Emergency Medicine Clinical Protocols
Evidence-Based Clinical Practice
2nd Edition
Chief Editors
Dr. Hendry R. Sawe, MD, MMED, MBA Emergency Physician, MUHAS, and MNH
Dr. Brittany Lee Murray, MD Pediatric Emergency Medicine Physician, MNH
MNH | EMAT | MUHAS
Contributors
Contributing Editors Dr. Upendo George, MD, MMED Emergency Physician, MNH
Dr. Jennifer Jamieson, MBBS, BBiomedSc, MPH&TM EMAT Volunteer, MNH
Dr. Irene B. Kulola, MD, MMED Emergency Physician, MNH
Dr. Juma A. Mfinanga, MD, MMED Emergency Physician, MNH and MUHAS
Authors Dr. Bhupinder Singh
Dr. Winfrida Kaihula
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Dr. Catherine Reuben Shari
Dr. Ally Akrabi
Dr. Edward Amani
Dr. Francis Sakita
Dr. Meera Nariadhara
Dr. Peter Mabula
Dr. Mundenga Muller
Dr. Prosper Bashaka
Dr. Patrick Shao
Dr. Shahzmah Suleiman
Dr. Amiri Kaduri
Dr. Renatus Tarimo
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
Resident Emergency Medicine, MUHAS
i
Preface
This is the second edition of the Emergency Medicine clinical protocols (EM Protocols) of the Muhimbili National Hospital Emergency Medicine Department, which were first published in 2011. This is a compilation of the updated protocols for the management of selected common emergency conditions at the emergency department of MNH, and is applicable to acute intake areas (casualty) in Tanzania and across Africa. The protocols focus mainly on up-to-date, evidence based management of acutely ill patients presenting with undifferentiated illnesses, such as acute exacerbation of asthma, seizures, hypertensive emergencies, malaria, burns, sepsis, hypoglycemia, hypokalemia, hyperkalemia, hyperglycemic states (DKA and HHS), upper GI bleeding, rapid sequence intubation and guidelines for administration of inotropes. However, it should be noted that at times, certain recommendations are tailored towards locally available medications and resources, and therefore should be reviewed before use at any institution. The second edition of the clinical protocols was necessitated by the protocol review committee, which provided evidence of changes that needed to be incorporated to improve the first edition. Residents in Emergency Medicine, who went through evidence-based sources to implement changes from the first edition, authored the second edition. A panel of emergency physicians reviewed all the changes, going through the protocols point by point to ensure content is backed by up-to-date literature. The Emergency medicine department (EMD) at Muhimbili National Hospital (MNH) and Muhimbili University of Health and Allied Sciences (MUHAS) has played an active role in the development of the clinical protocols. The Emergency Medicine Association of Tanzania (EMAT) has endorsed the contents of the protocol and advocates for its use across Tanzania. The protocol is an open source material, NOT for sale.
ii
Acknowledgements
The EMD expresses its gratitude to all the members of the protocol development committee who volunteered their own time in order to review and re-review of the contents of the second edition. Original contributors of the first edition EMD thanks the original contributors of the first edition who developed and edited the contents of the first edition: Dr Teri Reynolds, Dr Hendry R. Sawe, Prof Victor Mwafongo, Dr Juma Mfinanga and Dr. Andi Tenner. The Emergency Physicians The EMD thanks the Emergency Physicians who provided their inputs during resident presentation of different drafts of the second edition; Dr. Ghaniya Mbarouk, Dr Said Kilindimo, Dr. Mgalula Sifaeli, Dr Kepha Bernard, Dr Sherin Kassamali, Dr. Hendry R. Sawe, Dr Brittany L. Murray, Dr Irene Kulola, Dr. Geminian Festo, Dr. Philip Michael, Dr. Upendo George, Dr Juma Mfinanga, Dr. Khalid Mbaya and Dr. Jennifer Jamieson. Last, but not least, thank you to all of the EMD-MNH Registrars who provided technical inputs and critiques to improve the content of the protocols. Smart phone App support The EMD thanks Hitesh J. Chohan for generously donating his time to develop Android App to support the accessibility of the contents easily.
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Disclaimer
The EMD Clinical protocols are only intended for use by qualified Emergency Medicine healthcare providers. The EM providers using the protocols must also use their own clinical judgments, knowledge and expertise when deciding whether it is appropriate to apply this protocol to any particular patient. Locally available medications and resources must always be considered in the application of the protocols. The EMD, MNH, MUHAS, EMAT, and all the providers who supported the development of the protocols do NOT assume any liability for the information contained herein, be it direct, indirect, consequential, special, exemplary, or other damages.
Contact
Please contact Chief Editor-Dr. Hendry Sawe by sending and e-mail to:
[email protected] in case of any noted errors or suggestions for the protocols. The Chief Editor is also happy to discuss and advise medical directors, and other EM health care providers on the local implementation of these protocols with providers in acute intake areas.
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Table of content Contributors………………………………………………………….........………………………………………...........
i
Preface………………………………………………………………………..………………………………………..........
ii
Acknowledgment………………………………………………………...………………………………………..........
iii
Disclaimer…………………………………………………………………..………………………………………….......
iv
Contact……………………………………………………………………….………………………………………...........
iv
Hypoglycemia.…………………………………………………………….…………………………………..…….....
1
Rapid Sequence Intubation (RSI)………………………………….……………………………………….....
2
Seizures……………………………………………………………………………………………………………….....
3
Malaria………………………………………………………………………..………………………………………......
4
Hypokalemia……………………………………………………………….………………………………………......
5
Hyperkalemia……………………………………………………………..……………………………………….......
6
Pediatric Sepsis…………………………………………………………..……………………………………….......
7
Adult Sepsis………………………………………………………………..……………………………………….......
8
Asthma……………………………………………………………………….………………………………………........
9
Burn…………………………………………………………………………………………………………………….......
10
DKA and HHS……………………………………………………………….………………………………………......
11
Hypertensive Urgency and Emergencies……………………….…………………………………….........
13
Inotropes and Chronotropes………………………………………...………………………………………........ 14 Nitroglycerine and Sodium Nitroprusside……………………..………………………………………........ 17 Upper GI Bleeding…………………………………………………………………………………………………....... 19 Recommended Further Readings………………………………………………………………………………
20
Hypoglycaemia Protocol For Adult and Paediatric Patients
HYPOGLYCAEMIA
IF NO RBG
CONFIRMED (RBG<3 mmol/L) or SUSPECTED (hx, signs/symptoms)
MACHINE,
DON’T WAIT, TREAT.
IV/IO access available/easy to get
Yes
No
For Children <40kg give: 5 ml/kg 10% Dextrose IV OR 10ml/kg 5% Dextrose IV OR 2 ml/kg 25% dextrose DILUTE 50% DEXTROSE BEFORE USE IN CHILDREN For Children >40kg and Adults give:
While continuing to attempt IV / IO access, begin to correct hypoglycaemia by: Children: 5 ml/kg 10% dextrose via NGT Adults: 50ml 50% dextrose via NGT NB: Look for IV/IO access for continued resuscitation of hypoglycaemia
50ml 50% Dextrose IV OR Follow above weight based dosing
RECHECK RBG after 10 minutes
RBG ≥3 mmol/L
RBG <3 mmol/L
START GLUCOSE-CONTAINING IVF:
Children: 10% dextrose 2ml/kg/hr IV
Adults: 5% dextrose 2ml/kg/hr IV
AND If conscious, and able to tolerate oral intake, encourage oral feeds. Re-check and record RBG hourly or immediately if mental status changes.
1
RAPID SEQUENCE INTUBATION (RSI)
GO THROUGH THIS CHECKLIST TO ENSURE ALL EQUIPMENT IS PREPARED (MNEMONIC: SOAP ME)
• • • • • •
Suction - suction apparatus, Yankauer, suction catheter Oxygen - working oxygen, non re-breather mask (NRBM), BVM Airways - NPA, OPA, ETT, LMA, surgical cric kit Pre-oxygenate - 15L/min via NRBM Medications / Monitor – prepare & decide on RSI drugs Equipment - stylet, bougie, laryngoscope, glidescope
ETT SIZE FOR CHILDREN: Refer to Broselow Tape OR • Age in years/4 + 3 (Cuffed) • Age in years/4 + 4 (Uncuffed) ALWAYS HAVE DIFFERENT SIZE TUBES AVAILABLE
NOTE: The INTUBATING TEAM should be a minimum of 3 people. Physician performing intubation should verbalise intubation plan to all team members. Specialists must be involved in all EMD intubations. RSI DRUGS FIRST: CHOOSE ONE SEDATIVE 3. MIDAZOLAM 1. ETOMIDATE Dose: IV 0.2mg/kg DOSE: IV 0.3mg/kg (0.15mg/kg if *** Intubation doses are higher than sedation hypotensive); not to exceed 20 mg doses (15 – 20mg) *** 2. KETAMINE 4. PROPOFOL DOSE: IV 2mg/kg Dose: 2-2.5mg/kg IV *** Ketamine is the preferred agent for Onset: 10-15 seconds intubation for asthma and anaphylaxis *** *** Suitable for patients with seizures or status epilepticus *** SECOND: CHOOSE ONE PARALYTIC *** Always give sedation before paralytics ***
2. PANCURONIUM DOSE: 0.1 mg/kg IV Onset of action: 1-2 minutes Duration of action: 1-2 hours
1. SUCCINYLCHOLINE DOSE: 2mg/kg IV Onset of action: 30-60 seconds Duration of action: 10 minutes **Use with caution: may cause hyperkalemia**
POST INTUBATION CARE
1. GIVE PAIN MEDICATION • MORPHINE - DOSE: 0.05-0.1 mg/kg IV every 30 minutes as needed (maximum: 10 mg per dose) • PETHIDINE - DOSE: 1 mg/kg IV every 4 hours as needed
2. GIVE CONTINUOUS SEDATION • MIDAZOLAM - DOSE: 0.05-0.1 mg/kg IV every 30 minutes as needed (usual starting dose: 2mg) • DIAZEPAM - DOSE: 0.05 – 0.2 mg/kg IV every 60 minutes as needed (usual starting dose 5-10 mg)
! POST INTUBATION - CXR OR ULTRASOUND TO CONFIRM ETT POSITION ! INSERT NGT
2
SEIZURE MANAGEMENT SUPPORT ABCs
CHECK RBG
FIRST LINE TREATMENT FOR SEIZURE
PEDIATRICS:
IF RBG < 3.5mmol/l, refer to Hypoglycemia protocol
IV DIAZEPAM 0.3mg/kg slow IV push (max 10 mg per dose), repeat every 5min up to 3 doses as needed OR IV MIDAZOLAM 0.1mg/kg slow IV push (max 10mg), repeat every 5min up to 3 doses as needed *** If no IV access, give diazepam solution rectally at 0.5mg/kg, not to exceed 10mg ***
ADULTS:
IV DIAZEPAM 5-10mg stat slow IV push, repeat every 5min up to 3 doses as needed OR IV MIDAZOLAM 5-10mg slow IV push, repeat every 5min up to 3 doses as needed *** If no IV access, give IM 10mg midazolam, repeat up to 3 times ***
SECOND LINE TREATMENT PEDIATRICS: IV PHENYTOIN 20mg/kg IV slowly (NOT MORE THAN 30 mg/min) OR IV PHENOBARBITONE 20mg/kg IV slowly (NOT MORE THAN 30 mg/min)
ADULTS: IV PHENYTOIN 20mg/kg IV slowly (NOT MORE THAN 50mg/min) OR
IV PHENOBARBITONE 20mg/kg IV slowly (NOT MORE THAN 50mg/min)
THIRD LINE TREATMENT
IF SEIZURES CONTINUES
*** Consider INTUBATION if patient still seizing. See RSI protocol *** 1. IV MIDAZOLAM Adults: 0.2mg/kg loading dose, followed by 0.1-0.2mg/kg/hr infusion Paeds: 0.1mg/kg, followed by 0.06 – 0.4mg/kg/hr infusion 2. IV PROPOFOL: Adults: 2mg/kg loading dose, followed by 2-10mg/kg/hr infusion Paeds: 3mg/kg loading dose, followed by 7.5-18mg/kg/hr infusion 3. IV THIOPENTAL Adults: 3-6mg/kg loading dose, then 25-100mg infusion as needed Paeds: 2-5mg/kg loading dose
3
MALARIA Clinical suspicion of MALARIA (signs & symptoms) or patient referred with diagnosis of MALARIA with/without prior treatment.
No
Do NOT perform mRDT or BS for MPS
Yes FEATURES OF SEVERE MALARIA? Anaemia, convulsions, shock, jaundice, DIC, hypoglycemia, coma, LOC, weakness, AMS, vomiting everything, respiratory distress, hypoglycemia, AKI
Do mRDT/BS for MPS
Yes
No
Do mRDT and BS for MPS
mRDT/BS NEGATIVE
mRDT/BS POSITIVE
mRDT/BS NEGATIVE
Malaria NOT LIKELY, NO ANTIMALARIAL
UNCOMPLICATED MALARIA TREAT WITH ANTIMALARIAL (for 3 days)
SEVERE DISEASE
Investigate and treat other causes.
Do appropriate disposition.
1. Artemether Lumefantrine (ALU®) OR 2. DihydroartemisinPiperaquine (Artequick®, Duo-cotecxin®) Artesunate-mefloquine (Artequine®) OR 3. Oral quinine tablets 600 mg 8 hrly for 5 days (10mg/kg in children) plus Clindamycin (10mg/ kg twice daily for 7 days) or doxycycline
Treat other causes (If any)
Do appropriate disposition.
MALARIA NOT likely, BUT give first dose of IV antimalarial, antibiotics and supportive treatment. Then REPEAT mRDT/BS within 6 – 8 hours if malaria is still possible.
mRDT/BS POSITIVE
SEVERE MALARIA 1. ARTESUNATE (IV/IM) Dose: 2.4 mg/Kg at (time=0), then at 12 hrs and 24 hrs. OR
2. QUININE (IV) Dose: 10mg/Kg in 10 ml/kg (max 500ml) of 5% Dextrose (time=0) every 8 hours. OR 3. ARTEMETHER (IM ONLY)
mRDT/BS NEGATIVE
mRDT/BS POSITIVE
SEVERE DISEASE
SEVERE MALARIA Continue Antimalarial and antibiotics
STOP Antimalarial Treat other causes
Dose: 3.2 mg/Kg at (time=0), then 1.6 mg/Kg at 24 hours, then 1.6 mg/Kg at 48 hours
Note: SMALL INFANTS: ALu should not be given in infants < 5 kg. Those infants should be treated as indicated above in the “SEVERE MALARIA” box. PREGNANT WOMEN: Parenteral antimalarial drugs should be given to pregnant women with severe malaria in full doses without delay. Parenteral artesunate is the treatment of choice in all trimesters. Treatment must not be delayed. If artesunate is unavailable, intramuscular artemether should be given, and if this is unavailable then parenteral quinine should be started immediately until artesunate is obtained.
4
HYPOKALAEMIA
(K+ < 3.5 mEq/L)
Check blood K+ Level (ECG changes suggest severe hypokalaemia)
MILD (3.0-3.5) CHILDREN: ORAL Potassium supplements 2 mEq/kg three times a day diluted in oral fluids or food. NB: In case of diarrhea, give ORS (5ml/kg/hr) ADULTS: ORAL Potassium tablets 20-40 mEq three times a day (dissolved in 100-150mL water)
MODERATE (2.5-2.9) CHILDREN: IV (via peripheral vein) KCl 0.5 mEq/kg/hr DILUTED in 25-50mls of Normal Saline or DNS or 5% dextrose. Do not exceed 10 mEq/hr.
ADULTS: IV KCl 10mEq/hr
ADMINISTRATION OF POTASSIUM
.
Place the patient on CARDIAC MONITOR BOTH IV & ORAL REPLACEMENT
CHILDREN: ORAL diluted potassium tab 2mEq/kg three times a day. ! This is the route of choice for severe malnutrition or other high patients at high risk for volume overload ! Not used for nil per oral patients IV (via peripheral vein) potassium chloride 1 mEq/kg/hr. The calculated hourly dose is multiplied by 12.5ml volume for dilution with NS/DNS/D5%. Do not exceed 10 mEq/hr Max. 20 mEq/hr via central line
ROLE OF MAGNESIUM
• KCl must never be given IM or as an IV push • Oral Potassium (Slow K) 600mg tab is equivalent to 8 mEq • Inj. KCL 7.5% 1ml = 1 mEq 15% 1ml = 2 mEq
Magnesium should be checked. IF LOW, give Magnesium as follows:
• 20 mEq of Potassium will raise K+ by 0.25 mEq/L. • Aim to replace 25% of K+ deficit in 6 hours
ADULTS: IV Initially give 4 ml 50% MgSO4 diluted to 10ml NaCl 0.9% over 20min, then then KCl infusion, then IV MgSO4 50% 0.12 ml/kg/day
CHILDREN: IV 50% MgSO4 0.1 ml/kg/dose administered over 2 hours
5
SEVERE (<2.5)
ADULTS: IV 20 mEq KCl in 100mL IV fluid over 1 hour via cubital fossa vein. Continue to measure serum potassium every 1 to 2 hours until K+ > 2.8 mmol/L ORAL: Potassium tablets (28mmol K+) per hour if tolerated (dissolved in 100150mL water)
ECG CHANGES IN HYPOKALEMIA
Increased P wave amplitude, Prolonged PR interval, ST segment depression, QT prolongation, flattening or T wave inversion, and prominent U waves.
HYPOKALEMIA IN CARDIAC ARREST In Adults: IV KCl 10 mEq over 5 min; the dose may be repeated once
Hyperkalaemia Protocol K+ > 5mEq/L
1. If potassium ≥6 mEq/L, begin HYPERKALEMIA treatment IMMEDIATELY. 2. If potassium is 5 to 5.9, if no ECG changes or symptoms then observe and repeat serum K+. If symptoms, or ECG changes, treat IMMEDIATELY 3. ECGs can be helpful in screening for hyperkalemia when timely lab testing is not available. Begin treatment IMMEDIATELY if ECG changes suggestive of hyperkalemia are found. 4. Serum potassium levels and ECGs should be repeated to monitor treatment effects
1.
CARDIAC MEMBRANE STABILIZATION CALCIUM GLUCONATE Note concentration: 10mls of 10% = 1g ADULTS: 1g IV slowly over 5 min PAEDIATRICS: 100mg/kg IV slowly over 5 min, not to exceed 1g *If ECG changes persist, repeat dose every 10min (or if K is still > 6 after first dose and no ECG available)
OR
CALCIUM CHLORIDE- 10mls of 10% Reserve for critical patients with life threatening conditions Give through a central line ADULTS: 1g IV slowly push over 3-5 min PAEDIATRICS: 20mg/kg IV slowly over 5 min *If ECG changes persist, repeat dose every 10min (or if K is still > 6 after first dose and no ECG available)
2. SHIFT K+ INTO CELLS Give glucose immediately followed by insulin. GLUCOSE ADULTS: 50ml of 50% Dextrose IV If unavailable, use 5ml/kg of 10% Dextrose PAEDIATRICS: 5ml/kg of 10% Dextrose INSULIN ADULTS: 10 IU of regular (soluble) insulin IV over 5-10 min. PAEDIATRICS: 0.1 IU/kg of regular (soluble) insulin IV over 5-10 min (maximum 10 IU) Monitor RBG every 15 min for at least 1 hour Β2-AGONISTS- SALBUTAMOL ADULTS: 10mg of nebulized PAEDIATRICS: <5 years - 2.5mg nebulized >5years - 5mg nebulized SODIUM BICARBONATE ADULT: 50 mEq IV stat PAEDIATRICS: 1mEq/kg IV (MAX 50 mEq)
6
3. REMOVE K+ FROM THE BODY LOOP DIURETICS - FRUSEMIDE ADULT: 40 mg IV once PAEDIATRICS: 1mg/kg IV once (maximum 40 mg) HEMODIALYSIS/PERITONEAL DIALYSIS Definitive treatment Consult Nephrology
ECG FINDINGS IN HYPERKALEMIA Slightly peaked T waves Peaked T waves P wave widens and flattens PR segment lengthens P waves disappear Prolonged QRS with bizarre morphology Bradycardia Sine wave appearance Asystole/Vfib
PAEDIATRIC SEPSIS PROTOCOL
RECOGNITION OF SEPSIS
Sepsis: ≥ 2 SIRS criteria PLUS suspected/proven source of infection Severe Sepsis: Sepsis + organ dysfunction + hypo perfusion ± hypotension Septic Shock: Severe Sepsis + hypotension refractory to adequate (6L) of fluid therapy
SIRS CRITERIA: See table 1 for modified SIRS criteria.
INITIAL RESUSCITATION
0 – 20 MIN
20-40 MIN
< 60 MIN
1-3 HRS
Airway: Protect as appropriate
Breathing: Give Oxygen
Circulation: • Establish IV / IO access and draw blood samples for investigations • FLUIDS: Administer 20ml/kg bolus of NS or RL over 5-10mins (FIRST BOLUS). If malnutrition, give 10ml/kg. Disability: Document GCS / AVPU REASSESSMENT Reassess after each bolus: RR, HR, capillary refill, BP, Sp02, temperature, urine output. If necessary, repeat UP TO 3 FLUID BOLUSES unless rales or hepatomegaly develop.
ANTIBIOTICS First Line Treatment: IV Ceftriaxone 100g/kg + IV Metronidazole 10mg/kg PLUS Vancomycin 10mg/kg (if immunocompromised and if available)
Second Line Treatment: IV Meropenem 20mg/kg TDS
Adjust antibiotics based on lab results. Treat any fungal, viral or parasitic infections.
SOURCE CONTROL: CXR, blood cultures, urine dipstick Other labs: RBG, FBP, mRDT, lactate, RFTs & electrolytes, LFTS. If indicated: wound swab, LP IF SHOCK NOT REVERSED (AFTER 2 FLUID BOLUSES) Start dopamine 10mcg/kg/min for cold shock. Cold Shock: cap refill > 3 sec, reduced Start adrenaline 0.05 – 0.3mcg/kg/min if resistant to dopamine or peripheral pulses, cool/mottled for warm shock. extremities If no improvement, give IV hydrocortisone 1mg/kg stat Warm Shock: flash cap refill, bounding peripheral pulses, warm extremities & Consider blood transfusion when Hb <7g/dl: wide pulse pressure • 20mls/kg whole blood or 10mls/kg of packed red blood cells. If needed, repeat after 6 hours
Goals of Resuscitation & Disposition:
Goals of Resuscitation: SBP / MAP > age-specific; SpO2 > 95%, urine output > 1mls/kg/hr; source control as early as possible. DISPOSITION: Patients with septic shock should receive consultation in the EMD
Table 1: Modified SIRS Criteria:
Age Group 1 month - <1 year 1 – 5 years >5 – 12 years >12 - <18 years
HR >180 or < 90 >140 >130 >110
RR > 34 > 22 > 18 > 14
T >38.5 or <36 °C >38.5 or <36 °C >38.5 or <36 °C >38.5 or <36 °C
7
SBP <100 < 94 < 105 < 117
WBC >17.5 or <5 >15.5 or <6 >13.5 or <4.5 > 11 or < 4.5
ADULT SEPSIS PROTOCOL
RECOGNITION OF SEPSIS
Sepsis: ≥ 2 SIRS criteria PLUS suspected/proven source of infection Severe Sepsis: Sepsis + organ dysfunction + hypo perfusion ± hypotension Septic Shock: Severe Sepsis + hypotension refractory to adequate (6L) of fluid therapy
SIRS CRITERIA: HR > 90 RR > 24 Temp < 36 or > 38 WBC < 4 or > 12
INITIAL RESUSCITATION Airway: Protect as appropriate Breathing: Give Oxygen Circulation: 0 – 20 • Establish 2 x large bore IV access MIN • FLUIDS: Administer 2L of NS or RL over 20 mins (FIRST BOLUS) • NB: Small boluses of 250-500ml in CCF Disability: Document GCS REASSESSMENT Reassess HR, BP, Sp02 and volume status (IVC by ultrasound). Repeat fluid bolus as necessary (2L) unless crepitations or hepatomegaly develop (SECOND BOLUS). EMPIRIC ANTIBIOTICS First Line Treatment: 20-40 IV Ceftriaxone 2g + Metronidazole 500mg MIN PLUS Vancomycin 15mg/kg (if immunocompromised or nosocomial and if available) Second Line Treatment: IV Meropenem 1g stat Adjust antibiotics based on lab results. Treat any fungal, viral or parasitic infections. SOURCE CONTROL: CXR, blood cultures, urine dipstick < 60 Other labs: RBG, FBP, mRDT, lactate, RFTs & electrolytes, LFTS. If indicated: wound swab, LP MIN
1-3 HRS
IF SHOCK NOT REVERSED (AFTER 2 FLUID BOLUSES)
If shock persists or dopamine unavailable start adrenaline infusion (refer to inotropes protocol) If no improvement, give IV hydrocortisone 200mg stat Consider blood transfusion when Hb <7g/dl. Goals of Resuscitation & Disposition: Goals of Resuscitation: SBP / MAP > 65mmHg; antibiotics within 60 mins; SpO2 > 94%, urine output > 0.5mls/kg/hr; source control as early as possible. DISPOSITION: Patients with septic shock should receive consultation in the EMD 8
ACUTE EXACERBATION OF ASTHMA FOR ADULT AND PAEDIATRIC ASTHMA PATIENTS
*Signs of severe illness include: Silent Chest, Altered Mental Status, Bradycardia, Hypoxia <90%. If noted consult senior immediately.*
RESUSCITATE
A- Ensure airway patency B- Give oxygen, support ventilation if needed, order bronchodilators to begin C- Place an IV line, begin IVF bolus D- Check RBG, if <3mmol/L manage as per hypoglycemia protocol
BRONCHODILATORS AND STEROIDS
SALBUTAMOL NEBULIZATION ADULTS: 5-10mg PEDIATRICS: 0.15mg/Kg (MAX 5mg)
PLUS
IPRATROPIUM BROMIDE NEBULIZATION + 500mcg/dose if >20Kg 250mcg/dose if <20kg
DEXAMETHASONE
ADULTS: 20mg IV stat PEDIATRICS: 0.5-1mg/kg IV stat (MAX 20mg)
IF NOT AVAILABLE USE
HYDROCORTISONE ADULTS: 200mg IV stat PEDIATRICS: 2mg/kg IV stat IF THE PATIENT CAN TAKE ORALLY
PLUS
EQUAL VOLUME OF NORMAL SALINE
ORAL PREDNISOLONE ADULTS: 60mg stat PEDIATRICS: 2mg/kg (MAX 60mg) stat
REASSESS PATIENT CONDITION
NOT IMPROVED
MAGNESIUM SULFATE – IV OR IM (SINGLE DOSE) *IF IV, DOUBLE CHECK MEDICATION CONCENTRATION* OVED
ADULTS: 2g IV (MAX 2g) DILUTE WITH 250mls NS, RUN FOR 30min PEDS: 50 mg/kg (MAX 2 g) DILUTE WITH 20mls/Kg NS , RUN FOR 30min
IMPROVED OBSERVE IN EMD FOR 4HRS REASSESS AT LEAST EVERY 30MIN
* * IF IM GIVE THE SAME DOSE IN THE THIGH WITH NO DILUTION IF SYMPTOMS RECUR G REPEAT I BRONCHODILATORS V HOURLY AS NEEDED ETHEN NOT IMPROVED IMPROVED ADMIT FOR NOT IMPROVED CONTINUED CARE 1 EPINEPHRINE – NEB OR IM (1:1000) ADMIT FOR CONTINUED AND MONITORING NEB 3-5ML dilute with double CARE AND D volume of Normal Saline MONITORING O ADULTS: 0.3 mg IM every 5MIN CHILDREN: 0.15 mg IM every 5MIN S E *TREATMENT SHOULD PRECEED INVESTIGATIONS * E *GIVE ANTIBIOTICS ONLY IF THERE ARE SIGNS OF INFECTION* V E 9 R Y 2
IF NO RECURRENCE AND STABLE THEN
DISCHARGE HOME WITH BRONCHODILATOR INHALER AND ORAL STEROID
BURN PROTOCOL
PARKLAND FORMULA:
! A-B-C-D-E OF BURNS
A: Assess Airway and C-Spine • Protect C-spine if needed • If facial or inhalational burns, consider intubating promptly B: Assess Breathing • Give oxygen if needed • If failure to ventilate adequately, consider assisted ventilation C: Assess Circulation • Large bore IV access x 2 • Ringers lactate (as per Parkland formula) D: Assess Neurology • Document GCS • Check RBG E: Expose the Patient • Remove rings, bracelets, jewelry • Assess the Total Burned Surface Area (TBSA) front and back (Fig 1) NB: superficial burns are not counted • Assess burn depth • Consider escharotomies • Keep patient warm
4ml x TBSA (%) x body weight (kg)/24hours 50% given in first 8 hours 50% given in next 16 hours
Palm and patient’s fingers = 1% TBSA
ADULT RULE OF NINES
Posterior
LUND-BROWDER CHART
Analgesia: ! Morphine IV 0.1mg/kg Q4H Pethidine IV 1mg/kg every 3-4 hours (max 300mg in 24 hours)
Dressing: ! Perform debridement ! Use sedation - Ketamine IV 2mg/kg ! Use silver-based cream for burns ! Use paraffin gauze or sterile gauze to dress
Tetanus Toxoid: IM 0.5ml
Antibiotics: Consider IV antibiotics (for dirty wounds or obviously infected wounds) Urine Output Goals: Adults: 0.5-1.0 ml/kg/hour| Children: 1.0-1.5 ml/kg/hour| Infants: 2-4 ml/kg/hour
10
Anterior
DKA and HHS
Diabetic ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS)
DIAGNOSTIC CRITERIA
Biochemical criteria for DKA Hyperglycemia (RBG) > 11mmol/L
Biochemical criteria for HHS Hyperglycemia (RBG) usually > 30mmol/L
Venous pH <7.3 HCO3 <15mmol/L
Venous pH >7.30 HCO3 >15mmol/L Hyperosmolality (2Na + BUN + RBG) > 320mOsm/L
Anion gap = Na – (Cl- + HCO3 ) > 12 Ketonuria 2+
THESE CRITERIA REFLECT AN UNDERLYNG METABOLIC ACIDOSIS (NOT A HIGH GLUCOSE PROBLEM)
Immediate bedside investigations: RBG, urine dipstick, VBG/ABG, sodium & potassium (repeat hourly).
Further investigations: Electrolytes (re-check Na & K every 2 hours), BUN, Creatinine, Urinalysis, FBP. C/S for blood and urine if fever or localizing signs of infection are present. UPT (for all women of reproductive age). CXR and ECG (in proper clinical context).
MANAGEMENT: The stepwise management of DKA / HHS is essential. 1. CORRECTION OF DEHYDRATION/ HYPOVOLEMIA (OVER 48HRS)
! ! ! !
Initial Bolus: IV NS 2000ml over 1 hour. In children: 20ml/kg over 1hr. THEN for the next 3 hours: give IV NS 1000ml per 1 hour (total of 3000ml). In children: 10ml/kg/hour. THEN for the next 3 hours: give IV NS 500ml per 1 hour (total of 1500ml). In children: 5mls/kg/hour. THEN until resolution: give IV NS 250mls per hour. In children: 2.5mls/kg/hour.
NOTE: 1. During treatment if RBG < 14mmol/L, provide DNS 250mls/hr (in children: 2.5mls/Kg/hr) instead of NS 2. During treatment if RBG > 14mmol/L, switch IV DNS to Normal Saline 3. During treatment if RBG < 3 mmol/L, provide IV 50% Dextrose 50mls bolus or IV D10% 250mls (in children: 5mls/kg of D10%); then re-check RBG.
2. CORRECTION OF POTASSIUM * 4. 250mls (5ml/kg in pediatrics) bolus and then recheck blood glucose
* If results of serum k+ have not returned in 3 hours, then provide IV KCL 10mmol/hr in adults and 0.5 mmol/kg/hr for children (providing they are not anuric) - until you have the investigation results. Otherwise, follow potassium replacement guidelines as below:
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CORRECTION OF K+ FOR ADULTS
CORRECTION OF K+ FOR PAEDIATRICS
If Potassium level is > 4.5 mmol/L NO potassium replacement is necessary. Check the levels every 2 hours. If Potassium level is 2.5 - 4.5 mmol/L THEN: Give 10 mmol/hour, check the levels every 2 hours until level of potassium is >4.5 mmol/L
"
"
"
"
If Potassium level is <2.5mmol/L THEN: Give 20 mmol/hour, check the levels every 2 hours until level of potassium is >2.5 mmol
"
"
If potassium level is > 5mmol/L, NO potassium replacement is necessary. Check the levels every 2 hours. If Potassium level is 2.5 - 5 mmol/L THEN: Add IV KCL 0.5 mmol/kg/hour in a bolus of NS (maximum 10mmol/hour). Repeat potassium level every 2 hours. If Potassium level is <2.5mmol/L THEN: add IV KCl 1mmol/kg/hour in NS (maximum 10mmol/hour). Repeat potassium level every 2 hours until K > 2.5mmol.
3. CORRECTION OF ACIDOSIS / HYPERGLYCEMIA
Dose: Start an insulin infusion at a rate of 0.1 units/kg/hr IV for both adults and children until resolution of acidosis. In case of insulin sensitivity use lower doses; 0.05units/kg/hr in adults and children. Infusion composition: Dilute 50 units regular (soluble) insulin in 50mL NS Concentration: 1 unit = 1mL DO NOT GIVE IV INSULIN BOLUS INITIALLY (↑ risk of cerebral edema and can exacerbate hypokalemia). Consider SC insulin 0.05U/kg when the venous pH > 7.3, serum HCO3 >16mmol/L or anion gap is normal.
" " "
If RBG = 14mmol/L add 5% Dextrose If RBG <14mmol/L and ketosis is corrected switch fluids to DNS as above If RBG < 14mmol/L before resolution of ketoacidosis use 10% Dext
4. EXAMINE, INVESTIGATE AND TREAT THE PATIENT FOR ALL POTENTIAL PRECIPITATING FACTORS
END GOALS OF RESUSCITATION BEFORE DISPOSITION
DKA: Stop resuscitation when below criteria met: • pH > 7.3 • HCO3 > 18mmol • Calculated anion gap <12mmol/L • Patient is mentating well and able to eat • Presenting signs & symptoms have resolved
HHS: Adequate resuscitation has been achieved when: • • •
The patient has regained normal mentation The patient can eat Euvolemia has been achieved
Consider HCO3 if impending cardiovascular collapse and pH < 6.9. Possible complications of treatment include: a. Hypoglycemia b. Cerebral edema 12 c. Hypochloremic acidosis
Hypertensive Urgency / Emergency
HYPERTENSIVE URGENCY: severe hypertension of SBP > 180mmHg or DBP 110mmHg WITHOUT signs of end organ damage.
HYPERTENSIVE EMERGENCY: severe hypertension of SBP > 180mmHg or DBP 110mmHg WITH signs of end organ damage. Signs of end organ damage includes: • • • • • • • •
Altered mental status (may indicate hypertensive encephalopathy) Neurological deficit (may indicate cerebrovascular accident) Shortness of breath (may indicate acute pulmonary oedema or myocardial infarction (MI)) Chest pain / Epigastric pain (may indicate acute MI or aortic dissection) Poor left ventricular contractility (may indicate left ventricular dysfunction) Decreased urine output or increased RFTs (may indicate acute renal failure/insufficiency) Pregnancy > 20 weeks (may indicate pre-eclampsia or impending eclampsia) Blurring of vision / abnormal fundoscopy (may indicate hypertensive retinopathy)
TREATMENT
HYPERTENSIVE URGENCY: • Re-check BP to confirm the initial reading • Look for and treat other causes of hypertension (e.g. pain, anxiety, withdrawal, intoxication) • Do baseline investigations (RBG, ECG, creatinine / BUN, urinalysis, FBP) • Consult cardiac (for initiation of oral HTN, disposition & arranging long term follow-up)
HYPERTENSIVE EMERGENCY: ! Re-check BP to confirm the initial reading ! Look for and treat other causes of hypertension (e.g. pain, anxiety, withdrawal, intoxication) ! Use a short-acting, titratable IV drug (see below) ! Lower MAP by 20% over an hour (NB: achieving “normal” BP too quickly is dangerous) ! Do baseline investigations (RBG, ECG, creatinine / BUN, urinalysis, FBP) ! Admit to hospital with cardiac consultation
MEDICATIONS for Hypertensive Emergencies
Choose ONE of these medications based on underlying cause and check BP before / after every dose. 1.
2. 3.
4.
IV LABETOLOL: preferred in aortic dissection. Avoid in CCF, asthma and bradycardia. Dose: Give 15mg over 2 minutes. Repeat every 10 minutes if needed (max total dose = 300mg). If giving infusion, start at 1 mg/min (mix 100mg in 100ml NS, then give 1 drop every 3 seconds). Titrate upward to a maximum of 4 to 5 mg/min if needed. IV NITROGLYCERIN: preferred in MI and CCF. Avoid in Inferior MI. (For dose and administration refer to nitroglycerin protocol) IV SODIUM NITROPRUSSIDE preferred in CCF. Avoid in renal failure and pregnancy. (For dose and administration refer to sodium nitroprusside protocol) IV / IM HYDRALAZINE: preferred in pre-eclampsia / eclampsia. Dose: give 5mg, repeat every 30 minutes if needed (max total dose = 300mg per day).
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INOTROPES AND CHRONOTROPES PROTOCOL ADULT AND PEDIATRIC PATIENTS
DOPAMINE Indications: Recommended for hypotension (adults < 100SBP) and low cardiac output states due to cardiogenic, septic or neurogenic shock. Contraindications: Pheochromocytoma, tachyarrhythmia, hypersensitivity, idiopathic hypertrophic sub-aortic stenosis Remember: Ensure patient has been adequately fluid resuscitated first • PAEDIATRICS: 3 boluses of normal saline 20ml/kg if not severely anaemic (Hb ≤4) • ADULTS: 2L of normal saline if not severely anaemic (Hb ≤4) • All patients require continuous cardiac monitoring Infusion Composition: Mix 200 mg in 500 ml Normal Saline Final Concentration: 400mcg/ml Start Dose: 5mcg/kg/min Infusion Rate: 1-20 mcg/kg/min • IF NO RESPONSE, INCREASE DOSE AT A RATE OF 2MCG/KG/HR EVERY 5 MINS • Administer via dedicated line (i.e. ideally central venous line) • Once target goal reached, start tapering down at same rate Target SBP: • Adult: ≥ 90mmHg or MAP ≥ 65 • Children: 70 + (2×age) to 90 + (2×age) mcg/min ml/hr drops/min mcg/min ml/hr drops/min
50 7.5 2.5
75 11.25 3.75
100 15 5
125 18.75 6.25
150 22.5 7.5
200 30 10
250 37.5 12.5
300 45 15
350 52.5 17.5
400 60 20
500 75 25
600 90 30
700 105 35
800 120 40
900 135 45
1000 150 50
1250 187.5 62.5
1500 225 75
1750 262.5 87.5
2000 300 100
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INOTROPES AND CHRONOTROPES PROTOCOL ADULT AND PEDIATRIC PATIENTS
DOBUTAMINE Indications: Recommended for afterload support in hypotension due to cardiogenic shock and severe heart failure. Contraindications: Pheochromocytoma, tachyarrhythmia, hypersentivity, conditions resulting in cardiac outflow obstruction. Tachyphylaxis may occur during prolonged use. Remember: Ensure patient has been adequately fluid resuscitated first • PAEDIATRICS: 3 boluses of normal saline 20ml/kg if not severely anaemic (Hb ≤ 4) • ADULTS: 2L OF normal saline if not severely anaemic (Hb ≤ 4) • All patients require continuous cardiac monitoring Composition: Mix 200 mg in 500 ml NS Final Concentration: 400mcg/ml Start Dose: 5mcg/kg/min Infusion Rate: 1-20 mcg/kg/min • IF NO RESPONSE, INCREASE DOSE AT A RATE OF 2MCG/KG/HR EVERY 5-10 MIN • Administer via dedicated line (i.e. ideally central venous line) • Once target goal reached, start tapering at same rate Target SBP: • Adult: ≥ 90mmHg or MAP ≥ 65 • Children: 70 + (2×age) to 90 + (2×age) mcg/min ml/hr drops/min mcg/min ml/hr drops/min
50 7.5 2.5
75 11.25 3.75
100 15 5
125 18.75 6.25
150 22.5 7.5
200 30 10
250 37.5 12.5
300 45 15
350 52.5 17.5
400 60 20
500 75 25
600 90 30
700 105 35
800 120 40
900 135 45
1000 150 50
1250 187.5 62.5
1500 225 75
1750 262.5 87.5
2000 300 100
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INOTROPES AND CHRONOTROPES PROTOCOL ADULTS AND PEDIATRIC PATIENTS
ADRENALINE
Indications: Septic shock, anaphylactic shock, post CPR care Contraindications: Pheochromocytoma, tachyarrhythmia, known hypersensitivity to sympathomimetics Remember: Ensure patient has been adequately fluid resuscitated first • PAEDIATRICS: 3 boluses of normal saline 20ml/kg if not severely anaemic (Hb ≤ 4) • ADULTS: 2L OF normal saline if not severely anaemic (Hb ≤ 4) • All patients require continuous cardiac monitoring Composition: Mix 1 mg adrenaline in 500 ml of normal saline Final Concentration: 2mcg/ml Infusion Rate: usual dose range 0.05 - 2mcg/kg/min • Adjustment rate 0.01mcg/kg/min every 15 min • Administer via dedicated line (i.e. ideally central venous line) • Once target SBP reached, start tapering at same rate Target SBP: • Adult ≥ 90mmHg or MAP ≥ 65 • Children 70+ (2×age) to 90+(2×age) mcg/min 1 ml/hr 30 drop/min 10
2 60 20
3 90 30
4 120 40
5 150 50
6 180 60
mcg/min 15 ml/hr 450 drop/min 150
20 600 200
25 750 250
30 900 300
35 40 50 1050 1200 1500 350 400 500 16
7 210 70
8 240 80
9 270 90
10 300 100
60 70 80 1800 2100 2400 600 700 800
IV Nitroglycerin
Indications:
Hypertensive emergency Treatment of myocardial ischaemia Treatment of acute decompensated heart failure CCF Treatment of flash pulmonary oedema
• • • •
Contraindications: ! ! ! !
SBP < 90mmHg Patient has known or suspected right-sided or inferior myocardial infarct Patient has marked bradycardia (HR ≤ 50/min) Patient is using phosphodiesterase inhibitors such as Sildenafil / Tadalafil i.e Viagra®)
Infusion Composition: Mix 5mg of Nitroglycerin in 250ml of NS/DNS Final Concentration: 20mcg/ml Start Dose: 5mcg/min Infusion Rate: 5 – 400mcg/min
mcg/min mL/hr drops/min mcg/min mL/hr drops/min
5 15 5
10 30 10
15 45 15
20 60 20
25 75 25
30 90 30
35 105 35
40 120 40
45 135 45
50 150 50
100 300 100
150 450 150
200 600 200
250 750 250
300 900 300
350 400 450 500 1050 1200 1350 1500 350 400 450 500
*
Sublingual Nitroglycerin
Indications / Contraindications – same as for IV nitroglycerin Caution: absorption may be less predictable via this route than IV nitroglycerin. Spray: a single spray sublingually contains 400mcg nitroglycerin Tablet: a single tablet sublingually contains 300mcg, 400mcg or 600mcg nitroglycerin Administration: give one spray or tablet sublingually every 10 minutes (check BP before giving another spray or tablet).
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SODIUM NITROPRUSSIDE
Indications:
• •
Hypertensive emergency Acute decompensated heart failure
Contraindications:
• •
Avoid in pregnancy Avoid in renal impairment
Side effects:
• • •
Increased ICP Toxic metabolites (causing cyanide poisoning) Severe necrosis
Remember: Start at a lower dose and titrate to effect Always check blood pressure before giving more medications Infusion Composition: Mix 25mg of sodium nitroprusside in 125ml of NS/DNS. Final Concentration: 200mcg/ml Start Dose: 1mcg/kg/min (titrate to effect up to maximum dose of 10mcg/kg/min) NB: Medication is unstable if exposed to UV light – please cover infusion bag. PATIENT’S Dose in mcg/Kg/min WEIGHT IV DRIP RATE 1 2 3 4 5 6 7 8 40 mL/hr 12 24 36 48 60 72 84 96 KG drops/min 4 8 12 16 20 24 28 32 50 mL/hr 15 30 45 60 75 90 105 120 KG drops/min 5 10 15 20 25 30 35 40 60 mL/hr 18 36 54 72 90 108 126 144 KG drops/min 6 12 18 24 30 36 42 48 70 mL/hr 21 42 63 84 105 126 147 168 KG drops/min 7 14 21 28 35 42 49 56 80 mL/hr 24 48 72 96 120 144 168 189 KG drops/min 8 16 24 32 40 48 56 64 90 mL/hr 27 54 81 108 135 162 189 216 KG drops/min 9 18 27 36 45 54 63 72 100 mL/hr 30 60 90 120 150 180 210 240 KG drops/min 10 20 30 40 50 60 70 80
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9 108 36 135 45 162 54 189 63 216 72 243 81 270 90
10 120 40 150 50 180 60 210 70 240 80 270 90 300 100
UPPER GASTROINTESTINAL BLEEDING
1.RESUSCITATION (ABCs)
2.MEDICAL THERAPY
1. MAINTAN ABCs
2. IVF: Give normal saline or Ringers lactate Adult 2000mL* Pediatrics 20ml/kg * ****Cautious fluids in anaemia (Hb <5) 3. GIVE BLOOD if: • Severe pallor • Ongoing bleeding • Hb <5 • Hb <7 (with active bleeding)
Adults 2 units within 1hr Paediatric 20ml/kg 1hr (whole blood) or 10ml/kg (PRBC) If ongoing indication for blood, start transfusion in the following ratio: 1 unit PRBCs (20ml/kg in Paeds) 1 unit FFP (20ml/kg in Paeds) 1 unit PLT (20ml/kg in Paeds) 4. LABS: FBE, urea & creatinine, electrolytes, crossmatch, PT / PTT / INR
3.DEFINITIVE CARE
CONSULT GASTROENTEROLOGY EARLY FOR ALL ACTIVE UPPER GI BLEEDS for possible endoscopic intervention
I. PROTON PUMP INHIBITORS PANTOPRAZOLE: • ADULT: 80mg IV stat, then continue with infusion of 8mg/hr for 72hrs • PEDIATRIC: 1mg/kg IV stat (max 80 mg), then infusion 1mg/kg/hr for 72hrs OR ACCEPTABLE ALTERNATIVES: IV RABEPRAZOLE, IV OMEPRAZOLE, OR IV ESOMEPRAZOLE 2. OCTREOTIDE Only in suspected variceal bleeding (e.g. cirrhosis, hepatosplenomegaly, hepatocellular carcinoma or ascites) • ADULT: 50 mcg IV slow bolus, then continue as an infusion 50 mcg/hr for 5 days • PEDIATRICS: 1 microgram/kg/hour IV (MAX 50mcg/hr) for 5days 3. PROPHYLACTIC ANTIBIOTICS If features suggestive of cirrhosis, give antibiotics: • IV ciprofloxacin 500mg BD OR • IV ceftriaxone 2g daily
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Recommended Further Readings These protocols are intended as a starting point only and many will be contextspecific. Please refer to more detailed readings listed below for additional information on emergency medicine practice. AFEM Handbook The AFEM Handbook is a leading resource for local and visiting providers practicing in the African setting and provides an integrated approach to early resuscitation, stabilization and transfer of acutely ill patients. The handbook covers a wide range of medical, surgical, and obstetric conditions. Wallis, L.A., Reynolds, T.A. AFEM Handbook of Acute and Emergency Care. Oxford University Press; 2014. Up-To-Date An evidence-based, physician-authored clinical decision support resource which contains over 22 specialties and over 10,500 topic reviews. Available at: https://www.uptodate.com Life in the Fast Lane Life in the Fast Lane is a medical blog and website dedicated to providing free online emergency medicine and critical care insights and education for everyone, everywhere. Globally, this is one of the leading resources for free open-access medical education. Available at: http://lifeinthefastlane.com Rosen’s Emergency Medicine: Concepts and Clinical Practice A leading global textbook on emergency medicine practice. Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010 Tintinalli’s Emergency Medicine: A Comprehensive Study Guide Another prominent textbook for emergency medicine practice. Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, David M. Cline, Rita K. Cydulka, Garth D. Meckler. The American College of Emergency Emergency medicine: a comprehensive study guide. (2011). New York, McGraw-Hill.
