Management Of Medical Emergencies

Management Of Medical Emergencies

U.S. Aging Population 35 million people (12%) 65 years or older Number will increase by nearly 75% by year 2030 The number of people more than 85 years old will approach 11 million by 2030

Physiologic Studies Aging In general basal function of the major organ systems are relatively uncompromised Functional reserve and ability to compensate for physiologic stress significantly reduces

Management Of Medical Emergencies Prevention Recognition Treatment

Decreased Level of Consciousness Altered Consciousness Unconsciousness

Altered Consciousness Confusion - mental state marked by the mingling of ideas with disturbances of comprehension and understanding -> bewilderment Delirium - mental disturbance characterized by illusions, delusions, cerebral excitement, physical restlessness, and incoherence Derangements of speech, thought, motion, or sensation

Mechanisms of Altered Consciousness Inadequate delivery of blood or oxygen to the brain Systemic or local metabolic deficiencies Direct or reflex effects on the CNS Psychic mechanisms

Mechanisms of Altered Consciousness Inadequate delivery of blood or oxygen to the brain Myocardial Infarction Congestive Heart Failure Respiratory Failure

Mechanisms of Altered Consciousness Systemic or Local Metabolic Deficiencies Hyperglycemia or Hypoglycemia Hyperthyroidism or Hypothyroidism Drug Overdose Acute Allergic Reactions

Mechanisms of Altered Consciousness Direct or Reflex Effects on CNS Cerebrovascular Accident Convulsive Episodes Psychic Mechanisms Hyperventilation Vasodepressor Syncope

Call for Help Emergency numbers 6 2233 (Internal school number) 9 911 (Emergency EMS) Bring Emergency Equipment to Site

Altered Consciousness Examine Patient Place Supine or Upright PRN Obtain Vital Signs Administer Oxygen Definitive Care based on History and Physical findings

Differential Diagnosis Altered Consciousness Skin warm and dry - hyperglycemia Skin cold and moist - hypoglycemia, angina, AMI, severe acute allergic reaction Skin hot and wet - hyperthyroidism Skin cold and dry - hypothyroidism Paresthesia - hyperventilation syndrome, TIA -> CVA Headache - CVA, hypoglycemia

Acute Stroke (CVA) Altered consciousness Intense headache, severe neck or facial pain Aphasia or dysarthria One sided sensory loss or motor weakness Ataxia Visual loss mono or binocular Vertigo, double vision, unilateral hearing loss, nausea, vomiting, photo or phonophobia

Supportive Treatment Patients are placed in upright position Oxygen supplied by nasal canula (6 L/min) or facemask (15 L/min) CPR prn Vital signs are monitored q5m Transport patient to hospital for definitive treatment CAT scan Fibrinolytic therapy tpa within 3 hrs onset symptoms (not hemorrhagic stroke)

Unconsciousness Inadequate Delivery of Blood or Oxygen to the Brain (respiratory &/or cardiovascular failure) Vasodepressor Syncope Orthostatic Hypotension Cardiac Arrest, Major Dysrhythmia, Failure Respiratory Failure Airway Obstruction, Respiratory Depression or Arrest

Management of Unconscious Patient Place patient supine with legs elevated Basic Life Support ABCs Airway - Obstruction Breathing Circulation carotid pulse

Management of Unconscious Patient Absent Pulse Administer CPR Defibrillate ASAP AED

Management of Unconscious Patient Breathing with Pulse Maintain patent airway Administer supplemental oxygen Obtain vital signs - BP, HR & Rhythm, RR and examine patient Differential Diagnosis

General Considerations Differential Diagnosis: Neurogenic - Vasodepressor Syncope Vascular - Postural Hypotension Cardiogenic dysrhythmia, CHF Drugs Psychogenic Endocrine - Adrenal Insufficiency

Predisposing factors Stress Impaired Physical Status (ASA III or IV) Ingestion of Drugs (Narcotics, Benzodiazepines, Barbiturates, Antidepressants, ETOH)

Prevention Both physiologic and psychological stress reduction Acknowledging fear IV sedation Supplemental oxygen/nitrous oxide Supine positioning

Vasodepressor Syncope Predisposing factors Fainting 1. Male, under 35 years, and administration of local 2. Psychogenic- fright, pain 3. Physiologic- Upright position, hunger

Pathophysiology Fight or flight response Hypotension Bradycardia Resulting in decrease cerebral perfusion

Clinical manifestations Presyncope: pale, cold sweat, nausea, yawning, pupils dilate Syncope: convulsive movements, hypotension, bradycardia. Typically lasts seconds to minutes Post syncope: weakness, sweating, nausea, pallor

Clinical manifestations If unconsciousness persists for more then 5 minutes, or complete recovery is not achieved in 15-20 minutes then other causes of unconsciousness must be considered. Especially if patient is over 40

Management Stop procedure! Call for help Assess level of consciousness Place in supine position A,B,C s: Airway, Breathing, Circulation Oxygen Vitals Aromatic Ammonia

Postural Hypotension A fall in systolic pressure of 20 mm/hg or more upon standing

Predisposing factors 1. Age: over 65 population 2. Drugs: AntiHTN, Antidepressants, Antipsychotics, Narcotics, Antiparkinson 3. Prolonged recumbence 4. Hypovolemia 5. Pregnancy 6. Venous defects 7. Post sympathectomy 8. Shy- Drager syndrome (autonomic atrophy)

Pathophysiology Normal response to upright position: 1. Arteriole constriction 2. Tachycardia 3. Venous constriction 4. Increase muscle tone

Pathophysiology In postural hypotension these reflexes are diminished or delayed. Consciousness will be lost if systolic pressure falls below 70 mm/hg at heart level in a normotensive patient.

Clinical manifestations Lightheaded Diaphoretic Hypotension Tachycardia Syncope Upon sitting upright

Management Stop procedure! Call for help Assess level of consciousness Place in supine position A,B,C s: Airway, Breathing, Circulation Call EMS Oxygen Vitals Slowly reposition chair

Adrenal Insufficiency Adrenal Cortex 1. Glucocorticoids 2. Androgens 3. Aldosterone Normally 20 mg cortisol is produced daily, and increases to over 60 mg when stressed.

Endogenous steroids Gluconeogenesis Protein utilization Fat utilization Intravascular volume Electrolytes: Na + K

Predisposing factors Primary adrenal insufficiency: Addison s disease, decrease in cortisol Secondary adrenal insufficiency: Decrease in ACTH production Hypothalamus CRF Pituitary ACTH Cortisol Adrenal

Exogenous Steroids Rule of two s 20 mg of cortisone or equivalent daily For continuous 2 weeks Within past 2 years After obtaining an adequate history the decision must be made whether supplementation is needed.

Clinical manifestations Lethargy Hypotension Hypoglycemia Hyperkalemia Cardiovascular collapse Death

Management Stop procedure! Call for help Place in supine position A,B,C s: Airway, Breathing, Circulation Call EMS Oxygen Vitals Definitive Management Administer 100 mg hydrocortisone or equivalent IV/IM immediately