MMC

Practice
Protocol
A Ready Reckoner

A RGGGH INITIATIVE
Copy Right Content
Dedication

Dedicated
To
All the Teachers of Madras Medical College
Who taught us
And
The Patients of Rajiv Gandhi Government General Hospital
Who continue to teach us

iii
Message from Dean

Greetings to all!

Current day practice of medicine is quite challenging, given the

increasing number of diseases and the expanding trends of diagnostics
and therapeutics.

Algorithmic approach to clinical issues is getting greater emphasis in

medical education. Simple, methodical and easy-to-follow algorithm
will be of great help for the medical fraternity. Such an approach will
minimise errors, obviate unnecessary investigations and ensue appro-
priate management. More importantly, uniformity of delivery of care to all the beneficiaries will
be ensured.

We intend to come up with algorithmic management protocol for all the diseases. As a first step of
that formidable venture, as a pilot work, the faculty of Madras Medical College & Rajiv Gandhi
Government General Hospital have prepared protocol for some diseases / clinical syndromes of
each speciality.

I am glad to have initiated this project and convey my felicitations to all the faculty who have
contributed.

Dr E. Theranirajan,
MD DCH, MRCPCH (UK), FRCPCH (UK)

DEAN

iv
Preface

The protocol committee expresses its gratitude to our beloved Dean Prof. Dr.E.Theranirajan for
initiating the ‘MMC PRACTICE PROTOCOL - A READY RECKONER’ project. We are
grateful for the commendable efforts made by all the departments. We thank all the Directors
and the contributors for dedicating their invaluable time, upon short notice in making this Project
successful. This pilot project is a unique effort in the Government of Tamil Nadu Health Services.
This compendium of simplified algorithms is aimed at empowering the medical fraternity to adopt
standardized protocols in patient care. We hope this book will improvise decision making and
promote multidisciplinary approach, which will in turn improve patient care and benefit the com-
munity at large.

R. Lakshmi Narasimhan
Director
Institute of Neurology
Chairman &
All members of protocol committee

v
Protocol Committe

COMMITTEE CHAIRPERSON

Dr Lakshmi Narasimhan Ranganathan

DM (Neurology)., DNB (Neurology)., Ph.D., FAAN., FIAN., FRCP
(London)., FRCP (Glasgow), FEBN, FACP, MNAMS

Director - Institute of Neurology

Madras Medical College

CO-MEMBERS

Dr R Madhu Dr E Uma Maheswari Dr Cheralathan S

MD (Derm), DCH MAMS M.D D.M MS Ortho, D Ortho,
Associate Professor, Assistant Professor, DNB Ortho
Department of Dermatology Institute of Neurology Senior Assistant Professor,
Institute of Orthopaedics and
Traumatology

vi
protoCoL CoMMitte vii

Dr S Subitha Dr Vikas C Kawarat Dr P Balamanikandan

MD (Pathology) DNB M.D. (Gen Med)
Senior Assistant Professor, Assistant Professor Assistant Professor, I
Institute of Pathology of General Surgery nstitute of Internal Medicine

Dr T S Karthigeyan Dr T Dinesh Kumar Dr Yogesh Subramanian

M.D. (Gen Med) M.D. D.M (Nephrology) M.D. (Gen Med)
Assistant Professor, Assistant Professor, Assistant Professor,
Institute of Internal Medicine Institute of Nephrology Institute of Internal Medicine

Dr Tanuj Moses Lamech Dr Kaushik Dr M Nirumal Khumar

M.D D.M. (Nephrology) M.D D.M DNB (Neurology) Resident,
Assistant Professor, Assistant Professor Institute of Neurology
Institute of Nephrology of Neurology

Dr Durgam Sathya Tejaswini Dr Noel James Dr S Guhan

Resident, Resident, Resident,
Institute of Neurology Institute of Neurology Institute of Nephrology
List of Contributors

MEDICAL SPECIALITIES
Bone Marrow Transplant

● Dr Aruna Rajendran MD, DM

Assistant Professor
Department of Haematology

Cardiology

● Dr G Justin Paul MD., DNB (Gen Med)., DM., DNB (Cardiology).,

Director (I/C)
Institute of Cardiology

● Dr M Nanda Kumar MD., DM.,

Professor
Institute of Cardiology

Dermatology

● Dr V Sampath MD., (Derm)

Professor and HOD
Department of Dermatology

● Dr C Vijayabhaskar MD., (Derm), DCH

Professor
Department of Dermatology

Diabetology

● Dr P Dharmarajan MD., D.Diab

Professor and HOD
Department of Diabetology

viii
List of Contributors ix

● Dr Pushpa Saravanan MD., D.Diab

Associate Professor
Department of Diabetology

Endocrinology

● Dr T B Uma Devi MBBS., MD (Gen Med)

Professor in charge
Department of Endocrinology

● Dr A Anis Preethi MBBS., MD (Gen Med)

Assistant Professor
Department of Endocrinology

General Medicine

● Dr C Hariharan MD (Gen Med).,

Director
Institute of Internal Medicine

● Dr N Ravishankar MD (Gen Med).,

Associate Professor
Institute of Internal Medicine

Geriatric Medicine

● Dr Gnanasambandam Usha M.D (Geriatric Medicine)

Director
National Centre for Aging, Guindy

● Dr K Umakalyani
Senior Assistant Professor
Department of Geriatric Medicine

Haematology

● Dr Karthikeyan MD, DM
Prof and HOD (Rtd)
Department of Haematology
x MMC PRACTICE PROTOCOLS

● Dr H Gokulakrishnan MD
Assistant Professor
Institute of Internal Medicine

Hepatology

● Dr K Prem Kumar MD, DM (Hepatology)

Director (I/C)
Institute of Hepatobiliary Sciences

● Dr J L Joeimon MD, DM (Hepatology)

Assistant Professor
Institute of Hepatobiliary Sciences

Medical Gastroenterology

● Dr P Ratnakar Kini MD., DM (Gastro).,

Director (I/C)
Institute of Medical Gastroenterology

● Dr A M Vishnu Dev MD.,

Senior Resident
Institute of Medical Gastroenterology

Nephrology

● Dr N Gopalakrishnan MD., DM., FRCP

Director
Institute of Nephrology

● Dr S Jayalakshmi MD., DM.,

Professor
Institute of Nephrology

Neurology

● Dr Lakshmi Narasimhan Ranganathan DM (Neurology)., DNB (Neurology)., Ph.D.,

FAAN., FIAN., FRCP (London)., FRCP (Glagow), FEBN, FACP, MNAMS
Director
Institute of Neurology
List of Contributors xi

● Dr S Balasubramanian MD., DM (Neurology) FRCP (London)

Professor
Institute of Neurology

Oncology

● Dr S G D Gangadaran MD., DM.,

Professor and HOD (Retd)
Department of Medical Oncology

● Dr E Senthil Kumar MD., DM.,

Senior Assistant Professor
Department of Medical Oncology

● Dr T N Vijayasree MDRT., DCH.,

Professor and HOD
Department of Radiation Oncology

● Dr J Indhumathi MDRT.,
Assistant Professor
Department of Radiation Oncology

● Dr G Gopu MS., MCH.,

Professor and HOD
Department of Surgical Oncology

Paediatrics

● Dr Rema Chandramohan MD., DCH., DNB., Ph.D.,

Director
Institute of Child Health

● Professors of Pediatrics
Institute of Child Health

Psychiatry

● Dr M Malaiappan MD (PSY)
Director
Institute of Mental Health
xii MMC PRACTICE PROTOCOLS

● Dr S Bevin MD (PSY)
Asst Professor
Institute of Mental Health

Rheumatology

● Dr P S Arul Rajamurugan MD., DM.,

Associate Professor and Head
Institute of Rheumatology

● Dr Ramesh MD., DM.,

Assistant Professor
Institute of Rheumatology

Department of Transfusion Medicine

● Dr S Subash DCH., MD (Blood Transfusion)

Professor and HOD
Department of blood bank and transfusion medicine

● Dr B Latha MD (Blood Transfusion)

Associate Professor
Department of blood bank and transfusion medicine

Thoracic Medicine

● Dr A Sundararajaperumal MD (TB & RM)., DCH.,

Professor and HOD
Department of Thoracic Medicine

● Dr A Arunbabu MD (TB & RM).,

Assistant Professor
Department of Thoracic Medicine

Venereology

● Dr S Kalaivani MD DVL
Director
Institute of Venerology
List of Contributors xiii

● Dr H Dhanaselvi MD DVL
Senior Assistant Professor
Institute of Venerology

SURGICAL

Anaesthesia

● Dr M Vellingiri MD DA
Director (I/C)
Institute of Anaesthesia and Critical Care

● Dr E Kathiravan MD.,
Assistant Professor
Institute of Anaesthesia and Critical Care

Cardiothoracic Surgery

● Dr B Mariappan M.Ch.,
Director (I/C)
Institute of Cardiothoracic Surgery

● Dr Sanjeev Pandian M.Ch.,

Professor
Institute of Cardiothoracic Surgery

Endocrine Surgery

● Dr S Zahir Hussain MS., M.Ch.,

Professor and HOD
Department of Endocrine Surgery

● Dr S Dhalapathy MS., M.Ch.,

Associate Professor
Department of Endocrine Surgery

General Surgery

● Dr P S Shanthi MS (Gen Surgery)., DGO., FAIS.,

Director (I/C)
Institute of General Surgery
xiv MMC PRACTICE PROTOCOLS

● Dr Vikas C Kawarat DNB (Gen Surgery)., MRCS Ed.,

Assistant Professor
Institute of General Surgery

Interventional Radiology

● Dr Kalpana S DMRD., MDRD., DNB., Ph.D., EBIR

Director
Barnard Institute of Radiology

● Dr K Shivashankar DMRD, DNB.

Professor
Barnard Institute of Radiology

Neurosurgery

● Dr R Raghavendran M.Ch.,
Director
Institute of Neurosurgery

● Dr Vidhya Narasimhan MCh.,

Associate Professor
Institute of Neurosurgery

Obstetrics and Gynaecology

● Dr K Kalaivani MD., DGO.,

Director
Institute of Obstetrics and Gynaecology

● Dr Arvindh Santhosh MS (OG)., DNB (OG).,

Assistant Professor
Institute of Obstetrics and Gynaecology

Ophthalmology

● Dr M R Chitra MS (Ophthal).,
Director
Regional Institute of Ophthalmology and Government Ophthalmic Hospital
List of Contributors xv

● Dr Shanthi MS (Ophthal).,
Associate Professor
Regional Institute of Ophthalmology and Government Ophthalmic Hospital

Orthopaedics

● Dr V Singaravadivelu MS (Ortho), D. Ortho, Ph.D.,

Director I/C
Institute of Orthopaedics and Traumatology

● Dr Cheralanathan S MS (Ortho), D. Ortho, DNB Ortho

Senior Assistant Professor
Institute of Orthopaedics and Traumatology

Otorhinolaryngology

● Dr R Muthukumar MS., DLO., DNB

Professor and Head
Upgraded Institute of Otorhinolaryngology

● Dr N Suresh Kumar MS., DLO.,

Professor
Upgraded Institute of Otorhinolaryngology

Paediatric Surgery

● Dr R Velmurugan MS., M.Ch. (Paediatric Surgery)

Professor and Head
Department of Paediatric Surgery

● Dr V Rohit Gopinath MS., M.Ch. (Paediatric Surgery)

Assistant Professor
Department of Paediatric surgery

Plastic Surgery

● Dr N C Hariharan MS (ENT)., M.Ch. (Plastic Surgery)

Professor and HOD
Department of Plastic Surgery
xvi MMC PRACTICE PROTOCOLS

● Dr N A Gunasekaran MS., M.Ch. (Plastic Surgery)

Senior Assistant Professor
Department of Plastic surgery

Surgical Gastroenterology

● Dr O L Naganath Babu MS (Gen Surg)., M.Ch. (Surgical Gastro)

Director
Institute of Surgical Gastroenterology

● Dr R Prabhakaran MS (Gen Surg)., M.Ch. (Surgical Gastro)

Associate Professor
Institute of Surgical Gastroenterology

Urology

● Dr V Ezhil Sundar, MS (Gen Surg), M.Ch. (Urology)

Associate Professor / Director (I/C)
Institute of Urology

● Dr P R Saravanan, MS (Gen Surg), M.Ch. (Urology)

Assistant Professor
Institute of Urology

Vascular Surgery

● Dr N Sritharan MS (Gen Surg)., DNB (Gen Surg)., FRCS (Edin)., M.Ch. (Vascular).,
Director
Institute of Vascular Surgery

● Dr S Prathap Kumar MS (Gen Surg)., M.Ch. (Vascular).,

Senior Assistant Professor
Institute of Vascular Surgery
Table of Contents

MEDICAL SPECIALITIES

1. Bone Marrow Transplant 1

I. Thalassemia-HSCT 1
II. Acute Lymphoblastic Leukemia-Adult-HSCT 2
III. Acute Myeloid Leukemia-HSCT 3
IV. Aplastic Anaemia-Adults-HSCT 4
V. Multiple Myeloma-HSCT 5

2. Cardiology 6

I. Management Protocol for STEMI 6

II. Management Protocol for NSTEMI 7
III. Management Protocol for Acute decompensated Heart failure 9
IV. Management Protocol for Pulmonary Embolism 11
V. Management protocol for complete heart block 12

3. Dermatology 13

I. Bullous Pemphigoid 13
II. Pemphigus 14
III. Psoriasis 15
IV. SJS TEN 16
V. Utricaria 17

4. Diabetology 18

I. Management of Type 1 DM 18
II. Management of Type 2 DM 19
III. Management of Glucose intolerance in pregnancy 20
IV. Diabetic Ketoacidosis 21
V. Hypoglycemia 22

xvii
xviii MMC PRACTICE PROTOCOLS

5. Endocrinology23

I. Hyperprolactinemia-Approach23
II. Hypocalcemia-Approach24
III. Hypothyroidism-Approach25
IV. Micropenis-Approach26
V. Short Stature-Approach 27

6. General Medicine 28

I. Hypertensive Emergency-Management 28
II. Acute Febrile illness 30
III. OPC poisoning 31
IV. Snakebite32
V. Sepsis33

7. Geriatric Medicine 34

I. Delirium34
II. Falls35
III. Functional decline-Algorithm 36
IV. Urinary incontinence  37

8. Hematology38

I. Thalassemia38
II. Acute Lymphoblastic Leukemia 39
III. Acute Myeloid Leukemia 40
IV. Aplastic Anaemia 41
V. Multiple Myeloma 42

9. Hepatology43

I. Acute viral Hepatitis A and E management 43

II. Management algorithm of alcoholic hepatitis 45
III. Decompensated Liver disease with altered mental status 46
IV. Hepatitis B-management Protocol 47

10. Medical Gastroenterology 50

I. Acute Cholangitis 50
II. Chronic diarrhea 53
III. Chronic pancreatitis 56
IV. Crohn’s disease 58
V. Ulcerative colitis 60
VI. Upper Gastrointestinal bleeding 66
Table of Contents xix

11. Nephrology68

I. Diabetes and chronic kidney disease 68

II. Acute kidney injury 71
III. Chronic kidney disease 73
IV. Glomerular disease 75

12. Neurology77

I. Guillain Barre syndrome 77

II. Meningitis78
III. Myasthenia Gravis 79
IV. Status Epilepticus 80
V. Stroke Protocol  81

13. Oncology82

I. Carcinoma Cervix 82
II. Carcinoma Breast 91
III. Carcinoma Esophagus 97
IV. Carcinoma Lung 101
V. Carcinoma oral cavity 105

14. Paediatrics  110

I. Acute diarrhea 110

II. Acute severe asthma 113
III. Status epilepticus in children 116
IV. Approach to childhood anemia 118
V. Management of dengue in children  122

15. Psychiatry125

I. Alcohol dependence 125

II. Anxiety disorders 129
III. Bipolar disorder 131
IV. Depression135
V. Schizophrenia  139

16. Rheumatology142

I. Spondyloarthropathy142
II. Rheumatoid arthritis 143
III. Systemic sclerosis 144
IV. Systemic Lupus Erythematosus 145
V. Gout146
xx MMC PRACTICE PROTOCOLS

17. Department Transfusion Medicine 147

I. ABO Mismatch 147

II. Cryopreservation148
III. Management of acute severe autoimmune hemolytic anemia 149
IV. Adult massive transfusion protocol 150
V. Paediatric massive transfusion protocol 151
VI. Patient blood management with ROTEM 152

18. Thoracic Medicine 153

I. Management of Asthma 153

II. COPD management 154
III. Tuberculosis management 155
IV. Pneumothorax Protocol 156
V. Interstitial Lung disease 157
VI. Management of Bronchiectasis 158

19. Venereology  159

I. Herpes Genitalia 159

II. Vulvovaginal candidiasis 160
III. Adult Gonococcal urethritis 161
IV. Genital wart 162
V. Primary chancre 163

SURGICAL
20. Anaesthesia164

I. Air Embolism 164

II. Cant intubate, Cant Ventilate 165
III. Laryngospasm165
IV. Local Anesthetics systemic toxicity  166
V. Severe intraoperative Hemorrhage  167

21. Cardiothoracic Surgery 168

I. Adult -congenital heart disease 168

II. Ischemic heart disease 169
III. Lung masses 170
IV. Mediastinal/ lung tumours 171
V. Chest trauma 172
VI. Valvular heart disease 173
Table of Contents xxi

22. Endocrine Surgery 174

I. Approach to Hypercalcemia 174

II. Approach to Hyperthyroidism 175
III. Adrenal incidentaloma 176
IV. Algorithm to approach a thyroid nodule 177

23. General Surgery 178

I. Abdominal trauma 178

II. Carcinoma breast 179
III. Hollow viscus perforation 180
IV. Lower Gastrointestinal bleed 181
V. Ventral hernia 182

24. Intervention Radiology  183

I. Portal hypertension 183

II. Budd Chiari syndrome 184
III. Chronic kidney disease 185
IV. Intracranial aneurysm 186
V. Percutaneous transhepatic biliary drainage procedures 187

25. Neurosurgery188

I. Management of Acute Subdural Hemorrhage 188

II. Management of C2 fractures 189
III. Management Algorithm for Epidural hematoms 190
IV. Management Algorithm for Acoustic tumours 191
V. Management Algorithm for Meningioma 192

26. Obstetrics and Gynaecology 193

I. Anemia in pregnancy 191

II. Gestational Diabetes Mellitus 194
III. Hypertensive disorder in pregnancy 195
IV. Management of Pre-eclampsia 196
V. Management of Uterine fibroids 197
VI. Modified pathway for female pelvic floor dysfunction 198
xxii MMC PRACTICE PROTOCOLS

27. Ophthalmology199

I. Management of Cataract 199

II. Refractive errors 200
III. Diabetic Retinopathy 201
IV. Ocular injuries 202
V. Management of Glaucoma 203

28. Orthopaedics204

I. Management of pediatric Supracondylar fractures 204

II. Management of distal radius fracture 205
III. Management of open fractures 206
IV. Protocol of management of non-union 207
V. Protocol for work up of bone tumour 208

29. Otorhinolaryngology  209

I. Newborn hearing screening  209

II. Chronic otitis media(tubotympanic)-mucosal disease  210
III. Chronicle otitis media(atticoantral)-active squamosal disease 211
IV. Sinusitis212
V. Stridor  213

30. Paediatric Surgery 214

I. Hypospadias214
II. Inguinal hernia 215
III. Intussusception216
IV. Malrotation217
V. Undescended testis 218

31. Plastic Surgery 219

I. Cleft Lip/palate 000

II. Hemifacial microsomia 219
III. Vascular anomalies 220
IV. Algorithm for Hypospadias repair 221
V. Congenital aural atresia 222
VI. Facial trauma-management guidelines 223
VII. Hand surgery 224
VIII. Limb and torso avulsion injuries 225
Table of Contents xxiii

32. Surgical Gastroenterology 226

I. Carcinoma Esophagus 226

II. Carcinoma rectum 227
III. Ca Stomach 228
IV. Corrosive injury 229
V. Hepatocellular Carcinoma 230

33. Urology236

I. Carcinoma Prostate 236

II. Carcinoma Urinary bladder 237
III. Renal cell carcinoms 238
IV. Renal trauma 239
V. Urolithiasis240

34. Vascular Surgery 242

I. Aortic Aneurysm 242

II. AV access 243
III. Deep venous thrombosis 244
IV. Peripheral arterial occlusive disease 247
V. Varicose Veins 248
MEDICAL SPECIALITIES

Bone Marrow Transplant

Hematopoiec Stem Cell Transplantaon Protocols
1. Thalassemia - HSCT

Principal indication for BMT is Ideal candidate

transfusion dependenceanemia -child treated with regular
transfusion and chelation
- having HLA ident ical sibling donor
-No evidence of end organ damage

Risk factor Adverse favourable

Hepatomegaly >2cm <2cm
Liver fibrosis Presence Absence -Optimal age is childhood
Iron chelation Irregular regular -No absolute age cut off if patient is
Risk class healthy and can tolerate procedure
Class I patients have all 3 favourable risk factors - However candidates < 14 years have 2
Class II patients have 1 or 2 adverse risk factors year survivial of 96%
Class III patients all 3 adverse risk factors

Pretransplant evaluation
-liver iron estimation( liver biopsy or MRI)
Donor selection
-Viral markers HbsAg, HCV,CMV
1.HLA MSD
-cardiac evaluation (echocardiography, T2 cardiac
2.HLA MUD
MRI)
3.Haploidentical donor
-Splenic function
-endocrine function
-fertility- post pubertal males-sperm banking

Stem cell source preferred

Myeloablative conditioning regimens
1.Bone marrow harvest
1.Busulfan 3.2mg/kg IV X 4 day
2.umbilical cord
2.Inj Cyclophosphamide 50mg/day X 4 days
3.PBSC
3. in high risk patient Fludarabine is added

GVHD REGIMEN
Hematopoietic support
1.Cyclosporin
-CMV negative, irradiated blood
2.Short Methotrexate Regimen
Blood products
ANTIMICROBIAL PROPHYLAXIS
-Fluoroquinolone prophylaxis
-Antifungal to cover Candida and aspergillus
-PCP prophylaxis
-antiviral prophylaxis for HSV, VZV, CMV

1
2 MMC PRACTICE PROTOCOLS

2. ACUTE LYMPHOBLASTIC LEUKEMIA – ADULTS - HSCT

Whom to transplant in ALL? Which donar to select?

COMPLETE REMISSION(CR1) Match sibling Donar>Match Unrelated
High risk cytogenetics Donar>Mismatched Unrelated
Donar>Haplo
No CR in d33
Poor Prednisolone response
T-ALL
MRD>1X10 -4 after 2 courses of chemotherapy PRETRANSPLANT WORK UP
CR2 -All relapsed Patients Completebloodcount,
RFT,LFT,Electrolytes,PT/APTT,Blood
grouping&typing
Viral markers,Cardiology,Pulmonology and Dental
fitness

CONDITIONING REGIMEN
<45YRS - 1.Total Body irradiation in fractions to cumulative dose of 12-13GY/INJ.CYCLOPHOSPHAMIDE
60mg/kg/Day for2 days 2.TBI/ETOPOSIDE 3.BUSULPHAN/CYCLOPHOSPHAMIDE
>44YRS - 1.FLUDARABINE/MELPHALAN 2. FLUDARABINE/TBI8Gy

SOURCE OF STEM CELL

PERIPHERAL BLOOD/BONE MARROW

GVHD PROPHYLAXIS
CYCLOSPORINE and Inj.METHOTREXATE 15mg/kg-D1
Inj.METHOTREXATE 10mg/kg-D3,D5

MAINTAINENCE
Ph +ve ALL-To add Tyrosine Kinase Inhibitors
Bone Marrow Transplant 3

3. ACUTE MYELOID LEUKEMIA - HSCT

AML Counseling for

Except favourable risk Allogenic HSCT

Initial Assessment

Pretransplant work up for patient & donor High Resolution HLA typing Disease-specific restaging
Complete blood count of patient and sibling donor studies
RFT,, LFT, ,Electrolytes
Serology :HIV, hepatitis B, hepatitis C, herpes If no sibling match, perform Bone marrow aspiration and
simplex, varicella, and cytomegalovirus; MUD (Matched unrelated biopsy with MRD to look for
Urine analysis; donor) search in stem cell remission
Blood grouping and Rh typing; registries
Pregnancy test in females
Chest radiograph, If no MSD or MUD, plan HLA
Electrocardiogram, Echocardiogram typing of parents will be
Pulmonary function test performed for Haplo match in
Dental fitness High Risk AML

PATIENT DONOR
Conditioning regimen (Myeloablative regimen) PBSC stimulation
Inj Fludarabine 40 mg/m2/day x 4 days GCSF based stimulation +/- Plerixafor.
Inj Busulfan 3.2 mg/Kg/day x 4 days
Inj Ra bbit ATG 1.5 mg/Kg
PBSC collection
Collection of stem cell via apheresis.
Stem cell infusion Target stem cell dose:
●≥3 x 10 6 CD34+ cells/kg

GVHD Prophylaxis
Stem cells from
Cyclosporine
MUD donor
Inj Methotrexate

Blood component support

Measures to prevent Infection
Treatment of complications (if any)
To monitor for CMV Reactivation

Follow up and vaccination

4 MMC PRACTICE PROTOCOLS

4. APLASTIC ANAEMIA – ADULTS - HSCT

TRANPLANT ELIGIBILITY CRITERIA DONOR SELECTION PRETRANSPLANT WORKUP

•Matched sibling donor •Counselling

•Matched unrelated donor • CBC,RFT,LFT,ELECTROLYTES,
•Haploidencal donor THYROID FUNCTION TEST,FASTING
LIPID PROFILE,RBS
•Age less than 40 years as first line •VIRAL SEROLOGY-
•Donor work up for related donors is
therapy HbsAg,HCV,HIV,CMV IgG, EBV IgG,
done in the instuon
Parvovirus
•Counselling
•Urine pregnancy test
•CBC,RFT,LFT,ELECTROLYTES,
•Stress cytogenecs
THYROID FUNCTION TEST,FASTING
LIPID PROFILE,RBS •Molecular gene panel to rule out
IBMFS
•VIRAL SEROLOGY-
HbsAg,HCV,HIV,CMV IgG, EBV IgG, •Blood grouping and typing
•Elderly without comorbies in case of
Parvovirus •Ultrasound abdomen and pelvis
relapse or refractory to
immunosuppressive therapy •Urine pregnancy test •Chest X-ray PA view
•Chest X-ray PA view •ECG,ECHO
•ECG,ECHO •FITTNESS- Cardiology, Pulmonology,
•FITTNESS- Cardiology, Pulmonology, Dental, General physician
Dental, General physician •Serum Ferrin, DCT
•Vascular access - PICC line
•Unrelated donor work up for
unrelated donor is done by the
registry and MUD product received
with or without cryopreservaon

CONDITIONING

STEM CELL COLLECTION

Aer 5 days of GCSF +/-
Plerixafor

GVHD PERIPHERAL
LESS THAN 40 YEARS
MORE THAN 40 YEARS OR WITH
COMORBIDITIES
PROPHYLAXIS BLOOD STEM
CELL

CYCLOSPORINE
Day -1 onwards BONEMARROW
REDUCED INTENSITY
HARVEST
MYELOABLATIVE REGIMEN
CONDITIONING
* Fludarabine 160 mg/m2
* Fludarabine 160 mg/m2
*Cyclophosphamide 120 mg/kg SHORT COURSE
*Cyclophosphamide 60 mg/kg METHOTREXATE
*Rabbit ATG (thymoglobulin)
*Rabbit ATG (thymoglobulin) Days 1,3,6,11with folate
rescue 24 hours later
Bone Marrow Transplant 5

5. MULTIPLE MYELOMA - HSCT

Transplant eligible patients with Counseling for

Multiple Myeloma after 3-6 cycles Autologous HSCT
of VRd/VTd.

Initial Assessment
Laboratory Evaluation: Disease-specific restaging
History &Physical  Complete blood count with differential; studies
Examination  RFT,LFT,Electrolytes, Calcium SPEP, Immunofixation
 Serology :HIV, hepatitis B, hepatitis C, electrophoresis, Free light chain
Comorbid illnesses herpes simplex, varicella, and assay
Current and prior infections cytomegalovirus;
Drug allergies,  Urine for micro- and macro-analysis; Bone marrow aspiration and
Alcohol and drug use disorder,  ABO typing; biopsy
Psychological history  Pregnancy test
ECOG performance status  Chest radiograph, Whole Body PET CT
 Electrocardiogram, Echocardiogram
 Pulmonary function test

Fitness for procedure PB SC stimulation

1.Cardiology GCSF based simulation +/- Plerixafor.
2.Nephrology (In cases with renal impairment)
3. Respiratory medicine
4. General medicine
5. Dental
PB SC collection
Collection of stem cell via apheresis.
Target stem cell dose:
Processing and storage of stem cells ●≥3 x 10 6 CD34+ cells/kg
●2 x 10 6 CD34+ cells/kg (Minimum)
Non-cryopreserved, refrigerated PBPCs.
or
Cryopreserved in 5 percent dimethylsulfoxide to be
thawed at the bedside at the time of infusion Conditioning regimen
Melphalan at a dose of 200
mg/m2 (Mel200), with dose reductions
based on age and kidney function.

Standard Risk High Risk

Maintenance with Lenalidomide Maintenance with Bortezomib and
lenalidomide

RFT: Renal function test, SPEP: Serum protein electrophoresis, FLC:Free light chain assay, PET:Positron Emission Tomography, ECOG:
Eastern Cooperative Oncology Group,HSCT: Hematopoietic stem cell transplant, VRd: Boretezomib , Lenalidomide , Dexamethasone , VTd:
Bortezomib , Thalidomide , Dexamethasone, GCSF:Granulocyte Colony Stimulating Factor,PBPC:Peripheral blood progenitor cells

Reference: 1.Rajkumar SV, Kumar S. Multiple myeloma: diagnosis and treatment. InMayo Clinic Proceedings 2016 Jan 1 (Vol. 91, No. 1, pp.
101-119).Elsevier.
2. Kumar S, Rajkumar SV. Multiple myeloma: Use of hematopoietic cell transplantation– UpToDate.
Cardiology

MANAGEMENT PROTOCOL FOR STEMI

STEMI -DIAGNOSED

●
●
● Apply oxygen for SaO2 < 90%
●
●
● Subligual ISDN 5mg for chest pain
(May repeat every 5 minutes for a maximum of 3 tablets)
●

TW <12 HOURS TW 12 - 24 HOURS

TW 24 – 48 HOURS

ELIGIBLE FOR PRIMARY PCI

PRIMARY PCI IF ELIGIBLE ELECTIVE CAG
YES N

PRIMARY CAG FIBRINOLYSIS

● Streptokinase 1.5 million units over 30-60 min i.v

CRITICAL SVD DVD TVD
● Tenecteplase single i.v bolus

- 30 mg if < 60 kg
PRIMARY PCI TO - 35 mg if 60 to <70 kg
PRIMARY PCI POBA TO CULPRIT ARTERY
CULPRIT ARTERY - 40 mg if 70 to <80 kg
- 45mg if 80 to <90 kg
- 50mg if > 90 kg
STAGED PCI TO
CABG It is recommended to reduce to half dose in patient
NON CULPRIT
>75 years
ARTERY

FAILED SUCCESSFUL
THROMBOLYSIS THROMBOLYSIS

RESCUE PCI PHARMACOINVASIVE

PCI

6
Cardiology 7

MANAGEMENT PROTOCOL FOR NSTEMI

FIRST MEDICAL CONTACT – ACS/ NSTEMI

VERY HIGH RISK HIGH RISK

1. ESTABLISHED NSTEMI.
1. CARDIOGENIC SHOCK
2. DYNAMIC NEW ST CHANGES
2. REFRACTORY CHEST PAIN
3. RESUSCITATED CARDIAC
3. VT/ VF
ARREST WITHOUT STE/
4. MECHANICAL
SHOCK
COMPLICATIONS OF ACS
4. GRACE SCORE > 140
5. ADHF
6. ST DEPRESSION > 1mm in 6
leads with STE IN avR/ V1

EARLY INVASIVE <24 HOURS

IMMEDIATE INVASIVE < 2 HOURS
8 MMC PRACTICE PROTOCOLS

PHARMACOTHERAPY FOR ACS

● Supplemental oxygen If hypoxemia SpO2 < 90% or respiratory distress. Routine Oxygen
supplementation not recommended

Anti Anginal drugs:

1. Nitrates-Sublingual Isosorbide Dinitrate 5mg every 5 minutes for up to three doses

● IV nitroglycerine for persistent angina, heart failure or hypertension
● Start with 5 10 mcg/min with SBP ≥ 90mm Hg and up titrate to 200mcg/min
● Avoid use of nitrates in patients on Phosphodiesterase inhibitor
2. Beta blockers
● Started orally within 24hours
● Contraindicated in patients with PR interval > 240msec, 2nd or 3rd degree heart block,
active asthma, reactive airway disease, signs of heart failure, cardiogenic shock

Analgesics:

● Morphine 1 to 5mg IV
● Hypotension and respiratory depression should be watched for

Anti platelet therapy:

● Aspirin loading dose 300mg of chewable/crushed aspirin followed by maintenance dose of

75mg OD
● Clopidogrel loading dose 300mg followed by maintenance dose of 75mg OD

Anticoagulant therapy:

● Unfractionated heparin (60U/kg bolus and 12U/kg/hr infusion or 5000U IV QID)

● Enoxaparin 1mg/kg every 12hours ( in patients with eGFR < 30ml/min dose is reduced
to OD)
● Lipid lowering therapy: Atorvastatin 80mg should be initiated and continue
● Thrombolytic therapy
1. Inj. Streptokinase 1.5 million IU iv over 1 hour
2. Inj. Tenecteplace single iv bolus. (35mg if wt < 70kg ; 45mg if wt <90kg
Cardiology 9

MANAGEMENT PROTOCOL FOR ACUTE DECOMPENSATED HEART FAILURE

Patient with acute heart failure

Bedside assessment to identify hemodynamic profiles

Presence of congestion?
YES NO

“Wet” patient “Dry” patient

YES DRY ADJUST ORAL

Adequate peripheral WARM THERAPY

perfusion? NO
YES DRY COLD
FLUID
Hypoperfused CHALLENGE,
,hypovolemic INOTROPES
Wet and Warm
(Typically elevated NO
or normal SBP)
WET &COLD
SBP<90 mm Hg

YES NO

DIURETICS ● INOTROPES VASODILATORS

● VASOPRESSORS
VASODILATORS (REFRACTORY CASES) DIURETICS
DIURETICS(WHEN
INOTROPES
PERFUSION (REFRACTORY
IMPROVES)
CASES)
10 MMC PRACTICE PROTOCOLS

INTRODUCTION:

Pulmonary Embolism(PE) is globally the third most frequent acute cardiovascular syndrome
behind myocardial infarction and stroke. Major trauma, surgery, lower-limb fractures,joint replace-
ments and spinal cord injury are strong provoking factors for venous thromboembolism.

SYMPTOMS:

PE is suspected in a patient with dyspnoea out of proportion to lung signs, chest pain, pre- syn-
cope, syncope or haemoptysis.

INVESTIGATIONS:

ECG: SINUS TACHYCARDIA, RBBB, S1Q3T3 pattern.

ECHO
CTPA
COMPRESSION USG/DOPPLER: To rule out DVT

Suspected PE in a paent without haemodynamic instability a

Assess clinical probability of PE

Clinical judgement or predicon rule b

Low or intermediate clinical probability, High clinical probability

or PE unlikely or PE likely

D-dimer test

Negave Posive

CTPA CTPA

No PE PE confirmedd No PE PE confirmedd

No treatment c Treatmentc No treatment c Treatmentc

or invesgate
furthere
Cardiology 11

ALGORITHM FOR MANA GEMENT OF PULMONARY EMBOLISM

NORMOTENSIVE PESI CLASS III/IV HYPOTENSION

S-PESI >=1 (SBP <90 mmHg for >= 15
NORMAL BIOMARKERS ECHO EVIDENCE OF RV mins)(HEMODYNAMIC
DYDFUNCTION UNSTABLE)
LOW RISK PESI CLASS I, II CARDIAC BIOMARKERS THROMBUS IN TRANSIT
SIMPLIFIED PESI SCORE <1 SYNCOPE
CARDIAC ARREST

LOW RISK PE INTERMEDIATE RISK PE HIGH RISK PE

INTERMEDIATE LOW RISK INTERMEDIATE HIGH RISK PE

RV DYSFUNCTION OR TROPONIN (+)

ELEVATED TROPONIN OR 1.MECHANICAL
RV DYSFUNCTION +
NEITHER SUPPORT TO ALLOW
STABILITY FOR
ANTICOAGULATION THROMBOLYSIS
ANTICOAGULATION:
2.CATHETER
1.HEPARIN ANTICOAGULATION DIRECTED THERAPY
IF CLINICAL WORSENING
2.DOAC 3.SURGICAL
1. SYSTEMIC THROMBO LYSIS EMBOLECTOMY
3.CANDIDATES FOR
EARLY DISCHARGE 2.CATHETER DIRECTED
THERAPY

3.SURGICAL EMBOLECTOMY

ANTICOAGULATION:

1. STREPTOKINASE: 2.5 LAKHS UNITS IV as loading dose over 30 minutes, followed by 1 lakh IU/hour 12 -24 hours
Accelerated Regimen: 1.5 million units over 2 hours
2. TENECTEPLASE: 0.5 mg/kg over 24 hours
Accelerated Regimen – 0.5 mg/kg (half dose bolus, half dose infusion)

3. Inj. HEPARIN 80U/kg iv bolus followed by 18 U / kg/hr for 24 hours f/b VKA (INR 2-3)
4. T.Rivaroxaban (15 mg twice daily for 3 weeks, follo wed by 20 mg once daily for 3-6months)
5. T.Apixaban (at a dose of 10 mg twice daily for 7 days, followed by 5 mg twice daily for 6 months
12 MMC PRACTICE PROTOCOLS

MANAGEMENT PROTOCOL FOR COMPELTE HEART BLOCK

COMPLETE HEART BLOCK

History, vital signs, physical examination

Assess for and treat reversible causes

(Drugs, Hyperkalemia, Acidosis, Myxedema, Lyme’s disease)

No
Moderate or severe symptoms1
Evaluate
Yes Highrisk features

PPI
ATROPINE ( class IIa ) 2
0.5-1.0 mg every 3-5 min , max 3 mg

IWMI (nodal block)-

Narrow QRS escape rhythm
● Symptomatic hypotension, with
● HR<50/min (or) PVC,HF,BBB Yes
MI with block AWMI (infranodal block)-
IV ATROPINE (<6 Hrs of MI) Wide QRS escape rhythm
IV AMINOPHYLLINE (class IIb ) 250 mg IV bolus

Target HR >60 /min Yes

No
TPI

Persistent symptoms after therapy

(or) Degenerative disease
Haemodynamically unstable
Yes

IV ISOPRENALINE (class IIb) 1-20 mcg/min

Oral T.ORCIPRENALINE 10 mg qid
2 mg in 500 ml NS , start @ 15 drops/min = 4 mcg/min
if no SA attacks for 48 hours
TPI

TPI/PPI

1
Symptomatic bradycardia - Bradycardia directly responsible for symptoms of syncope, dizziness, heart failure, confusional states
due to cerebral hypoperfusion.
2
Avoid Post-transplant , Wide QRS (>120 ms) escape rhythm.
Dermatology

Algorithmic Approach to Bullous Pemphigoid

Assessment-Nikolsky sign,Bulla spread sign,Tzanck smear,Biopsy ,Immunofluorescence

Localised Generalized

Admission
Saline /KMno4 compresses

Topical potent or Investigations:CBC,ESR,RFT,LFT,S Electrolytes,HBsAg,Anti HCV,VCTC,VDRL,CXR,Stool

superpotent corticosteroids Occult Blood ,CXR,ECG,USG abd&pelvis , Culture & Sensitivity (pus,blood,urine)
except on face and
flexures(mild potent
steroids)
Saline /KMno4 compresses
Topical antibiotics
Topical potent or superpotent corticosteroids except on face
Oral antibiotics and flexures(mild potent steroids)
Antihistamines Topical antibiotics

Oral antibiotics
Antihistamines

Inj.Dexamethasone 0.5-1 mg/kg/day

If improving, maintain on

Steroid sparing agents li

Methotrexate Dapsone
Azathioprine
or MMF
Doxycycline and
Niacinamide

13
14 MMC PRACTICE PROTOCOLS

Algorithmic Approach to PEMPHIGUS

PEMPHIGUS

ADMISSION

ASSESMENT: Complete Blood Count, Liver Function Test,

Renal Function Test, Electrolytes, Lipid Profile, Urine
routine, Nikolskiy sign and Bulla spreading sign

INVESTIGATION: Tzanck, Biopsy, D irect Immunofluorescence,

ECG, Chest X Ray, Blood Culture, Pus Culture, Urine Culture

TREATMENT :
• Saline/Potassium permanganate compresses
• Topi cal Antibiotic (2% Mupirocin cream/ Fusidic acid cream over raw areas
• Topical corticosteroid (0.1% B etamethasone) over non erosive lesion
• IV Antibiotic as per c ulture report
• Triamcinalone acetonide gel for oral lesions

• Methyl Prednisolone Pulse 1 gram

• Systemic steroid- Inj. or
Dexamethasone 1mg/kg/day • Dexamethasone(100mg) and
• ( taper on improvement) C yclophosphamide pulse (500mg)
Add steroid sparing agents on D ay1 and
• Cyclophosphamide (1- Dexamethasone(100mg) on the
3mg/kg/day) or next 2 days
• Azathioprine (2-3 mg/kg/day) • Dexamethasone(100mg) and
or Azathioprine (oral 50 – 100 mg) on
• Mycophenolate mofetil (1-3 Day1 and Dexamethasone(100mg)
mg/kg/day) on thenext 2days

Workup for Injection IV Rituximab with USG abdomen and KUB, Hepatitis B & C Viral Markers,
ICTC, VDRL, Fitness from Hepatology, Cardiology and Thoracic medicine.
Hepatitis B Vaccination to be done

Inj. Rituximab 1gm iv infusion two weeks apart and a booster dose after 6 months

Intravenous Immunoglobulin 2g/kg split over 3-5 days

No improvement or Resistant -------- → Plasmapheresis

Dermatology 15

Algorithmic Approach to Psoriasis

Assessment –
Involvement -% Body Surface Area (BSA)

MILD
MODERATE(3-10%) SEVERE(>10%)
(<3% BSA)

• Emollients Emollients, topical steroids Emollients, topical steroids

• Topical corticosteroids + Nb-UVB (flat lesions) / + Oral Methotrexate
• Vitamin D analogues PUVA (thick plaques)
(for maintenance) No response
Biologicals:

Inj.Etanercept 50mg weekly

Improvement- vitamin D Noimprovement- for 24 weeks
analogues for maintenance Oral Methotrexate
Inj.Secukinumab 300mg SC
once in a week for 5 weeks
followed by monthly doses
If joint symptoms present, refer to
Inj.Infliximab 5mg/kg IV for
Rheumatologist
0,2 & 6 weeks followed by
SPECIAL SITUATIONS: infusions every 6-8 weeks

ERYTHRODERMIC PSORIASIS: PUSTULAR PSORIASIS:

 Admit the patient, vitals LOCALISED: GENERALIZED:

monitoring, thermoregulation,
 Topical corticosteroids  Admit the patient
fluid and electrolyte balance
 Improving - reduce potency of  Systemic steroids plus
 Systemic steroids (to taper
topical steroids & maintain  Cyclosporine (or)
after improvement) plus
with Vitamin D analogues Methotrexate (or)
 Cyclosporine (or)
 Not improving -add Oral Biologicals
Methotrexate (or)
Methotrexate or Acitretin
 Biologicals

INVESTIGATIONS FOR PSORIASIS

1. Base line and for Drug monitoring - CBC, ESR, Serum lipids, LFT, RFT, Chest X ray, Serum electrolytes, ECG,
ECHO, USG abdomen
2. To find triggering factors and co-morbidities - ENT evaluation, Dental evaluation, Serum uric acid,HIV, Anti-
HCV, HBsAg, RPR, Mantoux, Pregnancy test (for females in reproductive age group)
16 MMC PRACTICE PROTOCOLS

Algorithmic Approach to Steven Johnson

Syndrome /Toxic Epidermal Necrolysis
Initial assessment for drug or viral etiology; To rule out sepsis;
IV access, body surface area and mucosa involvement. Stabilize
circulation and monitor urine output

Monitoring pulse rate, blood pressure, respiratory rate, fluid

intake and urine output, Pus, blood and urine culture and
sensitivity

Prompt withdrawal of drug **Assess SCO RTEN

SUPPORTIVE THERAPY INVESTIGATIONS SPECIFIC THERAPIES

• Thermoregulation • Hemogram • Corticosteroids (1mg/kg)
• Monitoring vital signs • Blood g lucose • Cyclosporine short course
• Saline compresses • Liver and Renal function
• IVIG
• Fluid and electrolyte tests
• Etanercept
balance • Serum electrolytes
• Topi cal /systemic • Urine routine and • Cyclophosphamide
antibiotics microscopy • N-acetyl cysteine
• Oral care • Blood culture • Infliximab
• Ophthalmic care • Skin swab culture • Plasmapheresis
• Respiratory care
• Antacids, analgesics
• Psychological support Special Situation

Children HIV
Pregnancy
• Early and short course • Low dose IVIG
• Avoid steroid in first trimester
of IV corticosteroids (0.2-0.5 mg/kg)
• IVIG : Safe and effective
• Low dose IVIG
• Cyclosporine : Second line
(0.2-.05 mg/kg)

• Management of patients of SJS/TEN may preferably be carried out in an intensive care setting with maintenance of sterile
atmosphere with a multidisciplinary approach involving dermatologist, physician/ pediatrician, Ophthalmologist,
respiratory physician, intensivist, dietician and any other specialist as per need of the case.

**SCORTEN Parameters Score SCORTEN Score Predicted mortality (%)

Age > 40 years 1 0–1 3.2

Malignancy 1 2 12.1
Tachycardia (>120/min) 1 3 35.8
Initial surface of epidermal detachment > 10% 1 4 58.3
Serum urea > 10 mmol/l 1 >5 90
Serum glucose > 14 mmol/l 1
Bicarbonate > 20 mmol/l 1
Dermatology 17

Algorithmic Approach to Urticaria

Chronic urticaria ( > 6 weeks)

INVESTIGATIONS:
Acute urticaria : (< 6 weeks) H1 Antihistamine responsive
CBC , Absolute Eosinophil count, ESR , Liver
CBC, ESR, LFT, Urine analysis, stool for ova ,cyst function tests,ANA , RF, Stool for ova , cyst , &
To rule out Infection: parasites.
Throat swab if pharyngeal symptoms. Other investigations as per clinical presentation
Other appropriate samples for bacterial or viral infection Thyroid autoantibodies
Consider hepatitisA, B, C, infectious mononucleosis Thyroid function tests
-Drugs: Withdrawal of suspected drugs. H1 Antihistamine nonresponsive
Thyroid function tests -Chest X -ray ( if lymphoma suspected)
-Thyroid autoantibodies
-Thyroid function tests
-Additional testsdependingupon clinical
presentation:
-C4 complement( angioedemawithout wheals)
organ specific autoantibodies ( if associated
autoimmunedisease possible)
Stool for ova , cyst , & parasites.

iggers

NON DRUG THERAPY PHARMACOLOGIC THERAPY

COUNSELLING Second H1

If symptoms persist for

Inducible
1 to 2 week

-
to 4 fold or
-Avoid aspirin , NSAIDS, codeine,morphine, ACEi,
added spicy foods. -
-
-Add H2 antagonist
-Autologous serum therapy

Short course(5-7 days) of

n
case of angioedema Omalizumab/Cyclosporine/Methotrexate,
Diabetology

MANAGEMENTOFT1DM
● Insulin is the only drug of choice for the management of T1DM, anditis required for
survival.
● In people with T1DM who are no longer producing endogenous insulin, the
administration of exogenous insulin is required to try, as far as possible, to mimic
physiological Insulin release using a combination of both rapid acting and basal insulin.
● In general, individuals with Type 1 diabetes require 50% of their daily insulin as basal
and 50% as prandial, but this is dependent on a number of factors, including the type and
amount of carbohydrate in the meals.
● Total daily insulin requirements can be estimated based on weight, with typical doses
ranging from 0.4 to 1.0 units/kg/day. Higher amounts are usually required during puberty,
pregnancy, and medical illness.
● Tight control can be achieved better by means of basal bolus insulin therapy than premixed
insulin administration.
● Intensified insulin therapy consists of multiple daily injections of mealtime insulin to
cover the hyperglycemia after meals and basal insulin to overcome the post absorptive
hyperglycemia.
● Insulin replacement regimens typically consist of basal insulin, mealtime insulin, and
correction insulin.
● Basal insulin includes NPH insulin, long-acting insulin analogs, and continuous delivery
of rapid acting insulin via an Insulin pump. Basal Insulin analogs have a longer duration
of action with flatter, more constant plasma concentrations and activity profiles than NPH
insulin.
● Rapid-acting analogs (RAA) have a quicker on set and peak and a shorter duration of
action than regular human insulin.
Portable pumps provide a continuous subcutaneous insulinin fusion via athin needle that is peri-
odically changed. These systems deliver insulin at a set rate determined by the physician, guided
by periodic monitoring of blood glucose.

18
Diabetology 19

MANAGEMENT OF T2DM
● Metformin remains the first drug of choiceinun complicated T2DM patients due to its
efficacy as well as properties such as weight loss, low cost, and no major adverse effects like
hypoglycemia.
● In the presence of heart failure or CKD, the present guidelines recommend the use of
SGLT-2 inhibitors for reducing heart failure and CKD progression. In the presence
of established ASCVD, aGLP-1-RAorSGLT- 2 inhibitor with CVD benefit is
recommended.
● Though international guidelines suggest SGLT-2 inhibitors, GLP 1 analogues as the first
line drug, this decision has to be weighed forits cost and access, risk of adverse effects.
● Inpatients without established ASCVD or CKD, the second-line drugs can be DPP-4
inhibitors, GLP-RA, SGLT-2 inhibitors, TZD, or sulfonylureas.
● GLP-1 receptor agonist usage in Indiais limited by its cost and injectable form.
● SGLT-2 inhibitors are potent drugs that reduce weight and can be used in obese patients.
These drugs are now widely used by practitioners, as recommended by several guidelines.
The limiting factors are cost and frequent adverse effects like urogential infections,
euglycemic ketosis,and electrolyte abnormalities.
● Considering that many Indian patients do not have medical insurance and treatment needs
to be continued life long, the cost of therapy should be borne in mind when planning
treatment.
● Sulfonylureas can be combined with metformin, considering their additive effect and lower
cost. Glitazones,DPP-4inhibitors,andSGLT-2inhibitors can be considered when goals
aren’t achieved.
20 MMC PRACTICE PROTOCOLS

MANAGEMENT OF GLUCOSE IN TOLERANCE IN PREGNANCY

Medical nutrition therapy

● Insulin is the drug of choice.

● Metformin should not be used as a first-line agent, as it crosses the placenta, it can be
added to control blood sugars during the second and third trimesters in GDM.

CHOICE OF INSULINS

● Prandial insulin: – Regular Insulin, Aspart, Lispro, Fiasp

● Basal insulins - NPH, Detemir
● Glargine is not FDA-approved for use in pregnancy. However, it can be continued for
patients with Diabetes who become pregnant.

POSTPARTUM CARE

Insulin resistance decreases dramatically immediately postpartum and Insulin requirements need
to be evaluated and adjusted for the initial few days postpartum.

● Screen individuals with a recent history of gestational diabetes mellitus at 4–12 weeks
postpartum, using the 75-g oral glucose tolerance test
● Individuals with a history of gestational diabetes mellitus should have lif elong screening
for the development of type2 diabetes or prediabetes every 1–3 years.
Diabetology 21

DIABETICKETOACIDOSIS

Reference: ITDM 4th edition

22 MMC PRACTICE PROTOCOLS

HYPOGLYCEMIA

Treatment

● Mild to moderate symptomatic hypoglycemia can be effectively treated with a reasonable

dose of 20g of carbohydrate containing juice, soft drinks, candy, or other snacks or meals.
● Repeat the blood glucose level by blood sample/CBG within 15 to 20 minutes.
● Parenteral treatment is required when the patient is unable to take carbohydrates orally.
○ IVF 25% dextrose given Intravenously.
○ Glucagon 1.0mg in adults given S.C or I.V or intramuscularly, it is often used.
○ 4th hourly monitoring of blood glucose is needed if long acting sulfonylurea or Insulin
is used.
○ Continuous dextrose infusion if needed.
Endocrinology
HYPERPROLACTINEMIA – APPROACH

DOPAMINE AGONISTS USED

Bromocripne

2.5 – 15 mg / day, in 2-3 divided doses

Cabergoline

0.25 – 1 mg / week, 2 doses / week

23
24 MMC PRACTICE PROTOCOLS

HYPOCALCEMIA–APPROACH

MANAGEMENT OF HYPOCALCEMIA

SEVERE HYPOCALCEMIA:

 2g IV calcium gluconate in 100 ml NS over 1 hour

 If symptoms doesn’t resolve, 5g in 500 ml NS @ 50 cc/hr
 Start T. Calcitriol 0.5 µg PO twice a day, increase to 4 times a day

Once symptoms improve, switch to T. Calcium carbonate or citrate – 500 mg elemental calcium, along with
calcitriol supplementation

In case of vitamin D deficiency

 Supplement 60,000 IU / week * 5 doses

In case of hypomagnesemia,

 1.3 – 2 mg/dl : T. Magnesiu m oxide 400 mg BD

 < 1.3 mg/dl : IV Magnesium sulphate 2 – 3 g

MILD HYPOCALCEMIA:

 Managed with oral calciumSHORT STATURE- APPROACH

supplements
Endocrinology 25

HYPOTHYROIDISM – APPROACH

PEDIATRIC LT4 DOSAGE PREGNANCY TSH REFERENCE RANGE

Neonate 10 – 15 μg / kg I Trimester 0.1 – 2.5 μIU/L
< 1 year 6 – 10 μg / kg II Trimester 0.2 – 3 μIU/L
1 – 5 years 4 – 6 μg / kg III Trimester 0.3 – 3 μIU/L
5 – 12 years 3 – 5 μg / kg
12 – 18 years 2 – 3 μg / kg
26 MMC PRACTICE PROTOCOLS

MICROPENIS – APPROACH

Stretched penile length < - 2.5 SD (cut off) is defined as micropenis.

(Adult >12 years: cut off - 9.3 cm)

Buried penis is the most common cause of micropenis.

Thus ensure correct measurement of penile length from base of pubis to tip of glans penis (exclud-
ing foreskin) before proceeding with evaluation.

Management :

1. Growth hormone therapy if GH deficient

2. Inj HCG therapy for Kallman syndrome / Idiopathic Hypogonadotropic Hypogonadism
3. Inj Testosterone therapy for testicular agenesis / dysgenesis / atrophy
Endocrinology 27

SHORT STATURE – APPROACH

GH DEFICIENCY EVALUATION IF

1. Height >3 SD below the mean for

age and gender
2. Height <−2 SD with a height
velocity <−1 SD over a period of 12
months
3. Height velocity SDS <−2 SD over
a period of 12 months
4. Predicted adult height >1.5 SD
below the target height
5. Growth curve crosses downward
by ≥1 centile curve in the growth
chart over a period of 12 months

CA – Chronological Age
BA – Bone Age
HA – Height Age
WA – Weight Age
FSS – Familial Short Stature
CDGP – Constitutional Delay in
Growth & Puberty

Replace all deficient hormones

General Medicine
BLOOD PRESSURE ≥180/120 MMHG

WITHOUT TARGET ORGAN WITH TARGET ORGAN

DAMAGE DAMAGE

HYPERTENSIVE URGENCY HYPERTENSIVE

EMERGENCY

Treat with oral anti

hypertensive drugs.

Aim to achieve Target BP in

days to weeks.

28
General Medicine 29

HYPERTENSIVE EMERGENCY
CONDITION DRUG AND DOSE TARGET
HYPERTENSIVE Inj. Labetalol 50mg iv bolus iv in Reduce 25% MAP
ENCEPHALOPATHY 2 mins. within 2 hours
Repeat every 5 to 10 mins.
Maximum total dose 300mg.
INTRACEREBRAL Inj. Labetalol 50mg iv bolus iv in Target SBP 140 – 180 mmhg
HEMORRHAGE 2 mins.
Repeat every 5 to 10 mins.
Maximum total dose 300mg
ISCHEMIC STROKE Inj. Labetalol 50mg iv bolus iv in Reduce BP only if ≥
2 mins. 220/120 mmhg.
Repeat every 5 to 10 mins. If thrombolysis is planned, BP ≤
Maximum total dose 300mg 185/110 mmhg.
SUB-ARACHNOID T.Nimodipine 60mg orally / ryles Reduce BP only if MAP>130
HEMORRHAGE tube 4th hourly for 21 days.

ACUTE AORTIC Inj. Labetalol 50mg iv bolus iv in 2 Target SBP <120mmhg Pulse rate
SYNDROMES mins. Repeat every 5 to 10 mins. - 60/min
Maximum total dose 300mg.
OR
Inj.Nitroprusside 2 to 4 micro-
gram/kg/min for 10 minutes
ACUTE CORONARY Inj.Nitroglycerin infusion start at Reduce 25% MAP
SYNDROMES 5microgram/min uptitrate every within 2 hours
5 minutes upto maximum of
200microgram/min
LV FAILURE / PULMONARY Inj.Nitroglycerin infusion start at Reduce 25% MAP
EDEMA 5microgram/min uptitrate every within 2 hours
5 minutes upto maximum of
200microgram/min.
+
IV Furosemide 40 to 80 mg bolus
ECLAMPSIA / SEVERE Inj. Labetalol 50mg iv bolus iv in 2 Reduce 25% MAP
PRE-ECLAMPSIA mins. Repeat every 5 to 10 mins. within 2 hours
Maximum total dose 300mg
+
Inj. MgSO4 4gm iv in 15 minutes
1gm/hour infusion for 24 hours
(for seizures)
PHEOCHROMOCYTOMA Inj.Nitroprusside 2 to 4 micro- Reduce 25% MAP
gram/kg/min for 10 minutes within 2 hours
30 MMC PRACTICE PROTOCOLS
General Medicine 31

ORGANOPHOSPHORUS POISONING

A-Left lateral position/Head INTUBATION if

down/Extn of the neck 1.Poor GCS
B-RR>8 or <35/min/O2@60% 2.LIMB/NECK Muscle
C-IV fluids@20ml/hr,SBP>80mmhg Weakness
U.O>30ml/hr 3.Apneic spells
4.PaO2<60mmhg or
Spo2<90%
DECONTAMINATION
Gastric Lavage using Ryle’s tube
Whole body wash

Activated Charcoal @ 1gm/kg

Oral Magnesium sulphate CATHARSIS

30 g orally given

INJ.Atropine 1to 2mg(2-3amp) every

5 mins until Atropinization
Signs of Atropinization
-Clear chest
-Dry axilla
-Pupils no longer pinpoint
-SBP>80/min
-HR>100/min

Maintenance of Atropine INJ Pralidoxime (only for

If signs of atropine toxicity
20% of atropine required organophosphate compounds)
develops Reduce atropine
for atropinization is given NOT FOR CARBAMATES
infusion.
hourly for maintenance Stat-30mg/kg/hr for 30 min
Signs of Atropine Toxicity
Targets Maintenance-8mg/kg/hr for 48 hrs
-Absent Bowel sounds
-HR>90/min
-Fever
-SBP>90mmhg
-Delirium
-Dry axilla
-Clear chest

After 48 hrs gradually taper dose of After 48 hrs reduce Pralidoxime to

Atropine 1gm IV TDS
32 MMC PRACTICE PROTOCOLS
General Medicine 33

S US P E C T S e p s i s i n
1 Warm s hoc k
g
erature
4 he elderly

S C R E E N f o r s e p s is .__
___

A ny 2 lo w in g
1 . Te m pe 8 ° C or < 3 6 ° C
2 . H e a rt rat
at min
3 .RR > \ = 2 0 / m i n
4 . T C < 4 0 0 0 or > 1 2 0 0 0 /uL
P lu s
S e ru m l a c ta te l e ve l > 2 m m o l / L

S C R E E N f o r s e p tic
s ho c k
1 .M A P < 6 5 m m H g
2 . S la c ta te > 4 m m ol/ L

1 h o u r B u n d le
• O b t ain c ult ure
( 2 b lo o d + + /- s p ut um + /- s w ab )
• S t ar t IV ant
• S t ar t IV F - B d c r y s t allo id s at 3 0
m l/k g and c o m p let e w it hin 3 hrs

3 h o u r B u n d le

•R ec h ec k if S . lac tate >2 m m o l /L o r M A P <

6 5 m m H g an d
S T A RT Vas o p res s o rs

6 h o u r B u n d le
• S ta rt In j.H yd roc ortis on e 1 0 0 m g iv b d if M A P < 6 5 m m H g
• T re a t h yp e rg lyc e m ia if R B S > 1 8 0 m g / d L
• T ra n s fu s e P R B C if H b < 7 g / d L
• D V T p rop h yla xis
• B ic a rb on a te in fu s ion if p H < 7
• S tre s s u lc e r p rop h yla xis
• M e c h a n ic a l ve n tila tion for A R D S
Geriatric Medicine

Delirium

34
Geriatric Medicine 35

Falls in older adults

36 MMC PRACTICE PROTOCOLS

FUCTIONAL DECLINE ALGORITHM

Geriatric Medicine 37

Urinary incontinence

Focused history
Assess goals of care
Targeted physical examination
including mobility and cognitive
assessment

Identify and treat reversible

causes

Determine need for caregiver

involvement

Caregiver Independent Caregiver Dependent

Multicomponent atrategy Multicomponent atrategy

Fluid Management Fluid Management
Caffeine Management Caffeine Management
Constipation Management Constipation Management
Pelvic Floor Muscle Exercises 3 Day Trial Prompted Voiding
Bladder Control Strategies Containment Strategies

Treatment effective Treatment effective

Inadequate Inadequate response
Reinforce as necessary Reinforce as
response necessary

Medication options
In Men: Selective alpha blockers and consider 5 alaha
redutase inhibitors
In Men and Women: Bladder relaxants

Inadequate response after Treatment effective

drug titration or
intolerable side effects Continue to monitor

Consider other treatment options or Referral to

Urologist
Percutaneous tibial nerve stimulation
Sacral neuromodulation
Cystoscopic injection of botulinum toxin
In men with BPE: Evaluation for prostate
reduction procedure
Hematology
HEMATOLOGY PROTOCOL

1. THALASSEMIA

Target Group MCV < 80 fl in adults

Suspected anaemic patients
MCH< 27 pg
Antenatal anaemic patients
Microcytic Hypochromic Target cells
Health checkup referrals

Full medical history

Family history Mentzer Mentzer index
Physical examination Index < 13 > 13

Serum Iron Studies

Hb Electrophoresis by Refractory Adequate iron correction

HPLC for 3 months

T DT NTDT Beta thalassemia minor

Moderate microcytic Anemia HbA2 > 3.5%
Severe microcytic anemia;
HbA2 > 3.5% HbF upto 5%
Hepatosplenomegaly
HbF upto 50% asymptomatic
HbA2 > 3.5% ; HbF upto
95%

Initiate regular Transfusion as needed

transfusions Monitor iron stores
Initiate chelation therapy
Monitor iron stores
> 10 transfusions given
Individualize the decision
Ferritin > 1000 ng/L
regarding the following
Cardiac T2 < 20ms No
-MSD
-MUD Yes
-Splenectomy Initiate chelation therapy Monitor
Monitor -transfusion requirement
-transfusion requirement -iron stores
-iron stores
-Transfusion transmitted
Viruses

38
Hematology 39

2. ACUTE LYMPHOBLASTIC LEUKEMIA

HISTORY AND PHYSICAL EXAMINATION

CBC, PERIPHERAL SMEAR, RFT, LFT, S r .ELECTROLYTES, PT/APTT, LDH, S.URIC

A CID, CALCIUM, PHOSPHORUS, X -RAY CHEST, USG ABDOMEN ECHO, C.S.F ANALYSIS

BONE MARROW ASPIRATION, BIOPSY, IMMUNOHISTOCHEMISTRY KARYOTYPING,

FISH for BCR -ABL and MLL G ENE, FLOW CYTOMETRY, HLA TYPING

BMA, BIOPSY & IHC KARYOTYPING STANDARD FLOW CYTOMETRY

>20% LYMPHOBLAST AND HIGH RISK CD 10,CD19,CyCD22,CyCD79a,
CD1 Positive in - B -ALL
CyCD3,TdT&CD7 - T -ALL
CD1a and CD8 Negative and one
Positive myeloid marker- Early T
RISK STRATIFICATION PRECURSOR ALL
HIGH RISK
AGE>35 yrs
Total WBC count->50,000 in B -ALL:
>1,00,000 inT -ALL
Early T PRECURSOR ALL
STANDARD RISK CYTOGENETICS
Hyperploidy,Trisomy 4,10 and 17, t(12:21)
TREATMENT:
POOR RISK CYTOGENETICS
1.Age <45 years: Modified BFM - 95
Hypoploidy, TP53 mutation, KMT2A rearranged, BCR -
protocol.
ABL1 With IKZF1 , Complex Karyotype
2. Age group- 45 years to 65 years-
HyperCVAD - alternate with
Mtx/AraC protocol.
SUPPORTIVE CARE:
3. Age group >65 years and frail
1.Hydration: 2000-3000ml m/2 . Input output charting and constant monitoring patients: Individualised therapy.
4.Ph positive ALL: TKI is added
2. Tumor lysis monitoring especially with elevated WBC counts, renal
along with BFM or HyperCVAD
dysfunction, massive organomegaly and elevated LDH at presentation.
protocol
Hyperkalemia management 5. CD20 positive: Rituximab is
Hyperuricemia management:prevention:T.Allopurinol 100mg TID or Febuxostat added along with BFM or
during first week of induction; treatment:Inj Rasburicase if hyperuricemic, with hyperCVAD protocol
or without renal dysfunction.

3. Pneumocystitis carinii prophylaxis - cotrimoxazole

4.Antifungalprophylaxis antiviral prophylaxis during neutropenic phase.

5. GCSF 300ug S/C can be administered for promoting neutrophil recovery.

40 MMC PRACTICE PROTOCOLS

Acute Myeloid Leukemia

Complete blood count Acute Myeloid leukemia
Peripheral smear
LFT,RFT, LDH, Uric acid, RBS
Peripheral blood or bone marrow
aspirate flowcytometry HLA typing of pt and
Bone marrow aspiration, bone Risk sibling donors
marrow biopsy with karyotyping MUD search

Favourable risk Intermediate Risk Adverse risk

t(8;21)(q22;q22.1)/RUNX1::RUNX1T1 MutatedNPM1 with FLT3 -ITD t(6;9)(p23;q34.1)/DEK::NUP214
inv(16)(p13.1q22) or Wild -type NPM1 with FLT3 -ITD t(v;11q23.3)/KMT2A -rearranged
t(16;16)(p13.1;q22)/CBFB::MYH11 (without adverse-risk genetic lesion) t(9;22)(q34.1;q11.2)/BCR::ABL1
MutatedNPM1 without FLT3 -ITD t(9;11)(p21.3;q23.3)/MLLT3::KMT t(8;16)(p11;p13)/KAT6A::CREBB
bZIP in -framemutatedCEBPA 2A P
Cytogenetic and/or molecular inv(3)(q21.3q26.2) or
abnormalities not classified as t(3;3)(q21.3;q26.2)/GATA2 , MEC
favorable or adverse OM (EVI1 )
t(3q26.2;v)/MECOM (EVI1 )-
rearranged
-5 or del(5q); -7; -17/abn(17p)
Complex karyotype or monosomal
karyotype
MutatedASXL1, BCOR, EZH2,
RUNX1, SF3B1, SRSF2, STAG2,
U2AF1, or ZRSR2
MutatedTP53

Medically unfit
Medically fit ECOG 3
ECOG PS: 0 -2 CCI 3
CCI: 0 -2
Karnofsky PS:
Hypomethylating agents +/-
Induction chemotherapy X 1 -2 cycles Venetoclax
Inj Cytarabine 100 – 200 mg/M2 daily as a Low dose/ Subcutaneous cytarabine
continuous IV infusion x 7 days
Inj Daunorubicin 60-90 mg/M2 Day 1 -3 or To assess BMA for Remission after 1st cycle of
Idarubicin 12mg/M2 Day 1 -3 (IV) induction and 2nd cycle of induction. If in remission
F/B Intermediate dose cytarabine x 4 cycles to proceed with Allogenic HSCT (CR1).
Inj Cytarabine 1.5 gm/M2 IV BD x 3 days If not in remission. Plan FLAG -IDA to get into
To add Midostaurin if FLT3 is positive remission and plan Allogenic HSCT (MSD or MUD
or Haplo)
Hematology 41

4. Aplastic Anemia

Peripheral blood cytopenias

Rule out reactive causes of

cytopenias

- Peripheral blood smear

- Bone marrow evaluation
• Morphology on aspirate
• Flow cytometry of the aspirate
• Conventional cytogenetics
• Molecular gene panel if age less than 40 years

Hypocellularity < 30%

Positive stress
Age less than 40 Stress Karyotyping, IBMFS
cytogenetics
years associated genetic mutations

Fanconi anemia Normal karyotype

without significant Abnormal karyotype with IBFMS
dysplasia dysplasia

Acquired aplastic anemia Hypocellular MDS

Grading of severity
Severe / very severe Nonsevere aplastic Follow up and treat if it
• Nonsevere
aplastic anemia anemia meets severe criteria
• Severe
• Very severe

Transplant
eligible and
donor availability - Immunosuppressive therapy
- Anabolic steroids
Yes No - TPO agonists
- Triple therapy
HSCT - Supportive care
• MSD
• URD *as per ASH Guidelines
• If no response to IST,
can consider
HAPLOIDENTICAL
HSCT
42 MMC PRACTICE PROTOCOLS

5. Multiple Myeloma
Anemia -Normocytic Suspected clonal plasma cell disorder. Monoclonal (M) Protein
Normochromic Complete blood count present on SPEP and /or
C l i ni cal features

Bone pain Peripheral smear (rouleaux formation) Immunofixation or

Elevated creatinine Serum calcium, RFT, LDH,Skeletal survey abnormal FLC ratio with
Fatigue/generalized weakness SPEP / Serum immunofixation increased FLC.
Hypercalcemia electrophoresis/ Free light chain assay (FLC)
Weight loss

Bone marrow plasma cytosis more than 10% or biopsy proven

extramedullary plasmacytoma. *Bone marrow aspiration and
With any of the following present. biopsy with immunophenotyping,
Hemoglobin < 10g/dl. conventional cytogenetics and
Renal insufficiency with creatinine > 2mg/dl FISH
*Serum Albumin, LDH, beta 2
Calcium > 11mg/dl
microglobulin
Bone lesions -One or more osteolytic lesion on skeletal
survey, CT or PET CT

*Bone marrow clonal plasma cells ≥60%

*Serum involved/uninvolved free light chain (FLC) ratio ≥100
Multiple myeloma (provided involved FLC level is ≥100 mg/L)
*More than 1 focal lesion (5 mm or more in size) on magnetic
resonance imaging (MRI)

Transplant eligibility
Age >65years Transplant ineligible
Liver cirrhosis
ECOG performance scale 3 or 4 High Risk Features
NYHA functional status 3 or 4 8 to 12 cycles of VRd or VTd t(14;16)
followed by single agent or dual t(14;20)
drug maintenance. del17p13
t(4;14)
Transplant eligible 1q gain or amplification
RISS stage iii
High Risk
Standard Risk 3 to 6 cycles of DVRd (Preferred) or
3 to 6 cycles of VRd VRd or VTd
or VTd

Autologous HSCT Early Autologous HSCT

Single drug maintenance 2 drug maintenance

(Lenalidomide or Thalidomide) (Bortezomib with lenalidomide or
Thalidomide)

RFT: Renal function test, LDH: Lactate dehydrogenase ,SPEP: Serum protein electrophoresis, FLC:Free light chain assay ,CT :
Computerised tomography, PET:Positron Emission Tomography, ECOG: Eastern Cooperative Oncology Group, NYHA: New York
Heart Associatio n ,HSCT: Hematopoietic stem cell transplant, RISS:Revised International Staging System, VRd: Boretezomib ,
Lenalidomide , Dexamethasone , VTd: Bortezomib , Thalidomide , Dexamethasone.

Reference: 1.Rajkumar SV, Kumar S. Multiple myeloma: diagnosis a nd treatment. InMayo Clinic Proceedings 2016 Jan 1 (Vol. 91, No. 1, pp.
101-119). Elsevier.
2.Rajkumar, S. Vincent, et al. "International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma." The lancet
oncology 15.12 (2014): e538-e548.
Hepatology

ACUTE VIRAL HEPATITIS A AND E MANAGEMENT PROTOCOL

HEPATITIS A MANAGEMENT PROTOCOL

Suspected HAV infecon

History of prodromal symptoms followed by
Fever, malaise, Jaundice
AST, ALT Elevaon > 1000 IU/L

An HAV IgM

POSITIVE NEGATIVE

Consider other cause

Acute hepas A Acute liver failure

Supporve care Plasma Exchange ( Bridge to Liver transplant)

Symptomac management Liver Transplantaon

43
44 MMC PRACTICE PROTOCOLS

HEPATITIS E MANAGEMENT PROTOCOL

Suspected Hepas E infection

Prodromal symptoms followed by

Jaundice, dark urine

AST, ALT Elevaon > 1000 IU/L

Pregnant women with Acute liver Failure

An HEV IgM

Immunocompetent Immunocompromised

IgM Posive IgM Posive IgM Negave

HEV RNA

Acute Hepas E Acute Hepas E Posive

Supporve care Monitoring of HEV RNA for 3 to 6 months

Symptomac management

No HEV RNA HE V RNA-posive

No Improvement HEV clearance Chronic HEV infecon

Acute Liver Failure Reducon of immunosuppression

Plasma Exchange ( Bridge to Liver Transplant) No HE V clearance

Liver Transplantaon 3 months Ribavirin monotherapy given

If no response 6 months Ribavirin given

Hepatology 45

Management algorithm of alcoholic hepatitis

Diagnostic criteria

Biochemical criteria Clinical criteria

● Serum bilirubin level >3 mg/dL. ● Heavy alcohol use (> 40 g/dl in females and >60
g/dl in males for > 6 months)
● H/O Binge drinking of until at least 3 to 4
weeks before the onset of illness. ● Active alcohol use until at least 8 weeks prior to
presentation
● AST > 50 U/L and <400 U/L,
● Recent < 1 month onset or worsening of
● AST:ALT – 2:1
jaundice
● Frequent presence of features of SIRS
● Exclude other confounding factors

SCORING

● Maddrey Discriminant Function Score - 4.6 × (prothrombin time in seconds − control

value) + serum bilirubin
● GAHS Score
● ABIC score
● Lillie score (For treatment response)
 46
DECOMPENSATED LIVER DISEASE WITH ALTERED MENTAL STATUS

–
– –
– –

–
–
MMC PRACTICE PROTOCOLS
 CHRONIC HEPATITIS B - MANAGEMENT PROTOCOL
Hepatology

>20,000 IU/ml

>20,000 IU/ml

>2000 IU/ml

>2000 IU/ml

HBsAg -ve
47
48 MMC PRACTICE PROTOCOLS
Hepatology 49

RECOMMENDED DRUGS FOR THE TREATMENT OF CHB AND THEIR

DOSES IN ADULTS

DRUGS DOSE
1 Tenofovir disoproxil fumarate (TDF) 300 mg once daily
2 Entecavir (adult with compensated liver disease and lamivudine 0.5 mg once daily
naive)
3 Entecavir (adult with decompensated liver disease) 1 mg once daily
4 Tenofovir alafenamide fumarate (TAF) 25 mg once daily
Medical Gastroenterology

Acute Cholangis – Diagnosis and Management Protocol

1. Diagnosis of Acute Cholangis (Tokyo Guidelines)

● Presence of all three diagnostic criteria (A + B + C) - definitely confirms obstructive

cholangitis.
● If one pathological finding from category A and another from categories B or C are
present, then an urgent suspicion of obstructive cholangitis is to be considered.

50
Medical Gastroenterology 51

2. Grading of Severity in Acute Cholangis:

52 MMC PRACTICE PROTOCOLS

3. Treatment of Acute Cholangis

Medical Gastroenterology 53

Chronic Diarrhoea – Diagnosis and Management Protocol

1. Evaluaon of Chronic Osmoc Diarrhoea

2. Evaluaon of Chronic Secretory Diarrhoea

54 MMC PRACTICE PROTOCOLS

3. Evaluaon of Chronic Inflammatory Diarrhoea

4. Evaluaon of Chronic Fay Diarrhoea

Medical Gastroenterology 55

5. Empirical Management of Chronic Diarrhoea

● Empirical antibiotic therapy is less useful.

● Nonspecific antidiarrheal agents – loperamide, octreotide (in carcinoid syndrome, dumping
syndrome, chemotherapy induced diarrhea, AIDS) and clonidine (Diabetic Diarrhea)
● Probiotics - speed the resolution of travelers’ diarrhea, antibiotic-associated diarrhea, and
infantile diarrhea.
● Enkephalinase inhibitor like Racecadotril.
● Bile acid sequestransts like Colesevelam 3 tabs twice daily, Colestipol 4 g one to four times
daily
● Fiber supplements Calcium polycarbophil 5-10 g daily or Psyllium 10-20 g daily
● Therapeutic trials of pancreatic enzyme replacement and conjugated bile acid
supplementation in patients with unexplained steatorrhea can be done.
56 MMC PRACTICE PROTOCOLS

Chronic Pancreas – Diagnosc and Management Protocol

1. DIAGNOSIS OF CHRONIC PANCREATITIS

Not consistent with Chronic Pancreatitis; Search for alternate etiology.

Medical Gastroenterology 57

2. Management of Chronic Pancrea s

Other
58 MMC PRACTICE PROTOCOLS

IBD – Crohn’s Disease Management Protocol (Non-perianal disease)

Non-Perianal Disease

CDAI Score
INDUCTION REGIMEN

Mild-Moderate
Moderate-Severe
Disease (CDAI 150-
Disease (CDAI >=220)
219)

1. Systemic Steroids:
Budesonide 9mg/kg Methyl Prednisolone
for 8 weeks 0.5-0.75mg/kg, max
60mg

Assess Clinical Assess the Clinical

Response Response

If response+, taper by
CDAI Score <150/Fall No Response/Partial
5mg/week in 8-12 Non responder
of 100 points Response
weeks

Initiate Ustekinumab,
Achieve Taper Anti-TNF Agents
Thiopurines/Biologicals Vedolizumab

Infliximab 5mg/kg IV @ 0, 2, 6
weeks, then every 8th week

Note:
Adalimumab 160mg SC stat, 80mg after 2 weeks,
then 40mg SC every 2 weeks
1. Budesonide given for total duration of 8-12
weeks, after that tapering is initiated.
2. Ustekinumab is IL-12/23 inhibitor,
Vedolizumab is anti-Integrin.
Certolizumab 400mg @ 0, 2, 4 weeks,
then at every 4 weeks
Medical Gastroenterology 59

IBD – Crohn’s Disease Management Protocol

(Non Perianal Disease) connued….

Maintenance
Regimen

Response on
Response on
Corticosteroids

Taper Steroids Anti-TNF Agents Ustekinumab/Vedolizumab

Continue the
Maintain on
same long term

Thiopurines- Continue the

Azathioprine same long term
2.5mg/kg

OR Methotrexate
15mg/week
60 MMC praCtiCe protoCoLs

IBD-Ulcerative Colitis Management Protocol

1.Severity of Ulcerative Colitis by Truelove Witts Criteria

2. Ulcerative Colitis Endoscopic Index of Severity (UCEIS):

Medical Gastroenterology 61

3. Management of Mild to Moderate Ulcerative Colitis:

Ref: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Eleventh Edition.
62 MMC PRACTICE PROTOCOLS

4. Management of Severe Ulcerative Colitis:

Ref: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Eleventh Edition.

AZA-Azathioprine, 6-MP-6-mercaptopurine, ASA-aminosalycylates

MediCaL gastroenteroLogy 63

IBD-Ulcerative Colitis Management Protocol

1.Severity of Ulcerative Colitis by Truelove Witts Criteria

2. Ulcerative Colitis Endoscopic Index of Severity (UCEIS):

64 MMC PRACTICE PROTOCOLS

3. Management of Mild to Moderate Ulcerative Colitis:

Ref: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Eleventh Edition.
Medical Gastroenterology 65

4. Management of Severe Ulcerative Colitis:

Ref: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Eleventh Edition.

AZA-Azathioprine, 6-MP-6-mercaptopurine, ASA-aminosalycylates

66 MMC PRACTICE PROTOCOLS

Upper Gastrointestinal Bleeding – Management Protocol

Specific Endoscopic Treatment

Medical Gastroenterology 67

OGD suggestive of
Varices

Esophageal Varices Gastric Varices

Octreotide IV 50ug Bolus followed by

Antibiotics for a week;
50ug/hour infusion for 3-5 days
IV Ceftriaxone 1g Q24H, or
Inj Ciprofloxain 400mg Q12H
Give Vasoactive
Moderate to Large Varices Agents

OGD and EVL every 2 weeks till

Oral Alternatives: Norfloaxacin obliteration
400mg BD; or
Ciprofloxacin 500mg BF

OGD after 1- months

6-12 monthly OGD

Ref:

1.Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Eleventh Edition

2. Laine, Loren et al. “ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.” The American
Journal of Gastroenterology Vol. 116,5 (2021): 899-917. Doi:10.14309/ajg.0000000000001245
Nephrology

Diabetes and chronic kidney disease

Definition:

● Diabetes mellitus is defined by fasting plasma glucose values of ≥ 126 mg/dl, 2-h post-load
plasma glucose ≥200 mg/dl or HbA1c ≥ 6.5%; or a random blood glucose 200 mg/dl in the
presence of signs and symptoms
● CKD is defined as persistently elevated urine albumin excretion (>30 mg/g), persistently
reduced eGFR (<60 ml/min per 1.73 m2), or both, for greater than 3 months

Screening:

● CKD screening should start at diagnosis of type 2 DM; for type 1 DM, screening is
recommended commencing 5 years after diagnosis
● Annual screening- creatinine based eGFR (CKD-EPI), urine albumin excretion (Spot
urine albumin to creatinine ratio), urine for microalbuminuria
● Confirm abnormal tests by repeat investigations over a 3 to 6-month period

Diagnosis:

● CKD in diabetes is presumed to be diabetic kidney disease especially if there is long

standing diabetes and retinopathy
● Kidney biopsy to be considered where there is a high suspicion of alternative diagnosis
● Clues to suggest a probable non-diabetic kidney disease in a diabetic patient:
○ Absence of retinopathy
○ Active urinary sediment – presence of RBCs/RBC casts in urine
○ Rapidly worsening renal function
○ New onset of nephrotic range proteinuria

68
Nephrology 69

Management:

● Holistic approach:
○ Periodic assessment of microvascular and macrovascular systems including fundus
examination, neuropathy evaluation and cardiac assessment with appropriate
management
○ Prompt identification and early treatment of any infectious focus particularly urinary
tract infections owing to increased risk of complicated UTI
● Lifestyle:
○ Cessation of smoking and usage of other tobacco products, reduce second hand smoke
exposure
○ Moderate intensity physical activity for at least 150 minutes per week
○ Weight management
● Nutrition:
○ Diet high in vegetables, fruits, whole grains, fiber, plant-based proteins, unsaturated
fats
○ Avoid processed foods, red meat, refined carbohydrates and sweetened beverages
○ Protein intake 0.8-1 g/kg/day for those not on dialysis; 1-1.2g/kg/day for those on
dialysis
○ Sodium intake <2g/ day (salt intake <5g/day)
● Glycaemic monitoring:
○ Advise self-monitoring of blood glucose
○ HbA1c to be done atleast twice a year, more frequently if target not achieved
○ Individualize HbA1c target (6.5% to 8%)
○ Accuracy and precision of HbA1c measurement declines with advanced CKD (G4–
G5), particularly among patients on dialysis
● Pharmacological management:
○ First line drugs - both Metformin and SGLT2 inhibitors (eGFR >30ml/min/m2)
○ Long acting GLP1 receptor agonists – for those who have not achieved glycaemic
targets despite first line therapy
○ Additional drugs such as sulfonylurea, Insulin to be added guided by patient
preferences, comorbidities, eGFR, and cost
● Renin angiotensin system blockade:
○ ACEi or ARBs to be started in patients with diabetes, albuminuria and/or
hypertension
○ Monitor serum creatinine and potassium 4 weeks after initiation or increase in dose
○ Continue ACEi or ARB therapy unless serum creatinine rises by more than 30%
within 4 weeks following initiation of treatment or an increase in dose
○ Symptomatic hypotension or uncontrolled hyperkalemia despite medical treatment –
consider reducing the dose or discontinuation of ACEi or ARB therapy
70 MMC PRACTICE PROTOCOLS

● SGLT2 inhibitors in patients with diabetes and CKD (if eGFR >20ml/min/m2)
○ High priority - patients with heart failure, severe albuminuria
○ Avoid SGLT2i in those with genital infections, urinary tract infections, DKA, foot
ulcers, peripheral vascular disease
○ Educate patients to withhold drug during fasting, critical illness, surgery (sick day
protocol)
● Consider non-steroidal mineralocorticoid receptor antagonist for patients with diabetes and
persistent albuminuria despite maximal tolerated RAS inhibitor
● Moderate intensity statin for all diabetic patients with CKD (not on dialysis)
● Antiplatelet agents based on ASCVD risk
Nephrology 71

Acute Kidney Injury

Definition and staging:

● AKI is defined as any of the following

○ Increase in serum creatinine by ≥0.3 mg/dL within 48 hours
○ Increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to
have occurred within the prior 7 days
○ Urine volume <0.5 ml/kg/hr for 6 hours
● AKI is staged for severity according to the following criteria

History:

● Clinical presentation – oliguria, pedal oedema, breathlessness

● H/o hypovolemic episodes (diarrhoea, vomiting, hypotension)
● H/o concurrent illness (sepsis, acute coronary syndrome, recent surgery, obstetric
complication)
● H/o nephrotoxic medication (NSAIDs, PPI, aminoglycosides, cisplatin, ARBs, ACEi,
SGLT2i)
● H/o indigenous medication, toxic ingestion, envenomation
● H/o excessive physical exertion

Clinical examination:

● Assessment of volume status – pedal/sacral oedema, JVP, cardiac auscultation, hepatomegaly

● Clues to aetiology – purpura, livedo reticularis, peripheral gangrene, ulcers
● Pallor, icterus
● Fundus examination
● Palpate for overdistended bladder

Investigations:

● Urine routine with microscopy

72 MMC PRACTICE PROTOCOLS

● Complete blood count

● Blood urea, serum creatinine
● Serum sodium, potassium, calcium, phosphorus
● Serum CPK, LDH (if clinical suspicion)
● USG KUB

Management:

● Nutrition
○ Calories: 25-30 kcal/kg/day
○ Carbohydrates: 50-60% of total calorie intake
○ Fat: 20-30% of total calories intake
○ Protein intake: 0.8-1.2g/kg/day (1.5-1.7g/kg/day if on renal replacement therapy)
○ Adjustment factors may be needed based on severity of infection, mode of renal
replacement therapy and need for mechanical ventilation
● Daily assessment of volume status and urine output
○ Fluids as per volume status
○ Furosemide if hypervolemic
● Cessation of offending medication
● Treatment of the underlying cause of AKI
● Await spontaneous resolution while providing supportive care
● Renal replacement therapy (PD/HD/CRRT) if
○ Refractory hyperkalemia
○ Refractory hypervolemia
○ Refractory metabolic acidosis
○ Uremic features (asterixis, uremic gastritis, uremic pericarditis, uremic encephalopathy)
● Renal biopsy may be considered on a case-to-case basis, if non-resolution of AKI after 2
weeks with unclear aetiology
Nephrology 73

Chronic Kidney Disease

Definition:

CKD is defined as abnormalities of kidney structure or function, present for >3 months, with
implications for health.

History:

● H/o pedal oedema, oliguria, exertional dyspnoea

● H/o previous nephritic or nephrotic syndrome
● H/o previous urological procedures, stones
● H/o nephrotoxic medications (analgesics, native medications)
● Family history of CKD
● H/o heat stress
● H/o childhood UTI, nocturia, double voiding

Investigations:

● Urine routine with microscopy

● Urine protein-creatinine ratio
74 MMC PRACTICE PROTOCOLS

● Complete blood count

● Creatinine, electrolytes
● Anemia work-up – ferritin, transferrin saturation
● Mineral bone disease work-up – calcium, phosphorus, alkaline phosphatase, iPTH
● Cardiac evaluation
● Viral markers
● Ultrasound KUB

Management:

● Lifestyle modifications
○ Avoidance of smoking and alcohol
○ Physical exercise and weight reduction
○ Avoidance of all nephrotoxic medication
○ Salt restriction <5 gram/day
○ Fluid restriction if hypervolemic
○ Potassium restriction if hyperkalemic
● Blood pressure control (Stepwise protocol to target SBP < 120mmHg)
○ Initiate with low dose Calcium channel blocker (CCB) + Angiotensin receptor blocker
(ARB)
○ Escalate to high dose CCB + ARB
○ To consider add on maximal tolerated dose of beta-blocker (or) spironolactone (or)
chlorthalidone as indicated
● Glycemic control (Target HbA1C: 6.5-8.0% as per Diabetic Kidney Disease guidelines)
● Anaemia management (Target Hb: 9.5-11 mg/dL)
○ Iron supplementation until TSAT >40% or ferritin >700 ng/mL
○ If not on dialysis - Oral ferrous sulphate 200 mg once a day
○ If on dialysis – IV iron sucrose 200 mg once every two weeks
○ Erythropoetin 4000 U subcutaneously twice a week if anemic despite iron repletion
● Sodium bicarbonate supplementation (1-2mEq/kg/day to target serum bicarbonate around
22-26 mEq/L)
○ Oral diuretics as required, targeting euvolemia
○ Hepatitis B vaccination [40ug x 3-4 doses - 0,1,2/6 months]
○ Preparation for dialysis if eGFR <20 mL/min/1.73 m2 – access creation, counselling
regarding renal replacement therapy, exploring transplant options
Nephrology 75

Glomerular disease
Definition:

● Nephrotic syndrome is the pentad of

○ Proteinuria: adult >3.5 g/day, child >40 mg/hr/m2
○ Hypoalbuminemia <3.5 g/dL
○ Oedema
○ Hypercholesterolemia
○ Lipiduria
● Nephritic syndrome is characterized by glomerular inflammation resulting in a reduction
in GFR, non-nephrotic proteinuria, oedema and hypertension (secondary to sodium
retention), and hematuria with RBC casts

History:

● H/o pedal oedema, facial puffiness, abdominal distension

● H/o haematuria, frothy urine
● H/o new-onset hypertension
● H/o native medication intake
● H/o recent skin infection
● Systemic signs
○ H/o arthralgias, oral ulcers, hair fall, rashes over face or legs (suggestive of SLE)
○ H/o haemoptysis, breathlessness (suggestive of pulmonary-renal syndrome)
○ H/o epistaxis, polyposis, purpuric spots (suggestive of ANCA vasculitis)
○ H/o hard of hearing, visual defects (suggestive of Alports syndrome)

Investigations:

● Urine routine with microscopy for RBC casts

● Urine protein creatinine ratio
● Complete blood count
● Serum creatinine, electrolytes
● Coagulation profile
● Viral markers
● C3, C4, ANA
● Cardiac evaluation
● Ultrasound KUB
● Percutaneous renal biopsy if indicated
76 MMC PRACTICE PROTOCOLS

Management:

● Salt restriction <5 gram/day

● Fluid restriction if hypervolemic
● Diuretics to achieve euvolemia (if refractory, sequential blockade of loop + thiazide + MRA)
● Statin therapy if severe dyslipidemia (exception: first episode of MCD/FSGS)
● Anticoagulation if serum albumin <2.5 g/dL
● Immunosuppression as per renal biopsy, as described in the “Clinical Practice Guidelines,
Institute of Nephrology, Madras Medical College” (2021)
Neurology
GUILLAIN BARRE SYNDROME- PROTOCOL
1. How to diagnose GBS 2. Whento admit to ICU
Check diagnostic criteria1 One or more:
Exclude other causes Rapid progression of weakness
Consider Severe autonomic or swallowing dysfunction
Routine laboratory tests Evolving respiratory distress
Electrophysiological studies EGRIS >4 (at high risk of mechanical
(AIDP/AMAN/AMSAN)2 intervention - 65%)3
CSF examination

3. When to start treatment 4. Treatment options

One or more: Intravenous immunoglobulin (0.4 g/kg daily for
Inability to walk >10m independently (Hughes 5 days)
GBS disability score 3 or more)4 Plasma exchange (200- 250 ml/kg for 5
sessions)
Rapid progression of weakness
Severe autonomic or swallowing dysfunction
Respiratory insufficiency

5. Monitoring 6. Early complications

Regularlyassess: Choking Constipation
Muscle strength (MRC grading scale) Cardiac arrhythmias Corneal ulceration
Infections Dietary deficiency
Respiratory function Deep vein thrombosis Hyponatremia
Swallowing function Pain Pressure ulcers
Delirium Compression
Autonomic function Depression neuropathy
Hughes GBS Disability Scale Score4 Urinary retention Limb contractures

7. Clinical progression 8. Predicting outcome

Treatment related fluctuation: Calculate mEGOS on admission 5
Repeat same treatment 0- 6 = low risk (>90%)
No initialresponse or incompleterecovery: 7- 9 = intermediate risk (70- 85%)
No evidence for repeating treatment 9- 12 = high risk (40- 70%)
Recovery can continue >3 years after onset
Recurrence is rare (2- 5%)

9. Rehabilitation
Start rehabilitation program early
Manage long term complaints: fatigue, pain
and psychological distress

77
78 MMC PRACTICE PROTOCOLS

ACUTE MENINGITIS

Any 2 of the following

1. Fever
2. Headache
A 95% chance of harboring CNS
3. Neck stiffness
infection
4. Altered sensorium

1. Stabilizing hemodynamics
2. Intubation if necessary (GCS<8)
3. Blood glucose

1. Initiate Dexamethasone (0.15

mg/kg/dose) q6hrly lasting for ~ If any of the following are present
4 days
2. Empirical Antibiotics- 1. Immunocompromised state
Ceftriaxone 2 gm Iv BD and Inj. (HIV/transplant/drugs)
Vancomycin 1 gm IV BD 2. History of CNS disease
3. Antiepileptic drugs if seizures+ (stroke/mass lesion)
4. Inj. Acyclovir (10 mg/kg/dose) 3. New onset seizure (last 1 week)
IV TDS if viral prodrome, altered 4. Altered metal state
mentation, focal neurological 5. Focal neurologic deficits
deficits are present 6. Papilledema
5. Inj. Ampicillin 2 gm q4hrly if
age>50 yrs

DON’T DELAY STEROID AND

ANTIBIOTICS FOR THE SAKE OF YES NO
IMAGING OR LP OR BLOOD CULTURES
CT Blood culture and Lumbar
BRAIN Puncture

Contraindication for LP
Normal
1) Mass lesion
2) Obstructive
hydrocephalus

Blood culture and Lumbar Blood culture only

Puncture
Neurology 79

Myasthenic crisis

Without previous MG previously

diagnosis (15-20%) diagnosed

Confirm diagnosis
ICU
RNST

Evaluate bulbar and

Search for precipitating respiratory function
factor RR,SBC,Use of accessory
respiratory muscles,ABG

Specific immunotherapy

Treat the trigger Ventilatory support Plasmapharesis*-

50ml/kg/exchange
Infection NIV-PCO2>45mmHg every other day x 5times
Drug induced-Avoid Intubation & Mechanical IVIg-400mg/kg/d x
macrolides,quinolones, ventilation- 20/30/40 rule 5days
aminoglycosides,beta
FVC<20ml/kg,NIP<30cm Coticosteroids-MPS i.v
blockers and calcium
H2O,PEP<40cmH20 1mg/kg/d
channel blockers
Abrupt drug or prednisolone P.O 60-
withdrawal of 100mg/d
pyridostigmine or Decrease anti
immunomodulators cholinesterase dose-
reintroduce once
weaning is started
80 MMC PRACTICE PROTOCOLS

INTERVENTIONS FOR EMERGENCY DEPARTMENT, IN-PATIENTSETTING,OR

PREHOSPITAL SETTING WITH TRAINED PARAMEDICS-STATUS EPILEPTICUS

(airway, –
neurologic exam)
Time seizure from its onset, monitor vital signs.

Adults : 100 mg thiamine IV then 50 mg D50W IV

Children >2 years : 2 ml / kg D25W IV
Children <2 years : 4 ml / kg D12.5W IV
tes, hematology, toxicology SEIZURES NOT CONTROLLED
.

frequency:
Intramuscular midazolam (10 mg for > 40 kg, 5 mg for 13- 40 kg, single dose, Level A) OR
Intravenous lorazepam (0.1 mg/kg/dose, max: 4mg/dose, may repeat dose once, level A)
OR
Intravenous diazepam (0.15-0.2mg/kg/dose, max:10 mg/dose, may repeat dose
once, Level A) SEIZURES NOT CONTROLLED

Intravenous phenobarbital (15 mg/kg/dose, single dose, Level A) OR

Rectal diazepam (0.2-0.5 mg/kg, max : 20mg/dose, single dose, Level B) OR
Intranasal midazolam (Level B), buccal midazolam (Level B)

There is no evidence based preferred second therapy of choice (Level U):

SEIZURES NOT CONTROLLED
Intravenous fosphenytoin (20 mg PE/kg, max : 1500 mg PE/dose, single dose, Level U) OR
Intravenos valproic acid (40 mg/kg, max: 3000 mg/dose, single dose, Level B) OR

ilable, choose of the following (if not given already):

Intravenous phenobarbital (15 mg/kg, single dose, Level B)

There is no evidence to guide therapy in this place (Level U):

Choices include: repeat second line

REFERENCES

American Academy of Neurology Continuum journal - Epilepsy 2022 Pg 576

Neurology 81

STROKE PROTOCOL

FAST PROTOCOL
F-FACIAL WEAKNESS, A-ARM WEAKNESS, S -SPEECH DIFFICULTY T-TIME TO CALL FOR HELP

ON ARRIVAL TO HOSPITAL

VITAL MONITORING(PULSE , BLOOD PRESSURE, BLOOD

SUGAR (FINGER PRICK METHOD), ROUTINE
INVESTIGATIONS (CBC, PT/INR, UREA, CREATININE

NIHSS SCORE , TIME OF ONSET OF SYMPTOMS

ANTIPLATELETS, STATINS

>4.5
HEMORRHAGE HOURS
AND <6
MEDICAL OR SURGICAL HOURS

CT ANGIOGRAM(BRAIN NIHSS>6OR
WITHIN
4.5 HOURS LARGE VESSEL
OCCLUSION

CONTRAINDIC THROMBECTOMY

tPA

TABLE 1 TABLE 2

RELATIVE CONTRAINDICATION
•ABSOLUTE CONTRAINDICATION • HISTORY OF CHRONIC, SEVERE, POORLY
CONTROLLEDHYPERTENSION
•PRIOR INTRACRANIAL HEMORRHAGE • SEVERE UNCONTROLLED HYPERTENSION ON
•KNOWN STRUCTURAL CEREBRAL PRESENTATION (SBP >180 MMHG OR DBP >110
MMHG)
VASCULAR LESION • HISTORY OF ISCHEMIC STROKE MORE
•KNOWN MALIGNANT THAN THREE MONTHS PRIOR
• TRAUMATIC OR PROLONGED (>10 MINUTE)
INTRACRANIAL NEOPLASM CPR OR MAJOR SURGERY LESS THAN THREE
•ISCHEMIC STROKE WITHIN WEEKS
• RECENT (WITHIN TWO TO FOUR WEEKS)
THREE MONTHS (EXCLUDING INTERNALBLEEDING
STROKE WITHINTHREE • NONCOMPRESSIBLE VASCULAR PUNCTURES
RECENT INVASIVE PROCEDURE
HOURS*) •
• FOR STREPTOKINASE/ANISTREPLASE - PRIOR
•SUSPECTED AORTIC DISSECTION EXPOSURE(MORE THAN FIVE DAYS AGO) OR
•ACTIVE BLEEDING OR PRIOR ALLERGIC REACTION TO THESE AGENTS
PREGNANCY
BLEEDINGDIATHESIS •
• ACTIVE PEPTIC ULCER
(EXCLUDING MENSES) • PERICARDITIS OR PERICARDIAL FLUID
•SIGNIFICANT CLOSED-HEAD • CURRENT USE OF ANTICOAGULANT (EG,
WARFARIN SODIUM) THAT HAS PRODUCED
TRAUMA ORFACIAL TRAUMA AN ELEVATED INTERNATIONAL
WITHIN THREE MONTHS NORMALIZED RATIO (INR) >1.7 OR
PROTHROMBIN TIME (PT) >15 SECONDS
• AGE >75 YEARS
• DIABETIC RETINOPATHY

SBP: systolic blood pressure; DBP: diastolic blood pressure; CPR: cardiopulmonary resuscitaon.
* The American College of Cardiology suggests that select paents with stroke may benefit from thrombolyc therapy within 4.5 hours of the
onset of symptoms.
Oncology

CA CERVIX

EVALUATION:

ASYMPTOMATIC:

SCREENING- Pap smear, VIA/VILI, HPV DNA testing

● The ACS guidelines of 2017, state that Pap smear should begin from 21 years of age
regardless of sexual activity and should continue every 2 years until 30 years.
● From > 30 years, this should be done along with HPV DNA cotesting
● If there are 3 consecutive negative results with no history of CIN/ risk factors, this can be
done every 3 years.
● Women treated for CIN 2,3 should be screened for 20 years
● If contesting is done, it can be done every 5 years.
● Women can discontinue screening if 3 consecutive screening returns negative within 10
year period or if more than 65 years age or if they had undergone hysterectomy for non
cancerous lsion
● Women who had taken HPV vaccines should follow same screening guidelines.
● If CIN 1, we can observe and repeat annually. If repeated results come as CIN 1, or
progresses to CIN 2,3, colposcopic biopsy should be done.

SYMPTOMATIC:

EVALUATION:

History and clinical examination

Imaging – CT/MRI abdomen and pelvis

PET CT.

82
Oncology 83

STAGING:

I - Confined to cervix

I A - Microscopic disease.

IA1 - <3 mm stromal invasion

I A2 - 3-5 mm stromal invasion

I B - macroscopic disease/ > 5 mm stromal invasion

I B1 - <2 cm

I B2 - 2-4 cm

I B3 - >4 cm

II - tumour not extending beyond lower third of vagina/pelvic wall

II A1 - tumour involving upper 2/3rd of vagina <4 cm

II A2 - tumour involving upper 2/3rd of vagina >4 cm

II B - parametrial invasion not extending to pelvic wall

III - tumour extending to lower third vagina/pelvic wall/lymphadenopathy.

III A - tumour extending to lower third vagina

III B - tumour extending to pelvic wall causing hydroureteronephrosis/non functioning kidney.

III C1 - pelvic lymphadenopathy

III C2 - para aortic lymphadenopathy

IV A - locoregional tumour spread to adjacent organs

IV B - tumour spread to distant organs

MANAGEMENT:

No visible lesion/ pap smear positive for malignancyThorough clinical examination Colposcopy
and biopsy
84 MMC PRACTICE PROTOCOLS

MICROINVASIVE LESIONSTAGE IA1

CONIZATION TYPE I HYSTERECTOMY

IF FERTILITY NEEDS TO BE RADICAL HYSTERECTOMY

PRESERVED
● IN PTS WITH
(PT SHOULD BE COMPLIANT LYMPHOVASCULAR
FOR FOLLOW UP) INVASION
● CONIZATION WITH
POSITIVE MARGINS

STAGE IA2

OPTIONS:

1. TYPE III RADICAL HYSTERECTOMY

PLUS
PELVIC LYMPHADENECTOMY

2. RADICAL RADIOTHERAPY
IF PATIENT IS UNFIT FOR SURGERY
EBRT+ICA (POINT A DOSE 70 Gy)

*INCIDENATALLY DETECTED CARCINOMA CERVIX POST TAH BSO

TO BE TREATED WITH ADJUVANT RADIOTHERAPY WITH CHEMOTHERAPY

● IF STAGE IA1 WITH NO LVSI – PELVIC RADIOTHERAPY

● IF STAGE IA2 OR IB – PELVIC RADIOTHERAPY PLUS CONCURRENT
CHEMOTHERAPY
*PAP SMEAR POSITIVE, COLPOSCOPY AND CONIZATION NEGATIVE

FOLLOW UP
Oncology 85

CLINICALLY VISIBLE LESION

WORK UP

● Biopsy
● Chest X ray
● CT/MRI Abdomen/pelvis – plain and contrast

STAGE IB1, STAGE IB2, STAGE IIA1

1. TYPE III RADICAL

HYSTERECTOMY PLUS PELVIC
LYMPHADENECTOMY
2. PELVIC EBRT PLUS
BRACHYTHERAPY

ADJUVANT RADIOTHERAPY PLUS CHEMOTHERAPY INDICATIONS

● Positive margins
● Positive lymph nodes
(If pelvic nodes positive – pelvic radiotherapy

If para aortic nodes positive – extended field radiotherapy)

● Parametrial invasion

ADJUVANT RADIOTHERAPY INDICATIONS

● T > 4cm
● Lymphovascular space invasion
● Deep invasion of cervical stroma

LOCALLY ADVANCED CERVICAL CANCER

EVALUATION

● Biopsy
● CT abdomen/pelvis – P & C
● EUA [ if clinical examination findings are equivocal]
● Cystoscopy and sigmoidoscopy
● Chest X ray
86 MMC PRACTICE PROTOCOLS

STAGE IB3, IIA2, III A, IIIB, III C1, IIIC2

CONCURRENT CHEMORADIOTHERAPY
FOLLOWED BY BRACHYTHERAPY.

IF PARA AORTIC NODES ARE POSITIVE,

EXTENDED FIELD RT SHOULD BE GIVEN

RADIOTHERAPY GUIDELINES

Dose of approximately 45-50 Gy EBRT. Primary tumour is then boosted using brachytherapy with
additional 30-40Gy using wither image guidance (preferred) or to Point A by HDR brachytherapy

CHEMOTHERAPY:

● *Weekly Cisplatin – 40 mg /m2 during EBRT.

● *If cisplatin intolerant – weekly Carboplatin – 2 AUC
● *DJ stent insertion should be advised for patients with elevated renal parameters due
to obstructive uropathy. If renal parameters become normal, patient may be considered
for cisplatin based chemotherapy. If renal parameters remain elevated, patient may be
treated only with radical radiotherapy. (If DJ stenting is not technically feasible- PCN
(percutaneous nephrostomy may be considered) as per urologist’s opinion.

STAGE IVA

WORK UP

● Biopsy
● CT/MRI Abdomen/pelvis – P & C
● Chest X ray
● Cystoscopy/sigmoidoscopy along with biopsy confirmation

CONCURRENT CHEMO-RADIOTHERAPY FOLLOWED

BY BRACHYTHERAPY, IF GC IS GOOD. IF ECOG
> 3, PALLIATIVE RADIOTHERAPY FOLLOWED BY
PALLIATIVE CHEMOTHERAPY

[Note: In patients presenting with fistula, diversion procedures/Pelvic exenteration should be con-
sidered first, followed by local radiotherapy]
Oncology 87

STAGE IV B (SYSTEMIC METASTASES AT PRESENTATION)

PALLIATIVE CHEMOTHERAPY

PALLIATIVE RADIOTHERAPY IF
PERSISTENT PAIN OR BLEEDING
PRESENT

CHEMOTHERAPY OPTIONS:

FIRST LINE REGIMENS:

1. PACLITAXEL /CARBOPLATINPaclitaxel – 175 mg/m2

Carboplatin 5 AUC every 3 weeks

2. CISPLATIN /5 FU Cisplatin – 30 mg/m2

5 FU - 750 mg/m2 day 1 to day 3 every 21 days

SECOND LINE REGIMENS/OTHER REGIMENS

(In case of progression)

(Singlet or doublelet along with platinum may be used depending on the general condition of the
patient)

● Docetaxel (75 mg/m2)

● Gemcitabine (1gm/m2)
● Vinorelbine (40 mg/m2)
● Ifosphamide (1 gm/m2)
● 5FU – (750 mg/m2)

FOLLOW UP

● H & P every month in first 3 months

● Every 3 months in the first year
● Every 4 months in 2nd year
● Every 6 months in 3 – 5 yrs
● Annually thereafter
88 MMC PRACTICE PROTOCOLS

RECURRENT CERVICAL CANCER:

WORK UP:

● Biopsy
● PET /CT whole body or CT abdomen and pelvis and CT thorax

LOCAL/REGIONAL RECURRENCE:

IF PRIOR CENTRAL IF PATIENT NOT

SURGERY - PELVIC RECURRENCE: WILLING FOR /OR
RADIOTHERAPY IF HAD NOT SUITABLE FOR
PLUS RECEIVED PRIOR EXTENTRATION
CHEMOTHERAPY CHEMORADIATION – PALLIATIVE
- RADICAL CHEMOTHERAPY.
HYSTERECTOMY
OR PELVIC
EXTENTRATION
(ANTERIOR,
POSTERIOR, TOTAL)

PELVIC EXENTERATION – CONTRAINDICATIONS

● Disease beyond pelvis/M1 disease

● Extension of disease upto pelvic side wall
● Leg edema, sciatica
● Frozen pelvis

SYSTEMIC RECURRENCE/METASTASES:

● PALLIATIVE CHEMOTHERAPY
● PALLIATIVE RADIOTHERAPY IF
INDICATED

CHEMOTHERAPY OPTIONS:

FIRST LINE REGIMENS:

1. Weekly cisplatin 40 mg/m2, along with RT

2. PACLITAXEL /CARBOPLATIN Paclitaxel – 175 mg/m2
Carboplatin 5 AUC every 3 weeks
Oncology 89

3. CISPLATIN /5 FU Cisplatin – 30 mg/m2

5 FU - 750 mg/m2 day 1 to day 3 every 21 days

SECOND LINE REGIMENS/OTHER REGIMENS

(In case of progression)

(Singlet or doublelet along with platinum may be used depending on the general condition of the
patient)

● Docetaxel (75 mg/m2)

● Gemcitabine (1gm/m2)
● Vinorelbine (40 mg/m2)
● Ifosphamide (1 gm/m2)
● 5FU – (750 mg/m2)

FOLLOW UP

● H & P every month in first 3 months

● Every 3 months in the first year
● Every 4 months in 2nd year
● Every 6 months in 3 – 5 yrs
● Annually thereafter

RECURRENT CERVICAL CANCER:

WORK UP:

● Biopsy
● PET /CT whole body or CT abdomen and pelvis and CT thorax

LOCAL/REGIONAL RECURRENCE:

IF PRIOR IF HAD IF PATIENT NOT

SURGERY - PELVIC RECEIVED PRIOR WILLING FOR OR
RADIOTHERAPY CHEMORADIATION NOT SUITABLE FOR
PLUS - RADICAL EXTENTRATION
CHEMOTHERAPY HYSTERECTOMY – PALLIATIVE
OR PELVIC CHEMOTHERAPY.
EXTENTRATION
90 MMC PRACTICE PROTOCOLS

PELVIC EXENTERATION – CONTRAINDICATIONS

● Disease beyond pelvis

● Extension of disease upto pelvic side wall
● Bilateral hydroureteronephrosis
● Leg edema, sciatica

SYSTEMIC RECURRENCE/METASTASES:

● PALLIATIVE CHEMOTHERAPY
● PALLIATIVE RADIOTHERAPY IF
INDICATED

CHEMOTHERAPY OPTIONS:

FIRST LINE REGIMENS:

1. PACLITAXEL /CARBOPLATIN Paclitaxel – 175 mg/m2

Carboplatin 5 AUC every 3 weeks
2. CISPLATIN /5 FU Cisplatin – 30 mg/m2
5 FU - 750 mg/m2 day 1 to day 3 every 21 days

SECOND LINE REGIMENS/OTHER REGIMENS

(In case of progression)

(Singlet or doublelet along with platinum may be used depending on the general condition of the
patient)

● Docetaxel (75 mg/m2)

● Gemcitabine (1gm/m2)
● Vinorelbine (40 mg/m2)
● Ifosphamide (1 gm/m2)
● 5FU – (750 mg/m2)
Oncology 91

CARCINOMA BREAST
● EARLY CARCINOMA
● LOCALLY ADVANCED
● METASTATIC

EARLY BREAST CANCER (T1,2 N 0, T3N0)

EVALUATION

History and clinical examination

Bilateral X ray mammogram/sonogram

● Trucut/ Image guided biopsy

● ER/PR/HER2 neu
● Chest Xray
● USG , CT Chest

MANAGEMENT:

Option 1: BCS

Option 2: MRM

EARLY BREAST
CANCER

BCS/MRM

ADJUVANT CHEMO,
ADJUVANT RT (WHOLE BREASTR RT/BRACHY/APBI)
ADJUVANT HT IF HR +, ANTI HER 2 THERAPY IF HER 2 +

Adjuvant RT after BCS includes Whole Breast RT/Brachytherapy/ APBI

Anti Her 2 therapy should be given if Her 2 is 3+ positive

92 MMC PRACTICE PROTOCOLS

LOCALLY ADVANCED BREAST CANCER WORK UP

● History and physical examination

● Trucut biopsy, wedge biopsy if ulcerated
● ER, PR, HER2 neu, Ki-67
● Contralateral breast mammogram
● CT chest + CT Abdomen + Bone scan or PET CT

T3,4, N1-3

INOPERABLE, Her 2 +,
OPERABLE (T3 N1) Triple negave

NEOADJ CHEMO 8
MRM
CYCLES

ADJUVANT CHEMO RESPONSE + RESPOBSE -VE

ACX4,TX4 ADJUVANT RT
ADJUVANT ET FOR ER/PR+ MRM 2ND LINE
ANTI HER 2 THERAPY IF
HER2 + ADJ RT/HT CHEMO
Oncology 93

SECOND LINE CHEMO

RESPONSE +VE RESPONSE -VE

MRM PRE OP RT

ADJ CHEMO
RESPONSE +VE RESPONSE -VE
ADJ RT/HT/TARGETED
IF FEASIBLE, MRM PALL CHEMO
THERAPY

IF
STATIC/PROGRESSIVE
DISEASE PALLIATIVE
CHEMO

GUIDELINES FOR SURGERY

● Axillary lymph node dissection involves level I and II lymph nodes

● Level III nodal dissection is done if there is gross disease apparent in level II/III nodes
The post-operative pathology report should include details regarding:

● T size
● Histology
● Margin status
● Number of axillary nodes
● Evidence of extracapsular disease in the node
● ER/PR/HER2 neu/ Ki-67 index
94 MMC PRACTICE PROTOCOLS

GUIDELINES FOR SYSTEMIC CHEMOTHERAPY EARLY BREAST CANCER

● Adjuvant chemotherapy – AC X 4, T X 4
● For patients with low ejection fraction: CMF/ TC based chemo indications:
● Positive lymph nodes
● Triple negative cancers
● HER2 + cancers
● >1cm tumor size
● Premenopausal women

LABC

● AC 4 cycles followed by Paclitaxel 4 cycles

● AC X 4,T X 4 ,CMF, FAC, AC, TC based on general condition.

OTHERS AGENTS – Single agents like Paclitaxel, Capecitabine, Gemcitabine, Vinorelbine

ADJUVANT RADIOTHERAPY GUIDELINES:

Adjuvant Radiotherapy Indications:

● pT3, T4
● Positive lymph nodes > 4 LN
● < 3 LN with high risk features
● Positive margins
It is common for RT to follow chemotherapy when chemotherapy is indicated to avid radiation
recall.

Radiation to the breast/chest wall and nodal regions is generally delivered with single energy or
mixed energy photons ± electrons. Preferred modality is conformal technique

Whole breast radiation Dose

● Whole breast should receive hypofractionated dose of 40-42.5Gy in 15-16#; in selected

cases 45-50.4Gy in 25-28#.
● Boost to tumour bed recommended in patients at higher risk for recurrence. Typical boost
doses are 10-16 Gy in 4-8#
● Lumpectomy cavity boost can be delivered using enface electrons,photons or brachytherapy
● 3D planning is used to minimize inhomogeneity and exposure to heart and lung.
Oncology 95

CHEST WALL/AXILLARY
RECURRENCE

RESECTABLE
UNRESECTABLE

SURGICAL EXCISION+
CHEMO/HORMONES+ RT [IF
NOT TREATED EARLIER]

ADJUVANT ENDOCRINE TREATMENT GUIDELINES:

● Adjuvant hormones to be started after completion of radiotherapy in hormone receptor

positive patients.
● Hormonal agent:
● Premenopausal patients: T.Tamoxifen l0mg bd for 5-10 years
● Postmenopausal patients: T.Tamoxifen/Aromatase inhibitor for 5-10 years

FOLLOW UP

Clinical examination

● Every 2 months till 1year [ for patients on tamoxifen]

● Every 3 months in 2 - 3 years
● Every 6 months 4- 5th
● Early thereafter

Contralateral mammogram/USG Abdomen-Pelvis every year

LOCOREGIONAL RECURRENCE

WORKUP

History and Physical examination

● PET CT
● Biopsy, ER/PR/HER2neu if more than 6 months of remission
96 MMC PRACTICE PROTOCOLS

METASTATIC WORKUP

● PET CT
● Biopsy of metastatic site
● ER/PR/HER2 neu
● Aim of treatment of metastasis is mainly palliative

NOTE:

● In selected patients with oligometastases, local treatment with MRM + RT with chemo
may be considered.
● In patients with bone metastases, Inj. Zoledronic acid [4mg every 3 month] may be
considered.
● Palliative chemotherapy is to be continued until disease progression/patient tolerance

HORMONAL Rx IF HR+ SYSTEMIC

CHEMO IF HR – LOCAL CHEMOTHERAPY
RT BISPHOSPHONATES
Oncology 97

CARCINOMA ESOPHAGUS
EVALUATION

● History and physical examination

● UGI scopy and biopsy
● CT chest with upper abdomen plain and contrast
○ Bronchoscopy [ for lesions above carina]

STAGING

Tis – high grade dysplasia

T1a – tumor invades lamina propria/ muscularis mucosa

T1b – tumor invades sub mucosa

T2 – tumor invades muscularispropria

T3 – tumor invades adventitia

T4a ( resectable) – tumor invades pleura, pericardium, diaphragm

T4b ( unresectable) – tumor invades aorta, vertebral body, trachea

N0 – no regional lymph nodes

N1 – 1 to 2 regional lymph nodes

N2 – 3 to 6 regional lymph nodes

N3 – 7 or more regional lymph nodes

STAGE GROUPING

STAGE 0 – Tis N0 M0

STAGE IA – T1 N0 M0 Gr1

STAGE IB – T1 N0 M0 Gr 2 -3 ; T2-3 N0 M0 Gr1 (lower)

STAGE IIA – T2-3 N0 M0 Gr 1 (upper and middle); T2-3 N0 M0 Gr 2-3 (lower)

STAGE IIB – T2-3 N0 M0 Gr 2-3 (upper and middle); T1-2 N1 M0

STAGE IIIA – T1-2 N2 M0; T3 N1 M0; T4a N0 M0

STAGE IIIB – T3 N2 M0
98 MMC PRACTICE PROTOCOLS

STAGE IIIC – T4a N1-2 M0; T4b ANY N M0; ANY T N3 M0

STAGE IV – ANY T ANY N M1

DISTANCE FROM INCISORS (CM) VERTEBRAL LEVEL

CERVICAL 15-20 C7-D1
UPPER THORACIC 20-25 D1-D3
MIDDLE THORACIC 25-30 D3/4-D7
LOWER THORACIC 30-40 D7-D11

Management

RESPONSE ASSESSMENT AT 6 WEEKS

● UGI scopy
● CT chest

UP FRONT
SURGERY NOT
STANDARD
Oncology 99

UP FRONT
SURGERY NOT
STANDARD

PRE OP CHEMORADIATION

● RT 50.4Gy/180Cgy/#
● This is irrespective of histology

Chemo:

● Cisplatin 75mg/m2 D1 – D3
● 5FU 750mg/m2 D1 D3
● 2 cycles during RT

ADJUVANT CHEMORADIATION

● EBRT 45 to 50Gy/ 180cGy/#

● Cisplatin 75mg/m2 D1 – D3
● 5FU 750mg/m2 D1 D3, repeat every 21 days, 6 cycles
ILRT (Intra-Luminal Radiotherapy- Brachytherapy) – CONTRAINDICATIONS

● Severe stenosis where applicator can’t be negotiated

100 MMC PRACTICE PROTOCOLS

● T.O. fistula
● Primary tumor > 10 cm long
● Extensive adjacent structure involvement
● Extension to cardia
● Cervical esophagus lesions

ADENOCARCINOMA OF DISTAL ESOPHAGUS AND OG JUCNTION

WORK UP

● UGI scopy and biopsy

● CT chest and upper abdomen plain and contrast
Oncology 101

INDICATIONS FOR STENT:

● Tracheoesophageal fistula
● Patient unfit for RT

FOLLOW UP

● H & P Every 3 months in year 1 -2

● H & P Every 6 months in year 3 -5
In metastatic settings, palliative procedure with feeding procedure/stenting

Palliative chemotherapy

CARCINOMA LUNG
EVALUATION

History and clinical examination

CECT/MRI Chest

● Image guided biopsy, Pathology review, IHC, Molecular study

● Bronchoscopy
● PFT
● Mediastinoscopy
Metastic workup - MRI brain, PETCT
102 MMC PRACTICE PROTOCOLS

MANAGEMENT

T1-3N0 OR
INOPERABLE

SURGICAL RESECTION
MEDIASTINAL LYMPH NODE
SAMPLING

ADJUVANT CHEMO: ADJUVANT CHEMORT

4cm FOLLOWED BY CHEMO:
Wedge resecon POSITIVE MARGINS
Node posive N2

Vascular invasion
Visceral pleura involvement
Nx

T1–3N0,N1
MEDICALLY INOPERABLE

T1-2N0 N+

RADICAL
CHEMORADIATION
Oncology 103

T3N2/T4

Depends on pt GC,
RT field

CCRT SEQUENTIAL CHEMORT

ANY T, ANY N, M1

PALLIATIVE CHEMO OR
TKI ± RT

GUIDELINES FOR CHEMOTHERAPY AND RADIOTHERAPY

CONCURRENT CHEMO

● Cisplatin 25mg/m2 + etoposide 100mg/m2 D1-D3 Q21 days

● Cisplatin 75mg/m2 D1 + Etoposide 100mg/m2 D1-3 Q21 days

OTHER REGIMENS

● Cisplatin 75mg/m2, Docetaxel 75mg/m2 D1 Q21 days for 4 cycles

● Cisplatin 50mg/m2 D1D8 + vinorelbine 25mg/m2 D1,8,15,22
● Q28 days for 4 cycles
● Cisplatin 75mg/m2 D1 + Gemcitabine 1250mg/m2 D1,8 Q21 days 4 cycles
● TKI for metastastic disease
104 MMC PRACTICE PROTOCOLS

Adenocarcinoma with EGFR mutation positive

● T.Gefitinib 250 mg OD
● T.Afatinib 40 mg OD

Radiotherapy Dose:

● Radical – 60 Gy / 200cgy/# / 30#No Role For Prophylactic Nodal Rt

● POSTOP RT–45-54GY/1.8GY/fraction Palliative Dose: 30gy/10#+18gy/6#
● RADICAL RT
● SBRT -25-30GY/1 fraction

Follow up

● Smoking cessation advice

● H&P CHEST CT every 6 months for 2-3 years, after that annually

SMALL CELL LUNG CANCER

LIMITED STAGE

T1-T2N0M0
T1-T4N1-N3M0

T3-T4N0M0
SURGERY

ECOG0 2 ECOG3-4

TREATMENT

CCRT SEQENTIAL
CHEMORT OR
SUPPORTIVE
CARE
Oncology 105

EXTENSIVE STAGE

ECOG0-2 ECOG3-4

SYSTEMIC THERAPY SUPPORTIVE CARE

SYMPTOMATIC
PALLIATIVE RT SITES – LOCAL OR
METS

CHEMOTHERAPY

● Cisplatin 25mg/m2 + Etoposide 100mg/m2 D1-D3 Q21 days

● Cisplatin 75mg/m2 D1 + Etoposide 100mg/m2 D1-3 Q21 days 4 Cycles

ORAL CAVITY CANCERS

EVALUATION

History and clinical examination

Biopsy

● CT/MRI with contrast of primary and neck

● Chest X ray/CT Chest
● Dental evaluation

STAGING

T1 – tumor 2 cm or less in greatest dimension

T2 – tumor more than 2 cm but not more than 4cm in greatest dimension

T3 – tumor more than 4 cm in greatest dimension

106 MMC PRACTICE PROTOCOLS

T4a –tumor invades cortical bone, deep extrinsic muscles of tongue, maxillary sinus and skin of
face

T4b – tumor invades masticator space, skull base, pterygoid plates and encases internal carotid
artery

[Note: superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to clas-
sify a tumor as T4]

NX: Regional lymph nodes cannot be assessed

N0: No regional lymph node metastasis

N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension

N2: Metastasis in a single ipsilateral lymph node, >3 cm but not >6 cm in greatest dimension, or in
multiple ipsilateral lymph nodes, none >6 cm in greatest dimension, or in bilateral or contralateral
lymph nodes, none >6 cm in greatest dimension

N2a: Metastasis in a single ipsilateral lymph node >3 cm but not >6 cm in greatest dimension

N2b: Metastasis in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension

N2c: Metastasis in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension

N3: Metastasis in a lymph node >6 cm in greatest dimension

ASTRO CONSENSUS–POSITIVE NODE ON CT

● Size > 1cm [ > 1.5cm for level Ib]

● Spherical shape rather than ellipsoidal
● Necrotic center,
● Irrespective of size Cluster of 3 or more borderline nodes

[NOTE:any suspicious node to be documented before upstaging the disease]

MANAGEMENT GUIDELINES
Oncology 107

T3-4a and/or N1-2

Surgery

Primary in oral cavity –

For Early Carcinoma - wide local excision/Hemiglossectomy + selective neck dissection (I-III) or
extended supra omohyoid neck dissection (I-IV - Tongue) with or without Reconstruction (Local/
Microvascular free flap)

Neck to be addressed if Depth of invasion is > 4 mm

● Bilateral neck dissection for midline lesions

For Resectable Locally advanced carcinoma, Composite resection, which includes Comprhensive
neck dissection + Bone resection + Soft tissue resection along with 1.5 cm margin for primary
3-dimensionally, with reconstruction (Regional/Microvascular soft tissue free flap/composite
reconstruction flaps)

● If adverse risk factors + in post op HPE – adjuvant Rx indicated.

Radiationtherapy-Indications of postoperative RT
Early Carcinoma:

Margin positive

LVSI/PNI + ve

> 1 node +ve

Locally advanced carcinoma:

1. pT3/4
2. Node positive
3. LVSI
4. PNI
5. Level III/IV nodes
108 MMC PRACTICE PROTOCOLS

6. Close Margins (<5mm)

7. Positive margins
Area of treatment – Primary tumor and involved nodes

Dose- 60 to 66 Gy in 2 Gy/# daily Monday to Friday in 6 - 6.5 weeks

Radical RT – A dose of 66 Gy/33#/2 Gy/# 5 days/week in 6.5 weeks

Primary in buccal mucosa, RMT, hard palate and alveolus – Target

volume– primary + 2cm clearance + ipsilateral level I – III LN

● v Primary in anterior third tongue and floor of mouth – Target volume – primary + 2 cm
clearance + bilateral neck nodes [ level I – IV] In post-op cases, DOSE: 60 Gy/200 cGy/#
/30# [off cord at 40 Gy]
● Primary in buccal mucosa, RMT, hard palate and alveolus – Target volume– tumor bed +
ipsilateral level I – III LN [ if N0-1]; if N2b – treat level I – V LN [ ipsilateral]
● Primary in anterior third tongue and floor of mouth – Target volume – tumor bed +
bilateral neck nodes [ level I – IV] [ if N0 -1]; if N2b – treat level I – V LN [ bilateral]
● Adjuvant RT 60 Gy/30#
● Brachytherapy interstitial brachytherapy is considered in selected cases.

Consider HDR boost 21 Gy at 3 Gy/# if combined with 40 – 50 Gy EBRT or 45-60 Gy at 3-6

Gy/# if using HDR as sole therapy.

INDICATIONS OF CHEMOTHERAPY:

● Adjuvant Chemoradiotherapy: Post-op margin positivity and Extra-nodal extension.

● Radical Chemoradiotherapy:
1. Locally advanced unresectable
2. Patient not willing for surgery;
3. Poor PS, other comorbidities precludes surgery

CHEMOTHERAPY REGIMENS:

1. Inj. CISPLATIN 100mg/m2 once in 21 days.

2. Inj. CISPLATIN 40mg/m2 once in 7 days.
3. Inj. CARBOPLATIN AUC 2 once In 7 days for cisplatin ineligible patients
Oncology 109

FOLLOWUP

● Every month [ Clinical examination] – 1st year

● Every 3 months [Clinical examination]-2–3rd Year
● Every 6 months [Clinical examination]–4th and 5th year

PALLIATIVE CHEMOTHERAPY:

First line chemotherapy:

Inj. Cisplatin–30mg D1–D3 with Inj. 5 FU–750 mg D1–D3.Inj. Carboplatin AUC – 5 and Inj
Paclitaxel 175 mg/ m2 D1.

Second line chemotherapy:

Inj 5 FU 500 mg weekly

Third line chemotherapy:

Tab. Methotrexate 20 mg weekly with Tab celecoxib 200 mg BD

Paediatrics

Management of acute diarrhoea with dehydraon in children

Ask for Look for
1. Duration 1. G eneral condition of the child
2. Blood in stools 2. Nutritional status – weight/weight for
3. Fever, vomiting, cough height/MUAC,
4. Immunization status 3. C lassify malnutrion if present
5. Pre illness feeding practices 3. Signs of dehydration and classify
6. Current feeding and remedies given dehydration

Classify dehydration

Not enough signs to Two or more of the following signs Two or more of the following signs
classify as some or
severe dehydration • Restlessness/irritable • Lethargic/unconsciousness
• Sunken eyes • Sunken eyes
• Drinks eagerly, thirsty • Unable to drink/drinks poorly
• Skin pinch goes back slowly • Skin pinch goes back very slowly

No dehydration – Plan A Some dehydration – Plan B Severe dehydration – Plan C

110
 No dehydration – Plan A Some dehydration – Plan B Severe dehydration – Plan C

Paediatrics Management of diarrhea 111

Rehydration therapy in acute diarrhea.

Treatment plan Plan–A Plan–B Plan–C

State of hydration No dehydration Some dehydration Severe dehydration

Percentage of body <5 5–10 >10

weight loss

Estimated fluid <50 50–100 >100

deficit (mL/kg)

Goals of Replacement of ongoing Correction of existing Urgent replacement of

management losses of fluid and deficits of fluid and existing deficits of fluid and
electrolytes electrolytes electrolytes

Fluid therapy Maintenance (oral) Rehydration (oral) Rehydration [intravenous

(IV)]

Treatment facility Home Health facility Health facility

Rehydration fluid Oral rehydration solution ORS RL*

(ORS)/homemade
solutions

Amount of For every loose stool: 75 mL/kg IV fluid

rehydrating fluid
10 mL/kg Over 4 hours Infants

Age up to 2 months—5 Plus 30 mL/kgOver 1 hour

teaspoons/purge
Non-breastfed infants 70 mL/kg Over 5 hours
2 months to < 2 years 50–
100 mL <6 months—100–200 Age > 1 year
mL of clean drinking
Age 2–10 years 100–200 water 30 mL/kg Over ½
hour 70 mL/kg Over 2½
mL
Older children and hours
Older child: As much as adults: Free access to
desired plain water in Plus
addition to ORS ORS (5 mL/kg/h) start
Plus
orally as soon as child is
Free access to drinking able to drink
water

Monitoring Watch for vomiting, early Monitor every hour Monitor ½ hourly and
signs of dehydration, and reassess after 4 reassess after 6 hours
blood in stools, etc. hours (infants) 3 hours (older
children)
If still in plan B,repeat
as above If still in plan C, repeat
as above.If rehydrated,
If rehydrated, shift to shift to plan B/A
plan A
112 MMC PRACTICE PROTOCOLS

Counsel the mother on the four rules of diarrhea treatment:

1. Give extra fluid- If the child is being breastfed, advise the mother to breastfeed frequently
and for longer at each feed; In non-breastfed children, give one or more of the following: ORS
solution, food-based fluids (such as soup, rice water) to prevent dehydration.
Teach the mother to give small sips from a clean cup (for older children) or spoon. For babies a
dropper or syringe (without a needle) can be used to put small amounts of ORS into mouth. If the
child vomits, wait 10 min, and then give more slowly. Mother should continue giving extra fluid
until the diarrhoea stops. Teach the mother how to mix and give ORS solution, and give her two
packets of ORS to take home.

2. Give zinc supplements. It reduces the duration of a diarrhoea episode by 25% and are asso-
ciated with a 30% reduction in stool volume.Use plain zinc sulphate and not zinc containing
multivitamins
● Age2-6 months: (10mg) OD;
● Age >6 months :(20mg) OD for 10 -14 days.
It also reduces the risk of new episodes of diarrhea for following 2-3 months.

1. Continue feeding. Food should never be withheld and the child’s usual food shouldn’t be
diluted. Continued feeding also speeds the recovery of normal intestinal function. Frequent
and small feedings are well tolerated. Foods rich in potassium such as banana, coconut water
and fresh fruit juice are beneficial. Don’t give carbonated commercial drinks or sugar contain-
ing commercial juices.

2. Teach when to return to the clinic.

● If the child becomes sicker, is unable to drink or breastfeed, drinks poorly, develops a fever
or has blood in the stool.
● If the child shows none of these signs but is still not improving, advise the mother to return
for follow up after 2-3 days
Paediatrics 113

Acute Severe Asthma

DEFINITION:

Acute exacerbation of wheeze that remains unresponsive to initial treatment with bronchodilators
is called acute severe Asthma.Usually occurs in a child with previous history of wheeze but very
rarely it can be the first presentation of asthma.

NOTE:

Not all wheezes are acute severe exacerbations.

Suspect

Foreign body -sudden onset monophonic wheeze not responding to Salbutamol.

Tracheobronchomalacia -Young infants with wheeze not responding to salbutamol. Metabolic
acidosis in case of children presenting with tachypnoea without retractions.

Wheeze cannot be heard in life threatening asthma.(Silent chest) OVERVIEW OF ACUTE

SEVERE ASTHMA/STATUS ASTHMATICUS:

STEP 1:

Rule out causes of wheeze that is not due to asthma.

STEP 2:

Assess severity based on Pulmonary Index Score(PIS)and treat accordingly.

Accessory Muscle
Score Respiratory Rate Wheezing
Sternocleidomastoid Activity
6 YEARS >6 YEARS
0 <30 >30 None No Apparent Activity
1 31-45 21-35 Terminal Doubtful Increase
Expiration
2 46-60 36-50 Entire Apparent Increase
Expiration
3 >60 >50 Expiration Maximal Activity
As Well As
Inspiration
114 MMC PRACTICE PROTOCOLS

Mild Exacerbation Moderate Exacerbation Severe Exacerbation

PIS SCORE 0-3 PIS SCORE 4-6 PIS SCORE >6
HOME CARE WARD CARE PICU CARE

STEP 3:

Elements of treatment :

Management of bronchospasm (Bronchodilators).

Management of inflammation (steroids).

Management of hypoxemia(oxygen).

Stepping down acute care:

Follow the principle-Last in first out

Discontinue terbutaline/Aminophylline drip in 24 hours

Discontinue ipratropium neb in 24 hours

Reduce SABA to 2-4 hourly then 4-6th hourly

Replace iv steroid with oral steroids

Discharge criteria:

Pulmonary score <3.

Sleeping well at night.

Eating well.

Appears comfortable.

SABA requirement more than 4-6th hourly

Discharge plan:

Inhaled SABA MDI with spacer ±Mask 4-6th hourly

Rescue steroids 3-7 days. No need to taper.

Plan follow up within 7-14 days.

Review compliance trigger elimination

Should be started on daily Inhaled corticosteroids for three months minimum.

Paediatrics 115

Mild Attack Moderate Attack Severe Attack

Salbutamol with MDI+Spacer or Salbutamol with MDI+Spacer or Salbutamol with MDI+Spacer or
nebulizer every 20 minutes up to and ipratropium bromide nebulizer and ipratropium bromide nebulizer
three doses every 20 minutes up to three doses every 20 minutes up to three doses
Oral corticosteroids Consider SC/IM Adrenalin in case
of silent chest
O2 therapy if spo2 > 95%
Oral corticosteroids

Admit in ward Admit in PICU

Good response Poor response Good response Poor response Good response Poor response
Continue sal- Continue salbu- Progressively Repeat Progressively Repeat
butamol every tamol Add oral reduce fre- Salbutamol and reduce fre- Salbutamol and
4-6th hourly corticosteroids quency of ipratropium quency of ipratropium
taper over 7 Salbutamol and bromide 120 Salbutamol and bromide 120
days ipratropium minutes up to 3 ipratropium minutes up to 3
bromide doses Continue bromide doses
Continue only oral corticoste- Continue only Continue oral
salbutamol roids O2 therapy salbutamol corticosteroids
And Oral if spo2 > 95% And Oral O2 therapy if
corticosteroids corticosteroids spo2 > 95%

Consider con- Treat as moder- Tapering doses Treat as severe Tapering doses Intravenous
trollers in case ate attack as per clinical attack as per clinical magnesium
of recurrent response response sulphate
exacerbations Intravenous
terbutaline
Intravenous
salbutamol
Intravenous
aminophylline
116 MMC PRACTICE PROTOCOLS

Status Epilepticus in Children

Definition:

Status Epilepticus is defined asseizures lasting for 5 minutes or more/ recurrent seizures without
regaining of consciousness in between.

Type Time beyond which if seizures persist, patient Time after which persistent seizures
is considered to be in SE(t1) have long-term consequences(t2)
GCSE 5 mins 30mins
Focal seizures 10mins >60mins
with impaired
consciousness

Refractory Status Epilepticus:

Status epilepticus persisting despite sufficient dose of benzodiazepines and at least one AED

Super Refractory Status Epilepticus:

Status Epilepticus that continues for 24 hours despite anaesthetic treatment, or recurs on
attempted weaning of anaesthetic regimen.

NEED FOR EARLY TREATMENT:

Early in status epilepticus, there is a marked impairment of GABA mediated inhibitory function.
Simultaneously,there is NMDA,AMPA mediated hyper excitability which leads to seizures becom-
ing resistant to many anti-convulsive medications,including benzodiazepines and barbiturates.

This results in neuronal injury in prolonged status epilepticus.

Paediatrics 117

Treatment Algorithm: Status Epilepticus

Airway If IV access available,

Inj Lorazepam- 0.1 mg/kg/dose (max 4 mg) OR
Breathing:O2/BMV/Intubation
Inj Midazolam - 0.15 - 0.2 mg/kg/dose (max 5 mg) OR
Circulation:IV/IO access Inj Diazepam - 0.15 - 0.3 mg/Kg/dose (max 10 mg) Slow IV
If Glucose <60mg/dl,5ml/kg of 10%dextrose If IV access not available:
0-5 mins CBC,Blood sugar,S.Electrolytes,Calcium, IM Midazolam 0.2 mg/kg/dose (max 5 mg) OR
ABG/VBG,Toxic screening (if appropriate) Buccal/Nasal Midazolam 0.2 - 0.3 mg/kg/dose (max 5 mg) OR
Blood culture if fever present Rectal Diazepam 0.2-0.5 mg/kg/dose (max 10 mg)
Quick History and Examination

If Seizures persist, above drugs

repeated once @5-10 mins Interval
If seizure persists

Yes Non
IV Phenytoin 20 mg/kg in NS @ 1 mg/kg/min (Max: 1000mg) OR
Inj Fosphenytoin 20 mg PE/ kg @ 3 mg PE/kg/min OR Continue
HEART RATE
symptomatic
IV Levetiracetam 20 mg/kg @5 mg/kg/min up to 60mg/kg OR MONITORING medical care
5-30mins IV Valproate 20 mg/kg @ max 6 mg/kg/minute up to 30mg/kg
(Preferrable Choice : Phenytoin/Fosphenytoin/Leveteracetam)
Established status If none of the options above are available
Epilepticus IV Phenobarbitone 20 mg/kg @ 1.5 mg/kg/min

If seizure persists
Yes Non

Continue symptomatic medical care

Repeat any one of the second
30-60mins line drugs previously not used

Refractory status
Epilepticus
If seizure persists

Yes
Non
IV Midazolam - 0.2 ml /kg bolus, followed by infusion @ 1μg/kg/min, increasing Continue symptomatic
1 μg/kg/min, every 5-10 min, till seizures stop, up to a maximum of 12μg/kg/min medical care
OR
IV Thiopentone - Loading: 2-7 mg/kg,followed by infusion @ 0.5-5 mg/kg/hr.
1-24 hours OR
IV Propofol - Loading: 1-2 mg/kg, followed by [email protected] -3.9 mg/kg/hr.
Preferably with EEG Monitoring

If seizure persists

Therapeutic options on a case to case basis as follows:

>24 hrs
Ketamine infusion - Loading: 1 mg/kg. Maintenance: 0.5-2 mg/kg/hr.
Oral Topiramate- Loading: 5-10 mg/kg ;Maintenance: 5-12 mg/kg/day(max 400 mg/day)
Super Refractory status Epilepticus
Immunotherapy, Ketogenic Diet, Pyridoxine
118 MMC PRACTICE PROTOCOLS

Approach to Childhood Anemia

Definition:

Hemoglobin < 2 S.D below the mean for a child of same age, gender and altitude of resisdence.

WHO Recommended Hb cut off values (g/dl)

Age Group No anemia Mild anemia Moderate anemia Severe anemia

6-59 month >/= 11 10-10.9 7-9.9 <7
5-11 years >11.5 11-11.4 8-10.9 <8
12-14 years >12 11-11.9 8- 10.9 <8

Clinical Symptoms & Signs :

● Pallor - Common sign

● Tiredness
● Lassitude
● Easy fatigability
● Weakness
● Reduced concentration
● Breathlessness
● Facial puffiness
● Pedal edema
Paediatrics 119

Etiological Classification :

Decreased effective Increased destruction Blood loss

production

• Deficiency : iron, folate,Vit B12, Hemolytic Anemia • Acute : massive

Vit C GI hemorrhage,
• Extracorpuscular causes: trauma, massive
reduced intake
Immune : acquired immune
cephalhematoma
hemolytic anemia
increaseddemand • Chronic : rectal
Mechanical : eg : prosthetic valve,
polyp, hookworm
DIC, HUS.
reduced absorption infestation,
Infection : eg: malaria
chronic peptic
• Bone Marrow failure: Sequestration: eg : hypersplenism
ulcer
Congenital red cell aplasia • Intracorpuscular causes :
(Diamond- Blackfen syndrome) Membrane defect –
Acquired red cell aplasia spherocytosis,elliptocytosis,
(transient erythroblastopenia of Stomatocytosis
childhood) Enzyme defect – G6PD deficiency,
Failure of all cell lines : Aplastic PK deficiency
Anemia. Hemoglobin defect – sickle cell
• Bone Marrow Infiltrative anemia, thalassemia, HbC, HbD
disease: disease.
Leukemia, lysosomal storage
disorder, metastatic tumor.

Lab Evaluation :
< 75 fl- Microcytic anemia

75 – 90 fl : Normocytic anemia
CBC, RBC indices – MCV

>90fl : Macrocytic anemia

Reticulocyte count – Increased : blood loss, hemolysis

Decreased : reduced production
Peripheral smear – Essential part for evaluation of anemia.
120 MMC PRACTICE PROTOCOLS

Child with Hb <2 S.D for same age, gender and altitude of residence

Are the other cell lines affected ?

NO YES

MCV

LOW: Microcytic Normocytic High : Macrocytic

Retic count
Iron deficiency

Thalassemia

Sideroblastic anemia Low or normal (<3 %) High : >3%

Lead intoxication
Infection Is there evidence of
Anemia of chronic disease hemolysis?
Lead poisoning

Acute blood loss

Anemia of chronic disease yes NO

TEC
Hemorrhage

Hemolytic anemias:

Membranopathy (eg: HS,HE)

Enzymopathy : (G6PD deficiency, PK

deficiency)

Hemoglobinopathy

Autoimmune hemolytic anemia

Microangiopathic hemolytic anemia

Vitamin B12/ folate deficiency

Drugs (anticonvulsants,
zidovudine,methotrexate)

Diamond- blackfen anemia

Hypothyroidism

Myelodysplastic syndrome
Paediatrics 121

Hb < 2 S.D for same age, gender and altitude of residence

Other cell lines affected?

yes no

pancytopenia Anemia with LOW Anemia with HIGH Anemia with

platelet count platelet count HIGH WBC

Leukemia HUS Iron deficiency Infection

Myelosuppressive TTP Infection Leukemia
drugs
DIC Post-splenectomy
Aplastic anemia anemia
Evans syndrome
Infection

Vitamin B12
deficiency

Hypersplenism
122 MMC PRACTICE PROTOCOLS

Management of Dengue in children

Prof Lakshmi Velmurugan,Prof Poovazhagi V.

Dengue is caused by dengue virus of Flavivirus family, and it has four serotypes: DENV-1, DENV-
2, DENV-3, and DENV-4. It is the most common acute febrile illness presenting with systemic
manifestations.

Case Definitions in Clinical Practice

Probable dengue fever (DF)/dengue hemorrhagic fever (DHF):Acute febrile illness of 2–7 days
with two or more of features such as “headache, retro-orbital pain, myalgia, Arthralgia, rash, and
hemorrhagic manifestations” during an outbreak.OR

Non enzyme-linked immunosorbent assay (non-ELISA) based non structural glycoprotein- 1

(NS1) antigen/immunoglobulin M (IgM) tested to be positive.

Confirmed dengue fever:A case compatible with the clinical description of dengue fever With at
least one of the following:

● Isolation of dengue virus by viral culture

● Demonstration of IgM antibody against dengue virus by ELISA
● Demonstration of dengue virus antigen (NS1) by ELISA
● Immunoglobulin G seroconversion in paired sera after >2 weeks with fourfold titre rise
● Detection of viral nucleic acid by polymerase chain reaction (PCR)
Dengue with warning signs:Probable or confirmed dengue fever with any of the following

Abdominal pain or tenderness, Persistent vomiting Clinical

fluid accumulation, Mucosal bleeds Lethargy Restlessness
• Liver enlargement >2 cm

Laboratory: Increase in HCT concurrent with rapid decrease in

platelet count

Severe dengue:

● Severe plasma leakage leading toShock (DSS): Fluid accumulation with respiratory distress
● Severe bleeding: As evaluated by clinician
● Severe organ involvement:
● Liver: Aspartate transaminase (AST) or alanine transaminase (ALT) ≥1,000 Central
nervous system (CNS)—impaired consciousness
● Heart and other organs involvement
Paediatrics 123

Classification of dengue based on the severity is shown in fig 1

Management of dengue:

Complete blood count is a simple bedside investigation and the trend of hematocrit is the most-
important parameter to decide therapy. In children with warning signs renal and liver dysfunction
should be monitored. Leucopenia, thrombocytopenia and elevated hematocrit are seen in dengue
during the leak phase. C reactive protein is usually normal in dengue. Elevated liver enzymes
(SGOT more than SGPT), coagulopathy, and hypoalbuminemia. elevated urea creatinine, hypo-
natremia, metabolic acidosis, elevated lactate are frequent in Dengue. Ferritin should be cautiously
interpreted as it is elevated in dengue, yet may not need intervention unless worsening with hae-
mophagocytosis. NS 1 antigen in the first 3-5 days of illness and dengue IgM and IgG antibodies
after day 5 of illness help for microbiological confirmation.

Figure1 Classification of Dengue and triaging

Group A needs only paracetamol for fever, adequate hydration and monitoring for warning signs.
Group B need to be monitored continuously during the afebrile phase and needs prompt fluid ther-
apyas given in Fig 2. Group C needs ICU management with more frequent monitoring as given in
Fig 3 .Shock and fluid load are the reasons for mortality.
124 MMC PRACTICE PROTOCOLS

Figure 2 Management of dengue with warning signs

Figure 3 Management of severe Dengue

(Fig, 3-Adopted from IAP standard treatment guidelines 2022)

Criteria for discharge: Afebrile, no respiratory distress, return of appetite, good urine output, plate-
let>50,000, 2-3 days after recovery of shock and visible clinical improvement.
Psychiatry

Alcohol dependence
Introduction: Alcohol dependence is a chronic relapsing and recurring condition - requires
a continuous and prolonged care over a long period of time.

Age of onset: typically starts from early teen and peaks in mid-20’s.

Risk factors: family history, comorbid psychiatric conditions, social and cultural factors.

Diagnosis: Based on ICD 10, alcohol dependence is characterized by a pathological pattern of alco-
hol use that causes serious impairment in social or occupational functioning.

Figure 1: Assessment of alcohol use

125
126 MMC PRACTICE PROTOCOLS

Figure 2: Assessment of alcohol use and toxicity

Psychiatry 127

Figure 3: Assessment of alcohol withdrawal

Figure 4: Assessment of Delirium tremens

128 MMC PRACTICE PROTOCOLS

Management of alcohol withdrawal and detoxification:

Benzodiazepines: Used in withdrawal due to cross tolerance with alcohol. Long acting BZD is better
in prevention of seizures and delirium tremens. Short acting BZD (Oxazepam and Lorazepam)
are preferred in liver damage, elderly and in cognitive impairment.

Thiamine supplementation: all cases of alcohol dependence to be given thiamine supplementation

Maintenance of abstinence: anti-craving drugs (naltrexone, acamprosate, baclofen), aversive agent
(disulfiram) – under supervision can be used.

Anti-anxiety agents like SSRI to reduce comorbid anxiety and depressive disorders Antipsychotics:
useful in patients developing psychotic symptoms due to alcohol use.

Psychological interventions: Motivational enhancement therapy, self-help groups (AA) are very
effective.

NOTE: All the references, algorithms and flow charts are based on clinical practice guidelines of Indian
Psychiatric Society.
Psychiatry 129

Anxiety Disorders
Introduction:

It is the most common mental health problem characterized by intense, excessive and persistent
worry and fear about everyday situations. Anxiety disorders can cause significant distress and
impairment in daily functioning.

Age of onset: Symptoms may start during childhood or the teen years and continue into adulthood

Risk factors: Genetic factors, hypothalamic-pituitary axis abnormalities, childhood abuse, neuro-
chemical factors, stress, smoking, alcohol, comorbid medical conditions and other illicit substance
use.

Diagnosis:

Generalized Anxiety Disorder (GAD): excessive worry and stress that interferes with daily life.

Panic Disorder: sudden and intense episodes of fear or anxiety with symptoms like palpitations,
chest discomfort, shortness of breath, and dizziness.

Agoraphobia: fear of open spaces or public places.

Social Anxiety Disorder: extreme self-consciousness and fear of social situations.

Specific Phobias: characterized by extreme fear of specific objects or situations (heights, animals,
blood, needles, etc).

Investigations:

Anxiety disorder is a clinical diagnosis due to the presence of specific features. But the other
medical conditions like substance withdrawal, hypoglycemia, cardiac abnormalities, respiratory
problems, thyroid and other endocrine causes and metabolic causes to be ruled out.

Figure 5: Management of Anxiety Disorders in Special Population

130 MMC PRACTICE PROTOCOLS

NOTE: All the references, algorithms and flow charts are based on clinical practice guidelines of Indian
Psychiatric Society.

Figure 6: Management of Generalized Anxiety Disorder

Figure 7: Management of Panic Disorder

Psychiatry 131

Bipolar Disorder
Introduction:

A major mental illness characterized with disturbances in emotions and behavior. Bipolar disorder
is a mood disorder with episodes of both mania and depression. It has an episodic and chronic
course.

Age of onset: usually develops between late teen to early 20’s. Men have an earlier onset than women.

Risk factors: Genetic factors, hypothalamic-pituitary axis abnormalities, childhood abuse, neuro-
chemical factors, brain damage, stress, smoking, alcohol, social isolation and other illicit substance
use.

Diagnosis:

Mania: characterized by an abnormal and persistently elevated, expansive or irritable mood, which
leads to impairment in social and/or occupational function. Other main symptoms are increased
energy, excessive talk and grandiose ideas. If these symptoms last more than a week a diagnosis of
bipolar disorder – mania is made as per ICD -10.

Depression: characterized by a persistently low mood or loss of interest/pleasure in normal activ-

ities. Other main symptoms are Insomnia, Feelings of worthlessness/ helplessness and suicidal
thoughts. If these symptoms last more than two weeks a diagnosis of bipolar disorder – depression
is made as per ICD -10.

Investigations:

Bipolar disorder is a clinical diagnosis due to the presence of specific features. But the other med-
ical conditions like substance withdrawal, infections, organic brain disease, endocrine causes,
metabolic and nutritional causes to be ruled out.
132 MMC PRACTICE PROTOCOLS

Figure 8: Initial evaluation and management plan for Bipolar disorder

Psychiatry 133

Figure 9: Management of Hypomania/ Mania/Mixed Episode

134 MMC PRACTICE PROTOCOLS

Figure 10: Management of Bipolar Depression

NOTE: All the references, algorithms and flow charts are based on clinical practice guidelines of Indian
Psychiatric Society.
Psychiatry 135

Depression
Introduction:

A common mental illness characterized by low mood and anhedonia. It is a leading cause of dis-
ability and contributes significantly to the global burden of disease.

Age of onset: common among all age groups with high risk in the early 40’s. Females have more
prevalence than males

Risk factors: Genetic factors, hypothalamic-pituitary axis abnormalities, childhood abuse, neuro-
chemical factors, chronic medical conditions, old age, brain damage, stress, smoking, alcohol,
social isolation and other illicit substance use.

Diagnosis:

Depression: characterized by a persistently low mood or loss of interest/pleasure in normal activities.

Other main symptoms are Insomnia, Feelings of worthlessness/ helplessness, suicidal thoughts.

If these symptoms last more than two weeks causing impairment in function a diagnosis of depres-
sion is made as per ICD -10.

Depression is classified into three categories as mild, moderate and severe. Depression with sui-
cidal risk and psychotic symptoms are classified as severe.

Investigations:

Depression is a clinical diagnosis due to the presence of specific features.

But the other medical conditions like substance withdrawal, infections, organic brain disease,
endocrine causes, metabolic and nutritional causes to be ruled out.
136 MMC PRACTICE PROTOCOLS

Figure 11: Initial evaluation and management plan for Depression

Psychiatry 137

Figure 12: Treatment algorithm of mild to moderate Depression

138 MMC PRACTICE PROTOCOLS

Figure 13: Treatment algorithm of Severe Depression

NOTE: All the references, algorithms and flow charts are based on clinical practice guidelines of Indian
Psychiatric Society.
Psychiatry 139

SCHIZOPHRENIA
Introduction:

A major mental illness characterized with disturbances in thought, emotions and behaviour. It is
a condition which can have a chronic and a varied course.

Age of onset: usually develops between late teen to early 20’s. Men have a higher incidence and
illness develops earlier than in women.

Risk factors: Genetic factors, neurochemical factors(dopamine), brain damage, stress, smoking,
alcohol, social isolation and other illicit substance use.

Diagnosis:

Positive symptoms: Delusions, hallucinations (auditory > visual), disorganized thinking Negative
symptoms: social withdrawal, affective flattening, lack of motivation, reduced speech

If the patient is suffering from these symptoms for more than a month a diagnosis of schizophrenia
is made as per ICD -10.

Investigations:

Schizophrenia is a clinical diagnosis due to the presence of specific features. But the other medical
conditions like substance withdrawal, infections, organic brain disease, metabolic and nutritional
causes to be ruled out.
140 MMC PRACTICE PROTOCOLS

Figure 14: Initial evaluation and management plan for schizophrenia

Psychiatry 141

Figure 15: Evaluation of patient with non-response to antipsychotic medications

NOTE: All the references, algorithms and flow charts are based on clinical practice guidelines of Indian
Psychiatric Society.
Rheumatology

SPONDYLOARTHROPATHY

142
Rheumatology 143

RHEUMATOID ARTHRITIS
144 MMC PRACTICE PROTOCOLS

SYSTEMIC SCLEROSIS
Rheumatology 145

SYSTEMIC LUPUS ERYTHEMATOSUS

146 MMC PRACTICE PROTOCOLS

GOUT
Department Transfusion
Medicine
Acute Transfusion
Reac on (<24 hrs)

Look for Physical

cause of hemolysis
Repeat Blood Grouping

Non Immune HTR

NEGATIVE

YES Sign of NO YES

ABO
DCT Hemolysis ABO AHTR
Mismatch

No
Iden fy NON Yes
the ABO DCT
HTR Others
an body (UCT)
NEGATIVE

GENERAL SYMTOMS RESPIRATORY SYMTOMS ‚DYSPNOEA, RR„ CARDIOVASCULAR SYMPOTOMS

 Chills, Rigors  Itching  Hypoxemia  HR  HR ISOLATED  BP

 1-C or 1.8F rise  Rash  B/L infiltrates  BP  BP HR  BP by
in temp.  Edema on lungs  Posi ve  Evidence >30mm Hg
 Rule out  Ur caria  No evidence Fluid of Bronhos systolic or
Bacterial of Circulatory Balance pasm systolic B.P
Contamina on overload ≤80mm Hg
 Circulatory  Laryngeal
 Hypotension overload symptoms Anxiety

Allergic
FNHTR Reac on

TRAL I TACO Anaphylac c TAH

Reac on

NOT FITTING INTO ANY OF THE ABOVETAD

147
148 MMC PRACTICE PROTOCOLS

CRYOPRESERVATION OF HAEMATOPOIETIC STEM CELLS

For 250ml of stem cells

Add 125mL of normal saline in a satellite bag

Add 35mL of DMSO ( Dimethlsulfoxide) in that transfer

bag

Refrigerate the above mixture in the BBR (2-4 °C)

for 2 hours

By the awaing me, add 250mL of the stem cell product

in the cryo bag

A€er 2 hours of storage in BBR, add 94mL albumin in the

cryomix& Followed by heparin 5000IU (1mL) in the
cryomix bag

Add the equal volume of cryomix and stem cell product

in the cryobag by gentle agitaon and properly mixing
the content

Keep the above cryobag in -80°C -40°C

Department Transfusion Medicine 149

ABO Incompable Blood Transfusion: Challenging yet lifesaving in the

management of acute severe autoimmune hemolyc anemia (AIHA)

Paent blood sample and cross

cr match requision

Requision details entered in

n Cross
Cros match/ Blood issue
register

Confirmaon of paent
aent blood group

YES Resolve as per standard operang

Discrepancy procedure (SOP)

Cross matching off requ

required units

YES
Compable Documentaon and issue

NO

Immunohematology work up Minimum test required

DAT IAT
AUTO CONTROL

Posive
Tesng with
h Polyspecific
Poly AHG Transfusion/Pregnancy
CXM angen
Posive
Anbody screened
eened and idenfied negave blood
Tesng with Monospecific
Adsorpon & Eluon
The remaining eluate is used to run the Issue best match
IgG Ab screening and idenficaon

To run cold Ab tre at 4˚C if >1:64 is

C3d/c3b considered as significant
150 MMC PRACTICE PROTOCOLS

ADULT MASSIVE TRANSFUSION PROTOCOL

Paent at Risk of Massive Bleeding

Major Trauma/Surgery Hemodynamically unstable paent ± ongoing bleeding

2 Units of O -Ve PRBC’s+ Immediate need for Transfusion

2 Units of AB FFP
Check for ongoing Bleeding
Refer the paent to higher YES
No
centre if the paent is in PHC

Ancipate if total need is more Convenonal resuscitaon on going

than 10 units evaluaon at interval

YES
No

Baseline Test OPTIMIZE

 CBC, Blood Grouping & Rh Typing  Oxygenaon
 Coagulaon screen(PT/aPTT/INR/Fibrinogen)  Cardiac output
 ROTEM  Tissue perfusion
 Electrolytes, ABG  Metabolic state
 Tranexamic acid as per indicaon

Acvate MTP

6 Units of PRBC
6 Units of FFP
1 Unit of SDP
Include Cryoprecipitate, if

Inial Lab Results

Normal Limits
Repeat Inial MTP Pack
Consider recombinant Factor VII a may be given
YES No
a–er 2 – 3 rounds of MTP pack.

Check for ongoing bleed

Repeat Lab Test
No

Stop MTP

Normalized Lab values, No

evidence of ongoing bleeding
Department Transfusion Medicine 151

PAEDIATRIC MASSIVE TRANSFUSION PROTOCOL

Paent at Risk of Massive Bleeding with shock or abnormal coagulopathy

Unstable Paent with ongoing bleed

< 10 kg < 20 kg < 45 kg

1 adult RBC, O -Ve 1 adult RBC, O -Ve 1 adult RBC, O -Ve

15 ml/kg 150 ml

Baseline Test
Inform Transfusion Medicine (Blood Bank)  CBC
 Coagulaon
screen(PTT/aPTT/INR/Fibrinogen)
 Electrolytes, ABG
Acvate MTP  Tranexamic acid as per indicaon

First Box First Box First Box

1 Adult RBC, 1 Adult FFP, 1 Adult RBC, 1 Adult FFP, 0.3 2 Adult RBC, 2 Adult FFP, 0.3
1 cryoprecipitate, 1 ml/kg Calcium gluconate ml/kg Calcium gluconate
Platelets
Second Box Second Box
Transfuse 10 ml/kg in 1 Adult RBC, 1 Adult FFP, 0.3 2 Adult RBC, 2 Adult FFP, 0.3
the following order ml/kg Calcium gluconate, ml/kg Calcium gluconate,
1 cryoprecipitate 2 cryoprecipitate
 Packed Red Cells, FFP
 Packed Red Cells,
Third Box Third Box
Cryo
1 Adult RBC, 1 Adult FFP, 0.3 2 Adult RBC, 2 Adult FFP, 0.3
 Calcium gluconate
ml/kg Calcium gluconate, ml/kg Calcium gluconate,
0.45 ml/kg
150 ml of platelets 1 adult platelets
 Packed Red Cells, FFP
 Packed Red Cells,
Alternate 2nd and 3rd Box
Platelets
 Calcium
gluconate 0.45 ml/kg
 Check for potassium
values Repeat the lab results every 30 minutes

Repeat Check for potassium values

152 MMC PRACTICE PROTOCOLS

PATIENT BLOOD MANAGEMENT WITH

ROTEM

Paent with acute bleeding

ng with
wi elevated PT/ INR

Blood sample collected in sodium

m citra
citrate ancoagulant tube

Non Heparinized Paents Heparinized Paents

To do To do
EXTEM INTEM

If CT Prolonged
olong If CFT Prolonged
Prolo If CT Prolonged

Clongng factor
fac FIBTEM
TEM
Rule out Hepar
Heparin
deficiency
induced Coagulopathy

Give Fresh
h
Iff A10 If A10
10
Frozen Plasma
Normal Abnormal Runn
(FFP)
10 -12ml/Kg HEPTEM
to confirm
Platele
Platelet Fibrinogen
brinog
deficiency deficiency
If HEPTEM
TEM
Normal/Decreased

If needed Give
e
Platelets cryoprecipitate
5-10mL/Kg 1 Unit/10kg Heparin
rin
induced
Coagulopathy
Thoracic Medicine

153
154 MMC PRACTICE PROTOCOLS
Thoracic Medicine 155
156 MMC PRACTICE PROTOCOLS

PNEUMOTHORAX MANAGEMENT PROTOCOL

Thoracic Medicine 157

APPROACH TO TREATMENT
158 MMC PRACTICE PROTOCOLS
Venereology
HERPES GENITALIS

C/o : Fluid filled lesions over the

external genitalia

C/o: Painful ulcer over the external

genitalia.

Detailed clinical history and physical

examination

O/E - Multiple grouped vesicles on an

erythematous base / Multiple, tender,
superficial erosions with polycyclic border
over the external genitalia with painful
inguinal lymphadenopathy

Investigations

• Bedside investigation
Tzanck smear - Multi nucleated giant cells
• ELISA for HSV 1& 2 IgM
• ELISA for HIV 1 &2 antibody
• Blood VDRL

Management

• Tab . Acyclovir 400 mg TDS x 7 days

• Safe sexual practices
• Counselling and condom promotion
• Partner screening and management

159
160 MMC PRACTICE PROTOCOLS

VULVOVAGINAL CANDIDIASIS

C/o: Vaginal discharge on and off

H/o burning sensation over the external

genitalia

Detailed clinical history and physical examination

O/E

• Vulval erythema
• Fissures over the vulval region
• Maceration and soddening
• Curdy white vaginal discharge

Bed side investigations

Vaginal discharge

• KOH smear – Pseudohyphae

and spores +
• Candida culture

Management

Uncomplicated vulvovaginal candidiasis

• Tab Fluconazole 150 mg 1 Stat

• 2% clotrimazole cream for external
application – two weeks
• Partner screening and management
Venereology 161

ACUTE GONOCOCCAL URETHRITIS

C/o: Urethral discharge

H/o Burning micturition

Detailed clinical history and physical examination

O/E

• Purulent , moderate to profuse urethral

discharge
• Whitish to grey colored urethral discharge
• Urethral meatal erythema
• Assess for complications

Bed side investigations

• Urethral discharge

1. Grams stain - gram negative

intracellular diplococci
2. Gonococcal culture

• Screening for other STI s

Management

1. Tab Cefixime 400 mg 1 stat

2. Sexual partner – Epidose treatment
3. Safe sexual practices
4. Counselling and condom
promotion
5. Screening for other STIs
162 MMC PRACTICE PROTOCOLS

GENITAL WART
C/o : Raised skin lesions over the
external genitalia

Detailed clinical history and physical

examination

O/E

• Single or multiple ,verrucous

surfaced ,papules or plaques
over the external genitalia

Investigations

• Excision biopsy if necessary

• ELISA for HIV 1 &2 antibody
• Blood VDRL

Management

• Treatment options
1. 20% podophyllin external application -6
sessions at weekly intervals
2. Cryotherapy using liquid nitrogen
6 sessions at weekly intervals
3. TCA(Trichloro acetic acid) 80 % External
application
4. Radiofrequency ablation
5. Excision
• Treatment varies according to the age, sex, site,
pregnancy status and immunosuppression.
• Safe sexual practices
• Counselling and condom promotion
Venereology 163

PRIMARY CHANCRE

C/o: Painless ulcer over the

external genitalia

Detailed clinical history and physical examination

O/E

• Single, nontender , indurated, round to oval ulcer

with serous exudate over the external genitalia.
• Bilateral nontender , inguinal lymphadenopathy +

Investigations

• Bed side investigation:

Dark field microscopy from the
serous exudate - Motile
treponemes +
• Blood VDRL
• Serum TPHA
• ELISA for HIV 1 &2 antibody

Management

• Inj. Benzathine penicillin 2.4 MU single dose

deep intramuscular after test dose

Alternative regimens

• Cap. Doxycycline 100 mg twice daily –two weeks

• Tab. Erythromycin 500 mg qid – two weeks

Regular follow up till 2 years

Sexual partner – Epidose treatment

Safe sexual practices

Counselling and condom promotion

SURGICAL

Anaesthesia

AIR EMBOLISM
● Call for help, communicate the problem and delegate roles and responsibilities.
● Prevent further entrainment of air.
● Flood the operative field.
● Ventilate with 100% O2. Avoid Nitrous Oxide.
● Place the patient in a head down, lateral position.
● Consider the use of PEEP.
● Aspirate the CVC. Attempt closed cardiac massage.
● Commence IV fluid therapy and keep hydrated.
● Use Adrenaline for haemodynamic support.Consider PACU admission following
successful resuscitation
Aspirate only if a central venous catheter or pulmonary artery catheter is in place.

Closed cardiac massage has been shown to break up large volumes of air in the cardiac chambers.

Drug dosages Adult:

Adrenaline : Bolus 25 to 100mcg.

Infusion of 3mg in 50ml commenced at 5ml/hour.

Paediatric:

Adrenaline : Bolus 0.1mcg/kg.

Infusion 0.05–0.5mcg/kg/min

164
Anaesthesia 165

CANT INTUBATE CANT VENTILATE

Scalpel Cricothyroidotomy

If the anatomy is palpable.

● Identify cricothyroid membrane by “laryngeal handshake”

● Stab incision through skin and membrane. Enlarge with dilator or blunt dissection (scalpel
handle or forceps).
● Caudal traction on cricoid cartilage with tracheal hook.
● Insert 6mm ETT or tracheostomy tube.
● Ventilate from a standard low pressure source.
● Confirm ventilation with EtCO2.

Alternatively, once a horizontal stab incision is made, the scalpel blade can be rotated caudally and
with lateral pressure allowing a space for a ventilating bougie to be passed.

If the anatomy is not palpable, a 6 to 8cm midline vertical neck incision with blunt finger dissec-
tion to separate the strap muscles will expose the trachea. Rest of the steps remain as mentioned
above.

In all cases, once there has been successful oxygenation, early conversion to a definitive airway is
required.

CICV sometimes referred to as CICO (can’t intubate can’t oxygenate).

LARYNGOSPASM
● 100% oxygen.
● Cease all stimulation.
● Remove airway devices and suction*.
● Apply gentle CPAP with jaw thrust.
If spasm persists and desaturation continues,

● Call for help, communicate the problem and delegate.

● Deepen anaesthesia.
● Give Suxamethonium and continue CPAP.
● Intubate if SpO2 does not improve
● Consider atropine 10–20mcg/kg for the treatment of associated bradycardia
The situation deteriorates rapidly in children.
166 MMC PRACTICE PROTOCOLS

Deepening anaesthesia is an option in adult anaesthesia. Rapid development of hypoxia in children

usually precludes this.

Spasm will ‘break’ with sufficient hypoxia and time, but predisposes to bradycardia, cardiac arrest,
regurgitation and pulmonary oedema. These can be prevented with early intervention.

Dosage: suxamethonium 0 .1 to 1mg/kg IV.

2 to 4mg/kg IM/IO/IL.

Consider stomach deflation before emergence.

In a rapidly desaturating child, immediate intubation without relaxation may be the appropri-
ate treatment.

IO=Intraosseous. IL=Intralingual

LOCAL ANESTHETICS SYSTEMIC TOXICITY

● STOP giving the drug.
● Call for help, communicate the problem and delegate.
● Review the airway, secure if necessary with intubation and ventilate with 100% O2.
● Commence CPR if there is circulatory arrest.
● Secure intravenous access and treat convulsions.
● Follow standard arrhythmia protocols .
● Administer 20% intralipid intravenously.
● Consider cardiopulmonary bypass if readily available

Drug dosages

Anticonvulsants

Midazolam 0.05-0.1 mg/kg

Diazepam 0.1-0.2 mg/kg

Thiopentone 1mg/kg

Propofol 0.5-2 mg/kg

Intralipid regimen

Immediately: 1.5mg/kg bolus over 1 minute (100ml in adult).

Commence infusion of 15ml/kg/hr (1000ml per hour in adults).

At 5 minutes: Repeat the bolus dose and double the infusion rate if not responding.
Allow a total of three bolus doses 5 minutes apart
Anaesthesia 167

SEVERE INTRAOPERATIVE HEMORRHAGE

● Call for help, communicate the problem and delegate roles & responsibilities.
● Confirm there is surgical effort to control bleeding.
● Switch to 100% oxygen until the crisis is resolved.
● Use vasopressors only if necessary to maintain vital organ perfusion.
● Warm fluids. Warm theatre. Warm patient.
● Insert two 14g cannulae and consider an 8.5FG PA sheath.
● Contact blood bank to crossmatch blood early and consult transfusion specialist to plan
component therapy.
● Utilize the rapid fluid infuser and cell saver.
● Consider antifibrinolytic agents.
● Carefully monitor calcium levels.
● Establish bedside monitoring: Arterial line, urinary catheter, CVP, temperature ,
ROTEM.
● Follow up with laboratory testing: CBC, electrolytes, ABG, clotting screen.

THERAPY INDICATION INITIAL DOSAGES

FFP PT,aPTT<1.5 normal, 15ml/kg
Fibrinogen <1g/L
Cryoprecipitate Fibrinogen <1g/L 5-10ml/kg
Tranexmic Acid Fibrinolysis 1g IV over 10min
Then 1g over 8hrs
Platelets Platelet count <75x109 15-20ml/kg
Cardiothoracic Surgery

168
Cardiothoracic Surgery 169
170 MMC PRACTICE PROTOCOLS
Cardiothoracic Surgery 171
172 MMC PRACTICE PROTOCOLS
Cardiothoracic Surgery 173

VALVULAR HEART DISEASE

RHEUMATIC VALVULAR DEGENERATIVE VALVULAR HEART

HEART DISEASE DISEASE

STENOTIC REGURGITANT REPLACEMENT

MS AS AR MR

MEDICAL MANAGEMENT
1. ASO ELEVATED

2. CRP REVIEW AFTER 6 WEEKS

WNL
3. ESR
SURGICAL EVALUATION

>40 CAG

NORMAL CAD CABG+ VALVE REPLACEMENT

CORONARIES

1. WITHOUT SUB VALVULAR DISEASE

2. YOUNG AGE
3. WITHOUT - DENSE ANNULAR / LEAFLET CALCIFICATION

REPAIR
Endocrine Surgery
APPROACH TO HYPERCALCEMIA

Increased
serum calcium
levels

Proper history,clinical
examination,Creatinine,electrolytes,phosphorus,albumi
n,Vitamin D ,PTH,ALP

PTH high
PTH LOW PTH Normal
phosphorus low
vitamin D Normal/low
vitamin
D
search for
malignancies <30ng
/ml
suggestive of PHPT >30ng/ml
correction of vit D
60000IU Weekly for
8 weeks

repeat PTH suspect

normohormonal
PHPT
LOCALISATION IMAGING
(Ultrasound neck and
sestamibi scan)

corcondant Discordant
Non localised

4 gland exploaration
Focused and parathyroidectomy
parathyroidectomy Other imaging modalities like
4D CT,fluorocholine PET CT
scan

localised
Non localised

surgery

Neck exploration/observation

174
Endocrine Surgery 175

APPROACH TO HYPERTHYROIDISM

Suspected Hyperthyroidism

↑↔TSH ↓TSH ↓TSH

↑Total T3/Free T4 ↔Total ,T3/Free T4 ↑Total T3/Free T4
↑↑ Β-hCG

Secondary Subclinical Overt Β-hCG associated

Hyperthyroidism Hyperthyroidism Hyperthyroidism Hyperthyroidism

MRI
Pituitary gland- to
rule out TSH adenoma
Graves’ disease? thyrotoxicosis,pregnancy,
Yes -Graves Ophthalmopathy Β-hCG
- myxedema

Check TRAb High suspicion No

-ve
+ve
Tc99m uptake scan /

Low uptake

High uptake

Check -TPO Ab
-TG Ab

Diffuse Nodular
-ve
+ve

Graves’ disease AFTN MNG -

Early Hashimoto
-Iodine
-Struma ovary
(leaking preformed -Amiodarone
Medical treatment hormones) -
followed by Hemithyroidectomy
Total
RAI/Surgery
Thyroidectomy
c Mx
176 MMC PRACTICE PROTOCOLS
Endocrine Surgery 177

Algorithm to approach a thyroid nodule

Thyroid nodule found

clinically incidentally

History taking, physical examination,

measurement of TSH

Normal / high TSH Low TSH

Thyroid Ultrasound Scan

TRAB Test AMA/ATG
No Nodule Nodule (+)
Thyroiditis Inconclusive

-Benign - Low suspicion TC 99 scan

Followup/ - Intermediate Suspicion
observation -Very Low suspicion
- High Suspicion
Treat
Hyperthyroidism
USG guided FNAC
USG guided FNAC
done irrespective
If nodule > 1 cm
of size of nodule

FNAC / Bethesda classification

Non diagnostic Repeat FNAC under USG guidance

Benign Repeat FNAC / Surgery

Hemithyroidectomy (Frozen section)

AUS / FLUS / Total thyroidectomy
Follicular neoplasm
Hemithyroidectomy (Frozen section)
/ Suspicious of
/ Total thyroidectomy
Follicular neoplasm
Suspicious of
Malignancy Total thyroidectomy
Malignancy
178
General Surgery

Schwartz’s Principles of Surgery, 11

General Surgery 179
–
180 MMC PRACTICE PROTOCOLS

Hamilton Bailey’s Emergency Surgery, 13

 General Surgery

Harrison’s Principles of Internal Medicine, 19

181
 182

Shackelford’s Surgery of the Alimentary Tract (8

MMC PRACTICE PROTOCOLS
Intervention Radiology
–

183
184 MMC PRACTICE PROTOCOLS

•
•
• – •
•

•
•


 


Intervention Radiology 185

–
186 MMC PRACTICE PROTOCOLS

• •
• •
• •
•
•

•
•
•
•
•
•

• • •
• • •
• •
• •
• •

•
• •
•
•
•
•
Intervention Radiology 187

Percutaneous transhepac biliary

drainage procedures
INDICATION:
Treatment for biliary obstrucon (pre op decompression, malignant stricture, failed ERCP), cholangis, bile duct injury,
complex strictures, to facilitate intra ductal procedure like biopsy and brachytherapy for cholangiocarcinoma.
CONTRA INDICATION:
FOR PTBD :Absolute: Uncorrectable coagulopathy. Relave : large volume ascites, hemodynamic instability.
FOR STENTING : infected bile, acve hemobilia, coagulopathy, worsening LFT despite adequate drainage, Life
expectancy < 30 days, intra ductal stones/debris

Pre op invesgaon Imaging Pre op PREPARATION

WBC, PLATELET, PT -INR, Confirm diagnosis To opmise INR<1.7,
LFT, RFT. USG/MRCP/CECT Platelet>50000IU, IV access and
To establish base line conjugated Look for IHBR dilataon and site hydraon, IV anbiocs (gram –
and unconjugated bilirubin level of obstrucon, communicang or ve) within 1 hr pre-procedure.
not.
INTERVENTIONAL Biliary obstrucon confirmed with Acute cholecyss
RADIOLOGICAL
DIAGNOSTIC imaging Poor surgical
candidate
PROCEDURE
INTERVENTIONAL RADIOLOGICAL
PROCEDURE
Percutaneous
In Cholangis Percutaneous
transhepac
Cholecystostomy
Cholangiogram

PTBD with palliave

PTBD with external PTBD with biliary PTBD with external
stenng, 2o stenng
drainage stricture dilataon + internal drainage
if bilirubin > 5
Neurosurgery

MANAGEMENT ALGORITHM FOR ACUTE SUBDURAL HEMORRHAGE

Acute SDH >65years

3-8 GCS 9-15

Pupils
Vigilance

-/- -/+ +/+

N0 SURGERY- Midline shi

Decrease Stable
Mortality almost
100%

>10mm <10mm

SURGERY-
Difference between OBSERVATION
Good
hematoma and shi SURGERY prognosis
good –
<0 >0 moderate
results
ICP
(mmHg)

SURGERY-
Moderate
>40 <40 prognosis

NO SURGERY

188
Neurosurgery 189

MANAGEMENT ALGORITHM FOR C2 FRACTURES

COMPUTED TOMOGRAPHY
C2 RING FRAQCTURE

NO FRACTURE DISLOCATION >2MM YES

AND/OR ANGULATION C2/3>11”?

MRI NO MRI NO FACET JOINT C2/3LOCKED?

DISCC2/3 , PLL INTACT? ALLC2/3 INTACT? (UNI OR BILATERALLY)

YES NO
YES YES

LEVINE I/ JOSTEN 1 LEVINE IIA/JOSTEN 2 LEVINE II/JOSTEN 3 LEVINE II/JOSTEN 4

STABLE POTENTIAL UNSTABLE UNSTABLE UNSTABLE

NO YES

DYNAMIC X-RAY
DISLOCATION/SEVERE LORDOSIS
C2/3 IN EXTENSION?

FOR LEVINE TYPE IIA HANGMAN’S FRACTURE , SURGERY IS RECOMMENDED

LEVINE TYPE 3 HANGMAN FRACTURE MAY REQUIRE BOTH ANTERIOR AND POSTREIOR SURGERY

CONSERVATIVE TREATMENT FOR HANGMAN FRACTURE SHOULD BE PERFORMED WITH A RIGID COLLAR
INSTEAD WITH HALOVEST DUE TO ITS COMPLICATIONS
190 MMC PRACTICE PROTOCOLS

MANAGEMENT ALGORITHM FOR EPIDURAL

HEMATOMA

EPIDURAL HEMATOMA

EDH> 30cc

Surgical GCS 8 or less

evacuation
Thickness >15mm

Midline shift >5mm

Focal neurological deficit

Timing: ASAP if
anisocoria

Method: Craniotomy Close neurological

preferred observation with
serial CT scanning
in neurosurgical
centre possible
Neurosurgery 191

MANAGEMENT ALGORITHM FOR ACOUSTIC

TUMORS

TUMOR SIZE AND BRAINSTEM COMPRESSION

INTRACANALICULAR TUMOR DIAMETER <3 CM, TUMOR DIAMETER >3 CM,

TUMOUR NO OR MILD BRAINSTEM SIGNIFICANT BRAINSTEM
COMPRESSION COMPRESSION

AGE, HEALTH REVIEW OF TREATMENT MICROSURGERY

GOALS, PATIENTS CHOICE

>75 YRS <75YRS

RESIDUAL TUMOR COMPLETE
RESECTION

OBSERVATION OBSERVATION MICROSURGERY RADIOSURGERY

DOCUMENTED DOCUMENTED RESIDUAL OR DOCUMENTED

TUMOR TUMOR RECURRENT TUMOR
GROWTH GROWTH TUMOR GROWTH

RADIOSURGERY MICROSURGERY RADIOSURGERY MICROSURGERY

192 MMC PRACTICE PROTOCOLS

MANAGEMENT ALGORITHM FOR MENINGIOMA

A. PRESENTATION

Radiographic diagnosis: Possible meningioma

Meningioma by radiographic criteria Consider biopsy/resection
-Dural-based mass OR Consider octreotide scan if diagnostic
-Homogenously contrast-enhancing doubt exist

-Dural tail

-CSF cleft

asymptomatic symptomatic

TUMOUR Small Large

Large
SIZE Small <30mm >30mm
>30mm
<30mm

Observe (preferred) Surgery if accessible, Surgery if accessible, Surgery if accessible,

or followed by RT if WHO followed by RT if WHO
Grade 111; consider Grade III
Surgery if potential neurologic followed by RT if WHO
RT for resected or
consequences and if Grade III ; consider RT
incompletely resected Or
accessible, followed by RT if for resected or
WHO Grade II or
WHO Grade III and consider RT incompletely resected
Incompletely resected WHO Grade II or
RT for resected WHO Grade II WHO Grade I
incompletely resected
Or Or WHO Grade I
Radiotherapy if potential Observe Or
neurologic
consequences from surgery RT

B. FOLLOW UP
Surgery if accessible RT primary or re-irradiation

WHO Grade I and Not surgically accessible Further RT possible RT

II or unresected
meningiomas:MRI Recurrent
at 3,6, and 12 disease Not surgically accessible Further RT not CHEMOTHERAPY
monthsthen every possible
6-12 mo for 5 yrs,
then every 1-3
years
Treatment not clinically indicated OBSERVATION
Obstetrics and Gynaecology

193
194 MMC PRACTICE PROTOCOLS

GESTATIONAL DIABETES MELLITUS

Obstetrics and Gynaecology 195
196 MMC PRACTICE PROTOCOLS
Obstetrics and Gynaecology 197
198 MMC PRACTICE PROTOCOLS
 Management of
Cataract Cataract

Immature Mature

vision Surgery

199
Ophthalmology

Mild to Moderate Small Incision Phacoemulsificati

Severe
Defective Vision Cataract Surgery on

Glasses if vision Surgery if vision

Surgery
improves doesn’t improve

Small Incision Phacoemulsificati

Cataract Surgery on
 200
Refractive Errors
Vision

Children Adult

Cycloplegic
dilataon Improvement No improvement
Refracon, with glasses with Glasses
Renoscopy

Dilataon,
Renoscopy,
Subjecve Dilataon &
Refracon &
verificaon Renoscopy
Fundus
Examinaon

Fundus Fundus
Glass Prescripon
Examinaon Examinaon

Post mydriacc
Test & Treat the cause
Prescripon
MMC PRACTICE PROTOCOLS
Diabetic Retinopathy
Vision
Ophthalmology

Dilatation &
Fundus
Examination

Moderate
Mild Diabetic Severe Diabetic
Diabetic
Retinopathy Retinopathy
Retinopathy

Observation & Investigation

With Macular Without Blood Sugar
Control of (Fundus, OCT,
Edema Macular Edema Control
Blood Sugar FFA)

Investigation Observation & Laser Anti VEGF

(Fundus, OCT, Control of Intra Vitreal
FFA) Blood Sugar Injection

Posterior
Anti VEGF Intra
Grid Laser Segment
Vitreal Injection
Surgery
201
 202

Ocular Injuries Eye Injuries

Superficial Deep

Penetrating/P
Vision Blunt Chemical
erforating

Medical Conservative Vision

Management Management

Medical
Conservative
Management
Management
/Surgical
MMC PRACTICE PROTOCOLS
Management of Glaucoma

Glaucoma
Ophthalmology

Primary Secondary

Open Angle Angle Closure Open Angle Angle Closure

Vision, Tension, Vision, Tension,

Vision, Tension, Vision Tension
Fields, OCT – Fields, OCT –
Gonio Gonio
RNFL, Gonio RNFL, Gonio

Medical Surgical Medical Surgical Surgical

Suspect Closed Angle
management Management Management Management management

Surgical
Laser Iridotomy
Management
203
Orthopaedics
Management of Pediatric Supracondylar fracture of humerus

Pediatric supracondylar fracture

History Clinical examina on Xray of elbow in AP and

- History of trauma lateral view
- Nature of injury
- Time since injury Emergency situa on
- Any treatment - Severe swelling in the Assess the xray findings
elsewhere forearm and or elbow - Displacement of distal
- Na ve bandages - Skin puckering or fragment
anterior bruising - AP view: Varus/Valgus
- Open injury assessment by
- Neurovascular injury Baumann's angle
Vascular injury* - Lateral view:
- Absent radial pulse Neurological injury* Anterior/Posterior
-Capillary refill time - Check OK sign displacement by anterior
> 3 seconds - AIN injury in posterolateral humeral line
- Cold extremity displacement of distal
- Pale limb fragment
Flexion type or Extension type
- Radial nerve injury in
Perform Doppler posteromedial displacement
study and document - Ulnar nerve injury in flexion
findings* type

Type 1 Type 2 Type 3 Type4

Minimally >2mm displaced with Displaced Multidirectional
displaced an intact posterior fracture that instability
cortex and may lacks an intact
benefit from surgical cortex
-Anterior management
humeral line depending on the
intersects amount of Closed reduction with
middle third displacement percutaneous pinning
capitellum
-Minimal
swelling If not satisfactory, then open
present reduction and fixation with K-wires
-No medial
comminu on
Immobilization in an above elbow backslab in 90 degrees flexion with
sling for 3 weeks. Backslab should extend as high above the elbow as
possible (close to axilla) and down to the metacarpophalangeal joint.

Repeat radiographs at 1 week to asses any displacement. If no displacement convert into cast
(if initial slab holds good). Any loosening put fresh above elbow cast in 90 degree elbow
flexion. Give parent undisplaced fracture fact sheet. Weekly review with follow-up un l union

*In case of neurovascular injury and red flag signs the timing of surgery is as soon as possible in
emergency basis, otherwise to be taken up as elective case the next day. In case of
neurovascular injury, involve vascular surgery and plastic surgery department in management.

204
Orthopaedics 205

Management of Distal radius fracture

Distal radius fracture

History Clinical examina on Xray of wrist in AP and

- History of trauma lateral view
- Nature of injury
- Time since injury - Swelling and tenderness
- Any treatment in the wrist and hand Assess the xray findings
elsewhere - Open injury - Displacement of distal
- Native bandages - Shoulder and elbow fragment
status - Dorsal or volar tilt and
- Neurovascular injury displacement
- Radial tilt and
Vascular injury displacement
- Absent radial pulse Neurological injury* - Supination and
-Capillary refill me - Median nerve injury: Loss of Impaction
> 3 seconds sensation over lateral three
- Cold extremity and half fingers
- Pale Hand - Ulnar nerve injury: Loss of Assess the xray findings
adduction and abduction of - palmar itlt (normally 11
fingers with loss of sensa on degrees)
Perform Doppler - ulnar variance
study and document over medial one and half
fingers (normally −2 mm)
findings* - radial
height (normally 12 mm)
Classify the fracture (Frykman) - Intra-articular stepoff
<2mm

LaFontaine five’s factors indicative of instability: (1) initial dorsal angulation of more than 20
degrees (volar tilt); (2) dorsal metaphyseal comminution; (3) intraarticular involvement; (4) an
associated ulnar fracture; and (5) patient age older than 60 years

Stable patern Unstable patern

Closed Manual reduction: Under hematoma block, Closed reduction +

disimpaction by traction, Correction of dorsal percutaneous pinning +
tilt/displacement, correc on of radial Protection with POP slab
tilt/displacement and application of slab. Repeat xray
and check for alignment. If satisfactory continue slab If not sasisfactory, open reduc on
for 1 week, followed by cast conversion and follow-up and fixation with
until union pins/plates/external fixator

*In case of neurovascular injury and red flag signs the timing of surgery is as soon as possible in
emergency basis, otherwise to be taken up as elective case the next day. In case of
neurovascular injury, involve vascular surgery and plasticc surgery department in management.
206 MMC PRACTICE PROTOCOLS

Management algorithm for open fractures

First aid at Trauma ward or Splinting

casualty Bleeding control
Wound cover with wet saline dressing
Tetanus prophylaxis as per WHO guidelines
Management at - Saline wound wash, (Grade I open fractures – 3 litres, Grade II open fractures
emergency OT - 6 litres, Grade III open fractures - 9 litres)
- Thorough wound debridement of the entire injury zone
- External fixator application, spanning the joint if needed
- Wound cover in discussion with plastic surgery department
- Vascular repair if indicated
An bio c prophylaxis First generation cephalosporin (e.g., cefazolin 1-2 grams/8 hours) except for
patients with penicillin allergy, Clindamycin (600mg IV BD) is used
For more severe open-fracture wounds, add an aminoglycoside (eg.,
gentamycin 80 mg/8-12 hours).
If “agricultural” contamination is present, high-dose intravenous penicillin is
usually added (e.g., 5 million-10 million units/24 hours) and add
Inj.Metronidazole 500mg IV TDS

Definitive management of open fractures

Grade 1 Grade 2 Grade 3

- Thorough wash of - Thorough debridement - Thorough debridement of fracture at EOT

fracture at trauma ward of fracture at EOT + - External fixation & approximation of skin
- Primary Skin closure + Antibiotic prophylaxis edges without tension with tag sutures +
Antibiotic prophylaxis - External fixation and antibiotic prophylaxis
- Adequate skin cover without - Vascular repair if needed
immobilization with POP tension - Plastic surgery opinion regarding wound
splint - Early definitive internal cover & Redo debridement if needed
- Early definitive internal fixation as per fracture - Delayed definitive fixation – internal
fixation as per fracture fixation/ ring fixator/ LRS
Orthopaedics 207

Protocol for management of non-union

Patient with non-union

History Clinical examination Lab investigations

- Symptoms - Bone affected, - CBC
- Detailed history of abnormal mobility - ESR
injury mechanism - Joint affected - CRP
- Previous treatments - Soft tissue status - Renal functional Test
- Current disability - Limb deformity - HbA1c
- Smoking/ Alcohol - Limb length - Serum Calcium
- Diabetes discrepancy - Serum Vitamin D
- Immunodeficiency/ - Clinical signs of - Parathormone leves
Immunosuppressant infection - Wound swab from
medications - Neurovascular status sinus or wound if
- Medications including present
steroids
- Narcotics
- Allergy Radiological investigations
- Xray of the affected part AP & lateral view
- CT scan of the part with 3D reconstruction
- MRI in case of infected non-union to know the extent of
Paley lesion
classification
Weber Muller Judet Cech classifica on

Non-union management

Curetage of
nonunion site
208 MMC PRACTICE PROTOCOLS

Protocol for work up of bone tumour

Patient with bone tumour

History Clinical examination Laboratory investigations

- Onset of pain/swelling - Local examination of - CBC
- Rest pain swelling - ESR
- Disability due to swelling - Examination of lung, - CRP
- Treatment history thyroid, breast, renal, - Serum calcium
- Prior investigations prostrate - Serum phosphate
- Presence of pathological
- Alkaline phosphatase
fracture
- Lactate
dehydrogenase
Radiological examination - Serum parathyroid
- Prostrate specific
Xrays CT scan antige
1. Affected region AP and 1. Affected region with 3D - CA 125 (Cancer
lateral view reconstruction antigen)
2. Chest xray PA view 2. In case of unknown - CEA
3. Skeletal screening in primary whole body CT (Carcinoembryonic
case of multiple myeloma including Chest, antigen)
including skull, spine and abdomen, pelvis - Alpha fetoprotein
pelvis 3. Contrast CT if needed - Renal function test
- Liver function test
- Plasma
Angiogram MRI
1. To know the proximity electrophoresis
1. To know the
of tumour to vessel involvement of - Urinary Bence jones
2. To plan for resec on anatomical compartments protein
3. Therapeutic involved
emboliza on in case of 2. For staging of tumour
renal cell carcinoma and 3. Proximity to vital Other specialty opinions
aneurysmal bone cyst structures 1.Surgical, medical, and
4. Spinal cord radiation oncology
PET CT involvement in spinal opinion
1. In case of unknown tumours 2.OG opinion in case of
primary gynaecological tumours
3. General surgery
opinion for breast
Biopsy
tumours
1. Only after completion of all non-invasive investigations and
3. Surgical/Medical
other specialty opinion
endocrinology opinion for
2. Incision for biopsy should be marked by surgical oncology if
thyroid/adrenal tumours
they will be involved in surgical management
4. SGE/MGE opinion for
3. Incision should not cross different muscle compartments
Gastro-intestinal tumours
4. Drains should be avoided when possible. If needed should
5. CTS opinion for lung
be close and in line with skin incision, to facilitate later
tumours
removal of the region
5. Skin hatch marks should be minimal

Definitive treatment
1. All above findings should be presented at the tumour board
2. Definitive treatment plan in consensus with all involved departments
3. Individualized treatment depending on the situation – amputation/limb salvage/palliative
Otorhinolaryngology
Newborn Screening

209
210 MMC PRACTICE PROTOCOLS

COM (TUBOTYMPANIC DISEASE) MUCOSAL DISEASE

Otorhinolaryngology 211

COM (ATTICOANTRAL DISEASE) ACTIVE SQUAMOSAL DISEASE

212 MMC PRACTICE PROTOCOLS

Sinusitis
Otorhinolaryngology 213

Stridor Protocol
Paediatric Surgery

214
Paediatric Surgery 215
216 MMC PRACTICE PROTOCOLS
Paediatric Surgery 217
218 MMC PRACTICE PROTOCOLS
Plastic Surgery

219
220 MMC PRACTICE PROTOCOLS
Plastic Surgery 221
222 MMC PRACTICE PROTOCOLS
Plastic Surgery 223
 Composite Tissue defect
224

Thorough debridement

Assessment of defect

Grade I,II,III A injury Grade III B injury Grade III C injury

Fracture fixation f/b Local soft tissue

Emergent extremity revascularization
coverage
Is stable skeletal fixation achievable

Proceed with Internal or External Fixation Determine size of bone gap requiring
reconstruction

Once stable bone fixation achieved, need to • <5 cm : Conventional Bone grafting with coticocancellous grafts.
assess soft tissue defect • 5-10 cm:Distraction bone lengthening according to Lizarov principles or Free vascularized
bone graft.
• >10cm: Free vascularized bone graft (fibula)
• For major bone loss,antibiotic spacers are used to bridge gap until definitive bony
Middle 1/3 rd reconstruction is performed.
Distal 1/3 rd
Proximal 1/3rd Medial Gastrocnemius
• Distally based pedicle flap
Medial/Lateral gastrocnemius Soleus
(sural,peronel)
Free tissue transfer Tibialis anterior
• Free tissue transfer
Free tissue transfer

End to side anastomosis

1-2 artery runoff
If free tissue transfer is chosen,
must define blood flow to distal
extremity
3 atery run off End to end or end to side

• Fascial
Strict Post operative • Muscle
Choice of flap based on wound dimensions, depth of wound, weight bearing status of wound, vascularity
rehabilitation • Fasciocutaneous
of underlying tissue
• Myocutaneous
MMC PRACTICE PROTOCOLS
Plastic Surgery 225
Surgical Gastroenterology

Clinical features

Evaluation

1.OESOPHAGEAL(THORACIC) CARCINOMA (ADENO

CARCINOMA/SQUAMOUS CELL CARCINOMA) AND SIEWERT Cervical oesophageal carcinoma
TYPE 1 OG JUNCTION CARCINOMA:

LOCOREGIONAL DISEASE and MEDICALLY FIT FOR METASTATIC AND T4B LESIONS:
SURGERY:(UP TO T4a )

If ECOG <2 Submit for palliative

NACRT (CROSS PROTOCOL)
chemotherapy.
/NACT AND REASSESSMENT
If ECOP >2 Best palliative
after 6 weeks
supportive care.

NO Evidence of disease/persistent local disease Definitive chemo radiation

D-Lap/MIE

226
Surgical Gastroenterology 227

WORK UP

CBC sigmoidosc CT MRI pelvis (To assess TRUS for

RFT CHEST/Abdo local extent)
opy/ sphincter
LFT men to R/O TME invasion, nodal
procto involvement, involveme
CEA (Metastases
scopy adjacent organ nt & early
lung/liver) involvement, restaging
biopsy disease

MDT

Stage T1- T2Bulky,

T2 (non T3-T4, Obstructing Metastatic
bulky),N0 anyT,N+ lesion disease

Neoadjuvant CRT Long

SURGERY course
Anterior resection with TME- Diversion
upper rectum colostomy& staging
Low anterior resection with
TME – Mid rectum
Response
Ultra Low anterior resection/
assessment
Intersphincteric resection Operable Metastatic
with TME - low rectum after 6 weeks
APR/ ELAPE with TME - lower
Rectum/anal canal
Operable
228 MMC PRACTICE PROTOCOLS

Metastatic disease

M1a M1b M1c

(Isolated Liver mets/
(Isolated lung mets
Resectable
Pallative
management

Resection with
metastasectomy
f/b chemotherapy

Surveillance

Preop Colonoscopy Preop scopy Not done Increasing CEA level

done

Clinical examination, CEA (USG

abdomen) every 3 months for
Scopy after 3
months
PET CT
2years then every 6months
upto 5 years CT chest &
Abdomen yearly upto 5 years

Suspicious Recurrence / Metastases

Respectable Non Respectable

Palliative treatment
Re Resection and Chemo therapy
Surgical Gastroenterology 229

CARCINOMA STOMACH PROTOCOL

Clinical presentation

Symptoms
Signs
• Abdominal pain
• Left supraclavicular lymph
• Loss of appetite and weight
node
• Vomiting
• Axillary node
• Malena
• Ascites
• Hematemesis
• Palpable mass/ liver mass
• Abdominal distension
• Umbilical nodule
• Complications: Bleeding , Gastric outlet
• P/R: rectal deposit
obstruction (GOO), Perforation

WORK UP

Blood Metastatic
Diagnostic
CBC CECT chest
Upper GI endoscopy with Biopsy
RFT PET CT (not routinely
CECT abdomen and pelvis (oral
LFT recommended)
and iv contrast)

UNCOMPLICATED CARCINOMA STOMACH PROTOCOL

Resectable (T1-T3, N0)

Locally advanced: Adjacent organ Metastatic
Stage 1 and 2
involvement (>T3, N1, N2) Stage 3 Stage 4

Surgery- D2 gastrectomy
Perioperative Chemotherapy
Palliative therapy
(MAGIC)
• Pain
management
Response assessment • Palliative
chemotherapy

Resectable disease Unresectable disease

Surgery- D2 gastrectomy Gastrojejunostomy if GOO present
Second line Chemotherapy

Adjuvant Chemotherapy (depending on HPE)

Follow up
• Clinical examination and USG abdomen every 3 months for 2 years then every 6 months up to 5
years
• CT chest & Abdomen yearly upto 5 years
230 MMC PRACTICE PROTOCOLS

CARCINOMA STOMACH PROTOCOL

Recurrence

Restaging

Resectable disease Unresectable disease/ Metastatic

Surgery- Total gastrectomy Palliative therapy

COMPLICATED CARCINOMA STOMACH PROTOCOL

Bleeding
Gastric outlet Perforation
obstruction

Unstable
Resectable Stable
Unresectable

Resectable Unresectable

Surgery- D2 Palliative Gastrectomy Lavage and

gastrectomy GJ/JJ patch
repair+ FJ
Surgery- D2 Hemostatic RT
gastrectomy
Surgical Gastroenterology 231

Management protocol for corrosive esophageal injury

Time of ingestion
tt
Type of substance (concentration) For quantifying injury
History of physical examination Volume of ingested material

Presence of co-ingestion

Sign and symptoms of burn, tissue damage (dysphagia,

odynophagia, bleeding, etc).

Respiratory and cardiovascular instability

CBC with platelet count

Blood typing

Prothrombin time For assessing sepsis and other organ

assessment involvement
Laboratory tests
Arterial blood gas

Electrolytes

Liver biochemical tests

Renal function tests

Airway protection and hemodynamic stabilization

General measures Place on NPO

If with sign of upper GI injury, provide gastric acid suppression

and mucosal protection

Referral to GI endoscopy ( within 48 hrs )

Referral to surgery ( if necessary )

Referral to psychiatry for non-accidental ingestions ( as routine )

Specific management
232 MMC PRACTICE PROTOCOLS

Acute injury
Corrosive ingestion

Iv assess, maintain vitals

Resp. assessment (if required endotracheal, tracheostomy)

X-ray neck, chest,

Abdomen, CT chest

&abdomen(soluble contrast study)

Perforation no perforation Endoscopy(<48 hrs of ingestion)

Grade 1 grade2 grade3 grade4

Hyperemia

Surgery

Diversion A B A B
Esophagostomy
Superficial deep focal necrosis extensive

Ulcer circumferential necrosis

Ulcer
Vitals
Vitals
Monitor 24hrs stable
unstable

Discharge conservative tt. Surgery

Nutrition, TPN feeding -gastrectomy

Feeding Jejunostomy -Diversion+FJ

Surgical Gastroenterology 233

Chronic injury
Corrosive ingestion 6 weeks back

Dysphagia/ vomiting

Barium swallow & meal study

Esophageal stricture GOO non dilatable Esophageal stricture & GOO

Site, length & tightness of Surgery(antrectomy)

Stricture

Endoscopic dilatation with bougienage

Under fluoroscopy initially

Weekly dilation & biweekly for surgery (antrectomy, coloplasty)

Difficult stricture

Successful fails

On demand local steroid+

Dilation dilation

Fails

Surgery

(esophageal substitution with stomach/colon/jejunum)

234 MMC PRACTICE PROTOCOLS

E v a l u a t i o n o f HC C

SYMPTOMS
history. Clinical examination
Abdominal pain Performance status /
Mass per abdomen CLD, Blood transfusion , iv drug pallor / jaundice / CLD features /
Weight loss; loss of appetite abuse Abdomen examination for any mass
Jaundice Hepatomegaly
Abdominal distension Ascitis
Fever
Vomiting/ altered bowel habits

INVESTIGATIONS

routine blood investigations USG Abdomen CECT Abdomen

CBC ,LFT ,RFT , echogenicity of liver TRIPLE PHASE CT

PTINR Any cirrhotic features
Any lesion in liver charector of lesion in three phases
If present ,cystic / solid No of lesions
TUMOUR MARKERS No of lesions Parenchymal status
Extend of involvement in liver FLR
AFP Size of the lesion Portal hypertension features
CEA,CA 19-9 Any IHBRD Portal vein status
Status of CBD Vascular anomaly
Any lymphnode enlargement Nodal status
Ascitis Any mets
Spleen size.
PORTAL DOPPLER Collaterals

portal hypertension features

Splenomegaly
collaterals status

any lesion
OGD
Any varices

MRI if necessary ,like atypical features in CECT or contrast allergy or altered renal function
MRCP ; for bile duct anomalies and in suspected cholangiocarcinoma
PET Scan - done in PVT +
AFP more than 1000
FNAC - indicated in

lesion in Noncirrhotic
liver ,suspicious of HCC
Cirrhotic liver ,atypical lesion
Any atypical lesion
planned for any palliative
chemo
Surgical Gastroenterology 235

Confirmed case of HCC

CTP SCORE ASSESSED
ASSESSMENT & ASA scoring done
ECOG scoring done
confirmed cases of HCC

In noncirrhotic patient. Cirrhotic patient

resectable patient Resectable lesion unresectable lesion

ECOG 0-2 CTP A/ B Within the transplant crieteria
ASA 1/2 ECOG 0-2 ( milans crieteria )
No pHTN ASA 1/2 Transplant advised
No portal hypertension

metastatic disease
vascular involvement that
perclude resection ->
systemic treatment

poor ECOG
FLR CTP C score
-> palliative treatment

FLR inadequate - PVE done .

FLR Adequate Reassessd after 4-6 week .
If adequate then taken for surgery

D LAP to rule out mets

lesions of large size and AFP is
high with no evidence of mets ->
TACE given & later if response is
surgery- hepatectomy based on
good surgery advocated
location of tumour .

Selective vascular occlusion done

Parenchymal resection with kelly
clamp RFA for lesions upto 5cm and
unresectable because of other
parameters like poor ECOG ,
Urology
Urolithiasis Algorithm

236
Urology 237

Renal Trauma Algorithm

238 MMC PRACTICE PROTOCOLS

Renal Cell Cancer Algorithm

Urology 239

Bladder
Cancer
Algorithm
 240 MMC PRACTICE PROTOCOLS
Prostate Cancer Algorithm
Urology 241
Vascular Surgery
AORTIC ANEURYSM – ALGORITHM FOR MANAGEMENT

ANEURYSM IN AORTA –
THORACIC,
THORACOABDOMINAL,
ABDOMINAL

ABDOMINAL AORTIC ANEURYSM THORACIC OR THORACOABDOMINAL AORTIC ANEURYSM

CTVS TAKEOVER
URGENT VASCULAR OPINION N VASCULAR OPINION
SERIAL FOLLOW-UP ASCENDING/ARCH/DESCENDING AORTA
>50% NORMAL DIAMETER
HEMODYNAMICALLY STABLE
SACCULAR ANEURYSM ANY DIAMETER

Y Y
N HYPOTENSION
ABDOMINAL PAIN HEMODYNAMICALLY STABLE
PULSATILE
Y
CT ANGIOGRAM RUPTURED ABDOMINAL
MASS N
REDUCED PULSES ELECTIVE
RUPTURED
IN LOWER LIMB
SIZE <5.5 CM SIZE >5.5 CM EMERGENCY SURGICAL EMERGENCY
REPAIR ENDOVASCULAR
REPAIR FEASIBLE

N Y
SACCULAR ANEURYSM? Y
PAIN? ELECTIVE SURGERY
THROMBOEMBOLISM?
INCREASE SIZE >1CM IN 1 YEAR OPEN REPAIR ENDOVASCULAR
INTRA OP ASSISTANCE TO (TEVAR/FEVAR/BEVAR)
CTVS TEAM CAN BE
N PROVIDED AORTIC
BYPASS +/- VISCERAL
DEBRANCHING
SERIAL FOLLOW-UP

OPEN REPAIR ENDOVASCULAR (EVAR)

242
Vascular Surgery 243

CKD – ALGORITHM FOR MANAGEMENT

INDICATIONS FOR REFERRAL FOR AV ACCESS

 eGFR is 15- 20 ml/min/1.73 m2 stage iv
 Rapid rates of eGFR decline (eg, >10 ml/min/year)
 Paents who have a failing transplant.
 Recurrent vascular access problems - recurrent need for cvc use
and/or >3 correcve intervenons/6 months
 Complicaons due to pd

PHYSICAL EXAMINATION

ARTERIAL SYSTEM  CVS Examinaon VENOUS SYSTEM

 Character of peripheral  Examinaon for  Evaluaon for edema
pulses Peripheral Catheters  Assessment of arm sizes
 Allen test comparability
 Bilateral upper extremity BP  Examinaon for collateral veins.
 Evaluaon of veins: Augmented
palpaon

DUPLEX EXAMINATION

ORDER OF PREFERENCE
 Non-dominant handRCF
 Size of artery and veins - >/=  Dominant hand RCF
2mm
 Non-dominant handBCF
 Compressibility of Vein
 Dominant handBCF
 Distensibility of the vein
 Connuaon of the vein  Non-dominant hand BBF
 Distance between artery and vein  Dominant hand BBF
 Av gra’
 Permcath
 Complex AV Access Procedures

POST -OP PERIOD

 Arm and fing er exercise
 Clopidogrel therapy
 Post op doppler

POST -OP FOLLOW UP

 A t 2 weeks and 6 weeks
 Flow Rate (600ml/sec)
 Size (6mm)
 Dis tancefrom Skin (<6mm)
 Look for Seroma / Hematoma
 Flow distribuon to Tributaries
244 MMC PRACTICE PROTOCOLS
Vascular Surgery 245
246 MMC PRACTICE PROTOCOLS
Vascular Surgery 247

PERIPHERAL ARTERIAL OCCLUSIVE DISEASE–ALGORITHM FOR MANAGEMENT

DISTAL PULSES ABSENT IF DISTAL PULSES PRESENT
R/O OTHER CAUSES – ATHEROEMBOLISM,
DIABETIC FOOT SYNDROME

CHRONIC SYMPTOMS- SMOKING TOBACCO ACUTE ONSET SYMPTOMS

ACUTE ONSET SYMPTOMS WITH 6PS- PALLOR, PARESTHESIA,
ABUSE, PREVIOUS ADMISSION FOR SIMILAR HISTORY OF CHRONIC PAOD
COMPLAINTS, PRIOR LIMB CLAUDICATION, PARALYSIS, COLD LIMB, PAIN,
6PS- PALLOR, PARESTHESIA, PULSELESSNESS
H/O DRUG INTAKE- ANTIPLATELETS, PARALYSIS, COLD LIMB, PAIN,
PREVIOUS CABG, LONG DURATION OF H/O SOURCE OF EMBOLUS- LA/LV
PULSELESSNESS
SYMPTOMS-WASTING, DRY GANGRENE, CLOT, ATRIAL FIBRILLATION, ACUTE
PREVIOUS CLAUDICATION +
H/O AMPUTATIONS ON I/L OR C/L LIMB MYOCARDIAL INFARCTION, KNOWN
WASTING + HYPERCOAGULABLE STATE
ACUTE SYMPTOMS IN OPPOSITE
LIMB

CHRONIC LIMB THREATENING ACUTE LIMB ISCHEMIA

ACUTE ON CHRONIC LIMB
ISCHEMIA
THREATENING ISCHEMIA
-UFH 80U/KG STAT IV
-UFH 18U/KG INFUSION
-ANALGESICS

SALVAGEABLE ASSESS SENSORY / MOTOR DEFICIT

N
Y Class I: VIABLE Class IIA: Class IIB: Class III: NON SALVAGEABLE
MARGINALLY IMMEDIATELY
THREATENED THREATENED
AMPUTATION
-SENSATIONS
AND -SENSATIONS -SENSATIONS -COMPLETE PARALYSIS/
LOW PLATELET COUNT CBC, RLE – IF MOVEMENTS MAY BE MAY BE INSENSATE LIMB
ANEMIA PLATELETS > 1 PRESERVED REDUCED REDUCED -CALF TENSE
LAKH, HB 8 GM -ARTERIAL FLOW -MOVEMENTS -MOVEMENTS -NO FLOW (ARTERIAL/ VENOUS)
ON DOPPLER + PRESERVED PRESERVED
-ARTERIAL FLOW -ARTERIAL
DECREASED FLOW -
-VENOUS AMPUTATION
-R/O HEMATOLOGICAL -UFH 80U/KG STAT IV -HEPARINISE
DISORDER FLOW+
-UFH 18U/KG INFUSION -URGENT CT
- HEMATOLOGY OPINION IF REQUIRED ANGIOGRAPHY
- CAN USE LMWH, -ANALGESICS
FONDAPARINUX -HEPARINISE -HEPARINISE
-URGENT CT ANGIOGRAPHY -URGENT
-INTERVENTION FOR REVASCULARIZATION OPEN
REVASCULARIZATION (EMBOLECTOMY)
ACUTE ON CHRONIC LIMB CHRONIC PAD (OPEN (EMBOLECTOMY) (NO NEED FOR IMAGING)
ISCHEMIA /ENDOVASCULAR-CDT)

N
-HYDRATE WELL
EMERGENCY ECHO- R/O -R/O AKI/CKD
LV/LA CLOT IS RFT NORMAL? - NEPHROLOGIST
DUPLEX – TO R/O ACUTE OPINION FOR
THROMBUS ANGIOGRAM
Y
CT ANGIOGRAM

Y FIT FOR SURGERY N

RECONSTRUCTIBLE VESSEL? RECONSTRUCTIBLE VESSEL? Y

Y
N N
ENDOVASCULAR PROSTAGLANDIN
OPEN BYPASS
REVASCULARISATION THERAPY
Y -CATHETER DIRECTED THROMBOLYSIS Y SYMPATHECTOMY
ANTICOAGULATION
STEM CELL THERAPY
RECONSTRUCTIBLE DISTAL RUNOFF AFTER THROMBOLYSIS N NO OPTION CLI AMPUTATION
248 MMC PRACTICE PROTOCOLS

VARICOSE VEINS – ALGORITHM FOR MANAGEMENT

Patients with Chronic Venous Disease

Clinical examination of lower limbs

Classify according to CEAP Classification

Dilated Veins Lower Abdominal Wall/Groin

No Yes
Infra-inguinal
pathology Suspicion of Supra-
inguinal pathology
Lower Limb Duplex
Abdominal DUS
Deep Vein Reflux +
Superficial venous Deep venous
incompetence ± incompetence MRV or CTV
Perforator
Incompetence Venography and/or IVUS

Deep venous
obstruction

Interventional
Treatment
Venous symptoms Iliac vein outflow
C (1,2) obstruction - Venous
Healed Venous Ulcer (C5) stenting
Edema (C3) Elastic compression stockings
20 – 40 mmHg Active Venous Ulcer (C5)

Pigmentation
Eczema (C4a)
LDS/Atrophie
blanche (C4b)
Early Endo venous ablation
(EVLA/RFA)
Minimal Stab Avulsion
Ultrasound Guided Foam
Sclerotherapy of Sub-ulcer venous
plexus