General Medical Emergencies: Part I

General Medical Emergencies: Part I

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

Major Topics Skin Infestations
Lice Scabies Myiasis

Major Topics Endocrine Emergencies
Adrenal Crisis Diabetic Ketoacidosis Hyperglycemic Hyperosmolar Nonketotic Coma Hyperglycemia Myxedema Coma Thyroid Storm

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

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

HIV Infection and AIDS Mean between exposure to HIV to AIDS-10 years
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

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

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

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

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

HIV infection and AIDS 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 Diagnostic procedures CXR CBC ABG’s
Anemia Lymphopenia Thrombocytopenia ABG’s Electrolytes, liver function tests

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)

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

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

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

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

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

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)

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

Encephalitis 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 Assessment Subjective Medical history Immune disorders
Allergies Medications

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

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

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

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

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

Hepatitis Hep B surface
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

Hepatitis Hep B-(HBV) blood and sexual contact 3 antigens
Hep B antigens 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

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

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

Hepatitis History of present illness
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

Hepatitis History of Illness cont’d
Rash, with type B usually May or may not progress to icteric phase Incubation: A days B days C days Duration: A 4 weeks; B AND C weeks

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

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

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

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

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

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

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

Hepatitis Report to appropriate health departments
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

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

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

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

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

Herpes Assessment Subjective data History of present illness
Symptoms depend on organ system affected Neurological system: headache, confusion, seizures, coma, olfactory hallucinations Liver: ABD pain, vomiting Lung: cough, fever Esophagus: dysphagia, substantial pain, weight loss

Herpes Medical history HSV infection Chronic illness, cancer, HIV
Medications: immunosuppressants Allergies

Herpes Objective data Physical exam Fever
Other vital sign abnormalities depend on organ system involved Focal neurological signs Anosmia (loss of smell) Aphasia Temporal lobe seizures Confusion, somnolence, coma Respiratory crackles

Herpes Diagnostic Procedures Viral cultures: blood and skin
Lumbar puncture: cerebrospinal fluid for culture Biopsy of target organ, especially brain Clotting studies for DIC Liver Function CBC

Herpes Prepare to assist intubation O2 PRN
Interventions Prepare to assist intubation O2 PRN Monitor VS with PO Neurological status Maintain airway, breathing, circulation I&O Administer Antiviral meds FC PRN Establish IV of isotonic solution at rate to maintain blood pressure and fluid balance Protect from injury from seizures Explain procedures and illness to patient or significant others Practice standard precautions

Measles Highly acute and contagious virus
Caused by rubeola virus, late winter and early spring Airborne droplets, incubation days Contagious few days before and after onset of rash Most recover, incidence of OM, diarrhea, pneumonia, and encephalitis

Measles More serious in infants and in malnourished children, pregnancy with preterm delivery and spontaneous abortion Most born <1957 are permanently immune Vaccine (MMR) months, active disease or two immunizations in childhood Booster elementary school, all high school or college revaccinated unless active disease or two immunizations

Measles Exposure to measles Prodrome Fever Cough
Assessment Subjective data History of present illness Exposure to measles Prodrome Fever Cough Coryza (nasal mucosal inflammation) Photophobia Anorexia Headache Rarely seizures

Measles Subjective Medical history Immunizations History of measles
Current age: born before 1957 Allergies Medications

Measles Objective data Physical exam Fever
Koplik’s spots on buccal mucosa (bluish-gray specks on red base) Conjunctivitis Harsh cough

Measles Red, blotchy rash Vital signs: normal, except fever
Appears on third to seventh day Maculopapular, then becomes confluent as progresses Starts on face, then generalized to the extremities Mild desquamation Lasts 4-7 days Vital signs: normal, except fever Neurological system: may have altered LOC, encephalitis Respiratory system: may have OM, pneumonia

Measles Diagnostic procedures
Viral cultures (expensive and difficult, so not usually done) Immunoglobulin M antibodies: measles specific CBC: leukopenia Other studies if seriously ill

Measles Interventions Provide respiratory isolation
Isolate patient/significant others from other people in waiting room Advise patient to avoid school, day care centers, and people outside immediate family until after contagious period Initiate immunization of high-risk contacts Live vaccine if given within 72 hours of exposure (use monovalent vaccine if infants younger than 12 months; need reimmunization at 15 months with MMR) Immune globulin up to 6 days after exposure Immunocompromised persons should receive immune globulin even if previously immunized

Measles Persistent fever or cough Change in mental status or seizures
Encourage rest in darkened room Administer acetaminophen for fever Encourage parents to have children immunized at appropriate times Instruct patient/parent about S&S of serious illness or complications Persistent fever or cough Change in mental status or seizures Difficulty in hearing

Meningitis Bacterial or viral of the pia and arachnoid meniges
Late winter or early spring Viral mild and short lived Bacterial severe and life threatening Streptococcus pneumoniae, Haemophilus influenzae (H. flu), and Neisseria meningitidis subgroups A, B, and C H. Flu incidence decreased because of vaccination Bacteria can enter the blood, basilar skull fracture, infected facial structures, and brain abscesses

Meningitis Bacteria initially colonize in the nasopharynx
In bacterial disease, the subarachnoid space is filled with pus, which obstruct CSF, resulting in hydocephalus and increased ICP Infants and elderly often do not exhibit classic signs of meningeal irritation and fever Death most common within a few hours after diagnosis Up to 33% of pediatric survivors left with some type of permanent neurological dysfunction Any infant younger that 2 months with a fever, must be evaluated for meningitis

Meningitis Assessment Subjective data History of present illness
Antecedent illness or exposure Onset: sudden Headache, especially occipital Fever and chills Anorexia or poor feeding Vomiting and diarrhea Malaise, weakness Neck and back pain Restlessness, lethargy, altered mental status Disinclination to be held: infants Seizures Recent basilar skull fracture

Meningitis Medical history Medications Allergies
Immunizations if child Chronic disease: liver or renal, DM, multiple myeloma, alcoholism, malnutrition Asplenic Recurrent sinusitis, pneumonia, OM, mastoiditis

Meningitis Objective data Physical examination
High-pitched cry in infants Hyperthermia >101 or hypothermia <96 Petechiae that do not blanch: 1-2 mm on trunk and lower portion of body, also mouth, palpebral and ocular conjunctiva Purpura Cyanosis, mottled skin, and pallor

Meningitis Vital signs Tachycardia, hypotension, tachypnea
Objective data Physical examination Vital signs Tachycardia, hypotension, tachypnea Bradycardia in neonates Meningeal irritation: persons older than 12 months, seen in about 50% Contraction and pain of hamstring muscles occur after flexion and extension of leg: Kernig’s sign Bending of neck produces flexion of knee and hip; passive flexion of lower limb on one side produces similar movement on other side: Brudzinski’s sign Nuccal rigidity

Meningitis Confusion, delirium, decreased LOC
Infants with meningeal irritation cry when held and are more quiet when left in crib Photophobia Focal neurological signs, cranial nerve palsies, and generalized hyperreflexia Altered mental status Confusion, delirium, decreased LOC Lethargy and confusion may be only signs in elderly Bulging fontanelle Irritability

Meningitis Diagnostic procedures
Blood glucose levels: infants younger than 6 months are prone to hypoglycemia Electrolyte levels: hyponatremia BUN and creatinine levels Serum osmolality Low because of inappropriate vasopressin secretion High because of dehydration

Meningitis Diagnostic procedures CBC Blood cultures
Bacterial: high WBC Viral: normal or low WBC Meningococcal: WBC tends to be less that 10,000 Blood cultures ABG’s if severely ill Clotting studies UA CXR and skull radiographs

Meningitis Lumbar puncture: CSF Bacterial infection: cloudy appearance; elevated pressure; WBC ,000 with increased polymorphonuclear cells; glucose level decreased; protein level elevated; bacteria present on Gram’s stain Viral infection: clear appearance; WBC <500; normal pressure; glucose level normal; no bacteria present on Gram’s stain

Meningitis Interventions
Ensure that health care providers wear masks if infection with meningococcus is suspected Undress patient completely to check for petechiae O2 PRN Monitor VS Prepare to suction and assist with aggressive ventilatory support as needed Prepare to assist with LP Insert NG to prevent aspiration

Meningitis Establish IV catheter, IO in necessary
Monitor IV fluids as related to I&O or excessive secretion of antidiuretic hormone KCL replacement PRN, antiemtics PRN Infuse antibiotics (usually ampicillin, aminoglycosides, cephalosporins) Administer benzodiazepines, corticosteroids Control fever Reduce ICP Use hyperventilation with caution to avoid cerebral ischemia Elevate HOB 30 degrees Administer barbiturates and diuretics

Meningitis Insert FC, monitor I&O
Monitor for signs of dehydration or fluid excess Monitor mental status and neurological signs every 15 minutes to 1 hour, depending on patient’s stability May need to restrain confuse patient Protect seizing patient form physical harm Explain procedures and need for ICU

Meningitis Administer chemprophylaxis(rifampin, ceftriaxone) within 24 hours of disease identification to household contacts, day care center contacts, and health care providers if bacterial disease Side effects GI, lethargy, ataxia, chills, fever, and red-orange urine, feces, sputum, tears, and sweat Soft contact lenses may be permanently stained with rifampin use Medication may need to be taken with food for GI intolerance, although it is best absorbed on empty stomach Birth control pills may not work Do not give to pregnant women

Meningitis Educate parents to have infants immunized against H. Flu B beginning at 2 months

Mononucleosis Acute viral illness with broad range of S&S lasting 2-3 weeks, very contagious EBV transmitted in saliva About 50% of the population serovonverts to EBV before 5 years of age with sublclinical infection or mild illness Another wave of seroconversion in med adolescence Peak years Incubation 2-5 weeks CMV is the other most frequent causative agent Complications include: glomerulonephritis, autoimmune hemolytic anemia, pericarditis, hepatitis, guillain-Barre syndrome, meningitis, and pneumonia

Mononucleosis Rarely death may occur from splenic rupture or airway obstruction as a result of tonsillar hypertrophy Assessment Subjective data History of present illness Prodrome lasting 3-5 days: malaise, anorexia, nausea and vomiting, chills/diaphoresis, distaste for cigarettes, headache, myalgias

Mononucleosis History of present illness Medical history
Subsequent development of fever to 104 lasting days, sore throat,diarrhea, earache Medical history Exposure to mononucleosis, usually not known Allergies Medications

Mononucleosis Objective data Physical examination
May appear acutely ill Red throat with exudate; tonsils may be hypertrophied Tender lymphadenopathy, particularly posterior cervical Petechiae on palate Fine red macular rash 5% of adults: if given ampicillin, % of patients will experience rash Abdominal tenderness with heptomegaly Splenomegaly in 50% of patients

Mononucleosis Diagnostic procedures
Heterophile antibody titer (Monospot): positive by second week of illness; may remain negative in children younger than 5 years Throat culture to rule out group A streptococcus CBC: neutropenia, thrombocytopenia, lymphocytosis with atypical lymphs, leukocytosis Liver functions: may be abnormal CXR if pneumonia suspected

Mononucleosis Interventions Isolation not necessary
Avoid kissing No sharing eating or drinking utensils Activity as tolerated Extra rest early in illness Avoid heavy lifting and contact sports for at least 4 weeks if splenomegaly present

Mononucleosis Interventions
Administer antipyretics, analgesics (Avoid ASA) Administer corticosteroids therapy for severe Pharyngitis, evolving airway obstruction, chronic or disabling symptoms, or profound splenomegaly

Mononucleosis Warm salt water gargles for sore throat
Encourage fluids to avoid dehydration Diet as tolerated Liquids initially Soft foods Do not donate blood for 6 months

Mononucleosis Instruct patient about S&S of serious illness or complications Increased fever Cough, chest pain Progression of innless Difficulty breathing Signs of dehydration Increasing abdominal pain

Mumps Acute, usually benign, viral infection caused by Paramyxoviridae family Swelling and tenderness of salivary glands and one or both parotid glands Direct contact, droplet nuclei, or fomites Incubation averages days Peak incidence is January to May Most contagious just before swelling More severe illness in the post pubertal age group; 20-30% of adult men experience epididymoorchitis Complications include viral meningitis, arthritis, arthralgias, and pancreatitis

Mumps Exposure to mumps
Assessment Subjective data History of present illness Exposure to mumps Prodrome: fever (<104), anorexia, malaise, headache Earache and tenderness of ipsilateral parotid gland Citrus fruits or juices increase pain Fever, chills, headache, vomiting if meningitis Testicular pain if orchitis Abdominal pain if pancreatitis

Mumps Subjective cont’d Medical history Childhood immunizations
Previous mumps Allergies Medications

Mumps Objective data Physical examination
Swelling of gland, maximal over 2-3 days, with earlobe lifted up and out and mandible obscured by swelling Trismus with difficulty in pronunciation and chewing Testicle warm, swollen, tender Scrotal redness

Mumps Diagnostic procedures
CBC: WBC and differential normal or mild leukopenia Serum amylase elevated for 2-3 weeks

Mumps Interventions Provide respiratory isolation
Advise to avoid school/work until swelling gone Administer analgesics Encourage rest until feeling better Encourage fluids, avoid citrus Warm or cold packs For orchitis Bed rest Scrotal elevation Ice packs Pain meds

Mumps Administer IV fluids for acutely ill patients
Recommend immunization to family and health workers who have no mumps antibodies

Pertussis Acute, widespread, highly contagious bacterial disease of the throat and bronchi Gram-negative Coccobacillus Bordetella Pertussis Airborne droplets Most common children <4 years Females higher incidence of morbidity and mortality Partially immunized children have less severe illness Adults have only minor respiratory symptoms and persistent cough, majority unrecognized

Pertussis Vaccine immunity is <12 years, most adults are not protected Incubation period 7-10 days but can vary 6-21 Peak incidence is during late summer and early fall Pertussis bacteria invade the mucosa of URT Complications include: pneumonia, pneumothorax, seizures, and encephalitis Children also frequently experience laceration of the lingual fremulum and epistaxis

Pertussis Exposure to pertussis Three stages: last up to 2 weeks
Assessment Subjective data History of present illness Exposure to pertussis Three stages: last up to 2 weeks Conjuctivitis and tearing Fever/chills Rhinorrhea, sneezing Irritability Fatigue Dry nonproductive cough, often worse at night

Pertussis Paroxysmal: lasts 2-4 weeks Convalescent: residual cough
Severe cough with hypoxia, unremitting paroxysms, and clear, tenacious mucous; patient appears well between paroxysims of coughing; cough often triggered by eating and drinking Apnea can occur in rate cases Vomiting follows cough Anorexia Convalescent: residual cough

Pertussis Medical history Recent illness or infection Medications
Allergies Immunization status

Pertussis Objective data Physical exam
Paroxysmal explosive coughing ending in prolonged high-pitched crowing inspiration Coryza Clear, tenacious mucous in large amounts Temperature >101 Restlessness Crepitus from subcutaneous emphysema Periobital/eyelid edema

Pertussis Diagnostic procedures
C&S testing of nasopharynx using calcium alginate dacron-tip swab Immunofluorescent antibody staining of nasopharyngeal specimens CBC with differential leukocyte count: lymphocytosis

Pertussis Interventions Maintain respiratory isolation
Monitor vital signs and respiratory status Be prepared to assist with intubation O2 PRN Isolate patients with active disease from school or work until they have taken antibiotics for 14 days Monitor for signs of dehydration or nutritional deficiency secondary to vomiting

Pertussis Administer prescribed medication Position comfortably
Antibiotic: EES Antitussive Analgesic Antipyretic Position comfortably

Pertussis Admit patients younger than 1 year: prepare for nasotracheal suctioning Initiate immunization Educate parents about importance of complete immunization Household and other contacts <1year: prophylactic EED Household and close contacts ages 1-7 years who had less than four DTP vaccine doses or more that 3 years since: EES for 14 days DTP immunization

Pertussis Review S&S that necessitate return to ER
Difficulty in breathing recurs or worsens Blue color of lips or skin Restlessness or sleeplessness develops Medicines are not tolerated Fluid intake decreases

Shingles (herpes zoster)
Acute localized infection cause by varicella-zoster virus (VZV) During chickenpox, VZV travels from skin lesions to sensory nerve ganglia sets up latent infection Postulated that when immunity to VZV wanes, the virus replicates VZV moves down nerves, causing dermatomal pain and skin lesions Lasts up to 3 weeks Exact triggers unknown, old age and immunosuppression are risk factors

Shingles 20% of population 4% second exposure
Fluid from lesion is contagious, but likelihood of transmission is low Susceptible exposed persons may develop varicella (chickenpox) Complications: post herpetic neuralgia, debilitation pain syndrome lasts several months, blindness, disseminated disease, and occasionally death

Shingles Assessment Subjective data History of present illness
Pain, itching, tingling, burning of involved dermatome precede rash by 3 to 5 days Rarely headache, malaise, fever Medical history History of chickenpox, HIV infection, cancer, chronic steroid use Allergies Medications

Shingles Objective data Physical examination
Tenderness over involved dermatome Rash Unilateral; does not cross midline Usually thoracic or lumbar dermatome Small fluid-filled vesicle on red base May become hemorrhagic New lesions occur for about 1 week

Shingles Diagnostic procedures Fever (low grade if present)
Visual acuity, if eye involved Diagnostic procedures Viral culture Other studies if seriously ill

Shingles Interventions Provide contact isolation
Advise patient to avoid school/work until all lesions are crusted over Recommend immunizations of high-risk contacts Varicella-zoster immune globulin (VZIG)

Shingles Administer medications as prescribed Analgesics
Antihistamines Antivirals (acyclovir, famciclovir) will lessen disease severity and incidence of post herpetic neuralgia if administered within 72 hours of onset of rash

Shingles To prevent infection of lesions, cut fingernails short
Topical baking soda paste or baths and calamine lotion may help Ophthalmological consult if facial/eye involvement Instruct patient about S&S of serious illness or complications Increased fever Cough Becoming more ill Signs of skin infection

Skin infestations: Lice
Three types of lice infest humans: Pediculus humanus var corporis (human louse) 2-4mm, grayish-white, flattened, wingless, and elongated with pointed heads Overcrowding and poor sanitation

Skin infestations: Lice
Three types of lice infest humans: P. humanus var capitis (human head louse) Wider and shorter, resemble a crab Eggs (nits) laid by female Affects all socioeconomic groups Phthirus pubis (pubic or crab louse) Sexually or close body contact Can be seen eyebrows, eyelashes, axillary hair, and back and chests 33% with lice have 2nd STD

Lice Can cause significant cutaneous disease
Lice serve as vectors for typhus, relapsing fever, and trench fever

Lice Assessment Subjective data History of present illness
Itching infected areas Fever, malaise in severe infection Exposure to lice Recent sharing of clothing, beds, combs/brushes Concurrent STD’s

Lice Medical history Previous infestations Allergies Medications
Objective data

Lice Physical exam Excoriation of scalp
Secondary bacterial infection, especially of scalp Weeping and crusting of skin Lymphadenopathy Small, red macules, papules on trunk Small,gray to bluish macules measuring <1cm on trunk(maculae ceruleae) from anticoagulant injected into skin by biting louse Nits on hairs Thick, dry skin, brownish pigmentation on neck, shoulder, back form chronic infection Signs of concurrent STD’s

Lice Interventions Contact isolation
Advise patient/parent to avoid school/work until one treatment completed Administer analgesics, antihistamines, antibiotics

Lice Interventions Use pediculicides Treat sexual contacts
Pyrethrin liquid Permethrin crème Treat sexual contacts Administer medications for STD’s Instruct patient/parent that itching may continue after treatment: do not re-treat without physician order

Lice Instruct patient/parent to Remove nits
Soak hair with equal parts warm vinegar and water If eyelashes or eyebrows, apply layer of petroleum jelly Soak combs and brushes in pediculicide for 1 hour Launder clothing/bedding in hot water; dry in hot drier if possible, discard clothing and linen if practical

Lice Instruct patient/parent to Iron seams of clothing
Put socks over hands of small children at bedtime Cut fingernails short Put hats, coats, other non-launderable item away for at lest 72 hours Avoid hat sharing, combs, brushes

Skin infestations: Scabies
Highly contagious by the itch mite Sarcoptes scabiei var hominis Eggs are laid in burrows several millimeter in length Not a vector for other infections Transmitted by intimate personal or sexual contact; or by casual contact Always consider when patient complains of rash with intense itching

Scabies Assessment Subjective data History of current illness
Intense itching, worse at night Rash Previous treatment for current problem Exposure to scabies Medical history Previous infestations Allergies medications

Scabies Objective data Physical exam Rash
Red papules, excoriations, and occasionally vesicles More common in interdigit web spaces, wrists, anterior axillary folds, periumbilical skin, pelvic girdle, penis, ankles For infants and small children, soles, palms, face, neck, and scalp are often involved Patient scratching Signs of infection of lesions

Scabies Interventions Contact isolation
Advise patient/parent to avoid school/work until one treatment completed Administer analgesics, antihistamines, antibiotics Use pediculicides Pyrethrin liquid Permethrin crème

Scabies Instruct patient/parent
Instruct patient/parent that itching may continue after treatment: do not re-treat without physician order Launder clothing/bedding in hot water; dry in hot drier if possible, discard clothing and linen if practical Put socks over hands of small children at bedtime Cut fingernails short Put hats, coats, other non-launderable item away for at least 72 hours

Skin infestations: myiasis
Invasion of living, necrotic, or dead tissue by fly larvae (maggots) Do not carry infectious agents, but can cause significant disease of the tissues

Skin infestations: myiasis
Ability to care for self Substance abuse Previous myiasis Medications Allergies Assessment Subjective data History of present illness Skin lesions or wound Social History Living conditions

Myiasis Physical examination Skin wound or lesion Boil-like lesion
Objective data Physical examination Skin wound or lesion Boil-like lesion “creeping eruption” of open wounds Poor hygiene: may see maggots in skin folds or on intact skin surface

Myiasis Interventions Contact isolation
Advise patient/parent to avoid school/work until treatment completed Administer analgesics and antibiotics Prepare to assist with surgical debridement

Myiasis Interventions Apply petroleum jelly to cutaneous boils
Instruct patient about prevention Eradicate flies Keep open wounds properly dressed Stay indoors, away from fly-infested areas Referrals to Social Services or Substance Abuse if needed

Tuberculosis Mycobacterium tuberculosis, acid-fast bacillus (AFB)
Not highly contagious, requires close, frequent exposure for transmission Droplet nuclei, which can remain in still air for days Susceptibility of host usually determines whether infection occurs TB occurs when symptoms occur and is infectious 2-10 weeks after infection, develop immunological response, allows healing and +PPD

Tuberculosis Greatest risk of disease in the first 2 years after infection Lung primary site 15% Extrapulmonary Kidney, Lymphatic, Pleura, Bones, Joints, and blood (disseminated or miliary) Diagnosed by one of two criteria: Culture of bacteria + PPD or S&S of TB, unsteady CXR Noncompliance of medication regimen

Tuberculosis Assessment Subjective data History of present illness
Exposure to TB Productive prolonged cough Longer than 2 weeks Becoming progressively worse

Tuberculosis History of present illness Fever and chills, night sweats
Easy fatigability and malaise Anorexia, weight loss Hemoptysis Recent +TB skin test Foreign born or travel to high-prevalence country: Vietnam, Philippines, Mexico, Haiti, China, Korea

Tuberculosis History of present illness
Resident or staff of nursing home, prison, or homeless shelter Alcoholic or other substance abuser Racial/ethnic minority: African-American, Hispanic, Alaska native, American Indian

Tuberculosis Medical History DM Malignancy CRF Immunosuppression
HIV and AIDS Medications, especially prolonged steroid therapy Allergies

Tuberculosis Objective data Physical exam Healthy or ill appearance
Chest: decreased breath sounds Fever Signs of underlying disease

Tuberculosis Diagnostic Procedures
PPD: induration 5mm or > +if HIV, 10mm + all others CXR: infiltrate, especially of upper lobes Sputum for AFB: 3 successive early-morning LFT: obtain before starting INH

Tuberculosis Interventions Decrease transmission of disease
Isolate coughing patient, preferably in negative pressure Teach to cover nose and mouth Educate to dispose of tissue and wash hands Isolate at home first 2 weeks of therapy; considered infectious until 14 days of directly observed therapy Decrease cough and afebrile Three consecutive negative AFB smears

Tuberculosis Surgical masks are helpful for patient; not effective for health care staff or family Ventilate living quarters with fresh air: 20 times every day Unnecessary to dispose of clothes, to wear caps, gowns, gloves Encourage patient/significant other for reading of TB skin test, compliance with medication regimen Reportable disease

Tuberculosis Administer and educate about meds
All patients with active disease should have directly observed therapy Preventive therapy for 6 months HIV with PPD +5> :treat 12 months Household members and close contacts of newly diagnosed patient Recent TB converter IV drug users known to be HIV- with PPD induration of 10mm>

Tuberculosis Encourage HIV testing Provide Social Service in needed
Medications: preventative and therapeutic 4-drug regimen Isoniazid Pyridoxine: Rifampin: Pyrazinamide Ethambutol Encourage HIV testing Provide Social Service in needed

Varicella (chickenpox)
Highly contagious caused by VZV Direct contact, droplet, or aerosol from skin lesion fluid Incubation days Contagious period start 1-2 days before rash and ends when all lesions are crusted 90% cases children <3

Varicella (chickenpox)
Adolescents, adults, and immunocompromised at risk for severe disease <5% of cases >20 years, but 55% of deaths Complications Bacterial infection, pneumonia, DIC, renal failure, and encephalitis 31% mortality to neonates born to infected mothers

Chickenpox- Assessment
Subjective data History of present illness Exposure to chickenpox Prodrome: 48 hours before rash: fever, malaise, headache, rash often with itching Medical history Immunizations Pregnant or trying to become pregnant HIV, cancer, or other immunocompromised state Allergies Medications

Chickenpox Objective data Physical exam
Rash, typically lesions Starts on trunk as faint, red macules Becomes teardrop vesicles on a red base, which dry and crust over New crops appear over several days Palms and soles are spared Vesicles may occur in mucous membranes, rupture, and become shallow ulcers

Chickenpox Objective data Fever, low grade
Skin excoriations form scratching Signs of lesion infection: red, swollen, tender Altered mental status Dehydration Cough

Chickenpox Diagnostic procedures Generally none

Chickenpox Interventions Provided respiratory and contact isolation
Isolate patient/significant others from waiting room Advise to avoid school/work until all lesions are crusted

Chickenpox Interventions Recommend immunization of high-risk contacts
VZIG Post exposure prophylaxis Immunocompromised (HIV, AIDS, cancer, steroid therapy) Effective up to 96 hours after exposure Susceptible health care workers should be vaccinated

Chickenpox Acetaminophen Never use ASA (risk of Reye’s syndrome)
Administer medications Acetaminophen Never use ASA (risk of Reye’s syndrome) Antihistamines Antivirals to older children will lesson the severity To prevent infection of lesions Suggest putting socks over small children’s hands at bedtime to decrease scratching and excoriation

Chickenpox To prevent infection of lesions Cut fingernails short
Topical backing soda paste or baths and calamine lotion Encourage parents to have children immunized

Chickenpox Instruct patient/parent about S&S or serious illness
Increased fever Cough Becoming more ill Signs of skin infection

General Medical Emergencies: Part I

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General Medical Emergencies: Part I

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Presentation on theme: "General Medical Emergencies: Part I"— Presentation transcript:

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