Emergencies

Insect And Arachnid Bites And Stings Causing Skin Diseases

1. Tab. Cetrizine 10 mg once daily to relieve pruritis.
2. Topical antimicrobial preparation to prevent secondary bacterial infection (see section on pyogenic skin infections).

1. Topical administration of calamine lotion for symptomatic relief.
2. Systemic antihistamines and analgesics can be given to relieve pruritus or pain.
3. Systemic corticosteroids may be appropriate if there are severe sideeffects.
4. Any person who collapses, or who complains of wheezing, feeling of anxiety or faintness, generalized itching, or tightness in the chest within approximately 1 hour of being stung by an insect should be treated as having anaphylactic shock, (see section on anaphylactic shock).
   Inj. Adrenaline 1 mg (as hydrogen tartrate) 0.5-1.0 ml IM injection of Adrenaline (1:1000 solution) repeated every 15-20 min if required.
   All patients should be observed at least for 24 hours for recurrent anaphylaxis.

1. Simple analgesics, such as paracetamol and aspirin, can be given to relieve pain. However, because of the potential for severe reactions, every effort should be made to get the patient to a hospital as soon as possible.
2. Vasodilators, administered in a hospital setting within 24 hours of the attack, may attenuate the cardiovascular response and possibly reduce mortality.
3. In endemic area, species-specific antiscorpions sera may be available locally and this can be of value if administered within few hours.

1. Specific antivenoms.
2. Analgesics.
3. Muscle relaxants should be given to relieve pain and muscular spasms.
4. Oral corticosteroids, if administered within 24 hours of the attack, may reduce the risk of local necrosis and the incidence of disfiguring scars.

Drugs used in Skin Diseases. In: WHO Model Prescribing Information, 1997, WHO, Geneva.

Dog Bites (Rabies)

Rabies can be transmitted by dog bites or licks of rabid animals on abraded skin and intact mucosa. Other animals which can transmit rabies are cat, monkey, horse, sheep, goat, mongoose, jackal, fox, hyena and bat.

A. Treatment (Post exposure prophylaxis)

Every instance of human exposure to a suspected rabid animal must be treated as a medical emergency. Irrespective of the class of wound, the combined administration of a single dose of antirabies serum with a course of vaccine along with local treatment of the wound is the best specific prophylactic treatment.
Specific indications for antirabies treatment are: if the animal shows signs of rabies or dies within 10 days of observation, the biting animal cannot be traced or identified, all unprovoked bites, Fluorescent Rabies Antibody (FRA) or test for Negribodies of the brain of the biting animal are positive and all bites by wild animals.

1. Local wound treatment must be done even if several hours or days have elapsed. The wound is immediately flushed and washed with plenty of soap and water. Punctured wounds should be irrigated with the help of catheters. Following this, apply 70% alcohol or povidoneiodine.
   Do not suture bite wounds immediately. If suturing is required, hold it for 24-48 hours, applying minimum number of stitches under the cover of antirabies immunoglobulin locally.
2. Antitetanus treatment can be given after local wound treatment.
3. Antirabies vaccination. Post exposure vaccination depends on the degree of risk of rabies to which the person is exposed. In India, the classification of wounds is being followed as under:

• Licks on healthy unbroken skin.
• Consumption of unboiled milk of the suspected animal.
• Scratches without oozing of blood.

• Licks on fresh cuts.
• Scratches with oozing of blood.
• All bites except those on head, neck, face, palms and fingers.
• Minor wounds less than 5 in number.

• All bites or scratches with oozing of blood on head, neck, face, palms and fingers.
• Lacerated wounds on any part of the body.
• Multiple wounds 5 or more in number.
• Bites from wild animals.

• When the patients antibody titre is unknown or if the bite is severe, advise vaccination with cell culture on days 0, 3, and 7.
• If the antibody titre is known to be more than 0.5 IU/ml or if the bite is not severe, cell culture vaccine should be used on days 0 and 3 only.
• Antiserum immunoglobulin must not be administered systemically in patients who have previously had pre or post-exposure vaccination.

Rabies Virus and other Rhabdoviruses. In: Harrison’s Principals of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2000, McGraw Hill Company Inc., New York, pp 1149-1152.

Snake Bite

1. The aim is rapid and safe transport to a place where optimal medical care is available.
2. Ensure airway, breathing and intravenous access.
3. Reassurance.
4. Keep the patient warm, and at rest. Activity may enhance the spread of venom.
5. Immobilize the bitten limb by splinting the limb.
6. If possible, kill the offending snake and preserve it for identification.
7. For pain, a mild, nonsedating analgesic can be administered (aspirin or paracetamol).
8. A tourniquet (constricting band in the form of a strap or belt, etc.) can be applied lightly proximal to the bitten site to prevent lymphatic spread.
   It should be capable of admitting a finger beneath it. It is used till the patient is shifted to the hospital and approximately tied 10 cm above the bite. Once applied, the tourniquet should be loosened or removed only after antivenom administration has begun. A recent suggested modification to the tourniquet is a broad, firm constrictive bandage (elastic bandage) wrapped over the bitten area, including the entire limb with the limb placed in a splint.
9. Wipe the bitten site and cover loosely with a piece of clean cloth.
   As far as possible, avoid incision and suction since it increases the chances of wound infection, aggravates bleeding and may cause accidental severance of nerves, tendons etc. It may however be done if :

1. medical help is more than 1 hour away or
2. if it is decided to be done, avoid cruciate incision. Parallel incisions must be made through the fang marks, about 1 cm long and not deeper than 3 mm. Use of a commercial suction device is preferable to suction by mouth although some clinicians advocate cryotherapy (local application of ice), the general trend now is to discourage such a practice since it can enhance necrosis of tissue.

1. Oval head with large scales (shields) or triangular head with small scales.
2. Broad ventral scales extending completely across the belly.
3. Tail short and tapering abruptly.
4. Scales on the undersurface of the tail (sub caudates) divided.
5. Third supralabial shield (i.e. upper lip scale) is the largest of the supralabials.
6. 4th infralabial shield (i.e. lower lip scale) is the largest of the infralabials.
7. Presence of control row of hexagonal vertebral scales.
8. Presence of hood in the neck.
9. Presence of fangs (i.e. modified long teeth, usually in the upper jaw, which may be grooved or channelized. Usually 2 in number, they are connected to the poison gland).

1. Check for and monitor the following:
   1. Pulse rate, respiratory rate, blood pressure and WBC count every hour.
   2. Blood urea, creatinine, WBC count.
   3. Urine output, urine for RBCs (in case of Viper bite).
   4. Vomiting, diarrhoea, abnormal bleeds.
   5. Extent of local swelling and necrosis. ECG, arterial blood gas analysis, BT, CT, PTT (to be repeated 6 hourly if abnormal).
   2. Antivenom therapy
      Do not administer antivenom as a routine measure in every case of snake bite. It is associated with serious risks of anaphylaxis. It should be given only when features of envenomation are present. It is most effective in the first four hours although can be given upto 24 hours.
      The lyophilized powder is dissolved in distilled water or normal saline to make a clear solution before use.
      (CAUTION: Do not use if reconstituted solution is opaque to any extent).

1. For bites with local swelling but no systemic features: 20-50 ml.
2. If the swelling has progressed beyond the bitten site and there are mild systemic features or bleeding diathesis: 50 to 100 ml.
3. If there are marked local and systemic features with haemolysis, clotting abnormalities etc: 100-150 ml.
   For children, the dosage of antivenom should be reduced proportionately.
   Inj. hydrocartisone 200 mg and pheniramine maleate 22.75 mg should be given prior to the administration of antivenom to avoid allergic reactions.

1. Clean the bitten site with povidone-iodine solution, but do not apply any dressings.
2. Leave blisters alone. They will break spontaneously and heal. If there is local necrosis, excise and apply saline dressings. Surgical decompression may be necessary in some cases..
3. Tetanus toxoid injection must always be given
4. Prophylactic antibiotic.
5. Aspirin or other mild analgesic for pain.
6. Diazepam 5-10 mg for sedation in some cases.
7. Rehydration and nutrition.

1. Whole blood or fresh frozen plasma, if there are clotting abnormalities and anomalous bleeding.
2. IV fluids, vasopressors etc. if there are features of shock.
3. Inj. Neostigmine 0.56 mg half hourly, if there are signs of neuroparalysis. Give Inj. Atropine 0.6 mg IV before every injection of neostigmine to block its muscarinic side effects.
4. Oxygen, assisted ventilation etc. if there is respiratory failure.
5. Renal failure must likewise be treated on appropriate lines if it develops.

1. Pocket Handbook of Clinical Psychiatry, 1996, BI Waverly Pvt Ltd, New Delhi, pp 56- 58.
2. Emergency Toxicology. In: Management of Common Poisons. S.K. Gupta (ed), 2002, Narosa Publishing House.
3. Illness due to Poisons, Drug Overdosage and Envenomation. In: Harrison’s Principles of Internal Medicine, Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2000, McGraw Hill Company Inc., New York 2000, pp 2505-2596.
4. Common Paediatric Emergencies. Postgraduate Institute of Medical Education & Research, Chandigarh, pp 53-70.
5. Disorders caused by Reptile Bites and Marine Animal Exposures. In: Harrison’s Principals of Internal Medicine, Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2000, McGraw Hill Company Inc., New York, pp 2616-2622.
6. Snake Bite. In: Common Paediatric Emergencies. Post Graduate Institute of Medical Education and Research, Chandigarh, pp 71-77.

Pelvic Fractures

1. Low energy fractures resulting in isolated fractures of individual bones of pelvis without disruption of pelvic ring.
2. High energy fractures generally producing pelvic ring disruption.

• Assess pelvic stability, very carefully, by pushing anterior superior iliac spines towards each other and then apart (preferably perform this manoeuver once only).
• Perform perineal and digital rectal examination.
• Secondary detailed survey is carried out once the patients condition is stable and x-rays and other relevant investigations are done.

• Volume replacement (see section on shock)

• Control haemorrhage – Apply pressure dressing for conspicuous external bleeding. Open pelvic fracture wounds can be packed to control bleeding. Apply external fixator as a resuscitative measure in patients with demonstrable haemodynamic instability after an initial fluid bolus.
• As an alternative to fixator, pelvic clamp can be applied, but it is not a popular modality as complication rate with this clamp is higher than fixator (Pelvic clamp is contraindicated for iliac wing fracture close to the sacroiliac joint).
• Urological management – Catheterize the urinary bladder to document urinary output as a crucial determinant of adequate volume resuscitation. Blood at urethral meatus/inability to void urine/perineal haematoma/ high riding prostate/indicate uretheral injury. Microscopic haematuria indicates bladder contusion.

• Gastrointestinal injuries – Concomitant small bowel/large bowel/rectal/anal tears or perforation can occur. Peritoneal lavage and abdominal CT are required to exclude GI trauma with close pelvis fractures. Further management is required in consultation with general surgeon.

Fractures and Dislocations of the Pelvic Ring. In: Chapmans Operative Orthopaedics.

Fractures

• Give temporary immobilization (called splintage) after grossly correcting the deformation without moving or manipulating much. With either wooden stick/an umbrella/a folded magazine or newspaper. A fractured lower limb temporarily can be supported and tied with opposite lower limb for splintage and transfer of patient; a fractured upper limb can be splinted by supporting it on the chest wall and wrapping any cloth piece around it. Take a note of the colour of the finger or toes before applying splintage.
• If the patient has an open fracture with excessive bleeding, attempt stopping bleeding by applying compressive dressing over the wound.
• If injury to the spine is suspected, carefully move the person from the site of accident in one piece like a log of wood without any twisting or flexion.

1. Patient with fracture in an extremity: Splint the limb with either Crammer wire (a malleable metallic support) or a slab or goose splint (thin layers of wood adhered to cloth) or a Thomas Splint (for femoral fractures) or Bohler Braun splint (for fractures around the knee or leg bones fractures), include the proximal and the distal joint of the fractured segment of the limb (Table 1).

   Table 1. Splinting in injured/fractured part of the limb

    

   Injured/Fractured part of limb	Extent of Splintage
   Fingers	Support with adjacent finger (called Buddy’s Strapping)
   Hand	Terminal pulp of fingers to proximal third of forearm
   Wrist	Distal palmar crease to upper one third forearm
   Elbow and forearm	Distal palmer crease to upper one third of arm
   Arm	Middle one third of forearm to base of neck (include shoulder)
   Foot and ankle	Base of toes to upper one third leg
   Leg	Base of toes to upper one third thigh (include knee and ankle). Can apply Bohler Braun splint also
   Knee	Just above the malleoli to upper one third of thigh
   Thigh	Base of toes to nipple line on trunk. The better option is application of Thomas Splint
   Pelvic	See section on Pelvic fractures

   
   Any open wound is dressed before application of splintage. For wounds of open fractures, irrigation of the wound with copious amount of saline (0.9% NaCl) helps removing dirt and foreign particles/bodies. The definitive treatment should be provided by an orthopaedic surgeon after radiological examination.

2. Multiple Injuries: Remove clothing and examine the patient rapidly from head to toe

• Ensure patency of the airway.
• Perform throat suction, if secretions are present in the throat.
• The neck may be “gently” turned to one side to prevent aspiration and ensure patent airway and breathing.
• Check for pneumothorax or a flail segment and take appropriate measures.
• Record vital parameters. Assess the level of consciousness according to the Glasgow Coma Scale. Establish intravenous line and catheterize the patient.
• Splint the limbs and note down distal neurovascular status. The patient, if required to be shifted, is handled with great care as he might be having spinal injury.

1. Inj. Diclofenac sodium 75 mg IM stat for pain relief.
2. (CAUTION: Do not give any sedative or centrally acting analgesic
3. (like morphine or its derivatives) to keep a watch on their level of consciousness and early detection of any complication arising secondary to any fracture in the limb).

2. Inj. Tetanus toxoid 0.5 ml IM stat if open injuries or wounds
3. IV fluids for management of haemorhagic shock (see section on shock)
4. give an initial rapid fluid bolus of 1-2 litres of Ringer’s Lactate in the adult patient and 20 ml/kg in the paediatric patient. Send blood for grouping and cross matching.

4. In case of open fractures, give intravenous antibiotics after sensitivity testing. Various combinations can be used but each should provide coverage for Gram-positive as well as Gram-negative organisms. The antibiotics should be continued for at least a period of 7-14 days.
   Inj. Cloxacillin 500 mg 6 hourly (50-100 mg/kg in children)
   Inj. Gentamicin 80 mg 12 hourly (5-7.5 mg/kg in children)
   Or
   Inj. Cefotaxime 1 g 12 hourly (100-200 mg/kg in children)
   Inj. Amikacin 500 mg 12 hourly (15 mg/kg in children)
   Or
   Inj. Ceftriaxone 1 g 12 hourly (50-100 mg/kg in children)
   Inj. Amikacin 500 mg 12 hourly (15 mg/kg in children)
   The patient or parents should report to the hospital in case of severe pain in the limb, difficulty in moving fingers/leg or has sense of numbness, fingers/toes are swollen, any change in the colour of toes or finger nails, i.e. pale, dusky or blue, rashes in skin under plaster in perineal or buttock, in case of vomitings or abdominal distension develops in patient in a spica cast, pain in a localised area with discolouration of the distal organ, or reappearance of swelling (could be because of plaster sore) or if the plaster cracks, breaks or becomes soft.

• The plaster immediately after application feels warm/hot during setting. Don’t cover the plastered limb with clothing or bed sheet to allows the plaster to dry and to permit direct observation of the limb.
• Keep the limb elevated and keep on moving toes/fingers frequently
• In children to cover the edges of the plaster with water proof material like polythene or plastic adhesive tape to avoid soiling of a hip spica or GT cast with urine or faeces.
• Not to bear weight on plaster unless permitted by the doctor, other wise it gets spoiled/cracked
• Avoid resting the plaster over any edge or hard surface to avoid dents and plaster sore.

1. Principles of Fractures and Dislocations. In: Rockwood and Green’s Fractures in Adults. Charles A.Rockwood Jr, David P Green, Robert W Bucholz et al (eds), 4th Edition, Volume 1, 1996, Lippincott-Raven, Philadelphia, New York.
2. Complications of Fractures. In: Rockwood and Green’s Fractures in Adults. Charles A.Rockwood Jr., David P. Green, Robert W. Bucholz et al (eds). 4th Edition, Volume 1, 1996, Lippincott-Raven, Philadelphia, New York.

Foreign Body In The Eye

This could be a small insect or a piece of grit or a loose eyelash.

Treatment (at the site of injury)

Nonpharmacological

Not to rub the affected eye if possible, make the patient blink the eyelids, with the eye under clean water. If this is not effective, make the patient sit in good light, wash your hands with soap and water and try to remove the foreign body gently by flushing the eye with clean water or saline. For foreign body under the upper eyelid, turn the eyelid up and identify the foreign body and then remove it gently with moistened and twisted cotton wool or a clean piece of cloth. In case the foreign body is in the lower lid, gently draw the lower lid down and identify the particle and remove it with a moistened wisp of cotton. (If the foreign body cannot be easily picked away or is embedded, do not try to remove it and cover the eye with a light bandage and refer the patient to a doctor.) After removal, Tetracycline eye ointment/eye drop should be applied and the eye should be bandaged. In case the foreign body cannot be removed or corneal perforation occur immediately refer to a higher centre.

Chemical Burns Or Injuries Of The Eye

1. Irrigation in the hospital – retract the eye lids and irrigate the conjunctival sac with normal saline or ringer lactate or water using intravenous tubing connected to the irrigating solution for 30 minutes or until litmus paper touched to the inferior fornix indicates neutrality.
   (CAUTION: Do not try to neutralize the alkali with acids or vice versa)
2. Remove retained solid particles of lime, lye or any other material from superior and inferior fornix after anaesthetizing the conjunctiva. It may require double eversion of eye lid and use of forceps. If double eversion is not possible, a moistened cotton-tipped applicator should be swept in the fornix.
3. Sodium ethylene diamine tetra acetic acid (EDTA) 0.01 to 0.05 molar solution may be used as an irritant to dissolve calcium hydroxide.

1. Homatropine eye drops 2% 3 times a day.
2. Gentamicin eye drops 0.4% 4 times a day.
   Or
   Ciprofloxacin eye drops 0.3% 4 times a day.
3. Tab. Ibuprofen 400 mg if required.
   Patch the eye and refer to an ophthalmologist.

Manual of Ocular Diagnosis and Therapy, 4th Edition, 1996, Little Bran and Company, pp 32-33.

Blunt Abdominal Trauma

1. Immediately transfer the patient to the hospital along with intensive monitoring, where facilities for operation are available after providing first-aid treatment for bleeding and shock. Evaluate for head injury and intrathoracic injuries.
2. Immediate exploratory laparotomy should be done, if the patient is in shock, has rigid distended abdomen, evidence of peritonitis or evisceration of the bowel:
3. a) Diagnostic peritoneal lavage (DPL) in patients with trauma who are hypotensive with possible intra-abdominal bleeding but physical examination findings are not reliable due to altered sensorium (injury to brain, ingestion of alcohol or drugs), loss of sensation (injury to spinal cord) or injuries to adjacent structures (pelvis, ribs, dorsolumbar spine):

• Insert nasogastric tube and urinary catheter.
• Use an infraumbilical incision (supraumbilical if patient has pelvic fracture).
• Lavage is considered positive, if you get 10-20 ml non-clotting blood or bile, succus entericus, stool or food material.

  In a hypotensive patient with grossly negative ‘tap’ (i.e. no fresh blood aspirated), the value of time-consuming lavage with 1000 ml of saline and its evaluation by microscopy (often not available) is questionable .

  b) Contrast Enhanced Computer Tomography (CECT) of abdomen should be performed in patients who are haemodynamically stable and in whom physical examination is unreliable because of the above mentioned factors. If CECT detects diaphragmatic injuries, intraperitoneal or retroperitoneal free air, contrast extravasation from bowel, disruption of pancreas, urinary bladder injury or grade IV or V injuries of liver, spleen and kidney with hot spot (active haemorrhage), exploratory laparotomy should be performed.

  Patients with lesser grades of liver or splenic injuries can be managed conservatively, provided intensive monitoring facilities and facility for immediate exploration, should the need arise, is there.

  It must be reiterated that during conservative management, these patients need intensive monitoring and frequent reviews by an experienced surgeon. If these are not available or there is doubt about the nature of injuries, exploration is safer. When CT scan is not available, chest x-ray in erect posture, plain xray films of abdomen and contrast studies of the bowel or urinary tract as and when indicated will detect all the injuries except injuries to liver, spleen and pancreas. Ultrasound examination can help to detect solid organ injuries, collections in the peripheral cavity etc. Imprint abrasions or patterns of injury are the marks of ecchymosis due to restraint devices like seat belts. When present, they often are signs of serious intra-abdominal injuries especially to hollow viscous or to lumbar spine.

1. Maingot’s Abdominal Operations, Zinner MJ, Schwartz SI, Ellis H. (eds), 10th Edition, 1987, Prenttice Hall International, pp 763-786.
2. Abdominal trauma. In: Hamilton Bailey’s Emergency Surgery. Ellis BW, Paterson-Brown S. Arnold (eds), 13th Edition, 2000, London.

Thoracic Trauma

1. Direct blow e.g., rib fracture.
2. Deceleration injury e.g., pulmonary contusion.
3. Compression injury e.g., cardiac and diaphragm injury.

1. Resuscitation. Assess for the patency of airway, breathing and circulation. Ensure the patency of the airway and adequacy of ventilation. Insert two 16G intravenous cannulae and start resuscitation with crystalloid. If haemothorax or a pneumothorax are suspected in a patient with acute respiratory distress, chest tube should be inserted through the 4th/5th intercostal space in the anterior axillary line on the affected side without waiting for chest radiography.
2. Quick assessment of injuries

1. Rib fracture can vary from simple fracture to fracture with haemopneumothorax, to severe multiple fractures with flail chest and internal injuries. In case of simple fractures, pain with inspiration and localized tenderness and occasional localized crepitus on examination are present. Diagnosis is confirmed with a chest x-ray anteroposterior view. Exclude other intrathoracic injuries. Patients are treated with adequate analgesic drugs and muscle relaxants.In cases of multiple fractures, intercostal nerve blocks or epidural analgesia is required to ensure adequate pain relief and ventilation. Elderly patients need admission for pain relief, ventilation assistance and observation.
2. Flail chest occurs due to unilateral fracture of 4 or more ribs, both anteriorly and posteriorly, or bilateral anterior or costochondral fracture of more than 4 ribs causes a paradoxical respiratory motion. It leads to hypoventilation, atelectasis, hypercapnia and inadequate ventilation (RR>40/min, pO2< 60 mmHg with 60% FiO2). It requires immediate endotracheal intubation and ventilatory support.

1. Haemothorax should be suspected with penetrating or severe blunt thoracic injury. It is classified according to the amount of blood collected inside the pleural cavity and more importantly rate of bleeding after evacuation. In 85% of the patients with haemothorax, only tube thoracostomy is required. After tube thoracostomy, if the rate of continuing haemorrhage is more than 100-200 ml/hour or the haemorrhagic output exceeds 1000 ml in 24 hours, thoracotomy should be performed.
2. Pneumothorax is a true surgical emergency requiring immediate diagnosis and chest tube insertion. Subcutaneous emphysema, absent breath sound, mediastinal shift and acute respiratory distress warrant immediate chest tube insertion without waiting for a chest X-ray examination. Sucking chest wounds which allow air to pass in and out of the pleural cavity should promptly be treated by closure of the wound (initially sealing with large pads and later with suturing) and concomitant tube thoracostomy.Simple pneumothorax (without tension) should also be managed by chest tube insertion but only after documentation by chest X-ray.

1. Pulmonary parenchymal injury can be effectively managed nonoperatively, but about 15% of penetrating lung injury requires thoracotomy for control of haemorrhage. Approximately 80-90% of pulmonary injuries requiring operation can be managed by simple suturing or stapling of the involved segments. Only 10-20% require anatomical lung resection.
2. Pulmonary contusion in most patients with flail chest can also appear without any evidence of rib fracture (particularly in children). Treatment is often delayed because clinical and X-ray findings may not appear until 12-24 hours after injury.
   Clinical findings are loose, copious, blood tinged secretions, chest pain, restlessness, and laboured respiration. X-ray changes consist of patchy parenchymal opacification or diffuse peribronchial densities.
   Management involves careful pulmonary support and clearing of secretions,
   with ventilatory support if arterial blood gases cannot be maintained in a physiologic range. PEEP is a useful adjunct in the management of those requiring ventilation. Fluid overload should be avoided.

Thoracic Injury and Sepsis. In: Hamilton Bailey’s Emergency Surgery. Ellis BW, Paterson-Brown S. Arnold (eds), 13th Edition, 2000, London, pp 285-288.

Head injury trauma

• Symptoms and signs of severe forms may appear immediately as in concussions or contusions or may appear after a few minutes to hours as in acute subdural hematoma. It is mandatory that a patient should be observed for at least 24 hours for appearance of symptoms and signs of serious intracranial problem even if trauma appears trivial.
• Patient with history of unconsciousness, bleeding from nose/ear, seizures or presence of black eye, suspected fracture of skull and hematoma of scalp indicate severe form of head injury and require hospitalization.

1. Check and maintain air way and breathing (see section on CPR)
2. Check circulation by pulse volume, rate, blood pressure
3. Establish IV access
4. IV fluids according to volume loss (see section on shock)
5. Check for and stabilize extra cranial injuries
6. If spinal injuries are excluded then transfer the patient in side position with head down, to a tertiary care center where neurosurgical interventions are available.
7. If spinal injury is suspected then transfer the patient on a hard board, place two sand bags on either side of the head
8. Assessment by Glasgow coma scale as given in a section on coma may be used to prognosticate or follow a patient of head injury for improvement/deterioration of neurological status. Patients with Glasgow coma scale score 8 or less or with deterioration of level of consciousness should be transferred to a center where facilities for neurosurgical interventions are available. Over 85% of patients with aggregate score of 3 or 4 die within 24 hours while score of 11 or more indicates death in only 5- 10%
9. A subdural hematoma, epidural hematoma or large intracerebral hematoma may require surgical intervention and must immediately be attended to by a neurosurgeon.
10. Hyperthermia, hypoxia and hypercarbia exacerbate intracranial pressure, so does an awkward head position like acute flexion. These conditions must be appropriately treated, if necessary by mechanical ventilation.
11. Increased intra cranial pressure can be treated with Inj. Mannitol (20%) 0.25 g – 1 g every 3 to 4 hours.

• If a patient has been sent home considering the initial diagnosis of minor head injury, the family members must be advised to report back in case of persistent/increasing headache, vomiting, deterioration of level of consciousness or appearance of any focal motor weakness.
• A guarded prognosis in severe head injury is given but some children and young adults show remarkable recoveries despite low score on Glasgow coma scale.

1. Traumatic injuries of Head and Spine. In: Harrison’s Principles of Internal Medicine. Braunwald E, Fauci AS, Kasper DL et al (eds), 15th Edition, Mc Graw Hill Company Inc. New York, pp 2434 – 2442.

Opioid Intoxication

Opioid overdose can be a medical emergency and is usually accidental. It can result from incorrect estimation of dose or erratic pattern of use in which person has lost previous tolerance to drug. Often caused by combined use with other CNS depressants e.g. alcohol or sedativehypnotics.

Treatment [Immediate admission in Intensive Care Unit (ICU)].

1. Establish adequate airway and respiration. Oxygen inhalation and IV fluids. If facilities are available, give artificial ventilation
2. If ingested, gastric lavage can be given with 1:10,000 potassium permanganate solution.
3. Inj. Naloxone 0.8 mg IV (0.01 mg/kg for neonates) and wait for 15 minutes.If the patient shows no response, give another dose of 1.6 mg IV and wait for 15
   minutes. If the patient still shows no response, give 3.2 mg IV and suspect another diagnosis. If successful, continue at 0.4 mg every hour IV until the opioid
   has been cleared (up to 3 days for methadone).Babies born to opioid-abusing mothers may experience intoxication, overdose or withdrawal.
4. Always consider possible polysubstance overdose. A patient successfully treated
   with naloxone may wake up briefly only to succumb to a subsequent overdose from another slower acting drugs e.g. sedative-hypnotic taken simultaneously.
5. Supportive measures for hypotension.
6. Body warmth to be maintained with hot water bottles.
7. If convulsions are present Inj. Diazepam 10 mg IV and repeated asrequired (for details see section on status epilepticus).
8. The patient should not be made to walk forcibly in opium poisoning, as it is frequently done, but attempts should be made to keep him aware, by flicking a wet towel on the face.

Datura Poisoning

1. The stomach is washed out with 1:10,000 potassium permanganate solution or 5 per cent tannic acid solution. (For details see Poisoning)
2. In severe poisoning only Inj. Physostigmine 1-2 mg IM or IV repeated after half an hour, if necessary. Watch for side effects (bradycardia, heart block, excessive secretions).
   Or
   Inj. Pilocarpine nitrate 6-15 mg injected subcutaneously.
3. Inj. Diazepam may be given for convulsions (see section on status epilepticus)
4. For delirium, chloral hydrate, Inj. Paraldehyde or any short acting barbiturate is usually given. (CAUTION: Morphine is contraindicated).

Hydrocarbons (Kerosene, Petrol)

1. Prevention of aspiration is the main goal. Do not induce emesis.
2. Lavage with a cuffed endotracheal tube in situ has been advocated in comatose patients. If large amount (1-2 ml/kg) is ingested, controlled gastric emptying must be done in an alert patient by a stomach tube.
3. Instillation of oils to slow gastric emptying and decrease intestinal absorption has not proved to have practical application.
4. Specific treatment is aimed at aggressive correction of hypoxia with humidified oxygen and CPAP (continuous positive airway pressure).
5. Prophylactic antibiotics to prevent secondary bacterial infection may be used.
6. Proper supportive care especially to maintain fluid balance and to prevent hypoxia.
   1. Value of corticosteroids to prevent chemical pneumonia is doubtful.
   2. Pneumatocele, pneumothorax, cardiomegaly or arrhythmia may occur occasionally. Recovery is usually complete. However, pulmonary fibrosis and bronchiectasis have been known on long term follow up.

Organophosphorus Poisoning (OP)

1. Establish airway, suctioning, and oxygen. This is most urgent as death can occur from respiratory failure. Establish an IV line, monitor BP, do not rush fluids.
2. Decontamination of the skin, mucous membrane and gut (if skin is contaminated, clean with soap water and change the clothings; gastric lavage and catharsis if poison has been ingested).
3. Inj. Atropine IV 0.05 mg/kg every 10 minutes until signs of atropinism appear; maintain it for 24 hours. The signs of atropinism are: drying of all secretions (most reliable) delirium, restlessness, fever, tachycardia, dryness of tongue and dilated pupils. As much as 10 times of usual dose of atropine may be required. (CAUTION: There is no fixed dose of atropine in OP poisoning. The aim is to keep patient atropinised till poison effect weans off).
4. In severe cases, immediately give Inj. Pralidoxime (PAM) 25-50 mg/kg IV in older children and 250 mg IV in infants over 5-10 minutes, 8 hourly up to 36 hours.
5. Assisted ventilation may be required in upto 25% of patients.

Poisoning

• Diagnosis – Suspect and identify poison, if possible.
• Treatment includes basic principles, antidotes, symptomatic and supportive.
• Anticipate complications, preserve evidence, and prevent sequelae as well as recurrence.

1. Suspicion of poisoning should be aroused by sudden onset of symptoms, uniform and increasing severity of symptoms in a group e.g. food poisoning or industrial poisoning. Unexplained nausea, vomiting, diarrhoea, drowsiness or coma, euphoria, increased psychomotor activity, convulsions, delirium and unusual breath smell are symptoms which in the absence of disease need careful evaluation for suspected poisoning. Signs and symptoms helpful in diagnosis of poisoning are shown in Table 1.
2. Identification of the substance should not take precedence over the first step, since the process is slow and unreliable or lack of proper history might cause confusion. Action of poisons is modified by physical factors like quantity, form, chemical combination, dilution, route of administration and host factors like age, idiosyncrasy, sleep, food and use (abuse) of multiple substances.

• Attention to ABC of resuscitation is utmost priority at all times.
• Removal of poison from the person or person from the poison.
• In case of skin contamination with toxic materials, a shower or drenching the skin in a water tub and use of soap and water will mechanically remove the substance.
• For eye contamination, washing the eye with running clean water, holding the lids apart is a useful measure. Rubbing of eyes is to be discouraged. Use of sterile liquid paraffin will prevent irritation.
• When a toxic substance has been inhaled, removal of the person away to open surroundings, loosening of clothes and if necessary, artificial respiration are important first aid measures.

1. Induce emesis
   (CAUTION: Contraindicated in cases of corrosive poisoning, unconscious patients and in those who have swallowed petroleum products.)
   Mechanical tickling of the throat with fingers, spatula or tongue depressor will induce vomiting.
   Or
   Two tablespoons of common salt or a tablespoonful of mustard powder in a glassful (200 ml) of water orally.
   Or
   Two to four teaspoonful (10-20 ml) of syrup ipecac followed by half a glass of water.
   (CAUTION: Contraindicated in children with age less than 6 months)
   Or
   Inj. Apomorphine hydrochloride 6 mg subcutaneously causes vomiting in 3-4 minutes but should be used with caution since it is also a depressant.
2. Following vomiting, dilute any poison left in the stomach by asking the patient to drink milk. Alternatively, one can use charcoal powder (activated). Charcoal should not be used in patients with poisoning due to an acid or alkali. It is prepared by dissolving 4 tablespoonful of powder in about 400 ml of water and half a glass is given to drink every
   15 minutes. If charcoal is not available, powder of burnt bread can be used.
   And/Or
3. Gastric lavage – A lavage within one hour of ingestion of poison is useful in removing unabsorbed poison. It is carried out by using a stomach tube (working on siphon system) or a Ryle’s tube, or soft rubber or plastic tube introduced into the stomach and washing out contents using water, saline, faint pink potassium permanganate solution (1 in 5000 to 10,000). Initial gastric aspirate in water should be preserved for medicolegal purposes to carry out chemical analysis.
   If the poison is known then an antidote solution can be left in the stomach after
   the lavage.
   Large amounts of fluid should not be used at the time of lavage as this opens the pylorus and causes the substance to go into the duodenum.Before carrying out lavage, dentures must be removed and mouth gag used if the patient is non-cooperative.
   (CAUTION: Lavage with stomach tube is contraindicated in corrosive poisonings, petroleum product ingestion, small children, unconscious patients without cuffed endotracheal tube in place and patients having convulsions. However, a careful use of Levin’s tube is recommended by some in patients of corrosive poisoning seen within half an hour of ingestion).
4. Purging – Purging is carried out using sodium sulphate, magnesium sulphate, mineral oil (for glutethimide), castor oil (for phenol poisoning).(CAUTION: Castor oil is contraindicated in chlorinated insecticides since it enhances their absorption.)

1. Complications of various types arise commonly in poisonings.
   Anticipating such complications and proper management helps in successful
   outcome.

2. Preserving evidence for medicolegal purposes and toxicological studies is the responsibility of the attending physician. Urine, stool, gastric contents (vomited or aspirated), blood and food samples and viscera should be preserved.
3. Prevention of sequelae like strictures following corrosive poisoning is done by using corticosteroids. Corticosteroids are useful in petroleum product poisoning to treat shock lung syndrome and to prevent pulmonary fibrosis.
4. Preventing recurrence of poisoning is by proper labeling, keeping such substances away from children, keeping medicines, cosmetics and household products separately, and psychiatric attention to patients who have taken drugs with suicidal intention.

Coma

• Oxygen inhalation, intubation if needed, control of blood pressure and establish IV line and take history of patient.
• Drug screen, glucose, metabolic parameters, ABG, temperature.

1. Inj. Glucose (25 or 50%) 50 g IV.
2. Inj. Thiamine 100 mg IV.
3. If opiate overdose is suspected, give Inj. Naloxone 0.8 mg IV. If response is inadequate, double the dose every 15 minutes (for details see section on opioid intoxication).
4. If benzodiazepine over dose is suspected, give Inj. Flumazenil 200 mcg IV slowly. If no response repeat 100-200 mcg after 1 minute. If required, give maximum dose of 1 mg or give as IV infusion of 100-400 mcg/h if drowsiness recurs.
5. If focal neurological deficit or signs of herniation/decerebration/decortication occurs, CT scan, EEG and neurologic consultation is required.
6. If no clear aetiology and no herniation – CSF examination should be done.
7. If signs of raised intracranial tension (papilloedema, convulsions, decerebrate posture indicating herniation) occurs:
   1. Avoid giving free fluid (glucose solution) intravenously.
   2. Inj. Frusemide 40 mg IV to maintain adequate urine output of 30-50 ml/h).
   3. Hyperventilate to bring down PCO2 to 25 mmHg.
   4. Inj. Dexamethasone 20 mg IV stat and 6 mg 4 hourly.
   5. Inj. Mannitol 1.0 g/kg IV over 10 minutes.

Acute Confusional States and Coma. In: Harrison’s Principles of Internal Medicine, Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 132-140.

Septicaemia

1. Care of airway and breathing as given in chapter on CPR.
2. Removal or drainage of a focal source of infection. Indwelling intravenous catheter, Foley’s catheter etc should be replaced if considered as a source.
3. General care of skin, orodental hygiene and nutrition supplementation should be taken care of in prolonged severe sepsis.

1. Oxygen therapy: 2-4 litres/min with catheter/mask (to keep SPO2 >95%).
2. Intravenous fluids: to be guided by haemodynamic status. If in shock, aggressive fluid therapy as mentioned in chapter on Shock to maintain urinary output at more than 1 ml/kg/hour.
3. Dopamine and dobutamine are required if haemodynamic stability is not achieved by fluid therapy.
4. Antimicrobial agents: Antimicrobial therapy should be initiated as soon as samples for culture are withdrawn from blood and other relevant sites. Choice of antibiotics depends on suspected organism.

1. Inj. Cefotaxime 150-200 mg/kg/day in 3 divided doses.
   Or
   Inj. Ceftriaxone 100 mg/kg/day (maximum dose 4 g/day) in 2 divided doses.
2. Inj. Gentamicin 7.5 mg/kg/day in 2-3 divided doses.
   Or
   Inj. Amikacin 15 mg/kg/day in 2-3 divided doses.
3. Add Penicillin/Vancomycin if Streptococcis/Staphylococcis organisms are suspected
   Inj. Penicillin G aqueous 200,000-300,000 units/kg IV 4 hourly.
   Or
   Inj. Vancomycin 15 mg/kg/day in 2 divided doses.

1. Inj. Ceftizidime IV 150 mg/kg/day in 3 divided doses.
2. Inj. Vancomycin 15 mg/kg/day in 2 divided doses.

• Continuous monitoring of pulse, respiratory rate, blood pressure, capillary filling time, urinary output and neurological status should be done for early detection of septic shock or multiorgan failure.
• Patient should be referred to tertiary level centre if very sick or shows no signs of improvement after initial therapy.

• Immunocompromised patients should be informed about features of early sepsis. Fever in any child with congenital or acquired immunodeficiency state should be taken very seriously.

1. Sepsis and Septic Shock. In: Harrison’s Principles of Internal Medicine. Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 799-804.
2. Sepsis and Shock. In: Nelson’s Textbook of Paediatrics. Behrman, Leigman, Jenson (eds), 16th edition, 1999, pp 747-751.

Stridor

1. Acute laryngitis/laryngotracheobronchitis
2. Epiglottitis
3. Diphtheria

Anaphylaxis

1. Inj. Adrenaline 1:1000, 0.01 ml/kg (maximum 0.3 ml in children and 0.5 ml in adults) by IM injection. If necessary, dose can be repeated every 15 minutes. If the anaphylaxis is to injection of an allergen extract or to a hymenoptera sting into an extremity, half the dose of adrenaline can be infiltrated locally, subcutaneously after dilution with 2 ml saline.
   A tourniquet above the site can also slow systemic distribution of allergen. It can be loosened every 3 minutes.
2. For severe anaphylaxis with shock as in all medical emergencies, initial management should be directed at the ABC of resuscitation, namely maintenance of adequate airway – suction, breathing, and circulation. If working alone, call for assistance.
3. Establish one or preferably two, wide bore intravenous lines. Commence rapid fluid resuscitation with normal saline.
4. If there is severe laryngeal obstruction, bronchospasm, circulatory shock or coma, intubate and commence intermittent positive pressure ventilation.
5. If there has been little or no response to the initial intramuscular dose of adrenaline, administer adrenaline 5 mcg/kg slowly in to the intravenous line. Repeat at 5 minutes intervals depending on response. If the patient remains in shock, start an adrenaline infusion (preferably via a central venous line), commencing 0.1 mcg/ kg/min in children and 0.2 mcg/kg/min in adults, titration is required to restore blood pressure. Large doses of adrenaline may be needed.
6. If the only manifestation of anaphylaxis is urticaria or angioedema initial IM dose of adrenaline should be given in addition to H1-antagonists. If no progression occurs, patient can be kept under observation for at least 12 hours and then discharged.

1. Administer Salbutamol or Terbutaline by aerosol or nebuliser.
2. Inj. Diphenhydramine 1 mg/kg slow intravenously.
3. Inj. Ranitidine 1 mg/kg slow intravenously.
4. Inj. Hydrocortisone 2-6 mg/kg or Dexamethasone 0.1-0.4 mg/kg IV.

• To check and look for the cause (food, drugs etc.) and to avoid it in future.

1. General Aspects of Treatment. In: Textbook of Dermatology. Champion RH et al (eds), 6th Edition, Blackwell Science Ltd. London, pp-3289.
2. Urticaria and Angioedema. In: Dermatology in General Medicine. Freedberg IM et al (eds), 5th edition, The McGraw Hill Company Inc., pp-1409.
3. Anaesthesia at the District Hospital. In: World Health Organization in collaboration with the World Federation of Societies of Anaesthesiologists, Geneva, 2nd Edition, 2000, World Health Organization.
4. Drugs Used in Anaesthesia. In: WHO Model Prescribing Information, 1989, World Health Organization.
5. Anaesthesia at the District Hospital. In: World Health Organization in collaboration with the World Federation of Societies of Anesthesiologists, Geneva, 1988, World Health Organization.

Fluid & Electrolyte Imbalance And Replacement (In Adults)

1. Replacement fluids are used to replace abnormal loss of blood, plasma or other extracellular fluids as first line treatment for hypovolemia in:
• Treatment of patients with established hypovolemia e.g. haemorrhagic shock.
• Maintenance of normovolemia in patients with ongoing fluid losses e.g. surgical blood loss.
2. Intravenous replacement fluids are the first line of treatment for hypovolemia. Initial treatment with these fluids may be lifesaving and provide some time to control bleeding and obtain blood for transfusion if it becomes necessary.
3. Crystalloid maintenance fluids, which contain dextrose, are not suitable for use as replacement fluids.Only crystalloid solutions with a similar concentration of sodium to plasma (normal saline or balanced salt) solutions, (Ringer’s lactate or Hartmann’s solutions) are effective as replacement fluids. These should be available in all hospitals where intravenous replacement fluids are used.
4. Crystalloids should be infused in a volume at least three times the volume lost in order to correct hypovolemia.
5. All colloid solutions (albumins, dextrans, gelatins and hydroxyethyl starch solutions) are replacement fluids. However, they have not been shown to be superior to crystalloids in resuscitation.
6. Colloid solutions should be infused in a volume equal to the blood volume deficit.
7. Plasma should never be used as a replacement fluid.
8. Plain water should never be infused intravenously. It will cause haemolysis and will probably be fatal.
9. In addition to the intravenous route, the intraosseous, oral, rectal or subcutaneous routes can be used for the administration of fluids, blood and certain drugs. However, with the exception of intraosseous route, other routes are generally unsuitable in severely hypovolemic patients.
10. Rectal fluids are administered through a plastic or rubber enema tube which is inserted into the rectum and connected to a bag or bottle of fluid. The fluid rate can be controlled by using a drip giving-set, if necessary. The fluids used need not be sterile. A safe and effective solution for a rectal rehydration is 1 litre of clean drinking water with teaspoon of table salt.
11. Subcutaneous fluids: Occasionally, when other routes of administration of fluids are unavailable, a subcutaneous infusion can be used. A cannula or needle is inserted
    into the subcutaneous tissue (the abdominal wall is a preferred site) and sterile fluids are administered in a conventional manner.Do not give dextrose-containing solutions subcutaneously as they can cause sloughing of tissues.
12. Oral and nasogastric fluids: Oral rehydration can often be used in mildly hypovolemic patients if the oral route is not contraindicated. Do not use if:
    - The patient is unconscious.
    - The patient has gastrointestinal lesions or reduced gut motility e.g. obstruction.
    - General anaesthesia and surgery is planned imminently.

1. Check that the seal of the infusion fluid bottle or bag is not broken.
2. Check the expiry date.
3. Check that the solution is clear and free from visible particles.

Volume Excess

1. Anaesthesia at the District Hospital. In: World Health Organization in collaboration with the World Federation of Societies of Anesthesiologists, Geneva, 2nd Edition, 2000, World Health Organization.
2. Drugs Used in Anaesthesia. In: WHO Model Prescribing Information, 1989, World Health Organization.
3. Anaesthesia at the District Hospital. In: World Health Organization in collaboration with the World Federation of Societies of Anesthesiologists, Geneva, 1988, World Health Organization.

Disturbances in fluid and electrolyte balance occur in a wide spectrum of diseases, are not confined to any particular field of medicine, and are common following burns, trauma and major surgery.

The conventional and easy method of evaluating disturbances in fluid and electrolyte balance is the frequent measurement of the concentration of serum electrolytes. It is crucial to remember that intracellular and extracellular electrolytes are normally constant, and that major shifts in and out of ‘compartments’ can occur in disease with minimal changes in serum electrolyte. Compositional changes also involve disturbances in acid-base balance.

Volume changes: volume deficit

I. Obvious causes
Vomiting, diarrhoea, intestinal fistulae, nasogastric suction, fluid loss following burns, sequestration of fluid in soft tissue injuries and infections, diuretics, renal disease/adrenal insufficiency.

II. Less obvious causes
Unsuspected inadequate fluid intake fluid loss through excessive sweating as in high fever, hot humid temperatures, in diseases like tetanus. Fluid loss during haemodialysis, haemofiltration and from surgical incisions.

Management

The first principle is to restore circulating volume through infusion of intravenous fluids. Once this is satisfactorily achieved, disturbances in electrolytes and acid-base balance if present need to be rectified. Various fluids used for volume replacement are given below:

A. Replacement fluids

1. Replacement fluids are used to replace abnormal loss of blood, plasma or other extracellular fluids as first line treatment for hypovolemia in:
• Treatment of patients with established hypovolemia e.g. haemorrhagic shock.
• Maintenance of normovolemia in patients with ongoing fluid losses e.g. surgical blood loss.
2. Intravenous replacement fluids are the first line of treatment for hypovolemia. Initial treatment with these fluids may be lifesaving and provide some time to control bleeding and obtain blood for transfusion if it becomes necessary.
3. Crystalloid maintenance fluids, which contain dextrose, are not suitable for use as replacement fluids.Only crystalloid solutions with a similar concentration of sodium to plasma (normal saline or balanced salt) solutions, (Ringer’s lactate or Hartmann’s solutions) are effective as replacement fluids. These should be available in all hospitals where intravenous replacement fluids are used.
4. Crystalloids should be infused in a volume at least three times the volume lost in order to correct hypovolemia.
5. All colloid solutions (albumins, dextrans, gelatins and hydroxyethyl starch solutions) are replacement fluids. However, they have not been shown to be superior to crystalloids in resuscitation.
6. Colloid solutions should be infused in a volume equal to the blood volume deficit.
7. Plasma should never be used as a replacement fluid.
8. Plain water should never be infused intravenously. It will cause haemolysis and will probably be fatal.
9. In addition to the intravenous route, the intraosseous, oral, rectal or subcutaneous routes can be used for the administration of fluids, blood and certain drugs. However, with the exception of intraosseous route, other routes are generally unsuitable in severely hypovolemic patients.
10. Rectal fluids are administered through a plastic or rubber enema tube which is inserted into the rectum and connected to a bag or bottle of fluid. The fluid rate can be controlled by using a drip giving-set, if necessary. The fluids used need not be sterile. A safe and effective solution for a rectal rehydration is 1 litre of clean drinking water with teaspoon of table salt.
11. Subcutaneous fluids: Occasionally, when other routes of administration of fluids are unavailable, a subcutaneous infusion can be used. A cannula or needle is inserted
    into the subcutaneous tissue (the abdominal wall is a preferred site) and sterile fluids are administered in a conventional manner.Do not give dextrose-containing solutions subcutaneously as they can cause sloughing of tissues.
12. Oral and nasogastric fluids: Oral rehydration can often be used in mildly hypovolemic patients if the oral route is not contraindicated. Do not use if:
    - The patient is unconscious.
    - The patient has gastrointestinal lesions or reduced gut motility e.g. obstruction.
    - General anaesthesia and surgery is planned imminently.

WHO/UNICEF formula for oral rehydration fluid

B. Maintenance fluids
Maintenance fluids are fluid used to replace the normal physiological loss that occur in a patient through skin, lung, faeces and urine. Since a considerable proportion of these losses is water, maintenance fluids are mainly composed of water in the form of a dextrose solution. Some electrolytes may also be included in these solutions.
All maintenance solutions are crystalloid solutions. Some examples of crystalloids that are suitable as maintenance fluids are: 50% dextrose and 4% dextrose in sodium chloride 0.18%

Table 2: Fluid & electrolyte requirements for adult & children under normal circumstances

*These figures represent the fluid requirements in ml/kg/hour.

Safety

Before giving any intravenous infusion:

1. Check that the seal of the infusion fluid bottle or bag is not broken.
2. Check the expiry date.
3. Check that the solution is clear and free from visible particles.

Volume Excess

Volume excess is often iatrogenic when the fluid intake has consistently exceeded the output. Excessive intravenous infusions of saline, and blood transfusions are important causes of hypervolemia. Renal insufficiency, congestive heart failure, liver disease and other causes of sodium retention, or excessive sodium administration can all produce increase in extracellular fluid content and hypervolemia.

Treatment

In cases of moderate volume excess, salt restriction, restriction of fluid intake and the use of frusemide as a diuretic will solve the problem. Fulminant pulmonary oedema secondary to overhydration from overtransfusion of blood or fluids is more appropriately dealt with by phlebotomy in stages so that PCWP is reduced below 15 mm Hg. Rarely ultrafiltration (dialysis) may be required

References

1. Anaesthesia at the District Hospital. In: World Health Organization in collaboration with the World Federation of Societies of Anesthesiologists, Geneva, 2nd Edition, 2000, World Health Organization.
2. Drugs Used in Anaesthesia. In: WHO Model Prescribing Information, 1989, World Health Organization.
3. Anaesthesia at the District Hospital. In: World Health Organization in collaboration with the World Federation of Societies of Anesthesiologists, Geneva, 1988, World Health Organization.