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 STANDARD TREATMENT PROTOCOL OF EMERGENCY HEALTH SERVICE PACKAGE

STP EHS

STANDARD TREATMENT PROTOCOL OF EMERGENCY HEALTH SERVICE PACKAGE

CONTENTS

STP BHS

FOREWORD iii

ACKNOWLEDGEMENT V

ABBREVIATIONS X

BACKGROUND 1

Definition of Emergency Health Services 1

Rationale of the STP 2

Development Process of the STP 3

Utilization of the STP 3

Assumptions made for the implementation of the STP 4

How to use the STP 4

ABCDE Approach in the Emergency Room 7

Adult Basic Life Support 28

Paediatric Basic Life Support 29

Paediatric Cardiac Arrest Algorithm 30

Adult Cardiac Arrest Algorithm 31

Adult Tachycardia with a Pulse Algorithm 32

Adult Bradycardia Algorithm 33

Adult Post- Cardiac Arrest Care Algorithm 34

LIST OF EMERGENCY CONDITIONS 35

1. Respiratory Emergencies 37

2. Cardiac Emergencies 62

3. Neurological Emergencies 89

4. Gastrointestinal Emergencies 101

5. Genitourinary Emergencies 128

6. Gynaecology and Obstetrical Emergencies 135

7. Orthopedics and Trauma 152

8. Metabolic Emergencies 168

9. Ocular Emergencies 179

10. ENT Emergencies 182

11. Burns 185

12. Mental Health Emergencies 191

13. Toxicological Emergencies 204

14. Snake bite, Animal bite, Insect bite 225

15. Pediatric Emergencies 234

16. Miscellaneous 244

STANDARD TREATMENT PROTOCOL OF EMERGENCY HEALTH SERVICE PACKAGE

viii

ANNEXES 253

ANNEX I: Schedule 2: Emergency Health Services 254

ANNEX II: List of Essential Medicines 257

Annex III: Patient Referral Form 270

ANNEX IV: Participants of Pre Planning/ Preliminary Consultative

Meeting with key government officials on STP of EHS 271

ANNEX V: Participants of Consultative TWG Meeting on STP of EHS 272

ANNEX VI: Participants of Consultative Meeting with Subjects/

Emergency Experts on STP of EHS 273

ANNEX VII: Participants of Consultative Meeting with Professional

Council and Association Members on STP of EHS 274

ANNEX VIII: Participants of High Level Consultative Meeting on STP of EHS 275

BIBLIOGRAPHY 277

STANDARD TREATMENT PROTOCOL OF EMERGENCY HEALTH SERVICE PACKAGE

ix

LIST OF FIGURES

Figure 1 Head tilt and chin lift 10

Figure 2 Head tilt and chin lift 10

Figure 3 Jaw thrust 11

Figure 4 Jaw thrust 11

Figure 5 Oropharyngeal airway (Guedel airway) 12

Figure 6 Nasopharyngeal airway 12

Figure 7 Bag and mask ventilation (One person technique) 13

Figure 8 Bag and mask ventilation (Two person technique) 13

Figure 9 LMA (Laryngeal mask airway) 14

Figure 10 Endotracheal tube 15

Figure 11 Cervical collar application 25

Figure 12 Cervical collar application 25

Figure 13 Log roll 27

Figure 14 Log roll 27

Figure 15 Acute anterior wall myocardial infarction 68

Figure 16 Acute inferior wall myocardial infarction 68

Figure 17 Atrial fibrillation with fast ventricular rate 76

Figure 18 Supraventricular tachycardia 78

Figure 19 Complete heart block

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Table of Contents(toc)

Introduction

Introduction

A structured approach makes ECG interpretation systematic and reliable. A commonly used mnemonic is:

RRAHI

• R = Rhythm
• R = Rate
• A = Axis
• H = Hypertrophy
• I = Ischemia

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How to Calculate Heart Rate in Regular Rhythm ECG

For a regular rhythm, use either of the following methods:

Method 1 (Big boxes)

• Take any two R waves
• Count the number of big boxes between them
• Divide 300 by that number
• The result is the heart rate

Method 2 (Small boxes)

• Take any two R waves
• Count the number of small boxes between them
• Divide 1500 by that number
• The result is the heart rate

---

How to Calculate Heart Rate in Irregular Rhythm ECG

For irregular rhythms, use a longer rhythm strip:

• Take 10 big boxes in the rhythm strip
• Count the number of QRS complexes (R waves) within those 10 big boxes
• Multiply that number by 30

👉 This gives the heart rate in beats per minute (bpm)

Completed Formula

Heart rate = (Number of QRS complexes in 10 big boxes) × 30

Why this works:

• 1 big box = 0.2 seconds
• 10 big boxes = 2 seconds
• 60 seconds ÷ 2 seconds = 30

So you are converting a 2-second sample into a 1-minute rate.

---

How to Check Rhythm of an ECG

To determine the rhythm:

• Check if R–R intervals are regular or irregular
• Look for P waves before every QRS complex
• Ensure P waves have a consistent shape
• Confirm that each P wave is followed by a QRS

Normal (Sinus Rhythm) Features:

• Regular rhythm
• One P wave before each QRS
• Normal PR interval
• Heart rate between 60–100 bpm

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How to Check Axis of an ECG

Axis refers to the overall direction of electrical activity in the heart.

Basic Method (using limb leads):

• Look at Lead I and aVF

Lead I	aVF	Axis
+	+	Normal axis
+	–	Left axis deviation
–	+	Right axis deviation
–	–	Extreme axis deviation

Normal Axis:

• Between -30° to +90°

The electrical impulse normally:

• Starts from the right atrium
• Travels toward the left ventricle
• Occurs 60–100 times per minute

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How to Identify Myocardial Ischemia on ECG

Look for these three key changes:

• ST segment changes
  • Elevation → possible acute injury
  • Depression → ischemia
• T wave changes
  • Inversion
  • Flattening
• Q waves
  • May indicate previous myocardial infarction

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How to Identify Hypertrophy on ECG

Hypertrophy leads to increased voltage (amplitude) on ECG.

Left Ventricular Hypertrophy (LVH)

A commonly used method:

• S wave in V1 + R wave in V5 or V6 ≥ 35 mm

Additional clues:

• Deep S waves in V1
• Tall R waves in V5/V6
• Possible left axis deviation

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This completes the full ECG reading framework using the RRAHI approach, covering all essential steps: rate, rhythm, axis, hypertrophy, and ischemia.