Module 5

DEPARTMENT OF EMERGENCY MEDICINE

SINGAPORE GENERAL HOSPITAL

1 MARITIME RADIO-MEDICAL SERVICE

Ships without a doctor on board may seek medical advice from a shore
station, which is either a port health station or a hospital. The department,
since 1980, has provided such a radio-medical service. In 1985, a telex
service with facilities for transmission via a satellite communications system
(INMARSAT - International Maritime Satellite) was introduced for this service.
Singapore's strategic location makes it accessible to maritime communication
traffic in two ocean regions, viz., the Indian and Pacific Oceans covering a
total ocean area of 253 million sq. km. We handle about 150 radio-medical
calls annually covering both major and minor illnesses.

When a message is received, either by telex or by telephone, the Staff Nurse

in charge passes the message to the doctor on duty. The Master of the ship
usually sends the message. Information given would be sex, age, vital signs,
chief complains and action taken to-date by ship's master. The doctor is
expected to make a reasonable diagnosis and, if not, make specific requests
for additional information so that a diagnosis could be made as early as
possible. The doctor then lists down clearly the medical advice to be given.
Such medical advice may be in the form of: -

a) Procedures e.g. CPR

b) Medication as named in the Ship Captain's Medical List

(available in the Emergency Dept).

c) Evacuation to nearest port of call. If ship is close to Singapore,

to also offer the telephone number of the Marine Department
(available in ED), so that the ship's Master could liaise directly
with Marine Dept to arrange for helicopter evacuation to
Singapore.

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2 BLOOD FOR ALCOHOL LEVELS

The police sometimes refer persons arrested for drunken driving or drunken
behaviour and request for a medical examination to exclude alcoholic
intoxication. In all instances, the following will need to be recorded: -

a) Any odour of alcohol in the breath.

b) Any conjunctival injection.

c) Pupil size.

d) Heart rate.

e) Facial flushing.

f) Coherence of speech.

g) Unsteadiness of gait (by tandem walking).

Blood for alcohol levels are to be taken only for drunken driving (even if no
clinical evidence exists), and only when requested by police. This is because
there is currently a legal limit of 80 mm/dl for blood alcohol. There is no legal
limit for alcohol for partygoers or for those who fight. However, at least verbal
consent is required from the arrestee for the blood to be taken for alcohol
assay. The name of the Staff Nurse assisting in the taking of blood has to be
recorded in the A&E Case Record for medico-legal purposes. The blood
sample and toxicology must then be sealed and signed by the doctor
immediately. The nurse will then arrange to despatch the sample to the
Toxicology Laboratory. The doctor should advise drunken drivers who are
arrested by the police and who refused consent for blood sample for alcohol
that such refusal could be held against them in a court of law.

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3 SEXUAL ABUSE AND PEOPLE ABUSE

Frequently the Police and Social Welfare Department refer cases of sexual
abuse and child abuse to the department for medical assessment or
treatment. In addition during the course of attending to patients, we
occasionally pick out instances of probably child abuse, sexual assault,
spouse abuse and even elderly abuse/neglect.

All such instances must be reported to Medical Social Worker Department

and departmental procedure for these are as given in Annex 1.

4 FREQUENT ATTENDANCES

There is a long history of frequent attendees (regulars) in Emergency

Medicine Department. A list of such regulars is kept in the department. Such
frequent attendees often do not pay their hospital bills and abscond. When
assessing such patients, they should not be brushed aside or scolded.

Rather, they should be adequately assessed. If they do not require inpatient

treatment, then they should be discharged after treatment. If in-hospital stay
is required they should, as far as possible, be admitted to "C" class wards.

5 PSYCHIATRIC PROBLEMS

Occasionally, we encounter patients with acute psychiatric problems. Once

again, there is the need to exclude a likely organic cause for the psychiatric
presentation. But having done so, it would be necessary to refer such
patients immediately to either Institute of Mental Health Admission Room or
NUH Psychiatric-on-duty. When doing so it would be preferred that we call
the respective doctors-on-duty in those hospitals to inform them. We must
also inform our nursing staff so that they could make the necessary
transportation arrangements.

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6 PUBLIC RELATIONS AND PUBLIC RELATIONS BOOK/ATTIRE/
CODE OF CONDUCT

(a) PUBLIC RELATIONS AND PUBLIC RELATIONS BOOK

Public relations form an extremely important aspect of your duties in

the Emergency Department. Being a service department with
extremely high public contact, we must be conscious of how we interact
with patients, their relatives and colleagues, our nursing and
administrative staff and our medical colleagues in the department, in
other departments of the hospital, other hospitals and private medical
institutions and clinics. We should always conduct ourselves in a
caring, concerned and dignified manner worthy of our social position as
doctors. We must demonstrate understanding and show that we care.
Therefore, patients and their relatives cannot be brushed aside. We
must also not adopt a patronizing or condescending manner or argue
needlessly with patients and relatives. Try to see their point of view.
Imagine how you would want to be treated or handled if you are in their
shoes. Now give to them what you would have wanted for yourself if
roles were reversed.

If, in spite of all your efforts at maintaining good PR, an unpleasant

situation is developing, pause a while, take a deep breath and seek the
help of your seniors, viz. Registrar, Associate Consultant or Consultant.
Do not be afraid or shy to call for help. Your seniors would appreciate
it, if you call early, rather than late.

If unpleasant situation do arise, you should record the details of the

incident in one of the department's PR Books. These books are kept
by the Nurse Manager on duty. This book will serve to answer any
queries or complaints and is reviewed daily by Head, Department of
Emergency Medicine.

(b) Attire

All doctors should be attired in hospital issued scrubsuits. Jeans,

slippers, T-shirts, shorts and extremely colourful shirts are not
permitted. Hair of male staff should be kept short and combed tidily.
Females should either pleat long hair or have it tied in a neat manner.
The dress code is as follows: -

i) Males - Hospital issued scrub suits.

- Name tag to be clearly displayed either over

or above left breast pocket or on folded
collar sleeve.

ii) Females - Hospital issued scrub suits

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 - Name tag to be clearly displayed as for
males above.

(c) Code of Conduct

These are just a few simple rules: -

i) Courtesy with patients, staff and colleagues.

ii) No food or drinks for staff in consultation rooms, especially when

talking to or examining patients. All meals are to be consumed
at roof top.

iii) Punctuality at work.

iv) Respect for all medical, nursing and administrative colleagues.

v) Attendance at department meetings and teaching rounds.

vi) Check your mail daily and answer queries and medical reports
promptly.

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 Protocol for Domestic Violence Victims: recognition of victims

1) Recognition of DV

a) Types of abuse: physical

emotional / verbal
psychological
economic
damage to property

b) Characteristics of DV victims:

- want medical treatment for injury

- not prepared to disclose DV to doctor
- few agree to see MSW

c) Indicators of abuse from history:

- patient’s explanation does not fit injury

- delay in seeking medical care
- “accident-prone” patients
- frequent ED visits
- drug or alcohol abuse
- marital problem

d) Suspicious injury or medical conditions:

- central injury (to face, neck, chest, heart, abdomen, genitalia)

- injury in various stages of healing
- injury to defensive areas of body (ulnar aspect of forearm or palms, bottom of
feet, contusion limited to back, legs, buttocks, back of head resulting from
crouching for protection)
- depression
- stress-related disorders: irritable bowel syndrome, eating disorder
- anxiety attacks
- forced sexÆ urinary tract infection, sexual dysfunction, vaginal and anal
tearing, sexually transmitted disease

2) Action by doctors:

- routine screening for DV victimisation

- assessment (especially safety need of victims)
- intervention
- documentation
- note: perpetrators may accompany victims to hospital and refuse to leave
victim to see doctor or nurse alone

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3) Attending skills:

Do:

Eye contact
Attentive body language
Accurate listening
Assure confidentiality
Encourage DV victims to talk and share their feelings
Express concern for their safety
Be understanding and non-blaming
Talk in private (do not use patient’s family or friends to interprete)
Be proactive in giving help
Make appropriate referrals

Don’t:

Downplay danger
Judge or criticise
Attempt to mediate
Lose patience

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 Appendix 1

DEPARTMENT OF EMERGENCY MEDICINE SOP FOR MANAGEMENT,

REFERRAL AND REPORTING OF CHILD, WOMEN AND ELDERLY ABUSE CASES
TO MEDICAL SOCIAL WORKER

1. Do not compel patient or victim to be referred to MSW. However, all abuse

patients have to be reported to MSW either for statistical and/or follow-up. As is
usual practice, all child abuse victims require in-hospital admission.

2. Use MSW form for referring/reporting to MSW. Indicate whether or not the case
was referred to the Police. Enter details about the abuse in the remarks column
of the MSW form and send the referral form with a photocopy of the emergency
case record.

3. For abused Persons who do not require urgent temporary shelter

a. During office hours

Monday to Friday 0800 to 1730 hours
Saturday 0800 to 1230 hours

i) Direct patient to MSW office with MSW referral form and photocopy of
emergency case record to receive counselling.

ii) Patients who present to ED when there is long waiting time or who are
triaged close to the end of office hours (after 4pm) should be referred to
the MSW immediately after triage by the triage nurse without waiting for
consultation. These patients should be assessed by the MSW at the ED
(either in the family room or consultation room at green area) after which
they will be seen by the doctors.
Note: triage nurse should note that the person accompanying the
victim may be the perpetrator and may turn aggressive if he/she
finds out that the victim is seeing the MSW first instead of the
doctor, so any referral to the MSW should be done discreetly.

iii) The pamphlet “STOP FAMILY VIOLENCE” will be given to abuse cases.

b. After office hours

i) Patients who are seen after office hours can be given appointment to
see the MSW the next working day. However, if the patient is perceived
to be at risk of further violence if he/she returns home, he/she should
be kept under observation in the ED till the next day when the MSW is
available. If the patient comes on a weekend where the MSW is not
available the next day, he/she should be referred to a crisis shelter.
The nurse will assist by calling the shelter on the patient’s behalf. If
there is difficulty in getting a shelter for the patient or if advice is
required, the MSW in charge of DV, Ms Crystal Lim (pg 95349267) and
Ms Esther Lim (pg 95349260) can be activated.

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 ii) The pamphlet “STOP FAMILY VIOLENCE” will be given to abuse cases.

4. For drug overdose cases associated with child, women or elderly abuse, admit
major cases according to clinical evaluation and ward doctor will refer to MSW
who will identify whether there is any abuse.

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 DEFINITIONS AND TYPES OF ELDERLY, WOMEN AND CHILD ABUSE
DEFINITION
Elderly abuse shall mean an
act or omission which results in
harm or threatened harm to the
health or welfare of an elderly
person.
Abuse includes intentional
Elderly Abuse infliction of physical or mental
injury, sexual abuse or
withholding of necessary food,
clothing and medical care to
meet the physical and mental
needs of an elderly person by
one having the care, custody or
responsibility of an elderly
person.
An elderly person refers to any
person who is aged 65 years
and above.
Abused women are those who
have been subjected to
violence within an intimate adult
relationship. This violence may
take the form of physical,
sexual, financial, emotional or
psychological abuse by their
male partners.
Women Abuse
The abused women face
problems such as fear of more
abuse from her partner should
she make a report or seek help,
fear of a marriage breakup and
loss of financial support, fear of
publicity and ignorance of
services for abused women.
Physical
Infliction of physical pain or
injury/physical confinement.
Includes direct, aggressive
behaviour such as bodily
assault, sexual abuse, physical
restraint, torture or
imprisonment.
Punching, hitting, slapping,
throwing objects, choking and
other forms of physical assault.
Use of weapons.
Types of Abuse
Psychological/Emotional Neglect/Abandonment/Financial Sexual
Verbal Deliberate refusal to meet basic needs Any form of sexual
aggression/intimidation/humiilia i.e. failure to provide food, shelter, assault/abuse.
ting behaviour/unreasonable clothing and medical care.
demands/deliberate ignoring.
Deliberate attempt to desert e.g.
Includes actions that cause fear abandoning the elderly person in the
of violence, isolation or streets, in hospitals, etc.
deprivation, feelings of shame,
harrassment, threat and insults. This includes actions of misuse of
property or financial resources. It
involves misappropriation of money,
valuables or property.
Threats and intimidating Intentional deprivation of basic needs Any form of sexual
behaviour. such as food or contact with others. assault/abuse.
Verbal abuse of a kind which
impairs the woman’s self
esteem and ability to function
normally.
Pressure to accept behaviours
which violate the woman’s
rights

DEFINITION
Child abuse is defined as the
wilfull assault, ill-treatment,
neglect, abandonment or
exposure of a child/young
person in a manner likely to
cause the child/young person
unnecessary suffering or injury
to his health including injury to
or loss of sight, hearing, limb or
organ of the body and any
Child Abuse mental derangement. Neglect
is defined as wilful neglect to
provide adequate food,
clothing, medical aid or lodging
for the child or young person.
A child means a person who is
below the age of 14 years and
a young person means a
person who is between 14 to 16
years old.
Types of Abuse
Physical Psychological/Emotional
Refers to non-accidental Occurs when the parents or
injuries found in a child. The guardians have failed to
injuries could be the result of consistently provide a loving
caning or repeated assaults. home environment for the child
to grow and develop.
These could take the form of
ignoring, discriminating or
blatantly rejecting the child. It is
often difficult to detect these
cases as it is not as clear as
physical abuse.
11
Neglect/Abandonment/Financial Sexual
Failure of the parent or guardian to Any form of sexual
provide the basic necessities of life for assault/abuse
the child. This includes the lack of:-
• Proper medical care
• Adequate nourishment
• Proper clothing
• Proper lodging
It also includes cases where there is
no supervision at all for children under
8 years old
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 Orientation Module 5

Give short answers for the following:-

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1) Name 4 clinical points that have to be recorded in a patient referred for a medical
examination to exclude alcohol intoxication.

2) Who do we refer abuse (sexual or people) patients to after attending to their

medical needs?

3) What should you do when an unpleasant public relation situation occurs despite
your efforts at maintaining good PR?

4) Name the only 2 instances we take blood for alcohol levels.

5) What service do we provide to offshore ships without a doctor on board?

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 Abdominal Pain Flowchart

Abdominal pain +/- Vomitting +/- Diarrhoea

Yes Note 1 No
Admit ? Surgical abdomen Dehydrated

No Note 2 Yes
Note 3

Blood investigations
Symptomatic medication:
? FBC, UEC, sugar, amylase
Antacid (e.g. Mist Polysillic 50ml) if no diarrhoea
Antispasmodic (e.g. i/m or i/v hyoscine butylbromide 20-40mg) Urinalysis (UC9 & HCG)
Antiemetic (e.g. i/m prochlorperazine 12.5mg, i/m or i/v metoclopramide
10mg) CXR, AXR
Activated charcoal tablets
ECG
Clear fluids – either intravenous or oral (ad lib)
Intravenous drip
Observation for up to 12H (vital signs q2H)
Note 4

Review at 3 Hrly intervals: Symptomatic

Vital signs & physical examination

Normal Abnormal

Yes
Home with ? Need for admission Admit
medication,
abdominal advice, No
dietary advice
+/- referral Add medication
Observe 3H more

Review after 3H: ? Symptomatic

Vital signs & physical examination No
Normal Abnormal

Home with ? Need for admission

medication,
abdominal advice,
dietary advice Yes Admit
+/- referral

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 Observation Ward Protocol for Abdominal Pain (APP)
Note 1
Indication for observation:

1. Abdomen should be soft. There should be no guarding or rebound tenderness. Bowel sounds
should be present.

2. Hemodynamically stable (SBP >90).

Exclusion criteria:

1. Patients with an obvious surgical abdomen, peritonitis, intestinal obstruction, ectopic

pregnancy, AAA etc.

2. Patients with bleeding PR or melena.

3. Patients who are hemodynamically unstable. (For these patients, the ED senior physician on
duty should first be consulted, and pending approval, the surgical registrar on call should be
informed and the patient should be admitted to the general surgical dept. All unstable patients
should be admitted to the HD or ICA.)

4. Patients who have non-abdominal causes of pain eg AMI, pneumonia, DKA etc.

5. Patients who are to be admitted for other reasons.

Caution

Elderly patients with IHD, AF, hypertension, DM, hyperlipidemia may be at risk for ischaemic
bowel. They may present with severe abdominal pain and tenderness with minimal signs or a soft
and unguarded abdomen. Consult the senior ED physician on duty in all these instances.

Note 2

1. All patients should be observed for a minimum of 3 hours and a maximum of 12 hours, with 3
hourly reviews.

2. FBC, U/E/Cr/S, seAmylase, urine dipstick, urine HCG, KUB, erect CXR, erect or lateral
decubitus AXR may be performed if clinically indicated, e.g. check FBC if appendicitis or
intestinal infection is suspected, seAmylase if pancreatitis is suspected, U/E/C/S if patient is
dehydrated, urine HCG in young woman with lower abdominal pain, ECG in patients older than
35 years old with epigastric pain, erect CXR if abdomen is guarded, erect AXR if intestinal
obstruction is suspected.

3. Vital signs should be monitored every 2 hourly. The I/O chart should be put up.

4. For patients who have severe diarrhoea or dehydration, iv hydration should be started. In fit
and young adults, at least 2 litres of normal saline should be given over 4 to 6 hours. Patients
with co-morbidities eg IHD, CCF should in general be admitted for rehydration.

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 Note 3
Treatment

1. Patients who have pain from intestinal colic should be given im buscopan 40 mg.

2. Patients who are vomiting may be given im or iv stemetil 12.5 mg or maxolon 10 mg.
(Intestinal obstruction and other non-abdominal causes of vomiting eg raised ICP must be
excluded first).

3. Patients with renal or ureteric colic may be given im voltaren 50 – 75 mg or im pethidine 50-
75 mg in addition to im buscopan 40 mg.

4. Patients with acute gastritis may be given a combination of im buscopan 40mg and mist
polysillic antacid 50 ml – 60 ml, which may be repeated after two hours.

5. Activated charcoal tablets may be given to patients with diarrhoea.

Note 4
Disposition

1. At the end of 3 hours if the patient’s abdominal pain has not improved, he should be re-
examined and the disposition will depend on the examination findings.

2. If there is leukocytosis or there are signs of peritonitis, the patient should be admitted to
general surgery or the appropriate surgical department (eg colorectal surgery) after
consultation with the senior ED physician on duty.

3. If he has renal colic, which does not respond completely to adequate treatment in the
Emergency Department, he should be admitted to urology.

4. If the abdomen is soft, non-guarded, the patient is not toxic or unstable hemodynamically, he
should continue to be observed for a further 3 hours till his symptoms and signs have
completely subsided. Any patient who is observed for more than 3 hours must be made
known to the senior doctor on shift.

5. At the end of 6 hours of observation, if the patient feels well and there is no abdominal
tenderness or guarding at all, he may be discharged with the appropriate medication and
abdominal pain advice. If there is still minimal tenderness, the patient should be observed for
another 3 hours to ensure that the pain does not recur or has completely subsided. If the pain
is severe, he should be admitted.

6. At the end of 9 hours, if the patient is well and there is no abdominal pain, the patient may be
discharged with medication and abdominal pain advice. Patients whose pain improved only
slightly or have recurrence of pain should be admitted to the appropriate department after
consultation with the senior Emergency Physician on duty.

7. If the symptoms do not improve, and a surgical cause is not considered likely, the patient
should be re-evaluated by the senior ED physician on duty for possible admission to
Department of Gastroenterology.

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Asthma Flowchart

Asthma

Note 1

Is observation
indicated?

Note 2 Yes

Vital signs, PEFR, SaO2 hourly Deteriorate at any time

x2, then 2 hourly Admit

Review by doctor 3 hourly

Note 3

Review at 3H Yes
? Symptom resolution Discharge with
? Normal examination asthma advice
Outpatient appointment

No

Salbutamol nebulisation
Observe 3 H more

Yes
Review at 6H Discharge with
? Symptom resolution asthma advice
? Normal examination Outpatient appointment

No

Admit

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 Observation Ward Protocol for Asthma (ASP)

Note 1
Indication for observation:

1. Acceptable vital signs (SBP >90, SaO2 >95)

2. Alert and orientated
3. PEFR >50% of predicted
4. Patients given 2 nebs and steroids prior to transfer to Observation Ward

Exclusion criteria:

1. Unstable vital signs

2. PEFR < 50% after initial treatment
3. Persistent use of accessory muscles or RR > 40 after initial treatment
4. SaO2 < 95% on room air after initial treatment
5. PCO2 > 45, PO2 < 70 on ABG if it is done
6. Presence of pneumonia

Note 2
Observation intervention

1. Patients can be observed for a maximum of 6 hours

2. Vital signs and PEFR hourly x2, then 2 hourly
3. Intermittent SaO2 monitoring hourly x2, then 2 hourly
4. Review by doctor 3 hourly
5. Bronchodilator nebulisation if indicated.

Note 3
Disposition

1. Patients can be discharged after 3 hours if they have acceptable vital signs, there is
resolution of breathlessness, bronchospasm and accessory muscle usage, PEFR >
75% predicted and SaO2 > 95% on room air. They should be discharged with
medication and advised to see their family practitioners within 72 hours.

2. Patients who do not satisfy these criteria at 3 hours should be treated and observed
at the observation ward for another 3 hours.

3. Patients who have unstable vital signs or whose condition deteriorates should be
admitted.

4. At the end of 6 hours, patients whose PEFR < 75%, RR > 35, or SaO2 < 95% on
room air should be admitted.

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Head Injury Protocol Flowchart
Stable Head Injury

Note 1

Is observation indicated?

Yes
Note 2
Deterioration of
Consciousness level & vital consciousness level at
signs hourly x2, then 2 any time
hourly CT head
Review by doctor 3 hourly Admit
Note 3
? Normal serial
Review at 6H No No
? Symptomatic neurological
examination CT head
Admit
Yes Yes

? Normal serial Discharge

neurological with Head
examination Injury advice

Yes
Observe 3H more

Review at 9H ? Normal serial No

? Symptomatic No CT head
neurological Admit
examination
Yes
Yes
? Normal serial
neurological Discharge
examination with Head
Injury advice
Yes

Observe 3H more

? Normal serial No CT head

Review at 12H
No neurological Admit
? Symptomatic examination

Yes
Yes

Discharge with Head

Admit Injury advice

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 Observation Ward Protocol for Head Injury (HIP)

Note 1
Indication for observation:

1. Hemodynamically stable (SBP >90, SaO2 >92)

2. Normal GCS (unless intoxicated)
3. Headache, dizziness, vomitting, confusion, loss of consciousness, amnesia associated
with HI is acceptable
4. Alcohol or drug intoxication associated with HI
5. Unreliable or inadequate history
6. Patients with bleeding tendencies eg. Anticoagulation, thrombocytopenia
7. Age less than 3 (unless injury is very trivial)
8. Scalp hematoma, laceration, contusion, abrasion, soft tissue facial injury

Exclusion criteria:

1. Unstable vital signs

2. Depressed level of consciousness (GCS <15) not due to intoxication
3. Focal neurologic abnormality
4. Skull fracture
5. Acute psychiatric disorder or suicidal patient

Note 2
Observation intervention

1. All patients should be observed for a minimum of 6 hours and a maximum

of 12 hours.
2. Consciousness level (GCS, pupil size, limb movement) and vital signs (as in A&E
Critical Care Chart 1) hourly for 2 hours, then 2 hourly thereafter
3. Review by doctor 3 hourly

Note 3
Disposition

1. Patients can be discharged at the end of 6 hours if their vital signs are acceptable and serial
neurologic examinations are normal

2. Patients whose GCS deteriorates during observation should have urgent CT scan of the head
and admitted to hospital.

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 Giddiness Flowchart

GIDDINESS

History, examination
Note 1

Antiemetic Note 2
Appropriate intravenous hydration
Diet of choice
Fluids ad lib

Admit
Review at 3H
No
Note 3 Normal examination
Yes Acceptable vital signs
Symptomatic relief Normal laboratory results (if done)
No Able to ambulate and care for self
Partial relief
Able to take oral medication Yes
Re-examine
Admit
Discharge

Normal examination
Acceptable vital signs
No Yes

Alternative antiemetic
Admit
Observe 3H more

Review at 6H Discharge
Yes
Symptomatic relief Admit
No

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 Observation Ward Protocol for Giddiness

Note 1
Indication for Observation

1. Severe giddiness needing parenteral medications

2. Haemodynamically stable (SBP >90, HR <100)
3. Normal neurological examination, including cerebellar and gait examination
4. Exclude postural hypotension
5. Exclude cerebral haemorrhage or infarct, acute myocardial infarction, bleeding
gastrointestinal tract, tachy- or brady- arrhythmia, anaemia, hyper- or hypo-glycaemia
6. Consider laboratory tests: FBC, UECS, cardiac enzymes

Note 2
Observation intervention

1. Antiemetic e.g. i/m stemetil 12.5mg, i/v or i/m metoclopramide 10mg, i/m promethazine
25mg
2. All patients should be observed for a minimum of 3 hours and a maximum of 6 hours
3. Vital signs should be monitored every 2 hourly

Note 3
Disposition

1. Patients whose symptoms persist after 3 hours of observation should be re-examined

carefully. Patients whose symptoms have not improved at all and those whose
physical examination reveals abnormality should be admitted to the relevant medical
department.
2. Patients whose symptoms have improved slightly but not relieved completely can be
treated with alternative antiemetics if required and observed for another 3 hours.
3. Patients whose symptoms are relieved completely can be discharged if
(1) their physical examination and vital signs remain normal,
(2) they have normal laboratory results (if done),
(3) they are able to ambulate and care for self, and
(4) they are able to take oral medication.
4. Patients who are fit for discharge should be given prescription for antiemetic medication
and an appointment to the relevant specialist outpatient clinic.

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 Musculo – Skeletal Pain

MUSCUL0-SKELETAL PAIN

Note 1

Parenteral analgesics Note 2

NSAIDS (if not contraindicated)

Note 3

NSAIDS contraindicated Review at 3H Relieved

Note 4 Discharged

Not relieved

Parenteral opiates
Note 5

Relieved
Review at 6H Discharged

Not relieved

Re-examine
Admit Note 6

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Observation Ward Protocol for Musculo-Skeletal Pain (MSP)

Note 1
Indication for observation:

1. Severe pain needing parenteral analgesics

2. Inability to control pain by oral medications
3. Haemodynamically stable (SBP >90)
4. Normal x-ray (if indicated)
5. Compartment syndrome has been excluded

Note 2

1. Parenteral NSAIDS (e.g. i/m diclofenac 1mg/kg)

2. NSAIDS are contraindicated if patients have previous allergy to NSAIDS, NSAID-
induced asthma, active peptic ulcer disease or renal disease

Note 3
Observation intervention

1. All patients should be observed for a minimum of 3 hours and a maximum of 6 hours
2. Vital signs should be monitored every 2 hourly

Note 4
Disposition

1. Patients whose symptoms persist after 3 hours of observation should be re-

examined. They can be treated with more analgesics (e.g. parenteral opiates) if
required and observed for another 3 hours.
2. Patients can be discharged at the end of 3 hours if their vital signs are acceptable
and their symptoms are relieved. Patients should be able to tolerate pain on oral
medication, ambulate and care for self at home. Discharge the patients with RICE
(Rest, Ice, Compression, Elevation) advice. Patients can be referred for outpatient
physiotherapy.

Note 5

1. Parenteral opiates (e.g. i/m morphine 0.1mg/kg, i/m pethidine 1mg/kg)

2. Reduce dose of opiates for elderly patients and patients with hepatic or renal impairment
(e.g. i/m morphine 0.05mg/kg, i/m pethidine 0.5mg/kg), preferably titrated intravenous
doses with close monitoring of blood pressure and oxygen saturation

Note 6

1. If the patients are still symptomatic at the end of period of observation, they
should be re-examinaed. Fractures and compartment syndrome should be
excluded. They may need to be admitted for further treatment. They should be
referred to orthopaedics doctors for assessment.
2. Patients can be discharged at the end of 6 hours if their vital signs are acceptable
and their symptoms are relieved. Patients should be able to tolerate pain on oral
medication, ambulate and care for self at home. Discharge the patients with RICE
(Rest, Ice, Compression, Elevation) advice. Patients can be referred for outpatient
physiotherapy.

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 Observation Ward Protocol for Hyperglycemia

Indication for observation

1) BSL > 15mmol/dl, < 25mmol/dl

2) Normal FBC, electrolytes and HCO3 (to do ABG if HCO3 < 20 on UEC)
3) Urine ketone –ve (or blood ketone –ve)
4) Readily treatable cause, e.g. non-compliance to medication
5) Clinically well, asymptomatic and hyperglycemia is incidental finding only
6) No acute ischaemic changes on ECG

Exclusion criteria

1) DKA

glucose >14 mmol/L

pH <7.3
HCO3< 15
urine ketones > 2+

2) HHNK

glucose usually >33

effective osmolarity 2(Na+K) + glucose > 320
pH>7.3
HCO3 >15
urine ketones 0-2+

3) BSL > 25 mmol/dl

4) Precipitating cause unknown or not readily treatable
5) Intercurrent illness e.g. infection or other conditions which require inpatient treatment
6) Acute ischaemic changes on ECG
Observation intervention

1) Subcutaneous soluble insulin injection according to sliding scale, titrate to BSL

15-17 mmol/dl: 8u
17.1-19 mmol/dl: 10u
19.1-21 mmol/dl: 12u
21.1-23 mmol/dl: 14u
23.1-25 mmol/dl: 16u

• to give less (half of dose by above regime) for patients who have renal
impairment

2) Check BSL 3 hourly

3) 2 hourly vital signs, viz HR, BP, Resp rate
4) 3 hourly review by doctor and to document clinical findings from Subjective and
Objective assessment
5) Patients should be observed for a minimum of 6 hours and a maximum of 12 hours. If
adequate control not achieved, to admit Endocrinology.
6) Features of adequate control include relief of symptoms, normal vital signs, blood sugar
< 15 mmol/dl, absence of ketonuria.

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Disposition

1) Discharge if:

a) BSL < 15 mmol/dl

b) Resolution of symptoms
c) Stable vital signs
d) Tolerating oral fluid

If for discharge,

i) refer to Diabetes Centre within 3 days

ii) diabetic counselling by nurse educator within a week
iii) adjust diabetic medication or insulin regime

2) Admit if:

a) Worsening symptoms
b) Unstable vital signs
c) BSL uncontrolled, labile, remains > 15mmol/dl
d) Development of DKA
e) Unable to tolerate oral fluid
f) Dehydrated.

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