Emergency Medicine & Trauma Management Training Data

Comprehensive Clinical Reference for Small Hospital/Clinic Operations

MODULE 1: TRIAGE SYSTEMS AND PATIENT PRIORITIZATION

The START Triage System (Simple Triage and Rapid Treatment)

START triage is designed for mass casualty incidents. Every patient arriving at the clinic during an emergency should be rapidly categorized:

Category RED (Immediate): Life-threatening conditions requiring immediate intervention. Respiratory rate >30 or <10, absent radial pulse, altered mental status. These patients will die without immediate care but have a reasonable chance of survival with treatment. Examples: tension pneumothorax, major hemorrhage with shock, airway compromise, open chest wounds.

Category YELLOW (Delayed): Serious injuries that are not immediately life-threatening. These patients can wait 1-4 hours for treatment. Examples: open fractures without vascular compromise, moderate burns (10-20% BSA), abdominal injuries without signs of shock, eye injuries.

Category GREEN (Minor/Walking Wounded): Minor injuries. Patients who can walk and have minor wounds. Examples: minor lacerations, sprains, small burns, minor fractures of fingers/toes, psychological trauma without physical injury.

Category BLACK (Expectant/Deceased): Patients who are either dead or have injuries so severe that survival is extremely unlikely even with full resources. In a resource-limited setting, this threshold may be lower than in a fully equipped hospital. Examples: massive head injury with brain matter visible, full-thickness burns >80% BSA, cardiac arrest in a mass casualty setting.

Triage Decision Tree

Step 1: Can the patient walk? → YES → GREEN Step 2: Is the patient breathing? → NO → Open airway → Still not breathing? → BLACK Step 3: Respiratory rate? → >30 breaths/min → RED Step 4: Radial pulse present? → NO → RED Step 5: Can the patient follow simple commands? → NO → RED If all checks pass → YELLOW

Daily Clinic Triage (Non-Mass Casualty)

For day-to-day clinic operations, use a 5-level Emergency Severity Index (ESI):

ESI-1 (Resuscitation): Requires immediate life-saving intervention. Cardiac arrest, respiratory failure, massive hemorrhage, anaphylaxis, status epilepticus.

ESI-2 (Emergent): High-risk situation, confused/lethargic/disoriented, or severe pain/distress. Chest pain with cardiac risk factors, stroke symptoms, severe allergic reaction, acute abdominal pain with vital sign abnormalities, suicidal ideation with plan.

ESI-3 (Urgent): Requires two or more resources (labs, imaging, IV fluids, procedures). Abdominal pain, moderate lacerations needing sutures, high fever, fractures.

ESI-4 (Less Urgent): Requires one resource. Simple laceration, urinary symptoms needing urinalysis, prescription refill with exam needed.

ESI-5 (Non-Urgent): Requires no resources. Prescription refill, simple rash, minor cold symptoms.

MODULE 2: AIRWAY MANAGEMENT

Basic Airway Maneuvers

Head-Tilt/Chin-Lift: Standard airway opening technique. Place one hand on the forehead and tilt the head back. With fingertips of the other hand, lift the chin forward. Contraindicated in suspected cervical spine injury.

Jaw-Thrust Maneuver: For patients with suspected cervical spine injury. Place fingers behind the angle of the mandible bilaterally and lift the jaw forward without extending the neck. This displaces the tongue from the posterior pharynx.

Recovery Position: For unconscious patients breathing adequately. Place the patient on their side with the upper leg bent at the hip and knee for stability. The lower arm extended forward, upper arm supporting the head. Mouth pointing downward to allow drainage. Check breathing every minute.

Oropharyngeal Airway (OPA)

Indications: Unconscious patient without gag reflex who needs airway maintenance. Sizing: Measure from the corner of the mouth to the angle of the jaw. Insertion: Insert with the curved side toward the palate (upside down), then rotate 180 degrees as it passes the soft palate. Alternatively, use a tongue depressor to depress the tongue and insert directly. Complications: Vomiting if the patient has a gag reflex, improper placement can push the tongue posteriorly.

Nasopharyngeal Airway (NPA)

Indications: Semi-conscious patient who cannot tolerate OPA, or when jaw clenching prevents OPA insertion. Sizing: Measure from the tip of the nose to the tragus of the ear. Diameter should be slightly smaller than the patient’s nostril. Insertion: Lubricate with water-soluble lubricant. Insert into the right nostril (larger passage in most people) with the bevel facing the septum. Advance perpendicular to the face along the floor of the nasal cavity. Contraindications: Suspected basilar skull fracture, severe facial trauma, coagulopathy.

Bag-Valve-Mask (BVM) Ventilation

Technique: Use the C-E hand grip. Form a C with thumb and index finger around the mask, pressing it to the face. The remaining three fingers form an E along the mandible, lifting the jaw into the mask. If available, two-person technique is superior: one person holds the mask with both hands (C-E on each side), the other squeezes the bag.

Ventilation parameters: Deliver one breath every 5-6 seconds (10-12 breaths/min for adults). Each breath should last about 1 second. Watch for chest rise. Tidal volume of approximately 500-600 mL (do not over-inflate).

Troubleshooting poor seal: Reposition the head, apply more jaw thrust, consider two-person technique, use OPA or NPA as adjunct, suction if secretions present.

Endotracheal Intubation

Indications: Failure to maintain adequate oxygenation/ventilation with BVM, need for prolonged airway protection, inability to protect the airway (GCS ≤8), anticipated clinical deterioration.

Equipment needed: Laryngoscope (Mac or Miller blade), endotracheal tube (ETT) — sizes 7.0-7.5 for adult women, 7.5-8.0 for adult men, stylet, 10 mL syringe, tape or tube holder, suction, BVM, stethoscope, CO2 detector if available.

Direct laryngoscopy technique:

Position: Sniffing position (neck flexed, head extended) unless C-spine precautions needed.
Open the mouth with the right hand using scissors technique.
Insert laryngoscope blade with left hand into right side of mouth, sweeping the tongue to the left.
Macintosh (curved) blade: Advance tip into vallecula (space between base of tongue and epiglottis), lift anteriorly and cephalad at 45 degrees to expose the glottis.
Miller (straight) blade: Place tip directly under the epiglottis and lift to expose the vocal cords.
Pass the ETT through the vocal cords. The cuff should pass 1-2 cm beyond the cords.
Inflate cuff with 5-10 mL air.
Confirm placement: auscultate bilateral breath sounds and epigastrium (should be silent), observe chest rise, use CO2 detector, note tube depth at teeth (typically 21-23 cm at incisors for adults).

Failed intubation: Maximum 3 attempts. Between attempts, ventilate with BVM. If unable to intubate, consider supraglottic airway (LMA if available) or surgical airway.

Cricothyrotomy (Surgical Airway)

Indications: “Can’t intubate, can’t oxygenate” — complete airway failure with inability to ventilate by any other means.

Anatomy: The cricothyroid membrane is located between the thyroid cartilage (Adam’s apple) superiorly and the cricoid cartilage inferiorly. It is approximately 9 mm tall and 30 mm wide.

Surgical technique:

Stabilize the larynx with the non-dominant hand.
Make a vertical skin incision approximately 3-4 cm over the cricothyroid membrane.
Palpate the membrane through the incision.
Make a horizontal stab incision through the membrane.
Insert the scalpel handle or a tracheal hook and rotate 90 degrees to open the airway.
Insert a cuffed tracheostomy tube or small ETT (6.0) through the opening.
Inflate cuff and ventilate.
Confirm placement and secure the tube.

Needle cricothyrotomy (temporizing measure): Insert a 14-gauge IV catheter through the cricothyroid membrane at 45 degrees caudally. Attach a syringe and aspirate air to confirm placement. Connect to oxygen source. This only provides oxygenation for approximately 30-45 minutes and does not allow adequate ventilation.

MODULE 3: HEMORRHAGE CONTROL AND SHOCK MANAGEMENT

External Hemorrhage Control

Direct Pressure: First-line treatment for all external bleeding. Apply firm, continuous pressure with gauze or clean cloth directly over the wound. Do not remove saturated dressings — add more on top. Maintain pressure for at least 15 minutes before checking.

Wound Packing: For deep, penetrating wounds where direct pressure alone is insufficient (especially junctional wounds — groin, axilla, neck). Pack the wound tightly with gauze, preferably hemostatic gauze (QuikClot, Celox) if available. Pack from the deepest point outward. Apply direct pressure over the packed wound.

Tourniquet Application: For life-threatening extremity hemorrhage not controlled by direct pressure. Apply 2-3 inches above the wound (not over a joint). Tighten until bleeding stops AND distal pulse is absent. Note the time of application. A properly applied tourniquet is painful — this is expected. Modern evidence supports tourniquet use for up to 6 hours with acceptable limb salvage rates. Improvised tourniquet: use a 3-4 inch wide band (belt, cravat, torn clothing) with a windlass (stick, pen) to tighten.

Pressure Points: Supplementary to direct pressure.

Temporal artery: anterior to the ear (scalp bleeding)
Facial artery: mandible anterior to masseter (facial bleeding)
Brachial artery: medial upper arm (forearm/hand bleeding)
Femoral artery: inguinal crease (lower extremity bleeding)

Hemostatic Agents: If available, kaolin-impregnated gauze (QuikClot Combat Gauze) or chitosan-based dressings (Celox) significantly improve hemorrhage control. Pack into the wound and apply pressure for 3-5 minutes.

Classification of Hemorrhagic Shock

Class I (up to 750 mL / 15% blood volume): Heart rate: <100, Blood pressure: Normal, Respiratory rate: 14-20, Urine output: >30 mL/hr, Mental status: Slightly anxious. Typically requires no intervention beyond crystalloid.

Class II (750-1500 mL / 15-30%): Heart rate: 100-120, Blood pressure: Normal (narrowed pulse pressure), Respiratory rate: 20-30, Urine output: 20-30 mL/hr, Mental status: Mildly anxious. May require crystalloid and potentially blood products.

Class III (1500-2000 mL / 30-40%): Heart rate: 120-140, Blood pressure: Decreased, Respiratory rate: 30-40, Urine output: 5-15 mL/hr, Mental status: Confused/anxious. Requires crystalloid AND blood products.

Class IV (>2000 mL / >40%): Heart rate: >140, Blood pressure: Severely decreased, Respiratory rate: >35, Urine output: Negligible, Mental status: Lethargic/obtunded. Requires massive transfusion. Without intervention, death is imminent.

Shock Resuscitation

Permissive Hypotension (Damage Control Resuscitation): In trauma patients with uncontrolled hemorrhage, target a systolic blood pressure of 80-90 mmHg (or presence of radial pulse) rather than normalizing blood pressure. Aggressive fluid resuscitation before hemorrhage control can worsen bleeding by disrupting clot formation and diluting clotting factors.

Exception: Traumatic brain injury patients need systolic BP >90 mmHg to maintain cerebral perfusion.

Fluid Resuscitation: Initial: 1-2 liters of warmed isotonic crystalloid (Normal Saline or Lactated Ringer’s) via large-bore IV (16-gauge or larger) in both antecubital fossae. If no improvement after 2 liters: patient needs blood products, not more crystalloid. Blood products: If available, transfuse in 1:1:1 ratio (packed red blood cells : fresh frozen plasma : platelets). Type O-negative for women of childbearing age, O-positive for others in emergencies when crossmatch is unavailable.

Intraosseous (IO) Access: When IV access cannot be obtained within 90 seconds in a critically ill patient. Sites: proximal tibia (2 cm below tibial tuberosity, on flat medial surface), distal tibia (above medial malleolus), proximal humerus. Insert IO needle perpendicular to bone with firm rotary pressure until a “pop” is felt entering the marrow cavity. Aspirate marrow to confirm placement. Can infuse crystalloids, blood products, and most medications.

Types of Shock (Differential Diagnosis)

Hypovolemic: Loss of circulating volume. Hemorrhagic (trauma, GI bleed, ruptured aneurysm) or non-hemorrhagic (dehydration, burns, third-spacing). Treatment: volume replacement, hemorrhage control.

Cardiogenic: Pump failure. MI, arrhythmia, valvular emergency, myocarditis, cardiac tamponade. Signs: JVD, pulmonary edema, hypotension. Treatment: treat underlying cause, inotropes (dobutamine), avoid excessive fluids.

Distributive: Vasodilation with relative hypovolemia.

Septic: Infection causing systemic vasodilation. Warm peripheries initially. Treatment: antibiotics, fluids, vasopressors (norepinephrine).
Anaphylactic: Allergic reaction. Urticaria, angioedema, bronchospasm, hypotension. Treatment: epinephrine 0.3-0.5 mg IM (anterolateral thigh), repeat q5-15 minutes, IV fluids, diphenhydramine, steroids.
Neurogenic: Spinal cord injury causing loss of sympathetic tone. Warm, dry skin, bradycardia, hypotension. Treatment: fluids, vasopressors (phenylephrine or norepinephrine).

Obstructive: Mechanical obstruction to cardiac output. Tension pneumothorax, cardiac tamponade, massive pulmonary embolism. Treatment: relieve obstruction (needle decompression, pericardiocentesis, thrombolytics).

MODULE 4: TRAUMA ASSESSMENT — PRIMARY AND SECONDARY SURVEY

Primary Survey (ABCDE)

Systematic rapid assessment to identify and treat immediately life-threatening conditions:

A — Airway (with cervical spine protection): Assess: Is the patient talking? Stridor? Gurgling? Snoring? Interventions: Jaw thrust (if C-spine concern), suction, OPA/NPA, intubation, cricothyrotomy. Maintain C-spine immobilization in all trauma patients until cleared.

B — Breathing and Ventilation: Assess: Expose the chest. Look for asymmetric chest rise, flail segments, open wounds. Listen for bilateral breath sounds. Percuss for hyperresonance (pneumothorax) or dullness (hemothorax). Count respiratory rate. Check oxygen saturation. Life threats to identify and treat immediately:

Tension pneumothorax: Tracheal deviation away from affected side, absent breath sounds, hyperresonance, hypotension, JVD. Treatment: immediate needle decompression (14-gauge needle, 2nd intercostal space, midclavicular line) followed by chest tube.
Open pneumothorax: Sucking chest wound. Treatment: three-sided occlusive dressing (tape on three sides, leaving one side open as flutter valve), then chest tube.
Massive hemothorax: >1500 mL blood in pleural space. Dullness to percussion, absent breath sounds, hypotension. Treatment: chest tube (36-40 Fr) and fluid resuscitation. If >1500 mL immediate output or >200 mL/hr for 2-4 hours, consider thoracotomy.
Flail chest: Two or more ribs fractured in two or more places creating a free-floating segment. Paradoxical chest wall movement. May require positive pressure ventilation.

C — Circulation (with hemorrhage control): Assess: Pulse rate and quality, skin color/temperature/moisture, capillary refill (<2 seconds normal), blood pressure, obvious external hemorrhage. Interventions: Direct pressure, tourniquets, wound packing, IV access (two large-bore IVs), fluid resuscitation, blood products.

D — Disability (Neurological Status): Glasgow Coma Scale (GCS):

Eye Opening: Spontaneous=4, To voice=3, To pain=2, None=1
Verbal Response: Oriented=5, Confused=4, Inappropriate words=3, Incomprehensible=2, None=1
Motor Response: Obeys commands=6, Localizes pain=5, Flexion withdrawal=4, Abnormal flexion=3, Extension=2, None=1
Total: 15 (best) to 3 (worst). GCS ≤8 = coma, intubate for airway protection.

Pupil assessment: Size, equality, reactivity. Unilateral fixed dilated pupil = herniation until proven otherwise — emergent intervention needed.

AVPU rapid assessment: Alert, responds to Voice, responds to Pain, Unresponsive.

E — Exposure and Environment: Completely undress the patient to identify all injuries. Log-roll to examine the back. Prevent hypothermia — cover with warm blankets after examination. The lethal triad in trauma: hypothermia + acidosis + coagulopathy. Aggressive warming is essential.

Secondary Survey

Performed only after the primary survey is complete and life threats are addressed. This is a systematic head-to-toe examination.

Head: Palpate skull for depressions, lacerations. Check ears for hemotympanum (blood behind TM) and CSF otorrhea. Check nose for septal hematoma and CSF rhinorrhea. Palpate facial bones for instability. Inspect mouth for dental injuries, lacerations.

Neck: Palpate cervical spine for midline tenderness, step-off deformity. Check for subcutaneous emphysema, tracheal position, JVD, carotid pulses.

Chest: Repeat primary survey findings. Palpate for rib fractures, sternal fractures, subcutaneous emphysema. Auscultate heart sounds (muffled = tamponade?).

Abdomen: Inspect for distension, bruising (seatbelt sign = high suspicion for hollow viscus injury). Palpate all four quadrants for tenderness, rigidity, guarding. If positive, assume intra-abdominal hemorrhage. FAST exam (Focused Assessment with Sonography for Trauma) if ultrasound is available — checks for free fluid in Morrison’s pouch, splenorenal recess, pelvis, and pericardium.

Pelvis: Gently compress and distract iliac crests ONCE (do not repeatedly test). Instability suggests pelvic fracture with potential for massive hemorrhage. If unstable, apply pelvic binder or circumferential sheet at level of greater trochanters.

Extremities: Inspect and palpate all four extremities. Check for deformity, swelling, crepitus, pulses, sensation, motor function. Document all fractures and dislocations. Check compartments for firmness (compartment syndrome).

Back (Log Roll): Palpate entire spine. Inspect for wounds. Perform rectal exam (tone, gross blood, prostate position in males).

AMPLE History

A — Allergies M — Medications P — Past medical/surgical history L — Last meal E — Events leading to injury

MODULE 5: SPECIFIC TRAUMA MANAGEMENT

Head Trauma

Concussion (Mild TBI, GCS 13-15): Symptoms: Headache, confusion, amnesia, brief loss of consciousness (<30 min), nausea. Management: Neurological observation q1h for 24 hours. Watch for deterioration. Rest. Acetaminophen for headache (avoid NSAIDs due to bleeding risk). Return precautions: worsening headache, vomiting, confusion, unequal pupils, seizure, weakness.

Moderate TBI (GCS 9-12): Often requires CT imaging. Admit for observation minimum 24 hours. Frequent neuro checks. May deteriorate to severe TBI.

Severe TBI (GCS ≤8): Intubate for airway protection. Elevate head of bed 30 degrees. Maintain systolic BP >90 mmHg. Target PaCO2 35-40 mmHg (avoid hyperventilation except as temporizing measure for active herniation). Mannitol 1g/kg IV for signs of herniation (blown pupil, posturing). Hypertonic saline (23.4% 30 mL or 3% 250 mL) as alternative to mannitol.

Signs of herniation: Unilateral fixed dilated pupil, decerebrate posturing, Cushing’s triad (hypertension, bradycardia, irregular respirations). This is an emergency — give mannitol or hypertonic saline immediately.

Epidural Hematoma: Typically from middle meningeal artery rupture with temporal bone fracture. Classic presentation: brief loss of consciousness, lucid interval, then rapid deterioration. Lens-shaped (biconvex) hematoma on CT. Requires emergent surgical evacuation (burr holes/craniotomy).

Subdural Hematoma: Bridging vein rupture. More common in elderly, alcoholics, patients on anticoagulants. Crescent-shaped on CT. Acute subdural with significant midline shift requires surgical evacuation.

Skull Fracture Management: Open/depressed: Requires surgical debridement and elevation if depressed >1 skull thickness. Basilar: Raccoon eyes, Battle’s sign (mastoid ecchymosis), CSF rhinorrhea/otorrhea, hemotympanum. Do NOT pack nose or ears. Do NOT insert NG tube (use OG tube instead). Treat with antibiotics if CSF leak persists >7 days.

Chest Trauma

Rib Fractures: Most common chest injury. Pain management is critical to prevent splinting, atelectasis, and pneumonia. Multimodal analgesia: acetaminophen + NSAID + opioid if needed. Incentive spirometry. Intercostal nerve block with local anesthetic for severe pain. Elderly patients with 3+ rib fractures have significant morbidity/mortality — consider admission.

Pulmonary Contusion: Bruising of lung parenchyma. May not be apparent on initial chest X-ray; develops over 24-48 hours. Management: oxygen supplementation, fluid restriction, pain management, incentive spirometry, positive pressure ventilation if severe.

Cardiac Tamponade: Blood in pericardial sac compressing the heart. Beck’s triad: hypotension, JVD, muffled heart sounds (often difficult to detect clinically). Pulsus paradoxus (>10 mmHg drop in systolic BP with inspiration). FAST exam shows pericardial fluid. Treatment: pericardiocentesis — insert 18-gauge spinal needle just below and to the left of the xiphoid process, directed toward the left shoulder at 45 degrees. Aspirate as needle advances. Even 20-30 mL removal can dramatically improve hemodynamics. Definitive management is surgical.

Chest Tube Insertion (Tube Thoracostomy): Indication: Pneumothorax, hemothorax, post-decompression. Site: 4th-5th intercostal space, anterior axillary line (safe triangle). Technique:

Prep and drape. Local anesthesia (lidocaine) to skin, subcutaneous tissue, periosteum, pleura.
Make a 3-4 cm incision along the rib at one interspace below intended insertion point.
Blunt dissect with Kelly clamp through subcutaneous tissue and intercostal muscles, going OVER the top of the rib (to avoid the neurovascular bundle on the inferior rib margin).
Puncture the pleura with the clamp — expect a rush of air or blood.
Insert a gloved finger to sweep and confirm intrapleural space (check for adhesions, lung).
Guide the chest tube (28-36 Fr for adults) posteriorly and superiorly using the clamp.
Connect to underwater seal/Heimlich valve.
Suture in place. Apply occlusive dressing.

Abdominal Trauma

Blunt Abdominal Trauma: Most commonly injured organs: Spleen (most common), Liver (second), Kidneys. Assessment: Serial abdominal exams every 15-30 minutes. FAST exam if available. Signs of peritonitis (rigid abdomen, rebound tenderness, involuntary guarding) indicate need for surgical exploration.

Splenic injury: Left upper quadrant pain, Kehr’s sign (referred left shoulder pain). May cause hemodynamic instability. Management ranges from observation (minor) to splenectomy (severe/unstable).

Liver injury: Right upper quadrant pain. High-grade injuries can cause massive hemorrhage. Most blunt liver injuries can be managed non-operatively if the patient is hemodynamically stable.

Penetrating Abdominal Trauma: Gunshot wounds to the abdomen generally require surgical exploration. Stab wounds: Evaluate for peritoneal violation. If hemodynamically unstable or signs of peritonitis, immediate surgical exploration. If stable, serial exams and observation may be appropriate.

Damage Control Surgery Principles: In severely injured patients (lethal triad), prioritize:

Hemorrhage control (packing, ligation, shunting)
Contamination control (staple/tie off bowel injuries, do not reanastomose)
Temporary abdominal closure
ICU resuscitation (warm, correct coagulopathy, correct acidosis)
Return to OR in 24-48 hours for definitive repair

Orthopedic Trauma

Fracture Management Principles: Assessment: Neurovascular status distal to injury (pulses, sensation, motor, capillary refill) BEFORE and AFTER any intervention. Open vs. closed. Description: location, pattern (transverse, oblique, spiral, comminuted), displacement, angulation.

Splinting: Immobilize the joint above and below the fracture. Pad bony prominences. Check neurovascular status before and after splinting. Common splints:

Sugar-tong splint: forearm fractures (wraps around elbow)
Ulnar gutter splint: 4th and 5th metacarpal fractures (boxer’s fracture)
Thumb spica: scaphoid or first metacarpal fractures
Posterior ankle splint: ankle fractures, severe ankle sprains
Long leg splint: tibial fractures, knee injuries

Open Fractures (Gustilo Classification): Type I: Wound <1 cm, clean, simple fracture. Low energy. Type II: Wound 1-10 cm, moderate soft tissue damage, no flaps. Type III: Wound >10 cm, extensive soft tissue damage, high energy.

IIIA: Adequate soft tissue coverage despite extensive damage
IIIB: Extensive soft tissue loss requiring flap coverage
IIIC: Arterial injury requiring repair

Management: Irrigate copiously (at least 3 liters normal saline for Type I, 6+ liters for Type II/III), debride devitalized tissue, IV antibiotics (cefazolin 2g for Type I/II; add gentamicin for Type III), tetanus prophylaxis, stabilize fracture, plan for definitive fixation.

Dislocations: Shoulder (anterior most common): Arm held in external rotation and abduction. Humeral head palpable anteriorly. Reduction techniques: external rotation method, Cunningham technique, traction-countertraction. Post-reduction: sling and swathe, check axillary nerve function (lateral deltoid sensation).

Hip (posterior most common): Leg shortened, adducted, internally rotated. Emergency — reduce within 6 hours to minimize avascular necrosis risk. Allis maneuver: patient supine, hip and knee flexed 90 degrees, apply longitudinal traction along the femur with gentle rotation.

Compartment Syndrome: Increased pressure within a closed fascial compartment compromising tissue perfusion. The 6 P’s: Pain (out of proportion, worst sign), Pain with passive stretch, Pressure (tense compartment), Paresthesias, Paralysis (late), Pulselessness (very late — loss of pulse means significant tissue death has occurred).

Diagnosis: Clinical. Compartment pressure >30 mmHg or within 30 mmHg of diastolic BP is diagnostic. Treatment: EMERGENT fasciotomy. Remove all circumferential dressings/casts. Four-compartment fasciotomy of the lower leg (most common site): medial and lateral incisions.

Burns

Burn Depth Classification: Superficial (1st degree): Epidermis only. Red, painful, dry, no blisters (sunburn). Heals 3-5 days. Partial thickness — superficial (2nd degree superficial): Epidermis and superficial dermis. Red, painful, wet, blisters. Blanches with pressure. Heals 10-21 days. Partial thickness — deep (2nd degree deep): Epidermis and deep dermis. White/red, less painful, may have blisters. Sluggish capillary refill. May require grafting. Heals 3-8 weeks. Full thickness (3rd degree): Through entire dermis. White/brown/black, painless (nerve destruction), dry/leathery, no blisters. Requires excision and grafting. 4th degree: Extends to muscle, bone, tendon. Charred appearance.

Burn Size Estimation (Total Body Surface Area — TBSA): Rule of Nines (adults): Head 9%, each upper extremity 9%, anterior trunk 18%, posterior trunk 18%, each lower extremity 18%, perineum 1%. Palm method: Patient’s palm (including fingers) ≈ 1% BSA. Useful for scattered burns. Do NOT include superficial (1st degree) burns in TBSA calculation.

Parkland Formula for Fluid Resuscitation: Total fluid in first 24 hours = 4 mL × body weight (kg) × %TBSA Give half in the first 8 hours from time of burn (not time of arrival). Give the remaining half over the next 16 hours. Use Lactated Ringer’s solution. Titrate to urine output: 0.5-1 mL/kg/hr in adults, 1-2 mL/kg/hr in children.

Example: 80 kg patient with 40% TBSA burn: 4 × 80 × 40 = 12,800 mL in 24 hours First 8 hours: 6,400 mL (800 mL/hr) Next 16 hours: 6,400 mL (400 mL/hr)

Burn Wound Care:

Cool the burn with room temperature water for 20 minutes (not ice).
Remove jewelry and clothing from burned areas.
Debride devitalized tissue gently.
Clean with mild soap and water or dilute chlorhexidine.
Apply topical antimicrobial: Silver sulfadiazine (most common, avoid on face and in sulfa allergy), Mafenide acetate (penetrates eschar, good for deep burns and cartilage), Bacitracin (face and ears).
Dress with non-adherent dressing (petrolatum gauze) and absorbent outer layer.
Change dressings 1-2 times daily.

Escharotomy: Full-thickness circumferential burns can cause compartment syndrome or restrict chest wall expansion. Incise through the eschar (full-thickness burn is insensate) down to subcutaneous fat along the mid-lateral and mid-medial lines of the extremity or along the anterior axillary lines of the chest.

Inhalation Injury: Suspect when: burns in enclosed space, facial burns, singed nasal hair, soot in mouth/nose, hoarse voice, stridor, carbonaceous sputum. Management: Early intubation (airway edema progresses rapidly), 100% oxygen, bronchoscopy if available, bronchodilators for bronchospasm. Carbon monoxide poisoning: Cherry-red skin (often absent), headache, confusion, coma. Pulse oximetry is UNRELIABLE (reads falsely high). Treatment: 100% oxygen via non-rebreather.

MODULE 6: CARDIAC EMERGENCIES

Cardiac Arrest and CPR

Adult BLS Algorithm:

Confirm unresponsiveness and absence of normal breathing.
Activate emergency response, get AED if available.
Check for pulse (carotid) for no more than 10 seconds.
If no pulse, begin CPR: 30 compressions : 2 breaths.

High-Quality CPR:

Rate: 100-120 compressions per minute
Depth: At least 2 inches (5 cm) but no more than 2.4 inches (6 cm) in adults
Allow full chest recoil between compressions
Minimize interruptions (<10 seconds)
Rotate compressors every 2 minutes
Hand placement: heel of hand on lower half of sternum

Shockable Rhythms (VF/Pulseless VT): Defibrillate as soon as possible. Biphasic defibrillator: 120-200J (or manufacturer recommendation). Monophasic: 360J. Immediately resume CPR after shock (do not check rhythm). Epinephrine 1mg IV/IO every 3-5 minutes. After second shock: Amiodarone 300mg IV push, second dose 150mg. Consider reversible causes (H’s and T’s).

Non-Shockable Rhythms (PEA/Asystole): CPR + Epinephrine 1mg IV/IO every 3-5 minutes. Identify and treat reversible causes.

H’s and T’s (Reversible Causes): H’s: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia. T’s: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (coronary/pulmonary).

Acute Coronary Syndromes

STEMI Recognition: Chest pain/pressure with ST elevation in 2 or more contiguous leads on ECG. Distribution: Leads II, III, aVF = inferior MI (RCA), Leads V1-V4 = anterior MI (LAD), Leads I, aVL, V5-V6 = lateral MI (LCx).

Acute MI Management (MONA+):

Morphine: 2-4 mg IV for pain unresponsive to nitroglycerin (use cautiously)
Oxygen: Only if SpO2 <94%
Nitroglycerin: 0.4 mg sublingual every 5 minutes × 3. Contraindicated in right ventricular MI (leads V4R), systolic BP <90, recent PDE-5 inhibitor use.
Aspirin: 162-325 mg chewed immediately
Additional: Heparin (enoxaparin 1mg/kg subQ or unfractionated heparin IV), beta-blocker (metoprolol 5mg IV if not hypotensive or bradycardic), statin (atorvastatin 80mg), clopidogrel (loading dose 300-600mg).

In resource-limited settings without cath lab: Thrombolytics if available (tenecteplase, alteplase, streptokinase) within 12 hours of symptom onset. Streptokinase 1.5 million units IV over 60 minutes as most accessible option.

Acute Heart Failure / Pulmonary Edema

Presentation: Severe dyspnea, orthopnea, bilateral crackles, frothy pink sputum, JVD, peripheral edema, hypoxia.

Management:

Sit patient upright
Oxygen — high flow, non-rebreather. CPAP/BiPAP if available (dramatically improves outcomes)
Nitroglycerin: sublingual or IV drip if systolic BP >90
Furosemide (Lasix): 40-80 mg IV (double the patient’s daily dose if already on furosemide)
Morphine: 2-4 mg IV cautiously (reduces preload and anxiety)
If hypotensive: Dobutamine 2-20 mcg/kg/min IV and/or norepinephrine

Arrhythmia Management

Unstable Tachycardia (any rhythm with hemodynamic instability): Synchronized cardioversion. Narrow complex: start at 50-100J. Wide complex: start at 100J. Sedate first if conscious (midazolam, etomidate, ketamine).

Stable Narrow Complex Tachycardia (SVT):

Vagal maneuvers (modified Valsalva, carotid sinus massage)
Adenosine 6mg rapid IV push (followed by 20mL saline flush), may repeat 12mg × 2
If refractory: diltiazem 15-20 mg IV over 2 min, or beta-blocker

Stable Wide Complex Tachycardia: Assume VT until proven otherwise. Amiodarone 150mg IV over 10 minutes, may repeat. Procainamide 20-50 mg/min IV until arrhythmia suppressed or max dose 17mg/kg.

Bradycardia with Symptoms:

Atropine 0.5mg IV every 3-5 minutes (max 3mg)
If refractory: transcutaneous pacing, dopamine 5-20 mcg/kg/min, or epinephrine 2-10 mcg/min

MODULE 7: ENVIRONMENTAL EMERGENCIES

Hypothermia

Classification: Mild (32-35°C / 90-95°F): Shivering, confusion, poor judgment, tachycardia. Moderate (28-32°C / 82-90°F): Shivering stops, progressive confusion, bradycardia, atrial fibrillation. Severe (<28°C / <82°F): Unconsciousness, fixed dilated pupils, VF risk, appears dead.

Treatment: Remove wet clothing. Passive external rewarming (blankets, warm environment) for mild. Active external rewarming (warm blankets, forced warm air devices, warm water bottles to axillae/groin/neck) for moderate. Active core rewarming for severe: Warm IV fluids (40-42°C), warm humidified oxygen, peritoneal lavage with warm saline, thoracic lavage.

Important: Handle severely hypothermic patients gently — rough handling can precipitate VF. Defibrillation may be ineffective below 30°C — attempt once, if unsuccessful defer until rewarmed above 30°C. Withhold IV medications until core temp >30°C (drug metabolism severely impaired). “No one is dead until they are warm and dead.”

Heat Emergencies

Heat Exhaustion: Core temp 37-40°C. Profuse sweating, weakness, headache, nausea, tachycardia. Move to cool environment, oral/IV hydration, cooling measures.

Heat Stroke: Core temp >40°C with CNS dysfunction (confusion, seizures, coma). This is a TRUE EMERGENCY — mortality >50% if not rapidly cooled. Treatment: Rapid whole-body cooling. Most effective method: ice water immersion (cold water immersion if ice unavailable). Target core temp 38.5-39°C then stop active cooling. Alternative methods: evaporative cooling (wet skin + fan), ice packs to neck/axillae/groin. IV fluid resuscitation. Monitor for rhabdomyolysis, DIC, organ failure.

Drowning

Remove from water with C-spine precautions if diving injury suspected. Begin CPR if not breathing. Rescue breaths are critical in drowning (hypoxic arrest). All submersion victims need observation — even if initially asymptomatic, delayed pulmonary edema can occur up to 24 hours later.

Anaphylaxis

Diagnostic Criteria: Rapid onset (minutes to hours) with involvement of skin/mucosal tissue AND respiratory compromise or hemodynamic instability. OR two or more of: skin symptoms, respiratory symptoms, hypotension, GI symptoms after exposure to likely allergen.

Treatment:

Epinephrine 0.3-0.5 mg IM (1:1000 concentration) in anterolateral thigh. THIS IS THE MOST IMPORTANT TREATMENT. Repeat every 5-15 minutes as needed.
Position: Supine with legs elevated (unless respiratory distress, then sitting up). Pregnant: left lateral decubitus.
IV fluids: 1-2 liters NS bolus for hypotension.
Adjuncts: H1 blocker (diphenhydramine 50mg IV/IM), H2 blocker (ranitidine 50mg IV), corticosteroids (methylprednisolone 125mg IV) to prevent biphasic reaction.
Albuterol nebulization for bronchospasm.
If refractory: Epinephrine IV infusion 1-4 mcg/min (mix 1mg in 250mL NS).
Observe for minimum 4-6 hours (up to 24 hours for severe reactions — biphasic reactions occur in 5-20% of cases).

Envenomation

Snakebite: First aid: Immobilize the limb, keep at heart level, remove constrictive clothing/jewelry. Mark the edge of swelling with time. Transport to medical facility. Do NOT: Apply tourniquet, ice, suction, cut the wound, or apply electric shock. Pit viper envenomation: Progressive swelling, ecchymosis, pain, coagulopathy. Antivenom (CroFab in North America) for moderate-severe envenomation. Monitor: CBC, PT/INR, fibrinogen, D-dimer every 6 hours. Watch for compartment syndrome.

Insect Stings/Bites: Most reactions are local. Treat severe allergic/anaphylactic reactions as above. Remove bee stingers by scraping (do not squeeze with tweezers as this injects more venom).

MODULE 8: PEDIATRIC EMERGENCY CONSIDERATIONS

Pediatric Vital Signs (Normal Ranges by Age)

Newborn (0-1 month): HR 120-160, RR 30-60, SBP 60-80 Infant (1-12 months): HR 100-150, RR 25-40, SBP 70-90 Toddler (1-3 years): HR 90-140, RR 20-30, SBP 75-100 Preschool (4-5 years): HR 80-120, RR 20-25, SBP 80-110 School age (6-12 years): HR 70-110, RR 15-20, SBP 85-120 Adolescent (13+ years): HR 60-100, RR 12-20, SBP 95-140

Minimum systolic BP formula: 70 + (2 × age in years) = lower limit of normal SBP for ages 1-10.

Pediatric Airway

Children have anatomically different airways: larger head/occiput, larger tongue relative to mouth, higher/more anterior larynx, epiglottis is floppy and omega-shaped, narrowest point is at cricoid ring (below the cords) in children <8 years.

ETT size (uncuffed): (Age in years / 4) + 4 ETT size (cuffed): (Age in years / 4) + 3.5 ETT depth at lip: ETT size × 3

Pediatric Resuscitation

Weight estimation: (Age × 2) + 8 (for ages 1-10) in kg. Broselow tape if available. Compressions: Infant — two-thumb encircling technique or two-finger technique. Child — one or two hands. Depth: 1/3 anterior-posterior diameter. Ratio: 30:2 (single rescuer), 15:2 (two rescuers) for children and infants. Defibrillation: 2 J/kg first shock, 4 J/kg subsequent shocks. Epinephrine: 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO every 3-5 minutes. Fluid bolus: 20 mL/kg isotonic crystalloid, reassess after each bolus.

Common Pediatric Emergencies

Croup (Laryngotracheobronchitis): Barking cough, stridor, hoarse voice. Ages 6 months to 3 years. Treatment: Dexamethasone 0.6 mg/kg PO/IM (single dose). Racemic epinephrine nebulization for severe stridor. Cool mist. Observe for 2-4 hours after racemic epinephrine (rebound).

Epiglottitis: Drooling, tripod position, muffled voice, high fever, toxic appearance. Do NOT examine the throat (can precipitate complete obstruction). Secure airway in OR if possible. Antibiotics: ceftriaxone.

Febrile Seizures: Ages 6 months to 5 years. Simple: generalized, <15 minutes, single episode in 24 hours. Management: supportive, antipyretics, parental reassurance. Complex febrile seizures (focal, prolonged >15 min, recurrent in 24 hours) require further workup.

Pediatric Dehydration Assessment: Mild (3-5%): Slightly dry mucous membranes, mildly decreased urine output. Moderate (6-9%): Sunken eyes, sunken fontanelle (infants), decreased skin turgor, tachycardia, significantly decreased urine output. Severe (≥10%): Lethargy/unconsciousness, very sunken eyes, very dry mucous membranes, tachycardia, hypotension, mottled/cool extremities, no urine output.

Oral rehydration: 50 mL/kg over 4 hours for mild-moderate. WHO ORS formula: 2.6g NaCl, 2.9g trisodium citrate, 1.5g KCl, 13.5g glucose per liter of clean water.

IV rehydration for severe: 20 mL/kg NS bolus, repeat as needed. Then replace deficit plus maintenance.

Maintenance IV fluids (Holliday-Segar):

First 10 kg: 100 mL/kg/day (4 mL/kg/hr)
Second 10 kg: 50 mL/kg/day (2 mL/kg/hr)
Each additional kg: 20 mL/kg/day (1 mL/kg/hr)

MODULE 9: COMMON EMERGENCY PROCEDURES

Wound Closure

Wound Assessment: Mechanism (sharp, crush, bite), contamination, depth, structures involved (tendon, nerve, vessel, joint capsule), time since injury. Wounds >6-8 hours old (>12-24 hours on face) may need to be left open for delayed primary closure.

Local Anesthesia: Lidocaine 1%: 4.5 mg/kg max without epinephrine, 7 mg/kg max with epinephrine. Each mL of 1% lidocaine = 10 mg. Onset 2-5 minutes, duration 30-120 minutes (longer with epinephrine). Bupivacaine 0.25-0.5%: 2.5 mg/kg max. Onset 5-15 minutes, duration 4-8 hours. Better for longer procedures. Buffering: Add 1 mL of sodium bicarbonate 8.4% per 10 mL of lidocaine to reduce injection pain. Epinephrine: Causes vasoconstriction, reduces bleeding, prolongs anesthesia. Safe on digits (old teaching about digital necrosis has been disproven for lidocaine with epinephrine).

Digital Nerve Block: Inject 1-2 mL of lidocaine (without epinephrine traditionally, but with is now accepted) on either side of the base of the digit at the 2 o’clock and 10 o’clock positions. Wait 5-10 minutes for complete anesthesia.

Suturing: Simple interrupted: Most versatile. Enter skin at 90 degrees, 3-5 mm from wound edge, equal depth on both sides, exit perpendicular. Tie with square knots (3-4 throws for nylon, 5-6 for absorbable). Mattress sutures (horizontal and vertical): For high-tension wounds, wound eversion. Deep/buried sutures: For dead space closure and tension reduction. Use absorbable suture (Vicryl). Place knot deep. Running suture: For long, linear, low-tension wounds. Faster than interrupted. Corner stitch (half-buried horizontal mattress): For flap tips to avoid devascularization.

Suture Selection: Face: 6-0 non-absorbable (nylon/Prolene), remove 3-5 days Scalp: 4-0 or staples, remove 7-10 days Trunk: 4-0 or 3-0, remove 7-10 days Extremities: 4-0 or 5-0, remove 10-14 days Hands: 5-0, remove 10-14 days Deep closure: 4-0 or 3-0 absorbable (Vicryl, Monocryl)

Wound Care Instructions: Keep clean and dry for 24 hours, then gentle washing daily with soap and water. Apply thin layer of antibiotic ointment. Cover with non-adherent dressing. Watch for signs of infection: increasing redness, warmth, swelling, purulent drainage, red streaking, fever.

Abscess Incision and Drainage

Confirm fluctuance (indicates drainable collection).
Mark the area. Prep with chlorhexidine or betadine.
Local anesthesia: Field block around the abscess (injecting into the abscess cavity is painful and less effective). Consider procedural sedation for large abscesses.
Make a linear incision over the point of maximum fluctuance. Extend the incision the full length of the cavity.
Express all purulent material.
Break up all loculations with a hemostat or finger.
Irrigate the cavity with normal saline.
Loosely pack with iodoform gauze (leave a tail for removal).
Cover with absorbent dressing.
Follow-up in 48 hours for packing change.
Antibiotics only if: cellulitis extends beyond abscess, immunocompromised, systemic signs of infection (fever, tachycardia), multiple abscesses, or high-risk location (face, hands, genitals).

Lumbar Puncture

Indications: Suspected meningitis, subarachnoid hemorrhage, CNS infections, therapeutic (reduce ICP in pseudotumor cerebri).

Contraindications: Signs of increased ICP with mass effect (papilledema, focal neuro deficits — get CT first), infection at puncture site, coagulopathy, hemodynamic instability.

Technique:

Position: Lateral decubitus (preferred) with knees drawn to chest and chin tucked, or seated upright leaning forward over a table.
Landmark: L3-L4 or L4-L5 interspace. The iliac crest line crosses at approximately L4.
Prep with chlorhexidine, drape.
Local anesthetic: Lidocaine 1% — skin wheal, then deeper infiltration.
Insert spinal needle (20-22 gauge) with stylet, bevel facing laterally (patient on side) or superiorly (patient seated). Aim toward the umbilicus.
Advance slowly. You will feel a “pop” through the ligamentum flavum and dura.
Remove stylet, observe for CSF flow.
Measure opening pressure with manometer (normal 10-20 cm H2O).
Collect tubes: Tube 1 (cell count), Tube 2 (glucose, protein), Tube 3 (Gram stain, culture), Tube 4 (cell count — compare with Tube 1 to differentiate traumatic tap from SAH).
Replace stylet and remove needle. Apply bandage.

CSF Interpretation: Normal: Clear, WBC <5, RBC 0, Glucose 40-70 (>60% serum glucose), Protein 15-45. Bacterial meningitis: Turbid, WBC 1000-5000+ (neutrophil predominant), low glucose (<40), high protein (>250), positive Gram stain. Viral meningitis: Clear, WBC 50-1000 (lymphocyte predominant), normal glucose, mildly elevated protein, negative Gram stain. SAH: Bloody/xanthochromic, elevated RBC (does not clear between tubes), xanthochromia on centrifuged supernatant.

Chest Tube Removal

Indications for removal: Resolution of pneumothorax/hemothorax, drainage <100-200 mL/day (for hemothorax), no air leak for 24 hours, lung re-expanded on imaging.

Technique: Remove dressing. Have patient perform Valsalva (or remove at end-expiration). Swiftly pull the tube while an assistant applies an occlusive (petroleum gauze) dressing. Monitor with chest X-ray to confirm no recurrent pneumothorax.

MODULE 10: TOXICOLOGY AND POISONING

General Approach to the Poisoned Patient

Stabilize: ABCs first. Many toxidromes cause rapid deterioration.

Decontamination: Activated charcoal: 1 g/kg PO (max 50g) within 1-2 hours of ingestion. Most effective within first hour. Contraindicated in: unprotected airway, caustic ingestion, hydrocarbons, intestinal obstruction. Whole bowel irrigation: Polyethylene glycol (GoLYTELY) for sustained-release preparations, body packers, iron, lithium. 1-2 L/hr via NG tube until clear effluent. Do NOT induce vomiting (ipecac is obsolete).

Common Toxidromes

Anticholinergic: “Blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, bloated as a toad, fast as a hare.” Dilated pupils, dry skin, tachycardia, urinary retention, decreased bowel sounds, hyperthermia, altered mental status, seizures. Causes: antihistamines, tricyclics, atropine, jimsonweed. Treatment: Physostigmine 1-2mg slow IV for severe toxicity (only with cardiac monitoring, avoid in TCA overdose).

Cholinergic: DUMBELS — Diarrhea, Urination, Miosis, Bronchospasm/Bradycardia, Emesis, Lacrimation, Salivation. Causes: organophosphates, nerve agents, some mushrooms. Treatment: Atropine 2mg IV, double every 3-5 minutes until secretions dry. Pralidoxime (2-PAM) 1-2g IV for organophosphate poisoning.

Sympathomimetic: Tachycardia, hypertension, hyperthermia, diaphoresis, mydriasis, agitation. Causes: cocaine, amphetamines, MDMA. Treatment: Benzodiazepines (diazepam 5-10mg IV, repeat as needed). Avoid beta-blockers in cocaine toxicity (unopposed alpha stimulation).

Opioid: Respiratory depression, miosis (pinpoint pupils), CNS depression, bradycardia. Treatment: Naloxone 0.04-0.4 mg IV (start low and titrate — goal is to restore adequate breathing, not full consciousness). Can be given IM, SQ, intranasal, or via ETT. Duration of naloxone may be shorter than the opioid — observe for re-sedation.

Sedative/Hypnotic: CNS depression, respiratory depression, hypotension. Normal pupils. Causes: benzodiazepines, barbiturates, GHB. Treatment: Supportive. Flumazenil for benzodiazepine overdose (0.2mg IV, repeat 0.5mg q1min, max 5mg) — use cautiously, can precipitate seizures in chronic users or mixed ingestions.

Specific Antidotes

Poison	Antidote	Dose
Acetaminophen	N-acetylcysteine (NAC)	150 mg/kg IV over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours
Opioids	Naloxone	0.04-2 mg IV/IM/IN, repeat q2-3min
Benzodiazepines	Flumazenil	0.2 mg IV, then 0.5 mg q1min (max 5 mg)
Organophosphates	Atropine + Pralidoxime	Atropine 2 mg IV; 2-PAM 1-2 g IV over 15-30 min
Beta-blockers	Glucagon	3-5 mg IV, then infusion 2-5 mg/hr
Calcium channel blockers	Calcium, high-dose insulin	CaCl 1-3 g IV; Insulin 1 unit/kg bolus + 1 unit/kg/hr with dextrose
Warfarin	Vitamin K, FFP, PCC	Vitamin K 10 mg IV; 4-factor PCC for emergent reversal
Heparin	Protamine	1 mg per 100 units of heparin
Iron	Deferoxamine	15 mg/kg/hr IV (max 6 g/day)
Methanol/ethylene glycol	Fomepizole or ethanol	Fomepizole 15 mg/kg IV load; or ethanol to blood level 100-150 mg/dL
Cyanide	Hydroxocobalamin or nitrite/thiosulfate kit	Hydroxocobalamin 5 g IV
Carbon monoxide	Oxygen	100% O2 via NRB; hyperbaric if available for severe cases
Tricyclic antidepressants	Sodium bicarbonate	1-2 mEq/kg IV bolus for QRS >100ms
Digoxin	Digoxin-specific Fab	Based on estimated body load

Acetaminophen Overdose (Most Common Poisoning)

Potentially toxic dose: >150 mg/kg or >7.5 g (whichever is less) in a single ingestion. Timeline: Stage 1 (0-24h) — nausea, vomiting, malaise. Stage 2 (24-72h) — apparent improvement, rising LFTs. Stage 3 (72-96h) — hepatic failure, coagulopathy, encephalopathy, renal failure. Stage 4 (4-14 days) — recovery or death.

Rumack-Matthew nomogram: Plot acetaminophen level (drawn at 4+ hours post-ingestion) against time. If above the treatment line (150 mcg/mL at 4 hours), treat with NAC.

NAC is most effective within 8 hours but should be given up to 24+ hours. IV protocol (21-hour): 150 mg/kg in 200 mL D5W over 1 hour, then 50 mg/kg in 500 mL over 4 hours, then 100 mg/kg in 1000 mL over 16 hours. Oral protocol (72-hour): 140 mg/kg loading dose, then 70 mg/kg every 4 hours for 17 additional doses.

This completes the Emergency Medicine and Trauma Management training module. Each section is designed to provide the level of detail needed for clinical decision-making in a resource-limited setting. Regular review and practical simulation of these protocols is essential for maintaining competency.