HASEEB A. KHAWAJA, M.D.DIPLOMATE AMERICAN BOARD OF INTERNAL

MEDICINEDIRECTOR EMERGENCY DEPARTMENT

SHIFA INTERNATIONAL HOSPITAL, ISLAMABAD

Emergencies in general practice

1. Coma2. Seizures3. Meningitis4. Disturbed behavior5. Attempted suicide6. Poisoning/overdose7. GI bleeding8. Acute abdominal pain9. Chest pain10. MI and unstable angina11. Choking both adults and children12. Acute breathlessness13. Exacerbation of asthma14. Anaphylaxis15. Burns16. Electrocution17. Lacerations18. Fractures

UNAROUSABLE UNRESPONSIVENESS IN WHICH THE SUBJECTS LIE WITH EYES CLOSED

Coma

Responsiveness – visual, tactile, auditory

Respirations Posturing Fundi, pupils, oculocephalics Corneals, nasal tickle Gag Facial sensation, motor Spinociliary reflex Reflexes, sensation and plantars

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)

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)

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

Occulocephalic Reflex

Brisk rotation of head with eyes held openWatch for contraversive movementsNext:

Flexion: eyes deviate up and eyelids open (doll’s head phenomenon)

Extension:eyes deviate downward

Other Reflexes

Deep tendon Biceps, brachioradialis, triceps Patellar, Achilles Plantar Responses

Superficial skin Abdominal, cresmasteric

Coma Mimics

Akinetic mutism 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 Catatoniao 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

• SEIZURES: TRANSIENT OCCURRENCE OF CLINICAL SYMPTOMSDUE TO ABNORMAL NEURONAL BEHAVIOR– CONVULSIONS: SEIZURES WITH PROMINENT BODY MOVEMENT– NON-CONVULSIVE SEIZURES: SEIZURES WITH MINIMAL OR NO BODYMOVEMENT• EPILEPSY: BRAIN DISORDER WITH AN ENDURING PREDISPOSITIONTO GENERATE EPILEPTIC SEIZURES• EPILEPSY SYNDROMES: GROUPS OF EPILEPTIC PATTERNS OFVARYING CAUSE BUT SIMILAR COURSE AND RESPONSE TOTREATMEN

Seizures

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

Status Epilepticus

Definition: Two or more seizures without recovery ofconsciousness in between Single seizure >20-30 min (operationally, >5 min)

Causes?

Medication non-complianceCerebrovascular disease such as cerebral infarction,

cerebralhemorrhage, and venous thrombosisHead traumaCNS infections such as meningitis or encephalitisNeurodegenerative diseasesAutoimmune diseaseBrain neoplasmGenetic diseasesSubstance intoxication or withdrawalMetabolic medical disorders such as uremia,

hypoglycemia,hyponatremia, and hypocalcemia

Hypoxia

Hemorrhage

Infarct

Depressed Skull Fracture

Tumor

Vascular Malformation

CorticalDysplasia ?

InfectionUnknown/Cryptogenic

Clinical discrimination between Epileptic and non-epileptic events

Non Epileptic Events

Epileptic Events

Onset Gradual RapidAudience Common UnusualPelvic Thrusting/Opisthotonus

Common Uncommon (Consider Frontal)

Tongue biting Uncommon (tip) Lateral aspectEyes Closed (Resisting

opening)Deviated/Nystagmus

Autonomicfeatures

Uncommon Common

Plantars Normal Babinski +

DOAttempt to time duration ofseizure

Loosen clothing and remove glasses

Help patient lie down and roll onto side to helpavoid aspiration

Do NOT attempt to place anything in the patient’smouth, including medication and water

Do NOT leave patient lying on backDo NOT restrain during or after seizure; mayprovoke aggressive behavior or cause injury

DO NOT

Status Epilepticus on the scene

DefinitionABC’sSugar checkOther causesBenzodiazepinesPhenytoinPhenobarbitonePropofol

“INFECTION OF THE MENINGES”

Meningitis

Issues to consider

Suspecting the diagnosis Clinical clues

How to diagnose CT vs. LP

Choice of emperic antibiotics Rocephin Vancomycin Dexamethasone

Clinical Suspiscion

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

Emperic Antibiotics

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

“ACUTE NEUROLOGICAL DISTURBANCE”

Delirium

DSM IV Criteria

1. Disturbance of consciousness with reducedability to focus, sustain or shift attention.2. A change in cognition or development ofperceptual disturbances that is not betteraccounted for a preexisting, existed or evolvingdementia.3. The disturbance develops over a short periodof time and tends to fluctuate during the courseof the day4. There is evidence from this history, examination or

labs thatthe disturbance is caused by the physiologicalconsequence of a medical condition.

causes

InfectionsElectrolyte abnormalitiesEndocrine dysfunctions (hypo or hyper)Liver failure- hepatic encephalopathyRenal failure- uremic encephalopathyPulmonary disease with hypoxemiaCardiovascular disease/events: CHF, arrhythmias, MICNS pathology: tumors, strokes, seizuresDeficiency states: Thiamine, nicotinic or folic acid, B12

Drugs that can cause delirium

Anticholinergics (furosemide, digoxin,theophylline, cimetidine, prednisolone,TCA’s, captopril) Analgesics (morphine, codeine..) Steroids Antiparkinson (anticholinergic anddopaminergic) Sedatives (benzodiazepines, barbiturates) Anticonvulsants Antihistamines Antiarrhythmics (digitalis) Antihypertensives Antidepressants Antimicrobials (penicillin, cephalosporins,quinolones) Sympathomimetics

Dementia vs Delirium

Dementia has an insidious onset, chronicmemory and executive function disturbance,tends not to fluctuate. In delirium cognitivechanges develop acutely and fluctuate.Dementia has intact alertness and attention

butimpoverished speech and thinking. In deliriumspeech can be confused or disorganized.Alertness and attention wax and wane.

Schizophrenia vs Delirium

Onset of schizophrenia is rarely after 50.Auditory hallucinations are much morecommon than visual hallucinationsMemory is grossly intact and disorientationis rareSpeech is not dysarthricNo wide fluctuations over the course of a dayDelusions and hallucinations

Acutely Agitated Patient

Safety Management and Response Techniques (SMART) SMART staff education Managing dangerous situations Preventing escalation Maintaining environmental safety

Respond as a team!

Physician staff Nursing staff Social work Technical staff Security staff Trainees

Nonpharmacologic intervention

Communication with the patient Behavioral management Safety/physical restraints Medication response and side effectsRespect/concern

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

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 emergencyIn general, antipsychotics are still the

pharmacologic intervention of choice in the acutely agitated patient

Found down patient

DONT

A SAD BUT PERMANENT SOLUTION TO A TEMPORARY PROBLEM

Suicide

Why Talk About Suicide?

because ~ suicide doesn’t discriminate bygender, age, race, ethnicity, education, or socio-economic status.because ~ 90% of people who die of suicidehave a treatable mental illness or substance

abusedisorder; 60% have a depressive disorder.because ~ suicide is the most preventableform of death in the U.S. today.

Depression in disguise

Drug / alcohol abuseAggressive behaviorDelinquent behaviorReckless / antisocial behaviorEating disordersHappy maskFrequent “accidents”Self – destructive actsExtreme boredom / apathyUnexplained physical symptomsSleeping disorderExtreme restlessness

Facts!

Females attempt three times more than males.Males choose more lethal methods (lessopportunity for life saving techniques).Most suicidal people don’t really want to die ~ they justwant their pain to end.About 80% of the time, people who kill themselves havegiven definite signals or talked about suicide.The key to prevention is to know the signs and what youcan do to help.If someone you know seems depressed or gloomy and hasspent a lot time questioning whether life is worth the

bother ~it’s time toPay Attention!

Myths about suicide

“People who talk about suicide won’t really doit.” FALSE“Anyone who tries to kill him/herself must becrazy.” FALSE“If a person is determined to kill him/herself,nothing is going to stop him/her.” FALSE“People who commit suicide are people whowere unwilling to accept help.” FALSE“Talking about suicide may give someone theidea.” FALSE

Suicide Symptoms

Verbal suicide threatsBehavior changesIncrease in mention of body painDepressionSleeping and eating patternsFatigueIrritabilityLifting of prolonged depressionFinal arrangementsDeath wish behavior

SAVE A LIFE!

ASK DIRECT QUESTIONS

Poisoning/Overdose

What to do?

ABCGCSVitalsECGIV access

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?

Paracetamol

Aspirin

TCA’s

Benzodiazepines

Insecticide

Lead?

Food Poisoning