General Medical Emergencies: Part I

1. General Medical Emergencies: Part I

2. HIV Infection and AIDS Diphtheria Encephalitis Hepatitis Herpes: Disseminated Measles Meningitis Mononucleosis Mumps Pertussis Shingles (Herpes Zoster) Tuberculosis Varicella (Chickenpox) Major TopicsCommunicable / Infectious Diseases

3. Major TopicsSkin Infestations • Lice • Scabies • Myiasis

4. Major TopicsEndocrine Emergencies • Adrenal Crisis • Diabetic Ketoacidosis • Hyperglycemic Hyperosmolar Nonketotic Coma • Hyperglycemia • Myxedema Coma • Thyroid Storm

5. HIV Infection and AIDS • Caused by a retrovirus • Viral symptoms start 2-6 weeks • Antibody seroconversiontakes place within 45 days - 6 months • Asymptomatic period for months to years • Replication, mutation, and destroying the immune system

6. HIV Infection and AIDS • Persistent generalized lymphadenopathy occurs • Constitutional disorders, neurological disorders, secondary infections, secondary cancers, and pneumonitis

7. HIV Infection and AIDS • All HIV infections will develop into AIDS • Mean between exposure to HIV to AIDS-10 years • AIDS to death • Sooner the treatment, better long-term survival

9. HIV Infection and AIDS Assessment • Subjective data • History of present illness • Generalized lymphadenopathy, persistent • Fever for longer than 1 month • Episodic spiking • Persistent low-grade fever • Diarrhea for longer than 1 month • Weight loss • Anorexia • Night Sweats

10. HIV Infection and AIDS Assessment • Malaise or fatigue, arthralgias, myalgias • Mild opportunistic infections • Oral candidiasis • Herpes Zoster • Tinea • Skin lesions, rashes • Cough • Broad range of neurological complaints, both focal and global, including dementia

11. HIV Infection and AIDS Assessment • Current medications • Antiretroviral agents: zidovudine (AZT), zalcitabine (ddC), didanosine (ddI), stavudine (d4T), lamivudine (3TC), nevirapine, delavirdine • Pneumocystis prophylaxis: trimethoprim-sulfamethoxazole, pentamidine, dapsone • Protease inhibitors: indinavir, saquinavir mesylate, nelfinavir, ritonavir

12. HIV Infection and AIDS Assessment • Medical History • Blood transfusions, especially before 1985 • Hemophilia • Occupational needle sticks or blood exposure • Sexually transmitted diseases (STD’s) • Tissue transplantation • Infant with HIV-positive mother • Sexual contact with IV drug user • Sexual contact with HIV-positive partner • Sexual practices including multiple partners, anal sex, oral-anal sex, or fisting • Recent TB exposure

13. Physical examination Chronically ill appearance Kaposi’s sarcoma skin lesions Chest: crackles and wheezes Dyspnea Abnormal vital signs Lymphadenopathy Dementia Wasting syndrome; signs of volume depletion Withdrawn, irritable, apathetic, depressed Slow, unsteady gait; weakness; poor coordination HIV infection and AIDS

14. HIV Infection and AIDS • Diagnostic procedures • CXR • CBC • Anemia • Lymphopenia • Thrombocytopenia • ABG’s • Electrolytes, liver function tests

15. HIV Infection and AIDS Assessment • Determination of HIV antibodies (e.g., via enzyme-linked immunosorbent assay [ELISA] and Western blot analysis) • decreased CD4 cell count • blood cultures • urinalysis • TB skin test (5 mm is positive in HIV infected person)

16. Diphtheria • Alteration in neurological functions • Lethargy • Withdrawal • Confusion • Cranial nerve neuropathies • Alteration in cardiac functions • ST-and T-wave changes • First-degree heart block • Dyspnea, heart failure, circulatory collapse • Anxiety

18. Diphtheria • Diagnostic procedures • Throat culture: specimen swabbed from beneath membrane or piece of membrane • Notify lab that C. diphtheria is suspected: requires special media and handling

19. Diphtheria • Interventions • Provide strict respiratory isolation • Maintain airway, breathing, circulation • Monitor vital signs and pulse ox • Assemble emergency cricothyrotomy equipment at bedside • Administer O2 for dyspnea or cyanosis • Establish IV catheter for administration of IV fluids

20. Diphtheria • Interventions • Diphtheria antitoxin • Equine serum • Test for sensitivity (intradermal or mucous membrane) before administration • Often administered before diagnosis is confirmed because of virulence of disease

21. Diphtheria • Antibiotic: EES or PCN G • Antitussive • Antipyretic • Topical anesthetic agent • Minimize environmental stimuli • Instruct patient on importance of complete bed rest

22. Diphtheria • Provide immunization • Regular booster Q10years, combined with TD, after completion of initial series of 3 doses • Identify close contacts • Culture and prophylactic Booster of TD in none within 5 years • Antibiotics • Active immunization for nonimmunized persons (series of 3 doses)

23. Encephalitis • Viral infection of the brain • Often coexists with meningitis and has broad range of S&S • Most cases in North America, caused by arboviruses, herpes simplex I, varicella-zoster, EB, and rabies • Transmission by animal bites, or seasonally form vectors (mosquitoes, ticks, and midges) • More common human viruses are airborne via droplet or lesion exudate • All age groups, with mortality from 5-10% from arboviruses and 100% for rabies

25. Assessment Subjective History of present illness Recent viral illness or herpes zoster Recent animal or tick bite Travel to endemic area, season of the year Fever Headache Photophobia Nausea, vomiting Confusion, lethargy, coma New psychiatric symptoms Encephalitis

26. Encephalitis • Assessment • Subjective • Medical history • Immune disorders • Allergies • Medications

27. Encephalitis • Objective data • Physical exam • Altered LOC • Rash specific to cause • Meningism • Altered reflexes • Focal neurological findings • Abnormal movements • Seizures

28. Encephalitis • Diagnostic Procedures • Lumbar puncture, CT scan • CBC • Blood cultures • Serology

29. Encephalitis • Interventions • Institute standard precautions and isolation until causative agent identified • Monitor airway, breathing, circulation • Monitor vital signs and pulse oximeter • Administer O2 • Prepare to assist with intubation • Insert large bore IV catheter, and administer isotonic solutions as ordered • Administer medications as ordered

30. Encephalitis • Administer antimicrobial/antiviral agents, steroids • Monitor blood sugar and electrolytes • Insert urinary catheter PRN • Monitor I&O, cerebral edema, keep HOB >30 degrees • Institute seizure precautions • Elevate HOB 30 degrees

31. Encephalitis • Restrict IV fluids • Keep body temperature normal • Administer diuretics as ordered • Explain procedures and disease to family/patient • Allow patient/significant others to verbalize fears • Prepare patient/family for admission to hospital

32. Hepatitis • Viral syndrome involving hepatic triad (bile duct, hepatic venule, and arteriole, and central vein area. • Hep A-fecal-oral route, infectious for 2 weeks before and 1 week after jaundice • Hep B-(HBV)blood and sexual contact and consists of 3 antigens • Hep B surface

33. Hepatitis • Hep B-(HBV) blood and sexual contact • 3 antigens • Hep B e antigens • Dane particle- two part antigen: inner core (hep B core antigen) and surface antigen (hep surface antigen) • Persistence of core antibody indicates chronic infection • Persistence of surface antibody indicates immunity to reinfection • Hep B surface antigen in the serum without symptoms is indicative of a carrier state

34. Hepatitis • Hep C identified by antihepatitis C virus antibody • 50% of Hep C become chronic, and no immunity is developed • Hep C 90% of hepatitis cases transmitted by blood transfusion

35. Hepatitis • Hep E is an epidemic, enterically transmitted infection from shellfish and contaminated water • Hep D found with acute or chronic HBV infection • Chronic infections result in cirrhosis and liver cancer

37. Hepatitis • Assessment • History of present illness • Prodrome: preicteric phase, occurs 1 week before jaundice • Low-grade fever • Malaise: earliest, most common symptom • Arthralgias • Headache • Pharyngitis • Nausea, vomiting

38. Hepatitis History of Illness cont’d Rash, with type B usually • May or may not progress to icteric phase • Incubation: • A 15-45 days • B 30-180 days • C 15-150 days • Duration: • A 4 weeks; • B AND C 8 weeks

39. Icteric phase Disappearance of other symptoms Anorexia Abdominal pain Dark urine Pruritus Jaundice Hepatitis

40. Hepatitis cont’d • Medical History • Immunizations • ETOH consumption • Allergies • Medications: all are significant • Blood transfusions, IV drug use, Hemophilia or dialysis • Chronic medical problems, travel, living in institution • Living in recent floods or natural disasters

41. Hepatitis • Objective data • Physical exam • Posterior cervical lymph node enlargement • Enlarged, tender liver • Splenomegaly in 20% • Jaundice • Vital signs: may have tachycardia, hypotension • Fever

42. Hepatitis • Diagnostics • Liver enzymes: SGOT & SGPT elevated • Direct and indirect bilirubin levels: elevated • Alkaline phosphatase: elevated • Differential leukocyte count: leukopenia with lymphocytosis, atypical lymphocytes • CBC, UA: elevated bilirubin, PT: elevated, ABD X-ray • Antigen and/or antibody titers

43. Hepatitis • Interventions • Provide increased calories • Monitor for signs of dehydration, replacement with isotonic solution • Record I&O • Assess support systems of patients • Hospitalize if unable to care for self or PT >15 seconds

44. Hepatitis • Initiate prophylaxis • Type A • Immune serum globulin 80-90% effective if 7-14 days after exposure • Vaccine administered in two doses: given to high-risk population: foreign travel, endemic areas (e.g. Alaska), military, immunocompromised or risk for HIV, chronic liver disease, hep C • Type B: hepatitis B immune globulin plus vaccination, for exposure to serum, saliva, semen, vaginal secretions, breast milk

45. Hepatitis • Initiate prophylaxis • Type B: vaccination with HBV vaccine inactivated (Recombivax HB) • Vaccinate high-risk persons • Health care and public safety workers, clients and staff at institutions • Hemodialysis patients, recipients of clotting factors • Household contacts and sexual partners of HBV carriers • Adoptees from countries where HBV in endemic: Pacific Islands and Asia • IV Drug users, sexually active homosexual and bisexual men • Sexually active men and women with multiple partners • Inmates of long-term correctional facilities

46. Hepatitis • Vaccinate all infants (universally) regardless of hepatitis B surface antigen status of mother (administer first dose in newborn period, preferably before leaving hospital) • Report to appropriate health departments • Limit exposure of medical personnel to blood, secretions, and feces

47. Hepatitis • Instruct patient/significant others • Strict hygiene, private bathroom if possible • Diet of small, frequent feedings low in fat, high in carbs, patient should avoid handling food to be consumed by others • S&S: bleeding, vomiting, increased pain • Take meds as prescribed • Avoid intake of alcohol • Take meds only if necessary • Avoid steroids: they delay long-term healing

48. Herpes: Disseminated Herpes simplex virus (HSV) is a relatively benign disease when cutaneous • Can invade all body systems and lead to death • Primary viremia occurs from spill-over of the virus at the site of entry • During the second stage, HSV disappears from he blood but grows within cells of infected organs, which in turn causes seeding to other organ systems. • Dissemination occurs in susceptible persons: newborns, malnourished children, children with measles, people with skin disorders, such as burns, eczema, immunosuppression, and immunodeficiency, especially HIV

49. Herpes: Disseminated • HSV has a predilection for temporal lobe. • Encephalitis most common • 70% mortality rate without treatment • 50% with treatment residual neurological deficits • Latency period within sensory nerve resulting in mild or life-threatening infection years later

50. Herpes • Assessment • Subjective data • History of present illness • Onset: usually acute • After other illness • After outbreak of cutaneous infection • After any stressor