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«FOR THE MINISTRY OF HEALTH, TONGA- 2007. Standard Treatment Guidelines Tonga 2007 Standard Treatment Guidelines and Essential Drugs List: Ministry of ...»

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STANDARD TREATMENT

GUIDELINES

AND

ESSENTIAL DRUGS LIST

FOR THE

MINISTRY OF HEALTH, TONGA-

2007.

Standard Treatment Guidelines Tonga 2007

Standard Treatment Guidelines and Essential Drugs List:

Ministry of Health.

First Edition, 2007 Copyright © 2007, Ministry of Health, Tonga All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, scanned or transmitted in any form without the permission of the copyright owner.

Ministry of Health PO Box 59 Nuku’alofa Tonga Phone: 676 23200 Fax: 676 24291 E-mail address: vhclnser@kalianet.to Editors: Siale ‘Akau’ola & Siutaka Siua Cover design by: Owen Towle Formatted by: T. Nauna Paongo Printed by: Taulua Press STG 2 Ministry of Health Standard Treatment Guidelines Tonga 2007

TABLE OF CONTENTS

1. FOREWORD: 13

2. ABBREVIATIONS AND ACRONYMS: 14

3. ACKNOWLEDGEMENTS: 17

4. INTRODUCTION: 19

5. ACCIDENT AND EMERGENCY (A&E): 21 5.1. General Approach to A&E 21 5.2. Cardiac Arrest 26 5.3. Other Life Threatening Emergencies 30 5.4. Infectious Diseases 52 5.5. Severe Hypertension 58 5.6. Abdominal Pain 59 5.7. Surgical Problems 60 5.8. Red Eye 66 5.9. Dog Bite 67

6. CARDIOVASCULAR CONDITIONS. 68 6.1. Heart Failure 68 6.2. Myocardial Infarction 72 6.3. Cardiogenic Shock 77 6.4. Acute Coronary Syndrome (ACS) 79 6.5. Cardiac Arrythmias 80 6.6. Cardiac Arrest 87 6.7. Hypertension 89 6.8. Aortic Dissection 93 6.9. Bacterial Endocarditis 96 6.10. Infective Endocarditis Prophylaxis 97

7. CENTRAL NERVOUS SYSTEM (CNS) CONDITIONS

104 7.1 Headache

–  –  –

LIST OF TABLES

Table 1 Triage Scale

Table 2 Asthma Severity Scale

Table 3 Acute poisoning and their antdsotes

Table 4 Diazepam dosing rates

Table 5 Signs and Symptoms of dehydration

Table 6 Mild dehydration

Table 7 Moderate dehydration

Table 8 Severe dehydration

Table 9 Common causes of food poisoning

Table 10 Abdominal Pain (Location of pain can help arrive at...59 Table 11 Levels of hypertension

Table 12 Step wise treatment of hypertension:

Table 13 Antibacterial Recommendations for Dental, Oral, Respiratory Tract or Oesophageal Procedures............ 101 Table 14 Antibacterial Recommendations for Genitourinary Tract and Gastrointestinal Tract (excluding oesophageal) procedures

Table 15 Types of headache

Table 16 Benign headaches

Table 17 Treatment of Benign Headaches:

Table 18 Management of conjunctivitis

Table 19 Signs and symptoms of Iritis

Table 20 Prognostic Factors in Acute Pancreatitis

Table 21 Levels of severity of hypertension in pregnancy....... 181 Table 22 Treatment of hypertension in pregnancy

Table 23 Drug treatment of pain in labour

Table 24 Vaccination of children in Tonga

Table 25 Interpretation of BMI results:

Table 26 Vitamin deficiencies

Table 27 Warfarin; first five days of treatment

Table 28 Recommended INR levels for warfarin treatment...... 226 Table 29 Severity Assessment in COPD

Table 30 Theophylline Therapy

Table 31 Severity Assessment in Acute Asthma

Table 32 Management of Asthma

Table 33 Key Points – Acute Severe Asthma in Adults............ 269 Table 34 Asthma Self-Management Plan

STG 10 Ministry of Health Standard Treatment Guidelines Tonga 2007 Table 35 Antibiotic Treatment for Community Acquired......... 278 Table 36 Acute Pulmonary-Renal Syndrome

Table 37 Different types of Tinea

Table 38 Treatment of Tinea fungal infection

Table 39 Treatment of different types of psoariasis.................. 318 Table 40 Treatment of cervicitis and vaginitis

Table 41 Treatment of urethritis

Table 42 Treatment of genital ulcers

–  –  –

Figure 1 Basic Life Support Flow-Chart

Figure 2 Advanced Life Support

Figure 3 Use of Thrombolysis Therapy

Figure 4 Diagnosis of Aortic Dissection

Figure 5 Steps in Neonatal Resuscitation:

Figure 6 Acute Asthma Management

–  –  –

In 1985, the World Health (WHO) provided a definition of Rationale use of Medicines as “Patients receive medications appropriate to the clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community”.

Worldwide, more than 50% of all medcines are prescribed, dispensed, or sold Foreward inappropriately, while 50% of patients fail to take their medicines correctly.

Moreover, about one-third of the world’s population lacks access to essential medicines.

In our effort to address this very important issue, legistations were formulated and work started to develop this document.

I am very glad indeed with this publication and the tremendous work of the editors and all the contributions of other health professionals are very much appreciated.





It is sincerely hoped that this will help all health professionals in the kingdom of Tonga maintain and improve our patient management. We should all try to be very familiar with this publication as education is an ongoing, process.

I would like to thank the editors, Dr. Siale ‘Akau’ola and Mr. Siutaka Siua, and everyone else who has contributed to this edition. Every country is expected to have her own version of Standard Treatment Guidelines and Essential Drug List. Tonga now joins those countries.

–  –  –

STG 19 Ministry of Health Standard Treatment Guidelines Tonga 2007 A request for a new product to be included in the EDL must be directed to the National Drugs and Medical Supplies Committee, supported by scientific data and appropriate references, on the advantages and benefits over an existing product.

As noted above, all recommended treatment regimes in this guideline have been carefully tailored to utilize the drugs listed in our EDL.

However, since this is the first edition of the STG, a few of the drugs recommended for treatment may not be in the EDL. Health workers, particularly those who are stationed in the community health centers, are urged to consult relevant clinical consultants, when such situations arise; and especially, if the management recommendation is beyond the capacity of his/her health-care setting.

The production of this STG was a collaborative effort by senior clinicians and pharmacists, at Vaiola Hospital. It is intended to be used by: medical officers, dentists, health officers, nurses and pharmacy staff in Tonga.

The information provided are based on the latest scientific evidence available to the co-authors.

We plan to update this document on a regular basis in future, when new information comes to hand.

–  –  –

Remember, that a clinician’s professional standing is often judged by how well he/she performs his/her note keeping!

Handing Patients over.

It is important to complete activities needed for a patient, either to the point of discharge, or handing over to an inpatient team, before one finishes his/her shift. If this is not possible, careful hand-over to the new A&E clinician should be done and at the same time, to inform the nursing staff too. It is also courteous to tell patients that further care will be provided by a new doctor.

Coping with A&E.

The majority of time when one is working at A&E, he/she will be on his/her feet; working, thinking and making decisions. It is physically demanding so one needs to be fit, well rested and ready to tackle this area, everytime one is rostered to work there.

–  –  –

Another problem frequently faced by clinicians at A&E is mental fatigue. If one feels he cannot cope with the pressure; please, do tell someone!! Do not bottle it up; try to ignore it or assume that it reflects inadequacy. Trying to disguise or deny the situation is unfair to yourself, your colleagues and your patients. Always remember that as a professional, you should never loose your cool in public and you always put your patient’s interest first.

Shifts.

Remember the following general rules about shift work:

• Never be late to your shift.

• If, for what ever reason you cannot work a shift, let the department know in good time to allow time for replacement.

• Remember, working at A&E demands the highest ethical and professional standards from a doctor or health officer.

• Casual and special leaves must always be approved first by the Officer-In -Charge before they can be taken. Never send in a Casual leave request, on the same day one plans to take the leave. This is irresponsible behaviour, which is unfair to your colleagues who have to cover for your absence and also for the patients who may not be attended to in time, due to staff shortages c.

Breaking Bad News.

Death at the A&E is usually a sudden, unexpected tragic experience to the relatives, who may already be distressed after witnessing the event which led to the fatality. Breaking the bad news to them should be done by the medical personnel in charge, who has good communication skills and empathy.

Common responses to bereavement include emotional distress, denial, guilt and aggression.

Remember to report the death to the police whenever indicated, as in MVA or suspected unnatural deaths.(Report to police should be done

–  –  –

After each death, staff involved should take 5 to 10 minutes break, have a cup of tea, and try to relax before continuing on with the A&E activities.

Violence.

Most violent episodes can be predicted by watching warning body languages of the patient. (eg. Tone of voice, gestures and postures.) Do not aggravate it by confrontational postures. Try to give reassurance you are trying to help and keep your voice low. Engage the patient in a conversation.

Underlying causes of aggression in patients include hypoglycemia, hypoxia, distended bladder, mental illness. All can be compounded by alcohol.

Approach to aggressive patient.

• Avoid physical confrontation.

• Keep an escape route open.

• Direct body or eye contact can be provocative to patients.

• Remember personal space by psychotic patients.

• Get immediate help from security or police.

Management.

With physical violence, safety for staff and other members of the public takes priority. Concern for property is secondary. A calm approach with talking and listening can resolve a violent act.

Employ physical restraint only if there is risk that other members of the public may get hurt. Use minimum degree of force to control episode. Hold limbs near joints to prevent fracture. Grasp clothes not body if possible. Don’t apply pressure to neck, throat, chest or abdomen. If patient bites, the hair can be held firmly. Use the hospital’s security staff to assist in restraining violent patients and if necessary, call the police for assistance.

At the same time, talk to the patient and try to reassure you are trying to help.

STG 24 Ministry of Health Standard Treatment Guidelines Tonga 2007 Pharmacologic restraint should be a last resort. IV diazepam is probably safest. However, be wary of the patient who may file a legal case against you for injecting him/her without consent. An alternative choice is midazolam IMI, at 0.1mg/kg up to 5-20mg.

Report all cases of violence to the appropriate authority (Medical Superintendent,Matron, Police and/or Psychiatrist).

Aggressive and confused patients

• Think of possible causes

• Sedate patient if necessary

• Maintain ABC and treat any reversible cause

• If psychiatric cause is suspected; admit to psychiatry ward.

• If organic cause is suspected, admit to medical ward after proper sedation.

• Always inform ward doctor and document it.

Possible causes:

• Substance intoxication or withdrawal: eg: alcohol, cocaine, benzodiazepines etc.

• Psychiatric disorders especially if there is history present, eg:

psychosis due to schizophrenia, mania, personality disorders or dementia.

• Organic delirium due to hypoglycaemia, electrolyte disturbance, hypoxia, sepsis, head injury, meningitis, liver/renal failure.

• Intracerebral haemorrhage

• Epilepsy- postictal state or temporal lobe epilepsy.

Restraint:

• Use relatives, security guards or if necessary police to hold the patient.

• Sedation using IMI initially. The IV access may be safely obtained after initial control with IMI.

–  –  –

Medico-legal aspects.

Avoiding trouble with the law at A&E can be achieved by the

adoption of the following approaches:

• Be polite, honest and open with patients and explain reasons for delays/errors promptly.

• Use consent forms when needed.

• Take extra care of return visits. (Treat as if for first visits and review investigations and so forth).

• Absconding needs to be well documented and patients should be well informed of possible outcome of such actions.

• Remember the principals of good note keeping.

Precautions against nosocomial infections (Please refer to the Universal Precaution guideline in the “Infection Control Manual for Vaiola Hospital.”)

5.2. Cardiac Arrest Process Standards

First on the Scene:

• Assess the patient.

• Call for help and commence one person CPR.

• Ask for the resuscitation trolley to be brought to the bed side.

• Assemble oxygen equipment, using bag mask device with oxygen flow at 15 litres.



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