Cases In Emergency Room

.Haematemsis & melena

-: 1st aid measures .Vital data : pulse .. ... Bl.pr-1 Canula & give : ((haematemsis cocktail )) ...............> Dicynon"hemostatic" ,-2 Konakion "vit.k ", Cyclokabron " antifibrinolytic" ,and Zantac "H2 blocker " Ryle --------------- Never before canula-3 Values : -Ensure no bleeding* To wash by cold water with or without adrenaline to cause.local VC . Continue wash till it become clear to prepare pt. For endoscopy* -: N.B.: Pt. Fit for endoscope means . Ryle wash becomes clear .Pt. is not shocked .Pt is not in encephalopathy (( blood samples ((obtained from the canula before giving cocktail 3 -4 One for CBC ----- baseline Hbe (( .Plat. ((decrease in HCV +ve pt----.. One for metabolic profile ----Routine .One for blood preparation .ECG ....to exclude ISHD -5 If bleeding severe or pt not fit for endoscope or not available ** endoscope We may use Sangstakin ---inflate gastric ballon with 250-300 cc saline ** . sangstakin should not be left more than 48 hours to prevent necrosis ** -: Also in case of severe bleeding we can give ** Somatostatin:- [Octeriotide = antigrowth hormone] 25-50 ug\h..."one"ampoule contain 100 ug + 4 saline or Ringer 400 .Value : VC " Glypressin "One ampoule contain 1mg 2 1 6 : Take care .$$ It cause coronary VC, so give nitroderm patches if blood .pr. Allows ..Glypressin is # in IHD, old age

.Blood is given if pt. chocked Plasma is given if pt INR >1.5 Plat. Is given if pt plat. >50,000 Till blood --give Colloid which last in intravascular space more than crystalloids. .E.g. : Dextran,haemgel .If Colloid not available ----- give crystalloids E.g.: Saline, Ringer

: II- History taking History of :- chronic liver dis., Gu or Du, Drug Intake : aspirin, NSAID, .anticoagulant .III-Examination : HSM , ascites , flapping tremors . IV:-Upper GIT endoscope should be done when Pt. becomes fit for it Value : 1- Diagnostic for cause of bleeding .(Therapeutic ( as mentioned before -2

:TTT of bleeding Oesophageal varices

. I ) 1st aid measures .II) Injection sclerotherapy ..III) Anticomato avoid encephalopathy .Enema \4 h* .protein restriction 20gm\d * Lactulose 30 cm\3 times\d stopped if diarrhea * : Eradicate bact. Flora* Flagyl 250 mg (1*3*7)esp with renal impairment .Neomycin 500 mg (2*4*5) #with renal impairment Side effect : ototoxicity so not given >5days . IV)Guard against SBP by Noroxin (Norfloxacin ) 1*2 V) Give (Dicynon ,konakion, Cyclocapron, Zantac) 2 amp\8h.{ Zantac is # with (.thrombocytopenia -: If bleeding persist we give. Sandostatin, Glypressin : After bleeding stopped follow up GI for injection -1 ( .) 2Drug to decrease portal hypertensionIndral 10mg 1*4 (If Indral can't be given as in case of DM\BAor PVD or CHF) Give Effox 40 mg 1*2 (Vit. K (1*3 -3

Liver support Eg: Legalon 1*3 -4 Diuretics depend on pt is compensated or not i.e. pt has -5 .ascites

TTT OF PU
a)1st aid measures b)Upper GIT endoscopy for D.D.- if active bleeding injection with adrenaline .c) Losec ( Omeprazole) vial + 200 cc Ringer over 2 hours d) If anteral gastritis or Du Tripple therapy to eradicate h.pylori It includes :- PPI e.g. : Gastrazole 1*2*15 days Clarithromycin 2*2*15 days .Amoxicilin 2*2*15 days -: Discharge Pt. when Melena stopped .Hb = 8 or more Avoid spicy food , smoking , NSAID .NB: If pt. with PU with severe haematemsis consult Surgery :Indication of admission of pt Haematemsis, melena Tense ascitis SBP Hepatic encephalopathy !!! Recommended pt Haematemsis & melena EX (Tense ascitis ( TTT Tapping :( SBP ( spontinous bacterial peritonitis -: Hepatic encephalopathy

(Tense ascitis ( TTT

:Rest in bed.2-Salt restriction ( salt free diet )3-Diuretics-1 a) Start with Spironolactone (Aldactone) 100 mg And increase gradually up to 4 tablets \day Value : K sparing diuretic, .Aldosterone antagonist

(b) Lasix 40 mg daily up to 4 tablets ( 160 mg\d N.B.: Diuretics esp. Lasix stopped if there is hyopkalemia or precoma Follow up pt. with fluid chart-4 (.body wttarget: decrease B.wt by 1\2 kg \day) If resistant Tapping or paracentesis should be done if tense-5 ascitis cause significant discomfort or resp. distress ( Therapeutic ( purpose of tapping

:Tapping-6 a-Exclude encephalopathy. b-Palpation of abdomen to avoid injury to any organ during tapping . c-Sterilization of (Macburny's point) or mid way bet. Costal margin & ASIS( most dependant area) ***Sterilization is done in circular manner from in into out by .betadine then alcohol. d-introduce canula + IV line (Replacement with albumin if tapping > 3L (one bottle contain 10gm .Stop if : hypotension , bleeding of tapping ,, disturbed conc. Level -

-:.N.B
Diagnostic purpose of tapping : if suspicion of malignant ascitis or .SBP or new onset ascitis Fluid obtained from tapping : 3 samples for : culture & sensitivity, .chemistry, pathological exam :.Indication of Albumin in CLD Pt

Tapping > 3 L of ascitis fluid. - Infection - Surgery - SBP - $ Hepatorenal

:( SBP ( spontinous bacterial peritonitis

Infectious complication of portal HTN related ascitis in absence of

.cause for peritonitis . most commen org : E-coli

C\P : Pt with CLD with [ marked deterioration precipitate [hepaticencephalopathy],, [ fever, abd.pain , tenderness ] ,, [ silent

D.D : leucocytosis may be present Diagnostic paracentesiscell count [WBC >500\ m3\HPF with out [ sympt.,,PNL >250 \m3\HPF with symptoms

.TTT: - Antipyretic Antibiotic3rd generation cephalosporin E.g. : cefotaxime "claforan" 1 gm \ 8 h for 5 days unless there is renal failure ((dose adjustment)) - Anticoma measures ( previousely mentioned ) .Albumin

-: Hepatic encephalopathy
It's neuropsychiatric complex in pts with acute or chronic LCF or portosystemic shunting(i.e.: disorderd conciousness, abnormal (behavior : Ask about ppt factors in Ch. Liver disease pts Diuretics.High dietary prot Haematemsis, melena (Fever (infection SBP .Severe vomiting or diarrhea, excess tapping of ascitis (Hepatotoxicity ( alcohol ,drugs e.g. : sedative, opiod -

: Management Vital data ((fever. Haematemsis ))2-Canula sample for metabolic-1 profile. ( Na, K, Creat, RBS)3-Ryle &wash to exclude haematemsis.4Chest x ray ( chest infection. . Rt sided P.effustion.5-ECG

:TTT To avoid prot. In diet. 2- Eradicate bact. Flora by: - Neomycin 500 -1 mg 2*4*5 Flagyl 250 mg 1*3*7 - Lactulose 30 ml \8 h. (osmotic purgative ) - Enema \4h Hepamerz"L-Arnithine L-aspanate (2 amp +200cc glucose 10% \12 -3 (.h if creat > 3 Aminolesan 500ml\12h (AA infusion-4 : TTT of the cause-5 .E.g. : Haematemsis Dicynon ,konakion, cyclokapron ,zantac Infection TTT SBP Antipyretic, Antibiotic, Anticoma, Albumin

Fever
:Management Cold fomentation2-Cold saline enema (# in diarrhea)3-NSAIDs: --1 Paracetamol (R/ Cetal or PyralBrufen or Novalgen 4Aspegic: - ?? ( 38 thrombocytopenia - ?? Reye $ 5- Search for the cause: sore throat, chest infection, ear infection, UTI if u dont find a cause for fever & fever is prolonged > 2 wks >>>>>> FUO

(Investigations

For FUO

CBC 2-ESR3-Blood culture , urine culture , sputum analysis + ZN stain4--1 Collagen markers5-Malaria & Toxoplasmosis6-Widal & Brucella 7- X- ray chest

:UTI
C/O: dysuria, frequency, urgency, hematuria. Ask for urine analysis: if pus cells > 100 / hpf (N=0 /hpf) >>>> ask for urine culture ttt: Give the best antibiotics which is sulfa or Quinolones e.g. -Sutrim tab. 2*2*5-Chemotrim fort 1*2*5-Septrin 1*2*5 ORQuinolones if there is hypersensitivity to sulfa or resistance to it-Tarivid 200mg (ofloxacin) 1*2*5-Oflicin 200mg (ofloxacin) (1*2*5if pylonephritis: IV AB is required (hospital admission

:Tonsillitis or oropharingitis
:TTT: 1- Antibiotics for 1 wk the best is penicillin e.g. Ampiclox 1*4 - 1st generation cephalosporins e.g. Velosef or Duricef - Sulfa e.g. Sutrim2- Antipyretic 3- mouth wash

:Otitis Media
As above + nasal decongestant e.g. Afrin drops 1*3*7

:Bronchitis
As above + expectorants & mucolytics e.g. Mucosol syrup 1*3 Mucophylline Bronchophene Bisolvon 1*3 Trisolven if pneumonia >>>>> it is indication of admission for IV AB (( penicillin & 3rd generation Cephalosporins

:Gastroentritis
(SI C/O: Watery diarrhea (no blood, no mucous, no tenesmus this is viral infection >>>> give antiseptic e.g. streptomycin 1*3 <<<< . LI C/O: Diarrhea + blood + mucous + tenesmus + fever (Renal Colic: (loin pain radiating to the groin (Give Glucolynamine IV >>>>> # IM (may cause abscess (Papaverine IM >>>>>>>> # IV (cause hypotension ** if no response give {Ca+ atropine + Buscopan + Papaverine + Brufen * Ask for urine analysis, pelviabd. U/S*

Bronchial asthma
:During attacks
VD 2- ABG if severly distressed 3- Start by Nebulizer 1 amp.lasix + 2cc -1 saline +1 amp Atrovent {Ibratropium Bromide** + 1cm Ventoline {B2 agonist >>> # if tachycardia** 1-if severe ( distressed or not responding) >> give Cocktail 500 cc saline or Glu + 2 amp. Solucortef + 1 amp. Aminophilline

Mg Sulphate {Smooth ms relaxant** >>> # in hypotension & renal **impairment

:.N.B In case of cocktail if the pt is diabetic give saline & if the pt is * hypertensive gives glucose. *If the pt has HF or CRF give minimal fluids 100cc or 200cc
:Home ttt R/- ttt of ppt factor e.g. infection - Spray e.g. Clenil (salbutamol+ (Beclomethasone 6

Coma
(disturbed level of conscious)

:Signs of lateralization .deviation of the angle of the mouth .Deviation of the tongue Weakness on one side with withdrawal on painful stimulus. .Change in the tone on one side Eye deviation (Babiniski (extensor planter response :Causes
A-With lateralizing signs: ( need CT
1CVS (stroke): cerebral hge or infarction( thrombus or (embolism 2Hypoglycemia

B-Without lateralizing signs: (mostly metabolic causes

hypertensive encephalopathy Chronic liver ds (LCF) >>>if he came with lateralizing signs, do CT Chr. renal failure Resp. failure Hypoglycemia DKA Severe electrolyte disturbance CNS infection e.g. encephalitis or meningitis

:Other causes of DLC

Drugs & toxins Hysterical

Space occupying lesion e.g. abscess or brain tumor

N.B.: Hypoglycemic coma & coma due to HTN encephalopathy are not essentially .associated with lateralizing signs

:Management
Rapid history

of DM ( hemotest, urine for sugar & acetone Of HTN Of alcohol intake Of drug abuse >>>> Antidote Of any systemic ds VD BP >>>>> HTN encephalopathy Temp. >>>>> fever for e.g. meningitis, encephalitis, chest infection Pulse RR >>>>> resp. distress due to RF e.g. COPD Examine for signs of lateralization Metabolic profiles ABG , ECG , X- ray chest , CT brain

(Cerebrovascular stroke (CVS

The hallmark is abrupt onset of symptoms & neurological deficits e.g. weakness, deviation of angle of mouth, tongue, convulsions, incontinence, coma Risk factors .Ask rapidly about DM, HTN, old age, smoking, heart ds (AF>> embolism) valve replacement, collagen ds >> vasculitis, obesity :1st Aid ,VD: BP, pulse History

Examination .if DM >>> hemotest, urine for sugar & acetone .CXR, ECG , .PT, PTT if AF or recurrent stroke .Ryle for feeding if chocking .Catheterization CT scan . Value of CT scan (white>>> hge, black>>> infarction It demonstrates: - Cerebral hge (from the 1st moment): consult neurosurgery Cerebral infarction: if free follow up CT should be done after 48hrs Space occupying lesion >>> CT with contrast, MRI: consult neurosurgery Brain edema>>> sulci & gyri are not clear :TTT of stroke

:ttt of risk factors HTN >>> BP should be reduced gradually (not more than 140/90 to maintain ...cerebral perfusion), DM, Ht ds, hyperlipidemia Brain dehydrating measures .To treat brain edema around area of hge or infarction Mannitol followed by lasix If # as in renal failure or ht failure >>> give Decadron or Glycerin Pt on Mannitol should follow serum creatinine Nootropil ( neuroprotective) 2amp /6hr Care of comatosed pt .Frequent change of position in bed .Ryle for feeding Catheter Regularly check: urine output, DVT, Bed sores, auscultate chest :Anticoagulants in case of infarction Indications Valve replacement - : AF Dilated cardiomyopathy Stroke in evolution Post circulation stroke Recurrent stroke -

# Recent surgery - : Malignant HTN Bl. Tendency .Inf. endocarditis except if the pt with valve replacement :Dose Heparin 5000IU IV/ 4hr >>>follow up with PT Antiplatlet (Aspocid) (Trental) in case of infarction .Epanotin is given in case of IC hge to inhibit fits especially in lesions near cortex

:DM with disturbed level of conscious

According to urine sugar & acetone

:Management of DKA Hemotest Urine sugar & acetone ABG & ECG MP (glu >250mg/dl, +++ urine sugar &acetone (ABG shows PH < 7.3 or HCO3 low We have 4 problems -1 :Hyperglycemia Give insulin 10 IU IM/hr + urine sugar & acetone & hemotest/ hr if the pt is markedly dehydrated start by 10 IU IV once Glu is < 250 mg/dl give Glu. 5% to improve cellular dehydration -2 :Acidosis HCO3 is not given unless PH < 7.1 or deficit is > -10 -3 :Dehydration L in the 1st 24 hrs 6 -4 500cc/ hr for 2hrs 500cc/ 2hr for 4hrs 500cc/ 4hrs -

with follow up by fluid chart N.B. diabetic pt with Chr renal failure >>> fluids will lead to pulmonary Edema, so central line is fixed & measure CVP & if low compensate by oral route -4 :Hypokalemia if K > 6 dont give.give 1 amp 6- 4.5 .give 2 amp 5 3.4 .give 3amp 3 > -5 .Correction of PPT factors e.g. chest infection >>>>give AB N.B.:- In hyperosmolor non ketotic coma, heparin is given for prophylaxis as .hyperosmolarity >>>> hyperviscosity >>>> infarction AGAIN: if the pt with hyperosmoler coma is not improved, do CT .exclude infarction

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