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Emergency Medicine
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Donald J. Sefcik is the Associate Dean at the Chicago College of Osteopathic Medicine (CCOM), Midwestern University (N[WU), in Downers Grove, IL. He is a tenured professor and board certified in both Emergency Medicine and Family Medicine. From June 1997 through May 2000, Dr. Sefcik served as Medical Director for the Physician Assistant Program, Coliege of Health Sciences (CHS), at MWU. Dr. Sefcik's lectures are based upon his experiences as a clinician and preceptor, tenure as a medical school faculty member, and his student assessrnent research.
Dr. Sefcik has practiced with physician assistants since 1988 and been involved in the clinical training of physician assistants since 1990. Prior to joining Midwestem University's faculty, Dr. Sefcik was a faculty member in the Pharmacology Department at Butler University and in the Nursing Department at Marian College, both in Indianapolis, Indiana. Dr. Sefcik has a Bachelor of Science in Pharmacy (1981), a Master of Science in Pharmacology (1994), both from Butler University, ffid an MBA (May 2004) from Purdue University.
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Learning Objectives
Upon completion of flris portion of the review course, the participant should be able to:
2. Describe colnmon toxidromes and their management. 3. Differentiate the three common causes of primary headaches. 4. Discuss cofirmon secondary headaches. 5. Describe the evaluation/management of common ophthahnologic fraumatic injuries. 6. Discuss hyperkalemia - its presentation and management. 7. Discuss cerebrovascular accidents and traumatic brain injuries. 8. List and describe corrmon abnormal findings in urine specimens. 9. List and describe common physical examination "signs" and findings.
1.
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Overdose Sfafes
ldentifu the Druq
A, History
Who was there ? What did they find out ? Are there any bottles ? Abiliiy to 'quantity'the ingestion ? Pafient's medical history ?
'
B. Physical Data
1 Rate-----r ,Z-.1 gz SignsBiood Pressure / Toxidrome \ (-symptoms. Temperature / -1 \Heart Rate Respiratory * Level of consciousness, Pupil size, Breath..,.etc.
Toxidromes
Signs
VIChssic Toxidromes ,-+ AnTih"sIr rer,AGS q)9..d\.W \ LhS''- L Cholinergic Aqents nnticno[nerqic A
-.
S - Salivaiion
..Nff)
opiates
(-
L.
Lacrimaiion
Hyperemia (Red as a Beet) Dry Skin (Dry as a Bone) Dilated Pupils (Blind as a Bat) Delirium (Mad as a Hatter) Tachycardia
Iin;.t\ p.ry',r(
ftr'\.rxo^e-\
Flo'ir:;
sG'rr'r'u-u
?d^pt(
Nomoqrams
Acute, One-time lnqestions
*Acetarninophen - Rumack-Matthew
*
Aspirin -
Done
( b e".,e
ncr\v:.ig-^
Y1
\
)
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(G
CIIARACTERISTICS
Age of Onset
MIGRAINE
Childhood-< 3Oyo
TENSION
Eariy Adulthood
CLUSTER
20-40
LIt".u" Lln s)
F>M
Frequenelt
M>>F
Variable
30 min - weelcs Cyclic,
yo \ (,f .. t 1
l-4 /.month
(Muitipie/day) Duratiott
Description Site Time of Onsa Associated Featura
+-tzLrs
"Throbbiag"
Unilateral (65%) Variable (often AIv!
10-120 mi:r
"Vise-like'l
Biiateral
Later in day
t'Boring"
Peri-orbital Uniiateral
Bed time
AA{A/
(75o/o)
Anorexia
Muscle tendemess
Ipsilateral
AI,IS Dvsfxn
Multiple
Withdrawal from activify
Prescription Rx
Aicohol
Pace
Mild disability
MildAaalgesics
Agitated
02
Many Rxs
Abortive
Prophylactic
hsgrp"d','.\ h nl
s*-:t<;;Ae
rale,
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50%(+; with Altered LOC Average age = 50yq,..: . "Sentinel" Headache Hx in 30% 75% Neck Stifiness V.f e e-,),,n5 15% New-onset Seizures CT Scan Misses 10-20% (False Negative) If CT Scan is negative and suspicion is high, DO A LUMBAR PLINCTTIRE
- ,f s,3
Hemo6hagrt fup (False Positive) a i;t-) a;t $Rr-'! ,\ isl'\i.tr '' ltuf b. Cerebral Aagiography is the "GOLD" standard for diagnosis/aneurysm location RE FENNAL TO NE UROS URGE ON
a,
ii$e-
crscans$S+t,
MEI-.llNGtTlS HEADACHE
Usualiy involves entire head Often associated with feverivomiting Often associated with Nuchal signs
Kcrnig's Sign Brudzinski's sign
q HYPERTENSIVE HEADACHE
Usually a throbbing, occipital headache Most often a morning headache Usually does not occur until the diqslolic biood pressure ir Often overdianosed cause of headaches Treafinent- Antihypertensives
o:gi-]{mmHg'
\4.
L TEMPORAL ARTERITIS
Pa1*-*^g.r,.
Rh"o*.";!z^ Lfncrc\
Infiln'ation of Temporal Artery with lymphocytes, plasma cells and multinucleate giant cells Disease of patients over 50yo/ESR> 50 t Women with 4:1 predorninance \i LUI<a { c:hcui'} Unilaterai, jabbing pain/worse at night Artery tender/pulseless- Biopsy=Diagnosis '*?t'* 'r', \e154\ sui''i'h to prevent biindness ?,0 High dose
rry
pt7
i*Y
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Ophthalmologic Trauma
ORBIT & LID
a.
e' 1;'
Flydraulic forces tbroughout the globe; rupture of medial wall and floor, fapping faVmuscle and occasionally injuring nerve
)r
c. Treatrnent-
CORNEA A CONJUNCTWA
-1..
!!!
a.
Alkali Bums - Liquefaction Nemosis - Irrigate (sometimes 24 hrs+) Check pH with litnus paper -Refer/ConsultNOW !
b. Acid Burns
a.IJV radiation causes comeal epithelial sweliing; pain & bluned vision, hours afterthe
exposure
a^reas
,s
ut4\})
Jce r,vr k RiSn
g(i\6b Lorrta {*TfD,.Ly. bdY
r
b.
Findings
Multiple Punctate
on fluorescein
staining
b,
Trearnent
- Mydriatic - Systemic Analgesic - Follow-up
agent
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4. Corneal Abrasions
a. b.
c.
Treatnent
- Cycloplegic Agent
- Antibiotic topically - Follow-up in 24-48 hrs
. Sub conj
mctiv al Hemorchage
a. Bright Red blood overlying sciera b. Be sure no bleeding diathesis exists c. Blood Stops at limbus
l.
Traumatic Hyphema
a. Blood in anterior charrber due to ciliary body or iris vessel disruption b. Best seen with patient sitting upright with slit lamp
c. Must R/O other iqiuries d. Findings - MaY be ary':nPtomatic - PainlPhotophobia.tslured Vision - May cause N & V e. Consult OphthaLnologist - Place a FOX Eye shield - Keep patient quiet @ 30-45 degree angle Risk of secondary glaucoma
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^ ^ F{I?ERLATEMLA q R
t"rl
/o
L.,\rrnue\\u;\er
1. Definition
2. Pathophysiology
Hod\4/hy
does
it happen
-Xedun'ibution t 'T uf)ll .r \r'so"o*htq\rb'^ Kt Y. 1, Hemolysis; lnsulin deirciency; Exercise . C'-t Acidosis: .KAJ 6r C G], \ 2. Decreased Excrerion b, Endogenous
Kr Lh.,ire kt" \
Hemolysis (of
Sims/Symptoms
sp
Cardiac
Peaked T-waves
^jU-*.-.-llh-t
Neuromusc-
Paresthesias
Weakness
Fiaccidity
^ni\**
/JWII.
3. Differential Diagnosis -
Sodi'hpolystlrene
s{Y:}G\GXALATE)
orally or rectaiiy
More sevet'e cases (Cardiac arrhythnzias, etc) may require: Dextrose & Insulin fV - temporizing measure/shifts potassium intracellular S o dium B i carb onate - temp orizin g measure/shifts potas sium intraceilular Calcium Giuconate - cardioprotective/potassium antagonist c, Other
*\u_le"ut "{X s.
Hemodialysis
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A.
B. Risk Factors
Uncontrollable
a. b.
Advancing {ge - 2/3 occur in patients > 65 yo feach decade after 55 yo doubles the risk......] Gender:Verr t Women Diabetes mellitus:
Controllable
a.
b,
Hypertension:
- 4-
A contributing factor in up to 70
of all CVAs
,c, Transient
d.
Cigarette smoking:
e.
Males:
Prior CVA
Females:
42 o/o risk of a second CVA within 5 years 24 % risk of a second CVA within S years
f,
STROKE SYNDROMES
lschemic Attack (TlA) + - transient neurologic deficii, ihat by definition, lasts less than 24 hours rF 't - - 90 % last less than 60 minutes (many < 15 minutes) - Amaurosis fugax - transient, partial or complete monocular blindness - Rule of 1/3s r' 1/3 will have a CVA in \f l4l ,,r.,.1*",.trJ ./ 1/3 will have a second the future TIA ,/ 1/3 will have no sequelae \r rD^ lz.i fr. ir,l{ B, Lacunar lnfarct (Deep Subcortical/"Whiie Matter" Area Changes; - Contralateral PURE Motor Deficit (lnternal capsule) lj'T N) pt - Contralateral PURE Sensory Deficii (Thalamus) - Clumsy Hand - Dysarthria (Pons or lnternal capsule)
- Nofes
A. Transient
-LC
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Onset/Progressiou
50% comatose at
Active at onset
Rapicl onset
presentation)
Etiology
Aneurysm (berry)
Itisk(s)
furatomic Locatiott
History
Severe Cephalgia
Severe Cephalgia
Usually no Cephalgia
Physical Exanr
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Arteny'Site of Involvernent
lnternal Carotid Artery
Vertebrobasilar Artely
Diplopia (PPRF or CN ltr, fV, VD Watch for CN dysftrnction Ataxia / Vertigo (cerebellar signs) Bilateral Motor/Sensory Changes
Purc Motor (basilar pons or internal capsule) conlralateral to lesion Pure Sensory (thalalnus) contralateral to lesion Clurnsy I-Iand-Dysaltlu ia
Lacunar CVA
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A. lncidence
a. - 2 million Americans with Head Trauma annually b, - 500,000 are admitted to the hospital c, - 100,000 deaths per year (- 60 % occur before arrivalto the ED) d, Aicohol consumpiion is involved in - 25 - 50 % of cases B. Classificaiions (arrival to ED) a. Mild Head lniury EYE Ooeninq 4
3 2
1
.ay
n
erra$1^*J ^. .. h{'-1 -( ' d9. n v-.<v"' b, Moderate Head lniurv ecs=9-13 d'n*>Z
oof' \
-ze%die
c. Severe head lniury
GCS=14-15
80 % of rniuries
VERBAL Response
5
-1o%oflnjuries
4
3
2
1
-40%die
- 10 % of lnjuries
GCS=Eorless
MOTOR Response
6
4
5
I
1
Follows commands Localizes pain Withdrawals from oain Decorticate posturinq Decerebrate posturinq No response
,R
Primary Injury
NeuralTissue ^/ lniuru
Contusion Laceration Difiuse Axonal lnjury
\.|
Cerebral
V ascul ar
I
niury
Secondary lnjury
Hypotension Hypoxemia Hypovolemia lncreased lntracranial Pressure
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cLosED "
{-Eng-aryAl
rec Lesions
#hcrL,'.a'h
-l
,/ - 1 % of all traumatic brain injuries (- 12 % die) ./ - 80 - 90 % associated wiih a skull fracture (often tears a meningeal artery) \/ Only - 20 % have classic: lnjury - LOC - Lucid lnterval - Deterioration
Up to 60 % have no loss of consciousness Underlying brain injury is generally not severe 60 % occur in patients < 20 yo < 10 % occur in patients > 50 yo
'/ ./ r'
'v\.{a.
Subdural Hematorna - 35 % of severe traumatic brain injuries Most occur in patients > 60 yo * Atrophic brains (elderly and alcoholics) are at greatest risk
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. t . ^. i,",*.r
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yd
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-
'- J
i '/
mechanisms Underlying brain injury is generally more severe * Simple (no associated parenchymal injury - - 20 % die) * Complicated (associated brain injury - - 50 % die)
Hffiliil3.tffii$;,ti:1?H,ltiJlla...r.,"tion
(:f1s(,^f/
b. lntra-axial Lesions - Cerebral Coniusions & Lacerations * Concussions
4t
Cn^
it:ru'cr{t,t\
cYc [c'-
- Herniation Syndromes
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t,'
.-
f ro.'lrrt
A, Salvage brain tissue not already irreversibly injured B. ldeniifyicorrect eniiiies that may cause secondary injury
tqtut ' t
/-'"'''
'
LFr"rl'+tt
lnjury
GCS<9
lntubate (ETT) Hyperventilate lVs Monitors Resuscitate Sedation/Paralysis Secondary Survey (Life Threats....,)
GCS>9
lVs Monitors Frequent Serial Examinations (NEURO) Secondary Survey Monitor for ETTiHyperventilaiion need
,/ /
CT Scan
,/
4--""'
Neurosureeon
----a
Operative Lesion
Epidural Hematoma Subdural hematoma lntracranial Hemorrhage with shift Depressed Skull Fracture
Non-Operative Lesion
Non-Depressed Skull Fracture Contusion Subarachnoid Hemorrhage
Causes
A. Causes
Motor Vehicle Accidents (MVA) - 45 o/o (cause - 60 % of deaths) Falls - 15 % (cause - 12 0/o of deaths) Assaulis - 14 o/o (Firearms - 14 o/o of deaths - approximately 75 o/o occur at the scene) OccupationalAccidents 10 % RecreationalAccidents 10 %
B.
Prevention
c. Firearm Legislation
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Considerations at Presentation:
a. Low-risk lniuries
- Not likely to deteriorate - Normal neurologic examination * Asymptomatic; Subjective complaints: Headache, Dizzy... .,. - Minor injury: * Scalp wound Hematoma, Abrasion, Laceration....
*"* Approximately 0,3
3 % will deteriorate
- Difficult group to ass.ign a prognosis - Neurologic Signs & Symptoms of unclear significance " Brief LOC; Vomiting; Post-traumatic amnesia.....
* Progressive headache; Child age < 2 yo..
- lnjury (?):
" Arduous Assessment to make (Work-up ???) *** Approximately 40 % will have an abnormal CT scan
** Approximately I
- Neurolog ic Assessment dem onstrates si gnificant findings * Depressed LOC (not explained by drugs, EIOH...) * Focal Neurologic signs
References
Manual of Neurology; McGraw-Hill 2002 (0-07-137351-9) Handbook of Neurosurgery; Thieme New York; 2001 (0-865Z7-909-0) Emergency Medicine Reporls December 3, 2001: Head Trauma: Emergency Management and lmaging December 17,20Q1: Head Trauma: Severe, Moderate and Minor Head Trauma May 11, Traumatic Brain lnjury: State-of-the-Art Proiocols
1998: