Emergencies in General Practice Lessons to Be

8/3/2019 Emergencies in General Practice Lessons to Be

1/42

DR.ARUN MANNIKAR. M.D.


2/42

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.


3/42

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.


4/42

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.


5/42

EMERGENCY BAG.1.INJECTIONS:

ADRENALINE * FORTWIN

ATROPINE * VOVERONEFFCORLIN * CONTRAMOL WYMASONE *CYCLOPAM AVIL * PARACETAMOLLASIX * OMEZ

DERIPHYLLIN * VOMISETMEPHENTIN * PERINORM

*DOPAMIN * ETHAMSYLATE*SODABICARBONATE *BOTROPASE


6/42

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.


7/42

TYPES OF EMERGENCIES.DISEASE INDUCED.POISONINGS

BITES : SNAKE, SCORPION, HONEYBEES, DOG.ELECTRIC SHOCK

ACCIDENTSDROWNINGDOCTOR INDUCED : DRUG REACTIONS.


8/42

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


9/42

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.


10/42

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.


11/42

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.


12/42

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 ].


13/42

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.]


14/42

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.]


15/42

BRADYCARDIA.HEART RATE LESS THAN 40/min :

I.V. LINEI.V. ATROPINT. ALUPENT 10 mg.REFFERRAL TO I.C.U.


16/42

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.


17/42

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. ]


18/42

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.


19/42

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.


20/42

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.


21/42

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.


22/42

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.


23/42

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.


24/42

DIAGN. BY SYMPTS : UNCONSCIOUSNESS

ALL CONDITIONS WHICH CAUSE DROWSYNESS

IF SEVERE WILL LEAD TO UNCONSCIOUSNESS.


25/42

DIAGN. BY SYMPTS :

ABNORMAL BEHAVIOUR.DISEASES:

CEREBRAL STROKE.

HEPATIC ENCEPHALOPATHY.URAEMIC ENCEPHALOPATHY.ENCEPHALITIS.HYPOGLYCAEMIA.

CLUES:

OLD AGE, HTN, JAUNDICE, OLIGURIA, FEVER, D.M.


26/42

DEFINITION.EMERGENCY:

SERIOUS ANDUNEXPECTED SITUATION

REQUIRING IMMEDIATE ACTION.


27/42

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.

.


28/42

RESTLESSNESS.LOOK FOR :

TACHYCARDIA BRADYCARDIA HYPOTENSION

HYPERTENSIONTACHYPNOEA FEVER.


29/42

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.


30/42

EPISTAXIS.BLEEDING NOSE .

TREATMENT : * PINCH NOSE.* APPLY ICE PACK.* LOCAL BOTROPASE.*INJ.LASIX * ANTI HTNSIVE.

REFERRAL : TO ENT SURGEON.


31/42

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


32/42

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. ]


33/42

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


34/42

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.


35/42

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.


36/42

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.]


37/42

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.


38/42

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.


39/42

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.


40/42

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. ]


41/42

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.


42/42

Documents

Emergencies in General Practice Lessons to Be