Management of Office Emergencies - University of …faculty.washington.edu/fvega/download/Week 9...

Management of Office Emergencies

Fernando Vega, M.D. 1

Fernando Vega, M.D.

Classic PresentationInitially: prutitus, urticariaAngioedema, swellingf/b: respiratory Sx – stridor, dyspnea, wheeze

Other PresentationsNausea, cramps, diarrhea, vomiting



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

SkinSkin Angioedema, flushing, urticaria, pruritusAngioedema, flushing, urticaria, pruritus

CardiovascularCardiovascular Tachycardia, palpitations, arrhythmias, Tachycardia, palpitations, arrhythmias, hypotension,syncopehypotension,syncope

GastrointestinalGastrointestinal Nausea, vomiting diarrhea, crampsNausea, vomiting diarrhea, cramps

RespiratoryRespiratory Dyspnea, stridor, wheezing, chocking, rhinorrhea,Dyspnea, stridor, wheezing, chocking, rhinorrhea,

OtherOther Sense of impending doom, diaphoresis, metallic Sense of impending doom, diaphoresis, metallic tastetaste

UrticariaHyperventilationVasovagal reactiongGlobus hystericusHereditary angioedemaScromboid poisoning

0.3 – 0.5 cc epinephrine 1:1000 intramuscularlyMay repeat every 15 minutes if necessaryDi h h d i f iDiphenhydramine after epiGlucocorticosteroids after that:Predinsone 40-60mg/day……



o Persistent bronchospasmo Hypotensiono Hypoxiaypo 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)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 media20-40% on contrast media10-20% on penicillin

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



Immediate Posibilities:AsthmaPulmonary EmbolusHyperventilationAnaphylaxisForeign Body ObstructionCardiac asthma

Respiratory SystemBronchospasmPulmonary EmbolusPneumothoraxPulmonary infectionUpper airway obstruction: aspiration, anaphylaxis

Cardiovascular SystemAcute myocardial ischemiaCongestive Heart FailureCardiac tamponade

If you hear hoof beats: asthma or hyperventilation

No strange painNo strange historyNo strange physical findings

HistoryPrevious episodes, outcomesRelative to current episode:How serious? How anxious?How long? Tired?

Co-morbid conditions:CHFHypertension (use of beta-blockers)

Physical ExaminationStarted when you first looked at patientLevel of anxietyAbility to complete sentencesAccessory breathing:

Position of handsPursed lipsAccessory muscles



Physical Examination WheezesNo wheezesAir movementPulse ratePulsus paradoxus – 12 mm Hg Δ w/ inspr

Laboratory AssessmentPeak Flow meter

A fall of 50% from baseline is considered severeHypercapnea happens only when PF falls below 20

tpercentSpirometry

DemonstrationOxygen Saturation Meter

Initial treatment Inhaled albuterol2nd best: OTC sympathomimmeticsy pMDI w/spacer vs. updraft

Followed by:Ipratropium bromide

When to use steroidsLess than 10% improvement in PEFR after first dose of inhaled beta agonistLess than 70% improvement of PEFR after first hour Less than 70% improvement of PEFR after first hour of treatmentAn asthma attack that developed in spite of steroidsProtracted course

How to use steroidsAs a rule 40 – 80 mg Prednisone qd Equivalent to 200 400 mg HydrocortisoneEquivalent to 200 – 400 mg HydrocortisoneMay taper, may notIV steroids for severe cases

How to use steroidsThe effect of a single dose of oral prednisone begins within 3 hours and reaches a maximum within 8-12 hoursIn a study of 15, 40 and 125 mg of y , gmethylprednisolone q6h of patients in status asthmaticus

125mg group got better end of first day40mg group got better by middle of second day

Inhaled steroids are for chronic use only



Pulmonary EmbolusPulmonary Embolus Sudden onset, Pleuritic pain and dyspneaSudden onset, Pleuritic pain and dyspnea

Aortic dissectionAortic dissection Tearing pain with radiation to backTearing pain with radiation to back

PericarditisPericarditis Positional ache, dyspneaPositional ache, dyspnea

PneumothoraxPneumothorax Pleuritic pain and dyspneaPleuritic pain and dyspnea

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

Chest Wall PainChest Wall Pain Pleuritic PainPleuritic Pain Visceral PainVisceral PainCostochondritisCostochondritis Pulmonary EmbolusPulmonary Embolus Exertional anginaExertional angina

Precordial catchPrecordial catch PneumothoraxPneumothorax Unstable anginaUnstable anginaPrecordial catchPrecordial catch PneumothoraxPneumothorax Unstable anginaUnstable angina

Slipping ribSlipping rib PericarditisPericarditis PericarditisPericarditis

XyphodyniaXyphodynia PleurisyPleurisy Aortic dissectionAortic dissection

FibromyalgiaFibromyalgia Esoph reflux or spasmEsoph reflux or spasm

Gall bladder PainGall bladder Pain

Acute MIAcute MI

Worst CaseFor patient (when you know the diagnosis)F D ( h d ’ k h D )For Doctor (when you don’t know the Dx)

Acute Coronary Syndromes:Acute Coronary Syndromes:Myocardial Ischemia and Infarction

Acute Coronary Syndromes:Myocardial Ischemia and Infarction

Ischemic/anginal pain is similar to AMI painIschemic/anginal pain is similar to AMI painAMI pain resolves with aggressive interventionAMI pain resolves with aggressive interventionIschemic/anginal pain resolves with rest or Ischemic/anginal pain resolves with rest or NTGNTG




Severe, deep painSevere, deep pain

Pain radiates to jaw or armPain radiates to jaw or armPain radiates to jaw or armPain radiates to jaw or arm

Gesture of resignationGesture of resignation


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

“Like an elephant stepping on my chest”“Like an elephant stepping on my chest”

Gesture of resignationGesture of resignation


Can be silent painCan be silent painEspecially in diabeticsEspecially in diabeticsEld lEld lElderlyElderlyWomenWomen


15 15 –– 20 % AMI have some CHF20 % AMI have some CHFPapillary muscle rupture in 1Papillary muscle rupture in 1--3 days 3 days Pericarditis in 20% in 2Pericarditis in 20% in 2--4 days 4 days

Dysrhythmias occur in 72 Dysrhythmias occur in 72 –– 100% of AMI100% of AMI


Dysrhythmias occur in 72 Dysrhythmias occur in 72 –– 100% of AMI100% of AMI

Acute Coronary Syndromes:Management

Direct admission to CCUDirect admission to CCU




Direct admission to CCU (not the ER)Direct admission to CCU (not the ER)

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

Antithrombin drugs:Antithrombin drugs:HeparinHeparinLMWHLMWH

Fibrinolytic Agents (for STEMI)Fibrinolytic Agents (for STEMI)Coronary reperfusionCoronary reperfusion


Direct admission to CCUDirect admission to CCU

Other antiOther anti--ischemic therapies:ischemic therapies:NitroglycerinNitroglycerinMorphineMorphineMetoprololMetoprololAtenololAtenolol

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

Not Atrial FibrilationNot Atrial FibrilationNot Atrial FibrilationNot Atrial Fibrilation

Not prolonged QT intervalNot prolonged QT interval

Not Torsade de PointesNot Torsade de Pointes

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

If they need to be treated they willIf they need to be treated they willIf they need to be treated, they will If they need to be treated, they will complaincomplain

If they complain, they need to be treatedIf they complain, they need to be treated

In the absence of ACS, palpitations are overwhelmingly benign

Even NSVT = 4% of populationEven NSVT = 4% of population

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



What do non-benign arrhythmias look like?

Not normal ECGNot normal ECGAtrial fibrilation flutterAtrial fibrilation flutterAtrial fibrilation, flutterAtrial fibrilation, flutterProlonged qt has to be measuredProlonged qt has to be measured

Most common complaint in ER

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

b bb bAbsent bowel tones are not clinically useful Absent bowel tones are not clinically useful findingsfindingsHyperactive or obstructive sounds are more Hyperactive or obstructive sounds are more helpfulhelpfulRebound tenderness or “cough pain” is very Rebound tenderness or “cough pain” is very usefuluseful

Non specific abdominal painNon specific abdominal pain 34%34%AppendicitisAppendicitis 28%28%Biliary tract diseaseBiliary tract disease 10%10%Small Bowel ObstructionSmall Bowel Obstruction 4%4%Small Bowel ObstructionSmall Bowel Obstruction 4%4%Acute Gynecological diseaseAcute Gynecological disease 4%4%PancreatitisPancreatitis 3%3%Renal ColicRenal Colic 3%3%Diverticular diseaseDiverticular disease 2%2%

1800 pts, WBC >10k doubled odds of appendicitis

1800 pts, WBC <10k halved the odds of 1800 pts, WBC <10k halved the odds of di i idi i iappendicitisappendicitis

Same with acute cholecytstitisSame with acute cholecytstitis

In NSAP 28% of WBC counts >10.5KIn NSAP 28% of WBC counts >10.5K



Peptic Ulcer bleed accounts for 60% of Upper GI bleeding

Followed by erosive gastritis and esophagitisFollowed by erosive gastritis and esophagitis

Followed by variceal bleedingFollowed by variceal bleeding

Followed by Mallory WeissFollowed by Mallory Weiss

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

Followed by diverticular bleeding, AVM, IBD, Followed by diverticular bleeding, AVM, IBD, d ld land polypsand polyps

Both UGI LGI bleeding more common in Both UGI LGI bleeding more common in ♂♂

Diarrhea is the most important differentiating Diarrhea is the most important differentiating symptomsymptom

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

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

BrainBrain Severe HA, nausea, Severe HA, nausea, vomiting, altered sensorium, vomiting, altered sensorium, CVACVA

End organ dysfunction makes it an urgency

CVACVAHeartHeart Ischemic symptomsIschemic symptoms

KidneysKidneys Proteinurea, hematuria, Proteinurea, hematuria, azotemiaazotemia

VascularVascular AneurysmAneurysm



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

Not so common in office settingNot so common in office settingC t ith lf l rC t ith lf l rCaveat with sulfonylureasCaveat with sulfonylureas

SweatingSweating ShakinessShakiness

Typical symptoms

gg

AnxietyAnxiety NauseaNausea

DizzinessDizziness ConfusionConfusion

Blurred visionBlurred vision HeadacheHeadache

LethargyLethargy

Typical SignsDiaphoresisDiaphoresisT h diT h diTachycardiaTachycardiaAlmost any neurological findingAlmost any neurological finding

Altered mental statusAltered mental statusTremorTremorFocal Neurologic deficitFocal Neurologic deficitSeizureSeizure



ManagementOral GlucoseOral GlucoseIV D50 1 /k f/b ti dripIV D50 1 /k f/b ti dripIV D50 1gm/kg f/b continuous dripIV D50 1gm/kg f/b continuous dripGlucagon 1mg IM if IV access unavailableGlucagon 1mg IM if IV access unavailableHydrocortisone 100mg IV or glucagon 1mg IV Hydrocortisone 100mg IV or glucagon 1mg IV if hypoglycemia is refractory to glucose if hypoglycemia is refractory to glucose administrationadministrationOctreotide for refractory cases due to Octreotide for refractory cases due to sulfonylureassulfonylureas

ManagementReview coReview co--morbid conditionsmorbid conditionsReview social situationReview social situationReview social situationReview social situationMost diabetics with insulin reactions respond Most diabetics with insulin reactions respond rapidly to treatmentrapidly to treatmentPatients with prolonged or recurrent Patients with prolonged or recurrent hypoglycemia from sulfonylureas need to be hypoglycemia from sulfonylureas need to be admittedadmitted

Ketosis on UA or not?Ketosis on UA or not?

How high is too high?How high is too high?

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

and precipitous with ketosis.and precipitous with ketosis.

Occurs predominantly in insulin dependentOccurs predominantly in insulin dependent

N t di b t t DKA i 25%N t di b t t DKA i 25%

Mortality is 5% and is higher in elderlyMortality is 5% and is higher in elderly

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

Precipitated by nonPrecipitated by non--compliance with insulin compliance with insulin therapy or any type or physiologic stress such therapy or any type or physiologic stress such as:as:

infectioninfectionStrokeStrokeMIMIpregnancypregnancy



Clinical Picture directly related to metabolic Clinical Picture directly related to metabolic dd

Clinical Picture

derangementsderangementsHyperglycemia causes osmotic diuresis Hyperglycemia causes osmotic diuresis →dehydration, hypotension, tachycardia→dehydration, hypotension, tachycardiaKetonemia causes acidosis with myocardial Ketonemia causes acidosis with myocardial depression, vasodilation and Kussmauldepression, vasodilation and Kussmaul’’ss

Admit to hospitalAdmit to hospital

Management

Correct HypovolemiaCorrect HypovolemiaCorrect Electrolyte abnormalitiesCorrect Electrolyte abnormalitiesCorrect Acidosis and ketonemiaCorrect Acidosis and ketonemiaTreat underlying causeTreat underlying cause

Is a common presentation of newIs a common presentation of new--onset onset di b llidi b lli

Pathophysiology

diabetes mellitusdiabetes mellitusOccurs in poorly controlled type II DMOccurs in poorly controlled type II DMContraction alkalosis f/b metabolic acidosisContraction alkalosis f/b metabolic acidosis

Typical patient is elderly with complaints of Typical patient is elderly with complaints of k l hk l h

Clinical Features

weakness or mental status changesweakness or mental status changesPhysical exam: dehydration and altered Physical exam: dehydration and altered mental statusmental statusCan have focal deficits or seizuresCan have focal deficits or seizures

Glucose > 600mg/dLGlucose > 600mg/dL

Clinical Features

HCO3 > 15 mg/dLHCO3 > 15 mg/dLpH > 7.3pH > 7.3Ketosis absent or mildKetosis absent or mild

AdmitAdmit

Management

Correct hypovolemiaCorrect hypovolemiaCorrect free water deficitCorrect free water deficitHCO3 > 15 mg/dLHCO3 > 15 mg/dLpH > 7.3pH > 7.3Ketosis absent or mildKetosis absent or mild



Rectal Temp > 38Rectal Temp > 38°°C (100.4C (100.4°°F)F)

Priority is to identify the child Priority is to identify the child with a serious bacterial illnesswith a serious bacterial illness

The higher the fever, the higher incidence of The higher the fever, the higher incidence of b ib i

Infants 0- 3 months

bacteremiabacteremiaAge 0Age 0--8 weeks at high risk of SBI8 weeks at high risk of SBIHighest risk for sepsis first few days of lifeHighest risk for sepsis first few days of life

The higher the fever, the higher incidence of The higher the fever, the higher incidence of bacteremiabacteremiaAge 0Age 0--8 weeks at high risk of SBI8 weeks at high risk of SBIHighest risk for sepsis first few days of lifeHighest risk for sepsis first few days of lifeAge 0Age 0 8 week infant may have Bacterial8 week infant may have Bacterial

Infants 0- 3 months

Age 0Age 0--8 week infant may have Bacterial 8 week infant may have Bacterial Sepsis w/o clinical findingsSepsis w/o clinical findingsFebrile infants < 4 weeks 13% incidenceFebrile infants < 4 weeks 13% incidenceFebrile infants < 8 weeks 10% incidenceFebrile infants < 8 weeks 10% incidence

Clinical impression is more reliable in this groupClinical impression is more reliable in this group

Infants 3-24 months

Viral illnesses including pneumonia account for Viral illnesses including pneumonia account for the most common etiologythe most common etiologyStrep pneumoniae is the most common bacterial Strep pneumoniae is the most common bacterial etiologyetiology.019% of bacteremia develop meningitis.019% of bacteremia develop meningitis

Indications for Admission to HospitalIndications for Admission to Hospital

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

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

Toxic appearance regardless of age or degree Toxic appearance regardless of age or degree of feverof fever



Occurs typically Oct Occurs typically Oct –– MayMayI f l h 2 k 2I f l h 2 k 2

Epidemiology

Infants less than 2 years, peak at 2 moInfants less than 2 years, peak at 2 moIncreased risk of complicationsIncreased risk of complications

PrematurityPrematurityBPDBPDCongenital HeartCongenital Heart

Begins with nasal discharge, pharyngitis, Begins with nasal discharge, pharyngitis, cough and fevercough and fever

Clinical Features

ggWheezing and respiratory distress follow Wheezing and respiratory distress follow later.later.Tachypnea, nasal flaring and gruntingTachypnea, nasal flaring and gruntingOminous signs of RF: Decrease or absence Ominous signs of RF: Decrease or absence of breath sounds signifies severe of breath sounds signifies severe bronchocnstrictionbronchocnstriction

Symptoms peak in 3Symptoms peak in 3--5 days5 daysUsually resolve in 2 weeksUsually resolve in 2 weeks

Clinical Features

Usually resolve in 2 weeksUsually resolve in 2 weeksImmunity is variableImmunity is variableReinfection may occurReinfection may occur

May respond to albuterol but probably not.May respond to albuterol but probably not.

Management

Nebulized epinephrine may be helpfulNebulized epinephrine may be helpfulHeliox may be helpfulHeliox may be helpfulHydrationHydrationSteroidsSteroids

Indications for hospitalizationIndications for hospitalization

Management

ApneaApneaRespiratory distress unresponsive to TxRespiratory distress unresponsive to TxHypoxiaHypoxiaVomiting or dehydrationVomiting or dehydrationTachypnea > 60Tachypnea > 60

Clinical Features

Life threateningLife threateningCan occur at any ageCan occur at any ageCan occur at any ageCan occur at any ageAbrupt onset of High fever, sore throat, Abrupt onset of High fever, sore throat, stridor, dysphagia and drooling over 2 d.stridor, dysphagia and drooling over 2 d.Severe sore throat with normal appearing Severe sore throat with normal appearing oropharynx.oropharynx.XX--rays are unnecessaryrays are unnecessary



Lifetime likelihood of one Sz is 9%Lifetime likelihood of one Sz is 9%Age 0Age 0--9 years prevalence is 4.4/10009 years prevalence is 4.4/1000Age 0Age 0 9 years prevalence is 4.4/10009 years prevalence is 4.4/1000Age 10Age 10--19 yrs prevalence is 6.6/100019 yrs prevalence is 6.6/1000Simple febrile Sz are a different category with Simple febrile Sz are a different category with incidence of 3incidence of 3--4% 4%

Clinical Features

Symptoms can be any of the following:Symptoms can be any of the following:Alteration of consciousnessAlteration of consciousnessAuditory, sensory or olfactory hallucinationsAuditory, sensory or olfactory hallucinationsInvoluntary motor activityInvoluntary motor activityChoreoathetoid movementsChoreoathetoid movements

Clinical Features

Neonatal seizures may be subtle and Neonatal seizures may be subtle and sometimes w/ only autonomic changes:sometimes w/ only autonomic changes:y gy g

MydriasisMydriasisApneaApneaCardiac irregularityCardiac irregularity

Know mechanism of injuryKnow mechanism of injuryCheck neurovascular statusCheck neurovascular statusGeneral fracture care:General fracture care:

Ice, traction, splintingIce, traction, splinting

Special Fractures:Special Fractures:ScaphoidScaphoidRadial headRadial headMetatarsal shaftMetatarsal shaftAnkle domeAnkle dome

AbcessesAbcessesBite woundsBite woundsW dW dWound managementWound management

“Golden Rule” of 8 hours“Golden Rule” of 8 hoursNeurovascular examNeurovascular exam



Mechanism of injury will help identify risk of Mechanism of injury will help identify risk of foreign body, contamination and wound foreign body, contamination and wound complicationcomplicationcomplicationcomplicationCrush injuries more likely to cause wound Crush injuries more likely to cause wound infectioninfectionHematomas often require drainageHematomas often require drainage

History of prodromeHistory of prodrome

WitnessesWitnesses

Differentiation syncope from seizures

PostPost--ictal phenomenonictal phenomenon

Memory of the eventMemory of the event

WitnessesWitnesses

Subconjunctival hemorrhageSubconjunctival hemorrhage

Corneal abrasionCorneal abrasion

Trauma: check integrity and acuityTrauma: check integrity and acuity

Corneal Foreign bodyCorneal Foreign body

Corneal abrasionCorneal abrasion

Acute angle closure glaucomaAcute angle closure glaucoma

Testicular TorsionTesticular Torsion

EpididymitisEpididymitis

Urinary retentionUrinary retention

EpididymitisEpididymitis

Threatened abortionThreatened abortion2020--40% of pregnancies abort spontaneously40% of pregnancies abort spontaneously

Ectopic PregnancyEctopic Pregnancy

MenorrhagiaMenorrhagia

2020 40% of pregnancies abort spontaneously40% of pregnancies abort spontaneouslyChromosomal abnormalities account for mostChromosomal abnormalities account for most

Dysfunctional Uterine BleedingDysfunctional Uterine Bleeding

Management of Office Emergencies - University of …faculty.washington.edu/fvega/download/Week 9...

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