Emergencies in general practice

1. Emergencies in general practice Haseeb A. Khawaja, M.D. Diplomate American Board of Internal Medicine Director Emergency Department Shifa International Hospital, Islamabad

2. Objectives for session • Coma • Seizures • Meningitis • Disturbed behavior • Attempted suicide • Poisoning/overdose • GI bleeding • Acute abdominal pain • Chest pain • MI and unstable angina • Choking both adults and children • Acute breathlessness • Exacerbation of asthma • Anaphylaxis • Burns • Electrocution • Lacerations • Fractures

3. Coma Unarousable unresponsiveness in which the subjects lie with eyes closed

4. How/What to examine • Responsiveness – visual, tactile, auditory • Respirations • Posturing • Fundi, pupils, oculocephalics • Corneals, nasal tickle • Gag • Facial sensation, motor • Spinociliary reflex • Reflexes, sensation and plantars

5. 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)

6. 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)

7. 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

8. Occulocephalic Reflex • Brisk rotation of head with eyes held open • Watch for contraversive movements • Next: • Flexion: eyes deviate up and eyelids open (doll’s head phenomenon) • Extension:eyes deviate downward

9. Other Reflexes • Deep tendon • Biceps, brachioradialis, triceps • Patellar, Achilles • Plantar Responses • Superficial skin • Abdominal, cresmasteric

10. Coma Mimics • Akineticmutism • 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 • Catatonia • 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

11. Seizures • Seizures: Transient occurrence of clinical symptoms due to abnormal neuronal behavior – Convulsions: Seizures with prominent body movement – Non-convulsive seizures:Seizures with minimal or no body movement • Epilepsy: Brain disorder with an enduring predisposition to generate epileptic seizures • Epilepsy syndromes: Groups of epileptic patterns of varying cause but similar course and response to treatmen

12. 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

15. Status Epilepticus • Definition: • Two or more seizures without recovery of consciousness in between • Single seizure >20-30 min (operationally, >5 min)

16. Causes? • Medication non-compliance • Cerebrovascular disease such as cerebral infarction, cerebral • hemorrhage, and venous thrombosis • Head trauma • CNS infections such as meningitis or encephalitis • Neurodegenerative diseases • Autoimmune disease • Brain neoplasm • Genetic diseases • Substance intoxication or withdrawal • Metabolic medical disorders such as uremia, hypoglycemia, • hyponatremia, and hypocalcemia

17. Infection Unknown/ Cryptogenic Depressed Skull Fracture Tumor Cortical Dysplasia ? Hypoxia Hemorrhage Infarct Vascular Malformation

18. Clinical discrimination between Epileptic and non-epileptic events

19. DO Attempt to time duration of seizure Help patient lie down and roll onto side to help avoid aspiration Loosen clothing and remove glasses

20. DO NOT Do NOT attempt to place anything in the patient’s mouth, including medication and water Do NOT restrain during or after seizure; may provoke aggressive behavior or cause injury Do NOT leave patient lying on back

21. Status Epilepticuson the scene • Definition • ABC’s • Sugar check • Other causes • Benzodiazepines • Phenytoin • Phenobarbitone • Propofol

22. Meningitis “infection of the meninges”

23. Issues to consider • Suspecting the diagnosis • Clinical clues • How to diagnose • CT vs. LP • Choice of emperic antibiotics • Rocephin • Vancomycin • Dexamethasone

24. Clinical Suspiscion

27. 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

28. Emperic Antibiotics Treatment of bacterial meningitis. N Engl J Med 1997;336:708-716

29. Delirium “Acute neurological disturbance”

30. DSM IV Criteria 1. Disturbance of consciousness with reduced ability to focus, sustain or shift attention. 2. A change in cognition or development of perceptual disturbances that is not better accounted for a preexisting, existed or evolving dementia. 3. The disturbance develops over a short period of time and tends to fluctuate during the course of the day 4. There is evidence from this history, examination or labs that the disturbance is caused by the physiological consequence of a medical condition.

31. causes Infections Electrolyte abnormalities Endocrine dysfunctions (hypo or hyper) Liver failure- hepatic encephalopathy Renal failure- uremic encephalopathy Pulmonary disease with hypoxemia Cardiovascular disease/events: CHF, arrhythmias, MI CNS pathology: tumors, strokes, seizures Deficiency states: Thiamine, nicotinic or folic acid, B12

32. Drugs that can cause delirium • Anticholinergics (furosemide, digoxin, theophylline, cimetidine, prednisolone, TCA’s, captopril) • Analgesics (morphine, codeine..) • Steroids • Antiparkinson (anticholinergic and dopaminergic) • Sedatives (benzodiazepines, barbiturates) • Anticonvulsants • Antihistamines • Antiarrhythmics (digitalis) • Antihypertensives • Antidepressants • Antimicrobials (penicillin, cephalosporins, quinolones) • Sympathomimetics

33. Dementia vs Delirium • Dementia has an insidious onset, chronic memory and executive function disturbance, tends not to fluctuate. In delirium cognitive changes develop acutely and fluctuate. • Dementia has intact alertness and attention but impoverished speech and thinking. In delirium speech can be confused or disorganized. Alertness and attention wax and wane.

34. Schizophrenia vs Delirium • Onset of schizophrenia is rarely after 50. • Auditory hallucinations are much more common than visual hallucinations • Memory is grossly intact and disorientation is rare • Speech is not dysarthric • No wide fluctuations over the course of a day • Delusions and hallucinations

35. Acutely Agitated Patient • Safety Management and Response Techniques (SMART) SMART staff education • Managing dangerous situations • Preventing escalation • Maintaining environmental safety

36. Respond as a team! • Physician staff • Nursing staff • Social work • Technical staff • Security staff • Trainees

37. Nonpharmacologic intervention • Communication with the patient • Behavioral management • Safety/physical restraints • Medication response and side effects • Respect/concern

38. 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

39. 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 emergency • In general, antipsychotics are still the pharmacologic intervention of choice in the acutely agitated patient

40. Found down patient • D • O • N • T

41. Suicide A sad but permanent solution to a temporary problem

42. Why Talk About Suicide? • because ~ suicide doesn’t discriminate by • gender, age, race, ethnicity, education, or socio- • economic status. • because ~ 90% of people who die of suicide • have a treatable mental illness or substance abuse • disorder; 60% have a depressive disorder. • because ~ suicide is the most preventable • form of death in the U.S. today.

43. Depression in disguise • Drug / alcohol abuse • Aggressive behavior • Delinquent behavior • Reckless / antisocial behavior • Eating disorders • Happy mask • Frequent “accidents” • Self – destructive acts • Extreme boredom / apathy • Unexplained physical symptoms • Sleeping disorder • Extreme restlessness

44. Facts! • Females attempt three times more than males. • Males choose more lethal methods (less opportunity for life saving techniques). • Most suicidal people don’t really want to die ~ they just want their pain to end. • About 80% of the time, people who kill themselves have given definite signals or talked about suicide. • The key to prevention is to know the signs and what you can do to help. • If someone you know seems depressed or gloomy and has spent a lot time questioning whether life is worth the bother ~it’s time to Pay Attention!

45. Myths about suicide • “People who talk about suicide won’t really do it.” FALSE • “Anyone who tries to kill him/herself must be crazy.” FALSE • “If a person is determined to kill him/herself, nothing is going to stop him/her.” FALSE • “People who commit suicide are people who were unwilling to accept help.” FALSE • “Talking about suicide may give someone the idea.” FALSE

46. Suicide Symptoms • Verbal suicide threats • Behavior changes • Increase in mention of body pain • Depression • Sleeping and eating patterns • Fatigue • Irritability • Lifting of prolonged depression • Final arrangements • Death wish behavior

47. SAVE A LIFE! • ASK DIRECT QUESTIONS

48. Poisoning/Overdose Accidental? Intentional?

49. What to do? • A • B • C • GCS • Vitals • ECG • IV access

50. 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?