ED Handbook Jan 2018

January
10th
Edition
2018
DEPARTMENT OF EMERGENCY MEDICINE

CLINICAL & ADMINISTRATIVE
GUIDELINES
Table of Contents
INTRODUCTION...................................................................................................................5
HOW TO USE THIS GUIDEBOOK...................................................................................6
SURVIVING EMERGENCY MEDICINE............................................................................6
CARDIOLOGY.......................................................................................................................7
ACUTE CORONARY SYNDROME (ACS)........................................................................8
ACUTE PULMONARY OEDEMA (APO)/ DECOMPENSATED CCF..............................12
PALPITATIONS................................................................................................................12
DIRECT ADMISSION GUIDELINES FOR CVM VS DIM................................................17
POORLY CONTROLLED HYPERTENSION...................................................................19
CARDIOTHORACIC EMERGENCIES................................................................................22
ENT EMERGENCIES..........................................................................................................24
GASTROINTESTINAL EMERGENCIES.............................................................................29
ABDOMINAL PAIN..........................................................................................................29
BLEEDING GIT...............................................................................................................31
DYSPEPSIA/ GERD........................................................................................................32
HEPATOBILIARY EMERGENCIES.................................................................................32
PANCREATTIS................................................................................................................34
ISCHAEMIC BOWEL......................................................................................................34
ABDOMINAL AORTIC ANEURYSM (AAA).....................................................................34
PROTOCOL FOR MANAGEMENT OF GS CASES IN DEPARTMENT OF EMERGENCY
MEDICINE.......................................................................................................................35
CT PROTOCOL/ WORKFLOW FOR ABD PAIN.............................................................36
HEMATOLOGY AND RHEUMATOLOGY...........................................................................38
ANAEMIA........................................................................................................................38
THROMBOCYTOPENIA.................................................................................................39
MANAGEMENT OF OVER- ANTICOAGULATION WITH WARFARIN...........................40
APPROACH TO SUSPECTED DVT...............................................................................41
GOUT..............................................................................................................................44
METABOLIC & ENDOCRINE..............................................................................................45
HYPERKALEMIA.............................................................................................................45
HYPOKALEMIA...............................................................................................................46
HYPONATREMIA............................................................................................................47
HYPOGLYCEMIA............................................................................................................48
DIABETIC KETOACIDOSIS............................................................................................50
HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS)...................................................51
HYPERTHYROIDISM......................................................................................................52
NEUROLOGY/ NEUROSURGERY.....................................................................................53
CEREBROVASCULAR ACCIDENT................................................................................53
TRANSIENT ISCHAEMIC ATTACK................................................................................54
INTRACRANIAL HEMORRHAGE (ICH).........................................................................55
URGENT CT ANGIOGRAPHY FOR STROKE IN DEM..................................................56
SEIZURES.......................................................................................................................58
HEADACHE.....................................................................................................................59
OBSTETRICS AND GYNAECOLOGY...............................................................................60
CONDITIONS TO BE REFERRED TO O&G FROM ED................................................60
WORKFLOW FOR PREGNANT PATIENTS...................................................................61
EMERGENCY CONTRACEPTION.................................................................................62
ONCOLOGY........................................................................................................................63
FEVER IN ONCOLOGY PATIENTS................................................................................63
2
SPINAL CORD COMPRESSION....................................................................................64
PERICARDIAL EFFUSION.............................................................................................65
HYPERCALCEMIA..........................................................................................................65
SUPERIOR VENA CAVA SYNDROME...........................................................................66
TUMORLYSIS SYNDROME...........................................................................................66
OPHTHALMOLOGY............................................................................................................67
SUBCONJUNCTIVAL HAEMORRHAGE........................................................................67
VIRAL CONJUNCTIVITIS...............................................................................................68
CHALAZION...................................................................................................................68
CORNEAL ABRASION....................................................................................................70
ORTHOPAEDICS................................................................................................................71
UPPER LIMB FRACTURE WITH OR WITHOUT DISLOCATION..................................73
LOWER LIMB FRACTURE WITH OR WITHOUT DISLOCATION.................................79
PHYSIOTHERAPY REFERRALS...................................................................................87
PODIATRY REFERRALS................................................................................................89
BITE WOUNDS PROTOCOL..........................................................................................92
PAEDIATRICS.....................................................................................................................93
RECOGNIZING A SICK CHILD WHO NEEDS TRANSFER TO KKH............................93
WORKFLOW FOR CASES REFERRED FROM SISTER EMERGENCY
DEPARTMENTS TO KKH CHILDREN’S EMERGENCY (CE)........................................96
TREATMENT OF COMMON CONDITIONS IN PAEDIATRIC EMERGENCY MEDICINE
.........................................................................................................................................97
NEONATAL JAUNDICE (GUIDELINES FOR SGH A&E DEPARTMENT)....................100
PALLIATIVE MEDICINE IN THE ED.................................................................................104
PSYCHIATRY....................................................................................................................105
MENTAL HEALTH (CARE AND TREATMENT) ACT (MHCTA)....................................105
WORKFLOW FOR MANAGEMENT OF MENTALLY DISORDERED PATIENTS IN DEM
.......................................................................................................................................106
DISPOSITION OF PSYCHIATRIC PATIENTS IN DEM................................................107
CHEMICAL RESTRAINT IN DEM.................................................................................109
RISK FACTORS TO EVALUATE THE SERIOUSNESS OF A SUICIDE ACT...............110
RENAL...............................................................................................................................112
RESPIRATORY..................................................................................................................113
APPROACH TO PATIENTS PRESENTING WITH SHORTNESS OF BREATH..........113
ASTHMA based on GINA guidelines.............................................................................117
PNEUMOTHORAX WORKFLOW (NON TRAUMATIC)................................................118
COPD............................................................................................................................120
PULMONARY EMBOLISM............................................................................................121
CT PROTOCOL/WORKFLOW for PE...........................................................................124
SEPSIS PATHWAY AND COMMON INFECTIONS..........................................................128
MANAGEMENT OF SEPSIS.........................................................................................128
COMMON INFECTIONS...............................................................................................130
INFECTIOUS DISEASES..................................................................................................133
COMMUNICABLE DISEASES......................................................................................136
MANAGEMENT OF GENITAL ULCERS AND DISCHARGES.....................................137
MANAGEMENT OF EMERGING INFECTIOUS DISEASES........................................138
MANAGEMENT OF RABIES........................................................................................139
TOXICOLOGY...................................................................................................................140
TOXIDROMES..............................................................................................................141
TRAUMA............................................................................................................................142
APPROACH TO TRAUMA............................................................................................142
PAN SCAN CRITERIA / GUIDELINES..........................................................................146
MINOR HEAD INJURY.................................................................................................155
3
ABDOMINAL INJURIES................................................................................................156
CHEST INJURIES.........................................................................................................156
NECK PAIN...................................................................................................................157
BURNS..........................................................................................................................159
UROLOGY.........................................................................................................................161
ACUTE RETENTION OF URINE..................................................................................161
RENAL/URETERIC COLIC...........................................................................................162
UROLOGY WORKFLOW IN DEM................................................................................163
EMERGENCY OBSERVATION WARD (EOW).................................................................166
RESUSCITATION WORKFLOWS.....................................................................................167
INTUBATION WORKFLOW..........................................................................................167
MANAGEMENT OF SEPSIS.........................................................................................169
SEVERE SEPSIS/SEPTIC SHOCK CHECKLIST........................................................170
CARDIAC ARREST AND POST CARDIAC ARREST...................................................171
GUIDELINE FOR ACTIVATION OF CTS FOR ECMO- CPR IN PATIENTS WITH
CARDIAC ARREST IN ED............................................................................................173
MISCELLANEOUS............................................................................................................175
SYNCOPE.....................................................................................................................175
PATIENTS WITH RADIOACTIVE IMPLANTS..............................................................177
NSAIDs PRESCRIPTION GUIDELINES.......................................................................179
ADMINISTRATION............................................................................................................181
CULTURE OF SAFETY AND RISK MANAGEMENT IN DEM......................................181
SUPERVISION, PATIENT FEEDBACK & COMPLAINTS.............................................186
APPROPRIATE ORDERING OF INVESTIGATIONS, RESULT ACKNOWLEDGEMENT
.......................................................................................................................................187
LEAVE, ROSTER, REPORTING SICK, OFF STANDBY..............................................188
MEDICATION ERRORS, CORRECT PATIENT IDENTIFICATION, MEDICAL REPORTS
.......................................................................................................................................191
4
INTRODUCTION
MESSAGE FROM THE HEAD
Welcome to the Department of Emergency Medicine. For the next few months of your
posting, you will be managing a wide range of medical and surgical conditions. To assist
you in your posting, our department has prepared this guidebook to aid you in your daily
interactions and management of patients.
The department is divided into resuscitation, critical care, consultation, fever areas and
the observation ward. Patients are triaged into 4 basic categories; P1, P2, P3 and P4
patients, with P1 being the most critically ill patients, requiring immediate attention, P2
being major emergencies, P3 being minor emergencies and P4 being non-emergencies.
Unlike other disciplines where clinicians spend much time delving into the patient’s
detailed history, physical examination and management, Emergency Medicine is a
specialty where the clinician’s aim is to save or manage as many patients as possible in
a fixed period of time. The practice of emergency medicine is to take focused history,
perform pertinent examination and order investigations relevant to the immediate care
of the patient in order to administer focused treatment and immediate life-saving or limb
saving therapy.
You are expected to fulfill the following during your posting:

At least 12 to 15 P2 cases per shift
At least 18 P3 cases per shift
You will also be assigned to resuscitation shifts with senior doctors to give you an
experience in managing critically ill patients.
Do note that the number of patients you attend to, your clinical skills, test results,
working attitude, attendance at teaching sessions, punctuality and your interaction with
your peers, nursing staff and senior doctors, as well as any medication errors and
patient feedback will be considered during your appraisal.
Each shift has 4 senior doctors for each area in the department except night shifts.
Morning shifts: M1, M2, M2A, M3
Evening shifts: E1, E2 E2A, E3
Night shifts: c, C
If any senior consultation is needed, please contact the specific senior doctor.
You can discharge patients if you deem them suitable for discharge but do consult
seniors when in doubt.
Your roster will be prepared by Dr Tan Tiong Peng and you are to contact him for any
roster issues. Important administration guidelines can be found at the end of the
guidebook.
We trust that you will have an educational and fulfilling posting with us.
Dr Evelyn Wong
Head and Senior Consultant
5
HOW TO USE THIS GUIDEBOOK
This guidebook has been prepared by the senior staff of DEM, with the aim of helping
the junior staff understand the work processes, and as a guide to all things in EM in
general.
We have attempted to cover as much ground as possible, hence this guidebook is NOT
a substitute for your own reading. And while it is updated every 6 months, there is a
need to constantly keep abreast with the latest developments in the medical science.
SURVIVING EMERGENCY MEDICINE
Emergency medicine has traditionally been viewed as a “hardship” posting. Its varied
set of patients and shift work are factors that make it difficult for junior doctors to adapt
to. However it can be one that is enjoyable and where much can be learnt. Bearing
these in mind, here are some ways to make the posting more bearable:
1. Do not over investigate. They cost patients money and results take time to come out.
As a general rule of thumb, any investigation that takes more than 2 hours to be
completed should not be ordered in the ED.
2. Update relatives. They are naturally anxious and have to wait outside the
department not knowing how their loved ones are doing. A simply phone call or bringing
them to the bedside to see the patients and to give a rough plan of management is often
enough to reassure them.
3. Get enough R&R. Watch a movie, exercise and get enough sleep in between shifts
to de-stress. And there’s always post shift supper or breakfast to catch up with each
other!
4. Aim to learn. We all have different backgrounds, and so will take away different
learning points from our postings. But no matter your learning objectives, your posting
will only fulfilling if it helps you grow as a doctor.
6
CARDIOLOGY
(A/P Lim Swee Han / Dr Sohil Pothiawala)
APPROACH TO CHEST PAIN
A. Life threatening Causes B. Other Important Causes
1. Acute Coronary syndrome 1. Cardio-vascular

2. Aortic Dissection - Stable Angina
3. Pulmonary Embolism - Pericarditis/Myocarditis
4. Tension Pneumothorax 2. Respiratory
5. Esophageal rupture - Simple pneumothorax
- Pneumonia
3. Gastrointestinal
- GERD/Gastritis
- Acute mediastinitis
- Esophageal spasm
4. Others
- MSK pain eg. rib fracture
- Costochondritis
Suggested Workflow
Chest pain
Typical Atypical
Normal ECG OR
Risk factors present Risk factors absent
ECG with ST ECG with ST
with normal or with normal or
elevation depression or new
baseline ECG baseline ECG
deep T inversions
NSTEMI / UAP -
CPP and / or rule
STEMI - activate Consult senior
CPP with MIBI out other causes of
cath lab for PCI doctor and refer to
chest pain
CVM
7
ACUTE CORONARY SYNDROME (ACS)
Symptoms and signs Management
STEMI (ST-elevation MI) Uptriage to P1

Monitor, supplemental O2
Chest pain ECG stat and repeat if necessary
Radiation to arm/shoulder/jaw/neck Activate CVL lab after consulting senior
SOB doctor
Lasting > 10 mins Take consent for PCI
Diaphoresis FBC, U/E, Trop T, PT/PTT, GXM
Giddiness (CK, CKMB are not necessary)
CXR
NHC PCI activation ECG criteria: S/L GTN v/s IV GTN, IV morphine
- >2mm ST elevation in anterior (Note: Avoid GTN in RV infarct)
leads for two or more anatomically
contiguous leads
- >1mm ST elevation in inferior leads LOAD:
for two or more contiguous leads
- ST elevation in II, III, aVF less than 1. Aspirin 300mg PO stat
1mm with ST depression in aVL
- De Winter T waves – Tall AND
symmetrical T waves with up-sloping
ST depression seen in leads V2-6 2. Ticagrelor 180mg PO stat
- New infarct Q waves in ≥ 2
adjacent leads Or if C/I for Ticagrelor: ventricular
- Posterior infarction – ST pauses > 3 seconds, then
depression ≥ 1mm over either V1,
V2, V3 and ST elevation ≥ 1mm in 3. Clopidogrel (Plavix) 600mg PO instead
either V7, V8, V9
- Wide spread ST depression (≥2
areas) and ST elevation ≥1mm over Admit CCU
aVR
Refer to Sgarbossa Criteria to detect

AMI in presence of LBBB
Note: Right-sided chest pain may not

be atypical
8
PCI Inclusion Criteria in SGH (from March 2016 onwards)
ECG Criteria:
 2mm ST elevation in anterior leads for two or more contiguous leads
  1mm ST elevation in inferior leads for two or more contiguous leads
 ST elevation in II, II, aVF less than 1 mm with ST depression in aVL
 De Winter T waves - Tall symmetrical T waves with up-sloping ST depression seen
in leads V2-V6
 New infarct Q waves in ≥ 2 adjacent leads
 Posterior infarction ST depression ≥ 1 mm over either V1, V2, or V3 and ST
elevation ≥ 1 mm in either V7, V8 or V9
 Wide spread ST depression (≥ 2 areas) and ST elevation ≥ 1 mm over aVR
AND
 Symptom Onset < 12 hours ago or the patient is still in pain at ED
Exclusion Criteria (Refer CVM stat if any present)

 Age  80 years old
 Poor premorbid status (bed bound / wheelchair bound)
 Collapse / comatose / semi-conscious states
 Heparin-Induced Thrombocytopenia (HIT)
 Risk of active bleeding (GI bleeding, traumatic head injury)
 Contrast allergy
What Constitutes Informed Consent by A&E
Summary of information need to convey to and discuss with patient before signing the
informed consent:
1. Explain the cause of AMI
2. Explain the mortality and morbidity risk of AMI
3. Emphasize the need to recannalize the artery as soon as possible
4. Explain two treatment strategies for AMI: thrombolytic therapy vs. primary PCI
5. Explain why primary PCI is better in terms of efficacy and safety
NSTEMI (non ST-elevation MI)

9
Uptriage to P1
Hx similar as above Monitor, supplemental O2
Reduced effort tolerance ECG stat and repeat if necessary
Relieved with rest or use of s/l GTN FBC, U/E, Trop T, CKMB, PT/PTT,
GXM, CXR
ECG shows ST-T changes but no ST S/L GTN v/s IV GTN, IV morphine
elevation Aspirin 300mg PO stat
Plavix 300mg PO stat
Elevated cardiac enzymes s/c Clexane 1mg/kg 12 hrly
Call CVM to admit HD (refer to checklist
below for high risk NSTEMI criteria and
management)
Unstable Angina Pectoris (UAP) Supplemental O2

ECG stat and repeat if necessary
Hx similar as above FBC, U/E, Trop T, CKMB, PT/PTT,
GXM
Angina Equivalents: CXR
- Exertional SOB S/L GTN v/s IV GTN v/s GTN patch,
- Exertional pain in KIV IV morphine
jaw/neck/arm/shoulder/epigastrium Aspirin 300mg PO
- diaphoresis Refer CVM to admit HD if needs IV
- fatigue GTN
CHECKLIST FOR HIGH RISK NSTE-ACS (Refer CVM stat if any present)
 Load Aspirin + Ticagrelor in place of Clopidogrel if no contraindications
Inclusion Criteria
I. STEMI not for direct activation of PCI by DEM
e.g. New infarct Q waves in ≥ 2 adjacent leads and Symptom Onset
> 12 hours ago and the patient is not in pain
II. NSTEMI and

a) VF or VT
b) Persistent refractory or recurrent angina
c) ST depression ≥ 1 mm in 2 adjacent leads
d) Clinical symptoms of heart failure
e) Haemodynamic instability (Cardiogenic shock)
f) Patient already on Clopidogrel
g) TIMI score ≥ 4 (P.T.O)
Exclusion Criteria
1. Significant Co-morbidities:
Poor premorbid status (bed-bound / wheelchair bound)
Comatose / semi-conscious states
2. Contraindications to Heparinsation or Anti-Platelet Therapy:
Heparin-Induced Thrombocytopenia (HIT)
Risk of active bleeding (GI bleeding, traumatic head injury)
3. Contrast allergy
TIMI Score
Use: Estimates mortality for patients with unstable angina and non-ST elevation MI.
10
Valu Point
Criteria
e s 14 day risk of all-cause
mortality, new or recurrent
Age ≥ 65 Yes +1 MI, or severe recurrent
ischemia requiring urgent
revascularization
≥ 3 CAD risk factors Yes +1
Known CAD (Stenosis ≥ 50%) Yes +1 0 to 1 score is 5%

2 score is 8%
Aspirin use in past 7 days Yes +1 3 score is 13%
4 score is 20%
5 score is 26%
Severe angina (≥2 episodes in 24 6 to 7 score is 41%
Yes +1
hours)
ECG ST changes ≥ 0.5mm Yes +1
Positive cardiac marker Yes +1
Risk factors for CAD : Family history of CAD, Hypertension, Hypercholesterolemia,

Diabetes, or Current Smoker
11
ACUTE PULMONARY OEDEMA (APO)/ DECOMPENSATED CCF
Moderate to severe SOB Uptriage to P1

Orthopnoea/PND Monitor, supplemental O2
Diaphoresis FBC, U/E, Trop T, CKMB, Pro-BNP,
Chest pain/discomfort PT/PTT, GXM
Palpitations ECG, CXR
IV GTN infusion (up to 300mcg/min)
O/e: tachycardic, IV frusemide
hypertension/hypotension, raised JVP, KIV IV morphine 1-2mg
lung crepitations, wheeze, pedal edema Non Invasive Ventilation (NIV) Consider
+/- Intubation
IV Digoxin/amiodarone to control fast AF
Inotropes if hypotensive
ODD CVM for HD/CCU admission
PALPITATIONS
No CAD risk factors, NSR or occasional FBC, U/E, ECG, FT4, TSH
PVC/PAC, WPW, no prolonged QTc, no
Brugada pattern, no FHx of sudden death Observe in telemetry x 3 hours
or cardiac dysrhythmias
If bloods normal and patient
asymptomatic, discharge with TCU CVM
arrhythmia clinic 1-2/52
+/- chest pain +/- CAD Risk factors +/- FBC, U/E, ECG, Trop T, FT4, TSH
frequent PVC/PAC/bigeminy
Admit EOW under CPP
review telemetry recording
If CPP uneventful, discharge with TCU

CVM arrhythmia clinic 1-2/52
If elevated cardiac enzymes during CPP,

admit CVM
Hx of syncope FBC, U/E, ECG, Trop T, CXR

Family hx of Sudden death
ECG shows Brugada pattern Refer CVM stat
ECG shows non-sustained VT/salvos
12
Narrow Complex Tachycardia – Specific Management
Sinus tachycardia Management
FBC, U/E, ECG

Rule out fever/dehydration/bleeding FT4, TSH (if clinical suspicion of
GIT/PE/thyrotoxicosis/recreational drug thyrotoxicosis)
use/occult bleed
IV hydration
PO paracetamol if fever
Check postural BP
If bloods normal and tachycardia

resolves, discharge
Supraventricular tachycardia Management
ECG
AVNRT – commonest No need to do bloods unless clinically
AVRT – eg WPW indicated (1st presentation in Elderly with
CAD risk factors)
Uptriage to P1
Monitoring, O2
Proximal IV access
Patient stable
Vagal maneuvers:
Valsalva
carotid sinus massage (C/I in
elderly/carotid bruit)
No response
IV Calcium channel blockers eg.

Diltiazem 50mg or verapamil 20mg
infusion over 20 minutes
No response
IV adenosine 6mg rapid bolus with 20cc

IV NS flush
If no response, can repeat IV adenosine

12mg x 2 times
Patient unstable
IV adenosine 6mg bolus

If no response, can repeat IV adenosine
12mg x 2 times
13
Synchronized cardioversion 50J
If NSR, observe in telemetry x 3 hours.

Discharge with TCU CVM arrhythmia
clinic 1/52
Advice to avoid caffeinated products
If persistent SVT, ODD CVM for

admission
Atrial Fibrillation Management
Rate controlled Observe in telemetry x 3 hours

No other complaints
Assess CHADS-VASC score and
commence on Aspirin if indicated
Advice to continue aspirin/warfarin if

patient already on it
TCU CVM arrhythmia clinic

Consider admitting to AF EOW
FBC, U/E, ECG, CXR

Rapid ventricular rate without CCF FT4, TSH (only if 1st presentation of AF)
(ventricular rate > 130/min) Trop T if patient suspected of associated
ACS
Digoxin level if pt on it
PT/INR if pt on warfarin
Uptriage to P1
Monitoring, O2
Patient stable
IV Calcium channel blockers eg.

Diltiazem 50mg infusion over 1hour AF
protocol
Consider admitting to AF EOW
Patient unstable
IV heparin 18 IU/kg pre-shock
Synchronized cardioversion
Atrial Fibrillation 100 – 200 J
Atrial Flutter 50J
Anticoagulation with IV heparin
infusion/LMWH/warfarin after shock
ODD CVM for admission to HD
14
Rapid ventricular rate with CCF IV amiodarone 150mg over 30 minutes.
Can repeat dose if needed
KIV IV digoxin 250 mcg over 30 minutes

after CVM consult
IV frusemide
GTN patch or IV
ODD CVM for admission to HD
Others Management
Narrow complex tachycardia with See “Thyrotoxicosis”

abnormal thyroid function tests
Wide complex tachycardia Follow ACLS protocols

- VT/VF
15
CHA2DS2-VASc Score for stroke risk stratification in AF patients
Criteria Value Points
<65 0
Age 65-74 +1
≥ 75 +2
Sex Male 0
Female +1
Congestive Heart Failure History Yes +1
Hypertension History Yes +1
Stroke/TIA/Thromboembolism History Yes +2
Vascular Disease History Yes +1
Diabetes Mellitus History Yes +1
0 score is "low" risk and may not require anticoagulation.
1 score is "low-moderate" risk and should consider antiplatelet or anticoagulation*.
2 or greater is "moderate-high" risk and should otherwise be an anticoagulation*

candidate.
*Carefully consider all the risks and benefits prior to initiating anticoagulation in
patients
16
DIRECT ADMISSION GUIDELINES FOR CVM VS DIM
CVM (GW) with telemetry if available DIM CVM review at ED* Chest Pain
Protocol ± MIBI
Heart Failure Heart Failure with Requirement for

-Uncomplicated -obvious pneumonia HD/CCU
-severe anemia Heart Failure with
-chronic renal failure hemodynamic
-Sepsis instability
-Other non- cardiac outstanding
problems
Unstable Angina Atypical chest pain Requirement for Atypical Chest
-Chest pain resolved -with other non-cardiac HD/CCU pain
-Trop T negative outstanding issues/ potential NSTEMI Known IHD with
-No severe ischemic changes on ECG concerns -if straightforward can admit stable angina
Stable angina Angina/ACS but not suitable after phone consult -with no other
for coronary intervention STEMI (activation) outstanding issues
-eg age >80 years, bed bound, High risk ACS with requiring DIM
uncommunicative) consideration for management
urgent cath
SVT resistant to cardioversion Secondary rhythm disorders Requirement for
AF with rapid ventricular rate -AF from thyrotoxicosis/Sepsis - HD/CCU
-but rate stabilized in ED with no other rate control in ED first Infrahisian 2nd/3rd
significant outstanding issues Bradyarrhythmic conditions degree heart block
Sick sinus with symptomatic where conservative where pacing is
bradycardia management has been considered
decided upon with other
outstanding non cardiac
problems
-patients choice
-Poor premorbid
Symptomatic/complicated valvular Valvular heart disease with
heart disease non- cardiac outstanding
problems
Pericarditis, myocarditis
Adult congenital heart ACHD cases with

disease cases with 1) single medical/surgical issues
ventricle 2)fontan correction with NO single ventricle,
3)Eisenmengers syndrome fontans, Eisenmengers
4)Cyanotic congential heart syndrome, cyanotic
disease congenital heart disease.
-With NON-SURGICAL medical
issues requiring admission
(need not be cardiac)
* When in doubt consult CVM
18
POORLY CONTROLLED HYPERTENSION
(Dr Fua Tzay-Ping)
Definition: BP 140/90 mmHg or higher. No absolute BP defines a hypertensive crises, but

diastolic BP in range of 120-130mmHg may be used as a guide
Hypertensive emergency: elevated BP assoc with acute or on-going end-organ

dysfunction or damage
Hypertensive urgency: elevated BP assoc with imminent end-organ dysfunction or

damage. Severe hypertension in an otherwise relatively asymptomatic patient is usually
described as urgency
Important history
-known hypertensive? (to check HIDS/emrx for f/u and meds records -> MUST!)
->On meds and what meds? Recent adjustments?
->On follow-up with?
->Compliance issues. Defaulted meds for how long and what reasons?
-symptoms to look out for: chest pain/SOB/leg

swelling/headache/giddiness/nausea/vomiting/blurring of vision/altered mental
state/weakness/numbness, possibility of pregnancy in female of reproductive age
-newly diagnosed? Any other reasons for raised BP like pain, anxiety (white coat) or
discomfort?
-family history? other co-morbidities? possible drug or stimulant overdose?
Important physical examination
Repeat BP using a manual sphygmomanometer
To do manual BP bilaterally if not contraindicated i.e. Post mastectomy or dialysis patients
Check for correct cuff size
To repeat BP later if other causes like pain or discomfort is treated or if patient is otherwise
asymptomatic
Look out for end organ damage: fundoscopy, neurological exam to look out for focal
deficits, altered mental state, cardiovascular exam for LVF, new AR murmur, pedal edema,
pulses for evidence of aortic dissection
*To do postural BP in elderly patients

Relevant Inxs
ECG/CXR/UC9/FBC/UECr
Urine HCG in females who may be pregnant
Cardiac enzymes, CT thorax or CT head only if indicated –> will require senior Dr input
and review
ED management
!! Never treat the patient on a single BP measurement alone. Overzealous correction of BP

may result in CVA or AMI
!! Avoid S/L calcium channel blockers! Absorption is unpredictable and BP may drop too
fast
-If hypertensive emergency is diagnosed, to inform senior Dr stat KIV uptriage to CC/resus
KIV start IV meds and further inxs and mx
-If hypertensive urgency is diagnosed, to inform senior Dr re: EOW hypertensive protocol
(to refer to existing EOW hypertension protocol re: inclusion and exclusion criteria)
-Initial treatment in known but otherwise asymptomatic hypertensive:
->to serve the patient’s own meds (from existing records) if defaulted and obs 2-4hrs
vs. EOW (to consult senior Dr)
->if meds not known, to serve PO nifedipine 5mg or 10mg if no contraindications and
titrated to patient’s serial hourly BP readings and obs 2-4hrs vs. EOW (to consult
senior Dr). For elderly patients, important to note not to drop BP too drastically or too
fast.
-Initial treatment in ?newly diagnosed hypertensive:
->to treat other possible underlying causes of raised BP first like pain or discomfort
and to repeat BP later when feeling better usually 2-4hrs later
->if serial hrly BP readings persistently high despite observation, rest and otherwise
asymptomatic, for PO nifedipine 5mg or 10mg if no contraindications and titrated to
patient’s serial BP readings during obs KIV EOW (to consult senior Dr)
Disposition (if not admitted to EOW or ward)
If BP controlled after short period of observation and patient otherwise asymptomatic with
no abnormal inxs, good social support and no compliance issues:
20
-in known hypertensive:
->dc with memo to GP/OPD for follow-up within 2-3days and to prescribe patient’s
usual meds if defaulted or increase dose of existing drug or add on another agent if no
contraindications in a compliant pt. Do not prescribe meds for more than 1 week.
-in newly diagnosed hypertensive:
->dc with memo to GP/OPD or family med clinic for follow-up within 2-3 days to re-
check BP
->can consider starting any of the 5 main classes of drugs (diuretics, b-blockers,
Calcium channel blockers, ACE-i, ATII blockers) as initial therapy in hypertensive
patients who do not have any compelling indications or contraindications especially if
mod to high risk profile patients with no other causes of raised BP found
**to reinforce importance of compliance and lifestyle modification before dc**
21
CARDIOTHORACIC EMERGENCIES
(Dr Kenneth Tan)
AORTIC DISSECTION
Sudden onset tearing chest pain Uptriage to P1

Pain maximum at onset Monitor, supplemental O2
Radiates to back esp interscapular FBC, U/E, PT/PTT, GXM
Diaphoretic and distressed d-dimer, lactate after discussion with
Restless senior doctor
Abdominal pain ECG, CXR
Occ only back pain Ultrasound – pericardial effusion, aortic
Syncope flap
Stroke/weakness both lower limbs Arrange for CT Aortogram
IV morphine
Normotensive/Hypertensive/ Control BP with IV labetalol 50mg/hr
hypotensive infusion (maintain SBP 110-120mm Hg)
Pulse deficits
Differential BP in both ULs CTS ODD stat for admission and
definitive repair
Note: CT Aortogram may show Type A

or Type B aortic dissection
For “AORTIC ANEURYSM”, see “ABDOMINAL PAIN”.
22
CT PROTOCOL AND WORKFLOW FOR AORTIC DISSECTION
23
ENT EMERGENCIES
(Dr Oh Jen Jen)
FB throat
Initial Management Refer ENT MO on call when:

 Inspect tonsillar region with light and  Suspected FB throat requiring IDL /
tongue depressor and remove FB if seen. flexiscope evaluation +/- removal (if
 If FB absent, order lateral neck X-ray and DEM doctor unable to do so).
ODD ENT.
 IDL / flexible nasopharyngoscopy to be
attempted only by experienced doctors.
 If all of the above are normal: TCU ENT
clinic x 1-2/7, provided:
1) patient is comfortable,
2) has minimal discomfort and is
able to swallow,
3) has no fever /haemetemesis
 If fit for discharge, prescribe lozenges
and thymol gargle; consider adding
Augmentin if any significant ulcers/abrasions
seen
 Give FB advice: to return stat if pain
increases, develops fever/chest pain, or if
haemoptysis occurs.
FB ear
Initial Management Refer ENT MO on call when :

 Insect FB: instill 1% lignocaine /olive oil  Initial attempt fails to remove FB.
to drown insect.  FB is a battery.
 Syringing is not a recommended method  Refer pediatric FBs to ENT MO
for removing FBs of the ear. stat.
 Attempt FB removal once.
If successful :
 Home with antibiotic ear drops if external
ear canal abraded.
 TCU ENT clinic x 1/52
24
FB nose

 Attempt removal of FB once.  Initial attempt fails to remove FB.
 Home with no TCU if nasal mucosa  If FB is a battery, refer ENT MO
healthy and no evidence of sinusitis. even if successfully removed to assess
mucosa damage and for irrigation.
If successful:  Refer pediatric FBs to ENT MO
 Home with Augmentin x 2 weeks if stat.
sinusitis of mucosal trauma evident, TCU
ENT clinic x 1/52.
Ear Wax

 Impacted ear wax is not a medical  Call ENT MO if there is clinical
emergency. suspicion of malignant otitis externa,
 Prescribe olive oil 2 drops qds x 1/52. i.e. elderly/ diabetic/
 Explain that ear wax must be softened to immunocompromised (or if there is
allow suction removal severe otalgia)
 TCU ENT clinic x 1/52
Epistaxis

 Stabilise patient haemodynamically if  If bleeding persists:
necessary with IV fluids.  Prepare merocel packs 10cm
 Sit patient up. x 4, tetracycline cream for
 Spray co-phenylcaine (obtain from ENT anticipated nasal packing.
room) generously into both nostrils.  Stand by Foley’s catheter
 Pinch nostrils between finger and thumb size Fr12 or 14 for posterior nasal
x 10 mins. packing.
 Apply ice packs to nose bridge area.
 Ice-cold gargle (do not swallow) Refer ENT MO regardless if:
intermittently.  epistaxis prolonged
 Inform patient to open mouth and let  repeat visit
blood flow freely from mouth into receptacle  recurrent epistaxis
(discourage swallowing of blood).  sigf drop in Hb
 Check Hb/FBC if significant volume loss;  recent nasal surgery
consider PT/PTT, GXM.
 Monitor haemodynamic status. Caution in patients with h/o NPC
 If bleeding ceases: monitor patient for who present with epistaxis,
rebleed x1 hour, discharge if no further especially if known to have CA
bleeding. recurrence.
 may be sentinel bleed
heralding possible
25
carotid artery blowout.
 consider consulting ENT MO
as such cases may require
admission.
Adult Otorrhea
Initial management Call ENT MO on call if :

 Look for likely causes: CSOM,  High fever.
otitis externa.  LMN 7th nerve palsy.
 Treat with topical antibiotics i.e.  Signs of intracranial involvement. .
ciprofloxacin/ofloxacin 3 drops TDS  Signs of mastoiditis present.
if TM not intact; sofradex 3 drops tds
if TM intact x 2/52. Sofradex avoided
if TM perforation noted due to
possible ototoxicity.
 Add oral antibiotics only in
serious infections.
 TCU ENT x 1/52.
 Instruct to keep ear dry.
Traumatic TM perforation
Initial Management
 Symptomatic Rx.
 Do not prescribe ear drops.
 Keep ear dry.
 TCU ENT x 1/7 if labyrinthine
injury suspected (i.e. hearing
loss/vertigo).
 Otherwise, can TCU ENT x 1/52.
Sudden unilateral sensorineural hearing loss
Initial Management
 Perform otoscopy to exclude  Refer Neurology if focal neurological
possible conductive hearing loss and deficit present.
perform neurological examination.
 Confirm sensorineural hearing
loss with Weber’s and Rinne’s test
If no obvious cause is found:

 Ensure no contraindications to
pulse steroids ie Hep B/Hep C,
bleeding GI history, uncontrolled
DM/hypertension
26
 Prescribe prednisolone 1mg/kg
up to 60mg OM. Recommended
tailing regimen as follows: 60mg OM
x 5 days; 50mg OM x 4 days, 40mg
OM x 3 days, 20mg OM x 2 days for
a total of 14 days.
 Steroid efficacy best if given
within 4-6 weeks of onset of SSNHL
 TCU ENT next working day for
audiogram.
27
Bell’s Palsy
Initial Management
 Exclude other causes of facial  Refer neurology for atypical
paralysis. presentation of Bell’s palsy i.e. other
 Document degree of eye neurological sign found/atypical
closure/facial deformity at rest and history
on attempted movement.
 Ensure no contraindications to
pulse steroids ie Hep B/Hep C,
bleeding GI history, uncontrolled
DM/hypertension
 Prescribe prednisolone 1mg/kg
up to 60mg OM. Recommended
tailing regimen as follows: 60mg OM
x 5 days; 50mg OM x 4 days, 40mg
OM x 3 days, 20mg OM x 2 days for
a total of 14 days.
 Eye care: lubricating artificial
tears / eyeshields /night time taping
of lids if needed
 TCU ENT clinic x 3/7.
Vertigo
Initial management Refer ENT MO on call if :

 Ascertain type of dizziness.  Cases of severe vertigo
 Neurological and ear requiring admission should be sent
examination. to neurology for exclusion of central
 Postural BP (potentially life-threatening)
 Drug history pathology.
 ECG, FBC and U/E/Cr if  However, if patient is on follow-
indicated. up with ENT for vertigo which has
 IM stemetil and bed rest, been previously investigated,
observe x 1-2 hours. consider consulting ENT MO for
 Refer ENT clinic x 1/52 if patient admission.
well enough for discharge.  Consider admission to
Giddiness Co-ordinated Care
Pathway.
Nasal trauma /fracture
Initial Management Refer ENT MO on call if :

 Examine for septal haematoma /  Complications such as septal
CSF leak / epistaxis. haematoma/ CSF leak / persistent
 Order nasal view x-rays, epistaxis present.
especially if there are medicolegal
issues.
 Order facial views if associated
28
injuries suspected, KIV refer plastics
accordingly.
 Note any nasal obstruction and
deformities in case notes.
 TCU ENT clinic x 5/7 post injury
for consideration of manipulation
and reduction
Lacerations ear/nose
Initial Management Call ENT MO on call if :

 Attempt T&S if simple  Complex injuries: avulsions,
lacerations. exposed cartilage, through-and-
 IM ATT through lacerations.
 Oral antibiotics in contaminated
wounds.
 TCU ENT clinic x 5/7 for STO
Tonsillitis

 Prescribe antibiotics, lozenges,  Patient is dehydrated and
analgesics x 10/7 cannot swallow.
 TCU ENT x 2-3/52  Patient has prolonged fever.
 Patient has severe pain / trismus
Antibiotic choices: on oral examination which is out of
proportion to symptoms (possible
 Augmentin quinsy).
 If allergic to penicillin:
- Erythromycin / EES
- Klacid
- Ciprofloxacin
- Bactrim
Sinusitis

 Prescribe antibiotics ( refer  Orbital complications (refer eye
above list ) x 14/7 for immediate assessment 1st)
 Prescribe decongestants  Facial osteomyelitis
(oxymetazoline x 5/7 )  Intracranial extension present
 TCU ENT x 14/7
Original guidelines prepared by Dr Ian Loh (ENT) & Dr Oh Jen Jen (DEM), vetted by
A/Prof Christopher Goh (ENT) & A/Prof Lim Swee Han (DEM)
29
Jan 2018 version updated by ENT Dr Barrie Tan and Dr Shaun Loh.
30
GASTROINTESTINAL EMERGENCIES
(Dr Annitha / Dr Jeremy Wee / Dr Sohil Pothiwala/ Dr Faraz)
We acknowledge the input of Dr Lim Chee Hooi (Gastro) for the Jan 2017 edition of this
chapter.
ABDOMINAL PAIN
Minimum documentation for patients presenting with abdominal pain
History
Pain:
Onset
Severity
Position and radiation
Character
Other symptoms:
Nausea or Vomiting
Altered bowel habit
Haematuria / Dysuria
Testicular pain or lump
LMP
Menorrhagia / Dysmenorrhoea
PV bleed, discharge, dyspareunia
Any significant past medical / surgical history
Examination
Vital signs:
Pulse / BP / RR / Glucose / Temp
Positive findings on physical examination
Diagnosis or differential
Investigations
All female patients of reproductive age with abdominal pain must a UPT
done
Treatment given
Referral time and arrangement
If discharged
Advice to patient
Instructions for GP
31
RIF pain Consider differential diagnosis:

Male: Acute appendicitis, renal colic,
Associated symptoms: nausea, UTI/pyelonephritis, peritonitis,
vomiting, dysuria, PV bleed/discharge perforated viscus, rupture AAA in
elderly
Female: all of above, ovarian
cyst/torsion, endometritis, Ectopic or
abortion in pregnancy
NBM
FBC, U/E, LFT, Amylase, CXR, ECG
UC9
UPT for all females in reproductive age
group
Ultrasound
IM/IV buscopan, opioids
IV NS
Admit GS unless high likelihood of
Gynae cause in females
ODD urology if pyonephrosis
LIF pain Consider above differentials

Diverticular disease in elderly
Associated symptoms: nausea, NBM
vomiting, dysuria, PV bleed/discharge, FBC, U/E, UC9
PR bleed UPT for all females in reproductive age
group
Blood cultures if diverticulitis
CXR, ECG
Ultrasound
IM/IV buscopan, opioids
IV ceftriaxone 1gm and IV
metronidazole 500mg in diverticulitis
Admit CLR if diverticulitis suspected
Constipation Do PR examination
Impacted stools – Dulcolax suppository
Need to rule out IO x2
Fleet enema x 2
Observe at least 3 hours.
Discharge if well with senna tablets and
syrup lactulose
If persistent constipation, do FBC, U/E,
AXR, admit CLR
32
BLEEDING GIT

If unstable vital signs, uptriage to P1
Upper GIT bleed NBM
FBC, U/E, GXM. PT/PTT, CXR
LFT if patient jaundiced
NG tube (if not variceal)
IV N/S, IV E-blood
IV omeprazole 80 mg
Consider infusion 8mg/hr
Consider early rv by GS Reg
Confirm past hx of variceal bleed/portal

Esophageal Varices hypertension
FBC, U/E, GXM. PT/PTT, LFT, CXR
IV N/S, IV E-blood
IV omeprazole 80 mg
IV somatostatin 250 microgram bolus,
followed by infusion of 250 microgram
per hour
Sengstaken-Blackmore tube if
exsanguinating hemorrhage after
discussion with DEM senior doctor
If unstable vital signs, uptriage to P1.

Lower GIT bleed NBM
FBC, U/E, GXM. PT/PTT, CXR
IV N/S, IV E-blood
Admit colorectal GW (stable)
Call colorectal Reg for HD if unstable
vital signs, profuse bleed
Normal PR exam
? BGIT [c/o Black stools] Normal abdominal examination
Stable vital signs
No postural BP drop
Normal Hb/FBC
Discharge with omeprazole 20mg BD
till TCU
TCU GS SOC (Call reg for early TCU)
Hemorrhoids on proctoscopic
PR bleeding (Hx of small amount of PR examination with no active bleeding
bleed with nil active bleeding) Stable Vitals with no postural drop
Stable Hemoglobin
Discharge with Tab Daflon 2 BD x 1
week and TCU Colorectal 1-2/7
33
DYSPEPSIA/ GERD
Mild to moderate symptoms IV or IM Buscopan 40mg

Oral H2 blockers eg. famotidine 20mg
Epigastric pain Magnesium trisilicate 30ml
Burping Consult senior for abdominal pain
Nausea/vomiting protocol if pain persists
Poor appetite Discharge with famotidine or
omeprazole and MMT and abdominal
Exclude life-threatening causes: Eg pain advise
AMI, perforated ulcer, pancreatitis, Memo to OPS for young patients and
aortic dissection, ruptured AAA, acute patient with infrequent symptoms
abdomen Consider TCU Gastro if recurrent
symptoms
Discharge with MMT 10mls TDS/PRN,
Omeprazole 20mg BD
Severe symptoms FBC, U/E, GXM. PT/PTT, CXR (erect)

ECG
Exclude life-threatening causes: Eg LFT if patient jaundiced
AMI, perforated ulcer, pancreatitis, Ultrasound to look for gall stones, AAA
aortic dissection, ruptured AAA, acute IV omeprazole 40 mg
abdomen Consult senior for EOW versus
gastro/GS admission
HEPATOBILIARY EMERGENCIES
Biliary Colic NBM

FBC, U/E, LFT, Amylase, CXR, ECG
Epigastric or RHC pain Ultrasound
Radiates to back Buscopan 40mg IM/IV
Worse after meals IM pethidine 50-75mg
Associated bloatedness, nausea,
vomiting If pain persistent, for admission to EOW
for abdominal pain protocol
KIV discharge with buscopan,

famotidine and TCU GS if pain free and
normal blood tests.
If blood tests abnormal, KIV consult

senior dr.
34
Acute Cholecystitis
NBM
Epigastric or RHC tendneress FBC, U/E, LFT, Amylase, Blood cultures
Murphy’s sign CXR, ECG
Ultrasound
Buscopan 40mg IM/IV
IM pethidine 50-75mg
metronidazole 500mg
Consult DEM Snr Dr for GS admission
Cholangitis If unstable vital signs, uptriage to P1.

NBM
Charcot’s Triad: RHC pain + fever + FBC, U/E, LFT, Amylase, GXM. PT/PTT,
obstructive jaundice Blood cultures
CXR, ECG
IV N/S
buscopan 40mg IM/IV
metronidazole 500mg
Inotropes if septic shock
to HD/ICU
Hepatic encephalopathy
Liver disease with altered mental state Triage to P1

Signs of chronic liver disease: spider NBM
naevi, hepatic flap, gynecomastia Blood sugar
FBC, U/E, LFT, amylase, GXM, PT/PTT,
Blood cultures
CXR, ECG
KIV CT Brain
IV N/S
IV dextrose 50% 40mls for
hypoglycemia
IV thiamine 100mg if alcoholic liver
cirrhosis
NGT insertion (if no history of varices)
Lactulose 30ml PO/NG or lactulose
enema
IV omeprazole 40mg
Broad spectrum antibiotics
Admit gastroenterology and call Med R1
for HD/ICU
35
PANCREATTIS
Epigastric or upper abdominal pain NBM

Radiates to back FBC, U/E, LFT, Amylase, Lipase,
Nausea/vomiting PT/PTT, GXM
fever CXR, ECG
Ultrasound
IV NS
IV omeprazole 40 mg
ISCHAEMIC BOWEL
abdominal pain out of proportion to NBM

physical findings FBC, U/E, LFT, Amylase, lactate,
+/- PR bleed PT/PTT, GXM
Atrial fibrillation on exmn and ECG ABG, CXR, ECG
Diabetics are at higher risk Ultrasound
IV NS
IV ceftriaxone 1gm and metronidazole
500mg
Urinary catheterization
ABDOMINAL AORTIC ANEURYSM (AAA)
Ruptured AAA Uptriage to P1

Monitor, supplemental O2
Abdominal mass, often pulsatile FBC, U/E, PT/PTT, GXM
Back pain ECG, CXR
Syncope Ultrasound – aortic diameter > 3cms
Arrange for CT Aortogram
Normotensive or hypotensive Control BP with IV labetalol 50mg/hr
Pulse deficits infusion
GS/Vascular ODD stat for HD
Risk factors: age, hypertension, admission and surgical v/s
smoking, vasculitis, connective tissue endovascular repair
disorders
Asymptomatic AAA US diameter < 5.5cm, incidental

No postural drop in BP, No PR bleed
Discharge with early outpatient Vascular
TCU (call GS Reg)
36
Abdominal pain is distressing to patients. Treating the pain does not mask, or obscure the
diagnosis. Prompt, sympathetic and proactive administration of analgesia often helps in
further decision making. Combination therapy is synergistic, if you are giving intravenous
morphine, Paracetamol will still be effective.
**Please refer to Protocol for Management of GS cases in DEM **
PROTOCOL FOR MANAGEMENT OF GS CASES IN DEPARTMENT OF EMERGENCY

MEDICINE
1. Straightforward GS admissions
DEM admits directly after DEM Senior Dr’s approval.
Senior doctors MUST personally see all patients with abdominal pain for admission to GS.
Registrars/Senior Residents who are unsure when assessing abdominal pain (especially
elderly, paediatrics, patients with constipation colic), please consult AC/Cs.
2. Indeterminate abdominal pain cases
To consult senior DEM doctor to put on abdominal pain protocol.
Female patients - KIV gynae consult and observe for about 8h for eg constipation colic to
await patient’s bowel opening before reviewing abdomen.
If still painful despite bowel opening -> CT abdo/ pelvis (CTAP). Please refer to CTAP
protocol
If CT AP verbal report abnormal, to admit to respective discipline as per pathology. If CTAP

normal, to trace official CTAP report before discharging patient. The patient may need an
early force-in GS TCU. The CTAP cost is charged under EOW charges which can be paid
by Medisave for Singaporeans/ permanent residents.
- GS registrar may be called for an opinion if despite seeking DEM senior Dr’s opinion,
doubt still exists about patient's disposition.
3. Ill cases
For haemodynamically stable, relatively well patients who need HD/ICA for eg acute
pancreatitis /perforated viscus
-> to admit directly to HD after approval by AC and above. GS registrar to be informed by

phone and SMS and told that patient is to be admitted to HD.
For unstable/ unwell patients like possible ischaemic bowel, to call GS registrar to review
at DEM and decide plan of management from DEM. It has been agreed with GS HOD that
the GS registrar has to come to DEM within 30min or even sooner.
37
4. Force-in GS TCUs – to seek approval from DEM senior before calling GS Registrar
on call.
Be conscientious with management of GS cases which may require catheterisation for I/O
monitoring, prompt IV antibiotics/IV omeprazole, NGT insertion, etc. for cases who need
them.
CT PROTOCOL/ WORKFLOW FOR ABD PAIN

Please tick in the blank boxes as applicable
Presents with abdominal pain

Take appropriate history and PE and perform necessary investigations
and management
NO
Is there a history of AAA
Perform blood
YES tests and Xrays
Order CT Aortogram
Fulfills one or Does not fulfill any

more the above of the above
To admit to GS or call
for urgent GS consult or
refer to OBGYN on call
Arrange for CT
Abdo/Pelvis
38
Annex A
1. All EOW cases have to be vetted by senior doctors.
2. The EOW cases that are applicable in the above pathway applies mainly to patients with RIF pain
with normal WBC count and are initially indeterminate for appendicitis. Such cases are to be
placed in EOW and reviewed and treated periodically. If they have persistent or worsening RIF
pain despite treatment in EOW, they should have a CT Abd/pelvis
3. Other patients in EOW abdominal pain protocol that still have persistent pain but not a surgical
abdomen as reviewed by the senior on call is to be admitted for further investigation
4. If patients in point 3 however have been deemed as an acute abdomen after review by the senior
doctor on call should also have a CT abd/ pelvis ordered
Approved by DDR and DEM
39
HEMATOLOGY AND RHEUMATOLOGY
(Dr Oh Jen Jen / Dr Sohil Pothiawala)
ANAEMIA
Hb > 8 gm/dL FBC, U/E (high U/Cr ratio implying

acute BGIT, R/O renal impairment as
Rule out: cause) ECG
- Bleeding GIT If hypo/micro – iron tablets (could still be
- Menorrhagia thalassemia)
- Functional decline If Hyper/macro – folate deficiency (could
still be B12)
Asymptomatic
Discharge with Iron tablets
TCU DIM and memo for OPS for f/u
If bleeding GIT (upper), ODD GS

If bleeding GIT (lower), admit colorectal
If menorrhagia, ODD Gyn
Unknown cause but patient
symptomatic, admit DIM
NMB and GXM.
Hb < 8 gm/DL FBC, U/E, PT/PTT, GXM

ECG, CXR
Admit DIM for blood transfusion
If identifiable etiology, admit accordingly
40
THROMBOCYTOPENIA
- Rule out dengue fever/viral FBC, U/E

infections UC9, CXR, joint x-ray if haemarthrosis
- Look for bleeding tendencies
(rash/purpura, gum bleeding, epistaxis, Asymptomatic and platelet count 80-139
menorrhagia, haemarthrosis) x 109/L
Discharge with TCU Hematology 1-2/52
and KIV call hematology reg
If platelet count < 80 x 109/L and/or

bleeding tendencies, admit DIM with
inpatient hematology consult
HEMOPHILIA A
Hemarthrosis, bruising, hematuria, Factor VIII replacement:

epistaxis, ICH, muscle hematoma
Contact Hematology registrar for
dosage required
Each U/kg of Factor VIII raises its levels

by 2%
Units of factor VIII required = weight

(kg) x 0.5 x ( % activity desired - %
intrinsic activity)
Discharge v/s admit patient based on

hematology registrar’s advice
41
MANAGEMENT OF OVER- ANTICOAGULATION WITH WARFARIN
No Significant bleeding or low

bleeding risk
INR 4 - 5 Withhold warfarin and check INR after

24 hours
INR 5 - 9 Omit next 1-2 doses and check INR

after 24 hours
Alternatively, give Vitamin K 1-3mg PO
INR > 9 Omit warfarin and give Vitamin K 3-

5mg PO
Recheck INR after 6 hours then daily
for 3 days
Severe bleeding
a. Intravenous 4-factor PCC
INR > 1.5 (Prothromplex) at a starting dose
20-25 iu/kg (needs Haematology
approval)
b. Intravenous Vit K of 5-10 mg
Search for “Warfarin Therapy Guide” on Infonet.
42
APPROACH TO SUSPECTED DVT
Well’s Criteria for DVT
Use: Calculates risk of DVT.
The model should be applied only after a history and physical suggests that venous
thromboembolism is a diagnostic possibility. It should not be applied to all patients with
chest pain or dyspnea or to all patients with leg pain or swelling
No Clinical Characteristics Score

.
Active Cancer (Ongoing treatment or within previous 6/12 or
1 1
palliative)
2 Paralysis, paresis or recent Plaster of the lower limb within 4/52 1
Recently bedridden  3/7

3 1
Major Surgery within 4 /52
4 Localized tenderness along distribution of the deep venous system 1
Swelling of the entire leg

5 1
( not just ankle)
Calf swelling >3cm larger than other limb (at 10cm below tibial
6 1
tuberosity)
7 Pitting edema confined to the symptomatic limb 1
8 Collateral superficial veins (non-varicose) 1
9 Previously documented DVT 1
10 Alternative Dx at least as likely as DVT -2
-2 to 1 score: Low risk group for DVT: ‘Unlikely’ according to Well’s DVT studies.
2 and above: High risk group for DVT: ‘Likely’ according to Well’s DVT studies.
A score of 1 or less is determined as low pretest probability,

A score of 2 or more is determined as high pretest probability.
43
INVESTIGATION
A D dimer should also be done in conjunction with the above. D dimer has high specificity
but low sensitivity. The D dimer is read in conjunction with the Well’s criteria. It will result in
the following combinations:
Well’s D dimer Interpretation/Actio Duplex results

criteria n
for DVT Negativ Positiv
e e
Low Negativ DVT can be ruled out N.A N.A
Probabilit e and no further action
y is needed
Positive Duplex of the leg will Look for Treat for

need to be arranged other DVT
causes
of LL
swelling
High Negativ Duplex will need to Follow- Treat as
Probabilit e be arranged, no need up scan for DVT
y to await for d dimer is
Positive needed,
DVT
cannot
be rule
out
TREATMENT
If able to obtain scan on the same day, await scan results.

- if scan is positive, consult senior doctor for admission to hematology for anticoagulation.
- if scan negative in low probability patient, look for other causes of leg swelling
- if scan negative in patients with high probability and d dimer negative, look for other
causes of DVT
- if scan negative in patients with high probability and d dimer positive, to arrange for
early hematology TCU and KIV repeat scan
If unable to perform scan on the same day,

- If D-dimer positive, admit patient to DIM for DVT scan
- If D-dimer negative, look for other causes of LL swelling
44
Special Circumstances
All pregnant patients with DVT should be referred to O&G for further management.
Contraindications to Clexane:
- Contraindications to discharge and /or use of Clexane
 Comorbidities requiring hospital management
 Bleeding risk:
Active bleeding
High risk of bleeding, including

 Recent Haemorrhage within 3/52
 Recent Major Trauma within 3/52
Underlying coagulopathy or cytopenia
 Allergy to heparins
 Renal impairment: Creatinine Clearance < 30 ml/min
Please use Cockroft Gault Formula for Cr Cl:

Cr Cl = (140 - age) X weight (in kilograms)/ 812 X SCr (in mmol/L)
 Extensive DVT with potential for phlegmasia cerulea dolens

 Necessity for parenteral narcotics for pain control
 Inability to have injections administered at home
All above patients should not be discharged and should be considered for admission.
PLEASE CONSULT SENIOR DOCTORS BEFORE STARTING CLEXANE OR THOSE

WITH SPECIAL CIRCUMSTANCES
45
GOUT
- Sudden onset of pain, swelling and FBC, U/E, uric acid

inflammation in joint (esp 1st MTP joint) KIV joint x-ray
- Hx of gout or Gouty tophi
- Polyarticular arthritis in 10% Acute attack: NSAIDs, Colchicine 0.5mg
patients
Re NSAIDs: check if baseline creatinine
available, AVOID if patient has h/o renal
impairment or Creatinine done in ED
found to be elevated.
Alternative: Opioids(codeine/tramadol)
If symptoms improve and able to

ambulate, discharge with
NSAIDs/opioids and colchicine and
memo for GP/OPS review 1/52 and KIV
TCU rheumatology next available date
(Note: Do not prescribe allopurinol at

discharge to patients not on that
medication, but it should be continued
at regular dose in those already on it)
Consider suitability for gout protocol and

consult senior doctor eg. 1-2 joint
involvement, no other indication for
inpatient admission
If persistent pain despite protocol or

poor social support, admit rheumatology
Gout dietary advice: avoid alcohol, soy-

rich foods, etc
46
METABOLIC & ENDOCRINE
(Prof Anantharaman / Dr Sohil Pothiwala)
HYPERKALEMIA
Mild FBC, U/E, ECG, VBG
K: 5 -5.5mmol/L Can be discharged with syrup

ECG: normal to tall tented T waves Resonium PO 15gm TDS x 3 days
TCU OPS/GP 3/7 to re-check K level
Moderate FBC, U/E, ECG, VBG, CXR
K: 5.5 – 6.5mmol/L IV Insulin-Dextrose – 10units actrapid

ECG: tall tented T waves, prolonged insulin + 40mls of 50% Dextrose
PR, absent P
Syrup Resonium 15gm PO
Admit DIM
Admit renal if missed dialysis
Severe FBC, U/E, ECG, VBG, CXR
K: > 6.5mmol/L IV 10% calcium gluconate 10ml, can

ECG: QRS widening, junctional rhythm, repeat if necessary
sine wave, PEA, any other
dysrythmmias IV Insulin-Dextrose – 10units actrapid
insulin and 40mls 50% Dextrose
PO Resonium 15gm stat or PR

resonium enema
IV sodium bicarbonate 1mEq/kg if

severe
Salbutamol nebulization
Hemodialysis
CPR if cardiac arrest
Call R1/ MICU registrar or renal reg:
Admit HD/ICA/MICU
47
HYPOKALEMIA
Mild FBC, U/E, ECG, VBG
Weakness, lethargy, symptoms of Can be discharged with Syrup

precipitating cause (e.g. GE) Potassium Chloride 5ml TDS x 3 days
K: 3 -3.5mmol/L TCU OPS/GP 3/7 to re-check K level
ECG: normal to flattened T waves
Moderate FBC, U/E, ECG, VBG, CXR
Weakness IV KCl 10mEq/hr

K: 2.5 – 3mmol/L
ECG: U wave, non specific ST-T Admit DIM GW early review
changes
Severe FBC, U/E, Mg, PO4

ECG, VBG, CXR
Hypokalemic periodic paralysis
IV KCL 10-20 mEq/hr
K: < 2.5mmol/L
IV Magnesium Sulphate 2gm slow IV
ECG: Prolonged QTc, dysrhythmias infusion if Mg level low or resistant to K
replacement
Admit DIM GW early review, KIV Call

R1/ MICU registrar for HD/ICA
48
HYPONATREMIA
Mild to moderate FBC, U/E, ECG, VBG

Na: 121-135 mEq/L
Hypovolemic: rehydration with IV NS
Weakness, lethargy, symptoms of slowly
precipitating cause (e.g. GE, heart Euvolemic (SIADH): free water
failure, DKA) restriction
Hypervolemic (heart and renal failure):
water restriction, diuretics, dialysis
Pseudohyponatremia: falsely low
reading due to other osmolar particles
(eg hyperglycemia,
hypertriglyceridemia)
Admit DIM GW
Severe FBC, U/E, ECG, VBG, CXR
Na <120 mEq/L IV diazepam 5mg to control seizures
Symptoms as above + Altered Mental state 3% Hypertonic saline 1-2ml/kg (100ml)

including coma, seizures over 10 minutes after discussion with
senior doctor
Admit DIM, Call R1/ MICU registrar for

HD/ICA
Note: Risk of Central Pontine Myelinolysis with Hypertonic Saline
49
HYPOGLYCEMIA
(updated June 2017)
Blood Sugar <4 mmol/L Monitor, supplemental O2

Bedside capillary blood sugar
Behaviour: lethargic, irritable FBC, U/E, ECG, VBG
Decreased conscious level
Focal neurologic deficits Conscious and cooperative patient: Oral
seizures dextrose sachets (nurse-led protocol as
below)
Unconscious:
IV 50% dextrose 40mls followed by 10%
dextrose drip over 4 hours
Recheck blood sugar in 15 minutes
Admit hypoglycemia protocol if patient

alert and hypoglycemia due to missed
meal
Admit DIM GW if persistent AMS,

patient on sulphonylureas, underlying
etiology or comorbidities
Admit Endocrine if persistent

hypoglycemia despite treatment,
overdose of sulfonylureas, ingestion of
power walnut
50
51
DIABETIC KETOACIDOSIS
(updated June 2017)
- Uptriage to P1
Diagnostic criteria: - Monitor, supplemental O2
- Blood glucose > 14mmol/l
- PH <7.3, HCO3 < 15mmol/l Investigations:
- Ketonemia (serum ketones > 1) or Bedside capillary blood sugar
ketonuria (urine ketones > 2+) FBC, U/E
ABG/VBG
Serum ketones
UC9, ECG, CXR
Blood/Urine cultures if sepsis
Treatment:
IV fluids (see table below)
Insulin infusion (see table below)

- 0.1unit/kg/hr
- Hourly blood sugar monitoring
- Slow infusion dose but maintain
infusion till acidosis clears
Electrolyte management
- If K > 5 mmol/l, no KCl needed.
Recheck K every 2 hrs
- K 3.3 - 4.9 mmol/l, IV KCl 10mEq/hr if
urine output
- K <3.3 mmol/l, IV KCl 20 mEq/hr
- Sodium bicarbonate only if PH < 7
(8.4%NaHCO3 50mls over 1 hr)
IV Antibiotics if sepsis
Treatment of the underlying cause
Admit Endocrine. Call Med R1/ICU

registrar/SR for ICA/ICU bed
100-200ml/kg Na < 145

Correct over 24- 0.9% NS Until glucose <= 14 Na < 145
mmol/L Dextrose - saline
48hrs*
0.45% NS 5% Dextrose
Na>145
Na > 145
Hyperosmolar Hyperglycemic Non-ketotic state (HHNK)
*Infuse 1-1.5 litres of NS over the first hour. Subsequent rate depends on parameters and clinical state
52
HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS)
Uptriage to P1
Diagnostic criteria: Monitor, supplemental O2
- Blood glucose > 33mmol/l
- pH > 7.3, HCO3 >15mmol/L Investigations:
- Absence of ketonemia or ketonuria Bedside capillary blood sugar
- Serum Osmolality >320 mOsm/kg FBC, U/E
ABG/VBG
Serum osmolality = 2 x Na + glucose Serum ketones
(normal 280-290 mOsm) UC9, ECG, CXR
Blood/Urine cultures if sepsis
Treatment:
IV fluids (similar to DKA)
Insulin infusion (similar to DKA)

- 0.1unit/kg/hr
- Hourly blood sugar monitoring
- Titrate infusion to keep glucose 14-
16 mmol/L until serum osmolality has
resolved and patient mentally alert
Electrolyte management
- If K > 5mmol/l, recheck every 2 hrs
- K 3.3 - 4.9 mmol/l, IV KCl 10mEq
per litre of IV fluid if urine output
- K <3.3 mmol/l, IV KCl 20 mEq/hr
- Sodium bicarbonate only if PH < 7
(8.4%NaHCO3 50mls over 1 hr)
Treatment of the underlying cause
Admit Endocrine. Call Med R1/MICU

reg/SR for ICA bed
53
HYPERTHYROIDISM

FBC, U/E, FT4, TSH
Thyrotoxicosis ECG, CXR
Palpitations, tremors, agitation, B-blocker: Propranolol 20mg PO stat

anxiety, weight loss, heat Antithyroid: Carbimazole 20mg PO stat
intolerance, menstrual irregularity,
goiter, thyroid eye disease (eg. Observe in telemetry if patient in AF/sinus
Proptosis, exophthalmos, lid tachycardia
retraction)
If tachycardia resolves and stable vital signs,
ECG shows sinus tachycardia/AF dc with propranolol 20mg TDS and
carbimazole 30mg OM. Memo for OPS in 1-2
weeks for f/u
If persistent tachycardia/AF or heart failure,

discuss with senior doctor for admission to
endocrinology
Uptriage to P1
Thyroid Storm Monitor, supplemental O2
FBC, U/E, FT4, TSH, cardiac markers and
All of above BNP, LFT,
Altered mental state ECG, ABG, CXR, UC9
Fast AF and CCF Blood cultures if underlying sepsis
Underlying sepsis
B-blocker: Propranolol 20mg TDS (C/I: if
Burch-Wartofsky Score 45 or more patient in CCF or hypotensive)
Antithyroid: Propylthiouracil (PTU) 400mg PO
stat, followed by 200mg 6 hrly
IV hydrocortisone 100mg and q 6hrly

Lugol’s iodine 15ml TDS PO at least 1-2 hrs
after PTU (alternatively IV sodium iodide 1g
12hrly diluted in NS can be used if patient not
in failure may be preferred as a more direct
administration of iodine, also given at least an
hour after PTU).
Paracetamol 1gm PO stat if fever and q 6hrly

(avoid aspirin)
IV NS judiciously
Intubation if respiratory failure
Consult endocrine reg on-call if needed

Call Med R1/MICU reg for ICA/ICU bed
54
NEUROLOGY/ NEUROSURGERY
(A/P Fatimah / Dr Kenneth Tan)
CEREBROVASCULAR ACCIDENT
55
Management of Strokes Presenting Outside of RTPA Window
(For Contraindications to RTPA: available from SGH Intranet > Department of Neurology)
Manage in P2 area.
Bloods: FBC, U/E/Cr, PT/PTT, GXM, capillary blood glucose
Others: ECG, CT Brain
If not bleed on CT or decision not for thrombolysis: PO or S/L Aspirin 300mg if no

contraindications
Admit to Stroke Holding Area.
TRANSIENT ISCHAEMIC ATTACK
ABCD2 Score for TIA
Use: Estimate the risk of stroke after a TIA.

Age ≥ 60 Yes +1
BP ≥ 140/90 Yes +1
Clinical Features Unilateral weakness +2
Speech disturbance without +1
weakness
Other symptoms 0
Duration of symptoms ≥ 60 minutes +2
10-59 minutes +1
<10 minutes 0
Diabetes Mellitus Yes +1
0 to 3: Low – 2-day stroke risk 1.0%, 7-day stroke risk 1.2%, 90-day stroke risk 3.1%
4 to 5: Moderate – 2-day stroke risk 4.1%, 7-day stroke risk 5.9%, 90-day stroke risk 9.8%
6 to 7: High – 2-day stroke risk 8.1%, 7-day stroke risk 11.7%, 90-day stroke risk 17.8%
ED Management
Investigations are the same as for CVA

Load PO Aspirin 300mg if no contraindications
Admit to Stroke Holding Area for further workup.
56
INTRACRANIAL HEMORRHAGE (ICH)
Patient presenting with
Stroke like symptoms
Worst headache of their lives with other features like sudden in

onset and thunderclap headache
Drowsiness, altered mental state
Head injury that fulfills Canadian CT head rule for scan
All such individuals should have a CT brain. Please consult a

senior doctor.
Proper physical examination and history taking with particular

note of anticoagulation should be taken
CT brain -ve for

bleed
Treatment as for other
causes
CT brain +ve for

bleed
Management:
Manage patient in resus
Contact NES
Ensure FBC, renal panel, PT/PTT, GXM done
If patient on warfarin, to give IV Vitamin K and arrange for 4 Factor PCC
Control BP. If BP high, KIV start IV labetalol or oral anti HTN
IV mannitol if there are clinical signs or radiological evidence of raised ICP
Discuss with NES about starting anti-epileptics
Catheterize patient
If GCS< 8, intubate patient for airway protection

57
Ensure patient’s bed is raised at a 30 degree head up position

URGENT CT ANGIOGRAPHY FOR STROKE IN DEM
(updated June 2017)
58
GIDDINESS Patient presenting with giddiness
Determine:
- Vertiginous vs non vertiginous
- ? chest pain or palpitations
- Any infective symptoms
- Any PR bleeding or melena
- Whether it is postural in nature
- Any head injury
- Any change in medication
- Past medical hx
VERTIGO NON VERTIGINOUS GIDDINESS
1. ?a/w tinnitus Look for other causes

2. ?worse with head movement
3. ?recent URTI ECG, H/C, FBC renal panel, Trop T
4. ?any unsteady gait
5. ?any neurological symptoms Thorough physical examination. Postural BP.
6. ?any diplopia
DDX:
Ensure ECG and H/C normal Giddiness secondary to cardiac cause
BGIT
Neuro exam may reveal multidirectional Metabolic disturbances, eg. hyponatremia, hypoglycemia
nystagmus and cerebellar signs Non- specific symptoms
Vertigo of peripheral origin:
BPPV or vestibular neuronitis
Usually has above features 1, 2, 3
Neuro exam normal but can have

unidirectional nystagmus
Treatment:
Vertigo of central origin:
Give IV/IM stemetil
May have all 6 features but have
positive neurological examination IV hydration
Ensure routine bloods done and Ensure appropriate bloods done

arrange for CT brain
If bloods normal, can observe till better and discharge ENT/OPS.
Administer symptomatic treatment Supervising senior can also admit patient under EOW giddiness protocol
Admit to neuro if CT brain NAD If bloods abnormal, eg hyponatremia, admit to appropriate discipline
If CT brain +ve ie. mass or ICH If patient still symptomatic after protocol, KIV CT brain with admission to
refer NES medical or admit to DIM depending on supervising senior’s clinical
judgement
Fall precautions
59
SEIZURES
Confirm seizures from witness or patient.

Ask for any past hx of seizures
All actively seizing patients are to be treated in
resus, administer up to 10mg of IV diazepam (can
repeat another dose) to abort
Caution: drop in BP or RR
Known hx of
1st episode of seizures seizures
If known seizures, assess for compliance to meds and triggering factors
Look for other causes of seizures, eg:

Cardiac cause- ECG, hx Toxicology causes Movement disorders
Hypoglycemia- check h/c CNS infections Tremors
Assess suitability for EOW seizures protocol

No further
seizures Those with known seizures check drug level No further
if applicable, kiv increase drug dose seizures
If no more seizures, discharge with early

TCU neuro
Still seizing can use up to total of 20mg IV diazepam
If still persistent seizures, consider and treat as for status

Still epilepticus Still
seizing seizing
Start IV phenytoin or IV phenobarbitone, KIV intubate if
needed, arrange for monitored bed or ICU
60
HEADACHE
Red flags:
Worst headache of life, different from previous

headaches/ migraines episodes
Neck stiffness
Photophobia
fever
Thunderclap, acute in onset
a/w profused vomiting
a/w drowsiness
Red flag Red flag present
absent a/w neurological deficits
trauma with clinical signs of skull fractures or BOS #

CT brain
Treat symptomatically with IM stemetil or CT brain
maxalon. Can add on NSAIDs if needed CT brain positive
negative
Observe patient for 2-3 hrs
If pain has subsided, discharged with stemetil CT brain Admit to

and NSAIDs/ codeine and OPS apt negative appropriate
Admit to
discipline
DIM
Please ensure NSAIDs are not contraindicated depending on CT
findings
If pain has not subsided despite analgesia, for
IM pethidine and KIV CT scan depending on
senior doctor’s review and clinical impression
If for further observation, observe another 2 hrs

CT brain positive
If still symptomatically not better, for CT brain
Note:
Please also take note of any eye symptoms
Headache has subsided Glaucoma can present with headaches as well. If there is
decreased vision and unilateral eye redness, please refer to
eye to rule out glaucoma
Temporal arteritis:
Discharge with stemetil Usually presents with eye symptoms as well. However
/maxalon and appropriate physical examination might reveal tenderness at the temporal
analgesia region with thickened arteries. It is a sight threatening
condition and the rheumatology registrar on duty must be
TCU OPS/ DIM with advice to informed to start early treatment if suspected
return if pain occurs
61
OBSTETRICS AND GYNAECOLOGY
CONDITIONS TO BE REFERRED TO O&G FROM ED
1. Hyperemesis with positive urine ketones

2. Threatened/missed/evitable/incomplete abortion
3. TRO Ectopic pregnancy
4. Pregnancy related issues after 28 weeks e.g. pre-eclampsia
5. Pregnant women with abdominal pain, bleeding or gastrointestinal symptoms
6. Symptomatic anaemia or unstable vital signs sec to menorrhagia or PV bleed (with or
without ongoing PV bleed)
7. Pain sec to ovarian cyst accident
8. RIF pain sec to pelvic inflammatory disease
9. Trauma in Pregnancy
10. Pulmonary embolism in Pregnancy. (Pulmonary embolism in gynaecological oncology
should be admitted to the medical ward).
Stable conditions that should be referred to gynaecological clinic during office hours or
the next morning (no need to call for appointment) with DEM referral letter:
1. Ovarian cyst with minimal or no pain
2. Worried patients with mild PV bleed or other gynaecological complaints.
Stable conditions with referral to gynaecology clinic in 2 weeks

1. Asymptomatic patients with PV bleed – to start NE 5 mg tds x 1 week first (KIV
preceded by IM progesterone 100 mg stat)
2. Other non-urgent gynaecological problems.
Approved by Dr Evelyn Wong (DEM) and Dr Tan Hak Koon (O&G) on 30 Sept 2013
Annex A
1. All unstable O&G patients will be seen by the O&G team in the resuscitation room.
2. Stable patients will be sent to the labour ward for assessment during office hours (8
am to 5 pm), and in DEM Consultation Room A5 after office hours.
3. Pregnant patients above 24 weeks should be directed to the labour ward for
assessment.
4. A designated ultrasound machine from the O&G Centre would be brought to the DEM
for use after office hours
o The O&G Centre is responsible for transferring the machine from O&G Centre to DEM
at 5 pm every weekday (Sister Janet Khoo to arrange).
o The DEM is responsible for transferring the machine from DEM to O&G Centre at 8 am
every weekday (Sister Ho Soo Ling to arrange).
o The machine will be left in the DEM over weekends or public holidays as it will not be
needed at the O&G Centre.
o The O&G Centre and DEM are separately responsible for keeping a movement log of
the ultrasound machine (Sisters Janet Khoo and Ho Soo Ling to note).
62
5. Referral of female patients with abdominal pain to OBGYN
 If the DEM clinical impression was that of appendicitis, the patient should be admitted to
General Surgery or reviewed first by the general surgical team. Should the general
surgeon think that it is clinically appropriate for the patient to be assessed by
O&G before admission, it is the responsibility of the surgeon (and not the DEM
doctor) to call the O&G team for review after he has reviewed the patient.
 When a woman requires admission for management of abdominal pain but the clinical
suspicion of an O&G cause is low (e.g pain in the upper abdomen, significant
gastrointestinal or urinary symptoms), DEM is advised to admit the patient to the most
appropriate specialty with inpatient referral if necessary
 Non- urgent cases (e.g vaginal discharge without abdominal pain, chronic pelvic pain)
that present after office hours should be given an outpatient appointment. TCUs on the
following day can be arranged if clinically indicated.
 It is not encouraged to refer to OBGYN for routine US of female abdominal pain.
As agreed upon by A/P Tan Hak Khoon and Dr Evelyn Wong (13 October 2014)
WORKFLOW FOR PREGNANT PATIENTS
1. Less than 20 weeks gestation
- To register at DEM and to be seen by DEM MO
- To refer to O&G if needed
2. More than 20 weeks gestation
- To refer to Ward 52A ELS
- To call 4520 before sending patient to WD 52A
- No registration at DEM
3. Unconfirmed Pregnancy
- To register at DEM and Urine Pregnancy Test to be done
- To register at DEM and to be seen by DEM MO
- To refer to O&G if needed
(agreed upon after discussion with Dr Devendra from O&G, updated May 2017)
EMERGENCY CONTRACEPTION
63
For ALL patients:
• Reinforce contraceptive methods – long term (e.g. IUD, OCP) vs short term (e.g.
condoms)
• Do UPT in ED and advice it to be repeated during the time that the period is due
Less than 72 hours post coitus:
 PO Levonorgestrel 1.5mg ONCE – S$3.74 (before GST)
Between 72 to 120 hours (5 days):
 PO Ulipristal (Ella) 30mg ONCE – S$33.33 (before GST)
Side effects for both include: nausea and vomiting, bloatedness, delayed menses
(sometimes more than 7 days later than expected)
Absolute contraindication: porphyria. Higher doses might be needed in patients on drugs

such as phenytoin, carbamazepine, rifampicin.
Beyond 5 days:
Refer to O&G for IUD insertion
64
ONCOLOGY
(Dr Kenneth Tan / Dr Juliana Poh)
FEVER IN ONCOLOGY PATIENTS
Fever in an oncology patient

Ask history for source of fever,
Date of last chemotherapy (risk of
neutropenic sepsis increases around D7 to
D10)
Physical examination to look for

source of sepsis (skin, chest,
abdomen, urine)
Perform necessary
investigations notably FBC
ANC>0.5 and patient
well (for discharge
with no source)
ANC<0.5 ANC>0.5 but

needs
admission
NEUTROPENIC SEPSIS TREAT AS FOR SEPSIS OR CAN BE TREATED

SOURCE OF INFECTION OUTPATIENT
Ensure blood c/s is done. Minimise Ensure blood c/s done. Start IV Consider outpatient treatment
unnecessary procedures for pt. cefepime 2g. If allergic to if patient and family agreeable
penicillin to follow as and patient clinically well
No PR examination recommended by antibiotic
guideline If unsure, please consult senior
Start IV cefepime 2g. If allergic to doctor
penicillin to follow as Fluid resus if patient is
recommended by antibiotics hypotensive, pls refer to septic Discharge with oral antibiotics
guideline shock guideline Advise to proceed to walk in
Fluid resus if patient is Admit to oncology GW early oncology clinic next day or to
hypotensive, pls refer to septic contact their respective
review
shock guideline oncologist for early
appointment
Arrange for isolation bed or single
room for admission Advise to return if unwell
65
SPINAL CORD COMPRESSION
Patient can present with

- Back pain
- ARU or fecal incontinence
- LL weakness or numbness with sensory level
- Important history of cancer and site of any
metastasis
Physical examination can have findings of

- sensory level
- bilateral LL weakness
- poor or no anal tone
- distended bladder
- spinal tenderness
Investigations:
Spinal X-rays may reveal compressions fractures,
winking owl sign, osteopenic vertebrae
- If suspected spinal cord compression, patient to be

referred to either orthopaedics or neurosurgery.
- Definitive management would include either RT or spinal

surgery. Palliative treatment to improve quality of life
- Start IV dexamethasone 8mg and IV losec to decrease

spinal edema from spinal metastasis
- If not for orthopaedics/ NES admission, admit to med

oncology
66
PERICARDIAL EFFUSION
History Physical examination Investigations
- present with SOB - muffled heart sounds - CXR can show globular
- chest pain - distended neck veins heart +/- pleural
- previous hx of metastasis - hypotension effusions
to lung, pericardium *the above 3 makes up - ECG shows low voltages or
Beck’s triad electrical alternans
- normal lung sounds - Bedside US shows
- can also be associated with pericardial effusion +/-
pleural effusions signs of tamponade
- pulsus paradoxus
Treatment
- Start iv fluids aggressively
- Contact CVM/ CTS for urgent
pericardiocentesis or pericardial window
- If patient has cardiac arrest,
pericardiocentesis can be performed by
ED physician
HYPERCALCEMIA
Oncology patients can present with complications of hypercalcemia. Hypercalcemia is

usually due to paraneoplastic effects or bony metastasis.
Patients can present with
- altered mental state
- abdominal pain
- severe dehydration secondary to polyuria, polydipsia
- generalized bodyaches
Investigations include routine bloods as well as calcium levels and ECG. ECG may
show shortened QT interval and narrow QRS complex.
Mainstay of treatment is fluid resuscitation. IV bisphosphonates are given in the ward. Iv
Lasix or diuresis is also attempted when the patient has reached euvolemic state.
67
SUPERIOR VENA CAVA SYNDROME
Previously considered as an oncological emergency, it is now considered at most an

oncological urgency. This condition usually presents in patients with invasion of SVC or
compression, commonly in Pancoast tumors.
Patients with SVCO can present with
- shortness of breath
- facial swelling and congestion
- upper limb swelling
Treatment in the ED is supportive in nature with oxygen. Recent papers showed that
dexamethasone does not show significant improvement. Definitive treatment includes
stenting of SVC or radiotherapy.
TUMORLYSIS SYNDROME
This normally occurs after chemotherapy and in patients of lymphoproliferative disease or

high tumor load. This condition can present in a wide spectrum of presentations and
should be considered in the above cases.
To diagnose the above, the following blood tests should be done
- renal panel, hyperkalemia and ARF
- phosphate level, hyperphosphatemia
- calcium level, hypocalcemia
- uric acid, hyperuricemia
Treatment of the above will include

- IV fluids
- Treatment of hyperkalemia
- Allopurinol, usually started in the ward
- KIV dialysis
68
OPHTHALMOLOGY
(Dr Joy Quah)
SUBCONJUNCTIVAL HAEMORRHAGE
History
 May occur with coughing, straining,
 sneezing
History of trauma Examination
Look for proptosis
Refer to eye MO on call Not for immediate referral

 Traumatic  Non-traumatic
 Proptosis present  Spontaneous
 RAPD present
Management:
Check BP
Tears Naturale Preservative Free
TCU eye X 2/52 if not resolved by then
Advise that may take 2/52 to subside
69
VIRAL CONJUNCTIVITIS
History
Contact history/Recent flu
Check pupil – ensure not mid dilated and
cornea not hazy (TRO acute glaucoma)
History of trauma or contact lens use
Examination
Stain cornea with fluorescein – any
epithelial defect?

 Contact lens user
 Bilateral
 Trauma or Post-Op Patients
 Associated corneal infiltrate
 Contact history/Recent flu +ve
 All others
 Uveitis (unilateral, pupil stuck down,
severe photophobia, very tender on *Note: Can take up to 2 weeks to
globe palpation.) resolve
 RAPD/hypopyon present
Management
Uveitis Topical chloramphenicol QDS, occ.
Chlortetracycline Cream 1% TDS
Tears Naturale Preservative Free
*If wish to change antibiotic drops:
Hypopyon Ciprofloxacin QDS
Advise can take 2/52 to resolve
Strict hand hygiene. TCU eye X 2/52
*Most conjunctivitis are due to viruses. Antibiotic use is only for prophylaxis
against secondary bacterial infection and will not speed up recovery.
70
CHALAZION
History & Examination
Check for signs of orbital cellulitis:

injected conjunctiva, RAPD,
restriction of extraocular
movements, proptosis

Associated severe preseptal
All others
cellulitis/orbital cellulitis
Note: May take a month to resolve
(see above history and examination)
Management
Daily warm compress TDS

Fucithalmic Acid ointment BD
TCU Eye x 2/52
* Warm Compress is performed by taking a clean towel dipped in warm water (NOT boiling water) and
placing it over the chalazion, applying gentle pressure. Can be repeated 5-6 times a day.
71
CORNEAL ABRASION
History
Recurrent corneal erosion
Associated with trauma
Pain, tearing, blurring of vision, photophobia
Examination
Stain cornea
Evert upper and lower lids to ensure no FB
Refer to eye MO on call

Not for immediate referral
Not for immediate referral
All others
Presence of overlying cornea
All others
opacity/infiltrate
Contact lens wearer
Management
Topical antibiotics (Ciprofloxacin QDS,

Cravit QDS)
Tears Naturale Preservative Free 1 hrly
Visidic Ointment TDS
TCU eye x 1-2/7
72
ORTHOPAEDICS
(Dr Jean Lee / Dr Cheah Si Oon)
GENERAL ORTHO INFORMATION

1. Ortho patients managed by DEM doctor who requires Ortho Admission or fast track
Ortho TCU(3 days): such cases must first be approved by the DEM senior doctors.
2. X-rays should include the joint above and below the fracture site.
Recommended workflow when seeing Orthopaedics cases
A. Admissions
All ortho cases for admission MUST go through the approval of the DEM senior Dr. If DEM
senior is unsure of management of the ortho condition, he/she or the DEM MO may then
call the Ortho Registrar for advice as to whether admission is required. Unstable Medical
patients with fractures eg severe pneumonia, septic shock etc should be admitted to the
medical units.
For urgent admission cases of eg open fractures/necrotizing fasciitis, the ortho ward MO
should be called.
Patients with multiple stable medical comorbidities with concomitant fractures should still
be admitted to ortho.
B. One week force- in appointments to SOC Trauma / Fracture Clinic

(As of 2016, the trauma/fracture clinic appointments are all now 3 days)
Only limb fractures and dislocations are to be seen in the FRACTURE/DISLOCATION

ortho CLINICS. Do not put ankle or knee contusions, backaches or lacerations there.
- For Weber B ankle fractures, please call ortho reg on-call to see whether they want
patient to be admitted or to TCU fracture clinic.
- Compression fractures of the spine may be given fracture/dislocation clinic TCU.
- Distal wrist fractures requiring ORIF may now be ODDed to hand surgery for
admission and management.
Only patients with fractures/dislocations are to be given hospitalization leave of 10 days to

cover until fracture clinic TCU.
C. Fast track Clinic
Ortho Dept has initiated a fast track fracture/dislocation SOC clinic (3-4 days) for
traumatic fractures which do not need immediate admission but require very early
TCU. This has been scheduled to be 5 slots a day. DEM MO must again get the approval
of DEM senior before slotting such a case into a fast track clinic.
Please ensure you advise patient to elevate the limb as much as possible to prevent gross
swelling of fractured limb.
73
D. Podiatry clinic
Patients with ingrown toenails and paronychia, leg wounds requiring reviews may be
referred to podiatry clinic during office hours (Mon to Fri 8 am to 5pm, Sat 8 am to 1pm).
Please call Ms Sophie at 81256460 to inform her of such a case. She might come to the
ED to provide free consult and recommendations. After office hours, the patient can be
referred to the podiatry clinic on the next working day.
E. Appointments for non-trauma ortho patients
For non-trauma patients with back pain/OA knee, please give early physio TCU AND
spine/knee ortho TCU respectively as well, following the queue. If the physiotherapist
deems that the patient needs an earlier spine TCU, they will arrange with the spine
surgeon for an early TCU. These cases are NOT to be slotted into fracture/dislocation
clinic TCU just so as to see ortho early.
If the patient has seen multiple GPs/A&Es for the problem and truly needs an earlier ortho
TCU, please speak to appointment clerk and they will see if they can slot into a general
ortho clinic. Continue to give early physio appts to these pts.
If an early doctor review is needed, you may consider referring to the Chinatown
Singhealth Family Clinic.
For cases where knee aspiration has been done and pt discharged, the pt will be given an
early ortho TCU (within 1/52) to the general ortho clinic.
Other remarks
DEM seniors are to vet ortho admissions, force-in appointments and one week fracture
clinic appointments to ensure appropriate admissions and referrals.
Patients with sciatica should be advised that the pain may last for 4-6 weeks and seeing
an orthopaedic surgeon is only with a view for surgical intervention. Meanwhile bed rest
and hospitalization MC (1-2 weeks by putting the patient on the EOW back pain protocol
first) may be warranted. For the elderly with compression fractures and failed Back Pain
protocol after 12h, admission to ortho is advised for KIV vertebroplasty. For other forms of
non-traumatic back pain without any neurological signs/symptoms, admission to ortho is
strongly discouraged and if admission is for social reasons, one may consider DIM or SKH
(AH) instead.
74
UPPER LIMB FRACTURE WITH OR WITHOUT DISLOCATION
Triage Condition Investigations ED Disposition Special

Cat. Management Note
General Principles
Open Xrays AP+ IM ATT Consult
Fractures or Lateral Analgesia DEM Snr Dr Try to
Penetrating Bloods incl IV Cefazolin to admit align limb
injuries GXM 2gm Ortho in long
IV Inform axis
clindamycin ORTHO stat
600mg ( if
penicillin
allergy)
Haemostasis
and wound
dressing
Extensive Xrays only if IM ATT TCU OPS Deep,

Abrasions bony injury / Analgesia for dressing contamina
Foreign body Wound change/insp ted
suspected dressing ection wounds
may
require
inpatient
care.
Advise
those that
are
discharge
d to look
out for
infection.
Lacerations Xray to IM ATT Admit ortho Deep,

with cut exclude Analgesia or ODD contaminated
tendons, foreign bodies IV cefozolin Hand wounds may
possible Surgery for require
joint admission. inpatient
involvement care.
or Advise those
complicated that are
deep discharged to
wounds(eg look out for
breech of infection.
underlying
fascia)
75
Clavicle
3 Fracture X ray clavicle Analgesia; TCU Fracture # Clavicle:
Clavicle / AP & Zanca Broad arm Clinic 1/52 For ortho
Acromio- sling admission
clavicular only if
Joint (ACJ) fracture is
injury comminuted
AND
presence of
tenting of
skin
Comminution
does not
need
admission
but lung
contusion
does.
Shoulder
Scapular Xrays Analgesia ; Isolated Fracture- High energy

fracture Shoulder AP Broad arm TCU Fracture injury –MUST
with scapular Sling Clinic 1/52 look for assoc
lateral view Associated injury- intra-
consult GS thoracic/chest
wall injuries
Shoulder Xrays shoulder -M&R under -Collar and cuff Consult

Dislocation AP+ y- conscious - TCU Fracture DEM Senior
scapular view sedation in Clinic 2/52 Dr for
resus room guidance
Fracture AP/Lat view Collar and Fracture- Look for other

Proximal/ Humerus Cuff dislocation or 4- distal injuries
Surgical Analgesia part # - consult and check
Neck DEM Snr Dr to neurovascular
admit Ortho. status
Minimal
displacement -
TCU fracture clinic
1/52
76
Humerus
3 Fracture AP/Lat view U Slab with TCU Fracture

Humerus Humerus sling to support Clinic 1/52
forearm Vascular
and check compromise
neurovascular needs to be
status after admitted,
Radial N injury( ortho and
wrist drop) vascular
-Vascular registrar
Compromise( b alerted for e
rachial Art) surgery within
warm
ischaemia
time. New
radial nerve
deficit after
application of
U slab to
admit
Distal X rays Supra- Undisplaced- Document
Humerus Elbow (AP condylar- Long TCU Fast- neurovascular
Fracture and lateral) Arm Backslab track fracture status
(undisplaced) clinic Explain to
patient about
Undisplaced Displaced, NV signs of
Medial compromise – compartment
Epicondylar # - splint in as syndrome
Long Arm near normal
Backslab anatomic Admit Ortho
position as -If bilateral
Lateral possible and humeral #s
Epicondylar #- admit Ortho -Incarceration
higher chance and inform of medial
of malunion stat condyle
-Long Arm fragment
Backslab at 90 within the joint
deg flexion and or
forearm displacement
supination of 1 cm or
more.
Analgesia for
all
77
Elbow
2 Elbow AP /Lat M&R Admit Ortho if Perform
Dislocation Views of under there is NV post
elbow Conscious compromise/un reduction X-
Sedation stable # rays.
TCU Fracture Document
Gentle Clinic 1/52 NV status
ROM pre and
testing post
post reduction
reduction, Consider
then splint compartme
with nt
forearm in syndrome
slight with
pronation persistent
and elbow pain, esp
flexed at with passive
90 deg or finger and
beyond wrist
extension
Radius & Ulna

3 Closed AP/Lateral Long arm If Open/ ALWAYS
Fracture Views of above dislocation of look at
Radius / Ulna Forearm- elbow proximal or Proximal
(Undisplaced) MUST backslab distal joint: and distal
include -Admit Ortho joints for
Elbow and after DEM senior dislocation
Wrist joints consult
TCU Fracture
Clinic 1/52
Monteggia/ AP/Lat Long arm Admit Ortho after To call ortho

Galleazi view of above DEM senior MO if any
Fractures – forearm elbow consult NV deficit.
fracture with backslab
distal or +/- prior
proximal M&R
radio ulnar
dislocation
3 Colles AP/Lat M&R under If neurovascular Document
Fracture / views of Bier’s Block compromise esp. Neurovascular
Reverse wrist / Carpal Tunnel Checks
Colle’s haematoma Syndrome/ Open
78
(Smith’s) block / fractures
conscious -Admit ortho Intra-
sedation in after DEM senior articular #
Resus consult should be
referred to
Analgesia TCU Ortho Hand
Fracture clinic Surgery stat
Below OR Hand for KIV
elbow back Surgery 1/52 ORIF.
slab strictly
4 Extensive TCU General Advice to
abrasions Bank 3 weeks look out for
with Referral to infection
GP / OPS for
dressing change
Hand/Finger
Dislocation Xrays if Digital TCU Hand Splint side
open, or block then Surgery 1 week of
fractures M&R. dislocation
suspected Splint if unstable.
Consider
buddy
splint.
Fracture Xrays Open tuft: TCU Hand Tuft #:
Digital block, Surgery 1 week, Bandage
irrigate analgesia only, do not
use
Non tuft: Zimmer’s
Zimmer Non tuft:
splint
Never extends
immobilise proximal
entire and distal to
finger! fracture site
79
UPPER LIMB INJURY MANAGEMENT PEARLS
1. Patients with upper limb injuries on wheel chair need to be examined for lower limb
injuries.
2. History must include- Mode of Injury (use interpreter if necessary)
Hand Dominance
Occupation and Hobbies
Time of Injury and Lag time to presentation
3. ALWAYS look for injury to other fingers in the hand, scaphoid tenderness as well as
injury to other limbs and the trunk/head.
4. Analgesia and IM ATT MUST always be provided (unless IM ATT given within last 5
years). Use opioids for amputations.
5. Deformed limbs should be aligned in the long axis as far as possible to preserve
circulation.
6. Patients in severe pain or with a lot of bleeding should be monitored for precipitous drop
in BP
7. Severe pain in a bone-intact limb should make you think about vascular insult, Brachial
Plexus Injury or Compartment Syndrome
8. Pediatric Fractures— minor, undisplaced/non-angulated fractures away from growth
plate may be discharged with back slab and given TCU 3/7 to Paeds Ortho. All others
should be sent to KKH.
80
LOWER LIMB FRACTURE WITH OR WITHOUT DISLOCATION
Triag Conditio Investigatio ED Dispositio Special

e n ns Manageme n Note
Cat. nt
General Principles
Any Open X-ray of Analgesia, Admit

Fracture, involved Antibiotics, Ortho after
Crush or parts (AP + IM ATT DEM
Penetratin lateral) Wound senior
g Injuries Bloods irrigation if consult
including contaminate and inform
GXM d Ortho
STAT by
calling.
Laceratio X-ray of Analgesia, TCU ADMIT
n / Incised involved IM ATT OPS/GP Ortho after
wound parts (AP + Antibiotic if 1/52 for DEM
lateral) if high contaminate wound senior
impact injury; d review; consult for
look for FB For T&S STO 2/52 complicate
after d or deep
copious wounds
irrigation if (i.e.
contaminate breach of
d (100- underlying
200mls or fascia)
more saline
via a
beveled
syringe)
Pelvis
2 Pelvic X-ray pelvis Analgesia Inform Advice to

Fracture AP Pelvic Ortho return if
Bloods binder for STAT for difficulty in
including open-book unstable PU or
GXM fracture fracture haematuri
TRAUMA a.
SERIES IF Admit
HIGH Ortho after
ENERGY DEM
senior
consult for
stable
fractures
who are
unable to
ambulate
81
Able to
walk –
TCU
Fracture
Clinic
2/52.
Hip & Thigh
Neck of X-ray Analgesi Admit Ortho after Treat NOF

Femur pelvis a, CXR, DEM senior fracture in
Fracture AP ECG consult young
Intertrochanter X-ray of pre-op patients (<
ic Fracture involved 60 yrs) like
hip an open
(lateral) fracture, i.e.
inform
Ortho STAT
Hip X-ray For M&R Admit Ortho after All cases
Dislocation pelvis Abductio DEM senior need
AP n pillow consult admission
X-ray of post For
involved M&R prosthetic
hip hip
lateral dislocation,
inform
Ortho early
post M&R
Femoral Shaft X-ray Analgesi Admit Ortho and GXM, large
/ Condyle femur a inform Ortho bore IV
fracture AP + For M&R STAT. Fat
lateral and long embolism needs
Bloods backslab ABG and O2
including , saturation
GXM Donway monitoring.
and ABG splint
TRAUM
A
SERIES
IF HIGH
ENERG
Y
Patella
2 Undisplaced X-ray Analgesi Admit for open Discharge

Patella knee AP a, fractures from DEM
Fracture with + lateral Knee when
intact extensor brace in TCU Fracture patient able
mechanism full Clinic 1/52 to walk with
82
extensio crutches
n NWB
2 Patella X-ray M&R TCU Sports FWB with

Dislocation knee AP with Clinic 2/52 crutches
+ lateral knee in
extensio
n and
long
backslab
Knee Assess INFORM ORTHO All cases
Dislocation popliteal STAT FOR need
and POSSIBLE admission
DP/PT NEUROVASCUL after DEM
pulses, AR INJURY. senior
M&R Admit Ortho consult
STAT Due to
and long worry about
backslab vascular
, X-ray concern
knee AP
+ lateral
after
M&R
3 Knee Effusion X-ray Analgesi TCU Fracture Admit Ortho
knee if a Clinic 1-2/52 after DEM
OM / KIV joint senior
septic aspiratio consult if
arthritis n for septic
suspecte tense arthritis
d effusion, suspected
pressure or previous
bandage TKR.
NO
ASPIRATIO
N IN ED IF
TKR IN
SITU
3 Soft Tissue X-ray Analgesi TCU Knee Clinic Admit Ortho
Injuries (e.g. knee AP a, RICE, 1/52(force-in) to after DEM
ligaments, + lateral Knee see if early repair senior
meniscus) to look brace if is needed. consult if
for unable to tendon
avulsion ambulate rupture
fracture suspected
Chronic Knee X-ray Analgesi TCU Ortho knee Consider
Pain (e.g. OA, knee AP a clinic according to admission for
RA, CMP) + lateral queue. TCU debilitating
physio early. OA/RA flare.
May consider
admitting to
rheumato/DIM
83
as emergency
surgery for OA
RA is high
infection risk
Leg
2 Tibial Spine & X-ray Analgesi To be admitted Small
Tuberosity tibia/fibul a for observation undisplaced
Fractures a AP + & KIV avulsion
lateral Angiogram fracture can
be treated
with long
backslab and
TCU Fracture
Clinic 1-2/52
2 Tibia / Fibula X-ray Analgesia Admit ortho after
Shaft tibia/fibula For M&R if DEM senior
Fractures AP + vascular consult
lateral compromis
e If isolated fibula
Long #,TCU Fracture
backslab Clinic 1/52.
Educate
Compartment
Syndrome
Ankle
3 Archilles X-ray Analgesia TCU Ortho 1 Simmonds’ test

Tendon ankle Below knee week positive
Rupture AP/lateral front slab
to look for with ankle in Admit Ortho
avulsion full plantar after DEM
fracture flexion, senior consult
NWB if calcaneum
crutches avulsed or
tented skin
3 Soft X-ray Analgesia, TCU OPS/GP TCU Ortho
Tissue ankle RICE, crepe 1-2/52 Fast Track if
Injuries AP+latera bandage ligamentous
(e.g. l injuries
ankle suspected or
sprain) SYNDESMOSI
S WIDENED
3 Ankle X-ray For M&R For Weber B
Fracture / ankle AP STAT before fractures, to
and or + lateral x-rays if consult ortho
Dislocatio overlying reg on-call re
n skin is need for
84
compromise admission/ORI
d F.
Short
backslab Admit all ankle
Crutches dislocations
and ankle
ankle fractures
with disruption
of ankle
mortise after
DEM senior
consult.
If for
discharge,TCU
Fracture Clinic
1/52
Foot
3 Talar X-ray Analgesia Admit talar

Fracture / ankle AP neck fractures.
Dislocatio + lateral For others if
n fragments
remain close
together and
joint surfaces
well-aligned->
NWB crutches.
TCU Fast
Track clinic.
If bone
fragments big
-> admit Ortho
3 Calcaneal X-ray Analgesia Admit Ortho if Undisplaced,
Fracture calcaneu Exclude Bohler’s angle extra-articular
m AP + associated disrupted after fracture with
lateral + injuries (e.g. DEM senior intact
axial view long consult or if Boehler’s
axis/spinal bilateral angle can be
injury) calcaneal # treated with
jones bandage
NWB and TCU
Fracture Clinic
1-2/52
3 Tarsal X-ray foot Analgesia TCU Fracture Consult if
Fracture AP + Short Clinic 1/52 suspicious of
lateral backslab, Lisfranc
NWB fracture /
crutches dislocation
before
85
discharge from
DEM
3 Metatarsa Fast track SOC

l Fracture for displaced
Consider
Analgesia MT #s
Lisfranc injury
X-ray foot Short Admit Ortho if
if # of proximal
AP + backslab, open # or NV
1st to 4th MT
lateral NWB compromise or
-> admit ortho
crutches compartment
stat
syndrome in
multiple #s
3 Phalange X-ray Analgesia TCU Ortho
s Fracture toes AP + For M&R of Trauma 1-2/52
and or lateral displaced
Fracture fracture and
Dislocatio buddy splint
n
Others:
3 Laceratio Refer GP / Advice to look
n/ OPS for out for
Incised dressing infection
Wounds change
4 Foot pain TCU Ortho

(e.g. General 4-6
Plantar wks
fasciitis)
86
Ottawa Knee Rule
Use: To identify low risk patients with knee trauma who do not to warrant knee imaging.
Criteria Value
Age ≥ 55 Yes
Isolated tenderness of the patella (no other boney

Yes
tenderness)
Tenderness at the fibular head Yes
Unable to flex knee to 90o Yes
Unable to bear weight immediately and in ED (4 steps,

Yes
limping is okay)
If any 1 of the above criteria is met, this patient may need knee imaging: the rule is
sensitive to rule-out fractures, but not specific to suggest who may have a fracture.
For significant non-bony injuries, often crutches and a knee immobilizer can be helpful to
assist with ambulation.
Ottawa Ankle and Foot Rules
Use: Shows areas of tenderness to be evaluated in ankle trauma patients to determine

need for imaging.
Patients without criteria for imaging by the Ottawa ankle rule are highly unlikely to have a
clinically significant fracture and do not need plain radiographs.
Other conditions for admission to orthopaedics
-All bilateral lower limb fractures that have homecare issues.
-All post prosthesis insertion joint infections (unless very superficial skin infection.
-Extremity abscesses > 4 cm diameter
-Necrotizing Fasciitis of extremities - Start IV Penicillin, clindamycin and Ceftazidime

according to antibiotic guideline.
Management of ingrown toenails
87
Prior to avulsion of nails please ensure diabetic status of patient before undergoing surgical
therapy. In doubt, please consult senior DEM Doctor.
IGTN in diabetics, without paronychia, should be treated conservatively with elevating the nail with
a wisp of cotton.
88
PHYSIOTHERAPY REFERRALS
Pathway for Management of Spinal and other MSK conditions in the Emergency Department
Patient Consultation in ED Yes
No Admit Orthopedics
Red Flag
Yes
Yes
No
Fast Track
Orthopedic SOC
within 3 days
All Types of MSK Pain:

 Acute (< 1 month)
 Sub-acute ( 1-3 months)
 Acute-on-chronic (sudden rise in pain score regardless of duration)
 Chronic (> 3months)
Pain Assessment
(Pain score)
Mild Moderate/Severe
(Pain score 1-3) (Pain score ≥ 4)
Analgesia in ED
 Analgesia
Yes No
 Patient Education
No
 Reassure patient Pain better
 Memo for OPS for

KIV inclusion in Not better
Primary care
Physiotherapy
Pathway
dc from EOWAdmitguidelines
EOW as per
Is daily function
No significantly affected? Yes
 Analgesia  Analgesia
 Patient Education  Patient Education
 89
TCU Physio (next available)  TCU Physio < 1 week and TCU
Ortho
Discharge
Conditions suitable for outpatient referral to Physiotherapy
Neck  Neck sprains

 Non-traumatic neck problems e.g.
spondylosis
 Acute wry neck
Back  Acute non-specific low back pain
 Lumbar spondylosis, lumbar spinal stenosis
 Back pain with radiculopathy
Shoulder  Rotator cuff/biceps tendinopathy / minor
tears
 Shoulder contusion
Elbow and  Elbow/wrist contusion
wrist  Elbow/wrist sprain
 Tennis’s elbow, Golfer’s elbow
Knee  Ligament sprains
 Meniscus injury
 Anterior knee pain such as patellofemoral
pain
 Arthritis
Hip  Arthritis
Foot and  Ligament sprains
ankle  Achilles tendinopathy
 Plantar fascitis
 Arthritis
Soft tissues  Hip adductors
injuries  Hamstrings
 Quadriceps
 Calf
Elderly falls  Falls due to balance issues
 Recurrent falls
 Falls requiring walking and balance
assessments
Physiotherapy referral pathway by Dr Sohil (Dec 2016)
90
PODIATRY REFERRALS
(SGH DEM and Podiatry collaboration)
Podiatry will be providing consult in the emergency department with effect from 11 January 2014
for specific foot conditions.
Feel free to call The Podiatry on-call hp within the timeframe listed below if you find that the patient
will benefit from podiatry input and/or follow-up. The on-call Podiatrist will attend the ED within 15
minutes to triage the patient.
As their service is only during office hours, in the event that you see a patient after office hours
and has no other acute conditions that require admission, you can arrange for the patient to
present to Podiatry the next day or Monday morning with an ED referral letter if the problem is
urgent. For non-urgent problems please book the next available outpatient appointment (see
criteria below).
Please direct them to go to the Podiatry clinic located on Blk 1, level 1 within the Rehab
department.
For initial assessment in the ED, the patient would not be charged any additional fee beyond the
ED charges. However, please let patient know that for subsequent reviews at the podiatry clinic
and or surgical procedures done while in the ED or as outpatient in their clinic, payment is as for
any outpatient care rendered.
Conditions suitable for podiatry referral:
Inclusion criteria:
Urgent (Patient can present to Podiatry as a walk-in)
a) DM foot with ulcers
b) Any foot ulcers (ischemic, venous)
c) Ingrown toe nails (State on referral that referring doctor gives approval for nail avulsion under
local anaesthetic if indicated)
d) Localized paronychia on toes
Non-Urgent (Patient should be booked the next available outpatient appointment)

e) Newly diagnosed DM for DM foot screening
f) Musculoskeletal / overuse injuries
Exclusion criteria:
a) Do not refer any traumatic lacerations or fractures to podiatry.
b) Do not refer anyone with cellulitis with ascending lymphangitis, necrotizing fasciitis and the
likes.
c) Do not refer anyone with an acute ischemic limb please
If in doubt, please consult the senior ED physician on shift for further advice.
Service hours:
Mondays to Fridays 8 to 5 Podiatrist on-call: 81256460 Podiatry Contact:
pm Sophie Whitelaw
91 Principal Acute Podiatrist
Sophie.coral.whitelaw@sgh.com.sg
Saturdays 8.30 to 1 pm.
8125 6460
Podiatry Contact:
Sophie Whitelaw
Principal Podiatrist
Sophie.coral.whitelaw@sgh.com.sg
92
Workflow for DEM to Podiatry referral
DEM Patient requiring

Podiatry input
During OFFICE Hours After Office hours

Week day 8am – 4.30pm After 4.30pm on week days
Week- ends Sat 8am – 12.30pm After 12.30pm on Sat
Sun/Public holidays)
ED Nurse to call the podiatry

re: patient and location of patient
93
Technique of Knee aspiration for diagnostic/therapeutic Knee Effusions
DEM
- Flex the knee to 90 deg if possible. If patient is in too Dr topain
much treattoas necessary
flex, then leave the
knee in extension.
Podiatrist On- Call:
8125 the
- From 6460lateral aspect of the affected knee, mark the point 1/3 from the superior aspect
of patella. Alternatively mark the point inferior to the femoral condyle and superior to the
IF for discharge, then IF for admission, then
tibial plateau at the lateral aspect of the knee.
arrange outpatient carryout admission as
podiatry
- Using sterile technique, clean the knee with per usual solution
apt then chlorhexidine
cetrimide, process.
** if patient fits Refer to inpatient
followed
Podiatry willby iodinept
assess solution.
in ED Leave the iodine solution to dry before attempting aspiration.
inclusion criteria) Podiatry team if
-Attach a green needle to a 20ml syringe. Enter from the marked point necessary
as described above
Fax: referral to 6220
and aim the needle towards the suprapatella pouch.
2577
DEM doctor to review podiatry
- Aspirate the knee effusion until you can a dry knee tap. Note and document the
input and decide disposition and
appearance of the aspirate, namely purulent, bloody or straw coloured. Send the aspirate
subsequent care.
for stains and cultures. You will need 7 bottles, each with 3-5mls of aspirate.
- They are to be sent for knee aspirate :-
1. G stain
2. Culture
3. FEME
4. Crystals
5. AFB smear
6. AFB culture
7. Fungal culture
Additional precautions
-Do not advance the needle after withdrawal so as to minimize any risk of introducing infection
to the knee.
-When removing the 1st syringe, one may like to attach a 2nd new syringe the needle stat so as
to minimize open exposure of interior knee environment.
-Hemophiliacs and over-warfarinised patients with tense knee haemarthrosis should not have
knee aspiration unless the coagulopathy is corrected.
94
BITE WOUNDS PROTOCOL
History
Points to note:
1. Time of bite, location/ country of event.
2. Type of animal & its status. ( Health, vaccination history, behaviour)
3. Location of bites
4. Treatment received so far.
5. Patient’s medical history ( ?immunocompromised, DM, PVD, tetanus vaccination hx)
Physical Examination
Points to note:
1. Distal neurovascular status
2. Tendon or tendon sheath involvement
3. Bone injury
4. Joint space violation
5. Visceral injury
6. FB (e.g. teeth) in wound
Investigations
1. X-ray the affected region, usually an extremity to exclude FB, fracture.
2. Labs usually not indicated unless patient septic, and requiring admission.
Treatment
1. Tetanus prophylaxis ( IM ATT)
2. If complicated bite wound requiring surgical debridement, especially with
neurovascular/ tendon involvement, to consult Hand/ Ortho/ Vascular urgently.
3. If simple bite wound, for copious irrigation in the A&E. Recommend running tap water
if possible, otherwise copious saline flush.
4. Generally, to leave wounds open to heal by secondary intention.
5. Exception, for facial wounds, to refer to Plastics or primary closure.
6. To give oral Augmentin 625 mg bd x 1/52
If allergic to penicillin, give Clindamycin 300mg qds & Ciprofloxacin 500mg bd x 1/52.
________________________________________________________________________
Special cases:
1. For human bites, treat as for needle stick injury, with Hep B, C, HIV screening.
KIV prophylaxis. Give ID follow-up appointment.
2. For monkey bites, to consult ID/ IM physician for PEP valacyclovir and follow-up.
_______________________________________________________________________
Follow- up
Close follow-up essential.
Review within 48 hours for low-risk wounds and within 24 hours for high- risk wounds.
95
PAEDIATRICS
RECOGNIZING A SICK CHILD WHO NEEDS TRANSFER TO KKH
The Sick Child would include a child with the following:
1) Hemodynamically Unstable:
a) Pulse rate: <= 60 for all age group if haemodynamically unstable,
>=180 if younger than 5 years old, >=160 if older than 5 years old,
Tachycardia is often the 1st sign of shock, also consider SVT
b) Respiratory rate: >60 or < 16 in newborn to 1 month, >=50 or <=8 over 1 month
Clinical Evidence of severe respiratory distress:
a) Moderate to severe supraclavicular, sternal or intercostal retractions
b) Moderate accessory muscle use
c) Nasal flaring <2 yrs old
d) Grunting respiration
e) Tripod position
f) Recent stridor <12 hrs
g) Cyanosis (or history of cyanotic event, especially in infants)
c) Blood pressure: Neonate: <60 mmHg, Infant (1 month to 1 year): <70mmHg,
Child: SBP less than (70+age x 2)
Clinical Signs of shock:
Pale, sweaty, drowsy, thready pulse, cool peripheries, cap refill > 2 sec
d) Glasgow Coma Scale: <=14
e) Pulse oximetry: <=92%
96
2) High risk markers of serious illness in infants under 6 months:
Feeding <1/2 normal, Weak cry, Decreased activity, Convulsions, Apnoeic episodes,
Cyanotic episodes, Pale and hot, Green vomitus, Bloody stool, < 4 nappies in 24 hrs
3) Major trauma:
a) Mechanism of trauma:
i) Fall from greater than 10 feet or 3 body heights
ii) Motor vehicle crash:
Shattered windscreen
Intrusion into passenger compartment
Bent steering wheel
Vehicle rollover (with unrestrained patient)
Ejection from vehicle
Death of any occupant
Extraction time more than 15 mins
iii) Bicycle injuries (especially handle bar injuries to the abdomen)
iv) Motor vehicle versus pedestrian incident (at >20 mph/ 32 km/h)
v) Burns: > 10 % BSA, facial burns
v) Blast injuries
vi) suspected inhalational injuries
b) Abnormal Physiology: Age dependent variables are HR, RR, BP
AGE HEART RATE RESPIRATORY RATE
Minimum Maximum Minimum Maximum
Birth – 3 months 90 180 30 60
97
3 months – < 6 months 80 160 30 60
6 months – <1 year 80 140 25 45
1 year – 6 years 75 130 20 30
6 years – < 10 years 70 110 16 24
10 years – < 14 years 60 100 14 20
14 years and above 60 100 12 16
Adapted from the Canadian Paediatric ED Triage & Acuity Scale & Melbourne
Metropolitan Ambulance Service guidelines
AGE SYSTOLIC BLOOD PRESSURE
Minimum Maximum
0 – 1 month 61 105
1 month – < 1 71 (>70) 105

year
1 year – < 2 year 81 (>80) 105
2 year – < 3 year 81 109
3 yr – < 4 yr 81 112
4 – < 5 yr 81 114
5-<6 81 115
98
6 – < 7 yr 82 116
7 – < 8 yr 84 118
8 – < 9 yr 86 119
9 – < 10 91 (>90) 120
10 – < 11 yr 91 122
11 – < 12 91 124
12 – < 13 91 126
13 – < 14 91 129
14 – < 15 101 (>100) 131
15 – < 16 101 134
16 –< 17 101 136
17 and above 101 139
Adapted from: National High Blood Pressure education Program Working Group, National
Heart, Lung and Blood Institute. The 4th report on the diagnosis, evaluation and treatment
of high blood pressure in children and adolescents. Pediatr 2004;114(2);555 – 76.
c) Severe Anatomical disruption
Initial Management Principals follow that of adults, viz Airway, Breathing, Circulation, using
age specific equipment and weight-based dosage. Use a Broselow-Luten tape.
Call the friendly KK CE Senior Shift Dr to discuss all transfers which may be via CHETS,
ambulance or own transport depending on the severity of the child.
99
Compiled by:
Dr. Jade Kua
Prof Ng Kee Chong
Dr. Arif Tyebally
Childrens’ Emergency, KKH
WORKFLOW FOR CASES REFERRED FROM SISTER EMERGENCY DEPARTMENTS

TO KKH CHILDREN’S EMERGENCY (CE)
DIRECT ADMISSION
CALL KK CE SENIOR ABOUT DIRECT ADMISSION (SEE MONTHLY

KK CE SENIOR ROSTER WITH THE SENIORS’ HANDPHONE
NUMBERS)
TO BOOK CLASS OF BED, CALL 6394 1188 OR 63941187
NOT FOR DIRECT ADMISSION
ALL CASES SEEN BY THE EDs FROM SGH, CGH, TTSH, KTPGH,
JGH, NUH AND SENT OR THAT PRESENT TO KK CE WILL BE
SEEN BY CE WITHIN 15 MINUTES OF BEING RE-TRIAGED BY
KKH.
NO NEED TO CALL KK CE UNLESS –

NON KKH ED REQUIRES SPECIAL CONSULT ON SPECIFIC
ASPECTS OF THE CASE
Note –
If Case Needs Specialised Transport – Call KKH CHETS (Children’s Hospital

Emergency Transport Service) Team @ 63941778 Not KK CE.
While there is a main telephone line at KK CE, this is not fully manned at all times
and hence this mode of contact is not recommended for emergency calls.
100
TREATMENT OF COMMON CONDITIONS IN PAEDIATRIC EMERGENCY MEDICINE
(Dr Chan Jing Jing)
This section serves as a quick reference for the cases we commonly see in DEM P2/3 area
only and is NOT meant to replace the CE guidelines (available from KK Intranet accessible
from SGH Intranet) or clinical judgment, nor does it replace a proper history and physical
examination to rule out emergent conditions. Please refer to a shift senior if you are not sure.
Remember:
1) Vitals should be appropriate for age, if not please inform a senior.
2) Involve parents in the care of the patient and do not separate child from parent where
possible!
Casemix in DEM
All ill-looking or unstable patients must be seen in resus.
Situations where stable cases may be re-directed to KK:
Investigations not available in DEM eg clean catch urine for UFEME to work up a preverbal
child for fever x 5/7
Treatment/facilities available only in KK eg laceration which clearly requires Ketamine
sedation, post circumcision bleeding
Fever
History Physical Management Special Notes
Examination
Besides eliciting the Perform a thorough If Temp>39 at Always recheck ALL
usual history to physical examination, triage, serve stat vitals before
localize the source of especially in the pre- doses of: discharge!
fever, ask also: verbal child. Look out PO Paracetamol Prolonged or high
Past medical history for:
15mg/kg (above 3 fever does NOT
eg. Ex-prem with Vitals not months) OR increase the risk of
chronic lung appropriate for age PO Ibuprofen febrile fits - do not
disease Hydration status 10mg/kg (if feed fever phobia!
Contact history Include in your
examination:
Paracetamol served Advise thin clothing,
Intake and output ie recently, and only if tepid sponging, oral
amount of fluids Otoscopy (for otitis
media) above 1 year old) hydration
taken, and number Find the source
of PUs/ diaper Mouth (HFMD,
tonsillitis) (usually viral) and
changes, including treat appropriately.
how heavy the Genitalia and
perineum Common causes:
diapers are UTI, pneumonia,
Activity level URTI. Consider
malignancy,
Kawasaki’s.
101
Respiratory
History Physical Management Special notes
Examination
Bronchiolitis Respiratory Nebs: 3mls of 1:1,000 Use Respiratory
Presents with conditions are what Adrenaline Index Score (RIS) to
wheezing following kill in children. No need for CXR if prognosticate (KK
URTI typical – clinical dx! book)
Birth history Look out for signs
of respiratory
Ask for feeding (see
distress:
notes on “Fever”)
Tachypneoa
Asthma Nebs: <10kg use 0.5mls Consider discharging
Subcostal/interco with Asthma Action
Atopic triad: of Salbutamol and
stal retractions Plan with tailing
asthma, eczema, Atrovent, >10kg use
“Head-bobbing” ventolin (print from
allergic rhinitis 1mls each
Nasal flaring CE book)
Triggers: URTI, Steroids: PO
Grunting
pets, carpets, Prednisolone 1.5mg/kg
Tripod position Discharge follow up to
stuffed toys stat then for 5/7 on be based on criteria
Drooling
Compliance to discharge OR (see flowchart under
Silent chest
meds IV hydrocortisone 4- Asthma in KK book)
SpO2<95%
5mg/kg
IV MgSO4 50mg/kg over
20min
CXR only if first wheeze
or not responding to
treatment
Blood gas if moderate to
severe attack
Croup Steroids: PO Consider other
Recent URTI, fever Dexamethasone causes of stridor in a
Complaint of “noisy 0.6mg/kg stat (crush child, eg epiglottitis,
breathing” tablets and dissolve) foreign body,
retropharyngeal
Nebs: (only if in distress)
abscess
3mls of 1:1,000
Adrenaline Use Wesley Croup
Score for severity (KK
book)
Pneumonia High dose amoxicillin is Admission for children
Fever, tachypnea first line as per under 6 months
and cough international guidelines
History of recent
abx
URTI Oxymetazoline nose drops Do not give
Contact and travel (Iliadin): doses in mucolytics
history RxManager (bromhexine,
PO Promethazine: fluimucil) for more
0.1mg/kg every q6H if 2 than one week as
years and older (prescribe these will cause
only ONE antihistamine at prolonged cough
a time)
PO Chlorpheniramine
0.1mg/kg TDS if between
6 months and 2 year old
102
Gastrointestinal
History Physical Management Special Notes
Examination
Contact history Assess hydration Mild Discharge only if
Rule out other status PO Ondansetron: tolerating orally and
causes of vomiting Look for surgical (1st line anti-emetic, no more abdominal
(including abdomen only in >1yo) 0.1- pain
conditions such as 0.2mg/kg once. Clinical findings and
meningitis, DKA, Syringe out required abdominal pain
UTI, testicular amount from vial advice must be
torsion) and give it orally. documented before
Stocked at DEM discharge.
pharmacy. DO NOT give
PO MgCO3 if buscopan, lomotil or
abdominal pain maxolon
present. DO NOT discharge
Consider short with Ondansetron,
observation with and do not give it
trial of feeds 30min “prophylactically”.
after ondansetron:
<3 years old: 15mls
every 15 min x 4
>3 years old: 30mls
every 15 min x 4
Moderate to Severe
IV hydration, obtain
VBG and correct
electrolytes. Senior
review, then
transfer.
Chan JJ with Pek JH, Dec 2014

Based on KK CE’s June 2014 guidelines
103
NEONATAL JAUNDICE (GUIDELINES FOR SGH A&E DEPARTMENT)
Disclaimer: This guideline is meant for SGH A&E management of NNJ. If in doubt,
please inform Neonatal Registrar on call.
1 Policy
1.1 Well babies with serum bilirubin levels very near to or exceeding phototherapy
criteria require early admission to SGH Neonatal wards. The Neonatal Registrar
on-call should be informed and approve.
1.2 Jaundiced babies who appear unwell, septic-looking, have abnormal vital signs
or hemodynamic instability should be resuscitated and transferred to a tertiary
paediatric hospital for appropriate care.
2 Standards / Guidelines (optional)
Refer to guidelines below
3 Definition
3.1 A “neonate” is defined as an infant aged less than 30 days old.

3.2 “Gestation” refers to the gestation of the baby at birth
3.3 “Neonatal Jaundice” (or NNJ) refers to jaundice (a yellow discoloration of the
skin) occurring soon after birth and commonly resolves by the end of the
second week of life.
3.4 “Prolonged neonatal jaundice” refers to NNJ lasting for ≥15 days.
3.5 “SB” refers to the serum bilirubin.
3.6 “PT” refers to single blue phototherapy.
3.7 “DB” refers to double blue phototherapy.
3.8 “EXΔ” refers to exchange transfusion.
4 Procedure
Refer to guidelines below.
5 Reference Documents
NA
104
GUIDELINES
1. The history includes (but is not limited to) the following:
 Date and time of birth (to calculate the exact age as “hours of life”)
 Preterm or term gestation
 Difference between birth weight and current weight (relative hydration status)
 G6PD deficiency (check baby’s health booklet)
 Cord blood TSH level (check baby’s health booklet)
 Perinatal medical history (check baby’s health booklet)
 Feeding history and type of milk (breast milk or formula milk)
 History of illness – e.g. fever/ poor feeding/ vomiting/ weight loss
 Maternal / Baby ABO-Rh blood groups
2. Babies with jaundice exceeding phototherapy levels require early admission to SGH
Neonatal Wards. Such admissions require approval of the Neonatal Registrar on-call.
Please refer to the table below (serum bilirubin as umol/L)
 Admit babies who require “single blue phototherapy” (PT) or “double blue phototherapy” (DB)
to nursery (NEO1) WD 53.
 Admit babies needing intensive phototherapy or “exchange transfusion” ( EXΔ) would be

admitted to the High Dependency nursery (NEO2) at Ward 54.
Babies 35 weeks gestation with Abnormal Jaundice States
DAY (HOUR) LOW RISK (UMOL/L) MEDIUM RISK (UMOL/L)

PT DB EXΔ PT DB EXΔ
D1 (24H) 130 225 255 100 200 230
D2 (25-48H) 170 250 280 130 225 255
D3 (49-72H) 220 295 325 190 260 290
D4 (73-96H) 260 330 360 230 285 315
D5 (97-120H) 290 350 380 245 295 325
D6 ONWARDS
305 370 400 255 295 325
(>120H)
PT = single blue phototherapy level

DB = double blue phototherapy level
Ex = exchange transfusion level
Low Risk: Gestation full term (37 weeks or more) without risk factors
Medium risk: Gestation 35 to 36 weeks 6 days without risk factors OR Gestation full term with any risk
factor:
 ABO/Rh incompatibility, G6PD deficiency, DCT +ve
 Altered blood-brain barrier (BBB): sepsis, asphyxia, acidosis, significant lethargy, temperature
instability, albumin <3g/dl (if available)
3. Babies <35 weeks gestation: Consult Neonatal Registrar or MO for advice.
105
4. Only well, non-infected babies with no other medical problems can be admitted to SGH
neonatal wards. Babies with the following symptoms/ signs should not be re-admitted to
SGH but will require transfer to a tertiary paediatric hospital (KKH or NUH) for admission
and management:
 fever, symptoms and signs of infection

 lethargic, quiet, or irritable
 poor feeding, vomiting or dehydration
 respiratory distress, cyanosis or pallor
 an otherwise unwell infant requiring inpatient observation, isolation, workup or investigation
5. Babies with the following may be discharged from A & E to a general practitioner / Family
doctor/ Polyclinic/ Neonatal Outpatient clinic (located at O&G Centre, block 5 Level 1) for
outpatient review:
 SB already shows a downward trend;

 SB remains stable over the past 24-48 hours and baby remains clinically well;
 Baby born at term and aged > 7days with no risk factors (refer to abnormal criteria above)
 Baby born preterm (<36 weeks gestation) and aged > 10days with no risk factors (refer to
abnormal criteria above)
6. Discharge instructions:
 Ensure adequate hydration and normal bowel movement

 Return to A&E immediately if unwell e.g. poor feeding, vomiting, febrile.
 “Sunning” the baby is strongly discouraged as it is ineffective in lowering SB levels and will
cause sunburn and dehydration.
 Feeding baby with supplementary water in place of milk is not recommended.
 No treatment is required at this point; only careful assessment is required.
Keep appointment at SOC/ polyclinic/ neonatal clinic
7. Prolonged NNJ (defined as NNJ lasting for ≥ 15 days)
 Phototherapy should not be routinely instituted.

 Most babies with prolonged jaundice require careful evaluation for the cause of prolonged
jaundice, including physical examination and investigations. Consult the Neonatal
Registrar and refer to the Neonatal Outpatient clinic (at Obstetric Gynaecology Centre,
Block 5 Level 1) with an appointment within the next 3 working days.
106
NNJ (≤14 days)
Essential history:
DOB time of birth, prem?

Day of life, weight
G6PD, cord TSH status
Feeding regime, type of milk
Fever/poor feeding/vomiting/
Assess vital signs (Temp, weight loss
HR, RR, SpO2, BP) Maternal/Baby blood group
Clinically unwell or
Clinically well
abnormal vital signs
SB not available Resuscitation as required

Office hours (After office inform Neonatal
hours/weekends) Reg/MO
Transfer to other
institution by ambulance
OGC (Neonatal clinic) Do SB at DEM
or CHETS team after
stabilization
Refer to Table 1 for

admission criteria
Call Neonatal Reg/MO
on call if admission or
advice needed
Updated September 2017

Drs Poon Woei Bing, Daisy Chan, Amanda Zain
107
PALLIATIVE MEDICINE IN THE ED
(Dr Puneet Seth)
SGH DEM sees a large number of patients who are on palliation. Most of these patients
are under the care of Medical Oncology, but may come from Respiratory, Cardiology or
Gastroenterology,
The DEM Comfort Care Protocol was created to allow care for such patients to be
expedited. Refer to Infonet for details. Forms are kept in the Resuscitation Room.
108
PSYCHIATRY
MENTAL HEALTH (CARE AND TREATMENT) ACT (MHCTA)
Institute of Mental health (IMH) is one of the two Designated Psychiatric Institutions (DPI) in
Singapore gazetted under the Mental Health (Care and Treatment) Act for the purpose of detaining and
treating mentally disordered persons under the Act. The other DPI in Singapore is Changi Prison
Complex Medical Center.
Section 7: Apprehension of mentally disordered person
It shall be the duty of every police officer to apprehend any person who is reported to be mentally
disordered and is believed to be dangerous to self or other persons by reason of mental disorder and
take the person together with a report of the facts of the case without delay to —
(a) any medical practitioner for an examination and the medical practitioner may thereafter act
in accordance with section 9; or
(b) any designated medical practitioner at a psychiatric institution and the designated medical
practitioner may thereafter act in accordance with section 10.
Section 9: Mentally disordered person may be referred to psychiatric institution

Where a medical practitioner has under his care a person believed to be mentally disordered or to
require psychiatric treatment, he may send the person to a designated medical practitioner at a
psychiatric institution for treatment and that designated medical practitioner may thereafter act in
accordance with section 10.
Section 10: General provisions as to admission and detention for treatment

(1) A designated medical practitioner at a psychiatric institution who has examined any person who is
suffering from a mental disorder and is of the opinion that he should be treated, or continue to be
treated, as an inpatient at the psychiatric institution may at any time sign an order in accordance with
Form 1 in the First Schedule -
(a) for the admission of the person into the psychiatric institution for treatment; or
(b) in the case of an inpatient, for the detention and further treatment of the person,
and the person may be detained for a period of 72 hours commencing from the time the designated
medical practitioner signed the order.
(2) A patient who has been admitted for treatment or detained for further treatment under an order
made under subsection (1) may be detained for a further period of one month commencing from the
expiration of the period of 72 hours referred to in that subsection if —
(a) before the expiration of the period of 72 hours, the patient has been examined by another
designated medical practitioner at the psychiatric institution and that designated medical
practitioner is of the opinion that the patient requires further treatment at the psychiatric
institution; and
(b) that designated medical practitioner signs an order in accordance with Form 2 in the
First Schedule.
(3) A patient who has been detained for further treatment under an order made under subsection (2)
shall not be detained for any further period at the psychiatric institution for treatment unless before the
expiration of the period of one month referred to in that subsection, the patient has been brought before
2 designated medical practitioners working at the psychiatric institution, one of whom shall be a
psychiatrist, who have examined the patient separately and who are both satisfied that he requires
further treatment at the psychiatric institution. Form 3 up to 6 months.
109
WORKFLOW FOR MANAGEMENT OF MENTALLY DISORDERED PATIENTS IN DEM
DISPOSITION OF PSYCHIATRIC PATIENTS IN DEM
Indications for admission under Psychiatry:

For general psychiatry patients, they only admit patients who are 18 years and above (have
to have turned 18), EXCEPT for cases with eating disorders, they admit those >13 years
(the calendar year they turn 13 is OK e.g those born in 2004 in the year 2017)
So for the under 18s without eating disorder, the alternate sites of admission are:
1. IMH
2. NUH
3. Private psychiatrist
Discharging patients with outpatient SOC appointment

- Patients presenting with insomnia/mild anxiety – Discharge with Tab Hydroxyzine 10-
25mg which is less addictive and which you can give for a longer duration like 2 weeks
till they are reviewed in the psychiatry clinic. It is less addictive than giving
Benzodiazepines and also addresses the issue of patient presenting to ED for benzo
abuse
- If prescribing benzodiazepines – to prescribe not more than 3 days duration
- Kindly Follow the workflow below for outpatient referral to psychiatry clinic
- Patients eligible for SOC appointment to Psychiatry clinic at SGH should be given an
appointment in 1 week
Indicators for Outpatient Referral to Psychiatry clinic

110
Psychiatry will not accept the following cases for outpatient review:
1. Patients who NEITHER live near SGH nor are also NOT on medical follow-up in SGH -
please refer them to psychiatry in the nearest RH. (ALL the RHs have a Psych dept)
2. Patients <18 (except Eating Disorder cases >13 years as mentioned above)
3. Addiction problems
4. Those with past psych history followed up elsewhere (please inform them to see their
own psychiatrist first to get a proper transfer memo to SGH if patients request to be
followed up at SGH)
PROCESS FOR TRANSFER OF PATIENTS UNDER SECTION 9 OF MHCTA FROM SGH

ED TO IMH
1. After a mentally disordered patient is reviewed by doctor in the ED and also by the
psychiatrist on-call, according to the workflow described above, decision will be made
to transfer the patient to IMH for further definitive management
2. If the patient or accompanying family members, for any reason, refuse the decision
made by the doctors to transfer the patient to IMH and if this patient is deemed as
being a risk to himself/herself or to the society due to refusal of care at IMH, pursuant
to Section 9 of MHCTA, SGH ED doctor/psychiatrist on-call may send the person to a
designated medical practitioner at IMH for treatment and that designated medical
practitioner at IMH may thereafter act in accordance with section 10.
3. The initial management of these patients with acute behavioural disturbances should
aim for the rapid tranquilization as this reduces the risk of harm to the individual as
well as to all health care workers involved with their care. The following strategies may
be adopted:
a) Verbal calming and de-escalation techniques
b) Physical or manual restraint - This should be kept to a minimum using a level of
force that is reasonable and proportional to the individual case and should be
rapidly followed by sedation with close monitoring of vital signs.
c) Chemical restraint/Sedation - The clinician must make a decision regarding the
safety of the patient (minimizing duration of restraint) and team (avoiding both
physical and needle stick injury) as to whether it is better to attempt cannulation
(accepting the difficulty of the procedure in an uncooperative patient) for
intravenous sedation or whether to administer an intramuscular agent of sufficient
strength to allow rapid control of the patient followed by cannulation and monitoring
of vital signs. It is important to note that the absorption of IM medication can occur
far more rapidly when an individual is agitated or physically overactive. It should
also be remembered that these individuals may need much higher doses of
sedative agents than are typically required or recommended.
Note: There are currently three groups of agent used for sedation -
benzodiazepines (eg. diazepam) and antipsychotics (eg. haloperidol) or ketamine.
However, there is a lack of high quality evidence in the literature to determine the
most suitable single agent or a combination of agents.
4. Once the patient is adequately sedated and monitored, the individual should be
transferred to IMH in an ambulance accompanied by the ED nurse.
111
5. Decision to activate hospital security and/or police officers for highly agitated patients
or family members should be on a case by case basis
CHEMICAL RESTRAINT IN DEM

Benzodiazepines are generally the medications of first choice
Anti-psychotic medications should be restricted to those who have psychotic symptoms or
who have been previously treated with anti-psychotics. Those who have never been exposed
to anti-psychotic medications may respond to smaller doses.
The doses appended below are recommended for physically healthy average- sized adults
Drug Type Initial Dosage Max dose

in 24 hrs
Oral Haloperidol Antipsychotic 2- 5mg 30mg
IM Haloperidol Antipsychotic 5 mg stat & tds 20mg
prn
Oral Olanzapine Antipsychotic 5-10 mg 20mg
Oral Quetiapine Antipsychotic 50-100mg 400mg
Oral Lorazepam Benzodiazepine 1– 2 mg tds prn 4-6mg
IM/IV Diazepam Benzodiazepine 10 mg stat tds 30mg
prn
Oral Promethazine Antihistamine 25mg 100mg
IM Promethazine Antihistamine 25mg 100mg
Table 1: Common Medications used during chemical restraint
Note: please consult ePharmacopeia for more details

IV Diazepam should be administered over 5 minutes. Have Flumazenil available. If suspected benzodiazepine
overdose, 0.2mg IV Flumazenil may be given over 15 seconds, then 0.1 mg Iv repeated every 60 seconds until
desired level of consciousness has been achieved. (Consult DEM senior doctor for advice in such cases.)
Reduced Dosages
Use half the recommended doses for patients who are very young or elderly, or who have
renal/hepatic impairment, or who are dehydrated.
Use oral medications wherever possible. If oral medication is not possible or is ineffective
intramuscular injection may be considered.
If there is no desired response after 30-60 minutes:

- Give another dose of the initial agent.
- Give a dose of an agent which has not been tried.
- If desired response is still not achieved following this, the psychiatrist on call should be
consulted for further management.
Post Chemical restraint monitoring

112
CR should be carried out in a place where resuscitation equipment and medications are
available. Appropriate monitoring and positioning of patients post CR is required to ensure
that there is no airway obstruction, respiratory depression, aspiration, hypotension.
Where anti-psychotic medications have been administered, monitor for extrapyramidal side
effects e.g. laryngospasm, dystonia, or akathisia.
Level of sedation
Aim to achieve sedation and calmness in the patient. If asleep, the patient should be
arousable but not unconscious.
Monitor the following parameters

 Temperature
 Pulse
 Blood pressure
 Respiratory Rate
 Continuous SpO2
If SaO2 is less than 95% (measured by pulse oximeter) give supplemental oxygen.
If respiratory rate is < 10/min or SaO2 <90% following benzodiazepines, contact senior
doctors for advice with a view to administer Flumazenil.
If orthostatic blood pressure drops by > 20% of systolic baseline, or diastolic values drops to
<50mmHg, senior doctors should be consulted.
Should the patient be given more than one injection, the monitoring schedule is timed from
the last injection.
Frequency of Monitoring
 Every 15 minutes for 60 minutes post- injection
 Every 30 minutes for the next 60 minutes, then
 Hourly until patient is awake
RISK FACTORS TO EVALUATE THE SERIOUSNESS OF A SUICIDE ACT
Risk factors are useful in helping clinicians to evaluate the seriousness of a suicidal act and
assess the predictive likelihood of a repeated attempt.
Circumstances suggesting high suicidal intent
Advance planning
Precautions to avoid discovery
No attempts to obtain help
Dangerous method (as perceived by patient)
“Final acts” i.e. leaving a suicide note, preparing a will
Predictive factors for suicide
Serious intent (see previous table)

Previous suicide attempts
Psychiatric illness (especially Depression)
Alcohol and/or substance abuse
Personality Disorder
Personal factors: Elderly, male, widowed, divorced, living alone
113
Social Factors: lack of social support, unemployment financial difficulties,
relationship problems
Workgroup members:
Dr Sohil Pothiawala (DEM), Dr Lee Huei Yen (PSY), Dr Jaufeerally (DIM), Dr Victor Kwok (PSY)
114
RENAL
DEM note: Call PD nurse to help with drawing effluent and giving IP antibiotics. PD nurses are on call at home after office hours. DEM doctor to order tests for peritoneal fluid
only if found cloudy by PD nurse.
RESPIRATORY
(Dr Jeremy Wee/Dr Kenneth Tan)
APPROACH TO PATIENTS PRESENTING WITH SHORTNESS OF BREATH
Shortness of breath is one of the more common presentations to the emergency department.
The challenge is that there is a wide variety of differential diagnosis. The below table is a list of
differential diagnosis but not exhaustive.
SYSTEMS DIFFERENTIAL DIAGNOSIS HISTORY / PHYSICAL EXAMINATION
CARDIOLOGY CCF/APO History of IHD

Chest pain , SOB with exertional
Angina equivalent (no CP, but symptoms
SOB) Fluid indiscretion
Bibasal crepitations
LL swelling
ECG changes
RESPIRATORY Asthma Known history of asthma

Wheezing
COPD Smoker, known COPD

On LTOT
Wheezing with crepitations
Pneumonia, infective causes eg

Fever, cough
bronchitis Unilateral crepitations, dullness to
percussion
Septic looking
+/- wheezing
Pulmonary embolism Will be discussed in next chapter
Other chronic lung diseases eg

Known history of CLD
pulmonary fibrosis Bilateral crepes +/- wheezing
RENAL Fluid overload in ESRF/CRF Known ESRF,

patients AVF not working
AOCRF fluid indiscretion
ingestion of nephrotoxic drugs
bibasal crepitations
AVF present with weak or no thrill
GI Symptomatic Ascites Hx of CLD, abdominal distension, gain in

weight
Anasarca from liver disease Signs of CLD, ascites
Decreased air entry bilaterally
NEUROLOGY Neuromuscular disorders eg Hx of neuromuscular disorders. May

myasthenia gravis, Guillian Barre
present with softness of voice and
generalized weakness
Clinically can have abdominal/paradoxical
breathing, ptosis
METABOLIC Severe metabolic acidosis eg,Known hx of DM, or evidence of polyuria,

DKA, salicylate, toxic alcohol polydipsia. Hx of overdose.
overdose, ARF +/- Clear lung fields, Kussmaul’s
breathing (air hunger)
OTHERS Stridor eg. Epiglottitis Fever with sore throat, hx of allergy

angioedema, Ca larynx Hx of Ca or RT
Inspiratory and expiratory stridor +/- clear
lung field
Urticarial, periorbital edema
Pericardial effusion Hx of Ca, recent MI or cardiothoracic

surgery
Beck’s triad, +/- clear lung fields
117
Investigations
After history taking and physical examination, appropriate investigation should be done to reach
a diagnosis. It can be divided as below:
Blood tests Miscellaneous Radiological
1. FBC 1. ECG 1. CXR

2. Renal panel 2. Hypocount 2. CT Pulmonary angiogram if
3. ProBNP indicated
4. ABG in selected cases eg, severe 3. Bedside US to look for pericardial
asthma, pts in respiratory distress, effusion or evidence of PE
severe COPD
5. D dimer- only if there is suspicion of
PE
6. LFT if suspected or known liver
disease
Management
The below subgroups of patients must be managed in the resus area:

1. Stridor
2. Drowsy patients with SOB
3. In severe respiratory distress
The above list is not exhaustive. In summary any patient that is n distress should be managed in
P1 unless ordered by a senior doctor. MOs whose evaluation of their patient thinks warrants
management in P1 are to approach a senior immediately.
Subsequent management is then disease specific.
SYSTEMS DIFFERENTIAL DIAGNOSIS

MANAGEMENT
CARDIOLOGY CCF/APO IV frusemide

GTN KIV IV GTN
NIV
Angina equivalent (no CP, but
SOB)
RESPIRATORY Asthma Nebs, IV hydrocortisone/

prednisolone
KIV IV magnesium
COPD Nebs, Iv hydrocortisone

KIV NIV
Pneumonia, infective causes

IV abx, high flow O2
eg bronchitis
118
If patients do not respond to treatment and rapidly deteriorating or presented in extremis, the
myasthenia gravis, Guillain-IVIG, IV methylprednisolone
Pericardiocentesis in ED if
Will be discussed in next
Supportive management
High flow 02 kiv steroids
evidence of tamponade
Treat underlying cause
IV NAHCO3 if pH <7.1
Call ENT immediately
KIV E tracheostomy
IV dexamethasone
Peritoneal tap
High Flow O2
IV augmentin
GTN KIV IV
Mild to Moderate Severe to Life threatening

IV Lasix
eg,fluids
Dialysis
chapter
NIV
Severe metabolic acidosis IV

DKA, salicylate, toxic alcohol
Anasarca from liver disease
Fluid overload in ESRF/CRF
Managed in resus
Neuromuscular disorders eg
Other chronic lung diseases
Managed in critical care FBC, renal panel, ECG CXR, ABG
angioedema, Ca larynx
Perform peak flow if patient is able to Back to back neb of ventolin (2): N/S (2) KIV
Patient
eg pulmonary fibrosis
Stridor eg. Epiglottitis

Pulmonary embolism
Symptomatic Ascites
deteriorates add on atrovent (1)
Pericardial effusion
CXR, blds are not neccessary
119
Start IV hydrocortisone 100mg
overdose, ARF
Neb ventolin (2): N/S (2) x3 cycles
Start IV magnesium sulphate 1-2g over 1 hr
ASTHMA based on GINA guidelines

Administer prednisolone 30mg stat
patients
AOCRF
If CXR reveals a PTX, to decompression

Observe for a total of 1hr after the 3 nebs immediately followed by chest tube insertion
Barre
given
If ABG shows worsening respiratory failure or
patient should be intubated.

patient clinically deteriorating, intubate
patient. To only start BIPAP with respi consult
Patient has no more Still having wheezing
wheezes, Vital signs stable
SPO2 > 95%
PEFR >40% predicted
NEUROLOGY
If patient improves
METABOLIC
best Previous ICU
Can discharge with and with ICU
admissions Admit to ICA
OTHERS
prednisolone 30mg x5/7 review and
or ICU
RENAL
and ventolin MDI recommendation
Instruct them to use 2
GI
puffs TDS for the next 3
days followed by PRN Admit to EOW Admit to Respi
GW
Pt improves No improvement
Confirmed pneumothorax
(non-traumatic)
Stable Unstable
-Treat as for tension pneumothorax
-Needle decompression followed by

chest tube insertion
- Admit to respi once stabilised
Secondary PTX
- Insert Wayne catheter
(Seldinger technique) kiv
chest tube insertion Primary PTX
- Admit to respi
PTX >2cm* or symptomatic PTX <2cm*
Offer either needle decompression, wayne catheter Can be discharged with early tcu with respi within 3
insertion or chest tube insertion days with CXR OA, MC till TCU
Consider EOW pneumothorax protocol as needed
If needle decompression, to admit to EOW PTX They are to be discharged with the following advice:
protocol. If PTX stable or no further recurrence, no swimming or diving
discharge with TCU respi in 3/7. MC till TCU CXR no strenuous physical activities
OA. If recurrence of PTX or worsening of PTX, for no flying
PNEUMOTHORAX
wayne WORKFLOW
catheter insertion or chest tube insertion.(NON TRAUMATIC)
to come back with worsening Updated Dec 2014
of symptoms
Please leave the 3 way valve attached to catheter to inform them that the PTX may become larger
and need intervention
If wayne catheter inserted, to admit to EOW PTX
protocol If no complications, discharge with tcu
respi in 3/7 CXR OA MC till TCU
However, if patients not confident to care for

catheter or chest tube inserted, to admit to respi If patient has been discharged and
returns to DEM, senior doctor to
reassess. Please look at Annex A for
further action
*PTX measured from visceral to parietal pleural at level of120
hilum
For Wayne catheter insertion, there should be at least 2cm margin of PTX for insertion, if not for chest tube insertion
Please do not let any fluid into hemilich valve and keep note of direction for valve to function
121
ANNEX A
If patient returns, Senior doctor on duty is to assess the patient regarding patient’s complaint.
Complaint 1: PAIN
Action:
 Ensure that PTX has not expanded by repeating CXR
 Ensure that adequate analgesia has been given to patient
 If PTX re-expanded, please refer to complaint 2
Complaint 2: BREATHLESSNESS
Action:
 Ensure that PTX has not re-expanded by repeating CXR.
 Ensure that dyspnoea is not pain related.
 If PTX has re-expanded, ensure that three way tap is aligned correctly, Heimlich valve is aligned
in the right direction and catheter is in place
 If related to 3 way valve, realign and observe for 2 hours before repeating CXR. If CXR reveals
stable or smaller PTX; and Heimlich valve functioning, discharge with old TCU. If PTX larger,
switch to underwater seal and admit to RCCM.
 If Heimlich valve is aligned incorrectly, readjust and repeat CXR after 2 hrs. If PTX is stable,
discharge with old TCU with RCCM. If Heimlich valve is wet, switch to underwater seal and
admit to RCCM
Complaint 3: FLUID IN THE TUBING

Action:
 If fluid present in tubing, repeat CXR. If PTX still present, switch to underwater seal and admit to
RCCM. If PTX resolved, please look under action for resolved PTX**.
 If blood present in tubing, repeat CXR and ensure no hemothorax. If hemothorax present or
suspected lung or vascular injury, refer to CTS.
 If CXR shows persistent PTX and no hemothorax, switch to underwater seal and admit to RCCM
 If PTX resolved, please refer to action for resolved PTX**
** IF PTX RESOLVED:
 If CXR at any of the above shows resolved PTX, clamp the catheter via 3 way valve.
 Observe for 2 hrs and repeat CXR.
 If CXR shows no PTX, remove the catheter and stitch or apply steristrip to catheter site
 Discharge with analgesia and MC with initial RCCM TCU on previous discharge
122
COPD
History to note:
SOB with wheezing
Fever, any URTI symptoms
Chest pain
Known hx of COPD, ex-smoker or current heavy smoker
Ascertain whether patient is on LTOT
Physical examination
Ascertain whether patient is in respiratory distress
Respiratory examination can reveal wheezing, crepitations or
silent chest
Stable patients:
Unstable patients, those in respiratory distress Can be managed in P2
Unstable vital signs or drowsiness: ECG, FBC, renal panel, CE+/- bld c/s
CXR to look for pneumothorax and
consolidation
Manage in resus IV hydrocortisone 100mg
ECG, FBC, renal panel, CE +/- bld c/s Neb ventolin (1): N/S (2): atrovent (1) x 3
cycles
CXR to look for PTX or infection Start appropriate IV abx if needed
ABG
IV hydrocortisone 100mg
Back to back neb ventolin (1):N/S (2): atrovent (1)
IV abx if needed
If CXR shows a PTX, immediate decompression of
PTX is needed followed by chest tube insertion
If ABG shows worsening respiratory failure, start
BIBAP if no contraindications
Patient responsive to
If unable to start BIBAP, consider intubation
treatment
Admit to respi GW
If patient improves and asymptomatic

May discharge for those with good family support
Edited June 2017

Arrange for admission to
ICA or ICU
123
PULMONARY EMBOLISM
After clinical hx and physical examination, the Well’s criterion for PE is used to assess the
probability of PE.
Well’s Criteria for Pulmonary Embolism
Use: Objectifies risk of pulmonary embolism.
The model should be applied only after a history and physical suggests that venous
thromboembolism is a diagnostic possibility. It should not be applied to all patients with chest
pain or dyspnea or to all patients with leg pain or swelling.

Clinical Signs and Symptoms of DVT Yes +3
PE is number 1 diagnosis, or equally likely Yes +3
Heart rate > 100 Yes +1.5
Immobilisation at least 3 days, or surgery in the previous 4 weeks Yes +1.5
Previous, objectively diagnosed PE or DVT Yes +1.5
Hemoptysis Yes +1
Malignancy with treatment within 6 months, or palliative Yes +1
0 to 1.5 score: Low risk group – 1.3% chance of PE in an ED population.
2 to 6 score: Moderate risk group – 16.2% chance of PE in an ED population.
7 and above score: High risk group – 40.6% chance of PE in an ED population.
*Another study assigned:
Scores ≤ 4 as 'PE Unlikely' and had a 3% incidence of PE.
Scores > 4 as ‘PE Likely’ and had a 28% incidence of PE.
Low : 0-1 points

Intermediate : 2-6 points
High : 7 or more points
124
PERC**
Those with low probability of PE will undergo another clinical decision rule, Pulmonary Embolism
Rule Out Criteria (PERC)
The PERC rule is as follows:
1. Younger than 50 yrs of age
2. HR <100beats/min
3. Spo2 >94%
4. No Hemoptysis
5. No unilateral leg swelling
6. No OCP usage
7. No previous DVT or PE
8. No recent surgery or immbolization within 4weeks
If patient meets all 8 criteria and low probability of PE, PE can be safely rule out without D dimer.
Investigations
Blood tests Radiological Miscellanous
FBC CXR ECG

Renal Panel CT PA
D dimer Bedside US
ABG
Management
All unstable patients are to be managed in resus. Large PEs are referred to CTS for urgent
embolectomy or catheter directed thrombolysis. Initial dose of IV heparin can be given. Small
PEs can be managed in CTS or respi/ hematology but the medical registrar will need to be
informed for possible ICA bed arrangement if not for CTS admission.
In small PEs, IV heparin or S/C clexane can be administered while anticoagulation is initiated in
the ward.
125
**PERC has high sensitivity and negative predictive value but low specificity. However, if the above is
applied only around 0.5% of PEs are missed.
Patients presenting with SOB

Assess probability of PE using Well’s
criteria
Low probability High Probability

0-1 points 7 points or more
Intermediate
probability
2-6 points
Does not fulfill PERC
PERC
D dimer D dimer positive
Fulfills all 8 PERC

criteria
CT PA (refer to CT
protocol for PE)
Look for other
causes of SOB D dimer negative
Look for other causes
of SOB
126
CT PROTOCOL/WORKFLOW for PE
Ordering of CT Pulmonary Angiogram for Pulmonary embolism
Patients presenting with shortness of breath or chest pain with suggestion of

pulmonary embolism may be considered for scan.
Three factors should be considered:
1. the stability of the patient

2. high pretest probability for PE before going on to no 3.
3. determining the clinical probability of PE. To do so, we will use the Wells Prediction Rule for
Diagnosing Pulmonary Embolism and the pulmonary embolism rule out criteria.
Please refer to the flowchart on the next page.
127
PNEUMONIA
Mild OR PSI Risk Class I-II FBC, U/E, CXR

Unilobar Can be discharged with oral antibiotics based on
Normal or near normal vital signs SGH antibiotic guidelines.
Young < 65 years old TCU Resp SOC x 1 week.
Does not fulfill the criteria below. MC till TCU
Moderate OR PSI Risk Class III-V FBC, U/E, CXR, ABG

Does not fulfill the criteria below. Blood c/s
Antibiotics according to SGH antibiotics
guidelines
Admit Respiratory General Ward, early ward
review.
Severe – Scores 2 or more: FBC, U/E, CXR, ABG

Septic shock = 2 Blood c/s
RR > 30/min = 1 Antibiotics according to SGH antibiotics
PaO2 / FiO2 < 250 (FiO2 in decimal point) = 1guidelines
CXR : bilateral / multilobar pneumonia = 1 Call R1/ MICU registrar
Systolic BP < 90 mm Hg or Diastolic BP < 60 Admit HD/ICA/MICU
mm Hg = 1
Confusional State = 1
PSI = Pneumonia Severity Index
PSI has evolved from a prediction rule for prognosis to a decision aid to guide the choice of the
initial site of treatment for patients with CAP.
128
CURB-65 Severity Score
Use: Estimates mortality of community-acquired pneumonia to help determine inpatient vs.

outpatient treatment.
Value Points
Criteria
Confusion Yes +1
Urea > 7mmol/L Yes +1
Respiratory rate ≥ 30 Yes +1
Systolic BP < 90mmHg or Diastolic BP ≤ 60mmHg Yes +1
Age ≥ 65 Yes +1
0 score: Low risk group: 0.6% 30-day mortality. Consider outpatient treatment.
1 score: Low risk group: 2.7% 30-day mortality. Consider outpatient treatment.
2 score: Moderate risk group: 6.8% 30-day mortality. Consider inpatient treatment or outpatient
with close follow up.
3 score: Severe risk group: 14.0% 30-day mortality. Consider inpatient treatment with possible
intensive care admission.
4 and 5 score: Highest risk group: 27.8% 30-day mortality. Consider inpatient treatment with
possible intensive care admission.
129
SEPSIS PATHWAY AND COMMON INFECTIONS
(A/P Mark Leong / Dr Kenneth Tan)
MANAGEMENT OF SEPSIS
(See also Resuscitation Workflow for Severe Sepsis)
Surviving Sepsis Campaign
SIRS is present if there are 2 or more of the following:
•Temperature >38.3C or <36C
•HR>90/min
•RR>20/min or PaCO2 <32
•WBC>12,000/mm3 or <4,000/mm3 or >10% immature forms
Sepsis is SIRS + source of infection
Severe sepsis is defined as end organ dysfunction from sepsis with:

Lactate>2mmol/L
AMS from baseline
Respiratory failure
Kidney or hepatic failure
DIC
Troponin elevation
Transient hypotension
Unexplained acidosis
Septic shock is defined sepsis plus any of the following:

Hypotension (SBP<90, MAP<65 unresponsive or >40mmHg SBP decrease from baseline) refractory to IVF
Lactate greater than 4mmol/L
Multiple Organ Dysfunction Syndrome: Evidence of ≥ 2 organs failing
*based on Surviving Sepsis Campaign. Sepsis 3 was released in 2016 but is not used in SGH MICU.
Severe sepsis/ Septic Shock
EARLY GOAL DIRECTED THERAPY (3 hour bundle) Sepsis
Measure Lactate level

Initiate appropriate antibiotics early
Adequate fluids
Obtain blood c/s before giving antibiotics
If BP drops or deteriorates, for IV
Administer broad spectrum antibiotics
fluid boluses** up to 2L
If BP still unresponsive, this is septic
Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
shock, proceed to septic shock
pathway
If BP stabilizes and patient’s general

EARLY GOAL DIRECTED THERAPY (6 hour bundle) condition improving, admit to GW
with early review
Apply vasopressors for hypotension that does not respond to initial fluid Patient
resuscitation ) to main MAP ≥65mmHg deteriorates If BP stabilizes but patient’s general
condition not improving, to proceed
In the event of persistent hypotension after initial fluid administration to septic shock pathway
(MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume
status and tissue perfusion and document findings as stated below. **Suggested fluids: Hartmann’s
Remeasure lactate level
DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION

WITH:
130 Updated June 2016
EITHER • Repeat focused exam (after initial fluid resuscitation) by licensed
independent practitioner including vital signs, cardiopulmonary, capillary
refill, pulse, and skin findings.
cardiovascular ultrasound • Dynamic assessment of fluid responsiveness
with passive leg raise or fluid challenge
COMMON INFECTIONS
(Dr Nausheen / Dr Kenneth Tan)
Soft tissue infections

Cellulitis Diabetic or immunocompromised individuals,:
All such patients are to be admitted.
Perform FBC, U/E, Blood c/s
Start IV augmentin (IV clindamycin for penicillin
allergy)
Admit to DIM
Stable patients with:

Uncomplicated cellulitis with stable vital signs and no
further acute medical issues
Can be considered for EOW Cellulitis protocol.
Please refer to EMERGE for details
If there is suspicion of concomitant deep tissue

infection, abscess or need for surgical intervention,
please discuss with DEM senior doctor KIV admit GS
or ortho
Necrotising fasciitis Clinical suspicion of NF:

Tenderness out of proportion of clinical pictures
Hemorrhagic blisters
Subcutaneous emphysema
Gas seen in soft tissues on X-ray
High CK levels
Alternative:
Use LRINEC scoring as below
FBC, U/E, PT/PTT,CRP ( if using LRINEC scoring),

GXM
X-ray of the affected limb
CXR
Start IV Penicillin, clindamycin and Ceftazidime
according to antibiotic guideline
Discuss with DEM senior doctor STAT to admit ortho
Abscess If abscess is present, and no other acute medical
conditions, eg DKA, discuss with DEM senior doctor
to admit ortho for I&D (small abscess can be drained
in procedure room)
If there are any acute medical conditions present,

inform ortho first and KIV admit to medical with
inpatient ortho input
Diabetic foot/ gangrene GS has requested that all lower limb gangrene to be
131
Vascular foot admitted under GS
- to discuss with DEM senior doctor regarding GS
(updated June 2017) admission
However, if there are pulses felt and GS has

reviewed and not for GS admission, to discuss with
DEM senior doctor to admit Ortho
Bloods and IV antibiotics as per usual
Input by Prof SG Tan:

Note that even if Doppler signal is present,
circulation may not be adequate. All gangrene,
ulcers and rest pain with absent or questionable
pulses should be admitted to Vascular. If there are
acute and sudden symptoms (pt recalls time
symptoms started) the Vascular consultant on call
should be informed.
Osteomyelitis If there is radiological evidence of OM and pulse well

felt,
Bloods as per usual
IV antibiotics
Discuss with DEM senior doctor to admit ortho
If pulses not well felt, or follow-up with GS

Discuss with DEM senior doctor for GS admission
132
LRINEC SCORING FOR NECROTISING FASCIITIS
Use: To distinguish necrotizing fasciitis from severe cellulitis or abscess. If high suspicion for
necrotizing fasciitis through clinical history and physical exam, do not calculate a LRINEC score
or wait for blood results. Refer to the appropriate surgical discipline immediately for operative
debridement.
A LRINEC score ≥ 6 is a reasonable cut-off to rule in necrotizing fasciitis, but a LRINEC < 6 does
not rule out the diagnosis (low risk but not no risk). Remember:
- Prompt fluid resuscitation and antibiotic administration are crucial in the treatment of
necrotizing fasciitis.
- Any patient with severe cellulitis or worrying signs of deep skin infections which might not
appear to be necrotizing fasciitis must have the LRINEC scoring performed. If the score is ≥ 6,
he must be referred to the appropriate surgical discipline immediately.
Criteria Value Points Criteria Value Points

CRP (mg/L) < 150 0 Sodium ≥ 135 0
≥ 150 +4 < 135 +2
WBC (per mm3 <15 0 Creatinine (mmol/L) ≤ 141 0
15-25 +1 > 141 +2
> 25 +2 Hemoglobin (g/dL) > 13.5 0
Glucose (mmol/L) ≤ 10 0 11-13.5 +1
> 10 +1 < 11 +2
133
INFECTIOUS DISEASES
(Dr Nausheen / Dr Kenneth Tan)
DENGUE FEVER
INDICATIONS FOR ADMISSION: Any of the following
Dizziness, lethargy, restlessness and altered mental status
Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation
No urine output for 4 to 6 hours
Signs of bleeding (e.g. mucosal bleeding or internal bleeding such as malaena)
Liver enlargement > 2cm
Increase in haematocrit concurrent with rapid decrease in platelet count
Hct > 50% or > 20% above baseline
Relative hypotension of 20mmHg from baseline or postural hypotension
Significant bleeding (e.g. epistaxis, GI haemorrhage, menorrhagia, haematuria)
Pregnancy
Co-morbid conditions (e.g. DM, hypertension, peptic ulcer, haemolytic anaemia, congestive
cardiac failure, chronic renal failure, chronic obstructive lung disease, immunocompromised
state)
Obesity (BMI > 28)
Infancy
Old age (> or = 65 years old)
Platelet count < or = 80 x 109/L
INDICATIONS FOR REFERRAL TO POLYCLINIC OR GP:
Patients who have platelets > or = 80 x 109/L, AND
Able to drink adequate fluids, AND able to pass urine at least once every 6 hourly.
134
MALARIA
Singapore has been declared malaria free by WHO. However, we still see cases from time to
time as patients who come back from malaria infested countries or from neighboring countries.
Workflow:
Patient presents with fever with positive travel
history to malaria infested countries
Perform FBC and blood film for malaria parasite
BFMP negative BFMP positive

Look for other causes <2% plasmodium falciparum or
of fever other plasmodium species and
patient stable
Admit to GW
Start antimalarial meds,
Please refer to SGH antibiotic

guidelines
BFMP positive for plasmodium falciparum with features of severe falciparum malaria
Clinical features
Laboratory
- Impaired sensorium
- Hypoglycemia
- Generalized weakness
- Metabolic acidosis
- Failure to feed
- Severe anemia
- Multiple seizures
- Hemoglobinuria
- Kussmaul breathing
- Hyperparasitemia >2%
- Shock
- High lactate
- Hemoglobinuria ( black
- Renal impairment
urine)
- Spontaneous bleeding
- Pulmonary edema
- Clinical jaundice or other
end organ damage
IV fluids
Start IV antibiotics to cover for superimposed bacterial infection
Arrange for HD/ICU bed
Consult SGH antibiotic guideline for antimalarial meds or contact ID Registrar on treatment options
135
HERPES ZOSTER
Herpes zoster presenting as either chickenpox or shingles can usually be treated as outpatient.
Treatment would include symptomatic treatment with anithistamines and patient should be
isolated. Acyclovir can be prescribed but has to be renal adjusted for patients with renal failure.
IV acyclovir remains the drug of choice for the following populations of immunocompromised
patients:
1. Patients with evidence of disseminated disease or visceral organ involvement
2. Patients with ophthalmic involvement
3. Patients with advanced HIV/AIDS who harbor active opportunistic infections or exhibit prominent
wasting
4. Transplant recipients who have just undergone transplantation or are being treated for rejection
These patients should be admitted to isolation wards.
Antiviral therapy has been demonstrated to halt progression and dissemination of acute herpes
zoster in immunocompromised patients, even when initiated more than 72 hours after rash
onset. Accordingly, such therapy is recommended for all immunocompromised herpes zoster
patients who present before the full crusting of all lesions.
PYREXIA OF UNKNOWN ORIGIN
This is defined as fever for more than 10 days with no source of infection. Such patients will
need to be admitted for more extensive workup.
136
COMMUNICABLE DISEASES
MANAGEMENT OF HIGH RISK PATIENTS WITH INFLUENZA-LIKE ILLNESS
Antiviral treatment can potentially reduce morbidity and mortality. Medical practitioners are
reminded that antiviral treatment is recommended for high-risk patients with ILI when the
prevalence of Influenza A (H1N1-2009) in the community is significant. In the current mitigation
phase, doctors should offer anti-virals to their high-risk patients with ILI. Patients should be
advised to seek medical assistance immediately should their condition worsen.
Laboratory testing for Influenza A (H1N1-2009) under prevailing prevalence is NOT

necessary before commencement of treatment.
Testing to confirm the diagnosis of Influenza A (H1N1-2009) infection

Is only required in patients who are seriously ill, or in high risk patients e.g. children less than
1 year old or those who are pregnant, for initiation of treatment or continuation of treatment
and/or in situations where it will be of significant public health importance.
PERSONS AT INCREASED RISK FOR INFLUENZA-RELATED COMPLICATIONS
1. Persons aged 65 years and older

2. Children < 5 years
3. Adults and children who have chronic pulmonary or heart disease
4. Adults and children who have required regular medical follow-up or hospitalisation during the
preceding year because of chronic metabolic diseases (including diabetes mellitus), renal
dysfunction, haemoglobinopathies or immunosuppression (including immunosuppression
caused by medications or by the Human Immunodeficiency Virus)
5. Children and teenagers aged 6 months to 18 years who are receiving long-term aspirin
therapy and therefore might be at risk for developing Reye syndrome after influenza infection
6. Pregnant women
Please be reminded of the need to adjust dose of Tamiflu for children and patients with
renal impairment. Please consult the patient's primary specialist/ID for advice
137
MANAGEMENT OF GENITAL ULCERS AND DISCHARGES
138
MANAGEMENT OF EMERGING INFECTIOUS DISEASES
updated 24 June 2015, based on MOH notification MH 34:24/15 dated 20 June 2015
(Dr Chan Jing Jing)
As front line staff, we need to be aware of emerging infectious diseases both for patient care and
our protection. Examples of such diseases in recent times are Ebola and MERS-CoV.
It is hence important to stay up to date with the latest advice and protocols from MOH. These
and other SGH specific protocols can be obtained from the Nursing Officers on duty as
well as SGH Infonet.
Important notes:
1. Basic hygiene – surgical masks should be worn at all times on shift. Hand hygiene should be
observed between patients.
2. Personal Protective Equipment – Infectious disease, together with the Infection Control
nurses, will develop institution specific instructions regarding PPE for specific diseases based on
the latest information available. This will be taught to all front line staff in times of heightened
awareness. Please get fitted for an N95 mask.
3. Isolating patients – Be disciplined in taking travel and contact histories for ALL patients
during consultation, and do not delay isolating patients who might fit the criteria.
4. MOH directives – All suspected cases of such infections are immediately notifiable to MOH
via phone call to the Surveillance Duty Officer of the Communicable Diseases Division and
online submission of the MD 131 Form on the Communicable Diseases Live & Enhanced
Surveillance (CDLENS) system (link in EMERGE).
Suspected cases are usually transferred to TTSH or KKCH if stable. If the patient refuses
admission or transfer, call the Surveillance Duty Officer on 9817 1463 (available 24 hours) for
assistance and advice. Unstable patients would be managed in DEM and admitted.
139
MANAGEMENT OF RABIES
(Chan Jing Jing)
Singapore is rabies free, but our department often receives patient from nearby islands
who have been bitten by stray animals for post exposure prophylaxis.
Proper wound management
All mammal scratch or bite wounds should be immediately and thoroughly cleansed with
soap and water. If available, a virucidal agent, such as povidone iodine solution, should be
used to irrigate the wound(s).
Post exposure prophylaxis
Rabies post-exposure prophylaxis in unvaccinated individuals consists of 4-5 doses of

rabies vaccine as well as rabies immunoglobulin.
For individuals who have been vaccinated against rabies, the post-exposure
schedule is two doses of the rabies vaccine at Days 0 and 3.
For individuals who have not been previously vaccinated, the post-exposure
schedule consists of:
• Rabies immunoglobulin infiltrated around the wound(s) if anatomically
feasible3; AND
• Four doses of rabies vaccine on Days 0, 3, 7 and 14 in immunocompetent
individuals; OR
• Five doses of rabies vaccine on Days 0, 3, 7, 14 and 28 in
immunosuppressed individuals.
If there are any queries or concerns, please consult a DEM senior doctor and/or ID on call.
condensed from the MOH Circular 20/2017 dated 14th July 2017
140
TOXICOLOGY
(A/P Palam / Dr Kenneth Tan)
History taking: Physical examination:
- What drug was taken , the amount, time/ Is - Check vital signs
the amount consumed all in one shot or over - Pupillary size
time - General condition of patient:
- Any co ingestion of any other drugs nervous, lethargic diaphoretic,
- Circumstances that lead to overdose, this is agitated
to look for any life threatening conditions that - Systemic review
lead to overdose eg panadol overdose in
patients with SAH Investigations:
- Is the patient experiencing any symptoms ECG, H/C FBC U/E, LFT, PT/INR (if
necessary), paracetamol and salicylate
now
level
- Any past medical history or risk factors that
will affect management of overdose
Drug identified?
Drug identified, proceed to Unable to identify drugs. Go on to look

treatment algorithim with kiv for any toxidromes, from hx and physical
antidote if available examination
TREATMENT ALGORITHIM
- Ensure PPE is used especially if high possibility of contamination
- Do a quick ABC assessment and stabilisation of patient before decontamination. All

unstable patients are to be managed in resus
- Decontamination: remove all contaminated clothing and wash patient if there is any
chemical on the body. This acts to protect HCW and prevent further absorption of
agent
- Reassess ABC and stabilize them further after decontamination
- Reduce Absorption of drug: if within 1 hr of ingestion or possibility of decreased GI

absorption, administer activated charcoal. Consider orogastric lavage if within 1 hr
and airway is protected (pt intubated) and no contraindications.
- Antidotes: If drug or toxidrome identified, look for any antidote and administer ASAP.
Eg, IV parvolex for Paracetamol overdose, IV pralidoxime for organophosphate
poisoning
- If no antidote is available, continue with supportive management
- Arrange for admission to general ward or monitored bed as needed
141
TOXIDROMES
Cholinergic Toxidrome: Anticholinergic Toxidrome:
D iarrhoea ‘hot as hare’- hyperthermia

U rination ‘red as a beet’- flushed appearance
M iosis ‘dry as a bone’- decreased glandular secretions
B radycardia ‘blind as a bat’- mydriasis
B ronchorrea ‘mad as a hatter’- delirium
E mesis
L acrimation
S alivation
Sympathomimetics Opiates
- Hypertension - Miosis
- Mydriasis - Respiratory depression
- Tachycardia - Hypotension
- Agitation, delirium - Drowsiness
- Hyperpyrexia
Sedation
- Respiratory depression
- Hypotension
- Drowsiness
Common Antidotes:
N-Acetyl Cysteine (Parvolex) Paracetamol overdose

Flumazenil Benzodiazepine
Naloxone Opiates
Digibind Digoxin overdose
2PAM and atropine Organophosphate overdose
142
TRAUMA
(Dr Jean Lee / Dr Jeremy Wee / Dr Kenneth Tan)
APPROACH TO TRAUMA
TRAUMA
PHYSIOLOGICAL ANATOMICAL MECHANISM
- Airway - Penetrating injury - Prolonged entrapment (>20

compromise to head, neck or mins)
- RR < 10/min or torso - Ejection from vehicle/ flung
>30/min - Fracture pelvis by vehicle
- Pulse > 120/min - 2 or more - High velocity/ high transfer
- SBP < 90mmHg proximal long of forces/energies:
- GCS ≤ 13 bone fractures → Fall from height ≥ 3m
- 2 or more body → RTA: speed ≥ 50km/h
region injury
- Spinal cord injury
- Proximal limb
amputation
- Flail chest
Fulfills above Does not fulfill

criteria above criteria
Treat as for major trauma Please refer to respective

pathways:
Trauma Activate
- Minor head injury
- Chest injury
- Abdominal injury
- Neck injury
- Minor injuries eg.
Abrasions and lacerations
143
Trauma Team
1. The Trauma Team (TT) is responsible for the resuscitation and initial management of a
multiply injured patient.
2. The core team comprises of 4 doctors, 2 nurses, a radiographer and a health attendant. The
trauma team leader (TTL) will be a general surgeon. He will work with a team comprising an
A&E Registrar/ MO, a General Surgery MO and an Orthopaedic MO. Doctors involved in the
trauma team should have completed the Advanced Trauma Life Support Course (ATLS).
3. Each member of the team should have specific duties. This horizontal organization allows
tasks to be performed simultaneously. The trauma team layout and each member’s role are as
outlined (See Picture)
4. Additional disciplines as deemed appropriate or necessary by the Trauma Team Leader may
be activated when the need arises (Anaesthesia, Neurosurgery, Radiology, Plastics,
Cardiothoracic and Obstetrics etc).
5. For Burns patients, all trauma activations and those with TBSA >20% are to be referred to
the registrar. Smaller burns with TBSA<20% can be referred to the MO.
(with effect from January 2015)
6. All Trauma Team members should practice universal precautions. Waterproof gowns, gloves
and masks should be used for all trauma resuscitation.
7. The decision of the Trauma Team Leader is binding. Any disagreements can be brought to
the attention of the Trauma Director the following day or; the Trauma Office:
trauma.service@sgh.com.sg.
8. The TTL is responsible for coordinating the resuscitation and ensuring that the necessary
specialists are contacted. A management plan is formulated by prioritizing both the investigation
and management of the various injuries. The relevant areas should be alerted – ICU, OT, CT or
angiographic room. The TTL is responsible for ensuring that the Trauma Resuscitation Record is
filled up at the completion of the resuscitation.
144
145
PREHOSPITAL INFORMATION
The following minimum information should be obtained:
M mechanism
I injury
S signs (vital)
T treatment
CONDUCT OF RESUSCITATION
This follows the principles laid out in the ATLS®.
Observe universal precautions.
Documentation of parameters -Every 10 min (HR, RR, BP, GCS)
For severe trauma - Bloods = FBC, UES, ABG, PT/PTT, GXM, LFT, amylase, lactate,
cardiac enzyme
Radiology - Chest, Pelvic, C-spine (in this order)
Selective Tests - ECG, UPT, Extremity X-rays
Specialised Tests - CT head (no IV contrast)

CT chest
CT abdomen
(Oral contrast if used is given 30 min before scan)
Angiographic procedures (may need to activate interventional radiology team – takes 1h)
If patient is not responding to fluid resuscitation or obviously exsanguinating –

GIVE BLOOD EARLY
Involve consultants early in the severely injured patients.

Do not keep patient in the resuscitation room longer than necessary. As a general guideline,
keep ED time to less than 2 hours. Some patients will require a rapid transfer to OT with
minimal investigations (eg. penetrating trauma patient in shock).
Make decision for definitive investigation and treatment within 30 minutes.
Never leave patient unattended in the resuscitation room!
146
PAN SCAN CRITERIA / GUIDELINES
Regardless of whether there is visible evidence of neck, chest or abdominal injury, as

long as the patient is:
Hemodynamically stable, (contra-indication to CT is haemodynamic instability)

AND meet one of the following criteria/ clinical scenarios:
(1) Unable to evaluate examination results secondary to a depressed level of consciousness or

intoxication (GCS 13 or less), i.e regardless of severity of mechanism
Or
(2) Normal abdominal examination results in neurologically intact patients / clinically no evidence
of significant chest / abdominal injury
AND
Significant mechanisms of injury as any of the following:
(a) Motor vehicle crash at greater than 50 km/hr
(b) Falls of greater than 3m
(c) Ejection from vehicle/ flung by vehicle
Then patient should undergo CT scan of the head, cervical spine, chest, abdomen, and pelvis
(pan scan).
If you think your case should be an exception to the above criteria, please discuss with
consultant on call.
147
Updated 22 April 2016
Annex A
148
MANAGEMENT OF HYPOTENSION IN TRAUMA
149
MANAGEMENT OF PELVIC TRAUMA
Indication for the use of Pelvic Binder (T-POD, Trauma Pelvic Orthotic device)
1) For initial treatment to stabilize a suspected open pelvic fracture until definitive treatment is
rendered.
2) Create a circumferential compression (tamponade) to the pelvic region.
3) To help minimise blood loss and reduce pain.
* T-POD should be released slowly every 2 hourly to prevent skin damage by medical personnel
for 10 mins - 15 mins. (Write down date and time of the release on the T-POD).
*To confirm with the principal doctor before the 1 st release
Monitor the haemodynamic status when T-POD is released. There is a possibility of hypotension
as the tamponade in the pelvic region is lost. Re-apply the T-POD and inform the medical team.
150
COMMON RESTRUCTURED HOSPITAL MASSIVE TRANSFUSION PROTOCOL
GENERAL NOTES AND GUIDELINES
A) Blood selection if blood group is unknown:
Red Cells
Blood group O Rhesus Negative pRBC for Caucasian & Indian Female patients of child-
bearing age or younger
Blood group O Rhesus Positive pRBC for all other patients
FFP
Blood group AB Rhesus Positive FFP for all patients
Platelets & Cryoprecipitate
Platelets will usually be Group O, but cryoprecipitate can be of any ABO group. ABO
compatibility is not essential for platelet and cryoprecipitate transfusion
The cryoprecipitate will be either pre-pooled (if available and stored at the hospital blood
bank) or prepared and provided direct from 24-Hour Cross-match Lab, BSG).
Blood group should be determined by each hospital’s blood bank as an urgent priority so that
ABO identical blood products can be issued as soon as possible.
Therefore clinical teams activating the MTP should send a group and cross-match sample at
the earliest opportunity. Patients should be transfused with type specific and cross matched
blood as soon as their blood group has been determined.
Patients who are already known to be RH negative & who have positive antibodies
should be excluded from this MTP protocol:
(a) For MTP patients of known RH Negative Blood Group, the team doctor should use the
1st two units of Emergency O-ve Blood if necessary, (already available) but also contact
the BSG MO/Team urgently for advice.
(b) For patients with known requirement for rare blood due to clinically significant red cell
allo-antibodies, the team doctor should contact the BSG MO/team immediately to seek
advice.
(PLEASE NOTE: NOT ALL ANTIBODIES ARE CLINICALLY SIGNIFICANT. IF IN DOUBT-

PLEASE CHECK WITH BSG TEAM)
B) Constituents of MTP (Mass Transfusion Protocol) Pack are as follows:
Pack 1: 4 units pRBC, 4 units FFP, 4 units PLC, with Tranexamic Acid 1g Stat Dose
Pack 2: 4 units pRBC, 4 units FFP, 4 units PLC
151
Pack 3: 4 units pRBC, 4 units FFP, 4 units PLC, with cryoprecipitate (10 units); Consider use of
recombinant activated factor VII (dose: 90 mcgm per kg) with Pack 3.
(Recombinant FVIIa has a role in MTP but their use will have to be governed by each hospital’s
oversight policy on the use of this agent
C) Criteria for Activation of the MTP:
Activation of the MTP based on clinical judgment alone or on traditional criteria (such as > 150ml
of blood loss per minute or 1 blood volume transfused in a 12-hour period) can be challenging. It
is also clinician-dependent and subjected to inconsistencies.
We therefore recommend the use of validated scoring systems in risk assessment of trauma
patients for MTP Activation. (eg. ABC Score, TASH Score)
The Assessment of Blood Consumption (ABC) Score.
The ABC Score consists of 4 dichotomous, non-weighted components that are available at the
bedside of the acutely injured patient early in the assessment phase. The presence of any one
component contributes one point to the total score, for a possible range of scores from zero to
four. The parameters include:
 Penetrating mechanism (0 = no, 1 = yes)
 ED SBP of 90 mmHg or less (0 = no, 1 = yes)
 ED HR of 120 bpm or greater (0 = no, 1 = yes)
 Positive FAST (0 = no, 1 = yes)
Assessment of Blood Consumption (ABC) Score > 2 or 3 will trigger activation of the hospital
MTP
D) When to contact the BSG MO:
 The Clinical Team calls their hospital Blood Bank directly for release of MTP Packs 1
& 2. They do not need to call BSG MO for approval or release of Pack 1 & 2 since the standby
inventory of MTP blood products in each hospital would be adequate to meet the requirements
of packs 1 & 2 (including 8 units of platelets and 8 units of FFP)
 Hospital team only needs to call the BSG MO immediately after calling the local
hospital blood bank for delivery of MTP Pack 2. This is to inform BSG of current MTP activation
and potential escalation to MTP Pack 3, as well as confirm the need for preparation and
thawing of cryoprecipitate at BSG Lab (if in-house prepooled cryoprecipitate is not available in
that hospital). (Note : Under current arrangements, the hemostatic blood products in MTP Pack
3 will still be issued from BSG)
 Please also inform BSG MO when the MTP has ceased or if the MTP needs to be
extended beyond MTP Pack 3, so that arrangements for rapid transfer of additional blood
products can be quickly arranged.
 Patients who are already known to be RH negative & who have positive antibodies
will be exempted from MTP activation. The team doctor should contact the BSG MO & request
for blood products in the usual manner for such patients.
152
E) Typical Locations for MT Delivery:
1. ED resuscitation room
2. OT
3. ED Radiology Department during diagnostic and therapeutic procedures
4. Surgical Intensive Care Unit (SICU)
F) Who can activate the MTP:
To be decided by the individual hospital HTC
As a guide, the authority to activate MTP should be generally restricted to a senior Doctor (Reg
& above) of the following disciplines:
Haematologist for medical cases and the Anaesthetist in the OT, and Trauma Team or A&E
Physician for trauma cases.
Such restriction would be necessary to minimize unnecessary activation and wastage of blood
products.
G) Supportive Measures
1. Avoid Hypothermia (keep T>35C: eg. with IV warming device, Bair Hugger, Ambient
Temperature Control, etc), Acidosis (keep pH> 7.1) and Hypocalcaemia.
2. Constant monitoring of FBC, coagulation profile (PT, aPTT, serum fibrinogen), with a aim to
further correct any coagulation abnormalities on lab result beyond MTP replacement of
hemostatic factors (keep PT/PTT < 1.5x reference value, fibrinogen > 1g/dl, platelets >50x10 9/L).
For example, additional transfusions of cryoprecipitate should be considered if fibrinogen <
1g/dl.
3. All labs are sent STAT while MTP is in progress. Laboratory values and amount of products
administered should all be tracked
4. Strict compliance with product/recipient identification procedures is mandatory, regardless of

time pressures
5. The MTP leader or designee keeps the BB informed of changing needs or location.
6. Patients are to be transfused with type specific and cross matched blood whenever possible.
H) Other adjunctive monitoring & treatment options:
 Point of Care thromboelastography Test: TEG analysis may be helpful in identifying

specific issues with hemostasis and guiding its treatment (e.g. whether patient needs FFP, cryo,
platelets, antifibrinolytic drugs, or thrombolytic drugs). However adoption of TEG point of care
testing will be at the discretion of individual hospitals.
 Novo-7 (recombinant activated factor VII, initial dose at 90 ugm per kg): Our
recommendation is for Novo-7 be given together with or immediately after transfusion of
cryoprecipitate and platelets of MTP Pack 3, so as to maximize the benefits of Novo-7.
153
I) Daily Returns of MTP Cases:
Restructured Hospital Blood Banks should give daily returns of MTP activation cases that
include a breakdown of blood products used during the MTP activation period, as well as basic
clinical details such as the name, registration number, main clinical problems and reason for
MTP activation.
154
MINOR HEAD INJURY
Defined as GCS 13-15
To assess need for CT brain, please use the Canadian CT head rule.
Canadian CT head rule:
Use: Clears head injury without imaging.
Note: Only apply to GCS 13-15 Patients with LOC, Amnesia to the Head Injury Event, or
Confusion
Criteria (Major) Criteria (Minor)

GCS < 15 at 2 hours post injury Retrograde amnesia to the event ≥ 30 minutes
Suspected open or depressed skull fracture Dangerous mechanism – pedestrian struck by
motor vehicle, occupant ejected from motor
vehicle, fall from >5 stairs
Any sign of basilar skull fracture 0 score: CT head is unnecessary.
(hemotympanum, racoon eyes, battle’s sign, CSF
otorrhea/rhinorrhea)
≥ 2 episodes of vomiting
Age ≥ 65
Any 1 Major: “high risk” for an injury requiring neurosurgical intervention. (sensitivity 100%).
Any 1 Minor: “medium risk” to rule out an intracranial traumatic finding (sensitivity 83-100%).
Rule does not apply to age below 16yrs, non trauma, those with bleeding tendencies, GCS <13
or obvious depressed skull fractures.
Patients on warfarin or aspirin are to be scanned if the supervising senior deems the injury
significant.
Disposition:
If CT brain normal, admit patient to head injury protocol
Please T and S all lacerations before discharge/ handing over
At the end of 8 hrs, if GCS stable and neurological examination normal, the patient can be
discharged with head injury advice.
All alcohol intoxicated patients with no significant head injury (as determined by senior doctor)
are to be admitted to HIP and observed for 4 hours first. If GCS does not improve by then, a CT
brain should be performed.
If CT brain normal, proceed as per disposition.
155
ABDOMINAL INJURIES
If not for trauma activation, consider admitting patient under minor injury protocol for further
observation and treatment.
Inclusion Criteria:
- no acute abdomen
- FAST negative
- No significant abrasions or seatbelt sign
- Patient is not on warfarin
All other patients are to be referred to GS for further evaluation
If the patient fulfills the above criteria, admit him/her to minor injury protocol.
A FBC, Renal Panel, Amylase and LFT should be performed.
Serial abdominal examinations, minimum of 2 inclusive of bedside FAST (this included initial
examination). Blood investigations should also be repeated at the 6hr mark. Treat with
appropriate analgesia.
If there is no change in blood results, no significant changes during serial abdominal

examinations and no more abdominal pain, the patient can be discharged with abdominal pain
advice.
If there is a drop in Hb, rising trend of WBC or amylase, changes in serial abdominal
examination or persistent abdominal pain, a CT abdomen/pelvis is to be arranged.
If CT normal, supervising doctor can choose to observe the patient further in EOW or discharge
patient with analgesia and an appointment with GS trauma clinic.
If CT scan has a positive finding, inform GS ASAP.
CHEST INJURIES
If not for trauma activation, consider admitting patient to minor injury protocol.
Exclusion Criteria:
- more than 3 rib fractures

- fractures of the 1st and 2nd rib or scapula fracture
- flail chest
- obvious pulmonary contusion on CXR
- pneumothorax, hemothorax, widened mediastinum
- ECG changes- suggestive of cardiac contusion
The above patients should be referred to GS as there is a possibility of significant thoracic

injuries.
All other patients can be considered for minor injury protocol. These patients should be placed
under cardiac monitoring.
A FBC, renal panel, trop t should be done and a further 2 sets of ECG and trop t should be
performed.
If there are no ECG changes, maintain good spo2 on room air and stable blood results, the
patient can be discharged with analgesia and chest pain advice.
156
If there are ECG changes, rising trop t and increasing oxygen requirement, an immediate chest
x-ray should be done and bedside US to look for possible pericardial effusion. These patients
must be referred to GS ASAP.
NECK PAIN
All major trauma should have C spine X-ray done. All other neck injuries post trauma should be
cleared using the Canadian C spine rule/NEXUS.
Canadian C spine rule
Use: Clears patients from cervical spine fracture clinically, without imaging.
NEXUS
Use: Clears patients from cervical spine fracture clinically, without imaging.
Criteria Value
Focal neurological deficit Yes
Midline spinal tenderness Yes
Altered level of consciousness Yes
Intoxication Yes
Distracting injury Yes
If none of the above criteria are present, the C-Spine can be cleared clinically by these criteria.
Imaging is not required.
If any of the above criteria are present, the C-Spine cannot be cleared clinically by these criteria.
Consider Imaging.
If there is midline tenderness and c spine X-ray done which appears normal, administer
analgesia and observe patient for 2 hrs. If still having pain, to refer to ortho for c spine clearance
If:
1. Fulfill Canadian rule/NEXUS and no x ray done
2. C Spine X-ray normal with resolution or improvement of midline tenderness
Patients can then be discharged with early TCU orthopaedics and analgesia
MULTIPLE ABRASIONS/ LACERATIONS
157
If the patient does not fulfill trauma activation criteria, patient can be considered for further
observation without protocol or admission to minor injury protocol.
All patients regardless of disposition are to have their tetanus status updated and wounds to be
dressed and all lacerations to be T and S.
After observation, all patients are to be discharged with an OPS TCU for STO or change of
dressing.
BURNS
(Dr Chan Jing Jing)
SGH is the regional burns centre and hence we receive a large number of burns cases. The
burns unit is housed in Ward 43, and has a high dependency, ICU as well as an operating
theatre.
Some important points to note:
History
Time of injury
Location, including whether in enclosed space, and type of material that burnt
Type of burn – inhalational, chemical, flame, scalds, electrical
Duration of exposure
Accidental vs deliberate injury?
Physical Examination
-Total body surface area (TBSA)
o Rule of 9s in adults, patient’s palm (including fingers) estimated as 1%
-Look for suggestion of airway burns: singed eyebrows and nasal hair, carbonaceous sputum,
hoarseness of voice, stridor
-Entry/exit wound for electrical burns (not often found)
Management of Major Burns (>20% TBSA)

ABCDE (Burns are to be managed according to the tenets of ATLS.)
Secure airway – edematous airways are airway emergencies
Large bore IVs, preferably in unaffected areas
FBC, U/E, PT/PTT, GXM, CXR, ECG
Special tests: ABG, COHb (can run on COBAS machine in resus), CK (esp in electrical burns)
Fluids according to Modified Parkland’s formula

Total replacement fluids (N/S or L/R) = 4mls x BW x TBSA, of which 50% in the first 8 hours and
the remaining 50% over 16 hours starting from time of burn
Insert IDC – target urine output of 0.5ml//kg/h
Consider nasoscopy to assess airway – by ED or Burns
IV Morphine – do not withhold analgesia from any conscious burns patient; it is not uncommon
to be giving more than 10mg of morphine in total
IM ATT
Call Burns Registrar in ED for early evaluation and admission
(Do not forget that patients can have CO or cyanide toxicity too!)
Management of Minor Burns (<20% TBSA)

158
(often from scalding injuries)
Irrigate wound with clear water/ saline
Analgesia, before dressing
Update tetanus
TCU Burns 2-3/7 (there is no need to ODD Burns in minor cases, if in doubt, ask a senior).
Cases that might require ODD to Burns MO would be those that involve the face, perineum,
hands and circumferential burns.
159
UROLOGY
ACUTE RETENTION OF URINE
(Dr Kenneth Tan / Dr Poh Juliana)
History: Important Considerations and Differentials
Male or female patient

Acute onset or acute on chronic
Dribbling, complete ARU, haematuria, hesitancy, frequency
Need to strain to PU
Likely hx of stricture eg hx of STDs
Symptoms of UTI
Ingestion of drugs
Bowel hx: constipation
Injuries eg: low back, spine
Hx of malignancy/ metastatic disease
Recent procedure, instrumentation or surgery
Pregnancy/ gynae hx: e.g. retroverted gravid uterus, impacted fibroid
Examination:
General examination of patient/ systematic review

Ascertain the size of bladder if possible.
Inspect end of urethra for stricture
Prostate bimanual examination
Look also for signs of cord compression: e.g. Enlarged bladder with perianal
anaesthesia and lax anal tone
Investigations: order as appropriate
UC 9 (post catheterisation)
Routine blood investigations such as FBC and U/E are generally not required unless there are
other significant issues.
Management:
Bladder catheterization
Review volume and bladder evacuation
Record volume of urine drained (nurses to do SMU and chart in Emerg)
Note characteristics: colour, sediments and debris, blood etc
If stable and suspect simple case of BPH, can send home with indwelling catheter
Relatives must be instructed to empty urine bag, look out for complications etc
If ARU is secondary to other causes suspected, consider admission for management of the
appropriate problem
Give a follow up with Urology SOC 1-2 weeks

If the appointment is too long to give interim TCU with OPD/GP for change of catheter as
necessary and review
160
RENAL/URETERIC COLIC
(A/Prof Marcus Ong)
Sudden onset of colicky flank pain UC9, KUB

Radiates anteriorly and inferiorly Bedside Ultrasound kidneys
Nausea/vomiting FBC, U/E (only if suspect renal impairment,
Diaphoresis pyelonephritis)
Occult hematuria (microscopic hematuriaIV NS (if vomiting)
on UC9) IM diclofenac 75mg (Contraindicated if patient has
Normal testicular exam, no hernia renal impairment secondary to obstructive uropathy),
And IM/IV buscopan 40mg
Or
(consider alternative medications, oral route etc)
Discharge if pain free with analgesia, Tamsulosin

(Refer to Worklow) and TCU Urology 1/52. If TW
elevated, KIV cover with ciprofloxacin 500 mg bd x 7
days.
If hydronephrosis on ultrasound without pain – call
urology for early TCU
Admit EOW renal colic protocol if persistent pain

despite analgesia
ODD urology/for admission if persistent pain despite

protocol, hydronephrosis with renal impairment,
pyelonephritis etc
161
UROLOGY WORKFLOW IN DEM
(Dr Jean Lee)
Guidelines to Management of Ureteric Colic at DEM

-To prioritise treatment with administration of analgesia -> IM Pethidine 50/75mg according to
patient’s build with IM Maxolon.
-Review the pain 1 hour later. If still in pain, to top up with another analgesia eg IM diclofenac.
Consider enrolling into EOW renal colic protocol.
-If ureteric colic recurs during EOW observation, to top up meds if 2nd round has not been given. If
already administered, to consider admission to urology
Indications for direct admission to Urology

-Recurrence of pain during renal colic EOW protocol after at least 2 administrations of painkiller.
-2nd attendance in DEM with prior EOW observation during the 1st DEM visit.
- If there was not any EOW admission during the 1st DEM visit for ureteric colic, consider enrolling in
EOW renal colic protocol. Admit urology for failed EOW observation.
-3 DEM attendance in 1 week for ureteric colic
rd
-Complications from obstructive calculus

i) Obstructive UTI, pyelo- or pyo-nephrosis , especially on background of diabetes
ii) Acute kidney injury with Cr > 200.
If patient is for discharge after successful pain control, recommended treatment includes:
-TCU urology 2 weeks. If stone > 8mm, TCU Urology walk-in clinic 1 week. Order CT KUB for post
EOW pts (not CT urogram which uses IV contrast).
-Advise to drink 3-4L of water a day in an attempt to flush out the calculus. Stones < 5mm distal to
the sacroiliac joint have a 70% chance of spontaneous per urethral passage in 4-6 weeks.
-Oral analgesia such as tab Diclofenac (ensure no asthma nor renal impairment) with famotidine
cover and paracetamol prn x 1/52. Alternative will be tramadol.
-One may consider tab Tamsulosin 0.4mg ON x 10 days ($0.70 a tab which causes smooth muscle
relaxation) if the following criteria are fulfilled :-
 stones 5-10 mm diameter and distal to the SI joint (If < 5mm, very likely to be spontaneously
expelled. If > 10mm, DO NOT prescribe as unlikely to have expulsion despite Tamsulosin.)
 Age of pt <70y
 Strict advice MUST be given that Tamsulosin may cause postural hypotension and pt has to
take it before bedtime. When getting up from a supine/sitting position, pt has to do it gradually
and carefully due to risk of postural dizziness.
-Advice to return to DEM if :-

• persistent severe pain despite the oral analgesics
• fever /flank pain (pyelonephritis)
Guidelines to Management of UTI in a male
162
-Perform UFEME and urine c/s if underlying urological structural defect/BPH is suspected to be the
cause of the UTI. Prescribe augmentin/ciprobay x 1/52.
TCU Chinatown Family clinic 1/52 (trace UFEME and c/s OA) with urology routine TCU (which
may be 3-4/12 later for further investigations.
-If STD is suspected and there is presence of urethral discharge, perform a urethral swab and
UFEME and c/s. Prescribe doxycycline 100mg bd and ciprobay 500mg bd x 2/52. TCU Kelantan
clinic 2/52 for contact tracing. Trace Urethral swab results OA at Kelantan Clinic.
-Advise pt about additional costs for above urinary tests - ?cost
Conditions which warrant urgent Uro consult (to call Uro MO direct) with direct admission
-ARU with failed urinary catheterisation
-Fournier’s gangrene, testicular rupture etc
-Unwell urological pts requiring HD bed.
-Pyonephrosis – as evidenced by hydronephrosis on U/S, presence of leucocytes on UC-9 and
positive renal punch. Blood culture to be done and pt is to be started on IV rocephine or IV
Ciprobay if allergic to penicillins.
For ALL direct Uro admissions, to CALL Uro MO to inform them of the admission (not for
consult) and to highlight any complications eg pyonephrosis etc. Exception being gross
haematuria which will need further input by uro MO on call.
Management of Gross Haematuria:
Ensure patient not in clot retention.

1) If in retention, can attempt to insert IDC first to relieve symptoms.
-If drainage is faint haematuria with UC-9 showing UTI and pt is for discharge, to prescribe oral
antibiotics (ciprobay or augmentin) and TCU urology walk-in 2 weeks.
Admit if poorly controlled DM and/or patient unwell.
-If draining gross haematuria with clots or frank blood, ODD uro mo to review -> take urine culture
and start iv antibiotics(Rocephine/Ciprobay)
-Any difficulty with IDC insertion, ODD uro mo
2) If not in retention
-Visualise urine sample, if gross haematuria with clots or frank blood, ODD uro mo to review
-Otherwise take urine culture, start oral antibiotics and TCU urology walk-in within 2/52
3) Any gross haematuria with recent urological procedures/surgery, ODD uro mo.
Scrotal pain:- for all patients , send UC-9
1) Young patients (<35Y) and acute onset within 24hours, need to exclude testicular torsion
-ODD uro mo.
2) Older age group, scrotal mass > 3 days history

-treat as for Epididymitis Ochitis with oral ciprofloxacin 500mg bd and doxycycline 100mg bd x 2/52.
-TCU urology walk-in early within 1 week
163
3) If febrile/septic, suspicious of abscess/Fournier’s gangrene, ODD uro MO.
-do blood and urine cultures, start IV antibiotics
Written with Dr Allen Sim (Urology), Updated October 2015
164
EMERGENCY OBSERVATION WARD (EOW)
(Dr Chan Jing Jing)
The EOW is a unique set up in the Emergency Department where stable patients are admitted
for treatment of specific conditions.
The benefits are that they are considered inpatient (for Medisave and insurance purposes) and
they can receive inpatient care without being admitted to the wards. This is especially helpful
during times of high bed occupation rates.
Senior doctors must be consulted before placing on protocols. Patients need to be admitted for a
minimum of 8 hours, and a maximum of 23 hours. Should the patient’s symptoms persist or
worsen during this period, he will be transferred to an inpatient ward.
Duties of the EOW MO
1. Take handover from the primary MO

2. Ensure all orders (medications, MSW, physiotherapy etc) are correctly entered into the
system in the EOW inpatient account.
3. Regular reviews of patient’s symptoms and signs (must be documented) and to alert senior
doctor in charge if there is any deterioration or new issues.
4. Prepare discharge documents and medications.
5. Update patient’s family.
List of EOW Protocols
Below are the EOW protocols in our department. Please refer to the Infonet for the latest
protocols.
Medical Conditions Surgical Conditions
Asthma Abdominal pain protocol

Atrial Fibrillation (added Dec 2016)
Bites and stings (allergy) Giddiness co-ordinated pathway (ENT)
Cellulitis Head injury
Chest pain Back pain
Gastroenteritis (dehydration) Minor injury
Giddiness Renal colic
Heart failure Toxic inhalation
Hyperglycemia
Hypoglycemia
Hypertension
Pneumonia
Pneumothorax
Poisoning
Pyelonephritis
Seizures
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RESUSCITATION WORKFLOWS
(by Dr Kenneth Tan, Dr Pek Jen Heng)
INTUBATION WORKFLOW
Is NIV contraindicated?
Is intubation necessary?
Please check HIDS or past notes to check for resus status if possible
Preparation:
-Assess patient for possible difficult airway
-Prepare suction and intubation set, size of tube for paeds, age/4 +4, infants size 3.5
-Prepare glidescope or other rescue airway if needed
-ETCO2
-Prepare ventilator settings
-Prepare RSI drugs:
- Etomidate 0.3mg/kg, usual first line drug
- Propofolol 2mg/kg, consider its use in neurosurgical patients
- Ketamine 1-2mg/kg consider for sepsis, asthma or hypotensive
- Succinylcholine 100mcg if no hyperkalemia or neuromuscular disease. If any present,
please use
- Rocuronium 50mg
Preoxygenation:
-Consider delayed sequence intubation ie, proper preoxygenation or using NIV as an interim
-Please prepare high flow intranasal oxygen in addition to preoxygenation for apnoeic
oxygenation
Premedication:
-lignocaine
-fentanyl
-atropine
Paralysis and induction:
-Rapid sequence induction with selected drugs
Placement/Position of tube:
-Ensure person who intubates sees tube pass through vocal cords
-5 point auscultation
-ETCO2
-Inflate balloon
Post-intubation care:
-Connect to ventilator, practice permissive hypercapnia maintain SpO2 >94%, ETCO2 32-35, VT
6-8 ml/kg, RR 10-12
-Check CXR
-Sedation and analgesia
- Fentanyl or morphine bolus
- Propofolol infusion1mg/kg/hr
- IV midazolam 1-5mg/hr
- Judicious use of paralytic agents

- Look out for post intubation issues
Problems /Issues post intubation
Saturation dropping
166
-Disconnect from ventilator and bag patient
-Check ventilator: Is oxygen connected, Is machine faulty
-Not ventilator- Is it related to ETT? Reconfirm placement with ETCO2 monitor and auscultation
-Not ETT issue- is it patient related. Look for pneumothorax and for ‘tight lungs’ in asthma or
COPD patients. Consider autoPEEP as well.
Hypotension
-Observe and start fluid boluses as it could be induction drugs
-If hypotension persist, start inotropes.
-Consider autoPEEP, disconnect ventilator and allow full expiration
-Consider PTX
167
MANAGEMENT OF SEPSIS
To diagnose sepsis:
2 or more of the following SIRS criteria in addition to bacteriaemia or
suspected bacteremia:
•Temperature >38.3 C or <36C
•HR>90/min
•RR>20/min
•WBC>12,000/mm3 or 4,000/mm3 or >10% immature forms
Sepsis
Initiate appropriate abx within the first hour

Adequate fluids
If BP stabilizes and patient’s general condition improving,
admit to GW with early review
Severe sepsis or
Septic Shock
Patient deteriorates
Initiate EARLY GOAL DIRECTED THERAPY (modified)
BP targets: MAP ≥ 65mmhg (aim higher if chronic hypertension)

IV fluid resus. If still hypotensive despite 2L of fluids or based on US assessement of
IVC, to initiate inotropes. Dopamine vs NA (will need CVP)
CVP line are usually not inserted unless high levels of inotropic support is needed.
Urine output ≥ 0.5ml/kg/hr
Catherise patients and fluid resus to achieve objective
Initial Lactate levels and followed by rate of lactate clearance
Start appropriate abx (as according to SGH ABX guidelines) within 1hr
All pts in severe sepsis or septic shock must have a lactate level done. High lactate levels
correspond to poorer prognosis
Arrange for ICA or ICU admission
Refer to: ProCESS, ARISE, ProMISE trials, SEPSISPAM
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SEVERE SEPSIS/SEPTIC SHOCK CHECKLIST
CONFIRM SEVERE SEPSIS OR SEPTIC SHOCK,
Eliminate any other treatable causes
Perform blood cultures, lactate and blood gas
Catherise patient
Initiate IV fluids
Confirm fluid status by US of IVC and by urine output
Start IV antibiotics within the first hour
Use SGH antibiotic guidelines as reference
Consider the use of inotropes, blood transfusion and steroids as needed
169
CARDIAC ARREST AND POST CARDIAC ARREST
RESUSCITATE ACCORDING TO ACLS PROTOCOL
Is patient suitable for ECMO?

Please refer to ECMO protocol.
Yes/No
If for ECMO, please proceed to post cardiac arrest protocol
If ROSC achieved and for active management, proceed below
Proceed to investigate for cause of arrest
Start mechanical ventilation

6ml/kg RR 12, maintain SpO2 >94% and ETCO2 around 35-40
Start Therapeutic hypothermia if patient not responsive after 10mins

Start external cooling with ice pads. Start cold saline based on US
assessment of IVC with max 2L
Maintain MAP ≥ 65mmHg.
Catherise patient. Maintain urine output 0.5ml/kg/hr
Start IV insulin infusion. Maintain hypocount 6-10mmol
Start sedation if patient is waking up

- IV propofolol 1mg/kg/hr
- IV midazolam 1-5mg/kg
Consider paralytics agents as necessary
Arrange for ICU bed
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ROSC Flowchart
Return of Spontaneous Circulation post
cardiac arrest
Assess if for further active No For

management comfort/palliativ
e care
Yes
Low pressure ventilation if

Identify and treat
possible Maintain a MAP of 65 and above.
underlying cause ie
Start first at 6ml/kg, RR 10- Administer fluid resuscitation if
continue with 5H and
12 indicated or guided by bedside US
5Ts
Aim SpO2 94-96 %., maintain Catheterise patient
KIV contact CVM for PCI
pETCO2 35-40 Start inotropes early, consider
CVP insertion if high doses of
inotropes needed to prepare for
NA or dual inotropes
Maintain h/c 6-10mmol if possible

giving boluses or start IV insulin
infusion if patient is waiting for ICU
bed Check blood sugar hourly
Initiate therapeutic hypothermia if patient still unconscious

If unsure, observe patient for 10-15mins,
If GCS still low or unconscious, start cooling patient
Start cold fluids max 2L- this is dependent on patient fluid
status as assessed by attending clinician.
Apply ice pads externally
Prevent patient from shivering. Consider paralysing patient if
needed
Check temperature every half an hr if patient still in the ED
using rectal temperature
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GUIDELINE FOR ACTIVATION OF CTS FOR ECMO- CPR IN PATIENTS WITH CARDIAC
ARREST IN ED
Patient still in Cardiac Arrest
ROSC
Continue
No ROSC despite CPR and ACLS for resuscitation
>15mins per ACLS
? Out of hospital Cardiac

Arrest (OHCA)
OHCA IHCA
Does it have any of the below contraindications Does it have any of the below contraindications
Age > 65 yrs old Age > 65 yrs old
Un-witnessed Cardiac arrest Un-witnessed Cardiac arrest
CPR not initiated within 10mins CPR not initiated within 10mins
Total Arrest time > 30 mins Total Arrest time > 40 mins
Absence of Signs of Life Absence of Signs of Life
Initial rhythm Asystole Initial rhythm Asystole
Severe Chronic/ End organ failure Severe Chronic/ End organ failure (kidney,
(kidney, liver or lung) liver or lung)
Advanced Malignancy Advanced Malignancy
Severe brain Injury/ Preexisting Severe brain Injury/ Preexisting

neurological disease with poor ADL neurological disease with poor ADL
Shock due to sepsis or hemorrhage Shock due to sepsis or hemorrhage
Traumatic Cardiac Arrest
Traumatic Cardiac Arrest
Severe AR or suspected Aortic Dissection
DNR order Severe AR or suspected Aortic Dissection
DNR order
Continue as per ACLS

CONTRAINDICATED
If fulfill the above with no contraindications, to contact CTS R1 after office hour or
ICU reg during office hours for ECMO support
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APPENDIX
Definitions
ECMO- Extracorporeal Membrane Oxygenation
OHCA- Out of Hospital Cardiac Arrest
IHCA- In hospital cardiac arrest
SOL- Signs of Life, defined as pupillary reflexes present, Spontaneous breathing, VT,VF or PEA
DNR- Do not resuscitate order- as decided by family or advanced medical directive
ECMO set to prepare
- Sponge Holder
- Gauze Pack x4
- Drape- Sheet x2, towel x6
- Surgical Blade- size 22 x1
- Artery Forceps x2
- Scissors x1
- 10cc syringe x2
- 20cc syringe x1
- Gallipot x1
- Saline
- Heparin
- Heparin saline
- Size 1-0 silk cutting x4
- 16 G single lumen arterial line x2
- Triple Lumen CVP set x1
- Ultrasound with equipment for sterile set
- Oxygen tank and power source
- Arterial pressure monitoring systems x2
Prepared by Dr Kenneth Tan Consultant DEM, Dr Mathew AC CTS,
Approved by
--------------------------------------- -------------------------------------
A/P Kenny Sin HOD CTS A/P Evelyn Wong HOD DEM
173
MISCELLANEOUS
SYNCOPE
(Dr Nausheen)
Important points in the History

Chest pain, SOB, palpitations, sweating,
Giddiness
Abdominal pain, radiation of pain, back pain, black stools
Headache
Fever
LMP and PV bleeding for women of child bearing age
Precipitating event – e.g. standing from lying, crowds
Aura and/ pre-syncopal symptoms- tinnitus, BOV, sweating, nausea
Duration, posturing, post-syncopal period (quickly returns to normal)
History of previous syncopal episodes
Past Medical History –Epilepsy, CHF, WPW, CAD, CMP, valvular heart dis, DM
FHX of Sudden cardiac death- Brugada and Long QT syndromes
Medications/Drug History
Important point in the Examination

Vital signs
Postural BP
General exam (Pallor, Hydration)
Chest (heart and lungs) exam; Cardiac murmurs; Pulses (equality and nature)
Abdominal (tenderness, masses) + Per rectal exam
Full Neurological examination
Differential Diagnoses
Cardiac causes
a) Obstruction to flow - Valvular heart dis-AS, MS, PS, HOCM, tamponade).
b) Dysrhythmias - Tachyarrythmias, WPW, Long QTc & Brugada syndromes, bradyarrythmias,

and pacemaker malfunction).
Vascular
AMI, Pulm Embolism, Aortic Dissection/AAA leak, subclavian steel, Pulm HYPT
CNS/Neurologic causes
TIA/CVA, SAH and other i/cranial bleeds, Seizures, Migraine
Situational
Micturation, defaecation, cough, valsalva, post-tussive
Hypovolaemic
Dehydration, internal bleeding e.g. ectopic pregnancy, BGIT
Metabolic
Hypoglycemia, hypoxia
174
Toxic
CO toxicity, other toxic exposures.
Vasovagal
Psychogenic
Anxiety/ panic disorder, conversion, hyperventilation, breath-holding spells
*May be mistaken for syncope: Seizures (atonic, absence)

Drop attacks (posterior circulation TIA, no LOC)
Presyncope, Vertigo, Atypical migraine.}
Suggested Investigations
Hypocount
ECG
Urine HCG
FBC, U/E/Cr
KIV D-dimer if suspected PE,
CXR
ED Management
If Cardiac syncope : move to resus and put on cardiac monitor, inform senior Dr, send bloods,
add TropT, treat according to ACLS, call CVM for admission KIV to monitored bed.
If BGIT: iv fluids, iv losec, NBM, kiv NG tube, call GS for admission kiv monitored bed.
If hypovolaemic: IV fluids, supportive and directed treatment.
Disposition
As above, according to cause of the syncope
Admit all with Hx of CHF/ ventricular arrhythmia

Chest pain/ SOB with syncope
Examination suggests CHF/ valvular heart disease
ECG shows ischaemia, arrythmia, prolonged QT, Bundle branch/heart blocks
Hypotension with syncope; Hct<30%
References:
-Emergency medicine practice January 2004
-ACEP Guidelines 2001
-Derivation of San Francisco Syncope Rule to predict patients with short-term serious outcomes. (Quinn
JV, Stiell IG et al. Ann Em Med 2005; 43: 224-232)
SOB – shortness of breath

BOV – blurring of vision
CHF- congestive heart failure
175
CAD- coronary artery disease
CMP- cardiomyopathy
WPW –Wolff-Parkinson White syndrome
TIA- transient ischaemic attack
LOC – loss of consciousness
Hct – haematocrit
NEEDSTICK INJURIES AND PEP
Please refer to Infonet for the latest NSI and PEP protocols.
PATIENTS WITH RADIOACTIVE IMPLANTS
Please refer to Infonet for the latest protocol.
176
NSAIDs PRESCRIPTION GUIDELINES
(Please note that this is a draft document and further revisions may be made.)
Absolute Contraindications
1. Development of allergic reactions ( e.g. urticarial, generalized rashes, angioedema ) or shortness

of breath after taking NSAIDs.
2. Hypersensitivity to sulfonamides (for Celecoxib only).
3. Children < 16 years old ( COX-2 inhibitors ). Ibuprofen and Diclofenac can be prescribed in
children > 1 year old.
4. Pregnant
5. Severely impaired renal function (CrCl < 30ml/min ), deteriorating renal function, or
hyperkalemia.
6. Active PUD or upper GI bleeding.
7. Child’s C liver cirrhosis
8. Asthmatic attacks, worsening asthma control or acute rhinitis which are directly associated with
NSAIDs use.
( NSAIDs are not contraindicated in COPD patients. )
9. Ischemic heart disease, cerebrovascular disease or peripheral vascular disease.
10. Congestive heart failure
11. Uncontrolled hypertension
Prescribe with caution
1. Age ≥ 65
2. Renal impairment with CrCl > 30 ml/min ( stable renal function, normal potassium level ).
3. Patients with end stage renal failure on dialysis.
4. History of PUD or upper GI bleeding.
5. Inflammatory bowel disease
6. History of asthma (NSAIDs may be prescribed if asthma is well-controlled, but should be
stopped if adverse reactions occur in relation to consumption of NSAIDs – see point 8 above ).
7. Concomitant use of anti-platelets (Aspirin, Clopidogrel), anticoagulants ( Warfarin, NOACs) or
steroids ( especially long term use for rheumatological, endocrine or other conditions ).
8. Concomitant use of SSRIs.
9. Comorbid conditions:
a. IHD
b. CVA (ischemic and haemorrhagic)
c. Uncontrolled hypertension
d. Heart failure
e. Atrial fibrillation
10. Drug interactions:

a. Diuretics
b. ACE inhibitors, angiotensin II receptor blockers ( e.g. Losartan, Valsartan, Telmisartan,
Candesartan, Irbesartan )
c. Nephrotoxic immunosuppresants ( Ciclosporin, Tacrolimus )
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11. High dose NSAIDs prescribed for prolonged periods (rheumatological, orthopaedic conditions).
12. Breastfeeding ( consult O&G team if necessary ).
Recommended regimen
1. For patients with criteria listed under “prescribe with caution”:

a. Start at the lowest effective dose.
b. Advise patient to take only when needed.
c. Titrate dose gradually.
d. Stop as soon as possible.
e. PPI cover if not already taking (Omeprazole 20mg OM for the duration of NSAID use).
f. Stop if adverse reactions occur ( e.g. rash, angioedema, SOB, gastritis, melena, chest pain,
TIA / stroke symptoms ).
2. Consider topical NSAIDs, paracetamol or opiates as first-line or alternative options.
This is a draft document written by SOC Pharmacy

Updated April 2017
178
ADMINISTRATION
CULTURE OF SAFETY AND RISK MANAGEMENT IN DEM

(Assoc Prof Fatimah Lateef)
Introduction
The International Federation for Emergency Medicine defines an Emergency Department as the
“area of a medical facility devoted to the provision of an organised system of emergency medical
care that is staffed by appropriately trained personnel and has the basic resources to
resuscitate, diagnose and treat patients with medical emergencies”
Doctors in the DEM face daily challenges that are unique. These include managing conditions
that are emergent and time-dependent. Despite these challenges the patients must be treated
with utmost care and respect, and be updated on their condition and what they have to go
through. Safe practice and promoting a department wide Culture of Safety is critical to ensure
the delivery of high quality care to our patients. It is everyone’s responsibility to ensure our
patients receive holistic, appropriate care and are managed according to departmental protocols
where available.
Work in the DEM is also very much team-based and thus, it is important for doctors to work with
other staff such as nursing personnel, radiographers and even clerical staff to ensure a
seamless level of care as much as possible.
Universal Precautions, Personal Safety and Responsibility
It is important to apply all aspects of universal precautions in our day to day work. All doctors
must have gone through Infection Control Briefing and Training before starting work in the
DEM. If you have not, please update your supervisor who will help to arrange. Wear gloves in
all procedures and processes where there is contact with body fluid, including blood taking. You
are to don surgical masks in all areas of the department. When handling and managing certain
high risk cases and especially in the Fever Area, there may be occasions where you may need
to step up and use an N95 mask or don impervious gowns (alert advisory will be provided from
time to time as well).
All procedures involving sharps (venepuncture, IV cannula setting, suturing, delivering injections,
etc) must be managed responsibly. It is your responsibility to discard sharps appropriately after
each use. Do not leave these lying around in the cubicles and bedside.
If you are involved in a needle stick injury, please clean the affected areas and administer
immediate care. You are to follow the Needle Stick Injury Protocol for management and
reporting as appropriate.
AS the DEM is often very crowded with people and trolleys, do be careful when moving about,
pushing trolleys and doing other procedures.
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Reporting and Handling Complaints/ Feedback
All cases involving needle stick injuries, personal injuries or trauma, abuse of staff, falls,
medication errors , including near misses which were detected by another staff/ personal
( adverse effect did not reach patient) must be reported on the RMS System. Please ensure you
have access/ password to the RMS System. If you do not, please contact the Nursing Officer on
duty to assist you. Please report truthfully and accurately what exactly happened in these cases,
as each one will be investigated and assessed in detail to sort out their root causes. If the senior
staff request for you to be interviewed and to make clarifications on the incident, please
cooperate with them.
When patients or relatives bring up the issue of long waiting times to you, do acknowledge (“I
understand”) and apologise if you need to (“ I apologise you had to wait”), without placing any
blame on any components of the DEM ( eg “ we do not have enough staff, we have several
doctors on MC today or that staff is slow”)
If you are faced with any complaints and feedback you are unsure how to handle, do highlight to
the senior doctor on duty during clinical hours or consult your supervisor (senior doctor assigned
to mentor you)
Patient Identification and Right Siting and Ordering the Right medication
The patient load in the DEM is high and there are many days when it is very crowded. Patients
are also seen and managed in several different areas of the Department, eg, Resuscitation,
Critical Care Area, Consultation Area, Fever Area, the Chest Pain Observation Unit or
Emergency Observation Ward. It is thus very important that you identify the patients
appropriately and accurately. Patients may also be sent from one area to another in the course
of their stay in the DEM. Therefore, at every point of contact with the patient do confirm their
identity (do use two identifiers as much as possible which include their names, IC number) to
ensure you are managing the correct patients. This is critical, as often there are patients who
look very similar, have almost similar names (including the spelling) and IC numbers. Wrong
identification of patients can have downstream repercussions and will affect a variety of
processes such as delivery of medication and care. This can be very serious and even harmful
in some cases.
In alignment with the above, do also ensure when taking blood tests and doing other
investigations, correct identification is applied as well . These should be quickly labelled and
ensure that you read and review the label you have printed in order to prevent any mix-ups. X-
Ray, CT scan and all other forms printed must be counter- checked against the patients to
ensure correct identification.
Similarly, when you pick up the patients folder or letters and ECGs belonging to them, please
ensure you return them to the appropriate folders for the particular patient. Always check the
names on these documents to ensure you are dealing with the correct patient. Patients who
180
have DRUG ALLERGY will have their notes placed in a pink or red folder whilst the rest will
have a clear transparent folder. If you are managing a patient who has any drug allergy, please
get the DRUG ALLERGY sticker and stick it onto all their documents to help alert all providers
who come in contact with the patient. These patients should also have a red alert wrist tag with
their names on it.
When ordering drugs on EMERGE, please always review and counter check your orders to
ensure you have made the right order and not ordered a next drug on the list, due to parallax
error. Also please check all allergies everytime you are making orders
Fall Precaution
If you are managing a patient with a predisposition to fall eg elderly, frail patients, those with
weak legs etc, please alert the nurse to put up the identification sign. These patients will be kept
closer to the nurses station as much as possible so that staff can keep an eye on them. After you
have completed managing a patient at their bedside, please put up the cord side. If you have to
leave the patient at any point in time, do also put up the cord side to prevent patients from rolling
over or falling.
Patient Handovers
Continuity of care for our patients is critical. Whilst you work shifts in the DEM, it is important that
you ensure appropriate and adequate hand-over of your patients at the end of your shift to
ensure all the relevant information, history, management plans, etc get passed on to the doctor
you are asking to follow up with the care/ who is coming on shift. Please ensure these cases and
patients are handed over electronically to your colleague who should accept the transfer. You
must also verbally pass these patients on and include all the following information as relevant.
Please document all these clearly in the follow up notes on EMERGE.
(Refer to Annex 1).
Confidentiality and Privacy
All patients must be accorded the privacy they deserve in their management and care in the
DEM. Please draw the curtains when examining them and doing procedures. Do explain and
ask for permission when doing certain examination and procedures on them. For male doctors
and staff examining or doing procedures on female patients, do ensure you have a female staff
as chaperone at all times.
Our patients share a lot of important, personal and private information with us and it is our
responsibility to make sure we keep these in confidence and maintain confidentiality at all times.
When updating relatives, use the Family room or a private area as much as possible so that
medical information and care plans are not overheard by public members in the waiting areas.
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Finally, if you are taking photographs of patients or any part of the patients’ body please ask for
permission and consent must be taken formally on the forms made available. This is even if the
photographs are for teaching purposes.
Managing Pregnant Patients in DEM
(Addendum by Dr Evelyn Wong, May 2017)
All female patients of reproductive age group with abdominal pain of any location should have a
UPT done.
Any radiological investigation ordered (AXR, CT scan) must be after the UPT result is known. If
the UPT is pending the radiological investigation must be held-off.
If the history and physical examination negates the possibility of pregnancy and if the UPT was
previously ordered, the UPT must be cancelled before the radiological investigation is ordered or
performed. The only exception is when the patient has a life-threatening situation requiring
immediate radiological investigation regardless of the pregnancy status.
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Annex 1
Patient Handover Check List
1. Patient Identifiers
Name
Age
Sex
Location in Department
2. Diagnosis or Problem List
3. Treatment Plans
Test done/ results available or pending
Imaging done/ Results available or pending
Medication given or to be given
Referrals made and ODD referrals to be made
Test to be repeated as needed
4. Allergies
5. Communications
Relatives updated/ state relationship
Name of Doctor handing over

Name of receiving Doctor
Name of Senior Doctor to consult/ Senior Doctor in charge
183
SUPERVISION, PATIENT FEEDBACK & COMPLAINTS
Supervision
All medical officers, clinical associates, and residents are assigned supervisors who will
feedback to you about your performance. In addition, while on shift there are senior doctors
(registrars, senior residents, associate consultants, consultants and senior consultants) who will
supervise your clinical work. It is your responsibility to seek help, supervision or advice in the
following situations:
1. Procedures that you are unfamiliar with or are not credentialed to perform
2. Patients with time sensitive conditions – AMI, acute CVA, sepsis, open fractures
3. Patients with persistent abdominal pain, elderly patients with abdominal pain
4. Patients requiring observation under the listed protocols
5. Patients requiring admission
6. Patients who are unstable and require close monitoring or resuscitation
7. When in doubt with regards to patient’s presentation or physical findings or investigations or
management or disposition
It is your responsibility to be self-directed in your learning and practice. This MO guidebook and
the multiple assessments have been developed to enable you to be more competent and
independent in your management of emergency conditions.
Patient feedback and complaints
Patients often give feedback about the care they received from their doctors. They also often
want clarification about the experience. Upon receiving such feedback and requests from
patients, the HOD or Director of Clinical Service or Manager will forward the feedback for your
explanation of the events that had happened. This is an opportunity for service recovery, if
warranted. It is important for HOD, manager and SQ to understand your version of the story so
that they can craft an acceptable response that will prevent further escalation, and have the
case closed. Some SQ staff are non-clinicians and they do not have access to our patients’
records. Therefore, it is important not to assume that they understand the patient’s conditions or
your clinical decisions. Since they are in direct contact with the patient or relatives, they bear the
brunt of their expressions of unhappiness. We should not make things difficult for them as they
are on our side. Sometimes it is also a learning experience about medical knowledge, patient
care and systems based practice and improvement. If you encounter a difficult patient, do
document the incident in the patient’s confidential notes.
184
APPROPRIATE ORDERING OF INVESTIGATIONS, RESULT ACKNOWLEDGEMENT
Appropriate ordering of investigations
There is no such thing as a routine test in the ED. Do not take the four blood tubes “just in case”
you need to add on blood tests later. Do not routinely order chest radiographs either.
You will have to discuss with the senior doctors with regard to ordering the following:
CRP, ProBNP, ESR, lactate, therapeutic levels of drugs, toxicology tests, CT scans.
The following tests are not to be ordered in the ED as they do not affect ED management or
disposition:
Pro-calcitonin, HBA1c, lipid profile, tumour markers, immunological markers
Do not order radiographs for every abrasion that you see on physical examination as this will
lead to over exposure of patient to unnecessary radiation and many fractures can be excluded
by clinical examination e.g. axial loading examination, functional testing, examining the gait etc.
The Canadian CT head rule is used for deciding whether to order CT head for head injury.
Results Acknowledgement
Please acknowledge all reported laboratory or radiological tests performed by you. Delayed
acknowledgement might result in delayed reimbursement of locum, night duty, call back,
transport or other claims as this is part of your job responsibility.
185
LEAVE, ROSTER, REPORTING SICK, OFF STANDBY
Leave matters (updated 08th September 2015)
1 MOs who wish to apply leave in the first month of the posting must inform either Ms Sharon Huin
or the Roster Planner before the start of posting.
2 Everyone is otherwise required to give at least 2 months advance notice for any leave
application; priority will be given to those who have forecasted their leave early. ( By the end of
1st week of the posting, you should have forecasted your 2 nd and 3rd months leave, if there is
any, and so on.)
3 At any one time, not more than 5 MOs are allowed to go on leave (this number might change,
subjected to the total number of MOs available).
4 Everyone is required to forecast his/her leave for the whole posting; he/she should forecast as
accurately as possible the dates and the periods of intended leave early in the beginning of
posting.
5 The categories of leave are shown as follow, in descending orders of priority for approval:
i. maternity leave, in-camp training (should notify at least 3 months in advance, or as

soon as SAF 100 is received)
ii. training leave: for examination (for exam proper, not for studying), conference, or
course
iii. marriage or paternity leave
iv. foreigner going back home town
v. all other annual leave
6 Please inform the roster planner about your exam/course leave in advance, even if the exam
dates or acceptance for course is not confirmed; this is because the planner needs to take
all leave commitment into consideration in order to advise other applicants. It is always easier to
cancel than to try and squeeze in a leave later. (Failure to give prior notice might result in
disapproval of leave application, regardless of whether the examination or course has
been fully paid for.)
7 Please limit your total leave period to a maximum of 2 weeks (calendar days) in the whole 6-
month posting. Any leave length longer than 2 weeks would require applicant to speak to HOD
for approval. The department might not be able to sign you up for the posting if you take
excessive leave.
8 You are discouraged to take multiple small blocks of leave consisting of 1 or 2 days that covers
weekends or PH.
9 The onus is in you to inform the roster planner of all leave/course you intend to take.
(Paper/electronic submission of leave or course does not imply that such information will be
passed on to the roster planner.)
186
10 Please remember to apply for your leave electronically once approved verbally by the roster
planner. Failing which your leave might be cancelled and will not be reflected on the roster, and
a competing request might be granted.
For those who have not electronically applied for leave after you have taken it, you have up to 2
weeks post leave to apply for it, failing which we will apply leave for you and will also send an
email to MOHH informing them that you had taken leave but had not applied for it. This has
implications related to professionalism and integrity.
11 All training/conference/exam leave must be substantiated by proof of course/conference/exam.

Please document this electronically under the “remarks“ section when you apply for leave.
12 Saturday is counted as 0.5 day in leave application, and Sunday is counted as an Off day.
Leave over the festive periods
1 Please note that each person is allowed to apply for only 1 block of leave covering any one of
the coming festive periods: i.e. Deepavali, Hari Raya, Christmas, New year, and Chinese New
year.
2 Approval is based strictly on adequacy of working manpower; a ballot might be necessary if

there are too many applications.
3 You must decide and book the slot thru the roster planner by the 1 st week of the new
posting if you do intend to take any of this leave.
Your cooperation to adhere to these guidelines would help greatly in the projection of manpower,
in engaging locum in advance, and thus eventually ensuring that everyone has a fair and
successful chance of obtaining leave.
Roster
1 You will need to submit your shift requests to the roster planner before the 15 th day of each
preceding month. (You would be reminded thru emails of the deadline for submission every
month)
2 No Off-in-lieu will be given for working on PHs. You are to claim pay-in-lieu for all.
3 Please check your email regularly as communication will be mainly through emails.
Executive: Ms Sharon Huin

Email: sharon.huin.p.s@sgh.com.sg
Roster Planer: Dr Tan Tiong Peng

Email: morequest@yahoo.com.sg
Reporting Sick
187
1 Please report to work and look for the senior doctor on duty (M2, E2 or c) as early as possible if
you are unable to work before any shift. You will be assessed clinically to determine the number
of medical leave days you require for rest. Medical certificate from SGH DEM will be issued to
you for submission. Medications, if any, will also be given to you.
2 You need to submit and apply medical leave electronically for the day(s) of absence due to
sickness.
3. If 4 or more MOs report sick on any one day, you will be notified by phone to go to the SGH staff
clinic for further assessment and evaluation. Infection control team will also be notified of the
people taking MC for follow up measures. This is in view of the fact that you are frontline staff
and have direct patient contact who may have been infectious during the course of your
preceding shift(s).
4 For sick leave that falls on Night shift, you need to inform the senior doctor whether you are
applying for:
[a] 02 days of medical leave covering the Night shift and the following day (Night Off); or
[b] 01 day of medical leave covering only the Night shift, and you would be able to work a shift
on your Night Off instead.
5 You are not allowed to go overseas if you are on medical leave.
Off Standby and recall
1 All doctors have to remain contactable at all times as we have to be ready to respond to any civil
emergency.
2 In the event of manpower shortage due to medical leave or emergency leave by medical officers
or clinical associates, the OS1 (off-standby 1) will be activated to return to work. In the event of
multiple doctors being on emergency leave; the OS2 will also be activated.
3 If the recalled OS works more than 6 hours, another Off day replacement will be given
subsequently by the roster planner; or claim locum pay in the event that a replaced Off is not
possible. (the roster planner will advise according to manpower situation and OS cannot request
which mode of compensation to give).
However, if the recalled OS works anything less than 6 hours, then no Off replacement will be
given, instead, compensation will be in the form of worked hours pay-back.
Please inform the roster planner of your OS recall timely in order to get your
compensation.
4 If OS1 is not contactable or is unable to return to cover the shift and resulted in OS2 being
activated, then OS1 will have to give up an off day to repay OS2 (Roster planner will subtract
this off day from the roster and replace a shift from OS2 to OS1). In this case the OS1 will not be
able to claim ‘replaced Off’ or “locum” but will only be allowed to claim the work as “emergency
call back”.
MEDICATION ERRORS, CORRECT PATIENT IDENTIFICATION, MEDICAL REPORTS
Medication Errors
188
The hospital and the department take medication errors very seriously.
Pay attention to the 5 rights:
1. Right patient – use two identifiers before giving a prescription and administering a drug. Not
uncommonly, the doctor fails to give the patient the right prescription because he/she had printed the
prescription from a wrong patient’s case notes.
2. Right drug – you must check that the drug you are about to give is intended for the patient that you
are attending to. Also be mindful of
- Drug allergies,
- Drug interactions e.g. with warfarin, anti-epileptics, OCPs and immunosuppressants, macrolides
- Contraindications and adverse effects to certain drugs eg beta-blockers with asthma, NSAIDs with
renal impairment
3. Right dose – be careful when prescribing drugs that you are unfamiliar with. Also be mindful of renal
impairment and dose adjustments
4. Right route – do check if the drug is intended for oral or intravenous, or subcutaneous or
intramuscular or other routes and do be clear when writing the prescription.
5. Right time – be mindful of the dosing intervals
The hospital has installed the Rx Manager which has to be used for all discharge medications. This has
alerts to help you minimise medication errors, those of drug allergies, interactions and renal dosing, and
there is no excuse for not using this when writing prescriptions unless the computer is experiencing a
down time. However, you still have to make sure that the prescription or medication is given to the right
patient. The Rx Manager is there to help you but nothing replaces safe practices e.g. look and ask for
drug allergy before any drug is administered.
When prescribing stat doses of medications to patients in the ED, be careful when you use the EMERGE
which does not have built in features to detect errors in dosing or interactions or allergies. You are
responsible for the correct dosing, allergies and interactions.
No verbal orders of drugs will be entertained by the nurses unless given in the resuscitation room for
resuscitation purposes.
For every commission of a medication error, you will have to write a report in the RMS to describe why
and how the error was committed and what steps you will take to prevent this from happening again.
Recurrent commissions of medication error will affect your performance appraisal.
Correct patient identification
To prevent wrong laboratory or radiological investigations from being performed or wrong prescriptions
from reaching the patient, it is mandatory that you identify the patient and the investigation or prescription
forms with two identifiers. If an error is made in any of these actions, it must be reported in RMS.
Recurrent commissions of this error will affect your performance appraisal.
Medical reports
189
Our department receives the most requests for medical reports. While they are not usually urgent, the
patient and hospital would appreciate our timely completion.
It is part of our job to write the reports. If for some reason you do not wish or cannot complete medical
reports that are assigned to you within the time frame, please ask Ms Wong Lai Peng to help you
reassign the report to someone else. You should however write those for patients whom you had direct
contact with.
Please complete your medical reports within 7 days of receiving them.
Always write down the diagnosis at the end of your report to minimise to and fro correspondences
between the lawyers and you for clarification.
With regard to neck pain after an RTA, do not use the diagnosis of whiplash but rather neck sprain or
neck contusion. The diagnosis of whiplash should be left to the orthopaedic consultant when he reviews
the patient.
Do not bounce the requests back to the MRO as far as possible. Trace the investigation results online.
Try not to trace the hard copies of the medical records unless absolutely necessary, but use whatever
reports available from EMERGE/SCM. Only trace the records if there is a contradiction between your
diagnosis and the radiographic reports.
Do not answer on behalf of another department. If the patient has been referred to another department
after your encounter, please write, for example, "For further information about his condition, please refer
to the department of Orthopaedic Surgery". Then you can complete your medical report in a timely
fashion.
Do not bring the patient's records home. Leave them in your shelves/pigeon holes as the patient might
have an appointment and require his records. Many medical records have been misplaced and lost as a
result of doctors taking them out of the hospital.
Do not fill up insurance forms asking for percentage of disability unless you are absolutely sure that there
is no disability eg an abrasion. If there is a possibility of disability, the forms should be redirected to the
appropriate department eg hand surgery or orthopaedics. If in doubt, please ask a senior doctor early so
that medical reports are completed on time.
190

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January

DEPARTMENT OF EMERGENCY MEDICINE

You are expected to fulfill the following during your posting:

SURVIVING EMERGENCY MEDICINE

APPROACH TO CHEST PAIN

A. Life threatening Causes B. Other Important Causes

1. Acute Coronary syndrome 1. Cardio-vascular

Symptoms and signs Management

STEMI (ST-elevation MI) Uptriage to P1

Refer to Sgarbossa Criteria to detect

Note: Right-sided chest pain may not

Exclusion Criteria (Refer CVM stat if any present)

What Constitutes Informed Consent by A&E

1. Explain the cause of AMI

2. Explain the mortality and morbidity risk of AMI

3. Emphasize the need to recannalize the artery as soon as possible

5. Explain why primary PCI is better in terms of efficacy and safety

NSTEMI (non ST-elevation MI)

Unstable Angina Pectoris (UAP) Supplemental O2

II. NSTEMI and

Known CAD (Stenosis ≥ 50%) Yes +1 0 to 1 score is 5%

ECG ST changes ≥ 0.5mm Yes +1

Positive cardiac marker Yes +1

Risk factors for CAD : Family history of CAD, Hypertension, Hypercholesterolemia,

Symptoms and signs Management

Moderate to severe SOB Uptriage to P1

Symptoms and signs Management

If CPP uneventful, discharge with TCU

If elevated cardiac enzymes during CPP,

Hx of syncope FBC, U/E, ECG, Trop T, CXR

Sinus tachycardia Management

FBC, U/E, ECG

If bloods normal and tachycardia

Supraventricular tachycardia Management

IV Calcium channel blockers eg.

IV adenosine 6mg rapid bolus with 20cc

If no response, can repeat IV adenosine

IV adenosine 6mg bolus

If NSR, observe in telemetry x 3 hours.

If persistent SVT, ODD CVM for

Atrial Fibrillation Management

Rate controlled Observe in telemetry x 3 hours

Advice to continue aspirin/warfarin if

TCU CVM arrhythmia clinic

FBC, U/E, ECG, CXR

IV Calcium channel blockers eg.

IV heparin 18 IU/kg pre-shock

ODD CVM for admission to HD

KIV IV digoxin 250 mcg over 30 minutes

Narrow complex tachycardia with See “Thyrotoxicosis”

Wide complex tachycardia Follow ACLS protocols

Criteria Value Points

Congestive Heart Failure History Yes +1

Hypertension History Yes +1

Stroke/TIA/Thromboembolism History Yes +2

Vascular Disease History Yes +1

Diabetes Mellitus History Yes +1

0 score is "low" risk and may not require anticoagulation.

1 score is "low-moderate" risk and should consider antiplatelet or anticoagulation*.

2 or greater is "moderate-high" risk and should otherwise be an anticoagulation*

Heart Failure Heart Failure with Requirement for

Adult congenital heart ACHD cases with

* When in doubt consult CVM

Definition: BP 140/90 mmHg or higher. No absolute BP defines a hypertensive crises, but

to reinforce importance of compliance and lifestyle modification before dc

Please refer to Protocol for Management of GS cases in DEM