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First exclude any potentially life threatening causes virtue of history, brief examination & limited investigations. Then consider other potential causes.
Life threatening:
-
Acute myocardial infarction Angina Aortic dissection Tension Pneumothorax Pulmonary embolism Esophageal rupture
Others:
-
Pneumonia Empyema Chest pain: Muscular Rib fracture Bone metastases Costochondritis Pleurisy Gastroesophageal reflux Pericarditis Esophageal spasm Herpes zoster Cervical spondylosis Intra- abdominal cholecystitis Peptic ulceration Pancreatitis Sickle cell crisis
Before discharging patients with undiagnosed chest pain be sure in your own mind that the pain is not cardiac( this pain is usually dull, may radiate to jaw , arm or epigastrium & is usually associated with exert on). Do CXR, ECG, FBC, U&E & cardiac enzymes including troponin T. Discuss options with colleague & the patient. Dont simply turn people out on the street.
IV access Bloods for FBC, U & Es, glucose, lipids, cardiac enzymes (CK,AST,LDH)
Brief assessment History of cardiovascular ds, risk factors for IHD, # to thrombolysis. Examination: pulse, BP, JVP, crdiac murmurs, signs of heart failure, Peripheral pulses, scars from previous cardiac surgery
Aspirin 300mg chewed (unless already given by GB) Morphine 5-10mg IV + antiemetic e.g. metoclopramide 10 mg IV GTN sublingually 2 puffs or 1 tab. as required B- blocker e.g. atenolol 5 mg IV (unless asthma of lt ventricular failure) Thrombolysis CXR
Dont delay thrombolysis while waiting unless aneurysm suspected Consider glucose, insulin,& potassium infusion for patients with DM
Continue medication except Ca channel blockers (unless specific indications) - If pain is uncontrolled, esp. if continuing ST elevation, consider re- thrombolysis with rtPA (no bolus) or rescue PTCA/ angioplasty.
1-Check electrocardiogram 2- Aspirin 3- Supplement O2 4- Sublingual nitroglycerine 5- Morphine pm 6- Check cardiac enzymes
1PCI available
No recurrent chest pain Serial studies - ve Provocative stress test LMWH, consider GP IIb / IIIa inhibitor
-ve results
High risk markers present: -elevated troponin -persistent/ recurrent chest pain -persistent ST elevation -associated heart failure -hemodynamic instability -LVEF < 40% -PCI in preceding 6 months
+ve results
-ve results
Acute
Chronic AF
Paroxysmal
Stable?
-Evaluate /treat
underlying cause -Early conversion ,risk based anticoagulation
Start Coumadin and convert in 3 weeks vs TEE + Herparin , then 4 wks Coumadin ,or rate control & anticogulate if rhythm not tolerated
-Early cardioversion vs observation -Risk-based anticoagulate -Rate control or antiarrhythmic to patient unable to tolerate symptoms
Risk based long term anticoagulation conversion requires anticoagulation 3 weeks with Coumadin vs TEES/Heparin, then Coumadin for 4 weeks Convert if AF poorly tolerated
AF= atrial fibrillation PAF= persistent atrial fibrillation TEE= transesopageal echocardiography
IV access & start Heparin Either unfractionated Heparin 5000U IV bolus Then 1000- 2000U/h IVI as guided by APTT Or low molecular wt Heparin e.g. Tinzaprin 175U/Kg/24h SC2
If BP still after 500ml colloid dobutamine 5-10 ug/Kg/min IV: aim for systolic BP > 90 mmHg
Confirm diagnosis
If the systolic BP < 90mmHg after 30-60min of standard treatment, clinically definite PE & no CL Consider thrombolysis*
*A standard regimen is: loading dose: Streptokinase 250000 IVI over 30 min. Maintenance dose: Streptokinase 100000U/h IVI for 12-72h according to response. ** Controversial, but some aythroities say it is best to infuse plasma- expanding fluids even if CVP , to maintain BP & organ perfusion.
Low probability
D-dimer ELISA -ve < 500 Stop No treatment Search for alternative diagnosis
V/O scan
Normal scan
High probability
Clinically stable
Treat
+ve for PE
No DVT
Pulmonary angiogram
-ve for PE
Stop ttt
* Clinical clues: 1- Sudden onset of dyspnea or worsening of chronic dyspnea. 2- Pleuritic chest painor pleural rub. 3- Hypoxemia (SaO2< 92%) 4- Hemoptysis. 5- Recent surgery or immobilization. 6- Prior Hx of DVT or PE. CT angiography can be considered.
Management of shock:
If BP unrecordable, call the cardiac arrest team
Investigations: FBC, U&E, ABG, glucose, BL.culture , urine culture ECG, CXR, others e.g. lactate, echo, abd. CT. USS
Consider arterial line, central venous line& bladder catheter (aim for a urine flow > 30 ml/h)
Further management: treat underlying cause if possible Fluid replacement as dictated by BP, CVP, urine output Dont overload with fluids if cardiogenic shock If persistently hypotensive consider inotropes N.B.- Remember that higher flow rates can be achieved through peripheral lines than that through standard gauge central lines. -If in doubt as to the cause treat as hypovolemia as it is the most common cause & reversible. - Ruptured abdominal aortic aneurysm aim for a systolic BP of ~ 90 mmHg.
Management of anaphylxis
Secure the airway give 100%O2 Intubate if respiratory obstruction imminet
Remove the cause : raising the feet may help restore the circulation.
secure IV access
IVI (0.9%saline, e.g. 500ml over h: up to 2L may be needed ) Titrate against blood pressure
If still hypotensive admission to ITU and an IVI of adrenaline may be needed aminophlline & nebulized salbutamol: get expert help.
Bleeding management :
Any suspicion of variceal bleeding?
No
yes
Peptic ulcer
other diagnosis
yes
no
Are risk factors present: - 6 units transfused - Haematemesis & melaena - Rebleeding - Bleeding vessel seen on endoscope, or clot in an ulcer
Sclerotherapy
Draw bloods, Cross match 6 units FBC, U&E, LET, glucose, clotting screen
Give high-flow O2
If remains shocked give blood group specific or ORh -ve until cross match done
Set up CVP line to guide fluid replacement Aim for >5cm H2O CVP may mislead if there is ascites or ccf A Swan- Ganz catheter may help
Avoid saline in patients with decompensted liver disease (ascites, peripheral edema) as it worsens ascites & despite a low serum sodium, patients have a high body sodium. Use whole blood or salt-poor albumin for resuscitation & 5%dextrose for maintenance. ** Poor prognostic signs: - Age > 60 - chronic liver disease - signs of shock - consciousness level
No systemic signs
Systemic illness: - fever >39 C - blood diarrhea lasting >2 wks - dehydration
Special circumstances: - Food poisoning outbreak - Travel - Recent antibiotic use - Recent intercourse - Immunocompromised host - Raw sea food ingested
symptomatic treatment
Consider noninfectious causes Admit to hospital Give oral fluids Consider presumptive antimicrobial therapy *
polymorphs seen
no polymorphs
parasites seen
likely culture : - Shigella ** - Campylobacter - E coli (Yersinia rare) (Salmonella rare) (C. difficile*)
specific therapy
** prompt, specific treatment (e.g. ciprofloxacin) may be needed before sensitities are known be guided by likely diagnosis following microscopy * pseudo membranous colitis is caused by overgrowth of Clostrium difficile , following any antibioyic .treatment :Vancomycin 125mg/6h po metronidazole 400 mg /8h po (cheaper ; more palatable ).liaise with a microbiologist. Note : another classification distinguishes secreory diarrhoea (eg infections ,us/crohn's etc) from osmotic causes (water drawn into the gut , as in laxative use).
- ve
+ ve
- ve
+ ve
Treat
Treat
Specific therapy
Chronic diarrhea
Absent
Present
Blood in stool
- ve
Small bowel radiography/ biopsies Evaluate laxative use/abuse Celiac serology Circulating hormone levels
- ve
Managing dyspepsia those 45 yrs not on NSAIDs, with no weight loss, dysphagia, repeated vomiting, anaemia ,masses or bowel habit change*
Simple antacids antireflux measures (p200) if symptoms of reflux (e.g. pain stooping)
H pylori absent
Eradicate H pylori (if past DU no test for H Pylori is needed before eradication therapy ,see above)
Patient well
No further action
Upper GI endoscope
Do endoscope urgently in dyspeptic adults not falling into this group, or stop NSAIDs & monitor closely. Why dont we give under 45s with dyspepsia a helicobacter ttt?
NNT ~ 9 for nonulcer dyspepsia & peptic ulcers are prevented. But we dont know enough about longterm effects of such a strategy for clear recommendations. We also know that nonulcer dyspepsia doesnt improve with eradication therapy. In known peptic ulceration, test before treating if its a gastric ulcer & treat before testing if its a duodenal ulcer. The 13C- urea breath test is the best noninvasive method for detecting H. pylori even when monitoring efficacy of ttt. Serology methods are less good here, as antibodies stay months after eradication. An immunoassay detecting bacterial antigen in faeces is a new ( under evaluated), noninvasive method for determining efficacy of eradication.
DD of headache:
No signs on examination: Tension headache Migraine Cluster headache Post traumatic Drugs (nitrates, Ca channel antagonists) Carbon monoxide poisoning or anoxia Signs of meningism: Meningitis (may not have fever or rash) Subarachnoid Hge Decreased conscious level or localizing signs: Encephalitis/ meningitis Stroke Cerebral abscess Subarachnoid He Tumor Subdural haematoma TB meningitis Papilloedema Tumor Malignant HTN Benign IC HTN Any CNS infection, if prolonged (e.g.> 2 wks) >>>>e.g. TB meningitis Others: Temporal arteritis ( ESR elevated) Glaucoma Pagets ds Sinusitis Altitude sickness Cervical spondylosis
Two vital questions: - where have you been? (malaria) - Might you be pregnant? ( eclampsia especially if proteinuria & BP)
Breathlessness:
* Wheezing? - Asthma - COPD - Heart failure - Anaphylaxis * Stridor? - Foreign body - Acute epiglottitis - Anaphylaxis - Trauma e.g. laryngeal fracture * Crepitations? - Heart failure - Pneumonia - Brochiectasis - Fibrosis * Chest clear? - Pulmonary embolism - Hyperventilation - Metabolic acidosis e.g. DKA - Anemia - Drugs e.g. salicylates - Central causes * Others - Pneumothorax - Pleural effusion
If no response: 1- Consider nasal intermittent +ve pressure ventilation If resp. rate > 30 or PH < 7.35. It is delivered by nasal mask & a flow generator.
3-Cosinder a respiratory stimulant drug , e.g. doxapram 1-2mg /min IV SE.: agitation, confusion tachycardia , nausea Only for patients who are not suitable for mechanical ventilation A short-term measure only * Aminophylline: Do Not give a loading dose to patients on maintenance methylxanthines ( theophyllines/aminophylline). Load with 250mg over 20min, then infuse at a rate of ~ 500g/kg/hour. Check plasma levels if given for > 24h. ECG monitoring is required. ** A decision to ventilate will depend on the patients premorbid state, exercise capacity, home oxygen and comorbidity. Ask at out this information before you need to make this decision.
Oxygen therapy:
The greatest danger is hypoxia, which probably accounts for more deaths than hypercapnia . Dont leave patients severely hypoxic. However, in some patients, who rely on their hypoxic drive to breathe, too much oxygen may lead to a reduced respiratory rate, and hypercapnia, with a consequent fall in conscious level. Therefore, care is required with O2 , especially if there is evidence of CO2 retention. Start with 24-28% O2 in such patients. Reassess after 30min. Monitor the patient carefully. Aim to raise the Pa O2 above 8.0 KPa with a rise in Pa CO2 < 1.5 KPa. In patients without evidence of retention at baseline use 28-40% O2 but still monitor and repeat APG.
Inadequate response
good response
discharge on inhaled 2 against inhaled anticholinergic Corticosteroids x 5days arrange outpatient follow up with in 5 days
persistent bronchospasm
admit to hospital
respiratory failure
consider aminophylline heliox (helium =oxygen )iv magnesium Endotracheal intubation and mechanical ventilation
Continued symptoms
Continued symptoms
Continued symptoms
Continued symptoms
Continued symptoms
Continued symptoms
Continued symptoms
Cough gone
ACEI
Chest radiography
Normal
Abnormal
Order according to likely clinical possibility
Avoid irritant
Cough gone
Cough persists
Treat accordingly Evaluate for three most common conditions singly in the following order, or in combination: 1- PNDS 2- Asthma 3- GERD
Cough persists
Cough gone
Cough gone
Cough persists
Cough gone
Cough persist Reconsider adequacy of treatment regimens before considering habit or psychogenic cough
First Stone Episode Detailed dietary history. Serum electrolytes, creatinine, calcium, phosphorus, uric acid. Urinalysis, crystallographic studies. Non-contrast CT scan. Advise > 3 liters of fluid/24hours. Protein 1-1.5 g/kg/24 hours. Moderate salt restriction
24-hour urine collection for volume, calcium, phosphorus, uric acid, citrate, oxalate, creatinine, magnesium, cystine
Hyperuricosuria
Hyperoxaluria
Hypocitraturia
Hypercalciuria
No abnormalities
Stable Patient
Unstable Patient
Perform EKG
Perform EKG Abnormal EKG, or history suggestive of serious pathology (no clear prodrome), age >60 years, history of cardiac disease (especially congestive heart failure), exertional syncope, chest pain, dyspnea, neurological findings. Arrhythmia
Normal EKG, plus reassuring historical features (vasovagal, situational, orthostatic, young, no comorbidities)
Apply appropriate ED testing (such as echo, V/Q scan, CT, Doppler studies, labs)
Noncardiac ( hypovolemia, anemia, pulmonary embolism, abdominal aortic aneurysm, aortic dissection, toxicologic)
Treat
Strongly consider admission, but discharge with expedient outpatient follow up may be appropriate depending on the specific scenario
Admission