Management of Office Emergencies - University of...

Management of Office Emergencies

Fernando Vega, M.D. 1

Fernando Vega, M.D.

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¨ Classic Presentation¡ Initially: prutitus, urticaria¡ Angioedema, swelling¡ f/b: respiratory Sx – stridor, dyspnea, wheeze

¨ Other Presentations¡ Nausea, cramps, diarrhea, vomiting





¨ Presence of an allergic sign (urticaria….)¨ Involvement of at least two organ systems¨ Exposure to agent or activity known to…¨ Absence of condition that can mimic

anaphylaxis

Skin Angioedema, flushing, urticaria, pruritus

Cardiovascular Tachycardia, palpitations, arrhythmias, hypotension,syncope

Gastrointestinal Nausea, vomiting diarrhea, cramps

Respiratory Dyspnea, stridor, wheezing, chocking, rhinorrhea,

Other Sense of impending doom, diaphoresis, metallic taste

¨ Urticaria¨ Hyperventilation¨ Vasovagal reaction¨ Globus hystericus¨ Hereditary angioedema¨ Scromboid poisoning

ü 0.3 – 0.5 cc epinephrine 1:1000 intramuscularly

ü May repeat every 15 minutes if necessaryü Diphenhydramine after epiü Glucocorticosteroids after that:

Predinsone 40-60mg/day……



o Persistent bronchospasmo Hypotensiono Hypoxiao Patient is on beta-blockerso 20% of reactions are “biphasic” with

further mediator release 4 – 8 hours later.

Most common causes of anaphylaxis include:

Drugs (particularly beta-lactams, NSAIDS, ACE inhibitors)Hymenoptera (bees, wasps)Radiographic contrast mediaBlood productsFoods (particularly seafood, milk, nuts)

5 foods responsible for more than ¾ of food reactions in children:

Eggs (36%)Peanuts (24%)Cow’s milk (8%)Mustard (6%)Cod (4%)

Fin fish and shellfish more common in adultsChildren outgrow sensitivities to milk, eggs, soy but not usually to peanuts, nuts or fishFatalities most common in teens following ingestion of peanuts or tree nuts

Anaphylaxis is not automatic on recurrent exposure:

40-60% on insect stings20-40% on contrast media10-20% on penicillin

Concurrent use of beta-blockers is a risk for severe prolonged anaphylaxis



¨ Immediate Posibilities:¡ Asthma¡ Pulmonary Embolus¡ Hyperventilation¡ Anaphylaxis¡ Foreign Body Obstruction¡ Cardiac asthma

¨ Respiratory System¡ Bronchospasm¡ Pulmonary Embolus¡ Pneumothorax¡ Pulmonary infection¡ Upper airway obstruction: aspiration, anaphylaxis

¨ Cardiovascular System¡ Acute myocardial ischemia¡ Congestive Heart Failure¡ Cardiac tamponade

¨ If you hear hoof beats: asthma or hyperventilation¡ No strange pain¡ No strange history¡ No strange physical findings

¨ History¡ Previous episodes, outcomes¡ Relative to current episode:¡ How serious? How anxious?¡ How long? Tired?

¨ Co-morbid conditions:¡ CHF¡ Hypertension (use of beta-blockers)



¨ Physical Examination¡ Started when you first looked at patient¡ Level of anxiety¡ Ability to complete sentences¡ Accessory breathing:ú Position of handsú Pursed lipsú Accessory muscles

¨ Physical Examination ¡ Wheezes¡ No wheezes¡ Air movement¡ Pulse ratePulsus paradoxus – 12 mm Hg Δ w/ inspr

¨ Laboratory Assessment¡ Peak Flow meterú A fall of 50% from baseline is considered severeú Hypercapnea happens only when PF falls below 20

percent¡ Spirometryú Demonstration

¡ Oxygen Saturation Meter

¨ Initial treatment ¡ Inhaled albuterol¡ 2nd best: OTC sympathomimmetics¡ MDI w/spacer vs. updraft

¨ Followed by:¡ Ipratropium bromide



¨ When to use steroids¡ Less than 10% improvement in PEFR after first dose

of inhaled beta agonist¡ Less than 70% improvement of PEFR after first hour

of treatment¡ An asthma attack that developed in spite of steroids¡ Protracted course

¨ How to use steroids¡ As a rule 40 – 80 mg Prednisone qd ¡ Equivalent to 200 – 400 mg Hydrocortisone¡ May taper, may not¡ IV steroids for severe cases

¨ How to use steroids¡ The effect of a single dose of oral prednisone begins

within 3 hours and reaches a maximum within 8-12 hours

¡ In a study of 15, 40 and 125 mg of methylprednisolone q6h of patients in status asthmaticusú 125mg group got better end of first dayú 40mg group got better by middle of second day

¡ Inhaled steroids are for chronic use only

Pulmonary Embolus Sudden onset, Pleuritic pain and dyspnea

Aortic dissection Tearing pain with radiation to back

Pericarditis Positional ache, dyspnea

Pneumothorax Pleuritic pain and dyspnea

Acute coronary syndrome Vague, pressure-like pain, radiating to arm, neck, jaw

Chest Wall Pain Pleuritic Pain Visceral PainCostochondritis Pulmonary Embolus Exertional angina

Precordial catch Pneumothorax Unstable angina

Slipping rib Pericarditis Pericarditis

Xyphodynia Pleurisy Aortic dissection

Fibromyalgia Esoph reflux or spasm

Gall bladder Pain

Acute MI



¨ Worst Case¡ For patient (when you know the diagnosis)¡ For Doctor (when you don’t know the Dx) Acute Coronary Syndromes:

Myocardial Ischemia and Infarction

Acute Coronary Syndromes:Myocardial Ischemia and Infarction

n Ischemic/anginal pain is similar to AMI painn AMI pain resolves with aggressive interventionn Ischemic/anginal pain resolves with rest or

NTG


n Severe, deep pain

n Pain radiates to jaw or arm

n Gesture of resignation


n Visceral pain induces autonomic responses: nausea, vomiting, diaphoresis

n “Like an elephant stepping on my chest”

n Gesture of resignation


n Can be silent painn Especially in diabeticsn Elderlyn Women




n 15 – 20 % AMI have some CHFn Papillary muscle rupture in 1-3 days n Pericarditis in 20% in 2-4 days

n Dysrhythmias occur in 72 – 100% of AMI


n Dysrhythmias occur in 72 – 100% of AMI

Acute Coronary Syndromes:Management

Direct admission to CCU (New information)


n Direct admission to CCU

n Antiplatelet drugs:n ASA 160 – 325mg PO (↓ mortality by 23%)n Clopidrogel 300mg loading f/b 75mg qd (more benefit)

n Antithrombin drugs:nHeparinn LMWH

n Fibrinolytic Agents (for STEMI)n Coronary reperfusion


n Direct admission to CCU

n Other anti-ischemic therapies:n Nitroglycerinn Morphinen Metoprololn Atenolol



¨ In the absence of structural heart disease, palpitations are overwhelmingly benign when the ECG is normal.

n Not Atrial Fibrilation

n Not prolonged QT interval

n Not Torsade de Pointes

¨ In the absence of structural heart disease, palpitations are overwhelmingly benign

n If they need to be treated, they will complain

n If they complain, they need to be treated

¨ In the absence of ACS, palpitations are overwhelmingly benign

n Even NSVT = 4% of population

n In 60 – 85 year olds with no structural heart disease followed for 10 years NSVT did not predict a coronary event

¨ What do non-benign arrhythmias look like?

n Not normal ECGn Atrial fibrilation, fluttern Prolonged QT

¨ Most common complaint in ER

n Location, quality, severity, onset, duration, aggravating and alleviating factors

n Absent bowel tones are not clinically useful findingsn Hyperactive or obstructive sounds are more

helpfuln Rebound tenderness or “cough pain” is very

useful



Non specific abdominal pain 34%Appendicitis 28%Biliary tract disease 10%Small Bowel Obstruction 4%Acute Gynecological disease 4%Pancreatitis 3%Renal Colic 3%Diverticular disease 2%

¨ 1800 pts, WBC >10k doubled odds of appendicitis

n 1800 pts, WBC <10k halved the odds of appendicitis

n Same with acute cholecytstitis

n In NSAP 28% of WBC counts >10.5K

¨ Peptic Ulcer bleed accounts for 60% of Upper GI bleeding

n Followed by erosive gastritis and esophagitis

n Followed by variceal bleeding

n Followed by Mallory Weiss

¨ Hemmorrhoids are by far the most common cause of lower GI bleeding

n Followed by diverticular bleeding, AVM, IBD, and polyps

n Both UGI LGI bleeding more common in ♂

n Diarrhea is the most important differentiating symptom



¨ How High?¨ How quickly did it get high?¨ Symptoms of acute hypertensive effects?¨ Symptoms of end organ damage?

An acute hypertneisve episode is defined as SBP > 180 and DBP > 110

Brain Severe HA, nausea, vomiting, altered sensorium, CVA

Heart Ischemic symptoms

Kidneys Proteinurea, hematuria, azotemia

Vascular Aneurysm

End organ dysfunction makes it an urgency

Should have a glucose monitor in the office

Should have urinalysis sticks in the office

Hyper or hypoglycemia?

Ketotic or non ketotic?

Catch first presentation of diabetes

Ongoing management of diabetes



n Not so common in office settingn Caveat with sulfonylureas Sweating Shakiness

Anxiety Nausea

Dizziness Confusion

Blurred vision Headache

Lethargy

Typical symptoms

Typical Signsn Diaphoresisn Tachycardian Almost any neurological findingn Altered mental statusn Tremorn Focal Neurologic deficitn Seizure

Managementn Oral Glucosen IV D50 1gm/kg f/b continuous dripn Glucagon 1mg IM if IV access unavailablen Hydrocortisone 100mg IV or glucagon 1mg IV

if hypoglycemia is refractory to glucose administration

n Octreotide for refractory cases due to sulfonylureas

Managementn Review co-morbid conditionsn Review social situationn Most diabetics with insulin reactions respond

rapidly to treatmentn Patients with prolonged or recurrent

hypoglycemia from sulfonylureas need to be admitted

Ketosis on UA or not?

How high is too high?



Ketosis changes the whole clinical picture.Metabolic derangements are far more reaching

and precipitous with ketosis.

n Occurs predominantly in insulin dependent

n Mortality is 5% and is higher in elderly

n New onset diabetes presents as DKA in 25% of cases

n Precipitated by non-compliance with insulin therapy or any type or physiologic stress such as:n infectionn Stroken MIn pregnancy

n Clinical Picture directly related to metabolic derangements

n Hyperglycemia causes osmotic diuresis →dehydration, hypotension, tachycardia

n Ketonemia causes acidosis with myocardial depression, vasodilation and Kussmaul’s

Clinical Picture

n Admit to hospitaln Correct Hypovolemian Correct Electrolyte abnormalitiesn Correct Acidosis and ketonemian Treat underlying cause

Management

n Is a common presentation of new-onset diabetes mellitus

n Occurs in poorly controlled type II DMn Contraction alkalosis f/b metabolic acidosis

Pathophysiology



n Typical patient is elderly with complaints of weakness or mental status changes

n Physical exam: dehydration and altered mental status

n Can have focal deficits or seizures

Clinical Features

n Glucose > 600mg/dLn HCO3 > 15 mg/dLn pH > 7.3n Ketosis absent or mild

Clinical Features

n Admitn Correct hypovolemian Correct free water deficitn HCO3 > 15 mg/dLn pH > 7.3n Ketosis absent or mild

Management

Rectal Temp > 38°C (100.4°F)

Priority is to identify the child with a serious bacterial illness

n The higher the fever, the higher incidence of bacteremia

n Age 0-8 weeks at high risk of SBIn Highest risk for sepsis first few days of life

Infants 0- 3 months



n The higher the fever, the higher incidence of bacteremia

n Age 0-8 weeks at high risk of SBIn Highest risk for sepsis first few days of lifen Age 0-8 week infant may have Bacterial

Sepsis w/o clinical findingsn Febrile infants < 4 weeks 13% incidencen Febrile infants < 8 weeks 10% incidence

Infants 0- 3 months

n Clinical impression is more reliable in this groupn Viral illnesses including pneumonia account for

the most common etiologyn Strep pneumoniae is the most common bacterial

etiologyn .019% of bacteremia develop meningitis

Infants 3-24 months

Indications for Admission to Hospital

All infants <4 weeks with T> 38.1°C (100.6°F)

Most infants <3 moths with focal infection other than otitis media

Toxic appearance regardless of age or degree of fever

n Occurs typically Oct – Mayn Infants less than 2 years, peak at 2 mon Increased risk of complicationsn Prematurityn BPDn Congenital Heart

Epidemiology

n Begins with nasal discharge, pharyngitis, cough and fever

n Wheezing and respiratory distress follow later.

n Tachypnea, nasal flaring and gruntingn Ominous signs of RF: Decrease or absence

of breath sounds signifies severe bronchocnstriction

Clinical Features

n Symptoms peak in 3-5 daysn Usually resolve in 2 weeksn Immunity is variablen Reinfection may occur

Clinical Features



n May respond to albuterol but probably not.n Nebulized epinephrine may be helpfuln Heliox may be helpfuln Hydrationn Steroids

Management

n Indications for hospitalizationn Apnean Respiratory distress unresponsive to Txn Hypoxian Vomiting or dehydrationn Tachypnea > 60

Management

Clinical Features

n Life threateningn Can occur at any agen Abrupt onset of High fever, sore throat,

stridor, dysphagia and drooling over 2 d.n Severe sore throat with normal appearing

oropharynx.n X-rays are unnecessary

n Lifetime likelihood of one Sz is 9%n Age 0-9 years prevalence is 4.4/1000n Age 10-19 yrs prevalence is 6.6/1000n Simple febrile Sz are a different category with

incidence of 3-4%

Clinical Features

n Symptoms can be any of the following:n Alteration of consciousnessn Auditory, sensory or olfactory hallucinationsn Involuntary motor activityn Choreoathetoid movements

Clinical Features

n Neonatal seizures may be subtle and sometimes w/ only autonomic changes:n Mydriasisn Apnean Cardiac irregularity



¨ A convulsion associated with an elevated temperature greater than 38ºC

¨ A child younger than six years of age¨ No central nervous system infection or

inflammation¨ No acute systemic metabolic abnormality that

may produce convulsions¨ No history of previous afebrile seizures

¨ Seizures that last less than 15 minutes¨ Have no focal features¨ If they occur in a series, the total duration is

less than 30 minutes

¨ Last more than 15 minutes¨ Have focal features or postictal paresis¨ Occur in a series with a total duration greater

than 30 minutes.

Meningitis and encephalitis are the main concerns in a child presenting with fever and seizures.

.



n Know mechanism of injuryn Check neurovascular statusn General fracture care:

n Ice, traction, splinting

n Special Fractures:n Scaphoidn Radial headn Metatarsal shaftn Ankle dome

n Abcessesn Bite woundsn Wound managementn “Golden Rule” of 8 hoursn Neurovascular exam

n Mechanism of injury will help identify risk of foreign body, contamination and wound complication

n Crush injuries more likely to cause wound infection

n Hematomas often require drainage

n History of prodrome

n Post-ictal phenomenon

n Memory of the event

n Witnesses

Differentiation syncope from seizures

n Subconjunctival hemorrhage

n Trauma: check integrity and acuity

n Corneal Foreign body

n Corneal abrasion

n Acute angle closure glaucoma

n Testicular Torsion

n Urinary retention

n Epididymitis



n Menorrhagia

n Threatened abortionn 20-40% of pregnancies abort spontaneouslyn Chromosomal abnormalities account for most

n Dysfunctional Uterine Bleeding

n Ectopic Pregnancy

PneumothoraxBurnsWound careHead injuriesPoisonings

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