Office Emergencies in Clinical Medicine PDF

Clinical Medicine and Systemic Disease 1 Evaluation and Treatment of Annette Bade ,O.D., M.S.,F.A.A.O. Diplomate American Board of Optometry Office Emergencies Professor NSU College of Optometry ...

Clinical Medicine and Systemic Disease 1 Evaluation and Treatment of Annette Bade ,O.D., M.S.,F.A.A.O. Diplomate American Board of Optometry Office Emergencies Professor NSU College of Optometry  Case Case: 58 Yr old HM CC: HA x 4 days. PMHx: +HTN VA (sc) OD 20/25; OS 20/25 ❖ Pupils: sluggish -APD ❖ IOP: 16 mmHg OU ❖ What is the patients ocular diagnosis? ❖ Is this an ocular Emergency? Case: 58 Yr old HM CC: HA x 4 days PMHx: +HTN  Objectives ❖ Recognize signs and symptoms of common of ce emergencies ❖ Develop a differential diagnoses ❖ Create and of ce plan or protocol ❖ Rapid assess ❖ Initiate treatment ❖ Arrange for de nitive care fi fi fi  What is an office emergency? ❖ Patients View: ❖ An acute event that is of signi cant concern to the patient ❖ May or may not be life threatening ❖ May require initial stabilization before hospital transfer fi  Doctor Perspective of an Office Emergency ❖ Anything you don’t want to happen in your of ce ❖ Anything you do not have experience dealing with in the of ce setting ❖ Anything for which you are unprepared fi fi  Emergency ❖ A medical emergency is an injury or illness that is ACUTE and poses an immediate risk to a person’s life or long term health  Potential Office Emergencies ❖ Myocardial Infarction (MI) or heart attack ❖ Stroke ❖ Syncope ❖ Seizure ❖ Hypertensive Crisis ❖ Allergic Reaction ❖ Childbirth ❖ Trauma Altered Mental Status ❖ Hypoglycemia Primary Patient Assessment  Airway ❖ Does the patient have a patent airway? ❖ Is the patient talking? ❖ Do you anticipate closure of the airway within a brief period of time? ❖ Inspect the patient’s voice; gag re ex; position of trachea; presence or absence of foreign body fl  Breathing ❖ Is the patient breathing spontaneously? ❖ Do the respirations move suf cient air? ❖ Are both sides of the chest rising symmetrically? ❖ Equal breath sounds? ❖ Does the patient require ventilatory assistance? fi  Circulation ❖ Does the patient have a pulse? ❖ Is the pulse strong, thready, rapid, regular, irregular? ❖ Is the pulse palpable at the carotid artery? Radial artery? Femoral artery? ❖ Does the patient require circulatory support?  Disability ❖ Is the patient talking coherently? ❖ Are the patient’s pupils equal? Reactive to light? ❖ Are there any noticeable focal neurological de cits? ❖ Speech patterns, arm/leg weakness, facial weakness fi  Exposure ❖ Not necessarily performed in an of ce ❖ May be necessary to evaluate a possible extremity fracture ❖ Apply pressure directly in the cases of bleeding fi  Acute Myocardial Infarction ❖ “Heart Attack” ❖ Leading cause of morbidity and mortality in the US ❖ 1.3 million cases of non-fatal MI/ year ❖ Rapid development of necrosis secondary to critical imbalance of oxygen demand and supply Levine’s sign  Acute Myocardial Infarction ❖ Levine’s sign is 80% sensitive for MI- Call 911 ❖ Chest pain ❖ Abdominal Paim (Epigastric) ❖ Shortness of Breath ❖ Diaphoresis ❖ Nausea and vomiting ❖ Altered Mental Status ❖ Syncope  Heart disease is the #1 killer of women ❖ Women are more likely than men to have back or neck pain, heartburn, shortness of breath, nausea, vomiting and indigestion. They may also feel extremely tired, light headed or dizzy. Flu-like symptoms and sleep problems may also occur 2 weeks before a heart attack  Acute Myocardial Infarction ❖ Activate EMS System ❖ Oxygen (if available) ❖ Acetylsalicyclic Acid= ASA or aspirin ❖ Nitroglycerin (if the patient has it) ❖ Time is crucial ❖ Patient is more likely to survive if treated within 90 minutes ❖ Case #2 ❖ What is the patient’s diagnosis? ❖ Is this an ocular emergency?  CRAO Management 2018 ❖ An OAO or RAO patient of any age should have a systemic evaluation for vascular occlusive disease; generally a vasculitis or hyper coagulable workup in younger patients and an embolic workup in older patients  Emergent Stroke Evaluation ❖ Acute symptomatic OAO or CRAO from embolic etiologies should prompt an immediate referral to the nearest stroke referral center for assessment of an acute intervention. However, the current evidence is limited for a similar referral for patients with an asymptomatic BRAO  Stroke : 911 Emergency ❖ “Brain Attack”, Cerebrovascular accident (CVA) ❖ 3rd leading cause of death ❖ 3 types: ischemic (83%), hemorrhagic (13%), and TIA ❖ Approximately 800,000 strokes will occur this year ❖ stroke/40 seconds ❖ Anyone anytime  Are you at Risk? ❖ Risk Factors: ❖ HTN ❖ Atrial brillation ❖ Artherosclerosis ❖ DM ❖ Other heart disease ❖ Health behaviors : alcohol, ❖ High cholesterol smoking, diet ❖ Blood disorders (sickle cell anemia) fi  Risk Factors ❖ 44% increase in hospitalization for stroke in patients 25-44 years of age ❖ Why? ❖ Increase in systemic disease ❖ DM, HTN, Metabolic syndrome and obesity ❖ Medications: BCP  Ischemic Stroke ❖ Ischemic injury ❖ Thrombotic (clot within vessel) ❖ Embolic (vessel blockage) ❖ Carotid artery disease (CAD) ❖ Cardiogenic ❖ Lacunar (small vessel disease=DM, HTN)  Hemorrhagic Strokes ❖ Weakened Blood vessel ruptures: ❖ Aneurysms: ballooning of a weakened spot of a blood vessel ❖ Arteriovenous malformations (AVMs): cluster of abnormal blood vessels ❖ Subarachnoid Hemorrhage-“worst headache of my life” ❖ Intracerebral Hemorrhage- sustained elevated BP (retinal sign?) ❖ Subdural/Epidural Hemorrhage-trauma/aneurysm ❖ High Fatality: 50% who survive will die within 2 weeks  5 Warning Signs of a Stroke ❖ Sudden confusion, trouble speaking or understanding ❖ Sudden trouble seeing in one or both eyes (Transient vision loss, diplopia) ❖ Sudden trouble walking, dizziness loss of balance or coordination ❖ Sudden severe headache with no known cause ❖ Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Time is critical- 3 hour window  Therapies for Ischemic Stroke ❖ Clot busting medications called t- PAs, or tissue plasminogen activator that can dissolve the blood clot that cause most strokes  Warning Strokes=TIA ❖ Transient Ischemic Attack=Medical Emergency ❖ Acute neurological de cit of vascular origin ❖ Clear completely < 24 hours ❖ Lasts minutes to an hour ❖ If > 30 minutes, usually due to an infarct ❖ Increased risk of a stroke by 9.5 times fi  Syncope ❖ Transient loss of consciousness (TLOC) ❖ Due to generalized cerebral ischemia (de ciency of blood ow to the brain) ❖ Characterized by rapid onset, short duration and spontaneous and complete recovery ❖ May or may not have preceding symptoms ❖ Orthostatic Hypotension ❖ (+/-) transient altered mental status after incident fi fl  Syncope ❖ Cardiac Syncope ❖ CNS ❖ Arrhythmias ❖ Seizure ❖ Vasovagal (re ex (epilepsy) syncope) ❖ Heart attack ❖ Disorders of the ❖ Common faint ❖ Tachycardia brain stem ❖ Benign ❖ Aortic Stenosis condition ❖ Young adults fl  Causes of Syncope ❖ Hyperventilation ❖ Orthostatic HTN ❖ Sudden drop in blood pressure ❖ Cerebrovascular disease when you change position ❖ Hypoglycemia ❖ Dehydration, standing up too ❖ Drug Induced fast, and medications for high pressure  Vasovagal Syncope Symptoms ❖ 1. Initial increased sympathetic tone: ❖ 3. Breathing -irregular, jerky, ❖ Tachycardia and gasping ❖ Elevate blood pressure ❖ 4. Dilated pupils ❖ 2. Followed by rapid decrease in sympathetic tone: ❖ 5. Convulsive Movements ❖ Hypotension ❖ 6. Loss of consciousness ❖ Bradycardia (< 50 beats per minute) ❖ 7. Partial or complete airway ❖ Weak thready pulse obstruction  Vasovagal Syncope Management ❖ Place the patient in a supine position with brain and heart at the same level ❖ During exercise or vigorous activity and feet elevated slightly (10-15 degrees) ❖ Without warning or when you are ❖ ABC of basic life support already lying down ❖ Monitor vital signs ❖ With loss of signi cant amount of blood ❖ Administer aromatic (smelling salts) ❖ Accompanied with shortness of ❖ When fainting is a problem or more breath, chest pain or palpitation serious concern: ❖ Accompanied with numbness or ❖ Multiple times in a short period of tingling on one side of the face or body time fi  Associated Symptoms of Hyperventilation ❖ Lightheadedness ❖ Chest pain ❖ Cramps ❖ Confusion ❖ Syncope ❖ Determine the cause: if due to anxiety or drug reaction, cardiac or pulmonary disease  Seizure Disorder ❖ Convulsions occurring through excessive neuronal discharge ❖ Most common of the neurological disorders ❖ Estimated 4 million people in the US ❖ 1 in 10 will have a seizure some time in their lifetime ❖ 3% of the population have chronic seizures  Seizures ❖ Causes: Spontaneous (epilepsy), drugs, metabolic disorders (hypoglycemia), rapidly increasing fever, brain tumor or aneurysm, medication withdrawal, stroke and infection (meningitis) ❖ Treatment: place the patient supine ❖ DON’T put anything in the patient’s mouth (you may lose a nger) fi Types of Seizures  Seizure ❖ Most will resolve spontaneously without intervention ❖ Patient may experience bowel incontinence ❖ Possible bleeding from the mouth ❖ Post-ictal: ❖ Altered state of consciousness after an epileptic seizure ❖ Don’t touch or restrain the patient ❖ Goal is to prevent secondary injury  First Aid for Seizures ❖ Call 911 ❖ Seizure last for over 5 minutes ❖ Patient not regaining consciousness ❖ Do not let the patient drive home ❖ Notify PCP ❖ Check Blood pressure and blood glucose  Headaches ❖ 1 of 10 top presenting complaints ❖ 1 to 2% of visits to ER ❖ 18 million outpatient visits ❖ 638 million days of work lost per year ❖ 78% of women and 64% of men had experienced at least one in the prior year ❖ 36% of women and 19% of men suffer from recurrent headaches  Life-threatening headaches ❖ Red ags: ❖ Sudden onset- severe persistent headache that reaches maximal ❖ Venous sinus thrombosis density within a few seconds or ❖ Pituitary apoplexy minutes after the onset of pain warrants aggressive investigation ❖ Acute angle closure glaucoma ❖ Subarachnoid hemorrhage (SAH) ❖ Hypertensives emergencies ❖ Carotid/ vertebral artery dissection fl  Headache Red Flags ❖ Headache (HA) that is associated with neurological symptoms: ❖ Weakness, dizziness, numbness or tingling, paralysis, speech dif culties, blurry vision, TIA ❖ HA with a fever, shortness of breath, stiff neck, or rash ❖ HA that awakens you at night ❖ HA with severe nausea and vomiting ❖ HA that occurred after a head trauma or accident ❖ New type of headache after the age of 55 fi  Migraine HA ❖ 5-25% of patients with headaches ❖ Begins with mild-moderate pain and then gradually increases to maximal level over one to two hours ❖ Increased prevalence in females ❖ Two types ❖ Migraine with (classical) and without aura ❖ Migraine with aura (classical) does carry a small risk of ischemic stroke  Common Etiologies for Ocular Headaches ❖ Ocular in ammation ❖ Orbital cellulitis ❖ Acute angle-closure glaucoma ❖ Orbital Bone fracture ❖ Retrobulbar optic neuritis ❖ Temporal arteritis ❖ Bilateral disk edema=papilledema fl 2018 Classification of Hypertension  Hypertensive Urgency Severe Hypertension (stage 2) + ❖ NO End Organ Damage ❖ Usually due to under controlled HTN  End Organ Damage ❖ Hypertensive Encephalopathy ❖ Intracerebral Hemorrhage ❖ Acute MI ❖ Left Ventricular failure with pulmonary edema ❖ Acute Coronary Syndrome (ACS) ❖ Dissecting Aortic Aneurysm ❖ Eclampsia  Signs and Symptoms of End Organ Damage ❖ Chest pain ❖ Shortness of breath (SOB) ❖ Nausea/vomiting ❖ Confusion ❖ Cerebral edema ❖ Loss of Consciousness ❖ Diplopia ❖ Dizziness ❖ Other neurological signs and ❖ HA symptoms ❖ TIA/AF  Treatment Hypertensive Urgency ❖ Hypertensive Urgency: ❖ Goal: reduce BP to