Management of Office Emergencies Fernando Vega, M.D. - PDF document

Management of Office Emergencies Fernando Vega, M.D. height="344"></embed></object> � http://www.youtube.com/watch?v=olFD1R5Gu- � A&feature=player_embedded <object width="425" height="344"><param name="movie" � value="http://www.youtube.com/v/olFD1R5Gu- A&color1=0xb1b1b1&color2=0xcfcfcf&hl=en&feature=player_em bedded&fs=1"></param><param name="allowFullScreen" value="true"></param><paramname="allowScriptAccess" value="always"></param><embed src="http://www.youtube.com/v/olFD1R5Gu- A&color1=0xb1b1b1&color2=0xcfcfcf&hl=en&feature=player_em bedded&fs=1" type="application/x-shockwave-flash" allowfullscreen="true" allowScriptAccess="always" width="425" height="344"></embed></object> http://www.youtube.com/watch?v=y3bOgdvV- � Classic Presentation _M&feature=related � Initially: prutitus, urticaria � Angioedema, swelling � f/b: respiratory Sx – stridor, dyspnea, wheeze http://www.youtube.com/watch?v=ywdk3BTjK 2s&feature=related � Other Presentations � Nausea, cramps, diarrhea, vomiting Fernando Vega, M.D. 1

Management of Office Emergencies Fernando Vega, M.D. 2

Management of Office Emergencies Angioedema, flushing, urticaria, pruritus Skin � Presence of an allergic sign (urticaria … .) Cardiovascular Tachycardia, palpitations, arrhythmias, � Involvement of at least two organ systems hypotension,syncope � Exposure to agent or activity known to … Nausea, vomiting diarrhea, cramps Gastrointestinal � Absence of condition that can mimic anaphylaxis Dyspnea, stridor, wheezing, chocking, rhinorrhea, Respiratory Other Sense of impending doom, diaphoresis, metallic taste � 0.3 – 0.5 cc epinephrine 1:1000 � Urticaria intramuscularly � Hyperventilation � May repeat every 15 minutes if necessary � Vasovagal reaction � Diphenhydramine after epi � Globus hystericus � Glucocorticosteroids after that: � Hereditary angioedema Predinsone 40-60mg/day …… � Scromboid poisoning Fernando Vega, M.D. 3

Management of Office Emergencies o Persistent bronchospasm o Hypotension o Hypoxia o Patient is on beta-blockers o 20% of reactions are “ biphasic ” with further mediator release 4 – 8 hours later. 5 foods responsible for more than ¾ of food Most common causes of anaphylaxis reactions in children: include: Eggs (36%) Peanuts (24%) Drugs (particularly beta-lactams, NSAIDS, Cow ’ s milk (8%) ACE inhibitors) Mustard (6%) Cod (4%) Hymenoptera (bees, wasps) Radiographic contrast media Fin fish and shellfish more common in adults Blood products Children outgrow sensitivities to milk, eggs, soy but not usually to peanuts, nuts or fish Foods (particularly seafood, milk, nuts) Fatalities most common in teens following ingestion of peanuts or tree nuts Anaphylaxis is not automatic on recurrent exposure: 40-60% on insect stings 20-40% on contrast media 10-20% on penicillin Concurrent use of beta-blockers is a risk for severe prolonged anaphylaxis Fernando Vega, M.D. 4

Management of Office Emergencies � Immediate Posibilities: � Asthma � Pulmonary Embolus � Hyperventilation � Anaphylaxis � Foreign Body Obstruction � Cardiac asthma � Respiratory System � Cardiovascular System � Bronchospasm � Acute myocardial ischemia � Pulmonary Embolus � Congestive Heart Failure � Pneumothorax � Cardiac tamponade � Pulmonary infection � Upper airway obstruction: aspiration, anaphylaxis � If you hear hoof beats: asthma or � History hyperventilation � Previous episodes, outcomes � No strange pain � Relative to current episode: � No strange history � How serious? How anxious? � No strange physical findings � How long? Tired? � Co-morbid conditions: � CHF � Hypertension (use of beta-blockers) Fernando Vega, M.D. 5

Management of Office Emergencies � Physical Examination � Physical Examination � Started when you first looked at patient � Wheezes � Level of anxiety � No wheezes � Ability to complete sentences � Air movement � Pulse ratePulsus paradoxus – 12 mm Hg Δ w/ inspr � Accessory breathing: � Position of hands � Pursed lips � Accessory muscles � Laboratory Assessment � Peak Flow meter � A fall of 50% from baseline is considered severe � Hypercapnea happens only when PF falls below 20 percent � Spirometry � Demonstration � Oxygen Saturation Meter � Initial treatment � Inhaled albuterol � 2 nd best: OTC sympathomimmetics � MDI w/spacer vs. updraft � Followed by: � Ipratropium bromide Fernando Vega, M.D. 6

Management of Office Emergencies � When to use steroids � How to use steroids � Less than 10% improvement in PEFR after first dose of inhaled beta agonist � As a rule 40 – 80 mg Prednisone qd � Less than 70% improvement of PEFR after first hour � Equivalent to 200 – 400 mg Hydrocortisone of treatment � May taper, may not � An asthma attack that developed in spite of steroids � IV steroids for severe cases � Protracted course � 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 asthmaticus � 125mg group got better end of first day � 40mg group got better by middle of second day � Inhaled steroids are for chronic use only Pulmonary Embolus Sudden onset, Pleuritic pain and dyspnea Chest Wall Pain Pleuritic Pain Visceral Pain Costochondritis Pulmonary Embolus Exertional angina Aortic dissection Tearing pain with radiation to back Precordial catch Pneumothorax Unstable angina Pericarditis Positional ache, dyspnea Slipping rib Pericarditis Pericarditis Xyphodynia Pleurisy Aortic dissection Pneumothorax Pleuritic pain and dyspnea Fibromyalgia Esoph reflux or spasm Acute coronary syndrome Vague, pressure-like pain, radiating to arm, neck, jaw Gall bladder Pain Acute MI Fernando Vega, M.D. 7

Management of Office Emergencies � Worst Case � For patient (when you know the diagnosis) Acute Coronary Syndromes: � For Doctor (when you don ’ t know the Dx) Myocardial Ischemia and Infarction Acute Coronary Syndromes: Acute Coronary Syndromes: Myocardial Ischemia and Infarction Myocardial Ischemia and Infarction � Ischemic/anginal pain is similar to AMI pain � Severe, deep pain � AMI pain resolves with aggressive intervention � Pain radiates to jaw or arm � Ischemic/anginal pain resolves with rest or NTG � Gesture of resignation Acute Coronary Syndromes: Acute Coronary Syndromes: Myocardial Ischemia and Infarction Myocardial Ischemia and Infarction � Visceral pain induces autonomic responses: � Can be silent pain nausea, vomiting, diaphoresis � Especially in diabetics � Elderly � “ Like an elephant stepping on my chest ” � Women � Gesture of resignation Fernando Vega, M.D. 8

Management of Office Emergencies Acute Coronary Syndromes: Acute Coronary Syndromes: Myocardial Ischemia and Infarction Myocardial Ischemia and Infarction � 15 – 20 % AMI have some CHF � Papillary muscle rupture in 1-3 days � Pericarditis in 20% in 2-4 days � Dysrhythmias occur in 72 – 100% of AMI � Dysrhythmias occur in 72 – 100% of AMI Acute Coronary Syndromes: Acute Coronary Syndromes: Management Management � Direct admission to CCU � Antiplatelet drugs: � ASA 160 – 325mg PO ( ↓ mortality by 23%) Direct admission to CCU � Clopidrogel 300mg loading f/b 75mg qd (more benefit) (New information) � Antithrombin drugs: � Heparin � LMWH � Fibrinolytic Agents (for STEMI) � Coronary reperfusion Acute Coronary Syndromes: Management � Direct admission to CCU � Other anti-ischemic therapies: � Nitroglycerin � Morphine � Metoprolol � Atenolol Fernando Vega, M.D. 9

Management of Office Emergencies � In the absence of structural heart disease, � In the absence of structural heart disease, palpitations are overwhelmingly benign when palpitations are overwhelmingly benign the ECG is normal. � Not Atrial Fibrilation � If they need to be treated, they will complain � Not prolonged QT interval � If they complain, they need to be treated � Not Torsade de Pointes � In the absence of ACS, palpitations are � What do non-benign arrhythmias look like? overwhelmingly benign � Not normal ECG � Even NSVT = 4% of population � Atrial fibrilation, flutter � Prolonged QT � In 60 – 85 year olds with no structural heart disease followed for 10 years NSVT did not predict a coronary event � Most common complaint in ER � Location, quality, severity, onset, duration, aggravating and alleviating factors � Absent bowel tones are not clinically useful findings � Hyperactive or obstructive sounds are more helpful � Rebound tenderness or “ cough pain ” is very useful Fernando Vega, M.D. 10