SREE VASANTHAM HOSPITAL, SALEM

1. ER PROTOCOL FOR ACUTE INTOXICATION (POISONING)

1. Patient once received in ER, his general condition (ABC) will be assessed by ER
physician.
2. Nasal 02 will be started if condition warrants. If he or she is in respiratory distress or
GCS<s than 5 oral airway ETT will be established by ER physician.
3. IV access will be established and depending upon the volume of the patient IV fluids will
be started.
4. Gastric lavage will be done by ryles tube aspiration , if patient presented to our ER within
2hrs of intoxication except for corrosive poisoning.
5. Activated charcoal @ 1gms/kg/wt will be administered through RT according to the
nature of the substance taken.
6. In case of pesticide poisoning decontamination procedures will be followed.
7. The antidotefor the particular poison will be given in ER.
8. Once the patient is established in ER then he/she will transferred in ICU for further
hemodynamic monitoring.
9. In case of suspected poisoning cases after through examination in ER he/she will be
admitted in emergency.

EMERGENCY MEDICAL OFFICER MEDICAL DIRECTOR

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 SREE VASANTHAM HOSPITAL, SALEM

2. ER PROTOCOL FOR STROKE (CVA)

1. Patient once received in ER will be examined by ER doctor and IV line & Nasal O2will
be established.
2. A detailed history will be obtained about the incidence form relatives.
3. ER physician will examine the case, if he/she is unconscious (GCS<8) and found to have
features aspiration then intubation will be done orotracheally by ETT.
4. If there is sign of raised ICT then anti oedema drugs will be started in ER.
5. He/she will be shifted to CT/MRI scan to rule out the nature of the stroke. If it is an
ischemic nature and within the window period then thrombolysis will be done after
explaining the procedure and the complications to the attenders and getting proper
consent. The consultant neurologist will be informed about the case.
6. In case of a hemorrhagic event he/she will be managed accordingly to that and if needs
for surgical intervention, neurosurgeon opinion will be obtained.

Once patient is stabilized then he/she will be transferred to ICU.

EMERGENCY MEDICAL OFFICER MEDICAL DIRECTOR

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 SREE VASANTHAM HOSPITAL, SALEM

3. ER PROTOCOL FOR ACS (ACUTE CORONARY SYNDROME)

1. IV access will be established to the patient in ER.

2. Nasal oxygen will be started.
3. Patient will be connected to multipara monitor (BP/HR/RR/SPO2).
4. Detailed history will be collected from attenders by ER medical officer.
5. ER physician will examine the case in detail and 12 lead ECG will be taken.
6. IF ECG confirms STEMI then he/she will be given tab. Clopilet 450mg, aspirin
325mg and atorvostatin 80mg and LMWH/Heparin according to patient’s weight.
7. Cardiologist will be informed about the case, patient will be explained about the
methods of thrombolysis
8. According to his opinion and considering the best for patient either
inj.streptokinase will be administered in ER
9. In case the patient comes to ER within the window period, he/she will be shifted
MMHRCScath lab for PTCA after proper examination by cardiologist and with
consent of the patient

Post thrombolysis / PTCA he/she will be transferred to cardiac ICU.

EMERGENCY MEDICAL OFFICER MEDICAL DIRECTOR

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 SREE VASANTHAM HOSPITAL, SALEM
4. ER PROTOCOL FOR UPPER GI-BLEED

1. Once the patient enters ER iv access will be established

2. Nasal o2 will be started according to the need of the patient
3. Volume status of the patient is known and iv fluids will be administered
(crystalloids/colloids)
4. A detailed history will be collected from patient/bystanders
5. Ryels tube will be introduced to know whether there is ongoing fresh bleed
6. Hemostats will be started, supportive drugs will be initiated, Consultant
medical gastroenterologist will be called to see the case in ER
7. Blood samples will be collected and grouping, typing & cross matching will
be done, if needed emergency blood transfusion (PRBC/FFP/WB) will be
started in ER
8. Vassopressors if warranted will be started in ER
9. Once patients is stabilized in ER thenhe/she will be shifted to
multidisciplinary ICU for further hemodynamic monitoring
10. If patient needs urgent UGI-Scopy then he/she will shifted to endoscopy
room.

EMERGENCY MEDICAL OFFICER MEDICAL DIRECTOR

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 SREE VASANTHAM HOSPITAL, SALEM

5. PROTOCOL FOR ANY TRAUMA VICTIM

1. Patient received in spinal board from ambulance to our ER.

2. Patient will be connected to multipara monitor(NIPB/HR/RR/SPO2)
3. ER physician along with ER medical officer will examine the case.
4. 2 wide bore peripheral iv access will be established and blood samples for lab
will be collected.
5. IV fluids will be started t restore the volume status of the patient.
6. A detailed history will be collected from the bystanders.
7. Primary survey including ABC along with spine protection will be done
according to ATLS protocol.
8. If there is signs of raised ICT GCS< 3 patient will be electively intubated in
ER by ER physician.
9. If there is sings of raised ICT then anti edema drugs will be started.
10. Pelvic compression test is done to rule out pelvic # and if positive then pelvic
binder will be applied and hemostasis will be ensured.
11. A head to toe secondary survey will be done to access other injuries to other
extremities.
12. Any cut injuries/ deep lacerations leading to severe bleeding will be sutured
and hemostasis will be ensured.
13. In case of a blunt injury chest with evidence of shocked/decreased air entry on
the affected side of chest/subcutaneous emphysema/ flial chest then needle
thoracocentesis followed by ICD will be done by ER physician.
14. All trauma cases x-ray will be taken in ER as directed by the ER Physician.

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 SREE VASANTHAM HOSPITAL, SALEM
6. PROTOCOL FOR STATUS EPILEPTICUS IN ER

1. IV line established and nasal oxygen started and connected to monitor.

2. In case of compromised airway, airway protection is done by oral ETT/CAG
3. CBG is done, if needed 25% dext is administered and thiamine 100mg IV in
case of seizures due to alcoholic intoxication.
4. Lorazepam 2mg/ midazolam 2mg iv will be given.
5. Phenytoin @ 20mg/kg iv @ 50mg/min or phosphenytion @20mg/kg
@150mg/min iv administered.
6. If seizures persists them additional dose of phenytion 10mg/kg or
phosphenytion 10mg/kg iv given.
7. For future seizures phenobarbitone up to 20mg/kg IV at 50-75mg/min will be
administered.
8. If still seizures persist then either midazolam @ 0.2mg/kg slow iv followed by
0.75-10mic/kg/min or propofol 1-2mg/kg/hr iv infusion will be started, after
intubating the patient in ER.
9. Blood samples will be sent to lab for further investigations.
10. Duty neurologist will be informed about the case and management.
11. Patient will be shifted to MRI/ CT to rule out any intracranial lesion and
further transferred to neuro ICU.

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 SREE VASANTHAM HOSPITAL, SALEM
7. PROCEDURES TO BE FOLLOWED DURING MASS CASUALTY

1. ER physician and ER team including the medical officers/ward

staff/supporting staff/technicians/front offices staff will be alerted about the
mass casualty.
2. A check list will be made once the ambulance driver/staff informed about the
number of VICTIM’S and nature of injuries to be shifted to ER from accident
spot.
3. Once the casualty victims are received in hospital ER, they will be triaged
according to the nature of injury by triage medical officer.(ER Physician)
4. Patients will be transferred to respective ER bed, and attended by ER
physician/medical officer.
5. According to nature of injury, they will be stabilized in ER.
6. Patients who need critical care urgently will be transferred to ICU after
informing the ICU incharge and conforming the availability of beds.
7. Patients needing minimal attention will be stabilized and transferred to ward
for observation and further care as required.
8. All the blood samples collected from the patients will be labeled and sent to
lab for investigation.

EMERGENCY MEDICAL OFFICER MEDICAL DIRECTOR

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