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Flashcards in 1 - Office Emergencies Deck (45):
1

Objectives for office emergencies

Demonstrate knowledge of symptoms and recommend treatment for the following office emergencies: syncope, local anesthetic reactions, anaphylactic reactions, seizures, hyperglycemia, hypoglycemia, asthmatic attack and chest pain.

2

True or false: All office emergencies should be managed by calling 911

False

3

A 39-year old male presents for a nail avulsion. During the initial injection patient feels the room getting darker, and eventually loses consciousness. What is the initial treatment for this patient?
o Epinephrine
o Oxygen
o Trendelenburg w/leg elevation
o Glucose

Trendelenburg with leg elevation

4

A 55 year old diabetic female believes her blood sugar is dropping and eventually loses consciousness. What treatment should be used for this patient? Your office does not have the ability to hang IV’s.
o Glass of orange juice
o 10 units of insulin
o 20-50 ml of D50
o Glucose gel
o None of the above

Glucose gel - You can put glucose gel on the gums

5

Syncope

- A transient loss of consciousness due to sudden release of the arterial vasomotor tone and temporary insufficiency of cerebral circulation
- May result from cardiovascular and non-cardiovascular causes
- A syncopal patient revives spontaneously

6

Signs and symptoms of syncope

- Pallor, sweating
- Yawning & marked transient hypotension
- Faintness
- Dizziness
- Lightheadedness
- Pupil dilation
- Loss of consciousness
- Unresponsive
- Loses postural tone
- Reflex tachycardia

7

Syncope of cardiac etiology

- Arrythmia (typically occurs with or after palpitations)
- Can occur in a seated patient

8

Vasovagal syncope

- Precipitated by an unpleasant physical or emotional stress

9

Treatment of syncope

- Trendelenberg w/ legs elevated
- Inhalation of spirits of ammonia
- Oxygen (O2)
- "Trendelenburg position" by Saltanat ebli (head down)

10

Anaphylactic reaction

Acute allergic reaction to which an individual has been sensitized

11

Agents that cause anaphylactic reaction

- Antiserum
- Hormones
- Pollen extracts
- Foods
- Polysaccharides
- Drugs

12

Signs and symptoms of anaphylactic shock

- Pulmonary: Bronchospasm, dyspnea,  mucous production (sneezing, wheezing, coughing)
- Cardiovascular: hypotension, bradycardia, hypoxia, cardiorespiratory collapse
- Dermatological: urticaria, wheals, angioedema, itching, facial swelling

13

Treatment of anaphylactic shock

- Airway control - O2 (may require endotracheal tube)
- Epinephrine 1:1000 0.5cc IM or .2cc.into site Q15min.
- CPR
- Hypotension – give ephedrine .25-.5cc IM/IV
- Bronchospasm – aminophylline 250-500mg. IV given slowly

14

CASE STUDY
- A 63 year old male is receiving an injection for a nail procedure
- The patient is very anxious and becomes light headed during the injection
- Post-injection, the patient states he is having difficulty breathing and his chest feels tight

- The patient could be anxious and having a panic attack, could be having an asthmatic attack, but anaphylaxis would be the most likely cause ***
- You should assume this is anaphylaxis and give epinephrine
- The epinephrine is not going to hurt them even if they are not actually experiencing anaphylaxis, so you should give it and monitor for whether or not it resolves the problem

15

Acute asthmatic attack

- Asthma: A lung disease that is characterized by inflammation, obstruction, that is reversible
- Acute attack may be triggered by various stimuli: (aspirin, NSAIDs, pollen, mold, dirt, smoke, perfumes, paints, animal dander, etc.)

16

Pathophysiology of acute asthmatic attack

- Spasm of the smooth muscle
- Edema of the airway
- Increased mucous secretion
- Eosinophilic infiltration
- Injury and desquamation of the epithelium

17

Signs and symptoms of acute asthmatic attack

- Dyspnea
- Wheezing (inspiratory & expiratory)
- Patient prefers to sit upright and lean forward
- Cyanosis
- Difficulty talking
- Lethargy and confusion

18

Treatment of acute asthmatic attack

- Reassurance
- O²
- IV Access
- Emergency drugs

19

Emergency drugs for acute asthmatic attack

- Salbutamol (short acting β-2 adrenergic)
- Epinephrine
- Ipratropium (anticholinergic )
- Aminophylline
- Corticosteroids

20

Seizures

- Convulsive disorders characterized by abrupt transient symptoms of motor, sensory, psychic or autonomic nature frequently associated with change in consciousness (usually related to pre-existing epilepsy or drug toxicity).

21

Grand mal seizures

- Central nervous over stimulation, and muscular spasms
- Loss of consciousness
- Profound muscle contraction
- May become pale or cyanotic
- Often loss of bowel and bladder control

22

Treatment of grand mal seizures

- Safety
- Monitor Airway
- Reassurance as patient comes out of seizure for status epilepticus
- Valium 10-15 mg every 10-20min.
- Dilantin 4 mg/kg IV

23

CASE STUDY
- A 23 year old female has consented for an injection with lidocaine
- During the injection, patient states she is getting light headed and loses consciousness
- Patient is having additional symptoms which are consistent with convulsions

- Typically, if someone is having a reaction to the injection, it is typically IV and not in the soft tissues, so it is not likely the result from the injection
- We would consider syncope and seizures on our differential
- The patient experienced seizures for 30 seconds to 1 minute while going in and out of consciousness
- Need to secure the patient, maintain an airway and clear the area of potential hazards

24

Hypertensive crisis

- Acute rise in blood pressure
- BP of 180/110 mm Hg

25

Signs and symptoms of hypertensive crisis

- Stroke
- Angina/ heart attack
- Loss of consciousness/ memory loss
- Pulmonary edema
- Visual loss
- Kidney damage

26

Treatment of hypertensive crisis

- Goal is to lower diastolic to 90-100mm Hg over 15 min.
- Supportive
- Nifedipine(procardia) 10mg SL
- Amlodipine(norvasc) 10mg
- Sit at 45 degree angle
- Treatment will also be dependent upon etiology (neurological, cardio-vascular, renal)

27

CASE STUDY
- A 57 year old diabetic male is electing to have a surgical procedure
- Prior to the injection, the patient’s blood pressure rises to 190/110

- Need to give nifedipine or amlodipine and recline the patient back to 45 degrees
- Monitor the blood pressure over the next 10 to 20 minutes until the blood pressure is stabilized
- Give 10 mg nifedipine, monitor, give another 10 mg if needed

28

Insulin shock

- Hypoglycemia secondary to either too much insulin or insulin taken without food

29

Signs and symptoms of insulin shock

- Weakness, faintness
- Hunger
- Fast pulse
- Sweating
- Convulsions
- Irritability
- Moist skin
- Confusion
- Coma

30

Treatment of insulin shock

Conscious - able to swallow
o Give oral sugar and/or orange juice

Unconscious
o Start IV 20-50 ml of D50 slowly
o 1 mg glucagon IM

31

CASE STUDY
- A 62 year old female presents for high risk foot care
- During the evaluation patient states she has not eaten and her blood sugars are dropping and she is not feeling well
- You are able to give the patient some oral glucose, but the patient still has episodes where she is in and out of consciousness

- Need to keep the patient safe because she was going in and out of consciousness
- They monitored glucose with finger sticks, to get the patient’s blood sugar up to 110
- Needed to have someone pick her up and take her home to avoid another blood sugar drop while she was driving
- If you do not know if the patient has a low blood sugar and you do not have the means to check the blood sugar, but they seem to be having the symptoms of hypoglycemia, always give them glucose as a prophylaxis because glucose will not harm them

32

CASE STUDY
- A 38 year old IDDM male is being evaluated for chronic ulcers
- Patient reports nausea, abdominal pain, polydipsia, tachycardia, dehydration, ketosis

- Diagnosis is diabetic ketoacidosis, so you call 911 and initially check blood sugar
- The first step in management in the hospital is IV fluids and oxygen

33

Local anesthetic toxic reaction

Lidocaine toxicity

34

Symptoms of lidocaine toxicity - pulmonary

o Increased/irregular respiration
o Respiratory Arrest

35

Symptoms of lidocaine toxicity - neurological

o Paresthesias
o Nervousness
o Depression
o Blurred vision
o Tinnitus
o Convulsions
o Coma

36

Symptoms of lidocaine toxicity - neurological

o Arrythmia
o Hypotension
o Cardiac arrest

37

Treatment of lidocaine toxicity

- Mental changes (observe)
- Hypotension: vasopressors
- Respiratory depression: (o2), ephedrine SO4
- Convulsions: Valium 5-10 mg IV or 25 mg IM

38

Signs and symptoms of epinephrine reaction

- Neurological: Headache, seizure, restlessness, agitation, nervousness
- Cardiovascular: Tachycardia, palpitations
- Nausea, vomiting, SOB, weakness

39

Treatment of epinephrine reaction

- Thorazine 0-5 mg-1.0 mg IV
- Demerol 12.5 mg-25 mg IV

40

CASE STUDY
- A 29 year old male consents to a lidocaine injection for the management of an ingrown toenail
- During the injection the patient states the room is getting dark and closing in on him


- Make sure the patient is safe so they don’t get hurt
- If they are sliding off the chair, you can assist them down to the floor, but they are going to be heavier than you expect

41

Diabetic ketoacidosis

- Occurs when the blood sugar becomes too high, either because the insulin dose was too small or because it was neglected altogether

42

Signs and symptoms of diabetic ketoacidosis

- Polyuria (excess urine output) because of osmotic diuresis
- Polydipsia (excessive thirst) because of dehydration
- Polyphagia (excessive eating), probably related to inefficient utilization of nutrients
- Nausea and vomiting, the latter worsening dehydration
- Tachycardia, reflecting dehydration
- Deep, rapid respirations (KUSSMAUL’S RESPIRATION), in an attempt to blow off excess acids by CO2 elimination
- Warm, dry skin and dry mucous membranes, also reflecting dehydration
- Fruity odor on the breath
- Sometimes fever, abdominal pain, and falling blood pressure

43

Treatment of diabetic ketoacidosis

- Follow the procedure for any comatose patient with regard to AIRWAY maintenance and oxygen. Be alert for vomiting, and have suction ready.
- Start an IV LIFELINE, draw blood for laboratory tests, and infuse a liter of normal saline at the rate ordered by the physician. The patient in ketoacidosis is severely dehydrated, often to the point of shock, and needs volume.
- MONITOR cardiac rhythm. Changes in serum potassium caused by acidosis can lead to marked cardiac instability. Note the contour of the T waves on the rhythm strip. If they are sharply peaked, the patient’s potassium level may be dangerously high, and the physician may wish to order bicarbonate.

44

***Two general rules to remember about emergency treatment of diabetics***

- Any patient in coma of unknown etiology should receive glucose
- Diabetics have trouble with hyperglycemia and hypoglycemia. When in doubt, give glucose. One will not harm a hyperglycemic patient by giving glucose (the amount administered is trivial compared to what he/she already has in his blood), but one may save the life of a hypoglycemic patient by this treatment.

45

- You have just given a plantar fascitis injection (0.05% marcaine: 40 mg/ml Kenalog). Patient is developing a pruritic rash on the affected foot and lower leg 15 minutes post-injection. What is the most appropriate treatment?
o 1:100,000 IM injection of epinephrine (local anesthetic)
o 1:1,000 IM injection of epinephrine (systemic effects)
o 50 mg Benadryl PO
o 250 mg of aminophylline
o Emergent I&D

50 mg Benadryl PO

The most likely cause of the allergic reaction is the preservatives in the injection