Complaint

Chest pain

Coma

Assessment
Ask for classic pain
Retrosternal, compressing, Radiating into
the interior of the left shoulder, arm till
fingers, Associated with Nausea, vomiting
,& dizziness, for more than 15 minutes,
Relieved by SL nitrate , Increased by
exercise , with Risk factors old-age, male
sex, smoking
Look for
G. condition (Diaphoresis, tachypnea,
hypotension, & anxiousness)
Investigate for
ECG findings (STE)
+ve Biomarkers

Classification
2 of the followings:
1. Classic Chest pain
2. +ve ECG findings
3. +ve biomarkers

Not enough criteria for

diagnosis
If the flowing:
1. Atypical chest
pain
2. Normal ECG
3. ve Biomarkers

MI suspicion

Ask for
The cause
Ass GCS (look page 4)
Examine for signs of localization:
Hemiparesis, or hemi paralysis, hemi
hypothesia, focal fits, +ve Babinski sign
Investigations:
ABG + (CBC, RBG, serum creatinine) + CT
scan + ECG

GCS less than 8

Very severe
brain injury

GCS between 8-12

Moderate
brain injury

CT + Call Neurosurgery resident

GCS more than or 13

Mild brain
injury

CT + Call Neurosurgery resident

+Ve history
+ Some signs including
suffocation
+ shock

Severe
Anaphylactic
shock

Anaphylactic Ask for

reaction
History of Drugs (penicillin, Sulfa, tetanus
toxoid, injection), Food
) ), Stings ()

IMER

Myocardial
infarction

Others chest
pain causes
as Myositis,
dyspepsia.

Treatment
1. Dinitra 5 tab (Sublingual once, can be
repeated up to 3times with 5min
interval, it causes hypotension)
2. Nalufin amp. IM
3. Oxygen by mask
4. Aspocid chew tab. (4tabs.)
5. Call cardiology resident
As MI
Myositis
SMR as (Myofen caps. 1X2)
Analgesic &Anti-Inflammatory (Voltaren amp.)
Dyspepsia
ER:
Primperan amp. + Zantac amp. + Spasmofree
amp. On 200 ml saline or IM
Home:
Zantac 150 tab (1X2) or Pepzol 20 cap (1X1) +
Epicogel susp. (1X3)
CT + Call Neurosurgery resident

1. Oxygen by mask
2. Urgent adrenaline amp. IM
3. Treat hypotension & Asthmatic attack as
usual

Integrated management of emergency room by. Mustafa M. Bayoume

Cough &
Wheezy
chest

Vomiting of
blood

Coma in
diabetic
patient
(Polyuria,
polydipsia)

IMER

Look for
Tachycardia , hypotension, dyspnea,
stridor, suffocation, angioedema , urticarial
rash
Investigations:
ABG & CXR if resistant
Ask for : Cough, dyspnea & history of
asthma
look for wheeze by auscultation
Investigations:
ECG (if risky) , if not responding to ER.RX
do CXR & ABG & call Pulmonology resident

+Ve history
+ Some signs (no
suffocation)
No shock

Anaphylactic
reaction

+ history & cough

+ wheeze

Attack of
asthma

Ask for:
Drugs (NSAIDs). Diseases (Liver, Peptic
ulcer)
Look for:
Hypotension, tachycardia, cold skin,
oliguria (shock)
Investigations:
ABG + (CBC, RBG, Serum creatinine) + LFTs
+ RFTs + Blood grouping & matching
Ask for:
GIT changes (Abdominal pain, nausea &
vomiting)
Look for:
Breathing changes (Acetone odor in
breath, Kaussmaul breathing),
Dehydration (dry tongue, sunken eyes,
delayed skin turgor)
Investigation:
RBG, ABG, Acetone in urine

+ve liver history

Mostly
bleeding es.
varices
Mostly
bleeding PU

+ve PU history
Any one of them with
hypotension,
tachycardia,& cold skin

Shocked
patient

GIT changes
Breathing changes
Dehydration
Metabolic acidosis
RBG >250
Acetone in urine

DKA

GIT changes
Dehydration
RBG >500
No acetone in urine

HONK

1. Oxygen by mask + Solucortef vial IV +

Avil amp. IV
2. If still no response give adrenaline amp.
IM
3. Treat hypotension & Asthmatic attack as
usual
1. 20 drops Farcolin + 3 ml saline +
Atrovent vial by nebulizer if no response
repeat it
2. If no response give Solucortef vial IV
3. If no response give Minophylline amp.
On 100 ml saline IV (Avoid in cardiac
patients)
1. 2 cannulas + 1 blood bag + cross
matching
2. 500 ml saline 0.9 + Dycinone amp +
Kapron amp. + Zantac amp. + Ryle tube
and lavage with saline until clear
3. Refer to Gastroenterologist for further
assessment

1. 2 liters saline 0.9 rapid then continue

under resident supervision
2. Insulin (Humalin R) on (1 unit / 10 raise
in RBG) IM
3. If K is low (normal 3.5 5.5) give KCl
amp. Very slow IV with the fluid before
insulin
1. 2 liters saline 0.9 rapid then continue
under resident supervision

Integrated management of emergency room by. Mustafa M. Bayoume

tremors ,
palpitation,
Sweating&
hunger

Severe
headache

Diarrhea
and
abdominal
pain

IMER

Look for
Drowsiness & blurred vision, Irritability,
tremors, Tachycardia, palpitation,
Sweating& hunger
Measure: BP
Investigation: RBG
Ask for
- Epistaxis , dyspnea or anxiety, and
history of hypertension
- Other problems: Eye error, Ear
problems, runny nose, dental
problems, chronic constipation, and
history of anemia
Measure: BP
Investigation: CBC

Ask for:
Frequency, characters, blood in stool,
vomiting,
abdominal pain (site, character, radiation,
association),
high grade fever, perianal itching
Look for:
General condition (toxic /non)
Surgical causes (guarding, rigidity,
tenderness),
Dehydration (sunken eyes, dry mouth,
delayed skin turgor)

Some presentation
+ RBG (<60)

Hypoglycemia

Some presentation
Normal RBG
BP <90/60
- High BP 180/100
(with or without
history)
- With or without
Epistaxis/ dyspnea
- No other problems

Hypotension

Other problems
Normal BP

According to
the case;
sinusitis, OE,
OM, anemia

Bacterial GE

Bloody diarrhea
High grade fever
Pt. looks toxic

Hypertensive
urgency

1. If patient is conscious: PO glucose

2. If patient is comatosed: 250 ml glucose
(or dextrose 10%) IV then PO after
getting conscious
1. ER:500 ml saline 0.9 %
2. Home: Corasore drops
20 drops on 0.5 gls of water (1X3)
Capoten 25 tab (sublingual tab. Then rest for 15
mint. Then repeat the BP measurement.
if not lowered below (160/100) repeat the
Capoten up to 3 times with 15 minutes interval .
If no response give Lasix amp (1/2 1 amp) IM
Home:
If the BP go less than 160/100 send him home
with Capoten 25 tab. (0.5 tab twice)
Give declophen amp. At the ER
Then send him home with Brufen 400 tab (1X3)
and referral to specialist

ER: Spasmofree amp. + Primperan amp. On 250

ml Ringer
Home: Cipro 500 tab (1X2 for 5days) + Antinal
Cap (1X3) + Motinorm tab (1X3) + Buscopan tab
(1X3)
As bacterial but no Cipro 500 tab

Perfuse watery diarrhea

Low grade fever
Pt. non-toxic
Abdominal colicky pain
Perianal itching

Viral GE

Parasitic GE

As bacterial but Flagyl 500 tab(1X3) Instead of

Cipro

sunken eyes, dry mouth,

delayed skin turgor
guarding, rigidity,
tenderness

Dehydrated
pt.
Acute
abdomen

As bacterial but 500 ml ringer

Refer to surgery ER

Integrated management of emergency room by. Mustafa M. Bayoume

Assessment of consciousness (Glasgow coma scale)

Verbal

1
Not
opened
No sounds

Motor

No

Eye

movements

General data of any patient

IMER

2
Pain =
open

Pain =
extend
arm

3
Call =
open

Pain =
flexed
arm

4
Open
alone
Disoriented
Pain =
withdraw
his arm

Oriented
Can
localize
pain

Obey
commands

1. Present:
Name . Sex (/), Age .. Occupation ..
Special habits Residence ..
2. Past:
DM (/) HTN (/) similar conditions (/)
Drugs .. Operations
3. Complaint: .
4. General examination:
Vital signs (BP .. Pulse temperature .. )
Level of consciousness GCS (.. / 15)
Complexions (pallor, jaundice, cyanosis)

Integrated management of emergency room by. Mustafa M. Bayoume