Arab Republic of Egypt

Ministry of Health & Population

Curative & Critical Care Sector

EMERGENCY DEPARTMENT
UNIFIED PROTOCOL
PART IV ( ALGORITHMS)

Prepared by
Dr.Hamid Shaalan .
General Director Of EDs.
Curative & Critical Care Sector
G.Surgeon. ATLS.,ACLS Instructor ACS, SHA, AHA.

Cairo 2007

FREE NOT FOR SALE

 Arab Republic of Egypt
Ministry of Health & Population
Curative & Critical Care Sector

EMERGENCY DEPARTMENT
UNIFIED PROTOCOL

Prepared By

Dr.Hamid Shaalan .
G.Surgeon, ATLS Instructor ACS.,
ACLS Instructor SHA, AHA.

Approved By

Prof.Nagwa El-Hosseiny. Dr.Hany Moro

Quality Consultant Of Minister Of Health & Population. Emergency &Disaster Management Consultant
Professor Of Medicine Cairo University Of Minister Of Health & Population

Under Supervision Of

Prof.Nasser Rasmi.
,
Assistant Minister of Health & Population Egypt
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" The kind of spirit we generate, the kind of enthusiasm we

initiate, will tell – in the long run- whether we will settle
high on the luminous peaks of life or down its low, dim
slums."

WÜA [tá{xÅ YÉâtw

"Every life is precious", A wonderful thing to say, So all
honest and perfect effort should be exerted to save whenever
in danger.

WÜA[tÅ|w f{ttÄtÇ

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Acknowledgements

This protocol is intended to serve as a guide in the practice of emergency

medicine & mass casualties in Emergency Departments in MOHP hospitals in
EGYPT.

I wish to sign out the encouragement and support of the following

professionals:

Prof. Nasser Rasmi

(Assistant Minister Of Health&Population.)
Prof. Nagwa EL-Hossieny
( Quality Consultant of Minister Of Health & Population, Professor Of Medicine.).
Dr. Hany Moro
(Emergency &Disaster Management Consultant Of Minister Of Health & Population).
Dr. Mohamad Sultan
(Acting Chief Of Central. Administration Of Curative &Critical Care)

WÜA [tÅ|w f{ttÄtÇA

Vt|ÜÉ fxÑàAECCJ

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‫מ‬ ‫א‬ ‫א‬
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INTRODUCTION
The emergency department (ED) is an integral unit of a hospital and the
experience of patients attending the ED significantly influences the public
image of the hospital offering medical service.

Thousands of people attend ED every year for more than come into contact
with any other hospital service .Some of them are acutely ill or injured and
need immediate, sometimes life-saving treatment. Many of whose condition
are not so serious, require urgent assessment and treatment for their injury
or sickness.

Non-urgent visits comprise a significant proportion of total pts., attending

ED , but still their medical conditions have to be evaluated and managed.

The ED also providers for reception and management of disaster plan in the
region. For these reasons EDs have a high public profile and are viewed by
many as essential local service.

To achieve our goal towards offering best service according to accepted

standards, this proposed plan for developing and evolution EDs. is created.

This plan suggests :

I ) Structure and Manpower Standards .

II ) Policies and Procedures.
III ) Protocols for management of critical cases commonly
encountered in ED.
VI) Algorithms

The purpose of these standards is to establish an organized, safe, efficient

and customer service focused utilization of the Emergency Depatment.

WÜA[tÅ|w f{ttÄtÇ
Vt|ÜÉ? TâzA ECCJ

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ACUTE CORONARY SYNDROMES ALGORITHM

1
Chest discomfort suggestive of
ischemia
2
EMS assessment and care and hospital preparation:
• Monitor, support ABCs. Be prepared to provide CPR and defibrillation
• Administer oxygen aspirin, nitroglycerin, and morphine if needed
• If available, obtain 12-lead ECG: if ST-elevation
- Notify receiving hospital with transmission or interpretation
- Begin fibrinolytic checklist (Figure 2)
• Notified hospital should mobilize hospital resources to respond to STEMI

Immediate ED assessment (<10 min) Immediate ED general treatment

• Check vital signs: evaluate oxygen • Start oxygen at 4 L/min: maintain O2 sat >
saturation 90%
Establish IV access • Aspirin 160 to 325 mg (if not given by EMS)
• Obtain/review 12-lead ECG • Nitroglycerin sublingual, spray, or IV
• Perform brief, targeted history, physical • Morphine IV if pain not relieved by
exam check contraindications (Table 1) nitroglycerin
• Obtain initial cardiac marker levels, initial
electrolyte and coagulation studies
4 Review initial 12-lead ECG
13
5 9
ST elevation or new or presumably ST depression or dynamic T-wave Normal or nondiagnostic changes
new LBBB; strongly suspicious for inversion; strongly suspicious for in ST segment or T wave
6 injury ischemia
10 14
Start adjunctive treatment as indicated
Start adjunctive treatment as (see text for contraindications) Develops high or intermediate risk
indicated (see text for • Nitroglycerin criteria (Tables 3. 4)
contraindications) • ß-Adrenergic receptor blockers OR
Do not delay reperfusion troponin-positive
• Clopidogrel
• ß-Adrenergic receptor blockers • Heparin (UFH or LMWH)
• Clopidogrel • Glycoprotein llb/llla inhibitor 15
• Heparin (UFH or LMWH)
11 Consider admission to
7 ED chest pain unit or to
Time from onset of Admit to monitored bed
Assess risk status (Tables monitored bed in ED
symptoms ≤ 12 hours
3 4) Follow:
8 12 • Serial cardiac markers
Reperfusion strategy: High-risk patient (Tables 3, 4 for risk (including troponin)
Therapy defined by patient and center stratification):
• Repeat ECG/continuous ST
criteria (Table 2) • Refractory ischemic chest pain
• Recurrent/persistent ST deviation segment monitoring
• Be aware of reperfusion goals:
- Door-to-door balloon inflation • Ventricular tachycardia • Consider stress test
• Hemodynamic instability
(PCI) goal of 90 min
• Signs of pump failure 16
- Door-to-needle (fibrinolysis)
goal of 30 min • Early invasive strategy, including Develops high or
• Continue adjunctive therapies and: catheterization and revascularization for shock intermediate risk criteria
- ACE inhibitors/angiotensin within 48 hours of an AMI (Tables 3. 4)
receptor blocker (ARB) within 24 Continue ASA, heparin, and other therapies as OR
hours of symptom onset indicated. troponin-positive?
- HMG CoA reductase inhibitor • ACE inhibitor/ARB
17
(statin therapy) • HMG CoA reductase inhibitor (statin therapy) If no evidence of ischemia
• Not a high risk: cardiology to risk-stratify or infarction, can
discharge with follow-up

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 Ingestion of an unknown
drug

Unconscious pt.

Conscious pt.
Patient
Stabilization
Stomach Physical exam.
Evacuation Baseline Lab
Investigations
Airway Breathing Circulation Altered mental status

Coma Cocktail: *** Ipecac* or Activated

Naloxone Glucose + thiamine Gastric Charcoal + Symptomatic
Lavage MgSo4** Management
* Ipecac dosing:
Adults: 15-30 ml, Child> 1yr: 15 ml, Child < 1yr: 10 ml
** Activated charcoal
Adults: 60-100 mg
Child: 1-2 mg/kg
MgSo4:
Adult: 16 mg
Child: 250 mg/kg
*** Coma cocktail:
Naloxone: opioid antagonist
Adult/Child: 0.2-2 mg IV; repeat at 2-3 minutes intervals until desired effect or a total dose of 10-15 mg. Careful in opioids-dependent patient.
Flumazenil: Benzodiazepine antagonist.
Adult: 0.2 mg IV over 30 seconds, then 0.3 mg, then 0.5 mg (every 30 seconds) up to 3 mg.
Child: 0.01 mg/kg, titrate up to 1 mg
Careful use in case of mixed ingestion, may precipitate seizures or arrhythmias
Glucose:
Adults: 50-100 ml of 50%
Child: 2-4 ml/kg of 25%
Thiamine 100 mg is indicated concomitantly for alcoholic or malnourished patients.
 Insecticide Exposure

- Dermal,Eye, Inhalation
Oral
Dermal + Eye
Pyrethroids Caramate Organophophate
1. Removal of clothes
2. Local Irrigation of the
exposed are
Carbamate
Inhalation: No Antidote Suction of secretions until Establish an
1. Remove to fresh air. Symptomatic Full atropinization airway
2. Give oxygen if Treatment only
i d LD: 10-100 mg
If any symptomaticManifestations refer to oral Is the patient
Exposure management 1. Comatosed
2. Convulsing
* Refer for dosing to the section: management of unknown ingestion 3. Without a gag reflex
** Treatment Guidelines:
Atropine: for treatment of muscrinic effects.
1. Diagnostic dose: IV/IM adult: 1 mg; child: 0.25 mg (0.02 mg/kg).
No Yes
If patient exhibit toxic effects of atropine (dry mouth, dilated pupil, and
rapid pulse) then probably not seriously poisoned. Induction of Emesis 1. Endotracheal
2. Dosage: IM/IV Mild symptomology, initially 2-4 mg (child 0.05 mg/kg) Intubation
further 2 mg doses may be given every 10 minutes to maintain full
atropinization.
Severe symtomatology, initially 4-6 mg (child 0.05 mg/kg), followed by 2 mg
every 5-10 minutes to maintain full atropinization (not to exceed 50 mg/24
Activated Charcoal + MgSo4*
hours for adults).
3. Therapeutic endpoint: Administer until full atropinization (dry mouth,
pulse) (130-140/minute, and dilated pupil, clearing of rales). Maintain
some degree of atropinization fpr 48 hours. Severe Symptoms with/or
Pralidoxime: for treatment of nicotinic manifestations, use as without Mild Symptoms
adjunct and not a substitute to atropine. 1. Weakness
Adult: 1-2 GM/IV in 100 ml NS 0.9% at 15-30 minutes.
2. Respiratory Depression
1. Child: 20-40 mg/kg IV.
Alternatively doses may be administered IM or SC. Atropine + Pralidoxime (for Carbamate give Atropine Therapy
2. Administration may be repeated x 3 or as needed at an interval of 8-12 atropine only) Atropinization should be alone
hours if muscle weakness has not been relieved. performed adequately & rapidly**
 UNIVERSAL ALGORITHM FOR ADULT
(Emergency Cardiac Care)

Assess
Responsiveness

Responsive Not Responsive

• Observe • Activate EMS
• Treat as indicated • Call for defibrillator
• Assess Breathing (open the airway,
look, listen, and feel

Breathing Not breathing

• Place in rescue • Given 2 slow
Position if no breaths
trauma • Assess circulation
Pulse No Pulse

™ Oxygen - history Start CPR

™ IV - physical exam.
™ Cardiac monitor
™ 12 leads ECG
™ Vital signs

Ventricular fibrillation/tachycardia
Suspected cause? (VF/VT) present on
No Yes
Hypotension/shock
acute pulmonary
edema • Intubate VF/VT
• Confirm tube
Placement
Acute MI
• Confirm
ventilations
• Determine
Arrhythmia rhythm

Electrical activity?
Too slow Too fast
Yes No

Pulsless electrical Asystole

activity
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BRAYCARDIA ALGORITHM
1
PULSELESS ARREST
Heart rate <60 bpm and
inadequate for clinical
condition
2
• Maintain patent airway; assist breathing as needed
• Give oxygen
• Monitor ECG (identify rhythm), blood pressure, oximetry
• Establish IV access

3
Signs or symptoms of poor perfusion caused by the bradycardia?
(e.g. acute altered mental status, ongoing chest pain; hypotension or other
signs of shock)

4A 4
• Prepare for transcutaneous pacing;
Observe/Monitor use without delay for high-degree block
(type II second-degree block or third-
degree AV block)
• Consider atropine 0.5 mg IV while
awaiting pacer. May repeat to a total
dose of 3 mg. If ineffective, begin
pacing.
• Consider epinephrine(2 to 10 µg/min)
or dopamine (2 to 10 µg/kg per minute)
infusion while awaiting pacer or if
Reminders pacing ineffective

• If pulseless arrest develops, go to Pulseless Arrest

Algorithm 5
• Search for and treat possible contributing factors: • Prepare for transvenous pacing
• Treat contributing causes
- Hypovolemia - Toxins • Consider expert consultation
- Hypoxia - Tamponade, cardiac
- Hydrogen ion - Tension pneumothorax
(acidosis) - Thrombosis (coronary or
- Hypo- pulmonary
/hyperkalemia - Trauma (hypovolemia,
- Hypoglycemia increased ICP)
- Hypothermia

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ACUTE CORONARY SYNDROMES ALGORITHM

1
Chest discomfort suggestive of
ischemia
2
EMS assessment and care and hospital preparation:
• Monitor, support ABCs. Be prepared to provide CPR and defibrillation
• Administer oxygen aspirin, nitroglycerin, and morphine if needed
• If available, obtain 12-lead ECG: if ST-elevation
- Notify receiving hospital with transmission or interpretation
- Begin fibrinolytic checklist (Figure 2)
• Notified hospital should mobilize hospital resources to respond to STEMI
3
Immediate ED assessment (<10 min) Immediate ED general treatment
• Check vital signs: evaluate oxygen • Start oxygen at 4 L/min: maintain O2 sat >
saturation 90%
• Establish IV access • Aspirin 160 to 325 mg (if not given by EMS)
• Obtain/review 12-lead ECG • Nitroglycerin sublingual, spray, or IV
• Perform brief, targeted history, physical • Morphine IV if pain not relieved by
exam check contraindications (Table 1) nitroglycerin
• Obtain initial cardiac marker levels, initial
electrolyte and coagulation studies
4 Review initial 12-lead ECG
5 9 13
ST elevation or new or presumably ST depression or dynamic T-wave Normal or nondiagnostic changes
new LBBB; strongly suspicious for inversion; strongly suspicious for in ST segment or T wave
6 injury ischemia
10 14
Start adjunctive treatment as Start adjunctive treatment as indicated
indicated (see text for (see text for contraindications) Develops high or intermediate risk
contraindications) • Nitroglycerin criteria (Tables 3. 4)
Do not delay reperfusion • ß-Adrenergic receptor blockers OR
troponin-positive
• ß-Adrenergic receptor blockers • Clopidogrel
• Clopidogrel • Heparin (UFH or LMWH)
• Heparin (UFH or LMWH) • Glycoprotein llb/llla inhibitor 15
7 11 Consider admission to
Time from onset of ED chest pain unit or to
Admit to monitored bed
symptoms ≤ 12 hours Assess risk status (Tables monitored bed in ED
3 4) Follow:
8 12 • Serial cardiac markers
Reperfusion strategy: High-risk patient (Tables 3, 4 for risk (including troponin)
Therapy defined by patient and center stratification):
• Repeat ECG/continuous ST
criteria (Table 2) • Refractory ischemic chest pain
• Recurrent/persistent ST deviation segment monitoring
• Be aware of reperfusion goals:
- Door-to-door balloon inflation • Ventricular tachycardia • Consider stress test
• Hemodynamic instability
(PCI) goal of 90 min
• Signs of pump failure
16
- Door-to-needle (fibrinolysis)
goal of 30 min • Early invasive strategy, including Develops high or
• Continue adjunctive therapies and: catheterization and revascularization for shock intermediate risk criteria
- ACE inhibitors/angiotensin within 48 hours of an AMI (Tables 3. 4)
receptor blocker (ARB) within 24 Continue ASA, heparin, and other therapies as OR
hours of symptom onset indicated. troponin-positive?
- HMG CoA reductase inhibitor • ACE inhibitor/ARB
17
(statin therapy) • HMG CoA reductase inhibitor (statin therapy) If no evidence of ischemia
• Not a high risk: cardiology to risk-stratify or infarction, can
discharge with follow-up
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Goals for Management of Patients With Suspected Stroke Algorithm.

1 Identify signs of possible
stroke

2
NINE D’S Critical EMS assessments and actions
• Support ABCs; give oxygen if needed
TIME • Perform prehospital stroke assessment (Tables 1 and 2)
GOALS • Establish time when patient last known normal (Note: therapies
may be available beyond 3 hours from onset)
• Transport; consider triage to a center with a stroke unit if
appropriate; consider bringing a witness, family member, or
caregiver.
• Alert hospital
• Check glucose if possible.
ED Arrival
10 min 3
Immediate general assessment and stabilization
• Assess ABCs, vital signs
• Provide oxygen if hypoxemic
• Obtain IV access and blood samples
• Check glucose; treat if indicated
• Perform neurologic screening assessment
• Activate stroke team
• Order emergent CT scan of brain
• Obtain 12-lead ECG
ED
Arrival
25 min

4
Immediate neurologic assessment by stroke team or designee
• Review patient history
• Establish symptom onset
• Perform neurologic examination (NIH Stroke Scale or Canadian Neurologic
ED Scale)
Arrival
45 min 5
Does CT scan show any haemorrhage?

No Haemorrhage Haemorrhage
6
7
Probable acute ischemic stroke; consider fibrinolytic Consult neurologist or
therapy neurosurgeon; consider transfer if
• Check for fibrinolytic exclusions (Table 3) not available
• Repeat neurologic exam: are deficits rapidly improving

8 9
Patient remains candidate for Not a Administer aspirin
fibrinolytic therapy? Candidate
ED Arrival
60 min 10 • 11Begin stroke pathway
Candidate • Admit to stroke unit if available
Review risks/benefits with patient and family: • Monitor BP; treat if indicated (Table 4)
If acceptable – • Monitor neurologic status; emergent CT if
• Give tPA deterioration
• No anticoagulants or antiplatelet treatment for 24 • Monitor blood glucose; treat if needed
hours • Initiate supportive therapy; treat
comorbidities

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Paediatric Healthcare Provider BLS Algorithm. Note that the boxes

with underlined text are performed by healthcare providers and not
by lay rescuers.
1
No movement or response
Send someone to phone EMS, get AED

2
Lone Rescuer: For SUDDEN COLLAPSE, PHONE
EMS, Get AED
3
Open AIRWAY, check BREATHING

4
If not breathing, give 2 BREATHS that make chest rise

5 5A
If no response, check pulse: Definite • Give 1 breath every 3
DEFINITE pulse Pulse seconds
within 10 seconds. • Recheck pulse every
2 minutes
6 No Pulse
One Rescuer: Give cycles of 30 COMPRESSIONS and 2 BREATHS
Push hard and fast (100/min) and release completely Minimize interruptions in compressions
Two Rescuers: Give cycles of 15 COMPRESSIONS and 2
BREATHS

If not already done, PHONE EMS , for child get AED/defibrillator

Infant (<1 year): Continue CPR until ALS responders take over or victim starts to move
Child (>1 year): Continue CPR; use AED/defibrillator after 5 cycles of CPR
(Use AED as soon as it is available for sudden, witnessed collapse)

8 Child > 1 year:

Check rhythm
Shockable rhythm?

9 Shockable Not Shockable

10
Give 1 shock Resume CPR immediately for 5 cycles
Resume CPR immediately 5 cycles; continue until ALS providers
for 5 cycles take over or victim starts to move

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ACLS PULSELESS ARREST ALGORITHM
1
PULSELESS ARREST
• BLS Algorithm: Call for help, give CPR
• Give oxygen when available
• Attach monitor/defibrillator when available

2
Shockable Not Shockable
Check rhythm
3 Shockable rhythm? 9
VF/VT Asystole/PEA
4 10
Give 1 shock
• Manual biphasic: device Resume CPR immediately for 5 cycles
specific (typically 120 to 200 J) When IV/IO available, give vasopressor
Note: if unknown, use 200 J • Epinephrine 1 mg IV/IO
• AED: device specific Repeat every 3 to 5 min , or
• Monophasic: 360 J • May give 1 dose of vasopressin 40 U IV / IO to replace first
Resume CPR immediately or second dose of epinephrine
• Consider atropine 1 mg IV/IO for asystole or slow PEA rate
5 Give 5 cycles of CPR* • Repeat every 3 to 5 min (up to 3 doses)

Check rhythm No
Shockable rhythm?
Give 5 cycles of
6 CPR*
Continue CPR while defibrillator is charging 11
Give 1 shock Check rhythm
• Manual biphasic: device specific (the same as Shockable rhythm?
first shock or higher dose)
Note: if unknown, use 200 J
• AED: device specific
Not
• Monophasic: 360 J Shockable Shockable
Resume CPR immediately after the shock
When IV/IO available, give vasopressor during
CPR (before or after the shock)
• Epinephrine 1 mg IV/IO
Repeat every 3 to 5 min 12
or
• May give 1 dose of vasopressin 40 U IV/IO to • If asystole, go to Box 10 13
replace first or second dose of epinephrine • If electrical activity, check pulse.
• If no pulse, go to Box 10 Go to
Box 4
7 Give 5 cycles of CPR* • If pulse present, begin
postresuscitation care
Check rhythm No
Shockable rhythm? CPR
• Push hard and fast (100/min)
• Ensure full chest recoil
8 Shockable
• Minimize interruptions in chest compressions
Continue CPR while defibrillator is charging • One cycle of CPR: 30 compressions then 2 breaths; 5 cycles – 2 min
Give 1 shock • Avoid hyperventilation
• Manual biphasic: device specific (the same as first shock or • Secure airway and confirm placement
higher dose) • After an advanced airway is placed rescuer no longer deliver cycles of CPR.
Note: if unknown, use 200 J • Give continuous chest compressions without pauses for breaths.
• AED: device specific • Give 8 to 10 breaths/minute.
• Monophasic: 360 J • Check rhythm every 2 minutes.
Resume CPR immediately after the shock • Rotate compressors every 2 minutes with rhythm checks
Consider antiarrhythmics after the shock (before or after the • Search for and treat possible contributing factors:
shock) • Hypovolemia
amiodarone (300 mg IV/IO once, then consider additional • Hypoxia
150mg IV/IO once) or lidocaine (1 to 1.5 mg/kg first dose, then • Hydrogen ion (acidosis)
0.5 to 0.75 mg/kg IV/IO, maximum 3 doses or 3 mg/kg) • Hypo/hyperkalemia
Consider magnesium, loading dose 1 to 2 g IV/IO • Hypoglycemi
for torsades de pointes
• Hypothermia
After 5 cycles of CPR,* go to Box 5 above

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Figure 2 Anaphylactic Reactions: Treatment Algorithm for Children by First

Medical Responders

1 An inhaled beta2-agonist such as salbutamol may be used as an adjunctive measure if bronchospasm

is severe and does not respond rapidly to other treatment.
2. If profound shock judged immediately life threatening give CPR/ALS if necessary. Consider slow
intravenous (IV) adrenaline (epinephrine) 1:10,000 solution. This is hazardous and is recommended
only for an experienced practitioner who can also obtain IV access without delay. Note the different
strength of adrenaline (epinephrine) that may be required for IV use.
3. For children who have been prescribed an adrenaline auto-injector, 150 micrograms can be given
instead of 120 micrograms, and 300 micrograms can be given instead of 250 micrograms or 500
micrograms.
4. Absolute accuracy of the small dose is not essential.
5. A crystalloid may be safer than a colloid.

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Anaphylactic Reactions: Treatment Algorithm for Adults

Consider when compatible history of severe allergic-type

reaction with respiratory difficulty and/or hypotension
especially if skin changes present

Oxygen treatment
when available

Stridor, wheeze,
respiratory distress or
clinical signs of shock1

Adrenaline (epinephrine)2,3
1:1000 solution
0.5 mL (500 micrograms) IM

Repeat in 5 minutes if no clinical

improvement

Antihistamine (chlorphenamine)
10-20 mg IM/or slow IV

IN ADDITION
If clinical manifestations of shock
For all severe or recurrent do not respond treatment
drug reactions and patients give 1-2 litres IV fluid.4
Hydrocortisone Rapid infusion or one repeatdose
100-500 mg IM/or slowly IV may be necessary

1. An inhaled beta2-agonist such as salbutamol may be used as an adjunctive measure

if bronchospasm is severe and does not respond rapidly to other treatment.
2. If profound shock judged immediately life threatening give CPR/ALS if necessary. Consider
slow IV adrenaline (epinephrine) 1:10,000 solution. This is hazardous and is recommended
only for an experienced practitioner who can also obtain IV access without delay.
Note the different strength of adrenaline (epinephrine) that may be required for IV use.
3. If adults are treated with an adrenaline auto-injector, the 300 micrograms will usually be sufficient.
A second dose may be required. Half doses of adrenaline (epinephrine) may be safer for patients on
amitriptyline, imipramine, or beta blocker.
4. A crystalloid may be safer than a colloid.

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References:
1. Cummins RO, etal : Advanced Cardiac Life Support, Provider Manual. AHA 2006 .
2. Fundamental Critical Care Support: Society of Critical Care Medicine 3rd Edition
2001.
3. Advanced Trauma Life Support for Doctors : American College of Surgeons
Committee on Trauma 6th Edition 1997
4. Stone C. Humpries R. Current Emergency Diagnosis and Treatment 5th Edition
2004
5. Markovchick V, Pons P. Emergency Medical Secrets.3rd Edition 2003.
6. Coterino J, Kahan s.In a Page of Emergency Medicine. 1st Edition 2003.
7. Lefor A. Critical Care on Call. 1st Edition 2002
8. Haist S, Robbins J. Internal Medicine on Call 3rd Edition 2002
9. Ma O.J, etal: Emergency Medicine Maual. 6th Edition 2004
10. Biddinger P,etal: Emergency Medicine . 2nd Edition 2003
11. Tallia A, etal: Swanson's Family Practice Review, A problem-oriented approach.
a. 5th Edition
12. Al-Khuwaiter T, etal: Guidelines for treatment of hypertensive emergencies 2004
13. Standards for Accident & Emergency Departments in Ireland. EMS in Ireland-2001
14. Emergency Policy & Procedures. MOH, KSA
15. Subash F, etal:Team Triage Improves Emergency Department Efficiency:
Emer.Med. J 2004
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