NCM118 Past Paper PDF

NCM118n-LEC made by @shenyllefaye 4th YEAR 1ST SEM PRELIMS | A.Y. 2024-2025 ➔ Differentiate between critical and non- critical condition COURSE OUTLINE...

NCM118n-LEC made by @shenyllefaye 4th YEAR 1ST SEM PRELIMS | A.Y. 2024-2025 ➔ Differentiate between critical and non- critical condition COURSE OUTLINE ➔ Gather focused history and choose appropriate assessment I. ACUTE BIOLOGIC CRISIS II. HEMORRHAGE III. POISONING FOCUSED HISTORY (PE): MEDICAL IV. EMERGING AND RE-EMERGING DISEASE A. SCENE SIZE UP o Body substance isolation precaution (BSI) ACUTE BIOLOGIC CRISIS o Evaluating scene safety o Determining the MOI/NOI o Determining the total WHAT? number of patients o Determining the need for ➔ Deals with human responses to life- additional resources threatening disease/problems ➔ Responsible for ensuring acutely and B. INITIAL ASSESSMENT o Initial impression critically ill patients and their families o Mental status received optimal care o ABC’s ➔ Licensed professional nurse o Assign priority (stable/unstable) CRITICALLY ILL PATIENT o Treatment and transportation ➔ Patient who are high-risk for decisions actual/potential life-threatening health FOCUS OF CRITICAL CARE NURSING FOCUSED HISTORY & PHYSICAL EXAM o Provide comfort and facilitate healing of Sequence depends on the patients’ patient whole lives under the threat from conditions illness or trauma, whether sudden or Components chronic accident and surgery HPI - Why was EMS called? o Critical illness influences all body systems (Emergency Medical and has a profound impact on the people Service) health - Elaboration on chief complaint - CC ASSESSMENT ★ Focused history ★ Comprehensive history ASSESSMENT OF COMPLAINTS, S/SX, OPQRST - Pain - Respiratory difficulties - Altered mental status GOALS IN ASSESSING MEDICAL PATIENTS - Allergic reaction - Poisoning/overdose - Environmental ➔ Taken 8-14 min that addresses patients emergencies presenting health issue - Obstetric conditions ➔ Explore and characterize patients main - Behavioral emergencies / health concern psychiatric emergencies ➔ No need to go into each item of critical - Onset = what was the pt background history in great detail, but doing? Sudden? should briefly touch on each item or at Gradual? least consider them 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE - Provocation/Palliative = EMERGENCY MEDICAL CARE anything makes the (ICU, SURGICAL,WARD) symptom better or worse - Quality = describe (dull, sharp, crushing, aching, ➔ When assessment is complete, plan or tearing, throbbing) initiate care - Radiation = location / ➔ Care should be focused on sign and does it move to other symptoms parts? - Severity = pain scale / HEMORRHAGE wong-baker - Time = when did s/sx first occur? WHAT? RAPID ASSESSMENT ➔ Loss of blood from a damaged blood - Conscious patient vessel - Critical/unstable patient ➔ Bleeding can be internal/external = Hx & assessment ➔ Blood loss can be minor/major - Unresponsive patients = assessment first then hx - Head to toe order (head, ETIOLOGY OF HEMORRHAGE neck, chest, abdomen pelvis, back, and o Trauma extremities o Medical condition (hemophilia, liver - Focused assessment for responsive patients disease, GI ulcer, aneurysm) - Unresponsive patients o Obstetric hemorrhage (postpartum, placenta abruption) SAMPLE HISTORY o Surgical complications (intraoperative & - S/sx - Allergies postoperative bleeding) - Medications - Past medical history TYPES OF HEMORRHAGE - Last oral intake - Events leading to episode EXTERNAL ★ Occurs outside the body TRAUMA ★ Wound injury - Deformities ★ Results from trauma, - Contusions surgical problems - Abrasions ★ Medical conditions that - Penetration cause blood vessel to - Burns rupture - Tenderness ★ ARTERIAL BLEEDING - Laceration - Spurting blood, - Swelling pulsating flow, MEDICAL bright, red color - Function (more severe, - Guarding hard to control), - Masses synchronized - Pain with heartbeat - Tenderness ★ VENOUS BLEEDING BASELINE VS - Steady, slow flow, - Temperature dark red color - Blood pressure (easier to - Pulse control, requires - Respiratory rate prompt - O2 saturation - Pain attention) ★ CAPILLARY BLEEDING 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE - Slow, even flow, oozing blood MEDICATIONS from small capillaries ➔ Anticoagulants and antiplatelet agent (minor cuts/ (warfarin, aspirin, increase risk of internal abrasions, stops bleeding) on its own with minimal ➔ NSAIDS – long term use can lead to GI intervention) bleeding INTERNAL ★ Occurs inside of the body BLOOD DISORDERS ★ Blood escapes from blood vessels into ➔ Hemophilia/thrombocytopenia (low blood internal count) can predispose a person to spaces/cavities spontaneous internal bleeding ★ Not immediately visible ★ More difficult to diagnose and manage ★ Life threatening if not STAGES OF HEMORRHAGE promptly recognized and treated STAGE 1 ★ Volume loss up to 15% of total blood volume (750ml) CAUSES OF INTERNAL HEMMORHAGE ★ Heart rate minimally elevated/normal ➔ Blunt forces injuries (e.g. car accidents, ★ No change in BP, pulse falls) can cause internal bleeding in pressure or respiratory organs such as liver, spleen, or brain rate ➔ Penetrating injuries (e.g. stab wounds, gunshot wounds) damage internal blood STAGE 2 ★ Volume loss up to 15- vessels and organs 30% of total blood volume (750-1,500ml) ★ Respiratory rate, heart MEDICAL CONDITIONS rate elevated (100-120 bpm) (22-24 cpm) GI BLEEDING ★ Ulcers ★ Pulse pressure narrow ★ Diverticulosis but systolic blood ★ Varices lead to pressure unchanged to internal bleeding in slightly decreased digestive system STAGE 3 ★ 30-40% of total blood RUPTURED ★ Burst blood vessels volume ANEURYSM ★ Often in brain/aorta ★ Hypotension with lead to significant narrow pulse pressure internal hemorrhage (250mmhg) ★ Tachycardia more ECTOPIC ★ Pregnancy outside pronounced (>120bpm) PREGNANCY the uterus, typically ★ Mental status altered in fallopian tube increasingly ★ Can rupture and ★ Urine output cause severe minimal/absent internal bleeding ★ Capillary refill delayed HEMMORHAGIC ★ Bleeding within the STROKE brain due to ruptured blood vessels 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE CLINICAL ASSESSMENT - Direct pressure & elevation not effective, apply pressure in the Patient is assessed & sx of shock: artery supplying in the affected - Cool, moist skin (resulting from area (e.g. brachial artery for arm poor peripheral perfusion) injuries/femoral artery for leg - Decreasing blood pressure, injuries) increasing heart rate TORNIQUET USE (LAST RESORT) - Delayed capillary refill, decrease - Cannot be controlled by other urine volume methods, apply torniquet above - Dizziness or fainting and altered the site of the injury to constrict level of consciousness blood flow, note the time the torniquet was applied and ensure it is not loosened until SPECIFIC SYMPTOMS advanced medical care is available ➔ Abdominal pain & distention (bleeding in HEMOSTATIC AGENTS abdomen & pelvis) - If available, promote clotting and control bleeding specially in severe cases ➔ Flank/back pain (retroperitoneal WOUND CARE bleeding/ruptured aortic aneurysm) - Clean the wound with sterile saline/clean water, apply sterile ➔ Blood in stool/vomit (GI bleeding) dressing/bandage to protect the wound and prevent infection ➔ Hematuria (blood in urine, bleeding in MONITOR FOR SHOCK urinary tract) - Watch signs of shock such as pale, cool, clammy skin, rapid ➔ Brusing (cullen’s sign – around the navel, pulse, shallow breathing or flanks – grey turners sign) confusion. - Lay patient flat and keep them ➔ Headache, LOC/neurological (intracranial warm if possible hemorrhage) - Raise the legs slightly to improve blood flow to organs GOALS IN ASSESSING MEDICAL PATIENTS TRANSPORT TO MEDICAL FACILITY - Ensure patient is transported to medical facility ASAP, especially ➔ Emergency management due to control if the bleeding is severe or bleeding cannot controlled ➔ Maintain circulating blood volume for DOCUMENTATION tissue oxygenation and prevent shock - Record the location, severity, and type of breathing, interventions FIRST AID & NURSING INTERVENTIONS FOR applied, and patients response, communicate this information to EXTERNAL HEMMORHAGE emergency medical personnel or at the hospital APPLY - Direct pressure USE EMERGENCY MANAGEMENT FOR INTERNAL - Clean cloth/sterile dressing to apply firm pressure directly on HEMORRHAGE the wound DO NOT REMOVE INITIAL ASSESSMENT - If blood persist, do not remove - Conduct rapid assessment of dressing instead add more patient’s airway, breathing, and layers & apply pressure circulation (ABCs) ELEVATION - Look for signs of internal bleeding - Elevate the injured limb above the such as hypotension, level of the heart to reduce tachycardia and altered mental blood flow to the area (unless status fractures are suspected) STABILIZATION - Immobilization is preferred - Administer oxygen to support PRESSURE POINTS tissue oxygenation 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE - Establish large bore-IV access for Albumin Rapidly Expensive, fluid resuscitation / blood (5%, 25%) expands requires transfusion plasma human donors, - Start fluid resuscitation with volume limited supply isotonic crystalloids (e.g. normal BLOOD PRODUCTS saline) and consider blood products if available Plasma, Rapidly Crossmatch MONITORING Packed RBC, replaces type-specific - Monitor vital signs and volume lost blood is - Monitor urine output as indicator platelets due to desired for " of renal perfusion and overall hemorrhage optimal circulatory status massive IMAGING & DIAGNOSIS transfusion - Prepare patient for imaging protocols to studies such as ultrasound, ct reduce transfusion- scan, or x-ray to identify the related source and extent of the complications. bleeding DEFINITIVE CARE - Internal hemorrhage often requires surgical intervention radiology to BLOOD TRANSFUSION control the source of bleeding - In the case of hemorrhagic stroke, COMPONENT COMPOSITION INDICATIONS neurological intervention may be AND necessary CONTRAINDICA POST INTERVENTION CARE TIONS - After controlling the bleeding, monitor for signs of re-bleeding, Cells and Volume replacement WHOLE plasma, and oxygen carrying capacity; usually used organ dysfunction and infection BLOOD hematocrit only in significant - Provide supportive care, including about 40% bleeding (>25% blood volume lost) pain management and on-going assessment of hemodynamic PRBCs RBCs with little Increase RBC mass, status plasma symptomatic anemia. (hematocrit Platelets within about 75%); the unit are not some platelets functional FLUID REPLACEMENT IN HYPOVOLEMIC SHOCK and WBCs WBCs within the unit may cause remain reaction and, are FLUIDS ADVANTAGE DISDVANTAGE not functional CRYSTALLOIDS Platelets, Bleeding due to PLATELETS - plasma, some severe low RANDOM platelet. Lactated Widely Requires large RBCs WBCs ringer’s available, volume of lactate ion infusion, over PLASMA Plasma; all Bleeding in patients that helps resuscitation coagulation factors with coagulation factor buffer can result in complement deficiencies, metabolic pulmonary plasmapheresis acidosis edema, abdominal compartment syndrome 0.9% Widely Requires large sodium available volume of chloride infusion, can (normal cause saline hypernatremia, solution) hypokalemia, metabolic acidosis COLLOIDS 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE RISK FOR SHOCK RELATED TO: Severe blood loss leading to inadequate tissue perfusion NURSING INTERVENTIONS: Monitor for early signs of shock, such as increased heart rate, hypotension, restlessness, and decreased urine output Ensure rapid IV access and prepare for administration of fluids, blood products, and medication as needed Keep the patient warm to prevent TABLE 11-2: SELECT VASOACTIVE AGENTS USED IN TREATING SHOCK hypothermia, which can worsen shock MEDICATION DESIRED DISDVANTAGES ACTION IN Provide psychological support to the SHOCK patient and family, explaining the Inotropic Improve Increase situation and interventions Agents contractility, oxygen increase demand of the Dobutamine stroke heart Dopamine volume, INEFFECTIVE TISSUE PERFUSION Epinephrine increase Milrinone cardiac RELATED TO: output Reduced-oxygen carrying capacity and Vasodilators Reduce Cause blood flow secondary to hemorrhage preload and hypotension AS EVIDENCED BY: Nitroglycerin afterload, nitroprusside reduce Cyanosis, delayed capillary refill, altered oxygen demand of mental status, and cold extremities heart NURSING INTERVENTIONS: Vasopressor Increase blood Increase Monitor oxygen saturation and Agents pressure by afterload, vasoconstriction thereby administer supplemental oxygen Norepinephrine increasing Dopamine Phenylephrine cardiac as needed Vasopressin workload; Epinephrine compromise Assess peripheral pulses and skin Angiotensin II perfusion to skin, color regularly kidneys, lungs, gastrointestinal Position the patient to promote tract optimal blood flow to vital organs (e.g. Trendelenburg position if appropriate) Prepare for possible blood transfusion to restore oxygen- carrying capacity 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE DECREASE CARDIAC OUTPUT RELATED TO: Reduced blood volume secondary to hemorrhage AS EVIDENCED BY: Hypotension, tachycardia, weak peripheral pulses, and decreased capillary refill NURSING INTERVENTIONS: Continuously monitor cardiac rhythm and vital signs Administer oxygen as prescribed to enhance tissue oxygenation Elevate the patient’s legs to improve venous return and support blood pressure Prepare for possible administration of inotropic agents if ordered DECREASE CARDIAC OUTPUT RELATED TO: Excessive blood loss due to hemorrhage AS EVIDENCED BY: Decreased blood pressure, increased heart rate, decreased urine output, altered mental status, and pallor NURSING INTERVENTIONS: Monitor vital signs frequently, especially blood pressure and heart rate Assess for signs of shock (e.g. cold clammy skin, confusion) Administer IV fluids or blood products as ordered Monitor intake and output closely, including urine output Prepare possible surgical intervention if bleeding is not controlled 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE POISONING NURSING INTERVENTIONS WHAT? IDENTIFY THE TYPE OF POISON - Common ingested poisons (e.g. ➔ Poison is any substance when injected, medications, household absorbed, applied to the skin or produced chemicals, plants, and within the body in relatively small foodborne toxins) amounts, injuries the body by its chemical - Toxicology principles: action dose-response relationships, acute vs chronic exposure ➔ Poisoning from inhalation and ingestion of toxic materials, both intentional and unintentional, constitutes a major health hazard & emergency situation ASSESSMENT AND DIAGNOSIS: A. HISTORY o Identifying the substance EMERGENCY TREATMENT IS INITIATED TAKING o Time of ingestion WITH THE FOLLOWING GOAL: o Quantity o Intent (accidental or intentional) ➔ Removal or inactivation of the poison before it is absorbed B. SIGNS AND o Gastrointestinal distress ➔ Provision of supportive care in maintaining vital organ function SYMPTOMS o Altered mental status ➔ Administration of a specific antidote to OF o Respiratory distress neutralize a specific poison POISONING o Cardiovascular changes ➔ Implementation of treatment that hastens the elimination of the absorbed poison C. LABORATORY o Toxicology screens TESTS o Blood gases o Electrolyte levels FOOD (SWALLOWED) POISON NOTE: WHAT? The patient who has ingested a corrosive poison, which can be a strong acid or alkaline ➔ Swallowed poisons may be corrosive substance is given WATER OR MILK TO DRINK FOR DILUTION. CORROSIVE POISONS However, DILUTION IS NOT ATTEMPTED if the patient HAS ACUTE AIRWAY EDEMA OR ➔ Include alkaline and acid agents that can OBSTRUCTION; potential for vomiting; if there is cause tissue destruction after coming in clinical evidence of esophageal, gastric, or contact with mucous membranes intestinal burn or perforation ◆ ALKALINE PRODUCTS - Lye, drain cleaners, toilet bowl GASTRIC EMPTYING PROCEDURE cleaners, bleach, non-phosphate detergents, oven cleaners, and Gastric lavage for patient who is button batteries (batteries used to obtunded is only useful within 1hour of power watches, calculators, ingestion, for sustained-release hearing aids, or cameras) substances, or massive life-threatening amounts of a substance; however, ◆ ACID PRODUCTS complications of aspiration and - Toilet bowl cleaners, pool stomach or esophageal perforation cleaners, metal cleaners, rust outweigh its useless. If performed, removers, and battery acid gastric aspirate is saved and sent to the laboratory for testing (toxicology screens) Active charcoal administration if the poison is one that is absorbed by charcoal; given orally or by nasogastric tube, it is effective in small intermittent doses to decrease vomiting. It should 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE be diluted as a slurry so that it is easier HYDROXYCOBALAMIN ★ cyanide toxicity to drink or pass through the nasogastric tube. Activated charcoal absorbs most commonly ingested poisons except SODIUM BICARBONATE ★ tricyclic corrosives, heavy metals and antidepressant hydrocarbons, iron, and lithium Cathartics, which had traditionally overdose accompanied the use of activated ★ aspirin toxicity charcoal, are rarely indicated because they can result in severe electrolyte imbalances, diarrhea, and hypovolemia PATIENT EDUCATION Syrup of ipecac to induce vomiting in the patient who is alert is not Educating patients and families on recommended due to risk of aspiration poison prevention and should never be used with - safe storage of medications and corrosive poisons or with petroleum chemicals distillates (e.g. lubricating oil, fuel oil) or - proper labeling further corrosive damage to the upper - emergency contact numbers (e.g. airway and pharyngeal structures may Poison Control Center/Hospital) occur Teaching signs and symptoms of poisoning and when to seek immediate VOMITING is never induced after ingestion of medical help caustic substances (acid or alkaline) or petroleum distillates PSYCHOSOCIAL SUPPORT Addressing anxiety and fear in patients and families COMMON ANTIDOTE FOR Referral to mental health services for INGESTED POISONING cases involving intentional poisoning or substance abuse ACTIVATED ★ used for many CHARCOAL types of poisoning CARBON MONOXIDE POISONING by binding the toxin in the WHAT? gastrointestinal tract, preventing absorption ➔ May occur as a result of industrial or household incidents or attempted suicide N-ACETYLCYSTEINE ★ acetaminophen ➔ Most common cause of fatality from (paracetamol poisoning overdose) ➔ Frequently under-reported to poison control centers or misdiagnosed NALOXONE ★ opioid overdose ➔ Carbon monoxide exerts toxic effect, by (NARCAN) (morphine, heroin) binding to circulating hemoglobin and thereby reducing the oxygen-carrying capacity of the blood. ATROPINE ★ insecticide ➔ Hemoglobin absorbs carbon monoxide poisoning 200 times more readily than it absorbs oxygen FLUMAZENIL ★ benzodiazepine ➔ Carbon monoxide-bound hemoglobin overdose called carboxyhemoglobin does not transport oxygen DEFEROXAMINE ★ Iron poisoning GLUCAGON ★ Insulin overdose 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE - Helps to displace CO from ASSESSMENT AND DIAGNOSIS: hemoglobin, reducing carboxyhemoglobin levels in the A. Carboxyhemoglobin Blood tests to blood and restoring oxygen Levels delivery to tissues measure ✓ Hyperbaric Oxygen Therapy (HBOT): carboxyhemoglobin - Severe CO poisoning (e.g. levels help confirm significant neurological symptoms, loss of CO poisoning and consciousness, pregnancy, or assess its severity high carboxyhemoglobin levels) - It involves breathing 100% B. Arterial Blood Gas May show metabolic oxygen in a pressurized (ABG) Analysis acidosis or other chamber, which further abnormalities in accelerates the elimination of severe cases CO and reduces the risk of long- term neurological damage ✓ Cardiac Monitoring: - CO poisoning can cause CLINICAL MANIFESTATIONS myocardial ischemia or arrhythmias, so continuous Person with carbon monoxide cardiac monitoring is essential poisoning may appear intoxicated (from ✓ Neurological Monitoring: cerebral hypoxia) - Assess for signs of neurological Signs and symptoms: impairment, as CO can cause - headache both acute and delayed - muscular weakness neurological effects - palpitation ✓ Fluid Management: - dizziness - Ensure adequate hydration and - confusion monitor for any signs of - progress rapidly to coma, skin hypotension or shock color, which can range from pink or cherry-red to cyanotic and PATIENT EDUCATION AND PREVENTION pale, is not a reliable sign Pulse oximetry may reveal a high Educate the patient and family on the hemoglobin saturation which may be sources of CO (e.g. faulty heating deceiving, since the hemoglobin systems, car exhaust, gas appliances) molecule is saturated with carbon and the importance of using CO monoxide rather than oxygen detectors in the home Discuss the dangers of using generators of charcoal grills indoors or MANAGEMENT in enclosed spaces ✓ Move the patient to fresh air immediately, if possible FOOD POISONING ✓ Open all doors and windows ✓ Loosen all tight clothing WHAT? ✓ Initiate traditional cardiopulmonary resuscitation ✓ Prevent chilling; wrap the patient in ➔ A sudden illness that occurs after blankets ingestion of contaminated food or drink ✓ Keep the patient as quiet as possible ➔ Caused by bacteria, viruses, parasites or ✓ Do not give alcohol in any form or toxins permit the patient to smoke more MONITORING AND SUPPORTIVE CARE ✓ 100% Oxygen via Non-rebreather Mask: - Initial treatment for CO poisoning 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE CAUSES SIGNS & SYMPTOMS BACTERIAL o Salmonella ➔ Gastrointestinal: - Found in raw or undercooked eggs, ✓ Nausea poultry, and meat ✓ Vomiting o Escherichia coli (E. coli) ✓ Diarrhea - Undercooked beef ✓ Abdominal cramps (ground) and ✓ Fever (sometimes) contaminated produce ➔ Neurological: (cases like botulism) o Listeria - Found in unpasteurized dairy ✓ Blurred vision products, deli meats, ✓ Difficulty swallowing and certain ready- ✓ Muscle weakness to-eat foods ✓ paralysis o Campylobacter - raw or undercooked ➔ Dehydration: (due to excessive poultry and vomiting and diarrhea) unpasteurized milk o Clostridium botulinum ✓ Dry mouth (botulism) ✓ Decreased urine output - Improperly canned ✓ Dizziness foods and certain preserved or fermented foods ASSESSMENT AND DIAGNOSIS: VIRAL o Norovirus - Highly contagious virus A. HISTORY o Gather information on often linked to TAKING recent food intake contaminated food, o Onset and duration of water, or surfaces symptoms o Hepatitis A o Any potential food sources - Transmitted through linked to the illness contaminated food or water, particularly in B. PHYSICAL o Assess for signs of areas with poor EXAMINATION dehydration sanitation o Abdominal tenderness o Neurological symptoms PARASITIC o Giardia lamblia - Transmitted through C. LABORATORY o Stool cultures contaminated water TESTS o Blood tests o Toxoplasma gondii o Imaging (sometimes if - Found in undercooked complications like contaminated meat sepsis or organ and can also be involvement are spread by suspected) contaminated water or surfaces 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE ➔ It is a medical emergency that requires prompt recognition and treatment FOOD POISONING USUAL QUESTIONS: ➔ Alcohol is a CNS depressant How soon, after eating did the symptoms occur? SIGNS & SYMPTOMS (immediate onset suggests chemical, plant or animal poisoning) ➔ Drowsiness What was eaten in the previous meal? ➔ Impaired coordination Did the food have an unusual odor or ➔ Slurring of speech taste? ➔ Sudden mood changes (most foods causing bacterial poisoning ➔ Aggression do not have usual odor or taste) ➔ Belligerence Did anyone else become ill from eating ➔ Grandiosity the same food? ➔ Uninhibited behavior ➔ In excess it can cause stupor Did vomiting occur? What was the ➔ Eventually coma and death appearance of the vomitus? Did diarrhea occur? MANAGEMENT (diarrhea is usually absent with botulism and with shellfish or other fish ✓ Airway Management poisoning) - Ensure the airway is clear and protected Any neurologic symptom present? - Intubation may be necessary if (these occur in botulism and in the patient is unresponsive or chemical, plant, and animal poisoning) has a compromised airway Does the patient have a fever? ✓ Oxygen Therapy (fever is characteristic in salmonella, - Provide supplemental oxygen if ingestion of fava beans, and some fish the patient has respiratory poisoning) depression or hypoxia ✓ Intravenous - Administer IV fluids to correct SUBSTANCE USE DISORDER (SUD) dehydration and hypotension - Isotonic fluids like normal saline WHAT? are commonly used ✓ Glucose Administration ➔ Misuse of specific substances such as - Administer IV dextrose if drugs or alcohol, to alter mood or hypoglycemia is present or behavior suspected ➔ Drug abuse is the use of drugs for other than legitimate medical purposes ✓ Thiamine Administration ➔ People who abuse drugs often take a - Thiamine (vitamin B1) should be variety of drugs simultaneously (such as given before glucose to prevent alcohol, barbiturates, opioids, and Wernicke’s encephalopathy, tranquilizers) and the combination may especially in chronic alcohol have additive and addictive effects users ACUTE ALCOHOL INTOXICATION COCAINE (CNS STIMULANT) WHAT? Routes may include: - Intranasally (“snorting”) ➔ Also known as “alcohol poisoning” Inhaled through straws ➔ Occurs when a person consumes a large amount of alcohol in a short period - Smoking (“freebasing”) leading to toxic effects on the body 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE Cocaine hydrochloride CLINICAL MANIFESTATION dissolved in ether to yield a pure cocaine alkaloid base Acute intoxication (overdose) can result (“crack,” “rocks”); smoking in a in: small pipe delivers large Pinpoint pupils (may be dilated with quantities of cocaine to lungs severe hypoxia) Decreased blood pressure - IV Marked respiratory depression/arrest - Polysubstance (cocaine and Pulmonary edema + stupor to coma heroin) Seizures Fresh needle marks along course of any CLINICAL MANIFESTATION superficial vein Skin abscesses (from “popping”) Increased heart rate and blood pressure Hyperpyrexia THERAPEUTIC MANAGEMENT Seizures Sluggish, dilated 1. Support respiratory and cardiovascular Pupillary response functions Muscle rigidity 2. Establish IV lines Increased energy Agitation, aggression 3. Obtain blood for chemical and Ventricular arrhythmias toxicologic analysis Intense euphoria, then anxiety, 4. Patient may be given bolus of glucose sadness, insomnia, and sexual to eliminate possibility of indifference hypoglycemia Cocaine hallucinations with delusions 5. Administer narcotic antagonist Psychosis with extreme paranoia and (naloxone hydrochloride IV, IM) as ideas of persecution prescribed to reverse severe Hypervigilance respiratory depression and coma 6. Continue to monitor level of THERAPEUTIC MANAGEMENT responsiveness and respirations, pulse, and blood pressure. Duration of 1. Maintain airway and provide naloxone hydrochloride is shorter than respiratory support that of heroin; repeated dosages may 2. Control seizures be necessary 3. Monitor cardiovascular effects; have 7. Send urine for analysis; opioids can be antiarrhythmic drugs and defibrillator detected in urine available 8. Obtain an ECG 4. Treat for hyperthermia 9. Do not leave patient unattended; they 5. If cocaine was ingested, evacuate may lapse back into coma rapidly. stomach contents and use activated Clinical status may change from charcoal to treat. Whole bowel minute to minute. Hemodialysis may irrigation may be necessary to treat be indicated for severe drug body packers (“mules”) intoxication. Activated charcoal may 6. Refer for psychiatric evaluation and be considered if opioids were taken treatment in an inpatient unit that orally and if the patient is alert eliminates access to the drug. Include 10. Monitor for pulmonary edema, which is drug rehabilitation counseling frequently seen in patients abuse/overdose on narcotics 11. Refer patient for psychiatric and drug OPOIDS rehabilitation evaluation before discharge - Heroin - Opium or paregoric - Morphine, codeine - Semisynthetic derivatives: Oxycodone, methadone, tramadol, fentanyl 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE LORAZEPAM AMPHETAMINE MIDAZOLAM Ecstasy Methamphetamine “meth” FLUNITRAZEPAM (“ROOFIES,” DATE RAPE DRUG”) THERAPEUTIC MANAGEMENT CLINICAL MANIFESTATION SUPPORTIVE CARE: Respiratory depression 1. Sedation Decreasing mental alertness Benzodiazepines are often used to Confusion manage agitation, anxiety, and Slurred speech seizures Decreased blood pressure 2. Cooling measures Ataxia For hyperthermia, use external cooling Pulmonary edema methods such as cool blankets, fans, or coma ice packs 3. Cardiac monitoring THERAPEUTIC MANAGEMENT Continuous monitoring of heart rate, SUPPORTIVE CARE: blood pressure, and rhythm is essential 1. Airway management due to the risk of arrhythmias and ensure the airway is clear and provide hypertensive crises oxygen if necessary. Intubation may be 4. Hydration required for severe respiratory Administer IV fluids to prevent depression dehydration and correct electrolyte imbalances 2. Monitoring MANAGEMENT OF COMPLICATIONS continuous monitoring of vital signs, including heart rate, respiratory rate, blood pressure, and oxygen saturation HYPERTENSIVE CRISIS administer hypertensive agents like 3. Flumazenil nitroglycerin or labetalol if needed A benzodiazepine receptor antagonist used as an antidote in causes of RHABDOMYOLYSIS benzodiazepine overdose. It should be monitor for muscle breakdown, which used with caution due to the risk of can occur with severe hyperthermia or precipitating seizures, particularly in prolonged agitation. Treat with patients with chronic benzodiazepine use aggressive hydration to prevent kidney or those who have taken multiple CNS damage depressants SEIZURES 4. IV fluids treat with benzodiazepines or other administer IV fluids to maintain blood anticonvulsants as needed pressure and hydration MANAGEMENT OF COMPLICATIONS DRUGS PRODUCING SEDATION, RESPIRATORY DEPRESSION INTOXICATION, OR PSYCHOLOGICAL AND Provide mechanical ventilation if PHYSICAL DEPENDENCE necessary (NONBARBITURATE SEDATIVES) HYPOTENSION DIAZEPAM May require vasopressors, if fluid resuscitation is insufficient CHLORDIAZEPOXIDE HYPOTHERMIA OXAZEPAM Rewarm patient if body temperature drops significantly 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE LONG TERM EFFECTS AND COMPLICATION EMERGING INFECTIOUS DISEASES (EIDS) COGNITIVE IMPAIRMENT long-term use of sedatives, especially WHAT? benzodiazepines, is associated with memory problems, decreased cognitive ➔ ElDs are diseases that have not function, and increased risk of dementia occurred in humans before; have PHYSICAL DEPENDENCE occurred previously but affected only long-term use leads to physical small numbers of people in isolated dependence, characterized by places; or have occurred throughout withdrawal symptoms if the drug is human history but have only recently abruptly stopped been recognized as distinct diseases or as a result of a new mutant strains. ADDICTION psychological dependence may develop, ➔ According to US CDC, the EIDs are leading to misuse and addiction defined as diseases whose incidence PATIENT EDUCATION AND PREVENTION numbers in humans have increased in the past two decades, causing SAFE USE OF SEDATIVES public health problems either locally Educate patients on the risks of long- or internationally. term use, potential for dependence, and the importance of following prescribed RE-EMERGING INFECTIOUS DISEASES dosages (REIDS) AVOIDING POLYPHARMACY Advise against mixing sedatives with WHAT? other CNS depressants like alcohol or opioids due to the increased risk of ➔ diseases that were once major respiratory depression and overdose health problems and then declined dramatically but are recently REFERRAL TO SUPPORT SERVICES For patients struggling with dependence, reoccurring, leading to major health provide information on addiction complications. treatment programs and support groups PATTERNS OF OCCURRENCE AND EMERGING AND RE-IMERGING DISEASE DISTRIBUTION OF DISEASE SPORADIC – On and off occurrence EPIDEMIC – sudden increase, above normal threshold, outbreak ENDEMIC – continuous occurrence, cases are constant PANDEMIC – simultaneous epidemic of disease (in other countries) 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE ASSESSMENT: LEVEL OF CONCERN RA 11332 (MANDATORY REPORTING OF NOTIFIABLE Potential spread of disease Magnitude of severity DISEASES AND HEALTH EVENTS OF PUBLIC Response capacity HEALTH CONCERN) Provide additional information on the response and assistance needed by ➔ An act Providing Policies and Prescribing the ESU (epidemiology and Procedures on Surveillance and Surveillance unit) Response to Notifiable Diseases Epidemics, and Health Events of Public PUBLIC HEALTH EVENT OF LOCAL CONCERN Health Concern and Appropriating Funds (PHELC) Therefor, repealing for the Purpose Act The health event is confined in a No. 3573, Otherwise Known as the "Law specific geographical location or Reporting of Communicable (barangay/cities/municipalities) Diseases" The number of cases, deaths, and ➔ Reporting of notifiable diseases affected population are higher than under the Philippine Integrated expected but within the healthcare Disease surveillance and response, system capacity and Event -based surveillance. The health event may involve diseases with existing guidelines for the implementation of preventive and/or PHILIPPINE INTEGRATED DISEASE control measure to manage the event SURVEILLANCE AND RESPONSE (PIDSR) PUBLIC HEALTH EVENT OF REGIONAL CONCERN (PHERC) LIST OF NOTIFIABLE DISEASE/SYNDROMES The health event has the potential to spread to other provinces/HUCs (highly urbanized cities) / ICCs (independent CATEGORY I CATEGORY II component cities) (Immediately Notifiable) (Weekly Notifiable) The number and severity of cases, deaths, and affected population are Acute Flaccid Paralysis Acute Blood Diarrhea higher than expected and/or cases are Adverse Event Acute Meningitis continuously increasing despite Following Encephalin response activities conducted; and Immunization Syndrome (AEFI) Acute Encephalin The health event requires technical Anthrax Syndrome assistance from the regional level in Ebola Virus Disease Acute Hemorrhagic the conduct epidemiological Hand, Foot and Mouth Fever Syndrome Acute Viral Hepatitis investigation and/or conduct of control Disease measures Malaria Bacterial Meningitis Measles-Rubella Chikungunya Meningococcal Cholera PUBLIC HEALTH EVENT OF NATIONAL CONCERN Disease Dengue (PHENC) MERS-CoV Diphtheria Influenza-like illness The health event has potential Neonatal Tetanus Paralytic Shellfish Leptospirosis characteristics to cross boundaries or Poisoning Non-neonatal Tetanus borders (regions or other countries) Rabies Pertussis Novel health event Severe Acute Rotavirus The health event involved vulnerable Respiratory Typhoid and Infection (SARI) Paratyphoid Fever population (Example: children, Zika Virus Disease pregnant, elders, healthcare workers) Outbreak (clusters of from two or more regions and diseases & unusual The health event may require national diseases or threats) level attention, resources and immediate implementation of control measures due to either the following: - has attracted public, media, or political interest 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE - epidemic transmission route is new or unusual - epidemics associated with health service failure or linked to breakdown in standards of health care delivery such as the following but not limited to infection control failure or systemic immunization failure PUBLIC HEALTH EVENT OF INTERNATIONAL CONCERN (PHEIC) The health event formally declared by Worl Health Organization (WHO) 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE 4TH YEAR 1ST SEMESTER PRELIMS | NCM 118 LECTURE