Emergency Medicine Summary

8/11/2019 Emergency Medicine Summary

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EMERGENCY MEDICINE SUMMARY

COMMON EMERGENCIES

Syncope, Seizures, Allergic reactions, Cardiac events, Unresponsiveness,

Respiratory/cardiac arrest, Hypoglycemia

GENERAL PRINCIPLES Prevention

o Get a good medical hx (meds and allergies)

Preparation: Plan for the worst case scenario

o Office personnel should be certified in CPR

o Have emergency equipment available and be familiar with it

o Dentists should ideally be ACLS certified

o Personnel should practice plan

SYNCOPE

20% of the general population will experience syncope

Benign causes: vasovagal syncope

Malignant causes:o Cardiac issues: MI, arrhythmias, Allergic reaction, Hypovolemia,

Hypoglycemia, Pulmonary embolism, Aortic dissection, GI bleeding,

Ruptured ectopic pregnancy

Vasovagal syncope: Most common

o Precipitating factors: Pain, Fear, Sight of blood

o Caused by hypotension due to bradycardia and venous pooling.

o Symptoms: warmth, light-headedness, nausea, decrease in vision.

o Recovery should be rapid, and without confusion

Who to transfer to emergency department:

o Patients with precipitating symptoms:

Chest pain, Dyspnea, CNS deficits, Abdominal pain, Patients

who are found to be orthostatic

o Age 40 or older: increase risk of serious underlying cause

SEIZURES

Most commonly due to non-compliance with seizure medications.

Stressmay trigger seizures in those with a history of them.

Hypoglycemia: seen in those on insulin or oral hypoglycemics.

Hyponatremia

Iatrogenic: Most often due to local anesthetic agents and epinephrine.

Treatment:

Protect patient from injury Maintain airway

Provide high flow oxygen: use non-rebreather mask.

May use a bite block or padded tongue depressor to open the mouth.

Never stick your fingers in a seizing patients mouth

Call 911

Have bag-valve-mask available


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Initiate IV

If patient is still seizing, administer 5-10mg of valium.

If an IV cannot be initiated, valium can be administered rectally

Coat needleless syringe with lubricant and administer medication as a

bolus rectally.

Be aware of injuries associated with the seizure.

Do not move the patient unless they are in danger.

Use caution- post-ictal patients can be confused and combative.

ALLERGIC RXNS AND ANAPHYLAXIS

Symptoms: can progress rapidly

Rashes: urticaria is red, splotchy, pruritic (itchy).

Airway compromise: tongue feels bigger, throat tightening, difficulty

swallowing, speech problems, stridor.

Dyspnea: wheezing due to bronchospasm

Hypotension

Gastrointestinal complaints Mild reactions:

H1 Blockers: Benadryl, Allegra, Zyrtec, Claritin

H2 Blockers: Zantac, Pepcid, Axid

Major reactions:

Epinephrine: oropharyngeal edema and/or hypotension

Steroids

Treament:

o Airway, breathing, circulation

o IV access: large bore IV with normal saline

o Benadryl 50mg IV

Can administer IM if no IV accesso Pepcid 20mg IV

o If severe case, epinephrine 1:1000, 0.3mg SC

Coronary artery disease is relative contraindication

If patient hypotensive, may consider epinephrine 1:10,000

0.3mg IV SLOWLY.

CARDIAC PROBLEMS

Myocardial Infarction

Risk factors: hypertension, diabetes, hypercholesterolemia, family

history, smoking.

Symptoms:

o

Chest pain: may radiate to arms, shoulder, neck, jaw, back. Pain

often described as a pressure or squeezing

o Associated symptoms: dyspnea, diaphoresis, nausea, vomiting,

palpitations, syncope-- symptoms vary!

Angina patients:


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If a patient with a history of angina is having his typical chest pain in

its typical anginal pattern, and it is relieved by nitroglycerin, just

monitoring patient ok.

Any change in pain, pattern warrants ER referral.

Be suspicious of a patient presenting with jaw pain- could be of cardiac

origin. Clues to fact that it is cardiac:

No intra-oral or facial etiology

Unclear pain distribution

Associated chest discomfort, dyspnea, nausea, vomiting, diaphoresis,

abnormal vital signs, look like FTD (Fixing To Die).

Treatment:

ABCs

Call 911-only transport by EMS!!

Oxygen

Monitor

IV line

Aspirin if available

Nitroglycerin if available and blood pressure stable

CARDIAC ARREST

A-Airway

Check for foreign bodies

Perform jaw thrust/chin lift

B-Breathing

If breathing, place on high flow oxygen

If patient not breathing, then ventilate patient using bag-valve-mask

or other adjunct Ventilate at 12-20 breaths per minute.

Administer 100% oxygen

C-Circulation

Check a carotid pulse

If no pulse, start chest compressions

Start IV with normal saline in one antecubital fossa

If unresponsive:

Administer narcan 0.4mg and glucose D50, 25 grams IV

If no IV established, can administer narcan IM or glucagon 1mg IM.

HYPOGLYCEMIA Patients usually on insulin or oral hypoglycemics

Patient often skips a meal prior to hypoglycemic episode.

If making a patient NPO prior to a procedure, be certain to adjust the insulin

dose. Have IV fluids with glucose on hand, such as D51/2NS.

If suspect patient is hypoglycemic, treat immediately.

If patient is awake, administer orange juice with sugar or oral glucose.

If patient has altered mental status:


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If IV established, administer D50 25grams IV

If no IV, then administer glucagon 1mg IM (caution: vomiting)

All patients with hypoglycemic episode should eat a meal and be observed.

Patients should be referred to the emergency department if :

they are on oral hypoglycemics

the reason for the hypoglycemic episode is unclear the patient does not return to baseline

CPR/ACLS

Airway control:

Jaw thrust, Chin lift, Maintain cervical spine immobilization if injury is

suspected.

Ventilate with:

Bag-valve-mask, Mouth-mask, Face shield

OXYGEN THERAPY

Nasal Cannula: 1-6 LPM--Provides 24-44%

Simple masks: 40-60% Non-rebreather masks: 90-100%

Bag-valve-mask: 100%

You can never give too much oxygen, even if patient has COPD.

BASICA AIRWAY ADJUNCTS

Nasal trumpets: Lube them up; Bevel points medially

Oropharyngeal Aiways

Measure from lips to angle of jaw; Insert inverted and turn upright as

you reach the back of the tongue; Only tolerated in unconscious

patients without a gag reflex

ADVANCED AIRWAY TECHNQUES

Endotracheal Intubation: Cuffed tube passed through vocal cords utilizingdirect laryngoscopy and placed in the trachea, securing the airway

Alternate techniques: Nasotracheal, Digital, Fiberoptic, Lighted stylet,

Retrograde intubation, Combitube, LMA

SURGICAL AIRWAY TECHNIQUES

Needle cricothyrotomy: large bore IV catheter through the cricothyroid

membrane.

Surgical cricothyrotomy: 6.0 ETT placed through incision in anterior neck

and through the cricothyroid membrane

TRANSPORTING PATIENT TO ED

If you feel a patient is ill enough to be seen in the emergency department, he

should come by ambulance

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Emergency Medicine Summary