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ARMED FORCES MEDICAL COLLEGE, PUNE AFMC Pune • 1 MESSAGE The quality of a healthcare institution is reflected not only in its clinical services but also in its commitment to learning, innovation, and the continuous development of its human resources. In an ever-evolving healthcare environment, nursing professionals must be equipped to translate scientific knowledge into sound clinical decisions and deliver care that is safe, timely, and responsive to the needs of every patient. The development of this handbook on emergency protocols represents a constructive effort to strengthen the practical preparedness of nursing personnel. By bringing together clearly organized guidelines and decision-making algorithms, this resource aims to support a systematic approach to emergencies, where timely assessment, appropriate action, and continuous evaluation are integral to patient management. Medical emergencies often demand coordinated action within a limited time frame. A well-prepared nursing professional must be able to recognize warning signs, anticipate complications, communicate effectively with the multidisciplinary team, and maintain composure in challenging circumstances. These capabilities are strengthened through structured learning, simulation-based training, regular practice, and adherence to established clinical standards. As an institution dedicated to medical education and professional development, AFMC recognizes the importance of resources that connect academic learning with clinical responsibilities. I appreciate the initiative undertaken by the team in developing this handbook and acknowledge their efforts in creating a resource that can support teaching, learning, and clinical preparedness. I hope this publication will encourage nursing professionals to pursue continuous improvement, strengthen their clinical reasoning, and approach emergency situations with confidence, discipline, and a strong sense of responsibility. May it also serve as a valuable aid for nursing students and educators in fostering a culture of patient safety, teamwork, and professional excellence. I extend my best wishes to the editorial team and all contributors for their dedication to this endeavor. I trust that this initiative will make a meaningful contribution to nursing education and the delivery of quality healthcare. Jai Hind! Place: Pune Date: 31 Oct 2026 (Manish Honwad) Surg Vice Adm Commandant, AFMC Pune

ARMED FORCES MEDICAL COLLEGE, PUNE AFMC Pune • 1 MESSAGE The advancement of healthcare depends on the integration of scientific knowledge, clinical expertise, and a sustained commitment to improving patient outcomes. Within this endeavour, nursing professionals occupy a vital position, translating clinical evidence into practice while ensuring that patients receive timely, compassionate, and competent care. Emergency management is an essential component of professional nursing practice, requiring the ability to recognise clinical warning signs, interpret patient findings, establish priorities, and initiate appropriate measures without unnecessary delay. The development of a structured reference handbook dedicated to emergency protocols is therefore a valuable academic initiative that supports the application of knowledge in demanding clinical situations. A well-designed clinical algorithm can assist healthcare professionals in following a logical sequence of actions, reducing uncertainty during critical events and promoting consistency in patient management. However, effective implementation also depends on clinical reasoning, professional judgement, familiarity with institutional protocols, and the ability to work collaboratively within a multidisciplinary team. From an academic perspective, resources of this nature provide an opportunity to strengthen the connection between classroom instruction, skills laboratory training, and clinical experience. They can facilitate independent learning, support competency-based education, and encourage nursing students and practitioners to remain updated with evolving standards of healthcare practice. I congratulate the team involved in conceptualizing and preparing this handbook. The initiative reflects the importance of developing educational resources that are practical, accessible, and relevant to the responsibilities of nursing professionals. I hope this work will inspire further academic engagement, promote reflective clinical practice, and contribute to the development of confident and competent healthcare practitioners. May this publication serve as a useful companion for nursing educators, students, and practicing professionals, reinforcing the principles of lifelong learning, patient-centered care, and professional accountability. I extend my sincere wishes to all contributors for the successful dissemination and effective utilization of this resource in nursing education and clinical practice. Jai Hind! Place: Pune Date: 31 Oct 2026 (Atul Seth) Maj Gen Dean & Commandant AFMC Pune

MESSAGE Nursing Officers of the Military Nursing Service, through successive generations, have stood as an unwavering pillar of quality patient care within the Armed Forces Medical Services. The dynamic and high-acuity nature of clinical practice demands that nursing professionals possess the knowledge, skills, and confidence to recognise emergencies early, exercise sound clinical judgement, and initiate timely and appropriate interventions to ensure safe and effective patient outcomes. This handbook is a valuable compilation of systematic approaches and clinical algorithms designed to support nursing professionals in the management of emergencies. The clear and practical presentation of protocols provides a useful framework for rapid decision-making while reinforcing the principles of patient safety, prioritisation, teamwork, and evidence-based practice. The increasing complexity of healthcare delivery necessitates that Nursing Officers remain clinically competent, confident, and prepared to respond effectively to emergencies. Resources such as this handbook serve as an important reference for strengthening clinical knowledge, improving preparedness, and promoting standardized approaches to emergency management across healthcare settings. I commend the efforts of the contributors, reviewers, and organizing team for bringing together this practical and clinically relevant resource. Their commitment to professional excellence and continuous learning reflects the enduring values of the Military Nursing Service and its commitment to delivering high-quality patient care. I am confident that this handbook will serve as a useful reference for Nursing Officers, educators, and healthcare professionals in strengthening their emergency nursing competencies and translating clinical knowledge into timely and effective patient care. I extend my sincere appreciation to all those associated with this endeavor and wish the publication every success in its contribution towards excellence in nursing practice. Jai Hind! Place: New Delhi Date: 31 Oct 2026 (Rachel Thomas) Maj Gen ADG MNS

MESSAGE The delivery of safe and effective patient care during emergencies requires vigilance, sound clinical judgement, and the ability to make timely decisions under pressure. Nursing Officers are often at the forefront of patient management, where early recognition of deterioration, prompt intervention, and continuous monitoring are essential to achieving favourable outcomes. The compilation of this handbook is a meaningful step towards enhancing emergency preparedness and strengthening clinical decision-making among nursing professionals. The systematic presentation of protocols and clinical algorithms provides a structured reference for managing critical situations, establishing priorities, and ensuring that essential interventions are carried out in an appropriate sequence. Effective emergency management depends not only on technical proficiency but also on clear communication, coordinated teamwork, and the ability to anticipate potential complications. Regular reference to standardized guidelines, together with ongoing clinical learning and practical skill development, can further enhance the confidence and competence required in demanding clinical environments. I appreciate the efforts of the team involved in developing this resource. Their contribution reflects a commitment to professional education, clinical excellence, and the continuous improvement of nursing practice. Such initiatives play an important role in bridging the gap between theoretical learning and the practical demands of patient care. I hope this handbook will serve as a useful resource for Nursing Officers, educators, and nursing students, supporting them in refining their clinical skills and responding to emergencies with greater preparedness and confidence. May it encourage a sustained commitment to patient safety, professional accountability, and excellence in healthcare delivery. I convey my best wishes to all those associated with this publication and trust that their efforts will make a meaningful contribution to the advancement of nursing practice. Jai Hind! Place : Pune Date : 31 Oct 2026 (Sreeletha P S) Brig Brig MNS (SC)

MESSAGE The strength of the Military Nursing Service lies in its unwavering dedication to patient welfare, professional integrity, and the highest standards of clinical practice. As healthcare continues to advance, nursing professionals must remain adaptable, vigilant, and proficient in applying their knowledge to complex clinical situations, particularly when timely decisions are critical to patient survival and recovery. The preparation of this handbook on emergency protocols is a purposeful initiative towards promoting a systematic and disciplined approach to emergency nursing care. By presenting clinical procedures and decision-making pathways in an organized manner, this resource can assist nursing personnel in recognizing priorities, initiating appropriate interventions, and coordinating care effectively during time-sensitive situations. Preparedness is built through a combination of sound theoretical understanding, practical training, clinical exposure, and the ability to respond confidently under pressure. Equally important are effective communication, interprofessional coordination, accurate documentation, and continuous reassessment of the patient’s condition. Integrating these elements into routine professional practice strengthens the delivery of safe and reliable emergency care. I appreciate the dedication of the team that has undertaken the responsibility of compiling this handbook. The effort reflects a commitment to professional development and the dissemination of practical knowledge that can be applied across diverse clinical settings. Such initiatives also reinforce the importance of standardization, accountability, and continued learning among nursing personnel. I encourage Nursing Officers, nursing educators, and students to utilize this publication as a reference for strengthening their emergency management skills and refining their clinical judgement. May it motivate every reader to remain prepared for unforeseen challenges, uphold professional standards, and place patient safety at the centre of every intervention. I convey my sincere appreciation to all contributors and extend my best wishes for the successful use of this handbook in nursing education, clinical training, and patient care. Jai Hind! Place : New Delhi Date : 31 Oct 2026 (Kiron Jeet) Brig Brig MNS(P&T)

CONTENTS Adult Critical Care Nursing Manual · Categorised clinical reference CATEGORY PAGE Respiratory 8–15 Oncology 16–26 Orthopaedic 27–31 CTVS 32 Neurology 33–44 General Topics of Medicine and Surgery 45–62 Psychiatric 63–66 OBG 67 Miscellaneous 68 Front matter: Five messages from AFMC and Military Nursing Service leadership precede this index. Original clinical pages are retained in their supplied layout.

SECTION 1 RESPIRATORY Included material Respiratory Emergency Protocols AFMC • EMERGENCY NURSING MANUAL 3

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SECTION 2 ONCOLOGY Included material Oncology Emergencies — Maj Ramya AFMC • EMERGENCY NURSING MANUAL 11

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SECTION 3 ORTHOPAEDIC Included material Acute Compartment Syndrome Fat Embolism Syndrome AFMC • EMERGENCY NURSING MANUAL 22

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SECTION 4 CTVS Section reserved for source material No matching document was supplied in this upload set. AFMC • EMERGENCY NURSING MANUAL 27

SECTION 5 NEUROLOGY Included material Neurological Critical Care — Maj Saranya Spinal cord reference image AFMC • EMERGENCY NURSING MANUAL 28

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SECTION 6 GENERAL TOPICS OF MEDICINE AND SURGERY Included material Emergency Management Protocols — Lt Col Ranjana AFMC • EMERGENCY NURSING MANUAL 40

SNAKE BITE Snakebite Envenoming: The World Health Organization (WHO) defines snakebite envenoming as a potentially life- threatening disease caused by toxins injected from the bite of a venomous snake or through venom sprayed into the eyes Clinical syndromes of snakebite : Progressive weakness (neuroparalytic/neurotoxic), bleeding (vasculotoxic/haemotoxic), myotoxic and painful progressive Swelling Source: https://ncdc.mohfw.gov.in/uploads/pdf/Standard-Treatment-Guidelines-for-Management-of-Snake-Bite.pdf AFMC • EMERGENCY NURSING MANUAL 41

Source: https://nirrch.res.in/wp-content/uploads/2023/10/Management-Flowchart.pdf AFMC • EMERGENCY NURSING MANUAL 42

SNAKE BITE : KEY NOTES Anti Snake Venom Reaction Anaphylaxis can be of rapid onset and life-threatening, monitor closely after giving ASV Urticaria, itching, fever, chills, Nausea, vomiting, diarrhoea, abdominal cramps, Tachycardia, hypotension, bronchospasm and angio-oedema A second dose of 0.5 mg (0.01mg/kg) of adrenalin 1: 1000 iv is given. this can be repeated for a third and final occasion but in the vast majority of reactions, 2 doses of adrenaline will be sufficient If there is hypotension or hemodynamic instability, IV fluids should be given. Once the patient has recovered, the ASV can be restarted slowly for 10-15 minutes, keeping the patient under close observation. Then the normal drip rate should be resumed. At the first sign of any of these ASV to be discontinued give dose of 0.5 mg (0.01mg/kg) of adrenalin 1:1000 In case of Asthmatic symptoms, give Salbutamol bronchodilator.  After Adrenaline, give intravenous antihistamine anti-H1 blocker (e.g. Chlorphenamine maleate, adults 10 mg, children 0.2 mg/kg intravenously) and Hydrocortisone (adults 100 mg, children 2 mg/kg body weight).  Anaphylactic shock unresponsive to adrenaline is treated by laying patient supine, legs elevated, and giving intravenous volume replacement (0.9% saline, adults 1-2 litres rapidly).  Unresponsive Bronchospasm or Angioedema is treated with optimal nebulised/inhaled and/or parental bronchodilator and oxygen.  Late Serum sickness reactions occur after 5 to 7 days can be easily treated with an oral steroid such as prednisolone, adults 5 mg 6 hourly, paediatric dose 0.7 mg/kg/day. oral Antihistaminic provide additional symptomatic relief. AFMC • EMERGENCY NURSING MANUAL 43

MANAGEMENT OF OP POISIONING: KEY NOTES Immediate Priorities (ABCDE Approach) • Ensure personal safety – wear gloves, mask, gown. • Remove patient from exposure. • Decontaminate skin by removing contaminated clothing and washing with soap and water. • Establish IV access with two large-bore cannulas. • Attach cardiac monitor and pulse oximeter. • Send blood samples as advised (ABG, electrolytes, glucose, cholinesterase if available. • Maintain Airway; suction excessive secretions. • Prepare for early intubation if airway is compromised. Signs of OP Poisoning Remember SLUDGE-M • S – Salivation • L – Lacrimation • U – Urination • D – Defecation/Diarrhea • G – Gastrointestinal cramps • E – Emesis (Vomiting) • M – Miosis (Pinpoint pupils) Other findings: • Bronchorrhea • Sweating • Bradycardia • Muscle fasciculations • Weakness/paralysis • Altered consciousness • Seizures MANAGEMENT Medico-Legal Case (MLC) :Every suspected OP poisoning should be treated as a Medico-Legal Case. Nursing Responsibilities ✓ Inform the treating doctor immediately. ✓ Ensure MLC registration as per hospital protocol. ✓ Inform the police through the hospital as per institutional policy. ✓ Preserve poison container/bottle, vomitus (if required),gastric lavage sample, Contaminated clothing (properly labeled) ✓ Maintain chain of custody for all medico-legal specimens. ✓ Maintain documents & records. Signs of Adequate Atropinization ✔ Chest clear on auscultation ✔ Secretions dry ✔ Oxygen saturation improving (>94%) ✔ Heart rate >80/min ✔ Systolic BP >90 mmHg ✔ No bronchospasm Do NOT use pupil size alone to judge atropinization. Atropine Therapy Initial Dose Adult: 2–3 mg IV bolus Repeat every 3–5 minutes Double the previous dose if no response 2 mg → 4 mg → 8 mg → 16 mg → 32 mg Pralidoxime (2-PAM) Loading Dose 2 g IV over 20–30 minute Maintenance dose 500 mg/hour IV infusion OR 1–2 g IV every 6–8 hours Diazepam Give if: Seizures, Agitation, Severe poisoning Typical adult dose: 5–10 mg IV slowly AFMC • EMERGENCY NURSING MANUAL 44

MANAGEMENT OF ACUTE ABDOMEN: KEY NOTES Sub Acute Intestinal Obstruction Key Points • Assess and stabilize Airway, Breathing, Circulation (ABC). • Keep the patient Nil Per Oral (NPO). • Insert large-bore IV cannula and begin IV fluid resuscitation. • Correct dehydration and electrolyte imbalance. • Insert Nasogastric (NG/Ryle's) tube for gastric decompression. • Monitor NG tube drainage. • Administer oxygen if required. • Give prescribed analgesics and antiemetics. • Administer broad-spectrum antibiotics if strangulation or perforation is suspected. • Monitor for signs of bowel ischemia (severe pain, fever, tachycardia, guarding). • Prepare for emergency surgery if indicated (complete obstruction, strangulation, perforation, peritonitis). • Obtain informed consent and preoperative investigations. Acute Pancreatitis Key Points • ABC assessment and stabilization. • Keep patient NPO to rest the pancreas. • Aggressive IV fluid resuscitation (especially within first 24 hours). • Administer oxygen therapy if needed. • Provide adequate pain relief (opioids as prescribed). • Administer antiemetics. • Correct electrolyte imbalance. • Monitor blood glucose. • Nutritional support (enteral feeding preferred if prolonged NPO). • Treat underlying cause (e.g., gallstones, alcohol, hypertriglyceridemia). • Antibiotics only if infected pancreatic necrosis is suspected. • Surgical or endoscopic intervention when indicated. Intussception Key Points • ABC stabilization. • Keep patient NPO. • Establish IV access. • Correct dehydration and electrolyte imbalance. • Insert NG tube if persistent vomiting or abdominal distension. • Pain management. • Ultrasound confirmation. • Non-operative reduction with air or contrast enema (if no perforation/peritonitis). • Emergency surgery if: o Perforation o Peritonitis o Failed enema reduction o Hemodynamic instability AFMC • EMERGENCY NURSING MANUAL 45

FOREIGN BODY INGESTION Foreign body ingestion occurs when a non-food item or problematic object is swallowed, requiring urgent medical attention if it involves button batteries, multiple magnets, or sharp objects. MANAGEMENT OF FOREIGN BODY INGESTION 1. Obtain history: Ensure no concern for button battery or magnet ingestion (refer to those algorithms if there is concern). 2. Obtain STAT X -rays: lateral neck (including nasal cavities and nasopharynx) and AP or PA chest, and AP abdomen/pelvis views. 3. Keep NPO. If symptomatic or esophageal FB, start IV and MIVF. 4. Consult: ENT for above the clavicles; Peds GI for esophagus, below clavicles, or as needed for stomach or intestinal FB. Any concern for perforation or obstruction or history of esophageal or abdominal surgery: Consult Pediatric Surgery ESOPHAGUS STOMACH SMALL BOWEL Symptomatic: Drooling, dysphagia, Asymptomatic Symptomatic Asymptomatic Symptomatic respiratory compromise, severe pain Timely endoscopic removal depending on symptom severity 1. Repeat X -ray to ensure coin is still present 2. Urgent endoscopic removal No endoscopy needed. Consider straining stools, laxatives. Repeat X-ray at 2 weeks to confirm passage, or sooner if symptoms develop. Depending on size of object, consider admission for observation (larger objects could get caught at ileocecal valve). Consider alternative etiologies and alternative foreign bodies. Surgical removal if indicated. Coin Sizes: Quarter: 24mm Nickel: 21mm Penny:19mm Dime: 18mm Endoscopic removal if not passed in 2-4 weeks. Repeat X-ray before removing to ensure coin is still present. COIN & OTHER BLUNT OBJECT OBJEINGESTIONAFMC • EMERGENCY NURSING MANUAL 46

Endoscopic Retrieval Tips • Removal should be performed under general anesthesia • Inspect mucosa for extent, location, and depth of damage Discharge Considerations • Bowel regimen • Reliable/competent caregiver • Regular diet • Encourage activity • Educate on signs of GI bleed (blood-stained vomiting, melena, abdominal pain, change in eating pattern) or features of intestinal obstruction (persistent vomiting, abdominal distention) AFMC • EMERGENCY NURSING MANUAL 47

MAGNET INGESTION 1. Obtain history: known magnet ingestion? 2. Obtain STAT X -rays: lateral neck (including nasal cavities and nasopharynx) and AP or PA chest, and AP abdomen/pelvis views : Determine single versus multiple magnets. 3. Keep NPO. Start IV and MIVF. 4. Consult: ENT for above the clavicles; Peds GI for esophagus, stomach, intestine, or below clavicles. MULTIPLE MAGNETS Or single magnet + other metal object(s) Any concern for perforation or obstruction or history of esophageal or abdominal surgery: Consult Pediatric Surgery SINGLE MAGNET Assess risk factors for further ingestion All within stomach or esophagus Beyond stomach In stomach or esophagus Beyond stomach Symptomatic: EMERGENT endoscopic removal Successful Removal: Discharge home after feeding tolerance with appropriate follow-up and education Asymptomatic: URGENT endoscopic removal Unsuccessful removal: Notify Pediatric Surgery for removal Symptomatic: 1. Admit for further monitoring. 2. Consult Peds GI and Pediatric surgery for endoscopic, laparoscopic removal 3. Keep NPO, IVF. Asymptomatic AND no concerning radiographic findings: 1. Admit for further monitoring 2. Consult Pediatric GI & Pediatric Surgery 3. Clear liquid diet 4. Serial radiographs q4- 6hrs 5. Can use Golytely, Miralax, or another laxative Non-urgent endoscopic removal if patient at risk for further ingestion Outpatient management with bowel regimen, serial X-rays, parental education if no risk factors. Confirm passage with X- rays at 2-3 days in outpatient. No progression on serial X-rays in 24-48 hours: Attempt removal by colonoscopy or endoscopy Progression of magnets on serial X-rays: Option 1: Option 2: Continue bowel regimen and serial x-rays until magnets have passed Outpatient management with bowel regimen, serial X-rays, parental education See reverse for additional informationAFMC • EMERGENCY NURSING MANUAL 48

Endoscopic Retrieval Tips • Removal should be performed under general anesthesia • Inspect mucosa for extent, location, and depth of damage Discharge Considerations- When Waiting for Single Magnet to Pass • Bowel regimen • Reliable/competent caregiver • Regular diet • Encourage activity • Educate on signs of GI bleed (blood-stained vomiting, melena, abdominal pain, change in eating pattern) or features of intestinal obstruction (persistent vomiting, abdominal distention) • Remove any magnetic objects nearby • Avoid clothes with metallic buttons or belts with buckles • Ensure no other metal objects or magnets are in the child’s environment for accidental ingestion • Discuss notification of Product Safety Commission AFMC • EMERGENCY NURSING MANUAL 49

SHARP OBJECT INGESTION 1. Obtain STAT X -rays: lateral neck (including nasal cavities and nasopharynx) and AP or PA chest, and AP abdomen/pelvis views. 2. Keep NPO. If esophageal or symptomatic, start IV and MIVF. 3. Consult: ENT for above the clavicles; Peds GI for esophagus, intestine, or below clavicles. RADIO-OPAQUE Any concern for perforation or obstruction or history of esophageal or abdominal surgery: Consult Pediatric Surgery RADIO-LUCENT For example: toothpick, fishbone, glass Endoscopic removal within 2hrs Symptomatic or Length ≥ 3cm Width ≥ 2cm Gastric or Duodenal Asymptomatic and Length < 3cm Width <2cm Small Bowel (distal to ligament of Treitz) Asymptomatic Timely surgical removal Symptomatic, self-reported, or witnessed ingestion Timely endoscopic evaluation & removal Consider CT, ultrasound, MRI, or esophagram for further assessment Timely endoscopic removal Consider observation with bowel regimen, serial X -rays, parental education. Confirm passage with X-ray at 2 -3 days if outpatient. Remove if symptoms develop. Object found: Follow guidelines for found radio- opaque objects No object found: Observe or discharge with return precautions Esophageal Asymptomatic SymptomaticAFMC • EMERGENCY NURSING MANUAL 50

Endoscopic Retrieval Tips • Removal should be performed under general anesthesia • Inspect mucosa for extent, location, and depth of damage • If sharp end is facing cephalad, consider pushing the object into the stomach and rotate the sharp end caudally before removal • Safety pin: polypectomy snare can be used to close it before withdrawal • Toothpick: polypectomy snare is a good option Discharge Considerations • Reliable/competent caregiver • Regular diet • Encourage activity • Educate on signs of GI bleed (blood-stained vomiting, melena, abdominal pain, change in eating pattern) or features of intestinal obstruction (persistent vomiting, abdominal distention) AFMC • EMERGENCY NURSING MANUAL 51

ESOPHAGEAL FOOD IMPACTION 1. Obtain STAT X -rays: lateral neck (including nasal cavities and nasopharynx) and AP or PA chest, and AP abdomen/pelvis views. 2. Keep NPO. Start IV and MIVF. 3. Consult Peds GI. SEVERE SYMPTOMS Difficulty breathing, retching, severe pain, not tolerating secretions Any concern for perforation or obstruction or history of previous esophageal surgery: Consult Pediatric Surgery MILD/ MODERATE SYMPTOMS No difficulty breathing, mild pain, tolerating secretions Timely endoscopic removal depending on symptom severity Consider X-ray with water soluble contrast: 1. Obtain AP chest/ abdomen 2. Patient drinks 50mL water soluble contrast 3. AP chest/abdomen immediately afterwards Endoscopic removal at provider discretionEndoscopic Retrieval Tips • Removal should be performed under general anesthesia • Inspect mucosa for extent, location, and depth of damage • Obtain proximal and distal esophageal biopsies • Assess for stricture. Dilation is cautioned against if eosinophilic esophagitis is suspected, or food has been impacted for a long duration Discharge Considerations • Ensure patient has appropriate GI follow-up AFMC • EMERGENCY NURSING MANUAL 52

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SECTION 7 PSYCHIATRIC Included material Psychiatric Emergencies — Maj Arthi AFMC • EMERGENCY NURSING MANUAL 58

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SECTION 8 OBG Section reserved for source material No matching document was supplied in this upload set. AFMC • EMERGENCY NURSING MANUAL 62

SECTION 9 MISCELLANEOUS Section reserved for source material No matching document was supplied in this upload set. AFMC • EMERGENCY NURSING MANUAL 63