Transcript Office Urgencies 2006

Office Urgencies
Gil C. Grimes, MD
April 2006
Competing Interests
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This take is funded by an unrestricted
free time grant from my wife.
First Thoughts
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Office emergency???
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Call 911
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Not an interesting lecture
Second Thoughts
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Nurse calls in sick
Billing computer crashes
Personality disorder family scheduled for 11 arrives
at 8
EHR displays only Cyrillic Text
Four unmedicated ADHD children in waiting area
141 pre-authorization requests on the morning fax
35 Medication refill list on double book patient
Handling the 2 inch internet search on the interaction
between Fibromyalgia and chronic yeast infection
Final Outline
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Hypertensive crisis
Asthma Exacerbation
Hypoglycemia
Syncope
Febrile Seizure
Epistaxis
Hypertensive Crisis
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Hypertensive Urgency if 180/100
Hypertensive Emergency if end-organ
damage
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Stroke, heart failure and hypertensive encephalopathy
commonest example of end-organ damage
Cerebral Infarction 16-32%
Acute pulmonary edema 14-30%
Hypertensive encephalopathy 9.6-24%
Acute CHF 7.4-20%
Acute MI or unstable angina 5.9-18%
Intracranial bleeding 0.7-8.6%
Aortic dissection 0-4.4%
Hypertension 1996;27(1):144-147 Level 2c
Hypertensive Crisis
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Causes
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Essential hypertension 54-86%
Renovascular 0-21%
Neurogenic 0-16%
Diabetic Nephropathy 0-21%
Pheochromocytoma 0-10%
Primary Hyperaldosteronism 0.46-0.75%
BMJ 1983;286:19-21 Level 4
NEJM 1979;301(23):1273-1276 Level 4
Hypertensive Crisis
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Investigations
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Urinalysis with microscopy
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Complete blood count
Electrolyte, urea, creatinine, glucose
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Signs of strain
LVH
CXR
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Low potassium think hyperaldosteronism 2
EKG
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Dymsorphic red cells
Pigmented granular casts
Absence of blood or protein make glomerular disease less likely1
Signs of heart failure
Doppler US to look for renal artery stenosis 3
1- Am J Kidney Disease 1992;20(6):618-628 Level 2b
2- NEJM 1979;301(23):1273-1276 Level 4
3- Ann Intern med 2001;135:401-411 Level 2a
Hypertensive Crisis
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Goal blood pressure control
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Evidence of end organ damage immediate
reduction of pressure 1
No end organ damage, reduce over 24
hours
Reduce BP but keep MAP >70 mm HG
(prevents cerebral hypoxia) or greater than
20 mm Hg with frequent readings 2
1- Arch Intern Med 1997;157:2413-2446 Level 5
2- BMJ 1973;1:507-510 Level 4
Hypertensive Crisis
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Drugs of Choice
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Sodium Nitroprusside (clonodine, nifedipine,
nicardipine or fenoldopam alternative)
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NNT 2 for clonodine vs. nifedipine
Labetalol in patients without heart block or
pulmonary disease
Nitroglycerine for ischemia or angina
Phentolamine if catecholamine related
hypertension
Esmolol for aortic dissection
Hydralazine for pregnancy if pre-eclamptic
Arch Int Med 1989;149:260-265 Level 1b
Hypertensive Crisis
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Mortality is high
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40% patient dead within 3 years 1
Mainly renal failure or stroke
Admit to hospital
ICU if end organ damage
1- J Hypertension 1995;13:9150924 Level 2b
Asthma Exacerbation
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Prevalence 1
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3.7% persons of all ages had attacks 1999
Male 3.3% Females 4.4%
Caucasian 3.7% African Americans 4.6%
High rate of severe asthma exacerbations
in pregnant women with moderate to
severe asthma 2
1- National Health Interview Survey 1999
2- Ob Gyn 2005;106(5):1046-54 Level 2b
Asthma Exacerbation
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Triggers
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Allergens, house dust, molds, grass
pollens, cedar 1
Air pollutants such as ozone, sulfur
dioxide, cigarette smoke 2-4
Respiratory tract infections
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RSV, parainfluenza, rhinovirus common
offenders 5
Atypical bacteria
1- BMJ 2002;324:763 Level 3b
2- Thorax 2005;60(10):814-21 Level 3b
3- Lancet 2003;361(9373):1939-44 Level 2b
4- JAMA 2003;290(14):1859-67 Level 2b
5- Pediatr Asthma Allergy Immunol 2002; 15:69 Level 2b
Asthma Exacerbation
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Medication triggers
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Eye drops (timolol etc) 1
Glucosamine-chondroitin 2
Aspirin some non-selective beta-blockers 3
1- Cortland Forum 1996;9(2):83,96-114 Level 5
2- DynaMed Asthma Exacerbation access March 2006 Level 5
3- J Am Board Fam Pract 2002;15(6):481-484 Level 4 Level\\\
Asthma Exacerbation
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History
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Ask and establish about precipitating factors
Generally worse in the afternoon
Past therapy
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Steroids
Hospitalization
Intubation
What has worked
Descriptors of dyspnea
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Out of air, need to take a deep breath, tight throat, voice
tight, scared, agitated
Descriptors differ by race
Chest 2000;117(4):935-43 Level 2b
Asthma Exacerbation
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Investigations
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Peak expiratory flow
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<100 l/min prior to therapy
<300 l/min after therapy
Consider admission 1
Pulse Oximetry
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<92% marker for resp failure
LR+ 4.2 2
1- Ann Emerg Med 1982;11:64-69 Level 4
2- Thorax 1995;50:186-188 Level 4
Asthma Exacerbation
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Therapy
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Oxygen 40-60% titrate with pulse oximetry
Beta-2 agonists via MDI with spacer or nebulizer
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3 doses MDI 20 minutes apart (shorter duration of
treatment)
Continuous better than intermittent nebulizer 1
Ipratropium reduces likelihood of admission in
children (NNT 10) 1
Steroids (40 mg prednisolone) within one hour to
reduce admissions (NNT 6) 1
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No additional benefit oral vs. IV
Inhaled steroids not as much data
1- Cochrane Library 2001 Issue 1:CD002178 Level 1a
Asthma Exacerbation
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Additional measures
Out of office to hospital
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Mag Sulfate
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Evidence on IV form only after failing other therapy 1
Lots of data disease oriented, very conflicting outcomes
May be more effective inhaled as neb 2
Antibiotics have an unclear role (trial data
lousy)
Consider watching or contacting patient 4
hours later (as beta effect wanes)
1- Cochrane Library 2001 Issue 1:CD002178 Level 1a
2- Cochrane Library 2005 Issue 4:CD003898 Level 1a
Hypoglycemia
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Consider in patients with reduced level of
consciousness (7%) 1
Biggest risk is diabetes aggravated by- 2
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Missed meals 25-52%
Alcohol consumption 22-48%
Insulin overdose 15-20%
Exercise 6-14%
Unidentified causes 19-24%
Medications 4%
1- J Emerg Med 1992;10:679-682 Level 1b
2- Arch Emerg Med 1989;6:183-188 Level 2b
Hypoglycemia
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Treatment (based on Level of consciousness)
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Oral sugar if conscious
Glucagon IV or IM if semiconscious
Give long-acting carbohydrate as follow up
Inquire about the following for prevention
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Insulin regimen
Duration of diabetes
Glycemic control
Prior episodes
Current medications and new medications
Herbals
Syncope
Causes
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Arrhythmias
Aortic Stenosis
Myocardial Infarction
Aortic dissection
Pulmonary Embolism
Seizure
TIA
Subclavian Steal
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Carotid Sinus
Hypersensitivity
Vasovagal
Orthostasis
Drugs
Situational Syncope
(Micturation or
defecation)
Psychogenic
Hypoglycemia
Syncope
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Symptoms
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Palpitations…arrhythmia
Chest pain…ischemia, PE, aortic stenosis
Nausea…vasovagal, bradyarrythmia
Diaphoresis...MI, vasovagal syncope
Pallor…Vasovagal syncope
Hunger palpitations, sweating,
anxiety….hypoglycemia
Multiple nonspecific associated
complaints…psychogenic
Syncope
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Prodrome to
vasovagal
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Pallor
Nausea
Headache
Sweating
Faintness
Palpitations
Flush
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Warning period
typically present up
to 5 minutes prior
Assuming supine
position may abort
episode
Observer may note
cold hands, pale
skin, tachycardia
Syncope
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Body Position
Most episodes do not occur when
supine
When first standing…orthostasis
When sitting or recumbent...arrythmia,
hypoglycemia, seizure, psychiatric
Syncope
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Preceding Events
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Psychological stress…vasovagal
Preceded by exertion…cardiac causes
Micturation
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Can occur at beginning during or end
Young men otherwise healthy likely related to
valsalva mechanism
Older men and women orthostasis, drugs, age
Older men with BPH predispose to valsalva
Syncope
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Seizure activity
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Activity after syncope is often present form multiple
causes
Single tonic convulsion most common postsyncopal
seizure
Clonic movements may occur usually brief
Incontinence common with hypoglycemia
Best discriminating features for seizure 1
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Orientation immediately after event (5x more likely if pt
disoriented)
Age <45 (3x more likely)
Nausea or sweating prodromal reduce likelihood of
seizure
1- J Neurol 1991;238(1):39 Level 2b
Syncope
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Investigations
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ECG with rhythm strip diagnostic in 11% cases 1
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Especially if no obvious cause
Older patient
Palpitations
Labs may be useful in selected cases
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CBC…rule out anemia
Lytes, BUN, Creatinine, Glucose, Magnesium Calcium
may identify metabolic disorders
ABG….hypoxia or hypercarbia
Tox screen
Cardiac Enzymes if preceding chest pain
1- NEJM 1983;309(4):197-204 Level 2c
Syncope
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Investigations
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Tilt table testing
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Recurrent syncope
Single syncopal episode in high risk patient
with no evidence of structural CV disease
Part of evaluation of exercise-induced syncope
Not indicated
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Single syncopal episode without injury
Clear-cut vasovagal features
American College of Cardiology 1996 Level 3
Syncope
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Investigations
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Carotid sinus massage
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All patients >60 with unexplained syncope
Syncope with shaving, turning heads, wearing
tight collars
Prerequisite
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IV access
Absence of bruits
Atropine available
ECG and BP monitoring
Syncope
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Investigations
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Technique
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Apply pressure over each sinus for up to 5
seconds
Patient is supine position
Interpretation
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JAMA 1992;268(18):2553
Abnormal asystole >3 seconds
Vasodepressor response Systolic BP drops
>50 mmHg no bradycardia
Syncope
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Simple Algorithm
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First Stage
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H&P
12 lead EKG with
rhythm strip
Hemoglobin &
glucose
DX in 42%
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Second Stage
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Eur Heart J 2000;21(11):935-40 Level 1b
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Echocardiogram
Carotid sinus
massage
Tilt testing
EEG
Brain imaging or
Carotid Doppler
Selected EP
Studies
Dx in 41 %
Febrile Seizures
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Simple (most common)
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Brief (15 minutes or less)
Generalized tonic-clonic activity
No focal component
Normal neurological and physical exam
Resolves spontaneously
Febrile Seizures
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Complex (less common)
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>15 minutes
Partial or focal onset
>1 seizure in 24 hours
Consider CNS infection
Febrile Seizures
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Prevalence
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2-5% in US and Europe
5-10% India
8.8% Japan
14% Guam
Age 6 months to 3 year peak 18 months
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6-15 % occur after 4
Rare after 6 year
Arch Dis Child 2004;89(8):751 Level 4
Febrile Seizures
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Viruses frequently implicated
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Human Herpesvirus 6 in 26% patients 1
Enteroviruses 2 15-19%
Influenza virus 3 19-20%
Parainfluenza 12%
Adenovirus 9%
1- J Pediatr 1995;127(1):95 Level 3
2- J Infect Dis 1997 ;175(3)700 Level 3
3- Pediatrics 2001;108(4):e63 Level 3
Febrile Seizures
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Risk Factors
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DTP (whole cell) 5.7x risk day of
vaccination 1
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MMR 2.83x risk 8-14 days 1
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6-9 cases per 100K
25-34 cases per 100K
Absolute risk 1.56 per 1,000 2
Causation unclear
No long-term Sequela
1- NEJM 2001;3459):656 Level 1b
2- JAMA 2004;292(3):351 Level 1b
Febrile Seizures
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History
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Look for features of complex febrile seizure
Peak temperature <102 F tend to be
complex febrile seizures
If seizure occurs >1 day after onset of fever
consider complex seizure
Physical Exam
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Nuchal rigidity, Brudzinski sign, Kernig’s
sign not sensitive or specific
Febrile Seizure
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Investigation
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Electrolytes, Glucose, Calcium, Urinalysis
Lumbar puncture and blood culture if clinically
indicated 1
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Hx of irritability, decreased feeding, lethargy
AMS post-ictal
Meningismus signs
Complex seizure features
Pretreatment with antibiotics
2-5% incidence of meningitis 2
1- Ann Emerg Med 2003;41(2):215 Level 4
2- Arch Dis Child 2004;89(8):751 Level 4
Febrile Seizure
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EEG
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Best predictor of recurrence
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54% had recurrence abnormal EEG
25% had recurrence with normal EEG
Timing in question (better to wait 2 weeks)
Neuroimaging
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Indicated if focal seizure or partial
Delayed resolution or prolonged seizure
Prolonged pos-ictal mental status changes
Neurology 2000;56:616 Level 1a
Febrile Seizure
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Recurrence
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1/3 will recur 1
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Increased if younger
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50% in 1st year
90% in 2nd year
50% recurrence if <1
Decreased risk if temperature >104
1- Arch Dis Child 2004;89(8):751 Level 5
Febrile Seizure
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Risk for future non-febrile seizures
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FHx of epilepsy
Preexisting neurologic deficits
Preexisting delayed development
Atypical febrile seizures
2-4% will have 1 unprovoked seizure
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Risk 4-5x of general population
NEJM 1987;316(9):493 Level 2b
Febrile Seizures
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Treatment 1
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No medications unless prolonged seizure
Diazepam or midazolam effective
Prevention
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Systematic review of acetaminophen no
difference 2
Ibuprofen not effective a preventing
seizures 3
1- BMJ 200;321(7253):83 Level 1b
2- Cochrane Librar 2002Issue 2:CD003676 Level 1a
3- Pediatrics 1998;102(5):e51 Level 1b
Epistaxis
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90-95% anterior
5-10% posterior
Fracture associated anterior ethmoidal
artery
Am Fam Physician 2005;71:305
Epistaxis
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Causes
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Trauma
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Rubbing, picking
Foreign body
Substance abuse
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Cocaine
Tobacco
Local Infection
Nasal Polyps
Neoplasm
Medications
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Steroids
Aspirin, Plavix etc.
Systemic disease
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HTN
Hemophilia
Leukemia
Liver disease
Platelet dysfunction
Thrombocytopenia
Epistaxis
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Risk Factors
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Posterior nosebleed
48% hypertensive
37% prior epistaxis
Follow circadian patterns
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Peak in morning
Smaller peak evening
BMJ 2004;321:112 Level 2b
Epistaxis
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Management
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Go with what is common
Anterior nasal compression
Use of decongestant soaked cotton helps
Tilt head forward
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Reduces pharyngeal pooling
Decreases nausea and vomiting
Am Fam Physician 2005;71:305 Level 5
Epistaxis
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Management Anterior
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If simple measures do not work
consider…….
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Suction clots
Anesthetize nose with cotton pledget 1%
tetracaine 1-3 minutes (slows blood flow)
Use of sympathetic agent helps
Cautery
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Silver nitrate (preferred)
Electrocautery risk possible perforation
Epistaxis
Epistaxis
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Management Posterior
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Consider hospitalization
Pack nasopharynx