Emergencies in General Practice Lessons to Be
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Transcript of Emergencies in General Practice Lessons to Be
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DR.ARUN MANNIKAR. M.D.
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IMPORTANCE.
1.LAW : COMPULSORY TO GIVE PRIMARY T/T. 2.UNAVOIDABLE SITUATION : PATIENT BROUHT IN SERIOUS CONDITION
BECOMES SERIOUS IN YOUR CLINIC eg.COLLAPSE,CONVULSION.
3.REACTION TO YOUR T/T : ANAPHYLAXIS, DRUG RASH.
4. GOOGLIES IN SYMPTOMS : LEADS TO WRONG DIAGNOSISE.g. HEART BURN mistaken as hyperacidity in AC. MYOCARDIAL INFARCTION.
5. G.P. : FIRST DR. TO FACE THE EMERGENCY.
6. CORRECT REFFERRAL OF PATIENT : WHEN ? WHICH ? WHERE ? TO WHOM ?
7. CORRECT DIAGNOSIS AND CORRECT DECISION SAVES PATIENT &DOCTOR.
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DIAGNOSIS :
BY SYMPTOMS1. PAIN.2.RESTLESSNESS.3. BREATHLESSNESS.
4. EXTREME WEAKNESS.5. SYNCOPE.6. DROWSYNESS.7. ABNORMAL BEHAVIOUR.
8. CONVULSIONS.9. UNCONSCIOUSNESS.10. TRANSIENT PARALYSIS.11. HICCOUGHS.
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HICCOUGHS.DISEASES: CLUES:
RENAL FAILURE ------------------------- OLIGURIA,OEDEMA.
G.I.BLEED ------------------- ABD.DISCOMFRT,TACHYCARDIA,HYPOTENSION.
MYOCARDIAL INFARCT ------ CHEST PAIN, ECG CHANGES.
BRAIN STEM ISCHAEMIA ---------- DROWSYNESS, N.DEFICIT.
LIVER ABSCESS ---------------------- FERVER, RT. HYPOCHONDRIACPAIN.
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EMERGENCY BAG.1.INJECTIONS:
ADRENALINE * FORTWIN
ATROPINE * VOVERONEFFCORLIN * CONTRAMOL WYMASONE *CYCLOPAM AVIL * PARACETAMOLLASIX * OMEZ
DERIPHYLLIN * VOMISETMEPHENTIN * PERINORM
*DOPAMIN * ETHAMSYLATE*SODABICARBONATE *BOTROPASE
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EMERGENCY BAG.TABLETS: MISCELLANIOUS:
DISPRIN 325 mg SCALP VEIN SETSORBITRATE 5 mg I.V.SETS- MICRO & REGULAR C. DEPIN 1O mg DISPO.SYRINGESSTEMETIL M.D. RYLES TUBE, ORAL TUBE,AMBU BAG.
I.V. FLUIDS: 25% DEXT, N.SALINE, R.L., MANNITOLTORCH.
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TYPES OF EMERGENCIES.DISEASE INDUCED.POISONINGS
BITES : SNAKE, SCORPION, HONEYBEES, DOG.ELECTRIC SHOCK
ACCIDENTSDROWNINGDOCTOR INDUCED : DRUG REACTIONS.
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PALPITATIONS.CHECK PULSE:
REGULAR
IRREGULAR FAST ---------- more than 150/min.SLOW -------- less than 40/min.
CHECK B.P. :
HIGH more than 200/110 mmHgLOW less than 90 mmHg
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SUB CUTENIOUS BLEED.PETICHIAE, ECHYMOSES, PURPURA :INDICATES COAGULATION PROBLEM OR THROMBOCYTOPENIA.DISEASES: CLUES:
LEUKAEMIA ------------------------------------------------SPLENOMEGALY.
HAEMORHAGIC FEVERS :- -----------------DENGUE, F.MALARIA, V.FEVERS.
ANTICOAGULANT OVERDOSE ----------- H/O VALVE REPLACEMENT
COLLAEGEN DISORDERS.---------------- POLY ARTHRITIS, BUTTERFLY RASH.
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SPECIAL SITUATIONS.1.SEVERE HYPERTENSION.2.HYPOTENSION.3.TACHYCARDIA.
4.BRADYCARDIA.5.TACHYPNOEA.6.HYPERPYREXIA.7. UNCONSCIOUS PATIENT.
8.DRUG REACTION : ANAPHYLAXIS.9.BLEED FROM ORIFICES : EPISTAXIS, HAEMATEMESIS,HAEMOPTYSIS.10. POISONING.11.BITES.
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SEVERE HYPERTENSION.B.P. more than 200/110 mmHg.
ASYMPTOMATIC : ORAL ANTI. HTN DEPIN 10, NUMLO 5, T.RESTYL0.25SYMPTOMATIC : *S.L. DEPIN 5mg
*I.V. LASIX 1 AMP.*T. ALPRAZOLAM 0.25 mg*NJ.DICLOFENAC IF HEADACHE*INJ. CONTRMOL IF CHEST PAIN.WORD OF
WORD OF CAUTION:
* AVOID SUDDEN DROP IN BP IF SUSPECT THROMBOTICSTROKE. AVOID ACE INHIBITORS IF SUSPECT RENAL FAILURE,PREGNANCY.
AVOID B. BLOCKERS IF COPD, BR.ASTHMA, BRADYCARDIA.
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HYPOTENSION.B.P. LESS THAN 90 mmHg: ASYMPTOMATIC : HYPOTHYROIDISM
STENOTIC VALVULAR DISEASE-A.S/M.S.PERICARDIAL EFFUSION
[ NO I.V. FLUIDS STRICTLY.]SYMPTOMATIC :
WITH S/O DEHYDRATION: I.V. N SALINE/RL - FASTI.V. SODABICARB 10cc
FOOT ELEVATIONT/T OF CAUSE
[ DONT USE 5% DEXTROSE, USE WIDE BORE NEEDLE, USEREGULAR IV SET ].
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HYPOTENSION. WITHOUT S/O DEHYDRATION:
DISEASES: *MYOCARDITIS
*ENDOTOXIC SHOCK*PULM.EMBOLISM*CARDIOGENIC SHOCK
TREATMENT : *I.V. SODABICARB*I.V. DOPAMIN INFUSION
*I.V. EFFCORLINE*OXYGEN[ USE MICRO DRIP I.V. SET. SPEED OF INF. 30 microDROPS/MIN.]
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TACHYCARDIA.HEART RATE 100 TO 120/min :
T.RESTYL 0.25 mgT.CIPLAR 10 mgT/T UNDERLYING
DISEASE[THYRO,ANAEMIA]
HEART RATE 120 TO 150/min : REGULAR SAME AS ABOVE.IRREGULAR- T.AMIADARONE
200mg.
HEART RATE MORE THAN 150/min: T. AMIDARONE 200 mgREFFERRAL TO ICU.
REGULAR : SVT / V.T. IRREGULAR : A.FIB., A.FLUTTER.[PRECAUTION: AVOID I.V. FLUIDS.]
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BRADYCARDIA.HEART RATE LESS THAN 40/min :
I.V. LINEI.V. ATROPINT. ALUPENT 10 mg.REFFERRAL TO I.C.U.
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TRANSIENT PARALYSIS.LOOK FOR UNDERLYING: CLUES:
VALVULAR HEART DISEASE ----------------------- CARDIAC
MURMER.I.H.D. -------------------------------------------- H/O MYOCARD.INFARCT.CARDIOMYOPATHY ---------------------------- S/O C.H.F.
AORTO-ARTERITIS ---------------------------- ABSCENT PULSE INUPP. LIMBS
AORTIC ANEURYSM -------------PRECORDIAL PULSATION,TRACHEAL TUGCAROTID ARTERY DISEASE -------------- WEAK CAROTID PULSE.
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DIAGNOSIS BY SYMPT. : PAIN.HEAD ACHE: HYPTN,
I.C. BLEED,SOL,ENCEPHALITIS,
MENINGITIS.I. C. ABCESS.
CEREBRAL THROMBOPHLEBITIS
CLUES: LOOK FOR ASSOCIATED SYMPTOMS VOMITING, BRADYCARDIA, CONVULSIONS, FEVER
[ S/O RAISED I.C.P. ]
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DIAGNOSIS BY SYMPT : CHEST PAINCLUES:
PROFUSE SWEATING, TACHYCARDIA, HYPOTENSION,DYSPNOEA, FEVER, COUGH.
UNDERLYING DISEASES:
AC. MYOCARDIAL INFARCTION. AC.PERICARDITIS.PNEUMONIA WITH PLURITIS.PNEUMOTHORAX.
AC. PULMONARY EMBOLISM.DISSECTION OF AORTA.
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DIAGNOSIS BY SYMPT : AC. ABDOMENCLUES: VOMITINGS, CONSTIPATION, TACHYCARDIA, HYPOTENSION, AMENORRHOEA, ABD. DISTENSION.
DISEASES :
PERFORATION : DUODENAL ULCER, ILEAL, APPENDICULAR, G.BLADDER.
OBSTRUCTION : INTESTINALHERNIAL
STRANGULATED HERNIA . AC.PANCREATITIS.COLICS.RUPTURED ECTOPIC PREGNANCY.TORSION TESTIS.
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DIAGNOSIS BY SYMPT : LIMB PAIN.PAIN IN TOES & / FINGERS :
SYSTEMIC EMBOLISM, RAYNAUDS DISEASECALF PAIN : UNILATERAL DVT.
CLUES: DISCOLOURATION OF SKINSWELLING
ABSENT PULSEHOMANS SIGN.
LOOK FOR UNDERLYING: RHD, IHD, D.M.
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DIAGN.BY SYMPTMS : BREATHLESSNESSDISEASEAS:
AC.PULM. OEDEMA. ARDS.
AC.PNEUMONIAS.PNEUMOTHORAX. AC. PULMONARY EMBOLISM.SEVERE BR. ASTHMA
AECB.
AC. RENAL FAILURE.DIABETIC KETO-ACIDOSIS. CLUES: PREVIOUS H/O RHD, IHD, COPD, PULM. T.B., D.M.
SOB, CALF PAIN, OLIGOURIA, FEVER,COUGH.
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DIAGN.BY SYMPTS : SYNCOPE.DISEASES :
VALVULAR HEART DISEASE : A.S., M.S.CARDIAC ARRHYTHMIAS.
MASSIVE INTERNAL BLEED.POSTURAL HYPOTENSION.HYPOVOLAEMIA.DRUG INDUCED : NITRATES[ SL], ANTI. HTN.COUGH SYNCOPY.
MICTURITION SYNCOPY.
CLUES : TACHY/BRADYCARDIA, HYPO/HYPERTENSIONH/O DRUGS, COUGH, PROLONGED
STANDING, RHD, IHD.
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DIAGN. BY SYMPTMS : DROWSYNESS.CLUES : SWEATING, OLIGOURIA, PARALYSIS, JAUNDICE, SOB,FEVER. H/O D.M.,HTN, COPD, SEDATIVE CONSUMPTION,STARVATION.
DISEASES :HYPOGLYCAEMIA.HYPERGLYCAEMIA.HEPATIC ENCEPHALOPATHY.URAEMIC ENCEPHALOPATHY.
BRAIN STEM ISCHAEMIA.HYPOXIA.DRUG INDUCED.ENCEPHALITIS.HYPONITRAEMIA.
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DIAGN. BY SYMPTS : UNCONSCIOUSNESS
ALL CONDITIONS WHICH CAUSE DROWSYNESS
IF SEVERE WILL LEAD TO UNCONSCIOUSNESS.
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DIAGN. BY SYMPTS :
ABNORMAL BEHAVIOUR.DISEASES:
CEREBRAL STROKE.
HEPATIC ENCEPHALOPATHY.URAEMIC ENCEPHALOPATHY.ENCEPHALITIS.HYPOGLYCAEMIA.
CLUES:
OLD AGE, HTN, JAUNDICE, OLIGURIA, FEVER, D.M.
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DEFINITION.EMERGENCY:
SERIOUS ANDUNEXPECTED SITUATION
REQUIRING IMMEDIATE ACTION.
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DIAGN. BY SYMPTMS : CONVULSIONSDISEASES: CLUES:EPILEPSY. ---------------------------------- YOUNG AGE, F/H, NON.DEFICITI.C. BLEED. ------------------------------------ HEADACHE, HTN,N.DEFICIT.I.C. SOL. ---------------------------------------- ,, N. DEFICIT.I.C. THROMBOPHLEBITIS. ------------------ ,, ,,FEVER,SINUSITIS.ENCEPHALITIS. ----------------------------- ,, ,, ,,
CARDIAC ARRHYTHMIAS. -------------------- CHEST PAIN, IHD, RHD,DCM.DRUG INDUCED : QUINOLONE, ALCOHOL,
RAT POISONSCAR SEIZURES. ------------------------------- H/O CVA.
.
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RESTLESSNESS.LOOK FOR :
TACHYCARDIA BRADYCARDIA HYPOTENSION
HYPERTENSIONTACHYPNOEA FEVER.
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EXTREME WEAKNESSDISEASES: CLUES:D.M. KETOSIS ------ DIABETIC MISSINGINSULIN/INFECTION
C.R.F. ------------------ OLIGOURIA, OEDEMA,PUFFY FACE.
THYROTOXICOSIS.-------- GOITRE, TACHYCARDIA,TREMORS.
HYPONITRAEMIA. ------- STARVATION,CVA, OLD AGE.
HYPOKALAEMIA. --------- DIURETICS- LASIX, DYTOR.
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EPISTAXIS.BLEEDING NOSE .
TREATMENT : * PINCH NOSE.* APPLY ICE PACK.* LOCAL BOTROPASE.*INJ.LASIX * ANTI HTNSIVE.
REFERRAL : TO ENT SURGEON.
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HAEMATEMESIS.BLOOD IN VOMITUS.
TREATMENT : * I.V. N.SALINE* INJ. OMEZ / RANITIDIN*ICE WATER LAVAGE*ORAL ANTACIDS.
REFERRAL : TO ICU / GASTRO-ENTEROLOGIST.
CAUTION : AVOID INJ. STEROIDS
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HAEMOPTYSIS.BLOOD IN SPUTUM .
TREATMENT: * ANTITUSSIVE- LINCTUS CODEIN
* INJ. ANTIBIOTIC* INJ.BOTROPASE.*ALPRAZOLAM 0.25
REFERRAL : TO ICU / PULMONOLOGIST WITH FACILITY OFBRONCHSCOPY.
PRECAUTION : AVOID COUGH EXPECTORANT.URGENT REFERRAL TO CENTRE FOR
PULM.ART.EMBOLISATION [IF MASSIVE HAEMOPTYSIS. ]
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EMERGENCIES CREATED BY G.P.DRUG REACTIONS :
BY PRICK VASOVAGAL SYNCOPE----- T/T : FOOT ELEVATION, INJ ATROPIN
MINOR RASH, ITCHING --------- T/T: INJ AVIL, EFFCORLINE MAJOR ANAPHYLACTIC SHOCK :
PRESENTS WITH RESTLESSNESS,YAWNING,GIDDINESS,PROFUSE SWEATING,BREATHLESSNESS, TACHYCARDIA,HYPOTENSION.
TREATMENT: INJ. ADRENALIN 0.5 CC S.C.INJ EFFCORLINE I.V.INJ AVIL I.V.I.V. N.SALINEBRONCHODILATORS - NEBULISATION
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POISONING.MLCS SO BE CAREFUL TO KEEP PROPER RECORDS .
GENERAL GUIDE LINES :
* STOMOCH WASH* I.V. LINE* SPECIFIC ANTIDOTES
* REFERRAL TO ICU/PHC/MCHSPECIFIC T/T :
OPP - ATROPINE, PAM.KEROSINE- HIGH DOSE VIT- C.OPIATES - NALORPHINE.
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BITES.SNAKE BITE : PTOSIS TREATMENT:
DYSPHAGIA * TORNIQUETT ABD. PAIN *IMMOBALISATIONLOCAL SWELLING *REFERRAL TO ICU
PHC/MCH
SCORPION : LOCAL PAIN *LOCAL XYLOCAINEHYPOTHERMIA *I.V. FLUIDS ARRHYTHMIAS *T.PRAZOCIN
HONEY BEES: RASH *INJ AVILITCHING *INJ
HYDROCORTISONE ANAPHYLAXIS *INJ ADRENALINE S.C.
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APPROACH TO UNCONSCIOUS
PATIENT.SYSTEMATIC APPROACH.
1.BREATHING : YES- AUSCULTATE FOR HEART SOUNDS][
NO RESP & H.SOUNDS][C.P.R.
2. HEART SOUNDS : PRESENT FEEL RADIAL PULSE
3. RADIAL PULSE : FEEBLE SHOCKTACHYARDIA = A.F. WITH CEREBRAL T.I.A
VENTRICULAR ARRHYTHMIA BRADYCARDIA= ICH, I.C. SOL, HEART BLOCKS
[ YOU MAY WRONGLY INTERPRETE YOUR PULSE FOR PTS PULSE.]
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UNCONSCIOUS PATIENT.RECORD B.P. : HYPOTENSION- I.V. FLUIDS, DOPAMIN, STEROIDS.
HYPERTENSION- T/T IF 200/110.
MANAGEMENT : * HEAD LOW * TURN ON SIDE* I.V. 25% DEXTROSE - SUSPECTED HYPOGLYCAEMIA.* I.V. MANNITOL SUSPECTED RAISED I.C.P.*I.V. ANTIBIOTICS - ,, MENINGO
ENCEPHALITIS.* I.V. INJ FALCIGO - ,, CEREBRAL MALARIA
REFERRAL : TO I.C.U./ NURO. SPECIALIST.
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LESSONS TO BE LEARNED.DO`S.
1. KEEP COOL.2.ASSESS SERIOUSNESS OF CONDITION.3.DISCUSS WITH RELATIVES ABOUT SERIOUSNESS OF PT.4.CALL FOR ADDITIONAL HELP.5.ARRANGE FOR TRANSPORT WHILE T/T PATIENT.6.KNOW YOUR LIMITS WHILE T/T.7.GIVE PROPER PRIMARY T/T.8.USE SAFE DRUGS WITH MINIMUM SIDE EFFECTS.9. REFER TO PROPER PLACE.10.BE HONEST TO RELATIVES.
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LESSONS LEARNED.DONTS.
1.AVOID ARROGANCE.
2.AVOID I.V FLUIDS TO EVERY PT.3.AVOID SEDATIVES IN NURO PT.4.AVOID INJ VOVERON,KETOROL IN CHEST PAIN PT.5.AVOID NPHROTOXIC INJ IN PT. WITH HYPOTENSION.6. AVOID S.L. DEPIN TO ASYMPTOMATIC SEVERE HTN.
7.DONT USE DRUGS ABOUT WHICH YOU DONT KNOW. 8. DONT MIX TOO MANY INJ IN SAME DRIP. 9. DONT CRITICISE YOUR FELLOW COLLEAGUES. 10. DONT LEAVE RESPONSIBILITY TO YOUR STAFF IN UR
ABSENCE.
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LESSONS LEARNED.I.V. FLUID IN EMERGENCY -------- AVOID IF DYSPNOEA PRESENT OR
USE MICRO DRIP SET[60 Dr.= 1ml ]
ANTIBIOTICS IN EMERGENCY ------- I.V. CEFTRIAXONE FORTE.
ANTIMALARIAL IN EMERGENCY ------ I.V. FALCIGO.
STEROIDS IN EMERGENCY ------------- I.V. HYDROCORTISONE.
ANAPHYLACTIC SHOCK --------------- DRUG OF CHOICE INJ ADRENALINE [ AND NOTSTEROIDS OR AVIL. ]
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SUMMARY.NO ESCAPE FROM EMERGENCY.
PROMPT & PROPER DIAGNOSIS & T/T SAVES LIFE.
REFERRAL IN PROPER TIME & TO PROPER PLACE SAVES LIFE.
IN NUT SHELL KNOWING DOS & DONTS SAVES PATIENT & YOU.
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