Management Of Medical Emergencies

U.S. Aging Population

35 million people (12%) 65 years or older

Number will increase by nearly 75% by year 2030

The number of people more than 85 years old will approach 11 million by 2030

Physiologic Studies Aging

In general basal function of the major organ systems are relatively uncompromised

Functional reserve and ability to compensate for physiologic stress significantly reduces

Management Of Medical Emergencies

Prevention Recognition Treatment

Decreased Level of Consciousness

Altered Consciousness Unconsciousness

Altered Consciousness

Confusion - mental state marked by the mingling of ideas with disturbances of comprehension and understanding -> bewilderment

Delirium - mental disturbance characterized by illusions, delusions, cerebral excitement, physical restlessness, and incoherence

Derangements of speech, thought, motion, or sensation

Mechanisms of Altered Consciousness

Inadequate delivery of blood or oxygen to the brain

Systemic or local metabolic deficiencies

Direct or reflex effects on the CNS Psychic mechanisms

Mechanisms of Altered Consciousness

Inadequate delivery of blood or oxygen to the brain Myocardial Infarction Congestive Heart Failure Respiratory Failure

Mechanisms of Altered Consciousness

Systemic or Local Metabolic Deficiencies Hyperglycemia or Hypoglycemia Hyperthyroidism or Hypothyroidism Drug Overdose Acute Allergic Reactions

Mechanisms of Altered Consciousness

Direct or Reflex Effects on CNS Cerebrovascular Accident Convulsive Episodes

Psychic Mechanisms Hyperventilation Vasodepressor Syncope

Call for Help Emergency

numbers 6 2233 (Internal

school number) 9 911 (Emergency

EMS) Bring Emergency

Equipment to Site

Altered Consciousness

Examine Patient Place Supine or Upright PRN Obtain Vital Signs Administer Oxygen Definitive Care based on History and

Physical findings

Differential Diagnosis Altered Consciousness

Skin warm and dry - hyperglycemia Skin cold and moist - hypoglycemia,

angina, AMI, severe acute allergic reaction

Skin hot and wet - hyperthyroidism Skin cold and dry - hypothyroidism Paresthesia - hyperventilation

syndrome, TIA -> CVA Headache - CVA, hypoglycemia

Acute Stroke (CVA)

Altered consciousness Intense headache, severe neck or facial pain Aphasia or dysarthria One sided sensory loss or motor weakness Ataxia Visual loss mono or binocular Vertigo, double vision, unilateral hearing loss,

nausea, vomiting, photo or phonophobia

Supportive Treatment Patients are placed in upright position Oxygen supplied by nasal canula (6 L/min) or

facemask (15 L/min) CPR prn Vital signs are monitored q5m Transport patient to hospital for definitive

treatment CAT scan Fibrinolytic therapy tPA within 3 hrs onset

symptoms (not hemorrhagic stroke)

Unconsciousness Inadequate Delivery of Blood or Oxygen

to the Brain (respiratory &/or cardiovascular failure) Vasodepressor Syncope Orthostatic Hypotension Cardiac Arrest, Major Dysrhythmia, Failure Respiratory Failure – Airway Obstruction,

Respiratory Depression or Arrest

Management of Unconscious Patient

Place patient supine with legs elevated

Basic Life Support ABCs Airway -

Obstruction Breathing

Circulation carotid pulse

Management of Unconscious Patient

Absent Pulse Administer CPR Defibrillate ASAP

AED

Management of Unconscious Patient

Breathing with Pulse Maintain patent airway Administer supplemental oxygen Obtain vital signs - BP, HR & Rhythm,

RR and examine patient Differential Diagnosis

General Considerations

Differential Diagnosis: Neurogenic - Vasodepressor Syncope

Vascular - Postural Hypotension

Cardiogenic – dysrhythmia, CHF

Drugs Psychogenic Endocrine - Adrenal Insufficiency

Predisposing factors

Stress Impaired Physical Status

(ASA III or IV)

Ingestion of Drugs (Narcotics, Benzodiazepines, Barbiturates, Antidepressants, ETOH)

Prevention

Both physiologic and psychological stress reduction

Acknowledging fear IV sedation Supplemental oxygen/Nitrous oxide Supine positioning

Vasodepressor Syncope

“Fainting” Predisposing factors 1. Male , under 35 years, and

administration of local 2. Psychogenic- fright, pain 3. Physiologic- Upright position, hunger

Pathophysiology

“Fight or flight response” Hypotension Bradycardia Resulting in decrease cerebral perfusion

Clinical manifestations

Presyncope: pale, cold sweat, nausea, yawning, pupils dilate

Syncope: convulsive movements, hypotension, bradycardia. Typically lasts seconds to minutes

Post syncope: weakness, sweating, nausea, pallor

Clinical manifestations

If unconsciousness persists for more then 5 minutes, or complete recovery is not achieved in 15-20 minutes then other causes of unconsciousness must be considered. Especially if patient is over 40

Management Stop procedure! Call for help Assess level of consciousness

Place in supine position A,B,C’s: Airway, Breathing, Circulation Oxygen Vitals

Aromatic Ammonia

Postural Hypotension

“ A fall in systolic pressure of 20 mm/hg or more upon standing”

Predisposing factors 1. Age: over 65 population 2. Drugs: AntiHTN, Antidepressants, Antipsychotics,

Narcotics, Antiparkinson 3. Prolonged recumbence 4. Hypovolemia 5. Pregnancy 6. Venous defects 7. Post sympathectomy 8. Shy- Drager syndrome (autonomic atrophy)

Pathophysiology

Normal response to upright position: 1. Arteriole constriction 2. Tachycardia 3. Venous constriction 4. Increase muscle tone

Pathophysiology

In postural hypotension these reflexes are diminished or delayed.

Consciousness will be lost if systolic pressure falls below 70 mm/hg at heart level in a normotensive patient.

Clinical manifestations

Upon sitting upright Lightheaded Diaphoretic Hypotension Tachycardia Syncope

Management Stop procedure! Call for help Assess level of consciousness

Place in supine position A,B,C’s: Airway, Breathing, Circulation Call EMS Oxygen Vitals

Slowly reposition chair

Adrenal Insufficiency

Adrenal Cortex 1. Glucocorticoids 2. Androgens 3. Aldosterone Normally 20 mg cortisol is produced

daily, and increases to over 60 mg when stressed.

Endogenous steroids

Gluconeogenesis Protein utilization Fat utilization Intravascular volume Electrolytes: Na + K

Predisposing factors Primary adrenal insufficiency: Addison’s disease,

decrease in cortisol

Secondary adrenal insufficiency: Decrease in ACTH production

Pituitary

ACTH

Adrenal

Cortisol

Hypothalamus

CRF

Exogenous Steroids Rule of two’s

20 mg of cortisone or equivalent daily For continuous 2 weeks Within past 2 years After obtaining an adequate history the

decision must be made whether supplementation is needed.

Clinical manifestations

Lethargy Hypotension Hypoglycemia Hyperkalemia Cardiovascular collapse Death

Management Stop procedure! Call for help Place in supine position A,B,C’s: Airway, Breathing, Circulation Call EMS Oxygen Vitals Definitive Management

Administer 100 mg hydrocortisone or equivalent IV/IM immediately