Transcript Emergencies in general practice

Emergencies in general practice
HASEEB A. KHAWAJA, M.D.
DIPLOMATE AMERICAN BOARD OF
INTERNAL MEDICINE
DIRECTOR EMERGENCY DEPARTMENT
SHIFA INTERNATIONAL HOSPITAL,
ISLAMABAD
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Coma
Seizures
Meningitis
Disturbed behavior
Attempted suicide
Poisoning/overdose
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GI bleeding
Acute abdominal pain
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Chest pain
MI and unstable angina
Choking both adults and children
Acute breathlessness
Exacerbation of asthma
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Anaphylaxis
Burns
Electrocution
Lacerations
Fractures
Coma
UNAROUSABLE UNRESPONSIVENESS IN WHICH THE
SUBJECTS LIE WITH EYES CLOSED
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Responsiveness – visual, tactile, auditory
Respirations
Posturing
Fundi, pupils, oculocephalics
Corneals, nasal tickle
Gag
Facial sensation, motor
Spinociliary reflex
Reflexes, sensation and plantars
Respirations
 Abnormalities of respiration can help localize but
almost always in the context of other signs
 Central-reflex Hyperpnea (midbrain-hypothalamus)
 Apneustic, cluster, Ataxic (Lower pons)
 Loss of automatic breathing (medulla)
Cranial Nerve Exam
 Cranial Nerve Exam
 Pupillary light response (CN 2-3)
 Occulocephalic/calorics (CN 3,4,6,8)
 Corneal reflex (CN 5,7)
 Gag refelx (CN 9,10)
Spinociliary Reflex
 1-2 mm pupillary dilatation evoked by noxious
cutaneous stimulation
 More prominent in sleep or coma than during
wakefulness
 Test integrity of symp.pathways in comatose patients
 Not particularly useful in evaluating brainstem
function
Occulocephalic Reflex
 Brisk rotation of head with eyes held open
 Watch for contraversive movements
 Next:
 Flexion: eyes deviate up and eyelids open (doll’s head
phenomenon)
 Extension:eyes deviate downward
Other Reflexes
 Deep tendon
 Biceps, brachioradialis, triceps
 Patellar, Achilles
 Plantar Responses
 Superficial skin
 Abdominal, cresmasteric
Coma Mimics
 Akinetic mutism
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Silent, immobile but alert appearing
Usually due to lesion in bilateral mesial frontal lobes, bilateral thalamic lesions or lesions in
peri-aqueductal grey (brainstem)
 ‘Locked-in’ syndrome
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Infarction of basis pontis (all descending motor fibers to body and face)
May spare eye-movements
Often spares eye-opening
EEG is normal or shows alpha activity
 Catatonia
o CatatoniaSymptom complex associated with severe psychiatric disease with:
 stupor, excitement, mutism, posturing
 can also be seen in organic brain diease: encephalitis, toxic and drug-induced psychosis
 Conversion reactions
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Fairly rare
Occulocephalics may or may not be present
The presence of nystagmus with cold water calorics indicates the patient is physiologically
awake
EEG used to confirm normal activity
Seizures
• SEIZURES: TRANSIENT OCCURRENCE OF
CLINICAL SYMPTOMS
DUE TO ABNORMAL NEURONAL BEHAVIOR
– CONVULSIONS: SEIZURES WITH PROMINENT
BODY MOVEMENT
– NON-CONVULSIVE SEIZURES: SEIZURES WITH
MINIMAL OR NO BODY
MOVEMENT
• EPILEPSY: BRAIN DISORDER WITH AN
ENDURING PREDISPOSITION
TO GENERATE EPILEPTIC SEIZURES
• EPILEPSY SYNDROMES: GROUPS OF EPILEPTIC
PATTERNS OF
VARYING CAUSE BUT SIMILAR COURSE AND
RESPONSE TO
TREATMEN
International Classification of
Epileptic Seizures
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Partial (focal, local) seizures
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Generalized seizures (convulsive or nonconvulsive)
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Simple partial seizures
 With motor signs
 With somatosensory or special sensory symptoms
 With autonomic symptoms or signs
 With psychic symptoms
Complex partial seizures
 Simple partial onset followed by impairment of consciousness
 With impairment of consciousness at onset
Partial seizures evolving to secondarily generalized seizures
 Simple partial seizures evolving to generalized seizures
 Complex partial seizures evolving to generalized seizures
 Simple partial seizures evolving to complex partial seizures evolving
 to generalized seizures
Absence seizures
 Typical absences
 Atypical absences
Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic-clonic seizures
Atonic seizures (astatic seizures)
Unclassified epileptic seizures
Status Epilepticus
 Definition:
 Two or more seizures without recovery of
consciousness in between
 Single seizure >20-30 min (operationally, >5 min)
Causes?
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Medication non-compliance
Cerebrovascular disease such as cerebral infarction, cerebral
hemorrhage, and venous thrombosis
Head trauma
CNS infections such as meningitis or encephalitis
Neurodegenerative diseases
Autoimmune disease
Brain neoplasm
Genetic diseases
Substance intoxication or withdrawal
Metabolic medical disorders such as uremia, hypoglycemia,
hyponatremia, and hypocalcemia
Unknown/
Cryptogenic
Infection
Depressed Skull Fracture
Tumor
Cortical
Dysplasia ?
Hypoxia
Hemorrhage
Infarct
Vascular
Malformation
Clinical discrimination between Epileptic and
non-epileptic events
Non Epileptic Events
Epileptic Events
Onset
Gradual
Rapid
Audience
Common
Unusual
Pelvic Thrusting/
Opisthotonus
Common
Uncommon (Consider
Frontal)
Tongue biting
Uncommon (tip)
Lateral aspect
Eyes
Closed (Resisting
opening)
Deviated/
Nystagmus
Autonomic
features
Uncommon
Common
Plantars
Normal
Babinski +
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Attempt to time duration of
seizure
Help patient lie down and roll onto side to help
avoid aspiration
Loosen clothing and remove glasses
DO NOT
Do NOT attempt to place anything in the patient’s
mouth, including medication and water
Do NOT leave patient lying on back
Do NOT restrain during or after seizure; may
provoke aggressive behavior or cause injury
Status Epilepticus
on the scene
 Definition
 ABC’s
 Sugar check
 Other causes
 Benzodiazepines
 Phenytoin
 Phenobarbitone
 Propofol
Meningitis
“INFECTION OF THE MENINGES”
Issues to consider
 Suspecting the diagnosis
 Clinical clues
 How to diagnose
 CT vs. LP
 Choice of emperic antibiotics
 Rocephin
 Vancomycin
 Dexamethasone
Clinical Suspiscion
CT scan before LP
Baseline clinical features associated with a
high risk for abnormal findings on CT were
age greater than 60, immunocompromise,
history of a CNS lesion, a seizure within 1
week before presentation, an abnormal
level of consciousness, and abnormal focal
signs on examination
 Journal Watch Neurology January 24, 2002
Emperic Antibiotics
Treatment of bacterial meningitis. N Engl J Med 1997;336:708-716
Delirium
“ACUTE NEUROLOGICAL DISTURBANCE”
DSM IV Criteria
1. Disturbance of consciousness with reduced
ability to focus, sustain or shift attention.
2. A change in cognition or development of
perceptual disturbances that is not better
accounted for a preexisting, existed or evolving
dementia.
3. The disturbance develops over a short period
of time and tends to fluctuate during the course
of the day
4. There is evidence from this history, examination or labs that
the disturbance is caused by the physiological
consequence of a medical condition.
causes
Infections
Electrolyte abnormalities
Endocrine dysfunctions (hypo or hyper)
Liver failure- hepatic encephalopathy
Renal failure- uremic encephalopathy
Pulmonary disease with hypoxemia
Cardiovascular disease/events: CHF, arrhythmias, MI
CNS pathology: tumors, strokes, seizures
Deficiency states: Thiamine, nicotinic or folic acid, B12
Drugs that can cause delirium
 Anticholinergics (furosemide, digoxin,
theophylline, cimetidine, prednisolone,
TCA’s, captopril)
 Analgesics (morphine, codeine..)
 Steroids
 Antiparkinson (anticholinergic and
dopaminergic)
 Sedatives (benzodiazepines, barbiturates)
 Anticonvulsants
 Antihistamines
 Antiarrhythmics (digitalis)
 Antihypertensives
 Antidepressants
 Antimicrobials (penicillin, cephalosporins,
quinolones)
 Sympathomimetics
Dementia vs Delirium
 Dementia has an insidious onset, chronic
memory and executive function disturbance,
tends not to fluctuate. In delirium cognitive
changes develop acutely and fluctuate.
 Dementia has intact alertness and attention but
impoverished speech and thinking. In delirium
speech can be confused or disorganized.
Alertness and attention wax and wane.
Schizophrenia vs Delirium
 Onset of schizophrenia is rarely after 50.
 Auditory hallucinations are much more
common than visual hallucinations
 Memory is grossly intact and disorientation
is rare
 Speech is not dysarthric
 No wide fluctuations over the course of a day
 Delusions and hallucinations
Acutely Agitated Patient
 Safety Management and Response Techniques
(SMART)
SMART staff education
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Managing dangerous situations
Preventing escalation
Maintaining environmental safety
Respond as a team!
 Physician staff
 Nursing staff
 Social work
 Technical staff
 Security staff
 Trainees
Nonpharmacologic intervention
 Communication with the patient
 Behavioral management
 Safety/physical restraints
 Medication response and side effects
 Respect/concern
AAP. Practice guideline for the treatment of
patients with delirium.
 Monotherapy with a typical antipsychotic: haloperidol or
droperidol
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Droperidol has a faster onset and less frequent need for a second dose
Need to monitor ECG and serum Mg levels
 Benzodiazepines as a monotherapy is reserved for delirium
from drug withdrawal
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Generally avoided as monotherapy in the elderly
Lorazepam possibly preferred in patients with liver disease
 Combined therapy of a antipsychotic plus a benzodiazepine
may have faster onset of action with fewer side effects
 Am J Psychiatry 1999; 156 (suppl):1-20
Delirium, take home messages
 Patients with an acute change in behavior require a
careful medical evaluation
 Historical and physical findings provide the baseline
necessary to determine diagnostic testing
 Delirium is a medical emergency
 In general, antipsychotics are still the pharmacologic
intervention of choice in the acutely agitated patient
Found down patient
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Suicide
A SAD BUT PERMANENT SOLUTION TO A
TEMPORARY PROBLEM
Why Talk About Suicide?
 because ~ suicide doesn’t discriminate by
 gender, age, race, ethnicity, education, or socio economic status.
 because ~ 90% of people who die of suicide
 have a treatable mental illness or substance abuse
 disorder; 60% have a depressive disorder.
 because ~ suicide is the most preventable
 form of death in the U.S. today.
Depression in disguise
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Drug / alcohol abuse
Aggressive behavior
Delinquent behavior
Reckless / antisocial behavior
Eating disorders
Happy mask
Frequent “accidents”
Self – destructive acts
Extreme boredom / apathy
Unexplained physical symptoms
Sleeping disorder
Extreme restlessness
Facts!
 Females attempt three times more than males.
 Males choose more lethal methods (less
opportunity for life saving techniques).
 Most suicidal people don’t really want to die ~ they just
want their pain to end.
 About 80% of the time, people who kill themselves have
given definite signals or talked about suicide.
 The key to prevention is to know the signs and what you
can do to help.
 If someone you know seems depressed or gloomy and has
spent a lot time questioning whether life is worth the bother
~it’s time to
Pay Attention!
Myths about suicide
 “People who talk about suicide won’t really do
it.”
 “Anyone who tries to kill him/herself must be
crazy.”
 “If a person is determined to kill him/herself,
nothing is going to stop him/her.”
 “People who commit suicide are people who
were unwilling to accept help.”
 “Talking about suicide may give someone the
idea.”
FALSE
FALSE
FALSE
FALSE
FALSE
Suicide Symptoms
 Verbal suicide threats
 Behavior changes
 Increase in mention of body pain
 Depression
 Sleeping and eating patterns
 Fatigue
 Irritability
 Lifting of prolonged depression
 Final arrangements
 Death wish behavior
SAVE A LIFE!
 ASK DIRECT QUESTIONS
Poisoning/Overdose
What to do?
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 GCS
 Vitals
 ECG
 IV access
Management
 Remove the chemical
 Remove clothes, clean mouth etc
 Reduce absorption
 Consider gastric lavage
 NEVER FOR CORROSIVES
 Activated Charcoal
 Increase elimination
 Urine alkalinasation
 Dialysis
 Diuresis?
Paracetamol
Aspirin
TCA’s
Benzodiazepines
Insecticide
Lead?
Food Poisoning