Acute exacerbation of COPD

Assess the severity of the patient (History, signs and symptoms, vitals, ABG, CXR) Administer Nebulization Duolin without O2 (3 times) Administer Nebulization Buedecort without O2 STAT Methylprednisolone 125 mg IV STAT If SpO2 still <85%, start NIV (BIPAP) If SpO2 improved to 90%, apply nasal cannula at 2-4 L/min. Maintain SpO2 at 90-92%

Pulmonology consultation

Dr.Binu Ramesh ,MD, DM , Dr.Rehman & Arunshree-R

Anaphylaxis
Mild Anaphylaxis (only skin reactions)
Inj.Avil 45mg IV st Inj.Ranitidine 50mg IV st T.Prednisolone 60mg PO st Observe for at least 2 hours

Moderate Anaphylaxis
Inj. Adrenaline 0.5mg of 1:1,000 IM, every 5 minutes, titrate to effects (0.01ml/kg in paediatrics)

Severe Anaphylaxis
Inj.Adrenaline 0.1 mg IV, only if severe hypotension / life-threatening shock (0.1ml/0.1mg of 1:1000 in 10ml NS, give over 5-10 minutes) Closely watch for chest pain or arrhythmias
Dr.Binu Ramesh ,MD, DM , Dr.Rehman & Arunshree-R

(contd) Common for moderate and severe anaphylaxis

IVF - 1 to 2 L of Crystalloid bolus (20ml/kg in paediatrics) Inj.Avil 45mg IV st Inj.Ranitidine 50mg IV st Inj.Methylprednisolone 125mg IV st (1-2mg/kg in paediatrics)

Anaphylaxis

Bronchospasm: Nebulized Levo-salbutamol 1.2mg.

Nebulized Ipratropium 0.5mg. Refractory Bronchospasm: Inj. Aminophyline 5.6 mg/kg IV over 20 minutes Or Inj.Magnesium 2gm over 30 minutes (25-50mg/kg in paediatrics) Refractory Hypotension: Inj.Glucagon 1-5mg IV over 5 minutes followed by 5-15 g/min continuous infusion Inj.Dopamine 10-15 g/kg/min IV infusion (after discontinuing adrenaline)
Dr.Binu Ramesh ,MD, DM , Dr.Rehman & Arunshree-R

SNAKE BITE
ASV- If the patient has evidence of envenomation, then 10 vials of
ASV administered over 1 hour, diluted in 5-10ml/kg NS / 5D

Adrenaline is made ready in two syringes of 0.5 mg in 1:1000 for IM

administration if symptoms of any adverse reaction appear. Repeat every 5-10 minutes If symptoms appear, ASV is temporarily suspended and then recommenced Neostigmine 1.5-2.0mg IV with Atropine 0.6mg IV, Observe for 1 hour

Neostigmine Test

for Neurotoxic envenomation - Neostigmine 1.52.0mg IV with Atropine 0.6mg IV, Observe for 1 hour Dr.Binu Ramesh ,MD, DM , Dr.Rehman & Arunshree-R

Eclampsia
Keep a wedge on right side of patient / turn the patient to left lateral position Maintain Airway, Breathing, Circulation GRBS & ABG analysis Magnesium for 24 hours

sulphate 4 gms iv in 100 ml NS over 15 minutes, followed by 1 gm/hour

Watch out for toxicity (respiratory depression, loss of deep tendon reflex, decreased urine
output)

Dr.Binu Ramesh ,MD, DM , Dr.Rehman & Arunshree-R

Status Epilepticus
Airway, Breathing, Circulation
Inj. Lorazepam 0.1 mg/kg or 4 mg IV (Can be repeated once if no response in 5 min) OR Inj. Diazepam 0.15 mg/kg or 5 - 10 mg IV Inj. Phenytoin 20-30 mg/kg IV @ 50 mg/min OR Inj. Fosphenytoin 20-30 mg/kg/PE @ 150 mg/min

Refractory Status Epilepticus (Any one drug below)

Inj. Valproate 20 - 30 mg/kg loading dose @ 5mg/kg/min (in patients already on valproate) Inj. Levetiracetam 1000 mg IV Inj. Phenobarbital 20 mg/kg @ 60 mg/min Inj. Propofol 2 5 mg/kg IV loading dose + infusion @ 2-10mg/kg/hr Inj. Midazolam 0.2 mg/kg IV loading dose + infusion @ 0.5 -2 mg/kg/hr Inj. Ketamine 1.5 mg/kg bolus + 0.01 -0.05 mg/kg/hr Dr.Binu Ramesh ,MD, DM , Dr.Rehman & Arunshree-R

Organo-Phosphorous Poisoning
Atropine 2-5 mg IV every 10-15 mins - to reverse muscarinic symptoms End point - drying of respiratory secretions and normal pupil size Pralidoxime (PAM) or obidoxime 1-2 gm IV over 30-60 mins to reverse nicotinic symptoms (should not be given in carbamate poisoning)

Methanol Poisoning
Loading dose : 10 ml/kg of 10% EtOH in 5% Dextrose IV over 30 min OR give PO/NG Maintenance: 1-2 ml/kg/hr Dr.Binu Ramesh ,MD, DM , Dr.Rehman & Arunshree-R