Medical Emergencies

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2. Medical Emergencies

3. Remember…• Emergency care for medical emergenciesis based on the patient’s signs &symptoms• If the patient feels or appears unusual—assume a medical emergency• If the patient has unusual vitals signs—assume a medical emergency• Consider all patient complaints to bevalid—LISTEN TO THE PATIENT!!!

4. Chest Pain, Angina & PossibleHeart Attacks

5. • Occurs when theheart needs moreoxygen than isavailable• Usually brought onby exertion or stress

6. Angina Pectoris • Signs and Symptoms… – Chest discomfort—pain brought on by exertion – May radiate to jaw/arms/neck – A pressure or squeezing feeling in chest – Shortness of breath – Pain usually relieved by rest

7. MI (Myocardial Infarction or HeartAttack) • A failure of circulation to the heart muscle that damages or kills a portion of the heart. • The amount of damage depends on the size & area of the blockage. • If too much muscle dies, the heart will be unable to pump enough blood—leading to shock and death.

8. Damaged Heart

9. MI (Myocardial Infarction or HeartAttack) Signs and Symptoms: – Early symptom?? mimic indigestion. – Chest discomfort—may radiate to arms, jaw or neck. – Nausea and vomiting. – Shortness of breath. – Sweaty. – Weakness. – Restlessness. – Last symptom—CARDIAC ARREST.

10. Common Complaints Shoulder, neck and jaw pain • May occur with or without chest pain • Described as: • Heavy sensation • Pressure • Aching • Squeezing

11. Nitroglycerin Dilates blood vessels • Decreases the workload of the heart

12. Contraindications– Heart rate less than 50 bpm– Systolic blood pressure less than 100 mm/Hg– Head injury– Pediatric emergencies– Already taken maximum prescribed dose– Viagra use within past 24 hours

13. Dosage• 1 tablet or spray, under tongue• REPEAT in 3 to 5 minutes IF…– No relief in pain– Medical control has been advised– Blood pressure remains above 100 mg/Hg NOTE: Make sure you document administration time

14. Side Effects– Hypotension– Headache– Pulse rate changes– Tingling sensation under tongue Reassessment – Monitor blood pressure every 3-5 minutes

15. Aspirin—(ASA) EARLY administration of 160-325 mg Aspirin can reduce the effects of a heart attack by as much as 20%

16. The Emergency CardiacCare (ECC) coalitionrecommends that allindividuals experiencingacute onset of chest pain,which may be cardiac innature, be encouraged tochew 160-325 mg ofAspirin, then swallowwithout water.

17. Emergency Care for ChestPain and Possible HeartAttacks

18. • Provide emotional support—reassure and calm the patient• Loosen any restrictive clothing• Ensure adequate airway• Apply high flow O2• Monitor vital signs• ASSIST patient with their Nitroglycerin medication• Administer 160-325 mg (chewable) uncoated Aspirin– Explain why you want to administer it– Has to be patient’s choice• Constantly reassess patient’s status and vital signs

19. Congestive Heart Failure (CHF)

20. Condition in which the heart cannotcirculate the blood• Causes a backup of fluids in the lungs andother organs• CHF leads to respiratory difficulty

21. Signs and Symptoms… Shortness of breath – Rapid heart rate – Increased blood pressure – Pulmonary edema (fluid in lungs) – Swelling in feet/ankles/legs/abdomen – Engorged neck veins – Skin, lips and nail beds may turn blue – Anxiety

22. Congestive Heart Failure

23. Emergency Care for CongestiveHeart Failure Ensure EMS has been called (911) • Provide emotional support—reassure and calm the patient • Loosen any restrictive clothing • Ensure adequate airway • Apply high flow O2 • Monitor vital signs • Position patient in greatest ease when breathing

24. Respiratory Emergencies

25. A patient’s breathing can be consideredadequate or inadequate

26. Adequate Breathing

27. Breathing that is sufficient to support life• Breathing should be easy, effortless and quiet• Characterized by rate, rhythm and quality– Rate—number of breaths/minute• Adult 12-20 breaths/min• Child 15-30 breaths/min• Infant 25-50 breaths/min– Rhythm—pattern of respirations• Regular or irregular– Quality—how well the patient is breathing• Noisy or quiet

28. Inadequate Breathing

29. Breathing that is not sufficient to support life• If left untreated—will eventually result in death• These patients will have– Rate—faster or slower than normal– Rhythm—irregular– Quality—decreased with noisy respirations• Abdominal breathing/retractions• Will also show restlessness & anxiety

30. Types of RespiratoryEmergencies

31. Acute Pulmonary Edema (fluid in lungs)• COPD (chronic obstructive pulmonary disease)• Asthma• Allergic reactions• Pulmonary embolism• Hyperventilation

32. Acute Pulmonary Edema Fluid build up in the alveoli which impairs the exchange of gases

33. • Signs and Symptoms… – Shortness of breath – Increased heart rate – Sweaty – Cyanosis – Rales—fluid in smaller airways

34. COPDChronic Obstructive Pulmonary Disease Disease of the airway passages or exchange levels • Retain high levels of CO2 (stimulus to breathe) & lower levels of O2 • COPD examples: – Emphysema – Chronic bronchitis – Black lung disease

35. Signs and Symptoms… Shortness of breath (breathing through pursed lips) – Barrel-like chest – Rapid pulse – Abdominal breath sounds – Persistent cough – Tightness in chest

36. Asthma/Allergic Reaction

37. Chronic inflammatory disorder of the airways• Signs and Symptoms…– Wheezing– Cyanotic—(bluish color)– Severe respiratory distress– Tripod position

72. Hypertensive Crises

73. Definitions Hypertensive Emergency: • Marked HTN associated with Target Organ Damage/Dysfunction (TOD) – Hypertensive Urgency: • Marked HTN NOT associated with TOD

74. Definitions (old terminology) Malignant HTN – Marked HTN with papilledema (Grade 4 KW hypertensive retinopathy) – Renal involvement called malignant nephrosclerosis • Accelerated HTN – Same as malignant hypertension but without papilledema (Grade <4 KW)

75. Definitions• Hypertensive encephalopathy– the presence of signs of cerebral edemacaused by breakthrough hyperperfusion fromloss of cerebral autoregulation

76. End Organ Damage

77. Hypertensive encephalopathy• Cerebral Infarction• Subarachnoid Hemorrhage• Intracranial Hemorrhage• Eclampsia• Retinopathy• Aortic Dissection• Myocardial ischemia and infarction• Acute LV dysfunction• Pulmonary Edema• Renal Insufficiency• Microangiopathic hemolytic anemia

78. Stages of CHRONIC HTN • Stage 1: SBP>140 DBP>90 • Stage 2: SBP>160 DBP>100 • Stage 3: SBP>180 DBP>110 • Stage 4: SBP>210 DBP>120

79. Stage 3 and 4 CHRONIC • Non-urgent: reduce BP in 1 week • MYTH: You can’t send someone home from hospital with high blood pressure

80. Hypertensive Urgency ACUTE Acute Stage 4 HTN • (hypertension.ca definition: DBP>130) • Reduce BP within hours (24-48) • ORAL MEDICATIONS • Short admission to hospital CAN BE reasonable for frequent vitals and monitoring for development of TOD • BUT, MAY ALSO BE DONE AS OUTPATIENT IF CLOSE FOLLOW UP

81. Hypertensive Emergency

82. Reduce BP immediatelyReduce MAP by 20-25%OrReduce MAP to 110-120Whichever is higherAchieve target BP in 2-4 hoursIV MEDICATIONS

83. Initial Management Confirm BP in both arms • Assess target organ involvement – Clinically – Laboratory/Imaging • Frequent monitoring of vital signs • Initiate treatment

84. Target Organ Involvement Clinical: – Detailed neurologic examination including fundoscopy – Complete cardiac exam • Acute AI, ischemic MR, S3 – Volume assessment • JVP • Peripheral edema • Lung crackles

85. Target Organ Involvement Laboratory/Investigations – CBC, Lytes, Urea, Cr,– EKG – CXR – U/A – CT/MRI head (if indicated) – CT Chest (if indicated)

86. PO DRUG THERAPY

87. Oral Therapy If you are using PO meds, there is no urgency to bring down the BP • USE ANYTHING REASONABLE • Fast Acting: – sl captopril 25mg • Others: – ACE-I, DHP-CaCB, labetalol, hydralazine,

88. IV Drug Therapy

90. Post-operative Hypertension Classically ~2h post op • Short lived – Usually requires treatment for <6hrs • Most feared complication is bleeding from operative site • Caused by sympathetic stimulation and catecholamine surge • Use whatever, labetalol po works great

91. Thank you Dr Mohamed Shahee