Rosen & Barkin's 5-Minute Emergency Medicine Consult (197 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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PRE HOSPITAL
  • Obtain history from friends, family
  • Provide for patient and staff safety
  • Manage agitation
  • Attentiveness to comorbid conditions
  • Treat acute toxic and metabolic disorders:
    • Hypoglycemia
    • Hypothermia
    • Hyperthermia
INITIAL STABILIZATION/THERAPY
  • Ensure adequate airway
  • Administer O
    2
    if hypoxic
  • Ensure normal vital signs
  • Establish IV access if required
  • In agitated patients, provide for patient and staff safety
ED TREATMENT/PROCEDURES
  • Must determine if patient presents with acute change in mental status
  • Consider full differential diagnosis—evaluate and treat appropriately:
    • Treat hypoglycemia with PO or IV dextrose.
    • Treat narcotic overdose or excess with naloxone.
    • Rewarm if hypothermic.
    • Antipyretic for hyperthermia
    • IV fluids for dehydration
    • Correct electrolyte abnormalities
    • Administer antibiotics for infection:
      • UTI and pneumonia most common occult infections; look for wounds and decubitus ulcers
    • Treat seizures:
      • Lorazepam, other agents as needed
      • Long-term management in conjunction with neurology
  • Sedation for agitation:
    • Start with low doses and increase as necessary to achieve clinical result.
    • Neuroleptics: Haloperidol, risperidone, ziprasidone
    • Benzodiazepines: Lorazepam, midazolam
  • Soft restraints if chemical sedation ineffective
  • Attempt to limit number of medications:
    • Reduced likelihood of toxicity
    • Reduced likelihood of drug–drug interaction
    • If agitation not an issue, eliminate all sedative-hypnotics
  • Treat depression
MEDICATION
  • Alzheimer’s agents: Always start at lowest dose:
    • Donepezil: 5–10 mg PO at bedtime
    • Rivastigmine: 1.5–6 mg PO BID
    • Galantamine: 4–12 mg PO BID
    • Above 3 anticholinergics without clear superior agent, watch for side effects including nausea, vomiting, diarrhea
    • Consider memantine (NMDA receptor antagonist) in those with poor response to anticholinergics: 5 mg PO QID–10 mg PO BID
    • Effects generally modest, best started, and changed by primary provider
    • Numerous trials showing inconsistent or negative benefit of anti-inflammatory agents, estrogens, and statins for Alzheimer
  • Antidepressants: Start with lowest dose:
    • Oversedation a problem
    • May worsen dementia
    • Useful in patients who cannot sleep
  • Sedative agents: Always start with lowest dose
    • Droperidol: 0.625–2.5 mg IV—advantage, rapid onset; disadvantage, risk for QT prolongation
  • Haloperidol: 0.5–2 mg PO BID; start with lowest dose 0.5–2.5 mg IM or IV if rapid onset required
  • Lorazepam: 0.5–1 mg IV, 0.5–2 mg PO
  • Midazolam: 0.5–2 mg IV slow push
  • Naloxone: 0.4–2 mg IVP
  • Risperidone: 0.5–2 mg PO BID; start with lowest dose
  • Ziprasidone: 20–80 mg PO BID, 10–20 mg IM q4h; start with lowest dose
FOLLOW-UP
DISPOSITION
Admission Criteria
  • Unstable vital signs
  • Significant comorbid condition requiring parenteral medications:
    • Pneumonia
    • UTI
    • Fluid and electrolyte disorder
  • Uncertain diagnosis requiring evaluation and management that is not suitable for outpatients
  • Inadequate home support coupled with inability to arrange suitable placement from ED
Discharge Criteria
  • Stable vital signs
  • No significant unstable comorbid conditions
  • Secure diagnosis or elimination of life-threatening organic disease
  • Adequate home support, watch for caregiver burnout
  • Reliable access to follow-up care
Issues for Referral
  • Patients may need assistance with transportation, finances, etc.
  • Patients with other comorbidities need referral to appropriate specialists.
FOLLOW-UP RECOMMENDATIONS
  • Primary care
  • Geriatrician
  • Psychiatrist
  • Neurologist
PEARLS AND PITFALLS
  • Primary dementia is characterized by slow, steady progression:
    • Course is generally 5–10 yr from diagnosis to death.
  • Can fluctuate as consequence of intervening illness and comorbid conditions
  • Cholinesterase medications can improve functional status in patients with Alzheimer disease.
  • Careful attention to medications, secondary illnesses, and prompt intervention for infections can improve quality of life and longevity.
  • Death is generally consequence of infection, cardiovascular disease, or injury.
ADDITIONAL READING
  • Holsinger T, Deveau J, Boustani M, et al. Does this patient have dementia?
    JAMA
    . 2007;297:2391–2404.
  • Langa KM, Foster NL, Larson EB. Mixed dementia: Emerging concepts and therapeutic implications.
    JAMA
    . 2004;292:2901–2908.
  • Mayeux, R. Clinical practice. Early Alzheimer’s disease.
    N Engl J Med
    . 2010;362:2194–2201.
  • Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia.
    N Engl J Med
    . 2009;361:1529–1538.
  • Petersen RC. Mild cognitive impairment.
    N Engl J Med
    . 2011;364:2227–2234.
  • Savva GM, Wharton SB, Ince PG, et al. Age, neuropathology, and dementia.
    N Engl J Med
    . 2009;360:2302–2309.
See Also (Topic, Algorithm, Electronic Media Element)
  • Altered Mental Status
  • Delirium
CODES
ICD9
  • 294.10 Dementia in conditions classified elsewhere without behavioral disturbance
  • 294.20 Dementia, unspecified, without behavioral disturbance
  • 331.0 Alzheimer’s disease
ICD10
  • F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
  • F03.90 Unspecified dementia without behavioral disturbance
  • G30.9 Alzheimer’s disease, unspecified
DENGUE FEVER
Jessica Freedman
BASICS
DESCRIPTION
  • Dengue fever occurs secondary to dengue viral infection.
  • Most prevalent mosquito-borne viral infection.
  • Poorly understood immunopathologic response causes dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS).
  • DHF and DSS usually occur in patients with previous exposure to dengue virus.
  • Hemorrhagic manifestations occur after defervescence of fever.
  • Vascular permeability increases.
  • Plasma extravasates into extravascular space, including pleural and abdominal cavities.
  • Bleeding tendency
  • Shock may ensue.
  • Disseminated intravascular coagulation (DIC) may develop.
  • Dengue fever, DHF, and DSS are all self-limited.
  • World Health Organization—required criteria for the diagnosis of DHF:
    • Fever
    • Bleeding evidenced by one of the following: Positive tourniquet test, petechiae, ecchymosis, purpura, GI tract bleeding, injection site bleeding
    • Increased vascular permeability and plasma leakage as evidenced by an elevated hematocrit (>20%), decreased hematocrit >20% after volume replacement or pleural effusions, ascites or hypoproteinemia
    • Thrombocytopenia (<100,000/mm
      3
      )
  • World Health Organization—required criteria for diagnosis of DSS:
    • All 4 criteria of DHF +
    • Rapid and weak pulse
    • Narrow pulse pressure or hypotension for age
    • Cold, clammy skin
    • Restlessness
ETIOLOGY
  • Occurs in tropical and subtropical regions: Asia, Africa, Central and South America, and the Caribbean
  • Caused by dengue virus serotypes 1–4
  • Transmitted by mosquitoes: Aedes aegypti and Aedes albopictus
  • Incubation period of 3–14 days
  • There is only transient and poor cross protection among the 4 serotypes
DIAGNOSIS

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