1. Emergency management in bleeding from esophageal verices.
1. bleeding from esopgageal varices restore circulatory blood volume, establish Iv access for blood transfusion, rapid infusion of 5%dextrose and colloid solution till BP restored, airway protection, correct clotting factor with fresh frozen plasma, fresh blood and vit K, nasogastric tube and gastric lavage, than endospoy. somatostatin 250 mcg IV in bolus, vasopressin 02-0,4 U/min IV
2.Emergency management for a patient with acute gastric bleeding.
Provide hydration and volume support.
Transfusion may be required.
If an acute bleed is suspected and there is hemodynamic instability, access with 2 large-bore IV catheters must be obtained.
Histamine-2 blockers or proton-pump inhibitors are used to inhibit gastric acid production in peptic ulcer disease, GERD, and duodenal ulcer disease. Alkaline suspensions are used to directly neutralize gastric acid secretions. Bleeding from esophageal varices may be prevented with vasoconstrictors, such as octreotide. Those with the etiology of infectious diarrhea should not be given antimotility agents, though some may benefit from antibiotics.
Somatostatin is not currently available in the United States for pediatric use
H2 blockers are reversible competitive blockers of histamine at the H2 receptors, particularly those in the gastric parietal cells where they inhibit acid secretion
Aluminum and magnesium hydroxide (Maalox)
Drug combination that neutralizes gastric acidity and increases pH of stomach and duodenal bulb. Aluminum ions inhibit smooth muscle contraction and gastric emptying. Magnesium-aluminum antacid mixtures used to avoid changes in bowel function.
Vasopressin (Pitressin)
At high doses, can cause vasoconstriction, with many other effects (eg, promoting water resorption, increasing peristaltic activity). Effective in reducing portal pressure.
3.Emergency management of angina pectoris episode.
1. Avoid situations that can produce increased myocardial
oxygen demand
2. Stop procedure and allow the patient to rest
3. Monitor vital signs repeatedly
4. Place the patient in a semi reclined position
5. Provide supplemental oxygen
Administer sublingual nitroglycerin (0.4 mg) every 5 minutes for three doses; if symptoms are not relieved, assume that the patient is having a myocardial infarction and transport him or her to an appropriate emergency medical facility.
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4.Emergency management for patient with acute myocardial infarction.
1. Discontinue dental treatment.
2. Place Patient in a semi reclined position
3. Administer supplemental oxygen
4. Continually monitor and record vital signs
5. Administer sublingual nitroglycerin, 0.4 mg every 5
minutes for three doses.
6. Assume that the patient is having an infarction if he or
she continues to have symptoms after the administration
of three doses of nitroglycerin
7. Notify rescue unit and prepare for transport
8. Transport patient to the hospital as soon as possible
1. Start IV with normal saline solution
2. Monitor ECG and treat dysarhythmias according to
advanced cardiac life support protocols
3. Administer morphine, 1 to 6 mg IV, to relieve pain and
anxiety and to decrease systemic vascular after load.
5.Emergency management for paroxysm of supraventricular tachycardia.
emergency of supraventricular tachycardia vagal maneuvers ( eg. breth holding, carotid massage), IV adenosine(6mg rapid, Ca channel blocker -verapamil 2,5-5mg IVover 2 -3min pepeat in 5-10min, beta blockers, IV procainamide, digoxin, electrical cadrioversion, cardiac glycosides -digoxin 0,125 mgPO
6.Emergency management of paroxysmal ventricular tachycardia.
paroxysmal ventricular tachycardia cardiac monitor, ECG, defibrillation, cardioversion , vasopressors, epinephrine 1mg IV every 3-5min, vasopressin 40U IV, IV amodarone 150mg infusion, lidocaine 1mg/1kg, magnesium sulfate, electrolytes
7.Write emergency management for a patient with ventricular fibrillation.
ventriculkar fibrillation AHA algorithm-defibrillation, initate CPR, oxygen vasopressors - epinephrine 1mg every 3-5min, antidysrhytmics- amiodarone 300mg IVonce, than 150mg, kidocaine 1-1,5mg/kg , magnesium and sodium bicarbonate
8.diagnosis and emergency management of hypertensive crisis
BP should be lowered to 100-110mmHg over min to hours. More rapid reduction of BP should be avoided since it may worsen end-organ fxn.
-beta adrenergic blockers: they have negative inotropic fxn and they r contraindicated when: asthma,DM, broncial obstruciton, pulmonary, edema. AV block.
-loop diuretics: furasemide 80mg IV and if needed may increase dose to 160 mg.
-dihydropyridine group: nifidipine 5-10 mg PO
-ACE inhibitors: enalapril 5-10mg PO. Most safe drugs:loop diuretics +ACEI. Diagnosis:increase blood pressrue, check history of hypertension, symptoms: angina, dyspnoe
9. Write emergency management for a patient with complete heart block and Adam's-Stokes syndrome
Atropine ( cholinergic blocker) - atropine sulphate SC
-Contraindicated in a patient with A.M.I because the increase in oxygen demand of myocardium will increase necrosis.
Beta-agonists (Beta-adrenergic receptor stimulating)
Isodrine
Isprotenol
Call ambulance and have patient sent to the cardiology department or emergency room.
10.emergency management of acute left ventricular failure.
-provide O2 at speed 4ml/h by nasal cannula, together with antifonesilen because 100% O2 produce formation of froathy sputum and it reduces that
-diuretics IV 80mg furasemide,
-Vasodialators infusion( if BP is not so highnitroglycerin, if BP is high than nitroprusside sodium.
-morphine bdus2-5mg Iv and if it's needed repeat often 30min
11. Write emergency management for a patient with cardiac arrest
Call ambulance
Basic life support
Cardiopulmonary Resuscitation (CPR) - for restoration of airway and maintenance of breathing and circulation
If trained perform defibrillation to restore normal cardiac rhythm.
12.emergency management for syncope
-anticholinergics:0.5mg IV/IM/SC
-nutrient supplements: dextrose 1-2 ampules of 5%.IV
-benzodiazepines: Alprazolam 0.25-0.5 mg PO
Provide fresh air, position of patient should be with legs slightly elevated,or leamng forward and the head btwn the knees. Provide solution of ammonia(for patient to smell)
When symptoms passed sleep is recommended and after that differnetiated reatment of disease is needed.
13. Clinical manifestations and emergency management of cardiogenic shock
-Cardiogenic shock following acute MI generally develops after admission to the hospital, although a small number of patients are in shock at presentation. Patients demonstrate clinical evidence of hypoperfusion (low cardiac output), which is manifested by sinus tachycardia, low urine output, and cool extremities. Systemic hypotension, defined as systolic blood pressure below 90 mm Hg or a decrease in mean blood pressure by 30 mm Hg, ultimately develops and further propagates tissue hypoperfusion.
-Most patients who develop acute MI present with an abrupt onset of squeezing or heavy substernal chest pain; the pain may radiate to the left arm or the neck. The chest pain may be atypical, the location being epigastric or only in the neck or arm. The pain quality may be burning, sharp, or stabbing. The pain may be absent in persons with diabetes or in elderly individuals.
-Patients also may report associated autonomic symptoms, including nausea, vomiting, and sweating.Other associated symptoms are diaphoresis, exertional dyspnea, or dyspnea at rest. Presyncope or syncope, palpitations, generalized anxiety, and depression are other features indicative of poor cardiac function.
-Characteristics:
-Intracardiac pressures are elevated (pulmonary artery weged pressure more than 18mmHg)
-Cardiac output is depressed (index less than 2.0 liters/minute/m2
-Peripheral vascular resistance is increased
Mean arterial blood pressure is low less than 60 mmHg)
Emergency Management
Treatment of underlying disease
Hospitalized to cardiac department
Non-glucosides - Dopamine, Dobutamine Oxygen Therapy
Initial treatment is guided by hemodynamic monitoring; Vasopressors or inotropes, such as Dopamine or Dobutamine are recommended. Mechanical support with intra-aortic balloon counter-pulsation may be necessary. Patient presenting with cardiogenic shock should proceed directly to the catheterization lab, if available, for mechanical revascularization.
14write emergecy management for a patient with asthma attack
Emergency management of asthma attack includes: 1-relieve medications
Short-acting bronchodilators- salbutamol
Corticosteroids, such as prednisone or methyl prednisone PO or IV. O2therapy.
2-preventive medicaiton(according to severity
-anticholninergic agents
-corticosteroids (hydrocortisone, dexomethasone IV)
15. Diagnostic criteria of anaphylactic shock, prescribe epinephrine
Diagnostic Criteria:
-3 Main clinical signs must all be present:
Tachycardia - Heart rate greater than 90 bpm
Hypotension - systolic BP < 90 and or diastolic BP < 60)
Oliguria (20 -40 ml per hour)
-Another sign is cold extremities
-Unconciousness is sometimes present
-Known allergies to medications, bee stings, certain foods, iodine containing contrast antibiotics, Vitamin B
Rp: Sol. Epinephrine (or adrenalini
hydrochloride) 0.1% - 1.0ml
D.t.d: N2 in ampulla
S: use IV/SC/IM 1 ml diluted in 10 ml
Signiture
16.emergancy management of anaphylactic shock.
resuscitation, airway management, oxygen, IV fluids, close monitoring, administration of epinephrine, antihistamines, steroids epinephrine-500 (0,5 mL injection 1in 1000) IM, dose 300 for immediate self administration, repeat in 5min, if necessary IV using dilute solution
17. Diagnosis and emergency management in alcohol poisoning
Diagnosis
Symptoms
Confusion, stupor
Vomiting
Seizures
Slow breathing (less than eight breaths a minute)
Irregular breathing
Blue-tinged skin or pale skin
Low body temperature (hypothermia)
Unconsciousness ("passing out")
Patient sleeps for a long time without waking
Blood tests to check blood alcohol levels and identify other signs of alcohol toxicity, such as low blood sugar.
A urine test also may help to confirm a diagnosis of alcohol poisoning.
Emergency Management
If ingestion was recent (within 30 - 45 minutes), ipecac emesis or gastric lavage or activated charcoal may be attempted.
Protect and maintain adequate airway
Give thiamine 100 mg IV slowly over 5 min or IM
Maintain body temperature, treat coma and seizures
IV infusion dextrose 5% if hypoglycaemic
Correct acid-base balance
Perform haemodialysis if blood ethanol level above 500 mg / dL
Avoid depressant drugs
Antidote: slow IV naloxone 2-5 mg. Naloxone may antagonise the depressant effects following acute ethanol overdose..
18.emergency management of diabetic ketoaciosis prescribe insulin.
diabetic ketoacidosis IV 2L of isotonic NaCL for 2h, than 3000ml/h during 6h, IV insulin 0,1units/kg, than IV infusion 0,1units/kg every 4h, +potassium, bicarbonate, phosphate, magnesium
19. Possible causes of hyperosmolar coma, emergency management
CAUSES
Inadequate therapy
Intercurrent illness
Infection: sepsis, pneumonia, urinary tract infection, dental infection
Cardiovascular diseases: myocardial infarction, cerebrovascular accident, arterial thrombosis, pulmonary embolism
Other: pancreatitis, severe burns, renal failure, ACTH-producing tumors, Cushing's syndrome, thyrotoxicosis
Drugs: corticosterioids, glucagon, interferon, second generation antipsychotic agents, loop and thiazide diuretics, sympathomimetic agents (albuterol, terbutaline, dopamine, dobutamin), calcium channel blockers, diazoxide, phenytoin, propranolol, total parenteral nutrition, chemotherapeutic agents, cimetidine
Alcohol abuse, cocaine use
TREATMENT
IV 0.9% isotonic Saline then send to hospital
Start IV fluids: 0.9% NaCI - 1.0 L/hour
Insulin: 0.1 units/kg IV bolus → 0.1 units/kg/h IV infusion. Glucose should fall by 2.75-3.85 mmol/l (50-70 mg/dl) in first hour, if not - double insulin infusion hourly until glucose falls by 50-70 mg/dl/h
Check serum sodium: if normal or high → 0.45% NaCI 250-500 ml/h; if low → 0.9% NaCI 250-500 ml/h. When serum glucose reaches to 11- 13.75 mmol/l (200-250 mg/dl), change to 5% dextrose with 0.45% NaCl at 150-250 ml/h
When serum glucose reaches 16.5 mmol/l (300 mg/dl) → reduce regular insulin infusion to 0.05-0.1 units/kg/h IV. Keep serum glucose between 13.75 and 16.5 mmol/l (250 and 300 mg/dl) until plasma osmolarity is ≤ 315 mOsm/kg and patient is mentally alert.
Check serum potassium: if <3.3 mEq/l → hold insulin and give 20-30 mEq/h until K > 3.3 mEq/L; if 3.4-5.3 mEq/l → give 20-30 mEq in each liter of IV fluid to keep serum K+ at 4-5 mEq/L; if ≥ 5.3 mEq/l → do not give K+, but check K+ every 2 h.
20. clinical manifestation and emergency management of hypoglycemic coma.
hypoglycemic coma manifestations: hypothermia, tachypnea, tachycardia, hypertension, blurred vision, pupils fixed and dilated, icterus, parotid pain, cardiovascular disturbances, vomitting dyspepsia, dehydrated skin, neurologic symptoms: coma, confusion, fatigue, loss of coordination, stroke, tremors, convulsion if pattient consciius-glucos eorally 10-12g, sugar in water, in severe cases- glukagon 1mg IV, repeat in 10min 0,2g/kg
21. Emergency management of hypoglycemic coma, prescribe glucose IV
If hypoglycaemia causes unconsciousness, or patient is unco-operative
* 50 mL of glucose intravenous (IV) infusion 20% can be given.
* Alternatively, 25 mL of glucose intravenous infusion 50% may be given, but this higher concentration is viscous, making administration difficult; it is also more irritant.
Once the patient regains consciousness oral glucose should be administered as above.
If the patient is at home, or IV access cannot be rapidly established
* Glucagon 1 mg should be given by intramuscular (IM), or subcutaneous (SC) injection.4
* This dose is used in insulin-induced hypoglycaemia (by subcutaneous, intramuscular, or intravenous injection), in adults and child over 8 years (or body-weight over 25 kg). N.B. 1 unit of glucagon = 1 mg of glucagon.
Rp: Sol. Glucosi 40% - 10.0ml
D.t.d: N10 in ampulla
S: use IV 10ml. under the control of
Blood glucose level
Signiture
Rp: Sol. Glucosi 5% - 200.0ml
D.t.d: N2
S: use as IV infusion
Signiture
22.emergency management in mucosal bleeding caused by thrombocytopenia,
mucosal bleeding in thrombocytopenia glucocorticosteroids: prednisone 1-2mg/kg/d PO, IV immunoglobulins 1-2g/kg IV over1-5 days, platelet transfusion, sts splenectomy must be performed