General Medical Emergencies: Part I

1. General Medical Emergencies: Part I

2. Major TopicsCommunicable / Infectious Diseases • HIV Infection and AIDS • Diphtheria • Encephalitis • Hepatitis • Herpes: Disseminated • Measles • Meningitis • Mononucleosis • Mumps • Pertussis • Shingles (Herpes Zoster) • Tuberculosis • Varicella (Chickenpox)

3. Major TopicsSkin Infestations • Lice • Scabies • Myiasis

4. Major TopicsEndocrine Emergencies • Adrenal Crisis • Diabetic Ketoacidosis • Hyperglycemic Hyperosmolar Nonketotic Coma • Hyperglycemia • Myxedema Coma • Thyroid Storm

5. HIV Infection and AIDS • Caused by a retrovirus • Viral symptoms start 2-6 weeks • Antibody seroconversion takes place within 45 days - 6 months • Asymptomatic period for months to years • Replication, mutation, and destroying the immune system

6. HIV Infection and AIDS • Persistent generalized lymphadenopathy occurs • Constitutional disorders, neurological disorders, secondary infections, secondary cancers, and pneumonitis

7. HIV Infection and AIDS • All HIV infections will develop into AIDS • Mean between exposure to HIV to AIDS-10 years • AIDS to death • Sooner the treatment, better long-term survival

9. HIV Infection and AIDS Assessment • Subjective data • History of present illness • Generalized lymphadenopathy, persistent • Fever for longer than 1 month • Episodic spiking • Persistent low-grade fever • Diarrhea for longer than 1 month • Weight loss • Anorexia • Night Sweats

10. HIV Infection and AIDS Assessment • Malaise or fatigue, arthralgias, myalgias • Mild opportunistic infections • Oral candidiasis • Herpes Zoster • Tinea • Skin lesions, rashes • Cough • Broad range of neurological complaints, both focal and global, including dementia

11. HIV Infection and AIDS Assessment • Current medications • Antiretroviral agents: zidovudine (AZT), zalcitabine (ddC), didanosine (ddI), stavudine (d4T), lamivudine (3TC), nevirapine, delavirdine • Pneumocystis prophylaxis: trimethoprim-sulfamethoxazole, pentamidine, dapsone • Protease inhibitors: indinavir, saquinavir mesylate, nelfinavir, ritonavir

12. HIV Infection and AIDS Assessment • Medical History • Blood transfusions, especially before 1985 • Hemophilia • Occupational needle sticks or blood exposure • Sexually transmitted diseases (STD’s) • Tissue transplantation • Infant with HIV-positive mother • Sexual contact with IV drug user • Sexual contact with HIV-positive partner • Sexual practices including multiple partners, anal sex, oral-anal sex, or fisting • Recent TB exposure

13. HIV infection and AIDS • Physical examination • Chronically ill appearance • Kaposi’s sarcoma skin lesions • Chest: crackles and wheezes • Dyspnea • Abnormal vital signs • Lymphadenopathy • Dementia • Wasting syndrome; signs of volume depletion • Withdrawn, irritable, apathetic, depressed • Slow, unsteady gait; weakness; poor coordination

14. HIV Infection and AIDS • Diagnostic procedures • CXR • CBC • Anemia • Lymphopenia • Thrombocytopenia • ABG’s • Electrolytes, liver function tests

15. HIV Infection and AIDS Assessment • Determination of HIV antibodies (e.g., via enzyme-linked immunosorbent assay [ELISA] and Western blot analysis) • decreased CD4 cell count • blood cultures • urinalysis • TB skin test (5 mm is positive in HIV infected person)

16. Diphtheria • Alteration in neurological functions • Lethargy • Withdrawal • Confusion • Cranial nerve neuropathies • Alteration in cardiac functions • ST-and T-wave changes • First-degree heart block • Dyspnea, heart failure, circulatory collapse • Anxiety

17. Diphtheria • Diagnostic procedures • Throat culture: specimen swabbed from beneath membrane or piece of membrane • Notify lab that C. diphtheria is suspected: requires special media and handling

18. Diphtheria • Interventions • Provide strict respiratory isolation • Maintain airway, breathing, circulation • Monitor vital signs and pulse ox • Assemble emergency cricothyrotomy equipment at bedside • Administer O2 for dyspnea or cyanosis • Establish IV catheter for administration of IV fluids

19. Diphtheria • Interventions • Diphtheria antitoxin • Equine serum • Test for sensitivity (intradermal or mucous membrane) before administration • Often administered before diagnosis is confirmed because of virulence of disease

20. Diphtheria • Antibiotic: EES or PCN G • Antitussive • Antipyretic • Topical anesthetic agent • Minimize environmental stimuli • Instruct patient on importance of complete bed rest

21. Diphtheria • Provide immunization • Regular booster Q10years, combined with TD, after completion of initial series of 3 doses • Identify close contacts • Culture and prophylactic Booster of TD in none within 5 years • Antibiotics • Active immunization for nonimmunized persons (series of 3 doses)

22. Encephalitis • Viral infection of the brain • Often coexists with meningitis and has broad range of S&S • Most cases in North America, caused by arboviruses, herpes simplex I, varicella-zoster, EB, and rabies • Transmission by animal bites, or seasonally form vectors (mosquitoes, ticks, and midges) • More common human viruses are airborne via droplet or lesion exudate • All age groups, with mortality from 5-10% from arboviruses and 100% for rabies

24. Encephalitis • Assessment • Subjective • History of present illness • Recent viral illness or herpes zoster • Recent animal or tick bite • Travel to endemic area, season of the year • Fever • Headache • Photophobia • Nausea, vomiting • Confusion, lethargy, coma • New psychiatric symptoms

25. Encephalitis • Assessment • Subjective • Medical history • Immune disorders • Allergies • Medications

26. Encephalitis • Objective data • Physical exam • Altered LOC • Rash specific to cause • Meningism • Altered reflexes • Focal neurological findings • Abnormal movements • Seizures

27. Encephalitis • Diagnostic Procedures • Lumbar puncture, CT scan • CBC • Blood cultures • Serology

28. Encephalitis • Interventions • Institute standard precautions and isolation until causative agent identified • Monitor airway, breathing, circulation • Monitor vital signs and pulse oximeter • Administer O2 • Prepare to assist with intubation • Insert large bore IV catheter, and administer isotonic solutions as ordered • Administer medications as ordered

29. Encephalitis • Administer antimicrobial/antiviral agents, steroids • Monitor blood sugar and electrolytes • Insert urinary catheter PRN • Monitor I&O, cerebral edema, keep HOB >30 degrees • Institute seizure precautions • Elevate HOB 30 degrees

30. Encephalitis • Restrict IV fluids • Keep body temperature normal • Administer diuretics as ordered • Explain procedures and disease to family/patient • Allow patient/significant others to verbalize fears • Prepare patient/family for admission to hospital

31. Hepatitis • Viral syndrome involving hepatic triad (bile duct, hepatic venule, and arteriole, and central vein area. • Hep A-fecal-oral route, infectious for 2 weeks before and 1 week after jaundice • Hep B-(HBV)blood and sexual contact and consists of 3 antigens • Hep B surface

32. Hepatitis • Hep B-(HBV) blood and sexual contact • 3 antigens • Hep B antigens • Persistence of core antibody indicates chronic infection • Persistence of surface antibody indicates immunity to reinfection • Hep B surface antigen in the serum without symptoms is indicative of a carrier state

33. Hepatitis • Hep C identified by antihepatitis C virus antibody • 50% of Hep C become chronic, and no immunity is developed • Hep C 90% of hepatitis cases transmitted by blood transfusion

34. Hepatitis • Hep E is an epidemic, enterically transmitted infection from shellfish and contaminated water • Hep D found with acute or chronic HBV infection • Chronic infections result in cirrhosis and liver cancer

35. Hepatitis • Assessment • History of present illness • Prodrome: preicteric phase, occurs 1 week before jaundice • Low-grade fever • Malaise: earliest, most common symptom • Arthralgias • Headache • Pharyngitis • Nausea, vomiting

36. Hepatitis History of Illness cont’d Rash, with type B usually • May or may not progress to icteric phase • Incubation: • A 15-45 days • B 30-180 days • C 15-150 days • Duration: • A 4 weeks; • B AND C 8 weeks

37. Hepatitis • Icteric phase • Disappearance of other symptoms • Anorexia • Abdominal pain • Dark urine • Pruritus • Jaundice

38. Hepatitis cont’d • Medical History • Immunizations • ETOH consumption • Allergies • Medications: all are significant • Blood transfusions, IV drug use, Hemophilia or dialysis • Chronic medical problems, travel, living in institution • Living in recent floods or natural disasters

39. Hepatitis • Objective data • Physical exam • Posterior cervical lymph node enlargement • Enlarged, tender liver • Splenomegaly in 20% • Jaundice • Vital signs: may have tachycardia, hypotension • Fever

40. Hepatitis • Diagnostics • Liver enzymes: SGOT & SGPT elevated • Direct and indirect bilirubin levels: elevated • Alkaline phosphatase : elevated • Differential leukocyte count: leukopenia with lymphocytosis, atypical lymphocytes • CBC, UA: elevated bilirubin, PT: elevated, ABD X-ray • Antigen and/or antibody titers

41. Hepatitis • Interventions • Provide increased calories • Monitor for signs of dehydration, replacement with isotonic solution • Record I&O • Assess support systems of patients • Hospitalize if unable to care for self or PT >15 seconds

42. Hepatitis • Initiate prophylaxis • Type A • Immune serum globulin 80-90% effective if 7-14 days after exposure • Vaccine administered in two doses: given to high-risk population: foreign travel, endemic areas (e.g. Alaska), military, immunocompromised or risk for HIV, chronic liver disease, hep C • Type B: hepatitis B immune globulin plus vaccination, for exposure to serum, saliva, semen, vaginal secretions, breast milk

43. Hepatitis • Initiate prophylaxis • Type B: vaccination with HBV vaccine inactivated (Recombivax HB) • Vaccinate high-risk persons • Health care and public safety workers, clients and staff at institutions • Hemodialysis patients, recipients of clotting factors • Household contacts and sexual partners of HBV carriers • Adoptees from countries where HBV in endemic: Pacific Islands and Asia • IV Drug users, sexually active homosexual and bisexual men • Sexually active men and women with multiple partners • Inmates of long-term correctional facilities

44. Hepatitis • Vaccinate all infants (universally) regardless of hepatitis B surface antigen status of mother (administer first dose in newborn period, preferably before leaving hospital) • Report to appropriate health departments • Limit exposure of medical personnel to blood, secretions, and feces

45. Hepatitis • Instruct patient/significant others • Strict hygiene, private bathroom if possible • Diet of small, frequent feedings low in fat, high in carbs, patient should avoid handling food to be consumed by others • S&S: bleeding, vomiting, increased pain • Take meds as prescribed • Avoid intake of alcohol • Take meds only if necessary • Avoid steroids: they delay long-term healing

46. Herpes: Disseminated Herpes simplex virus (HSV) is a relatively benign disease when cutaneous • Can invade all body systems and lead to death • Primary viremia occurs from spill-over of the virus at the site of entry • During the second stage, HSV disappears from he blood but grows within cells of infected organs, which in turn causes seeding to other organ systems. • Dissemination occurs in susceptible persons: newborns, malnourished children, children with measles, people with skin disorders, such as burns, eczema, immunosuppression, and immunodeficiency, especially HIV

47. Herpes: Disseminated • HSV has a predilection for temporal lobe. • Encephalitis most common • 70% mortality rate without treatment • 50% with treatment residual neurological deficits • Latency period within sensory nerve resulting in mild or life-threatening infection years later

48. Herpes • Assessment • Subjective data • History of present illness • Onset: usually acute • After other illness • After outbreak of cutaneous infection • After any stressor

49. Herpes • Assessment • Subjective data • History of present illness • Symptoms depend on organ system affected • Neurological system: headache, confusion, seizures, coma, olfactory hallucinations • Liver: ABD pain, vomiting • Lung: cough, fever • Esophagus: dysphagia, substantial pain, weight loss