DKA
• Confi rm the patient ID
• Brief Hx and PE if the patient is stable if unstable start with ABC
Check vital sign and LOC
Diuresis (polyuria), Dizziness, Dehydration, Delirium, Drinking (polydipsia)
Kussmaul respirations (rapid, deep, fast respirations that attempt to correct for metabolic acidosis)
Abdominal pain + N/V, “Fruity” (acetone) breath odor
Check Vital sign and Level of conscious
Order laboratory tests: blood glucose, arterial blood gas, CBC, electrolytes, BUN, creatinine, and
urinary analysis. ECG, CXR, and cultures.
Initiate IV fluids.
• Diagnosis
Diabetic: blood glucose >14mmol/L (Hyperglycemia)
Ketotic: beta-hydroxybutyrate >3mmol/L or ketonuria (3+)
Acidotic: pH <7.3 and HCO3– <15mmol/L with increase AG
• Management
Dehydration: IV Fluid (NS until the blood glucose reaches 200 mg/dL then add 5% glucose)
Potassium (K): monitoring + other electrolytes (Pseudohyponatremia)
Acidosis and hyperglycemia : insulin therapy (don’t give in hypokalemia)
Close monitoring (ICU admission)
Search for the precipitating factor and treat
‣ Inadequate administration of insulin (skip dose)
‣ Any type of stress or illness
Avoid complications of therapy
‣ Cerebral edema (Fluid over load)
‣ Hypokalemia (insulin therapy)
• Further information about DKA
Consequences of DKA include hyperglycemia, ketonemia, metabolic acidosis, and volume
depletion.
• Differential Diagnosis of DKA
Alcoholic ketoacidosis
Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)
Hypoglycemia (altered mental status, abdominal pain, and acidosis are possible)
Sepsis
Intoxication (e.g., methanol, ethanol, salicylates, isopropyl alcohol, paraldehyde, ethylene glycol)
Vaso-occlusive Crisis & Acute chest syndrome in SCD
• Confirm the patient ID
• Complte Hx and PE if the patient is stable if unstable start with ABC
PAIN (SOCRATES) most commonly involves the back, legs, knees, arms, chest and abdomen.The
pain generally affects two or more sites. Bone pain tends to be bilateral and symmetric
Precipitating factor (Infections, Low oxygen tension, Concomitant medical conditions (e.g.,
sarcoidosis, diabetes mellitus, herpes), Dehydration, Acidosis, Extreme physical exercise, Physical or
psychologic stress, Alcohol, Pregnancy and Cold weather)
Order lab test : CBC, reticulocyte count and urinalysis.
Hospital admission in moderate to severe cases
• Diagnosis
Clinically
If fever is present, a chest radiograph should be obtained, and urine, sputum and blood should be
cultured for a possible source of infection.
If possible, identify and treat underlying precipitating factors.
• Management
Hydration: oral or IV depends on the severity
opioid analgesics: such as Morphine on a regular basis in a full therapeutic dosage or by patient-
controlled analgesia. Avoid “as-needed” dosing.
Blood transfusions: as needed and in Acute chest syndrome
‣ Early simple transfusion should be considered early in patients with hypoxia; however,
exchange transfusion is necessary in patients with severe clinical features or evidence of
progression despite initial simple transfusion
Rest
HYDROXYUREA
Oxygen: should be administered only if hypoxemia is present
In Acute chest syndrome: give Antibiotics, with cover for atypical organisms, even if blood
cultures and sputum cultures are negative
Prevent crisis by: vaccination, patient education about Precipitating factor
• Further information
When a vaso-occlusive crisis lasts longer than seven days, it is important to search for other causes
of bone pain, such as osteomyelitis, avascular necrosis and compression deformities.
An acute abdominal pain crisis often resembles an intra-abdominal process such as cholecystitis or
appendicitis
Patients should be transfused to their baseline hemoglobin level. A higher hematocrit may make the
blood more viscous and further increase sickling.
• Differential diagnosis of SC crisis
Asthma exacerbation
• Confirm the patient ID
• Complate Hx and PE if the patient is stable if unstable start with ABC
Start with vital sign
Tachypnea, diaphoresis, wheezing, speaking in incomplete sentences, and use of
accessory muscles of respiration.
Paradoxic movement of the abdomen and diaphragm on inspiration is sign of impending respiratory
failure.
Cough and sometimes Fever (infection)
Hospital admission
• Diagnosis
Peak expiratory flow rate (PEFR)
PFTs (after stabilizing the patient)
Routine lab test
Chest X-ray, ABG
• Management
ASTHMA
‣ A = Albuterol: Via nebulizer
‣ S = Steroids: oral or IV
‣ T = Theophylline (not that effective)
‣ H = Hydration
‣ M = Mask O2 (keep oxygen saturation >90%).
‣ A = Anticholinergic
Antibiotics, only if suspicion of bacterial pneumonia (as most triggers are viral).
identify and treat underlying precipitating factors (triggers)
Review the medication and make sure if the adherence
• Differential diagnosis
COPD exacerbations
Pneumonia
• Further information
Magnesium helps relieve bronchospasm. Magnesium is used only in an acute, severe asthma
exacerbation not responsive to several rounds of albuterol while waiting for steroids to take effect.
Classifying severity: 33, 92 CHEST
‣ Life-threatening:
• PEFR <33% , O2 saturation <92% , Cyanosis , Hypotension , Exhaustion , Silent chest ,
Tachycardia
‣ Severe:
• PEFR <50% , RR >25 PR >110
‣ Moderate
• PEFR <75%
‣ Mild
• PEFR >75%
GI bleeding
• Confirm the patient ID
• Complete Hx and PE if the patient is stable if unstable start with ABC
Vital sign and Level of conscious
Hematemesis, Melena, hematochezia ans S/S of anemia
Constitutionals Symptoms and medication Hx
Hx of Liver disease
Risk stratification using any score
• Diagnosis
Lab test
‣ Blood: CBC, Coagulation Profile, LFT, H.pylory test.
‣ BUN/Cr ratio: high in upper GI bleeding.
‣ Stool: occult blood
Endoscopy: site, source, therapy
• Management
Monitoring: Vital signs
Hydration
Blood transfusions as needed (don’t forget the target Hb in cirrhosis is 7-8)
Treat the cause
‣ PUD: Acid suppression, H. pylori eradication, Endoscopic (Dx & Rx) simple over sewing/
‣ Variceal bleeding: resuscitation (avoiding over transfusion and keeping hemoglobin ~7-8),
antibiotics and infusion of a splanchnic vasoconstrictor (Octreotide).
• Differential diagnosis
PUD
Esophageal varices
Mallory Weiss tear
Malignancy (usually not ER)
Bleeding disorders
• Further information
Risky stratification:
‣ Risk assessment (AIMS65 score): the higher the score the higher risk of further bleeding and
death.
‣ You can used your Hx and PE in Risk assessment
More than 0 require admission
Status Epilepticus
• Confirm the patient ID
• Complete Hx and PE if the patient is stable if unstable start with ABC
If patient currently seizing:
‣ For how long? SE (more than 5min), know seizure? on anticonvulsant? DM?
‣ ABCDE: Place patient in decubitus position until airway can be secured
• Maintain Airway- patient at risk for aspiration
• Breathing-place O2, be ready for intubation
• Circulation-obtain 2 IV access
• Dextrose: check glucose levels
• Electrolytes: check electrolytes (Na, Ca, Mg), and anticonvulsent levels
‣ level of consciousness and remove all the sharp object
‣ Finger-prick glucose test:If the patient is hypoglycemic, give glucose
‣ Management
• Keep calm and make sure to protect the patient from injury and aspiration, administer
oxygen by face mask or nasal cannula
• Watch and wait for 2 minutes
• Start Benzodiazepine: 5 mg Diazepam slowly (over 3-5 minutes) If seizure does not
stop another 5 mg , Rectal diazepam if no IV access.
• Elicit any further history not obtained initially and observed seizure type
• PHENYTOIN: If seizure does not stop with full dose of benzodiazepines, Monitoring:
ECG + BP during infusion
• ICU: if seizure persists > 30 minutes for probable intubation
• If not stop Phenobarbital and If you haven’t called Neurology, please call !!!
• Finally, the ultimate therapy for unresolving seizure is to use a neuromuscular
blocking agent to allow you to intubate the patient and then give general anesthesia
such as midazolam or propofol. The patient must be placed on a ventilator before the
administration of propofol, which can stop breathing.
If seizures stop
‣ Stabilizing the patient
‣ Search for the causes
• Diagnostic workup
All the patient
‣ FS glucose
‣ Monitor vital signs.
‣ Head CT(appropriate for most cases)
‣ Labs: blood glucose,CBC,BMP,Ca,Mg
‣ cEEG monitoring
Consider based on clinical presentation
‣ LP: when suspecting meningitis
‣ Toxicology panel
• Differential diagnosis
Vascular
Infection
Trauma
Autoimmune
Metabolic
Ingestion / withdrawal
Neoplasm
Psychological
Status Epilepticus
De nition of status epilepticus (SE)
SE de ned as 5 min or more of continuous clinical and/or electrographic seizure activity or
recurrent seizure activity without recovery between seizures
De nition of Refractory SE
SE that does not respond to Quality the standard treatment regimens, such as an initial Evidence
benzodiazepine followed by Phenytoin.
Cause:
Intracranial hemorrhage, subarachnoid hemorrhage, meningitis or abscess ,head injury ,SLE ,hypo-
or hypernatremia, hypo- or hypercalcemia, hypomagnesemia, hyperthyroidism, ethanol toxicity or
withdrawal, drugs , idiopathic epilepsy ,neoplastic
Step 1 “ABCDE”
Airway- lateral decubitus position to prevent aspiration of gastric contents. All hard or sharp
objects should be removed from the bed.
Breathing-place O2, be ready for intubation” An Ambu bag at the bedside because
benzodiazepines can cause respiratory depression.”
Circulation-obtain 2 IV access “. on the Dorsum of the hand or arm”
Dextrose: check glucose levels
Electrolytes: check electrolytes (Na, Ca, Mg), and anticonvulsent levels
Ask about
Previous episodes -use anticonvulsants -DM- fever in last 24h
Additional to diazepam If the patient is hypoglycemic ,give glucose (50 ml of D50W).
Or suspicion of alcoholism, administer thiamine100 mg direct injection over 3 to 5 minutes.
Step 2
Give 5 mg Diazepam or Lorazepam “Slowly over 3-5 min To prevent cardiopulmonary arrests”->
not stop give another 5mg .
Not stop ->phenytoin 15 to 20 mg/kg as a slow IV infusion “not exceed 50 mg/min To prevent
cardiac arrhythmias -prolongation QT interval,-and hypotension.” (ECG) should be monitored
continuously.
Not stop -> transfer to ICU before give phenobarbital” risk of respiratory depression is very high.”
Phenobarbital should be infused loading dose of 15 to 20 mg/kg.
Not stop -> If you haven’t called Neurology, please call !!! Consider IV Valproic Acid (Depacon)
If stop you should Continues EEG monitoring And You have to investigate the cause of seizure:
“Considering clinical presentation”
-do head CT
-Lumbar puncture
Complication:
HTN-tachycardia-arrhythmia -apnea-hypoxia-respiratory failure-Hyperthermia -Aspiration -Head
injury -Lactic acidosis- cerebral edema.
Notes
allergy of phenytoin ->Valproic acid or levetiracetam
Alternatives to phenobarbital -> midazolam, propofol.
Rectal diazepam -> if no IV access and IM administration of midazolam is contraindicated
If Refractory Status Epilepticus - >Dosing of continuous infusion AEDs for RSE should be
titrated to cessation of electrographic seizures or burst suppression
Ideal drug for treating SE
Rapid entry into CNS -Rapid onset of action
Long duration of action -Safety
Absence of sedation
General Side E ects of AEDs
decreased LOC, respiration and BP, arrhythmias.
STIM and NSTMI
A 63-year-old male presents to ER with chest pain and diaphoresis.
What do you want ask in history
DM -HTN-smoke -hyperlipidemia - family history of premature coronary heart diseases
(F<65, M<55)
Complications
Arrhythmia -complete heart block-pericarditis all layers -valvar damage ➡ severe mitral
regurgitation.
TIMI risk score مهم يجي ام سي كيو واالوسكي
One point is given for each of the following :
1. being older than 65
2. using aspirin within the last week
3. having at least two angina episodes in the last 24 hours
4. having elevated serum cardiac biomarkers
5. having ST-segment deviation change either desperation 0.5mm or elevation 0.5mm
6. having known coronary artery disease
7. having at least three risk factors for heart disease, which include:
—high blood pressure (greater than 140/90)
—smoking (being a current smoker)
—low HDL cholesterol (less than 40 mg/dL)
—diabetes
—a family history of heart disease
The lowest score you can receive is 0, and the highest is 7.
3;4,5,6,7 Complication rate high at 28 days in the rst month.
Ischemic Cascade
muscles injury ➡ Diastolic dysfunction ➡ systolic dysfunction (akinesis -dyskinesis) ➡ ECG
changes ➡ chest pain
hypertensive emergency.
What characteristic ndings
will you nd on chest and CV
examination?
agog
Loud S2 -Bilatera mediu
basal crackles
investigation you would ask fo ?
ECG
Chest x-ray
LVH because sum large R-
waves in (V5, V6) and deep
S-waves in (V1, V2) more
than 7 big box
cephalization of pulmonary vessels, Kerley B
lines which are signs of pulmonary edema.
What ar the precipitating factor for hypertensive emergency?
-Not Compliance to medication and Dietar salt restriction
-secondary hypertension
-Previous episodes
-drugs like Cocaine amphetamine
Strok and TIA
