emergencies in general practice
DESCRIPTION
Emergencies in general practice. Haseeb A. Khawaja , M.D. Diplomate American Board of Internal Medicine Director Emergency Department Shifa International Hospital, Islamabad. Objectives for session . Coma Seizures Meningitis Disturbed behavior Attempted suicide Poisoning/overdose - PowerPoint PPT PresentationTRANSCRIPT
HASEEB A. KHAWAJA, M.D.DIPLOMATE AMERICAN BOARD OF INTERNAL
MEDICINEDIRECTOR EMERGENCY DEPARTMENT
SHIFA INTERNATIONAL HOSPITAL, ISLAMABAD
Emergencies in general practice
1. Coma2. Seizures3. Meningitis4. Disturbed behavior5. Attempted suicide6. Poisoning/overdose7. GI bleeding8. Acute abdominal pain9. Chest pain10. MI and unstable angina11. Choking both adults and children12. Acute breathlessness13. Exacerbation of asthma14. Anaphylaxis15. Burns16. Electrocution17. Lacerations18. Fractures
UNAROUSABLE UNRESPONSIVENESS IN WHICH THE SUBJECTS LIE WITH EYES CLOSED
Coma
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 openWatch for contraversive movementsNext:
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 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
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 Catatoniao 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
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: TRANSIENT OCCURRENCE OF CLINICAL SYMPTOMSDUE TO ABNORMAL NEURONAL BEHAVIOR– CONVULSIONS: SEIZURES WITH PROMINENT BODY MOVEMENT– NON-CONVULSIVE SEIZURES: SEIZURES WITH MINIMAL OR NO BODYMOVEMENT• EPILEPSY: BRAIN DISORDER WITH AN ENDURING PREDISPOSITIONTO GENERATE EPILEPTIC SEIZURES• EPILEPSY SYNDROMES: GROUPS OF EPILEPTIC PATTERNS OFVARYING CAUSE BUT SIMILAR COURSE AND RESPONSE TOTREATMEN
Seizures
International Classification ofEpileptic Seizures
Partial (focal, local) seizures 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
Generalized seizures (convulsive or nonconvulsive) 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 ofconsciousness in between Single seizure >20-30 min (operationally, >5 min)
Causes?
Medication non-complianceCerebrovascular disease such as cerebral infarction,
cerebralhemorrhage, and venous thrombosisHead traumaCNS infections such as meningitis or encephalitisNeurodegenerative diseasesAutoimmune diseaseBrain neoplasmGenetic diseasesSubstance intoxication or withdrawalMetabolic medical disorders such as uremia,
hypoglycemia,hyponatremia, and hypocalcemia
Hypoxia
Hemorrhage
Infarct
Depressed Skull Fracture
Tumor
Vascular Malformation
CorticalDysplasia ?
InfectionUnknown/Cryptogenic
Clinical discrimination between Epileptic and non-epileptic events
Non Epileptic Events
Epileptic Events
Onset Gradual RapidAudience Common UnusualPelvic Thrusting/Opisthotonus
Common Uncommon (Consider Frontal)
Tongue biting Uncommon (tip) Lateral aspectEyes Closed (Resisting
opening)Deviated/Nystagmus
Autonomicfeatures
Uncommon Common
Plantars Normal Babinski +
DOAttempt to time duration ofseizure
Loosen clothing and remove glasses
Help patient lie down and roll onto side to helpavoid aspiration
Do NOT attempt to place anything in the patient’smouth, including medication and water
Do NOT leave patient lying on backDo NOT restrain during or after seizure; mayprovoke aggressive behavior or cause injury
DO NOT
Status Epilepticus on the scene
DefinitionABC’sSugar checkOther causesBenzodiazepinesPhenytoinPhenobarbitonePropofol
“INFECTION OF THE MENINGES”
Meningitis
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
Journal Watch Neurology January 24, 2002
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
Emperic Antibiotics
Treatment of bacterial meningitis. N Engl J Med 1997;336:708-716
“ACUTE NEUROLOGICAL DISTURBANCE”
Delirium
DSM IV Criteria
1. Disturbance of consciousness with reducedability to focus, sustain or shift attention.2. A change in cognition or development ofperceptual disturbances that is not betteraccounted for a preexisting, existed or evolvingdementia.3. The disturbance develops over a short periodof time and tends to fluctuate during the courseof the day4. There is evidence from this history, examination or
labs thatthe disturbance is caused by the physiologicalconsequence of a medical condition.
causes
InfectionsElectrolyte abnormalitiesEndocrine dysfunctions (hypo or hyper)Liver failure- hepatic encephalopathyRenal failure- uremic encephalopathyPulmonary disease with hypoxemiaCardiovascular disease/events: CHF, arrhythmias, MICNS pathology: tumors, strokes, seizuresDeficiency 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 anddopaminergic) Sedatives (benzodiazepines, barbiturates) Anticonvulsants Antihistamines Antiarrhythmics (digitalis) Antihypertensives Antidepressants Antimicrobials (penicillin, cephalosporins,quinolones) Sympathomimetics
Dementia vs Delirium
Dementia has an insidious onset, chronicmemory and executive function disturbance,tends not to fluctuate. In delirium cognitivechanges develop acutely and fluctuate.Dementia has intact alertness and attention
butimpoverished speech and thinking. In deliriumspeech 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 morecommon than visual hallucinationsMemory is grossly intact and disorientationis rareSpeech is not dysarthricNo wide fluctuations over the course of a dayDelusions and hallucinations
Acutely Agitated Patient
Safety Management and Response Techniques (SMART) SMART staff education 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 effectsRespect/concern
AAP. Practice guideline for the treatment of patients with delirium.
Monotherapy with a typical antipsychotic: haloperidol or droperidol 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 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 emergencyIn general, antipsychotics are still the
pharmacologic intervention of choice in the acutely agitated patient
Found down patient
DONT
A SAD BUT PERMANENT SOLUTION TO A TEMPORARY PROBLEM
Suicide
Why Talk About Suicide?
because ~ suicide doesn’t discriminate bygender, age, race, ethnicity, education, or socio-economic status.because ~ 90% of people who die of suicidehave a treatable mental illness or substance
abusedisorder; 60% have a depressive disorder.because ~ suicide is the most preventableform of death in the U.S. today.
Depression in disguise
Drug / alcohol abuseAggressive behaviorDelinquent behaviorReckless / antisocial behaviorEating disordersHappy maskFrequent “accidents”Self – destructive actsExtreme boredom / apathyUnexplained physical symptomsSleeping disorderExtreme restlessness
Facts!
Females attempt three times more than males.Males choose more lethal methods (lessopportunity for life saving techniques).Most suicidal people don’t really want to die ~ they justwant their pain to end.About 80% of the time, people who kill themselves havegiven definite signals or talked about suicide.The key to prevention is to know the signs and what youcan do to help.If someone you know seems depressed or gloomy and hasspent a lot time questioning whether life is worth the
bother ~it’s time toPay Attention!
Myths about suicide
“People who talk about suicide won’t really doit.” FALSE“Anyone who tries to kill him/herself must becrazy.” FALSE“If a person is determined to kill him/herself,nothing is going to stop him/her.” FALSE“People who commit suicide are people whowere unwilling to accept help.” FALSE“Talking about suicide may give someone theidea.” FALSE
Suicide Symptoms
Verbal suicide threatsBehavior changesIncrease in mention of body painDepressionSleeping and eating patternsFatigueIrritabilityLifting of prolonged depressionFinal arrangementsDeath wish behavior
SAVE A LIFE!
ASK DIRECT QUESTIONS
Poisoning/Overdose
What to do?
ABCGCSVitalsECGIV 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