| Appendix 9–2 Emergency Situations
Appendix 9–2 Emergency Situations
| Medical Emergency |
Underlying Causes |
Findings |
Treatment |
Acute myocardial infarction (MI, AMI)
Acute coronary syndromes (ACS) |
Most heart attacks are caused by the rupture of a plaque in the wall of the coronary artery that results in the blockage of blood flow and the death of myocardial tissue. Risk factors often present include tobacco use, hypertension, hypercholesterolemia, diabetes mellitus, obesity, physical inactivity, or family history of heart disease. Men and postmenopausal women are at greater risk than premenopausal women. Modification of risk factors lowers the risk for disease. |
Patients often complain of tightness, heaviness, pressure, pain, or burning in the chest. The symptoms may radiate into the neck, jaw, shoulders, back, or arms. Shortness of breath, nausea and vomiting, or sweating often accompany the chest pain or pressure. Some patients (esp. older individuals, women, or diabetics) may report difficulty breathing, nausea and vomiting, or loss of consciousness as their only symptoms. A 12-lead ECG may show evidence of an MI, although a large percentage of patients may have a nondiagnostic ECG initially. Abnormal levels of cardiac enzymes (e.g., troponins, creatinine kinase) usually appear in the blood about 8 hr after chest pain begins. |
Supplemental oxygen, aspirin, other antiplatelet drugs, anticoagulants, beta blockers, and narcotics like morphine should be used acutely to alleviate pain, improve oxygenation and blood flow, and reduce stress. Cardiac monitoring, oximetry, and automatic blood pressure monitors are used to identify changes in heart rhythm, hemodynamics, and breathing. A 12-lead ECG should be completed within 10 min of the patient’s presentation to the hospital, and preferably while the patient is in transit to the hospital. If an ST segment elevation MI is identified, patients should be triaged to percutaneous coronary intervention (PCI) in the first 90 min or, if PCI is not available, to fibrinolytic therapy within 30 min (unless contraindicated). Other treatments depend on the presentation (e.g., the patient in shock may be treated with pressors; a patient with acute pulmonary edema may need diuretics, etc.). Nonsteroidal anti-inflammatory drugs (esp. those that are COX-2 selective) should be discontinued. The patient in full cardiac arrest is treated with advanced life support protocols. |
| Airway obstruction |
Complete or partial obstruction of the oropharynx or nasopharynx, larynx, or trachea, with impairment of gas exchange, caused by foreign bodies, anatomical abnormalities, allergic reactions, infection, or trauma. |
Signs of respiratory distress, including a rapid respiratory rate, wheezing, stridor, or labored breath are usually present. The patient usually appears agitated. Cyanosis of the fingers or lips may be present when there is inadequate oxygen in the blood. Loss of consciousness may occur if airway obstruction is not effectively relieved. |
Foreign body airway obstruction is treated using the Heimlich maneuver in adults and back blows and chest thrusts in infants and children. Endotracheal intubation or cricothyroidotomy, along with mechanical ventilation, may be lifesaving interventions. |
| Angina pectoris |
Inadequate supply of oxygen to the myocardium when oxygen demand exceeds supply. Unstable angina, marked by more frequent attacks, pain with less exertion or at rest, reduced response to nitroglycerin, or more severe episodes may indicate a progression in the patient's coronary artery disease and a higher risk for MI. Stable angina is discomfort typical of the patient's usual pattern. |
Similar to MI. Chest discomfort typically resolves in less than 15 min, and improves with nitroglycerin and rest. There may be evidence of ischemia on a 12-lead ECG. Cardiac enzymes usually do not show evidence of acute MI on initial testing. |
Oxygen, nitroglycerin, and aspirin are given initially, and the patient’s response is noted. Beta blockers, to slow heart rate and lower blood pressure, are used unless there is evidence of heart block, heart failure, or active wheezing. Morphine is used for refractory pain and breathlessness. Heparins are used for pain that does not resolve with initial treatments. Persistent symptoms, ECG changes, or elevated cardiac enzymes suggest an acute coronary syndrome and may require further treatments (see above under Acute Myocardial Infarction). The patient with new or unstable angina is usually admitted to the hospital for further studies and stabilization. |
| Arterial bleeding |
Trauma to blood vessels; surgery; erosion of arteries by ulcers, infection, or cancer. |
Blood that spurts out in pulsatile fashion from a vessel is characteristic of bleeding from an artery. (Blood that oozes from a vessel continuously is characteristic of bleeding from a vein.) |
Arterial bleeding from a vessel in an arm or leg can often be controlled with pressure applied directly over the bleeding vessel or just proximal to it. Arterial ligation may be performed surgically if direct pressure does not limit blood loss. Arterial bleeding from peptic ulcers is typically controlled with the injection of sclerosing agents during endoscopy or with electrocoagulation or coaption. Bleeding from other internal vessels may also be controlled endoscopically (e.g., bleeding from bronchial arteries during bronchoscopy). In some instances, blood flow through internal arteries can be stopped with therapeutic embolization. |
| Asthma |
Episodic bronchospasm, caused by exposure to allergens (such as pollens), smoke, pollutants, cold air, exercise, or other triggers of airway inflammation. |
Difficulty breathing, wheezing, and chest tightness. Patients are often able to identify the triggering event. They may report that their inhalers are not providing adequate relief. Physical findings include tachypnea, tachycardia, and labored breathing, often with a prolonged expiratory phase and wheezing. Cyanosis of the fingers or the lips suggests inadequate oxygenation. Patients may be agitated, frightened, or, in severe attacks, lethargic or comatose. |
Supplemental oxygen should be supplied, and the patient should be given inhaled bronchodilators (e.g., albuterol and ipratropium). Oral or intravenous steroids are used to reduce airway inflammation. Epinephrine may be injected subcutaneously in severe asthma; antibiotics are used when there is evidence or suspicion of a bacterial infection. Severe asthma may result in respiratory failure and the need for ventilatory support (e.g., noninvasive ventilation or tracheal intubation). |
| Medical Emergency |
Underlying Causes |
Findings |
Treatment |
| Chronic Obstructive Pulmonary Disease (COPD), exacerbation of |
An acute or gradual worsening of pulmonary function in patients with chronic lung disease, typically brought on by a viral or bacterial infection, or by congestive heart failure, allergies, pulmonary emboli, or the rupture of an emphysematous bleb at the margins of the lung. |
Patients typically report increased shortness of breath, cough, sputum production, and fevers, and appear to labor more than usual to breathe. Tachypnea, tachycardia, and hypoxemia or carbon dioxide retention are often present. Breath sounds may be distant, or wheezing may be present. |
Oxygen is supplied, and the patient is carefully monitored clinically. Continuous oximetry should be used, and arterial blood gases checked when there is clinical suspicion of impending respiratory failure. Bronchodilators (such as albuterol and ipratropium) are given by inhalation. Corticosteroids are used to reduce airway inflammation. Antibiotics are used when there is evidence or suspicion of a bacterial infection. Severe exacerbations may result in respiratory failure and the need for ventilatory support (e.g., noninvasive ventilation or tracheal intubation). |
| Cold-induced soft tissue injury (frostnip, chilblain, frostbite) |
Frostnip: superficial, reversible injury caused by ice crystal formation on the surface of the skin. Chilblain: superficial injury caused by exposure to cold, humid air. Tissue does not freeze. Frostbite: destruction of tissue by freezing. The extent of tissue loss reflects the duration of cold exposure and the magnitude of temperature depression. |
Frostnip: usually, paresthesias, pain, and numbness. Chilblain: redness, itching, numbness, burning, and pain. Frostbite: similar to chilblain. Frostbitten skin may be waxy and white or mottled and cyanotic. The frozen part will have no sensation. Surrounding tissue may be painful and tender. As the tissue thaws its appearance changes. In partial-thickness frostbite the skin becomes red and warm. Blisters containing clear fluid may appear. In full-thickness frostbite the blisters contain a bloody fluid. There is no sensation in full-thickness frostbite. |
Initial treatment involves removing the patient from the cold environment. Concomitant hypothermia is a hazard. The frozen parts should not be rewarmed if there is danger of refreezing. Rapid rewarming should be performed by soaking the injured part in warm water (42°C). Rubbing or other manipulation of frozen tissue may worsen the injury. Further treatment may be needed for more serious injuries. |
| Congestive heart failure (CHF) |
An impairment in the ability of the heart to move blood into the systemic circulation, either because of damage to heart muscle (e.g., after a heart attack), failure of the heart muscle to relax properly, pericardial restriction, valvular heart disease, or other causes. |
Most patients are winded with exertion, and some are short of breath at rest. Many cannot lie flat in bed at night because the supine position makes them breathless. Lower extremity and sacral swelling are common physical findings, along with ascites, liver enlargement, and elevated jugular veins. Crackles or wheezes may be heard in the lung bases or throughout the lungs in left ventricular CHF. The patient is often hypoxemic. Chest x-rays may show an enlarged heart with fluffy infiltrates near the hila. |
Oxygen, potent diuretics, morphine sulfate, nitroglycerin, nesiritide, and ACE inhibitors may be used to manage CHF or acute pulmonary edema as long as the patient is not hypotensive. Noninvasive positive pressure ventilation, or intubation and mechanical ventilation may be needed to support respiration. Hypotensive patients may be treated with dobutamine, combinations of dopamine and nitroprusside, or other drugs and interventions. |
| Medical Emergency |
Underlying Causes |
Findings |
Treatment |
| Fractures and Dislocations |
Most fractures and dislocations are caused by significant trauma, e.g., automobile collisions, falls, or sports injuries. Fractures that occur without a powerful mechanism of injury are termed “pathological.” They may occur in patients with underlying malignancies that have spread to bone or in patients with osteoporosis. |
Limb fractures or joint dislocations are often clinically obvious. The affected limbs are usually swollen, visibly deformed or rotated, and exquisitely painful to gentle touch or any movement. Patients with rib fractures may complain of pain on breathing or coughing. The injured chest wall is tender and may be bruised. Patients with fractures of the vertebral bodies (or patients suspected of having vertebral fractures) often complain of neck, thoracic, or lumbar pain after a fall or automobile accident. X-rays of the affected bones confirm the diagnosis. |
Primary treatment includes immobilization (splinting) of any affected bones or joints until diagnostic x-rays can be obtained. Analgesics are given as required, and cold packs or ice are applied to limit pain and inflammation. Limb fractures or dislocations are sometimes amenable to immediate treatment with closed reduction, although operative reductions and placement of fasteners may be needed to obtain optimal healing. Patients suspected of having vertebral fractures should be placed in firm cervical collars or restrained on spinal boards until examination and x-rays clearly demonstrate that the spine is stable. |
| Medical Emergency |
Underlying Causes |
Findings |
Treatment |
| Gastrointestinal (GI) bleeding |
Upper gastrointestinal bleeding often results from esophagitis, esophageal tears, gastritis, peptic ulcer disease, esophageal varices, or vascular malformations. Lower GI bleeding typically is caused by hemorrhoids, anal fissures, diverticuli, vascular malformations, or cancers. |
The rapidly bleeding patient may present in shock (i.e., dizzy on arising, hypotensive, tachycardic, cool, clammy, diaphoretic, and confused). Bleeding from the upper GI tract often reveals itself when the patient vomits bright red blood or digested blood that resembles coffee grounds. Occasionally, bleeding from the upper tract is so vigorous that it causes the loss of bright red blood from the rectum. Usually, however, this is a finding in lower GI bleeding. Digested blood that is expelled in the feces is typically black and tarry (melenic). |
Patients with significant blood loss are treated immediately with intravenous fluids. Blood is obtained for typing and cross-matching, and transfusions are given when indicated. Upper GI bleeding resulting from peptic ulcer disease, esophagitis, or gastritis may respond to treatment with IV or oral proton pump inhibitors. The loss of bright red blood from the upper GI tract should be promptly evaluated with esophagogastroduodenoscopy (EGD). Patients with a bleeding ulcer vessel or esophageal varices may be treated with endoscopic therapies to cauterize or band bleeding vessels or with medical therapies including agents such as octreotide. Patients suspected of having lower GI blood loss are evaluated with colonoscopy, e.g., to identify arteriovenous malformations, cancers, diverticuli, or ulcerative colitis. |
| Medical Emergency |
Underlying Causes |
Findings |
Treatment |
| Hyperglycemia |
Elevated blood glucose is usually caused by impairments in glucose metabolism (type 1 or type 2 diabetes mellitus, gestational diabetes mellitus, or drugs or infections that temporarily predispose patients to high blood glucose levels). In diabetics sudden elevations of blood glucose are typically caused by failure to maintain a careful dietary and medical regimen, taking medications such as coticosteroids, or serious ilnesses (e.g., infections, heart attack, stroke). |
Patients often report thirst, frequent urination, increased appetite, and increased consumption of fluids. Those who become dehydrated may be dizzy when they get up from a bed or chair. Blood chemistries typically reveal a blood glucose of more than 200 mg/dl, and glucose is present in the urine. |
Fluids are administered by mouth (if possible) and intravenously. Insulin or oral hypoglycemic agents are given. |
| Hyperthermia (heat cramps, heat exhaustion, heatstroke) |
Inability of the body to cope with heat stress resulting from excessive heat production or decreased heat loss. Heat cramps: muscle cramps and fatigue accompanied by water and mild salt depletion. Heat exhaustion: serious dehydration with water and electrolyte depletion. Patients maintain thermoregulatory control. Heat exhaustion may progress to heatstroke, characterized by thermoregulatory failure and profound dehydration. |
The person with heat cramps complains of painful muscle spasms. There is a history of recent exertion in a hot environment. The patient has been sweating profusely with inadequate or hypotonic fluid replacement. The patient with heat exhaustion has also been sweating in a hot environment. Symptoms include thirst, weakness, fatigue, vomiting, and anorexia. The skin is cool and clammy. Body temperature may be normal or subnormal. The heatstroke victim will have an altered mental status and will be tachycardic, hypotensive, hyperthermic, and tachypneic. Signs of dehydration will be present. |
First aid begins with removal of the patient from the hot environment. Heat cramp victims are treated with an oral or intravenous fluid and electrolyte solution. Heat exhaustion is treated by intravenous fluids. Patients with severe dehydration may require more than 4 L of IV fluid. Patients with heatstroke require rapid cooling. Many techniques are available, but evaporation with water is practical and effective. The patient may be sprayed with water and fanned until the core temperature is about 38.5°C. Cooling beyond this may cause overshoot hypothermia. IV fluid resuscitation as for heat exhaustion is also needed. |
| Hypoglycemia |
The most frequent causes are an excessive dose of insulin or an oral hypoglycemic agent, or inadequate food intake by a diabetic patient treated with those drugs (e.g., during an illness that causes anorexia, nausea, or vomiting). Low blood sugars deprive the brain and other organs of the glucose they need for normal metabolism. |
Mental status may vary from confused to agitated to unconscious. The patient is often sweaty, tremulous, and tachycardic. Occasionally, hypoglycemia may mimic strokes or seizures. |
Glucose or dextrose should be given immediately—intravenously if the patient is unable to safely eat, orally if the patient is conscious and sufficiently oriented. One mg of glucagon, administered by intramuscular injection, is an alternative. Blood sugar levels should be tested with a glucometer. Hospitalization may be necessary if the patient has taken an overdose of long-acting insulin or an oral antihyperglycemic agent. |
| Hypothermia |
Core temperature less than 35°C (95°F), caused by decreased heat production, increased heat loss, or impaired temperature regulation. Exposure to cold or wet conditions, sepsis, or profound hypothyroidism may be predisposing conditions. Central nervous system, cardiovascular, and respiratory systems are impaired when the temperature is below 35°C. |
Lethargy, confusion, and fatigue in mild cases. Heart rate and respiratory rate may be increased. As hypothermia worsens, the patient stops shivering. Heart rate, blood pressure, and respirations slow. The patient eventually loses consciousness. Respirations and pulses may be difficult to detect. |
Cold or wet clothing should be removed. The patient should be rewarmed. Warm blankets, warm oxygen, and warm IV fluids may be used. An accurate core temperature must be recorded, if possible. Temperatures less than 32°C may require more aggressive rewarming techniques, such as gastric lavage, peritoneal lavage, hemodialysis, or cardiopulmonary bypass. If pulses are absent, cardiopulmonary resuscitation is indicated. |
| Medical Emergency |
Underlying Causes |
Findings |
Treatment |
| Seizure |
An abnormal electrical discharge by central nervous system neurons that produces autonomic, behavioral, motor, or sensory abnormalities. Seizures may result from structural diseases of the brain (e.g., arteriovenous malformations, strokes, trauma, or tumors), from metabolic disorders (e.g., severe electrolyte disorders, low blood sugars, renal failure, or hypoxia), or from drugs (or drug or alcohol withdrawal). |
During a generalized motor seizure, the patient is unconscious and has repetitive back-and-forth movements of the upper and lower extremities. Patients may bite the tongue, lose control of the bowels or bladder, or injure themselves when they fall. After the seizure, there is usually a period of gradual and progressive return to normal consciousness, which may take 30 to 60 min. Some patients may have a brief period of focal paralysis after the event. |
During the seizure, the patient should be guarded against injury. This may involve helping the patient to the floor and moving furniture out of the way. Supplemental oxygen should be given. Objects should not be inserted into the patient's mouth—an obstructed airway may result. Medications such as lorazepam, diazepam, fosphenytoin, or phenobarbital may be used to abort the seizure. Most seizure patients will require some investigation into the cause of the seizure. In patients with a history of prior seizures, this may include checking blood levels of anticonvulsant medications. Patients with first-time seizures may need a more extensive evaluation, including a CT scan, an EEG, MRI, blood work, and a lumbar puncture. |
| Stroke (cerebrovascular accident) |
Inadequate blood flow to an area of the brain causing tissue death. In thrombotic stroke, blood vessels narrowed by atherosclerosis limit delivery of oxygenated blood to the brain or a portion of it. In embolic stroke, clots travel from other areas of the body to block cerebral vessels. Hemorrhagic stroke results from bleeding caused by hypertension or rupture of cerebral aneurysms. |
Patients often present with weakness or numbness on one side of the body or the face; with speech disturbances; or with confusion, clumsiness, difficulty walking, loss of consciousness, or coma. |
Oxygen is administered and cardiac monitoring is begun. A computed tomographic (CT) scan of the brain is used to rule out a hemorrhage as a cause of new neurological deficits. Tissue plasminogen activator (a thrombolytic, or “clot-busting” drug) may be given to patients who present in the first 3 hr of nonhemorrhagic stroke. |
| Suicidal ideation |
Major depression; alcohol abuse; dysphoria; adjustment disorders; borderline personality disorders; psychotic disorders; poor social situations and recent stressful events. Older men living alone are most likely to use lethal means to harm or kill themselves. Younger persons are most likely to come to an emergency department in distress. |
Patients may report feelings of hopelessness, misery, anxiety or tension, or may feel that life has lost its meaning or joy. People who have taken medications in an attempt to overdose may have signs and symptoms related to the ingested drug(s) and may need inpatient stabilization. Consult Appendix 9–1. |
Hospitalization is indicated for patients who are intoxicated by drug or alcohol overdose or who have a concrete plan to take their own lives. Outpatient therapy may be appropriate for people without the means to use potentially lethal drugs or devices to jeopardize their health and safety. Antidepressant medications, counseling, alcohol and drug rehabilitation, therapies, and psychiatric consultation are used individually or in combination for selected suicidal patients. |
| Medical Emergency |
Underlying Causes |
Findings |
Treatment |
| Thermal burns |
First- and second-degree burns: partial-thickness injuries involving only the epidermis or the epidermis and dermis. Third-degree burns: full-thickness injuries involving the deeper tissues. Burns impair the skin's ability to prevent heat and water loss. Burned skin is not an effective barrier to injection. Severity depends on the character and temperature of the agent, the duration of exposure, and the type of skin injured. |
First-degree burns: red and painful. Second-degree burns: red, painful, and blistered. These burns heal without scarring. Third-degree burns: may be white or charred. The subcutaneous nerves have been destroyed; thus there is no pain. Surrounding areas are painful. Full-thickness burns heal poorly, leaving a scar. |
The first step is to stop the burning process. Oxygen should be administered if there has been smoke inhalation. Jewelry and clothing should be removed in anticipation of swelling. Sterile sheets or dressings should be applied to the burned areas. |
| Transient ischemic attack (TIA) |
See Stroke. |
Symptoms and signs are similar to those of a stroke, but usually last less than 1 or 2 hr. |
Patients with TIAs are treated with antiplatelet therapies, such as aspirin or clopidogrel, and are evaluated with electrocardiographic monitoring (e.g., to rule out atrial fibrillation), CT scans of the head (to rule out small strokes), and carotid ultrasonography (to determine whether the patient has a surgically correctable stenosis of the carotid arteries). |
Appendix 9–2 Emergency Situations
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