48 hrs.
Tetanus prophylaxis in wound management
Clean, minor wounds
If uncertain h/o previous vaccination or fewer than 3 doses: give vaccine
3 or more previous doses: no need to vaccinate unless≥10 years since last dose.
All other wounds
If uncertain h/o previous vaccination or fewer than 3 doses: give vaccine & tetanus
Immunoglobulin (TIG)
3 or more previous doses: give vaccine if ≥5 years since last dose
Note: The practise of giving Inj TT every 6 months is wrong, as frequent TT may decrease
immune response.
Note:
Simple suture: - Superficial wounds, face ,neck; Mattress suture:- Deep wound, upper & lower limb.
For injuries associated with severe bleeding, do Hb, PCV.
For phlebitis, thrombophlebitis, swelled up injection sites,haematoma:
Thrombophob Oint (heparin sodium), T Serrapeptase,warm compresses, rest to the part etc.
Haematoma: If minimal may resolve spontaneously;If massive, may require drainage or
aspiration
For periorbital ecchymosis(black eye) & SCH due to trauma, :
Moxiflox/gatiflox/ciplox eye drops, cold compress, T Serratiopeptidase & ophthal consultation
For muscle injuries: ice, compression, elevation
Crush injuries:Look for degloving, compartment syndromes;Extensive removal of devitalised
tissue & fasciotomy may be required;Monitoring of Renal function & urine output is needed.
Give IV fluids generously(6 -12 L over 24 hr)
In trauma involving ear auricle: only skin is approximated & sutured with 5.0 or 4.0 prolene
(cartilage is spared).
Soft tissues of the neck:
Open wounds are frequently associated with vascular involvement. A patent airway may be
compromised by progressive soft tissue swelling. Perform pressure tamponade. Tracheostomy may
be needed.
Injury of larynx/trachea are a/w subcutaneous emphysema, airway obstruction, dysphonia, lack of
thyroid cartilage prominence.
Note on Specific Lacerations
Scalp: shaving of the hair has shown to increase the rate of infection and should n’t be performed.
Hair may be trimmed, if needed.
Lacerations of the eye lid margin or those involving the medial fifth of the lid should be referred to a
surgeon or ophthalmologist as improper repair may produce disastrous and disabling consequences.
Eyebrows must never be shaved because in a small percentage of patients, regrowth may n’t occur.
13
Abrasion
1.Inj TT 0.5 ml IM stat if indicated.
2.C & D.Preferably dressing is not necessary.
Large abrasions or skin loss lesions may be dressed with cuticell(non medicated), cuticell-c or
bactigras (chlorhexidine), jelonet(non medicated paraffin gauze dressing), cuticell plus
(polymyxin B, bacitracin, neomycin)
3.T-bact oint,Metrogyl-P Gel, Megaheal(colloidal siver), Sepgard ointment(feracrylum), Neosporin
powder/oint [zinc bacitracin, neomycin sulphate, polymyxin B sulphate], healex spray(Benzocaine
+poly vinyl polymer), cetrimide, Savlon(cetrimide+ chlorhexidine), Neosporin-H for L/A
4.Oral antibiotics , if Diabetic / multiple abrasions
5.Analgesics + Serratiopeptidase
6.Vit C, Rantac
I&D
Diagnosed based on Fluctuation.
I & D by Hilton’s method
Ask patient to lie down to avoid shock induced by pain. Start an IV fluid. Incision put
parallel to neurovascular structures.Press at root with cotton, till frank blood comes. Clean
well with betadine.Dress with GM(glycerine Mag sulf) to reduce edema at the site.
Check RBS, Urine sugar.
Suture Removal
1.Clean with Betadine
2.Cut close to skin using Blade no. 11 or 10
3.Avoid thread from outside entering inside
4.Remove intermittent sutures to prevent Gaping.
Days of suture removal:-
Thyroid- 4-5 days Scalp- 5 days Abdominal- ~10 days
Inguinal- 8-9 days Knee- 10 days Ankle,foot- 14 days
Burns
Attend only if burns <15 %. Refer large Burns to surgery.Do BRE, LFT, RFT
Put iv line before edema develops. R/o inhalational injury(burns in closed space, fire work
accidents, high velocity explosion).Rapid primary survey is performed to assess the ABCs.
Any constricting clothing and jewelry should be removed to prevent these items from exerting a
tourniquet like effect after the development of burn edema.Don’t apply ice to burns
1.Inj fortwin 1cc IM / IV st or Tramadol (& emeset). For severe burns morphine 5 mg iv Q8H
2.Clean gently with copius volume of cold water for 20 minutes, as it will minimize degree
of burns,then with betadine
3.Smear antiseptic ointment like soframycin(framycetin) for face, silverex(silver sulfadiazine)
for trunk & limbs; Fusidic acid oint(fucidin-L, fucibact, fusiderm), Betadine etc
4. Inj TT 0.5 cc IM st if indicated.
5. Inj tetglob 250 IU IM st ATD
6.Oral Antibiotics(iv antibiotics like taxim, metrogyl for severe burns)
7.IV fluids(Ringer Lactate is preferred) using parkland’s formula (4ml/% burn/ kg body
wt/24hrs) with half given during first 8 hours & remaining half given during next 16 hours.
8.Inj Dexona 2cc IV/IM Q12H x 2 days(dexamethasone) or hydrocortisone(efcorlin)
9.Inj Pantop/Rantac to prevent curling’s ulcer.
10.For severe burns requiring admission ,give O2 ,RT,CBD & measure urine output.
Note:give cold water compress,large blisters may be deroofed with a sterile needle or
aspirated; leave blisters on the palms or soles intact. Immobilisation is suggested for upper
limb burns.For chemical and eye burns irrigate with copious volume of water
14
Chest Trauma
Rapidly fatal conditions: tension pneumothorax,flail chest, open pneumothorax, massive
hemothorax,cardiac tamponade(engorged neck veins,hypotension,muffled heart sounds)
Potentially fatal conditions evolving less acutely:simple pneumothorax,Rib fracture and
contusion,blunt cardiac injury, traumatic asphyxia, thoracolumbar vertebral injury,
scapular/sternal fracture,esophageal perforation,subcutaneous emphysema,
diaphragmatic rupture, pulmonary contusion,
Diagnosis: history, physical examination, X-ray, CT etc
Immediately refer the patient to higher centre without any delay
If cold + fever:-
1.T Wikoryl or Sinarest or Febrex Plus or T-minic Plus or Tusq-P or Alex-P 1-1-1x 3 days(Syp &
Dps available) )(Pmol+Phenylephrine HCl +Chlorpheniramine maleate)(Wikoryl Dps 125/1)
2.T Rinostat or Flucold (Syp and Dps available) 1-1-1x 3 days (P’mol+Phenylpropanolamine
+CPM)
3.T Nasivion (Pmol+Phenylephrine HCl+Caffeine+Diphenhydramine HCl)
4.T Hatric 3(Pmol+ pseudoephedrine+CPM)
For cold + fever + cough
1.Syp Fluzet or Alex-P (Pmol+Phenylephrine HCl +CPM+ Dextromethorphan)
2.Syp Nasocare Plus or Pedia-3 (Pmol+Pseudoephedrine HCl +CPM+DM)
3.T Sudin+(Pmol+Phenylephrine HCl +CPM+Guaiphenesin+Bromhexine HCl)
4. Syp Sinarest (Pmol+Phenylephrine HCl +CPM+Na citrate +menthol)
Note: T Sinarest AF- with out P mol (Syp or Dps available)
17
Sore Throat
Aetiology:infection(a/c pharyngitis - 80% viral, retropharyngeal & parapharyngeal
infections),malignancy, ulcers,trauma,referred pain due to angina, reflux esophagitis etc
1.Antibiotics if any associated infection. E.g Azithromycin, augmentin
2.Analgesics like ibugesic plus
3.Steam inhalation,bed rest, plenty of fluids
4.Warm saline gargle x 3 times/day or Betadine gargle in 10ml of warm water tds
5.Throat lozenges
Note: refer peritonsillar abscess to ENT, as it requires I & D
Parotitis
Commonly due to stone.
1. Antibiotics e.g.Ampiclox / Cephalexin. If no response give Taxim
2. Anti-inflammatory drugs
3. Adequate hydration, oral hygiene, local heat
4. L/A of Ichthammol Glycerine to reduce edema.
5. Lime juice & other Citrus fruits to promote salivary secretion
In cases of Mumps(viral Parotitis),
Rx: hydration,rest, analgesics, hot/cold compresses over the parotid (to relieve pain).
Food which promote salivary flow should be avoided.
Complications:Orchitis,Ophritis,Pancreatitis,aseptic meningitis etc.
Advise scrotal support & cold compresses for orchitis
Laryngitis
C/f: hoarseness, inability to speak, Dry sore burning throat, cough, dysphagia, fever,
cold, hemoptysis,dyspnea, Increased production of saliva, swollen lymph nodes in the
throat, chest, or face, sensation of swelling in the area of the larynx
1.Voice rest, steam inhalation, cough suppressants, plenty of oral fluids,
2.Antibiotics (e.g Azithromycin) if due to bacterial infection
3.Rantac/pantoprazole if due to GERD
Other causes of hoarseness of voice: vocal cord nodules, thyroid problems, allergies,
inhalation of respiratory tract irritants, smoking,CA, trauma, GERD,postnasal drip etc
Rectal Bleeding/hematochezia/melena
Aetiology:Hemorrhoids,fissure,fistula,rectal trauma, rectal FB,proctitis, carcinoma, IBD,polyp,
diverticulosis, infectious diarrhea, any cause of brisk upper GI bleeding,meckel’s diverticulum,
angiodysplasia, intussusception,drugs, coagulation disorder, uremia etc
Inv: FBC, U & E, LFT, Coagulation profile
Medicine/Surgery consultation
Joint sprain
Commonly involve ankle & wrist joints
C/f: pain, swelling, restriction of movement, contusion
1.RICE- rest, ice application, compression(using dressing/crepe bandages), elevation
Crepe bandage size(in cm),adult: knee 15, ankle 10, wrist 8;children:knee 10, ankle 8, wrist 6
2.Analgesics
Pain of muscle spasm / musculoskeletal/osteoarthritic pain
1.Foment with hot water bag 3 times per day for c/c pain;local ice application for a/c
inflammation
2.Diclonac /volini (diclofenac)/ ketorol/ketanov (ketorolac),Dolonex/pirox (piroxicam) for LA
3.T Ibugesic plus bd /pirox 20 mg OD /ketorol 10 mg Qid/ etoshine(etoricoxib) 60mg / 90mg
or 120mg OD
4.T Bidanzen or Flanzen or Lyser forte 10 mg tds (serrapeptase) or T chymoral forte Qid 1/2
hr before food (trypsin, chymotrypsin) or T zymoflam/Rutoheal (trypsin, bromelain, rutoside) if
contusion +.
5.Inj Myoril(thiocolchicoside) 4 mg IM st for muscle spasm
Muscle relaxants + NSAID combinations
T Robinax 500mg Qid(methocarbamol), T Myoril 2/4/8 mg (Thiocolchicoside)
Ibugesic-M (Ibuprofen + methocarbamol), Xykaa MR 4/8 mg( P mol + Thiocolchicoside)
Robinaxol(methocarbamol 350 + P mol 250) , Volitra MR,Bruspaz(Diclo+ Thiocol),
Mobiswift –D or Myospas D (metaxalone 400 + Diclo),Orthokind-P 400(etodolac 400+ P/L
500), Aceclo-MR(aceclo+P mol +chlorzoxazone), Thioceclo SR/Thiox OD(aceclo+ Thiocol)
Robinaxol-D(Methocarbamol+ P/L +Diclofenac), Etoshine MR( etoricoxib + Thiocol)
24
Neck Pain
Aetiology:spinal ,extraspinal, psychogenic. Extraspinal causes include ACS,brachial plexus pain,
shoulder disease, pancoast tumour of lungs, carpal tunnel syndrome, retropharyngeal abscess,
carotid artery dissection, etc. Others include stress, prolonged postures,minor injuries,over use,
whiplash,RA, torticollis, ankylosing spondylitis, head injury,SAH,lymphadenitis etc. The common
neck pain radiating to one arm is cervical spondylosis with radiculopathy.
1.Inj Voveran 2cc IM st ATD if very severe pain
2.T voveran 50mg bd after food
3.T Decadron 1mg tds x 5days after food( if acute pain)(dexamethasone)
While giving steroids, always prescribe calcium + vit D3( Trade name- Shelcal, Shelcal-CT,
Bio-D3 plus, minosta, macalvit, Rockbon-D) also, to prevent osteoporosis
4.Gelusil MPS 2 tsp tds
5.Volini/Voveran (diclofenac) or Pirox gel / dolonex gel (piroxicam) or Thiox gel( Diclo +
thiocolchicoside, methylsalicylate, menthol) for LA
6.Neck collar; ortho consultation
X-ray Views
Ankle/elbow/shoulder/ hip/knee,forearm,leg,wrist - AP/lateral
Foot/hand/- AP/oblique
C spine/T-L spine/ L-S spine- AP/lateral
Chest- PA view
Acromioclavicular Jt- AP view
X-ray pelvis with both hips- AP view
Back Pain
Aetioligy:musculoligamentous strain/sprain, osteoarthritis of spine, spinal stenosis,
spondylolisthesis, degenerative, osteoporotic vertebral collapse, renal or urethral colic, ruptured
intervertebral disc, pneumonitis, pleurodynia, rib fracture, pneumothorax, aortic dissection,
aortic aneurysm, P embolism, pyelonephritis, malignancy(10 or 20), pancreatitis, cholecystitis,
herpes zoster , ankylosing spondylitis , myeloma, etc.
Factors indicating serious pathology: wt loss,fever, night pain,cancer history, age > 55 yrs
1.Give analgesics,muscle relaxants,
2. Voveran or pirox gel for LA
3.T Duloxetine 30 mg 0-0-1; Ortho consultation
Heel pain
Aetiology: Plantar fascitis, achilles tendonitis,heel spurs, stress fractures, bursitis etc
Inv: X-ray foot
First Aid in Fractures
1. Analgesic
2. If there is a open wound near the fracture site, clean it thoroughly and cover it with
sterile dressing. No attempt should be made to put the bone lying out inside.
3. Immobilise the limb with a Splint; Splint should be long enough to fix one joint above
& one joint below the suspested # site.For traumatic head or neck injury, suspect a
cervical fracture unless otherwise proved & apply a cervical collar (preferably a
Philadelphia collar). A backboard/spineboard can be used to stabilize the remainder of
the spinal column; Refer the patient to ortho as soon as possible.
25
Anaemia
Can cause exertional dyspnoea,lethargy, fatigue, weakness, pallor, tachycardia,
dizziness, loss of concentration, headache, hypotension, tinnitus,glossitis, angular
cheilosis, koilonychia
Most c/c illnesses(e.g infection,Malignancy,renal d/s) are accompanied by a moderate
fall in Hb level.
Inv: CBC, red cell indices,reticulocyte count, peripheral smear, s ferritin, Bone
marrow biopsy etc
Rx for iron deficiency anemia
1.Dexorange (contains ferric ammonium citrate, cyanocobalamine and folic acid)15-30
ml bid after meals; children 2-5 yrs 5ml; 5-12yrs 10ml bid after meals
Dexorange Cap (1 cap bid after meals) & Paed Syp available or
T orofer –XT( 0-1-0)(elemental Fe + folic acid)Dps /Syp available,
C autrin/HB plus/hemfast.
Tonoferon(Fe, FA, B12) Syp(80/1) or Dps(25/1) Dose: 6 mg/kg/day after food, 2-3
months.
Hemsi-PD drops(fe, FA, B12)( Fe - 30mg/1ml)
Iron supplements need to be taken for several months for iron deficiency.
Iron supplements may cause dark stools, stomach irritation etc.
Iron supplements may also be given for children with wheeze.
2.Vit C (vit C improves the absorption of iron)
Fall/impaired consciousness
Aetiology: Orthostatic hypotension, carotid sinus syndrome, neuro cardiogenic
syncope,cardiac arrythmias, structural heart diseases,stroke , Parkinsonism, arthritic
changes, neuropathy, neuromuscular disease or vestibular disease, visual impairment,
dementia, post prandial hypotension, urinary incontinence, low blood pressure,
hypoglycemia, emotional distress, and lack of sleep, hyper ventilation, head trauma,
ICH, seizure disorder,DKA, alcohol or drug intoxication, dehydration, CO inhalation,
hyponatremia, hypo/hypercalcemia, high g-force, uremic/hepatic/hypertensive
encephalopathy, Medications (Polypharmacy ,Sedatives, Cardiovascular medications
etc), hyper/hypothermia,
There may be a loss of consciousness at the onset of SAH
Generalised edema
Cardiac oedema: over legs in a pt of known heart disease.
Refer to physician
Angioneurotic edema/Drug induced edema:
Sudden onset with itching, urticaria, hoarse voice, dyspnoea
Sudden onset of swelling of face including lips, eyelids & feet following drug intake
Withdraw the drug, give antihistamines, steroids
Myxoedema or hypothyroidism: non pitting oedema, puffiness of face, wt gain,
hoarse voice, lethargy Do T3, T4, TSH
Premenstrual edema
Restrict salt, give lasix
Renal
Generalised oedema more on face & in the morning. Do urine examination
T Dytor 10mg(1-0-0)(torasemide) or T Lasix 40 mg (1-0-0)(Furosemide)
Restrict salt, syp potklor if diuretics are given for a long period. Nephrology consultation.
Hepatic oedema
Known alcoholic develops ascitis & oedema over legs.
T Aldactone, iv human albumin if S. Albumin low
Anemia with hypoproteinaemia
Seen in poor patients. Pallor, stomatitis, puffiness of face etc.
Treat anaemia.
Idiopathic oedema
28
Left ventricular failure
S/s: dyspnoea at rest that rapidly progresses to a/c respiratory distress, orthopnoea,
PND, pink frothy sputum
Signs: distressed, pale, sweaty, tachypnoea, gallop rhythm, pulmonary edema(basal
crepitations), Pulsus alternans, pitting edema, raised JVP
Feature of RHF: raised JVP, hepatomegaly, ascites, bilateral pitting pedal edema
Rx
Ideally LVF should be managed in ICU
The management of a/c pulmonary edema can be remembered as L M N O P ie
Lasix, morphine, oxygen, & propped up position
1.Sit the pt up/CBD
2.Bed rest
3.Oxygen inhalation
4.Inj Lasix 20- 80 mg iv st followed by 40 mg Q8H or Q12H( if there is no significant fall in
BP)(larger doses required in renal failure)
Note:Pt currently treated with furosemide may receive twice the daily oral dose by
intravenous administration.
5.Inj Morphine 2mg iv st ( + inj phenergan 25 mg iv st)( may be repeated as needed
every 5-10 minutes
6.Inj NTG infusion(only if the pt is in ICU)
7.Inj Aminophylline 250 mg in 20 ml NS iv bolus Q8H.
8.ACE inhibitors like Enalapril 5mg 1-0-1(if BP above 120 mm Hg & creatinine < 1.5 mg/dl)
9.Positive inotropic agents such as dopamine/dobutamine may be needed in pt’s with
concomitant hypotension or shock.
10.Manage precipitating causes like MI/ infections/arrhythmias
Hypoglycemia
C/f: sweating, trembling, pounding heart, hunger, anxiety, confusion, drowsiness,
speech difficulty, inability to concentrate,seizure, nausea, tiredness, headache,
irritability, anger, incordination
1.Check GRBS; if very low give 25% Dextrose 3 or 4 amp( 1 amp= 25 ml) or 25D 75 or
100 ml infusion or 50%D 25-50 ml; followed by 5%D infusion because insulin has
prolonged action.
2.GRBS should be repeated every 10 minutes until>100 mg/dL
Note: All cases of unexplained hypoglycemia should have an ECG taken.
For infants: 2ml/kg & children: 4ml/kg 25 % dextrose or D10 if RBS <40.
Pt may be observed for 24 hours.
29
Hyperglycemia
Diabetic Ketoacidosis
c/f->
Anorexia, nausea, vomiting, polyuria, feeling thirsty
Abdominal pain, flushed hot, dry skin
Altered sensorium/coma, blurred vision
Kussmaul’s breathing- fruity odour in breath due to acetone
Features of volume depletion, dehydration or co-existent infection may be present
Diagnosis requires acidosis(pH<7.3), hyperglycemia(>250 mg/dl), bicarbonate< 15
mmol/l, moderate ketonemia or ketonuria(+++).
Inv:- RBS, Urine sugar & acetone, BRE, URE, S. Na, K, urea,creatinine,ABG, Serum
amylase. Features of a pre-renal type of renal failure due to volume depletion may also
be seen, ECG to look out for electrolyte imbalance & for unsuspected myocardial
ischemia.
31
Rx
1.IVF NS 1L over 30 min(if cardiac function normal), 1L over 1 hr, 1L over 2hr, 1L over
next 2-4 hrs. Those >65 yrs or with CCF need less saline more cautiously.Once blood
glucose decreases to 200-250 mg/dl, start IVF DNS @ 50 to 100 ml/hr over a parallel
line.
2.Inj Regular Insulin 10 to 15 U iv st (0.15 U/kg)
Another option is to give RI 0.3 U/kg, half iv & half sc or im st f/b inj 0.1 u/kg/hr sc or im.
Note: Subcutaneous absorption of insulin is reduced in DKA because of dehydration;
therefore, using intravenous routes is preferable
3. Continuous Regular Insulin infusion in 1 pint NS @ 5 to 10 U/hr(or 0.1 U/kg/hr)
(100 U in 500 ml of 0.9% NS infused @ 50 ml/hr or 14 drops/min delivers a 10 U/hr
infusion or 50 U in 500 ml of 0.9% NS infused @ 100 ml/hr or 25 drops/min delivers a
10 U/hr infusion ).For 60 kg, 50U in 1 pint NS at 150/min; 70 kg-170/min;80kg- 200/min;
90kg-220/min;100 kg-250/min delivers 0.1 U/kg/hr.Check BG hourly initially.A decrease
in BG levels of 50 to 75 mg/dl/hr is an appropriate response.If no reduction in 1st
hour,rate of infusion should be increased by 50-100 % until an appropriate response is
observed or repeat the iv loading dose. Excessively rapid correction @ >100 mg/dl/hr
should be avoided to reduce the risk of osmotic encephalopathy. Once BG level
decreases to 250 mg/dl, the insulin infusion rate should be decreased to 0.05 U/kg/hr to
prevent dangerous hypoglycemia. Maintenance insulin infusion rates of 1 to 2 U/hr can
be continued (indefinitely) until the pt is clinically improved. Once oral intake resumes,
insulin can be administered s/c & the parenteral route can be discontinued. Restoration
of the usual insulin regimen by s/c injection should not be instituted, until the pt is able
to eat and drink normally.
Note: Give a s/c dose (~10 U) of insulin 1/2 hr-1 hr prior to discontinuing insulin infusion.
A rough estimate of the amount of insulin required for s/c administration can be
calculated from the total amount of insulin given in the infusion till the time RBS became
<200-250 mg/dl. This amount of insulin is given in three divided doses.
4.RBS every 1-2 hrs/urine sugar acetone chart/ electrolytes every 4 hrs.
5.Antibiotics if infection suspected
6.ECG
7.Catheterisation if pt unconscious or if no urine passed after 3-4 hrs of starting fluid
replacement.
8. Ryle’s tube aspiration to keep stomach empty in unconscious or semiconscious pts
9. K+ replacement.
K+ levels can fluctuate severely during the treatment of DKA, because insulin decreases
K+ levels in the blood by redistributing it into cells. K+ should be added routinely to the IV
fluids from second or third liter of fluid replacement except in pts with hyperkalemia(>6
mmol/L & or ECG evidence), renal failure, or oliguria.
If baseline serum K+ levels are <3.3 mmol/L (<3.3 mEq/L), insulin therapy should not be
commenced until the K+ level reaches 3.3 mmol/L. Likewise, if K+ levels reach <3.3
mmol/L at any point of treatment, insulin should be stopped and K+ replaced
intravenously. In all patients with a K+ level <5.3 mmol/L and an adequate urine output
of >50 mL/hour, 10 to 20 mmol (10 to 20 units [mEq]) of K+ per hour should be given
routinely to prevent hypokalaemia caused by insulin. If the K+ level is >5.3 mmol/L
replacement is not needed but K+ level should be checked every 2 hours
Complications of DKA
Cerebral edema due to excessive rapid correction of DKA.
Rebound ketoacidosis due to premature cessation of IV insulin infusion or inadequate
doses of s/c insulin after the insulin infusion has been discontinued.
32
Lactic acidosis due to prolonged dehydration, shock, infection etc
Arterial thrombosis, Shock, aspiration pneumonia etc
Hyperglycemic hyperosmolar Nonketotic coma(HONK) or HHS(hyperosmolar
hyperglycemic state)
It is characterised by severe hyperglycemia (>600 mg/dl) & dehydration without
ketoacidosis.Treatment is similar to DKA with two exceptions:
1.Fluid requirements are often higher (with 0.45% saline) &
2.Total insulin requirements are less(~half the dose of insulin recommended for DKA)
UTI
c/f :Fever with chills , Burning sensation during micturition,frequency, abd pain,
Burning pain on micturition indicates urethritis. Suprapubic pain, frequency, dysuria:-
cystitis; High fever, toxicity, flank pain, tender renal angles:- pyelonephritis; palpable
kidney swelling:hydronephrosis.
Inv: URE ,RFT , C & S etc. Urine culture is must for recurrent infection, children,
pregnancy, DM, Indwelling catheter, older people, failure of initial therapy
1.T P/L 500 mg tds X 3 days or T cyclopam(for ureteric/renal colic)
2.T Norflox 400mg 1-0-1 X 5-7 days for uncomplicated UTI ( for men give for more
days) or T Furudantin 50/100 mg (nitrofurantoin) 1-0-1(if resistant or recurrent UTI).
For upper UTI give antibiotics for 7-14 days.
(others:Cefpodoxime,cephalexin,cotrimoxazole,amoxicillin + clavulanic acid etc)
Norflox, ofloxacin,nalidixic acid,ciplox are C/I in pregnancy & lactation
Note:Always collect urine in a sterile bottle before giving antibiotics.
If C & S is done, give antibiotics only till the result comes. Once the result comes,
Antibiotic can be changed according to the report
3.Syp Citralka ( Di Na hydrogen citrate) 2 tsp in one tumbler of water tds( can be given
in pregnancy)
4.T pyridium (phenazo pyridine) 200 mg 1-1-1 x 2 days( it is a urinary analgesic. It
produces reddish discolouration of urine. So warn about it. Not to be used for more than
2 days.C/I in pregnancy)(12 mg/kg/24 hr div into 3 for 2 days)
5.Plenty of oral fluids(~2L or more / day)
Note: In pediatric cases we may give cefixime, septran or gramoneg.Refer all pediatric
UTI to pediatrician for work up(MCU, USG etc),as child below 5 yrs(especially < 2 yrs)
are vulnerable for permanent renal damage following UTI.
T Urikind/Urispas (Flavoxate) 200 1-1-1 (for dysuria, urgency, nocturia, suprapubic pain,
frequency & incontinence, bladder spasm due to catheterization etc)(given in pregnancy)
Hematuria
Aetiology: UTI,pyelonephritis, trauma, Hemorrhagic cystitis, nephrolithiasis,kidney injury
(from accidents),a/c prostatitis, urethral stricture,drugs(like penicillin, anticoagulants like
aspirin, heparin,certain anticancer drugs), food dyes like beet root, neoplasm, TB,
traumatic urethritis due to sexual intercourse or masturbation, allergy, strenuous
exercise, viral illness, glomerulonephritis, excessive coagulation therapy, urethral FB,
renal infarction, myoglobinuria, hemoglobinuria.
Inv: URE, BRE, RFT, USG abdomen etc
Advise medicine/Nephrology consultation.
33
Hyperventilation
Aetiology: stress or anxiety, stroke, head injury, DKA, metabolic acidosis, bleeding,
infection, heart/lung disease, drugs, pregnancy,severe pain
1. Breath into a paper/plastic bag
2. O2 inhalation
3. Propped up position
4. Diazepam if necessary
Hypertension
(pts with newly discovered asymptomatic hypertension or asymptomatic known
hypertensive patients with elevated BP)
Acute lowering of BP is unnecessary and may be harmful in asymptomatic
patients.
Just advise them to consult their primary physician for therapy change.Asymptomatic
Pt with newly discoverd BP, should be advised to consult physician to start on
antihypertensive therapy. Reduce BP, if greater than 220/110.
Don’t give Nicardia /Lasix to reduce hypertension in an asymptomatic, otherwise normal
patient as it causes sudden decrease in blood perfusion to organs and may lead to end-
organ damage.
Note:a/c reduction of BP is required only in hypertensive emergency like MI with HTN,
stroke with HTN, hypertensive encephalopathy etc
Palpitation
Aetiology:physiological, psychogenic, organic
Organic conditions include MR,AR,AF, ectopics,anemia,thyrotoxicosis,fever of any
cause, hypoglycemia (pounding heart), drugs causing bradycardia and tachycardia etc.
Check for anemia, hyperthyroidism,LVH, arrhythmias
1.T ativan 1mg 1-0-1 (lorazepam)
2.T Ciplar 10mg tds(propranolol); Physician consultation
Chest pain
Aetiology: a/c MI,angina,aortic dissection, tension pneumothorax, pulmonary embolism,
GERD, pericarditis, pneumonia, chest wall pain, pleurisy, empyema, bronchitis, cervical
spondylosis.
Inv: ECG, CXR, Trop T/ Trop I/ CPK MB
A patient is diagnosed with MI if two (probable) or three (definite) of the following criteria
are satisfied:
1.Clinical history of ischemic type chest pain lasting for more than 20 minutes
2.Changes in serial ECG tracings
3.Rise and fall of serum cardiac biomarkers
Note: Trop T becomes + ve only after 6 hrs, CPK-MB + ve after 4 hrs,
Window period for thrombolysis: 12 hrs
34
Heartburn/pyrosis/cardialgia/acid indigestion
Etiology:gastritis,GERD, IHD etc
Inv: ECG all leads to r/o ACS.
1.inj Pantop/Ranitidine,
2.Antacids
3.C or syp Aristozyme bd/tid after food
Note: 10% of cases of discomfort due to cardiac causes are improved with antacids
Avoid overweight,avoid lying down soon after a meal,avoid late meals,avoid smoking,
avoid tight fitting clothes,elevate the head end of bed, avoid foods that trigger heartburn.
Unstable Angina
1.O2 inhalation
2. Absolute Bedrest. Later graded ambulation 2 min in the morning & 5 min in the
evening.
3.300 mg dispirin(don’t give ecospirin as it is enteric coated & thus delayed release ) st
followed by 75 mg/150 mg ecospirin 0-1-0
4.If normal BP s/l sorbitrate(isordil) 5mg/10 mg st & 1-1-1
5.T Clopidogrel(clopilet/clopikind) 75 mg x 4 tab & 1-0-0
6.If severe pain persists,IV morphine 2-3 mg/pethidine 50-100mg(may cause vomiting)
Note:C/I in asthmatics, COPD, already in hypotension
7. Metoclopramide10 mg / phenergan 25 mg for nausea/vomiting associated with
Morphine
8.If BP low, don’t give lasix.
9. β blockers, e.g T metoprolol 25 / 50 1-0-1(Monitor Pulse Rate) or T Carvedilol 3.125-
25mg (Cardivas) bid or nebivolol 5-40 mg daily(Nebicard)
10.ACE inhibitors, e.g T envas(enalapril) 2.5/5 mg 1-0-1(monitor BP, RFT)
11.T Atorvastatin 40 mg st & 10mg 0-0-1
12.Heparin/LMW Heparin(clexane )i.e. Inj heparin 5000 U s/c Q6H x 5 days Or
Inj clexane (enoxaparin)0.6 ml s/c BD(if RFT normal).
13.Syp cremaffin HS (as stool softner); semi solid diet.
In those patients not tolerating Sorbitrate, we may give T.Monotrate 20mg 1-1-0
Aspirin + Clopidogrel Combinations: T.Complatt, T.Deplatt-A, T.Cidogrel-A
T. Complatt CCU-> a unique combination with high loading doses of Aspirin &
Clopidogrel for initiating therapy in cases of emergency. Consists of 2 tabs, one of
which has to be dispersed in water & the other to be swallowed whole.
Discussed in detail in HS manual
Note: Unstable angina:ST depression or new T inversion and Trop T –ve,
NSTEMI: ST depression or T ↓ and Trop T +ve , STEMI: ST elevation and Trop T +ve
Nocturnal leg cramps
Etiology: peripheral artery disease, spinal stenosis, drugs( like statins, diuretics, BP drugs),
DM, dehydration, diarrhoea,fatigue, OA, pregnancy, hyper/hypothyroidism,CKD, cirrhosis,
electrolyte abnormalities, B complex deficiency, dialysis, idiopathic etc
1.Analgesics
2.Vit B12(Cap Meganeuron OD Plus 0-0-1)/T Shelcal OD/ C evion 400 mg OD,
3.T gabapentin(Gabantin) 300 mg od.
4.Plenty of oral fluids, stretching, massage
35
Status Epilepticus
Occurrence of Seizures for more than 20 min or fits occurring in succession without
regaining consciousness in between.
R/o hypoglycemia
Course->
Stoppage of current Anti-epileptic medication.
Metabolic conditions like Hypoglycemia, Hyponatremia
Infections like Meningitis, Encephalitis
Other causes of seizures like ICSOL, Trauma etc.
The aim of treatment is to control seizure first and then identify any correctable cause
and treat it if possible.
Rx:
Maintenance of airway + throat suctioning
Maintain iv line & draw blood for metabolic work up
Intravenous antiepileptic medications
1.Lateral position
2.Inj Lorazepam 4 mg iv st/ inj diazepam 10 mg iv st over 2 minutes
3.Send RBS
4.Inj 25% dextrose 100 ml iv st
5.Inj thiamine 100 mg iv st
6.Inj phenytoin(eptoin) loading dose 10-20 mg/kg( 20 mg/kg first dose as 50 mg/min in
running NS).Usually it is given as inj eptoin 600/800/1000 mg in 100 ml NS(1 pint NS if
dose >1000 mg) over 20 min.
Phenytoin should not be injected through the same cannula as lorazepam because of
the possibility of crystallization. IV lines should be flushed prior to and after the
administration of phenytoin. Watch for hypotension & arrhythmia during infusion. Don’t
exceed 50 mg/min infusion rate as this may cause hypotension/cardiovascular collapse.
7.Later inj phenytoin 100 mg Q8H or inj Levipil(levitiracetam) 500mg or inj Na valproate
250 mg iv Q8H
8.If even after step 6, no improvement, rpt diazepam & ½ dose phenytoin
If still no improvement refer the patient to physician/ neurologist
Haemoptysis
Etiology: TB, a/c LVF, MS, bronchiectasis, pulmonary embolism, AVM, a/c bronchitis,
lung abscess, suppurative pneumonia, bronchial CA, trauma, SLE, FB, parasites,
mycetoma, hemophilia, aortic aneurysm, pulmonary infarction, leukemia ,
drugs(anticoagulants , aspirin, cocaine)
Inv: CBC, coagulation studies, URE, AFB, ANA,ECG, CXR, Chest CT,
Physician consultation
1.Reassure the pt;Q4H temp chart, I/O chart, pulse/BP chart(watch for hypotension)
2.Prevent aspiration; raise foot end, turn head to one side
3.Absolute bed rest
4.Broad spectrum antibiotics
5.Blood transfusion if systolic BP less than 90 mmHg or massive hemoptysis.
6.Antitussives like codeine 5 ml tds
7.Bronchodilators
8.Sedation e.g: diazepam
9.Inj ethamsylate 500 mg iv Q8H.
36
Drugs predisposing to renal dysfunction
NSAIDs, ACE inhibitors,Lithium, radiographic contrast media, Aminoglycosides,PPI ,
penicillins,chemotherapy
Monotherapy
If >55 yrs, 1st choice is a Ca2+ channel blocker or a thiazide. If <55 yrs, 1st choice is
ACE-i(or ARB if ACE-i intolerant). T clonidine(arkamine) 0.1 mg preferred in renal pts.
In elderly hypertensive pt’s(>60 yrs), start diuretics as initial therapy.Ca2+ antagonist/
ACEI/ARB are also effective.
Multitherapy
When a second drug is needed, it should be generally be chosen from among the
other first-line agents.A diuretic should be added first, as doing so may enhance
effectiveness of the first drug.
Another method is, in combination one out of two groups A (ACEI/ARB) or B (β
blockers) is combined with C (calcium channel blocker) or D (thiazide diuretic) ie.
A/B + C/D. In refractory pts, when 3 agents are to be used, A+C+D is a good
choice.ACE-i with CCBs is better than a combination of ACE-i with diuretic. β
blockers are not a 1st line for HTN
In pt’s with stage 2 HTN, therapy may be initiated with a 2 drug combination,
typically a thiazide diuretic + Ca2+ antagonist/ACEI/ARB/β-blockers.
37
Antihypertensives which can be used safely in pregnancy:->
Alpha Methyl Dopa
Nifedipine
Brands :
Telmisartan(40-80 mg /day)(ARB)
Telma,Telpres, Telmikind
Atenolol + amlodipine
Amlong-A, Amcard-AT,Amlokind-AT, Stamlo beta, Aten-AM, Amlopres-AT
Amlodipine + Losartan
Amcard LP, Amlokind-L, Amchek Z, Amlopres- Z, Amlotin HS,
Hyperlipidaemia
Note: measurement of fasting lipids is indicated if the total cholesterol is >200 mg/dl, or
HDL cholesterol is < 40 mg/dl. If fasting profile can’t be obtained, total & HDL
cholesterol should be measured.
Rx
1st line therapy: Statins are given .
2nd line: fibrates, e.g bezafibrate,fenofibrates or cholesterol absorption inhibitors, e.g
ezetimibe(useful combined with a statin to enhance LDL reduction).
Response to therapy should be assessed after 6 weeks.
39
For hypertriglyceridaemia fibric acid derivatives are given. E.g bezafibrate.
Note: Statins are associated with myalgia, myositis, abdominal pain, derangement in
LFT , raised CPK. Give T Levocarnitine for associated muscle pain. T.N: carnisure
Drugs containing levocarnitine: C evion- LC, T nurokind-LC
Rosuvastatin(5/10/20 mg OD)
Rosuvas, Novastat, Lipirose, Razel
Atorvastatin + Fenofibrate
Stator-F, Lipikind-F
Atorvastatin + Ezetimibe
Atorlip EZ,Storvas-EZ
Hyperuricemia
Etiology:renal d/s, drugs(e.g diuretics, immunosuppressive drugs), alcohol, starvation,
hypothyroidism, obesity,psoriasis, purine rich diet(organ meat, seafood, dried beans,
dried peas, mushrooms), vit B3,genetic, etc.
Rx
T Febuxostat(febutaz/febuget) 40/80 mg 1-0-0(monitor S.creatinine)
Steroid tapering
If steroids are tapered too quickly, withdrawal symptoms can occur, such as joint
pain, fatigue, dizziness, muscle pain, vomiting, shortness of breath, fainting,
headaches, low blood sugar, fever, nausea etc
One view is that tapering is not necessary in short term therapy (14 days or less)
Gradual withdrawal of systemic corticosteroids is advisable in patients who have
received more than 2 weeks treatment or have history of adrenal suppression or
have had repeated courses of steroids or received doses at night or have received
Prednisolone >40mg daily or equivalent (e.g. dexamethasone 6mg) for any length of
time
Prednisolone tapering
A decrease in dose is usually made every 2-3 days
Reduce dose by 2.5- to 5.0-mg decrements every 3–7 days until physiologic dose (5 to
7.5 mg of prednisolone per day) is reached.
Other recommendations state that decrements usually should not exceed 2.5 mg every 1–2
weeks
Dexamethasone tapering
In patients who have received less than 14 days of dexamethasone therapy, treatment
may be abruptly discontinued without adverse events, because the HPA axis is not
suppressed. Dexamethasone tapering schedules are often prescribed for short-term
therapy, and usually consists of a reduction in dose of 2-4 mg every 1-3 days, by either
reducing the dose and/or the interval.
40
Hypothyroidism
C/f: cold intolerance, fatigue, poor memory, constipation, menorrhagia, myalgias, hoarseness,
somnolence
Rare manifestations: carpal tunnel syndrome, deafness, hypoventilation, pericardial or pleural
effusions.
Diagnosis
TSH is the best initial test. A normal value excludes primary hypothyroidism, and a
markedly elevated value(>20 µU/mL) confirms the diagnosis. Mild elevation(<20 µU/mL)
may be due to nonthyroidal illness, but usually indicates mild(or subclinical) primary
hypothyroidism, in which thyroid function is impaired but increased secretion of TSH
maintains free T4 levels. These pt’s may have nonspecific symptoms that are compatible
with hypothyroidism & a mild increase in S.cholesterol & LDL. Plasma free T4 should be
measured if TSH is moderately elevated, or if secondary hypothyroidism is suspected, and
pt’s should be treated for hypothyroidism if free T4 is low
ECG
Rx
Thyroxine is the drug of choice. The average replacement dose is 1.6µg/kg PO daily, and most
patients require doses between 75 and 150 µg/d. In elderly patients, the average replacement
dose is lower. The need for lifelong therapy should be emphasized. Thyroxine should be taken
30 minutes before a meal, preferably morning.
Initiation of a therapy.
Young & middle-aged adults should be started on 100µg/d. This regimen gradually corrects
hypothyroidism, as several weeks are required to reach steady-state plasma levels of T4.
Symptoms begin to improve within a few weeks.
In otherwise healthy elderly patients, the initial dose should be 50 µg/d.
Patients with cardiac disease should be started on 25 to 50 µg/d and monitored carefully for
exacerbation of cardiac symptoms.
Follow-up
In primary hypothyroidism, the goal of therapy is to maintain plasma TSH within the normal
range. TSH should be measured 6 to 8 weeks after initiation of therapy. The dose of
thyroxine should then be adjusted in 12- to 25- µg increments at intervals of 6 to 8 weeks
until TSH is normal. Thereafter , annual TSH measurement is adequate to monitor therapy.
In secondary hypothyroidism, TSH cannot be used to adjust therapy. The goal of therapy is
to maintain the free T4 near the middle of the reference range. The dose of thyroxine
should then be adjusted at 6 to 8 weeks intervals until this goal is achieved.Thereafter ,
annual T4 measurement is adequate to monitor therapy.
CAD may be exacerbated by the treatment of hypothyroidism. The dose of thyroxine should
be increased slowly in pt’s with CAD, with careful attention to worsening angina, heart
failure, or arrhythmia.
Trigeminal Neuralgia
DoC is Carbamazepine 200mg tds
Rx same as above
Giddiness/syncope
Etiology:
1.Hypoglycemia-> h/o DM + Cold extremities, Sweating-> give 25% or 50% dextrose.
2.Vasovagal attack-> Can occur due to prolonged standing, excessive heat or
large meal. Keep the pt in lying down position & feet elevated
3.Bradicardia- drugs(beta blockers, verapamil, diltiazem, digoxin), AV block, SA
node disease
4.Tachycardia-AF, SVT
5.Postural Hypotension- hypovolemia, sympathetic degeneration(DM, Parkinson’s
disease, old age), drugs(anti anginals, antidepressants, neuroleptics) can cause or
aggravate the condition. Advise to avoid prolonged standing and to get up slowly from
sitting or lying down position.
6.Carotid sinus hypersensitivity- when pressure is applied to neck e.g. wearing a
tight collar
7.Myocardial ischemia; LV outflow tract obstruction- AS, HOCM
Note: Whenever a pt is brought with c/o unconsciousness, r/o head injury
42
Motion Sickness
1.T. Avomine 25mg about 1-2hrs before journey[Promethazine theoclate]
2.Avoid alcohol,dietary excess, reading. Position themselves where there is least
motion,a supine/recumbent position with the head braced is best. Keeping the axis of
vision at an angle of 450 above horizon may reduce susceptibility.
Headache
Primary headache syndromes : migraine with (classic) or without (common) aura,
tension headaches, cluster headaches, rebound headache, trigeminal neuralgia,
temporal arteritis
Secondary headache: have specific etiologies & symptoms vary depending on
underlying pathology, i.e., SAH, HTN,sinusitis, tumour, glaucoma,SDH, meningitis,
encephalitis, vasculitis, obstructive hydrocephalus, intracerebral hematoma, cerebral
ischemia or infarction, dental problems, pseudotumour cerebri,optic neuritis.
Systemic causes include fever, viremia, hypoxia, CO poisoning, hypercapnia, allergy,
anemia, caffeine withdrawal etc.
Clinical presentation: the sudden onset of severe headache(worst ever headache) or
a severe persistent headache that reaches maximum intensity within a few seconds or
minutes warrants immediate investigation for possible SAH. There may be a loss of
consciousness at the onset of SAH.
Physical examination
Check BP, pulse. Look for possible bruits. Check temporal arteries.
If neck stiffness & meningismus(resistance to passive neck flexion,headache etc)
present, then consider meningitis.Check sinus tenderness over maxillary & frontal sinuses.
If papilledema observed, consider an intracranial mass, meningitis or idiopathic
intracranial HTN.
Inv: CT Brain to exclude secondary etiologies.
Rx
Analgesics
Note: Naproxen is the preferred NSAID in people with high risk of cardiovascular
complications like stroke, MI
In pt’s presenting with headache,fever,polymyalgia rheumatica , tenderness & sensitivity
on the scalp, raised ESR , suspect Giant-cell arteritis.Start treatment immediately with
prednisolone (30-40 mg/day, tapered off in 4-6 weeks)to prevent blindness.
Migraine
In case of any headache R/o refractive errors. Ask for throbbing/pulsating nature,
chronicity, whether U/L or B/L, Duration, presence/absence of nausea/vomiting,
photophobia, phonophobia
Also ask for any aura->visual blackouts, diplasia, nasal block, giddiness, fortification
spectra.
Also ask for any precipitation factors-> like TV, food, alcohol,caffeine, mental stress,
sleep deprivation etc.
43
Rx:
1. Inj Migranil [dihydroergotamine]1mg iv over 2-3 min/im stat [C/I in pregnancy,
lactation, HTN,CAD] Or T.Migranil 2 tabs, rpt after 30 min if necessary.
Note: ergotamine preparations should be best avoided since they easily lead to
dependence.
2. Inj P’mol 2cc im stat[if 1 not available]
3. Inj phenergan 25mg or perinorm or stemetil-> for nausea
4. T.Alprax 0.5mg stat
5. T metoclop-P st( metoclopramide + P mol) or T Domstal-P(domperidone + P/L) st Or
6. T Headset st & SOS (sumatriptan succinate, Naproxen)(Only for A/c migraine
& cluster headache attack)(in elderly, avoid sumatriptan due to risk of CVA, MI) Or
7. T Clotan 200 mg (tolfenamic acid) st & SOS (for a/c migraine)
8. Headache calender
Prophylaxis is considered if a pt has at least 3 disabling migraines per month.
1. T.Flunarizine 10 mg HS x 2 weeks-1mnth[T.sibelium/Fine/Flugraine] Or
2. T.Inderal 20mg 1-0-1[propranolol] (C/I in BA, CCF, POVD, Severe bradycardia) or
3. T sodium valproate 200 mg 0-0-1 x 1 week f/b 1-0-1 to continue or
4. T amitriptylline 25 mg HS
Tremor
Aetiology: alcohol withdrawal tremors, drug induced(salbutamol, deriphylline,
metoclopramide), hyperthyroidism, parkinsonism, senile tremors, hypoglycemia, stress
induced, vitamin deficiency(thiamine, B12), CKD, liver failure, Stroke,traumatic brain
injury, Hypocalcemia, hyponatremia, caffeine or alcohol induced
Inv: TFT, RFT, LFT, S.electrolytes,
1. T ciplar 40 mg 1-0-1(for essential tremors). Dose has to be tapered gradually over
several days. C/I in RAD, bradycardia, AV block, shock, severe hypotension, etc
2. T Alprax 0.25 mg 1-0-1 for stress induced tremor.
3. C Gabapentin OD
For tremors due to parkinsonism give T Syndopa(levodopa + carbidopa) bd,
T pacitane or parkin 2mg (trihexyphenidyl) bd
Caries Tooth
Rx:
1. Analgesics->Brufen
2. Antibiotics; Amoxicillin, Metronidazole
Dental consultation
Gum Abscess
Rx:
1. Antibiotics; Amoxicillin, Metronidazole
2. Analgesics ; Vit C
3. Warm saline gargle, Apply Pressure
4. Refer to dentist for I & D
Gingivitis
Rx:
1. Clohex Plus oral rinse(chlorhexidine)
2. Vit C
3. Antibiotics
4. Analgesics
44
Cheilosis/angular stomatitis
Etiology: Iron/Vit B 12 deficiency, infection
1. C. Becosules Z/ Berocin CZ [vit B-complex, C & Zinc] 1-0-1x 5dys, then 0-0-1.
Other drugs with Vit B12: Matilda forte, ME-12, trinerve
2. Antibiotics like septran / Erythromycin may be given
3. Inj Trineurosol H/ neurobion forte(Vit B1 100mg,B6 50mg,B12 1000mcg) im od
Halitosis
Aetiology->Gingivitis, poor oral Hygiene,smoking,dry mouth, Caries Tooth , hepatic
failure, uremia,DKA, bronchiectasis, lung abscess, atrophic rhinitis,alcohol,etc.
Rx:
1. Metrogyl DG gel[chlorhexidine gluconate, metronidazole] or
Hexidine mouth wash or Betadine Mouth Gargle
T Metrogyl may be given for severe cases.
2. Maintain proper oral hygiene
3. Tongue cleaning twice daily
4. Chewing gum help in production of saliva, preventing dry-mouth.
5. Holding 2 curry leaves in the mouth for 5-7 minutes decreases bad breath
Aphthous Ulcers
Aetiology-> Vit/Fe/folate Deficiency, Antibiotic Induced etc.
Rx:
1. Vit B 12 +Vit C+ Antioxidants; adequate hydration
2. Dologel for pain or Dologesic gel(has Lignocaine), Dentogel(lignocaine+
choline salicylate), Lexanox QID (Amlexanox,anti-inflammatory) or
3. Chlorhexidine mouth wash/ betadine mouth wash, or
4. Kenacort /oraways/Tess oral paste for LA(triamcinolone) or
5. Antibiotics like tetracyclin 250 mg dissolved in 50 ml of water administered as
a mouth rinse for 3 min(to coat ulcers) & then to be swallowed, Qid or
6. Syp Sucralfate (sparacid)5-10 mL PO swish and spit/swallow Qid.
Biopsy of the ulcer may be needed, if it does n’t heal.
In cases of herpetic gingivostomatitis: Rx-> given as above + T. Acyclovir daily [Acivir,
Zovirax, Herperex]
Whatever be the opthalmic solution, not more than a drop needs to be instilled
into the conjunctival sac at a time because the conjunctival sac holds only 10-15
microliters of fluid at a time & the average volume of one drop is 60 microliter.
Only the frequency of instillation needs to be adjusted depending on the clinical
condition.
If an eye drop & an eye ointment has to be instilled at the same time, instill the
drop first followed by ointment.
Conjunctivitis
C/f: Bacterial:conjunctival congestion with matting of lashes, mucopurulent discharge,
gritty sensation, normal pupil, viral: conjunctival congestion, watery discharge, gritty
sensation.
1.Moxiflox /Gatilox / Ciplox(not preferred) eye drops 10 Q1H-Q4H as per severity.
2.Frequent Washing. Dark glasses, if photophobia. Never pad & bandage.
3.Tocin(tobramycin) eye oint at night to prevent glueing of the eyelashes in the morning
4.If severe -> Antihistamines, Anagesics, Antibiotics[Oral] e.g Ciplox
Note: no role for prophylactic topical antibiotics in unaffected eye.
In children give tobramycin e/d
Eye pain causes: ocular pain- conjunctivitis, corneal abrasions/ulcerations, burns,
blepharitis, chalazion,stye;
orbital pain-glaucoma,iritis,optic neuritis, sinusitis, migraine, trauma
A/c red eye: conjunctivitis, glaucoma, injury, iritis,keratitis, scleritis, blepharitis,SCH etc
Scleritis
Systemic therapy is always required.
1.Oral NSAIDs like indomethacin (100 mg od).
2.Steroid + Antibiotics e/d e.g:
Betnesol-N[betamethasone sodium phosphate, neomycin sulphate] e/d or
Toba-DM [dexamethasone, tobramycin] e/d or
Microflox-DX [ciprofloxacin hydrochloride, dexamethasone] e/d
Superficial punctuate Keratitis
Mainly due to viral infections, So give Acyclovir.
C/f: pain, photophobia, lacrimation,
1. Acivir or Zovirax or Herperex eye drops 1 drop Q4H
2. Topical steroids
3. Tobramycin [eyebrex,toba,tocin] or moxiflox (milflox)e/d to prevent 20 infection.
4. Artificial tears like Refresh eye drops.
Corneal Ulcer
C/f: redness, pain, watering, photophobia, redness, foreign body sensation etc
R/o DM
1. Pad & bandage;hot fomentation; dark goggles
2. Moxiflox /Ciplox/ Tobra eye drops; if the corneal ulcer is not responding to above
treatment in two days time or the ulcer is more than one mm size at the time of
presentation fortified antibiotic eye drops(cefazolin & gentamycin) should be
given.
Fortified Cefazoline(Reflin) e/d 10 Q1H-Q2H;it is prepared by adding 5-10 cc distilled
water into a vial of injection cefazoline 500 mg to get a strength of 50-100 mg/ml. The
solution should be kept in refrigerator & every 3rd day fresh e/d should be prepared as
cefazoline is not stable in aqueous solution.
46
Fortified gentamicin (13.6 mg/ml) e/d Q1H-Q2H;prepared by reconstituting
gentamicin (0.3%) e/ d with gentamicin (40 mg/ml) injection. inject 2 mL of gentamycin,
40 mg/mL, directly into a 5-mL bottle of gentamycin 0.3%, ophthalmic solution
3. Vit C; Analgesics & antiinflammatory drugs.
4. 1% atropine or 2 % homatropine e/d tds to relieve ciliary spasm.
Refer to Ophthalmology.
Never prescribe steroid eye drops if corneal ulcer is suspected, as it will lead to
rapid corneal perforation
Blepharitis
Inflammatory d/s of eyelid usually chronic & involves the part where the eyelashes grow.
Rx
1.Steroid + antibiotic eye oint application at lid margin
Eg.ciplox+ dexamethasone (ciplox-D),tobramycin+ dexa (tobaren-D) bd x 2 weeks
2.Antibiotic e/d
3.Oral antibiotics
4.Treat scalp dandruff
Corneal abrasion
C/f: pain, watering of eyes, photophobia
Rx
1.Wash with NS if FB’s are present
2.Instill Homatropine eye drops( T.N Homide) followed by antibiotic eye ointment
3.Pad & Bandage
4.Advice to instill antibiotic eye drops eg.Moxiflox Q4H at home
5.R/w next day.
47
A/c Dacrocystitis
Rx
1. Broad spectrum antibiotics like ciplox
2. Analgesics
3. Local hot compress 3-4 times a day; I & D if abscess points
A/c iridocyclitis
C/f: acute red eye, moderate to severe pain, watering, photophobia, defective vision;
circum corneal congestion, small sluggishly acting irregular pupil, ciliary tenderness etc
1. Atropine e/d tds
2. Prednisolone acetate e/d Q2H-Q4H depending on severity to be tapered over a
period of 4-6 weeks.
Note: never stop topical steroids abruptly as it will precipitate uveitis.
3. Dark goggles
48
IBS(Irritable Bowel syndrome)
C/f: recurrent abdominal pain, abdominal bloating, alternating episodes of diarrhoea &
constipation, mucus in stools, feeling of incomplete defecation.
Diagnosis is mostly clinical.
Diet: avoid excess tea, coffee, fried food etc.
Increase leafy vegetables & fruits (if constipation predominant).
Note: fibre rich diet can cause bloating & occasional impaction if ingestion is not
accompanied by adequate volume of liquid.
Also explain the nature of the illness to stressful situations.
1.T Colospa / Morease (mebeverine - antispasmodic) 100 1-1-1
2.T Librax / Spasril (chlordiazepoxide + clidinium bromide) 1-1-1
Note: T Normaxin (chlordiazepoxide + clidinium bromide+dicyclomine) tds can also be
given
3.C Econorm (saccharomyces Boulardii) 250 1-0-1
4.T Amitriptylline 10-25 mg HS.
Liver abscess
C/f: fever, chills,jaundice,wt loss, tender hepatomegaly,intercostal tenderness, dry
cough, pain in the right shoulder etc.
Inv:CBC, LFT, Blood C&S,coagulation profile,Stool RE, CXR,USG abdomen, CCT.
Rx
For pyogenic liver abscess: iv antibiotics e.g cephalosporin (3rd gen) ± gentamycin
For amoebic liver abscess/Amoebiasis:
1. Inj Metrogyl 500 iv Q8H x 7-10 days or T metrogyl 400/800 mg tds or T Tinidazole /
ornidazole 2g daily x 3-5 days(After 10 days give T Diloxanide 500 mg tds x 10 days ) +
Inj CP 10 LU iv q6H ATD x 5 days
2.T Chloroquine 250 2-0-2 x 2 days followed by 1-0-1 x 10-14 days
Needle aspiration for large abscess or if the response to chemotherapy is not prompt.
Prevention is by avoiding fresh uncooked vegetables or drinking unclean water.
Scrub typhus
C/f: high grade continous fever with HSM & lymphadenopathy. Eschar in a hidden wet
area of the body.
Inv: IgM, IgG Scrub
C Doxy 100 1-0-1 x 5-7 days
Rheumatoid arthritis
C/f: pain, early morning stiffness(>30 min), joint swelling,tenderness,rheumatoid
nodules. Suspect the diagnosis if there is symmetric arthritis in 3 or more joints
(especially involving small joints).
Inv:ESR,CRP,RF, anti-CCP antibody, x-ray, ultrasound,MRI
General measures:
Education, Exercise, Diet(lipid lowering diet, fibre rich), Physiotherapy.
1.NSAIDs e.g Indomethacin 25/50 mg 1-1-1, Lornoxicam 4-8mg 1-0-1, Etoricoxib 90-
120 mg OD or Naproxen 250/500 mg BD etc
2.DMARDs e.g T HCQ (hydroxychloroquine) 200-400 mg OD( s/e retinal toxicity). Also
used are methotrexate,sulphasalazine, leflunomide etc.
3.T Wysolone(low dose in early stages for disease modifying effects & high dose for
severe disease)
Note:before commencing DMARD therapy, check CBC, LFT,RFT, CXR, visual acuity(if
HCQ is given).
49
Suspected Weils
Leptospirosis with jaundice, renal impairment & haemorrhages.
c/f-> fever, myalgia, conjunctival congestion,calf tenderness, oliguria, icterus,HSM etc.
Inv-> BRE, URE, ECG, CXR, RFT, LFT,Blood C & S,peripheral smear, Weils IgM.
Investigate for DD’s like Dengue (NS1 antigen,IgM, IgG), malaria, typhoid, scrub typhus.
Classical picture: ESR ↑, TC ↑ , polymorphs ↑, moderate elevation of SGOT/PT,
abnormal & serially increasing levels of urea & creatinine, elevated S.Bilirubin.
1. Temp chart, I/O chart, Daily platelet count chart, RFT.
2. Inj CP 20 LU iv Q6H ATD//Inj. Taxim 1 gm BD // Inj.doxycycline[As hyclate:
Initially, 200mg on day 1 followed by 100mg daily in a 0.1-1 mg/ml solution infused over
1-4 hr] x 5 days or
T Doxy-1 100mg 1-0-1[prophylaxis](after food; take plenty of water, otherwise sticks to
esophagus; avoid direct sunlight exposure) x 5-7 days
3. If not taking orally, IVF like DNS with polybion
4. Inj P’mol 2 cc im sos;Tepid sponging sos
5. Inj Pantop 40mg iv od
6. Syp Looz 1 oz (30 ml) tds
Suspected Dengue
c/f-> Fever,headache, gastroenteritis, Myalgia, Conjunctival congestion. There may be
bleeding manifestation, rash, altered level of consciousness or syncope.
Inv->Same as above . Serial Platelet count is of significance.
NS1 antigen +ve by 1st week, IgM +ve by 2nd week, IgG +ve by 3rd week
Classical picture:PCV ↑, TC ↓ , lymphocytic dominance, ESR normal, plt ↓ when fever
subsides
1. Temp chart, I/O chart, Platelet count chart, RFT
2. T P’mol 500mg 1-1-1 & Inj P’mol 2cc im sos// Tepid sponging sos
3. If not taking orally, IVF like NS or RL
4. Inj Pantocid 40 mg iv od
5. Platelet transfusion sos(PLC<10,000 without bleeding or<50,000 with bleeding)
6. Adequate bed rest;
Note: Chikungunya presens as sudden onset of fever, crippling joint pain, headache,
lymphadenopathy, conjunctivitis, maculopapular rash, fatigue etc.Rx; Rest, fluids, NSAIDs
like Naproxen or P’mol. T Chloroquine 250 mg/day may help in c/c arthritis. A short course
of steroids may also be useful.
Suspected Meningitis
c/f->Fever + vomiting + headache,Seizures, Altered sensorium, Cranial nerve deficits,
neck stiffness,+ kernig’s/ brudzinski’s sign. Altered sensorium more common in
encephalitis.
Inv->BRE, URE, RFT, LFT, LP, CT Brain(prior to LP if signs of raised ict or FND), Blood
c/s, Urine c/s(if suspected UTI), Sputum AFB etc.
1. 4th hourly Temp chart , I/O chart
2. Inj CP 40 LU iv Q4H ATD Or Inj Monocef 2g iv bd ATD
3. Inj Mannitol 20 % 100ml iv Q8H
4. Inj thiamine 100mg iv bd
5. If not taking orally, IVF DNS or NS, as dehydration is common.
6. Inj Pantocid 40mg iv od
7. Inj P’mol 2cc im sos// Tepid sponging sos
8. Inj Phenytoin 100 mg iv q6h( for Px & control of seizures).
9. RTF, Bladder catheterization sos, frequent change of position q2h, intermittent throat
suction if unconscious.
50
If Encephalitis is suspected add Inj Acyclovir 500mg iv Q8H x 14/21 days
If H influenza infection is suspected or established(usually in children), prophylaxis
is needed for contacts if child < 5yrs is at home.T Rifampicin 600 mg (20 mg/kg)
single dose x 4 days(warn about orange discolouration of urine & other body
secretions).
If meningococcal infection is suspected or established, chemoprophylaxis with T
Rifampicin(10 mg/kg/dose) 600mg bd x 2 days or T Ciplox 500mg single dose is to
be taken.
In pediatric cases treat with Inj Ceftriaxone 100mg/kg/day in 2 divided doses.
Another regime is taxim + Amikacin. Treat according to culture and sensitivity.
Note: 1st dose empirical antibiotic should be given on clinical suspicion, prior to all inv.
Suspected Enteric Fever(Typhoid fever)
c/f->Fever with Splenomegaly, headache, lethargy,abdominal pain, dry cough,poor
appetite,generalized aches,constipation followed by diarrhoea,epistaxis,malena.
Inv->Routine investigations(leucopenia with relative lymphocytosis) , Widal test , 2
samples 7-10 days apart; O titre>1/160 & H titre >1/320 is significant(a single absolute
value of O titre >200 or an increasing titre of O over one week especially a four-fold
rise is considered positive), blood c/s, Clot culture
DoC is Ciprofloxacin. Other drugs used: Ceftriaxone, cefotaxim,cefixime,Azithromycin
Rx
1. Temp chart, I/O chart
2. Inj Ciplox 200mg iv bd x ~ 10-14 days/Inj Monocef 1-2 g iv bd ATD
T ciplox 500-750 mg bd for 10-14 days can also be given.
3. Inj or Tab P’mol sos + Tepid sponging
4. If not taking orally, IVF DNS, NS, RL, Isolyte P->as required
5. w/f signs of perforation, other complications like arthritis etc & get expert
opinion & management.
6. Blood transfusion sos.
Tetanus
Diagnosis is clinical -> Trismus, Tonic spasms, Opisthotonus, h/o injury
Rx
1. Keep in a quiet, dark room , with minimal handling
2. O2 inhalation and respiratory support sos
3. Inj Telglob 5000 IU im.(Each vial contains 250 IU. So 20 vials are required.
Sites->Deltoid, Anterolateral aspect of thigh. Give as multiple doses as early
as possible)
4. Inj Diazepam 0.2 mg/kg Q4H or more frequently
5. Muscle relaxants
6. IVF->DNS or NS; Ryle’s tube feeding, care of bladder
7. Immunization after recovery
8. Tracheostomy and mechanical ventilation sos.
TB Prophylaxis
Px
In <6 years->T INH 10mg/kg OD X 6months.
In adults, there is no proven benefit for prophylaxis.
Upper GI Bleed
Inv->Hb, PCV, Blood grouping & crossmatching ,RFT, LFT, HBsAg, Anti HCV, USS
Abdomen, OGD scopy.
Rx:
1. Nil per orally(NPO)
2. Ryles tube aspiration
3. Inj Octreotide 50 microgm iv st, followed by 25 microgm/hr infusion till 4 hrs
after bleeding stops or till pt is taken to endoscopy. Or Inj terlipressin 1
mg(1mg/10ml) iv q8H(it is very costly~ Rs 1500 per 10 ml)
4. Inj Pantop 40mg iv od Or Inj omez(omeprazole) 80mg iv st f/b 8mg/hr
infusion
5. IVF 2 DNS, 2NS, 2% 5D in 24 hrs.
6. Blood Transfusion/FFP sos.
7. Inj vit K 1 amp (10 mg) iv/sc OD x 3 days
8. Bowel wash with lactulose BD
9. Syp lactulose 30 ml tds( if not NPO)
10.Inj taxim 1 g iv Q8H
11.T Misoprostol 200mg 1-0-1(If thought to be associated with irritant drugs like
NSAID’s. Also stop the offending drugs)
52
Hepatic Encephalopathy
Ideally Refer to a higher centre
Upper GI Bleed may be associated. Hence orders and investigations may be similar.
INV->BRE, Platelet count, PCV, Peripheral smear, Blood grouping, URE, LFT, RFT,
ECG, PT-INR, APTT, Blood Ammonia levels, HBsAg, AFP (alpha feto protein), Serum
Ferritin(to r/o secondary haemochromatosis)USS abd, OGD Scopy, RBS.
Rx:
1. Ryle’s tube aspiration(for upper GI bleed), NPO, I/O chart
2. Packed cell transfusion sos
3. Give NS if BP is low. Once BP is rectified, NS is not to be given
4. Inj Octreotide 50 microgm st, followed by 25 microgm/hour infusions, ideally till
OGD scopy is done and endoscopic sclerotherapy is done. It is to be given in
5% Dextrose, Never in NS.
5. Inj Vit K 1 amp s/c or iv od x 3 days
6. Inj Pantop 40mg iv od or Inj omez(omeprazole)80mg iv st f/b 8mg/hr infusion
7. Inj thiamine 100 mg(Trineurosol H)iv bd x 7 days if alcohol related liver disease.
8. Inj Ampicillin 500mg iv Q6H ATD/ Inj taxim
9. T Rifagut (rifaximine) 400 1-1-1 (gut sterilizer)(thru Ryle’s tube, or orally if there
is no hemetemesis & sensorium is normal).
10. Bowel wash with lactulose enema bd
11. Syp Looz 30ml tds(if not NPO)(r/o ileus/bowel obstruction before oral lactulose)
12.Inj Hepamerz/analiv(L-ornithine L-aspartate) 5g(10 ml) iv bd if RFT is normal
13.If Vomiting present, Inj Emeset 4 mg iv Q8H
14.Inj Mannitol 20% 100ml iv Q8H, if RFT is normal.
15.IVF DNS 2 pint, NS 2 pint , 5%D 2 pint in 24 hrs..Fresh blood/FFP transfusion
16.If stable ofter OGD scopy, propranolol (to decrease portal HTN) may be started
at a dose of 20mg 1-0-1. Dose may be adjusted so as to cause of 25% decrease
in pulse rate
17.T Monotrate 20mg 1-0-1(isosorbide mononitrate)(Px for variceal bleedeing)
18.If Ascites is present give T Aldactone 25 (1-0-1)(spironolactone)(to decrease fluid
overload) or T Lasilactone(furosemide + spironolactone) 1-0-0.
Refractory ascites means no response to Aldactone.
19.If Viral Hepatitis was the cause of CLD give T Lamivudine 100mg od or tenofovir,
probably long term.
20.Clinical worsening of the patient may due to the development of Spontaneous
Bacterial Peritonitis. The patient may present with suddenly developing abdominal pain,
with rebound tenderness, absent bowel sounds and fever. In such cases, do a
diagnostic tap and send for cytology study. Diagnosed if PMN >250cells/µL or if >50%
polymorphs, cloudy nature of fluid and positivity on culture-> mostly E coli. A culture of
mixed organisms may indicate a hollow viscus perforation. Give Inj Taxim 2g iv Q8H till
clinical improvement(for a minimum of at least 5 days). Other options include AmoxClav
or other 3rd generation Cepholosporins or Genta.
21.If Ascites is present do therapeutic tap, ideally only after giving Human Albumin
intravenous infusion or FFP.
22.Any CLD patient with ascites, give long term prophylaxis with T Norflox 400mg
Once daily to prevent SBP.
Diet in Hepatic Encephalopathy
1. Restrict Proteins
2. Fluid intake should be such that the daily weight loss is not more than 1 kg.
3. Carbohydrate rich diet.
53
Factors Which Preceipitate hepatic encephalopathy
1. Uraemia-spontaneous or diuretic induced.
2. Drugs like Sedatives, Hypnotics or Antidepressants
3. GI Bleeding
4. Excessive protein intake
5. Large volume paracentesis
6. Hypokalemia
7. Infections
8. Constipation
9. Trauma,Development of portosystemic shunts
Correction of metabolic abnormalities
Hypokalemia (K+ <3.5 mEq/L):If S. K+ >2.5 give Syp Potklor (Pottasium chloride) 1-2
meq/kg/day in 1 glass water(15ml=20 meq =1.5g )if normal urine output. Oral doses of
40 mEq are generally well tolerated & can be given as often as every 4 hours.
Traditionally, 10 meq of pottasium are given for each 0.10 mEq/L decrement in S. K+.
Monitor S. K+ every 4 hr.Monitor ECG, urine output.If S. K+ <2.5 , give iv pottasium.
Administer 4 g of Inj KCl in 100 ml of NS over 4 hrs. Replace at 10 -20 mEq/hr if urine
output is normal.
Hypocalcemia: Inj calcium gluconate 10 ml 10% slow iv over 10 minutes.Also check
phosphorus (for hyperphosphatemia)& Mg(for hypomagnesemia).
Hyponatremia: fluid restriction(hypertonic saline is reserved for very severe cases)
Viral Hepatitis
C/F: fever, malaise,fatigue, anorexia, nausea, arthralgia, jaundice,pruritus, headache,
abdominal pain,
Inv: Hep A: AST & ALT rise 22-40 d after exposure, & usually return to normal over 5-
20 weeks.IgM rises from day 25 & signifies recent infection.IgG remains detectable for
life.Hep B: HBsAg(surface antigen) is present from1 to 6 months after exposure. HBeAg
is present for 11/2 - 3 months after the a/c illness & implies high infectivity.The
persistence of HBsAg for >6months defines carrier status.Antibodies to HBcAg(anti-HBc)
imply past infection. Antibodies to HBsAg(anti HBs) alone imply vaccination.
HCV: anti-HCV antibodies, SGOT:SGPT <1:1 until cirrhosis develops.
Admit if ->
>15 Bilirubin, prolongation of PT
Enzymes grossly elevated, Coagulopathies
Significant Vomiting, abdominal pain, malaise
Ascites and Encephalopathy, Hypoglycemia,Co-morbid conditions
Among investigation, the prolongation of PT is the earliest marker. If the test value
exceeds the control value by >4sec, it is considered abnormal.
Rx: Mainly supportive
1.Absolute bed rest, avoid alcohol
2.Protein and fat restricted, carbohydrate rich diet.
3.T Silybon (silymarin, herb derivative used as hepatoprotective)140mg 1-0-1
4.T Udihep/Udiliv/Ursochol (ursodeoxycholic acid/ursodiol) 300mg 1-0-1.
Note: ursodiol used in cholestasis, cirrhosis, other hepatic disorders)
5.Inj Vit K 1 amp s/c od x 3 days if coagulopathy is suspected.
6.Avoid P’mol. Do tepid sponging for fever
7.Hepatic drip(Usually in children if oral feeds are not well tolerated. (100ml NS
400ml 10% glucose + 5ml 15% KCL + 2ml Polybion)
Note:Fulminant hepatitis, C/c Hep B, a/c or c/c Hep C may require specific antivirals.
54
ADD/Gastroenteritis
C/f: Diarrhoea, vomiting, abdominal discomfort,fever etc.
Inv: BRE, RFT, electrolytes,stool RE, C & S etc.
1. 4th hrly Temp chart , I/O chart
2. Inj Ciplox 200mg iv BD [Ciprofloxacin] or T Ciplox 500 mg bd
3. Inj Metrogyl 500mg iv Q8H[Metronidazole] or T Metrogyl 400 mg tds
4. Inj Rantac 50mg iv tds [Ranitidine]
5. Inj P’mol 2cc im sos
6. Inj Cyclopam / Buscopan 1 amp im sos[dicyclomine / hyoscine butylbromide]
7. Plenty Of Oral Fluids/ORS.If not taking orally IVF RL/DNS/NS
8. C.Hydral or Redotil 1-1-1[Racecadotril]
Note: C Doxy 100mg bd x 3-5 days can also be given.
Malaria
C/f: fever, shivering, headache, jaundice, joint pain, vomiting, convulsions,HSM.
Do RMT,peripheral smear for malarial parasite, RFT, LFT etc.
1.4th hrly temp chart
2.For uncomplicated malaria: chloroquine 250 mg 4 tabs st, 2 tabs after 6 hrs, 24 hrs
& 48 hrs.For P ovale & P.vivax same as above + T Primaquine 15mg 1-0-0 x 14 days
Note:G6PD deficiency must be ruled out before starting primaquine.
For uncomplicated P.falciparum- T artisunate 4 tab daily x 3 days, SP (sulpho -
methoxazole pyremethamine) 3 tablets on day 1. For severe cases -artesunate 2.4
mg/kg iv/im given on admission, then at 12 hrs & 24 hrs & then OD.
3. Inj 25% Dextrose 100ml iv Q8H
4. Inj Pantoprazole 40mg iv od;If not taking orally, IVF 2 pint DNS; P’mol for fever.
Chemoprophylaxis(<6 weeks): doxycycline 100 mg OD in adults(1.5 mg/kg for children>
8 yrs) 2 days before travel & continued for 4 weeks after leaving the malarious area.
Influenza / H1N1
C/f:fever,cold, sore throat, muscle pain, head ache, cough, tiredness etc
1.Antipyretics, analgesics, cough medications, antibiotics for 20 infection
2.Antiviral agents: T. Oseltamivir 75 mg bd x 5 days(tamiflu). Syp Oseltamivir (12mg/ml)
Prophylaxis: T. Oseltamivir 75 mg OD x 10 days
Pneumonia
C/f: fever, chest pain, dyspnea, hemoptysis, productive cough, malaise, chills,rigors,
other non specific s/s like myalgia, headache, abdominal pain, nausea, vomiting,
diarrhea, anorexia,wt loss, altered sensorium.
Inv: CXR, CBC, ABG,pulse oximetry, LFT , U & E, blood culture, CRP,
Hospitalised pt’s should have regular monitoring of pulse, RR,BP, O2 saturation. Assess
severity using CURB-65
Rx
In pt’s with mild community acquired pneumonia, amoxicillin may be used.
Out Pt- macrolides(Azithromycin 500 mg PO od single dose followed by 250mg PO
daily x 4 more days) or doxycycline(100 mg PO x 5 days),
In pt’s with exposure to antibiotics within the last 90 days or those with comorbidities,
use a respiratory FQ monotherapy or β-lactam(like amox high dose 1g tds) + a
macrolide x 5 days
IP, non ICU pt’s, choose one option from below:-
β-lactam im /iv(ceftriaxone/cefotaxim) + macrolide iv/oral(Azithromycin)
β-lactam im /iv + doxycycline iv/oral
FQ(antipneumococcal) iv/im(levoflox)
55
If the pt is younger than 65 yrs with no risk factors for drug-resistant organisms,
administer macrolide iv/oral
For ICU pt’s, choose one from below:-
β-lactam iv + macrolide iv
β-lactam iv + FQ(antipneumococcal) iv
If the pt has a documented β-lactam allergy, administer iv FQ(antipneumococcal) +
aztreonam iv
For pt’s with increased risk of infection with Pseudomonas, choose one from below:-
Antipseudomonal β-lactam iv (piptaz,cefepime,meropenem,imipenem)+
antipseudomonal FQ(ciprofloxacin,levofloxacin)
Antipseudomonal β-lactam iv + aminoglycoside iv + macrolide iv//
FQ(antipneumococcal)// if the pt has β-lactam allergy, give aztreonam iv +
aminoglycoside iv + FQ(antipneumococcal) iv
4th hourly temp chart, PR/RR/BP monitoring. SpO2 monitoring for severe cases.
Supportive: rest, adequate hydration, symptomatic treatment for fever,bodyache,
pleuritic chest pain,O2 inhalation,Nebulisation with salbutamol for 20 min Q6H,inj
deriphylline Q8H, syp Ambroxol 2tsp tds, chest physiotherapy, rpt x-ray on day 7.
Atypical pneumonia: azithromycin
Aspiration pneumonia: cephalosporin + metronidazole+ respiratory FQ
Hospital acquired: aminoglycoside iv + antipseudomonal penicillin iv or 3rd gen
cephalosporin
Filariasis
Acute lymphangitis & lymphadenitis, Tropical eosinophilia:
T DEC 100 mg 1-1-1 x 3 weeks(Hetrazan, Banocide)(children-6mg/kg/day div into 3)
Prophylaxis
T DEC 300 mg + albandazole 400mg one dose yearly
Tropical eosinophilia, c/f- cough aggravating at night, asthmatic attacks, weakness,
wt loss, low fever, enlarged spleen, prominent LN in the neck etc
For persistent eosinophilia & c/c dry cough, T prednisolone may be given
A/c Appendicitis
C/f: Rt lower quadrant pain, periumbilical pain, nausea, vomiting, anorexia, diarrhoea,
constipation, Rebound tenderness, pain on percussion, rigidity, and guarding
Inv: FBC, URE,RFT, LFT,CRP,USG abdomen, CT abdomen
1.Bed rest
2.NPO
3.IV fluids
4.Nasogastric suction
5.Analgesics,antiemetics
6.Antibiotics if perforated /gangrenous appendicitis or peritonitis, e.g taxim + metrogyl
7.Surgery consultation
A/c Pancreatitis
C/f: abdominal pain/tenderness/guarding/distension, nausea, vomiting, diarrhoea,fever,
jaundice, hematemesis or melena, dyspnea, tachypnea, diminished bowel sounds, left
side basal lung creps, hypotension etc
Inv:FBC, RFT, LFT,S.electrolytes with S.calcium, CRP,BUN,Lipid profile, S.Amylase,
S.lipase, LDH, USG abdomen, CT abdomen
1.Bed rest
2.NPO
3.Aggressive iv fluid therapy, continous nasogastric aspiration, antiemetics
4.Analgesics like tramadol
5.Antibiotics only if associated infection is suspected
6.Inj Ranitidine or Pantoprazole
7.Inj octreotide 100 µg iv or s/c bd/tds x 3 days
Note: also treat metabolic complications like hyperglycemia, hypocalcemia etc
For c/c pancreatitis: T Creon 10,000U 1-1-1 x 2 weeks(lipase, amylase, protease)
Paronychia
Most common hand infection. Another infection is felon(commonly bacterial,viral also)
A/C paronychia is commonly bacterial(Staph).
If soft tissue swelling is present without fluctuance, the infection may resolve with warm soaks
3-4 times daily.If abscess, do I & D.
Drain the pus by making an incision over the eponychium. If there is a floating nail,
removal of nail is required.
1.C.Ampiclox 1-1-1-1 x 5 days or amoxiclav or cephalexin or doxycycline.
2.T.Lyser D 1-0-1 X 5 days
3.Fucidin or T-bact oint for LA
C/c paronychia is commonly due to fungal infection
1.T. Flucos 150mg once weekly X 6 months[fluconazole] for c/c paronychia.
2.Topical antifungals like Daktarin(miconazole) or Onylac nail lacqer(ciclopirox) to be
applied over the affected nails at bed time. Should be applied starting from the skin
adjacent to the nail bed.Use the brush provided to apply into crevasses & ridges.Cut
nails weekly & rub over the nails using accessory provided once every week.
62
Intertrigo
Inflammation of the body folds. Bacterial/fungal/viral
Commonly Candidial infection, usually involves the lateral two interdigital spaces, inner
thighs,genitalia, under the breasts, underside of the belly, behind the ears. Sometimes
there may be superimposed bacterial infection
1.T. Flucos 150mg once weekly x 1 month
2.Aciderm G for L/A x 10 days[betamethasone, gentamycin, clotrimazole]
3.C Carofit 1-0-0 x 1 month[vit C, vit E, zinc sulphate, beta carotene, carrot]
Pyodema
(impetigo, folliculitis,furuncle, carbuncle,tropical ulcer etc)
1.Antibiotics ->Ampiclox/ciplox/amoxclav/doxycycline/ cephalosporins
2.Analgesics, antihistamines
3.T-bact /Futop/Neosporin Oint for LA bd
4.Saline washing – One tsp salt in 2 glasses of water
5.Good hygiene.
Impetigo:Highly contagious bacterial skin infection,primarily caused by Staphylococcus
Dandruff
1.Warm oil Massage; after 10 min, apply Nizral 2 % shampoo on to scalp for a period of
ten minutes; then wash away all the oil. Rpt twice or thrice weekly x 2 months
Other options include Danclear shampoo, KTC medicated shampoo,Scalpe/Dandrop
shampoo [Ketoconazole + Zn pyrithione]
2.Ionax-T[Coal tar + Salicylic acid] :-> relieves itching & flaking in dandruff,
seborrheic dermatitis & psoriasis of the scalp.
Acne Vulgaris
Wash the face with soap & hot water 2-3 times a day.
Avoid excessive exposure to sun.
Persol-AC Gel or Benzac - AC 2.5% - 5%, apply; wait for 2 min & then wash off
[benzoyl peroxide](start as once daily, during day time) (for black heads) or
Clindac A gel [clindamycin] for inflammatory & pustular lesion
Clinmiskin cream -> Clindamycin, Niacinamide. or
Retino-A/eudyna cream, to be applied 2-3 times a week HS(for black heads)
C Doxycycline 100 1-0-1 x 10 days or T Azithromycin 500 mg od x 5 days
Other drugs used: Azelaic acid 2% or Adapelene 0.1 % gel(adaferin, deriva)
Deriva-CMS gel(adapelene + clindamycin)
T isotretinoin 10 or 20 mg(isotret)(0.5mg/kg/day) at night (teratogenic)
With all anti-acne creams look for irritation, dryness, redness, itching, burning every
10-15 days.
Alopecia
Aetiology: Poor nutrition,tinea capitis, hyper/hypothyroidism,prregnancy, SLE,Diabetes,
Drugs(eg. Steroids), excessive dandruff
Check for iron deficiency. Do FBC, LFT, RFT,TFT, S.Fe, Ferritin
1.Multivitamins (with biotin)e.g.T Xtraglo OD x 1 month(biotin,L-methionine, L-cysteine)
or Keraglo-Men or Keraglo eva(gamma lenolenic acid, multivitamin, natural extracts).
2.ProAnagen Shampoo
For Alopecia areata: Diprovate scalp lotion(betamethasone) or Flucort lotion
(fluocinolone). Apply OD
For androgenetic alopecia: Minoxidil topical solution BD. 2% for women, 5 % for men
(T N: hair 4 U, morr, morr-F)
63
Corns & callosities
Usually they go by themselves, once the irritating factor is avoided. Use proper fitting
footwear or MCR footwears.
1.Keratolytic agents like Salicylic acid 40% pads and plaster or solution. Apply & leave
for 4-5 days. Also used- 40% urea cream, and 12% lactic acid cream.
Note:patients with peripheral neuropathies should avoid or use topical salicylic acid with
caution.
TN:- cleanoderm/duofilm(salicylic acid+ lactic acid) lotion/solution daily x 3 weeks
2.Carnation Decorn corn caps(salicylic acid), To be kept in position with the corn for
few days. To be reapplied again till the corn drops out.
Contact Dermatitis
Definitive treatment of allergic contact dermatitis is the identification and removal of any
potential causal agents; otherwise, the patient is at increased risk for chronic or
recurrent dermatitis
1.Wet compresses/ saline soaks
2.Emollients Emoderm/novasoft or calamine may be beneficial in chronic cases.
3.Oral antihistamines like T CPM 4mg 1-0-1
4.Topical corticosteroids like clobetasol are the mainstay of treatment.
Note:When choosing a topical glucocorticosteroid, match the potency to the location of
the dermatitis and the vehicle to the morphology (ointment for dry scaling lesions; lotion
or cream for weeping areas of dermatitis).
5.For severe acute allergic contact dermatitis or widespread and severe chronic
dermatitis, systemic glucocorticosteroids may be required( administered for 2 weeks).
Excessive Sweating/hyperhydrosis
Seen in Hypoglycemia, MI, Defervescence in fevers, Hyperthyroidism, Vasovagal
attacks, Rheumatic fever, gout, nervous excitement,alcohol/drug withdrawal, anxiety etc.
1.Palmoplantar/ axillary sweating: Aldry lotion for LA HS(aluminium chlorohydrate) or
2.Losweat powder for LA(miconazole, chlorhexidine )
Stasis Dermatitis
Due to venous stasis on the lower portions of legs.
1.Wet compresses/saline soaks for 5 minutes(10 teaspoon salt in 20 glass of water)
2.Emollients like Emoderm/Novasoft(white soft paraffin, liquid paraffin)
3.T Caldob 500 mg OD (ca2+ Dobesilate)
4.Topical corticosteroids like triamcinolone 0.1 %(T.N: Ledercort oint)
5.Daily use of elastic stockings.Raise leg end of bed at night by 15 cm( 2 brick).
Pediculosis
C/f: LNE-> Sub occipital & post auricular
C/o may be itching & constant ulceration.
1. Antibiotics like Ampiclox
2. Medicare, Zeromite[Permethrin 1%]
Massage into scalp, Bath after 10 min & then comb. Rpt after 7-10 days to kill nits
3. T ivermectin 12 mg single dose to be taken on empty stomach(0.2 mg/kg)
4. Anti inflamatory-> brufen
5. Rantac / Omeprazole
6. T.Celin 500mg OD / BD
In case of lice ulcer in Axilla, Permethrin Cream for L/A. Petrolatum ointment, is the
preferred treatment for infestations of the eyelashes and eyebrows.
64
Ringworm infection of skin(Tinea/Dermatophytosis)
Most of the cases are managed with topical preparations. Topical therapy is indicated
for limited infection of the body, groin, superficial involvement of the beard region, palms,
& soles
Nizral(ketoconazole 2%) or exifine(terbinafine 1%) or fungitop(miconazole 2%) or
candid(clotrimazole 1%) or whitfield ointment(benzoic acid 6%, salicylic acid 3%).
Duration of the therapy is 4 to 6 weeks or 2 weeks more after clearance of lesions.
Seborrhoeic dermatitis
1.Nizral shampoo for scalp & body wash twice weekly.
2.Keto-B cream for LA (ketoconazole+ betamethasone) x 5 days
After 5 days Ketoconazole oint 2%(nizral) for LA BD x 2 weeks
Scabies
Permethrin 5% lotion is the DOC.It is applied from the neck down, usually before
bedtime, and left on for about 8 to 14 hours, then washed off in the morning. One
application is normally sufficient for mild infections. For moderate to severe cases,
another dose is typically applied 7 to 14 days later Or
Initially scrub bath is advised to open up the burrows. Then apply Gamma Benzene
Hexachloride(lindane) 1% Lotion [Scaboma] for a period of atleast 10-12 hours and
Rpt scrub bath.All clothes,towels & bed sheets etc should be washed well(ideally in
hot water) & dried in sun or if possible ironed well.It may be repeated after 1 week
Ideally, treat all family members at a time
Apply over entire body, below the neck to toes
Scabies may also get infected, so in such cases, give antibiotics eg. Ampiclox
Antihistamines
Another option is T.Ivermectin. If > 50kg give two 6mg tabs at early morning on
empty stomach. If <50 kg give 3mg tabs. Rpt after 2 weeks
Crotorax/Eurax(crotamiton) 2-3 times a day , can also be given
Psoriasis
Scaly lesions over extensor aspect[mainly]
1. Dipsalic/betnovate-S/betasalic/Saltopic lotion/ointment [betamethasone, salicylic acid]
or Diprovate MF cream [betamethasone, lactic acid, salicyclic acid, urea, sodium
lactate] bd for L/A .
2. Antihistamines to prevent scratching.
3. T Calcium OD/BD, liquid paraffin for LA;
4. Oral antibiotics like Doxycycline bd for a/c psoriasis
5. Cetrilak mild shampoo for scalp (cetrimide)
Note: Dry scaly conditions like Psoriasis, Atopic dermatitis, Ichthyosis requires
moisturizing cream e.g Elovera cream to be applied after bathing [vit E, aloe vera]
Strecth marks, striae, cracked nipples, dark circles :
1.Alovit-AF cream for L/A. [lactic acid, vitamin E, sunflower oil, aloe]
Antioxidants:
It is a usual practice to give antioxidants- C Evion 400mg /T Carofit / T antoxid OD
x 1month
Fissuring of soles(athlet’s foot/tenia Pedis)
Keep the foot dry. Foment in hot water for 10 mins, 2 times daily, followed by drying
and application of antibiotic & keratolytic ointments.
1.Moisturex cream (urea, lactic acid,propylene glycol, liquid paraffin) for LA Or
Salytar-ws/Salicylix-SF(salicylic acid) to be applied on the hard skin only or vaseline.
2.If secondary infection : Surfaz –SN or candid-B for LA
Note: if inflamed or swollen, give antibiotics, anti inflammatory drugs, steroids
Icthyosis
Avoid using strong soaps/excess sun exposure
After a bath , apply emollients or moisturizers to prevent scaling & dryness.
Moisturex cream for LA
Other topical preparations: Retino-A cream(tretinoin) for LA OD or Daivonex oint for
LA(calcipotriol) or Keralin oint for LA(salicylic acid, benzoic acid,hydrocortisone) or
Copriderm(Betamethasone, urea, lactic acid, propylene glycol, salicylic acid) for LA
Warts
Caused by HPV
1.Salicylix-SF 12% cream(salicylic acid) for LA or
2.Imiquad/Nilwart cream(imiquimod) for LA on alternate days ; wash after 8 hours.
Dry skin/Xeroderma
Etiology:Zn & essential fatty acid deficiency,end-stage renal disease, hypothyroidism,
HIV, malignancies,sjogren’s syndrome, neurologic disorders, drugs, topical preparations
containing alcohol, detergents, harsh bathing soaps, vitamin A/D deficiency, winter etc
1.Emolients/moisturizers e.g Emoderm/Elovera/Novasoft for LA
2.Adequate hydration
Herpes simplex
1.For initial infection:Acyclovir cream(Zovirax) for LA
2.T Acyclovir 200 mg 1-1-1-1-1 or 400 1-1-1 x 7- 10 days (5-20 mg/kg Q8H)
Dermatology consultation.
67
Hand-Foot-mouth Disease
C/f:fever, feeling tired, generalized discomfort, loss of appetite, and irritability.Skin
lesions/rash followed by vesicular sores with blisters on palms of the hands, soles of the
feet, buttocks, around the nose,mouth and lips.HFMD usually resolves on its own after
7–10 days.
1.Antihistamines
2.Antipyretics
3.Adequate fluid intake, preferably Cold fluids. Avoid spicy foods.
4.Soothing lotions like calamine lotion for rashes.
Dyschromias in children
Most commonly hypopigmentation of face
Aetiology:Pityriasis alba, tinea versicolor, etc
1.Deworm
2.Multivitamins,Calcium supplements,Leafy vegetables & milk in diet,
3.Advise to use Dermadew baby soap(glycerin,aloe vera, coconut oil etc) or Dove/Pears
soap for bathing.
4.Moisturizers like elovera/cetaphil lotion for LA to be applied just after bathing.
5.If no improvement, Eumosone cream (clobetasone) for LA x 1 week.
Chickenpox/varicella
Infection is by exposure to respiratory droplets, or direct contact with lesions, within a
period lasting from three days prior to the onset of the rash, to four days after the onset
of the rash. Centripetally distributed vesicles.
Keep the skin clean by frequent showers. Avoid vigorous rubbing.
1.T Acyclovir 800 mg(Zovirax 200,400,800 mg available) (1-1-1-1-1) x 7 days
2.T CPM; T Rantac
3.Calamine Lotion for LA after bath; or Mupirocin Oint for LA onto the vesicles.
If 20 infection: Amoxiclav / azithromycin
Note: Acyclovir for Paed 20 mg/kg QID or 80 mg/kg/day div into 5 doses,Zovirax(400/5)
Balanitis(balanoposthitis)
C/f: Pain, discharge, redness
1.Gentle retraction of the foreskin daily and soak in lukewarm water to clean penis and
foreskin. Avoid soaps when inflammation is present. Use a moisturising cream/ointment
(emollient) to clean, instead of soap.
2. Clotrimazole LA for candidial balanitis.
3.Mild Steroids like Betamethasone 0.05% for inflammation in addition to antibiotic
creams
Note: steroid creams shouldn’t be used alone, as it may worsen the infection
4.Antibiotic ointments like neosporin, if bacterial infection suspected.
Non-specific urethritis in Men
1.T Azithromycin, 1gm, single oral dose or
2.T Doxycycline 100 mg bd x 7-14 days or
3.T Levoflox 500 mg Od x 7 days or
4.T Oflox 300 mg PO bd x 7 days
Note: Tinidazole may be combined with azithro/doxy.
Photodermatitis
1. Avoid Sun exposure
2. Apply sunban lotion 20 minutes before going out.
3. Betamethasone for LA at night for 1-2 weeks.
4. T Cetrizine 10 mg HS
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Common Psychiatric Disorders
Note: Ideally Always Refer the pt to a Psychiatrist.
Bipolar Disorder
Manic episode
In aggressive pt’s: Inj haloperidol 5mg IM, or Inj Lora 2 mg IM or Inj Olan 10 mg im st.
1.T Valproate 500 1-0-1 [Lithium is the DOC]
2.T Olanzapine 5 mg 0-0-1 or Risperidone 1 or 2 mg 1-0-1 or T Haloperidol 5mg 1-0-1
or T Quetiapine 100 mg 0-0-1(Antipsychotics)
3.T Lora 1mg 0-0-1
Depression episode
1.T Escitalopram 5 mg 0-0-1 x 2 weeks; after 2 weeks 10 mg HS x 2 weeks(T.N-Nexito,
stalopam, szetalo, cilentra, citel, citofast)
2.T Clonazepam 0.5 mg 0-0-1 x 2 weeks; after 2 weeks 0.25 mg HS x 2 weeks(T.N-
clonotril, clonafit, epizam, lonazep,rivotril)
Panic attack
Intense fear with s/s related to various systems like sweating, palpitation, feeling of
choking, trembling,sweating, chest discomfort,dizziness,
For aggressive pt’s ,Inj Lora 2mg IM or slow iv st or Inj Diazepam 10 mg slow iv or IM or
Inj Serenace 5mg IM St.
1.Antidepressants like SSRI eg Escitalopram or
2.BZD eg T clonazepam 0.5 mg 1-0-1 x 4 weeks, then tapered off.
Post-coital contraception
Within 72hrs , I -PILL 1 tab st & 1 tab 12 hr later [levonorgestrel] Or single 1.5 mg
dose or
IUCD insertion within 5 days or
Mifepristone 600mg [200mg x 3] as a single dose (with in 72 hrs) followed 2 days
later by 4mg of misoprostol [T.Misoprost] as single dose.
Mifepristone, T N: T. Mtpill,T.unwanted, T.Mifegest Cost~1000rs.
Injectable Contraceptives
Inj Depot Provera (Medroxyprogesterone Acetate)150mg deep IM (or 104 mg sc)
every 90 days during first 5 days of menstrual cycle
Inj Noristerat (norethisterone enanthate) 200 mg deep IM during first 5 days of
menstrual cycle at 2 months interval
Dysmenorrhea(painful menstruation)
0
1 Dysmenorrhea: Pain in lower abdomen & may radiate to the back & legs; may be
accompanied by nausea, vomiting, diarrhoea, headache, malaise.
20 Dysmenorrhea: dull pain , deep seated in pelvis with no radiation.
1. Inj cyclopam/ voveran 1 amp IM st ATD
2.T cyclopam or Baralgan tds x 3 days or T Meftal-Spas(Mefenamic acid+
dicyclomine) or T Drotin-M(drotaverine + mefenamic acid).
Note:If pt doesn’t respond to the treatment, suspect endometriosis
Enhancement of Lactation
1.C.Lactare 2-2-2 x 5 days(asparagus racemosus 200 mg,withania somnifera100mg etc)
2.T perinorm 10 mg(1-1-1) x 5 days
Suppression of lactation
T. B-long (pyridoxine) 100 mg 2-2-2
Menopause
Nutritious diet with proteins, wt bearing exercises
Calcium + Vitamin D
Pap smear / Breast examination
Bleeding pv in pregnancy
During first trimester,Mnemonic :AGE IS Low
Abortion,Gestational trophoblastic disease( e.g vesicular mole), ectopic pregnancy,
implantation bleeding,spotting, lower GU tract causes like cervical or vaginal bleed.
During second or third trimester :Pacenta praevia , placental abruption,preterm labour
Inv: CBC,coagulation profile, β-hCG,URE, USS
Refer to O & G.
71
Drugs C/I in lactation
Ciplofloxacin,fluconazole,iodine,iodides,ketoconazole,metformin,tetracycline,amiloride,
amphetamine, ethosuccimide,indomethacin,anti cancer drugs, chloramphenicol,
ergotamine, amiodarone, etc
Drugs to be used with special precaution in lactation:
ACEI, acyclovir,aminoglycosides,amlodipine, ampicillin, amoxicillin, anticonvulsants,
antihistamines, azithromycin, beta blockers, atorvastatin, corticosteroids,cotrimoxazole,
ephedrine, furosemide, losartan, metoclopramide, metronidazole, montelukast,
morphine, naldixic acid,nifedipine, norfloxacin, omeprazole, pencillins, ranitidine,
theophylline, Carbamazepine, isoniazid etc. Avoid tramadol, diazepam, ketorolac etc
Hyperemesis gravidarum
C/f: nausea followed by excessive vomiting, severe dehydration, confusion, low BP,
DD:vesicular mole, multiple pregnancy, hepatitis, Appendicitis,Biliary
Disease,DKA,Esophagitis,Fatty Liver, Gastroenteritis, GERD, Hyperparathyroidism,
Hyperthyroidism, Irritable Bowel Syndrome, Nephrolithiasis, Pancreatitis, Acute
Intermittent Preeclampsia, peptic ulcer disease, Acute Paralytic Ileus/Bowel Obstruction
Inv: PCV,S.electrolytes, β-hCG, TFT, LFT, URE,urine acetone, USS to r/o multiple
pregnancy, vesicular mole
Look for dehydration
Rx
1.Inj phenergan or emeset or perinorm
2.IV fluids
3.Vit B1(thiamine) / B6
4.T Doxinate (doxylamine + pyridoxine)
Hanging
Inv: CXR, x-ray c-spine, ABG, electrolytes,creatinine, CT- brain with C-spine screening.
Early aggressive oxygenation is life saving; majority of pt’s recover with ventilator
management.
1.Oxygen by face mask at 8L/min. Intubate & ventilate if SpO2 <90 % or GCS <9
2.Protect C-spine with hard cervical collar until x-rays have ruled out fracture.
3.Inj Mannitol 20% 100 ml iv st over 20 minutes
4.Inj Dexona 8 mg iv st & tds or Inj Methyl pred 1g iv st (to prevent tracheal edema).
5.Inj eptoin 100 mg iv q8h for prevention & control of seizure.
6.Inj Rantac or Pantop
Note: aggressive behaviour is due to hypoxia & should prompt ventilatory management.
Associated methods of DSH such as poisoning or drug overdose should be kept in mind.
ARDS or aspiration pneumonia is a frequent event.
All DSH pt’s need psychological evaluation & support, prior to discharge.
Drowning(Submersion injury)
C/f: altered consciousness,cardiopulmonary arrest, tachypnoea, dyspnoea, hypoxia,
metabolic acidosis,
Inv: ECG, ABG, RBS, electrolytes, CXR,X-ray c-spine(to r/o neck involvement in diving
accident), CT Head(in pt’s with altered mental status or unclear history), bronchoscopy
may be necessary for removal of inhaled sediments. Examine oral cavity.
1.100% O2 by mask. Airway suction,OPA. If pt still dyspnoeic use CPAP or intubate.
2.Monitor blood sugar, BP (for hypotension),SpO2, ECG( for dysrhythmias)
3.Inj methyl pred 1g iv st or Dexona 8 mg iv st & tds
4.Immobilise the neck with hard cervical collar.
5.Aggressive warming is mandatory in the presence of hypothermia. Remove the wet
clothing before the victim is wrapped in warming blankets.
6.Inj taxim 1g iv Q8H; Inj Metrogyl 500 mg iv bd.
7.Treat complications; cerebral edema: IV mannitol; Bronchospasm: bronchodilators
(neb with salbutamol, inj deriphyllin); metabolic acidosis: sodium bicarbonate &
mechanical ventilation; seizures: eptoin; pulmonary edema: lasix
Electrical injuries
C/f: Entry & exit burns may be present. Haemorrhage behind the intact tympanum is an
occasional feature in lightning injury; perforation of the tympanic membrane is common.
High energy electrical injury causes massive muscle damage with myoglobinuria.
Ventricular fibrillation may occur. In males burns may occur on the undersurface of the
scrotum.
Inv: CBC, ECG,LFT,URE for myoglobin, RFT, CPK,ABG
1. Administer Oxygen
2. Monitor ECG for arrhythmia.
3. CBD, spine immobolization
4. Hydrate all pt’s with RL 10 ml/kg/hr during initial resuscitation. Hydration is the key to
reduce the morbidity of electrical injury.
5. Provide pain relief.
6. Mannitol when there is elevated CPK level & or myoglobinuria. This provides diuresis
for prevention of a/c tubular necrosis & renal failure, secondary to myoglobinuria.
7. Fasciotomy may be needed to improve circulation in circumferential burns or when
compartment syndrome is suspected.
8. Look for acidosis, if present give bicarbonate
75
Snake bite
Inv; CBC, electrolytes, RBS, creatinine, coagulation profile, URE,
Monitor BT, CT, aPTT every 4 hours & WBC count every day. Monitor RFT every day
(urine output, urea, S creatinine, S electrolytes).
Observe for e/o envenomation : local bleeding, swelling, ptosis, respiratory depression,
diplopia, dysphagia, severe pain. Examine extra ocular movement.
Single breath count(>20 - normal) to be tested every 15 minutes in suspected cobra or
krait bites.
If an extremity is bitten, it should be kept slightly dependant. IV access should be
established in an unbitten extremity.Observe for ascending cellulitis.
Apply tourniquet proximal to site of bite(loose enough to allow a finger in between).
Release tourniquet 1 hr after ASV or every 30 min advance proximally if swelling
advances.
Rx
1.Hourly pulse/BP chart; 4th hourly temp chart;I/O chart
2.Inj TT 0.5 ml IM st.
3.ASV is given if there is local reaction or signs of systemic envenomation.
Inj ASV 5 vials (in case of local reaction only) or 10 vials (for moderate systemic
envenomation) & 15 vials(for severe systemic envenomation) diluted in NS as iv
infusion 16-20 drops per minute over 1-2 hrs.
4.Premedicate with Inj efcorlin or methyl pred, inj Avil 20 min prior to ASV
5.Inj Metrogyl 500 mg iv Q6H ATD
6.Inj Ampicillin 500 mg iv Q6H ATD
7.Inj Rantac 50 mg iv Q8H
8.Inj clox 500 mg iv Q6H or T Klox 500 1-1-1-1
9.Glyceryl Mag sulph for LA; surgical management of local reaction with excision of
areas of necrosis.
10.In case of neurotoxic snake bite coming with ptosis, give all the above plus the
following:
Inj Neostigmine 0.5 mg q30 min, 1 hr, 2 hr & then 4 hr intervals + inj atropine 0.6 mg iv
before every injection of neostigmine.
11.Nephrology consultation for appropriate renal failure management.
12.IV FFP or whole blood transfusion (if clotting abnormalities persisits).
Note: Non-poisonous bites can be observed for 24 hrs, coagulation parameters
repeated & discharged.
Pulmonary embolism
Aetiology:Thrombosis in peripheral veins, Major surgeries, major trauma, indwelling
venous catheter, pregnancy, puerpeurium, woman on oral contraceptives or HRT.
C/f: unexplained hypotension, haemoptysis,unexplained dyspnoea, chest pain,
hiccoughs, pleuritic or chest pain aggravated by deep breaths, new adult onset asthma.
Inv: ECG(tachycardia, S1 Q3 T3),D-dimer, ABG, WBC, Coagulation study, CXR, Ct
angiography
1.Administer Oxygen
2.Propped-up position
3.Avoid fluid overload.
4.Inj Heparin 5000 IU as iv bolus.
Note:Investigate aPTT,INR & repeat Heparin Q6H to maintain an INR of 3.
Note:Suspect PE in unexplained dyspnoea;no baseline investigation is diagnostic.
Start heparin on suspicion of diagnosis.
76
ACS-STEMI
Give loading dose of aspirin 325mg , clopilet 300 mg, atorva 40mg,sorbitrate 10mg s/l st
Admit in ICU
1.Absolute Bed rest
2.Hourly BP, PR; Q4H temp chart
3.If pt is in severe pain give Inj Morphine 2-4 mg iv st + Inj phenergan 25 mg iv st
4.Inj SK 1.5 MU in 100 ml NS over 1 hr with continous BP monitoring.
In case of allergy to SK, administer efcorlin, avil.
Note: thrombolysis is indicated if given within 12 hours of onset of symptoms & it is most
effective when given in the first 3 hours of symptom onset.
Thrombolysis is C/I in pt’s with ST depression(unless posterior MI suspected)
5.Inj NTG 50 mg in 1 pint NS starting at 2 drops/min(for relief of chest pain & or control
of BP)(titrate upwards to a max of 12-14 drops).
6.T Ecospirin 150 0-1-0
7.T Clopidogrel 75 1-0-0
8.T Atorva 10 mg 0-0-1
9.T Metolar 25-100 1-0-1(β-blockers are not given if HR,60/1’ or systolic BP< 90 mm Hg)
10.T Envas 2.5-5 mg 1-0-1
11.T Sorbitrate 10 mg s/l tds(after checking BP) & 5mg s/l sos
12.T Rantac 150 1-0-1
13.Syp Lactulose 30 ml HS(as stool softner).
Note: Bradycardia: if the pulse rate is low, it is a clue that the pt may be having a
bradyarrhythmia like complete heart block.Mild degrees of bradycardia don’t require any
intervention in the casualty. Severe Bradycardia may be treated with Inj Atropine 1.2 mg
iv stat after definite ECG diagnosis. The vagolytic dose of atropine is 2 mg, so give 2-3
ampoules of atropine with a relatively fast push. T Alupent (orciprenaline)10 mg may be
given for mild cases of bradycardia.
A/c on CKD
Inv: BRE, URE, RFT, LFT, ECG,RBS, Urine C & S, USG abdomen, CXR, S.Ca/P
1.Q4H temp chart
2.Daily I/O chart, weight chart,RFT, RBS, ABG,hemogram
3.Restrict Na+, K+
4.Input= output + 500 ml
5.Inj lasix 40 mg iv Q8H(use diuretics if oedema, weight gain, hyponatremia,
uncontrolled HTN) or T Lasix 40 1-1-0
6.Treat hyperkalemia
7.If acidosis : T sodabicarb 1-1-1
8.T shelcal 500 mg OD
9.Treat underlying factors like anaemia,infection, DM, HTN, hyperlipidemia, obstruction.
10.Dialysis if indicated.
Hyperkalemia
(S. K+ >5.0 mEq/L)
C/f: muscle weakness/cramps, paraesthesia, hypotonia, focal deficits,
ECG: tall peaked T waves,prolonged PR & QRS, loss of P waves,sine wave pattern.
1.Nebulisation with salbutamol Q8H
2.Inj Ca gluconate 10% 10 ml over 10 min iv Q8H.
3.Inj RI 8U in 25% D 100 ml iv Q8H.
4.K-bind 1/3 rd sachet(5mg)(calcium polystyrene sulfonate) in 10 ml sorbiline (tricholine
citrate, sorbitol) TDS.
77
CVA
S/s: Change in alertness,consciousness, sense of hearing/taste.Clumsiness/Confusion/ loss of
memory, balance, coordination.Seizure/weakness in the face,arm,or leg (usually unilateral).
Difficulty in swallowing/ writing / reading/ walking/ speaking/ understanding others;Lack of
control over the bladder or bowels.Dizziness, vertigo,headache, decreased vision, double vision,
or total loss of vision.Numbness or tingling on one side of the body; Personality, mood, or
emotional changes. Changes that affect touch and the ability to feel pain, pressure, or different
temperatures
Inv: CT Brain, ECG, FBC, RBS,
If CT report pending
1.RTF/CBD
2.Inj Mannitol 20% 100ml over 20 min iv Q8H
3.Inj Ranitidine 50 mg iv Q8H
4.C Diamox(acetazolamide) 250 1-1-1
If CT shows IC Bleed
1.RTF/CBD, Q4H temp chart.
2.Inj Mannitol 20% 100ml over 20 min iv Q8H
3.Inj Ranitidine 50 mg iv Q8H
4.Inj eptoin 100 mg iv Q8H
5.T Atorvastatin 10 mg 0-0-1
6.Syp Cremaffin 30 ml tds
7.C Diamox 250 1-1-1
8.IVF as /if necessary
9.T Amlo 2.5-5 mg bd to maintain a target BP of 150/90
10.Oral glycerine 30 ml tds for 3-5 days
11.Frequent change of position, intermittent throat suction if unconscious.
12.Neurosurgery consultation
If CT shows Infarct
1.RTF/CBD, Daily BP monitoring, Q4H temp chart.
2.Inj Mannitol 20% 100ml over 20 min iv Q8H
3.Inj Ranitidine 50 mg iv Q8H
4.T Ecospirin 325 mg st & 150 0-1-0
5.T Atorvastatin 10 mg 0-0-1
6.Syp Cremaffin 30 ml tds
7.C Diamox 250 1-1-1
8.Inj Strocit(citicholine) 500 mg tds or T Strocit 500 mg 1-1-1 for 3-5 days
9.T Amlo 2.5-5 mg bd to maintain a target BP of 150/90
10.Oral glycerine 30 ml tds for 3-5 days
11.IVF as /if necessary
12.Neurosurgery consultation
13.Frequent change of position, intermittent throat suction if unconscious.
Delirium
Sudden transient, usually reversible confusional state occuring with physical / mental illness.
C/f:decreased attention, fluctuating confusion, disorganized thinking, decreased mobility,
incontinence & obtundation.
Aetiology: infections, metabolic & electrolyte abnormalities, hypoglycemia, alcohol or
sedative withdrawal etc.
Inv: pulse oximetry, ECG, RBS, CBC, electrolytes, URE, LFT, RFT, CT head, LP.
78
Cardiac arrest
Check carotid pulse, confirm pupillary reaction, start basic life support.
Consider advanced life support if defibrillator available. Cardiac thump if rhythm can be
monitored. Don’t repeat cardiac thump.
Start external chest cardiac massage(ECCM)
Place the pt on a flat & hard surface. Extend the jaw & keep neck extended. Stand at a
height higher than the pt. Keep the hands straight & elbows extended at 1800. Place
both hands over the sternum, one above the other. Give firm steady compression to the
chest wall squeezing the heart between the sternum & vertebra. Give compressions
approximately 4cm in depth at a rate of 30 cardiac compression & 2 assisted
respirations.
Continue cardiac compressions unremittingly till pt is revived or decision to discontinue
ECCM is made. Interrupt cardiac compressions only for giving assisted respirations or
DC shock.
Check cardiac rhythm to see for any ventricular fibrillation; if so connect defibrillator &
charge to 200 joules non synchronized shock. Make sure no one touches the cot or the
pt & the provider does not touch the cot. Apply conductive jelly to the pads of the
fibrillator & place it at the right & left axilla respectively. Press both buttons of the pads
simultaneously to deliver the shock. Check the monitor to see whether the rhythm has
reverted to normal sinus rhythm. If yes discontinue ECCM & make sure the pt is stable
with normal BP. Otherwise continue ECCM till decided on giving a second or if
necessary third shock.
Assisted ventilation should be given at the rate of 2 mouth to mouth breathing(or
preferably use an ambu bag) for every 30 cardiac compressions. If mouth to mouth
respiration is applied insert a gauze in between the mouths.ECCM should be
discontinued only after such a decision has been made taking into all considerations.
Needlestick injuries
Immediate care
For needlestick injuries & for skin exposure: wash with soap & water.
For mucous membrane splash e.g eyes: make the pt lie down, open the concerned eye
& allow 1 pint of NS (connected to an iv set) to run freely into the conjunctival sac.
Treatment
Exposure to Hepatitis B positive pt. If not vaccinated administer HBIG x one dose &
Initiate vaccination.
If previously vaccinated, Test for anti-HBs antibody levels.
If anti-HBs antibody > 10 mlU/ml- reassurance & no specific treatment is needed;
if anti-HBs antibody < 10 mlU/ml- administer HBIG x one dose & Initiate revaccination.
If exposure to HCV source: check for HCV antibody & LFT at 0, 3 & 6 months, &
follow-up.
Exposure to HIV source: immediate chemoprophylaxis( Pg No.51) & test for HIV
antibodies after 6 weeks, 3 months & 6 months following the exposure.
79
Adrenal crisis
It is a medical emergency. It is caused usually due to rapid withdrawal of longterm
steroid therapy, drugs such as ketoconazole, phenytoin, rifampin & frequently due to
septic shock.
C/f: unexplained shock, usually refractory to resuscitation. H/o nausea, vomiting,
abdominal pain, hyperthermia or hypothermia.
Inv: RBS, S.cortisol, electrolytes, creatinine, WBC
1. Inj hydrocortisone 100 mg iv bolus (after collecting sample for S.cortisol level) Q6H,
until pt is stable.
2.Replenish volume deficit.
Poisoning
Odollum poisoning
Explain prognosis
Inv:ECG, toxicological analysis of gastric aspirate
1.If the pt has bradycardia, give inj atropine 1 or 2 amp iv st &
Inj Atropine 1.2 mg iv sos if the HR < 50/min
2.Stomach wash if the pt is conscious
3.RTA/CBD
4.Syp cremaffin 30 ml tds
5.T Distenil 10 1-1-1
6.Inj Rantac/Pantop
7.IVF as necessary.
Also address two associated complications: hyperkalemia & heart blocks.
81
Adult Glasgow coma Scale
Spontaneous--open with blinking 4
Opens to verbal command, speech, or shout 3
Eye Opening Opens to pain, not applied to face(a peripheral pain stimulus, such as squeezing
Response the lunula area of the patient's fingernail is more effective than a central stimulus such as
2
a trapezius squeeze, due to a grimacing effect).
None 1
Oriented(Patient responds coherently and appropriately to questions such as the
patient’s name and age, where they are and why, the year, month, etc.) 5
Withdraws from pain(Absence of abnormal posturing; unable to lift hand past chin with
supra-orbital pain but does pull away when nailbed is pinched) 4
Motor
Response Abnormal (spastic) flexion, decorticate posture accentuated by pain (flexor
response: internal rotation of shoulder, flexion of forearm and wrist with clenched fist, leg
extension, plantarflexion of foot) 3
None 1
Individual elements as well as the sum of the score are important. Hence, the score
is expressed in the form eg ."GCS 9 = E2 V4 M3 at 07:35".
Generally, brain injury is classified as:
Digital blocks are extremely useful for anesthetizing the digit, there by facilitating the
repair of lacerations, paronychia drainage, nail removal and so on. Each digit is supplied
by two dorsal and palmar nerve branches. To obtain adequate anesthesia, all 4
branches must be anesthetized with local instillation.
A small gauge needle is inserted dorsally, into the web space and should touch the
periosteum at the base of the proximal phalanx; after withdrawing the needle slightly,
1.0 to 1.5 ml of anesthetic agent, usually 1% lignocaine without epinephrine/adrenaline,
is then injected. Without withdrawing the needle, it may then be redirected toward the
plantar corner until it is palpable on the palmar surface and a similar volume of
anesthetic agent injected. This procedure must be repeated on the opposite side of the
digit and will produce total anesthesia within 10-15 minutes.
For nail removal, wing block may also be given.
Rx
Check airway, Inj avil, Inj efcorlin, Inj adrenaline(if bronchospasm), remove stings, apply ice ,
elevate extremity to limit edema
Scorpion stings are very painful, so infiltrate the area with lignocaine 2% through the puncture
wound.
Look for systemic symptoms. If present refer.
Fluid requirement
In a normal person fluid requirement over 24 hr is roughly 2500 ml. Normal daily losses
are through urine(1500 ml), stool(200 ml), & insensible losses(800 ml). This requirement
is normally met through food(1000 ml) & drink (1500 ml).
Intravenous fluids are given if sufficient fluids can’t be given orally. About 2500 ml fluid
containing roughly 100 mmol Na+ & 70 mmol K+ per 24 hr are required. Thus a good
regimen is 2L of 5% Dextrose and 1 L of 0.9% saline every 30 hr with 20 mmol of K+
per litre of fluid.
Remember that all cannulae carry a risk of MRSA infection, so always resume oral fluid
intake as soon as possible.
In sick pt’s, don’t forget to include additional sources of fluid loss when calculating daily
fluid requirements, such as drains, fever, or diarrhoea
Underfilled
Tachycardia, postural drop in BP, ↓ capillary refill time, ↓ urine output, cool peripheries,
dry mucous membrane, ↓ skin turgor, sunken eyes
Over filled
Pitting edema of the sacrum, ankles, or even legs & abdomen, tachypnoea, bibasal
crepitations, pulmonary edema on CXR, ↑ JVP
Pottasium in IV fluids
Pottasium can be given with 5% dextrose, or 0.9% saline, usually 20 mmol/L or
40mmol/L.
K+ may be retained in renal failure, so beware giving too much IV. GI fluids are rich in
K+, so increased fluid loss from the gut(eg diarrhoea, vomiting, high-output stoma,
intestinal fistula) will need increased K+ replacement.
The maximum concentration of K+ that is safe to infuse via a peripheral line is 40
mmol/L, at a maximum rate of 20 mmol/h.
Note
Elderly pt’s are more prone to fluid overload, so give iv fluids with care
Pancreatitis: aggressive fluid resuscitation is required in a/c pancreatitis
Fever, burns: large amounts of fluid can be lost unseen through transpiration.
Liver failure: these pt’s often have a raised total Na+, so restrict 0.9 % saline
Heart failure: use IV fluids with care to avoid fluid overload.
Shock: resuscitate with colloid or 0.9% saline via large bore cannulae.
Hypertonic dextrose(10% or 50%): irritant to veins, so infusion sites inspected & flushed
with 0.9% saline after use.
IVF
DVT prophylaxis,
Pulmonary toilet: early mobilization, incentive spirometry
Medications: antiemetics, peptic ulcer prophylaxis, Pain ctrl, antibiotics,
Lab tests
General complications
Pyrexia
May be due to atelectasis, tissue damage, blood transfusions. Look for signs of wound
infection,UTI, chest infection, cannula site erythema, peritonism, endocarditis,DVT.
Send FBC, CRP, RFT, LFT
Confusion/agitation/disorientation
Look for hypoxia, urinary retention, MI, stroke,infection,alcoholwithdrawal, drugs,
liver/renal failure
Dyspnoea/hypoxia
Sit up, give O2, monitor peripheral O2 by pulse oximetry. Examine for evidence of
pneumonia, aspiration, LVF, pulmonary embolism,pneumothorax,
Send FBC,ABG,CXR,ECG
Hypotension
Inadequate fluid input(monitor urine output),hemorrhage(r/w wounds & abdomen).Also
consider sepsis, cardiogenic/neurogenic causes, anaphylaxis.Look for evidence of MI,
Pulmonary Embolism.
Check pulse,BP. If severe, tilt bed head down (unless cardiogenic)& give O2, IVF(unless
cardiogenic)
↓ Na+ :look pre-op level. SIADH can be precipitated by perioperative pain, nausea,
opioids, chest infection. Over administration of iv fluids may exacerbate the situation.
Correct slowly.
87
Specific complications
Thyroid surgery
Dyspnoea: tracheal obstruction due to hematoma in the wound.Relieve by immediate
removal of stitches or clips.
Voice muffled/different due to intubation & local edema, injury to rec Laryngeal nerve.
Mastectomy
Arm lymphoedema, skin necrosis
Colonic surgery
Sepsis, ileus, fistula, anastomotic leak, hemorrhage, obstruction from adhesions, trauma
to ureters, spleen.
Laparotomy
Wound dehiscence leading to burst abdomen with evisceration of bowel. Put the gut
back into the abdomen, place a sterile dressing over the wound, give iv analgesics, IVF.
Call Ur seniors.
Biliary surgery
Biliary colic,jaundice,hemetemesis, pancreatitis,post-op hemorrhage, biliary peritonitis
Tracheostomy
Stenosis,mediastinitis,surgical emphysema
Splenectomy
A/c gastric dilatation, thrombocytosis, sepsis
Genitourinary surgery
Septicemia
Hemorrhoidectomy
Constipation,infection, bleeding, stricture
Bariatric surgery
Dumping syndrome,wound infection,hernias,diarrhoea,malabsorption
Hernioplasty
Infection, mesh extrusion,FB reaction, Mesh inguinodynia causing Hyperaesthesia &
pain along the distribution of ilioinguinal or iliohypogastric nerves.
88
ECG Basics
Six Limb leads – L1, L2, L3, aVR, aVL, aVF
Six Chest Leads – V1 V2 V3 V4 V5 and V6
L1, L2 and L3 are called bipolar leads
aVR, aVL, aVF are called unipolar leads
Inferior wall:11, 111, aVF
Lateral wall:1, aVL, V4, V5, V6(V5 and V6 record events of left lateral wall
To record right side events V2R to V6R are needed – In dextrocardia, in RV infarction)
Anterior wall:V1 to V4(V1 and V2 record events of septum)
(V3 and V4 record events of the anterior wall) Axis of ECG
Standardization – 10 mm (2 boxes) = 1 mV
P Wave is Atrial contraction – Normal 0.12 sec or 120 ms
PR interval is from the beginning of P wave to the beginning of QRS- Normal up to 0.2s
QRS is Ventricular contraction –Normal 0.08 sec or 80 ms
ST segment – Normal Isoelectric (electric silence)
QT Interval – From the beginning of QRS to the end of T wave , Normal:- 0.40 sec
RR Interval – One Cardiac cycle, 0.80 sec
X-Axis represents time - Scale X-Axis – 1 mm = 0.04 sec
Y-Axis represents voltage - Scale Y-Axis – 1 mm = 0.1 mV
One big square on X-Axis = 0.2 sec (big box)
Two big squares on Y-Axis = 1 milli volt (mV)
Each small square is 0.04 sec (1 mm in size)
Each big square on the ECG represents 5 small squares
=> 0.04 x 5 = 0.2 seconds
5 such big squares => 0.2 x 5 = 1sec = 25 mm
One second is 25 mm or 5 big squares
One minute is 5 x 60 = 300 big squares
Sinus Rhythm – Each P followed by QRS, R-R constant
P waves – always examine for in L2, V1, L1
QRS positive in L1, L2, L3, aVF and aVL; Neg in aVR
R wave progression from V1 to V6
Normal T↓ in aVR,V1, V2
T inversions in V2, V3 and V4 – Juvenile T ↓
Similarly in women also T↓
Low voltages in obese women and men
If in, ECG the R-R intervals are not constant-sinus arrythmia
Ischemia produces ST segment depression with or without T inversion
89
Injury causes ST segment elevation with or without loss of R wave voltage
Infarction causes deep Q waves with loss of R wave voltage.
Upward sloping depression of ST segment is not indicative of IHD
It is called J point depression or sagging ST seg
Downward slopping or Horizontal depression of ST segment leading to T↓ is
significant of IHD
Evolution of Acute MI
Acute Anterior MI
Significant Q waves, ST elevation and T inversions in Leads V2, V3 and V4
Q waves and T inversion in L1
If only V1 and V2 show the changes it is called septal MI
Acute Anterio-Lateral MI
Significant Q waves, ST elevation and T inversions in Lead 1, aVL, V5 and V6
This is the most common form of MI
Acute Inferior wall MI
Significant Q waves, ST elevation and T inversions in Lead II, Lead III, aVF
Acute True Posterior MI
Lead V1 shows unusually tall R wave (it is the mirror image of deep Q),ST ↓,
peaked T
V1 R/S > 1, Differential Diagnosis - RVH
Hyperkalemia
Small or absent P waves
Atrial fibrillation
Wide QRS
Shortened or absent ST segment
Wide, tall and tented T waves
Hypokalemia
Small or absent T waves or inverted T
Prominent U waves
T wave is the tent house of K (pottasium)
More K – tall T, less K -flat or inverted T
Atrial Fibrillation
The heart rate is irregularly irregular
The R-R intervals are very different from beat to beat
There is narrow QRS tachycardia
90
There are no P waves – instead small fibrillary waves called ‘ f ’ waves are seen
especially in V1.
Atrial Flutter
The heart rate is regular or variable
Atrial rate is 300 per minute
All P waves are not conducted to ventricles
The R-R intervals very depending on the AV conduction ratio
The QRS is narrow : < 0.12 sec
The P waves have a ‘saw toothed’ appearance called ‘F’ waves
Ventricular Tachycardia
A wide QRS tachycardia is VT until proved otherwise.
Features suggesting VT include:
Evidence of AV dissociation
Independent P waves
Beat to beat variability of the QRS morphology
Very wide complexes (> 0.14 ms)
The QRS is similar to that in ventricular ectopics
Concordance (chest leads all positive or negative)
Pathological Q wave
The pathological Q wave of infarction in the respective leads is due to dead muscle
It is deep in amplitude–more than 25% of the succeeding R wave,or more than 4 mm
Its duration is > 0.04 sec or > 1 small box
It is seen in Leads facing the infarcted muscle mass
Normal Q waves
The normal Q wave in lead I is due to septal depolarization
It is small in amplitude – less than 25% of the succeeding R wave, or less than 3 mm
Its duration is < 0.04 sec or one small box
It is seen in L1 and sometimes in V5, V6
T Wave Inversion
Deep symmetric inverted T waves in more than 2 precordial(chest) leads
85% of the patients with such T wave ↓ had > 75% stenosis of the coronary artery
T wave ↓ are significantly associated with MI or death during follow up
Right Atrial Enlargement
Always examine Lead 2 for RAE
Tall Peaked P Waves, Arrow head P waves
Amplitude is 4 mm ( 0.4 mV) - abnormal
Causes:
Pulmonary Hypertension, Mitral Stenosis
Tricuspid Stenosis, Regurgitation
Pulmonary Valvular Stenosis ,Pulmonary Embolism
Atrial Septal Defect with L to R shunt
Left Atrial Enlargement
Always examine V 1 and Lead 1 for LAE
Biphasic P Waves, Prolonged P waves
P wave 0.16 sec, ↑ Downward component
Causes:
Systemic Hypertension, MS and or MR
Aortic Stenosis and Regurgitation
Left ventricular hypertrophy with dysfunction
Atrial Septal Defect with R to L shunt
91
Right Ventricular Hypertrophy
Tall R in V1 with R >> S, or R/S ratio > 1
Deep S waves in V4, V5 and V6
The DD’s are RVH, Posterior MI, Anti-clock wise rotation of Heart
Associated Right Axis Deviation, RAE
Deep T inversions in V1, V2 and V3, Absence of Inferior MI
Left Ventricular Hypertrophy
High QRS voltages in limb leads
R in Lead I + S in Lead III > 25 mm
S in V1 + R in V5/V6 > 35 mm or V5/V6 R wave ht > 25 small squares
R in aVL > 11 mm or S V3 + R aVL > 24 ♂, > 20 ♀
Deep symmetric T inversion in V4, V5 & V6
QRS duration > 0.09 sec, Associated Left Axis Deviation, LAE
Complete RBBB
Complete RBBB has a QRS duration > 0.12 sec
R' wave in lead V1 (usually see RSR' complex)
S waves in leads I, aVL, V6, R wave in lead aVR
QRS axis in RBBB is -30 to +90 (Normal)
Incomplete RBBB has a QRS duration of 0.10 to 0.12 sec with the same QRS features
as above.
The "normal" ST-T waves in RBBB should be oriented opposite to the direction of QRS
Complete LBBB
Complete LBBB has a QRS duration > 0.12 sec
Always pathological
Prominent S waves in lead V1, R in L I, aVL, V6
Usually broad, Bizarre R waves are seen, M pattern
Poor R progression from V1 to V3 is common.
The "normal" ST-T waves in LBBB should be oriented opposite to the direction of QRS
Incomplete LBBB looks like LBBB but QRS duration is 0.10 to 0.12 sec, with less ST-T
change.
This is often a progression of LVH changes
Myocarditis
Diffuse T wave ↓
Saddle shaped ST elevation
Dextrocardia
Rt axis deviation; Positive QRS complex(with upright P & T waves) in aVR
Lead 1- inversion of all complexes(global negativity-inverted P & T,negative QRS)
Absent R wave progression in the chest leads (dominant S wave through out)
Pericarditis
ST↑ in all leads( bulges downwards/concave upward)( In MI ,ST segment elevation
bulges upwards)
PR segment depression
Pulmonary embolism
Sinus tachycardia,
anterior T wave inversion,
S1Q3T3, RBBB, low amplitude deflections
Long QT Syndrome (QT> 440 ms)
C/f: syncope, Seizures, sudden death,
Etiology: inherited, drugs like certain antibiotics, antidepressants, antihistamines, diuretics, heart
medications etc, QT prolongation in the course of other diseases, e.g MI, cerebral hemorrhage
Inv: S.K, Mg, Na, TFT, ECG(of the pt & family members), genetic study. Rx: beta blockers
Miscellaneous:P wave >2.5 small segment ht- P pulmonale( Rt atrial enlargement), P wave
>2.5 small segment breadth and notch- P mitrale( Lt atrial enlargement)
92
LABORATORY VALUES
BRE
Hb
Males:13.5-17.5 g/dl
Females:12-15.5 g/dl
RBC count
Males:4.5-6.5 x 1012/L
Females: 3.8-5.8 x 1012/L
Normal Reticulocyte count: 0.8 – 1.5 %
Red cell distribution Width(RDW):42.5±3.5 fL or 12.8±1.2%
Direct count
Polymorphs(neutrophils): 40-75%
Lymphocytes: 20-50%
Monocytes: 2-10%
Eosinophils :1-6% Basophils : <1%
Absolute eosinophil count: 50-350/mm3
Total count
Adults: 4,000-11,000
Infants(1 yr): 6,000-16,000, at birth (10,000-25,000)
Platelets:1,50000-4,00000
PCV
Male(40-54%) Female(37-47%)
ESR
Male(0-9 mm/hr) Female(0-20 mm/hr) - wintrobes method
Male(0-15 mm/hr) Female(0-20 mm/hr) – westergen method
Coagulation screening tests
Normal bleeding time : 2-7 min
Normal clotting time : 4 -9 min
Prothrombin time:12-15 sec
aPTT(activated partial thromboplastin time):28-31 s
INR: 1
Thrombin time:<20 s(control ± 2 sec)
LFT
SGOT or AST: <40 units/ml(12-38 U/L)
SGPT or ALT : <40 units/ml(7-41 U/L)
S Alkaline Phosphatase: adult 30-120 U/L, children <350 IU/L
S Albumin: 3.5-5.5g/dL or gm%
S Bilirubin(Total): 0.3-1.3 mg/dL
S Bilirubin(Direct or conjugated): 0.1-0.4 mg/dL
S Total protein:6.7-8.6 g/dL
Gamma glutamyl transpeptidase: 0-40 IU/L
RFT
B Urea:20-40 mg/dL
Urea Nitrogen(BUN):7-20 mg/dl
S Creatinine: 0.6- 1.6 mg%
S Uric acid: 3.1-7mg/dL(males), 2.5-5.6 mg/dl(females)
93
S.Electrolytes
S Na : 136-145mM/L
S K: 3.5-5.4 mM/L
S Ca,total: 8.5 -10.5 mg%
S P: 2.5 - 4.5 mg/dL
S Mg: 1.5-2 mEq/L
S Cl:102-109 mEq/l
Lipid profile
Total cholesterol:150-200mg%, borderline high: 200-239 mg/dl, high undesirable:≥240 mg/dl
Triglycerides:50-160 mg%(<160 mg/dl)
HDL: 40-60mg%(desirably >60mg%), low:<40 mg/dl
LDL:80-160mg% (desirably <130mg%, borderline high:130-159 mg/dl, high undesirable: ≥160 mg/dl)
Cardiac Biomarkers
LDH:115-221 u/l
C Tn i: 0-0.08 ng/ml
C Tn T:0-0.01 ng/ml
Creatine kinase: males:51-294 U/L, females:39-238 IU/L
CK-MB:0-5.5 ng/ml
Blood sugar monitoring
Fasting (8hrs of fasting with no calorie intake);Normal:70-100 mg/dl, In DM≥ 126 mg/dl
Post prandial(2hrs after 75 mg glucose intake) :<140 mg/dl, In DM >200 mg/dl
RBS>200 in DM
HbA1c :4-6% ( a rise of 1% corresponds to an approx average increase of 36 mg/dl (2 mmol/L)in blood
glucose.
TFT
T4: 5.4-11.7 µg/dl or 70-151 nmol/L
T3: 77-135 ng/dl or 1.2-2.1nmol/L
TSH:0.4-5 µU/ml or 0.4-5 mU/L
FT3: 1.4-4.2 pg/ml
FT4:0.8-2 ng/dl
Plasma Proteins
Albumin: 3.5-5.5 g/dL
Globulin: 2-3.5 g/dL
Fibrinogen:0.2-0.4 g/dL
A/G:1.5-3:1
Others
C reactive protein:0-10 mg/L
S Ferritin: 30-250 ng/ml or µg/L(males), 10-150 ng/ml(females)
PSA: 0-4 ng/ml
β –HCG: <3 mIU/L or IU/L
Prolactin: 2-20 ng/ml (males), 2-30 ng/ml(females), 10-209 ng/ml(pregnant woman)
S. Amylase : 20-96 u/l
S. Lipase:0-160 U/L
Rheumatoid factor: <30 IU/ml
S Vit B12:140-980 ng/L
LDH:208-460 U/L
94
Urine examination
pH:5-9
Colour: pale yellow to deep amber
Specific gravity ,quantitative:1.002-1.028
Protein excretion(24 hr):<150 mg/day
Protein qualitative:negative
Gucose excretion, quantitative(24 hr):50-300 mg/day
Glucose , qualitative:negative
Porphobilinogen:negative
Urobilinogen:1-3.5 mg/day
Microalbuminuria(24 hr): 0-30 mg/24 hr
Red cells:0-2/hpf
WBC:0-5/hpf
Epithelial cells:0-2/hpf
Bilirubin:0.02 mg/dl or negative
Bence-jones protein: negative
Casts
Hyaline cast- dehydration, strenuous exercise
Granular cast- CKD, strenuous exercise
RBC cast(always pathological)- glomerulonephritis, vasculitis
WBC cast- inflammation/infection
Stool examination
Coproporphyrin:400-1000 mg/day
Fecal fat excretion:<6 g/day
Occult blood:negative(<2 ml blood/day)
Urobilinogen:40-280 mg/day
Gases, arterial
Bicarbonate(HCO3-): 22-30 mEq/L
pH: 7.35-7.45
Pco2: 22-45 mmHg
Po2: 72-104 mmHg
Total CO2: 23-30 mmol/L or 100-132 mg/dL
H+: 35–45 nmol/L (nM)
Red cell indices
Mean corpuscular volume, MCV: 80 - 100 femtoliter
Mean corpuscular haemoglobin,MCH: 27 - 32 picograms/cell
Mean corpuscular hemoglobin concentration, MCHC: 32 - 36 grams/deciliter
Ascitic Fluid Analysis
Total count- less than 500 WBC/µL
Polymorphs- less than 250 /µL
CSF analysis
Opening pressure: 90-180 mm H2O
Appearance & colour: clear, colourless
Blood cell count,WBC: <5, RBC:<5
Glucose: 50-80 mg/dl or > 60% of blood level
T protein: 15-60 mg/dl or < 0.45 g/L
Oligoclonal bands: negative
95
Catheters
The size of Foley catheter is measured commonly using french scale. It is abbreviated
as F or Ch(charriere, it’s inventor). The diameter of a french catheter can be determined
by Dividing the French size by 3, i.e
D (mm)= Fr / 3. An increase in French size corresponds to a larger external diameter.
The commonly available catheters in our wards are F 12(white), 14(green), 16(orange),
18(red). The colour corresponds to the colour of the balloon port. The volume of the
fluid recommended to inflate the balloon is marked in the drainage port.
During catheterization, insert to the hilt;wait until urine emerges before inflating the
balloon.
Remember to reposition the foreskin in uncircumcised men after the catheter is inserted
to prevent massive edema of the glans & paraphimosis. In men , stretch the penis
perpendicular to the body & then insert the catheter.
Position of women: knees flexed, hips abducted with heels together
Urine output should be >400 ml in 24 hr or >0.5ml/kg/hr
Ryle’s Tube
Place lubricated tube in nostril with it’s natural curve promoting passage down, rather
than up. Advance directly backwards(not upwards). When the tip is estimated to be
entering the throat, rotate the tube by ~180 to discourage passage into the mouth.
Advance the tube into the esophagus during a swallow. It may be easier to swallow with
a sip of water.Advance >60 cm. Common size FG12(white), FG14(green),
FG16(orange)
Cannula
In contrary to a catheter , in needle- gauge size, an increase in gauge corresponds to a
smaller diameter needle.
Purple 26 G 13 ml/min
Yellow 24 G 23ml/min( commonly used in pediatrics)
Blue 22 G 36 ml/min
Pink 20 G 65ml/min
Green 18 G 96 ml/min
Grey 16 G 180 ml/min
Hypodermic Needle
Brown 26 G, Purple 24 G,Blue 23 G, Grey 22 G, Green 21 G, Yellow 20 G, Pink 18 G
Suction Catheter
6(green), 8(blue),10(black),12(white)
Endotracheal Tube
Common size(mm)- adults: 6, 6.5, 7, 7.5, 8, 8.5; children: 3, 3.5, 4, 4.5, 5
Venturi mask
24%- blue 2L/min, 28% white 4L/min,31% orange 6L/min, 35% yellow 8L/min,40% red 12L/min,
60% green 15L/min
96
Common injections Amp/vial volume - Total strength
Adrenaline 1ml-1mg
Atropine 1ml/2ml- 0.6mg/1.2 mg
Aminophylline 10ml-25mg/ml
Avil(pheniramine maleate) 2ml-22.75mg/ml
Atarax(hydroxyzine) 2ml-25 mg/ml
Betnesol 1ml-4mg
Buscopan(hyoscine) 1ml-20mg
Chlorpheniramine maleate 1ml-10 mg
Cyclopam(dicyclomine) 2ml- 20mg
Ca gluconate 10ml-100mg/ml
Deriphylline 2ml-220mg(each ml, etofyl 84.7 mg+Theo 25.3mg)
Diazepam 2ml-10mg
Dexona 2ml-8mg
Dopamine 5ml-200mg
Dobutamine 5ml-250mg
Ethamsylate 2ml- 125mg/ml
Eptoin(phenytoin) 2ml-100mg
Emeset(ondansetron) 2ml/4ml- 4mg/8mg
Fortwin(pentazocine) 1ml-30 mg
Gentamycin 2ml-80mg
Ketorolac 1ml-15mg
Kcl(15% w/v) 10ml-150mg/ml or 2meq/ml
Lasix(furosemide) 1ml/2ml-10 mg/20 mg
Midazolam 5ml-5mg
Nitroglycerine 5ml-25mg
Na bicarbonate 10ml-7.5% w/v each ml
Noradrenaline 2ml- each ml contains norad 0.2 % w/v
P’mol 2ml-150mg,2ml-150mg/ml, 3ml-150mg/ml
Perinorm 2ml-10mg
Phenergan 2ml-50 mg
Rantac(ranitidine) 2ml-50mg
Serenace(haloperidol) 1ml-5mg
Stemetil(prochlorperazine) 1ml-12.5mg
Terbutaline 1ml-0.5mg
Tramadol 1ml-50 mg
Tranexa 5ml-500mg
Vitamin K 1ml-10mg
Voveran(diclofenac) 3ml-75 mg
Respules
Asthalin 2.5 ml-2.5 mg, respirator solution 15 ml- 5mg/ml
Ipravent 2ml-500mcg, respirator solution 15 ml-250mcg/ml
Levolin 2.5ml-0.31 mg/0.63 mg/1.25 mg
Duolin 2.5 ml-ipra 500mcg+ levosalbu 1.25 mg
Budecort 2ml-0.25mg/0.5 mg/1mg
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Ampicillin
Aminopenicillin; Mainly effective against Grain +ve & also some gram –ve
1. Drops 100mg/ml
0-1.5 months > 0.5ml qid (8 drops)
1.5-5 months > 1ml qid (16drops)
2. Syrup:125mg/5ml or 250mg/5ml
3. Cap:250mg or 500mg
Indications: UTI, RTI, meningitis, cholecystitis,
May be combined with gentamycin or third gen cephalosporins
Always give test dose.
Complication > May produce rashes, especially in cases of IMN. It may be combined
with sulbactum (given parenterally only)
Dosage is 50-100 mg/kg/day in 4 divided doses, oral.
Usual pediatric inj dose: 50 mg/kg Q6H if > 7 days of age, Q8H if <7 days of age.
T.N: Roscillin, Campicillin, Presmox
Amoxicillin
Preferred over ampicillin for bronchitis,UTI,
Dose: 0.25- 1 g tds oral/im, children: 30-50 mg/kg/24 hr div into 2 or 3 PO
T.N: Mox, Novamox
Cloxacillin
More active than methicillin against pencillinase producing staph.
Dose: 500 mg Q6H oral/iv, children: 100 mg/kg/day
C 250 mg, 500 mg, syp 125/5 available
T.N: klox
Coamoxiclav
Addition of clavulanic acid (β- lactamase inhibitor) re-establishes the activity of
amoxicillin against β-lactamase producing resisitant staph aureus
Indications: skin/soft tissue infections, intra abdominal & gynaecological sepsis, urinary,
biliary, respiratory infections
Dose: 1.2 g iv bd/tds
T.N: Mega-CV, Augmentin. T 375, 625, 1g available.
Cephalexin
1st generation cephalosporin.
Indications
Severe LRI
Infections during pregnancy
Bone & joint infections, skin & soft tissue infections
Pharyngitis, tonsillitis, UTI
CSOM, ASOM
Usually combined with Metrogyl in cases of mild diarrhea + URI or LRI
Dose> 50-100mg/kg/day in 4 divided doses > similar to Ampicillin
T.N: Phexin, Sporidex, Blucef, Citacef, Lexin
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Cefadroxil
1st generation cephalosporin
Indications
Pharyngitis
Skin & soft tissue infections
UTI
May produce gastritis, nausea, epigastric distress
Available as Tab 125, 250, 500 & Syp 125/5ml, 250/5ml & drops 100mg/ml
Dose 30mg/kg/day in 2 divided doses orally
T.N: cefadur, droxyl,cefastar
Cefazolin
1st generation cephalosporin
Available as 125mg, 250mg, 500mg, and 1g vials
Indications
Surgical prophylaxis
Bone and joint infections
Skin and soft tissue infections
Speticemia
Pneumonia, UTI
Doses > 50-100mg/kg/day in 4 divided doses im or iv(similar to Ampicillin)
For im use either distilled water or normal saline may be used as the diluent. For iv use
10ml distilled water is to be used. It may be administered over a period of 3-5 min
For newborn, 20mg/kg/dose 12th hourly if <7 days and 8th hourly if > 7 days
T.N: Maxicef-O,Reflin
Cefaclor
2nd generation cephalosporin
Available as 250mg cap, dry syp or readymade suspension 125 or 187 mg/5ml and
drops 50mg/5ml.
Dose 40mg/kg/day in 2 or 3 divided doses
Indications
PUO in children
LRI
Intra abdominal infections like Cholecystitis Appendicitis, Pancreatitis
T.N: Distaclor, Keflor.
Cefuroxime Axetil
2nd generation. Preventing bacterial infections before, during, or after certain surgeries.
Other indications: Respiratory infections, uncomplicated skin & soft tissue,UTI
Dose: 250-500 mg BD, children:30 mg/kg/day div into 2-3, IM/IV:100-150 mg/kg/24 hr
div into 3. Adult iv dose: 1.5 g Q8H
T.N: Ceftum,Spizef, altacef
Cefixime
Oral 3rd generation cephalosporin
Available as susp 50 or 100mg/5ml and T or Cap 100mg or 200mg
Strong antibiotic useful especially in diabetic patients and in other serious infections,
Useful for continuation therapy after initial parenteral therapy.Highly active against
enterobacteriaceae, H influenzae. Not active against Staphylococci and Pseudomonas.
Other indications: RTI, uncomplicated UTI, STD, typhoid fever
Doses -> 8mg/kg/day, od or bd.
T.N: Taxim-o,Milixim,Fixx, Extracef, Cefspan, topcef, Ceftiwin,Omnix
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Cefotaxime
3rd generation. Indications > Meningitis, Specticemia, serious bone and soft tissue
infections
Dose > 100-200mg/kg/day in 4 divided doses im or iv. In newborn, 50mg/kg/dose 12th
hourly, if < 7 days old & 8th hourly if > 7 days old. Available as 250mg, 500mg & 1g
vials.Usual Adult dose: 1g iv tds
May be reconstituted with D5, D10 or NS.
T.N: Taxim, Omnatax,
Ceftazidime
rd
Parenteral 3 generation cephalosporin
Highly Active against Pseudomonas aeruginosa. Also, Gram –ve coverage, synergistic
action with Aminoglycosides
Available as Inj 250mg, 500mg, & 1g.
Dose > 100-150mg/kg/day in 3 divided doses im or iv. Max of 6g/day
T.N: Fortum , Psedocef.
Ceftriaxone
3rd generation cephalosporin. Effective against Gram+, gram- & some anaerobes
Indications
Enteric fever (DOC is Ciprofloxacin 500mg bd x 2 wks)
Bacterial Meningitis
Abdominal sepsis, Septicemias
Compicated UTI
Dose > 50-100mg/kg/day in 2 doses im or iv. May be reconstituted with D5, D10 & NS
Do not mix other antimicrobials.Available as Inj 250mg & 1g.usual adult dose 1g iv bd
T.N: Monocef, Monotax, Ciplacef.
Cefdinir
rd
Oral 3 generation cephalosporin
Wide spectrum with gram + & gram – coverage, Good activity against Beta-lactamase
producing strains. Effective in RTI – both upper and lower and skin & soft tissue
infections.
Dose > Adults 300mg bd x 10 days or 600mg od x 10 days; children 14mg/kg in 2
divided doses or even as a single dose.
T.N: Aldinir, Cefdins, available as syp 125/5ml and 300mg cap; Expensive
Cefpodoxime Proxetil
rd
3 generation. Useful mainly in respiratory tract infection , skin & soft tissue infections
and also in cases of uncomplicated UTI. Highly active against enterobacteriaceae &
streptococci. Not against pseudomonas
Available as a T 100mg, 200mg or as dry syrup 50 or 100mg/5ml.
Dose> 10mg/kg/day in 2 divided doses, to be taken with food.
T.N: monocef-o, cepodem, podocef
Cefoperazone + sulbactum
3rd generation cephalosporin + β- lactamase inhibitor.
Useful for empirical therapy.Wide spectrum, including pseudomonas.Achieves high
biliary concentration & hence useful in case of cholecystitis
Indications: Severe urinary, biliary, respiratory, skin-soft tissue infections, meningitis,
septicaemia
100
Dose: 1 or 2 g iv in adults in two divided doses.Usual adult dose: 1.5 g iv bd.
In children, 50-200mg/kg in 2 divided doses.
T.N: cefactum,cefpar SB(very costly)
Doxycycline
Tetracycline
Indications
Leptospirosis treatment & prophylaxis
Scrub typhus, malaria prophylaxis, brucellosis, cholera
Prophylaxis for COPD exacerbation
Acne, UTI, RTI like a/c bacterial rhinosinusitis,
Chlamydia, gonorrhoea, prevention of STD’s following sexual assault
Inflammation of the gums
Dose: 100 mg/ 200mg bd, children: 5mg/kg/day div into 2 PO or OD
T.N: Doxy-1
Gentamicin
Aminoglycoside. Wide spectrum, mostly gram negative including pseudomonas
Remember oto and nephrotoxicity
Dose>5-7.5 mg/kg/24 hr div into 2 or 3 doses im or iv. In case of neonates give 2.5
mg/kg Q12H.Usual adult dose: 80 mg iv od/bd
Available as vials of 100mg, 250 mg and 500 mg/ml.
T.N: garamycin
Amikacin
Widest spectrum of activity than other aminoglycosides
Usual adult dose : 500 mg iv od/bd
Dose:15mg/kg/day
T.N: mikacin
Vancomycin
Glycopeptide; Useful mainly against staphylococcus , MRSA
Indicated in septicemia, bone & joint infections. LRTI and skin & soft tissue infections.
Dose->500mg 6th hourly or 1g iv 12th hourly in adults. In children 40-60 mg/kg/day in 4
divided doses. Administrated slow iv only. Monitor auditory & renal functions
T.N: Vanlid, vanmax
Teicoplanin
Semisynthetic Glycopeptide; Has lesser nephrotoxicity when compared with
vancomycin
Mainly active against staphylococci
Dose->10mg/kg once daily im or iv; Available as 200 mg & 400 mg vials.
T.N: targocid
Aztreonam
Monobactam; Novel Betalactam antibiotic, active against pseudomonas and
enterobacter. Poor activity against gram +ve cocci and anaerobes
Indications: hospital acquired infections originating from urinary, biliary, GI & female
genital tracts.
Dose->100mg/kg/day in 3 or 4 divided doses im or iv. Smaller dose for neonates
May be reconstituted with D5, D10 or NS for iv infusions
T.N: Azenam, Trezam 250 mg /500mg /1g Inj
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Ciprofloxacin
FQ; wide spectrum, Active mainly against gram-negative.
Indications
UTI,Bacterial gastroenteritis,Typhoid,Respiratory infections,bone,soft tissue,
gynaecological & wound infections, gram - ve septicemia, conjunctivitis,
Dose: 250 - 750 mg BD oral, 100-200 mg BD iv,
For children: 20-30 mg/kg/24 hr div into 2 PO/IV
T.N: cifran, ciplox
CAUTION: Don’t prescribe NSAIDs & FQ together at a time, because of it’s
seizurogenic potential.
Norfloxacin
FQ. Effective against a wide range of gram +ve, gram -ve organisms including
pseudomonas. Not effective against anaerobes
Indications
A/c UTI - 400 mg bd x 7-10 days
C/c UTI - 400 mg bd x 4 weeks and then 400 mg od x 12 weeks(especially in cases
of reflux as seen in ultrasound scan)
Dysentry 200-400 mg bd x 5 days
Urological procedures in neutropenic patients-> 400 mg bd x 8 weeks
T.N: norflox, uroflox
Ofloxacin
Highly potent FQ. Useful in serious infections like septicemia
Dose->200mg iv infusion over 30 min or oral-200 mg bd
T.N: oflacin, bactof
Levofloxacin
FQ; Very useful in resp infections,skin/soft tissue infections.
May be used in combination with pencillins in pneumonia.
Dose->500 mg od x 5 days oral or inj
T.N:levobact, levoday, glevo
Linezolid
Oxazolidinone, Active against MRSA,VRSA,VRE, penicillin resistant streptococci
Restrict use to serious hospital acquired pneumonia, febrile neutropenia, wound
infections to prevent emergence of resistance.
Available as 300ml infusion; each 100ml contains 200mg. 600 mg tablets available
Usual adult dose 600 mg iv bd, children: 10 mg/kg/dose Q12H PO/IV
T.N: Linox, Lizoforce
Azithromycin
Macrolide with high activity on respiratory pathogens.
Indications:
RTI, Atypical pneumonia,
Uncomplicated Skin & skin structure infections,
STD’s, prevention of STD’s following sexual assault,genital ulcer disease,
Cat scratch disease,
a/c PID etc
Dose: 500 mg PO/IV OD x 3 days,children: 10 mg/kg/day on first day, then 5mg/kg/day
on days 2-5.
T.N: Azee, Atm, Azimax
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Piperacillin +Tazobactum
Piperacillin: ureidopenicillin. Tazobactum: β- lactamase inhibitor.
Indications: peritonitis, pelvic/urinary/respiratory infections
Concurrent use of gentamycin is advised.
Dose: 4.5 g iv Q8H, 200-300 mg/kg/24 hr div into 4 doses, im or iv.
Term newborn:<7days, 50 mg/kg/dose Q8H; and >7days, Q6H
T.N: Piptaz
Meropenem
Carbapenem; Active against both gram-positive & gram-negative bacteria, aerobes &
anaerobes
It is the reserve drug for the treatment of septicemia, intra abdominal & pelvic infections
Usual adult dose: 1 g iv bd,children: 60 mg/kg/day div into 3 doses IV
T.N:Meronem
Metronidazole
Activity for anaerobic organisms.
Usual adult dose 500 mg iv Q8H, oral- 400 mg tds, children:30-50 mg/kg/24 hr div into 3
PO. Tab 200, 400 & Syp 200/5 available
T.N: Metrogyl,Flagyl
Tinidazole
Similar to metronidazole, better tolerated,long duration of action, higher cure rate
Usual iv adult dose : 800 mg infusion once daily. Tab 300mg, 500 mg, 1g available
T.N: Tiniba
Combinations
Cefixime 200 + ofloxacin 200: Mahacef Plus,Milixim-O,Cefolac-O, zenflox-plus
Cefixime 200 + Ornidazole 500: Milixim-OZ,Cefolac-OZ
Cefixime + clavulanic acid : Milixim-CV
Cefixime 200 + Azithromycin 500/250 : Azifine-C, Cefolac-AZ
Ornidazole 500 + ofloxacin 200: Ornof, Oflomac-OZ
Azithromycin 250/500+ Levofloxacin 250/500: Azifine-L
Cefuroxime axetil 250/500 + Clavulanic acid 125: Altacef CV, Forcef-CV
Cefpodoxime + clavulanic acid :Kefpod CV, Monocef-O CV
Cefpodoxime + Ofloxacin: Macpod-O
Cefpodoxime + Azithromycin: Macpod-AZ
Cefpodoxime + Levofloxacin: Macpod LX
Note: HPV 2(1 month after 1st dose), HPV 3(after 6 months),Two doses of HPV vaccine for
adolescent/preadolescent girls aged 9-14 years
For two-dose schedule, the minimum interval between doses should be 6 months
Three dose schedule for adolescent girls aged 15 years and older to continue
Note: if measles vaccine is given at 9 months, then MMR 1 at 12-18 months & 2nd dose 8
weeks after 1st dose. Varicella 2 can be given anytime 3 months after 1st dose.
Note: for 6, 10 & 14 week vaccination, always give paracetamol Q6H for 1day.
Others
Meningococcal vaccine: recommended over 2 yrs of age, single dose 0.5 ml s/c or IM,
T N : Mencevax A & C
PCV : Pneumococcal conjugate vaccine, T N :Prevenar
Pneumococcal Polysaccaride vaccine : after 2 yrs of age, one booster dose after 5 years of age,
T N :Pneumo 23 (0.5 ml IM)
Varicella Vaccine, T N : Varilrix
Rotavirus, T N: Rotarix,
HPV, T N: Gardasil, Cervarix;
Typhoid Vaccine ,T N: Typherix(IM)
Hepatitis B, T N: Engerix-B IM
Hepatitis A , T.N: Havrix 0.5 ml IM
MMR, T.N: Tresivac 0.5 ml s/c;
Hib Vaccine, T N: Hiberix (IM)
Cholera vaccine: given for children above 1 yr, 2 doses 2 weeks apart.
JE Vaccine : 1st above 8 months of age, 2nd dose at 16-18 months, T.N:JEEV
Influenza: 1st dose above 6 months, 2nd dose after 1 month , T.N: Fiuarix
Ventilatory support
Modern ventilators deliver a gas flow with a cycling mechanism to cut airflow during
expiration.The ventilator breath may be volume controlled (a predetermined tidal volume is
delivered), pressure controlled(gas flow is at a pre-determined pressure), or volume controlled
with a limited pressure( the ventilator delivers a preset VT within a pressure limit unless the
lungs are non-compliant or airway resistance is high. Various mixed modes are also available.
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Modes of ventilation: Controlled mechanical ventilation (CMV), assist control mechanical
ventilation(ACMV), intermittent mandatory ventilation(IMV), pressure support ventilation(PSV),
Volume support ventilation(VSV)
High PaO2: decrease FIO2 or I:E ratio or PEEP or level of pressure control/pressure support if
VT adequate.
High PaCO2: increase VT (if low) or RR. Reduce rate if too high( to reduce intrinsic PEEP),
reduce dead space. In CMV, increase sedation ± muscle relaxants
BRADYCARDIA ALGORITHM
107
TACHYCARDIA ALGORITHM
108
Sample Referral letter
Date:
Time:
To whom it may concern
Sir/madam
I’am referring Mr./ Smt ..............., ......yrs, a k/c/o ................. .....................
now presented with c/o .................................................................................................
O/e, he/she has.............................................................................................................
The investigation done show.........................................................................................
My clinical impression is ...............................................................................................
I have given the following treatment..............................................................................
I’am referring him/her to you, for expert evaluation, care & Management. Kindly do the
needful.
Thanking you
Your’s sincerely
Signature
When a pt dies, write the following format, in the pt’s case sheet irrespective of the
cause of death.
00:00
Pt gasping 1.Inj Atropine 1 amp, inj adrenaline 1 amp iv st
Pulse not palpable , BP unrecordable 2.Inj Dopamine 400 mg in NS @ 14 dps/min
CPR started
Pt intubated;Ambu bag ventilation given
Note: 2010 ACLS guidelines excludes atropine administration for PEA/asystole
00:05
Pulse, BP unrecordable 1.Inj Atropine 1 amp, inj adrenaline 1 amp
CPR & Ambu bag ventilation continued 2.Inj Dopamine
00:10
Pulse, BP unrecordable 1.Inj Atropine 1 amp, inj adrenaline 1 amp
CPR & Ambu bag ventilation continued 2.Inj Dopamine
00:15
Pulse, BP unrecordable
ECG shows no cardiac activity
No spontaneous respiratory effort
Pupils Dilated & fixed
Irrespective of all resuscitative efforts, pt expired at _ _:_ _ am/pm on _ _/_ _/_ _(Date)
Pt declared clinically dead.
Signature
******