clinical approah in patient with emergency diseases

7/25/2019 Clinical Approah in Patient With Emergency Diseases

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Clinical approach inpatient with

emergency diseases.Marshell Tendean, MD DPCP.Dept of internal medicineUKRIDA Jakarta


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Objective :

To understand aout tria!eTo undestand aout initial

mana!ement in emer!enc" casesTo understand aout primar" sur#e"

and seconda" sur#e"To understand aout se#ere asthmaTo re#ie$ the mana!ement of se#ere

asthma


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Triage

% The sortin! of patients into priorit"!roups accordin! to their need and

the resources a#ailale %

E&mer!enc"PPriorit"Q 'ueue (non)ur!ent*


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Triage Pathway


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Those $ith EMERE!C" #$!# $ho re+uireimmediate emer!enc"

treatment. If "ou nd an" emer!enc" si!ns, dothe follo$in! immediatel"- tart to !i#e appropriate emer!enc" treatment.

Call a senior health $orker and other health $orkers tohelp.

Carr" out emer!enc" laorator" in#esti!ations.

Those $ith PR$OR$T" #$!#, indicatin! that the"should e !i#en priorit" in the +ueue, so that the"can rapidl"e assessed and treated $ithout dela".

Those $ho ha#e no emer!enc" or priorit" si!ns

and therefore are !O!%&RE!Tcases.


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&/ample of emer!enc" cases - &mer!enc" - se#ere trauma, acute

m"ocardial infarction, air$a"ostruction, tension pneumothora/,h"po#olemic shock !rade III)I0, urnin1uries $ith respirator" tract

in#ol#ement Ur!ent - spine trauma, open fracture,

closed head trauma, urn in1ur", acuteappendicitis

2on ur!ent - arasion, fe#er, upper


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Eval'ation sho'ld be done incase o( emegency :

0ital si!n assessment and patientcondition

Assesment for li#e e/pectanc"Kno$in! "our resourcesArran!e priorit" of action3aelin!


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Clinical approach (oremergency cases

Initial e#aluation (4hat should $e do* 5 0ital si!n assesment

6ull histor" takin!

Comprehensi#e ph"sical e/amination

Inte!rated ancilar" procedures


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Do rief histor" takin!.

Important data durin! emer!enc" -

Trauma 7 non trauma

ur!ical 7 non sur!ical

Into/ication dru! 7 to/in

Primary s'rvey : ) * C + E


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). )irway :

aluate the presence of air$a"ostruction -

3ar"n/ edema. 6orei!n od" aspiration.

4hat to do 5Triple air$a" manou#er.

In cases possile of possile cer#icaltrauma, 1ust do head staili8ation


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*. *reathing

aluate for reathin! patternUndress patient to oser#e chest

mo#ement.3ook for si!ns of respirator"

distress - Minimal chest e/pansion

Acessor" muscle use

Decrease repirator" rate (9: 7 minute*


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C. Circ'lation

3ook for pulses (carotid or radialarter"*.

3ook for an" si!n for shock. Pale, cold and $et skin

Capillar" rell time (9 ; sec*

3ook for the presence of leedin!


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+. +isability

aluate sensorium, h"po!l"cemia,menin!ismus, pupilar" re


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E ,Environment-epos're/

aluate for rashes, h"potermia orh"pertermia and si!ns or chronic

disease sti!mata.&n!!a!e initial e#aluation - Pulse o/"metr", &C=

=lucose le#el and lactate

>lood !as anal"sis and electrol"te


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#igns o( organ distress

Respirator"Cardio#ascular2eurolo!ic


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Respirator" - Respirator" arrest

Air$a" ostruction or compromise

tridor

Respirator" rate 9 : 7 min or ? @ 7 min

Assesor" respirator" muscle use (diBculties

to speak in complete sentence* p; 9EF in hi!h pressure o/"!en

Pa; ele#ation ?G Kpa (;mmH!* or ;kPa mmH!* ao#e normal $ith acidosis


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Cardio#ascular si!ns- Cardiac arrest

Heart rate 9E7min or ?E7min "stolic lood pressure 9EE mmH!

i!ns of inade+uate /"!en deli#er",metaolic acidosis and h"perlactatemia.

Poor response to >7hour


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2eurolo!ic si!ns Air$a" ostruction or compromise

2e!ati#e cou!h or s$alo$ re


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#econdary s'rvey :

Complete anamnesisComprehensi#e ph"sical e/amination

&/tensi#e ancilar" procedures

Deniti#e treatment.


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#tat's )sthmatic's

Marshell Tendean MD, DPCP

Dept of Intenal medicine Jakarta


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#tat's )sthmatic's

% tatus asthmaticus is a condition in

$hich se#ere air$a" ostruction andasthmatic s"mptoms persist despitethe administration of standard acute

asthma therap" %

Donnell 4J, 3ife)threatenin! asthma. In-

Te/took ofcritical care. th ed;EEE-):


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Epidemiology :

6rom to E F of asthmatic patientsha#e se#ere disease.

The mechanisms that diLerentiateet$een easil" mana!ed andunresponsi#e asthma are still ein!in#esti!ated

Data indicate that in nearl" :percent of asthma deaths, the nalepisode lasted lon!er than ; hours

Mc6adden &R Jr, 4arren &3. Ann Intern MedG;G-;)G


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Trigger (actors

0iral upper respirator" tract infection isthe most common precipitant of anasthma attack.

In addition chlam"dial pneumonia andherpes simple/ #irus infections ma" pla"a role in e/acerations of ronchospasm

in patients with and witho't asthma.Aller!ic reactions to foods (e.!., peanuts*

can result in life)threatenin! asthmaattacks.


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Criteria (or severe )sthmaattac0s

"mptoms >reathlessness $hile at rest

Talkin! in $ords, not full sentences

A!itation (usuall"*i!ns

Respirator" rate ? @E per minute in adults Use of accessor" muscles for reathin!

4hee8in! durin! inhalation and e/halation

Pulse rate ? ;E per minute

Pulsus parado/us

6unctional assessment P&6 rate 9 E to ;EE m3 in adults, or 9 EF of predicted or personal est eLort

/"!en saturation 9 F on room air

Pa;9NE mm H! on room air or PC;?; mm H!

Adapted $ith permission from &/pert Panel report ;- !uidelines for the dia!nosis and mana!ement of asthma.>ethesda, Md.- 2ational Institutes of Health, 2ational Heart, 3un!, and >lood Insti)tute, G 2IH pulication no.G)E

P&6 O peake/pirator"


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)ncilary and 2aboratoryEaminations:

Chest ra"A>= (Acid >lood =as*Peak


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Peak


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Management :

&mer!enc" mana!ement (A > C D*Con#entional mana!ement - k"!en

Inhaled medication ,)nticholinergic 3 *eta 4

)gonist/3 #ystemic Corticosteroid

Treatment for non respondin! patients - Parenteral >eta ; A!onist

Ma!nesium sulfate Meth"l/antines

3eukotriene inhiitors

2on I#asi#e #entilation

Helio/


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)c'te #evere )sthmaManagement


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$nhaled dr'gs :


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)nticholinergic

)nticholinergic dr'gs, can e !i#en incomination $ith inhaled eta;a!onists.

Ipratropium romide ,)trovent/initiall"can e !i#en " MDI (four to ei!ht puLs*or neuli8ed solution (three doses of ;Emc! each*.

The recommended follo$)up dosin! of;E to EE mc! at si/)hour inter#als is$ell tolerated.


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$nhaled beta4 adrenergicagonists

%Reco!ni8ed as mainsta"s of ronchodilatortherap"Q.

If patients can coordinate hand motion andreathin!, aluterol (0entolin* deli#ered "

metered)dose inhaler (MDI* $ith a spacer (four toei!ht puLs e#er" ;E to @E min)utes for threedoses* compares fa#oral" $ith neuli8ation (;.to m! e#er" ;E minutes*.

In patients $ith more se#ere asthma, MDI dosin!can e increased to one puL e#er" @E to NEseconds, or continuous neuli8ation can einstituted (E to m! per hour* to impro#e

s"mptoms.


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#ystemic corticosteroid

In patients $ho can tolerate oral medications, oralcorti)costeroid therap" is as eLecti#e as intra#enoustherap". ( Ro$e >H. Am J &mer! Med ;E-@E)E*

T"picall", prednisone is !i#en orall" in a dosa!e of

to ; m! per k! once dail" (usual ma/imum- NE to :Em! per da"* for #e to se#en da"s.

6or intra#enous treatment, meth"lprednisolone

sodium succinate (olu)Medrol* is administered in adosa!e of E. to ; m! per k! e#er" si/ hours (usualma/imum- ; m! per da"*, or h"drocortisone is!i#en in a dosa!e of ; to m! per k! e#er" four tosi/ hour


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Oygen therapy

Patients $ith se#ere asthma ha#e a#entilation)perfusion mismatch and,thus, enet from supplemental

o/"!en therap".5igh%6ow s'pplemental oygen is

est deli#ered usin! a partial or

complete nonrereather mask. (/"!en saturation !reater than

percent*.&/pert Panel report ;- !uidelines for the dia!nosis and mana!e)ment of

asthma. >ethesda, Md.- 2ational Institutes of Health, 2ational Heart,3un!, and >lood Institute, G 2IH pulication no. G)E


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5ospitali7ation

Indicated in - Patients $ith a pretreatment arterial

o/"!en saturation of less than E per)cent

Persistent respirator" acidosis.

e#ere ostruction that does not

impro#e (or $orsens* $ith theadministration of s"mpathomimetica!ents (i.e., the P&6 rate remains at lessthan GE percent of the predicted #alue*

Mc6adden &R Jr, 4arren &3. Ann Intern MedG;G-;)G

P t l * t 4


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Parenteral *eta 4)gonist

' or I0 administration of eta; a!onists ma" e indicated in patients $hoare cou!hin! e/cessi#el", too $eak to inspire ade+uatel", or moriund.

Terutaline (>rethine* is !i#en sucutaneousl" (E. to E.; m!* orintra#enousl".

In patients $ith %rittle asthmaQ t$ice)dail" ' administration of

terutaline im)pro#ed s"mptoms, medication use, and P&6 rates. ,)yres83 Miles 813 *arnes P8. Thora 9;:>9=%49/ I0 or ' administered epineph)rine ma" help a#oid the need for mechanical

#entilation in patients $ith status asthmaticus.The ' dose of epinephrine is E. to E. m! in adults (E.E m! per k! in

children*, usuall" !i#en as E. to E. m3 of a -,EEE solution e#er" ;E

minutes or lon!er.6or con#enience, adult patients ma" e !i#en three E.@)m! doses at ;E)min


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Methylantines

These a!ents are second)line ronchodilators(one third as eLecti#e as eta; a!onists*.

Unfortunatel", the therapeutic le#el of this

a!ent (appro/imatel" E m! per 3* is close tothe to/ic le#el.

i!ns of to/icit" include cardiac d"srh"th)mias,nausea, tremor, and headache.

Aminoph"lline re!imen is a loadin! dose of to N m! per k! administered intra#enousl"o#er @E minutes, then E. m! per k! per hour


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Magnesi'm s'l(ate

Ma!nesium sulfate is a calcium anta!onist

that induces smooth muscle rela/ation.A dose of @E to GE m! per k! ( to @ !* is

!i#en intra#enousl" o#er ;E to @E minutes.The safet" and potential enets of

ma!nesium sulfate 1ustif" its use innonrespondin! patients. This a!ent ma" e

particularl" enecial in patients $ho areprone to h"poma!nesemia ecause ofprolon!ed, hea#" use of inhaled eta;a!onists.


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2e'0otriene $nhibitors

In the acute settin!, 8arlukast(Accolate* ma" e !i#en orall" t$ice

dail" the dose for adults is ;E m!,and the dose for children up to ;"ears of a!e is E m!.

ileuton ("


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!O!$!?)#$?E ?E!T$2)T$O!

Continuous positi#e air$a" pressureor i)le#el positi#e air$a" pressure

machines use ti!ht)ttin! facemasks to assist #entilation andreduce the $ork of reathin! $ithoutintuation.

2onin#asi#e #entilation is indicatedin cooperati#e patients $ho ma"ha#e impendin! respirator" failure


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!$$? )parat's


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5elio

Helio/ is a helium)o/"!en mi/turethat decreases turulent airenets include decreases in the$ork of reathin!, muscle fati!ue,and caron dio/ide production.

$ t b ti d M h i l


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$nt'bation and Mechanical?entilation

@hen possible3 int'bation sho'ld beavoided.

Indications for intuation include cardiac or

respirator" arrest, se#ere h"po/ia,e/haustion,or deterioration of mental status.

To pre#ent complications, it is recommendedthat rapid normali8ation of the caron dio/ide

le#el e a#oided, and that mild h"percapnia etolerated until lun! function impro#es.

0olume c"cle and pressure c"cle


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% Reco!nition of &mer!enc" situationneeds most e/posure and

e/perience %Rememer Tria!in! patients.Handle A>C prompl"&n!a!e for deniti#e mana!ement.

clinical approah in patient with emergency diseases

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